Skip to main content

Full text of "Medical record; a journal of medicine and surgery"

See other formats 


handbound 

AT  THE 


UNIVERSITY  OF 


MEDICAL  RECORD 


A    Weekly  yournal  of  Medicine  and  Surgery 


EDITED    BY 

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

CONSULTING    SURGEON   TO   ST.    FRANCIS     HOSPITAL.    TO    THE    GENERAL    MEMORIAL    HOSPITAL.    To    THE    COLUMBUS    HOSPITAL      TO  THE 

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

OF   THE   HEALTH   DEPARTMENT   OF  THE  CITY   OF  NEW  YORK 


'Volume  56 

JULY    7,   1900— DECEMBER    29,   1900 


NEW    YORK 
WILLIAM     WOOD     AND     COMPANY 

19C0 


The  Publishers'  Printing  Company, 

S2  and  J4  Lafayette  Place, 

New  York. 


LIST   OF   CONTRIBUTORS   TO   VOL.    LVIII, 


Abrams,    Dr.   Alrert,    San   Fran-  Cujiston,    Dr.    Charles    Greene,  Hands,  Dr.  W.  C,  New  York. 

Cisco.  Boston.  Hanson,  Dr.  J.   G.,  New  York. 

Allen,  Dr.   Charles  Lewls,  Tren-  Curtis,    Dk.    R.   Farouhar,    New  Hayden,  Dr.  James  R.,  New  York. 

ton,  N.  J.  York.  Haynes,  Dr.  Irving  S.,  New  York. 

Allen,    Dr.    Charles    W.,    New  Cutler,  Dr.  E.  G.,  Boston,  Mass.  Haynes,  Dr.  S.,  Saranac,  N.  Y. 

York.  Hays,   Dr.   Benjamin   K.,  O.xforcl, 

Amberg,  Dr.   Emil,  Detroit,  Mich.  Dana,  Dr.  Charles  L.,  New  York.  N.  C. 

Davies,    Dr.   M.    J.,  Utica,  X.  Y.  Hill,  Dr.  L.  L.,  Montgomery.  Ala. 

Bainbridge,    Dr.     William     Sea-  Davis,  Dr.  Kdward  P.,  Philadel-  Holder,    Dr.  O.   H.,  New  York. 

MAN,  New  York.  phia.  Horsi.ey,  Dr.  J.  Shelton.  El  Paso, 

Bandler,  Dr.   S.  VV.,  New  York.  Davis,  Dr.  George  E.,  Lawrence-  Tex. 

Baran,  Dr.  J.,  New  York.  burg,  Ky.  Huber,  Dr.  John  B.,  New  York. 

Baruch,  Dr.  Simon,  New  York.  Dayton,  Dr.   Hughes,  New  York.  Huhner,  Dr.  Max,   New  York. 

Beck,  Dr.  Carl,  New  York.  Deane,  Dr.    Louis  C,  San  Fran-  Hussey,  Dr.  M.  F.,  Sidney,  Ohio. 
Becker,  Dr.  W.  F.,  Milwaukee.                cisco. 

Bellamy,  Dr.  Russell,  New  York.  Doty,   Dr.   Alvah  H.,  New  York.  Lsaacs,  Dr.  A.  E.,  New  York. 

BissELL,  Dr.  Joseph  B.,  New  York.  Dulles,   Dr.    Charles  \V.,  Phila-  Isa.acson,    Dr.    Charles    K.,  New 
BissELL,  Dr.  William  G.,  Buffalo,             delphia.  York. 

N.  Y.  Dunning,    Dr.    L  H.,    Indianapo- 

Blaise,    Dr.    T.    T.,  Mason    City,  lis.  Jacobi,   Dr.  A.,  New  York. 

Iowa.  Jenkins,   Dr.    Norburne  B.,   Chi- 

Blake,  Dr.  Joseph  A.,  New  York.  Edebohls,  Dr.    George   M.,    New  cago. 

Bleything,    Dr.    George    Dacre,             York.  Johnson,  Dr.  Alexander  B.,  New- 
New  York.  Ehrenfest,  Dr.  Hugo,   St.  Louis,  York. 
Borden,  Dr.  W.  C,  U.  S.  Army.                 Mo.  Jones,    Dr.    Hugh    E.,    Liverpool, 
Brannan,     Dr.     John     Winters,  Einhorn,  Dr.  Max,  New  York.  England. 

New  York.  Eisen,  Dr.  Gustav,  San  Francisco.  Jones,    Dr.     Mary    Dixon,    New 

Brewer,    Dr.    George    Emerson,  Elliot,  Dr.  John  W.,  Boston,  Mass.  York. 

New  York.  Elliott,  Dr.  H.  A.,  Barnet,  Yt.  Jones,  Dr.  Noble  W.,  Chicago. 

Brown,  Dr.  Sanger,  Chicago.  Erdmann,  Dr.  John  F.,  New  York.  Jones,     Dr.     William,     Portland, 

Brown,  Dr.  Willia.m   M.,  Roches-  Ewald,   Dr.    C.    A.,    Berlin,   Ger-  Ore. 

ter,  N.  Y.  many. 

Buck,  Dr.   Louis,  Portland.  Ore.  Kales,   Dr.    J.   W.,    Franklinville, 

Buffet,    Dr.    Edward    P.,    Jersey  Finlay,    Dr.    Charles,     Havana,  N.  Y. 

City,  N.  J.  Cuba.  Keefe,    Dr.     D.    E.,    Springfield, 

Bull,     Dr.     Charles     Stedman,  Fischer,  Dr.  Louis,  New  York.  Mass. 

New  York.  Fisher,    Dr.     Charles    S.,    New  Kellogg,    Dr.    Edward    L.,    New 
Bullock,  Dr.   Earl    Spr.«;ue.  U.             York.  York. 

S.  Army.  Fisher,  Dr.  W.  C,  Clarinda,  Iowa.  Kemp,  Dr.  Robert  Coleman,  New 

Burger,  Dr.  G.  Leo  Hagen,  He-  Floersheim,     Dr.     Samuel,    New  York. 

lena,  Mont.  York.  Kendall,      Dr.     H.     E.,     Sidney, 

Burke,     Dr.     VYillia.m     P.,     New  Fordyce,  Dr.  J.  A.,  New  York.  Nova  Scotia. 

Haven,  Conn.  Foster,   Dr.    Hal,    Kansas    City,  Keyes,  Dr.    Edward  L.,  Jr.,  New 

Mo.  York. 

Campbell,     Dr.     C.    G.,    Phoenix,  Freudenthal,  Dr.  W.,  New  York.  Kime,     Dr.     J.     \\.,    Fort    Dodge, 

Arizona.  Fruh,  Dr.  Carl  D.  S.,  Philadel-  Iowa. 

Cartwright,   Dr.   S.   S.,  Roxbury,  phia.  King,  Dr.  Clarence,  Machias,  N. 

N.  Y.  Y. 

Cavey,  Dr.    J.    D.,    West   Alexan-  Gant,  Dr.   Samuel  G.,  New  York.  King,    Dr.    George    VV.,    Helena, 

dria,  Ohio.  Gillette,  Dr.  William  J.,  Toledo,  Montana. 

Claiborne,  Dr.  J.    Herbert,  New  Ohio.  Knapp,  Dr.  Mark  L,  New  York. 

York.  GoLDAN,    Dr.    S.    Ormond,    New  Knopf,  Dr.  S.  A.,  New  York. 

Clouting,  Dr.    Charles  A.,  New  York.  Kurth,    Dr.   Henry  A.,  Schenec- 

Vork.  Goldspohn,  Dr.  A.,  Chicago.  tady,  N.  Y. 

Cohn,  Dr.  Robert  D.,  San   Fran-  Gordon,    Dr.    Alfred,    Philadel- 

cisco.  phia.  Ladinski,  Dr.  Louis  J.,  New  York. 

Converse,  Dr.    George    M.,  New  Graves,    Dr.    Schuyler    Colfax,  Langmann,     Dr.      Gustav,     New 

York.  Grand  Rapids,  Mich.  York. 

Corning,    Dr.    J.    Leonard,  New  Gray,  Dr.  Ethan  E.,  Chicago.  Larimore,  Dr.  F.  C,  Mount  Ver- 

York.  non,  Ohio. 

Courtney,  Dr.    J.  E.,  Poughkeep-  Ha.mmond,   Dr.  Gr^me    M.,  New  Larson,  Dr.  C.   Frithiof,  Crystal 

sie,  N.  Y.  York.  Falls,  Mich. 


IV 


CONTRIBUTORS   TO    VOL.    LVIII. 


LuzzATTO,  Dr.  M.  ,  New  York. 

Macalester,  Dr.  Richard  K., 
Glenwood  Springs,  Colo. 

McCaskev,  Dr.  G.  W.,  Fort  Wayne, 
Ind. 


Valentine,    Dr.    Ferd.    C,    New 

York. 
VoGEL,  Dr.  Karl  M.,  New  York. 
Voo.RHEEs,    Dr.    Ja.mes    D.,    New 

York. 

Walker,  Dr.  Ejima  E.,  New  York. 


Lepine,  Dr.  R.,  Lyons,  France.         Pillsbury,    Dr.    B.,    Middletown,  Study,     Dr.     J.     N.,      Cambridge 

Levin,  Dr.  Isaac,  New  York.  N.  Y.  City,  Ind. 

Leviseur,  Dr.  Fred.  J.,  New  York.     Porter,     Dr.     William     Henry, 

Linsley,    Dr.    J.    H.,    Burlington,  New  York.  Talmey,  Dr.  B.  S.,  New  York. 

Vt.  Preston,  Dr.  George  J.,  Baltimore.  Thienhaus,  Dr.  Otto,  Milwaukee. 

Little,    Dr.    Seelye     W.,    Koch-     Pryor,  Dr.  William  R.,  New  York.  Thompson,      Dr.      Guion,      New 

ester,  N.  Y.  York. 

LocKwooD,  Dr.  George  Roe,  New    Quintard,     Dk.      Edward,     New  Trimble,   Dr.    William    B..    New 

York.  York.  York. 

Loomis,  Dr.  Henry  P.,  New  York.  Turck,  Dr.  Fenton    B.,  Chicago. 

Li-CKETT,  Dr.   W.  H.,  New  York.       Rannev,    Dr.    A.mbrose    L.,    New  Tuttle,     Dr.    George    H.,  Cam- 
York,  bridge,  Mass. 
Richardson,  Dr.   Everard    Ham- 
ilton. Atlanta,  Ga. 
Richardson,  Dr.    J.    J.,  Washing- 
ton, D.  C. 
Robin,  Dr.   A.,  Newark,  Del. 
Mandel,  Dr.  Louis  J.,  Brooklyn.      Robinson,    Dr.     Beverley,     New 
Marcus,  Dr.  L.,  New  York.                         York. 
Martin,    Dr.    E.    H.,    Clarksdale,     Robinson,  Dr.  Byron,  Chicago. 

Miss.  Rockwell,  Dr.  A.  D.,  New  York.  Welch,  Dr.  George  K.,  Hartford, 

Marx,  Dr.  S,  New  York.  Rodman,  Dr.  H.,  New  York.  Conn. 

Mayer,  Dr.  Abraham,  New  York.     Rogers,     Dr.     Philip     F.,     Mil-  Whiting,  Dr.  James  R.,  Jr.,   San 
Meyer,  Dr.  Leo  B.,  New  York.                   waukee.  Francisco. 

Miller,  Dr.  George  L,  New  York.     Rome,  Dr.  Robert  R.,  Minneapo-  Wiggin,  Dr.    Frederick    Holme, 
Miller,    Dr.    H.    T.,    Springfield,             lis.  New  York. 

Ohio.  Rose,  Dr.  A.,  New  York.  Woodruff,   Dr.    Charles    E.,    U. 

Mock,  Dr.  E.  V.,  Cambridge,  111.     Rosewater,  Dr.  Charles,  Omaha.  S.  Army. 

Moor,    Dr.    William    Ovid,   New  Wright,  Mr.  John  D.,  New  York. 

York.  St.  John,  Dr.  David,  Hackensack, 

Morrison,  Dr.  J.   H.,  St.  John,  N.  N.  J. 

B.  Sargent,  Dr.  George  \\.,  Seneca  Societies  oj  ichich  Reports  have  been 

Castle,  N.  Y.  PiibJished. 

Satterlee,    Dr.    G.    Reese,    New 

York.  American  Academy  of  Medicine. 

Munde,  Dr.  Paul  F.,  New  York.      Schlapp,  Dr.  M.  G.,  New  York.  American     Association    of     Ob- 
Myers,     Dr.    T.    Halsted,    New    Schroeder.  Dr.  Aimee  Raymond,  stetricians       and      Gyneco- 

York.  New  York.  logists.     • 

Seaman,     Dr.     Louis      L.,     New  American     Electro-Therapeutic 
Nammack,  Dr.  Charles    E.,  New            York.  Association. 

York.  Seiler,  Dr.  Carl,  Scranton,  Pa.  American  Proctologic  Society. 

Neftel,     Dr.    William    B.,    New     Semeleder,  Dr.  F.,  Cordova,  Mex-  American    Public    Health    Asso- 

York.  ico.  ciation. 

Newcomb,  Dr.  James  E.,  New  York.     Shannon,  Dr.  J.  R.,  New  York.  British  Medical  Association. 

Newman,  Dr.  Robert,  New  York.     Sharp,   Dr.    C.   Edwards,   Colum-  Canadian   Medical  Association. 

bus,  Ohio.  International      Medical      Con- 
Oettinger,  Dr.  Bernard,  Denver.     Shiels,    Dr.    George    Franklin,  gress. 

Otis,  Dr.  Edward  O.,  Boston.  San   Francisco. 

Shipps,   Dr.  William  H.,  Borden- 
Page,  Dr.  C.  L.,  Litchfield,  Conn.  town,  N.  J. 

Panton,  Dr.  a.  C,  Portland,  Ore.     Shrady,     Dr.     George    F.,     New 
Paul,  Dr.  Thomas  M.,  Hazleton,  York. 

Pa.  Smith,  Dr.  Stephen,  New  York. 

Payne,  Dr.  Albert   S.,  Manistee,     Squires,  Dr.  G.  W.,  New  York. 

Mich.  Stanton,    Dr.    Margaret,     Syra-  New  York   County   Medical  As- 

Peckham,   Dr.    Frank    E.,   J^rovi-  cuse,  N.  Y.  sociation. 

dence,  R.  I.  Steiuiins,  Dr.    Roswell    O.,  New  New  York  Neurological  Society. 

Peery,  Dr.  E.  W.,  Rural  Retreat,  \'ork.  New  York  Pathological  Society. 

Vt.  Stedman,    Dr.    Thomas    L.,    New  New  York  State  Medical  Asso- 

Phelps,  Dr.  a.  M.,  New  York.  York.  ciation. 

Phillips,  Dr.    Wendell   C,  New    Stern,  Dr.  Heinrich,  New  York.  Practitioners'    Society    of    New 

York.  Stone,  Dr.  B.  H.,  Burlington,  Vt.  York. 

Piffard,    Dr.     Henry     G.,    New     Stone,  Dr.  R.  M.,  Omaha.  Southern    Surgical    and    Gyne- 

York.  Storer,  Dr.  F.  B.,  Holley,  N.  Y.  cological  Association. 


Moschcowitz,     Dr. 

New  York. 
Moser,  Dr.   W.,  Brooklyn 


:\lexis     v.. 


Medical  Association  of  the 
Greater  City  of  New  York. 

Medical  Society  of  the  Counti- 
OF  New  York. 

Mississippi  Valley  Medical  As- 
sociation. 

New  York  Academy  of  Medicine. 


Medical  Record 

A    IVeekly  yoiirnal  of  Aledicine  and  Surgery 


Vol.  58,  No.  I. 
Whole  No.  1548. 


New  York,  July   7,    1900. 


$5.00  Per  Annum. 
Single  Copies,  loc. 


THE  NONSUPPURATIVE  INFLAMMATIONS 
OF  THE  BRAIN,  WITH  REPORT  OF  A 
CASE  OF  HEMORRHAGIC  (MALARIAL?) 
ENCEPHALITIS. 

By  CHARLES  L.  DANA,  M.D.,  and  M.  G.  SCHLAPP,  M.D., 

NEW    YORK. 

Forms  of  Non-Suppurative  Brain  Inflammation.— 
The  chief  inflammatory  disease  of  the  brain,  and  the 
one  with  which  every  one  is  more  or  less  clinically 
familiar,  is  suppurative  encephalitis,  which  causes  the 
various  forms  of  brain  abscesses.  This  is  the  only 
type  of  acute  inflammation  that,  until  recent  years, 
has  been  described  definitely  in  systematic  works. 
Within  the  last  ten  years  it  has,  however,  been 
found  that  there  are  forms  of  acute  brain  inflam- 
mation which  do  not  end  in  suppuration  and  which 
are  curable.  Some  of  these  are  distinctly  and  easily 
recognized,  while  our  knowledge  of  others  is  still  im- 
perfect. In  sifting  out  the  mass  of  material  which 
has  been  contributed  to  the  subject  of  acute,  non-sup- 
purative  encephalitis,  we  find  that  we  can  make  out 
the  following  pretty  well  recognizable  forms:' 

First:  The  infectious  encephalitis  of  infants. 
There  is  no  doubt  whatever  now  of  the  actual  exist- 
ence of  a  pathological  condition  of  this  kind,  although 
it  does  not  involve  the  cortex  alone,  as  Striimpell  first 
supposed,  but  is  a  more  or  less  diffuse  process. 

Second:  The  hemorrhagic  polioencephalitis  of 
adults     (polioencephalitis    superior     and     inferior). 


Fig.  a.— Shaded  Area  showing  Area  under  which  Lesion  lay.     (This  should 
represent  the  right  hemisphere.) 

This  is  usually  alcoholic  in  origin  and  affects  the  gray 
matter  in  the  floor  of  the  fourth  ventricle,  and  the 

'  The  historj'  and  literature  of  encephalitis  has  been  recently 
and  fully  studied  by  Oppenheim  (Nothnagel's  "Special  Patho- 
logic," art.  '■  Encephalitis").  A  valuable  addition  to  the  litera- 
ture has  been  made  by  M.  Koppen  :  "  Encephalitis,"  Arch.  i. 
Psych.     Bd.  .\.\.\.,  p.  954. 


aqueduct,  causing  acute  ophthalmoplegia  and  bulbar 
palsy. 

Third:  Hemorrhagic  encephalitis  of  adults,  due 
often  to  influenza  or  some  other  infection,  called  some- 
times an  "influenzal  encephalitis." 

Under  this  last  .head  we  class  cases  of  acute  hem- 
orrhagic encephalitis  which  vary  somewhat  in  cause 


■Spj 


Fig.  B.— Section  through  A,  Showing  Location  of  the  Lesion.     The  darkest 
spot  represents  a  solid  clot  of  blood. 

and  symptoms,  though  always  acute,  and  accom- 
panied with  small  hemorrhages.  It  is  to  this  group 
of  "hemorrhagic  encephalitis  of  adults"  that  the  case 
here  reported  belongs.  The  patient  was  an  old  man, 
whereas  in  most  cases  hemorrhagic  encephalitis  of 
adults  affects  persons  in  early  or  middle  life.  There 
was  a  distinct  history  of  alcoholism,  but  at  the  same 
time  no  evidence  that  he  belonged  to  the  worst  type 
of  such  cases;  besides  this,  his  blood-vessels  were  not 
atheromatous,  nor  was  there  a  general  arterial  sclero- 
sis throughout  the  brain.  He  had,  on  the  other  hand, 
distinct  malarial  infection,  and  it  is  extremely  prob- 
able that  the  influence  of  a  malarial  infection,  acting 
upon  the  blood-vessels  weakened  by  the  use  of  alcohol, 
led  to  the  condition  from  which  he  suffered.  Cases  of 
this  kind  may  be  classed  as  those  of  degenerative,  in- 
fectious encephalitis,  and  they  lead  to  clinical  types 
which  resemble  those  of  ordinary  apoplexy  with 
hemiplegia  plus  an  encephalitic  process.  Such  cases 
are  mentioned  by  Striimpell ;  they  are,  however,  certain- 
ly rare  in  the  ordinary  history  of  hospital  experience. 
Looking  over  the  records  of  the  autopsies  in  sixty- 
seven  cases  of  apoplexy  which  are  in  our  possession,  we 
find  that  there  were  of  hemorrhagic  apoplexy,  42  ;  em- 
bolic apoplexy,  11;  thrombotic  apoplexy,  11;  enceph- 
alitic apoplexy,  3.  This  would  give  the  proportion 
of  encephalitic  apoplexies  as  about  four  per  cent.,  and 
that  seems  to  us  to  represent  about  the  correct  num- 
ber of  cases  of  this  kind  which  we  meet  with  in  post- 
mortem examinations. 

The  case  we  have  to  report  seems  to  belong  to  the 


MEDICAL   RECORD. 


[July  7,  1900 


same  class  as  that  described  by  Koppen.'  The  dis- 
ease has  a  tendency  to  affect  the  smaller  vessels  sup- 
plying the  cortex  and  the  gray  matter  of  the  cranial 


!^- 


.«S?  .  ' 


f/Hn 


Fig.   C— Section  tlirouKh  B. 

nerve  nuclei,  though  it  is  not  strictly  limited  to  those 
parts;  still  it  is  in  contrast  to  the  morbid  processes 
which  lead  to  atheroma  of  the  larger  arteries,  to  mil- 
iary aneurisms,  embolisms,  thrombosis,  and  massive 
hemorrhages. 

History  of  Case.— Christian  S ,  age  sixty- 
seven,  German,  married;  occupation  gardener;  was 
brought  to  Bellevue  Hospital  on  June  4,  1899,  in  a 
semi-conscious  state.  The  family  history  was  un- 
important, there  being  no  record  of  apoplexy  or  paraly- 
sis, so  far  as  friends  knew.  The  patient  had  never 
used  tobacco;  he  had,  however,  drunk  beer  and 
whiskey  all  his  life,  also  a  great  deal  of  kiimmel. 
The  testimony  of  some  of  his  friends  was  to  the  effect 
that  he  had  been  immoderate  in  the  use  of  alcohol. 
We  could  get  no  specific  history.  His  wife  was  a 
healthy  woman,  but  had  never  had  children.  He  had 
never  been  acutely  and  seriously  ill.  Fifteen  years 
ago  his  right  leg  had  been  frozen  and  this  had  left 
him  with  an  ulcer  which  had  not  healed,  but  had 
never  been  septic.  Six  years  ago  he  suffered  from  a 
sunstroke  and  ever   after  was  extremely  sensitive  to 


''I 


JUi^^:^ 


Section  through  C. 


heat.     He  had  become  somewhat  of  an  invalid,  not 
doing  much  work,  but  going  out  every ^day  and  gener- 

'  Loi.  (it. 


ally  to  a  saloon  to  drink  beer  and  play  cards.  There 
was  some  weakness  of  the  e.xtremities  during  this  time, 
and  they  were  always  cold  and  feeble,  but  he  was  not 
paralyzed.     He  was  a  right-handed  man. 

On  June  4,  1899,  the  patient  complained  of  a  head- 
ache. He  took  two  cups  of  strong  tea  and  went  to 
bed  at  about  8  o'clock  p.m.  At  10  o'clock  he  fell 
out  of  bed,  and  was  then  discovered  by  his  wife  to  be 
suffering  from  left  hemiplegia.  He  was  brought  in 
a  semi-conscious  condition  to  Bellevue  in  a  carriage. 
Under  medication  he  rallied  and  the  following  day  he 
became  conscious.  At  the  time  of  his  admission  his 
temperature  was  104.5°  F->  but  it  dropped  the  next 
day  to  99.25'^  F.  and  continued  so  for  several  days. 
The  pulse  on  admissiot.  was  108,   respiration,  34. 

A  physical  examination  on  June  5th  showed  him  tt 
be  a  man  of  good  physique  and  nutrition,  but  viith 
evidence  of  his  years.  He  lay  in  bed  conscious  and 
appreciative,  but  unable  to  speak  a  word  and  quite 
hemiplegic  on  the  left  side.     He  could  not  protrude 


^  -^^ '^ i  y  ■'• : ■'■■■  "' ' '      ^■ 


Fig.  I.— General  View  of  the  Seat  of  Lesion.     X  i-inch  objective.     A^  B,  C, 
Hemorrhagic  and  softened  areas. 

the  tongue,  and  it  lay  almost  immobile  in  the  mouth. 
He  could,  however,  draw  it  back  a  little  and  could 
swallow  without  much  difficulty,  showing  that  there 
was  no  paralysis  of  the  throat.  His  larynx  was  also 
normal.  He  breathed  naturally  and  could  make 
sounds.  He  was  paralyzed  almost  completely  on  the 
left  side  as  regarded  the  arm  and  leg  and  the  lower 
face.  He  could  close  the  eyes  and  lift  the  eyebrows, 
but  the  lips  were  markedly  affected.  He  could  not 
purse  them  up  to  whistle.  The  tongue  was  somewhat 
coated.  The  pupils  were  even  and  normal.  The 
heart  showed  a  systolic  murmur  at  the  apex.  The 
pulse  was  full  and  irregular.  The  lungs  showed 
some  broncho-vesicular  breathing  posteriorly  at  the 
base.  The  abdomen  was  somewhat  rigid  and  tym- 
panitic over  the  iliac  fossa.  The  patella  reflexes  were 
normal.  Ankle  clonus  was  absent.  There  was  some 
hyperesthesia  over  the  left  side  of  the  body  to  touch; 
sensation  to  heat  and  cold  was  normal.  The  urine 
was  normal. 

The  patient  continued  in  about  the  same  condition 
until  the  25th  of  June,  a  period  of  three  weeks.     Four 


July  7,  1900] 


MEDICAL    RECORD. 


Fig.  3.— Same  as  Fig.  2. 


Enlarged  X  \  inch.      Showing   hcmurrhage,  dilated   vessels,  and  epithe. 
lioid  cells. 


days  after  his  admission  he  had  a  chill  and  tempera-      and  there  was  no  evidence  of  laryngeal  palsy.     He 

ture  of   105.5"  F.     His  blood  was  examined  and  was      understood   perfectly   what   was  said  to  him,  and  he 

found  to  contain  the    plasmodium  of   malaria.     The      was  able  to  read  as  shown   by  various  tests.     He  un- 

temperature  fell   to  normal   the    n«xt 

day  and   rose   again    four   days    later 

to    102°    F.     After  that  it    continued 

normal    until    the    day  of    his  death. 

He    had    thus    three    attacks   of  con- 
siderable   fever  and   one   chill.     His 

paralysis    and   dysarthria    continued, 

remaining  about  the  same  during  his 

illness  in  the  hospital. 

A    physical  examination    made    by 

me  after  he  had  been  in  the  hospital  a 

week  gave    the    following:      He  was 

still  partly  paralyzed  on  the  left  side, 

the  left  arm  being  very  weak,  the   left 

leg  less  so.    There  was  no  paralysis  of 

the  right  leg  or  right  arm.     The  knee 

jerks  of  the  left  side  were  somewhat 

exaggerated  and   there  was  some  rig- 
idity of  the  arm  and  leg.      The  face 

showed  paralysis  of  the  lower  portion 

of  the.  left  side.      The    most    notable 

feature   of    his  condition,   as  already 

noted,  was  the  paralysis  of  the  tongue 

and  of  the  lips.     The  patient  was  quite 

unable  to  protrude  the  tongue  and  could 

lift  it  and  retract  it  only  slightly.     It 

was  practically  an  immobile  organ  ;  he 

could,  however,   swallow  both  liquids 

and    solids  without    much    difficulty. 

He  had,  in  addition,  a  paresis  of  the 

lips  so  that  he  could   not  extend   the 

lips  when  told  to  show  the  teeth,  and 

could  not  purse  up  the   lips  when  told 

to  make  the  motion  of  whistling  or  blowing.     The  pa-      derstood  the  uses  of  things  and  had  no  evidence  in 

tient  was  unable  to  articulate  a  single  word  with  any      any  way  of  sensory  aphasia.     His  mind  was  at  times 

distinctness — he  made  simply  inarticulate  sounds,  and      confused  and  he  was  occasionally  somewhat  delirious. 

could    not  even    say  "yes"  or  "no";  this,  however,      He  had    no  convulsions   or   spasmodic     movements. 

The    patient    died     June    25th,    three 
weeks  after  his  admission. 

Autopsy :  At  the  autopsy,  made  by 
Dr.  Dana  and  the  house  physician,  Dr. 
Armstrong,  on  the  following  day,  only 
the  brain  and  cord  could  be  examined. 
Upon  opening  the  skull,  which  pre- 
sented no  anomalies,  the  dura  mater 
was  found  non-adherent  and  normal. 
Removal  of  this  membrane  showed 
slight  oedema  and  congestion  of  the 
pia-arachnoid,  but  no  evidences  of 
hemorrhage  or  softening  in  any  part. 
The  vessels  of  the  base  were  not  at  all 
atheromatous,  and,  on  following  them 
up  in  the  Sylvian  fissure,  no  evidence 
of  thrombosis  could  be  found.  The 
crura  cerebri  were  cut  and  the  cerebel- 
lum was  removed  with  the  medulla  and 
pons,  and  a  longitudinal  incision  di- 
viding the  hemispheres  was  made. 
Transverse  sections  were  then  carried 
through  each  hemisphere.  In  the 
right  hemisphere  an  area  of  capillary 
hemorrhages  and  softening  was  found 
lying  in  the  lower  portion  of  the  pos- 
terior central  convolution  and  the  an- 
terior part  of  the  marginal  gyrus.  It 
involved  mainly  the  cortex  of  the  deep 
part  of  the  upper  lip  of  the  fissure  of 
Sylvius  and  extended  for  a  distance  of 
an  inch  and  a  half  from  the  posterior 

was  not  due  to  loss  of  memory  of  words,  but  simply      part  of  the  lower  end  of  the  posterior  central  convolu- 

to  the   defect   in    the    peripheral   muscles   of    speech,      tion   to   the   posterior    end   of  the  fissure  of   Sylvius 

He  could  swallow  as  already  stated,  and  could  cough,      (Figs.  \  B,  0,  D).    In  the  centrum  ovale  to  the  inter- 


FiG.  2.— Softened  and  Hemorrhagic  Area.     Indicated  aX.  A  in  Fig.  i. 


MEDICAL    RECORD. 


[July  7,  1900 


nal  and  upper  side  of  the  large  lesion  were  two  or 
three  small  areas  of  capillary  hemorrhage  almost  punc- 
tate in  size.  No  evidence  of  hemorrhage  or  softening 
was  seen  in  any  other  part  of  the  brain  or  in  the  cere- 


FiG.  4.— Showing  Epithelioid  Cells  (Schlapp). 

bellum  or  pons.  The  spinal  cord  showed  two  small 
foci  of  similar  hemorrhagic  degeneration,  one  in  the 
upper  dorsal  and  one  in  the  lumbar  region.  The  brain 
and  cord  were  placed  in  formalin  solution  until  har- 
dened, and  were  then  stained  in  various  ways  for  the 
purpose  of  microscopic  study  of  the  diseased  part. 

General  Results  of  Microscopical  Examination 

Sections  were  made  of  the  brain,  medulla,  and  cord, 
by  Dr.  M.  G.  Schlapp,  and  stained  by  Nissl,  VVeigert, 
hasmatoxylon,  and  fuchsin  methods. 

The  brain:  The  disease  was  confined  to  the  region 
described  (Fig.  1).  There  were  two  specially  affected 
areas,  one  in  the  cortex  chiefly,  the 
other  in  the  white  matter  beneath. 
The  former  showed  enormously  dis- 
tended blood-vessels,  small  hemor- 
rhages, and  round-cell  infiltration. 
The  vessel  walls  were  not  much  thick- 
ened. The  deeper-lying  areas  showed 
small  hemorrhages  and  much  softened 
and  destroyed  tissue.  Here  were 
found  lying  around  the  capillaries  and 
small  vessels  peculiar,  large,  globular, 
so-called  "epithelioid"  cells,  which 
have  been  described  by  previous  ob- 
servers and  appear  to  be  characteris- 
tic of  the  process.  They  are  perhaps 
derived  from  neuroglia  cells. 

Medulla:  There  were  found  here  a 
few  very  small  hemorrhages  which 
must  have  occurred  shortly  before 
death.  There  were  no  "epithelioid  " 
cells,  which  characterize  a  later  stage 
of  the  encephalitic  or  degenerative 
process. 

Spinal  cord:  The  vessels  here  were 
enormously  distended  and  thickened. 
A  small  spot  of  recent  hemorrhagic 
softening  was  found  in  the  second  to 
third  dorsal  segments  and  another  in 
the  lumbar  cord. 

The  nerves  were  not  examined. 
Summary:  Relatively  large  capil- 
lary hemorrhagic  and  inflammatory 
focus  with  "epithelioid"  proliferation  deep  in  the 
upper  lip  of  the  fissure  of  Sylvius  under  the  foot  of 
the  post-central  convolution  and  involving  the  ante- 
rior part  of  the   supra-marginal  convolution.  .  Small 


and  more  recent  hemorrhagic  foci  in  the  medulla  and 
in  the  spinal  cord.  Great  general  congestion  and  dis- 
tention of  the  spinal  vessels  near  the  affected  areas. 

Detail    of    Microscopical    Examination    (By   Dr. 
Schlapp).— The  location  of  the  different  lesion's  hav- 
ing  been    described,   it  remains   but  to  give    a    brief 
description  of  the  histological  nature  of  each  lesion. 
That  these  lesions  which  are  so  widely  distributed  in 
the  nervous  system  are  caused  by  some  toxin  circulat- 
ing in  the  blood  is  hardly  to  be  questioned,  and  in  this 
case  the  toxin  was  probably  produced  by  the  malaria 
germs.     The  blood-vessels',  as  above  stated,  were  enor- 
mously distended  throughout  the  whole  nervous  sys- 
tem, and  in  two  of  the  lesions,  namely,  in  the  medulla 
and    in    the    cortex,  hemorrhages    were    found.     The 
lesion  in  the  cortex  shows  two  distinct  areas  of  tissue 
change  viewed  with   a   low-power   lens.     In   the  one 
area  which  seems  to  be  almost  entirely  confined  to  the 
cortex,  we  have  the  enormously  distended  blood-ves- 
sels, the  hemorrhages,  and  the  round-cell  infiltration. 
In   the  other    area   which   surrounds    the  former    but 
which   seems   to    be  confined   to  the   white  substance 
only,  one  can  plainly  distinguish  a  very  marked  dis- 
tention   of   the    capillaries.      Around    the   capillaries 
there  is  also  to  be  seen  the  round-cell  infiltration,  but 
not  to  such  a  degree  as  in  the  former  picture.     The 
most  characteristic  appearance  of  this  area  is  the  pres- 
ence of  very  large  round  globular  cells.     A  striking 
thing  about   this  area   containing  the  epithelioid   or 
globular  cells  is  that  it  extends  to  the  cortex  but  not 
into  it.     It  seems  as   if  the  gray  matter  resisted  the 
penetration  of  these  large  proliferating  cells. 

Viewing  the  area  in  the  gray  matter  with  a  high 
power,  the  pia  shows  to  a  not  very  marked  degree 
round-cell  infiltration,  but  is  not  verj-  much  thickened. 
In  the  walls  of  the  blood-vessels  (which  are  not  much 
altered)  can  be  seen  round  cells,  and  surrounding 
them  these  round  cells  are  present  in  great  numbers 
(Fig.  6) ;  they,  however,  do  :iot  spread  very  far  from  the 


From  Area  marked  B  ia  fig.  i.      Showini;  dilated  vessels  and  softenins. 


vessels.  The  blood-vessels  are  enormously  distended 
with  blood.  The  hemorrhages  are  almost  exclusively 
confined  to  the  gray  matter  and  are  of  an  infiltrating  na- 
ture (Fig.  2).     Brown  and  yellow  pigment  particles  are 


July  7,  1900] 


MEDICAL   RECORD. 


seen  throughout  the  hemorrhagic  area.  The  ganglion  cell  division.  The  amitotic  cell  division  is  not  seen 
cells  are  destroyed  around  the  hemorrhages;  some,  how-  so  frequently  as  the  mitotic,  and  the  cell  body  proper 
ever,  still  showing  the  nucleus  and  nucleolus  sur-  in  which  the  amitotic  divisions  are  taking  place  is 
rounded  by  a  broken  and  torn  mass,  the  remaining  cell      small  and  irregular  in  shape,  whereas  the  cell   bodies 

in  which  the  mitotic  changes  are  going 
on  are  large,  well-developed,  and  usu- 
ally regular  in  shape  (Fig.  5). 

There  were  found  in  the  sections 
no  cells  which  Koppen  described  as 
cells  having  no  nucleolus,  but  instead 
a  mass  of  chromatic  substance  lying 
in  the  centre  of  the  cell.  The  greater 
number  of  cells  contain  one  nucleus; 
many  contain  two  (about  one-fifth),  and 
here  and  there  one  can  see  a  cell  hav- 
ing three  nuclei.  Where  this  area  of 
epithelioid-cell  proliferation  meets  the 
relatively  healthy  tissue,  we  see  these 
large  cells  massed  in  larger  numbers; 
some,  however,  can  be  seen  entering 
the  normal  tissue  to  some  distance 
like  advance  guards,  but  their  cell  body 
soon  begins  to  break  down.  Vacuoles 
appear  in  the  protoplasm  of  the  cell 
body,  and  it  finally  breaks  up  in 
pieces,  leaving  the  nucleus  apparently 
intact  and  alone,  or  still  surrounded 
by  the  remaining  pieces  of  the  cell 
body. 

The   lesions   in  the  medulla  oblon- 
gata were   confined*  to    several   small 
hemorrhages     which     must    have    oc- 
curred   very     shortly     before     death. 
There  was  here  and  there  only  a  little 
round-cell  infiltration,  but  no  pigmen- 
tary deposit.     A  large  number  of  the 
cells  of  the  different  cranial  nerve  nuclei  throughout 
the  medulla    and  the  ganglion   cells   in   the  olivary 
bodies  show   pigmentary  degeneration.     The  pigment 
had,   in   some  cells,   entirely  replaced  the  chromatic 
substance,  and  in  these  cells  the  nucleolus  had  taken 
a  position  at  the  periphery  of  the  cell-body,  in  some  in- 
stances even  partly  protruding  therefrom. 

Throughout  the  whole  spinal  cord  the  blood-vessels 
were  distended,  and  the  connective  tissue  surrounding 
the  blood-vessels  was  so  much  increased  that  in  some 
places  even  in  the  nerve  roots  the  nerve  tissue  seems 


KiG.  6, — The  same  as  t-i;,;.  5,  enlarged  1^.  showing  vessels  and  proliferatioa. 


body.  Around  the  hemorrhages  and  in  the  whole  infil- 
trated area  the  nerve  fibres  have  been  destroyed.  Here 
and  there  a  single  fibre  is  seen,  thickened,  running  a 
very  tortuous  course,  the  sheath  of  Schwann  being  torn 
and  distorted  (Weigert's  method).  The  other  area, 
which,  as  above  stated,  is  confined  to  the  white  matter 
adjoining  the  hemorrhagic  area  in  the  gray  matter, 
shows  very  interesting  and  characteristic  features. 
The  capillaries  are  all  enormously  distended,  the  ner- 
vous tissue  is  destroyed,  and  in  its  place  we  find 
placed  side  by  side  large  and  small  cells  whose  bodies 
are  sharply  outlined  by  what  seems  to  be  a  mem- 
brane. These  are  the  globular  or  "epithelioid" 
cells  (Fig.  3).  The  protoplasm  of  the  bodies  of  these 
cells  shows  the  network  structure.  The  spaces  be- 
tween the  meshes  are  filled  with  a  homogeneous 
mass  (Delafield  haematoxylon  stain,  formol).  The 
nucleus  is  sharply  set  off  from  the  protoplasm  of  the 
cell.  The  nuclei  of  these  large  proliferating  cells 
do  not  all  present  the  same  appearance  in  size  and 
structure.  One  kind  is  small,  round,  has  more  than 
one  nucleolus  well  defined,  usually  three  or  four, 
and  its  protoplasm  is  more  intensely  stained  than 
the  other  larger  kind  (Delafield  h.-ematoxylon). 
With  the  Weigert  method  this  small  round  nucleus 
stains  intensely  black.  The  other  kind  of  nucleus 
is  large,  irregular  in  shape,  usually  shows  only  one 
well-defined  nucleolus,  and  its  protoplasm  is  not  so 
intensely  stained.  There  are,  however,  small  gran- 
ules in  the  protoplasm  of  the  nucleus  besides  what 
seems  to  be  the  nucleolus,  and  these  granules  seem 
to  be  connected  by  a  fine  fibrillar  network.  This 
large  nucleus  does  not  stain  black  with  the  Wei- 
gert method,  has  rather  a  reddish  tinge,  and  its  nu- 
cleolus and  granules  can  be  clearly  distinguished  (Fig. 
4).  These  epithelioid  cells  are  massed  in  greater 
numbers  around  the  capillaries,  and  are  smaller  here, 
increasing  in  size  as  we  recede  from  them.  The  nu- 
clei show  both  direct  (amitotic)  and  indirect  (mitotic) 


-Showing  Spinal  Cord.  Upper  Dorsal  Region,  Congestion,  and  Dilated 
Vessels  (Schlapp). 


to  have  suffered  from  it  (Fig.  7).  In  the  region  of  the 
second  and  third  dorsal  roots  there  was  an  area  of  soft- 
ening about  I  cm.  in  length,  confined  almost  entirely  to 
the  gray  matter.  There  were  deposits  of  blood  pigment 
in  patches  around  this  lesion,  and  at  several   places 


MEDICAL    RECORD. 


[July  7.  1900 


very  small  hemorrhagic  areas  surrounding  small 
blood-vessels  (Fig.  8).  Scattered  throughout  the  cord 
in  this  region,  and  less  so  in  other,  regions,  there  are 
quite  a  number  of  corpora  amylacea.  A  remarkable 
feature  of  this  lesion  consists  in  the  almost  entire  ab- 
sence of  round-cell  infiltration;  so  that  the  lesion  has 
not  the  appearance  of  an  inflammatory  one,  but  looks 
more  like  the  breaking  down  of  tissue  due  to  occlusion 
of  the  blood-vessel  or  vessels  supplying  this  area. 

In  the  lumbar  cord  there  is  an  area,  however,  not  so 
large  as  the  above,  and  not  having  progressed  so  far 
in  its  disintegration.  The  tissue  around  the  blood- 
vessels is  beginning  to  break  down,  showing  in  some 
instances  spaces  filled  partly  with  disintegrated  tis- 
sue. There  were  no  secondary  systemic  degenerations 
present  in  the  white  matter,  but  around  the  large  lesion 
in  the  dorsal  region  the  sheath  of  Schwann  and  mye- 


.'. ''••I'-f.  1'!  i '  I'uifm'W'-''^ K""'"" 


■Ml 


^-^j/e^i 


1      >   '■^^-      ' 


Fig.  8.— Showing  Same  Area  as  in  Fig.  7.     Central  canal,  Clarke's  columns, 
posterior  horn,  greatly  dilated  vessels  (Schlapp). 

lin  substance  of  the  white  matter  were  destroyed  in 
patches  here  and  there. 

Remarks  (By  Dr.  Dana).  — The  foregoing  case 
is,  as  has  been  shown,  undoubtedly  an  illustration  of 
a  form  of  hemorrhagic  encephalitis.  It  difi^ers  some- 
what from  the  ordinary  (third)  type  in  that  the  patient 
was  an  old  man,  whereas  in  most  cases  this  trouble 
affects  persons  in  early  or  middle  life.  There  was  a 
distinct  history  of  alcoholism,  but  at  the  same  time 
no  evidence  that  he  belonged  to  the  worse  type  of 
such  cases.  Besides  this,  his  blood-vessels  were  not 
atheromatous,  nor  was  there  a  general  arterial  sclero- 
sis throughout  the  brain.  The  undoubted  existence 
of  malarial  infection  is  interesting  and  I  believe 
unique.  According  to  Marchiafava  and  Bignami,'  the 
parasites  of  malaria  do  not  have  a  tendency  to  attack 
the  brain  tissue  very  markedly,  while  in  pernicious 
malarial  fever  it  is  common  to  find  the  blood-vessels 
of  the  brain  filled  with  the  parasites  and  even  many 
punctate  hemorrhages.  The  authors  state  that  the 
relative  rarity  of  any  nerve  changes  led  them  to  dis- 
continue any  systematic  research.  The  parasites 
seem  to  produce  special  changes  in  the  endothelium 
of  the  capillaries,  and  in  very  bad  conditions  small 
hemorrhages  and  also  chromatolysis  and  nuclear 
changes  in  the  nerve  cells.  Although  it  seems  to  be 
pretty  well  established  that  the  malarial  germs  do  not 
have  any  special  tendency  to  produce  reactive  changes 
in  the  brain  tissue,  yet  when  infection  occurs  in  an 
aged  person  with  the  blood-vessels  already  damaged 
'  "  Twentieth  Century  Practice  of  Medicine,''  vol.  xi.\. 


by  a  previous  sunstroke  and  the  excessive  use  of 
alcohol,  a  destructive  inflammation  may  well  be 
deemed  possible.  The  symptoms  are  not  like  those  in 
the  more  classical  cases.  In  these  there  is  usually  a 
high  fever  associated  with  vertigo,  vomiting,  and 
delirium,  and  other  symptoms  of  cerebral  irritation 
followed  by  symptoms  of  cerebral  depression,  such  as 
semi-coma  or  stupor.  There  is  then  often  some  par- 
alysis such  as  occurred  in  this  disease,  and  at  times 
there  may  be  an  epileptic  convulsion.  Perhaps  on 
the  whole  the  chief  difference  between  my  own  and 
the  ordinary  cases  is  the  early  occurrence  of  the 
apoplexy. 

Hemorrhagic  encephalitis  has  to  be  distinguished 
from  acute  meningitis,  and  from  an  ordinary  cerebral 
hemorrhage.  In  encephalitis  there  are  not  the  stiff 
neck,  the  small  pupils,  or  the  general  rigidity  and 
twitching  of  meningitis.  On  the  other  hand,  there  do 
occur  occasional  convulsions,  and  sooner  or  later  some 
form  of  paralysis.  Usually  the  disease  can  be  distin- 
guished from  a  hemorrhage  or  thrombosis  by  the  signs 
of  severe  cerebral  irritation  lasting  for  from  one  to  four 
or  five  days  before  any  paralysis  occurs.  The  fact  that 
the  patient  has  had  an  attack  of  grippe,  or  some  severe 
infection,  helps  the  diagnosis,  as  does  also  the  pres- 
ence of  some  alcoholic  history,  although  alcoholism  is 
not  usually  present  in  the  grippe  cases. 

It  is  possible  that  examination  of  the  blood  and  the 
absence  of  leucocytosis  may  assist  in  excluding  the 
suppurative  process.  Optic  neuritis  may  occur  in  this 
trouble,  but  certainly  very  rarely;  much  less  often  than 
in  suppurative  encephalitis  or  any  suppurative  menin- 
gitis. There  is  much  practical  importance  in  being 
able  to  recognize  encephalitis,  because  the  non-sup- 
purative  forms  are  sometimes  curable,  especially  if  the 
paralysis  is  not  extensive.  There  still  remains  a 
good  deal  to  be  done,  however,  in  order  to  enable  one 
to  make  the  diagnosis  with  certainty. 


PRELIMINARY  REPORT  ON  THE  PRESENCE 
AND  NATURE  OF  PARASITIC  AMCEB^ 
(CANCRIAMCEBA  MACROGLOSSA)  IN  THE 
EPITHELIAL   CARCINOMATA. 

By   GUSTAV   EISEN.    Ph.D., 

CL'RATOR     CALIFORNIA     ACADEMY    OF    SCIENCES,     BIOLOGICAL     DEPARTMENT, 
SAN    FRANCISCO,    CAL. 

The  following  account  is  intended  to  be  a  prelimi- 
nary report  upon  parasitic  amcebEe  found  in  epithelial 
carcinomata,  which  are  undoubtedly  the  cause  of  the 
peculiar  structure  of  these  tumors  and  probably  of  the 
tumors  themselves.  The  object  of  this  paper  is  to  en- 
gage the  attention  of  other  workers  in  this  field  of  re- 
search in  order  that  they  may  with  the  same  methods, 
or  with  better  ones,  corroborate  or  refute  the  conclu- 
sions at  which  I  have  arrived.  I  have  been  engaged 
for  several  years  in  the  study  of  the  structure  of  carci- 
nomata and  their  so-called  cell  degeneration,  but  it  is 
only  within  the  last  few  weeks  that  I  have  succeeded 
in  demonstrating  satisfactorily,  to  my  own  mind,  the 
nature  of  these  cell  enclosures  or  degenerations,  so 
called,  and  in  proving  that  parasitic  amcebae  are  cer- 
tainly the  cause  of  the  carcinomatous  structure  and 
probably  also  the  cause  of  the  tumor  itself.  My  in- 
vestigations are  not  yet  so  far  advanced  that  a  final 
report  is  ready,  including  an  account  of  the  reproduc- 
tion of  the  parasites  and  the  effect  of  injections  of 
their  cultures  into  animal  tissues.  These  researches, 
I  hope,  will  be  finished  during  the  present  jear.  In 
this  report  I  merely  wish  to  set  forth  the  main  points 
in  my  conclusions,  leaving  a  full  review  of  the  subject 
to  some  other  time. 

Cause  of  Previous   Failures.— The  failure  of  my 


July  7,  1900] 


MEDICAL    RECORD. 


early  investigations  as  well  as  those  of  many  other  in- 
vestigators is,  I  think,  entirely  due  to  the  methods  em- 
ployed in  fixing  the  tissue.  No  success  was  had  by 
the  old  methods  in  so  differentiating  tlie  aniotba  that 
it  could  with  certainty  be  decided  if  the  darker  stain- 
ing centre  constituted  a  nucleus  or  not.  On  the  con- 
trary it  suggested  itself  to  me  that  this  darker  centre 
could  best  be  compared  with  tiiat  part  of  the  cytoplasm 
known  as  the  sphere,  and  I  based  on  this  supposition 
a  theory  which,  however,  my  new  researches  prove  to 
be  erroneous,  as  the  nucleus  of  the  amceba  can  be 
most  beautifully  differentiated  by  the  new  method. 

Another  cause  of  failure  refers  to  the  form  of  the 
amceba;,  which  by  the  employment  of  the  old  methods 
could  not  be  ascertained.  As  will  be  stated  more  fully 
in  the  next  paragraph,  the  cancriamcebse  are  readily 
contracted,  and  when  in  this  state  cannot  be  properly 
studied.  All  effort  must  thus  be  directed  toward  the 
instantaneous  fixing  of  the  tissue  and  with  it  of  the 
parasitic  amoebae,  which  I  take  to  be  the  prime  cause 
of  epithelial  carcinomata  (and  perhaps  also  of  other 
forms  of  carcinomata),  and  for  which  I  propose  the 
name  of  Cancriamoeba  macroglossa,  on  account  of  the 
most  characteristic  feature  — the  long  snouts — of  the 
animal.  There  is  little  doubt  that  other  methods 
will  be  found  which  will  differentiate  these  amcebas, 
but  the  one  directly  to  be  described  accomplishes  this 
in  a  manner  much  superior  to  any  others  tried  by  me. 

It  is  not  my  intention  to  claim  that  the  cancriamoeba; 
here  to  be  described,  have  not  previously  been  seen. 
On  the  contrary,  I  am  satisfied  that  the  organisms 
found,  for  instance,  by  Plimmer  are  identical,  not  with 
the  fully  developed  cancriamoeba,  but  with  its  spores. 
The  fully  developed  cancriamoebffi,  when  badly  fixed 
and  contracted,  have  repeatedly  been  taken  for  cell 
degenerations,  cornifications,  etc.  The  methods  ad- 
vocated in  this  paper  are  capable  of  fixing  these  bodies 
instantaneously,  and  in  such  a  manner  that  no  doubt 
can  remain  as  to  their  true  nature. 

Method  for  Differentiating  the  AmcEba. — This 
method  is  based  upon  the  necessity  of  fixing  the  amctba 
while  it  is  yet  alive.  I  found  that  in  all  carcinoma 
tissue  which  had  been  allowed  to  lie  for  some  little 
time  at  common  room  temperature  the  amoebae  could 
not  be  properly  recognized  as  such.  Instead  of  char- 
acteristic amcebai  only  contracted  globules  were  found, 
and  these  were  so  distorted  that  no  trace  remained  of 
their  otherwise  most  characteristic  form.  Neither 
was  their  interior  structure  (that  of  the  cytoplasn.) 
brought  out,  nor  could  their  nucleus  be  differentiated 
by  staining.  In  such  tissue,  however,  all  other  cells, 
v.hen  otherwise  properly  treated,  were  in  perfect  pres- 
ervation; and  I  concluded  that  the  partial  destruction 
of  the  amcebas  did  not  result  merely  from  ordinary  de- 
composition caused  by  the  coagulation  of  the  blood 
and  by  other  chemical  changes.  It  then  suggested 
itself  to  me  that  the  contraction  of  the  amcebae  was  due 
to  cold.  As  long  as  the  amoebae  were  retained  in  the 
warm  tissue  their  characteristic  amoeboid  forms  re- 
mained distinct,  while  when  exposed  to  a  lower  tem- 
perature outside  the  body  of  the  host  a  contraction 
would  take  place  which  would  so  distort  the  form  and 
structure  of  the  amoebae  that  they  could  no  more  be 
recognized  as  such.  Acting  upon  this  suggestion  I 
determined  to  fix  the  amoebae,  if  such  they  were,  before 
the  tissue  had  time  to  cool  off.  Experience  further 
showed  that  another  improvement  consisted  in  warm- 
ing the  fixative  to  as  near  blood  temperature  as  pos- 
sible. This  can  best  be  done  in  a  thermostat,  but 
when  none  is  handy  it  may  be  accomplished  by  sim- 
ply warming  the  fixative  in  an  inner  pocket  until  the 
very  moment  when  the  tissue  is  dropped  in. 

Fixation The  following  fixative  has  given  most 

excellent  results:  Bichromate  of  potassium,  3  parts; 
glacial  acetic  acid,  5  parts;   water,  100  parts.     Use  at 


least  twenty  times  as  much  fixative  as  tissue,  and 
change  the  fixative  if  there  is  any  sign  of  cloudiness. 
The  ?iwiius  (Operandi  of  fixation  is  then  as  follows:  Be- 
fore the  carcinoma  is  operated  on,  small  pieces  are 
cut  out,  none  to  exceed  one-half  cubic  inch,  smaller 
slices,  say  from  one-fourth  to  one-eighth  inch  in  the 
narrower  diameter,  being  preferable.  These  pieces 
while  yet  warm,  and  without  first  having  been  placed 
on  the  table,  are  dropped  in  the  fixative,  which  until 
that  moment  must  have  been  kept  at  a  temperature  as 
near  to  that  of  the  blood  as  possible.  It  is  better  to 
keep  up  the  temperature  of  the  fixative  for  some  little 
time  until  the  tissue  will  have  become  penetrated  and 
fixed.  This  is,  however,  not  absolutely  necessary,  as 
I  have  had  most  excellent  results  by  simply  keeping 
the  small  fixative  bottle  in  my  pocket  for  half  an  hour 
or  less.  After  twelve  hours'  time,  or  longer,  the  tis- 
sue is  taken  out  and  washed  in  running  water  until  all 
trace  of  the  color 
of  the  fixative  is 
gone.  This 
takes  from  ten  to 
twelve  hours 
more. 

The  after-treat- 
ment is  the  one 
generally  adopt- 
ed for  paraffin 
work.  The  tis- 
sue is  passed 
through  succes- 
sive alcohols  of 
thirty,  fifty,  sev- 
enty-five, ninety- 
five,  and  one  hun- 
dred per  cent. 
In  the  latter  it 
must  remain  over 
night,  a  change 
of  alcohol  being 
made  once  o  r 
twice.  From  the 
absolute  alcohol 
the  tissue  is  car- 
ried through  two 
changes  of  ber- 
gamot     oil     and 

two  changes  of  xylol,  and  again  into  bergamot  oil. 
This  last  change  is  made  in  order  not  to  cause  a  too 
violent  evaporation  of  the  xylol  when  placed  in  paraffin. 
The  tissue  must  on  no  account  be  placed  in  the  paraf- 
fin until  it  is  perfectly  cleared.  Paraffin  melting  at  54° 
C.  is  preferable,  and  two  changes  are  sufficient.  The 
preparation  of  the  tissue  should  not  require  more  than 
three  days,  and  even  this  time  may  be  considerably 
shortened  by  frequent  changes  of  alcohols  and  clearing 
oils.  Sections  should  not  be  cut  thicker  than  4  //, 
otherwise  the  amcebce  will  not  be  properly  differen- 
tiated by  the  staining-method.  The  sections  are  fixed 
on  the  slides  by  the  alcohol  method."  After  drying 
for  several  hours  the  paraffin  is  dissolved  by  xylol,  and 
the  xylol  is  eliminated  by  alcohol. 

Staining. — From  the  alcohol  baths  the  slides  are 
immersed  in  a  one-per-cent.  solution  of  Griibler's 
eosin,  soluble  in  alcohol,  and  kept  there  over  night  or 
for  less  time  if  necessary.  The  slides  are  now  taken 
out  and  placed  for  some  minutes  in  water  until  all  the 
alcohol  is  extracted.  The  slide  must  be  washed  clear 
of  any  superfluous  stain.  The  next  step  is  to  drop  on 
the  slide  a  one-per-cent.  solution  of  methylene  blue 
"o"  in  water,  to  which  ten  per  cent,  of  alcohol  has 
been  added.  The  action  of  the  latter  stain  cannot  be 
predetermined,  as  no  two  stains  are  alike.  My  own 
solution  stains  sections  4  ;i.  thick  in  about  five  seconds, 
'  See  Zeitsch.  f.  uiss.  Mik.,  Bd.  ,xiv.,  1897.  p.  igS- 


Fig.  1. — A  Cancriamoeba  lying  in  a  VacuOie,  the 
latter  being  a  remnant  of  a  (iestroycd  cell.  In 
the  lower  apex  of  the  amreba  is  seen  a  small 
vacuole.  This  part  of  the  body  of  the  can- 
criamceba  is  slightly  drawn  out,  forming  a 
tongue-like  projection.  The  darker  central 
part  is  the  nucleus.  Above  in  the  same  cell  is 
seen  a  part  of  another  cancriamoeba,  the  main 
body  of  which  is  found  in  another  section. 


8 


MEDICAL   RECORD. 


[July  7,  1900 


but  as  much  as  five  minutes  may  be  required.  After 
that  length  of  lime  hold  the  slide  slanting  and  with  a 
dropper  cause  a  small  stream  of  absolute  alcohol  to 
flow  over  the  slide,  being  careful  to  place  the  mouth 
of  the  dropper  close  to  the  higher  edge  of  the  slide. 
In  two  or  three  seconds  the  tissue  is  sufficiently  washed 
free  of  superfluous  blue  stain,  and  the  slide  is  then 
dropped  into  a  jar  with  bergamot  oil,  or  simply  flushed 
with  pure  bergamot  oil,  which  must  not  contain  any 
trace  of  alcohol.  The  next  step  is  immersion  in  xylol 
and  mounting  in  gum-thus  in  xylol  (or  in  balsam  in 
xylol  if  thus  cannot  be  had).  If  the  operation  has 
been  successful  the  tissue  will  be  stained  pale  red  with 
bluish  nuclei,  while  the  amctbaj  are  intensely  red  with 
deep  blue  nuclei.  If  the  first  staining  does  not  differ- 
entiate successfully,  the  tis- 
sue may  be  re-stained  one 
or  more  times  by  simply  im- 
mersing the  slides  in  the 
eosin  bath,  thus  beginning 
the  process  anew.  It  re- 
quires some  practice  to  dif- 
ferentiate the  amcEba;  prop- 
erly in  the  most  eiYective 
manner,  but  the  above 
method  will  not  offer  any 
great  difficulties  even  to  the 
beginner.  It  is,  however, 
entirely  useless  to  endeavor 
to  dilYerentiate  the  amoeba; 
in  sections  thicker  than  4 
or  5  p.. 

The  nature  and  structure 
of  the  cancriamoeba;  will 
now  be  considered. 

Definition.  — Cancriamce- 
ba  macroglossa,  gen.  et  sp. 
nov. :  Parasitic  amoeba;  dia- 
meter of  adult  specimens 
from  7-30  //.;  body  sac-like, 
pear-shaped,  capable  of  pro- 
jecting pseudopodia.  The 
cytoplasm  is  frequently  dif- 
ferentiated into  a  cortical 
layer  and  an  inner  layer. 
The  cytoplasm  is  of  a  foamy 
structure,  frequently  inter- 
spersed with  granules  of 
difierc.it  sizes.  The  nu- 
cleus is  large,  apparently 
homogeneous,  at  times  fur- 
nished with  one  to  three  nu- 
cleoli.  Propagation  by 
spores  is  preceded  by  a  fragmentation  of  the  nucleus. 
Cytophague.  Found  in  all  tissues  of  epithelial  carci- 
nomata  examined  by  the  author. 

In  properly  prepared  sections  of  epithelial  carcino- 
mata  the  cancrianicebae  are  found  in  enormous  num- 
bers all  through  the  tissue,  but  especially  in  cell-nests 
or  cell-plugs.  The  cancriamoebaj  are  recognized  by 
their  shape,  which  is  that  of  typical  amoebfe,  by  the 
deep  red  color  of  their  cell  body,  and  by  the  deep  blue 
of  their  nucleus.  Many  of  the  larger  as  well  as  the 
smaller  specimens  lie  free  in  a  vacuole.  Sometimes 
there  is  only  one  specimen  in  the  vacuole,  again  there 
are  several  or  many.  The  vacuole  is  caused  by  the 
destruction  of  one  or  more  epithelial  cells,  which  have 
been  eaten  out  by  the  cancriamabae. 

The  most  characteristic  part  of  the  cancriamoeba  is 
the  projectile  snouts.  (Generally  there  is  but  one  snout 
projected,  but  as  many  as  three  have  been  observed 
by  the  author  in  large  specimens.  These  pseudopodia, 
which  characterize  all  amaba;,  are  also  the  most  char- 
acteristic features  of  the  cancriamoeba;.  Not  only  is 
the  pseudopodium   used  as  a  locomotive  organ,  but 


Fig.  2. — A  Cancriamoeba  Fully 
Extended,  entering  an  epithe- 
lial cell,  the  nucleus  of  which 
is  not  visible  in  the  section. 
The  apex  of  the  cancriamceba 
is  slightly  flared  and  crenulated. 
The  larger  part  of  the  body  as 
well  as  the  nucleus  of  the  can- 
criamtcba  lies  in  the  vacuole, 
the  latter  being  the  remnant  of 
an  eaten-out  epithelial  cell. 
The  nucleus  contains  three 
small  nucleoli. 


also  as  a  suctorial  one.  When  the  cancriamaba  has 
eaten  out  an  epithelial  cell  it  projects  a  certain  part 
of  the  body,  in  the  shape  of  a  foot  or  tongue,  into  an 
adjacent  cell,  which  is  in  time  fully  destroyed.  Gen- 
erally only  one  epithelial  cell  is  attacked  at  a  time,  as 
is  seen  in  Figs.  2-5,  but  in  many  instances  I  observed 
an  amceba  which  had  projected  pseudopodia  into  two 
or  three  different  cells  at  one  and  the  same  time  (Fig. 
6).  The  structure  of  the  pseudopodium  is  frequently 
more  open  than  the  rest  of  the  body,  and  at  its  apex 
a  small  pore  is  sometimes  seen.  In  some  cancri- 
amcebas  a  distinct  vacuole  is  seen  to  exist.  It  can, 
however,  not  be  demonstrated  in  all  specimens. 

A  nucleus  is  always  present.  It  stains  intensely 
blue.  It  is  generally  of  a  polymorphous  outline,  and 
in  many  specimens  in  a  stage  of  fragmentation.  This 
fragmentation  is  piobably  the  first  stage  in  the  forma- 
tion of  spores.  In  spermatobium,  a  parasitic  protozoon 
in  the  testes  of  certain  oligocha;ta,  the  formation  of 
spores  has  been  studied  more  in  detail.  Here  the  nu- 
cleus sends  out  ramifications  which  gradually  separate 
from  each  other  and  then  contract,  forming  small  iso- 
lated centres  of  nuclear  substances  all  through  the 
cytoplasm.  Each  such  nuclear  centre  becomes  the 
central  part  of  a  spore.  There  is  every  reason  to  be- 
lieve that  the  same  process  of  sporulation  takes  place 
in  the  cancriamoeba,  and  that  the  fragmentation  of  its 
nucleus  is  actually  the  beginning  of  sporulation. 

The  size  of  the  cancriamoeba  varies  considerably. 
Some  few  are  a  little  larger  than  a  red  blood  corpuscle, 
while  others  reach  a  diameter  of  30  ,a  or  even  over. 
The  form  of  the  body  is  sometimes  strongly  elon- 
gated, undoubtedly  due  to  the  narrow  place  in  which 
the  cancriamoeba  is  confined.  At  other  times  the 
elongated  form  is  the  effect  of  the  voluntary  effort  of 
the  cancriamoeba  to  project  itself  from  one  cell  to  the 
other.  That  the  cancriamoebas  actually  consume 
the  epithelial  cells  can  be  proven  not  only  by  the 
pseudopodia  of  the  parasites  penetrating  into  the  ceils, 
but  more  convincingly,  perhaps,  by  observing  the  act- 
ual consumption  of  the  cellular  tissue.  In  many  in- 
stances we  may  observe  how  the  granules  of  the  cell 
tissue  are  separating  from  the  cell,  and  we  can  follow 
a  stream  of  these  granules  from  the  cell  that  is  being 
eaten  into  the  body  of  the  cancriamceba.  These  cell 
granules,  after  having  been  taken  into  the  body  of  the 
amceba,  stain  at  first  just  as  the  granules  of  the  cells, 
that  is,  a  violet-red,  but  as  the  granules  are  found  deeper 
and  deeper  in  the  amceba  they  are  seen  to  stain  deeper 
red.  There  is  thus  every  reason  to  believe  that  the 
deep-staining  granules  of  the  amoebae  constitute  the 
cell  substance  of  the  epithelial  cells  which  are  con- 
sumed by  the  amceb.Te  and  gradually  have  been  digested 
and  differentiated  in  the  body  of  the  cancriamoeba;. 

Propagation. — The  cancriamoebas  propagate  both  by 
spores  and  by  amitotic  division.  In  my  preparations 
the  amitotic  division  is  the  most  frequent.  The 
amoeba  contracts  at  the  centre,  each  half  possessing  a 
part  of  the  original  nucleus.  The  nuclear  parts  are 
often  of  unequal  size,  as  far  as  can  be  judged  from 
sections,  though  it  is  possible  that  part  of  the  nucleus 
may  have  been  cut  away.  Each  half,  even  before  full 
separation,  is  often  seen  to  send  out  pseudopodia  into 
new  cells.  The  propagation  by  sporulation  has  been 
mentioned  in  the  definition,  and  I  have  no  further  de- 
tails to  add  to  those  already  given. 

The  Structure  of  the  Epithelial  Carcinomata — 
It  may  be  stated  at  once  that  the  cause  of  the  structure 
is,  in  my  opinion,  due  to  an  effort  of  the  epithelial 
cells  to  surround  the  cancriania'ba;  and,  by  encysting 
them,  to  protect  the  tissue  of  the  human  body  from 
being  further  invaded  by  the  parasites  and  destroyed 
by  them.  The  only  cells  which  can  do  this  effectively 
are  the  epithelial  cells,  which  on  account  of  their  pe- 
culiar toughness  and  size   are  especially   adapted  to 


July  7,  1900] 


MEDICAL    RECORD. 


perform  this  work.  As  soon  as  a  cancriamctba  makes 
its  entrance  among  the  cells  of  the  body,  the  epithe- 
lial cells  in  the  vicinity  increase  with  great  rapidity 
and  by  growing  inwardly  try  to  enclose  the  cancri- 
amcebae,  or,  so  to  say,  to  fence  them  in.  Hence  the 
large  masses  of  epithelial  cells  which  like  large  waves 
approach  inwardly  from  the  original  epithelial  layers 
of  the  body.  The  formation  of  the  cancer  cell  nest  or 
cancer  plug  is  a  secondary  consequence  of  this  effort 
of  the  epithelial  cells.  In  my  preparations  this  forma- 
tion of  cancer  plugs  can  be  readily  studied,  as  they  are 
present  in  all  stages  of  development.  Roughly  stated, 
the  formation  of  the  nest  is  due  to  several  processes 
about  as  follows:  The  centre  of  the  nest  always  con- 
tains one  or  more  cancriamoebie.  'J'his  primary  can- 
criamoeba  increases  in  size  or  multiplies  by  division 
and  thus  presses  on  the  epithelial  cells  and  pushes 
them  aside.  In  this  manner  the  epithelial  cells  near 
the  cancrianittba;  become  tlatteped  out  and  lunate. 
Those  epithelial  cells  nearest  the  cancriamoeba;  become 
the  most  flattened,  those  farther  away  less  so.  Those 
epithelial  cells  situated  nearest  tiie  cancriamoebce,  and 
which  are  not  directly  eaten  by  them  and  thus  de- 
stroyed at  once,  evidently  succumb  either  to  the  pos- 
sible toxic  properties  of  the  cancriamoeboe,  or  to  the 
pressure  e.xerted  on  them.  It  is  also  probable  that 
these  epithelial  cells  on  their  own  account  undergo  a 
certain  cornification  in  order  the  more  effectively  to 
encyst  the  cancriamoebc'E  and  separate  them  from  the 
surrounding  tissue.  This  cornification  seems  in  some 
instances  to  extend  also  to  the  cancriama-baj  them- 
selves, the  result  perhaps  of  some  infiltration  of  a 
cornifying  substance  or  exudation  from  the  epithelial 
cells  themselves.  In  some  instances  it  is  demonstrable 
that  the  epithelial  cells  are  eaten  up  by  the  cancri- 
amoebae,  the  remnants  of  the  former  being  scattered 
about.  The  true  structure  of  a  cancer  cell  nest  is  thus 
as  follows:  In  the  centre  of  the  nest  there  is  one  or 
many  cancrianicebE  feeding  on  several  epithelial  cells 
of  general  form.  Surrounding  this  group  of  cancri- 
amoebjE  and  epithelial  cells  are  seen  one  or  more  lay- 
ers of  lunate  and  strongly  flattened  epithelial  cells. 
These  latter  cells  often  separate  from  the  rest  of  the 
epithelial  cells,  forming  a  thin-walled  capsule  more  or 


is  thus  a  constant  struggle  for  supremacy  going  on  be- 
tween the  epithelial  cells  and  the  cancriamcebae. 
Often  the  amoebae  are  seen  to  have  succumbed  and  are 


Fir..  3.— A  Cancriamceba  projecting  its  tongue  like  apex  from  the  vacuole  in 
which  it  is  situated,  into  an  epithelial  cell  (£"/*.  .?).  1  his  latter  contains  a 
nucleus.  Ihe  nucleus  of  the  cancriamceba  is  polymorphous.  The  vacuole 
{Ep.  tt)  is  the  remnant  of  an  epithelial  cell  which  has  been  eaten  out  by 
the  cancriamceba. 

less  firmly  surrounding  the  cancriamcebae.  In  many 
instances  the  cancriamceba;  are  seen  to  be  penetrating 
this  epithelial  capsule  in  their  effort  to  get  away  in 
order  to  find  new  epithelial  cells  to  feed  on.     There 


Fig.  a.  The  Centre  of  the  Cancer  Cell  Nest.  In  the  central  vacuole,  n-hich 
IS  tne  remnant  of  an  eaten  out  epithelial  cell,  is  seen  a  cancriamceba  in 
the  act  of  prnrtratinf^  into  a  healthy  epithelial  cell  furnished  with  a  nu- 
cleus (A"/.  Si.  The  nucleus  of  the  cancriama-ba  is  sliRhtly  polymorphous. 
In  the  rpithrlial  cells  numbered  /.  2.  5,  parts  of  nuclei  are  seen  ;  in  the  other 
epithelial  cells  except  J*  the  nuclei  are  seen  in  succeeding  sections.  Between 
the  cancrianiteba  and  epithelial  cells  6,  J,  /.  and  z  are  seen  dark  and  irregu- 
lar bands,  probably  remnants  of  epithelial  cells  destroyed  by  the  amceba. 

found  firmly  enclosed  by  the  cell  nests  and  apparently 
in  a  dying  condition,  or  fully  dead  and  solidified. 
But  in  the  majority  of  cell  nests  the  epithelial  cells 
seem  to  be  the  losing  ones,  the  cancriamcebae  escaping 
to  other  parts.  The  vacuole  surrounding  the  parasites 
is  the  place  formerly  occupied  by  epithelial  cells  eaten 
by  the  cancriamoebje.  In  innumerable  places  the  can- 
criamoebas  have  been  fixed  in  the  very  act  of  penetrat- 
ing into  the  epithelial  cells,  and  it  is  this  view  of  them 
which  is  to  me  the  most  convincing  one  as  regards  the 
true  nature  of  the  parasites.  Their  identity  with 
amcebffi  is  unmistakable.  Not  only  is  the  form  of  the 
body  and  the  formation  of  the  spores  characteristic  of 
amcebas,  but  the  presence  of  pseudopodia  excludes  the 
possibility  that  we  here  have  to  deal  with  blastomy- 
cetes  or  other  fungi. 

The  leucocytes  of  the  blood  seem  not  to  be  attracted 
by  the  cancriamoebiE,  at  least  I  have  nowhere  seen  any 
indication  of  a  sfrtiggle  between  them  and  the  parasites. 
In  some  instances  cancriamceba;  may  be  seen  which 
have  actually  swallowed  erythrocytes  and  parts  of 
erythrocytes,  but  nowhere  have  I  seen  remnants  of  leu- 
cocytes in  the  cancriamceba;,  or  'vice  versa.  This  is 
probably  due  to  the  manner  of  feeding  of  the  parasites. 
They  appear  to  consume  only  small  particles  of  cyto- 
plasm at  one  time,  absorbing  them  by  the  aid  of  the 
apex  of  their  snout.  The  latter  is  nearly  always  flared 
at  the  point  intruded  into  the  cell,  the  very  apex  form- 
ing an  absorption  surface,  strongly  indented  or  cre- 
nated  in  order  to  present  a  large  surface  to  the  cyto- 
plasm cf  the  cell.  A  most  interesting  fact  noticed  is 
that  the  cancriamceba:  are  frequently  found  with  one 
part  of  the  body  in  one  cell  while  the  other  part  is  sit- 
uated in  another  cell.  Or  different  parts  of  the  same 
individual  cancriamoeba  may  be  projected  out  into 
several  different  cells  while  the  main  part  of  the  body 
remains  in  its  vacuole.  This  demonstrates  to  my 
mind  conclusively  that  we  have  before  us  an  extra-cel- 
lular organism  and  not  any  degenerations  or  chemical 
transformations.  Such  degenerations  could  not  pos- 
sibly assiune  the  function  of  actual  protozoa,  that  is, 


lO 


MEDICAL    RECORD. 


[July  7,  1900 


they  could  -not  project  parts  of  their  own  mass  into 
adjacent  cells.  It  is  also  of  importance  to  note  that 
in  all  such  individual?  occupied  in  phagocytosis  of 
epithelial  cells,  the  nucleus  is  generally  polymorphous, 
a  form  especially  effective  in  promoting  and  facilitat- 
ing an  exchange  of  metabolic  products  between  nucleus 
and  cytoplasm.  In  cancriamoeba;  which  are  not  thus 
engaged  in  phagocytosis  (Fig.  i)  the  nucleus  is  gen- 
erally more  compact,  barely  showing  an  indented  out- 
line. 

In  tissues  treated  by  the  methods  suggested  in  this 
paper  the  cancriamceba;  appear  without  any  perceptible 
distortion  and  contraction,  and  any  one  acquainted 
with  these  animalcules  cannot  fail  to  recognize  at  once 
their  true  nature.  They  do  not  appear  as  mere  con- 
tracted lumps  of  protoplasm,  but  may  be  seen  as  if  in 
the  very  act  of  crawling  about  with  extended  pseudo- 
podia.  It  is  fully  evident  that  the  vacuole  which 
nearly  always  surrounds  the  cancriamctba  is  entirely 
due  to  the  destruction  of  one  or  more  epithelial  cells. 
The  remnants  of  the  cytoplasm  of  these  cells  are  often 
found  in  the  vacuole,  but  what  is  yet  more  convincing 
of  the  nature  of  the  vacuole  is  that  the  shrunken  and 
partly  destroyed  nuclei  of  these  cells  are  now  and 
then  seen  in  the  vacuole.  Their  presence  could  not 
be  explained  except  by  the  supposition  that  they  are 
the  actual  remains  of  cells  which  have  been  destroyed 
by  a  cancriamceba. 

As  regards  the  number  of  cancriamoebag  in  the  tis- 
sue nothing  definite  can  be  stated.     They  occur  there 


Fig.  5.— The  Centre  of  the  Cancer  Cell  Nest.  /I  ^  is  a  cancriamocba  in  the  act  of  pen- 
etrating from  the  vacuole  to  another  epithelial  cell  (Ei.  j)  in  which  is  seen  the  partly 
destroyed  nucleus.  Adjoining  this  cancriamoiba  arc  three  others  in  various  stages  of 
sporulation.  \n  A  2  the  nucleus  had  undergone  a  fragmentation  but  the  spores  are  not 
yet  sumcjently  formed  to  be  recognized  as  such.  In  A  /,  however,  the  new  spores  are 
quite  distinct,  having  formed  around  a  fragment  of  the  nucleus.  W  J  is  a  cancriamtcba 
with  polymorphous  nucleus  and  a  v.icuole.  ^  J  is  part  of  a  cancriamceba,  the  other  part 
of  which  is  seen  in  the  following  section.  This  group  of  amoeba-infested  epithelial  cells 
IS  surrounded  by  many  other  epithelial  cells  of  concave  form,  and  which  have  not  yet 
been  eaten  out  by  the  cancriamrcba.  The  large  central  vacuole  (/?/.  if)  is  the  result 
of  the  destruction  of  several  epithelial  cells,  which  have  been  eaten  by  the  amceba:. 


larger  nests  they  may  be  counted  by  the  hundreds. 
The  centrally  situated  cancriamoebte  are  generally 
thicker  and  less  elongated,  w-hile  those  situated  nearer 
the  margin  of  the  nest  are  thin  and  long,  often  bend- 
ing in  a  semicircle  around  those  situated  nearer  the 
centre  of  the  nest.  This  form  is  due,  I  think,  to  the 
inability  of  the  cancriamcebae  to  develop  in  any  other 
direction,  the  epithelial  cells  on  the  outside  of  the  nest 
only  slowly  yielding  to  the  constantly  increasing  can- 
criamceba;. When  such  nests  finally  cause  the  sur- 
rounding epithelial  tissue  to  yield,  the  cancriamcebae 
together  with  the  remnants  of  epithelial  cells,  more  or 
less  fully  consumed,  are  set  free,  and  it  may  then  be 
seen  that  in  such  places  the  cancriamceba;  are  more  or 
less  rapidly  regaining  their  natural  form. 

A  distinction  can  always,  with  some  little  practice, 
be  made  between  cancriamcebae  and  leucocytes.  The 
body  of  the  former  stains  much  more  deeply  with  the 
eosin  than  that  of  the  leucocytes;  besides,  the  leuco- 
cytes are  nearly  always  smaller,  the  cancriamceba;  being 
generally  many  times  larger  than  the  leucocytes.  The 
nuclei  of  the  cancriamcebae  are  also  quite  distinct  from 
those  of  the  leucocytes,  being  more  solid  and  homo- 
geneous than  those  of  the  latter.  Taking  it  all  in  all, 
by  a  little  practice  the  cancriamceba  can  readily  be 
distinguished  from  all  other  cells,  provided  the  tissue 
has  been  successfully  fixed  and  stained. 

Solidity  of  the  Cancer-Plugs. — The  increased  hard- 
ness of  tissue  containing  cancer-plugs  is  well  known  to 
every  student  of  these  structures.  This  hardening  of 
the  plug  is  caused  by  two  things.  As  the 
epithelial  cells  are  being  eaten  out  the  cell 
walls  remain  and  form  more  solid  masses 
nearest  the  amoebae,  and  as  the  cell  walls  are 
more  solid  than  the  cytoplasm  of  the  cell  it 
explains  the  increased  toughness  of  the  plugs. 
But  besides  this  concentration  of  cell  walls 
there  appears  also  to  take  place  a  chitiniza- 
tion  of  the  cells  nearest  to  the  amoeba;,  and 
thischitinization  seems  also  to  extend  to  some 
of  the  amcebae,  which  in  this  way  are  effect- 
ually destroyed. 

Are  the  Cancriamcebce  Accidental  Inhabi- 
tants of  Carcinomata,  or  Are  They  the 
Cause  of  the  Structures  Characterizing  Car- 
cinomata ? — This  question  has  partially  been 
treated  in  the  preceding  paragraphs.  \\'ith- 
out  producing  carcinomata  by  the  injection  of 
cultures  of  cancriamctba;  this  question  cannot 
be  fully  answered.  At  present  we  must  con- 
fine the  question  to  whether  the  cancrianicebje 
are  the  cause  of  the  peculiar  structures  known 
as  cell  nests  or  cell  plugs,  or  whether  they 
simply  inhabit  them.  This  point,  I  think,  can 
be  most  readily  answered.  In  all  the  carci- 
nomata examined  by  me  two  facts  are  evident 
—  first,  no  cell  nests  are  found  which  do  not 
possess  one  or  more  cancriamceba;  in  their 
core;  second,  while  many  cancriamceba;  are 
found  free  among  the  epithelial  cells,  many 
are  also  seen  to  be  surrounded  by  a  few  cells 
of  a  primitive  cell  nest.  By  studying  a  large 
number  of  such  cell  nests  a  perfect  series  may 
be  had  from  the  most  primitive  one,  consist- 
ing of  only  a  few  epitlielial  cells  enclosing  a 
centrally  located  cancriamceba,  to  fully  devel- 
oped cell  nests  consisting  of  numerous,  con- 
centrically arranged  cells  enclosing  numerous 
cancriamoebre.  There  can  be  thus  no  reason- 
able doubt  that  the  cancriamceba  actually 
cause  the   formation    of   the  cell  nests.      As 


these  cell  nests  are  the  characteristic  structure 
in  enormous  numbers  all  through  the  tissue,  either  of  the  epithelial  carcinomata  we  may,  I  think,  expect 
singly  or  in  nests.  In  the  centre  of  some  nests  there  that  it  will  be  proven  that  the  cancriamceba;  are  also 
will  be  seen  only  a  few  cancriamcebae,  but  in  other  and      the  cause  of  the  carcinoma  itself. 


July  7,  1900] 


MEDICAL    RECORD. 


It 


I  may  here  add  that  so  little  time  has  passed  since 
I  found  the  method  of  differentiating  the  cancriamoeba' 
that  1  have  had  no  time  to  examine  many  carcinomata 
pertaining  to  the  type  in  which  cell  nests  are 
not  found,  and  I  am  consequently  not  able  to 
state  to  what  extent  cancriamoebas  are  found  in 
such  cancers,  liut  I  have  during  the  last  few 
days  examined  two  cancers  of  this  type  prepared 
by  the  new  method,  and  both  these  cancers  were 
found  swarming  with  the  same  cancriamabae  as 
in  the  other  class.  The  want  of  cell  nests  is  prob- 
ably due  to  some  peculiar  condition  of  the  epi- 
thelial cells,  but  investigations  have  not  yet 
proceeded  far  enough  to  solve  the  question  fully. 

Summary. — i.  A  parasitic  amceba  (Cancria- 
moeba  macroglossa)  is  found  in  all  epithelial 
carcinomata.  This  amcKba  may  be  readily  fixed 
while  in  action  if  the  tissue  is  fixed  while  yet 
warm,  the  lowering  of  the  temperature  below  that 
of  the  blood  causing  the  amcebae  to  contract. 

2.  The  cancriamtebai  are  the  cause  of  the  char- 
acteristic structure  of  epithelial  carcinomata  in 
which  are  found  cell  nests  or  cell  plugs.  In 
each  such  nest  we  can  always  distinguish  two 
distinct  parts — an  inner  core  or  amoeba  nest  con- 
sisting mainly  of  one  or  many  cancriamcebae 
mixed  with  some  leucocytes  and  loose  epithelial 
cells,  and  an  outer  zone  consisting  of  epithelial 
cells,  the  inner  one  of  which  are  flattened,  con- 
cave, and  in  section  lunate,  while  the  outer  ones 
are  normal. 

3.  The  peculiar  structure  of  these  cancer 
plugs  is  caused  by  the  effort  of  the  epithelial 
cells  of  the  infected  locality  of  the  human  body 
to  fence  in  the  amoebai  and  prevent  them  from 
spreading  through  the  tissue.  This  effort  is  also  more 
or  less  successfully  accomplished  by  an  enormous  in- 
crease in  epithelial  cells  and  by  a  chitinization  of  the 
cells  nearest  the  cancriamcebc'E.  The  concentric  struct- 
ure of  the  cancer  plug  is  the  result  of  the  pressure 
on  the  epithelial  cells  caused  by  the  cancriamcebae  sit- 
uated in  the  centre  of  the  cancer  plug  through  contin- 
uous increase  in  number  and  size. 

4.  A  constant  struggle  is  going  on  between  the  can- 
criamosbffi  and  the  epithelial  cells.  The  latter  are 
trying  to  fence  in  the  amcebre  and  to  kill  them  by  en- 
cysting or  by  chitinization,  while  the  amcebas  on  their 
side  feed  on  the  epithelial  cells  by  projecting  pseudo- 
podia  into  the  cells  and  sucking  out  their  cytoplasm. 
The  cancriamcebaj  are  not  caryophagues. 

5.  The  propagatioi!  of  the  cancriamoeba;  is  by  spores 
and  by  amitotic  division.  Mitotic  division  has  not 
been  observed.  There  are  numerous  cells  in  mitotic 
division  all  through  the  tissue,  but  these  cells  seem  to 
be  exclusively  epithelial  cells. 

6.  The  cancriamo;baj  are  nearly  always  found  sur- 
rounded by  a  small  vacuole.  This  vacuole  is  the  re- 
sult of  the  destruction  of  one  or  more  epithelial  cells 
by  the  parasites.  The  vacuole  becomes  gradually 
larger  as  more  and  more  cells  are  destroyed,  until 
finally  when  the  epithelial  cell  fence  gives  way  and 
breaks  up  a  large  pus  cavity  is  formed,  containing 
cancriamoeba;,  fragments  of  epithelial  cells,  and  leu- 
cocytes. 

7.  The  cancriamcebae  are  distinguished  from  all 
leucocytes  by  their  larger  size.  While  the  leucocytes 
seldom  reach  10  to  12  ,a  in  diameter,  the  cancriamcebae 
frequently  exceed  25  to  30  //  in  length.  Many  of  the 
cancriamoebce  possess  a  vacuole,  an  organ  never  found 
in  the  leucocyte. 

8.  The  acute  sensitiveness  to  cold  suggests  the 
treatment  of  carcinomata  by  freezing. 

Explanation  of  the  Figures — All  the  figures  have 
been  studied  with  a  Zeiss  apochromatic  2  mm.,  ap.  1.40; 
oc.  12.     The  outlines  were  drawn  with  a  camera  and 


then  redrawn  on  a  larger  scale.  The  details  were 
filled  in  diagrammatically,  imitating  as  near  as  possi- 
ble the  natural  structure.     The  cancriamoebae  appear  in 


Fir,.  6. — A  Large  Polymorphous  Cancriamceba,  lying  in  a  vacuole  and  extending  pro- 
lon^'ations  into  lhr''e  different  epithelial  cells  at  the  same  time.  In  one  of  these 
(A/.  5)  a  nucleus  is  seen.  In  the  others  the  nuclei  have  been  cut  away.  The  nu- 
cleus of  the  cancrtam<eba  is  strongly  polymorphous. 


the  preparations  deep  red  with  blue,  generally  homo- 
geneous nurlei,  sometimes  containing  one  to  three 
nucleoli.  The  cell  walls  have  in  some  of  the  dia- 
grams been  shaded,  in  others  only  indicated  by  black 
lines. 

The  following  letters  refer  to  all  the  figures:  £/>. 
(numbered),  epithelial  cells,  not  yet  destroyed  by 
the  cancriamceba;  Ep.d.,  epithelial  cells  already  de- 
stroyed, and  now  forming  a  mere  vacuole  in  which  are 
situated  one  or  more  cancriamceba;;  A.c,  one  or  more 
cancriamabae  macroglossa;  A.n.,  nucleus  of  the  can- 
criamceba; /,  vacuole  of  the  cancrianiorba. 

8ig  Market  Street, 


thrp:e  cases  of  vascular  tumor  of 
the  orbit:  two  cured  by  opera- 
tion, one  apparently  cured  spon- 
taneously," 

Bv   CHARLES   STEDMAN   BULL,    A.M.,    M,D,, 

NEW   YORK. 

Case  I. — Large  venous  naevus  of  orbit  and  lid.  Miss 
E.  W — — ,  aged  forty-one  years,  first  seen  January  14, 
1898,  The  patient  has  been  a  teacher  for  many  years, 
and  her  eyes  have  been  under  a  more  or  less  constant 
strain.  Refraction  is  hypermetropic  and  astigmatic. 
Vision  is  normal  with  correcting  glasses.  The  media 
are  clear  and  fundus  is  normal,  though  slightly  hyper- 
£emic.  The  field  of  vision  is  normal;  tension  normal. 
About  two  years  before  I  saw-  her,  she  first  noticed  a 
slight  protrusion  of  the  right  upper  lid,  coming  on  in  the 
morning  after  she  had  risen,  and  increasing  somewhat 
toward  evening.  It  remained  about  the  same  size  for 
eighteen  months,  but  since  then  it  has  steadily  in- 
creased in  size,  and  during  the  last  two  months  has 
grown  somewhat  rapidly.  At  first  it  always  disap- 
peared during  the  night  or  after  she  lay  down,  but  of 

'  Read    before    the    .American    Ophthalmological     Society    in 
Washington,  D.  C,  May  i,  1900. 


t3 


MEDICAL    RECORD. 


[July  7,  1900 


late  it  has  been  constantly  present.  When  I  first  saw 
her,  there  was  partial  ptosis,  the  lid  covering  about 
three-fifths  of  the  cornea,  but  it  could  be  completely 
raised  by  the  united  action  of  the  levator  palpebra; 
and  occipito-frontalis  muscles.  The  tumor  presented 
just  above  the  middle  of  the  right  upper  lid,  as  a  dis- 
tinct congeries  of  vessels  showing  blue  through  the 
skin.  This  mass  of  blood-vessels  involved  the  upper 
portion  of  the  lid  and  could  be  follawed  inward  and 
backward  along  the  nasal  wall  of  the  orbit.  There 
was  neither  pulsation  nor  bruit,  and  there  had  been 
no  pain  at  any  time.  Any  forced  muscular  exertion, 
lifting,  coughing,  or  forced  e.xpiration  caused  a  dis- 
tinct increase  in  the  size  of  the  tumor,  and  stooping 
or  bending  toward  the  ground  produced  a  rapid  in- 
crease in  size  so  far  as  entirely  to  close  the  eye,  and  this 
condition  did  not  subside  for  about  five  minutes  after 
resumption  of  the  erect  position.  When  she  lay  on  the 
back  for  fifteen  minutes  there  was  a  perceptible  dimi- 
nution in  the  size  of  the  tumor.  A  careful  e.xamina- 
tion  of  the  nasal  meatus  and  naso-pharynx  revealed  an 
hypertrophy  of  the  turbinated  bones  and  cystic  disease 
of  the  right  middle  turbinated  bone,  with  a  subacute 
laryngitis.  On  the  inner  aspect  of  the  left  thigh  just 
above  the  internal  condyle  of  the  femur,  there  was 
a  large  purple  naevus,  about  two  and  a  half  inches  in 
diameter  and  of  an  irregular  circular  form,  with  some 
elevation  above  the  surrounding  skin,  and  a  similar 
nrevus  somewhat  smaller  on  the  inner  aspect  of  the 
left  tibia  just  below  the  condyle.  These  navi  had 
existed  for  many  years.  Pressure  upon  the  tumor  with 
the  finger  caused  its  complete  disappearance  within  the 
orbit,  but  it  reappeared  as  soon  as  the  pressure  was 
discontinued.  There  was  no  sign  of  a  similar  growth 
in  the  other  orbit.  There  was  no  cardiac  complica- 
tion of  any  kind. 

After  a  careful  study  of  the  case  on  several  visits, 
it  was  decided  to  try  what  could  be  efifected  by  elec- 
trolysis, though  I  had  never  employed  this  method  of 
treatment  in  so  old  a  patient.  The  first  application, 
lasting  five  minutes,  produced  no  apparent  effect. 
Between  February  17  and  November  19,  1898,  elec- 
tiolysis  was  applied  sixteen  times,  at  intervals  of 
varying  length.  Then  the  patient  was  obliged  to 
absent  herself  from  observation  for  a  period  of  three 
months,  when  the  electrolytic  treatment  was  resumed 
and  continued  at  intervals  of  four  days  for  a  month. 
This  method  of  treatment  produced  some  consolidation 
in  the  tumor,  but  no  diminution  in  its  size.  It  was 
then  decided  to  attempt  its  excision. 

On  March  14th  the  patient  was  prepared  for  the 
operation  under  the  strictest  antiseptic  precautions. 
She  took  the  anaesthetic,  ether,  extremely  well,  and 
was  profoundly  anffisthetized  in  about  six  minutes.  I 
was  about  to  make  the  preliminary  incision,  when  the 
tumor  suddenly  increased  rapidly  in  size  and  extended 
in  all  directions,  upward  upon  the  forehead,  inward 
over  the  bridge  of  the  nose,  outward  upon  the  temple, 
and  downward  upon  the  side  of  the  nose,  and  soon 
reached  the  size  of  an  orange.  The  skin  covering 
this  area  was  of  a  dark  purple  color  and  was  very 
tense.  The  anesthetic  was  at  once  discontinued,  and 
all  operative  procedures  were  temporarily  postponed. 
The  enormous  swelling  began  slowly  to  subside  as 
soon  as  the  patient  recovered  consciousness,  but  did 
not  entirely  disappear  for  two  days.  She  remained 
in  the  hospital  till  the  end  of  March,  and  as  I  went 
off  duty  on  April  ist  I  did  not  resume  charge  of  the 
case  until  the  following  October. 

When  I  saw  the  patient  again  on  October  ist,  the 
condition  was  about  the  same  as  it  had  been  in  the 
preceding  March,  and  it  was  decided  to  attempt  the 
removal  of  the  tumor  by  excision. 

On  October  11,  i8gg,  the  operation  was  performed 
under  cocaine    anaesthesia  hypodermically.     Two  in- 


jections were  made,  each  of  tT[  xx.  of  a  five-per-cent. 
solution  of  cocaine  into  the  mass,  one  on  the  temporal 
side  and  one  on  the  nasal  side.  An  incision  was 
made,  an  inch  and  a  half  long,  just  beneath  the  supe- 
rior orbital  margin,  through  the  skin  and  tarso-crbital 
fascia,  care  being  taken  to  avoid  incising  the  tendon 
of  the  levator  muscle.  The  index  f.r.ger  was  then  in- 
troduced through  the  wound  for  exploratory  purposes. 
No  distinct  tumor  was  found,  but  a  mass  of  enlarged 
vessels  was  discovered  filling  the  whole  nasal  side  of 
the  orbital  cellular  tissue,  extending  back  nearly  to 
the  apex  of  the  orbit  and  upward  along  the  roof  of 
the  orbit.  The  bleeding  was  somewhat  profuse.  No 
opening  into  the  ethmoid  cells  or  frontal  sinus  was 
found.  The  mass  of  connective  tissue  and  enlarged 
vessels  was  separated  as  rapidly  as  possible  from  the 
eyeball  and  periosteum,  and  then  grasped  by  a  pair  of 
stout  forceps  with  very  broad  blades.  The  mass  tiien 
was  put  on  the  stretch,  being  drawn  forward  and  up- 
ward, and  a  stout  catgut  ligature  was  then  passed 
around  it,  pushed  back  as  far  toward  the  apex  of  the 
orbit  as  possible,  tied  tightly,  and  the  ends  were  then 
cut  off.  Much  of  the  bleeding  then  ceased,  and  an 
examination  showed  that  the  pulley  of  the  superior 
oblique  and  the  belly  of  the  muscle  were  uninjured. 
After  all  active  bleeding  had  ceased,  the  cavity  in  the 
orbit  was  carefully  irrigated  and  packed  with  iodoform 
gauze.  The  patient  did  very  well.  There  were  no 
secondary  hemorrhage  and  very  'ittle  oozing.  The 
dressing  was  left  undisturbed  for  three  days,  and  was 
then  removed,  the  cavity  was  again  washed  out,  and 
the  gauze  packing  re-applied.  Fresh  dressings  were 
applied  every  two  days  for  two  weeks,  at  the  end  of 
which  period  the  cavity  had  filled  up  from  the  bottom. 
The  wound  in  the  skin  was  then  closed  by  six  sutures. 
One  montli  after  the  operation,  the  improvement  was 
very  marked,  but  there  were  still  some  bulging  and 
protrusion  at  the  inner  end  of  the  upper  lid,  and  the 
enlarged  vessels  could  be  distinctly  seen  through  the 
lid. 

On  December  7,  1899,  a  second  operation  was 
done,  under  the  hypodermic  injection  of  cocaine,  for 
the  removal  of  the  palpebral  portion  of  the  growth. 
An  incision  was  made  through  the  skin  of  the  lid, 
about  an  inch  long  and  extending  toward  the  top  of 
the  bridge  of  tiie  nose.  The  skin  was  dissected  up  in 
all  directions,  and  the  mass  of  enlarged  vessels  was 
then  grasped  with  the  same  broad  forceps  and  rapidly 
separated  from  the  tarsus  as  far  as  the  inner  angle  of 
the  orbit  and  lacrymal  bone,  where  there  seemed  to  be 
quite  a  firm  connection  with  the  penosteum.  The  mass 
was  then  tied  off  in  a  similar  way  with  a  catgut  liga- 
ture. There  was  but  little  hemorrhage,  but  the  wound 
was  packed  with  gauze  as  at  the  first  operation.  This 
was  removed  on  the  fourth  day;  the  wound  was  care- 
fully cleansed,  and  closed  by  three  sutures.  The 
result  was  very  successful,  and  on  April  i8th  the  scars 
were  scarcely  visible;  there  was  no  protrusion  or  dis- 
coloration, and  only  a  very  slight  condition  of  ptosis. 
The  two  masses  of  tissue  and  enlarged  vessels  were 
examined  by  Dr.  Dixon,  the  pathologist  of  the  eye  in- 
firmary, who  reports  as  follows:  "The  specimens  sub- 
mitted by  you  are  composed  of  fat,  loose  connective 
tissue,  a  large  number  of  blood-vessels,  and  a  few 
cavernous  spaces,  with  considerable  extravasation  of 
free  blood  into  the  tissue.  Diagnosis,  caverno-angi- 
oma." 

Case  II.— Pulsating  tumor  of  the  orbit.     J.  B , 

aged  twenty-three  years,  was  first  seen  September  2, 
i88g.  Two  years  before  I  saw  him,  he  had  received 
a  violent  blow  on  the  right  side  of  the  head  by  a  large 
timber  falling  from  a  height.  He  was  unconscious  for 
two  days,  and  then  slowly  regained  his  senses.  There 
was  a  large,  irregular  scalp-wound  running  from  the 
middle  of  the  sagittal   suture  downward  and   forward 


July  7,  1900] 


MEDICAL    RECORD. 


13 


across  the  parietal  and  squamous  bones  as  far  as  the 
middle  of  the  zygoma.  He  said  that  he  understood 
that  no  fracture  of  the  skull  had  been  found.  He 
was  confined  to  his  bed  for  two  months,  with  more 
or  less  constant  headache  and  mental  torpor.  When 
he  first  attempted  to  walk,  he  staggered  and  com- 
plained of  dizziness,  but  does  not  remember  that 
he  ever  had  diplopia.  The  tendency  to  vertigo  grad- 
ually diminished,  though  the  attacks  still  come  on 
at  irregular  intervals.  He  never  fully  regained  his 
physical  strength  or  mental  vigor.  For  some  weeks 
after  the  accident  the  eyelids  were  swollen  and 
bruised  as  if  from  subcutaneous  e.\travasation  of 
blood,  and  there  was  an  extensive  hemorrhage  be- 
neath the  conjunctiva,  downward  and  on  the  nasal 
side.  Somewhat  more  than  a  year  after  the  accident, 
the  upper  lid  began  to  swell  and  the  eye  to  protrude, 
and  these  symptoms  have  steadily  increased  up  to 
date.  The  headaches  have  also  become  more  con- 
tinuous, and  are  always  worse  when  he  bends  forward 
or  stoops. 

When  I  saw  the  patient,  the  right  eye  protruded  for- 
ward and  downward,  but  was  freely  movable  in  all 
directions  e.xcept  upward,  in  which  direction  its  mo- 
tility was  limited.  The  upper  lid  was  much  enlarged 
and  drooped  over  the  eye,  was  of  a  dark  red,  almost 
dusky  hue,  and  pulsated  strongly.  The  whole  eyeball 
also  pulsated  visibly,  and  a  very  distinct  thrill  was 
communicated  to  the  fingers  when  placed  upon  the 
lid.  On  auscultation,  a  harsh  blowing  sound  was 
heard  over  the  closed  lids,  on  the  right  side  of  the 
forehead,  and  on  the  right  temporal  region,  like  the 
e.xhaust  of  steam  pipes  heard  at  a  distance.  The 
media  of  the  eye  were  clear;  the  retinal  veins  were 
engorged,  tortuous,  and  pulsating.  Vision  was  n;|  in 
the  right  eye  and  !v[}  in  the  left  eye.  A  rough  broken 
ridge  of  bone  was  discovered  on  the  floor  of  the  orbit, 
running  backward  from  the  inferior  orbital  margin 
near  the  inner  canthus,  and  another  sharp  edge  of 
bone  at  the  infero-temporal  angle  of  the  orbit  was 
found  which  ran  backward  and  inward  toward  the 
median  line.  Pressure  on  the  common  carotid  artery 
on  the  right  side,  just  below  the  region  of  its  bifurca- 
tion, caused  an  immediate  and  marked  diminution  in 
the  pulsation  and  bruit,  and  in  the  prominence  of  the 
eyeball,  but  it  could  not  be  continued  for  more  than 
four  minutes,  because  of  an  apparent  marked  interfer- 
ence with  the  breathing  produced  by  the  pressure. 

There  seemed  to  be  no  doubt  that  the  accident  two 
years  before  had  caused  a  fracture  at  the  base  of  the 
skull,  involving  the  floor  of  the  orbit  and  probably  the 
optic  foramen.  The  main  point  to  determine,  if  pos- 
sible, was  whether  the  pulsating  tumor  evidently  ex- 
isting in  the  orbit  behind  the  eyeball  was  a  pure  arte- 
rial aneurism  of  the  ophthalmic  artery  and  possibly  of 
the  ciliary  arteries,  or  whether  the  fracture  extended 
farther  back  and  involved  the  internal  carotid  artery 
and  the  cavernous  sinus.  The  history  of  severe  trau- 
matism and  the  gradual  development  of  all  the  orbital 
symptoms  would  seem  to  favor  the  idea  of  aneurism 
of  the  ophthalmic  artery.  But  this  lesion  is  rare  and 
has  been  found  in  very  few  cases.  The  more  frequent 
lesion  of  laceration  of  the  carotid  artery  within  the 
cavernous  sinus  is  always  due  to  fracture  at  the  base 
of  the  skull,  and  the  orbital  symptoms  generally  de- 
velop somewhat  rapidly  within  a  few  weeks  after  the 
injury.  In  my  patient  the  orbital  symptoms  did  not 
develop  until  a  year  after  the  receipt  of  the  injury. 
It  may  be  here  remarked  that  the  literature  of  this 
subject  is  quite  extensive,  but  our  exact  knowledge  of 
such  cases  is  relatively  very  small. 

It  was  thought  best  to  try  what  could  be  effected  by 
compression  of  the  common  carotid  in  the  neck,  first 
by  the  fingers,  and  afterward  by  a  pad  devised  for  the 
purpose;   but  all  these  efforts  were  abandoned  at  the 


end  of  the  first  week  on  account  of  their  interference 
with  respiration.  It  was  then  decided  to  ligate  the 
right  common  carotid,  which  was  done  under  the 
strictest  aseptic  precautions.  The  incision  was  made 
in  the  usual  place  and  followed  the  inner  border  ^f 
the  sterno-mastoid  muscle,  extending  from  just  below 
the  cricoid  cartilage  nearly  to  the  slerno-clavicular 
articulation.  Careful  dissection  exposed  the  arterv 
without  any  difficulty;  the  sheath  was  opened  and  the 
aneurism  needle  was  gently  passed  between  the  sheath 
and  the  vessel  and  around  the  artery  till  the  end  ap- 
peared in  the  incision.  The  ligature  was  'hen  passed 
through  the  eye,  and  the  needle  was  witiidrawn.  the 
ligature  coming  with  it.  The  latter  was  then  slowly 
and  firmly  tied.  Xo  vessels  of  any  size  were  wounded 
in  the  operation.  All  pulsation  and  bruit  ceased 
immediately  in  the  tumor.  The  wound  was  then 
closed,  covered  with  iodoform,  and  a  small  pad  and 
bandage  were  applied.  The  wound  healed  rapidly, 
but  the  patient  was  kept  in  bed  for  two  weeks.  On 
the  fourth  day  there  was  a  return  of  the  bruit  and 
thrill  to  a  slight  extent,  but  no  positive  pulsation,  and 
these  symptoms  continued  with  varying  intensity  for 
nearly  six  weeks.  Even  after  the  patient  was  dis- 
charged, he  was  kept  under  observation  for  more  than 
a  year,  and  there  was  a  slight  thrill  perceptible  to 
the  fingers,  though  auscultation  revealed  no  bruit. 
Somewhat  more  than  a  year  after  the  operation,  the 
patient  contracted  pneumonia,  which  rapidly  involved 
the  entire  right  lung,  and  he  died  on  the  eighth  day. 
I  endeavored  to  procure  an  autopsy  but  was  unsuccess- 
ful, and  I  am  still  ignorant  of  the  exact  pathological 
condition  of  things  in  the  orbit.  The  protrusion  of 
the  eyeball  gradually  subsided,  and  its  motility  was 
restored  to  the  normal  condition.  The  vision  was  im- 
mediately impaired  by  the  operation  and  sank  to  T,y'„, 
but  in  about  three  weeks  it  began  to  improve  and 
finally  rose  to  -j'-„"jy.  The  fundus  immediately  after  the 
operation  was  very  pale  but  gradually  regained  an  ap- 
proximately normal  appearance,  though  the  retinal 
arteries  never  attained  their  normal  calibre. 

C.'kSE  III. — Pulsating  tumor  of  the  orbit.     Mrs.  T. 

W ,  aged  thirty-nine   years,  was  first  seen  January 

9,  1899.  This  patient  had  had  more  or  less  occipital 
headache  for  nearly  six  months,  and  had  pain  in  the 
right  orbit  for  nearly  four  months.  Three  niontlis  ago 
the  right  eye  began  to  protrude.  Pour  weeks  ago  the 
right  upper  lid  began  to  droop,  and  this  ptosis  in- 
creased. On  examination  I  found  complete  ptosis, 
and  complete  paralysis  of  all  the  branches  of  the  right 
third  nerve,  including  the  branches  to  the  sphincter 
iridis  and  to  the  ciliary  muscle.  The  exophthalmos 
was  forward  and  outward  and  could  not  be  reduced 
by  pressure.  The  eye  could  be  moved  toward  the  ex- 
ternal canthus.  The  media  were  clear  and  the  oph- 
thalmoscopic examination  was  negative;  R.E.,  V  = 
-f„\,  and  with  -f  D  3  =  5^;  L.E.,  V  =  f ;;.  Nothing 
could  be  discovered  in  the  orbit  by  palpation,  and 
there  was  no  bruit  or  pulsation,  nor  any  thrill. 

A  careful  examination  of  the  nose,  naso-pharynx,  and 
ears  revealed  nothing  but  a  chronic  catarrhal  condition 
of  the  mucous  membrane  and  a  moderate  amount  of 
hypertrophy  of  the  turbinated  bones  on  the  right  side. 
There  was  no  evidence  of  trouble  in  the  maxillary 
antrum.  The  patient  was  seven  and  a  half  months 
pregnant  with  her  eighth  child.  The  urine  was  ex- 
amined and  was  of  normal  specific  gravity,  acid,  clear, 
light  straw  color,  and  contained  about  one  per  cent, 
of  albumin,  but  no  sugar  and  no  casts.  The  heart 
sounds  were  normal,  and  there  was  no  hypertrophy. 
There  was  no  history  of  any  injury  to  the  head  nor  of 
any  traumatism.  The  patient  was  put  on  small  doses 
of  potassium  iodide  and  carefully  watched.  There 
was  a  slight  improvement  in  the  ptosis,  but  none  in 
the  motility  of  the  eyeball  or  in  the  exophthalmos. 


H 


MEDICAL    RECORD. 


[July  7,  1900 


On  jAunary  29th  the  patient  complained  of  a  sharp 
pain  in  and  around  the  orbit,  and  of  a  constant  rush- 
ing noise  in  tlie  head  on  the  right  side,  which  had 
come  on  suddenly  two  days  before,  and  sounded  like 
the  falling  of  water  from  a  height.  There  was  a  well- 
marked  thrill  on  palpation  over  the  closed  lids,  a  slight 
visible  pulsation  to  the  eyeball,  and  a  well-marked 
bruit  on  auscultation  over  the  eyeball,  forehead,  and 
temple.  Deep  pressure  over  the  carotid  artery  in  the 
neck  produced  no  appreciable  effect  upon  either  the 
pulsation  or  the  bruit. 

On  February  6th  the  patient  complained  of  an  ob- 
struction in  the  right  nostril,  but  an  e.\amination 
showed  nothing  more  than  a  swollen  mucous  mem- 
brane. 

Owing  to  her  advanced  pregnancy  it  was  thought 
wiser  to  wait  until  she  had  recovered  from  her  con- 
finement before  attempting  any  operative  treatment. 
On  March  21st  she  was  delivered  of  a  rather  small 
but  healthy  male  infant,  the  labor  being  brief  and 
without  instrumental  assistance.  There  was  almost 
immediate  relief  from  the  pain  in  the  head  and  orbit, 
which  had  become  continuous  until  her  confinement 
was  over.  Ten  days  after  delivery  a  purulent  dis- 
charge appeared  from  the  left  ear,  not  accompanied 
or  preceded  by  any  pain. 

On  April  12th  the  thrill  under  the  finger  was  par- 
ticularly marked  at  the  inner  canthus  and  over  the  in- 
ternal angular  artery.  There  was  a  slight  visible 
pulsation  of  the  eyeball,  and  a  strong  blowing  sound 
was  heard  over  the  eyeball,  forehead,  and  temple,  and 
indistinctly  at  the  vertex  and  over  the  malar  bone. 
She  complained  of  a  constant  dull  ache  in  the  eye,  but 
the  severe  pain  in  the  head  and  orbit  had  disappeared 
after  the  birth  of  the  child  and  had  not  returned.  The 
discharge  from  the  left  ear  had  ceased,  and  the  perfora- 
tion in  the  drumhead  was  closing,  but  she  complained 
of  constant  tinnitus.  No  effect  on  either  pulsation  or 
bruit  was  produced  by  compression  of  the  carotid  in 
the  neck.  The  pulse  was  132  and  regular.  There 
was  no  enlargement  of  the  thyroid. 

On  April  23d  there  was  a  marked  improvement  in 
the  ptosis  and  in  the  motility  of  the  eye  and  in  the  e.\- 
ophthalmos.  The  bruit  was  less  audible  and  the  pul- 
sation less  noticeable.  The  patient  did  not  complain 
of  the  noise  in  her  head,  and  said  that  it  sounded  very 
much  farther  away. 

On  June  ist  all  bruit  and  pulsation  had  ceased,  the 
ptosis  was  nearly  gone,  the  eye  was  freely  movable  in 
all  directions,  and  the  protrusion  much  diminished. 
The  tinnitus  in  the  left  ear  was  perceived  only  when 
she  was  tired  or  e.xcited,  and  the  hearing  had  im- 
proved. This  patient  has  not  been  seen  since,  but  the 
case  looks  like  a  spontaneous  recovery. 


FISTULA      IN 


ANO:      ITS      RELATION 
PHTHISIS.' 


TO 


By   SAMUEL   G.    G.\NT,    M.D., 

PROFESSOR     OP      RECTAL      AND     ANAL     SfRGERY,     POST-GRADfATE     MEDICAL. 
SCHOOL   AND    HOSriTAL,    NEW    YORK    CITV 

Fistula  in  ano  is  a  very  common  affection;  in  fact  it 
occurs  with  greater  frequency  than  any  other  disease 
found  about  the  anal  region.  It  is  not  uncommon  in 
the  well-to-do,  but  is  met  with  more  frequently  in  peo- 
ple living  in  crowded  communities.  Out  of  the  16.- 
060  cases  of  rectal  diseases  treated  in  St.  Mark's 
Hospital,  London,  from  1872  to  189 1,  as  compiled  by 
Cooper  and  Kdwards,  8,497,  or  a  little  more  than  fifty 
per  cent.,  were  treated  for  fistula  in  ano  in  some  form. 
Of  these  5,829  were  men,  and  2,668  women.  This  is 
about  the  usual  percentage  as  regards  the  sex.     I  have 

'  Read  before  the  Medical  Association  of  the  Greater  City  of 
New  York,  June  n,  1900. 


not  found  in  my  work,  however,  that  fistula  occurs  as 
frequently  as  all  other  rectal  diseases  combined.  In 
dispensary  work  I  find  that  about  one  person  in  three 
has  fistula.  The  proportion  of  fistulae  to  other  dis- 
eases is  not  so  great  in  the  upper  circles  of  society 
because  their  occupations  are  not  so  arduous,  they  are 
not  exposed  to  inclement  weather,  and  do  not  live  in 
densely  populated  districts  where  tuberculosis  is  com- 
mon. The  rectal  surgeon  is  frequently  called  upon  to 
treat  patients  suffering  from  fistula  in  ano,  whose  con- 
dition is  aggravated  by  coughing,  the  result  of  lung 
involvement,  and  I  dare  say  the  general  practitioner 
in  turn  sees  many  phthisical  patients  who  under  the 
very  best  treatment  fail  to  improve  because  of  the  ex- 
hausting discharge  from  an  anal  fistula. 

Fistula  and  phthisis  occur  in  the  same  individual 
with  a  regularity  that  cannot  be  explained  by  mere 
coincidence.  At  the  present  time  I  have  under  treat- 
ment three  men  and  one  woman  suffering  from  fistula 
who  have  tuberculosis  of  the  lungs.  In  order  to  show 
the  proportion  of  fistula  to  phthisis  Allingham  reports 
1,632  cases  of  fistula  operated  upon,  and  of  this  num- 
ber no  less  than  234  had  phthisis.  From  the  analysis 
of  the  statistics  of  others,  together  with  my  own,  I 
have  arrived  at  the  conclusion  that  from  four  to  six 
per  cent,  of  all  phthisical  patients  suffer  from  fistula, 
while  a  much  larger  percentage  of  those  afflicted  with 
fistula  have  phthisis.  It  is  extremely  difficult  to  arrive 
at  the  correct  ratio  of  the  one  disease  to  the  other;  for 
instance,  a  patient  going  to  his  family  physician  for  a 
lung  complaint  does  not  deem  it  necessary  to  tell  him 
that  he  has  a  fistula.  On  the  other  hand,  when  a  pa- 
tient goes  to  the  surgeon  to  have  a  fistula  cured,  the 
latter  will  at  once  suspect  lung  involvement  because 
of  the  patient's  cough  and  general  debilitated  condi- 
tion. Medical  and  surgical  writers  not  long  since  be- 
lieved there  was  some  anatomical  or  pathological  con- 
nection between  anal  fistula  and  the  lungs,  and  as  a 
result  advised  against  operation  for  the  cure  of  fistula. 
They  maintained  that  in  case  the  operation  was  suc- 
cessful and  the  sinus  healed,  there  would  be  no  outlet 
for  the  discharge.  As  a  result  the  existing  lung 
trouble  would  be  made  worse,  and  the  patient  would 
die.  In  case  phthisis  did  not  exist  before  the  cure,  it 
would  develop  as  a  result  of  retained  poison  finding 
its  way  to  the  lungs. 

The  trouble  with  these  gentlemen  was,  they  had  the 
cart  before  the  horse.  I  do  not  doubt  that  phthi- 
sis is  frequently  a  cause  of  fistula,  but  1  am  extremely 
sceptical  if  fistula  is  ever  an  etiological  factor  in 
phthisis.  I  do  not  wish  it  understood  that  I  believe 
all.fistulfB  are  the  result  of  tuberculous  lung  disease, 
for  in  fact  not  more  than  one  in  six  or  eight  are 
caused  by  it,  the  remainder  being  the  result  of  abscess 
induced  by  exposure,  trauma,  foreign  bodies,  and  pyo- 
genic bacteria.  I  will  not  attempt  to  discuss  simple 
fistula  as  seen  in  robust  persons,  but  will  confine  my 
remarks  to  a  study  of  fistula;  in  tuberculous  subjects. 
Of  these  we  have  two  kinds  (i )  true  tuberculous  fistu- 
las, the  result  of  localized  deposits;  (2)  fistula;  in- 
duced or  made  difficult  to  cure  because  of  the  cough 
and  lowered  vitality,  the  result  of  phthisis. 

1.  True  tuberculous  fistula;  are  nearly  always  sec- 
ondary to  intestinal  ulceration,  which  in  turn  is  sec- 
ondary to  tuberculous  disease  in  some  other  organ, 
especially  the  lung.  Tubercle  bacilli  may  gain 
admittance  to  the  intestine  in  our  food,  but  most 
obser\ers  hold  to  the  opinion  that  intestinal  tubercu- 
losis is  the  result  of  the  swallowing  of  sputum  con- 
taining tubercle  bacilli.  It  appears  that  their  vitality 
is  not  materially  interfered  with  by  the  gastric  or 
intestinal  contents.  ■  This,  however,  may  be  partly 
explained  by  the  impaired  digestion  coincident  with 
general  tuberculosis. 

2.  Non-tuberculous  fistulas  are  frequent  in  phthisical 


July  7,  1900] 


MEDICAL    RECORD. 


15 


patients.  They  are  troublesome  to  treat,  for  several 
reasons:  (a)  persons  having  general  tuberculosis  are 
particularly  prone  to  suppuration  from  slight  causes; 
(/')  because  of  the  absence  of  fat  in  the  ischio-rectal 
fossa,  large  blood-vessels  are  left  unsupported  and 
readily  become  dilated  and  congested;  ^t)  lastly  the 
constant  coughing  of  phthisical  patients  is  most  notice- 
able at  the  anus,  and  frequently  results  in  bruising  of 
the  parts,  causing  abscess  and  fistula. 

Differential  Diagnosis. — The  symptoms  and  general 
characteristics  of  tuberculous  fistula;  are  so  different 
from  those  of  the  ordinary  kind,  that  it  is  not  a  diffi- 
cult matter,  if  one  is  careful,  to  differentiate  between 
them,  as  will  be  noticed  from  the  following  compari- 
son: 

Fistula. 

N^on-luherculous .  Tuberculous. 

1.  Internal  and  external  open-  E.xternal  and  internal  open- 
ings small  and  round,  the  ings  large  and  triangular, 
edges  red,  and  situated  in  edges  of  a  bluish  tint  and 
the  centre  of  an  elevation.  drooping  into  the  opening. 

2.  Buttocks  rounded  and  sup-  Skin  undermined, 
ported  by  fat. 

3     Hair    about     the    buttocks  Abundant,  long,  and  silky, 
normal. 

4.  N'ails  normal.  Nails  clubbed. 

5.  Face  and  ears  and  nose  Face  pinched,  nostrils  wide 
normal.  open,  ears  large  and  sticking 

out     prominently    from     the 
head. 

6.  Voice  natural.  Voice  husky. 

7.  Complexion  ruddy.  Complexion  sallow. 

3.  Rarely  loss  of  flesh.  Loss  of  flesh  considerable  and 

rapid. 

9.  Discharge  slight  and  yel-  Profuse,  whitish  in  color,  and 
low.  watery. 

10.  Introduction  of  probe  Introduction  of  probe  causes 
causes  considerable  pain.  slight  pain. 

11.  .Vppetite  normal.  Appetite  poor. 

12.  Digestion  good.  Digestion  bad. 

13.  Sleep  natural.  Interrupted     and    occasionally 

disturbed  by  night  sweats. 

14.  Discharge  contains  prin-  Discharge  contains  tubercle 
cipally  colon  bacilli.  bacilli. 

15.  Not  accompanied  by  hoe-  Frequently  complicated  by 
moptysis  or  cough.  hemorrhage  of  the  lungs  and 

annoying  cough. 

16.  Tight  sphincter.  Patulous  anus. 

During  examination  of  a  fistula  the  first  and  most 
important  thing  is  to  determine  if  it  is  simple  or  tu- 
berculous in  character.  This  point  can  be  settled  by 
the  finding  of  the  tubercle  bacilli  by  the  aid  of  the 
microscope;  their  presence  in  the  discharge  makes  it 
almost  certain  that  there  is  localized  tuberculosis,  jet 
they  are  occasionally  found  when  sputum  from  a  tu- 
berculous lung  has  been  swallowed.  On  the  other 
hand,  there  maybe  tuberculous  disease  and  the  bacilli 
not  be  present.  When  the  tuberculous  process  is  pro- 
gressive and  the  stools  are  watery,  the  bacilli  become 
mixed  with  the  fKces  and  difficult  to  locate.  To  over- 
come this  difficulty,  Rosenblatt  administers  sufficient 
laudanum  to  produce  hardened  stools,  and  then  ex- 
amines the  muco-purulent  discharge  coming  away 
upon  the  surface  of  the  fecal  mass.  In  this  way  he 
has  little  difficulty  in  demonstrating  their  presence. 
I  have  frequently  examined  the  pus  from  tuberculous 
fistulce  without  finding  the  bacilli  of  Koch.  In  such 
cases  I  then  curette  the  abscess  and  fistula  wall  and 
examine  the  debris.  By  this  procedure  I  have  never 
failed  to  find  them  or  little  caseous  bodies,  which 
positively  prove  the  tuberculous  nature  of  the  dis- 
ease. When  neither  is  found,  we  can  safely  conclude 
that  the  fistula  belongs  to  the  non-tuberculous  type. 

Treatment. — Modern  surgeons  pretty  generally 
agree  that  the  ordinarj-  fistula,  as  found  in  vigorous 
persons,  should  be  operated  upon  and  the  wound 
allowed  to  heal  by  granulation.  There  is,  however, 
some  difference  of  opinion  among  both  physicians 
and  surgeons,  even  in  this  enlightened  age,  regarding 
the  operative  procedure  for  the  relief  of  tuberculous 


as  well  as  the  simple  form  of  fistula  complicated  by 
phthisis.  It  has  been  my  custom  to  operate  on  all 
fistulae,  irrespective  of  the  kind,  and  the  results  ob- 
tained have  been  equally  satisfactory  to  the  patients 
and  myself.  It  is  the  condition  of  the  patient  that 
should  determine  if  an  operation  is  necessary,  and  not 
the  fact  that  he  is  suffering  from  this  or  that  form  of 
fistula.  I  believe  we  are  justified  then  injoperating 
upon  all  patients  suffering  from  tuberculous  fistula;  in 
its  strictest  sense,  and  those  who  have  simple  fistula 
with  or  without  lung  complications,  provided  their 
general  condition  will  permit  it.  I  would  not  operate 
upon  a  fistula  in  a  person  who  would  die  of  phthisis 
in  the  course  of  two  or  three  months,  neither  would  I 
operate  for  fistula  in  a  person  similarly  afflicted  with 
Bright's  disease.  Each  case  should  be  a  law  unto  it- 
self, and  the  treatment  given  should  be  the  best  for 
the  case  in  hand,  be  it  palliative  or  operative. 

Palliative  Treatment. — In  non-operable  cases  we 
should  use  our  best  efforts  to  make  our  patients  com- 
fortable and  improve  their  general  condition. 

1.  This  is  accomplished  by  keeping  the  fistulous 
openings  free,  thus  encouraging  drainage. 

2.  Assist  healing  and  relieve  pain  by  copious  injec- 
tions, or  the  application  of  caustics,  stimulating,  anti- 
septic, and  soothing  remedies. 

3.  Entice  the  appetite  and  supply  palatable  foods, 
known  to  have  nourishing  qualities. 

4.  Stop  all  medication  which  disturbs  the  stomach 
and  irritates  the  intestine. 

5.  Administer  oils,  creosote,  and  other  medicines 
which  tend  to  improve  the  patient's  general  condition. 

6.  Do  not  keep  these  patients  in  bed  in  a  dark 
room;  on  the  contrary  allow  them  the  fresh  air,  sun- 
shine, and  the  sea  breeze  or  proper  altitude  when  near 
the  ocean  or  mountains. 

7.  Make  things  pleasant  and  cheerful  for  them,  for 
their  lot  in  life  is  not  a  happy  one,  and  their  mental 
state  is  occasionally  pitiable  in  the  extreme.  To  re- 
lieve pain  and  induce  sleep  medication  should  be 
given  by  mouth  or  hypodermic  injection.  By  fol- 
lowing these  stiggestions,  we  can  at  least  make  all  of 
our  patients  comfortable  and  cure  not  a  few  througli 
palliative  measures. 

Anaesthetics — Having  decided  that  an  operation  is 
necessary,  a  suitable  anaesthetic  must  be  selected. 
Local  anaesthesia  should  be  practised  when  feasible. 
Of  these  local  anesthetics  I  have  derived  the  most 
benefit  from  cocaine  and  orthoform.  The  former  is  in- 
jected freely  along  the  line  of  tissues  to  be  severed,  the 
latter  is  dusted  over  abscess  cavities  and  fistulous  si- 
nuses to  be  curetted.  These  agents  lessen  but  do  not 
entirely  obliterate  pain  during  operation.  In  the  selec- 
tion of  a  general  anasthetic  for  this  class  of  cases 
chloroform  should  have  preference  over  ether  or  the 
A.  C.  E.  mixture:  (i)  It  renders  the  patient  uncon- 
scious in  a  shorter  time;  (2)  patients  recover  from  it 
more  quickly;  (3)  they  vomit  less  after  it,  thus  obvi- 
ating strain  at  the  anus  and  a  possible  hemorrhage; 
(4)  it  does  not  provoke  inflammation  of  the  lungs  or 
kidneys.  From  personal  experience  I  have  been  forced 
to  the  conclusion  that  many  of  the  deaths  from  lung 
complications  following  shortly  after  fistula  operation 
are  the  result  of  an  inflammation  induced  by  the  ad- 
ministration of  ether,  and  are  not  due  to  the  cutting 
and  cure  of  the  fistula. 

Operative   Treatment \\'e    should    endeavor    to 

build  our  patients  up  to  a  high  standard  before  operat- 
ing. The  morning  preceding  operation  a  mild  laxative 
may  be  administered  ;  strong  purgatives  never,  because 
they  frequently  start  up  a  diarrhcea  difficult  to  control. 
In  other  respects  these  patients  are  prepared  as  for  any 
other  operation.  I  will  not  mention  the  various  opera- 
tions devised  for  the  cure  of  fistula  in  ano,  and  will 
describe  those  only  which  are  best  suited  for  the  class 


i6 


MEDICAL   RECORD. 


[July  7,  1900 


of  cases  under  discussion.  They  are  tliree  in  number : 
(i)   ligation;   (2)  division;    (3)  excision. 

Ligation:  The  ligature  operation  was  first  described 
by  Celsus.  It  consists  in  passing  a  silk,  wire,  or 
elastic  ligature  through  the  sinus  and  out  at  the  anus, 
where  the  ends  are  securely  tied.  It  gradually  cuts 
its  way  out,  usually  requiring  from  a  week  to  ten  days. 
The  following  are  some  of  the  advantages  claimed  for 
it:  (i  )  It  does  away  with  the  knife;  (2)  it  can  be 
performed  without  an  anaesthetic;  (3)  it  is  comparative- 
ly painless;  (4)  there  is  no  bleeding;  (5)  the  patient 
can  walk  about,  having  the  benefit  of  the  fresh  air 
and  sunshine.  The  ligature  method  is  not  suited  to 
the  treatment  of  fistulae  in  general,  as  (i)  it  takes  a 
longer  time  to  effect  a  cure;  (2)  it  does  not  sever 
branch  sinuses.  This  operation,  however,  is  espe- 
cially adapted  to  the  treatment  of  tuberculous  fistula  as 
well  as  the  simple  variety  complicated  by  phthisis, 
since  it  does  not  deprive  such  patients  of  the  air,  sun- 
shine, and  exercise,  and  causes  little  pain. 

Division  :  This  is  the  usual  operation  for  fistula,  and 
is  performed  in  the  following  manner:  A  director  of 
suitable  size  is  introduced  through  the  sinus  until  its 
distal  end  can  be  reached  by  the  finger  in  the  rectum, 
when  it  is  withdrawn  and  rests  across  the  anus.  The 
bridge  of  tissue  resting  thereon  is  then  divided. 
Next  the  back  part  of  the  sinus  is  incised,  and  the 
whole  tract  curetted,  irrigated,  and  packed  with  gauze. 
If  it  is  a  true  tuberculous  fistula,  every  vestige  of  the 
involved  area  should  be  destroyed  with  the  Paqiielin 
cautery  before  the  dressings  are  applied.  The  sphinc- 
ter muscles  should  be  handled  very  carefully,  for  it  is 
after  these  operations  that  incontinence  is  likely  to 
follow. 

Excision :  The  excision  of  fistulous  tracts  is  not  a 
popular  operation,  because  the  results  from  it  are  not 
so  good  as  from  the  operation  just  described.  It  con- 
sists in  dissecting  out  the  sinus  and  the  immediate 
closure  of  the  wound,  with  the  object  of  obtaining 
primary  union.  Occasionally  it  is  successful;  more 
often  it  is  a  failure  because  of  infection  through  the 
rectal  end  of  the  wound.  Some  surgeons  maintain 
that  this  operation  is  especially  suitable  in  the  treat- 
ment of  tuberculous  fistula  because  a  large  suppurating 
wound  is  avoided.  I  agree  with  these  gentlemen  that 
it  is  better  suited  for  this  than  other  forms  of  fistula, 
yet  I  would  not  give  it  preference  over  the  ligature  or 
division  operations. 

I  will  conclude  my  paper  with  the  following  ob- 
servations: 

1.  Tuberculous  fistula  of  the  anus  is  usually  second- 
ary to  tuberculous  disease  of  the  lungs. 

2.  Pulmonary  phthisis  is  rarely,  if  ever,  secondary 
to  fistula  in  ano,  either  before  or  after  operation. 

3.  Tuberculosis  of  the  anal  region  should  be  dealt 
■with  radically,  as  is  recommended  when  it  attacks  other 
parts. 

4.  When  the  patient's  general  condition  will  permit 
we  should  operate  on  all  fistula,-  irrespective  of  the  kind. 

5.  We  should  not  refuse  to  operate  on  persons  suf- 
fering from  a  mild  form  of  phthisis,  nor  on  those  who 
give  a  family  history  of  tuberculosis.  Certainly,  if 
we  arrest  one  destructive  process,  nature  is  all  the 
more  capable  of  dealing  with  the  other. 

6.  I  believe  that  those  patients  o]5erated  upon  for 
tuberculous  fistula  and  those  that  are  non-tuberculous 
complicated  by  phthisis,  who  rapidly  decline  and  die, 
do  so  as  the  result  of  an  infiammation  of  the  lungs  in- 
duced by  the  anaesthetic,  especially  ether.  Such  acci- 
dents have  not  followed  any  of  the  operations  which  I 
iiave  made  under  local  anesthesia. 

7.  Lastly,  I  believe  we  are  justified  in  discarding  the 
erroneous  teachings  of  writers  who  believe  that  the  cure 
of  a  fistula  will  result  in  a  development  of  phthisis. 

58  West  Fiftv-sixth  Street. 


A  Case  of  Pseudokeloid  after  Syphilis.^ — Vordan 
distinguishes  true  keloids  from  pseudokeloids.  The 
latter  appear  only  after  traumatisms  and  in  some  cases 
after  syphilitic  ulcers.  He  reports  a  case  of  his  own 
observation,  in  which,  after  rupia  syphilitica,  many 
pseudokeloids  appeared  all  over  the  body;  the  pseudo- 
keloid character  of  the  scars  was  proven  by  microscop- 
ical examination.  Anti-syphilitic  treatment  in  those 
cases  is  of  no  value.^ — Meditsinskoe  Olwzrenii-,  April, 
1900. 

Median  Osteotomy  of  the  Hyoid  Bone. — Maurice 
Vallas  holds  that  this  operation  is  simple,  easy,  and 
in  itself  benign,  and  that  it  enables  the  surgeon  to 
reach  the  pharynx  and  to  examine  its  inferior  portion 
and  the  vestibule  of  the  larynx  better  than  does  supra- 
hyoid pharyngotomy.  The  indications  for  the  opera- 
tion are  foreign  bodies,  benign  removable  tumors,  can- 
cers limited  to  the  epiglottis,  and  above  all  severe 
syphilitic  constrictions.  The  procedure  greatly  facil- 
itates the  removal  of  intra-muscular  tumors  at  the  base 
of  the  tongue,  and  permits  total  amputation  of  the 
tongue  in  cases  of  cancer  of  the  posterior  portion  of 
that  organ.  Neither  deformity  nor  functional  disorder 
follows  osteotomy  of  the  hyoid  bone. — Rnue  dc  C/ii- 
/■iirgie.  May  10,  1900. 

Pseudo-Appendicitis. — R.  Condamin  and  J.  Vo- 
ron  report  several  cases  which  seem  to  indicate 
that  hysteria  or  neuropathies  are  capable  of  creating 
morbid  conditions  which  closely  simulate  the  local 
symptoms  of  appendicitis,  without  causing  a  rise  of 
temperature  or  modifying  the  general  condition.  In 
addition  sypliilis  causes  pseudo-appendicitis.  Syph- 
ilitics  are  apt  to  suffer  from  enteralgia,  and  should 
this  pain  be  situated  in  the  vicinity  of  the  caecum  and 
the  appendix,  and  should  there  be  at  the  same  time 
any  fever  such  as  is  so  liable  to  be  present  in  cases  of 
untreated  secondary  syphilis,  the  symptoms  will  cer- 
tainly resemble  a  somewhat  severe  case  of  appendi- 
citis.— Archives  Frovinciaks  de  Chirurgie,  May  i,  1900. 

Cerebral  Tuberculosis  in  Children. — Leone  Maes- 
tro reports  two  fatal  cases.  The  first  was  that  of  a 
child  aged  four  years,  with  tuberculosis  of  the  corpora 
quadrigemina.  There  were  gradual  emaciation  and  en- 
feeblement;  pulse  somewhat  intermittent.  Convulsions 
occurred;  there  were  convergent  strabismus  of  both 
eyes,  paralysis  of  the  motor  muscles  of  the  iris,  dulness 
of  hearing,  uncertainty  of  gait,  and  finally  ataxia. 
Death  occurred  six  months  after  the  appearance  of  the 
first  symptom.  In  the  second  case,  that  of  a  child  three 
years  old,  the  chief  symptom  was  pain  in  the  frontal  re- 
gion. At  the  autopsy,  in  addition  to  basilar  meningitis, 
there  was  found  one  tubercle  situated  in  the  right  side 
of  the  cerebellum.  The  frontal  lobes  were  normal, 
and  the  pain  was  probably  a  symptom  of  compression. 
— La  Rijornux  Medica,  May  15  and  16,  1900. 

Voluntary  Luxations. — Francesco  Parona  reports  a 
case  of  voluntary  or  habitual  luxation  of  the  left  shoul- 
der. The  patient  was  a  girl  aged  seventeen  years, 
and  the  dislocation  had  first  appeared  when  she  was 
eight  years  old,  a  few  months  after  she  had  had  a  fall. 
She  could  put  her  shoulder  out  of  joint  at  any  time; 
there  was  no  asymmetry,  swelling,  or  other  deformity, 
and  when  the  bone  was  in  place  the  left  arm  could  be 
used  as  freely  in  every  direction  as  the  right.  The 
author  decided  to  operate,  and,  having  opened  the  cap- 
sule, found  that  the  head  of  the  humerus  was  perfectly 
formed,  and  the  serous  and  cartilaginous  tissues  were 
normal.  Having  made  folds  in  the  capsule,  he  stitched 
them  down,  and  the  possibility  of  dislocating  the 
joint  was  prevented.  The  patient  made  a  good  recov- 
ery, and  the  cure  had  been  perfectly  maintained  two 
years  later. — Jl  Polklhtko,  May  15,  1900. 


July  7,  1900] 


MEDICAL    RECORD. 


17 


Medical  Record: 

A    Weekly  Journal  of  Medicine  ami  Surge?-}'. 


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

Publishers 
WM.   WOOD  &.  CO  ,  51    Fifth   Avenue. 

New  York,  July  7,  1900. 


THE     DIFFERENTIATION'     OF     DEFORMING 
ARTHRITIS,  GOUT,  AND   RHEUMATISM. 

The  time  is  ripe  for  a  more  refined  differentiation  of 
tlie  various  diseases  in  which  joints  may  be  involved. 
It  is  well  known  that  arthritis  may  result  from  several 
causes — traumatic,  toxic,  infective,  primarily  or  sec- 
ondarily, and  in  association  with  disease  of  the  ner- 
vous system — but  among  the  different  forms  there 
stands  out  prominently  one  that  can  be  distinctly  rec- 
ognized as  a  definite  clinical  entity,  in  which  succes- 
sive joints  become  the  seat  of  pain,  redness,  and  im- 
paired mobility,  with  acid  sweats  and  elevation  of 
temperature,  often  complicated  by  inflammation  of  the 
endocardium  and  the  serous  membranes,  and  yielding 
therapeutically,  with  almost  specific  promptness,  to 
salicylic  acid  and  its  salts.  This  disease  we  know  as 
acute  rheumatism  or  rheumatic  fever.  It  may  pursue 
a  subacute  course,  or  leave  behind  chronic  changes  in 
the  joints.  This  disorder  is  almost  certainly  depend- 
ent upon  bacterial  activity,  although  opinions  are  not 
agreed  as  to  the  identity  of  the  causative  micro-organ- 
ism. 

In  addition,  as  has  been  suggested,  inflammation  of 
one  or  more  joints  may  occur  as  a  complication  of  va- 
rious infectious  diseases,  as  for  instance  scarlet  fever, 
influenza,  smallpox,  syphilis,  gonorrhoea,  pyaemia;  but 
this  condition  cannot  properly  be  considered  rheu- 
matism. 

The  pains  in  muscles  and  fibrous  tissues,  and  even 
in  joints,  that  often  appear  after  exposure  to  cold  and 
like  influences,  may  not  be  rheumatic  at  all,  but  may 
be,  rather,  manifestations  of  metabolic  disturbance, 
and  due  to  alterations  in  the  fluids  of  the  body,  in 
consequence  of  which  certain  substances  are  thrown 
out  of  solution,  and  act  as  irritants,  generally  or  lo- 
cally. 

Finally,  so-called  chronic  rheumatism  may  be  con- 
sidered as  representing  a  number  of  forms  of  chronic 
arthritis  of  varied  origin. 

Except  in  their  common  involvement  of  joints,  there 
is  no  relation  between  rheumatism,  gout,  and  deform- 
ing arthritis,  and  error  in  diagnosis  should  not  occur, 
if  careful  investigation  is  made  in  the  individual  case. 
Some  of  the  points  of  differentiation  are  discussed  by 
Luff'  in  a  recent  communication.  This  observer  con- 
tends that  rheumatism  may  occur  as  an  abarticular  as 
'  I'ractitioner,  May,  igoo,  p.  4yi. 


well  as  an  articular  disorder,  manifesting  itself  in  the 
form  of  chorea  or  erythema,  or  endocarditis  or  peri- 
carditis. Rheumatism,  unlike  deforming  arthritis,  is 
not  attended  with  hyperplasia  of  articular  cartilage, 
osteophytic  outgrowths,  and  grating  of  the  ends  of  the 
bones.  The  rheumatic  joints  often  undergo  fusiform 
enlargement  from  thickening  of  the  articular  capsule. 

In  the  differentiation  of  deforming  arthritis  and 
gout,  it  should  be  borne  in  mind  that  the  former  oc- 
curs most  commonly  in  females,  the  latter  in  males; 
the  former  among  the  poor  and  ill-nourished,  and  es- 
pecially under  conditions  of  depressed  health,  pro- 
longed anxiety  and  exposure  to  damp,  and  sudden  al- 
terations of  temperature,  the  latter  among  the  well-to-do 
and  the  well  nourished.  The  one  disorder  is  im- 
proved by  good  dieting,  and  the  other  by  a  spare  and 
plain  diet.  Deforming  arthritis  sets  in  insidiously; 
gout  suddenly.  The  latter  most  commonly  appears 
first  in  one  of  the  feet,  especially  a  joint  of  the  great 
toe;  the  former,  although  ultimately  affecting  fre- 
quently many  joints  of  both  hands,  almost  always  be- 
gins in  one  joint,  most  commonly  one  of  the  joints  of 
the  thumb,  and  spreads  rapidly  to  other  joints.  The 
joint  affection  of  deforming  arthritis  is  at  first  unat- 
tended with  obvious  swelling  and  marked  redness, 
while  that  of  gout  is  attended  with  swelling  and  red- 
ness, and  a  glossy  appearance  of  the  overlying  skin. 
Deforming  arthritis  is  attended  with  little  pain  at  first. 
There  is  some  aching,  but  the  onset  is  insidious. 
Gout  begins  with  severe  pain,  the  patient  as  a  rule 
being  awakened  in  the  early  morning  with  excruciat- 
ing pain  in  the  great  toe.  The  temporo-maxillary 
articulation  is  commonly  affected  in  cases  of  deform- 
ing arthritis,  but  not  in  cases  of  gout.  The  lesions 
of  deforming  arthritis  are  remarkably  symmetrical  in 
the  hands,  while  this  feature  is  wanting  in  cases  of 
gout.  Finally,  sodium  biurate  can  be  found  in  the 
joints  in  cases  of  gout,  but  not  in  cases  of  deforming 
arthritis. 

A  disorder  has  been  described  as  chronic  villoi  > 
arthritis,'  which  is  characterized  by  chronic  inflamma- 
tory enlargement  and  hyperplasia  of  the  villi  of  the 
synovial  membrane,  while  the  cartilage  and  the  bone 
of  the  articular  extremities  remain  uninvolved.  The 
affection  may  be  seated  in  one  or  several  joints,  and 
is  attended  with  pain,  enlargement,  and  deformity 
and  with  impaired  mobility  and  functional  ineffi- 
ciency. It  differs  from  deforming  arthritis  essen- 
tially in  the  involvement  of  the  synovial  membrane 
rather  than  the  articular  cartilage  and  the  adjacent 
bone. 

ANOTHER      INDICTMENT      AGAINST      THE 
MOSQUITO. 

The  more  we  learn  of  the  mosquito  in  her  role  of 
transmitter  of  disease  the  more  clearly  does  she  show 
forth  as  one  of  man's  most  deadly  enemies.  She  of 
the  Anopheles  tribe  is  proven  to  be  the  active  agent 
in  the  transmission  of  malaria  from  man  to  man;  it 
is  claimed  by  Findlay  and  others,  with  apparent  rea- 
son, that  the  mosquito  is  instrumental  in  the  spread 

'SchuIIer  ;  Berliner  klinische  Wochenschrift,  1900,  Nos.  5,  6,  7. 


i8 


MEDICAL    RECORD. 


[July  7,  1900 


of  yellow  fever,  though  whether  this  is  the  only  means 
(if  a  means  at  all)  of  transporting  the  disease,  and 
vhat  kind  of  mosquito  carries  the  germ,  we  do  not  yet 
know;  and  it  has  long  been  an  accepted  belief  that 
the  otiier  species  of  mosquito  (Culex)  is  the  interme- 
diate host  of  filaria  nocturna.  In  the  latter  case, 
however,  it  has  been  supposed  that  the  parasite  was 
liberated  in  water  on  the  death  of  the  mosquito  and 
that  man  became  infected  by  drinking  such  water. 
The  mosquito  was  therefore  simply  a  passive  agent, 
culpable  in  having  bitten  a  filaria-infected  man  but 
guiltless  of  the  infection  of  healthy  individuals.  It 
seems  now,  however,  that  this  is  not  the  case,  or  at 
least  not  always  the  case,  and  that  the  insect  may  be 
the  active  agent  in  inoculating  man  with  this  danger- 
ous parasite. 

In  some  recent  work  on  a  series  of  filarial  mos- 
quitos  at  the  London  School  of  Tropical  Medicine, 
George  C.  Low  has  found  the  mature  worm  in  the 
proboscis  of  the  mosquito  evidently  ready  to  enter  the 
blood  of  the  next  victim  of  tlie  insect's  bite  {British 
Medical  Journal,  June  16,  1900).  It  is  now  known  that 
the  mosquito  does  not  necessarily  die  immediately 
upon  depositing  her  eggs  in  the  water,  but  can,  if  fed, 
goon  living  and  laying  eggs  for  many  weeks;  and 
Low  has  found  that  the  filaria:  do  not  remain  passive 
in  the  thoracic  muscles  of  the  mosquito  after  issuing 
from  the  stomach,  but  leave  that  tissue  and  travel 
toward  the  head  of  the  insect  and  pass  into  the  loose 
cellular  tissue  in  the  neighborhood  of  the  salivary 
glands.  They  are,  of  course,  too  large  to  pass  through 
the  salivary  duct,  as  is  the  case  with  the  malarial 
parasite,  but  they  bore  their  way  through  the  base  of 
the  labium  and  push  forward  along  the  proboscis. 
"It  is  difficult,"  Low  says,  "to  avoid  the  deduction 
that  the  parasites  so  situated  are  there  normally, 
awaiting  an  opportunity  to  enter  the  human  tissues 
when  the  mosquito  next  feeds  on  man." 

If  this  observation  is  shown  to  be  correct,  it  will 
only  add  emphasis  to  the  warning  against  exposure  to 
mosquito  bites  in  the  tropics  and  sub-tropics,  and  \\\\\ 
stimulate  to  greater  activity  those  who  are  searching 
for  a  certain  means  of  protecting  man  against  these 
literally  pestiferous  insects  and  for  some  efficient 
culicicide. 


TYPHOID   FEVER    IN    PARIS. 

Our  Paris  correspondent,  in  the  Medical  Record  of 
June  23d,  calls  timely  attention  to  the  importance  of 
the  sanitary  condition  of  Paris  during  the  Exhibition, 
when  the  city  is  overcrowded  with  people  from  all 
parts  of  the  world,  and  further  points  out  that  consid- 
ering the  lack  of  knowledge  of  hygiene  obtaining 
among  a  large  proportion  of  these  visitors,  the  wonder 
is  that  a  serious  outbreak  has  not  already  occurred. 
The  writer  referred  to  appears  to  dread  the  importa- 
tion of  diseases  more  than  those  which  already  prevail 
in  Paris,  and  is  of  tlie  opinion  that  an  epidemic  of 
bubonic  plague  is  especially  to  be  feared.  While  al- 
lowing that  this  note  of  warning  is  warranted  by  the 
situation,  and  that  the  danger  from  the  outside   is  a 


real  one  which  should  be  strictly  guarded  against,  it 
may  be  doubted,  after  all,  whether  the  chief  menace 
to  the  health  of  "those  on  pleasure  bent"  will  not  be 
found  in  the  sanitary  conditions  of  Paris  itself.  For 
some  considerable  time  typhoid  fever  has  been  un- 
pleasantly active  in  the  city  on  the  Seine.  In  1899 
four  thousand  three  hundred  and  twenty-nine  cases  of 
tliis  malady  were  notified,  of  which  number  eight  hun- 
dred and  two  proved  fatal.  A  comparison  of  the  re- 
ports of  the  first  ten  weeks  of  the  years  1899  and  1900 
can  hardly  be  called  reassuring.  During  that  period 
last  year  three  hundred  and  ninety-eight  cases  were 
notified,  and  in  the  corresponding  period  of  the  current 
year  these  figures  have  been  more  than  doubled.  As 
usual,  when  the  matter  was  investigated  the  cause  for 
this  prevalence  of  enteric  fever  was  discovered  to  be 
due  to  a  contaminated  water-supply.  The  affected 
districts  were  found  to  be  those  whose  drinking-water 
is  drawn  from  a  stream  named  the  Vanse.  Observa- 
tions made  by  Drs.  Thoinot,  A.  J.  Martin,  and  Miguei 
verified  the  suspicions  that  to  the  polluted  water  of 
the  Vanne  is  due  the  increase  of  enteric  fever  in  and 
about  Paris. 

For  obvious  reasons  the  Paris  authorities  and  press 
have  almost  wholly  ignored  or  discredited  these  re- 
ports. Public  Heaith,  touching  on  this  point,  says. 
"The  specific  bacillus  is  said  to  have  been  recog- 
nized and  isolated  from  samples  of  the  water  taken 
from  the  river  itself  from  a  reservoir  at  Montsouris 
and  from  the  supply  of  two  army  barracks,  by  several 
bacteriologists.  Yet  the  prefect  of  the  Seine  tried 
recently  to  persuade  the  council  that  a  mistake  had 
been  made  by  those  who  had  examined  the  water, 
and  that  they  had  been  misled.  Other  evidence, 
however,  is  too  strong  in  incriminating  the  water  of 
the  Vanne,  which  seems  liable  to  pollution  from  its 
source.  Thus  in  that  part  of  the  town  of  Sens  which 
is  supplied  with  water  by  a  branch  taken  from  the 
main  aqueduct  of  the  Vanne  enteric  fever  has  ap- 
peared, while  other  parts  of  the  town  with  a  different 
supply  have  escaped."  Under  these  circumstances  it 
would  be  folly  for  visitors  to  Paris  not  to  take  certain 
precautionary  measures,  such  as  not  to  drink  water 
unless  they  are  satisfied  that  it  has  been  boiled  or 
efficiently  filtered,  and  to  use  discretion  in  the  con- 
sumption of  raw  vegetables  and  oysters  which  may 
have  been  washed  or  allowed  to  stand  in  unboiled 
water. 


The  American  Association  for  the  Advancement 
of  Science. — At  the  closing  session  of  the  meeting  of 
this  association,  which  was  held  in  this  city  the  last 
week  in  June,  the  following  officers  were  elected  for 
the  ensuing  year:  President,  Prof.  Charles  Sedgwick 
Minot,  of  the  Harvard  L'niversity  Medical  School; 
Permanent  Secretary,  L.  O.  Howard,  United  States  De- 
partment of  Agriculture,  Washington,  D.  C. ;  General 
Secretary,  Prof.  William  Hallock,  Columbia  l'niver- 
sity; Secretary  oj  the  Council,  D.  T.  McDougall,  New 
York  Botanical  Garden;  Treasurer,  Prof.  R.  S.  Wood- 
ward, of  Columbia.  The  next  annual  meeting  of  the 
association  will  be  held  in  Denver. 


July  7,  1900] 


MEDICAL    RECORD. 


19 


iacius   of  the  W^cch. 

Dr.  William  Moser  has  been  appointed  assistant 
visiting  physician  to  the  German  Hospital,  Brooklyn. 
Dr.  Moser  was  formerly  pathologist  to  the  same  insti- 
tution. 

Dr.  Augustin  H.  Goelet  writes  that  in  his  remarks 
reported  in  the  Medic.\l  Record  of  June  23d,  p. 
1,098,  he  advocated  the  use  of  morphine  for  the  relief 
of  severe  pain,  not  of  shock,  following  laparotomy. 

The  American  Institute  of  HomcEopathy. —  The 
election  of  the  officers  of  this  society  for  the  ensuing 
year  resulted  in  the  choice  of  Dr.  A.  B.  Norton,  of 
New  York,  for  president,  instead  of  Dr.  W.  W.  \'an 
Baun  as  announced  last  week.  Dr.  Norton  and  Dr. 
Van  Baun  were  opposing  candidates  for  the  office  of 
president,  and  the  vote  was  198  for  Dr.  Norton  to  70 
for  Dr.  Van  Baun. 

American  Medical  Editors'  Association. — At  the 
annual  meeting  of  this  association,  held  in  Atlantic 
City,  June  4th,  the  following  officers  were  elected  for 
the  ensuing  year:  President,  Dr.  Alexander  Stone,  of 
St.  Paul;  Vue-Presiiie/if,  Dr.  Charles  F.  Taylor,  of 
Philadelphia;  Treasurer,  Dr.  S.  W.  Kelley,  of  Cleve- 
land; Secretary,  Dr.  O.  F.  Ball,  of  St.  Louis.  The 
next  meeting  of  the  association  will  be  held  at  St. 
Paul  in  June,  1901. 

The  Study  of  Mosquitos.— Dr.  \V.  N.  Berkeley, 
121  East  Twenty-sixth  Street,  writes  that  he  is  anxious 
during  the  coming  three  months  to  determine  as  fully 
as  possible  the  various  species  of  mosquito  to  which  the 
malaria  endemic  in  our  locality  may  be  due.  Without 
the  help  of  physicians  practising  in  the  near-by  towns 
the  difficulties  of  the  work  will  be  almost  insuperable, 
and  he  therefore  requests  that  physicians  having  pa- 
tients with  malaria  notify  him  in  order  that  he  may, 
with  the  patients'  consent,  send  a  properly  qualified 
man  to  collect  mosquitos  in  houses  and  premises 
where  fresh  cases  have  developed. 

Tho  Thirteenth  International  Medical  Congress. 
— The  following  is  the  programme  of  entertainments 
to  be  given  during  the  session  of  the  International 
Congress  in  Paris:  On  August  2d,  the  day  of  the 
opening  of  the  congress,  the  president  of  the  munici- 
pal council  will  give  a  reception  to  the  members  in 
the  name  of  the  French  government.  The  following 
day  a  reception  will  be  given  by  the  president  of  the 
congress.  On  August  5th  the  president  of  the  French 
republic  will  receive  the  members  of  the  congress  at 
the  Elyse'e  Palace.  On  August  7th  a  reception  will 
be  given  by  the  municipal  council  of  Paris  in  the 
grand  hall  of  the  Hotel  de  Ville.  On  the  evening  of 
August  8th  there  will  be  a  fete  in  the  palace  and  gar- 
den of  the  Luxembourg,  given  by  the  committee  on  or- 
ganization in  honor  of  the  members  of  the  congress. 
Special  entertainments  will  also  be  provided  for  the 
members  of  the  different  sections.  Invitations  for  all 
these  fetes  will  be  extended  to  the  ladies  accompanying 
the  members  of  the  congress,  and  there  will  also  be  a 


special  committee  of  ladies  who  will  look  after  the 
comfort  and  pleasure  of  the  families  of  the  members. 
There  will  be  special  rooms  for  the  convenience  of  the 
ladies  in  one  of  the  buildings  of  the  Faculte  de  Me- 
decine. 

The  New  York  School  of  Clinical  Medicine  has 
been  closed.  This  action  was  decided  upon  by  the 
medical  board  at  a  recent  meeting,  in  consequence,  it 
is  said,  of  a  disagreement  with  the  board  of  trustees 
of  the  institution.  It  is  possible,  however,  that  the 
school  will  reopen  in  the  autumn  under  different  man- 
agement. 

St.  John's  Guild.— The  Seaside  Hospital  at  New 
Dorp,  Staten  Island,  is  open  for  the  reception  and 
care  of  sick  children  and  their  mothers.  Lentil  the 
floating  hospitals  are  put  in  commission  the  patients 
will  be  conveyed  to  tJie  hospital  free  of  cost  by  the 
Staten  Island  ferry  at  10  a.m.  and  2  :30  p.m.,  on  which 
boats  will  be  a  nurse  and  orderly.  Physicians  may 
obtain  tickets  for  distribution  to  their  poor  patients 
upon  application  at  the  office  of  the  Guild.  501  Fifth 
Avenue. 

The  Plague  in  Rio  de  Janeiro,  accounts  of  the  out- 
break of  which  are  given  in  another  column,  has  at- 
tained rather  alarming  proportions.  On  June  26th  25 
new  cases  were  officially  reported,  and  the  deaths  num- 
bered 12.  —  In  Manila  the  total  number  of  plague  cases 
reported  during  .April  was  53.  Of  these  38  were  cer- 
tified by  the  medical  officers  to  be  genuine  cases  of  the 
disease  (29  Chinese  and  9  Filipinos),  while  15  were 
declared  not  to  be  plague.  For  the  preceding  three 
months  the  number  of  cases  certified  as  plague  was  195 
(134  Chinese  and  61  Filipinos)  out  of  212  reported, 
leaving  17  which  were  declared  not  to  be  cases  of 
plague.     Of  the  195  plague  patients,  150  died. 

Quarantine  Service  in  Cuba — The  President  has 

recently  signed  an  order  systematizing  the  quarantine 
service  in  the  island,  and  providing  that,  beginning 
July  15th,  a  commissioned  officer  of  the  Marine-Hos- 
pital service  shall  be  detailed  on  the  staff  of  the  mili- 
tary governor  of  Cuba,  as  chief  of  the  quarantine  ser- 
vice of  the  island.  Estimates  of  expenditures  for  the 
service  and  auditing  of  accounts  will  be  under  the 
supervision  of  the  military  governor,  while  the  en- 
forcement of  the  treasury  quarantine  regulations  and 
details  of  officers  remain  as  provided  in  the  executive 
order  of  January  17,  1899.  The  chief  quarantine  offi- 
cer of  the  Marine-Hospital  service  in  Cuba,  being  on 
the  staff  of  the  military  governor,  will  be  able  to  estab- 
lish a  thorough  co-operation  in  all  the  ports,  and  with 
the  Marine-Hospital  bureau  in  Washington,  in  enforce- 
ment of  its  regulations. 

The  British  Medical  Service  in  South  Africa 
has  recently  been  severely  attacked  in  I'arliament 
and  in  the  newspapers,  the  allegation  being  that  the 
sick  and  wounded  had  been  neglected  cruelly,  and 
that  their  sufferings  had  been  needlessly  increased 
through  mismanagement  and  insufficiency  in  the  sup- 
plies. The  medical  staff  was  said  to  be  inadequate, 
and  houses  which  might  have  been  utilized  as  hospi- 


20 


MEDICAL    RECORD. 


[July  7,  1900 


tals  were  occupied  by  officers.  In  reply  to  these  criti- 
cisms, the  parliamentary  secretary  of  the  War  Office 
admitted  that  the  allegations  as  to  neglect  of  the  sick 
and  wounded  were  true  to  a  lamentable  extent.  They 
were  exposed,  he  said,  to  terrible  hardships,  but  it  was 
not  due  to  any  stinting  of  supplies,  but  to  the  insuper- 
able difficulties  of  distributing  those  that  had  accumu- 
lated in  South  Africa.  Every  demand  on  the  govern- 
ment in  behalf  of  the  troops,  he  said,  had  been  com- 
plied with.  The  officials  in  South  Africa  said  the 
hospitals  had  beds  in  excess  of  the  demand.  There 
were  5,000  beds  in  Natal  and  13,600  in  Cape  Colony. 
There  were  in  South  Africa  466  army  and  440  civilian 
medical  officers  and  556  female  and  5,668  male 
nurses,  besides  the  doctors  and  nurses  engaged  lo- 
cally. The  War  Office,  he  said,  had  cabled  Lord 
Roberts  that  disquieting  reports  regarding  the  hospi- 
tals were  accumulating,  and  asked  him  if  anything 
could  be  done,  and  particularly  whether  more  nurses 
were  needed.  Lord  Roberts  replied  that  he  did  not 
wish  to  shirk  responsibility  or  to  screen  the  shortcom- 
ings of  the  medical  corps,  and  he  suggested  a  committee 
of  inquiry.  He  said  there  had  been  an  abnormal  num- 
ber of  sick  at  Bloemfontein,  due  to  the  exhausting 
nature  of  the  march  and  the  terribly  unsanitary  con- 
dition of  the  camp  at  Paardeberg,  where  the  only 
water  available  for  drinking  Howed  from  the  Boer  camp, 
higher  up,  where  the  river  was  crowded  with  decom- 
posing animals,  and  to  this  number  had  been  added 
many  wounded  after  the  fight  on  March  loth.  To  im- 
provise accommodations  at  Bloemfontein  for  such  a 
number,  which  had  become  two  thousand  before  he  left 
there,  was  no  easy  task.  No  tents  were  carried,  and 
the  public  buildings  had  to  be  turned  into  hospitals. 
In  three  months  there  had  been  6,369  admissions  to 
the  hospital  of  patients  suffering  from  enteric  fever, 
while  the  deaths  numbered  1,370,  about  twenty-one 
per  cent.  Lord  Roberts  observed  that  he  did  not 
know  whether  this  would  be  an  abnormal  rate  in  civil 
hospitals  in  peace  times,  but  if  it  were,  it  was  due  to 
the  exhausted  state  of  the  men  and  not  to  the  neglect 
of  the  medical  corps.  The  strictures  on  the  efficiency 
of  the  army  medical  service  were  evidently  made  by 
amateur  critics  who  seem  to  think  it  is  as  easy  to  pro- 
vide for  the  comfort  of  a  body  of  troops  in  an  enemy's 
country  as  for  a  party  of  Cook's  tourists,  and  who 
never  think  that  a  vast  amount  of  suffering  is  insepar- 
able from  the  rapid  march  of  a  constantly  fighting 
army. 

Cuban  Sanitary  Ideas Several  Cuban  newspa- 
pers of  the  baser  sort,  when  other  occasions  for  fault- 
finding fail,  accuse  the  American  government  of  ex- 
travagance in  carrying  out  the  various  sanitary  reforms 
which  have  been  instituted.  The  writers  share  Sven- 
gali's  amused  horror  at  the  waste  of  so  much  good 
water  in  bathing,  and  deprecate  the  expenditure  of  so 
much  time  and  labor  in  preventing  the  reaccumulation 
of  the  mountains  of  filth  which  formerly  blocked  the 
streets  of  their  towns.  El  Cubaiio  recently  revealed 
one  of  the  reasons  for  this  opposition.  The  Cubans, 
it  said,  justly  and  properly  object  to  the  expenditure 
of  such  a  large  proportion  of  the  revenues  of  the  isl- 


and in  measures  intended  to  repress  yellow  fever,  for 
the  only  result  of  such  measures  is  to  protect  the  lives 
of  the  Americans,  since  the  Cubans  themselves  are 
immune  from  yellow  fever.  The -editor  of  El  Cubaiio 
is  evidently  a  man  of  broad  views  and  unselfish  ideals 
who  ought  to  be  made  president  of  the  first  Cuban 
antivaccination  society. 

A  Medical  Book  Thief.— A  Boston  physician,  a 
graduate  in  medicine  of  McGill  University  in  1833, 
has  been  convicted  on  his  own  confession  of  stealing 
book  plates  from  the  library  of  Harvard  University. 
His  case  has  been  continued  to  the  next  term  of  the 
court  for  sentence. 

Award  of  Prizes  at  the  College  of  Physicians 
and  Surgeons. — At  the  recent  commencement  of  Co- 
lumbia University,  Dr.  August  Jerome  Lartigau  was 
awarded  the  Alonzo  Clark  scholarship.  Dr.  James  D. 
Voorhees  the  Stevens  triennial  prize,  and  Dr.  David 
Bovaird,  Jr.,  the  Alumni  Association  prize  of  the  Col- 
lege of  Physicians  and  Surgeons. 

Cholera  in  India. — A  despatch  from  Bombay,  dated 
July  3d,  says  cholera  prevails  to  an  unusual  degree  in 
the  entire  Bombay  Presidency  with  the  exception  of 
three  districts.  The  cases  reported  for  the  week  end- 
ing June  26th  numbered  20,689,  and  the  deaths  during 
the  same  period  12,333. 

Physicians  Saved  from  Burning. — The  surgeons  of 
the  three  North  German  Lloyd  steamers,  burned  on 
Saturday  last  at  the  Hoboken  dock  fire,  were  all  saved.. 
They  were  Drs.  Leuthe  of  the  Bremen,  Staby  of  the 
Saale,  and  Brauns  of  the  Alain.  They  sailed  on  the 
Kaiser  Willu-bn  der  Grosse  on  Tuesday. 

The  Celtic  Medical  Society. — At  a  regular  meet- 
ing of  the  Celtic  Medical  Society  of  New  York,  held 
recently,  the  following  officers  were  elected  for  the 
ensuing  year:  Fresidenf,  Dr.  John  J.  Morrissey;  Vice- 
President,  Dr.  William  J.  Farrell;  Secretary,  Dr.  J.  J. 
Cronin ;    Treasurer,  Dr.  M.  C.  O'Brien. 

A  Hospital  Romance.— That  truth  is  not  less  strange 
than  fiction  is  illustrated  by  a  recent  occurrence  at  the 
Philadelphia  Hospital.  Some  two  years  ago  a  woman 
was  found  on  the  street  in  a  demented  and  destitute 
condition,  and  was  sent  to  the  hospital.  She  could 
not  give  her  name  or  any  information  as  to  where  she 
had  come  from.  For  a  long  time  there  was  no  im- 
provement, but  after  eighteen  months  the  woman  was 
able  to  relate  something  about  herself  and  her  family. 
Her  husband  was  communicated  with,  and  as  a  result 
her  son  came  from  a  distant  city  to  take  her  home.  It 
turned  out  that  she  had  disappeared  five  years  before, 
and  large  sums  of  money  had  been  spent  in  the  search 
for  her. 

The  County  Association  Officially  Recognized.— 
The  New  York  County  Medical  Association  has  won 
a  suit  brought  to  compel  the  city  to  pay  it  a  penalty 
of  J50  secured  by  the  prosecution  of  a  person  practis- 
ing as  a  physician  without  a  license.  The  association 
furnished  the  proof  on  which  the  man  was  convicted, 
but  the  fine  of  $50  was  paid  into  the  city  treasury. 


July  7,  1900] 


MEDICAL   RECORD. 


21 


The  association  contended  that  the  law  of  1895  pro- 
vides that  when  the  complainant  in  such  cases  is  a 
State  medical  society  or  a  county  medical  society  en- 
titled to  representation  in  a  State  society,  such  fines 
shall  be  paid  to  the  complainant.  The  city  took  the 
position  that  the  act  referred  to  the  Medical  Society 
of  the  County  of  New  York.  The  court  decided,  how- 
ever, that  the  association  is  entitled  to  representation 
in  the  New  York  State  Medical  Association,  which  is 
a  legally  organized  society  in  affiliation  with  the 
American  Medical  Association,  and  thai  therefore  it 
must  have  the  money  as  provided  in  the  law  of  1895. 

Dr.  Jameson,  who  has  passed  successfully  two  or 
three  medical  e.xaminations.  led  a  body  of  raiders  into 
the  Transvaal,  been  imprisoned  therefor  in  South 
Africa  and  in  England,  suffered  from  a  severe  attack 
of  typhoid  fever  while  besieged  in  Kimberly,  and  has 
had  other  adventures  of  various  sorts,  has  now  been 
elected  unanimously  a  member  of  the  Cape  parliament 
from  Kimberly. 

Tlie  International  Congress  of  Medical  Electrol- 
ogy  and  Radiology — The  principal  railways  of 
France  announce  a  reduction  of  fifty  per  cent,  in  rates 
for  the  members  of  this  congress,  and  the  Italian  roads 
will  allow  a  reduction  of  from  thirty  to  fifty  per  cent., 
according  to  the  distance.  The  membership  cards 
will  give  the  right  of  free  entrance  to  the  Exposition 
duri.Tg  the  session  of  the  congress. 

Tuberculosis  in  the  Schools The  board  of  edu- 
cation of  Honolulu  has  adopted  a  resolution  prohibit- 
ing any  one  from  teaching  in  the  public  schools  who 
is  suffering  from  tuberculosis  or  other  contagious  or 
infectious  diseases,  and  also  prohibiting  children  af- 
flicted with  such  diseases  from  attending  the  schools. 
It  is  said  that  there  has  been  a  great  influx  of  con- 
sumptives to  the  islands  during  the  past  year,  the 
attraction  being  the  mild  climate,  and  the  health  au- 
thorities have  become  alarmed  for  the  safety  of  the 
susceptible  native  population. 

Navy  Department,  Bureau  of  Medicine  and  Sur- 
gery, Washington,  D.  C. — Changes  in  the  medical  corps 
of  the  United  States  navy  for  the  week  ending  June 
^o.  1900.  June  22d. — Assistant  Surgeon  C.  N.  Fiske 
ordered  to  the  Boston  navy  }ard.  June  23d. — Sur- 
geon VV.  H.  Rush,  when  discharged  from  treatment  at 
the  naval  hospital,  Mare  Island,  Cal.,  ordered  to 
\V.ishington,  D.  C,  July  loth,  for  examination  for  re- 
tirement, and  then  home  and  to  await  orders.  Assist- 
ant Surgeon  O.  M.  Eakins  detached  from  the  Bufialo 
and  ordered  to  the  Scindia.  June  26th. — Surgeon  C. 
F.  Stokes  promoted  to  surgeon  from  May  31,  1900. 

The  Late  Dr.  Landon  Carter  Gray The  follow- 
ing resolutions  upon  the  death  of  Dr.  Landon  Carter 
Gray  were  passed  at  a  meeting  of  the  medical  board 
of  the  St.  Mark's  Hospital,  held  June  23.  1900: 

"  Whereas,  The  medical  board  of  the  St.  Mark's 
Hospital  has  heard  with  profound  sorrow  of  the  death 
of  their  colleague  and  consulting-physician,  Dr.  Lan- 
don Carter  Gray,  which  occurred  on  May  8,  1900; 

"  Whereas,  Dr.  Landon  Carter  Gray  was  an  esteemed 


member  by  reason  of  his  broad  know  ledge  of  medicine 
and  his  rare  talents  in  neurology ;  he  was  a  kind  friend 
to  many  and  especially  cordial  in  his  relations  with 
the  younger  members  of  the  profession;  therefore 
be  it 

''Resolved,  That  the  members  of  the  board  hereby 
express  their  great  grief  at  the  removal  of  their  es- 
teemed colleague  by  death,  and  extend  their  sympathy 
to  the  widow,  relatives,  and  friends  of  the  deceased. 

"  Resolved.  That  a  copy  of  this  tribute  to  the  mem- 
ory of  Dr.  Landon  Carter  Gray  shall  be  spread  on  the 
minutes  of  this  board  and  a  copy  thereof  be  sent  to 
the  family." 

Carl  Beck,  M.D.,  president;  Ignatz  Morvav  Rot- 
TEXBERG,  M.D.,  secretary. 

The   Late   Dr.  William   Pierson The  following 

resolutions  were  adopted  by  the  staff  of  the  Orange 
Memorial  Hospital  on  June  13,  igoo*: 

"  Whereas,  It  has  pleased  the  Master  to  take  from 
us  our  friend  and  chief  of  staff,  U'illiam  Pierson, 
M.D.  ;   and 

"  Whereas,  We,  the  medical  staff  of  the  Orange 
Memorial  Hospital,  in  special  meeting  assembled, 
wishing  to  make  known  to  all  our  feeling  of  deep 
grief  caused  by  his  death,  do  hereby 

"  Residve,  That  a  suitable  memorial  be  prepared 
and  presented  to  his  bereaved  family  expressive  of  our 
sympathy  and  of  our  own  loss;   and 

"Resolve,  That  the  staff  will  attend  the  funeral  in  a 
body;  and  that  these  resolutions  shall  be  printed  in 
the  medical  and  secular  press,  and  transcribed  upon 
the  records  of  the  staff  of  the  Orange  Memorial  Hos- 
pital." 

Obituary  Notes — Dr.  George  S.  Ward,  of  New- 
ark, X.  J.,  died  on  June  26th  of  pulmonary  trouble.  He 
was  born  in  Bloomfield,  N.  J.,  in  1827,  and  was  grad- 
uated from  the  College  of  Physicians  and  Surgeons, 
New  Vork,  in  1849.  He  retired  from  active  practice 
many  years  ago. 

Dr.  King  Wvllv,  of  Savannah,  Ga.,  died  of  apo- 
plexy on  June  24th,  in  Saratoga,  N.  Y.  He  was  fifty- 
nine  years  old,  and  was  a  graduate  of  the  medical 
department  of  the  University  of  Virginia  in  1869. 

Dr.  Bennett  Bussev,  the  oldest  physician  in  Cali- 
fornia, died  at  his  home  in  Biggs,  on  June  34th,  at 
the  age  of  ninety-three  years.  He  was  graduated  from 
the  medical  school  of  the  University  of  Maryland 
April  7,  1828.     He  went  to  California  in  1S76. 

Dr.  Howard  P.  Balliet,  of  Philadelphia,  twenty- 
three  years  old,  a  recent  graduate  of  the  medical  "de- 
partment of  the  University  of  Penns}lvania,  was 
drowned  at  Atlantic  City  on  June  25th. 

Dr.  Frederick  May  Foster  died  in  Kingston, 
Ohio,  on  May  19th,  at  the  age  of  twenty-five  years. 
He  was  a  graduate  of  the  Ohio  Medical  College  in 
1899,  and  had  just  completed  his  term  of  ser\-ice  as 
interne  at  the  Protestant  Hospital  of  Columbus. 

Dr.  Louis  Arcularius  died  at  his  home  in  this 
city  on  July  ist  of  apoplexy.  He  was  born  in  Hessen, 
Germany,  in  1838.  and  came  to  this  country  almost 
immediately  after  graduation  from  the  L'^niversity  of 
Giessen,  in  1867. 


22 


MEDICAL   RECORD. 


[July  7,  1900 


g'rotTivcss  0f  ^Xcdical  Science. 

.y,:i'  )'<;;•/(•  yfeiiical  Journal.  Jiiiu-  ^o,  iqoo. 

The   Laryngeal   Manifestations   of   Typhoid   Fever.  —  L.    B. 

Lockard  reviews  the  literature  of  the  subject,  and  describes 
the  case  of  a  man  of  thirty-hve  years  who  in  the  sixth  week 
of  the  disease  presented  an  abscess  of  the  left  arytenoid. 
Owing  to  threatened  suffocation,  tracheotomy  was  per- 
formed, followed  by  endolaryngeal  incision  of  the  tumor, 
and  the  evacuation  of  a  considerable  amount  of  pus.  After 
recovery  the  left  vocal  cord  was  found  fi.Ked  in  adduction, 
due  to  ankylosis  of  the  crico-arytenoidal  articulation.  The 
right  cord  was  abducted  and  perfectly  rigid,  due,  no  doubt, 
to  a  perichondritis  that  had  extended  across  the  median 
line.  After  all  signs  of  inflammation  had  disappeared  di- 
latation was  daiiy  performed  and  continued  for  a  long 
time.  The  cords  readily  separated,  but  upon  withdrawal 
of  the  instrument  would  immediately  fall  back  into  their 
old  positions.  The  tracheal  cannula  was  constantly  worn 
except  when  the  pp.tient  was  at  rest.  In  order  to  make  its 
removal  possible  tlie  cords  were  taken  away  piecemeal  by 
the  double  curette  of  Heryng,  and  an  opening  was  made 
sufficiently  large  to  permit  free  breathing. 

The  Cl'sme  of  a  Cleft  Palate  by  Lingual  Implantation.— 
In  a  case  of  cleft  palate  in  wliich  the  Langenbeck  as  well 
as  the  Davies-Colley  operation  failed  to  cover  the  immense 
congenital  defect,  Car!  Beck  recently  implanted  a  portion 
of  the  tongue.  The  ease  with  which  even  extensive  resec- 
tion of  the  tongue  is  tolerated  by  carcinomatous  patients 
induced  him  to  form  a  lateral  flap  from  the  tongue,  which, 
after  being  turned  and  reflected  near  the  base,  was  united 
with  the  freshened  edge  of  the  cleft  of  the  same  side.  The 
gaping  wound  margins  of  the  side  of  the  tongue  were  then 
accurately  united,  and  the  floor  of  the  mouth  and  the  lin- 
gual angle  were  packed  with  iodoform  gauze.  During  the 
after-treatment  a  mild  solution  of  boric  acid  was  sprayed 
through  the  nostrils  every  fifteen  minutes.  Liquid  diet 
was  given  exclusively.  After  nine  days  the  basis  of  the 
flap  was  severed,  and  one  week  later  the  flap  was  united 
with  the  opposite  margin  of  the  cleft  according  to  the  usual 
uranoplastic  procedures. 

A  Contribution  to  the  Study  of  Influenza  in  Children,  with 
Special  Reference  to  its  Treatment  with  Sodium  Benzoate. — 
H.  B.  Sheffield  gives  a  general  review  of  the  subject  and 
appends  a  lengthy  bibliography.  Concerning  treatment 
he  says  that  he  has  found  sodium  benzoate  to  relieve  all 
SN'mp'toms  within  forty-eight  hours.  For  high  temperature 
he  occasionally  gives  a  little  acetanilid,  which  also  relieves 
pain,  adding,  when  the  latter  is  severe  a  little  codeine. 
When  rheumatoid  pains  predominate,  he  combines  salol 
with  the  foregoing.  In  connection  with  internal  remedies 
he  uses  the  compound  tincture  of  benzoin  for  inhalation, 
regarding  it  as  an  admirable  respiratory  antiseptic,  expec- 
torant, and  anti-spasmodic. 

The  Role  of  Purulent  Rhinitis  of  Childhood  in  the  Produc- 
tion of  Atrophic  Rhinitis. — R.  McKinney  gives  the  clinical 
histories  which  bear  out  the  truth  of  Bosworth's  dictum  as 
to  the  causative  relation  of  the  early  purulent  rhinitis  of 
children  to  the  later  atrophic  condition  so  frequently  found. 
McKinney  is  not  disposed,  however,  to  believe  that  this 
relation  of  cause  and  effect  invariably  holds. 

Formalin  as  an  Antiseptic  in  General  Surgery,  Gynsecol- 
ogy,  and  Obstetrics. — By  G.  K.  Crawford. 

Are  there  Veritable  Valves  in  the  Rectum  ? — By  \V.  Boden- 
hamer. 

The  Treatment  of  Puerperal  Infection.  — By  J.  B.  Kille- 
brew. 

The  Medical  Si'ics.  /:iiu\jo,  rgoo. 

When  is  it  Proper  to  Interfere  in  Apparently  Difficult  or 
Delayed  Cases  of  Labor,  Especially  in  Primiparse?— Mal- 
colm McLean  directs  attention  to  the  fact  that  a  woman 
bearing  her  first  child  is,  for  reasons  peculiar  to  her  class, 
particularly  liable  to  certain  difficulties  and  dangers,  which 
seldom  menace  the  woman  who  has  before  gone  through 
the  normal  stages  of  labor.  Since  malpresentations  and 
mali>ositions  of  the  child,  and  deformities  of  the  bonj-  pel- 
vis of  the  mother,  may  obtain  in  the  case  of  the  multipara 
as  in  that  of  the  primipara,  the  conclusion  is  obvious  that 
the  peculiar  danger  menacing  the  latter  resides  in  the  con- 
dition of  the  soft  structures  of  the  parturient  canal.  The 
difference  between  the  primipara  and  the  multipara  in  this 
respect  is  to  be  found  in  the  fact  that  in  the  primipara  that 
peculiar,  physiological  softening  down  and  relaxation  of 
the  soft  parts,  which  should  precede  the  passage  of  the 
child,  goes  on  generally  very  slowly,  occupying  many  more 
hours  in  its  accomplishment  than  in  the  case  of  the  multi- 
para. The  deduction  which  the  author  draws  from  this 
fact  is  that  it  is  meddlesome  midwifery  to  interfere  too 
early  in  the  course  of  a  first  labor.     He  holds  that,  if  the 


presenting  part  is  high  up  and  movable,  if  the  pelvic 
measurements  are  within  normal  limits,  the  soft  parts  un- 
relaxed  and  not  edematous  or  swollen,  the  ca.se  may  be 
and  should  be  allowed  to  proceed  without  interference. 
When  the  forces  are  apparently  normal  and  the  presenting 
part  is  arrested  at  any  given  point  for  over  half  an  hour, 
or  if  the  soft  parts  of  the  mother,  having  once  been  relaxed 
and  thoroughly  moistened  with  mucus,  are  becoming  hot, 
oedematous,  and  discolored,  the  indications  are  for  early 
assistance. 

The  Indications  for  Prematurt  Delivery,  with  Special  Ref- 
erence to  Eclampsia  and  the  Pre-Eclamptic  State. — Bv  S. 
.Marx. 

The  Prevention  of  Dystocia  due  to  Foetal  and  Pelvic  Dis- 
proportion.—  By  Edward  A    Avers. 

The  Treatment  of  Tumors  Complicating  Pregnancy. — By 
Brooks  H.  Wells. 

Boston  MiiUcal  and  Siirgioal  /ournal.  June  28,  jqoo. 

A  Study  of  Twenty-Four  Cases  of  Typhoid  Fever  with 
Symptoms  of  Peritoneal  Infection  .  Laparotomy.— George  B. 
Shattuck.  J.  Collins  Warren,  and  Farrar  Cobb,  a  com- 
mittee of  the  Boston  Society  for  Medical  Improvement, 
report  upon  these  cases,  seventeen  of  which  were  cases  of 
perforation  of  the  bowel,  two  of  preperforative  necrotic 
areas,  one  of  ruptured  mesenteric  gland,  one  of  general 
septic  peritonitis,  the  cause  of  which  was  not  clear,  and 
three  were  cases  in  which  symptoms  of  intra-abdominal 
infection  existed,  but  in  which  no  cause  for  the  symptoms 
could  be  discovered  at  operation.  Of  the  three  cases  last 
mentioned,  recovery  occurred  in  two,  and  of  the  remain- 
ing twenty-one,  in  which  peritoneal  infection  was  found 
at  operation,  recovery  occurred  in  three.  From  a  study 
of  these  ca.ses  the  committee  concludes  that  (i)  in  many 
very  sick  patients  perforation  or  peritoneal  infection  can- 
not'be  diagnosed  until  the  results  are  already  widespread 
and  of  fatal  extent.  The  chances  of  a  fatal  issue  from  an 
abdominal  operation  in  such  cases  are  overwhelming.  (2) 
In  mild  cases  of  fair  general  condition  an  abdominal  opera- 
tion is  readily  borne,  provided  no  peritoneal  infection  is 
present.  (3)  A  small  number  of  mild  cases  m.ay  have 
sudden  perforation  with  free  extravasation.  In  these  the 
symptoms  are  fulminant,  but  localized  to  a  great  extent, 
and  in  these  (4)  operation  must  be  done  at  once,  for  general 
infection  may  become  past  relief  in  from  one  to  five  hours, 
and  walling  oft'  of  the  perforation  by  protecting  adhesions 
is  so  rare  as  not  to  be  counted  upon.  (5)  In  the  majority  of 
mild  cases,  beginning  infection  (whether  from  perforation 
or  not)  is  marked  by  comparatively  slight  symptoms — local 
pain,  tenderness,  spasm,  and  leucocytosis.  The  severe 
following  symptoms  mean  general  peritonitis.  (6)  These 
warning  symptoms  demand  serious  consideration  and 
studv,  but  in  many  ca.ses  are  either  not  rightly  understood 
or  not  acted  upon.  (7)  Complaint  of  abdominal  pain  in  a 
case  of  typhoid  fever  should  always  lead  to  a  suspicion  vi 
beginning  peritoneal  infection.  (S)  Frequent  leucocyte 
counts  are  needed  in  every  case.  In  the  presence  of 
abdominal  pain  an  hourly  count  is  necessary.  (9)  Pain 
associated  with  local  tenderness  and  a  muscular  spasm  and 
a  rising  white  blood  count  indicates  in  most  cases  an  opera- 
tion. 

Separation  of  the  Epiphysis  of  the  Olecranon. — By  F.  J. 
CotKra. 

A  Modification  of  the  Sphygmograph. — By  Robert  T.  Edes. 

Jiunnal  of  tlie  .  Inierii  an  Mcdital  Ass'  n,  June  30,  ii)oo. 

Intracranial  Pressure. — W.  N.  Bullard  calls  attention  to 
certain  non-traumatic  conditions,  without  localizing  symp- 
toms, in  which  operation  is  useful.  After  giving  cases,  he 
concludes:  (i)  There  exist  certain  non-traumatic  cases  of 
increased  intracranial  pressure  of  unknown  or  doubtful 
origin.  (2)  Whenever  such  an  excess  of  intracranial  pres.s- 
ure  exists  as  to  cause  serious  symptoms,  the  question  of 
its  relief  by  opening  the  cranium  and  cutting  the  dura 
should  always  be  considered.  (3)  In  certain  non-trau- 
matic cases  of  excess  of  intracranial  pressure,  mor-  or  less 
permanent  relief — or  even  cure — may  be  obtained  by  proper 
surgical  interference.  (4)  In  ca.se  of  acute  severe  optic 
neuritis  of  unknown  origin,  the  question  of  opening  the 
cranium  and  relieving  the  excessive  intracranial  pressure 
should  be  considered. 

Abdominal  vs.  Vaginal  Hysterectomy  for  Uterine  Carci- 
noma.— J.  B.  1  leaver  favors  abdominal  hysterectomy  for 
the  great  majority  of  cases  of  uterine  carcinoma,  though 
in  some  instances  the  vaginal  route  may  be  better.  The 
advantages  are  completeness  of  <)])eration,  removal  of  pel- 
vic glands,  better  area  for  complete  extirpation  of  carcino- 
matous tissue,  lessened  danger  to  the  uterus  and  of  infect- 
ing the  peritoneum,  and  less  risk  of  hemorrhage. 

TjTJhoid  Fever. — J.  H.  Sackrider  says  the  indications  for 
treatment  are  not  always  alike.  Since  1897  he  has  used 
cold  water  internally  as  an  enema  to  reduce  temperature, 


July  7,  1900] 


MEDICAL    RECORD. 


at  the  same  time  spraying  the  skin.  Cases  are  cited. 
Cold  enemata  relieve  sleeplessness  and  restlessness.  Early 
antisepsis  of  the  gastro-intestinal  tract  is  greatly  to  be  de- 
sired. 

Should  the  Dental  Student  be  Educated  Independently  of 
General  Medicine?— By  O.  V.  I.  Brown. 

Practical  Value  of  a  Medical  Education  to  the  Student  of 
Dentistry. — By  Warren  Brown  Hill. 

Is  Medical  Education  a  Necessary  Qualification  for  Dental 
Practice? — By  R.  R.  Andrews. 

Hemorrhage  after  Confinement  and  its  Treatment. —  By 
Herman  E.  Hayd. 

7//t-  Phihuh-lphia  Mcdiial  Journal,  June  30,  igoo. 

A  New  Pathogenic  Mould.— W.  Ophiils  and  Herbert  C. 
Moffitt  report  the  case  of  a  farm  laborer,  nineteen  years 
old,  who  died  after  suffering  from  pleural  effusion,  inflam- 
matory joint  swellings,  cough,  constantly  elevated  tem- 
perature, slight  chills,  and  profuse  sweating.  The  diag- 
nosis was  septico-pysmia.  At  the  autopsy  numerous 
abscesses  were  found  in  various  parts  of  the  body,  in  the 
pus  of  which  were  present  peculiar  parasitic  org;anisms 
which  in  similar  recorded  cases  have  been  described  as 
protozoa — coccidioides  inmitis  pyogenes.  In  cultures  of 
these  organisms  a  mould  developed  on  the  second  day. 
A  pure  culture  of  this  mould  in  the  third  generation  was 
injected  into  the  ear-vein  of  a  rabbit.  The  animal  showed 
no  symptoms  and  was  killed  three  weeks  after  the  inocula- 
lation.  Tubercle-like  nodules  were  found  in  the  lungs, 
spleen,  and  kidneys,  and  in  them  the  protozoon-like  bod- 
ies were  seen,  but  no  mycelium.  The  authors  therefore 
conclude  that  the  protozoon-like  bodies  and  the  mycelium 
are  different  stages  in  the  development  of  the  same  fun- 
gus. The  relation  between  the  mould  and  protozoon-like 
bodies,  they  think,  is  that  the  latter  are  a  form  of  fructifi- 
cation of  the  mould.  The  way  in  which  they  develop  from 
the  mould  after  injection  into  the  animal  body  remains  to 
be  studied. 

Especial  Hospitals  for  Consumption  among  the  Poor  in  Our 
Cities.— By  Edward  ().  Otis. 

Questions  of  the  Day  in  Medicine. — By  J.  M.  Da  Costa. 

Angina  Pectoris. — By  Clifford  Allbutt. 

7 he  Lancet,  /une  3j,  igoo. 

A  Plea  for  Early  Operation  in  Cases  of  Undoubted  Tu- 
bercle of  the  Lung. — In  discussing  the  dangers  of  o]K-ra- 
tion  in  cases  of  this  nature,  J.  F.  Palmer  finds  three  to  be 
especially  noteworthy  :  first,  pneumothorax  ;  second,  sur- 
gical emphysema;  third,  hemorrhage.  Emphysema  may 
result  from  rupture  of  the  trachea  or  larger  bronchial  tubes, 
external  wounds  intf>  the  cellular  tissues  surrounding  the 
costal  pleura  without  lesion  of  the  latter,  lesion  of  the  cos- 
tal pleura  only  with  external  wound,  and  lesions  of  both 
pleurje  with  or  without  external  wound.  In  regard  to 
hemorrhage,  the  writer  says  that  when  a  cutting  opera- 
tion is  required  at  the  apex  of  the  lung,  and  no  adhesions 
are  present,  the  diseased  part,  if  not  too  extensive,  might 
be  included  in  a  single  ligature  and  the  whole  excised.  In 
all  operations  on  the  lung  the  introduction  of  bacteria  from 
without,  through  the  wound  in  the  chest-wall,  can  be  effec- 
tually prevented  by  modern  antiseptic  methods.  But  there 
is  in  these  ca,ses  another  channel  of  entrance  for  bacteria, 
viz.,  the  trachea  and  bronchial  tubes.  The  general  expe- 
rience of  internal  wounds  of  the  lung  when  the  skin  is 
intact  points  to  the  pneumococcus  as  most  to  be  feared  in 
this  direction.  Pneumonia  is  the  most  frequent  complica- 
tion of  rupture  of  the  lung  and  the  wounds  caused  by  frac- 
tured ribs,  injuries  in  which  the  trachea  is  the  only  pas- 
sage for  microbes,  and  which  resemble  in  this  respect 
operations  on  the  lung  with  the  external  opening  in  the 
chest  wall  hermetically  sealed. 

Acroparsesthesia. — Three  cases  of  this  affection  are  de- 
scribed by  F.  H.  Edgewovth.  The  common  feature  was 
a  dead,  tingling  feeling  in  the  hands  and  arms,  either  at 
night  or  on  using  the  hands,  or  persistent,  though  much 
wor.se  on  manual  labor.  No  objective  sign  could  be  found 
in  any  of  the  cases.  The  pathology  of  acropara;sthesia  is 
unknown.  According  to  Lereboullet  the  fault  lies  in  the 
peripheral  venous  circulation,  which,  by  producing  ischiE- 
mia,  or  it  may  be  passive  hyperaemia,  results  in  .serous  in- 
filtration of  the  terminal  branches  of  the  nerves.  And 
certainly  in  some  instances  objective  signs  of  vasomotor 
disturbance  have  been  noted.  But  this  theory  would  cover 
at  most  a  few  only  of  the  recorded  cases,  and  does  not,  for 
instance,  explain  those  described  above  in  which  no  vaso- 
motor changes  were  apparent.  The  origin  of  the  disease 
is  probably  to  be  found  in  the  age  and  sex  of  the  patients, 
and  the  affection  may  be  related  to  those  other  abnormal 
actions  of  the  central  nervous  system  which  are  so  apt  to 
occur  in  women  during  the  years  preceding  and  following 
the  menopause.     The  diagnosis  should  be  based  on  the 


conjunction  of  these  abnormal  sensations  with  an  absence 
or  insignificance  of  signs  of  vasomotor  disturbance  The 
affections  with  which  acropariesthesia  is  most  likely  to  be 
confounded  are  hysteria,  peripheral  neuritis,  erythrome- 
lalgia,  acrocyanosis,  acromegaly,  and  arterial  degenera- 
tion. 

Some  Notes  on  the  Introduction   and   Spread  of  Plague. — 

From  a  personal  experience  in  Bombay  and  Calcutta  G. 
J.  Blackmore  discusses  the  possibility  of  the  invasion  of 
England  by  the  dreaded  disea.se.  He  believes  that  if  the 
plague  is  to  be  prevented  from  entering  the  mother  coun- 
try there  must  be  (i)  a  mo«t  careful  search  made  for  modi- 
fied cases  of  plague  for  some  considerable  time  after  the 
disease  has  apparently  died  out  in  places  that  have  been 
attacked  by  it ;  (2)  rigid  inspection  of  vessels  and  passen- 
gers coming  from  infected  places,  not  only  while  they  are 
known  to  be  infected  but  for  months  afterward;  (3)  disin- 
fection of  dirty  clothing  and  rags  coming  from  such  places  ; 
(4)  a  sharp  lookout  kept  for  any  increased  mortality  among 
rats  in  seaport  towns,  with  rejieated  search  for  the  plague 
bacillus  in  the  bodies  of  those  found  dead  ;  (5)  an  attempt 
made  to  exterminate  the  vermin  which  may  act  as  carriers 
of  the  plague ;  and  (6)  early  inoculation  of  the  people 
when  plague  has  appeared  among  rats. 

On  Chylous  Ascites,  with  an  Illustrative  Case.  —  The  pa- 
tient of  J.  H.  doom  was  a  woman  aged  thirty-nine  years, 
with  abdominal  swelling  and  gradual  weakness  and  ema- 
ciation. On  dee])  jialpation  several  hard  masses  could  be 
felt  in  the  abdominal  and  epigastric  regions.  The  diagno- 
sis was  cancer  of  the  omentum  and  mesentery.  Later  the 
abdomen  was  aspirated  and  the  fluid  found  to  be  essen- 
tially finely  emulsified  fat  with  much  granular  fatty  debris. 
Death  resulted  in  about  two  months  after  admission  to 
hospital.  The  autopsy  showed  diffuse  cancerous  masses 
at  different  points  in  the  abdomen.  Especially  marked 
was  the  malignant  inflluation  in  the  neighborhood  of  the 
receptaculum. 

The  Comparative  Germicidal  Action  of  Some  Disinfectants. 

—  By  A.  n.  Burgess. 

Acute  Glossitis  Complicating  a  Case  of  Typhoid  Fever. — 
By  H.  C.  Thomson. 

Imperforate  Hymen  and  Retained  Menstrual  Accumulation. 

—  By  H.  H.  Borland. 

On  the  Degeneration  of  the  Neuron. — First  Croonian  lect- 
ure, by  W.  Moll. 
Differentiation  in  Diabetes. — By  F.  W.  Pavy. 

/Sritish  Medical  Journal ,  /une  3j,  /goo. 

A  Case  of  Hemorrhagic  Pancreatitis. — J.    C.    Uhthoff  and 

E.  F.  Maynard  relate  the  case  of  a  man  seventy-seven 
years  old,  who  had  recently  complained  of  "  indigestion." 
The  morning  before  admission  he  was  suddenly  .seized 
with  abdominal  pain,  followed  by  sickness  and  collap.se. 
Coffee-ground  matter  was  vomited  until  death,  three  days 
later.  The  head  of  the  pancreas  was  dark  and  the  size  of 
an  orange.  The  entire  organ  was  firmly  adherent  to  ad- 
jacent structures.  Spots  of  fat  necrosis  were  scattered  in 
it.  There  was  one  large  hemorrhage  in  the  head  of  the 
gland  and  smaller  ones  throughout. 

Epidemic  Cerebro-Spinal  Meningitis  in  Dublin. — A.  R.  Par- 
sons and  H.  E.  Littledale  report  an  outljreak  in  Ireland, 
which  had  been  free  from  the  epidemic  form  since  1S86. 
The  records  of  cases  seen  at  the  Dublin  Hospital  are  given 
with  pathological  reports.  The  diplococcus  as  described 
by  Weichselbaum  was  found,  and  kept  alive  by  trans- 
planting it  on  Loeffler's  serum  every  three  or  four  days, 
keeping  it  constantly  at  37    C. 

Acute  Pancreatitis  Complicating  Mumps.— H.  W.  Jacob 
gives  notes  of  a  case  of  this  rare  complication  of  parotitis. 
Vomiting  of  severe  nature  was  seen  in  a  boy  of  ten  yeais. 
followed  by  violent  pain  in  the  upper  abdomen,  and  an 
enlarged  pancreas  was  made  out.  One  week  later  all  ten- 
derness had  disap])eared.  The  parotitis  subsided  as  the 
pancreatic  affection  developed. 

The  Croonian  Lectures  on  Degeneration  of  the  Neuron. — 
By  Frederick  W.  M<.lt. 

General  Emphysema  Complicating   Fractured  Ribs. — By  J. 

F.  Heise  Elk-rton. 

Two  Lectures  on  Antenatal  Diagnosis. — By  J.  W.  Ballan- 
tyne. 

Berliner  klinisclie  W'ochensclirijt,  June  n.  igoo. 

Epidemiological  Contribution  to  the  Question  of  Malaria  In- 
fection.—E.  Grawitz  alludes  to  the  mosquito-infection  the- 
ory, and  then  gives  statistics  of  the  amount  of  malaria  oc- 
curring during  given  periods  in  certain  divisions  of  the 
German  army.  His  figures  show  that  the  greatest  amount 
of  malaria  did  not  occur  during  those  months  when  the 
mosquitos  are  most  active  and  liable  to  sting,  but  cases  of 
the  fever  were  more  numerous  in  the  spring.     He  expres.ses 


24 


MEDICAL    RECORD. 


[July  7,  1900 


the  view  that  there  are  other  organisms  than  the  mosquito 
whieh  may  be  the  intermediate  host  of  the  malarial  para- 
site, particularly  those  which  live  in  water,  and  therefore  , 
calls  attention  to  the  necessity  of  a  water-supply  above  re- 
proach in  our  efforts  to  eradicate  malaria. 

The  After-Treatment  of  Operations  on  the  Eyeball.— G. 
Gutman  describes  the  technical  procedures  followed  by 
him  in  operations  of  this  class,  with  special  reference  to 
the  application  of  bandages  and  the  kind  to  be  preferred. 

Significance  of  the  Word  "Gastric  Dilatation"  in  German 
Literature  since  1875. — By  A    Hesse. 
Inflammations   and   Displacements  of   the   Uterus.— By  J. 

Veil. 

Cataract  Extraction  in  Unilateral  Vision.— By  F.  Mendel. 

Typhoid  Fever.- By  Th.  Rumpf. 

French  Joiirna/s. 

Phthisiotherapy. — Letulle  discusses  the  cure  of  phthisis 
by  alimentation  in  hospital  practice.  "The  kitchen  is  the 
best  pharmacy  of  the  lungs  "  is  a  saying  which  cannot  be 
too  often  repeated.  It  is  likewise  the  cheapest  form  of 
treatment.  The  mode  of  carrying  out  the  plan  with  menus 
for  different  meals,  and  results,  are  given.  The  following 
practical  conclusions  are  drawn:  (i)  The  cure  by  food  in 
hospital  practice  is  easy,  cheap,  and  often  most  favorable, 
whatever  may  be  the  stage  of  the  disease.  (2)  Young  tu- 
berculous subjects  benefit  most  from  the  hygienic  hospital 
course.  (3)  Increase  in  weight  is  shown  especially  during 
the  first  four  or  six  weeks  after  admission  to  the  hospital. 
(4)  When  there  is  a  stationary  period  after  an  increase,  the 
patient  should  be  sent  to  the  country,  the  hospital  having 
done  all  it  can  in  the  case.  (5)  Male  patients  seem  to 
benefit  more  than  female  from  the  hospital  food  cure. — La 
J'rc-sst'  Mcu/ica/t',  June  16,  kjoo. 

Some  Clinical  Contributions  to  the  Disease  Called  Malta 
Fever. — Edmond  Neusser  describes  this  aftection,  which 
infects  the  borders  of  the  Mediterranean,  the  Red  Sea,  and 
many  islands  including  Porto  Rico.  It  begins  with  head- 
ache, pains  in  the  extremities  and  lumbar  regions,  insom- 
nia, l^ok  of  appetite,  vomiting,  and  constipation.  Sweat- 
ing is  so  profuse  that  the  acute  attack  has  been  termed 
febris  sudoralis.  The  chronic  course  has  been  called 
phthisis  Mediterranea.  The  febrile  attack  has  a  duration 
of  one  to  five  weeks.  The  mortality  is  one  to  two  per  cent. 
Recurrences  may  give  a  course  of  man\-  months  and  even 
of  several  years.  Neusser  showed  at  the  Wiesbaden  con- 
gress a  subject  of  Malta  fever  sick  for  eight  years.  This 
disease  has  a  great  importance  for  armies,  since  in  the  at- 
tack a  soldierl  ises  about  three  months'  time. — /.<•  Prcgii'-s 
A/i'i/ncj/,  June  16,  igoo. 

The  Geographical  Distribution  of  Goitre  in  France. — L. 
Mayet,  in  calculating  the  mean  coefficient  of  each  depart- 
ment for  a  period  of  years,  obtained  the  proportion  of  young 
men  classed  in  the  auxiliary  service  of  the  army  for  goitre. 
This  number  of  goitre  cases  in  each  thousand  examina- 
tions gave  the  coefficient  of  the  actual  frequency  in  each 
department.  Six  departments  gave  from  ten  to  forty-five 
goitrous  subjects  of  twenty  years  of  age  in  one  thousand 
examined.  In  eleven  departments  goitre  appears  to  have 
no  existence.  Between  these  two  extremes  are  four  series 
having  from  ten  in  one  thousand  down  to  0.50  to  1.25  in 
one  thousand.  For  the  whole  of  France  goitre  appears  to 
have  diminished,  while  on  the  increase  in  certain  regions. 
— Go:f//t'  Hebdomadaire  dc  Medcciue  et  dc  Chiriirgic, 
June  14,  1900. 

Erythema  Scarlatinifonne. — Breton  records  an  instance 
of  scarlatina-like  rash  due  to  subcutaneous  injections  of 
cacodylate  of  sodium  given  to  a  man  thirty-eight  years  of 
age,  as  a  cure  for  phthisis.  During  the  night  succeeding 
an  injection  there  are  general  malaise,  heat,  and  irritation 
of  the  skin  preventing  sleep,  and  followed  by  itching.  The 
erythema  is  generalized  in  from  twelve  to  fourteen  hours 
from  the  time  of  injection,  and  is  most  marked  over  zones 
of  pressure.  There  is  no  fever.  Thirty-six  hours  later  the 
erythema  grows  pale  and  disappears  on  the  third  day,  and 
is  not  followed  by  desquamation. — Ga::cttc  dcs  Hopitaii.x , 
June  ig,  igoo. 

Botryomycosis. — Xavier  Delore  refers  to  a  case  recently 
reported  by  him  as  occurring  on  the  ulnar  border  of  the 
hand.  He  now  adds  another  from  the  service  of  Professor 
Poncet,  in  which  the  tumor  was  located  on  the  right  little 
finger  near  the  insertion  of  the  nail.  The  vascular  peduncu- 
lated tumor  of  pea-size  was  excised,  and  no  recurrence  took 
place.  The  infection  had  undoubtedly  occurred  in  caring 
for  horses. — Gazette  dcs  Hopitaii.x.  June  12,  igoo. 

Uni-'crsity  Medical  Maj(a~i>ic.  June,  igoo. 

Two  Cases  of  General  Anaesthesia. — C.  W.  Burr  finds  an- 
aesthesia of  the  whole  surface  rare,  even  in  hysteria.  The 
two  ca.ses  illustrate  the  fact  that.  Iiesides  hysteria,  evi- 
dences of  organic  disease  maybe  found.     In  the  hysterical 


case  a  man  aged  twenty-four  years  had  for  eleven  numths 
numbness  and  tingling  in  the  legs,  with)  gradual  loss  of 
power.  He  became  suddenly  unconscious,  and  remained 
so  for  two  or  three  days.  On  regaining  his  senses  he  was 
paralyzed  in  both  legs,  and  had  incontinence  of  urine  and 
faeces.  This  lasted  for  six  months.  Subsequently  there 
was  complete  anaesthesia  to  touch,  pain,  and  temperature 
over  the  entire  body.  There  were  attacks  of  unconscious- 
ness, followed  by  hysterical  manifestations,  and  once  the 
temperature  reached  112'  F.  The  second  case  was  that  of 
an  utmiarried  woman  aged  twenty-eight  years.  At  the  age 
of  five,  after  a  fright,  she  began  to  stagger  and  became  un- 
able to  walk.  In  about  a  year  she  rapidly  became  blind. 
After  two  years  following  convulsions  she  became  deaf  in 
the  left  ear  and  insensitive  on  the  left  side.  Xine  years  ago, 
after  serious  illness  and  convulsions,  she  became  insensi- 
tive on  the  right  side,  and  partially  deaf  in  the  right  ear. 
The  movement  of  the  limbs  is  awkward,  and  when  placed 
on  her  feet  she  stands  for  a  few  minutes  and  then  sinks  to 
the  floor.  There  is  complete  anesthesia  to  touch,  pain,  and 
temperature  over  the  entire  body,  with  loss  of  the  senses  of 
taste,  smell,  and  touch,  and  roots  of  teeth  can  be  extracted 
without  pain.  It  would  appear  that  earlj-  in  life  there  had 
been  some  organic  brain  disease. 

Observations   of  Blood   Changes  following  Coeliotomy. — C. 

Y,  White  has  pursued  studies  to  determine  whether  the 
blood  showed  a  reaction  to  major  gynaecological  opera- 
tions. The  average  leucocyte  count  on  the  hospital  chart 
is  useless.  The  blood  examination  should  be  considered 
only  in  connection  with  a  thorough  examination  of  the 
patient.  In  the  early  stages  of  malignant  disease  slight 
changes  or  none  may  be  found ;  later  the  picture  is 
variable,  and  in  the  cachectic  stage  we  may  have  profound 
secondary  ana;mia  with  or  without  leucocytosis.  The  leuco- 
cytes are  studied  before  and  after  operation  and  in  the 
complications  during  convalescence.  A  series  of  tables 
shows  the  results  obtained. 

Acute  Enlargement  of  the  Thyroid  Gland,  with  Roport  of 
Cases. — Alfred  Stengel  refers  to  enlargement  of  the  gland 
from  fright,  emotional  disturbances,  menstruation,  eroti- 
cism, etc.  Acute  inflammatory  enlargement  may  b^  due 
to  traumatism,  pressure,  possibly  cold,  and  infection  (diph- 
theria, scarlatina,  hereditary  syphilis,  tuberculosis).  The 
case  reported  was  that  of  a  boy  aged  seventeen  years, 
whose  swelling  was  of  three  weeks'  duration.  It  was  soft 
and  elastic.  The  general  sj-mptoms  resembled  those  of 
Graves'  disease.  Death  finally  occurred  from  asphyxia. 
Malignancy  was  suspected  from  the  rapid  course.  The 
marked  feature  was  the  suddenness  with  which  severe 
symptoms  developed. 

Historic  and  Practical  Remarks  on  the  Operative  Treat- 
ment of  Cancer  of  the  Cervix. — By  J.  G    Clark. 

Prosthesis  of  the  Jaw  at  Time  of  Operation. — By  M.  H. 
Crytr. 

Report  of  Two  Cases  from  the  Neurological  Service  of  the 
University  Hospital. — By  B.  A.  Anspach. 

T/ic  Journal  of  Tropical  Medicine,  June,  igoo. 

Blackwater  Fever. — David  Kerr  Cross,  discussing  this 
disease  as  it  is  seen  in  British  Central  Africa,  says  that  it 
has  not  yet  been  definitel)-  determined  whether  or  not  ha;- 
moglobinuric  fever  is  malarial  fever  in  an  exaggerated 
form.  While  there  are  marked  similarities  in  the  two  affec- 
tions, there  are  also  marked  differences.  The  similarities 
are :  rigors,  oscillations  of  temperature,  sweating,  and  re- 
currences. The  dift'erences  are  :  (i)  Natives  are  immune  ; 
(2)  many  Europeans  also  enjoy  complete  immunity  ;  (3) 
Europeans  rarely  take  the  disease,  if  at  all,  until  they  have 
been  a  year  or  two  in  the  malarious  country  ;  (4)  those  sub- 
ject tc  blackwater  fever  may  have  an  ordinary  malarial  at- 
tack without  bringingon  hsemoglobinuria  ;  (5)  no  European 
once  subject  to  blackwater  fever  ever  acquires  an  immunity 
from  it ;  (6)  even  after  the  sufferer  from  blackwater  fever 
has  left  the  endemic  area  where  he  acquired  the  disease 
the  affection  is  apt  to  recur,  pointing  to  the  likelihood  of 
blackwater  fever  being  due  to  some  parasite  peculiar  to 
itself,  lodged  in  the  bone  marrow,  liver,  spleen,  or  brain  ; 
(7)  it  appears  to  resist  the  action  of  quinine.  The  author 
distinguishes  f.,ur  forms — the  paro.xysmal,  the  regular,  the 
typhoid,  and  the  suppressionary.  The  three  pathognomic 
physical  signs  of  blackwater  fever  are:  (i)  the  black  01 
blood-red  urine,  (2)  the  development  of  yellow  coloring- 
matter  which  invades  every  tissue  of  the  l)ody,  and  (3) 
melanin  in  the  blood  plasma  or  within  the  affected  red 
blood  corpuscles.  We  do  not  know  what  is  the  parasite 
of  blackwater  fever,  for  the  Plasmodium  malaria'  has  not 
been  seen  in  this  aft'ection.  The  tr<;atmeut  is  symptomatic  ; 
quinine  does  no  good  and  may  do  harm. 

Upon  the  Part  Played  by  Mosquitos  in  the  Propagation  of 
Malaria.-  By  George  H.  F.  Xuttall. 
Notes  from  South  Africa.— Bv  M.  T.  Yarr. 


July  7,  1900] 


MEDICAL    RECORD. 


25 


§lcinciUB  mxtl  31  ot ices. 

The  SiRiwcAL  Diseases  of  the  Genito-Ukinarv  Tract — 
Venereal  and  Sexi'al   Diseases.     A  Text-book  for  Stu- 
dents and  Practitioners.     By  G.  Frank  Lydston,  M.L).. 
Professor  of  the  Surgical  Diseases  of  the  Genito-Urinary 
Organs  and  Syphilology  in  the  Medical  Department  of  the 
State  University  of  Illinois,  etc.     Illustrated  with  235  en- 
gravings.    Philadelphia,  New  York,  and  Chicago  :   F.  A. 
Davis  &  Co.     1S99. 
The  author  has  written  a  work  of  over  one  thousand  pages, 
and  the  type  is  not  large.     The  subjects  embraced  are  often 
presented  separately,  and  either  the  "genito-urinary  sur- 
gery "  or  the  "se.xual  and  venereal  diseases  "  would  make  a 
volume  by  itself.     With  tlie  exception  of  what  the  author 
is  pleased  to  call  "a  few  heresies  of  his  own  "  there  is  not 
much  that  differs  from  the  text-books  presented  from  time 
to  time  for  the  use  of  students  and  practitioners.     This 
work,  as  the  author  states,  is  not  designed  for  the  special- 
ist, nor  will  the  latter  find  much  that  he  cannot  get  else- 
where.    There  are  few  of  the  very  large  number  of  illustra- 
tions  which   have   much   to  recommend  them   especially. 
Some  fall  far  short  of  elegance  from  an  artistic  standpoint, 
and,  what  is  of  greater  importance,  several  fail  to  give  an 
adequate  idea  of  the  conditions  which  they  are  intended  to 
represent.     In  running  over  the  pages  the  impression  is 
not  given  of  a  profusely  illustrated  work,  so  many  of  the 
figures  are  small  cuts  of  instruments,  pathological  speci- 
mens, etc.,  reproduced  from  other  works.     Not  the  least 
attractive  feature  of  the  work  is  that  it  is  written  in  the  au- 
thor's characteristic  free  style  and  is  pervaded  by  his  per- 
sonality. 

Surgical  Patholocy  and  Therapeutics.     By  John  Col- 
lins W.^RREN,   Profes.sor  of  Surgery  in  Harvard  Univer- 
sity,  Surgeon   to   the  Massachusetts  General  Hospital. 
Illustrated.     Second  edition,  with  an  appendi.x.     Phila- 
delphia :   W.  B.  Saunders,     igoo. 
The  chief  additions  in  this  edition  have  been  placed  in  an 
appendix,  which  contains  an  enumeration  of  the  scientific 
aids  to  surgical  diagnosis,  together  with  a  series  of  sections 
of  regional  bacteriology.     Besides  this,  a  new  chapter  on 
antiseptic  surgery  has  been  added.     An  important  feature 
of  this  work  is  the  aid  it  furnishes  to  the  specialist  in  vari- 
ous departments.     The  sections  on  "regional  bacteriology  " 
are  not  alone  of  interest,  but  are  of  decided  importance, 
coupled  as  are  the  descriptions  of  the  findings  with  princi- 
ples of  treatment  drawn  from  the  latest  teachings  of  those 
having  authority  to  speak.     The  illustrations  are  generally 
above  the  average. 

International  Clinics.     Edited  by  Judson  Dai.and,  M.D., 
Instructor  in  Clinical  Medicine  in  the  University  of  Penn- 
sylvania,  etc.     Vol.   IV.,  Ninth  series,    igoo.     Philadel- 
phia :  J.  B.  Lippincott  Company.      1900. 
There  are  thirty-seven  generally  well-known  names  among 
the  present  contributors,  and  their  articles  are  illustrated 
with  twenty-one  drav,-ings.    As  usual,  the  reading-matter  is 
of  a  rather  high  order.     This  quarterly  of  clinical  lectures 
on  various  branches  of  medicine  and  surgery  now  contains 
specially  prepared  articles  on  treatment  and  drugs  by  pro- 
fessors and  lecturers  in  the  leading  medical  colleges. 

1  he  American  Year  Book  of  Medici.ne  and  Surgery. 
Under  the  general  editorial  charge  of  George  M.  Gould, 
M.D.  Philadelphia:  W.  B.  Saunders.  1900. 
This  yearly  digest  of  scientific  progress  and  opinion  in  all 
branches  of  medicine  and  surgery,  drawn  from  journals, 
monographs,  and  text-books  foreign  and  American,  has 
this  year  been  divided  so  that  the  subscriber  receives  two 
volumes— one  on  surgery,  the  other  on  medicine.  This  is 
an  excellent  plan.  The  original  volume  was  altogether  too 
ponderous.  Changes  in  the  editorial  staff  include  the  new 
names  of  Drs.  David  Reisman,  R.  W.  Wilcox,  A.  A.  Ste- 
vens, Reid  Hunt,  and  Walter  Jones.  The  number  of  co- 
workers has  fallen  from  twenty-eight  to  fifteen.  The 
subject-matter  comprises  the  usual  quantity  and  quality 
of  abstracts,  with  critical  editorial  comment  covering  the 
various  branches. 

Gyn.scology  :  A  Manual  for  Students  and  Practitioners. 
By  Montgomery  A.  Crockett,  Adjunct  Professor  of  Ob- 
stetrics and  Clinical  Gynaecologv,  Medical  Department 
University  of  Buffalo,  etc.     Series  edited  by  Bern  B.  Gal- 
laudet.  M.D.     Illustrated  with  107  engravings.     Phila- 
delphia and  New  York  :  Lea  Brothers  &  Co. 
This  addition  to  the  red-covered  series  of  pocket  text-books 
put  out  by  this  well-known  house  fills  the  requirements  of 
essential  feature  in  moderate  compass.     It  is  not  alone  an 
e.xpos^  of  the  author's  views  and   experience  which  one 
reads,  but  a  rcstimc  oi  what  many  recognized  writers  and 


teachers  have  given  the  world.     However,  the  writer's  per-" 
sonality  stands  out.  making  the  subject-matter  much  more 
than  a  compilation. 

Nervous  and  Mental  Diseases:  A  Manual  for  Students 
and   Practitioners.     By   Charles   S.    Potts,    M.  D.,    In- 
structor in   Nervous  Diseases,    University  of   Pennsyl- 
vania, Assistant  Neurologist  to  the  University  Hospital, 
etc.     Philadelphia  and  New  York  :   Lea  Brothers  &  Co. 
This  is  another  of  the  above-mentioned  series  illustrated 
with  eighty-eight  engravings.     Such  matter  as  is  deemed 
necessary  for  the  student's  requirements  is  here  presented, 
exception  being  made  in  the  matter  of  anatomy  of  the  ner- 
vous system.     Naturally,  larger  text-books  will  have  to  be 
consulted   for   an   exhaustive   knowledge  of   any  subject. 
The  therapy  has  been  presented  in  such  a  way  that  it  will 
be  useful  as  well  to  the  practitioner.     Methods  of  examina- 
tion have  received  considerable  attention. 

Diseases  of  the  Intestines.  Bv  Max  Einhorn,  M.D., 
Professor  of  Medicine  at  the  New  York  Post-Graduate 
Medical  School  and  Hospital,  etc.  Pp.  391.  New  York  : 
William  Wood  &  Company,  igoo. 
This  treatise  is  offered  to  the  profession  as  a  continuation 
of  the  author's  work  on  "Diseases  of  the  Stomach,"  and  as 
in  that  book,  so  here  also,  practical  points  in  diagnosis  and 
treatment  are  always  placed  in  the  foreground.  After  a 
.short  account  of  the  anatomy  and  physiology  of  the  intes- 
tines, there  follows  a  careful'description  of  the  methods  of 
examination  and  treatment,  especial  attention  being  paid 
to  the  microscopical  examination  of  the  faeces.  Acute  and 
chronic  intestinal  catarrh  and  dysentery  are  treated  of  in 
separate  chapters.  The  writer  gives  a  good  description  of 
the  symptoms  of  intestinal  ulcers,  and  a  very  readable  de- 
.scription  of  carcinoma  of  the  bowel.  The  chapter  on  hem- 
orrhoids is  very  complete,  and  in  the  chapter  on  appendi- 
citis the  author  gives  a  good  summary  of  the  indications 
for  surgical  interference  in  this  disease.  Acute  and  chronic 
obstruction,  diarrhoea,  constipation,  nervous  affections  of 
the  bowel,  and  intestinal  parasites  are  treated  of  in  some 
detail.  We  believe  that  the  book  will  be  of  value  and  prac- 
tical utility  to  the  practitioner,  and  will  fully  accomplish 
the  aim  of  the  author — to  give  to  the  physician  a  short, 
practical,  and  useful  reference  book  on  intestinal  diseases. 

The  Irrigation  Treat.ment  of  Gonorrhcea  :  Its  Local 
Complications  and  Sequelae.  By  Ferd.  C.  Valentine. 
M.D.,  Professor  of  Genito-Urinary  Diseases,  New  York 
School  of  Clinical  Medicine;  Genito-Urinary  Surgeon. 
West  Side  German  Dispensary.  New  York:  William 
Wood  &  Compay.  1900. 
This  is  one  of  the  class  of  books,  unfortunately  only  lOo 
rare  in  medicine,  written  by  one  who  combines  with  a 
knowledge  of  his  subject  the  art  of  expressing  his  meaning 
in  easily  comprehensible  language.  It  is  intended  more 
particularly  for  the  general  practitioner,  who  must  treat 
gonorrhoea  along  with  all  the  other  ills  of  suffering  human- 
ity, and  who  wishes  to  do  so  in  some  more  effective  way 
than  by  filling  the  stomach  with  a  nauseous  mixture  of 
balsams  and  oils.  As  is  set  forth  in  the  title,  the  treatment 
here  expounded  is  that  by  irrigation — a  treatment  which  is 
as  rational  in  theory  as  it  is  efficacious  in  practice.  In  ad- 
dition to  the  details  of  simple  irrigation,  the  advantages  of 
dilatation  and  irrigation  in  chronic  cases  are  dwelt  upon, 
and  the  methods  of  procedure  in  such  cases  are  minutely 
and  most  clearly  described.  But  the  book  is  by  no  means 
a  treatise  on  irrigation  of  the  urethra  only — it  is  rather  a 
complete  guide  to  the  management  of  gonorrhoea  in  all  its 
forms  and  complications  and  of  the  sequelae  of  the  disease. 
The  means  of  locating  foci  of  disease  in  uncured  cases  are 
referred  to  at  sufficient  length,  as  are  also  the  various  steps 
in  the  performance  of  circumcision  and  other  multitudinous 
details  in  the  cure  of  a  case  of  gonorrhoea.  The  work  is 
illustrated  by  fifty-seven  engravings,  mostly  drawn  from 
actual  scenes  in  office  work,  which  add  greatly  to  the  value 
of  the  book  as  an  aid  in  every-day  practice. 

Trait^  pratique  des  Maladies  des  Pays  Chauds  et  Tropi- 
caux.  Par  le  Docteur  J.,Brault,  ex-Medecin-Major  de 
I'Armee,  Professeur  a  I'licole  de  Medecine  et  de  Phar- 
macie  d'Alger.  Paris:  J.  B.  Bailliere  et  Fils.  1900. 
The  works  on  tropical  diseases  are  beginning  to  multiply 
themselves,  and  none  too  rapidly  in  these  days  when  phy- 
sicians educated  in  northern  countries  are  sent  to  the 
tropics,  where  the  aspect  of  familiar  diseases  is  often  so 
changed  as  to  render  them  almost  unrecognizable,  and 
where  many  unknown  affections  are  encountered.  The 
work  before  us  is  divided  into  seven  parts:  (i)  vegetable 
parasitic  diseases ;  (2)  skin  diseases  due  to  the  action  of 
vegetable  parasites;  (3)  animal  parasitic  disea.ses ;  (4) 
affections  caused  by  noxious  animals  ;  (5)  diseases  due  to 
physical  and  chemical  agents;  (6)  auto-into.xicatiou ;  (7) 
diseases  of  an  indeterminate  nature.  The  work  is  a  valu- 
able addition  to  the  literature  of  tropical  medicine. 


26 


MEDICAL   RECORD. 


[July  7,  1900 


La    ClURlKGIA    DEI,   PeRICARDIO    E    DEI.    Cl'ORE.       FaiPKiiK. 

Errico  Giordano,  Libero  Docente  di  Medicina  Operato- 
ria  nella  R.   Universita  di  Napoli  ;  Chirurgo  Ordinario 
neir  Ospedale  dei  Pellegrini.     Napoli :  F.  Sangiovanni. 
1900. 
This  is  an  excellent  little  monograph  on  the  surgery  of  the 
heart  and  pericardium.     The  work  is  divided   into  three 
parts,  dealing  respectively  with  the  anatomy  of  the  peri- 
cardium, the" surgery  of  the  pericardium,  and  the  surgery 
of  the  heart.     It  is  especially  valuable  on  account  of  the 
very  e.xtensive  bibliography  which  it  contains.     In  reading 
the  book  one  is  placed  in  possession  of  all  that  is  known 
and  all  thrt  has  been  done  in  this  interesting  field. 

Diet  and  Food.  Considered  in  Relation  to  Strength  and 
Power  of  Endurance,  Training  and  Athletics.  Bv  Ai.e.\- 
andek  Haig,  M.A.,  M.D.  Oxon.,  F.R.C.P.,  Physician  to 
the  Metropolitan  Hospital  and, to  the  Royal  Hospital  for 
Children  and  Women.  Second  edition.  Philadelphia : 
P.  Blakiston's  Son  &  Co.     1900. 

TuEvi.-ws  of  the  author  of  this  little  work  in  relation  to 
uric  a.^.id  as  the  cause  of  many  of  the  common  ills  of  man- 
kind are  too  well  known  to  need  restatement  here.  In  this 
book  he  goes  a  little  further  in  placing  fatigue  among  the 
conditions  frequently  caused  by  the  presence  of  uric  acid 
in  the  blood.  The  remedy,  of  course,  is  the  same  as  that 
advocated  by  the  author  for  other  uric-acid  manifestations, 
namely,  a  vegetable  diet.  The  writings  of  Haig  are  al- 
ways interesting  because  of  his  evident  sincerity,  but  they 
are  not  necessarily  convincing.  Here  especially  ought  the 
saying  to  apply,  that  the  proof  of  the  pudding  is  in  the 
eating. 

La  Ginnastica  Razioxale  senza  Attrezzi.     Par  Dott.  T. 

E.  Gatti.     Roma  ;  L.  Cecchini.     1S99. 
This  little  work  treats  of  the  various  forms  of  exercise 
which  are  possible  without  the  aid  of  apparatus  of  any  sort. 
There  are  seventy-eight  outline  sketches  showing  the  dif- 
ferent exercises. 


©ox'XTspouclciice. 


OUR   LONDON   LETTER. 

(From  Our  Special  Correspondent.) 

GENERAL  MEDICAL  COUNCIL — P-\THOLOGICAL  SOCIETY — BALNEO- 
LOGICAL .•VND  CLIM.AT0L0GIC.\L  SOCIETY  —  SIR  JOSEPH 
FAYRER — BIRMINGHAM  UNIVERSITY  AND  THE  CONSULTING 
AIDS  CLUB — ROYAL  COLLEGE  OF  SURGEONS^LO.NDON  HOSPI- 
TAL—  RECENT  DEATHS — STORMS — SUNSTROKE  — •  AMBULANCE 
SERVICE — MEDICO-CHIRURGICAL  SOCIETY — PVORRHCE.\  ALVEO- 
L.\RIS — LORD  LISTER  OPENS  WEST.MINSTER  HOSPITAL  LABOR.\- 
TORY — MR.  .MYLES,  P. R. C.S.I. — SUICIDES — DE.'VTHS  OF  DRS. 
ALTHAUS,  WILLIAMSON,  FITZP.WRICK,  AND  BLAKE. 

Lo.NDON,  June  8,  igoo. 
There  is  little  more  to  rejjort  from  the  prolonged  sitting  of 
the  General  Medical  Council.  The  tenderness  with  which 
the  corporations  are  treated  is  what  one  might  expect  from 
its  constitution.  The  two  colleges  have  formulated  their 
objections  to  fall  into  line  with  the  other  bodies  on  the 
question  of  the  first  years  of  study.  These  two  Londun 
colleges  are  determined  if  possible  to  maintain  their  right 
to  recognize  ordinary  schools  as  places  of  scientific  instruc- 
tion, so  that  a  few  lessons  in  chemistry  at  a  boarding- 
school  are  to  enable  the  sclioolboy  to  count  himself  a  medi- 
cal student.  The  Council  wishes  students  to  complete 
their  general  education  and  pass  the  preliminary  examina- 
tion before  the  five  years"  curriculum  commences.  The 
reasonableness  of  this  requirement  is  obvious  to  every  one 
except  the  rulers  of  the  two  colleges  which  dispute  the  au- 
thority of  the  Council  to  lay  down  a  law  to  that  effect,  and 
the  Council  once  more  had  not  the  courage  of  its  convic- 
tions, and  so  it  passed  on  to  the  lawyers  the  question 
of  its  power  to  enforce  its  regulations.  If  it  had  refused 
to  register  any  student  who  had  not  complied  with  tliese 
regulations  the  recalcitrant  colleges  would  have  been  on 
their  knees  ;  for  of  course  the  students  would  have  re- 
sorted to  other  qualifying  bodies,  and  these  two  would 
have  lost  more  fees  than  they  can  hope  to  gain  by  thus 
stealing  a  march  on  the  other  corporations. 

The  Apothecaries'  Society  invited  the  Council  to  join,  in 
a  lawsuit  as  to  the  right  of  a  licentiate  to  call  himself 
"physician  and  surgeon,"  but  the  Council  decided  to  let  the 
society  pull  its  own  chestnuts  out  of  the  fire. 

There  was  much  additional  talk  about  personation,  and 
as  to  this  also  refuge  was  sought  in  the  legal  advisers. 

The  difficulties  of  raising  the  standard  of  preliminary 
education  were  reported  upon,  and  a  fear  was  expressed  of 


creating  a  dearth  of  candidates  for  admission  into  the  pro- 
fession— a  notion  which  must  cause  curious  emotions  where 
overcrowding  is  most  marked.  The  limit  of  age  for  entry 
was  left  at  sixteen  years,  though  a  hope  was  e.xpressed  of 
raising  it  shortly  to  seventeen.  The  attention  of  these 
grave  seniors  might  well  be  turned  to  the  question  as 
to  whether  boys  of  sixteen  or  seventeen  are  old  enough  to 
enter  the  wards  of  our  ho.spitals. 

The  annual  meeting  of  the  Pathological  Society  was  held 
on  the  29th  ult.  The  report  indicated  a  prosperous  condi- 
tion with  six  hundred  and  eighty-one  members.  The  lab- 
oratory meetings,  a  new  departure  on  which  I  have  com- 
mented, are  pronounced  a  conspicuous  success.  Some 
alterations  in  the  rules  have  been  made  to  meet  the  devel- 
opments of  pathological  science.  A  vote  of  thanks  was 
passed  to  Mr.  Gould,  who  acted  for  the  president  in  th3 
latter  part  of  the  session  and  to  the  other  officials.  Mr. 
Cheyne  was  appointed  president  for  19OC-1901,  and  the 
other  officers  and  council  were  also  elected. 

Among  the  exhibits  was  the  thyroid  of  a  puppy,  from 
the  mother  of  which  the  thj-roid  had  been  removed  by  Mr. 
Walter  Edmunds.  Nearly  the  whole  thyroid  was  removed, 
leaving  only,  one  parathyroid  and  a  mor.sel  of  thyroid 
proper.  A  few  months  later  the  bitch  gave  birth  to  the 
puppj',  and  it  was  found  that  the  puppy's  thyroid  was 
large,  the  colloid  being  absent  and  the  secreting  cells  lin- 
ing the  vesicles  hypertrophied.  These  appearances  were 
the  same  as  Halsted  had  previously  shown  to  take  place  in 
such  circumstances. 

It  has  been  observed  that  women  suffering  from  Graves' 
disease  or  from  myxcedema  improve  in  health  during  preg- 
nancy. Perhaps  the  hypertrophied  thyroid  of  the  foetus 
may  compensate  for  the  loss  of  the  mother's  thyroid. 

The  Balneological  and  Climatological  Society  has  had 
the  good  fortune  to  secure  an  address  by  Sir  Joseph  Fayrer 
for  its  annual  meeting,  which  was  held  on  the  30th  ult. 
Sir  Joseph  took  for  his  subject  "The  Hill  Stations  of  India 
as  Health  Resorts."  He  spoke  of  them  not  merely  in  refer- 
ence to  the  treatment  in  disease  and  convalescence,  but  as 
places  where  Europeans  might  colonize.  Not  that  he  had 
proof  to  offer,  but  he  thought  there  were  some  grounds  for 
Iselieving  that  there  was  a  prospect  of  success  in  those  sta- 
tions, though  none  in  the  plains  of  India.  There  is  every 
vai-iety  of  climate  in  India,  and  some  of  these  were  de- 
scribed, to  the  delight  of  the  society.  Sir  Joseph,  however, 
only  professed  to  touch  the  fringe  of  the  subject,  which  he 
said  might  be  investigated  with  advantage  by  the  society. 

Birmingham  just  now  presents  a  curious  contrast.  Her 
new  university  is  established,  and  Mr.  Chamberlain  has 
been  made  its  first  chancellor.  The  institution  may  be  ex- 
pected to  infuse  scholarship  into  the  restless  activities  of 
the  midland  capital,  and  to  encourage  a  high  standard  in 
the  learned  professions.  Yet  at  the  same  time  the  chan- 
cellor's .son,  Mr.  Arthur  Chamberlain,  is  pushing  in  a  most 
objectionable  manner  the  consulting-institution  which  he 
has  started  in  conjunction  with  the  local  Saturday  fund  on 
the  lines  of  medical-aid  associations  and  against  the  unan- 
imous opinion  of  the  local  practitioners.  Advertisements 
of  this  institution  have  appeared  in  the  local  papers  (ap- 
propriately enough,  in  the  columns  devoted  to  quackery) . 
which  should  bring  it  under  the  condemnation  of  the  Med- 
ical Council,  as  would  probably  be  the  case  had  they  been 
issued  by  a  general  practitioner.  The  patronage  of  the 
son  of  the  Colonial  Secretary  ought  not  to  protect  it.  The 
medical  man  who  sells  his  services  to  it  should  be  ignored 
by  all  other  practitioners. 

The  coming  election  of  the  council  of  the  College  of  Sur- 
geons is  exciting  rather  more  attention  than  usual — per- 
haps because  of  the  centenary  to  be  celebrated.  There  are 
thirteen  candidates  for  the  four  vacancies,  but  perhaps 
some  of  these  will  not  go  to  the  poll.  The  election  will  be 
on  July  5th,  The  centenary  is  to  be  celebrated  on  July 
25th,  26th,  and  27th.  On  the  first  of  these  days  there  will 
be  a  conversazione ;  on  the  second  a  meeting  in  academic 
costumes,  an  address,  conferring  of  honorary  fellowships, 
and,  of  course,  a  dinner  ;  on  the  third  the  Lord  Mayor  will 
give  a  conversazione.  Objects  of  interest  will  be  demon- 
strated each  day  in  the  museum,  library,  and  laboratories. 

At  a  meeting  of  the  governors  of  the  London  Hospital 
the  day  before  yesterday  it  was  stated  that  the  working- 
classes  had  diminished  their  contributions  to  the  extent  of 
;^700  per  annum  since  the  managers  had  levied  a  charge  of 
threepence  for  bandages,  dressings,  or  medicines.  This 
is  what  was  expected  In-  many  when  the  new  departure 
was  determined  upon,  notwithstanding  a  general  feeling 
that  it  was  uiiadvisable.  to  use  the  mildest  term. 

The  niidwives  bill  is  postponed  to  the  27th,  and  as  that 
is  an  early  day  it  may  not  then  be  taken  up. 

A  select  committee  has  been  appointed  on  the  rating  of 
hospitals  aiKf  other  cliarities. 

Tlie  medical,  surgical,  and  hygienic  exhibition  opened 
on  Tuesday  and  closes  to-day.  It  is  of  the  same  kind  as 
its  three  predecessors. 

Jlr.  J.  G.  Mackialay  died  on  the  24th  ult.     He  was  oph- 


July  7,  1900] 


MEDICAL   RECORD. 


27 


thalmic  surgeon  to  the  Royal  Eye  and  the  Royal  Free  hos- 
pitals, and  much  esteemed.  He  was  an  original  fellow  of 
the  Ophthalmological  Society  and  contril^uted  a  number  of 
IKiiiersto  its  Transactions.  His  health,  never  very  good, 
had  quite  failed  for  the  last  year. 

The  war  is  taking  a  toll  from  the  Royal  Army  Medical 
Corps  as  well  as  the  other  forces.  Maj.  T.  A.  Marsh  and 
Capt.  R.  Fawssett  have  to  be  added  to  our  list  of  heroes. 
South  Africa  has  also  called  for  civil  surgeons,  and  death 
has  taken  some  of  these:  Dr.  Adair  on  board  a  transport. 
Dr.  Irvine  at  Ladysmith  may  be  named.  The  death  of 
Colonel  Hayes,  R.A.M.C,  is  a  fitting  crown  to  his  hard 
service  and  unflinching  courage  on  the  field.  At  Aldershot 
he  had  the  care  of  returned  invalids  from  South  Africa, 
and,  though  suffering  from  malignant  disease  of  the  gul- 
let, carried  on  his  work  until  six  days  before  he  died. 


London.  June  15,  1900. 
The  week  opened  with  promise  of  summer,  but  the  heat 
increa.sed  so  rapidly  that  it  soon  became  oppressive,  and 
then  violent  thunder-storms  were  reported  from  all  parts  of 
the  country.  The  maximum  shade  readings  of  the  ther- 
mometer e.xceeded  the  June  average  of  the  last  thirty  years 
by  about  12'  F.  on  Sunday  ;  by  16'  on  Monday  :  and  by  10 
on  Tuesday.  Since  then  there  has  been  a  fall  and  showery 
weather. 

There  were  military  manoeuvres  on  Monday,  and  our 
red-tape-ridden  War  Office  provided  no  helmets,  but  sent 
the  men  out  in  forage  caps  ;  it  is  said  the  reason  was  that 
they  had  not  enough  helmets  on  hand.  No  one  seems  to 
have  had  the  sense  or  the  authority  to  postpone  the  ma- 
nieuvres,  and  so  the  men  were  out  all  day  expo.sed  to  the 
sun,  with  the  natural  result — six  deaths  and  hundreds  of 
admissions  to  hospital.  At  the  inquest  it  further  tran- 
spired that  the  men  were  without  food  all  the  time — eleven 
hours.  It  is  said  that  the  present  forage  cap  is  a  design  of 
Lord  Wolseley's.  Whether  or  no,  it  is  useless  as  a  protec- 
tion from  the  sun. 

The  deficiency  of  London  in  ambulance  service  is  attract- 
ing attention,  and  New  York  is  being  held  up  to  us  as  an 
example.  We  are  told  you  have  a  motor  car  fitted  with 
every  requisite  for  immediate  aid  and  rapidly  taking  the 
surt'erers  from  accident  in  the  easiest  way  to  hospitals  or 
their  homes.  With  daily  street  accidents  London  should 
be  able  to  improve  on  her  antiquated  system,  or  rather 
want  of  system.  An  estimate  of  the  number  injured  in 
our  streets  places  it  at  fifty  thousand  yearly.  Last  week 
our  hospitals  received  three  hundred  and  forty-one  cases. 
There  is  certainly  scope  enough  for  the  best  system.  It 
seems,  however,  that  the  provision  made  is  not  regularly 
used — the  police  not  seldom  putting  a  person  into  a  cab 
within  a  short  distance  of  an  ambulance  station. 

The  Medico-Chi  has  adopted  the  alterations  in  by-laws 
recommended  by  the  Council.  The  effect  of  these  changes 
is  that  the  publishing  of  the  Proceedings  will  be  discontin- 
ued, and  the  Transactions  will  contain  reports  of  the  dis- 
cussions as  well  as  the  papers  read  at  the  meetings.  Fur- 
ther, the  fellows  are  no  longer  to  be  precluded  from  pub- 
lishing their  papers  in  the  journals.  After  these  changes 
were  agreed  to,  the  ordinary  work  was  resumed  by  the 
reading  of  a  paper  by  Mr.  R.  J.  Godlee  on  "The  Compli- 
cations of  Pyorrhoea  Alveolaris — Riggs'  Disease,  as  it  is 
Sometimes  Called."  It  consists  of  a  spongy  condition  of 
the  gums  with  recession,  and  deposit  of  tartar.  This  last 
is  often  regarded  as  the  cause.  Infiammation  extends  to 
the  peridental  membrane  or  periosteum  of  the  fang,  and 
suppurating  pockets  are  formed.  Not  often  considered 
serious,  it  may  give  rise  to  symptoms  of  grave  disease, 
three  examples  of  which  Mr.  Godlee  related.  The  discus- 
sion was  interesting  as  involving  both  medical  and  surgi- 
cal points,  but  there  was  not  much  adjustment  of  view 
between  the  physicians  and  surgeons.  The  disease  is  so 
often  looked  upon  as  a  dental  affair  that  the  remarks  of 
Mr.  Tomes  were  naturally  listened  to  with  attention.  He 
pointed  out  that  the  majority  of  cases  presented  scarcely 
any  symptoms,  the  discharge  being  so  commonly  swal- 
lowed ;  but  at  night  a  bloody  fluid  might  run  out  and  stain 
the  pillow,  thus  leading  to  its  detection  If  without  obvi- 
ous cause  pressure  along  the  margin  of  the  gums  caused 
purulent  fluid  to  exude,  the  diagnosis  was  clear.  Antisep- 
tics should  be  applied,  but  the  improvement  they  produced 
did  not  always  last.  Riggs'  method  of  scraping  the  mar- 
gin of  the  alveolus  was  tedious  and  painful,  and  with  this 
plan  relapses  also  occurred.  If  a  tooth  was  extracted  from 
an  affected  socket  the  wound  seldom  went  wrong,  though 
that  might  seem  strange.  The  question  as  to  the  local  or 
constitutional  origin  of  the  disease  was  raised,  and  some- 
thing was  said  on  each  side.  It  occurs  in  animals,  is  com- 
mon in  glycosuria,  is  often  symmetrical,  and  sometimes 
seems  to  be  hereditary.  Gout  and  rheumatism  were  men- 
tioned as  often  as.sociated,  and  one  speaker  thought  many 
cases  of  malignant  endocarditis  might  originate  in  the  dis- 
ease. 


Lord  Lister  opened  the  new  clinical  laboratory  of  the 
Westminster  Hospital  on  Tuesday.  It  has  cost  some 
/'2,ooo.  His  lordship  said  the  public  owed  the  managers 
a  debt  of  gratitude  for  so  wi.sely  spending  the  money,  and 
urged  that  before  many  years  it  would  be  generally  recog- 
nized that  such  laboratories  were  among  the  most'  impor- 
tant means  of  rendering  good  service  to  mankind. 

The  presidents  of  the  two  royal  colleges  also  spoke. 

Jlr.  Myles  has  been  elected,  unopposed,  president  of  the 
Royal  College  of  Surgeons  in  Ireland.  At  an  earlier  stage 
there  was  a  threat  of  opposition  founded  on  an  unaccount- 
able blunder.  A  circular  was  issued  charging  Mr.  Myles 
with  associating  himself  with  the  Irish  League.  On  being 
called  to  account  by  a  writ  for  damages,  his  opponent  had 
to  acknowledge  he  had  in  .some  way  confused  two  para- 
graphs in  an  evening  paper,  and  so  he  tendered  an  ample 
-  apology  and  had  to  pay  costs.  Hitherto  I  am  told  politics 
have  not  been  introduced  into  the  college  elections,  and 
when  feeling  runs  so  high  it  is  to  be  hoped  the  old  reticence 
will  continue  to  be  observed. 

There  has  been  quite  an  epidemic  of  suicide  lately — 
nearly  sixty  cases  have  been  reported  within  a  month,  a 
number  far  beyond  any  recorded  in  any  month  for  the  last 
ten  years.  One  poor  lady  took  morphine  and  then  shot 
herself  for  fear  of  being  buried  alive.  A  medical  man  took 
prussic  acid,  but  the  jury  at  the  inquest  could  not  say 
whether  by  mistake  or  intentionally. 

Dr.  Julius  Althaus,  well  known  as  a  writer  on  neurology 
and  on  electrotherapeutics,  died  on  the  nth  inst.,  a.ged 
sixty-seven  years.  He  was  one  of  the  founders  of  the  Hos- 
pital for  Epilepsy  and  Paralysis,  where  he  worked  for  .some 
twenty-eight  years.  On  his  holiday  last  year  he  injured 
his  knee,  and  his  friends  noticed  that  from  that  time  he 
had  failed.  In  fact,  he  had  attacks  which  were  spoken  of 
as  gout,  but  some  thought  the  explanation  insufficient.  He 
has  been  quite  laid  aside  for  some  months,  and  though  the 
case  was  a  little  obscure,  it  seemed  to  be  phlebitis,  and  so 
it  has  proved. 

George  Edward  Williamson,  F.R.C.S.,  died  on  the  5;.h 
inst.,  within  a  week  of  a  full  day's  work  at  the  Royal  In- 
firmary, Newcastle-on-Tyne,  to  which  he  was  ophthalmic 
surgeon.  He  had  also  been  professor  of  physiology  and 
surgery  in  the  Durham  College.  He  was  only  forty-eight 
years  old. 

Dr.  Thomas  Fitzpatrick,  who  died  on  the  31st  ult.,  was  a 
man  of  many  attainments,  a  distinguished  graduate  of 
both  Dublin  and  Cambridge  universities,  1862-67.  ^'ou 
may  have  met  with  his  "Autumn  Cruise  in  the  ^gean  " 
or  his  "Transatlantic  Holiday."  Among  his  accomplish- 
ments may  be  mentioned  acquaintance  with  several  lan- 
guages, including  modern  Greek,  and  a  wide  knowledge  of 
ancient  classical  literature. 

Dr.  J.  Gibbs  Blake,  of  Birmingham,  died  on  the  27th  ult. 
He  was  one  of  the  original  trustees  of  Mason  College  and 
bestowed  great  labor  on  its  foundation.  He  was  educated 
at  L'niversity  College,  where  he  had  a  very  distinguished 
career,  crowned  by  the  London  M.D.  and  his  election  to  a 
life  governorship.  He  was  also  an  accomplished  classical 
scholar  and  had  great  artistic  talent. 


OUR    PARIS    LETTER. 

(From  our  Special  Correspondent.) 

THE  POZZI-DEVILLERS  Dl'El. — DEATH  OF  DR.  CHEROX — XET- 
TER's  ARTICLE  ON  PLAGUE  AND  MEASURES  TAKEN  AGAINST 
THIS  DISEASE — PROFESSIONAL  SECRECY  IN  FRANCE — OFFICIAL 
LIST  OF  FESTIVITIES  CONNECTED  WITH  THE  THIRTEENTH 
INTERNATIONAL   CONGRESS. 

P.'\Ri?,  June  15.  1000. 

A  GENERAL  topic  of  Conversation  in  the  social  as  well  as  the 
medical  world  in  Paris  is  the  Pozzi-Devillers  duel,  which 
took  place  last  Sunday,  on  June  loth.  This  duel,  like  so 
man}-  others  of  recent  occurrence,  has  sprung  out  of  the 
political  agitation  brought  on  by  the  Deroulede  trial  before 
the  senate.  Dr.  Pozzi.  the  gynecologist  who  performed  an 
abdominal  operation  on  Sarah  Bernhardt,  has  been  a  sena- 
tor for  several  years,  like  Dr.  Labbe,  the  great  surgeon, 
who  performed  gastrostomy  in  187O  to  remove  a  fork  from 
the  stomach  of  a  waiter.  He  was  therefore  obliged  to  take 
part  in  the  discussions  which  were  held  at  the  Lu.xembourg 
during  the  progress  of  the  trial,  and  it  would  seem  to  be 
clear  that  he  was  in  favor  of  banishment  being  pronounced 
against  Deroulede.  Dr.  Devillers,  Deroulede's  physician, 
was  present  at  the  last  meeting  held  in  the  rooms  of  the 
Medical  Club  in  the  Avenue  de  I'Opera  on  June  -th.  This 
club  was  founded  a  few  months  ago  by  Dr.  Doleris,  and 
Dr.  Pozzi  had  been  offered  the  president's  chair.  Dr. 
Devillers  began  by  making  some  disagreeable  remarks  to 
Dr.  Pozzi  about  politics,  but  but  the  latter  told  him  he  did 
not  consider  a  medical  club  a  fit  place  for  discussing  such 
a  question.     Dr.    Devillers   thereupon    insulted  him   and 


28 


MEDICAL    RECORD. 


[July  7,  1900 


threw  his  glove  in  his  face.  The  man  was  at  this  junction 
taken  care  of  bv  his  friends  and  led  into  another  room. 
On  hearing  Dr. 'Po.'.ii  say  tliat  he  thought  it  likely  that 
Devillers  was  njt  in  his  right  mii.d,  he  burst  forth  again 
into  the  most  violent  language.  As  might  be  expected,  a 
duel  was  decided  upon,  and  though  it  is  thought  advisable 
generally  to  carry  out  these  encounters  within  twenty-four 
hours  after  the  offence,  the  "rencontre,"  as  they  say  in 
French,  only  took  place  on  Sunday,  and  was  carried  out  in 
the  most  orthodox  manner.  The  place  chosen  was  Louve- 
ciennes,  a  small  town  near  St.  Germain-en-Laye,  and 
though  Dr.  Pozzi  had  not  done  any  fencing  for  the  last  ten 
years,  he  chose  swords.  Dr.  Devillers  is,  on  the  other 
hand,  an  expert  fencer.  The  swords  were  sterilized  to 
prevent  any  infection  of  the  wounds,  and  immediately 
after  the  word  was  given  Dr.  Devillers  ran  his  sword  into 
Dr.  Pozzi's  right  hand  between  the  fourth  and  fifth  fingers. 
Dr.  Pozzi  was  therefore  unable  to  continue,  and  the  two 
adversaries  shook  hands.  I  have  been  told  that  Dr.  De- 
villers wished  to  wound  Dr.  Pozzi  seriously,  a  fact  which 
does  not  agree  with  the  result  of  the  duel.  It  seems  that 
Dr.  Devillers  will  be  prosecuted  for  having  attacked  a 
magistrate  in  the  e.xercise  of  his  functions.  Dr.  Pozzi  hav- 
ing this  quality  while  acting  as  senator  in  the  recent  trial. 
A  procedure,  as  it  is  called,  has  already  been  put  in  mo- 
tion against  him,  but  Dr.  Pozzi,  who  has  shown  through- 
out a  most  conciliatory  spirit,  states  he  will  do  his  utmost 
to  prevent  any  further  action  being  taken  in  the  matter. 

It  can  be  asked  if  it  is  advisable  for  doctors  to  take  an 
active  part  in  politics,  when  they  have  a  large  practice  to 
attend  to.  Dr.  Pozzi's  political  opinions  are  not  of  a  nature 
to  attract  to  him  the  sympathy  of  the  Faubourg  St.  Ger- 
main, as  the  French  nobility  residing  in  Paris  is  called,  as 
it  seems  that  he  advocates  measures  which  are  not  con- 
servative. However,  medical  men  are  being  heard  of 
more  and  more  in  political  life,  and  can  bring  quite  a  good 
deal  of  influence  to  bear  upon  the  measures  and  laws  en- 
acted at  the  Chamber  of  Deputies. 

Dr.  Jules  Cheron,  who  was  well  known  for  his  works  on 
subcutaneous  injections,  died  recently  in  Paris.  He  was 
the  son  of  a  military  doctor,  and  began  by  taking  up  the 
study  of  natural  history.  He  decided  later  to  become  a 
physician,  and  was  chosen  as  doctor  of  the  St.  Lazare  In- 
firmary for  Prostitutes  in  1S70.  His  principal  works  are  as 
follows:  "The  Use  of  Electricity  in  the  Treatment  of  Fi- 
bromas,"  "On  Treatment  by  Oxygen  in  Consumption," 
"The  Cicatricial  Properties  of  Picric  Acid."  He  was  one 
of  the  first  to  use  artificial  serum,  and  he  recommended  the 
use  of  a  solution  containing  carbolic  acid  as  a  hypodermic 
injection  in  the  treatment  of  certain  forms  of  general  de- 
bility and  exhaustion.  His  formula  was :  Pure  carbolic 
acid,  I  gm.  ;  chloride  of  sodium,  2  gm.  ;  sulphate  of  sodium, 
8  gm.  ;  phosphate  of  sodium,  4  gm.  ;  boiled  distilled  water, 
1,000  gra.  From  5  to  120  gm.  was  to  be  injected  into  the 
gluteal  or  retro-trochanteric  region  very  slowly ;  slight 
massage  was  performed,  and  the  injection  was  repeated 
according  to  the  needs  of  the  case.  For  the  space  of  nine- 
teen years  Dr.  Cheron  directed  the  Rt-7'iie  Mcdico-cliirur- 
gicale  dis  Mahidies  des  Feinmes,  in  which  paper  he  ad- 
vocated conservative  treatment,  being  bitterly  opposed  to 
the  surgical  interventions  which  were  too  much  in  fashion 
a  few  years  ago. 

Dr.  Netter,  who  is  an  authority  in  France  on  questions 
of  hygiene,  has  published  recently  in  the  Prase  Medicaid 
an  article  on  the  spread  of  plague  in  Australia  and  Amer- 
ica. A  map  is  given,  wherein  are  indicated  the  different 
ports  visited  by  the  scourge.  This  article  and  that  of  Dr. 
Lochelongue,  about  which  I  have  already  spoken,  show 
that  we  are  awakening  to  the  fact  that  stringent  measures 
should  be  taken  to  prevent  the  spread  of  this  disease. 
A  method  for  suppressing  rats  is  now  being  studied  in 
Paris,  and  measures  have  been  taken  by  the  mayor  at  Mar- 
seilles to  insure  the  destruction  of  all  rodents  such  as  mice 
and  rats.  He  published  a  decree  offering  a  premium  of 
half  a  cent  for  every  mouse  and  of  a  cent  for  every  rat, 
dead  or  alive,  that  should  be  delivered  at  the  municipal 
offices  in  the  city.  In  the  space  of  two  weeks  after  the 
promulgation  of  this  order,  five  hundred  and  two  rats  and 
one  hundred  and  eighty-four  mice  had  been  handed  in. 

Professional  secrecy  is  a  rule  which  is  enforced  with 
a  great  deal  of  strictness  in  France,  and  a  recent  occur- 
rence will  show  how  far  this  jirinciple  will  command  silence 
on  the  part  of  a  medical  witness.  For  a  case  of  supposed 
suppression  of  childbirth  tried  before  a  French  court,  one  of 
the  witnesses  was  the  midwife  who  had  attended  the  wo- 
man accused  of  the  deed.  When  judgment  was  pro- 
nounced, it  was  clearly  stated  that  the  testimony  of  the 
midwife  would  not  be  accepted,  and,  on  the  attorney-gen- 
eral sending  the  case  before  the  criminal  chamber  of  the 
court  of  cassation,  the  action  was  decided  against  him.  In 
the  decree  published  by  this  august  body  it  was  declared 
that  all  medical  attendants  were  bound  over  to  complete 
professional  secrecy,  barring  those  cases  in  which  the  law 
demanded  divulgation.     As  such  cases  no  longer  exist,  it 


may  be  said  that  professional  secrecy  is  now  of  an  absolute 
nature  in  France. 

The  official  list  of  the  festivities  that  are  to  take  place  in 
Paris  in  connection  with  the  Thirteenth  International  Med- 
ical Congress  has  at  last  been  published.  On  August  2d 
there  will  be  a  reception  offered  by  the  president  of  the 
council  of  ministers  in  the  name  of  the  French  Rejiublic. 
This  reception  will  most  likely  be  held  in  the  rooms  of  the 
Palais  Bourbon.  On  August  3d  there  will  be  a  festival 
given  by  Professor  Lannelongue.  Special  invitations  will 
be  sent  out  for  this  social  function,  which  will  take  place 
either  in  Dr.  Lannelongue's  large  house  in  the  Rue  Fran- 
<;ois  I.  or  else  in  some  hall  chosen  for  this  affair.  On 
August  5th  the  president  of  the  republic  will  receive  the 
members  of  the  congress  at  the  El}-see  in  the  evening.  On 
the  Sth  there  is  to  be  a  grand  festival  in  the  palace  and 
gardens  of  the  Luxembourg,  under  the  direction  of  the 
bureau  of  the  organizing  committee.  The  municipal  coun- 
cil may  also  have  some  sort  of  entertainment,  and  of  course 
in  each  section  there  will  be  special  dinners  and  receptions. 
I  may  state  also  that  at  all  these  functions  the  wives,  sis- 
ters, and  daughters  of  the  members  of  the  congress  will  be 
invited,  and  a  special  ladies'  committee  will  be  established 
to  receive  them. 


LETTER  FROM  BEYROUT,  SYRIA. 

( From  our  Special  Correspondent.) 

The  spring  is  bringing  on  the  time  of  flowers,  some  one 
said  or  sung  some  time  ago.  It  came  to  us  with  the  20th 
of  March  or  thereabouts.  Flowers  are  everywhere  ;  on  the 
highways  and  hedges,  even  on  the  trees — primulas  and 
primroses  with  their  companions,  the  fair  chaste  margue- 
rites, the  little  speedwell  "with  its  darling  blue  "  ;  ro.ses  of 
all  tints,  most  beautiful  and  most  fragrant ;  camellias  of 
surpassing  beauty,  and  perfect  poppies,  the  largest  and 
comeliest  we  have  ever  seen,  and  many  more  besides.  So 
much  for  the  flowers. 

Disease  is  not  rife  among  us  at  this  time.  There  is  talk 
of  plague  coming  on  ;  but  we  think  it  is  a  myth.  Neverthe- 
less, it  has  been  reported  at  Cairo  and  at  Smyrna,  and  it 
is  thought  to  be  approaching  us.  If  it  does,  it  will  do  its 
duty  on  the  rats  that  stroll  about  our  streets,  where  the 
barley  is  on  sale,  regardless,  may  it  be  understood,  of 
passers-by — the  rats,  we  mean. 

An  order  went  forth  the  other  day  to  kill  six  hundred 
dogs.  This  was  on  account  of  a  young  man  of  the  town 
having  been  bitten  by  a  little  dog  that  he  owned.  The 
master  of  the  dog  (which  saw  instant  death)  was  treated 
by  modern  methods,  and  has  now  no  fear  of  the  infection. 
Speaking  of  the  spring,  I  forgot  to  say  that  the  swallows 
have  come.  They  are  killing  millions  of  mosquitos  a  day. 
Here,  no  one  would  think  of  pointing  a  gun  at  one  of  those 
swift  scavengers  of  ours.  What  our  death  rate  is  here  (as, 
I  think,  I  said  before)  I  cannot  tell,  as  I  have  got  no  ref- 
erences ;  but  in  any  case  our  little  feathered  friends  can 
reduce  it. 

Lebanon  has  got  his  night-cap  on  and  looks  well.  It  is 
cold  up  there.  Here  we  have  an  average  of  73°  F.  in  the 
shade.  Out  in  the  sunlight  it  ranges  about  110°  F..  and 
the  glare  is  far  beyond  the  electric  light.  The  changes  of 
temperature  in  this  month  of  May  are  very  great  just  now 
— rising  and  dropping  10  F.,  coming  and  going,  and  mak- 
ing us  all  miserable  from  a  disease  which,  rudely  speak- 
ing, has  been  facetiously  baptized  as  "sniffles."  It  is  not 
aristocratic  enough  to  be  the  great  influenza,  but  it  seems 
to  have  an  affection  for  it  (perhaps  an  offspring).  It  does 
not  do  so  much  evil,  however,  as  the  after  results  are  more 
or  less  ;;//.  The  misery  during  the  attack,  which  la.sts  for 
about  a  week,  is  modified  by  the  patient's  wishing  for  a 
better  land.  The  treatment,  of  course,  depends  on  the  cir- 
cumstances and  the  patient's  history— the  attendant  phy- 
sician's judgment  to  boot.  Dysentery  and  enteric  seem  to 
have  been  doing  their  duty  in  the  beleaguered  towns  in  far 
South  Africa.  Horse  broth  and  mule  stew  with  fricasseed 
locusts  might  have  been  good  enough  without  risk  :  but 
"pea-soup  water  tinted  drab,"  wherein  dead  horses  were 
having  their  last  siesta,  was  not  good  for  what  is  generally 
.spoken  of  as  "health";  and  many  went  down  under  the 
regimen. 

We  have  had  a  wind  on  us  for  the  last  three  weeks. 
Rain  came  with  the  advance  of  spring,  and  was  of  a  spo- 
radic character,  raining,  as  it  did,  spasmodically  and 
most  uncertainly,  and  even  when  the  sky  was  blue.  It 
cooled  us  and  refreshed  us,  and  laid  the  dust,  and  we  were 
all  glad  for  those  pigmy  showers, 

A  catastrophe  occurred  on  April  21st  on  one  of  his  Maj- 
esty the  Sultan's  torpedo-boats.  The  boiler  exploded,  and 
out  of  seventy  there  were  seventeen  persons  either  rescued 
or  saved.  One  man  was  carried  home,  dying  two  hours 
afterward.  presumal.>ly  from  shock.  Rigor  mortis  setting 
in  four  hours  later,  a  movement  of  the  hand  was  seen.     A 


July  7,  1900] 


MEDICAL    RECORD. 


29 


consultation  was  called,  and  he  was  pronounced  dead,  as 
he  most  certainly  had  been  for  six  hour;,  at  least. 

Mosquitos  and  cock-crowing  are  here,  botli  of  which  are 
mischievous,  and,  other  reasons  apart,  indirectly  insalu- 
brious, as  they  prevent  sleep.  The  mosquito  does  his  duty 
as  a  manufacturer  of  germs — besides,  the  source  of  the — 
lie  it  confessed — necessity  of  looking  up  our  vocabulary  for 
fresh  words.     This  causes  much  evil  to  Ijody  and  spirit. 

In  conclusion  we  may  say  that  the  authorities  are  regu- 
larly watering  our  streets  lately;  there  is  very  little  dust — 
formerly  a  notable  thing  here — and  we  think  the  people  «f 
this  larid  can  (even  by  frightening  them)  learn  to  be 
cleanly. 

By  the  way,  I  have  just  noticed  an  article  in  T>  c a hii c  11 1 
suggesting  changing  of  camps  in  cases  of  enteric  or  diar- 
rhoea or  dysentery  or  any  of  the  other  diseases  that  come  to 
the  beleaguered  and  to  those  who  have  to  sit  and  watch 
them.  We  will  remember  the  advice  of  an  old  expert  in 
fevers,  and  those  of  that  ilk — "Always  change  your  patient 
from  room  to  room,  morning  and  evening,  and  keep  your 
windows  open."  He  was  very  successful  in  his  treatment, 
and  others  who  may  adopt  his  method  may  be  so,  too. 
When  we  are  shut  up  we  have  no  option,  but  being  free,  it 
devolves  upon  us  to  keep  ourselves  and  others  clean  and 
pure  as  much  as  in  us  lies. 


LETTER     FROM    BRAZIL. 

(From  our  Special  Correspondent.) 
THE    PLAGUE     AT     RIO — -GENERALIZATION     OK     YELLOW     FEVER. 

Sao  Joao  dki.  Rei,  Brazil,  May  25,  19C0. 

ALTiiorr.it  the  bubonic  plague  has  been  threatening  Rio  de 
Janeiro  for  the  past  six  months,  there  being  one  or  two 
sporadic  cases  on  two  different  occasions,  it  is  only  within 
the  past  week  that  it  can  be  said  to  have  gotten  a  foothold. 
On  the  16th  inst.  there  were  two  cases  reported  as  susjii- 
cious.  Both  patients  died,  and  the  bacteriological  exami- 
nation proved  them  to  be  genuine  cases.  Upon  examina- 
tion it  was  discovered  that  within  a  short  time  seven  otliers 
had  died  in  the  same  locality  presenting  similar  symp- 
toms. Since  that  date  a  large  number  have  been  i.solaled, 
and  on  the  24th  one  case  was  found  in  another  part  of  the 
city  several  miles  from  the  primary  focus.  On  the  iSth 
inst.,  at  the  laboratory  in  connection  with  the  custom  house, 
and  in  streets  adjoining,  there  were  found  a  number  of  dead 
rats,  and  the  director  of  the  laboratory  discovered  the 
plague  bacillus  in  the  one  he  examined. 

The  section  of  the  city  in  which  the  first  cases  were  found 
bears  the  pleasing  name  of  Saude  (health)  ;  however,  the 
following  extract  from  one  of  the  Rio  papers  would  indi- 
cate that  there  is  considerable  irony  in  the  name  as  applied 
to  that  locality  : 

"The  police  inspector  of  the  fifth  city  district  made  a 
visit  of  inspection  last  night,  and  at  No.  7  of  the  Alley 
Costa  Velho  found  a  tavern  in  which  were  sleeping  twenty- 
four  persons,  among  whom  were  the  well-known  thieves 
Perua,  Fina,  and  Alsaiate,  who  were  removed  to  jail.  In 
No.  55  Misericordia  Street  they  found  eighty-six.  In  No. 
94  of  the  same  street  were  found  seventy-seven  in  a  de- 
plorable state  of  uncleanness.  In  No.  44  were  found  one 
hundred  and  two  ;  and  in  No.  ig  of  the  same  street  were 
sleeping  sixty-six.  In  this  house  the  air  was  unbreathable, 
in  all  parts  there  being  a  most  nauseating  smell.  Imme- 
diately upon  learning  of  the  vile  condition  of  these  lodging- 
houses.  Dr.  Graca  Conto  took  energetic  measures  to  im- 
prove them." 

Another  extract  from  the  same  journal.  May  25th,  gives 
some  idea  of  the  origin  and  present  extent  of  the  disease  : 

"It  has  been  absolutely  impossible  for  the  sanitary 
authorities  to  circumscribe  the  plague  which  is  attempting 
to  fix  itself  in  this  city.  The  cases  have  appeared  simul- 
taneously in  various  points,  and  from  this  come  the  difli- 
culties  the  authorities  have  in  trying  to  limit  the  evil  to  a 
single  zone.  The  absolute  lack  of  cleanness  in  which  are 
found  the  sections  of  Saude,  Sao  Jose,  and  others  has 
helped  wonderfully  in  spreading  this  terrible  evil.  The 
hundreds  of  third-class  passengers  who  have  come  to  this 
port  in  various  steamers  from  Europe  and  the  Argentine, 
with  large  quantities  of  dirty  baggage,  have  also  been  a 
powerful  agent  in  making  our  sanitary  condition  worse. 
The  sanitary  authorities  are  sparing  no  pains  or  expense 
in  fighting  the  evil,  and  consequently  our  people  ought  to 
be  confident  and,  above  all,  heed  the  hygienic  counsels. 
If  they  will  do  this  they  will  render  inestimable  help  to 
the  authorities." 

Dr.  Nunc  de  Andrede,  chief  federal  health  officer,  is  in 
cli  irge  and  is  employing  the  same  means  which  he  used  in 
Santos  and  Sao  Paulo,  where  it  was  conquered  in  a  short 
time.     A  quarantine  station  has  been  established  at  Ilh.a 


Grande,  about  six  hours  from  Rio,  where  all  vessels  must 
be  disinfected.  Disinfecting-stations  have  been  also  estab- 
lished at  the  terminal  railroad  stations,  where  all  passen- 
gers and  baggage  must  be  disinfected.  There  seems  to 
be  no  panic,  and  the  presence  of  the  disease  has  not  affecteil 
the  money  market,  which  here  is  a  very  good  thermometer 
of  public  confidence.  There  is  not  much  fear  that  it  will 
spread  into  the  interior,  and  it  is  sincerely  to  be  hoped  that 
it  will  be  stamped  out  in  Rio  itself. 

There  has  been  very  little  yellow  fever  in  Rio  this  sea- 
son, but  epidemics  of  it  have  recurred  in  several  interior 
towns  where  it  was  never  known  before,  and  there  is  a  fear 
that  it  will  eventually  reach  all  parts  of  the  country.  Juiz 
de  Fora,  in  the  state  of  Minas,  which  was  so  terribly  vis- 
ited last  year,  is  again  suffering  from  the  same  evil, 
although  the  city  spent  a  large  sum  in  perfecting  its  sew- 
erage system  during  the  past  year. 


THE    MEDICAL   ASPECTS    OF 
AFRICAN    WAR. 


THE    SOUTH 


(From  our  Special  Correspondent.) 

Tins  will  be  the  last  regular  communication  that  I  sliall 
send  your  readers,  for  although  the  war  still  flickers  on. 
the  medical  aspects  are  not  likely  to  present  any  more 
novel  features.  Since  my  last  communication  the  British 
flag  has  been  hoisted  in  Johannesburg  at  the  end  of  May 
and  five  days  later  at  Pretoria  by  Roberts  ;  while  Buller 
has  forced  Almond's  Nek,  with  the  result  that  all  the  Boers 
have  been  driven  from  Natal  and  that  the  operations  are 
now  being  conducted  entirely  upon  the  soil  of  the  repub- 
lics. Two  minor  Boer  victories  after  the  occupation  of 
Pretoria  by  the  British  have  shown  that  the  Boers  are  able 
to  act  with  concerted  force  and  great  spirit,  but  although 
guerilla  resistance  is  still  to  be  expected,  regular  pitched 
battles  are  not  now  likely  to  occur.  Hence  it  may  be 
taken  for  granted  that  the  medical  lessons  to  be  learned 
from  the  campaign  are  at  an  end,  although  desultory  fight- 
ing will  go  on  for  simie  time,  while  the  ravages  of  epidemic 
disease  will  certainly  add  many  hundreds  to  the  total 
losses  of  either  side. 

The  Total  Losses  of  the  British  up  to  the  occupation  of 
Pretoria  amount  to  25,(xxj  men,  the  figures  being  made  up 
as  follows : 


OfBcers. 

Men. 

»35 
63 

186 
112 

664 

2 ,28.3 
55' 

4,486 

3.609 

58 

13,481 

Missing  and  prisoners  (excluding  those  who  have  been 

Totals 

1,260 

24,468 

Total  losses  (exclusive  of  sick  and  wounded  men  now  in 
British  hospitals  in  South  Africa),  25,728. 

The  figures  are  instructive.  In  eight  months  the  British 
army  has  lost  twelve  and  one-half  percent,  of  its  strength. 
The  officers,  whose  ratio  to  the  men  is  less  than  i  to  100, 
have  lost  in  the  proportion  of  i  to  10  killed  in  action  and  i 
to  9  died  of  wounds,  the  figures  showing  that  the  ofliicers 
have  not  feared  to  take  risks  and  have  had  no  advantages 
whatever  over  their  men  in  the  way  of  surgical  treatment. 
In  death  from  disease  the  ratio  of  officers  to  men  is  i  to  30, 
and  here  the  superior  accommodation  in  officers'  quarters 
and  the  superior  food  at  their  messes  have  probably  not 
counted  for  so  much  as  the  possession  of  private  means. 
On  the  march  the  officers  and  men  have  fared  alike,  but  in 
times  of  inaction  the  officers  have  had  a  healthier  or  less 
crowded  environment  and  have  been  able  to  purchase 
small  comforts.  The  two  largest  items  in  the  roll  call  of 
disaster,  being  between  them  responsible  for  more  than 
two-thirds  of  the  total,  are  the  lists  of  missing  and  prison- 
ers and  of  invalids  sent  back  home.  These  men,  or  at  anv 
rate  a  large  proportion  of  them,  can  be  regarded  as  ony 
temporarily  lost  to  their  country,  for  the  long  sea  voyage 
to  England  as  a  rule  completely  recuperates  the  sick,  while 
the  prisoners  who  are  daily  being  released  by  their  friends, 
despite  stories  of  their  treatment,  have  been  found  gen- 
erally in  good  conditit  n. 

The  Prevalence  of  Enteric  Fever  and  Dysentery  among  the 
British  troops  was  by  the  end  of  May  simply  awful.  The 
figures  with  regard  to  the  former,  when  they  can  be  made 
known,  will  constitute  a  record.  They  are  being  very 
carefully  kept,  as  they  should  prove  an  absolute  answer  to 
the  question  that  all  medical  men,  military  and  civil  alike, 
are  putting  as  to  the  efficacy  of  the  anti- typhoid  serum  in- 


30 


MEDICAL    RECORD. 


[July  7,  1900 


oculation.  At  every  hospital  that  I  have  mentioned  pa- 
tients are  being  nursed  for  enteric  fever,  and  several,  the 
Portland  and  the  Langman,  for  example,  have  been  com- 
pelled to  increase  their  accommodations,  which  in  the  time 
of  hot  figlning  had  been  found  sufficient.  The  percentage 
of  recoveries  is  very  large,  and,  as  I  have  just  pointed  out, 
ouce  the  patient  is  sufficiently  convalescent  to  be  put  on 
board  ship,  he  usually  arrives  in  England  well,  the  voyage 
home  being  exactly  what  he  requires  to  build  him  up  again. 
In  Conclusion,  I  trust  that  your  readers  will  have  been 
able  to  derive  the  proper  medical  lessons  of  the  war  from 
the  brief  accounts  that  I  have  sent.  It  may  have  seemed 
that  I  have  occasionally  dwelt  with  unnecessary  detail 
upon  the  merely  military  conduct  of  the  campaign,  but  un- 
less the  progress  of  the  ditl'erent  generals  was  followed  the 
enormous  difficulties  of  transport  and  the  reasons  for  the 
locations  of  the  hospitals  would  not  have  been  apparent.  I 
need  not  recapitulate  the  views  that  must,  until  some  new- 
weapon  of  precision  alters  both  prognosis  and  treatment, 
prevail  among  all  surgical  authorities  concerning  bullet 
wounds.  Sir  William  MacCormac  and  Mr.  Treves  have 
laid  down  rules  which  will  be  authoritative  until  new  con- 
ditions upset  them.  But  it  will  not  be  out  of  place  to 
enumerate  briefly  the  reasons  why  the  British  Royal  Army 
Medical  Corps  has  emerged  from  the  tierce  trial  of  the 
South  African  war  with  so  much  credit  to  themselves. 
Finstly,  their  organization  was  excellent,  the  military 
training  at  Netley,  following  upon  the  course  of  hospital 
work  necessitated  to  qualify  for  the  corps,  making  of  them 
a  body  of  obedient,  hard-working  men.  Secondly,  their  un- 
dermanned ranks  were  early  tilled  by  well-chosen  young 
men  of  hospital  experience,  able  adjuvants  in  the  wards 
and  still  fresh  from  the  discipline  of  their  civilian  stafl' 
surgeon.  Thirdly,  the  corps  was  cheered  as  well  as  helped 
by  the  presence  of  great  scientific  surgeons,  so  that  they 
always  felt  that  undeniable  testimony  would  be  forthcom- 
ing to  the  value  of  any  good  work,  and  that  a  first-class 
surgical  opinion  could  always  be  obtained  for  the  asking  in 
cases  of  difficulty.  Fourthly,  the  choosing  of  the  hospital 
sites  was  left  to  the  medical  department,  so  that  the  sick 
when  brought  to  the  base  were  always  treated  under  the 
most  favorable  hygienic  conditions.  Bearing  these  facts 
in  mind,  I  believe  that  the  result  of  the  war  will  be  a  reor- 
ganization of  the  Royal  Army  Medical  Corps,  so  that  the 
success  which  they  have  secured  in  this  campaign  by  ex- 
traordinary efforts  will  in  future  campaigns  follow  upon 
ordinary  routine.  And  the  other  tirst-class  powers  of  the 
world,  who  are  compelled  to  keep  a  standing  army,  will 
probably  organize  the  medical  department  of  their  armies 
in  much  the  same  direction.  The  pay  of  tlie  Royal  Army 
Medical  Corps  will  be  raised,  chiefly  by  way  of  special  al- 
lowances, so  that  the  service  may  be  made  attractive  to 
the  best  class  of  young  medical  men.  Leave  will  be 
granted  to  the  medical  department  in  order  to  enable  them 
to  return  home  occasionally  and  revise  their  learning  ;  and 
other  encouragement  will  be  offered  to  them  to  pursue 
original  scientific  study.  And  a  reserve  of  tirst-class 
operating-surgeons  will  in  some  way  be  affiliated  to  the 
corps,  .so  that  the  government,  by  paying  a  small  annual 
sum  in  times  of  peace,  will  be  able  to  secure  the  pick  of 
surgical  skill  in  times  of  war.  It  should,  and  possibly  will, 
also  become  the  rule  of  the  British  War  Office  to  send  a 
medical  attache  to  join  the  head  staff  of  the  army  of  any 
other  nation  engaged  in  war,  a  practice  which  has  been 
observed  by  the  German  War  Office  in  South  Africa. 


several  cases  of  plague  occurred  from  which  the  typical 
bacillus  was  obtained.  When  quarantine  was  tinally  de- 
clared, there  were  nine  cases  and  five  deaths  reported. 
Since  then  the  daily  increase  has  been  as   follows ; 

n«»-  New        Total        r^^^.u 

°*"=-  Cases.      Cases.       ^ealhs. 

May  23d 3  12  5 

May  24th 5  17  3 

May  25th  4  21 

May  26lh 3  24  2 

May  27th 9  33  7 

May  28th 6  39  2 

Through  the  courtesy  of  Dr.  Havelburg,  of  the  United 
States  Marine-Hospital  service,  to  whom  I  am  indebted  for 
much  of  my  information,  I  am  able  to  state  the  above  fig- 
ures with  some  certainty. 

Propliy lactic  measures  have  not  been  taken  with  much 
apparent  energy,  although  the  usual  general  quarantine 
has  been  established.  Vessels  leaving  for  Brazilian  ports 
must  be  disinfected  at  Ilha  Grande  (the  regular  quaran- 
tine station),  and  no  vessels  are  allowed  alongside  the 
wharves  to  load  or  discharge  cargo.  Local  measures  con- 
sist of  isolation  of  the  patient  by  removal  to  the  Jurujuba 
Hospital,  across  the  harbor,  and  by  disinfection  of  the 
house  with  sulphur  or  formaldehyde.  Incidentally  the 
people  object  strenuously  to  sanitary  restrictions  and  i)lace 
every  obstacle  in  the  way  of  disinfection  and  cleanliness. 
The  following  quotation  from  the  Rio  i\VH'.f  of  May  22d 
gives  an  idea  of  the  feeling  toward  modern  medicine  down 
here.  After  noting  the  fact  that  the  presence  of  the  plague 
has  been  officially  acknowledged  and  the  city  i)laced  under 
sanitary  law,  the  editor  says:  "With  all  due  respect  to 
the  professional  gentlemen  who  have  discovered  the  bu- 
bonic bacillus  in  the  blood  of  a  guinea-pig  after  being  in- 
oculated with  the  blood  of  a  person  dying  of  suspected 
plague,  we  are  compelled  to  say  that  we  do  not  believe 
there  is  any  such  thing  as  bubonic  pest  in  this  city,  nor 
that  there  is  any  occasion  n-hatever  for  the  irritating  and 
prejudicial  restrictions  placed  upon  the  commerce  of  this 
port.  The  doctors  are  clearl}-  bacillus-mad,  and  the  losses 
caused  by  their  ridiculous  restrictions  are  worse  even  than 
any  likely  to  be  caused  by  the  plague.  These  quarantines 
are  as  worthless,  besides,  as  they  are  prejudicial,  and,  to 
speak  plainly,  they  serve  no  other  purpose  than  to  afford 
extra  pay  to  a  few  doctors  and  quarantine  employees." 

Professor  Lerin  and  Dr.  Gomes  have  been  studying  the 
plague  in  the  bacteriological  laboratory,  and  Professor 
Lerin  has  succeeded  in  obtaiaing  a  prophylactic  similar  to 
that  of  Haft"kine.  LTntil  last  week  only  a  few  expei  imental 
inoculations  had  been  made,  but  now  many  people  are 
being  inoculated,  and  figures  should  .soon  be  forthcoming. 

As  to  the  treatment  of  the  disease  in  the  hospital,  little 
can  be  learned.  A  shrug  of  the  .shoulders  may  be  ex- 
pressive, but  it  is  neither  encouraging  nor  enlightening. 
The  Yersin  serum  can  be  obtained  here,  but,  I  believe,  has 
not  been  u.sed. 

The  outlook  is  certainly  not  promising.  The  poorer 
classes  are  half-starved,  half-naked,  and  altogether  dirty. 
They  live  in  dirty  districts  which  the  authorities  do  not 
seem  disposed  to  clean.  There  is  every  opportunity  for  a 
large  mortality  in  the  next  few  weeks,  unless  vigorous 
measures  are  undertaken  at  once. 

James  R.  Whiting,  Jr.,  M.D. 

Rio  de  Janeiro,  Brazil,  May  29,  1900. 


THE   PLAGUE   IN    RIO    DE   JANEIRO. 

To  THE  Editor  of  the  Medical  Record. 

Sir  :  A  note  on  the  recent  outbreak  of  bubonic  plague  in 
this  city  may  be  of  .some  interest,  although  full  information 
at  this  time  is  hard  to  obtain. 

After  a  long  delay,  probably  due  to  a  reluctance  to  allow 
quarantine  to  mar  the  celebration  of  the  fourth  centennial 
of  the  discovery  of  Brazil,  the  government,  on  May  21, 
lyoo,  officially  declared  the  existence  of  bubonic  plague  in 
the  city  of  Rio  dc  Janeiro.  Sporadic  cases  of  plague  have 
been  ob.served  here  since  January  last,  and  several  cases  of 
adenitis  inguinalis  perniciosa  have  proved  fatal,  as  may  be 
seen  in  the  reports  of  the  United  States  Marine-Hospital 
service.  The  manner  in  which  the  original  case  was  intro- 
duced is  still  a  disputed  point,  but  the  best-informed  here 
believe  that  it  was  brought  on  a  ship  arriving  here  from 
Tamatave,  Madagascar.  On  May  15th  a  suspicious  mor- 
tality among  the  rats  in  the  custom  house  was  observed, 
and  upon  examination  of  the  bodies,  the  bacilli  of  pestis 
bubonica  were  found,  and  cultures  were  made  in  the  bac- 
teriological laboratory  under  the  direction  of  Professor 
Lerin  and  Dr.  Gomes.  The  authorities  were  informed, 
but   no  official   action  was  taken.     About  the  same  time 


THE  SAVING  OF  LIFE  IN  CUBA.     * 

To  THE  Editor  of  the  Medical  Record. 

Sir  :  I  have  read  your  remarks  on  the  report  of  Chief  Sur- 
geon Ives  of  the  Department  of  Matanzas  ana  Santa  Clara. 
I  had  just  received  an  extract  from  the  report  of  Maj. 
George  S.  Cartwright,  quartermaster,  who  has  had  ch;  rge 
of  the  Department  of  Street  Cleaning  and  other  sanitary 
improvements,  such  as  drainage,  etc.,  and  I  send  you  the 
number  of  deaths  per  month  in  Matanzas.  As  an  object- 
lesson  I  think  it  will  emphasize  your  remarks: 


Deaths. 

December,  1898     449 

Jatiuary,  iSijg 323 

February.  1899 257 

March,  1899 205 

April,  1899 136 

May.  1899 '31 

June,  189Q 118 

July.  iSyg _ 121 

AuKiisl,  1899 112 


Deaths. 

September,  1899 103 

October,  1899 73 

Kuveinber,  1899 88 

December.  1899 "35 

January,  1900 89 

V'ebruary,  1900 85 

March,  1900 107 

April,  1900 68 


The  city  of  Matanzas  had  a  population  of  38,000  in  1898. 
It  would  appear  that  American  occupation  has  not  been  a 
failure  so  far  as  saving  life  is  concerned. 

S.  S.  Cartwright,  M.D. 

RoxuuRV.  N   y. 


July  7,  1900] 


MEDICAL   RECORD. 


31 


PRESENTATION    OF     A     LOVING-CUP     AND 
ALBUM  TO  PROF.  ABRAHAM  JACOBI,  M.D. 

At  the  annual  meeting  of  the  Section  on  Diseases  of 
Children  of  the  American  Medical  Association,  held 
at  Atlantic  City,  June  5,  1900,  a  very  unusual  and 
interesting  ceremony  took  place,  occasioned  by  a  din- 
ner to  Dr.  Abraham  Jacobi  and  the  presentation  of  a 
loving-cup  to  that  gentleman. 

Dr.  Louis  Fischer,  of  New  York,  secretary  of  the 
Section  on  Diseases  of  Children,  American  Medical  .As- 
sociation, made  the  presentation  of  the  cup  as  follows: 

Mr.  Chair.man,  Friends,  and  Members  ok  the 
Section  on  Diseases  of  Children:  It  appears 
to  me  that  it  is  with  malice  prepense  that  I  have 
been  chosen  to  address  our  honored  guest  of  the 
evening.  Dr.  .\braham  Jacobi.  The  committee  in 
charge  have  evidently  noticed  that  a  handsome  woman 
chooses  as  her  steady  companion  one  who  is  ex- 
tremely plain  and  homely;  her  reason  for  such  ac- 
tion is  evidently  a  desire  to  shine  by  contrast.  In  this 
way  I  explain  perfectly  the  fact  that  upon  me  has  de- 
volved this  pleasant  task.  My  youth  and  verdancy, 
I  suppose,  are  to  set  off  our  guest's  venerable  age;  in- 
experience is  to  be  placed  in  juxtaposition  with  the 
accumulated  lore  of  three  generations;  the  bubbling, 
fervid  passion  for  his  chosen  profession  of  the  Bache- 
lor of  Medicine  is  opposed  to  the  staid,  dignified,  and 
ripened  love  of  the  Master,  the  Father,  the  Nestor  of 
American  pediatrics. 

But,  be  that  as  it  may,  I  take  courage  in  knowing 
that  I  stand  here  as  the  representative  of  American 
pediatrists,  as  the  mouthpiece  of  the  followers  of  the 
Doctor  Jacobi,  and  as  an  admirer  among  admirers  of 
the  many  lovable  qualities  and  the  sterling  character 
of  the  man  Jacobi. 

It  is  unnecessary  for  me  to  discourse  on  the  achieve- 
ments of  our  Grand  Old  Man!  His  numerous  contri- 
butions to  medical  science  are  well  known  to  you. 
From  1859,  when  he  published  with  Xoeggerath  "  Con- 
tributions to  Midwifery  and  Diseases  of  Children,"  to 
the  present  year,  1900,  when  at  Paris,  as  an  honorary 
president  at  the  International  Congress,  he  delivers 
an  address  on  "  Report  on  Artificial  Feeding  and  Ster- 
ilization of  Milk" — -during  all  these  years  we  find 
him  never  tiring,  ever  busy,  ever  discovering,  ever 
studying,  and  ever  teaching.  His  reputation,  indeed, 
is  far  from  being  merely  local,  or  confined  only  to  the 
limits  of  this  section,  proud  to  call  him  founder.  We 
find  him  known,  quoted,  honored,  loved  abroad  as  well 
as  at  home.  As  an  example  of  the  regard  in  which  he 
is  held,  allow  me  to  mention  that  such  societies  as  the 
Deutsche  Gesellschaft  fiir  Kinderkrankheiten  sends 
congratulations  signed  by  their  prominent  members, 
on  the  occasion  which  we  are  gathered  to  celebrate  to- 
night. 

But  enough  of  this!  I  fear  that  by  enumerating 
all  the  virtues  of  our  guest,  I  should  most  assuredly 
bring  down  upon  my  head  the  imprecations  prompted 
by  his  modesty.  I  had  occasion  to  ask  him  in  a  jok- 
ing way,  whether  all  these  celebrations  might  not 
prove  too  much  even  for  his  modesty,  and  whether 
they  would  not — to  use  the  vernacular — swell  even 
his  cranium.  He  laughingly  answered  that  such 
could  not  be  the  case,  since  he  believed  only  about 
one-half  of  all  the  encomiums  showered  upon  him. 
You  must,  therefore,  not  blame  me  if,  to  punish  him 
for  his  disbelief  in  honestly  expressed  opinions,  I 
omit  three-quarters  of  what  I  intended  to  say,  or  rather 
of  what  you  intended  to  say  through  me.  But  I  shall 
use  his  own  words  and  apply  them  to  him  with  perfect 


propriety.  In  a  presentation  speech  delivered  nine- 
teen years  ago  in  honor  of  the  noted  Dr.  George  F. 
Shrady,  Dr.  Jacobi  spoke  as  follows: 

"We  know  quite  well  that  he  meant  to  perform  his 
duty  only.  Neither  he  nor  any  other  sterling  man 
works  for  thanks  or  appreciation  expressed  in  any 
way.  The  best  intellectual  and  social  labors  are  al- 
ways performed  by  those  who  work  from  inner  neces- 
sity only.  But  when  one  man  works  industriously, 
honestly,  and  usefully  in  the  service  of  society,  coun- 
try, or  scientific  body,  it  is  both  natural  and  becom- 
ing, it  is  good  instinct  and  wise  principle  on  the  part 
of  those  who  derived  benefit  from  his  personal  efforts 
to  prove  themselves  worthy  of  them  by  word  and  ac- 
tion." 

And  this,  my  dear  friend  Dr.  Jacobi,  we  tried  to  do 
to-night.  I  beg  you  to  accept  this  loving-cup  as  a 
token  of  our  appreciation  of  your  successful  efforts  in 
the  behalf  of  science  and  in  our  behalf.  May  you 
remain  with  us  a  long  time  to  come;  yes,  may  you 
live  to  witness  the  presentation  of  loving-cups  on  the 
seventieth  birthdays  of  those  who  now  take  such  delight 
in  otTering  this  one  to  you. 

And  lastly,  as  regards  these  engrossed,  signed  reso- 
lutions, we  beg  you  to  look  upon  them  as  an  expres- 
sion of  our  desire  to  be  remembered  by  you  as  your 
friends  and  admirers. 

Permit  me  to  read  them  : 

"  W/iereas,  In  the  fulness  of  time,  the  life  and  ca- 
reer of  men  conspicuous  for  unselfish  devotion  to  duty 
become  the  common  property  of  all;  and  the  subject 
of  pride  to  those  with  whom  he  may  be  connected  by 
reason  of  friendship,  respect,  and  love,  whose  work 
has  impressed  not  only  those  with  whom  he  is  sur- 
rounded, the  student  to  whom  he  spoke,  the  brother 
with  whom  he  advised,  the  profession  with  whom  he 
dwelt,  but  the  whole  world  of  medicine,  and  most  es- 
pecially that  pertaining  to  the  diseases  of  children, 
alone  in  the  ripeness  of  his  years,  with  a  reputation 
unsullied,  and  the  pride  of  his  profession,  stands 
Abraham  Jacobi,  '  The  Father  of  American  Pedi- 
atrics,' 

"  We,  his  friends  and  admirers,  brethren  in  the  same 
profession,  and  followers  to  his  teachings,  bring  to 
him  our  felicitation.  We  entertain  for  him  that  re- 
spect and  esteem  which  has  been  engendered  by  his 
many  estimable  qualities.  That  unusual  progress  that 
has  been  made  in  advancement  of  the  scholastic  repu- 
tation of  the  institutionSj  societies,  or  associations  with 
which  he  has  ever  been  connected. 

"  As  an  expression  of  our  deep  and  enduring  appre- 
ciation of  his  unvarying  courtesy  toward  all;  his  un- 
flagging interest  in  the  professional  welfare  of  all; 
and  his  indefatigable  efforts  for  the  practicable  and 
liberal  enlightenment  in  the  subject  of  pediatrics — 

"We,  the  members  of  the  American  Medical  Asso- 
ciation, and  especially  the  Section  on  Diseases  of 
Children,  of  which  he  was  the  original  founder,  ten- 
der to  Abraham  Jacobi  every  sentiment  of  veneration 
and  respect  and  gratitude  for  that  unvarying  virtue 
that  points  to  him  as  the  true  physician,  and  as  a 
partial  acknowledgment  of  the  great  obligation  to  his 
zealous  personality  present  him  with  this  loving-cup, 
and  hope  that  the  memories  of  our  yearly  intercourse 
may  ever  linger  with  him." 

Toasts  were  given  and  responded  to  as  follows: 
"The  American  Pediatrist,"  by  William  Perry  North- 
rup,  of  New  York;  "The  International  Medical  Con- 
gress," by  F.  X.  Dercum,  of  Philadelphia,  Pa.;  "The 
American  Medical  Association,"  by  Joseph  M.  Ma- 
thews, of  Louisville,  Ky.;  "The  Section,"  by  A.  C. 
Cotton,  of  Chicago,  111. :  "  The  Medical  College,"  by 
James  C.  Wilson,  of  Philadelphia,  Pa.;  "The  De- 
ceased Members,"  by  H.  E.  Tuley,  of  Louisville, 
Ky. ;  "  Fraternal   Greetings,"'   by  John   H.  Musser,  of 


32 


MEDICAL    RECORD. 


[July  7,  1900 


Philadelphia,  Pa.,  William  Osier,  of  Baltimore,  Md., 
Henry  Koplik,  of  New  York,  N.  V.,  and  R.  C.  Moore, 
of  Ohama,  Neb. 

Dr.  Jacobi  replied  as  follows: 

Mr.  Chairman,  Ladies,  and  Gentlemen:  When 
I  was  invited  to  be  present  at  your  annual  dinner, 
I  took  it  for  granted,  until  this  afternoon,  this  was 
to  be  an  informal  affair,  and  no  address  was  ex- 
pected of  me.  The  outcome  is  quite  fortunate  for  all 
of  you,  for  I  shall  be  brief,  but  less  so  for  me  who 
hates  to  be  unjust  to  men  and  things.  Knowing  I 
should  find  many  friends  here,  I  accepted  the  invita- 
tion, though  I  admit  that  my  eagerness  was  mingled 
with  sadness.  The  latter  is  based  on  the  fact  that  for 
eighteen  long  years — though  engaged  in  the  same  work 
with  you  and  every  honest  professional  man — I  have 
not  been  inside  your  doors.  After  all,  however,  I 
know  I  belong  here,  for  I  am  among  pupils,  co-opera- 
tors, peers,  or  masters  as  the  case  may  be,  but  always 
among  friends. 

I  am  afraid  when  I  speak  at  all — I  always  was  a 
better  listener  than  talker — I  shall  repeat  what  I  have 
said  a  great  many  times  before.  It  is  true  a  man  may 
quote  himself,  and  copy  his  former  sayings  without 
quotation  marks.  In  that  respect  I  have  the  advan- 
tage over  all  of  you.  They  have  told  me  so  often 
lately  I  was  seventy  years  old,  that  I  begin  to  believe 
it  myself.  Now,  in  scores  of  years  I  have  said  many 
things  that  fortunately  are  forgotten,  and  when  I  re- 
peat them  now  and  then  for  a  new  generation,  they  are 
not  remembered.  Indeed,  perhaps  your  fathers  were 
my  pupils.  Think  of  itl  it  is  nearly  a  generation 
that  Busey  and  Rotch  and  I  founded  this  section, 
which  has  since  gone  on  flourishing  and  growing. 

It  was  a  wondrous  contrast  to  former  failures. 
Twenty  years  previous  to  that  memorable  meeting  at 
Richmond,  I  undertook  to  found  a  section  for  pedia- 
trics in  the  New  York  Academy  of  Medicine,  and^ 
failed  utterly.  Evidently  neither  I  nor  the  time  was 
matured.  It  is  true  that  a  few  papers  and  books  had 
been  written  on  the,  or  on  some  of  the  diseases  of 
children,  but  they  were  isolated  creations.  You  are 
well  acquainted  witii  the  names  of  Dewees,  Eberle, 
Condie,  Ch.  D.  and  Forsyth  Meigs,  \V.  V.  Keating, 
and  their  individual  exertions.  It  was  only  in  i860 
that  the  first  systematic  instruction  could  be  arranged 
for  tlie  New  York  Medical  College,  for  the  University 
Medical  College  in  1865,  for  the  College  of  Physi- 
cians and  Surgeons  in  187.0.  In  that  same  decade 
other  schools  in  the  Atlantic  States  followed  those  ex- 
amples. Among  the  men  who  were  at  that  early  time 
most  active  in  the  study  of  diseases  of  children,  I 
consider  as  most  prominent  J.  L.  Smith,  of  New 
York,  and  Parry,  of  Philadelphia.  I  should  also 
mention  my  friend  Fountain,  of  Davenport,  Iowa, 
whose  tragic  end  some  of  you  may  have  found  de- 
scribed in  my  treatise  on  diplitheria  (1880),  or  in  tlie 
famous  patriarch  Stillc's"  Materia  Medica  and  Thera- 
peutics." Fountain's  history  is  brief.  Both  of  us  ex- 
perimented with  potassic  chlorate.  A  letter  I  wrote 
him  on  the  results  of  my  experiments  with  one-half 
ounce  of  the  drug,  consisting  in  temporary  polyuria, 
crossed  the  news  of  his  death,  which  was  caused  by 
his  taking  one  ounce  with  speedy  fatal  termination. 
He  was  an  unselfish  and  enthusiastic  worker,  and 
neither  liis  life  nor  his  death  should  be  forgotten.  If 
he  had  been  a  general,  he  would  be  remembered  by  a 
monument.  Being  only  one  of  us,  maybe  nobody 
knows  now  where  it  is  that  the  soil  covers  his  remains. 
That  was  forty  years  ago.  Sketches  of  the  history  of 
pediatrics  in  the  United  States  have  been  published 
by  S.  S.  Adams  and  Crozer  Griffith;  with  both  of 
them  you  are  acquainted.  Its  progress  is  marked  by 
the  interest  taken  in  it  by  a  large  number  of  indus- 
trious and  scientific  men,  and  by  the  co-operation  of 


many  of  them  for  a  common  end.  Such  co-operative 
enterprises  are  John  M.  Keating's  '"  Cyclopardia  "  and 
L.  Starr's  "American  Text-book,"  accompanied  or  fol- 
lowed by  two  journals  exclusively  dedicated  to  ped- 
ology. 

All  this  you  know  as  well  as  I.  With  some  of  the 
phases  of  this  development  many  of  you,  who  have 
worked  so  assiduously,  are  better  acquainted  than  I. 
What  is  particularly  encouraging  in  the  rapid  strides 
pediatrics  has  taken,  is  not  only  the  charm  its  study 
has  by  itself,  but  the  mutual  relation  of  pediatrics 
with  all  branches  of  medicine  and  its  special  doc- 
trines; so  that  it  gives  and  takes  in  equal  measures. 
A  narrow  specialism  has  never  been  e.xhibited  in 
pediatrics  or  in  pediatrists.  Co-operation,  as  it  is  the 
signature  of  the  end  of  the  century  in  commercial  enter- 
prises, is  also  the  source  of  unprecedented  results  in 
medicine;  it  is  true,  on  a  different  basis  and  with  dif- 
ferent results.  Combination  of  efforts  in  financial 
and  commercial  enterprises  is  apt  to  lead  to  jealousy 
and  avarice,  and  to  prove  destructive  to  the  public 
welfare;  in  scientific  pursuits  it  improves  and  benefits 
all.  This  sort  of  scientific,  moral,  and  professional 
"trust,"  as  they  call  it,  is  beneficial  to  mankind. 

With  the  development  of  pediatrics  in  our  and  in 
other  countries,  my  name  has  often  been  connected; 
also  by  you,  to  an  exorbitant  degree  I  am  certain.  It  is 
true  I  commenced  at  an  early  time  to  furnish  abstracts 
of  European  literature;  soon  I  ventured  into  writing 
papers.  In  that  early  time  I  published  a  case  of  in- 
tussusception with  obstructive  ha;matomata,  or  perhaps 
obstructive  ha;matomata  with  intussusception,  also 
an  essay  on  the  diagnosis  and  pathological  importance 
of  the  premature  closure  of  the  fontanelle.  That  was 
—  if  you  permit  me  to  speak  of  antediluvian  times — in 
1858.  In  the  next  year  Noeggerath  and  I  published 
a  big  volume  of  contributions  to  midwifery  and  the 
diseases  of  women  and  children,  of  which  I  speak 
because  Osier  could  not  find  it,  and,  therefore,  accord- 
ing to  tiie  pathologic  and  dead-house  turn  of  his  mind, 
which  probably  never  admits  anything  he  has  not  seen 
or  felt,  thought  it  was  perhaps  apocryphal.  I  say  there 
is,  or  rather  was,  such  a  book,  and  it  was  one  of  my 
great  successes,  financial  and  otherwise.  The  book 
appeared,  was  sent  to  the  journals,  was  favorably 
criticised,  and  made  some  reputation  for  the  authors; 
but  nobody  purchased  it.  ^\'e  paid  $1,000  for  print- 
ing and  publishing.  After  a  few  years  we  sold  the 
edition  as  old  paper  for  $68.  Clear  profit  $68,  a  good 
deal  for  poor  young  doctors.  Such  financial  successes 
I  had  many  in  my  life.  Another  book  of  mine,  also 
out  of  print,  of  those  times  is  "  Dentition  and  its  De- 
rangements," 1862.  It  is  queer  all  my  books  are  out 
of  print,  with  the  exception  of  my  "Therapeutics," 
which  mv  kind-hearted  publishers  say  mav  still  be 
had. 

From  what  I  have  been  told  to-night,  and  several 
times  lately,  I  am  to  conclude  that  it  is  a  common  be- 
lief that  I  had  a  good  deal  to  do  with  the  development 
of  pediatrics  as  a  pet  study  in  the  profession,  and  as 
a  subject  for  instruction  all  over  the  land.  It  is  said 
I  had  my  finger  in  most  pediatric  pies.  It  is  true,  in 
spite  of  unspeakable  stage  frights,  I  began  to  lecture 
very  early,  even  in  the  spring  course  of  the  College  of 
Physicians  and  Surgeons  in  1857,  and  then  i860,  as 
what  they  call  a  professor,  in  the  New  York  Medical 
College.  I  also  attached  myself  to  a  children's  ser- 
vice in  the  newly  established  German  Dispensary  in 
1857.  Indeed  I  had  the  ambition  that  if  ever  the  his- 
tory of  pediatrics  in  the  Ihiited  States  would  be  writ- 
ten, my  name  should  not  be  absent  from  its  pages. 

My  merits,  however,  have  been  overrated,  I  am  sure. 
But  as  an  excuse  for  the  mistakes  made  in  my  favor,  I 
may  say  that  I  have  been  very  fortunate  in  many  re- 
spects.    Mind,  I  was  the  first  in  the  field  when  most 


July  7,  1900] 


MEDICAL    RECORD. 


33 


of  you  had  not  even  the  foresight  of  being  born. 
Then  I  could  recognize  early  how  little  had  been 
done  in  America;  and  moreover  all  sorts  of  facilities 
were  given  me.  As  early  as  i860  I  could  speak,  long 
before  I  published  my  papers  in  the  American  Aledical 
Times,  on  diphtheria  in  a  discussion  of  the  Academy 
of  Medicine,  simply  because  it  had  been  my  luck  to 
see  many  cases  and  not  to  overlook  them.  For  they 
were  not  quite  so  rare  as  they  were  believed  to  be. 
Indeed,  their  presence  was  denied  by  most.  One  of 
my  warmest  friends— at  least  1  thought  he  was — was 
reported  to  say  that  week,  but  that  week  only:  "I 
always  thought  Jacobi  was  an  honest  man.  How  the 
world  is  given  to  lying!"  It  so  happened,  however, 
that  a  week  after  the  discussion  alluded  to  a  great 
many  cases  were  reported. 

Besides,  the  profession  of  New  York,  and  of  the 
State  at  large,  was,  as  I  think  it  is  to-day,  unpreju- 
diced, anxious  to  learn  even  from  the  young  who  had 
facilities,  and  atiforded  me  many  more  to  learn  and  to 
teach.  It  gave  me  any  and  every  opportunity  for 
work,  and  many  places  of  honor,  showed  me  implicit 
confidence,  and  enabled  me  to  use  my  influence  in 
favor  of  young  men  whom  I  knew  or  believed  to  be 
willing  and  able  to  work.  While  I  was  busy  myself, 
I  could  encourage  others  to  work  and  to  come  to  the 
front  in  pediatrics  and  otherwise.  That  is  perhaps 
the  best  I  have  done  in  my  life.  Never  has  a  for- 
eigner, a  young  man,  been  treated  with  so  much 
consideration,  regard,  and  favor  as  the  man  who  is 
speaking  to  you  has  been  treated  by  the  democratic 
generosity  of  the  medical  profession  of  America. 
And  you  here,  all  of  you,  form  no  exception.  I  am 
the  more  grateful  for  all  I  have  received  from  you  and 
from  others  lately,  the  less  I  may  have  the  claim  of 
having  worked,  though  ever  so  successfully,  in  limited 
lines,  or  ruts  perhaps,  of  a  narrow  specialty.  I  always 
was  a  general  practitioner. 

Indeed,  the  most  important  factor  in  active  medical 
work,  both  curative  and  preventive,  is  the  general 
practitioner,  and  among  his  class  the  pediatrist.  His 
responsibility  is  the  very  greatest,  his  duties  are  the 
most  serious.  The  questions  of  feeding  at  different 
ages,  and  of  educating  the  well  and  the  sick,  the  bright 
and  the  idiotic,  must  be  answered  by  him.  His  do- 
main is  at  the  same  time  hygiene  and  pedagogy.  The 
prevention  of  constitutional  disorders,  such  as  rickets 
and  scrofula,  and  of  infectious  and  contagious  diseases 
such  as  scarlatina,  measles,  diphtheria,  tuberculosis, 
and  syphilis,  are  his  studies  and  his  duties.  Whatever 
concerns  the  future  citizen  of  the  republic  he  is  re- 
sponsible for.  In  the  performance  of  these  duties  he 
has  to  co-operate  with  nurses  and  mothers.  I  draw  the 
line  at  grandmothers,  with  their  hearts  swelled  with 
untimely  sympathies  and  their  pockets  with  indiges- 
tible sweetmeats.  They  are  a  constant  danger.  Moth- 
ers-in-law cannot  hold  the  candle  to  these  in  point  of 
dangerousness.  One  of  the  greatest  dangers  in  the 
pediatrist's  life — for  that  matter  in  that  of  every  medi- 
cal man — -is  overfeeding.  In  that  respect  I  simply 
remind  you  of  what  you  all  know,  that  more  infants 
are  suffering  from  over-  than  from  underfeeding. 
Still,  the  overfeeding  of  some  adults  is  attended  with 
equal  danger.  There  are  some  of  our  trained  nurses, 
who  after  a  two  years'  course  of  instruction  are  burst- 
ing with  learning.  I  met  one  lately,  filled  to  her  throat 
with  Greek  si.x-syllable  terms,  that  ran  a  thermome- 
ter into  an  eight-weeks-old  baby's  vagina  instead  of 
the  rectum.  If  you  will  look  at  the  big-bellied  text- 
books they  are  compelled  to  swallow  whole,  you 
understand  how  those  things  can  happen.  What  is 
wanted  is  more  training,  and  less  improvident,  too 
technical  learning.  The  tendency  of  our  times  is 
meddling  with  other  people's  business;  that  is  why 
nurses  are   interfering  with  yours  all  the  time.     The 


public  at  large  also  is  tempted  to  embark  in  the  most 
dangerous  dilettanteism  of  all,  viz.,  that  in  medicine. 
The  cheap  yellow  or  otherwise  colored  newspapers, 
and  the  facility  with  which  strictly  technical  books 
can  be  obtained,  are  a  positive  calamity.  I  know  that 
a  certain  good  text-book  on  the  diseases  of  children, 
meant  for  the  practitioner  and  the  advanced  student 
of  medicine,  is — to  the  advantage,  I  suppose,  of  the 
publisher,  and  of  the  retailer  who  pockets  his  commis- 
sion, and  to  tile  detriment  of  the  public—  sold  over  the 
counter  of  a  well-known  New  York  milk-shop.  This 
is  a  demoralizing  measure  which  appears  to  be  quite 
general,  if  I  may  judge  from  what  happened  to  me  two 
years  ago.  I  at  that  time  received  the  invitation  from 
the  secretary  of  a  so-called  congress  of  (alleged) 
mothers,  in  which  I  was  told  that  I  was  considered 
competent  to  deliver  an  address  before  them  at  3  p.m. 
on  a  certain  day,  on  the  physical  education  of  chil- 
dren, and  that  they  would  refund  my  travelling-ex- 
penses to  and  from  Washington,  D.  C,  and  also  give 
me  the  permission  to  sell  my  books  then  and  there. 

Now,  my  friends,  if  there  be  anybody  among  you 
that  thinks  I  am  not  at  all  pleasant  in  my  remarks,  but 
rather  abusive,  I  could  only  reply  that  I  was  made  that 
way.  You  see  I  must  be  consistent.  If  I  were  not,  you 
would  say:  "Old  age  has  changed  him  wonderfully." 

That,  however,  reminds  me  of  old  Cicero,  who  was 
an  intolerably  garrulous  man  in  the  most  polished 
Latin;  he  said — when  he  looked  into  the  glass,  I  sup- 
pose— loquar  sciiectus,  old  age  is  talkative.  Unless  I 
stop  right  here  you  will  say  I  have  grown  old,  and  I 
want  to  do  some  work  before  I  die,  worthy,  if  possible, 
of  the  reception  you  have  given  me. 

Of  this  reception  what  shall  I  say?  Though  I  do 
not  respond  to  your  roll-call,  you  have  treated  me  as 
if  I  belonged  here;  indeed,  much  better  than  that. 
You  never  honored  a  man  as  you  honored  me.  That 
proves  to  me  that  I  belong  here  after  all.  Indeed  I 
find  so  many  friends  here  that  it  is  an  impossibility 
not  to  feel  perfectly  at  home.  The  honors  your  confer 
upon  me  prove  only  one  thing  to  me,  of  which  I  am 
both  glad  and  proud,  viz.,  that  you  are  firmly  attached 
to  pediatrics  in  the  sense  in  which  I  always  considered 
it,  as  a  study  full  of  interest  in  itself,  of  import  to  man- 
kind, intimately  connected  with  all  branches  of  medi- 
cine, taking  from  them,  giving  to  them,  and  combining 
the  interests  of  biological  research  with  the  necessities 
and  wants  of  the  people.  It  finally  proves  one  more 
thing,  viz.,  that  I  have  been  able  to  gain  your  confi- 
dence, and  that  I  have  not  lived  in  vain.  Goethe 
says,  that  whosoever  has  succeeded  in  satisfying  the 
best  of  his  era  has  lived  for  all  times.  I  thank  you 
from  all  my  heart. 


AMERICAN  ACADEMY  OF  MEDICINE. 

Twetity-fijth  Annual  Af-eiing,  Held  at  "  The  Shelhiirne," 
Atlantic  City,  N.  J.,  June  2  and  4,  igoo. 

First  Day — Saturday,  June  2d. 

The  meeting  was  called  to  order  at  1 1  a.m.  by  the 
president.  Dr.  G.  Hudson  Makuen,  of  Philadelphia. 

The  secretary,  Dr.  Charles  Mclntire,  read  the  min- 
utes of  the  Columbus  meeting. 

The  treasurer  reported  that  the  Academy  was  free 
from  debt,  but  that  the  balance  on  hand  was  not  so 
large  as  usual.  The  year  had  been  marked  by  several 
losses  from  death. 

.Among  the  election  of  fellows  to  the  Academy  were: 
Drs.  O.  A.  Emberly,  of  Massachusetts;  Ella  B.  Ev- 
erett, of  Philadelphia;  Thomas  Snyder,  of  Niagara 
Falls;  A.O.J.  Kelley,  of  Philadelphia;  J.  Addison 
Joy,  of  Atlantic  City  ;  Judson  Daland,  of  Philadelphia; 
W.  R.  Powley,  of  Atlantic  City. 


34 


MEDICAL    RECORD. 


[July  7.  i9(X) 


Drs.  Risley  and  Carhart  were  appointed  auditing- 
committee,  and  Drs.  Connor,  of  Detroit,  Jackson,  of 
Denver,  and  Wilson,  of  Columbus,  were  appointed  on 
the  nominating-committee. 

Report  of  the  Special  Committee  for  the  Study 
and  Formation  of  Principles  Respecting  Specialism 
and  Respecting  Advertising.— The  secretary  read  the 
report  of  this  committee,  which  first  defined  the  word 
"specialism,"  as  used  by  the  committee,  and  presented 
the  following  propositions:  (1)  Specialism  was  not 
only  desirable;  it  was  unavoidable.  (2)  It  was  proper 
for  a  physician  to  seek  to  perfect  himself  in  the  direc- 
tion of  his  greatest  ability,  even  to  the  neglect  of  some 
other  field  of  practice.  (3)  A  specialist  as  well  as  the 
general  practitioner  could  have  a  practice  directly 
with  his  patients,  or  indirectly  through  consultation. 

(4)  In  his  direct  practice,  a  specialist  ought  not  to  be 
an  exclusivist.  (5)  In  his  consulting-practice,  a  spe- 
cialist stood  in  a  different  relation  to  his  fellow-physi- 
cian than  did  the  general  practitioner  in  consultation. 
He  was  rather  a  coadjutor  than  a  consultant.  (6)  Spe- 
cialism per  sc  did  not  create  discord  in  the  harmony  of 
professional  intercourse.  (7)  The  time  to  enter  upon 
a  specialty  could  not  be  predetermined  by  rule. 

As  to  advertising:  (i)  No  physician  could  escape 
advertising.  (2)  The  true  physician  served  humanity 
first;  the  earning  of  a  livelihood  being  secondary.  (3) 
Any  method  of  advertising  reversing  this  order  was 
not  to  be  commended.  (4)  Any  method  of  advertising 
which  only  sought  to  inform  the  public  that  the  ad- 
vertiser was  ready  to  be  of  service  was  permissible. 

(5)  The  above  principles  were  fixed  ;  their  application 
varied    with    the   environment.     (6)    Regulations    re-* 
stricting  advertising  should  be  equal  in  their  action. 

A  symposium  on  "The  Medical  Aspect  of  the 
Home  "  followed. 

The  Essential  Conditions  for  a  Habitation  to 
Develop  and  Maintain  a  Healthful  Family  Exist- 
ence.— Dr.  Rosa  Engelmann,  of  Chicago,  read  a  pa- 
per with  this  title.  She  stated  that  healthy  family  life 
depended  upon  health,  character,  intelligence,  indus- 
try, frugality,  mutual  affection,  forbearance,  and  the 
wherewithal  to  furnish  a  happy  and  healthy  environ- 
ment. Of  supreme  importance  for  the  development 
and  maintenance  of  these  attributes  was  the  separate- 
housing  system.  Among  the  essential  conditions 
mentioned  were  fresh  air  and  sunshine,  adequate  pure- 
water  supply  and  good  plumbing,  healthful  employ- 
ment, healthful  recreation,  educational  facilities.  Lack 
of  these  conditions  in  large  cities  was  considered, 
with  the  results,  and  the  remedies  therefor. 

The  Influence  of  Early  Training  of  Manly  and 
Womanly  Qualities  to  Avoid  Degeneracy.— Dr.  J. 
Cheston  Morris,  of  Philadelphia,  furnished  as  a  text 
an  incident  of  a  little  girl  poutingly  disobedient,  and 
the  necessity  of  an  early  training  in  submission  to 
authority.  Acts  spoke  more  effectively  to  children 
than  mere  exhortations  or  coiijmands.  Dr.  Morris 
stated  that  the  training  in  self-control  must  begin 
early  in  life,  and  that  the  reign  of  law  and  the  influ- 
ence of  patient  example  was  necessary  to  bring  them 
about.  Heredity,  so-called,  was  often  but  the  uncon- 
scious imitation  of  the  parents'  peculiarities  by  the 
very  young.  The  lack  of  this  early  development  per- 
mitted many  forms  of  degeneracy,  hence  the  impor- 
tance of  this  early  training. 

The  Influence  of  Medical  Supervision  of  Children 
in  their  Homes — Dr.  J.  Madison  Taylor,  of  Phila- 
delphia, read  this  paper.  He  said  that  the  child  was 
supposed  to  be  capable  of  satisfactory  development  if 
allowed  moderately  good  opportunity  and  environment, 
and  was  seldom  or  never  systematically  directed  in  its 
physical  growth  or  development.  The  consequence 
was  that  very  many  faults  of  both  mind  and  body  were 
acquired,  many  of  which  seriously  affected  the  subse- 


quent activity  of  the  child.  He  stated  also  that  no 
attention  was  paid  to  the  mating  of  the  parents,  as 
was  done  in  the  case  of  domestic  animals,  and  conse- 
quently many  faults  of  inheritance  or  heredity  showed 
themselves.  It  was  the  purpose  of  the  paper  to  call 
attention  to  these  facts,  and  to  demonstrate  that  if  an 
intelligent  direction  was  given  to  the  growth  and  de- 
velopment of  children  these  early  faults  could  be  cor- 
rected. He  said  that  the  province  of  the  physician 
was  limited,  as  yet,  to  the  relief  of  actual  illness  and 
to  repairing  the  effects  of  disease.  If  he  were  only 
encouraged  to  direct  the  growing  child,  his  position 
as  an  apostle  of  preventive  medicine  would  enable  him 
to  accomplish  infinitely  better  results  than  merely  the 
repair  of  damage.  He  then  discussed  the  question  of 
motherhood  and  the  difficulties  which  arose  from  the 
lack  of  knowledge  of  those  things  which  constituted 
a  good  mother.  He  stated  that  the  first  thing  needed 
was  that  mothers  should  realize  that  the  best  speci- 
mens of  human  beings  were  not  likely  to  come  from 
haphazard  up-bringing.  He  thought  it  safe  to  assume 
that  skilled  direction  from  a  medical  adviser  would 
soon  become  recognized  as  of  the  greatest  importance, 
and  that  the  children  of  the  poor  should  be  provided 
with  opportunities  to  receive  skilled  physical  direc- 
tion. This  could  be  done  only  by  educating  the  pub- 
lic to  realize  the  importance  of  this  fact,  and  by  se- 
curing the  co-operation  of  teachers  of  all  grades  in 
furthering  such  work. 

School  Hygiene  and  Medical  Inspection  of 
Schools. — Dr.  W.  M.  Carhart,  of  New  York,  read 
a  paper  on  this  subject.  He  said  that  school  life 
should  be  harmonious  with  and  supplementary  ^o 
home  life.  The  growth  of  the  child  in  bodily  vigor, 
in  strength  of  character,  and  in  intellectual  attain- 
ments should  be  as  continuous  at  school  as  at  home. 
School  hygiene  was  divided  into:  (i)  Hygiene  relat- 
ing to  the  personal  habits  of  the  child:  necessity  for 
cleanliness  of  both  body  and  clothing,  the  avoidance 
of  infection,  and  the  exclusion  of  contagious  cases. 
Vice  had  a  physical  basis;  vicious  habits  should  be 
discovered  and  corrected.  (2)  Hygiene  in  relation  to 
methods  of  instruction.  All  children  were  not  alike, 
and  should  not  be  taught  as  if  they  were.  Backward 
and  dull  children  needed  special  care.  An  inatten- 
tive child,  usually  defective  in  special  senses,  may  pos- 
sibly be  slightly  deaf.  The  human  e)*e  was  going 
through  the  period  of  adaptation  to  the  needs  of  the 
twentieth-century  civilization,  and  in  the  interval  as- 
thenopia was  a  necessity  under  the  modern  methods  of 
culture;  the  result  was  that  weak  eyes  were  perma- 
nently damaged  and  developed  into  myopia  and  astig- 
matism. (3)  Hygiene  in  reference  to  the  school  en- 
vironment. In  this  connection  the  writer  stated  that 
school  buildings  should  be  healthy  in  location,  with 
adequate  playgrounds,  well  furnished  and  well  built, 
and  with  dry  cellars.  Good  ventilation  and  clean 
rooms  and  lavatories  with  modern  plumbing  were  also 
necessary.  Desks  and  seats  should  be  adjusted  to  the 
size  of  children. 

Defectives  and  Delinquents  Inside  and  Outside 
the  Family  Circle.— Dr.  James  \V.  Walk,  of  Phila- 
delphia, gave  in  this  paper  the  sociological  definition 
of  defectives  and  delinquents.  The  influence  of  de- 
fectives upon  other  members  of  the  family  circle  was 
considered,  as  was  also  the  influence  of  aggregate  life 
(in  hospitals,  asylums,  etc.)  upon  defectives.  The 
influence  also  of  family  life  upon  defectives  was 
spoken  of.  Delinquents  and  their  environment  were 
discussed  in  a  similar  manner.  The  author  stated 
that  efforts  to  benefit  defectives  and  delinquents 
should  be  consistent  with  the  welfare  of  society  in 
general. 

The  Relation  of  the  Habitual  Use  of  Alcoholic 
Intoxicants   to   the  Sanitation  of   the   Home. — Dr. 


i 


July  7,  1900] 


MEDICAL    RECORD. 


35 


J.  VV.  Grosvenor,  of  Buffalo,  read  this  paper.  He 
•considered  the  effect  of  the  use  of  intoxicants  on  the 
moral  character,  intellectual  development,  and  physi- 
cal integrity  of  the  inmates  of  a  home.  Two  remedies 
of  value  for  the  relief  of  the  unsanitary  condition  of 
the  home  were  suggested — education  and  law.  The 
writer  considered  that  the  enlightenment  of  the  public 
along  all  sanitary  lines  was  incumlDent  upon  all 
boards  of  health.  In  the  conservation  of  public  health 
the  medical  profession  had  an  important  position.  It 
was  the  opinion  of  the  writer  that  the  physician  should 
not  only  by  precept  teach  the  danger  of  alcoholic  in- 
toxicants, but  place  himself  and  his  home  outside  the 
use  of  alcoholic  stimulants  of  every  description.  The 
clink  of  the  inebriating  cup  should  not  be  heard  at 
his  festive  board. 

The  Hygiene  of  Vision  in  the  Home Dr.  .S.  D. 

Risi.EY,  of  Philadelphia,  read  this  paper.  He  de- 
scribed the  family  living-room — its  origin,  pleas- 
ures, and  evils.  The  natural  and  artificial  lighting 
of  the  home  were  spoken  of,  and  the  importance  of 
sufficient  and  suitable  illumination  of  the  home  in 
conserving  the  general  health  and  vision  of  the  family 
was  emphasized. 

The  Physician's  Influence  in  Regard  to  Vacation 
Schools. — This  paper  was  read  by  Dr.  Helen  C 
Putnam,  of  Providence,  R.  I.  She  said  that  inven- 
tions and  municipalization  had  altered  the  popular 
minds  that  free  schools  were  originally  planned  to 
supply,  and  that  to-day  more  should  be  done  for  citi- 
zenship, character-building,  and  physical  development. 
In  the  speaker's  opinion  liberally  educated  medical 
specialists  were  needed  in  this  readjustment.  Refer- 
ence was  made  to  vacation  schools  started  by  philan- 
thropists to  protect  from  their  environment  the  chil- 
dren living  in  the  poorest  wards,  and  developing  into 
a  permanent  institution  of  direct  influence  upon  edu- 
cational systems.  In  these  schools  no  books  were 
used  ;  pedagogic  excursions  into  the  country  were  made; 
manual  training  by  wood  and  iron  work  was  taught; 
the  aesthetic  development  of  music,  color  work,  out- 
door sketching  were  encouraged,  out-door  gymnastic 
games  were  indulged  in,  and  self-government  obtained 
in  place  of  autocratic. 

President's  Address :  Some  Measures  for  the 
Prevention  of  Crime,  Pauperism,  and  Mental  De- 
ficiency.— The  president,  Dk.  (i.  Hudson  Makuen, 
of  Philadelphia,  in  his  address  stated  that  crime,  pau- 
perism, and  mental  deficiency  were  on  the  increase 
and  were  beginning  to  be  a  menace  to  our  national 
life.  The  causes  of  this  increase  were  many  and  com- 
plex. Civilization  had  not  progressed  uniformly. 
Many  of  its  most  important  advances  had  a  tendency 
to  swell  the  ranks  of  the  defective,  delinquent,  and 
dependent  classes.  The  survival  of  the  unfit  liad  be- 
come our  motto,  and  the  fact  that  hand-in-hand  with 
their  survival  went  their  reproduction  had  been  ig- 
nored. The  natural  resources  of  our  country  had  at- 
tracted foreigners  in  great  numbers  and  in  all  condi- 
tions of  mental  and  physical  depravity;  hence  the 
necessity  for  restricted  immigration,  more  stringent 
marriage  laws,  and,  in  carefully  selected  cases,  the 
entire  removal  of  the  power  of  procreation.  The  evils 
of  promiscuous  almsgiving  and  promiscuous  dispen- 
sary service  were  also  pointed  out,  and  attention  was 
called  to  the  fact  that  real  charity  was  that  which 
helped  people  to  help  themselves.  He  also  touched 
upon  the  evils  of  institutionalism  in  the  care  and 
treatment  of  the  defective,  delinquent,  and  dependent 
classes,  and  suggested,  as  a  final  measure  for  the  pre- 
vention of  crime,  pauperism,  and  mental  deficiency,  the 
widening  of  the  scope  and  infiuenceof  our  methods  of 
education.  The  object  of  education  should  not  be  so 
much  the  acquirement  of  knowledge  as  the  develop- 
ment of  character  and  of  brain   power,  of  which  the 


acquirement  of  knowledge  and  its  effective  applica- 
tion were  the  natural  corollaries.  Every  possible  av- 
enue to  the  brain  should  be  utilized  in  education. 
The  action  and  effects  of  the  various  kinds  of  mental 
and  physical  training,  and  the  best  methods  for  their 
application,  should  be  studied.  Thus  could  be  de- 
monstrated the  important  fact  that  the  moral  nature  was 
as  capable  of  development  as  the  intellectual  nature; 
and  that  muscle  training  in  all  its  varied  forms  was 
an  essential  factor  both  in  the  formation  of  character 
and  in  the  development  of  brain  power. 


Second  Day — Monday,  June  4th. 

At  the  opening  of  the  session  the  nominating-com- 
mittee announced  the  following  nominations:  Presi- 
dent, Dr.  S.  D.  Risley,  of  Philadelphia;  Vice-Presi- 
dents, Drs.  C.  M.  Culver,  of  Albany,  Rosa  Engelmann, 
of  Chicago,  G.  G.  Groff,  of  San  Juan,  VV.  C.  McClin- 
tock,  of  Detroit;  1  reasiirer  and  Secretary,  Dr.  Charles 
Mclntire;  Assistant  Secretary,  Dr.  Alexander  Craig,  of 
Columbia,  Pa. 

The  above  candidates  were  elected. 

The  selection  of  time  and  place  of  meeting  was 
placed  in  charge  of  the  council. 

How  One  College  Endeavors  to  Teach  Social 
Health  Problems.— Dr.  Charles  McIntire,  in  this 
paper,  gave  Billings'  definition  of  hygiene,  which  was 
approved  by  sanitarians  and  included  sociology.  It 
was  stated  that  Lafayette  College  offered  an  elective 
on  sanitary  science  to  the  seniors,  and  the  paper  out- 
lined the  course  given,  with  the  purpose  of  presenting 
the  social  problems  having  an  influence  upon  the  pub- 
lic health. 

The  paper  of  Dr.  E.  Stuver,  of  Fort  Collins,  Colo., 
on  "The  Home  and  the  School,"  was  read  by  title. 

The  discussion  of  the  papers  read  in  the  symposium 
on  "  The  Medical  Aspect  of  the  Home  "  was  taken  up 
at  this  point. 

Dr.  Tuckerman,  of  Cleveland,  in  reference  to  this 
topic  said  that  they  had  in  Cleveland  just  succeeded 
in  the  adoption  of  medical  inspection  in  schools.  He 
cited  a  case  in  which  a  teacher  having  sore  throat  had 
gone  into  her  school,  and  as  a  result  in  two  weeks' 
time  five  children  had  died  and  forty  cases  of  diph- 
theria had  developed.  In  reference  to  Dr.  Walk's 
paper  on  "  The  Treatment  of  Defectives  and  Delin- 
quents," Dr.  Tuckerman  approved  of  the  suggestion 
of  the  president  of  asexualization,  believing  that  these 
male  defectives  coming  to  puberty  were  as  dangerous 
as  wild  animals  let  loose  in  the  community. 

Dr.  Grosvenor,  of  Buffalo,  referring  to  one  of  the 
papers  on  the  parental  teaching  of  children,  spoke  of 
a  custom  of  some  parents,  of  teaching  their  children 
to  call  their  parents  by  their  first  names.  He  had 
observed  this  custom  in  his  own  city.  He  feared  that 
if  a  strong  protest  was  not  made  against  it  the  custom 
would  become  more  prevalent. 

In  the  discussion  of  the  paper  of  Dr.  Engelmann,  of 
Chicago,  Dr.  Knopf,  of  New  York,  thought  that  while 
the  separate-housing  system  for  habitation  was  very 
desirable,  the  suggestion  seemed  impracticable.  He 
thought  the  solution  of  the  problem  could  be  more 
easily  secured  in  the  improvement  of  tenements,  and 
the  destruction  of  old  tenements  and  the  erection  of 
new  ones  with  proper  appliances  of  sanitation.  In 
reference  to  the  early  training  of  children  he  sug- 
gested that  the  whole  problem  might  be  solved  by 
adding  to  the  higher  schools  for  girls  a  chair  of  prac- 
tical motherhood. 

Dr.  Connor,  of  Detroit,  thought  that  the  great  un- 
derlying principle  of  the  papers  and  discussion  was 
to  attempt  to  find  out  the  weak  meliliods  in  our  art  of 
training  men. 


36 


MEDICAL    RECORD. 


[July  7,  1900 


A  paper  entitled  "A  Few  Notes  Concerning  the 
Relation  of  the  Academic  to  the  Medical  Course,"  by 
Dr.  Howard  S.  Hansell,  of  Philadelphia,  was  read 
by  title.  The  purpose  of  the  paper  was  to  advocate 
the  admission  of  the  college-bred  man  into  the  second 
year  of  the  medical  course. 

The  Opportunity  of  the  Small  Medical  College. 
— Dr.  Bayard  Holmes,  of  Chicago,  read  this  paper. 
He  said  that  the  tendency  toward  large  classes  was 
not  consistent  with  good  pedagogy,  and  that  small 
classes  and  individual  supervision  were  possible  in 
the  small  school.  As  requisites  were  mentioned  the 
following:  A  few  teachers  and  leaders  of  men,  with 
time  and  adequate  salary;  suitable  buildings  and 
laboratory  equipment;  a  small  hospital  under  the 
complete  control  of  the  college;  a  well-selected  work- 
ing-library, containing  the  material  for  the  study  of 
medicine;  intimate  relations  between  the  various  de- 
partments; a  curriculum  granting  freedom  to  teacher 
and  student.  All  of  these  requisites  it  was  stated 
were  possible  to  the  small  college. 

Neglected  Clinical  Opportunities  in  American 
Medical  Centres. — This  paper  was  read  by  Dr.  S.  A. 
Knopf,  of  New  York.  He  endeavored  to  show  that 
in  spite  of  the  vast  progress  many  of  our  medical  col- 
lege had  made  during  the  past  year  toward  a  more 
thorough  curriculum,  clinical  teaching  was  still  very 
deficient,  not  from  lack  of  clinical  opportunities,  but 
from  the  neglect  to  utilize  those  available.  The 
wTiter  contended  that  the  essentials  for  a  college 
graduate  leaving  college,  feeling  that  his  clinical 
teaching,  if  not  quite  equal  to  that  of  any  hospital 
graduate,  was  at  least  nearly  so,  were:  (i)  A  co- 
operation of  all  the  medical  colleges  located  in  one 
medical  centre  for  the  purpose  of  a  general  and  equal 
utilization  of  all  the  clinical  material  of  their  city; 
(2)  the  appointment  of  every  physician  and  surgeon 
attached  to  a  subsidized  hospital  as  a  clinical  teacher 
independent  of  college  affiliation,  and  the  payment  of 
a  reasonable  fee  to  these  clinical  teachers  for  their 
services  rendered  as  teachers  to  the  students;  (3)  the 
suppression  of  all  didactic  lectures  for  second,  third, 
and  fourth  year  students  during  the  morning  hours; 
(4)  the  obligatory  presence  of  every  second,  third,  and 
fourth  year  student  in  his  capacity  as  senior  or  junior 
externe  at  the  clinic  or  at  the  daily  hospital  visit  of 
his  teacher;  (5)  the  keeping  by  the  clinical  teacher 
of  a  record  of  attendance  and  work,  to  be  counted  in 
the  final  examinations. 

Psychology  as  Preliminary  to  Medical  Educa- 
tion  Dr.   W.  J.   Herdman,  of    Ann    Arbor,   Mich., 

read  this  paper.  He  stated  that  normal  anatomy  and 
histology  were  essential  to  a  right  understanding  of 
normal  physiology.  Psycho-physiology  must  be  known 
if  we  would  correctly  interpret  psycho-pathology  and 
create  a  rational  psychotherapy.  The  speaker  con- 
sidered that  at  the  present  day  a  very  small  percentage 
of  candidates  for  the  degree  of  Doctor  of  Medicine 
had  pursued  a  systematic  study  of  physiological  psy- 
chology. Such  knowledge  was  claimed  to  be  essen- 
tial to  a  right  understanding  and  direction  of  educa- 
tional methods,  since  faulty  methods  of  education 
resulted  in  disease.  Functional  disorders  would  be 
much  better  understood  and  more  rationally  treated 
were  the  physician  well  trained  in  psyciio-physiology. 
The  mental  element  of  disease  was  largely-ignored  by 
the  practitioner  of  to-day.  and  in  this  soil  left  unculti- 
vated by  the  scientific  physician  faith-cures  and  other 
noxious  weeds  took  root  and  llourished.  He  believed 
that  a  broader  preparation  was  needed  to  fit  the  phy- 
sician to  take  possession  of  this  field. 

Dr.  Elmer  Lee,  of  New  York,  said  that  Dr.  Herd- 
man's  paper  was  along  the  line  of  his  own  observa- 
tions, and  upon  v^hich  some  words  of  his  own  had 
befen  published.     The  fact  that  there  was  a  mental 


state  in  the  practice  of  medicine  was  too  little  under- 
stood and  too  seldom  successfully  used. 

Dr.  Knopf,  of  New  York,  advocated  the  including 
in  the  curriculum  for  senior  students  the  study  of 
hypnotism,  so  that  this  important  therapeutic  agent 
might  be  taken  out  of  the  hands  of  those  who  by  their 
wrong-doing  depreciated  the  value  of  hypnotism  as  a 
therapeutic  agent. 

Dr.  Connor,  of  Detroit,  thought  that  Dr.  Herd- 
man's  presentation  was  a  clear  demonstration  that 
what  he  called  psychology  was  simply  a  refined  part 
of  physiological  and  pathological  processes. 

Some  Experiences  of  a  Volunteer  Surgeon  in  the 

Philippines Dr.  H.   P.  Ritchie,  of  St.  Paul,  late 

captain  and  assistant  surgeon  in  the  Thirteenth  Regi- 
ment Minnesota  Volunteer  Infantry,  read  a  paper  on 
this  topic.  He  said  with  reference  to  the  transport 
service  that  the  causes  of  complaint  and  discomfort 
during  the  first  expeditions  were  unnecessary,  as  shown 
by  the  pleasant  experiences  of  the  home  voyage  eigh- 
teen months  afterward.  The  effect  of  the  campaign 
before  Manila  upon  the  future  health  of  the  troops 
was  considered.  The  condition  of  Manila  at  the  time 
of  its  occupation,  and  its  transformation  under  Ameri- 
can rule,  were  described.  The  climate  was  discussed, 
and  the  diseases  among  the  troops  were  briefly  con- 
sidered, with  their  prophylaxis  and  their  danger  to 
the  civilian.  The  paper  closed  with  a  plea  for  the 
establishment  of  schools  for  instruction  in  tropical 
diseases. 

"Good  Form"  in  Professional  Cards.— Dr. 
Charles  McIntire,  of  Easton,  Pa.,  in  this  paper  re- 
ferred to  the  source  of  gratification  to  the  fellows  of  the 
Academy  of  Medicine  that  there  had  been  almost  no 
necessity  to  discuss  the  individual  actions  of  its  mem- 
bers. Last  year  an  exception  was  taken  to  the  word- 
ing of  a  professional  card,  and  the  secretary  was  in- 
structed to  correspond  with  the  member  whose  card 
was  criticised.  The  present  paper  was  the  result  of 
that  correspondence,  classifying  a  number  of  profes- 
sional cards  from  various  parts  of  the  United  States. 

The  Desirability  of  a  Medical  Editor  on  the  Staff 
of  the  Daily  Newspapers. — This  paper  was  read  by 
Dr.  Walter  L.  I'vle,  of  Philadelphia.  As  an  indi- 
cation for  this  need  the  speaker  called  attention  to  an 
article  recently  appearing  in  the  New  York  Herald 
entitled  "  Sleep  Cure  for  Nervous  Dieases."  This 
cure  consisted  of  "  eight  grams  of  bromine  every 
two  hours  in  a  glass  half  full  of  water."  It  was 
further  stated  in  this  issue  that  the  discoverer  of  this 
rest  cure  maintained  that  rest — absolute,  prolonged 
rest — was  the  one  thing  which  persons  suffering  from 
nervous  disorders  stood  most  in  need  of,  and  that  they 
could  obtain  the  rest  through  the  agency  of  bromine 
better  than  in  any  other  way.  It  was  suggested  that 
the  medical  member  of  the  newspaper  staff  would 
prove  satisfactory,  particularly  in  editorial  work  upon 
such  subjects  as  food  adulteration,  water  filtration,  and 
quarantine.  The  offensive  medical  advertisements 
might  be  corrected  by  the  medical  editor,  who  should 
act  as  a  censor  on  all  notices  of  a  medical  nature. 

Domestic  Hygiene. — Dk.  Elmer  Lee,  of  New  York, 
read  this  paper.  He  said  that  sickness,  suffering,  and 
death  were  the  most  expensive  factors  in  human  exist- 
ence, and  that  each  human  being  enjoyed  or  forfeited 
his  rights  exactly  in  proportion  to  his  use  or  abuse  o' 
them.  Air  was  referred  to  as  the  most  important  fac 
tor  of  all  tlie  agencies  which  contributed  to  animal 
life;  everywhere  it  was  adapted  to  the  creature  who 
rightly  used  it.  A  drink  of  cool  water  had  virtues 
superior  to  any  and  all  life-saving  agencies.  Mineral 
waters,  either  natural  or  artificial,  were  less  whole- 
some, in  the  writer's  opinion,  than  water  which  held 
no  minerals  in  solution.  The  rainfall  was  the  source 
of  pure  water.     Carbonic  acid  gas  was  an   ingredient 


July  7,  1900] 


MEDICAL   RECORD. 


37 


of  dangerous  nature,  and  was  the  basis  of  the  effer- 
vescing waters.  This  gas,  it  was  stated,  was  a  deadly 
poison  to  all  animal  life,  and  was  at  all  times  a  waste 
product  in  the  blood.  Water  was  stated  to  be  man's 
sweetest  and  safest  drink,  and  if  rightly  used  would 
in  itself  largely  help  to  extend  his  life  well  toward  the 
century  mark.  In  the  matter  of  food,  in  the  author's 
opinion,  there  were  ansple  proofs  to  show  that  it  was 
not  a  greater  variety  in  vegetable,  flesh,  or  mixed  diets 
consistent  with  health  that  was  needed,  but  rather  the 
use  of  any  diet  in  moderation.  The  subject  of  human 
feeding  was  regarded  as  the  one  most  neglected  in 
popular  education,  and  it  was  incumbent  on  mothers 
to  form  health  kindergartens,  first  for  their  own  in- 
formation and  secondly  to  lead  and  direct  their  chil- 
dren in  the  light. 


'^zvo  Instruments. 

PRACTICAL    HINTS    FOR    A'-RAY   WORKERS. 
By   GUION   THOMPSON, 

NEW   YORK. 

The  choice  of  an  A--ray  apparatus  is  usually  perplexing 
to  the  person  buying  it  for  the  first  time  and  who  is 
unfamiliar  with  the  results  and  methods  of  operation 
of  the  different  styles  of  apparatus,  and,  after  making 
a  choice,  many  give  up  on  account  of  failure  to  get 
good  results.  It  is  not  my  intention  to  consider  the 
advantages  and  disadvantages  of  different 
apparatus,  but  to  give  my  opinion  as  to 
which  is  best,  and  how  to  operate  it  pro- 
perly, and  this  opinion  is  arrived  at  by 
experience  and  study  in  electrical  science. 
The  static  machine  is  the  ideal  gen- 
erator of  electricity  to  operate  the  .v-ray 
tube.  It  should  not  be  smaller  than  one  To^.,.>a 
of  eight  thirt}-inch  revolving  plates,  and 
should  be  run  by  a  motor  capable  of  a 
speed  of  about  six  hundred  revolutions 
per  minute.  The  plates  should  be  of 
glass  of  the  best  insulating  qualities  ob- 
tainable, and  the  machine  should  be  of 
the  type  known  as  the  "  Holtz-Influence  " 
and  not  the  "  Holtz-Toepler."  The 
"  Holtz-Toepler "  machine  has  small 
metal  discs  on  its  plates  for  the  purpose  of  mak- 
ing it  self-exciting,  and  these  discs  cause  the  ma- 
chine to  generate  a  pulsating  current  that  will  often 
reverse  while  the  machine  is  in  operation.  In  the 
"  influence "  type  the  electric  current  is  steady  and 
generated  in  an  even  flow  that  will  not  reverse  unless 
it  is  purposely  made  to  do  so.  The  tubes  should  be 
those  that  are  made  to  be  used  with  the  static  machine, 
and  must  have  their  terminals  far  apart  at  opposite 
ends  of  the  tube.  The  body  of  the  tube  should  be  a 
sphere,  and  the  centre  of  the  anode  disc  should  be  ex- 
actly in  the  centre  of  this  sphere.  The  cathode  termi- 
nal is  a  cup-shaped  disc  whose  concave  face  should 
focus  exactly  on  the  centre  of  the  anode,  which  is  set 
at  an  angle  of  45''  to  reflect  the  cathode  rays  focused 
on  it  to  the  side  of  the  tube.  The  cathode  cup  and 
the  anode  disc  should  not  anywhere  approach  nearer 
than  within  one-half  inch  of  the  glass  walls  of  the 
tube.  When  nearer  than  this,  liability  of  the  tube  to 
puncture  is  increased.  Have  a  proper  adjustable 
stand  for  holding  the  tube  in  any  desired  position  and 
another  to  hold  a  thirty-inch  porcelain  or  ebonite  rod, 
with  hooks  or  clips  on  each  end.  This  is  extremely 
handy — half  the  time  absolutely  necessary — to  sup- 
port the  conductors  from  machine  to  tube.  These 
conductors  have  small  hooks  at  each  end,  one  to  con- 


nect to  the  eyes  at  the  external  terminals  of  the  tube 
and  the  other  to  connect  with  the  "  interrupters ''  at 
the  terminals  of  the  machine. 

Start  your  machine  and  see  that  it  is  charged  and 
generating,  and  determine  which  is  the  positive  pole. 
To  find  this,  draw  the  sliding  poles  about  half  an  inch 
apart  and  observe  the  spark;  it  will  be  of  a  violet 
color  with  white  tips  at  each  end.  The  end  at  which 
the  white  tip  is  largest  is  the  positive  side  of  the  ma- 
chine. Now  attach  the  interrupters,  leaving  them 
wide  open,  and  hook  on  the  conductors. 

Adjust  the  tube  in  the  stand  so  that  the  anode  re- 
flects the  cathode  toward  the  point  from  which  you 
wish  to  observe,  and  see  that  the  tube  is  so  placed  that 
the  anode  can  be  connected  with  the  positive  of  the 
machine  and  the  cathode  with  the  negative  without 
crossing  the  conductors;  hook  them  to  the  tube  in 
this  position,  using  the  porcelain  rod  to  support  and 
separate  them.  Close  the  interrupters  and  draw  apart 
the  sliding  poles  of  the  machine.  Before  they  are  an 
inch  apart  the  spark  stops  and  the  tube  lights  up 
faintly  a  palish  green  all  over  the  glass  in  front  of  the 
anode  disc,  while  back  of  it  is  shadow,  faintly  tinged 
with  violet.  The  tube  is  "low";  its  vacuum  is  low. 
Open  the  positive  interrupter  so  that  you  have  a  spark 
gap  in  the  circuit  on  the  anode  side  of  the  tube.  Two 
or  three  hours'  use  of  the  tube  connected  in  this  man- 
ner will  bring  it  up,  especially  if  it  is  "shut  off"  fre- 
quently for  short  rests.  These  low  tubes  can  be  used 
for  such  light  work  as  making  radiographs  of  the 
hands,  etc.,  until  they  come  to  their  best  working  con- 
dition, when  they  should  be  kept  for  heavier  and  more 


difficult  work.  Close  the  sliding  poles  of  the  machine 
to  within  about  a  quarter  of  an  inch  of  each  other; 
open  both  interrupters  and  remove  the  conductors  from 
the  tube,  and  try  another.  Connect  up  the  same  as 
before,  close  the  interrupters,  and  draw  the  sliding  poles 
slowly  apart.  The  spark  lengthens  out  perhaps  to 
eight  or  ten  inches  before  the  current  passes  through 
the  tube,  and  when  it  does  there  is  only  a  faint  and 
fluttering  tinge  of  light  on  the  walls  of  the  tube,  with 
here  and  there  bright  oval  spots  of  greenish  light  that 
come  and  go  all  over  the  walls  of  the  tube.  The  tube 
is  said  to  be  too  "high."  To  bring  it  down,  open  the 
interrupter  at  the  negative  terminal  of  the  machine  so 
that  there  is  a  spark  gap  in  the  circuit  at  the  cathode 
side  of  the  tube.  If  this  does  not  bring  it  down  in  a 
few  minutes,  heat  the  tube  carefully  and  evenly  with 
a  spirit-lamp  or  3unson-burner  gas  flame,  and  it  will 
work  beautifully.  If,  when  we  try  to  start  a  tube,  it 
stays  perfectly  dark  and  shows  no  action  whatever,  it 
may  possibly  be  brought  down  by  persistently  working 
at  it,  but  it  had  better  be  re-exhausted,  as  it  will  always 
be  a  nuisance  when  most  wanted  if  left  so  high. 

Disconnect  this  tube  and  connect  up  another.  If, 
when  you  draw  apart  the  sliding  poles,  the  spark 
stops  when  it  gets  about  four  inches  long,  and  the  tube 
lights  up  with  a  clear,  even,  bright  glow  on  the  hemi- 


38 


MEDICAL    RECORD. 


[July  7,  1900 


sphere  in  front  of  the  anode  disc  and  remains  dark  be- 
hind it,  then  you  have  an  almost  perfect  tube.  The 
fluoroscope  will  show  more  finely  how  a  tube  is  work- 
ing, and  each  tube  should  be  examined  with  it  for 
penetration,  focussing  qualities,  etc.  A  tube  running 
without  a  spark  gap  in  circuit  will  give  the  finest  defi- 
nition. When  using  the  fluoroscope  it  will  be  noticed 
that  a  tube  will  appear  to  give  more  light  with  a  spark 
gap  in  circuit  than  without,  but  with  less  clearness 
and  definition.  For  many  reasons  it  is  best  always  to 
run  the  tube  without  any  spark  gaps  at  all,  if  possible. 
The  spark  causes  the  current  passing  through  the 
tube  to  be  an  intermittent  one  of  exceedingly  fast  pe- 
riods, and  as  the  tube  is  of  a  certain  resistance  it  al- 
lows just  so  much  current  to  pass  whether  with  or 
without  the  spark  gap,  and  as  the  current  is  varied  in 
any  given  tube  so  are  the  rays  emitted  by  that  tube. 
Therefore  it  is  clear  that  the  spark  gap  cannot  increase 
the  .v-rays  generated  by  any  tube,  but  by  interrupting 
the  current  so  that  it  passes  in  flashes  through  the 
tube,  each  Hash  becomes  brighter  than  the  light  of  a 
continuous  current,  because  in  it  is  stored  the  energy 
of  the  dark  periods  between  flashes. 

These  rapid,  bright  flashes  affect  the  eye  so  that 
there  appears  to  be  a  brighter  light  than  when  they 
are  absent;  but  in  making  a  radiograph  we  have  to  in- 
crease the  exposure  of  any  tube  if  we  have  a  spark  gap 
in  circuit,  and  the  exposure  increases  in  proportion  to 
the  length  of  the  spark  gap,  proving  that  the  spark  gap 
absorbes  energy,  which  of  course  it  must  do.  Also, 
when  we  make  a  radiograph  with  a  spark  gap  in  cir- 
cuit we  lose  definition  in  the  shadowgraph;  this  is 
seen  also  in  the  fluoroscope,  and  is  caused  by  the 
rapidly  pulsating  current  inducing  an  opposite  poten- 
tial in  the  tube  at  each  flash,  which  has  the  effect  of 
"upsetting"  the  focusing  of  the  cathode  rays  on  the 
anode  disc  and  causing  them  at  each  flash  to  focus  at 
a  different  spot,  so  throwing  the  shadow  caused  by 
each  flash  at  a  slightly  different  place,  the  whole  ap- 
pearing to  the  eye,  or  coming  out  on  the  sensitive 
plate,  as  a  blurred  shadow.  The  spark 
also  increases  the  danger  of  burning 
the  patient  a  hundred-fold,  as  the 
strong  pulsating  currents  it  causes  set 
up  opposite  currents  and  charges  of 
electricity  in  near-by  bodies  by  induc- 
tion from  the  tube.  These  currents 
have  "  burned  "  patients  badly  at  times, 
and  an  example  of  how  strongly  a  pa- 
tient will  become  charged  under  a 
tube  being  operated  in  this  manner  is 
shown  by  the  shock  received  on  touch- 
ing the  subject  after  a  few  minutes'  exposure.  If  you 
will  always  use  a  thin  metal  screen  between  the  pa- 
tient and  the  tube,  and  ground  the  screen  by  connect- 
ing with  gas  or  water  pipes,  you  need  never  fear  "  burn- 
ing "  the  patient.  The  screen  is  inductively  acted  on 
instead  of  the  patient,  and  the  currents  that  would 
make  a  "  burn  "  are  carried  off  to  earth.  A  thin  alumi- 
num screen  is  the  best  of  metal  screens,  as  it  is  less 
opaque  to  the  rays  than  other  metals.  A  damp 
cloth  may  also  be  used — the  water  acting  as  the  con- 
ductor. 

When  running  a  tube  without  any  spark  gap  in  cir- 
cuit it  is  almost  needless  to  use  the  screen,  but  the 
safest  practice  is  always  to  use  it,  as  any  moment  dur- 
ing an  exposure  may  necessitate  a  spark  gap  to  control 
the  action  of  the  tube. 

In  making  radiographs,  the  patients  should  be  in  as 
restful  a  position  as  possible,  so  that  they  may  have 
every  advantage  for  keeping  still.  Lay  the  sensitized 
plate,  emulsion  side  up,  on  a  perfectly  flat  surface,  and 
let  the  region  to  be  taken  rest  upon  it.  The  plate 
should  be  in  a  light-proof  envelope  to  protect  it  from 
the  action  of  ordinary  light.     Place  the  tube  above  the 


plate  and  patient  so  that  its  rays  shall  pass  through 
the  subject  to  the  plate.  The  distance  of  the  tube 
from  the  plate  is  governed  by  the  thickness  of  the  sub- 
ject being  taken,  and  should  always  be  far  enough 
away  not  to  distort  the  shadow  unduly.  The  exposure 
can  be  judged  only  by  watching  the  light  with  the  fluo- 
roscope, and  experience  is  the  only  instructor  here.  Be 
careful  that  no  plates  are  near  by — not  even  in  the 
next  room — or  you  will  wonder  what  makes  so  many 
of  your  plates  develop  "  fogged,''  or  altogether  black. 
The  rays  from  the  tube  will  go  through  walls  and  fur- 
niture and  spoil  many  a  plate  if  you  are  not  careful. 
You  cannot  keep  them  far  enough  away.  Do  not  use 
a  fluorescent  screen  with  your  plates.  It  shortens  the 
exposure  but  kills  definition  and  sharpness  in  the 
radiograph,  and  this  result  is  most  unsatisfactory. 

289  Fourth  A\enle. 


A  NEW  URETHROSCOPE. 
By   FRED.  J.   LEVISEUR.    M.D.. 

NEW    YORK. 

This  instrument,  which  is  destined  for  the  examina- 
tion and  treatment  of  the  pendulous  part  of  the  urethra 
only,  consists,  like  the  ordinary  urethroscope,  of  a 
hollow  tube  with  disc,  and  obturator.  The  tube  is 
closed  at  the  distal  end  and  fenestrated  on  the  side, 
the  slit  extending  to  within  a  quarter  of  an  inch  of 
each  end.  The  obturator  has  the  shape  of  an  ordinary 
straight  sound,  and  fits  loosely  in  the  tube.  A  V-shaped 
mark  on  the  disc  indicates  the  position  of  the  fenes- 
tration. The  instrument,  well  lubricated,  is  introduced 
with  the  obturator  in  situ.  When  the  latter  is  with- 
drawn, a  considerable  portion  of  the  mucous  mem- 
brane becomes  visible,  slightly  bulging  into  the  lumen 
of  the  tube.  The  picture  thus  presented  markedly 
differs  from  that  which  we  are  accustomed  to  see  with 
the  ordinary  urethroscope,  where  a  small  cone  of  the 


mucous  membrane  only  is  visible  at  the  time,  and  the 
rest  is  brought  into  view  by  gradually  withdrawing 
the  tube.  With  this  instrument  the  remaining  three 
longitudinal  sections  of  the  urethra  can  be  inspected 
by  introducing  the  obturator — also  lubricated — each 
time  and  rotating  the  urethroscope  through  an  angle  of 
90°.  Before  the  removal  of  the  instrument  from  the 
urethra  the  obturator  is  introduced  again. 

The  examination  can  be  made  either  with  direct  or 
reflected  light,  though  I  have  found  the  direct  light 
the  best.  The  introduction  of  the  instrument  is  not 
more  painful  than  that  of  an  ordinary  sound,  and  there 
is  no  danger  of  injuring  the  mucous  membrane. 

Pathological  conditions  situated  at  the  distance  of 
one-half  to  one  inch  from  the  meatus  can  be  seen  espe- 
cially well.  It  is  also  possible  to  locate  the  position 
of  a  stricture  by  noting  some  additional  bulging  of  the 
mucous  membrane  in  front  as  well  as  behind  the 
affected  spot.  What  renders  the  picture  a  particularly 
interesting  one  is  the  presence  of  the  numerous  circu- 
lar folds,  which  give  the  mucous  membrane  a  finely 
striated  ©r  rifled  appearance. 

640  Madison  Avenue. 


July  7,  1900] 


MEDICAL   RECORD. 


39 


|3iiXctUcat   Jtcms. 

Contagious  Diseases — Weekly  Statement — Report 
of  cases  and  deaths  from  contagious  diseases  reported 
to  the  Sanitary  Bureau,  Health  Department,  for  the 
week  ending  June  30,  1900: 


Tuberculosis 

Typhoid  fever 

Scarlet  fever 

Measles 

Diphtheria 

Laryngeal  diphtheria  (croup) 
Cerebro-spinal  meningitis. . . . 
Chicken-pox 


Law  for  the  Control  of   Milk  Dealers  in  Japan. 

— The  following  is  a  brief  translation  of  the  law  re- 
cently promulgated  for  the  control  of  dealers  in  milk: 

Art.  II.  The  specific  gravity  of  milk  shall  be  from 
1.028  to  1.0.34  in  the  case  of  new  milk  and  from  1.032 
to  1.038  in  the  case  of  skimmed  milk;  in  both  cases 
at  a  temperature  of  15°  C.  In  new  milk  the  quantity 
of  fat  must  exceed  2.7  per  cent.,  and  in  skimmed  milk 
it  shall  not  be  less  than  0.5  per  cent. 

Art.  V.  Dealers  in  milk  are  not  allowed  to  obtain 
milk:  (i)  from  cows  affected  by  contagious  diseases, 
such  as  cattle  plague,  rabies,  jaundice,  dysentery, 
fever,  etc. ;  (2  )  from  cows  being  medically  treated  with 
powerful  or  poisonous  drugs;  (3)  from  cows  which 
have  calved  within  the  space  of  one  week. 

Art.  VI.  Dealers  in  milk  are  forbidden  to  use  porce- 
lain vessels  glazed  with  zinc,  copper,  bronze,  or  other 
injurious  materials,  or  vessels  of  iron  coated  with 
materials  containing  lead. 

Art.  VII.  No  milk  dealer  shall  undertake  the  sale, 
transport,  or  preservation  of  sour  milk;  milk  which  is 
curdled  or  of  bitter  taste,  or  is  of  blue,  red,  or  other 
unusual  color;  milk  mixed  with  other  materials. 

Art.  XII.  Dealers  in  milk  shall  not  allow  persons 
suffering  from  consumption,  leprosy,  syphilis,  or  other 
contagious  disease  to  handle  milk  or  milk  products  or 
vessels  used  for  holding  or  measuring  the  same,  or  to 
enter  into  a  place  where  such  articles  are  handled. 

Art.  XIV.  The  local  governor  may  despatch  offi- 
cials to  inspect  the  cows  owned  by  milk  dealers,  and 
upon  finding  any  diseased  animal  may  brand  or  mark 
its  horn,  or  afifix  a  ring  to  its  ear. 

Art.  XVIII.  Offences  enumerated  below  shall  be 
punishable  with  a  fine  not  exceeding  twenty-five  yen: 
(i)  Dealing  in  milk  without  obtaining  official  permis- 
sion;  (2)  contravention  of  Article  V. 

Art.  XIX.  Any  person  failing  to  inscribe  the  qual- 
ity of  milk  on  the  vessels  containing  it,  or  to  segregate 
a  diseased  cow  or  cows,  shall  be  liable  to  a  fine  not 
exceeding  ten  yen. 

Art.  XX.  These  regulations  shall  come  into  opera- 
tion from  the  ist  of  July  in  the  thirty-third  year  of 
Meiji  (igoo). 

Definition  of  the  Word  Physician. — Dr.  Murray, 
of  Oxford.  England,  and  the  editor  of  the  Oxford  Di- 
rectory, thus  defines  the  origin  of  the  word  physician: 
The  word  physician  was  taken  by  us  from  Norman- 
French  in  the  thirteenth  century  in  the  form  fisicien, 
and  in  its  present  sense  of  practiser  of  the  healing  art, 
medicus,  the  only  sense  which  it  had  in  contemporary 
French.  It  has  never  had  any  other  sense  in  English, 
though  one  or  two  writers  have  expressed  a  desire  to 
abolish  this  and  to  convert  the  word  back  to  the  sense 
of  Latin  physicus  (Greek  e-tvrrjzof),  student  of  nature, 
naturalist,  natural  philosopher.     Hume  did  this,  but 


only  as  an  etymological  fancy.  In  F.ench  it  has  been 
different;  medecin  has  successfully  ousted  physicien, 
and  the  latter  in  modern  French  since  the  sixteenth 
century  has  meant  physicist.  If  you  will  turn  to  Du 
Cange's  "  Lexicon  of  Mediaval  Latin,"  you  will  find 
that  the  regular  mediaeval  Latin  sense  of  physica  in 
medicine  is  medicina,  and  physicus  equals  medicus. 
But  in  classical  Latin  and  as  late  as  the  Latin  lexi- 
cons come  down,  i.e..,  to  the  fifth  century  or  so,  physica 
in  Latin  literature  meant  natural  science,  and  physicus 
a  physicist.  What  you  have  to  do  then  is  to  show  how 
the  Latin  physicus  and  physica  passed  between  the 
fourth  and  fifth,  and  say  the  eighth  or  ninth  centuries 
— during  the  very  midnight  of  the  middle  ages — from 
the  ancient  to  the  medieval  and  modern  sense.  This 
is  an  inquiry  that  lies  far  away  behind  the  scope  of 
an  English  or  even  a  French  dictionary;  it  is  part  of 
the  general  history  of  the  Latin  language  during  the 
period  of  the  break-up  of  the  Roman  Empire  and  civ- 
ilization, for  which  perhaps  no  materials  exist,  and  all 
that  can  be  said  is  that  the  change  took  place  and  was 
a  very  natural  and  intelligible  one.  I  have  little  doubt 
that  even  in  the  third  century  the  common  peasant  of 
Italy  or  Gaul  thought  a  physicus  must  know  some- 
thing about  the  influence  of  stars  and  planets  and 
mysterious  influentias  or  influenzas  generally,  and 
about  the  position  of  bones  and  virtues  of  herbs,  the 
only  practical  use  of  physica  to  him,  and  so  thinking 
the  physicer  a  medicus  called  the  medicus  a  physicus. 
Does  not  the  ignorant  nineteenth-century  Englishman 
call  a  drug-seller  a  chemist  for  the  same  reason,  and 
does  not  the  drug-seller  find  it  profitable  to  call  him- 
self a  chemist,  which  he  is  much  less  than  a  baker  or 
whiskey  maker  is?  ^^'ell,  when  the  Roman  civiliza- 
tion perished  all  the  literary  class  (as  a  class)  per- 
ished, and  the  peasant  survived,  and  his  Latin  became 
the  language  of  the  modern  world.  He  did  not  call 
in  a  medicus  to  use  his  medicina  to  cure  his  bad 
"crures"'  or  his  aching  "caput,"  but  got  a  physicus 
with  his  physica  (fisicus  and  fisica  he  wrote  them 
when  he  could  write)  to  attend  to  his  "gampas  "  (pins 
or  hockey  sticks),  or  his  "testa"  (shell  or  cocoanut). 
The  substitution  of  physicus  for  medicus  is  the  only 
part  of  the  great  revolution,  but  it  is  a  long  way  ante- 
rior to  English,  and  to  the  Englishmen  of  thirteenth 
century  who  accepted  physicien  or  fisicien  as  quite 
the  fashionable,  courtly  learned  title  for  their  own 
leche  or  leech.  Of  course  modern  etymologists,  going 
back  to  the  original  Latin  and  Greek  sense,  are  apt  to 
think  the  words  ought  to  have  the  original  sense, 
which  is  to  undo  history  and  pull  down  the  Tower, 
St.  Paul's,  and  Westminster,  to  say  nothing  of  Cannon 
Street  station,  in  order  to  restore  Roman  London. 
(They  do  so  at  Athens  and  Rome.) — Meeting  of  Gen- 
eral Council  of  Medical  Education  and  Registration 
in  England. 

Endemic  Centres  of  Plague. — In  China,  in  the 
Himalayas,  in  Mesopotamia,  in  Persia,  in  Arabia,  and 
in  Tripoli  centres  of  plague  have  long  been  known  to 
exist  and  have  always  been  regarded  as  possible 
sources  of  danger  in  the  future,  and  recent  inquiry 
has  further  brought  to  light  the  fact  that  similar  foci 
of  the  disease  have,  at  least  for  some  years  past,  been 
more  or  less  active  in  Siberia,  in  Mongolia,  and  in 
Central  Africa.  Plague  has  for  a  long  period  been 
endemic  in  Yunnan,  the  province  in  the  extreme  south- 
west corner  of  the  Chinese  empire,  closely  bordering 
on  pjurmah  on  the  w'est,  and  extending  northward  tow- 
ard the  frontiers  of  Tibet.  ...  A  Chinese  gentleman 
has  quoted  in  the  pages  of  Nature  a  passage  in  a 
Chinese  work,  which  he  found  in  the  library  of  the 
British  Museum,  and  which  he  says  "bears  witness  to 
the  much  earlier  occurrence  of  the  pest  in  Yunnan, 
insomuch  as   the  author,  who  was  born    in  1736  and 


40 


MEDICAL    RECORD. 


[July  7,  1900 


Deaths. 


died  in  1809,  speaks  of  his  contemporary  dead  thereby 
thus:  "  Shi-Tan-Nan,  the  son  of  Shi  Tan,  now  governor 
of  Wang-Kiang,  was  notorious  for  his  poetic  gift.  .  .  . 
Then  in  Chan-Chan  [in  Yunnan]  it  happened  that  in 
the  daytime  strange  rats  appeared  in  the  houses,  and 
lying  down  on  the  ground  perished  with  blood-spit- 
ting. There  was  not  a  man  who  escaped  the  instanta- 
neous death  after  being  infected  with  the  miasma, 
Tan-Nan  composed  thereon  a  poem  entitled  '  Death 
of  Rats' — the  masterpiece  of  his;  and  a  few  days 
after  he  himself  died  of  this  queer  rat  epidemic." 
The  close  association  of  this  peculiar  behavior  of  rats 
with  the  prevalence  of  plague  in  man  observed  in  the 
same  province  in  recent  years  makes  it  almost  certain 
that  the  disease  here  referred  to  was  plague,  although 
no  symptoms  are  mentioned  by  which  it  can  be  finally 
identified. — Journal  of  Tropical  Medicine. 

Health  Reports. — The  following  cases  of  smallpox, 
yellow  fever,  cholera,  and  plague  have  been  reported 
to  the  surgeon-general  of  the  United  States  Marine- 
Hospital  service  during  the  week  ended  June  29, 
1900: 

Cases. 
Smallpox— United  States. 

District  of  Columbia,  Wash- 
ington             June  i6th  to  23d 14 

Illinois.  Chicago June  16th  to  23d  7 

Indiana,  Indianapolis.       ..  .June  15th  to  22d 2 

Kansas,  Wichita June  i6th  to  23d 3 

Kentucky,  Covington June  i6th  to  23d 12 

Louisiana,  New  (Weans June  i6th  to  23d 16 

Shreveport.    ...     June  i6th  to  23d 3 

Massachusetts,  Fall  River  .  .June  i6th  to  23d 5 

Lowell June  i6th  to  23d i 

Michigan,  Grand  Rapids. ..  .June  16th  to  23d r 

N.Hampshire.   Manchester.  June  i6th  to  23d 3 

New  Jersey,  Jersey  City. . .  .June  lyth  to  23d ....  10 

^3ewark June  8th  to  23d I 

New  York.  New  York June  i6th  to  23d 4 

Ohio,  Cleveland June  i6th  to  23d 12 

Pennsylvania.  Pittsburg June  16th  to  23d i 

Tennessee.  Nashville June  i6th  to  23d 5 

Washington.  Tacoma June  8th  to  i6th I 

West  Virginia,  Charlestnwn.June  igth 14 

Wheeling  . . .  June  22d I 

Smallpox— Foreign  and  Insul.\r. 

Austria,  Prague June  2d  to  9th  8 

Belgium,  Antwerp May  26th  to  June  2d i 

Brazil,  Rio  de  Janeiro May  nth  to  18th 7 

Canada,     (Quebec     Province, 

Bonaventure  Co May  21st  to  28th i 

China,  Hong  Kong May  5th  to  17th I 

England,  Liverpool June  2d  to  9th 4 

London June  2d  to  9th  11 

Southampton June  2d  to  i6th a 

France,  Lyons May  19th  to  26th 

Paris June  2d  to  9th 

Gibraltar June  3d  to  10th i 

t;reece,  Athens June  2d  to  9th 4 

India,  Bombay Ma)r  i6th  to  29th 

Calcutta April  21st  to  28lh 

Kurrachee May  13th  to  27th 61 

Madras May  5th  to  25th 

Mexico,  Chihuahua May  26th  to  June  9th 

Vera  Cruz June  8th  to  i6th 

Porto  Rico,  Ponce June  4th  to  nth 2 

Russia,  Moscow May  26th  to  June  2d 13 

Odessa June  2d  to  9th 6 

St.  Petersburg May  25th 47 

Warsaw May  19th  to  June  2d 

Scotland,  Glasgow June  15th 

Spain,  Corunna June  2d  to  9th 

Straits    Settlements,    Singa- 
pore  May  loth  to  17th 

Yellow  Fever. 

Colombia,  Rarranquilla June  2d  to  9th 4 

Panama June  nth  to  18th 3 

Cuba,  Havana June  6th  to  17th 6 

Santa  Clara May  i6th  to  June  21st 26 

Tnnidad June  19th i 

Mexico,  Progreso June  8th  to  15th 2 

Vera  Cruz June  8th  to  i6th 

Cholera. 

India,  Bombay May  17th  to  29th 

Calcutta A  pril  2 1  st  to  28th 


29 
41 
48 


141 
410 

.143 
ns 


Plague. 

Ar.ibia,  Aden May  12th  to  June  2d 170 

China,  Anioy June  23d Reported. 

Hong  Kong May  sth  t..  19th 155 

India,  Bombay May  i7lh  l(»  29th 

Calcutta April  2 1  St  to  28th 

Kurrachee May  I3lh  to  27th 154 

Japan,  Osaka May  2sth  to  June  2d 4 

Shidzuoka  Ken May  2sth  to  June  2d 5 

Turkey,  Smyrna May  29th i 

White  Meat  and  Dark  Meat  in  Dietetics — In  a 
recent  series  of  articles  published  in  a  German  medi- 
cal journal  Drs.  Opper  and  Rosenquist  deal  with  the 
opinion  that  has  been  accepted  by  many  that  white 


meats  are  more  suitable  for  the  sick  owing  to  greater 
digestibility  and  the  presence  of  less  uric  acid  and 
nitrogenous  extractives.  This  belief  is  shaken  by  the 
analyses  made  by  the  medical  men  referred  to,  which 
show  that  while  white  meats,  such  as  poultry  and  fish, 
do  in  certain  cases  contain  less  extractive  and  nitrog- 
enous derivatives,  the  average  amount  does  not  ap- 
preciably differ  in  dark  and  white  meats,  such  as  poul- 
try, veal,  beef,  pork,  mutton,  etc.,  to  make  either 
preferable.  They  point  out  that  the  only  way  of  lim- 
iting the  ingestion  of  these  deleterious  extractive  and 
nitrogenous  substances  is  by  diminishing  the  amount 
of  meat  taken  rather  than  by  forbidding  dark  meats. 
They  also  assert  that  among  the  extractives  present  in 
meat,  the  most  important  ones  are  by  no  means  harm- 
ful if  taken  in  small  quantities  as  is  ordinarily  done. 
The  same  holds  good  as  regards  the  other  organic  ex- 
tractives which  are  nitrogenous. — Public  Opinion. 


^ooks  ^ecettjctl. 

While  the  Medical  Record  is  pleased  to  receive  all  new  pub- 
lications which  may  be  sent  to  it,  and  an  acknowledgment  will  be 
promptly  made  of  their  receipt  under  this  heading,  it  must  be  with 
the  distinct  understanding  that  its  necessities  are  such  that  it  can- 
not be  considered  utider  obligation  to  notice  or  revierv  any  publica- 
tion received  by  it  which  in  the  judgment  of  its  editor  luill  not  be 
of  interest  to  its  readers. 


By  Henry  Jacob 
Little,  Brown  & 


Svo,    297  pages. 


Orthopedic  Surgery.  Medical  Papers. 
Bigelow,  M.D.  Svo,  373  pages.  Illustrated. 
Co.,  Boston. 

A   Memoir   of    Henry  Jacob   Bigelow. 
Little,  Brown  &  Co.,  Boston. 

The  Mechanism  of  Dislocations  and  Fractures  of  the 
Hip,  and  Litholapaxy  or  Rapid  Lithotrity  with  Evac- 
uation. By  Henry  Jacob  Bigelow.  Svo,  356  pages.  Illus- 
trated.    Little,  Brown  &  Co.,  Boston. 

A  Text-Book  of  Practical  Therapeutics.  By  Hobart 
Amory  Hare,  M.D.  Svo,  798  pages.  Illustrated.  Lea  Broth- 
ers &  Co.,  Philadelphia. 

Surgical  .\N.t:sTHESiA ;  Addresses  and  Other  Papers. 
By  Henry  J.icob  Bigelow,  M.D.  Svo,  37S  pages.  Little, 
Brown  &  Co. ,  Boston. 

Contributions  to  the  Science  of  Medicine.  By  the  pu- 
pils of  William  Henry  Welch.  Svo,  1,066  pages.  Illustrated. 
Johns  Hopkins  Press,  Baltimore. 

Sexual  Disorders  of  the  Male  and  I'emale.  By  Dr. 
Robert  W.  Taylor.  Svo,  438  pages.  Illustrated.  Lea  Brothers 
&  Co.,  Philadelphia. 

Medical  Treatment  of  Diseases  and  Symptoms.  By 
Nestor  Tirard,  M.D.  Svo,  632  pages.  Lea  Brothers  &  Co., 
Philadelphia  and  New  York. 

Transactions  of  the  New  York  State  Medical  Asso- 
ciation FOR  iSgg,  Edited  by  M.  C.  O'Brien,  M.D.  Svo.  887 
pages.      Published  by  the  Association,  New  York. 

Annales  de  l'Institut  de  Pathologie  et  de  Bacterio- 
LOGiE  DE  Bucharest.  By  Victor  Babes.  Folio,  465  pages.  Il- 
lustrated. 

Contributions  from  the  William  Pepper  Laboratory 
OF  Clinical  Medicine.  Folio,  419  pages.  Illustrated. 
Phoebe  A.  Hearst  Foundation,  Philadelphia. 

Encyklop.'EDIE  der  Therapie.  Ilerausgegeben  von  Oscar 
Liebreich.  Svo,  1043  pages.  Verlag  von  August  Hirschwald, 
Berlin. 

Progressive  Medicine.  By  Hobart  Amory  Hare,  M.D. 
Svo,  411  pages.      Lea  Brothers  &  Co.,  Philadelphia. 

Normal  Histology.  By  Edward  K.  Dunham,  M.D.  Svo. 
318  pages.  Illustrated.  Lea  Brothers  &  Co.,  New  York  and 
Philadelphia. 

.\  Manual  OF  Medicine.  By  W.  H.  AUchin,  ^LD.  i2mo, 
442  pages.      The  Macmillan  Company,  New  York. 

A  Manual  of  Obstetrics.  By  A.  F.  A.  King,  M.D. 
i2mo,  612  pages.     Illustrated.     Lea  Brothers  &  Co. ,  New  York. 

Obstetrical  Technique.  By  Joseph  Brown  Cooke,  M.D. 
i2nio,  109  pages.  Illustrated.  J.  B.  Lippincott  Company. 
Philadelphia. 


Medical  Record 

A    IVeekly  yotirnal  of  Medicine  and  Surgery 


Vol.  58,  No.  2. 
Whole  No.  1549. 


New  York,   July   14,    1900. 


$5.00  Per  Annum. 
Single  Copies,  loc. 


SOME  CLINICAL  OBSERVATIONS  ON  LUPUS 
ERYTHEMATOSUS;  THE  PATHOLOGY  OF 
LUPUS  ERYTHEMATOSUS.' 

liY  J.    -A..    FORDYCE,    M.D., 

AM) 

O.   II.   HOLDER,   M.D.. 

NEW    YORK. 

A  NUMBER  of  the  so-called  chronic  inflammations  of 
the  skin,  whose  clinical  manifestations  are  so  unlike 
that  we  do  not  hesitate  to  give  them  distinct  and  defi- 
nite names,  present  very  similar  microscopic  pictures. 
In  lichen  planus,  psoriasis,  and  other  superficial  af- 
fections, we  find  in  the  papillary  area  of  the  derma 
an  accumulation  of  lymphoid  cells  accompanied  by 
a  proliferation  of  the  prickle-cell  layer  of  the 
epidermis  with  varying  degrees  of  parakeratosis. 
Some  cause  with  which  we  are  unfamiliar  operates 
either  through  the  blood  stream  or  possibly  through 
the  skin  from  without,  exciting  an  outpouring  of 
leucocytes  and  the  subsequent  changes  which  take 
place.  The  pathogenic  agent  not  being  sufficient 
to  destroy  the  implicated  tissues,  complete  restitu- 
tion takes  place,  and  little  or  nothing  remains  to 
show  that  a  struggle  has  occurred  between  the  tis- 
.sues  and  the  foreign  organism  or  poison.  This 
happy  outcome  is  not  often  met  with  in  the  deeper- 
seated  infectious  granulomata,  for  even  after  the 
involution  of  such  lesions  without  ulceration,  more 
or  less  destruction  of  the  connective-tissue  ele- 
ments of  the  derma  takes  place  with  resulting 
atrophy. 

In  lupus  erythematosus,  which  is  under  consider- 
ation  in  this  paper,  we  have  a  chronic  inflamma- 
tion of  peculiar  type,  which,  in  the  early  stages  of 
the  affection,  appears  to  be  exclusively  confined  to 
the  small  vessels  of  the  upper  and  middle  regions 
of  the  derma.     In  its  later  stages  the  connective 
tissue  undergoes  a  peculiar  degeneration  leading 
to  a  superficial  but  pronounced  atrophy  of  the  skin, 
the  leading  clinical  feature  of  the  disease  (Fig.  i). 
The  negative  results  which  have  followed  attempts  ' 
to  find  a  local  bacterial  agent,  as  well  as  the  failure 
of  repeated  culture  and   inoculation  experiments, 
have  led  many  clinical  observers   to  the  opinion 
that  we  have  to  do  with  a  toxic  agent  which  is  car- 
ried by  the  blood  current  from  some  extra-cutaneous 
focus.     The  resemblance  of  lupus  erythematosus  to  lu- 
pus vulgaris  in   its  gross  clinical  features  led  many 
of  the  elder  dermatologists  to  regard  them  as  closely 
allied  processes,   if  not  actually  identical.      A  more 
careful  clinical  as  well  as  microscopical  study  of  the 
two  affections,  however,  showed  them  to  differ  in  so 
many  respects  that   they  were,  with  few  exceptions, 
looked  upon  as  totally  dissimilar  diseases. 

The  fact  that  lupus  erythematosus  is  at  times  asso- 
ciated with  tuberculosis  of  the  lymph  nodes,  the  lungs, 
or  other  visceral  tuberculosis,  has  prevented  Hutchin- 

'  From  the  Dermatological  Laboratory  of  the  University  and 
Bellevue  Hospital  Medical  College. 


son,  Besnier,  and  others  from  accepting  the  view,  until 
lately  almost  universally  held  in  Germany,  that  they 
are  in  no  respect  related.  Besnier  and  the  majority 
of  the  French  school  uphold  in  the  most  emphatic 
manner  the  close  relationship  of  the  affection  to  the 
tuberculous  process. 

Boeck  '  in  an  elaborate  article  supports  the  same 
view.  In  his  carefully  tabulated  record  of  thirty-six 
cases  he  finds  pronounced  symptoms  of  tuberculosis 
in  two-thirds  of  them,  and  a  family  history  of  tubercu- 
losis in  half  the  remainder.  It  would  not  be  possible, 
as  he  well  states,  to  find  so  large  a  percentage  of  tu- 
berculosis in  an  equal  number  of  the  adult  population. 

Roth  '  has  collected  from  literature  records  of  about 
two  hundred  and  fifty  cases  of  lupus  erythematosus, 
and  in  one  hundred  and  eighty-five  of  them  there  was 


Fig.  I. — Lupus  Erythematosus  Discotdes  of  Eight  Years"  Duration,  Showing 
the  Characteristic  Atrophy.  In  addition  to  the  lesions  on  the  face  there  are 
three  bald  and  atrophic  spots  on  the  scalp.  The  patient,  aged  thirty  years, 
is  a  tailor,  and  though  somewhat  anxmic  gave  no  personal  or  family  history 
of  tuberculosis. 


more  or  less  pronounced  evidence  of  tuberculosis. 
As  tuberculosis  frequently  exists  in  a  latent  form 
which  is  difficult  or  impossible  to  recognize,  it  is  not 
improbable  that  the  percentage  of  such  cases  in  con- 
nection with  lupus  erythematosus  may  be  even  greater 
than  the  statistics  of  Boeck  and  Roth  would  seem  to 
show. 

In  Boeck's  opinion,  the  symmetrical  outbreak  of  the 
disease  is  due  to  the  action  of  the  tubercle  bacilli  tox- 
ins on  certain  vasomotor  nerve  centres.  The  symme- 
try of  the  eruption  is  by  no  means  a  constant  feature 

'  Arch,  fur  Derm.  u.  Syph.,  B.  xlii.,  S.  71,  1898. 
''Ibid.,  B.  li.,  S.  3.  1900. 


42 


MEDICAL    RECORD. 


[July  14,  1900 


of  the  disease  and  may  be  susceptible  of  otlier  expla- 
nations. 

The  absence  of  positive  knowledge  concerning  the 
etiology  of  the  affection  under  consideration  has  led 
to  the  most  varied  views  as  to  its  causation.  It  has 
been  regarded  as  a  tuberculosis;  an  inflammation  pio- 
duced  by  local  causes  in  individuals  of  slight  resisting- 
power;  an  angioneurosis;  a  specific  infectious  disease 
caused  by  the  growth  of  micro-organisms;  a  form  of 
skin  tuberculosis  produced  by  a  species  of  bacilli  sup- 
posed to  differ  from  those  found  in  the  lungs  and  in 
lupus  vulgaris;  a  neuritic  inflammation  of  the  skin, 
the  result  of  the  growth  of  the  tubercle  bacilli  in  the 

nerve  fibres  in  anal- 
ogy with  the  skin 
changes  caused  by 
nerve  leprosy. 

As  most  of  these 
theories  have  been 
shown  to  be  unten- 
able, an  attempt  is 
now  being  made 
by  an  increasing 
number  of  derma- 
tologists to  explain 
its  frequent  associa- 
tion with  tubercu- 
losis by  the  action 
of  the  toxins  of  the 
bacilli.  Although 
difficult  to  demon- 
strate, the  hypothe- 
sis is  an  attractive 
one  and  has  much 
to  commend  i  t . 
The  poisonous  sub- 
stances which  result 
from  the  growth  of 
tubercle  bacilli  are 
not  well  known. 
We  have  learned, 
however,  from  the 
experiments  of 
Prudden  and  Ho- 
denpyl,  Vissman, 
and  others,  that 
dead  tubercle  ba- 
cilli when  injected 
in  animals  are  ca- 
pable of  producing 
tuberculous  nodules 
ending  in  fibrosis. 
E.  A.  de  Schweinitz' 
has  shown  that  a 
crystalline  sub- 
stance which  he  obtained  from  pure  cultures  of  the 
tubercle  bacilli  produced  necrosis  of  the  liver  cells  of 
guinea-pigs  when  injected  in  minute  quantities  directly 
into  this  organ,  and  in  the  skin  of  these  animals  when 
used  subcutaneously.  This  substance,  he  is  led  to 
believe,  is  the  temperature-reducing  agent  and  is  dis- 
tinct from  the  fever-producing  principle  of  the  germ. 
We  can  only  surmise,  in  view  of  our  lack  of  positive 
knowledge,  that  certain  cases  of  lupus  erythematosus, 
when  met  with  in  conjunction  with  visceral  or  other 
tuberculosis,  may  be  due  to  the  action  of  the  toxic  pro- 
ducts of  the  tubercle  bacillus.  The  primary  involve- 
ment of  the  blood-vessels,  together  with  the  symmetri- 
cal outbreak  of  the  eruption  in  the  majority  of  cases, 
favor  the  supposition  that  the  causative  agent  is  one 
acting  through  the  blood  stream. 

'  "  .Some  Products  of  the  Tuberculosis  Bacillus  and  the  Treat- 
ment of  Experimental  Tuberculosis  with  Antitoxic  Serum." 
Reprinted  from  the  Transactions  of  the  Association  of  American 
Physicians,  1897. 


Fig.  2. — T.upus  Erythematosus  Dissemina- 
tus.  The  eruption  began,  two  months 
after  the  patient  became  pregnant,  as  an 
erythema  multiforme  of  both  hands  and 
forearms.  The  centre  of  the  erythema- 
tous patches  was  marked  by  superficial 
atrophy. 


The  involvement  of  the  flush  area  of  the  face,  which 
is  so  frequently  met  with  in  this  affection,  can  be 
readily  explained  by  the  slowing  of  the  blood  current 
and  the  diminished  resisting-power  which  the  paretic 
vessels  offer  to  the  hypothetical  toxin. 

It  is  not  improbable  that  lupus  erythematosus,  like 
many  other  diseases  in  dermatology,  may  have  more 
than  one  etiological  factor;  that  it  is  not  a  distinct 
entity,  but  the  result  of  the  action  of  other  agents  than 
those  formed  by  the  bacillus  of  tuberculosis. 

In  view  of  our  imperfect  knowledge  concerning  the 
etiological  factors  in  skin  affections,  we  are  not  in  a 
position  to  assert  that  all  eruptions  apparently  alike 
must  be  due  to  a  single  cause.  In  the  skin,  no  less 
than  in  other  organs,  we  may  have  the  same  conditions 
caused  by  various  toxic  or  bacterial  agents;  on  the 
other  hand,  a  definite  pathogenic  bacterium,  as  the 
tubercle  bacillus,  may  give  rise  to  symptoms  more  or 
less  dissimilar,  but  which  we  are  able  to  class  in  a 
single  group  by  reason  of  our  ability  to  detect  the 
germ  by  the  microscope  or  through  culture  or  inocula- 
tion experiments.  The  supervention  of  the  disease  on 
local  injury  to  the  tissues,  as  in  the  case  of  frost  bite, 
sunburn,  etc.,  and  on  previous  affections  of  the  skin, 
like  seborrhctic  dermatitis,  suggest  that  a  purely  local 
cause  may,  at  times,  be  responsible  for  its  occurrence. 
Atrophy  of  the  skin  has  been  observed  to  follow  the 
dermatitis  produced  by  the  Roentgen  rays  without  an- 
tecedent ulceration.  Some  observations  which  have 
recently  been  made  in  syphilis  by  one  of  us  would 
seem  to  show  that  we  may  have  in  that  disease  an 
eruption  closely  allied  in  its  clinical  and  anatomical 
features  with  lupus  erythematosus. 

The  following  brief  clinical  reports  of  some  of  the 
cases  which  have  come  under  our  observation  are 
intended  to  illustrate  a  few  of  the  types  of  the  af- 
fection. 

Case  I. — Lupus  erythematosus  disseminatus  disap- 
pearing during  pregnancy.  The  patient,  whose  case 
has  been  previously  reported,'  developed  two  months 
after  the  beginning  of  pregnancy  a  symmetrical  erup- 
tion of  the  dorsal  surfaces  of  both  hands  and  over  the 
forearm  not  unlike  an  erythema  multiforme.  A  very 
superficial  but  distinct  atrophy  appeared  in  the  centre 
of  the  larger  patches  (Fig.  2).  The  margins  of  the 
eruption  were  only  slightly  infiltrated  and  no  scaling 
was  evident.  The  patient  was  again  examined  when 
almost  at  term,  when  all  evidence  of  the  disease  had 
disappeared,  except  the  atrophied  spots,  surrounded 
by  a  pigmented  zone.  She  was  seen  again  after  her 
confinement,  and  stated  that  preceding  labor  she 
had  had  a  number  of  convulsions  from  which  she  re- 
covered. 

We  have  in  this  case  a  suggestion  at  least  that  some 
form  of  toxamia  was  responsible  for  the  symmetrical 
erythematous  eruption,  and  that  the  toxic  agent  was  of 
such  a  character  as  to  destroy  permanently  a  portion 
of  the  connective  tissue  of  the  true  skin.  Although 
tuberculosis  could  not  with  absolute  certainty  be 
excluded,  it  is  quite  unlikely  that  it  was  present 
in  view  of  the  absence  of  all  positive  signs  of  the 
disease. 

Crocker"  has  called  attention  to  a  variety  of  types  of 
lupus  erythematosus  resembling  papular,  nodular,  and 
diffuse  erythemata,  from  which  they  were  distinguished 
by  their  slow  development,  persistence,  and  tendency 
to  spread  at  the  margins.  Similar  cases  have  come 
under  our  observation  in  which  the  diagnosis  was  for 
a  long  time  doubtful,  and  could  be  made  only  by  ex- 
cluding other  conditions.  The  disseminate  form  of 
the  disease  not  infrequently  simulates  polymorphous 
erythema  in  its  evolution  and  distribution,  and  is  at 

'  Journal  of  Cutaneous  and  Genito-urinary  Diseases,  vol.  xiv., 
iSgf),  p.  8y. 
'//'/</.,  vol.  X.,  l8y4,  p.  I. 


July  14,  1900] 


MEDICAL   RECORD. 


43 


times  accompanied  by  vesicular  and  bullous  eruptions, 
fever,  and  severe  constitutional  disturbances  which 
are  followed  by  death.  We  have  in  such  cases  a  clin- 
ical picture  of  a  severe  toxaemia,  the  nature  of  which, 
however,  can  only  be  surmised. 

Intermittent  fever,  headache,  and  other  general 
symptoms  may  accompany  the  localized  forms  of  the 
disease,  as  shown  in  the  following  case: 

Case  II. — Lupus  erythematosus  of  the  face  and  scalp 
with  general  symptoms.  The  case  was  one  of  long 
duration  but  attended  by  acute  exacerbations,  during 
which  the  patient  suffered  with  chills,  fever,  intense 
headache,  pains  in  the  bones,  and  from  a  swollen  and 
painful  condition  of  the  face.  These  attacks  have  re- 
curred each  year  for  fifteen  years,  lasting  several  weeks. 
The  patient,  a  woman  aged  seventy  years,  says  her 
scalp  was  affected  twenty  years  ago;  the  left  side  of 
the  face  was  next  involved;  the  right  side  for  only  a 
year.  The  vermilion  border  of  the  lower  lip  is 
slightly  affected.  Both  forearms  are  the  seat  of  an 
itching  papular  eruption,  the  skin  in  this  location 
being  much  thickened.  The  scalp  patches  are  mark- 
edly atrophied.  On  the  face  the  atrophy  is  not  so 
marked,  but  can  be  made  out.  She  was  seen  during 
a  febrile  attack  and  it  was  noted  that  the  face  was 
much  swollen,  painful  to  touch,  and  the  color  a  more 
vivid  red.  After  the  fever  subsided,  the  pain  and 
swelling  of  the  face  almost  completely  disappeared. 
The  development  of  new  patches  was  not  observed 
during  the  acute  febrile  attack.  Notiiing  in  the  gen- 
eral condition  of  the  patient  was  detected  which  could 
be  invoked  to  explain  the  skin  affection. 

Case  III. — Lupus  erythematosus  secondary  to  tu- 
berculosis of  the  skin.  This  case  was  presented  be- 
fore the  New  York  Dermatological  Society,'  at  which 
time  several  opinions  were  expressed  as  to  the  nature 
of  the  eruption.  She  would  not  consent  to  have  a  pic- 
ture made,  nor  to  the  excision  of  a  piece  of  skin  for 
microscopic  purposes.  The  patient  was  a  woman  fifty 
years  old,  a  widow.  She  had  been  married  twenty- 
five  years,  during  which  time  she  had  had  six  children 
and  one  miscarriage;  five  of  her  children  are  living 
and  well.  Eleven  years  ago  she  had  a  paralytic  stroke 
affecting  the  right  side  and  followed  by  a  loss  of 
speech  which  persisted  for  two  weeks.  At  the  present 
time  she  has  a  symmetrical  erythema  of  the  cheeks 
and  nose  of  a  purplish-red  color,  with  slight  elevated 
and  well-defined  edges;  on  the  right  cheek  there  is 
considerable  atrophy  of  the  skin,  while  on  the  oppo- 
site side  there  are  several  retracted  scars.  On  the 
right  side  also  a  subcutaneous  nodule  can  be  made  out. 
The  left  ala  nasi  is  partly  destroyed  from  an  old 
ulceration.  There  is  considerable  induration  under- 
neath the  erythematous  lesions,  but  no  scaling  or  sep- 
arate nodule  suggesting  lupus  vulgaris.  Her  right 
ring  finger  is  swollen  from  involvement  of  one  of  the 
phalangeal  bones. 

We  were  at  first  inclined  to  think  that  the  woman  had 
had  syphilis,  upon  which  a  lupus  erythematosus  had 
become  engrafted.  Large  doses  of  potassium  iodide 
had  failed  to  produce  any  effect  upon  the  induration 
or  the  bone  lesion.  Lesions  on  the  cheek  had  existed 
about  eight  years.  After  a  thorough  trial  of  the 
iodides  the  diagnosis  of  tuberculous  gummata,  which 
had  healed  leaving  retracted  scars  and  the  present 
affection,  an  unusual  type  of  lupus  erythematosus  sec- 
ondary to  skin  tuberculosis  suggested  itself.  It  is 
difficult  to  impart  to  others  the  impression  produced 
on  one  by  the  careful  observation  of  a  case  of  cutane- 
ous disease  which  does  not  conform  to  the  usual  types. 
In  this  patient  the  long-continued  redness  and  infil- 
tration of  the  nose  and  cheeks,  with  atrophy,  and  abso- 
lutely none  of  the  diagnostic  features  of  lupus  vulga- 

'  Journal  of  Cutaneous  and  Genito-urinary  Diseases,  vol.  xv. . 
1S97.  P-  133- 


ris,  would  almost  force  one  to  the  conclusion  that  the 
active  process  was  a  lupus  erythematosus. 

At  the  same  meeting  of  the  society'  Dr.  Jackson 
presented  a  young  man  who  had  previously  had  numer- 
ous patches  of  lupus  erythematosus  of  the  face,  which 
had  disappeared  after  the  excision  of  strumous  lymph 
nodes  from  the  neck.  Two  years  after  he  was  found 
to  have  lupus  vulgaris.  The  history  of  the  case  seemed 
to  show  clearly  the  intimate  connection  between  the 
tuberculous  lymph  nodes  in  the  neck  and  the  eruption 
on  the  face,  the  spontaneous  disappearance  of  which 
after  removal  of  the  tuberculous  foci  would  speak 
against  its  having  been  a  primary  lupus  vulgaris. 

lironson'  has  reported  a  case  of  erythematous,  scaly 
and  pustular  eruption,  probably  an  atypical  lupus 
erythematosus,  in  a  woman  with  tuberculous  lymph 
nodes  in  the  neck,  which  disappeared  after  the  nodes 
were  removed.  The  eruption  recurred  with  each  re- 
'crudescence  of  the  focus  in  the  neck. 

These  cases  are  exceedingly  suggestive,  if  they  do 
not  furnish  the  actual  proof  that  an  extra-cutaneous 
tuberculous  focus  may  be  the  source  of  toxins  capable 
of  producing  lupus  erythematosus  or  closely  allied 
eruptions.  In  addition  to  the  cases  briefly  referred 
to  in  this  paper,  we  have  notes  of  three  others  in  which 
the  patients  were  affected  with  general  tuberculosis. 
A  report  of  one  of  them  with  the  autopsy  findings  can 
be  found  in  the  Journal  of  Cutaneous  and  Genito-uri- 
nary Diseases,  vol.  xvii.,  1899,  p.  113. 

The  frequent  association  of  lupus  erythematosus 
and  tuberculosis,  together  with  the  occasional  out- 
break of  the  former  disease  as  a  generalized  eruption 
with  severe  constitutional  symptoms,  favors  the  view 
of  those  who  connect  the  two  processes  by  means  of 
the  toxin  of  the  bacilli.  The  characteristic  atrophy 
of  the  connective  tissue  may  be  brought  about  by  the 
necrotizing  principle  of  the  germs,  which  Dr.  de 
Schweinitz  has  shown  to  be  a  crystalline  substance  that 
is  intensely  active  in  minute  quantities. 

Should  it  ever  be  possibly  to  prove  this  hypothesis, 
which  has  a  certain  amount  of  clinical  evidence  to 
support  it,  a  satisfactory  explanation  would  be  afforded 
of  those  rapidly  fatal  cases  of  the  disease  which  have 
been  described  by  Kaposi,  Hardaway,  Besnier,  and 
others. 

The  Pathology  of  Lupus  Erythematosus. — By  O. 
H.  Holder,  M.D.  Two  years  ago,  in  a  paper  read  be- 
fore the  Harvard  Medical  Society  of  the  city  of  New 
York,  and  afterward  published  in  the  Journal oj  Cutane- 
ous and  Genito- L'rinary  Diseases,  May,  1897,  an  attempt 
was  made  to  bring  the  condition  of  lupus  erythemato- 
sus into  closer  relation  with  the  obstructive  processes 
seen  in  the  finer  vessels,  a  point  which  was  not  of  gen- 
eral observation  and  which  seemed  worthy  of  the  most 
careful  consideration.  At  that  time  but  few  sections 
were  at  our  disposal,  but  through  the  efforts  of  Dr.  For- 
dyce  and  myself,  during  the  two  years,  tissue  has  been 
obtained  which  has  afforded  us  sections  which  number 
slightly  over  one  thousand.  In  regard  to  the  treat- 
ment of  this  material,  formalin  two  per  cent.,  absolute 
alcohol,  and  saturated  solution  of  bichloride  of  mer- 
cury were  used  as  fixing  agents,  and  the  specimens 
were  afterward  embedded  in  paraffin  and  mounted 
serially.  The  paraffin  and  staining  on  the  slide 
methods  seemed  especially  applicable  to  our  work,- as 
we  wished  to  retain  as  far  as  possible  the  contents  of 
the  vessels,  and  that  the  albumen  fixative  perfectly 
accomplished  its  object  is  demonstrated  by  the  pres- 
ence of  the  mononucleated  leucocytes  in  the  capil- 
laries. Comparing  these  sections  with  the  older  ones 
embedded  by  the  celloidin  process,  we  cannot  help 
feeling  that  this  important  factor  of  the  disease  is 
often   lost,  and   it  may  account  for  the  difference  of 


'  Ibid. , 

'Jlnd., 


vol.  .\v. ,  1897,  p.  134. 
vol.  XV.,  1897,  p.  225. 


44 


MEDICAL   RECORD. 


[July  14,  1900 


opinion  recently  expressed  by  writers.  None  of  the 
killing  fluids  used  by  us  seemed  of  especial  value. 
After  all  of  them  the  tissue  cuts  readily,  for  the  epi- 


:•:  -^i- 


>^^^ 


Fig.  3.— Lupus  Erythematosus:  I  .1  >  Spencer  objective  %  inch;  Zeiss 
pro],  ocular  2.  Approxiraatf  !Ma^[iil"n_.itiun  X  120.  Stain,  haematoxylon 
and  eosin.  From  fully  developed  erythema.  Very  irregular  dilatation  of 
capillary.  Granular  masses  to  the  left  are  normal  red  blood  corpuscles. 
The  peninsula  in  centre  is  completely  surrounded  by  endothelium  which 
shows  the  hyaline  strip  below  to  be  within  vessel.  The  two  blood  areas 
above  connect  over  isthmus  in  next  section.  Slight  development  of  plasmo- 
ma  to  the  right.     Finger  and  toe  processes  of  the  epithelium  obliterated. 

thelial  layer  is  exceedingly  thin  and  the  scar-like 
atrophy  differs  entirely  from  sclerotic  tissue. 

When  serial  sections  were  made,  hasmatoxylon  and 
eosin  or  Congo  red  were  used.  The  special  stains 
used  in  the  investigation  of  the  connective-tissue 
changes  will  be  taken  up  in  detail  later  in  this  paper. 
All  the  specimens  were  from  the  discrete  class  of  the 
disease,  only  one  case  of  the  disseminate  type  appear- 
ing at  the  clinics,  this  patient  refusing  to  submit  to 
the  removal  of  tissue.  The  most  acute  of  our  speci- 
mens was  the  telangiectatic  case  reported  by  Dr. 
Fordyce  in  the  Journal  oj  Cutaneous  and  Genito-  Uri- 
tiary  Diseases,  March,  1899. 

In  order  that  a  comprehensive  view  of  the  process 
might  be  obtained,  tissue  was  excised  with  the  Keyes 
circular  punch  from  the  three  clearly  defined  clinical 
areas,  the  periphery  of  the  lesion,  the  raised  erythema, 
and  the  atrophic  centre.  The  microscopical  appear- 
ances in  these  areas  differ  widely,  and,  in  a  full  de- 
scription of  the  disease,  it  has  been  the  custom  to  give 
a  separate  place  to  each;  but  as  these  differences  are 
only  a  question  of  degree,  such  a  scheme  gives  a 
wrong  impression,  and  is  hereby  abandoned  to  take 
up  the  main  pathological  factors  as  they  vary  in  going 
from  the  periphery  toward  the  centre.  These  factors 
making  up  the  histo-pathological  complex  are  few, 
and  may  be  divided  into  three  groups:  (<?)  The  round- 
cell  infiltration;  (/;)  the  peculiar  degenerated  condi- 
tion of  the  connective  tissue;  (/)  the  secondary 
atrophy. 

(</)  The  round-cell  infiltration  has  for  a  long  time 
been  considered  the  most  important  phenomenon  of 
the  process,  and  is,  as  far  as  can  be  seen,  the  primary 
departure  from  the  normal.  It  is  best  studied  in 
young  lesions,  although  tissue  taken  from  2  to  4  mm. 
outside  an  old  erythema  answers  as  well.  In  both  of 
these  positions,  in  which  it  is  fair  to  presume  that  the 
process  is  in  the  earliest  stage  of  development,  the 
infiltration  is  distinctly  perivascular,  and  is  well  de- 
scribed by  Unna  under  the  name  of  plasmomatic. 
These    infiltrated   areas  consist  of  open  capillaries, 


which  are  surrounded  by  very  loosely  packed  leuco- 
cytes. The  capillaries  here  are  enormously  dilated 
and  of  irregular  outline,  but  show  no  sign  of  endothe- 
lial proliferation  (Fig.  3).  Those  affected  are  confined 
to  the  network  of  the  upper  and  middle  corium,  and 
in  the  early  stages  there  is  no  tendency  to  involve  the 
capillaries  of  the  hair  follicles  or  glands.  This  error 
has  crept  into  the  literature  of  the  subject  by  the  ex- 
amination of  mature  lesions. 

The  round  cell  consists  here  of  a  brightly  staining 
nucleus  surrounded  by  a  clear  homogeneous  body  with 
a  very  slightly  differentiated  cell  wall.  I  have  been 
unable  to  bring  out  any  body  reticulum  of  these  cells 
with  acid  fuchsin,  eosin,  or  other  plasma  stains,  but 
attach  little  importance  to  the  fact  beyond  inferring 
that  they  are  well  placed  as  far  as  their  food  supply 
goes.  In  this  connection  our  observations  are  also  in 
accord  with  those  of  Unna  that  there  is  no  granular  or 
fatty  degeneration.  When  we  move  toward  the  atrophy, 
the  leucocytes  become  more  and  more  closely  packed, 
making  it  even  more  difficult  to  make  out  the  cell 
walls.  The  dilated  capillary  in  their  centre  becomes 
compressed  and  is  often  difficult  to  trace.  New  and 
deeper  areas  are  involved  and  now  extend  to  the  fol- 
licles and  glands,  and  down  into  the  fat  bodies  where 
the  typical  plasmomatic  appearance  of  the  earlier  af- 
fected vessels  is  beautifully  paralleled. 

It  is  not  vmusual  now  to  see,  in  those  cases  which 
do  not  have  a  tendency  to  sink  in,  a  great  mass  of 
leucocytes  filling  the  corium  from  the  level  of  the 
sweat  coil  to  the  epidermis,  or  running  horizontally 
for  great  distances.  These  larger  areas  are  appar- 
ently unconnected  with  any  vessel  and  are  sharply 
circumscribed.  Such  a  one  is  shown  in  the  photo- 
graph (Fig.  4)  and  tallies  well  with  one  of  the  recent 
descriptions  of  the  French.  There  is,  however,  no 
evidence  of  a  tuberculous  nature  in  this  process,  for 
this  particular  photograph  was  taken  from  a  lupus 
erythematosus  of  the  cheek  in  an  English  coachman, 
who  insisted  on  the  fact  that  it  came  four  years  be- 


FlG.  4.— I.upus  Krythematosus:  lace  (Check).  .Spencer  objective  i  inch; 
Zeiss  proj.  ocular  4.  Approximate  niaKuilication  X  too.  Stain,  h;tmatoxy- 
lon  and  eosin.  Height  of  erythema.  Shows  extensive  focus  of  infiltration 
in  a  case  which  had  no  tendency  to  atrophy.  Small  plug  in  opening  of  sweat 
duct.     This  is  the  circumscribed  area  described  by  the  French. 

fore  from  a  frost-bite.  The  erythema  was  about  the 
size  of  a  silver  dollar  and  showed  no  tendency  at  all 
to  atrophy  or  spread. 

When  we  get  to  the  atroj^hy,  the  leucocytes  are  again 
beginning  to  lessen  in  number,  and  here  occupy  the 
dilated  lymph  space  last  involved,  namely,  between 


July  14,  1900] 


MEDICAL   RECORD. 


45 


the  muscle  and  nerve  fibres.  Before  leaving  this  sub- 
ject one  point  must  be  mentioned  that  has  the  most 
important  bearing  on  the  pathology — that  is,  our 
knowledge  of  the  life  history  of  these  cells.  How 
much  is  really  known  of  their  origin,  how  long  do  the/ 
exist,  and  what  is  their  ultimate  fate?  Of  the  first 
and  last  of  these  questions,  the  answer  is  pretty  clear. 
We  are  almost  sure  that  they  come  from  the  blood 
current.  Such  is  the  general  opinion  of  dermatolo- 
gists, and  this  point  may  be  considered  closed,  for  they 
can  be  demonstrated  lying  free  in  the  capillaries.  It 
is  also  the  opinion  that  they  undergo  some  form  of 
degeneration  and  disintegrate,  and  as  they  have  mostly 
disappeared  in  atrophic  portions,  this  point,  too,  may 
be  considered  justly  terminated.  How  long  these 
cells  live  is  an  absolutely  unknown  quantity,  for  there 
are  no  means  at  our  disposal  of  estimating  any  such 
question  of  time.  It  may  be  weeks  or  months.  In 
our  opinion  past  writers  have  put  the  probable  time 
much  too  short.  They  give  in  their  works  the  im- 
pression that  the  cells  are  rapidly  dying  and  being 
replaced,  and  we  feel  that  there  is  no  ground  for  such 
an  idea.  The  fatty  and  granular  degeneration  is  an 
error  of  observation  when  spoken  of   as   characteristic 


Fig.  5.— I.upus  Er>'theraato5us :  Scalp.  Spencer  objective  yi  inch  ;  Zeiss 
proj.  oculars.  Approximate  majjnilication  X  140.  Stain,  haematoxylon 
and  erythrosin.  P'rora  central  atrophy.  Cloudy  appearance  of  the  connec- 
tive tissue  in  upper  corium.  On  left  irregularly  shortened  duct  of  sweat 
gland.  General  infiltration  about  region  of  coil.  Large  number  of  leuco- 
cytes within  the  atrophied  Malpighian  layer. 


of  the  process,  and  as  to  the  compressed  look  of  the 
cells  in  the  older  lesions,  this  is  probably  due  to  con- 
traction of  the  connective  tissue,  and  is  of  no  special 
significance  as  regards  the  vitality  of  the  cells. 

{b)  In  passing  to  the  changes  in  the  connective  tis- 
sue, we  come  to  the  consideration  of  a  less  recognized, 
though  equally  important  process  of  the  disease.  In- 
deed, were  it  necessary  to  make  a  diagnosis  from  sec- 
tions, it  is  here  that  the  nearest  approach  to  a  path- 
ognomonic sign  could  be  found.  In  the  youngest 
lesions,  this  change  is  slight  but  always  present,  and 
is  confined  to  small  areas  in  the  upper  corium,  which 
are  irregularly  surrounded  by  the  typical  plasmomatic 
capillaries.  The  collagenous  tissue  in  them  looks 
grayish  and  swollen,  suggesting  the  appearance  of 
a  coagulation  necrosis,  and  with  the  usual  dyes  does 
not  stain  (Fig.  5).  As  Unna  points  out,  his  acid  or- 
cein solution  gives  a  sharp,  dark-brown  color,  but  his 
inference  that  this  degeneration  contains  elastin  is  not 
proved.  The  tinctorial  characteristic  of  this  sub- 
stance  is  decidedly  against  Unna's  statement,  for  al- 


though it  takes  up  acid  orcein  (Fig.  6),  it  does  not  re- 
act to  the  other  recognized  stains  for  elastic  fibres.  The 
three  mordanted  haematoxylon  methods,  namely,  Mal- 


Fic.  6. — Lupus  Erythematosus ;  Scalp.  Spencer  objective  i  inch  ;  Zeiss 
proj.  ocular  2.  Approximate  magnification  X  80.  Stain,  acid  orcein  and 
thionin.  _  Area  from  height  of  erythema.  Shows  position  of  changetl  con- 
nective tissue  which  reacts  to  orcein.  This  is  the  most  characteristic  fea- 
ture of  the  disease,  histologically. 

lory's  tungstic  acid-heematoxylon,  Herxheimer's  iron 
process,  and  the  iron-alum  method  of  Heidenhain,  give 
beautiful  stains  here  for  the  elastic  fibres,  which  are 
well  preserved  even  to  the  end  of  the  process,  but 
leave  this  substance  absolutely  uncolored.  Van  Gie- 
son's  stain  gives  an  opaque  yellow.  With  the  plasma 
stains,  eosin,  erythrosin,  orange  G  and  Congo  red, 
there  is  a  marked  color,  but  the  peculiar  opacity  is 
still  retained  and  brings  it  into  sharp  contrast  with 
the  normal  collagenous  tissue  below.  When  the  old 
lesions  are  examined  to  see  the  ultimate  fate  of  this 


Fig.  y. — Lupus    Erythematosus :   Scalp.     Spencer     objective  %  inch  ;    Zeiss 
proj.   ocular  2.     Approximate    magnification   X  120.     Stain,   hxmatoxylon. 


Atrophied  portion.    Cast  in  upper  part  of  sweat  gland. 
was  plugged,  and  below  the  coil  was  almost  destroyed. 


Above  the  opening 


tissue,  we  see  it  forced  up  toward  the  surface  and 
slowly  disappearing.  Its  height  of  development  seems 
to  be  when  the  height  of  the  erythema  is  reached,  and 
its  formation  is  in  some  way  connected  with  the  plas- 


46 


MEDICAL    RECORD. 


[July  14,  1900 


momata.  Of  these  two  important  processes,  it  is  im- 
possible to  say  surely  which  is  the  cause  of  the  other, 
but  we  are  inclined  to  put  the  vascular  disturbance  as 


4:  :iif;W% 


Fig,  8. — Lupus  Erythematosus;  Scalp.  Spencer  objective  X  inch;  Zeiss 
proj.  ocular  2.  Approximate  magnification  X  180,  Stain,  hcematoxylon. 
From  atrophied  portion.     Granular  obstruction  in  fine  vessel. 

the  primary  one,  because  a  similar  change  can  be 
found  in  rosacea.  In  no  other  disease  have  we  ever 
had  any  success,  although  it  is  our  custom  to  stain 
almost  every  specimen  that  we  get  with  this  solution. 
No  other  stain  can  compare  with  acid  orcein  when  it 
is  the  object  to  bring  out  the  elastic  fibre,  but  we  have 
found  thionin  superior  to  Unna's  polychrome  methy- 
lene blue  for  its  counter-chromatin  stain.  It  gives 
a  much  sharper  color,  and  is  recommended  for  lupus 
erythematosus. 

Besides  this  cloudy  appearance  of  the  collagenous 
tissue,  there  are  many  other  changes  in  the  connective 
tissue,  though  none  belong  to  the  early  lesion.     In  le- 


FlG,  9. — Ijupus  Krythematosus :  Seal}-.  Sjn  n^ci  objective  %  inch;  Zeiss 
proj,  ocular  2.  Approximate  maRnification  X  200.  Stain,  haematoxylon. 
Longitudinal  and  transverse  cut  of  obstructed  vessel. 

sions  fully  developed,  a  clear  homogeneous  band  runs 
along  below  the  lowest  layer  of  the  epidermis,  giving 
the  appearance  of  a  much-thickened  basement  mem- 


brane. Above  it,  the  epidermis  is  always  thin,  and 
through  it  vessels  pass  and  carry  the  leucocytes  into 
the  prickle  layer,  A  similar  metamorphosis  seems  to 
be  present  in  the  walls  of  the  vessels,  and  possibly  to 
it  may  be  connected  the  casts  found  in  the  sweat 
glands  and  in  the  dilated  capillaries  of  our  telangiec- 
tatic case.  This  substance  is  not  stained  by  acid  or- 
cein, and  must  not  be  confused  with  the  change  in  the 
collagenous  tissue. 

((■)  Included  in  the  secondary  atrophy  must  be 
grouped  not  only  all  the  epithelial  changes,  but  many 
of  those  of  the  cells  of  the  connective  tissue  and  its 
differentiation.  While  there  may  be  a  slight  degree 
of  thinning  of  the  prickle  layer  in  early  lesions,  I 
should  say  that,  as  a  rule,  all  the  epithelial  constitu- 
ents are  close  enough  to  it  to  be  called  normal.  It  is 
extremely  difficult  to  be  sure  in  this  regard,  for  the 
two  places  where  these  lesions  are  most  common,  i.e., 
on  the  cheek  and  scalp,  differ  anatomically  from  each 
other  in  a  marked  degree.  The  method  of  excising 
small  pieces  is  faulty,  because  it  gives  us  no  healthy 
skin  for  comparison  with  the  diseased. 

The  changes  in  old  lesions  have  been  fully  de- 
scribed, and  were  it  not  that  many  curious  develop- 


FiG.  10. — Lupus  Erythemattisiis  :  ihcck.  Spencer  objective  J^  inch;  Zeiss 
jiroj.  ocular  2.  Approximate  magnification  X  180.  .Stain,  haematoxylon 
and  eosin.  From  long-standing  erythema.  Organization  of  old  thrombus 
in  vessel  from  the  deep  portion  of  corium.  The  irregular  oblong  space 
toward  bottom  of  vessel  is  still  open. 

ments  have  appeared  in  our  sections,  we  should  have 
nothing  to  add.  Of  these  the  most  interesting  are  the 
sweat  glands.  More  or  less  dilatation  of  the  coil  seems 
to  be  an  extremely  common  result  as  soon  as  the  infil- 
tration has  reached  the  adjacent  capillaries.  It  must 
not  be  considered  a  general  feature,  for  while  one  coil 
is  much  dilated,  the  next  may  be  little  or  not  at  all. 
In  those  we  followed  out,  there  were  both  a  large  plug 
(Fig.  7)  in  the  orifice  and  a  marked  lymphangiecta- 
sis,  with  infiltration  in  the  upper  part  of  the  duct.  As 
there  is  no  reason  to  suppose  that  the  normal  sweat  is 
under  pressure,  this  transference  of  the  lymph  pressure 
to  the  fluid  in  the  cavity  of  the  gland  may  account  for 
the  dilatation.  The  intra-canalicular  growth  of  the 
duct  shown  in  the  jihotograph  was  rare,  being  confined 
to  one  case  from  the  face.  Both  hair  follicles  and 
sebaceous  glands  in  these  sections  present  much  the 
appearance  generally  described,  the  atrophy  in  both 
being  always  accompanied  by  the  presence  of  the  in- 
filtration among  the  epithelial  cells.  The  muscle  and 
nerves,  as  have  been  said,  are  attacked  only  after  a 
long  time, 


July  14,  1 900] 


MEDICAL    RECORD. 


47 


Turning  our  attention  to  the  condition  of  the  vascu- 
lar system,  we  see  the  most  interesting  of  ail  the  path- 
ological changes.  It  was  stated  early  in  the  paper 
that  the  obstructions  in  the  vessels  had  been  formerly 
noted  (Figs.  8  and  9),  and  that  our  work  of  the  last 
two  years  had  been  carried  on  with  the  e.xpress  pur- 
pose of  verifying  the  question  of  their  existence.  The 
literature  on  this  point  is  extremely  scanty  and  does 
not  do  justice  to  its  importance. 

An  obstructive  intiammatory  process  in  the  larger 
vessels  is  described  by  Leloir,  under  the  name  of  en- 
doangiotitis  obliterans,  but  no  great  stress  is  laid  on 
it.  The  existence  of  this  process  is  denied  by  Unna, 
whose  descriptions  and  observations  are  always  most 
careful.  Recently  two  large  meetings  of  dermatolo- 
gists have  been  held  in  which  the  discussion  of  tiiis 
disease  was  made  a  principal  feature.  In  that  of  the 
American  Dermatological  .Association,  held  in  Prince- 
ton June,  1898,  Dr.  Robinson,  of  New  York,  the  reader 
of  the  paper  on  etiology  and  pathology,  absolutely  de- 
nied that  there  was  any  thrombosis,  but  later  Professor 
Boeck,  of  Christiania,  at  the  meeting  of  the  section  in 
dermatology  of  the  British  Medical  .Association,  lield 
in  Edinburgh,  Scotland,  July,  1898,  said  he  had  seen 
the  throiubosis  as  described.  As  far  as  our  own  obser- 
vations go,  we  can  say  that  we  have  seen  markedly 
obstructed  vessels,  as  described  by  Leloir,  but  as  these 
vessels  are  much  atrophied,  the  identification  of  an 
endarteritis  is  impossible.  In  most  cases  the  cells, 
which  occupy  the  old  calibre  of  the  vessel,  seem  to  be 
quite  similar  to  those  familiar  to  pathologists  in  organi- 
zation of  thrombi  from  the  vessel  wall  (Fig.  10).  Never 
is  there  seen  anything  wliich  resembles  the  endarteritis 
of  syphilis,  and  hence  Leloir's  nomenclature  is  con- 
fusing. Emphasis  must  be  laid  on  the  fact  that  tiiis 
involvement  of  the  large  vessels  belongs  to  the  proc- 
ess only  after  a  long  time,  for  it  is  never  seen  at  the 
periphery  of  the  lesion,  and  cannot  throw  light  on  the 
etiology  of  the  disease. 

Of  those  changes  of  the  early  lesion,  two  are  ever 
present,  the  mantling  infiltration  of  the  capillaries  and 
the  dilatation  of  their  calibre.  On  the  strength  of  this 
infiltration  alone,  the  disease  has  been  classed  as  an 
inflammation  of  the  skin  by  Kaposi  and  others.  Much 
better  would  it  be  to  call  it  a  disease  in  which  the 
vascular  condition  of  an  acute  inflammation  is  reached 
and  persistently  maintained.  That  these  two  condi- 
tions can  be  other  than  evidence  of  an  abnormally 
high  pressure  is  impossible,  and  it  is  clear  that  tiiey 
must  afford  the  main  basis  for  theoretical  speculation 
on  the  pathology. 

Most  important  in  the  first  place  would  be  the  rela- 
tion of  this  condition  to  general  pathology.  Nothing, 
however,  has  ever  been  obtained  along  this  line,  and 
a  pathology  has  been  devised  for  the  disease  more  or 
less  based  on  the  peculiar  anatomy  of  the  skin. 
Among  those  to  whom  I  have  shown  sections  was  Prof. 
E.  K.  Dunham,' who  said  that  the  only  place  which  he 
had  seen  similar  vascular  changes  was  in  certain  speci- 
mens of  interstitial  nephritis,  but  that  he  was  not  fa- 
miliar enough  with  the  various  inflammations  of  tiie 
skin  to  give  an  opinion.  It  is  true  that  the  skin  has 
much  in  it  that  has  a  separate  pathology,  and  there  is 
nothing  in  it  more  specialized  than  the  vascular  sys- 
tem wiien  we  consider  it  over  the  flush  area,  one  of  the 
favorite  sites  of  lupus  erythematosus.  Yet  I  cannot 
help  feeling  that  some  time  light  may  be  thrown  on 
this  subject  by  the  comparative  study  of  general  path- 
ology. Professor  Dunham's  observation  is  particu- 
larly valuable  in  that  an  increase  of  pressure  is  the 
chief  feature  of  these  two  processes;  and  the  sugges- 
tion is  not  out  of  place  that  both  lupus  erythematosus 
and  rosacea  are  worthy  of  the  most  careful  comparison 
witii  the  various  conditions  embraced  under  the  name 
of  interstitial  inflammation. 


If  we  admit  that  an  abnormally  high  pressure  exists 
in  these  plasmomata,  we  are  able  then  to  work  out  to 
a  certain  degree  the  cause.  By  following  along  the 
course  of  the  vessels,  we  are  able  to  tell  whether  ob- 
structions from  within  exist.  While  the  short  down- 
ward extension  into  the  fat  bodies  gives  a  clear  an- 
swer to  this  question  in  the  affirmative,  the  extremely 
small  lateral  extent  of  our  sections  prevent  the  follow- 
ing out  of  most  of  the  plasmomata  at  the  periphery. 
In  a  few  cases  I  have  reached  the  area  of  densely 
packed  capillaries  and  lymphatics,  but  in  following 
out  others  would  say  that  this  plasmomatic  condition 
never  leaves  the  vessel  in  going  toward  the  centre  of 
the  lesion.  'I'his  unbroken  involvement  of  the  upper 
corium,  and  in  fact  all  evidence  that  the  microscope 
can  afford,  exclude  all  ideas  of  an  inflammation  from 
a  local  septic  cause.  It  is  extremely  rare  to  find  red 
blood  corpuscles  in  these  dilated  capillaries,  though 
they  must  be  free  from  any  tendency  to  contract  and 
drive  them  out  during  fixation.  Free  leucocytes  are 
extremely  common,  and  help  to  prove  that  owing  to 
high  pressure  and  slowed  stream  the  marginal  currents 
are  alone  deflected  into  tiie  lesion,  and  the  segregation 
of  the  white  blood  corpuscles  is  the  result. 

The  choking  of  the  capillaries  and  lymph  spaces,  as 
above  described,  is  the  main  vascular  condition  in  the 
erythema,  and  to  it  may  be  attributed  the  mechanism 
by  which  the  pressure  is  maintained  in  the  plasmo- 
mata, and  the  lesions  spread.  It  is  hardly  correct  to 
speak  of  it  as  a  capillary  thrombosis,  for  all  evidence 
of  clotting,  beyond  the  massing  of  the  leucocytes,  is 
absent.  No  fibrin,  even  in  the  most  densely  packed 
areas,  can  be  demonstrated  by  W'eigert's  stain,  but  this 
has  nothing  to  do  with  the  obstructed  action  of  the 
position  of  the  cells,  and  is  a  sign  only  of  the  extreme 
chronicity  of  tlie  process. 

The  etiology  of  lupus  erythematosus  throws  almost 
no  light  on  the  pathology,  two  conditions  only  appear- 
ing to  hold  antecedent  relations  with  the  disease. 
One  of  these,  a  local  injury  of  the  corium,  includes 
cases  which  have  been  reported  to  have  followed  frost- 
bites and  tattooing.  The  other  is  tuberculosis.  In 
the  last  two  years  three  cases  in  the  first  group  have 
come  under  our  observation,  two  of  frost-bite,  and  a 
third  rather  vague  case  which  followed  scarification  for 
rosacea.  Of  the  second  group,  we  have  one  in  which 
there  was  no  uncertainty  of  coexisting  tuberculosis. 
This  was  the  telangiectatic  case  which  came  to  au- 
topsy. Five  others  complete  our  list.  In  these  no 
special  examination  of  the  lungs  was  recorded,  but 
granting  them  all  to  be  tuberculous,  our  list  shows  no 
such  percentage  as  that  of  the  French  school.  So 
uniformly  do  tiieir  records  run  that  it  is  not  out  of 
place  to  bring  up  a  possible  solution  of  the  actions  of 
toxin.  If  anything  is  absolutely  known  about  lupus 
erythematosus,  it  is  that  Koch's  bacillus  is  not  present 
in  its  lesion,  and  the  disease  is  not  true  tuberculosis 
of  the  skin.  Were  it  possible  to  establish  the  chain 
by  whicii  remote  foci  can  act  through  the  blood  cur- 
rent, the  long  record  of  cases  in  France  becomes  of 
great  interest  and  importance.  The  link  in  this  chain 
is  commonly  ascribed  to  the  stimulation  or  paralysis 
of  the  vasomotor  centres,  or  to  the  direct  action  of  the 
soluble  poison  on  the  walls  of  the  vessels.  Both  these 
ideas  are  unanswerable,  for  pathological  anatomy  can 
neither  indorse  nor  refute  them,  and  it  is  not  unlikely 
that  they  may  always  remain  to  explain  in  a  vague 
way  the  existence  of  many  of  the  erythemata  and  gen- 
eral tuberculides.  Lupus  erythematosus  is  too  local 
a  process  to  be  attributed  to  a  chemical  disturbance 
of  the  vessel  wall,  for  all  the  vessels  of  the  skin  must 
be  subjected  simultaneously  to  an  identical  action,  and 
they  show  no  sign  of  it.  To  the  early  observation  of 
ihe  skin,  the  vasomotor  theory  of  the  physiologists  and 
the  allied  theories  of  pathology  owe  in  part  their  ex- 


48 


MEDICAL   RECORD. 


[July  14,  igcx) 


istence.     No   one   can  dispute  the  care  with   which 
these  observations  have  been  made,  nor  the  clearness 
of  the  experiments  and  their  results.     It  is  only  the 
inferences  that  are  too  hasty.     The  limited  space  of 
this   paper  does  not   permit   a  lengthy  discussion  of 
these  theories,  and  so  in  a  few  words  I   shall  try  to 
point  out  what  seems  to  be  one  of  the  gravest  errors 
in  their  application  to  the  skin.     An  important,  and 
perhaps  the  most  important  specialization  of  the  skin 
in  warm-blood  animals  is  the  control  of  heat  by  the 
dermic  blood  supply.     In  giving  that  control  to  the 
differentiated  arterial  walls,  as  the  modern  vasomotor 
theory  does,  not  only  is  the  seat  of  action  removed 
from  the  upper  corium,  but  the  main  muscles  of  their 
skin  are  completely  neglected.     In  the  well-known  ex- 
periments on  the  rabbit's  ear,  dilation  follows  the  cut- 
ting of  the  svm pathetic  nerve.     The  question  is.  Does 
this  nerve  go  to  the  vessel  walls  or  to  the  unstriped 
musculature  of  the  corium;  and  is  the  secondary  con- 
traction the  result  of  a  return  of  the  arterial  tone  or 
a  filling  of  the  lymph  spaces,  and  the  closing  of  the 
walls  of  the  capillary  by  the  equalization  of  lymph 
and  blood  pressure?     Not  the  slightest  evidence  has 
ever  been  brought  forward  that  the  normal  capillary 
wall  in  the  skin  is  not  at  rest,  and  the  pressure  with- 
out equal  to  that  within.     The  known  movements  of 
lymph  and  venous  blood  are  an  absolute  proof  of  this 
statement.     This  all-important  question  of  the  lymph 
pressure  is  always  lightly  touched  on  in  physiologies, 
because  it  affords  almost  no  means  for  experimenta- 
tion   nor    data    for   abstruse    mathematical    calcula- 
tions. .        ,. 
Anatomical  findings  show  many  muscles  running  di- 
a<^onally  from  the  deep  corium  toward  the  surface,  and 
as  these  are  attached  indirectly  to  the  epithelial  layer 
through  the  attachments  of  the  connective  tissue,  either 
they  must  have  no  normal  traction  or  the  skin   must 
be  pulled  down  on  the  lymph  space  and  capillaries. 
The  laws  governing  the  movement  of  fluid  in  the  body 
are  those  which  physics  has  proved  in  regard  to  con- 
fined fluids  and  should  be  so  applied,  the  capillary 
wall  being  really  submerged  whether  it  is  patent  or  not. 
We  place,  then,  this  lymph  pressure  under  the  control 
of  these  muscles,  though  the  entire  connective  tissue  is 
concerned   in    its   maintenance.     It  is  clear  that  any 
interference  with  their  contraction  must  mean  the  loss 
of  lymph  pressure.     Following  out  the  possible  varia- 
tions, it  is  clearly  seen  that  relaxation  of  either  the 
muscles  or  the  connective  tissue  would  cause  dilated 
lymph  spaces  and  diapedesis,  and  although  there  might 
be  a  paralysis  of  the  muscle  from  a  toxaemia  affect- 
ing the  vasomotor  centre,  it  is  more  likely  that  it  is 
the  connective  tissue  which  is  concerned  and  which 
we  have  shown  to  be  very  early  involved  in  lupus  ery- 
thematosus.    If  the  swelling  of  the  collagenous  tissue 
means  loss  of  function,  it  is  possible  that  the  infiltra- 
tion is  secondary  to  it.     I  admit  that  our  sections  by 
no  means  exclude   this   solution,   and   this  unknown 
chemical  change  may  be  the  result  of  toxffimia  and 
hence  tuberculosis. 

In  summing  up  the  results  of  our  work  there  is 
little  to  be  said.  Everything  that  is  seen  in  the  mi- 
croscope points  conclusively  to  the  fact  that  lupus 
erythematosus  is  a  disease  in  which  the  blood  supply 
is  interfered  with.  The  normal  capillary  pressure  is 
raised,  but  the  cause  is  open  to  further  investigation. 
Of  the  two  phenomena  that  are  characteristic  of  the 
early  lesion,  we  are  inclined  to  place  the  infiltration 
secondary  to  a  capillary  obstruction  in  the  height  of 
the  erythema,  but  we  allow  at  the  same  time  that  it 
may  be  the  effect  and  not  cause  of  the  connective-tis- 
sue change.  As  this  still  requires  further  work,  we 
again  take  the  opportunity  to  recommend  to  both  pa- 
thologist and  dermatologist  the  use  of  Unna's  acid 
orcein  in  lupus  erythematosus. 


ENDOCARDIAL  MURMURS  OF  ORGANIC 
ORIGIN,  LOCALIZED  IN  THE  PULMO- 
NARY AREA  OF  THE  HEART.' 

By   JOHN   WINTERS   BRANNAN,    M.D., 

NEW    VORK. 

At  the  last  meeting  of  the  society,  a  patient  was  pre- 
sented with  full  clinical  history  and  well-marked 
physical  signs  of  cardiac  disease,  and  yet  the  difficul- 
ties in  the  case  were  so  great  that  most  of  the  gentle- 
men present  hesitated  to  venture  a  diagnosis  without 
further  observation  and  study  of  the  case.  I  have 
brought  the  patient  again  to-night,  in  order  that  the 
members  of  the  society  may  have  another  opportunity 
for  examination. 

The  case,  in   brief,  is  as  follows:  The  patient,  Ar- 
thur Jasper, 'a  well-nourished  young  negro  aged  sixteen 
years,  was  born  a  healthy  baby,  with  no  evidence  of 
congenital  defect  of  any   kind.     He    remained  well 
until  the  age  of  five  years,  when  he  had  an  attack  of 
acute  articular  rheumatism   involving  also  the  heart. 
At  seven  years  of  age  he  had  another  attack,  accom- 
panied with  cardiac  disturbance.     Since  that  time  he 
had  had  more  or  less  palpitation  and  dyspncea,  but 
has  been  able  to  pursue  his  occupation,  that  of  a  ped- 
dler.    The  illness  from  which  he  has  recently  recov- 
ered began  about  March  i,  1900,  with  cough  and  pain 
in   the   side,  fever,  sore   throat,  and   headache.     The 
ankles  and  knees  became  swollen,  painful,  and  ten- 
der, and  he  was  unable  to  walk.     The  cardiac  symp- 
tom's mentioned   above  became  more  marked  and  at 
times  he  could  not  breathe  in  the  recumbent  position. 
On  March  21st,  he  was  brought  to  Bellevue  Hospital. 
On  entrance,  the  patient's  temperature  was  104°  F., 
the  pulse  100,  and  respiration  28  to  the  minute.     He 
had  frequent  cough  with  slight  muco-purulent  expecto- 
ration  and   some   dyspnoea.     The  lungs  were  normal 
except   for    sonorous    and    sibilant    rales    throughout 
both  sides  of  the  chest.     On  examination  of  the  heart, 
the  apex-beat  was  difficult  to  locate,  but  could  be  seen, 
wave-like  in  character,  with   greatest  distinctness   in 
the  fifth  space   in   the  nipple  line.     The  cardiac  im- 
pulse was   stronger  over   the   base   than   at  the  apex. 
Over  the  whole  prascordium  there  was  a  systolic  thrill 
with  maximum  intensity  in  the  second  left  intercostal 
space.     On  percussion,  the  left  border  of  the  heart  ap- 
peared to  be  three  inches  from  the  median  line  of  the 
sternum,  the  upper  border  at  the  third  rib,  and  the 
right  border  three-quarters  of  an  inch  beyond  the  right 
edV  of   the   sternum.     A  long,  loud,  rough,  systolic 
murmur  was  heard  over  the  whole  cardiac  area,  with 
maximum  intensity  in  the  second   left  space  close  to 
the  sternum.     The  murmur  was  also  heard  over  the 
left  side  of  the  chest  in  front  and  behind,  and  was  ap- 
parently transmitted   into  the  carotid  and  subclavian 
arteries.     The  second  aortic  sound  was  very  faint,  the 
second    pulmonic    accentuated.     The    action    of    the 
heart  was  rapid  and  irregular.     There  was  no  pulsa- 
tion in  the  epigastrium  nor  in  the  vessels  of  the  neck. 
The  mucous  membranes  were  of  a  healthy  red  color, 
and  the  sphvgmographic  tracings  were  alike  in  both 
radial  arteries,  not  varying  much  from  the  normal. 

The  patient  rapidly  improved  with  rest  in  bed  and 
treatment  with  the  salicylates,  and  at  the  end  of  ten 
days  he  was  up  and  about  the  ward  doing  light  work. 
The  physical  signs  in  the  chest  remained  as  before, 
except  that  the  lungs  were  free  from  rales  and  the 
heart's  action  had  become  slow  and  regular. 

When  he  was  presented  at  our  meeting,  five  weeks  ago, 
there  was  no  cyanosis,  no  clubbing  of  the  finger  ends, 
no  embarrassment  of  breathing  or  of  the  circulation, 
and  nothing  to  suggest  disease  of  the  right  side  of  the 
heart  except  the  murmur  and  thrill  in  the  pulmonary 
area  and  the  cardiac  enlargement  to  the  right  of  the 
1  Read  at  a  meeting  of  the  I'ractitioners'  Society.  May  11,  lyoo. 


July  14,  1900] 


MEDICAL    RECORD. 


49 


sternum.  The  murmur  was  heard  with  equal  inten- 
sity throughout  the  respiratory  act.  The  thrill  was 
then  present,  but  has  now  disappeared. 

Before  I  had  been  able  to  make  even  a  probable 
diagnosis  of  this  case,  a  second  patient  entered  the 
hospital  with  physical  signs  which  were  almost  iden- 
tical with  those  in  the  first  patient.  The  history  of 
the  case  is  as  follows:  The  patient  is  a  young  man 
twenty-three  years  of  age,  a  stoker  by  occupation. 
He  has  been  a  hard  drinker,  but  has  had  no  illness 
except  the  diseases  of  childhood.  His  present  illness 
began  about  February  ist,  with  pain  and  tenderness  in 
the  wrists  and  ankles,  and  gradually  involved  the 
knees,  right  shoulder,  and  hips.  The  pain  was  ac- 
companied with  some  swelling  of  the  joints.  There 
has  also  been  at  times  palpitation  of  the  heart,  but 
no  dyspncea  or  cough.  On  April  5th,  when  the  pa- 
tient entered  the  hospital,  the  temperature  was  102.2° 
F.,  the  pulse  100,  and  the  respiration  24  to  the  min- 
ute. Both  knees  were  painful  and  tender  and  the  left 
knee  was  red  and  swollen.  There  was  also  some  stiff- 
ness of  the  left  hip.  The  heart  presented  the  following 
conditions:  The  apex  beat  was  in  the  fourth  space, 
distinctly  seen  and  felt  in  the  nipple  line  four  inches 
from  the  middle  of  the  sternum.  The  beat  was  for- 
cible, not  diffuse  nor  wavelike.  The  right  border  on 
auscultatory  percussion  was  one-quarter  inch  to  the 
right  of  the  sternum,  the  upper  border  was  at  the  third 
rib,  the  left  border  five  inches  from  the  median  line. 
In  the  second  left  intercostal  space  close  to  the  ster- 
num was  felt  a  systolic  thrill.  In  this  same  region 
was  heard  a  long  systolic  murmur,  not  transmitted  in 
any  direction.  The  murmur  was  somewhat  inconstant. 
The  valvular  sounds  elsewhere  were  normal.  On  the 
7th  of  April  it  is  noted  in  tiie  records  that  the  joints 
were  much  improved  and  that  a  distinct  impulse  was 
to  be  seen  in  the  second  left  space.  Three  days  later 
the  thrill  was  no  longer  to  be  felt,  and  when  the  pa- 
tient left  the  hospital  on  the  17th  of  April  the  murmur 
was  not  to  be  heard.  I  liad  hoped  to  present  the  pa- 
tient to-night,  but  unfortunately  he  has  left  the  city. 

.Since  our  last  meeting  I  have  given  much  thought 
and  study  to  the  subject  of  systolic  murmurs  in  the 
pulmonary  area,  and  have  made  such  search  of  tiie  lit- 
erature as  time  would  permit.  The  patient  Jasper  has 
also  been  kept  under  constant  observation.  The  prob- 
lem presented  by  this  case  may  be  stated  as  follows: 
Does  the  murmur  originate  in  the  pulmonary  artery 
itself  either  as  a  result  of  structural  ciiange  in  the  ves- 
sel or  its  valves,  or  as  a  result  of  pressure  from  with- 
out, or  is  it  generated  at  the  aortic  or  mitral  orifice 
and  conveyed  thence  in  some  manner  to  the  pulmonary 
area? 

Acquired  affections  of  the  pulmonary  artery  are  ex- 
tremely rare,  whereas  congenital  malformations  are  not 
uncommon  but  are  seldom  observed  except  in  infancy 
or  early  childhood.  In  the  Transactions  of  the  Lon- 
don Pathological  Society,  from  its  foundation  down 
to  the  present  year,  I  have  found  but  two  cases  of  ac- 
quired endocarditis  of  the  right  side  of  the  heart.  In 
one  of  the  cases  there  was  also  a  congenital  defect  of 
the  interventricular  septum,  but  the  endocarditis  was 
apparently  of  recent  origin.  The  mitral,  pulmonary, 
and  tricuspid  valves  were  all  affected.  In  the  second 
case  the  patient  was  apparently  healthy  at  birth,  though 
there  is  no  note  to  that  effect.  The  symptoms  dated 
from  an  attack  of  scarlet  fever  in  early  childhood. 
The  physical  signs  were  indicative  of  pulmonary  ob- 
struction and  regurgitation  and  of  tricuspid  insuffi- 
ciency. Death  occurred  at  the  age  of  eighteen  years, 
and  on  autopsy  there  was  extensive  disease  of  the  pul- 
monary and  tricuspid  valves.  There  was  no  congeni- 
tal defect,  and  the  left  side  of  the  heart  was  normal 
with  the  exception  of  two  or  three  small  warty  growths 
on  the  mitral  valve.     There  are  manv  cases  of  con- 


genital malformations  reported,  and  in  all,  when  any 
clinical  notes  are  given,  there  is  a  history  of  cyanosis 
or  of  dyspnoea  or  of  more  or  less  embarrassment  of  the 
circulation.  A  search  of  the  transactions  of  the  New 
York  and  Philadelphia  Pathological  Societies  gives 
similar  results.  In  our  case,  as  we  have  seen,  there 
was  no  cyanosis  nor  any  sign  of  circulatory  disturb- 
ance until  the  attack  of  rheumatism  at  the  age  of  five 
years.  I  think,  then,  we  are  fairly  justified  in  exclud- 
ing congenital  disease,  and  in  believing  that  acquired 
disease  of  the  pulmonary  artery  is  in  the  highest  de- 
gree improbable.  Pressure  upon  its  walls  may  cause 
systolic  murmurs  in  the  pulmonary  artery.  The  press- 
ure may  be  produced  by  aneurisms  of  the  aorta,  or  by 
enlarged  bronchial  glands,  or  by  tumors  in  the  medi- 
astinum or  in  the  lungs.  In  the  case  of  Jasper  there 
are  none  of  the  usual  local  signs  of  an  aneurism,  and 
its  existence  is  rendered  improbable  by  the  similarity 
of  the  pulse  tracings  in  the  two  radial  arteries.  It  is 
of  course  possible  that  there  may  be  pressure  from 
a  gland  or  by  a  growth,  but  I  do  not  think  it  likely  in 
this  instance.  Systolic  murmurs  heard  in  the  pulmo- 
nary area  are  believed  by  Quincke  and  by  Broadbent 
to  be  sometimes  due  to  incomplete  covering  of  the 
conus  arteriosus  by  the  overlapping  left  lung,  so  that 
a  part  of  the  conus  or  the  pulmonary  artery  itself 
comes  into  contact  with  the  chest  wall,  and  during 
systole  is  more  or  less  flattened  against  the  chest  wall. 
An  eddy  is  thus  formed  in  the  current  of  blood  rush- 
ing into  the  pulmonary  artery  which  gives  rise  to  a 
murmur.  Quincke  states  that  in  these  cases  the  pul- 
sation of  the  pulmonary  artery  can  be  seen  and  felt 
in  the  second  left  interspace.  During  a  full  inspira- 
tion the  murmur  disappears,  as  a  cushion  of  lung  is 
then  brought  over  the  conus  arteriosus  between  it  and 
the  chest  wall.  Bramwell,  however,  thinks  it  doubt- 
ful whether  the  heart  does  or  can  compress  the  pulmo- 
nary artery  in  the  manner  which  Quincke  has  supposed, 
as  the  "conus  arteriosus  descends  to  the  plane  of  the 
base  during  the  ventricular  systole;  and  the  length  of 
the  ventricle  does  not  alter  during  the  contraction  of 
the  heart."  On  the  other  hand,  he  reports  two  cases 
under  his  observation  in  which  the  left  lung  was  re- 
tracted and  systolic  murmurs  were  heard  in  the  second 
left  interspace.  In  these  cases  he  concluded  that  the 
murmur  was  exocardial  and  produced  by  the  contact 
of  the  pulmonary  artery,  or  rather  the  roughened  por- 
tion of  the  pericardium  which  covers  the  root  of  the 
pulmonary  artery,  with  the  anterior  wall  of  the  chest 
In  both  cases  the  retraction  of  the  lung  was  due  to 
pleurisy,  and  there  was  reason  to  suppose  that  the  outer 
portion  of  the  pericardium  was  roughened  by  a  deposi*" 
of  lymph.  Bramwell  noted  the  peculiar  loudness, 
roughness,  and  localized  character — not  propagated  in 
any  direction — of  the  murmur  in  his  two  cases.  I 
have  never  to  my  knowledge  met  with  an  instance  of 
the  murmur  with  the  characteristics  described  by 
Quincke  and  Broadbent.  The  explanation  offered  by 
them  can  hardly  apply  to  our  case,  for,  as  we  have 
seen,  the  murmur  is  not  at  all  affected  by  the  act  of 
respiration. 

Turning  now  to  the  left  side  of  the  heart,  let  us  con- 
sider the  aortic  and  mitral  valves  as  possible  points  of 
origin  for  the  murmur.  An  aortic  obstructive  murmur 
is  sometimes  heard  to  the  left  of  the  sternum  with 
greater  distinctness  than  to  the  right,  but  never,  1 
think,  is  the  difference  so  great  as  in  this  case.  Nor 
is  the  murmur  in  our  patient  really  transmitted  into 
the  carotid  arteries,  although  it  is  so  stated  in  the 
notes  of  the  case.  On  careful  examination  I  find  that 
the  sound  is  simply  conveyed  up  the  left  side  of  the 
neck  through  the  bones  and  tissues  just  as  it  is  carried 
everywhere  throughout  the  left  side  of  the  chest.  On 
the  right  side  of  the  neck,  and  especially  over  the 
carotid  ?rtery,  the  murmur  is  heard  very  faintly  if  at 


50 


MEDICAL    RECORD. 


[July  14,  1900 


all.     The  pulse  also  does  not  show  the  tracing  charac- 
teristic of  aortic  obstructive  disease. 

Having  eliminated  all  other  sources  for  the  mur- 
mur, the  mitral  valve  alone  remains.  Many  writers 
have  noted  that  the  murmur  of  mitral  regurgitation  is 
occasionally  heard  in  the  pulmonary  area,  and  various 
explanations  have  been  offered  for  the  fact.  Naunyn 
was  among  the  first  to  make  this  observation,  and  his 
theory  of  the  causation  of  the  murmur  has  been  ac- 
cepted by  Balfour  and  other  authorities.  Naunyn 
holds  that  the  murmur  is  conducted  to  the  second  left 
interspace  through  the  dilated  appendix  of  the  left 
auricle.  Normally  the  left  auricle  is  almost  com- 
pletely hidden  by  the  right  side  of  the  heart  and  the 
root  of  the  pulmonary  artery.  But  in  disease  of  the 
mitral  valve  with  dilatation  of  the  auricle,  the  auricu- 
lar appendix  winds  around  the  pulmonary  artery  and 
lies  in  front  of  it,  in  contact  with  the  chest  wall.  In 
a  case  of  mitral  insufficiency,  therefore,  the  reflux  cur- 
rent of  blood  flows  into  the  auricle,  and  as  the  appen- 
dix communicates  freely  with  the  auricular  chamber 
we  can  readily  see  how  the  sound  should  be  conducted 
to  the  second  intercostal  space  better  than  toward  the 
apex.  Naunyn's  murmur,  however,  is  not  heard  with 
maximum  intensity  at  the  edge  of  the  sternum,  but  at 
a  considerable  distance  from  it,  about  one  and  one- 
half  or  two  inches  to  tlie  left,  or  at  the  point  which 
corresponds  with  the  situation  of  the  auricular  appen- 
dix in  these  cases.  In  our  case,  on  the  other  hand, 
although  the  murmur  is  heard  very  loudly  at  this  point, 
the  place  of  maximum  intensity  is  without  question 
close  to  the  left  border  of  the  sternum.  This  situa- 
tion is  just  over  the  mitral  valve,  and  I  have  finally 
come  to  the  conclusion  that  the  murmur  in  this  case 
is  due  to  regurgitation  through  the  mitral  orifice  and 
th^t  it  is  transmitted  directly  upward  from  the  place 
of  its  production.  Sansom,  in  discussing  the  murmur 
of  mitral  regurgitation,  states  that  in  rare  cases  it  may 
be  audible  only  at  the  second  and  third  left  costal  car- 
tilages and  the  neighboring  interspaces.  He  believes 
that  in  these  exceptional  cases  it  is  due  to  the  morbid 
material  about  the  mitral  valve  being  a  good  con- 
ductor of  the  vibrations,  which  become  sonorous,  to  the 
so-called  pulmonary  area.  In  one  case  under  his  ob- 
servation, he  found  on  autopsy  that  a  calcareous  thick- 
ening about  the  mitral  orifice,  involving  the  cords  and 
curtains  in  this  position,  was  so  extensive  as  to  en- 
croach upon  the  conus  directly  below  the  aortic  valves, 
distinctly  narrowing  the  lumen  of  the  aortic  orifice  in 
this  situation,  and  he  thought  that  this  might  very 
probably  be  the  cause  of  the  systolic  murmur  heard  in 
the  position  mentioned.  Balfour,  also,  lays  stress 
upon  "  the  natural  tendency  of  murmurs  to  be  propa- 
gated to  the  surface  through  the  organ  in  which  theu 
are  produced  (in  this  case  by  the  impingement  of  re- 
gurgitant fluid  waves  upon  the  tense  wall  of  the  left 
auricle),  provided  the  conditions  are  suitable."  In 
another  place  he  asserts  that  the  slightest  dilatation 
of  the  right  ventricle  pushes  the  left  apex  backward 
into  the  thoracic  cavity  and  away  from  the  chest  wall. 
In  our  case  the  right  ventricle  is  not  dilated  at  pres- 
ent, whatever  it  may  have  been  when  the  patient  was 
in  the  hospital.  It  is,  however,  a  fact  that  the  apex 
beat  has  never  been  felt  very  strongly  in  the  fifth 
space.  At  the  time  of  my  last  examination,  one  week 
ago,  I  made  the  following  notes:  "Systolic  impulse 
strong  over  the  fourtii  left  costal  cartilage  and  in 
spaces  above  and  below,  more  marked  than  over  apex. 
Murmur  heard  with  greatest  distinctness  in  second 
left  space  close  to  sternum  and  carried  loudly  directly 
to  left  for  an  inch  or  two,  also  diagonally  upward  to 
the  left  with  steadily  diminishing  intensity,  but  never- 
theless more  distinct  under  the  clavicle  than  at  apex. 
No  second  sound  to  be  distinguished  at  the  base  over 
either  aortic  or  pulmonic  orifice,  but  well   marked  at 


apex."  It  would  seem,  then,  that  we  have  here  the 
conditions  necessary  for  the  transmission  of  the  mur- 
mur from  the  mitral  valve  directly  to  the  surface 
above,  the  base  of  the  heart  being  apparently  in  close 
apposition  to  the  chest  wall.  The  murmur  is  also 
conveyed  strongly  to  the  left  by  the  reflux  blood  cur- 
rent through  the  auricle  into  the  left  auricular  appen- 
dix, in  the  manner  described  by  Naunyn.  But  the 
essential  feature  of  the  case,  if  I  comprehend  it 
rightly,  is  the  conduction  of  a  mitral  regurgitant  mur- 
mur directly  to  the  chest  wall  above,  to  the  so-called 
pulmonary  area. 

I  have  not  discussed  the  mechanism  of  the  func- 
tional murmurs  heard  in  the  pulmonic  area  nor  the 
diastolic  murmurs  of  organic  origin  localized  in  this 
region,  as  they  did  not  seem  pertinent  to  the  subject 
under  consideration  and  would  have  added  unneces- 
sarily to  the  length  of  the  paper. 


CONVULSIONS.' 

By   clarence    KING,    M.D., 

MACHIAS,    N.    V. 

So  accustomed  are  we  to  hearing  certain  symptoms 
spoken  of  as  the  names  of  disease,  that  it  is  difficult 
for  us  to  realize,  or  for  the  public  to  comprehend,  that 
we  have  not  made  a  diagnosis  when  we  assign  one  of 
these  as  a  cause  of  sickness.  We  recognize  as  a  dis- 
ease a  condition  attended  by  definite  pathological 
changes  of  a  nearly  uniform  nature  and  accompanied 
during  life  by  a  certain  line  of  symptoms.  Hence 
every  disease  is  made  up  of  several  symptoms;  and, 
likewise,  each  one  of  these  symptoms  may  belong  to 
several  diseases.  So  it  is  well  for  us,  occasionally,  to 
study  these  general  symptoms,  and  to-day  I  shall  con- 
sider convulsions  and  point  out  some  of  the  diseases 
which  they  may  accompany. 

A  convulsion  may  be  defined  as  a  sudden  explosion 
of  nerve  force  which  is  manifested  by  involuntary 
tonic  or  clonic  contractions  of  the  general  muscular 
system  or  a  large  part  thereof,  usually  with  loss  of 
consciousness  and  insensibility,  and  tending  to  irregu- 
lar recurrences.  Convulsions  are  very  common,  and 
every  one  who  has  seen  much  sickness  or  mingled 
much  with  the  world  has  seen  them  in  some  form. 
Practically  all  convulsions  partake  of  the  same  general 
characteristics,  the  only  difference  being  in  degree. 
Thus,  general  eclampsia  or  a  fully  developed  case  of 
grand  mal  may  be  taken  as  the  type  of  the  more  vio- 
lent forms,  while  localized  convulsions  or  Jacksonian 
epilepsy  represent  the  milder  forms.  Spasms,  which 
involve  a  single  muscle  or  a  very  small  group  of  mus- 
cles, like  wry-neck,  athetosis,  or  writer's  cramp,  are 
of  the  same  general  order,  yet  should  not  be  classed  as 
convulsions  on  account  of  their  strictly  localized  and 
very  mild  nature,  and  unimportance  as  regards  life  or 
future  health.  Likewise  chorea,  paralysis  agitans, 
and  the  tremor  which  is  common  to  advanced  age  do 
not  come  within  the  scope  of  our  definition  because  of 
their  continuous  and  protracted  character,  and  the 
want  of  that  sudden  "motor  discharge  "  which  forms 
one  of  the  leading  features  of  a  convulsion. 

Clinically,  we  may  divide  convulsions  into  two 
classes — those  which  occur  in  adult  life  and  those 
which  occur  in  infancy  and  childhood.  In  adults 
convulsions  are  most  often  produced  by  epilepsy,  hys- 
teria, or  poisoning  by  some  substance  introduced  from 
without  or  developed  within  the  body.  Many  organic 
diseases  of  the  brain,  as  tumor,  hemorrhage,  inflamma- 
tion of  the  substance  of  the  brain  or  its  coverings,  and 
traumatic    injuries,    especially    those    which    produce 

'  Read  before  the  Thomas  J.  King  Medical  Club,  November  23, 
1899. 


July  14,  1900] 


MEDICAL    RECORD. 


51 


irritation  or  pressure  on  the  motor  centres,  are  frequent 
causes.  Cerebral  syphilis,  tetanus,  the  flushing  out 
of  a  pleuritic  cavity,  and  sudden  disturbances  of  the 
circulation,  as  sometimes  happens  in  syncope  or  in 
fatty  degeneration  of  the  heart,  are  also  well-recognized 
causes.  Reflex  irritation  from  other  organs,  as  the 
uterus,  the  nose,  or  the  eyes,  has  been  considered  by 
many  a  potent  factor  in  producing  convulsions  in  some 
persons;  but  its  influence  in  adults  is  denied  by 
others.  Malingering  is  an  occasional  cause  among 
prisoners  accused  of  crime  or  rogues  seeking  to  profit 
by  the  excitement  which  a  fit  in  a  public  place  pro- 
duces. And,  lastly,  it  occasionally  happens  in  the 
course  of  an  acute  rheumatic  or  malarial  attack  or 
certain  other  diseases,  but  here,  as  in  tetanus,  it  is  a 
question  if  it  is  not  due  to  the  same  poison  which  is 
responsible  for  the  primary  illness,  and  hence  should 
not  be  mentioned  as  a  separate  cause  but  included  in 
the  class  due  to  poisoning. 

Case  I. — Looking  back  at  least  twenty-five  years  I 
well  remember  the  first  case  of  general  convulsions  I 
ever  saw.  It  was  the  case  of  a  man  aged  about  twenty- 
five  years,  who  was  a  patient  at  the  county  almshouse, 
and  who  had  strayed  away  to  a  picnic  in  a  neighboring 
grove.  I  heard  his  initial  scream,  and  with  the  crowd 
hurried  to  the  place  where  he  lay.  He  was  then  in 
tonic  spasms,  his  face  turned  to  one  side,  his  mouth 
and  eyes  drawn  to  the  same  side,  his  arms  and  legs 
extended.  The  muscles  of  his  whole  body  were  rigid 
so  that  respiration  was  nearly  suspended,  and  as  a 
consequence  his  face  was  cyanosed.  Soon  he  slowly 
turned  his  face  to  the  opposite  side  and  clonic  tuitch- 
ings  of  the  muscles  of  his  face  and  eyelids  began, 
which  extended  to  the  limbs  and  body.  His  respira- 
tion was  irregular  and  froth  came  from  his  mouth,  but 
it  was  not  bloody.  After  a  little  the  twitching  of  the 
muscles  gradually  subsided,  and  in  about  ten  minutes 
he  sat  up  and  looked  around  in  a  dazed  and  bewil- 
dered manner.  Soon  after  he  got  up  and  slowly  made 
his  way  to  the  cottage  some  half-mile  distant. 

Here,  then,  was  a  typical  case  of  epilepsy.  How 
long  it  had  lasted  or  what  was  its  cause  were  alike  un- 
known to  me.  It  might  have  been  idiopathic;  that  is, 
it  might  have  occurred  without  assignable  cause,  and  it 
is  to  this  class  of  cases  I  would  restrict  the  word  epi- 
lepsy; or  it  might  have  been  due  to  one  of  the  other 
causes  I  have  enumerated.  Idiopathic  epilepsy  is 
perhaps  most  commonly  due  to  heredity  or  the  neurotic 
temperament,  in  which  one  form  of  nervous  disease 
appears  in  one  member  of  a  family  while  other  forms 
attack  other  members  of  the  family.  Sex  and  age  are 
also  important  factors,  the  greater  proportion  of  cases 
occurring  in  females  under  thirty  years  of  age.  So 
important  is  age  as  a  predisposing  factor  that  we  can 
lay  it  down  as  a  general  rule  to  which  there  are  few  if 
any  exceptions  that  "an  epilepsy  developing  after  the 
age  of  thirty-five  is  not  idiopathic  but  is  due  to  organic 
brain  disease,  the  abuse  of  alcohol,  reflex  irritation,  or 
other  cause,"  which  may  be  so  obscure  that  we  cannot 
discover  it.  Climate,  season,  race,  and  occupation 
may  also  have  determining  influences  as  tending  to 
enfeeble  the  general  stability  of  the  nervous  centres. 
But  these  are  practically  all  the  causes  of  idiopathic 
epilepsy,  as  now  recognized,  and  undoubtedly  true 
idiopathic  epilepsy  is  rarer  than  generally  believed. 
Every  case  of  convulsions  should  be  thoroughly  in- 
vestigated before  being  pronounced  epilepsy  of  idio- 
pathic origin,  as  such  a  diagnosis  amounts  to  practi- 
cally the  same  as  an  admission  of  ignorance. 

Case  II. — F.  B .  aged  about  thirty  years,  suffered 

a  fracture  of  the  skull  in  the  temporal  region  when 
only  two  or  three  years  old.  He  was  attended  by  a 
competent  surgeon  who  removed  several  pieces  of  bone, 
and  the  wound  healed  nicely.  Some  years  afterward 
he  began   having  convulsions,  whicii   became   so  fre- 


quent that  he  would  sometimes  have  six  or  eight  a 
day  for  a  week  or  more  at  a  time.  These  convulsions 
differed  in  no  way  from  those  described  in  the  first 
patient,  and  as  a  result  of  them  he  lost  his  mind  en- 
tirely and  also  became  partially  deaf.  Dr.  Hammond, 
of  New  York,  was  consulted,  but  refused  to  make  any 
operative  interference  on  the  ground  that  all  was  done 
for  him  at  the  time  of  the  injury  which  it  was  possible 
to  do,  and  that  the  point  of  irritation  was  probably 
inaccessible  to  the  knife.  The  man  remained  in  this 
way  until  his  death  some  four  or  five  years  ago. 

The  convulsions  in  this  case  were  evidently  due  to 
the  injury,  but  whether  the  irritation  was  caused  by  a 
spiculum  of  bone  which  was  overlooked  at  the  time  of 
the  operation,  or  by  inflammatory  thickening  of  the 
dura,  I  was  unable  to  ascertain,  as  an  autopsy  was 
denied  me.  I  am,  however,  inclined  to  the  latter  view 
on  account  of  the  time  which  followed  the  injury  be- 
fore the  convulsions  began. 

Injuries  to  the  head  causing  concussion  or  contusion 
of  the  brain  often  give  rise  to  convulsions,  as  in  the 
following  case : 

Case  III. — J.  M ,  aged  thirty-two  years,  weight 

one  hundred  and  ninety  pounds,  fell  a  distance  of 
about  twenty  feet  and  struck  on  his  head  and  shoulder. 
When  I  reached  him  he  was  sitting  up  supported  by 
his  companion,  but  did  not  know  any  one  and  could 
not  speak.  He  had  been  unconscious  for  a  short  time, 
but  would  then  look  up  when  spoken  to  sharply.  He 
was  taken  to  his  home  and  put  to  bed,  and  soon  after 
had  a  convulsion  which  was  followed  that  night  and 
the  next  day  by  several  others.  He  vomited  several 
times,  the  first  being  clear  blood,  and  had  a  sanious 
discharge  from  his  right  ear.  Within  a  few^  days  his 
right  eyelid  became  badly  ecchymosed.  I  do  not 
recollect  that  there  was  any  paralysis,  but  it  was  fully 
three  weeks  before  he  regained  his  consciousness  suffi- 
ciently to  be  able  to  tell  what  was  passing  around  him. 

The  next  cause  of  convulsions  which  I  shall  con- 
sider is  poisoning,  and  the  list  of  toxic  agents  which 
may  produce  convulsions  is  quite  large.  Thus,  we  all 
know  convulsions  may  be  caused  by  alcohol,  by  lead, 
by  strychnine,  by  arsenic,  by  mercury,  and  by  urea. 
But  there  are  many  other  poisonous  substances  which 
may  cause  convulsions  which  are  not  so  well  known 
but  which  we  are  liable  to  meet  with  at  any  time. 
Among  these  I  may  mention  tobacco,  aconite,  vera- 
trum  viride,  oxalic  acid,  and  tartar  emetic,  as  per- 
haps the  most  important.  I  have  already  mentioned 
malaria  and  rheumatism  as  sometimes  causing  con- 
vulsions, but  it  has  also  been  demonstrated  that  the 
poison  of  other  diseases,  as  pneumonia,  typhoid  fever, 
erysipelas,  scarlet  fever,  and  other  grave  diseases, 
especially  if  accompanied  by  excessive  vital  depres- 
sion, high  temperature,  or  marked  toxfemia,  may  also 
produce  them.  As  an  instance  of  convulsions  caused 
by  poisoning  by  an  unusual  drug  I  will  relate  the  fol- 
lowing : 

Case  IV. —  Mrs.  A.  B ,  mother  of  two  children, 

the  younger  two  or  three  years  old,  kept  an  almanac  at 
hand  for  ready  consultation,  and  her  peace  of  mind 
was  regulated  by  it.  She  discovered  one  day  that  she 
had  passed  the  time  for  her  menses  by  at  least  three 
days,  and  after  worrying  all  day  took  a  drachm  of  oil 
of  tansy  at  bed-time.  Within  half  an  hour  she  began 
having  severe  convulsions  which  were  continued  for 
at  least  an  hour,  during  which  time  she  must  have  had 
a  dozen  or  fifteen.  Most  of  these  were  severe  and  ac- 
companied by  frothing  at  the  mouth.  She  finally  re- 
covered, but  menstruation  was  not  established  until  a 
week  or  ten  days  afterward. 

The  diagnosis  of  toxic  convulsions  must  be  made 
from  the  history  of  the  case  and  those  special  features 
which  are  generally  present,  but  often  the  character  of 
the  attack  itself  will  greatly  aid  us.     Thus,  in  ursemia 


52 


MEDICAL    RECORD. 


[July  14,  1900 


the  convulsions  are  generally  preceded  by  headache, 
by  vomiting,  and  by  cedenia  of  the  face  and  eyelids; 
there  is  seldom  an  initial  scream;  defecation  and 
micturition  do  not  occur,  and  tonic  spasms  are  gen- 
erally if  not  always  absent.  In  addition  to  these  an 
examination  will  show  evidences  of  i<idney  disease, 
and  the  convulsions,  if  left  to  themselves,  are  apt  to 
be  repeated  several  times  within  an  hour.  Coma  or 
unconsciousness  supervenes  after  the  first  convulsion 
and  defies  all  efforts  to  arouse  the  patient.  In  tetanus 
the  spasms  are  developed  gradually  and  first  appear 
in  the  muscles  of  the  lower  jaw,  are  always  tonic,  and 
may  last  for  many  hours;  consciousness  is  preserved, 
although  obviously  talking  is  impossible.  Convul- 
sions due  to  alcoholism  are  usually  preceded  by  head- 
ache, vomiting,  and  excessive  tremor,  and  are  followed 
by  mental  derangement,  often  with  hallucinations, 
especially  of  terror.  The  convulsions  of  strychnine 
poisoning  take  the  form  of  opisthotonos  and  are  ex- 
cited by  any  noise  or  jar  of  the  bed;  clonic  spasms  of 
the  neck  and  extremities  are  also  present. 

Hysterical  convulsions  form  an  important  class  and 
are  frequently  met  with.  Generally  they  occur  in 
women  of  the  child-bearing  age,  but  are  not  confined 
exclusively  to  this  period  of  life  or  even  to  this  sex. 
Neurotic  and  emotional  people  are  more  prone  to  such 
attacks  than  others,  and  often  some  sudden  mental 
impression,  as  joy,  grief,  or  fear,  can  be  given  as  the 
cause.  The  following  case  is  typical,  although  more 
severe  than  many: 

Case  V. — G.  L ,  male,  aged  about  twenty-eight 

years.  I  was  called  to  see  this  patient  as  a  consult- 
ant and  arrived  a  short  time  before  the  attending  phy- 
sician. As  the  patient  was  then  having  convulsions  I 
was  hurried  to  his  room,  notwithstanding  my  expressed 
desire  to  await  my  colleague.  I  found  the  man  on  a 
bed  with  two  men  and  half  a  dozen  women  and  girls 
around  him  to  hold  him  from  throwing  himself  to  the 
floor.  His  hands  were  firmly  clinched  and  he  was 
trying  to  free  his  arms  from  his  attendants.  As  I  en- 
tered he  turned  and  looked  at  me  and  was  quiet  for  a 
moment,  but  soon  after  arched  his  back  in  opisthotonos 
and  while  in  that  position  threw  himself  violently  to 
one  side.  Respiration  was  irregular  and  his  face 
flushed  from  the  exertion  of  his  efforts,  but  not  cya- 
nosed.  After  the  convulsion  he  appeared  exhausted 
and  relaxed  all  his  muscles.  His  breathing  was  then 
rapid  and  shallow.-  They  told  me  that  before  I  arrived 
he  had  spoken  and  asked  to  be  fanned  ;  so  they  fanned 
him  in  the  intervals  between  the  convulsions,  and  he 
turned  his  face  toward  the  person  with  the  fan.  Soon 
the  rigidity  of  the  arms  returned  and  in  about  eight  or 
ten  minutes  he  had  another  convulsion.  I  watched 
him  through  one  of  these,  and  left  the  room  without 
speaking.  My  diagnosis  was  made,  but  I  refused  to 
disclose  it,  and  only  told  the  anxious  friends  he  would 
recover.  When  the  doctor  came  I  met  him  at  the  gate. 
He  had  seen  the  case  before  and  thought  it  suggested 
strychnine  poisoning;  and  later,  upon  learning  that 
they  had  had  a  party  at  the  house  the  night  before  at 
which  the  patient  had  eaten  of  ice-cream,  advanced  the 
idea  of  ptomain  poisoning  from  the  cream.  I  adhered 
to  my  original  diagnosis,  but  said  little  to  the  family, 
only  that  it  was  my  opinion  he  would  get  well,  which 
of  course  he  did  in  two  or  three  days.  Afterward  I 
learned  that  he  has  since  had  similar  attacks,  and  that 
in  every  case  they  followed  excitement  or  disappoint- 
ment, or  other  mental  emotions. 

Syncope  occasionally  produces  partial  or  general 
convulsions  which  are  known  as  cardiac  epilepsy. 
The  most  prominent  features,  aside  from  the  clonic 
spasms,  are  an  intense  coldness  and  pallor  of  the  sur- 
face, which  afterward  becomes  flushed,  and  a  greatly 
diminished  pulse  rate.  This  never  occurs  unless 
there  is  fatty  degeneration   or   other   disease   of    the 


heart  or  blood-vessels  which  interferes  with  the  proper 
nutrition  of  the  brain ;  and  hence  happens  most  often 
in  aged  people. 

Epilepsy  and  insanity  are  the  diseases  of  all  others 
which  are  simulated  with  the  object  of  escaping  punish- 
ment for  crime  or  gaining  sympathy.  Ordinarily,  the 
deception  can  be  easily  recognized,  as  the  malingerer 
is  apt  to  overdo  the  convulsive  feature,  while  he  omits 
or  cannot  simulate  certain  other  symptoms  which 
should  accompany  the  convulsion.  He  seldom  bites 
the  tongue  or  falls  so  as  to  hurt  himself.  The  corneal 
reflexes  react  normally,  the  pupils  respond  to  light,  the 
color  of  the  face  is  rarely  changed,  and  the  prick  of  a 
sharp  instrument  produces  evident  pain.  Yet  the 
malingerer,  by  study  and  determination,  may  so  school 
himself  as  to  imitate  nearly  all  the  symptoms  of  epi- 
lepsy with  some  degree  of  perfection.  Thus  the  cele- 
brated case  of  Clegg,  the  prince  of  malingerers,  may 
be  mentioned.  Clegg  was  known  in  street  parlance  as 
a  "dummy-chucker,"  and  his  business  was  to  travel 
the  streets  and  have  fits  wherever  he  could  get  a  crowd 
without  danger  of  arrest,  and  then  collect  what  alms 
was  offered  him  and  hurry  away,  while  an  accomplice 
picked  pocktts  among  the  spectators.  He  was  often 
arrested  on  various  charges,  but  so  well  could  he  simu- 
late epilepsy  that  he  deceived  many  prison  officials 
and  physicians,  and  repeatedly  escaped  punishment 
and  prison  duty  because  of  his  supposed  affliction.  By 
practice  he  was  able  to  imitate  the  clonic  and  tonic 
spasms  perfectly,  could  control  the  action  of  the  eye 
so  as  not  to  flinch  when  the  cornea  was  touched  with 
the  finger,  nor  show  any  feeling  when  pins  were  thrust 
into  his  flesh.  In  an  attack  he  fell  heavily,  often  in- 
juring himself,  bit  his  tongue  or  injured  his  gums  so 
that  blood  would  be  mixed  with  the  froth  which  came 
from  hjs  mouth,  and  held  his  breath  so  as  to  produce  a 
livid  countenance.  The  fraud  in  his  case  was  exposed 
by  the  facts  that  the  nails  were  not  livid,  the  rigidity  of 
the  muscles  could  be  easily  overcome,  the  sphincters 
were  not  relaxed,  the  fingers  were  not  closed  over  the 
thumb,  and  there  were  no  ecchymoses  or  extravasation 
to  indicate  recent  injury. 

In  infants  and  children  convulsions  partake  mostly 
of  the  same  general  features  as  in  idiopathic  epilepsy 
of  adults,  but  the  causes  are  not  the  same.  In  infants 
the  nervous  system  is  more  highly  developed  in  pro- 
portion to  the  other  organs  of  the  body  than  in  adults, 
and  hence  they  are  more  susceptible  to  disturbing 
impressions  of  these  centres.  Consequently,  reflex 
irritations  hold  a  higher  place  in  the  etiology  of  con- 
vulsions in  them  than  they  do  in  older  people;  and 
hysteria  and  intentional  deceit  cannot,  of  course,  be 
considered. 

Convulsions  which  occur  during  the  first  few  weeks 
of  life  are  generally  caused  by  injuries  received  at 
birth.  Obviously  injuries  to  the  brain  are  more  apt 
to  be  received  in  instrumental  deliveries,  in  breech 
presentations,  and  in  cases  of  difficult  labor  in  which 
the  head  has  been  subjected  to  compression  for  a  long 
time.  Just  what  these  injuries  are,  or  in  what  part  of 
the  brain  they  are  located,  it  would  be  diflficult  to  de- 
termine, but  they  are  probably  minute  extravasations 
in  various  parts  of  the  encephalon.  \A'e  know  that 
the  infantile  brain  is  poorly  protected  from  pressure 
and  that  consequently  it  must  be  more  tolerant  than 
in  the  adult;  otherwise  it  would  be  difficult  to  see  how 
any  child  escapes  death  at  birth. 

The  most  frequent  cause  of  infantile  convulsions  in 
reflex  irritation  from  some  disturbance  of  the  gastro- 
intestinal tract.  Thus,  difficult  dentition,  indigesti- 
ble food,  intestinal  parasites,  a  foreign  body,  or  a 
loaded  rectum  may  result  in  reflex  action  and  produce 
them.  We  all  know  how  common  they  are  as  a  com- 
plication in  the  summer  diarrhctas  of  young  children, 
and  that  they  generally  cease  when  the  bowel  is  flushed 


July  14,  1900] 


MEDICAL    RECORD. 


53 


its  whole  length.  Other  causes  of  irritation  which 
may  produce  them  are  severe  injuries  or  burns,  phi- 
mosis, retention  of  urine,  foreign  bodies  in  the  ear  or 
nose,  and  in  older  children,  according  to  Stevens,  in- 
sufficiency of  the  ocular  muscles. 

The  acute  infectious  diseases,  as  scarlet  fever, 
measles,  influenza,  mumps,  and  typhoid,  may  be 
ushered  in  by  convulsions,  and  it  is  asserted  by  some 
that  high  fever,  whatever  its  cause,  is  sufficient  to 
produce  convulsions  in  children  predisposed  to  them. 
i"he  various  toxic  agents  which  produce  convulsions 
in  adults  may  also  cause  them  in  children.  Rickets 
is  a  common  cause  among  city  infants  but  rare  in  the 
country,  where  rickets  is  seldom  met  with  ;  and  organic 
diseases  of  the  brain,  as  tumor  or  meningitis,  either 
tuberculous  or  not,  may  cause  them.  Acute  cerebral 
and  spinal  palsy  are  occasional  causes,  and  enlarge- 
ment of  the  thymus  gland  is  mentioned  by  Holt  as  a 
cause.  And  there  are  undoubtedly  some  cases  which 
occur  without  assignable  cause,  unless  we  call  them 
idiopathic  epilepsy,  but  such  cases  are  very  uncom- 
mon. Other  rare  causes  are  also  mentioned  by  authors, 
but  we  can  disregard  them  as  of  little  practical  impor- 
tance clinically,  and  their  treatment  differs  in  no  way 
from  those  here  mentioned. 

The  first  indication  to  be  met  in  a  case  of  infantile 
convulsions,  whatever  their  cause,  is  to  relieve  the 
muscular  spasms  and  afterward  to  prevent  their  recur- 
rence. To  do  this  the  child  should  be  placed  on  a 
hard  bed  and  left  undisturbed  as  much  as  possible. 
Chloroform  should  be  administered  by  inhala- 
tion and  chloral  by  rectal  injection.  Cold  should 
be  applied  to  the  head  and  heat  to  the  body.  It  is 
hardly  advisable  to  place  the  child  in  a  hot  bath  on 
account  of  the  disturbance  it  produces,  but  it  is  well 
to  substitute  a  mustard  pack  for  it.  As  soon  as  the 
immediate  indications  are  met  we  should  try  to  ascer- 
tain the  cause  of  the  convulsion,  and  if  possible  re- 
move it.  If  due  to  intestinal  irritation  calomel  should 
be  given  and  an  injection  administered  to  empty  the 
colon.  Difficult  dentition  calls  for  lancing  of  the 
gums;  high  fever  should  be  reduced  by  the  cold  bath 
or  pack,  and  rickets  treated  with  the  usual  remedies. 
In  urjemic  convulsions  from  kidney  disease  free  sweat- 
ing should  be  induced  by  the  hot  pack  or  vapor  bath, 
and  pilocarpine  given  combined  with  alcoholic  stimu- 
lants to  counteract  its  depressing  effects.  Saline 
cathartics  should  be  given  and  hot  poultices  applied 
over  the  kidneys.  As  nephritis  in  children  is  almost 
always  acute,  stimulating  diuretics  should  be  avoided 
as  tending  to  increase  the  congestion  and  inflammation 
of  the  kidneys;  but  in  older  children  the  free  drinking 
of  plain  or  feebly  alkaline  water  should  be  encouraged 
to  flush  out  the  system  without  causing  irritation  to 
the  diseased  organs.  Complications,  such  as  pneu- 
monia, pleurisy,  endocarditis,  and  dropsy  of  serous 
cavities,  should  be  watched  for  and  treated,  but  most 
cases  of  ursemia  in  children  result  fatally. 

In  adults  it  is  hardly  proper  to  institute  treatment 
before  making  a  diagnosis  as  to  the  cause  of  the  con- 
vulsions or  at  least  deciding  that  they  are  not  due  to 
hysteria  or  fraud.  Of  course  no  particular  harm  would 
come  from  giving  chloroform  in  these  cases,  but  it  is 
unnecessary,  as  they  tend  to  spontaneous  recovery  and 
are  not  attended  with  danger  to  life.  Uramic  con- 
vulsions and  those  due  to  strychnine  or  other  drugs 
should  have  chloroform,  and  efforts  should  be  made 
to  eliminate  the  poison.  Stimulating  diuretics  may 
be  employed,  as  the  Bright's  disease  of  adults  is  usu- 
ally chronic  in  nature  from  the  outset,  and  hence  there 
is  little  danger  of  increasing  the  inflammation  of  the 
kidneys.  Atropine  may  be  given  hypodermically  as 
a  spinal  depressant  in  strychnine  poisoning  and  those 
other  cases  due  to  irritation  of  the  spinal  centres. 
Hysteria  calls  for  nervines  and  offers  a  promising  field 


for  the  use  of  hypnotism  or  suggestion.  Idiopathic 
epilepsy  rarely  requires  treatment  during  the  stage  of 
convulsions,  but  should  have  large  doses  of  bromide 
of  potassium,  or  better  the  combined  bromides  of 
sodium,  potassium,  and  strontium,  in  the  intervals, 
with  arsenic  added  to  prevent  cutaneous  symptoms,  as 
they  must  be  continued  for  a  long  time.  Cardiac 
epilepsy  calls  for  stimulants  and  the  lowering  of  the 
head,  and  syphilitic  convulsions  require  iodide  of 
potassium. 

Convulsions  which  can  be  traced  to  tumor  or  former 
injury  of  the  head  siiould  usually  be  treated  by  opera- 
tion. Trephining  of  the  skull  and  the  removal  of 
thickened  dura,  spicula  of  bone,  blood  clots,  or  foreign 
growths  have  added  lustre  to  modern  surgery  and  cured 
many  otherwise  hopeless  cases  of  convulsions.  And 
in  all  cases  of  head  injuries,  even  i^f  apparently  trivial, 
we  should  remember  the  great  danger  of  convulsions 
as  a  late  sequela. 


Abortive  Pneumonitis — G.  Pieraccini  gives  this 
name  to  the  variety  of  pneumonia  which  lasts  less 
than  four  days,  its  symptoms  being  otherwise  the  same 
as  those  of  the  usual  fibrinous  pneumonia.  He  reports  a 
case.  Jaccoud  believes  that  these  cases  are  not  rare. 
The  trouble  may  easily  be  overlooked  because  of  its 
rapid  course,  and  because  it  is  often  circumscribed. 
Leube  saw  two  cases  that  lasted  only  one  day.  In  the 
author's  case,  the  finding  of  capsulated  lanceolate  diplo- 
cocci  in  the  sputum  and  in  the  blood,  the  injection  of 
which  in  a  guinea-pig  caused  its  death  from  sep- 
ticaemia, settled  the  diagnosis. —  Lo  Sperhnentale,  No. 
2,  1900. 

On  Some  Diagnostic  DiflBculties  Associated  with 
Dilatation  of  the  Right  Ventricle. — J.  Stacey  Wil- 
son draws  attention  to  the  following  signs  of  diagnos- 
tic value:  (a)  The  character  of  the  murmur:  it  is 
apt  to  be  softer  and  more  blowing  in  tricuspid  regurgi- 
tation. (/')  The  nature  of  the  vessel  up  which  the 
murmur  is  conducted.  The  character  of  the  pulsation 
is  often  a  useful  guide,  being  weaker  and  more  flutter- 
ing in  the  veins,  stronger  and  more  even  in  the  arte- 
ries. Also  the  pulsating  parts  of  the  vessel  can  often 
be  felt  to  come  to  an  end  suddenly  in  the  case  of  a 
vein,  (c)  The  relative  loudness  of  the  murmur  in  the 
neck  as  compared  with  its  loudness  in  the  second 
right  interspace  may  prove  of  service  for  diagnosis. 
In  the  case  of  the  aorta,  the  loudness  in  the  neck  is 
always  equal  or  nearly  equal  to  its  loudness  over  the 
second  rib  or  interspace.  In  the  case  of  murmur  of 
tricuspid  origin,  if  there  is  free  regurgitation  up  the 
veins,  the  murmur  may  be  as  well  conducted  as  the 
aortic,  but  as  a  rule  it  is  not,  and  the  conduction  is 
not  loud.  (^)  Another  important  sign  is  the  relation- 
ship between  the  loudness  of  the  first  sound,  and  the 
murmur  as  heard  in  the  arteries  of  the  neck.  If  the 
first  sound  of  the  heart  can  be  heard  over  the  arteries 
of  the  neck,  while  the  murmur  is  heard  faintly  or  not 
at  all,  it  is  strong  evidence  against  the  murmur  being 
of  aortic  origin. —  The  Birmitigham  Medical  Review, 
June,  1900. 

The  Formation  of  a  Circumscribed  Intra-Dural 
Abscess  at  the  Site  of  the  Saccus  Endolymphati- 
cus — Jobson  Home  says  that  when  pus  is  pent  up  in 
the  labyrinth,  it  follows  the  line  of  least  resistance 
in  endeavoring  to  escape  into  the  cranial  cavity.  One 
route  is  along  the  aqueductus  vestibuli  to  a  fissure  on 
the  posterior  aspect  of  the  petrous  bone.  Through 
this  fissure  the  prolongation  of  the  membranous  laby- 
rinth originally  passes.  This  process,  known  as  the 
saccus  endolymphaticus,  may  remain  in  adult  life  suffi- 
ciently patent   to  allow  the  passage  of  pus.     Home 


54 


MEDICAL    RECORD. 


[July  14,  1900 


describes  two  cases  of  circumscribed  abscesses  at  this 
point.  Such  abscesses  he  regards  as  within  the  reach 
of  surgery,  and  this  gives  a  practical  bearing  to  the 
recognition  of  their  possible  occurrence  in  cases  with 
symptoms  pointing  to  intra-labyrinthine  suppuration. 
As  a  point  of  interest,  Home  states  his  belief  that  the 
pus  is  not  contained  within  the  saccus  itself,  but  be- 
tween the  two  layers  of  dura  mater  which  originally 
contained  the  sac. — Journal oj  Laryngology,  June,  1900. 

Carbonic  Acid  Gas  in  Nasal  Affection. — Joal 
highly  indorses  this  agent  and  figures  a  special  ap- 
paratus which  renders  its  application  easy.  The  most 
beneficial  results  have  been  attained  in  hyperaesthetic 
rhinitis.  The  ordinary  carbonic  siphon  offers  an 
easy  means  of  applying  the  gas. — Revue  Jiebdomadaire 
de  Laryngologie,  etc.,  May  12,  1900. 

Persistent  Adenoids  in  a  Woman  Aged  Forty- 
Seven  Years. — E.  ¥.  Potter  reports  the  case,  the 
symptoms  in  which  were  impaired  hearing  and  diffi- 
culty of  breathing  through  the  nose.  Examination 
showed  the  post-nasal  space  to  be  occupied  by  a  con- 
siderable mass  which  obscured  the  upper  half  of  the 
septum  and  extended  across  the  vault  from  tube  to 
tube.  The  growths  were  removed  with  forceps  under 
an  anaesthetic,  and  proved  to  be  adenoid  tissue  which 
had  undergone  inflammatory  changes.  Nothing  of  a 
sarcomatous  nature  appeared  under  the  microscope. 
The  patient's  hearing  improved  greatly  within  two 
weeks  after  the  operation. — Journal  oJ  Laryngology, 
June,  1900. 

Cystic  Degeneration  of  Both  Kidneys.  —  Fin 
Holnisen  reports  a  case  of  this  sort  observed  in  an 
infant  delivered  at  term  by  craniotomy.  Both  kidneys 
were  found  enlarged  and  filled  with  numerous  small 
cysts  separated  by  thick  layers  of  connective  tissue. 
No  normal  renal  tissue  could  be  found  by  either  ma- 
croscopical  or  microscopical  examination.  Most  of 
the  glomeruli  were  in  a  state  of  arrested  development. 
The  connective  tissue  was  most  abundant  near  the  hi- 
lum  around  the  calices,  which  were  partially  oblit- 
erated. The  mucous  membrane  of  the  calices  and  of 
the  renal  pelvis  was  atrophied.  The  ureters  were 
contracted,  but  were  not  obliterated. — Norsk  Magazin 
for  Lagevidenskahen,  April,  1900. 

The    Thyroid    Gland    in    Infective    Diseases — 

Odoacre  Torri,  from  the  result  of  experimentation, 
concludes  that  there  is  hypersecretion  of  colloid  sub- 
stances in  the  gland,  in  acute  or  chronic  infective  dis- 
eases, as  well  as  marked  epithelial  proliferation  and 
an  abundant  neoformation  of  glandular  tissue.  Inter- 
stitial inflammatory  processes,  such  as  abscesses  and 
tubercles,  are  rarely  met  with  in  the  gland.  The  col- 
loid substance  has  the  property  of  destroying  micro- 
organisms. The  epithelial  proliferation  and  the 
hypersecretion  of  colloid  substances  are  due  to  a  toxic 
product  of  the  infective  process,  perhaps  caused  by 
destruction  of  the  micro-organisms  by  colloid  sub- 
stance, or  brought  to  the  gland  by  the  circulating 
blood. — II  Policlinico,  May  15,  1900. 

The  Koplik  Sign  in  Measles IC.  Manasse  states 

that  in  three  cases  in  which  he  could  determine  the 
presence  of  the  peculiar  eruption  described  by  Kop- 
lik, measles  followed  in  the  course  of  twenty-four 
hours;  in  one  case  in  which  it  was  present,  no  exan- 
them  followed,  while  two  cases  of  undoubted  measles 
did  not  present  the  sign  at  all.  The  sign  in  the  latter 
cases  was  as  typical  in  appearance  as  in  the  first 
group.  Manasse  is  therefore  of  tiie  opinion  that,  while 
the  Koplik  spots  are  frequently  valuable  as  a  forerun- 
ner of  measles,  they  cannot  always  be  depended  upon 
nor  are  they  pathognomonic. — Miinchencr  medicinische 
Wochenschrijt,  June  5,  1900. 


A  Case  of  Cured  Tuberculous  Cerebro-Spinal 
Meningitis — M.  Henkel  reports  the  case  of  a  child 
aged  ten  years  (male),  who  presented  the  symptoms  of 
this  affection.  Some  of  the  spinal  fluid  was  with- 
drawn by  puncture  and  gave  positive  evidence  of  the 
presence  of  tubercle  bacilli.  The  case  ran  a  long 
course,  but  finally  recovery  took  place.  The  only 
remedy  given  internally  was  calomel.  In  addition, 
daily  baths  at  28°  R.  were  given  for  ten  minutes,  the 
water  cooling  to  24^  R. — Aliinchoter  medicinische  Wo- 
clwnschrijt,  June  5,  1900. 

An  Overlooked  Cause  of  Pulmonary  Lesion  Sug- 
gesting  at   the  Outset   Tuberculosis P.  de  c:ham- 

peaux  records  the  case  of  man  who  came  under  obser- 
vation with  all  the  symptoms  of  initial  pulmonary 
tuberculosis.  After  he  had  been  watched  for  some 
time,  the  presence  of  a  small  laryngeal  polyp  was 
made  out.  Removal  was  somewhat  difficult,  but  after 
the  tumor  was  finally  disposed  of  all  the  pulmonary 
symptoms  abated  and  the  patient  made  a  good  recov- 
ery.— Revue  Hehdomadaire  de  Laryngologie,  etc..  No.  14, 
1900. 

The  Surgical  Treatment  of  Primary  Renal  Tu- 
berculosis, with  a  Consideration  of  the  Results 
Obtained  by  Operation. — Otto  G.  Ramsay  has  col- 
lected the  majority  of  the  reported  cases  of  operation 
and  tabulated  them.  The  following  conclusions  seem 
justified  from  the  study,  both  of  the  individual  cases 
and  from  the  statistics  which  were  gathered:  (i) 
That  in  renal  tuberculosis  some  form  of  surgical  treat- 
ment is  always  indicated;  (2)  that  this  surgical  treat- 
ment may  have  a  palliative  or  curative  effect  in  view, 
depending  upon  the  condition  of  the  patient  and  the  ex- 
tent of  the  disease;  (3)  that  nephrotomy  as  a  palliative 
operation  for  the  immediate  relief  of  dangerous  symp- 
toms is  most  valuaMe,  and  that  it  does  not  preclude  a 
later  nephrectomy;  (4)  that  resection  of  the  diseased 
part  of  the  kidney  is  contraindicated  in  every  case  of 
renal  tuberculosis;  (5)  that  nephrectomy  or  nephro- 
ureterectomy  is  indicated  in  every  case  in  which  tuber- 
culosis has  not  developed  in  other  organs,  or  when  there 
is  no  fatal  disease  of  other  organs;  (6)  that  tubercu- 
losis of  the  bladder  or  a  small  focus  of  tuberculosis 
in  one  lung  are  not  considered  contraindications  to 
nephrectomy ;  (7 )  that  primary  nephrectomy  or  nephro- 
ureterectomy,  when  performed  in  suitable  cases,  has 
been  followed  by  final  cure  in  fifty-six  per  cent,  of  the 
cases  operated  on;  (8)  that  with  the  present  advances 
in  the  methods  of  examination  and  in  the  technique 
of  operations,  the  percentage  of  final  cures  should  be 
materially  increased. — Annals  oJ  Gyncecology  and  Pe- 
diatry, June,  igoo. 

Pelvic  Pain  from  Impacted  Ureteral  Calculi. — 
Septimus  Sunderland  believes  that  many  cases  of  per- 
sistent pelvic  pain  are  caused  by  a  stone  in  one  or  the 
other  ureter,  although  the  pain  is  assigned  to  uterine 
or  ovarian  trouble  or  perhaps  to  some  neurosis  or  hys- 
teria. If  the  pain  is  on  the  right  side,  the  appendix 
may  be  suspected.  Diagnosis  may  be  made  by  -v-ray, 
palpation  of  abdominal  parietes,  palpation  of  the  ure- 
ters, and  the  inspection  of  the  orifices  of  the  ureters 
through  the  cystoscope.  Finally  the  ureters  may  be 
sounded  through  the  bladder.  The  medical  treatment 
is  the  same  as  for  renal  stone.  As  to  su;'gical  meas- 
ures, if  the  stone  projects  into  the  bladder  from  the 
orifice  of  the  ureter  it  must  be  removed  through  the 
bladder.  Fenwick  teaches  that  a  stone  lodged  in  the 
lower  part  of  the  ureter  within  the  last  two  inches  will 
sometimes  set  up  symptoms  precisely  like  those  of 
stone  in  the  bladder,  that  is  to  say,  bladder  irritation 
and  spasm.  If  the  stone  can  be  detected  by  bimanual 
vaginal  exainination  in  the  lower  three  inches  of  the 
ureter,  but  does  not  project  into  the  bladder,  it  can  be 


July  14,  1900] 


MEDICAL    RECORD. 


55 


safely  extracted  by  incising  thie  roof  of  tiie  vagina  in 
the  female.  If  the  stone  is  located  at  or  aboi'.t  the 
pelvic  brim,  Fenwick  recommends  the  abdominal  in- 
cision used  for  ligature  of  the  common  iliac  artery. 
The  peritoneum  having  been  raised,  the  lower  end  of 
the  ureter  is  reached  extra-peritoneally.  For  stone  in 
the  upper  third  of  the  ureter,  the  ordinary  lumbar 
renal  incision  is  indicated. — Alcdical  Press  and  Circu- 
lar, May  30,  1900. 

Concealed  Tuberculosis  of  the  Tonsils — F.  Baup 

has  repeated  the  experiments  so  frequently  made  by 
various  observers  during  the  last  few  years,  finding 
tuberculosis  present  only  once  in  forty-eight  cases. 
He  believes  that  we  may  distinguish  three  forms  of 
this  condition — a  common  form  described  by  most  au- 
thors, characterized  in  a  general  way  by  isolated  or 
grouped  tubercles  more  or  less  caseous  and  sur- 
rounded by  a  zone  of  lymphoid  tissue  which  is  but 
little  changed  ;  an  indefinite  infiltration  but  one  show- 
ing without  question  the  presence  of  the  bacillus;  and 
possibly  a  sclerotic  form  which  represents  a  step  tow- 
ard repair.  Baup  discusses  also  the  relation  of  this 
form  of  tuberculosis  to  adenopathy,  to  pulmonary  tu- 
berculosis, and  to  tuberculous  meningitis. — Aniialcs 
des  Maladies  de  V Oreille,  du  Larynx,  etc..  May,  1900. 

Splenic  Hypermegaly  with   Hepatic  Cirrhosis 

Professor  Cardarelli  reports  the  case  of  a  man  aged 
thirty-three  years,  suffering  from  anaemia  and  weak- 
ness. The  abdomen  was  ascitic  and  tense,  without 
oedema  of  the  lower  limbs.  The  spleen  was  notably 
enlarged,  the  liver  markedly  reduced.  The  urine  was 
scanty,  saffron  colored,  rich  in  uro-erythrin.  The  au- 
thor holds  that  the  affection  should  come  under  the 
head  of  hepatitis  of  splenic  origin.  He  also  believes 
that  in  cases  of  chronic  and  incurable  splenic  tumors, 
when  the  spleen  not  only  does  not  perform  its  func- 
tions properly  but  threatens  infection  to  other  organs, 
we  should. not  hesitate  to  perform  splenectomy. — Ke- 
vista  Critica  di  Clinica  Aledica,  May  5,  1900. 

Hay  Fever  ;  its  Preventive  Treatment W.   C. 

Hollopeter  is  a  firm  believer  in  the  local  origin  of 
this  disease.  He  removes  polyps,  hypertrophied  tur- 
binates, etc.,  straightens  deviated  septa,  and  thor- 
oughly irrigates  the  nose  and  naso-pharynx  with  a 
warm  Dobell  solution.  The  whole  mucosa  is  then 
brushed  with  cotton  carrying  a  saturated  solution  of 
boric  acid.  Suprarenal  extract  may  be  added  to  a 
boric-acid  solution  and  the  whole  used  in  spray.  Im- 
mediately after  the  foregoing,  an  oily  covering  is  ap- 
plied. The  one  preferred  by  the  author  has  for  its 
base  liquid  petroleum,  and  contains  in  solution  cam- 
phor, menthol,  and  palmetto  oil.  Finally,  after  the 
treatment  is  finished,  the  patient  is  made  to  wait 
quietly  a  few  minutes  before  going  out  into  the  air. — 
International  Medical  Magazine,  June,  1900. 

Primary  Epithelioma  of  the  Tonsil. — The  patient 
of  J.  M.  IngersoU  was  an  Irishman  aged  forty-two 
years,  whose  right  tonsil  began  to  enlarge  slowly  with- 
out apparent  cause.  Twice  the  enlargement  was  am- 
putated with  a  tonsillotome  before  Dr.  IngersoU  saw 
the  case,  which  was  thirteen  weeks  after  the  swelling 
first  became  apparent.  Pain  had  now  become  very 
severe.  The  tonsil  was  covered  by  a  fairly  firm,  irreg- 
ular, fungoid  mass,  projecting  out  about  2  cm.  beyond 
the  anterior  pillar.  The  whole  surface  presented  an 
uneven,  cauliflower-like  appearance  and  was  covered 
by  a  muco-purulent  secretion.  The  mass  extended  up- 
ward on  to  the  soft  palate,  involving  both  the  anterior 
and  posterior  pillars;  it  also  followed  the  anterior  pillar 
downward  and  extended  on  to  the  tongue;  posteriorly 
the  growth  extended  along  the  posterior  pillar  down- 
ward to  its  attachment  to  the  pharyngeal  wall,  but  the 


wall  itself  was  not  involved.  The  surrounding  tissue 
was  inflamed  and  infiltrated.  The  lymphatic  glands 
at  the  angle  of  the  jaw,  on  the  right  side,  were  in- 
volved. Operation  was  refused,  and  death  followed  in 
a  short  time. —  The  Laryngoscope,  June,  1900. 

When   to  Operate   in  Appendicitis,  and  Why.— 

John  B.  Murphy  belie\es  with  most  surgeons  that  we 
are  unable  to  state  in  the  first  twenty-four  hours  what 
the  course  of  a  case  is  going  to  be.  He  believes  that 
every  honest  man  admits  that  the  mortality  of  appen- 
dicitis is  greater  than  ten  per  cent.  He  believes  that 
every  competent  surgeon  thinks  that  he  can  operate  on 
a  case  of  appendicitis,  when  the  disease  is  still  con- 
fined to  the  wall  of  the  appendix,  with  a  mortality  of 
two  per  cent,  or  less.  Therefore  he  concludes  tliat  we 
are  not  justified  in  holding  a  single  case  of  appendi- 
citis beyond  the  first  twenty-four  hours  after  the  diag- 
nosis is  made,  and  that  in  an  enormous  percentage  of 
cases  the  diagnosis  can  be  made  as  absolutely  in  the 
first  twenty-four  hours  as  it  can  at  any  other  time. — 
Jnternational  Journal  oj  Surgery,  June,  1900. 

Surgical  Treatment  of  Chronic  Empyema.— 
Francis  Reder  says  that  an  empyema  should  never 
be  allowed  to  become  old  if  it  can  be  avoided;  after 
an  expiration  of  six  weeks  an  accumulation  of  pus  in 
the  pleural  cavity  may  be  looked  upon  as  chronic. 
The  pathological  conditions  of  chronic  empyemata  re- 
quire heroic  measures  on  the  part  of  the  surgeon  to  stay 
their  progress.  Even  weak  patients  bear  well  an  ex- 
tensive resection  of  the  ribs  when  skilfully  and  dex- 
terously performed.  The  author  describes  in  detail 
the  operation  for  a  total  empyema.  The  convalescence 
is  slow  and  protracted.  It  is  during  this  period  that 
great  good  can  be  accomplished  by  the  various  forms 
of  graduated  exercise  and  respiratory  gymnastics  in- 
telligently practised. — International  Journal  oj  Surgery, 
June,  1900. 

Enteroptosis  with  Factitious  Urticaria G.  Gor- 
don Campbell  relates  a  case  in  which,  though  there 
was  marked  enteroptosis,  the  patient  sought  relief  only 
for  red  blotches  which  followed  any  slight  stimulation 
of  the  skin.  Itching  had  begun  three  years  before, 
after  childbirth.  It  is  relieved  by  the  warmth  of  the 
bed.  Stinging  and  burning  accompany  the  outbreak 
of  red  blotches  upon  washing  the  face,  etc.  Emo- 
tional blushing  comes  out  in  similar  scattered  patches. 
Factitious  urticaria  is  brought  out  by  drawing  a  blunt 
pointed  instrument  over  the  back.  This  is  shown  in 
a  photograph.  In  a  second  picture  is  illustrated  the 
enteroptosis.  There  is  deformity  at  the  waist  from 
tight  lacing.  A  rounded  prominence  is  seen  in  the 
lower  abdomen  resembling  pregnancy  in  the  fourth  or 
fifth  month.  The  right  kidney  can  be  felt  an  inch 
below  the  level  of  tlie  umbilicus  and  midway  between 
it  and  the  crest  of  the  ilium,  while  what  is  presumably 
the  left  kidney  can  be  felt  at  about  the  level  of  the 
umbilicus.  An  abdominal  supporter  gives  a  feeling 
of  strength  and  relief.  It  is  believed  that  the  enterop- 
tosis bears  a  causal  relation  to  the  erythema  and  fac- 
titious urticaria. — Alontreal  I^Iedical Journal,  June,  1900. 

Some  Cases  of  Relapse  in  Diphtheria. — Carlo 
Comba  considers  that  the  causes  of  relapses  are  two- 
fold. In  the  first  place  there  may  be  a  loss  of  the 
immunity  acquired  in  the  first  attack.  The  exact  na- 
ture of  the  immunity  is  not  yet  known,  but  Escherich 
and  Klemensiewicz  have  shown  that  the  blood  serum 
of  persons  who  had  just  had  a  diphtheritic  attack  has 
the  power  of  attenuating  and  even  of  neutralizing  the 
diphtheritic  toxin.  How  this  natural  or  acquired  im- 
munity is  lost  is  not  yet  understood;  probably,  how- 
ever, by  the  intervention  of  other  infective  diseases. 
In  the  second  place,  certain  local  conditions  are  favor- 


56 


MEDICAL   RECORD. 


[July  14,  1900 


able  to  the  occurrence  of  diphtheria  and  its  relapses — 
such,  for  instance,  as  repeated  intiammatioiis  of  the 
phar^'ngeal  mucosa,  hypertrophy  of  the  tonsil,  etc., 
which  would  tend  to  reduce  the  power  of  resistance 
against  infective  germs. — Rivista  Critica  di  Clinica 
Medica,  June  2,  1900. 

A  Case  of  Acquired  Stenosis  of  the  Pulmonary 
Artery. — A.  Kasem-Beck  is  led  by  the  great  rarity  of 
a  stenosis  of  the  pulmonary  artery  coming  on  in  the 
later  years  of  life,  and  the  marked  difficulties  of  an 
exact  diagnosis,  to  publish  a  case.  The  patient  was 
a  laborer  fifty  years  old,  who  showed  compensatory 
disturbances  of  the  heart,  oedema,  ascites,  cyanosis, 
and  expiratory  dyspnoea.  There  were  bilateral  ..ydro- 
thorax,  hydropericardium,  and  dilatation  of  the  right 
ventricle.  The  physical  signs  are  given  and  the  few 
undoubted  cases  in  literature  are  referred  to.  The 
result  of  the  autopsy  is  appended. —  Centralhlalt  Ji'ir 
iimere  Median,  June  9,  1900. 

Mucous  Disease. — Philip  F.  Farbour  defines  this 
disease  as  being  characterized  by  an  irregularly  occur- 
ring profuse  discharge  of  mucus  from  the  intestinal 
tract,  accompanied  by  more  or  less  marked  nutritional 
disorder.  In  its  treatment  the  inherited  gouty  or  uric- 
acid  tendencies  must  be  counteracted.  Food  should 
be  simple  and  easily  digested;  fats  and  carbohydrates 
should  not  be  taken.  Hygienic  surroundings  should 
be  of  the  best.  Cold  sponging  with  brisk  rubbing  is 
of  value.  Bitter  tonics  are  used  to  relieve  the  patient 
of  the  accumulations  of  mucus.  Bismuth  has  a  seda- 
tive and  mildly  astringent  action.  A  combination  of 
hydrastis  and  sanguinaria  will  be  found  to  have  a  de- 
cidedly curative  influence.  Copper  arsenite  has  a  de- 
cidedly antiseptic  action. —  Virginia  Medical  Semi- 
Monihly,  June  8,  1900. 

Hysteria  in  the  Child. — Ruggiero  Lambranzi  reports 
two  cases.  The  first  was  that  of  a  boy  aged  nine 
years,  who  at  times  had  a  spasm  of  the  hand  which 
would  close  the  fingers  so  tightly  that  they  could  be 
opened  only  by  force.  The  symptoms  did  not  point  to 
organic  lesion.  The  author  placed  a  bit  of  money  in 
the  child's  hand,  and  told  him  that  if  he  succeeded  in 
extending  his  fingers  without  the  aid  of  his  other  hand, 
he  might  keep  the  pennies.  The  treatment,  which  the 
author  calls  a  new  kind  of  metallotherapy,  was  suc- 
cessful. The  second  case  was  one  of  blepharospasm 
in  a  little  girl  aged  eleven  years,  the  attacks  lasting 
about  three  days,  and  being  accompanied  by  amblyo- 
pia and  headache.  A  visit  to  the  clinic  and  the 
manoeuvres  of  the  objective  examination  caused  a  ces- 
sation of  the  trouble. — La  Riforiiia  Medica,  May  30 
and  31,  1900. 

The  Medical  Treatment  of  Gall  Stones. — Edward 
S.  Stevens  believes  that  it  is  frequently  difficult  and 
often  impossible  to  make  a  positive  diagnosis  of  gall 
stones.  He  says  that  there  is  no  known  medicine  by 
means  of  which  a  solution  of  gall  stones  can  be  effected 
by  any  of  the  ordinary  means  of  administration.  The 
introduction  of  a  cannula  into  the  gall  bladder  for  the 
purpose  of  sounding  for  stones,  introducing  solvent 
remedies,  or  withdrawing  fluids,  is  dangerous  when 
compared  with  the  amount  of  good  likely  to  be  accom- 
plished, and  should  not  be  practised.  The  practice  of 
attempting  to  empty  the  gall  bladder  by  massage  is 
dangerous.  There  is  but  one  safe  and  radical  cure 
for  gall  stones,  and  that  is  by  cholecystotomy  or  some 
similar  surgical  operation. —  Virginia  Medical  Semi- 
Monthly,  June  8,  1900. 

Symptomatic  Diagnosis  of  Valvular  Obstipation. 

— Thomas  C.  Martin  says  that  valvular  obstruction 
below  the  recto-sigmoidal  juncture  is  characterized  by 


straining  at  stool  for  the  passage  of  solid  feeces.  Ob- 
struction at  the  recto-sigmoidal  juncture  is  character- 
ized by  long  intervals  between  the  acts  of  defeca- 
tion, by  an  occasional  passage  of  a  quantity  of  fa;ces 
without  much  straining,  and  by  tenderness  and  a  sense 
of  fulness  in  the  left  iliac  fossa  and  lower  abdominal 
regions.  Valves  sometimes  interlock  and  form  an  al- 
most impassable  barrier  to  the  descent  of  the  fffices. 
Hypertrophy  of  the  rectal  valve  is  characterized  by  the 
almost  sudden  establishment  of  obstipation.  The  con- 
dition is  initiated  by  a  sense  of  gentle  aching  and 
moderate  heat  in  the  sacral  region,  by  aching  down  the 
thighs,  and  by  discharges  of  a  small  amount  of  viscid 
mucus.  Fibrosis  of  the  rectal  valve  is  characterized 
by  a  very  gradual  development  of  the  obstipation. 
Valvotomy  cures. —  Virginia  Medical  Semi-Monthly, 
June  8,  1900. 

Acute  Osteomyelitis. — E.  Koch  says  that  within 
the  past  ten  years  we  have  come  to  look  upon  the 
etiology,  frequency,  etc.,  of  acute  osteomyelitis  in  a 
new  light.  Many  former  confusing  instances  of  joint 
affection  would  now  be  referred  to  this  condition. 
Small  nodes  on  the  ribs  can  cause  severe  empyema  of 
the  pleural  cavity,  and  acuted  intracranial  abscesses 
by  the  severity  of  their  symptoms  mask  a  primary 
osteomyelitis  of  the  skull.  *An  instance  of  osteomye- 
litis of  the  sternum  in  a  man  thirty  years  old  is  re- 
corded, in  which  the  symptoms  suggested  actinomyco- 
sis of  the  lungs  or  tuberculous  bone  disease.  There 
was  here  present,  as  in  the  five  recorded  instances  in 
literature,  a  pure  primary  osteomyelitis  of  the  sternum, 
but  the  other  patients  were  nearer  the  typical  age. 
The  patient  was  successfully  operated  upon.  In  view 
of  the  possibility  of  mediastinitis  a  primary  free  tre- 
panning of  the  sternum  and  early  removal  of  the  en- 
tire diseased  bone  would  be  the  most  rational  form 
of  treatment. — Aliinchener  medicinische  Wochenschrift, 
June  19,  1900. 

Infantile  Amaurotic  Family  Idiocy J.  H.  Clai- 
borne, Jr.,  gives  the  report  of  a  case  and  its  autopsy, 
reviewing  the  original  observations  of  Waren  Tay 
upon  changes  at  the  macula  lutea,  and  subsequent 
descriptions  of  the  same  ophthalmoscopic  picture  by 
other  observers.  The  writer  has  had  five  cases  under 
his  notice.  His  observations  agree  with  those  of 
Sachs,  who  in  1898  reviewed  the  subject  and  tabu- 
lated twenty-nine  instances.  The  case  in  question 
was  that  of  a  female  infant  of  eleven  months.  There 
was  double  ophthalmoplegia;  the  left  eye  was  farther 
out  and  the  left  lid  lower  than  the  right.  The  father 
had  phthisis.  Great  somnolence  developed,  and  the 
child  could  not  hold  up  its  head  or  sit  up  straight. 
At  the  macular  region  in  each  eye  there  was  a  marked 
white  area  with  the  macula  lutea  in  the  centre  like  a 
cherry-red  point.  At  the  autopsy  there  was  found  a 
tuberculous  tumor  of  the  corpora  quadrigemina  the 
size  of  a  hickory  nut,  with  tuberculous  deposits  in  the 
lungs,  bronchial  and  mesenteric  glands,  liver,  spleen, 
and  kidneys.  These  children  are  born  apparently 
healthy  and  remain  so  for  several  months;  there  are 
then  sluggishness  and  somnolence,  with  irregular  move- 
ments. The  eye  picture  resembles  that  seen  in  em- 
bolism of  the  central  retinal  artery.  The  optic  disc 
is  at  first  normal  and  later  shows  complete  atrophy. 
Death  is  invariable,  usually  before  the  end  of  the  sec- 
ond year.  The  majority  of  the  parents  have  Hebraic 
blood,  a  large  number  being  of  Polish-Hebraic  origin. 
It  seems  reasonable  to  regard  the  changes  in  the  ner- 
vous system  as  due  to  arrest  of  development.  Tuber- 
culosis may  be  a  probable  general  cause.  The  ques- 
tion is  raised  whether  the  symptoms  are  not  those  of 
a  disease  not  yet  recognized,  rather  than  constituting 
a  definite  entity. — Pediatrics,  July  i,  1900. 


July  14,  1900] 


MEDICAL   RECORD. 


57 


Medical  Record: 

A    Weekly  Journal  of  Medicine  and  Surgery. 


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

Publishers 
WM.  WOOD  &.  CO.,  51    Fifth  Avenue. 

New  York,  July  14,  1900. 


YELLOW      FEVER      IN      MEXICO       AND     IN 
CENTRAL    AND    SOUTH    AMERICA. 

An  exhaustive  account  was  published  in  "Public 
Health  Reports,"  June  15th,  of  the  sanitary  condition 
of  Central  American  and  Colombian  towns  with 
special  reference  to  their  geographical  position  and 
the  possible  routes  by  which  yellow  fever  is  conveyed 
from  one  to  another,  and  the  dangerous  lines  of  com- 
munication with  the  United  States.  The  fact  is 
pointed  out  that  the  history  of  yellow  fever  can  be 
traced  back  to  many  years  before  the  invasion  by 
Cortez,  and  that  since  the  first  settlement  by  the 
Spanish  the  fever  situation  has  apparently  undergone 
no  improvement.  Vera  Cruz — which  has  been  since 
its  foundation  a  hot-bed  of  the  disease,  and  which 
last  year  had  a  mortality  rate  of  six  hundred  and 
seventy  out  of  a  population  of  thirty  thousand — is  un- 
doubtedly the  Mexican  port  most  to  be  dreaded  by 
the  United  States  as  a  source  of  infection.  Fortu- 
nately the  quarantine  regulations  are  strict,  and  all 
freight  and  passenger  traffic,  with  the  exception  of  a 
few  steamers  which  trade  between  Vera  Cruz  and 
Pascagoula,  Miss.,  and  New  Orleans,  has  been  de- 
flected to  the  northern  ports.  The  bulk  of  the 
passenger  traffic  goes  to  or  through  Havana,  and,  as 
the  writer  of  the  report  remarks,  the  danger  of  infec- 
tion of  Havana  from  this  source  is  a  problem  that  can 
be  solved  only  by  an  absolute  quarantine  or  the 
hearty  co-operation  of  the  Mexican  health  authorities. 
The  railroads  are  a  source  of  dangerous  communica- 
tion, and  it  is  only  by  constant  vigilance  on  the  part 
of  the  Marine-Hospital  service  inspectors  on  the  border 
that  yellow  fever  is  kept  out  of  the  United  States  so 
successfully  as  is  at  present  the  case. 

"Public  Health  Reports"  reviews  at  length  the 
situation  in  the  Central  and  South  American  towns, 
which  by  reason  of  their  location  and  on  account  of 
the  intercourse  between  them  and  this  country  are 
ever  a  probable  means  of  disseminating  yellow  fever 
through  parts  of  the  North  American  continent.  The 
author  of  the  report  says  that  the  prevalence  of  Chagres 
and  yellow  fever  on  the  isthmus  of  Panama  during  the 
construction  of  the  canal  by  the  French  should  be 
borne  in  mind,  should  the  United  States  Government 
undertake  to  build  this  canal.  There  is  an  infected 
territory  from  ocean  to  ocean,  and  the  importation  of 
a  number  of  non-immune  workmen  would  be  the  signal 


for  an  outbreak  of  an  epidemic  of  yellow  fever.  The 
yellow-fever  infection  is  there,  and  the  Chagres  will 
come  when  the  excavations  commence.  The  whole 
isthmus  should  be  disinfected  before  any  workmen 
are  imported,  and  a  thoroughly  equipped,  strictly  en- 
forced maritime  quarantine  maintained  at  Panama 
and  Colon.  This  should  be  done  not  only  for  the 
protection  of  the  army  of  workmen  that  will  be  nec- 
essary for  such  an  undertaking,  but  for  the  protection 
of  the  infectable  States  that  will  be  in  direct  com- 
munication with  the  isthmus  just  as  soon  as  timber  and 
supplies  are  needed  for  the  construction  of  the  canal. 
The  route  of  the  Nicaraguan  Canal  is  not  infected 
with  yellow  fever,  and  there  is  no  history  of  any  in- 
fection having  been  in  the  country  for  many  years. 
There  should  be  suitable  quarantine  stations  main- 
tained at  each  end  of  the  canal,  and  they  should  be 
the  first  things  constructed.  It  matters  not  which 
route  is  selected,  there  will  be  a  rush  of  people  from 
all  over  Central  and  South  America  coming  from  in- 
fected localities  and  bringing  the  infection  with  them. 
Yellow  fever  is  now  extremely  prevalent  in  Vera 
Cruz  and  along  the  southern  coast  line  of  Mexico 
and  the  Central  American  States.  It  is  therefore 
fitting  that  attention  should  be  called  to  the  unsanitary 
conditions  of  these  towns,  and  to  the  importance  to  the 
people  of  this  country  that  measures  should  be  taken 
to  render  them  healthy,  especially  with  a  canal  at 
Panama  or  Nicaragua  in  view.  No  serious  attempt 
has  ever  been  made  to  extirpate  or  check  yellow  fever 
in  any  of  the  South  American  republics.  The  towns 
along  the  coast  and  the  ports  are,  as  a  rule,  the  most 
unhealthy  localities,  and  the  physicians  furnished  by 
the  government  are,  owing  to  these  insalubrious  con- 
ditions and  to  poor  pay,  by  no  means  of  a  high  class. 
Taking  then  into  consideration  the  constant  menace 
the  existing  state  of  affairs  in  the  South  American 
republics  is  to  the  health  of  the  inhabitants  of  the 
United  States,  it  is  somewhat  a  matter  for  wonder 
that  the  government  does  not  exert  its  persuasive 
powers  or  even  exert  some  pressure  to  induce  the  re- 
publican governments  to  initiate  a  policy  of  sanitary 
reform. 

THE  SIGNIFICANCE  OF  TUBERCLE  BACILLI 
AND  OTHER  BACTERIA  IN  THE  SPUTUM. 

In  the  presence  of  symptoms  and  signs  of  disease  of 
the  lungs  the  discovery  of  tubercle  bacilli  in  the  spu- 
tum may  be  regarded  as  indicative  of  the  existence 
of  pulmonary  tuberculosis.  Failure  to  find  the  bacilli, 
even  on  repeated  examination,  cannot,  however,  be 
accepted  as  evidence  against  pulmonary  tuberculosis. 
The  bacilli  can  appear  in  the  sputum  only  if  breaking 
down  of  tubercles  has  taken  place  and  communication 
exists  between  the  ulcerated  tissues  and  the  air  pas- 
sages. They  are  thus  absent,  as  a  rule,  in  cases  of 
miliary  tuberculosis;  and,  sometimes,  in  cases  of  early 
or  even  advanced  tuberculosis  careful  and  oft-repeated 
examination  may  fail  to  disclose  their  presence.  On 
the  other  hand,  the  persistent  expectoration  of  large 
numbers  of  bacteria  is  indicative  of  the  presence  of  a 
cavity,  although  sometimes  the  number  varies  widely 


58 


MEDICAL    RECORD. 


[Jul}'  14,  1900 


accordingly  as  the  cavity  communicates  with  the  air- 
passages  or  not.  In  an  address  on  the  diagnostic 
and  therapeutic  significance  of  tubercle  bacilli  and 
other  bacteria  in  the  sputum,  Brieger  {Berliner  klinische 
Wocheiischrijt,  No.  13,  1900)  points  out  that  a  factor 
of  great  importance  in  cases  of  pulmonary  tuber- 
culosis is  the  matter  of  mixed  infection.  There  is 
reason  to  believe  that  to  this  is  due  principally  the 
violent  febrile  movement  so  often  observed  in  cases 
of  advanced  tuberculosis.  Pure,  uncomplicated  local 
tuberculosis  of  the  lungs  is,  it  is  thought,  almost  wholly 
unattended  with  fever,  and  the  sputum  is,  besides, 
rather  scanty. 

The  micro-organisms  principally  responsible  for 
secondary  infection  are  streptococci,  staphylococci, 
and  pneumococci,  singly  or  in  association.  The 
hectic  fever,  with  chills  and  night  sweats,  is  believed 
to  be  due  principally  to  streptococci,  while  to  the 
staphylococci  are  attributed  the  suppurating  and 
softening  processes  in  tuberculous  lungs.  Influenza 
bacilli  also  are  not  rarely  found  in  the  sputum  from 
tuberculous  patients,  and  they  are  highly  capable  of 
aggravating  the  tuberculous  process.  The  bacillus 
pyocyaneus  and  the  micrococcus  tetragenus  are  occa- 
sionally found  in  sputum  from  tuberculous  patients. 
From  the  evidence  the  role  of  mixed  infection  would 
seem  to  be  the  conversion  of  pulmonary  tuberculosis 
into  pulmonary  consumption. 

In  the  prophylaxis  of  mixed  infection  in  cases  of 
pulmonary  tuberculosis  especial  attention  should  be 
given  to  the  care  of  the  mouth.  Inhalations  of  aro- 
matic oils,  especially  peppermint  oil,  probably  exert 
a  useful  therapeutic  influence  in  this  direction.  Fresh 
air  rich  in  ozone  and  hydrotherapeutic  measures  may 
also  be  productive  of  good  by  neutralizing  the  evil 
effects  of  mixed  infection. 


INSANITY    IN    VIRGINIA. 

Virginia  can  lay  claim  to  the  proud  distinction  of 
having  founded  the  first  institution  exclusively  for  the 
insane  upon  this  continent.  According  to  Dr.  Drewry, 
superintendent  of  the  Central  State  Hospital,  Peters- 
burg, Va.,  who  writes  interestingly  on  the  matter,  in 
1769  the  House  of  Burgesses  provided  for  a  building 
for  the  insane  at  Williamsburg,  then  the  capital  of 
the  colony.  This  event  preceded  by  thirty  years  the 
revolution  in  the  treatment  of  the  insane  introduced 
by  Pinel  of  France  and  Tuke  of  England.  In  1802 
Virginia  provided  a  second  public  institution  for  her 
insane  at  Staunton,  and  in  1870  she  organized  the 
first  asylum  exclusively  for  the  colored  insane  in  the 
world.  Dr.  Drewry  states  that  at  the  present  time  the 
population  of  Virginia  is  about  1,700,000,  two-thirds 
being  white  and  one-third  colored.  Of  these  3,100 
have  been  adjudged  insane,  a  ratio  of  one  in  nearly 
every  600  of  the  population.  The  ratio  in  the  whites 
is  slightly  larger  than  that  in  the  negroes,  though  in 
recent  years  insanity  has  increased  more  rapidly 
among  the  latter  than  the  former.  The  following 
statistics  are  significant:  On  October  i,  1887,  there 
were  in  the  State  hospitals  1,171  white  and  434  colored 


insane;  total  1,605.  There  are  now  1,950  white  and 
870  negro  insane  at  these  institutions,  a  total  of  2,820, 
showing  an  increase  of  1,215,  or  an  annual  net  gain 
of  92  in  the  hospital  population.  From  the  above 
figures  it  will  be  gathered  that  as  in  all  parts  of  the 
world  insanity  in  Virginia  seems  to  show  an  increase, 
and  in  consequence  accommodation  in  the  State  hos- 
pitals for  the  unfortunates  suffering  from  that  disease 
is  altogether  inadequate.  It  is  stated  that  during  the 
past  two  years  182  colored  and  many  white  insane 
have  died  in  jail  or  at  their  homes  while  waiting  for 
vacancies  to  occur  in  the  hospitals. 

Attention  has  been  drawn  in  the  Medical  Record 
on  several  occasions  to  this  condition  of  affairs,  which 
prevails  to  a  greater  or  less  extent  throughout  the 
United  States.  The  fact  has  been  demonstrated  that, 
in  addition  to  being  an  expensive  manner  of  treating 
lunatics,  it  is  also  inhuman  to  a  degree.  In  the  earlier 
stages  of  insanity,  if  the  malady  is  treated  intelligently 
the  chances  of  recovery  are  favorable,  while  if  an  op- 
posite course  is  pursued  the  majority  of  cases  will 
become  incurable  and  chronic.  The  practice  of  con- 
demning an  insane  person  to  jail  like  a  common 
criminal  is  unworthy  of  a  rich,  civilized,  and  Christian 
land. 

THE   MIDWIVES    BILL   IN    ENGLAND. 

THEmidwives  bill  introduced  into  the  English  House 
of  Commons  early  in  the  session  has  passed  the  second 
reading  and  been  amended  by  the  standard  commit- 
tee on  law.  It,  therefore,  seems  certain  that  it  is 
within  measurable  distance  of  being  put  into  force. 
The  bill  would  appear  to  have  divided  the  medical 
profession  of  England  into  two  camps,  the  larger  of 
which  is  altogether  opposed  to  the  projected  licensing 
of  midwives,  while  the  lesser  division,  appreciating 
the  fact  that  some  such  legislation  is  needed  and  must 
come,  and  recognizing  the  futiliity  of  kicking  against 
the  pricks,  have  concluded  that  the  wisest  course  is  to 
bow  to  the  inevitable  and  to  concentrate  their  energies 
on  obtaining  as  perfect  a  bill  as  is  possible. 

Dr.  Glover,  a  prominent  member  of  the  British 
General  Medical  Council,  and  who  is  with  Professor 
Horsley  the  most  conspicuous  advocate  of  the  latter 
mode  of  dealing  with  the  question,  read  a  paper  at  the 
conference  on  medical  organization  recently  held  at 
Manchester,  in  which  the  situation  viewed  from  this 
standpoint  is  clearly  indicated.  He  states  the  facts 
to  be  as  follows:  First,  that  midwives  exist,  and  that 
they  attend  on  a  low  estimate  two  hundred  thousand 
cases.  Secondly,  that  the  title  "  midwife"  exists  and 
is  recognized  by  law,  and  can  be  taken  by  any  woman 
and  used  for  making  a  living.  Thirdly,  that  any 
woman,  however  drunken,  or  ignorant,  or  dirty,  may 
without  hindrance  use  this  title  and  under  its  name 
may  do  an  incalculable  amount  of  harm.  Dr.  Glover 
is  of  the  opinion  that  either  very  cheap  midwifery 
must  be  done  by  physicians,  or  midwives  must  do  it; 
that  opposition  to  all  legislation  on  midwives  means 
the  continuance  of  the  old  midwife,  and  finally  that 
public  and  parliamentary  opinion  is  too  decided  in 
favor  of  legislation  for  things  to  remain  as  they  are. 


July  14,  1900] 


MEDICAL    RECORD. 


59 


The  supporters  of  the  bill  further  hold  that  the  Gen- 
eral Medical  Council  may  be  relied  upon  to  do  its 
best  in  the  interests  of  the  medical  profession. 

The  opposition  to  the  bill  as  it  stands  is  undoubtedly 
strong  among  medical  men  throughout  England.  This 
was  plainly  shown  by  the  fact  that  out  of  sixty  thou- 
sand and  three  hundred  practitioners  who  responded 
to  a  request  from  The  Lamct  for  an  expression  of 
their  views,  four  thousand  were  against  the  measure, 
and  only  thirteen  hundred  and  eleven  declared  in 
its  favor.  The  contention  is  made  that  a  training 
of  but  three  months  is  insufficient  time  to  fit  a  person 
to  undertake  the  seriously  responsible  duty  of  attend- 
ing upon  a  parturient  woman,  even  though  the  midwife 
be  authorized  to  call  in  a  qualified  practitioner  in 
cases  of  abnormal  labor.  There  are  also  many  other 
features  of  the  bill  to  which  grave  exception  is  ni;ide. 
Ihere  is  no  doubt,  however,  that  legislation  on  mid- 
wives  will  in  the  near  future  be  enacted  in  England, 
whether  for  good  or  evil  time  alone  can  prove.  Our 
opinion  on  tiie  subject  as  concerns  this  State,  which 
we  have  as  yet  seen  no  cause  to  withdraw,  has  been 
already  expressed  in  these  pages. 


^cxus  of  the  "Smccli. 

Enraged  Anti-Vaccinationists.  —  Half  a  dozen  or 
more  members  of  the  American  Anti-Vaccination  So- 
ciety met  recently  in  New  York,  and  decided  that  Mc- 
Kinley  and  Roosevelt  must  be  defeated  at  the  polls  in 
November  unless  before  that  time  Governor  Roosevelt 
has  exculpated  himself  of  complicity  in  the  recent  com- 
pulsory vaccination  by  the  public  health  authorities  of 
one  hundred  negro  laborers  in  the  smallpox-infested 
brickyards  at  Stockport,  near  Hudson,  N.  Y.  This 
formidable  society,  which  now  threatens  to  enter  into 
politics,  is  composed  largely  of  what  doctors  in  their 
case  reports  are  wont  to  call  females. 

The  Dangerous  Fourth The  Chicago  Tribune  of 

July  5th  contained  a  partial  list  of  the  casualties  re- 
sulting from  the  insane  method  which  Americans 
have  of  demonstrating  their  patriotism  on  the  national 
fete  day.  According  to  reports  received  from  one 
hundred  and  twenty-five  cities,  thirty  persons  were 
killed  and  thirteen  hundred  and  twenty-five  injured. 
The  toy  pistol  and  the  toy  cannon  are  shown  to  have 
done  as  deadly  execution  as  sometimes  has  been  done 
in  war  by  those  loaded  with  bullets  and  canister  and 
aimed  to  kill.  Skyrockets,  powder  explosions,  and 
the  premature  discharges  of  cannon  help  to  complete 
the  list  of  mishaps.  Out  of  this  total  of  thirteen  hun- 
dred and  twenty-five  persons  hurt  in  an  attempt  to  be 
patriotic,  four  hundred  and  forty-two  can  attribute 
their  injuries  to  firecrackers  and  dynamite  torpedoes. 
The  deadly  cannon  firecracker  did  most  of  this  execu- 
tion. Out  of  one  hundred  and  fifty-two  injured  by 
firearms  in  sixty-seven  cities,  the  toy  pistol  caused  one 
hundred  and  five.  Gunpowder  explosions  caused  the 
injury  of  one  hundred  and  eighty-seven.  Many  of  the 
injuries  included  in  the  lists  were  reported  as  prospec- 


tively fatal.  In  several  instances  persons  were  killed 
through  runaw-ay  accidents,  due  directly  to  fireworks. 
A  fire  loss  of  $123,327  was  caused  by  fireworks,  in 
addition  to  the  injury  to  human  life.  To  the  number 
of  deaths  caused  directly  by  these  explosive  accidents 
must  be  added  those  yet  to  occur  from  tetanus  due  to 
infected  wounds. 

Dr.  Charles  F.  Chandler,  professor  of  chemistry 
at  Columbia  University,  has  received  the  degree  of 
D.Sc.  from  Oxford. 

The  Hospital  Ship  "Maine,"  equipped  by  the 
Anglo-American  committee  for  service  in  the  South 
African  war,  has  returned  a  second  time  with  wounded 
and  invalided  soldiers  to  Southampton.  The  commit- 
tee has  now  offered  the  British  government  the  use  of 
the  ship  for  service  in  China,  and  this  offer  has  been 
accepted.  The  vessel  will  sail  soon  with  the  same 
staff  she  had  in  South  Africa.  She  will  be  used  as  a 
base  hospital  ship,  but  it  has  not  yet  been  decided  at 
what  port  she  will  be  located. 

The  Osteopaths  held  their  third  annual  meeting  in 
Chattanooga,  Tenn.,  during  the  first  week  in  July,  and 
devoted  much  of  the  time  to  rejoicing  over  the  fact 
that  the  legislatures  in  several  of  the  States  have 
passed  bills  legalizing  their  dealings  with  the  sick. 
The  curious  title  of  one  paper  was  "  The  Fake  Osteo- 
pathist  and  How  to  Deal  with  Him."  A  fake  osteo- 
pathist  must  be  about  on  the  level  of  an  anti-Eddy 
Christian  Scientist. 

A  Curious  Acquittal. — In  the  court  of  assizes  in 
Brussels,  a  few  days  ago,  Sipido,  the  youth  who  at- 
tempted to  assassinate  the  Prince  of  Wales  while  the 
latter  was  passing  through  the  city  en  route  to  Copen- 
hagen, and  his  three  accomplices  were  acquitted  on 
the  ground  that  they  were  too  young  to  understand  the 
gravity  of  their  acts.  The  four  lads  were  all  between 
sixteen  and  seventeen  years  old.  The  public  prose- 
cutor asked  the  court  to  commit  Sipido  to  a  reforma- 
tory, but  the  application  was  refused.  It  would  be 
interesting  to  know  when,  in  the  opinion  of  a  Belgian 
judge,  the  age  of  reason  or  of  responsibility  for  crim- 
inal acts  is  reached. 

The  Health  of  Manila. — A  report  of  the  health 
conditions  in  Manila,  which  has  recently  been  issued 
by  Major  G.  L.  Edie  of  the  army  medical  department, 
shows  that  American  sanitary  methods  are  as  happy 
in  their  results  in  the  Philippines  as  they  are  in  the 
West  Indies.  According  to  this  report,  the  death  rate 
in  Manila  from  October,  1899,  to  June,  1900,  was  28 
per  1,000.  The  total  number  of  deaths  was  8,535,  of 
which  180  w'ere  caused  by  the  plague  and  1,073  by  in- 
testinal disease.  The  sanitary  conditions  have  been 
greatly  improved  in  the  city  since  the  end  of  the 
organized  rebellion  has  permitted  the  health  authori- 
ties to  give  more  attention  to  such  matters. 

Medical  Missionaries  in  China The  following  are 

among  the  American  medical  missionaries  in  the  dis- 
turbed districts  of  China  concerning  whose  safety  grave 
fears  are  entertained:  Dr.  John  M.  Inglis,  of  Peking. 
Dr.   Cortlandt  Van   Rensselaer  Hodge,  of  Pao-Ting- 


6o 


MEDICAL    RECORD. 


[July  14,  1900 


Fu,  a  native  of  Philadelphia  and  a  graduate  of  the 
medical  department  of  the  University  of  Pennsylvania 
in  1897.  Dr.  Maud  A.  Mackey,  of  Pao-Ting-Fu,  a 
native  of  Evanston,  111.  Dr.  G.  Yardley  Taylor,  of 
Pao-Ting-Fu,  a  native  of  Taylorsville,  Pa.  Dr.  Vir- 
ginia Murdock,  of  Peking,  a  native  of  Zanesville, 
Ohio,  and  a  graduate  of  the  medical  department  of  the 
University  of  Michigan  in  1887.  She  was  formerly 
in  practice  in  Chicago.  Dr.  James  H.  Ingram,  of 
Tung-Chow,  a  native  of  Mansfield,  Ohio,  and  a  grad- 
uate of  the  medical  department  of  the  University  of 
Pennsylvania  in  1883.  He  formerly  lived  in  ^'ine- 
land,  N.  J.  Dr.  Ceorge  D.  N.  Lowry,  of  Peking.  Dr. 
Rachel  R.  Benn,  of  Tien-Tsin.  Dr.  Anna  D.  Gloss, 
of  Peking.  Dr.  M.  S.  Barrow,  of  Tai-Nan.  Among 
those  believed  to  be  safe  are  Drs.  Charles  Lewis  and 
Edna  B.  Parks,  of  Se-Nan-Fu;  Dr.  W.  R.  Faries,  of 
Wei-Hien;  and  Drs.  C.  F.  Johnson  and  E.  E.  Flem- 
ing, of  I-Chow-Fu.  Dr.  Sylvester  G.  Hill,  United 
States  vice-consul  at  Tien-Tsin,  is  a  dentist,  a  gradu- 
ate of  the  Philadelphia  Dental  College.  He  was 
born  in  Muscatine,  la.,  in  1856. 

Navy  Department,  Bureau  of  Medicine  and  Sur- 
gery, Washington,  D.  C. — Changes  in  the  medical  corps 
of  the  United  States  navy  for  the  week  ending  July  7, 
1900.  June  30th. — Surgeon  O.  D.  Norton  detached 
from  the  Monadnock  and  ordered  to  duty  with  marines 
at  Taku,  China.  July  2d. — Medical  Director  G.  W. 
Woods  will  be  detached  from  naval  hospital,  New  York, 
and  placed  on  retired  list,  August  24,  1900,  having 
reached  the  age  of  sixty-two  years.  July  5th. — Passed 
Assistant  Surgeon  F.  C.  Cook  detached  from  the  naval 
hospital,  Norfolk,  Va.,  and  ordered  to  the  naval  hospi- 
tal, Washington,  D.  C.  Passed  Assistant  Surgeon  J. 
F.  Leys  detached  from  the  Franklin  and  ordered  home 
and  to  wait  orders. 

Summer  Mortality.— The  influence  of  the  intense 
heat  of  the  past  week  upon  the  death  rate  is  shown  by 
the  fact  that  for  the  week  ended  July  7  th  there  were 
reported  to  the  Philadelphia  bureau  of  health  544 
deaths — 47  more  than  for  the  preceding  week  and  109 
more  than  for  the  corresponding  week  of  the  previous 
year.  Of  the  whole  number  nearly  one-third  occurred 
in  children  under  the  age  of  five  years- — 73  from 
cholera  infantum,  30  from  marasmus,  23  from  convul- 
sions, 24  from  inanition,  and  7  from  teething.  Be- 
sides 5  deaths  are  attributed  to  sunstroke,  4  to  dysen- 
tery, 3  to  diarrhoea,  9  to  old  age,  and  6  to  debility. 
In  New  York  during  the  first  week  in  July  the  daily 
average  of  deaths  of  children  of  five  years  of  age  or 
under  was  52  in  the  boroughs  of  Manhattan  and  the 
Bronx,  and  45  in  Brooklyn.  This  is  a  high  infant 
death  rate  for  New  York. 

The  Nathan  Straus  Milk  Charity.— This  charity, 
which  was  organized  in  1893,  in  a  little  shed  on  a 
dock  at  the  foot  of  East  Third  Street,  now  occupies  a 
large  twostory  building  and  dispenses  during  the  year 
from  various  branches  some  five  hundred  and  fifty 
thousand  bottles  of  pasteurized  milk.  In  order  to 
furnish  a  food  better  adapted  to  very  young  or  sick 
infants,  two  new  modifications  have  recently  been  pre- 


pared, one  intended  for  sick  infants  and  the  other  for 
healthy  infants;  the  former  is  a  dilution  of  milk  with 
three  times  its  bulk  of  water  and  lime-walcr  with  sugar 
added  so  as  to  provide  a  food  containing  one  per  cent, 
fat,  five  per  cent,  sugar,  and  one  per  cent,  proteids; 
this  is  dispensed  in  three-ounce  bottles.  The  second 
new  modification,  intended  for  healthy  infants  of  early 
age,  represents  two  per  cent,  fat,  five  per  cent,  sugar, 
and  one  per  cent,  proteids,  also  dispensed  in  three- 
ounce  bottles.  Another  modification  containing  about 
four  per  cent,  fat,  seven  per  cent,  sugar,  and  two  per 
cent,  proteids  is  dispensed  in  six-ounce  bottles. 
Whole  milk  is  also  dispensed  in  pint  bottles.  All 
this  milk  is  accurately  pasteurized  in  hygienic  nurs- 
ing-bottles at  75°  C.  (167°  F.),  is  rapidly  cooled,  and 
is  delivered  to  the  branch  depots  in  refrigerator 
wagons.  With  each  bottle  a  sterile  nipple  is  supplied. 
The  milk  will  be  supplied  free  to  any  applicant  who 
presents  a  statement  from  a  physician  that  she  is  un- 
able to  pay  for  it.  Such  applicant  must,  however, 
leave  a  deposit  to  insure  the  return  of  the  bottles. 

Dr.  Karl  Lange,  of  Copenhagen,  died  recently  at 
the  age  of  sixty-six  years.  He  was  professor  of  path- 
ological anatomy  at  the  University  of  Copenhagen, 
and  editor  of  the  Hospitals  Tidende,  a  weekly  medical 
journal. 

The  British  Army  Medical  Scandal The  gov- 
ernment has  appointed  on  the  committee  to  investi- 
gate the  South  African  hospital  charges  Dr.  Daniel  J. 
Cunningham,  of  Trinity  College,  Dublin,  Dr.  Henry 
M.  Church,  of  Edinburgh,  and  Lord  Justice  Romer. 

Compulsory  Vaccination  Legal  in  Pennsylvania. 
— By  a  decision  of  court  in  favor  of  the  defendant  in  a 
suit  instituted  by  a  citizen  of  Philadelphia  against  the 
principal  of  a  school  to  compel  the  admission  of  a 
pupil  without  vaccination,  the  legality  of  compulsory 
vaccination  in  the  schools  of  Pennsylvania  is  sus- 
tained. 

Thermometry  in  Germany. — An  order  has  been 
promulgated  that  after  January  i,  1901,  the  use  of  the 
Centigrade  thermometer  shall  displace  that  of  the 
Re'aumur  in  Germany.  In  medicine  the  Centigrade 
scale  has  been  almost  universally  used  for  a  long 
time.  The  freezing-point  on  both  scales  is  o,  but  the 
boiling-point  is  100  on  the  Centigrade,  while  it  is  80 
on  the  Re'aumur. 

The  Vienna  Society  of  Obstetrics  and  Gynaecol- 
ogy is  a  society  of  about  fifty  members.  It  meets  at 
the  call  of  the  president.  Dr.  Libotzky,  in  the  amphi- 
theatre of  the  No.  2  (Chrobak)  clinic  in  the  General 
Hospital.  This  seems  a  peculiarly  fitting  place,  for 
not  only  are  there  hundreds  of  cases  of  obstetrics  and 
gynaecology  above,  below,  and  on  either  side,  but  fre- 
quently during  the  evening  the  speaker's  voice  is 
drowned  by  the  cries  of  women  in  labor. 

Infanticide   Not  a  Capital  Offence  in   France 

The  law  regarding  infanticide  in  France  has  been 
amended  by  the  senate,  the  punishment  for  the  crime 
being  made  imprisonment  for  a  term  of  years  instead 
of  death.     The  reason   urged  for  the  change  was  that 


July  14,  1900] 


MEDICAL    RECORD. 


61 


juries  would  not  convict  in  trials  for  infanticide,  even 
when  guilt  was  established,  so  long  as  the  penalty  was 
death. 

Obituary  Notes. — Dr.  Charles  P.  Judkins,  of 
Cincinnati,  died  on  July  ist,  at  the  age  of  fifty-seven 
years.  He  was  a  graduate  of  the  Miami  Medical  Col- 
lege in  1867,  and  had  practised  continuously  in  Cin- 
cinnati since  that  time.  He  belonged  to  a  family  of 
physicians,  his  father,  two  uncles,  two  brothers,  and  a 
cousin  all  being  members  of  the  medical  profession. 

Dr.  Thomas  P.  Edwards  died  at  his  home  in  New- 
ark, N.  J.,  on  July  4th,  of  heart  disease,  at  the  age  of 
thirty-nine  years.  He  was  born  in  Marcy,  N.  Y.,  and 
was  graduated  from  the  medical  department  of  the 
University  of  New  York  in  1885. 

Dr.  Gerald  Freeman,  surgeon  of  the  Allan  Line 
steamer  Carf/mgciiian,  was  lost  overboard  from  the 
steamer  in  Halifax  harbor  on  July  6th.  The  steamer 
was  entering  the  harbor  on  her  return  voyage  from 
Liverpool.     Dr.  Freeman  studied  medicine  in  Dublin. 

Dr.  J.  L.  M.  Cardeza  died  at  Claymont,  Del.,  on 
June  28th,  in  an  apoplectic  attack,  at  the  age  of 
seventy-nine  years.  He  was  a  graduate  of  the  med- 
ical department  of  the  University  of  Pennsylvania. 

Dr.  Franklin  Gauntt  died  at  Burlington,  N.  J., 
on  July  7th,  in  the  seventy-seventh  year  of  his  age. 
He  was  graduated  from  the  medical  department  of  the 
University  of  Pennsylvania  in  1847.  He  was  a  sur- 
geon in  the  war  of  the  Rebellion  and  at  the  time  of 
his  death  one  of  the  surgeons  to  the  Pennsylvania 
Kailroad. 


(Dliituaini. 

ALEXANDER  J.  C.  SKENE,  M.D.,  LL.D., 


BROOKLYN, 


Dr.  Alexander  J.  C.  Skene,  of  Brooklyn,  died  on  the 
night  of  July  4th,  at  his  summer  home  at  Highmount, 
in  the  Catskill  Mountains.  His  death  was  unexpected, 
for  although  he  had  been  suffering  for  some  time  from 
an  ailment  of  the  heart,  nothing  was  suggested  by  his 
condition  to  cause  his  family  or  his  friends  concern. 
Dr.  Skene  was  born  in  1838  in  the  Parish  of  Fyvie, 
Aberdeenshire,  Scotland.  He  came  of  a  noted  Scotch 
family,  many  of  the  members  of  which  had  been  closely 
identified  with  much  of  the  history  of  Scotland.  He 
came  to  this  country  when  nineteen  years  old,  and  soon 
after  his  arrival  he  entered  the  University  of  Michigan. 
From  there  he  went  to  the  Long  Island  College  Hospital 
in  Brooklyn,  from  which  institution  he  was  graduated 
in  1863.  He  offered  his  services  to  the  government 
in  the  Civil  War,  and  went  to  the  front  as  a  surgeon. 
While  with  the  army  he  evolved  a  plan  for  a  hospital 
corps  which  is  to-day  in  use  in  the  army  and  the  Na- 
tional Guard. 

After  the  war  Dr.  Skene  returned  to  Brooklyn  and 
was  appointed  adjunct  professor  of  medicine  at  the 
Long  Island  College  Hospital  Medical  College.  For 
many  years  he  was  professor  of  gynaecology  and  dean 
of  tiie  college,  but  resigned  from  the  faculty  about  a 
year  ago  in  order  to  devote  his  energies  to  the  estab- 
lishment of  the  Skene  Hospital  for  Self-Supporting 
Women.  It  was  intended  to  open  this  hospital  in  the 
autumn  of  the  present  year. 


Dr.  Skene  was  a  gynaecologist  of  great  skill  and  was 
widely  known  through  his  writings  on  the  diseases  of 
women.  He  was  formerly  professor  of  g)n£Ecology  in 
the  New  Vork  Post-Graduate  Medical  School,  and  had 
been  president  at  different  times  of  the  American  Gy- 
necological Society,  the  New  York  Obstetrical  Society, 
and  the  Kings  County  Medical  Society.  He  was  a 
member  of  several  other  medical  societies  and  was 
also  a  corresponding  member  of  the  Boston,  Detroit, 
British,  and  Belgian  gynaecological  societies. 

Dr.  Skene  was  a  lover  of  art  and  was  himself  a 
sculptor  of  fair  abilities.  He  also  had  literary  tastes 
and  had  published  one  novel. 


JOHN  ASHHURST,  JR.,  M.D.,  LL.D., 


rHILADELl'HIA. 


Dr.  John  Ashhurst,  Jr.,  died  at  Philadelphia  on 
June  7th,  at  the  age  of  si.\ty-one  years.  He  was  grad- 
uated from  the  department  in  art  of  the  University  of 
Pennsylvania  in  1853,  received  the  degree  of  A.B.  in 
1857,  and  that  of  A.M.  in  i860,  when  also  he  was 
graduated  from  the  medical  department.  In  1895  he 
received  the  honorary  degree  of  doctor  of  laws  from 
Lafayette  College.  Soon  after  the  outbreak  of  the 
Civil  War,  and  while  still  a  resident  physician  in  the 
Pennsylvania  Hospital,  Dr.  Ashhurst  was  commis- 
sion?d  acting  assistant  surgeon  and  placed  in  charge 
of  Cuyler  General  Hospital,  Ciermantown,  serving  here 
and  at  the  Chester  United  States  Army  General  Hos- 
pital from  1862  to  1865. 

Dr.  Ashhurst  was  from  1863  to  1880  surgeon  to  the 
Episcopal  Hospital.  In  1870  he  was  appointed  sur- 
geon to  the  Children's  Hospital,  in  1874  consulting 
surgeon  to  the  Hospital  of  the  Good  Shepherd,  in  1875 
consulting  surgeon  to  St.  Christopher's  Hospital  and 
to  the  Pennsylvania  Institute  for  the  Blind.  In  1877 
he  was  elected  clinical  professor  of  surgery  in  the 
medical  department  of  the  University  of  Pennsylvania 
and  surgeon  to  the  University  Hospital.  In  1887  he 
became  surgeon  to  the  Pennsylvania  Hospital  and  in 
1888  was  appointed  John  Rhea  Barton  professor  of 
surgery  in  the  university. 

Dr.  Ashhurst  was  an  able  and  voluminous  writer, 
and  he  was  a  member  and  an  officer  in  many  medical 
societies. 


progress  of  l^ctlical  J>cicnce. 

.\e7i'  }>;■/!•  Medical  Journal,  July  7,  igoo. 

The  Identification  of  the  Blood  of  Individuals.— W.  H.  Birch- 
more  has  made  a  series  of  studies,  the  general  residts  of 
which  may  be  summarized  as  follows;  The  measurements 
of  the  blood  of  children  show  variations  large  in  amount 
and  not  easily  explained  ;  there  is  no  order  in  the  changes, 
but  in  practice  the  result  is  as  follows :  Beginning  in  a 
child  two  years  old,  the  variations  became  distinctly  less 
during  the  time  he  was  under  observation.  About  twenty 
satisfactory  counts  were  made,  covering  about  one  thou- 
sand corpuscles  each,  and  each  corpuscle  was  measured. 
In  a  boy  of  twelve  years  the  variations  were  very  small : 
as  between  two  boys  of  this  age,  there  was  no  question  of 
the  identity  of  any  specimen  examined.  As  to  the  degree 
of  certainty  obtainable,  it  seemed  quite  certain  that  a 
blood  stain  can  be  positively  identified  as  belonging  to  the 
same  blood  as  another  given  stain,  or  as  not  so  belonging. 
In  practice  the  question  will  usually  take  the  form  of  a 
strictly  limited  inquiry:  "Is  the  blood  of  this  stain  the 
same  as  the  blood  of  that  one?"  or,  "To  which  of  these 
various  blood  stains  does  the  blood  of  this  stain  corre- 
spond?" To  both  of  these  inquiries  positive  answers  can 
be  given.  Within  limits,  the  expert  can  say  positively, 
"The  blood  stain  A  is  not  the  same  as  that  of  stain  B  "  ;  or 
he  can  say,  "It  is  my  opinion  that  the  blood  of  stain  A  is 
the  same  as  the  blood  of  stain  B. " 

Acute  Traumatic  Prostatitis  of  External  Origin  Involving 
the  Bladder  and  Seminal  Vesicles. — J.  JI.  Thomson  reports 
the  case  of  a  man,  aged  fifty-one  years,  who,  as  the  result 


62 


MEDICAL    RECORD. 


[July  14,  1900 


of  a  bicycle  accident,  struck  his  perineum  on  the  pommel 
of  the  saddle.  Pain  in  the  perineum  and  rectum  became 
intense,  while  he  experienced  a  sense  of  heat,  fulness,  and 
weight  in  the  region  of  the  bladder  and  along  the  floor  of 
theurethra.  Micturition  soon  became  urgent,  frequent, 
and  jiainful  ;  and  defecation  also,  but  to  a  milder  degree. 
Bodily  movement  caused  an  exacerbation  of  pain,  and  even 
the  sitting  posture  proved  uncomfortable. 

A  Case  of  Typhoid  Presenting  Some  Unusual  Features. — 
The  noteworthy  points  in  this  case,  under  care  of  C.  E. 
Skinner,  were  ;  (i)  A  sudden  rise  of  temperature  ;  (2)  per- 
sistent and  obstinate  constipation  ;  (3)  absence  during  the 
entire  illness  of  bronchial  symptoms  and  headache;  (4) 
atypical  color  of  stools;  (5)  acute  pain  in  the  left  iliac 
fossa ;  (6)  nausea  and  vomiting ;  (7)  a  severely  painful 
myositis;  (S)  absence  of  eruption  ;  (g)  an  excessively  high 
temperature  extending  over  ten  weeks  ;  (10)  the  gratifying 
effect  upon  the  myositis  of  heat  at  a  high  degree. 

Acute  Gonorrhoeal  Arthritis,  etc.,  of  the  Left  Shoulder, 
which  Necessitated  Operation  and  was  Followed  by  Rapid 
Recovery. — By  J.  C.  Stinson. 

Secondary  Cataract :  A  Experimental  Study. — By  W.  H. 
Bates. 

The  Unrequited  Service  of  a  Physician. — By  A.  N.  Smith. 

A  Case  of  Hairpin  in  the  Urethra.—  By  W.  L.  Biown. 

The  Boston  Meilical  ami  Suigkal  Journal,  July  s,  igoo. 

The  Use  of  the  Angiotribe. — J.  H.  Davenport  describes  the 
clamp  first  advocated  by  Doyen  for  controlling  hemor- 
rhage and  subsequently  modified.  The  instrument  seems 
especially  indicated  in  vaginal  hysterectomy.  His  mode 
of  employing  it  is  described.  There  is  almost  no  pain, 
practically  no  bleeding,  and  convalescence  is  easy  and 
rapid,  making  the  technique  an  advance  in  securing  com- 
plete compression  of  the  interstitial  connective  tissue  with 
all  its  lymph  spaces.  The  danger  from  secondary  hemor- 
rhage is  slight,  as  indicated  by  many-  cases  reported.  The 
author's  own  e.xperience  relates  to  five  operations  in  which 
it  was  employed  with  great  satisfaction. 

A  Case  of  Morbid  Fear. — J.  W.  Courtney  speaks  of  the 
widely  varying  forms  of  fear  encountered  in  neurasthenic 
subjects,  and  relates  an  instance  in  a  young  woman  sten- 
ographer of  neurotic  ancestry  who  acquired  such  a  ])ro- 
nounced  fear  of  death  as  to  have  it  dominate  her  entire 
existence.  She  was  finally  cured  by  tonic  treatment  (iron) , 
hypnotic  suggestion,  tasks  of  memorizing,  etc. 

Remarks  on  the  Surgery  of  Uterine  Fibroids,  with  Special 
Reference  to  the  Importance  of  Early  Removal  in  the  Young. — 
By  il.  H.  Richardson. 

Colostomy  for  Obstruction  due  to  Malignant  Disease.— By  J. 
B.  Blake. 

Pliiladclphia  Medical  Journal,  July  7,  igoo. 

Total  Excision  of  the  Scapula  alone,  and  with  the  Arm 
(Interscapulo-thoracic  Amputation):  Partial  Excision  of  the 
Scapula  for  Tumor. — J.  J.  Buchanan  reviews  the  literature, 
classilies  the  cases,  gives  histories  of  his  own  cases,  and 
describes  Berger's  method,  which  was  followed  with  slight 
modification.  The  essential  elements  of  this  method  are 
preliminary  ligation  of  the  great  vessels  and  the  formation 
of  anterior  and  posterior  flaps. 

A  Case  of  Primary  Adenocarcinoma  of  the  Gall  Bladder 
with  Secondaries  in  Both  Adrenals,  Melanosis  of  the  Skin 
(Addison's  Disease?) ,  Vitiligo,  and  Hypertrophy  of  the  Pan- 
creas.— By  Aldred  Scott  Warthin. 

The  Action  of  Rennin  upon  Milk  Digestion.— By  I.  H. 
Coriat. 

A  Case  of  Myoma  of  the  Bladder. — By  Otlo  G.  Ramsay. 
Medical  AVii'j',  July  7,  tc)oo. 

The  Treatment  of  Tetanus. — Alexander  Lambert  reviews 
Thallmann's  recent  article  and  reports  various  experiments 
and  observations.  Tetanus  wounds  should  be  thoroughly 
cleansed  with  iodine  trichloride,  one  percent.,  or  Gram's 
or  Lugol's  solutions,  carbolic  solutions  (one  and  a  half  per 
cent.),  cresol  (one  per  cent.),  formalin  (one  to  two  per 
cent.).  Deep  incisions  should  bo  made  to  make  sure  that 
no  dirt  or  wads  of  cartridge  are  retained,  as  has  been  too 
often  the  case.  We  should  aim  at  (i)  speedy  elimination 
of  the  poison  ;  (2)  the  administration  of  physiological  anti- 
dotes ;  (3)  chemical  antidotes  to  render  the  poison  inert. 
The  kidney  action  must  be  increased  by  free  use  of  water. 
The  best  physiological  antidote  is  chloral.  Bromides, 
physostigmine,  and  antimony  act  in  the  same  way  by  di- 
minishing the  intense  reflex  excitability  of  the  central  ner- 
vous system.  The  prognosis  is  in  direct  ratio  to  the  short- 
ness of  the  incubation  period  and  to  the  rapidity  and 
intensity  of  the  development  of  the  symptoms.  There  is 
no  doubt  that  many  cases  of  human  tetanus  could  be 
avoided  by  preventive  doses  of  antitoxic  serum  (10  c.c. ) 
in  cases  of  wounded  persons   in  localities  where  tetanus 


prevails.  In  the  records  of  fifty-two  cases  treated  by  in- 
tracerebral injections  there  was  a  mortality  of  over  sixty- 
three  per  cent. 

The  Immunizing  Cure  of  Hay  Fever. — H.  H.  Curtis  first 
tried  to  immunize  a  hay-fever  subject  by  giving  internally 
the  watery  extracts  of  certain  flowers  and  their  pollen. 
He  has  recently  taken  ujj  the  question  anew,  and  reports 
some  successful  trials  in  this  direction  by  administering 
solidago  odorata  and  convallaria  majalis. 

The  Hospital  Governor  and  his  Staff :  Being  a  Glance  at 
the  Personnel  of  a  Modern  Hospital  and  a  Plea  for  a  Per- 
manent Resident  Staff. — By  Thomas  J.  lliUis. 

Significance  of  the  Stool  in  Infantile  Diarrhoeas. — By  Wil- 
liam Edgar  Darnall. 

Journal  of  the  American  Medical  Ass' n,  July  7,  igoo. 

The  Surgery  of  Biliary  Calculi.— W.  D.  Haggard,  Jr., 
discusses  the  surgical  aspects  of  biliary  calculi  and  gives 
the  various  operations  which  have  of  recent  years  been 
devised  for  their  relief,  and  the  bibliography  of  the  subject. 
He  gives  a  report  of  a  case  of  colo-cholecystostomy  for 
chronic  catarrhal  cholangitis  with  gall  stones.  He  gives 
Robson's  conclusions  from  experiments  on  a  case  of  biliary 
fistula:  (I)  The  bile  is  probably  chiefly  excrementitious, 
and,  like  the  urine,  is  constantly  being  formed  and  cast  out. 
(2)  Though  the  bile  probably  assists  in  the  absorption  of 
fats,  its  presence  in  the  intestine  is  not  necessary  for  the 
digestion  of  such  an  amount  of  fat  as  is  capable  of  support- 
ing life  and  keeping  up  nutrition.  (3)  Increase  in  body 
weight  and  good  health  are  quite  compatible  with  the  en- 
tire absence  of  bile  from  the  intestines.  (4)  The  antiseptic 
properties  of  the  bile  are  unimportant.  (5)  Whatever  little 
antiseptic  quality  bile  may  have  is  probably  derived  from 
its  admixture  with  the  gall-bladder  fluid.  (6)  The  sup- 
posed stimulating  effect  of  the  bile  on  the  intestinal  walls 
is  not  necessary  for  a  regular  action  of  the  bowels. 

Paroxysmal  Tachycardia. — J.  M.  Patton  makes  a  defence 
of  the  name  and  illustrates  by  clinical  examples  the  differ- 
ence between  the  essential  and  ordinary  forms  of  symp- 
tomatic "  heart  hurry."  He  finds  the  morbid  anatomy  in- 
definite, but  believes  myocardial  lesions  frequently  present. 
The  prognosis  is  unfavorable  and  the  treatment  unsatisfac- 
tory. The  discussion  by  members  of  the  Chicago  Society 
of  Internal  Jledicine  accompanies  the  paper. 

Experimental  and  Clinical  Notes  on  the  Subarachnoid 
Space. — Dudley  Tait  and  Guido  Caglieri  give  historical 
data  and  methods  of  reaching  the  subarachnoid  space. 
They  maintain  the  priority  of  Dr.  Leonard  Corning  in 
cocaine  analgesia  by  the  spinal  route.  Experiments  relat- 
ing to  the  diffusion  of  the  cerebrospinal  fluid  are  given, 
and  also  the  results  in  man  from  the  injection  by^  the  cervi- 
cal and  lumbar  routes. 

Common  but  Generally  Unrecognized  Symptoms  of  Eye- 
Strain.— E.  G.  Starr  speaks  of  other  symptoms  besides  the 
headaches  which  are  due  to  eye-strain.  Among  them  are 
pain  in  the  back  of  the  neck,  mental  confusion,  confusion 
of  ideas,  inability  to  fix  the  attention  withotlt  eft'ort,  back- 
wardness in  children  ;  irritability  in  adults  as  well  as  in 
children,  vertigo,  fluctuating  character  of  the  handwriting, 
disturbances  of  the  digestive  apparatus,  etc. 

Diseases  of  the  Pancreas. — Review  of  the  present  status 
of  knowledge  concerning  them,  by  Crayke  Priestley. 

Review  of  the  Present  Status  of  Jonnesco's  Operation. — By 
Marcel  Hartwig. 

Case  of  Perforating  Gastric  Ulcer. — By  Allan  Jones. 

The  Lancet,  June  jo,  igpo. 

The  Excretion  of  Urinary  Water  and  Urea  from  the  Human 
Body  with  Diminished  Kidney  Weight. — According  to  J.  B. 
Xash,  the  following  conclusions  ajipear  to  be  justified  :  (I) 
If  one  kidney  be  removed,  then  three  years  subsequently 
the  healthy  kidney  //;  situ  will  excrete  more  than  the  av- 
erage quantity  of  urinary  water  produced  by  two  normal 
kidneys.  (2)  This  same  kidney  will  execrete  per  cubic 
centimetre  of  urine  and  per  diem  the  average  amount  of 
urea  that  would  be  produced  by  two  healthy  kidneys.  (3) 
If  one-half  of  one  kidney  be  removed,  then  two  years  after- 
ward the  urine  voided  will  be  the  same  in  quantity  as  if 
two  healthy  kidneys  were  present.  (4)  The  loss  of  the 
half  of  one  kidney  will  cause  no  increase  or  diminution  in 
the  percentage  of  total  amount  of  urea  execreted.  (5)  If 
one  kidney  be  removed,  then  the  quantity  of  urinary  water 
excreted  by  the  other  during  the  seven  weeks  immediately 
succeeding  the  operation  will  be  below  the  average  daily 
amount.  (6)  The  urea  produced  by  this  one  kidney  will 
be  less  than  the  average  proportion  usually  seen  as  the 
result  of  the  work  of  two  healthy  kidneys,  but  probably  not 
below  the  average  excreted  by  two  healthy  kidneys  from 
an  individual  recovering  from  a  serious  operation. 

On  the  Use  of  Mercury  in  the  Treatment  of  Cardiac  Fail- 
ure due   to   Arteriosclerosis. — \.  Morison  gives   the  history 


July  14,  1900] 


MEDICAL    RECORD. 


63 


of  a  case  in  which  mercury  seemed  to  subserve  a  useful 
purpose,  and  discusses  the  effect  of  the  addition  of  some 
preparation  of  this  remedy  to  diuretic  combinations  in  gen- 
eral. He  sliares  the  opinion  of  Broadbent  that  mucli  im- 
portance is  to  be  assigned  to  its  effect  in  lowering  vascular 
tension.  How  this  is  brought  about — whether  by  the  elimi- 
nation from  the  blood  of  waste  material  which  has  a  spas- 
tic effect  upon  the  arterioles  or  by  direct  dilatation  of  the 
peripheral  vessels  in  the  process  of  its  own  elimination — it 
is  not  necessary  at  present  to  inquire  and  is  very  dillicult 
to  determine.  That  the  permeability  of  peripheral  vessels 
by  a  lessening  of  their  resistance  is  secured  appears  to  be 
clinically  demonstrable.  This  being  so  it  is  not  diflicult  to 
imagine,  and  is  indeed  permissible  to  suppose,  tliat  the 
combination  of  mercury  (a  peripheral  dilatant)  with  digi- 
talis and  squills  (which  are  in  part  central  stimulants  as 
well  as  peripheral  contractors)  constitutes  it  a  rationally 
indicated  adjuvant  to  the  action  of  the  latter  in  cardiac 
failure  due  to  arteriosclerosis. 

The  Primary  Disorders  of  Growth. — H.  Gilford  concludes 
a  lengthy  article  by  stating  that  the  four  primary  growth 
diseases— hypoplasia,  hypertrophy,  degenerative  hypo- 
plasia, and  degenerative  hyperplasia — are  all  represented 
in  the  skeleton.  They  form  two  divisions  of  which  the  one 
— hypoplasia  and  hypertrophy — is  distinguished  by  mere 
defect  or  e.^eess  of  normal  growth  ;  while  the  oilier,  in 
which  are  comprised  the  two  degenerative  diseases,  shows 
all  those  broad  clinical  and  anatomical  features  which  in 
tlie  first  part  of  his  article  were  seen  to  be  characteristic 
of  the  degenerative  diseases  of  growth,  whatever  the  tissue 
may  be  that  they  effect.  And  as  degenerative  hypoplasia 
of  the  skeleton  is  seen  to  run  into  degenerative  hyperplasia 
by  imperceptible  gradations,  each  being  distinguished 
from  the  other  by  characters  imprinted  by  age  alone,  so 
degenerative  hyperplasia  is  subdivided  into  two  diseases 
according  to  tissue.  If  it  affects  the  hard  substance  of  the 
skeleton  especially,  it  is  called  osteitis  deformans  ;  if  the 
soft  substance,  it  is  called  osteomalacia. 

A  Case  of  Syphilitic  Fibro-Spongioid  Osteitis.— J.  B.  Hall 
describes  the  case  of  a  boy  aged  fourteen  years,  wlio  pre- 
sented the  lesions  suggested  by  the  title.  As  a  result  of 
congenital  syphilis  there  had  been  an  osteitis  of  the  clavi- 
cles, lower  jaw,  the  right  humerus,  and  both  tibiae.  Ac- 
cording to  Parrot,  states  the  author,  the  fibro-spongioid  or 
rachitic  form  of  the  disease  never  appears  before  the  fi'fth 
month  of  life.  It  begins  as  a  subperiosteal  growth  of  yel- 
lowish pearly  fibroid  material  over  which  the  periosteum 
is  much  thickened  and  closely  adherent  to  it.  It  may  at- 
tain as  much  as  half  an  inch  in  thickness  and  is  very  Vas- 
cular. There  is  always  a  distinct  line  of  demarcation  be- 
tween the  new  tissue  and  the  bone  beneath.  The  bones 
most  commonly  affected  are  the  humerus  at  its  lower  end, 
the  ulna,  the  femur,  and  the  tibia.  Although  two  distinct 
forms  are  thus  described  by  Parrot,  both  are  usuallv  pres- 
ent together  in  varying  degree,  the  osteoid  tissue  being 
covered  by  a  layer  of  the  fibro-spongioid  material. 

Remarks  on  the  Value  of  Urotropin  and  its  Practical  Ap- 
plication as  an  Antiseptic. — By  H.  E.  Drake. 

The  Action  of  the  Water  of  Llangammarch  Wells  on  Uric 
Acid.— By  W.  B.  Jones. 

The  Degeneration  of  the  Neuron.— Second  Croonian  lec- 
ture, by  F.  \V.  Molt. 

The  Commoner  Neuroses  of  Childhood. — Ingleby  lecture, 
by  O.  J.  Kaufmann. 

Application  of  Pathology  to  Surgery. — Cavendish  lecture, 
by  H.  T.  Butlin. 

Differentiation  of  Diabetes.— By  F.  \V.  Pavy. 

British  Medical  Jciirnal.  June  30,  igoo. 

On  Lead  Encephalopathy  and  the  Use  of  Diachylon  as  an 

Abortifacient. — \V.  H.  Ransom  records  three  cases  of  cere- 
bra!  disease  due  to  lead  poisoning,  two  of  which  were 
caused  by  diachylon  taken  to  procure  abortion,  and  some 
other  cases  in  wliich  diachylon  taken  with  the  same  object 
produced  a  different  set  of  symptoms.  It  seems  that  in 
England  balls  of  diachylon  to  sell  for  a  half-penny  or 
penny  are  kept  by  druggists,  and  are  commonly  purchased 
for  this  purpose.  The  dose  represents  about  23  gm.  of 
lead.  It  appears  to  be  a  fast-growing  evil.  The  treat- 
ment consisted,  among  other  things,  of  moderate  doses  of 
iodide  of  potassium  and  Epsom  salts. 

Note  on  a  Case  of  Lannslongue's  Craniectomy. — Charles 
Ward  relates  the  case  of  a  presumably  syphilitic  boy,  aged 
six  years,  presenting  hard,  regular,  symmetrical  thicken- 
ing of  the  skull,  haziness  of  the  cornea,  profound  sym- 
metrical deafness,  etc.,  from  whose  skull  strips  of  bones 
were  removed  from  either  side  with  marked  relief  of  symp- 
toms. Five  months  after  the  operation  the  boy  died  sud- 
denly. Down  to  1894  Treves  reports  only  thirty-si.x  such 
operations,  with  four  deaths. 


The  Cavendish  Lecture  on  the  Application  of  Pathology  to 
Surgery.— By  Henry  T.  Butlin. 

'Ossified  Stylo-Hyoid  Ligament  Simulating  a  Foreign  Body. 

— By  C.  Frank  \\'iglitnian. 

The   Croonian  Lectures  on  Degeneration  of  the  Neuron.— 

By  Frederick  \V.  Mutt. 

Pin  Introduced  in  the  Ear  Passed  per  Anum.— Bv  Allan 
I.  Petyt. 

Dei  liner  kliniselie   W'oehenschriJ t .  June  iS,  rgoo. 

The  Effect  of  White  and  Dark  Meat  in  Chronic  Kidney  Dis- 
ease.—A.  Pabst  has  made  a  series  of  experiments  with 
these  articles  of  diet,  attention  being  paid  to  the  amount, 
specific  gravity,  albuminous  contents,  casts  in  the  urine, 
and  the  general  condition  of  the  jiatient.  The  results  as 
tabulated  arc  conllictiiig  and  variable,  but  in  a  general 
way  it  may  be  said  that  they  show  that  dark  meat  in- 
creases the  albumin  and  dimini.shes  the  quantity.  In  gen- 
eral condition  no  special  change  could  be  noticed.  Fur- 
thermore it  was  shown  that  patients  did  better  on  a  milk 
diet  than  one  containing  either  kind  of  meat. 

The  Present  State  of  our  Knowledge  of  the  Anatomical 
Relations  of  the  Cerebellum  to  the  Rest  of  the  Nervous  Sys- 
tem, and  its  Significance  for  the  Understanding  of  the 
Symptomatology  and  the  Diagnosis  of  Cerebellar  Diseases.^ 
By  P.  Hruns. 

Bacteriological  Experimental  Contribution  to  the  Question 
of  Gastro-Intestinal  Disinfection. — By  R.  Scluilz. 

The  Methods  of  Early  Diagnosis  of  Pulmonary  Tubercu- 
losis.—  By  II.  Slrauss. 

Prognosis  of  Glycosuria  and  Diabetes. — By  F.  Hirschfeld. 

Deutsclie  ineilieiinse/ie   W'oLliensehrift,  June  21,  igoo. 

The  Value  of  Courmont's  Serum  Reaction  in  the  Early 
Diagnosis  of  Tuberculosis. — Beck  and  Rabinowitscli  have 
made  a  large  number  of  observations  on  the  agglutinating 
power  of  the  serum  of  tuberculous  subjects  on  cultures  of 
tubercle  bacilli  grown  under  the  conditions  described  bv 
Courmont.  The  blood  of  seventy-three  individuals  was 
investigated,  and  as  the  results  of  their  observations  the 
authors  are  forced  to  admit  that  the  new  procedure  is  not 
likely  to  be  of  practical  value  in  diagnosis.  On  the  one 
hand,  in  cases  of  beginning  tuberculosis  only  in  compara- 
tively few  instances  did  the  serum  exhibit  it's  agglutinat- 
ing properties,  while  on  the  other  a  relatively  large  num- 
ber of  patients  in  advanced  stages  of  the  disease,  and 
who,  according  to  Courmont.  should  in  general  not  give 
the  reaction,  possessed  a  very  high  agglutinating  index. 
In  addition  it  was  observed  that  the  blood  serum  of  a  large 
number  of  non-tuberculous  individuals  had  the  property  of 
agglutinating  the  tubercle  bacil'i,  while  others  distinctly 
in  the  earlier  stages  of  tuberculous  diseiise,  some  of  them 
responding  unmistakably  to  tuberculin,  gave  an  abso- 
lutely negative  result.  In  consequence  the  inference  is 
made  that  the  Courmont  serum  reaction  is  not  specific  for 
tuberculosis,  occurring  in  non-tuberculous  human  beings 
and  animals,  and  often  being  absent  in  true  tuberculous 
cases,  and  therefore  is  not  to  be  regarded  as  of  any  sig- 
nificance in  arriving  at  a  diagnosis. 

The  Relations  of  Mosquitos  to  the  Malarial  Parasites  in 
Kameroon. — Ziemann  has  for  over  a  year  been  collecting  evi- 
dence bearing  on  the  mosquito  theory  of  the  propagation 
of  malaria.  After  a  laborious  search  which  included  the 
investigation  and  sectioning  of  hundreds  of  individuals  of 
thirteen  different  species  of  mosquitos,  a  variety  of  Ano- 
plieles  was  finally  found  which  gave  positive  results. 
Thirty  per  cent,  of  the  mosquitos  of  this  species  caught 
in  a  certain  malaria-infected  locality  contained  in  their 
stomachs  malaria  coccidia  of  various  degrees  of  develop- 
ment and  corresponding  closely  to  those  described  by  the 
Italian  investigators.  Experiment  with  insects  cultivated 
from  larvcB  gave  negative  results,  but  the  same  insects, 
after  sucking  blood  containing  malarial  crescents,  became 
infected.  Anopheles  which  had  not  imbibed  any  of  the 
crescent  forms,  but  had  obtained  only  the  blood,  never 
developed  the  coccidia.  Although  the  author's  material  is 
still  small,  he  considers  it  of  importance  to  have  shown 
that  in  Kameroon,  as  elsewhere,  the  parasite  of  febris  trop- 
ica is  metamorphosed  into  a  coccidia-like  body  in  whose 
interior  the  so-called  sporozoites  subsequently  develop,  and 
which  takes  the  mosquito  as  host. 

The  New  Carbonic  Acid  Spring  in  Nauheim. — By  Lepsius 
and  Schott. 

Observations     on     Some     Rhinological     Instruments. — By 

Jaenicke. 

Fourth  Report  of  the  Malaria  Expedition. — By  R.  Koch. 
American  Journal  oj  the  Medical  Sciences,  July,  igoo. 

Notes  on  Diabetes. — J.  B.  Herrick  speaks  of  casts  found 
in  large  numbers  in  the  urine  during  or  just  preceding 
diabetic  coma.     If  urine  obtained  as  coma  approaches  be 


64 


MEDICAL    RECORD. 


[July  14,  1900 


allowed  to  stand  for  a  few  hours,  a  light,  hazy,  grayish  or 
slightly  yellowish  sediment  will  be  seen  at  the  bottom, 
consisting  almost  entirely  of  short,  broad,  light-colored, 
finely  granular  casts.  There  is  no  relation  between  the 
amount  of  albumin  and  the  number  of  casts  found.  The 
casts  may  occur  twenty-four  hours  in  advance  of  the  coma, 
and  thus  give  warning.  He  next  speaks  of  the  occasional 
low  specific  gravity  of  saccharine  diabetic  urine,  being 
lowered  below  the  average  of  saccharine  urine  or  even  that 
of  normal  urine.  The  only  safe  plan  is  to  examine  for 
sugar,  no  matter  what  the  specific  gravity.  This  is  of  im- 
portance to  life-insurance  examiners. 

A  Case  of  Dermoid  Cyst  of  the  Mediastinum. — F.  S.  Man- 
dlebaum  gives  a  pathological  account  and  history  of  a  case 
of  dermoid  cyst  seen  at  the  Jit.  Sinai  Hospital  in  1S98. 
Cvsts  of  the  mediastinum  are  rare.  Eleven  of  Hare's  five 
hundred  and  twenty  cases  of  mediastinal  tumors  were  der- 
moid cysts.  Hoffman  found  but  fourteen  cases  recorded. 
He  divides  them  into  true  dermoids,  those  containing  car- 
tilage and  cylindrical  cells,  and  those  combined  with  lym- 
phoid tumor.  The  author's  collected  cases,  including  his 
own,  brings  the  number  up  to  thirty-seven.  He  thinks 
certain  tumors  should  be  classed  with  the  teratomata,  and 
suggests  the  following  division:  (i)  True  dermoids  con- 
taining only  ectodermal  structures  ;  (2)  teratoma  or  those 
with  structures  from  the  entoderm  and  mesoderm  ;  (3) 
teratomata  with  the  addition  of  tumor  formation. 

Pneumonic    Complications     in    Pulmonary    Phthisis. — \V. 

Ophiils  has  examined  the  lungs  of  fifty-six  phthisical  pa- 
tients with  regard  to  pneumonic  complications,  and  among 
thirty-seven  successive  cases  he  found  them  in  twenty-five 
instances.  He  is  able  to  confirm  the  statement  first  made 
by  Orth  that  there  is  one  form  of  pneumonic  process  met 
with  in  tuberculous  lungs  which  seems  to  be  produced  by 
a  simple  infection  with  tubercle  bacilli.  Among  sixteen 
cases  of  mixed  infection  there  were  nine  of  acute  broncho- 
pneumonia without  caseation  ;  four  with  apparently  rapid 
and  extensive  caseation,  and  four  with  carnification. 
There  is  much  to  be  attributed  to  mixed  and  secondary 
infections  in  the  development  of  the  destructive  process  in 
jjhthisical  lungs. 

Carbolic  Gangrene. — F.  B.  Harrington  reports  eighteen 
cases  of  gangrene  of  the  fingers  resulting  from  weak  car- 
bolic dressings.  These  added  to  those  found  recorded  in 
various  countries  make  a  total  of  one  hundred  and  thirty- 
two  cases,  and  it  is  assumed  that  manj'  hundreds  have 
never  been  made  public.  Carbolic  acid  in  any  strength 
as  a  moist  dressing  is  dangerous  and  ought  never  to  be 
used.  This  needless  destruction  of  fingers  should  be 
stopped  by  including  carbolic  acid  in  the  list  of  drugs 
obtainable  only  on  physician's  prescription,  and  having 
it  always  labelled  as  dangerous. 

Clinical  Study  of  Ocular  Symptoms  Found  in  So-called 
Posterior  Spinal  Sclerosis. — C.  A.  Oliver  says  that  accord- 
ing to  the  newest  teachings  so-called  posterior  spinal 
sclerosis  is  a  disease  dependent  upon  an  atrophy  or  degen- 
eration of  the  sensory  neurons,  followed  by  sclerosis, 
though  most  probably  antedated  by  varying  degrees  of 
low-grade  inflammation.  He  makes  broad  generalizations 
of  the  ocular  symptomatology  of  this  affection  from  studies 
extending  over  more  than  five  years. 

Report  of  the  Committee  of  the  American  Surgical  Associ- 
ation on  the  Medico-Legal  kelations  of  the  X-Rays. 

Report  of  a  Case  of  Acute  Ascending  Paralysis,  Showing 
Haematoporphyrinuria. — By  C.  (i.  Stockton. 

A  Critical  Summary  of  the  Literature  of  the  Serum  Diag- 
nosis of  Tuberculosis. — By  D.  L.  Edsall. 

Excision  of  the  Lacryinal  Sac  and  Gland. — By  C.  A. 
Veasey. 

A  Case  of  Brown-Sequard's  Paralysis. — By  R.  F.  Woods. 

IMonatsschriJt f.  Ccbm-tshulfc  u.  Gyndkologie,  June,  iqoo. 

Irritable  Bladder  in  Women. — Richard  Knorr  calls  atten- 
tion to  the  fact  that  more  modern  methods  of  examination 
have  done  much  to  clear  up  the  etiology  of  the  various 
bladder  symptoms  so  common  in  women,  and  that  espe- 
cially the  diagnosis  of  "neurosis  "  of  the  bladder  is  to  be 
made  with  the  greatest  caution.  The  careful  use  of  the 
cystoscope  will  in  nearly  every  instance  reveal  the  pres- 
ence of  some  organic  lesion,  and  also  make  possible  local 
applications  to  the  seat  of  the  trouble.  Thus,  out  of  sixty- 
three  cases  studied  by  him,  in  only  seven  were  the  indica- 
tions present  in  the  urine  itself  such  as  to  point  toward 
disease  of  the  uropoetic  mucous  membrane,  and  without 
a  local  examination  the  trouble  would  doubtless  have  been 
ascribed  to  hysteria.  The  most  common  cause  is  chronic 
cystitis  of  the  vesical  neck,  which  was  present  in  nearly 
one-half  of  the  above-mentioned  series.  Complicating 
tliis,  or  as  distinct  etiological  factors,  arc  ulcerations  or 
papillomatous  growths  of  the  bladder  wall,  chronic  ure- 
thritis, pericystitis,  and,  dependent  on  this  latter,  distor- 


tions or  displacements  of  .the  bladder  due  to  peritoneal  ad- 
hesions. Fissure  of  the  internal  sphincter,  hyperajmia,  or 
phlebectasis  of  the  trigonum,  malignant  disease,  subacute 
catarrhal  cystitis,  thickenings  and  sacculations  of  the  blad- 
der wall  are  all  lesions  readily  seen  with  the  cystoscope 
and  capable  of  producing  severe  vesical  symptoms.  Aside 
from  the  purely  operative  measuresrequired,  from  the  gyna;- 
cological  standpoint  the  treatment  is  simple.  Cystitis  colli 
is  treated  with  one-quarter  to  one-per-cent.  sjlver-nitrate 
injections  ;  urotropin,  oil  of  sandal,  and  boric  acid  inter- 
nally clear  up  the  cloudy  urine ;  pericystitis  yields  to  re- 
peated dilatations  of  the  bladder  with  boric-acid  solution. 

The  Origin  of  Placental  Cysts. — Ue  Jong  gives  a  resume 
of  the  literature  on  this  subject  and  cites  the  following 
conclusions :  The  cysts  may  be  situated  (i)  in  the  amnion  ; 
(2)  in  the  omphalo-mesenteric  duct ;  (3)  in  the  chorion  on 
its  foetal  surface  or  in  the  membrana  intermedia  of  Hun- 
ter. They  may  be  due  to:  (i)  Malformations  of  the  am- 
niotic folds ;  (2)  persistence  of  the  omphalo-mesenteric 
duct;  (3)  stagnation  of  its  contents;  (4)  malformation  of 
the  chorionic  villi ;  (5)  local  myxomatous  formations;  (6) 
infarcts  or  hemorrhages.  His  own  observations  lead  him 
to  conclude  that:  (i)  placental  cysts  occur  either  singly 
or  in  groups  and  varying  in  size  from  microscopic  dimen- 
sions to  a  diameter  of  from  9  to  10  cm.  {2)  They  are  situ- 
ated on  the  foetal  side  of  the  placenta  and  are  most  often 
found  in  the  basal  portion  of  the  chorion.  (3)  They  are 
due  to  malformations  of  jiarts  of  the  chorionic  villi  which 
become  adherent  through  the  fibrin  secreted  by  the  cells 
of  Langhans.  (4)  Their  inner  surface  is  lined  with  the 
cells  of  Langhans,  which  may  show  overgrowth  or  degen- 
eration. (5)  Their  contents  consist  of  detritus  from  the 
cells  of  Langhans,  the  secretion  of  the  same  cells,  and  also 
blood  fibrin  and  coagula.  (6)  They  are  not  the  results  of 
a  local  or  general  disease,  and  themselves  do  not  occasion 
any  disturbances  of  clinical  interest. 

Massage  in  the  Treatment  of  Tubal  Diseases. — Richard 
Palm  enters  a  vigorous  protest  against  hasty  operative 
interference  in  every  case  of  tubal  disease,  and  strongly 
recommends  massage  as  a  most  valuable  conservative 
measure.  Properh'  and  carefully  carried  out  it  is  free 
from  danger  and  may  be  practisecl  even  during  pregnancy 
without  causing  any  mischief.  Tumors  known  to  be 
formed  by  a  hydrosalpin.x  may  be  very  advantageously 
treated  in  this  way  ;  the  effort  should  be  made  to  cause  the 
fluid  to  empty  itself  into  the  uterus,  from  which  it  drains 
without  risk  of  sequelce  ;  care  should  be  taken  not  to  exert 
pressure  near  the  fimbriated  extremity  of  the  tube,  though 
even  expression  of  the  contents  of  a  hydrosalpin.x  into  the 
abdominal  cavity  need  not  occasion  alarm.  In  cases  in 
which  the  fluid  is  known  to  be  purulent  an  interval  of 
three  months  is  sufficient  to  insure  its  sterility.  The  au- 
thor reports  a  case  of  cyst  of  doubtful  location  and  nature 
which,  after  prolonged  massage  treatment,  was  purposely 
ruptured.  No  bad  results  followed,  and  under  continued 
massage  the  fluid  was  completely  absorbed  and  a  cure  was 
effected. 

Rcviic  lie  Chirurgie,  June,  igoo. 

Intermittent  Fibrous  Polyps  of  the  Rectum. — Maurice 
Peraire  says  that  although  rectal  polyps  and  polypoid 
growths  are  frequent  enough  in  children,  in  adults  tumors 
of  this  sort  are  comparatively  rare,  and  furthermore  differ 
from  the  former  in  being  hard  and  fibrous,  instead  of  soft 
and  mucous  as  is  the  case  in  younger  patients.  After  an 
exhaustive  resume  of  the  literature  on  the  subject  he 
divides  the  tumors  pathologically  into  :  (i)  mucous  polyps  ; 
(2)  fleshy,  sarcomatous,  or  vascular  polyps  ;  (3)  polyps  due 
to  hypertrophy  of  the  intestinal  follicles  ;  (4)  fibrous  polyps 
—  (<!)  the  true  fibrous  polyp  growing  from  the  submucous 
tissue,  (/')  the  fibroid  of  the  rectum.  This  is  aualogous  to 
the  uterine  fibroid  and  develops  in  the  recto-vaginal  sep- 
tum or  in  the  thickness  of  the  intestinal  wall  itself.  A 
peculiarity  of  the  symptomatology  is  that  the  patients 
usually  do  not  seek  professional  advice  until  the  tumor 
has  attained  considerable  size,  though  close  questioning 
reveals  the  fact  that  for  several  years  they  have  been  suf- 
fering from  a  sensation  of  weight  in  the  rectum,  obstinate 
constipation,  tenesmus,  and  bloody  defecations.  Charac- 
teristic symptoms  are  the  grooving  of  the  fecal  masses  in 
their  passage  over  the  tumor,  and  if  it  be  placed  low 
enough  down  in  the  rectum  the  intermittent  ap|iearance  of 
the  growth  after  defecation  and  requiring  manual  reposi- 
tion. Of  the  complications  tlie  most  important  is  the  .gen- 
eral debility  wliich  often  results  from  the  re])eated  hemor- 
rhages ;  strangulation  is  not  common,  thougli  prolapse  of 
the  rectal  mucous  membrane  is  not  infrequent,  especially 
in  children.  The  treatment  in  all  cases  consists  in  extir- 
pation. When  the  growth  is  accessible  from  the  anus,  the 
most  satisfactory  method  consists  in  exposing  the  pedicle 
of  the  tumor  by  a  V-shaped  incision,  and  then  ablating  it 
after  ligating  it  cither  cii  iiiassv  or  in  sections.  In  tho.se 
cases  in  which  the  tumor  is  out  of  reach  or  involves  the 


July  14,  1900] 


MEDICAL    RECORD. 


65 


entire  rectal  wall,  and  invasion  of  the  perirectal  tissues  is 
necessary,  accordingly  as  the  tumor  is  anterior  or  posterior 
laparotomy  or  resection  of  the  sacrum  after  Kraske  is  in- 
dicated. 

Chronic  Proliferating  Osteomyelitis. — Kozlovsky,  under  this 
title,  considers  a  form  of  bone  affection  often  diagnosti- 
cated and  treated  as  sarcoma.  The  clinical  picture  does 
not  vary  essentially  from  that  of  a  malignant  new  growth, 
but  on  aspiration  the  fluid  obtained  is  found  to  be  rich  in 
staphylococci,  especially  the  staphylococcus  pyogenes  au- 
reus. The  reason  why  the  same  organism  should  .some- 
times produce  a  typical  acute  osteomyelitis  and  sometimes 
under  apparently  similar  conditions  cause  this  puzzling 
sarcoma-like  new  growth,  is  hard  to  find  ;  the  most  logical 
explanation  seems  to  be  that  of  Kocher,  who  refers  it  to 
variations  in  bacterial  virulence  and  tissue  reaction.  If 
the  conditions  are  unfavorable  for  the  growth  of  the 
sta])hylococcus,  and  its  vitality  is  not  great,  there  will  be 
pi-oduced  an  obscure  symptom  complex  commonly  classed 
among  the  manifestations  of  "subacute  rheumatism";  if 
the  activity  of  the  germs,  however,  is  somewhat  greater 
and  phagocytosis  in  consequence  more  energetic,  there 
will  result  foci  of  necrosis  surrounded  by  areas  of  reaction- 
ary inflammation,  vascular  and  actively  proliferating,  and 
giving  the  physical  signs  of  a  sarcoma  from  which  also  the 
diagnosis  can  be  made  only  when  the  microscopical  exami- 
nation is  supplemented  by  a  bacteriological  investigation. 

Endotheliomata  of  the  Bones. — Thevenot  has  collected 
from  the  literature  fifteen  cases  of  endothelioma  of  the 
bones,  and  discusses  their  morphological  and  clinical  fea- 
tures. Most  of  these  had  been  diagnosticated  as  sarcomata 
or  aneurisms  of  bone,  and  even  microscopically  the  distinc- 
tion is  a  difficult  one  to  make.  Characteristic  points  are 
the  disposition  of  the  cellular  elements  about  the  vessels 
either  directly  in  contact  with  the  blood  or  separated  from 
it  by  an  endothelial  layer;  the  regular  form  of  the  cells 
without  budding  nuclei,  and  the  absence  of  cells  having 
multiple  nuclei.  The  new  growth  is  found  in  patients  of 
all  ages ;  sex  apparently  is  also  without  influence.  No 
cause  can  be  assigned,  though  trauma  seems  to  act  by 
producing  a  locus  minoris  resistentiaj  which  undergoes  a 
secondary  degeneration.  The  history  of  the  growths  is 
essentially  that  of  malignancy.  Left  to  themselves  they 
conquer  the  patient  as  quickly  as  sarcomata.  The  clinical 
diagnosis  is  extremely  difticult,  and  the  treatment  is  that 
for  all  malignant  growths,  though  in  suitable  cases  a  ten- 
tative conservative  operation  is  permissible. 

Compression  of  the  Pedicle  of  a  Movable  Kidney  by  a 
Distended  Gall  Bladder.— By  E.  Reymond. 

Cancer  of  the  Large  Intestine  Excepting  the  Rectum. — By 
R.  De  Bovis. 


©orrespondcuce. 

OUR   LONDON    LETTER. 

(From  our  Special  Correspondent.) 

THE  REBELLION  OF  THE  ROYAL  COLLEGES — BRIBERY  IN 
ASYLUMS  FOR  LUNATICS — THE  WORLD'S  TEMPERANCE  CON- 
GRESS— HOSPITAL  SUNDAY  FUND — MISMANAGF.MENT  AT  THE 
HOSPITAL  FOR  PARALYSIS  AND  EPILEPSY — TYPHOID  INOCULA- 
TION— JENNER    INSTITUTE. 

Lo.vDON,  June  22,  igoo. 

The  two  London  colleges  have  adhered  to  their  determina- 
tion to  defy  the  Medical  Council,  and  now  proceed  to  deny 
the  existence  of  any  sovereignty.  The  diplomatic  docu- 
ment announcing  this  was  presented  at  the  last  meeting  of 
the  Council,  when  it  could  not  be  considered,  and  so  active 
hostilities  are  postponed  until  the  next  session.  The  docu- 
ment is  not  easy  of  access,  being  marked  "confidential," 
as  too  many  of  the  Council's  printed  matters  are.  But  a 
glimpse  at  the  one  in  question  shows  that  the  colleges  are 
cognizant  of  the  possibility  of  the  course  I  indicated,  for  they 
assert  that  the  Council's  action  is  "outside  its  powers,  "  and 
then  proceed  to  declare  that  the  attempt  to  enforce  its  de- 
cision by  "  refusing  registration  to  students  of  those  schools  " 
it  has  not  approved  "would  have  no  justification."  If  the 
colleges  mean  that  they  would  not  consider  this  course  jus- 
tifiable, they  are  welcome  to  their  opinion.  But  that  the 
course  would  be  legal  is  clear  enough,  and  that  all  unpreju- 
diced persons  would  consider  it  justifiable  is  certanily  the 
general  conviction.  But  the  rebellious  colleges  are  deter- 
mined, if  possible,  to  obtain  complete  independence.  They 
declare  that  "the  whole  of  the  structure  of  regulations  and 
requirements  which  the  Council  has  erected  on  the  same 
groundless  assumption  of  authority  are  invalid  as  such, 
and  can  only  be  received  for  what  they  are  worth  as  recom- 
mendations." 


Often  have  I  smiled  at  the  Council  recommending  what 
it  should  have  required,  and  this  is  the  reward  of  its  weak- 
ness. But  the  colleges  had  better  beware.  It  is  a  very 
simple  procedure  to  refuse  to  register  any  stude-  t  who  has 
not  complied  with  the  requirements,  and  let  the  colleges 
make  good  their  boasting  by  an  appeal  to  the  law.  It 
would  be  something  strange  to  see  the  Royal  College  of 
Physicians  and  the  Royal  College  of  Surgeons  join  hands 
in  an  attempt  to  set  back  the  educational  clock.  To  many 
it  would  be  a  revelation  of  the  innate  selfishness  of  these 
colleges.  But  they  will  not  dare — for  though  they  might 
defy  the  Council  if  it  were  the  interest  of  the  other  corpora- 
tions to  do  so,  just  the  opposite  is  the  case.  These  two 
colleges  want  to  steal  a  march  on  the  others  for  their  own 
profit.  It  is  hardly  in  corporate  nature  to  help  to  transfer 
the  corporation  profits  to  the  coffers  of  a  rival. 

Great  indignation  is  being  expressed  at  a  system  of 
bribery  which  has  just  been  exposed  by  a  committee  of  the 
St.  Pancras  Guardians.  A  report  of  this  committee  shows 
that  the  relieving  officers  received  money  from  licensed 
lunatic  asylums  for  giving  them  the  preference.  These 
asylums  charged  the  board  two  guineas  a  week  for  a  pa- 
tient, while  other  parishes  only  paid  igi'.  yi.,  so  there  was 
ample  room  for  bribery.  This  system  of  bribery  of  officials 
seems  to  have  secured  nearly  all  the  pauper  lunatics  of  St. 
Pancras — the  amount  paid  to  the  two  asylums  reaching 
over  £  12,000  a  year.  It  is  the  old  story  of  improper  com- 
missions defrauding  the  public,  and  seems  to  have  been 
going  on  for  many  years  with  the  St.  Pancras  relieving- 
officers.  It  is  well  that  the  fraud  has  at  last  been  detected, 
for  St.  Pancras  is  not  the  only  parish  in  which  it  has  flour- 
ished. A  few  months  ago  there  was  an  allegation  against 
Bethnal  Green,  and  I  heard  that  a  local  government  board 
inquiry  was  made,  but  the  result  has  not  been  made  pub- 
lic.    Perhaps  now  the  board  may  awake  from  its  sleep. 

I  regret  to  say  that  some  doctors  have  been  weak  enough 
to  connive  at  the  commission  system  by  giving  the  odd 
shilling  of  their  guirrea  for  certifying  a  lunacy  case  to  the 
officer  who  brought  it — some  indeed  outbid  their  neighbors 
and  gave  half-a-crown  or  five  shillings.  Of  course  the.  doc- 
tors who  stood  on  their  dignity  and  refused  to  give  presents 
seldom  had  a  case  brought  for  certification.  It  is  to  be 
hoped  the  exposure  of  the  system  will  prove  effectual  to 
prevent  its  recurrence, 

The  World's  Temperance  Congress  has  been  held  at  the 
Examination  Hall  of  the  Royal  Colleges.  A  thousand 
delegates  assembled  from  various  countries,  and  about  half 
of  them  attended  a  preliminary  meeting  to  welcome  the 
veterans  who  were  present  at  the  convention  of  1846.  The 
Archbishop  of  Canterbury  was  president  of  the  Congress 
and  delivered  a  spirited  address.  The  only  country  that 
sent  delegates  in  1S46  was  America,  and  those  who  took  part 
in  that  meeting  scarcely  could  have  anticipated  the  world- 
wide character  of  its  successor.  The  scientific  and  medical 
aspects  of  the  question  were  well  represented. 

In  connection  with  this  may  be  named  the  Medical  Tem- 
perance Association's  annual  meeting  on  the  12th  inst., 
when  the  president,  Dr.  Sims  Woodhead,  gave  a  reception 
to  the  medical  and  scientific  delegates  to  the  congress.  A 
demonstration  with  the  electric  lantern  was  given  in  the 
lecture  theatre  by  Dr.  Ridge,  showing  that  minute  quanti- 
ties of  alcohol  interfered  with  the  growth  of  both  vegetable 
and  animal  cells  and  delayed  oxidation.  The  removal  of 
waste  products  was  thereby  hindered  and  other  functions 
were  interfered  with. 

On  Sunday  sermons  were  preached  on  the  temperance 
question  in  most  of  the  London  places  of  worship  and  in 
many  of  those  in  the  provinces. 

This  reminds  me  that  next  Sunday  is  the  metropolitan 
Hospital  Sunday,  when  sermons  will  be  preached  on  behalf 
of  the  hospitals  and  collections  made.  T/ie  Lancet  has 
again  distributed  a  special  supplement  teeming  with  facts 
which  will  be  useful  to  ministers  preparing  their  appeals. 
There  is  naturally  some  misgiving  lest  the  demands  on 
public  generosity  made  by  the  war  funds  should  cause  a 
diminution  in  the  collection  for  hospitals.  And  yet  this 
should  not  be,  for  the  hospital  donations  should  be  re- 
garded as  regular  annual  subscriptions,  for  the  poor  and 
sick  are  always  with  us  ;  while  the  war  contributions  may 
happily  be  looked  upon  as  exceptional  calls  on  the  patriot- 
ism and  generosity  of  the  nation. 

Last  year  the  Hospital  Sunday  Fund  amounted  to  above 
^53,000,  but  some  ^^  15,000  of  this  came  from  donations 
leaving  ^38,000  only  to  represent  the  collection  of  small 
amounts.  This  is  less  than  2^  pence  per  head  of  the 
population — a  fact  which  ought  to  stimulate  the  working- 
classes  to  rush  in  with  their  pence  to  make  up  for  the  class 
above  which  gives  fewer  shillings  than  might  be  expected. 

The  National  Hospital  for  the  Paralyzed  and  Epileptic 
is  so  identified  with  good  work  that  you  may  fancy  its 
management  is  a  model.  This,  however,  is  not  the  case. 
The  good  work  is  that  of  the  medical  staff.  But  the  board 
of  managers  seem  unconscious  of  their  own  insignificance, 
and  trouble  has  for  some  time  been  brewing.     The  staff 


66 


MEDICAL    RECORD. 


[July  14,  1900 


have  at  last  been  goaded  into  stating  that  the  administra- 
tion of  the  hospital  is  "unsatisfactory."  This  is  a  very- 
serious  step,  and  unless  the  board  takes  the  advice  of  the 
staff  the  success  of  the  hospital  will  be  imperilled.  I  have 
for  some  time  been  aware  of  blots  on  the  management,  and 
now  the  staff  has  moved  hope  for  reform.  The  sooner  the 
board  makes  peace  with  the  staff  the  better  will  it  be  for  the 
institution. 

The  large  number  of  typhoid  cases  among  our  troops  in 
South  Africa  is  naturally  a  cause  of  au.N.iety  lest  the  hope 
of  success  for  antityphoid  inoculation  should  end  in  disap- 
pointment. A  great  number  of  officers  and  men  submitted 
to  inoculation  in  hope  of  preventing  attacks  of  the  disease, 
but  so  far  as  can  be  gathered  no  case  for  immunity  has 
been  made  out.  In  fact  the  figures  rather  point  the  other 
way.  It  may  be  that  when  the  statistics  are  more  com- 
plete a  more  favorable  result  will  appear,  but  for  the 
present  we  can  only  hope  it  may  be  so,  and  the  hope  grows 
fainter. 

The  Jenner  Institute  has  been  unsuccessful  in  its  attempt 
to  escape  paying  rates  as  an  institution  for  the  promotion 
of  science.  The  judge  regarded  its  object  as  the  prepara- 
tion and  sale  of  medicines.  This  seems  rather  hard  lines 
on  its  effort  to  supply  the  profession  with  reliable  serum, 
which  it  does  at  a  loss  instead  of  a  profit. 


NEGROES  IN  THE  MEXICAN  REPUBLIC. 

To  THE  Editor  of  the  Medical  Rrcord. 

Sir  :  An  article  on  the  American  negro  in  a  recent  issue  of 
the  Medic.vl  Record  led  me  to  examine  into  the  condition 
of  the  Mexican  negro,  and  I  send  you  herewith  the  results 
of  my  inquiries.  Bishop  Bartolome  de  las  Casas,  seeing 
the  pitiable  treatment  the  Mexican  Indian  was  subjected 
to  by  the  Spaniards,  and  moved  to  compassion,  brought 
about  the  introduction  of  the  African  negro,  whom  he  con- 
sidered an  inferior  being  and  better  fitted  for  hard  work  in 
the  mines.  Slavery,  not  only  of  the  negro  but  of  the  In- 
dian likewise,  existed  in  Mexico  until  1S13.  when  the  first 
national  congress,  at  Chilpancingo,  on  a  motion  made  by 
the  Priest-General  Morelos,  abolished  slavery  forever. 

In  no  one  of  the  Spanish-American  countries  was  there 
ever  to  be  found  proportionally  so  large  a  number  of  ne- 
groes as  in  the  southern  States  of  the  United  States.  It  is 
to  be  noted  that  the  negro  is  much  less  reproductive  than 
the  Mexican  Indian.  It  is  utterly  impossible  to  give  even 
an  approximate  estimate  of  the  number  of  black  people  in 
Mexico.  According  to  a  census  taken  in  1S35  there  were 
then  six  thousand  negroes  in  the  republic.  I  have  not 
found  in  any  other  census  any  data  with  regard  to  tlie 
number  of  inhabitants  of  African  descent.  In  fact,  any 
black  man,  if  asked  his  race,  will  hardly  call  himself  a 
negro,  but  will  hold  himself  to  be  of  dark  complexion. 
Yet  in  an  old  book  by  an  Englishman,  who  travelled  in 
Mexico  some  one  hundred  and  twenty  years  ago,  I  have 
read  that  then  in  the  City  of  Mexico  there  was  such  a  great 
number  of  negroes  (over  forty  thousand)  that  they  were 
considered  a  dangerous  factor. 

I  estimate,  however,  that  in  this  country  there  live  over 
ten  thousand  negroes  and  numberless  individuals  in  whose 
veins  some  African  blood  flows.  Those  negroes  live  mostly 
in  the  state  of  Vera  Cruz,  in  the  south  of  the  state  of  Mo- 
relos, and  in  Guerrero.  They  enjoy  perfectly  equal  rights 
with  the  white  man  and  the  Indian,  not  only  by  law,  but 
practically.  No  man  is  slighted  because  his  skin  is  black  ; 
every  career  is  open  to  him.  We  have  seen  black  generals 
(that  does  not  mean  much) ,  black  lawyers,  congressmen, 
professional  musicians.  I  confess  never  to  have  met  with 
a  negro  doctor  or  priest.  Yet  there  is  no  doubt  that  a  black 
boy  would  be  admitted  to  either  profession  if  he  wished. 

The  negro  in  Mexico  lived  in  general  under  a  milder  rule 
than  in  the  North,  and  after  the  abolition  of  slavery  he  was 
not  treated  or  regarded  as  an  outcast  and  an  inferior 
being.  All  the  negroes  in  this  country  are  farmers,  many 
of  them  well  off.  One  hardly  ever  sees  a  negro  girl  serv- 
ing as  a  domestic,  or  a  negro  craftsman  in  a  workshop. 
Their  number  increases,  though  more  slowly  than  that  of 
the  Indians,  as  they  are  less  prolific.  They  are  somewhat 
industrious  and  not  remarkably  immoral.  No  case  of  fe- 
tishism or  cannibalism  among  them  has  been  known.  Their 
social  condition  imjiroves  visibly. 

When  slavery  was  abolished  in  Mexico,  the  negro  was 
certainly  not  better  prepared  for  freedom  than  he  was  in 
the  southern  States.  Consequently,  if  we  try  to  find  a  rea- 
son for  the  difference  in  their  development  and  for  the  differ- 
ent use  they  made  of  their  liberty,  we  must  look  for  it  else- 
where than  in  the  sudden  transition  from  slavery  to  liberty 
and  their  un]M-eparedness  for  freedom.  There  must  be  some 
other  cause  for  the  different  development  of  the  same  ele- 
ment in  two  different  countries  and  under  much  the  same 
circumstances.     May  it  not  have  been  of  the  greatest  moral 


effect  that  in  this  country  the  negro,  from  the  day  he  was 
freed,  was  held  to  be  a  man  and  a  citizen  and  anybody's 
equal? 

Sir  Spenser  St.  John,  who  had  lived  as  British  minister 
in  Hayti  and  later  on  in  Mexico,  in  his  book  on  Hayti 
gives  a  most  pitiable  description  of  the  blacks  of  that 
island,  who  fell  back  into  all  the  horrors  of  savagery  of 
their  native  Africa,  into  a  condition  toward  which,  accord- 
ing to  some  American  authorities,  the  North  American 
negro  is  drifting. 

It  might  be  used  as  an  argument  against  the  black  race, 
that  in  Hayti  nobody  interfered  with  the  development  of 
the  negroes,  and  that  their  actual  condition  in  Hayti  is 
only  their  natural  one.  But  I  wish  the  friendly  reader  to 
consider  that  the  negro  of  Hayti  obtained  his  liberty  only 
after  a  cruel  and  bloody  strug,i;le  which  quickened  all  his 
atavistic  instincts,  and  that  the  civilizing  influence  and 
example  of  the  white  man  were  completely  withdrawn 
from  him.  F.   Semeleder,  M.D. 

CoRDOtjA,  V.  C. ,  Mexico. 


THE  ALLEGED  BREEDING  OF  TAILLESS 
MICE  THROUGH  THE  INHERITANCE  OF 
MUTILATIONS. 

To  THE  Editor  of  the  Medical  Record. 

Sir  •  There  is  not  a  more  important  question  in  theoretical 
medicine  than  the  one  which  at  present  absorbs  so  much 
of  the  time  of  our  biologists,  whether  modifications  acquired 
by  an  organism,  and  not  inherited  as  a  normal  variation, 
can  be  transmitted  to  its  offspring.  Physicians,  as  a  class, 
are  so  thoroughly  convinced  that  acquired  modifications 
are  transmitted  in  family  lines,  that  to  ask  them  to  give 
up  their  belief  is  almost  as  futile  as  to  ask  them  to  renounce 
their  faith  in  a  future  existence.  Nevertheless  Weismann 
has  shown  that  there  is  not  a  single  unchallenged  instance 
of  the  transmission  of  an  acquired  modification,  and  his 
teachings  are  apparently  being  accepted  by  the  younger 
generation  of  biologists,  just  as  Darwin's  theories  were 
accepted  by  the  younger  men  of  a  generation  ago.  It  is 
interesting  to  note  that  all  the  facts  of  organic  evolution, 
though  first  explained  by  Lamarck  on  the  theory  that  cer- 
tain individuals  became  modified  by  their  environment  and 
thus  originated  new  species  by  transmitting  these  modifi- 
cations to  offspring,  are  now  wholly  explained  by  the  sur- 
vival of  congenital  variations  making  the  possessors  better 
fitted  to  the  environment  than  were  the  parents.  1  tarwin 
believed  in  both  processes,  yet  as  he  grew  older  he  con- 
fessed that  he  saw  less  and  less  evidence  of  the  transmis- 
sion of  certain  alleged  acquired  modifications.  The  com- 
mon mistake  among  physicians  is  the  failure  to  recognize 
that  their  instances  are  not  the  transmission  of  acquired 
modifications,  but  are  really  variations  in  development 
which  are  strictly  transmissible  in  varying  degrees.  The 
character  which  the  child  possesses  in  an  excessive  form 
may  not  have  been  acquired  by  the  parents  at  all,  but  have 
existed  from  birth. 

Telegonv.  or  the  influence  of  one  father  upon  subsequent 
pregnancies  by  other  males,  has  always  been  a  stumbling- 
block.  But  now  comes  the  almost  certain  proof  '  that  there 
are  absolutely  no  instances  of  this  alleged  fact,  and  in 
hundreds  of  experiments  of  breeding  an  animal  to  a  male 
of  a  different  variety,  and  in  subsequent  years  breeding 
her  to  a  male  of  her  own  variety,  these  later  offspring  are 
always  pure.  Weismann  also  shows  that  there  are  no  reli- 
able instances  of  telegony. 

Mutilations  were  long  ago  resorted  to  for  proof  of  the 
transmission  of  acquired  modifications,  and  although  muti- 
lations are  not  the  modifications  usually  thought  of  as  bet- 
ter fitting  an  organism  to  its  environment,  yet  it  was  seen 
that  if  such  gross  changes  could  be  transmitted,  surely  the 
more  subtle  ones  could  be.  In  only  one  case  has  there  been 
a  report  of  the  successful  transmission  of  mutilations.''  and 
it  lias  been  so  extensively  quoted  that  I  have  taken  the 
trouble  to  trace  the  fake  down,  thought  it  has  taken  nearly 
three  years  to  do  so.  It  was  alleged  that  tailless  mice  had 
been  bred  by  cutting  off  the  tails  of  the  young  as  soon  as 
they  were  born,  and  in  six  or  eight  generations  tailless 
litters  were  born. 

Dr.  Charles  E.  Lockwood,  of  New  York,  is  generally  re- 
ferred to  as  the  experimenter,  but  he  writes  me  that  he  had 
nothing  to  do  with  it  except  as  below  mentioned.  In  dis- 
cussing the  subject  of  the  transmission  of  mutilations  with 
Col.  S.  D.  Bruce,  editor  of  Turf.  I'ielii.  and  Far)ii.  the 
latter  referred  to  a  Mr.  A.  S.  Shiddell.  of  Lexington,  Ky., 
who  had  thus  bred  tailless  mice.  They  wrote  to  Mr.  Shid- 
dell, who  kindly  detailed  the  experiments,  and  his  letter 
was  given  to  Prof.  II.  F.  Osborn,  who  quoted  the  foUow- 

'  Popular  Science  Monthly,  June,  igoo. 
■■'Medical  Record,  May  14,  1892. 


July  14,  1900] 


MEDICAL    RECORD. 


67 


ing  extract  in  his  Cartwright  lecture:  "I  selected  a  pair 
of  white  mice  on  account  of  their  rapid  breeding.  I  bred 
them  in  and  in  for  ninety-six  generations,  as  they  breed 
every  thirty  days,  and  when  they  are  thirtj'  days  old  they 
are  able  to  reproduce  themselves.  I  destroyed  all  sickly 
and  defective  ones  by  breeding  only  the  fittest.  I  bred  all 
disease  out  of  them,  and  had  a  pure-blooded  animal,  larger 
and  finer  every  way  than  the  original  pair.  In  breeding 
their  tails  off,  1  selected  a  pair  and  put  them  in  a  cage  by 
themselves,  and  when  they  had  young  I  took  the  young 
and  clipped  their  tails  off.  When  old  enough  to  breed  I 
selected  a  pair  from  the  young  and  bred  them  together, 
and  when  they  had  young  I  clipped  their  tails.  I  contin- 
i:ed  this  breeding  in  and  in,  clipping  each  generation-,  and 
selecting  a  pair  of  the  last  young  each  time.  In  seven 
generations  some  of  the  young  came  without  tails  until  I 
got  a  perfect  breed  of  tailless  mice.  I  then  took  one  with 
a  tail  and  one  without  a  tail  and  bred  them  together,  and 
by  changing  the  sexes  each  time — a  male  without  a  tail 
and  a  male  with  a  tail — I  was  finally  rewarded  with  all-tail 
mice."  Professor  Osborn  said:  "There  is  such  general 
scejJticism  now  in  regard  to  the  inheritance  of  mutilations 
that  it  will  be  necessary  to  repeat  these  experiments  in 
some  well-known  physiological  laboratory.  As  told  above, 
they  seem  to  be  perfectly  trustworthy,  but  facts  which  go 
against  a  theory  must  be  doubly  attested." 

Jlr.  Shiddell,  in  a  letter  to  me,  says  that  he  was  ten 
years  at  this  work,  yet  by  his  own  statement  not  more  than 
six  generations  can  be  obtained  in  one  year,  so  that  his 
ninety-si.x  generations  would  take  sixteen  years  alone  tor 
the  preliminary  experiments  before  he  began  the  tail  clip- 
ping. It  is  absurd  to  suppose  that  a  man  would  take  such 
a  long  time  for  the  preliminary  work.  In  another  letter  he 
states  that  it  was  only  ninety  generations,  but  as  the  hand- 
writing is  not  that  of  an  old  man  but  rather  that  of  a  young 
woman,  we  presume  that  there  is  an  error  in  copying.  1 
have  been  unable  to  find  the  length  of  gestation  in  white 
mice,  but  as  they  are  merely  albinos  of  the  common  house 
mouse,  we  presume  that  they  have  the  same  period — 
twenty-seven  days,  and  are  not  developed  until  three 
months  old.  This  would  limit  them  to  three  generations 
a  year,  and  for  the  whole  length  of  Shiddell 's  experiments 
a  period  of  thirty-three  years  is  necessary.  It  is  not  likely 
that  in-and-in  breeding  for  ninety-six  generations  will  re- 
.sult  in  finer  specimens  than  the  original,  nor  will  it  breed 
all  disease  out  of  them.  We  are  taught  to  believe  the  re- 
verse. 

He  states  that  he  got  .some  tailless  ones  in  seven  genera- 
tions, but  does  not  state  how  much  longer  it  took  to  get 
them  all  tailless.  In  a  letter  to  me,  he  says  that  in  the 
sixth  generation  some  came  tailless,  and  "in  the  seventh 
generation  all  came  without  tails  and  they  continued  com- 
ing without  tails."  In  a  letter  to  Dr.  Lockwood  he  states 
that  he  had  no  time  to  make  other  e.xperiments,  yet  the 
above  letter  claims  to  have  reversed  the  process. 

It  is  interesting  to  note  that  while  Shiddell  succeeded  in 
seven  generations,  Weismann  failed  in  identical  experi- 
ments after  nineteen  generations,  that  Retzema  Bos  and 
Rosenthal  failed  both  with  rats  and  mice,'  and  that  Dr.  S. 
M.  Worthington'^  calls  attention  to  the  utter  failure  of  such 
mutilations  to  be  transmitted  in  the  dehorning  of  cattle, 
and  clipping  the  ears  of  hogs  and  the  tails  of  lambs. 

Shiddell  gives  the  following  as  his  reasons  for  attempt- 
ing the  experiments :  "  Quite  a  number  of  years  ago,  I 
wished  to  carry  oat  a  theory  of  mine,  which  was  that  each 
particular  part  of  the  animal  organization  furnished  the 
substance  to  reproduce  that  part,  this  being  entirely  origi-  . 
nal  with  me,  never  having  heard  of  any  experiments  being 
made  " — (Darwin's  pangenesis). 

The  cause  of  this  remarkable  publication  of  imaginary 
experiments  is  found  in  Mr.  Shiddell's  mental  equipment. 
He  is  evidently  well  known  locally,  as  shown  by  the  fol- 
lowing extract  from  a  letter  sent  to  me  by  the  editor  of  Tlic 
Kentucky  Ga-ette,  of  Lexington  :  "  He  is  a  gentleman  who 
for  a  long  time  conducted  a  small  grocery,  and  was  known 
as  a  .sort  of  amateur  with  flowers,  white  rabbits,  etc.  He 
must  be  about  seventy  years  of  age,  always  bore  a  good 
reputation,  and  as  far  as  we  know  bore  a  name  unsullied 
by  falsehood.  We  know  nothing  of  his  raising  white 
mice,  but  it  is  like  him  to  do  so,  and  if  he  undertook  such 
a  vocation  he  would  watch  it  closely." 

As  Mr.  Shiddell  claims  to  have  been  personally  known 
for  over  forty  years  to  Colonel  Bruce,  we  can  well  believe 
his  reputation  for  eminent  respectability.  His  real  person- 
ality was  not  known  to  either  of  the  above  gentlemen.  I 
learn  from  Dr.  S.  M.  Worthington,  of  Versailles,  Ky. ,  that 
some  of  his  friends  who  have  seen  Shiddell  have  informed 
him  that  Shiddell  is  not  reliable.  He  is  evidently  a  gentle, 
dear  old  soul,  of  visionary  nature,  full  of  strange  conceits, 
who  had  thought  so  much  of  his  theory  of  pangenesis  that 
he  finally  brought  himself  to  believe  that  he  had  actually 

'  "The  Germ  Plasm."  p.  397. 

'  Medical  Record,  Feb.  20,  1897. 


made  the  experiments  which  he  de.scribes  with  so  much 
irreconcilable  detail.  Deliberate  falsehood  or  practical 
joking  is  quite  out  of  the  question  in  such  a  case. 

It  is  highly  important  that  the  real  facts  be  known,  for 
the  alleged  experiments  have  been  published  far  and  wide 
as  attested  scientific  facts.  Dr.  R.  Harcourt  Anderson 
refers  to  them  in  the  Medical  Recoud  of  October  2,  1897; 
Dr.  E.  S.  Talbot  quotes  them  in  his  book  on  "Degener- 
acy"; an  editorial  wiXh^  Journal  of  the  American  Meili- 
cal  Association,  November  iS,  1S99.  accepts  as  a  fact  that 
mutilations  are  transmissible,  and  Dr.  Lockwood  informs 
me  that  he  has  received  so  many  letters  of  inquiry  on  the 
subject  that  it  is  evident  that  the  original  1892  report  has 
been  universally  accepted.  It  is  remarkable  that  scientists 
should  have  been  so  taken  in,  and  almost  amusing  that 
Dr.  Talbot,  in  his  work  on  people  of  nervous  instability, 
should  have  been  the  victim  of  one  of  these  subjects. 

We  can  rest  assured  that  the  only  way  to  breed  tailless 
mice  is  to  select  those  with  the  shortest  tails  and  continue 
the  process  for  untold  generations,  imitating  nature's 
method  of  natural  selection.  The  process  will  be  a  grad- 
ual diminution  of  the  tails  to  their  ultimate  extinction  ;  but 
to  suppose  for  a  moment  that  the  tails  will  suddenlv  dis- 
appear in  a  whole  litter,  except  as  a  teratological  freak  due 
to  causes  we  know  nothing  about,  is  the  height  of  ab- 
surdity. Charles  E.  Woodrlff,  M.D.,  U.S.A. 

Fort  Rilev,  Kansas. 

P.  S. — Since  the  above  was  written  the  following  tele- 
gram has  appeared  in  the  daily  papers:  "Lexington,  Ky., 
June  30th. — ^B.  N.  Shiddell,  aged  eighty-three  years,  dietl 
here  to-day.  He  was  a  man  of  eccentric  habits,  and  was 
known  throughout  Kentucky  as  a  man  who  bred  the  tails 
off  white  mice.  He  labored  for  nine  years  to  accomplish 
this  result,  during  which  time  he  bred  ninety-six  genera- 
tions of  the  prolific  animals.  He  swore  that  he  would  not 
shave  until  Henry  Clay  was  elected  President,  and  he  wore 
his  long  beard  several  feet  in  length,  knotted  and  massed 
under  his  vest  to  keep  it  out  of  the  way.  Shiddell  was 
born  in  the  house  in  which  he  died." 


WOMEN  MEDICAL  GRADUATES  IN  SWEDEN. 

To  THE  Editor  of  the  Medical  Record. 

Sir  :  I  beg  to  correct  the  heading  of  your  notice  on  page 
1087,  vol.  Ivii.  :  "A  Woman  Medical  Graduate  in  Sweden." 
There  are  at  least  a  dozen  women  medical  graduates  or  prac- 
titioners in  Sweden,  but  Miss  Stecksen  is  the  first  to  receive 
the  degree  of  M.D.  L'pon  the  completion  of  the  medical 
course  in  Sweden,  the  graduate  receives  the  degree  of  med- 
ical licentiate,  which  entitles  him  to  practise.  To  receive 
the  degree  of  M.D.  an  original  thesis  must  be  written  and 
publicly  defended  ;  if  this  work  is  satisfactory  to  the  fac 
ulty,  the  author  receives  the  degree  of  M.D.  Miss  Sleek- 
sen  is  the  first  woman  medical  graduate  to  do  this,  and  re- 
ceives and  deserves  much  praise  for  her  thesis:  "A  Study 
in  the  Etiology  of  Tumors."  The  heading  of  your  notice 
conveys  the  impression  that  Miss  Stecksen  was  the  first 
and  only  woman  medical  graduate  in  Sweden,  which  I  beg 
to  correct.  C.  Frithiof  Larson,  M.D. 

Crystal   Falls,  Mich. 


Salicylate  of  Methyl  applied  on  cotton  compress 
with  two  parts  of  oil  rapidly  diminishes  pain  in  epi- 
didymitis.— Bettmann. 

Threatened  Abortion. — To  decrease  irritability  of 
the  uterine  mucous  membrane  give  iodide  of  potassium, 
gr.  V.  three  times  a  day. —  Montgomery. 

Ataxia  should  be  treated  by  compensatory  move- 
ments. Since  innervation  of  the  antagonistic  force  is 
at  fault,  resisting  movements  should  be  carried  out. 
It  is  not  the  degree  of  inco-ordination,  but  the  char- 
acter of  the  case  which  should  determine  prognosis. — 
Bu.MM,  in  Gesell.  der  Aerzte,  Vienna,  January  13, 
1900. 

Thinness. — Physical  and  cerebral  rest,  country  air, 
hydrotherapy;  fatty  meats  an  '  fatty  food  ;  breadcrust, 
pastry,  beans,  peas,  nuts,  sugars,  honey;  Fowler's  solu- 
tion up  to  gtt.  xv.-xx.,  graduated.  Condiments  should 
be  avoided  excepting  salt,  acids,  sour  fruits,  salads, 
cabbage,  coffee,  turnips,  tea,  hot  drinks,  sour  wines, 
tobacco. —  Le  Roy,  Gaz.  des  Hop.,  February  22d. 


68 


MEDICAL    RECORD. 


[July  14,  1900 


Clinical  gcpuvtmcut 

A  DIPROSOPUS. 

By   J.    E.    CAVEV,    M.D., 

WEST   ALEXANDRIA,    OHIO. 

My  first  case  of  obstetrics  in  the  new  year  was  of  such 
unusual  occurrence  that  I  believe  a  report  of  it  would 
be  of  interest  to  the  profession.  It  was  the  spon- 
taneous delivery  of  a  diprosopus. 

On   January  8th   I   was   called  to   attend   Mrs.  H. 

S ,  white,  aged  thirty-eight  years,  mother  of  four 

children  born  singly.     Her  mother  had  given  birth  to 

twins.  The  child 
was  born  dead  at 
about  the  seventh 
month  of  preg- 
nancy and  weighed 
six  pounds.  I 
was  unable  to  pro- 
cure the  specimen, 
but  obtained  a 
photograph. 

Both  heads  were 
of  uniform  size,  the 
bones  of  each  head 
being  well  devel- 
oped. The  fea- 
tures were  mark- 
edly alike.  The 
body  was  very  well 
formed.  The  gen- 
erative organs  re- 
sembled those  of 
both  sexes,  a  small 
but  well-defined 
penis  springing 
from  the  upper  por- 
tion of  the  vulva. 
Labor  was  tedious 
but  uncomplicated.  The  right  head  rested  against  the 
ilium,  while  the  left  head  escaped  from  the  vulva. 
The  recovery  of  the  woman  was  uneventful. 


A    CASE    OF    EPILEPSY    CURED    BY    OPERA- 
TION   ON    THE    NOSE. 

By   J.    J.    RICHARDSON,    M.D., 

WASHINGTON,    D.    C, 

DEMONSTRATOR   OF    RHINOLOGV     AND     LABVNGOLOGY,    GEORGETOWN     UNIVER- 
SITY  MEDICAL  SCHOOL. 

Epilepsy  is  one  of  the  neurotic  diseases  which  we 
cannot  associate  with  any  constant  pathological  le- 
sion. The  exciting  cause  in  individual  cases  differs 
widely,  and  there  is  no  definite  or  uniform  etiological 
factor  demonstrable.  The  clinical  phenomena  are 
usually  the  same,  regardless  of  the  etiology.  The  nose 
has  many  sins  to  answer  for,  and  among  them  is  epi- 
lepsy, as  shown  by  the  following  case  which  has  come 
under  my  care : 

Boy,  aged  twelve  years,  of  neurotic  temperament  and 
son  of  healthy  parents  with  good  family  history.  The 
boy  had  been  having  epileptic  seizures  very  fre- 
quently for  eighteen  months,  but  much  oftener  the 
six  months  preceding  the  time  he  came  under  my  care. 
Scarcely  a  day  would  pass  without  a  paroxysm,  and 
sometimes  several  would  occur  in  twenty-four  hours. 
The  seizures  usually  were  abrupt  in  tiieir  onset,  with- 
out any  apparent  aura.  There  were  loss  of  conscious- 
ness, frothing  at  the  mouth,  and  at  times  bleeding  of 
the  tongue.     The  symptoms  usually  quickly  subsided. 


and  were  followed  by  a  short  period  of  confusion  of 
thought.  A  rhinoscopic  examination  revealed  a  hy- 
peraesthetic  nasal  passage  and  a  marked  hypertrophy 
of  the  middle  and  inferior  turbinated  bodies  of  the 
right  nasal  cavity.  The  breathing  was  obstructed  and 
there  was  considerable  pressure  on  the  septum  from 
the  hypertrophied  tissue.  Under  cocaine  with  the 
electro-cautery  I  destroyed  the  thickened  tissue  by 
two  operations,  one  week  apart.  The  month  preced- 
ing the  first  operation  the  boy  had  not  missed  a  single 
day  without  having  a  "spell,"  and  the  week  following 
the  first  operation  he  had  only  three.  After  the  sec- 
ond operation  he  did  not  have  another  paroxysm.  He 
has  been  under  observation  eight  months  and  is  en- 
joying perfect  health.  Xo  other  treatment  was  admin- 
istered, but  he  had  been  taking  bromides  before  the 
nasal  treatment  with  no  apparent  effect. 


MUMPS  IN  PNEUMONIA. 
By   CHARLES   W.    DULLES,    M.D., 

FHILADELPHIA. 

It  is  a  curious  but  well-known  fact  that  at  certain 
times  there  occurs  almost  simultaneously  a  consider- 
able number  of  cases  of  forms  of  disease  or  injury 
which  are  in  general  quite  rare.  This  has  been  re- 
cently illustrated  by  the  publication  by  several  obser- 
vers of  reports  of  the  development  of  mumps  in  the 
course  of  pneumonia.  The  articles  in  which  these 
cases  have  been  recorded  indicate  that  insufficient 
mention  of  this  complication,  in  the  text-books,  has 
led  to  the  impression  that  it  is  more  rare  than  it  actu- 
ally is.  As  a  matter  of  fact  the  occurrence  of  infiam- 
matory  swelling  of  the  salivary  glands  in  the  course  of 
pneumonia  has  been  described  in  really  comprehen- 
sive works  like  that  of  Wilson  Fox  on  "  Diseases  of 
the  Lungs  and  Pleura.''  Still,  the  publication  of  re- 
cent observations  is  more  likely  to  put  the  members  of 
the  profession  on  their  guard  than  its  mention  in  the 
books.  For  this  reason — and  for  another — I  think  it 
worth  while  to  make  public  an  observation  of  my  own 
occurring  during  the  past  winter,  when  the  other  cases 
were  noted.  My  patient  was  a  woman  over  eighty 
years  of  age,  living  in  the  Presbyterian  Home  for 
Widows  and  Single  Women,  in  this  city,  a  person  of 
great  neatness  and  careful  habits,  who  contracted  a 
cold  which  passed  at  once  into  a  croupous  pneumonia 
affecting  the  left  lung.  She  became  very  ill,  but  after 
the  crisis  she  began  to  improve,  and  eventually  she 
fully  recovered.  Just  after  the  crisis  I  found  that  she 
had  marked  swelling  of  the  right  parotid  gland,  which 
presented  all  the  characteristics  of  mumps,  and  after- 
ward the  left  parotid  gland  went  through  precisely  the 
same  stages.  In  this  case  there  was  no  question  of  a 
second  infection  from  without :  it  was  a  plain  case  of 
auto-infection. 

The  second  motive  for  this  publication,  referred  to 
above,  is  to  describe  the  treatment  adopted.  On  each 
side  successively  I  applied  a  fairly  thick  compress  of 
surgical  gauze  saturated  with  boroglyceride  and  cov- 
ered with  a  layer  of  paraffin  paper  and  just  enough 
bandage  to  keep  it  in  place.  The  relief  of  pain  and 
the  subsidence  of  swelling  which  promptly  followed 
the  application  I  am  disposed  to  attribute  to  the  boro- 
glyceride. This  is  an  application  of  the  greatest  util- 
ity in  a  variety  of  inflammatory  swellings,  and  espe- 
cially in  the  case  of  incipient  boils  and  carbuncles. 
In  my  hands  it  has  wholly  replaced  the  poultice;  and 
since  some  years  ago,  when  I  began  to  use  it  where 
poultices  used  to  be  employed,  I  liave  not  had  to  apply 
the  knife  to  either  boil  or  carbuncle.  I  have  also 
found  it  useful  in  infianunatory  swellings  below  but 
near  to  the  true  skin,  and  I  have  obser\ed  recently  the 


July  14,  1900] 


MEDICAL    RECORD. 


69 


extensive  advertisement  of  a  nostrum  recommended 
for  use  in  similar  cases,  wliich  I  am  informed  consists 
of  a  mixture  of  glycerin  and  talcum  powder.  If  this 
nostrum  proved  of  \alue,  I  believe  that  it  was  through 
the  depleting  influence  of  the  gljxerin ;  and  boro- 
glyceride — of  a  strength  not  greater  than  fifty  per 
cent.  —I  presume  would  be  a  more  rational  and  equally 
useful  application. 


FECUNDITY. 


By   WILLIAM    P.    BUKKE,    M.D., 

NEW   HAVEN,   CONN. 

Ox  the  evening  of  May  23d  I  was  called   to  attend 

Mrs.  H in  her  fourth  labor.     After  a  tedious  and 

rather  severe  labor  I  delivered  her  on  the  morning  of 
the  24th  of  triplets,  two  boys  and  one  girl.  The  boys 
weighed  eight  and  nine  pounds  respectively,  and  the 
girl  seven  pounds,  making  twenty-four  pounds  of  chil- 
dren in  all.  There  was  but  one  placenta,  which  was 
attached  in  three  places,  arranged  very  much  like  a 
clover-leaf  with  membranous  connections  between  the 
patches  of  placental  tissue. 

One  of  the  children,  the  second,  a  bo\-,  presented 
by  the  feet  and  died  in  about  fifteen  minutes  after 
birth.  The  others  were  vertex  presentations.  On 
May  I,  1898,  I  delivered  this  woman  of  twins,  a  boy 
and  girl.  She  also  had  previously  had  two  other 
labors  with  one  child  at  each  birth.  Ten  months  be- 
fore she  gave  birth  to  the  twins  and  about  the  same 
time  before  giving  birth  to  the  triplets  she  miscarried 
at  five  months.  All  of  this  occurred  within  six  years 
and  one  month.  Of  the  seven  full-term  children  but 
three  are  living. 

Her  mother  gave  birth  to  eight  children  in  all,  and 
her  grandmother  to  eleven. 


A  CASE  OF  SUDDEN  AND  UNEXPECTED 
DELIVERY  OF  TWINS. 

By   W.    C.    hands,    M.D.. 

NEW    YORK. 

Mrs.  E.  C ■,  aged  twenty-four  )'ears,  who  had  pre- 
viously after  a  lingering  labor  given  birth  to  one  child, 
some  time  ago  sent  her  husband  for  me.  His  remarks 
to  me  were:  ''  Doctor,  mother  would  like  you  to  stop 
at  the  house  some  time  this  morning.  Emmie  [his 
wife]  is  not  feeling  well;  there  is  no  hurry,  any  time 
will  do."  By  chance  I  responded  at  once.  Upon  ar- 
rival at  their  apartments,  I  found  every  one  in  great 
excitement,  standing  about  in  the  most  ridiculous  at- 
titudes. On  the  bed,  in  the  knee-hand  position,  was 
the  patient,  naked  from  the  shoulders  down.  As  I 
entered  the  room  my  view  of  things  was  a  rear-end 
one,  and  I  saw  extending  through  and  from  the  vulva 
what  proved  to  be  an  umbilical  cord,  dangling  from 
the  end  of  which  was  a  stnall  baby  boy.  I  think  my 
smile  was  excusable.  The  patient  had  been  in  that 
position  for  fifteen  or  twenty  minutes,  not  daring  to 
move,  and  no  one  present  had  the  temerity  to  render 
her  any  assistance.  After  making  her  comfortable 
and  delivering  the  placenta  I  was  surprised  to  find 
two  cords  attached.  I  mentioned  the  fact  that  there 
must  be  another  child  around  somewhere,  and  hunted 
about  the  bed  without  success.  Upon  questioning  the 
patient  as  to  what  room  she  was  in  before  going  to 
her  bedroom,  she  replied,  "The  dining-room,  but 
stopped  in  the  bath-room,  where  the  waters  broke,  and 
I  hurried  right  in  here. '" 

I  went  into  the  bath-room,  and,  sure  enough,  there  in 
the  liopper  was  the  other  child,  a  boy,  doing  his  best 


to  wriggle  into  a  comfortable  position.  Fortunately, 
the  mother  had  not  pulled  the  handle,  or  the  child 
would  have  gone  down,  it  being  an  ordinary  pan- 
closet.  The  patient  afterward  told  me  she  had  pain 
while  in  the  bath-room  and  a  gush  of  water,  but  did 
not  have  the  slightest  idea  that  anything  but  the  water 
had  passed  from  her,  and  when  she  reached  the  bed  and 
was  about  to  lie  down  in  it  a  child  dropped  from  her, 
and  she  was  afraid  to  move  or  lie  down.  There  was 
absolutely  no  pain  with  the  delivery  of  the  second 
child,  only  the  tug  when  it  readied  the  end  of  the  cord, 
which  did  not  break  as  the  first  one  had  done.  There 
had  been  a  miscalculation  of  two  months  in  this  case 
of  the  probable  date  of  parturition,  and  the  mother 
had  no  idea  of  the  cause  of  the  pain,  even  when  tlie 
waters  broke,  until  the  second  child  fell  from  her  while 
stepping  on  to  the  bed.  Neither  child  received  any 
injury,  and  together  with  the  mother  both  are  in  fine 
feather.  The  parents  were  intending  to  name  one  of 
the  boys  William  Cornelius,  but  when  they  thought  of 
the  initials,  W.  C,  it  occurred  to  them  that  it  might 
be  too  suggestive  of  the  place  where  the  doctor  found 
him. 

205  West  One  Hundred  and  Thirtieth  Street. 


A  CASE  OF  MYXCEDEMA,  WITH  TREATMENT. 


By    ETHAN    E.    GRAY,    .M.D., 

CHICAGO,    ILL, 

aged  fifty-nine  years,  came  to  me  for 


Mrs.   H- 

treatment  of  a  general  "dropsy,"  which,  she  stated, 
had  existed  for  thirteen  years,  at  the  beginning  of 
which  time  the  feet  began  to  swell.  The  oedema,  or, 
rather,  swelling,  gradually  extended  upward,  and  in 
the  fourth  year  of  the  disease  swelling  of  the  face  be- 
came apparent.  The  arms  and  hands  also  swelled, 
and  the  latter  became  useless  for  finer  work.  The 
hair,  eyebrows,  and  eyelashes  began  to  fall  out,  and 
depilation  continued  until  there  were,  in  January  of 
this  year,  but  a  few  wisps  of  dry,  split  hair  left  on  the 
scalp. 

The  headaches  became  more  and  more  frequent,  the 
mind  became  obtunded,  and  reading  was  abandoned 
on  account  of  the  difficulty  of  concentration  of  the 
mind.  The  patient  became  moody,  desired  to  live 
alone,  refusing  society,  and  leading  a  drowsy  existence. 
She  became  so  somnolent  that  she  slept  while  engaged 
in  the  lighter  tasks  of  housework.  The  tongue  was 
thick,  making  speech  somewhat  indistinct  at  times. 
As  her  thoughts  were  slow,  so  was  her  speech.  Her 
voice  became  deep,  almost  masculine  in  character,  and 
rough.  She  stated  that  a  sister,  near  her  age,  was 
affected  similarly,  though  in  a  lesser  degree. 

The  appearance  of  the  patient  at  the  time  of  my 
first  examination  was  in  thorough  accord  with  tlie  ac- 
cepted description  of  Gull's  disease:  The  head  was 
greatly  bloated,  the  scalp  nearly  hairless;  the  cheeks 
were  heavy,  pendulous,  and  pale.  The  ears  were  thick- 
ened, the  eyes  almost  concealed  by  overhanging  water- 
bags,  the  lips  as  thick  as  a  negro's,  and  the  nose  was 
broad  and  thick.  Here  and  there  were  patches  of  rosy 
color,  but  the  skin  as  a  rule  presented  a  shiny,  pale 
appearance. 

The  abdomen  was  enormous,  its  walls  being  very 
thick  and  imparting  a  brawny  feel  to  the  fingers. 
The  legs  were  enormously  swollen,  as  were  the  feet. 
The  thyroid  gland  was  not  palpable,  the  trachea 
being  felt  well  down  toward  the  base  of  the  neck, 
through  the  thickened  tissues.  Examination  of  the 
abdominal  organs  elicited  nothing  of  note.  The 
spleen  and  liver  were  of  normal  size,  but  it  was  im- 
possible to  locate  the  kidneys.     The  heart  was  normal. 

Uranalysis  revealed  no  albumin,  no  sugar,  no  casts. 


^o 


MEDICAL    RECORD. 


[July  14,  1900 


Urea  was  excreted  in  fair  quantity;  specific  gravity, 
1.020-1.035.     The  bowels  were  constipated. 

The  patient  was  at  once  placed  on  desiccated  thy- 
roids, a  haematic,  and  occasional  eliminants  in  the  form 
of  the  mild  chloride.  The  dose  of  the  thyroids  was 
gr.  iii.  four  times  daily  at  first,  later  reduced  to  three 
times  a  day.  At  the  end  of  the  third  week  of  thyroid 
feeding  the  swelling  in  the  abdomen  and  in  the  legs 
had  begun  to  disappear.  In  six  weeks  the  patient  had 
taken  an  interest  in  household  affairs,  beginning  sew- 
ing, reading,  and  brightening  up  mentally.  The  hair 
began  to  grow  all  over  the  scalp,  the  eyebrows  and 
eyelashes  reappeared.  The  voice  became  higher 
pitched  and  more  feminine  in  character.  The  eyelids 
had  become  normal  in  size,  while  wrinkles  appeared 
over  the  face.  At  this  date.  May  25th,  the  patient  is 
in  a  normal  condition  mentally,  and,  barring  a  thick 
crop  of  short,  dark  hair  on  the  scalp,  is  in  no  way  dif- 
ferent from  other  women  of  her  age. 

This  case.  I  think,  presents  as  typical  a  history  of 
adults'  myxcedema  as  can  be  desired;  and  yet,  during 
the  thirteen  years  she  has  been  afflicted,  she  has  under- 
gone much  treatment  for  nephritis  and  cirrhosis  of  the 
liver. 

The  salient  features  of  the  case  should  not  be  for- 
gotten, viz.,  (a)  the  general  swelling  of  the  features 
and  of  the  body;  (/')  the  mental  condition  of  the  pa- 
tient, i.e.,  the  disinclination  to  effort;  (c)  the  slow 
speech  and  dragging  of  words.  With  these  points  in 
mind,  it  should  be  a  simple  matter  to  differentiate  be- 
tween the  myxoedematous  condition  and  the  dropsies 
due  to  renal,  hepatic,  or  cardiac  disease. 

158  EvANSTON  Avenue. 


A  CASE  OF  TUBERCULOUS  INTRAPERI- 
TONEAL EFFUSION  CURED  BY  INCISION 
AND  PERMANENT  DRAINAGE.' 


peritoneum  was  found  to  be  thickened,  hypera.-mic, 
and  studded  with  tuberculous  nodules.  There  were 
slight  adhesions  in  places.  The  effusion  was  general, 
occupying  the  whole  peritoneal  cavity.  The  liquid 
was  slightly  turbid,  containing  some  flocculi  of  lymph. 
The  abdominal  cavity  was  drained  with  a  rubber  tube 
passed  deep  down  into  the  pelvis  and  loosely  packed 
with  iodoform  gauze.  This  drain  was  allowed  to  remain 
for  two  months,  after  which,  on  October  30,  1897,  the 
patient  was  discharged  from  the  hospital  as  improved. 

During  her  stay  in  the  hospital,  her  highest  temper- 
ature was  102.6"  F.,  pulse  138;  but  most  of  the  time 
her  condition  in  this  respect  was  normal.  The  wound 
was  dressed  every  other  day.  The  treatment  otherwise 
was  symptomatic. 

On  May  3,  1900,  nearly  three  years  later,  the  patient 
presented  herself  at  Dr.  Brothers'  office.  She  said  that 
after  leaving  the  hospital  she  visited  relatives  in  the 
country  with  whom  she  remained  a  long  time.  The 
fluid  did  not  reaccumulate,  and  she  gradually  recov- 
ered her  health  and  strength  so  that  at  present  she  is 
perfectly  well.  No  medical  or  surgical  treatment  was 
followed  after  she  left  the  hospital. 

Nearly  fifteen  years  ago  the  method  of  draining  the 
peritoneal  cavity  with  tubes  after  laparotomy  wr.~  in 
general  vogue,  and  it  is  still  in  use  among  certain 
operators,  notably  W.  Gill  Wylie  and  Tuffier.  Many 
years  ago  Caille',  of  this  city,  published  a  sei'es  of 
observations  in  which  permanent  drainage  of  the  peri- 
toneal cavity  in  cases  of  persistent  or  recurrent  effu' 
sions  (as  after  cirrhosis  of  the  liver)  was  resorted  to. 
The  method,  however,  was  never  apparently  generally 
adopted,  the  profession  preferring  to  make  repeated 
tappings  v.'ith  trocar  and  cannula.  This  case,  how- 
ever, would  seem  to  justify  the  more  extensive  employ- 
ment of  this  method  of  permanent  drainage  in  a  se- 
lected class  of  cases. 

257  East  Broadway. 


By   GEORGE   I.    MILLER,    M.D., 

NEW  YORK, 
LATE    HOUSE    SURGEON   TO    UETH   ISRAEL   HOSPITAL. 

O.  F ,  forty-six  years  of  age,  a  Hebrew  woman, 

was  admitted  into  the  Beth  Israel  Hospital  on  August 
31,1897.  The  family  history  was  negative.  She  had 
had  the  usual  diseases  of  childhood.  She  began  to 
menstruate  when  fifteen  years  of  age,  and  the  period 
was  always  regular,  lasting  three  to  four  days,  moderate 
in  quantity  and  painless.  She  married  at  the  age  of 
twenty-one  years;  she  gave  birth  to  twelve  healthy 
children — her  last  child  being  born  when  she  was 
thirty-five  years  old.  She  never  aborted.  At  the  age 
of  forty-three,  or  three  years  ago,  her  menstruation 
ceased. 

She  always  felt  strong  and  healthy  up  to  six  months 
ago,  when  she  was  suddenly  seized  with  pains  in  the 
stomach  and  had  alternate  chills  and  hot  flushes. 
This  condition  lasted  about  a  week.  Later  on  she 
began  to  notice  swelling  of  the  hands  and  feet.  On 
admission  her  feet  were  found  to  be  swollen,  and  her 
abdomen  was  greatly  distended  with  fluid.  The  heart, 
lungs,  liver,  and  spleen  were  examined  and  found  to 
be  normal.  The  temperature  was  99°  F.  and  the  pulse 
72.  Urinary  examination  was  negative;  specific  grav- 
ity, 1. 016;  no  albumin,  a  trace  of  phosphates. 

Operation :  The  woman  was  operated  on  by  Dr.  A. 
Brothers  on  September  3,  1897,  after  the  usual  prepa- 
rations. .An  incision  three  inches  in  length  was  made 
in  the  linea  alba  midway  between  the  umbilicus  and 
symphysis  pubis.  The  peritoneum  was  opened  and 
about  three  gallons  of  liquid  evacuated.  The  abdom- 
inal  and   pelvic  organs  seemed  to  be  normal.     The 

'  Presented  at  a  meeting  of  the  Eastern  Medical  .Society,  held 
on  May  11,  iqoo. 


REPORT  OF  A  CASE  OF  CARBOLIC-ACID 
POISONING  SUCCESSFULLY  TREATED 
WITH  ALCOPIOL.' 

By    II.    RODMAN,    M.D., 

NEW   YORK. 

As  this  case  admits  of  no  possible  doubt  in  the  saving 
of  life  by  the  employment  of  alcohol  in  carbolic-acid 
poisoning,  I  feel  it  my  duty  to  report  it,  and  state  all 
details  as  they  occurred. 

Although  I  thought  at  the  time  that  the  particular 
method  I  emplo)ed  was  original  with  me,  I  have  since 
learned  that  several  other  patients  had  been  treated, 
and  successfully  too,  in  like  manner.  It  had  been 
fully  demonstrated  by  Drs.  Powell  and  Phelps  that 
alcohol  was  a  direct  antidote  to  carbolic  acid.  Powell 
himself,  in  front  of  his  class,  filled  his  mouth  with 
pure  carbolic  acid  and  allowed  it  to  remain  thirty 
seconds;  he  then  filled  his  mouth  with  pure  alcohol, 
and  sul'fered  no  bad  results  whatever.  We  all  know 
its  efficacy  in  the  treatment  of  sinuses,  and  various 
experiments  have  been  made  proving  the  direct  action 
of  alcohol  on  the  escharotic  and  destructive  action  of 
carbolic  acid.  It  was  then  suggested  that  alcohol 
could  and  should  be  employed  when  carbolic  acid 
has  been  taken  into  the  stomach.  It  may  seem  he- 
roic treatment  to  pour  pure  alcohol  into  the  stomach 
and  then  wash  out  the  organ,  but  we  know  that  car- 
bolic acid  is  one  of  the  most  deadly  poisons,  particu- 
larly when  large  quantities  have  been  swallowed,  and 
that  almost  every  such  case  terminates  fatally. 

The  treatment  of  carbolic-acid  poi>»oning  up  to  the 
present  time  has  been  most  unsatisfactory,  and  when 

'  Read  at  the  regular  meeting  of  the  Harlem  Medical  Associa- 
tion on  March  12,  igoo. 


July  14,  1900] 


MEDICAL    RECORD. 


7^ 


one  considers  how  common  a  poison  it  is,  and  how 
readily  obtained  by  a  layman,  we  can  congratulate 
ourselves  on  the  discovery  of  so  valuable  an  antidote. 
When  carbolic  acid  has  been  allowed  to  remain  for 
any  considerable  time,  and  when  the  destruction  of 
tissue  has  been  extensive,  alcohol  cannot  exert  much 
influence  on  the  tissues,  but  it  should,  nevertheless, 
be  employed. 

My  case  is  as  follows:   On  December   17,  1899,  I 

was  called  to  attend  a  woman,  Mrs.  M ,  of  this 

city,  who  had  talcen  poison  by  mistake.  When'  I  ar- 
rived in  a  very  short  time,  I  found  the  patient,  si.\ty 
years  of  age,  lying  prostrate  in  bed,  with  a  two-ounce 
bottle  of  pure  carbolic  acid  on  the  dresser,  and  en- 
tirely empty.  The  fact  of  it  being  pure  carbolic  acid 
was  evident,  both  from  the  label  and  after  testing  it 
personally,  and  from  the  patient's  own  statement  sub- 
sequently. I  had  been  told  by  her  son  that  his 
mother  had  been  suffering  with  neuralgia,  and  had 
been  in  the  habit  of  taking  medicines;  that  she  had 
bought  pure  carbolic  acid  the  night  previous  for  dis- 
infecting purposes,  and  had  placed  it  on  the  dresser 
with  the  other  bottles;  that,  being  seized  with  severe 
pains,  she  poured  out  the  contents  of  this  bottle  into 
a  wine-glass  and  drank  it.  She  soon  realized  her  mis- 
take, calling  to  her  son,  who  ran  around  for  me.  By 
the  time  I  reached  her  she  was  completely  uncon- 
scious; her  pulse  was  thready  and  scarcely  percep- 
tible; there  was  extreme  dyspnea,  the  face  was  con- 
gested, the  lips  were  cyanotic,  and  the  conjunctival  and 
pupillary  reflexes  were  absent.  Her  extremities  were 
limp  and  cold.  The  temperature  per  rectum  was  96.2° 
F.  The  patient  was  in  an  extreme  condition  of  col- 
lapse. An  eschar  had  already  formed  on  her  lips  and 
tongue.  I  gave  a  very  bad  prognosis,  expecting  that 
the  patient  would  surely  die.  Of  course  she  could  not 
swallow,  so  I  introduced  a  stomach  tube  carefully  into 
the  pharynx,  not  into  the  stomach,  and  poured  down 
four  ounces  of  pure  alcohol,  which  I  had  in  my  satch- 
el. I  allowed  this  to  remain  two  or  three  minutes, 
considering  that  sufficient  time  first  to  exert  its  anti- 
dotal action,  and  then  introduced  the  tube  into  the 
stomach,  and  washed  out  the  contents  with  warm  wa- 
ter. I  then  washed  out  the  stomach  again  with  di- 
lated alcohol  which  I  had  ordered,  and  then  withdrew 
my  stomach  tube.  Nothing  else  had  been  done  up  to 
this  point.  A  second  physician,  who  had  been  called, 
pronounced  the  case  hopeless,  and  criticised  my  treat- 
ment. An  ambulance  surgeon,  who  was  also  sum- 
moned, said  the  patient  would  surely  die,  and  that 
it  was  useless  to  take  her  to  the  hospital.  I  had  no- 
ticed some  improvement  already,  and  considered  the 
patient  strong  enough  to  be  removed  to  the  hospital, 
not  knowing  what  complications  would  ensue,  and 
that  even  should  the  patient  rally,  I  did  not  think  that 
she  could  be  treated  properly  at  home  under  the  cir- 
cumstances. The  family  refused  to  do  this,  and  I  left 
the  house,  the  other  physician  remaining  in  charge. 
In  twenty  minutes  I  was  recalled,  my  colleague  having 
left  after  telling  the  people  that  the  patient  would  not 
recover.  When  I  returned,  I  found  the  patient  with 
consciousness  returning,  her  eyes  wide  open,  begging 
for  cold  water.  Her  pulse  had  improved  consider- 
ably, her  breathing  had  become  less  frequent,  and  her 
appearance  less  cyanotic.  She  vomited  a  little  and 
her  bowels  moved  twice,  but  no  blood  passed.  I 
then  administered  strychnine  hypodermically  and 
other  cardiac  stimulants,  and  employed  the  usual 
methods  for  combating  shock.  I  must  not  neglect  to 
say  that  I  injected  whiskey  hypodermically  at  fre- 
quent intervals.  Whether  alcohol  introduced  this  way 
combines  chemically  with  the  carbolic  acid  already 
absorbed,  or  not,  has  not  been  sufficiently  demon- 
strated. Within  an  hour  and  a  half  I  had  the  pleas- 
ure of  seeing  my  patient  in  a  cheerful  mood,  with  some 


mental  excitement,  probably  as  a  result  of  the  alcohol 
absorbed.  No  epigastric  pain  or  abdominal  tender- 
ness was  present,  either  at  that  time  or  at  any  subse- 
quent period.  With  the  exception  of  pain  in  the 
nasopharynx,  which  I  had  neglected  to  spray  with 
alcohol,  she  was  free  not  only  from  pain  but  also 
from  any  discomfort  whatever.  The  patient  rallied 
completely,  and  made  an  uneventful  recovery.  On  the 
evening  of  the  same  day  her  temperature  was  102°  F., 
pulse  no,  but  of  good  quality.  She  swallowed  with 
slight  difliculty.  Her  urine,  which  had  to  be  drawn 
off  with  a  catheter,  was  brownish-black,  of  sufficient 
quantity,  and  contained  no  albumin.  I  ordered  Ep- 
som salts  to  be  given  regularly  every  four  hours  and 
mucilaginous  drinks  const.intly.  She  passed  a  com- 
fortable night.  Next  day  the  temperature  was  loi'' 
F.,  pulse  100;  the  urine  still  much  discolored;  there 
was  slight  pain  in  swallowing,  obviated  by  cocaine 
spray.  On  the  third  day  the  temperature  and  pulse, 
were  normal,  and  the  urine  was  also  normal.  On  the 
fifth  day  the  patient  required  no  further  attention,  and 
I  discharged  her  as  perfectly  cured.  She  has  had  no 
bad  symptoms  whatever  since.  Three  weeks  after  she 
called  at  my  office,  and  said  she  was  in  excellent 
health  and  never  felt  better.  Two  months  later  she 
suffered  from  a  severe  attack  of  lobar  pneumonia  fol- 
lowing influenza,  from  which  she  has  fully  recovered. 

I  believe  from  the  foregoing  history  there  is  only 
one  conclusion  possible.  Here  was  a  patient  who  had 
swallowed  a  large  quantity  of  pure  carbolic  acid, 
about  which  there  is  no  doubt  whatever.  Nothing  had 
been  given  to  the  patient  previous  to  my  arrival,  and 
she  was  nigh  moribund  when  I  saw  her.  The  carbol- 
ic acid  had  already  produced  its  destructive  action, 
and  simply  washing  out  the  stomach  would  have  been 
of  little  value.  We  know  at  least  that  even  if  such 
patients  should  recover  from  the  shock,  the  after-effects 
are  most  serious,  such  as  gastric  and  intestinal  ulcera- 
tion, with  severe  epigastric  and  abdominal  cramps, 
purging,  with  bloody  stools,  vomiting,  etc.  All  of 
these  symptoms  were  absent,  no  complications  what- 
ever resulting.  We  had  been  taught  that  soluble  sul- 
phates were  an  antidote  to  carbolic  acid,  but  it  has 
been  proven  that  carbolic  acid  by  mere  contact  with 
soluble  sulphates  cannot  unite  chemically  to  form  sul- 
pho-carbolates.  The  scope  of  this  paper  will  not  al- 
low me  to  go  into  full  details  on  the  complete  action 
of  sodium  sulphate,  but  I  am  sure  any  physician  can 
demonstrate  it  to  his  own  satisfaction.  That  they  do 
combine  with  carbolic  acid  to  form  sulpho-carbolates 
we  know  by  the  examination  of  the  urine,  but  this  for- 
mation takes  place  after  absorption  in  the  body.  So- 
dium sulphate  certainly  would  be  of  little  value  in 
saving  the  oesophagus,  stomach,  etc.,  from  the  rapid 
destructive  action  of  carbolic  acid,  which  alcohol  cer- 
tainly does.  I  did  employ  soluble  sulphate,  but  after 
the  patient  had  rallied,  and  to  combine  with  carbolic 
acid  already  absorbed,  as  I  considered  that  rational. 

The  advantages  of  this  method  of  employing  alco- 
hol are  many.  The  disadvantages  are  few.  One  pos- 
sible disadvantage  may  be  the  introduction  of  a  stom- 
ach tube,  but  this  is  more  than  balanced  by  the  fatality 
of  the  drug  when  the  patient  is  left  alone,  and  most 
authorities  of  the  present  day  advise  washing  out  the 
stomach  in  all  poison  cases.  If  the  tube  is  introduced 
carefully  and  intelligently  the  danger  is  very  slight. 
The  steps  should  be  in  the  following  order:  (1)  Intro- 
duction of  alcohol ;  (2)  washing  out  the  stomach;  (3) 
use  of  soluble  sulphates. 

In  conclusion,  I  must  say  that  although  my  perso- 
nal experience  is  limited  to  this  one  case,  the  evidence 
is  so  strong  as  to  the  efficacy  of  alcohol  in  the  saving 
of  life  in  carbolic-acid  poisoning  when  thus  employed, 
and  in  the  prevention  of  complications  subsequently, 
that  I  would  not  hesitate  to  employ  it  in  every  case. 


72 


MEDICAL    RECORD. 


[July  14,  1900 


If  I  may  be  permitted  to  do  so,  I  would  also  suggest 
that  every  ambulance  surgeon  be  provided  with  pure 
alcohol  to  be  used  in  just  such  an  emergency  as  men- 
tioned here,  and  which  occurs  so  frequently  in  this 
city.  Future  experiences  will,  I  hope,  strengthen  the 
facts  related  here. 


THE    PRACTITIONERS'    SOCIETY. 

One  Hundred  and  Fi/ty-si.xth   Regular  Meeting,  Held 
on  Friday,  May  11,  igoo. 

A.    Alexander  Smith,    M.D.,    President,    in  the 
Chair. 

A  Case  of  Venous  Obstruction  Complicating  Car- 
diac Disease. — This  was  presented  by  Dr.  A.  Alex- 
ander Smith.  The  patient  was  a  young  man  aged 
twenty-three  years,  a  chemist  by  profession.  Seven 
years  ago,  while  a  student  and  bugler  at  a  military 
school,  he  began  to  suffer  from  attacks  of  palpitation 
of  the  heart,  and  a  physician  whom  he  consulted  ad- 
vised him  to  remain  quiet.  He  went  home,  and  soon 
afterward  developed  an  attack  of  chorea,  from  which 
he  recovered  after  several  weeks.  A  few  weeks  ago, 
while  engaged  at  his  work,  he  noticed  for  the  first 
time  that  there  was  a  difference  in  the  color  and  size 
of  his  two  upper  extremities:  the  left  hand  and  arm 
were  cyanotic  in  appearance,  and  the  arm  was  oedema- 
tous.  Varicosities  were  also  noticed  in  the  left  pec- 
toral region.  Examination  of  the  heart  showed  a 
mitral  obstructive  murmur.  Tl  e  patient  had  never 
suffered  from  pain  or  other  synptoms  than  those 
mentioned.  Dr.  Smith  said  he  had  been  induced  to 
present  this  case  on  account  of  the  paper  which  Dr. 
Welch,  of  Baltimore,  read  at  the  recent  meeting  of  llie 
Association  of  American  Physicians,  at  Washington. 
In  that  paper,  which  was  entitled  "  Venous  Thrombo- 
sis as  a  Complication  of  Cardiac  Disease,"  Dr.  Welch 
reported  three  cases  of  this  unusual  complication,  and 
stated  that  the  literature  on  the  subject  was  rather 
meagre.  In  one  of  Dr.  Welch's  cases  the  thrombosis 
complicated  mitral  stenosis,  in  another  mitral  insuffi- 
ciency, and  in  the  third  aortic  and  mitral  insufficiency. 
In  all  of  the  cases  the  venous  obstruction  was  on  the 
left  side.  In  the  discussion  following  Dr.  Welch's 
paper,  several  of  the  gentlemen  present  reported  simi- 
lar cases,  and  Dr.  Cary,  of  Buffalo,  suggested  that  en- 
largement of  the  left  auricle  might  produce  sufficient 
pressure  to  cause  a  slowing  of  the  circulation  and  thus 
allow  the  formation  of  a  thrombus.  Dr.  Smith  said 
that  in  the  case  he  had  shown  he  suspected  the  pres- 
ence of  an  endophlebitis. 

Dr.  Peabody  said  he  thought  the  case  shown  by 
Dr.  Smith  was  a  good  illustration  of  the  condition 
which  Dr.  Welch  had  described  in  his  recent  paper. 
The  swelling  of  the  arm  in  Dr.  Smith's  case  was  an 
example  of  the  so-called  hard  cedema,  and  was  probably 
the  result  of  a  partial  thrombosis  or  a  phlebitis  with- 
out thrombosis. 

In  reply  to  a  question.  Dr.  Peabody  said  he  thought 
it  possible  that  there  might  be  a  condition  of  partial 
occlusion  of  a  vein  by  a  thrombus.  A  phlebitis  might 
cause  a  swelling  of  the  vessel,  with  partial  occlusion, 
and  the  same  result  might  follow  upon  a  thrombosis. 

Dr.  Charles  S.  Bull  said  that  not  infrequently  a 
partial  thrombosis  of  the  retinal  veins  was  found. 

Dr.  Janeway  said  that  while  a  peripheral  thrombo- 
sis might  be  partial,  a  thrombosis  of  the  large  veins 
was  usually  complete,  although  it  might  be  partial. 

Dr.  Andrew  H.   Smith  said  that  anything  which 


interfered  with  the  perfect  smoothness  or  polish  of  the 
intima  might  cause  a  collection  of  fibrin,  and  in  the 
vein  thus  produce  a  partial  or  complete  thrombosis. 

Dr.  Robert  F.  Weir  said  that  in  those  veins  in  which 
the  blood  current  was  slow,  like  the  varicose  veins, 
there  was  a  possibility  of  a  partial  thrombosis  which 
very  frequently  developed  into  complete  obstruction. 
It  was  rare  to  find  such  obstructions  in  the  large 
veins,  as  they  were  usually  washed  away  by  the  force 
of  the  circulation.  In  former  days,  when  the  Esmarch 
bandage  was  resorted  to  in  the  treatment  of  aneurism, 
it  was  not  uncommon  to  see  a  thrombosis  which  filled 
the  sac  become  dissipated  twenty-four  or  forty-eight 
hours  after  the  blood  current  was  re-established,  and  it 
very  seldom  gave  rise  to  any  trouble  in  the  peripheral 
vessels. 

Dr.  Joseph  D.  Bryant  said  that  whenever  a  vessel 
like  the  external  jugular  was  ligated  with  sufficient 
force  to  cause  a  thrombosis,  the  latter  was  very  apt  to 
become  complete. 

Dr.  Robert  Abbe  said  that  in  the  jugular  vein  he 
had  observed  a  thrombosis,  apparently  of  the  septic 
type,  involving  only  one-half  of  the  vessel  wall,  the 
rest  of  it  being  healthy.  He  said  he  had  seen  a  num- 
ber of  cases  of  unilateral  cedema  of  the  leg,  usually 
the  right  leg,  in  patients  who  gave  a  vague  history  of 
appendicitis.  In  these  cases,  the  oedema  was  prob- 
ably due  to  pressure  rather  than  to  inflammation  of 
the  vein;  there  was  no  reason  to  suspect  septic  venous 
obstruction.  In  the  case  shown  by  Dr.  Smith,  the 
cedema  also  seemed  to  indicate  a  venous  obstruction 
resulting  from  pressure  rather  than  from  a  septic  proc- 
ess, as  the  latter  type  would  be  apt  to  give  rise  to 
more  severe  symptoms.  Dr.  Abbe  expressed  the  opin- 
ion that,  in  the  majority  of  cases,  when  a  vein  was 
once  sealed  it  was  permanently  sealed. 

Dr.  Weir  said  that  the  effect  of  pressure  on  the  vein 
as  a  factor  in  the  production  of  cedema  reminded  him 
of  the  cases  of  extensive  cedema  of  the  arm  after 
breast  operation.  In  former  years,  when  the  axilla 
was  only  imperfectly  cleaned  out  after  removal  of  the 
breast,  the  subsequent  (xdema  of  the  arm  was  attributed, 
and  in  many  cases  justly,  to  the  pressure  of  the  enlarged 
glands  upon  the  veins,  but  to-day,  after  the  most  radi- 
cal operation,  which  included  the  removal  of  all  the 
glands  in  the  axillary  region,  this  oedema  of  the  arm 
was  even  more  apt  to  occur  and  to  be  more  or  less 
permanent.  Dr.  Weir  said  he  was  inclined  to  attribute 
it  to  the  pressure  of  the  cicatricial  tissue  upon  the 
veins,  thus  interfering  with  the  return  circulation. 
Another  possible  explanation  was  that  this  very  thor- 
ough removal  of  the  glands  interfered  with  the  return 
of  the  lymphatic  circulation. 

A  Consideration  of  Endocardial  Murmurs  of  Or- 
ganic Origin,  Localized  in  the  Pulmonary  Area  of 
the  Heart:  Illustrated  by  Two  Cases. — Dr.  J.  W. 
Brannan  read  this  paper  (see  page  48). 

Dr.  Walter  B.  James  reported  the  case  of  a  boy 
who  had  two  attacks  of  rheumatism,  both  mild  in 
character.  During  his  second  attack  he  developed  a 
systolic  murmur  in  the  second  left  interspace,  very 
similar  to  the  one  in  the  case  presented  by  Dr.  Bran- 
nan,  but  somewliat  more  distinct  over  the  great  vessels 
of  the  nesk.  There  was  no  cyanosis  or  other  cardiac 
symptom,  and  no  enlargement  of  the  left  or  right 
heart.  Dr.  James  said  he  was  disposed  to  regard  the 
case  as  one  of  mitral  regurgitation. 

Dr.  George  L.  Peabody  said  he  thought  the  colored 
boy  who  had  been  presented  by  Dr.  Brannan  at  the  pre- 
vious meeting  of  the  society,  and  again  at  this  meeting, 
had  a  mitral  systolic  murmur.  It  was  heard  very  dis- 
tinctly over  the  usual  site  of  such  murmurs.  In 
addition  to  this,  there  was  possibly  some  adventitious 
thickening  in  the  pericardium  over  the  apex,  which 
interfered  somewhat  witli  the  sound  reaching  the  ear. 


July  14,  1900J 


MEDICAL    RECORD. 


72> 


That  would  not,  however,  explain  the  intensity  of  the 
sound  farther  up. 

Dr.  E.  G.  Janevvay  said  he  could  recall  a  number 
of  cases  of  loud  systolic  murmur  over  the  pulmonary 
area  of  the  heart  in  which  the  murmur  was  apparently 
independent  of  a  mitral  lesion,  and  was  produced  by 
pressure  on  the  pulmonary  artery.  It  was  possible, 
for  example,  that  such  a  murmur  might  be  due  to 
pressure  symptoms  produced  during  the  movements  of 
respiration,  and  in  such  a  case  no  explanation  of  the 
murmur  could  be  found  at  autopsy.  Another  possible 
explanation  of  such  murmurs  could  be  found  in  ana- 
tomical abnormalities  which  could  not  be  made  out 
during  life. 

Dr.  Beverley  Robinson  said  he  thought  the  sim- 
plest and  most  rational  explanation  of  a  murmur  like 
the  one  heard  in  Dr.  Brannan's  case  was  that  it  was 
the  result  of  pressure  on  the  pulmonary  artery,  due  to 
thickening  and  adhesions  of  the  left  pleura. 

A  Case  of  Pneumonia  Ending  Fatally  with  a 
Convulsion  of  Uraemic  (?)  Origin. — This  case  was 
reported  by  Dr.  Beverley  Robinson.  This  patient 
was  seen  by  him  in  consultation  with  Dr.  J.  E.  Traub, 
who  furnished  the  following  history  of  the  case:  Man, 
fifty-one  years  old,  single;  a  native  of  Ireland,  and  a 
dry-goods  merchant  by  occupation.  He  used  alcohol 
to  a  considerable  extent.  Fifteen  years  ago,  when  he 
first  came  under  Dr.  Traub's  observation,  he  com- 
plained of  neuralgic  pains,  chiefly  occipital,  with 
headache,  dizziness,  dimness  of  vision,  and  insomnia. 
The  urine  at  that  time  showed  the  characteristic  signs 
of  chronic  diffuse  nephritis  :  its  specific  gravity  ranged 
from  1. 010  to  1. 015,  with  varying  amounts  of  albumin 
and  some  granular  casts.  In  1885  the  diagnosis  of 
Bright's  disease  was  confirmed  by  Dr.  F.  Delafield. 
The  urine  gradually  cleared  up,  and  during  the  past 
eight  or  nine  years  it  was  normal.  (Jn  P'ebruary  g, 
1900,  the  patient  had  an  attack  of  grippe,  complicated 
by  gastritis  and  pleurisy,  with  marked  prostration. 
On  February  15th  he  was  seen  by  Dr.  Delafield  in 
consultation,  and  a  favorable  prognosis  was  given. 
At  this  time  the  specific  gravity  of  the  urine  was 
1.020,  and  it  contained  no  albumin,  sugar,  or  casts; 
it  was  acid  and  but  slightly  diminished  in  quan- 
tity; there  was  some  diminution  in  the  quantity  of 
urates.  On  February  i8th  a  pneumonia  developed 
on  the  left  side  posteriorly.  The  urine  was  repeated- 
ly examined  with  negative  results.  On  February  23d 
the  patient  had  two  attacks  of  syncope,  from  which  he 
rallied.  Later  in  the  day  he  had  a  general  urasmic  ( .') 
convulsion,  and  died  in  less  than  a  minute  and  a  half. 
At  the  time  death  occurred  he  was  perfectly  con- 
scious, and  his  mind  was  clear.  Dr.  Robinson  said 
that  his  main  reason  for  reporting  the  above  case  was 
to  emphasize  the  importance  of  ascertaining  the 
amount  of  the  daily  excretions  of  urea  in  cases  of  sus- 
pected nephritis,  independent  of  the  specific  gravity, 
and  the  presence  or  absence  of  albumin  or  casts. 
Bearing  upon  this  joint,  he  read  the  following  letter 
from  Dr.  Frederic  E.  Sondern : 

"In  connection  with  cases  of  chronic  diffuse  ne- 
phritis, I  take  the  liberty  of  making  the  following 
comments:  After  a  chronic  diffuse  nephritis  has  be- 
come well  established  the  evidences  found  in  the 
urine  are  in  the  large  majority  of  cases  always  charac- 
teristic, even  at  times  when  the  lesion  is  most  quies- 
cent— polyuria,  lowered  specific  gravity,  decreased 
daily  excretion  of  urea,  usually  small  amounts  of  albu- 
min and  a  small  number  of  hyaline  and  occasionally 
granular  casts.  During  the  most  quiescent  periods 
the  albumin,  the  casts,  or  both  may  entirely  disappear, 
and  at  such  times  the  only  characteristic  feature  is  the 
diminution  in  the  daily  excretion  of  urea.  In  my 
opinion  this  latter  point  is  the  most  important  and  is 
the  one  which  is  not  given  sufficient  attention  by  most 


observers.  I  will  go  further  and  say,  that  during  these 
entirely  quiescent  periods,  which  may  extend  over  a 
considerable  time,  even  the  polyuria  may  decrease  to 
such  an  extent  that  the  normal  daily  excretion  is  ap- 
proached, and  then  these  specimens  very  closely  re- 
semble normal  ones,  excepting  the  fact  that  the  daily 
amount  of  urea  is  considerably* below  the  normal  min- 
imum. As  the  normal  daily  excretion  of  urea  is  no 
constant  factor,  and  varies  between  extremely  wide 
limits,  and  the  fact  that  so  many  other  circumstances 
in  the  body  metabolism  affect  this  daily  excretion  of 
urea,  it  can  easily  be  understood  how  some  of  these 
cases  may  be  overlooked,  and  others  declared  cured 
when  such  is  by  no  means  the  case.  In  following 
these  cases,  it  is,  I  believe,  extremely  important  to  keep 
track  of  this  daily  excretion  of  urea,  for  it  is  a  far  bet- 
ter guide  to  the  functional  impairment  of  the  kidney 
than  is  the  amount  of  albumin  or  the  number  of  casts, 
of  which  accurate  record  is  usually  kept.  Of  all  the 
cases  of  this  kind  that  I  have  followed,  while  the 
polyuria  usually  persists  throughout,  it  sometimes  dis- 
appears for  longer  or  shorter  periods;  albumin  and 
casts  may,  one  or  both,  occasionally  disappear  entirely 
for  a  time,  but  a  very  critical  examination  usually  re- 
veals very  faint  traces  of  the  former,  and  a  thorough 
microscopic  examination  of  sediments  obtained  by 
centrifuge  usually  shows  a  few  hyaline  casts  at  least. 
As  these  cases  go  from  bad  to  worse,  the  only  change 
sometimes  observed  is  the  continually  diminishing 
daily  excretion  of  urea.  As  the  result  of  compara- 
tively slight  causes,  acute  exacerbations  of  this 
chronic  condition  may  break  out  at  any  time,  and 
then  usually  we  have  a  picture  of  acute  nephritis.  On 
the  other  hand,  a  sudden  uramia  may  develop,  quickly 
followed  by  death,  without  changes  in  the  condition  of 
the  urine  excepting  what  might  be  accounted  for  by 
the  ante-mortem  stasis.  If  these  patients  withstand 
the  ureemic  attack,  subsequent  specimens  of  urine 
present  the  picture  of  a  renal  congestion  or  of  an 
acute  exacerbation  of  the  chronic  lesion." 

Dr.  Peabody  said  he  could  not  agree  with  Dr. 
Robinson  as  to  the  value  of  a  knowledge  of  the 
amount  of  urea  excreted  in  the  prognosis  of  kidney 
disease.  If  any  one  fact  had  been  established  with 
regard  to  urremia,  it  was  that  urea  had  usually  noth- 
ing to  do  with  it.  Urea  could  be  injected  into  the 
veins  of  animals  in  very  large  doses  without  produc- 
ing any  effect  excepting  to  increase  the  amount  of 
urine.  Urea  was  given  therapeutically  in  consider- 
able doses.  What  did  produce  the  convulsive  seizure 
in  ursmia  was  still  uncertain.  The  most  recent  theory 
was  in  favor  of  the  extractives,  such  as  creatin  and 
creaunin.  The  urea  in  the  urine  simply  indicated  the 
amount  of  nitrogenous  material  excreted,  and  must  be 
considered  in  comparison  with  the  amount  taken  in. 

Dr.  Charles  L.  Dana  said  it  was  not  at  all  certain 
that  the  convulsion  in  the  case  reported  by  Dr.  Robin- 
son was  uraemic,  as  no  post-mortem  examination  was 
made.  It  might  possibly  have  been  due  to  an  embol- 
ism or  a  cerebral  hemorrhage  or  sudden  heart  failure. 
The  speaker  said  that  in  his  experience  a  sudden  gen- 
eral eclampsic  seizure  in  adults  was  very  rarely  due  to 
uraemia.  Urajmic  convulsions,  while  they  were  some- 
times general,  were  usually  preceded  by  twitching  and 
prodromata  that  gave  us  an  indication  of  what  was 
going  to  happen. 

Dr.  Brannan  said  it  was  generally  taught  that  a 
good  deal  of  importance  should  be  attached  to  the 
specific  gravity  of  the  urine,  and  that  urea  was  prob- 
ably the  chief  factor  in  influencing  the  specific  gravity. 
In  advanced  chronic  nephritis  we  found,  as  a  rule,  a 
low  specific  gravity,  and  this  generally  went  with  a 
grave  condition  of  the  patient.  On  the  other  hand,  if 
the  specific  gravity  was  high,  there  was  usually  less 
danger  to  the   patient,  as  it  indicated  that  the  excre- 


74 


MEDICAL    RECORD. 


[July  14,  1900 


tory  functions  of  the  kidney  were  being  performed. 
Of  course  the  quantity  of  food  taken,  the  presence  or 
absence  of  fever,  etc.,  must  all  be  taken  into  account 
in  the  individual  case. 

Dr.  Peabody  said  that  while  we  were  prone  to  at- 
tach considerable  importance  to  the  specific  gravity  of 
the  urine,  a  low  specific  gravity  did  not  necessarily 
indicate  a  grave  condition  if  the  patient  was  passing 
a  large  quantity  of  urine. 

L)R.  Andrew  H.  Smith  said  that  in  Dr.  Robinson's 
case  the  possible  influence  of  the  pneumonic  intoxica- 
tion should  not  be  overlooked  Such  convulsions 
were  not  infrequently  observed  in  the  course  of  a 
pneumonia  in  children. 

Dr.  E.  G.  Janeway  said  he  agreed  with  Dr.  Dana 
that  the  convulsion  in  Dr.  Robinson's  case  might  have 
been  due  to  another  cause  than  uraemia.  There  might 
have  been  a  hemorrhage  in  the  medulla  or  brain.  In 
a  case  which  recently  came  under  his  observation  the 
patient  had  a  convulsion  which  was  regarded  as  ure- 
mic, as  it  was  known  that  the  urine  had  long  contained 
albumin  and  casts.  Upon  his  recovering  conscious- 
ness, however,  one  side  of  the  patient  was  found  to  be 
paralyzed,  showing  that  the  convulsion  was  due  to  a 
hemorrhage  of  the  brain.  As  regards  the  urine  in 
kidney  disease,  the  quantity  and  specific  gravity  were 
the  important  points,  according  to  the  recent  experi- 
ments made  by  Dr.  C.  A.  Herter.  The  excretion  of 
urea  was  not  so  important.  Dr.  Janeway  said  he  did 
not  think  Dr.  Robinson's  patient  would  have  died  so 
quickly  from  a  ura;mic  convulsion. 

Dr.  Robixsox,  in  closing,  said  he  was  well  aware 
that  the  question  as  to  the  causative  factor  of  urzemia 
was  still  unsettled.  While  it  might  not  be  caused  by 
urea,  still  an  estimation  of  the  daily  quantity  of  urea 
excreted  gave  us  an  idea  of  the  amount  of  urinary 
solids  eliminated,  which  was  a  very  important  factor 
in  the  prognosis  of  chronic  nephritis. 


NEW    YORK     COUNTY     MEDICAL    ASSOCIA- 
TION. 

Stated  Meeting,  Alay  21,  igoo. 

Frederick  Holme  Wiggin,  M.D.,  President. 

Two  Cases  of  Sarcoma  Cutis. — Dr.  William  S.  Gott- 
HEIL  presented  these  cases.  The  first  was  that  of 
a  man  on  whom  purplish  nodules  appeared  on  various 
parts  of  the  skin  about  six  years  ago.  At  present  the 
condition  was  typical  of  that  variety  known  as  the 
multiple  pigment  sarcomata  of  Kaposi.  The  man  had 
been  treated  for  a  long  time  with  arsenic  injections, 
and  under  this  a  number  of  the  nodules  had  disap- 
peared completely.  The  second  case  also  occurred  in 
a  man  who,  for  fifteen  years  or  more,  had  had  a  naevus 
of  some  kind.  This  had  given  him  no  trouble  for 
many  years.  At  present,  there  were  sarcomatous  nod- 
ules at  the  site  of  the  excision  of  the  first  growth. 
The  prognosis  in  such  a  case  was  much  better  than  in 
sarcomata  of  the  internal  organs — indeed,  a  few  cases 
of  cure  had  been  reported. 

Symposium  on  Organo-Therapy. — The  evening 
was  devoted  to  this  discussion. 

The   Therapeutics  of   the  Suprarenal  Capsule 

Dr.  VVilliam  H.  P.ates  opened  the  discussion  with 
a  paper  on  the  suprarenal  extract.  He  first  exhibited 
an  aqueous  solution  of  the  suprarenal  gland  made  by 
him  in  1894,  and  sterilized.  With  the  exception  of 
having  become  darker  it  had  remained  practically  un- 
changed, and  had  retained  its  therapeutic  properties. 
From  long  experience  with  this  extract  he  was  con- 
vinced that  sterile  preparations  of  it  were  harmless, 
their  chief  action  being  as  a  muscle  tonic.     The  su- 


prarenal extract  was  unique  in  that  while  one-tenth  of 
a  grain  had  produced  the  maximum  physiological  ef- 
fect, two  ounces  had  produced  no  further  action.  Ex- 
periment had  shown  that  when  an  excess  was  used,  the 
additional  quantity  was  stored  in  the  system. 

Preparation:  One  part  of  the  dried  extract  should 
be  boiled  in  ten  parts  of  a  saturated  solution  of  boric 
acid,  filtered,  and  again  boiled  in  the  permanent  re- 
ceptacle. No  matter  how  carefully  prepared,  the  solu- 
tion should  not  be  sprayed  into  the  nose  and  left  there 
in  any  quantity,  because  under  such  circumstances, 
though  sterile  at  the  time  of  its  introduction,  it  soon 
became  putrid,  and  would  then  sometimes  give  rise 
to  severe  sepsis. 

Therapeutic  uses:  In  some  cases  of  acute  conjunc- 
tivitis he  had  been  able  to  effect  a  cure  by  one  treat- 
ment with  the  suprarenal  extract.  Excellent  results 
followed  this  treatment  in  gonorrhceal  ophthalmia. 
Some  cases  of  deafness  which  had  not  been  benefited 
by  the  usual  treatment  had  resulted  in  a  cure  by  the 
use  of  this  extract.  Operations  on  the  nose  and  throat 
could  be  performed  almost  bloodlessly  with  its  aid. 
Chronic  rhinitis  was  temporarily  benefited  by  its  use. 
Dr.  H.  Hoi  brook  Curtis  had  found  it  very  useful  in 
laryngeal  phthisis,  relieving  the  painful  deglutition 
more  effectively  than  even  cocaine.  The  suprarenal 
extract  Dr.  Bates  looked  upon  as  a  specific  for  hay 
fever.  Three  cases  of  oedema  of  the  glottis  had  been 
reported  in  which  the  use  of  suprarenal  extract  had 
acted  admirably.  It  had  been  found  decidedly  bene- 
ficial in  apparently  opposite  states  of  the  heart. 

The  Therapeutics  of  the  Pituitary  Body.  — Dr. 
William  M.  Leszynsky  read  this  paper  (see  page 
1 122,  vol.  Ivii.). 

The   Therapeutics  of    the    Thyroid   Gland Dr. 

Herman  M.  Bigos  discussed  this  subject.  He  said 
the  whole  question  of  thyroid  therapy  was  still  in  an 
unsettled  condition.  In  cretinism  the  influence  of  this 
treatment  was  most  remarkable,  but  the  remedy  must 
be  employed  throughout  the  remainder  of  the  person's 
life.  The  conditions  in  which  this  remedy  had  been' 
chiefly  used  were  classified  as  follows:  (i )  Exoph- 
thalmic goitre;  (2)  psoriasis,  eczema,  alopecia,  lupus, 
and  certain  other  diseases  of  the  skin;  (3)  goitre;  (4) 
various  forms  of  insanity;  (5)  obesity;  (6)  retarded 
development  in  children;  (7)  tetany;  (8)  in  a  number 
of  conditions,  such  as  chlorosis,  anaemia,  syphilis,  and 
arteriosclerosis,  in  which  the  remedy  had  been  used 
empirically.  In  two  instances  he  had  used  thyroid 
preparations  in  Graves'  disease,  and  in  both  instances 
it  had  resulted  in  an  aggravation  of  the  symptoms. 
There  seemed  to  be  no  means  at  present  by  which  one 
could  determine  in  what  class  of  cases  of  chronic 
eczema  or  of  psoriasis  the  thyroid  preparations  would 
be  of  service,  for  in  some  the  results  were  good,  while 
in  others  they  were  absolutely  ;///.  In  lupus  the  results 
following  thyroid  treatment  were  not  unlike  those  ob- 
served after  the  use  of  tuberculin.  The  lupus  nodules 
had  never  bjen  completely  removed  by  it.  In  leprosy 
there  seemed  to  be  no  rational  ground  for  the  use  of 
this  remedy,  yet  certainly  results  had  been  secured 
which  might  at  least  be  characterized  as  encouraging. 
Fairly  favorable  results  had  been  secured  in  some 
cases  of  stuporous  insanity,  and  in  mental  derange- 
ments occurring  about  the  time  of  the  menopause.  In 
the  treatment  of  goitre  there  was  usually  improvement, 
the  goitre  being  reduced  in  size.  In  fibroid  goitres 
there  was  naturally  but  little  benefit  observed.  In 
some  cases  of  obesity  a  very  rapid  loss  of  weight  had 
followed  tlie  administration  of  thyroid  preparations, 
and  without  any  harmful  effects.  In  these  cases  the 
dosage  should  be  at  first  small,  being  gradually  in- 
creased, while  the  case  was  kept  under  constant  obser- 
vation in  order  to  note  the  first  symptoms  of  thyroid- 
ism.     A  few  striking  results  had  been  reported  from 


July  14,  1900] 


MEDICAL    RECORD. 


75 


the  use  of  thyroid  preparations  in  children  in  whom 
development  had  been  retarded  without  any  evidence 
of  cretinism.  The  chemistry  of  the  thyroid  gland  was 
still  obscure.  Thyroidin  had  been  long  ago  isolated. 
It  was  the  proteid  portion  of  the  gland.  The  activity 
of  the  preparation  depended  largely  upon  the  careful 
selection  of  glands  from  young  animals,  and  the  use 
of  them  in  the  fresh  state  for  making  the  thyroid  ex- 
tract employed  for  therapeutic  purposes. 

The  Therapeutics  of  the  Thymus  Gland.— Dr.  S. 
SoLis  CoHE.v,  of  Philadelphia,  spoke  on  this  topic. 
He  said  that  it  had  long  been  known  that  in  cases  of 
so-called  thymic  asthma  children  died  through  some 
mysterious  influence  exerted  by  the  thymus  gland,  and 
while  many  authors  had  written  learnedly  on  the  sub- 
ject, he  personally  felt  that  they  had  shed  very  little 
light  on  it.  One  reason  for  contradictory  statements 
from  different  competent  observers  was  to  be  found  in 
the  varying  qualities  of  different  preparations.  He 
had  addressed  a  letter  of  inquiry  to  the  principal 
manufacturers  of  these  products,  and  from  their  re- 
plies he  had'learned  that  no  two  of  the  American  prod- 
ucts were  alike.  Mr.  David  Owen's  supposed  cure  of 
a  case  of  exophthalmic  goitre  by  the  administration 
of  thyroid  extract  turned  out,  on  further  investigation, 
to  be  a  case  in  which,  without  his  knowledge,  the 
butcher  had  substituted  thymus  gland.  This  had  nat- 
urally led  to  the  deliberate  use  of  thymus  gland  from 
the  calf.  In  one  of  his  cases  that  showed  no  im- 
provement, it  was  discovered  that  the  thymus  gland 
from  the  sheep  had  been  used  instead.  In  a  case  of 
severe  exophthalmic  goitre,  reported  by  Mr.  Todd,  of 
England,  recovery  ensued  after  the  use  of  the  thymus 
gland  from  the  calf,  although  previously  it  had  proved 
most  obstinate  under  all  the  approved  methods  of 
medication.  Dr.  Cohen  said  that  he  had  personally 
seen  many  good  results  from  the  use  of  this  gland,  but 
he  had  recently  abandoned  it  in  favor  of  suprarenal 
gland  extract,  which  acted  still  better.  Some  cases 
presented  symptoms  which  were  best  controlled  by  the 
suprarenal  extract;  others  yielded  better  to  the  thymus 
extract.  On  the  whole,  a  combination  of  the  two  had 
seemed  to  work  better  than  either  one  alone.  Physi- 
ologists had  not  given  us  much  light  on  this  matter. 
We  were  told  that  the  active  principle  of  the  thymus 
gland  when  injected  into  the  veins  caused  extensive 
va.scular  clotting,  and  hence  this  remedy  had  been 
used  as  a  styptic,  and  had  been  recommended  in  cases 
of  ha-niophilia.  This  extract  had  also  been  used  and 
recommended  in  leukaemia,  rickets,  and  rheumatoid 
arthritis.  Kinnicutt  and  others  had  claimed  good  re- 
sults from  it  in  pulmonary  tuberculosis.  Chittenden 
had  shown  that  the  thymus  gland  contained  an  exceed- 
ingly large  proportion  of  phosphorus,  which  might 
possibly  explain  some  of  the  good  results  claimed 
for  it. 

The  Therapeutics  of  the  Mammary  and  Parotid 

Glands Dr.  John  B.  Shoiser,  of  Philadelphia,  read 

this  paper.  He  said  that  he  made  use  of  tablets,  each 
of  which  represented  twenty  grains  of  the  fresh  mam- 
mary gland  of  the  sheep.  The  dose  was  from  three  to 
six  tablets  daily.  It  acted  very  much  like  ergot,  though 
more  efficiently.  The  bleeding  from  uterine  fibroids 
could  often  be  most  satisfactorily  controlled  by  this 
remedy.  The  tumors  themselves  were  inhibited  in 
their  growth,  and  diminished  in  size  up  to  a  certain 
point.  It  was  possible  that  the  continued  use  of  this 
remedy  might  indefinitely  postpone  operation  in  many 
such  cases.  He  had  used  the  mammary-gland  ex- 
tract in  many  cases  of  subinvolution  of  the  uterus, 
and  with  marked  success.  In  regard  to  the  parotid 
gland,  he  said  that  this  gland  was  taken  from  the 
sheep  and  prepared  in  the  same  way  as  the  extract  of 
the  mammary  gland.  Its  principal  action  was  as  a 
powerful   sedative  to  ovarian   nain,  and   he  had  em- 


ployed it  with  entire  satisfaction  in  those  cases  of 
ovarian  neuralgia  unaccompanied  by  marked  pelvic 
disease.  In  these  cases  vaginal  examination  would 
show  great  sensitiveness,  with  tender  and  prolapsed 
ovaries,  the  latter  becoming  swollen  just  before  the 
menstrual  period.  In  such  cases  he  had  had  very 
astonishing  results,  having  cured  within  a  few  weeks 
patients  who  had  suffered  for  many  years.  The  treat- 
ment should  be  begun  some  time  before  the  expected 
menstrual  period.  When  there  was  also  inflamma- 
tory disease  of  the  tubes  and  ovaries  he  did  not  think 
anything  was  to  be  gained  by  temporizing  with  the 
parotid  medication,  as  they  were  really  operative 
cases;  nevertheless  this  remedy  had  a  very  pro- 
nounced influence  in  relieving  the  pain.  He  recom- 
mended the  parotid  gland  only  in  cases  of  uncom- 
plicated ovaritis,  and  he  found  such  cases  rather 
infrequent,  as  he  made  it  a  rule  to  examine  carefully 
the  patients  under  ether  in  order  to  be  sure  of  the 
true  condition  present. 

Prof.  Oliver  T.  Osisorne,  of  Yale,  opened  the 
general  discussion  with  a  few  remarks  on  the  physi- 
ology of  the  subject.  He  said  that  extirpation  of  the 
thyroid,  pancreas,  suprarenals,  and  the  pituitary  body 
caused  death.  He  believed  exophthalmic  goitre  was 
the  result  of  hypersecretion  of  the  thyroid,  as  the 
symptoms  of  the  two  were  almost  identical.  In  his 
opinion,  the  size  of  the  gland  had  been  given  too 
much  prominence  in  discussions  on  this  subject. 
There  seemed  to  be  no  reason  why  there  might  not 
be  all  stages  of  secretion,  even  though  the  gland  was 
not  enlarged  sufficiently  to  be  easily  palpated.  After 
the  age  of  forty  years  the  gland  began  to  atrophy — in 
other  words,  just  at  the  time  that  persons  normally  put 
on  flesh.  Women  constituted  eighty  per  cent,  of  all 
cases  of  Graves'  thyroid  disease,  and  the  same  was 
true  of  myxoedema.  The  thyroid  hypersecreted  during 
each  menstruation  and  each  pregnancy,  and  these  two 
facts  taken  together  should  afford  food  for  thought 
and  speculation.  Those  who  became  obese  while 
young,  from  hereditary  or  other  causes  not  easily  as- 
certainable, were  not  usually  benefited  so  much  by 
thyroid  treatment  as  persons  between  the  ages  of  forty 
and  fifty  years.  He  was  of  the  opinion  that  it  was 
the  custom  to  give  altogether  too  large  doses  of  thy- 
roid, and  he  made  this  statement  because  of  the  very 
small  quantity  of  thyroid  secretion  distributed  through 
the  system  daily.  It  seemed  to  him  rational  to  em- 
ploy thyroid  preparations  in  eczema,  particularly  in 
that  form  found  in  old  age.  Thymus,  being  very  rich 
in  nuclein,  should  do  good  whenever  a  nuclein  seemed 
to  be  indicated.  In  regard  to  hypersecretion  of  the 
pituitary.  Dr.  Osborne  said  that  two  or  three  years 
ago  he  had  suggested  that  giantism  was  due  to  this 
cause,  and  that  acromegaly  was  the  result  of  a  per- 
verted secretion  of  the  pituitary.  He  believed  that 
cases  of  giantism,  if  the  patients  lived  long  enough, 
would  become  acromegalic.  The  pituitary  body  con- 
sisted of  two  parts,  the  hypophysis  and  the  infundibu- 
lum.  The  latter  was  capable  of  raising  the  blood 
pressure;  the  hypophysis  gave  results  quite  similar 
to  the  thyroid.  He  was  now  using  pituitary  body  in 
two  cases  of  acromegaly,  and  the  results  seemed  to 
indicate  its  influence  on  acromegaly  to  be  distinct  and 
definite.  The  laboratory  experiments  at  Yale  showed 
that  the  blood  pressure  could  not  be  raised  by  giving 
suprarenal  extract  hypodermically  or  by  the  mouth, 
although  the  pressure  rose  rapidly  if  the  extract  was 
injected  into  the  veins. 

Dr.  Francis  J.  Quinla.v  said  that  he  personally 
believed  that  suprarenal  extract  was  second  only  to 
cocaine  as  an  addition  to  our  armamentarium.  Acute 
and  passive  hypera;mias  of  the  nose  were  promptly 
relieved  by  the  use  of  this  extract,  and  its  action  in 
acute  colds  w-as  most  salutary.     It  was  entirely  different 


76 


MEDICAL    RECORD. 


[July  14,  1900 


in  this  respect  from  the  transient  effect  observed  from 
the  use  of  cocaine,  and  so  far  had  not  been  known  to  give 
rise  to  any  habit,  or  indeed  to  any  deleterious  effects. 

Dr.  Bates,  in  closing,  said  that  it  was  to  Dr.  S. 
Solis-Cohen  that  the  profession  owed  the  knowledge, 
in  the  first  instance,  that  the  internal  administration 
of  suprarenal  extract  would  cause  a  rise  of  the  blood 
pressure.  This  was  not  observed  in  patients  having 
a  normal  heart,  but  was  very  evident  when  there  was 
disease  of  the  heart. 

Dr.  Cohen  said  he  had  no  doubt  regarding  the  ac- 
curacy of  the  physiological  experiments  referred  to  by 
Dr.  Osborne,  any  more  than  he  had  of  the  clinical 
observations  referred  to  by  Dr.  Bates.  A  possible 
explanation  of  the  failure  of  adrenal  substance  to  pro- 
duce a  rise  of  blood  pressure  in  normal  animals  was 
the  fact  that  throughout  the  body  there  was  a  system 
of  checks  and  balances — thyroid  secretion,  thymus 
secretion,  and  adrenal  secretion — balancing  one  an- 
other, and  preventing  any  excess  of  one  or  the  other 
in  the  normal  individual.  However,  in  an  abnormal 
individual,  having  a  low  blood  pressure,  there  was  no 
call  upon  these  checks,  and  the  result  of  the  adminis- 
tration of  the  substance  in  question  was  a  rise  in  the 
blood  pressure. 


NEW  YORK  ACADEMY  OF  MEDICINE. 

SECTION     ON     OBSTETRICS     AND     GYN-ECOLOGY. 

Stated  Meeting,  May  24,  igoo. 

J.  Riddle  Goffe,  M.D.,  Chairman. 

Nephrectomy Dr.  J.   Riddle   Goffe   presented   a 

young  woman  who  had  been  seen  by  him  in  October, 
1894,  for  an  ovarian  cyst.  He  had  removed  this 
without  difficulty.  After  the  operation  the  urine  had 
been  found  loaded  with  pus,  and  examination  had  re- 
vealed the  presence  of  a  greatly  enlarged  right  kidney. 
With  the  assistance  of  Dr.  Brooks  H.  Wells  there  had 
been  no  difficulty  in  catheterizing  the  left  ureter,  and 
withdrawing  perfectly  normal  urine.  He  had,  there- 
fore, subjected  her  to  a  nephrectomy,  removing  the 
right  kidney.  He  had  used  the  usual  oblique  inci- 
sion. After  the  removal  of  the  kidney  he  had  opened 
it  and  found  it  riddled  with  abscesses,  varying  in  size 
from  that  of  a  pea  to  a  hen's  egg.  He  had  followed 
the  ureter  down  as  far  as  possible,  and  put  a  double 
silk  ligature  upon  it.  With  the  exception  of  a  sinus 
which  had  continued  for  two  months  she  had  made 
a  very  smooth  recovery.  The  sinus  had  closed  after 
the  removal  of  a  silk  ligature.  The  pathologist  had 
reported  the  kidney  to  be  tuberculous,  and  that  the 
tuberculous  process  extended  down  the  whole  length 
of  the  ureter  that  had  been  left  attached  to  the  kidney. 
He  had  then  placed  the  woman  on  beechwood  creo- 
sote and  cod-liver  oil  for  six  months  or  more.  She 
had  completely  recovered,  and  examination  at  the 
present  time  showed  no  evidence  of  disease.  The 
patient  was  now  a  nurse  on  active  duty.  In  another 
case  of  this  kind  he  thought  he  would  remove  the 
entire  ureter,  cutting  it  off  close  to  the  bladder,  and 
suturing  the  opening. 

Nephrorrhaphy. — Dr.  Goffe  also  presented  a  woman 
whose  kidneys  he  had  anchored  last  February.  She 
had  come  to  him  with  all  sorts  of  nervous  symptoms. 
Physical  examination  had  revealed  nothing  but  two 
floating  kidneys.  He  had  performed  double  nephror- 
rhaphy. On  the  right  kidney  he  had  made  the  inci- 
sion through  the  capsule  on  the  convex  surface,  and 
dissected  back  two  flaps.  Then  turning  them  back, 
he  had  inserted  three  sutures.  On  the  otiier  kidney, 
for  purposes  of  comparison  he  had  adopted  the  method 
suggested  to  him  recently  by  Dr.  Robert  T.  Morris. 


He  dissected  off  a  saddle-shaped  flap,  and  then  passed 
the  flap  itself  through  the  fibres  of  the  muscle,  and 
stitched  it  there.  She  had  left  the  hospital  at  the  end 
of  six  weeks,  and  since  then  her  general  health  had 
improved  decidedly. 

Dr.  A.  Ro.sE  said  that  in  cases  in  which  this  oper- 
ation was  undesirable,  or  consent  was  withheld,  he  had 
made  use  of  plaster.  Rubber  adhesive  plaster  was 
applied  so  as  to  fasten  the  kidney.  In  cases  in  which 
he  had  used  it  the  many  dyspeptic  symptoms  that  had 
been  present  had  disappeared  almost  as  if  by  magic. 
The  rubber  plaster  had  been  very  well  borne,  but  he 
had  found  subsequently  that  it  was  desirable  to  pro- 
tect the  skin  with  Unna's  zinc-rubber  plaster  before 
applying  ordinary  rubber  plaster.  He  had  had  sixty 
or  more  such  cases,  and  they  had  done  very  well. 
The  plaster  was  more  satisfactory  than  bandages  on 
these  thin  persons. 

Dr.  R.  H.  Greene  said  that  Dr.  Goffe's  second 
patient  had  come  to  him  about  six  months  after  hav- 
ing been  subjected  to  two  operations  at  the  City  Hospi- 
tal for  some  adhesions  around  the  uterus.  She  com- 
plained of  a  general  and  vague  abdominal  pain,  and 
his  diagnosis  at  the  time  had  been  neurasthenia. 
Finding  no  pelvic  disease  he  had  referred  the  girl  to 
Dr.  Goffe,  fully  expecting  that  the  neurasthenia  would 
be  aggravated  by  the  proposed  operation.  It  was  evi- 
dent, however,  that  he  had  been  mistaken  on  that 
point.  She  was  still  quite  neurasthenic,  but  better 
than  at  the  time  of  the  operation.  He  was  not  yet 
convinced,  however,  that  this  operation  was  a  useful 
one. 

Dr.  S.  Marx  took  much  the  same  view  as  the  last 
speaker  regarding  the  real  value  of  this  operation. 
The  improvement  noted  in  this  case,  he  said,  could  be 
easily  explained  by  the  better  care  and  diet  the  patient 
had  received  while  at  the  hospital.  In  these  poorly 
nourished  individuals  the  diminution  in  the  amount 
of  the  fat  around  the  kidney  would  naturally  increase 
the  normal  mobility  of  this  organ.  He  had  treated 
such  cases  by  overfeeding  with  equally  good  results. 
A  recent  laparotomy  for  another  condition  had  af- 
forded him  the  opportunity  to  see  the  condition  of 
a  kidney  that  had  been  anchored  by  an  eminent  sur- 
geon one  year  previously.  It  was  instructive  to  note 
that  the  "  anchor  "  was  six  inches  long,  and  the  organ 
was  displaced. 

Dr.  G.  H.  Balleray  said  he  believed  the  kidney 
would  soon  become  displaced  again  in  this  patient 
unless  certain  precautions  were  taken.  These  pa- 
tients should  be  especially  forbidden  to  wear  corsets 
and  to  make  sudden  and  violent  motions.  The  skirts 
should  be  supported  from  the  shoulders.  It  was  also 
important  to  maintain  a  proper  state  of  nutrition. 
These  individuals  were  almost  invariably  very  thin 
and  poorly  nourished.  He  had  just  examined  this 
woman,  and  had  found  both  kidneys  in  a  normal 
position.  Regarding  the  case  of  tuberculous  kidney 
it  was  well  that  Dr.  Goffe  had  not  been  content  with 
simply  draining  the  organ. 

Dr.  p.  a.  Harris  said  that  the  examination  left 
little  doubt  about  the  operation  having  effected  an 
anatomical  cure  in  this  case. 

An  Aseptic  Gynaecological  Emergency  Instru- 
ment Case. — Dr.  Augi'stin  H.  Goklet  exhibited 
such  a  case.  Packed  in  a  convenient  leather  case  were 
two  trays  of  instruments  and  two  enamelled  trays. 
The  latter  enclosed  the  instruments  and  in  this  way 
could  be  utilized  as  a  sterilizer.  Curettes,  clamps, 
and  irrigators  were  provided,  and  there  was  room  in 
the  outer  leather  case  for  a  fountain  syringe  and  a 
rubber  air-cusiiion. 

Carbonic  Acid  Gas  to  Relieve  Labor  Pains.  — Dr. 
A.  Rose  exhibited  an  ajiparatus  for  applying  carbonic 
acid  gas  to  the  vagina  or  uterus  with  the  idea  of  facili- 


July  14,  1900] 


MEDICAL    RECORD. 


77 


tating  the  dilatation  of  the  cervix  and  rendering  labor 
comparatively  painless.  In  one  case  in  which  he  had 
tested  it  the  relief  was  as  great  as  if  chloroform  had 
been  administered.  The  mode  of  giving  the  gas  by 
means  of  a  simple  and  portable  apparatus  was  demon- 
strated. 

Cases  Simulating  Pregnancy. — Dr.  S.  Marx  pre- 
sented two  specimens.  The  first  case  was  that  of  a 
young  woman  in  perfect  health  up  to  two  months  ago, 
when  she  skipped  her  menstrual  period,  and  about  one 
month  later  gave  the  classical  signs  of  a  ruptured 
extra-uterine  pregnancy.  On  opening  the  abdomen 
he  had  found  instead  of  an  ectopic  pregnancy  two  ova- 
rian abscesses.  The  second  case  was  that  of  a  woman 
whose  abdomen  had  presented  the  configuration  of  a 
woman  pregnant  at  about  the  eighth  month.  She  de- 
nied having  been  exposed,  but  stated  that  she  had 
menstruated  very  scantily  for  a  number  of  months 
past.  Local  examination  was  almost  out  of  the  ques- 
tion because  of  a  nearly  imperforate  hymen,  but  a 
mass  was  felt  that  resembled  the  head  of  a  small 
fcetus.  No  foetal  heart  could  be  heard,  but  there  was 
a  very  distinct  and  typical  placental  souffle.  On 
opening  the  abdomen  he  had  found  a  typical  parasitic 
fibroid.  Corresponding  to  the  situation  of  the  bruit 
were  enormous  vessels  spread  out  in  the  shape  of  a  fan. 
Through  these  vessels  the  main  tumor,  weighing 
twelve  pounds,  had  derived  its  blood  supply.  The 
entire  tumor  was  attached  to  the  fundus  of  the  uterus 
by  a  very  small  pedicle. 

Dr.  Johx  O.  Polak  advised  in  every  doubtful  case 
of  this  kind  to  make  a  posterior  section  through  the 
vagina.  This  would  enable  one  to  make  the  diagno- 
sis, and  it  was  surprising  how  well  cases  of  ectopic 
pregnancy  and  pus  cases  could  be  treated  by  this 
route. 

Hysterectomy   for    Procidentia ;    Ovariotomy   for 
Ovarian    Pain — Dr.  G.   H.  Ballerav  presented  an 
ovarian   cyst  which^  he   had   removed  from  a  woman 
supposed   to   have   a   fibroid 
until  the  abdominal   section 
had    revealed    its    true    na- 
ture.    It   had  a   very   large, 
broad  pedicle.     He  also  re- 
ported a  case  of    prociden- 
tia which  he  had  treated  by 
hysterectomy.        A     third 
specimen  was  an   ovary  and 
tube  removed  because  of  severe 
menstrual   pain  occurring   in  a 


Dr.  Ballerav  replied  that  in  a  young  woman  the 
plastic  operations  should  certainly  be  tried,  but  in  a 
woman  of  the  age  of  his  patient  he  considered  hys- 
terectomy the  better  method. 


Sexu 


^nstvumcnts. 


MODIFICATIONS  OF  BOTTINI'S  INSTRU- 
MENT FOR  THE  TREATMENT  OF  HY- 
PERTROPHY OF  THE  PROSTATE  BY 
GALVANO-CAUTERY. 

By   ROBERT   NEWMAN,    M.D.. 

NEW    YORK. 

This  instrument,  suggested  in  former  papers,  is  a 
modification  of  the  Bottini  instrument  altered  by  Freu- 
denberg.  The  reasons  for  the  alterations  have  been 
stated  in  the  author's  paper  read  at  the  last  meeting 
of  the  American  Electro-Therapeutic  Association,  held 
in  Washington. 

Fig.  I  shows  the  instrument  in  perspective,  with 
platinum  burner  shown  in  dotted  lines  slightly  ex- 
posed. Fig.  2  is  the  end  of  the  instrument  with  the 
platinum  knife  fully  exposed.  The  instrument  con- 
sists of  a  hollow  metal  shaft  B,  terminating  in 
Thompson's  curve  with  tunnelled  end  C.  The  plati- 
num knife  D  is  propelled  backward  and  forward  by 
means  of  a  rack  and  pinion  £.  Two  insulated  copper 
wires  pass  through  the  shaft  and  carry  the  electric  cur- 
rent to  the  platinum  burner.  The  conducting  cords  of 
the  battery  or  Edison's  street  current  are  adjusted  to 
the  instrument  at  staples  G  and  J:/.  The  current  may 
instantly  be  thrown  on  or  off  by  means  of  the  switch  K 
A  scale  and  indicator  /  shows  at  a  glance  the  extent 
to  which  the  knife  is  exposed.  Freudenberg's  im- 
provements on  the  original  Bottini  are  very  good,  and 


Ficr  I. 


G."t\tW^HH  fc.C^  ^.'f 


menstrual  and  inter- 
w'orking-woinan.  He 
had  operated  on  this  case  because  he  had  seen  several 
in  which  there  had  been  immediate  improvement  fol- 
lowing this  establishment  of  an  artificial  menopause. 

Dr.  p.  a.  Harris  cautioned  against  doing  ovariot- 
omy for  the  relief  of  pain  until  the  history  had  been 
most  carefully  considered,  including  the  probability  of 
the  existence  of  salpingitis.  It  was  only  exceptionally 
that  a  good  result  could  be  expected. 

Dr.  Polak  expressed  the  belief  that  there  were  very 
few  cases  of  procidentia  that  demanded  hysterectomy. 
This  operation  removed  the  keystone  of  the  arch,  so 
to  speak,  and  unless  the  abdominal  wall  could  be  at- 
tached to  the  vagina  there  would  be  prolapse  of  the 
vaginal  wall,  and  the  woman  would  complain  of  an 
unpleasant  sensation  of  pelvic  weight  and  pain. 
Plastic  procedures  seemed  to  him  far  better. 

Dr.  Goffe  thought  the  question  of  performing  hys- 
terectomy for  procidentia  depended  largely  upon  the 
age  and  condition  of  the  patient.  In  a  woman  near- 
ing  the  menopause,  who  had  borne  her  modicum  of 
children,  he  favored  hysterectomy,  and  found  it  simple 
and  efficient.  Ovariotomy  for  ovarian  neuralgia  was, 
in  his  opinion,  rarely  indicated,  though  it  might  be 
proper  in  exceptional  cases  that  had  been  under  care- 
ful observation  for  a  long  time. 


were  needed.  On  this  improved  instrument,  the  writer 
tias  made  the  following  modifications,  as  shown  in  the 
cut: 

(i)  Omitting  the  water-cooler,  in  order  to  make  the 
mechanism  of  the  instrument  simpler.  The  water- 
cooler  is  an  impediment,  takes  up  space,  and  needs  for 
its  proper  management  a  special  assistant.  As  the 
burner  is  smaller  than  in  the  original  instrument,  it 
does  not  need  so  much  heat,  and  this  can  be  controlled 
more  easily.  It  has  been  questioned  whether  it  is 
better  to  dilate  the  bladder  with  water  or  air.  Each 
method  has  its  own  advantages  and  objections.  J'ut 
it  is  better  to  do  away  with  the  heat  of  the  instru- 
ment which  is  accomplished  by  (2)  the  two  con- 
ducting wires  conveying  the  heat,  attached  one  to 
either  end  of  the  burner  and  each  running  separately, 
being  insulated.  This  arrangement  will  heat  the 
burner  immediately,  and  prevent  the  heating  of  any 
other  part  of  the  instrument.     The  shaft  remains  cool. 

(3)  The  end  of  the  instrument  is  conical  and  of  a 
smaller  size  in  order  to  pass  any  obstruction  and  en- 
ter the  bladder  more  easily.  Thus  the  operation 
can  be  performed  in  cases  in  which  the  larger-sized 
portion  of  the  instrument  could  not  be  introduced. 

(4)  There  is  a  tunnel  at  the  conical  end  for  a  filiform 
guide,  over  which  the  instrument  passes,  to  be  used  at 
the  option  of  the  operator. 


78 


MEDICAL   RECORD. 


[July  14,  1900 


(5)  The  burner  of  platinoiridium  is  thinner  and 
stationary,  and  thereby  cannot  get  out  of  shape  and 
place,  and  besides  the  greater  heat  is  avoided. 

(6)  The  protector  of  the  burner,  when  moved,  acts 
at  the  same  time  as  a  meter,  the  operator  thereby 
knowing  the  exact  place  of  the  burner.  This  burner 
or  knife  can  cut  to  any  depth,  as  the  operator  desires, 
and  by  rotating  can  cut  in  different  directions.  The 
instrument  can  be  taken  apart  for  cleaning  and  sterili- 
zation. 

(7)  This  in.strument  is  cheaper  and  costs  about  one- 
half  as  much  as  the  Bottini  original  or  the  one  modi- 
fied by  Freudenberg. 

14S  West  Sixty-third  Street,  April,  1900 


A   MODIFIED    ARTERY    CLAMP. 
By    RUSSELL   BELLAMY,    M.D., 


NEW    YORK. 


About  two  years  ago  I  had  the  pleasufe  of  presenting 
to  the  Society  of  the  Alumni  of  Bellevue  Hospital  a 
clamp  designed  and  used  extensively  by  Professor 
Theodor  Kocher.  After  a  long  sojourn  in  Professor 
Kocher's  clinic  in  Berne,  I  many  times  realized  the 
great  advantages  of  this  forceps,  and  purchased  a 
number  from   the  original  instrument-maker.     These 


clamps  have  proven  very  satisfactory,  but  the  absence 
of  the  French  lock  has  made  it  very  difficult  to  cleanse 
them  thoroughly,  and  the  extreme  straightness  of  the 
long  blades  has  at  times  proven  awkward.  To  over- 
come these  disadvantages  Messrs.  George  Tiemann 
&  Co.  have  constructed  for  me  a  new  clamp  which 
has  the  French  or  detachable  lock  and  a  graceful,  easy 
curve  of  the  blades  (see  cut,  two-thirds  original  size). 
The  curve  in  the  new  clamp  adapts  itself  well  to 
angles  and  allows  the  passage  of  ligatures  with  the 
greatest  ease. 

Through  the  kindness  of  my  confrere.  Dr.  Fielding 
Lewis  Taylor,  I  have  used  the  new  clamp  with  the 
greatest  satisfaction,  in  the  clinic  at  the  House  of 
Relief,  Hudson  Street,  this  city. 


The  Detection  of  "  Bacillus  Typhosus  "  in  Water 
and  Other  Substances Hankin,  employing  a  modi- 
fication of  the  well-known  method  of  Parietti,  claims 
that  he  has  repeatedly  been  able  to  demonstrate  the 
presence  of  bacillus  typhosus  in  the  water  of  piped 
supplies  in  Agra  in  which  sand  filtration  had  been  em- 
ployed, and  also  in  some  earth  six  inches  from  the 
surface  of  the  foreshore  of  a  village  on  the  banks  of 
the  Jumna.  Until,  however,  some  additional  confirma- 
tion is  obtained  Hankin's  interpretation  of  his  results 
must  be  accepted  with  some  reserve.  Tlie  facility 
with  which  the  organism  appears  to  have  been  isolated 
is  strangely  at  variance  with  the  experience  of  most 
able  bacteriologists,  who,  using  practically  similar 
methods  for  many  years,  have  experienced  the  greatest 
possible  difficulty  in  attempting  the  identification  of 
this  bacillus  in  contaminated  water  supplies. —  Ceti- 
tralblatt Jiir  Baiteriologie,  1899,  Bd.  26,  Nos.  18  and  19. 


§acdicaT  |tcms. 

A  New  Army  Stretcher.  —  Dr.  Chavernac,  of  Aix 
(France),  has  just  designed  a  new  army  stretcher.  It 
is  a  rigid  contrivance  made  in  two  halves,  and  its  ad- 
vantage over  the  existing  French  ambulance  is  that  the 
wounded  man  can  be  lifted  off  the  ground  without 
experiencing  any  shock  or  pain.  The  halves  of  the 
stretcher  are  placed  on  each  side  of  the  sufferer  and 
by  pressure  they  hold  together  under  the  body  of  the 
patient,  who  is  not  touched  with  hands  at  all  in  the 
operation.  When  loaded,  the  stretcher  is  mounted  on 
a  light  bicycle  carriage.  Under  the  existing  condi- 
tions of  ambulance  work  in  France,  four  men  are  re- 
quired to  lift  the  wounded  man,  but  by  the  aid  of  the 
new  stretcher  only  two  attendants  are  needed. — Scieti- 
tific  American. 

Treatment  of  Pulmonary  Tuberculosis  with  Sub- 
cutaneous Injections  of  01.  Camphor  (German  Phar- 
macopoeia).—  Ur.  V,.  Alexander  [^Muiicliemr  medidni- 
sc/ie  Wochenschrift,  February  27,  1900,  p.  29)  advocates 
this  treatment,  from  which  he  has  obtained  the  most 
satisfactory  results.  He  refers  to  equally  satisfactory 
reports  of  similar  treatment  by  Professor  Huchard  and 
Dr.  Faure  Midler,  and  gives  particulars  of  two  recent 
cases  of  his  own.  His  method  consists  in  subcutane- 
ous injection  of  o.oi  to  0.02  (i  to  2  cgm.)  daily  of  the 
officinal  oil  of  camphor,  German  Pharmacopoeia,  for 
febrile  cases,  continued  for  several  weeks  or  months. 
For  non-febrile  cases  he  uses  a  much  larger  amount 
(i  dcgm.)  injected  daily  for  four  days  and  repeated  at 
intervals  of  not  less  than  eight  days. .  As  camphor 
has  a  cumulative  effect,  the  smaller  doses  will  gener- 
ally produce  satisfactory  results.^ — Treatment,  April. 

The  Ideal  Ration  for  an  Army  in  the  Tropics. 

— In  X\\&  Journal  of  the  Military  S^n'ice  Institution  for 
May  appears  the  thesis  on  "The  Ideal  Ration  for  the 
Army  in  the  Tropics"  which  won  for  its  writer,  Cap- 
tain E.  L.  Munson,  assistant  surgeon  U.S.A.,  the  prize 
offered  in  1899  by  Dr.  Louis  A.  Seaman.  Dr.  Munson 
in  the  course  of  his  essay  says :  "  Prolonged  heat  ex- 
erts an  unfavorable  influence  upon  the  digestive  and 
assimilative  functions.  Hcp.ce  work  should  not  be 
imposed  upon  the  alimentary  tract  in  excess  of  its 
powers,  and  the  diet  should  be  restricted  as  compared 
with  that  of  temperate  climates,  particularly  since 
both  diarrhcea  and  dysentery  are  known  to  be  favored 
by  the  presence  of  a  large  amount  of  undigested  food 
in  the  intestines,  while  tropical  anteniia  may  be  hast- 
ened by  malassimilation  resulting  from  overtaxation 
of  the  digestive  powers.  The  respiration  is  much  less 
energetic  after  arrival  in  the  tropics,  and  this  com- 
bined with  rarefaction  of  the  atmosphere  and  other 
factors  results  in  a  much  less  amount  of  oxygen  being 
introduced  into  the  blood  than  is  the  case  in  temper- 
ate climates.  If  the  reduced  quantity  of  o.<ygen  avail- 
able finds  in  the  organism  an  excess  of  alimentary 
substances,  it  is  evident  that  oxidation  of  the  latter 
will  be  delayed  if  even  ultimately  complete,  and  meta- 
bolic equilibrium  is  thus  disturbed.  Further,  accord 
ing  to  Foster,  the  amount  of  heat  evolved  by  the  inter- 
nal organs  depends  largely  upon  their  stimulation. 
In  the  case  of  the  salivary  gland  the  temperature  of 
the  saliva  during  irritation  of  the  chorda  has  been 
found  to  be  1°  to  1.5°  higher  than  that  of  the  blood 
in  the  carotid  artery  at  the  same  time;  and  the  same 
author  states  that  in  all  probability  the  investigation 
of  other  secreting  glandular  organs  would  yield  simi- 
lar results.  I'articularly  is  this  true  of  the  liver,  an 
organ  in  which  a  large  amount  of  heat  is  produced, 
as  is  shown  by  the  fact  that  a  temperature  of  40.73"^ 
C.  has  been  observed  in  the  hepatic  vein,  while  that 


July  14,  1900] 


MEDICAL    RECORD. 


79 


of  the  right  heart  was  37.70°  C.  Hence  the  excita- 
tion of  the  liver,  either  through  the  improper  selection 
of  foods  or  an  excess  of  nutritive  material  requiring 
disposal,  is  to  be  avoided  in  hot  climates.  It  is  obvi- 
ous that  the  consumption  of  any  considerable  amount 
of  food  for  the  production  of  internal  heat  is  here  as 
unnecessary  as  it  is  undesirable,  while  the  nutritive 
needs  of  the  organism  require  a  smaller  amount  of 
material  to  repair  the  systemic  losses  resulting  from 
the  decreased  oxidation  and  normally  less  active  life 
of  the  tropics." — American  Review  0/  Reviews. 

«'  Maine  "  Hospital  Ship. — The  American  male 
nurses  who  served  on  the  hospital  ship  Maine  are  very 
much  dissatisfied  with  the  manner  in  which  they  were 
treated  on  their  voyage  in  her  to  South  Africa  and 
back.  Of  those  originally  engaged,  but  four  have 
returned  with  the  Maine  to  the  Cape,  and  several  of 
them  have  come  home.  Before  starting  for  New  York, 
in  an  interview  with  a  representative  of  Lloyd's  Jour- 
nal, they  gave  an  account  of  their  grievances.  Of  the 
original  committee  and  the  London  committee  those 
complaining  had  only  good  things  to  say;  all  the 
trouble  occurred  on  the  vessel.  The  male  nurses  and 
the  orderlies,  all  trained  men  possessing  certificates 
of  competency,  and  no  one  of  whom  has  had  less  than 
three  years'  training  in  a  public  hospital,  were  en- 
gaged in  New  York.  The  majority  of  them  threw  up 
good  positions  on  purpose  to  go  with  the  Maine.  They 
received  agreements  engaging  them  for  a  minimum 
service  of  five  months,  at  $30  a  month  each.  The 
agreements  which  were  signed  by  Lady  Randolph 
Churchill  and  Mrs.  Blow  stipulated  that  the  male 
nurses  should  be  under  the  control  of  the  sister  super- 
intendent on  board,  and  that  they  were  to  perform  the 
nursing-duties  for  which  their  training  fitted  them. 
'I'hey  distinctly  understood  themselves  to  be  engaged 
for  nursing-duties  only,  and  that  the  rough  work  of 
the  wards  would  be  performed  by  hands  engaged  for 
the  purpose.  When  the  Maine  had  got  to  sea  on  her 
way  to  the  Cape  they  were  ordered  to  clean  the  ves- 
sel's wards.  Before  they  arrived  at  the  Cape  the  wa- 
ter had  become  almost  undrinkable  owing  to  the  rusty 
tanks  in  which  it  was  carried.  Much  of  the  food  was 
so  bad  that  it  could  not  be  eaten.  On  reaching  the 
Cape  the  nurses  learned  to  their  astonishment  that  the 
Maine,  instead  of  becoming  a  hospital  ship  on  the 
coast  as  they  were  told  she  would  be,  was  to  return  to 
England _with  a  number  of  convalescents.  At  whose 
instance  this  alteration  in  the  original  plans  was  made 
they  could  not  say,  but  all  agree  that  the  vessel  was 
entirely  unfitted  for  the  conveyance  of  the  sick,  though 
suitable  enough  for  receiving  and  nursing  the  worst 
cases.  On  the  voyage  back  to  England  the  nurses 
were  treated  exactly  as  they  were  going  out,  with  the 
addition  that  they  could  obtain  nothing  to  drink  on 
board  except  ginger  ale,  which  was  supplied  them  at 
twelve  cents  per  bottle.  Their  sleeping-accommoda- 
,  tion  was  cramped.  In  addition  to  the  male  nurses 
there  were  four  female  nurses  on  board,  but  they  were 
found  to  be  entirely  out  of  place;  complaints  of  their 
being  in  the  way  and  interfering  with  work  were  con- 
tinual, and  thus  it  is  the  vessel  returned  to  Cape  Town 
with  male  nurses  only. 

The  Boer  and  his  Medical  Advisers. — The  Boer 
is  not  given  to  "  nerves  "  as  a  rule,  but  when  his  health 
fails  him  he  loses  heart  at  once.  About  half  the  popu- 
lation of  the  Transvaal  suffer  from  indigestion.  This 
of  course  is  the  natural  outcome  of  an  unvarying  diet 
of  boiled  mutton,  and  bread  of  the  consistency  of  putty. 
When  a  member  of  a  Boer  homestead  is  taken  ill  the 
family  first  of  all  draw  on  their  old  homely  remedies, 
but  if  these  fail  they  have  recourse  to  the  store.  The 
storekeeper  is  the  medical  adviser  for  the  district. 


Every  trading-store  keeps  on  hand  a  large  supply  of 
patent  medicines.  When  the  patient,  if  he  is  able  to 
travel,  comes  over  and  describes  his  symptoms  the 
storekeeper  will  prescribe  for  him.  The  Boers  as  a 
rule  have  not  much  ready  cash,  but  what  little  they  do 
possess  they  cling  to,  and  the  first  question  the  pa- 
tient will  ask  is,  how  much  does  it  cost.  The  store- 
keeper of  course  does  not  recommend  the  cheapest 
article  in  his  stock,  and  the  Boer  will  say:  "  But  that 
is  too  much,  I  am  very  ill ;  I  may  have  to  take  many  of 
those  bottles.  No;  I  will  buy  something  cheaper." 
And  he  will  go  over  the  medicine  shelves  and  will  get 
the  trader  to  tell  him  what  each  one  is  and  what  the 
writing  on  it  says.  Time  is  not  of  much  importance 
in  the  Transvaal,  as  trade  is  never  very  brisk  at  the 
up-country  stores;  in  fact,  it  is  a  very  rare  occurrence 
to  find  two  customers  in  a  store  at  the  same  time. 
So  the  trader  will  light  his  pipe  and  go  over  the  stock 
with  his  customer.  After  a  time  the  latter  will  decide 
on  what  he  will  purchase,  and  will  carry  off  a  supply 
sufficient  to  last  an  ordinary  man  for  a  lifetime. 
Should  this  not  do  him  any  good  he  will  return  later 
on  and  endeavor  to  get  the  storekeeper  to  exchange 
the  balance  of  what  he  has  on  hand  for  some  other 
medicine.  The  number  and  variety  of  empty  phials 
and  boxes  to  be  found  in  a  Boer  house  are  something 
alarming.  The  Boer  takes  a  kind  of  gloomy  pride  in 
his  illness,  and  when  he  recovers  will  treasure  all 
these  as  mementos,  and  will  bring  them  out  and  show 
them  to  any  neighbor  who  may  call  on  him.  "  See," 
he  will  say,  "  I  took  all  this  medicine  when  I  was  ill, 
and  this  is  the  only  one  that  did  me  good.  It  is  good 
medicine  this.  I  am  always  going  to  take  it  when  I 
am  ill  again."  And  his  visitor  will  sympathize  with 
him  and  will  probably  take  away  an  empty  bottle  so 
that  he  may  know  what  to  ask  for  when  he  gets  ill 
himself.  Besides  the  storekeepers  there  are  others 
who  supply  the  Boers  with  cures  for  all  the  "ills  that 
flesh  is  heir  to."  These  are  the  peddlers  who  travel 
from  farm  to  farm  selling  patent  medicines  and  trinkets. 
As  a  rule  they  give  away  a  trinket  with  every  bottle 
purchased,  and  many  of  them  make  a  good  living  at 
the  business.  The  Boer  believes  anything  that  is  told 
him  where  medicine  is  concerned,  and  these  people 
take  advantage  of  the  fact.  It  is  not  so  long  ago  that 
smallpox  broke  out  in  the  Transvaal.  At  that  time 
an  ingenious  individual  amassed  a  respectable  pile 
by  travelling  through  the  country  vaccinating  people 
with  condensed  milk.  Besides  all  these  the  Boer  has 
a  medical  adviser  in  his  Hottentot  servant.  The  Boer 
regards  every  "  nigger  "  as  an  animal,  but  he  knows 
that  the  Hottentots  are  really  very  clever  at  curing 
simple  ailments  with  herbs,  and  he  often  falls  back 
with  satisfactory  results  on  the  "Tottle"  woman  when 
all  else  has  failed  him. — Indian  Lancet. 

Balneotherapy  as  Practised  by  the  Indians Dr. 

Richard  K.  Macalester,  of  Glenw6od  Springs,  Colo., 
writes  that  the  healing  properties  of  the  Glenwood 
Springs  thermal  waters  were,  many  years  prior  to  the 
advent  of  the  first  settlers,  appreciated  by  the  Ute  In- 
dians who  populated  this  district.  They  called  the 
largest  spring,  with  a  flow  of  seventeen  hundred  gal- 
lons per  minute,  Yampeh  (Little  Bear),  and  utilized 
its  waters  for  bathing  and  drinking  purposes.  Besides 
this  there  are  numerous  other  springs  of  uniform 
chemical  constituency  of  their  sulpho-saline-alkaline 
waters,  and  a  temperature  of  126°  F.,  in  which  the 
average  person  can  hold  his  hand  but  a  few  seconds 
without  experiencing  great  discomfort.  The  Utes  are 
said  to  have  come  from  far  and  near  in  search  of 
health  at  this  natural  sanatorium,  and  when  a  patient 
was  pronounced  to  be  a  fit  subject  for  balneological 
administration  by  his  wise  medicine-men,  the  follow- 
ing method  was  employed :  Across  two  long  poles  a 


8o 


MEDICAL    RECORD. 


[July  14,  1900 


blanket  was  stretched  and  fastened,  on  which  the  vic- 
tim was  laid.  His  comrades  then,  grasping  the  ends 
of  the  poles,  raised  and  carried  him  to  the  hot  pool, 
in  which  he  was  immersed.  A  cry  of  agony,  or  the 
length  of  endurance,  was  the  signal  for  the  "  bath  at- 
tendants" to  lift  him  out  of  the  water,  and  with  brief 
intermissions  this  procedure  was  repeated  as  often  as 
the  patient  could  stand  it. 

The  Indians  were  also  not  unfamiliar  with  the 
virtues  of  the  unique  cave  baths,  which  are  small  caves 
in  the  rocks  by  the  river  side,  in  the  floors  of  which 
thermal  springs  boil  up,  heating  and  saturating  the 
air  with  vapor.  These  baths  are  very  potent  in  an 
eliminating  sense,  exerting  a  specific  sudorific  action 
far  in  excess  of  plain  water  vapor  of  a  much  higher 
temperature. 

Twenty  Per  Cent,  cash  is  offered  to  physicians 
sending  patients  to  a  certain  Thousand-Island  Hotel. 
How  pleasantly  inclined  toward  the  family  physician 
would  the  paterfamilias  feel  some  morning  after  a 
bad  breakfast,  if  he  should  pick  up  one  of  these  left- 
over tempting  circulars  and  discovered  why  his  doctor 
was  so  anxious  for  him  to  patronize  this  particular 
house ! 

Utilization  of  Putrid  Meat  in  France The  Medi- 
cal Neios  states  that  putrid  meat  is  utilized  in  France, 
where  nothing  is  allowed  to  go  to  waste,  in  a  highly 
ingenious  manner.  Meat  unfit  for  food  and  the  bodies 
of  animals  that  have  died  of  disease  are  exte;isively 
used  for  the  manufacture  of  superphosphates.  The 
meat  is  placed  in  a  vat  containing  sulphuric  acid, 
which  separates  the  resulting  nitrogenous  products 
from  the  fat.  The  dead  animals  are  thrown  whole 
into  covered  lead-lined  vats  full  of  sulphuric  acid.  If 
these  animals  have  died  from  anthrax  or  glanders  they 
are  cut  up  before  being  thrown  in.  In  the  course  of 
forty-eight  hours  the  fat  alone  remains  and  the  ani- 
malized  sulphuric  acid,  rich  in  nitrogenous  substances, 
is  drawn  off  and  sent  through  an  underground  conduit 
to  the  superphosphate  factory.  Thus,  instead  of  the 
unsanitary  method  of  burying  such  putrid  substances 
in  the  ground,  they  are  effectually  disposed  of,  all  in- 
fectious germs  being  completely  destroyed;  and  there 
results  a  product  available  in  the  manufacture  of  a 
valuable  fertilizer. 

Medical  Comforts  Supplied  to  the  South  African 
Troops.— The  term  medical  comforts  embraces  a  num- 
ber of  articles  which  fall  outside  ordinary  victualling 
and  are  intended  for  the  use  of  sick  men.  They  are 
all  supplied  from  Woolwich,  and  their  preparation 
forms  an  important  department  there.  They  are  packed 
in  "  panniers  "  and  boxes.  The  former  are  intended  to 
be  carried  by  mules — two  panniers,  weighing  ninety- 
two  pounds  each,  to  a  mule.  The  contents  of  the 
panniers  are  as  follows:  Brandy,  one  bottle;  port,  one 
bottle;  whiskey,  two  bottles;  arrowroot  one  and  one- 
half  pounds;  sago,  one  pound;  extract  of  meat,  six 
pounds;  bovril,  three  pounds;  condensed  milk,  sixteen 
tins;  sugar,  six  pounds;  also  mustard,  pepper,  salt, 
candles,  matches,  soap,  spirits  of  wine,  with  knives 
and  forks,  canisters,  spirit  lamp,  and  other  necessary 
hardware.  Two  panniers  go  to  each  field  hospital, 
two  to  each  bearer  company.  The  contents  of  the 
"  medical  comforts  box  "  are  similar,  but  it  holds  less 
and  is  more  portable.  The  wine  and  spirits  are  all 
bottled  at  the  depot,  as  is  the  rum  used  for  rations, 
and  a  very  considerable  business  it  is.  Two  pipes  of 
port,  about  one  hundred  and  twenty  dozen,  are  bottled 
every  day,  and  a  corresponding  quantity  of  whiskey 
and  brandy,  but  the  rum  handled  there  runs  to  twelve 
hundred  gallons  a  day.  It  is  not  supplied  in  bottles 
but  in  wicker-covered  gallon  jars,  two  jars  to  a  case. 
Rum  is  the  only  alcoholic  liquor  served  for  rations. 


Its  use  appears  to  be  traditional,  but  it  does  not  strike 
one  as  particularly  suited  to  the  climate  of  South 
Africa.  For  the  purchase  of  liquor  the  services  of  an 
expert  taster  are  engaged.  He  periodically  makes  a 
selection  from  a  series  of  numbered  samples  without 
knowing  their  origin,  so  that  no  favoritism  is  possible. 
Spirits  are  reduced  to  twelve  and  fifteen  degrees  below 
proof  before  bottling,  by  the  addition  of  distilled 
water. — London  Times. 

Action  of  Soil  on  the  Plague  Bacillus Dr.   Z. 

Yokote  {Centralhlatt Jiir  Bacieriologie,  Abth.  1,  Bd.  23, 
No.  24)  took  mice  that  had  died  of  infection  with  plague 
bacilli,  placed  them  in  wooden  boxes,  and  buried  them 
in  garden  soil  which  was  kept  from  thorough  drying. 
The  boxes  were  exhumed  from  time  to  time  and  the 
contents  examined  to  ascertain  if  infective  material 
still  existed.  The  longest  time  that  elapsed  between 
the  burying  and  the  demonstration  of  the  still  virulent 
organism  was  thirty  days,  and  the  higher  the  tempera- 
ture and  the  more  active  the  rate  of  decomposition  the 
shorter  the  life  of  the  organism.  The  soil  in  the  im- 
mediate vicinity  of  the  boxes  was  examined  for  the 
organisms,  but  the  results  were  negative. — American 
Journal  oj  the  Medical  Sciences. 

Health  Reports — The  following  cases  of  smallpox, 
yellow  fever,  cholera,  and  plague  have  been  reported 
to  the  surgeon -general  of  the  United  States  Marine- 
Hospital  service  during  the  week  ended  July  7, 
1900 : 

Cases.    Deaths. 


Smallpox — United  States. 


District  of  Columbia,  Wash 

ington 

Illinois,  Chicago 

Indiana,  Evansville 

Indianapolis 

Michigan  City 

Kansas,  Wichita 

Kentucky,  Covington 

Louisiana,  New  Orleans  .... 

Maryland,  Baltimore 

Cumberland 

Massachusetts,  Fall  River  . 

Ohio,  Cincinnati 

Cleveland •.  .    . 

Portsmouth 

Voungstown 

Pennsylvania,  Pittsburg  . . . 


June  23d  to  30th.    4 

June  23d  to  30th 2 

,  June  23d  to  30th 2 

June  23d  to  3Qth i 

June  24th  to  July  1st i 

June  23d  to  30th 6 

June  23d  to  30th 16 

June  23d  to  30th  12 

June  23d  to  30th 3 

June  i6lh  to  23d 3 

June  23d  to  30th 3 

f une  loth  to  26th 10 

June  23d  to  30th. .    10 

June  23d  to  30th I 

June  23d  to  30th   2 

June  23d  to  30th 3 


Smallpox — Foreign. 

Austria,  Prague June  8th  to  i6th 8 

China,  Hong  Kong .Vlay  19th  to  June  2d i 

Egypt,  Cairo May  20th  to  June  3d 

England,  Liverpool June  8th  to  i6th   ,.    .    2 

London June  8th  to  16th 15 

Manchester June  8th  to  i6th i 

France,  Lyons June  Sth  to  i6th 

St.  Etienne June  1st  to  13th 3 

Germany,   Frankfort   on   the 

Main June  8th  to  16th 

Greece,  Athens June  Sth  to  iCth 2 

India,  Bombay May  28th  to  June  5th 

Calcutta April  28th  to  May  5th 

Karachi May  28th  to  June  3d 12 

Japan,  Nagasaki. June  ist  to  loth i 

Osaka  and  Hiogo  .    .   June  2d  to  9th 1 

Mexico,  Chihuahua June  6th  to  i6th 

Mexico April  30th  to  June  17th 164 

Vera  Cruz June  17th  to  23d 

Russia,  Moscow June  2d  to  9thT 6 

Odessa June  Sth  to  i6th 5 

St.  Petersburg June  Sth  to  i6th 71 


Warsaw June  2d  to  gth, 

•  June  IS  ■ 


Scotland,  Glasgow June  15th  to  22d 66 

Spain,  Madrid May  igth  to  June  2d      

Straits    Settlements,    Singa- 
pore  May  12th  to  19th 

Uruguay,  Montevideo    May  12th  to  26th \ 

Yellow  Fever. 

Colombia,  Barranquilla June  Sth  to  i6th 40 

Cartagena June  ist  to  13th 3 

Cuba,  Havana June  13th  to  20th 8 

Santa  Clara June  21st  to  25th 4 

Mexico,  Vera  Cruz June  i6th  to  23d 

Cholera, 

India,  Bombay May  29th  to  June  5th 

Calcutta April  28th  to  May  5th 

Plague. 

Arabia,  Aden June  2d  to  9th 11 

China,  Hong  Kong May  loth  to  June  2 170 

Egypt.  Port  Said May  28th  to  June  4th 133 

Intlia,  Bombay May  28th  to  June  5th 

Calcutta April  28th  to  May  5th 

Karachi May  27th  to  J  une  3d 16 

Japan,  Formosa,  Tanisui. . . .  May  1st  to  3jst 379 

Osaka June  12th  to  15th x 

Shidzuoka June  12th  to  15th i 


13 
40 
7 


100 
7 

5 


3 
26 


18 
3 
3 


51 
7» 


7 

■57 

57 

I3< 

316 


Medical  Record 

A    IVeekly  yournal  of  Medicine  and  Surgery 


Vol.  58,  No.  3. 
Whole  No.  1550. 


New  York,  July  21,    1900. 


$5.00  Per  Annum. 
Single  Copies,  loc. 


©ricjinaX  Articles. 


THE    EVIDENCES     OF     PROSTATIC     ATRO- 
PHY   AFTER    CASTRATION. 

By   EDWARD   L.-  KEVES,   Jr.,  M.D., 

NEW   YORK. 

As  in  its  pliysical  structure  a  chain  has  the  strength 
of  its  weakest  link  only,  so  it  is  in  the  chain  of  argu- 
ment. The  glamour  of  its  apparent  strong  points  can- 
not long  hide  its  inherent  weakness.  Yet  in  the  latter 
case  each  really  strong  link  adds  a  real  value  to  its 
weaker  brethren  and  thereby  merits  prominence  and 
consideration. 

Such  a  link  in  the  chain  of  pathological  evidence 
which  is  gradually  encircling  the  claims  of  castration 
as  a  cause  of  prostatic  atrophy  is  presented  in  this 
paper  in  the  entirety  of  its  hard  facts,  namely : 

(i)  A  large  glandular  prostate;  (2)  castration;  (3) 
the  lapse  of  si.xteen  months;  (4)  undiminished  size 
of  the  prostate  to  rectal  touch,  undiminished  length 
of  the  urethra,  undiminished  persistence  of  the  clini- 
cal symptoms;  (5)  prostatectomy  with  shelling  out  of 
two  solid  tumors  the  size  of  pullet's  eggs;  (6)  fail- 
ure by  an  expert  to  find  any  evidences,  macroscopic 
or  microscopic,  of  atrophy  of  the  prostate. 

Nowhere  in  surgery  are  pathology  and  practice  ap- 
parently drawing  wider  apart;  nowhere  does  the  micro- 
scope seem  to  give  the  lie  more  absolutely  to  clinical 
reports  of  hundreds  of  observers  scattered  over  two 
continents  than  in  the  matter  of  castration  for  hyper- 
trophy of  the  prostate.  Born  in  the  brains  of  White' 
and  Ramm'"  independently  and  at  about  the  same 
time;  founded  upon  a  theoretical  homology  between 
the  hypertrophy  of  the  prostate  and  uterine  fibroma, 
and  the  results  of  castration  on  the  latter  class  of 
tumors;  and  fortified  by  e.xperiments  upon  animals 
and  a  few  clinical  data,  the  operation  of  castration  for 
the  cure  of  hypertrophy  of  the  prostate  was  formally 
presented  to  the  world  in  1893. 

Since  then  seven  years  have  passed,  and  this  sum- 
mer the  International  Congress  at  Paris  purposes  to 
enlighten  us  upon  the  present  state  of  the  question. 
It  is  to  be  hoped  that  the  discussion  then  entered  into 
by  many  of  the  leading  lights  of  the  genitourinary 
world  will  help  to  determine  more  accurately  than 
ever  before  the  advantages  and  limitations  of  the 
various  methods  of  treatment.  The  Bottini  renais- 
sance- is  of  too  recent  a  date  to  receive  an  absolutely 
impartial  verdict;  but  castration  and  the  allied  opera- 
tions can  now  be  rated  at  their  true  worth. 

The  history  of  castration  as  a  method  of  sexual 
depletion  may  be  divided  into  three  overlapping 
periods.  During  the  first  period,  which  reached  its 
highest  expression  in  White's  essay  of  1895,'  enthusi- 
asm ran  riot,  and  asexualization  was  hailed  as  the 
prostatic's  Utopia.  The  second  period,  beginning 
with  Albarrin's  report  to  the  French  Congress  of 
Surgery  in  the  same  year,  and  reaching  its  climax  in 
Cabot's'  report  of  the  year  following,  and  the  erudite 
researches  of  Albarrin  and  Motz  in  1898,"  was  one 
of  adhesion  to  the  primary  principles  with  a  beginning 


of  wholesome  doubt  and  careful  investigation,  but  in- 
definite conclusions.  The  third  period,  one  of  firm 
,  convictions  based  on  pathological  findings,  was  first 
voiced,  as  far  as  I  have  been  able  to  learn,  by  Flo- 
derius"  in  1897,  and  will  culminate,  we  trust,  in  the 
coming  congress. 

In  the  early  days,  in  spite  of  the  protests  of  a  few 
men  (Keyes  and  Alexander  in  this  country),  the  gen- 
eral enthusiasm  over  a  novel  and  comparatively 
simple  surgical  procedure  promising  such  brilliant 
results  dazzled  the  cautious  and  emboldened  the  in- 
competent, while  the  accumulation  of  favorable  evi- 
dence from  all  sides  soon  overbore  all  but  the  most 
sceptical.  Comparative  anatomy,  embryology,  pathol- 
ogy, teratology,  each  contributed  its  share  to  round 
out  with  scientific  fulness  the  monument  of  clinical 
success.  There  were  flaws — here  and  there  a  failure 
to  attain  the  anticipated  result,  in  one  report  an  un- 
due mortality,  in  another  the  warning  of  post-operative 
dementia;  but  these  availed  nothing  to  check  the 
pendulum  of  public  opinion,  and  ^\'hite  was  able  to 
publish,  in  1895,  a  table  of  one  hundred  and  eleven 
cases  with  twenty  deaths,  chiefly  attributable  to  ursemia 
uninfluenced  by  the  operation  or  induced  by  the  an- 
esthesia and  shock.  In  the  mean  while  various  similar 
but  less  radical  operations  were  advocated.  Sir  Reg- 
inald Harrison''  introduced  vasectomy,  of  which 
twenty-two  cases  with  seven  deaths  (all  at  the  hands  of  a 
single  surgeon)  were  tabulated  by  Cabot  in  1896.' 
Unilateral  castration,  angioneurectomy  of  the  cord, 
and  the  injection  into  the  testicle  of  irritating  fluids 
for  the  purpose  of  producing  atrophy  were  not  slow  to 
follow. 

But  the  success  of  these  latter  operations  did  not 
bear  out  their  early  promise  in  any  large  proportion 
of  cases,  and  although  many  surgeons  continued  and 
still  continue  to  employ  them  undaunted,  the  ever- 
increasing  number  of  failures  and  relapses  encouraged 
closer  scrutiny  into  the  merits  of  the  whole  class  with 
a  less  prejudiced  eye  and  a  fuller  equipment  of  patho- 
logical facts  than  had  hitherto  been  available. 

This  second  period  of  searching  investigation  but 
hesitating  conclusion  is  ably  expressed  in  the  essay 
of  Albarrin  and  Motz*  (i8q8).^  These  observers  en- 
force by  personal  observation  the  following  con- 
clusions: 

"  I.  Atrophy  of  the  prostate  occurs  after  castration 
in  all  the  animals  that  have  been  tested:  viz.,  the 
horse,  the  ox,  the  hog,  the  dog,  and  the  cat.  This 
atrophy  is  constant  whatever  the  age  of  the  animal 
employed. 

"  II.  However  incomplete  the  array  of  facts  we  have 
cited,  they  seem  to  prove  that  double  castration  in  in- 
fancy prevents  the  development  of  the  prostate. 

"  In  the  absence  of  direct  evidence  it  is  impossible 
to  say  that  the  same  operation  performed  on  an  adult 
or  an  old  man  would  produce  similar  effects;  but, 
judging  from  experiments  on  animals,  it  is  fair  to 
assume  that  this  atrophy  should  result"  (p.  23). 

So  far  the  agreement  between  science  and  practice 

*  This  in  spite  of  the  fact  that  their  tables  of  cases,  which  I 
have  been  at  pains  to  verify,  are  full  of  inaccuracies.  Thus 
among  the  cases  of  double  castration.  Nos.  4,  93,  and  94,  are 
identical.      The  same  is  true  of  Xos.  5  and  43,  6  and  72,  7  and  3. 


82 


MEDICAL    RECORD. 


[July  2  1,  1900 


is  complete.  But  from  the  series  of  nine  autopsies 
after  castration  that  they  are  able  to  collect  from  the 
^eportsof^^■hite/ Griffiths,'  Kelsey,"  Bryson,'  Mansell 
Moullin,'"  Watson,"  Socin,"  CoUey,"  and  Cabot," 
they  conclude  (p.  35)  that  "all  we  can  say  is  that  no 
autopsy  has  shown  a  real  atrophy,  and  that  in  four 
autopsies  performed  at  five,  seven,  eight,  and  twelve 
months  after  operation  respectively,  there  has  been  no 
macroscopic  evidence  of  a  diminution  in  the  volume 
of  the  prostate.  In  one  of  these  observations,  Bry- 
son's,'  in  which  the  castration  dated  back  a  year,  the 
microscope  showed  no  trace  of  atrophy.'' 

Yet  in  the  teeth  of  these  facts  the  authors  conclude 
from  clinical  data  (p.  47),  that: 

"  I.  It  is  rational  to  admit  a  priori  that  double  cas- 
tration would  diminish  the  volume  of  the  hypertrophied 
prostate,  especially  in  the  glandular  varieties. 

"2.  .-Mthough  the  anatomo-pathological  data  are 
insufficient,  clinical  e.xperience  proves  that  there  is  a 
diminution  in  the  volume  of  the  hypertrophied  prostate 
after  castration. 

"3.  The  diminution  in  the  volume  of  the  prostate 
is  due  at  first  to  the  decongestion  of  that  organ,  and 
later  to  a  real  atrophy. 

"4.  This  atrophy  may  come  on  slowly,  appearing 
as  late  as  six  months  or  even  later  after  operation  and 
progressing  for  more  than  two  years.  Finally  the 
prostate  may  be  no  longer  distinguishable  by  rectal 
touch. 

"5.  In  certain  cases  the  atrophy  may  predominate 
in  certain  parts  of  the  gland.  It  may  involve  lobes 
jutting  into  the  bladder. 

"6.  It  is  impossible  to  say  at  the  present  day  that 
every  prostate  atrophies  after  castration,  or  how  much 
atrophy  may  be  e.xpected  in  a  given  case.  It  is  even 
probable  that  in  certain  cases  atrophy  fails  to  occur." 

These  conclusions  unfortunately  attempt  to  recon- 
cile the  pathological  facts  with  the  clinical  figures  by 
minimizing  the  force  of  the  former.  But  despite  this 
fact  the  formal  array  of  pathological  findings  marks 
an  advance  from  which  there  is  no  retreat.  The  stress 
laid  upon  the  immediate  efl:ect  of  decongestion  forms 
the  central  point  of  later  theories,  and  the  critical  dis- 
cussion of  the  two  pathological  reports  upon  which 
enthusiasts  chiefly  based  their  claims  is  e.xtremely 
fair.  The  pith  of  those  reports — White's  and  Griffiths' 
— is  as  follows: 

White"  states  briefly,  of  a  prostate  removed  from  a 
patient  who  died  the  second  day  after  castration,  that 
"the  stroma  of  the  gland  shows  beginning  prolifera- 
tion of  the  connective-tissue  cells,  but  especially  of 
the  muscle  cells.  The  acini  tubules  are  also  becom- . 
ing  filled  with  proliferated  columnar  cells,  and  here 
and  there  some  fine  granular  matter  may  be  seen  in 
the  tubules;  some  of  the  cells  appear  to  contain  fine 
granules  which  have  not  taken  the  stain,  evidently 
fat.     The  changes  are  typical  of  beginning  atrophy." 

Griffiths'  reports  a  similar  case  in  which  he  found 
in  a  prostate  removed  at  autopsy  eighteen  days  after 
castration,  (i)  proliferation  of  the  epithelium,  (2) 
acute  fatty  degeneration,  disintegration  and  absorption 
of  the  cells  cast  off  into  the  lumen  of  the  tubules,  (3) 
a  shrinking  of  the  tubules  with  transformation  of 
their  usual  cylindrical  epithelium  into  cuboidal  and 
pavement  cells,  and  (4)  proliferation  of  the  muscular 
and  connective-tissue  elements. 

Albarrin  refuses  to  accept  the  proof  offered  by  these 
authors  as  conclusive,  arguing  that  the  picture  of  cell 
proliferation  and  epithelial  degeneration  as  they  pre- 
sent it  is  not  uncommonly  the  evidence  of  inflamma- 
tion in  a  hypertrophied  prostate,  and  moreover,  "  in 
the  numerous  experiments  [of  castration]  that  we  have 
made,  we  have  never  seen  cell  proliferation  result" 
(p.  28).  And  again  on  page  30:  "We  cannot  admit 
this    proliferation    of    the     tissues    constituting    the 


stroma;  it  is  in  direct  contradiction  to  the  results 
obtained  in  all  animals.  Apparently  there  is  question 
in  this  case  [Griffiths']  of  simple  inflammatory  phe- 
nomena superimposed  upon  the  classical  lesions  of 
prostatic  hypertrophy." 

A  critique  of  these  opposed  views  would  carry  us 
beyond  all  bounds.  Suffice  it  to  say  that  Kirby's 
animal  experiments  bear  out  White's  view;  but  the 
trend  of  recent  investigators  is  all  in  the  other  direc- 
tion. Since  Motz's'"  able  theses,  the  "prostatic 
myoma  "  of  Thompson  and  others  is  disappearing  from 
the  nomenclature,  and  hypertrophy  of  the  prostate  is 
recognized  to  be  a  hypertrophy  of  all  the  normal  ele- 
ments of  the  gland,  but  especially  the  epithelium,  an 
adenoma,  in  short,  in  which  secondary  changes  of  an 
inflammatory  character — round-celled  infiltration  go- 
ing on  to  sclerosis — are  frequent. 

Atrophy,  on  the  other  hat-d,  begins  in  the  epithelium, 
not  as  a  result  of  an  overgrowth  in  the  stroma,  but 
with  the  result  that  the  stroma  subsequently  fills,  in 
part  at  least,  the  space  left  by  the  atrophic  epithelium. 
Such  a  change  could  scarcely  be  expected  within  eigh- 
teen days.  Subsequent  commentators,  be  it  noted, 
have  accepted  Albarrin's  conclusions  either  explicitly 
or  implicitly. 

VVe  must  go  back  a  year  to  reach  the  monograph  of 
Floderius,"  the  inauguration  of  the  third  period. 
This  author,  collecting  the  previous  pathological  find- 
ings and  adding  two  cases  of  his  own,  concludes  that 
there  is  no  pathological  evidence  to  show  that  castra- 
tion ever  did  cause  atrophy  of  tiie  hypertrophied 
prostate.  The  evidence  unfortunately  was  scant  and 
is  so  still,  but  three  years  later  the  verdict  is  the  same. 
No  one  since  White  and  Griffiths  has  (to  my  knowl- 
edge) claimed  to  possess  a  case  showing  microscop- 
ical evidence  of  atrophy  after  castration. 

Before  tabulating  the  authorities  I  have  been  able 
to  consult,  I  add  a  case  which  has  fallen  into  my 
hands.     The  patient's  history  is  as  follows: 

H.J ,  an  Irishman,  carpenter  by  trade;  sixty- 
three  years  of  age;  married;  presented  himself  on 
August  31,  1898,  suffering  intense  dysuria.  He 
denied  gonorrhoea  or  sexual  excess  in  youth.  His 
urinary  organs  and  functions  had  been  entirely  nor- 
mal until  the  autumn  of  1897,  when  he  was  seized  with 
an  acute  complete  retention  of  urine.  A  physician 
relieved  him  by  passing  a  catheter  and  taught  him  the 
use  of  the  instrument.  The  complete  retention  lasted 
a  week  and  then  rapidly  disappeared,  so  that  the 
patient  was  able  to  dispense  with  the  catheter  until 
June,  1898;  at  that  time  he  began  to  suffer  some  little 
pain  on  micturition.  In  spite  of,  or  perhaps  on  ac- 
count of,  the  use  of  the  catheter  the  dysuria  increased; 
until  a  few  days  before  I  saw  him  he  had  to  resort 
to  a  woven  catheter.  This  gave  him  little  relief  and 
brought  blood  every  time  he  used  it,  every  hour  or 
two,  day  and  night. 

Physical  Examination:  The  patient  is  anamic, 
feeble,  and  flabby.  Heart  and  lungs  normal.  No 
oedema  except  a  puffiness  under  the  eyes.  The  urine 
is  drawn  at  eight  and  a  quarter  inches.  It  is  ammoni- 
cal  and  so  filled  with  blood  and  muco-pus  as  to  be 
unfit  for  any  test.  The  bladder  capacity  is  three 
ounces,  practically  all  residual ;  no  atony.  The 
searcher  detects  no  stone.  By  the  rectum  the  prostate 
feels  large  and  firm.  It  contains  no  nodules,  nor  is 
it  tender.  The  vesicles,  which  can  barely  be  reached, 
are  not  distended.  The  kidneys  are  not  tender  and 
cannot  be  felt. 

By  exciianging  his  woven  catheter  for  a  small  rubber 
one  (11  F.)  his  hemorrhages  were  checked.  He  was 
made,  as  far  as  possible,  to  use  the  catheter  but  three 
times  a  day  and  to  wash  daily  with  boric-acid  solution. 
For  six  weeks  irrigations  of  silver  nitrate,  sublimate, 
and  thallin  sulphate  were  tried,  while  salol,  urotropin, 


July  2  1,  1900] 


MEDICAL    RECORD. 


83 


boracic  acid,  oil  of  wintergreen,  and  strychnine  were 
administered  internally  in  various  combinations.  At 
the  end  of  this  time  the  urine  was  but  slightly  less 
muddy ;  the  bladder  capacity  had  risen  to  four  ounces. 
On  the  other  hand,  although  he  had  given  up  his 
work,  he  was  growing  progressively  weaker,  and 
urinating  in  great  distress  every  half-hour.  Although 
having  no  great  faith  in  the  efficacy  of  castration,  I 
did  not  think  he  would  survive  prostatectomy  or  en- 
dure a  permanent  catheter. 

October  18,  i8g8,  double  castration  was  done 
through  a  single  incision  in  the  raphe.  I  neglected 
to  search  for  stone  while  the  patient  was  under 
chloroform. 

The  patient  remained  in  bed  for  ten  days,  but  in 
spite  of  the  rest  and  systematic  medication,  general 
and  local,  he  left  the  hospital  but  little  improved, 
urinating  hourly,  using  the  catheter  nearly  every 
time.  A  month  later  he  urinated  every  one  and  a 
half  to  two  hours  day  and  night.  The  urine  was  clear 
enough  of  pus  to  test  for  albumin,  of  which  it  con- 
tained one-half  of  one  per  cent,  by  weight.  Specific 
gravity  was  1.012.  His  pains  were  no  less.  I  then 
lost  sight  of  him  till  October  2,  1899;  at  that  time 
he  was  urinating  hourly,  depending  almost  entirely 
upon  the  catheter.  Although  he  had  continued  liis 
daily  boric-acid  wash  his  pains  were  unrelieved.  He 
came  on  account  of  a  profuse  hemorrhage  of  the  blad- 
der lasting  several  days.  He  brought  with  him  a 
small,  faceted  phosphatic  stone  that  he  had  recently 
passed.  He  stated  that  he  was  no  stronger  than  at 
the  time  of  operation,  but  he  looked  brighter.  The 
prostate  seemed  undiminished.  The  urine  was  full  of 
blood,  the  urethral  length  undiminished.  He  passed 
two  ounces  of  urine  voluntarily  and  then  six  ounces  by 
the  catheter.  A  few  days  later  I  touched  a  stone. 
He  refused  operation,  and  did  not  return  until  Febru- 
ary, 1900,  his  local  and  general  condition  still  un- 
changed. 

On  February  22,  1900,  epicystotomy  was  done  under 
chloroform  anesthesia.  The  bladder  wall  was  thick 
and  congested  but  fairly  smooth.  The  prostatic  ob- 
struction was  in  the  form  of  a  horse-collar,  the  right 
and  middle  lobe  constituting  the  major  part  of  the 
tumor.  Thirty-two  phosphatic  stones  weighing  five 
hundred  and  eighty  grains  (37.58  gni.)  just  filled  the 
bas  Jond  to  the  level  of  the  bar.  These  were  re- 
moved, and  a  median  incision  made  with  serrated 
scissors  through  the  whole  thickness  of  the  bar. 
Through  this  incision  two  tumors  were  easily  enucle- 
ated from  the  bar  and  right  lobe,  measuring  respective- 
ly one  and  seven-eighths  by  one  and  three-fourths  by 
one  and  one-fourth  inches,  and  one  and  one-half  by 
one  and  one-half  by  one  and  one-fourth  inches,  and 
weighing  seven  hundred  and  si.xty  grains  (49.24  gm.). 
The  suprapubic  wound  was  partly  sutured,  with*  double 
tube  drainage.  The  operation  was  performed  in 
forty-five  minutes.  Convalescence  was  uneventful 
save  that  union  was  delayed  by  persistent  sloughing 
of  the  whole  surface  of  the  wound,  which  could  not 
be  controlled  until  the  urotropin  (of  w^hich  a  daily 
dose  of  I  gm.  was  being  administered)  was  withdrawn 
on  March  8th.  A  month  longer  was  required  for  the 
slough  to  separate  and  the  wound  to  heal. 

April  1 2th:  He  urinates  without  pain  every  two 
hours  day  and  night.  The  urinary  distance  is  seven 
and  three-fourths  inches;  residuum,  one  ounce;  bladder 
capacity,  si.x  ounces.  The  urine  is  still  slightly  am- 
moniacal. 

May  5th:  The  urethra  is  now  only  seven  and  one- 
half  inches  long.  The  residuum  is  down  to  three 
drachms.  The  urine  is  acid  and  only  slightly  hazy. 
The  prostate  feels  rather  smaller  than  usual;  the  right 
lobe  is  a  little  larger  than  the  left.  Although  he  still 
urinates  every  two  to  three  hours  day  and  night  he  has 


no  pain  whatever,  considers  himself  entirely  well,  and 
is  trying  to  get  back  to  work. 

The  tumors  removed  from  the  prostate  were  for- 
warded to  Dr.  H.  T.  Brooks,  whose  report  is  ap- 
pended : 

"New  York  City,  May  11,  1900. 

"Microscopic  examination  of  the  sections  made 
from  the  prostate  you  forwarded,  February  23d,  shows 


uiar  4. 


a  very  richly  muscular  and  glandular  structure,  and  a 
slight  amount  of  fibrous  connective  tissue.  The  prep- 
arations were  stained  in  hematoxylin  alone,  also  in 
hematoxylin  and  eosin,  and  in  borax-carmine,  all 
parts  of  the  tissue  staining  deeply  and  distinctly. 

"The  muscular  structure  is  arranged  in  broad  and 
slender  bands,  some  straight,  others  tortuous,  chiefly 
densely  interlaced  in  a  manner  closely  simulating  the 
distribution  of  the  muscle  elements  in  the  uterus. 

"The  glands  are  of  the  tubular  variety,  lined  with 
a  single,  sometimes  double  row  of  short  columnar  or 


^ 


Fig.  2. — From  Maryia  u£  Acinus.     Leitz  3,  ocular  4. 

cubical  epithelial  cells  which  lie  upon  several  layers 
of  smaller  and  more  rounded  cells  resting  against  the 
basement  membrane.  The  great  majority  of  the  tu- 
bules are  grouped  closely  in  a  more  or  less  regular 
manner,    presenting    collectively    the    appearance    of 


84 


MEDICAL    RECORD. 


[July  21,  1900 


lobuli  in  section  (Fig.  i).  In  some  areas,  on  the 
other  hand,  the  ducts  are  widely  separated  from  each 
other  by  broad  bands  of  muscular  tissue  including  a 
small  number  of  fibrous  elements  (Fig.  2).  In  many 
instances  the  inner  surface  of  the  tubules  is  convoluted 


Fig.  3.— Bans 


3,  ocular  I  inch. 


or  thrown  into  folds  in  the  form  of  papillae  (Fig.  i)  ; 
in  the  greater  number,  however,  these  surfaces  are 
smooth  and  the  tube  lamina  round  or  oval  in  form. 
Most  of  the  ducts  in  the  groups  above  mentioned  ap- 
pear to  be  in  every  way  normal,  the  muscle  structure 
and  epithelium  being  regularly  arranged  and  perfectly 
formed,  and  the  lumina  free  from  any  deposit  (Fig. 
3).  Pigmentation  of  the  epithelia  is  rarely  noted  and 
when  observed  is  of  but  slight  degree.  Occasionally 
ducts  are  seen  which  are  filled  with  a  fine  granular 
material  staining  faintly  with  eosin ;  others  contain  a 
small     number     of     isolated,    partially    disintegrated 


Fig.  4. — Bauscli  and  Luiub  j,  ocular  i  inch. 

cells  of  epithelioid  type  apparently  derived  from  the 
lining  epithelium.  At  wide  intervals  in  the  tissues 
several  lobuli  are  observed  in  which  the  tubules  are 
greatly  dilated,  often  of  cystic  nature,  and  the  internal 
surfaces  of  former  healthy  ducts  flattened  and  free  from 


convolutions,  the  epithelia,  however,  retaining  their 
normal  columnar  or  cubical  form,  and  only  exception- 
ally approaching  the  flat  squamous  or  endothelial  type 
of  cells  (Fig.  4).  Some  of  these  dilated  ducts  are 
completely  or  partially  occluded  with  a  coagulated, 
finely  granular,  almost  homogeneous  deposit  occasion- 
ally enclosing  cells  (Fig.  5,  A).  Corpora  amylacea 
are  rarely  met  with. 

"There  is  but  a  small  amount  of  fibrous  tissue  ob- 
served, and  this  appears  to  be  chiefly  confined  to  those 
areas  immediately  surrounding  the  lobuli,  particularly 
those  containing  dilated  ducts.  It  is  always  mixed 
with  muscle  elements — never  alone.  The  only  evi- 
dence of  active  proliferation  in  the  sections — which 
measure  3  x  I'j  cm.,  and  extend  from  the  external 
capsule  to  the  centre  of  the  prostatic  tissue — is  shown 
by  round-celled  infiltration  between  the  muscle  and 
connective-tissue  fibres  encircling  the  lobuli  and  sur- 
rounding the  individual  ducts  of  the  latter.  This  in- 
filtration is  met  with  at  wide  intervals,  being  in  some 
places  dift'use,  in  others  localized,  in  more  or  less 
nodular  form,  resembling  somewhat  the  smallest  soli- 
tary lymph  nodes  of  the  intestine  or  the  Malpighian 
corpuscles  of  the  spleen  (Fig.  6). 

"The  insignificant  amount  of  fibrous  change,  the 
comparative  infrequency  of  dilated  or  cystic  degene- 


FiG.  5. — Leilz  3.  ocular  4 

rated  tubules,  and  the  very  large  amount  of  muscle 
tissue  would,  it  appears  to  me,  indicate  that  there  had 
been  but  very  slight  development  of  fibrous  connective 
tissue,  i.e.,  fibroid  induration ;  for  it  is  reasonable  to 
suppose  that,  had  this  process  (fibroid  induration)  ad- 
vanced very  far  there  would  have  been  more  decided 
microscopical  evidence  of  it,  and  also  a  greater  num- 
ber of  dilated  or  cystic  tubules  resulting  from  the  ob- 
structing constrictions  on  the  efferent  side  of  the  ducts. 
This  view  seems  to  be  supported  by  the  exceptional 
occurrence  of  fibrous  bands,  which,  as  has  already 
been  stated,  are,  when  present,  chiefly  pronounced 
throughout  the  sections  in  those  areas  immediately 
surrounding  the  gland  acini, 

"  Another  interesting  feature,  to  me  at  least,  is  the 
comparative  absence  of  corpora  amylacea,  which  are 
rarely  observed  and  then  only  in  very  minute  form 
with  ill-defined  concentric  lamellae.  If  we  accept 
the  views  of  Zahn,  Favre,  Posner,  Hildebrand,  Seigert, 
Stilling,  and  others,  as  to  the  origin  of  these  bodies, 
namely,  that  they  are  derived  chiefly  from  the  degen- 
erated epithelial  elements  and  abnormal  secretions  of 
the  ducts,  it  would  seem  that  there  should  be  a  very 
much  larger  number  of  corpora  amylacea  present  in 


July  21,  1900] 


MEDICAL    RECORD. 


85 


this     case — provided     it     is    assumed     retrogressive 
changes  have  occurred  in  this  particular  instance. 

"In   conclusion   I   may  say  that,  judging  from  the 
collective  histological   appearances,  it  is  my  opinion 


Kic:.  6.— Leitz  6,  ocular  4. 

that  the  changes  noted  in  the  preparations  made  from 
this  prostatic  iissue  are  no  more  pronounced  than  are 
those  frequently  observed  in  many  so-called  normal 
prostates.  H.  T.  Brooks." 

The  table  below  shows  briefly  the  status  of  all  the 
similar  cases  I  have  found  in  the  literature: 


Reporter. 

Time  Elapsed 

since 

Castration. 

Atrophy 
claimed. 

Pathological  Findings. 

KirbyS  (White)  .. 

Floderius* 

M-ullinio 

Cabi.i* 

2  days. 

8  days. 
II  days. 

9  days. 

7  days. 

18  days. 

8  days. 

Yes. 

No. 
Ko. 

No. 

No. 

^'es. 
No. 

Uesquamatton  and  fatty  degen- 
eration in  the  epitheh'al  cells. 
Proliferation  of  stroma. 

Gives  a  detailed  description  of 
which  I  was  unable  to  obtain 
an  accurate  translation. 

■*  No  histological  changes" 
though  the  prostate  had 
shrunken. 

(Iriffiths'    

I.cnnander'* 

from  the  prostate  of  a  non- 
castrated  patient. 

Same  findings  as  Kirby. 

Fatty  degeneration  of  the  epi- 
thelium     *•  doubtless     inflam- 

I)e RouviUe'5.... 

35  days. 

No. 

matory." 
Fibrous  hypertrophy.      '*  Atro- 
phy could  not   have  been  ex- 

Cabot*  

49  days. 
sM  weeks. 

No. 

No. 

pected." 

Glandular  elements  sparse,  mus- 
cle tissue  increased  (?/.  No 
considerable  diminution  in  size 
of  gland. 

Detailed  report  showing  no  de- 

Brooks'^ (Kelsey). 

12  months. 
16  months. 

No. 
No. 

generative  organs. 

Brooks  {Keyesi   .. 

dence  of  degeneration. 
No   reduction   in  size ;   no   evi- 
dence of  degeneration. 

Here  then  are  twelve  cases  in  which  the  condition 
of  th%»prostrate  after  castration  was  tested  by  the  mi- 
croscope. Only  two  of  the  reporters  bel  ieved  they  found 
"beginning  atrophy";  and  this  opinion  was  based  on 
grounds  not  acceptable  to  other  authorities,  while  the 
time  allowed  for  the  occurrence  of  degeneration,  two 
days  and  eighteen  days  respectively,  is  suspiciously 
short  in  view  of  the  negative  results  obtained  after 
much  longer  periods,  viz.,  five  and  seven  weeks,  twelve 
and  sixteen  months. 

On  the  whole,  therefore,  it  is  fair  to  conclude  that  in 
no  case  has  atrophy  been  shown  by  microscopical  ex- 
amination, while  in  a  number  of  cases  (in  the  last 
five  of  the  twelve  cases  cited,  at  least)  it  has  been 


shown  not  to  exist  at  a  time  when  some  evidence  of  it 
might  have  been  expected. 

So  much  for  the  pathology;  now  for  the  clinical 
facts.  These  may  be  brieHy  drawn  from  the  tables  of 
various  authors,  although  the  vagueness  of  statement 
in  most  of  these  statistics  has  forced  me  to  compile 
some  of  the  percentages  myself,  thus: 


Reporter. 

Number 
of  cases. 

Cured.t 
Per  cent. 

Improved. 
Per  cent. 

Un- 
improved. 
Per  cent. 

Died. 
Per  cent. 

White'' 

.\Ibarrin' 

Wossidlo" 

Itl 
126 

154 

46.4 
43-7 
27.3 

28.3* 
35.7* 
47-4 

7.3* 
5.5* 
9.2 

18 

15 
16 

*  Kstimated. 

t  Including  all  those  "satisfactorily  well."  though  still  suffer- 
ing from  slight  cystitis,  etc. 

A  suggestive  feature  of  this  table  is  the  contrast  be- 
tween the  fluctuations  of  the  "cured"  and  "im- 
proved" columns  and  the  agreement  of  the  mortality 
and  "  unimproved  "  figures.  Though  figures  are  no- 
toriously misleading,  this  suggestion  hints  at  how  wide 
a  scope  is  possible  in  reporting  a  case,  how  easy  it  is 
to  feel  tliat  the  prostate  has  "diminished,"  to  mistake 
the  improvement  due  to  decubitus  and  systematic  local 
treatment  for  a  result  of  the  operation,  and  above  all 
things  to  report  the  case  too  soon.  If  the  primary 
effect  is  purely  a  reduced  congestion,  and  the  real 
atrophy  is  not  to  be  expected  for  three  months  or  a 
year  ( .\Ibarrin),  the  vast  majority  of  the  cases  reported 
at  the  end  of  three  months  or  six  months  as  cured  are 
absolutely  valueless  in  the  matter  of  ultimate  progno- 
sis. There  is  the  popular  phrase,  "The  operation  was 
a  great  success,  but  the  patient  died." 

Cabot's"  recent  article  (i8gg)  voices  a  change  of 
sentiment  which  must  have  been  felt  by  others  than 
himself.  In  1896  he  was  able  to  commend  orchi- 
dectomy,  but  three  years  latter  he  reports  a  personal 
series  of  nine  cases,  of  which  one,  probably  malignant, 
may  be  thrown  out.  Of  the  eight  remaining,  three 
were  unimproved;  five  improved,  but  of  these  three 
relapsed;  two  cures  against  six  failures  (subsequent 
prostatectomy  cured  three  out  of  four  of  these;  the 
fourth  patient  died). 

This  is  the  kind  of  statistics  we  need,  and  enough 
time  has  now  elapsed  since  the  earlier  ooerations  for 


Fig.  7. — Tumor  ol  Prostate  in  Section. 

those  men  who  have  conscientiously  followed  their 
cases  to  be  able  to  produce  clinical  information  of  a 
qualit)'  to  command  as  much  respect  as  the  pathologi- 
cal data.  Until  then  the  surgeon  must  regard  the 
statistics  on  castration — as  well  as  the  eminently  un- 
surgical  procedure  of  Bottini — with  interest  rather 
than  credulity. 


86 


MEDICAL    RECORD. 


[July 


2  1,    1900 


To  sum  up : 

1.  Experiments,  whether  on  man  or  the  lower  ani- 
mals, relating  to  the  normal  prostrate  do  not  of  neces- 
sity apply  to  the  enlarged  prostate. 

2.  I  know  of  no  direct  pathological  evidence  that 
castration  has  ever  caused  atrophy  of  a  hypertrophied 
prostrate. 

3.  There  is  direct  pathological  evidence  that  in  a 
few  cases  castration  has  failed  to  cause  atrophy  of  the 
hypertrophied  prostate. 

4.  The  majority  of  cases  reported  thus  far  have  been 
labelled  ''cured"  or  "improved"  so  soon  after  opera- 
tion that  many  of  them  are  doubtless  instances  of 
local  depletion. 

5.  Clinical  evidence  of  this  is  afforded  by  relapses 
occurring  months  after  the  operation. 

6.  Of  the  permanent  cures  some  may  well  be  in- 
stances of  permanent  advantage  derived  from  reduced 
congestion. 

7.  The  clinical  evidence  as  to  the  actual  atrophy  of 
the  prostate  after  castration  lacks,  as  yet,  its  scientific 
confirmation,  and  has  failed  thus  far  to  prove  its  title 
to  the  surgeon's  credence. 

109  East  Thirtv-foukth  Street. 

BIBLIOGRAPHY. 

1.  J.  William  White  :  Ann.  of  Surg.,  1S93,  xviii.,  152. 

2.  Ramm  :  Centralbl.  fur  Chir. ,  1893,  xx.,  759. 

3.  J.  William  White:  Ann.  of  Surg.,  1895,  xxii. ,  i. 

4.  A.  T.  Cabot  :  Ann.  of  Surg.,  iSg6,  xxiv. ,  265. 

5.  Albarrin  and  Motz  ;  Guyon's  Annales,  1898,  xvi.,  I,  113, 
225. 

6.  Floderius  :  Nord.  med.  Ark.,  1897,  vii..  No.  24,  p.   i. 

7.  Joseph  Griffiths:  Brit.  Med.  Jour.,  1S95.  i.,  579. 

8.  Kelsey  :  Medical  Record,  1S96.  xlix.,  727. 

9.  Brj'son  :  Boston  Med.  and  -Surg.  Jour.,  iSgfi,  cxxxv.,474. 

10.  Mansell  Moullin  :   Lancet.  1S96,  i.,  348. 

11.  Watson  :  Boston  Med.  and  Surg.  Jour.,  1895,  cxxxii.,  37S. 

12.  Socin :  Correspondenzblatt  fiir  -Schweizer  Aerzte,  i8g6, 
xxvi.,  529. 

13.  Sir  Reginald  Harrison:  Brit.  Med.  Jour  ,  1893.  ii. ,  708. 

14.  Lennander  :  Centralbl.  fiir  Chir.,  1S97,  xxiv.,  617. 

15.  De  Rouville:  Bull,  de  la  Soc.  Anat.  de  Paris,  1S97,  Ixxii., 

34- 

16.  Wossidlo  :  Deutsche  Praxis,  189S,  i.,  523,  564. 

17.  Cabot:  Boston  Med.  and  Surg.  Jour.,  iSgg,  cxl.,  393. 

18.  Motz  :  Structure  histologique  de  I'hypertrophie  de  la 
prostate,  Paris,  1896. 


NEGLECTED   CLINICAL  OPPORTUNITIES  IN 
AMERICAN   MEDICAL   CENTRES." 

By   S.    a.    KNOPF,    M.D.    (Paris  and  Bellevue,  N.  V.), 

NEW    ^■ORk'. 

Mr.  President  and  Fellows  of  the  American 
Academy  of  Medicine:  For  an  ordinary  practitioner 
like  myself,  not  connected  with  any  institution  for  in- 
struction, to  venture  to  address  this  distinguished 
academy  on  so  important  a  subject  as  the  clinical 
teaching  of  medicine  may  seem  temerity  to  many  of 
you;  but,  while  I  lay  no  claims  to  any  experience  as 
a  teacher  of  medicine,  I  have  spent  wellnigh  ten  years 
as  a  regular  medical  student  in  this  country  and 
abroad,  and  I  believe  I  have  learned  something  of  the 
needs  of  such  a  student  in  regard  to  clinical  instruc- 
tion. I  do  not  intend  to  imitate  the  critics  who  are  in 
the  habit  of  depreciating  American  institutions  to 
eulogize  foreign  medical  schools.  There  are  a  good 
many  of  the  latter  which  are  far  from  being  perfect, 
and  certainly  not  any  better  than  some  of  our  own. 

What  I  desire  to  do  is  to  point  out  to  you,  many  of 
whom  are  representative  teachers  of  the  leading  col- 
leges in  this  country,  that,  notwithstanding  the  vast 
progress  made  in  the  curriculum  of  many  of  our  medi- 

'  .\ddress  delivered  before  the  American  Academy  of  Medicine, 
at  its  twenty-fifth  annual  meeting  at  Atlantic  City,  N.  J.,  June  4, 
1900. 


cal  schools,  there  is  still  an  utter  inadequacy  of  clini- 
cal instruction  for  the  majority  of  students.  I  will 
show  at  the  same  time  that  this  inadequacy  is  not  due 
to  the  want  of  clinical  material,  but  to  the  neglect  to 
utilize  it. 

Only  the  few  fortunate  victors  in  the  competitive 
examinations  for  hospital  interneship  have  really  the 
clinical  training  necessary  to  make  good  physicians. 
These  internes  constitute  a  very  small  minority  of  that 
vast  army  of  physicians  who  annually  must  take  upon 
themselves  the  fearful  responsibility  of  treating  medi- 
cally and  surgically  the  various  ills  human  flesh  is 
heir  to. 

Of  every  one  hundred  medical  students,  about  ten 
receive  hospital  appointments.  You  will  probably 
tell  me  that  there  are  any  number  of  post-graduate 
schools,  and  you  are  right.  The  majority  of  these 
schools  are  really  excellent,  but  their  work  and  useful- 
ness lie  in  another  direction.  They  instruct  the  gen- 
eral practitioner  who  goes  to  some  great  medical  cen- 
tre every  two  or  three  years  in  order  to  brush  up,  and 
they  help  to  educate  him  in  special  branches  of  medi- 
cine or  surgery. 

There  is  no  want  of  opportunity  for  post-graduate 
instruction,  and  it  need  not  be  sought  abroad,  it  can 
be  found  in  our  own  country.  But  what  I  claim  is 
that  there  is  great  want  of  clinical  instruction  for  the 
medical  student  before  he  becomes  a  post-graduate. 
I  say  this  not  in  criticism  of  any  one  school,  but  of 
all  of  them.  Yet  this  state  of  affairs  can  be  remedied, 
and  to  attain  this  end  I  beg  leave  to  offer  the  follow- 
ing suggestions. 

There  should  be,  first,  a  co-operation  of  all  the 
medical  colleges  located  in  one  medical  centre  for  the 
purpose  of  a  general  and  equal  utilization  of  all  the 
clinical  material  of  their  city. 

Second,  every  physician  and  surgeon  attached  to  a 
subsidized  hospital  should  be  appointed  as  a  clinical 
teacher,  independent  of  college  affiliation,  and  be 
paid  a  reasonable  fee  for  his  services  as  instructor  to 
the  students. 

Third,  only  such  men  should  be  selected  for  hospi- 
tal physicians  as  are  well  qualified,  and  who  pledge 
themselves  to  perforin  their  duties  faithfully  as  clini- 
cal teachers. 

Fourth,  suppression  of  all  the  didactic  lectures  for 
second,  third,  and  fourth  year  students  during  the 
morning  hours,  which  should  be  devoted  exclusively 
to  clinical  work. 

Fifth,  the  obligatory  presence  of  every  second,  third, 
and  fourth  year  student  in  the  capacity  of  senior  or 
junior  externe  at  the  clinic,  or  at  the  daily  hospital 
visit  of  his  teacher. 

Sixth,  a  record  of  attendance  should  be  kept  by 
the  clinical  teacher  and  of  the  work  done  by  his  ex- 
ternes,  to  be  transmitted  periodically  to  the  respec- 
tive college  to  which  the  student  may  belong.  The 
reports  should  be  expected  to  count  in  the  annual  and 
final  examinations  of  the  students. 

As  to  the  manner  of  selecting  the  men  for  the  posi- 
tions of  hospital  physicians  and  clinical  teachers,  cus- 
toms vary  in  different  countries.  States,  and  even  cities. 
With  some  medical  boards,  the  politics;  witii  some,  the 
religion;  with  some,  the  social  standing;  with  some, 
the  affiliation  or  non-affiliation  with  a  certain  college; 
and  with  some,  the  medical  qualification  of  the  candi- 
date— decide  whether  or  not  he  shall  become  one  of 
theirs. 

In  certain  European  cities,  for  example  in  Paris,  the 
position  of  visiting  hospital  pliysician,  surgeon,  or  ob- 
stetrician (medecin,  chirurgien  ou  accoucheur  des  iiopi- 
taux)  can  be  obtained  only  by  a  competitive  oral  and 
clinical  examination  covering  tiiose  respective  branches 
of  medicine.  The  board  of  examiners  is  chosen  an- 
nually   by    ballot    from    among    the    hospital    piacti- 


July  2  1 ,  1900] 


MEDICAL    RECORD. 


87 


tioners.  This  system,  though  excellent,  might  meet 
with  some  opposition  in  our  American  cities,  at  least 
at  the  present  time.  Therefore,  I  venture  to  suggest 
that,  as  requirements  for  hospital  physician  and  clini- 
cal teacher,  the  following  qualifications  should  be 
necessary  :  (i)  Good  standing  as  a  regular  and  practis- 
ing physician.  (2)  One  year's  e.xperience  as  interne 
in  a  general  hospital  and  one  year's  service  as  interne 
in  a  special  hospital  or  hospitals.  Five  years'  active 
work  in  general  practice  should  be  accepted  as  an 
equivalent  to  two  years'  interneship.  (3)  The  ap- 
proval of  the  candidate  as  hospital  physician  and 
clinical  teacher  by  the  medical  board  of  the  hospital 
in  which  he  desires  to  work. 

Each  hospital  should  have  a  fixed  number  of  clini- 
cal teachers  according  to  the  number  of  beds.  These 
should  be  at  the  same  time  the  visiting  physicians, 
surgeons,  or  obstetricians,  with  a  sufficient  number  of 
internes  and  externes  to  assure  efficient  service  and 
good  care  of  the  patients. 

Wherever  there  is  an  important  surgical  or  obstetri- 
cal service,  there  should  be  an  arrangement  that  one 
of  the  visiting  surgeons  or  obstetricians  should  always 
be  within  calling  distance  to  aid  the  internes  in  case 
of  serious  accidents  demanding  immediate  interfer- 
ence. The  reproach  so  often  made,  that  serious  opera- 
tions are  performed  by  young  internes  without  the 
aid  or  consent  of  the  visiting  surgeon,  could  then  no 
longer  have  foundation. 

No  hospital  should  be  without  the  necessary  bacteri- 
ological and  patliological  laboratory  equipments,  where 
the  teachers  and  pupils  may  gather  to  verify  clinical 
observations  or  engage  in  special  studies. 

A  change  of  service  as  externe  from  one  hospital  to 
another  could  be  made  twice  during  the  second,  and 
three  times  during  the  third  and  fourth  college  years. 
Thus  each  student  by  the  time  of  his  graduation  would 
have  served  for  thirty  months  as  externe  in  six  to  eight 
different  hospitals;  having  actually  spent  half  of  his 
time  during  the  last  three  college  years  at  the  bedside, 
in  the  operating-room,  or  in  the  bacteriological  and 
pathological  laboratories  of  the  hospital.  Whenever 
there  is  a  dispensary  attached  to  the  hospital,  the 
material  it  affords  could  also  be  advantageously  used 
for  clinical  work  by  the  appointed  clinical  teacher. 

To  obtain  the  greatest  possible  good  out  of  the  three 
years'  externeship,  I  would  divide  the  work  as  follows: 

First  year  as  junior  externe,  five  months  in  the  sur- 
gical service,  five  months  in  the  medical  service;  sec- 
ond year  as  senior  externe,  four  months  in  the  surgi- 
cal service,  four  months  in  the  medical  service,  and 
two  months  in  the  obstetrical  service;  third  year  as 
past  senior  externe,  three  months  in  the  eye  and  ear 
service,  three  months  in  the  nose,  throat,  and  skin 
service,  two  months  in  the  hospital  for  contagious  dis- 
eases of  children,  and  two  months  in  the  service  for 
the  treatment  of  diseases  of  the  mind. 

The  service  in  medicine  would,  of  course,  have  to 
include  diseases  of  children,  with  the  exception  of 
acute  contagious  diseases.  The  instructions  in  dis- 
eases of  the  eye,  ear,  nose,  throat,  and  skin  might  be 
advantageously  taught  in  the  large  dispensaries,  and 
the  experienced  dispensary  fjhysician  should  also  be- 
come a  clinical  teacher.  The  three  years'  clinical 
curriculum  for  the  externe,  divided  in  the  manner  I 
Jiave  suggested,  should  be  obligatory  for  all  medical 
students.  It  covers  only  what  every  general  practi- 
tioner ought  to  know.  He  may  specialize  himself  in 
after-years.  While  at  the  college  he  should  learn  to 
know  how  to  treat  all  diseases  which  he  may  be  called 
upon  to  attend  as  a  general  practitioner. 

After  having  given  the  outlines  of  my  plan,  which, 
of  course,  only  represent  a  rough  scheme,  let  me  sub- 
stantiate what  I  have  said  in  regard  to  the  abundance 
of  clinical  material  in   large  medical  centres,  and  the 


neglect  to  utilize  it  for  clinical  instruction.  I  will 
cite  only  New  York  as  an  example;  but  the  conditions 
are  virtually  the  same  in  all  the  great  medical  centres 
of  the  United  States. 

Through  the  very  kind  and  prompt  replies  to  the 
letters  of  inquiry  addressed  to  the  superintendents  of 
the  hospitals  and  the  secretaries  of  the  three  medical 
schools  of  the  city  of  New  York,  I  am  able  to  present 
the  following  statistics:  The  number  of  medical  stu- 
dents during  the  college  year  of  i8g8  and  1899  ^'^'^^■ 
In  the  medical  department  of  Columbia  University, 
801 ;  in  the  medical  department  of  New  York  Univer- 
sity (former  University  and  Bellevue  colleges  united) 
442  ;  in  the  medical  department  of  Cornell  (including 
matriculates  at  Ithaca),  241 ;  this  makes  a  total  of 
1,484. 

The  following  is  a  list  of  the  twenty-five  general 
hospitals  usually  mentioned  in  the  announcements  of 
all  three  schools  as  an  inducement  to  medical  students 
to  compete  in  the  examinations  for  internes: 


Hellevue  Hospital 

Beth  Israel  Hospital 

City  Hospital 

Colored  Home  and  Hospital. 

Columbus  Hospital 

Fordham  Hospital 

French  Hospital 

German  Hospital 

Gouverneur  Hospital 

Harlem  Hospital 

House  of  Relief 

J.  Hood  Wright  Memorial  . . 

Lebanon  Hospital 

McDonough    Memorial     Hos 

pital 

Mount  Sinai  Hospital 

Xew  York  Hospital 

Presbyterian  Hospital 

Roosevelt  Hospital 

St.  Francis'  Hospital 

St.  Mark's  Hospital 

St.  Luke's  Hospital 

St.  Mary's  Hospital 

St.  Vincent's  Hospital 

Trinity  Hospital 

Woman's  Hospital 


1.1 

<ir< 

3  c 

-S-" 

?;- 

a    m 

0 
24 

760 

28 

4 

750 

24 

240 

2 

80 

3 

40 

4 

60 

3 

I  So 

6 

39 

4 

40 

3 

34 

5 

50 

4 

65 

3 

12 

0 

206 

6 

173 

Q 

188 

8 

170 

15 

230 

6 

65 

3 

227 

10 

100 

0 

325 

6 

21 

0 

90 

6 

4,173 

158 

Term 
of  Service. 


2  years. 
2  years. 
2  years. 

1  year. 

iS  months. 
16  months. 
r8  months. 

2  years. 
iS  months. 

2  years. 
20  months. 

2  years. 
12  months. 


iS  months. 
iS  months. 

2  years. 

I  year. 

I  year. 
20  months. 
18  months. 

iS  months. 

18  months. 


Z    fH 


32 

10 

32 
4 

8 
8 
6 

24 
10 
10 

5 

6' 

10 


10 

10 

7 

5 

7 

10 

12 

2 

6 

4 

5 


Thus  we  see  that,  to  nearly  fifteen  hundred  medical 
students,  the  three  schools  can  only  offer  one  hundred 
and  fifty-eight  places  for  internes  in  general  hospitals. 
Of  course  tfiere  are  numerous  institutions  for  the  treat- 
ment of  special  diseases,  such  as  cancer  hospitals, 
maternity  hospitals,  eye  and  ear  hospitals,  hospitals 
for  consumptives,  and  so  on;  but  the  interneship  in 
these  institutions  is  not  what  the  graduating  student 
desires  and  needs.  He  wants  above  all  the  clinical 
training  in  a  general  hospital.  He  reserves  the  spe- 
cial hospital  for  some  future  date;  thus,  positions  in 
special  hospitals  are  usually  sought  by  graduates  of 
general  hospitals,  and  I  understand  these  latter  are 
always  preferred  by  the  managers  and  visiting  physi- 
cians of  these  institutions  to  the  young  men  fresh  from 
college.  To  complete  my  statistics,  I  will  give  a  list 
of  special  hospitals,  and  the  clinical  advantages  they 
offer.      (See  table  on  next  page.) 

The  number  of  beds  in  general  hospitals  varies  in  the 
different  institutions  from  seven  to  sixty  per  interne; 
thus  some  internes  must  certainly  be  overworked, 
while  others  would  seem  to  have  hardly  enough  to  do. 
In  special  hospitals  we  find  even  a  greater  inequality 
in  regard  to  the  division  of  work.     In   some  there  are 


88 


MEDICAL    RECORD. 


[July  21,  1900 


ten  patients  per  interne,  in  some  about  fifty,  and 
among  the  three  hospitals  for  consumptives  one  insti- 
tution has  three  hundred  and  fifty  beds  per  interne, 
another  one  hundred  and  twent3--eight,  and  one  with 
thirty  beds  has  no  residing  medical  officer.  The  New 
York  Foundling  Hospital  with  its  seven  hundred 
beds  has  but  two  internes.  While  I  am  willing  to 
concede  that  in  a  hospital  for  consumptives  there  may 
be  no  need  of  quite  as  many  internes  as  in  a  hospital 
of  equal  size  devoted  to  the  treatment  of  general, 
acute,  or  surgical  diseases,  still  I  maintain  that  our 
knowledge  in  phthisiology  might  be  materially  in- 
creased if  all  these  great  hospitals  for  consumptives 
would  offer  a  number  of  places  for  internes  where  the 
young  men  could  carry  on  investigations  of  the  most 
interesting  kind.  Tuberculosis  is  certainly  a  disease 
which  is  prevalent  and  important  enough  for  such  a 
work,  and  many  of  the  clinical  phases  in  phthisis  pul- 
monalis  will  still  bear  some  study  and  observation, 
leaving  aside  the  vast  field  for  research  which  phthi- 
sio-therapy  still  offers  to  physicians  old  and  young 
alike.  Lastly,  the  poor  consumptive  patients  might 
also  have  a  better  chance  for  life,  if  they  would  be 
treated  instead  of  being  kept. 


Babies'  Hospital 

General  Memorial  Hospital.  .  . 

Hospital    for     the    New    York- 
Society 

Loomis   Sanatorium    for   Con- 
sumptives (City  Branch)   ... 

Manhattan  Eye  and  Ear  Hos 
pital 

Mothers  and   Babies'  Hospital 

New  York   Eye   and    Ear    In- 
firmary   

New      York       Infirmary      for 
Women  and  Children 

New    York    Orthop.-edic    Dis- 
pensary and   Hospital 

New    York    .Skin    and    Cancer 
Hospital 

Nursery  and  Child's  Hospital. 

Seton  Hospital 

.Sloane  Maternity  Hospital.  .  .  . 

.St.  Joseph's  Hospital 

Willard  Parker  Hospital 

New    York     Foundling    Hos- 
pital  


35 

0 

100 

4 

184 

4 

30 

0 

48 
60 

4 
3 

50 

5 

60 

4 

65 

2 

45 

85 

128 

3 
3 

I 

80 

4 

350 
60 

I 

2 

700 

2 

2,080 

42 

2  years. 
2  years. 


2  years. 

1  year. 

1 8  months. 
16  months. 

2  years. 

iS  months. 
I  year. 
Indefinite. 

3  months. 
Indefinite. 
Indefinite. 


2 

6 

3 
4 

9 

3 

23 

12 

I 

5 
4 
4 
2 
12 

6 


You  must  pardon  me  for  this  little  divergence  from 
the  real  subject,  but  I  consider  a  proper  training  for 
the  future  physician,  in  the  modern  ways  of  prevent- 
ing and  treating  consumption,  as  one  of  the  most 
essential  factors  in  the  solution  of  the  tuberculosis 
problem.  No  matter  how  many  sanatoria  and  similar 
institutions  we  may  eventually  have,  for  a  good  many 
years  to  come  the  majority  of  tuberculous  patients 
will  have  to  be  treated  at  home  by  the  general  practi- 
tioner, and  the  better  he  has  been  prepared  to  do  this 
the  greater  will  be  his  power  to  help  combat  this  ter- 
rible scourge  of  tlie  human,  race. 

Why  our  New  York  Foundling  Hospital,  with  its 
seven  hundred  beds  daily  occupied  by  little  waifs  and 
homeless  mothers,  should  have  only  two  internes  is  a 
matter  difficult  to  understand  when  we  consider  how 
great  the  morbidity  and  mortality  are  among  the  class 
of  infants  left  to  the  public  care. 

I  have  said  that  in  a  number  of  general  hos|5itals 
the  internes  are  overworked,  some  having  as  many  as 
sixty  beds  to  look  after.     They  have   little  time  for 


laboratory  work,  and  still  less  for  medical  reading; 
yet  they  are  happy.  They  know  they  are  the  favored 
few.  By  cramming  (pardon  this  expression,  but  it  is 
the  only  one  which  fits  the  case)  a  great  deal  of  theo- 
retical knowledge,  these  young  men  were  successful 
in  a  difiicult  competitive  examination.  They  worked 
hard,  and  they  deserve  their  distinction;  and  by  and 
by  they  can  put  behind  their  names  the  proud  title  of 
hospital  graduate.  What  becomes  of  those  who  fail 
by  a  few  points,  of  the  many  more  who  could  not  come 
up,  for  one  reason  or  another,  for  hospital  examination, 
the  college  authorities  do  not  and  cannot  care.  These 
young  men  less  favored  by  fortune  must  start  out  to 
practise  as  best  they  can  with  whatever  clinical  knowl- 
edge they  may  have  obtained  during  the  few  hours  de- 
voted to  section  teaching. 

Through  a  better  utilization  of  clinical  opportuni- 
ties in  all  our  American  medical  centres,  all  the  stu- 
dents could  receive  a  sufficient  clinical  training  by 
serving  three  years  as  hospital  externe.  That  there  is 
room  for  every  one  of  them  I  believe  I  am  able  to 
demonstrate.  For  convenience  I  will  again  refer  to 
my  New  York  statistics.  They  show  that  in  our  gen- 
eral hospitals  each  interne  has  to  look  after  an  average 
of  thirty  beds  constantly  occupied.  Now,  if  this  num- 
ber of  patients  in  each  interne's  care  should  be  reduced 
to  twenty  for  medical,  and  to  even  less  for  active  sur- 
gical services,  these  young  men  would  still  have  plenty 
to  do;  then  at  least  two  hundred  and  ten  instead  of 
one  hundred  and  fifty-eight  places  in  general  hospitals 
would  be  open  for  competition  to  the  graduating  stu- 
dent, even  should  the  present  term  of  service  of  trom 
eighteen  months  to  two  years  be  continued. 

Reducing  the  term  of  service  in  the  special  hospitals 
to  one  year,  and  adding  only  one  interne  for  every 
fifty  consumptives  and  one  for  about  fifty  babies  in 
the  Foundling  Hospital,  would  give  us  about  ninety 
additional  places.  Thus  we  would  have  three  hun- 
dred internes,  and  if  each  had  for  his  assistants  four 
externes,  two  seniors  and  two  juniors,  twelve  hundred 
positions  as  externe  would  be  open  every  year. 

As  has  been  said,  the  total  number  of  medical  stu- 
dents of  the  three  New  York  medical  colleges  was  last 
year  fourteen  hundred  and  eighty.  I  venture  to  say 
that  of  these  not  more  than  twelve  hundred  were  en- 
titled to  hospital  privileges;  for,  as  we  have  said,  only 
the  second,  third,  and  fourth  year  students  should  be 
attached  to  hospital  service.  But  I  am  inclined  to 
believe  that  if  the  system  of  an  obligatory  three-years' 
externeship  should  come  in  vogue,  in  a  few  years  the 
hospital  interne,  having  had  already  three  years'  ser- 
vice as  externe,  would  be  glad  to  content  himself  with 
one  year's  service  in  a  general  hospital,  and  devote  his 
second  year  as  interne  rather  to  the  work  in  a  special 
hospital.  Thus,  by  and  by,  instead  of  only  two  hun- 
dred and  ten,  about  four  hundred  positions  as  interne 
in  general  hospitals  will  be  open  to  the  graduates  of 
our  New  York  medical  schools.  Besides  these  there 
are  a  few  hospitals  offering  positions  to  internes,  of 
which  I  could  not  report  for  lack  of  data. 

With  an  obligatory  four  years'  college  course,  an 
increased  clinical  curriculum,  and  a  likely  increase  of 
tuition  fees,  there  will  hardly  be  an  increase  in  the 
number  of  medical  matriculates,  and  we  will  probably 
never  have  again  four  hundred  graduates  per  year 
from  the  three  New  York  schools;  on  the  contrary, 
there  are  indications  that  we  will  have  considerably 
fewer  in  coming  years.  I  have  learned  that  the  grad- 
uating classes  for  1901  will  be  a  good  deal  smaller 
than  were  those  of  1900. 

The  prospect  that  it  may  be  possible  in  the  near 
future  to  offer  a  position  as  interne  in  a  general  hos- 
pital for  one  year  to  every  medical  graduate  is  thus 
rather  bright.  'J'he  same  prospect  also  holds  good  for 
the  graduates  from  other  large  American  medical  cen- 


July  2  1,  1900] 


MEDICAL    RECORD. 


89 


tres.  Wherever  the  college  faculties,  the  hospital  au- 
thorities, and  the  profession  can  come  to  an  under- 
standing, wherever  the  interest  of  the  student  as  the 
future  American  physician  is  placed  above  all  other 
interests  which  may  concern  a  faculty  or  a  hospital 
board,  there  the  medical  students  will  receive  the  best 
clinical  training.  But,  in  the  mean  time,  let  us  reor- 
ganize our  hospital  work  in  all  the  large  centres  of 
medical  education  by  creating  a  sufficient  number  of 
internes  and  e.xternes,  and  place  over  them  competent 
men  as  clinical  teachers. 

The  duty  of  the  clinical  teacher  should  be,  besides 
the  daily  talk  or  conference  at  the  bedside,  to  give  at 
least  one  clinical  lecture  every  week,  alternating  with 
the  other  teachers  of  the  same  hospital.  The  attend- 
ance to  this  clinic  should  be  obligatory  for  all  stu- 
dents attached  to  this  particular  service  and  faculta- 
tive for  the  pupils  of  other  clinical  teachers.  The 
work  of  the  interne  would  be  what  it  is  now,  except 
that  each  would  be  aided  by  the  externes,  who  in  turn 
would  be  taught  by  the  interne  how  to  keep  a  record 
of  the  cases,  how  to  examine  urine,  sputum,  etc.  The 
internes  could  also  help  the  clinical  teacher  in  teach- 
ing the  students  physical  examination,  and  thus  pre- 
pare themselves  to  be  future  hospital  physicians  and 
clinical  teachers.  In  the  surgical  services,  the  ex- 
ternes should  attend  to  dressing  and  helping  the  in- 
ternes in  the  work  of  preparing  patients  for  operation, 
taking  care  of  instruments,  and  so  on. 

The  interne  like  the  externe  should  have  an  obliga- 
tory service  in  medicine  or  surgery  during  his  first 
year,  but  he  should  liave  the  right  to  devote  his  last 
year  to  whatever  special  or  other  work  he  should  feel 
the  greatest  desire  or  need  for. 

Before  answering  the  objections  which  might  be 
raised  to  my  plan,  let  me  call  your  attention  once 
more  to  the  fact  that  not  only  would  the  externes  be 
benefited  thereby,  but  the  interne  and  clinical  teacher 
as  well.  The  clinical  teachers  of  a  hospital  could  ar- 
range among  themselves  on  what  days  of  the  week  to 
lecture,  so  that  all  internes  and  externes  migiit  attend. 

By  teaching  the  teacher  will  learn.  He  will  not  go 
unprepared  to  deliver  a  clinical  lecture  before  an  au- 
dience of  medical  students  from  different  schools. 
He  will  be  anxious  to  make  his  work  as  interesting 
as  possible.  He  will  be  paid  for  this  work,  and  it 
should  be  his  duty  to  do  his  best.  The  interne,  in- 
stead of  eighteen  months,  will  get  five  years  of  clinical 
instruction,  three  years  as  externe  and  two  years  as 
interne.  This  experience  with  a  number  of  different 
clinical  teachers  can  only  be  of  vast  benefit  to  him. 

Lastly,  the  medical  student  who  formerly  had  to 
take  his  clinical  teachings  in  section  classes,  who 
rarely  had  a  chance  to  watch  a  patient  for  several 
weeks  in  succession,  will  have  had  at  the  end  of  his 
three  years'  service  as  externe  a  wide  range  of  clinical 
experience  certainly  equal  to  if  not  better  than  that 
which  the  average  interne  has  now.  The  externe 
need  no  longer  feel  inferior  to  the  hospital  graduate. 
He  will  feel  more  confident  to  start  out  in  life,  and 
his  future  patients  will  be  better  off  too.  He  can  tell 
the  world  that  he  has  had  three  years'  hospital  train- 
ing, and  feels  well  prepared  to  take  upon  himself  the 
responsibilities  of  physician  or  surgeon. 

Now,  as  to  the  objections :  as  conscientious  physi- 
cians let  us  first  see  how  our  patients  will  fare  under 
such  a  system.  How  will  they  like  it?  I  venture  to 
say  they  will  welcome  the  change  and  like  it  better 
than  section  teaching.  To  be  constantly  cared  for 
by  the  same  two  or  three  young  "doctors"  will  be  far 
less  disagreeable  to  the  patient  than  to  be  examined 
once  or  twice  every  week  by  a  class  of  from  ten  to 
fifteen  strange  young  men.  The  patients  will  not 
dread  the  visit  and  examination  of  these  few  young 
assistants   with   whom  they  become  acquainted,  as  I 


know  they  often  dread  the  arrival  of  the  class  with 
the  teacher,  who  at  times  is  not  even  the  physician  of 
the  patient. 

The  increased  amount  of  work  will,  of  course,  ne- 
cessitate a  four  years'  course  perhaps  of  even  ten 
months  each,  instead  of  eight  or  nine,  and  the  in- 
creased fees  for  tuition  are  likely  to  deter  a  number 
of  young  men  from  entering  upon  a  medical  career, 
although  in  reality  there  should  be  a  State  appro- 
priation for  medical  schools  as  there  is  for  other  edu- 
cational institutions.  Still  I  feel  that  you  will  all 
agree  with  me  when  I  say  that,  in  view  of  the  over- 
abundance of  physicians  at  the  present  time,  a  de- 
crease in  the  number  of  medical  students  would  be 
rather  a  gain  than  a  loss  to  the  profession. 

Another  objection  which  will  certainly  be  raised 
would  come  from  the  duly  appointed  clinical  profes- 
sors of  the  respective  colleges;  Ihey  might  fear  that 
their  vocation  would  suffer  in  prestige;  far  from  it. 
The  importance  of  the  chairs  of  clinical  surgery  and 
clinical  medicine  would  not  only  not  suffer  from  such 
a  system,  but  their  usefulness  would  be  vastly  in- 
creased. 

All  the  clinical  professors  would  have,  of  course,  a 
hospital  service.  The  hours  of  their  clinic  could  be 
arranged  so  as  not  to  conflict  with  the  clinics  of  other 
teachers,  and  they  would  have  the  honor  of  having 
among  their  hearers  not  only  the  pupils  of  their  own 
schools,  but  always  a  goodly  number  from  other  col- 
leges. 

The  suppression  of  some  of  the  didactic  lectures 
will  not  be  mourned  by  any  student  nor  any  well- 
meaning  professor.  I  believe  it  is  now  the  general 
opinion  of  modern  medical  educators  that  there  are 
really  but  very  few  subjects  in  medicine  which  need 
to  be  taught  didactically. 

The  last  most  serious  objection  which  is  likely  to 
be  raised  is  that  the  more  or  less  numerous  medical 
colleges  in  each  of  our  great  medical  centres  will 
never  unite  to  do  such  harmonious  work.  The  ob- 
jectors will  call  my  plan  impracticable.  Neverthe- 
less, Paris,  Berlin,  and  Vienna,  the  greatest  centres  of 
medical  learning  of  the  world,  have  each  but  one 
faculty  of  medicine;  and  Paris  has  three  times  as 
many  medical  students  as  New  York. 

The  union  of  medical  schools  has  very  happily  be- 
gun in  some  sections  of  the  United  States.  We  were 
very  near  reducing  the  number  of  our  medical  colleges 
in  New  York  by  one,  but  unfortunate  inharmonious 
conditions  created  a  new  school  alongside  of  the  two 
which  had  united.  Notwithstanding  this  discourag- 
ing occurrence,  I  am  rather  optimistic  for  the  future, 
and  when  so  much  is  at  stake  as  the  clinical  teaching 
of  the  future  medical  men,  I  think  the  schools  will 
have  to  listen  not  only  to  the  needs  of  the  student  and 
to  the  demands  of  the  profession  at  large,  but  perhaps 
also  to  the  State  boards  which  examine  physicians  be- 
fore granting  them  a  license  to  practise.  These  State 
boards  have  certainly  done  a  great  deal  of  good  in 
raising  the  standard  of  medical  education,  but  their 
examinations  are  of  necessity  all  theoretical.  They 
give  no  guarantee  that  the  candidate  has  sufficient 
clinical  training.  Supposing  all  State  boards  should 
make  a  demand  whereby  the  evidence  of  having  served 
three  years  as  hospital  externe  should  be  a  sine  qua 
non  for  all  candidates,  it  would  be  a  great  step 
toward  the  clinical  training  of  all  men  who  would 
hereafter  leave  our  colleges.  But  I  believe  that  if 
such  a  movement  as  I  have  endeavored  to  outline  be- 
fore you  should  be  inaugurated,  every  one  of  our  im- 
portant medical  schools  would  be  willing  to  respond 
to  such  an  essential  and  useful  innovation  as  a  thor- 
ough clinical  teaching  of  all  their  students. 

Through  an  amalgamation  of  the  clinical  teaching 
of  all  schools  in  every  large  city,  there  may  come  that 


90 


MEDICAL    RECORD. 


[July  2  1,  1900 


glorious  time  for  which  we  all  so  earnestly  pray: 
Fewer  and  better  schools,  fewer  and  better  educated 
physicians;  one  great  university  with  one  great  medi- 
cal faculty  in  each  great  medical  centre.  The  stand- 
ard of  medical  education  in  our  own  country  would 
thus  be  vastly  raised,  and  not  only  equal  that  of 
Europe,  but  become  ultimately  superior  to  that  of  any 
country  in  the  world. 

16  West  Ninetv-fifth  Street. 


DOES  "CROSS-EYE"  AFFECT  THE  GENERAL 
HEALTH? 

By   AMBROSE   L.    RANNEV,    M.D.. 

NEW   YORK. 

The  relative  percentage  of  the  total  population  that  is 
disfigured  by  "squint"  is  hard  to  estimate.  It  must 
confessedly  be  a  lar^e  one.  This  can  be  easily  proved 
to  a  careful  observer  by  the  inspection  of  any  large 
gathering.  My  own  leisure  moments  are  frequently 
employed,  while  in  public  conveyances  and  social  en- 
tertainments, in  counting  those  whose  eyes  tend  (either 
constantly  or  at  intervals)  to  assume  positions  in  one 
or  both  orbits  that  are  incompatible  with  binocular 
single  vision. 

To  the  untrained  observer,  however,  many  cases  of 
actual  strabismus  escape  detection.  This  statement 
applies  as  well  to  medical  men  as  to  the  laity.  It  is 
only  when  one  or  both  eyes  deviate  so  far  from  paral- 
lelism as  to  constitute  an  actual  and  ever-present  de- 
formity, that  some  medical  men  (who  are  keen  ob- 
servers in  other  lines)  detect  it  and  suggest  immediate 
treatment  for  squint. 

Yet  it  is  an  established  and  indisputable  fact  that 
eye-strain  ceases,  and  no  leakage  of  nervous  force  is 
created,  whenever  cross-eye  becomes  an  extreme  de- 
formity and  its  correction  seems  to  be  the  most  imper- 
ative. 

The  an.xiety  of  intelligent  parents,  whenever  they 
bring  a  hideously  cross-eyed  child  to  the  oculist  to 
have  the  eyes  straightened,  is  frequently  much  greater 
than  the  natural  dread  of  an  operation  would  account 
for;  simply  because  their  physician  has  unfortunately 
told  them  that  "such  extreme  cross-eye  would  event- 
ually injure  the  health  of  their  child,"  and  that  they 
must  get  rid  of  this  source  of  danger. 

Nothing  could  be  more  ridiculous!  The  absurdity 
of  such  statements  and  views  will  be  made  apparent 
to  the  reader  by  subsequent  physiological  explanation. 

The  correction  of  a  marked  eye-deformity  (in  either 
a  child  or  adult)  is  unquestionably  most  desirable.  It 
greatly  improves  the  personal  appearance  (if  properly 
done),  and  it  may  add  to  the  general  comfort  of  the 
patient  in  the  use  of  the  eyes;  but  extreme  degrees  of 
cross-eye  (in  which  the  two  eyes  cannot  be  made  to 
hold  single  images)  do  not  (save  in  exceptional  cases) 
affect  the  general  health,  or  justify  correction  as  purely 
a  therapeutical  measure. 

The  serious  damage  to  health  occurs  only  in  those 
patients  who  want  to  be  cross-eyed  but  can't.  It  oc- 
curs in  those  who  have  two  eyes  that  naturally  tend  to 
deviate  and  perhaps  occasionally  may  deviate  for  a 
time  from  parallelism,  but  which  can  still  be  used  to- 
gether by  an  unconscious  effort  and  a  large  expenditure 
of  nerve-force  on  the  part  of  the  patient. 

Such  subjects  have  constantly  to  make  this  uncon- 
scious and  unnatural  effort  simply  because  they  would 
"  see  double  "  if  they  didn't;  they  perhaps  may  or  may 
not  be  conscious  at  times  that  eye-work  (such  as  read- 
ing, sewing,  shopping,  attending  public  places  of 
amusement,  etc.)  causes  headache,  eye-pain,  or  nervous 
fatigue;  and  they  too  often  struggle  on  (as  I  person- 
ally did  for  thirty  years  until  I  collapsed)  with  an  un- 


natural load  to  carry  because  of  eye-strain  that  is  un- 
recognized to-day  by  too  many  medical  men,  and  not 
understood  or  suspected,  as  a  rule,  by  the  sufferer. 

The  eyes  themselves  are  but  two  cameras.  Two 
pictures  of  every  object  are  first  formed  upon  the  retina; 
and  are  then  telegraphed  to  the  brain  cells  (in  the  oc- 
cipital lobe).  Under  normal  conditions  they  are 
there  fused  into  a  single  visual  impression  of  which 
we  are  conscious. 

In  order  to  admit  of  this  fusion  of  two  visual  images 
into  one  visual  impression,  the  two  eyes  have  to  be 
most  accurately  adjusted  by  four  pairs  of  straight  mus- 
cles and  two  pairs  of  oblique  muscles;  while  the  one 
pair  of  muscles  that  controls  the  upper  eyelids  acts  in 
unison  with  the  other  six  pairs  whenever  the  eyes  are 
being  adjusted  so  as  to  work  properly  together. 

All  adjustments  of  the  eyes,  to  insure  the  desired 
effects,  have  furthermore  to  be  made  with  marvellous 
quickness  and  accuracy. 

Every  possible  combination  of  the  seven  pairs  of 
muscles  has  at  times  to  be  specially  arranged,  then 
suddenly  discarded,  then  a  new  one  made,  then  some- 
what modified  (and  so  on  ai/  iiifniilii7n)  whenever  the 
eyes  are  required  either  to  follow  or  to  be  steadily  di- 
rected upon  the  multitude  of  objects  that  are  brought 
sudddenly  or  slowly  to  our  conscious  recognition 
through  our  eyes.  The  human  mind  can  hardly  grasp 
a  numerical  computation  of  these  combinations  of 
muscular  efforts  or  the  lightning  changes  required  in 
seven  pairs  of  muscles  to  keep  the  two  eyes  in  perfect 
adjustment  at  all  times  and  under  all  conditions. 

Imagine,  for  example,  one  driver  (or  even  a  band  of 
drivers)  trying  to  direct  simultaneously  with  seven 
pairs  of  reins  seven  pairs  of  horses  in  tandem  through 
a  series  of  most  difficult  and  complicated  evolutions 
at  lightning  speed.  A  slight  mental  conception  may 
thus  be  formed  of  the  complicated  driving  of  the  eyes; 
with  the  brain  as  the  driver  and  the  eye-muscles  as 
the  reins. 

Again,  let  us  take  a  common  event  as  an  illustration 
from  our  experiences  in  every-day  life!  We  buy  a 
new  team  of  horses,  and  with  a  new  harness  (not  prop- 
erly adjusted  to  them)  we  start  out  to  drive.  One  of 
the  horses  is  soon  found  to  be  checked  very  much 
higher  than  the  other;  and  the  inside  reins  may  be  so 
short  or  so  long  that  when  tightened  they  draw  the 
heads  of  the  horses  close  together  or  wide  apart  and 
as  a  consequence  compel  the  team  to  travel  sidewise 
in  order  to  get  along  under  such  unnecessary  condi- 
tions. Every  one  knows  tiiat  the  best  horses  would 
be  spoiled  in  a  very  short  time  by  such  distressing 
annoyances;  and  the  trainer  would  be  driven  sooner  or 
later  to  utter  desperation  in  his  vain  attempts  to  make 
them  work  properly  as  a  pair,  if  at  all.  The  first  in- 
tuitive step  that  would  be  taken  (by  even  the  merest 
novice)  in  order  to  remove  such  sources  of  endless  ir- 
ritation both  to  man  and  beast  would  be  immediately 
to  re-adjust  the  reins  and  checks,  until  the  conditions 
became  satisfactory  to  both  the  driver  and  the  team. 

Now  nature  often  presents  the  same  type  of  problem 
to  the  oculists  for  correction! 

A  pair  of  eyes  that  are  simply  checked  too  high 
(anatropia  or  anaphoria)  may  swing  in  or  out  con- 
stantly or  occasionally  as  a  direct  result  of  that  spe- 
cial type  of  mal-adjustment;  an  unnatural  tension  upon 
one  or  both  of  the  inside  reins  (the  internal  recti)  may 
mak'j  one  or  both  eyes  turn  in  (esotropia);  a  shortness 
of  the  outside  reins  (the  external  recti)  may  give  con- 
stantly or  at  times  a  divergent  squint  (exotropia)  ;  the 
upper  eyelid  may  droop  (constanily  or  at  intervals) 
purely  as  a  result  of  some  maladjustment  of  the  eye- 
balls themselves;  and  a  tendency  to  turn  or  actual 
turning  of  both  of  the  eyeballs  downward  (kataphoria 
or  katatropia)  may  create  apparent  distortions  of  the 
eyes  in  other  directions  than  the  one  actually  at  fault. 


July  2  1,  1900] 


MEDICAL    RECORD. 


91 


Frequently,  as  a  result  of  some  abnormal  adjustment 
of  the  eye-muscles,  certain  peculiar  attitudes  of  the 
head  of  the  patient  become  a  fixed  habit;  because,  by 
simply  altering  the  position  of  the  head,  difficulties 
experienced  in  maintaining  binocular  single  vision 
upon  the  proper  plane  may  be  modified  unconsciously 
and  occasionally  overcome  entirely. 

In  my  recent  work,  entitled  "  Eye-Strain  in  Health 
and  Disease,"  '  I  devote  some  pages  to  this  interesting 
field  in  diagnosis.  I  show  in  those  pages  that  a 
marked  and  constant  elevation  of  the  chin  means  that 
the  eyes  are  adjusted  for  too  low  a  plane;  and  that  a 
marked  depression  of  the  chin  upon  the  chest,  with  a 
protrusion  of  the  forehead  and  a  persistent  stoop  of  the 
shoulders,  almost  always  indicates  that  the  eyes  are 
adjusted  for  a  plane  higher  than  the  horizon. 

These  types  of  patients  sometimes  have  a  very 
marked  apparent  "  squint '"  either  inward  or  outward; 
yet  an  operation  performed  upon  an  internal  or  ex- 
ternal rectus  in  a  case  of  these  peculiar  types  would 
not  cure  the  squint  or  rectify  the  unnatural  posture  of 
the  head.' 

The  principles  involved  in  the  surgical  relief  of 
cross-eye  are  fortunately  better  understood  to-day  than 
they  were  in  the  past.  It  is  safe  to  assert  that  in  no  field 
of  surgery  has  there  been  a  larger  percentage  of  failures 
in  the  past  than  in  the  treatment  of  squint.  The  re- 
markable improvement  in  the  results  now  obtained 
(after  surgical  attempts  to  rectify  the  various  types  of 
tliis  deformity)  has  been  due  largely  to  the  more  care- 
ful study  of  the  eye-muscles  by  the  tropometer  and  the 
phorometer.  Personally  I  should  not  deem  any  one 
to-day  competent  to  treat  scientifically  a  case  of  stra- 
bismus unless  he  was  well  versed  in  the  use  of  these 
modern  instruments. 

Red-Glass  Test. — One  recognized  clinical  distinc- 
tion between  actual  squint  and  simple  insufficiency  of 
ocular  muscles  is  this:  In  squint,  when  a  plain  red 
glass  is  held  before  either  eye  of  the  patient  and  the 
patient  is  instructed  to  gaze  with  both  eyes  open  upon 
a  candle-flame  at  the  distance  of  twenty  feet  from  the 
eye,  two  images  of  the  candle  are  seen  (a  red  and  a 
white  image). 

The  relative  position  of  the  double  images  to  each 
other  (when  unconquerable  diplopia  is  found  to  exist) 
is  the  guide  to  the  oculist  in  detecting  the  type  of 
squint;  and  the  strength  of  prism  required  to  enable 
the  patient  to  fuse  the  double  images  is  an  approxi- 
mate way  of  determining  the  amount  of  the  "  manifest  " 
tendency  of  the  eyes  to  cross. 

In  other  words,  the  presence  of  diplopia  (double 
vision),  when  a  red  glass  is  held  before  either  eye,  is 
a  diagnostic  sign  of  squint. 

liut  do  all  patients  with  squint  see  double  images 
with  or  without  the  red-glass  test ?  By  no  means!  In 
fact,  it  is  very  uncommon  in  testing  patients  with  ex- 
treme cross-eye  to  get  them  at  first  to  see  the  doui)le 
image.  The  reasons  for  this  difficulty  are  either  that 
patients  of  this  class  have  learned  to  suppress  visual 
perceptions  in  one  eye  when  the  other  is  fixed  upon 
some  object,  or  that  the  double  image  is  too  far  re- 
moved from  the  normal  field  of  vision  to  be  recognized 
without  long-continued  practice. 

I  have  known  patients  who  had  for  years  suppressed 
visual  images  on  account  of  squint  to  practise  for 
weeks  with  a  red  glass  before  they  could  simultane- 
ously see  the  image  of  a  candle-flame  with  both  eyes. 
I  commonly  teach  such  patients  to  do  this  by  having 
them  fix  one  eye  upon  the  candle-flame  while  the  other 

'  F.  A.  Davis  Co  .  Publishers,  Philadelphia.  iSg;. 

'  Dr.  George  T.  Stevens  considers  the  conditions  known  as 
"  kataphoria"  or  "' katatropia"  as  predisposing  causes  to  lung 
diseases  and  chronic  intlammatory  conditions  of  the  respirator)' 
tract  ;  because  depression  of  the  chin  tends  to  compress  the 
larynx,  and  the  stooping  shoulders  contract  the  chest  and  inter- 
fere with  its  proper  expansion. 


is  shielded  with  a  card  and  covered  with  a  red  glass. 
I  instruct  them  to  look  intently  at  the  candle-llame 
and  to  endeavor  to  detect  the  colored  candle  image 
when  I  remove  the  card  from  in  front  of  the  eye  that 
has  the  red  glass  before  it. 

After  repeated  attempts,  most  cross-eye  patients  can 
be  made  to  recognize  double  images  by  this  method; 
but  occasionally  a  strong  prism  has  to  be  used  in  con- 
nection with  the  red  glass  to  bring  the  double  images 
within  the  normal  field  of  vision  before  the  patient  can 
be  taught  to  use  both  eyes  simultaneously  while  tests 
are  being  made. 

Exclusion  Test. — A  second  point  of  great  value  in 
the  preliminary  investigation  of  cross-eye  is  the  em- 
ployment of  the  so-called  "exclusion  test." 

The  patient  is  instructed  to  look  intently  with  both 
eyes  open  at  a  candle-flame  twenty  feet  at  least  from 
the  eye,  while  a  card  is  held  as  a  shield  over  one  eye 
and  shifted  from  eye  to  eye  alternately  so  as  to  exclude 
either  the  right  or  the  left  visual  image.  While  either 
eye  is  shielded  the  observer  notices  carefully  how  that 
eye  deviates  from  parallelism  with  its  fellow  when  the 
card  excludes  its  visual  linage;  and  the  observer  also 
notes  with  care  in  what  direction  the  same  eye  moves 
when  the  card  is  shifted  to  cover  the  opposed  eye.  If, 
for  example,  the  right  eye  deviates  upward  and  outward 
behind  the  shield  and  jumps  downward  and  inwatd 
when  the  card  is  shifted  to  cover  the  left  eye,  and  the 
left  eye  deviates  downward  and  outward  behind  the 
shield  and  jumps  upward  and  inward  when  the  opposed 
eye  is  covered,  the  observer  knows  that  right  hyper- 
phoria exists  with  exophoria  (or  that  the  right  eye 
tends  to  assume  the  highest  vertical  planes  and  that 
both  eyes  tend  to  deviate  outward).  Prisms  are  now- 
placed  before  the  eyes  to  correct  properly  the  abnormal 
jump  of  the  eyes,  and  the  extent  of  the  manifest  squint 
can  usually  be  approximated  in  this  way. 

If  both  eyes  jump  downward  when  the  card  is 
shifted,  both  eyes  are  too  high;  if  both  jump  upward 
under  like  conditions,  both  eyes  are  too  low^;  if  both 
simply  jump  inward,  the  eyes  are  in  vertical  balance 
but  deviate  outward;  if  both  eyes  jump  outward,  the 
case  is  one  of  convergent  squint. 

A  third  preliminary  step  in  the  examination  of  cross- 
eye  patients  is  to  determine  the  refraction  of  each  eye 
with  certainty,  and  if  markedly  abnormal  to  correct 
the  refraction  with  glasses  for  some  weeks  before  any 
positive  conclusions  are  formed  or  advice  is  given  re- 
garding the  correction  of  the  squint. 

Refractive  Tests.— Without  thorough  tests  for  ab- 
normalities of  refraction,  no  muscular  tests  are  posi- 
tive and  many  are  often  misleading.  A  mydriatic 
ought  always  to  be  used. 

I  recall  a  case  in  which  a  physician  lately  brought 
a  terribly  cross-eyed  lady  to  my  office  for  operation. 
Her  disfigurement  was  extreme.  She  was  found  to 
have  marked  astigmatism  and  unequal  refraction. 
The  prescribing  of  proper  glasses  for  constant  wear 
for  one  month  was  advised.  At  the  end  of  a  month 
all  symptoms  of  cross-eye  had  totally  disappeared,  and 
by  careful  tests  no  abnormality  of  the  eye-muscles 
could  be  detected  by  me.  An  operation  on  this  pa- 
tient would  have  been  a  sad  mistake. 

Results  of  Eye-Strain. — The  amount  of  nervous 
disturbance  that  may  be  created  by  eye-strain  in  those 
subjects  that  are  on  the  border-line  of  '"squint"  with- 
out actual  deformity  is  sometimes  extreme. 

There  is  hardly  a  nervous  disease  of  the  functional 
type  that  cannot  be  induced  by  this  cause.  Patients 
who  suffer  from  headaches,  neuialgias,  chorea,  epi- 
lepsy, nervous  prostration,  and  even  insanity  from  this 
reflex  cause  are  unquestionably  encountered.  This  is 
no  idle  dream,  nor  is  the  statement  made  from  rash 
enthusiasm.  I  might  quote  from  my  work  on  '"  Eye- 
Strain  '■    (previously    referred    toj    many    cases    that 


92 


MEDICAL    RECORD. 


[J  uly  2  1,   1 900 


clearly  demonstrate  the  accuracy  of  my  statements  to 
all  unprejudiced  minds. 

I  owe  personally  to  this  great  discovery  in  medical 
science  my  ability  to  practise  my  profession  the  past 
*en  or  twelve  years;  and  the  gratitude  manifested  by 
others  who  have  been  restored  to  perfect  health  by  eye- 
treatment  after  all  other  avenues  of  escape  seemed 
closed  to  them,  does  not  exceed  my  own. 

Cases  Reported. — The  four  cases  of  squint  whose 
clinical  histories  are  given  in  connection  with  these 
preliminary  remarks  are  peculiarly  interesting  examples 
of  what  can  be  done  toward  restoration  of  single  vision 
by  modern  methods. 

Case  I.  presented  one  of  the  most  difficult  eye-prob- 
lems to  correct  that  I  have  ever  yet  encountered.  The 
combination  of  25°  of  vertical  squint  with  14°  of 
crossed  diplopia  (which  this  patient  disclosed  at  the 
first  examination)  is  not  one  from  which  most  oculists 
would  hope  to  obtain  binocular  vision  and  perfect 
muscular  balances. 

The  extreme  nervous  disturbances  caused  by  the 
eye-defects  seemed  to  me,  at  first,  as  totally  inconsistent 
with  so  marked  a  degree  of  diplopia.  I  attribute  them 
now  to  the  fact  that  this  patient  must  have  at  times 
made  great  efforts  to  obtain  single  vision  and  been 
partially  or  completely  successful.  He  always  had 
carried  his  head  on  one  side  to  an  extreme  degree. 
This  tended  to  aid  him  in  overcoming  his  vertical  de- 
fect. Had  he  suppressed  images,  he  would  not  have 
been  conscious  of  transient  diplopia  or  been  nervously 
afflicted.  One  thing  is  certain,  viz.,  that  the  estab- 
lishment of  binocular  vision  at  all  points  has  for  the 
past  four  years  totally  arrested  his  nervous  symptoms, 
which  were  the  cause  of  great  suffering  in  the  past. 

Case  II.  illustrates  well  the  fact  that  an  extreme 
maladjustment  of  the  ocular  muscles  combined  with 
unequal  refraction  can  cause  no  nervous  disturbances. 
A  part  of  the  parental  eye-defects  was,  however,  trans- 
mitted to  his  children;  to  a  less  degree,  but  sufficient 
to  entail  increasing  eye-strain  and  to  induce  very  seri- 
ous nervous  results. 

The  two  sons  who  developed  epilepsy  (and  who 
were  cured  by  me  through  eye-treatment  alofie)  inher- 
ited from  the  father  just  enough  of  iiis  eye-defects  to 
make  the  maintenance  of  single  vision  difficult  and  to 
entail  upon  them«a  constant  waste  of  nerve-force — 
hence  their  epilepsy. 

The  daughter  (who  for  years  was  a  victim  to  extreme 
and  alarming  nervous  prostration)  recovered  her  health 
completely  after  I  rectified  the  mal-adjustment  of  her 
eye-muscles  and  gave  her  proper  glasses.  She  also 
owed  the  cause  of  her  nervous  collapse  to  the  inheri- 
tance from  her  father  of  only  a  portion  of  his  extreme 
eye-defects. 

The  father  had  squint,  yet  no  nervous  disturbances; 
the  children  were  practically  on  the  border  line  of 
squint,  without  disfigurement,  and  were  nervously 
afilicted. 

Case  III.:  This  remarkable  case  of  sudden  nervous 
collapse,  associated  with  a  total  inability  to  use  the  eyes 
or  to  hold  single  images,  teaches  some  valuable  lessons 
to  those  not  familiar  with  the  results  of  eye-strain. 

Many  victims  to  congenital  eye-strain,  who  have  for 
their  entire  life  been  unconsciously  on  the  verge  of 
diplopia  and  who  have  in  consequence  been  making 
constant  and  almost  superhum.in  efforts  to  see  single, 
often  lose  control  of  their  eye-muscles  suddenly  and 
sometimes  do  not  ever  regain  tiieir  ability  to  overcome 
their  congenital  tendency  to  "cross-eye."  It  is  not 
necessarily  paresis;  nor  does  it  usually  mean  the  de- 
velopment of  brain-trouble.  It  is  more  apt  to  be  the 
result  of  simple  nervous  exhaustion,  and  a  rebellion 
(as  it  were)  on  the  part  of  nature  against  trying  to  use 
a  pair  of  eyes  together  that  are  not  properly  adjusted 
for  single  vision. 


When  the  reins  that  drive  such  eyes  are  readjusted 
properly  by  the  oculist,  and  when  nature  feels  assured 
that  all  former  difTiculties  of  adjustment  are  perma- 
nently removed,  slowly  the  ability  to  use  the  eyes  to- 
gether is  in  most  instances  re-established. 

In  this  particular  instance,  the  first  tenotomy  (not 
performed  by  myself)  corrected  a  part  of  the  muscular 
mal-adjustment  and  for  a  short  time  re-establisiied 
single  vision.  Soon  a  return  of  the  diplopia  occurred, 
and  the  patient  became  alarmed  and  the  oculist  doubt- 
ful about  further  operative  work. 

Because  the  difficulties  to  be  surmounted  and  the 
various  steps  required  were  not  fully  understood  by 
the  patient  he  naturally  regarded  the  first  operation  as 
a  dismal  failure — when,  in  reality,  it  constituted  but 
the  first  step  toward  a  re-establishment  of  muscular 
equilibrium  in  the  orbits.  He  lost  confidence  in  his 
oculist  simply  because  the  oculist  himself  had  not  ap- 
parently a  clear  conception  of  what  he  had  to  meet; 
and  because  he  failed  to  state  in  advance  to  the  patient 
his  exact  line  of  procedure,  which  probably  was  not 
very  clearly  defined  even  in  his  own  mind. 

Had  the  oculist  used  the  exclusion  test,  together 
with  phorometer  and  tropometer  records,  he  would 
have  known  early  that  one  eye  was  much  higher  than 
the  other  and  that  both  eyes  diverged;  he  would  have 
been  able  to  state  to  the  patient  before  operation  that 
several  graduated  tenotomies  might  be  demanded  to 
insure  permanent  relief;  he  could  have  explained  in 
advance  to  the  patient  just  what  each  proposed  step 
would  accomplish  toward  the  desired  end;  and  he 
would  have  been  able  to  carry  his  work  along  to  com- 
pletion with  the  full  confidence  and  support  of  his 
patient. 

The  tropometer  would  have  told  the  oculist  that  the 
case  was  not  one  of  paresis.  The  history  of  the  case 
did  not  justify  either  the  suspicion  or  diagnosis  of 
brain-disease.  The  sudden  development  of  diplopia 
pointed  naturally  to  a  high  degree  of  "latent  hetero- 
phoria."  In  all  human  probability  such  an  amount 
could  not  be  overcome  by  one  graduated  tenotomy; 
and  the  patient  should  have  been  prepared  early  by 
intelligent  explanation  for  probable  recurrences  of  his 
symptoms  from  time  to  time  until  the  muscular  mal- 
adjustment was  satisfactorily  corrected. 

The  perfect  re-establishment  of  control  of  the  eyes 
for  reading,  book-keeping,  and  business  pursuits  in 
fine  maciiine  work,  and  the  total  disappearance  of  dou- 
ble vision  after  three  subsequent  graduated  tenotomies 
had  been  performed  by  myself,  demonstrate  clearly 
that  the  first  operation  performed  upon  this  patient 
was  not  a  failure.  It  simply  corrected  a  small  part  of 
the  mal-adjustment  of  the  eyes.  It  enabled  the  patient 
to  see  single  images  for  a  time  only — but  the  hyper- 
phoria and  exophoria  that  still  remained  uncorrected 
eventually  caused  a  return  of  the  diplopia. 

Case  IV.  illustrates  some  important  clinical  points 
that  aided  materially  in  restoring  an  apparently  hope- 
less condition  of  the  eyes  to  the  normal  condition;  in 
spite  of  the  fact  that  a  persistent  diplopia  had  inter- 
fered seriously  for  years  with  every  pleasure  and  all 
use  of  the  eyes. 

When  I  first  saw  her  and  tested  her  eyes,  this  pa- 
tient presented  some  eye-problems  that  were  extremely 
puzzling  to  me  and  which  for  a  long  interval  seemed 
discouraging  both  to  the  sufferer  and  myself.  A  per- 
fect recovery,  however,  followed  after  two  years  of 
travel.  Prior  to  this  trip  I  had  by  graduated  tenoto- 
mies placed  the  eyes  where  the  patient  could  hold 
single  binocular  vision  for  short  periods  of  time;  but 
it  took  over  six  months  of  travel  before  any  satisfac- 
tory use  of  the  eyes  became  possible,  and  one  full 
year  before  the  patient  could  read  with  ease  and  com- 
fort. 

After  a  perfect  control  of  the  eye-musclos  in   Ihei*- 


July  2  1,  1900] 


MEDICAL    RECORD. 


93 


new  adjustment  had  once  been  acquired  by  this  pa- 
tient, no  return  of  diplopia  either  at  near  or  distant 
objects  has  ever  occurred. 

The  following  table  will  explain  the  meaning  of 
certain  terms  used  in  the  published  records  of  individ- 
ual cases  and  also  in  subsequent  pages  of  this  article: 


f  Hypermetropia    (far-sighlei/iiess).      A   shallow  eye 

(from  the  front  to  the  back) ,  causing  an  imperfect 

focus  of  objects. 
MyoI'I.\    {near-sightedness).      \n  elongated  eye    (from 

the  front  to  the  back),  causing  an   imperfect  focus 

of  objects. 
Astigmatism.     An  irregularly-curved eornea  or  lens. 

causing  distortion  of  images  on  retina. 
Emmetropia.      A  perfectly  constructed  eye. 

ESOPHORIA.  A  tendency  of  one  or  both  eyes  to  de- 
viate toward  the  nose. 

Esotropia.  An  actual  turning  of  one  or  both  eyes 
toward  the  nose  {convergent  squint). 

E.KOPIIORIA.  A  tendency  of  one  or  both  eyes  to  de- 
viate toward  the  temple. 

E.XOTROPIA.  An  actual  turning  of  one  or  both  eyes 
outward  (divergent  squint  or  "  wall-eye"). 

Hyperphoria.  A  tendency  of  one  eye  to  rise  above 
the  level  of  its  fellow. 

Hypertropia.  An  actual  turnini;  of  one  eye  above  its 
fellow  ( vertical  squint) . 

Anaphori.\.  a  tendency  of  both  eyes  to  assume  too 
"i        high  a  plane. 

K.\TAl'HORi.\.  A  tendency  of  Iwlh  eyes  to  assume  too 
low  a  plane. 

Heterophori.\.  Abnormal  adjustment  of  the  eye- 
muscles. 

Orthophori.^.  Xormal  adjustment  of  the  eye- 
muscles. 

Addi'ction.  The  power  of  the  internal  muscles  of  the 
eyeballs.      It  varies  in  health  between  2^    and  bo  . 

Adduction.  The  power  of  the  external  muscles  of  the 
eyeballs.     //  should  he  S   in  health. 

SuRSt  MUi'CTiON.  The  power  of  the  vertical  muscles 
of  the  eyeballs.       The  right  and  left  should  be  alike. 


lit  -.i 


•gJ5  >. 
p3  baJS 


L 

C  .Spherical.  Ground  upon  a  convex  or  concave  sphere. 
I  Used  to  correct  hypermetropia  and  myopia. 
I  Cylindrical.  Ground  upon  a  convex  or  concave 
I  cylinder.  Used  to  correct  astigmatism, 
j  Prism.\tic.  T~vo  plane  surfaces  0/  glass  meeting  at 
an  angle.  The  thick  side  is  termed  the  base  of  the 
I  prism.  Used  to  relieve  mechanically  errors  cf  ad- 
[       justment  of  the  eye-muscles. 

Case  I. — Mr.  M ,  aged  thirty-six  years,  married, 

lawyer.  Referred  to  me  May  loth,  1892,  by  Dr.  H. 
E.  Hayd  of  Buffalo,  N.  V.      Family  history  not  known. 

History  of  Case:  This  patient  had  always  been  an 
intensely  nervous  man,  with  many  choreic  symptoms. 
For  many  years  he  had  done  a  large  law  business; 
although  suffering  extremely  from  nervousness,  irrita- 
bility of  temper,  confusion  of  head  (with  slight  head- 
ache occasionally),  inability  to  use  his  eyes  steadily, 
and  at  times  almost  complete  nervous  collapse. 

When  he  came  to  me  he  complained  chiefly  of  his 
inability  to  use  his  eyes  or  to  concentrate  his  mind  on 
his  business  without  becoming  extremely  nervous. 
He  was  also  troubled  with  burning  and  watering  of 
his  eyes. 

He  was  so  nervous  that  he  would  nearly  jump  from 
his  chair  if  by  accident  I  touched  his  head  or  even 
his  hair  with  my  hand  while  testing  his  eyes.  Sud- 
den noises,  such  as  the  ringing  of  my  door-bell,  also 
caused  a  nervous  jump.  He  had  been  absolutely  un- 
able to  play  tennis  or  any  similar  game,  as  he  could 
not  concentrate  his  vision  on  the  ball  without  causing 
extreme  nervousness  and  distress  in  his  head. 

F.ye- Defects:  On  the  first  examination  this  patient 
had  #1}  vision  in  each  eye  with  or  without  the  glasses 
he  was  then  wearing,  which  were  O.D.  -\-  i.oo,  O.S. 
-f  0.75.  He  had  also  a  diplopia  (with  a  red  glass) 
corrected  by  25'  of  left  hyperphorial  prism  combined 
with  14    of  exophorial  prism. 

Under  homatropine,  he  had  vision  of  ']'}  in  each  eye 
with  -|-  0.50  c.  axis  90^  added  to  his  hypermetropic 
glasses ;  but  his  muscular  tests  were  the  same  as  before. 


Treatment  and  Results:  The  correction  of  this  ex- 
treme heterotropia  required  a  number  of  tenotomies, 
extending  over  a  period  of  two  years.  The  left  eye 
was  lowered,  the  right  raised,  and  both  eyes  let  in  by 
graduated  tenotomies  performed  upon  the  left  superior 
rectus,  the  right  inferior  rectus,  and  both  externi. 
The  full  correction  was  also  given  for  his  refraction. 

The  result  of  these  operations  was  the  establishment 
of  almost  absolute  orthophoria.  I  have  tested  his  eyes 
once  or  twice  a  year  for  the  past  four  years;  and  he 
invariably  shows  no  hyperphoria  and  an  exophoria  of 
from  ]"  to  I  .  His  adduction  is  30%  abduction  6°, 
right  and  left  sursumduction  4'^  each.  From  his  tro- 
pometer  tests,  it  will  be  seen  that  in  spite  of  several 
graduated  tenotomies  his  rotations  are  about  normal. 
They  are  the  same  in  each  eye,  upward  30°,  downward 
50°,  nasal  50°,  temporal  50'.  The  vision  of  each  eye 
with  his  refractive  correction  is  '^'i.  He  now  uses 
-)-i.25  s.  over  his  distance  correction,  for  reading. 

The  improvement  in  the  physical  and  nervous  con- 
dition of  this  patient  is  as  great  as  the  remarkable  im- 
provement in  his  eye  conditions  would  lead  any  one 
to  expect.  He  has  lost  all  of  his  nervousness;  has 
gained  twenty-five  pounds  in  weight;  attends  to  a  con- 
stantly increasing  law  practice  with  perfect  ease;  and 
uses  his  eyes  with  absolute  comfort  under  all  condi- 
tions. 

Case  II. — Mr.  P ,  aged  fifty-five  years,  married, 

banker. 

Family  History:  Nothing  is  known  of  the  patient's 
ancestry.  Two  of  his  sons  had  epilepsy  and  have  been 
cured  by  eye-treatment  under  my  hands;  one  of  them 
having  passed  over  five  years  and  the  other  over  three 
years  without  an  attack  since  their  eye-muscles  were 
rectified.  One  daughter  of  the  patient  had  complete 
nervous  prostration  for  five  years,  and  was  kept  in 
Europe  under  professional  care  for  that  condition 
without  benefit.  Subsequently  she  was  also  restored 
to  perfect  health  by  me  through  eye-treatment.  The 
mother  of  these  children  had  orthophoria;  so  that  all 
the  muscular  anomalies  found  in  them  were  evidently 
inherited  from  the  father. 

History  of  the  Case:  This  patient  had  always  been 
a  remarkable  rifle-shot  and  had  won  great  distinction 
during  the  \\'ar  of  the  Rebellion  as  an  officer  in  the 
sharpshooting  corps.  In  the  performance  of  feats  of 
marksmanship  only  one  eye  is  used;  hence  the  ex- 
treme strabismus  of  the  patient  and  the  bad  refraction 
of  one  eye  were  no  disadvantages  to  him  in  the  use  of 
the  rifle.  In  fact,  his  extreme  devotion  to  duck-shoot- 
ing and  its  out-of-door  life  had  probably  prevented 
many  ills  which  his  eye-strain  might  have  brought 
upon  him,  had  his  life  been  devoted  exclusively  to  in- 
door occupation.  For  some  years  before  he  placed 
himself  under  my  care,  he  had  a  pair  of  glasses  which 
he  used  to  amuse  himself  with  at  times  by  reversing 
them,  when  he  wished  to  use  them  at  the  reading- 
point;  thus  bringing  the  distance  glass  of  the  poor 
eye  into  use  as  a  reading-glass  for  the  good  eye,  and 
throwing  the  poor  eye  entirely  out  of  use  while  read- 
ing. 

For  many  years  prior  to  my  seeing  him  he  had 
frequent  and  unexplainable  attacks  of  aggravated 
urticaria.  These  attacks  came  on  when  he  was 
nervously  run  down,  and  often  confined  him  to  the 
house  for  several  days  at  a  time.  They  did  not  seem 
to  be  dependent  upon  any  errors  of  eating  or  drinking, 
and  were  most  puzzling  to  all  of  the  physicians  .that 
were  consulted  about  them.  Throughout  his  entire 
life  he  was  a  rather  nervous  man  with  an  enormous 
amount  of  physical  and  mental  energy;  but  his  pow- 
ers of  nervous  endurance  seemed  to  be  almost  unlim- 
ited, except  when  these  peculiar  conditions  of  the 
skin  would  develop.  He  placed  himself  under  my 
care,  after  I  had  cured  three  of  his  children  of  serious 


94 


MEDICAL    RECORD. 


[July 


21, 


1900 


nervous  troubles,  rather  for  the  purpose  of  enabling 
him  to  use  his  two  eyes  together  than  for  the  cure  of 
any  special  nervous  ailment. 

Eye-Defects:  This  patient  at  his  first  visit  showed 
the  following  refraction :  O.D.  V.  5]|  with  -f  4.00  s.3 
-I-  0.50  c.  axis  I8o^  O.S.  V.  ||;  wi'th  +  1.75  s.  His 
muscular  tests  (with  the  above  correction  on)  were: 
right  hyperphoria  5°,  esophoria  3°,  adduction  i8%  ab- 
duction 7°,  right  sursumduction  13°,  left  sursumduc- 
tion  2°.  He  had  vertical  diplopia  with  a  red  glass. 
He  required  -|-  2.50  s.  added  to  his  distance  glasses 
for  reading. 

Treatment  and  Results:  A  full  correction  was  at 
once  given  for  his  refractive  error,  and  it  has  never 
been  found  necessary  to  change  this  glass,  although  1 
have  tested  him  carefully  once  or  twice  each  year  since. 
-j-  2.50  was  added  to  his  distance  correction  for  read- 
ing, and  later  this  was  increased  to  -\-  2.75.  These 
glasses  were  worn  for  some  months  to  see  whether  his 
hyperphoria  would  disappear  after  the  correction  of 
his  unequal  refraction,  as  is  sometimes  the  case.  In 
this  instance,  however,  the  hyperphoria  proved  to  be 
genuine,  and  he  showed  the  same  muscular  tests  as 
when  the  glasses  were  first  given.  Accordingly  a 
3°  prism,  base  up,  was  combined  with  his  left  lens 
and  worn  for  a  few  months.  A  tenotomy  was  then 
performed  on  the  right  superior  and  on  the  left  inferior 
rectus.  Since  the  last  operation  he  has  never  shown 
any  hyperphoria,  and  his  esophoria  has  fluctuated  from 
0°  to  1°.  He  shows  adduction  23',  abduction  8  , 
right  and  left  sursumduction  6'  each. 

Since  the  establishment  of  binocular  vision  by  tenot- 
omies and  the  correction  of  his  unequal  refraction  by 
glasses,  this  patient  has  noticed  a  very  decided  im- 
provement in  his  general  nervous  tone,  an  ability  to 
bear  strain  with  much  less  fatigue,  and  a  wonderful 
sense  of  comfort  in  his  eyes  that  he  had  never  before 
experienced.  Strange  as  it  may  seem,  he  has  no  at- 
tacks of  urticaria  that  formerly  were  the  pest  of  his 
life.  I  interpret  their  absence  rather  as  the  result  of 
improved  nervous  tone  and  stronger  digestive  functions 
than  to  any  possible  eye-reflex;  although  there  are  too 
many  skin  conditions  that  are  unmistakably  traced  to 
nervous  origin  to  justify  us  in  ignoring  altogether  the 
eye-reflex. 

The  wife  of  this  patient  stated  not  long  ago,  while 
in  my  office,  "that  she  could  see  a  very  great  change 
for  the  better  in  her  husband's  health  in  a  thousand 
little  ways,  since  his  eyes  were  treated."' 

One  interesting  feature  in  connection  with  tliis  case 
is  this:  that  the  extreme  difference  of  refraction  in 
the  two  eyes,  which  for  over  fifty  years  had  been  un- 
corrected by  glasses,  and  the  extreme  strabismus  of  the 
patient  had  unquestionably  prevented  much  more  seri- 
ous ills  of  a  nervous  type  than  a  less  degree  of  hetero- 
phoria  had  produced  in  his  children. 

Case  ni. — Mr.  S ,  aged  twenty  years;  single; 

student. 

Family  History:  Both  parents  are  living  and  well. 
No  hereditary  tendencies  to  nervous  diseases  or  phtiii- 
sis  exist. 

History  of  the  Case:  This  patient  was  not  a  very 
robust  boy  and  suffered  considerably  with  headache, 
nervousness,  and  general  debility.  He  never  had  any 
acute  nervous  disease  up  to  June,  1897.  He  was  at 
that  time  a  student  at  a  prominent  university,  and  broke 
down  completely  with  headache,  nervousness,  and  ab- 
solute inability  to  use  his  eyes  (with  diplopia  at 
times). 

He  was  put  under  the  care  of  a  prominent  oculist 
in  New  York  City,  who  found  exotropia  18°  and  right 
hypertropia  6°.  A  well-known  physician,  who  was 
called  in  consultation,  diagnosed  "ocular  paresis  hav- 
ing its  origin  in  the  effects  of  the  diseases  of  child- 
hood."    He  had  had  meningitis  when  one  year  old. 


He  was  put  on   strychnine  at  once  and  atropine  was 
dropped  in  his  eyes,  but  he  did  not  improve. 

In  December,  1897,  the  left  externus  was  divided 
by  the  oculist  previously  referred  to.  He  regained 
single  vision,  and  improved  so  rapidly  in  general 
health  and  use  of  his  eyes  that  he  returned  to  the  uni- 
versity. 

In  March,  1898,  he  again  broke  down  with  nervous 
prostration,  headache,  and  double  vision.  He  re- 
turned to  the  oculist  who  treated  him  befoie,  who  re- 
ferred him  to  me  for  further  treatment,  as  the  case 
presented  some  problems  that  puzzled  him  and  others 
who  had  seen  the  case. 

Eye- Defects :  When  he  first  came  to  me  he  was  wear- 
ing constantly  a  full  atropine- correction  for  his  refrac- 
tion, /.(f.,  O.D.  4-  0.25  c.  axis  90",  O.S.  +  0.50  c.  axis 
90".  His  muscular  tests  were:  Right  hyperphoria 
4";  exophoria  11°;  adduction  16°;  abduction  17°; 
sursumduction,  right  4^,  left  3°.  His  rotations  with 
the  troponieter  were  about  normal,  showing  that  no 
paresis  existed  in  any  ocular  muscle. 

Treatment  and  Results:  A  tenotomy  was  at  once 
performed  on  the  right  external  rectus  muscle,  and  a 
few  weeks  later  a  second  tenotomy  was  done  on  the 
same  muscle.  A  4°  right  hyperphorial  prism  was  then 
combined  with  his  cylinders  for  constant  wear. 

With  this  correction  he  had  single  vision  and  began 
to  use  his  eyes  with  comfort  and  was  free  from  head- 
ache. Within  a  few  weeks  he  engaged  in  the  study  of 
his  father's  business,  which  was  the  manufacture  of 
machinery,  and  used  his  eyes  for  fine  work  seven  hours 
a  day  without  the  return  of  any  nervous  symptoms.  In 
September,  1899,  I  performed  a  tenotomy  on  the  right 
superior  rectus  and  removed  the  prism  from  his  glasses. 
He  is  still  working  very  hard  and  remains  perfectly 
well,  with  ability  to  use  his  eyes  steadily  for  seven  or 
eight  hours  a  day. 

His  muscular  tests  are:  Adduction  21";  abduction 
13";  sursumduction,  right  9",  left  5°;  exophoria  J'; 
right  hyperphoria  \-.  With  the  Maddox  rod  he'at 
times  shows  more  muscular  defect,  both  exophoria  and 
hyperphoria,  and  it  is  probable  that  he  has  more  latent 
muscular  trouble;  but  as  he  is  doing  his  work  com- 
fortably and  holding  single  images,  it  does  not  seem 
wise  to  push  the  correction  of  his  eye-muscles  any  fur- 
ther at  present. 

Case  IV.— Miss  W ,  aged  thirteen  years. 

Family  History:  Both  parents  are  living  and  well. 
One  sister  had  severe  headaches,  which  were  relieved 
by  my  prescribing  hypermetropic  glasses. 

History  of  the  Case:  This  young  lady  was  sent  to 
me  nine  years  ago  suffering  with  headache,  inability 
to  use  her  eyes,  and  extremely  annoying  double  vision. 
Eye-Defects:  This  patient  had  myopia  of  three 
diopters,  for  which  she  was  wearing  correcting  glasses. 
At  the  first  visit  s>ie  showed  crossed  diplopia  of  14° 
with  the  red  glass  and  at  times  showed  also  some  left 
hyperphoria. 

Treatment  ana  Results:  The  treatment  of  this  case 
required  a  great  deal  of  operative  work  on  the  eye- 
muscles.  Within  one  year  both  extern!  were  divided 
freely,  both  interni  were  advanced,  and  graduated 
tenotomies  were  performed  on  the  left  superior  and 
right  inferior  recti. 

By  these  steps  all  of  the  hyperphoria  was  corrected, 
and  she  showed  but  two  or  three  degrees  of  exophoria; 
but  in  spite  of  the  close  approach  to  orthophoria,  she 
was  unable  to  hold  single  images  for  more  than  five 
or  ten  seconds  at  a  time.  Static  electricity,  which 
had  been  applied  at  times  to  the  internal  recti  during 
treatment,  was  now  continued  daily  for  several  weeks 
until  she  was  able  to  hold  single  images  for  forty-five 
seconds  at  a  time.  The  diplopia  was  then  only  notice- 
able when  looking  at  a  very  small  bright  object,  as  a 
candle-flame  used  in  testing. 


July 


2  1,1  9OOJ 


MEDICAL   RECORD. 


95 


She  then  was  obliged  to  leave  for  Europe  for  two 
years.  On  her  return  she  showed  no  hyperphoria  or 
exophoria,  adduction  28',  abduction  8  .  Prismatic 
exercises  were  used  for  two  weeks,  and  her  adduction 
increased  to  45^. 

Ever  since  then  she  has  been  using  her  eyes  very 
hard,  with  no  discomfort  and  with  no  headache.  She 
has  had  no  return  of  diplopia. 

Summary  and  Conclusions i.  A  small  percent- 
age of  subjects  in  whom  cross-eye  exists  (even  to  a  de- 
gree of  extreme  deformity)  owe  their  existing  disfigure- 
ment entirely  to  errors  of  refraction.  Proper  glasses 
alone  will  correct  the  disfigurement  of  such  patients. 

Extreme  nervous  phenomena  may  coexist  in  this 
type  of  case  with  the  cross-eye,  and  disappear  entirely 
when  the  refractive  correction  is  properly  made  by 
glasses. 

2.  Extreme  and  constant  disfigurement  from  cross- 
eye,  which  does  not  prove  to  be  the  result  of  refractive 
errors,  does  not  as  a  rule  entail  eye-strain  or  tend  to 
create  reflex  nervous  disturbances. 

3.  Those  who  suffer  only  occasionally  from  cross- 
eye  and  at  other  times  show  no  cast  are  peculiarly 
liable  to  reHex  nervous  diseases. 

These  subjects  are  constantly  on  the  border  line  of 
double  vision,  and  are  wasting  nervous  force  inces- 
santly in  their  unconscious  endeavors  to  maintain 
binocular  single  vision.  The  red-glass  test  and  the 
exclusion  tests  are  of  great  diagnostic  value  with  such 
patients. 

4.  Extreme  cross-eye  inward  or  outward  (convergent 
or  divergent  squint)  is  occasionally  due  to  the  fact 
that  both  eyes  are  adjusted  either  too  high  or  too  low 
in  the  orbit  (anaphoria  or  kataphoria).  This  is  a 
clinical  fact  that  has  been  unrecognized  by  oculists 
until  of  late.  It  is  a  most  important  point  to  decide 
by  the  aid  of  the  tropometer  prior  to  operative  inter- 
ference in  all  cases  of  lateral  squint. 

5.  Some  subjects  are  unconsciously  able  to  adjust 
for  very  high  degrees  of  "  latent  "  squint,  and  actually 
to  maintain  binocular  single  vision  most  of  the  time. 
The  red-glass  test  in  such  cases  usually  develops  un- 
conquerable diplopia  at  once. 

Severe  nervous  troubles  are  very  common  in  patients 
of  this  type.  The  extreme  nial-adjustment  of  the  eye- 
muscles  is  very  apt  to  be  overlooked  and  remain  uncor- 
rected. This  is  because  the  squint  is  not  constant, 
and  when  present  is  too  often  attributed  solely  to 
physical  debility,  excessive  use  of  the  eyes,  etc. 

6.  The  "  phorometer"  and  "  tropometer  "  are  often 
essential  to  the  proper  recognition  of  the  causes  of 
cross-eye  and  the  particular  muscles  at  fault  in  indi- 
vidual cases. 

7.  To  those  of  the  profession  who  have  not  a  "pho- 
rometer "'  or  a  ■'  tropometer  "  the  employment  of  the 
"  Maddox  rod  "  '  and  the  red  glass  will  sometimes  fur- 
nish extremely  valuable  information  regarding  the 
causation  of  reflex  nervous  disturbances  from  eye- 
strain. 

Patients  who  are  on  the  border-line  of  squint  will 
very  often  reveal  their  existing  eye-strain  at  once  (in 
the  form  of  unconquerable  diplopia)  when  the  red- 
glass  test  alone  is  made. 

I  recall  a  rather  amusing  instance  when  a  brother 
physician  of  this  city,  who  had  broken  down  completely 
in  a  nervous  way  and  been  for  years  under  the  care  of 
an  oculist  of  national  reputation,  resented  as  a  serious 
affront  to  his  vanity  my  assertion  "  that  he  was  and 
always  had  been  cross-eyed  at  times."  I  offered  to 
prove  it,  and  when  a  red  glass  was  handed  to  him  sub- 
sequently in  my  office  to  use  as  a  test  for  his  own  per- 
sonal satisfaction,  he  found  that  unconquerable  double 
vision  existed.     He  was  operated   upon   immediately 

'  A  little  device  that  can  be  carried  in  the  pocket  and  that 
costs  but  a  trifling  sum. 


for  his  squint.  He  recovered  his  health  at  once,  after 
his  eye-strain  was  arrested.  'I'his  sufferer  had  previ- 
ously been  wearing  only  a  prism  of  two  degrees  for  his 
reading,  when  he  in  reality  had  been  unconsciously 
struggling  for  his  entire  life  to  overcome  his  tendency 
to  cross-eye. 

8.  The  "exclusion  test"  (previously  described)  is 
of  great  value  in  cases  of  squint.  It  is  often  extremely 
difficult  and  sometimes  almost  impossible  to  teach  pa- 
tients afflicted  with  cross-eye  to  abandon  their  uncon- 
scious habit  of  suppressing  visual  images.  The  "ex- 
clusion test  "  then  becomes  the  chief  reliance  of  the 
oculist  in  determining  both  the  form  and  degree  of  mal- 
adjustment that  exists,  and  in  many  instances  which 
operative  step  to  take  first. 

9.  VVhen  vertical  and  lateral  squint  coexist,  it  is 
usually  wise  to  correct  the  vertical  mal-adjustment 
(either  entirely  or  in  part)  prior  to  operation  upon  the 
lateral  muscles. 

There  are  enough  exceptions  to  this  rule,  however, 
to  make  it  wise  for  the  oculist  to  study  the  effect  of 
prisms  upon  his  squint  cases  (prior  to  operative  treat- 
ment) for  a  sufficient  length  of  time  to  observe  their 
inffuence.  It  is  also  advisable,  as  a  rule,  to  get  daily 
tropometer  measurements  for  a  week  or  two  in  cases 
of  this  peculiar  type.  Too  much  haste  in  operative 
procedures  for  the  correction  of  combined  lateral  and 
vertical  squint  is  apt  to  lead  to  unsatisfactory  results. 

I  have  had  to  do  many  advancements  in  my  office, 
simply  to  correct  mistakes  made  by  others  because  of 
undue  haste  in  undertaking  the  surgical  correction  of 
a  complicated  case  of  squint. 

10.  The  old  methods  employed  in  operating  for 
cross-eye  have  been  so  modified  since  the  discovery  of 
cocaine  that  the  most  extreme  deformities  can  be  recti- 
fied to-day  without  pain  and  even  with  no  confinement 
to  the  house. 

Formerly,  the  patient  was  obliged  to  take  a  general 
anaesthetic  (chloroform  or  ether)  ;  the  surgeon  had 
usually  to  have  two  assistants,  one  to  administer  the 
anaesthetic  and  the  other  to  assist  in  the  operation; 
antiseptic  dressings  were  applied  to  the  eye,  because 
it  had  a  large  conjunctival  wound;  and  the  patient 
was  prevented  from  following  his  customary  business 
pursuits  for  several  days  at  least.  To-day,  a  few  drops 
of  cocaine  solution  are  dropped  into  the  eye  at  inter- 
vals of  a  minute  or  two  until  the  eye  has  entirely  lost  all 
sensibility  to  pain  ;  the  opening  made  through  the  con- 
junctiva is  so  small  as  to  make  the  tenotomy  almost  a 
closed  wound  ;  the  tendon  is  "  buttonholed  "  through 
this  small  conjunctival  opening;  the  patient  is  able  to 
aid  the  operator  by  fixing  vision  steadily  upon  some 
designated  point  that  puts  the  desired  muscle  on  the 
stretch;  the  amount  of  tension  relieved  by  the  opera- 
tion can  be  measured  immediately  (because  the  pa- 
tient is  conscious,  not  being  under  a  general  anaes- 
thetic) ;  and,  finally,  no  surgical  dressings  are  requiied 
after  the  operation,  nor  is  it  necessary  to  confine  the 
patient  to  the  house. 

It  certainly  robs  an  operation  of  all  its  terrors  when 
it  is  possible  to  correct  extreme  deformities  by  so  sim- 
ple and  painless  a  method;  to  avoid  all  interruptions 
of  business  pursuits;  to  escape  all  danger  of  subse- 
quent inflammation  by  having  practically  a  closed 
wound;  to  be  able  to  measure  the  results  of  the  opera- 
tion at  the  time;  to  enlarge  the  buttonhole  in  the  ten- 
don at  one  sitting  as  often  as  seems  imperative;  and 
to  avoid  the  natural  dread  of  taking  ether  or  cnloro- 
form,  with  its  possible  dangers,  loss  of  consciousness, 
and  subsequent  nausea  and  vomiting. 

I  have  frequently  operated  upon  young  cross-eyed 
children  in  my  office  while  I  talked  with  them  about 
the  prospective  pleasures  or  awards  offered  them  by 
their  parents  in  case  they  earned  them  by  good  be- 
havior while  the  operation  was  being  performed. 


96 


MEDICAL    RECORD. 


[July  2  1,  1900 


1 1.  In  conclusion,  I  would  impress  upon  my  readers 
that  a  scientific  correction  of  most  cases  of  cross-eye 
takes  more  time  than  is  usually  allotted  to  such  cases. 

To  pick  up  the  tendon  of  an  eye-muscle  on  a  stra- 
bismus hook  without  any  special  study  of  the  existing 
conditions,  and  to  divide  it  completely  (as  has  been 
done  for  years  by  many  oculists  for  the  relief  of 
squint),  is  to-day  a  very  crude  and  practically  an  obso- 
lete method  of  procedure  with  those  who  aim  at  attain- 
ing orthophoria.' 

Simply  to  get  an  improvement  in  personal  appear- 
ance (that  must  of  necessity  be  more  or  less  uncertain, 
when  operative  procedures  are  attempted  on  so  crude 
a  basis)  is  not  all  that  should  be  sought  for  by  ocu- 
lists. 

Any  person  who  has  never  had  binocular  single 
vision  (in  consequence  of  cross-eye)  is  peculiarly  liable 
to  be  greatly  annoyed  by  double  images  whenever  the 
eyes  are  brought  approximately  but  not  quite  to  their 
normal  position  in  the  orbits  by  operations  upon  the 
eye-muscles  originally  at  fault.  The  eyes  will  pos- 
sibly look  better  to  the  casual  observer  than  they  did 
before  the  operations  were  performed;  but  the  patient 
may  become  a  sufferer  from  double  vision  and  also 
from  certain  nervous  disturbances  never  experienced 
while  disfigured  by  cross-eye. 

For  this  reason,  if  for  no  other,  it  is  vitally  impor- 
tant to  endeavor  to  get  as  exact  and  perfect  an  adjust- 
ment as  possible,  and  to  save  the  patient  many  annoy- 
ances and  possibly  a  nervous  break-down  that  are  apt 
to  be  entailed  by  imperfect  operative  work  and  the 
consequent  eye-strain  in  overcoming  a  tendency  to 
diplopia  that  never  before  existed  to  the  same  degree. 

345  Madison  Avenue. 


REPORT  OF  A  CASE  OF   PORRO-C^SAREAN 
OPERATION.' 

By    WILLIAM   J.    GILLETTE,    M.D.. 

PROFESSOR    OF  ABDOMINAL    AND     CLINICAL  SURGERY,    TOLEDO     MEDICAL     COL- 
LEGE :    SURGEON    TO    ROBINWOOI)    HOSl'ITAL,    TOLEDO,    OHIO. 

The  case  of  Porro-Ceesarean  section  I  have  to  report 
is  the  sixth  successful  one,  so  far  as  I  have  been  able 
to  learn,  in  this  State  (Ohio).  The  first  one  was  per- 
formed by  Dr.  J.  F.  Baldwin,  of  Columbus,  on  July 
12,  i88g,  upon  a  rachitic  dwarf  with  contracted  pelvis. 
He  saved  both  mother  and  child.  On  December  11, 
1894,  Dr.  Hunter  Robb,  of  Cleveland,  operated,  sav- 
ing   both    mother    and    child.     His  case  was  one  in 


Amputated  Portion  of  Uterus. 


which  the  pelvic  outlet  was  obstructed  by  a  fibroid 
tumor  arising  from  the  cervix.  On  May  22,  1896,  Dr. 
Edwin  Ricketts,  of  Cincinnati,  saved  a  mother.     The 

'  See  table  of  terms  on  preceding  page. 

*  Read  before  tlie  Northwestern  Ohio  Medical   Association,  at 
its  ineeting  in  I'indlay,  Ohio,  December  7  and  8,   i8gr). 


obstruction  was  also  a  fibroid  of  the  cervix.  The 
same  year  a  homoeopathic  physician  in  Toledo,  Dr.  O. 
Reese,  operated,  saving  both  mother  and  child;  the 
obstruction  was  a  specific  contraction  of  the  vagina. 
On  April  24th  of  the  present  year  Dr.  George  Crile, 
of  Cleveland,  saved  mother  and  child  in  a  case  of  con- 


c_ 


Fig.  2. — Fundus  of  Uterus  with  Tumor  .Attached. 

tracted  pelvis.  All  the  cases  here  mentioned,  except 
those  of  Drs.  Robb  and  Crile,  were  done  by  fixing  the 
pedicle  in  the  lower  angle  of  the  incision. 

The  history  of  my  case  is  briefly  as  follows:  I  was 
called  to  Findla)',  Ohio,  October  21st,  last,  by  Drs. 
George  F.  Suker  of  Toledo,  and  J.  P.  Baker  of  that 
city,  to  see  in  consultation  a  married  woman,  a  primi- 
para,  who  had  been  in  labor  at  full  term,  when  I  reached 
her,  about  forty-eight  hours.  Her  family  history  has 
no  bearing  upon  the  case.  Her  father  died  at  the  age 
of  sixty-two  years,  of  a  probable  perforative  peritonitis. 
The  mother  is  living,  aged  sixty-two  years,  and  well. 
One  brother  died  in  infancy.  One  brother  is  living, 
at  the  age  of  twenty-nine.  No  hereditary  disease  could 
be  traced.  She  began  to  menstruate  at  seventeen  years 
of  age;  menstruation  was  always  regular  after  the  first 
year,  but  painful,  never  profuse.  Ten  months  since, 
her  family  physician  in  Gambler,  Ohio,  discovered  a 
small  tumor  on  the  anterior  wall  of  the  uterus;  prior 
to  this,  she  supposed  herself  to  be  perfectly  normal. 
Aside  from  an  occasional  pain  in  the  back,  her  preg- 
nancy gave  her  no  discomfort. 

On  examination,  a  fibroid  tumor,  the  size  of  a  child's 
head,  was  found  so  completely  blocking  the  pelvic 
outlet  that  it  was  with  difficulty  that  the  cervix  could 
be  reached  at  all.  The  contractions  of  the  uterus  ap- 
parently had  so  impacted  the  tumor  in  its  position 
that  all  attempts  at  raising  it  out  of  the  pelvic  cavity, 
in  order  that  the  child  might  pass,  were  futile.  It 
was  so  fixed  that  I  could  not  move  it  at  all. 

The  gravity  of  the  condition  was  at  once  recognized, 
and  immediate  operation  was  urged  by  both  Dr.  Baker 
and  myself.  To  this  the  patient  and  friends  readily 
assented,  when  she  was  at  once  made  ready,  placed 
aboard  a  midnight  train,  and  taken  to  Robinwood 
Hospital  in  Toledo,  arriving  there  safely  at  about  two 
o'clock  in  the  morning.  It  was  not,  however,  until 
ten  o'clock,  or  about  sixty  hours  after  labor  had  com- 
menced, that  I  operated.  In  the  mean  time  Dr.  C.  A. 
Kirkley,  of  Toledo,  was  called  in  consultation. 

Though  labor  had  been  in  progress  for  sixty  hours, 
and  the  waters  had  long  since  drained  away,  the  pa- 
tient when  finally  placed  on  the  operating-table  was 
in  good  condition,  with  a  pulse  of  68,  a  normal  tem- 
perature, and  no  sign  of  exhaustion  whatever.  In  the 
presence  of  a  number  of  medical  gentlemen,  I  operated, 
opening  the  abdomen  by  a  median  incision,  when  the 
relation  of  the  tumor  to  the  uterus  could  be  clearly 
made  out,  it  being  connected  to  it  on  the  posterior  wall 
near  the  fundus  by  a  pedicle  the  size  of  a  wrist. 

The  tumor  occupied  such  a  position  and  was  so  im- 


July  2  1,  1900] 


MEDICAL    RECORD. 


97 


pacted  in  the  pelvis  that  it  was  quite  impossible  to 
deliver  either  it  or  the  uterus  before  the  child  was  re- 
moved. It  was  impossible  to  do  otherwise  than  incise 
the  uterus  in  situ.  It  was  also  quite  impossible  to 
throw  a  rubber  ligature  around  the  cervix  for  the  pur- 
pose of  controlling  hemorrhage. 

The  uterus  was  now  opened  anteriorly  and  a  fcetus 
weighing  seven  and  three-fourths  pounds  removed. 
The  umbilical  cord  having  been  clamped  and  cut,  the 
child,  in  good  condition,  was  taken  in  charge  by  the 
nurse.  The  hemorrhage  from  the  uterus  was  in  the 
mean  time  controlled  by  my  assistant,  Dr.  H.  L.  Green, 
who  compressed  with  his  hands  the  incised  walls  of 
the  uterus  against  the  abdominal  walls.  The  uteius 
did  not  properly  contract,  and  whenever  the  compres- 
sion was  rela.xed  in  the  least  the  bleeding  was  furious. 

I  removed  the  placenta  at  once  without  difficult)-, 
but  its  removal  was  followed  by  profuse  hemorrhage, 
which  was  only  in  part  controlled  by  packing  large 
sponges  firmly  into  the  uterine  cavity. 

The  tumor  was  now  with  considerable  difficulty 
enucleated  from  its  position  in  the  pelvis,  where  it  had 
acquired  rather  extensive  adhesions,  and  it,  together 
with  the  uterus,  was  brought  out  of  the  abdomen.  It 
was  now  for  the  first  time  possible  to  throw  a  rubber 
ligature  about  the  cervix,  which  was  done,  completely 
controlling  hemorrhage,  and  the  uterus  was  amputated. 

After  making  the  pedicle  as  small  as  possible  it  was 
placed  in  the  lower  angle  of  the  incision,  the  perito- 
neum was  stitched  about  it,  and  two  hysterectomy  pins 
were  inserted  to  hold  it  in  place.  Had  I  the  same 
operation  to  perform  again,  I  would  most  certainly 
drop  the  pedicle  or  do  a  panhysterectomy;  though  this 
patient  did  excellently  with  the  method  described. 
The  abdominal  cavity  was  now  well  washed  out  with 
decinormal  salt  solution  and  closed  with  interrupted 
deep  silkworm-gut  and  buried  catgut  sutures. 

The  patient  was  placed  in  bed  with  a  pulse  of  about 
80.  The  time  of  operation  was  forty-five  minutes. 
The  pedicle  came  away  at  about  the  end  of  the  second 
week.  The  rubber  cord  was  removed  at  the  end  of  the 
fourth  day.  For  a  few  days  after  the  pedicle  sloughed, 
solutions  used  for  vaginal  douches  came  out  through 
the  opening  left  by  it,  but  this  soon  closed,  and  the 
abdominal  incision  healed  perfectly.  At  no  time  did 
the  patient's  pulse  reach  100;  88  was  the  highest  re- 
corded, and  the  highest  temperature  was  loij"^  F. 

For  a  few  days  after  the  operation  the  patient  suf- 
fered from  a  cystitis,  which,  however,  entirely  subsided 
after  washing  out  the  bladder  a  few  times  with  a  car- 
bolic-acid solution.  As  soon  as  the  patient  came  well 
out  from  the  anaesthetic  the  child  was  placed  at  the 
breast.  It  has  since  grown  nicely.  At  no  time  has  it 
been  given  anything  but  the  mother's  milk. 


Gonorrhoea  in  its  Relation  to  Insurance. — D.  D. 

G.  Hall  says  that  if  an  examiner  meets  with  an  appli- 
cant for  insurance  suffering  from  gonorrhoea,  he  should 
pursue  the  following  course:  If  the  applicant  is  other- 
wise in  perfect  health,  if  the  case  is  uncomplicated 
and  apparently  likely  to  run  a  mild  course,  the  exami- 
ner should,  after  relating  briefly  and  exactly  the  true 
condition  of  things,  recommend  him  as  a  first-class 
risk.  Suppose,  however,  the  ever-cautious  medical 
director  should  see  fit  to  postpone  issuing  the  policy; 
who  will  be  the  loser,  the  company  or  the  healthy 
young  man,  who  can  easily  obtain  insurance  a  few  weeks 
later  in  any  company  he  may  desire  ?  A  case  postponed, 
on  account  of  gonorrhcea,  is  practically  the  same  as 
lost  to  the  company,  for  by  the  time  the  patient  has 
recovered,  and  the  medical  director  is  ready  to  accept 
him,  he  will  be  safely  landed  in  some  other.  In  re- 
gard to  women  the  writer  says  that  if  he  should  be 


asked  to  pass  upon  a  female  who  had  suffered  within 
two  years  from  suppurative  inflammation  of  the  ovaries 
he  would  feel  in  duty  bound  to  reject  her  on  account 
of  the  serious  character  of  the  affection  and  the  great 
liability  of  there  being  a  return  of  the  symptoms,  re- 
sulting perhaps  in  death  from  acute  peritonitis,  due  to 
rupture  of  the  abscess  into  the  abdominal  cavity. —  The 
Medical  Examiner  and  Practitioner,  June,  1900. 

Practice  of  Medicine  and  Surgery  in  the  Higher 
Altitudes. — l-i.  H.  Reed  makes  Rock  Springs,  \\'yo., 
sixty-two  hundred  and  sixty  feet  above  tide-water,  the 
basis  of  his  remarks  upon  typhoid  fever,  pneumonia, 
tuberculosis,  shock,  infection,  anassthetics,  etc.  'I'here 
is  no  phthisis  excepting  that  imported.  Tent  life  in 
the  open  is  advised  for  early  cases.  The  Rocky 
Mountain  air  is  favorable  to  all  kinds  of  surgery. 
Infection  is  less  prevalent  than  on  the  coast.  Shock 
is  usually  slight  even  in  grave  injuries.  Pneumonia 
rarely  reaches  the  stage  of  gray  hepatization,  and  the 
mortality  is  high.  Ether  seems  decidedly  irritating 
to  the  entire  respiratory  tract  and  more  than  usually 
exciting.  Chloroform  is  there  used  by  preference, 
and  it  is  noted  that  it  is  attended  with  nearly  the  same 
amount  of  excitement  as  accompanies  ether  adminis- 
tration in  the  East. — Columbus  Medical  Jourttal,  June, 
1900. 

Idiopathic  Osteopsathyrosis. — Ludwig  Lange  con- 
siders as  idiopathic  osteopsathyrosis  all  instances  of 
abnormal  fragility  of  the  bones  for  which  no  under- 
lying cause  can  be  found.  He  describes  a  case  of 
unusual  interest  in  a  boy  three  years  old,  who  alto- 
gether had  had  tvventy-tvio  fractures.  The  mother  and 
father  were  healthy,  and  this  was  the  fifth  child.  He 
began  to  walk  at  the  age  of  eighteen  months  and  vas 
well  up  to  the  twenty-second  month,  when  he  broke 
the  thigh  by  falling  from  a  sofa.  The  question  is 
considered  in  its  various  bearings,  and  it  is  thought 
that  the  prognosis  in  the  case  is  favored  by  the  fact 
that  the  boy  begins  again  to  walk.  It  is  possible  that 
under  the  well-known  favorable  influence  of  func- 
tional activity  an  improvement  in  the  quality  of  the 
bone  will  take  place,  so  that  the  patient  may  some  time 
outgrow  his  very  distressing  affliction. — Miinchener 
i/iedicinisc/ie  Wochenschrijt,  June  19,  1900. 

Surgery  among   the  Insane ;    its  Difficulties,  its 

Advantages,  its  Results Under  the  first  head,  A. 

T.  Hobbs  enumerates  difficulties  in  diagnosis,  exami- 
nation, anesthesia,  preparation  for  operation,'and  after- 
treatment.  The  advantages  are:  (i)  Little  or  no 
shock,  as  a  rule,  succeeds  even  a  prolonged  and  dan- 
gerous operation,  and  post-operative  pain  is  rarely 
complained  of.  (2)  Except  in  occasional  cases,  the 
regimen  laid  out  for  them  is  strictly  adhered  to  in 
spite  of  all  whims  and  fancies.  (3)  Ether  narcosis  is 
very  quickly  recovered  from  in  the  insane.  A  gentle 
slapping  of  the  face  will  quickly  arouse  the  most  pro- 
foundly anaesthetized  patient,  and  very  little  nausea  or 
vomiting  occurs  subsequent  to  the  use  of  ether.  The 
results  of  operative  surgery,  especially  gynecological, 
among  the  insane  are  twofold :  Primarily,  the  restora- 
tion of  physical  health;  secondarily,  the  improvement 
and  recovery  of  the  mental  condition.  In  summing 
up  mental  results  the  statistics  of  168  cases  are  given, 
divided  into  two  groups:  (i)  gS  inflammatory,  with 
.-".n  average  ratio  of  recoveries  of  51  per  cent,  and  a 
ratio  of  mental  improvement  of  17  per  cent.;  (2)  70 
non-inflammatory,  with  a  recovery  rate  of  25.5  percent, 
and  an  average  ratio  of  mental  improvement  of  31  per 
cent.  The  number  of  deaths  succeeding  operation  in 
the  168  cases  was  4,  or  a  little  over  2  per  cent. —  The 
Canadian  Journal  of  MediciJie  and  Surgery,  July,  1900. 


98 


MEDICAL    RECORD. 


[July  2  1,  1 900 


Medical  Record: 

A    ll'ccklf  Journal  of  Medicine  and  Surgery. 


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


Publishers 


WM.   WOOD   &.   CO  .  51    Fifth   Avenue. 


New  York,  July  21,  1900. 


RUPTURE   OF    THE   LIVER. 

Accumulating  experience  shows  us  that  traumatic 
rupture  of  the  liver  involves  a  prognosis  containing 
several  elements  beyond  the  immediate  dangers  of 
hemorrhage,  and  the  later  danger  of  peritonitis  which 
until  recently  has  almost  always  been  put  down  as  the 
cause  of  death  in  those  patients  who  have  survived 
the  first  few  hours.  The  fact  that  peritonitis  does  not 
necessarily  occur  after  laceration  of  hepatic  tissue  has 
perhaps  not  been  sufficiently  emphasized,  though  this 
fact  may  be  of  great  importance  in  prognosis.  In  fact, 
mere  laceration  of  the  liver  is  not  followed  by  peri- 
tonitis, even  when  the  hemorrhage  is  inconsiderable 
enough  to  postpone  death  for  several  days,  and  it  is 
only  when  the  large  or  main  gall  ducts  are  torn  tiiat 
the  infecting  medium  is  present  and  finds  a  favorable 
field  in  blood  clots  and  physiologically  disturbed  peri- 
toneum. We  are  able  to  study  the  efTects  of  intra-ab- 
dominal hemorrhage  better  after  injuries  of  the  liver 
and  the  anatomically  similar  organ,  the  spleen,  than 
after  lesions  of  any  other  organ,  because  in  the  case 
of  every  other  organ  of  importance  force  sufficient  to 
cause  laceration  will  also  almost  certainly  involve 
communication  with  some  mucous  tract  through  wliich 
the  exciting  cause  of  a  complicating  peritonitis  will 
enter. 

If  we  are  confronted  with  a  case  in  which  the  proba- 
ble diagnosis  of  rupture  of  the  liver  is  made,  and  in 
which  the  immediate  shock  is  rallied  from — in  other 
words,  one  in  which  the  patient  does  not  succumb  in 
the  first  few  hours  to  shock  and  hemorrhage,  we  shall 
find  that  further  developments  will  be  along  two  fairly 
similar,  though  differing,  lines.  It  is  clear  that,  when 
indications  are  distinct  enough  to  warrant  operation, 
the  fate  of  the  patient  is  decided  in  a  very  short  time; 
but  such  a  state  of  affairs  does  not  always  exist,  and 
we  are  sometimes  compelled  to  wait  and  observe.  One 
course  which  the  case  may  follow  is  indicated  by  the 
rapid  unfolding  of  the  clinical  picture  of  general  peri- 
tonitis, too  well  known  to  need  comment.  A  second 
picture  is  seen  when  peritonitis  does  not  develop,  but 
when  there  are  signs  of  slowly  or  rapidly  accumulating 
fluid  in  the  abdominal  cavity,  with  symptoms  of  loss 
of  blood,  and  a  temperature  course  which  is  somewhat 
peculiar.  The  peculiarity  consists  in  a  rise,  with  an 
unusual  difference  between  the  oral  and  rectal  figuius, 
amounting   sometimes   to  several    degrees,  which    ij 


pretty  certainly  caused  by  the  process  of  absorption 
of  degenerating  and  disintegrating  blood  clot.  The 
temperature  usually  maintains  or  increases  its  eleva- 
tion until  the  end,  and  as  in  some  other  conditions 
may  go  very  high. 

In  addition  to  the  temperature  there  are  other  signs 
and  symptoms  in  cases  of  this  sort,  which  maybe  use- 
ful in  distinguishing  them  from  those  cases  with  peri- 
tonitis. The  distention  and  tenderness  are  both  less 
marked  than  in  peritonitis,  and  the  fluid  moves  much 
more  easily  to  different  parts  of  the  abdomen  when  the 
patient  is  moved.  The  constipation  is  not  so  obsti- 
nate as  is  often  the  case  during  the  course  of  peri- 
tonitis. A  case  of  such  grave  visceral  injury  as  we 
are  considering,  in  which  peritonitis  supervenes,  is  al- 
most certainly  beyond  relief,  but  in  the  presence  of 
the  other  condition  it  is  possible  that  something  in  the 
nature  of  operative  relief  can  be  offered.  The  patient 
is  dying  from  unchecked,  though  perhaps  slow,  hemor- 
rhage, and  from  the  entrance  into  his  circulation  of 
the  products  of  disintegrating  extravasated  blood,  or, 
more  exactly,  of  the  chemical  substances  of  which  the 
important  parts  of  blood  are  formed.  He  may  die  of 
hemorrhage  before  his  peritoneum  has  time  to  absorb 
much  harmful  material,  but  when  the  bleeding  is  ac- 
tive the  indications  for  intervention  are  usually  dis- 
tinct enough  to  prevent  delay.  Should  the  patient, 
however,  survive  the  shock  and  immediate  effects  of 
the  hemorrhage,  he  still  has  a  very  serious  condition 
with  which  to  contend.  He  is  weakened  by  loss  of 
blood  and  disturbed  digestion,  and  his  peritoneum  is 
transferring  from  its  surface  into  his  circulation  quan- 
tities, perhaps  overwhelming,  of  the  chemical  and 
physical  break-up  of  blood. 

We  know  that  the  peritoneum  can  absorb  consider- 
able quantities  of  blood  without  trouble,  but  beyond  a 
certain  point  it  seems  to  lose  this  power  entirely.  The 
patient's  chance  of  survival  under  these  circumstances, 
if  treated  on  the  expectant  plan,  is  very  small;  we 
must,  therefore,  resort  to  something  more  positive  in 
therapeutics  than  treating  symptoms.  We  must  get 
rid  of  the  accumulated  blood  clots  and  fluid  blood, 
and  control  any  hemorrhage  which  may  still  be  going 
on,  though  the  amount  of  operative  work  must  be  as 
limited  as  possible.  The  operation  thus  has  a  double 
object — to  clear  away  the  blood  and  to  explore  as 
thoroughly  as  possible,  so  that  the  extent  of  the  lacera- 
tion of  the  liver  may  be  known.  Hot  surgical  salt 
solution  will  be  found  to  be  an  exceedingly  useful 
preparation  in  operations  of  this  sort,  both  in  the  ab- 
domen and  for  intravenous  infusion,  and  we  are  justi- 
fied in  hoping  that  this  line  of  treatment  will  be  suc- 
cessful in  a  good  proportion  of  cases  of  rupture  of  the 
liver  in  which  there  is  time  for  any  sort  of  systematic 
effort.  

TYPHOID     FEVER    AMONG    THE     BRITISH 
TROOPS    IN    SOUTH    AFRICA. 

Enteric  fever,  the  greatest  scourge  of  armies  in 
tlie  field,  is  raging  on  an  extensive  scale  in  South 
Africa.  Probably,  too,  its  scope  is  wider  than  is 
publicly  reported,  as  the  war  authorities  for  reasons 


July  21,  I  god] 


MEDICAL    RECORD. 


99 


of  expediency  will  doubtless  be  averse  to  making  all 
the  facts  known,  and  will  use  their  own  judgment  as 
to  how  much  of  the  truth  shall  be  suppressed.  The 
reports,  however,  that  have  come  to  hand  from  various 
sources  show  that  the  situation  is  serious.  Mr.  Fripp 
states  in  a  letter  to  the  British  Medical  Journal  that  at 
the  time  of  writing  there  were  nearly  two  thousand 
cases  of  typhoid  fever  in  Bloemfontein  alone.  In 
Kimberley,  Maf eking,  and  Ladysmith  the  disease 
during  the  sieges  of  those  towns  was  rife,  especially 
in  the  last-named  place.  This  condition  of  affairs 
was  for  obvious  reasons  more  or  less  unavoidable, 
but  it  was  hoped  that  when  the  opportunities  arrived, 
by  changing  the  location  of  the  camps  frequently  and 
by  using  every  possible  sanitary  precaution  a  wide- 
spread outbreak  might  be  avoided.  These  sanguine 
anticipations  have  unfortunately  not  been  realized. 
The  Journal  of  Tropical  Medicine,  June  15th,  says:  "  We 
have  lately  counted  the  number  of  deaths  in  the  South 
African  army  from  typhoid  fever  in  one  of  the  official 
lists  of  deaths  from  disease  recently  issued,  and  we 
find  no  fewer  than  one  hundred  deaths  from  typhoid 
fever  occurred  between  May  30th  and  June  6th,  and 
of  these  no  fewer  than  twenty-three  occurred  on  June 
4th.  It  is  plain  from  these  figures  alone  that  the 
army  is  suffering  from  an  epidemic  of  typhoid  fever, 
and,  since  the  deaths  are  not  reported  from  one  station 
but  from  many  stations,  that  the  infection  is  wide- 
spread." 

For  some  time  after  the  commencement  of  the  South 
African  campaign  the  health  outlook  appeared  de- 
cidedly favorable,  but  the  unexpected  prolongation  of 
the  war,  the  long  sieges  of  Ladysmith,  Kimberley,  and 
Mafeking,  and  the  lengthened  stay  of  large  bodies  of 
men  in  the  same  locality,  have  produced  the  inevitable 
results.  One  disappointing  feature  in  connection 
with  typhoid  fever  in  South  Africa  has  been  the 
failure  of  inoculation  as  a  preventive.  Surgeon-Gen- 
eral Jameson  reports  that  the  results  from  inoculation 
among  British  soldiers  going  to  the  front  has  been  the 
reverse  of  encouraging,  and  does  not  warrant  the  be- 
lief that  a  means  of  conferring  immunity  against  this 
disease  has  been  at  last  discovered.  He  further  said 
that  he  had  called  for  a  return  of  sickness  during  the 
siege  of  Ladysmith,  and  the  result  was  certainly 
somewhat  singular  and  rather  difficult  to  explain 
away.  It  would  appear  from  the  figures  in  question 
that  inoculation  against  enteric  fever  was  unfavorable 
to  the  incidence  of  the  disease,  but  rather  favorable 
to  the  case  mortality. 

Dr.  Victor  Vaughan,  in  the  oration  on  state  medicine 
delivered  by  him  at  the  late  meeting  of  the  American 
Medical  Association,  dealing  with  the  prevalence  of 
and  mortality  from  typhoid  fever  in  our  military 
camps  in  1898,  has  made  a  valuable  contribution  to 
the  literature  on  the  subject.  Among  other  causes  he 
lays  down  the  following:  "Camp  pollution  was  the 
greatest  sanitary  sin  committed  by  the  troops  in  1898, 
inadequate  space  allowing  a  large  body  of  men  to 
remain  on  one  site  too  long.  Flies  served  as  carriers 
of  the  disease,  and  infection  was  probably  disseminated 
through  the  air  in  the  form  of  dust."     These  last  two 


theories  are  peculiarly  applicable  to  the  condition  of 
things  in  South  Africa,  where  both  dust  and  flies  at 
certain  seasons  of  the  year  are  more  in  evidence  per- 
haps than  in  any  other  portion  of  the  world. 


THE  TREATMENT  OF  GONORRHOEA. 

There  is  no  single  remedy  or  procedure  capable  inva- 
riably of  curing  gonorrhcea  within  a  certain  limited 
time.  It  is  pretty  generally  agreed  that  an  ordinary 
uncomplicated  attack  of  specific  urethritis  is  not  a 
dangerous  disease.  The  conditions  are,  however, 
different  at  once  a  complication  arises,  and  in  accord- 
ance therewith  gonorrha-a  may  become  a  serious  or 
even  a  grave  disorder  with  unlimited  possibilities  in 
the  way  of  sequelce,  of  which  some  of  the  best  known 
are  lymphangitis,  adenitis,  stricture,  orchitis,  epididy- 
mitis with  secondary  impotence,  prostatitis  and  suppu- 
ration of  the  prostate  gland,  cystitis,  pyelitis,  pyone- 
phrosis, neuralgia,  rheumatic  affections  of  the  joints 
and  the  tendon-sheaths,  metastases  in  vital  organs 
(endocarditis),  tuberculosis,  especially  of  the  genito- 
urinary organs,  neurasthenia  of  varying  severity,  and 
actual  psychoses.  While  it  is  true  that  some  of  these 
complications  and  seqjelas,  such  as  stricture  of  the 
urethra,  may  result  from  the  long  duration  of  the  dis- 
ease, and  that  others  are  unavoidable  and  no  cause  can 
be  discovered  for  them,  it  is  likewise  true  that  some 
complications  may  be  due  to  improper  treatment,  or 
at  least  their  development  may  be  favored  thereby. 
The  fundamental  principle  in  the  treatment  of  gonor 
rhoea  is  that  the  therapeutic  measures  employed  should 
be  so  applied  that  complications  may,  so  far  as  pos- 
sible, be  avoided. 

With  these  preliminary  considerations  Casper  {Ber- 
liner klinische  Wochenschrift,  No.  22,  1900)  advises 
against  all  abortive  treatment  as  not  accomplishing  the 
desired  object,  but  favoring  the  occurrence  of  complica- 
tions. The  symptoms  of  the  disease  do  not  appear  un- 
til some  days  after  the  gonococci  have  penetrated  the 
mucous  membrane  of  the  urethra.  The  introduction  of 
instruments  into  the  urethra  during  the  acute  stage,  so 
long  as  a  florid,  purulent  discharge  is  still  taking  place, 
is  contraindicated,  as  are  also  injections  that  induce 
irritation  of  the  urethra  or  aggravate  existing  inflam- 
mation. Some  cases  of  acute  gonorrhcea  set  in  with 
marked  inflammatory  manifestations,  while  others  are 
wholly  unattended  therewith.  The  latter  occur  espe- 
cially in  patients  who  have  previously  had  gone  -rhoea. 
In  both  groups  injections  may  be  begun  on  the  first 
day,  but  in  the  first  no  remedy  should  be  employed 
that  causes  irritation  or  aggravates  the  inflammatory 
process,  such  as  preparations  of  silver.  Under  tiiese 
circumstances  potassium  permanganate  may  be  em- 
ployed in  dilutions  of  from  1:10,000  to  1:8,000. 
In  the  less  acute  stage  injections  of  antiseptic  silver 
salts  are  useful,  and  of  these  the  nitrate  is  the  best. 
This  may  be  employed  first  in  a  concentration  of 
1 :  10,000,  gradually  increased  to  a  strength  of  i :  4,000. 
Both  of  these  are  irritating  and  should  therefore  never 
be  employed  alone,  but  always   in   association   with 


lOO 


MEDICAL   RECORD. 


[July 


21, 


T9OO 


astringent,  secretion  -  reducing,  and  antiphlogistic 
agents.  Thus,  a  combination  of  silver  nitrate  with 
potassium  permanganate  is  injected  first;  then  sil- 
ver nitrate  and  zinc  sulphate  are  subsequently  em- 
ployed; and  finally  potassium  permanganate  and  zinc 
sulphate  in  the  last  stage.  The  more  frequently  the 
injections  are  made  the  better.  Attempts  have  been 
made  to  destroy  the  gonococci  and  control  the  secre- 
tion by  means  of  a  single  preparation — zinc  perman- 
ganate—  but  this  has  not  proved  so  successful  as 
the  combination  of  zinc  sulphate  with  potassium  per- 
manganate. 

Similar  principles  govern  the  treatment  of  acute 
gonorrhceal  cystitis.  In  a  large  number  of  such 
cases  improvement  and  recovery  can  be  brought 
about  by  means  of  diet,  rest,  diuretics,  and  balsamics. 
Should  these  fail  and  the  second  portion  of  urine 
voided  remain  turbid,  resort  may  be  had  to  irrigation 
through  a  catheter  of  the  posterior  urethra  with  solu- 
tions of  silver,  but  this  should  not  be  begun  too  early. 
In  cases  of  chronic  gonorrhoea  in  which  the  injections, 
usually  made  by  the  patient,  do  not  reach  the  affected 
parts,  namely,  the  posterior  urethra  and  the  more  su- 
perficial layers  of  the  submucosa,  relief  can  be  afforded 
with  certainty  and  promptitude  by  means  of  instilla- 
tions according  to  the  method  of  Guyon,  or  irrigation 
with  potassium  permanganate  according  to  the  method 
of  Janet,  or  a  combination  of  both. 

Two  varieties  of  chronic  gonorrhcea  occur  that  do 
not  respond  even  to  local  measures,  namely,  one  that 
resists  treatment  of  all  kinds,  and  another  that  yields 
only  so  long  as  the  treatment  is  maintained,  but  recurs 
as  soon  as  this  is  suspended.  The  first  is  almost  al- 
ways glandular  and  infiltrating,  and  the  other  is  at- 
tended with  the  presence  of  inflammatory  processes  in 
adjacent  glands,  especially  the  prostate.  The  former 
is  rather  uncommon  and  the  treatment  should  be 
jointly  mechanical  and  chemical.  Bougies  may  be 
used,  dilatation  of  the  urethra  may  be  carefully  and 
judiciously  practised,  local  urethrotomy  may  possibly 
be  undertaken,  and  injections  and  irrigations  should 
be  employed  in  the  intervals. 

The  proportion  of  cases  of  chronic  urethritis  com- 
plicated by  prostatitis  is  quite  large.  The  diagnosis 
must  be  based  upon  the  discovery  on  microscopic  e.x- 
amination  of  leucocytes  in  the  fluid  expressed  from 
the  prostate  gland  through  the  rectum.  The  results 
of  treatment  in  these  cases  are  not  very  gratifying. 
The  composition  of  the  prostatic  secretion  is  unin- 
fluenced by  the  use  of  iodine  or  ichthyol  or  electric- 
ity, or  tf  injections  of  hot  water,  although  the  sub- 
jective symptoms  may  be  relieved  by  the  last. 
Cauterization  has  been  proposed  in  the  treatment 
of  prostatitis,  but  the  results  cannot  yet  be  definitely 
estimated.  The  only  certain  and  harmless  means 
of  influencing  favorably  the  morbid  process  con- 
sists in  .systematic  massage  and  expression  of  the 
gland.  This  should  be  done  three  times  a  week  for 
months  by  a  masseur,  while  urethral  injections  are 
made  or  irrigation  is  practised.  Should  these  fail 
the  treatment  selected  will  depend  upon  whether  the 
process    is  still   infectious  or  not;    namely,  whether 


gonococci  are  present  in  the  discharge  or  not.  In  the 
former  event  the  treatment  by  well-known  methods 
should  be  persisted  in  until  the  cocci  have  disap- 
peared. In  the  other  cases  no  further  treatment  may 
be  required  at  all. 


^cxus   of  the  'Scacck. 

Dr.  F.  Savary  Pearce  has  been  elected  clinical 
professor  of  diseases  of  the  nervous  system  in  the 
Medico-Chirurgical  College  of  Philadelphia,  succeed- 
ing Dr.  C.  \V.  Burr,  resigned. 

St.   Vincent's   Foundling   Asylum,    Montclair 

The  Sisters  of  Charity  have  opened  a  new  institution 
for  homeless  infants  at  45  Elm  Street,  Montclair,  N.  J. 
It  is  known  as  St.  Vincent's  Foundling  Asylum.  It 
is  non-sectarian,  and  the  present  accommodations  pro- 
vide for  one  hundred  infants.  The  medical  staff  con- 
sists of  Drs.  J.  S.  Brown  and  M.  J.  Synnott,  of 
Montclair. 

The  Rocky  Mountain  Interstate  Medical  Associa- 
tion.— The  second  annual  meeting  of  this  society  will 
be  held  in  Butte,  August  28th  and  29th.  The  officers 
of  this  association  are:  President,  Dr.  C.  K.  Cole,  of 
Helena;  Fiist  Vice-President,  Dr.  Leonard  Freeman, 
of  Denver;  Second  Vice-President,  Dr.  R.  Harvey 
Reed,  of  Rock  Springs;  Treasurer,  Dr.  Charles  G. 
Plummer,  of  Salt  Lake  City;  Recording  Secretary,  Dr. 
Donald  Campbell,  of  Butte;  Corresponding  Secretary, 
Dr.  S.  D.  Hopkins,  of  Denver,  Colo. 

High  Death  Rate  in  Philadelflhia.— The  effects 
of  the  summer's  intense  heat  are  still  visible  in  the 
mortality  records.  There  were  reported  to  the  Phila- 
delphia bureau  of  health  633  deaths  for  the  week 
ended  July  14th,  being  89  more  than  for  the  preced- 
ing week,  and  151  more  than  for  the  corresponding 
week  of  the  previous  year.  Among  the  more  impor- 
tant causes  of  death  were:  cholera  infantum  96  cases, 
pulmonary  tuberculosis  65,  marasmus  38,  sunstroke 
2,T,,  heart  disease  31,  inflammation  of  the  stomach  and 
bowels  24,  pneumonia  26,  apoplexy  21,  nephritis  20, 
convulsions  19,  inanition  18,  uramia  18,  diphtheria 
17,  inflammation  of  the  brain  13,  typhoid  fever  11, 
paralysis  11,  old  age  10. 

Reorganization  of  the  Red  Cross.— On  July  loth 
the  American  National  Red  Cross  surrendered  its  char- 
ter of  incorporation  under  the  law  of  the  District  of 
Columbia  and  reorganized  under  the  national  charter 
granted  by  special  act  of  Congress  at  the  last  session. 
More  than  a  majority  of  the  fifty-five  incorporators 
named  by  the  act  were  either  present  or  represented  at 
the  meeting  on  that  day  in  Washington.  A  constitu- 
tion and  by-laws  were  adopted,  and  Miss  Clara  Bar- 
ton, B.  H.  Warner,  Stephen  E.  Barton,  Miss  Ellen 
Spencer  Musse)',  William  Flather,  Mrs.  James  Tan- 
ner, and  H.  B.  F.  Macfarland,  of  the  District  of  Co- 
lumbia; Walter  P.  Phillips,  of  Connecticut;  W.  H. 
Michael,  of  Nebraska ;  Samuel  E.  Jarvis,  of  New  York ; 
A.  C.  Kaufman,  of  South  Carolina;  Joseph  Gardner, 


July  21,  1900] 


MEDICAL    RECORD. 


lOI 


of  Indiana;  Gen.  Daniel  Hastings,  of  Pennsylvania, 
and  Mrs.  Phebe  Hearst,  of  California,  were  elected 
members  of  the  board  of  control,  which  will  choose 
officers. 

Dr.  H.  W.  Lincoln  has  been  appointed  gastrologist 
to  the  Bushwick  Central  Hospital,  Brooklyn. 

The  Yellow-Fever  Outbreak  at  Quemados  is  at 
an  end,  no  cases  having  been  reported  from  there  this 
month. 

The  Plague  continues  at  Hong  Kong,  the  report  for 
the  first  week  in  July  showing  sixty-eight  new  cases 
and  sixty-five  deaths. 

Dr.  Marie  L.  Benoit,  of  this  city,  has  been  ap- 
pointed woman  physician  to  the  State  Custodial  Asy- 
lum for  Women  at  Newark,  N.  Y. 

Noisy  Chicago. — The  mayor  of  Chicago  has  vetoed 
the  anti-noise  ordinance  passed  by  the  city  fathers,  and 
advises  a  removal  to  Philadelphia  for  those  who  object 
to  the  roar  and  racket  of  a  live  city. 

The  Brooklyn  Water  Supply — According  to  news- 
paper reports,  there  are  several  cases  of  typiioid  fever 
along  the  Massapequa  section  of  the  watershed  from 
which  the  supply  for  Brooklyn  is  obtained. 

Formaldehyde    in    Milk Many   milk  dealers   in 

New  Jersey  have  been  arrested  on  the  complaint  of 
the  State  dairy  commissioner  for  adulterating  milk,  the 
special  adulterant  being  formaldehyde,  added  as  a  pre- 
servative. 

Morton  County,  Kansas,  which  has  a  population 
of  about  four  hundred,  is  peculiar.  There  has  been 
no  case  of  serious  illness  and  no  physician  in  the  coun- 
ty for  over  a  year.  Which  is  cause  and  which  is 
effect  is  now  under  discussion  by  the  professional 
jokers. 

Another  Medical  Governor  in  Maine. — The  Re- 
publican nominee  for  governor  of  Maine  is  Dr.  John 
F.  Hill,  of  Augusta.  He  is  a  graduate  of  the  Bowdoin 
Medical  College  in  1877  ^^'^  °^  '^e  Long  Island  Col- 
lege Hospital  in  1887,  but  has  large  business  interests 
outside  of  medicine. 

Dr.  Thomas  M.  Lippitt,  the  surgeon  in  charge  of 
the  marines  sent  as  a  legation  guard  to  Peking,  was  an 
assistant  surgeon  in  the  army.  He  was  born  in  Berry- 
ville,  Va.,  in  1873,  was  graduated  from  the  Starling 
Medical  College  in  1897,  and  was  commissioned  as- 
sistant surgeon  in  the  navy  June  27,  1898.  During 
the  Spanish  war  he  served  on  the  hospital  ship  Solace, 
and  after  the  war  was  attached  to  the  flagship  Balti- 
more on  the  Asiatic  station.  Since  then  he  had  served 
on  the  Oregon  and  the  iV^ze/f?;-^,  going  to  Taku  with  the 
marine  detachment  aboard  the  latter  vessel. 

Texas  Threatened  with  Yellow  Fever. — Numer- 
ous Italians  employed  in  building  the  Vera  Cruz  and 
Pacific  Railroad  in  Mexico  have  deserted  their  work 
because  of  an  outbreak  of  yellow  fever  among  them. 
They  are  wandering  in  bands  through  Mexico,  Texas 
being  their  objective  point.     Coming  as  they  do  direct 


from  infected  camps,  it  is  feared  that  they  will  spread 
the  disease  throughout  their  route  of  travel  in  Mexico 
and  Texas.  Despite  the  fact  that  a  close  watch  is  be- 
ing kept  to  prevent  their  crossing  the  Rio  Grande,  a 
large  number  have  succeeded  in  evading  the  quaran- 
tine inspectors  and  customs  officials,  and  are  now  scat- 
ered  throughout  Texas. 

Ethnology   at  the    Pan-American   Exposition 

The  department  of  ethnology  and  arciia-ology  of  the 
Pan-American  Exposition  has  been  placed  in  charge 
of  Dr.  A.  L.  Benedict,  of  Buffalo,  who  requests  infor- 
mation and  the  loan  of  collections  for  the  use  of  this 
department. 

Famine   and  Disease    in  India According  to  a 

report  of  the  governor  of  Bombay,  there  were  9,928 
cases  of  cholera  in  the  famine  districts  during  the 
week  ending  July  7,  of  which  6,474  were  fatal,  and  in 
the  native  states  there  were  9,526  cases,  of  which  5,892 
were  fatal.  There  have  been  heavy  rains  lately,  and 
the  sowing  of  grain  has  begun;  but,  notwithstanding 
the  improved  prospects,  no  diminution  of  relief  will 
be  possible  for  a  long  time. 

A  Hospital  for  Tropical  Diseases  in  England It 

is  stated  in  The  Hospital  that  a  memorial  hospital  for 
tropical  diseases  is  to  be  founded  in  honor  of  the  late 
Miss  Mary  Kingsley,  and  to  be  called  after  her  name. 
Mr.  A.  L.  Jones,  the  chairman  of  the  Liverpool  School 
for  Tropical  Diseases,  has  headed  a  subscription  list 
with  _£"i,ooo;  Mr.  Blaize,  of  Lagos,  has  given  ;!^5oo, 
and  other  promises  have  been  made. 

Diphtheria  in  a  Faith-Cure  Colony. — Twenty-five 
children,  inmates  of  the  "Zook  Zion,"  in  Whiteside 
County,  Illinois,  have  been  ill  with  diphtheria,  or  have 
died  of  the  disease  during  the  past  week.  The  adult 
members  of  the  colony  refused  all  medical  attendance 
for  the  sick  children,  and  so  the  health  authorities 
quarantined  the  place,  and  the  inmates  died  or  recov- 
ered according  to  their  varying  powers  of  resistance. 

The  Medical  Directory  of  the  City  of  New  York 
for  1900  has  just  been  issued.  The  directory  is  pub- 
lished by  the  Medical  Society  of  the  County  of  New 
York,  and  contains  information  chiefly  concerning  the 
members  of  that  society  and  of  the  Medical  Society  of 
the  County  of  Kings,  but  the  membership  in  city  socie- 
ties and  hospital  appointments  in  New  York  hospitals 
only  are  given.  There  are  also  lists  giving  residence, 
office  hours,  and  place  and  date  of  graduation  of  all 
legally  qualified  practitioners  in  New  York  City.  The 
names  of  physicians  practising  in  New  York,  New 
Jersey,  and  Connecticut  are  also  given,  but  they  are, 
as  a  rule,  unaccompanied  by  any  data  other  than  indi- 
cation as  to  the  school  of  practice  followed. 

The  Study  of  Physiognomy  is  not  always  a  safe 
pursuit,  as  a  Bulgarian  journalist  named  Sangoff  has 
learned  to  his  cost.  He  wrote  an  article  not  long  ago 
in  a  Sofia  paper  on  the  subject  of  the  relation  of  the 
nose  to  character.  After  discussing  the  various 
shapes,  he  came  to  the  conclusion  that  persons  with 
long  noses  are  often  bad  characters.  The  public 
prosecutor  regarded  this  as  a  case  of  Vese  majesti,  be- 


I02 


MEDICAL   RECORD. 


[July  21,  1900 


cause  Prince  Ferdinand  has  a  long  nose.  Sangofi  was 
arrested,  tried,  and  sentenced  to  three  days'  imprison- 
ment. 

Diseases  at  Tien-Tsin. — Among  the  lesser  evils 
afflicting  the  inhabitants  of  Tien-Tsin  are  scarlet  fever 
and  plague,  epidemics  of  which  are  reported  to  be  rag- 
ing there,  the  former  among  the  whites,  the  latter 
among  the  natives.  Plague  is  said  also  to  have  been 
prevalent  in  Peking  for  some  time.  The  only  Euro- 
peans attacked  have  been  four  Italian  priests,  who  lived 
among  the  natives  and  who  died  early  in  June. 

Navy  Department,  Bureau  of  Medicine  and  Sur- 
gery, Washington,  D.  C. — Changes  in  the  medical 
corps  of  the  United  States  navy  for  the  week  ending 
July  14,  1900.  July  6th. — Passed  Assistant  Surgeon 
F.  W.  Olcott  detached  from  the  recruiting  rendezvous, 
Philadelphia,  Pa.,  and  ordered  home  and  granted  sick 
leave  for  two  months.  Passed  Assistant  Surgeon  W. 
B.  Grove  detached  from  the  Scindia  and  ordered  home. 
July  9th. — Surgeon  W.  H.  Rush  granted  sick  leave 
until  October  1st. 

The  Sanitary  Condition  at  Cape  Nome. — General 
Randal,  at  Fort  St.  Michael,  Alaska,  reports  that  the 
health  condition  at  Cape  Nome  is  serious,  measles, 
typhoid  fever,  and  smallpox  being  in  the  camp. 
There  were  eighteen  cases  of  the  latter  disease  re- 
ported on  July  ist,  and  the  disease  was  spreading. 
The  chief  surgeon  of  the  department  was  placed  in 
charge  of  sanitary  matters  there,  with  instructions  to 
employ  three  acting  assistant  surgeons  to  aid  him. 
Regulations  for  better  sanitation  of  the  place  were  is- 
sued and  every  effort  will  be  made  to  improve  the  con- 
dition of  affairs  and  control  the  spread  of  the  disease. 
The  epidemic  is  said  to  have  started  from  two  cases  of 
smallpox  brought  on  a  steamer  from  the  south.  The 
ship's  officers  were  afraid  they  would  not  be  permitted 
to  land  their  passengers,  so  hurriedly  disembarked 
them  at  night,  and  the  infection  was  thus  spread  in  all 
directions  through  the  camp. 

Leprosy  in  Crete. — We  learn  from  the  British  Mfd- 
ical  Journal  that  Drs.  O.  Cahnheim,  of  Dresden,  and 
Ehlers,  of  Copenhagen,  have  completed  the  investiga- 
tion on  leprosy  in  the  island  of  Crete,  which  they  un- 
dertook at  the  instance  of  Prince  George  of  Greece, 
the  high  commissioner  of  the  island.  In  the  provi- 
sional report  which  they  have  presented  to  the  prince, 
they  state  that  they  found  380  lepers,  of  whom  they 
personally  examined  293.  Of  these,  153  (92  men,  61 
women)  were  of  the  tubercular,  and  170  (79  men,  91 
women)  of  the  anesthetic  form.  As  in  cold  countries 
the  proportion  of  tubercular  to  anesthetic  cases  is  as 
I  to  2,  and  in  hotter  climates  as  i  to-  3,  the  figures 
quoted  appear  to  warrant  the  assumption  that  the  total 
number  of  lepers  in  Crete  is  from  600  to  800.  The 
investigators  have  no  doubt  that  Zambaco  Pasha's  es- 
timate of  4,000  is  immensely  exaggerated.  Drs.  Cahn- 
heim and  Ehlers  were  able  to  satisfy  themselves  that 
the  disease  was  on  the  increase  in  Crete.  The  type 
of  the  disease  met  with  in  Crete  is  less  severe  than  in 
colder  regions,  and  the  tendency  to  cure  is  on  the 
whole  greater.     Prince  George  of  Greece  is  anxious 


that  the  isolation  of  lepers,  which  is  still  carried  out 
on  the  lines  laid  down  by  the  Turks,  and  is  therefore 
very  defective,  should  be  made  more  stringent  through- 
out the  island.  It  is  proposed  to  establish  an  asylum 
for  lepers,  and  for  that  purpose  the  peninsula  of  Spina 
Longa  is  considered  suitable.  The  prince  has  also 
asked  Drs.  Cahnheim  and  Ehlers  to  draft  a  law  for 
the  repression  of  leprosy  in  accordance  with  the  condi- 
tions of  the  island  of  Crete. 

New  York  State  Hospital  for  the  Care  of  Crip- 
pled and  Deformed  Children The  following  gentle- 
men, in  addition  to  those  already  announced,  have 
been  appointed  upon  the  consulting-board  of  the  New 
York  State  Hospital  for  the  Care  of  Crippled  and  De- 
formed Children  :  Drs.  Samuel  B.  Ward  and  A.  Van- 
der  Veer,  of  Albany,  Jarvis  S.  Wight  and  John  A.  Mc- 
Corkle,  of  Brooklyn,  and  Richard  B.  Coutant,  of 
Tarrytown. 

Dr.  Senn  Again  Ready  for  War. — The  Chicago 
Tribune  says  that  Dr.  Nicholas  Senn,  who  served  as  a 
volunteer  medical  officer  during  the  war  with  Spain, 
has  again  offered  the  United  States  government  his 
services,  this  time  to  go  to  China  to  care  for  the  Amer- 
ican soldiers  who  may  be  wounded.  As  volunteer  in 
the  Spanish-American  war  Dr.  Senn  went  to  Cuba, 
where  he  was  chief  operating-surgeon  in  the  field  with 
the  rank  of  lieutenant-colonel. 

A  Divine  Healer  Acknowledges  His  Guilt. — A 
man  named  Francis  Truth,  who  was  on  trial  in  the 
United  States  circuit  court  in  Boston  for  using  the 
mails  to  defraud,  has  pleaded  guilty  on  the  seven  in- 
dictments found  against  him.  On  five  charges  he  was 
fined  the  maximum  penalty,  $500  each.  The  other 
two  indictments  were  placed  on  file  at  the  suggestion 
of  the  District  Attorney  as  a  matter  of  precaution. 
Should  the  man  attempt  to  engage  in  any  unlawful 
business  these  two  indictments  will  be  brought  up 
against  him  and  imprisonment  imposed.  He  did  his 
divine  healing  by  correspondence,  and  is  said  to  have 
made  a  moderate  fortune  from  the  advance  fees  re- 
ceived. 

Association  of  Surgeons  of  the  Confederate  States. 
— The  third  annual  meeting  of  this  association  was 
held  in  Louisville  on  May  30th  and  June  ist  and  2d, 
under  the  presidency  of  Dr.  Francis  L.  Parker,  of 
Charleston,  S.  C.  The  following  officers  were  elected 
for  the  next  annual  meeting,  which  will  be  held  in 
Memphis,  Tenn.:  President,  Dr.  Preston  B.  Scott, 
Louisville,  Ky. ;  Vice-President,  Dr.  J.  M.  Kel- 
ler, Hot  Springs,  Ark. ;  Secretary,  Dr.  Deering 
J.  Roberts,  Nashville,  Tenn. ;  Treasurer,  Dr.  V. 
G.  Hitt,  Atlanta,  Ga. ;  Chaplain,  Rev.  George  B. 
Overton,  Louisville,  Ky.  It  is  desired  to  enroll  all 
who  are  eligible  to  membership  in  the  association,  and 
therefore  it  is  requested  that  all  surgeons,  assistant 
surgeons,  acting  assistant  surgeons  or  contract  sur- 
geons, and  hospital  stewards,  who  ser\'ed  in  the  army 
or  navy  of  the  late  Confederate  States,  will  send 
their  post-office  address  to  Deering  J.  Roberts,  M.D., 
secretary  Surgeons'  Association  C.  S.  A.,  Nashville, 
Tenn. 


July  21,  1900] 


MEDICAL    RECORD. 


103 


progress  of  l^^etlical  J'Cicnce. 

.W-'W  ]\'ri  Medical  Journal,  July  14,  igoo. 

Primary  Carcinoma  of  the  Fallopian  Tube.  —  Elizabeth 
Marcelis  reports  the  case  of  a  woman  aged  thirty-five 
years,  who  was  operated  upon  successfully,  but  in  whom 
a  recurrence  took  place  eighteen  months  later.  At  this 
latter  time  the  case  was  regarded  as  inoperable  and  noth- 
ing was  done.  The  case  is  notable  from  its  rarity, 
there  being  but  twenty  similar  cases  on  record.  The  his- 
tological points  on  which  a  diagnosis  of  primary  carcinoma 
was  made  are  as  follows;  (i)  The  absence  of  malignant 
growth  in  the  uterus,  as  shown  by  microscopic  examination 
of  curettings  at  the  time  of  operation.  (2)  The  presence 
of  an  old  salpingitis,  together  with  the  freedom  of  the 
inner  end  of  the  tube  from  malignant  change.  (3)  An  en- 
larged tube,  the  lumen  of  which  was  filled  with  carcinoma- 
tous masses  of  2.5  cm.  diameter;  this  change  was  found 
throughout  two-thirds  of  the  tube,  and  with  the  existence 
of  a  pelvic  tumor  for  more  than  fifteen  months.  {4)  The 
advanced  stage  of  the  growth  within  the  tube  and  fairly 
healthy  condition  of  the  outer  muscle  layers.  This,  in 
view  of  the  resistance  of  the  tube  to  secondary  invasion 
from  the  ovary,  and  that  such,  when  occurring,  usually 
involves  the  peritoneal  surface  first,  the  mucosa  second- 
arily. (5)  The  ovary  was  not  only  small,  but  at  the  inner 
end  free  from  the  growth.  (6)  Microscopical  evidences  of 
a  more  rapid  proliferation  of  the  new  cells  in  the  ovary 
than  in  the  tube. 

"Floaters"  in  the  Urine. — By  this  term  W.  F.  Bernhart 
refers  to  the  gonorrhoeal  threads  so  commonly  met  with. 
From  experiments  with  fifty  different  specimens  of  urine, 
he  arrives  at  the  following  conclusions  ;  (i)  The  specific 
gravity  of  the  urine  is  a  prominent  factor  in  the  action  of 
floaters.  (2)  The  elements  composing  the  floaters  influ- 
ence their  action.  (3)  Their  suspension  at  diff'erent 
depths  in  the  urine  is  due  to  .some  mechanical  interfer- 
ence. (4)  Upon  filtration  of  the  urine  all  but  the  very 
lightest  floaters,  those  composed  of  flocculent  mucus,  will 
sink  to  the  bottom  of  the  beaker.  (5)  The  action  of  float- 
ers does  not  alone  depend  upon  their  composition  or  the 
specific  gravity  of  the  urine. 

Two  Unique  Rectal  Cases. — S.  G.  Gant  reports  a  case  of 
chronic  diarrhoea  due  to  rectal  ulceration  cured  by  divul- 
sion  of  the  sphincter,  curetting  of  the  ulcer,  and  application 
of  silver  nitrate  (thirty  grains  to  the  ounce) .  He  believes 
that  the  continuing  cause  of  diarrhoea  is  located  in  the 
colon  and  rectum  with  greater  frequency  than  is  generally 
supposed.  He  also  reports  a  case  of  rectal  stricture  caused 
by  stone  in  the  bladder.  A  stone  weighing  four  and  a  half 
ounces  was  removed,  and  the  stricture  broken  up ;  ulcer- 
ated surfaces  were  curetted  and  urine  was  allowed  to  pass 
through  the  lithotomy  (perineal)  wound  for  a  year.  The 
latter  finally  closed  of  itself. 

The  Proper  Care  of  the  Infant's  Nursing-Bottle.— T.  \V. 
Kilmer  describes  an  apparatus  devised  by  himself,  for  the 
perfect  sterilization  of  the  nursing-bottle  combined  with  a 
sterilizer  and  pasteurizer  for  milk.  The  article  is  illus- 
trated. 

The  Present  State  of  the  Galvano-Caustic  Operation  of 
Bottini  for  Ischuria. — By  G.  MacGowan. 

Atrophy  of  the  Ciliary  Muscle. — By  N.  B.  Jenkins. 

The  Elements  of  a  Good  Climate. — By  P.  Paquin. 

SyphUis  of  the  Brain.— By  J.  T.  Eskridge. 

Bos/on  Mculical  a/ul  Surj^u'al  Journal.  July  12,  /goo. 

A  Review  of  Recent  Studies  in  the  Nature  and  Origin  of 
Cancer. — J.  C.  Warren  says  there  is  little  doubt  that  can- 
cer is  on  the  increase.  He  review-s  the  geographical  dis- 
tribution, showing  the  almost  entire  freedom  of  far  north 
countries,  including  the  northern  coast  line  of  Europe  and 
Asia,  Egypt,  and  Abyssinia,  as  well  as  the  rarity  of  the 
disease  in  tropical  climes.  The  increase  has  been  marked 
in  the  past  fifty  years.  In  England  and  Wales  during 
twenty  years  deaths  from  cancer  more  than  doubled.  In 
New  York  State  cancer  is  the  only  disease  tabulated 
which  shows  a  progressive  and  steady  increment.  The 
greatest  increase  in  this  country  is  in  San  Francisco. 
Many  points  favor  the  inoculation  or  infective  theory. 
The  various  theories  of  cause  and  mode  of  growth  are  re- 
viewed. Cancer  houses,  streets,  and  villages  are  men- 
tioned, as  well  as  epidemic  prevalence  in  certain  regions. 
Recent  experiments  with  blastomyces  and  other  growths 
arc  referred  to,  and  especial  attention  is  directed  to  the 
first  laboratory  established  for  the  study  of  cancer  at  Buf- 
falo in  this  State.  The  parasitic  theory  seems  plausible, 
but  is  "not  proven." 

Cysts  in  the  Abdominal  Wall  Structurally  Identical  with 
Ovarian    Cysts. — John    Homans    reports    an   operation   for 


ovarian  cyst  weighing  one  hundred  and  two  pounds. 
There  was  present  at  the  same  time  a  cyst  in  the  abdomi- 
nal wall  of  identical  structure.  Other  cysts  of  like  nature 
subsequently  formed. 

A  Case  of  Mural  Endocarditis.- By  Harold  Williams. 

A  Case  of  Csesarean  Section. — By  T.  Kittredge. 

Journal  oj  the  American  Medical  Ass' n,  July  14,  igoo. 

The  Relation  of  Ethyl  Alcohol  to  the  Nutrition  of  the 
Animal  Body.— W.  S.  Hall  describes  the  nature  of  nutri- 
tive processes  and  answers  the  questions.  What  is  food 
and  what  is  alcohol?  pointing  out  the  relations  of  alcohol 
to  nutrition,  and  how  it  influences  certain  phases  of  meta- 
bolism. The  de-Tionstrated  facts  we  possess  are  set  against 
each  other  in  parallel  columns  : 

THE   TRUTH    ABOUT 


ALCOHOL. 

1.  A  certain  quantity  will 
produce  a  certain  effect  at 
first,  but  it  requires  more 
and  more  to  produce  the 
same  effect  when  the  drug 
is  used  habitually. 

2.  When  used  habitually, 
it  is  likely  to  induce  an  un- 
controllable desire  for  more, 
in  ever-increasing  amounts. 

3.  After  its  habitual  use 
a  sudden  total  abstinence  is 
likely  to  cause  a  serious  de- 
rangement of  the  central 
nervous  system. 

4.  Alcohol  is  oxidized  rap- 
idly in  the  body. 

5.  Alcohol,  not  being  use- 
ful, is  not  stored  in  the  body. 

6.  Alcohol  is  a  product  of 
decomposition  of  food  in  the 
presence  of  a  scarcity  of 
oxygen. 

7.  Alcohol  is  an  excretion 
and,  in  common  with  all 
e.xcretions,  is  poisonous.  It 
may  be  beneficial  in  certain 
phases  of  disease,  but  it  is 
never  beneficial  to  the 
healthy  body. 

8.  The  use  of  alcohol;  in 
common  with  narcotics  in 
general,  is  followed  by  a 
reaction. 

9.  The  use  of  alcohol  is 
followed  by  a  decrease  in 
the  activity  of  the  muscle- 
cells  and  the  brain-cells. 

10.  The  use  of  alcohol  is 
followed  by  a  decrease  in 
the  secretion  of  CO2. 

11.  The  use  of  alcohol  is 
followed  by  an  accumula- 
tion of  fat  through  decreased 
activity. 

12.  The  use  of  alcohol  is 
followed  by  a  fall  in  body- 
temperature. 

13.  The  use  of  alcohol 
weakens  and  unsteadies  the 
muscles. 

14.  The  use  of  alcohol 
makes  the  brain  less  active 
and  accurate. 


1.  A  certain  quantity  will 
produce  a  certain  effect  at 
first,  and  the  same  quantity 
will  always  produce  the  same 
effect  in  the  healthy  body. 

2.  The  habitual  use  of 
food  never  induces  an  un- 
controllable desire  for  it,  in 
ever-increasing  amounts. 

3.  After  its  habitual  use 
a  sudden  total  abstinence 
never  causes  any  derange- 
ment of  the  central  nervous 
system. 

4.  All  foods  are  oxidized 
slowly  in  the  body. 

5.  All  foods,  being  useful, 
are  stored  in  the  body. 

6.  All  foods  are  products 
of  constructive  activity  of 
protoplasm  in  the  presence 
of  abundant  oxygen. 

7.  All  foods  are  formed  by 
nature  for  nourishment  and 
are  by  nature  wholesome 
and  always  beneficial  to  the 
healthy  body,  though  they 
may  injure  the  body  in  cer- 
tain phases  of  disease. 

8.  The  use  of  foods  is  fol- 
lowed by  no  reaction. 


g.  The  use  of  food  is  fol- 
lowed by  an  increased  activ- 
ity of  the  muscle-cells  and 
brain-cells. 

10.  The  use  of  food  is  fol- 
lowed by  an  increase  in  the 
excretion  of  COj. 

11.  The  use  of  food  may 
be  followed  by  accumulation 
of  fat,  notwithstanding  in- 
creased activity. 

12.  The  use  of  food  is  fol 
lowed    by  a   rise    in    body- 
temperature. 

13.  The  use  of  food 
strengthens  and  steadies  the 
muscles. 

14.  The  use  of  food  makes 
the  brain  more  active  and 
accurate. 

The  Plague  in  San  Francisco. — D.  W.  Montgomery  re- 
lates eleven  cases  with  autopsies  and  laboratory  investi- 
gations. He  presents  arguments  against  the  existence  ot 
plague  and  answers  them.  No  diagnosis  has  been  made 
on  a  living  patient.  He  believes  the  plague  enters  a  com- 
munity slowly,  as  is  here  the  case.  The  outlook  for  the 
future,  he  believes,  is  not  bright.  He  expects  the  plague 
to  appear  with  increased  violence  next  winter.  The  daily 
press  and  the  people  afe  against  the  health  board,  but  the 
work  of  the  latter  goes  on  with  uninterrupted  fidelity. 

Diagnosis  of  Apoplexy  Unaccompanied   by  Motor  Paralysis. 

— William  X.  BuUard  believes  that  apoplexy  without 
motor  symptoms  is  often  overlooked  by  the  general  prac- 
titioner, and  he  presents  cases  showing  how  difficult  is  the 
diagnosis  when  it  is  impossible  to  obtain  a  history.  An 
element  in  differentiation  of  the  results  of  primary  apo- 
plexy from  paralytic  dementia  or  other  cerebral  affections 
is  the  presence  or  absence  of  symptoms  characteristic  of 
these  affections,  but  not  usual  in  the  simple  apoplexies. 


I04 


MEDICAL    RECORD. 


[July  2  1,  1900 


The  Specific   Treatment  of  Croupous   Pneumonia. — W.  O. 

Bridges,  iu  an  attempt  to  solve  the  question  whether  in 
guaiacol  carbonate  and  the  salicylates  we  have  a  speciiic 
medication  for  croupous  pneumonia,  presents  some  cases 
showing  how  much  reliance  can  be  placed  upon  these 
drugs.  He  prefers  guaiacol  in  cases  past  the  stage  of  con- 
gestion, in  the  enfeebled,  and  when  heart  lesions  are  pres- 
ent. Strychnine  obviates  in  part  the  depressant  effect 
upon  the  heart,  and  so  does  alcohol. 

Education    and    Legislative    Control   of    Tuberculosis. — By 

Charles  Denison. 

Substitute  Infant  Feeding.— By  H.  D.  Chapin. 

Appendicular  Fistula.— By  J.  B.  Deaver. 

The  Philadelphia  Medical  Jour?ial,  July  /^,  igoo. 

Dislocation  of  the  Jaw  in  Epilepsy. — Charles  J.  Aldrich 
reports  two  cases  of  this  unusual  accident.  The  first  was 
in  the  person  of  a  woman  aged  twenty-one  years,  and  the 
second  in  that  of  a  man  aged  twenty-five  years.  In  each 
case  the  first  physician  called  failed  to  make  a  correct  diag- 
nosis. From  our  knowledge  of  the  action  of  the  facial 
muscles  during  an  epileptic  paro.xysm,  the  author  says, 
we  would  hardly  expect  a  luxation  of  the  jaw  to  occur  as 
a  complication. 

A  Case  of  Primary  Adenocarcinoma  of  the  Gall  Bladder 
with  Secondaries  in  Both  Adrenals,  Melanosis  of  Skin  (Ad- 
dison's Disease  ?) ,  Vitiligo,  and  Hj^pertrophy  of  the  Pancreas. 
—By  Aldred  Scott  Warthin. 

Total  E.xcision  of  the  Scapula  Alone,  and  with  the  Arm 
(Interscapulothoracic  Amputation)  :  Partial  Excision  of  the 
Scapula  for.  Tumor.— By  J.  J.  Buchanan 

The   Action   of   Rennin   upon   Milk-Digestion.— By   I.    H. 

Coriat. 

A  Case  of  Myoma  of  the  Bladder.— By  Otto  G.  Ramsay. 
Medical  Xeivs,  July  14,  igoo 

Some  Remarks  on  the  Artificial  Feeding  of  Infants  and 
the  Regulation  of  the  Milk  Supply  in  the  Country. — J.  F. 
Bell  points  out  the  importance  of  proper  artificial  diet. 
Condensed  milk,  which  is  the  most  popular,  is  the  most 
pernicious,  being  responsible  for  more  malnutrition,  etc., 
than  all  other  articles  combined.  It  is  not  a  suitable  sub- 
stitute for  mother's  milk.  A  consideration  of  the  proper 
modification  of  milk  is  given.  There  is  something  radi- 
cally wrong  in  methods  heretofore  pursued.  The  care  of 
cows,  rules  for  milking,  regulations  assuring  cleanliness, 
etc.,  are  all  considered  with  the  view  of  producing  an  arti- 
cle which  will  not  require  sterilization.  First  of  all  a  suit- 
ably educated  dairyman  must  be  secured,  and  all  must  be 
under  health-board'  supervision. 

Subphrenic  Abscess  following  Appendicitis. — J.  F.  Bald- 
win gives  two  cases  from  his  practice  of  this  rare  and 
often  obscure  and  overlooked  complication.  An  important 
point  in  diagnosis  in  many  cases  is  that  frequently  a  sub- 
phrenic abscess  due  to  appendicitis  contains  gas  as  well  as 
pus,  due  to  perforation  of  some  neighboring  hollow  viscus 
or  more  likely  to  gas-producing  bacteria.  The  mortality 
under  surgical  procedure  is  not  over  fifty  per  cent. ,  while 
in  unrecognized  cases  recovery  is  to  be  expected  in  only 
about  five  per  cent,  of  instances. 

Tendon  Transplantation  in  the  Treatment  of  Deformities 
of  the  Hand.— By  W.  R.  Townsend. 

Petroleum  in  the  Treatment  of  Phthisis.— By  W.  D.  Rob- 
inson. 

The  Lancet,  July  7,  igoo. 

Note  on  a  New  Medium  for  the  Growth  and  Differentia- 
tion of  the  Bacillus  Coli  Communis  and  the  Bacillus  Typhi 
Abdominalis. — A.  T.  JIacconkey  says  that  in  this  medium 
advantage  is  taken  of  two  well-known  facts :  (i)  That  tlie 
salts  of  bile  are  precipitated  by  acids,  and  (2)  that  bacillus 
coli  communis  produces  acid  in  the  presence  of  lactose 
while  bacillus  typhi  abdominalis  does  not.  The  composi- 
tion of  the  medium  is  sodium  glycocholate,  0.5  per  cent.  ; 
peptone,  1.5  per  cent.  ;  lactose,  0.3  to  0.5  per  cent.  ;  agar, 
1.5  percent.  ;  tap-water,  q.s.  The  lactose  is  adiled  after 
filtration.  If  stab  cultures  be  made  in  this  medium  with 
bacillus  coli  communis  and  bacillus  typlii  abdominalis  and 
incubated  at  42'  C.  for  from  twenty-four  to  forty-eight 
hours,  it  will  be  found  that  the  tube  inoculated  with  bacil- 
lus coli  communis  has  become  cloudy  while  the  tube  con- 
taining bacillus  tyjihi  alxiominalis  remains  quite  clear.  If 
glucose  bu  used  instead  of  lactose,  both  tubes  become 
cloudy,  but  the  cloudiness  due  to  bacillus  coli  communis 
begins  from  below  and  that  due  to  bacillus  typhi  abdomi- 
nalis from  above.  In  plates  made  with  the  glucose  me- 
dium incubated  for  forty-eight  hours  at  42'  C. ,  and  tlien 
left  for  from  three  to  four  days  exposed  to  the  light  at  mom 
temper.-iture,  the  colonics  gr.-ulually  become  orange  colored. 

Contagious  Catarrh,  or  Roup,  in  Fowls,  and  Diphtheria  in 
Man. —J.  O.  Sharp  gives  the  following  as  his  conclusions  : 
(I)   Roup-likc  diphtheria  (including  the  somewhat  indefi- 


nite term  "croup")  varies  in  its  malignancy,  sometimes 
being  mild  with  only  one  or  two  deaths  in  a  large  hen-run, 
while  the  next  epidemic  may  almost  clear  out  the  whole 
coop.  (2)  The  disease  does  not  appear  to  be  transmis- 
sible to  man,  for  those  handling  the  affected  birds  without 
any  precautions  do  not  suffer  from  any  disease  resembling 
diphtheria.  (3)  Paralysis  was,  according  to  my  observa- 
tions, absent  in  roup  cases.  (4)  The  disease  is  evidently 
a  highly  contagious  catarrh  and  may  correspond  to  the 
morve  or  fowl  glanders  of  the  French.  (5)  Roup  probably 
differs  entirely  from  "fowl  diphtheria,"  so  called.  (6)  As 
we  have  already  seen,  bird  fanciers  distinguish  between  a 
"dry"  roup  and  a  "wet"  roup.  Dry  roup  is  most  likely  a 
simple  benign  catarrh  corresponding  to  the  recurring  croup 
affecting  children,  especially  those  inhabiting  valleys  and 
near  a  river  bank.  Wet  roup,  on  the  other  hand,  in  its 
malignancy  resembles  diphtheria  and  membranous  croup. 
(7)  The  micro-organism  of  roup  (the  wet  variety  or  ma- 
lignant variety)  probably  lives  for  a  considerable  time  at 
least  in  the  earth  near  the  surface,  and  thus  it  is  readily 
spread  from  animal  to  animal  (as  well  as  by  direct  contact 
with  affected  birds).  (8)  Conditions  of  soil  and  surround- 
ings favorable  to  the  spread  of  diphtheria  would  likewise 
appear  to  favor  the  spread  of  roup  in  fowls. 

One  Hundred  Consecutive  Cases  of  Abdominal  Section  in 
Hospital  Practice,  Without  a  Death. — Since  W.  liuncan's 
paper  was  sent  in  for  publication  he  has  added  eight  more 
successful  cases  to  his  list.  He  describes  in  detail  his 
method  of  preparation  of  the  patient,  his  routine  with  ref- 
erence to  assistants,  instruments,  sponges,  flushing  out  the 
abdomen,  drainage,  and  after-care.  He  combats  shock  by 
strychnine  and  endeavors  to  prevent  tympanites  by  pass- 
ing a  soft  rectal  tube  every  four  hours,  and  then,  if  flatus 
is  not  passing  freely,  giving  an  enema  of  an  ounce  of  oil 
of  turpentine  in  a  pint  of  hot  water.  This  is  given  high 
up  and  repeated  two  or  three  times  daily  until  escape  of 
flatus  is  free. 

Unusual  Complication  following  Gastro-Jejunostomy. — W. 
H.  Brown's  patient  did  well  for  two  weeks  following  oper- 
ation. At  the  end  of  that  time,  evidences  of  obstruction 
coming  on,  the  abdomen  was  reopened.  The  junction  be- 
tween stomach  and  gut  was  all  right,  but  insertion  of  the 
finger  through  an  incision  in  the  stomach  two  inches  above 
the  jtinction  showed  absence  of  bone-plate  and  no  trace  of 
an  opening.  A  membrane  had  formed  where  the  opening 
had  originally  been  and  was  easily  torn  through  with  the 
finger.     From  this  time  on,  recovery  was  uneventful. 

On  the  Treatment  of  So-Called  "Hay  Fever"  or  Summer 
Catarrh. — Karl  Grube  has  found  in  all  of  his  cases  a  gouty 
tendency,  and  therefore  lays  great  stress  on  a  careful  and 
strict  regulation  of  the  diet.  His  local  treatment  consists 
in  the  application  of  the  Neuenahr  waters  in  the  form  of 
inhalations,  gargle,  and  nose-douche.  Hot  baths  and  mas- 
sage may  be  added  when  there  are,  in  addition  to  catar- 
rhal symptoms,  muscular  and  articular  pains.  He  admits 
that  cases  without  a  distinct  gouty  history  are  not  benefited 
by  this  treatment. 

Hydatid  Cyst  in  a  Native  of  India. — This  case  is  reported 

by  W.  J.  Buchanan,  as  cysts  of  this  nature  are  very  rarely 

found  in  natives  of  India  who  have  never  left  their  homes. 

The   Present   State   of   Our   Knowledge   Regarding  Visual 

Sensation. — Bowman  lecture,  by  R.  M.  Gunn. 

A  Case  of  Primary  Carcinoma  of  the  Vermiform  Appen- 
dix.—By  H.  D.  RoUcston. 

Exercises  in  the  Treatment  of  Lateral  Curvature  of  the 
Spine. — By  Noble  Smith. 

Suppurative  Peritonitis  ;  Spontaneous  Evacuation  ;  Recov- 
ery.—By  J.  R.  Wallace. 

The  Degeneration  of  the  Neuron. — Third  Croonian  lec- 
ture, by  F.  W.  Mott. 

Miincheiier  iitedicinische  U'ochenschrifl,  June  26,  igoo. 

A  Contribution  to  the  Study  of  Multiple  Neuritis. ^Hen- 
rici  discus.ses  the  etiology  of  this  disease,  and  inclines  to 
the  views  of  Striimpell,  who  believes  it  to  be  always  ulti- 
mately referable  to  the  action  of  some  poison,  organic  or 
inorganic.  The  neuritis  following  the  infectious  diseases 
is  of  the  former,  while  that  due  to  lead,  arsenic,  or  alcohol 
is  of  the  latter  variety.  These  to.-cic  substances,  whether 
of  external  or  internal  origin,  affect  the  peripheral  nerve 
fibres  most  strongly,  the  cellular  elements  and  the  fibres 
situated  in  the  central  nervous  system  being  more  resist- 
ant. The  author  illustrates  his  statements  with  detailed 
accounts  of  five  cases,  one  an  arsenical  neuritis,  one  fol- 
lowin.g  pneumonia,  and  the  other  three  occurring  in  alco- 
holics. Alcohol  is  to  be  considered  as  merely  a  predispos- 
ing agent :  there  is  nearly  always  to  be  found  in  addition 
tuberculosis,  diabetes,  or  some  febrile  disease  which  forms 
tlic  determining  factor  in  the  etiology. 

Perithelioma  of  the  Carotid  Gland.— Heinleth  relates  the 
difficulties    experienced    iu    diagnosing   and   removing   a 


July  2  1,  1900] 


MEDICAL    RECORD. 


105 


tumor  which  finally  turned  out  to  be  a  perithelioma  of  the 
carotid  gland.  Only  six  similar  cases  are  to  be  found  in 
the  literature,  and  these  are  given  in  brief  by  the  author. 
Nothing  definite  is  kuown  of  the  causation  of  these 
growths,  which  occur  at  all  ages  and  give  all  the  manifes- 
tations of  malignancy.  The  frequency  with  which  they 
have  shown  themselves  at  about  the  end  of  puberty  gives 
color  to  tlie  belief  that  the  increased  general  hyperplastic 
activity  of  this  period  does  not  receive  its  natural  check, 
and  that  in  consequence  of  mechanical  or  inflammatory 
stimuli  the  overgi'owth  is  excited. 

The  Agglutinating  Properties  of  the  Blood  of  a  Healthy 
Infant  Born  of  a  Typhoid  Mother. — Zangerle  reports  the 
case  of  a  woman  who  in  tlie  third  week  of  her  typhoid 
gave  birth  to  a  child  which  continued  perfectly  well  until 
three  months  later,  when  it  died  of  a  combination  of  vari- 
cella and  pneumonia.  The  autopsy  showed  the  absence  of 
any  of  the  lesions  likely  to  have  been  caused  by  an  intrau- 
terine infection  of  the  foetus  by  typhoid,  yet  on  the  second 
day  after  birth  the  child's  blood  gave  a  definite  Widal 
reaction  in  a  dilution  of  i  :  30  of  the  blood,  corresponding  to 
1 :  60  of  the  serum.  While  the  observation  has  been  made 
■often  enough  that  intrauterine  infection  with  typhoid  is 
jyossible,  the  number  of  instances  reported  in  which  a 
healthy  child  was  born  of  a  woman  sick  of  the  disease,  and 
then  gave  the  characteristic  serum  reaction,  is  limited  to 
five,  which  are  abstracted  by  the  author. 

The  Action  of  Digitoxin  Merck  Contrasted  with  that  of 
Digitalis  Leaves. — By  Zeltner. 

Communications  from  the  Municipal  Diphtheria  Station  of 

Chemnitz. — By  Schoedt-l. 

A  Case  of  Apparent  Foot-and-Mouth  Disease  in  the  Human 
Being. — By  SchuUze. 

A  Case  of  Infantile  Cerebral  Palsy  with  Oculomotor  Paraly- 
sis.— By  Kissling. 

Deutsche  mediciiiisLlie  W'ochensihrijt.  June  2S,  /goo. 

The  Danger  of  Tubercle  Infection  through  Milk  and  Dairy 
Products. — Lydia  Rabinowitsch  recapitulates  the  dangers 
to  the  community  at  large  that  exist  in  the  constantlv  in- 
creasing number  of  tuberculous  cattle  used  for  the  produc- 
tion of  milk  and  its  various  modifications  exposed  for  sale. 
Although  for  obvious  reasons  the  general  legally  enforced 
application  of  the  tuberculin  reaction  is  meeting  with  much 
opposition  at  the  hands  of  dairymen,  it  still  represents 
the  best  and  most  reliable  -test,  and  it  is  only  by  its  rigid 
employment  that  an  absolutely  tubercle-free  milk  supply 
can  be  obtained.  This  is  conclusively  shown  by  the  au- 
thor's investigation  of  the  product  of  eight  Berlin  dairies 
supplying  at  an  increased  price  what  is  ostensibly  a  germ- 
free  milk  to  be  used  for  children  and  invalids.  In  three  of 
these  establishments  the  tuberculin  test  is  regular!)-  ap- 
plied and  the  milk  furnished  was  found  uncontaminated 
by  the  bacilli.  In  the  other  five  dairies  clinical  observa- 
tion is  depended  on  to  detect  disease  in  the  cattle  ;  repeated 
examination  demonstrated  the  presence  of  active  virulent 
tubercle  bacilli  in  the  milk  of  three  of  these.  The  autlior's 
investigations  were  carried  on  to  a  study  of  various  other 
dairy  products.  "Plasmon"  (Siebold's  milk  albumen)  was 
found  free  from  pollution,  but  pot-cheese  and  kefir  both 
furnished  virulent  cultures,  Margarin  and  its  modifica- 
tion "sana  "  being  prepared  from  beef  suet,  and  contain- 
ing no  milk,  are  supposably  free  from  danger  of  infection, 
but  the  author  calls  attention  to  the  fact  that  the  fat  used 
in  their  manufacture  may  easily  contain  diseased  Ivmph 
glands,  and  as  a  matter  of  fact  the  two  samples  examined 
were  found  to  give  a  positive  result  bacteriologicallj-. 

Fat  Embolism. — Ribbert  gainsays  the  prevalent  theory 
as  to  the  mechanics  of  fat  embolism,  and  believes  that  the 
following  considerations  prove  the  fallacy  of  the  belief  that 
the  oil  globules  found  in  the  pulmonary  and  systemic 
capillaries  are  thrown  into  the  circulation  through  the  local 
laceration  of  bone  marrow  at  the  site  of  fracture.  In  the 
first  jilace  the  torn  vessels  are  themselves  bleeding,  i.e.. 
pouring  out  their  contents,  and  therefore  incapable  of  re- 
ceiving and  carrying  off  anything,  and  though  it  mav  be 
said  that  the  local  pressure  is  greater  than  that  of  the  capil- 
laries, still  this  same  pressure  is  also  acting  bj-  compress- 
ing and  obstructing  the  orifices  of  the  ruptured  vessels. 
Secondly,  the  amount  of  fat  thus  set  free  is  never  sufficient 
to  produce  the  degree  of  embolism  found.  In  the  third 
place,  very  pronounced  fat  embolism  often  follows  com- 
paratively insignificant  fractures,  and  is  nearly  always 
present  in  fracture  of  the  skull  when  only  non-fatty  bones 
are  injured.  The  results  of  his  clinical  observations  and 
animal  experimentation  incline  the  author  to  believe  that 
the  jarring  and  commotion  produced  in  the  bone  mar- 
row at  large  throughout  the  body  by  every  serious  trau- 
matism cause  the  fat  to  enter  the  circulation,  and  he  main- 
tains that  every  shock,  such  even  as  that  experienced 
in  jumping  from  a  height,  is  sufficient  to  produce  a  greater 
or  less  degree  of  fat  embolism. 


A  New  Club-Shaped  Pathogenic  Bacterium  Found  in 
Lymph  iCorynebacterium  Lymphse  Vaccinalis)  .—Levy  and 
Fickler  publish  a  preliminary  report  on  a  bacterium  iso- 
lated by  them  from  calves'  vaccine  lymph.  Two  varieties 
were  cultivated,  jrossessing  practically  the  same  character- 
istics but  differing  in  that,  when  grow'-n  on  Loefller's  blood 
serum,  the  one  produces  an  orange-yellow  coloring-matter, 
while  cultures  of  the  other  are  colorless.  Voung  cultures 
consist  of  small  wedge-shaped  forms  or  cylinders  of  me- 
dium size  ;  as  they  grow  older  the  cylinder's  exhibit  a  ten- 
dency to  the  production  of  club-shaped  forms  which  are 
slightly  curved  and  beaded.  The  aniline  colors  are  readily 
taken  up.  Gram's  stain  is  positive,  but  in  spite  of  their 
evident  relationship  to  the  diphtheria  bacillus  Neisser's 
stain  for  the  metachromatic  bodies  is  negative.  Nakanishi 
has  just  published  (Ceiihalbl.  f.  Bact.  Purasil.  11.  Infect., 
vol.  xxvii.,  Nos,  iS  and  ig)  an  account  of  a  bacillus  found 
by  him  constantly  in  the  vaccine  pustules  of  children  and 
calves,  and  the  authors  consider  their  bacillus  as  very  sim- 
ilar to,  if  not  identical  with  this,  thougli  they  think  it  too 
.soon  to  indorse  his  belief  tha't  this  is  the  specific  organism 
of  vaccinia  and  variola. 

A  Rare  Complication  in  Tracheotomy. — Thomas,  in  oper- 
ating on  a  two-year-old  child,  whose  larynx  was  filled  with 
diphtheritic  membrane,  had  the  unusual  and  disconcerting 
experience  of  being  unable  to  find  any  trachea.  Having 
explored  the  middle  line  of  the  neck  in  vain,  two  fibrous 
cords  were  exposed  on  either  side,  but  an  attempt  to  open 
each  of  these  under  the  impression  that  it  might  be  the 
very  much  altered  trachea  was  imsuccessful.  Further  dis- 
section revealed  the  larynx  crowded  clo.se  down  on  the 
jugular  notch  of  the  sternum.  The  thyroid  cartilages  were 
.split  and  an  endeavor  was  made  to  pass  a  tube  in  this 
way,  but  the  manoeuvre  did  not  succeed,  and  the  patient 
died  in  a  very  few  moments.  At  the  autopsy  it  was  found 
that  the  fibrous  cords  were  the  greatly  contracted  and  de- 
generated sternohyoid  muscles,  which  had  pulled  the  lar- 
ynx down  to  the  sternum,  and  on  cutting  these  the  trachea 
popped  into  view.  Xo  explanation  of  the  anomaly  could 
be  given. 

Investigation  of  the  Behavior  of  Milk  Bacteria  in  the  Milk 
Thermophor. — By  Dunbar  and  Dreyer. 

Contributions  to  the  Significance  of  the  Oliver-Cardarelli 
Symptom. — By  Ritook. 

lodipin.— By  Klingmiiller. 

Berliner  klinische  W'ochensclnift,  /line  sj;,  /goo. 

Prognosis  of  Glycosuria  and  Diabetes.— F.  Hirschfeld  finds 
in  the  literature  of  rtctnt  times  a  hopeful  view  as  to  the 
prognosis  of  the  milder  forms  ot  the  disease.  According  to 
his  own  researches,  a  relative  cure  is  to  be  looked  for  (that 
is,  a  freedom  from  sugar  with  the  ingestion  of  200  gm.  of 
carbohydrates  daily)  if  upon  the  outbreak  of  the  affection 
eighty  to  eighty-five  per  cent,  of  the  carbohydrates  is 
burned  up  in  the  system.  The  assimilative  power,  with 
reference  to  this  form  of  ingesta.  he  has  seen  diminished 
after  influenza,  certain  forms  of  colic,  and  in  an  especially 
marked  degree  after  gangrene  and  furunculosis.  A  dete- 
rioration with  reference  to  glycosuria  is  seen  through  an 
increase  and  an  improvement  through  a  decrease  in  the 
quantity  of  the  urine.  Sometimes  accompanying  a  rapid 
increase  of  weight  an  increase  in  glycosuria  is  seen,  but 
it  will  subside  under  a  restricted  diet.  The  heart  weak- 
ness occurring  in  diabetes  is  favorably  influenced  by  a 
diet  of  diminished  carboliydrates.  but  these  should  not  be 
wholly  given  up. 

A  Case  of  Complete  Transposition  of  the  Viscera  Associ- 
ated with  Dissecting  Aneurism  of  the  Aorta. — A.  Barbo  de- 
scribes the  case,  wliicli  was  that  of  a  woman  aged  sev- 
enty-four years,  who  died  of  senile  dementia.  Autojjsy 
revealed  complete  transjiosition  of  the  viscera.  A  most 
careful  description  is  given  of  the  arrangement  of  the  vari- 
ous organs.  The  aorta  arose  from  the  right  ventricle  and 
the  pulmonary  artery  from  the  left.  The  aneurism  was 
situated  in  that  part  of  the  aorta  within  the  pericardial  sac 
into  which  it  had  ruptured.  The  adventitia  had  been  sep- 
arated from  the  median  coat.  A  valuable  biblography  of 
the  literature  of  dissecting  aneurisms  is  given. 

The  Present  Condition  of  Our  Knowledge  of  the  Anatomi- 
cal Relations  of  the  Cerebellum  to  the  Remainder  of  the 
Nervous  System,  and  its  Significance  for  the  Appreciation 
of  the  Symptomatology  and  Diagnosis  of  Cerebellar  Dis- 
eases.—  By  L,  Bruns. 

The  Anatomy  of  the  Brain  and  Psychology.— By  L.  Ed- 
inger. 

French  Joiirnixl.<:. 

The  Treatment  of  Wens  by  Interstitial  Injection  of  Ether. 

—  E.  Sergent  jiresents  a  new  method  of  treating  sebaceous 
cysts  by  injecting  pure  sulphuric  ether  by  means  of  a  ster- 
ile syringe  whose  platinum  needle  has  been  passed  through 
the  flame.     No  cyst  which  has  begun  to  show  signs  of  in- 


io6 


MEDICAL    RECORD. 


[July  2  1,  1900 


flammation  should  be  so  treated.  The  surf.ice  should  be 
prepared  as  for  any  operation.  Cysts  upon  the  face,  when 
small,  require  only  five  or  six  drops  of  ether  at  a  time,  but 
the  needle  can  be  left  in  place,  the  syringe  unscrewed,  and 
subsequent  injections  be  made  at  the  same  sitting.  Each 
day  or  two  the  needle  is  introduced  by  the  same  opening 
(a  follicular  orifice).  Ten  or  twelve  sittings  maybe  re- 
quired before  proceeding  to  the  extraction  of  the  sac.  An 
eschar  of  pin-head  size  at  the  point  of  injection,  together 
v'ith  fiaccidity  of  the  tumor,  indicates  the  time  for  extract- 
ing the  sac.  The  advantages  of  the  method  are  bloodless 
removal  without  pain  or  subsequent  scarring.  — jC<j  Presse 
Mstiicale,  June  30,  1900. 

The  Slow  Pulse  in  Syphilis.— M.  Degny  says  that  sypli- 
ilis  affects  the  heart  not  only  by  way  of  its  muscular  libres. 
its  interstitial  tissues,  and  its  vessels,  but  also  by  central 
innervation  giving  a  permanently  slow  pulse.  The  history 
of  one  case  is  given  and  several  others  are  referred  to. 
The  Stokes-Adams  syndrome  can  be  brought  about  in 
three  different  ways:  by  the  production  of  bulbo-cere- 
bral  or  bulbo-protuberant  gummous  tumors ;  by  the  pro- 
duction of  arteriosclerosis  or  of  arterial  lesions  situated 
wholly  or  predominately  in  the  bulb  (as  is  the  case  in  the 
majority  of  instances)  ;  or,  as  Thornton  has  observed,  by 
syphilitic  products  compressing  the  pneumogastric  at  some 
point  in  its  course. — Joiiinat  ih-s  Praticicns,  June  3", 
1 000. 

Treatment  of  Syphilis  by  Inunctions  with  Calomel  Oint- 
ment.— J.  Kazandjieff  recommends  in  place  of  mercurial 
ointment  frictions  with  calomel  pomade.  Each  dose  con- 
tains 4  gm.  of  calomel,  two  each  of  vaseline  and  lard,  and 
80  c.gm.  of  essence  of  turpentine.  It  is  more  cleanly, 
and  does  not  irritate  the  skin.  It  is  applied  to  the  back  and 
lower  extremities,  by  choice,  each  morning,  and  a  bath  is 
given  tliree  times  per  week. — Gazette  Hebdomadaire  de 
Medecine  ct  de  Chirurgie,  July  i,  1900. 

Zeitst/irijt f.  klinische  Medici n,  I'ot.  .\I.,Nos.  3  and 4,  igoo. 

Artificial  Modification  of  the  Gastric  Secretion. — Accord- 
ing to  Alder,  bismuth  subnitrate  is  so  far  the  only  drug 
that  experience  has  shown  to  possess  a  definite  therapeutic 
value  in  causing  a  diminished  secretion  of  h)-drochloric 
acid  in  cases  of  hyperchlorhydria.  Actuated  by  the  results 
of  Riegel,  obtained  by  experiments  on  animals,  he  was  im- 
pelled to  study  the  effect  of  atropine  on  the  gastric  secre- 
tion, the  theory  being  that  as  the  vagus  is  the  agent  pri- 
marily concerned  in  controlling  this  function  and  atropine 
inhibits  the  action  of  the  nerve,  the  administration  of  the 
drug  ought  to  decreise  the  amount  of  gastric  juice  formed. 
This  was  found  to  be  true  in  practice  and  by  analysis  of 
test  meals  given  first  without  and  then  with  atropine  ;  i . 
was  observed  that  under  the  latter  condition  the  percent- " 
age  of  hydrochloric  acid  was  very  markedly  cut  down. 
The  same  result  is  produced  by  the  administration  of  con- 
siderable quantities  of  sugar  .solution,  and  both  of  these 
substances  are  recommended  as  being  of  value  in  the  treat- 
ment of  cases  of  hyperacidity. 

The  Clinical  Aspects  of  Abscess  of  the  Lung. — Jacobson  states 
that  the  prognosis  in  abscess  of  the  lung  depends  largely 
on  the  nature  of  the  perforation  through  which  the  pus  finds 
its  way  into  the  bronchus,  to  be  expectorated.  A  large 
opening  corresponds  to  free  drainage  and  an  acute  course, 
while  in  cases  in  which  the  orifice  is  small  the  discharge 
takes  place  slowly  and  the  course  accordingly  becomes 
chronic  and  the  outlook  more  unfavorable.  Serous  or 
purulent  exudation  into  the  pleura  does  not  necessarily 
increase  the  gravity  of  the  situation,  but  metastatic  ab- 
scesses, especially  ia  the  brain,  ai  3  always  serious  compli- 
cations. Under  tho  treatment  pneumonotomy  is  to  be  con- 
sidered as  adapted  particularly  to  tha  acute  cases,  and  gives 
its  best  results  when  the  collection  of  pus  is  subpleural  or 
at  least  not  very  deeply  situated. 

The  Interrelationship  of  Diabetes  Mellitus,  Abdominal  Colic, 
and  (Edema. — Ebstein  discusses  this  symptom  syndrome, 
taking  as  text  a  case  history  in  which  frerjuent  severe  at- 
tacks of  abdominal  colic  were  accompanied  by  a  gljxosuria 
which  at  first  was  evanescent  but  later  became  permanent, 
and  in  which  finally  well-marked  oedema  of  the  feet,  legs, 
and  genitals  set  in.  The  possibility  is  noted  of  impacted 
gall  stones  or  pancreatic  concretions  producing  both  the 
attacks  of  pain  and  at  the  same  time  through  direct  or  in- 
direct action  on  the  pancreas  deterraiumg  a  state  of  glyco- 
suria. In  explaining  the  oedema,  inasmuch  as  all  the 
usual  local  and  general  causes  could  be  excluded,  the 
theory  is  advanced  that  the  effect  on  the  vasomotor  nerves 
of  the  toxic  substances  present  may  be  sufficient  to  pro- 
duce, or  at  least  predispose  to,  a  widespread  oedema. 

Fat  Diet  in  Hyperacidity. — Backmau  draws  the  following 
conclusions  from  an  elaborate  series  of  test-meal  exjieri- 
ments  with  different  foods  in  eases  of  hyperacidity;  (i| 
Fat  (butter  or  cream)  usually  markedly  decreases  the  free 
hydrochloric  acid   in  hy])eracidity.      (2)    Fat  probably  ex- 


erts an  inhibitory  action  on  the  total  hydrochloric-acid 
secretion.  (3)  Butter  and  cream  do  not  prolong  gastric 
digestion.  (4)  The  presence  of  fat  does  not  retard  the 
digestion  of  carbohydrates  nor  inhibit  the  secretion  of  pep- 
sin. (5)  Fat.  especially  in  the  form  of  butter  and  cream,  is 
an  eminently  suitable  food-stuff  in  cases  of  hyperacidity. 

The  Percussion  of  the  Spleen-Lung  Boimdary. — Buttersack 
says  that  under  the  conditions  usually  present,  viz.,  with 
the  lungs  in  the  mid-respiratory  phase,  percussion  of  the 
limit  between  spleen  and  lung  is  very  difficult.  If,  how- 
ever, the  patient  takes  a  deep  breath, the  contrast  between 
the  hyper-resonant  pulmonary  tissue  and  the  spleen  dul- 
ness  is  very  pronounced,  while  forced  expiration  is  also 
more  favorable,  for  then  the  organ  is  forced  more  closely 
against  the  abdominal  wall  and  its  outlines  are  very  dis- 
tinctly appreciable. 

Comparative  Observations  on  the  Action  of  Urotropin,  Pi- 
perazin,  Lysidin,  Urecidin,  and  Sodium  Bicarbonate  in  the 
Uric-Acid  Diathesis.  —By  Ortowski. 

The  Influence  of  Benzoic  Acid  in  the  Formation  of  Uric 
Acid. — By  Lewandow  sky. 

The  Chemical  Composition  of  the  Blood  in  Pernicious 
Anaemia. — By  Erben. 

Experimental  Observations  on  the  Action  of  Saccharin. — 
By  Bornstein. 

The  Chemical  Composition  of  Lymphamic  Blood. — By 
Erlien. 

Woemer's   Method    of    Uric-A;id   Determination. — By  Le- 
wandowskv. 
A  Method  of    Hippuric-Acid   Determination. — By  Blumen- 

thal. 


©orrcspanclcucc. 


OUR    LONDON    LETTER. 

(From  Our  Special  Correspondent  ) 

HOSPITAL  SUND.W  FUND — PRINCE  OF  WAI.F.s'  Fl/ND  AND 
MEDICAL  SCHOOLS — THE  ARMY  MEDICAL  SERVICE  — ALLEGED- 
WAR  HOSPITAL  DEFICIENCIES — EXIT  MIDWIVES  BILL — CAM- 
HRIDGE   SUMMER    SCHOOL — SIR    WILLIAM    GAIRDNER. 

Ll-INDON,    June    29,     IQOO. 

Chilly,  gloomy,  cold,  unseasonable,  such  were  the  milder 
adjectives  applied  to  the  weather  on  Sunday.  And  it  was 
Hospital  Sunday.  The  sermons  were  forthcoming  in  most 
of  the  churches  and  chapels,  but  the  congregations  were 
too  often  scanty,  and  fears  were  freely  expressed  for  the 
fund.  The  lord  mayor,  undeterred  by  the  other  demands 
on  the  public  benevolence,  had  issued  an  open  letter  ask- 
ing that  last  year's  amount  might  be  more  than  doubled — 
asking,  in  fact,  for  / 100,000.  It  is  hardly  to  be  expected 
he  will  get  it,  and  if  last  year's  collection  be  equalled  it 
will  be  as  much  as  I  anticipate.  On  Monday  evening  ;f  16,- 
000  had  reached  the  Mansion  House. 

A  memorial  was  sent  to  the  Prince  of  Wales  three 
months  ago  from  the  council  of  the  Metropolitan  Radical 
Federation  purporting  to  repre.sent  the  Radical  clubs. 
This  Council  had  the  assurance  to  pretend  that  the  Prince's 
hospital  committee  had  disregarded  His  Royal  Highness' 
intentions  and  devoted  part  of  the  funds  to  medical 
schools  and  'lauoratories.  You  may  judge  the  tone  of  the 
memorial  from  the  fact  that  it  incorporated  an  article  in 
77/1?  Co  11  temporary  Revie7ii  by  Mr.  Stephen  Coleridge,  to 
whose  allegations  about  vivisection  I  have  previously  re- 
ferred. The  executive  committee  of  the  Prince's  hospital 
fund  have  issued  a  report  which  completely  disproves  the 
"scandalous  charge, "in  which  they  state  thai  the  honorary 
secretary  of  the  Federation  has  already  been  informed  that 
no  grant  had  been  made  toward  the  su])port  of  laborato- 
ries. They  go  on  to  deny  in  detail  the  statements  in  the 
memorial  and  to  explain  some  of  the  figures  which  had 
been  impugned.  Mr.  Coleridge  and  his  followers  have 
thus  obtained  an  advertisement  which  the  article  in  7 //e 
Contemporary  could  not  give,  but  it  may  be  questioned 
whether  they  will  feel  much  satisfaction  in  the  result, 
which  is  calculated  to  enlighten  the  public  on  the  value  of 
assertions  made  by  Mr.  Coleridge  or  the  Radical  Federa- 
tion he  has  thus  led  by  the  nose.  One  can  feel  pity  for 
the  ignorance  of  the  person  who  can  believe  that  hos])ital 
patients  are  only  material  for  experiments  and  vivisection 
by  doctors.  For  an  educated  barrister,  even  though  the 
advocate  of  the  antivivisectionists,  contempt  seems  more 
appropriate. 

The  Royal  Army  Medical  Corps  has  had  so  much  praise 
that  it  was  sure  to  be  assailed  by  some  one.  A  fine 
encomium  was  passed  upon  the  corps  on  the  iSth  inst.  by 
.Sir   W.    MacCormac  on  the  occasion  of  his  receiving  the 


July  21,  1900] 


MEDICAL    RECORD. 


107 


freedom  of  the  Salters'  Company.     He  said  he  had  seen 
all  the  organizations  for  the  relief  of  the  sick  and  wounded 
and  could  "speali  in  their  praise  without  stint;  the  provi- 
sion made  for  them  has  been  unexampled  in  the  history  of 
war  and  profuse  in  every  way."     Other  commendation 'fol- 
lowed, and  the   newspapers  generally  praised  the   Royal 
Army  Medical  Corps  as  the  brightest  spot  in  the  army— 
until  Wednesday  last,  when  The   Times  published  a  letter 
from  Mr.  Burdett-Coutts,  M.P.,  giving  a  sensational  de- 
scription  of   the   sufferin.gs   and    hardships   to  which  our 
wounded  soldiers  are  subject.     He  has  just  returned  from 
South  Africa,  and  declares  he  is  impelled  to  speak  out  by 
the  knowledge  that  distinguished  medical  men  who  have 
come  home  have  testified  to  the  perfection  of  the  arrange- 
ments.     In   three   columns  of     The    Times   Mr.    Burdett- 
Coutts  piles  up  the  horrors  endured  by  the  wounded  and 
typhoid  patients— most  of  which,  to  those  with  experience, 
are  clearly  of  the  unavoidable  kind.     The  challenge  throwii 
down  thus  to  the  medical  men  was  promptly  taken  up  bv 
Mr.   Treves,  who  states  his  own  experience,   repeats  his 
pievious  assertions,  and  says  he  cannot  believe  "our  sick 
have  been  treated  with  neglect   and  inhumanity,   as  Mr. 
Burdett-Coutts  asserts."     You  will  not  be  surprised  from 
this  to  learn  that  the  subject  lias  almost  displaced  everv 
other  from  conversation  among  doctors,  and  that  the  news'- 
papers  are  coming  out  with  large  head-lines  on  "War  Hos- 
pital Horrors"  and  "  War  Hospital  Scandal."     Parliament 
was  moved  from  the  apathy  into  which  it  had  fallen  and 
demanded  explanations  of  ministers.     Mr.  Balfour  accord- 
ingly read  extracts  from  a  despatch  of  Lord  Roberts,  who 
tells  how  distressed  he   was   that  his  men  had  to  suffer 
much,  and  explains  the  impossibilitv  of  avoiding  terrible 
scenes  after  a  long  march,  repeated  fights,  and  interruption 
to  the  long  line  of  railway.     He  had  himself  constantly 
visited  the  h  jspitals,  and  considers  that  after  a  very  short 
time  they  were  in  good  order  and  not  overcrowded.     Lord 
Roberts  says  he  "has  no  wish  to  shirk  responsibility  or  to 
screen  any  shortcomings  which  mav  be  proved  against  the 
Royal  Army  Medical  Corps,"  and  he  suggests  that  a  "com- 
mittee, say  of  two  medical  men  of  recognized  ability,  and 
some   man   of  sound    common-sense,    should    proceed    to 
South  Africa  in  order  to  furnish  a  full  report  on  the  work- 
ing of  the  medical  arrangements  throughout  the  war."    As 
i\Ir.  Balfour  read  the  reference  to  "some  man  of  common- 
sense, "  the  house  indulged  in  roars  of  laughter  and  cheers 
—a  testimonial  which  Jlr.  Burdett-Coutts  perhaps  did  not 
anticipate  when  he  penned  his  sensational  charges.     No- 
body supjjoses  Lord  Roberts  intended  the  phrase  to  convey 
the  meaning  which  honorable  members  seemed  to  see  in 
it.  but  the  House  was  intenselv  amused. 

Sir  Evelyn  Wood  was  at  a  dinner  of  the  civil  engineers 
on  Wednesday  evening,  and  declared  that  the  sick  and 
wounded  had  been  adequatelv  looked  after— and  he  ought 
to  know.  Lord  Wantage,  V.C,  is  chairman  of  the  Red 
Cross  Society,  and  its  committee  meets  twice  a  week  to 
receive  and  consider  reports  from  the  field,  but  no  such 
complaints  have  reached  them.  He  savs  Mr.  Coutts  at- 
tended a  meeting  before  he  went  and  offered  to  act  as  their 
commissioner,  but  as  he  was  making  only  a  flying  visit  the 
offer  was  not  accepted.  He  did  not  inform  the  committee 
of  what  he  now  complains,  or  they  would  have  remedied 
wliat  needed  reform.  This  shows'  how  a  per.son  without 
proper  information  may  take  a  roving  commission  and 
perhaps  fall  into  errors  as  to  what  he  sees.  Mr.  Coutts  is 
evidently  not  qualified  to  write  about  war  or  to  judge  what 
is  preventable.  He  may  have  "sound  common-sense,"  but 
I  never  heard  of  his  doing  anything  to  show  it. 

Mr.  Julian  Ralph  is  a  correspondent  of  far  superior  intel- 
ligence. He  was  out  for  The  Daily  Mail,  and  sent  home 
interesting  descriptions— but  not  a  word  about  this  matter, 
until  now  on  his  return  he  proceeds  to  father  Mr.  Coutts' 
statements,  though  he  says  he  can  tell  only  of  "chance  ob- 
servations and  impressions"— a  very  loose  way  of  offering 
evidence.  Then  he  repeats  what  he  heard  from  an  officer, 
that  at  one  hospital  they  were  "trying  on  famished  pa- 
tients a  new  German  method  of  treatment  rightlv  called 
'the  starvation  treatment.'"  Then  he  saj-s  he  knows  no 
more  of  the  skill  required  that  is  to  be  seen  in  this  "crimi- 
nal adoption  of  the  starvation  method  at  Bloemfontein." 
He  then  goes  on  to  declare  that  one  of  the  greatest  Eng- 
lish surgeons  told  him  the  average  army  surgeon  was  a 
mere  tyro,  because  the  War  Office  would  not  let  them  go 
to  Pans.  Berhn.  or  New  York  in  their  holidavs  (?)  and 
only  those  stationed  near  London  "had  a  chance  to  walk 
the  metropolitan  hospitals"!  Evidently  Mr.  Ralph  has 
mixed  up  a  statement  of  one  of  the  army  grievances  about 
"study  furlough,"  and  made  a  mess  of  it  all.  He  is  a 
shrewd  and  able  correspondent,  and  he  acknowledges  he 
made  no  notes  on  this  matter  and  did  not  study  it.  I  can 
therefore  hardly  excuse  him  for  winding  up  his  inconse- 
quent statements  by  calling  the  treatment  of  the  sick  and 
wounded  "primitive,  cruel,  and  almost  barbaric,  as  well  as 
needless  and  inexcusable." 

Really  an  experienced  war  correspondent  should  be  more 


reticent  with  condemnatorv  adjectives.  Some  armv  sur- 
geon may  be  retorting  that  these  of  his  choice  are'  more 
applicable  to  the  man  who  accuses  the  staff  on  the  strength 
of  "chance  impressions." 

There  is  to  be  a  debate  on  the  subject  in  the  House  of 
Commons  this  evening. 

Exit  the  midwives  bill— it  has  gone  out  as  in  a  farce.     It 
came  on,  was  opposed  for  a  time,  and  to  save  it  from  the 
fate  of  rejection  one  of  its  supporters  talked  it  out.     Well 
we  are  rid  of  it  for  another  year,  but  shall  no  doubt  then 
have  to  fight  it  again. 

The  Cambridge  Summer  School  for  Practitioners  is  to 
be  discontinued,  as  the  response  has  been  too  small  to  the 
offer  made.  But  the  Pathological  Society  will  meet  at 
Cambridge  on  the  30th,  and  there  wind  'up  its  session 
having  been  invited  to  do  so  by  Professor  Dr.  Sims  Wood- 
head. 

Sir  William  Gairdner  was  last  week  entertained  to  a 
farewell  dinner  at  which  a  number  of  distinguished  per- 
sons were  present.  In  his  speech  replying  to  the  toast  of 
his  health  he  said  he  had  lived  thirt'v-eight  years  of  life 
preprofessorially  and  thirty-eight  prof'essorially.  and  that 
he  had  had  to  ask  for  only  two  things  that  were  of  much 
account— his  professorship 'and  his  wife.  The  rest  came 
unasked,  and  he  believed  many  went  about  suffering  much 
because  they  were  always  running  to  and  fro  begging  for 
all  manner  of  things  and  grudg:ing  others  their  success. 
He  was  inclined,  like  Lord  Kelvin,' to  regard  his  career  as 
failing  from  poverty  of  accomplishment  compared  with  the 
ideal  he  had  set  himself. 


OUR    PARIS    LETTER. 

( 1-  rom  our  Special  Correspondent . ) 

THE  NEW  P..\STEUR  HOSPITAL— THE  B.^ZV-ALEARRAN  DISCUSSION 
— NEW    METHOD    FOR   SUPPRESSING    RATS. 

Paris.  June  27.  1.100. 

Next  Sunday,  on  the  ist  of  July,  the  Pasteur  Hospital 
will  open  its  doors  and  patients  both  rich  and  poor  will  be 
admitted  free  of  charge,  the  first  time  such  a  plan  of  hospi- 
tal treatment  has  been  carried  out  in  Paris.  Hitherto  all 
patients  having  an  income  exceeding  400  francs  a  vear 
were  obliged  to  pay  a  little  over  two  francs  a  day 'in  a 
medical  ward,  three  francs  and  some  odd  centimes  in  a 
surgical  ward,  and  five  francs  in  a  maternity.  This  hospi- 
tal is  a  private  institution,  the  money  ha'ving  been  left 
anonymously  for  the  founditig  of  the  s'ame,  a  few  months 
before  Pasteur's  death,  in  1S95.  It  is  primarilv  intended 
for  the  reception  of  diphtheria  patients.  The  architect 
chosen  was  Florentin  Martin,  and  the  great  principles  to 
be  carried  out  in  the  organization  of  this  hospital  were  the 
following:  Complete  isolation  of  each  patient  from  the 
moment  he  entered  the  hospital ;  rigorous  suppression  of 
all  danger t>f  infection  from  his  clothes;  rooms  and  wards 
so  disposed  that  they  could  be  easily  washed  with  water  ; 
an  abundance  of  light,  and  hot  and  cold  water  in  every 
room  :  lighting  by  electricity,  and  a  modicum  of  furniture. 
One  can  safely  say  that  the  architect  has  taken  advantage 
of  all  the  ideas  he  could  gather  from  an  exhaustive  visit  to 
the  principal  hospitals  of  Germany,  Austria,  Switzerland 
and  Italy. 

The  patient,  on  arriving  at  the  hospital,  is  shown  into  a 
special  room,  where  he  is  examined  by  the  physician.  If 
he  is  found  to  be  suffering  from  diphtheria  or  other  con- 
tagious disease,  he  is  shown  into  a  "chambred'entree,"  and 
his  clothes  are  taken  from  him  and  sterilized.  A  new  suit 
of  hospital  clothes  is  given  him,  and  he  is  taken  to  a 
"chambre  d'isolement "  and  put  to  bed.  Both  rooms  are 
disinfected  as  soon  as  the  patient  has  left  them.  The 
"pavilion  d'isolement"  contains  twenty-four  rooms,  con- 
taining each  one  bed,  two  wards  for  convalescents  with 
twelve  beds  each,  and  five  chambers  with  two  beds,  the 
latter  being  used  for  children  accompanied  bv  their  moth- 
ers. The  construction  of  the  hospital  is  ca'rried  out  on 
strictly  scientific  principles,  stone  and  glass  being  used  for 
the  walls,  and  an  empty  space  being  left  at  one  side  of 
every  room  for  the  plumbing-pipes  and  electric-light  wires. 
Hot-air  pipes  serve  to  hea,  the  place.  Instead  of  a  director 
being  appointed.  Dr.  Martin,  who  is  the  chief  phvsician. 
has  been  made  more  or  less  general  super\  isor.  and'  all  the 
control  is  vested  in  the  board  of  trustees  of  the  Pasteur 
Institute,  which  meets  every  year. 

A  lively  discussion  has  taken  place  recentlv  at  the  Sur- 
gical Society  regarding  the  use  of  ureteral  c'atheterism  as 
a  means  of  diagnosing  renal  tuberculosis  in  its  early 
stages,  and  its  practical  advantages  in  leading  to  an  early 
intervention.  The  question  was  brought  up  for  the  first 
time  in  April,  and  since  then  it  has  been  "on  the  tapis"  at 
several  meetings,  but  during  the  last  three  weeks  the  war 
of  words  has  waged  hot  and  heavv,  and  each  side  would 
seem  to  wish  to  have  the  last  word.     Dr.  Pousson  started 


io8 


MEDICAL    RECORD. 


[July  2  1,  1900 


the  discussion  by  reading  a  report  of  twelve  cases  on 
whicli  he  had  operated  with  but  one  death.  He  stated 
that  he  liad,  however,  never  had  occasion  to  operate  on  a 
case  in  its  initial  stages.  Dr.  Tuftier  declared  that  ure- 
teral catheterism  was  no  means  of  giving  assurance  as  to 
the  condition  of  the  otlier  kidney.  Dr.  Albarrau,  who  has 
used  this  method  of  e-Kjiloration  very  extensively,  took  up 
the  cudgels  in  its  behalf  and  said  he  had  never  observed 
any  accidents  resulting  from  its  use,  when  complete  asep- 
sis was  enforced  and  the  operator  ]K)ssessed  a  certain  de- 
gree of  nianu;d  dexterity.  Dr.  Tutiier  answered  that  a 
discussion  held  two  years  ago  in  Berlin  showed  there  was 
some  danger  in  using  this  method,  and  chemical  analysis 
of  the  urine  passed  and  cryoscopy,  or  the  examination  of 
its  freezing  point,  would  often  suffice  to  establish  a  correct 
diagnosis  as  to  the  condition  of  the  other  kidney.  He  was 
not  in  favor  of  an  operation,  unless  the  symptoms  showed 
the  general  health  was  being  affected.  Dr.  Albarran  said 
it  was  to  be  remembered  that  cathe  erization  of  twenty- 
four  hours'  duration  was  not  called  for,  one  hour  amply 
sufficing. 

On  June  6th  Dr.  Bazy  made  a  long  speech,  in  which  he 
showed  how  difficult  cystoscopy  might  be  under  certain 
conditions,  such  as  spasm  of  the  bladder,  stricture  of  the 
urethra,  and  youth  of  the  subject.  Desnos  and  Israel  had 
cited  cases  in  which  accidents  had  occurred.  He  also  ex- 
pressed some  doubt  as  to  the  advisability  of  catlieterizing 
a  healthy  ureter  after  a  diseased  one  had  been  investi- 
gated, washing  out  the  bladder  not  being  sufficient  to  en- 
sure complete  asepsis.  Bazy  strongly  advocated  the  use 
of  methylene  blue,  which  is  eliminated  in  a  peculiar  man- 
ner if  both  kidneys  are  affected.  He  has  used  this  method 
almost  exclusively,  and  said  he  considered  catheterization 
not  only  a  useless  but  a  dangerous  operation  in  many  cases. 
As  for  operating  upon  renal  tuberculosis  in  its  early  .stages, 
Dr.  Bazy  said  he  was  strongly  opposed  to  it,  just  as  much,  for 
instance,  as  to  castration  unless  the  general  health  was  af- 
fected. Of  course  hemorrhage  was  an  important  symptom, 
which  could  not  be  overlooked,  and  which  might  lead  to  an 
early  intervention.  He  referred  to  a  case  in  which  Ricard 
had  removed  a  very  far  advanced  tuberculous  kidney,  on  ac- 
count of  hemorrhage,  but  it  was  found  that  the  hemor- 
rhage came  from  the  other  kidney.  If  cystoscopy  had 
been  used.  Dr.  Ricard  would  have  removed  the  relatively 
healthy  kidney  and  the  patient  would  not  have  survived. 

On  June  13th  Dr.  Albarran  answered  all  that  had  been 
said  against  his  first  speech  on  the  subject,  and  the  gist  of 
his  remarks  was  that  those  who  doubted  the  usefulness  of 
this  operation  were  those  who  bad  not  employed  it  suffi- 
ciently to  understand  how  easy  it  became  through  long 
practice.  A  week  later  another  speech  was  made,  this 
time  by  Dr.  Bazy,  and  the  observations  of  Dr.  Albarran 
were  more  or  less  severely  criticised.  Nothing  new  can 
now  be  said  on  the  subject,  and  it  is  to  be  hoped  that  the 
discussion  has  come  to  a  close. 

As  rats  have  been  shown  to  be  in  part  the  cause  of  the 
spread  of  plague,  investigations  are  being  carried  out  as  to 
the  best  means  of  suppressing  them.  The  Matin,  a  widely 
circulated  morning  paper,  had  an  interesting  article  on 
this  subject  a  few  days  ago.  Dr.  Danyez  has  been  trying 
a  new  method  at  the  Pasteur  Institute,  and  as  a  result  of 
his  experiments  this  method  was  given  a  trial.  A  section 
of  a  sewer  was  closed  in  on  both  sides,  two  hundred  large 
rats  were  placed  in  it,  and  they  were  fed  with  bread  on 
which  virulent  cultures  of  a  certain  microbe  had  been  de- 
posited. ■  Two  weeks  later  only  eight  rats  were  found 
alive.  In  the  bodies  of  the  dead  rats,  which  had  not  been 
eaten  by  the  surviving  ones,  the  lesions  were  found  on 
examination  to  be  always  the  same,  and  cultures  gave  the 
same  microbe  in  all  cases.  These  experiments  have  been 
carried  out  at  Lille,  at  Tunis,  at  Copenhagen,  and  at  Ham- 
burg. The  microbe  used  has  no  jiathogenic  action  on 
other  animals,  and  so  one  expeditious  means  of  disposing 
of  these  rodents  has  been  found. 


LKTTEK    FROM    BRAZIL. 

(Troin  our  Special  Correspondent.) 
SEPARATION    OK    XIPnorAGOfS  TWINS — THK   PLAGUE. 

Sao  Joao  del  Rki,  June  7,  iqoo 
The  medical  world  of  Brazil  was  startled  by  the  announce- 
ment that  on  the  30th  ult.,  in  the  operating-room  of  the 
hospital  of  St.  Sebastian  in  Rio  de  Janeiro,  Dr.  Chapot  Pre- 
vost,  one  of  Brazil's  most  distinguished  physicians,  had 
separated  the  eight-year-old  twins,  Rosalina  and  Maria, 
who  had  been  the  subject  of  much  medical  discussion  dur- 
ing the  past  year,  an  operation  that  will  mark  an  epoch  ni 
the  annals  of  surgery. 

These  twins  were  born  of  poor  parents  in  the  state  of 
Espirito  Santo,  Brazil,  and  were  brought  to  Rio  about  a 
year  ago.     They  were  not  united  by  a  single  band  as  were 


the  Siamese  twins,  but  their  abdominal  cavities  were  con- 
nected by  a  large  opening,  practically  forming  one  cavity, 
their  bodies  being  intimately  attached  as  will  be  seen  by 
the  accompanying  illustration.  And  as  it  afterward 
proved,  the  thoracic  cavities  were  also  implicated. 

The  following  brief  and  incomplete  account  of  the  opera- 
tion and  history  of  the  case  up  to  the  present  may  be  of 
interest  to  the  readers  of  the  Mf.dical  Rk.cokd.  On  June 
23d  of  last  year  one  of  the  leading  Rio  physicians  made  an 
exploratory  opening,  but  finding  the  livers  of  the  two  girls 
so  united  as  to  form  practically  one  liver  he  decided  to  go 
no  further.  Dr.  Prevost  then  hearing  of  the  case  began  a 
series  of  experiments  to  test  the  recu])erative  power  of  the 
liver,  and  the  best  means  of  controlling  hemorrhage  in  this 
organ.  Among  others,  he  cut  away  a  large  part  of  a  dog's 
liver,  and  in  eight  days  it  had  almost  reproduced  itself. 
From  these  experiments  he  became  convinced  that  this 
organ  would  bear  a  great  deal  of  surgical  interference,  and 
he  accepted  the  case. 

Since  last  October  the  twins  have  been  in  this  hospital 
under  his  care,  and  he  has  made  a  very  careful  study  of 
the  case  from  all  points  of  view — anatomical,  physiologi- 
cal, and  psychological.     He  had  several  .v-raj-  photographs 


y 


taken,  and  thus  ascertained  that  the  livers  were  united  in 
nearly  their  whole  extent. 

While  under  his  observation  Rosalina  had  an  attack  of 
grippe,  which  lasted  eight  days,  with  a  temperature  on  the 
third  day  of  40, 2°  C,  with  corresponding  pulse  and  respi- 
ration, while  Maria  remained  perfectly  well.  This  con- 
firmed him  in  his  opinion  that  there  were  no  psychological 
conditions  to  forbid  their  separation. 

Having  completed  his  studies  and  preparptions  he  called 
a  council  of  his  colleagues  who  were  to  assist  him,  and  ex- 
plained to  them  his  [dans,  and  at  6  a.m.  on  the  3olh  ult. 
they  assembled  at  the  hospital  to  make  the  final  prepara- 
tions. Everything  had  been  arranged  with  a  view  to  the 
most  perfect  asepsis.  The  attendants,  after  taking  a  full 
disinfecting  bath,  dressed  in  new  clothing  thoroughly 
sterilized,  and  before  entering  the  o])erating-room  washed 
their  hands  and  arms  in  six  disinfecting  .solutions. 

Before  the  operation  the  girls  were  given  clysters  of  500 
gm.  of  artificial  serum,  and  their  bodies  were  thoroughly 
washed,  first  with  soap  and  water,  then  with  sublimate 
solution,  and  finally  with  sulphuric  ether,  after  which  they 
were  wrapjjcd  in  sterilized  cotton  covered  with  gauze. 
They  were  then  jilaced  up<ni  a  table  especially  prepared, 
which  could  be  easily  unjointed  to  make  two,  Rosalina 
lying  upon  her  left  side  and  Maria  upon  li,er  right  side, 
the  cicatrix  of  the  former  operation  showing  upon  the  top. 

The  giving  of  the  chloroform  began  at  9:15  A.M.,  and 
after  slight  resistance  on  the  part  of  both  they  were  .soon 


July  2  1,  1900] 


MEDICAL    RECORD. 


109 


under  its  influence,  and  at  9  ;45  the  first  incision  was  made. 
This  extended  from  the  navel  upward,  having  its  middle 
at  the  ensiform  cartilage,  being  closer  to  the  false  ribs  of 
the  right  side  of  Maria.  Turning  back  the  flap  toward 
Ro.salina's  side,  the  anterior  superior  surface  of  the  liver 
was  seen.  This  occupied  two-tliirds  of  the  connecting 
space  and  formed  a  bridge  between  the  two  cavities.  Be- 
low this  was  di.scovered  another  connecting  bridge  formed 
by  the  union  of  the  two  mesenteries.  After  having  cut 
through  the  cartilage  in  the  median  line  another  bridge 
was  discovered.  This  was  formed  by  the  union  of  the  two 
pericardial  sacs,  2  cm.  in  extent,  through  which  the  fluid 
could  easily  be  seen  passing  from  one  sac  to  the  other 
owing  to  the  uneven  beating  of  the  two  hearts.  The  oper- 
ator placed  a  pair  of  pinces  de  Pean  upon  either  side  of 
this  connecting  bridge  preparatory  to  separating  it.  This 
was  one  of  the  most  intensely  exciting  moments  during  the 
wliole  operation,  for  by  the  severing  of  the  anastomosing 
branch  of  the  two  mammary  arteries  the  held  of  operation 
was  deluged  with  blood.  The  points  were  quickly  seized 
and  the  hemorrhage  controlled,  but  one  of  his  more  fearful 
assistants  inquired.  "  Doctor,  will  you  still  separate  tliem  ?  " 
He  simply  replied  "Separo"  {"I  will  separate"),  and  cut 
through  the  imprisoned  tissue,  and  sutured  llie  cut  edges  of 
each  sac  with  catgut.  Now,  it  was  discovered  that  the  pleura 
of  Maria  also  extended  across  the  line  of  union.  However, 
before  undertaking  the  task  of  correcting  this  it  was 
thought  best  to  attend  to  the  mesenteric  bridge,  as  its 
position  made  it  easy  for  the  intestines  of  one  to  pass  to 
the  cavity  of  the  other.  This  was  prevented  by  ligating 
it  with  silk  at  two  points  and  cutting  between  them  and 
returning  the  contents  of  each  cavity  to  their  proper  place. 
He  then  returned  to  the  remaining  (lifficulty  in  the  tiioracic 
cavity.  This  was  overcome  by  cutting  u])on  the  internal 
face  of  the  half  of  the  cartilage  yet  united,  detaching  the 
parietal  pleura,  and  uniting  it  with  a  fine  catgut  suture  to 
the   median  fold  which  adheied  to  the  jiericardial  bridge. 

Having  thus  completed  the  separation  of  the  internal 
parts  of  the  thorax,  he  then  cut  through  tlie  skin  and  car- 
tilage on  the  other  side,  opposite  to  the  flrst  incision,  leav- 
ing only  the  liver  to  be  separated.  This  he  accomplished 
in  such  a  way  as  to  give  to  each  an  uninjured  gall  bladder 
and  duct.  The  final  cut  having  been  made  at  10  :5o,  and  the 
table  separated,  he  turned  over  Kosalina  to  two  assistants, 
while  he  continued  to  care  for  Maria,  who  had  suffered 
most  from  the  operation.  However,  he  had  to  suspend  his 
work  of  closing  up  her  wound  to  retie  a  ligature  that  had 
slipped  from  one  of  the  hepatic  vessels  of  Rosalina. 

The  final  suturing  was  done  on  two  ])lancs,  the  deep 
peritoneal  and  the  superficial,  including  the  skin  and  mus- 
cular coat.  At  11:45  the  operation  was  completed.  The 
condition  of  Rosalina  was  encouraging  ;  that  of  Maria  was 
much  less  hopeful.  Little  by  little  they  were  awakened, 
and  upon  opening  her  eyes,  JIaria,  who  awoke  first,  said, 
"Where  is  Rosalina."  And  Rosalina,  upon  awaking, 
asked  the  same  in  regard  to  her  sister.  When  they  saw 
each  other,  and  realized  that  they  were  separated  and  still 
alive,  Maria,  looking  toward  iJr.  Chapot,  exclaimed,  "Oh, 
doctor,  how  good  you  are  !  " — he  had  received  his  fee 

The  children  both  vomited  three  times  after  tlie  o]iera- 
tion,  and  were  given  ice-water  several  times.  Both  dur- 
ing and  after  the  operation  they  were  given  injections  of 
artificial  serum.  They  urinated  without  difficulty.  After 
five  o'clock  they  slept  tranquilly  with  but  slight  interrup- 
tion. At  eight  o'clock  Rosalina  wanted  to  say  her  pray- 
ers, and  put  on  a  new  dress  the  doctor's  daughter  liad 
given  her.  The  following  is  the  schedule  of  temperature, 
pulse,  »'>d  respiration  for  the  first  twelve  hours : 


Maria. 

Rosalina. 

Temp 

Pulse. 

Kcsp. 

Temp. 

Pulse. 

Resp. 

11:52  A.M 

3  P.  M           ... 

36.0° 

36.7 

36.6 

37-3 

36.6 

no 
126 
12S 
126 
130 

64 
46 

44 
43 
43 

35.8° 
36.6 
36.6 
36.9 

37-2 

Weak 
no 
108 
112 
124 

45 
33 
42 

39 

40 

5  I'.  M 

»  I'.M 

1 2  M 

On  the  second  day,  both  slept  well,  though  Maria,  whose 
temperature  ran  up  to  38'  C.  at  4  a.m.  was  somewhat  dis- 
turbed. Her  pulse  at  this  time  was  160,  respiration  56  ; 
but  at  daylight  these  all  had  gone  down  somewhat.  At 
2:30  P.M.  her  temperature  again  ran  up  to  38.5'.  She  was 
then  given  injection  of  artificial  serum  and  inhalations  of 
oxygen,  after  which  she  became  better,  and  at  9  p.m.  was 
quietly  sleeping.  Rosalina  remained  in  good  condition  all 
day,  and  several  times  asked  to  sit  up. 

Third  day:  During  the  night  they  both  slept  well,  and 
during  the  day  the  general  condition  of  both  improved, 
and  they  closed  the  day  in  good  condition,  the  temperature 


of  neither  going  above  38.2".      At   midnight   Maria   was 
given  inhalations  of  o.xygen. 

Fourth  day  .  Until  2  p.m.  both  girls  were  doing  finely, 
when  Maria's  temperature  ran  up  to  39  ,  with  pulse  172. 
She  became  quite  weak  and  could  not  take  nourishment. 
After  taking  inhalations  of  oxygen  and  a  small  dose  of 
digitalin  she  became  better.  Her  bowels  were  washed 
out,  and  she  passed  a  large  worm.  At  9  p.m.,  temiiera- 
ture,  37.9°:  respiration,  36;  pulse,  150.  At  midnight  both 
were  sleeping,  though  Maria  was  somewhat  restless. 

Fifth  day  .  The  unfavorable  symptoms  of  Maria  of  the 
day  before  did  not  return,  and  althougli  very  weak  she  was 
in  every  way  better,  taking  with  relish  some  broth  at  dif- 
ferent times.  The  intestinal  washings  were  continued 
with  marked  benefit.  Oxygen  was  also  administered 
throughout  the  day.  The  temperature  did  not  get  above 
38.6',  and  fell  to  37.9'.  Pulse,  highest  150,  lowest  137; 
resijiration,  highest  40.  lowest  30. 

Rosalina  was  in  fine  condition  ;  she  ate  a  little  chicken 
and  was  anxious  to  sit  up. 

Sixth  day ;  In  the  early  part  of  the  day  Maria's  condi- 
tion was  so  flattering  that  the  surgeon  announced  her  to  be 
out  of  danger.  However,  at  2  ;3o  p.m.  she  began  to  vomit, 
and  although  this  was  checked,  she  became  so  prostrated 
that  she  could  not  rally  under  the  supportive  treatment 
given  her,  and  at  1  :3o  a.m.  of  the  f(jllowing  day  she  died. 

At  3:30  P.M.  the  autopsy  was  held,  at  the  request  of  Dr. 
Prevost,  by  the  police  physicians.  He  asked  them  to  tes- 
tify as  to  the  following  points,  in  addition  to  the  regular 
facts  of  cause  of  death,  etc.:  (i)  Had  there  been  hemor- 
rhage of  the  liver?  (2)  Had  there  been  infection?  (3) 
Was  the  death  due  to  lack  of  skill,  imjirudence,  or  neglect? 

The  examination,  made  in  the  presence  of  a  large  num- 
ber of  physicians,  revealed  a  state  of  inflammation  of  the 
pleura  and  pericardium  with  more  or  less  exudate  from 
each,  but  no  inflammation  of  the  peritoneum,  while  the 
liver  was  completely  healed  and  cicatrized,  as  were  all  the 
external  wounds.  All  present  agreed  that  everything  pos- 
sible had  been  done  that  could  have  been  done,  but  of 
course  there  were  some  who  could  find  something  to  criti- 
cise, either  in  the  method  of  ojierating  or  in  the  after-treat- 
ment.    The  experts  have  not  yet  made  formal  report. 

Rosalina  continues  to  imiJiove  without  any  drawback  so 
far. 

The  report  of  this  operation  has  made  a  great  sensation 
in  Rio,  almost  overshadowing  the  plague,  which  is  yet 
extending  itself  throughout  tlie  city.  However,  there  have 
been  since  May  i6th  up  to  June  5th  but  eighty-six  cases 
with  twenty-three  deaths,  which  in  a  city  of  six  hundred 
thousand  inhabitants  would  indicate  a  very  mild  type. 
It  is  rumored  that  a  case  has  developed  in  a  city  in  the 
interior  of  the  state  of  Minas,  two  hundred  miles  north- 
west from  Rio,  on  the  line  of  the  Central  Railroad  of 
Brazil ;  but  the  rumor  is  not  yet  confirmed. 


A  Contribution  to  the  Symptomatology  of  Senile 
Arteriosclerosis. —  Friedmann  rehearses  the  classical 
symptoms  of  this  condition,  and  then  goes  on  to  de- 
scribe a  new  sign  which  he  considers  of  value  in  the 
diagnosis.  Normally  in  adults  the  heart  sounds  are 
to  be  heard  by  careful  auscultation  over  the  descend- 
ing aorta,  and  in  health  and  under  the  age  of  forty  to 
fifty  years  are  most  plainly  appreciable  at  a  point  on 
a  level  with  the  spine  of  the  scapula  and  just  to  the 
left  of  the  vertebral  column.  With  advancing  years 
this  point  moves  downward,  and  if,  in  addition,  there 
is  atheroma  of  the  aorta  the  sounds  are  to  be  heard  with 
great  distinctness  and  force  on  a  line  joining  the  angle 
of  the  scapula  to  the  spinous  process  of  the  seventh  ver- 
tebra. The  cause  for  this  phenomenon  is  to  be  found 
in  the  fact,  first,  that  these  sounds  are  not  truly  trans- 
mitted heart  sounds,  the  first  being  certainly  purely 
vascular  in  its  origin,  for  it  is  present  even  when  over 
the  aortic  area  the  first  sound  is  entirely  replaced  by 
a  murmur;  and,  second,  accompanying  the  arterial 
lesion  there  is  nearly  always  a  concomitant  emphyse- 
matous condition  of  the  thoracic  walls  which  increases 
the  resonating-power  of  the  ribs  and  also  causes  an 
alteration  in  shape  favorable  for  the  direct  transmis- 
sion of  the  sound.  There  are  also  fixation  of  the  chest 
in  the  expiratory  position  and  prolonged  and  dimin- 
ished e.xpiration,  which  added  to  the  hypertrophy  of  the 
left  ventricle  combine  to  make  a  set  of  causes  suffi- 
ciently characteristic  to  give  the  sign  diagnostic  value. 
—  Wiener  klitiische  Wocheiischrijt,  June  21,  1900. 


I  lO 


MEDICAL    RECORD. 


[July  2  1,  1900 


Society  gleports. 

FIFTH     DISTRICT    BRANCH    OF    THE    NEW 
YORK.    STATE    MEDICAL   ASSOCIATION. 

Si.xtfin//i  Annua/  Meeting,    Held  in    Brooklyn,    May 
22,  igoo. 

J.  C.  BiERWiRTH,  M.D.,  OF    Brooklyn,    President. 

President's  Address.— Dr.  J.  C.  Bierwirth,  in  his 
address,  considered  "The  Necessity  and  Benefits  of 
More  Completely  Organizing  the  Medical  I'rofes- 
sion."  The  speaker  pointed  out  the  increasing  fre- 
quency of  malpractice  suits,  and  the  general  feeling 
among  the  unprincipled  that  physicians  are  an  easy 
prey  owing  to  their  sensitiveness  and  abhorrence  of 
publicity.  The  liability  of  physicians  to  unjust  arrest 
on  mere  suspicion  of  complicity  in  cases  of  criminal 
abortion  was  another  crying  evil.  The  remedy  was 
to  be  found  in  proper  organization,  such  as  could  be 
effected  under  the  charter  just  granted  to  the  New 
York  State  Medical  Association.  Believing  in  ]iome 
rule,  it  was  thought  best  that  members  should  be  ad- 
mitted through  their  local  organization,  the  county 
association,  as  here  the  character  of  candidates  was 
best  known.  In  time,  the  members  would  have  not 
only  protection  from  malpractice  suits,  but  a  death 
benefit  fund.  In  conclusion,  the  speaker  begged  all 
interested  in  the  welfare  of  the  new  and  enlarged 
State  association  to  put  aside  personal  ambitions  and 
differences,  that  all  might  work  shoulder  to  shoulder 
for  the  common  weal. 

The  address  was  ordered   printed  and  distributed 
gratuitously  to  the  regular  physicians  of  the  State. 

Discussion  on  Diabetes.  —The  afternoon  was  de- 
voted to  this  symposium. 

The  Identification  of  Dextrose  in  Human  Urine. 
— Dr.  Heinrich  Stern  presented  an  elaborate  paper 
on  this  subject,  which  he  read  in  abstract.  He  said 
that  while,  as  a  rule,  glucose  could  be  identified  in  urine 
containing  0.5  per  cent,  or  more  of  it,  great  difficulty 
was  experienced  when  the  quantity  was  less  than  this. 
He  knew  of  a  number  of  instances  in  which  persons 
had  undergone  treatment  for  diabetes  without  ever 
having  suffered  from  this  disease.  Many  spurious 
cases  had  come  under  his  observation  which  had  been 
diagnosticated  as  diabetes  by  life-insurance  compa- 
nies. He  was  cognizant  of  many  errors  which  had  been 
committed  in  testing  for  glucose,  which  would  never 
have  occurred  if  the  physician  had  taken  the  precau- 
tion to  make  use  of  control  tests.  Mention  was  made 
of  a  case  in  which  a  diagnosis  of  glycosuria  had  been 
made  in  a  person  who  had  indicanuria.  The  explana- 
tion was  to  be  found  in  the  fact  that  the  physician 
who  had  tested  the  urine  had  employed  only  the  bis- 
muth test,  and  had  fallen  into  the  error  because  the 
bismuth  had  been  reduced  by  the  indican.  Grape 
sugar  may  be  confounded  with  a  number  of  other 
urinary  constituents.  Comparing  the  more  important 
of  these  tests,  it  would  be  found  that  wilii  Boettger's 
test  the  limit  of  sensitiveness  was  one  per  cent.,  and 
tlie  limit  of  reliability  0.5  percent.;  with  Nylander's 
test,  0.1  per  cent,  and  0.3  per  cent,  respectively;  with 
Trommer's,  o.i  per  cent,  and  0.5  percent.;  with  the 
fermentation  test,  o.i  per  cent,  and  0.5  per  cent.,  and 
with  the  phenylhydrazin  test  the  limit  of  sensitiveness 
was  0.03  per  cent.,  and  limit  of  reliability  0.05  per 
cent.  The  delicacy  of  the  glucose  test,  moreover,  was 
not  the  same  in  all  urines.  For  instance,  Trommer's 
test  was  exceedingly  delicate  if  skilfully  applied  to 
certain  urines,  yet  in  a  great  majority  of  instances  it 
could  not  be  relied  upon  when  there  was  less  than  0.5 
per  cent,  of  glucose  present. 

Boettger's  Bismuth  Test :   Excessive  amounts  of  pig- 


ment, glycuronic  acid,  mucin,  and  other  urinary  con- 
stituents containing  sulphur,  gave  a  reaction  similar 
to  that  obtained  with  glucose.  Almost  every  urine 
blackened  bismuth  in  a  strongly  alkaline  medium,  but 
the  darkening  was  not  due  to  sugar.  Saccharin  was 
one  of  the  substances  which  prevented  the  reduction. 
The  working  of  the  test  was  interfered  with  in  urine 
containing  antipyrin,  acetanilid,  salicylates,  quinine, 
sulphur,  mercurials,  salts  of  iodine,  turpentine,  senna, 
tannic  acid,  chloral  hydrate,  benzol,  sulfonal,  trional, 
and  many  others. 

Trommer's  Test :  This  test  was  interfered  with  by 
the  presence  in  the  urine  of  uric  acid,  urates,  creatin, 
hippuric  acid,  indican,  nucleo-albuniin,  urinary  pig- 
ments, glycuronic  acid,  arsenic,  tannin,  gallic  acid, 
pyrogallol,  camphor,  copaiba,  cubebs,  chrysophanic 
acid,  salicylic  acid,  oxalic  acid,  chloral  hydrate,  tur- 
pentine, glycerin,  sulfonal,  thallin,  benzoic  and 
carbolic  acids.  Albumin,  parapeptone,  salts  of  am- 
monium, and  saccharin  retarded  or  prevented  the 
reduction.  Urine  rich  in  ammonia  might  keep  the 
cupric  oxide  in  solution. 

Phenylhydrazin  Test:  The  delicacy  and  trustworthi- 
ness of  the  jihenylhydrazin  test,  the  speaker  said,  had 
been  decidedly  overestimated.  The  true  nature  of  the 
crystals  must  be  demonstrated  beyond  a  doubt  before 
the  reaction  could  be  considered  positive. 

Picric  Acid :  This  test  was  very  fallacious. 

Fermentation  Test:  The  fermentation  test  was  one 
of  the  most  reliable  methods  of  detecting  the  presence 
of  grape-sugar  in  human  urine.  The  test  was  made 
with  fresh  beer  yeast,  or  with  German  yeast.  The 
method  of  determining  the  quantity  of  sugar  by  the 
amount  of  gas  generated  must  always  be  very  inaccu- 
rate. Roberts'  method — the  determination  oft  he  loss 
in  specific  gravity  by  fermentation — was  a  very  relia- 
ble one,  and  was  well  suited  to  the  needs  of  the 
medical  practitioner.  But  there  was  not  a  single 
method  of  determining  the  presence  of  glucose  in 
urine  that  was  not  open  to  sources  of  error;  hence 
absolute  reliance  should  not  be  placed  in  any  one  of 
them  alone.  The  employment  of  the  copper  test  in 
mere  routine  work  without  a  control  test  was  certainly 
objectionable.  The  speaker  asserted  tliat  one  case  in 
every  six  or  seven  coming  to  him  was  neither  diabetes 
nor  glycosuria,  yet  the  urine  in  the  majority  of  them 
gave  a  reduction  with  the  copper  tests. 

Diabetes  Mellitus  in  Children.  —  Dr.  Henry 
Dvvight  Chapin  considered  this  subject.  He  said 
that  the  literature  was  almost  silent  on  diabetes  in 
children.  A  case  had  been  reported  in  1895  in  which 
glucose  had  been  found  in  the  liquor  amnii  of  a  preg- 
nant woman  suffering  with  diabetes,  in  which  exami- 
nation of  the  infant's  urine  failed  to  show  any  glucose. 
Dr.  Chapin  reported  two  cases  seen  by  him  during  the 
past  year.  The  first  was  that  of  a  boy  aged  four  years 
and  a  half,  who,  following  the  fatigue  and  exposure 
caused  by  the  Dewey  parade,  had  developed  a  slight 
fever  and  had  rapidly  lost  flesh  and  strength.  Dr. 
Jackson,  on  being  called  in,  had  found  that  the  child 
was  passing  over  one  hundred  and  five  ounces  of  sac- 
charine urine  daily.  He  had  failed  to  find,  on  careful 
examination,  with  Dr.  Jackson,  any  evidence  of  tuber- 
culosis or  other  organic  disease  that  migiit  explain  the 
atrophy.  The  disease  lasted  about  three  weeks,  the 
child  dying  three  days  after  he  saw  it.  The  other  case 
had  been  seen  in  consultation  with  Dr.  McPhee,  and 
was  that  of  a  boy  aged  about  six  years,  in  whom  the 
disease  ran  about  the  same  course.  The  patient  was  in 
semi-stupor  at  the  time  of  the  examination,  but  this 
had  deepened  into  coma,  in  which  state  the  boy  had 
died  four  days  later.  In  both  of  these  cases  the  urine 
had  contained  about  five  per  cent,  of  sugar,  which  had 
persisted  to  the  last.  'I'he  extremely  rapid  emaciation 
was  specially  worthy  of   note.     Dr.   Chapin   said  that 


J  uly  2  1,1 900] 


MEDICAL    RECORD. 


1 1 1 


he  had  made  it  a  practice  to  have  the  urine  of  his  hos- 
pital children  systematically  examined,  and  it  had 
been  very  rare  to  meet  with  glycosuria.  It  was  ex- 
ceedingly fatal  in  early  life. 

Diagnosis,  Symptoms,  Treatment,  and  Prognosis 
of  Diabetes  Mellitus. —  Dr.  Egbert  Le  Fevre  read  a 
paper  with  this  title.  He  said  that  the  peculiarly 
aged  and  emaciated  appearance  of  diabetics  was  quite 
characteristic.  These  patients  did  not  present  an 
anaemic  condition  of  the  mucous  membranes.  The 
onset  of  the  disease  was  frequently  insidious,  and  the 
diagnosis  often  was  first  made  by  a  life-insurance  ex- 
aininer.  Ordinarily,  the  only  thing  noticed  at  first 
was  a  slight  loss  of  vigor  or  of  general  health.  The 
occurrence  of  thirst  and  the  increase  in  the  quantity 
of  urine  were  frequently  so  gradual  as  not  to  attract 
attention.  The  manner  of  onset  often  determined.the 
subsequent  course  of  the  disease.  In  the  aged  and  in 
stout  people  from  sixty  to  one  hundred  ounces  of  urine 
might  be  passed.  When  the  night  urine  was  equal  to 
or  greater  than  that  passed  during  the  day,  it  was  to 
be  considered  an  unfavorable  sign.  Polyuria  with  a 
decrease  in  the  quantity  of  sugar  was  always  a  good 
sign.  The  color  of  the  urine  was  usually  pale  or 
light  yellow;  a  greenish  or  greenish-yellow  tint  was 
an  unfavorable  sign.  Dark-colorud  urine,  or  a  sud- 
den increase  in  the  color,  should  lead  one  to  estimate 
the  presence  of  sugar  or  its  quantity,  as  this  change  in 
the  color  often  occurred  just  before  an  attack  of  coma. 
The  specific  gravity  usually  ran  parallel  with  the  per- 
centage of  sugar  contained.  A  low  specific  gravity, 
however,  did  not  preclude  the  presence  of  sugar,  as  a 
few  cases  had  been  reported  in  which  sugar  was  found 
in  urine  having  a  specific  gravity  of  1.012.  A  light- 
colored  urine  having  a  specific  gravity  of  1.025  should 
always  be  examined  for  sugar;  a  high-colored  urine 
having  a  specific  gravity  of  1.025  o""  1  030  was  of  little 
significance.  The  diurnal  variation  in  the  amount  of 
sugar  was  of  great  importance.  If  the  quantity  of 
sugar  passed  during  the  night  exceeded  that  voided 
during  the  day  it  indicated  that  the  disease  would  run 
a  severe  course,  and  would  rapidly  prove  fatal.  Every 
case  would  be  limited,  to  a  greater  or  less  extent,  by 
the  quantity  and  character  of  food  taken.  The  occur- 
rence of  phthisis  caused  a  reduction  in  the  quantity  of 
sugar.  When  diabetes  was  associated  witii  advanced 
disease  of  the  kidney  there  was  likely  to  be  a  progres- 
sive diminution  in  the  quantity  of  sugar,  so  that  tiiis 
was  not  necessarily  a  favorable  symptom.  Most 
authors  stated  that  the  quantity  of  urea  was  increased 
in  diabetes.  This  was  usually  due  to  the  exclusion  of 
the  carbohydrates  and  the  patient's  being  on  a  largely 
nitrogenous  diet.  The  quantity  of  urea  became  less 
than  normal  in  the  terminal  stage.  When  uric  acid 
was  present  in  diabetic  urine,  and  the  latter  had  a 
high  color,  it  usually  indicated  a  mild  type  of  the  dis- 
ease. It  was  most  commonly  observed  in  gouty  peo- 
ple. A  small  trace  of  albumin  in  the  urine  was  an 
almost  constant  symptom  of  diabetes.  In  the  large 
proportion  of  cases  showing  this  small  quantity  of 
albumin  there  were  no  other  evidences  of  nephritis. 
In  diabetic  coma  albumin  was  always  present,  and  as 
the  sugar  often  decreased  or  disappeared  on  the  occur- 
rence of  coma,  many  of  these  cases  had  been  erro- 
neously looked  upon  as  examples  of  urjemic  rather  than 
of  diabetic  coma.  Diacetic  acid  was  never  found  in 
normal  urine.  In  the  diabetic  it  was  readily  produced 
by  the  withdrawal  of  carbohydrates.  Gerhardt's  test 
for  diacetic  acid  was  exceedingly  simple.  It  was  ap- 
plied by  adding  to  the  urine  a  strong  solution  of  per- 
chloride  of  iron.  If  this  caused  a  deep  wine  color,  it 
indicated  the  presence  of  diacetic  acid.  In  answer  to 
the  question  as  to  whether  the  diagnosis  of  diabetes 
could  be  more  surely  made  by  an  examination  of  the 
blood  than  of  the  urine,  the  speaker  said  that  it  was. 


to  say  the  least,  a  most  useful  method  of  examination, 
as  the  reaction  with  the  blood  was  often  observed 
when  it  was  no  longer  obtained  in  the  urine.  One  of 
the  simplest  of  these  tests  was  that  known  as  V\'il- 
liams',  which  consisted  in  adding  a  small  quantity  of 
blood  to  a  measured  quantity  of  a  standard  solution  of 
methylene  blue,  and  noting  if  any  decolorization  took 
place.  The  peculiar  sweet,  aromatic  odor  of  ihe 
breath  was  often  of  more  or  less  diagnostic  import, 
and  was  especially  apt  to  be  present  just  prior  to  the 
occurrence  of  diabetic  coma.  Of  the  nervous  mani- 
festations the  most  important  were  the  mental  de- 
rangements. The  diabetic  was  never  cheeiful,  not 
even  when  the  diabetes  was  complicated  with  pulmo- 
nary tuberculosis.  The  patellar  reflex  was  diminished 
in  the  majority  of  cases  of  diabetes,  and  when  occur- 
ring in  an  early  stage  tiiis  was  an  unfavorable  sign. 
The  most  common  cause  of  death  in  diabetes  was 
coma.  It  was  most  common  in  those  who  rapidly 
emaciated,  and  the  most  frequent  exciting  causes  were 
mental  excitement,  fatigue,  and  sudden  indiscretions 
in  diet.  Severe  pain  in  the  epigastrium,  with  or  with- 
out nausea,  was  an  exceedingly  common  precursor  of 
diabetic  coma.  In  these  cases  albumin  was  always 
present,  generally  in  large  quantities,  and  whitish 
specks  would  be  found  frequently  floating  in  the 
urine.  The  latter  were  found,  on  microscopical  ex- 
amination, to  be  collections  of  casts.  The  mild  form 
of  diabetes  was  usually  the  result  of  errors  in  diet, 
and  was  associated  with  obesity.  The  second  form 
was  the  arthritic  or  gouty,  and  often  constituted  only 
a  transition  from  the  obese  to  the  severe  form  of  dia- 
betes. A  third  type  was  the  neurotic.  These  persons 
were  generally  spare  and  nervous,  and  such  cases  were 
apt  to  be  characterized  by  transient  glycosuria  for 
some  time  before  the  true  diabetes  was  established. 
Under  proper  management  tiiese  patients  enjoyed  good 
health  and  the  disease  could  be  controlled  for  a  long 
time.  The  severe  type  was  characterized  by  a  sudden 
onset  and  rapid  emaciation,  with  loss  of  muscular 
power.  In  the  well-to-do  the  disease  was  often  mild; 
in  the  poor  and  hard-working  the  disease  was  severe, 
and  its  course  was  rapid.  Von  Noorden  had  made  an 
excellent  suggestion  concerning  the  method  of  testing 
the  sugar-destroying  power  of  the  individual  organ- 
ism. This  the  speaker  had  carried  out  by  giving  in 
the  morning,  before  breakfast,  150  gm.  of  grape  sugar, 
and  following  this  shortly  afterward  by  the  usual 
breakfast.  The  patient  remained  in  bed  during  the 
test.  If  the  urine  showed  no  glycosuria  the  dose  was 
gradually  increased  up  to  one  of  250  gm.,  and  if  this 
failed  to  produce  transient  glycosuria  it  was  fair  to 
assume  that  the  sugar-destroying  power  of  the  system 
was  within  the  normal  limits.  A  case  was  cited  to  show 
the  valuable  aid  such  a  test  was  capable  of  rendering. 
In  regard  to  treatment  the  speaker  thought  the  ten- 
dency had  been  to  go  to  extremes  in  the  matter  of 
diet.  If  w-ith  a  certain  diet  the  sugar  diminished  in 
quantity,  and  yet  the  patient's  general  condition  was 
not  correspondingly  benefited,  or  was  even  made 
worse,  this  was  a  distinct  indication  that  the  dietary 
was  wrong.  The  quantity  of  urea  excreted  should  be 
determined  from  time  to  time.  Another  useful  guide 
in  regulating  the  diet  was  testing  the  urine  for  diacetic 
acid.  He  had  been  unfortunate  enough  to  see  three 
cases  of  diabetic  coma  within  the  past  five  months,  in 
which  the  patients  had  used  a  certain  combination  of 
arsenic  freely  advertised  and  now  quite  popular  for 
such  cases.  These  patients  had  shown  a  temporary 
diminution  in  the  quantity  of  sugar  in  the  urine,  but 
the  remedy  had  caused  gastro-intestinal  disturbance, 
and  he  believed  it  was  dangerous.  This  remedy  had 
one  deceptive  feature:  it  was  apparently  well  toler- 
ated by  the  patient,  though  in  reality  it  was  insidiously 
mischievous. 


112 


MEDICAL    RFXORD. 


[July  21,  1900 


The  Relations  of  Surgery  to  Diabetes  Mellitus. 
— Dr.  Chakles  I'.  Gildersleeve  contributed  this  pa- 
per to  the  discussion.  He  said  that  the  text-books 
on  surgery  gave  very  little  information  on  this  sub- 
ject. Many  of  them,  especially  the  older  ones,  in- 
sisted that  wounds  in  diabetics  were  prone  to  become 
gangrenous,  but  this  assertion  was  disputed  in  some  of 
tlie  more  recent  works,  the  contention  being  that,  with 
antidiabetic  diet  and  thorough  antisepsis  and  asepsis, 
this  should  not  occur.  The  author  did  not  think  it 
could  be  denied  that  in  some  instances  gangrene  oc- 
curred in  diabetics  apparently  from  no  other  cause 
than  the  existence  of  the  diabetes.  Cases  were  cited 
in  support  of  this  view.  Orie  of  the  most  striking  of 
these  was  a  case  of  rapidly  fatal  gangrene  developing 
in  a  man  upon  whom  he  had  operated  for  phimosis. 
This  man  stated  that  he  had  been  diabetic  for  several 
years,  yet  his  health  had  been  such  as  to  allow  of  his 
going  around  as  usual.  When  the  flaps  sloughed  in 
these  cases  the  healing-process  would  be  found  to  go 
on  with  exceptional  rapidity  under  the  use  of  charcoal 
poultices.  In  the  management  of  these  cases  surgi- 
cally he  was  guided  by  the  following  rules:  (i)  He 
would  not  operate  upon  any  patient  suffering  from 
diabetes  without  explaining  the  possible  dangers;  (2) 
he  would  not  operate  for  benign  tumors  or  other  sim- 
ple conditions  unless  there  was  some  special  reason 
for  so  doing;  (3)  for  the  rapidly  spreading  gangrene 
occurring  in  these  cases,  and  which  was  bound  to 
cause  death  if  left  alone,  he  believed  in  prompt  and 
high  amputation. 

Ocular  Manifestations  in  Diabetes  Mellitus — 
Dr.  L.  a.  W.  Alle.man  took  up  this  part  of  the  sub- 
ject. He  said  that  ocular  lesions  were  more  frequent- 
ly found  in  the  chronic  cases  with  mild  general  dis- 
turbance. Paralysis  of  the  extra-ocular  muscles  in 
both  mild  and  severe  cases  of  diabetes,  and  in  persons 
unaware  of  the  existence  of  any  serious  disorder,  were 
not  uncommon.  Any  of  the  extra-ocular  muscles 
might  be  involved.  Paralysis  of  accommodation  was 
perhaps  the  most  common  of  the  ocular  manifestations 
of  diabetes,  and  occurred  quite  early.  The  paralysis 
was  often  complete,  so  that  the  patients  would  observe 
perhaps  only  increased  diTiculty  in  reading.  Some 
authors  claimed  that  there  was  a  true  diabetic  cataract, 
while  others  contended  that  the  changes  in  the  lens 
were  no  more  common  in  diabetics  than  in  others  of 
the  same  age.  But  the  unexplained  occurrence  of  ju 
venile  cataract  required  an  examination  of  the  urine 
in  addition  to  the  physical  examination.  Hirschberg 
believed  that  there  was  a  true,  distinctive  diabetic 
retinitis,  and  the  speaker  was  disposed  to  agree  with 
him,  though  this  view  was  not  accepted  by  many.  A 
diabetic  retinitis  might  take  on  a  renal  character 
when  disease  of  the  kidney  developed  in  a  diabetic. 
Retinal  hemorrhages,  with  or  without  other  retinal 
changes,  were  always  suggestive  of  diabetes,  particu- 
larly the  small,  punctate  hemorrhages.  They  were 
always  associated  with  conjunctival  hemorrhages. 
Retinal  changes  were  always  present  in  a  case  of  dia- 
betes which  had  existed  more  than  ten  or  twelve 
years.  Wiiile  this  was  always  an  unfavorable  symp- 
tom, it  did  not  necessarily  indicate  an  immediate  termi- 
tion  of  the  disease.  Iritis  of  a  severe  type  was  often 
met  with  in  diabetes. 

Cutaneous  Manifestations  in  Diabetes  Mellitus. 
—  Dr.  Samcei,  Sherwei.l  discussed  this  topic.  He 
enumerated  the  more  important  cutaneous  manifesta- 
tions as  follows:  (i)  xeroderma,  a  condition  of  dry 
skin  which  was  almost  always  present;  (2)  pruritus 
without  any  noteworthy  subjective  lesions,  the  genital 
region  suffering  most;  (3)  eczema,  partly  neurotic, 
and  at  other  times  catarrhal,  having  its  chief  scats  on 
the  genital  and  tiexor  surfaces  of  the  Ijody:  (4)  furun- 
culosis,  often  general   in  cliaracter,  but  sometimes  re- 


gional; (5)  conditions  of  an  erysipelatous  nature,  and 
gangrene — usually  late  symptoms;  (6)  xanthoma  dia- 
beticorum, accompanied  by  immense  numbers  of  new 
growths;  (7)  the  recently  recognized  disease  named 
blastomycetic  dermatitis;  (8)  the  disease  termed 
dermatitis  herpetiformis,  or  Duhring's  disease.  Dr. 
.Sherwell  said  that  the  only  cases  of  erysipelas  of  the 
upper  air  passages  that  he  had  met  with  had  been  in 
diabetics.  Some  striking  photographs  of  a  case  of 
xanthoma  diabeticorum  were  exhibited.  In  this  case 
the  improvement  in  the  cut.meous  lesions  had  been 
most  remarkable  after  dietetic  treatment  continued  for 
only  a  fortnight. 

Manifestations  of  Diabetes  Mellitus  in  the  Up- 
per Air  Passages. — Dr.  Jonathan  Wright  spoke  on 
this  subject.  He  referred  to  a  case  of  glycosuria  de- 
veloping suddenly  after  a  third  nasal  operation  on  a 
boy  aged  fifteen  years.  This  glycosuria  had  disap)- 
peared  under  a  few  months  of  hygienic  and  dietetic 
treatment.  Extended  reference  was  then  made  to  Dr. 
W.  Freudenthal's  recently  published  five  cases  of 
ulceration  of  the  upper  air  passages  in  diabetics,  and 
the  opinion  was  hazarded  that  Dr.  Freudenthal  had 
not  positively  excluded  tuberculosis  and  syphilis. 
There  was  still  another  class  of  throat  cases  in  which 
it  had  been  claimed  diabetes  was  more  than  ordinarily 
frequent,  />.,  in  cases  of  laryngeal  vertigo.  He  had 
examined  the  reports  of  these  twenty  or  thirty  cases, 
and  had  found  diabetes  present  in  only  three  of  them. 
As  these  three  were  all  plethoric  persons  over  forty 
years  of  age,  it  did  not  seem  to  him  that  it  had  been 
proved  that  there  was  any  larger  proportion  of  cases 
of  diabetes  among  them  than  among  other  individuals. 

Dr.  Nelson  L.  North  said  that  he  believed  that 
some  emotion  or  serious  nervous  disturbance  was  al- 
most always  the  exciting  cause  of  diabetes,  and  that 
the  disease  was  essentially  a  failure  of  the  digestive 
and  assimilative  processes  brought  about  by  this  pro- 
fund  nervous  influence.  He  had  been  impressed  with 
the  part  played  by  heredity. 

Dr.  Heinrich  Stern,  in  closing  the  discussion, 
said  that  of  the  two  hundred  and  six  deaths  from 
diabetes  reported  in  the  boroughs  of  Manhattan  and 
the  Bronx  in  1899,  fifty-eight  had  occurred  in  coma. 
Of  fifty  cases  of  diabetic  coma  that  he  had  studied, 
fully  fifty  per  cent,  had  shown  no  excess  of  acetone,  or 
the  presence  of  aceto-acetic  acid.  To  his  mind,  dia- 
betes mellitus  was  only  one  stage  of  a  progressive  dis- 
ease characterized  by  the  elimination  of  glucose  and 
urea.  He  recognized  in  all  three  stages,  viz.,  (i)  a 
preglycosuric  stage;  (2)  a  glycosuric  stage — diabetes 
mellitus,  and  (3)  a  postglycosuric  stage,  or  a  stage  of 
toxaemia  arising  from  tlie  action  of  ethyl-diacetic  acid. 


AMERICAN  PROCTOLOGIC  SOCIETY. 

Second  AiDuial  Mcttijig,  Held  in    Waslrngtoii,  D.    C, 
A/ay  2  and  J,  igoo. 

First  Day —  Wednesday,  May  2d. 

President's  Address. — The  president.  Dr.  Joseph  M. 
Mathews,  of  Louisville,  said  that  the  bane  of  special- 
i,-m  of  to-day  was  the  "blooming  out"  of  a  class  of 
men  to  practise  specialties,  who  had  no  practical 
knowledge  of  them.  Such  action  should  receive 
the  strongest  censure  from  the  entire  profession.  He 
took  it  that  the  object  of  this  assemblage  was 
mainly  to  encourage  the  better  understanding  of  the 
diseases  of  the  rectimi,  by  the  reading  of  papers  and 
the  free  discussion  of  the  same.  If  permitted,  he  would 
suggest  that  the  membership  be  made  up  of  those  who 
desire  a  better  knowledge  of  proctological  subjects, 
whether   general   or   special    surgeons,  gyn.-ECologists 


July  21,  1900] 


MEDICAL   RECORD. 


"3 


or  obstetricians.  Indeed,  it  was  by  the  diffusion  of 
such  knowledge  in  a  general  way  that  societies 
were  of  profit.  Considered  from  a  special  stand- 
point, it  might  be  well  to  try  to  demonstrate  that  it 
was  just  as  difficult  to  excise  a  rectum  as  it  was  to  re- 
move an  ovary;  that  it  required  as  much  surgical 
knowledge  to  anastomose  the  colon  around  a  stricture 
as  it  did  to  sew  up  a  lacerated  perineum;  to  do  a  col- 
opexia  as  to  remove  a  fibroid  tumor;  or  to  do  a  colos- 
tomy properly  as  to  do  a  trachelorrhaphy. 

Report  of  a  Case  of  Excision  of  the  Rectum 
through  the  Vagina.  —  Dk.  S.  T.  Earle,  Jr.,  of  Haiti- 
more,  reported  this  case,  which  was  one  of  adeno-car- 
cinoma;  there  were  about  five  inches  of  the  rectum  re- 
moved. The  centrifugal  end  of  the  rectum  was  drawn 
down,  and  stitched  to  the  anal  margin;  the  vaginal 
and  perineal  incision  was  closed,  and  united  by  first 
intention.  The  results  were  most  satisfactory,  and 
the  patient  had  fair  control  of  her  evacuations. 

Unique  Cases  of  Rectal  Surgery. — Dr.  Samuel  G. 
Gant,  of  New  York,  reported  these  cases. 

Case  I. — Congenital  absence  of  the  coccyx  and  lower 
sacral  vertebra.  This  patient  was  referred  to  Dr.  Gant 
to  be  treated  for  anal  fissure.  He  was  thirty  years  old 
and  a  very  strong  man.  Kxamination  revealed  the 
absence  of  the  coccyx  and  lower  sacral  vertebra,  which 
made  the  broad  end  of  the  bone  stand  out  and  be  easily 
noticeable  tiirough  the  skin  because  of  the  fact  that 
the  tissues  below  it  were  drooped,  making  a  concavity 
large  enough  to  hold  a  goose-egg.  He  had  been  that 
way  since  birth,  but  had  suffered  no  inconvenience 
from  it,  having  perfect  control  over  his  bladder  and 
anus.  The  fissure  was  relieved  by  divulsing  the 
sphincter,  incising  the  rent,  and  stimulating  it  there- 
after with  a  mild  silver  solution. 

Case  H. — Stricture  of  the  rectum  in  a  little  girl 
eleven  months  old,  caused  by  swallowing  an  open  safe- 
ty-pin. This  case  was  of  unusual  interest  because  of 
the  child's  age.  At  the  time  the  pin  was  swallowed 
it  caused  considerable  pain  and  suffocation.  It  was 
passed  embedded  in  a  mass  of  fecal  matter  just  one 
month  later.  Several  days  preceding  this  she  suffered 
great  agony  and  passed  frequent  and  bloody  stools. 
From  this  time  on  the  child  continued  to  have  bowel 
trouble,  suffering  from  constipation,  occasional  diar- 
rhoea, and  the  discharge  of  pus,  blood,  and  mucus  with 
the  stools.  Digital  examination  revealed  a  tight  stric- 
ture three  inches  above  the  anus  which  appeared  to  be 
the  result  of  inflammatory  action  and  adhesions.  It 
was  easily  dilated  W'itii  first  one  and  then  two  fingers. 
The  ulceration  was  curetted,  the  rectum  irrigated,  and 
the  patient  sent  home.  After-treatment  consisted  of 
stimulating  applications  and  occasional  divulsion  with 
the  finger.  This  patient  was  discharged  cured  in  eight 
weeks. 

Case  III.  —  Closure  of  artificial  anus  of  more  than 
three  years'  duration.  The  left  inguinal  colostomy 
was  made  in  the  case  of  a  young  woman  eighteen  years 
old,  suffering  from  tuberculous  ulceration  which  would 
not  succumb  to  less  radical  means.  As  a  result  of 
treatment,  local  and  general,  she  fully  recovered  in  a 
year,  having  in  the  mean  time  supported  herself  as  a 
waitress.  She  desired  the  opening  closed,  but  she  was 
advised  to  wait.  Three  years  from  the  time  the  opera- 
tion was  made,  she  became  engaged  to  be  married  and 
insisted  upon  the  closing  of  the  opening  in  the  side. 
Thorough  examination  demonstrated  that  the  ulceration 
had  healed,  and  further  that  there  was  no  constriction 
of  the  bowel.  A  No.  10  VVales  bougie  passed  through 
the  anus  and  out  at  the  anal  aperture  in  the  groin. 
The  opening  was  included  in  two  elliptical  incisions 
which  were  carried  inward  until  the  bowel  was  sep- 
arated from  the  parietes.  Because  of  the  spur  both 
legs  of  the  original  loop  were  firmly  adherent  and  re- 
quired resection.     A  purse-string  suture  was  thrown 


around  each,  ?.  Murphy  button  inserted  and  locked, 
and  the  gut  dropped  into  the  abdominal  cavity.  Peri- 
toneum, muscles,  and  skin  were  united  with  catgut. 
Primary  union  obtained;  the  button  passed  on  the 
tenth  day,  and  the  patient  left  the  hospital  at  the  end 
of  three  weeks.  This  patient  made  a  complete  recov- 
ery. She  was  under  observation  for  two  years  after 
the  closure,  and  her  bowels  moved  naturally  during 
this  time. 

Submucous  Ligature  for  Hemorrhoids. — Dr.  B. 
Merrill  Ricketts,  of  Cincinnati,  read  this  paper. 
He  said  that  in  performing  this  operation  a  large 
needle  was  made  to  describe  more  than  a  semi- 
circle, carrying  a  moderate-sized  kangaroo  tendon 
submucously  around  the  varices  which  occupied  the 
rectum  as  much  as  three-  inches  above  the  muco-cuta- 
neous  border.  The  three  hemorrhoidal  vessels,  arte- 
rial and  venous,  entered  the  rectum  and  perforated  the 
rectal  muscular  tissue  about  three  and  a  half  inches 
above  the  sphincter  ani.  Great  difficulty  had  been 
experienced  in  passing  the  needle  to  complete  the  en- 
tire circle  submucously.  To  overcome  this  the  needle 
was  brought  out  at  a  point  corresponding  to  one-half 
of  the  circle,  again  to  enter  at  its  point  of  exit,  and 
then  made  to  pass  out  at  the  point  of  primary  entrance. 
In  cases  of  but  one  or  two  hemorrhoids  one  ligature 
of  this  character  was  sufficient.  If  there  were  many 
hemorrhoids  occupying  the  entire  circumference  of  the 
rectum  as  many  of  these  submucous  ligatures  might 
be  applied  as  necessary.  Then,  too,  it  was  not  neces- 
sary to  incorporate  all  the  varices  within  the  ligature, 
because  many  of  those  which  were  not  so  constricted 
by  the  ligature  would  become  so  as  a  result  of  the 
trophic  changes  which  ensued.  Sometimes  it  would 
be  found  most  convenient  to  introduce  all  the  ligatures 
before  making  them  taut.  By  doing  this  the  introduc- 
tion of  the  needle  was  made  with  greater  ease.  Before 
this  work  was  attempted  the  sphincter  ani  should  be 
divulsed  to  tlie  fullest  degree  with  the  finger.  Divul- 
sion once  being  completed,  the  hemorrhoids  would  at 
once  protrude,  and  were  most  easily  encircled  by  the 
ligature.  As  soon  as  the  ligatures  were  made  taut  the 
hemorrhoids  were  inverted  into  the  rectum.  Some- 
times it  was  desirable  to  puncture  some  of  the  larger 
hemorrhoids  that  the  distention  might  not  be  so  great, 
and  for  the  purpose  of  lessening  the  amount  of  hyper 
trophied  tissue  within  the  rectum.  After  a  few  weeks 
atrophy  would  have  taken  place  to  such  a  degree  as  to 
allow  the  sphincter  ani  to  resume  its  normal  tonicity, 
and  to  have  completely  destroyed  all  the  objectionable 
varices  wiiich  formerly  existed.  The  advantages  of 
this  operation  were,  (i )  the  impossibility  of  secondary 
hemorrhage;  (2)  there  was  no  tissue  destroyed  or  sac- 
rificed; (3)  the  loss  of  time  was  but  little,  if  at  all, 
greater  than  when  the  growths  were  removed  by  the 
clamp  and  cautery;  (4)  thus  far  there  had  been  no 
infection;  (5)  there  had  been  no  fistula,  abscess,  or 
fissures  resulting  therefrom;  (6)  the  pain  was  no 
greater,  and  perhaps  less,  than  with  other  methods  of 
ligaturing;    (7)  there  was  absolutely  no  stenosis. 

Temporary  Artificial  Anus.— Dr.  James  P.  Tut- 
TLE,  of  New  York,  read  this  paper.  He  said  that  the 
indications  for  temporary  artificial  anus  were:  (i) 
Obstruction  with  removable  cause;  (2)  in  cases  of  ex- 
cision of  the  rectum  in  which  the  sphincter  was  in- 
volved;  (3)  in   intractable   ulceration  of  the  rectum; 

(4)  in  stricture  of  the  rectum  with  large  area  of  ulcera- 
tion  which  did   not  readily  yield   to  local  treatment; 

(5)  in  neoplasms  in  the  sigmoid  and  colon  that  could 
not  be  found  through  the  rectum  ;  (6)  in  malformations 
and  imperforate  rectums,  in  which  the  gut  could  not 
be  easily  found  in  the  perineum;  (7)  in  chronic  mem- 
branous colitis;  (8)  in  certain  forms  of  recto-vesical, 
recto-vaginal,  and  recto-urethral  fistuls.  With  these 
numerous  and  clear    indications,    the    operation    was 


114 


MEDICAL    RECORD. 


[July 


21,    1900 


comparatively  seldom  recommended  because  of  preju- 
dice against  it,  and  the  false  impression  that  once  one 
had  an  artificial  anus  he  must  always  have  it.  Doc- 
tors hesitated  to  advise  it,  because  they  knew  that  by 
the  older  methods  closure  was  uncertain,  and  more 
dangerous  than  the  operation  or  the  disease  for  which 
it  was  made.  The  operation  advised  was  a  modifica- 
tion of  the  Rectus-Maydl  method.  It  was  quick,  sim- 
ple, and  effectual.  The  opening  was  a  T-shaped  in- 
cision so  made  that  the  transverse  flap  fell  into  the 
distal,  and  effectually  closed  it,  while  the  two  triangu- 
lar ones  rolled  outward  and  curled  up  like  a  dry  leaf, 
thus  leaving  free  exit  from  the  proximal  leg  of  the 
convolution.  No  part  of  the  gut  was  removed  or  de- 
stroved.  The  closure  was  made  by  simply  unrolling 
and  suturing  these  Haps  back  into  position,  first  with 
sutures  through  the  mucous  membrane  and  then  with 
Lenibert  sutures  of  chromicized  catgut.  After  the  gut 
was  thus  closed,  the  partial  parietal  peritoneum  was 
dissected  away  for  an  inch  or  more  all  around  the  ab- 
dominal incision,  so  that  the  gut  would  drop  back  into 
the  abdomen,  but  not  into  the  peritoneal  cavity,  thus 
eradicating  the  spur.  The  muscular  fascia  and  skin 
were  then  sutured  over  the  gut  with  silkworm  gut. 

Chronic  Interstitial  Proctitis  as  a  Factor  in  Ob- 
stinate Constipation  and  its  Radical  Treatment.— 
Dr.  ].  Ravvson  Pennington,  of  Chicago,  demonstrated 
that  the  sigmoid  flexure  in  the  distended  state  fre- 
quently extended  into  and  occupied  the  right  iliac 
fossa;  he  also  gave  conclusive  evidence  of  the  exist- 
ence of  the  rectal  valve  and  its  structure.  He  claimed 
that  deformity  of  the  rectal  valve  and  hypertrophy  of 
its  muscular  layers  were  the  two  principal  primitive 
causes  of  obstinate  constipation.  He  exhibited  his 
automatic  valve  clip  for  dividing  these  structures  when 
pathological. 

Demonstration  of  the  Rectal  Valves  in  the  Liv- 
ing Subject. — Dr.  Thomas  Charles  Martin,  of 
Cleveland,  Ohio,  showed  his  method  of  proctoscopy. 
VVithout  the  use  of  an  anesthetic,  by  means  of  his 
chair  the  subject  was  put  into  a  posture  equivalent  to 
the  knee-chest  posture,  the  rectum  inflated,  and  its  en- 
tire length  exposed  to  direct  view.  The  rectal  valves 
were  rendered  conspicuously  visible  and  palpable  to 
the  members  of  the  society,  and  the  fact  of  their  exist- 
ence was  generally  admitted. 


Second  Day — Thursday,  May  jd. 

The  New  Radical  Operation  for  Valvular  Obsti- 
pation.— This  was  described  by  Dr.  Thomas  Charles 
Martin,  of  Cleveland.  He  said  that  a  normal  valve 
might  be  effaced  under  the  pressure  of  the  test-hook. 
A  valve  situated  on  the  fixed  posterior  wall  of  the 
rectum  was  much  more  obstructive  than  was  one  situ- 
ated on  the  anterior  wall,  for  the  reason  that  the  de- 
scent and  backward  excursion  of  the  anterior  rectal 
wall  placed  the  faeces  more  securely  in  the  pocket 
afforded  by  a  posterior  valve.  A  valve  situated  on 
the  anterior  wall,  if  of  the  same  condition  and  dimen- 
sion as  one  situated  on  the  posterior  wall,  was  less 
obstructive  to  defecation,  for  the  reason  that  the  back- 
ward and  downward  excursion  of  the  rectal  wall  threw 
the  faeces  out  of  the  valve  pocket  and  over  its  free 
border.  If  the  number  of  the  valves  was  greater 
than  the  normal  three,  it  could  be  readily  understood 
that  such  an  addition  increased  the  obstruction.  For 
instance,  four  or  five  relatively  shallow  valves  placed 
close  together  were  more  obstructive  than  were  two 
somewhat  deeper  valves  if  these  two  valves  were 
placed  at  some  distance  from  one  another.  Anatomi- 
cal coarctation  or  physiological  juxtaposition  of  the 
valves  might  contribute  to  the  establishment  of  ob- 
stipation whether  the  valves  were  diseased  or  not.  If 
two  valves  were  so  closely  situated  that  their  borders 


were  seen  to  overlap,  or  if  it  was  seen  that  on  the 
patient's  bearing  down  two  valves  then  overlapped,  it 
might  be  assumed  that  these  valves  constituted  an  ob- 
struction to  defecation.  A  valve  situated  at  a  direct 
right  angle  to  the  axis  of  the  rectum  was  more  obstruc- 
tive than  one  that  was  obliquely  situated.  However, 
an  oblique  valve  might  contribute  to  the  establishment 
of  an  obstruction  in  a  transverse  valve  immediately 
below  it,  for  the  reason  that  the  oblique  valve  might 
deflect  the  fecal  column  directly  into  the  pocket  formed 
by  the  next  lower  and  transversely  situated  valve.  The 
resistance  which  any  given  valve  afforded  to  the  test- 
hook,  the  propinquity  of  other  valves  to  a  given  valve, 
and  the  direction  of  the  valve  next  above  a  given 
valve,  together  with  the  number  of  valves  in  the  rec- 
tum and  the  precise  situation  and  direction  of  each 
valve,  were  all  features  which  should  be  studied  as 
possible  component  factors  which  contributed  to  the 
obstipation.  Hypertrophy  of  the  rectal  valve  due  to  a 
proctitis,  local  or  general,  was  characterized  by  evident 
thickening  of  the  free  border  of  the  valve.  Fibrosis 
of  the  rectal  valve  was  not  characterized  by  an  in- 
creased size  of  the  valve,  though  its  resistance  to  the 
hook  might  be  as  great  as  in  the  case  of  the  hyper- 
trophied  valve.  There  was  always  noticeable  in  cases 
of  valvular  obstipation  a  very  conspicuous  redness  of 
the  mucous  membrane,  which  began  at  the  obstructing 
valve  and  extended  downward  toward  the  anus.  The 
rectal  mucosa  above  the  obstructing  valve  was  usually 
of  pale  complexion  except  in  those  cases  in  which 
there  was  invagination  of  the  upper  gut.  Dr.  Martin 
then  outlined  his  operation  for  division  of  the  valve, 
and  detailed  the  precautionary  measures  to  be  em- 
ploved  to  insure  safety  and  secure  success. 

Mooted  Questions  in  Proctology. — Dr.  A.  B. 
Cooke,  of  Nashville,  called  attention  to  a  number  of 
the  more  prominent  points  of  disagreement  among 
proctologists.  These  were:  (i)  Anatomy:  the  ex- 
istence of  the  rectal  valves  was  not  yet  generally  ad- 
mitted, when  in  truth  they  constituted  the  most  con- 
spicuous features  of  the  normal  rectum.  (2)  Physiol- 
ogy: many  points  in  this  connection  were  yet  to  be 
worked  out.  The  mechanism  of  defecation  was  a  much- 
disputed  subject.  (3)  Pruritus  ani:  was  this  a  dis- 
ease or  merely  a  symptom?  The  etymology  of  the 
term  itself  offered  the  readiest  solution  of  tlie  problem. 
Pruritus  meant  simply  itching,  and  itching  could  not 
be  regarded  as  other  than  a  symptom.  Though  some- 
times difficult  to  locate,  the  lesion  which  gave  rise  to 
it  was  practically  always  a  macroscopic  one.  In 
searching  for  it  the  reflexes  were  to  be  borne  in  mind. 
(4)  Simple  ulceration:  one  prominent  author  (Ma- 
thews) stated  that  this  disease  located  above  the 
sphincter  ani  muscle  was  a  very  uncommon  one.  Dr. 
Cooke's  experience  had  been  the  very  opposite.  The 
difference  of  opinion  is  probably  due  to  different  con- 
ceptions of  the  meaning  of  the  word;  properly  consid- 
ered, ulceration  and  ulcer  were  synonymous  terms,  and 
the  rectal  ampulla  was  a  frequent  site  of  such  disease 
process.  (5)  Penign  stricture:  the  author  called  at- 
tention to  tiie  different  views  held  as  to  the  frequency 
of  syphilis  as  a  causative  factor.  Sixty  per  cent,  is 
far  too  high  an  estimate.  The  rectal  valves  have 
much  to  do  in  the  etiology  of  this  disease.  (6)  Can- 
cer: discussion  of  this  disease  was  limited  to  the  ques- 
tion of  the  justifiability  of  colostomy  as  a  means  of 
prolonging  life  and  giving  comfort.  As  compared 
with  the  hypodermic  syringe  the  author  deemed  it 
greatly  to  be  preferred,  and  when  total  extirpation  was 
impossible  he  strongly  advised  resort  to  this  procedure. 

Pruritus  Ani,  with  Especial  Reference  to  its 
Local  Treatment Dr.  Lewis  H.  Adler,  Jr.,  of  Phil- 
adelphia, read  this  paper.  He  said  that  it  was  im- 
portant that  the  patient  had  a  daily  evacuation  of 
the  bowels,  and,   if   necessary,  medicines  were  to  be 


July  2  1,  1900] 


MEDICAL    RECORD. 


115 


used  for  this  purpose.  In  all  cases,  more  or  less  vari- 
cosity of  the  hemorrhoidal  vessels  existed;  at  all 
events,  he  was  in  the  habit  of  seeing  the  patient  daily 
for  a  time,  and  he  employed  an  injection  into  the  cavity 
of  the  rectum  of  one,  or  two,  or  two  and  a  half  drachms 
of  the  following  prescription:  I^  Fluid  extract  of 
hamamelis,  fl  3  '•;  HiJid  extract  of  ergot,  fluid  extract 
of  hydrastis,  compound  tincture  of  benzoin,  aa  fl  3  ii.; 
carbolized  olive  or  linseed  oil,  tl  3  i.  (carbolic  acid, 
five  per  cent.).  M.  S.  .Shake  well  before  using.  The 
patient  was  advised,  prior  to  using  this  injection,  that  a 
desire  to  have  the  bowels  evacuated  would  occur  as  a 
result  of  its  employment,  but  that  if  he  would  remain 
quiet  upon  the  examination  table,  the  sensation  would 
quickly  pass  away.  The  entire  surface  around  the 
anus  for  several  inches  outward  was  to  be  painted  with 
a  strong  solution  of  nitrate  of  silver.  If  any  break  in 
the  continuity  of  the  skin  existed  as  a  result  of  previous 
scratching,  a  little  of  a  two-per-cent.  cocaine  solution 
applied  to  the  abrasion  would  prevent  the  suffering 
incident  to  the  use  of  the  silver  salt.  In  his  experi- 
ence the  use  of  a  strong  silver  solution  was  not  nearly 
so  painful,  under  the  circumstances  surrounding  its 
use  in  the  class  of  cases  under  consideration,  as  the 
weaker  solutions.  So  soon  as  the  silver  had  dried  and 
from  the  first  visit  and  thereafter,  the  officinal  citrine 
ointment  or  unguentum  hydrargyri  nitratis  was  smeared 
over  the  anus  and  the  cutaneous  surface  of  the  parts 
for  a  distance  of  about  two  inches  around  the  orifice. 
The  ointment  was  used  in  its  full  strength.  Over  the 
salve  was  placed  a  wad  of  absorbent  cotton,  the  quan- 
tity of  cotton  varying  with  the  patient's  wishes  and 
comfort.  The  dressing  was  kept  in  place  with  a 
Tbandage.  If  the  itching  should  annoy  the  patient 
during  the  night  he  was  directed  to  bathe  the  anus 
with  hot  water,  as  hot  as  could  be  borne  with  comfort, 
but  under  no  circumstances  was  he  to  rub  the  parts. 
He  was  also  told  that  the  application  of  the  hot  w-ater 
would  momentarily  increase  the  itching,  but  that  he 
was  not  to  scratch.  After  he  had  used  the  water  he 
was  directed  to  use  either  a  solution  of  black  wash 
(lotio  nigra)  or,  what  was  better  in  some  cases,  calo- 
mel ointment,  either  of  wliich  was  to  be  applied  locally 
to  the  affected  parts. 

Fistula. — Dr.  George  B.  Evans,  of  Dayton,  Ohio, 
read  this  paper.  He  said  that  the  inefficacy  of  all  reme- 
dial measures  except  the  knife  for  curing  fistula  still 
remained  unquestioned,  unless  by  inaccurate  observers. 
A  fistula  which  was  not  due  to  ulceration  and  perfora- 
tion of  the  rectal  wall  from  within  was  the  result  of  a 
previous  abscess,  due  to  an  inflammation,  and  that  tiie 
result  of  traumatism.  He  had  sometimes  found  fistula 
due  to  caries  of  the  lower  portion  of  the  sacrum  and 
coccyx.  He  believed  it  to  be  a  safe  rule  to  operate  on 
phthisical  patients  as  upon  others.  During  the  past 
ten  years  there  had  been  over  six  hundred  phthisical 
patients  admitted  to  St.  Elizabeth  Hospital,  Dayton, 
Ohio;  during  the  past  six  years  he  had  operated  upon 
one  hundred  and  ninety-eight  cases  of  various  rectal 
diseases  in  the  charity  wards,  of  which  forty-two  had 
been  for  fistula;  seven  of  the  forty-two  had  been  with- 
out doubt  tuberculous.  Two  of  the  seven  patients 
died  after  several  months  of  comparative  comfort. 


Silver  Leaf  has  been  used  in  the  Johns  Hopkins  and 
Bellevue  hospitals  as  a  dressing  for  burns,  with  satis- 
factory results. 

Strangulated  Hernia The  parts  about  the  tumor 

should  be  covered  with  vaseline,  the  patient  placed 
upon  the  back,  with  the  pelvis  elevated  and  thighs 
flexed,  and  ether  be  poured  or  sprayed  upon  the  con- 
stricted neck.  This  depletes  the  tissues  and  permits 
of  reduction,  previously  impossible. 


NEW  YORK  PATHOLOGICAL  SOCIETY. 

Stated  Meetirg,  May  g,  igoo. 

Eugene  Hodenpvi,,  M.D.,  President. 

A  Case  of  Tubular  Cast  of  the  Bronchus. — Dr. 
Theodore  C.  Jankwav  presented  this  specimen.  It 
had  been  coughed  up  by  a  middle-aged  and  very  stout 
gentleman  who  had  been  sick  for  about  ten  days  wuth 
what  had  been  supposed  to  be  the  grippe.  He  had  been 
apparently  convalescent,  when  he  had  been  suddenly 
seized  with  dyspncea  and  increased  fever.  After  some 
hours  he  had  expectorated  this  cast,  which  was  per- 
fectly tubular  and  of  about  the  size  of  the  main  bron- 
chus. At  its  lower  end  it  showed  the  beginning  bifur- 
cation into  the  smaller  bronchi.  The  specimen  not 
having  been  seen  until  it  had  been  immersed  for  some 
time  in  alcohol,  no  cultures  had  been  made.  The 
man  died  a  few  days  later,  having  exhibited  signs  in- 
dicative only  of  bronchitis  with  marked  dyspna-a  and 
cyanosis.  On  section,  the  cast  showed  a  fibrinous  ex- 
udate with  numerous  cell  nuclei.  Scattered  through 
it  were  clumps  of  round-ended  bacilli,  which  in  their 
mor])hology  and  staining  exactly  resembled  diphtheria 
bacilli.  The  speaker  said  that  two  cases  had  been 
reported  before  the  London  Pathological  Society.  One 
of  these  had  been  reported  by  Dr.  Pye  Smith  in  1880. 
In  this  instance  a  woman  had  expectorated  a  cast  of 
the  trachea  and  primary  bronchi.  At  the  autopsy  the 
trachea  and  bronchi  were  found  lined  with  tubular 
casts.  Rod-like  bacteria  were  present.  The  other 
case  had  been  reported  by  Dr.  Murchison.  A  promi- 
nent laryngologist  had  seen  the  case  just  reported,  so 
it  seemed  safe  to  assume  that  no  evidence  of  diphthe- 
ria had  been  visible  during  life,  though  it  was  appar- 
ently a  case  of  diphtheria  of  the  bronchi. 

Dissecting  Aneurism  of  the  Aorta. — Dr.  H.  S. 
Carter  presented  this  specimen,  which  had  been 
taken  from  a  man  aged  eighty  years,  who  had  died 
some  months  ago  in  Bellevue  Hospital  from  chronic 
interstitial  nephritis.  At  the  autopsy  the  condition 
in  the  aorta  had  been  discovered  accidentally,  and  for 
this  reason  the  specimen  was  not  in  perfect  condition. 
The  dilatation  of  the  aorta  started  from  the  sinus  of 
V^alsalva.  The  dissecting  aneurism  began  at  the  junc- 
tion of  the  descending  part  of  the  arch  and  thoracic 
aorta  and  continued  through  into  both  common  iliacs. 
The  left  suprarenal  was  given  off  directly  from  the 
aneurismal  sac,  as  was  also  the  inferior  mesenteric 
artery.  Dr.  Carter  said  that  up  to  1856  only  eight 
cases  had  been  reported;  up  to  1895  there  had  been 
seventeen,  and  by  1897  two  hundred  cases  had  been 
collected,  including  ail  dissecting  aneurisms,  but  the 
greater  part  of  these  had  been  of  the  arch  of  the  aorta. 
There  was  only  one  case  on  record  in  which  the  diag- 
nosis had  been  made  during  life,  and  this  had  been 
confirmed  by  autopsy.  It  should  be  noted  that  the 
history  of  these  cases  had  been  pretty  uniform — a  his- 
tory of  sudden  pain  in  the  chest  and  back  and  shoot- 
ing into  the  abdomen,  but  not  radiating  down  the  arm 
as  in  angina  pectoris.  There  was  also  a  feeling  of 
something  having  given  way.  If  the  patient  did  not 
die  immediately,  there  were  oedema  and  other  evidences 
of  disturbed  circulation. 

Dr.  James  Ewing  said  that  he  had  studied  the  spec- 
imen a  good  deal.  At  first  it  had  appeared  to  be  a 
case  of  true  double  aorta,  largely  because  of  the  large 
vessels  given  off  unquestionably  from  the  aneurism. 
Though  not  familiar  with  the  literature  it  seemed 
to  him  rather  difficult  to  explain  the  separation  of  a 
trunk  of  the  size  of  the  inferior  mesenteric  from  the 
aorta,  and  the  subsequent  canalization  that  had  un- 
doubtedly taken  place  in  this  case,  if  it  was  one  of 
dissecting  aneurism.  .A  strong  point  in  favor  of  dis- 
secting aneurism  was  the  presence  of  three  openings 


ii6 


MEDICAL    RECORD. 


[July  2  1,  1900 


at  the  top  of  the  sac.  He  asked  if  Dr.  Carter  had 
seen  in  his  reading  any  description  of  the  manner  in 
which  these  large  vessels  were  given  off. 

Dr.  Carter  replied  that  in  looking  over  the  litera- 
ture of  the  subject  he  had  found  a  number  of  similar 
specimens  reported,  particularly  descriptions  of  the 
inferior  mesenteric  given  off  from  the  aneurismal  sac. 

A  Case  of  Non-Traumatic  Rupture  of  the  Heart. 
— Dr.  N.  B.  Potter  presented  this  specimen,  which 
had  been  removed  from  a  large,  stout  woman,  admitted 
to  the  City  Hospital  on  February  28th.  According 
to  the  history  she  had  suffered  for  five  or  six  years 
from  bronchitis  and  asthma.  Some  time  in  last  No- 
vember a  bronchitis  had  become  more  than  usually 
troublesome,  and  she  had  begun  to  complain  of  pain 
in  the  left  side  and  back,  radiating  to  the  shoulder  and 
down  the  arm.  When  first  seen  by  him  on  March  1st, 
she  had  been  pale  and  cyanosed,  and  there  had  been 
much  cough  and  expectoration.  The  physical  exami- 
nation had  revealed  nothing  further  than  a  diffuse 
bronchitis.  The  heart  sounds  were  rather  feeble.  In 
spite  of  stimulation  she  became  gradually  more  cya- 
nosed, and  finally  died,  about  two  weeks  after  admis- 
sion. At  the  autopsy  the  pericardium  had  been  found 
fairly  full  of  blood,  much  of  which  was  old  and  clot- 
ted. It  was  estimated  that  this  represented  about 
twenty  ounces.  A  rupture  was  found  in  the  left  ven- 
tricle, a  short  distance  from  the  interventricular  sep- 
tum. On  the  ventricular  side  was  a  large  thrombus 
attached  at  the  superior  extremity.  It  formed  a  sort 
of  valve  and  occluded  the  opening.  .Apparently  the 
rupture  had  taken  place  some  days  before  death.  The 
wall  of  the  ventricle  was  remarkably  thin. 

Dr.  G.  Langmann  thought  it  was  not  at  all  uncom- 
mon for  persons  to  live  for  days,  or  even  weeks,  after 
rupture  of  the  heart.  He  referred  to  the  case  of  a 
shoemaker  who,  while  moving  some  furniture  from 
one  room  to  another,  had  been  seized  with  distressing 
pain  over  the  heart  necessitating  his  going  to  bed. 
This  pain  had  gradually  subsided,  and  he  had  re- 
sumed his  work.  About  two  weeks  later  there  had 
been  a  second  severe  attack  of  pain,  and  physical  ex- 
amination at  that  time  had  shown  only  slight  increase 
in  the  cardiac  dulness,  and  a  feeble  and  small  pulse. 
'i'he  patient  had  died  about  four  hours  later,  and  the 
autopsy  had  revealed  not  only  the  fresh  rupture  in  the 
left  ventricle,  but  an  older  rupture  in  the  right  ven- 
tricle. From  its  appearance  and  from  the  history  this 
rupture  had  evidently  occurred  two  weeks  previously. 
Both  ruptures  were  about  midway  between  the  apex 
and  base  of  the  heart.  The  walls  were  thin,  but  there 
was  no  marked  fatty  degeneration. 

Three  Cases  of  Tuberculous  Peritonitis.— Dr. 
Leon  T.  Le  Wald  reported  these  cases  and  presented 
specimens.  The  first  case  was  that  of  a  man  aged 
thirty-five  years,  who  had  presented  at  autopsy  a  tuber- 
culosis of  the  seminal  vesicles  and  of  the  epididymis 
on  the  left  side.  The  tuberculous  process  had  appar- 
ently started  in  the  left  epididymis  and  spread  to  the 
prostate.  On  opening  the  peritoneal  cavity  a  small 
quantity  of  dark  fluid  had  been  found,  and  the  perito- 
neum had  been  generally  studded  with  tubercles  of 
large  size.  Miliary  tubercles  were  scattered  over  the 
peritoneum  covering  the  intestine,  and  they  were  par- 
ticularly abundant  on  the  under  surface  of  the  dia- 
phragm. There  was  also  a  rather  recent  miliary  tu- 
berculosis of  the  lungs.  The  oldest-looking  lesions 
were  in  the  region  of  the  prostate  and  the  seminal 
vesicles,  though  it  was  not  at  all  unlikely  that  some 
small  focus  in  the  lung  might  have  bren  the  original 
process,  but  the  peritoneal  tuberculosis  was  secondary 
to  the  genital  tuberculosis.  The  second  case  was  that 
of  a  man  aged  fifty  years,  who  had  been  treated  for  cir- 
rhosis of  the  liver  in  the  Roosevelt  Hospital  last  De- 
cember.     He  had  been  operated  on  with  the  idea  of 


determining  whether  he  had  a  tuberculous  peritonitis 
or  an  accumulation  of  fiuid  entirely  the  result  of  the 
disease  in  the  liver.  The  operation  had  revealed 
nothing  more  than  the  cirrhosis  of  the  liver.  On 
March  31st  the  man's  abdomen  had  been  tapped,  and 
fiuid  removed,  and  this  had  failed  to  show  any  tu- 
bercle bacilli  present.  On  April  4th  he  had  died,  and 
the  autopsy  had  shown  a  well-marked  tuberculous  peri- 
tonitis. The  lungs  showed  a  chronic  tuberculosis. 
The  third  case  was  that  of  a  man  aged  thirty-five  years, 
who  had  been  suffering  from  alcoholism  and  cirrhosis 
of  the  liver.  The  autopsy  showed  a  miliary  tubercu- 
losis of  the  peritoneum.  A  careful  search  had  failed 
to  show  any  other  tuberculous  process  in  the  body,  so 
that  the  case  was  considered  to  be  one  of  primary  tu- 
berculosis of  the  peritoneum  associated  with  a  marked 
cirrhosis  of  the  liver.  While  primary  tuberculosis  of 
the  peritoneum  was  quite  rare,  it  was  somewhat  less 
so  when  associated  with  cirrhosis  of  the  liver,  as 
shown  by  statistics  published  by  Osier.  Ziegler  men- 
tioned the  occurrence  of  primary  peritoneal  tubercu- 
losis, although  the  manner  of  its  occurrence  was  not 
understood. 

A  Case  of  Addison's  Disease —  Dr.  Le  Wald  also 
presened  specimens  from  a  case  of  Addison's  disease 
occurring  in  a  woman  fifty  years  of  age.  The  case 
was  typical,  so  far  as  the  bronzing  of  the  skin  was 
concerned.  The  skin  of  the  face  and  neck  was  of  a 
very  dark  bronze,  and  the  skin  on  the  hands,  wrist, 
and  forearms  of  a  somewhat  lighter  tint.  The  body 
was  emaciated.  The  bronchial  glands  were  markedly 
enlarged  and  pigmented,  'llie  heart  was  small  and 
showed  brown  atrophy.  The  coronary  arteries  showed 
very  slight  arteriosclerosis.  There  were  old  adhe- 
sions about  the  stomach,  liver,  and  spleen.  In  the 
large  intestine  were  some  cicatricial  areas  in  the  mu- 
cous membrane,  apparently  the  result  of  some  old  ul- 
cers. There  were  also  a  few  lymphatic  nodes  which 
were  apparently  tuberculous.  The  right  suprarenal 
was  of  about  twice  the  normal  size,  and  was  adherent  to 
the  under  surface  of  the  liver.  On  section,  it  had 
been  found  to  be  almost  entirely  replaced  by  caseous 
masses.  The  left  suprarenal  was  surrounded  by  a 
mass  of  adhesions,  which  bound  it  to  the  pancreas. 
A  small  abscess  had  formed  between  the  pancreas  and 
the  suprarenal  gland.  Its  contents  were  cheesy,  and 
the  suprarenal  gland  itself  was  largely  replaced  by 
cheesy  nodules.  .Sections  were  exhibited  under  the 
microscope. 

Dr.  Carlin  Philips  asked,  in  the  case  of  supposed 
primary  tuberculous  peritonitis,  whether  the  small 
nodules  contained  tubercle  bacilli  or  not.  About  four 
or  five  years  ago  Wagner  described  a  form  of  fibroid 
peritonitis  occurring  in  cases  of  cirrhosis  of  the  liver 
which  at  times  resembled  in  the  gross  appearance 
miliary  tuberculosis.  This  condition  was  termed 
pseudo-tuberculous  peritonitis. 

Dr.  Le  Wai.d  replied  that  one  of  the  sections  exhib- 
ited under  the  microscope  showed  typical  tubercles, 
and  he  also  had  a  specimen  showing  stained  tubercle 
bacilli. 

A  Case  of  Papilloma  of  the  Ovary  with  Second- 
ary Deposits  in  the  Peritoneum. — Dr.  G.  Lang- 
mann said  that  the  president  had  exhibited  at  the  last 
meeting  one  feature  of  the  interesting  specimen  that 
he  was  about  to  present.  The  specimen  had  been 
taken  from  a  woman  seventy-three  years  old.  He 
had  known  her  for  several  years,  and  knew  that  she 
had  a  large  tumor  on  the  right  side,  apparently  ovarian. 
Last  October  he  had  been  called  to  see  her  because  of 
a  considerable  enlargement  of  the  abdomen.  Inquiry 
showed  that  she  had  had  a  severe  fall  last  summer, 
and  that  since  that  time  her  health  had  failed,  and  the 
abdomen  had  been  increasing  in  size.  When  first 
seen  the  size  of  the  abdomen  had  precluded  thorough 


July  2  1,  1900] 


MEDICAL    RECORD. 


117 


examination  of  the  abdominal  organs.  There  was  a 
very  large,  smooth  tumor  in  the  abdomen  having  a 
hard,  blunt  border  running  from  side  to  side.  On 
November  8th,  the  abdomen  was  tapped,  and  about 
five  litres  of  clear,  amber-colored  fluid  evacuated.  Ex- 
amination after  the  tapping  showed  one  tumor  about 
the  size  of  a  man's  head  on  the  right,  and  another 
about  the  size  of  a  fist  on  the  left  side.  Percussion 
showed  that  regular  vesicular  resonance  ran  into  the 
tympanitic  resonance  of  the  colon.  \o  trace  of  the 
liver  could  be  found  by  percussion.  A  second  tapping 
had  been  required  in  a  short  time,  and  bloody  liuid 
had  been  removed  at  this  operation.  Shortly  after 
the  third  tapping  she  died.  The  autopsy  revealed  an 
immense  ovarian  tumor  on  the  right  side,  and  a 
smaller  one  on  the  left  side.  The  liver  had  not  been 
visible  on  opening  the  abdomen.  All  of  the  ileum  and 
the  omentum  were  matted  together.  The  vesical  and 
parietal  peritoneum  was  covered  with  small  nodules, 
as  was  also  part  of  the  surface  of  the  ovarian  cyst. 
The  ovarian  tumor  was  a  papillary  cystadenoma,  and 
some  of  the  cysts  were  already  suppurating.  Micro- 
scopical examination  of  the  nodules  by  I)r  Hodenpyl 
had  revealed  nothing  but  ordinary  pa|)illoma.  When 
these  cysts  broke  and  scattered  their  contents  over  the 
peritoneum  nodules  developed  from  direct  implanta- 
tion, so  that  the  result  was  practically  like  that  of 
a  malignant  growth.  The  fall  that  this  woman  had 
experienced  had  probably  caused  a  rupture  of  some  of 
the  cysts,  and  in  this  way  he  explained  the  decline  in 
her  health.  The  autopsy  also  showed  numerous  ste- 
noses in  the  colon,  probably  as  a  result  of  long-con- 
tinued pressure.  They  were  interesting  because  of  the 
absence  of  symptoms  pointing  to  such  a  condition. 
The  numerous  diverticula  along  the  colon  had  been 
exhibited  by  Dr.  Hodenpyl  at  the  last  meeting  of  the 
society. 

Dr.  Philips  stated  that  in  the  summer  of  1896  Zie- 
gler,  of  Freiburg,  presented  to  his  advanced  class  in 
pathology  a  similar  tumor  which  histologically  was 
a  papuliferous  cystadenoma  of  the  ovary.  He  con- 
sidered the  tumor  of  very  great  importance,  as  it  was 
histologically  benign  but  clinically  malignant  and 
capable  of  metastasis. 

Dr.  Hodenpyl  objected  to  looking  upon  the  case 
just  reported  as  a  malignant  growth.  It  was  primarily  a 
connective-tissue  tumor,  and  therefore  he  would  classify 
it  as  a  benign  tumor. 

Dr.  Langmann  replied  that  one  might  make  a  dis- 
tinction between  clinical  malignancy  and  microscopi- 
cal malignancy.  He  thought  no  one  would  be  justi- 
fied in  recommending  the  early  removal  of  such  a  cyst 
because  of  the  possibility  of  just  such  an  accident  as 
had  occurred  in  this  case. 

A  Demonstration  of  Nucleic  Acid  Extracted  from 
Bacillus  Tuberculosis. — Dr.  P.  A.  Levene  made  this 
demonstration.  The  products  exhibited  had  been  pro- 
cured from  cultures  made  on  synthetic  media,  i.e.,  such 
as  were  composed  of  mineral  salts  and  were  free  from 
proteid  material.  The  speaker  said  that  all  of  the 
nuclear  compounds  were  composed  of  nucleic  acid. 
Until  recently  it  had  been  known  only  that  they  con- 
tained phosphoric  acid,  and  that  some  of  them  con- 
tained xanthin  bases.  Only  very  recently  had  dif- 
ferent nucleic  compounds  been  recognized.  It  was 
natural  to  expect  that  cells  producing  diseases  would 
probably  store  up  this  power  of  producing  disease  in 
the  nuclei,  and  probably  in  the  nucleic  acid.  Nucleic 
acid  was  more  active  than  the  nuclear  compound  it- 
self. Last  year  he  had  presented  a  paper  on  the 
chemistry  of  the  tubercle  bacillus,  and  it  was  only 
since  then  that  he  had  succeeded  in  devising  a  method 
which  would  enable  him  to  obtain  nucleic  acid  from 
any  cell  or  tissue  whatever.  In  the  tubercle  bacillus 
one  found  a  free  nucleic  acid,  and  the  nucleic  acid  in 


combination  with  proteid  material.  He  exhibited  two 
samples,  one  a  copper  salt  obtained  from  the  free 
acid,  and  the  other  procured  from  the  combined  nu- 
clein.  The  acidity  in  the  growth  was  due  partly  to  the 
nucleic  acid.  This  could  be  demonstrated  by  the  fact 
that  nucleic  acid  had  the  property  of  precipitating  any 
proteid,  as  for  instance  peptone.  The  precipitation 
with  peptone  was  demonstrated.  It  had  occurred  to 
him  that  this  nucleic  acid  might  be  the  cause  of  cer- 
tain necrotic  processes  taking  place  around  the  ba- 
cilli. 

On  the  Property  of  Precipitating  Albumin  Ex- 
hibited by  Some  Pathogenic  Bacteria.— Dr.  K.  Lib- 
man  said  that  he  had  been  surprised  to  find  that 
nearly  all  pathogenic  bacteria  he  had  tested  could 
precipitate  serum-albumin  and  egg-albumin  in  the 
presence  of  sugar.  The  result  depended  largely  upon 
the  amount  of  acid  formed.  This  reaction  occurred 
if  only  O.I  per  cent,  of  glucose  was  present,  and  this 
percentage  was  present  in  the  blood  normally.  Pneu- 
mococci  did  not  precipitate  albumin  at  all.  These 
facts  might  possibly  be  of  interest  in  explaining  some 
lesions,  especially  in  diabetics.  This  study  opened 
up  interesting  possibilities  in  connection  with  acid 
toxa;mias  in  the  human  body.  Dr.  Bookman  had  exam- 
ined these  tubes  for  him,  and  had  reported  that  there 
was  no  doubt  about  the  precipitate  being  albumin. 

Dr.  p.  a.  Levene  thought  the  reaction  was  due  to 
the  presence  of  free  nucleic  acid. 

Dr.  Libman  said  that  if  the  acid  was  nucleic  acid, 
he  thought  it  should  act  even  though  sugar  was  not 
present. 

On   the   Influence   on   Normal  Animals  of  Blood 

from  Animals  Deprived  of  their  Adrenals Dr.  I. 

Levin  made  some  remarks  on  this  subject,  and  exhib- 
ited blood-pressure  tracings.  These  tracings  had  been 
made  to  illustrate  the  influence  on  the  blood  pressure 
of  injecting  into  a  normal  animal  the  defibrinated 
blood  from  an  animal  deprived  of  its  adrenals  five 
hours  previously.  The  tracings  showed  a  marked  rise 
of  blood  pressure  lasting  for  a  considerable  time.  As 
a  control,  tracings  were  shown  of  the  blood  pressure 
of  an  animal  who  had  received  an  injection  of  defibri- 
nated blood  from  a  normal  animal.  It  showed  that 
there  was  scarcely  any  perceptible  rise  of  blood  pres- 
sure following  this  injection.  These  tracings  showed 
that  the  first  injections  resulted  in  a  toxic  condition. 
He  thought  the  absence  of  the  tonic  action  of  the  ad- 
renals on  the  muscular  and  circulatory  system  was  not 
sufficient  to  explain  that  fatal  result  of  the  extirpation 
of  these  glands. 

Dr.  Langmann  said  that  some  experiments  had 
been  made  with  the  suprarenal  extract  in  connection 
with  snake  poisoning.  Guinea-pigs  were  particularly 
susceptible  to  snake  poison,  and  these  animals  had 
almost  no  adrenal  tissue.  Suprarenal  extract  obtained 
from  sheep  or  oxen  was  injected  into  the  guinea-pig 
poisoned  with  snake  poison.  These  animals  showed 
a  much  greater  resistance  to  the  snake  poison.  Ex- 
periment had  shown  that  only  tiie  suprarenals  pos- 
sessed this  power.  It  might  be  that  the  effect  of  the 
suprarenal  extract  on  the  heart  and  blood  pressure 
was  in  itself  sufficient  to  account  for  this  increased 
resistance  in  the  animal  without  supposing  that  the 
product  of  the  adrenals  was  an  antitoxin. 

Dr.  p.  a.  Levene  said  that  from  the  suprarenal  a 
substance  had  been  obtained  which  produced  a  tre- 
mendous rise  of  blood  pressure.  If  one  accepted  the 
theory  of  internal  secretions,  then  by  removing  the 
gland  the  substance  causing  this  increase  of  blood 
pressure  was  removed,  and  the  blood  of  the  animal 
should  not  contain  the  substance  which  caused  the 
rise  of  blood  pressure.  This  was  very  different  from 
what  had  been  just  described  in  the  experiment  of  Dr. 
I.  Levin. 


ii8 


MEDICAL    RECORD. 


[July  2  1,  1900 


On  a  Method  of  Photographing  Slides.—  Dr.  Bux- 
ton exhibited  some  pliotographs  taken  b)'  a  method 
which  he  thought  would  obviate  the  necessity  of  using 
drawings. 

Endotheliomata — Dr.  F.  C.  Wood  read  this  paper, 
and  exhibited  a  patient.  This  man  had  had  a  tumor 
in  the  parotid  region  for  about  five  years.  It  had 
grown  rapidly  only  during  the  past  few  months.  The 
tumor  was  adherent  to  the  deep  fascia,  and  was  almost 
cartilaginous.  The  object  of  the  paper  was  to  show 
that  there  was  a  class  of  mixed  tumors  characterized 
by  slow  growth  for  a  long  time,  and  then  by  a  more 
rapid  growth  and  a  change  in  structure  coincident 
with  the  change  to  malignancy.  These  tumors  W'ere 
derived  from  the  endothelium.  As  the  mesoderm  and 
the  tissues  which  it  formed,  notably  the  connective  tis- 
sue, came  from  the  tissues  epithelial  in  character,  cer- 
tain embryologists  insisted  that  all  tumors  so  derived 
should  be  called  epithelial  tumors.  Others  contended 
that  tumors  arising  from  the  endothelial  cells  of  the 
peritoneum  or  pleural  cavity  or  the  lymph  spaces 
should  be  known  by  the  name  of  endotheliomata. 
Within  a  year  two  prominent  foreign  pathologists  had 
taken  opposite  positions  on  this  question.  The 
Speaker  thought  it  was  inadvisable  to  go  back  to  the 
earliest  stage  ot  development,  and  that  it  was  better 
to  classify  tumors  according  to  their  origin  from  the 
tissues  as  found  at  birth.  A  number  of  microscopical 
specimens  were  tlien  projected  on  the  screen  by  means 
of  an  electric  lantern. 


Bciu 


DILATATION    OF 


instruments. 

THE    LACRYMAL     PUNC- 
TUM. 


liv   J.    R.    SHANNON,    M.D., 


NEW    YORIC. 


A  GREAT  many  cases  of  epiphora  coming  under  the 
care  of  ophthalmic  surgeons  are  undoubtedly  due  to  a 
constriction  of  the  lacrymal  punctum,  and  nothing 
more.     This  is  not  a  very  original  piece  of  informa- 


FiG.  I. — Dilator. 


Fig.  2.  — Syringe. 


tion,  and  yet  in  the  treatment  of  the  condition  the 
causal  element  seems  to  be  lost  sight  of  frequently, 
for  we  find  that  in  many  clinics — and  I  doubt  not  in 
the  private  practice  of  many  ophthalmologists — the 
appearance  of  a  patient  complaining  of  the  familiar 
symptoms  immediately  suggests  the  canaliculus  knife 
and  lacrymal  probe.  Now,  the  slitting  of  the  canalic- 
ulus probably  does  no  great  damage  -  although  this 
is  by  no  means  unquestioned — but  it  is  a  mutilation, 
and  an  absolutely  unnecessary  one  in  the  cases  under 
discussion,  while  the  use  of  the  probe  is  often  an 
offence  against  a  perfectly  healthy  and  uncomplaining 
duct. 

For  some  years  I  have  relieved  the  symptoms  aris- 


ing from  atresia  and  constriction  of  the  lacrymal 
punctum.  as  well  as  of  the  canaliculus,  by  dilating 
both  with  a  small  steel  dilator,  and  syringing  thorough- 
ly with  some  mild  lotions — boric  acid,  alum,  or  weak 
bichloride.  Nor  is  this  treatment  start! ingly  new,  for 
we  find  it  or  something  like  it  advocated  in  most  text 
books  on  ophthalmology — notably,  for  instance,  by 
Theobald,  in  his  article  in  Norris  and  Oliver's  Sys- 
tem. But  it  is  not  practised  at  all  generally,  and  why 
it  is  not  is  difficult  to  explain.  To  particularize 
briefly  for  those  who  may  need  it:  the  dilator  which 
I  employ  is  sufficiently  pointed  to  enable  it  to  enter 
any  punctum  not  absolutely  closed,  and  yet  not  sharp 
enough  to  wound  the  conjunctival  mucous  membrane 
when  carefully  used.  I  sit  in  front  of  the  patient  as 
a  rule,  though  if  the  patient  is  restless,  or  for  any 
reason  the  manipulation  is  difficult,  I  stand  behind 
the  head  as  for  passing  the  lacrymal  probe.  If  the 
punctum  is  quite  closed,  the  point  of  a  Graefe  knife 
may  be  used  to  facilitate  the  entrance  of  the  dilator. 
The  dilator  is  conically  shaped  for  about  one  inch  of 
its  length;  and  after  having  opened  the  punctum  by 
its  being  held  vertically  and  gently  pressed  downward, 
it  is  shifted  to  the  horizontal  and  the  point  passed 
well  along  the  canaliculus,  the  lid  meanwhile  being 
held  on  the  stretch  by  the  thumb  of  the  left  hand,  the 
punctum  dilating  as  it  passes  up  over  the  expanding 
instrument. 

The  syringe  is  not  unlike  an  ordinary  hypodermic 
as  to  the  barrel,  but  the  tip  is  of  pure  silver,  easily 
bent,  and  with  a  slightly  bulbous  end.  The  object  in 
having  the  syringe  small  is  that  it  does  not  drag  the 
canaliculus,  does  not  hurt  the  patient,  can  be  managed 
with  one  hand  while  the  other  steadies  the  lid,  and  at 
the  same  time  is  capable  of  all  the  force  that  is  neces- 
sary and  carries  quite  enough  lotion.  I  sit  in  front  of 
the  patient  always  when  using  it,  chiefly  th.at  I  may 
see  for  myself  whether  the  fluid  passes  freely  into  the 
nose.  I  think  this  is  important,  because  I  have  be- 
come convinced  that  patients  will  frequently  declare 
that  the  fluid  has  gone  through  when  it  has  not,  in  or- 
der to  avoid  further  treatment,  especially  if  it  is  un- 
comfortable, and,  secondly,  because  it  is  unpleasant  to 
have  boric  or  alum  lotion  syringed  into  a  pharynx 
which  does  not  want  it;  whereas  with  the  floor  of  the 
nose  inclined  forward  this  is  avoided,  and  the  operator 
sees  at  once  tlie  result  of  his  treatment. 

My  only  reason  for  communicating  this  note  is  to 
draw  attention  to  a  very  simple  method  of  relieving 
a  simple  condition — a  method  which  has  proved  most 
satisfactory  and  convenient  in  my  hands.  Of  course, 
when  there  is  an  obstruction  in  the  duct  the  probe- 
must  be  used — but  that  is  another  story. 

ao  West  Thirty-fifth  Street. 


LINGUAL    TONSIL    SCISSORS. 

By   J.    H.    MORRISON,    M.D., 

ST.    JOHN,    N.    B.,    CANAIiA. 

I  KNOW  of  no  more  awkward  predicament  into  which 
the  throat-surgeon  can  get  himself  than,  during  an  at- 
tempt to  remove  a  large  hypertrophied  gland  at  the 
base  of  the  tongue  with  any  of  the  ordinary  snares,  to 
find  that,  after  he  has  engaged  the  hypertrophied  mass 
in  the  wire  loop,  no  amount  of  traction  is  sufficient  to 
make  the  wire  cut  through  the  tough,  fibrous  pedicle 
or  base  of  the  tumor.  The  snare  is  fast  fixed  ///  situ, 
and  he  can  neither  complete  the  excision  nor  remove 
the  instrument;  the  patient  becomes  terrified,  gags, 
chokes,  coughs,  and  often  vomits  the  contents  of  his 
stomach  into  the  operator's  lap,  while  every  motion  of 
himself  or  of  the  operator  aggravates  his  discomfort 
and  increases  his  alarm. 


July  2  1,  1900] 


MEDICAL    RECORD. 


119 


With  the  Bosworth  snare  it  is  quite  impossible  to 
disengage  the  contracted  loop  without  detaching  the 
proximate  ends  of  the  wire  from  the  finger  rings,  cut- 
ting off  the  twisted  portion,  and  forcibly  pulling  the 
instrument  away,  leaving  the  wire  still  fast  to  the 
gland.  Then  one  or  perhaps  two  fingers  must  be 
inserted  into  the  patient's  throat  and  the  wire  un- 
hitched from  the  gland — a  difliicult  and  awkward  pro- 
ceeding. If  the  operator  prefers  to  take  up  tiie  slack 
wire  and  cut  the  loop  in  the  mouth  with  a  pair  of 
wire-cutters,  the  cut  ends  of  the  loop  fly  upward  and 
stick  into  the  soft-palate,  tonsils,  or  even  up  into  the 
naso-pharynx,  every  motion  of  the  patient's  tongue 
causing  him  the  greatest  distress  and  discomfort. 
Then  the  operator  must  insert  his  fingers  and  remove 
the  cut  loop,  and  admit  a  failure.  The  chances  are 
that  he  will  never  again  get  a  snare  into  that  patient's 
mouth. 

Kven  with  the  end-loop  snare,  in  wiiich  the  loop  of 
wire  may  be  quickly  pushed  out  of  the  cannula,  the 
greatest  difficulty  is  experienced  in  removing  it  from 
the  half-severed  pedicle  or  base. 

Generally  the  fibrous  base  cannot  be  cut  through  by 
traction  made  with  the  fingers;  and  the  nut,  wheel, 
screw,  and  ratchet  attachments  are  quite  useless. 

To  meet  such  an  emergency,  which  sooner  or  later 
comes  to  every  throat  surgeon,  I  have  devised  the  lin- 
gual tonsil  scissors  shown  in  the 
cut.  When  it  is  found  that  tiie 
gland  cannot  be  cut  through  by 
finger  traction  upon  the  sn.ire, 
the  throat  mirror  is  discarded, 
the  scissors  are  inserted,  the 
points  guided  by  the  forefinger 
of  the  left  hand,  and  the  gland 
is  snipped  off  with  the  wire  still 
engaging  it.  The  patient  con- 
siders it  an  essential  part  of 
the  operation,  and  the  whole 
difiiculty  is  over  in  a  moment.  The  forefinger  should 
be  pushed  quickly  along  the  dorsum  of  tlie  tongue  under 
the  cannula  until  the  wire  and  gland  are  reached,  and 
the  scissors,  passed  under  the  finger,  cannot  fail  to  reach 
the  exact  desired  spot.  As  the  parts  have  been  locally 
anaesthetized,  the  quiet  but  rapid  introduction  of  the 
finger  gives  the  patient  no  discomfort  or  concern. 
With  a  cool,  collected  patient,  who  will  continue  to 
pull  forward  tiie  tip  of  the  tongue,  the  snare  may  be 
passed  to  the  left  hand,  the  tip  of  tiie  cannula  some- 
what elevated,  bringing  the  base  of  the  tongue  into 
view,  when  the  contracted  pedicle  may  be  quickly 
severed  without  the  necessity  of  passing  the  finger 
into  the  mouth. 

The  instrument,  as  shown  in  the  cut,  is  in  reality  a 
combination  of  the  Asche  septum  forceps  and  the 
common  curved  uvula  scissors.  Beyond  the  pivot  the 
curve  is  somewhat  less  than  that  of  the  snare  cannula 
and  loop.  The  shanks  are  separated  and  rounded  to 
avoid  the  possibility  of  engaging  and  wounding  the 
dorsum  of  the  tongue.     This  is  an  essential  point  in 


ward  toward  the  cutting  line  to  avoid  the  possibility 
of  wounding  the  epiglottis,  which  might  be  thrown  up 
against  them  should  the  patient  gag  or  cougii  during 
their  introduction.  'I'he  handles  are  long,  so  that  the 
operator's  right  iiand  is  quite  free  and  entirely  outside 
of  the  patient's  mouth. 

In  favorable  cases  in  which  the  glands  are  large  they 
may  be  excised  with  the  scissors  without  having  re- 
course to  the  snare  at  all.  In  these  cases  the  scissors 
are,  of  course,  used  in  conjunction  with  the  throat 
mirror. 


AN    IMPROVED   STF.THOSCOPE. 

Bv    MARK    I.    KNAPP,    M.D.. 

NEW   YORK. 

The  present  stethoscope  is  an  improvement  on  my 
first  one,  a  description  of  which  was  published  in  the 
Medical  Record,  November  g,  1895,  in  so  far  only  as 
the  lessened  cost  is  concerned;  the  quality  remaining 
the  same,  although  the  shape  and  make-up  differ. 

The  principle  of  this  stethoscope  is  to  do  away  with 
the  humming  and  buzzing  and  incidentally  to  magnify 
the  volume  and  the  quality  of  the  sounds.  To  effect 
this  I  assumed  that  the  annoying  sounds  came  not 
from  within  the  instrument,  but  from  without,  from  the 


the  construction  of  the  instrument,  for  the  patient  is  apt 
to  let  go  his  tongue  and  pull  it  back  into  his  mouth, 
where,  being  arched,  it  would  be  sure  to  get  between 
the  cutting  blades  if  they  extended  back  to  the  pivot. 
The  cutting  edges  are  half  an  inch  long  and  concave, 
so  that  the  pedicle  cannot  escape  when  they  are  closed 
upon  it.     The  tips  are  blunt  and  slightly  rounded  in- 


atmospheric  waves  propagated  to  our  ears  by  the  ordi- 
nary metallic  ear-parts  of  all  other  stethoscopes.  The 
solution  of  the  problem  was  to  have  a  bad  sound  con- 
ductor, rubber,  cover  a  good  sound  conductor,  metal, 
by  which  combination  I  produced  an  ideal  material 
for  a  stethoscope. 

To  lessen  the  cost  of  the  instrument  I  have  dis- 
pensed with  its  solid  metal  and  rubber  covered  proxi- 
mal parts.  The  present  stethoscope  then  consists  of: 
(i)  The  distal  part,  the  chest  piece,  made  of  metal 
and  covered  with  rubber;  (2)  ear-tips,  and  (3)  flexi- 
ble tubing  which  intervenes  between  the  chest  and 
the  ear-tips.  This  flexible  tubing  consists  of  a  spiral 
wire  whose  individual  rings  are  so  closely  apposed  to 
one  another  as  practically  to  form  a  metal  tube;  this 
is  covered  with  soft-rubber  tubing  and  then  spun  over 
with  silk.  The  ends  of  the  ear-tips  have  soft-rubber 
covers  whose  object  it  is  to  prevent  painful  pressure. 
To  give  this  stethoscope  firmness  and  springiness,  a 
nickel-plated  steel  spring  wire,  of  sufficient  length 
and  breadth  to  allow  the  head  to  move  freely,  runs  from 
ear-tip  to  ear-tip;  two  nickel-plated  rings, 
a  quarter  of  an  inch  wide  and  three  inches 
apart,  are  soldered  on  to  the  spring  wire 
about  three  inches  from  its  ends;  the  pur- 
pose of  this  is  to  hold  the  flexible  tubing 
and  give  the  proper  shape  to  the  instrument. 
The  excellence  of  this  instrument  as  to 
its  quality  in  doing  away  with  the  buzzing 
and  humming  sounds  peculiar  to  all  stethoscopes,  at 
the  same  time  increasing  the  power  of  the  instrument, 
cannot  fail  to  recommend  it  to  the  medical  profession. 


Elbow-Joint  Fractures,  especially  the  intercondy- 
loid  in  children,  should  not  be  treated  by  too  early 
nor  too  forcible  passive  motion. 


I20 


MEDICAL    RECORD. 


[July 


21, 


1900 


Vertical 


items. 


Prehistoric  Bacteria.^Owing  to  the  ephemeral  na- 
ture and  to  the  exceedingly  small  size  of  bacteria,  it 
would  seem  wellnigh  impossible  to  study  the  minute 
forms  which  assuredly  must  have  existed  ages  ago. 
Two  French  investigators,  B.  Renault  and  C.  E.  Ber 
trand,  have,  however,  microscopically  examined  several 
varieties  of  anthracite  coal  and  partially  carbonized 
wood,  and  believe  they  have  discovered  petritied  bacilli. 
Renault  has  even  designated  several  of  his  species  by 
name  (micrococcus  carbo.  bacillus  carbo,  bacillus  col- 
letus).  He  advances  the  theory  that  these  bacteria 
have  effected  the  transformation  of  wood  cellulose  into 
coal,  a  theory  which  is  decidedly  opposed  to  our  con- 
ception of  the  carbonization  of  wood.  Bacteria,  ac- 
cording to  Renault,  would  therefore  be  most  powerful 
factors  in  the  geological  development  of  the  world. — 
Scientific  American. 

The  Open-Air  Treatment  of  Consumption  in 
Southern  Brittany. — The  open-air  marine  treatment 
for  consumption  has  been  practised,  says  an  English 
weekly  journal,  with  success  for  several  years  in 
Southern  Brittany,  The  Pen-Bron  Hospital  is  fa- 
mous for  its  cures.  It  is  used  mainly  by  working- 
people,  the  cost  of  maintenance  being  defrayed  by  the 
local  authorities  by  whom  they  are  sent.  Its  success 
has  led  to  the  creation  of  a  magnificent  private  insti- 
tution at  La  Baule,  a  few  miles  away,  for  well-to-do 
patients  who  can  afford  to  pay  for  treatment.  The 
new  hospital,  which  is  built  of  granite,  looks  out  upon 
the  sea  from  beautiful  grounds,  surrounded  by  ever- 
green pine  forests.  It  has  been  fitted  out  on  a  luxu- 
rious scale,  with  a  special  system  of  drainage.  The 
hydropathic  department  comprises  hot  and  sea-water 
baths,  seaweed  baths,  electric  brine  baths,  and  hot-air 
baths,  together  with  vapor,  douche,  rain,  shower,  and 
medicated  baths. 

Consumption  of  Alcohol  in  France. — In  France 
much  dread  is  being  expressed  at  the  steadily  growing 
increase  in  the  consumption  of  alcohol,  and  a  vigorous 
crusade  has  been  inaugurated  ugainst  its  excessive  use. 
Not  only  is  alcohol  prohibited  in  military  canteens  but 
in  civil  circles.  An  effort  is  being  made  to  secure 
the  registration  of  deaths  directly  traceable  to  alcohol- 
ism under  this  head. 

Famine  in  India. — The  reports  of  the  Indian  fam- 
ine, says  the  London  Spectator,  continue  to  be  heart- 
breaking. The  number  of  persons  on  the  relief  works 
is  now  five  million  seven  hundred  thousand,  and  the 
deaths  from  fever,  cholera,  and  the  diseases  promoted 
by  starvation  will  affect  the  next  census.  Mr. 
Klopsch,  the  .'\merican  gentleman  sent  to  distribute 
American  subscriptions,  draws  a  horrible  picture  of 
the  sufferings  of  children  in  Guzerat,  whose  bodies 
are  often  eaten  by  dogs;  and  in  Rajpootana,  Katha- 
war,  and  indeed  the  whole  Bombay  Presidency  the 
mortality  is  frightful. 

Average  Ages  of  Various  Groups.  — A  general 
summary  of  the  following  groups  and  individuals 
shows  that  the  average  duration  of  life  has  been  about 
sixty-eight  years  and  eight  months:  46  poets  average 
66  years,  39  painters  and  sculptors  66  years,  30  musi- 
cians 62  years,  26  novelists  63  years,  40  men  of  let- 
ters 67  years,  22  religious  66  years,  35  women  69 
years,  18  philosophers  65  years,  38  historians  65 
years,  58  scientists  and  inventors  72  years,  14  agita- 
tors 6g  years,  48  commanders  71  years,  112  statesmen 
7  I  years. 

Health  Reports. ^ — The  following  cases  of  smallpox, 
yellow  fever,  cholera,  and  plague,  have  been  reported 


to  the  surgeon-general  of  the  United  States  Marine- 
Hospital  service  during  the  week  ended  July  14, 
1900  : 

Cases.    Deaths. 
Smallpox— United  States. 

District  of  Columbia,  Wash- 
ington  July  'St  to  7th 4 

Florida,  Jacksonville J"iy  ">t  to  7th i 

Illinois,  Cairo July  ist  to  7th  7 

Indiana,  Kvansville Jn'y  ist  to  7th i 

Iowa,  Des  Moines June  1st  to  30th 3 

Kansas,  Wichita July  ist  to  7th g 

Kentucky.  Covingt<in July  1st  to  8th 13 

Louisiana,  New  <  Orleans July  1st  to  jlh 18                  5 

Maryland,  Cuinherland July  1st  to  7th  5 

Massachusetts,  Fall  River  .  .July  2d  to  Qth 2 

Michi.vjan,  Jackson July  1st  to  7th i 

Minnesota.  Minneapolis  .  ...June  8th  to  30th 20                  i 

Nebraska.  Omaha June  23d  to  loth 3 

N.  Hampshire.  Manchester.  .July  1st  to  7lh i 

New  York,  New  \'ork July  1st  to  7th 1 

Ohio.  Cincinnati June  3cth  to  July  6th 6 

Cleveland July  ist  to  7tn  37 

Pennsylvania.  Pittsburg July  ist  to  7th i 

Utah.  Ocden June  1st  to  30th 6 

Salt  Lake  City July  ist  to  7th i 

Virginia.  Roanoke June  ist  to  30th 22                  s 

Washington.  Tacoma June  23d  to  30th i 

West  Virginia, Charlestown.  July  7th 4 

Smallpox — Foreign  and  Insilar. 

Austria,  Prague June  i6th  to  23d 5 

Egypt,  Cairo    June  loth  to  17th i 

England,  Liverpool June  iCth  to  23d 1 

London  ...    June  16th  to  23d 13 

France,  Bordeaux May  1st  to  31st r 

Paris    June  16th  to  23d i 

Greece,  Athens June  i6th  to  2;d  10  6 

India,  Karachi June  3d  to  icth  8  7 

Madras May  zfth  to  June  1st i 

Mexico,  (  hihuahua July  ist  to  7th - 1 

Veracruz June  23d  to  30th 5 

Philippines.   Manila May  10th  to  26th 1 

Porto  Rico,  Ponce June  8th  to  23d i 

Russia,  Moscow June  8th  to  16th ig  2 

Odessa June  i6th  to  23d 2  : 

St    Petersburg June  16th  to  23d 27  n 

Warsaw June  8th  to  i6th 2 

Straits    Settlements.    Singa- 
pore   May  igth  to  26th i 

Yellow  Fever. 

Colombia,  Barranquilla June  i6th  to  23d 7  3 

Cartagena June  14th  to  21st 5  5 

Panama June  25th  to  July  2d i 

Cuba,  Havana June  20th  to  30th. p 

Santa  Clara June  20th  to  25th 4 

Cholera. 

India,  Madras    May  26th  to  June  ist 2 

Plague— Foreign  and  Insular. 

Egypt.  Port  Said April  20th  to  June  i8th   75  32 

India,  Karachi June  3d  to  loth 13  13 

Japan,  Osaka June  2d  to  12th 6 

Shidzuoka  Ken June  2d  to  12th   2 

Philippines,  Manila May  12th  to  26lh        7  4 

Turkey,  Smyrna June  6th  to  21st 5 


While  the  Medical  Record  is  pleased  to  receive  all  new pub- 
licatious  which  viav  be  sent  to  it,  and  an  aclsnozi<ledi^ment  ~cill  he 
promptly  tnade  of  tlieir  receipt  under  this  heading,  it  must  be  with 
the  distinct  understanding  that  its  necessities  are  such  that  it  can- 
not be  considered  under  obligation  to  notice  or  review  any  publica- 
tion received  by  it  which  in  the  judgment  of  its  editor  will  7iot  be 
of  interest  to  its  readers. 

Diseases  ok  the  Chest,  Throat,  and  Nasal  Cavities. 
Ry  E.  Fletcher  Ingals,  M.D.  8vo.  765  pages  Illustrated. 
William  Wood  and  Company.  New  York. 

Edinburgh  Hospital  REroRTS.  Edited  by  G.  X,  Gibson, 
M.I).,  C.  W.  Cathcart,  M.A.,  John  Thompson,  M.D. .  and  D. 
lieriy  Hart.  M.D.      6  volumes,  Svo,      Illustrated. 

Twenty-Third  Annual  Report  of  Boafd  of  Health  of 
State  of  New  Jersey,  iSgg.     Svo,  432  pages.     Illustrated. 

Forty  Years  in  the  Medical  Profession,  1858-1898. 
By  John  Janvier  Black;  M.D.  Svo.  49S  pages.  J.  B.  Lippin- 
cott  Co. ,  Philadelphia. 

Medical  and  Surgical  Nursing.  By  H.  J.  O'Brien, 
M.D.     l2mo,  287  pages.      G.   P.  Putnam's  Sons,  New  York. 

Diseases  of  the  Eye  By  Edward  Nettleship,  Revised 
and  edited  by  William  Campbell  Posey.  M.D  i2nio,  560  pages. 
Illustrated.      I.ea  Brothers  &  Co..   I'hiladelphia  and  New  York. 


By  Lewis  X.  Stimson. 
i2mo,   5S9  pages.     Lea 


A  Manual  of  Operative  Surgery 
M.D.,  and  John    Rogers.  Jr.,    M.D. 
Brothers  c^  Co. ,  Philadelphia. 

.•\TLAs  AND  Epitome  of  Special  Pathological  Hisiology. 
r>y  Hermann  Durck,  M.D.  Translation  from  the  German  by 
Ludvig  Hektoen.  M.D.  i2mo,  158  pages.  Illustrated.  W. 
B.  S.iunders.  Philadelphia 

Fractures.  By  C?rl  Beck.  M.D.  Svo,  335  pages.  Illus- 
trated.     W.  B    Saunders.  Philadelphia. 


Medical  Record 

A    JVeekly  yoitrual  of  Medicine  and  Sitrgeiy 


Vol.  58,  No.  4. 
Whole  No.  1551. 


New  York,   July  28,    1900. 


$5.00  Per  Annum. 
Single  Copies,  loc. 


©rigtuat  Articles. 

CHORIO-EPITH  ELIOMA    M ALIGNUM. 

r.v    K.    S.    TALMEV,    M.D., 

NEW    \OKK. 

The  study  of  the  new  growth  called  chorio-epithe- 
lioma  malignum  has  not  cast  as  yet  full  light  upon 
the  pathology  of  this  interesting  tumor.  It  is  there- 
fore desirable  to  put  on  record  all  recognized  cases. 
The  succinct  history  of  our  present  case  reads  as  fol- 
lows: 

In  the  first  days  of  July,  1899,  tiie  autopsy  of  a 
woman,  with  the  clinical  diagnosis  "ana;niia,"  was 
performed  in  the  pathological  institute  of  the  Univer- 
sity of  Zurich.  The  woman  was  delivered  in  April, 
and  had  had  since  her  confinement  a  light  bloody 
uterine  discharge.  The  rough,  lacerated,  papulous  ap- 
pearance of  the  surface  of  the  uterine  mucosa  of  the 


Fig. 


-a,  Fibrinous  masses  ;  b,  syncytial  masses  ;  c,  nests  of  wandering  cells 
of  Langhans'  layer. 


posterior  wall,  giving  the  impression  of  the  yet  pre- 
served placental  site,  three  months  after  delivery, 
caused  Professor  Ribbert,  the  director  of  the  institute, 
to  hand  me  over  the  uterus  for  microscopical  examina- 
tion : 

The  uterus,  13  cm.  in  length,  is  somewhat  thickened, 
the  posterior  wall  measuring  2  cm.,  the  anterior  i  cm. 
The  peritoneum  is  intact.  The  uterine  cavity  is  some- 
what enlarged.  The  mucosa  of  the  anterior  wall  gives 
the  aspect  of  a  simple  endometritis.  At  the  posterior 
wall,  occupying  almost  the  whole  surface  of  the  fun- 
dus, a  triangular  mass  is  seen  growing  from  the  wall 
and  projecting  forward  into  the  uterine  cavity.  The 
tumor  is  fungiform  in  appearance,  resting  on  a  broad 
base  (diameter  2'j  cm.)  in  the  uterine  mucosa,  the 
latter  arching  over  the  tumor  for  some  distance.  The 
surface  is  rough,  lacerated,  and  papulous.  The  color 
is  reddish-brown.  The  uterus  was  fixed  in  Zenker's 
fluid,  and  then  slices  involving  the  whole  thickness  of 


the  uterus  were  taken  from  the  anterior  and  posterior 
walls,  hardened  in  alcohol,  cut  partly  in  paraffin,  partly 
in  celloidin,  stained  with  ha;matoxylin-eosin  and  haema- 
toxylin-Van  Gieson,  and   mounted  in  Canada  balsam. 


O^ 


Fig. 


-Portion  of  Fig.  i.  More   Magnified  to  Show  the  Nests,     k.  Ecto- 
dermal ceil-nests  ;  >\  red  blood  globules. 


The  bright  rose-red  stained  masses  of  the  tumor  can 
be  noticed  with  the  naked  eye,  occupying  half  of  the 
uterine  wall  and  reaching  almost  to  the  vascular  in- 
terval between  the  circular  and  longitudinal  muscular 
coats.  The  circular  coat  has  either  totally  disappeared 
or  is  represented  by  mere  remnants.  The  blood-ves- 
sels appear  greatly  enlarged. 

The  microscopical  examination  shows  the  bulk  of 
the  tumor  to  consist,  first,  of  irregular,  branching,  mul- 
tinucleated, trabecular  masses,  which  are  distinguished 
by  darkly  stained  protoplasm.  Yet  the  greater  part 
of  the  tumor  is  changed  into  very  dense  fibrinous,  co- 
agulated masses  of  irregular  outline,  enclosing  spaces 
of  various  shape.  At  the  apex  of  the  tumor  the 
uterine  mucosa  has  entirely  disappeared,  the  fibrinous 
masses  reaching  the  uterine  cavity.  At  the  oppo- 
site side  the  fibrin  is  closely  adherent  to  the  uterine 
muscles,  sending  long  offshoots  into  the  remnants 
of  the  circular  layer,  upon  which  it  seems  to  en- 
croach. At  some  points  within  the  fibrinous  masses 
epitheloid  cells,  ectodermal  cells  of  Langhans'  cellular 
layer,  are  seen  either  single  or  in  small  groups  of  two 
to  three.  They  are  lying  in  lacunae  of  the  fibrin. 
Some  of  the  cells  are  in  a  state  of  degenerative  meta- 
morphosis,   showing   only    outlines    of    cells.      Other 


Fig.  3.— Portion  of  Fig.  2  at  jrx  to  Show  the  Residua  of  the  Cellular  Ele- 
ments within  the  Fibrin.  /,  Lymphocytes ;  r,  red  blood  globules ;  y, 
spindle-shaped  nuclei. 

cells  are  in-various  states  of  degeneration.  The  cells 
yet  normal  appear  to  have  only  for  a  time  survived 
this  degenerative  fate.  The  fibrin  gives  us  the  im- 
pression of  being  the  hyaline  metamorphosis  of  these 
degenerated  cells.      After  careful  search  some  cells 


122 


MEDICAL    RECORD. 


[July  28,  T900 


were  found  lying  in  larger  heaps  and  adhering  together 
without  any  intercellular  substance.  They  are  sur- 
rounded by  a  circular  layer  of  dense  fibrinous  tissue, 


Fig. 


-ii,  Fibrinous  masses ;   ^.  syncytial  masses ;  c,  ectodermal  cell  ;   d, 
disintegration  of  a  uterine  gland. 


giving  the  appearance  of  an  alveolar  sarcomatous 
tissue;  the  epithelioid  cells  are  the  large  granular 
wandering  cells  and  stain  less  than  those  derived  from 
the  glandular  epithelium.  The  cell  bodies  are  almost 
colorless.  They  are  irregularly  oval  in  outline  and 
have  usually  a  single  large,  well-stained  nucleus  con- 
taining a  nucleolus.  A  few  are  larger,  more  granular, 
and  multinucleated.  The  cells  are  less  individual  in 
the  large  patches  within  the  alveolus;  otherwise  there 
is  no  difference  between  them  and  the  single  cells 
scattered  within  the  fibrin.  Some  cells  within  the 
alveoles  show  mitotic  changes.  They  have  not  yet 
entirely  lost  their  proliferating-power. 

The  large  irregular  spaces  between  the  fibrinous 
masses  are  mostly  occupied  by  the  syncytial  multinu- 
cleated mass  of  protoplasm  without  recognizable  cell 
boundaries,  as  above  alluded  to.  The  nuclei  are  oval, 
round,  or  polyhedric   in   outline;    some  are  spindle- 


\    ^  \>:V-:>^i''  Q  ^i  % 


%.     _  — 


i 


Fig.  5. — Portion  of  Fig.  4  at  .r,  More  Magnified  to  Show  the  Nests. 

shaped  or  triangular.  The  masses  lie  usually  at  the 
margin  of  the  fibrin.  The  structure  is  trabecular  with 
processes  running  off  in  various  directions,  making  the 
thick  fibrinous  trabeculoe  appear  to  be  embedded  in 
the  syncytial  mass.  The  nuclei  of  the  syncytial  masses 
resemble  the  connective-tissue  nuclei,  but  are  greatly 
increased  in  size.  The  greater  part  of  them  resemble 
enlarged  lymphocytes.  Some  nuclei  are  surrounded 
by  a  light  area  so  as  to  make  a  cellular  structure  appear 
within  the  syncytium.  The  protoplasmatic  area  ap- 
pears often  homogeneous  and  hyaline,  resembling  in 
color  the  fibrinous  mass. 

On  both  sides  of  the  tumor  only  a  hyperplasia  of 
the  mucous  membrane  is  to  be  noticed,  showing  an 
increase  of  the  interglandular  connective-tissue  cells 
and  a  greater  widening  of  the  glands.  The  change 
of  the  glands  at  the  edge  of  the  syncytial  masses  is 


extremely  characteristic.  The  epithelial  cells  alter 
first  their  cylindrical  shape,  becoming  larger  and 
changing  into  spherical  or  cuboidal  elements  with  a 
central  nucleus  and  a  very  narrow  zone  of  protoplasm. 
They  soon  commence  to  proliferate,  and  instead  of  a 
single  layer  several  layers  are  now  lining  the  glandu- 
lar cavity.  In  this  stage  the  nucleus  is  very  little  en- 
larged, with  a  very  small,  scarcely  recognizable  mar- 
gin of  protoplasm.  The  glandular  epithelium  then 
breaks  down,  the  cells  lying  in  patches  within  the 
glandular  cavity,  while  some  of  them  still  adhere  to 
the  wall.  Finally  they  detach  themselves  entirely 
from  the  wall  and  lie  irregularly  scattered  around  the 
former  gland's  cavity,  resembling  enlarged  lympho- 
cytes. The  disintegrated  cells  are  irregular  in  out- 
line with  a  round,  darkly 


^jr***      t -...       -- — 


Fig.  6. — Portion  of  Fig.  4  at  .r.r,  to 
Show  the  Disintegration. 


Staining  nucleus.  Their 
bodies  stain  slightly  with 
eosin  and  appear  to  be  in 
a  stage  of  hyaline  meta- 
morphosis. These  aggre- 
gations of  epithelial  cells 
send  out  shoots  into  the 
syncytial  masses.  O  n 
their  way  the  nuclei   lose 

entirely  their  narrow  marginal  protoplasm  and  fuse 
finally  with  the  syncytium.  I  failed  to  find  any  de- 
cidual cells  anywhere. 

The  intermuscular  connective  tissue  is  somewhat 
thickened.  The  uterine  blood-vessels  in  the  interval 
between  the  rem.nants  of  the  circular  layer  and  the 
longitudinal  layer  are  greatly  dilated.  Especially  the 
media  is  much  thickened,  but  the  looser  layer,  the  ad- 
ventitia.  is  also  changed.  The  endothelium  seems  to 
be  normal.  In  some  transverse  sections  I  v.'as  able 
to  recognize  syncytial  masses  within  the  vessel's  lumen. 

From  the  description  it  is  seen  that  this  case  agrees 
in  most  particulars  with  those  already  recorded.  It 
represents  the  early  beginning  of  a  malignant  growth. 
By  far  the  greatest  part  of  the  tumor  appears  to  be  a 
pure  product  of  a  coagulation  as  described  by  Mar- 
chand.'  In  his  case  the  small  nodule  consists  also  of 
coagulated  products.  There  can  be  no  doubt  that  the 
tumor  is  a  pure  case  of  chorio-epithelioma  malignum. 
The  plasmodial  syncytial  masses  were  always  char- 
acterized by  three  points:  (i)  absence  of  cell-outline, 
(2)  deeply  staining  nuclei,  and  (3)  vacuolation. 
These  three  characteristic  points  are  found  in  our 
case  in  the  masses  surrounding  the  fibrin.     The  essen- 


Fig.  7. — Showing  the  Change  of  the  Glandular  Epithelium  into  Syncytial 
Masses.  a,  Glandular  Cavity  ;  d,  broken-down  epithelial  cells ;  r, 
lymphocytes. 

tial  part  of  deciduoma,  says  Pfannenstiel,^  is  the  large 
polymorphic,  multinucleated,  darkly  staining  proto- 
plasmatic masses,  which  were  found  by  all  the  authors  , 


July  28,  1900] 


MEDICAL    RECORD. 


12' 


and  which  are  partly  derived  from  the  syncytium. 
The  protoplasmatic  masses  in  our  case  are  also  multi- 
nucleated and  darkly  staining.  They  are  partly  seen 
in  coherent  chains,  partly  dissolved  into  single  indi- 
viduals as  Freund  ''  characterizes  them.  Freund  found 
also  that  in  the  malignant  chorionic  growths  the  syn- 
cytial proliferation  does  not  always  penetrate  the  tissue 
in  form  of  coherent  chains,  but  dissolves  into  single 
individuals,  which  are  lying  either  isolated  or  in  heaps 
near  each  other.  Besides  numerous  large  multiform 
cells,  the  syncytial  wandering  cells  are  also  found  in 
our  case  dispersed  through  the  fibrinous  tissue  and  at 
some  points  in  larger  aggregations.  There  is  there- 
fore no  doubt  that  the  tumor  is  composed  of  the  two 
elements  which  form  the  normal  epithelium  of  the 
choiionic  villi,  of  syncytium  and  ectodermal  cells. 
The  tumor  is  further  characterized  as  malignant  by  its 
completely  destroying  the  muscular  fascicles  to  the 
entire  depth  to  which  it  invades  the  uterine  wall. 

A  few  words  will  now  suffice  about  the  strange  pres- 
ence of  the  enormous  fibrinous  masses.  Marchand 
considers  this  coagulation  to  be  the  first  stage  in  the 
formation  of  the  tumor.  I,  on  the  other  hand,  am 
inclined  to  think-  it  is  the  last  stage  in  the  proc- 
ess. Hyaline  metamorphosis  is  generally  a  sign  of 
degeneration  and  not  of  proliferation.  I  perfectly 
agree,  therefore,  with  Gottschalk,'  who  found  that  the 
farther  the  villi  penetrate  the  wall  of  the  uterus,  the 
more  the  superficial  parts  are  separated  from  their 
nutritive  soil  and  suffer  a  speedy  necrosis.  This 
necrosis  may  easily  assume  larger  dimensions.  Even 
the  whole  nodule  can  be  affected  by  it.  In  our  case 
the  hyaline  degeneration  is  also  considerably  more 
advanced  in  the  deeper  than  in  the  peripheral  portions 
of  the  tumor.  This  necrosis  would  thus  represent  na- 
ture's attempt  at  healing,  as  the  formation  of  colloid 
in  carcinoma  colloids.  She  fails,  because  the  yet 
living  syncytial  masses  continue  to  proliferate,  de- 
stroying everything  in  their  advance. 

As  to  the  origin  of  the  fibrin,  it  seemed  to  me  that 
the  l.irge  ectodermal  cells  stand  mainly  in  close  rela- 


FlG.  8. — Showing  the  Degenerative  Metamorphosis  of  Langhans'  Cells  into 
P"ibrin.     a,  Fibrin  ;  ^,  syncytium  ;    (,  ectodermal  cells, 

tion  to  the  formation  of  the  fibrin.  I  will  not  deny 
the  possible  participation  of  the  syncytial  masses 
in  this  formation.  I  have  often  found  a  hyaline  de- 
generation in  the  round  granular  cells,  with  obvious 
division  into  nucleus  and  surrounding  protoplasm 
derived  from  the  glandular  uterine  epithelium.  The 
narrow  margin  of  protoplasm  becomes  more  homoge- 
neous, appearing  hyaline  and  glistening  and  greatly  re- 
sembling in  color  the  fibrinous  masses.  Minot's'  ob- 
servations show  also  conclusively  that  the  canalicular 
fibrin  arises  through  a  degenerative  metamorphosis  of 
the  epithelium,  which   begins  in  the  outer  layer  and 


Fig.  g.— Showing  a  Uterine  Vessel  in  the 
Inter\*al  between  the  Circular  and  Lon- 
gitudinal Muscular  layers,  a.  Syncytial 
mass  within  the  ve-Jsel's  lumen  :  i^,  en- 
larged media  ;  r,  adventitia  ;  i£,  perivas- 
cular connective  tissue. 


may  invade  the  inner  layer,  the  cell  layer  of  Langhans. 
In  tiie  large  patches  the  cells  are  less  individual, 
owing  to  the  spread  of  the  process  of  degeneration  into 
the  layer.  But  the  presence  of  the  polyhedral,  large 
granular  wandering  cells  irregularly  spread  through  the 
fibrinous  masses  makes  the  view  more  acceptable,  that 
the  fibrin  is  mainly  the  product  of  the  degenerated 
cells  of  Langhans'  layer,  and  the  outlines  of  cells  that 
ace  still  plainly  re- 
cognizable, show  the 
various  degrees  of  the 
process  of  degenera- 
tion    (compare     Fig. 

8). 

The  disintegration 
of  the  glandular  epi- 
t  h  e  1  i  u  m  and  its 
change  into  syncytial 
masses,  as  seen  in 
our  case  in  spots 
near  the  tumor,  are 
especially  instruc- 
tive. The  epithe- 
lium is  found  in 
various  stages  of  con- 
version into  syncy- 
tium. It  can  be 
noted  how  the  cylin- 
drical cells  become 
cuboidal  and  oval  in 
shape.  They  soon 
break  down.  Each 
cell   is  cleft  from  its 

fellows,  and  some  of  them,  loosened  from  the  wall,  lie 
free  in  the  glandular  cavity.  Finally  they  fuse  together 
and  dissolve  in  the  syncytial  masses.  I  have  therefore 
no  doubt  to  attribute  the  origin  of  the  syncytium  to 
the  glandular  uterine  epithelium.  Turner"  assigns  the 
deep  layer  to  the  chorion  as  its  true  and  only  epithe- 
lium and  the  outer  layer  to  the  uterus.  But  after  ac- 
cepting the  outer  layer  as  maternal  the  question  as  to 
its  origin  still  remained.  Marchand'  is  of  the  opinion 
that  the  syncytium  can  be  traced  back  to  the  changed 
uterine  epithelium  or  to  the  outer  epithelial  layer  of 
the  chorionic  villi  that  is  derived  from  the  former. 
Kossman'  says:  There  cannot  now  be  any  doubt  that 
the  syncytium  is  nothing  else  than  the  changed  uterine 
epithelium,  changed  by  an  obliteration  of  the  cell- 
boundaries.  Selenka'  also  found  that  the  villi  of  the 
chorion  invade  the  uterine  glands  and  in  further  ad- 
vancing receive  the  flattened  glandular  epithelium 
as  a  second  layer  for  their  investment.  In  our 
case  I  failed  to  recognize  true  chorionic  villi  any- 
where, yet  the  glandular  epithelium  continue*  to 
change  into  syncytium.  This  atypical  formation 
shows  the  malignancy  of  the  tumor;  the  glands  con- 
tinue to  furnish  syncytium  as  an  investment  for  villi 
that  are  no  more  in  existence. 

Bibliography. 

1.  Marchand:   Zeitschrift  fiir  Geburtshulfe    u.   Gynakologie, 
189S. 

2.  Pfannenstiel :  Centralblatt  fiir  Gynakologie,  l8gS. 

3.  Freund  :  Zeitschrift  fiir  Geburtshulfe  u.    Gynakologie,  No. 
34- 

4.  Gottschalk  :  Archiv  fiir  Gynakologie,  No.  46. 

5.  Minot  :   Human  Embryology, 

6.  Turner:  Journal  of  Anatomy  and  Physiology,  1S76, 

7.  Marchand  :   Monatschrift  fiir  Geburtshiilfe  u.  Gynakologie, 
1895. 

8.  Kossmann  :  Monatschrift  fiir  Geburtshiilfe  u.  Gynakologie, 
vol.  ii, 

9.  Selenka  :  Diolog.  Centralblatt,  vol.  .x, ,  iSrjl. 


Amputation  of  the  Tonsil  is  good  treatment  for 
foul  breath  originating  in  decomposing  secretions  in 
the  crypts. — Fraenkel. 


124 


MEDICAL    RECORD. 


[July  28,  1900 


HYPOSPADIAS    OPERATED 
METHOD. 


OX    BY    BECK'S 


By   FERD.    C.    valentine,    M.D., 

PROFESSOR  OF  GENITO-L'RISARV  DISE.*SES,  NEW  YORK  SCHOOL  OF  CLINICAL 
MBOICINE  ;  GENITO-URINARY  SURGEON,  WEST  SIDE  GERMAN  DISPENSARV; 
CBNITO-URINARV  CONSULTANT  TO  THE  METROPOLITAN  HOSPITAL  AND 
DISPENSARV  ;  TO   THE   INITED    HEBREW   CHARITIES,    ETC. 

The  hypospadias  in  this  case  was  penile;    the    ure- 
thra opened  half  an  inch  below  the  glans.     The  glans 


V 


Fig  I. — Front  View,  rt,  a.  Prepuce  partly  encircling  the  glans  ;  /',  sulcus 
taking  the  place  of  the  fossa  navicularis ;  c,  abnormal  urethral  orifice  ;  tf,  </, 
d^  d,  S,  openings  of  para-urethral  fistulcc. 


itself  appeared  normal,  except  when  its  lower  halves 
were  separated;  this  then  revealed  them  to  be  un- 
united, a  deep,  wide  sulcus  occupying  the  place  of 
the  fossa  navicularis  (Fig.  i).  Five  para-urethral 
fistula;  opened  irregularly  about  the  urethral  opening 
and  the  glans. 

On  inserting  a  sound  into  the  urethra,  the  relations 
became  more  evident  and  the  glans  seemed  almost  an 


Fig.  2. — Lateral  View,  a.  Prepuce  forming  a  ruff  about  the  posterior  part 
of  the  penis ;  /',  sulcus  in  place  of  the  fossa  navicularis  ;  c,  abnormal  ure- 
thral oriticc  ;  d,  d,  (/,  para-urethral  fistula;  ;  c,  sound  inserted  into  the  ab- 
normal urethral  orifice. 

independent  attachment  to  the  penis  (Fig.  2).     As  the 
treatment  of  this  case  demonstrates  the  typical  Beck 

'  Deinonstrated  before  the  Genito-Urinary  Section,  New  York 
Academy  of  Medicine,  April  18,  1900. 


operation  for  hypospadias,  it  will  be  well  to  recite 
each  step  of  the  procedure  as  it  was  performed: 

An  incision  was  carried  from  the  centre  of  the  ab- 
normal urethral  opening,  through  the  skin,  to  the  pos- 
terior third  of  the  pendulous  portion.  At  the  upper 
end  of  this  incision  another  was  made  througii  the 
skin,  encircling  the  lower  third  of  the  neck  of  the 
penis,  immediately  below  the  coronary  sulcus.  The 
skin-flaps  so  obtained  were  dissected  back  to  expose 
the  lower  third  of  the  penis.  Then  the  urethra,  to- 
gether with  its  corpus  cavernosum,  was  dissected  from 
its  bed  between  the  corpora  cavernosa  penis  (Fig.  3). 
A  narrow,  straight  bistoury  was  then  thrust  through 
the  glans  (Fig.  4)  from  below  upward  and  well  be- 
hind the  sulcus  which  normally  would  have  been  the 
fossa,  making  a  new  meatus  about  a  quarter  of  an  inch 
behind  the  topmost  angle  of  this  sulcus.  The  point 
of  emergence  of  the  knife  was  enlarged  by  turning  it 
to  the  right  and  the  left,  making  an  incision  at  each 
side. 

After  the  knife  was  withdrawn,  a  long,  narrow  for- 
ceps was  passed  from  above  through  the  channel  and 
the  urethra  grasped  (Fig.  j). 

Owing  to  the  longitudinal  extensibility  of  the  ure- 
thra, first  described  by  Beck,   it  was  rather  easy  to 


Fig.  3. — First,  Second,  and  Third  Steps  of  the  Beck  Operation  for  Hypo- 
spadias, a,  ti,  Skin  flaps  dissected  frnin  the  lower  surface  of  the  penis  ;  i, 
sulcus  in  the  glans;  c,  c,  urethra  dissected  out;  (/,  d,  d^  para-urethral 
fistulee,  disregarded  during  the  operation. 

Note:  The  skin  flaps  ^a,  a)  appear  in  this  illustration  somewhat  more 
widely  dissected  from  the  penis  than  they  were  in  reality. 

draw^  the  freed  end  of  the  urethra  through  the  channel 
perforating  the  glans  and  to  attach  its  opening  by 
means  of  four  sutures  to  the  new  meatus.  In  so 
doing  the  glans  was  somewhat  crushed  forward,  thus 
obliterating  the  deep  sulcus  which  had  occupied  the 
place  of  the  fossa  navicularis.  The  para-ureihral  fis- 
tulae  were  disregarded  during  the  c^erating. 

After  attaching  the  end  of  the  ure'hra,  as  before 
described,  the  flaps  beneath  the  glans  were  sutured 
into  their  former  position. 

On  the  third  night  after  the  operation,  the  patient 
had  a  seminal  emission,  during  which  one  of  the 
stitches  at  the  meatus  was  torn  out  of  the  tissues. 
Another  was  substituted  for  it  and  the  healing  there- 
after was  eventless. 

The  site  of  the  incisions  was  at  first  infiltrated,  as 
would  naturally  be  expected.  The  consequence  was 
that  erections  were  incurvated  at  an  angle  formed  by 
the  glans  and  the  penis.  This  infiltration  gradually 
yielded  to  dilatations  of  the  anterior  third  of  the  ure- 
thra, so  that  now,  two  months  after  operation,  the  pa- 
tient reports  his  erections  as  entirely  painless  and 
with  not  enough  incurvation  remaining  to  prevent  in- 
tromission in  coitus  (Fig.  6). 


July  2S,   1900] 


MEDICAL    RECORD. 


125 


The  para-urethral  fistulas,  which  were  disregarded 
during  the  operation,  closed  spontaneously.  Xo  ves- 
tige of  them  is  now  visible.  The  mental  depression 
of  the  patient,  due  to  the  continued  consciousness  of 
deformity,  has  also  disappeared. 

In  attributing  this  ingenious  operation  to  Carl  Beck, 
of  Xew  York,  I  am  not  actuated  solely  by  patriotism. 
The  special  facilities  that  were  so  kindly  afforded  me 
for  study  and  observation  by  the  great  men  of  Ger- 
many, France,  and  England  would  preclude  my  being 
ungrateful,  by  insisting  otherwise  than  that  science 
lias  no  country.  Moreover,  Beck  needs  no  champion 
to  advocate  his  cause.  But  I  may  be  allowed  to  avail 
myself  of  this  occasion  to  protest  against  the  all  too 
prevalent  tendency  that  exists  to  "originate"  an  oper- 
ation, a  method,  or  an  instrument  which  another  has 
fully  described  before.  In  such  secondary  "discov- 
eries," the  real  originator  is  most  egregiously  ignored. 
Sometimes  the  new  "originator,''  who  was  present  at 
the  first  demonstration,  or  studied  the  first  publication 
of  the  one  who  devised  the  novelty,  adds  to  it  a  use- 
less or  deleterious  suppendage;   it  would  be  charity  to 


In  this  report  3  cases  of  hypospadias  operated  upon 
by  Beck's  method  are  reported. 

After  presenting  the  case,  a  number  of  fellows  of 
the  Academy,  in  discussing  it,  warmly  congratulated 


Fig.  4. — Formation  of  a  New  Channel  through  the  G'ar.s. 

aver  that  he  did  so  through  a  capricious  memory, 
which  caused  him  to  forget  that  the  genuine  work  was 
done  by  his  predecessor.  Carl  Beck,  of  New  York,  is 
among  those  made  to  suffer  by  such  treatment,  as  liter- 
ature shows.  On  October  4,  1897,  he  demonstrated 
his  operation  for  hypospadias  before  the  Deutsche 
medicinische  Gesellschaft  der  Stadt  Xew  York;  this 
he  described  in  the  iVVw  Yorker  tiiedkitiische  Alomits- 
schrijt  for  November,  1897.  In  the  New  York  Medi- 
cal Journal  for  January  29,  1898,  he  detailed  the 
operation,  and  in  doing  so  he  distinctly  specified  its 
essential  features,  among  them  "dissecting  the  urethra 
from  its  bed  and  extending  it  to  do  the  service  of  a 
new  canal."  von  Hacker  ten  months  later  (^Beiirci,i;e 
zur  klinischen  C/iiruigle,  August,  1898)  announced  the 
identical  operation  as  his  own.  Another  author, 
Breveer,  performed  the  same  feat  {Centralblatt Jur  Chi- 
riirgie,  No.  29,  189S),  but  he  afterward  gracefully  con- 
ceded Beck's  priority.  I  hold,  therefore,  that  I  am 
fully  justified  in  designating  as  Beck's  the  operation 
done  in  this  case.  If  Beck's  priority  needs  further 
proof,  it  will  be  found  on  pages  157  and  158  of  the 
Beitrdge  ziir klinischen  Chirurgie  (April,  1900)  contain- 
ing the  reports  of  Heidelberg  Surgical  Clinic  for  1898. 


Fig.  5. — Drawing  the  Urethra  through  the  New  Channel. 

me  on  the  results.  I  deemed  it  my  duty  to  say,  and 
take  occasion  now  to  repeat,  tliat  all  the  congratula- 
tions I  received  belong  to  Dr.  Carl  Beck,  who  not  only 
devised  the  method  but  rendered  the  valuable  encour- 


^^^ 


Fig.  6. — Two  Months  After  Operation,  The  penis  is  raised  by  the  defective 
prepuce  (a,  <2),  which  is  stretched  so  as  thoroughly  to  expose  the  organ  ; 
f,  new  meatus  ;  d^  d,  */,  d,  d^  sites  of  the  former  para-urethral  fistula:, 

agement  of  his  presence  and  personal  aid  in  the  opera- 
tions. 

I  desire  publicly  to  thank  my  patient,  Mr.  C.  S , 

for  coming  before  the  section. 


For  Tremor  in   paralysis  agitans,  hyoscine  hydro- 
bromate,  gr.  ^i^,  twice  daily. 


126 


MEDICAL    RECORD. 


[July  28,  1900 


THE     PERITONEUM— ANATOMY,     PHYSIOL- 
OGY, AND  PATHOLOGY. 

By   BVRON    ROIUNSON,   IJ.S.,    M.D.. 


PROFBSSOR   IN   THE  CHICAGO    POST-GRADUATE  SCHOOL    OF    GVN-ECOLOGY    AND 
ABDOMINAL  SfRGERY. 

Anatomy The  peritoneum    is  a   lymph  sac  whose 

walls  line  the  abdominal  cavity.  The  peritoneum 
proper  begins  and  perfects  itself  in  the  fish.  From 
fish  to  man  the  peritoneum  is  the  same  structure: 
nothing  added,  nothing  subtracted,  only  modified. 
Peritoneal  pores  (pori  peritoneales)  begin  in  the  fish 
and  e.xist  in  the  man  as  the  ostia  abdominalia  at  the 
ends  of  the  oviducts.  It  appears  that  the  abdominal 
cavity  or  coelom,  i.e.,  the  space  between  the  ectoderin 
and  the  entoderm,  was  once  filled  with  mesoderm  and 
that  it  atrophied  or  partially  disappeared,  leaving  the 
viscera  covered  with  peritoneum  projecting  into  it. 

The  essential  structure  of  the  peritoneum  is  an  ex- 
ceedingly thin  membrane,  composed  of  endothelial 
cells  so  arranged  with  their  edges  in  contact  that  the 
membrane  is  continuous  or  uninterrupted.  The  endo- 
thelial cell  is  a  connective-tissue  cell  flattened  by 
pressure  or  stretching  in  the  embryo.  Lying  between 
the  endothelial  cells  are  interendothelial  spaces.  At 
the  junction  of  several  endothelial  cells  there  exists 
an  aperture  (mouth)  called  a  stoma  verum,  which  is 
lined  with  granular  polyhedral  nucleated  cells.  Lo- 
cated in  the  interendothelial  spaces  are  the  stomata 
spuria.  The  stomata  open  into  the  subperitoneal 
lymph  channels.  Silver  nitrate  one-fourth  per  cent, 
applied  to  fresh  peritoneum  brings  to  view  micro- 
scopically the  outlines  of  the  endothelial  cells,  sto- 
mata vera  at  spuria,  and  the  interendothelial  spaces. 

The  four  elements  of  the  peritoneum — (a)  endothe- 
lial cell,  (b)  interendothelial  spaces,  (c)  stomata  vera, 
[d)  stomata  spuria — constitute  the  structure  peculiar 
to  the  peritoneum.  The  subperitoneal  tissue  is  simply 
mesodermic  tissue.  The  anatomical  use  of  the  perito- 
neum is  to  anchor  and  limit  the  motion  of  the  viscera; 
to  produce  maximum  motion  with  minimum  friction. 
The  peritoneum  is  a  joint  of  vast  interest  and  dimen- 
sions. It  is  endowed  with  wonderful  elasticity  and  is 
very  mobile  on  its  base.  The  internal  peritoneum 
surface  is  smooth,  shiny,  moist,  and  slippery  from  its 
secretions.  It  is  a  closed  sac  except  in  the  female. 
Of  special  interest  in  the  peritoneum  are  the  mesen- 
teries, wliich  consist  of  a  peritoneal  (endothelial)  mes- 
entery (temporary  or  permanent),  and  a  mesodermic 
mesentery  (permanent).  The  utility  of  the  mesen- 
tery is  as  a  neuro-vascular  visceral  pedicle,  and  to 
limit  the  motion  and  position  of  viscera. 

Physiology. — The  physiology  of  the  peritoneum  is 
its  utility  in  the  animal  economy.  It  is  the  most 
important  serous  membrane  in  the  body,  from  its  rela- 
tion to  and  influence  over  numerous  and  different 
viscera,  and  also  its  life-protecting  capacity.  Experi- 
mentation alone  can  demonstrate  its  use.  It  is  a  joint 
in  all  its  functions.  It  absorbs  and  secretes  fluid. 
Fluids  poured  into  the  living  peritoneal  cavity  disap- 
pear at  the  rate  of  (in  the  dog)  ten  per  cent,  of  the 
body  weight  in  an  hour  (and  at  the  rate  of  five  per 
cent,  a  few  hours  after  death). 

To  discover  the  paths  of  fluid  exit  from  the  perito- 
neum, pour  in  fluid  containing  particles  of  Berlin 
blue,  which  will  be  found  to  be  directed  chiefly  tow- 
ard the  diaphragm  and  through  the  lymph  channels. 
The  particles  of  Berlin  blue  will  be  found  passing 
tiirough  the  chief  stomata  vera,  aided  by  thousands 
of  leucocytes  which  swarm  out  of  the  peritoneal 
mouths,  seizing  the  Berlin-blue  particles  and  hasten- 
ing onward  with  them  into  the  subperitoneal  lymph 
channels. 

From  my  own  numerous  experiments  and  those  of 


others,  it  appears  we  are  warranted  in  the  following 
physiological  conclusions: 

1.  The  primary  path  by  which  fluids  pass  from  the 
peritoneum  into  the  circulation  is  by  the  way  of  the 
lymphatics.  The  secondary  path  is  the  blood-vessels. 
Hamberger,  with  some  others,  asserts  that  the  primary 
path  is  by  the  way  of  the  blood-vessels. 

2.  A  stream  of  fluid  exists  in  the  peritoneum  di- 
rected toward  the  diaphragm. 

3.  The  anatomical  structure,  physiological  function 
(respiration),  of  the  diaphragm  enables  it  to  act  like 
a  suction  or  force  pump. 

4.  In  five  minutes  after  injection  of  a  solution  hold- 
ing Berlin  blue  in  suspension  into  the  abdomen,  the 
colored  granules  may  be  found  in  the  sub-diaphrag- 
matic lymph  bed  and  intra-thoracic  glands. 

5.  So  far  as  my  experiments  extend,  the  diaphragm 
is  the  primary  locality  of  peritoneal  absorption  of  solid 
granules.  Others  assert  that  the  rootlets  of  the  portal 
vein  also  absorb  solids,  but  I  have  not  been  able  to 
confirm  it. 

6.  The  vast  function  of  absorption  performed  by  the 
diaphragm,  and  the  very  small  part  taken  in  this  proc- 
ess by  other  portions  of  the  peritoneum,  account  for 
the  non-fatality  in  cases  in  which  there  is  a  purulent 
condition  found  at  the  oviductal  ends  and  aljout  the 
appendix,  and  when  there  is  a  ruptured  gall  bladder, 
which  is  circumscribed  and  confined  by  the  ligamen- 
tum  hepato-colicum.  The  virulent  microbes  or  their 
products  are  not  absorbed,  but  circumscribed. 

7.  On  account  of  vigorous  absorptive  powers,  the 
nearer  peritonitis  approaches  the  diaphragm  the  more 
dangerous  it  is  to  life. 

8.  The  stomata  vera  are  the  most  numerous  and 
constant  of  the  diaphragmatic  serosa.  They  are  the 
mouths  of  the  vast  lymph  bed  located  in  the  dia- 
phragm. 

g.  When  foreign  bodies  (microbes  or  colored  gran- 
ules) enter  the  peritoneum  the  leucocytes  swarm  out 
(ii)  to  digest  the  invader,  (/')  to  surround  or  imprison 
the  microbe,  or  (r)  to  sterilize  the  germ. 

10.  It  appears  to  be  the  leucocyte  which  carries  the 
colored  granules  from  the  peritoneal  cavity  through 
the  stomata  vera  into  the  sub-peritoneal  diaphragmatic 
lymphatics. 

11.  The  normal  peritoneum  is  automatic  in  regulat- 
ing the  quantity  of  fluids  contained.  Normally  it 
will  absorb  all  excessive  fluid;  but  in  abnormal  con- 
ditions it  may  only  add  to  the  fluid  injected. 

12.  If  potassium  ferrocyanide  is  injected  into  tlie 
peritoneal  cavity  it  will  appear  in  the  urine  much 
sooner  (about  twenty  minutes)  if  the  thoracic  duct 
is  not  ligated.  Ligation  of  the  thoracic  duct  retards 
its  appearance  in  the  urine.  Hence,  with  open  lym- 
phatics the  ferrocyanide  appears  in  the  urine  much 
more  rapidly. 

13.  The  diaphragm  absorbs  fluid  perhaps  by  imbi- 
bition. Imbibition  is  molecular  when  a  mass  of  tis- 
sue absorbs  the  fluid,  and  capillary  when  it  passes 
through  the  pores  of  the  vessels. 

The  forces  which  are  said  to  produce  peritoneal 
absorption  of  fluids  may  be  enumerated  as  follows: 
((7)  Vital  cell  forces,  (/')  stomata,  {c)  imbibition,  (<•/) 
infiltration,  (<■)  intra-abdominal  pressure  (mechani- 
cal), (/)  osmosis. 

The  leucocytes  act  as  a  body-guard  to  the  perito- 
neum. At  a  moment's  notice  (irritation),  the  army  of 
leucocytes  emerge  to  protect  the  peritoneum  against 
the  invasion,  viz.,  by  digestion,  imprisonment,  trans- 
portation, or  sterilization  of  the  foreign  body,  be  it 
vegetable  germ  or  inorganic  particle. 

The  peritoneum  has  a  limited  power  to  resist  septic 
germs.  At  present  we  have  no  standard  by  which  the 
power  may  be  measured.  The  power  to  resist  septic 
germs  is  slightly  different  in  animals.     The  perito- 


July  28,  1900] 


MEDICAL    RECORD. 


127 


neum  of  the  pig,  rabbit,  and  cow  resist  considerable 
quantities  of  septic  organisms.  The  mare's  perito- 
neum is  so  sensitive  to  septic  germs  that  laparotomy 
on  her  is  almost  always  fatal.  The  dog  and  man  are 
about  equal  in  their  power  to  resist  peritoneal  inva- 
sions of  pathogenic  germs.  Some,  however,  claim  that 
the  peritoneum  of  a  dog  resists  more  than  that  of  man. 

The  rapid  fluid  absorption  by  the  peritoneum  argues 
against  irrigation  in  laparotomy,  from  the  fact  that  by 
irrigation  the  germs  would  become  widely  and  rapidly 
distributed. 

Pathology. — That  disease  of  the  peritoneum  is  also 
a  matter  of  experimentation  was  demonstrated  in  the 
rapid  development  of  the  science  of  abdominal  sur- 
gery. Peritonitis  saves  life,  while  sepsis  kills.  Peri- 
tonitis is  a  life-saving  process:  it  builds  barriers 
against  the  invading  host,  while  absorption  overw^helms 
the  system  with  infective  products.  Peritoneal  exu- 
dates circumscribe  microbes;  imprison  and  sterilize 
them.  The  diagnosis  of  peritonitis  should  be  more 
cultivated.  The  temperature  is  often  of  the  least  value 
in  the  most  critical  cases.  The  pulse  is  the  most  re- 
liable. Tympanites,  abdominal  muscular  rigidity,  ten- 
derness on  pressure,  and  the  facies  peritonei  tell  their 
own  tale.  It  must  be  definitely  understood  that  pa- 
tients suffering  from  septic  peritonitis  are  in  a  state 
of  toxemia,  which  clinically  resembles  profound  shock. 
The  nervous  system  is  profoundly  impressed  with  sep- 
sis. Such  patients  bear  anaesthesia  very  badly,  hence 
the  operation  for  all  septic  cases  of  peritonitis  which 
are  surgical  should  be  done  under  very  little  anses- 
thesia,  supported  by  hot  rectal  injections,  or  hypodermic 
doses  of  strychnine  and  whiskey  in  the  rectum.  The 
pulse  must  be  watched  every  moment,  as  collapse  may 
occur  at  any  time.  With  definite  diagnosis,  a  median 
abdominal  incision  should  be  made.  During  opera- 
tion the  intestines  must  be  thorougiily  protected  and 
wrapped  in  moist,  warm  towels.  The  examination  of 
the  intestines  should  be  performed  systematically.  It 
should  be  the  rule  first  to  strike  for  the  landmarks, 
pelvic,  appendicular,  and  gall-bladder  region,  and  if 
the  lesion  is  not  found,  to  continue  systematic  exam- 
ination until  it  is  found.  Irrigation  should  not  be 
employed:  it  only  distributes  germs.  A  rubber  tube 
enclosed  in  strips  of  gauze  makes  the  best  drain. 

After  the  operation,  mild  chloride  in  one-grain 
doses  every  hour,  with  a  half  to  one  teaspoonful  of 
sulphate  of  magnesia  hourly,  until  five  grains  of  mild 
chloride  and  six  drachms  to  two  ounces  of  salts  are 
taken,  is  a  useful  course  to  follow.  This  revives  in- 
testinal peristalsis,  starts  the  secretions,  and  affords 
drainage  from  the  mucosa.  One-sixtieth  of  a  grain  of 
sulphate  of  strychnine  every  hour  aids  peristalsis.  All 
the  whiskey  a  septic  patient  can  bear  is  good  treat- 
ment. 

To  observe  the  plienomena  of  peritonitis  the  follow- 
ing experiment  speaks  volumes:  I  injected  the  peri- 
toneum of  a  turtle  with  an  ounce  of  water  holding 
Berlin  blue  in  fine  suspension.  Four  or  five  weeks 
later  the  turtle  (four  pounds)  died  of  peritonitis.  The 
autopsy  showed  cedematous  and  intensely  vascular 
peritoneum.  In  short,  the  interpreted  results  were  the 
following:  The  fine  particles  of  Berlin  blue  were  dis- 
tributed in  the  lymphatic  vessels  of  the  peritoneum. 
They  collected  especially  along  the  numerous  pig- 
ment cells  which  aid  to  make  the  walls  of  the  lymph 
vessels.  Large  masses  of  exudates  could  be  seen  over 
the  endothelial  surface.  The  endothelia  were  desqua- 
mated, leaving  pits  on  the  surface.  Numerous  leuco- 
cytes were  to  be  seen  emerging  through  the  stomata 
and  interendothelial  spaces.  They  attack  all  foreign 
bodies  and  surround,  imprison,  sterilize,  or  digest  them. 
Hemorrhagic  peritonitis  existed  in  localities,  i.e.,  thou- 
sands of  red  blood  corpuscles  were  emerging  on  the 
endothelial  surface  from  endothelial  lesions. 


The  signification  of  this  terribly  destructive  process 
is:  (a)  the  endothelial  surface  is  an  infective  atrium; 
(/')  the  endothelial  or  peritoneal  surface  is  trying  to 
defend  itself  by  (i)  calling  out  the  body-guard,  the 
army  of  white  corpuscles,  the  leucocytes,  who  are 
swarming  on  the  surface.  They  emerge  through  the 
stomata  and  interendothelial  spaces.  These  leuco- 
cytes may  be  seen  partially  through  and  fixed  in  the 
stomata  or  interendothelial  spaces.  They  are  merci- 
less on  intruders,  seizing  and  surrounding  them,  im- 
prisoning, sterilizing,  isolating,  and  even  devouring 
them.  (2)  The  exudate  pours  out  vast  quantities  in 
response  to  the  irritant  (microbe  or  its  product).  The 
exudate  builds  forts  or  barriers  and  checks  invasion 
by  mechanical  means.  The  battle  is  never  a  drawn 
one:  it  must  be  lost  or  won.  It  is  to  kill  or  to  be 
killed;  the  microbes  or  the  leucocytes  must  be  victo- 
rious. If  the  battle  between  the  leucocytes  and  mi- 
crobes lasts  long,  the  heaps  of  slain  leucocytes  or 
microbes  attest  the  fierce  combat  for  life. 

The  hemorrhagic  peritoneum  reports  partial  or 
complete  victory  of  the  microbe  or  its  products  (chem- 
ical). The  endothelia  have  become  desquamated, 
loosened  in  their  pitted  bed,  producing  a  lesion  in 
the  peritoneum,  out  of  which  ooze  thousands  of  red 
corpuscles;  the  enemy  is  conquering  the  territory. 
The  process  known  as  peritonitis — a  life-saving  proc- 
ess—has  yielded  to  infection,  which  kills. 

The  leucocytes,  the  body-guard  of  the  peritoneum, 
are  capable  of  vast  resistance.  The  leucocytes  are 
an  automatic  standing  army,  and  whatever  calls  out 
the  one  leucocyte  appears  to  call  out  a  host  sufficient 
for  the  occasion.  The  treatment  for  such  a  perito- 
neum is  drainage  and  not  irrigation,  which  would  rap- 
idly sweep  the  pathogenic  microbes  and  their  chemi- 
cal products  to  distant  fields,  entirely  out  of  reach  of 
the  mobilized  army  of  leucocytes  on  the  original  bat- 
tle-field. 

The  peritoneum  is  a  lymph  sac.  It  is  a  serous 
membrane,  similar  to  the  pleura,  pericardium,  and 
synovia.  If  one  will  imagine  the  empty  abdominal 
cavity  lined  with  peritoneum,  and  the  viscera  gradu- 
ally growing  from  the  dorsal  wall,  pushing  the  peri- 
toneum before  them  until  they  fill  the  cavity,  a  good 
view  of  the  peritoneal  relations  will  be  obtained.  It 
forms  supports  to  organs  by  anchoring  and  holding 
them  in  definite  relations.  The  supports  are  called 
mesenteries,  for  intestinal  supports;  ligaments,  for  the 
support  of  more  solid  organs;  and  omenta,  connecting 
the  stomach  to  some  other  organ. 

The  peritoneum  consists  of  two  diverticula — a  lesser 
and  a  greater — communicating  with  each  other  through 
the  foramen  of  Winslow.  All  organs  lie  outside  of 
the  peritoneum.  It  is  a  closed  sac  superimposed  on 
the  viscera  and  tucked  between  and  among  visceral 
folds.  In  woman  an  anatomical  peculiarity  exists, 
namely,  the  two  openings  in  the  peritoneum  for  the 
transmission  of  ova.  The  mature  egg  breaks  through 
the  folds  of  peritoneum  which  cover  the  ovary,  and 
the  oviduct  opens  into  the  peritoneal  cavity  in  order 
to  secure  it  for  carriage  to  the  uterine  cavity,  so  that 
the  ovum  really  passes  through  both  peritoneal  layers 
to  reach  the  uterus.  It  is  this  unique  connection  of 
oviduct  to  serous  cavity,  this  continuation  of  mucous 
membrane  with  serous  membrane,  that  constitutes  the 
peculiar  liability  of  the  female  to  local  peritonitis. 
The  pelvic  peritoneum  is  particularly  loose.  It  rests 
on  the  pelvic  organs  in  the  centre,  but  on  each  side  it 
rests  on  soft,  white  areolar  tissue  (the  subserosium). 

The  relations  of  the  peritoneum  are  much  altered 
after  labor.  I  have  found  the  pelvic  peritoneum 
thicker  in  women  than  in  men. 

The  use  of  the  peritoneum  is:  (a)  To  prevent  fric- 
tion to  moving  viscera;  (/')  to  anchor  and  support  the 
viscera  in  proper  relations;  (c)  to  prevent  the  invasion 


128 


MEDICAL    RECORD. 


[July  28,  1900 


of  infection  by  throwing  out  barriers  of  exudates  to 
protect  wounded  viscera;  {ti)  to  limit  viscera  so  that 
they  may  not  become  entangled;  {e)  to  furnish  the 
viscera  with  an  elastic  covering;  (/)  to  absorb  and 
secrete  fluid. 

In  the  abdominal  cavity  there  exists  a  great  fold  of 
peritoneum,  known  as  the  omentum.  It  acts  as  the 
great  protector  from  infectious  invasions.  It  will 
plug  visceral  wounds  and  heal  other  wounds.  It  is 
like  a  man-of-war  which  is  ready  at  any  time  to  move 
to  attacked  points,  wherever  infection  invades  the  peri- 
toneal cavity — at  the  appendix,  gall  bladder,  or  ovi- 
ductal  ends,  the  omentum  stands  ready  to  circumscribe 
the  infectious  invader.  It  corrals  the  enemy  of  the 
peritoneum  with  exudates.  It  indicates  the  point  of 
invasion.  It  is  like  a  moving  sentinel  whose  beat  is 
its  whole  coelom. 

The  peritoneum  is  liable  to  inflammation — perito- 
nitis. The  infection  must  generally  attack  the  peri- 
toneum from  the  inside,  for  it  withstands  very  much 
infection  and  trauma  from  the  outside,  without  appar- 
ent inflammation.  The  trauma  of  the  psoas  muscle 
on  any  segment  of  bowel  which  lies  within  its  range 
induces  the  migration  of  pathogenic  microbes  and  even- 
tually induces  peritonitis.  This  may  be  the  case  with 
any  segment  of  the  bowel  which  may  lie  on  the  psoas. 
It  may  be  the  case  also  with  the  appendix,  the  caecum, 
and  the  lower  end  of  the  ileum.  There  is  over  sev- 
enty-five per  cent,  of  peritonitis  in  the  right  iliac 
fossa  due  to  trauma  of  the  psoas  on  the  bowels.  Much 
appendicitis  is  due  to  trauma  of  the  psoas. 

One  of  the  chief  essentials  of  peritonitis  (after  in- 
fection) seems  to  be  that  the  epithelium  must  be 
denuded  to  start  the  infection,  i.e.,  there  must  be 
sufficient  trauma  to  break  off  the  flat  serous  epithe- 
lium in  order  to  give  a  growing  medium  for  the  patho- 
genic microbes.  Pathogenic  microbes  can,  it  is  true, 
be  injected  into  a  healthy  peritoneum  without  causing 
peritonitis,  but  in  contact  with  denuded  epithelium 
these  infectious  agents  give  rise  to  violent  peritonitis. 
Laparotomy  is  just  the  process  to  furnish  all  the  re- 
quired trauma  to  denude  the  delicate  epithelium. 
With  the  shingles  torn  off  a  roof,  it  will  leak;  and 
similarly  with  the  shingles  of  the  flat  epithelium  torn 
from  the  peritoneal  surface,  it  affords  ample  opportu- 
nity for  the  invasion  of  pathogenic  microbes.  Trauma 
leads  the  way  to  peritonitis. 

Peritonitis  always  begins  locally.  The  two  sexes 
seem  to  suffer  from  it  to  about  the  same  extent,  though 
from  different  causes.  !Man  has  much  more  hernia 
than  woman.  VVoman  has  much  more  pelvic  perito- 
nitis, or  peritonitis  at  the  ends  of  the  oviducts;  but 
man  has  four  times  as  much  appendicitis  from  trauma 
of  the  psoas.  Man  has  more  volvulus,  but  woman  is 
afflicted  much  oftener  with  derangement  of  the  gall 
bladder. 

Local  peritonitis  arises  at  the  following  points:  (a) 
at  the  ends  of  the  oviducts,  where  infection  passes 
•  into  the  peritoneal  cavity.  This  is  the  most  common 
localization  of  the  affection  designated  "  pelvic  peri- 
tonitis." The  gonococcus  prepares  the  way  for  all 
other  pathogenic  microbes — by  trauma. 

(/')  At  the  hernial  openings.  This  occurs  some 
three  or  four  times  as  often  in  man  as  in  woman.  The 
peritonitis  arises  from  irritation  or  strangulation, 
trauma  of  the  intestine  in  the  hernial  opening,  thus 
allowing  the  passage  of  pathogenic  microbes  through 
the  bowel  wall  to  the  peritoneum,  inducing  local  peri- 
tonitis. 

((•)  At  the  appendix.  Perforation  of  the  appendix 
induces  local  peritonitis  by  the  escape  of  pathogenic 
microbes.  This  form  of  local  peritonitis  is  four  times 
as  frequent  in  man  as  in  woman.  In  short,  peritonitis 
in  man  or  boy  should  be  considered  as  appendicitis 
until  otherwise  proven. 


{d)  At  the  gall  bladder.  Perforation  or  migration 
arises  and  peritonitis  follows.  This  form  is  four 
times  as  frequent  in  woman  as  in  man.  Over  one-third 
of  the  autopsies  I  have  made  on  women  above  forty- 
five  have  shown  local  peritonitis  around  the  gall 
bladder. 

((?)  At  the  pylorus  (sphincter)  peritonitis  chiefly 
arises  from  malignant  invasion. 

{/)  At  the  ileo-caical  valve  (sphincter). 

{g)  At  the  anus  (sphincter)  peritonitis  is  not  infre- 
quent. It  occurs  oftener  in  woman  than  in  man,  on 
account  of  the  more  frequent  occurrence  of  stricture  in 
the  female  rectum,  due  to  gonorrhoea. 

(/;)  At  the  hepatic  flexure. 

(/)  At  the  splenic  flexure. 

{J)  The  trauma  of  the  psoas  muscle  induces  the 
migration  of  pathogenic  microbes  or  their  products 
through  the  mucosa  muscularis,  ending  in  inflamma- 
tion of  the  adjacent  serosa.  Peritonitis  in  the  sigmoid 
flexure  is  due  chiefly  to  trauma  of  the  psoas.  At  the 
sigmoid  flexure  the  friction  of  faeces  abrades  the  mu- 
cous membrane,  thus  allowing  the  pathogenic  microbes 
to  pass  through  the  intestinal  walls,  where  they  induce 
peritonitis  around  the  flexure. 

(/')  Peritonitis  occurs  about  the  spleen  in  ninety- 
five  per  cent,  of  cases;  due  to  muscular  trauma  (dia- 
phragmatic). 

(/)  It  occurs  in  the  mesentery  on  its  lower  end, 
due  to  muscular  trauma  or  aortic  trauma. 

(in)  Local  peritonitis  occurs  in  the  range  of  action 
of  the  pillars  of  the  diaphragm,  especially  where  the 
duodenum  crosses  the  right  crus. 

(//)  It  may  occur  at  the  flexura  duodeno-jejunalis. 
Observe  that  local  peritonitis  occurs  about  flexures 
and  sphincters  of  the  bowel. 

{0)  At  any  point  where  infection  may  invade  the 
peritoneum,  e.g.,  at  any  perforation  of  the  alimentary 
canal,  the  genital  tract,  or  urinary  passages,  where 
infectious  matter  may  pass  into  some  part  of  the  peri- 
toneal cavity. 

(/)  Tuberculous  peritonitis  is  a  common  disease. 
It  frequently  begins  at  the  fimbriated  ends  of  the  ovi- 
ducts. It  is  chiefly  cured  by  peritoneal  incision  and 
drainage. 

Generally,  abdominal  tenderness,  muscular  rigidity, 
and  abdominal  pain  mean  peritonitis  which  has 
started  from  some  infectious  focus,  as  peritonitis  is 
a  secondary  disease. 

The  exquisite  tenderness  found  in  the  distinct  loca- 
tions of  large  tumors  generally  indicates  local  perito- 
nitis. Severe  tenderness  in  parts  of  the  pelvis  is  gen- 
erally caused  by  peritonitis,  induced  by  infectious 
matter  escaping  from  the  oviduct  ends.  The  local 
peritonitis  may  be  recent  and  very  tender,  or  old  and 
not  acutely  tender,  but  still  giving,  on  all  active  mo- 
tion, a  dull,  sickening,  aching  sensation  from  old  ad- 
hesions. The  adhesions  may  persist  and  induce  these 
dull  pains  for  many  years,  especially  in  child-bearing 
life,  as  monthly  exacerbations  occur. 

Satisfactory  recoveries  after  section,  when  the  ad- 
hesions have  been  broken  up,  show  the  adhesions 
were  the  cause  of  the  protracted  pain  and  illness.  The 
adhesions  seem  to  irritate  the  nerves  by  pinching  and 
compressing  them,  and  checking  peristalsis.  They 
disturb  circulation  by  congestion  or  anaemia  of  the 
parts,  and  by  drawing  viscera  out  of  normal  relations. 
It  may  be  observed  that  when  the  visceral  peritoneum 
is  involved  only,  the  pain  is  of  a  dull  character — only 
the  sympathetic  nerves  are  attacked — but  when  there 
is  parietal  peritoneum,  the  spinal  nerves  as  well  as 
the  sympathetic  are  involved,  and  the  pain  assumes 
an  acute,  lancinating  character.  Pain  which  involves 
the  sympathetic  is  dull,  w-hile  that  which  involves  the 
cerebro-spinal  nerves  is  sharp  and  lancinating.  A 
patient  practically  never  recovers  from  general  peri- 


July  28,  1900] 


MEDICAL    RECORD. 


129 


tonitis.  The  barriers  which  check  it  are  the  mesen- 
teries. The  colon  is  the  benign  area  ©f  peritonitis. 
The  enteron  is  the  fatal  area. 

The  following  forms  are  recognized  in  autopsies. 
However,  the  classilication  of  peritonitis  is  unsettled, 
but  traumatic,  infectious,  or  chemical  peritonitis  is 
observed  in  all  forms. 

(ii)  Progressive  fibrinous  peritonitis.  This  is  where 
exudates  and  adhesions  play  the  rule.  With  new  e.\- 
acerbations  new  exudates  arise;  so  that  many  centres 
of  septic  foci  may  be  circumscribed.  Such  pent-up 
collections  of  pus  may  be  separately  opened  without 
communicating  with  each  other  or  the  general  peri- 
toneal cavity. 

{/>)  Diffuse  suppurative  peritonitis.  Nearly  all  such 
cases  are  rapidly  fatal. 

((•)  A  so-called  dry  form  of  peritonitis.  In  some 
two  hundred  autopsies  on  dogs,  but  few  cases  of  dry 
peritonitis  were  found,  and  it  is  similar  in  man.  The 
disease  slowly  progresses  over  the  peritoneum.  In 
the  human  I  saw  it  a  few  times  only  in  over  five  hun- 
dred personal  autopsies.  Practically  excluding  per- 
foration, peritonitis  occurs  (a)  at  the  longest  range  of 
muscular  action  (trauma),  (/>)  at  the  bowel  flexures, 
(r)  the  sphincters  of  the  tractus  intestinalis,  and  (</) 
at  the  fimbriated  ends  of  the  oviducts. 

(</)  Another  form,  called  intestino-peritoneal  septi- 
cemia, exists.  It  may  depend  on  ptomains  or  mi- 
crobes. 

Man  has  relatively  the  least  amount  of  peritoneum 
of  any  animal.  The  folds  of  peritoneum  are  more 
ample  and  extensive  in  all  other  animals  which  I 
have  examined,  as  the  horse,  dog,  pig,  coon,  cow, 
monkey,  fish,  bird,  turtle,  frog,  seal,  snake,  sheep,  etc. 
The  different  animals  vary  in  their  susceptibility  to 
infection  and  peritonitis.  The  horse  has  a  perito- 
neum so  susceptible  to  infection,  and  peritonitis  with 
him  is  so  fatal,  that  equine  abdominal  surgery  is 
scarcely  possible  in  the  present  state  of  surgical 
knowledge.  The  dog's  peritoneum  is  comparatively 
the  same  in  extent  and  resistance  as  man's.  The  pig 
is  not  very  susceptible  to  peritonitis.  It  is  well 
shown  in  spaying  cows  that  these  animals  do  not 
possess  a  peritoneum  sensitive  to  inflammation. 

One  of  the  fell  destroyers  in  mammalian  life  is 
peritonitis.  When  a  horse  becomes  attacked  with  it, 
he  is  not  expected  to  recover.  But  happily  in  man 
the  majority  recover. 

Peritonitis  ranks  as  one  of  the  most  important  sur- 
gical conditions,  on  account  of  both  its  frequency  and 
its  fatality.  The  etiology  of  peritonitis  rests  on  patho- 
genic microbes  or  their  products  (chemical).  The 
various  germs  most  intimately  connected  with  peri- 
tonitis are  the  colon  bacillus,  streptococcus,  staphylo- 
coccus, pneumococcus,  and  gonococcus. 

Traumatic  peritonitis  is  nothing  more  than  the  estab- 
lishment of  a  focus  of  lessened  resistance,  with  infection. 

The  most  virulent  of  all  pathogenic  germs  in  peri- 
tonitis is  the  streptococcus.  The  mildest  is  staphy- 
lococcus. If  one  performs  several  hundred  adult 
post-mortems,  he  will  find  local  peritonitis  in  the  pel- 
vis of  about  eighty  per  cent.  In  females,  about  the 
sigmoid,  eighty  per  cent.;  about  the  C£eco-appendi.\-, 
seventy  per  cent. ;  about  the  gall  bladder  forty  per 
cent.;  and  around  tlie  spleen,  ninety -five  per  cent. 
With  partial  exception  of  pelvic  peritonitis,  the  other 
forms  of  local  peritonitis  are  due  to  muscular  trauma. 

The  chief  cause  of  appendicitis  is  trauma  of  the 
psoas  muscle.  The  sigmoid  and  appendicular  region 
is  traumatized  by  the  psoas  muscle,  the  gall  bladder 
region  and  that  of  the  spleen  by  the  diaphragm,  its 
crura,  and  the  abdominal  walls.  Mu.scular  trauma  on 
the  tractus  intestinalis  makes  a  focus  of  lessened  re- 
sistance and  enables  the  rapidly  multiplying  germs 
or  their  products  to  penetrate  the  muscularis  mucosae. 


and  enter  the  serosa.  The  most  common  cause  of 
grave  peritonitis  is  perforation  of  some  hollow  viscus, 
penetration  of  the  abdominal  wall,  or  infection  con- 
veyed through  the  blood. 

The  treatment  of  peritonitis  consists  in  medical  and 
surgical  intervention.  If  it  be  medical,  no  drug  equals 
opium  in  full  doses,  sufficient  to  arrest  peristalsis. 
Rest,  anatomical  and  physiological,  is  the  all-iinpor- 
tant  factor.  This  will  corral  the  infectious  atrium. 
The  trouble,  however,  with  opium  is  that  its  adminis- 
tration militates  against  subsequent  surgical  interven- 
tion; for  it  checks  secretion. 

After  all,  it  should  be  noted  that  all  cases  of  septic 
peritonitis  belong  to  the  domain  of  surgery.  There 
are  two  methods  by  which  surgical  intervention  suc- 
ceeds in  peritonitis,  viz.,  drainage  from  the  intestinal 
mucosa  (cathartics),  and  draining  from  the  serosa  (in- 
cision). The  best  cathartics  are,  the  mild  chloride 
and  magnesium  sulphate,  administered  in  small,  often 
repeated  doses.  The  best  drain  is  the  rubber  tube 
wrapped  in  gauze. 

The  Pelvic  Peritoneum  lines  the  greater  and  lesser 
pelvic  cavities.  In  the  lesser  pelvis  the  peritoneum 
intimately  lines  its  lateral  walls  and  floor,  and  invests 
more  or  less  completely  the  contained  viscera.  The 
slippery,  smooth,  and  elastic  serosa  enables  the  pelvic 
viscera  to  move  freely,  to  return  to  normal  after  vast 
changes  without  loss  of  integrity,  and  to  maintain  the 
relation  of  physiology  and  anatomy  among  the  pelvic 
organs.  The  pelvic  peritoneum  is  a  continuation  of 
the  lining  of  the  abdominal  cavity.  Some  deny  a 
peritoneal  covering  to  the  ovary. 

The  pelvic  organs  appear  as  if  thrust  into  the  peri- 
toneum from  below,  forming  the  peritoneal  invagina- 
tions which  enclose  more  or  less  of  each  organ.  Be- 
ginning wqth  the  lower  fold  of  the  peritoneum  on  the 
anterior  abdominal  wall,  one  and  a  half  inches  above 
the  crest  of  the  pubis,  the  peritoneum  reflects  itself 
posteriorly  on  the  summit  and  fundus  of  the  bladder, 
covering  this  organ  as  far  posteriorly  as  the  level  of 
the  OS  uteri  internum.  The  peritoneum  covering  the 
lateral  surfaces  of  the  bladder  is  limited  by  the  ab- 
dominal hypogastric  arteries.  It  covers  the  anterior 
surface,  fundus,  and  the  posterior  surface  of  the  uterus, 
whence  it  passes  downward,  covering  the  upper  one- 
third  of  the  posterior  surface  of  the  vagina.  It  then 
turns  upward  and  backward  to  cover  the  rectum  and 
sigmoid  to  the  pelvic  brim.  Then,  extending  laterally 
from  the  border  of  the  uterus,  its  two  peritoneal  blades 
enclose  the  oviducts,  ovary  and  its  ligament,  vessels, 
nerves,  muscles,  and  foetal  remnants.  It  then  passes 
to  the  lateral  pelvic  walls.  The  diverging  broad-liga- 
ment blades  contain  at  their  base  the  ureter,  uterine 
artery,  and  pelvic  brim. 

In  addition  to  investing  the  pelvic  viscera,  the  peri- 
toneum lines  the  lateral  walls  and  floor  of  the  pelvis. 
The  peritoneum,  covering  the  uterus,  passes  on  each 
side  to  the  lateral  pelvic  wall  forming  the  broad  liga- 
ments which  divide  the  pelvis  into  a  posterior,  larger 
and  deeper  fossa,  and  an  anterior  smaller  and  shal- 
lower fossa.  The  lowest  portion  of  the  posterior  pel- 
vic fossa  is  known  as  the  pouch  of  Douglas,  which  is 
bounded  superiorly  by  the  folds  of  Douglas  (utero-rec- 
tal  ligaments).  The  peritoneal  cavity  is  safely  and 
easily  opened  through  the  pouch  of  Douglas.  The 
peritoneum  in  the  anterior  pelvic  fossa  passes  as  low 
as  the  base  of  the  broad  ligament.  The  posterior  pel- 
vic peritoneal  fossa  is  divided  equally  by  the  utero- 
rectal  ligaments.  The  anterior  pelvic  peritoneal  fossa 
is  subdivided  by  the  utero-vesical  ligaments.  The 
serous  coat  covering  the  uterus  is  the  perimetrium; 
that  covering  the  bladder  is  the  perivesicum;  and  that 
covering  the  rectum  is  the  periproctium. 

The  pelvic  peritoneum  rests  on  a  large,  thick, 
spongy,  and  extensive  bed  of  snow-white  subperitoneal 


130 


MEDICAL    RECORD. 


[July  28,  1900 


areolar  tissue,  on  which  the  pelvic  peritoneum  with 
its  invested  organs  glides  and  rests.  The  subperito- 
neal pelvic  tissue  allows  contraction  and  expansion 
of  organs,  and  the  return  to  normal  without  loss  of 
integrity.  It  is  a  buffer  10  prevent  trauma,  and  it 
maintains  with  the  aid  of  the  pelvic  peritoneum  the 
relations  of  the  viscera,  nerves,  and  vessels. 

The  pelvic  peritoneum  does  not  completely  invest 
all  parts  of  the  pelvic  viscera.  The  anterior  vaginal 
wall,  the  anterior  surface  of  the  cervix,  the  anterior 
surface  of  the  bladder,  the  lower  posterior  (fourth)  of 
the  vagina,  and  lower  portion  of  the  entire  rectum 
(anus)  are  not  covered  by  peritoneum.  The  pelvic 
peritoneum  is  endowed  with  extensive  elasticity,  and 
freely  accommodates  the  changing  volume  of  viscera. 
Also  the  peritoneum  is  capable  of  being  partially 
stripped  from  pelvic  viscera  and  parietes. 

When  the  bladder  becomes  distended,  the  perito- 
neum is  not  only  dissected  from  the  anterior  abdomi- 
nal wall,  but  also  slightly  from  the  anterior  surface  of 
the  uterus.  In  pregnancy,  the  broad  ligament  not  only 
becomes  elevated  above  the  normal,  but  the  blades 
diverge  and  the  peritoneum  becomes  drawn  off  the 
uterus.  Some  organs  have  loosely  attached  serosa, 
as  the  bladder  and  oviducts,  the  pelvic  floor  and 
parietes.  The  folds  of  the  pelvic  peritoneum  form 
ligaments  and  pouches.  There  are  six  pelvic  perito- 
neal ligaments,  viz.,  broad,  utero-rectal,  utero-vesical, 
latero-vesical,  utero-abdominal,  and  vesical  superior. 

The  broad  ligaments  (ligamenta  lata  uteri)  con- 
sist of  (a)  a  thin  layer  of  endotiielia,  permanent  or 
temporary,  on  the  anterior  and  posterior  surfaces;  (/')  a 
mesenterii  membrana  propria  which  is  the  real  neuro- 
vascular visceral  pedicle.  It  is  the  mesodermic  or 
permanent  mesentery,  carrying  vessels  and  nerves  to 
the  viscera  by  means  of  the  fibrous  and  connective 
tissue.  This  broad  ligament  extends  from  the  lateral 
wall  of  the  uterus  to  the  lateral  wall  of  the  pelvis, 
immediately  anterior  to  the  sacro-iliac  joint,  subdi- 
viding the  pelvic  cavity.  It  is  a  secondary  uterine 
support  and  serves  chiefly  to  maintain  in  physiological 
and  anatomical  relations  the  contents  of  the  broad  liga- 
ment. 

The  two  utero-vesical  ligaments  connect  tiie  lower 
portions  of  the  uterus  to  the  posterior  surface  of  the 
bladder.  They  extend  from  the  lateral  portions  of  the 
uterus  to  the  lateral  and  posterior  surface  of  the 
bladder. 

The  utero-abdominal  ligament  extends  from  the 
cervix  to  the  posterior  abdominal  wall. 

The  two  utero-rectal  (sacro-uterine)  ligaments  ex- 
tend from  the  rectum  (second  and  third  sacral  verte- 
brre)  to  the  lateral  borders  of  the  internal  os.  These 
two  ligaments  being  primary  uterine  supports  must 
rupture  or  elongate  before  uterine  prolapse  or  sacro- 
pubic  hernia  can  occur. 

The  two  lateral  peritoneal  vesical  ligaments  extend 
from  the  iliac  fossa  to  the  lateral  surface  of  the  blad- 
der, where  they  join  it  at  the  line  of  the  obliterated 
hypogastric  arteries. 

The  superior  peritoneal  vesical  ligament  (ligamen- 
tum  suspensoriuni  vesica;)  extends  from  the  summit 
of  the  bladder  to  the  umbilicus.  It  covers  posteriorly 
the  urachus  and  the  obliterated  hypogastric  arteries, 
which  serve  as  a  guide  in  peritoneal  sections. 

There  are  six  peritoneal  pelvic  pouches  or  fossa, 
viz.,  Douglas,  utero-vesical,  ovarian,  paravesical,  utero- 
abdominal,  and  vesico-abdominal. 

The  Douglas  pouch,  located  between  uterus  and 
rectum,  is  bounded  laterally  by  the  utero-rectal  liga- 
ments, anteriorly  by  the  posterior  surface  of  the  uterus 
and  vagina,  and  posteriorly  by  the  rectum.  It  is  the 
most  dependent  part  of  the  peritoneum ;  hence  fluids 
will  gravitate  into  it. 

The  utero-vesical   pouch,  located  between   bladder 


and  uterus,  is  bounded  anteriorly  by  the  posterior  sur- 
face of  the  bladder,  and  posteriorly  by  the  anterior 
surface  of  the  uterus. 

The  ovarian  pouch,  located  between  the  uterus  and 
the  sacro-iliac  joint,  is  triangular  in  shape,  bounded 
in  front  by  the  base  of  the  broad  ligament,  externally 
by  the  wall  of  the  pelvis,  and  internally  by  the  utero- 
rectal  ligaments.  This  pouch  is  analogous  to  the 
ovarian  pouch  of  animals. 

The  para-vesical  pouch  lies  in  the  angle  formed  by 
the  utero-vesical  fold  and  the  broad  ligament. 

The  vesico-abdominal  pouch  exists  when  the  bladder 
is  distended. 

The  utero-abdominal  pouch  exists  when  the  bladder 
is  empty. 

The  pelvic  peritoneum,  with  its  folds  and  pouches, 
invests  more  or  less  intimately  the  pelvic  viscera, 
maintaining  them  in  proper  relations,  and  facilitating 
perfect  motion.  It  is  relatively  thicker  in  females 
than  in  males,  and  has  become  tolerant  to  peritonitis 
through  the  ages. 

The  pelvic  peritoneum  is  not  a  dangerous  region  for 
lymphangitis  (peritonitis),  because  it  is  limited  in  its 
capacity  to  absorb,  due  to  relatively  few  stomata  vera. 
Also  fluids  gravitate  and  remain  in  its  most  dependent 
portion,  and  visceral  motion  (peristalsis)  being  lim- 
ited the  infection  is  not  widely  distributed.  With 
empty  bladder,  and  the  uterus  lying  in  the  anterior 
portion  of  the  pelvis,  loops  of  enteron  lie  in  the  pouch 
of  Douglas.  The  enteron  is  the  dangerous  area  of 
absorption  (lymphangitis),  but  the  few  loops  contained 
in  the  pelvis,  becoming  gradually  infected,  cease  their 
peristalsis  and  throw  out  barriers  of  obstruction  to  the 
invading  infection. 

The  pelvic  peritoneum  becomes  infected  primarily 
at  the  fimbriated  ends  of  the  oviducts,  due  to  infection 
passing  from  the  endometrium  through  the  oviducts. 
Secondarily  it  becomes  infected  through  the  lymph 
and  blood  channels. 

The  etiology  of  peritonitis  or  lymphangitis  must  be 
attributed  to  pathogenic  microbes  and  their  products 
passing  from  the  ovary,  uterus,  and  especially  from 
the  oviducts.  During  the  course  of  disease  the  serosa 
becomes  reddened  and  hypera;mic,  loses  its  shiny  pol- 
ish, leucocytes  appear  on  the  surface,  the  endothelia 
become  desquamated,  and  an  exudation  appears  on  its 
surface.  There  is  usually  an  endometritis,  then  an 
endosalpingitis,  and  finally  a  lymphangitis  (perito- 
nitis). 

There  may  be  scarcely  any  serum  (dry  form  of  lym- 
phangitis), or  there  may  be  an  abundance  of  serum 
(wet  form).  Should  there  be  fluid  present,  the  recent 
inflammatory  lymph  is  usually  suspended  in  the  form 
of  ragged  flakes.  The  area  of  inflammation  is  coated 
with  a  reddish,  elastic  substance,  known  as  fibrin, 
which  lies  loosely  on  some  portion  of  the  serosa 
(the  serum  may  be  encapsulated  by  peritoneal  adhe- 
sion, and  final  absorption  may  occur).  It  extends  in 
the  form  of  threads  and  bands  between  opposed  sur- 
faces, or  makes  them  adherent,  binding  the  pelvic  or- 
gans, colon,  and  enteron  together  by  means  of  organ- 
ized peritoneal  adhesions.  In  severe  septic  cases,  tlie 
exudation  may  be  purulent.  The  chief  element  in  the  ex- 
udation is  Coagulated  albvmiin,  exudation  fibrin,  leuco- 
cytes, serum,  and  endothelial  cells.  For  practical  pur- 
poses there  are  four  varieties  of  pelvic  peritonitis,  viz., 
((?)  plastic,  (/')  serous,  (c)  septic,  and  (tf)  tuberculous. 

Practically,  the  method  by  which  pelvic  lymphangi- 
tis becomes  acquired  is  by  the  introduction  of  sepsis 
during  coition,  labor,  abortion,  or  operations.  Gonor- 
rhoea produces  jilastic  lymphangitis,  but  prepares  the 
way  for  other  forms  of  lymphangitis,  by  trauma  that  is 
due  to  staphylococcus,  streptococcus,  and  tubercle  bacil- 
lus. Catching  cold  at  the  monthly  period  means  pelvic 
lymphangitis  from  sepsis  forced  out  of  the  abdominal 


July  28,  1900] 


MEDICAL    RECORD. 


131 


end  of  the  oviduct,  when  increased  secretions  have 
induced  multiplication  of  germs,  with  perhaps  raised 
virulence.  Pelvic  cellulitis  generally  is  a  result  of 
lymphangitis  passing  into  the  subserosium,  or  it  may 
be  due  to  infection  passing  from  the  endometrium 
through  the  uterine  wall  into  the  cellular  tissue  at  the 
base  of  the  broad  ligament.  Tuberculous  lymphangitis 
begins  chiefly  at  tiie  fimbriated  extremity  of  the  ovi- 
ducts. Pelvic  lymphangitis  is  the  most  serious  gyne- 
cological disease,  because  {a)  it  has  a  tendency  to  recur ; 
(/')  it  produces  severe  pain;  (O  it  is  a  source  of  refle.x 
neuroses;  (rf)  it  disturbs  the  mechanism  of  circulation 
and  nerve  distribution  by  traumatism  of  connective- 
tissue  beds  of  the  subserosium  ;  (1?)  it  produces  atrophy 
of  structures  by  fixing  organs,  causing  an  excessive 
local  tension  or  slackness;  (/)  it  produces  adhesions 
binding  the  various  adjacent  viscera  together,  causing 
mechanical  and  functional  disturbances;  {£■)  it  is  al- 
most incurable. 

Woman  suffers  primarily  from  pelvic  lymphangitis. 
A  plastic  pelvic  lymphangitis  may  produce  an  exudate 
in  size  palpable  only,  or  it  may  fill  the  lesser  pelvis. 
The  serous  or  purulent  form  may  also  fill  the  lesser 
pelvis  witli  fluid  or  pus. 

The  most  frequent  variety  of  pelvic  lymphangitis  is 
the  chronic  plastic  form  whose  adhesions  produce  fixa- 
tions and  dislocation  of  viscera,  causing  disturbances 
in  anatomical  and  mechanical  relations,  impeding  circu- 
lation, nutrition,  and  function,  and  causing  nerve  trau- 
matism. The  uterus,  oviducts,  the  sigmoid,  and  the  en- 
teron  may  be  found  firmly  bound  together  by  organized 
cicatrizing  peritoneal  adhesions.  A  dislocated  organ 
is  one  permanently  fixed.  As  a  rule,  it  is  produced 
by  peritoneal  adhesions.  Thus,  after  lymphangitis  has 
swept  over  the  pelvis,  the  uterus,  oviducts,  ovaries, 
sigmoid,  and  enteron  may  be  found  dislocated,  fixed 
in  various  positions  by  the  exudates.  Some  ligaments 
may  be  shortened,  others  lengthened,  local  peritoneal 
areas  thickened,  and  viscera  partially  or  completely 
buried  by  exudates.  Sterility  following  pelvic  lym- 
phangitis is  chiefly  mechanical,  due  to  separating  the 
fimbrire  of  the  oviduct  permanently  from  the  ovary, 
preventing  the  transmission  of  an  ovum  to  the  uterus. 

The  Symptoms  of  pelvic  lymphangitis  are  pain, 
and  an  acute  or  chronic  course,  with  tenderness.  The 
acute  form  may  be  ushered  in  by  chill;  rapid,  small, 
wiry  pulse;  temperature  loi  to  105°  ¥.\  nausea,  \-om- 
iting,  and  tympanites.  Constipation  exists,  and  there 
may  be  irritability  of  the  bladder  and  menorrhagia. 
In  the  chronic  course  there  are  tenderness,  palpable 
exudates,  pain,  disturbances  in  the  vesical,  rectal,  and 
menstrual  functions.  Leucorrhcea  and  menorrhagia 
are  liable  to  exist.  Irregular  tympanites,  indigestion, 
and  anaemia,  and  finally  neurosis  play  a  significant 
part  in  the  chronic  form. 

Bimanual  examination  discovers  tenderness  in  the 
pelvis,  with  muscles  on  tension  for  protection,  dry  or 
moist  vagina,  with  uterus,  oviducts,  ovaries  with  ad- 
jacent sigmoid  and  enteron  generally  bound  in  fixed 
masses  of  exudates.  The  vaginal  fornices  are  sensi- 
tive and  rigid,  and  all  movements  and  pressure  induce 
pain.  Frequently  the  tenderness  and  size  of  the  pel- 
vic exudates  prohibit  examination.  The  most  usual 
situation  of  the  exudate  mass  is  in  the  pouch  of  Doug- 
las. The  course  of  chronic  pelvic  lymphangitis  of  the 
recurrent  type  is  serious  to  the  patient's  health,  from 
constant  irritation.  The  purulent  form  is  grave  while 
the  plastic  form  may  be  recovered  from.  However, 
there  is  generally  a  residual  exudate,  with  dislocation 
of  viscera,  giving  rise  to  symptoms — especially  pain 
and  sterility.  Pregnancy  frequently  cures  pelvic 
lymphangitis  by  vigorous  absorption  during  gestation. 
However,  interruption  of  pregnancy  is  liable  to  occur, 
producing  exacerbations.  Pelvic  lymphangitic  ex- 
udates may  result  in  absorption,  encapsulation,  inspis- 


sation,  or  cicatrization,  which  produce  mechanical  dis- 
turbances not  only  in  adjacent  but  also  in  remote  organs. 

The  Treatment  of  pelvic  lymphangitis  in  the  acute 
stage  is:  Place  the  patient  in  bed,  and  apply  hot  corn- 
meal  poultices.  For  pain,  give  opiates  and  liquid 
diet;  move  the  bowels  by  gr.  i.  of  mild  chloride  every 
hour,  for  three  to  four  hours,  and  3  ss.  of  magnesium 
sulphate  every  three  hours.  As  the  condition  sub- 
sides, employ  the  vaginal  (and  rectal)  douche  morning 
and  evening,  gradually  increasing  from  a  gallon  to 
five  gallons;  also  increase  the  heat  daily.'  Use  the 
boroglyceride  tampon  twice  weekly.  'J'he  use  of 
sounds,  pessaries,  repeated  examinations,  intra-uterine 
electricity,  and  massage  should  be  avoided. 

In  the  chronic  stage  employ  the  douche,  tampon, 
massage,  extra-uterine  electricity,  and  general  measures. 
Forcible  reposition  of  the  pelvic  viscera,  in  lymphan- 
gitis, may  be  dangerous.  Patients  suffering  with  se- 
vere pelvic  lymphangitis  (peritonitis),  being  liable  to 
exacerbations  at  menstruation,  should  rest  in  bed  dur- 
ing the  flow. 

In  cases  resisting  the  reliable  methods  of  treatment, 
the  uterus  should  be  removed.  'I'he  ovaries,  the  es- 
sential of  the  genitals,  should  be  left  in  order  to  avoid 
precipitate  menopause.  A  patient  fares  better  without 
the  uterus  and  oviducts  (the  menstrual  organs)  than 
without  the  ovaries. 

Gynaecological  cases  suffer  chiefly  from  pelvic  peri- 
tonitis. The  pelvic  peritoneum  is  supplied  not  only 
by  sympathetic  nerves  but  also  by  spinal  sensory 
nerves,  viz.,  (a)  sensory  branches  of  the  ileo-inguinal, 
(/')  sensory  brandies  of  the  ileo-hypogastric,  (<•)  sen- 
sory branches  from  the  lower  seven  intercostals,  and 
{//)  to  some  extent  branches  from  the  sacral  visceral 
nerves  (third  and  fourth). 

In  certain  pains  of  the  tractus  intestinalis,  the  seat 
cannot  be  accurately  located.  However,  in  appendi- 
citis and  pelvic  peritonitis  the  seat  of  pain  can  be 
practically  located.  Traumatic  pain  of  the  perito- 
neum (non-inflammatory)  is  trifling,  as  the  peritoneum 
on  the  digestive  tract  can  be  manipulated  without 
symptoms  of  pain. 

The  non-sensitiveness  of  the  normal  peritoneum  in- 
duces the  Orientals,  it  is  said,  to  slit  open  the  abdomen 
to  have  a  painless  death.  According  to  Hasse,  the 
sensory  nerves  of  the  peritoneum  are  few.  However, 
in  an  inflamed  condition,  the  pain  of  peritonitis  is  a 
sad  picture  of  a  few  distressful  days.  The  pain  in 
both  general  and  local  peritonitis  is  quite  intense. 
In  other  organs  similar  conditions  exist.  Bone,  mus- 
cle, and  tendon  are  not  very  sensiti\e  to  incisions,  but 
in  an  inflamed  state  are  extraordinarily  painful.  Per- 
haps in  peritonitis  it  is  vascular  spasm  and  vascular 
paralysis  which  are  the  base  of  the  pain  as  in  migraine. 
All  coarse  dragging  or  traumatism  of  the  peritoneum 
is  painful,  as  the  breaking  up  of  adhesions  and  liga- 
tion of  peritoneal  pedicles  demonstrate. 

The  non-sensibility  of  the  normal  peritoneum  and 
the  intense  pain  of  the  inflamed  peritoneum  are  not 
fully  explained  by  the  assertion  that  the  connective- 
tissue  cells,  containing  a  sensory  periphery,  are  isolated 
in  health  and  in  contact  during  inflammation. 

While  a  pupil  of  Mr.  Lawson  Tait,  he  called  my 
attention  to  severe  pain  in  patients  who  possessed  nu- 
merous peritoneal  cysts  located  on  the  broad  liga- 
ment. The  cysts  were  perhaps  remnants  of  previous 
peritonitis,  and  contained  a  yellow  albuminous  fluid. 

Analogous,  in  part,  are  the  oviducal  hernite.  Since 
every  viscus  may  become  hyperiEsthetic,  the  perito- 
neum, with  an  area  equal  to  that  of  the  skin,  has  ex- 
tensive opportunities  with  its  rich  nerve  periphery. 
Gubler's  peritonismus  is  doubtless  peritoneal  hyper- 
esthesia. In  clinical  cases  after  visceral  removal  dif- 
fuse peritoneal  hyperaesthesia  persists.  In  the  nerve 
periphery  of  the  skin  and  mucosa  we  observe  hyperses- 


MEDICAL    RECORD. 


[July  28,  1900 


thesia  and  anaesthesia.  Why  not,  in  the  rich  nerve 
periphery  of  the  free  peritoneal  surface,  find  hyperes- 
thesia and  anaesthetic  zones? 

The  peritoneum  invests  such  viscera  as  the  spleen, 
stomach,  enteron,  ovary,  CKCum,  liver,  and  sigmoid  so 
completely  that  they  could  scarcely  be  wounded  with- 
out injury  to  itself.  The  kidney,  right  and  left  colon, 
uterus,  oviducts,  and  bladder  are  partially  uncovered 
by  the  peritoneum,  and  may  be  wounded  without  in- 
volving it.  Inflammation  of  the  viscera  closely  in- 
vested with  the  peritoneum,  is  followed  by  visceral 
peritonitis,  as  typically  observed  in  the  spleen,  en- 
teron, ovary,  liver,  and  uterus.  Viscera  loosely  or 
partially  invested  by  peritoneum,  may  suffer  severe 
parenchymatous  inflammation  without  involving  the 
peritoneum;  as  may  be  observed  in  the  kidney,  adre- 
nal, right  and  left  colon,  posterior  surface,  oviduct, 
and  pancreas.  The  loose  subserous  bed  of  connective 
tissue  (mesoderm)  on  which  the  peritoneum  rests  al- 
lows it  to  glide  about  freely,  and  hence  large  abscesses 
may  form  from  behind  and  burrow  in  various  direc- 
tions, finally  discharging  through  the  skin,  without 
giving  rise  to  peritonitis.  The  e.xternal  surface  of  the 
peritoneum  withstands  inflammatory  attacks  to  a  re- 
markable degree,  while  the  internal  surface  is  very 
susceptible.  Quarts  of  pus  may  be  observed  extending 
over  large  areas  and  in  contact  with  the  external  peri- 
toneal surface,  for  long  periods,  without  fatal  or  even 
grave  effects,  while  a  single  drop  of  the  same  pus  com- 
ing in  contact  with  the  internal  peritoneal  surface 
would  result  in  an  immediately  fatal  peritonitis. 
The  difference  is  between  the  structural  apparatus  and 
function  of  the  peritoneal  surface,  and  those  of  simple 
connective  tissue.  The  posterior  surface  of  the  colon, 
right  and  left,  or  oviduct,  may  be  perforated  without 
involving  the  peritoneum,  while  perforations  of  the 
enteron  or  stomach  will  involve  peritonitis. 

Inflammation  of  the  peritoneum,  or  rather  lymphan- 
gitis, may  lead  to  the  formation  of  e.xudates,  adhesions, 
and  peritoneal  bands,  which  are  the  cause  of  one-third 
of  all  intestinal  obstruction.  The  peritoneal  bands 
may  strangulate  or  kink  loops  of  bowel,  fix  viscera, 
and  cause  pain  by  checking  peristalsis  and  visceral 
function.  Much  of  the  immediate  and  remote  pain  of 
laparotomy  is  due  to  peritoneal  bands  and  adhesions 
from  peritonitis,  previous  or  subsequent  to  the  opera- 
tion. To  relieve  post-operative  abdominal  pain,  re- 
open the  abdomen  aseptically  and  break  up  the  peri- 
toneal adhesions.  The  peritoneum  is  elastic  and 
will  allow  very  extensive  stretching,  if  gradually  per- 
formed, and  still  will  return  to  normal.  Examples 
are  observed  with  large  tumors  and  extensive  ascites. 
Distention  of  the  peritoneum  may  be  observed  in  the 
sac  of  a  hernia.  The  parietal  peritoneum  can  be  ex- 
tensively torn  without  damage  to  viscera. 

The  great  omentum  is  the  surgeon's  friend,  which 
covers  up  the  evil  his  hands  have  wrought.  It  is  fre- 
quently exposed  to  trauma.  It  will  quickly  plug  up 
small  punctured  wounds  on  the  enteron  and  lateral 
walls  of  tlie  belly.  In  a  wound  passing  through  the 
diaphragm,  pleura,  and  intercostal  spaces  I  saw  parts 
of  the  omentum  effectually  plug  the  holes  in  the  skin, 
found  at  an  autopsy  years  subsequent  to  the  injury. 
In  another  case  I  saw  a  large  piece  of  omentum  drag 
nine  inches  of  transverse  colon  with  it  through  an 
inguinal  hernia.  The  omentum  is  frequently  found 
in  hernia,  especially  in  umbilical,  and  in  small  pouches 
of  median  hernia  above  the  umbilicus,  causing  consid- 
erable suffering.  The  omentum  lies  chiefly  to  the  left 
side.  It  is  an  aid  to  diagnosis,  since  it  fixes  itself  to 
original  points  of  inflammatory  invasions,  at  the  hernial 
openings,  abdominal  ends  of  the  oviducts,  liver,  spleen, 
appendix,  and  other  points  where  visceral  inflammation 
may  arise.  The  omentum  checks  inflammatory  inva- 
sion   by    surrounding   it   with  exudates   and    malting 


organs  together,  and  thus  aiding  to  close  visceral 
perforation.  In  gunshot  perforations  of  the  tractus 
intestinalis,  I  have  observed  it  actually  closing  the 
wound.  The  omentum  will  nourish  isolated  tissue. 
Tumors  whose  pedicles  have  betn  twisted  off  by  axial 
rotation  may  secure  ample  subsistence  from  the  omen- 
tum. In  hernia  the  omentum  generally  contracts  ad- 
hesions to  the  bowel  wall  or  sac,  which  thus  becomes 
fixed;  whence,  by  frequently  dragging  the  omental 
band  on  the  attached  viscera,  reflex  and  other  disturb- 
ances will  be  produced.  By  its  attachment  in  the  her- 
nial sac,  or  at  the  other  points  in  the  abdominal  cav- 
ity, the  omentum  will  form  an  arcli  under  which  bowel 
loops  may  become  strangulated.  Apertures  should 
never  be  left  in  the  omentum,  as  animal  experimenta- 
tion demonstrates  that  loops  of  enteron  are  very  liable 
to  pass  through  them  and  become  strangulated.  In 
several  hundred  autopsies  I  found  the  omentum  cov- 
ering the  CcTCum  in  some  eight  per  cent,  of  subjects. 
It  is  an  abdominal  drain,  and  when  it  contains  much 
fat  it  acts  as  a  protector  to  the  bowels.  It  prevents 
the  bowels  from  becoming  adherent  to  the  anterior 
mobile  abdominal  wall. 

The  mesenteries  are  important  in  all  abdominal 
and  pelvic  surgery,  as  they  contain  the  blood-ves- 
sels, nerves,  lymphatic  vessels,  and  lymph  nodes. 
They  are  the  neuro-vascular  visceral  pedicles.  The 
mesentery  consists  mainly  of  three  layers,  viz.,  (a) 
the  middle,  permanent,  connective-tissue  layer,  con- 
taining nerves  and  vessels  all  woven  together  by 
connective  tissue.  This  is  the  mesenterii  mem- 
brana  propria.  (/')  On  each  side  of  the  mesenterii 
membrana  propria  or  middle  mesentery  is  a  thin 
endothelial  or  peritoneal  layer.  The  mesenteries  di- 
vide the  abdominal  cavity  into  compartments,  which 
aid  in  preventing  fluids  01  infectious  invasions  from 
general  distribution.  The  mesentery  acts  as  a  barrier, 
and  each  peritoneal  compartment  corrals  its  host.  The 
mesenteron  and  meso-sigmoid  aid  in  checking  infec- 
tions from  passing  upward.  The  mesocolon  ascen- 
dens  often  corrals  the  pus  of  appendicitis  between  it- 
self and  the  right  abdominal  wall,  and  with  the  aid 
of  the  colon  transversum  and  ligamentum  hepato-coli- 
cum  circumscribes  the  infection  which  may  emanate 
from  the  gall  bladder.  The  ligamentum  latum  uteri 
frequently  circumscribes  the  pus  from  the  oviduct, 
preventing  it  from  passing  forward  on  the  bladder, 
or  upward  into  the  enteronic  loops — the  dangerous 
grounds  of  peritonitis. 

Practically,  the  mesenteron  begins  at  the  distal  end 
of  the  duodenum,  near  the  distal  border  of  the  pan- 
creas, or  second  lumbar  vertebra,  whence  it  passes  in 
an  oblique  line  over  the  vertebral  column,  crossing  the 
great  vessels,  and  ending  in  an  uncertain  position  in 
the  right  iliac  fossa.  The  standard  for  the  location 
of  the  distal  end  of  the  mesenteron  should  be  the  right 
psoas  muscle.  The  left  layer  of  the  mesenteron  is 
continuous  with  the  right  blade  of  the  left  mesocolon, 
and  the  right  layer  is  continuous  with  the  distal  layer 
of  the  mesocolon  transversum,  and  also  the  left  blade 
of  the  right  mesocolon.  The  left  layer  of  the  mesen- 
teron passes  over  the  sacral  promontory  into  the  pel- 
vis, and  also  becomes  the  right  blade  of  the  meso-sig- 
moid. In  se-'eral  hundred  personal  autopsies  the 
average  length  of  the  dorsal  insertion  of  the  mesen- 
teron, the  root,  was  about  six  inches,  while  the  dis- 
tance from  the  dorsal  insertion  of  the  mesenteron  to 
its  ventral  visceral  surface  was  six  and  one-half 
inches.  The  dorsal  insertion  of  the  mesenteron  ex- 
plains how  iiemorrhage,  occurring  on  its  right  side, 
conducts  the  blood  first  into  the  right  iliac  fossa, 
while  if  the  hemorrhage  arises  on  tlie  left  side  it  will 
flow  into  the  pelvis.  The  length  of  the  mesenteron 
from  spine  to  enteron  varies  in  different  segments  of 
the  tract  from  zero  to  ten  inches,  averaging  six  and  a 


July  28,  1900] 


MEDICAL    RECORD. 


13: 


half  inches  in  women  and  seven  in  men.  Practically 
the  middle  seven  feet  of  enteron  has  the  longest  mes- 
enteron,  which  allows  the  loops  to  fall  into  the  pelvis 
or  pass  through  some  hernial  ring  (in  ninety-eight 
subjects  in  one  hundred). 

The  niesenteron  is  relatively  long  in  infancy,  shorter 
again  in  the  second  and  third  decade,  after  which  it 
elongates  every  subsequent  ten  years,  until  the  pro- 
nounced enteroptosis  of  old  age  e.xists.  The  root  of 
the  niesenteron  and  a  large  area  of  dorsal  peritoneum 
may,  after  thirty  years  of  age,  gradually  glide  distal- 
ward,  constituting  visceral  ptosis,  which  is  accompa- 
nied by  neurosis  and  deranged  digestion.  Hernias  are 
doubtless  not  so  much  due  to  visceral  ptosis  as  to  con- 
genital and  degenerative  defects  of  the  abdominal 
wall. 

Apertures  in  the  mesentery  may  arise,  through  which 
loops  of  bowel  may  glide  and  become  strangulated. 
Mesenterial  apertures  are  due  to  peritoneal  defects, 
especially  when  irregular,  and  to  trauma  when  slit 
shaped.  Defective  mesenterial  apertures  may  be  found 
about  the  lower  ileum,  due  to  lack  of  blood  supply. 
The  an.istomosis  of  the  ileo-colic  branch  of  the  supe- 
rior mesenteric  artery,  with  the  right  enteronic  artery, 
circumscribes  an  oval  area,  poorly  supplied  with  blood. 
It  is  an  atrophic  area  with  little  or  no  fat,  and  the 
peritoneum  becomes  so  thin  that  slight  trauma  pro- 
duces an  aperture.  In  peritonitis  deformans  the  mes- 
enteries may  become  practically  obliterated.  The 
mesosalpinx  and  mesometrium  frequently  become  dis- 
torted or  contracted  from  inflammatory  processes,  com- 
promising circulation,  compressing  nerve  periphery, 
and  inducing  trains  of  refie.xes. 


AMENORRHCEA.' 
By   L.    il.    DUNNING,    M.d!, 

PROFESSOR  OF  DISKASES  UF  WO.MEN,  MEDICAL  COLLEGE  OF  I.\DIANA,  UNI- 
\ERS1TY  OF  INDIANAPOLIS  ;  CONSULTING  GYNiKCOLOGIST  OF  THE  INDIAN- 
APOLIS CITY  HOSPITAL;  CHIEF  OF  STAFF  OF  DEACONESS  HOSPITAL, 
INDIANAPOLIS,    LND. 

Amenorrh(X.4  may  be  defined  as  a  permanent  or 
temporary  absence  of  the  menses  during  the  period  of 
life  at  which  they  should  be  present.  It  has  its  causa- 
tion in  general  states  of  the  system  or  local  pathologi- 
cal conditions  of  the  sexual  organs.  Of  the  general 
states  it  may  be  said  that  the  most  frequent  causes  of 
amenorrhoea  are  those  constitutional  diseases  which 
lead  to  the  general  impoverishment  of  the  blood  and 
to  ancemia.  Bright's  disease  is  a  frequent  etiological 
factor,  and  in  this  disease  the  cause  of  amenorrhcea 
may  be  found  in  circulatory  disturbances  as  well  as 
in  the  anaemia  always  present.  Tuberculosis  is 
another  common  cause  of  amenorrhoea.  Here  the 
antemia  due  to  malnutrition  and  the  exhaustive  nature 
of  the  disease  are  the  chief  factors  in  bringing  about 
amenorrhcea.  So  common  a  causative  factor  is  tuber- 
culosis, and  so  often  is  it  mistaken  for  a  result  of 
amenorrhcea,  that  it  is  worth  our  while  to  pause  a 
moment  and  consider  more  specifically  the  clinical 
aspect  of  amenorrhcea  dependent  upon  tuberculosis. 

The  laity  ascribe  to  the  absence  of  menses  a  causa- 
tion of  pulmonary  tuberculosis,  and  so  great  is  their 
solicitude  respecting  the  appearance  of  the  sanguin- 
ary flow  that  they  are  continually  importuning  the 
physicians  to  re-establish  this  function,  expecting 
thereby  to  turn  aside  or  to  cure  the  phthisis.  Noth- 
ing could  be  more  fallacious.  The  writer  has  been 
deeply  impressed  many  times  by  the  local  pathological 
findings  of  cases  of  tuberculosis  attended  by  amenor- 
rhoea.     He  can  best  illustrate  this  subject  by  briefly 

'  Read  before  the  St.  Joseph  County  Medical  Society.  January 
23.  igoo. 


relating  the  history  of   a   case  which   came   under  his 
observation  recently. 

A  young  married  woman,  thirty-two  years  of  age, 
came  to  the  City  Hospital  for  treatment  because  of 
the  absence  of  menses  and  presence  of  great  weakness. 
There  were  general  pallor  of  countenance  and  slight 
cough,  and  also  anasarca.  No  evidence  of  Piright's 
disease  was  found  on  examination  of  the  urine,  but 
an  examination  of  the  chest  revealed  extensive  tuber- 
culous involvement  of  one  lung.  The  patient's  anx- 
iety to  menstruate  seemed  to  be  emphasized  by  her 
great  fear  of  pregnancy.  There  had  been  an  absence 
of  the  menses  for  five  months.  The  repeated  efforts 
of  several  physicians  to  re-establish  the  function  had 
failed.  The  physical  examination  of  the  pelvic  or- 
gans revealed  atrophy  of  all  the  organs  of  generation. 
The  external  labia  were  infantile,  the  vagina  was  small 
and  short,  the  uterus  was  atrophied,  and  tlie  ovaries  were 
small;  indeed,  the  general  aspect  of  these  organs  was 
that  of  those  possessed  by  a  woman  who  had  passed  the 
menopause.  This  condition  of  the  sexual  organs  is 
such  as  has  forcibly  attracted  the  attention  of  the  writer 
upon  many  occasions,  and  is  sufficient  explanation  of 
the  futile  efforts  of  many  of  us  in  our  endeavor  to 
bring  about  the  restoration  of  the  menstrual  function 
in  tuberculosis.  The  change  of  life  which  has  taken 
place  prematurely  has  resulted  from  the  profoundly 
exhausting  effect  upon  the  system  of  the  phthisis. 

Chlorosis  is  another  disease  often  attended  by 
amenorrhcea  in  young  women.  This  disease  usually 
first  manifests  itself  at  puberty,  and  then  only  because 
of  the  unusual  demand  that  is  placed  upon  the  circu- 
latory and  nutritive  systems  at  the  period  of  the 
secondary  development  of  the  sexual  organs.  VVhile 
a  deficient  development  of  the  arteries  has  undoubtedly 
been  present  from  birth,  yet  this  has  not  been  mani- 
fested until  now.  The  amount  of  haKmoglobin  has 
been  just  sufficient  to  supply  the  ordinary  demands, 
but  now  an  unusual  supply  is  needed.  The  system 
cannot  furnish  it.  Anamia  results  and  the  menses 
are  not  established;  or  if  they  have  been  partially 
established,  they  cease  to  appear. 

Still  another  condition  of  the  general  state  resulting 
in  amenorrhcea  may  be  found  in  those  young  girls 
living  in  an  unhygienic  environment,  who  take  on 
rapid  growth  at  the  time  of  puberty.  The  air  they 
breathe  is  impure,  the  food  is  insuflicient,  and  their 
strength  is  taxed  beyond  their  power  of  endurance. 
The  result  is  anaemia,  and  the  imperfect  or  retarded 
growth  of  the  sexual  organs;  hence  the  absence  of 
the  menses  until  years  beyond  the  time  at  which  they 
usually  appear. 

The  writer  has  not  infrequently  seen,  and  dares  say 
his  observations  have  been  duplicated  by  many  of  the 
audience,  young  women  who  have  suffered  from 
amenorrhcea  after  acute  attacks  of  scarlet  fever  and 
pneumonia.  In  due  course  of  time,  after  the  blood 
supply  has  increased  and  general  nutrition  of  the  body 
is  restored,  the  menstrual  flow  is  re-established. 

Of  the  local  conditions  resulting  in  amenorrhcea  I 
shall  first  mention  atresia  of  the  vagina  or  occlusion 
of  the  outlet  from  an  imperforate  hymen.  This  is  a 
rare  occurrence,  but  I  dare  say  some  of  you  have  met 
with  one  or  more  instances  of  this  kind.  The  writer 
is  persuaded  that  amenorrhcea  from  complete  occlusion 
of  the  vagina  from  a  thickened  and  imperforate  hymen 
is  of  very  rare  occurrence,  inasmuch  as  he,  after  a 
somewhat  prolonged  and  extensive  practice,  has  never 
met  with  such  a  case.  He  has,  however,  met  with  one 
or  two  instances  of  partial  occlusion  of  the  vagina 
from  an  imperforate  hymen  and  partial  retention  of 
the  menstrual  flovi^,  but  never  an  instance  in  which 
there  was  complete  occlusion  and  retention.  He  once 
saw  a  marked  case  of  uterus  bilocularis  with  double 
vagina  in  which  there  was  a  minute  opening   in   one 


134 


MEDICAL   RECORD. 


[July  28,  1900 


vagina  which  allowed  a  very  slow  escape  of  the 
menstrual  flow,  so  that  oftentimes  the  vaginal  tube  was 
distended  during  the  period  of  menstruation  and  for 
some  time  afterward. 

The  writer  'las  also  met  with  a  curious  case  of 
atresia  of  the  uterus  and  vagina,  resulting  from  slough- 
ing following  the  retention  of  a  placenta.  After  heal- 
ing, the  woman  never  menstruated.  For  a  little  time 
this  did  not  attract  attention  from  the  patient,  but 
after  a  time,  as  the  cicatrix  became  more  dense,  other 
troubles  arose,  and  she  sought  relief.  I  saw  her  a  few 
months  after  her  confinement.  The  vagina  was  oc- 
cluded, and  there  was  every  evidence  of  general  atrophy 
of  the  sexual  organs.  I  dissected  my  way  through  the 
tissue  along  the  site  of  the  original  vagina  until  I 
reached  the  cervix  uteri,  which  was  also  found  oc- 
cluded. No  cavity  could  be  found  within  that  organ. 
The  patient  did  not  subsequently  menstruate,  and,  in 
spite  of  the  utmost  endeavor,  at  the  end  of  three 
months  after  the  operation  the  vagina  was  again 
obliterated. 

One  of  the  most  common  causes  of  amenorrhcea  in 
young  women  is  imperfect  development  of  the  uterus 
or  ovaries,  or  both,  and  it  is  surprising  how  frequently 
one  who  has  much  to  do  with  this  class  of  cases  will 
encounter  such  imperfect  development;  and  it  is 
surprising,  too,  to  note  the  characteristic  marks  that 
are  often  left  upon  the  woman  as  a  consequence  of 
such  imperfect  development — as,  for  instance,  in  case 
of  the  absence  or  imperfect  development  of  the  uterus 
and  ovaries,  we  will  as  a  rule  find  stunted  women, 
that  is  to  say,  women  who  have  never  reached  physical 
perfection.  We  will  observe  it  in  their  small  hands 
and  feet,  small  ears  and  nose,  low  stature,  frequently 
in  their  infantile  voice,  and  we  will  observe  it,  too,  in 
the  absence  of  those  characteristics  of  anatomical 
development  which  are  peculiar  to  the  mature  woman, 
namely,  the  broad  pelvis  and  the  rounded  bust. 

The  writer  has  under  his  observation  at  present  a 
patient  who  well  illustrates  these  facts.  She  is  nine- 
teen years  old,  and  has  never  menstruated.  She  is 
small,  and  while  she  has  been  engaged  in  outdoor 
work  and  has  a  ruddy  complexion,  yet  she  has  the 
small  hands  and  feet  above  referred  to,  childish 
voice,  and  general  immature  appearance.  A  physical 
examination  shows  an  under-development  of  all  the 
sexual  organs,  both  external  and  internal.  The  uterus 
measures  one  inch  in  depth,  the  cervi.x  is  scarcely  as 
large  as  one  end  of  the  finger.  The  proportionate 
size  of  the  body  and  the  cervix  is  nearly  normal, 
showing  that  there  is  congenital  atrophy  of  the  organ. 
The  ovaries,  or  what  I  took  for  ovaries  on  combined 
examination,  are  infantile.  The  curious  thing  about 
this  case  is  that  whereas  the  breasts  are  very  nearly 
the  size  of  those  of  a  well-developed  woman,  yet  the 
nipples  are  infantile.  In  other  words,  we  have  here 
that  rare  condition  known  as  micromasia.  In  some 
instances  in  which  there  is  an  absence  of  the  develop- 
ment of  the  sexual  organs  it  will  be  found  that  the 
victim  will  possess  many  characteristics  of  the  opposite 
sex,  that  is  to  say,  in  growth  and  general  appearance. 
The  voice  is  somewhat  coarse,  the  chest  is  flat,  the 
pelvis  has  the  form  of  that  of  the  male,  and  beard  is 
likely  to  appear  upon  the  face. 

In  not  a  few  cases  it  will  be  found  that  in  the 
development  of  the  organs  of  reproduction  there  has 
been  a  blighting  of  the  organs  developed  from  the 
ducts  of  Muller,  so  that  the  Fallopian  tubes,  uterus, 
and  vagina  are  either  absent  or  rudimentary,  and  yet 
the  ovaries  are  well  developed.  In  these  instances 
the  woman  may  be  well  developed  generally,  and  may 
possess  all  the  external  beauties  of  the  female  sex, 
and  unless  examined  by  a  competent  physician  will 
be  entirely  unconscious  of  the  extent  of  her  deformity 
until  united    in    marriage.     The  writer   has   met  with 


two  instances  of  this  kind.  The  patients  possessed 
sexual  instinct  and  the  menstrual  molimen  was 
present.  There  was,  however,  an  entire  absence  of 
the  menstrual  flow;  no  vagina,  and  not  a  vestige  of  a 
uterus  could  be  discovered  upon  combined  examina- 
tion. The  ovaries,  however,  could  be  palpated  through 
the  rectum.  My  efforts  to  establish  a  vagina  in  these 
instances,  while  at  first  promising  success,  were  in  the 
end  total  failures. 

There  remains  yet  to  be  discussed  another  form  of 
local  lesion  inducing  amenorrhcea.  It  is  that  form  in 
which  there  is  atresia  of  the  cervical  canal,  in  which 
there  are  well-developed  ovaries  and  a  well-developed 
fundus  uteri  containing  a  cavity  lined  by  normal 
mucous  membrane.  The  atresia  of  the  cervix  may 
have  been  congenital  or  caused  by  localized  inflam- 
mation, such  as  sometimes  occurs  during  the  progress 
of  an  attack  of  measles  or  scarlet  fever,  or  may  be 
due  to  an  injury  such  as  trauma  or  the  application  of 
caustics.  Such  cases  as  these  are  not  of  infrequent 
occurrence.  In  the  old  times  of  amputating  the  cervix 
for  epithelioma  when  the  thermo-cautery  was  employed, 
or  when  amputation  was  done  by  the  knife  and  the 
stump  treated  by  the  Sims  method,  it  was  not  an 
unusual  occurrence  to  find  after  a  year  or  two  atresia 
of  the  OS  and  the  retention  of  the  menstrual  flow. 

Suppression  of  the  menses  may  occur  in  women 
who  have  been  previously  healthy.  Not  a  few  ex- 
amples of  this  kind  will  be  found  in  schoolgirls  who 
are  overworked  or  neglect  to  take  sufficient  exercise 
in  open  air.  Women,  too,  who  are  subjected  to 
prolonged  mental  strain  are  prone  to  become  anarmic 
and  emotional.  Such  women  are  very  liable  indeed 
to  suffer  from  mental  disorders. 

Inflammatory  lesions  of  the  sexual  organs  resulting 
in  suppuration  are  not  infrequently  associated  with 
suppression  of  the  menses.  Here  we  may  meet  with 
perplexing  difficulties  in  making  a  diagnosis.  A 
woman  presents  herself  complaining  of  slight  fever, 
marked  pain  in  the  pelvic  region,  and  an  absence  of 
menses.  The  breasts  are  enlarged  and  tender,  the 
vagina  is  enlarged  and  purple  in  hue,  and  combined 
examination  reveals  a  mass  nearly  filling  the  pelvis; 
and  the  uterus  is  movable  with  the  mass — indeed,  is  a 
part  of  the  mass.  The  organ  cannot  be  isolated. 
The  mass  is  elastic  and  boggy.  The  patient  is  evi- 
dently sick,  but  she  has  walked  to  the  office  or  pethaps 
has  travelled  from  a  distant  city. 

In  all  my  experiences  as  a  practitioner  in  diseases 
of  women,  I  have  never  encountered  greater  difficulties 
in  diagnosis  than  are  sometimes  presented  in  such  a 
case  as  this.  The  diagnosis  arrived  at  after  the  most 
painstaking  care  has  not  always  been  entirely  free 
from  mistakes. 

Recently  in  a  patient  vi'ho  had  been  acutely  ill  for 
five  or  six  weeks,  who  had  had  suppression  of  the 
menses  for  four  months,  in  whose  pelvis  there  was 
a  mass  of  considerable  size  which  was  rapidly  grow- 
ing, and  whose  uterus  was  empty,  the  attendant  phy- 
sicians and  myself  diagnosed  a  double  tubo-ovarian 
abscess.  We  operated  through  the  vagina,  when  we 
encountered  a  three-and-a-half  months'  foetus  with  its 
placenta,  and  all  surrounded  by  a  considerable  amount 
of  clotted  blood.  Fortunately  our  procedure  was  the 
proper  one,  and  our  efforts  resulted  in  the  rescue  of 
the  woman.  In  this  instance  there  was  not  a  clear 
history  of  rupture  of  the  tulial  pregnancy.  Our 
diagnostic  error  lay  in  not  being  able  rightly  to  inter- 
pret the  meaning  of  a  small  amount  of  bloody  serum 
drawn  from  the  mass  by  plunging  a  hypodermic  needle 
into  it  through  the  cul-de-sac.  The  needle-point 
entered  the  sac  containing  a  blood  clot  and  only  a 
small  amount  of  bloody  fluid  was  obtained.  This 
demonstrated  mistake  worked  for  me  considerable 
good,  for    by    the    same    means   I    have    twice    since 


July  28,  1900] 


MEDICAL    RECORD. 


differentiated  ruptured  tubal  pregnancy  from  a  pus 
accumulation. 

Double  ovarian  cysts  are  sometimes  attended  by 
suppression  of  menses,  and  if  the  cysts  are  not  very 
large  and  the  woman  is  quite  fat,  the  physician  will 
encounter  almost  insurmountable  difficulties  in  diag- 
nosis. In*  such  cases  the  presence  of  fluctuation 
alone  may  be  accepted  as  the  determining  point  in 
the  diagnosis.  Every  experienced  gyna;cologist  has 
met  with  a  considerable  number  of  anomalous  cases 
of  amenorrhcea  which  are  to  him  interesting  and 
instructive.  I  will  not  weary  you  by  reciting  histories 
of  many  of  them,  but  beg  to  present  one. 

Two  or  three  years  ago  a  young  colored  woman  was 
sent  to  me,  bearing  a  note  from  her  mistress.  The 
note  ran  as  follows:  "Please  examine  Fannie  and 
write  me  your  diagnosis.  She  is  accused  of  being 
pregnant.  She  denies  it  and  I  am  inclined  to  believe 
her,  but  her  appearances  are  against  her  and  she  con- 
fesses to  an  absence  of  menses." 

Upon  e.vternal  examination  the  abdomen  was  found 
enlarged  to  about  the  form  and  size  of  that  of  a 
woman  si.x  months  pregnant.  She  confessed  to  me 
the  absence  of  menses,  but  said  she  had  never  men- 
struated though  thirty  years  old,  and  had  not  told  any 
one,  for  she  had  a  lover  whom  she  desired  to  marry. 
She  declared  it  was  not  possible  for  her  to  be  pregnant. 
I  e.xamined  her  and  found  the  tumor  hard,  nodular, 
and  movable.  The  cervix  uteri  was  very  small,  as 
was  also  the  vagina.  I  accepted  her  statement  that 
she  had  never  menstruated,  and  passed  a  small  sound 
into  the  uterus  one  inch.  Two  days  later  I  removed 
a  five-pound  pedunculated,  fibroid  tumor  of  the  uterus, 
and  found  the  uterus  and  ovaries  infantile.  The 
tumor  was  subserous  and  pedunculated.  The  peduncle 
was  not  larger  than  the  finger  and  not  more  than  half 
an  inch  long,  and  was  attached  to  the  fundus  of  the 
uterus. 

Treatment. — .Vn  efficient  treatment  of  amenorrhcea 
must  be  based  upon  a  correct  knowledge  of  the  lesion 
causing  the  absence  of  the  menstrual  flow.  Our  efforts 
to  restore  the  function  in  Bright's  disease  and  tuber- 
culosis will  be  unavailing  unless  we  can  arrest  and 
overcome  the  ravages  of  these  diseases.  Indeed,  the 
writer  would  emphasize  the  fact  that  active  efforts  by 
the  administration  of  powerful  emmenagogues  are 
harmful,  for  such  a  course  is  liable  to  result  in  con- 
gestion of  the  pelvic  organs  and  the  development  of 
new  and  distressing  symptoms  without  the  hoped-for 
appearance  of  menstruation;  and,  furthermore,  should 
the  flow  appear,  it  is  prone  to  lead  to  greater  anaemia, 
a  condition  which  the  attendant  physician  is  using  his 
best  efforts  to  overcome. 

Amenorrhcea  following  acute  and  debilitating 
diseases  need  not  as  a  rule  occasion  the  serious 
apprehension  of  physician  and  patient.  Here  the 
chief  end  should  be  to  restore  the  health  of  the  patient 
after  the  intensity  of  the  attack  has  passed. 

For  the  pale,  anasmic,  overgrown  girls,  the  develop- 
ment of  whose  sexual  organs  is  retarded,  out-of-door 
sports  wisely  indulged  in,  together  with  the  systematic 
administration  of  iron  and  arsenic,  are  generally 
efficient.  In  these  cases,  as  the  richness  of  the  blood 
appears  and  the  muscular  strength  develops,  if  the 
menstrual  function  is  not  established  the  stimulating 
properties  of  the  faradic  current  may  be  utilized. 
Mild  emmenagogues  are  often  beneficial.  Potassium 
permanganate  in  one-  or  two-grain  doses  is  quite 
efficient.  The  intra-uterine  application  of  the  faradic 
current  with  the  short,  coarse  wire  and  slow  vibrations 
powerfully  stimulates  the  muscular  and  circulatory 
activity  of  the  uterus,  and  is  quite  an  effective  agent 
in  restoring  the  menses  when  not  dependent  upon 
errors  in  development  or  constitutional  dyscrasia. 

Oftentimes  a  change  of  air,  scenes,  and  surroundings 


will  accomplish  the  greatest  good.  This  is  especially 
true  in  young  women  who  are  suffering  from  excessive 
mental  work  and  worry.  In  all  instances,  hygienic 
laws  must  be  observed. 

The  chlorotic  patient  may  be  expected  to  recover 
under  the  influence  of  appropriate  treatment.  Iron  is 
the  scrvereign  remedy,  but  it  must  be  employed  in 
conjunction  with  other  measures. 

Food  rich  in  blood-making  properties  should  be 
directed,  and  a  high  state  of  activity  of  the  digestive 
and  assimilative  functions  maintained. 

It  is  highly  important  that  the  activity  of  the  bowels 
should  be  secured.  In  case  of  constipation  aloes 
when  well  borne  may  be  counted  the  most  efficient 
laxative.  Scarcely  less  important  is  it  that  the 
functions  of  the  kidneys  and  skin  should  be  kept  in 
normal  condition.  Tepid  baths  and  friction  of  the 
surface  of  the  body  are  beneficial,  and  free  water-drink- 
ing between  meals  should  be  encouraged. 

On  account  of  circulatory  and  respiratory  disturb- 
ances some  chlorotic  patients  are  unable  to  endure 
sufficient  exercise.  Here  voluntary  exercise  may  be 
supplemented  by  massage,  Swedish  movements,  and 
surface  electricity. 

With  the  disappearance  of  anaemia  and  the  oncoming 
of  good  health,  the  menstrual  function  is  as  a  rule 
established.  If  it  is  not,  the  judicious  use  of  tlie 
faradic  current  may  be  employed  and  mild  emmena- 
gogues administered. 

The  treatment  of  amenorrhcea  due  to  occlusion  of 
the  vaginal  outlet  by  an  imperforate  hymen  is  obvious. 
Incise  the  hymen,  empty  the  vaginal  tube,  and  pack 
lightly  with  gauze.  Dilate  fistulous  tract  in  case  of 
double  vagina  with  partial  occlusion  of  one,  and  dilate 
a  stenosed  os  and  introduce  a  Wylie  drainage  stem 
pessary,  endeavoring  by  this  means  to  secure  a 
permanent  patulency  of  the  cervical  canal. 

When  the  amenorrhcea  is  due  to  retarded  develop- 
ment of  the  sexual  organs,  if  the  patient  presents  her- 
self early,  before  eighteen  or  twenty  years  of  age,  a 
reasonable  hope  may  be  entertained  of  establishing 
the  menstrual  function  as  a  result  of  stimulating  a 
growth  of  the  reproductive  organs. 

Among  the  most  efficient  means  to  accomplish  this 
purpose  is  the  faradic  current  applied  as  indicated 
above.  The  prolonged  administration  of  iron  in  small 
doses,  or  the  iron  and  aloes  pills,  is  not  infrequently 
efficient.  The  use  of  the  zinc  and  copper  stem  pessary, 
introduced  by  Simpson,  is  probably  the  most  efficient 
mechanical  means,  especially  in  cases  in  which  there 
is  anteflexion  of  the  uterus.  In  such  cases  the  uterine 
canal  should  be  dilated  previous  to  the  introduction 
of  the  stem  pessary.  There  can  be  no  doubt  that 
while  the  method  is  often  efficient,  it  is  in  some 
instances  attended  by  danger  to  the  patient.  The 
pessary  should  be  shorter  than  the  uterine  canal  and 
of  just  sufficient  size  to  be  readily  retained  in  the 
canal.  If  it  produces  the  slightest  pain  or  soreness 
it  should  be  discarded. 

A  happy  marriage,  if  the  woman  is  otherwise  healthy, 
not  infrequently  results  in  the  speedy  growth  of  the 
sexual  system  and  occasionally  in  pregnancy.  It  must 
be  remembered  that  in  this  class  of  patients  the  meno- 
pause is  prone  to  appear  early,  and  that  miscarriage 
may  occur  in  the  first  pregnancy,  while  a  subsequent 
pregnancy  may  be  followed  by  a  perfectly  noimal 
gestation  and  delivery.  In  young  women  possessing 
highly  atrophied  uteri  and  ovaries  we  need  not  expect 
to  see  the  menstrual  flow  appear,  no  matter  what  means 
are  adopted.  It  is  better  to  withhold  all  efforts  in  this 
direction.  Occasionally  in  young  women  possessing 
well-developed  ovaries  and  rudimentary  organs  devel- 
oped from  the  ducts  of  Miiller,  life  is  rendered  toler- 
able only  by  extirpation  of  the  ovaries.  This  is  a  pro- 
cedure the  necessity  of  which  is  greatly  to  be  deplored. 


I3b 


MEDICAL    RECORD. 


[July  28,  1900 


The  Weight  Curve  in  Infants. — Budin  has  given 
attention  to  the  correlation  between  fluctuations  in  the 
normal  weight  increase  of  infants  and  their  state  of 
bodily  health,  and  draws  the  following  conclusions 
from  his  observations:  A  weight  curve  which  steadily 
and  regularly  ascends  is  of  great  value  as  an  indica- 
tion of  good  health  in  infants,  but  can  be  taken  only 
as  a  relative  and  not  as  an  absolute  sign.  It  often 
happens  that  children  whose  curve  is  faultless,  syphi- 
litics  for  example,  suddenly  die  in  the  most  unex- 
pected manner.  Children  suffering  from  febrile  dis- 
eases both  of  mild  and  severe  grades  frequently 
exhibit  a  weight  curve  which,  instead  of  descending, 
rises  steadily;  these  may  recover,  but  are  also  liable 
to  die.  In  some  instances  infants  suffering  from  va- 
rious disorders  increase  in  weight  suddenly  and  then 
•die  after  two  or  three  days;  thus  the  author  has  ob- 
served an  increase  of  250  gm.  in  twenty-four  hours 
and  of  325  gm.  in  three  days.  Some  of  these  infants 
suffer  from  a  localized  oedema,  others  urinate  very 
slight  amounts;  the  quantity  of  nourishment  taken 
never  exceeded  the  usual  amount.  This  sudden  and 
very  marked  rise  of  the  weight  curve  in  sick  children 
is  never  a  favorable  indication,  seeming  rather  to  jus- 
tify a  hopeless  prognosis. — Annaks  dc  Aledecine  ct  dc 
Chirnrgie  JiiJantUes,  June  15,  1900. 

The  Recognition  of  Embolism  of  the  Pulmonary 
Artery. —  Drasche  reports  a  case  of  this  interesting 
complication  in  which  the  diagnosis  was  made  before 
death.  The  thrombus  originated  in  the  inflamed  vari- 
cose veins  of  the  lower  extremities  and  passing  into 
the  auricle  occasioned  a  temporary  occlusion  of  the 
venous  ostium.  From  this  point  it  travelled  into  the 
right  ventricle  and  lodged  in  the  pulmonary  artery, 
which  by  its  gradual  accretion  was  finally  completely 
blocked,  death  resulting  promptly.  The  symptom 
complex  attending  this  casualty  is  sufficiently  typical 
in  the  author's  opinion  to  permit  the  diagnosis  to  be 
made  without  difficulty.  The  phenomena  attendant 
on  such  a  sudden  interference  with  'the  circulatory 
mechanism  are  naturally  most  severe:  syncope,  loss 
of  consciousness,  convulsions,  great  restlessness  and 
mental  anguish,  dyspnoea,  cardiac  arrhythmia,  small 
or  imperceptible  pulse,  cyanosis,  clammy  skin,  and 
cold  extremities.  The  physical  signs  exhibit  the 
greatest  variety,  but  a  nearly  constant  sign  is  a  hum- 
ming thrill  perceptible  over  the  sternum  in  the  neigh- 
borhood of  the  second  and  third  intercostal  spaces. 
At  the  same  time  peculiar  sounds,  rumbling  murmurs 
that  outlast  the  systole,  are  audible.  In  the  case  cited 
all  of  these  were  present,  but  subsided  as  suddenly  as 
they  had  appeared,  the  patient  almost  entirely  regain- 
ing control  of  herself,  only  to  succumb  fifteen  hours 
later  to  another  similar  seizure.  The  author  explains 
the  temporary  recovery  as  being  due  to  the  dislodg- 
ment  of  the  thrombus  from  its  site  at  the  entrance  to 
the  auricle,  while  the  long  interval  before  the  fatal  end- 
ing corresponds  to  the  gradual  increase  in  size  of  the 
clot  after  reaching  the  pulmonary  artery. —  Wifiwr 
klmische  Wochenschrijt,  June  7,  1900. 

The  Etiology  of  Multiple  Sclerosis.— Under  this 
heading  Robert  Gaupp  discusses  the  question  of  the 
causation  of  this  obscure  disease.  Rejecting  as  un- 
tenable most  of  the  theories  advanced,  he  considers 
the  evidence  of  later  years  as  pointing  strongly  toward 
traumatism  of  some  sort  as  the  primary  etiological 
factor.  Nevertheless,  it  is  difficult  to  understand  how 
a  single  injury  can  be  capable  of  inaugurating  a  mor- 
bid process  which  often  after  a  quasi-latent  period  of 
considerable  duration  continues  to  increase  progres- 
sively for  a  practically  indefinite  length  of  time.  It 
is  also  impossible  directly  to  reconcile  this  theory 
with  the  anatomical  findings,  and  the  most  rational 


view  seems  to  be  that  either  the  continuous  formation 
of  some  chemically  toxic  substance  is  caused,  or  that 
at  the  time  of  the  injury  the  system  at  large  is  suffi- 
ciently disorganized  to  render  it  vulnerable  to  latent 
disease  foci  already  present.  It  is  in  this  vvay,  per- 
haps, that  most  of  the  causes  adduced  (such  as  infec- 
tious diseases,  acute  intoxications,  exposure,  over-exer- 
tion, etc.)  act,  viz.,  by  weakening  the  organism  at 
large  and  particularly  the  nervous  system.  In  con- 
firmation of  this  view  he  reports  at  length  the  case  of 
a  machinist  in  whom  all  causative  agencies  could  be 
excluded  except  a  fall  from  a  height  of  fifteen  or 
twenty  feet,  which  rendered  him  unconscious  for  a 
considerable  length  of  time.  Shortly  after  this  he  be- 
gan to  suffer  from  symptoms  which  gradually  devel- 
oped into  those  of  a  classical  multiple  sclerosis,  and 
inasmuch  as  up  to  the  time  of  the  injury  he  had  been 
perfectly  well  and  had  never  been  subjected  to  any 
other  hardships,  the  author  feels  justified  in  consider- 
ing the  disease  as  a  direct  consequence  of  the  trauma. 
—  Ceiitralhlatt  Jiir  Nervenhcilkinide  und  Psychiatrie, 
June,  1900. 

A  Case  of  Unusual  Cerebellar  Tumor  with  Hy- 
drops Ventriculi. — L.  R.  Morris  reports  a  case  occur- 
ring in  a  girl  of  six  years.  On  autopsy  the  cerebrum 
presented  no  notable  macroscopical  changes  except 
flattening  of  the  convolutions.  No  tumor  was  visible 
until  after  a  longitudinal  incision  through  the  corpus 
callosum  and  a  separation  of  the  hemispheres.  Then 
there  was  exposed  a  brownish-red  tumor,  about  the 
size  of  an  egg,  lying  in  the  median  line  and  touching 
the  cerebellum.  The  lateral  ventricles  were  opened 
and  were  full  of  a  thin,  reddish  fluid;  their  surfaces 
were  stained  yellow.  Projecting  into  the  right  ven- 
tricle from  the  foramen  of  Monro  was  a  cyst,  formed 
by  the  velum  and  filled  with  a  bloody  fluid.  No  fur- 
ther exploratory  incisions  were  made  at  that  time. 
There  was  about  six  ounces  of  fluid  in  the  cranial  cav- 
ity. The  microscopical  examination  showed  the  tumor 
to  have  the  structure  of  a  small  round-celled  sarcoma 
augmented  by  repeated  hemorrhages. — Medicine,  July, 
1900. 

Sterility  in  the  Male. — E.  Ries  makes  a  study  of 
this  condition,  paying  special  attention  to  azoospermia 
due  to  obstruction  in  the  system  of  sperm  channels. 
He  makes  two  classes  of  cases,  according  to  the  pres- 
ence or  absence  of  changes  in  the  cellular  tissue  sur- 
rounding the  seminiferous  tubules.  The  most  marked 
of  these  changes  is  the  formation  of  a  zone  of  hyaline 
tissue  around  the  seminiferous  tubules  in  the  place  of 
the  normal  flat  connective-tissue  cells  which  form  the 
physiological  sheath  of  the  tubules.  This  zone  of  hya- 
line tissue  cuts  off  the  epithelium  from  its  supply  of 
nourishmeni,  normally  derived  from  the  blood-vessels 
of  the  intertubular  connective  tissue.  Degenerative 
changes  of  the  epithelium  accompany  the  formation  of 
the  hyaline  rings,  ^^■here  the  hyaline  zone  is  thin  we 
find  the  epithelium  of  the  tubule  either  normal,  even 
containing  spermatozoa,  or  the  spermatozoa  are  ab- 
sent and  we  find  only  a  few  layers  of  epithelium,  or 
even  only  one  layer,  the  border-lines  between  the  cells 
frequently  becoming  indistinct.  There  is,  however,  a 
distinct  cavity  of  the  tubule  which  is  sometimes  filled 
with  spermatozoa.  With  the  further  encroachment  of 
the  hyaline  zone  the  epithelium  is  reduced  to  a  very 
thin,  flat  layer  resembling  endothelium,  and  these  tu- 
bules contain  nothing  but  a  few  fragments  of  cells.  In 
the  most  pronounced  cases  the  lumen  of  the  tubule 
disappears  completely,  and  instead  of  a  channel 
lined  with  epithelium  nothing  is  seen  but  a  more  or 
less  wavy  and  hyaline  mass  of  tissue  with  very  few 
nuclei,  without  any  trace  of  the  normal  testicular  epi- 
thelium.— Aledicine,  July,  1900. 


July  28,  1900] 


MEDICAL   RECORD. 


137 


Medical  Record: 

A    Weekly  Journal  of  Medicine  and  Surgery. 


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

Publishers 

WM.  WOOD  &  CO.,  51    Fifth  Avenue. 

New  York,  July  28,  1900. 


THE  RELATIONS  BETWEEN  INFLUENZA  AND 
CHRONIC  DISEASE  OF  THE  HEART. 

An  abundant  experience  has  shown  that  the  poison  of 
influenza,  among  other  evil  effects,  is  capable  of  exert- 
ing a  profoundly  deleterious  influence  upon  the  circu- 
latory apparatus.  It  is  well  known  that  especially  the 
aged  and  the  debilitated  are  prone  to  fall  victims  and 
to  succumb  to  the  disease,  and  this  result,  it  may  be 
readily  surmised,  is  principally  attributable  to  influ- 
ences acting  upon  the  heart.  An  interesting  discus- 
sion of  the  cardiac  complications  of  influenza  is  en- 
tered upon  by  Schott  {Berliner  kUnische  Wochenschrijt, 
1900,  Nos.  21  and  22),  who  points  out  that  several 
groups  of  cardiac  lesions  in  the  course  of  influenza 
may  be  distinguished:  (i)  those  due  directly  to  in- 
fluenza, (rt)  during  the  febrile  course,  (li)  during  a 
relapse;  (2)  those  occurring  as  sequelae;  (3)  those 
due  indirectly  to  influenza,  through  disease  of  other 
organs. 

Influenza  gives  rise  most  frequently  to  cardiac  neu- 
roses, both  motor  and  sensory.  These  are  generally 
attributable  to  the  action  of  toxins,  and  although  this 
is  probably  the  correct  explanation,  it  has  not  been 
determined  with  absolute  certainty.  Abnormally  in- 
creased frequency  of  pulse  is  often  attended  with  di- 
minution in  arterial  pressure,  with  dicrotism,  and  with 
arrhythmia  and  allorrhythmia.  The  frequency  of  pulse 
often  bears  no  relation  to  the  temperature,  being  dis- 
proportionately greater  than  in  other  febrile  diseases. 
Bradycardia  occurs  with  unusual  frequency  in  the  se- 
quence of  influenza,  but  likewise  in  association  with 
irregularity  and  inequality  of  the  pulse,  although  less 
commonly  with  dicrotism,  while  lowered  arterial 
pressure  is  not  rare.  There  may  further  be  alterna- 
tion between  tachycardia  and  bradycardia,  sometimes 
in  consequence  of  exciting  influences,  such  as  excessive 
physical  activity,  emotional  disturbances,  overloading 
of  the  stomach,  and  the  use  of  alcohol,  coffee,  or  tea; 
but  at  other  times  it  may  develop  suddenly  without 
obvious  cause.  These  uncomplicated  cardiac  neuroses 
are  by  no  means  always  free  from  danger,  but  they 
may  be  associated  with  weakness  of  the  myocardium 
and  dilatation  of  the  heart.  As  long  as  the  patient 
remains  at  rest  the  heart  may  exhibit  no  deviation 
from  the  normal  on  auscultation  or  percussion,  but  on 
slight  mental  or  physical  exertion  the  conditions  are 
changed,  and  one  or  both  ventricles  may  become  di- 


lated, and  the  first  sound  at  the  apex  may  occasion- 
ally be  dull  or  impure  on  auscultation.  Such  a  con- 
dition may  persist  for  a  long  time. 

The  sensory  neuroses  occur  less  frequently  than  the 
motor  in  association  with  influenza,  although  even 
they  are  quite  common.  Little  is  known  of  vasomotor 
cardiac  neuroses.  Cardiac  pain,  in  the  form  of  pseudo- 
angina,  as  well  as  true  angina,  is,  however,  not  infre- 
quent. A  neurasthenic  condition  of  the  heart  is  com- 
mon. As  already  stated,  the  toxins  of  influenza  may 
exert  a  directly  injurious  influence  upon  the  heart 
muscle,  and  thus  readily  bring  about  conditions  of 
exhaustion  and  relaxation,  and  thereby  frequently  myo- 
cardial weakness,  especially  as  a  result  of  careless- 
ness, as  from  getting  up  prematurely,  and  exposure  to 
cold  and  wet.  Such  conditions,  unattended  with  fur- 
ther complications,  may  either  disappear  spontane- 
ously, or  yield  speedily  to  appropriate  treatment. 
With  an  unsuitable  mode  of  life,  however,  permanent 
injury  may  result,  with  dilatation  and  all  of  itG  dele- 
terious effects,  and  even  fatty  and  parenchymatous  de- 
generation of  the  myocardium  may  occur.  The  dila- 
tation may  give  rise  to  relative  insuflScicncy  of  the 
mitral  valve,  with  a  systolic  murmur  at  the  apex,  and 
possibly,  also,  to  relative  aortic  insufficiency.  Influ- 
enza, further,  may  be  attended  with  acute  dilatation  of 
the  heart,  and  sudden  death  may  follow. 

Valvular  disease  of  the  heart,  in  consequence  of 
primary  endocarditis  due  to  influenza,  has  been  re- 
corded by  numerous  observers,  but  it  is  more  common 
as  a  result  of  disease  of  the  pericardium,  the  pleura, 
the  lungs,  or  as  a  complication  of  acute  rheumatism. 
Disease  of  the  myocardium  is  even  a  more  frequent 
result  from  this  cause.  Old  persons,  and  especially 
those  presenting  advanced  arteriosclerosis,  are  exposed 
to  especial  danger  in  this  connection,  and  a  large  pro- 
portion of  deaths  from  influenza  occur  in  such  indi- 
viduals. Other  disturbances  in  the  pulmonary  circu- 
lation, such  as  may  be  induced  by  influenza,  embarrass 
the  action  of  the  heart  in  part  in  a  purely  mechanical 
manner,  and  in  part  through  chemical  influences, 
such  as  accumulation  of  carbon  dioxide  in  the  blood. 
Those  suffering  from  universal  adiposis  are  predis- 
posed to  such  disease  of  the  heart,  even  in  the  absence 
of  any  trace  of  fat  heart  or  of  vascular  alteration. 
Influenza  may  convert  a  mild  variety  of  glycosuria 
into  one  of  moderate  severity,  and  it  may  render  latent 
mellituria  active,  and  thus  affect  the  heart.  Influ- 
enzal changes  in  the  heart  occur  with  relative  fre- 
quency in  cases  of  gout.  The  gastro-intestinal  disturb- 
ances of  influenza  may  induce  enfeeblement  of  the 
myocardium  in  two  ways — namely,  through  the  resul- 
tant anjemia,  and  through  distention  of  the  intestinal 
tract,  with  more  or  less  marked  flatulence  and  displace- 
ment of  the  diaphragm  upward.  It  is  not  definitely 
known,  although  it  is  possible,  that  the  toxins  of  influ- 
enza exert  a  directly  injurious  influence  upon  the  state 
of  the  blood. 

Influenza  most  readily,  and  most  rapidly,  attacks  a 
heart  already  diseased,  altered,  enfeebled,  or  irritated. 
The  danger  consists,  not  only  in  derangement  of  com- 
pensation, but  also  in  renewal  of  the  endocarditic 
process.     Patients  with  congenital  valvular  disease, 


138 


MEDICAL    RECORD. 


[July  28.  1900 


or  congenital  deficiency  of  the  inter-ventricular  sep- 
tum, are  often  destroyed  within  a  short  time,  or  present 
marked  derangement  of  compensation.  In  the  pres- 
ence of  myocarditis  of  arteriosclerotic  origin,  com- 
pensatory derangement  and  anginal  attacks  of  marked 
severity  occur  in  conjunction  with  more  or  less  rapidly 
progressive  inflammatory  processes.  Fat  heart  may 
be  readily  converted  into  fatty  degeneration,  and  the 
enfeeblement  may  be  marked.  Attacks  of  syncope  of 
longer  or  shorter  duration  may  also  occur,  and  throm- 
botic or  embolic  vascular  occlusion  may  result.  Not 
only  are  previously  existing  cardiac  neuroses  readily 
regenerated  or  aggravated  by  an  attack  of  influenza, 
but  the  toxins  also  impair  the  muscular  activity  of  the 
heart,  and  dilatation  consequently  results.  The  lat- 
ter may,  however,  be  due  to  other  causes,  such  as 
insufficiency  of  nutrition  during  or  immediately  fol- 
lowing the  febrile  influenzal  period,  especially  incon- 
sequence of  too  exclusive  a  milk  diet,  and  also  after 
excessive  doses  of  antipyrin,  abnormally  large  doses 
of  alcohol  given  with  especial  frequency,  and  over- 
irritation  of  the  heart.  Under  such  circumstances  the 
state  of  relaxation  is  all  the  more  marked.  The  de- 
bilitated conditions  of  the  heart  involve  sometimes 
the  right  and  sometimes  the  left  ventricle,  and  some- 
times both.  The  aggravations  in  the  conditions  of 
the  heart  induced  by  influenza  are  almost  unexcep- 
tionally  attended  with  lowering  of  the  blood  pressure. 


THE      NEED      OF      UNIFORMITY      IN      THE 
STANDARDS   OF  MEDICAL   EDUCATION. 

During  the  current  year  attention  has  been  called  on 
several  occasions  in  the  Medical  Record  to  the  ques- 
tion of  interstate  reciprocity  in  medical  licensing,  and 
the  best  means  of  bringing  about  this  most  desirable 
event  has  been  touched  upon.  On  February  loth  in  an 
article  "  Medical  Education  in  the  United  States,"  the 
opinion  was  given  that  the  National  Confederation  of 
State  Medical  Examining  and  Licensing  Boards  was 
the  only  body  fitted  by  its  composition  to  deal  efficiently 
with  the  matter,  and  that  to  it  must  be  left  the  solving 
of  the  problem,  and  the  hope  was  then  expressed  that 
at  its  meeting  at  Atlantic  City  a  discussion  of  the  sub- 
ject in  all  its  bearings  might  tend  to  evolve  order  from 
the  present  decidedly  chaotic  condition  of  affairs. 

Wt  are  glad  to  say  that  this  hope  has  been  realized 
to  a  considerable  extent.  The  Confederation  met  in 
Atlantic  City  on  June  4th,  and  the  reciprocity  diffi- 
culty was  pretty  thoroughly  threshed  out.  Drs.  Wil- 
liam Warren  Potter,  of  Buffalo,  James  A.  Eagan,  of 
Springfield,  111.,  E.  B.  Harvey  of  Boston,  J.  N.  Mc- 
Cormick,  N.  R.  Coleman,  of  Columbus,  Ohio,  and 
others  took  part  in  the  discussion.  The  agreement 
was  unanimous  as  to  the  need  of  reform  in  the  exist- 
ing State  medical  laws,  but  the  consensus  of  opinion 
was  that  any  movement  to  this  effect  should  be  delib- 
erate and  well  considered,  and  that  nothing  should  be 
done  hastily.  The  National  Confederation  appointed 
an  interstate  reciprocity  committee  consisting  of  the 
following  members:    Dr.  Spurgeon,  of  Indiana,  chair- 


man; Dr.  Amberg,  of  Detroit,  secretary;  Drs.  Har- 
vey, of  Massachusetts,  Korndoorfer,  of  Pennsylvania, 
and  Swarts,  of  Rhode  Island.  The  section  on  State 
medicine  of  the  American  Medical  Association  ap- 
pointed an  interstate  reciprocity  committee  of  three: 
Dr.  Motler,  of  Washington,  D.  C,  chairman  ;  Drs.  Am- 
berg, of  Detroit,  and  Mclntire,  of  Easton,  Pa. 

That  interstate  reciprocity  is  badly  needed  will  be 
allowed  by  all,  but  that  under  the  present  conditions 
it  is  impossible  is  a  fact  just  as  indisputable.  The 
first  steps  to  be  taken  is  the  introduction,  as  far  as  is 
possible,  of  a  uniform  standard  of  medical  education 
throughout  the  country.  Mr.  James  Russell  Parsons, 
the  author  of  an  excellent  monograph  on  the  subject, 
suggests,  as  a  uniform  standard  for  admission  to  med- 
ical practice  in  all  parts  of  the  United  States  is  at  pres- 
ent impracticable,  that  instead  of  the  adoption  of  a 
separate  standard  for  almost  every  political  division 
two,  or  at  most  three,  standards  should  answer  for  all. 
One  phase  of  the  situation  is  both  noteworthy  and  sat- 
isfactory: the  members  of  the  medical  profession  of 
this  country  are  becoming  more  and  more  alive  to  the 
incongruity,  not  to  say  absurdity,  of  the  existing  meth- 
ods of  medical  education  in  the  various  States.  After 
all,  the  remedy  lies  in  their  own  hands.  If  they  deter- 
mine that  the  standards  shall  be  raised  and  placed 
upon  a  uniform  plane,  all  obstacles  will  quickly  melt 
away. 


THE   "NEW   YORK    MEDICAL   JOURNAL' 
CHANGES    OWNERS. 

The  ownership  of  the  Neiv  York  Medical  Journal  has 
passed  from  the  publishing-house  of  D.  Appleton  & 
Company  to  Mr.  A.  R.  Elliott,  an  advertising  agent  of 
this  city.  We  understand,  however — we  certainly 
hope — that  the  editorial  department  will  remain  in 
charge  of  the  present  editor,  to  whose  able  manage- 
ment for  so  many  years  the  journal  owes  its  high 
professional  standing.  This  change  has  been  antici- 
pated for  some  time,  for  it  was  learned  last  spring,  at 
the  time  of  the  temporary  embarrassment  of  this  old 
and  honored  publishing-house,  that  some  of  their 
publications,  notably  the  IVe'iV  York  Medical  Journal, 
were  financially  unprofitable.  Notwithstanding  an 
actual  subscription  list  of  something  over  six  thousand, 
and  an  advertising  patronage  of  upward  of  forty  pages 
per  week,  the  expenses  of  publishing  this  journal  were 
considerably  in  excess  of  the  income  from  all  sources, 
and  the  receiver,  therefore,  decided  to  dispose  of  the 
property,  with  the  result  above  stated. 

It  will  doubtless  be  a  matter  for  surprise  to  the  great 
majority  of  the  profession  to  learn  that  a  medical 
journal  apparently  so  prosperous  was  financially  a 
failure,  and  it  will  perhaps  dispel  the  idea  which 
seems  to  prevail  that  the  profits  of  publishing  medical 
journals  are  fabulously  large.  Those  who  have  had 
experience  in  such  matters  know  well  that  the  publica- 
tion of  a  medical  journal  is  very  different  from  that  of 
an  illustrated  magazine  for  the  general  public.  The 
latter  can  be  sold  at  a  price  irrespective  of  the  cost  of 
manufacture,  and  thereby  secures  an  enormous  circu- 
lation, the    profit  on    the  undertaking  being  derived 


July  28,  1900] 


MEDICAL    RECORD. 


139 


wholly  from  the  advertisements.  The  number  and 
variety  of  the  latter  which  can  be  secured  for  a 
monthly  magazine  are  practically  unlimited,  whereas 
in  the  matter  of  reputable  medical  advertising  there 
is  a  very  sharply  defined  limit.  This  change  of  own- 
ership of  the  Neiij  York  Aledical  Journal  mzy  serve  to 
impress  the  truth  of  the  facts  just  stated  upon  the 
minds  of  the  more  or  less  experienced  financial  back- 
ers of  some  other  of  our  contemporaries  which  are  now 
being  published  at  a  heavy  loss. 


^eius  Df  the  ^mecfe. 

Yellow  Fever  in  Cuba.  —  During  the  first  half  of 
July  there  were  forty-five  cases  of  yellow  fever  re- 
ported in  Havana,  with  sixteen  deaths.  Nearly  all  of 
the  patients  were  newly  arrived  Spaniards,  very  few 
being  Americans.  A  woman  who  arrived  at  this  port 
last  week  in  a  steamship  from  Havana  was  found  to 
be  suffering  from  yellow  fever  and  died  at  quarantine 
the  day  after  her  arrival.  In  a  despatch  to  the  War 
Department  from  Havana,  it  is  reported  that  General 
Lee  has  obtained  information  that  leaves  no  doubt 
about  the  existence  of  yellow  fever  among  the  troops 
at  Pinar  del  Rio,  and  that  nine  deaths  there  last 
month,  reported  as  pernicious  malarial  fever,  are  now 
believed  to  have  been  yellow  fever.  Surgeons  sent  to 
Pinar  del  Rio  to  make  an  inspection  have  reported 
that  yellow  fever  exists  among  the  troops.  The  de- 
spatch also  says  that  there  are  five  suspected  cases  of 
yellow  fever  among  the  soldiers  stationed  at  Guanajay. 

Jubilee  of  the  St.  John's  Guild The  twenty- 
fifth  anniversary  of  the  beginning  of  the  floating-hos- 
pital service  of  St.  John's  Guild  was  celebrated  last 
week,  when  the  members  and  officers  of  the  Guild  and 
their  friends  took  a  trip  down  the  bay  with  the  chil- 
dren on  the  Etnma  Abbott,  had  a  luncheon  and  appro- 
priate exercise  on  board,  and  returned  to  the  city  later 
on  the  Helen  C.  Jiiillard.  The  first  trip  of  the  Emma 
Abbott  was  made  on  July  19,  1875.  The  Helen  C. 
Juillard  was  put  in  commission  last  summer.  The 
trained-nurse  department  was  started  in  1887,  and  the 
salt-water  bathroom  on  the  floating  hospital  the  fol- 
lowing year. 

Infant  Mortality  in  Brooklyn. — It  was  stated  re- 
cently in  a  Brooklyn  newspaper  that  the  mortality 
among  children  under  five  years  of  age  is  greater  in 
that  borough  than  in  any  city  in  the  United  States, 
and  very  much  higher  than  in  Manhattan.  The  main 
reason  for  this  difference  between  the  two  boroughs 
is  alleged  to  be  that  there  is  no  summer  corps  of 
physicians  to  visit  the  tenements  in  Brooklyn,  pre- 
scribe for  sick  babies  not  under  the  care  of  a  physi- 
cian, and  instruct  the  mothers  in  the  elementary  rules 
of  hygiene. 

Smallpox  Outbreak  in  Montreal. — Owing  to  an 
outbreak  of  smallpox  the  board  of  health  of  Montreal 
has  ordered  house-to-house  vaccination.  Within  the 
last  two  weeks  there  have  been  a  dozen  cases,  four  of 


which  terminated  fatally.     They  are  all   in  the  good 

English  residence  district. 

The    Prevention    of     Premature     Burial. — The 

American  Society  for  the  Prevention  of  Premature 
Burial,  which  is  modelled  on  about  the  same  general 
lines  as  the  London  society  of  the  same  name,  has 
been  organized  in  this  city.  The  founders  of  the 
society  are  Mr.  Clark  Bell,  Dr.  Thomas  Darlington, 
Dr.  Henry  J.  Garrigues,  Mr.  Cyrus  B.  Gale,  and  Mr. 
H.  Gerald  Chapin. 

Measles  on  a  Naval  Training-Ship — The  naval 
training-ship  Newport  returned  from  Boston  to  New- 
port recently  with  several  suspicious  cases  of  measles 
on  board.  During  the  previous  visit  of  the  Newport 
there  an  epidemic  of  that  malady  developed,  and  the 
cadets  sick  at  the  time  were  sent  to  the  Naval  Hos- 
pital, on  Coasters  Island.  All  recovered,  and  the 
ship  sailed  with  the  belief  that  the  sickness  had  en- 
tirely disappeared. 

Heroic  Therapeutics. — It  is  reported  that  as  the 
result  of  a  fall  from  the  roof  of  his  house  speech  has 
been  restored  to  a  man  in  Pittsburg  who  for  fifty  years 
had  been  unable  to  express  himself  in  other  than  the 
sign  language.  The  remedy  seems  an  unnecessarily 
violent  and  dangerous  one  when  it  is  known  that  hys- 
terical disorders,  as  this  can  only  be,  are  often  readily 
and  as  efficaciously  relieved  by  less  vigorous  sugges- 
tive treatment,  such  as  bread-pills,  hypodermic  injec- 
tions of  water,  applications  of  electricity,  the  laying 
on  of  hands,  prayer,  and  other  more  recent  and  more 
fashionable  delusions. 

A  New  German  Hospital  Building  will  soon  be 
erected  at  the  corner  of  Lexington  Avenue  and  Sev- 
enty-seventh Street.  The  cost  of  the  new  building, 
and  of  alterations  to  the  building  adjoining  this  site, 
and  now  used  as  the  woman's  ward  of  the  hospital, 
will  be  $150,000. 

Scholarships  of  the  American  Medical  Associa- 
tion.— In  accordance  with  the  recommendation  of  Dr. 
Keen  in  his  presidential  address,  the  trustees  of  the 
American  Medical  Association  have  established  a 
fund  of  $500  to  be  expended  annually  for  the  encour- 
agement of  scientific  research,  but  no  sum  given  to 
any  individual  shall  exceed  $100  at  one  time. 

The  Faith-Cure  Fad.— It  is  stated  in  the  Medical 
Sentinel  that  there  are  twice  as  many  persons  studying 
in  the  so-called  schools  of  mental  healing,  faith  cure, 
Christian  science,  and  the  like,  than  in  all  the  medi- 
cal schools  in  the  country  combined. 

The  Second  Cuban  Medical  Congress,  which  was 
to  have  been  held  in  Havana  the  last  week  in  Febru- 
ary, igoi,  has  been  postponed  to  a  corresponding  date 
in  1902.  This  action  has  been  determined  by  the 
resolution  of  the  international  executive  committee  to 
hold  the  third  Pan-American  Medical  Congress  in 
Havana  in  December  of  the  present  year. 

Dr.  George  O'Hanlon,  of  King's  Park,  has  been 
appointed  first  assistant  physician  at  the  Long  Island 
State  Hospital,  » 


140 


MEDICAL    RECORD. 


[July  28,  1900 


•'  Archives  de  Medecine  et  de  Chirurgie  Spe- 
ciales "  is  tlie  name  of  a  new  monthly  journal  of 
Paris,  established  and  edited  by  Dr.  Suarez  de  Men- 
doza.  It  is  a  sort  of  review  of  reviews  of  the  special- 
ties in  medicine. 

Care  of  Lepers  in  Louisiana. — The  State  legislature 
of  Louisiana  has  added  $5,000  to  the  §20,000  ap- 
propriated one  year  ago  to  purchase  the  site  and  erect 
suitable  buildings  for  the  care  and  treatment  of  the 
lepers  of  the  State.  The  present  hospital  is  only 
leased  for  a  definite  time  and  is  inconveniently  situ- 
ated. The  board  of  control  of  the  Leper  Home  intends 
to  purchase  a  site  as  near  New  Orleans  as  possible, 
in  order  that  every  facility  may  be  had  for  treating 
these  unfortunates.  The  board  applied  for  an  in- 
crease of  $20,000,  but  succeeded  in  getting  but 
$5,000. 

A  Deserting  Russian  Naval   Surgeon — Dr.  Leo 

Alexandroff,  an  assistant  surgeon  in  the  Russian 
navy,  was  sent  to  Philadelphia  recently  with  a  crew  of 
sailors  to  man  the  cruiser  Variag,  which  has  just  been 
built  here  for  the  Russian  government.  On  arrival 
here  he  deserted,  but  was  arrested  at  the  instance  of 
the  Russian  vice-consul  and  was  held  to  await  requi- 
sition papers.  It  was  contended  that  he  was  simply  a 
deserter  from  the  navy  and  not  from  any  particular 
vessel,  and  that  therefore  his  case  was  not  provided 
for  in  the  treaty  relating  to  deserters  from  naval  ves- 
sels. The  United  States  district  judge,  before  whom 
the  case  was  tried,  discharged  the  prisoner  on  this 
ground,  but  the  counsel  for  the  Russian  government 
immediately  took  an  appeal  to  the  United  States  court 
of  appeals,  and  Dr.  Alexandroff  was  held  in  bail  pend- 
ing a  decision  of  that  court. 

The  Spitting-Nuisance  in  Atlantic  City.— The 
board  of  health  of  Atlantic  City  has  declared  spitting 
in  public  places,  in  cars  or  'buses  or  any  conveyance, 
or  on  the  boardwalk  or  any  sidewalk,  a  nuisance,  and 
any  person,  persons,  or  corporation  making,  causing, 
maintaining,  or  permitting  any  such  nuisance  shall 
forfeit  and  pay  a  penalty  of  $20. 

Faith-Cure  in  Philadelphia. — The  coroner  of  Phil- 
adelphia has  committed  for  trial  a  man  under  whose 
care  death  occurr'".d  in  an  infant  seven  months  old, 
from  convulsions  during  teething,  as  a  result,  in  the 
opinion  of  the  coroner's  jury,  of  criminal  neglect. 
The  offender  claimed  to  be  one  of  the  ''children  of 
God,"  believing  in  the  "  cure  of  disease  by  prayer." 
Hence  the  services  of  a  medical  man  were  not  sought. 
Even  incarceration  was  without  terror,  from  a  sense  of 
"deliverance  through  faith." 

Philadelphia  Hospital.— Dr.  Emanuel  S.  Gans  and 
Dr.  Milton  B.  Hartzell  have  been  elected  dermatolo- 
gists to  tlie  Philadelphia  Hospital,  in  succession  to 
Dr.  J.  Abbott  Cantrell,  resigned. 

Mortality    Statistics    in    Philadelphia For   the 

week  ended  July  21st,  there  were  reported  to  the 
Philadelphia  bureau  of  health  564  deaths,  being  31 
more  than  for  the  preceding  week  and  41  more  than 


for  the  corresponding  week  of  the  previous  year.  Of 
this  number  17  were  due  to  sunstroke,  89  to  cholera 
infantum,  and  23  to  inanition  in  infants.  Among 
other  causes  of  death  are:  pulmonary  tuberculosis  45, 
gastro-enteritis  42,  marasmus  34,  convulsions  30, 
heart  disease  27. 

A  Fertile  Source  of  Typhoid-Fever  Infection  has 
been  found  in  the  handling  of  the  well-rope  or  chain 
by  those  in  attendance  upon  a  typhoid  patient.  Such 
being  the  case,  physicians  practising  in  country  dis- 
tricts should  see  to  it  that  these  attendants  do  not 
draw  water  from  the  well.  It  is  easy  to  see  how  a 
whole  family  may  be  infected  by  the  drinking-water 
when  such  infected  hands  have  been  literally  washed 
in  the  well.  Those  familiar  with  the  very  common 
mode  of  raising  water  from  wells  by  the  bucket  sys- 
tem will  readily  appreciate  the  force  of  this  sugges- 
tion.— Richtnond  Journal  oj  Practice,  June,  igoo. 

First  Steps  in  Medical  Reciprocity. — At  a  regu- 
lar meeting  of  the  State  board  of  medical  examiners 
held  at  Newark,  N.  J.,  July  sth,  a  resolution  was 
adopted  that  the  board  will  hereafter  indorse  the  li- 
censes of  any  State  board  of  medical  examiners  in 
the  United  States,  in  lieu  of  an  examination,  provided 
that  the  candidate  for  indorsement  shall  present  satis- 
factory evidence  of  having  the  academic  and  medical 
education  required  by  the  New  Jersey  State  board, 
and  that  the  license  presented  for  indorsement  shall 
have  been  issued  after  a  State  examination  of  the 
same  grade  and  kind  as  that  required  in  New  Jersey. 

A  Seasonable  Procedure. — In  its  unbounded  zeal 
and  enthusiasm  a  Philadelphia  homoeopathic  medical 
society  continues  its  monthly  meetings  during  the 
heated  term;  but  temperatures  of  100°  and  thereabouts 
are  not  conducive  to  a  large  attendance  and  an  inter- 
ested audience.  So,  adapting  itself  to  the  circum- 
stances, this  modern  and  progressive  society  engaged 
a  steamboat  for  its  July  meeting,  and  those  who  were 
loyal  and  fortunate  enough  to  attend  were  regaled  with 
river  breezes  while  listening  to  scientific  discourse. 

Typhoid  Fever  at  a  Golf  Club Alarm  has  been 

caused  among  the  members  of  a  golf  club  near  Chi- 
cago by  an  epidemic  of  typhoid  fever  which  has 
claimed  as  victims  nearly  fifty  persons  who  frequented 
the  club's  greens.  Thirty-three  caddies  are  suffering 
with  typhoid  fever  and  one  has  died.  Ten  employees 
of  the  club  are  confined  to  their  beds,  one  club  mem- 
ber has  died,  and  three  more  have  been  stricken.  The 
water  of  a  well  on  the  links  was  much  used  by 
the  golfers  in  preference  to  the  regular  supply  for  the 
club,  which  is  drawn  from  artesian  wells.  When  the 
outbreat  of  typhoid  fever  occurred,  suspicion  was  di- 
rected to  this  well,  and  a  bacteriological  examination 
of  the  water  showed  the  presence  of  Eberth's  bacillus. 

A  Day  Nursery. — Plans  have  been  filed  by  the 
Brightside  Day  Nursery  and  Kindergarten  of  this 
city  for  a  new  building,  five  stories  in  height,  to  be 
erected  on  Cannon  Street,  near  Rivington. 

Disease  at  Nome. — According  to  the  reports  of 
travellers  returning  from  Nome,  the  sanitary  condition 


July  28,  1900] 


MEDICAL   RECORD. 


141 


of  that  place  is  very  bad,  smallpox,  typhoid  fever,  and 
pneumonia  being  epidemic.  A  Chicago  physician  is 
quoted  in  the  papers  as  saying  that  things  there  "are 
fast  approaching  a  frightful  crisis.  Everything  is 
polluted  with  disease.  Water  is  filled  with  filth  and 
deadly  germs.  The  beach  for  six  miles  is  filled  with 
disease.  Here  and  there  can  be  seen  danger  signals 
flying  from  tent  poles.  As  the  pest  house  is  full, 
many  smallpox  patients  are  being  cared  for  in  their 
tents  until  the  government  houses  are  completed. 
People  are  dying  within  forty-eight  hours  after  being 
taken  ill  with  pneumonia.  Officials  at  Nome  are 
sending  out  orders  for  one  thousand  cots  for  use  in 
hospitals  that  are  being  built.  They  are  to  have  a 
pneumonia  hospital  and  a  separate  hospital  for  small- 
pox. Outside  of  the  regular  physicians,  it  is  almost 
impossible  to  get  men  to  work  in  the  pest  house,  even 
at  J2.50  per  hour,  which  was  being  offered." 

Navy  Department,  Bureau  of  Medicine  and  Sur- 
gery, Washington,  D.  C. — Changes  in  the  medical 
corps  of  the  United  States  navy  for  the  week  ending 
July  20,  1900.  July  14th. —  Medical  Director  P.  Fitz- 
simons  detached  from  the  naval  examining-board, 
Annapolis,  Md.,  and  ordered  to  duty  in  charge  of  the 
naval  hospital,  Newport,  R.  I.,  July  21st.  Medical 
Director  H.  J.  Babin  detached  from  duty  as  president 
of  the  medical  board  of  examiners,  naval  laboratory, 
Brooklyn,  N.  Y.,  July  25th,  and  ordered  home  and  to 
wait  orders.  Surgeon  L.  G.  Heneberger  detached 
from  the  naval  hospital,  Newport ,  R.  I.,  July  21st, 
and  ordered  to  duty  as  member  of  the  board  of  medi- 
cal examiners,  naval  laboratory,  Brooklyn,  N.  Y.,  July 
25th.  Passed  Assistant  Surgeon  A.  M.  D.  McCor- 
mick  detached  from  the  Chicago  and  ordered  to  the 
Montgomery.  Assistant  Surgeon  J.  R.  Whiting  de- 
tached from  the  Montgomery  and  ordered  to  the  Chi- 
cago. Assistant  Surgeon  C.  N.  Fiske  detached  from 
the  navy  yard,  Boston,  and  ordered  to  duty  with  ma- 
rines at  San  Francisco,  Cal.,  and  then  to  duty  at  the 
naval  hospital.  Mare  Island,  Cal.  Assistant  Surgeon 
J.  H.  Payne,  Jr.,  detached  from  the  naval  hospital, 
Mare  Island,  Ca!.,  and  ordered  to  the  Asiatic  station 
with  the  fifth  battalion  of  marines.  Pharmacist  A. 
Prosper!  detached  from  the  naval  academy,  July  21st, 
and  ordered  home  and  to  wait  orders;  retired  from 
July  3,  1900,  under  the  provisions  of  section  1,143, 
Revised  Statutes,  upon  his  own  application,  after 
forty  years'  service. 

The  '<  Archivos  de  la  Policlinica,"  a  medical 
weekly  publication  of  Havana,  has  suspended  publi- 
cation. It  was  established  eight  years  ago,  and  has 
been  ably  conducted  by  Dr.  Enrique  Lopez  and  a 
staff  of  collaborators. 

Obituary  Notes — Dr.  Divie  Bethune  McCartee, 
a  pioneer  among  medical  missionaries,  died  in  San 
Francisco  on  July  17th,  while  on  his  way  to  this  city 
from  Japan.  Dr.  McCartee  was  born  in  Philadelphia 
on  January  13,  1820,  and  was  the  eldest  son  of  the 
late  Dr.  Robert  McCartee  of  this  city.  He  attended 
Columbia  College,  and  then  went  to  the  University  of 
Pennsylvania,  from  which  institution  he  received  the 
degrees  of  A.B.  and  M.D.     He  began  the  practice  of 


medicine  in  Philadelphia,  but  in  1843  went  to  China 
and  opened  a  medical  mission  in  Ningpo  early  in  the 
following  year.  He  lived  in  China  for  forty  years, 
mastering  so  perfectly  the  official  language  of  the 
country  and  several  of  the  dialects  that  he  was  em- 
ployed as  interpreter  in  the  local  Chinese  courts.  The 
Chinese  government  gave  him  a  gold  medal  in  recog- 
nition of  his  services  in  connection  with  the  suppres- 
sion of  the  Macao  coolie  traffic,  and  later  he  received 
the  title  of  consul-general  for  services  in  the  Chinese 
legation.  He  afterward  went  to  Japan  and  worked  as 
a  missionary  there,  and  became  so  proficient  in  the 
language  that  his  services  as  interpreter  were  made 
use  of  again  by  this  government.  He  was  decorated 
by  the  Japanese  emperor  with  the  order  of  the  Rising 
Sun.     His  widow  survives  him. 

Dr.  Samuel  Russell  Welles  died  at  his  home  in 
Waterloo,  N.  Y.,  July  13th.  He  was  born  in  Water- 
loo, February  23,  1825;  was  graduated  from  Geneva 
College  (now  Hobart)  in  1845,  ^"d  received  the  de- 
gree of  M.D.  at  Buffalo  University  in  1848.  In  1862 
he  entered  the  military  service  as  acting  assistant 
surgeon  in  the  Sixty-First  Regiment,  New  York  State 
Volunteers,  and  received  a  commission  in  March  of 
that  year.  In  1875  he  was  elected  a  trustee  of  Hobart 
College,  and  was  twice  sent  to  the  legislature  from 
Seneca  County. 

Dr.  Elias  S.  Peabody  died  at  his  home  in  Taylor- 
ville,  111.,  on  July  20th,  at  the  age  of  eighty-seven 
years.     He  w'as  born  in  Stonington,  Conn. 

Dr.  Clitus  S.  Hoag,  of  Bridgeport,  Conn.,  died  on 
July  1 8th,  aged  forty-five  years.  He  was  a  graduate 
of  the  Hahnemann  Medical  College,  Philadelphia,  in 
1877. 

Dr.  Oswald  B.  Finney  died  at  his  home  in  Onan- 
cock,  Va.,  on  July  23d,  at  the  age  of  nearly  eighty 
years.  He  was  a  graduate  of  the  medical  department 
of  the  University  of  Pennsylvania  in  1843. 

Dr.  Charles  H.  Mersereau  died  on  May  2d,  of 
heart  disease,  at  his  home  in  this  city.  He  was  thirty- 
seven  years  old  and  was  unmarried.  Dr.  Mersereau 
was  born  in  Port  Chester  and  was  graduated  from  the 
College  of  Physicians  and  Surgeons  in  1884.  He 
served  two  years  in  the  Hartford,  Conn.,  Hospital,  and 
for  several  years  was  sanitary  inspector  in  this  city. 

Dr.  James  S.  Gillespie  died  of  appendicitis  at 
Philadelphia  on  July  19th,  at  the  age  of  thirty-seven 
years.  He  was  graduated  from  Jefferson  Medical 
College  in  1884,  and  became  a  resident  physician  in 
the  Jefferson  Medical  College  Hospital. 

Dr.  Thomas  Story  Kirkbride  died  of  typhoid 
fever  at  Philadelphia  on  July  19th,  at  the  age  of  thirty- 
one  years.  He  was  a  son  of  Dr.  Thomas  S.  Kirkbride, 
the  distinguished  alienist,  who  was  for  more  than  forty 
years  the  superintendent  of  the  Pennsylvania  Hospital 
for  the  Insane.  He  was  graduated  from  the  medical 
department  of  the  University  of  Pennsylvania  in  1893, 
and  in  1894  became  a  resident  physician  in  the  Penn- 
sylvania Hospital.  On  his  return  from  post-graduate 
study  abroad,  he  was  in  1897  appointed  director  of 
laboratories  in  the  Philadelphia  Polyclinic.  He  was 
also  assistant  physician  to  the  University  Hospital  and 
assistant  pathologist  to  the  Philadelphia  Hospital. 


142 


MEDICAL   RECORD. 


[July  28,  1900 


^r00vcss  0f  ^cdical  Science. 

The  Boston  Medical  and  Surgical  Journal,  July  ig,  igoo. 

General  Remarks  on  the  Pathology  and  Symptomatology 
of  Acute  Pelvic  Suppurative  Processes  in  the  Female,  and 
their  Treatment  by  Posterior  Colpotomy. — Charles  Greene 
Cumston  says  that  an  experience  of  more  than  six  years 
in  vaginal  work  has  proved  to  him  that  posterior  colpot- 
omy is  a  very  innocent  operation,  and  in  the  highest  de- 
gree consen-ative.  It  may  be  performed  not  only  in  cases 
of  acute  purulent  lesions  in  the  pelvis  when  it  would  be 
imprudent,  not  to  say  dangerous,  to  perform  laparotomy 
or  vaginal  hysterectomy,  but  also  in  cases  of  chronic  puru- 
lent pelvic  lesions.  It  should  be  preferred  in  every  case 
in  which  the  patient  is  a  young  woman,  it  being  the  sur- 
geon's duty  to  preserve  the  adnexa  at  any  cost.  Every 
suppurating  pelvic  collection  that  is  accessible  by  Douglas' 
cul-de-sac  is  suited  for  posterior  colpotomy  and  drainage. 
The  author  describes  the  technique  of  the  operation. 

Parturition   Complicated   with   Suppurating   Fibroids. — E. 

H.  Stevens  reports  a  case  in  which  labor  was  normal,  in 
spite  of  a  uterine  fibroid.  Symptoms  of  septic  infection 
developed,  and  injections  of  antistreptococcus  serum  were 
given.  A  complete  hysterectomy  was  performed  on  the 
seventeenth  day  after  labor.  Death  occurred  on  the 
twenty-first  day.  The  author  says  that  all  the  surround- 
ings of  the  patient  were  aseptic,  so  that  he  does  not  see 
how  anything  more  could  have  been  done  to  prevent  the 
tumor  from  becoming  septic.  As  to  the  operation  he  would 
not  hesitate  to  advise  it  in  any  similar  case.  The  injection 
of  the  serum,  he  thinks,  did  no  good,  and  probably  did 
harm,  as  evidenced  by  a  rash.  There  was  no  evidence  of 
streptococcus  infection,  and  therefore  the  use  of  the  anti- 
streptococcus  serum  was  irrational. 

Glandulopenile  Hypospadias  ;  Two  Urethras,  One  Extend- 
ing to  the  Bladder,  the  Other  Two  and  One-Half  Inches 
Long,  and  Terminating  in  a  Blind  Pouch. — By  J.  Coplin 
Stinson. 

Milk ;  its  Production,  its  Care,  its  Use.— By  J.  M.  Rotch. 

Medical  News,  July  21,  igoo. 

Appendicitis  and  Typhoid  Fever. — H.  A.  Hare  refers  to 
two  groups  of  cases  which  have  never  failed  to  puzzle 
him :  (i)  Cases  in  which  symptoms,  appearing  in  the 
neighborhood  of  the  appendix,  indicate  the  rapid  de- 
velopment of  appendicitis,  yet  in  which  these  symptoms 
gradually  subside  and  the  patient  passes  into  an  attack 
of  typhoid  fever ;  (2)  cases  already  well  advanced  in  the 
progress  of  typhoid  fever  which  develop  appendicular 
symptoms.  Histories  relating  to  each  are  given.  In  one 
the  symptoms  were  typical  of  appendicitis,  and  operation 
was  about  to  be  done  but  was  postponed.  At  the  end  of  a 
week  typhoid  fever  was  fully  developed.  The  possibility 
of  typhoid  infection  of  the  appendix  producing  appendicitis 
is  mentioned.  In  a  boy  aged  nine  years,  the  symptoms 
of  appendicitis  disappeared  under  ice-bag  treatment  and 
typhoid  developed.  He  regards  appendicular  trouble  in 
the  early  stages  of  typhoid  as  by  no  means  rare.  Ulcera- 
tion in  the  neighborhood  of  the  caput  coli  can  readily 
produce  tenderness,  resistance,  and  other  symptoms  of 
appendicitis.  Much  attention  should  be  paid  to  blood  ex- 
aminations. 

The  Continued  Use  of  the  Antiseptic  and  Eliminative 
Treatment  of  Typhoid  Fever  Without  Any  Deaths.— T.  Vir- 
gil Hubbard,  when  called  to  a  case  of  typhoid  fever, 
usually  commences  by  giving  the  patient  a  capsule  con- 
taining calomel,  gr.  ss.  ;  guaiacol  carbonate,  gr.  ii.  ;  po- 
dophyllin,  gr.  ^^  to  ^jJ;,,  every  two  hours  for  twenty- 
four  to  forty-eight  hours,  depending  on  the  condition  of 
the  bowels.  He  continues  this  until  he  has  secured  four 
or  five  intestinal  evacuations  for  two  successive  days,  and 
then  stops  administering  the  calomel  and  adds  gr.  ss.  of 
menthol  to  the  guaiacol  and  podophyllin.  Small  doses  of 
salts  or  Hunyadi  water  are  given  if  there  is  a  tendency  to 
inactivity  of  the  bowels.  Decinormal  salt  solution  is  given 
per  rectum  when  the  skin  and  kidneys  fail  to  act  well. 
The  proper  administration  of  calomel  is  the  point  to  which 
he  desires  to  call  especial  attention,  i.e.,  small  and  often 
rejjcated  doses.  A  typhoid  patient  can  take  more  mercury 
without  purgation  or  salivation  than  the  same  individual 
in  health.  He  has  treated  twenty  patients  without  a 
death. 

Moulds  in  the  Stomach. — J.  H.  Kellogg  found  in  seven 
thousand  analyses  mould  present  four  liundred  and  fifty- 
seven  times.  The  sources  of  moulds  in  food  are  numer- 
ous. Like  various  bacteria  they  give  rise  to  fermentations 
and  putrefactions.  They  grow  in  acid  media.  In  the 
cases  noted  simple  dyspepsia  was  present  thirty-two,  hy- 


perpepsia  one   hundred  and  seventy-six,  and  hypopepsia 

two  hundred  and  forty-nine  times. 

Iodide  of  Iron  in  the  Treatment  of  Certain  Forms  of  Infec- 
tive Arthritis. — J.  C.  Wilson  has  for  several  years  treated 
all  cases  of  gonorrhoeal  arthritis  with  large  doses  of  the 
syrup  of  the  iodide  of  iron.  Cases  are  reported.  The  sub- 
ject Ijelongs  to  the  realm  of  empirical  therapeutics. 

A  Simplified  Apparatus  Without  Valves  for  the  Adminis- 
tration of  Nitrous  Oxide  Alone  or  in  Combination  with  Ether. 

—  By  S.  Ormond  Goldan. 

The  Physiological  Effects  of  Preparations  of  the  Ductless 
Glands. — By  R.  H.  Cunningham. 

Brief  Notes  on  Rheumatic  Joints  Treated  by  Hot  Air. — 
By  Homer  Gibney. 

Ne'iu  York  Medical  Journal,  July  21,  igoo. 

Syphilis  of  the  Brain. — J.  T.  Eskridge  concludes  a  lengthy 
article  with  remarks  on  diagnosis  and  treatment.  The  lat- 
ter is  considered  under  the  headings  of  prevention,  general 
management,  and  anti-syphilitic  medication.  His  experi- 
ence has  been  that  the  activity  of.  the  syphilitic  process  is 
the  only  guide  to  the  choice  of  mercury  or  potassium 
iodide.  The  greater  the  activity  of  the  poison,  the  more 
acute  and  violent  the  symptoms,  the  greater  the  demand  for 
mercury.  On  the  other  hand,  potassium  iodide  apparently 
does  more  good  in  the  chronic  specific  process  than  does 
mercury.  He  does  not  wish  us  to  infer  that  mercury  does 
no  good  in  chronic  syphilitic  lesions  and  that  potassium 
is  useless  in  the  active  and  acutely  irritative  ones.  On  the 
contrary,  he  believes  that  each  may  be  indicated  in  almcst 
any  stage  of  intracranial  syphilis  ;  but  when  it  is  a  question 
under  which  drug's  influence  we  must  first  seek  to  bring 
our  patient,  then  the  acuity  or  chronicity  of  the  syphilitic 
inflammation  should  guide  us. 

The  Etiology  and  Cure  of  Hysteria.- F.  Walter  states  that 
if  a  massive  culture  of  the  colon  bacillus,  the  original  col- 
ony of  which  was  taken  from  a  non-infectious  source,  be 
administered  to  a  case  of  hysteria — that  is  to  say,  of  the 
active  or  convulsive  type — latent  or  post-hysterical  phe- 
nomena such  as  paralysis  being  excluded,  the  symptoms 
disappear  in  from  twenty-four  to  forty-eight  hours  and  the 
patient  is  restored  to  health  .so  far  as  the  hysteria  is  con- 
cerned ;  debility  or  neurasthenic  phenomena  may  remain 
for  an  indefinite  period.  As  to  etiology,  two  views  may  be 
propounded  ;  one  assumes  the  existence  of  a  specific  organ- 
ism causative  of  hysteria  not  to  be  differentiated  by  our 
present  methods  from  the  bacillus  coli  communis ;  the 
other,  that  in  the  intestinal  tract  of  predisposed  subjects 
the  otherwise  harmless  colon  bacillus  may  take  on  toxic 
properties.  In  either  event  the  offending  organism  is 
simply  displaced  by  the  method  of  treatment  here  advo- 
cated. 

The  Prevention  of  Colds  in  the  Newborn. — L.  B.  Lockard 
finds  the  chief  requisites  on  the  part  of  the  future  mother 
to  be  a  careful  diet,  loose  warm  clothing,  daily  exercise  in 
the  open  air  (omitted  in  the  later  months  of  gestation  by 
most  women  because  of  a  sense  of  false  modesty) ,  daily 
bathing  in  lukewarm  water,  and  mental  entertainment. 
The.se  directions  are  of  cardinal  importance  as  preparing 
the  way  for  the  birth  of  a  strong,  vigorous  child.  Then, 
during  the  very  first  weeks  of  infancy,  and  from  that  time 
on,  special  attention  should  be  paid  to  the  clothing,  and  the 
dwelling  should  be  kept  at  a  proper  temperature.  All  over- 
stimulation in  every  direction  must  be  forbidden,  while 
careful  attention  must  be  paid  to  bathing  and  exercise. 

A  Brief  Consideration  of  Gangrene  and  Mortification  (Trau- 
matic   and    Pathological)    of    the   Extremities. — By    T.    H. 

Manley. 

The  Pituitary  Gland  as  a  Factor  in  Acromegaly  and  Giant- 
ism.— By  Woods  Hutchinson. 

Journal  of  the  American  Medical  Ass' n,  July  21,  igoo. 

Surgery  of  the  Tear  Passages. — J.  G.  Huizinga  describes 
the  characteristics  of  catarrhal  inflammation,  infections, 
and  strictures  of  the  lacrymal  canal.  The  treatment  of 
stricture  is  comparatively  simple  because  of  the  ease  of 
access.  The  opening  into  the  canaliculus  is  not  always 
easy  for  the  inexperienced.  If  a  large  portion  of  the  canal 
is  closed,  it  becomes  necessary  to  make  an  opening  a  short 
distance  beyond  the  punctum  near  the  median  line  just 
within  the  upper  or  lower  border  of  the  lid.  The  tendency 
to  heal  must  be  prevented  by  the  daily  use  of  a  well-lubri- 
cated No.  6  probe  introduced  as  far  as  the  sac.  In  simple 
contraction  he  prefers  the  rapid  method  of  dilatation.  He 
agrees  with  Knapp  that  patients  with  moderate  epiphora 
should  bear  their  trouble  without  probing.  Slitting  the 
canal  and  converting  it  into  a  groove  is  as  unscientific  as 
its  results  are  unsatisfactory.     Simple  dilatations  of  the 


July  28,  1900] 


MEDICAL   RECORD. 


143 


constricted  portion  of  the  canaliculus  by  means  of  ordinary 
probing  alone  is  notoriously  unsatisfactory.  If  after  a 
careful  examination  it  has  been  ascertained  that  the  ob- 
struction to  tiie  canal  is  of  a  bony  nature,  the  treatment 
resolves  itself  into  extirpation  or  complete  destruction  of 
the  lacryraal  sac,  with  or  without  excision  of  the  lacry- 
mal  gland. 

Acute  Tonsillar  Diseases  and  their  Sequela. — J.  H.  Abra- 
ham describes  superficial  tonsillitis,  cryptic  tonsillitis,  and 
peritonsillar  abscess.  Tonsillitis  due  to  milk  infection,  to 
disordered  stomach  from  overfeeding  in  children,  and  to 
faulty  drainage  is  mentioned.  Treatment  is  given  at 
some  length.  The  author's  conclusions  are  :  (i)  All  cases 
of  acute  tonsillar  disease  should  be  considered  more  than 
trivial  affections.  (2)  Acute  lacunar  tonsillitis  is  an  infec- 
tious disease.  (3)  Isolation  should  be  practi-sed  in  all  cases 
of  acute  lacunar  tonsillitis.  (4)  Recurring  attacks  of  acute 
tonsillitis  are  an  indication  for  the  partial  or  complete  re- 
moval of  the  tonsils.  (5)  A  careful  systemic  examination 
and  treatment  should  be  applied  during  and  after  an  attack 
of  acute  tonsillitis. 

The  Differentiation  of  Chorea  and  the  Disorders  Simulat- 
ing it. — -Augustus  A.  Eshner  finds  that  in  chorea  wo  have 
a  suggestion  of  an  infectious  process,  although  the  cause 
has  not  been  fully  determined.  Various  irritations  which 
play  a  part  in  the  forms  of  spasmodic  tic  have  no  bearing 
upon  true  chorea.  The  apparent  relations  between  chorea 
and  rheumatism  are  still  obscure.  Mircoli  concludes  from 
investigations  that  both  are  dependent  on  infection  with 
pyogenic  cocci  which  do  not  give  rise  to  suppuration.  The 
distinctions  from  habit  cliorea,  mimic  spasm,  senile  chorea, 
hysteria,  torticollis,  nodding  spasm,  etc.,  are  pointed  out. 

Value  of  the  Angiotribe  in  Vaginal  Coeliotomy. — J.  H.  Car- 

stens  refers  to  the  difficulties  of  removal  of  the  ovaries  by 
the  vaginal  route  and  points  to  the  great  aid  of  the  angio- 
tribe in  these  operations.  The  instrument  he  prefers,  that 
of  Thuman,  has  a  narrow  blade  of  great  strength  and  is  pro- 
vided with  a  small  handle  lever  instead  of  a  wheel.  It  is 
less  difficult  to  apply  and  holds  in  exact  place  better  than 
others  he  has  tried. 

A  System  of  Personal  Biologic  Examinations  the  Condi- 
tion of  Adequate  Medical  and  Scientific  Conduct  of  Life. — 
By  George  M.  Gould. 

Recent  Progress  in  the  Roentgen-Ray  Method  of  Diagnosis. 

— By  Charles  Lester  Leonard. 

Laryngology  and  its  Relations  to  General  Medicine. — By 
J.  Solis-Cohen. 

Human  Temperature  in  Disease. — By  Norman  Bridge. 

Obstetrics  and  Gynaecology. — By  W.  E.  B.  Davis. 

Sarcoma  of  the  Stomach. — By  George  Dock. 

Philadclpliia  Medical  Journal,  July  21,  igoo. 

Peritonitis  in  the  Foetus. — J.  A.  Porter  reports  a  case  of 
somewhat  difficult  labor  occurring  in  a  woman  twenty-five 
years  old.  The  child  gave  one  or  two  unnatural  respira- 
tory movements  and  died,  all  attempts  at  resuscitation 
being  in  vain.  The  abdomen  was  very  large ;  the  perito- 
nal  cavity  was  found  to  be  filled  with  a  brownish-green 
fluid.  The  intestines  were  matted  together  with  soft 
lymph  adhesions,  and  the  mesentery  and  peritoneum  were 
deeply  congested. 

A  Case  of  Primary  Adenocarcinoma  of  the  Gall  Bladder 
with  Secondaries  in  both  Adrenals,  Melanosis  of  Skin  (Ad- 
dison's Disease  ?) ,  Vitiligo,  and  Hypertrophy  of  the  Pancreas. 
By  Alfred  Scott  Warthin. 

A  System  of  Personal  Biologic  Examinations  the  Condition 
of  Adequate  Medical  and  Scientific  Conduct  of  Life. — By 
George  M.  Gould. 

Three  Cases  of  Tuberculosis  of  the  Skin  due  to  Inoculation 
with  the  Bovine  Tubercle  Bacillus. — By  Mazyck  P.  Ravenel. 

A  Bacteriologic  Resumfe  of  the  San  Francisco  Plague.— By 
Ernest  S.  Pillsbury. 

Are  Consanguineous  Marriages  Injurious  to  the  Race  ?—  By 
Lawrence  Irwell. 

British  Medical  Journal,  fitly  7  and  14,  igoo. 

Some  Unusual  Sequelse  of  Epityphlitis. — A.  E.  Barker 
gives  a  series  of  cases  showing  that  when  we  delay  to 
operate  the  pause  must  not  be  too  protracted.  There  is 
often  unnecessary  haste,  but  in  many  other  instances  de- 
lay is  a  terrible  mistake.  The  first  case  illustrates  the 
development  of  subphrenic  abscess  as  the  result  of  epityph- 
litis, a  complication  probably  more  frequent  than  is  com- 
monly supposed.  Sonnenburg  met  with  this  complication 
nine  times  in  six  hundred  cases  operated  on  by  himself. 


The  second  case  also  emphasizes  the  danger  of  lung  com- 
plications from  either  e.xtension  of  the  inflammation  around 
the  caecum  upward  to  the  under  surface  of  the  diaphragm, 
or  of  infarcts  lodging  in  the  lung  and  producing  an  abscess 
there.  The  third  case  shows  the  disastrous  local  results  of 
leaving  a  perityphlitic  abscess  too  long  unopened,  and  the 
way  in  which  the  resulting  "artificial"  anus  may  be 
brought  to  heal.  The  fourth  case  illustrates  a  form  of 
ulceration  due  to  concretion  in  the  appendix  with  which 
the  author  was  before  unfamiliar,  and  that  it  may  open  up 
adjacent  small  intestine  without  the  formation  of  an  ab- 
scess. The  fifth  case  shows  almost  the  same  cour.se  of 
events,  in  which  an  appendi.x  inflamed,  but  without  any 
concretion,  and  nearly  ulcerated  into  the  colon.  Other  cases 
illustrate  the  dangers  from  adhesions  following  inflamma- 
tion of  the  appendix. 

The  Use  of  Borax  and  Formaldehyde  as  Preservatives  of 
Food. — W.  D.  Halliburton  urges  that  the  use  of  foreign 
substances  as  preservatives  of  food  be  replaced  by  the 
more  wholesale  use  of  cold  transportation  and  storage  on 
the  grounds  that:  (i)  An  antiseptic  is  inimical  to  the  life 
of  the  organisms  that  cause  putrefaction  ;  it  cannot,  there- 
fore, be  harmless  to  the  vital  processes  in  the  higher  ani- 
mals. (2)  Numerous  clinical  observations  have  been  re- 
corded which  show  that  dyspeptic  and  other  troubles  follow 
the  use  of  foods  which  have  been  treated  with  commonly 
employed  preservatives  like  borax.  (3)  Even  if,  as  in  the 
case  of  boric  acid  and  borax,  the  poison  is  not  cumulative, 
the  continuous  passage  of  foreign  substances  through  the 
kidney  cannot  be  beneficial  to  those  organs.  He  has  con- 
ducted experiments  with  artificial  digestive  mixtures  to 
test  the  action  of  borax  and  formaldehyde,  these  being  the 
preservatives  usually  employed.  The  tests  are  given  at 
some  length.  These  experiments  appear  to  the  author  to 
prove  conclusively  the  injurious  effect  produced  by  even 
minute  quantities  of  certain  preservatives  on  the  activity 
of  the  enzymes  concerned  in  ordinary  digestion,  and  to  fur- 
nish a  cogent  reason  why  the  use  of  these  substances  should 
be  prohibited  for  the  preservation  of  food  materials. 

Two  Cases  of  Concealed   Accidental    Hemorrhage. — A.   E. 

Larking  finds  concealed  hemorrhage  more  rare  and  fatal 
than  placenta  prsevia.  In  both  cases  reported  there  was 
absence  of  hemorrhage  from  the  vagina,  and  the  amniotic 
fluid  was  so  scanty  that  very  little  effect  would  have  re- 
sulted from  rupture  of  the  membranes.  The  uterine  con- 
tractions were  suflScient  to  stop  the  hemorrhage.  In  the 
second  case  there  was  sudden  death  in  convulsion.  Few 
of  the  symptoms,  such  as  loss  of  sight,  noises  in  the 
head,  hallucinations,  sighing  respiration,  and  impercepti- 
ble pulse,  were  present  in  this  case. 

The  Nature  and  Treatment  of  Puerperal  Infection.— T.  E. 

Mitchell  says  some  of  the  worst  cases  of  puerperal  fever  he 
has  seen  have  occurred  after  perfectly  natural  labor,  when 
no  digital  examination  or  manipulation  at  all  had  taken 
place.  Some  cases  originate  in  the  impossibility  of  induc- 
ing many  working-class  patients  to  observe  the  ordinary 
rules  of  post-partum  cleanliness.  Quinine  should  be  given 
in  large  doses  in  septica^mia  (gr.  xii.)  as  an  initial  dose. 
Vag^inal  douches  and  exploration  of  the  uterine  cavity  for 
retained  secundines  are  al.so  recommended. 

A  Combined  Recto-Vaginal  Opening  in  the  Human  Subject. 

— J.  G.  Modlin  relates  a  case  in  which  on  separating  the 
vulva  a  movable  septum  was  seen  formed  by  the  posterior 
vaginal  and  anterior  rectal  walls.  The  appearance  was 
that  of  the  muzzle  of  a  double-barrelled  gun.  The  steps 
of  an  operation  for  relief  of  the  condition  are  given.  It 
was  successful,  and  defecation,  previously  causing  very 
great  pain  and  always  hemorrhage,  was  rendered  more 
natural. 

A  Large  Multilocular  Ovarian  Tumor. — F.  A.  Baldwin 
gives  with  illustrations  the  history  of  a  tumor  which  caused 
death  without  operation,  and  which  was  found  to  consist  of 
several  cysts,  in  all  weighing  one  hundred  and  fifty-eight 
and  one-half  pounds,  and  containing  eighteen  gallons  of 
fluid. 

Conjunctival  Diphtheria. — H.  E.  Smith  tells  of  a  case  in 
which  the  diagnosis  was  suspected  and  at  once  confirmed. 
Such  cases  may  readily  pass  unnoticed  and  infection  be 
spread  without  the  original  source  being  recognized. 

Notes  on  Seventy-Two  Consecutive  Cases  of  Removal  of 
Goitre    by    Operation    (Extirpation    or    Enucleation). —  By 

James  Berry, 

Impaction  of  a  Bean  in  the  Air  Passages  :  Tracheotomy : 
Expulsion  through  the  Wound:  Recovery. — By  Bruce  Ham- 
ilton. 

Case  of  Extrauterine  Gestation  Ruptured  at  Mid-Term 
Treated  by  Abdominal  Section. — By  J.  B.  Hellier. 


144 


MEDICAL    RECORD. 


[July  28,  1900 


A  Case  of  Acute  and  Chronic  Torsion  of  the  Ovarian  Pedi- 
cle in  the  Same  Subject— By  Alban  Doran. 

A  Note  on  a  Series  of  Cases  of  Epidemic  Cerebro-Spinal 
Meningitis. — By  Henry  Handford. 

The  Croonian  Lectures  on  Degeneration  of  the  Neuron. — 
By  Frederick  \V.  Mott. 

An  Address  on  the  Importance  of  Post-Graduate  Study. — 
By  William  Osier. 

Separation  of  Chondro-Stemal  Junction  without  Fracture. 
— By  S.  Gross. 

Antistreptococcus  Senun  in  Erysipelas. — By  A.  W.  Har- 
rison. 

Schools  and  Diphtheria  Infectivity. — By  Frank  M.  Burnett. 

Opium  in  Pneumonia. — By  H.  Bowen  Williams. 

Weil's  Disease.— By  J.  H.  Marsh. 

T/i^  Lancet,  July  14,  igoo. 

On   the   Confusion   of    Two   Different   Diseases  under  the 

Name  of  Rubella  (Rose-Rash) . — C.  F.  Dukes  says  that  all 
authorities  admit  without  reservation  that  there  is  one 
disease  known  as  scarlet  fever,  a  second  as  measles,  and 
a  third  as  rubella  (German  measles) .  He  has  recently  ob- 
served a  series  of  cases  which  leads  him  to  believe  that 
under  the  symptom-complex  of  the  latter  disease  as  at 
present  regarded,  there  are  really  included  two  distinct 
affections.  The  second  he  speaks  of  as  the  "fourth  dis- 
ease." From  his  study  of  the  series  alluded  to  he  claims 
for  this  "fourth  disease":  (i)  that  although  its  resem- 
blance is  so  close  to  scarlet  fever  in  many  features,  it  can- 
not possess  any  affinity  with  that  disease  inasmuch  as  both 
diseases  occurred  concurrently  in  the  same  epidemic  ;  (2) 
that  some  of  the  sufferers  had  both  diseases  in  the  same 
epidemic;  {3)  that  one  patient  had  scarlet  fever  followed 
by  the  "fourth  disease  "  ;  {4)  that  several  had  the  "fourth 
disease  "  followed  by  scarlet  fever;  (5)  that  although  the 
"fourth  disease"  has  been  confused  with  rose-rash  and  re- 
garded as  a  mere  variety  of  rubella,  this  conclusion  is  fal- 
lacious, since  nearly  one-half  the  cases  in  an  epidemic  had 
already  had  rose-rash  within  a  year  or  two,  which,  accord- 
ing to  CuUen's  established  law,  is  incredible.  He  pur- 
posely refrains  from  attaching  a  name  to  the  disease  in 
order  to  avoid  the  anomalous  description  of  the  same  dis- 
ease under  an  indefinite  number  of  terms,  as  in  the  case  of 
its  ally,  which  has  been  variously  designated  as  "rubeola 
notha,"  "rotheln,"  "rubella,"  "German  measles,"  "epi- 
demic roseola, "  and  "rose-rash."  The  distinguishing  fea- 
tures of  rubella,  of  the  "fourth  disease,"  and  of  scarlet 
fever  are  found  in  the  tables  appended. 

Case  of  Pancreatic  Diabetes  due  to  Calculi. — E.  W.  Phil- 
lips records  the  case  of  a  man  aged  fifty-one  years,  who 
when  first  seen  was  passing  blood  in  defecation,  had  a 
rectal  discharge  which  stained  his  clothing,  and  was  much 
weakened  and  emaciated.  The  urine  contained  sugar ; 
specific  gravity  1.024  ;  no  albumin  ;  five  pints  were  passed 
in  twenty-four  hours.  He  died  some  seven  months  later. 
Autopsy  showed  that  the  pancreas  was  hard  and  its  duct 
was  filled  with  calculi  and  calcareous  matter.  The  largest 
mass  was  situated  in  the  head  of  the  pancreas  and  was  tu- 
bular in  shape  ;  the  next  largest  was  at  the  splenic  end  ;  a 
third  could  be  felt  in  the  posterior  part  of  the  head ;  the 
entrance  of  every  branch  duct  was  plugged  with  concre- 
tions. No  communication  could  be  found  between  the 
pancreatic  and  common  duct  or  with  the  duodenum.  The 
substance  of  the  gland  was  hard  but  it  was  not  enlarged. 
It  was  examined  by  the  Clinical  Research  Association,  and 
the  report  was  as  follows:  "The  pancreas  shows  great  in- 
crease of  fibrous  tissue  in  parts  with  atrophy  of  acini  and 
glandular  tubules.  A  section  of  moderately  large  duct 
shows  much  shed  epithelium  from  catarrh."  The  colors  of 
the  calculi  and  debris  were  chiefly  yellowish-white  and 
dark  gray  mixed. 

On  Immunity  against  Proteids. — W.  Myers  experimented 
on  rabbits,  using  crystallized  egg-albumen  from  the  white 
of  fowl's  egg,  serum-globulin  from  sheep,  serum-globulin 
from  the  bullock,  and  Witte's  "peptone."  The  results  of 
the  experiments  cannot  be  given  here  in  detail.  It  may 
be  noted  that  with  the  peptone,  strong  support  is  given  to 
the  view  that  the  production  of  immunity  is  due  to  proc- 
esses of  assimilation,  and  they  also  explain  a  physiological 
point  which  has  long  been  a  subject  of  discussion.  When 
injected  into  the  circulation  peptone  disappears  very 
quickly  from  the  blood-stream.  Practically  nothing  is 
known  as  to  the  fate  of  the  peptone  which  thus  vanishes. 
But  clearly  this  disappearance  of  peptone  is  exactly  paral- 
leled by  the  disappearance  of  the  tetanus  toxin  from  the 


bloodstream.  In  both  cases  we  produce  by  immunization 
a  specific  anti- substance. 

A  Note  on  the  Results  Obtained  by  the  Anti-Typhoid  Inoc- 
ulations in  the  Beleaguered  Garrison  at  Ladysmith. — From 
statistical  tables,  A.  E.  Wright  shows  that  the  proportion, 
on  the  one  hand  of  attacks,  and  on  the  other  hand  of 
deaths,  from  typhoid  fever  was  seven  times  smaller  in  the 
inoculated  than  in  the  uninoculated.  And  it  may  be  borne 
in  mind  that  if  the  number  (no  doubt  a  considerable  one) 
of  men  who  had  previously  suffered  from  typhoid  fever  had 
been  subtracted  from  the  number  of  the  uninoculated,  as 
might  quite  legitimately  have  been  done,  the  statistics 
would  have  borne  an  even  more  favorable  aspect. 

Illustrations  of  Vasectomy  or  Obliteration  of  the  Seminal 
Ducts  Relative  to  Hypertrophy  of  the  Prostate  and  Bladder 
Atony. — By  Reginald  Harrison. 

Impaction  of  a  Bean  within  the  Air  Passages;  Tracheot- 
omy; Expulsion  through  the  Wound;  Recovery. — By  Bruce 
Hamilton. 

The  Commoner  Neuroses  of  Childhood,  their  Pathology  and 
Treatment. — Second  Ingleby  lecture,  by  O.  J.  Kaufmann. 

Chronic  Empyema  of  the  Frontal  Sinus,  with  Notes  on  the 
Treatment  of  Fourteen  Cases. — By  Herbert  Tilley. 

A  Case  of  Addison's  Disease ;  Treatment  with  Suprarenal 
Extract;  Death.— By  E.  G.  Trevithick. 

The  Importance  of  Post-Graduate  Study.— An  address  by 
William  Osier. 

Degeneration  of  the  Neuron.— Fourth  Croonian  lecture,  by 
F.  W.  Mott. 

Milnchene}-  medicinische   Wochenschrtft,  July  3,  igoo. 

The  Atropine  Treatment  of  Intestinal  Obstruction. — Batsch 

strongly  advises  the  use  of  atropine  in  large  doses  (gr.  ^ 
hypodermically)  in  all  cases  of  intestinal  obstruction  be- 
fore deciding  on  laparotomy.  The  atropine  treatment  is  to 
be  persisted  in  as  long  as  the  patient's  life  is  not  in  imme- 
diate danger,  but  careful  supervision  is  necessary  lest  op- 
eration be  deferred  till  the  prognosis  has  become  hopeless. 
In  illustration  three  cases  are  cited,  two  of  which  were  re- 
lieved by  the  drug  alone,  while  in  the  third  the  abdomen 
was  opened  and  recovery  followed  the  section  of  a  strangu- 
lating adhesion. 

The  Demonstration  of  Bile  Pigment  in  the  Urine  in  Car- 
diac Diseases.— Ott  comments  on  the  yellow  discoloration 
of  the  skin  often  accompanying  chronic  cases  of  heart  dis- 
ease, and  gives  a  series  of  twelve  in  which  bile  pigment 
was  found  in  the  urine  by  the  Huppert-Salkowski  test, 
proving  that  it  is  a  true  jaundice.  It  is  of  importance  to 
note  that  Gmelin's  reaction  gave  a  negative  result  in  every 
one  of  these  cases,  and  furthermore  that  even  the  more 
delicate  test  employed  fails  in  the  presence  of  notable 
quantities  of  blood  pigment  or  albumin. 

Venesection  in  Heat  Prostration. — Klein  relates  the  case 
of  a  stoker  on  a  transatlantic  liner  who  suddenly  collapsed 
owing  to  the  extreme  heat,  and  was  brought  on  deck  un- 
conscious and  in  a  state  of  most  violent  convulsions.  All 
the  other  available  therapeutic  measures  having  failed,  and 
the  patient  being  apparently  about  to  succumb  to  respira- 
tory and  cardiac  paralysis,  venesection  was  tried  as  a  last 
resort.  About  eight  ounces  of  blood  was  allowed  to  flow, 
with  instantaneous  relief  of  the  symptoms  and  subsequent 
recovery. 

A  Severe  Case  of  Ursemia  Cured  by  Venesection. — Hoess- 
lin  succeeded  in  savmg  the  life  of  a  ur;emic  patient  in 
extremis  by  removing  thirteen  ounces  of  blood  from  the 
circulation.  The  attempt  was  not  made  until  every  other 
means  of  stimulation  had  been  resorted  to  without  avail, 
but  the  good  effects  of  the  operation  were  speedily  appar- 
ent, and  under  digitalis  the  patient  made  an  uncomplicated 
recovery. 

A  Foreign  Body  in  the  Eye,  its  Orientation  by  Means  of 
the  Roentgen  Rays,  and  Extraction  with  the  Magnet.— By 
Mock. 

Experiments  on  Disinfection  of  the  Hands. — By  Paul  and 

Sarwey. 

This  Year's  Influenza  Epidemic  in  Freiburg. — By  Clemens. 
A  Simple  Incubator  for  the  Practitioner. — By  Walz. 

Deutsdic  tncdicinische  Wochcnschrijt,  July  ^,  igoo. 

A  Contribution  to  the  Study  of  the  Cytolytic  Sera.— Schiitze 
considers  that  the  property  exhibited  by  the  blood  serum  of 
certain  animals,  of  causing  the  destruction  of  the  blood  cells 
of  other  animals  when  brought  into  contact  with  these  either 
in  the  circulation  or  in  the  test  tube,  is  due  to  the  presence 


July  28,  1900] 


MEDICAL    RECORD. 


145 


of  two  substances.  One  of  these,  the  'intermediate  body," 
possesses  an  equal  affinity  for  the  cellular  elements,  and 
the  second,  or  "end  body,"  and  by  acting  as  a  sort  of  go- 
between  enables  the  latter  to  produce  its  effect  on  the 
cells  in  question.  It  has  been  found  possible  to  produce 
sera  which  have  a  cytolytic  action  on  cells  otlier  than  tliose 
of  the  blood  (<■..?■.,  the  ciliated  tracheal  epithelium  of  the 
ox),  and  the  hope  is  advanced  that  it  may  perhaps  be 
feasible  to  manufacture  a  substance  which  shall  exert  this 
effect  on  the  cellular  components  of  malignant  new  growths. 
Working  toward  this  objective  point  the  author  has  made 
a  numljer  of  experiments  on  rabbits  and  guinea-pigs,  and 
sums  up  his  results  as  follows:  (i)  The  serum  of  normal 
guinea-pigs  after  having  been  subjected  to  repeated  injec- 
tions of  hasmolytic  rabbit's  blood  acquires  an  antihseniolytic 
property,  i.e..  the  a'tjility  to  check  or  prevent  the  destruc- 
tion of  the  blood  cells  of  guinea-pigs.  (2)  The  production 
of  the  antiha;molytic  serum  depends  entirely  on  the  pres- 
ence of  the  "  intermediate  body,"  the  "end  body  "  taking  no 
part  in  this  action.  (3)  It  has  not  yet  been  possible  to 
produce  an  emulsion  of  normal  guinea-pig  organs  (liver  rir 
kidney)  which  should  exhibit  properties  similar  to  the 
htcmolytic  rabbit  serum,  and  be  able  to  affect  the  cellular 
elements  of  the  organs  with  which  they  have  already  been 
treated. 

Subphrenic  Abscess  Resulting  from  a  Traumatic  Suppuration 
of  the  Pancreas. — Strohniayer  relates  the  case  of  a  middle- 
aged  laborer  who,  after  suffering  for  a  month  from  indefinite 
symptoms  accompanied  by  great  cachexia  and  general  de- 
bility, suddenly  had  an  attack  of  extreme  dyspnoea  and 
died  in  collapse.  The  autopsy  revealed  an  extensive  sub- 
phrenic abscess  which  had  perforated  the  diaphragm  on 
the  right  side  and  discharged  a  great  amount  of  pus  into 
the  pleural  cavity.  The  abscess  antrum  also  communi- 
cated with  a  suppurating  focus  surrounding  the  head  of 
the  pancreas,  which  seemed  to  be  its  place  of  origin.  The 
only  exjilanation  of  the  cause  of  the  lesion  seemed  to  be 
a  severe  blow  received  in  the  epigastrium  three  months 
before.  This  is  supposed  to  have  produced  contusion  and 
hemorrhage  of  the  pancreas,  the  damaged  area  later  being 
invaded  by  intestinal  germs  and  suppurating. 

Enucleatio  Bulbi,  its  Substitutes,  and  a  Consideration  of 
Sympathetic  Ophthalmia. — By  Schmidt-Rinipler. 

E.xperience  with  a  Morphine  Substitute. — By  L.  Nied. 

My  Experience  with  Photo-Therapy. — By  Strebel. 

Beiliner  klintsthc  M'ochenschrift,  July  2,  ic)oo. 

Is  the  Increase  of  Blood  Cells  in  High  Altitudes  an  Ap- 
parent One  or  Not? — A.  (lOttstein  and  G.  Schrader  discuss 
this  question  in  the  light  of  comparisons  made  of  the  same 
specimen  of  blood  at  different  altitudes.  They  consider 
the  instrument  in  which  the  chamber  containing  the  por- 
tion of  blood  to  be  examined  is  a  slit-shaped  cavity,  a  more 
reliable  one  than  the  Thoma-Zeiss  instrument,  which  has 
for  .so  long  a  time  been  employed  for  this  purpose.  They 
find  that  the  higher  the  altitude  the  greater  the  number 
of  corpuscles  seems  to  be.  Tlie  same  specimen  will  i)re- 
sent  variations,  the  cell  count  increasing  as  the  altitude 
rises.  This  is  the  case  with  the  Thoma-Zeiss  instrument, 
but  this  variation  does  not  obtain  with  the  slit  instrument. 
From  these  results  the  authors  conclude  that  the  former  is 
liable  to  error  dependent  on  the  atmospheric  pressure, 
which  at  the  lower  level  exerts  a  greater  force  on  the  fluid 
layer  in  the  chamber  and  so  forces  out  a  certain  number  of 
cells  which  are  not  so  influenced  by  the  lighter  pressure  at 
the  higher  altitude. 

A  Contribution  to   the   Therapeutics  of  Aspirin. — P.  Zim- 

mermann  has  used  this  remedy  in  some  tliirty  cases  of 
rheumatism,  neuralgia,  exudative  pleurisy,  and  renal  in- 
flammation. The  daily  dosage  ranged  from  2.5  gni.  to  4 
gm.  It  was  well  borne  by  all  the  patients,  generally  act- 
ing as  a  powerful  diaphoretic  and  causing  a  fall  of  temper- 
ature. It  answered  well  in  certain  rheumatic  cases  in 
which  the  salicylates  were  not  well  borne.  It  did  not  de- 
press the  heart,  and  the  presence  of  valvular  incompetency 
did  not  seem  to  be  any  contraindication  to  its  employment. 
Some  benefit  was  also  obtained  in  chronic  rheumatism.  It 
was  used  for  its  diuretic  effect  in  pleurisy  and  renal  dis- 
ease. It  acted  well  in  the  former  but  failed  in  the  latter. 
Zimmermann  considers  it  a  valuable  addition  to  the  list  of 
agents  to  be  given  in  rheumatic  states. 

The  Composition  of  Renal  Calculi. — L.  Spiegel  gives  the 
analyses  of  fifty-five  cases.  In  fourteen  of  these  the  main 
ingredient  was  calcium  oxalate,  and  in  a  like  number  cal- 
cium phosphate.  Nothing  can  be  learned  from  the  pecul- 
iarities of  the  urine  in  a  given  case  as  to  the  probable  com- 
position of  the  calculus,  except  that  he  has  found  that  in 
cases  in  which  the  oxalate  is  the  essential  ingredient  there 
is  more  ant  to  be  a  continuous  acid  reaction. 


The  Treatment  of  Pulmonary  Tuberculosis  in  Hospitals 
and  Among  the  Poor. — By  Dr.  Burghart. 

Causes  and  Local  Beginnings  of  Pulmonary  Tuberculosis. 
—By  Dr.  Aufrtcht. 

Experience  with  Aspirin  in  Private  Practice. — By  A. 
Dengel. 

The  Present  Status  of  Bacteriology.— By  Dr.  Baum- 
garteii. 

Brain  Anatomy  and  Psychology. —  By  L.  Edinger. 

French  /ournal.'!. 

Some  Pyrexias  of  Hot  Countries. — E.  Legrain  gives  notes 
upon  the  ftvcrs  of  hot  climates  and  the  influence  exerted 
upon  them  by  quinine.  The  two  great  classes  are  inter- 
mittents  and  febrile  affections  not  corresponding  to  the  va- 
rious types  of  malaria.  The  study  is  based  on  three  hun- 
dred cases.  He  finds  it  possible  from  a  single  access  to 
determine  the  type  of  intermittent.  A  number  of  conclu- 
sions are  drawn  as  to  the  changes  in  type,  the  only  stable 
type  being  the  quartan.  Intermittent  fever  gives  no  mor- 
tality. It  can  be  arrested  at  will  for  a  determined  period 
by  means  of  a  single  dose  of  quinine  appropriate  to  each 
case.  No  other  exotic  pyrexia  reacts  in  the  same  manner 
in  respect  to  quinine. — La  Presse  Medicale.  July  7,  1900. 

Intestinal  Syphilis. — Professor  Fournier  looks  upon  spe- 
cific aftectidiis  of  the  intestines  almost  as  curiosities,  hav- 
ing observed  in  all  not  more  than  a  dozen  instances.  Diar- 
rhoeas of  tertiary  syphilis  seem  quite  frequently  to  recur 
at  longer  or  shorter  intervals.  They  may  also. occur  quits 
late  ;  he  has  seen  them  in  per.sons  whose  infection  dated  back 
from  nineteen  to  forty  years.  Greater  confidence  is  placed 
in  mercury  than  in  the  iodides  ;  still,  mixed  treatment  does 
well,  although  protoiodide  pills  or  Van  Swieten's  solution 
will  effect  a  cure.  Inunctions  or  subcutaneous  injections 
seem  to  constitute  the  treatment  of  choice. — Joitnial  i/cs 
Pra/iciens.  July  14,  1900. 

Diagnosis  and  Treatment  of  Cutaneous  Actinomycosis.— 
Lenoir  and  Claisse  report  the  case  of  a  butcher  who  fre- 
quented abattoirs  where  infection  was  made  possible. 
The  first  signs  were  in  the  floor  of  the  mouth  in  the  form 
of  a  pseudo-ranula  ;  afterward  swelling  of  the  cheek  .showed 
characteristic  yellowish  discharge  and  granules.  Although 
iodide  of  potassium  is  almost  a  specific,  treatment  is  pro- 
tracted. Six  months  were  required  to  bring  about  decided 
improvement  under  as  large  doses  as  could  be  tolerated. — 
Journal  des  Pralkiens.  July  14,  igoo. 

Achondroplasia.— Pierre  Marie  gives  an  exhaustive  ac- 
count of  this  defect  of  development  of  the  human  skeleton 
in  adolescence  and  adult  age.  The  article  is  freely  illus- 
trated and  supplied  with  a  bibliography  of  cases  reported 
above  the  age  of  ten  years.  It  must  be  admitted  that  the 
aft'ection  may  be  of  hereditary  origin.  It  remains  for  fu- 
ture investigators  to  show  whether  the  lesion  of  the  carti- 
lage is  primordial  or  a  dystrophy  of  general  cause.  At 
present  facts  are  lacking  for  a  decision  of  this  question. — 
La  Presse  Medicale,  July  14,  igoo. 

llu-  lulinl'urgli  Medical  [ournal,  /uly,  /goo. 

The  Morbific  Agent  and  the  Reparative  Effort. — Andrew  H. 
Smith,  of  New  York,  asks  if  it  would  not  be  a  gain  to  both 
pathology  and  practice  if  a  direct  interaction  between  the 
morbific  agent  (noxa)  and  the  reparative  effort  were  recog- 
nized, the  conception  of  an  intermediate  so-called  inflam- 
matoiy  process  being  abandoned.  He  thinks  the  concep- 
tion of  inflammation  as  an  active  process  is  :;rroneous  and 
unfortunate  in  its  influence  upon  medicine.  The  noxa,  he 
says,  may  be  active,  the  tissues  may  be  active,  but  the 
inflammation  never.  "It  is  simply  a  name,  not  a  force. 
It  can  do  nothing.  The  collision  of  two  armies  is  called 
a  battle,  but  the  battle  is  not  an  entity  apart  from  the 
armies.  Much  less  can  it  join  forces  with  one  of  them  and 
help  on  the  fight  against  the  other.  Yet  this  is  what  in- 
flammation is  supposed  to  do  when  it  is  credited  at  one' 
time  with  opposing  the  noxa  and  helping  forward  the  re- 
parative effort,  and  at  another  time  with  attacking  and  de- 
stroying the  tissues."  furthermore,  the  energy  that  initi- 
ates the  "inflammation  "  is  the  energy  that  maintains  it, 
and  if  we  withdraw  this  energy,  the  noxa,  the  "inflamma- 
tion "  will  cease.  Medical  science  has  too  long  rested 
under  the  incubus  of  this  name,  and  the  author  urges  that 
the  entire  doctrine  of  "inflammation  "  be  abandoned,  and 
that  the  phenomena  ascribed  to  this  process  be  assigned 
to  new  relations,  in  accordance  with  recent  advances  in 
pathologj-,  and  especially  in  bacteriology — advances  that 
have  rendered  obsolete  a  conception  handed  down  to  us 
from  remote  ages.  In  the  matter  of  nomenclature,  this 
proposal  would  involve  doing  away  with  the  termination 
"itis. "  As  most  of  the  phenomena  heretofore  included 
under  the  term  "inflammation  "  are  manifestations  of  the 


146 


MEDICAL    RECORD. 


[July  28,  1900 


local  action  excited  by  a  micro-organism,  or  by  a  poison 
circulating  in  tlie  blood,  such  action  may  be  expressed  by 
a  termination  affixed  to  the  name  of  the  organism  or  poi- 
son, if  the  same  can  be  determined,  or  to  the  organ  or  part 
affected,  in  case  the  particular  infecting  organism  or  poi- 
son is  not  identified.  We  have  a  universally  accepted  pre- 
cedent for  the  first-named  use  in  the  case  of  tuberculosis, 
and  the  use  of  this  termination  might  be  extended  to  the 
action  of  other  organisms.  Thus,  streplocosis  would  ex- 
press an  infection  by  the  streptococcus,  stapliyloiosis  an 
infection  by  the  staphylococcus,  gonocosis  an  infection  by 
the  gonococcus,  and  so  on,  a  localizing  adjective  being  used 
to  denote  the  seat  of  the  affection.  Infection  by  an  unde- 
termined organism  would  be  iiu'crobiosis.  or  hac/i'iiosis  as 
a  general  term,  or  it  would  be  expressed  by  adding  the 
termination  to  the  name  of  the  part  in  the  same  waj-  as 
"itis  "  is  now  employed.  Thus,  pericardosis  would  denote 
simply  infection  of  the  pericardium  ;  pericardial pucunio- 
Ci'sis,  infection  of  pericardium  by  pneumococci.  We  should 
have,  also,  scarla/iiwsis  (renal,  glandular) ,  and  rheuiiia- 
tosis  (articular,  endocardial),  expressing  the  local  action 
of  a  poison  in  the  blood. 

If  a  general  term  is  still  demanded  as  a  substitute  for 
"inflammation,"  it  would  be  necessary  to  employ  at  least 
three  words  to  express  different  kinds  of  noxse,  acting  in 
different  ways,  and  leading  to  essentially  different  results. 
These  might  be  traumosis.  to  include  wounds  and  in- 
juries ;  to.xosis,  to  include  the  local  action  of  poisons  in 
the  blood  ;  and  bacteriosis,  to  include  the  action  of  micro- 
organisms. But  the  matter.  Dr.  Smith  says,  is  one  of 
great  practical  importance,  and  not  simply  one  of  nomen- 
clature. So  long  as  inflammation  presents  it.self  before  us 
as  something  to  be  combated,  so  long  we  are  tempted  to 
look  away  from  the  continuously  acting  morbific  agent, 
and  at  the  same  time  to  ignore  the  effort  that  the  tissues 
are  making  for  their  own  defence  and  repair.  In  striking 
at  the  ignis  fatuus  of  inflammation,  we  overlook  our  real 
enemy,  and  are  liable  to  injure  our  friend.  For  example, 
if  we  treat  the  inflammation  in  a  furuncle  by  application 
of  cold,  we  may  succeed  for  a  time  in  diminishing  tlie 
swelling,  redness,  heat,  and  pain,  but  the  noxa  in  the  form 
of  bacteria  will  still  be  there,  and  we  shall  certainly  have 
to  deal  with  it  in  the  end.  If  bacteria  are  at  work  in  the 
appendix  vermiformis,  and  we  are  very  successful  in  com- 
bating the  inflammation  by  our  local  and  general  treat- 
ment, we  may  succeed  in  preventing  the  effusion  of  lymph 
that  would  have  walled  in  the  infected  area,  and  be  re- 
warded by  seeing  our  real  enemy  in  possession  of  the  entire 
field  of  the  peritoneum. 

Or,  once  more,  if  we  have  a  multitude  of  colonies  of 
pneumococci  growing  in  the  exudate  which  is  occupying 
the  air  cells  of  a  portion  of  lung,  and  we  seek  to  control  the 
inflammation  by  means- of  arterial  sedatives,  we  may  find 
a  little  later  that  we  have  only  diminished  the  power  so 
sorely  needed  to  propel  the  blood  through  the  obstructed 
lesser  circulation,  and  added  to  the  danger  that  our  patient 
will  succumb  to  failure  of  the  right  heart. 

Finally,  in  doing  away  with  the  idea  of  inflammation  we 
shall  be  on  the  road  to  a  more  exact  diagnosis,  for  we 
should  then  be  driven  to  discriminate  in  our  language  be- 
tween conditions  as  unlike  as  sclerosis  of  the  tympanum 
and  hip-disease,  or  as  ulcer  of  the  cornea  and  diarrhwa. 
Then  the  use  of  a  less  exact  designation  would  be  a  con- 
fession of  failure  to  arrive  at  the  mure  precise  one. 

Some  Results  of  Antistreptococcus  Serum. — F.  J.  Harvey 
Bateman  prefaces  a  report  of  three  cases  with  a  consid- 
eration of  the  many  difficulties  in  the  way  of  arriving  at 
definite  conclusions  with  reference  to  the  beneficial  results 
of  antistreptococcus  serum.  The  first  arises  from  uncer- 
tainty as  to  the  number  of  varieties  of  streptococci.  Then, 
in  many  cases  the  causation  of  the  disease  is  complex,  the 
origin  often  lying  in  a  mi.xed  infection.  Still  another  rea- 
son for  doubt  as  regards  oixhotherapy  in  general  is  to  be 
found  in  the  frequent  absence  of  any  bacteriological  proof 
of  the  nature  of  the  infection.  And  finally  there  is  the  un- 
deniable fact  that  many  instances  even  of  grave  microbic 
infection  undergo  spontaneous  recovery.  This  has  been 
frequently  the  case  as  regards  streptococcal  disease,  and 
the  consideration  must  render  many  minds  sceptical  as  to 
the  beneficial  effects  of  antistreptococcus  serum.  In  two 
of  the  three  cases  reported  it  was  definitely  established 
that  the  disease  was  due  to  the  presence  of  streptococci.  In 
the  first  case  the  effect  of  the  serum  was  early  manifested, 
and  the  temperature,  which  had  been  fluctuating  consider- 
ably, came  to  normal  within  ten  days  of  the  commence- 
ment of  the  administration  of  the  serum.  In  tlie  second 
case  the  serum  was  not  employed  until  the  patient  liad 
been  under  treatment  for  six  weeks,  and  it  was  necessary 
to  continue  its  employment  for  a  considerably  hmger  time. 
As  regards  the  third  case,  although  every  means  had  been 
adopted  in  order  to  arrive  at  a  correct  diagnosis,  the  real 
cause  of  the  disease  remained  obscure.  The  employment 
of  antistreptococcic  serum,  therefore,  in  this  instance  was 


resorted  to  simply  on  the  chance  of  the  infection  being  due 
to  streptococci,  and  it  was  not  surprising  that  the  results  of 
treatment  were  unsatisfactory. 

Persistence  of  the  Arterial  Duct  and  its  Diagnosis.— G.  A. 
Gibson  reports  a  case  of  this  condition,  and  from  a  study 
of  it  and  of  four  other  cases  which  have  come  under  his 
care  during  the  last  few  years  he  notes  the  following  points 
upon  which,  he  thinks,  the  diagnosis  of  persistent  ductus 
arteriosus  may  be  founded  with  perfect  confidence.  There 
may  be  no  dyspnoea,  cyanosis,  oedema,  or  other  evidence 
of  disturbance  of  the  general  circulation,  and  the  recogni- 
tion of  the  lesion  may  depend  entirely  on  the  presence  of 
a  few  physical  signs.  Inspection  may  fail  to  yield  any 
facts  of  diagnostic  importance  ;  palpation  usually  reveal's 
the  long  thrill  following  the  apical  impulse,  and  enduring 
beyond  the  recoil  of  the  blood  on  the  semilunar  cusps, 
which  may  be  felt  during  the  thrill ;  percussion  may  not 
show  any  enlargement  of  the  cardiac  dulness  ;  but  auscul- 
tation gives  convincing  evidence  of  the  lesion  in  a  murmur 
which  may  be  regarded  as  almost  pathognomonic.  Begin- 
ning distinctly  after  the  first  sound,  it  accompanies  the 
latter  part  of  that  sound,  occupies  the  short  pause,  accom- 
panies the  second  sound,  which  may  be  accentuated  in  the 
pulmonary  area,  or  may  be,  and  often  is,  doubled,  and 
finally  dies  away  during  the  long  pause. 

Clinical  Notes  on  Cases  of  Beriberi. — J.  O.  Affleck  reports 
six  cases  of  beriberi  which  have  been  under  his  care  during 
the  past  five  years  at  the  Edinburgh  Royal  Infirmary.  .'Ml 
these  cases,  except  one,  occurred  in  seafaring  men,  and  all 
were  in  persons  who  had  come  from  tropical  or  subtropical 
regions.  Each  case  presented  the  characteristic  features 
of  a  peripheral  neuritis,  and,  in  addition  in  most  of  them 
there  was  more  or  less  oedema  of  the  legs.  The  treatment 
included  rest,  the  employment  of  sodium  bromide  and  nux 
vomica,  and  a  generous  diet,  under  which  the  patients  im- 
proved quite  rapidly.  In  three  cases  a  bacteriological  ex- 
amination of  the  blood  was  made,  but  with  a  negative 
result. 

Acute  Infantile  Intussusception,  with  Special  Reference  to 
Treatment  by  Primary  Laparotomy. — By  W.  Blair  Bell. 

Two  Cases  of  Agoraphobia  Cured  by  Hypnotic  Suggestion. 

— By  Charles  Lloyd  Tuckey. 

The  Therapeutics  of  Disorders  of   Menstruation. — By   H. 

Macnaughton  Jones. 

A  Case  of  Retroverted  Gravid  Uterus. — By  G.  R.  Fraser. 

Zeitsch.  f.   Dial  el.  v.  Physik.  Titer  apie.  vol.  iv.,  A'o.  j. 

The  Assimilative  Processes  in  Chronic  Rheumatism. — 
While  Weisz  considers  that  the  attempt  to  formulate  a 
specific  diet  as  being  necessary  or  indicated  in  chronic 
rheumatism  is  far-fetched,  he  believes  that  the  question  of 
feeding  is  of  great  importance  and  may  be  made  a  valu- 
able therapeutic  aid.  In  general  he  groups  the  cases  into- 
those  suft'ering  from  obesity  and  those  whose  weight  is 
steadily  decreasing.  In  the  first  class  the  most  important 
indication  is  to  cure  the  joint  disease  itself,  though  the 
various  obesity  cures  may  be  of  service  in  seconding  the 
process.  Very  much  more  frequent  are  cases  exhibiting' 
various  degrees  of  emaciation.  In  these  what  is  essen- 
tially a  stuffing  process  must  be  resorted  to,  and  the  pa- 
tients encouraged  to  consume  as  much  food  of  all  sorts  as 
possible. 

The  Therapeutic  Application  of  Natural  Animal  Gastric 
Juice. — .Mayer  discusses  the  theoretical  considerations 
which  justify  the  supposition  that  the  gastric  juice  of  dogs 
would  be  of  value  in  treating  achylia  in  man,  and  then  de- 
scribes the  Pawlow-.Shumow-Simanowski  operation  by 
means  of  which  large  quantities  of  secretion  may  be  ob- 
tained from  the  animals.  Experiments  with  this  agent 
have  already  been  made  in  France,  where  it  is  known  and 
commended  under  the  name  of  "gasterine."  The  author's 
clinical  observation  is  limited  to  one  case,  but  in  this  the 
results  were  encouraging,  and  he  advises  further  experi- 
mentation. 

The  Treatment  of  Vesical  Neuroses. — Auerbach  thinks 
that  properly  executed  massage  and  gymnastics  are  of 
great  value  in  the  treatment  of  irritable  bladder  not  due 
to  organic  lesion.  The  manipulations  and  movements  are 
described  in  detail  and  have  for  their  object  the  improve- 
ment of  the  nervous  and  muscular  tone  of  the  pelvic  con- 
tents. 

A  Comment  on  Professor  A.  Poehl's  Dissertation  on  "  The 
Osmotic  Pressure  of  the  Body  Fluids  in  its  Relation  to  the 
Origin  and  Persistence  of  Morbid  Processes.  —  By  Kuranyi. 

The  Influence  of  the  Newer  Food  Preparations  on  the  In- 
tensity of  Intestinal  Decomposition. — By  Lewin. 

An  E.xperimental  Contribution  to  the  Dietetics  of  Hyper- 
and  Hypochlorhydria. — By  Buch. 

Massage  Baths. — By  Preiss. 


July  28,  1900] 


MEDICAL   RECORD. 


147 


jiSlcuicius  mxA 


Notices. 


A  Manual   of  Operative   Surgery.     By  Lewis  A.  Stim- 
SON.M.D.,  Surgeon  to  the  New  York  and   Hudson  Street 
Hospitals,  «tc.,    and   John    Rogers.   M.D.,   Surgeon   of 
Gouverneur  Hospital,  etc.     Fourth  and  revised  edition. 
Illustrated.     Phila.'elphia ;  Lea  Brothers  &  Co.     1900. 
It  is  hardly  necessary  to  do  more  than  to  record  the  appear- 
ance of  another  edition  of  this  work,  which  already  is  very 
favorably  known.     This  edition  is  improved  by  some  con- 
densation and  the  elimination  of  a  number  of  obsolete  illus- 
trations, and  in  its  present  form  is  an  excellent  handbook  of 
the  subject.     The  descriptions  of  operations  are  terse  and 
to  the  point,  but  in  some  departments  the  necessary  cu- 
tailment  has  interfered  with  completeness,  so  that  the  book 
can  hardly  be  used  as  a  work  of  reference.     The  illustra- 
tions are  very  satisfactory,  and  the  general  appearance  and 
make-up  of  the  book  are  excellent. 

Medical  and  Surgical  Report  of  the  Presbyterian  Hos- 
pital IN  THE  City  of  New  York.     Vol.  IV.,  1900.     Ed- 
ited  by   Andrew    J.    McCosH,    M.D.,   and   W.    Gil.man 
Thompson,  M.D.     New  York:  Trow  Directory  Printing 
and  Bookbinding  Company.     Pp.  223. 
This  neat  little  volume  contains  many  interesting  articles 
on  various  medical  and  surgical  subjects  as  noted  in  the 
wards  of  the  hospital.     Among  them  may  be  mentioned : 
'1  he  Surgical  Treatment  of  Ascites  due  to  Cirrhosis  of  the 
Liver;   A   Case   of   Dermatitis  Exfoliativa;    Remarks  on 
tlie  Surgery  of  the  Biliary  Passages;  A  Contribution  to 
the  Surgery  of  the  Testicle  ;  Report  of  Ten  Cases  of  Sub- 
plirenic    Abscess;    Empyema;    Report    of    Twenty-eight 
Cases  of  Suppurative  Hepatitis  ;  Statistics  of  One  Hundred 
Cases  of  Cancer  of  the  Breast ;  Heart  Murmurs  and  Heart 
Lesions,  and  many  other  interesting  articles. 

The  Cell  in  Development  and  Inheritance.  By  Edmund 
B.  Wilson,  Ph.D.,  Professor  of  Zoology,  Columbia  Uni- 
versity. Second  edition,  revised  and  enlarged.  New 
York;  The  Macmillan  Company.  London:  Macmillan 
&  Co.,  Limited.  1900.  Pp.  483. 
Although  the  author  states  that  he  has  not  covered  the 
whole  subject  of  cytology,  he  is  to  be  congratulated  in  the 
very  efficient  manner  in  which  he  has  managed  his  selec- 
tions and  discarded  the  non-essential,  although  interesting 
matter.  His  work  is  a  model  of  conciseness  without  lack- 
ing clearness.  The  theories,  experiments,  and  data  are 
all  presented  in  a  most  interesting  way,  and  the  scientific 
standard  attained  is  very  high.  This  edition  differs  from 
its  predecessor  chiefly  in  being  brought  up  to  the  times,  in 
its  being  enlarged,  and  in  the  addition  of  fifty  or  more  il- 
lustrations. For  medical  men  who  are  willing  to  depart 
from  the  more  directly  practical  studies  of  their  profession 
this  work  will  prove  extremely  interesting.  The  bibliog- 
raphy and  indexing  are  worthy  of  the  highest  praise,  while 
the  glossary  makes  the  work  more  easily  handled  by  those 
not  thoroughly  conversant  « ith  the  technical  terms  of  the 
biologist. 

Forty  Years  in  the  Medical  Profession — 1858-1898.     By 
John  Janvier   Black,  M.D.,  Member  of  the  College  of 
Physicians  of  Philadelphia ;    Member  of  the  Delaware 
State  Medical  Society,  etc.     Philadelphia :  J.  B.  Lippin- 
cott  Company.     1900.     Pp.  498. 
Dr.  Black  has  given  us  a  most  pleasant  account  of  his  im- 
pressions as  a  medical  man,  his  thoughts  on  the  causation 
and  theories  of  disease,  the  different  methods  of  treatment, 
and  how  the  changes  have  taken  place  during  the  last 
forty  years,  in  all  of  which  time  he  has  been  active  as  a 
general  practitioner  not  only  in  doing  his  simpler  duties  as 
a  physician,  but  also  philosophizing  upon  all  he  saw.    The 
book  is  written  for  his  professional  brethren,  and  to  them  it 
cannot  fail  to  appeal  as  most  interesting  and  instructive, 
for  the  author  has  let  no  important  advance  in  his  art  es- 
cape him,  and  his  long  service  therein  seems  to  have  added 
zest  to  his  work  rather  than  to  have  tired  him. 

Chemistry    and    Physics  :    A   Manual    for   Students   and 
Practitioners.     By  Walton  Martin,  Ph.B.,M.D.,  Assist- 
ant   Demonstrator  of   Anatomy   College   of   Physicians 
and  Surgeons,  New  York,  and  William  H.  Rockwell, 
Jr.,  M.D.,  Assistant  Demonstrator  of  Anatomy  College 
of   Physi.  ians   and    Surgeons,   New   York.      Edited   by 
Bernard  B.  Gallaudet,  M.D. ,  Demonstrator  of  Anatomy 
and  Instructor  in  Surgery,  College  of  Physicians  and 
Surgeons,  New  York  ;  Visiting  .Surgeon  Bellevue  Hospi- 
tal, New  York.     Illustrated  with  137  engravings.     Phila- 
delphia and  New  York :  Lea  Brothers  &  Co.     Pp.  374. 
The  authors  have  succeeded  in  giving  a  very  satisfactory 
synopsis  of  the  subjects  treated,  with  a  special  view  to  the 
book's    adaptability  to  medical    students.      It   is   not   in- 


tended as  a  work  for  physicists  and  chemists,  but  merely 
as  an  introduction  to  knowledge  which  it  is  necessary  for 
the  practitioner  to  apprehend  at  least,  and  as  such  con- 
tains enough  and  even  more  than  enough  for  all  practical 
purposes. 

Diseases  of  the  Eye.    By  Edward  Nettleship,  F.R.C.S., 
Ophthalmic  Surgeon  at  St.  Thomas'  Hospital,  London; 
Surgeon  to  the  Royal  London  (iloorfields)  Ophthalmic 
Hospital.     Revised   and   edited    by   William    Campbell 
Posey,  A.B..  M.D.,  Ophthalmic  Surgeon  to  the  Howard 
and  Epileptic  Hospitals,   Philadelphia;    Assistant   Sur- 
geon, Will's   Eye  Hospital  ;    Fellow   of  the   College  of 
Physicians  of  Philadelphia  ;   Associate  Member  of  the 
American  Ophthalmolotical  Society,  etc.     Sixth  Ameri- 
can from  Sixth  English  edition.     With  a  Supplement  on 
Examinations  for  Color-Blindness  and  Acuity  of  Vision 
and    Hearing,   by   William   Thomson,    M.D.,    Emeritus- 
Professor  of  Ophthalmology  in    the  Jefferson   Medical 
College  of  Philadelphia.     With  5  colored  plates  and  192 
engravings.    Phi'adelphia  and  New  York  :  Lea  Brothers 
&  Co.     1900.     Pp.  560. 
This  well-known  text-book  again  appears  in  its  sixth  edi- 
tion in  a  form  adapted  to  American  readers  by  an  Ameri- 
can editor.     Although  the  book  has  been  thorough'y  re- 
vised, the  text  has  been  altered  as  little  as  was  consistent 
with  the  recent  advances  made  in  the  knowledge  of  the 
subjects  treated.     The  appendix  is  supplied  with  full  de- 
tails regarding"  the  examination  of  applicants  for  army, 
navy,  and  merchant  marine  of  the  United  States,  and  for- 
mulae, test  types,  etc.     The  popularity  of  the  vi  ork  is  bound 
to  be  sustained  by  this  new  and  improved  edition. 

The  Annual  of  Eclectic  Medicine  and  Surgery  (1897- 
1898).     Vol.  VIII.     Edited  by  John  V.  Stevens,  M.D., 
Professor  of  Diseases  of  the  Ner\-ous  System  in  Bennett 
Medical  College,  Chicago.     Cincinnati,  Ohio:  The  Scud- 
der  Bros.  Company. 
This  is  a  report  of  papers  and  proceedings  from  the  Stales 
having  eclectic  societies.     The  volume  was  somewhat  de- 
layed in  publication.     There  are  507  pages  exclusive  of 
index,  well  bound  and  containing  full-page  portrait  illus- 
trations of  physicians  from  different  sections.     The  fron- 
tispiece is  a  portrait  of  Dr.  Buchansu,  wlio  died  in  1899. 
The  papers  are  for  the  most  part  brief. 

Transactions  of  the  Luzerne  County  Medical  So- 
ciety. 
This  is  Vol.  VII.  of  the  society's  reports,  but  nothing 
shows  in  what  State  Luzerne  County  is  located.  On 
page  iSo  the  number  of  deaths  in  Wilkes-Barre  is  given, 
so  it  is  presumably  Pennsylvania.  There  are  a  number 
of  good  papers  and  a  picture  of  cancrum  oris. 

Membership  Directory  of  National  Medical  Societies 
OF  the  United  States.  New  York  ;  E.  R.  Trott.  1900. 
This  book  contains  the  names  and  addresses  of  officers  and 
members  of  the  nineteen  national  associations.  An  index 
to  the  whole  makes  the  s:  arch  for  a  given  name  easy.  The 
directory  will  be  of  value  to  the  layman  as  a  mailing-list 
or  when  looking  for  an  eminent  specialist  or  consultant. 
Yearly  editions  will  be  necessary. 

Untersuchungen  ueber  die  Moeller  Barlow'sche  Krank- 
heit.  Von  Dr.  J.  Schoedel  und  Prof.  C.  Nauwerck. 
Jena  :  Verlag  von  Gustav  Fischer.  1900. 
The  authors  here  present  in  a  brochure  of  one  hundred 
and  sixty  pages  the  individual  work  of  Moeller,  Barlow, 
and  others  referred  to  in  a  bibliography  containing  one 
hundred  and  thirty-nine  items.  The  pathological  anat- 
omy of  the  affection  is  carefully  studied,  and  tl  e  au- 
thors present  five  personal  cases  with  history,  comments, 
and  conclusions.  The  question  is  presented  in  as  well 
elaborated  a  report  as  one  could  desire,  and  will  un- 
doubtedly be  read  with  interest  by  all  engaged  in  practice 
among  children. 

Traite  de  Mf.decine.  Publie  sous  la  direction  de  MM. 
Bouchard,  Professeur  a  la  Faculte  de  Mtdecine  de  Paris, 
Membredel'Institut,  et  Brissaud,  Professeur  a  la  Faculte 
de  Medecine  de  Paris,  Medecin  de  I'Hopital  Saint  An- 
toine.  Deuxieme  Edition.  Tome  IV.  Paris;  Masson 
et  Cie.     1900. 

The  fourth  volume  of  the  second  edition  of  this  excellent 
system  of  medicine  is  devoted  to  diseases  of  the  mouth, 
pharynx,  stomach,  pancreas,  intestine,  and  peritoneum. 
The  diseases  of  the  mouth  and  pharynx  are  treated  of  very 
satisfactorily  by  Dr.  A.  Ruault  in  an  article  of  some  one 
hundred  and  fifty  pages.  About  half  the  volume  is  taken 
up  by  a  complete  treatise  on  diseases  of  the  stomach  by 
Dr.  A.  Mathieu,  who  is  also  the  author  of  the  article  on 
diseases  of  the  pancreas  in  the  same  volume.  The  third 
contributor  is  Dr.  Courtois-Suffit,  who  writes  on  diseases 


148 


MEDICAL   RECORD. 


[July  28,  1900 


of  the  intestine  and  peritoneum.  The  volume  is  a  notabie 
addition  to  the  rapidly  increasing  literature  of  diseases  of 
the  digestive  tract. 

RiCERCHE  SULL.\  Presexz.v  dki.i.a  Zucchero  nei.i.e  Orine 

DEI.LE  DONXE  Gr.WIDE  E  PuERl'ERE.     Par  DoTTOR  GlUSEI'I'E 

Crist.\li.i.      Napoli ;   Tipografia  Forense  Commerciale. 

1900. 
In  this  monograph  Dr.  Cristalli  studies  the  question  of  gly- 
cosuria in  pregnancy  and  the  puerperium,  and  records  the 
results  of  a  number  of  personal  observations.  He  distin- 
guishes carefully  between  lactosuria  and  glycosuria,  the 
former  being  an  almost  constant  condition  in  the  puerperal 
period,  while  the  latter  is,  though  not  very  rare,  much  less 
frequent  than  lactosuria.  The  one  is  of  no  patholog:ical 
importance  whatever,  the  other  of  a  much  more  serious 
nature. 

The  P.\thologv  .and  Surgical  Treatment  of  Tumors. 
By  N.  Senn,  M.D.,  Ph.D.,  LL.D.  .Second  edition,  71S 
pages,  illustrated.    W.  B.  Saunders,  Philadelphia.     1900. 

The  second  edition  of  this  book  is  as  admirable  as  the 
first.  The  work  has  been  revised ;  an  additional  chapter 
on  sarcoma  of  the  decidua  has  been  added,  together  with 
many  new  excellent  illustrations.  The  author  still  ad- 
heres to  the  Cohnheini  hypothesis  concerning  the  origin 
of  tumors,  and  rightly  considers  as  unproven  the  causative 
relation  between  bacteria  and  the  growth  of  carcinoma. 

Transactions  of  the  American  Derm.atologicai.  Associa- 
tion,  Twenty-third   Annual    Meeting,   Philadelphia, 

■  May  30  to  June  i,  1S99.  Official  report  of  proceedings, 
by  George  Thomas  Jackson,  M.D.,  Secretary.  Paper, 
176  pages.     The  Rumford  Press,  Concord,  N.  H.     1900. 

There  are  fewer  good  illustrations  in  this  than  in  several 
of  the  society's  recent  reports,  but  aside  from  this  the  vol- 
ume compares  fairly  well.  The  quality  of  the  papers  is  of 
the  usual  rather  high  order.  If  the  printer  would  put  the 
title  of  the  various  papers  at  the  head  of  the  page  instead 
of  monotonously  repeating  "  Amer.  Derm.  Assn.,"  it  would 
materially  aid  the  reader  and  increase  the  attractiveness 
of  the  reports. 

Progressive  Medicine,  Vol.  I.,  1900.  A  Quarterly  Digest 
of  Advances,  Discoveries,  and  Improvements  in  the 
Medical  and  Surgical  Sciences.  Edited  by  Houart 
Amory  Hare,  JI.D.,  Professor  of  Therapeutics  and  Ma- 
teria Medica  in  Jefferson  Medical  College  of  Philadel- 
phia. Octavo,  bound  in  cloth,  404  pages,  36  engravings 
and  a  colored  plate.  Lea  Brothers  &  Co.,  Philadelphia 
and  New  York.     Issued  quarterly. 

The  author  has  been  assisted  in  his  work  by  Charles  A. 
Holder,  of  the  Jefferson  School.  There  are  presented  in 
this  volume  the  surgery  of  the  head,  neck,  and  chest,  in- 
fectious diseases,  including  acute  rheumatism,  croupous 
pneumonia  and  influenza,  diseases  of  children,  pathology, 
laryngology,  rhinology,  and  otology.  The  contributors 
are'  Da  Costa,  Packard,  Blackader.  Hektoen,  Turner,  and 
Randolph.  There  is  an  excellent  colored  plate  in  illustra- 
tion of  Koplik's  spots,  and  points  of  interest  are  to  be  found 
in  each  department.  As  a  year-book  the  defect  stands  out 
that  so  few  branches  are  covered  in  each  quarterly  issue. 

Le  Lesioni  Traumatiche  DEI  Centri  Nervosi.  Par  Dott. 
Salvatore  Salinari.  Roma:  II  Giornale  Medico  del 
Regio  Exercito.     1900. 

This  is  a  treatise  of  three  hundred  and  twenty  pages  on 
injuries  of  the  brain  and  spinal  cord  and  their  meninges, 
which  was  the  Riberi  prize  essay  for  1898.  The  author  is 
a  surgeon-captain  in  the  Italian  army,  and  naturally  de- 
votes a  large  part  of  his  work  to  gunshot  wounds  and  their 
treatment  in  the  field. 

Twentieth  Century  Practice.  An  International  Ency- 
clopedia of  Modern  Medical  Science.  By  Leading  Au- 
thorities of  Europe  and  America.  Edited  by  Thomas 
L.  Stedman,  M.D..  New  York  City.  In  twenty  volumes. 
Vol.  XIX.,  "  Malaria  and  Micro-Organisms. "  5few  York  ; 
William  Wood  &  Company.     1900. 

To  this  important  volume  there  are  but  four  contributors. 
Their  names,  however,  carry  a  conviction  of  their  ability 
to  give  in  the  eight  hundred  pages  covered  by  their  con- 
tributions all  that  is  at  present  known  of  these  most  inter- 
esting topics.  There  arc  eleven  beautifully  executed  plates 
on  heavy  glazed  paper,  which  serve  as  frontispiece  illus- 
trations of  the  article  on  Malaria  by  Ettore  Marchiafava 
and  Amico  Bignami  of  Rome.  This  in  itself  makes  a  book 
of  over  five  hundred  and  twenty  pages,  going  into  every 
phase  of  the  question  to  which  of  late  so  much  interest  has 
attached  Simon  Flexner,  of  Philadelphia,  contributes  the 
greater  portion  of  the  text  on  Micro-organisms,  dealing  first 


with  the  history  and  technique  of  bacteriology,  then  consid- 
ering at  lengtli  bacilli  and  cocci  and  olher  forms.  Eugene 
L.  Opie,  of  the  Johns  Hopkins  LIniversity,  follows  with 
Protozoa,  arranged  according  to  classes  and  orders;  the 
whole  subject  is  made  as  concise  and  clear  as  is  consistent 
with  scientific  accuracy.  As  a  whole,  the  work  is  one  of 
great  interest,  and  the  part  played  by  the  mosquito  in 
transmitting  malaria,  now  attracting  such  general  interest, 
is  found  here  freelj^  discussed. 

Diseases  of  the  Genito-L^rinary  System:  A  Thorough 
Treatise  on  L'rinary  and  Sexual  Surgery.  By  Eugene 
Fuller,  M.D.,  Professor  of  Genito-L'rinary  and  Vene- 
real Diseases  in  the  New  York  Post-Graduate  Medical 
School,  etc.  New  York :  The  Macmillan  Companv. 
1900. 

The  author  finds  that  most  recent  works  on  genito-uri- 
nary  affections  have  been  w-ritten  from  a  purely  venereal 
or  dermatological  standpoint,  or  the  special  articles  relat- 
ing to  the  kidneys  and  bladder  in  works  by  many  writers 
have  been  prepared  by  general  surgeons  rather  than  by 
those  professing  special  skill  in  genito-urinary  affections. 
He  finds  the  attempts  made  by  venereal  specialists  to 
write  on  surgical  topics  usually  disappointing.  The  au- 
thor has  therefore  sought  to  avoid  the  shortcomings  enu- 
merated, and  has  w-ritten  from  the  purely  surgical  stand- 
point, giving  his  individual  views  and  methods  freely. 
Whether  the  term  "thorough"  in  the  title  will  stand  an 
exacting  test  is  questionable. 

TraiTe  de  MiiDECiNE  ET  DE  Therapeutique.  Publie  sous 
la  direction  de  MM.  P.  Brouardel  et  A.  Gilbert.  Tome 
septieme :  Maladies  du  Nez,  du  Larynx,  de  la  Trachee, 
des  Bronches,  et  des  Poumons.  Paris :  J.  B.  Bailliere  et 
Fils.     1900. 

In  the  list  of  contributors  to  the  present  volume  we  note 
the  names  of  Cartaz,  Castex,  Barbier,  H.  Barth,  P.  Claisse, 
Mosny,  L.  Landouzy,  H.  Triboulet,  Grancher,  Balzer, 
Mery,  and  Le  Noir.  In  such  a  treatise  not  much  that  is 
new  can  be  looked  for.  Suffice  it  to  say  that  the  various 
articles  display  an  acquaintance  on  the  part  of  their  re- 
spective authors  with  the  most  recent  advances  in  diseases 
of  the  air  tract,  and  can  be  accepted  as  representative  views 
of  the  present-day  school  of  clinical  teachers  in  France. 


©ovrcspontlcnce. 

OUR    LONDON    LETTER. 

(From  our  Special  Correspondent.) 

THE  BARTHOLOMEW  HOSPITAL  SITE — THE  CHARGE  AGAINST 
THE  WAR  HOSIMTALS — COMMISSION  PROPOSED  IN  PARLIA- 
MENT and  ADDED  TO — CONAN  DOYLE  ON  THE  STATE  OF 
BLOEMFONTEIN — KNIGHTHOOD — SUNDAY  FUND — DEATH  OF 
PROFESSOR    D.    J.   LEECH — COLLEGE   OF   SURGEONS  ELECTIONS. 

London,  July  6.  iqoo. 

On  Monday  the  Prince  of  Wales  presided  at  a  special  court 
of  the  governors  of  St.  Bartholomew's  Hospital.  The  re- 
port of  the  almoners  and  treasurer  gave  the  story  of  futile 
negotiations  for  the  purchase  of  part  of  the  site  of  Christ's 
Hospital,  now  removed  to  the  country.  In  December, 
1S93,  the  governors  of  the  latter  agreed  to  sell  an  acre  and 
a  half  of  the  land  to  St.  Bartholomew's  at  a  price  to  be 
fixed  by  arbitration,  but  up  to  this  time  it  has  been  impos- 
sible to  get  them  to  fulfil  their  agreement.  To  end  the 
deadlock  a  sum  of  ;^ii7,ooo  has  been  offered  and  declined, 
and  it  was  moved  that  if  this  be  not  atcepted  the  aid  of 
Parliament  he  sought.  The  Prince  expressed  deep  regret 
that  Christ's  Hospital  had  not  thought  fit  to  stick  to  llicir 
engagement,  and  "the  scanty  courtesy,  to  say  the  least  of 
it,\vrth  which  they  have  treated  us."'  He  trusted  that  the 
charity  commissioners  would  back  up  the  claim  of  St.  Bar- 
tholomew's, and  that  Parliament  would  not  refuse  what  is 
for  its  benefit.     The  resolution  was  carried  unanimously. 

Medical  questions  luive  been  forced  into  the  background 
by  the  general  news  of  danger  and  death  in  all  directions 
from  China  to  New  York,  where  the  terrible  catastrophe 
from  fire  opened  the  week  with  a  thrill  of  horror  which 
penetrated  to  the  remotest  telegraph  station. 

One  medical  question  has,  however,  made  itself  heard, 
but  chiefly  because  it  is  far  more  than  a  medical — it  is  a 
national  question.  Is  the  army  medical  service  a  failuj-e? 
Are  the  statements  of  Mr.  Burdett-Coutts,  which  I  men- 
tioned in  my  last,  true  in  substance?  The  committee  sug 
gested  by  Lord  Roberts  and  accepted  by  the  government 
will  have  the  responsibility  of  investigating  and  pro- 
nouncing upcm  the  charges  against  our  war  hospitals. 
Meanwhile  the   newspapers  are  flooded  with  correspond- 


July  28,  1900] 


MEDICAL    RECORD. 


149 


ence  and  interviews.  Of  course  very  opposite  views  are 
expressed.  Sir  W.  Thompson  and  Mr.  Conan  Doyle  and 
other  able  surgeons  at  the  front  repudiate  any  charge  of 
neglect  or  incapacity  of  the  medical  staff  as  distinctly  as 
Sir  W.  MacCormac  and  Mr.  Treves  have  done.  Here  it 
is  right  to  say  that  Mr.  Coutts  indignantly  repudiates  the 
idea  that  he  has  attacked  Lord  Roberts  or  any  officer 
whatever,  or  the  personnel  of  the  Royal  Army  Medical 
Corps.  As  to  the  latter,  he  agrees  with  all  observers  that 
they  have  nobly  done  their  duty  under  great  difficulties,' 
and  some  at  the  cost  of  their  lives.  T/ie  Tiiius,  too,  has 
written  in  the  same  sense. 

The  proposal  of  Lord  Roberts  to  send  out  a  small  com- 
mission to  inquire — "one  or  two  medical  men  and  some 
man  of  common-sense" — having  been  accepted  bj'  the 
government,  the  names  of  the  proposed  commission  were 
submitted  to  the  House  of  Commons  last  night.  They 
were  Ur.  Church,  president  of  the  Royal  College  of  Physi- 
cians of  London  ;  Profes.sor  Cunningham,  of  Dublin  ;  and 
Lord  Justice  Romer.  No  sooner  had  Mr.  Balfour  stated 
the  names  than  Mr.  Labouchere  moved  the  adjournment 
of  the  House  in  order  to  denounce  the  composition  of  the 
commission.  The  presence  of  two  doctors  to  inquire  into 
charges  against  doctors  and  the  medical  service  he  vehe- 
mently opposed.  He  was  seconded  by  Mr.  Burdett-Coutts. 
who  thus  largely  discounted  his  profession  that  he  did  not 
blame  the  department.  Mr.  Balfour  pointed  out  that  tlie 
medical  men  proposed  had  no  connecti<m  with  the  army,  but 
the  feeling  of  the  House  had  been  e.\cited  and  it  was  obvi- 
ous a  larger  commission  would  be  preferred.  Therefore, 
though  against  bis  own  judgment,  he  agreed  to  add  two 
members. 

At  the  meeting  of  the  cabinet  to-day  it  is  supposed  the 
subject  of  the  war  hospitals  will  be  considered.  There  is 
some  fear  that  one,  if  not  two,  of  the  proposed  gentlemen 
may  decline  to  act  in  consequence  of  the  remarks  made  in 
the  debate.  I  hope  they  will  not  withdraw,  but  will  con- 
sider how  exciting  were  the  charges  made  by  Mr.  Coutts, 
and  how  the  tension  in  the  House  only  reflected  that  out- 
side. The  question  is  not  one  for  party — it  is  a  national 
one. 

Mr.  Conan  Doyle  has  sent  home  a  letter  from  which  .ex- 
tracts appear  in  the  new-spapers  to-day,  and  which  is  a 
valuable  contribution  to  the  evidence,  inasmuch  as  it  was 
written  at  Hloemfontein  before  the  charges  of  Mr.  Coutts 
were  made,  being  dated  the  5th  of  June.  In  this  letter  he 
points  out  the  crisis  caused  by  the  terrible  epidemic  of 
typhoid,  and  says  that,  being  confronted  with  a  task  de- 
manding four  times  more  men  tlian  the  department  had, 
the  only  way  to  meet  it  was  for  the  men  to  work  four  times 
as  hard.  "This  is  exactly  what  occurred  and  the  crisis 
was  met.  In  some  of  the  hospitals  orderlies  were  on  duty 
for  thirty-six  hours  in  forty-eight."  Then  he  tells  how 
these  orderlies,  "not  picturesque  figures,  are  patriots  facing 
danger  twelve  hours  of  the  twenty-four,  just  as  real  and  far 
more  repulsive  than  the  scout  or  the  gunner."  Further, 
anticipating  the  adverse  criticism  likely  to  be  made  after 
the  war,  he  says  the  captious  may  quote  cases  of  over- 
crowding or  hardships,  and  asks,  "  How  can  it  be  otherwise 
when  a  department  sufficient  for  two  army  corps  has  to 
provide  for  the  wants  of  two  hundred  thousand  men  with 
typhoid  raging  among  them?  " 

Conan  Doyle  will  be  read  by  the  great  public,  and  his 
words  weighed  against  those  of  sensational  correspond- 
ents. He,  like  every  reasonable  man,  wishes  the  truth  and 
the  whole  truth  to  be  known — ^even  if  the  War  Office  should 
have  to  be  sacrificed  with  all  its  red  tape.  If  any  one  is  to 
blame,  let  him  be  called  to  account ;  but  no  one  department 
can  bear  the  burden  of  the  War  Office's  shortcomings. 

Dr.  Hector  Cameron,  of  Glasgow,  and  Dr.  Philipson,  of 
Newcastle-on-Tj-ne,  have  been  knighted. 

Surgeon-General  Jameson  and  Sir  William  MacCormac 
have  received  honorary  degrees  from  Dublin  Universit)-. 

The  Hospital-Sunday  fund  has  reached  at  present  only 
about  ;r£'3i,ooo,  so  that  there  is  certain  to  be  disappoint- 
ment to  the  optimists.  One  church,  at  Lancaster  Gate, 
made  the  largest  collection  ever  received  for  the  fund  by 
a  single  congregation — the  amount  being  ^i,  519. 

I  regret  to  announce  the  death  of  Dr.  Leech,  professor  of 
materia  medica  at  Owens  College,  on  the  2d  inst.,  in  his 
sixty-first  year.  He  was  well  known  in  London,  and  his 
work  will  be  known  to  you.  In  Manchester  he  is  mourned 
as  a  distinguished  citizen,  always  ready  to  help  the  ad- 
vance of  education,  the  public  health,  and  general  prog- 
ress. He  had  filled  most  of  the  chief  offices  in  the  Victoria 
IJniversity,  and  for  some  time  represented  it  in  the  Gen- 
eral Medical  Council.  For  some  years  he  edited  the  Medi- 
cal Chronicle.  You  will  remember  his  Qroonian  lectures 
in  1S93  on  the  nitrites  and  allied  compounds. 

Mr.  A.  Cooper  and  Mr.  Tweedy  were  yesterday  re-elected 
to  the  council  of  the  Royal  College  of  Surgeons.  Dr.  Ward 
Cousins  and  Mr.  Pearce  Gould  were  chosen  to  fill  ihe  other 
vacancies.  There  were  twelve  candidates  for  the  four 
vacancie;. 


Clinical  department. 

HEMOPHILIA  IN  THE  NEGRO 
By    LOUIS   BUCK,    M.D., 

PORTLAND,    OKE. 

I  WISH  to  add  to  literature  two  more  cases  of  hjemophi- 
lia  in  the  negro,  one  that  of  a  man  aged  thirty  years,  the 
other  that  of  a  woman  aged  twenty-four  years.  In  the 
latter  (which  was  the  second  attack  she  had)  plugging  of 
the  nares  was  kept  up  for  three  days,  but  when  the  plug 
was  removed  hemorrhage  recommenced.  Then  plug- 
ging was  again  resorted  to  for  four  days  more,  which 
had  the  desired  effect. 

In  the  former  case  suprarenal  extract  with  plugging 
was  tried  with  but  temporary  success,  the  hemorrhage 
returning  in  three  hours.  The  same  procedure  was 
again  performed,  with  the  same  results.  Then  I  ad- 
ministered internally  gr.  x.  calcium  chloride  in  solu- 
tion every  three  hours,  combined  with  anterior  and 
posterior  plugging  of  the  nares,  when  I  had  no  further 
trouble. 


EXTRAVAS.VTION    OF    URINE     FOLLOWING 
STRICTURE  OF  LARGE  CALIBRE." 

Bv   JOSEl'H    B.    BISSELL,    .M.D., 

NEW    YORK. 

The  following  case  illustrates  a  point  easily  overlooked 
at  times.  The  fact  that  a  stricture  of  moderate  or 
even  large  calibre  may  remain  unnoticed  and  still  lead 
to  disastrous  results  is  worth  recalling  to  your  atten- 
tion in  a  brief  way. 

The  patient,  J.  V ,  forty-one  years  of  age,  was 

brought  into  the  hospital  on  the  afternoon  of  May  3, 
1900,  with  a  temperature  of  105°  F..  pulse  of  124. 
The  history,  as  well  as  it  could  be  obtained,  is  as  fol- 
lows: He  had  been  ill  three  weeks.  His  illness  be- 
gan with  a  chill  and  rise  of  temperature.  He  has 
had,  as  far  as  we  could  learn,  irregular  chills  since, 
with  loss  of  appetite,  occasional  vomiting,  pain  in  the 
abdomen;  at  times  delirium.  He  complained  prin- 
cipally of  the  pain  all  over  the  abdominal  region. 
The  bowels  were  somewhat  loose.  He  was  able  to 
pass  his  urine  at  normal  intervals  in  normal  quantity, 
and  without  pain.  He  has  had  two  attacks  of  ure- 
thritis, the  last  several  years  ago.  He  lives  in  a  ma- 
larial district.  He  told  the  house  physician  that  he 
had  either  malaria  or  typhoid  fever,  his  doctor  was 
not  certain  as  yet  which.  On  examination,  the  surface 
of  the  abdomen  below  the  level  of  the  umbilicus  was 
found  to  be  tender  and  boggy,  extending  into  the  left 
loin  and  into  both  groins,  where  it  was  reddened  and 
at  points  fluctuated.  The  scrotum  was  swollen,  dis- 
colored, and  cedematous,  and  on  the  lower  portion  was 
a  patch  of  gangrene  the  size  of  a  trade  dollar.  The 
perineum  was  moderately  swollen  and  there  was  a 
fluctuating  swelling,  most  marked  to  the  left  of  the 
median  line.  The  perineal  region  was  not  especially 
tender,  neither  was  the  abdominal  wall.  He  says  his 
doctor  had  passed  a  catheter  a  few  days  before  without 
trouble,  and  while  in  hospital  he  passed  voluntarily 
without  much  pain  or  difficulty  a  pint  of  cloudy,  bad- 
smelling  urine.  This  being  examined  was  found  to 
contain  some  pus  and  albumin,  and  was  of  high  spe- 
cific gravity. 

The  man  was  at  once  taken  to  the  operating-room. 
A  26  French  sound  was  passed  with  a  little  difficulty 
into  his  bladder.  It  was  obstructed  slightly  at  about 
four  and  one -half  inches,  and  a  bougie  i  boule  de- 

'  Read  before  the  Medico-Surgical  Society  of  New  V'ork  City, 
Friday,  May  18,  igoo. 


I50 


MEDICAL    RFXORD. 


[July  28,  1900 


tected  a  decided  contraction  at  this  point  of  24  and  25 
mm.  The  sound  was  then  replaced,  an  external  ure- 
throtomy performed,  and  this  stricture  divided;  a  tube, 
carried  through  the  opening  along  the  urethra  into  the 
bladder,  brought  out  about  a  quart  of  ammoniacal 
urine.  Just  behind  the  perineo  scrotal  junction  and 
to  the  left  of  the  median  line  was  a  fluctuating  tumor 
containing  urine  and  pus,  communicating  with  the 
urethra  behind  the  stricture.  A  probe  carried  forward 
in  its  cavity  went  under  the  skin  and  superficial  fascia 
of  the  groin  and  under  the  fascia  of  the  abdomen  in 
all  directions,  showing  the  undermining  done  by  the 
urine  escaping  at  this  point  frpm  the  urethral  canal. 
The  other  tissues  of  the  abdomen,  the  scrotum,  peri- 
neum, and  even  into  the  lumbar  region,  were  incised 
and  drained.  A  tube  was  left  in  the  bladder  through 
the  perineal  wound.  The  patient's  temperature  and 
pulse  within  a  few  hours  fell  to  nearly  normal,  and  he 
appeared  to  be  improving  rapidly;  but  in  about  twenty- 
four  hours  after  the  operation  he  had  a  chill,  his  tem- 
perature and  pulse  rose  rapidly,  and  he  died  septic 
inside  of  thirty-six  hours  from  the  time  I  first  saw 
him.  The  infiltration  had  extended  even  into  the  tis- 
sues of  the  back  from  his  left  side. 

The  case  is  interesting  because  of  the  extensive  ex- 
travasation, in  spite  of  the  fact  that  he  was  passing  his 
urine  at  regular  intervals,  notwithstanding  that  an 
ordinary  catheter  passed  into  the  bladder  with  little  or 
no  difficulty,  and  that  there  was  no  sudden  or  complete 
rupture  at  any  part  of  the  urethral  canal.  An  indif- 
ferent or  careless  observer  would  thus  be  very  easily 
misled  as  to  the  disease  and  its  gravity. 

Extravasation  of  urine  following  stricture  of  large 
.calibre  is  not  uncommon  and  is  very  easily  explained. 
Following  a  chronic  urethritis  after  a  localized  point 
.of  inflammation  has  set  up  a  plastic  exudation  extend- 
ing to  the  submucous  structures,  new  connective  tissue 
forms,  and  as  a  result  becomes  an  obstruction  in  the 
canal.  This  obstruction  need  not  be  circumferential 
to  accomplish  its  object.  It  is  a  dam  in  the  way  of  the 
normal  outlet.  The  urine  is  forced  forward  by  pres- 
sure from  the  bladder  and  the  deeper  perineal  muscles. 
The  tissue  immediately  posterior  to  this  hyperplastic 
spot,  being  softer,  yields  gradually.  The  epithelial  pro- 
tective layer  is  damaged,  a  tiny  laceration;  then  slight 
ulceration  occurs,  infiltration  of  a  more  or  less  infec- 
tive urine  takes  place,  followed  by  a  folliculitis,  a 
periurethritis,  and  a  follicular  departure  from  the  ure- 
thra, into  which  is  constantly  being  absorbed  urine  con- 
taining pyogenic  bacteria,  and  the  rest  is  easy.  This 
process  is  a  very  slow  one,  taking  w-eeks,  months,  or  even 
years  before  much  impression  is  made.  The  condition 
is  continually  made  worse  if  the  stricture  or  obstruc- 
tion happens  to  be,  as  it  usually  is,  at  about  the  end  of 
the  most  dependent  portion  of  the  urethra  and  in  a 
straight  line  from  the  bladder,  so  as  to  receive  the  direct 
propulsive  force  of  the  muscular  efforts  to  expel  the 
urine.  Having  thus  got  out  into  the  layer  of  cellular 
tissue,  the  decomposing  fluids  and  gas  work  their  way 
in  the  direction  of  least  resistance  under  the  fascia, 
through  interstices  of  the  superficial  fascia  at  its  pubic 
attachments,  to  the  inguinal  region,  along  the  abdom- 
inal wall  and  into  the  cellular  tissues  of  the  scrotum  at 
the  same  time,  the  fascia  often,  as  in  the  case  re- 
ported above,  being  dissected  from  tlie  aponeurosis  of 
the  superior  oblique  in  various  directions  and  long 
spaces,  even  extending  into  and  beyond  the  lumbar 
region.  Infection  in  this  case  possibly  occurred  at 
the  passage  of  the  catheter. 

The  treatment  is  simple,  direct,  and  imperative. 
Perineal  swelling  without  external  injury  means  uri- 
nary infiltration,  always  excepting  the  recto-vesical 
abscess,  w'hich  at  times  extends  along  this  region. 
The  only  safe  course  in  such  a  case  is  a  prompt  and 
generous  incision   into   it  and  drainage  of  the  urethra 


and  bladder.  I3y  such  treatment  urethral  extravasa- 
tion can  always  be  prevented  and,  after  it  has  begun, 
relieved.  If  the  extravasation  is  not  too  extensive,  or 
the  treatment  too  long  delayed,  the  prognosis  is  al- 
ways good.  At  the  operation  the  urethra  should  be 
cleared  of  all  strictures  by  an  internal  urethrotomy. 

Applications  of  hot  bichloride-of-mercury  gauze 
1 :  6,000,  or  carbolic  gauze  i  :  40,  to  the  perineal  region 
and  the  other  affected  tissues  will  be  of  great  assist- 
ance to  deplete  and  drain  the  infiltrated  structures. 


POISONING  BY  OIL  OF  WINTERGREEN. 
Bv   B.    riLLSEURV.    M.D., 

WIDDUETOWN,    N.    V. 

I  REPORT  this  case  since  I  find,  among  such  records 
as  I  have  examined,  but  one  case  of  poisoning  by  oil 
of  wintergreen,  that  one  ending  in  recovery.     Gilbert 

G ,   a   middle-aged   farmer,   took  by   mistake   for 

whiskey  two  ounces  of  oil  of  wintergreen  at  4  p.m. 
He  went  about  his  work,  but  in  two  hours  began  to 
have  a  copious  diarrhcea,  which  continued  constantly 
until  his  death.  His  daughter,  with  rare  good  judg- 
ment, gave  him  mustard  as  an  emetic,  the  whites  of  a 
dozen  raw  eggs,  milk,  and  very  little  water.  It  was 
not  till  near  9  p.m.  that  a  doctor  arrived.  He  found 
the  patient  sweating  prodigiously,  feeling  as  if  on  fire 
inside;  pulse  100,  not  intermittent;  the  skin  was 
aflame.  On  the  following  day  the  skin  was  still  in- 
tensely red,  and  the  victim  was  harassed  by  a  terrific 
itching.  In  the  afternoon  the  pulse  was  still  non-inter- 
mittent, but  running  as  fast  as  possible.  The  odor  of 
oil  of  wintergreen  was  perceptible  in  the  fecal  evacu- 
ations. Death  occurred  from  exhaustion  forty-one 
hours  after  the  wintergreen  was  taken. 


EXTRAVASATION  OF  URINE.' 
Bv   JAMES    R.    HAYDEN,    M.D., 

CHIEF  OF  CLINIC  AND  INSTRUCTOR  IN  GENITO  UKINARV  AND  VENEREAL 
DISEASES,  COLLECiE  OF  PHYSICIANS  AND  SURGEONS,  COLUMBIA  UNI- 
VERSITY, NEW  \ORK;  ASSSISTANT  \ISITING  GENITO-URINARV  SIRGEON, 
BELLEVUE    HOSPITAL. 

The  serious  nature  of  urinary  extravasation  is  so  ap- 
parent that  I  trust  a  brief  report  of  the  following  cases 
may  possibly  be  of  interest,  especially  to  those  who 
are  called  upon  to  treat  this  grave  and  oftentimes 
fatal  complication  of  tight  urethral  stricture. 

Case  I. — Scrotal  extravasation.  The  patient,  a 
man  sixty-nine  years  of  age,  has  had  gonorrhaa  twice, 
the  first  attack  thirty  years  ago,  the  second  attack  fif- 
teen years  ago.  He  says  he  has  been  troubled  with 
more  or  less  difficult,  frequent,  and  painful  urination 
for  the  past  ten  years,  but  has  never  had  complete  re- 
tention. Twenty  hours  before  admission  and  without 
apparent  cause  he  was  suddenly  seized  with  intense 
pain  in  the  perineum,  and  in  a  short  time  the  scrotum 
began  to  swell  and  became  very  tender.  He  then  had 
a  constant  and  intense  desire  to  urinate,  but  was  able 
to  pass  only  a  few  drops,  after  violent  and  prolonged 
straining. 

Examination  on  admission:  Patient  entered  Belle- 
vue  Hospital  in  a  state  of  collapse.  Temperature,  to2° 
F. ;  pulse,  go  and  feeble;  respiration,  16.  The  urine 
is  purulent  and  ammoniacal.  The  scrotum  is  three 
times  its  normal  size,  blanched,  shining,  and  a'dem- 
atous,  and  very  tender  on  manipulation.  There  is 
no  swelling  in  the  perineum,  penis,  or  pubic  region, 
although  the  perineum  is  sensitive  if  touched  or 
pressed  upon.     There  is  a  dense,  fibrous,  and  filiform 

'  Read  before  tlie  Genito-Uriiiary  Section,  New  York  Academy 
of  Medicine.  Marcli  21,   1900. 


July  28,  1900] 


MEDICAL    RECORD. 


151 


stricture  situated  about  the  middle  of  the  bulbous 
urethra.  The  prostate  is  somewhat  enlarged  in  the 
rectum,  but  not  tender. 

Treatment:  The  patient  was  etherized,  and  an  ex- 
ternal urethrotomy  performed.  The  stricture  having 
been  freely  incised,  a  No.  30  French  sound  was  passed 
from  the  meatus.  No  urine  was  found  in  the  perineum, 
the  tissues  of  which  looked  perfectly  normal.  The 
bladder  was  e.xplored  and  drained  by  means  of  a  large 
perineal  tube.  Several  deep  incisions  were  then  made 
from  the  top  to  the  bottom  of  the  scrotum,  and  a  large 
quantity  of  foul,  decomposing  urine  liberated.  The 
sloughing  scrotal  tissues  were  freely  irrigated  with 
peroxide  of  hydrogen  and  hot  saline  solution,  dressed 
with  moist  saline  gauze,  and  supported.  The  patient's 
condition  now  became  so  precarious  that  he  was  given 
a  saline  infusion  and  the  usual  stimulants  hypoder- 
mically.  He  rallied  nicely  and  made  an  uneventful 
recovery;  and  now,  one  and  a  half  years  after  the 
operation,  he  urinates  normally,  passing  a  practically 
clean  urine  and  taking  a  full-sized  sound  with  ease. 
In  this  case  sounds  were  passed  every  other  day,  and 
the  bladder  and  urethra  were  irrigated  morning  and 
evening. 

Case  II. — Extravasation  into  spongy  body.  The 
patient,  forty-three  years  of  age,  has  had  gonorrhoea 
several  times,  the  first  attack  fifteen  years  ago,  the 
last  one  two  months  ago.  He  has  had  more  or  less 
difficulty  in  urination  for  several  years,  but  never  com- 
plete retention.  Ten  days  after  the  onset  of  the  last 
attack  of  gonorrha-a,  he  began  to  have  frequent,  pain- 
ful, and  difficult  urination  day  and  night,  which  was 
followed  in  a  few  days  and  without  apparent  cause  by 
a  hard,  tender  swelling  in  the  perineum,  which  grad- 
ually crept  forward  along  the  under  surface  of  the 
penis. 

Examination  on  admission:  Temperature,  102°  F. ; 
pulse,  100;  respiration,  32.  There  is  a  thick,  purulent 
urethral  discharge.  The  urine  is  ammoniacal,  very 
cloudy  from  pus,  and  is  passed  in  drops  after  much 
effort.  There  is  a  fibrous  stricture  two  inches  from 
the  meatus,  which  admits  with  difficulty  a  filiform 
guide  that  passes  unobstructed  from  this  point  to 
the  bladder.  The  perineum  is  very  tense  and  bulg- 
ing, caused  by  the  swelling  of  the  bulb  of  the  corpus 
spongiosum,  which  swelling  is  sharply  limited  to  the 
spongy  body  and  extends  to  within  two  inches  of  the 
meatus.  The  glans  is  normal.  The  swelling  is  very 
tender,  dense,  somewhat  fluctuating,  and  yields  on  as- 
piration a  thin,  bloody,  ammoniacal,  and  urinous  fluid. 

Treatment:  The  patient  being  etherized,  the  stric- 
ture was  cut  with  a  Fluhrer-Maissoneuve  urethrotome, 
and  a  full-sized  sound  was  passed  from  the  meatus  to 
the  bladder,  showing  the  rest  of  the  canal  to  be  free 
from  stricture.  External  urethrotomy  was  then  per- 
formed for  bladder  drainage.  The  corpus  spongiosum 
was  freely  incised  along  its  entire  length,  and  a  sur- 
prisingly large  amount  of  thin,  bloody,  purulent,  and 
ammoniacal  urine  liberated.  The  incisions  were 
freely  irrigated  and  dressed  as  in  Case  I.,  the  patient 
having  the  same  local  and  internal  treatment.  In 
eight  weeks  the  patient  was  discharged  from  Bellevue 
Hospital,  all  wounds  having  cicatrized,  the  urethra 
taking  a  full-sized  sound,  and  the  patient  urinating 
normally.  The  urine  was  acid  in  reaction,  and  clear, 
but  contained  a  few  light  flakes. 

The  point  of  interest  in  this  case  is,  that  although 
the  stricture  was  situated  near  the  meatus,  the  break 
in  the  urethra  must  have  occurred  in  its  bulbous  por- 
tion, as  the  extravasation  began  there  and  extended 
slowly  forward  to  the  stricture,  but  did  not  invade  the 
glans  itself,  probably  on  account  of  the  involvement 
of  the  corpus  spongiosum  by  the  stricture  tissue,  as  the 
whole  thickness  of  that  spongy  body  was  hard  and 
dense  at  this  point. 


Case  III. — General  extravasation.  The  patient, 
thirty-seven  years  of  age,  eight  years  ago  had  a  very 
severe  attack  of  gonorrhoea,  from  which  he  says  he  h;is 
never  recovered,  as  ever  since  that  time  there  has  been 
an  increased  frequency  of  urination.  Five  years  ago 
he  had  complete  retention  of  urine  following  alcoholic 
excess;  this  was  relieved  by  catheterization.  For  the 
past  few  months  he  had  been  urinating  every  fifteen 
minutes  during  the  day  and  hourly  during  the  night, 
each  act  being  accompanied  and  followed  by  tenesmus, 
during  a  recent  and  severe  attack  of  which  the  patient 
noticed  a  bleeding  and  painful  mass  protruding  from 
the  rectum.  Five  days  ago,  after  a  more  violent  and 
prolonged  attack  of  tenesmus  than  usual,  two  swellings 
suddenly  appeared,  one  above  the  symphysis  pubis 
and  another  in  the  perineum.  After  forty-eight  hours  _ 
these  swellings  became  very  hard  and  painful,  and  the 
integument  over  them  was  reddish  in  color.  The  pa- 
tient was  now  in  such  distress  that  he  entered  Bellevue 
Hospital. 

Examination  on  admission:  The  patient  is  poorly 
nourished,  thin,  and  aneemic.  Temperature,  102.4°  F- ; 
pulse,  no  and  feeble;  respiration,  24.  The  urine  is 
cloudy,  alkaline;  specific  gravity,  1.020;  albumin 
twenty  per  cent. ;  no  sugar  or  casts.  There  are  consid- 
erable pus,  red  blood  cells,  and  bladder  epithelium. 
There  is  a  firm,  dense,  filiform  stricture,  situated  at  the 
bulbo-membranous  junction.  The  anterior  abdominal 
wall,  from  the  symphysis  pubis  to  the  umbilicus  and 
between  the  iliac  spines,  is  dark  red  in  color,  cedema- 
tous,  and  tender,  and  gives  a  gaseous  crepitation  on 
pressure.  The  scrotum  and  perineum  are  in  the  same 
condition,  except  that  the  skin  of  the  scrotum  is  shin- 
ing and  blanched.  The  penis  is  normal.  The  rectum 
is  prolapsed,  bleeding,  and  held  tightly  by  the 
sphincter. 

Treatment:  The  patient  was  etherized,  the  sphinc- 
ter dilated,  and  the  prolapsed  gut  reduced.  An  exter- 
nal uretlirotomy  was  then  performed,  the  stricture 
thoroughly  divided,  and  a  full-sized  sound  passed 
from  the  meatus.  The  bladder  was  drained  by  a  large 
perineal  tube.  The  perineum  was  filled  with  green- 
ish-black gangrenous  and  sloughing  tissues,  from 
which  exuded  pus  and  ammoniacal  urine,  giving  rise 
to  a  most  horrible  odor.  As  much  of  these  tissues  as 
possible  were  liberally  cut  away,  and  the  perineum 
freely  incised  on  either  side  of  the  urethrotomy  cut. 
The  same  treatment  was  applied  to  the  scrotum,  whose 
tissues  were  infiltrated  with  decomposing  urine  and  in 
a  sloughing  condition.  Longitudinal  sections  were 
then  made  over  the  infiltrated  abdominal  area  down  to 
the  muscles,  and  a  large  quantity  of  foul  gas,  pus,  and 
ammoniacal  urine  liberated.  The  sloughing  tissues 
and  fat  in  the  prevesical  space  were  then  removed 
through  the  incisions,  all  of  which  were  thoroughly 
irrigated,  drained,  and  lightly  packed  with  strips  of 
gauze.  The  dressings  were  changed  and  wounds  irri- 
gated every  three  hours,  day  and  night,  for  the  first 
few  days. 

Immediately  after  the  operation,  the  temperature 
rose  to  104.4°  F..  the  pulse  became  very  feeble,  and 
the  patient  passed  into  a  condition  of  extreme  shock. 
He  was  infused  with  saline  solution,  a  quantity  of 
which,  with  a  few  ounces  of  brandy,  was  injected  hot 
into  the  rectum.  He  was  also  stimulated  hjpo- 
dermically.  The  patient  rallied  slowly  but  steadily 
after  the  operation,  the  temperature  and  pulse  gradu- 
ally becoming  normal.  The  same  local  and  internal 
treatment  was  employed  as  in  Case  I.  On  the  fiftieth 
day  after  operation  all  of  the  wounds  were  healed,  and 
the  patient  was  passing  a  clear  urine  naturally. 

From  a  study  of  the  above  cases,  which  have  been 
selected  as  illustrating  the  usual  forms  of  urinary  ex- 
travasation, we  are  warranted  in  drawing  the  following 
conclusions,  in  regard  to  the  treatment  of  this  condi- 


152 


MEDICAL    RECORD. 


[July  28,  1900 


tion:  (i)  The  location  of  the  stricture  or  strictures, 
and  their  immediate  relief  by  internal  urethrotomy, 
external  urethrotomy,  or  a  combination  of  both;  (2) 
through  bladder  drainage  by  means  of  a  large  peri- 
neal tube,  passed  through  tne  external  urethrotomy 
wound;  (3)  free  incisions  into  all  areas  of  extravasa- 
tion, with  liberation  of  urine,  gas,  and  gangrenous  tis- 
sues, and  their  copious  irrigation;  (4)  through  drain- 
age and  frequent  irrigation  of  these  incisions,  with 
change  of  dressings,  which  should  consist  of  moist 
saline  gauze  and  hot  saline  solution,  rather  than  iodo- 
form, bichloride,  or  carbolic,  on  account  of  the  pos- 
sible toxic  effects  of  the  latter,  on  a  subject  who  is 
already  in  a  more  or  less  precarious  condition;  (5) 
frequent  urethral  and  bladder  irrigations,  together 
ivith  the  occasional  passage  of  full-sized  sounds,  and 
internal  medication  to  keep  the  urine  in  a  normally 
acid  condition. 


ALVEOLAR  SARCOMA  OF  UTERUS.' 

By  A.    E.    ISAACS,    M.D., 

ASSOCIATE    PROFESSOR    OF   SURGERY.    NEW    YORK    SCHOOL   OF    CLINICAL     MEDI- 
CINE ;    VISITING  SURGEON,    BETH    ISRAEL   HOSPITAL. 

Fannie  K ,  twenty-one  years  old,  cigarmaker,  not 

married,  was  first  seen  by  me  at  her  home  on  October 
9,  1898.  She  gave  no  history  of  previous  sickness  or 
abdominal  trouble,  except  that  she  never  menstruated, 
but  had  nose-bleed  pretty  regularly  every  month.  Her 
present  trouble  began  about  a  week  previously  with  a 
severe  attack  of  abdominal  cramps,  which  was  only 
temporarily  relieved  by  an  enema  and  free  movement 
of  the  bowels.  The  cramps  returned  promptly  with 
pain  and  tenderness  all  over  the  abdomen. 

Examination  showed  a  temperature  of  104.6°  ;  pulse, 
120.  The  whole  abdomen  was  distended,  tense,  and 
very  tender.  There  seemed  to  be  some  induration  in 
the  right  iliac  fossa,  but  this  could  not  be  definitely 
ascertained  on  account  of  the  tenseness  of  the  abdo- 
men. The  bowels  had  not  moved  in  a  couple  of  days. 
There  was  no  vomiting,  but  nausea  was  present.  A 
vaginal  examination  was  not  permitted,  and  the  rectal 
examination  was  so  painful  as  to  prove  imsatisfactory. 
There  was  a  very  sparse  growth  of  hair  on  the  genitals. 
The  breasts  were  normal. 

Although  no  diagnosis  could  be  made,  appendicitis 
was  suspected,  and  the  patient  was  transferred  the 
same  evening  to  the  Beth  Israel  Hospital  to  be  ready 
for  operation  siiould  it  be  found  necessary.  At  the 
hospital  I  put  her  on  small  repeated  doses  of  calomel, 
followed  by  a  high  enema,  which  gave  a  good  fecal  re- 
sult, and  by  the  next  morning  her  temperature  was 
down  to  100.5°,  ^"'^'  pulse  to  102.  She  vomited  some 
dark-colored  lluid  this  day.  Her  bowels  were  kept 
free  with  salines  and  enemata,  and  within  a  few  days 
her  condition  was  very  much  improved.  After  one 
week's  stay  in  the  hospital  and  until  she  left,  her  tem- 
perature remained  between  gg°  and  100.5°,  ^^"^1  pulse 
90  to  104.  The  tympanites  and  abdominal  tenderness 
subsided,  so  that  on  external  palpation  a  smooth  sym- 
metrical central  tumor  could  be  felt  occupying  tiie  site 
and  about  tlie  size  of  a  four-and-a-half  niontiis'  gravid 
uterus.  Of  course  this  suggested  eitiier  untruth  as  to 
previous  history,  and  pregnancy,  or  uterine  retention 
of  the  menstrual  flow,  and  in  either  case  a  coexistent 
pelvic  inflammation.  She  positively  refused  to  allow 
any  vaginal  examination  or  any  operation,  and  left  the 
hospital  October  25th  rather  than  submit  to  examina- 
tion. 

Almost  three  weeks  later,  on  November  13th,  she 
applied  for  readmission  to  the  hospital,  willing  now 
to  submit  to  any  treatment  found  necessary.     She  had 

'  Specimen  presented  at  a  meeting  of  the  Eastern  Medical 
Society,  December,  1898. 


become  worse  after  leaving  the  hospital,  and  was  bed- 
ridden most  of  the  time.  Her  abdomen  was  very  large 
and  almost  filled  now  with  the  uterine  tumor.  Defe- 
cation and  micturition  were  both  painful.  Both  legs 
were  oedematous.  She  was  much  emaciated  and  ex- 
hausted. Temperature,  101.3°;  pulse,  128.  Vaginal 
examination  disclosed  a  normal  virgin  vagina,  an  im- 
pervious cervix  as  far  as  the  finger  could  judge,  and  a 
large  abdominal  tumor  occupying  the  site  of  the  uterus, 
which  was  supposed  to  be  that  organ  distended  with 
retained  menstrual  blood,  complicated  with  surround- 
ing inflammation  secondary  to  that  condition.  This 
examination  was  made  on  the  table  under  anaesthesia 
immediately  before  the  operation,  in  which  Dr.  A. 
Brothers  was  kind  enough  to  assist  me. 

The  patient  being  in  the  Trendelenburg  position,  an 
incision  was  made  in  the  median  line  between  the  um- 
bilicus and  pubes.  The  hand  introduced  into  the  ab- 
dominal cavity  felt  a  large,  smooth,  soft  median  tumor 
filling  the  whole  pelvis  and  extending  upward  to  a 
point  half-way  between  the  umbilicus  and  xiphoid. 
The  transverse  colon  lay  across  the  upper  portion  of 
the  tumor  and  was  firmly  adherent  to  it.  The  anterior 
abdominal  wall  below  a  transverse  line  midway  be- 
tween the  umbilicus  and  pubes  was  firmly  adherent  to 
the  growth.  Posteriorly  also  in  the  pelvis  the  whole 
lower  portion  of  the  tumor  was  adherent.  To  ascer- 
tain the  contents  of  the  tumor,  an  aspirator  needle  was 
introduced,  which  gave  only  a  few  drops  of  blood- 
stained serum.  A  large  cannula  gave  the  same  result. 
Incision  into  the  tumor  showed  that  it  was  composed 
of  soft  grayish  tissue  interspersed  with  small  serous 
collections,  some  clear,  some  bloody,  evidently  a 
malignant  growth. 

The  abdominal  incision  was  enlarged  to  the  upper 
limit  of  the  tumor  and  downward  to  the  pubes;  the 
adherent  transverse  and  descending  portions  of  the 
colon  were  with  difficulty  separated  from  it,  and  the 
fundus  of  the  tumor  was  delivered  through  the  in- 
cision. The  attempt  was  made  to  extirpate  the  tumor 
entire,  that  is,  including  the  uterus,  but  this  proved 
impossible  on  account  of  the  very  extensive  adhesions. 
The  whole  length  of  the  uterine  sac  was  incised,  and 
after  scooping  out  about  one-third  of  the  tumor  piece- 
meal the  rest  was  enucleated  in  one  mass.  The  ab- 
dominal cavity,  then  the  tumor  cavity  were  flushed  out 
with  hot  saline  solution,  and  the  abdominal  incision  was 
closed  to  somewhat  below  the  umbilicus.  The  redun- 
dant uterine  sac  was  cut  away  and  the  circumference 
of  the  remainer  stitched  to  the  circumference  of  the 
remaining  peritoneal  opening,  leaving  the  peritoneal 
cavity  open  at  its  upper  angle,  where  a  strip  of  gauze 
was  introduced  for  drainage.  Tlie  tumor  cavity  was 
packed  with  iodoform  gauze. 

The  patient  was  in  very  poor  condition  after  the 
operation,  necessitating  all  manner  of  stimulation,  but 
she  was  brought  around  and  within  a  few  days  was 
comparatively  much  improved,  though  she  had  to  be 
constantly  stimulated.  Gidema  of  the  legs  disap- 
peared, and  pain  with  stool  and  urination  subsided. 

The  tumor  promptly  began  to  grow  again,  and  in 
spite  of  repeated  removals  of  new  growth  gradually 
filled  up  the  pelvic  sac  again,  and  about  three  weeks 
after-  the  operation  it  began  to  protrude  tiirough  the 
w'ound.  During  the  fourth  week  the  woman  began  to 
decline  again,  and  died  of  exhaustion  on  December 
20th,  five  weeks  after  operation. 

Pathological  examination  of  the  tumor  by  Dr.  H. 
T.Brooks:  "Complex  neoplasm  of  embryonal  origin 
frequently  designated  as  '  blastoma.'  It  is  very  closely 
related  (this  one)  to  alveolar  sarcoma,  though  there  are 
also  some  areas  much  like  adeno-carcinoma." 

The  points  of  special  interest  in  the  case  are:  (1) 
Whether  uterine  retention  of  menstrual  flow  was  the 
cause  of  the  subsequent  malignant  growth.     (2)  The 


July  28,  1900J 


MEDICAL    RECORD. 


153 


rapidity  of  the  growth  of  the  tumor,  which  in  three 
weeks  from  the  time  she  left  the  hospital  till  she  re- 
turned grew  from  the  size  of  a  four  to  four-and-one- 
half  months'  pregnant  uterus  to  that  of  a  full-term 
uterus.  (3)  The  repeated  attacks  of  surrounding  peri- 
tonitis simulating  other  intra-abdominal  inflamma- 
tions, and  likely  to  be  mistaken  for  them. 


A  CASE  OF  EXORMOUS  ELEPHANTIASIS. 
By  PHILIl'   F.    ROGERS,    M.D., 

ASSISTANT   IN    ANATOMV,    MILWAL-KEE    MEDICAL   COLLEGE. 

The  patient,  a  Russian  Jewess  of  the  lower  class, 
found  her  way  into  the  clinic  at  the  Milwaukee  Med- 
ical College,  and  was  exhibited  there  before  a  large 
audience  by  Professor  Earles. 

She  was  born  near  Kieff,  in  southwestern  Russia, 
twenty-six  years  ago,  and  lived  there  until  coming  to 
Milwaukee  some  sixteen  months  since.  The  family 
history  is  negative.  Parents,  two  brothers,  and  two 
sisters — one  of  the  latter  older  than  herself,  all  the 
rest  younger — are  living  and  well.  She  herself  had 
nothing  more  serious  than  the  ordinary  sicknesses  of 
childhood  up  to  twelve  years  of  age,  and  was  a  lively, 
romping  girl. 

At  the  age  of  twelve  she  attended  a  wedding  and 
danced  all  night,  and  during  the  next  few  days,  when 
cold  and  wet  weather  prevailed,  was  running  about 
barelegged.  As  a  result  she  was  sick  abed  for  some 
days  with  fever  and  headache. 

A  subcutanous  abscess — attributed  to  the  strain  of 
dancing  and  the  subsequent  exposure — formed  on  the 
inner  side  of  the  right  knee,  was  evacuated,  and  dis- 
charged for  some  time,  but  finally  healed,  leaving  a 
small  scar,  which  can  still  be  seen.  For  six  months 
after  this  she  was  as  well  as  ever;  then  there  was  no- 
ticed a  beginning  thickening  of  the  skin  of  the  right 
foot,  and  it  has  increased  slowly  but  steadily  up  to  the 
present  time,  involving  progressively  the  foot,  leg,  and 
thigh.  The  enormous  mass  on  the  upper  right  thigh 
she  thinks  has  developed  within  the  past  year.  Local 
physicians  treated  her  with  medicines  and  bandaging, 
in  hopes  of  checking  the  process,  but  without  success. 
Specialists  in  Kiefl:  were  consulted.  One  advised  a 
"  let-alone  "  policy,  saying  nothing  could  be  done,  and 
that  she  could  live  to  old  age  with  the  disease  ;  another 
advised  a  course  of  hospital  treatment;  while  a  third 
wanted  to  amputate — the  process  having  at  that  time 
not  gone  above  the  knee.  As  the  family  wealth  was  at 
low  ebb  the  let-alone  plan  was  adopted.  Three  years 
ago  the  girl  was  married  I — she  explained  to  me  in  bad 
German  that  "  Er  hat  gewusst,  dass  das  rechte  Bein 
ein  bischen  dick  war,"  and  eight  days  later  she  noticed 
thickening  of  the  left  foot  and  leg.  Her  husband 
packed  his  bundle  and  stole  away  to  America  soon 
afterward.  The  process  must  have  been  much  more 
rapid  in  the  left  than  in  the  right  leg,  as  it  has  already 
overtaken  and  even  a  trifle  outstripped  it  in  measure- 
ments. 

Sixteen  months  ago  the  patient  emigrated  with  her 
family,  coming  directly  to  Milwaukee,  and  by  some 
hook  or  crook — her  jargon  gets  too  deep  for  me  at 
times — managed  to  recapture  her  recreant  husband, 
and  he  now  lives  with  her,  and  follows  the  profession 
of  rag-picker. 

Her  present  status,  aside  from  the  elephantine  con- 
dition of  her  legs,  is  one  of  good  health.  Lungs, 
heart,  digestion,  and  sexual  functions  are  normal ;  she 
suffers  no  pain,  and  although  greatly  inconvenienced 
by  her  deformity  and  easily  fatigued  upon  e.xertion, 
she  does  not  seem  to  realize  her  misfortune  so  keenly 
as  would  one  of  a  higher  order  of  intelligence;  she 
even  laughs  and  jokes  about  herself. 


She  performs  the  duties  of  her  cellar  home,  and  ekes 
out  a  pittance  by  running  a  sewing-machine,  doing 
piece-work  for  some  sweat-shop.  Her  gait  is  waddling 
and  slow,  but  she  mounts  street-cars  and  climbs  stairs 
with  tolerable  ease.  On  the  street,  one's  attention 
would  be  attracted  to  her  first  by  her  gait,  and  then  by 
her  great  breadth  across  the  thighs.  Her  figure  re- 
minds one  of  the  old  days  when  hoop-skirts  were  in 
fashion. 

As  to  the  clinical  appearance  of  the  disease,  a  de- 
tailed description  is  unnecessary,  as  the  illustrations 
speak  for  themselves.  I  had  hung  up  a  white  sheet 
for  a  background,  but  finding  it  a  poor  contrast  to  the 
figure  in  the  prints,  it  occurred  to  me  to  soak  the  films 
again,  outline  the  figure  with  a  sharp  knife,  and  scrape 
the  rest  of  the  emulsion  off.  This  left  the  negative 
outside  the  figure  very  thin  and  transparent,  giving  a 
perfectly  dark  background  so  that  the  body  stands  out 
like  a  statue.     One  of  the  side  views  is  unfortunately 


/' 


somewhat  blurred,  owing  lu  a  slight  movement  during 
exposure. 

Her  measurements  are  as  follows:  Height,  5  feet; 
weight,  248  pounds;  chest  girth,  32  inches;  waist 
girth,  28" J  inches;  right  thigh.  38  inches;  left  thigh, 
39  inches;  right  calf,  31  inches;  left  calf,  29  inches; 
ankles,  29  inches. 

The  color  of  the  masses  low  down  is  dark  red, 
gradually  shading  off  above  to  normal  flesh  tints.  The 
consistency  is  of  board-like  hardness  below,  but  above 
the  knees  the  skin  is  doughy  and  cedematous.  Some 
of  the  fissures  are  deep  enough  to  conceal  the  better 
part  of  one's  hand,  and  as  might  be  expected  the 
moisture  and  attrition  tend  to  the  production  of  eczema, 
although  the  really  excellent  care  and  cleanliness  ex- 
ercised by  the  patient  keep  it  at  a  minimum.  Tactile, 
pain,  and  heat  sense  are  everywhere  perfect. 

The  toes  and  borders  of  the  feet  are  normal,  and 
there  is  quite  free  ankle  motion.  She  wears  low-cut, 
soft  leather  shoes,  and  the  stockings  might  be  mistaken 
for  coffee-sacks.      No  nether  undergarments  are  worn. 

Knee  action  allows  flexure  at  a  right  angle,  and  the 
skin  over  the  patellae  is  not  very  much  thickened. 


154 


MEDICAL    RECORD. 


[July  28,  1900 


Hip  action  is  perfect.  She  can  stoop  and  touch  her 
toes  with  ease — in  fact,  always  stands  while  pulling 
on  her  stockings.  The  genitalia  are  only  slightly  in- 
volved. The  labia  majora  are  somewhat  larger  than 
normal,  and  their  posterior  juncture  and  the  perineum 
are  warty.  Urination  and  defecation  are  easily  ac- 
complished. Coitus,  she  says  involves  '' viel  trouble! 
viel  trouble!  "  The  buttocks  are  perfectly  normal,  the 
growth  stopping  short  at  the  subgluteal  fold,  but  the 
lower  abdominal  wall  is  quite  cedematous,  and  on  the 
right  side  over  Poupart's  ligament  several  tortuous 
dilated  lymph-vessels  appear  like  welts  on  the  skin. 
Repeated  blood  examinations  have  shown  no  filarijE 
and  no  noticeable  blood  changes. 

1130  State  Street. 


COMPLETE  RECOVERY  FOLLOWING  A  SE- 
VERE COMPOUND  FRACTURE  OF  THE 
SKULL. 


By   G.  REESE   SATTERLEE, 

NEW    VUKK. 


A.M.,   M.D. 


This  case  is  reported  by  the  permission  of  Dr.  C.  T. 
Parker,  the  attending  surgeon  of  the  J.  Hood  Wright 
Memorial  Hospital,  who  was  absent  at  the  time  and 
asked  me  as  house  surgeon  to  treat  it. 

The  patient  was  brought  into  the  hospital  by  ambu- 
lance about  8  P.M.,  November  4,  1899,  having  been 
struck  on  the  head  by  a  stone  from  a  blast.  He  was 
a  driver,  and  was  found  some  distance  from  his  wagon. 
When  I  saw  him,  he  was  conscious,  but  slightly  irra- 
tional. Examination  showed  a  large  lacerated  scalp 
wound  over  the  right  parietal  region.  Underneath 
this,  close  to  the  interparietal  and  about  two  inches 
back  from  the  coronal  suture,  was  a  depressed  fracture 
the  size  of  a  fifty-cent  piece.  A  number  of  small  frag- 
ments of  bone  were  seen  at  the  bottom  of  this  em- 
bedded in  the  brain  tissue  in  places  where  tlie  dura 
had  been  torn.  A  large  amount  of  hair  and  dirt  was 
ground  into  the  cortex  with  the  bone  fragments.  This 
corresponded  to  about  the  upper  part  of  the  motor  area 
of  the  brain.  There  was  free  arterial  hemorrhage  from 
the  left  ear.  There  were  no  paralyses  nor  any  symp- 
toms of  cerebral  compression. 

As  the  patient  suffered  from  considerable  shock,  he 
was  treated  for  that,  and  his  wound  was  cleansed  and 
dressed  temporarily.  Three  hours  after  entrance,  hav- 
ing recovered  from  shock,  he  was  taken  to  the  operat- 
ing-room, and  under  ether  the  wound  was  thoroughly 
cleansed,  and  the  depressed  bone  was  elevated  and  re- 
moved. The  hair  and  dirt  were  carefully  picked  out 
under  a  continuous  stream  of  decinormal  salt  solution. 
On  removing  the  fragments  of  bone  and  dirt,  the  dura 
was  found  to  be  torn  badly,  and  one  fragment  when 
dislodged  opened  up  a  large  ragged  tear  in  the  supe- 
rior longitudinal  sinus.  This  lodgment  of  bone  ex- 
plained why  there  had  not  been  a  severe  hemorrhage 
previously,  and  it  undoubtedly  saved  the  man's  life. 

On  removing  the  piece  of  bone,  there  was  a  profuse 
venous  hemorriiage,  which  amounted  to  over  a  quart 
before  it  could  be  controlled.  About  one  inch  of  the 
sinus  had  been  torn  away  and  macerated  so  that  it  was 
at  first  impossible  to  find  the  ends.  Finally,  however, 
the  proximal  end  of  the  sinus  was  packed  and  the 
hemorrhage  checked.  No  more  fragments  of  bone 
being  found,  a  dry  gauze  dressing  was  applied.  The 
patient  was  put  to  bed,  stimulated  freely,  and  given 
morphine. 

The  next  day  at  9  a.m.  the  left  arm  and  leg  became 
paralyzed.  The  dressings,  being  saturated  with  a 
bloody  discharge,  were  changed.  Retention  of  urine 
occurred  at  7  p.m.  Thinking  that  the  paralysis  might 
be  caused  by  a  blood  clot  on  the  cortex,  I  removed 
the  packing  and  about  a  pint  of  very  dark  blood  flowed 


out,  necessitating  repacking;  no  blood  clot  over  the 
cortex  could  be  found. 

On  November  6th  the  left  leg  was  stiff  and  the  re- 
flexes on  that  side  were  exaggerated;  urination  became 
voluntary.  The  dressings  were  soaked  with  .serous 
fluid. 

On  November  8th  there  was  a  free  serous  discharge 
from  the  wound  and  from  the  left  ear,  accompanied 
with  much  thirst  and  epistaxis.  The  patient  was  then 
placed  in  a  sitting  posture  to  prevent  the  loss  of  cere- 
bro-spinal  fluid. 

On  November  12th  the  packing  in  the  longitudinal 
sinus  was  slightly  loosened  and  a  wet  aluminum  ace- 
tate dressing  was  applied  to  soften  the  adhesion.  On 
the  next  day  the  gauze  packing  was  removed,  leaving 
a  sinus  about  an  inch  and  a  half  long,  at  the  bottom 
of  which  arterial  pulsation  was  very  distinct  A  small 
strip  of  gauze  was  inserted.  There  had  been  abso- 
lutely no  signs  of  infection  or  of  suppuration.  There 
had  been  but  slight  elevation  of  temperature,  and  no 
delirium  since  the  first  night. 

On  November  19th  there  was  a  slight  protrusion  of 
the  brain  substance  above  the  outer  table  of  the  skull. 
The  top  of  the  head  was  shaved  and  a  skin  flap  was 
drawn  over  the  protrusion  and  strapped  down  by  ad- 
hesive plaster.  On  the  25th  the  sinus  was  nearly 
healed,  the  protrusion  was  reduced  by  means  of  the 
shaving  and  strapping  every  day,  and  the  wound  was 
granulating  nicely. 

On  the  28th  the  paralysis  in  the  extremities  was 
unimproved. 

On  December  5th  the  patient  was  sitting  up  in  bed 
and  had  a  slight  amount  of  motion  in  the  left  lower 
extremity. 

On  the  gth  he  had  a  limited  amount  of  motion  in 
the  left  upper  extremity. 

On  the  19th  he  walked  around  the  bed  with  assist- 
ance. From  then  on  he  improved  rapidly,  and  on 
January  6,  1900,  about  two  months  after  the  injury,  he 
walked  without  difficulty  and  was  discharged  from  the 
hospital  cured. 

Since  that  time  I  have  seen  him  frequently,  and  he 
is  perfectly  well  in  every  respect.  He  is  working 
hard  as  a  driver,  has  no  weakness  in  any  of  the  ex- 
tremities, but  has  a  slight  tingling  sensation  in  the 
tips  of  the  fingers  of  the  left  hand.  The  wound  is 
healed  and  there  is  a  good  firm  cicatrix.  He  has 
neither  headache  nor  vertigo.  His  eyesight  is  excel- 
lent.    There  is  some  deafness  in  the  left  ear. 

136  Madison  .-Vn'enue. 


A    PECULIAR    DELUSION. 
By   \V.    MOSER,    M.D.. 

nROOKLVN,    N.    Y.. 

PATHOLOGIST  TO    ST.    CATHERINE'S   AND    ST.    MARV'S   HOSPITALS,    AND   ASSIST- 
ANT ATTENDING   PHYSICIAN  TO  THE   GERMAN    HOSPITALS. 

Many  of  us  have  delusions,  but  we  do  net  necessarily 
require  the  services  of  the  neurologist.  Medico- 
legally,  neurologists  themselves  sometimes  differ  as  to 
the  significance  of  a  given  delusion.  Certain  delu- 
sions or  false  beliefs  are  characteristic  of  a  certain 
disease  or  form  of  insanity;  as,  for  instance,  the  "de- 
lusions of  grandeur"  in  general  paresis.  Here  the 
unfortunate  is  laboring  under  the  false  belief  or  delu- 
sion that  he  owns  the  earth,  or,  as  I  recall  a  case  seen 
more  than  ten  years  ago,  the  individual  had  the  delu- 
sion that  he  was  the  "  king  of  Ireland."  In  the 
same  way  the  '"delusions  of  persecution"  suggest 
paranoia. 

Certain  delusions  pertaining  to  the  individual's 
health  are  sometimes  called  "hypochondriacal  delu- 
sions "  and  sometimes  classed  as  "  neurasthenic,"  or  the 
delusion  may  be  more  pronounced  and  suggest  melan- 


July  28,  1900] 


MEDICAL 


cholia.  The  form  of  delusion  to  which  I  visii  to  call 
attention  is  one  in  which  the  patient  does  not  believe 
himself  to  be  afflicted  with  some  particular  malady, 
but  labors  under  the  peculiar  delusion  that  there  are 
reptiles  in  the  abdomen.  This  patient  has  been  under 
observation  for  more  than  two  years,  and  comes  regu- 
larly to  St.  Catherine's  Dispensary  to  have  me  either 
destroy  or  e.xpel  the  snakes,  lizards,  and  blindworms 
which  inhabit  her  abdomen.  The  peculiarity  of  this 
delusion  is  that  her  menagerie  is  made  up  of  reptiles 
and  excludes  all  other  animals.  There  is  not  merely 
a  delusion  or  false  belief  of  the  presence  of  reptiles 
in  her  abdomen,  but  the  patient  distinctly  feels  their 
heads  and  insists  that  they  are  alive.  Whether  this  is 
a  case  of  melancholia  or  a  distinct  psychological 
phenomenon,  I  am  unable  to  say.  I  fear  she  will  re- 
tain this  menagerie  in  her  abdomen  until  her  mind  is 
forever  set  at  rest. 

These  psychological  phenomena  or  delusions  are 
not  infallible  signs  in  diagnosis,  but  sometimes  are  a 
great  aid  in  prognosis. 


Tuberculosis. — Drugs  containing  iodine  are  the  best 
aids  to  immunity.  They  are  best  given  by  inunc- 
tion. The  essential  oils,  and  especially  peppermint 
.and  thyme,  unfit  the  tissues  as  soil  for  the  propagation 
of  bacilli. — F.  L.  Flich. 

^  Oil  of  thyme. 

Oil  of  eucalyptus. 

Oil  of  cinnamon aa   I'l  Ix.xx. 

Oil  of  olives  (steril.) 3  iiiss. 

Iodoform 5  i-  gr-  vv. 

Bromoform Til  xxx. 

IM.     S.   P2mpty  45  minims  by  means  of  a  long  curved  syringe 
into  the  trachea. 

— Mendel. 
Pernicious  Anaemia 

I{  Fowler's  solution I  iiss. 

Acid  phosphate 3  iij. 

Bone-marrow  extract ad   3  viij. 

M.     S.  Dessertspoonful  after  each  meal 

J.  X.  Danforth. 

Laxative  Electuary  for  Children.^ 

^  Tears  of  manna 25  gm. 

Calcined  magnesia. 

Washed  flowers  of  sulphur aa  50    " 

White  honey 20    " 

In  iiabitual  constipation  one  or  two  soupspoonfuls 
in  a  cup  of  hot  milk.  For  a  purgative  effect  three  or 
four  spoonfuls. — Ferraxd. 

Enterocolitis  (Muco-Membranous )  in  the  Adult — 
Castor  oil  is  the  best  la.xative.     As  a  succedaneum : 

^  Magnes.  calcin.. 

Sulphur.  loti. 

Potass,  bitart aa  20 

S.   A  teaspoonful  before  each  meal. 

— G.  See. 

^  Podophyllin. 

Euonymin aa  0.40 

Ex.  bellad 0.20 

Ext.  hydrastis  canad I. 

M.  ft.  pil.  No.  XX.     S.  One  or  two  at  dinner. 

— G.  Lvox. 

Picric-acid  enemata,  i  in  120. — Cheron. 

Large  enemata  of  oil. — Fleiner. 

In  the  attacks  of  paro.xysmal  pain  repose  in  bed, 
hot  compresses,  belladonna  by  the  mouth,  or  morphine 
under  the  skin. 

Nervous  Insomnia.— Render  a  tumblerful  of  sour 
curds  and  whey  alkaline  with  bicarbonate  of  sodium; 
sweeten  and  grate  nutmeg  on  the  top.     Give  hot. 


RECORD.  155 

Stomach  Lavage. — 

^  Sodii  biborat   3  ij. 

Creolini gr.  iv. 

Acidi  salicylici gr.  .xviij. 

Thymolis gr.  iv. 

Use  in  washing  once  a  day  after  a  clear-water  lavage  by 
means  of  a  siphon  tube. 

— Rosenheim. 
Otalgia. — 

R  Ouin.  sulph gr.  xviij. 

Potass,  iodid gr.  xxxvi. 

Sacch.  alb gr.  xlv. 

M.  ft.  chart  No.  vi.     S.  One  twice  a  day. 

When  acute  give  antypyrin  in  initial  dose  of  gr. 
xvi.  with  half  this  quantity  every  hour  subsequently. 
In  chronic  forms: 

I{  Zinci  oxidi. 
Kad.  valerian.. 

Ext.  hyoscyami.  ale aa  3  ss. 

Pulv.  et  ext.  glycyrrhiz q.s. 

M.  ft.  pil.   No.  c.     S.  One  a  day,  and  increase  from  one 
a  day  up  to  thirty,  then  decrease. 

— Politzer. 

Whooping-Cough. — Pure  turpentine  and  sweet  oil 
should  be  applied  to  the  chest  night  and-  morning 
until  distinct  redness  is  produced. — Journal  ties  Fra- 
iii'ieris. 

Rachitis. — 

1}  Phosphorus o.oi  cgm. 

01.  morrhua; 1,000.  gm 

Saccharin o.  10  cgm. 

—  Kassowitch. 

Painful  Periods. — Menstrual  pains  are  said  to  be 

relieved  b}' 

'St  Codein gr.  ss. 

Chloral., 

Amnion,  brom aa  gr.  viij. 

Aqune  camph 3  i. 

For  one  dose.      Repeat. 

Foul  Breath. — Retained  secretion  behind  the  plica 
tonsillaris  is  a  frequent  cause.  Exclude  a  dental, 
nasal,  oesophageal,  or  respirator)' -  passage  origin. 
Give  antiseptic  gargles. — Fraenkel. 

Repair  of  Old  Lacerations The  Emmet  operation 

and  all  denudation  methods  of  the  vaginal  orifice, 
which  are  the  operations  in  almost  universal  use  to- 
day, fail  to  restore  in  any  degree  the  real  pelvic  floor. 
They  are  suitable  in  lacerations  of  the  so-called  peri- 
neal body,  but  not  when  the  muscles  are  torn.  The 
method  which  I  wish  to  present  involves  a  resection 
of  a  portion  of  the  pubo-rectalis  muscle  so  as  to  shorten 
up  the  pelvic  floor.  It  is  performed  as  follows :  When 
laceration  of  the  perineum  is  present,  the  denudation 
of  this  part  is  made  in  the  usual  manner.  If  this  body 
be  intact  the  denudation  is  omitted.  An  incision  is 
then  carried  up  each  lateral  wall  of  the  vagina  from  3 
to  5  cm.,  a  little  posterior-to  the  centre.  The  vaginal 
wall  is  raised  in  a  flap  each  way  from  the  incision. 
The  edge  of  the  muscle  can  now  usually  be  felt,  and 
an  incision  parallel  therewith  is  made  through  the 
perivaginal  connective  tissue,  exposing  the  muscle, 
which  may  easily  be  dissected  out  with  the  handle  of 
a  scalpel,  blunt  dissector,  or  the  finger,  ventrally  as 
far  as  the  symphysis  and  dorsally  until  it  curves  around 
posterior  to  the  rectum. — M.  L.  Harris,  in  The  Cana- 
dian Practitioner  anif  Reziew,  April. 

Appendicitis. — There  is  a  general  agreement  as  to 
high  mortality  in  severe  acute  cases  under  any  treat- 
ment, the  successful  issue  of  mild  cases  regardless  of 
treatment,  the  freedom  from  danger  of  the  interval 
operation  in  chronic  cases,  and  the  large  percentage 
of  relapses  after  one  attack.  While  purgatives  may  cut 
short  a  mild  attack  they  may  cause  perforation  in  crit- 


156 


MEDICAL    RECORD, 


[July  28,  1900 


ical  stages.  Opium  is  safe  but  not  curative.  Litera- 
ture abounds  with  ridiculously  contradictory  asser- 
tions which  a  statistical  study  should  obviate. — H. 
H.  YouxG,  Maryland  JMt-dical Journal,  April. 

Dysmenorrhcea. — The  spasmodic  element  can  be 
eliminated  by  belladonna.  If  pain  continues  after  a 
few  doses  it  is  because  mechanical  or  congestive  ele- 
ments are  present,  since  the  neuralgic  element  is  to  a 
great  extent  eliminated  by  the  drug.  A  suppository 
containing  one  or  two  grains  of  the  extract  is  the  best 
way  to  administer,  repeated  every  two  to  four  hours. — 
WiLLiA.M  Murray. 


^eu)  instruments. 

A   POCKET    AND  CANTEEN    FILTER. 
By    ROSWELL   O.    STEBBINS,    D.D.S., 

NEW    YORK. 

This  filter  is  constructed  of  aluminum.  First,  a  very 
finely  perforated  metal  disk  acts  as  a  strainer;  sec- 
ond, a  disk  of  specially  prepared  filtering-paper  will 
eliminate  all  decayed  vegetation  and  other  solids  held 
in  suspension  or  solution  in  the  water.  To  the  pocket 
filter  is  attached  a  tube  of  pure  rubber,  through  which 
water  may  be  sucked  slowly,  yet  freely  enough  to 
quench  thirst  readily. 

The  canteen  filter    is  attached    to    the    end  of    an 
aluminum  tube,   which   is  passed  through  a  cork  as 


Fig.  I 


Fig.  2. 


shown  in  Fig.  2.  A  disk  with  holes  of  moderate  size 
is  placed  above  the  filter  to  prevent  any  large  sub- 
stance from  passing  into  the  canteen  while  it  is  being 
filled  with  water. 


AN    IN.STRLIMENT   FOR"  DETERMINING  THE 
OBSTETRIC    CONJUGATE. 

By    ROBERT    R.    ROME,    M.D., 

MINNEAI'OLIS,    MINN., 

PROFESSOR    OF    OrERATlVH     OHSTETRICS,    MEDICAL     DEPARTMENT,    I'NITERSITV 
UF  MINNESOTA. 

The  subject  of  pelvimetry  is  of  importance  to  every 
physician  who  may  be  called  upon  to  officiate  at  the 
birth  of  a  human  being.  We  may  perhaps  truthfully 
say  that  abnormal  conditions  are  on  the  increase,  but 
we  are  being  provided  with  artificial  aids  to  overcome 
these  abnormal  conditions.  There  was  a  time  wiien 
the  finger  and  its  nail  was  the  sharpest  and  only  cu- 
rette at  our  disposal.  But  the  ingenuity  of  man  has 
made  a  finger  of  steel  mounted  with  a- nail  of  metal 
which  can  be  introduced  and  manipulated  where  the 


finger  of  man  is  forbidden  to  enter.  There  was  a 
time  when  the  hand  of  the  obstetrician  was  the  only 
aid  at  his  command  with  which  to  efTect  a  delivery. 
Now  we  have  forceps  of  all  forms  made  to  fit  the  pre- 
senting part  of  the  child,  making  artificial  delivery 
safer  and  easier  to  all  concerned. 

Baudelocque  made  use  of  his  fingers  to  estimate  the 
obstetric  conjugate;  he  gave  us  an  instrument  with 
which  to  estimate  the  diameters  of  the  pelvis  exter- 
nally; much  suffering  and  many  lives  have  been 
saved  by  the  faithful  use  of  that  instrument.  We  can 
determine  by  external  pelvimetry  whether  we  are  deal- 
ing with  a  justo-major,  a  justo-minor,  a  simple  fiat,  a 
rachitic  flat,  a  Roberts,  a  Naegele,  or  a  normal  pelvis. 
But  Baudelocque's  fingers,  employed  to  measure  the 
distance  from  the  promontory  to  the  subpubic  liga- 
ment or  the  diagonal  conjugate,  from  that  measure- 
ment a  guess  being  made  of  the  true  or  obstetric 
conjugate,  must  be  replaced  by  an  instrument  of  pre- 
cision. 

The  instrument  about  to  be  described  I  believe  will 
fill  a  long-felt  want.  It  has  the  three  elements  com- 
bined which  will  recommend  it  to  every  practising 
physicians,  namely,  simplicity,  accuracy,  and  prac- 
ticability. 

External  pelvimetry  leaves  us  to  guess  at  the  thick- 
ness of  the  bony  structures,  i.e.,  the  last  lumbar  verte- 
bra and  the  symphysis  pubis.  When  the  fingers  are 
employed  as  taught  by  Baudelocque  all  that  can  be 
determined  with  any  degree  of  accuracy  is  the  diagonal 
conjugate,  and  from  this  we  are  to  subtract  two-thirds 
of  an  inch,  providing  the  following  "ifs"  are  pres- 
ent: if  the  diameter  is  the  longest  side  of  the  scalene 
triangle,  if  the  symphysis  is  of  normal  thickness, 
if  the  symphysis  is  of  normal  height,  if  the  sym- 
Dhysis  forms  the  normal  angle  with  the  pelvis, 
f  the  sacrovertebral  articulation  or  joint  is  of 
lormal  thickness.  Should  any  one  of  these 
'  ifs  "  deviate  from  the  normal  standard  we  have 
ntroduced  an  error  into  the  problem,  and  the 
inswer  will  be  incorrect. 

The  instrument  I  have  devised  is  twelve  inch- 
is  in  length,  and  the  semicircle  described  by 
the  hook  is  two  and  one-half  inches  in  diameter. 
The  shaft  is  hollow  and  oval,  while  the  hook  is 
round.  The  shaft  is  provided  with  an  inch 
scale  on  one  side  and  a  centimetre  scale  on  the 
other.  The  sliding  T-bar  is  provided  with  a  set- 
screw  with  which  it  can  be  made  firm  when  nec- 
essary. 

How  to  use  the  instrument:  First  find  the 
height  of  the  symphysis,  i.e.,  from  subpubic  to 
suprapubic  ligament  or  tissues;  at  about  the  upper 
third  of  tlie  total  height  make  a  mark ;  this  corresponds 
to  the  thickest  portion  of  the  pubic  bone.  Bring  the 
patient  well  over  the  edge  of  the  table,  flex  the  knees 
and  thighs,  and  support  them.  Lubricate  the  fingers  of 
one  hand,  introduce  them  into  the  vagina,  retract  the 
perineum  by  continuous  and  firm  pressure,  lower  the 
arm  and  elbow  so  as  to  give  an  upward  direction  to 
the  fingers  in  the  vagina.  Now  request  the  patient 
to  raise  the  hips,  and  follow  the  hollow  of  the  sacrum 
until  the  middle  finger  is  firmly  fixed  on  the  true  sacral 
promontory.     Slide  the  shaft  along  the  palmar  surface 


p?^7?W.'""^^*'*'>W"*' 


of  the  fingers  until  the  end  A  is  made  to  take  the  place 
of  the  end  of  the  middle  finger,  the  latter  being  moved 
a  little  to  one  side.  The  shaft  being  held  in  position 
by  the  index  and  middle  fingers,  slide  the  T-bar  toward 


July  28,  1900] 


MEDICAL    RECORD. 


157 


the  symphysis  until  the  end  B  is  made  to  press  firmly 
on  the  mark  previously  made.  Turn  the  set-screw 
and  remove  the  instrument.  Note  carefully  the  num- 
ber of  inches  or  centimetres  from  the  end  A  to  the 
end  collar  nearest  the  end  A. 

Reverse  the  instrument;  pass  the  hook  into  the  va- 
gina with  the  end  D  upward  and  back  of  the  pubic 
bone.  Steady  the  instrument  in  this  position  while 
the  T-bar  is  moved  toward  the  symphysis  until  the 
end  C  is  made  to  press  firmly  on  the  mark  as  before. 
Now  turn  the  set-screw.  Read  off  the  thickness  of 
the  symphysis  on  the  scale  provided  for  that  purpose. 
Loosen  the  screw;  slide  back  the  T-b.ir  before  remov- 
ing the  instrument  in  order  to  avoid  bruising  the  soft 
parts  about  the  pubic  bone.  Subtract  the  last  meas- 
urement or  thickness  of  the  symphysis  from  the  first 
measurement,  and  the  difference  will  be  the  true  or 
obstetric  conjugate. 


A  GL.\SS 
GATOR 
DER. 


HYDROSTATIC-PRESSURE 
FOR    THE    URETHRA    OR 


IRRI- 
BLAD- 


Bv    ROKHRT   COLKM.VN    KEMP.    M.D., 

NEW    VURK. 

In  the  injection  of  solutions  into  the  urethra  with 
the  hand  syringe  for  gonorrhoea,  etc.,  especially  if  the 
treatment  is  carried  out  by  the  patient,  there  is  always 
the  danger  that,  through  too  forcible  or  irregular  press- 
ure, the  fluid  may  pass  too  far  up  the  canal  and  carry 
infected  material  to  the  iiealthy  parts.  Unfortunately 
this  accident  is  by  no  means  e.xtremely  rare,  and  as  a 
result  we  may  have  posterior  urethritis,  and  with  it  as- 
sociated epididymitis,  seminal  vesiculitis,  etc.,  or  even 
a  gonorrhceal  cystitis.  The  question  of  the  proper  in- 
strument for  irrigation  is  always 
important,  and  theie  are  catheters 
with  a  back  flow  (tlie  current  di- 
rected toward  the  meatus),  double- 
current  instruments,  and  such 
devices.  Some  advocate  gentle 
irrigation  with  the  fountain  svr- 
inge  hung  very  low,  so  as  to  secure 
but  light  pressure.  There  is  al- 
ways a  tendency  to  elevate  such  a 
reservoir,  it  seems  to  me,  higher 
than  it  should  be,  and  the  force  seems  too  strong 
the  accompanying  illustration  I  present  a  cheap  and 
simple    glass    irrigator    for    the    urethra,   which   can 


annealed  to  secure  strength — the  capacity  ot  which  is 
3  iiss.-  3  iii.  The  bulb  is  drawn  out  into  a  curved 
outflow  tube  at  the  bottom,  to  which  a  small  soft- 
rubber  catheter  is  to  be  attached. 

An  opening  of  small  size  may  be  cut  in  the  catheter 
about  half  an  inch  from  the  eye  on  the  opposite  side, 
the  edges  of  this  heated  over  a  flame,  and  quickly  wiped 
with  the  wet  finger,  to  transform  it  into  a  velvet  eye. 
Thus  we  secure  an  outflow  on  both  sides  of  the  instru- 
ment. The  catheter  may  be  cut  by  the  physician  the 
length  he  desires  the  irrigation  to  pass  into  the  organ, 
allowing  sufficient  length  in  addition  for  proper  eleva- 
tion of  the  bulb.  There  seems  to  be  just  sufficient 
pressure  to  wash  around  the  tip  of  the  catheter  and  flow 
back  and  out  of  the  meatus.  The  position  employed 
is  well  shown  in  the  illustration.  If  it  is  desired  to 
wash  the  bladder,  the  return  flow  is  secured  by  lower- 
ing the  bulb  below  the  bladder  level,  and  if  necessary 
starting  the  flow  by  siphonage — with  a  little  water  re- 
maining in  the  bulb — just  as  in  lavage.  A  simple 
hydrostatic  irrigator  may  be  improvised  as  follows: 
Take  a  cheap  glass  syringe  (sharp  pointed)  and  un- 
screw the  end  cap,  removing  this  and  with  it  the  pis- 
ton and  plunger.  .Attach  the  cathetej  to  the  point  of 
the  syringe.  Fill  this  with  solution  and  control  the 
flow  with  the  thumb  as  before. 


A    NEW    NEEDLE    HOLDER    TH.\T    WILL 
NOT    BREAK    NEEDLES. 

By   W.    H.    LUCKETT,    M.D., 

NEW   YORK. 

The  accompanying  one-half-size  cut  is  an  excellent 
illustration  of  a  new  needle  holder  or  forceps,  the 
chief  claim  of  which  to  originality  lies  in  theconsuuc- 


In 


also  be  employed  to  wash  the  bladder  by  gentle  si- 
phonage.    It    consists   of    a   glass    bulb — preferably 


tion  of  the  jaw.  The  average  needle  holder  has,  when 
grasping  an  ordinary  surgical  curved  needle,  three 
points  of  contact  with  the  needle:  two  points  of  con- 
tact, the  power  and  the  resistance,  are  on  the 
concave,  and  the  third  point  of  contact,  the  ful- 
crum, is  on  the  convex  surface  between  the 
power  and  resistance,  thus  making  a  lever  of 
the  first  class,  so  that  the  needle  frequently 
breaks,  when  tightly  grasped,  or  else,  if  loosely 
held,  it  turns  in  the  holder. 

I  have  labored,  therefore,  to  construct  a  holder 
that  will  not  make  a  lever  of  the  needle,  and 
have  accomplished  this  by  raising  a  flange  of 
softer  metal  around  the  edges  of  the  surfaces 
of  the  jaw,  so  that  it  will  grasp  the  needle 
at  four  points  of  contact:  two  on  either  side 
of  the  needle  and  almost  directly  opposite  each 
other. 

The  direction  of  the  force  exerted  by  the  holder 
being  through  the  needle  from  opposing  points, 
renders  it  impossible  to  break  the  needle. 
Considerable  trouble  was  encountered  by  the 
makers,  G.  Tiemann  &  Co.,  in  finding  metal  of 
the  proper  malleability  for  the  flange.  The 
detachable  spring  catch  has  been  placed  suf- 
ficiently far  forward  that  it  can  be  manipulated  by 
the  thumb. 


158 


MEDICAL    RECORD. 


[July  28,  19CX) 


l^ciUcaX  Jtcms. 

Enteric  Fever  among  Soldiers.  —  A  writer  in  the 
London  Lancet,  commenting  on  the  British  Army  Re- 
port for  1898,  and  speaking  of  enteric  fever  among 
soldiers,  says:  "A  glance  at  the  daily  journals  is  un- 
fortunately sufficient  to  show  the  important  role  which 
disease  and  notably  enteric  fever  occupies  in  the  his- 
tory of  the  South  African  war.  This  fever  is  a  veri- 
table scourge  of  armies  in  the  field,  and  this  has  been 
even  more  the  case  with  the  expeditionary  armies  of 
other  military  powers  than  ourselves.  U'e  find  abun- 
dant evidence  of  the  prevalence  of  enteric  fever  in  the 
report  under  review — at  Ladysiiiith,  Pietermaritzburg, 
Wynberg,  King  William's  Town,  and  Simonstown,  for 
example,  long  before  the  arrival  of  the  British  expe- 
ditionary force  had  taken  place  in  that  country,  and 
we  are  therefore  not  required  to  have  recourse  to  the 
theory  of  any  fresh  introduction  of  the  disease  there 
by  the  newly  arrived  troops.  As  the  subject  is  one  of 
vast  importance  in  relation  to  the  diseases  incidental 
to  war  service  and  camps,  we  need  make  no  apologies 
for  dealing  with  it,  more  especially,  as  we  said  on 
previous  occasions,  it  is  a  generally  recognized  fact,  be 
the  explanation  what  it  may,  that  there  is  an  increased 
liability  to  contract  typhoid  fever  at  certain  periods 
of  life;  in  other  words,  that  there  exists  an  enteric- 
fever  age  period  which  includes  the  time  during  which 
soldiers  are  serving  with  the  colors  in  all  short-service 
armies.  But  a  still  more  powerful  predisposing  cause 
is  recent  arrival  in  a  tropical  or  subtropical  climate, 
especially  during  the  hot  season.  As  far  as  India  is 
concerned  this  susceptibility  or  vulnerability  of  the 
European  constitution  to  enteric  fever  in  fresh  arrivals 
is  at  its  maximum  during  the  first  year,  markedly  de- 
clines the  second  and  third  year,  and  is,  practically 
speaking,  nearly  exhausted  between  the  third  and 
fourth  year  of  Indian  service.  It  is  not,  of  course, 
pretended  that  these  are  the  only  disease  factors,  for  if 
the  real  cause  of  enteric  fever  be  the  bacillus  of  Eberth 
and  Gaffky,  then  it  follows  that  the  presence  of  the 
specific  germ  or  micro-organism  is  indispensably 
necessary  to  its  production,  but  this  bacillus  must  in 
that  case  be  much  more  widely  distributed  in  nature 
than  our  present  knowledge  would  lead  us  to  suppose, 
in  order  to  account  for  all  the  enteric  fever  that  occurs; 
or,  to  put  it  in  another  way,  the  number  and  extent  of 
the  infected  areas  on  the  surface  of  the  globe  must  be 
greater  than  has  hitherto  been  thought  to  be  the  case." 

Railway  Hygiene  in  the  United  States. — An  in- 
vestigation made  in  Massachusetts  with  reference  to 
certain  infectious  diseases  in  1891  showed  that  small- 
pox, diphtheria,  scarlet  fever,  and  measles  were  rela- 
tively more  prevalent  in  the  towns  situated  on  railway 
lines  than  they  were  in  those  towns  not  so  connected. 
Out  of  2,298  deaths  from  smallpox  which  occurred  in 
twenty  years  in  that  State,  only  thirteen  occurred  in 
towns  not  directly  on  some  line  of  railway  communi- 
cation. The  same  fact  was  noted,  though  in  a  less 
marked  degree,  in  regard  to  diphtheria,  scarlet  fever, 
and  measles.  Undoubtedly  there  are  many  cases  of 
persons  having  unrecognized  infectious  disease  travel- 
ling on  railways;  hence,  measures  are  necessary  to 
provide,  first,  for  the  thorough  cleansing  and  disinfec- 
tion of  cars  and  their  furnishings,  especially  of  sleep- 
ing-cars, at  the  ends  of  their  respective  routes  or  lines 
of  travel;  second,  for  a  careful  supervision  of  the  wa- 
ter-closets on  the  trains,  and  that  they  are  not  allowed 
to  bs  used  at  or  near  the  stations  in  cities  and  towns. 
It  is  quite  practicable  also,  and  desirable,  to  require 
that  some  disinfectant  of  recognized  potency  be  added 
to  the  water  used  for  flushing  purposes  when  such  is 
provided;  third,  the  water  supply,  the  food  supply,  and 


the  ice-supply  used  on  long  lines  for  dining-cars  and 
lunch  rooms  at  stations  should  receive  careful  supervi- 
sion. It  is  also  desirable  that  the  milk  used  on  dining- 
cars  and  at  stations  should  be  procured  of  stated  par- 
ties, and  that  they  should  be  held  responsible  for  its 
quality  and  for  the  cleanliness  of  the  dairies  from 
which  it  is  obtained;  fourth,  measures  are  necessary 
for  the  exclusion  of  persons  sick  with  infectious  dis- 
eases, from  public  conveyances  (cars  and  steamers), 
and  if  this  is  impracticable  to  provide  for  their  isola- 
tion in  separate  cars  or  compartments. — "Public  and 
State  Hygiene  in  the  United  States,"  by  Samuel  \V. 
Abbott. 

Marriage  of  First  Cousins. — Mr.  Jonathan  Hutch- 
inson says  :  "  There  is  nothing  likely  to  be  prejudicial 
to  offspring  in  a  consanguineous  marriage  per  se,  but 
if  there  be  in  the  family  any  definite  tendency  to  such 
diseases  as  tuberculosis,  cancer,  or  insanity,  there  is  a 
risk  that  it  may  be  intensified.  On  the  other  hand, 
if  the  family  has  a  good  life  history,  then  there  may 
be  greater  security  in  such  a  marriage  than  in  one 
with  a  stranger  whose  antecedents  may  probably  be 
less  well  known. 

Deaths  from  Sunstroke  at  Aldershot,  says  the 
British  Medieal  Journal,  aroused  a  great  deal  of  in- 
terest among  members  on  both  sides  of  the  House  of 
Commons.  It  would  seem  that  some  18,000  men 
were  paraded  for  the  field  day  on  June  nth,  and  that 
in  consequence  of  the  excessive  heat  no  fewer  than  28 
men  were  received  into  the  hospital,  of  whom  4  died 
while  29  others  were  injuriously  affected.  The  troops 
covered  in  their  march  some  fourteen  miles,  and  wore 
the  ordinary  field  cap.  This  afforded  insufficient 
protection,  and  the  commander-in-chief  has  ordered 
that  helmets  should  be  worn  in  hot  weather  and  that 
troops  unprovided  with  helmets  are  not  to  take  part 
in  exhausting  operations.  There  were  also  regrettable 
defects  in  the  provision  of  food  and  water  for  the  men. 
The  whole  incident  exhibits,  members  think,  a  lapse 
from  common  sense  and  ordinary  prevision,  which 
strong  measures  should  be  taken  to  prevent  in  the 
future. 

Malaria  in  Canada. — Professor  Adami,  of  McGill 
University,  Montreal,  supplies  an  interesting  report  to 
X\\^  British  Medical  Journal  Qi  the  tropical  and  sub- 
tropical diseases  of  Canada.  Referring  to  malaria 
he  says:  "With  regard  to  malaria,  just  as  in  Great 
Britain,  even  to  the  middle  of  this  century,  cases  oc- 
curred with  considerable  frequency,  more  especially 
in  the  Fen  districts  and  in  Lincolnshire,  so  here  in 
Canada  during  times  within  the  memory  of  old  in- 
habitants I  am  informed  that  malaria  was  not  infre- 
quent along  the  St.  Lawrence,  even  in  the  neighbor- 
hood of  Montreal.  Now,  however,  it  is  only  in  the 
most  southerly  portion  of  Canada,  namely,  in  the 
peninsula  of  Ontario  between  the  great  lakes,  that 
malaria  is  met  with,  and  there  not  to  any  great  extent. 
So  far  as  I  can  learn,  members  of  the  genus  Anopheles 
are  still  present.  Some  other  conditions,  however, 
than  the  presence  of  the  hosts  of  the  malarial  micro- 
organism would  seem  necessary  for  the  persistence  and 
propagation  of  the  malarial  germ ;  and  when  the  ex- 
traordinary abundance  of  lakes  and  large  bodies  of 
water  throughout  Canada  is  called  to  mind  and  the 
relatively  small  proportion  of  the  country  that  has 
undergone  full  drainage  and  full  cultivation,  the 
gradual  disappearance  of  the  disease  becomes  a 
problem  difficult  to  solve.  For  myself,  during  the 
seven  years  I  have  been  pathologist  to  the  two  largest 
hospitals  in  Montreal  in  succession,  I  have  come  across 
but  one  case  of  malaria  in  one  who  had  not  been  out 
of  the  country;  this  was  in  an  old  Red  Indian  who 
came  from  Ontario.     Taking  into  account  the  enormous 


July  28,  1900] 


MEDICAL   RECORD. 


159 


numbers  of  mosquitos  present  throughout  Canada 
during  the  early  summer  months,  and  the  fact  that  the 
further  north  one  goes  into  Labrador  or  into  Alasica 
the  greater  becomes  their  number,  until  in  some 
regions  during  the  months  of  June  and  July  it  is  al- 
most impossible  to  live  on  account  of  them,  Canada 
should  supply  a  very  good  ground  for  the  study  of  the 
relationship  of  mosquitos  to  the  conveyance  of  more 
than  one  form  of  disease." 

An  Old  Argument  for  Alcohol.— The  London  Sfcc- 
tator,  referring  to  the  recent  temperance  congress,  says: 
"  Humanity  owes  everything  worth  having  to  the  races 
which  use  alcohol.  The  drinkipg  races  have  not  only 
conquered  but  moralized  the  world.  The  Jew  drank 
and  gave  us  monotheism  and  Christianity,  the  Greek 
drank  and  gave  us  literature  and  art.  The  Roman 
drank  and  gave  us  law,  the  Teuton  drank  (hard)  and 
gave  us  the  passion  of  freedom.  What  have  the  two 
great  races  which  rejected  alcohol — the  Hindoo  and 
the  Arab — done  to  counterweigh  the  benefits  conferred 
by  their  drinking  rivals?" 

The    Hospital     Scandal    in    South    Africa The 

Hospital  says:  "It  is  impossible  to  read  without 
distress,  and  indeed  without  the  strongest  sense  of 
indignation,  the  revelations  made  in  The  Times  of  the 
27th  inst.  by  Mr.  Burdett-Coutts  in  regard  to  the 
hardships  to  which  our  sick  soldiers  in  South  Africa 
have  been  exposed — exposed,  we  fear,  recklessly  and 
almost  wilfully  in  consequence  of  the  want  of  fore- 
sight displayed  by  the  central  administrative  authori- 
ties, who  ought  to  have  known  what  all  experience  has 
taught,  that  sickness  would  certainly  throw  a  far  more 
serious  strain  than  wounds  upon  the  medical  organiza- 
tion. No  doubt  we  have  now  in  .South  Africa  a  far 
larger  force  than  was  contemplated  when  the  war 
began;  but  those  who  sent  the  men  out  ought  surely 
to  have  had  the  foresight  to  send  out  the  necessary 
equipment  in  addition,  and  it  ought  not  to  have  been 
possible  for  such  horrors  to  have  come  into  existence 
as  those  which  Mr.  Burdett-Coutts  details  so  graphi- 
cally as  having  been  seen  with  his  own  eyes.  No  one 
can  doubt  that  the  men  on  the  spot  were  struggling 
manfully  to  meet  the  terrible  strain  of  supplying  the 
wants  of  the  twenty  thousand  oick  who  now  occupy 
the  whole  track  of  the  army.  More  than  half  of  these 
sick,  we  are  told,  are  down  with  typhoid  fever,  and 
those  who  know  best  what  care,  what  cleanliness, 
what  constant  attention  are  required  to  prevent  infec- 
tion spreading  far  and  wide,  will  recognize  not  only 
the  terrible  hardships  to  which  our  unfortunate  soldiers 
are  being  exposed,  but  the  serious  danger  which  hangs 
over  the  whole  expedition  from  the  unchecked  exten- 
sion of  this  disease.  We  will  not  now  enter  into  the 
details  of  the  horrible  neglect  which  Mr.  Burdett- 
Coutts  lays  bare,  but  we  will  join  with  him  in  saying 
that  the  whole  series  of  events  ought  to  have  been 
foreseen  and  provided  for.  That  fever  has  always 
been  the  scourge  of  South  Africa,  that  Bloemfontein 
is  always  a  typhoid  town,  and  that  this  town  would  of 
necessity  become  a  point  on  which  our  troops  would 
concentrate  in  large  numbers  was  always  known." 

The  Famine  in  India. — The  London  Spectator 
says:  "We  are  happy  to  record  that  the  famine  in 
India  approaches  its  termination.  The  monsoon 
though  late  has  brought  copious  rains  throughout 
India,  and  in  a  few  weeks  cultivation  will  be  possible. 
The  money-lenders,  secure  of  a  future  crop,  will  re- 
commence making  advances  by  which  seed  at  all 
events  may  be  secured,  while  the  State,  we  hope,  will 
render  assistance  in  the  collection  of  cattle.  The 
extinction  of  beasts  is  a  terrible  addition  to  the  weight 
of  the  calamity.  There  are  still,  we  believe,  men  who 
say  that  a  famine  of   this  kind  is  all  the  fault  of  the 


system  of  taxation  in  India,  which,  as  we  quite  admit, 
though  not  too  heavy  is  wanting  in  elasticity;  but  as 
a  matter  of  fact,  the  heaviest  blow  has  fallen  upon 
districts  still  taxed  only  by  their  native  rulers — 
Guzerat,  Rajpootana,  and  Kattiawar.  There  is  grave 
reason  to  fear  that  in  the  wide  regions  under  the  first 
and  second  names  the  loss  of  population  from  the 
famine  and  its  sequela;^cholera,  fever,  and  typhoidal 
disease — will  not  be  less  than  one-fifth  of  the  whole, 
while  the  destruction  of  beasts  will  be  in  yet  greater 
proportion. 

A  Plea  for  Antitoxin. — It  is  a  stock  argument  with 
the  antivivisectionists  against  the  value  of  diphtheria 
antitoxin  that 'the  use  of  this  remedial  agent  has  neither 
lessened  the  number  of  cases  nor  diminished  the 
death  rate  from  diphtheria.  It  is  perfectly  obvious, 
however,  that  more  successful  treatment  of  an  infective 
disease  does  not  necessarily  mean  a  diminished  in- 
cidence of  that  disease.  No  one,  it  is  to  be  presumed, 
not  even  the  most  pronounced  antivivisectionist,  would 
deny  that  the  plague  in  India  is  more  successfully 
treated — i.e.,  that  the  percentage  of  recoveries  is 
greater — during  the  present  epidemic  than  it  was  in  the 
Middle  Ages;  but  it  is  to  be  doubted  if  the  incidence 
of  the  disease  in  many  districts  is  less  than  it  was  in 
former  times.  The  antivivisectionists  always  quote 
the  death  rate,  and  not,  as  should  be  done,  the  case 
mortality;  if  the  latter  be  taken,  statistics  practically 
without  exception  show  the  great  reduction  in  mortal- 
ity brought  about  by  the  use  of  diphtheria  antitoxin. 
But  this  very  reduction  in  mortality  brings  with  it  a 
danger  to  the  community.  If  the  individual  who  is 
suffering  from  diphtheria  dies,  he  is  done  with,  and 
there  is  little  risk  of  the  spread  of  the  disease  from 
the  cadaver.  But  if  he  recovers  diphtheria  bacilli  will 
be  present  in  the  throat  for  a  shorter  or  longer  period, 
even  for  many  months,  and  while  they  are  present 
there  is  always  the  risk  of  those  with  whom  he  comes 
in  contact  contracting  the  disease.  Paradoxical  though 
it  may  seem,  therefore,  the  greater  the  number  of  re- 
coveries, tiieoretically  the  greater  the  number  of  cases, 
and  so  it  will  be  unless  isolation  be  vigorously  carried 
out  until  all  risk  of  infection  is  past.  A  high  mortality 
is  really  a  natural  "stamping  out"'  system  and  would 
tend  to  diminish  the  incidence  of  the  disease. — Dr. 
Hewlett,  in  Treatment,  April. 

The  Results  of  the  Open-Air  Treatment  of  Phthi- 
sis in  the  Berlin  Homes. — Klkan  gives  the  results 
of  the  treatment  of  consumptives  in  the  Malchow  Sana- 
torium for  men  and  that  of  Blankenfelde  for  women; 
5,581  patients  stayed  longer  than  fourteen  days,  the 
average  time  being  forty-nine  days.  The  average  in- 
crease in  weight  was  4.8  kgm.  He  divides  the  pa- 
tients into  classes:  class  A  consisting  of  those  in 
whom  no  bacilli  were  found,  the  only  physical  signs 
being  those  of  an  apical  catarrh;  1,245  belonged  to 
this  class,  and  of  these  876  greatly  improved,  the  lung 
signs  disappearing;  in  359  the  physical  signs  per- 
sisted, but  the  patients  were  able  to  go  back  to  work; 
and  in  40  no  improvement  occurred;  in  all  these  last 
some  complication  was  present.  Class  B,  including 
those  patients  in  whose  sputum  bacilli  were  discovered 
and  in  whom  the  signs  of  the  disease  were  well  marked, 
numbered  2,519;  of  these  1,047  were  much  improved, 
1,171  were  improved,  259  showed  no  change  or  were 
worse,  and  6  died.  In  class  C,  including  those  cases 
in  which  either  laryngeal  phthisis  or  intestinal  tuber- 
culosis had  been  present  before  admission,  there  are 
659  patients,  and  of  them  198  are  recorded  as  having 
improved  greatly;  310  as  having  improved,  147  as  not 
having  improved,  and  4  as  having  died.  Class  D 
comprised  729  cases  in  which  the  fever  was  persistent. 
Of  these  106  patients  greatly  improved,  306  partially, 


i6o 


MEDICAL    RECORD. 


[July  28,  1900 


Cases.    Deaths. 


294  did  not  improve,  and  23  died.  On  tlie  strength 
of  the  above  figures  the  author  points  out  how  essential 
it  is  that  only  early  cases  should  be  admitted  to  sana- 
toria, the  only  suitable  cases  being  those  in  which 
there  is  a  reasonable  prospect  of  more  or  less  com- 
plete cure. —  Quarterly  Medical  Magazine. 

Health  Reports. — The  following  cases  of  smallpox, 
yellow  fever,  cholera,  and  plague  have  been  reported 
to  the  surgeon-general  of  the  United  States  Marine- 
Hospital  service  during  the  week  ended  July  20, 
1900: 

Smallpox— United  States. 

Illinois,  Chicago July  7th  to  14th 2 

Kansas,  Wichita July  "th  to  14th 2 

Louisiana,  New  Orleans July  7th  to  14th 11                  5 

Shreveport July  7th  to  14th 3 

Maryland,  IJaltimore July  7th  to  14th i 

Massachusetts,  Fall  River  .  .July  7th  to  14th i 

Nebraska.  Omaha July  7th  to  14th 2 

N,  Hamp^ire.  Manchester.. July  7th  to  14th I 

Ohio,  Cleveland July  7th  to  14th 29 

Pennsylvania.  Philadelphia  .July  8th  to  16th i 

South^Carolina,  Greenville.  .July  7th  to  14th i 

Utah,  Salt  Lake  City July  7th  to  14th 2 

Washington,  Tacoma J  uly  ist  to  7th i 

Smallpox — Foreign  and  Insular. 

Brazil.  Bahia June  2d  to  gth 2 

England,  Liverpool June  23d  to  30th 3 

London June  23d  to  30th 16 

France,  Lyons June  16th  to  23d 1 

Paris June  23d  to  30th 4 

Roubaix May  ist  to  31st i 

Greece.  Athens June  23d  to  30th 4  2 

India,  Bombay June  2d  to  12th 12 

Italy,  Genoa June  8th  to  i6th 3 

Mexico,  Vera  Cruz July  ist  to  7th 9 

Scotland.  Glasgow June  22d  to  July  6th 170  3 

Switzerland,  Geneva June  8th  to  16th i 

Vei.low  Fever. 

Africa,  Goree  Dakar May  30th  to  June  i6th 3  2 

Colomljia,  Barranquilla June  23d  to  30th g  6 

Cartayena J  une  22d  to  20th 11  Q 

Cuba,  Havana June  Z7th  to  July  4th 5 

Santa  Clara June  26th  to  July  7th 7 

Mexico,  Cordoba July  1st  to  8th       Reported. 

Progreso June  23d  to  July  8th 3  2 

Cholera. 
India.  Bombay June  5th  to  12th 72 

Plague. 
Arabia,  Aden June  8th  to  16th. 


Australia,  Syfiney    June  3d  to  i6th ...     14  6 

India,  Bombay June  5th  to  12th 117 

Jfepan,  Osaka June  13th  to  19th I 

Shidzuoka June  13th  to  igth i 

Non-Hygienic    Gymnastics Mr.  Buckham  writes 

an  interesting  article  on  this  subject  in  the  current 
number  of  Harper's  Monthly  Magazkie,  some  of  which 
we  here  quote.  From  various  competent  sources  we 
have  received  warning  that  the  abuse  of  the  body 
among  athletes  is  increasing  functional  disease  and 
shortening  the  average  life  of  males.  Suspicion  that 
something  was  wrong  first  arose  when  it  began  to  be 
observed  that  college  athletes  upon  reaching  middle 
life  experienced  in  a  majority  of  cases  what  has  been 
called  the  premature  decay  of  physical  endurance. 
There  seems  to  be  among  them  a  marked  collapse  of 
vital  energy,  a  tendency  to  functional  weakness  and 
disorder,  an  inability  to  endure  hard  labor,  either 
mental  or  physical.  Men  of  slighter  physical  develop- 
ment who  had  not  indulged  in  indoor  gymnastics  of 
the  upside-down  and  violent  type,  retained,  it  was 
observed,  at  the  same  age  with  their  formerly  athletic 
fellows  sound  and  active  bodies  and  an  unimpaired 
capacity  for  solid  work.  .  .  .  Physicians  have  found 
in  nearly  all  cases  of  vital  exhaustion  from  excessive 
physical  development  enlargement  and  weakness  of 
the  heart  with  a  tendency  to  acute  heart  disease.  The 
lungs  also  seem  often  to  have  suffered  some  deteriora- 
tion of  cellular  tissue,  so  that  pulmonary  consumption 
is  not  an  infrequent  disease  with  adult  athletes. 
Generally  speaking,  the  trouble  seems  to  be  a  slow 
physical  decay  due  to  the  early  exhaustion  of  a  vital 
energy  which  was  intended  to  supply  the  body  for 
seventy  years  or  more,  and  to  the  disintegration  of 
tissues  which  have  been  stimulated  to  abnormal  de- 
velopment. Some  physicians  have  gone  so  far  as  to 
pronounce  this  excessive  enlargement  of  special  mus- 


cles and  parts  of  the  body  a  diseased  growth,  some- 
thing like  a  hard  tumor,  and  they  say  that  in  the  end 
the  result  will  be  the  same  as  with  other  diseased 
growths — a  pernicious  anaemia.  Indoor  athletics — 
that  is,  gymnasium  practice,  especially  when  applied 
chiefly  to  the  development  of  one  set  of  muscles  for 
competitive  purposes — is  extremely  injurious  from  the 
fact  that  it  is  almost  always  carried  to  excess,  and  evi- 
dences its  excess  by  the  increasing  malformation  or 
disproportion  of  the  body.  The  gymnast  with  huge 
shoulders  and  spindling  hips  and  legs  is  a  good  and 
not  infrequent  example  of  the  abuse  of  physical  ex- 
ercise. Anything  like  sjjecialization  in  physical 
development  ought  to  be  strenuously  avoided  by  one 
who  wishes  to  retain  throughout  life  a  symmetrical 
body  kept  in  perfect  health  by  orderly  and  harmoniously 
exercised  physical  functions. 

Athletics  Barred  from  Chicago  University. — The 

College  of  Physicians  and  Surgeons  of  Chicago  after 
an  animated  debate  has  decided  henceforth  to  refuse 
recognition  to  athletics,  and  no  longer  gives  official 
sanction  and  support  to  the  college  football  team, 
which  has  taken  so  prominent  a  part  in  intercollegiate 
athletic  competitions.  This  step  has  been  taken  be- 
cause experience  has  taught  the  faculty  that  college 
athletics  have  a  demoralizing  and  disturbing  influence 
on  the  students  and  interfere  with  the  educational 
work  of  the  college.  —  Sanitarian. 


While  the  Medical  Record  is  pleased  to  receive  all  new  pub- 
lications which  may  be  sent  to  it,  and  an  acknowledgment  will  be 
pyoniptly  made  of  their  receipt  under  this  heading,  it  must  be  with 
the  distinct  understanding  that  its  necessities  are  such  that  it  can- 
not be  considered  under  obligation  to  notice  or  review  any  publica- 
tion received  by  it  which  in  the  judgtnent  of  its  editor  will  not  be 
of  interest  to  its  readers. 

Tl(.'\NS.\CTIONS  OF  THE  MeDIC.\L  SoCIF.1V  OF  THE  ST.\TE 
OF  Californi.\.  Svo,  616  pages.  Illustrated.  Published  by 
the  Society. 

SURGIC.\L  Ax.tTO.MY.  By  John  B.  Deaver,  M.D.  Svo,  709 
pages.      Illustrated.      P.  Biakiston's  Son  &  Co. ,  Philadelphia.  Pa. 

A    DiCTIO.NARY    OF    MEDICINE    AND    THE   ALLIED    SCIENCES. 

By  Alex.  Duane,  M.D.  i2mo,  646  pages.  Lea  Brothers  &  Co., 
Philadelphia,  Pa. 

A  Treaiise  on  AppENDicrns.  By  ]ci\\n  B.  Deaver,  M.D. 
Svo,  300  pages.  Illustrated.  P.  Blakiston's  Son  &  Co.,  Phila- 
delphia, Pa. 

A  Mani'AL  OF  Surgical  Treat.ment.  By  W.  Watson 
Cheyne  and  F.  F.  Burghard,  M.D.  Svo,  305  pages.  Illus- 
trated.     Lea  Brothers  &  Co.,  Philadelphia,  Pa. 

A  Manual  of  Clinical  Diagnosis.  By  Charles  E.  Simon, 
M.D.  Svo,  55S  pages.  Illustrated.  Lea  brothers  &  Co., 
Philadelphia,  Pa. 

Transactions  of  the  .Vmerican  Association  of  Obstet- 
ricians AND  Gvn.t.cologists  for  the  year  1S99.  Svo,  371 
pages.     William  J.  Dornan,  Philadelphia.  Pa. 

Medical  Directory  of  the  City  of  New  York.  i2mo, 
314  pages.  Published  by  Medical  Society  of  the  County  of  New- 
York. 

Chirurgie  du  Rein  et  de  l'Uretere.  By  V.  Rochet. 
i2mo,  367  pages.     Illustrated.     G.  Steinheil,  Paris. 

Trait£  de  Chirurgie  Clinique  et  Op£ratoire.  By 
various  authors.  Yol.  i.x.,  955  pages,  Svo.  Illustrated.  J.  B. 
Baillicre  et  Fils,  Paris. 

Handereinigung,  Handedesinfektion  und  Handeschutz. 
By  Dr.  Carl  S.  Haegler.  Svo,  zio  pages.  Benno  Schwabe, 
Basel. 

CiRUNDRISs  der  orthopadischen  Chirurgie.  By  Max 
David,  M.I).     Svo,  212  pages.     Illustrated.     S.  Karger.  Berlin. 

Die  Urogenitalmuskulaiur  des  Da.mmes.  By  Dr.  Otto 
Kalischer.      Svo,  1S4  pages.      S.   Karger,  Berlin. 

Fliegenlarven  als  gei.egenti.iche  Parasiten  des 
Menschen.  By  Erich  Peiper.  iimo,  76  pages.  Illustrated. 
Louis  Marcus,  Berlin. 

Dermaiohistoi.ogische  Technik.  By  Max  Joseph  und 
Georg  Loewenbach,  M.D.  i2mo,  125  pages.  Louis  Marcus, 
Berlin. 


Medical  Record 

A    llf^eekly  Journal  of  Medicine  and  Surgery 


Vol.  58,  No.  5. 
Whole  No.  1552. 


New  York,   August  4,    1900. 


$5.00  Pfer  Annum. 
Single  Copies,  loc. 


©riginal  Articles. 

CANCER    OF  THE    STOMACH    AND 
INTESTINES. 

Uy    B.    FARQUHAR   CURTIS,    M.D., 

PROFESSOR  OF  CLINICAL  SURGBRV  AND  ADJUNCT  PROFESSOR  OF  THE  PRINCI- 
PLES OF  SL'KGERV,  UNIVERSITV  AND  BELLEVl'E  HOSPITAL  MEDICAL  COL- 
LEtiF.,    NEW    VOKK. 

The  recent  advances  in  surgery  have  much  improved 
the  results  of  operations  for  cancer,  both  by  lessening 
the  immediate  mortality  and  by  increasing  the  chances 
for  ultimate  cure.  This  paper  will  be  limited  to  the 
consideration  of  cancer  of  the  stomach  and  of  the  in- 
testines, omitting  the  rectum. 

A.  According  to  Heiniann's  statistics  collected  from 
the  general  hospitals  of  Prussia  in  1895  and  1896,' 
cancers  of  the  stomach  form  twenty-one  per  cent,  of  all 
cancers.  Of  men  afflicted  with  cancer  tlie  tumor  is 
located  in  the  stomach  in  thirty-two  per  cent.,  and  of 
women  so  aftlicted  in  thirteen  per  cent,  it  occurs  in 
that  organ. 

The  first  question  which  arises  is,  w'hether  opera- 
tion offers  a  chance  for  cure  of  cancer  of  the  stomacii, 
and  it  is  difficult  to  answer  this  question  by  any  com- 
plete statistics.  Wolfler,  however,  in  his  review  of 
the  subject  for  the  German  Congress  of  Surgeons  in 
1896,"  was  able  to  find  fourteen  patients  who  had  been 
submitted  to  pylorectomy  for  carcinoma,  alive  and 
well  two  years  after  the  operation,  and  ten  others  from 
four  to  eight  years,  making  a  total  of  twenty-four  pa- 
tients on  record  who  remained  well  from  two  to  eight 
years  after  the  operation.  These  f.gures  are  certainly 
encouraging,  and  the  fact  that  they  are  constantly 
and  rapidly  improving  of  late  years  indicates  that  be- 
fore long  we  shall  be  able  to  slate  definitely  the  pro- 
portion of  cases  in  which  the  patients  are  likely  to  re- 
main well  after  the  operation. 

The  second  question  is:  What  is  the  danger  of  re- 
section for  these  tumors?  VVolfler  finds  a  mortality  of 
thirty-one  per  cent,  in  one  hundred  and  seventy-three 
operations  performed  by  Jiillroth.  Czerny,  (iussen- 
bauer,  Kocher,  Mikulicz,  and  others  of  the  best  Ger- 
man surgeons  in  recent  years.  Some  operators  have 
had  a  mortality  of  only  twenty-five  per  cent.,  and  some 
have  had  a  series  of  many  consecutive  cases  without  a 
death  owing  to  the  improvements  in  technique.  Carle 
and  Fantino  in  fourteen  cases  lost  only  three,  a  mor- 
tality of  about  twenty-one  per  cent. 

The  next  consideration  is  the  decision  as  to  what 
cases  are  suitable  for  the  removal  of  the  tumor  with- 
out too  great  risk  of  life,  and  w  ith  a  hope  of  effecting 
a  cure.  Some  surgeons  have  laid  down  very  strict 
rules  for  the  limitation  of  the  operation  of  resection  of 
the  stomach  for  these  tumors,  considering  it  justifiable 
only  when  the  tumor  is  small  without  in\'olvement  of 
the  glands  and  without  adhesions— a  limitation  which 
would  almost  completely  debar  the  surgeon  from  this 
operation.  The  cases  of  Schlatter,  Richardson,"  and 
others  show  that   large   tumors   involving  the  entire 

'  Archiv  fiir  klin.  Chirurgie,  vol.  Ivii. 

'  Transactions,  vol.  x.xv. ,  p.  96. 

'See  Robson,  Lancet,  1900,  i. ,  p.  S42. 


Stomach  may  be  removed  with  an  immediate  success- 
ful result,  and  without  serious  interference  with  nutri- 
tion by  reason  of  the  loss  of  the  organ,  and  that  a  rea- 
sonably long  duration  of  life  can  be  expected  in  such 
cases. 

In  the  well-known  case  of  Schlatter  the  patient  sur- 
vived in  good  condition  for  a  year  after  the  operation. 
The  mere  size  of  the  tumor,  moreover,  is  not  an  indi- 
cation of  such  extensive  involvement  of  the  glands  or 
of  such  extensive  adhesions  as  to  forbid  operation,  for 
several  of  these  very  large  tumors  ha\e  now  been  oper- 
ated on  and  found  free  from  both  complications.  In 
fact,  this  evidence  shows  that  tumors  of  the  stomach 
may  reach  a  large  size  and  involve  a  large  part  of  the 
organ  without  forming  such  extensive  adhesions  as 
would  prevent  their  removal,  and  without  extensive 
infection  of  glands.  We  may,  therefore,  reject  a  limi- 
tation of  the  operation  of  resection  based  merely  on 
the  size  of  the  tumor. 

We  may  also  reject  the  second  limitation  mentioned 
above — the  presence  of  adhesions.  The  modern  tech- 
nique enables  us  to  remove  portions  of  the  colon, 
of  the  liver,  and  even  of  the  pancreas  in  these  oper- 
ations without  seriously  increasing  the  risk.  In 
fourteen  operations  Carle'  removed  portions  of  pan- 
creas in  three  cases.  It  might  be  thought  that  this 
secondary  involvement  of  other  organs  would  greatly 
increase  the  liability  to  recurrence,  but  some  of  these 
cases  will  be  found  among  those  of  longest  survival 
after  recovery  from  the  operation.  There  is,  there- 
fore, no  reason  for  excluding  these  cases  from  opera- 
tion, and  there  is  even  a  chance  for  a  radical  cure  if 
the  patient's  vitality  is  sufficient  to  bear  the  shock  of 
the  prolonged  and  complicated  operation. 

Finally  we  come  to  the  restrictions  imposed  by  the 
presence  of  enlarged  glands  in  the  neighborhood  of  the 
tumor.  Even  in  this  third  and  most  serious  limitation 
experience  has  shown  that  the  same  chance  of  error 
exists  as  in  operations  for  cancer  with  enlarged  glands 
elsewhere.  The  glands,  although  enlarged,  may  not 
be  carcinomatous,  and  even  when  the  glands  are  in- 
fected with  carcinoma  a  wide  removal  may  be  success- 
ful, and  may  guarantee  the  patient  against  a  return  of 
the  disease.  The  cases  in  which  the  glands  are  in- 
volved afford  naturally  the  least  prospect  for  a  cure,  but 
they  are  by  no  means  hopeless.  For  instance,  in  four 
of  his  fourteen  cases  Carle  found  that  the  glands  were 
enlarged,  but  examination  after  removal  proved  that 
they  were  not  carcinomatous. 

We  must  conclude,  therefore,  that  no  absolute  rule 
can  be  laid  down  limiting  the  removal  of  these  tumors 
and  that  each  case  should  be  judged  upon  its  own 
merits,  just  as  is  done  in  cancer  of  the  breast  and  of 
other  organs.  Here,  as  elsewhere,  there  will  be  favor- 
able and  unfavorable  cases,  and  the  surgeon  must  draw 
the  line  between  them  for  himself,  and  must  be  allowed 
to  remove  the  tumor  even  in  the  unfavorable  cases  if 
in  his  judgment  such  an  operation  is  to  the  advantage 
of  the  patient  by  insuring  him  a  longer  life  or  greater 
comfort  during  his  life.  The  fact  is  also  to  be  noted 
that  the  majority  of  the  patients  who  die  from  recur- 
rence after  pylorectomy  not  only  enjoy  a  longer  or 
shorter  period  of  freedom  from  all  symptoms,  but  ap- 
'  Archiv  fiir  klin.  Chirurgie,  iSgS,  Ivi. ,  221. 


l62 


MEDICAL    RECORD. 


[August  4,  1900 


pear  to  lose  strength  gradually,  linally  dying  with  less 
suiTering  than  those  who  have  not  been  operated  upon. 

If  a  patient  with  cancer  of  the  stomacli  is  to  have 
any  chance  whatever  of  a  cure  by  operation,  and  even 
a  chance  of  coming  through  the  operation  of  resection 
successfully,  an  early  diagnosis  of  the  condition  is  in- 
dispensable. To  make  this  early  diagnosis  is  really 
the  principal  difficulty  in  the  treatment  of  these  cases. 
Let  us  study 'the  symptomatology  of  the  disease.  We 
may  divide  cases  of  cancer  of  the  stomach  into  those 
with  a  tumor  and  those  in  which  no  tumor  can  be  felt. 
When  a  tumor  is  present,  it  will  usually  be  possible  to 
determine  its  connection  with  the  stomach  by  the  usual 
methods  of  examination  by  palpation,  distention  of  the 
stomach  with  air  or  water,  and  distention  of  the  large 
intestine  in  a  similar  way.  The  tumor  may  even  be 
discovered  accidentally  before  any  stomach  symptoms 
have  developed.  It  will  be  much  more  difficult,  how- 
ever, to  determine  whether  the  cases  are  so  far  ad- 
vanced that  even  an  e.xploratory  laparotomy  is  not 
worth  while,  or  whether  there  is  still  a  chance  for  suc- 
cessful removal.  As  will  be  understood  from  the  re- 
marks previously  made  about  the  impossibility  of  plac- 
ing strict  limitations  upon  the  radical  operation,  the 
writer  would  advise  an  exploratory  laparotomy  if  the 
patient  is  in  good  condition,  even  if  the  tumor  is  of 
large  size  and  somewhat  fixed  in  the  abdomen.  It  is 
impossible  to  determine  the  real  condition  of  affairs 
without  opening  the  peritoneal  cavity  and  examining 
its  contents. 

The  cases  in  which  no  tumor  can  be  felt  are  much 
more  difficult  of  diagnosis,  and  unfortunately  this  class 
includes  a  very  large  proportion  of  cases  of  cancer  of 
the  stomach.  The  tumor  in  the  first  stages  may  be 
very  small,  may  be  concealed  under  the  ribs  or  ad- 
herent to  the  lower  surface  of  the  liver,  so  that  it  is 
impossible  to  reach  it  by  palpation.  In  such  cases- 
the  diagnosis  must  be  made  from  the  history,  symp- 
toms, and  the  chemical  and  other  examinations  of  the 
stomach.  From  the  history  and  symptoms  one  can 
only  make  a  guess  at  the  real  nature  of  the  case  in  the 
early  stages,  for  characteristic  vomiting  is  a  very  late 
symptom.  The  physical  examination  of  tiie  stomach 
can  at  best  only  show  dilatation  of  the  organ,  and  dila- 
tation also  is  a  late  symptom.  The  modern  methods 
of  the  chemical  examination  of  the  contents  of  the 
itoniach  are  of  much  more  assistance,  although  not 
absolutely  reliable.  In  a  general  way  it  may  be  said 
that  the  majority  of  cases  of  cancer  of  the  stomach 
show  an  absence  or  a  great  reduction  of  the  quantity 
of  hydrochloric  acid  normally  present  in  tiie  stomach 
contents.  They  also  show  the  presence  of  lactic  acid 
and  a  great  reduction  of  the  gastric  digestive  power  for 
albumen.  There  is,  furthermore,  a  decided  impair- 
ment of  the  muscular  function  of  the  stomacli,  which 
results  in  retention  of  its  contents,  even  if  no  stenosis 
of  the  pylorus  be  present.  No  symptom  or  group  of 
symptoms,  however,  can  be  absolutely  relied  upon  to 
iprove  the  existence  of  a  cancer,  and  very  careful  study 
of  the  signs  found  and  all  the  symptoms  of  the  case  is 
necessary  in  every  case.  Some  authorities  (Hemme- 
'ter)  lay  much  stress  upon  the  microscopical  examina- 
tion of  fragments  in  the  washings  of  the  stomach  which 
may  be  detached  by  the  friction  of  the  eye  of  the 
stomach  tube,  and  upon  the  presence  of  the  Opplcr- 
Jjoas  bacillus  in  the  stomach  contents. 

As  an  example  of  the  manner  of  using  these  various 
signs,  take  a  case  with  symptoms  of  stenosis  of  the 
pylorus:  if  in  such  a  case  the  hydrochloric  acid  is  in- 
creased, the  stenosis  is  probably  due  to  a  benign  cause; 
but  if  it  is  decreased  or  absent,  the  cause  is  jirobably 
malignant.  If  in  any  case  there  are  no  symptoms  of 
stenosis,  but  the  hydrochloric  acid  is  reduced,  a  special 
study  should  be  made  of  the  motility  of  the  stomach, 
and  if  this  is  found  to  be  impaired,  the  probability  is 


in  favor  of  a  cancer.  It  is  by  the  intelligent  use  of 
these  various  symptoms  in  connection  with  each  other 
that  a  diagnosis  is  to  be  made — not  by  blind  reliance 
upon  a  single  symptom  or  group  of  symptoms  as  path- 
ognomonic of  cancer.  According  to  Hemmeter,'  if 
rapid  emaciation  takes  place  in  a  patient  with  stomach 
symptoms,  and  it  is  found  on  examination  that  hydro- 
chloric acid  is  absent  and  lactic  acid  is  present  in  the 
contents  of  the  stomach,  while  the  power  of  digesting 
albumen  has  been  reduced  under  thirty  per  cent,  of  the 
normal,  and  the  Oppler-Boas  bacillus  is  found,  and  if 
the  patient  shows  no  improvement  after  three  or  four 
weeks  of  medical  treatment,  one  may  be  sure  that  car- 
cinoma is  present. 

The  whole  aspect  of  the  question  of  the  treatment  of 
cancer  of  the  stomach  has  been  revolutionized  by  the 
rapid  modern  development  of  the  surgical  treatment  of 
the  benign  conditions  of  that  organ.  Formerly  it  was 
said  that  an  exploratory  laparotomy  would  not  render 
the  patient  worse  or  immediately  endanger  his  life  if 
it  should  reveal  a  condition  which  could  not  be  relieved 
by  operation,  or  if  the  suspected  cancer  was  shown  not 
to  be  present.  But  now  we  may  truthfully  say  that  if 
no  cancer  is  found  it  is  probable  that  some  other  seri- 
ous lesion  will  be  discovered,  which  can  be  cured  by 
operative  methods,  and  which  may  be  incurable  other- 
wise. To  give  an  idea  of  the  possibilities  of  the  sur- 
gical treatment  of  benign  conditions  of  the  stomach 
we  may  quote  the  report  of  Petersen  from  Czerny's 
clinic  at  Heidelberg,'  in  which  fifty-five  cases  of  pyloric 
stenosis,  seven  cases  of  gastric  pain  and  vomiting, 
three  cases  of  hcematemesis,  and  one  case  of  atonic 
dilatation  were  subjected  to  operation.  The  opera- 
tions done  consisted  in  the  excision  of  gastric  ulcers, 
pylorectomy,  pyloroplasty,  gastro-enterostomy,  separa- 
tion of  adhesions,  and  divulsion  of  a  narrow  pylorus. 
We  may  also  quote  Carle  and  Fantino's  report  ^  on 
forty-one  cases  of  operations  for  benign  stenosis  of  the 
pylorus  with  dilatation  of  the  stomach,  including  cases 
of  spasm  of  the  pylorus  and  of  muscular  atrophy  of  the 
stomach.  In  these  cases  pyloroplasty  was  done  four- 
teen times,  in  three  cases  the  pylorus  was  stretched, 
and  in  twenty-four  cases  gastro-enterostomy  was  per- 
formed. These  reports  claim  good  results  and  indi- 
cate how  wide  the  field  of  surgical  methods  has  be- 
come in  the  treatment  of  gastric  disorders,  supporting 
the  assertion  that  if  the  exploratory  laparotomy  should 
show  that  the  supposed  carcinoma  is  not  present  the 
surgeon  will  probably  find  some  lesion  which  he  may 
treat  successfully.  In  any  case  with  serious  gastric 
symptoms,  therefore,  the  surgeon  need  not  hesitate  to 
advise  an  exploratory  operation,  even  if  there  is  only 
a  suspicion  of  malignant  disease.  He  is  no  longer 
forced  to  wait  for  a  positive  diagnosis,  and,  when  that 
diagnosis  is  finally  made,  to  find  himself  too  late  to 
be  of  service. 

The  modern  indications  for  operation  in  cases  of 
suspected  malignant  disease  may  be  stated  somewhat 
as  follows:  (1)  The  presence  of  a  tumor,  (2)  dilata 
tion  of  the  stomach;  (3)  obstructive  vomiting;  (4) 
marked  chemical  changes  in  the  gastric  contents,  even 
if  other  symptoms  are  slight;  (5)  ha-mateniesis,  (6) 
severe  gastric  pain.  It  will  be  seen  that  the  above 
list  of  indications  might  lead  to  the  discovery  of  benign 
as  well  as  of  malignant  lesions,  but  in  such  a  case  a 
cure  could  be  obtained  the  more  easily  and  the  opera- 
tion would  be  the  better  justified. 

With  reference  to  one  non-malignant  lesion  which 
occasionally  simulates  cancer — ulcer  of  the  stomach — 
there  is  a  special  consideration  to  be  noted.  There 
can  be  no  doubt  that  cancer  is  very  often  preceded  by 
a  chronic  ulcer  of  the  stomach,  or  develops  directly 

'  Medicai.  Kr.roRii.  October  21,  1809,  P-  577- 

'•'  Deutsche  mellicini^clle  Woclienschrift    1899,  p.  3S7. 

^  Archiv  fiir  klin.  Chirurgic,  iSyS,  Ivi.,  p.  i. 


August  4,  1900] 


MEDICAL    RECORD. 


163 


upon  the  base  of  such  an  ulcer.  The  evidence  in  favor 
of  this  view  accumulates  constantly.  Rosenheim  re- 
ported '  that  in  fifty  successive  cases  of  cancer  of  the 
stomach  under  his  care  he  found  four  cases  in  which 
there  was  evidence  of  a  previous  ulcer.  He  remarks 
that  in  all  of  these  cases  hydrochloric  acid  was  pres- 
ent even  in  the  advanced  stages  of  the  malignant  dis- 
ease. This  would  make  eight  per  cent,  of  the  cases 
of  cancer  of  the  stomach  due  to  a  preceding  ulcer. 
Hauser,  quoted  by  Boas,  says  that  in  five  to  six  per  cent, 
of  the  cases  of  carcinoma  of  the  stomach  the  growth 
develops  from  an  ulcer  or  the  scar  of  an  ulcer. 
Thiersch"  was  one  of  the  early  observers  of  these 
cases,  but  instances  have  multiplied  much  more  rap- 
idly recently.  Karg'  reports  such  a  case  treated  by 
resection,  and  the  patient  was  well  (having  gained  fifty 
pounds  in  weight)  three  years  later.  Mikulicz'  men- 
tions five  cases  in  which  the  symptoms  were  those  of 
ulcer,  but  carcinoma  proved  to  be  present,  as  was  shown 
in  two  cases  by  microscopic  examination  after  resec- 
tion, and  in  three  by  a  truly  malignant  course  after 
operation — one  case  of  the  latter  being  treated  by  ex- 
cision and  the  others  by  gastro-enterostomy. 

Mathieu'  has  recently  reported  three  cases  in  which 
symptoms  of  ulcer  of  the  stomach  preceded  the  devel- 
opment of  cancer  by  two,  ten,  and  twenty-four  years — ■ 
by  far  too  long  to  allow  of  the  hypothesis  that  the  dis- 
ease was  malignant  from  the  first. 

In  tliree  cases  of  my  own  the  same  condition  existed, 
the  symptoms  previous  to  operation  being  as  follows: 

Case  I. — William  J.  E ,  steward  on  board  steam- 
ship, twenty-eight  years  old,  born  in  the  United  States, 
single.  He  was  admitted  to  St.  Luke's  Hospital  .August 
2,  1899.  Members  of  the  mother's  side  of  his  family 
are  said  to  have  had  stomach  trouble.  He  had  all  tiie 
diseases  of  childhood,  and  smallpox  when  a  child.  He 
has  had  no  rheumatism,  tuberculosis,  or  syphilis.  He 
is  very  moderate  in  using  alcohol;  smokes  consider 
ably.  He  had  exceptionally  good  health  until  the 
present  illness  began.  In  1893  he  had  "bush  fever" 
in  South  -America.  For  ten  years  he  has  had  consti- 
pation. The  stomach  symptoms  began  five  years  ago, 
with  distress  after  eating  and  poor  appetite,  but  some- 
times he  had  a  voracious  appetite.  Eructations  of  gas 
relieved  the  distress.  Three  years  ago  he  began  to 
vomit  after  eating,  only  two  or  three  times  a  week  at 
first,  then  oftener.  He  has  never  gone  more  than  six 
days  without  vomiting  since  that  time.  Now  he  usu- 
ally vomits  two  or  three  times  a  day,  and  a  larg._  quan- 
tity at  a  time.  Once  he  says  he  brought  up  a  gallon. 
He  has  noticed  in  the  vomited  matter  food  which  he 
had  eaten  three  or  four  days  before.  Mucus  is  present 
in  the  vomitus,  but  no  blood  or  coffee-grounds  material. 
The  distress  and  pain  are  now  less  than  they  were  six 
months  ago.  For  eighteen  months  he  has  been  using 
the  stomach  tube,  evacuating  and  washing  the  stomach 
regularly.  Fluids  agree  best  with  him.  He  was  a 
hearty  eater  before  his  illness,  but  there  is  no  history 
of  overeating..     He  has  lost  fifty  pounds  in  weight. 

August  2,  1899,  physical  examination:  The  pa- 
tient is  a  tall  man  of  large  frame,  emaciated,  weighing 
only  one  hundred  and  six  pounds,  but  of  good  color, 
and  with  firm  muscles.  The  heart,  lungs,  and  liver 
are  normal.  The  stomach  descends  to  the  umbilicus 
when  distended,  and  its  walls  appear  to  be  thickened. 
Its  capacity  is  about  fifty  Huidounces.  In  the  right 
hypochondriac  region  a  tumor  can  be  felt  in  the  abdo- 
men, about  one  and  one-half  inches  in  diameter,  roll- 
ing upward  and  downward  under  the  hand,  and  disap- 
pearing when  the  stomach  is  distended.     The  tumor  is 

'  Deutsche  medicinische  Wochenschrift,  iSgo.  p.  30S. 
'  Miinchener  medicinische  Wochenschrift,  1886,  No.  13. 
■' Centralblatt  flir  Chirurgie.  1S9S,  Bail..  126. 
■*  Berliner  klin.  Wochenschrift,  1897,  p.  523. 
'  Semaine  medicale,  iSg7    p    291. 


not  tender  or  painful.  Two  small  nodules  can  be  felt 
on  its  surface.  Chemical  examination  of  the  stomach 
contents  after  a  test  breakfast  showed :  hydrochloric 
acid  much  reduced,  total  acidity  reduced.  There  is 
some  mucus,  no  bile.  Starch  digestion  is  unusually 
good.  There  is  some  fermentation  and  acetic  acid  is 
present.  Urine  is  acid,  1.020  specific  gravity,  with  no 
albumin. 

On  August  5,  1899,  pylorectomy  was  done  by 
Kocher's  method.  There  was  an  uninterrupted  re- 
covery. Twenty-three  days  after  the  operation  he 
weighed  one  hundred  and  twenty  pounds,  and  Ihirty- 
.one  days  after  one  hundred  and  thirty-five  pounds,  hav- 
ing gained  in  that  time  just  twenty-eight  pounds.  On 
November  5th  he  reports  weighing  one  hundred  and 
sixty-eight  pounds,  able  to  eat  everything  except  fruit 
and  the  more  fibrous  vegetables. 

The  pathologist  of  the  hospital  reports  that  the 
tumor  is  a  pure  carcinoma,  in  spite  of  the  very  long 
iiistory  of  pyloric  obstruction. 

Case  II. — Louisa   K ,   twenty-eight  years  old, 

married,  born  in  Germany.  She  was  admitted  to  St. 
Luke's  Hospital  July  31,  1899.  Family  history  is 
negative.  The  patient  had  measles  and  mumps  in 
childhood.  F'our  years  ago  she  had  some  internal 
operation  for  uterine  displacement  (?).  Considers  her 
health  previously  good.  The  menstrual  function  was 
normal.  She  has  been  married  four  years,  and  had 
one  child  born  fifteen  months  ago  (now  dead),  w-ith 
normal  labor  and  convalescence.  After  birth  of  the 
child  she  had  dull  pain  in  the  epigastrium  and  the 
left  inguinal  region  after  eating,  with  some  nausea. 
She  brought  on  vomiting  by  tickling  her  tiiroat  with 
her  finger,  and  sometimes  saw  blood  in  the  vomited 
matter,  which  was  watery  and  slimy.  She  has  been 
seriously  aft'ected  about  three  months.  Her  appetite  is 
good  except  when  pain  is  present.  She  has  had  left 
lumbar  pain,  sometimes  worse  after  eating.  The  bow- 
els are  regular.  Her  principal  complaint  is  the  lum- 
bar pain,  which  occasionally  radiates  to  the  shoulder. 
She  has  not  noticed  the  tumor. 

Physical  examination:  The  patient  is  of  medium 
frame,  fairly  nourished,  and  appears  anx-mic.  There 
is  a  slight  systolic  cardiac  murmurover  the  base.  The 
lungs  are  normal.  The  abdomen  is  generally  tense. 
A  hard  tumor  about  half  as  large  as  the  fist  can  he  felt 
just  above  and  to  the  left  of  tiie  umbilicus,  apparently 
attached  to  the  rectus  mucle.  The  tumor  is  tender  on 
pressure  and  dull  on  percussion.  Distention  of  the 
colon  reveals  it  lying  below  and  partly  beneath  the 
tumor,  below  the  level  of  the  umbilicus.  The  stomach 
appears  to  descend  to  the  umbilicus.  The  tumor  can 
be  moved  when  the  abdomen  is  relaxed,  but  is  immov- 
able if  the  muscles  are  ten,se.  It  does  not  move  with 
respiration.  The  mass  appears  rather  flat,  and  there 
are  no  nodules  to  be  felt.  It  cannot  be  felt  in  the  loin. 
The  liver  can  be  mapped  out  one  inch  below  the  edge 
of  the  ribs.  The  genitals  are  practically  normal.  The 
temperature  was  practically  normal  up  to  the  date  of 
operation,  occasionally  reaching  100°  F.  The  bowels 
were  regular.  The  urine  was  acid,  specific  gravity 
1. 018,  containing  a  few  pus  cells  and  epithelial  cells. 
There  was  some  nausea  (perhaps  due  to  iodide  of  potas- 
sium given  experimentally)  and  sufficient  pain  to  make 
the  patient  sleepless.  There  were  14,000  leucocytes. 
No  examination  of  the  stomach  contents  was  made. 
An  exploratory  incision  was  determined  on. 

On  August  12,  1899,  the  operation  was  performed 
under  ether  anfesthesia.  A  vertical  incision  was  made 
directly  over  the  tumor  through  the  left  rectus  muscle. 
The  latter  was  found  infiltrated  and  the  peritoneum 
thickened  over  an  area  about  two  inches  in  diameter, 
and  the  stomach  was  adherent  at  this  point.  Tiie  an- 
terior stomach  wall  was  thickened  to  a  full  inch. 
After  separating  the  adhesions,  a  small  but  very  hard 


164 


MEDICAL   RECORD. 


[August  4,  1900 


apparently  carcinomatous  gland  was  found  above  the 
ulcer  on  the  lesser  curvature  of  the  stomach.  The 
thickening  in  the  stomach  extended  almost  entirely 
across  the  anterior  wall  of  the  stomach  near  its  mid- 
dle, leaving  the  pylorus  free  with  about  two  inches  of 
healthy  stomach  between  it  and  the  mass.  Resection 
was  decided  upon  and  carried  out  on  the  same  plan  as 
in  the  first  case — Kocher's  method  with  use  of  the 
Murphy  button.  In  this  case,  however,  the  portion 
of  stomach  removed  measured  five  inches  across.  The 
lower  line  of  excision  passed  through  the  stomach  one 
inch  from  the  pylorus,  the  upper  about  two  inches 
from  the  oesophageal  opening  (on  the  lesser  curvature). 
The  stomach  was  dilated,  hence  the  remaining  organ 
after  the  operation  was  about  half  the  size  of  a  normal 
stomach.  There  were  no  adhesions  except  those  de- 
scribed, and  no  other  glands  were  found  enlarged. 
Examination  of  the  piece  removed  was  made,  and  an 
ulcer  nearly  three  inches  in  diameter  was  found,  with 
an  immensely  thickened  base.  The  posterior  wall  of 
the  stomach  was  healthy.  The  stomach  contained  a 
dark  red,  thick  fiuid  of  intensely  fetid  odor.  A  little 
pus  formed  in  the  wound,  apparently  originating  in 
the  abdomen,  but  caused  no  rise  of  temperature  or  pain. 
It  was  discharged  on  the  eleventh  day,  and  the  open- 
ing healed  by  granulation.  Tiie  patient  felt  no  hun- 
ger until  about  two  weeks  after  the  operation.  She 
was  not  weighed  until  the  thirty-second  day  after  the 
operation,  and  then  weighed  eighty-seven  pounds.  She 
weighed  one  hundred  and  five  pounds  three  weeks 
later.  The  pathologist  reports  carcinoma  in  the  tumor 
and  in  the  lymphatic  gland  removed. 

( Cases  I  and  2  are  quoted  from  the  report  in  the 
Yale  Ah'diail  Journal,  January,  igoo. ) 

C.^seIII.  (shown  to  New  York  Surgical  Society  Feb- 
ruary 28,  1900). — Julia  C ,  thirty-eight  years  old, 

married;  employed  at  housework;  born  in  United 
States.  Admitted  to  St.  Luke's  Hospital  October, 
1899.  She  was  never  pregnant,  and  had  enjoyed  pre- 
vious good  health.  Four  years  before  admission  she 
began  to  be  troubled  with  eructations — "heart-burn." 
Her  symptoms  increased,  but  there  was  no  actual  pain 
in  the  stomach.  Nausea  and  vomiting  set  in  two 
years  before  admission,  and  gradually  the  vomiting 
became  so  complete  that  only  fluids  were  retained,  and 
the  patient  lost  ninety  pounds  in  the  last  year.  She 
now  weighs  only  one  hundred  and  twenty  pounds,  al- 
though of  large  frame.  Six  months  and  three  months 
ago,  and  again  lately,  she  has  had  attacks  of  '"  coffee- 
ground  ''  vomiting.  A  small  tumor  was  felt  at  the 
pylorus.  Examination  of  the  stomach  contents  showed 
the  hydrochloric  acid  slightly  diminished,  lactic  acid 
absent,  and  digestion  of  proteids  reduced. 

On  October  28,  1899,  pylorectomy  was  done  by 
Kocher's  method.  In  the  portion  removed  an  ulcer 
two  and  one-half  inches  in  diameter  was  found  on  the 
anterior  wall,  with  a  greatly  thickened  base,  the  latter 
having  occasioned  the  pyloric  stenosis  as  it  extended 
to  the  pyloric  ring.  The  patient  made  a  good  recov- 
ery, and  on  March  5,  1900,  weighed  one  hundred  and 
sixty  pounds,  being  able  to  eat  everything.  The  path- 
ologist reports  that  the  base  of  the  ulcer  is  carcinom- 
atous, but  some  enlarged  glands  removed  with  the 
tumor  were  free. 

It  is  not  surprising  that  the  frequency  of  the  asso- 
ciation of  chronic  ulcer  and  of  carcinoma  has  not 
been  brought  out  sooner.  When  the  study  of  carcinoma 
of  the  stomach  depended  upon  post-mortem  examina- 
tion, or  even  upon  operations  performed  in  cases  with 
well-developed  tumors,  it  was  impossible  to  say  if  any 
other  pathological  changes  had  preceded  the  malignant 
disease,  for  the  latter  would  by  that  time  have  de- 
stroyed any  evidence  of  the  previous  lesion.  It  was 
only  with  the  development  of  the  modern  methods  of 
diagnosis  in  stomach  diseases,  and  especially  of  the 


modern  surgical  treatment  of  benign  lesions  of  the 
stomach,  that  the  coexistence  of  an  ulcer  and  a  begin- 
ning carcinoma  was  likely  to  be  discovered.  The 
clinical  history  will  show  more  often  than  has  been 
realized  that  a  grave  lesion  of  the  stomach  must  have 
preceded  the  cancer  by  years.  But  this  history  cannot 
be  relied  upon  entirely,  for  many  cases  of  chronic 
ulcer  run  a  latent  course  like  those  described  above, 
and  give  no  sign  until  pyloric  stenosis  develops. 

The  practical  outcome  of  these  consideration  is  that 
every  patient  who  gives  evidence  of  serious  stomach 
trouble  should  be  carefully  studied  and  an  accurate  and 
early  diagnosis  made  if  possible.  This  study  should  in- 
clude a  careful  physical  examination  of  the  abdomen, 
in  order  to  determine  the  presence  or  absence  of  a 
tumor,  and  the  outlines  of  the  stomach  and  colon 
should  be  ascertained  by  distending  these  organs  with 
air  or  water.  It  would  also  include  a  chemical  ex- 
amination of  the  stomach  contents  and  a  microscopic 
examination  of  the  solid  particles  found  in  the  wash- 
ings. With  a  little  tact  patients  can  be  induced  to  sub- 
mit to  the  use  of  the  stomach  tube  and  the  necessary 
manipulations.  We  are  not  doing  our  duty  if  we  pre- 
scribe medical  treatment  which  will  merely  relieve  the 
most  urgent  or  annoying  symptoms — rather  should  we 
use  those  symptoms  to  persuade  the  patient  to  undergo 
a  thorough  examination.  To  neutralize  the  acidity  of 
the  stomach  with  alkalies,  relieve  the  pain  by  anes- 
thetics, or  control  the  vomiting  by  fluid  diet  in  such 
cases,  without  trying  to  discover  the  cause  of  these 
symptoms,  is  not  merely  foolish  temporizing,  it  is  crim- 
inal neglect. 

If  the  indications  for  operation  mentioned  above — 
the  presence  of  a  tumor,  vomiting,  dilatation  of  the 
stomach,  or  chemical  changes — are  found,  operation 
should  be  advised  even  if  the  diagnosis  is  not  alto- 
gether certain,  in  the  expectation  that  an  exploratory 
operation  will  not  merely  settle  the  diagnosis,  but  will 
probably  reveal  some  definite  lesions  which  can  be  re- 
lieved by  surgical  procedures.  These  indications  for 
operation  are  worthy  of  consideration  even  in  cases  in 
which  the  symptoms  are  not  very  serious,  but  are  ob- 
stinate, and  persist  in  spite  of  thorough  treatment  by 
drugs,  diet,  and  lavage.  If  the  diseases  have  advanced 
too  far  for  a  chance  of  cure  by  radical  operation,  it 
may  admit  of  palliative  measures,  such  as  gastro-en- 
terostomy,  which  will  prolong  life  and  make  its  end 
less  distressing.  Even  if  the  case  is  one  of  very  long 
duration  and  seems  unfavorable  for  a  radical  cure, 
there  is  still  a  possibility  that  the  laparotomy  may  re- 
veal a  condition  in  which  thorough  extirpation  of  the 
tumor  may  have  some  chance  of  permanent  success. 
Streit '  reports  fifty-four  cases  of  cancer  of  the  stomach 
examined  post  mortem  in  which  he  found  that  even  at 
that  late  period,  when  the  disease  had  caused  death, 
the  local  conditions  would  still  admit  of  successful  re- 
section in  twenty-five  per  cent,  of  the  cases. 

Gastro-enterostomy  has  its  limitations  as  well  as  re- 
section. Heimann'-  found  that  about  fifty  per  cent,  of 
the  cases  of  cancer  of  the  stomach  submitted  to  opera- 
tion in  Germany  in  1895  and  1896  were  treated  by 
gastro-enterostomy.  Gastro-enterostomy  overcomes  the 
consequences  of  the  obstruction  of  the  pylorus  or  of 
dilatation  of  the  stomach  through  muscular  atrophy. 
The  operation  acts  by  providing  a  free  outlet  from  the 
stomach  and  by  accomplishing  drainage  of  the  large 
pocket  formed  by  the  dilatation.  It  has,  therefore,  two 
favorable  effects — first  it  improves  nutrition  by  ena- 
bling the  food  to  pass  on  into  the  intestine  for  absorp- 
tion ;  and,  secondly,  it  drains  the  stomach  and  thus 
limits  the  fermentation  and  lessens  the  absorption  of 
poisons  produced  by  tiiis  decomposition.  The  per- 
formance of  gastro-enterostomy,    however,   will   have 

'  Deutsche  Zeitschrift  flir  Chirurgie,  xxvii.,  410. 
•  Loc.  (it. 


August  4,  1900] 


MEDICAL    RECORD. 


165 


little  or  no  effect  when  pain  is  the  prominent  symptom 
of  the  cancer,  for  the  reason  that  the  pain  seldom  if 
ever  originates  in  the  stomach  itself  in  these  cases, 
but  is  generally  due  to  the  pressure  of  the  enlarged 
retroperitoneal  glands  on  the  nerves,  and  is  naturally 
not  affected  by  drainage  of  the  stomach.  There  are 
certain  other  contraindications  to  gastro-enterostomy, 
namely,  such  excessive  weakness  of  the  patient  as  to 
make  death  probable  from  the  shock  of  the  operation, 
and  such  extensive  disease  as  to  leave  no  point  free  at 
whicii  the  outlet  can  be  made.  Wolfler'  found  in  one 
hundred  and  forty-nine  cases  of  gastro-enterostomy  per- 
formed for  cancer,  collected  from  tiie  German  clinics, 
a  mortality  of  thirty  per  cent.  'J'iie  longest  survival 
after  operation  was  two  and  one-quarter  years,  the  aver- 
age interval  before  death  being  only  six  months. 
Murphy  reported  ''  sixty-one  cases  operated  upon  by 
his  button  method,  with  a  mortality  of  forty-six  per 
cent.,  but  this  is  a  list  of  all  recorded  cases  and  should 
not  be  compared  witii  VVolfler's  series,  selected  from 
certain  first-class  clinics. 

The  weak  condition  of  patients  with  cancer  explains 
the  high  rate  of  mortality — certainly  three  times  as 
great  as  the  mortality  of  the  same  operation  performed 
for  benign  lesions  of  the  stomach.  It  also  explains 
why  the  palliative  operation  has  almost  as  high  a  rate 
of  mortality  as  the  operation  for  the  removal  of  the 
tumor,  for  resection  is  undertaken  only  in  patients  in 
the  earlier  stages  of  the  disease,  who  are  in  much  bet- 
ter condition  than  tlie  average  patient  submitted  to 
gastro-enterostomy.  Yet  in  spite  of  the  high  mortal- 
ity the  operation  is  well  worth  the  danger  it  involves, 
for  it  relieves  the  patient  of  the  harassing  vomiting 
and  the  sensations  of  starvation,  and  obtains  for  him 
a  much  more  comfortable  and  gradual  sinking  of  his 
strength  without  seriously  annoying  symptoms. 

15.  Carcinoma  of  the  Intestine. -^Not  long  ago 
carcinoma  of  the  intestine  and  of  the  stomach  would 
have  been  classed  together  from  a  clinical  point  of 
view,  both  occurring  in  organs  consisting  of  a  muco- 
musculo-peritoneal  canal  containing  digestive  mate- 
rial, and  differing  only  in  the  more  active  chemical 
changes  of  the  upper  end  toward  the  stomach  and  in 
the  more  active  bacteriological  life  of  the  lower  part. 
They  have  now,  however,  assumed  very  different  posi- 
tions, because  the  advances  made  in  the  chemical  ex- 
amination of  the  contents  of  the  stomach  have  rendered 
much  assistance  in  the  diagnosis  of  the  gastric  lesions, 
while  our  knowledge  of  intestinal  diseases  has  not 
progressed  so  far.  Malignant  tumors  of  the  intestine, 
with  the  exception  of  those  in  the  rectum,  are  quite 
rare.  According  to  Heimann,8.5  per  cent,  of  all  can- 
cers occur  in  the  intestine,  but  nearly  three-quarters  of 
t.hese  are  situated  in  the  rectum.  The  scope  of  the 
present  paper  does  not  include  the  lower  rectal  tumors, 
as  they  should  be  studied  rather  in  connection  with 
pelvic  disease,  or  with  external  tumors,  but  the  tumors 
higher  up  in  the  rectum  have  the  same  characteristics 
as  those  of  the  sigmoid  flexure.  Sarcoma  of  the  bowel 
is  rare,  nearly  all  its  malignant  tumors  being  carci- 
noma. The  sarcomata  are  found  more  frequently  in 
the  small  intestine  than  in  the  large,  but  are  so  rare 
as  to  be  of  little  surgical  importance.  Primary  car- 
cinoma of  the  small  intestine  is  also  rare,  the  great 
majority  of  these  tumors  occurring  in  the  large  intes- 
tine. Even  in  the  large  intestine  there  are  certain 
portions  in  which  the  tumors  are  especially  likely  to 
grow%  the  most  common  situations  being  the  sigmoid 
flexure,  the  splenic  Hexure,  and  the  ileo-caecal  region. 
Carcinoma  of  the  large  intestine  is  found  in  two 
very  different  varieties.  In  the  first  variety  tumors  of 
a  considerable  size  are  formed,  and  such  tumors  are 
apt  to  be  of  colloid  material.     They  are  most  frequently 

'  /-.v.  at. 

''  Medical  News,  February  and  November,  iSg5,  pp.  141.  533. 


found  in  the  neighborhood  of  the  ileo-caecal  valve, 
but  do  not  obstruct  the  passage  of  the  bowl  materially 
in  spite  of  their  size. 

The  other  form  is  the  annular  tumor,  which  is  far 
more  common  than  are  the  large  colloid  masses.  The 
annular  tumor  contains  a  large  proportion  of  fibrous  tis- 
sue in  its  structure  and  the  intestinal  wall  involved  in 
it  is  contracted,  so  that  instead  of  producing  a  tumor- 
like mass,  the  diseased  parts  are  actually  smaller  than 
before.  'J'hese  annular  growths  invade  the  epithelium 
first,  spreading  in  a  ring-like  manner  round  the  inner 
surface  of  the  bowel,  and  the  multijilication  of  the 
epithelial  cells  is  accompanied  by  an  abundant  growth 
of  connective  tissue,  forming  a  dense  fibrous  stroma. 
Its  growth  is  slow,  the  epithelial  changes  invading  the 
healthy  tissues  at  the  edges  of  the  annular  lesion,  and 
spreading  upward  and  downward,  constantly  widening 
tlie  annular  band.  The  connective-tissue  stroma  in 
the  submucous  coat  contracts  and  cuts  off  the  blood 
supply  at  the  centre  of  the  lesion,  causing  a  tendency 
to  sloughing  in  the  e])ithelial  cells  and  the  production 
of  a  ring-like  ulcerated  surface  in  the  centre  of  the  an- 
nular band.  Where  the  ulcer  is  deepest  there  arefew 
epithelial  cells,  its  base  being  mostly  formed  of  fibrous 
tisue,  with  a  granulating  surface.  The  central  por- 
tion of  the  growth  continues  to  contract  by  virtue  of 
the  cicatricial  propeity  of  the  fibrous  tissue  and  makes 
an  annular  stricture  of  the  bowel  at  this  point,  which 
projects  internally  into  the  lumen  like  a  diaphragm, 
while  externally  it  forms  a  groove  by  drawing  the  outer 
coats  of  the  bowel  inward,  with  the  appendices  epi- 
ploicas  and  the  mesentery.  At  this  stage  the  outside  of 
the  bowel  appears  on  inspection  to  have  had  a  con- 
stricting thread  tied  tightly  around  it,  making  a  groove 
which  is  almost  concealed  by  bunches  of  fat  made  up 
of  the  appendices  and  mesentery,  which  are  drawn 
toward  it.  When  the  affected  bowel  is  palpated,  a 
small  hard  thickening  is  felt  in  its  wall,  which  is  the 
annular  growth,  but  if  any  considerable  tumor  is  pres- 
ent, the  bulk  of  the  mass  is  made  up  of  the  appendices 
and  other  parts  drawn  into  it  by  its  contractile  power, 
and  not  of  the  new  growth  itself.  A  longitudinal  sec- 
tion of  the  bowel  shows  very  clearly  the  narrowing  of 
its  lumen  by  the  drawing  in  of  all  the  coats  as  if  by 
this  imaginary  thread. 

The  epithelial  growth  is  so  slow  that  the  width  of 
the  annular  lesion  may  not  be  over  an  inch,  although 
symptoms  of  constriction  have  been  present  for  a  year 
ur  more. 

Equally  slow  is  the  glandular  involvement.  Larde- 
nois'  calls  attention  to  the  arrangement  of  the  lymphat- 
ics, as  shown  by  Sappey's  dissections,  which  explain 
both  the  peculiar  form  of  the  growth  and  the  slow  gland- 
ular involvement.  The  lymphatics  of  the  intestine  may 
be  divided  into  a  submucous  and  a  subserous  set. 
.Sappey  states  that  both  sets  run  circularly  around  the 
bowel  like  the  blood-vessels,  and  discharge  into  small 
nodes  at  the  mesenteric  attachment.  There  is  com- 
paratively little  communication  between  the  two  sets 
of  lymphatics.  Having  entered  the  small  lymphoid 
nodes  at  the  mesenteric  border  of  the  bowel,  the  lym- 
phatic vessels  issue  from  them  unchanged  in  size,  form 
a  reticulum  along  the  mesentery,  and  then  pass  through 
another  set  of  nodes  near  the  first  before  reaching  the 
larger  lymphatic  glands  at  the  root  of  the  mesentery. 
Any  material  which  may  enter  the  lymphatics  must 
pass  through  three  lines  of  defence — the  small  nodes 
at  the  attachment  of  the  mesentery,  the  second  row  be- 
yond, usually  known  as  the  "  mesenteric  glands,"  and 
finally  the  retroperitoneal  glands  at  the  root  of  the 
mesentery,  before  a  general  infection  can  take  place. 
We  frequently  find  the  glands  entirely  free  or  the  in- 
fection extending  only  to  the  first  row  of  glands  in 
cases  in  which  it  is  evident  from  the  size  and  connec- 
'  "  Traitc  de  ciiirurgie  du  cancer  dii  j;ros  intestin,"  Paris,   1899. 


1 66 


MEDICAL   RECORD. 


[August  4,  1900 


tions  of  the  tumor  that  it  must  have  been  in  existence 
for  a  long  time.  This  slow  extension  is  also  evidenced 
by  the  fact  that  patients  have  remained  well  for  long 
periods  after  the  removal  of  a  tumor  with  glands 
shown  to  be  carcinomatous. 

In  many  of  the  malignant  growths  of  the  bowel  the 
minute  structure  is  often  misleading  in  its  character, 
as  it  is  marked  by  a  very  exact  reproduction  of  the 
tubular  glands  of  the  intestinal  mucous  membrane, 
with  very  little  or  no  tendency  of  the  epithelial  cells 
to  penetrate  the  basement  membrane  and  infiltrate  the 
fibrous  stroma.  The  minute  structure  even  in  the  late 
stages  is  often  that  of  an  adenoma  rather  than  of  a 
carcinoma,  and  this  fact  may  also  partially  explain  their 
slow  course.  But,  in  spite  of  these  benign  character- 
istics, the  tumors  are  exceedingly  likely  to  return 
after  removal  unless  widely  excised,  and  at  every  re- 
currence the  tumor  becomes  more  malignant.  A  con- 
siderable number  of  cases  are  on  record  in  which  mul- 
tiple polypi  of  adenomatous  structure  have  preceded 
the  development  of  the  more  malignant  growth. 

Malignant  tumors  of  the  bowel  are  almost  always 
single,  but  a  few  cases  are  on  record  in  which  multiple 
carcinomatous  strictures  of  the  large  and  small  intes- 
tine existed,  and  Kuttner  has  reported  "  a  case  in  which 
as  manv  as  twenty-two  strictures  were  found.  In  a 
case  of  Korte,  after  removal  of  a  tumor  from  the  sig- 
moid Hexure  the  patient  died  from  intestinal  obstruc- 
tion, caused  by  a  second  annular  carcinoma  at  the 
splenic  flexure. 

As  is  thecase  with  the  similar  tumors  of  the  stomach, 
the  symptoms  and  course  of  carcinoma  of  the  intes 
tine  are  largely,  and  sometimes  entirely,  the  result  of 
the  mechanical  obstruction  of  the  bowel,  occasioned 
by  the  new  growth.  The  patient  may  have  chronic  con- 
stipation, occasionally  developing  into  attacks  of  com- 
plete obstruction,  and  this  is  sometimes  accompanied 
with  violent  attacks  of  colic.  In  other  cases  the  bow- 
els move  regularly,  and  the  patient  is  not  aware  of  any 
disturbance  of  his  health,  but  suddenly  acute  obstruc- 
tion sets  in,  and  when  the  abdomen  is  opened,  the  local 
examination  shows  an  annular  growth  in  the  bowel,  with 
an  opening  through  the  stricture  so  narrow  that  a 
cherry  pit,  or  even  an  apple  seed,  is  sufficient  to  plug 
it,  and  it  seems  marvellous  that  so  close  a  stricture 
could  exist  for  so  long  a  time  without  symptoms. 
Probably  in  these  cases  the  muscular  hypertrophy  of 
the  bowel  above  the  tumor,  with  unusual  fluidity  of 
the  intestinal  contents,  has  been  sufficient  to  maintain 
the  passage  through  the  stricture  until  it  has  been  sud- 
denly plugged  by  the  foreign  body. 

In  some  cases' the  stagnation  of  the  contents  of  the 
bowel  above  the  stricture  may  give  rise  to  an  ulcera- 
tive inflammation  with  a  discharge  of  muco-pus  in  the 
stools  and  a  tendency  to  diarrhcea.  This  ulcerative 
process  may  also  cause  a  localized  peritonitis  or  an 
actual  perforation  of  the  bowel,  resulting  in  general 
peritonitis  or  in  the  formation  of  a  local  abscess. 
Metastatic  abscesses  of  the  liver  or  elsewhere  may  also 
be  the  consequence  of  this  ulceration  of  the  bowel, 
and  death  may  result  in  this  indirect  manner.  Ac- 
cording to  Treves,'  blood  is  to  be  found  in  the  stools 
in  fifteen  per  cent,  of  these  cases,  but  hemorrhage  is 
usually  a  late  symptom,  and  indicates  an  ulcerated 
tumor,  rather  low  down.  In  very  rare  cases  the  strict- 
ure has  completely  closed  the  bowel  and  caused  its 
rupture  above  with  fatal  peritonitis,  or  an  anastomotic 
opening  has  formed  after  adhesions  had  united  a  loop 
of  bowel  above  the  stricture  with  a  loop  below  it. 

It  may  truthfully  be  said  that  intestinal  cancer  affects 
the  health  and  causes  death  chiefly  by  the  purely  me- 
chanical obstruction  of  the  bowel  which  it  produces, 
or  by  some  consequence  of  that  obstruction,  such  as 

'  Beitra^e  zur  klinischen  Cliirurgie,  .\xiii.,  lift.  2, 
■■'      Intestinal  Obstruction,"  cliap.  xiii. 


ulceration  and  pya;mia,  or  perforation  and  peritonitis. 
In  some  cases,  however,  the  obstruction  is  not  com- 
plete, and  then  death  is  caused  by  a  cachexia,  brought 
on  by  changes  in  the  blood,  metastasis  in  vital  organs, 
or  such  complete  involvement  of  the  mesenteric  glands 
and  the  liver  as  to  impair  the  digestion  and  absorption 
of  food.  From  these  facts  it  results  that  an  early  diag- 
nosis of  carcinoma  of  the  intestine  is  seldom,  if  ever, 
to  be  made,  but  that  in  spite  of  this  difficulty  even  late 
operations  may  effect  a  permanent  cure,  or  at  least 
greatly  prolong  the  patient's  life. 

The  diagnosis  of  cancer  of  the  bowel  is  to  be  made 
from  obstinate  chronic  constipation,  or  constipation 
which  alternates  with  diarrhcea.  But  it  should  also 
be  remembered  that  chronic  diarrhcea,  with  a  muco- 
purulent discharge,  may  be  the  sole  symptom,  with  no 
tendency  to  constipation.  Attacks  of  intestinal  colic, 
with  more  or  less  intestinal  obstruction  of  a  subacute 
type,  which  yield  to  medication,  the  attacks  of  colic 
growing  more  severe  and  becoming  more  frequent  as 
the  case  advances,  form  another  common  clinical  pic- 
ture. These  attacks  may  progress  almost  to  complete 
obstruction,  and  yet  finally  yield  to  medical  treatment. 
True  fecal  vomiting  is  not  very  common  on  account  of 
the  low  situation  of  the  obstruction.  Occasionally 
blood  or  pus  will  be  found  in  the  stools.  Very  seldom 
can  reliance  be  placed  upon  stools  of  ribbon  or  pill- 
like shape,  for  there  are  many  other  conditions  besides 
stricture  of  the  intestine  which  cause  the  faeces  to  take 
this  form.  In  some  cases  a  tumor  may  be  felt  in  the 
abdomen  or  upper  rectum,  and  the  rectal  and  vaginal 
examinations  should  never  be  omitted  when  a  tumor 
of  the  intestine  is  suspected.  Some  tumors  of  the  sig- 
moid flexure  can  be  discovered  only  by  bimanual  pal- 
pation in  this  manner.  The  significance  of  these 
symptoms  will  be  greatly  increased  if  the  patient  is 
forty  years  of  age  or  older,  and  if  he  has  been  losing 
weight,  growing  pale  or  yellowish,  and  has  vague 
symptoms  of  indigestion,  such  as  pain,  tendency  to 
nausea,  etc.  A  tumor  will  often  be  discovered  acci- 
dentally before  any  other  definite  symptoms  develop, 
and  such  cases  are  the  most  fortunate,  for  in  them  the 
indication  for  operation  is  the  clearest. 

The  indication  for  operation  is  equally  urgent, 
however,  if  the  patient  presents  a  history  of  consti- 
pation (with  or  without  diarrhcea  at  intervals)  and 
has  severe  recurrent  attacks  of  colic,  with  obstruc- 
tion, such  as  described.  It  is  not  enough  to  treat 
such  patients  by  drugs  and  diet,  although  they  may 
be  made  comfortable  by  that  course,  and  the  attacks 
may  be  rendered  less  frequent.  What  has  been  said 
in  regard  to  those  who  suffer  from  severe  gas- 
tric symptoms  is  also  true  of  patients  with  symp- 
toms indicating  even  slight  obstruction  of  the  intes- 
tine- we  must  devote  the  greatest  possible  care  to  the 
study  of  these  cases  in  order  to  determine  at  the  ear- 
liest possible  moment  the  presence  of  malignant  dis- 
ease. Every  patient  with  such  symptoms  should  be 
thoroughly  and  repeatedly  examined  by  palpation  of 
the  abdomen  and  by  the  rectum,  for  one  examination, 
or  even  several,  may  prove  futile,  and  yet  finally  the 
tumor  may  come  under  the  surgeon's  hands.  Some  of 
these  tumors  are  so  small  and  so  movable  that  it  is 
difficult  to  recognize  them  unless  they  are  actually 
pressed  between  the  fingers  and  the  posterior  abdom- 
inal wall.  The  patients  are  liable  to  an  accumulation 
of  gas  in  the  intestines,  which  materially  interferes 
with  the  examination.  The  diagnosis  of  chronic  con- 
stipation so  often  entered  upon  our  case  books  should 
be  given  up,  and  a  more  scientific  recognition  of  the 
causes  of  constipation  substituted  for  it.  A  certain  num- 
ber of  cases,  in  which  no  tumor  has  been  recognized, 
will  come  to  the  surgeon  at  a  late  period  because  of 
intestinal  obstruction  or  perforation  of  the  bowel,  with 
general  peritonitis,  or  the  formation  of  an  abscess.     In 


August  4,  1900] 


MEDICAL    RECORD. 


167 


1892  I  was  called  to  operate  for  an  intra-peritoneal  ab- 
scess developing  in  an  Irisiiman  sixty  years  of  age, 
who  had  been  ill  only  two  days  and  a  half.  Two  or 
three  ounces  of  pus  were  discharged  through  an  inci- 
sion over  the  tumor,  near  the  middle  line  below  the 
navel.  A  sinus  persisted,  and  there  was  deep  indura- 
tion surrounding  it,  and  in  1894,  when  I  accidentally 
saw  him  again,  he  had  a  large  mass  of  new-growth, 
half  filling  the  abdomen,  and  was  emaciated  beyond 
recognition.  Of  the  other  type  of  acute  or  subacute 
obstruction  of  the  bowels,  coming  on  while  the  patient 
was  in  apparently  good  health  and  due  to  sudden  ])lug- 
ging  of  a  carcinomatous  stricture  of  the  bowel,  I  have 
seen  several  cases,  all  of  them  in  the  sigmoid  flexure. 

I  need  not  dwell  here  upon  the  various  points  upon 
which  to  rest  the  diagnosis  of  the  situation  of  tumors 
of  the  intestine,  but  merely  remark  that  the  diagnosis 
of  the  exact  seat  of  the  lesion  can  be  made  in  a  certain 
number  of  cases  if  pains  be  taken  in  the  examination. 
In  cases  in  which  no  tumor  can  be  felt,  but  recurrent 
attacks  of  colic  or  subacute  intestinal  obstruction  are 
present,  or  in  which  there  is  chronic  constipation  to  an 
extreme  degree  (with  or  without  diarrhoea),  exploratory 
laparotomy  is  justified.  It  is  true  that  there  are  many 
benign  conditions  which  may  cause  these  symptoms, 
such  as  peritoneal  adhesions  and  bands,  kinks  or  vol- 
vulus of  the  bowel,  pressure  upon  the  gut  by  inflam- 
matory masses,  enteroptosis,  and  so  on,  but  the  great 
majority  of  these  conditions  can  be  relieved  bv  sur- 
gical treatment,  and  often  can  be  benefited  by  no  other 
means. 

The  surgical  treatment  of  carcinoma  of  the  intestine 
consists  in  radical  removal  of  the  tumor,  or  in  merely 
relieving  the  obstruction  without  attempting  to  remove 
the  tumor.  The  mortality  of  resection  of  the  intestine 
is  serious,  but  it  is  constantly  being  reduced,  and  in 
simple  cases  should  hardly  exceed  that  of  pylorectomy. 
Wolfler  gives  thirty-three  per  cent,  as  the  mortality  of 
the  same  set  of  surgeons  upon  whose  stomach  work  he 
reported.  This  high  mortality  is  due  to  including  ir 
the  lists  many  cases  of  very  large  tumors  the  removal 
of  which  was  very  difficult,  and  also  some  cases  in 
which  resection  of  the  intestine  was  undertaken  when 
acute  obstruction  of  the  bowels  was  present  and  the 
patient  was  in  very  poor  condition.  Schiller  has  lately 
reported  a  series  of  cases  from  Czerny's  clinic,  with  a 
mortality  of  fifty  per  cent.  In  this  series  three  pa- 
tients remained  well  respectively  for  ten,  five  and  a 
half,  and  three  and  a  quarter  years,  three  patients  re- 
mained well  for  fourteen  to  sixteen  months,  and  still 
continued  under  observation.  Thus  three  patients  re- 
mained well  for  over  three  years  out  of  the  ten  who 
survived  the  operation.  Wolfler  reports  fifteen  pa- 
tients W'ho  remained  well  from  one  and  a  half  to  three 
and  one-half  years,  seven  remained  well  for  four  years, 
two  for  six  years,  and  one  for  seventeen  years.  These 
were  principally  cases  of  carcinoma  of  the  large  intes- 
tine. 

The  mortality  varies  greatly  with  the  part  of  the 
bowel  removed,  and  especially  with  the  cause  for  the 
operation,  resection  of  the  cajcum  giving  the  best  re- 
sults. Czerny  had  eight  and  Korte  nine  resections  at 
this  point  with  only  one  death.  The  mortality  of  re- 
sections of  the  bowel  for  tumors  is  much  greater  than 
that  of  the  same  operation  for  other  reasons.  Korte 
has  recently  reported  eighteen  cases  of  resection  for 
tumor,  with  only  six  deaths;  there  were  six  cases  of 
tumor  of  the  ileo-ca;cal  portion,  in  all  of  which  the  pa- 
tients recovered,  one  patient  living  eight  years  and  two 
patients  living  five  years  without  recurrence.  In  six 
cases  the  tumor  lay  in  the  transverse  colon,  and  only 
two  patients  recovered,  one  remaining  well  five  and 
one-half  years.  The  remaining  six  cases  were  of  tumors 
of  the  descending  colon  and  sigmoid  flexure,  in  which 
four  patients  recovered,  remaining  well  respectively 


for  two  and  one-half  years,  one  and  one-half  years,  one- 
half  year,  and  in  one  case  for  an  unknown  period.  I 
ha\'e  quoted  these  figures  fully  because  they  give  some 
idea  of  the  chances  of  recovery  from  operation  and  for 
obtaining  a  radical  cure. 

The  palliative  oi^erations  consist  in  the  formation  of 
an  artificial  anus  or  the  making  of  an  anastomosis  be- 
tween the  bowel  at  a  point  above  and  below  the  strict- 
ure, to  which  latter  operation  may  be  added  the  so- 
called  exclusion  of  the  diseased  part  of  the  bowel. 
The  formation  of  an  intestinal  anastomosis  will  often 
enable  us  to  dispense  with  the  inconvenience  of  an 
artificial  anus,  but  neither  this  operation  nor  resection 
should  be  attempted  in  the  presence  of  acute  obstruc- 
tion. When  the  obstruction  of  the  bowel  is  complete, 
or  nearly  so,  and  the  patient  is  in  poor  condition,  the 
only  proper  method  of  treatment  is  at  once  to  relieve 
the  obstruction  by  the  formation  of  an  artificial  anus, 
leaving  the  treatment  of  the  tumor  to  a  later  period. 
This  should  be  placed  preferably  in  the  left  groin,  for 
an  opening  in  the  cjecum  is  apt  to  be  more  trouble- 
some, because  the  greater  fluidity  of  the  contents  in- 
creases greatly  the  difliculty  of  their  retention.  A  lum- 
bar colostomy  on  the  left  side  would  be  preferable  to 
opening  the  caecum,  if  one  could  be  sure  that  the  point 
of  stricture  lay  in  the  sigmoid  flexure.  Even  if  the 
tumor  cannot  be  removed  great  relief  may  be  afforded 
and  life  may  he  indefinitely  prolonged  without  serious 
discomfort  by  the  artificial  anus,  and  it  should  be  made 
in  every  case  as  soon  as  symptoms  of  obstruction  pre- 
sent. Modern  methods  of  forming  the  artificial  anus 
render  it  possible  to  make  it  sufficiently  tight  to  con- 
trol solid  faeces,  sometimes  even  providing  a  sphincter- 
like action  of  the  fibres  of  the  abdominal  muscles 
around  the  opening,  so  that  life  becomes  quite  bear- 
able. 

The  newer  operation  of  intestinal  anastomosis  fulfils 
the  same  indication  as  an  articifial  anus,  for  it  relieves 
the  obstruction,  and  it  might  be  almost  termed  an  in- 
ternal anus.  It  is  suitable  for  many  cases  of  tumors 
of  the  intestine  which  cannot  be  removed,  but,  as  I 
have  said,  should  not  be  undertaken  in  the  face  of 
acute  intestinal  obstruction.  The  external  anus  should 
be  made  first  and  the  intestinal  anastomosis  done  as  a 
secondary  operation,  the  artificial  anus  being  then  al- 
lowed to  close.  The  bad  condition  of  the  intestinal 
wall  renders  it  dangerous  to  make  an  opening  in  the 
bowel  above  the  obstruction  when  it  is  acutely  dis- 
tended. \\'olfler  reports  the  mortality  of  intestinal 
anastomosis  to  be  thirty  per  cent.,  but  Marwedel  has 
reduced  his  mortality  for  this  operation  to  twelve  per 
cent. 

Attempts  have  been  made  to  shut  off  entirely  the  dis- 
eased part  of  the  bowel — the  operation  called  "exclu- 
sion of  the  intestine."  In  this  operation  an  intestinal 
anastomosis  is  made  between  the  bowel  above  and  that 
below  the  point  of  stricture,  and  the  bowel  is  then  en- 
tirely divided  above  and  below  the  tumor  between  the 
latter  and  the  anastomosis.  One  end  of  the  diseased 
bowel  must  be  attached  to  the  abdominal  wound,  so  as 
to  admit  of  the  escape  of  its  discharges,  and  the  other 
closed  if  desired.  Wolfler  reports  twenty-two  cases  of 
this  operation  performed  for  various  conditions,  not 
merely  for  cancer,  with  three  deaths,  a  mortality  of 
fourteen  per  cent.,  but  undoubtedly  the  mortality  for 
the  cases  of  malignant  disease  alone  would  be  some- 
what higher.  The  advantages  claimed  for  this  modi- 
fication of  the  operation  of  anastomosis  is  that  it  will 
keep  the  fecal  matter  from  contact  with  the  tumor  and 
lessen  the  liability  to  ulceration,  while  it  will  allow 
external  escape  to  the  discharges  without  interfering 
with  the  normal  bowel  below.  It  is  as  yet  uncertain 
what  is  gained  by  this  method  of  treatment,  and  more 
experience  is  necessary  before  passing  judgment  upon 
it. 


1 68 


MEDICAL   RECORD. 


[August  4,  1900 


The  operation  of  intestinal  anastomosis  has  one  dis- 
advantage as  compared  with  the  artificial  anus.  In 
the  latter  operation  it  is  possiljle  to  select  a  point  in 
the  bowel  far  away  from  the  tumor  and  not  likely  to 
be  invaded  later  by  the  disease.  In  intestinal  anasto- 
mosis the  point  of  anastomosis  is  apt  to  be  near  the 
diseased  part  of  the  bowel,  and  in  a  considerable  num- 
ber of  cases  it  becomes  involved  in  the  disease  later. 
In  two  cases  of  my  own,  however,  the  patients  lived 
for  five  months  and  eight  months  after  the  anastomo- 
sis was  completed,  dying  of  cachexia,  without  any  fur- 
ther obstruction.  In  both  cases  the  tumor  was  in  the 
sigmoid  He.xure,  and  the  anastomosis  was  made  between 
a  loop  of  the  sigmoid  just  above  the  tumor  and  the 
upper  part  of  the  rectum. 

I  have  no  better  statistics  to  give  for  the  duration 
of  life  after  an  artificial  anus  than  Bryant's,'  who  in  one 
hundred  and  nineteen  cases  found  that  thirty-six  died 
in  the  first  year,  forty-three  in  the  second,  and  twenty- 
six  in  the  third,  while  twelve  lived  from  three  to  six 
years  after  the  operation.  Probably  the  results  of  in- 
testinal anastomosis  would  be  nearly  the  same,  but 
with  a  higher  mortality  and  a  greater  liability  to  re- 
newed obstruction. 

7  East  Forty-first  Street. 


HYDROTHERAPY    IN    PNEUMONIA.' 

By   SIMON    BARUCH.    M.D. 

NEW    YORK. 

A  GLANCE  at  the  treatment  of  acute  diseases  during 
the  past  half-century  reveals  the  fact  that  a  revolution 
has  taken  place,  which  has  culminated  in  the  practi 
cal  abolition  of  the  treatment  of  these  diseases.  In 
our  own  country  this  revolution  was  initiated  by  Jacob 
Bigelow,  a  former  member  of  this  society,  by  his  work 
on  the  "  Self-Limitation  of  Diseases,"  published  in 
1835,  and  by  his  later  work  on  "Nature  in  Disease." 
Re-enforced  by  the  good  sense  and  captivating  elo- 
quence of  your  Oliver  Wendell  Holmes,  American 
medical  men  have  been  slowly — alas,  too  slowly!  — 
changed  from  destructive  to  constructive  therapy.  We 
realize  to-day  that,  with  few  exceptions,  the  raanifesta 
tions  of  disease  are  but  the  outward  expression  of 
pathological  conditions  which  no  remedial  agent  is 
capable  of  removing.  This  proposition  will  not  be 
construed  by  any  fair  mind  as  an  abandonment  of  the 
patient  to  his  fate,  it  simply  emphasizes  the  fact 
that  we  no  longer  attack  the  disease  by  violent  medi- 
cation, as  was  formerly  done  by  bloodletting  and 
mercury  and  blisters,  later  by  veratrum  and  aconite, 
and  more  recently  by  antipyretics.  If  the  symptoms 
of  disease  were  really  the  essence  of  disease,  our  com- 
plete control  of  the  pulse  by  veratrum,  of  temperature 
by  antipyrin,  of  sleep  by  chloral,  of  pain  by  morphine, 
of  feebleness  by  the  modern  foods  and  stimulants 
would  to-day  insure  our  triumph  over  disease.  The 
fact  that,  despite  the  response  of  the  most  significant 
symptoms  to  these  powerful  agents,  the  patients  con- 
tinue to  succumb,  has  awakened  the  medical  con- 
science to  a  realization  of  the  truth  of  the  doctrines 
taught  by  your  Bigelow,  Holmes,  and  Hooker  sixty  or 
more  years  ago — that  the  patient  rather  than  the  dis- 
ease must  be  treated. 

In  a  malady  like  pneumonia,  bloodletting,  mercury, 
and  other  spoliative  agents  relieved  pain,  softened 
the  pulse,  and  lulled  the  doctor  into  a  false  security 
from  which  he  was  too  often  rudely  awakened  when 
heart  failure  presaged  the  approach  of  the  end.     The 

'  "  Colotomy.'  Wood's  Med.  and  Surg  Monographs,  New 
York    1890.  vol.  vii. 

'  Part  of  a  symposium  on  pneumonia  before  the  Massachu- 
setts Medical  Society. 


old  spoliative  practice  was  abandoned  when  practical 
men  discovered  that  it  robbed  them  of  the  chief  ally 
in  the  camjiaign  against  the  disease — the  vis  niedica- 
trix  natura;. 

If  you  retlect  that  for  two  thousand  years  the  medi- 
cal profession  labored  under  the  fatal  error  of  fighting 
disease,  while  the  patient,  being  the  battle-ground, 
suffered  from  friend  and  foe  alike,  you  will  bear  wiih 
me  in  paying  a  tribute  of  gratitude  to  the  man  who 
courageously  blazed  a  pathway  through  the  confusing 
mazes  of  spoliative  medication  to  "  Nature  in  Disease." 
I  esteem  it  a  high  privilege  to  announce  here  amid  tlie 
very  scenes  of  his  professional  activity,  that,  like  Jacob 
Bigelow,  I  trust  to  "nature"  in  pneumonia  and  in 
every  other  acute  disease.  Not  blind,  as  that  of  the 
Christian  Scientist  in  prayer  and  faith,  is  my  reliance 
on  nature,  but  ready  in  armed  expectancy,  to  intercede 
in  her  behalf  when  peculiarities  of  the  patient,  or  the 
disease,  or  condition  of  environment  point  to  a  devia- 
tion from  normal  processes  of  restitution  Isolation, 
rest,  cleanliness,  ventilation,  food,  drink,  and  if  need 
be  medication,  should  be  so  directed  as  to  enhance  the 
resasting-capacity  of  the  patient — so  to  fortify  him  that 
his  inherent  powers  have  free  play  in  eliminating  the 
noxious  products  which  threaten  to  overwhelm  him. 

Among  these  agencies  I  esteem  hydrotherapy  as  one 
of  the  most  valuable.  The  application  of  water  is  not 
a  curative  agent  for  pneumonia,  but  its  judicious  use 
has  afforded  me  much  comfort,  and  has  doubtless  con- 
tributed greatly  to  the  diminution  of  mortality. 

A  somewhat  active  professional  life  of  nearly  forty 
years,  spent  in  country,  village,  city    army,  family, 
and  hospital   practice,  has  brought  me  to  the  convic 
tion  that  pneumonia   is  an   infectious  disease  which 
tends  to  destroy   life   by  enfeebling  the  nervous  and 
circulatory  systems,  and  that  the  indications  for  over 
coming  this   lethal   tendency  are     (1)  To  fortify  the 
nervous  system  ;  (2)   to  sustain  the  heart,  whose  integ 
rity  is  of  vital  import  in  overcoming  the  local  lesions 
and  in  removing  inflammatory  products  by  a  vigorous 
circulation,  {3)  to  strive  for  elimination  of  noxious 
products  arising  from  the  life  and  death  of  the  diplo- 
coccus;   (4)  to  render  the  patient  comfortable  by  re 
ducing  high  temperature,  deepening  inspiration,  and 
producing  sleep. 

Flexibility  is  a  notable  quality  of  hydrotherapy. 
By  various  procedures,  and  by  changing  temperature 
and  duration,  we  may  adapt  the  application  of  water  to 
the  most  opposite  conditions.  In  no  disease  is  this 
better  exemplified  than  in  pneumonia.  Although  its 
general  manifestations  resemble  in  many  respects  those 
of  typhoid  fever,  its  local  manifestations  differ  from  the 
latter  as  the  Eberth  bacillus  differs  from  the  diplococ 
cus  of  Fraenkel.  While  in  typhoid  fever  the  cold 
bath,  preferably  as  suggested  by  Brand,  has  proved  of 
surpassing  value,  such  a  bath  is  not  adapted  to  a  pa 
tient  suffering  from  pneumonia  The  reason  is  clear 
at  tlie  bedside,  the  typhoid  patient  resists  temperature 
abstraction  with  much  tenacity,  the  pneumonia  patient 
as  a  rule  quickly  responds  to  heat  abstraction  This 
clinical  fact  has  often  enabled  me  to  confirm  a  tenta 
tive  diagnosis,  especially  in  children  up  to  sixteen 
years. 

While  the  typhoid  patient,  as  a  rule,  bears  the  dis 
turbance  involved  in  tub  bathing  fairly  well,  such  a 
procedure  is  extremely  distressing  in  pneumonia  by 
reason  of  dyspnoea,  cough,  and  pain  .Although  Vogl. 
of  Munich,  Folsom,  of  Boston,  and  others  have  re 
ported  good  results  from  cold  full  baths.  I  have 
abandoned  them  with  adults  for  these  reasons  In  the 
pneumonias  of  young  children  who  are  easily  lifted.  I 
still  use  full  baths  of  moderate  temperature  (95-80 
F. ),  or  cold  affusions  with  water  of  lower  temperature 
(7o°-6o°  F. )  in  severe  broncho-pneumonias  w-itii 
bronchial  obstruction,  because  in  these  cases  pleurisy 


August  4,  1900] 


MEDICAL    RECORD. 


169 


is  usually  absent,  and  the  shallow  breathing  and  de- 
ficient oxygenation  due  to  bronchial  obstruction  are 
greatly  relieved  by  the  agitation,  crying,  and  coughing 
incident  to  the  full  bath,  with  friction.  It  is  my  rule 
in  all  cases  to  be  present  during  the  first  bath,  even  in 
consultation  cases  when  practicable,  in  order  to  note 
the  reaction  and  obtain  other  information  for  further 
guidance,  because  individuals  differ  materially  in  their 
response  to  bathing.  While  each  case  demands  more 
special  study  with  regard  to  baths  than  to  other  rem- 
edies, I  usually  begin  with  a  tub  bath  (given  alongside 
of  the  bed)  of  five  degrees  below  the  patient's  temijera- 
ture,  and  diminish  the  baths  two  or  three  degrees  at 
each  repetition  every  four  hours,  until  80  ¥.  is  reached. 
The  child's  head  and  face  are  bathed  in  water  at  65' 
F.  before  entering  the  buth,  and  gentle  friction  is 
made  over  the  body  during  the  entire  bath.  During 
the  intervals  between  the  baths  the  following  method 
pursued  with  adults  is  adopted.  In  the  latter  I  have 
for  reasons  stated  above  substituted  the  wet  thoracic 
compress  for  the  full  bath.  It  is  my  custom  to  have  the 
rectal  temperature  taken  every  hour  when  the  patient 
is  not  asleep.  So  long  as  the  thermometer  registers 
over  too  F.,  a  compress  made  of  three  folds  of  old 
coarse  linen,  wrung  out  of  water  at  60"^  F.,  is  wrapped 
around  the  chest  from  the  clavicle  to  the  umbilicus. 
It  should  be  long  enough  to  lap  over  one  inch  in  front, 
and  so  slit  in  its  axillary  portion  that  it  may  rise  easily 
up  to  the  clavicles  without  leaving  rough  folds  in  the 
axilla.  This  compress  is  smoothly  wrapped  around 
the  chest  and  covered  by  one  layer  of  thin  flannel, 
one  inch  wider  and  longer. 

The  effect  of  such  an  application  of  cold  is  so  read- 
ily observed  that  it  would  seem  needless  to  dwell  upon 
it,  did  not  so  much  misapprehension  exist  in  the  aver- 
age medical  mind  on  the  object  of  cold  applications  in 
febrile  disorders,  that  it  is  necessary  to  define  it  again 
and  again,  to  remove  these  erroneous  impressions. 
Pardon  me  if  I  advert  to  some  familiar  physiological 
data.  We  know  that  cold  and  heat  are  thermic  ir- 
ritants which  stimulate  when  mild,  depress  when  more 
severe,  and  destroy  vitality  when  sufficiently  intense. 
Applied  through  the  medium  of  water  and  regulated 
with  regard  to  temperature,  duration,  and  mechanical 
impact,  we  may  so  modify  these  thermic  impressions 
as  to  produce  therapeutic  results  for  which  we  look  in 
vain  in  other  remedies.  The  primary  effect  of  cold 
is  that  of  an  irritant  to  the  peripheral  sensory  network 
of  the  skin.  This  has  been  called  shock,  an  error 
which  is  evident  on  reading  the  definition  of  shock 
in  Gould's  dictionary,  which  is  "  depression,  a  grave 
effect  produced  by  severe  injuries,  operation,  and 
strong  emotion."  To  produce  shock  with  cold  water, 
it  would  be  necessary  to  put  the  individual  into  a  tub 
of  water  very  much  below  the  body  temperature,  and 
sufficiently  long  to  prevent  reaction.  If  the  water  be 
near  the  freezing-point,  and  he  could  not  escape,  the 
individual  would  become  unconscious  and  the  vitality 
of  the  skin  would  be  destroyed,  if  he  survived  long 
enough  to' suffer  from  frostbite.  Bear  in  mind  that 
the  same  effect  would  be  produced  by  hot  water,  under 
similar  conditions;  and  yet  no  one  ever  speaks  of  the 
shock  of  hot  water.  The  truth  of  the  matter  is — and 
I  trust  you  will  pardon  my  offering  so  simple  and 
familiar  a  proposition — that  cold  stimulates  when 
mild  and  shocks  when  it  is  intense,  and  upon  this 
principle  we  stimulate  the  nerve  centres  in  pneumonia. 
A  compress  containing  water  at  60°  F. ,  when  applied 
around  the  chest  of  a  patient  having  a  temperature  40° 
F.  higher,  produces  an  irritation  of  the  sensory  fila- 
ments in  the  skin,  which  is  conveyed  to  the  central 
nervous  system  and  thence  reflected  upon  the  organs 
receiving  impulses  from  the  latter.  This  is  plainly 
evidenced  by  the  patient's  momentary  gasp,  the  height- 
ened pulse  tension,  the  deepened  and  slowed  inspira- 


tion, and  the  lowering  of  temperature.  By  changes 
in  the  preparation  of  the  compress,  we  may  positively 
modify  its  effects.  If,  for  instance,  the  body  tem- 
perature is  not  very  high,  say  from  100°  to  102°  F. , 
the  compress  may  be  more  thoroughly  wrung  out,  so 
as  to  make  the  impression  of  cold  more  brief,  reaction 
more  rapid  and  less  enduring.  If  the  temperature  be 
high,  103"  F.  or  above,  the  water  temperature  may  be 
raised  to  95°  V.,  and  more  water  may  be  allowed  to 
remain  in  the  compress,  thus  rendering  the  reaction 
more  slow  and  enduring,  and  abstracting  more  heat.  In 
the  first  instance  the  application  will  be  more  stimu- 
lating, in  the  latter  more  soothing  and  antipyretic. 
If  the  patient  is  easily  chilled  or  does  not  react  read- 
ily whether  the  body  temperature  be  moderate  or  very 
high,  the  compress  may  be  allowed  to  remain  longer 
without  change;  its  repetition  may  vary  from  half  an 
hour  to  an  hour  or  even  longer,  according  to  the  pa- 
tient's condition,  his  reaction,  and  the  effects  pro- 
duced and  aimed  at.  Such  cautious  adaptation  will 
gradually  improve  and  regulate  the  reactive  capacity 
of  the  patient,  and  sooner  or  later  will  enable  him  to 
bear  more  frequent  repetition.  It  must  always  be 
borne  in  mind,  in  all  application  of  cold  water,  that 
shock  is  to  be  avoided;  there  should  be  no  prolonged 
chilliness,  no  chattering  of  teeth,  no  cyanosis  of  lips, 
nails,  or  face — in  fine,  every  manifestation  which  indi- 
cates a  depressing  effect  demands  a  modification  of 
the  procedure  or  its  abandonment,  if  need  be.  And 
right  here  let  me  emphasize  a  much-neglected  point. 
We  do  not  abandon  quinine  in  malarial  fever,  when  it 
produces  distressing  effects.  On  the  contrary,  bearing 
in  mind  the  importance  of  the  remedy,  we  circumvent 
its  untoward  effects  by  changing  the  method,  time  of 
administration,  etc.  Cold  water  is  often  entirely 
abandoned  when  it  produces  unfavorable  manifesta- 
tions, which  is  a  serious  error.  Treat  it  as  you  would 
any  other  remedial  agent :  change  the  method,  the  tem- 
perature, the  duration,  and  you  will  be  gratified  by 
the  result,  for  it  is  a  most  flexible  agent,  as  I  have 
shown. 

Besides  the  general  effect  referred  to,  we  observe  a 
local  stimulating  effect  upon  the  cutaneous  circulation. 
The  arterioles  contract  under  the  cold  compress;  but 
they  quickly  dilate  again,  as  is  evident  from  absence  or 
disappearance  of  chilliness,  and  the  gradual  warming 
up  of  the  part,  so  that  when  the  compress  is  removed  in 
an  hour  it  is  quite  warm.  This  dilatation,  be  it  re- 
membered, however,  is  not  a  passive  one  like  that  un- 
der a  warm  poultice.  The  skin  does  not  wrinkle  and 
become  cyanotic,  but  remains  smooth  and  becomes 
ruddy.  Moreover,  each  repetition  again  stimulates  the 
walls  of  the  arterioles  to  contraction  and  dilatation,  pro- 
pelling the  blood-How  through  them,  and  thus  relieving 
the  overburdened  heart  of  much  labor.  Romberg  and 
Paessler  have  recently  confirmed  by  laboratory  experi- 
ments what  I  have  several  years  ago  and  repeatedly 
since  that  time  insisted  upon,  that  in  acute  infectious 
diseases  we  encounter  disturbances  of  the  circulation 
which  manifest  themselves  clinically  as  reduced  ten- 
sion and  diminished  filling  of  arteries,  and  which  are 
commonly  described  as  heart  failure.  Undoubtedly 
this  condition  of  the  peripheral  vessels  bears  a  very 
large  share  in  the  production  of  cardiac  inadequacy, 
as  I  have  sought  to  impress  when  explaining  the  ra- 
tionale of  cold  applications  in  typhoid  fever.  Romberg 
has  shown  by  experiments  with  injections  of  Fraen- 
kel's  diplococci  into  rabbits  that  the  circulation  is 
damaged  by  a  paralysis  of  the  vasomotors  while  the 
heart  itself  remains  unaffected.  By  restoring  the  lost 
resiliency  of  the  cutaneous  arterioles,  the  compresses 
referred  to  relieve  the  heart  of  much  labor — labor, 
too,  which  it  vainly  endeavors  to  compensate  by  in- 
creased contractions,  the  sum  of  which  too  often  leads 
to  heart  failure. 


lyo 


MEDICAL    RECORD. 


[August  4,  1900 


Upon  this  principle  we  endeavor  to  meet  the  second 
indication  in   pneumonia. 

The  third  therapeutic  indication,  the  elimination  of 
noxious  products,  is  signally  met  by  the  improved 
conditions  of  the  central  nervous  system  and  of  the 
heart,  these  presiding  over  all  the  functions  of  the 
body.  The  urine  shows  by  its  increase  in  quantity 
and  toxicity  that  the  most  important  noxse  are  elimi- 
nated with  great  activity  under  the  external  applica- 
tion of  cold.  In  addition  to  the  latter  the  systematic 
administration  of  ice-water  (45°  F. )  3  iv.  every  two 
hours,  acts  as  a  cold  douche  to  the  stomach  and  by  in- 
creasing arterial  tension  increases  urinary  excretion. 
Allow  me  liere  to  controvert  an  erroneous  idea  which 
is  almost  universal,  viz.,  that  it  is  the  increased  quan- 
tity of  water  imbibed  which  increases  the  urine  (I  have 
observed  an  increase  of  one  to  four  hundred  per  cent.). 
Glax  has  shown,  and  I  have  confirmed  his  finding,  that 
the  imbibition  of  very  hot  or  very  cold  water  acts  upon 
the  arterial  tension,  and  consequently  upon  urinary  ex- 
cretion, precisely  as  in  its  external  application,  and 
not  by  reason  of  the  quantity  drunk.  This  is  readily 
demonstrated  by  the  fact  that  only  a  slight  increase  of 
urine  is  produced  by  drinking  tepid  water,  and  the  quan- 
tity is  increased  with  the  thermal  difference  between 
the  body  temperature  and  that  of  the  water  drunk. 
It  is  my  custom,  therefore,  to  alternate  oz.  vi.  milk 
or  other  liquid  food  with  oz.  iv.-vi.  of  very  cold 
water  (45°  F.),  giving  each  every  hour,  in  pneumonia. 
The  result  is  systematic  nutrition  and  renal  stimula- 
tion. 

The  fourth  therapeutic  indication  is  certainly  ful- 
filled by  these  mild  applications  of  cold  in  pneu- 
monia. The  comfort  of  the  patient  is  greatly  en- 
hanced by  the  reduction  of  temperature,  deepening 
of  the  inspiration,  and  general  bien-aise  which  are 
renewed  on  each  application.  The  cold  compress, 
when  its  temperature  is  equalized  to  that  of  the  pa- 
tient's body,  really  becomes  a  poultice,  soothing,  re- 
lieving pain,  dyspnoea,  shallow  and  rapid  breathing, 
but  not  relaxing  the  cutaneous  vessels  and  elevating 
temperature,  as  does  the  old-fashioned  hot  poultice. 
Another  important  result  of  the  cold  compress  has 
been  demonstrated  by  VVinternitz  and  others — an  in- 
crease of  the  blood  cells  beneath  it  when  reaction  oc- 
curs. How  much  such  an  awakening  of  leucocytosis 
and  such  a  removal  of  the  blood  cells  from  dormancy 
into  the  general  circulation  must  contribute  to  en- 
hance the  natural  processes  of  restitution,  is  self- 
evident. 

To  sum  up  briefly  the  effect  of  judicious  hydro- 
therapy in  pneumonia,  I  would  say  that  while  it  is  not 
a  direct  curative  agent,  it  fulfils  all  therapeutic  indi- 
cations, efficiently  forestalling  or  controlling  all  the 
■depreciating  elements  of  the  disease.  Only  one  con- 
dition is  unaffected  by  this  treatment,  viz.,  resolution. 
I  have  observed  crisis  in  only  about  twenty-five  per 
cent,  of  cases.  The  local  course  of  the  disease  ap- 
pears to  be  changed.  Resolution  proceeds  more  slow- 
ly but  more  surely.  The  patient  has  a  normal  tem- 
perature and  pulse,  and  almost  normal  respiration  from 
five  to  twenty  days  before  all  signs  of  consolidation 
have  disappeared.  In  the  mean  time  I  permit  him  to 
go  out  in  mild  weather,  and  endeavor  to  hasten  con- 
valescence by  the  usual  measures,  good  food,  gentle 
outdoor  exercise,  ventilation,  etc.  I  am  still  unable 
to  explain  theoretically  this  retardation  of  resolution 
in  fifty  per  cent,  of  the  cases,  except  on  the  same 
principle  as  the  relapses  in  typhoid  fever  after  the 
Brand  treatment  may  be  explained,  viz.,  there  are 
-more  cases  escaping  death,  and  therefore,  more  to  re- 
lapse. The  cases  which  do  not  have  crisis  and  reso- 
lution would  probably  be  added  to  the  great  silent 
majority,  or  pursue  a  slow  course  toward  convales- 
cence, if  not  treated  hydrotherapeutically. 


THE     USE     OF     HYPNOTISM    IN    GENERAL 
PRACTICE.' 

By   E.    H.    martin,    M.D., 

CLARKSDALE,   MISS., 

COl'.NTV  HEALTH  OFFICER  OF  COAHOMA  COUNTY,  MISS.;  FORMERLY  PRESI- 
DENT OF  THE  TRI-STATE  MEDICAL  ASSOCIATION  OF  MISSISSIPPI,  AR- 
KANSAS,   AND    TENNESSEE. 

It  is  not  the  purpose  of  this  paper  to  deal  exhaustively 
with  the  subject  of  "  hypnotism."  It  is  to  be  taken 
for  granted  that,  in  this  enlightened  age,  every  practi- 
tioner of  medicine  has  a  general  knowledge  of  the 
usefulness  of  suggestion  as  a  therapeutic  agent  The 
literature  of  the  subject  is  voluminous.  I  have  noth- 
ing new  to  add  to  the  mass  of  data  available  to  every 
one.  My  only  excuse  for  this  paper,  then,  is  the  ten- 
dency of  most  members  of  our  profession  to  shirk 
their  duty  to  use  this  agent  in  proper  cases  in  general 
practice,  and  to  relegate  its  use  to  specialists  and 
quacks. 

The  idea  seems  prevalent,  not  only  among  the  laity 
but  in  our  own  ranks,  that  hypnotism  can  be  of  use 
only  in  cases  of  hysteria  and  nervous  affections.  The 
truth  is  exactly  to  the  contrary,  as  I  will  show  further 
on.  Hypnotism  is  of  relatively  little  use  in  hysteria, 
though  minor  forms  of  suggestion  are  useful  in  that 
real  malady.  Hypnotism,  in  its  many  forms,  has 
been  used  as  an  adjunct  to  the  healing-art  from  the 
earliest  days.  If  we  are  to  believe  the  Garden-of- 
Eden  story,  the  first  use  of  anassthesia  on  record  was 
by  means  of  hypnotism,  when  the  Lord  caused  a  deep 
sleep  to  fall  upon  Adam,  and  exsected  a  rib;  and  the 
product  of  that  rib  has  had  a  tendency  to  hypnotize  us 
ever  since. 

Lack  of  knowledge  of  the  true  modus  operandi  of 
suggestion  kept  hypnotism  in  disrepute  for  thousands 
of  years  and  confined  its  use  to  priests  and  so-called 
sorcerers  and  wizards,  later  to  charlatans  and  mounte- 
banks. But  the  truth  in  it  could  not  be  kept  down  by 
all  the  cloaks  of  pretence  and  formality.  Not  even 
Mesmer's  extravagant  theories  of  animal  magnetism 
could  kill  it.  Rescued  by  Braid  and  elucidated  by 
the  school  of  Nancy,  it  now  rests  upon  a  sound  scien- 
tific basis,  and  no  one  need,  as  formerly,  be  ashamed 
to  practise  it.  In  fact,  it  is  our  plain  duty  to  use  it 
in  some  cases. 

The  modern  theory  of  suggestion  and  hypnotism  de- 
pends upon  the  recognition  of  the  fact  that  the  con- 
scious mind  is  the  product  of  the  activity  of  the  cells 
of  only  a  part  of  the  brain.  Other  parts  of  the  brain 
are  ordinarily  not  under  control  of  the  mental  efforts. 
We  must  know,  axiomatically,  that  every  organ,  every 
blood-vessel,  every  capillary,  every  square  millimetre 
of  skin  and  tissue  is  connected  with  th^  brain  by 
nerves,  and  that  the  nutrition  of  every  part  of  the  hu- 
man system  and  the  function  of  every  organ  are  under 
the  control  of  some  centre  in  the  brain.  These  cen- 
tres do  not  act  blindly  and  automatically  always. 
There  must  be  some  grand  controlling  centre  or  por- 
tion of  brain  tissue  that  governs  the  entire  system  of 
centres. 

The  product  of  the  activity  of  this  part  of  the  brain 
we  call  the  "sub-conscious  mind,"  in  contradistinc- 
tion to  the  conscious  mind.  Ordinarily  we  find  but 
little  connection  between  the  "conscious"  and  the 
"  sub-conscious,"  to  use  the  shortened  expression. 
But  there  is  some  connection,  and  many  everyday  in- 
cidents show  it.  For  instance,  a  man  cannot,  by  taking 
thought  thereof,  increase  or  decrease  the  rapidity  of 
the  pulse.  But  some  sudden  shock,  danger,  fear,  joy, 
or  pain  can  affect  the  "  conscious  "  deeply  enough  to 
impress  the  "  sub-conscious,"  and  a  change  of  pulse 
rate    ensues.       The    blush     is    another     illustration. 

'  Read  before  the  Mississippi  State  Medical  Association,  at 
.Meridian,  Miss.,  May  16,   1900. 


August  4,  1900] 


MEDICAL    RECORD. 


171 


Very  few  of  us  can  blush  at  will  or  can  refrain  from 
blushing  by  wish,  but  an  impression  of  the  proper,  or 
improper,  kind  will  cause  a  dilatation  of  the  capilla- 
ries of  the  cheeks  of  those  not  too  hardened  to  receive 
a  shock,  an  impression  on  the  "sub-conscious" 
through  the  "conscious"  mind.  The  familiar  fact 
that  some  people  can.  on  retiring,  think  hard  enough 
of  waking  at  a  certain  time  to  impress  the  "  sub-con- 
scious," which  at  the  appointed  time  nudges  the 
"conscious"  awake,  is  another  illustration.  Mental 
excitements  of  various  sorts  have  various  effects 
through  the  "sub-conscious"  upon  even  the  larger  or- 
gans.     The  heart  has  already  been  mentioned. 

An  unusually  large  increase  in  the  secretion  of  urine 
is  often  observed  after  mental  excitement.  The  sensa- 
tion of  nausea  often  comes  through  mental  effect  only, 
even  to  causing  the  husband,  at  too  rare  times,  to  feel 
the  nausea  of  pregnancy;  a  great  fright  will  some- 
times cause  imperative  and  immediate  defecation,  and 
"cold  feet"  are  not  unknown,  even  in  the  army. 

Thus  we  see  that  the  function  and  nutrition  of  every 
part  of  the  system,  even  of  the  thinking  part  of  the 
brain  itself,  is  controlled  by  the  vague  "sub-con- 
scious," which  never  sleeps.  We  also  see  that  under 
ordinary  conditions  the  "conscious"  can  affect  the 
"sub-conscious"  but  little,  while  under  extraordinary 
but  everyday  conditions  tiie  effect  is  vastly  greater. 

Now  we  have  to  find  only  a  means  whereby  we  can 
make  impressions  at  will  upon  the  "sub-conscious," 
and  we  can  then  do  wonders  toward  controlling  the 
functions  otherwise  beyond  control.  This  we  find  to 
a  greater  or  less  extent  in  suggestion  or  hypnotism. 
1  use  the  word  "suggestion"  as  meaning  an  impres- 
sion made  upon  the  "  sub-conscious  "  through  the  "  con- 
scious "  mind,  either  during  sleep  or  in  the  waking 
state,  and  the  word  "  hypnotism  "  to  mean  impression 
or  suggestions  made  during  sleep  only  and  when  this 
is  artificially  induced.  There  is  really  no  difference 
between  hypnosis  and  natural  sleep,  except  that  in  the 
latter  the  subject  is  ia  connection  with  no  one  but 
himself,  while  in  the  former  he  goes  to  sleep  with  the 
memory  of  the  operator  most  prominent,  and  is,  there- 
fore, more  or  less  under  the  operator's  control. 

During  natural  sleep  and  during  hypnotic  or  in- 
duced sleep,  and  also  during  the  lighter  stages  of  hyp- 
nosis, when  we  have  only  drowsiness  and  no  loss  of 
consciousness,  the  conscious  mind  is  in  abeyance, 
takes  a  back  seat,  and  the  "sub-conscious"  mind, 
controlling  every  function  of  every  part  or  organ, 
comes  more  or  less  to  the  surface,  and  is  more  or  less 
susceptible  to  impressions  from  without.  For  in- 
stance, a  man  awake  is  given  a  dose  of  inert  substance 
wiiich  he  is  made  to  believe  is  an  emetic;  his  con- 
scious mind  dwells  so  strongly  on  the  idea  of  emesis 
that  an  impression  is  soon  made  upon  the  "sub-con- 
scious," and  emesis  follows.  That  is  simply  sugges- 
tion, because  the  relation  between  the  "conscious" 
and  the  "sub-conscious"  is  undisturbed.  But  if,  by 
means  of  any  of  the  methods  in  vogue,  a  drowsiness 
or  a  light  sleep  or  a  deep  sleep  is  induced,  and  the 
inert  substance  administered  with  the  suggestion  of 
emesis,  or  the  suggestion  is  made  alone,  emesis  more 
certainly  follows.  That  is  hypnotism,  because  here 
the  normal  relation  between  "conscious"  and  "sub- 
conscious" has  been  disturbed. 

A  patient,  during  hypnosis,  is  given  a  swallow  of 
milk  and  assured  that  it  is  castor  oil ;  the  impression 
is  made  almost  directly  on  the  "  sub-conscious,"  and 
the  effect  of  castor  oil  promptly  follows.  Another  ex- 
periment showing  the  complete  control  of  the  vaso- 
motor system  by  the  "  sub-conscious "  is  that  of  the 
mental  blister.  It  has  succeeded  many  times,  but  re- 
quires a  very  fine  subject,  i.e.,  one  in  whom  the  "con- 
scious" can  be  made  to  give  way  to  the  "sub-con- 
scious" entirely.     A  piece  of  paper  or  a  few  postage 


stamps  are  applied  to  the  patient's  skin;  the  patient  is 
assured  that  the  application  will  blister,  a  bandage  is 
applied,  and  the  patient  is  watched.  If  the  sugges- 
tion has  "  taken  "  with  the  "  sub-conscious  "  the  blister 
follows.  And  why  not?  It  is  really  not  so  wonder- 
ful; the  brain  centre  that  can  bring  the  blood  to  the 
surface  in  a  blush  can  surely  keep  it  there  if  dulv  con- 
trolled. 

As  I  have  before  stated,  the  "sub-conscious"  con- 
trols not  only  the  functions  of  every  other  organ,  but 
of  the  thinking  part  of  the  brain  itself.  Hy  sugges- 
tion, the  thinking  part  of  the  brain  can  be  made  to 
think  more  or  less  with  the  operator;  the  hearing  part 
of  the  brain  to  shut  out  sounds  that  are  and  to  hear 
sounds  that  are  not;  the  seeing  part  of  the  brain  to 
be  blind  to  that  which  is  before  the  eyes  and  to  see 
things  that  do  no  exist;  the  feeling  centres  to  refuse 
to  receive  messages  from  without  or  to  feel  pains  that 
are  not  real.  And  this  "sub-conscious"  also  has  a 
memory  apart  from  the  everyday  memory. 

If  you  are  made  very  sick  from  eating  or  drinking  a 
certain  article,  the  "  sub-conscious  "  rarely  forgets  it. 
Years  afterward  a  single  taste  of  that  article  will  in- 
duce nausea.  So  if  an  order  be  given  to  a  patient 
during  hypnosi.s,  an  order  that  is  to  be  obeyed  days 
afterward,  the  patient  may  or  may  not  have  any  con- 
scious memory  of  the  order,  but  the  "sub-conscious" 
will  remember  it,  and  the  order  will  be  obeyed  with 
more  or  less  exactness,  depending  upon  how  perfectly 
the  impression  was  accepted.  This  is  called  "  post- 
hypnotic suggestion." 

And  now  we  come  to  the  application  of  the  facts 
which  I  have  tried  to  make  clear.  What  class  of 
cases  call  for  suggestion?  We  may  rightly  divide 
all  cases  into  three  classes  in  this  regard:  (i)  Those 
cases  which  nothing  will  do  so  well  as  hypnotism;  (2) 
those  cases  in  which  hypnotism  will  be  of  great  assist- 
ance to  other  treatment;  (3)  those  cases  in  which 
hypnotism  is  not  worth  while.  Under  the  first  head 
come  many  morbid  conditions  that  ordinarily  baffle 
the  doctor.  Persistent  insomnia  is  one.  It  is  very 
doubtful  if  we  are  justified  in  using  drugs  to  produce 
sleep  night  after  night  if  we  can  gain  the  same  result 
isy  hypnotic  suggestion.  That  we  can  do  so  in  most 
cases  is  a  fact.  That  to  use  drugs  in  such  cases 
makes  us  responsible  for  many  instances  of  drug  habit 
is  also  a  fact. 

I  will  give  one  case  to  illustrate  the  use  of  sugges- 
tion in  this  trouble.  The  patient,  a  lady  of  more  than 
ordinary  intelligence,  had  not  only  been  ill  for  some 
time  but  had  been  under  severe  mental  strain,  and 
her  physician  has  been  compelled  to  use  drugs  to  in- 
duce sleep  for  several  nights.  I  was  called,  and  the 
use  of  hypnotism  was  consented  to.  She  was  readily 
influenced,  and  light  sleep  was  induced.  She  was  or- 
dered to  go  to  sleep  every  night  at  ten  o'clock  and 
not  to  awaken  until  six  in  the  morning.  When  awak- 
ened from  the  hypnosis,  after  five  minutes  she  remem- 
bered the  order  and  laughed  rather  incredulously;  she 
said  she  hoped  it  was  possible,  but  that  as  chloral  in 
ordinary  doses  had  failed  for  several  nights  she  was 
afraid  it  would  not  work.  That  night  her  nurse  was 
agreeably  surprised  to  see  her  turn  over  and  drop  off 
to  sleep  as  the  clock  struck  ten,  and  she  slept  until  6 
A.M.  This  went  on  for  several  nights,  until  some  un- 
usual disturbance  caused  her  to  wake  up  suddenly  one 
morning  about  one  o'clock,  and  the  impression  lost  its 
effect.  The  next  day  I  repeated  the  hypnotic  sugges- 
tion, and  she  had  no  return  of  insomnia. 

Another  trouble  in  which  drugs  are  sometimes  fail- 
ures is  the  nausea  of  pregnancy.  Here  it  is  impossi- 
ble to  remove  the  cause  without  interfering  with  the 
sex  function  of  the  woman.  What  more  rational  than 
to  cut  off  the  disturbing  messages  from  the  sexual  or- 
gans  before    they   reach   the   vomiting-centre  in    the 


1.72 


MEDICAL   RECORD. 


[August  4,  1900 


brain?  Five  minutes  of  hypnosis,  a  few  positive  sug- 
gestions, and  you  can  awaken  your  patient  feeling  rea- 
sonably sure  that  if  you  have  made  an  impression  on 
the  "  sub-conscious,"  that  ?ll-powerful  secretary  of  the 
interior  has  shut  the  vomiting-centre  off — has  discon- 
nected it  at  central,  so  to  speak. 

Another  condition  in  whicii  drugs  are  not  only  use- 
less but  worse  than  useless,  is  in  cases  of  pressure 
pains  of  pregnancy.  About  the  fifth  or  sixth  month 
of  gestation  it  sometimes  happens  that  the  enlarged 
uterus  presses  too  much  upon  one  or  both  sets  of 
nerves  passing  over  the  brim  of  the  pelvis.  The  re- 
sult is  intense  pain  in  the  hip  or  thigh.  This  pain  is 
often  so  great  as  to  interfere  with  the  daily  life  of  the 
patient.  She  is  most  probably  a  multipara,  and  has  a 
lot  of  little  children  to  care  for,  and  so  she  cannot  stay 
on  her  back  all  the  time.  Life  under  such  circum- 
stances becomes  unbearable ;  but  what  can  the  doctor 
do?  He  cannot  remove  the  cause — the  pressure  on 
those  nerve  trunks.  The  condition  is  not  grave  enough 
to  call  for  the  destruction  of  the  unborn  child;  mor- 
phine is  his  only  weapon,  and  its  use  for  weeks  means 
the  habit.  But  if  he  will  hypnotize  the  woman,  and,. 
by  suggestion,  prevent  the  brain  from  receiving  those 
messages  of  pain,  he  will  have  sohed  the  problem. 
A  case  is  given  below  to  illustrate: 

Mrs.  B ,  aged  twenty-three  years,  pregnant  five 

and  one-half  months  witli  her  fourth  child,  had  been 
in  bed  a  week,  .-^ny  attempt  even  to  sit  up  was  fol- 
lowed by  excruciating  pain  in  the  right  hip  and  thigh. 
She  had  been  using  a  douche  in  the  knee-cliest  position 
by  my  order,  but  the  pressure  was  only  temporarily  re- 
lieved each  time.  I  hypnotized  her  and  ordered  that 
the  pain  should  stop,  that  she  should  not  feel  it  again 
in  any  position.  I  woke  the  patient  in  three  min- 
utes. She  had  no  recollection  of  any  order  I  had 
given  her,  but  the  pain  was  no  longer  felt.  The  next 
day  I  found  her  up,  sewing  on  baby  clothes.  A  week 
later  the  pain  returned,  and  the  suggestion  was  re- 
peated with  success.  In  this  case  hypnotic  suggestion 
had  to  be  used  several  times,  but  the  patient  passed 
through  gestation  comfortably  and  without  morphine. 

Another  condition  which  will  try  a  doctor's  soul  is 
that  of  "wrenched  back."  The  physical  injury  is  so 
slight  in  proportion  to  the  pain  caused  that  one  can 
only  sit  and  wonder.  It  may  not  amount  to  a  sprain; 
no  ruptured  ligament  is  present;  it  is  just  a  "  stitch 
in  the  back,"  as  the  darkies  say.  It  may  have  come 
from  a  sudden  turn  in  lifting  even  a  small  weight,  it 
may  have  come  from  merely  pulling  on  a  boot.  But 
there  is  your  patient,  rolling  his  head  because  he 
can't  roll  anything  else,  and  groaning  at  the  slightest 
movement  of  his  body.  I  say  "his"  because  I  have 
never  seen  a  case  in  the  female  sex.  There  he  is,  and 
there  he  is  apt  to  stay  for  from  three  days  to  a  month, 
and  what  are  you  going  to  do  about  it?  Local  appli- 
cations seem  to  do  no  good,  morphine  gives  only 
partial  relief,  and  every  day  you  go  to  see  that  man 
you  wish  he  would  get  sick  or  had  broken  his  leg.  In 
the  mean  time  he  is  eating  three  square  meals  a  day, 
and  losing  his  confidence  in  all  doctors  in  general, 
and  in  you  in  particular. 

Here  is  a  case    in    question,  Mr.   McE ,   aged 

about  thirty-five  years,  by  occupation  a  railroad  sec- 
tion foreman.  In  helping  to  lift  a  railroad  tie  his  foot 
had  slipped  on  the  side  of  the  dump,  and  he  had  fallen. 
He  had  not  fallen  hard,  but  lie  said  that  his  body  gave 
a  turn,  a  pain  struck  him  in  the  back,  and  he  col- 
lapsed. It  took  the  entire  section  crew  to  take  him 
off  his  car  and  put  him  into  bed,  and  several  more  to 
get  his  clothes  off.  Four  men  risked  his  profanity  in 
order  to  turn  him  over  so  tliat  I  could  examine  his 
spinal  column.  I  could  locate  no  injury.  I  pre- 
scribed a  liniment  and  gave  him  morphine.  The  next 
day,  there  being  no  improvement,  I  put  hot  applica- 


tions on  his  back  and  gave  more  morphine.  The  next 
day  it  was  ice  to  the  spine  and  morphine.  The  next 
day  I  found  that  he  was  using  hot  ashes  externally 
and  morphine  internally.  .At  the  end  of  the  week  the 
skin  on  his  back  was  about  used  up,  as  was  all  of  the 
horse  liniment,  coal  oil,  turpentine,  etc.,  in  the  local 
store,  with  which  he  had  been  helping  me  treat  the 
case.  It  then  occurred  to  me  for  the  first  time  to  try 
hypnotism.  His  condition  was  no  better  than  when  I 
first  saw  him,  and  I  was  ready  to  try  anything.  He 
went  to  sleep  almost  at  once.  In  fact  he  was  one  of 
the  best  subjects  I  have  ever  seen.  I  made  appropri- 
ate suggestions,  and  finally  ordered  that  he  would 
sleep  one  hour  and  then  wake  up  free  from  pain.  In 
one  hour  he  did  wake  up,  got  up  and  dressed,  and 
went  out  to  work.  He  did  not  have  another  moment's 
trouble  with  his  back. 

That  same  patient  sent  for  me  one  night  at  a  later 
date  to  extract  an  aching  tooth.  I  found  him  suffer- 
ing all  that  toothache  means,  and  proceeded  to  hypno- 
tize him,  as  at  that  period  I  was  so  enthusiastic  about 
hypnotism  that  I  never  did  a  minor  surgical  operation 
without  trying  to  get  hypnotic  ana;sthesia.  Having 
put  him  to  sleep,  I  examined  the  tooth  and  found  the 
cavity  very  small  and  the  tooth  very  much  needed;  so 
instead  of  extracting  the  tooth  I  ordered  him  to  quit 
having  the  toothache.  I  assured  him  that  it  would 
never  ache  again,  etc.  I  then  waked  him  up  and  ex- 
plained to  him  what  I  had  done.  He  was  gratified  at 
saving  the  tooth,  but  very  unbelieving  as  to  the  loss  of 
the  toothache.  In  fact  he  would  not  let  me  leave  him 
until  he  had  tried  ice-water  and  molasses  and  every- 
thing else  at  hand  to  try  to  make  the  tooth  ache  again. 
Three  years  later  he  told  me  that  it  had  never  ached 
afterward. 

The  conditions  in  which  hypnotism  is  better  than 
drugs  can  be  multiplied.  I  have  given  only  a  few  in- 
stances, but  the  cases  under  class  No.  2,  in  which 
hypnotism  may  be  of  great  assistance  to  other  treat- 
ment, are  even  more  numerous,  while  the  cases  under 
class  No.  3,  in  which  hypnotism  is  not  worth  while,  are 
by  far  the  most  numerous  of  all. 

Before  leaving  class  No.  i.  I  will  mention  headache 
not  of  organic  origin;  even  in  the  latter  relief  can  be 
given,  but  in  cases  of  nervous  or  functional  headache 
hypnotism  is  really  a  cure,  frequently  a  permanent  one. 

Under  class  No.  2,  we  have  a  vast  number  of  condi- 
tions in  which  hypnotism  is  a  very  useful  adjuvant  to 
treatment.  Not  to  go  into  tiresome  detail,  I  will  sim- 
ply report  a  few  cases  of  my  own  employment  of  it, 
and  the  thoughtful  can  readily  see  when  it  can  be 
brought  into  use  advantageously,  merely  to  remove  a 
troublesome  symptom. 

A  negro  woman  with  tertiary  syphilis  could  not  re- 
tain even  a  small  dose  of  iodide,  and  the  drug  was 
very  badly  needed.  I  hypnotized  her,  and  ordered 
her  to  retain  the  medicine.  She  did  and  recovered 
rapidly. 

A  young  girl  was  in  the  tenth  day  of  lobar  pneu- 
monia; resolution  was  well  under  way;  there  was  no 
fever,  but  the  patient  was  in  a  state  bordering  on  col- 
lapse, could  retain  neither  nourishment  nor  drugs. 
She  was  plainly  slated  for  a  speedy  death  under  ordi- 
nary circumstances.  I  hypnotized  her,  ordered  her  to 
sleep  two  iiours,  to  wake  up  hungry,  and  to  retain 
whatever  was  given  her.  She  obeyed  orders,  and  not 
only  retained  all  that  was  given  her  but  called  for 
more,  developed  a  ravenous  appetite,  and  recovered 
rapidly. 

In  this  and  a  few  other  similar  cases  I  am  confident 
that  I  have  actually  saved  life  by  making  nourishment 
and  stimulation  possible.  In  one  case  of  persistent 
vomiting  in  lysaniia,  or  malarial  hematuria  so  called, 
the  vomiting  was  controlled  and  the  medicine  re- 
tained. 


August  4,  1900] 


MEDICAL    RECORD. 


173 


When  chloroform  is  objected  to  during  labor,  h\p- 
notism  can  often  be  used,  though  few  women  now 
object  to  chloroform  when  the  labor  pains  become 
severe.  I  delivered  one  woman  of  a  large  boy  after 
keeping  her  in  hypnotic  sleep  for  ten  hours.  The 
case  was  very  difficult  and  podalic  version  had  to  be 
performed.  During  the  operation  of  turning  the  pains 
were  entirely  suspended  by  means  of  suggestion.  At 
all  times  the  pains  were  under  my  control  and  could 
be  increased  or  diminished  in  severity  or  frequency 
by  suggestion.  That  sounds  hard  to  believe,  but  it  is 
a  fact.  It  was  the  first  time  the  woman  had  ever  been 
hypnotized. 

In  minor  surgical  operations  anresthesia  can  often 
be  induced  and  an  abscess  evacuated,  a  tooth  extracted 
or  filled,  or  a  few  stitches  taken  painlessly.  I  have 
amputated  a  thumb  during  complete  anaesthetic  hyp- 
nosis. 

IJut  here  are  to  be  met  many  disappointments.  Near- 
ly every  patient  can  be  hypnotized  to  some  degree; 
even  if  only  drowsiness  is  obtained,  the  post-hypnotic 
suggestions  are  generally,  at  least,  partially  effective. 
But  complete  surgical  anesthesia  can  rarely  be  in- 
duced; very  often  the  pain  is  partly  relieved,  but  only 
in  a  small  proportion  of  cases  is  it  completely  so. 
This  is  probably  because  a  post-hypnotic  suggestion 
has  a  longer  time  in  which  to  sink  into  the  "sub-con- 
scious," while  the  immediate  suggestion  of  anesthesia 
is  hardly  accepted  and  grasped  by  the  "sub-con- 
scious"' before  the  operation  begins.  Also  the  pa- 
tient goes  to  sleep  expecting  pain,  and  that  expectation 
acts  as  a  counter-suggestion.  Repeated  hypnoses,  with 
suggestion  as  to  future  hypnosis  with  anjesthesia,  might 
be  effective,  but  that  is  rarely  practicable. 

And  now  having,  I  hope,  shown  tliat  hypnotism  is 
a  useful  therapeutic  agent,  and  that  it  is  every  medi- 
cal man's  duty  to  understand  and  be  able  to  use  it  in 
general  practice,  let  me  add  a  word  of  caution.  Do 
not  use  it  too  often.  Never  use  it  unless  you  think 
the  case  demands  it.  Never  under  any  circumstances 
use  it  for  fun.  I  would  as  soon  think  of  giving  a  man 
ether  to  amuse  a  crowd  as  to  hypnotize  him  for  the 
gaze  of  the  curious.  In  the  first  place  it  is  not  right, 
and  in  the  second  place  it  does  not  pay.  It  brings 
this  useful  agent  into  disrepute,  and  as  you  will  fail 
more  often  in  parlor  play  than  in  practice,  it  will 
bring  you  as  a  successful  operator  into  disrepute. 

I  have  said  nothing  as  to  methods,  because  there 
are  so  many  methods,  and  you  will  find  them  all  in 
the  text-books.  Read  Moll  first,  then  Bernheim,  and 
then  you  will,  probably  be  well  enough  placed  on  the 
subject  to  read  more  extravagant  authors  without  be- 
lieving all  they  say. 

I  have  not  referred  to  the  use  of  hypnotism  in  treat- 
ing naughty  children  for  their  bad  habits,  or  its  use  in 
any  other  special  way,  as  those  things  are  beyond  the 
scope  of  my  paper. 

.4.  word  before  closing  as  to  the  use  of  hypnotism  in 
cases  of  hysteria.  Here  we  will  find  ideal  cases  and 
surprising  disappointments.  In  a  few  cases  it  may 
be  found  useful,  but  in  most  cases  you  will  fail  to 
hypnotize  the  subject.  Hysterical  patients  resist  hyp- 
nosis most  when  thinking  that  they  are  trying  the 
hardest  to  go  to  sleep.  If  you  do  succeed  in  influenc- 
ing them  they  will  go  into  astonishingly  exaggerated 
stages  of  hypnosis,  catalepsy,  somnambulism,  will  ex- 
hibit contractures,  etc.  You  feel  sure  that  your  sug- 
gestions will  be  effective,  but  if  they  are  and  one 
hysterical  symptom  is  removed,  another  may  soon 
take  its  place.  The  reason  is  obvious.  Hysteria, 
this  disease  without  a  lesion,  is  evidently  a  functional 
derangement  of  the  "  sub-conscious,"  and  with  the 
"  sub-conscious  "  deranged  we  cannot  hope  to  use  it 
to  follow  our  suggestions.  It  is  with  the  "sub-con- 
scious "  that  we  accomplish  everything  in  the  domain  of 


hypnotism.  The  "  sub-conscious  "  is  our  servant,  and 
to  be  useful  it  must  be  in  good  working  order.  I  do 
not  know  that  this  definition  of  hysteria  has  ever  be- 
fore been  given,  but  I  am  sure  that  psychologists  will 
agree  with  me  that  hysteria  is  not  a  derangement  of 
the  conscious  mind,  but  of  the  functional  activity  of 
that  part  of  the  brain  the  product  of  which  has  been 
called  the  "sub-conscious"  mind. 

Simple  suggestion  does  more  good  in  the  largest 
number  of  cases  of  hysteria  than  hypnotism.  There 
already  exists  a  disturbed  relation  between  the  "  con- 
scious" and  the  "sub-conscious" — not  the  exact  dis- 
turbance that  we  seek  in  inducing  hypnosis,  but  suffi- 
cient and  of  a  nature  to  permit  suggestions  to  be  readily 
accepted  if  agreeable  to  tiie  patient. 

So  we  see  scores  of  these  people  benefited  by  relig- 
ion and  especially  by  osteopathy.  Christian  science, 
faith  healing,  or  anything  else  that  gives  prolonged 
suggestion  of  cure.  These  are  all  fraudulent  sys- 
tems grounded  upon  false  premises.  We  still  may 
use  them  in  rare  selected  cases,  preferably  through  the 
advice  of  a  third  person;  we  can  hardly  face  a  patient 
and  prescribe  Christian  science,  so  called.  Still,  if 
we  know  the  patient  to  be  just  that  sort  of  a  hysteric 
that  needs  prolonged  suggestion,  have  we  the  right  to 
advise  against  it? 


SOME  POINTS  BEARING  ON  THE  MEDICINAL 
TREATMENT  OF  APPENDICITIS.' 

By   CHARLES    RO.SEWATEK,    M.D,, 

OMAHA,    NEB. 

Deluded  on  the  one  hand  by  some  over-zealous  sur- 
geons who  see  things  only  from  their  own  point  of 
view,  and  awed  on  the  other  by  the  fear  of  fatal  results 
from  surgical  procedures,  the  general  practitioner 
stands,  as  it  were,  between  Scylla  and  Charybdis,  not 
knowing  which  way  to  turn  or  what  course  of  action  to 
pursue.  The  one  class  of  practitioners  tells  him  that 
he  is  not  doing  his  duty  by  his  patients  if  in  a  case 
of  appendicitis  he  does  not  promptly  call  in  a  surgeon 
and  have  the  offending  appendix  removed.  On  the 
other  hand,  he  may  have  seen  and  certainly  may 
have  heard  and  read  of  instances  when  a  simple,  un- 
complicated, non-septic  appendicitis,  or  no  appendi- 
citis at  all,  was  found  upon  abdominal  section,  and 
in  which  the  patient  died  from  the  operation  which  was 
found  to  have  been  entirely  unnecessary. 

Again,  we  see  cases  in  which  a  timely  recourse  to 
surgical  measures  might  have  saved  a  patient  who  was 
allowed  to  die  either  for  want  of  the  proper  diagnosis 
or  proper  interpretation  of  the  indications  present. 

We  are  brought  face  to  face  with  these  grave  condi- 
tions often  enough  to  feel  the  weight  of  responsibility 
resting  upon  us.  We  wish  to  do  our  full  duty  by  our 
patients.  Which  way  shall  we  turn?  What  course 
shall  we  pursue  so  as  to  insure  the  greatest  safety  to 
the  patient? 

Still  another  class  of  cases  presents  itself  in  which 
every  indication  warrants  and  demands  surgical  inter- 
vention, but  the  patient's  general  condition,  or  the  seri- 
ous impairment  of  some  vital  organ,  would  hold  out 
little  hope  for  tiie  success  of  such  a  procedure.  The 
patient  could  not  stand  a  laparotomy.  VVhat  shall  we 
do?  Shall  we  sit  down,  fold  our  arms,  and  say, 
"Nothing  can  be  done"?  Most  assuredly  not.  Yet 
this  is  just  what  I  found  several  members  of  our  pro- 
fession, otherwise  excellent  men,  do,  simply  on  account 
of  a  misinterpretation  of  their  duties  to  their  patients, 
or  on  account  of  blind  faith  in  the  guidance  of  some 
over-zealous  surgeon  who  has  issued  the  dictum, 
"  Operate  in  all  cases  if  you  wish  to  do  your  full  duty." 

'  Read  before  the  Nebraska  State  Medical  .Society  at  Omaha, 
May   10,  1900. 


'74 


MEDICAL    RECORD. 


[August  4,  1900 


This  is  the  dilemma  in  wiiicii  the  medical  profession 
to-day  tinds  itself.  JSefore  seeking  the  path  which  is 
to  lead  us  out  of  this  labjrinth  of  doubt  and  uncer- 
tainty, a  little  review  of  the  conditions  wiiich  confront 
us  will  not  be  amiss. 

.Appendicitis,  an  inflammation  of  that  little  offshoot 
from  the  bowel  in  the  ileo-CKcal  region,  whose  func- 
tion no  one  has  so  far  been  able  to  determine,  may  be 
catarrhal,  suppurative,  septic,  or  perforating;  it  may 
be  simple,  or,  what  is  more  frequently  the  case,  com- 
plicated by  a  localized  peritonitis,  involving  the  peri- 
toneum of  the  ileo-ca;cal  region,  or  spreading  over  the 
entire  abdominal  peritoneum.  This  peritonitis  is,  of 
course,  accompanied  by  the  formation  of  a  plastic  exu- 
date, which  agglutinates  the  various  coils  of  the  bow- 
els and,  becoming  organized,  permanently  impedes 
their  vermicular  movements,  thereby  impairing  intes- 
tinal digestion.  Intestinal  movement  becomes  imper- 
fect, painful,  and  deficient,  and  the  contents  of  the 
bowels  are  not  evacuated  as  they  should  be.  Fecal 
accumulations  are  liable  to  occur,  causing  new  irrita- 
tion and  leading  to  inflammatory  attacks,  the  relapses 
to  which  the  subjects  of  appendicitis  are  so  liable. 

The  primary  attack  of  appendicitis  sets  in  sometimes 
without  any  marked  symptoms  of  invasion,  insidiously 
producing  its  pathological  changes  without  the  pa- 
tient's being  aware  of  any  local  pathological  process 
until  the  introduction  of  some  irritating  ingesta,  the 
use  of  a  cathartic,  a  sudden  exertion  or  a  direct  injury, 
produces  decided  local  and  general  symptoms,  pain 
referable  to  the  right  groin  or  sometimes  to  the  umbi- 
licus, vomiting,  and,  as  a  rule,  constipation.  Now  the 
physician  is  called  in,  and  finds  a  tense,  tender  abdo- 
men, the  tenderness  being  greatest  at  the  spot  known 
as  McBurney's  point;  the  abdominal  muscles  are  rig- 
id; the  pain  is  constant,  temperature  elevated,  tongue 
badly  coated,  pulse  rapid  and  small.  Close  ques- 
tioning will  elicit  the  fact  that  the  patient  has  not 
been  well  for  some  time  past,  suffering  from  anorexia, 
occasional  colicky  pains  in  the  abdomen,  especially 
in  the  right  groin,  and  constipation  ;  but  he  was  either 
too  busy  to  attend  to  it,  or  did  not  think  it  of  sufficient 
importance  to  require  any  special  attention. 

In  other  instances  a  sudden,  sharp  abdominal  pain, 
accompanied  by  all  the  symptoms  of  shock  and  septic 
peritonitis,  announces  to  the  physician  that  some  septic 
accumulation  has  ruptured  into  the  general  peritoneal 
cavity.  The  locality  and  previous  history  tell  the  rest 
of  the  tale,  and,  if  they  don't,  the  findings  of  a  lapa- 
rotomy or  post-mortem  examination  will  reveal  them. 
Let  us  see  what  has  been  the  local  condition  which 
has  gradually  brought  about  such  results. 

That  only  a  very  small  percentage  of  cases  of  appen- 
dicitis are  really  primarily  due  to  the  lodgments  of  a 
foreign  body  in  the  cavity  of  the  appendix  is  now  gen- 
erally conceded,  but  the  majority  of  cases  are  due  to 
colds  and  improper  diet.  The  first  step  in  the  patho- 
logical process  is  the  congestive  swelling  of  the  mu- 
cous lining  of  the  appendix  with  narrowing  and  final 
closure  of  the  opening  into  tiie  bowel ;  then  a  retention 
o'f  the  accumulated  secretions  in  the  cavity  of  the  ap- 
pendix, distention  of  tiie  latter,  thinning  and  softening 
of  its  walls,  with  sometimes  local  ulceration  from  the 
mucous  surface  and  in  other  cases  gangrene  of  portions 
of  the  wall,  and  rupture.  Meantime,  however,  the 
inflammatory  action  has  not  been  confined  to  the  mu- 
cous and  muscular  layers  of  the  appendix,  but,  attack- 
ing its  peritoneal  covering,  produces  a  peritonitis  whicii 
most  frequently  is  circumscribed,  creating  a  localized 
tumefaction  in  the  right  iliac  region  containing  eitiier 
a  plastic  effusion  or  pus,  and  walled  off  from  the  gen- 
eral peritoneal  cavity  by  the  surrounding  adhesions. 
The  presence  of  this  tumor  in  the  groin,  the  course  of 
the  temperature,  and  previous  history  of  the  case  will 
assist  the  physician  in  recognizing  the  presence  of  pus. 


and  consequently  the  urgent  need  of  surgical  interven- 
tion. 

The  treatment  of  appendicitis  must,  of  course,  be 
carried  out  along  the  lines  indicated  by  the  conditions 
found  and  impending  dangers  to  be  avoided.  As  the 
presence  of  intestinal  accumulations  threatens  to  ag- 
gravate the  inflammatory  conditions  by  local  irritation, 
the  first  step  in  such  a  case  should  consist  in  the  thor- 
ough emptying  of  the  bowel  by  a  mild  mercurial  purge 
(calomel)  followed  by  a  saline  cathartic.  A  copious 
enema  of  warm  salt  water,  a  gallon  or  two,  injected 
high  up  into  the  colon,  assists  materially  in  many 
cases,  but  should  not  be  resorted  to  when,  by  increase 
of  the  peristalsis,  the  rupture  of  an  abscess  may  be 
brought  about.  Ice  applications  locally,  in  the  form 
of  an  ice-bag  over  the  groin,  do  much  to  assuage  the 
pain;  in  fact,  I  have  found  them  so  beneficial  that  the 
patients,  after  becoming  accustomed  to  the  ice,  will 
not  do  without  it.  Opiates  should  be  avoided  as  much 
as  possible,  not  because  they  stop  the  peristalsis,  but 
because  they  so  mask  the  picture  of  the  disease  as  to 
leave  the  physician  at  sea  as  to  its  progress.  The  pa- 
tient should  remain  in  bed  on  his  back,  with  his  sur- 
roundings quiet.  His  diet  should  be  confined  to 
liquid  food,  preferably  peptonized  milk,  either  warm 
or  cold,  according  to  his  predilection.  All  solid  food 
and  such  as  leaves  much  waste  should  be  forbidden 
until  all  signs  of  local  irritation  have  subsided.  Too 
great  care  cannot  be  taken  in  this  particular  during  the 
first  year  following  an  acute  attack  of  appendicitis,  for 
upon  this  care  will  depend  the  permanence  of  the  re- 
covery. In  the  beginning  of  an  attack,  when  vomiting 
is  a  prominent  symptom  and  the  stomach  is  very  ir- 
ritable, gr.  ,,\,  of  calomel  given  hourly  will  quiet  this 
irritability  in  a  large  proportion  of  cases.  Bits  of  ice 
swallowed  at  intervals  will  assist  in  accomplishing 
this  result.  Sometimes  iced  champagne  is  retained  in 
small  quantities  by  such  a  stomach  when  other  fluids 
are  vomited.  To  combat  the  fever  and  nervous  mani- 
festations, salol  and  phenacetin,  gr.  ii.  of  each  every 
two  to  four  hours,  with  gr.  J  of  citrate  of  caffeine,  yield 
good  results.  Judicious  stimulation  during  the  use  of 
phenacetin  is  deemed  advisable.  The  treatment  out- 
lined here  is  carried  on  during  the  height  of  the  dis- 
ease, with  the  object  of  relieving  the  local  irritation 
and  checking  the  progress  of  the  inflammation  until 
resolution  sets  in.  As  the  inflammation  subsides, 
gradually  a  new  element  enters  into  the  treatment, 
namely,  the  removal  of  the  effects  of  this  inflamma- 
tion, the  removal  and  absorption  of  the  inflammatory 
exudate,  which,  if  allowed  to  remain,  leads  to  aggluti- 
nation of  the  intestinal  coils  and  permanent  impair- 
ment of  the  intestinal  activity.  To  attain  this  object 
I  have  used  with  good  succe.ss  iodide  of  ammonium  in 
doses  of  gr.  i.-iii.  every  four  hours,  followed  by  copi- 
ous draughts  of  hot  water.  In  fact,  all  through  the 
attack  of  appendicitis  hot  water  should  be  given  freely 
and  in  large  quantities.  My  experience  with  this 
treatment  has  been  very  gratifying  in  cases  of  appen- 
dicitis in  whicli  patients,  apparently  needing  surgical 
intervention,  have  refused  to  be  operated  upon.  It 
was  employed  with  satisfaction  in  one  case  in  particu- 
lar, in  which  serious  valvular  heart  trouble  led  me  to 
fear  an  operation,  and  in  which  the  treatment  was  in- 
stituted without  expectation  of  favorable  results,  eight 
months  after  a  second  attack  of  appendicitis.  The 
patient,  aged  twelve  years,  presented  a  history  of  arsen- 
ical poisoning  occurring  at  the  age  of  two  years,  fol- 
lowed by  an  irritable  digestive  canal,  and  chorea;  at 
the  age  of  eleven  years  she  had  her  first  attack  of  ap- 
pendicitis, followed  in  a  few  months  by  a  relapse. 
Kight  months  had  passed  by  since  the  partial  recovery 
from  the  relapse,  and  a  number  of  physicians  who  had 
been  consulted  declined  to  treat  her,  claiming  that 
nothing  could  be  done  without  an  operation.     In  view 


August  4,  1900] 


MEDICAL    RECORD. 


175 


of  the  peculiar  complications  in  the  case  rendering  an 
operation  extra-hazardous,  I  felt  justified  in  postponing 
serious  consideration  of  the  latter  and  instituting  the 
treatment  as  outlined  above.  The  result  was  immedi- 
ate improvement  and  ultimate  complete  recovery  from 
the  effects  of  the  appendicular  troubU-.  This  patient 
suffered  from  chronic  constipation  due  to  the  aggluti- 
nation of  the  intestinal  coils,  but  was  entirely  relieved 
after  the  treatment  with  iodide  of  ammonium  and  co- 
pious hot-water  draughts  was  instituted,  so  that  htr 
bowels  acted  regularly  without  a  laxative.  This 
proved  to  me  conclusively  that  the  adhesions  must 
have  been  removed  and  the  intestinal  peristalsis  re- 
established. 

It  is  to  this  phase  of  the  subject  that  I  wish  to  call 
especial  attention,  applicable  as  it  is  in  numerous 
instances  in  which  operative  procedures  are  not  feasi- 
ble and  are  always  dangerous.  I  do  not  wish  to  be 
understood  as  opposing  surgical  measures,  especially 
when  they  are  clearly  indicated  and  not  contraindi- 
cated  by  the  presence  of  other  dangers. 


On  the  Symptoms  or  Phenomena  Formerly  Known 
as  Croup  ;  the  Diseases  which  Produce  Them  ;  and 
the  Clinical  ■  Significance  of  the  Various  Allied 
Affections  Embraced  by  the  Term. — The  conclusions 
of  I^angford  Synies  are  as  follows:  (i)  There  is  no 
such  true  disease  as  croup,  croupy  symptoms  being 
produced  by  a  variety  of  different  diseases.  (21 
Severe  croupy  symptoms  are  most  likely  to  be  due  to 
either  diphtheria  or  laryngitis  stridulosa.  (3)  In 
a  difficult  case  we  should  suspect  diphtiieria  and  treat 
it  as  such  from  the  start  with  antitoxin.  (4)  Recession 
and  restlessness  are  the  two  most  dangerous  symptoms, 
(s)  As  antitoxin  reduces  the  mortality  of  diphtheria 
and  enables  cases  to  be  tided  over  the  crisis  with  in- 
tubation, it  may  possibly  contribute  to  the  future 
success  of  tracheotomy.  (6)  Deaths  registered  as 
croup  are  mainly  due  to  diphtheria. — Dublin  Medical 
Journal,  July,  1900. 

Treatment  of  Diarrhoea  in  Tuberculous  Subjects 
by  Abdominal  Faradization. — E.  Doumer  has  had 
good  results  from  this  therapeutic  application  of  the 
faradic  current.  The  electrodes  are  covered  with 
chamois  skin  and  are  applied  well  moistened  over  the 
entire  surface  of  the  abdomen.  The  seances  shbuld 
last  five  minutes  and  should  be  repeated  two  or  three 
times  daily.  The  tampon  electrodes  should  be  partic- 
uarly  applied  along  the  course  of  the  colon,  and  the 
current  should  i)e  strong  enough  to  produce  good  con- 
tractions of  the  abdominal  muscles.  The  first  im- 
provement noticed  is  in  the  diminution  of  the  number 
of  stools;  later  their  consistency  changes  and  they 
become  formed.  By  the  fourth  or  fifth  day  the  cure 
is  generally  complete. — I.e  A'onl  Meilical,]u\\  i,  1900. 

The  Significance  of  a  Temporary  Temperature 
Rise  Limited  to  the  Day  of  Hospital  Admission. — 
Fromm  has  studied  the  case  histories  of  over  two 
thousand  patients  and  found  that  of  this  number  one 
hundred  showed  a  rise  of  temperature  on  the  first  day, 
which  speedily  subsided  again,  and  in  most  instances 
without  any  medication.  In  analyzing  these  cases  it 
was  found  that  in  nearly  fifty  per  cent,  some  disease 
of  the  respiratory  system  was  present,  and  one-half  of 
these  were  tuberculous.  The  fact  has  been  establ  ished 
by  Penzoldt  and  Hochstetter,  that  in  tuberculous  in- 
dividuals moderate  exercise  causes  a  much  greater 
temperature  elevation  than  is  produced  under  similar 
conditions  in  the  healthy.  Adopting  the  view  that 
the  increased  circulatory  activity  causes  the  distribu- 
tion of  a  larger  amount  of  toxin  from  a  tuberculous 
focus,   it   seems   rational   to  explain   this    anomalous 


"  first-day  rise  "  on  the  ground  of  the  unusual  exertion 
and  bodily  and  mental  disturbance  involved  in  reach- 
ing the  hospital.  In  other  cases,  no  doubt  the  change 
to  the  quiet  and  proper  nursing  of  the  hospital  causes 
the  subsidence  of  a  moderate  fever  already  present. 
In  concluding,  the  author  states  that,  other  things  be- 
ing equal,  the  existence  of  this  first-day  fever  may 
serve  as  an  additional  factor  to  strengthen  a  presump)- 
tive  diagnosis  of  tuberculosis. —  Ceiitrall'latt  Jur  Iniiere 
Mcdicin,  June  30,  1900. 

Latent  Tuberculosis  of  the  Pharyngeal  Tonsil.— 

L.  Retiii  reviews  the  recent  voluminous  literature  on 
this  subject,  adding  the  results  of  his  own  observa- 
tions. -Among  one  hundred  cases  examined,  tuber- 
culosis was  found  six  times,  cheesy  degeneration  being 
present  in  two  of  the  six  cases.  In  five  the  tuberculous 
deposit  was  near  the  surface  under  the  epithelium  and 
once  in  the  deeper  layers.  Giant  cells  were  present 
in  all  six. —  Wiener  klinische  Rundschau,  No.  26,  July 
I,  1900. 

Congenital  Elephantiasis — J.  E.  Dubt?  gives  with 
illustration  an  account  of  a  child  two  and  a  half 
months  old,  whose  right  leg  was  enlarged  at  birth  and 
continued  to  increase  in  size  until  the  foot  was  almost 
hidden  from  view,  and  the  calf  and  thigh  presented 
enormous  proportions.  The  mother  had  had  a  fright  in 
the  third  month  of  her  pregnancy.  The  leg  was  treated 
by  deep  multiple  puncture  and  elastic  compression. 
hX.  each  sitting  a  large  amount  of  orange  yellow  thick 
serum  ran  out  and  coagulated  at  once.  There  was 
some  improvement  up  to  the  time  the  patient  dis- 
appeared from  observation. — V  Union  iMedicale  dit 
Canada,  June,  1900. 

Two    Rebellious    Cases  of    Pyorrhoea    Alveolaris 

Cured  by  the    Cruet    Method J.   Chaminade   says 

text  books  as  a  rule  reconmiend  only  chromic  acid. 
Two  observations  are  given  in  which  the  application 
of  the  thermo-cautery,  after  mouth  washes  containing 
thymol  and  menthol  and  careful  cleansing  of  the 
dental  arcade  had  prepared  the  way,  resulted  in  per- 
fect and  permanent  cure.  'l"he  point  of  the  cautery 
is  passed  from  the  margin  of  the  gum  to  the  deepest 
points  opposite  the  root  of  the  tooth,  and  is  made  to 
enter  all  cul-de-sacs  so  as  to  destroy  all  infectious  foci. 
.Vntiscptic  washes  follow  the  application. — Aniiales 
de  la  roliclinique,  June,  1900. 

Two  Cases  ot  Malarial  Haematuria  with  Treat- 
ment.— A.  E.  Cox  treated  a  man  aged  twenty-one 
with  calomel  in  five-grain  doses  every  two  hours  until 
twenty  grains  were  taken,  strychnine  sulphate  every 
four  hours  (one-thirtieth  grain),  cold  to  the  head,  with 
tepid  sponging  first;  and  if  this  did  not  reduce  the 
fever  his  patient  was  to  be  sponged  with  cold  water. 
The  patient  had  taken  quinine,  and  this  was  continued 
in  five-grain  doses  every  three  hours  until  six  doses 
were  taken.  The  patient  continued  to  pass  bloody 
urine,  so  the  quinine  was  discontinued  and  sodium 
hyposulphite  in  drachm  doses  every  four  hours  was 
ordered,  to  be  diminished  after  the  bowels  should 
move  freely.  Strychnine  was  continued  and  one  dose 
of  morphine  with  atropine  given  hypodermically. 
Under  this  latter  treatment  the  patient  rapidly  con- 
valesced. A  second  case  was  treated  in  practically 
the  same  way  with  equally  good  results,  except  that 
no  quinine  whatever  was  given.- — Memphis  Medical 
Monthly,  July,  1900. 

Remarks  upon  the  Diplococci  Resembling  Gonococci 
Found  in  the  Normal  Vagina  of  Children. — C.  A. 
Rosenwasser  calls  attention  to  the  need  of  further 
study  of  a  condition  of  great  importance,  viz.,  the 
vaginal  discharges  of  childhood  supposed  to  be  caused 
by  gonococci.     Instances   are   reported   of   outbreaks 


176 


MEDICAL    RECORD. 


[August  4,  1900 


in  children's  wards  despite  all  precautions.  The 
work  already  done  in  the  study  of  intracellular  diplo- 
cocci  resembling  gonococci,  decolorizing  or  not  by 
the  Gram  method,  is  reviewed.  The  author  has  demon- 
strated in  the  apparently  heilthy  vagina  intracellular 
diplococci,  decolorizing  by  Gram,  differing  from  gono- 
cocci only  in  not  having  the  typical  arrangement.  He 
thinks  it  may  be  that  some  vaginal  discharges  are 
caused  by  an  attenuated  or  not  fully  developed  gono- 
coccus  which  does  not  react  to  Gram.  The  reason  the 
vagina  more  than  the  conjunctiva  suffers  is  that  the 
latter  is  not  so  susceptible  to  infection.  The  investi- 
gations will  be  continued. — Archives  of  Fediairiis, 
Jul}',  1900. 

The  Pericarditis  of  Bright's  Disease. — P.  Chatin 
reviews  the  literature  of  this  affection  and  gives  his- 
tories of  three  personal  cases.  A  careful  e.xamination 
was  made  of  the  bacterial  contents  of  the  pericardial 
sac  in  his  cases,  and  in  all  there  was  noted  a  markedly 
weak  infective  power.  From  this,  the  author  infers 
the  existence  in  certain  cases  of  Bright's  disease  of  an 
aseptic,  germless  pericarditis.  In  other  cases  it  is  one 
of  the  complications  of  an  ordinary  infection.  The 
suggestion  is  made  that  the  disease  may  at  times  be  a 
toxic  pericarditis,  but  the  author  is  not  willing  to  ex- 
press a  conclusive  opinion  on  this  point. — Revue  de 
Medecine,  June  10,  1900. 

Two  Forms  of  Pseudo-Meningitis  due  to  Lum- 
bricoides.  —  Dr.  Mcriel  gives  the  history  of  a  child 
ten  years  of  age,  who,  after  a  purulent  discharge  from 
the  ear,  fell  sick  with  all  the  symptoms  of  meningitis, 
which  was  at  first  attributed  to  extension  of  inflamma- 
tion from  the  ear.  The  ordinary  period  of  five  or  six 
days  passing  and  the  symptoms  continuing  unchanged 
caused  a  doubt  and  led  to  careful  inspection  of  the 
stools.  The  result  was  that  two  lumbricoid  worms 
were  discovered,  and  a  few  days  after  their  discharge 
convalescence  set  in.  In  the  second  case  there  were 
in  a  nine-year-old  child  immobility  of  the  head  on  the 
pillow,  rigidity  of  the  neck,  and  otiier  symptoms 
pointing  to  meningitis,  with  delirium,  convulsions,  etc. 
Santonin  and  calomel  were  given  as  in  Case  I.,  and 
after  four  ascarides  were  passed  the  child  recovered. — 
Aimales  de  Medecine  et  de  Chiriirgic  Injantiles,  July  i, 
1900. 

The  Treatment  of  Yellow  Fever  in  Children. — 
Jose'  Texeira,  basing  his  views  upon  the  observation  of 
two  hundred  cases  of  yellow  fever  in  children,  comes 
to  the  following  conclusions :  The  disease  is  often  com- 
plicated with  meningitis,  which  is  very  dangerous;  the 
renal  complications  are  very  rare  in  children.  In  or- 
der to  avoid  this  dangerous  complication  we  must  from 
the  onset  of  the  disease  apply  strong  derivatives  to  the 
skin,  especially  to  the  lower  extremities,  stimulate  the 
perspiration  of  the  skin  and  evacuation  of  the  bowels. 
Large  doses  of  castor  oil  and  copious  enemata  of  boric 
acid  are  very  efficient.  Of  course,  according  to  the  con- 
ditions present,  symptomatic  treatment  at  the  same  time 
is  very  important.  In  forty  cases  this  treatment  was 
successfully  carried  out. —  Clinical  Record. 

Losdorfer's  Bodies :  A  New  Discovery  in  Syph- 
ilitic Blood. — Victor  Neudorfer  looks  upon  the  recent 
discovery  in  Vienna  of  bodies  in  the  blood  of  syphi- 
litics,  which  are  perhaps  the  specific  germs  of  the  dis- 
ease, as  a  striking  illustration  of  the  importance  of 
hematology  to  general  medicine.  The  announcement 
of  Losdorfer  in  April  last  was  received  with  scepti- 
cism, but  Paltauf  had  controlled  the  examinations, 
which  embraced  one  hundred  and  twenty-five  syphilitic 
patients  for  over  a  year.  He  found  that  the  bodies 
described  often  appear  in  the  blood  before  the  exan- 
them    is  developed,   while    for   the  first    four  or  five 


weeks  after  infection  no  changes  can  be  noticed. 
The  bodies  are  not  found  in  other  patients.  In  the 
portion  of  the  field  which  contains  no  blood  corpuscles 
long,  oval  bodies  having  about  the  size  of  large  acid- 
ophile  granules  or  so-called  eosinophile  leucocytes, 
but  not  so  glistening,  make  their  appearance  after  two 
or  three  hours.  Later  on  they  show  movement  and 
form  chains.  Losdorfer  is  not  prepared  to  claim  as 
yet  that  they  are  specific  for  the  disease.  They  are 
found  also  in  hereditary  cases,  and  will  at  all  events 
have  a  diagnostic  significance. —  The  St.  Paul  Med- 
ical Jcurnal,  July,  1900. 

Cold  as  an  Etiological  Factor  in  Diseases  of  the 
Air  Passages. — J.  Zahorsky  says  that— (i)  Common 
"colds"  are  acute  infectious  diseases.  (2)  Severe 
exposure  acts  as  a  general  predisposing  cause  to  infec- 
tion. The  detrimental  effect  of  the  manifold  mild 
exposures  is  very  doubtful.  (3)  Rarely  the  normal  or 
accidental  bacteria  in  the  upper  air  passages  may  ex- 
cite disease.  (4)  Most  commonly  a  micro-organism 
from  some  one  else  having  a  "cold"  is  the  exciting 
cause.  (5)  Any  lesion  of  the  mucous  membrane,  such 
as  chronic  ulceration  in  the  nose,  or  recent  lesions 
produced  by  the  inhalation  of  dust,  impure  air,  nox- 
ious or  irritating  vapors,  and  possibly  very  cold  air 
predispose  to  infections  of  the  upper  air  passage.  (6) 
Congregation  of  persons  and  the  non-ventilation  of 
rooms  are  the  principal  factors  which  produce  the  in- 
creased prevalence  of  colds  during  the  winter  seasons. 
— St.  Louis  Courier  0/  Aledicine,  June,  1900. 

Clonic  Spasm  of  the  Palatine  Muscles  Producing 
a  Sound  Heard  at  a  Distance.— G.  Ostino  recently 
saw  a  physician,  aged  twenty-six  years,  who  from  the 
age  of  fourteen  had  been  conscious  of  a  noise  in  both 
ears  like  that  of  a  watch  ticking,  which  could  be  vol- 
untarily arrested  for  a  short  time,  but  would  immedi- 
ately return.  It  was  especially  annoying  at  night,  but 
disappeared  whenever  he  had  an  acute  coryza.  Ex- 
amination of  the  ears  revealed  nothing  abnormal,  nor 
was  anything  except  an  acute  coryza  found  in  the 
nose.  The  pharynx  showed  a  spasmodic  condition 
of  the  palatal  muscles  synchronous  with  the  pulse  and 
causing  a  sound  perceptible  to  the  observer.  The 
man  was  neuropathic,  but  no  special  cause  for  the 
spasm  could  be  found.  Its  disappearance  during 
acute  coryza  was  attributed  to  the  fact  that  the  swell- 
ing of  the  mucosa,  in  which  the  delicate  palatal 
muscles  are  contained,  so  hindered  their  action  that 
the  spasm  was  for  the  time  impossible. ^,4/r///?'^  Jta- 
liaiio  di  Otologia,  etc.,  vol.  x.,  No.  1,  1900. 

An  Experimental  Contribution  to  the  Knowledge 
of  the  Toxicology  of  Potassium  Chlorate. — S.  J. 
Meltzer  contributes  an  article  based  upon  the  study  of 
experiments  made  by  others,  and  upon  a  series  made 
by  himself  at  the  Columbia  University  laboratories. 
He  presents  an  analysis  of  the  existing  experimental 
data,  pointing  out  some  of  their  shor'comings,  and 
presents  some  new  experimental  facts.  On  introducing 
potassium  chlorate  into  the  peritoneal  cavity  of  rab- 
bits, the  animals  died  thirty-eight  hours  later  in 
convulsions,  especially  of  the  respiratory  muscles. 
This  led  to  a  study  of  the  eflfects  when  the  substance 
was  injected  into  the  brain.  Opisthotonos  was  usu- 
ally the  first  symptom.  Tonic  contractions  soon  gave 
way  to  clonic  convulsions.  With  strong  solutions,  vio- 
lent tetanic  convulsions  were  produced.  The  experi- 
ments show  the  drug  to  be  a  strong  poison  for  the 
nerve  cells,  which  are  first  excited,  then  paralyzed. 
On  introducing  it  into  the  circulation  it  seems  fair  to 
assume  that  a  certain  amount  reaches  the  brain  in 
sufficient  concentration  to  excite  and  paralyze,  espe- 
cially the  respiratory  centre. —  Therapeutic  Gazette,  July 
15,  1900. 


August  4,  1900] 


MEDICAL    RECORD. 


177 


Medical  Record: 

A    Weekly  Journal  of  Medicine  and  Surgery. 


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

Publishers 

WM.  WOOD  &  CO.,  51    Fifth  Avenue. 

New  York,  August  4,  1900. 

CHRONIC    BRASS    POISONING. 

The  physician  especially  is  never  secure  unless  he 
is  always  prepared  for  the  unexpected  and  the  expected 
alike.  Metallic  poisoning  in  its  various  forms  is  not 
uncommonly  observed  if  carefully  looked  for,  and  not 
a  few  obscure  cases  might  be  traced  to  such  an  origin. 
Probably  the  most  frequent  variety  of  this  kind  of 
poisoning  is  due  to  lead,  occurring  in  those  compelled 
to  manipulate  this  metal,  or  exposed  to  the  risk  of  its 
inhalation  in  the  form  of  powder.  It  is  especially 
common  in  those  employed  in  lead  works,  and  in  paint- 
ers who  use  lead  colors,  although  it  is  also  observed 
as  a  result  of  the  use  of  hair-dyes  and  cosmetics  con- 
taining lead,  of  snuffs  and  other  articles  wrapped  in 
lead-foil,  of  water  passing  through  and  exerting  a  sol- 
vent action  upon  lead  pipes.  An  epidemic  has  been 
recorded  among  those  who  have  partaken  of  cakes  col 
ored  richly  yellow  with  lead  chromate  by  an  unscrupu- 
lous baker.  Other  forms  of  metallic  poisoning  are 
less  common. 

Poisoning  with  lead,  as  also  with  mercury,  arsenic, 
silver,  copper,  etc.,  results  occasionally  from  excessive 
or  prolonged  administration  of  these  metals  or  their 
compounds  for  therapeutic  purposes.  Mercurial  poi- 
soning may  occur  also  in  those  engaged  in  the  manu- 
facture of  mirrors,  and  arsenical  poisoning  has  been 
attributed  to  the  inhalation  of  vapors  from  wall-papers 
impregnated  with  arsenical  colors.  Copper  poisoning 
is  not  commonly  observed,  although  it  may  occur  in 
those  engaged  in  operations  into  which  either  the 
metal  itself  or  its  alloy  with  zinc,  namely  brass,  en- 
ters. A  good  clinical  description  of  this  condition 
as  it  occurs  among  artisans  in  brass  at  Birmingham, 
England,  is  given  by  Murray  {British  Medical  Journal, 
June  2,  1900,  p.  1334).  The  patient  is  likely  to  be  a 
young  workman,  presenting  a  more  or  less  markedly 
anxious  expression,  with  a  thin  and  haggard  face,  a 
sallow  complexion,  and  an  unhealthy  and  wasted  ap- 
pearance. He  complains  of  gradual  loss  of  strength, 
with  a  dry  and  hacking  cough,  cold  sweats,  and,  pos- 
sibly, haemoptysis.  Pain  in  the  chest,  loss  of  appe- 
tite, and  progressive  emaciation  in  addition,  raise  a 
suspicion  of  pulmonary  tuberculosis,  but  careful  ex- 
amination of  the  chest  fails  to  disclose  signs  of  dis- 
ease of  the  lungs,  except,  perhaps,  those  of  slight  bron- 
chial catarrh.  The  urine  is  normal.  The  nature  of 
the  disorder  is  not  clear,  and  symptomatic  treatment 


fails  to  yield  relief.  Other  cases  of  a  similar  charac- 
ter present  themselves,  and  finally  it  is  learned,  upon 
inquiry,  that  all  occur  in  those  who  are  engaged  in 
some  way  in  manipulating  brass — such  as  stamping, 
finishing,  polishing,  etc.  Examination  will  now  dis- 
close a  typical  green  line  on  the  teeth,  probably  due 
to  deposition  of  copper. 

One  of  the  earliest  symptoms  is  anaemia,  and  with 
it  there  are  often  associated  palpitation  of  the  heart 
and  dyspnoea  on  exertion,  digestive  disturbances,  ano- 
rexia, and  epigastric  pain  after  food.  Tachycardia  is 
common,  while  nausea,  vomiting,  and  thirst  are  not  in- 
frequent. Slight  indefinite  pains  of  a  neuralgic  char- 
acter may  be  complained  of  early  with  headache,  a 
sense  of  weakness,  malaise,  and  nervousness.  As  the 
disease  progresses,  emaciation  becomes  conspicuous, 
with  loss  of  strength,  and  tremor.  The  knee  jerks  are 
normal  or  exaggerated,  unless  peripheral  neuritis  is 
present.  Headache  is  almost  always  present,  as  well 
as  pain  varying  in  character  and  situation,  neuralgic 
and  myalgic,  principally  in  the  abdomen,  then  in  the 
legs,  the  back,  the  chest,  etc.  As  a  rule,  digestive  dis- 
turbances are  present,  with  loss  of  appetite  and  gas- 
tralgia,  and  occasionally  nausea  and  vomiting.  The 
tongue  is  generally  coated,  moist,  and  tremulous.  The 
bowels  are  normal,  loose,  or  confined.  There  may  be  a 
dry,  tickling  cough,  sometimes  with  thick,  tenacious 
sputum,  and  occasionally  haemoptysis.  The  pallor  is 
distinctive,  the  complexion  being  sallow,  dirty,  and 
unhealthy-looking.  Symptoms  of  laryngeal  or  pharyn- 
geal catarrh  are  not  uncommon,  with  aphonia,  a  sense 
of  dryness  or  discomfort  or  constriction  in  the  throat, 
and  a  metallic  taste.  A  feeling  of  oppression  or  ner- 
vousness, sometimes  intense,  is  common,  and  so  are  re- 
peated attacks  of  faintness  or  sinking,  in  the  morning 
or  at  work.  Profuse  sweating  may  be  a  source  of  an- 
noyance, and  there  may  be  a  sense  of  coldness,  possi- 
bly confined  to  one  part,  as  the  knees,  the  legs,  or  the 
chest.  The  sweat  stains  the  linen  and  also  the  hair 
green.  Itching  cutaneous  eruptions  appear  in  various 
parts  of  the  body,  but  there  may  be  itching  without 
visible  eruption.  Pulmonary  fibrosis  is  common,  and 
paraplegia  due  to  peripheral  neuritis  may  occur. 
Poole  {The  British  Medical  Journal,  June  9,  1900)  re- 
fers to  marked  pulsation,  either  local  or  general,  of 
the  abdominal  aorta  as  frequently  associated  with  the 
advanced  stages  of  chronic  brass  poisoning,  and  which 
he  thinks  may  be  due  to  vasomotor  disturbances. 

In  treatment  potassium  iodide  failed  to  yield  antici- 
pated results,  but  phosphorus,  in  pills  of  gr.  ^'^  three 
times  a  day,  and  dilute  phosphoric  acid  in  doses  of 
ni  XV.  three  times  a  day,  yielded  satisfactory  results. 
The  use  of  milk  as  a  beverage  was  found  to  be  of  dis- 
tinct advantage. 

THE   PATHOLOGY   OF    ACUTE  YELLOW 
ATROPHY    OF   THE   LIVER. 

The  clinical  course  and  the  pathological  anatomy  of 
so-called  acute  yellow  atrophy  of  the  liver  suggest  the 
possibility  that  this  disorder  represents  an  acute 
parenchymatous  hepatitis  of  infective  or  toxic  origin. 
The  essential  lesions  consist  in  fatty  degeneration  of 


178 


MEDICAL    RECORD. 


[August  4,  1900 


the  liver  cells,  with  increase  in  the  interstitial  con- 
nective tissue,  but  there  is  some  difference  of  opinion 
as  to  which  of  these  processes  is  the  earlier.  The  dis- 
order, which  is  by  no  means  common,  usually  pursues 
a  short  and  fatal  course,  but  occasionally  cases  are  ob- 
served in  which  the  duration  is  more  protracted,  and 
the  lesions  are  rather  those  of  acute  atrophic  cirrhosis 
of  the  liver.  Such  an  instance  is  reported  by  Findlay 
{Bri/is/i  Medical  Journal,  June  2,  1900),  who  discusses 
the  pathology  of  these  allied  aflections.  The  patient 
was  a  girl,  fifteen  years  old,  who  presented  general 
dropsy,  excepting  in  the  face,  together  with  ascites.  She 
had  been  jaundiced  seven  months  previously,  with 
swelling  of  the  feet,  the  latter  returning  and  persisting. 
Diarrhcea  had  been  present  for  one  month.  There  was 
slight  bleeding  from  the  gums,  and  vomiting  occurred 
on  a  few  occasions.  Death  resulted  from  respiratory 
failure.  On  post-mortem  examination  the  spleen  was 
found  to  be  enlarged,  and  of  increased  consistency. 
The  liver  was  much  diminished  in  size,  firm,  and  on 
section  presented  a  yellowish  appearance;  its  capsule 
was  thickened  and  granular  in  places.  The  pancreas 
was  firm ;  the  mesenteric  glands  were  enlarged  and 
firm;  and  Peyer's  patches  and  the  solitary  glands  of 
the  intestine  were  swollen  and  congested.  Micro- 
scopic examination  disclosed  slight  fatty  degenera- 
tion of  the  myocardium,  fibroid  change  in  the  spleen, 
a  catarrhal  condition  of  the  kidneys,  degeneration  of 
the  cells  and  hyperplasia  of  the  interstitial  connective 
tissue  of  the  liver.  The  case  is  considered  one  of  yel- 
low atrophy  of  the  liver,  but  rather  chronic  than  acute, 
and  reasons  are  given  in  favor  of  the  view  that  chronic 
yellow  atrophy  of  the  liver  is  nothing  more  than  acute 
cirrhosis  of  the  liver,  dififering  from  other  varieties  of 
cirrhosis  in  quantitative  histogenetic  changes.  In 
cases  of  yellow  atrophy  of  the  liver  the  degeneration 
of  the  hepatic  cells  is  more  extreme  than  in  cases  of 
the  ordinary  type  of  cirrhosis,  tending  more  frequently 
to  death  than  to  recovery  of  the  cell.  The  connective- 
tissue  formation  differs  little  from  what  is  found  in 
other  varieties  of  cirrhosis,  but  the  regeneration  of  the 
hepatic  tissue  has  advanced  to  a  greater  degree  than 
in  cases  of  ordinary  cirrhosis,  and  has  exceeded  so- 
called  hypertrophic  or  biliary  cirrhosis  in  what  is  by 
some  regarded  as  its  special  feature. 


SOME  TENDENCIES   IN  MEDICAL  WRITING. 

Those  who  follow  the  subject  have  no  doubt  noticed 
in  the  enormous  contemporary  output  of  writing  upon 
medical  subjects,  the  development  of  certain  tenden- 
cies, the  ultimate  results  of  which  may  prove  of  ques- 
tionable value.  Modern  medical  education  both  be- 
fore and  after  graduation,  wiiile  it  is  undoubtedly 
raising  the  standard  of  requirement  and  of  general 
medical  knowledge  in  consequence,  is  at  the  same 
time  subjecting  the  medical  profession  to  a  process 
of  smoothing-out  by  which  the  least  well-equipped 
members  of  it  are  gradually  coming  to  assume  an 
appearance  at  least  of  equality  with  those  in  an  intel- 
lectually higher  plane.  The  rapid  development  of 
specialism  depends  to  some  extent  certainly  upon  con- 


centration of  teaching  force  and  clinical  material, 
which  has  been  made  possible  by  the  improvements 
in  our  educational  machinery  and  the  growing  iavish- 
ness  of  its  financial  lubrication.  The  specialist  judi- 
ciously developed  is  a  most  desirable  type  of  medical 
practitioner  certainly  for  large  cities,  but  unfortu- 
nately the  development  of  our  specialists  often  leaves 
much  to  be  desired  in  the  groundwork  of  medical 
education  and  in  general  cultivation,  a  very  consider 
able  admixture  of  both  of  which  should  be  present. 

The  great  increase  in  the  number  of  specialists, 
more  or  less  well  equipped,  which  our  present  system 
produces  has  for  its  unavoidable  and  to  some  extent 
undesirable  consequence  a  flood  of  writing  upon  vari- 
ous subjects  in  the  form  of  books,  from  small  up  to 
what  must  be  called  ponderous  tomes,  though  perhaps 
the  term  indicates  too  much  weight.  Many  such 
works  are  written  expressly  for  the  purpose  of  reach- 
ing and  instructing  the  advanced  student  and  also  the 
general  practitioner,  and  purport  to  teach  the  latter 
especially  how  certain  things  should  be  done  which 
are  usually  left  to  a  man  with  a  special  training. 

There  are  no  doubt  many  medical  and  surgical 
emergencies  in  the  presence  of  which  it  is  desirable 
that  the  general  practitioner  should  have  at  hand 
good  advice  in  the  form  of  a  work  of  reference,  but 
such  good  advice  cannot  take  the  place  of  trained 
fingers  guided  by  a  trained  mind,  w  ithout  recourse  to 
which  full  justice  may  not  always  be  done  to  the  pa- 
tient. Books  written  for  the  general  practitioner  par- 
ticularly are  usually  not  complete  enough  on  these 
subjects  of  pathology  and  diagnosis,  and  too  much 
space  is  devoted  to  the  more  easily  explained  subject 
of  treatment,  which  ought  to  be  left,  when  possible,  in 
the  hands  of  the  man  of  experience.  This,  of  course, 
does  not  refer  to  simple  conditions  about  which  there 
are  no  important  elements  of  doubt.  The  result  of  this 
is  that  the  reader,  encouraged  by  apparent  simplicity, 
gets  a  warped  and  incomplete  idea  of  conditions  with 
which  he  may  have  to  contend,  attempts  too  much, 
and  is  unable  to  cope  with  difficulties  which  in  the 
hands  of  an  expert  would  have  been  obviated. 

Another  noticeable  future  in  medical  works  of  the 
present  time  is  that  writers  seem  beset  with  the  fear 
that  their  works  will  not  mention  everybody  who  has 
spoken  of  their  subject  before,  and  that  something  in 
medicine  will  escape  recording.  There  is  not  appar- 
ently a  clear  idea  among  writers  as  to  what  is  of 
merely  historical  and  bibliographical  interest,  and 
what  is  of  present  scientific  value,  and  also  as  to  what 
is  tlie  relative  importance  of  such  things.  The  reali- 
zation of  a  distinction  here  would  reduce  the  thickness 
of  most  medical  volumes  and  would  not  interfere  with 
their  value  or  accuracy.  The  desire  to  write  a  book 
on  a  whole  department  of  medicine  with  an  approxi- 
mation to  completeness  is  responsible  for  much  that 
is  tiresome  and  unnecessary  in  modern  writing,  and 
has  led  to  a  great  deal  of  what  is  called  "padding." 
We  see  the  best  results  in  the  works  of  men  who  have 
taken  a  narrow  field  and  threshed  it  over  and  over, 
giving  us  n  monograph  in  which  we  can  find  some- 
thing upon  every  detail  of  the  subject,  supported  by 
evidences  of  work  and  investigation  which  add  much 


August  4,  1900] 


MEDICAL    RECORD. 


179 


to  the  convincing  power  of  the  argument.  Some  of  the 
most  recent  large  publications  have  been  written  on 
what  might  be  called  the  monograph  system,  and  in 
several  instances  the  results  have  been  very  satis- 
factory, so  that  in  them  we  have  really  valuable  and 
useful  works  of  reference.  It  is  a  mistake  on  the  part 
of  a  writer  to  try  to  do  too  much,  and  one  way  of  doing 
too  much  is  to  write  a  book  which  attempts  to  do  jus- 
tice to  a  whole  department  of  medical  science. 


THE   TREATMENT  OF  PULMONARY  TUBER- 
CULOSIS   WITH    SODIUM    CINNAMATE. 

The  number  of  remedies  recommended  for  the  treat- 
ment of  a  given  disorder  is  inversely  a  fair  inde.x  of 
its  amenability  to  therapeutic  intervention.  This  is 
particularly  true  of  pulmonary  tuberculosis,  in  the 
treatment  of  which  no  one  drug  of  the  many  proposed 
has  as  yet  received  general  application.  Among  the 
agents  that  have  been  used  for  this  purpose  in  recent 
years  are  balsam  of  Peru,  cinnamic  acid,  and  sodium 
cinnamate  (also  known  as  hetol).  Landerer  and 
others  have  reported  successful  results  from  the  use 
of  these  remedies.  Stimulated  by  the  favorable  re- 
ports Ewald  (^Berliner  kUnische  Wochenschrijt,  1900, 
No.  21)  began  the  employment  of  sodium  cinnamate, 
and  after  the  treatment  of  twenty-five  cases  of  pul- 
monary tuberculosis  by  this  means  has  reached  the 
conclusion  that,  while  the  remedy  has  not  yielded  the 
anticipated  results,  in  view  of  the  fact  that,  intelli- 
gently administered,  it  is  free  from  danger,  it  is  worthy 
of  further  trial.  There  was  no  case  of  pure  laryngeal 
tuberculosis;  eleven  of  the  cases  were  free  from  fever 
throughout  their  entire  course;  ten  exhibited  febrile 
periods  of  considerable  duration,  and  only  four  per- 
sistent fever.  In  no  case  was  a  cavity  of  any  consid- 
erable size  demonstrable,  but  in  all  e-xcept  two  tuber- 
cle bacilli  were  constantly  present  in  the  sputum.  In 
the  two  excepted  cases,  however,  the  conditions  were 
so  positive  as  to  leave  no  doubt  as  to  the  diagnosis. 
The  period  of  treatment  was  variable.  In  some  cases 
it  extended  over  three  hundred  days  and  more;  while 
one  patient  remained  under  observation  for  only  eigh- 
teen days.  The  treatment  consisted  in  intravenous  in- 
jections of  a  solution  of  sodium  cinnamate,  beginning 
with  a  dose  of  i  mgm.  and  gradually  increasing  at  in- 
tervals of  two  days  up  to  15  mgm.  In  all,  four  hun- 
dred and  sixty-one  injections  were  given  without  acci- 
dent. The  treatment  appeared,  however,  to  predispose 
to  the  occurrence  of  slight  hsemoptysis,  and  many  of 
the  patients  exhibited  marked  fatigue  and  a  tendency 
to  sleep.  In  many  cases  marked  relief  was  afforded, 
the  pain  in  the  side  being  mitigated  and  the  expecto- 
ration taking  place  more  readily.  No  influence  on 
the  tubercle  bacilli  in  the  sputum,  on  the  temperature, 
or  on  the  sweating  was  observed.  Recovery  took  place 
in  four  cases,  improvement  in  five  cases,  no  improve- 
ment in  six  cases,  and  ten  cases  pursued  an  uninter- 
rupted progressive  course.  These  results,  it  is  pointed 
out,  differ  little  from  those  that  are  obtained  from 
other  methods  of  treatment,  especially  when  the  aid  of 
climatic  and  other  hygienic  agencies  is  invoked. 


The  Plague  is  reported  to  have  reappeared  at  Asun- 
cion, Paraguay. 

American  Surgeons  Honored. — At  the  centenary 
celebration  of  the  Royal  College  of  Surgeons  in  Lon- 
don on  July  26th,  Drs.  Robert  F.  Weir,  of  this  city, 
and  William  W.  Keen,  of  Philadelphia,  were  given 
diplomas  of  honorary  fellowship  in  the  college. 

The  Dead  at  Pao-Ting-Fu.— Dr.  Cortlandt  Van 
Rensselaer  Hodge,  Dr.  G.  Yardley  Taylor,  and  Dr. 
Maud  A.  Mackey  are  three  American  medical  mission- 
aries who  are  reported  to  have  been  massacred  by  the 
Chinese  at  Pao-Ting-Fu.  They  had  been  sent  out  by 
the  Presbyterian  Hoard  of  Foreign  Missions. 

More  Acting  Assistant   Surgeons  Needed It  is 

reported  in  the  daily  papers  that  one  hundred  addi- 
tional medical  officers  are  wanted  by  the  surgeon-gen- 
eral for  duty  in  the  Philippines  and  China.  Only 
graduates  of  reputable  medical  colleges,  with  some 
experience,  and  under  forty  years  of  age,  will  be  ac- 
cepted. 

Smallpox  at  Dawson  City.— A  report  has  been 
received  by  the  Canadian  Department  of  the  Interior 
at  Ottawa  that  smallpox  has  broken  out  at  Dawson 
City.  It  is  said  that  the  disease  was  imported  from 
Cape  Nome.  Dr.  Montizambert,  the  Dominion  health 
officer,  has  been  sent  to  the  Yukon  to  make  the  neces- 
sary arrangements  for  quarantine  and  isolation.  He 
took  a  supply  of  vaccine  with  him  and  sailed  from 
Vancouver  on  August  ist. 

Pennsylvania  Hospital Dr.  Robert  G.  Le  Conte 

has  been  elected  surgeon  to  the  Pennsylvania  Hospital 
in  succession  to  the  late  Dr.  John  Ashhurst,  Jr.  A 
gold  medal  has  been  awarded  the  management  of  the 
Pennsylvania  Hospital  in  recognition  of  the  services 
it  has  rendered  humanity  during  the  past  century. 

Lewis  Stephen  Pilcher,  M.D.,  LL.D.— The  degree 
of  Doctor  of  Laws  has  been  conferred  by  the  Univer- 
sity of  Michigan  and  Dickinson  College  upon  Dr. 
Lewis  Stephen  Pilcher,  of  Brooklyn,  editor  of  the  An- 
nals of  Surgery. 

The  Elmira  Reformatory. — Dr.  Frank  M.  Robert- 
son, physician  to  the  Elmira  Reformatory,  has  been 
appointed  acting  superintendent  during  the  leave  of 
absence  of  Mr.  Z.  R.  Brockway.  Tlie  latter,  upon 
whom  there  was  some  time  ago  a  fierce  newspaper  at- 
tack for  allege^  cruelty,  but  who  was  officially  exon- 
erated, has  resigned,  the  resignation  to  take  effect 
December  31st.  Until  that  time  he  has  been  granted 
leave  of  absence. 

The  Brooklyn  Homoeopathic  Hospital  will  soon 
become  a  city  institution.  Under  an  act  passed  by 
the  last  legislature  and  approved  by  the  mayor,  the 
city  undertook  to  purchase  the  hospital  and  run  it  as 
a  public  institution.  When  the  details  came  up  for 
settlement,  there  were  $70,000  of  debts  on  the  hospi- 
tal, which  the  city  was  called  upon  to  assume.  Presi- 
dent Guggenheimer  objected  to  this  course  until  he 


i8o 


MEDICAL    RECORD. 


[August  4,  1900 


had  examined  the  assets.  At  a  recent  meeting  he 
expressed  his  satisfaction  with  the  arrangements,  and 
it  was  agreed  that  the  hospital  should  turn  over  its 
property  to  the  city,  which  should  assume  the  debts 
of  the  institution. 

The  Settlement  of  Dr.  Evans'  Will.— The  city 
of  Philadelphia  can  now,  in  consequence  of  the  set- 
tlement of  all  litigation  over  the  will  of  Dr.  Evans,  the 
American  dentist  who  practised  in  Paris  for  nearly 
half  a  century,  proceed  with  the  founding  and  estab- 
lishing of  the  Thomas  W.  Evans  Dental  Institute  and 
Museum.  The  institution  has  been  incorporated,  and 
it  will  be  built  on  property  that  belonged  to  the  testa- 
tor in  Philadelphia.  About  $3,000,000  will  be  de- 
voted to  the  structure  and  its  equipment  and  endow- 
ment. Dr.  Evans  left  an  estate  amounting  to  a  little 
over  $4,000,000,  one-quarter  of  which  goes,  under  the 
terms  of  the  settlement,  to  the  direct  legatees,  men- 
tioned in  the  will  for  smaller  sums,  and  the  remainder 
to  the  foundation  and  endowment  of  .the  Dental  Insti- 
tute and  Museum. 

The  American  Association  of  Obstetricians  and 
Gynaecologists  will  hold  its  thirteenth  annual  meet- 
ing in  the  assembly  room  of  the  Gait  House,  Louis- 
ville Ky.,  Tuesday,  Wednesday,  and  Thursday,  Sep- 
tember 18,  19,  and  20,  1900,  under  the  presidency  of 
Dr.  Rufus  Cartlett  Hall,  of  Cincinnati,  Ohio. 

Major  J.  Van  R.  Hoff,  who  was  at  the  head  of 
the  army  medical  service  in  Porto  Rico,  has  been 
selected  as  chief  surgeon  of  the  China  expedition,  and 
orders  relieving  him  of  his  duties  in  Porto  Rico  and 
directing  him  to  report  at  onee  in  VVashington  have 
been  telegraphed  to  him.  After  a  consultation  with 
General  Sternberg  he  will  proceed  immediately  to 
San  Francisco  and  take  the  first  transport  for  China. 

Wholesale  Libel. — A  criminal  prosecution  for  libel 
has  been  instituted  in  London  against  Mr.  Peter  An- 
derson Graham,  the  author  of  a  work  entitled  "  The 
Perils  of  English  Agriculture."  In  this  book  he 
charges  that  all  the  sanitary  inspectors  in  England 
are  corrupt,  except  perhaps  one  in  fifty.  A  general 
accusation  of  this  nature,  not  specifying  the  persons 
aimed  at  any  more  particularly,  has  usually  been 
deemed  by  the  courts  insufficient  to  sustain  a  civil 
action  for  defamation. 

The  Lane  Lectures  for  1900. — The  fifth  course  of 
the  Lane  Medical  Lectures,  inaugurated  in  Cooper 
Medical  College  in  1896,  will  be  given  in  1900  by 
Sir  Michael  Foster,  professor  of  physiology.  Univer- 
sity of  Cambridge,  England.  These  lectures  will  be 
given  on  August  2olh,  21st,  22d,  23d,  and  24th,  at  11 
A.M.  and  8  p.iM.  The  subject  of  the  lectures  will  be 
the  history  of  physiology,  each  lecture  being  devoted 
to  one  or  more  of  the  great  physiologists  and  to  the 
discoveries  connected  with  their  names. 

The  Red  Cross  in  China. — A  phase  of  the  trouble 
in  China  which  may  prove  to  be  of  great  importance 
is  the  fact  that  the  government  of  that  country  is  not 
a  party  to  the  Geneva  Red  Cross  Convention,  by 
which  the  signatory  powers  bound  themselves  in  time 


of  war  to  respect  the  Red  Cross,  and  to  treat  surgeons 
and  nurses  belonging  to  the  armies  of  the  enemy  as 
non-combatants.  It  is  thought  possible  that  this  fact 
may  deter  the  War  Department  from  permitting  any  of 
the  women  nurses  who  are  being  sent  to  the  Far  East 
from  landing  in  China  for  duty  there.  There  are 
nineteen  female  nurses  on  the  transport  Grant  with 
General  Chaffee,  and  five  on  the  Sumner  which  sailed 
from  San  Francisco  two  weeks  ago. 

The  Will  of  the  Late  Dr.  John  Ashhurst,  Jr., 
disposes  of  an  estate  valued  at  $190,000.  To  the  Col- 
lege of  Physicians  of  Philadelphia  are  devised  from 
his  medical  books  a  number  not  exceeding  fifteen 
hundred  volumes. 

The  New  York  School  of  Clinical  Medicine. — We 

are  informed  that  this  school  has  not  been  discon- 
tinued, but  six  members  of  the  teaching  staff  have  re- 
signed. Dr.  Marcus  Kenyon  has  been  elected  secre- 
tary of  the  medical  board. 

Mr.  Wu  Ting  Fang  was  what  might  be  called  a 
little  "previous,"  when  last  May  he  advised  the  gradu- 
ates of  a  woman's  medical  college  to  repair  at  once  to 
China  in  order  to  practise  their  profession  in  freedom 
and  to  their  pecuniary  advantage. 

M.  Pichon,  the  French  ambassador  in  Pekin,  was 
originally  a  medical  student,  but,  discouraged  at  his 
want  of  success  at  the  examinations,  he  relinquished 
medicine  and  took  to  journalism,  for  which  he  pos- 
sessed a  special  talent.  From  journalism  he  passed 
into  the  political  arena,  where  he  has  achieved  a 
reputation  which  led  to  his  being  appointed  to  this 
important  if  somewiiat  perilous  diplomatic  post.- — T/ie 
Medical  fress. 

Philadelphia  Mortality  Statistics. — There  were 
reported  to  the  Philadelphia  bureau  of  health  for  the 
w^eek  ending  July  27th  a  total  of  514  deaths,  50  less 
than  for  the  preceding  week,  but  2,3  more  than  for  the 
corresponding  week  of  the  preceding  year.  The  heat 
still  continues  an  important  cause  of  death:  75  chil- 
dren died  from  cholera  infantum,  and  26  deaths  were 
due  to  sunstroke,  27  to  inflammation  of  the  stomach 
and  bowels,  31  to  marasmus,  42  to  pulmonary  tuber- 
culosis, 26  to  heart  disease,  and  24  to  pneumonia. 

Gifts  to  a  Hospital — The  managers  of  St.  Tim- 
othy's Hospital  at  Roxborough,  Philadelphia,  have 
received  $10,000  from  J.  Vaughan  Merrick,  Sr.,  who, 
with  his  late  wife,  originated  the  hospital  as  a  memo- 
rial to  their  parents,  by  donating  the  house  in  which 
the  hospital  was  opened  in  1890.  Of  this  amount 
$8,000  is  for  the  extinction  of  a  ground-rent  and 
$2,000  for  the  endow-ment  fund.  The  hospital  has 
received  also  $5,000  from  John  H.  Dearnley,  to  en- 
dow a  free  bed  in  honor  of  his  daughter,  and  $50,000 
from  the  estate  of  Perceval  Roberts,  Sr.,  for  the  erec- 
tion of  an  annex  now  in  process  of  construction. 

Expert  in  Mental  Diseases  to  be  Sent  to  the 
Philippines. — In  view  of  the  cases  of  insanity  liable 
to  occur  in  such  a  large  force  as  is  now  stationed  in 
the  Philippines,  Surgeon-General  Sternberg  has  de- 
cided to  station  an  expert  in  mental  diseases  at  Manila 


August  4,  1900] 


MEDICAL    RECORD. 


181 


to  have  charge  of  insane  patients  prior  to  their  em- 
barkation for  this  country.  For  this  purpose  he  has 
given  a  contract  as  acting  assistant  surgeon  to  Dr. 
Charles  H.  Latimer,  who  has  been  a  member  of  the 
staff  of  the  government  insane  asylum  at  Washington 
(St.  Elizabeth's)  for  the  past  twelve  years.  Dr.  Lati- 
mer is  a  man  of  much  experience  and  ability,  and  will 
undoubtedly  be  of  great  assistance  in  the  general  hos- 
pital at  Manila  in  his  special  line  of  work.  He  takes 
with  him  as  assistants  two  attendants  from  the  govern- 
ment asylum  for  the  insane,  who  have  each  had  more 
than  ten  years'  experience  in  the  handling  of  cases  of 
mental  alienation. — Boston  Medical  and  Surgical  Jour- 
rial. 

Dr.  John  J.  Brownson,  of  Dubuque,  la.,  has  been 
appointed  president  of  the  Dubuque  County  Board  of 
Lunacy  Commissioners.  Dr.  Brownson  had  charge  of 
the  West  Dubuque  asylum  for  eight  years. 

International  Congress  at  Paris — In  addition  to 
the  Medical  Congress,  the  opening  session  of  which 
was  held  on  Thursday  of  this  week,  the  following,  the 
proceedings  of  which  are  of  more  or  less  interest 
to  physicians,  have  met  or  are  to  meet  during  the 
present  summer.  The  Medical  Press,  under  the 
presidency  cf  Professor  Cornil,  July  26th  to  28th; 
Professional  Medicine  and  Medical  Deontology,  un- 
der the  presidency  of  Dr.  Lereboullet,  July  23d  to 
28th;  Medical  Electrology  and  Radiology,  under  the 
presidency  of  M.  Weiss,  July  27th  to  August  ist; 
Public  Assistance  and  Private  Beneficence,  under  the 
presidency  of  M.  Casimir  Perier,  July  30th  to  August 
5th  ;  Dermatology  and  Syphilography,  under  the  presi- 
dency of  Dr.  Besnier,  August  2d  to  gth;  Improvement 
of  the  Condition  of  the  Blind,  u.ider  the  presidency  of 
Dr.  Dussouchet,  August  5th;  Deaf  and  Dumb,  under 
the  presidency  of  Dr.  Ladreit  de  la  Charriere,  August 
6th  to  8th;  Dental  Surgery,  under  the  presidency  of 
M.  Godon,  August  8th  to  14th;  Pharmacy,  under  the 
presidency  of  M.  Planchon,  August  8th  to  10th  ;  Hyp- 
notism, under  the  presidency  of  Dr.  Voisin,  August 
12th  to  15th;  Aid  in  Time  of  War,  under  the  presi- 
dency of  M.  A.  Me'zieres,  August  20th  to  24th ;  Anti 
tobacco,  under  the  presidency  of  M.  Decroix,  August 
20th  to  25th;  Pharmaceutical  Specialties,  under  the 
presidency  of  M.  Victor  Fumonge,  September  3d  to 
4th;  Vegetarian  Congress,  under  the  presidency  of  M. 
Grand,  June  21st  to  23d;  Homoeopathic  Congress, 
under  the  presidency  of  Dr.  P.  Jousset,  July  i8th  to 
2 1  St;  Accidents  to  Workmen  and  Social  Assurance, 
under  the  presidency  of  M.  Linder,  June  2Sth  to  30th; 
Physical  Education,  under  the  presidency  of  M.  Le'on 
Bourgeois,  August  30th  to  September  6th;  Chemistry, 
under  the  presidency  of  M.  Berthelot,  August  6th  to 
nth;  Ethnology,  under  the  presidency  of  M.  Block, 
August  26th  to  September  ist;  Conditions  and  Rights 
of  Women,  under  the  presidency  of  Madame  Pognon, 
September  sth  to  8th;  Acetylene,  under  the  presi- 
dency of  M.  Sebert,  September  23d  to  28th;  Pre- 
historic Anthropology  and  Archaeology,  under  the 
presidency  of  M.  Al.  Bertrand,  August  20th  to  25th; 
Sunday  Rest,  under  the  presidency  of  M.  Bdrenge, 
October  9th  to  12th;  Bibliography,  under  the  presi- 


dency of  General  Sebert,  August  i6th  to  i8th.  In 
the  Congress  of  Comparative  History,  held  from  July 
23d  to  25th,  under  the  presidency  of  M.  Gaston  Bois- 
sier,  there  was  a  section  devoted  to  the  history  of 
science,  including  the  history  of  hygiene  in  antiquity, 
the  history  of  medicine  in  the  Middle  Ages,  and  the 
history  of  medicine  among  non-European  peoples.  In 
the  Congress  of  Popular  Traditions,  to  be  held  under 
the  presidency  of  M.  Beauquier,  September  10th  to 
1 2th,  popular  medicine  and  magic  are  among  the  sub- 
jects to  be  discussed. 

A  Base  Hospital  for  the  Army  in  China. — It  is 
uncertain  as  yet  where  the  base  hospital  for  the 
American  army  in  China  will  be  located.  The  choice 
lies  between  Nagasaki  and  Chefoo. 

The  Roentgen  Society  of  the  United  States  will 
meet  in  New  York  City,  on  December  13  and  14, 
1900,  at  the  Academy  of  Medicine.  Papers  have 
been  promised  by  men  in  this  country  and  Europe,  and  a 
very  successful  scientific  meeting  is  anticipated.  Un- 
equalled advantages  will  be  offered  to  the  visiting  mem- 
bers for  instruction  in  A-ray  work. 

Navy  Department,  Bureau  of  Medicine  and  Sur- 
gery, Washington,  D.  C— Changes  in  the  medical 
corps  of  the  United  States  navy  for  the  week  ending 
July  28,  1900.  July  19th.— (Orders  issued  by  com- 
mander-in-chief of  the  Asiatic  station.)  Surgeon  A.  C. 
H.  Russell  detached  from  the  Nc7i'ark  and  ordered  to 
the  naval  hospital,  Yokohama,  Japan,  for  treatment. 
Passed  Assistant  Surgeon  R.  M.  Kennedy  detached 
from  the  Yorktown  and  ordered  to  the  /Newark.  As- 
sistant Surgeon  A.  G.  Grunwell  detached  from  the 
Brooklyn  and  ordered  to  the  Moiiocacy.  July  21st. — 
Surgeons  M.  F.  Gates  and  G.  Rothganger  commis- 
sioned surgeons  from  July  7,  1900.  Passed  Assistant 
Surgeon  R.  Spear  commissioned  passed  assistant  sur- 
geon from  June  22,  1900.  Assistant  Surgeon  M.  K. 
Elmer  commissioned  assistant  surgeon  from  July  18, 
1900. 

Obituary  Notes. — Dr.  James  M.  McNulty  died  at 
his  home  in  Santa  Barbara,  Cal.,  on  June  22d.  He 
was  a  native  of  New  York  State,  and  graduated  at 
Geneva  Medical  College,  N.  Y.,  in  1846,  going  soon 
after  as  a  surgeon  in  the  Mexican  War.  Then  com- 
ing to  California,  he  was  for  some  time  in  the  employ 
of  the  Pacific  Mail  Steamship  Company,  then  settling 
in  San  Francisco,  where  he  practised  for  many  years 
until  1889,  when  he  partially  retired  to  Santa  Bar- 
bara. In  1861  he  was  surgeon  of  the  First  California 
Volunteers,  and  for  the  last  two  years  of  the  war  was 
medical  director  of  the  Second  Army  Corps. 

Dr.  Henry  T.  Herold,  of  Newark.  N.  J.,  died  at 
his  home  in  that  city  on  July  25th,  following  an  opera- 
tion for  appendicitis.  He  was  thirty-eight  years  old. 
and  was  a  graduate  of  the  Bellevue  Hospital  Medical 
College  in  the  class  of  1887. 

Dr.  George  Edelmann,  who  always  asserted  that 
he  made  the  experiments  that  resulted  in  the  discov- 
ery of  chloroform,  died  at  the  City  Hospital  in  St. 
Louis  on  July  19th.  He  was  a  graduate  of  Jefferson 
Medical  College,  and  served  as  an  army  surgeon  dur- 
ing the  Civil  War. 


I82 


MEDICAL   RECORD. 


[August  4,  1900 


progress  of  ^edical  Jiciciicc. 

Medical  News,  July  28,  igoo. 

Headache  from  Eye-Strain.— Casey  A.  Woo  1  says  that  the 
site  of  the  ocular  headache  in  tlie  order  of  frequency  is  (i) 
the  supra-orbital;  (2)  the  deep  orbital;  (3)  the  fronto- 
occipital;  (4)  the  temporal.  The  character  of  the  pain  is 
more  likely  to  be  dull  and  heavy  than  very  acute.  '1  he 
exciting  causes  are  tasks  which  require  the  use  of  the  ac- 
commodation and  convergence,  reading,  writing,  drawing, 
painting,  typewriting,  sewing,  music,  card-playing,  bil- 
liards, shopping,  riding  in  trains  and  street-cars,  etc. 
Long-sighted  people  suffer  more  from  headache  than  the 
short-sighted.  Insomnia,  dyspepsia,  pelvic  disease  pre- 
dispose to  ocular  headache.  The  author  is  opposed  to  in- 
ternal drug  treatment,  but  advises  very  hot  or  very  cold 
fomentations.  In  conjunction  the  following  mixture  may 
be  rubbed  over  the  foreliead  and  temples,  or  a  towel,  wet 
with  one  part  in  ten  with  ice-water,  may  be  laid  over  the 
closed  eyes  and  forehead  while  the  patient  is  lying  down 
Spirits  of  lavender,  alcohol,  aa  fl  3  iii.  ;  spirits  of  camphor, 
fl  3  i.     The  author  also  suggests  other  remedies. 

Acute  Trional  Intoxication. — Warren  Coleman  reports  a 
case  due  to  the  ingestion  of  nine  drachms  in  seventy-two 
hours.     The  patient  recovered. 

Aspiration  in  the  Treatment  of  Acute  Traumatic  Empyema ; 
with  an  Illustrative  Case. — By  Joseph  D.  Bryant. 

A  Contribution  to  the  Management  of  Face  Presentations. 
— By  Malcolm  McLean. 

New  York  Medical  Journal,  July  28,  igoo. 

Some  Observations  upon  Sjrphilitic  Manifestations  in  the 
Uveal   Tract :    the   Iris,  Ciliary  Body,  and    Choroid.— P.  T. 

Vaughn  says  that  during  the  past  year  seventy  cases  of 
syphilis  have  been  seen  by  him  exhibiting  eye  symptoms, 
and  that  of  this  number  the  uveal  tract  (iris,  ciliary  body, 
and  choroid)  was  involved  in  twenty-nine,  or  41.4  percent. 
of  the  total  number.  He  describes  the  symptoms  of  the 
different  conditions  found,  quoting  from  various  authors  to 
substantiate  his  views,  which  are  also  supported  by  clinical 
histories  of  some  of  his  own  cases.  He  states  among  other 
facts  that  his  own  observation  has  been  that  the  symptoms 
of  plastic  and  serous  iritis  when  due  to  syphilis  vary  little 
from  the  symptoms  of  these  varieties  of  iritis  when  due 
to  other  causes.  Pain  is  one  of  the  most  prominent  symp- 
toms, and  it  extends  sometimes  over  the  entire  half  of  the 
head,  corresponding  to  the  branches  of  the  supraorbital 
nerve.  The  pain  is  usually  worse  at  night,  and  is  always 
aggravated  by  bright  illumination. 

The  Spectacle  and  Eye-Glass  Habit. — N.  B.  Jenkins  says 
that  wearing  spectacles  or  eye-glasses  out-of-doors  is  always 
a  disfigurement,  often  an  injury,  seldom  a  necessity.  'I'he 
old  rule,  "  Wear  glasses  all  the  time,  "  should  be  changed  to 
"  Wear  glasses  just  as  little  as  possible."  Some  wear  spec- 
tacles for  years,  and  then  by  lucky  chance  lose  them,  only 
to  find  that  they  get  along  better  without.  After  wearing 
glasses  only  a  few  days  many  find  the  print  looks  worse  to 
the  naked  eyes  than  before.  This  is  a  sure  way  to  tell  that 
glasses  are  wrong.  Most  people  witli  troublesome  imper- 
fections of  the  eyes  cannot  leave  their  glasses  off  even  for 
an  hour  or  so  without  discomfort.  This  is  because  they 
have  wrong  glasses.  The  right  glasses  can  be  put  on  and 
taken  off  at  any  time  with  ease,  and  no  more  discomfort 
will  follow  than  when  putting  on  and  taking  off  a  hat. 

Empyemas  of  the  Accessory  Nasal  Cavities,  with  a  Report 
of  Cases  in  which  the  Antrum  of  Highmore  was  Involved. — R. 
A.  Wright  gives  a  general  description  of  the  affection,  and 
reports  five  cases  of  antral  suppuration.  Concerning  ex- 
perimental puncture  for  diagnostic  purposes  he  gives  the 
following  direction  ;  A  thick,  large,  straight  aspirating 
needle  is  passed  into  the  nose  in  the  lower  meatus  under- 
neath the  inferior  turbinated  body,  a  little  posterior  to  its 
middle  half;  the  external  end  is  pressed  downward  and 
toward  the  middle  line,  forcing  the  point  up  to  the  junc- 
ture of  the  inferior  turbinated  body  with  the  lateral  wall  ; 
the  needle  is  now  thrust  through  the  bony  partition  into 
the  antruin.  This  point  of  puncture  is  important,  for  in 
front  of  and  below  it  the  bony  wall  is  too  resistant  to  punc- 
ture with  the  needle. 

Neurasthenia  and  Syphilis. — J.  G.  Kiernan  mentions 
syphilophobia  as  a  frequent  source  of  neurasthenia.  He 
advocates  for  this  condition  a  familiar  combination  of  gold 
with  arsenic  and  the  bromides. 

The  Pituitary  Gland  as  a  Factor  in  Acromegaly  and  Giant- 
ism.— Concluiling  article  by  Woods  Hutchinson. 

Typhoid  Fever  in  an  Infant  Eighteen  Months  Old ;  Recov- 
ery.— By  A.  Samuels. 


fournal  of  the  AiiiericaK  Medical  Ass' n,  July  28,  igoo. 

Post-Febrile  Insanity  and  its  Treatment. — F.  P.  Norbury 
discusses  nutritional  changes  as  they  affect  the  brain  and 
infectious  processes  leading  to  mental  disorder.  Abnormal 
metabolism,  he  believes,  permits  oftentimes  the  entrance 
of  infection.  The  writer  quotes  the  conclusions  of  Mills, 
taken  from  the  article  in  the  "Twentieth  Century  Practice  "  ; 
(I)  Specific  infection  must  be  included  among  the  causes 
of  mental  diseases  and  of  symptoms  which  precede,  accom- 
pany, or  follow  febrile  or  other  infectious  disorders.  (2) 
Much  negative  evidence  can  be  adduced  in  favor  of  acute 
delirium  being  due  to  toxaemia.  Such  evidence  is  afforded 
by  autopsies,  which  reveal  neither  gross  nor  histological  le- 
sions ;  and  in  these  cases  the  toxa:mia  probably  over- 
whelms the  patient  before  the  production  of  meningitis  or 
other  disease.  (3)  Analogies  to  nervous  affections  which 
are  known  or  believed  to  be  of  microbic  origin,  such  as 
multiple  neuritis,  myelitis,  and  chorea,  favor  the  view  that 
insanities  with  similar  or  related  phenomena  and  lesions 
are  also  microbic  in  origin.  (4)  The  evidence  afforded  by 
careful  bacteriological  investigations  of  acute  insanity  is 
thus  far  too  meagre,  but  shows  that  various  micro-organ- 
isms may  induce  the  same  or  similar  types  of  mental  d's- 
ease.  (5)  The  mental  disorders  of  pregnancy  and  the 
puerperal  state  are  probably  in  a  considerable  proportion  of 
cases  toxasmic.  without  reference  primarily  to  childbirth  ; 
but  it  cannot  be  regarded  as  proved  that  a  bacillus  of 
eclampsia  or  puerperal  mania  is  a  sole  cause  of  these  affec- 
tions. He  then  discusses  heredity,  occupation,  types,  di- 
agnosis, and  treatment. 

Exact  Infant  Feeding;  Accidents  and  Incidents.— W.  P. 
Northrup  calls  attention  to  the  accidents  which  may  arise 
from  the  very  exactness  of  the  methods  employed.  These 
may  occur  in  mechanical  waj-s.  Scurvy  may  arise  from 
the  prescription  for  modified  milk  not  being  supervised  and 
changed  at  the  proper  time.  A  safe  method  is  to  advance 
the  proportions  gradually  to  "full"  undiluted  milk.  This 
may  often  be  accomplished  by  the  eighth  month.  To  sum- 
marize, (i)  Clean  cow's  milk,  modified  to  some  definite 
formula,  is  demanded.  (2)  A  laboratory  for  modification 
is  desirable  ;  it  secures  greater  exactness  and  cleanliness. 

(3)  The  physician  should  frequently  revise  his  formula  ; 
frequent  small  percentages  of  increase  are  to  be  advised. 

(4)  Accidents  may  arise  from  consigning  an  infant  for  sev- 
eral months  to  insufficient  food  ingredients.  A  baby  is  not 
the  same  baby  for  many  weeks  at  a  time,  its  growth  and 
physiological  demands  change  so  much.  Discussion  fol- 
lows. 

The  Prophylaxis  and  Management  of  Interstitial  Nephritis. 
— C  W.  Purdy  says  proph)  laxis  must  include  some  definite 
knowledge  of  the  tendencies  of  the  patient  to  the  disease 
under  consideration.  Histories  of  cases  of  purely  acquired 
interstitial  nephritis  showed  heavy  appetites,  sedentary 
lives,  and  excessive  use  of  proteid  food.  The  dominant 
factor  is  over-ingestion  and  over-elimination  of  nitrogen, 
and  these  furnish  the  key  to  prophylaxis.  The  disease  is 
stamped  in  the  strongest  manner  by  heredity,  and  the 
family  history  furnishes  a  clew  to  a  large  proportion  of 
cases  suitable  for  prophylactic  measures.  Much  can  be 
done  to  prevent  advanced  cardiac  complications.  Abnor- 
mal friction  in  the  circulation  should  be  modified.  JIuscu- 
lar  tone  can  be  improved  by  digitalis  and  strychnine.  Ab- 
solute quietude  is  often  required  until  heart  lione  is  regained 
or  restored  to  a  measure  equal  to  its  work.  When  dropsy 
has  set  in  diuretics  have  to  be  resorted  to.  but  the  fight  fror' 
then  on  is  a  losing  one. 

Blood  Examination. — M.  H.  Fussell  directs  attention  to 
the  value  of  blood  tests  to  the  general  practitioner.  He 
finds  them  quite  as  important  as  examinations  of  the  urine, 
if  not  more  so.  They  are  of  great  value  in  obscure  cases. 
All  white-complexioned  people  are  not  subjects  of  anaemia, 
as  tests  will  demonstrate.  Conversely,  a  flushed  face  may 
disguise  a  decided  reduction  of  haemoglobin.  The  test  is 
of  value  in  showing  when  the  patient  has  recovered.  The 
clinical  symptoms  may  very  rapidly  improve  and  still  the 
blood  count  will  show  little  change.  Errors  in  reference  to 
leukajmia  and  pernicious  anaemia  may  be  obviated.  Cases 
in  illustration  are  given.  Fresh  blood  ma)'  be  preserved 
for  several  hours  by  letting  cedar  oil  run  in  under  the 
cover-glass.  Besides  a  micro.scope  with  oil  immersion  lens  a 
hsemoglobinometer  and  h;emocytometer  are  required.  The 
specimen  is  collected  in  a  few  minutes  at  the  bedside  and 
examined  .at  leisure  in  the  office. 

Practical    Physiology    of    the    Digestive    Organs. — A.    L. 

Benedict  describes  details  not  well  recognized  or  put  down 
in  textbooks  having  reference  to  digestive  practice.  The 
importance  of  mastication  and  insalivation  is  first  consid- 
ered, and  then  follows  a  study  of  the  oesophagus  and  its 
rate  of  peristalsis  (which  in  general  is  about  eight  seconds). 
The  sounds  of  liquids  passing  through  tlie  cardia  are  best 
described  as  varying  from  a  sharp  squirting  to  a  low  gur- 
gle.    Free  hydrochloric  acid  should  form  about  half  the 


August  4,  1900] 


MEDICAL   RECORD. 


183 


total  acidity  of  the  stomach  contents.  Numerous  experi- 
ments sliowthat  the  stomach  contents  do  not  change  mate- 
rially after  withdrawal  if  cooled  to  40'  F.  He  is  inclined 
to  believe  that  there  is  exceedingly  little  absorption 
through  the  glandular  membrane  of  the  stomach  ;  the 
potassium  iodide  test  really  marking  the  first  peristaltic 
wave  into  the  intestine. 

Infant  Feeding. — Alexander  McAlister  makes  a  plea  for  a 
closer  adherence  to  and  stronger  advocacy  of  nature's  meth- 
od of  infant  feeding,  on  the  part  of  medical  men.  He  finds 
an  alarming  disinclination  on  the  part  of  mothers  to  breast- 
nurse  their  offspring.  Breast-nursed  infants  may  not  be 
fat.  but  they  are  usually  robust  and  fleshy.  Considering 
the  chances  for  milk  infection  it  is  a  marvel  that  the  mor- 
tality of  bottle-fed  children  is  not  vastly  higher  than  it  is. 
Koplik  is  quoted  to  the  effect  that  even  one  breast-feeding 
in  the  twenty-four  hours  is  of  decided  advantage,  and  ho 
believes  that  "part  breast  is  superior  to  all-hand  feeding." 
Properly  collected,  cooled,  and  bottled  milk  is  better  than 
any  laboratory  milk. 

The  Credulity  of  the  People  as  it  Pertains  to  Medicine  and 
Religion. — By  T.  B.  Greenley. 

Neurology  and  Medical  Jurisprudence. — Address  of  chair- 
man. Hugh  T.  Patrick. 

Laryngology  and  Otology. — Address  of  chairman.  Chris- 
tian K.  Holmes. 

Hospital  and  Ward  Clinical  Laboratories. — By  C.  N.  B. 
Camac. 

The  Mammary  and  the  Parotid  Glands. — By  John  B.  Sho- 
ber. 

Philadelphia  Medical  Journal.  July  28.  igoo. 

Are   Consanguineous   Marriages   Injurious   to  the  Race  ?•»- 

Lawrence  Irwell  concludes  that  consanguineous  unions 
are,  in  the  great  majority  of  cases,  undesirable,  not  be- 
cause they  originate  diseases  de  hoto,  but  because  they 
intensify  existing  disorders  or  diatheses  from  which  very 
few  families  are  exempt.  They  should  not  even  be  thought 
of  in  any  family  in  which  idiocy,  insanity,  epilepsy,  con- 
genital deaf-mutism,  hare-lip.  cleft  palate,  the  phthisical 
or  litha;mic  diatheses  have  occurred,  for  all  of  these  dis- 
eases or  tendencies  toward  disease  may  be  handed  down 
from  one  generation  to  another.  As  it  is  not  improbable 
that  cancer  is  a  micro-organic  malady  which  attacks  only 
those  persons  who  have  a  proclivity  toward  it,  families  in 
which  cancer  has  appeared,  no  matter  how  far  back,  should 
avoid  consanguineous  unions.  Frequent  marriages  of  per- 
sons who.se  environments  have  been  very  similar  is  injuri- 
ous to  the  race,  and  extreme  exclusiveness  in  marriage  is 
not  commendable. 

A  New  Method  for  the  Clinical  Determination  of  the  Posi- 
tion of  the  Cardia.--  By  Ci.  W .  McCaskey. 

Cause  of  the  Decussation  of  the  Nerve-Fibres  in  the  Me- 
dulla and  Spinal  Cord.  — By  U.  T.  Smith. 

Miitter  Lectures  of  the  College  of  Physicians  of  Philadel- 
phia.—By  John  B.  Roberts. 

A  Method  for  the  Graphic  Study  of  Gastric  Peristalsis  — 
By  Clarence  Ouinan. 

The  Early  Recognition  of  Ectopic  Pregnancy. — By  DeWitt 
G.  Wilcox. 

Boston  Medical  and  Surgical  Journal,  July  26,  igoo. 

Morbid    Conditions   Caused   by   Bacillus  Aerogenes  Capsu- 

latus.— WiUiam  H.  Welch,  in  the  Shattuck  Lecture  for  lyoo, 
reviews  the  history  of  the  gas  bacillus  and  recalls  its  diag- 
nostic characteristics.  It  is  distinguished  from  the  colon 
bacillus  by  its  power  of  producing  gas  abundantly  in  the 
blood,  organs,  and  tissues  of  rabbits  killed  a  few  minutes 
after  intravenous  injection.  Among  the  points  distin- 
guishing it  from  the  bacillus  of  malignant  oedema  are  the 
following:  The  malignant  oedema  bacillus  is  somewhat 
thinner,  has  greater  tendency  to  grow  into  filaments,  is 
less  readily  stained  by  Gram,  produces  spores  regularly  in 
culture  media,  is  motile,  liquefies  gelatin  more  rapidly, 
produces  a  foul  odor,  produces  less  gas  in  lactose  bouillon, 
peptonizes  clotted  casein,  generates  little  or  no  gas  in  rab- 
bits inoculated  intravenously  and  then  killed,  and  by  sub- 
cutaneous inoculation  in  susceptible  animals  causes  spread- 
ing bloody  cedema  with  little  or  no  development  of  gas 
bubbles,  and  appears  after  death  in  filaments  on  serous 
surfaces.  The  gas  bacillus  is  widely  distributed  in  nature, 
the  natural  habitat  being  the  intestinal  canal  and  the  soil. 
It  has  been  found  repeatedly  in  Europe  and  America,  and 
by  Flexner  also  in  Manila.  The  gas  bacillus  has  been 
found  in  numerous  conditions  in  human  beings.  Its  pres- 
ence in  ordinary  cadaveric  decomposition  is  readily  explic- 
able by  the  occurrence  of  the  organism  in  the  healthy  in- 
testinal canal.  Of  a  different  nature,  however,  are  the 
cases  in  which  gas  bubbles  are  found  in  the  blood  and 
organs  within  from  one  to  eight  hours  after  death  and 
without  any  trace  of  putrefaction.     There  is  every  grada- 


tion from  cases  with  a  few  bubbles  of  gas  in  the  blood  or 
tissues  to  those  with  extensive  emphysema  of  the  organs 
and  tissues  (Schaumorgane) .  The  author  has  never  fou  nd 
these  gas  bubbles  unassociated  with  gas  bacilli.  The  in- 
vasion in  the  majority  of  cases  is  from  the  intestine,  but 
whether  it  and  the  development  of  gas  occur  ante  mortem 
or  post  mortem  has  not  yet  been  determined  with  certainty. 
The  finding  of  gas  bubbles  within  an  hour  after  death  offers 
no  conclusive  argument  against  the  post-mortem  invasion 
of  the  organism,  and  in  the  great  majority  of  instances 
there  is  no  doubt  that  the  formation  of  gas  bubbles  is  a 
post-mortem  phenomenon.  The  bacillus  is  of  interest  to 
surgeons  as  well  as  physicians,  since  it  is  a  frequent  cause 
of  that  most  dreaded  of  wound  complications,  emphysema- 
tous gangrene.  It  is  probably  not  the  sole  cause,  however, 
and  the  author  is  of  the  opinion  that  an  aerobic  bacillus, 
probably  identical  with  Sanfelice's  bacillus  pseudo-cede- 
matis  maligni,  is  also  capable  of  producing  this  affection. 
Among  the  uterine  infections  by  the  gas  bacillus  are  men- 
tioned emphysema  of  the  foetus,  physonietra,  emphysema 
of  the  uterine  wall,  and  puerperal  gas  sepsis.  The  bacillus 
has  been  found  also  in  cases  of  puerperal  endometritis  in 
which  there  was  no  gas  in  the  fcEtus  or  the  uterine  cavity 
or  wall.  The  urinary  tract  may  not  only  be  a  portal  of 
entrance  for  the  gas  bacillus  into  the  circulation  or  adja- 
cent tissues,  but  also  be  itself  the  seat  of  infection  by  this 
organism.  In  cases  of  pneumaluria  the  gas  bacillus  has 
been  found  in  the  bladder  post  mortem,  and  it  has  also 
been  encountered  in  gas  cysts  in  the  renal  pelves  and  in 
gas  blebsunder  the  vesical  mucous  membrane.  Thesesub- 
mucous  and  subserous  gas  cysts  or  blebs  are  among  the  most 
interesting  of  the  lesions  produced  by  bacillus  aerogenes 
capsulatus  ;  they  have  been  found  by  Welch  in  the  stom- 
ach, intestine,  gall  bladder  and  bile  ducts,  urinary  blad- 
der, renal  pelvis,  and  vagina.  The  intestine  is  by  far  the 
most  common  source  of  the  gas  bacilli  found  together  with 
gas  bubbles  in  the  blood  and  organs  at  autopsies.  This 
invasion  may  occur  either  with  or  without  definite  intes- 
tinal lesions,  and  is  probably  in  the  majority  of  cases  an 
agonal  or  post-mortem  event.  Especially  demonstrative 
of  invasion  of  gas  bacilli  from  the  intestine,  usually  post 
mortem,  is  the  occurrence  of  gas  bubbles  limited  to  the 
neighborhood  of  the  intestine,  as  in  the  intestinal  wall, 
within  the  portal  or  mesenteric  veins  or  lymphatics,  in  the 
subperitoneal  tissue,  mesentery,  and  omenta,  around  the 
pancreas,  in  the  mesenteric  glands,  and  especially  in  the 
loose  tissue  near  the  gall  bladder  and  in  the  porta  of  the 
liver,  without  gas  in  more  remote  situations.  Examples 
of  each  of  these  occurrences  have  been  observed  in  very 
early  autopsies  without  ordinary  cadaveric  decomposition. 
Among  the  infections  in  this  class  are  local  gastro-enteric 
lesions,  pneumoperitonitis  with  and  without  perforation, 
and  hepatic  and  biliary  invasions.  Pulmonary,  plenral, 
and  cerebral  infections  have  also  been  observed,  and  the 
gas  bacillus  has  been  found  in  the  blood  during  life. 

The  True  Function  of  the  State  Medical  Examining-Board. 
— By  AUard  Memminger. 

The  Lancet,  July  21 ,  igoo. 

On  Rupture  of  the  Apparently  Healthy  (Esophagus. — E.  J. 
McWeeny  reports  the  case  of  a  man  aged  forty  years,  who 
on  entrance  to  hospital  complained  of  pain  in  the  lower 
parts  of  the  chest  and  emphysematous  swelling  of  the  neck 
and  face,  which  later  mounted  to  the  eyelids  and  extended 
down  the  thorax.  His  general  condition  was  one  of  col- 
lapse, and  he  died  seven  hours  after  admission.  He  had 
been  a  heavy  drinker  and  v.'as  much  given  to  "dry  retch- 
ing." Autopsy  revealed  a  slit-like  aperture  in  the  oesopha- 
gus nearly  1.5  cm.  long,  in  the  anterior  surface  just  above 
the  diaphragm.  The  writer  analyzes  seventeen  similar 
cases,  giving  a  full  bibliography  and  emphasizing  the 
salient  points  of  each.  He  concludes  that  the  two  main 
factors  that  are  operative  in  causing  rupture  of  the  macro- 
scopically  normal  gullet  are  {a)  softening  of  the  coats  and 
(b)  sudden  increase  of  pressure  from  within.  The  soften- 
ing IS  due  partly  to  intra-vital  digestion,  and  partly  to  in- 
flammatory infiltration.  The  intra-vital  digestion  is  to  be 
accounted  for  by  (a)  circulatory  disturbance,  which  in  his 
case  took  the  form  of  venous  thrombosis,  and  (1^)  prolonged 
sojourn  of  peptic  matters  in  the  gullet  from  prolonged 
retching.  The  increased  pressure  from  within  is  doubtless 
ascribable  to  the  violent  propulsion  of  the  gastric  contents 
into  the  lower  part  of  the  gullet,  while  its  upper  outlet  is 
obstructed  by  the  contracted  state  of  the  muscle — in  other 
words,  to  want  of  co-ordination  of  the  muscular  action  of 
the  tube,  probably  due  to  exhaustion  from  prolonged  over- 
activity. Whether  a  localized  phlegmonous  oesophagitis — 
for  that  is  the  condition  which  existed  in  the  case  now  re- 
corded— is  a  constant  factor  in  these  cases,  it  is  of  cour.se 
impossible  to  assert  in  the  absence  of  microscopical  details 
of  the  other  cases. 

A  Case  of  Pernicious  Anaemia  following  on  Traumatic 
Stricture  erf  the  Small  Inteetine.— The  patient  of  A.  E.  Baiv 


1 84 


MEDICAL    RECORD. 


[August  4,  1900 


ker  was  a  man  who  had  been  run  over  by  a  wagon  seven 
years  previously,  and  had  ever  since  the  accident  suffered 
from  periodic  attacks  of  pain  and  vomiting.  Analysis  of 
the  blood  showed  red  cells.  2,000,000:  white  cells.  54,000; 
ha;mogIobin.  thirty  per  cent.  Symptoms  of  intestinal  ob- 
struction were  developed,  and  an  abdominal  incision  was 
made.  A  stricture  was  found  m  the  first  part  of  the  jeju- 
num, and  an  anastomosis  was  made  of  the  jiarts  above  and 
below.  The  patient  did  not  do  well  after  the  operation, 
and  died  on  the  second  day.  The  autopsy  was  made  by 
W.  Hunter,  who  summarizes  the  features  of  the  case  as 
follows-  (I)  A  man,  temperate,  well  fed,  and  living  in 
healthy  surroundings.  (2)  bad  teeth  causing  alternately 
alveolar  and  ethmoidal  suppuration  without  at  any  time 
occasionin.g  local  discomfort;  (3)  he  always  suffered  from 
"heartburn  "  (denoting  chronic  gastric  catarrh  with  dimin- 
ished acidity  of  gastric  juice)  ;  (4)  accident  causing  stric- 
ture of  jejunum  ;  (5)  more  or  less  severe  abdominal  and 
gastric  symptoms  lasting  six  years  ;  (6)  more  or  less  rapid 
supervention  of  the  features  of  pernicious  anfcmia  nine 
months  before  death ;  (7)  post  mortem  (a)  dental  decay 
with  local  complications — ^..^..  alveolar  and  ethmoidal  sup- 
puration, and  (1^)  definite  infection  (coccal  and  streptococ- 
cal) of  the  mucosa  of  the  intestine  and  colon,  with  definite 
catarrhal,  inflammatory,  and  necrotic  changes — to  a  less 
extent  of  the  stomach. 

The  Varieties  of  Acute  Pneumonia. — H.  Hanford  discusses 
some  of  the  unusual  forms  of  pneumonia,  calling  special  at- 
tention to  cases  with  low  temperature  and  cases  in  which 
the  symptoms  both  general  and  special  are  well  marked 
and  undoubted,  but  in  which  physical  signs  are  scanty  or 
ab.sent.  Some  of  these  have  been  explained  on  the  theory 
that  the  area  affected  is  central,  not  reaching  the  surface 
of  the  lung.  In  other  cases  it  has  been  suggested  that  the 
general  symptoms  have  been  caused  by  the  toxins  of  the 
pneumococcus  growing  in  other  than  the  pulmonary  organs. 
The  symptoms  are  due  not  only  to  the  local  lesions  but  in 
great  part  to  the  specific  nature  of  the  poison.  The  author 
also  discusses  the  question  of  infection  in  pneumonia,  food 
pneumonias,  and  those  eases  seen  in  connection  with  the 
grippe  and  the  plague. 

A  Case  of  Ulcerative  Endocarditis  with  Recovery  under  the 
Use  of  Antistreptococcic  Serum. — The  patient  of  J.  M. 
Clarke  was  a  girl  aged  twenty-two  years.  The  diagnosis 
of  ulcerative  endocarditis  was  made  on  the  following 
grounds  :  (i)  The  presence  of  a  chronic  valvular  lesion  on 
which  an  infective  process  is  apt  to  graft  itself;  (2)  the 
fact  that  the  illness  did  not  yield  to  the  several  salicylic 
compounds  which  were  tried  in  full  doses  without  effect ; 
(3)  the  occurrence  of  a  pulmonary  infarct;  and  (41  the 
steady  progress  of  the  patient  from  bad  to  worse  until  treat- 
ment.by  serum  was  begun,  which  treatment  again  would 
have  had  no  influence  on  acute  rheumatism.  No  special 
features  were  noticeable  after  the  injections  other  than  have 
been  reported  from  their  use  in  other  maladies.  At  first 
there  were  noticed  local  pain,  urticaria  at  the  site  of  injec- 
tion, and  slight  swelling,  but  later  only  malaise  for  several 
hours  and  headache  were  felt. 

Modern  Methods  of  Amputation  at  the  Hip-Joint. — Clin- 
ical lecture  reporting  fifteen  cases,  by  T.  F.  Chavasse. 

Rodent  Cancer  of  the  Cornea ;  Operation ;  Recovery  with 
Retention  of  Good  Sight. — By  Sydney  Stephenson. 

Malaria  and  the  Malarial  Parasite — Clinical  lecture  by 
Patrick  Manson. 

Four  Cases  of  Puerperal  Eclampsia. — By  T.  B.  Broadway. 

British  Medical  Journal,  July  21.  tgoo. 

The  Ethics  of  Secrecy  in  the  Learned  Professions. — C.  R. 
StPaton  compares  the  customs  of  the  past  with  those  pre- 
vailing and  the  rules  of  action  in  England  with  other  coun- 
tries relative  to  the  confessions  made  to  attorney.  Jihy- 
sician,  or  priest.  The  surgeon's  evidence  often  being 
essential  to  the  establishment  of  facts  upon  which  justice 
can  be  based,  it  is  held  that  excluding  tlie  physician  from 
the  witness  stand  often  interferes  with  the  proper  admin- 
istration of  justice.  Professional  secrecy  has  reached  a 
higher  development  in  France  than  el.sewhere,  and  a  brief 
sketch  of  its  evolution  and  operation  is  given.  Possible 
changes  in  the  law  of  England  are  considered,  tlie  ten- 
dency of  the  times  being  not  to  exclude  any  evidence 
which  may  lead  to  justice.  A  plea  is  made  for  an  obser- 
vance of  the  moral  proportion  of  things,  and  a  note  of 
warning  is  .sounded  before  the  medical  profession  drifts 
into  the  doctrine  of  absolute  secrecy  under  all  circum- 
stances Safeguards  should  be  devised  to  prevent  our- 
selves from  being  made  the  passive  agents  of  injustice  and 
vrong. 

The  Alleged  Increase  in  Insanity. — R.  H.  Noott  thinks 
that  the  reported  increase  in  insanity  of  late  has  been  due 
to  faulty  statistical  methods.  A  calculation  based  on  a  re- 
cently published  table  shows  that  in  the  year  2301  every 


one  will  be  mad.  There  has  been  during  the  past  ten  years 
in  England  an  unusually  rapid  accumulation  of  registered 
lunatics,  but  this  is  not  held  as  proving  that  the  actual 
number  has  increased,  and  is  to  be  explained  in  more 
complete  registration,  greater  confidence  m  asylum  treat- 
ment, etc.  Intemperance  prevention,  and  cure  are  con- 
sidered from  various  sides. 

The  Preliminary  Education  of  Medical  Students  — P  Q. 
Karkeer  is  of  the  opinion  that  tlie  present  standard  of 
scholarship  required  in  the  i)reliminary  examination  is  not 
a  sufficient  indication  that  the  candidate  for  entering  the 
medical  profession  has  received  the  education  of  a  gentle- 
man. He  discusses  the  best  ways  of  developing  a  boy's 
faculties  by  educational  training,  pointing  out  what  is  best 
for  the  student  and  what  best  for  the  profession. 

Thirty-five  Years'  Retrospect  in  the  Profession,  Including 
Some  Experiences,  Chiefly  Surgical. — By  T.  A.  Buck. 

Observations  on  the  Organization  of  the  Branches  of  the 
British  Medical  Association.— By  W.  Gordon, 

The  Future  of  the  Profession  and  of  the  Association.— By 

Sydney  Wilson  Maclhvaine. 

Our  Numbers  and  Our  Work  at  the  Close  of  the  Century. 

— By  George  Eastes. 
On  Some  Medical  Questions  of  the  Day. — By  Milner  Moore. 

Miinchencr  inedicinischc  W'ochcnschrtjt,  July  10,  igoo. 

A  Contribution  to  the   Knowledge  of  the  Action  of  Oil  of 

Turpentine.—  Schulz,  supplementing  former  studies  on  other 
drugs,  has  conducted  a  series  of  observations  on  the  action 
of  minimal  doses  of  oil  of  turpentine.  Two  sets  of  experi- 
ments were  conducted,  the  one  with  an  alcoholic  solution 
containing  one  per  cent,  of  the  dru?,  the  other  of  a  strength 
of^i  .  1,000.  In  either  case  the  daily  dose  was  twenty  drops 
of  the  solution  given  in  the  morning.  The  results  of  this 
almost  homoeopathic  medication  were  very  pronounced. 
The  central  nervous  system  gave  evidence  of  great  depres- 
sion ;  there  was  more  or  less  hebetude,  with  disinclination 
to  mental  and  physical  exertion,  and  extreme  muscular 
fatigue.  Nearly  all  the  experimenters  suffered  from  in- 
somnia. The  effect  on  the  gastric  system  was  character- 
istic. During  the  first  few  days  eructation  was  complained 
of ;  later  this  disappeared,  but  gastric  pains  of  greater  or 
less  severity  supervened.  There  were  vomiting,  anorexia, 
and  constipation.  The  urine  in  all  esses  acquired  a  notice- 
able odor  and  became  dark-colored  •  albumin  was  not  pres- 
ent. The  pulse,  contrary  to  most  published  observations, 
was  found  to  be  depressed  in  frequency.  In  two  cases  a 
well-marked  facial  acne  was  ;;aused. 

A  Case  of  Hysterical  Dumbness  the  Result  .f  Intoxication. 

—  Bloch  describes  the  case  of  a  boy,  fifteen  years  old,  who 
while  at  work  in  a  carpenter  shop  suddenly  fell  to  the 
ground  unconscious.  On  examination  the  eyes  were  found 
wide  open,  pupils  dilated  and  reacting  to  light;  neck, 
arms,  and  le.gs  rigid  and  resisting  efforts  at  flexion  ;  patel- 
lar reflexes  exaggerated.  The  patient  did  not  reply  when 
questioned  ;  the  mouth  was  firmly  closed,  and  medication 
by  that  channel  was  impossible.  The  temperature  was 
normal ;  pulse  70.  For  two  days  this  condition  continued 
unaltered  ;  on  the  third  the  patient  was  able  to  ind  cate  his 
wants  by  writing,  and  finally,  as  the  result  of  suggestive 
and  local  treatment,  on  the  sixth  day  he  regained  complete 
control  of  all  his  faculties.  The  author  considers  the  case 
of  particular  interest,  since  the  only  cause  that  could  be 
found  for  the  trouble  seemed  to  he  in  the  fact  that  the  stove 
in  use  in  the  shop  was  not  in  good  order,  and  that  on  the 
same  day  the  patient  was  affected  several  other  workmen 
complained  of  various  symptoms,  headache,  nausea,  etc., 
and  he  believes  that  these,  as  v  ell  as  the  patient's  attack, 
were  due  to  carbonic-oxide  poisoning. 

Dressings  Left  Behind  after  Laparotomy  -'W'underlich 
adds  two  more  to  the  instances  in  which  dressings,  etc.. 
have  been  unwittingly  left  behind  after  laparotomy.  In 
the  one  case,  three  and  one-half  months  after  making  an 
uneventful  recovery  from  the  operation  the  patient  voided 
with  the  faeces  a  compress  eight  inches  wide  by  forty  inches 
in  length.  No  bad  effects  followed.  In  the  other  case  the 
patient  succumbed  to  cardiac  collajise  thirty-six  hours  after 
a  cholecystectomy  ;  at  the  autopsy  a  cloth  of  the  size  of  a 
small  handkercliief,  such  as  had  been  used  for  packing, 
was  found  free  in  the  peritoneal  cavity  .  there  were  no  evi- 
dences of  peritonitis.  The  author  adds  the  trite  comment 
that  he  now  counts  the  instruments,  pads   etc.    himself. 

The  Etiology  of  Fibrinous  Bronchitis  — Ott  reports  a  case 
of  this  uncommon  disease,  and  gives  in  rtfsui/it' ihe  various 
theories  that  have  been  advanced  concerning  its  causation. 
In  the  case  of  his  own  patient,  a  knife-grinder  there  were 
found  in  the  sputum  the  pneumococcus  of  Fraenkel  and 
the  staphylococcus  pyogenes  aureus,  and  in  the  author's 
opinion  the  localization  of  the  trouble  in  the  bronchi  was 
due  to  the  continued  irritation  caused  by  the  inhalation  of 
the  metallic  particles  attendant  on  the  occupation,  while 


August  4,  1900] 


MEDICAL    RECORD. 


185 


the  protracted  course  of  the  disease  was  due  to  the  mixture 
of  micro-organisms. 

Experimental  Observations  on  the  Sterilization  of  the 
Hands. — By  Paul  and  Sarwey. 

Contributions  to  the  Study  of  Immunity.— By  Dungern. 

A  Case  of  Weil's  Disease.— By  Schottenhelm. 

/It-r/iiu-r  l-/iitfsi/ii    \Vocltensi:hyiJI.  /uly  g,  igoo. 

A  Constant  Bacteriological  Result  in  Scarlatina.— A.  Ba- 
ginsl<y  and  F.  Sonimerfeld  conclude  a  series  of  articles  witli 
the  following  propositions  (i)  In  all  cases  of  scarlatinal 
angina  we  find  streptococci,  sometimes  in  pure  culture,  gen- 
erally, however,  accompanied  by  other  cocci,  but  always 
overshadowing  them.  (2)  In  all  the  fatal  cases  (forty- 
two)  of  scarlatina  examined,  a  streptococcus  was  found  in 
all  the  organs  and  also  in  the  blood  and  bone  marrow. 
From  this  it  is  safe  to  conclude  that  it  is  constantly  present 
in  all  ca.ses  of  scarlatina.  (3)  The  streptococcus  reveals 
itself  in  its  morphological,  cultural,  and  biological  rela- 
tions as  do  the  streptococci  of  writers  in  general.  'With  all 
methods  of  differentiation  hitherto  u.sed  it  is  not  capable  of 
being  distinguished.  (4)  The  streptococcus  is  of  varying 
degrees  of  virulence,  and  this  can  be  increased  by  success- 
ive cultures.     It  develops  a  toxin  in  the  culture  medium. 

(5)  Specitic  peculiarities  of  the  streptococcus  found  in  scar- 
Uitina  cannot  be  developed  by  culture  methods  any  more 
than  IS  the  case  with  the  streptococci  heretofore  described. 

(6)  The  constancy  of  the  presence  of  this  streptococcus  in 
fatal  scarlatinal  cases  makes  the  same  significant  as  a  fac- 
tor in  the  disease.  (7)  The  collective  clinical  manifesta- 
tions of  scarlatina  are  due  to  the  spread  of  the  streptococcus 
in  the  organs  (infection)  and  the  poison  derived  from  its 
life  processes  (toxicity). 

Extirpation  of  a  Fibro-Lipoma  in  the  Retroperitoneal  and 
Pelvic  Connective  Tissue. —  F.  Konig  reports  the  case,  wliich 
occurred  in  a  man  aged  forty-four  years,  who  died  of  sud- 
den heart  failure  eight  days  after  operation.  The  mass 
rose  as  high  as  the  ensiform  process,  and  the  diagnosis  be- 
fore operation  lay  between  some  form  of  rapidly  growing 
tumor  of  unknown  nature  and  tuberculous  peritonitis. 
Bibliographical  reference  is  made  to  several  similar  cases 
jircviously  reported. 

Test  of  Pupil  Reaction  with  Reference  to  Refraction  of  the 
Eye  and  Central  and  Peripheral  Pupil  Reaction  by  Means  of 
a  New  Instrument.  —  By  H.  Wolff. 

The  Treatment  of  Pulmonary  Tuberculosis  in  Hospitals 
and  in  Practice  among  the  Poor.  — By  Burghart 

The  Present  State  of  Bacteriology. — By  Baumgarten 

The  Pathology  of  Morbid  Tumors.— By  O.  Israel. 

Deutsche  tiu-ditiiiisc  I'lr   W'oclu-nscJirtft.  July  12.  tgoo. 

Some  Contributions  to  the  Pathology  of  Influenza. — A.  Was- 

serman  was  surprised  to  find  that  the  influenza  epidemic 
which  lasted  through  the  first  three  months  of  this  year 
differed  notably  troni  the  great  pandemic  of  iSgo,  especially 
in  its  bacteriology.  In  the  earlier  epidemic  the  bacilli  as- 
sumed to  be  the  specific  cause  of  the  disease  were  con- 
stantly to  be  found  in  great  numbers  in  the  sputum,  and 
the  production  of  pure  cultures  was  a  simple  and  easy  mat- 
ter. In  the  cases  observed  this  year,  however,  it  was  at 
first  found  extremely  difficult  to  demonstrate  the  pre.sence 
of  any  bacilli  at  all,  and  further  study  revealed  the  fact 
that  though  invariably  present  early  in  the  disease  they 
disappeared  with  great  rapidity,  so  that  often  as  soon  as 
twenty-four  hours  after  infection  none  was  to  be  found. 
Linked  with  this  phenomenon  of  the  early  and  comjjlete 
disappearance  of  the  micro-organism  was  the  occurrence  in 
many  of  the  cases  studied  of  symptoms  of  severe  intoxica- 
tion, syncope,  cardiac  weakness,  etc.  To  explain  these 
facts  the  author  advances  the  theory  that  every  infectious 
disease  confers  a  certain  degree  of  immunity,  and  that  even 
epidemic  influenza  protects  its  victims  for  a  certain  length 
of  time  :  thus  no  case  is  recorded  of  any  one  individual's 
having  the  disease  twice  in  the  same  epidemic.  It  there- 
fore follows  that  there  are  present  in  the  blood  of  these 
mdividuals  immunizing  principles,  which,  although  not 
strong  enough  to  resist  infection,  yet  cause  the  speedy  de- 
struction of  the  bacilli.  As  a  result  of  this  sudden  dis.so- 
luti<m  of  the  germs  there  is  liberated  an  overwhelming 
amount  of  toxin  with  which  the  system  is  unable  to  cope, 
hence  the  serious  nature  of  the  symptoms.  The  author's 
belief  is  that  a  large  number  of  the  patients  in  whom  the 
disease  no-.v  runs  an  anomalous  course  have  been  partially 
immunized  in  the  great  pandemic  of  ten  years  ago,  and, 
furthermore,  that  the  conditions  are  rapidly  growing  more 
and  more  favorable  for  a  repetition  of  that  historical  event. 

Experiences  with  Phototherapy  (Conclusion). — Strebel's 
article  presents  his  ideas  on  the  value  of  this  mode  of  treat- 
ment after  having  given  it  extended  trial  in  a  large  num- 
ber of  cases.     In  general  his  opinions  are  favorable  to  the 


method,  though  in  nearly  every  instance  he  ascribes  al- 
most as  much  value  to  the  heat  produced  and  the  conse- 
quent diaphoresis  as  to  the  direct  effect  of  the  light  rays 
themselves.  Both  arc  and  incandescent  lights  are  used, 
but  preference  is  given  to  sunlight  as  being  more  efficacious 
and  cheaper  ;  its  disadvantage  is  that  it  is  not  always  avail- 
able when  desired.  Obesity  is  one  of  the  affections  in  which 
the  light  baths  seem  of  especial  service  ,  others  in  which 
they  have  been  tried  with  more  or  less  success  are  .  chronic 
rheumatic  and  gouty  conditions,  nephritis  heart  lesions  of 
various  sorts,  diabetes,  in  which  they  seemed  to  act  partic- 
ularly well,  ana;mia,  chronic  catarrhal  and  emphysematous 
affections  of  the  respiratory  system,  sciatica,  hard  and  soft 
chancre,  leg  ulcers,  and  furunculosis.  The  action  of  the 
light  pure  and  simple  is  perhaps  best  shown  in  cases  of  lu- 
pus vulgaris.  Here  the  remarkably  satisfactory  results 
can  be  due  only  to  the  direct  bactericidal  action  of  the 
concentrated  rays  on  the  bacilli  situated  just  beneath  the 
surface.  It  is  the  author's  belief  that  further  investigation 
and  clinical  testing  will  reveal  a  definite  sphere  of  useful- 
ness for  this  plan  of  treatment  and  accord  it  a  permanent 
place  among  the  list  of  therapeutic  agents 

The  Differential  Staining  of  Malaria  Parasites. — Ruge 
recommends  the  following  technique  The  smear  is  to  be 
made  by  touching  the  edge  of  a  cover-glass  to  the  drop  of 
blood,  and  having  placed  this  edge  in  contact  with  a  slide 
it  is  to  be  inclined  at  an  angle  of  45°  and  pushed  slowly 
and  evenly  along  the  surface  of  the  slide  in  such  a  way 
that  the  blood  lies  behind  the  advancing  edge,  i  e.,  is 
drawn  along  after  it  and  not  pushed  before  it.  The  prepa- 
ration IS  to  be  dried  and  fixed  in  absolute  alcohol,  and  is 
then  ready  for  staining  with  the  following  solution  .  To 
too  c.c.  of  water  0.2  gm.  of  soda  is  added,  and  the  solution 
is  heated.  While  boiling  0.3  gm.  of  methylene  blue  is 
stirred  in,  and  the  stain  is  filtered  forty-eight  hours  later. 
A  few  drops  are  to  be  poured  on  the  slide  and  immediately 
rinsed  off  with  water.  The  red  blood  cells  will  be  found 
stained  yellowish  or  bluish  green,  the  ring  forms  of  the 
parasites  blue-black,  the  larger  forms  grayish-blue  or  dark 
blue,  and  the  nuclei  of  the  white  cells  intensely  blue. 

Enucleation  of  the  Eye,  its  Substitutes,  and  its  Relation  to 
Sympathetic  Ophthalmia. — By  Schmidt-Rimpler. 

A  Contribution  to  the  Knowledge  of  Meningo-Typhoid. — 
By  Hofmann. 

French  Jouriuils. 

The  Value  of  Organic  Protective  Coverings. — J.  C.  Platon 
and  O.  Platon  relate  an  instance  of  severe  burn  treated  by 
covering  with  strips  of  the  shell  membrane  of  a  freshly 
laid  egg.  Over  this  was  laid  a  sheet  of  sterile  tinfoil  as  a 
protective  to  the  membrane.  After  five  days  the  egg  mem- 
brane was  intact,  and  beneath  it  there  were  isIand-like 
whitish  dots  of  epidermis.  Cicatrization  was  complete  in 
eight  days.  The  method,  first  proposed  by  Amat  in  1S95, 
was  described  at  length  by  Max  Schiller  w  ho  is  quoted, 
and  the  views  of  many  observers  bearing  upon  the  ques- 
tion of  protective  dressings  are  %w^vi.— Gazette  ties 
Hopitau.x,  July  12,   1900. 

Treatment  of  Aneurisms  with  Gelatin. — Lancereaux  and 
Paulesco  have  since  reporting  two  cases  applied  the  gela- 
tin treatment  to  a  number  of  others,  four  of  which  they 
now  report,  together  with  a  review  ot  the  treatment  as  it 
has  been  carried  out  by  others.  They  conclude  that  rest 
in  bed  is  not  sufficient  for  the  cure  of  aneurisms  of  the 
aorta,  as  Litten  has  claimed.  Complete  cure  of  a  large 
aneurism  by  total  obliteration  of  the  sac  is  obtained  only 
after  a  variable  number  of  injections  of  gelatin  according 
to  the  case,  but  approximately  from  twenty-five  to  thirty 
at  the  least. — Gazette  des  Hopitciitx,  July  17,  1900. 


The  Pathology  of  Hiunan  Milk.— John  Zahorsky  says 
milk  must  be  studied  as  a  modified  tissue  having  its  path- 
ological variations.  In  volume  it  is  subject  to  atrophy  and 
hypertrophy  ;  in  structure  it  may  show  pathological  degen- 
erations. In  galactorrhoea  we  have  a  hypersecretion .  in 
oligo-galactia  a  deficient  secretion  due  to  inherent  weak- 
ness of  glandular  activity  in  some  instances,  in  others  ix)n- 
tributed  to  by  irregular  nursing,  etc.  or  weakness  of  di- 
gestion and  metabolism  may  be  at  the  root.  Pathological 
changes  in  proteid  percentages  are  common.  Instead  of 
an  early  showing  of  two  per  cent.,  proteids  may  be  pres- 
ent in  percentage  of  two  and  a  half  to  three  and  a  half, 
and  decrease  but  little  as  lactation  proceeds  A  connection 
may  be  traced  between  this  high  percentage  of  proteids 
and  intestinal  colic  due  to  gases  so  frequent  in  infants 
Artificial  foods  containing  carbohydrates  which  inhibit 
proteid  decomposition  often  prevent  these  colics,  just  as 
does  dextrinized  gruel  as  a  diluent  for  mother's  milk 
Every  effort  should  be  made  to  preserve  the  mammary  se- 
cretion, and  the  child  is  to  be  taken  from  the  breast  only  as 
a  last  resort.— .iV.  Louis  Courier  of  Medicine,  July.  1900. 


1 86 


MEDICAL    RECORD. 


[August  4,  1900 


^euitnns  and  Notices. 

Diseases  of  the  Gali.-Bladder  and  Bii.f.-Dicts,  Includ- 
IN(-,  Gall  Stones.     By  A.  W.  Mayo  Rohson,  F.R.C.S., 
Senior   Surgeon    to   the   General    Infirmary   at    Leeds ; 
Emeritus  Professor  of  Surgery  in  the  Yorkshire  College 
of  the  Victoria  University  ;  Jlemberof  Council  and  Hun- 
terian  Professor  of  Surgery  and  Pathology  at  the  Royal 
College  of  Surgeons  of  England  ;  Assisted  by  Farquhar 
Macrae,  M.B..  CM.  (Glas.  i.     Second  edition.     Pp.  313. 
New  York :  William  Wood  &  Company.     1900. 
This  well-known  work  on  the  surgery  of  the  gall  bladder 
and  bile  ducts  appears  much  improved  in  its  second  edi- 
tion ;  the  lecture  form  has  been  abandoned  for  the  more 
readable  narrative,  and  certain  interesting  additions  have 
been  made,  among  which   may   be   mentioned    those  on 
membranous  cholecystitis  and  on  gall  stones.     To  his  orig- 
inal series  of  one  hundred  and  seventy  cases  the  author 
has  added  one  hundred  and  tliirty-five,  and  has  rearranged 
the  whole  number  under  the   various  headings  to  which 
they  separately  belong.     The  book  is   authoritative   and 
comes  from  the  ripe  personal  experience  of  a  successful 
operator.     It  is  well  illustrated  with  diagrams  and  plates 
taken  from  the  original  and  is  most  interesting  throughout. 
There  is  a  complete  list  of  the  operations  done,  with  date, 
age.  sex,  description  of  the  case,  result  and  after  history, 
which  is  a  great  help  to  one  wishing  to  study  them  in 
detail. 

CoNTRiBL'TioNS  TO  I  HE  SCIENCE  OF  Medicine.  Dedicated 
by  his  Pupils  to  William  Henry  Welch  on  the  Twenty- 
fifth  Anniversary  of  his  Doctorate.  Pp.  1,066.  The 
Johns  Hopkins  Press,  Baltimore,  igoo. 
To  review  the  contents  of  this  volume  would  take  many 
pages,  for  the  articles  are  numerous.  Among  the  arti- 
cles we  notice  the  following.  "A  Contribution  to  the 
Study  of  the  Pathology  of  Early  Human  Embryos,"  by 
Franklin  P.  Moll;  "On  Urea  in  Some  of  its  Physio- 
logical and  Pathological  Relations,"  by  C.  A.  Herter; 
"The  Direct  Action  of  Nicotine  upon  the  Mammalian 
Heart,"  bv  H.  G.  Bever;  "The  Effects  of  Shaking  upon 
the  Red  Blood  Cells/'  by  S.  J.  Meltzer ;  "The  Blood- 
vessels, Angiogenesis,  Organogenesis,  Reticulum,  and 
Histology  of  the  Adrenal, "  by  J.  M.  Flint;  Specirtc  De- 
generations of  the  Cortical  Arteries,"  by  H.  J.  Berkley; 
"The  Regeneration  of  the  Crystalline  Len.s,"by  R.  L. 
Randolph;  "The  Histology  of  Acute  Lobar  Pneumonia," 
by  J.  H.  Pratt ;  "  Bilateral  Cholesteatomous  Endotheji- 
omata  of  the  Choroid  Ple.xus, "  by  George  Blumer;  "Con- 
cerning the  New  Formation  of  Elastic  Fibres,  Especially 
in  the  Stroma  of  Carcinomata."  by  H.  V.  Williams;  "Cir- 
rhosis of  the  Liver  of  the  Guinea-pig  Produced  by  a  Bacte- 
rium and  its  Products."  by  G.  H.  Weaver;  "On  the  Mus- 
cular Architecture  and  Growth  of  the  Ventricles  of  the 
Heart,"  by  J.  B.  MacCallum  ;  "Some  Observations  upon 
the  Surgical  Anatomy  of  the  Gall-bladder  and  Ducts,"  by 
G.  E.  Brewer;  "A  Case  of  Plexiform  Neuroma  of  the  Eye- 
lid," by  Harry  Friedenwald  ;  "A  Case  of  Multiple  Mye- 
loma," by  J.  H.  Wright;  "The  Development  of  tlie  Mus- 
culature of  the  Body  Wall  in  the  Pi.g, "  by  C.  R.  Bardeen  ; 
"A  Rare  Variety  of  Adenocarcinoma  of  the  Uterus,"  by 
T.  S.  Cullen  ;  "A  Bacteriological  and  Microscopical  Study 
of  Over  Three  Hundred  Vesicular  and  Pustular  Lesions  of 
the  Skin  with  a  Research  upon  the  Etiology  of  Acne  Vul- 
garis," by  T.  C.  Gilchrist;  "The  Frequency  and  Sig- 
nificance of  Infarcts  of  the  Placenta,  Based  upon  the  Mi- 
cro.scopic  Examination  of  Five  Hundred  Consecutive 
Placentae,"  by  J.  Whitndge  Williams  ;  "A  Contribution  to 
the  Knowledge  of  the  Bacillus  Aerogenes  Cajjsulatus, "  by 
W.  T.  Howard;  "On  the  Intravascular  Growth  of  Certain 
Endotheliomata, "  by  W.  G.  MacCallum;  "The  Cultiva 
tion  of  Amoeba;,"  by  Caspar  O.  Miller;  "The  Bacillus 
Pseudo-Tuberculosis  Murium,"  by  Dorothy  M.  Reed; 
"Experimental  and  Surgical  Notes  upon  the  Bacteriology 
of  the  Upper  Portion  of  the  Alimentary  Canal,  with  Obser- 
vations on  the  Establishment  There  of  an  Amicrobic 
State,"  by  Harvey  Gushing  and  L.  E.  Livmgood  ;  "The 
Origin.  Development,  and  Degeneration  of  the  Blood-ves- 
sels of  the  Human  Ovary,"  by  J.  G.  Clark  ,  The  Gonococ- 
cus,"  by  H.  H.  Young;  "The  Histogenesis  of  the  Cellular 
Elements  of  the  Cerebral  Cortex,"  by  Stewart  Paton  ; 
"Experimental  Pancreatitis,"  by  Simon  Flexner  ;  "Chronic 
Hypertrophic  Gastritis  of  Syphilitic  Origin  As.sociated 
with  Hyperplastic  Stenosis  of  the  Pylorus,"  by  J.  C.  Hem- 
meter;  "A  Case  of  Adenocarcinoma  which  Originated  in 
the  Submucous  Glands  of  a  Trachea-like  Formation  Found 
in  a  Sacral  Teratoma,"  by  W.  H.  Hudson;  "(hi  Hydro- 
myelia,  in  its  Relation  to  Spina  Bifida  and  Cranioschisis," 
by  E.  B.  Block;  "Experimental  fJisseminated  Fat-necro- 
sis," by  E.  L.  Opie ;  "Multiple  Hy])eri)lastic  Gastric  Nod- 
ules Associated  with  Nodular  Gastric  Tuberculosis,  '  by 
Claribel  Cone  ;  "  On  Serum  .Substitutes  with  Special   Ref- 


erence to  Asiatic  Cholera,"  by  Arthur  Blackstein  ;  "Endo- 
carditis Due  to  a  Minute  Organism,  Probably  the  Bacillu.% 
Influenzse,'  by  Mabel  F.  Austin;  "On  the  Microscopic 
Alterations  Met  with  in  the  Tissues  from  a  Case  of  Chronic 
Diffuse  Nephritis,  Terminating  with  Symptoms  of  Lan- 
dry's Paralysis,"  by  L.  F.  Barker,  "Model  of  the  Medulla, 
Pons,  and  Jlidbrain  of  a  New-born  Babe,"  by  Florence  R. 
Sobin  ,  "  A  Contribution  to  the  Surgery  of  Foreign  Bodies," 
by  W.  S.  Halstead.  The  illustrations  are  exceptionally 
fine  and  very  numerous,  many  of  them  in  colors,  and  as  a 
frontispiece  there  is  an  excellent  heliotype  portrait  of  W. 
H.  Welch. 

Home  NtRsiNG.     By  Eveleen  Harrison.     New  York  :  The 

Macmillau  Co.  1900. 
This  is  an  elementary  work  for  mothers  and  others  on  mod- 
ern scientific  methods  of  caring  for  the  sick,  and  as  such 
will  fill  a  place  in  the  household  library.  Nurses  will  find 
in  it  many  useful  hints  and  practical  points,  especially  in 
the  preparation  of  foods  and  delicacies  for  the  sick-room 
and  during  convalescence.  Receipts  are  grouped  accord- 
ing to  the  diseases. 

The  International  Medical  Anntai.  and  Praci  n  ioner's 
Index.  A  Work  of  Reference  for  Medical  Practitioners 
by  American  and  Foreign  Contributors.  (Eighteenth 
Y'ear. )  New  York  .  E.  B.  Treat  &  Co.  1900. 
The  fields  of  medicine  and  surgery  including  the  collateral 
branches  are  here  reviewed  in  a  comprehensive  practical 
manner  for  quick  reference.  Condensed  original  articles 
by  able  writers  have  been  selected  with  care.  A  good  fea- 
ture of  the  work  is  the  rather  full  synoptical  index,  and  the 
alphabetic  arrangement  is  well  suited  to  the  reader's  re- 
quirements. New  remedies  are  first  considered,  then  new 
modes  of  treatment,  and  these  are  followed  by  notes  on 
legal  decisions  and  sanitary  science.  The  print  is  small, 
so  that  a  vast  amount  of  material  is  crowded  into  the  work. 
All  the  new  things  that  have  come  up  during  the  }-ear 
have  received  some  recognition  in  one  part  or  another  of 
the  annual. 

Essentials  of  Medical  Diagnosis  Arranged  in  the  Form 
OF   Questions   .\nd  Answers.      Prepared   especially  for 
students  of  medicine  by  Solomon   Solis-Cohen.   M.D., 
Professor    of    Clinical    Medicine    and    Therapeutics   in 
Philadelphia    Polyclinic ;    Lecturer    on    Clinical    Medi 
cine   in   Jefferson    Medical    College;    Physician   to   the 
Philadelphia   Hospital   and    to   the   Rush    Hospital   for 
Consumptives,   etc..   and   Augustus   A.    Eshner,  M. D.. 
Professor    of     Clinical     Medicine    in    the    Philadelphia 
Polyclinic  ;  Physician  to  the  Philadelphia  Hospital,  etc. 
Illustrated,    Saunders'  Question  Compends.  No.  17.    Sec 
ond  edition,  revised  and  enlarged.      Pp.  417.     Philadel- 
phia    W.  B.  Saunders,  925  Walnut  Street.     1900. 
This  is  an  excellent  book  for  students,  inasmuch  as  it  pre- 
sents the  es.sential  outlines  without  distracting  detail,  thus 
affording  a  good  ground  work  which  can  be  supplemented 
later  by  more  comprehensive  works.     The  .second  edition 
differs  from  the  first  chiefly  in  being  enlarged  and  brought 
thoroughly  up  to  date.     The  more  common  views  of  the 
profession  are  set  forth  fully,  while  the  less  accepted  views 
are  properly  omitted.     The  book  is  not  a  simple  compila- 
tion, like  so  many  of  the  smaller  works  on  medicine,  but 
presents  the  experiences  and  knowledge  of  two  well-known 
clinicians- 

Medicine  and  the  Mind  (La  Medecine  de  I'Esprit). 
Translated  from  the  French  of  Dr.  Maurice  de  Fleury 
by  Stacv  B.  Collins.  M.D.  (U.S.A.).  With  fourteen 
figures  and  diagrams.  London  Downey  &  Co.  New 
Y'ork  ,  Charles  Scribner's  Sons.  1900. 
This  work  received  the  Bordin  prize  at  the  French  Acad- 
emy, and  as  such  merits  our  respect  and  attention.  The 
subjects  treated  deal  chiefly  with  problems  in  modern  sci- 
entific psychology  in  an  entirely  new  way,  and  although 
we  cannot  agree  with  the  author  in  all  instances  and, 
moreover,  do  not  accept  all  his  dicta  as  proven,  still  he  has 
opened  a  new  field  from  which  the  future  may  and  prob- 
ably will  derive  some  benefit.  The  most  interesting  and 
novel  chapters  are  those  which  deal  with  the  problems  of 
human  fatigue  and  strength,  of  indolence  and  melancholy, 
and  the  therapeutic  measures  adaptable  to  each.  The  ra- 
ther material  explanation  of  differences  in  blood  pressure 
causing  these  different  emotional  states  is  not.  however, 
entirely  satisfactory,  and  the  consequent  method  of  treat- 
ment by  his  "artificial  serum"  is  not  one  which  we  think 
devoid  of  the  suggestion  element  which  is  so  well  recog- 
nized. The  work  should  be  read  by  all  physicians  who  are 
interested  in  medico-legal  medicine  or  psychology. 


Section  on  Hygiene  and  Sanitary  Science.— The 
Section  on  State  Medicine  of  the  .\iiierican  Medical 
Association  will  hereafter  be  called  the  Section  on 
Hygiene  and  Sanitary  Science. 


August  4,  1900] 


MEDICAL    RECORD. 


187 


CCox-vcspontlcuce. 

OUR    LONDON    LETTER. 

(From  our  Special  Correspondent.) 

WEATHER — PATHOLOGISTS  AT  CAMHRIDGE — TROPICAL  DISEASES 
— MALARIA  AND  MOSVUITOS — QUESTIONS  OF  NOMENCLATURE 
—  ARSE.NIC  IN  SODII  I'llOSPIlAS — ST.  I'ANCRAS  LCNACV  IN- 
QUIRY— MR.  COUTTS — SUNDAY  FUND — THE  ROYAL  ARMY 
MEDICAL  CORPS — SMALLPO.X — HRITISH  MEDICAL  ASSOCIATION. 

London,  July  13,  iqoo. 

Last  week  while  we  were  reading  of  your  sufferings  under 
a  heat  wave  we  were  shivering  and  complaining  that  sum- 
mer seemed  about  to  omit  its  visit  to  our  islands.  I  was 
glad  of  a  fire  in  my  consulting-room  up  to  Monday,  but  on 
Tuesday  a  welcome  change  set  in — summer  put  in  sn  ap- 
pearance, and  the  wie.xt  day  and  yesterday  people  were 
greeting  each  other  witli  the  whimsical  expression  '"  beastly 
tine  weather."  Tu-day  it  is  two  or  three  degrees  cooler  by 
the  thermometer,  but  people  feel  the  heat  as  much.  Not 
that  it  is  abnormal — 80  to  S3'  F.,  falling  in  the  evening 
into  the  seventies.  I  find  this  merely  comfortable  warmth 
to  what  you  have  experienced.  Storms  have  been  severe 
in  northern  districts  and  are  anticipated  here. 

The  Pathological  Society's  visit  to  Cambridge  on  the  in- 
vitation of  Prof.  Sims  W'oodhead  came  off  as  announced  on 
the  30th  ult.  Professor  Osier,  of  Baltimore,  was  invited  to 
preside  and  took  the  chair,  and  interesting  communica- 
tions were  made,  for  which  a  vote  of  thanks  was  accorded, 
as  well  as  one  to  the  chairman,  to  Dr.  Woodhead,  and  to 
the  university  authorities. 

Prof.  S.  A.  Flexner,  of  Philadelphia,  said  that  an  acute 
and  a  chronic  form  of  tropical  dysentery  occurred  in  ilanila. 
The  former  might  terminate  in  forty-eight  hours  or  become 
chronic.  The  chronic  /<•;■  Sc'  was  am<ebic  and  commonly 
followed  by  hepatic  abscess  ;  not  so  the  chronic  following 
acute.  The  acute  disease  was  not  amoebic,  but  a  bacillus 
very  much  like  that  of  typhoid  had  been  isolated.  It  seemed 
identical  with  that  from  the  endemic  dysentery  ot  Japan. 

Professor  Fle.xner  also  made  some  critical  remarks  on  the 
bacteriology  of  yellow  fever.  The  fatty  degenerations  of 
the  viscera  produced  by  the  supposed  bacillus  of  the  disease 
were  also  produced  by  other  organisms. 

Dr.  G.  H.  F.  Nuttall  gave  a  demonstration  on  the  rela- 
tion of  mosquitos  to  malaria.  He  showed  .some  live  Ano- 
pheles maculipennis  which  he  had  caught  in  the  neighbor- 
hood of  Cambridge.  He  illustrated  with  specimens, 
micro-photographs,  and  drawings  the  changes  undergone 
by  avian  and  human  parasites  in  the  species  of  Culex  and 
Anopheles  respectively.  Maps  showing  the  distribution  of 
malaria  and  Anopheles  were  exhibited.  There  was  an 
agreement  between  the  former  distribution  of  malaria  in 
England  and  the  present  distribution  of  Anopheles  (A. 
maculipennis  A.  bifurcatus.  A.  nigripes).  but  further  de- 
tails on  this  point  were  promised.  It  seems  curious  m 
some  respects  that  Anopheles  persist  in  England  although 
malaria  has  practically  disappeared.  The  fact  suggests 
further  research 

Dr.  Cobbett  showed  cultures  of  the  diphtheria  bacillus 
obtained  from  the  nasal  discharge  of  a  pony.  He  also  de- 
scribed experiments  showing  that  diphtheria  toxin  is  ex- 
creted in  the  urine  of  animals — even  from  some  which  are 
relatively  insusceptible. 

Dr.  J.  W.  H.  Eyre  remarked  on  the  influence  of  the  me- 
dium on  organisms  cultivated  on  it,  and  urged  the  adoption 
of  a  definite  standard  reaction  in  our  laboratories  similar  to 
that  used  in  America.  He  said  litmus  paper  and  solution 
were  alike  unsuitable,  and  recommended  phenolphthalein 
as  sensitive  and  satisfactory. 

Questions  of  nomenclature  are  interesting  enough  to 
many,  and  yet  not  seldom  vexatious  or  even  puzzling,  espe- 
cially when  relating  to  a  specialty.  Surgeons  and  gynae- 
cologists have  rivalled  each  other  in  the  combination  of 
similar  syllables  for  dissimilar  proceedings,  and  questions 
of  priority  have  often  been  mixed  up  with  those  of  nomen- 
clature. Take  an  example  or  two.  Dr.  A.  Routh  read  a 
paper  at  the  meeting  of  the  Obstetrical  Society  on  "  Porro- 
Caesarean  Hysterectomy,"  in  which  he  discussed  the  ad- 
vantages of  the  modern  Porro  operation  over  the  "Sanger- 
Ciesarean."  Dr.  Galabin  objected  to  his  nomenclature,  and 
proposed  "  Baer's  operation,"  or  "  Ca;sarean  hysterectomy." 
or  "Csesarean  panhysterectomy,"  as  the  case  might  be. 
Dr.  W.  Duncan  thought  the  operation  described  by  Dr. 
Routh  might  be  properly  called  "abdominal  hysterectomy 
of  the  gravid  uterus."  This  at  least  has  the  merit  of  con- 
veying some  idea  to  those  who  do  not  follow  the  specialty. 
Dr.  Horrocks  objected  to  the  t^rm  "Sanger-Cssarean  sec- 
tion," as  the  essential  part  of  Sanger's  operation  is  now 
generally  discarded.  Dr.  Spencer  hoped  that  whatever 
name  might  be  adopted  for  hysterectomy  of  the  pregnant 


uterus,  it  would  never  be  called  Baer's  operation,  for  Baer 
had  no  claim  to  it  and  did  not  make  any  claim  himself. 

Another  allied  question  was  lately  discussed  at  the  Royal 
Academy  of  Medicine  in  Ireland — and  that  in  the  obstetrical 
section.  Dr.  H.  Jellett  read  a  paperon  "  The  Dublin  Method 
of  Effecting  the  Delivery  of  the  Placenta,"  in  which  he 
maintained  that  Crede  only  arrived  independently  at  a 
method  which  had  been  taught  in  Dublin  from  time  imme- 
morial. He  introduce<l  it  in  Germany  without  a  suspicion 
apparently  that  it  had  long  been  the  familiar  plan  in  Dub- 
lin, and  so  it  got  associated  witli  his  name  and  is  still  spo- 
ken of  as  his  method.  Various  writers  were  cited  in  proof 
of  this,  and  the  term  "the  Dublin  method  "  was  pronounced 
to  be  the  correct  one.  Dr.  Smyly  said  there  was  a  distinc- 
tion between  the  two  methods,  and  Crede's  was  inferior 
because  it  was  too  active.  Spiegelberg,  who  had  observed 
both  methods  practised  by  those  responsible  for  them,  de- 
clared the  Dublin  to  be  superior,  as  it  waited  till  the  pla- 
centa had  been  expelled  from  the  uterus  and  then  exi)elled 
it  from  the  vagina.  Crede's  was  too  active,  for  by  expel- 
ling the  [ilacenta  too  soon  they  might  leave  portions  behind, 
leading  to  post-partum  hemorrhage  and  subinvolution. 

Dr.  Smyly  rai.sed  yet  another  question  of  the  kind.  He 
said  the  method  of  preserving  the  perineum  commonly 
called  von  Ritgen's  undoubtedly  originated  in  Dublin. 
The  credit  of  this  seems  likely  to  be  lost  by  the  Dublin 
school,  and  these  questions  show  the  inconvenience  of  at- 
taching a  man's  name  to  a  procedure  as  soon  as  he  writes 
a  paper  about  it,  whether  original  or  not. 

By  a  curious  coincidence  the  subject  of  nomenclature  has 
also  been  discussed  at  Edinburgh,  and  again  by  the  accou- 
cheurs. At  the  Edinburgh  Obstetrical  Society  on  the  13th 
ult.,  Dr.  Berry  Hart  read  a  paper  on  "the  nomenclature  of 
transverse  presentations  and  of  version."  He  divided  the 
former  into  "dorso-anterior  "  and  "  dorso-posterior  "  posi- 
tions, and  each  of  these  again  into  left  and  right  "acromio- 
iliac. "  "Scapulo-anterior  "  and  so  on  was  concise  but  not 
so  good.  The  varieties  of  version  he  preferred  were 
"Simpson's  combined,"  "Hicks'  bipolar,"  and  "combined 
external."     The  last  is  cephalic — the  other  two  are  podalic. 

A  chemical  manufacturer  here  lately  called  in  all  the 
sodii  phos.  effervesc.  which  he  had  sold,  because  he  found 
it  contaminated  with  a  dangerous  amount  of  arsenic.  So 
far  no  injury  has  been  done,  but  it  would  have  been  well 
for  him  had  the  tests  been  made  before  sending  the  drug 
out.  Most  samples  of  sodium  phosphate  contain  some 
arsenic  derived  from  the  sulphuric  acid  employed  in  the 
manufacture.  Commercial  oil  of  vitriol  is  often  loaded  with 
arsenic  which  appears  in  the  sodium  phosphate  as  arsenate. 
This  being  isomorphous  with  tlie  phosphate  cannot  be  re- 
moved by  recrystallization.  Professor  Tichborne  says 
many  specimens,  if  hurriedly  tested,  might  seem  sliglitly 
impure  although  loaded  with  arsenic,  as  the  arsenic  does 
not  readily  come  down  as  a  sulphide.  He  adds  that  com- 
mercial sodium  phosphate  is  only  fit  for  manure,  and  the 
pharmacopoeia  process  should  be  discarded,  the  salt  for 
medicinal  purposes  being  obtained  by  the  interaction  of 
phosphoric  acid  and  sodium  carbonate. 

The  inquiry  into  the  St.  Pancras  lunacy  scandal  is  bring- 
ing out  disagreeable  facts.  The  relieving  officers  have 
confessed  to  a  system  which  is  no  less  than  bribery,  and 
the  public  is  demanding  radical  changes. 

Mr.  Burdett-Coutts  has  shown  his  "common  sense"  by 
objecting  to  Professor  Cunningham  as  one  of  the  committee 
to  inquire  into  his  allegations,  because,  forsooth,  the  pro- 
fessor IS  an  examiner  of  army  surgeons. 

The  Hospital  Sunday  Fund  on  Wednesday  had  amounted 
to  more  than  _^  40,000. 

Some  cases  of  smallpox  have  occurred  in  London,  giving 
rise  to  alarmist  reports  of  the  usual  kind. 

An  extraordinary  general  meeting  of  the  British  Medical 
Association  has  been  called  for  next  Wednesday,  when  a 
draft  of  new  regulations  effecting  considerable  changes  in 
the  constitution  will  be  proposed  by  the  Council,  and  if  car- 
ried will  be  submitted  for  confirmation  at  the  forthcoming 
annual  meeting  at  Ipswich  on  August  2d. 

Out  of  seven  hundred  and  thirteen  fellows  who  voted  at 
the  late  election  at  the  College  of  Surgeons  only  thirty-four 
attended  personally — a  clear  indication  ihat  the  postal  sys- 
tem is  essential,  its  adoption  may  lead  to  a  more  liberal 
policy. 

Surgeon-General  Muir,  deputy  director-general  of  the 
Army  Medical  Department,  and  Col.  Egerton  Saunders 
have  received  the  decoration  of  C.  B. 

Many  more  surgeons  and  nurses  are  going  to  the  front, 
and  with  three  wars  upon  us  the  demands  for  the  army  and 
navy  medical  services  must  increase.  So,  too.  must  the 
losses. 

Dr.  FitzHugh  has  died  at  the  Yeomanry  Hospital,  where 
he  did  excellent  work.  He  was  only  twenty-eight  years 
old. 

Professor  Oyston.  of  Aberdeen,  is  down  with  typhoid  at 
Bloemfontein.  but  by  last  telegrams  was  progressing  fa- 
vorablv. 


1 88 


MEDICAL 


^hevapctttic  glints. 

Irritable  Bladder — 

If  Salol, 

Tinct.  hyoscyanii aa  3  ij. 

Infus.  buchu ad  3  vi. 

M.     S.   Tablespoonful  three  times  a  day. 

—  FOTHERGILL. 

Gout 

J^  Ext,  colchici  acet., 

Ext.  rhei, 

Ext.  aloes  soc aa  gr.  xij. 

Ext.  belladonnje gr.  ij. 

M.   ft.  pil.  No.  X.      S.   One  at  bed-time  twice  a  week. 

• — Garrod. 
In  Threatened  Uraemia 

^  Pilocarpin gr-  '• 

Ac.  hydrochl.  dil 3  ij. 

Aq.  destil  ...    3  ij. 

M.     S.   Teaspoonful  every  three  hours. 

Acute  Cystitis. — 

If  Ext.  hyoscyami. 

Ext.  cannabis  indie aa  0.4 

Sacch.  alb 5.0 

M.   It.  chart.  No.  xii.      S.    One  three  times  a  day. 

— Ultzmann. 
Salicylate  Mixture. — 

^  Sodii  salicylat 4-S  gm. 

Curasao 60     " 

Aq.  destil go  .   " 

Syr.  aurant    cort.  amar 60     " 

To  be  taken  in  twenty  four  hours  with  Vichy  water. 

(  — Zjou  Med.,  May  20th. 

Neuralgia,  especially  when  acute,  is  benefited  by 
a  dose  of  one  or  two  ounces  of  castor  oil  in  ale  con- 
taining considerable  gas,  administered  before  break- 
fast.— H.  M.   Mover. 

Epilepsy. — Santonin  gives  better  results  than  bro- 
mides, and  acts  when  the  httter  fail  or  are  not  well 
borne.  It  is  free  from  injurious  effect,  especially  the 
production  of  melancholia,  mental  hebetude,  depres- 
sion, eruptions,  etc, — Lydson. 

Morphine  and  Alcohol  Habits. — 

1^  .\mmon.  brom gr.  v. 

Ext.  bellad.  fid. , 

Ext.  nuc.  voni.  fid., 

Ext.  cannabis  ind.  fid aa  v\  ij. 

Aquoe ad  3  ij- 

M.     S.    At  dose  four  times  daily. 

— Wenthers. 
Chronic  Urethritis. — 

I^  lodi gr.  V. 

I'otass.  iod gr.  xxx. 

01.  oliv 3  ss. 

Lanolini q. s.  ad  2  i. 

M.      S.    Use  to  anoint  a  steel  bougie. 

— Horwick. 

Chancre  and  Chancroid Wash  with  a  camphorated 

solution  of  carbolic  acid,  and  apply  a  moist  dressing 
made  with  picric  acid  in  saturated  solution. — Haw- 
thorn. 

Chronic  Rheumatism. — The  "  Chelsea  pensioner," 
which  has  had  an  excellent  reputation  in  many  quar 
ters,  contains: 

if   Rhubarb 3  ij. 

Guaiac 3  i. 

Bitartrate  of  potash, 

Washed  sulphur aa  3  i. 

Nutmeg No.  i. 

Honey O  i. 

Dose;  .\  tablespoonful  night  and  morning. 

Exophthalmic  Goitre.  —  Hyoscine  hydrobrom,  gr. 
jj-j  and  picrotoxin  gr.  ^',7-y',r  given  over  a  protracted 
period  have  had  good  results. —  Herrick. 


RECORD.  [August  4,  1 900 

Oxaluria  with  anemia  and  nervous  atony: 

If  .\cid.  hydrochl.  dil |  ss. 

Tinct.  ferri  chl |  i. 

Syr.  simp |  iiss. 

Aqu;t 5  iij. 

M.     S.  Tablespoonful  three  times  a  day  through  a  glass 
tube. 

— Hazard. 
Ozaena.— 

R  -Aluminis aceto-tartratis  (ten-per-cent.  sol.)  ....   3  iv. 
S.    Teaspoonful  in  a  pint  of  tepid  water  as  a  douche  several 
times  daily  to  remove  secretions,  etc. 

Then  spray  with : 

If  Ext.  hydrastis  fid 3  i. 

Aquae O  i. 

— Bartholow. 
Orchitis. — 

If  Tinct.  pulsatillae gtt.  xxiv.-xlviij. 

Syr.  zingiberis |  i. 

Aquce .  .  q.  s.  ad    3  iij . 

M.     S.    Teaspoonful  every  hour  or  two. 

— Sturgis. 
Strap  the  testicle  and  give  three  times  a  day: 

If  Tinct.  aconiti    TI],  i. 

Morph.  sulphat gr.  j'j 

Antimonii  et  potass,  tart gr.  y^ 

Magnesire  sulphab gr.  xi, 

— Phila.  Jiosp.  Form. 
Remedy  for  dyspepsia  and  constipation: 

If   Fluid  e.\t.  of  cascara  sagrada. 

Fluid  ext.  of  rhubarb aa  |  iss. 

Fluid  ext.  of  wahoo, 

Fluid  ext.  of  juglans aa  3  vi. 

Glycerin q.s.  ad  3  viij. 

M.      S.    Half   a  teaspoonful   in    half  a  glass   of   sweetened 
water  after  each  meal. 

— R.  C.  Kenner,  Alcd.  Summary,  July. 

Nervous  Dyspepsia — Medical  treatment  as  in 
neurasthenia.  Weir-Mitchell  rest  cure.  Complete 
change  in  habits.  Substitution  of  out-of-door  for  a 
sedentary  life. — Boardman  Reed. 

Passiflora  Incarnata  in  dose  of  five  drops  of  the 
tincture  made  from  the  wild  plant  gives  better  results 
than  hyoscyamus,  belladonna,  or  conium  in  the  ner- 
vous phenomena  of  whooping-cough. — Carties. 

Neurasthenia.^ 

If  Zinci  bromidi, 

Zinci  valerianatis, 

Zinci  oxidi aa  gr.  xv. 

Ros.K  conserv q.s. 

M.    ft.   pil.   No.   XX.     S.   One  before  breakfast,  dinner,  and 
bedtime. 

Facial  Neuralgia — 

If  Butyl  chloral-hydrat., 

Spir.  vini  rect aa   3  iiss. 

Glycerini 3  v. 

Aqux q.s.  ad    3  ij. 

M.      S.    Teaspoonful  once  or  twice  daily. 

- — Med.  Times  and  Hosp.  Gaz.,  June  30th. 
Catarrhal  Conjunctivitis. — 

If  Zinci  sulphat., 

Morph,  sulphat aa  gr.  i. 

.■\qu,-e  destill 5  •• 

M.     S.    Apply  five  drops  to  the  eye  every  two  hours. 

Epsom  Salts  made  palatable: 

If  Magnes.  sulphat 3  ss, 

.Ac.  sulph.  dil "l  ij- 

Syr.  limonis 1  iss. 

Aquoe q.s.  ad  J  ij. 

Take  at  dose. 

Aphonia  Nervosa.  —  Draw  in  a  deep,  easy  breath, 
and  on  expiration  make  the  attempt  to  produce  a  clear 
note.  If  successful  proceed  to  other  sounds,  vowels, 
syllables,  and  words  of  two  syllables.  A  few  minutes' 
practice  may  result  in  distinct  talking.— Oliver, 


J 


August  4,  1900] 


MEDICAL    RECORD. 


189 


Camphorated  Oil  in  one-iialf  drachm  to  two-draclim 
dose  of  a  I  :  10  solution  for  an  adult  is  the  best  cardiac 
tonic  and  antispasmodic. — Vaillant. 

To  Cool  Water  when  ice  cannot  be  obtained,  wrap 
the  pitcher  in  cheese-cloth  previously  impregnated 
with  ammonium  nitrate  and  dried.  Moisten  slightly 
at  time  of  use,  dry,  and  use  again. 

Vaginitis. — 

Q  Aluminis. 

Sod.  biborat aa     30 

Quin.  sulph I 

01.  thymi, 

Ac.  carbol aa  gtt.  xxx. 

Glycerini 200 

M.     S.   Add  a  soupspoonful  to  a  quart  of  hot  water.     Inject 
two  or  three  times  a  day. 

— Jaxowsky. 
Dysentery — 

li  Sodii  suiphat 30 

Aqua;  destil go 

M.      S.   A  soupspoonful  three  times  a  day- 

— Buchanan,  Fortschr.  dcr  Med.,  No.  16, 1900. 
Supra-Orbital  Neuralgia. — 

1}  Ergot.t I 

yuininoe  mur 2 

Ferri  suiphat 5 

Ext.  gentian q.  s. 

Ut  ft,  pil.  No.  c.      S.   Two  pills  three  times  a  day. 

— Peters. 
Painless  Mercurial  Injections. — 

VI,  01.  oliv.x-  sterilizat 100.00 

Hydrargyri  biniodidi o.  50 

Guaiacol  (synthetic. )  pur 2.00 

Inject  slowly  2  gm.  into  the  buttock  daily  or  every  second 
day. 

—Bull.  Pharm.  Siid-Est. 

Sweating  in  Phthisis. — 

V,  Tellurate  of  sodium 0.10-0.20 

Alcohol 50 

M.     S.  -V  teaspoonful  morning  and  night. 

— Joitni.  des  Praticiens. 

Tannin  precipitating  gelatin,  it  is  suggested  to  make 
use  of  gelose  in  preparing  capsules  or  suppositories 
containing  this  drug: 

IJ  Gelose 3 

Aquae, 

Glycerin aa  ;o 

Tannin 10 

Dissolve  the  gelose  in  a  water-bath  in  a  mixture  of 
the  glycerin  and  water.  Add  the  tannin,  and  when  it 
is  dissolved  poured  into  moulds. — Journal  des  Pra- 
ticiens. 

Odontalgia. — 

5  Phenol, 

Menthol, 

Hydrochlorate  of  cocaine. 

Chloral, 

Guaiacol aa  2  gm. 

Triturate  in  a  mortar. 

Chronic  Coryza.  — 

I^  Sod.  bicarb. , 
Sod.  biborat.. 

Sod.  chlorat aa  0.40  gm. 

Sacch.  alb i.oo    " 

Dissolve  in  tepid  water,  pour  into  the  hand,  and 
snuff  up  forcibly  so  that  the  solution  passes  into  the 
pharynx,  or  inject    into    the   nostrils.- -Morell-Mac- 

KENZIE. 

Generalized  Eczema 

1}   l.iq.  aluminii  acetat 10.00  gm. 

Sod.  biborat    3. 50    " 

Ac.  salicyl 30  cgm. 

Aquas  destillat 1 70.00  gm. 

Glycerini 30.00    " 

M.     S.  Apply  as  a  lotion. 


For  Amenorrhoea  when  functional  and  slight,  give 
half  a  grain  of  thyroid  extract  at  bedtime. — Glynn. 

Smoker's  Heart. — 

R  Adonidin 0.005 

.Ammon.  carb o.  i 

Camphoras 0.03 

M.   ft.  chart.  No.  xxx.     S.   One  three  times  a  day. 

—  Stern. 
Haemoptysis. — 

IJ  Tinct.  iodi 3  i- 

Pulv.  camphora.-, 

01.  picis  (essent.) aa  5  iiss. 

■Spt.  a:th.  comp 5  ss. 

M.      S.    Use  for  inhalation  (five  to  twenty  at  a  time) .      Re- 
peat every  two  to  four  hours. 

— Chartier. 
Uterine   Fibromata. — 

^  Ergotin 2  gm. 

Chloral  hydrat i     " 

.'VquiC   260    " 

Inject  twelve  drops  every  day  for  several  months. 

— Simpson. 
Gastropathies  of  Cardiac  Origin. — 

I^   Digital! n    (crystal.) i  gm. 

Glycerini 333  c.c. 

Aq.  destil 147  c.c. 

Spt.  vini  rect.   (g5  per  cent.) q  s.  ad        i  litre. 

M.      S.   Ten  to  fifteen  drops  for  four  or  five  days. 

— C'ARRiiRE,  Gaz.  des  Hop.,  June  i6th. 

Pruritus 

V,  Plumbi  acetat i  gm. 

Acid,  hydrocyanic!  dil 5     " 

Spt.  vini  rect 15     " 

Aq.  destil 250    " 

M.     S.   Apply  as  required. 

— A.  Thompson. 
Delirium  Tremens. — 

1}  -\ntipyrin 4  gm. 

Potass,  brom     6    " 

SjT.  chloral  (Fr.  cod.) 30    " 

AquK , 125     " 

M.     S.   Teaspoonful  every  hour  until  hypnotic  effect  is  pro- 
duced. 

— ViLLARD,  Gaz.  des  Hop.,  June  12th. 

Scabies. — 

Vi,  Staphysagrice  pulv 300  gm. 

.Adipis  (melted   for  twenty-four  hours  at  a 

temperature  of  100'  C.) 500    " 

M.     S.   .Apply  for  four  days,  each  friction  being  preceded 
by  a  bath. 

—  BOURGUIGNON. 

Neuralgia. — 01.  ricini  relieves  or  greatly  improves 
neuralgia,  especially  that  of  the  fifth  nerve. — Ochsner. 

Prostatic  Enlargement. — Give  ammonium  chloride 
in  ten-grain  doses,  three  times  a  day  for  three  months. 
— Medical  Summary. 

Gonorrhoea. — Avoid  all  attempts  at  abortive  treat- 
ment with  strong  injections,  Janet's  washings,  etc. 
When  there  is  violent  inflammation  from  the  first,  a 
one-per-cent.  solution  of  thallin  is  used  as  an  injection. 
When  the  inflammation  is  slight,  nitrate  of  silver 
1:10,000  to  1:4,000,  or  permanganate  solution. — 
Casper. 

Croupous  Pneumonia. — I  have  found  hot  poultices 
more  agreeable  than  cold.  I  would  resort  to  venesec- 
tion when  there  is  an  overloaded  right  heart  with 
threatening  symptoms.  Digitalis  is  reserved  for  an 
irregular  and  flagging  heart;  codeine  in  small  doses 
for  the  relief  of  pain  and  delirium;  strychnine  in  in- 
creasing doses  and  alcohol  for  enfeebled  heart  action  ; 
calomel  and  saline  for  constipation  or  sluggish  portal 
circulation ;  oxygen  gas  is  commenced  at  the  first  sign 
of  cyanosis  and  in  quantity  sufficient  to  relieve;  and 
last,  but  by  all  means  first,  the  absolute  recumbent  pos- 
ture until  resolution  is  established. — W.  O.  Bridges. 


IQO 


MEDICAL    RECORD. 


[August  4,  1900 


©Unical  gcpavtmeut. 

THREE  CASES  OF  SPECIFIC  BASAL  MEN- 
INGITIS, WITH  SPECIAL  REFERENCE  TO 
EYE-SYMPTOMS. 

By  J     HERBERT   CLAIBORNE.    M.D.. 

NEW    YORK. 

Case  I. — A.  M ,  widow,  age  thirty-nine  years,  pre- 
sented herself  at  the  Vanderbilt  Clinic,  department  of 
nervous  diseases.  May  10,  1897.  She  had  married 
thirteen  years  previously;  her  husband  had  been  dead 
six  years,  she  had  never  been  pregnant.  At  the  time 
of  her  first  call  she  had  a  few  enlarged  cervical  glands, 
and  there  was  a  mucous  (?)  patch  on  the  left  side  of 
her  tongue.  Four  years  before  she  had  had  paralysis 
of  the  right  abducens,  and  recovered  after  three 
months  of  specific  treatment.  At  the  same  time  that 
she  had  paralysis  of  the  right  abducens  she  had  also 
paresis  of  the  right  arm  and  leg  for  three  or  four 
weeks,  and  her  mouth  was  drawn  down  to  the  right. 
Five  weeks  before  she  was  first  seen  by  me  she  liad 
had  pain  on  the  nasal  side  of  the  left  orbit  which  ran 
up  to  the  vertex  and  down  the  side  of  the  face.  The 
lid  then  drooped  and  the  eye  became  motionless.  For 
several  weeks  preceding  this  occurrence  she  had  had 
occasional  pains  with  temporary  drooping  of  the  left 
eyelid.  She  felt  dizzy,  her  legs  were  weak,  and  her 
calves  felt  numb.  The  gait  was  normal,  and  no 
Romberg  symptom  was  present.  The  right  knee  jerk 
was  weak,  the  left  normal.  There  was  prominence  of 
the  left  eyeball,  with  anaisthesia  of  both  cornea;  and 
sclerotica  but  not  of  the  face. 

Diagnosis:  ophthalmoplegia  sinistra  specifica.  retro- 
bulbar exudate. 

These  notes  were  transcribed  from  the  records  of 
nervous  diseases  in  the  V'anderbilt  Clinic.  I  saw  the 
patient  for  the  first  time  several  weeks  after  her  first 
visit  to  the  clinic.  At  that  time  she  had  a  slight 
drooping  of  the  left  lid,  no  apparent  muscular  palsy, 
and  normal  pupil  and  accommodations.  The  cornea 
an4  sclera  were  anaesthetic,  and  below  the  centre  of 
the  cornea  was  an  ulcer  about  one-eighth  of  an  inch 
in  length  and  one-sixteenth  of  an  inch  in  vertical  dia 
meter.  I  diagnosed  ulcer  and  paralytic  keratitis,  and, 
in  view  of  the  preceding  history,  located  the  lesion  in 
the  orbit  toward  the  apex.  I  considered  it  an  exudate, 
specific  in  origin,  probably  arising  from  the  structures 
around  the  apex. 

She  was  treated  for  more  than  a  year  with  antispe- 
cific  remedies  and  local  applications  for  the  ulcer.  I 
made  the  following  notes:  Status,  eighteen  months 
after  her  first  visit  to  me,  left  lid  slightly  drooping; 
moderate  anaesthesia  of  cornea,  infiltration  of  lower 
third  of  cornea,  covered  entirely  with  blood  vessels; 
field  of  vision  normal,  except  for  the  blurring  due  to 
the  infiltration;  no  fundus  lesion,  V  =  j{J  -{-. 

This  patient  came  under  my  observation  on  account 
of  the  ulceration  of  the  cornea.  The  characteristic 
location  of  the  ulcer  caused  me  to  test  the  sensibility 
of  the  cornea,  when  the  diagnosis  of  neuro-paralytic 
keratitis  was  immediately  made.  She  presented  no 
symptom  of  paralysis  except  a  drooping  of  the  upper 
lid. 

Eighteen  months  after  her  first  visit  to  me  there  re- 
mained partial  anaesthesia  and  infiltration  of  the  cornea 
over  the  site  of  the  old  ulcer. 

It  will  be  observed  that  there  is  a  singular  associa- 
tion of  lesions  in  this  case:  paralysis  of  right  abdu- 
cens, right  arm  and  leg,  left  facial  palsy,  left  opiithal- 
moplegia  complete,  followed  several  years  afterward 
by  complete  corneal  anaesthesia  of  the  left  eye.  The 
paralysis  of  the  right  abducens  associated  with  the 
paralysis  of   the  right   arm    and    leg   would    imply  a 


basal  lesion,  disseminate  in  character,  and  below  the 
pons.  There  was  probably  a  simultaneous  lesion  on 
the  left  side  at  the  base  to  account  for  the  left  facial 
palsy  and  left  ophthalmoplegia.  If  the  left  facial 
palsy  is  to  be  accounted  for  by  a  high  lesion  on  the 
right  side,  there  should  at  least  have  been  left  hemi- 
plegia. The  hemiplegia,  however,  was  on  the  right 
side.  These  facts,  coupled  with  the  corneal  compli- 
cation, lead  one  to  the  conclusion  that  the  lesion  was 
basal,  probably  meningeal,  and  certainly  disseminate 
and  multiple  The  subsequent  slight  levator  palsy 
on  the  left  side  is  corroborative  of  this  view. 

Case   II. — Mrs.    K ,   a   delicately   built   young 

woman  aged  twenty-four  years,  consulted  me  on  De- 
cember 22,  1899,  f'-"'  1°^^  °f  sight  in  the  left  eye. 
During  the  preceding  summer  she  had  suffered  con- 
siderably from  dizziness,  which  she  had  attributed 
to  constipation  that  was  chronic  and  obstinate.  Six 
weeks  before  I  saw  her,  her  right  arm  and  leg  became 
suddenly  numb  and  partially  paralyzed.  Five  days 
before  she  came  to  me,  she  noticed  her  left  eyelids 
were  drawn  together,  and  she  could  not  see  well  with 
that  eye.  The  left  side  of  her  face  was  draw-n  up. 
Her  speech  and  memory  were  good.  The  left  palpe- 
bral fissure  was  smaller  than  the  right,  there  was 
slight  convergence  of  the  eye  with  diminished  move- 
ment outward.  There  was  partial  tactile  anaesthesia 
of  the  right  upper  lid,  otherwise  the  sensibility  of 
the  two  sides  of  the  face  was  equal.  The  tongue,  on 
being  thrust  out,  was  inclined  to  the  right,  the  grip  of 
the  right  hand  was  distinctly  weaker  than  that  of  the 
left,  the  knee  jerks  were  excessive.  She  said  her  right 
leg  was  still  somewhat  numb,  and  the  skin  of  the  fore- 
arm of  that  side  was  found  also  to  be  numb  to  the  prick 
of  a  pin.  There  was  slight  Romberg  symptom,  but  no 
foot  clonus.  She  occasionally  still  had  some  difficulty 
in  walking. 

The  vision  of  the  left  eye  was  .f^^,  the  top  letter 
disappearing  and  reappearing  alternately,  exhibiting 
the  scotoma  centrale  fugax.  The  field  was  nearly 
normal  in  extent,  was  generally  hazy,  but  apparently 
was  slightly  constricted  above  and  to  the  outer  side. 
The  patient  was  so  nervous  that  it  was  decided  not  to 
take  the  field  with  the  perimeter.  Ordered  potassium 
iodide  gr.  x.  t.i.d.,  increasing  gr.  v.  daily. 

December  25th-  'J'he  facial  paralysis  was  much 
worse,  sensation  in  arm  and  leg  was  better,  grip  the 
same,  facial  anesthesia  better,  scotoma  fugax  less  fre- 
quent, V  =  v„\. 

December  29th:  V  =  M-";  no  central  scotoma,  op- 
tic disc  slightly  congested,  and  edges  fuzzy  above  and 
to  the  outer  side;  facial  paralysis  still  worse,  left 
eye  now  nearly  closed,  squint  the  same,  right  grip  a 
little  better;  knee  jerks  the  same;  field  about  normal, 
voice  husky  from  potassium  iodide;  iodide  headache, 
anaesthesia  in  arms  and  legs  gone. 

January  2,  1900:  Facial  palsy  better,  left  eye  more 
open;  field  normal,  V=  jj;  grip  not  quite  equal 
to  left  hand;  tongue  straight. 

January  7th:  V=  jjl;  grip  improved,  face  much 
better. 

January  14th:  Almost  recovered;  V=°, |;,  facial 
palsy  gone.  She  suffers  from  headache,  examination 
of  refraction  shows-  R.E.  V  =  -^^  w.  -f-  .50  D.  c.  ax. 
90";  L.E.  V  =  f'^  w.  +  .25  D.  c.  ax.  90°. 

She  went  to  the  theatre  one  night  and  had  a  blind 
spell;  on  that  account  and  on  account  of  the  persist- 
ent headache,  the  refractive  examination  was  made. 
She  was  then  sent  away  on  a  trip  to  the  South.  The 
potassium  iodide  had  been  given  in  as  large  doses  as 
gr.  Ixv.-lxx.  t.i.d.  This  was  finally  reduced  to  gr.  xx. 
t.i.d.  Subsequently  she  was  put  upon  the  mixed  treat- 
ment and  was  advised  to  continue  this  till  further  or 
ders.  Her  family  physician,  during  the  treatment 
with  potassium  iodide,  was  using  maltine  and  cascara 


August  4,  1900] 


MEDICAL    RECORD. 


191 


for  the  constipation.  The  galvanic  current  was  used 
regularly  over  the  area  of  distribution  of  the  palsied 
seventh  nerve. 

This  case  seems  simpler  and  clearer  than  the  first. 
A  young  married  woman  develops  right  hemiplegia, 
and   hemianesthesia  of   a  mild  type.     This  becomes 
better  without  treatment.     Six  weeks  afterward  there 
is  right  facial  paralysis  with  very  slight  palsy  of  the 
left  external  rectus.     The  tongue,  on  being  extruded, 
pointed   distinctly  to   the  right.     The   vision    in   the 
left   eye    was   lowered    to    f,;\^    with    a    fleeting    cen- 
tral scotoma.     When  I  saw  her  there  was  mild  right 
hemiplegia  and  ancesthesia.     The  lesion  on  the  right 
side  must  have  been   low  enough  down  to  catch  the 
motor   and   sensory  tracts  below   the  pons;    at  the 
same  time  the  hypoglossal  and  the  seventh  nerve 
were  attacked.     Another  lesion   on  the    left    side 
must  have  lain  between  the  chiasm  and  the  apex  of 
the  orbit,  jugulating  the   fibres  of    the    left  optic 
nerve  and  slightly  interfering  with  the  conduction 
of  the  left  abducens.     It  would  be  possible  to  ex- 
plain the  right  hemiplegia  and  right  facial  palsy 
on  the  ground   of  a  lesion   above  the  pons  on   the 
left  side,  but  the  fact  that  there  was  at  the  same 
time  a   right   hypoglossal   palsy  would  necessitate 
the  coexistence   of  a  right-sided  lesion.     It  is  far 
more  reasonable  to  assume  a  right-sided  low  basal 
lesion  for  the  palsies  of  the  right  side. 

The  facts  of  the  case  lead  one  to  the  diagnosis 
of  a  basal,  disseminate,  multiple  meningeal  lesion. 

Case   III. — B.   M ,   aged   twenty-four   years, 

a  mulatto  woman,  states  that  two  and  one-half 
years  ago,  she  awoke  one  morning  to  find  that  she 
could  not  see  with  her  right  eye.  At  i  140  p.m.  of 
the  same  day  she  was  taken  to  the  hospital.  The 
left  eye  remained  good  until  6  p..m.,  when  it  became 
totally  blind  like  the  right  eye.  Immediately  after 
this  she  became  unconscious  and  remained  so  four 
weeks.  She  stated  that  when  she  regained  con- 
sciousness the  left  side  of  her  face  was  paralyzed, 
was  numb,  and  that  her  tongue,  on  being  thrust  out, 
went  to  the  left.  She  had  difficulty  in  eating  and 
kept  biting  the  left  side  of  her  tongue.  Both  eyes 
bulged,  and  "shells  came  off  her  upper  and  lower 
teeth."  The  left  ear  was  quite  deaf  and  there  was 
much  roaring  in  it.  She  found  her  right  eye  still 
totally  blind;  she  could  see  with  her  left,  but  it 
was  weak;  she  had  to  bring  objects  close  to  see  them. 
Her  sense  of  smell  was  entirely  abolished.  In  two 
months  the  sight  of  her  right  eye  returned  imperfectly. 
The  sight  of  the  left  eye  was  good. 

I  saw  her  first  in  October,  1899;  she  said  that  dur- 
ing the  summer  of  that  year  the  sight  of  the  right  eye 
commenced  to  fail  again  and  became  totally  lost. 
Her  status  at  the  time  I  saw  her  was  as  follows:  R.  E., 
totally  blind,  the  pupil  was  extremely  dilated  from  atro- 
pine, cornea  and  sclera  were  completely  anesthetic ;  on 
the  lower  third  of  the  cornea,  extending  almost  to  the 
sclero-corneal  margin,  was  an  elliptical  ulcer;  the  op- 
tic nerve  was  dead  white ;  the  arteries  were  very  small ; 
the  veins  were  moderate  in  size;  there  was  no  other  le- 
sion in  the  fundus.  There  were  some  lacrymation  and 
conjunctivitis.  L.E.  V  =  f,'i,  but  the  field  was  distinct- 
ly hemianopic  on  the  left  side  as  shown  by  the  chart. 
The  field  was  somewhat  constricted  below  and  was 
totally  blind  to  the  temporal  side  of  demarcation. 
The  good  vision,  viz.,  ^  J,  is  explained  by  the  fact  that 
the  macula  fibres  were  not  involved  in  the  lesion. 

In  this  case  a  mulatto  woman  wakes  to  find  herself 
blind  in  her  right  eye;  at  6  p.m.  of  the  same  day  she 
becomes  blind  in  the  left,  then  falls  unconscious  and 
remains  so  for  four  weeks.  On  regaining  conscious- 
ness, she  has  left  facial  paralysis,  left  hypoglossal  pa- 
ralysis, deafness  and  tinnitus  in  the  left  ear;  right  eye 
5till   blind  and  left  eye's  sight  still  impaired.     Sense 


of  smell  destroyed;  in  two  weeks  sight  in  the  right  eve 
returned  imperfectly,  while  the  sight  of  the  left  eye 
was  good.  At  the  end  of  two  and  one-half  years  from 
the  original  attack  she  consulted  me  on  account  of  total 
blindness  of  the  right  eye  and  an  ulcer  on  the  cornea 
of  the  right  eye.  The  right  optic  nerve  was  totally 
atrophic  and  the  left  nerve  also  gave  the  appearance 
of  optic  atrophy,  while  the  field,  as  shown  by  the  ac- 
companying chart,  was  almost  classically  hemianopic. 
The  blindness  was  temporal,  and  the  \'  =  3,". 

It  is  difficult  to  conceive  of  a  more  characteristic 
picture  of  basal  meningitis  and  its  final  results. 
First,  blindness  in  the  right  eye,  then  in  the  left;  sub- 
sequently involvement  of  the  left  facial,  left  hypoglos- 


270' 

sal,  left  auditory,  the  olfactory  apparently  on  both 
sides,  total  atrophy  of  the  right  optic  nerve,  and  par- 
tial atrophy  of  the  left.  The  hemianopic  lesion  is 
particularly  interesting.  The  left-sided  temporal 
hemianopsia  indicates  a  lesion  in  the  right  optic  tract, 
and  if  there  had  not  been  a  complete  involvement  of 
all  the  fibres  destined  for  the  right  eye.  there  would 
assuredly  have  been  left-sided  homonymous  hemian- 
opsia. Since  the  right  eye  became  totally  blind,  the 
matter  resolved  itself  into  left-sided  temporal  hemian- 
opsia. 

The  complete  atrophy  of  the  right  optic  nerve  was 
doubtless  due  to  the  exudate  passing  beyond  the  tract 
and  chiasm,  and  choking  the  nerve  at  its  entrance  into 
the  optic  foramen.  That  perfect  vision  remained  in 
the  left  eye  was  due  to  the  fact  that  the  line  of  the 
dead  nerve  fibres  stopped  short  of  the  macula— the 
usual  fact  in  such  cases. 

The  neuro-paralytic  keratitis  in  this  case,  as  in  Case 
I.,  indicated  that  the  fifth-nerve  fibres  bound  for  the 
cornea  were  involved.  They  were  apparently  de- 
stro)ed  in  Case  III.,  since  the  corneal  anaesthesia  re- 
mained after  two  and  one-half  years.  In  Case  I.,  they 
were  not  totally  destroyed,  but  their  conduction  was 
interfered  with,  as  was  shown  by  the  moderate  sensi- 
bility of  the  cornea  at  the  time  of  my  observation. 

The  young  woman  described  in  Case  II.  was  a 
sufferer    from    chronic    constipation.      She    consulted 


192 


MEDICAL    RECORD. 


[August  4,  1900 


a  very  busy  practitioner  concerning  her  constipation 
and  mentioned  the  numbness  and  loss  of  power  in  her 
right  side.  He  paid  no  attention  to  the  symptoms, 
and  apparently  attributed  them,  together  with  the  diz- 
ziness, to  the  constipation.  A  few  days  after  she 
mentioned  the  fact  that  she  could  not  see  with  her  left 
eye  to  a  physician  whom  she  met  at  a  social  function, 
and  made  light  of  the  matter.  He  observed  a  slight 
facial  palsy  at  the  same  time,  and  immediately  re- 
ferred her  to  me.  Her  rapid  recovery  under  mercury 
and  iodide  of  potassium  proclaim  the  cause,  in  all 
probability,  to  be  specific. 

The  circumstances  surrounding  Cases  I.  and  HI. 
make  the  specific  etiology  clear.  The  three  cases 
present  an  excellent  opportunity  for  the  study  of  the 
lesions  at  the  base  of  the  brain. 

39  West  Thiktv-sixth  Street 


HERNIA   OF   THE   OVARY  AND   TUBE    AND 
THE   VERMIFORM    APPENDIX. 

By   F     C.    LARIMORE.    M.D., 

MOUNT    VERNON,    OHIO 

A  LEFT  oblique  inguinal  hernia  containing  the  ovary, 
tube,  and  vermiform  appendix  is  certainly  of  such  a 
rare  occurrence  as  to  justify  publication.  The  ovary 
or  the  ovary  and  tube,  and  on  the  right  side  the  appen- 
dix vermiformis,  have  been  found  in  a  hernial  sac,  but 
to  find  all  of  these  combined  in  an  inguinal  hernia  on 
the  left  side  may  be  unique. 

O.  A ,  aged  thirty-five  years,  consulted  me  first 

on  October  17,  1899,  for  a  hernia.  I  found  a  left 
oblique  inguinal  hernia,  irregular  and  doughy,  the 
size  of  a  small  orange,  and  irreducible.  The  mass 
could  be  crowded  up,  but  some  portion  would  still  re- 
main outside  the  external  ring.  The  woman  was  wear- 
ing a  truss,  and  stated  that  she  had  had  trouble  on  that 
side  in  childhood,  and  during  the  past  fifteen  years  the 
lump  had  increased  in  size  and  was  more  and  more 
painful.  Operation  was  advised  for  the  radical  cure. 
She  entered  my  private  hospital  May  31,  igoo.  I 
found  the  lump  as  above  described.  It  impre.ssed  me 
as  being  a  lipoma,  the  omentum,  or  an  ovary.  On  June 
I  St  I  operated,  chloroform  being  given  by  Dr.  R.  W. 
Colville.  A  three-inch  incision  was  made  over  the  in- 
guinal canal  one-half  inch  above  Poupart's  ligament. 
The  aponeurosis  of  the  external  oblique  was  divided 
on  a  grooved  director.  The  hernial  sac  was  dissected 
up  with  the  finger.  The  sac  was  opened  and  found  to 
contain  the  ovary  and  tube.  The  ovary  was  located 
outside  of  the  external  ring  and  firmly  attached.  The 
other  end  of  the  tube  ended  in  a  blunt  extremity. 
The  entire  tube  was  as  thick  as  the  little  finger  and 
four  inches  long.  The  ovarian  artery  was  as  large  as 
the  radial,  with  seven  other'arterial  trunks  in  the  sac 
wall,  three  in  one  group  and  four  in  the  other.  The 
appendix  vermiformis] was  found  in  the  neck  of  the 
sac  with  firm  adhesions.  This  was  ligated  off  with 
catgut,  and  the  sac  was  dissected  up' completely  with 
ovary  and  tube  transfixed,  the  two  tubes  were  ligated 
separately,  and  then  combined.  This  method  of  treat- 
ing the  sac  differed  from  my  usual  custom  in  the  use 
of  a  larger-sized  catgut,  and  in  the  firmer  tying.  This 
departure  put  my  mind  at  rest  when  I  discovered  the 
very  unusual  arterial  blood  supply.  Tiie  internal  ob- 
lique and  conjoined  tendon  were  united  to  Poupart's 
ligament  with  five  interrupted  sutures,  inserted  with  a 
full-curve  Hagedorn  needle.  J'he  aponeurosis  of  the 
external  oblique  was  closed  with  a  continuous  suture. 
These  sutures  were  of  kangaroo  tendon,  kept  in  car- 
bolized  oil,  and  at  the  time  of  operation  placed  in  a 
I  ;  1,000  sublimate  solution  in  a  tumbler,  and  used  di- 
rectly from  the  same.  The  skin  incision  was  closed 
with  a  subcuticular  suture  of  catgut,  o  size. 


There  was  no  vomiting  from  the  anaesthetic.  The 
highest  pulse  was  80;  the  temperature  99.2°  F.  on  the 
second  day.  Since  then  the  pulse  has  been  from  68 
to  72,  and  the  temperature  98.6°  F.  The  wound  was 
inspected  on  the  eighth  day,  and  primary  union  was 
found  to  be  complete. 

This  method  would  generally  be  styled  Bassini's, 
but  I  wish  to  render  tribute  to  whom  tribute  is  due, 
and  would  call  it  the  American  operation  as  first  de- 
vised by  Dr.  Henry  O.  Marcy. 


A   CASE   OF    HODGKIN'S    DISEASE. 

By   J.    N.    STUDY,    M.D  , 

CAMBRIDGE    CITY,    IND. 

This  curious  affection  of  the  lymphatic  glands  and 
tissues,  which  has  been  known  by  a  plurality  of  names, 
was  well  described  by  Hodgkin,  a  pathologist  to  Guy's 
Hospital,  in  1832.  Some  of  the  older  writers  had 
given  it  the  name  of  lymphatic  cancer.  It  has  been 
classed  in  the  same  category  as  cancer,  the  malignant 
nature  of  which  it  closely  resembles,  but  pathology 
teaches  us  that  it  bears  no  relationship  to  either  can- 
cer or  tuberculosis,  and  is  treated  of  under  the  title  of 
disease  of  the  blood  and  ductless  glands.  The  affec- 
tion is  simply  a  hyperplasia  of  the  lymphatic  glands. 
There  is  generally  marked' anaemia,  and  there  may  be 
an  increase  of  the  white  blood  corpuscles,  and  the 
character  of  the  blood  become  that  of  a  lymphatic  leu- 
kasmia.  The  affection  has  a  predilection  for  young 
adults  between  twenty  and  thirty  years  of  age;  next 
for  persons  between  fifty  and  sixty  years  of  age,  and 
children  are  not  infrequently  subjects  of  this  disease. 
Three-fourths  of  the  recorded  cases  are  said  to  have 
been  in  male  subjects.  As  to  the  cause  and  origin  of 
the  disease  we  know  nothing,  and  the  affection  sooner 
or  later  usually  terminates  in  death,  and  the  physician 
stands  practically  powerless  to  aid  the  sufferer.  It  is 
believed  that  the  following  case  presents  some  features 
worthy  of  being  recorded  : 

Ivan  L ,  male,  aged  six  years  and  nine  months, 

American,  an  intelligent  child,  well  developed,  and  in 
rugged  health.  The  father  is  living  and  there  is  an 
excellent  family  history;  the  mother  is  living,  but  in 
delicate  health.  One  sister  died  from  tuberculosis. 
The  child  was  observed  to  have  some  difficulty  in 
swallowing  some  varieties  of  food  on  January  15th  of 
the  present  year,  and  at  the  same  time  a  small  lump, 
barely  noticeable,  was  seen  immediately  below  and  pos- 
terior to  the  right  ear;  it  was  not  painful  and  was  free- 
ly movable.  Both  tonsils  were  much  fenlarged,  and, 
to  all  appearance,  the  disease  had  begun  in  the 
tonsils.  The  child  soon  showed  marked  anaemia  ac- 
companied by  a  rapid  pulse  and  occasional  increase 
of  temperature  in  afternoons  of  one  or  two  degrees. 
These  symptoms  all  persisted  throughout  the  illness 
of  the  child.  The  tonsillar  enlargement,  which  affected 
both  tonsils,  increased  until  the  vault  of  the  pharynx 
was  well  filled,  the  anterior  pillars  of  the  fauces  being 
pushed  forward  and  the  uvula  upward  and  forward. 
A  small  fissure  only  could  be  seen  between  the  tonsils, 
but  liquids  and  semisolid  articles  of  diet  were  swal- 
lowed surprisingly  well.  The  tonsils  bled  easily 
when  a  tongue  depressor  was  forcibly  drawn  over 
their  surfaces.  Air  was  admitted  almost  wholly 
through  the  posterior  nares,  and  sleeping  was  often 
interru])ted  by  the  most  distressing  and  at  times 
alarming  symptoms,  llpon  the  right  side  of  the  neck 
all  of  the  cervical  glands  rapidly  became  involved, 
at  first  each  was  movable  and  of  an  elastic  feel,  but 
finally  they  coalesced,  making  an  enormous  mass  ex- 
tending upon  the  right  side  from  the  mastoid  process 
down  to  and  obscuring  the  clavicle. 


August  4,  1900] 


MEDICAL    RECORD. 


'93 


The  enlargement  was  sufficient  to  cause  the  head  to 
be  considerably  turned  to  thu  left.  The  vertical  di- 
ameter of  this  tumor  measured  eight  inches;  its  trans- 
verse diameter  seven  inches.  There  was  a  glandular 
enlargement  below  and  behind  the  left  ear  as  large  as 
a  small  lemon,  freely  movable,  and  elastic  to  the 
touch.  The  skin  over  these  tumors  had  a  healthy  ap- 
pearance. There  was  a  glandular  enlargement  in  the 
right  axilla  of  considerable  size,  and  the  glands  in 
either  groin  were  perceptibly  enlarged  and  movable. 
At  no  time  was  any  pain  complained  of.  The  voice 
was  of  a  nasal  character  and  somewhat  difficult  to 
understand.  At  times  marked  drowsiness  was  pres- 
ent. 

Physical  examination  at  no  time  revealed  any  dis- 
ease of  the  lungs.  On  April  26th,  at  9:30  p.m.,  tiie 
child  was  sleeping,  when  his  breathing  became  very 
bad;  he  awoke,  and  in  an  effort  to  get  more  air  by  go- 
ing to  the  open  door,  as  he  had  done  before,  he  stran- 
gled and  died  in  his  mother's  arms  of  asphyxia. 

P'.ighteen  hours  after  death  the  large  mass  of  glan- 
dular tissue  was  dissected  out.  It  was  a  mass  extend- 
ing down  and  adhering  to  the  deep  muscles  and 
fasciiii.  The  large  vessels  and  nerves  were  deeply 
incorporated  into  the  glandular  mass,  which  weighed 
one  pound.  This  mass  of  glands  on  section  was  of  a 
dark  gray  color,  with  numerous  white  fatty  masses  as 
large  as  peas  scattered  through  it.  When  scraped  a 
milky  substance  exuded  from  the  surface.  There  were 
no  caseous  glands  nor  was  there  any  suppuration. 


A    CASE    OF     PERNICIOUS   AN.EMIA— HUN- 
TERS    TREATMENT— AUTOPSY.' 

By   CH.\RLES    E.    NAMMACK,    M.D., 

NEW     VORK. 

Patrick  L ,  forty-eight  years  old,  steamship  fire- 
man, was  admitted  to  Bellevue  Hospital  May  3,  1900. 
He  stated  that  for  four  months  past  he  had  suiTered 
from  occasional  attacks  of  vomiting,  with  gradually 
increasing  weakness  and  loss  of  Hesh  and  marked 
yellowness  of  the  skin.  Prior  to  this  illness,  he  had 
not  been  confined  to  bed  for  thirty  years.  He  is  in 
the  habit  of  sailing  to  southern  ports.  He  has  never 
drunk  while  on  board  ship,  but  would  drink  moderate- 
ly while  in  port.  He  has  never  acquired  venereal  dis- 
ease, but  admits  having  taken  many  chances  to  do  so. 
On  admission  the  pulse  was  100,  respiration  22, 
and  rectal  temperature  99.8^  F.  The  patient  was 
poorly  nourished.  The  skin  was  a  lemon-yellow  color 
without  variations  on  the  cheeks  and  forehead.  The 
subcutaneous  layer  of  fat  was  not  well  preserved.  There 
was  no  mucous  or  subcutaneous  hemorrhage.  The 
mucous  membranes  and  nails  were  strikingly  white, 
even  by  contrast  with  cases  of  cancer  and  scurvy 
present  in  the  wards.  The  tongue  was  pale,  smooth, 
and  shiny.  The  skin  had  a  soft  velvety  feel  which 
contrasted  well  with  the  dry,  harsh  skins  of  neighbor- 
ing cases  of  secondary  anaemia.  The  gums  were  not 
fungoid  and  did  not  bleed  on  pressure.  The  teeth 
showed  the  appearances  common  to  neglect,  but  were 
not  carious.  The  man's  expression  was  listless,  and 
his  breath  was  offensive.  The  pulse  was  small  and 
regular.  Arterial  tension  was  moderate.  Heart  im- 
pulse and  sounds  were  weak.  There  was  a  basic  sys- 
tolic murmur  transmitted  into  the  neck.  No  water- 
hammer  pulse  was  discovered.  Capillary  pulsation 
was  absent.  There  were  neither  symptoms  nor  physi- 
cal signs  of  involvement  of  the  peripheral  nerves, 
spinal  cord,  or  brain.  Uranalysis  was  negative.  An 
average  of   several  blood  counts  showed :    red    cells, 

'  Patient  presented  before  the  Section  on  Medicine,  New  York 

Academy  of  Medicine,  May  15,  1900. 


560,000;  white  cells,  2,900;  haemoglobin,  twenty  per 
cent.  (Fleischl).  Study  of  the  cells,  as  hereinafter 
mentioned,  determined  the  clinical  diagnosis  of  per- 
nicious anamia. 

This  patient  presented  a  profound  ana-mia  without 
adequate  known  cause,  characterized  by  extreme 
diminution  in  the  red  cells  and  other  changes  in  the 
blood,  and  by  absence  of  marked  emaciation.  The 
blood  changes  were  those  characteristic  of  pernicious 
anaemia,  namely:  (1)  Reduction  of  the  red  cells  to 
less  than  1,000,000;  (2)  absence  of  leucocytosis;  (3) 
presence  of  nucleated  red  cells,  of  which  a  majority 
were  megaloblasts;  (4)  presence  of  polychromatophilic 
red  corpuscles;  (5)  increase  in  the  average  diameter 
of  the  red  cells;  (6)  diminished  absolute  hamoglobin 
but  relative  individual  corpuscular  richness  in  ha-mo- 
globin.  Before  accepting  this  clinical  diagnosis,  gas- 
tric carcinoma,  which  closely  counterfeits  pernicious 
anajmia,  was  excluded  by  the  absence  of  progressive 
emaciation;  the  presence  of  lemon-yellow  instead  of 
muddy  skin;  the  absence  of  enlargement  of  the  supra- 
clavicular and  inguinal  glands;  the  absence  of  palpa- 
ble signs  of  stomach  affection;  the  negative  results  of 
chemical  examination  of  the  stomach  contents  after 
the  Boas  test  meal;  the  absence  of  leucocytosis;  and 
the  presence  of  the  essential  diagnostic  criterion,  to 
wit,  nucleated  red  cells,  of  which  a  minority  were  nor- 
moblasts and  a  majority  megaloblasts. 

Now  that  hematology  plays  so  important  a  part  in 
clinical  medicine,  cases  of  pernicious  anremia  are  not 
so  rarely  found.  Cabot's  list  of  cases  has  increased 
from  sixty-six  in  1897  to  one  hundred  and  ten  to  May 
1,  1900.  Its  prognosis,  however,  still  is  said  to  be 
almost  invariably  fatal.  Into  this  gloomy  picture  a 
ray  of  hope  has  recently  been  projected  by  the  studies 
of  Hunter.'  According  to  Hunter,  the  disease  is  a 
toxeemia,  resulting  from  special  infection  of  the  diges- 
tive tract,  and  treatment,  to  be  successful,  must  be 
based  upon  antisepsis  of  that  tract  and  the  introduc- 
tion of  some  serum  which  will  counteract  the  infection. 
In  the  absence  of  more  exact  know  ledge  of  any  specific 
serum,  W.  F,lder"  reports  a  case  treated  in  accordance 
with  Hunter's  idea  by  mouth  washes,  salol  with  sali- 
cylate of  bismuth,  and  injections  of  antistreptococcic 
serum.  The  result  was  truly  remarkable,  the  blood 
count  becoming  practically  normal  in  forty-five  days. 
But  whether  this  result  was  due  to  the  treatment,  or 
was  one  of  those  spontaneous  waves  of  improvement 
which  are  so  marked  a  feature  of  the  disease,'  remains 
to  be  proved. 

After  this  case  had  been  reported  as  above,  the  pa- 
tient failed  rapidly,  and  died  of  exhaustion  June  12th. 
Autopsy  was  made  by  Dr.  Harlow  Brooks,  sixty  hours 
after  death.  Dr.  Brooks'  report  follows:  The  body  is 
that  of  a  well-developed  man  and  moderately  well 
nourished.  The  skin  and  mucous  membranes  are 
much  blanched.  The  pupils  are  slightly  dilated  and 
the  sclera*  jaundiced.  A  depressed  scar  is  seen  over 
the  right  inginal  canal.  The  musculature  is  fairly 
abundant  and  of  light  color.  Axillary  lymph  nodes 
are  enlarged.  There  are  occasional  bands  of  pleu- 
ritic adhesions  in  both  pleural  cavities,  especially  in 
the  right.  A  few  pleuro-pericardial  adhesions  exist. 
The  pericardial  sac  holds  about  5°  c.c.  of  bright 
yellow  fluid  containing  floccules  of  fibrin.  The  epi- 
cardium  shows  numerous  old  patches  of  epicarditis. 
The  heart  is  enlarged  and  its  walls  are  collapsed. 
The  heart  muscle  is  very  soft  and  light  in  color.  The 
valves  are  universally  thickened.  There  is  decided 
fatty  infiltration.  The  coronary  arteries  are  large  and 
show  slight  arteriosclerosis,  which   is  also  noticed  in 

'  Lancet.  January  27.  February  3,  and  P'ebruan,-  lo,   1900. 
-  Lancet,  .April  28,  1900. 

^  Shattuck  and  Cabot:  "American  System  of  Practical  Medi- 
cine,"  vol.  ii. ,  p.  676. 


194 


MEDICAL    RECORD. 


[August  4,  1900 


the  arch  of  the  aorta.  The  heart  weighs  sixteen  ounces. 
The  tongue  is  moderately  coated  and  a  few  small  hemor- 
rhages are  seen  near  its  posterior  surface.  The  thyroid 
gland  is  small,  light  yellow  in  color.  The  peribronchial 
lymph  nodes  are  enlarged  and  anthracotic.  The 
pharynx  and  oesophagus  are  normal,  except  for  marked 
anaemia.  The  lungs  are  extremely  oedematous,  the  oede- 
ma being  of  a  characteristic,  greenish  color.  Marked 
anthracosis  exists  in  the  right  upper  lobe  with  exten- 
sive development  of  fibrosis. 

The  gall  bladder  shows,  about  its  fundus,  a  consid- 
erable extravasation  of  bile.  The  liver  is  adherent  to 
the  diaphragm  in  many  phices,  is  moderately  enlarged, 
and  there  is  marked  portal  congestion.  The  hepatic 
lobules  are  marked  out  in  light  yellow  from  bile 
staining,  and  there  is  quite  marked  interstitial  over- 
growth. The  liver  weighs  four  pounds.  The  gall 
bladder  contains  20  c.c.  of  mucoid,  greenish  bile. 

The  spleen  is  enlarged,  light  purple  in  color,  with 
markings  distinct,  consistency  soft,  weight  twelve 
ounces. 

The  lower  portion  of  the  ileum  is  attached  to  the 
sheath  of  the  right  psoas  muscle.  The  mesentery  is 
fairly  rich  in  bright  yellow  fat,  and  the  mesenteric 
nodes  are  enlarged.  The  small  intestine  has  an  ana- 
mic  mucous  membrane,  but  is  otherwise  normal.  The 
stomach  is  small,  mucous  membrane  ana;mic,  ruga;  are 
absent,  with  no  ulceration,  no  new  growth.  The  ver- 
miform appendix  is  6  cm.  long,  2  cm.  thick,  and  its  tip 
is  attached  and  adherent  to  the  colon  about  6  cm. 
above  the  caput.  The  wall  of  the  appendix  is  enorm- 
ously thickened  and  its  lumen  is  obstructed  by  an  over- 
growth of  connective  tissue  representing  long-standing 
self-healed  appendicitis,  which  probably  ruptured  into 
the  colon.  The  pancreas  is  large,  color  light,  tissue 
firm.  The  suprarenal  bodies  are  small,  with  cortices 
stained  light  yellow,  and  the  structure  is  apparently 
normal. 

The  kidneys  are  large,  weight  fifteen  ounces,  mark- 
ings distinct  and  regular,  the  cortex  is  very  thin,  con- 
nective tissue  markedly  increased,  consistence  very 
firm.  The  upper  portion  of  the  left  kidney  shows 
anaemic  infarction. 

The  skull  cap  is  symmetrical  and  well  formed,  and 
shows  a  small  amount  of  cancellous  bone.  The  dura 
mater  is  anaemic,  and  incision  liberates  a  considerable 
amount  of  deep-yellow  serum.  The  brain  is  small, 
well  formed,  the  convolutions  are  large  and  symmetri- 
cal, sulci  deep,  the  pia  is  quite  cedematous,  the  ven- 
tricles are  normal.  The  cause  of  death  is  chronic 
idiopathic  anaemia. 

42  East  Twentv-ninth  Street. 


PROTRACTED    GESTATION    IN    AN    OLD 
PRIMIPARA. 

By   J.    EARAX.    M.D.. 

NEW    YORK. 

Mrs.  L.  W — —  was  born  in  September,  1854.  She 
menstruated  first  at  the  age  of  twelve  years,  and  very 
regularly  thereafter  every  twenty-eight  days.  She  was 
married  in  1892,  being  then  thirty-eiglit  years  old. 
She  became  pregnant  about  two  years  later,  but  mis- 
carried at  about  two  and  one-half  months.  On  June 
II,  1899,  she  menstruated  for  the  last  time,  and  had 
symptoms  of  pregnancy  at  least  one  week  before  July 
9th,  at  which  time  her  menses  should  have  reappeared. 
But,  as  expected,  there  was  no  show.  She  felt  quick- 
ening on  November  1st.  According  to  calculation  she 
should  have  been  delivered  about  March  i8th,  but  no 
sign  of  beginning  labor  existed  even  on  April  19th,  on 
which  day,  fearing  the  growth  of  the  child  to  very 
large  proportions,  although  the  pelvis  appeared  am- 
ple, I   decided  to  force   labor  and  gave  the  patient  a 


large  dose  of  castor  oil.  I  cannot  believe  that  it  was 
a  coincidence,  but  after  the  oil  acted  labor  pains  de- 
veloped. The  first  stage  of  labor  lasted  sixty  hours, 
the  second  and  third  stages  only  a  short  time.  The 
woman  was  delivered  on  April  22d,  three  hundred 
and  fifteen  days  from  the  beginning  of  the  last  men- 
struation. How  much  longer  she  might  have  carried 
is,  of  course,  only  conjectural.  The  baby  was  large, 
bony,  not  fat;  it  had  considerably  elongated  nails,  but 
no  unusual  growth  of  hair.  Dr.  Lusksays:  "Gestation 
protracted  beyond  the  two  hundred  and  eighty-fifth 
day  is  certainly  of  very  rare  occurrence."  My  patient 
went  at  least  ten  days  over  that  time.  Her  age,  al- 
most forty-six  years,  is  certainly  also  very  unusual  for 
a  primipara. 

A   CASE   OF   TETANUS    TREATED    WITH 
ANTITOXIN. 

By  GEORGE   M.    CONVERSE.    M.D., 

NEW  YORK. 

Martin  T ,  thirty-four  year  old,  single,  a  gar- 
dener in  Long  Island,  entered  St.  Francis  Hospital, 
New  York,  on  March  6,  1899,  suffering  from  frozen  fin- 
gers, pain  all  over  the  body,  and  inability  to  open  the 
mouth.  He  had  always  been  healthy,  temperate,  and 
denied  any  venerea!  history.  The  fingers  of  his  right 
hand  were  frozen  during  the  blizzard  on  February  9, 
1899,  and  were  dressed  at  a  dispensary.  He  con- 
tined  with  his  work.  On  the  day  of  entrance,  the  last 
phalanges  of  the  ring  and  little  fingers  were  gangre- 
nous and  painful,  the  patient's  face  was  flushed  and 
covered  with  great  beads  of  perspiration  ;  the  forehead 
was  wrinkled  and  the  eyelids  were  drooping,  the  gen- 
eral expression  being  that  of  the"risus  sardonicus." 
He  couid  not  separate  the  teeth  more  than  i  cm.,  at 
the  same  time  the  lower  jaw  was  drawn  backward  so 
that  the  lower  incisors  were  nearly  2  cm.  posterior  to 
the  upper  incisors.  He  could  move  his  head  from 
side  to  side  but  not  antero-posteriorly.  At  intervals 
varying  from  fifteen  minutes  to  an  hour  he  had  pain- 
ful contractions  in  both  legs,  in  the  chest  which  felt 
as  if  it  were  squeezed  in  a  vice,  and  in  the  masseters. 
From  the  day  of  entrance  the  man  rapidly  became 
worse;  the  tonic  spasm  spread  to  all  the  muscles  of 
the  back  and  legs  until  these  were  as  rigid  as  thos.e  of 
a  cadaver  in  rigor  mortis.  At  varying  intervals,  mostly 
in  the  afternoon  and  night,  this  condition  was  exas- 
perated by  paroxysms  of  intensely  painful  clonic 
spasms.  During  these  and  until  relieved  by  chloro- 
form he  would  shout  at  the  top  of  his  voice.  This 
cry,  caused  at  first  by  intense  pain,  became  somewhat 
automatic,  so  that  frequently  during  the  succeeding 
days,  and  in  the  absence  of  clonic  spasms,  he  would 
begin  to  shout  at  the  top  of  his  voice  during  each  ex- 
piration. Two  days  after  admission,  and  while  in  this 
condition,  the  man  consented  to  amputation  of  the  dis- 
eased fingers.  This  was  done  by  the  nouse  surgeon. 
Dr.  G.  H.  Matthews,  under  general  anaesthesia.  Then 
followed  a  period  of  sixteen  days  during  which  the  gen- 
eral rigidity  persisted  and  clonic  spasms  occurred, 
with  maxinuiin  frequency  and  intensity  on  the  third, 
fourth,  and  fifth  days,  and  again  on  the  eighth  day, 
when  the  pectorals  and  tiie  muscles  of  the  arms  be- 
came involved  and  respiration  was  difficult  for  a  day; 
from  the  eighth  to  the  eighteenth  day  the  symptoms 
gradually  abated  in  intensity. 

At  various  times,  corresponding  to  maximum  injec- 
tions of  antitoxin,  the  muscles  would  relax  for  a  few 
hours  so  that  the  patient  could  bend  his  knees,  lie  on 
his  side,  and  thus  obtain  a  greatly  needed  rest. 

Consciousness  was  intact  most  of  the  time.  At  the 
height  of  this  period  the  patient  exhibited  a  num- 
ber of  times  what  is  called  echolalia.     On  saying  to 


August  4,  1900] 


MEDICAL    RECORD. 


195 


him  "  Hallo,  Martin!  "  he  would  repeat  vvith  each  ex- 
piration, "  Hallo,  hallo  1  "  etc.,  durin;^  a  minute  or  two. 

There  was  at  first  constipation,  followed  later  bv  in- 
voluntary evacuation  of  faeces  and  urine.  The  urine 
remained  scanty,  high-colored,  filled  with  urates  until 
the  fifteenth  or  sixteenth  day,  when  the  perspiration 
diminished  and  the  urine  increased  until  it  reached 
an  amount  of  two  and  one-half  litres  per  twenty-four 
hours. 

On  the  26th  of  March,  or  the  twentieth  day  in  the 
hospital,  when  the  patient  was  quite  well  of  the  tet- 
anus and  had  only  a  slight  rigidity  of  the  masseters, 
pain  and  rigidity  began  anew,  but  this  time  were  lim- 
ited to  the  right  leg.  A  diagnosis  of  phlebitis  was 
made,  and  it  was  only  at  the  autopsy  seventeen  days 
later  that  it  was  seen  that  pyemia  had  caused  death. 
The  treatment  consisted  of  a  few  whiffs  of  chloroform 
during  the  paro.xysms.  Chloral  and  potassium  bromide 
were  also  given  the  first  days,  but  abandoned  on  ac- 
count of  the  effect  on  the  heart,  the  pulse  becoming 
irregular  and  feeble. 

Tetanus  antitoxin  was  obtained  from  the  bureau  of 
the  board  of  health  in  vials  of  20  c.c,  and,  with  anti- 
septic precautions,  was  injected  deeply  into  the  arms 
and  thighs:  20  c.c.  on  the  second  day,  40  c.c.  on  the 
third,  80  c.c.  on  the  fourth,  and  thereafter  for  six  days, 


were  carefully  watched  for  three  weeks,  but  the  results 
were  negative.  The  autopsy  of  these  was  also  nega- 
tive. Microscopical  examination  of  the  diseased  fin- 
gers showed  only  granulation  tissue  and  necrosis  of 
the  phalanges. 

In  conclusion  I  would  say  that  this  was  not  an  acute 
case  of  tetanus;  it  was  a  severe  subacute  form,  one  in 
which  the  patient  might  have  recovered  without  anti- 
toxin; it  is  reported,  however,  because  antitoxin  was 
used. 

330  West  Fiftv-seve.nth  Stkeet. 


CRYING    OF    .A.    CHILD    IN    UTERO. 

Bv    M.    J.    DAVIES,    M.D., 

UTICA,   N.    V. 

The  history  of  the  following  case  may  be  of  consider- 
able interest  to  my  fellow-practitioners,  especially  to 
those  who  make  a  special  study  of  obstetrics.  To  my- 
self it  has  been  unique,  as  I  have  not  had  such  an 
experience  before,  and,  in  so  far  as  I  have  been  able 
to  learn,  none  of  my  professional  brethren  in  the  city 
has  met  with  a  similar  case. 

Mrs.  A — — ,  aged  twenty-four  years,  became  preg- 


105 

Ha 
6 

rch 

7 

8 

9 

10 

11 

12 

13 

14 

15 

16 

1; 

IS 

19 

•20 

21 

2*2 

23 

24 

25 

2G 

27 

2S 

29 

30 

3 

31 

April 
1      2 

s 

4 

5 

C 

7 

- 

S 

9 

10 

11 

104° 
103 
102 
101 

1 

1 

— 1 

^ 

—^ 

y 

^ 

r 

^ 

b 

t^ 

k 

h 

=? 

1 

1 

P 

~7\ 

^ 

[A 

\ — 

^ 

^ 

$s 

1 

^ 



B 

100' 

09 

88 

S 

4 

g 

u 

^ 

H 

f^ 

r 

4= 

i 

^ 

^ 

^ 

— 

y 

^\ 

/ 

N 

^ 

/ 

/ 

\ 

t> 

y 

\ 

1 

-^ 

/ 

X 

RAE 

H 

V 

/ 

XRASH 
DESQUA 

"ADES 
RATIOS 

''RASH  gone) 
DESQUAMATION 

NUMBER  OF  INJECTIONS  OF  SERUM  PER  24  MRS.   (  20  C.  C.   EACH) 

afterward  gradually  diminishing,  to  stop  on  the  twelfth 
day.     Altogether  720  c.c.  was  given. 

The  notes  of  the  case  kept  from  day  to  day  show 
that  the  number  of  paroxysms  of  clonic  spasms  were 
less  after  the  doses  of  80  c.c.  of  antitoxin  had  been 
reached.  , 

On  the  evening  of  March  13th,  seven  days  after  the 
first  injection,  and  when  500  c.c.  had  been  given,  an 
eruption  appeared  about  the  points  of  injection  on  the 
arm;  this  spread  rapidly  and  in  twelve  hours  covered 
both  arms,  the  back  and  legs,  and  the  abdomen.  At 
first  pink,  it  became  dark  red,  wine  red;  conHuent  on 
the  back  and  arms;  at  other  points  it  occurred  as  pro- 
fusely scattered,  hard  papules  also  of  deep  red  color. 
Five  days  later  desquamation  began,  and  in  ten  days 
the  eruption  had  disappeared  completely,  having 
caused  no  other  inconvenience  than  some  itchy  sensa- 
tions. 

The  diet  was  milk,  and  the  patient  also  drank  an 
enormous  quantity  of  water.  The  patient's  death  from 
pyaemia,  after  his  recovery  from  tetanus,  is  ascribed  to 
the  use  of  a  vial  of  serum  that  was  not  hermetically 
sealed,  and  that  had  been  standing  on  a  window-sill 
for  several  days  during  which  the  temperature  rose 
above  the  freezing-point. 

The  amputated  fingers  were  sent  to  Dr.  Larkin  at 
the  College  of  Physicians  and  Surgeons.  He  excised 
small  pieces  and  introduced  these  under  the  skin  of  two 
small  guinea-pigs  of  250  gm.  in  weight.     The  animals 


nant  for  the  third  time  about  March  20,  1899.  There 
were  no  exceptional  symptoms  during  the  succeeding 
nine  months.  At  2  a.m.  on  December  31,  1899,  I 
was  summoned,  the  message  being  that  pains  were 
very  severe  and  coming  on  rapidly.  Upon  arriving  at 
the  house  I  found  the  patient  as  stated  above,  every- 
thing indicating  a  rapid  delivery,  but  upon  making  an 
examination  there  was  found  a  very  rigid  cervix  with 
a  dilatation  of  the  os  that  would  admit  the  index  and 
middle  fingers.  Severe  contraction  continued.  At 
6  A.M.  another  examination  was  made.  I  found  no 
progress  toward  dilatation.  During  the  next  hour  the 
pains  grew  less  severe  and  frequent,  finally  stopping 
at  7  :3o  A.M.  Nothing  more  was  heard  of  the  case  un- 
til about  9  P.M.,  when  the  same  message  was  sent  as 
before.  I  arrived  at  the  house  about  9  :30,  and  found 
the  patient  in  good  spirits,  though  suffering  intensely. 
An  examination  revealed  the  same  conditions  as  during 
the  morning  hours.  At  2  a.m.  another  examination 
was  made.  The  os  was  found  to  be  dilated  about  the 
size  of  a  fifty-cent  piece;  the  membranes  were  not  rup- 
tured, the  presenting  part  being  the  head  and  in  the  right 
occipito-posterior  position.  At  6  a.m.,  January  ist,  the 
contractions  ceased  as  during  the  previous  morning. 
The  patient  passed  a  very  comfortable  day.  At  7  p.m. 
I  called  at  the  house  and  found  my  patient  beginning 
to  suffer,  contractions  being  severe,  and  at  intervals  of 
about  three  minutes.  The  cervix  was  more  flattened 
out,  with  the  os  slowly  dilating.     At  9  130  the  os  was 


196 


MEDICAL    RECORD. 


[August  ^,  I  goo 


about  three-fourths  dilated.  The  patient  began  to 
show  signs  of  weakening.  Thinlcing  that  perchance 
if  the  membranes  were  ruptured,  permitting  the  liquor 
aninii  to  escape,  the  head  would  become  engaged  in 
the  superior  strait,  and  a  rapid  delivery  would  he  the 
result,  this  was  done;  but  to  my  sorrow  this  result  did 
not  obtain. 

As  the  pulse  was  showing  signs  of  weakening,  I 
concluded  that  it  was  time  to  interfere  by  the  appli- 
cation of  the  forceps,  the  right  hand  being  used  to 
guide  the  left  blade  into  position,  which  was  easily 
accomplished,  but  when  an  attempt  was  made  to  intro- 
duce the  right  blade  there  were  violent  movements  of 
the  child,  which  made  the  sound  of  crying  six  or  eight 
times  that  was  heard  by  the  patient,  her  husband,  her 
mother,  and  myself.  Never  having  experienced  such  a 
thing  before,  1  was  very  much  surprised.  On  withdraw- 
ing the  forceps  the  little  one  again  cried,  the  sounds 
being  heard  as  distinctly  as  before.  At  the  same  time 
the  patient  exclaimed,  "  My  baby  is  born,  but  why  did 
you  push  it  back,  doctor?  "  The  husband  was  sent  for 
an  assistant,  that  an  anassthetic  might  be  administered 
and  the  woman  delivered. 

At  the  same  time  that  the  husband  left  the  house  I 
stepped  into  an  adjoining  room.  While  conversing 
with  a  friend  of  the  family,  I  heard  again  the  crying 
of  the  child;  the  sounds  were  so  loud  and  distinct 
that  I  supposed  a  spontaneous  delivery  had  taken 
place.  Hastening  to  the  bedside,  the  babe  was  still 
found  to  be  in  the  uterus.  The  sounds  made  by  the 
child  the  last  time  were  very  loud  and  long,  there  be- 
ing at  least  from  ten  to  fourteen  sobs.  Upon  the  ar- 
rival of  an  assistant  I  concluded  that  the  most  rapid 
method  of  delivery  would  be  to  perform  version,  having, 
as  before  mentioned,  attempted  to  adjust  the  forceps 
and  failed.  As  soon  as  the  patient  was  anasthe- 
tized  version  was  performed,  and  a  male  child  weigh- 
ing seven  and  one-half  pounds  was  delivered.  Very 
slight  pulsation  was  perceptible  at  the  cord.  Artificial 
respiration  was  performed,  when  soon  the  pleasing 
sound  of  crying  was  heard. 

The  child  is  now  four  and  one-half  months  old,  and 
doing  nicely.  The  mother  made  a  rapid  convales- 
cence, and  within  four  weeks  was  doing  her  own 
housework. 

Why  the  child  cried  before  birth  is  a  hard  and  diffi- 
cult question  to  answer.  Certainly  it  must  have  ob- 
tained air  in  some  manner.  At  the  time  of  first  crying 
it  is  easy  to  theorize  how  air  was  obtained,  with  three 
fingers  of  the  right  hand  in  the  vagina,  and  upon  at- 
tempting to  introduce  the  left  blade  of  the  forceps 
there  existed  a  patent  canal  up  to  the  os.  The  child 
being  in  the  R.  O.  P.  position  the  air  readily  reached 
the  face;  but  without  hand  or  forceps  in  the  vagina  it 
seems  almost  incredible  that  air  could  enter.  It  might 
be  said  that  there  was  sutficient  air  that  entered  the 
first  time  to  suffice  for  the  crying  later  on. 


ANEURISM  OF  THE  ARCH  OF  THE  AORTA. 
By    IIUCIIKS   DAYTON,    M.I)., 

NEW    YORK. 

The  following  case,  which  was  observed  at  the  New 
York  Hospital  during  the  term  of  service  of  Dr.  A. 
Brayton  Hall,  is  briefly  reported  in  view  of  the  pecul- 
iar physical  signs  due  to  interference  with  the  circu- 
latory system,  and  of  the  explanation  of  their  etiology 
which  was  furnished  by  the  autopsy.  Only  an  imper- 
fect history  could  be  obtained  from  the  patient,  Vin- 

cenzo  P ,  an  Italian,  fifty  years  old,  single,  a  barber, 

admitted  to  New  York  Hospital  April  9,  1900.  His 
family  history  presented  nothing  of  significance.  His 
past  history  was  negative  except  malaria  thirty  years 


ago  lasting  three  months,  and  three  attacks  of  gonor- 
rhcea.  No  history  of  syphilis  or  rheumatism  could  be 
obtained,  and  the  patient  had  never  suffered  from 
dyspncea,  cough,  bloody  expectoration,  or  cedema  of  the 
extremities.  He  did  not  recall  having  been  subjected 
to  any  sudden  or  protracted  strain.  He  acknowledged 
the  habitual  consumption  of  one  or  two  glasses  of 
wine  daily  and  occasionally  a  little  beer.  About  two 
years  before  admission  to  the  New  York  Hospital  he 
began  to  have  a  persistent  and  troublesome  cough  with 
rather  profuse  muco-purulent  sputum.  The  attacks  of 
coughing  were  accompanied  by  palpitation  of  the  heart 
and  were  sometimes  followed  by  vomiting.  There 
were  no  other  gastric  symptoms  at  any  time.  One 
year  before  admission  the  superficial  veins  of  the  ab- 
domen and  lower  extremities  became  enlarged,  and 
three  months  before  those  of  the  upper  portion  of  the 
chest  and  upper  extremities  were  similarly  affected. 
The  cough  had  continued  without  improvement,  though 
the  sputum  had  become  scanty,  and  there  had  been 
constantly  increasing  dyspnoea.  There  had  been  no 
thoracic  pain  at  any  time,  but  some  in  the  lumbar 
region  at  intervals  for  about  five  years.  The  appetite 
was  fair;  the  bowels  were  irregular.  The  chief  com- 
plaint was  of  the  cough  and  oppression  in  the  chest. 

Physical  examination,  April  g,  igoo:  General  ap- 
pearance—  rather  poorly  nourished,  somewhat  cyanotic, 
suffering  from  dyspnoea  which  was  practically  ortho- 
pnoea;  tongue  moist,  fissured,  heavily  coated.  The 
most  noticeable  feature  v.'as  the  great  distention  of  all 
the  superficial  veins,  which  were  also  extremely  tor- 
tuous, and  the  walls  of  which  were  much  thickened. 
An  excellent  idea  of  this  appearance  is  furnished  by 
the  accompanying  illustration  from  a  photograph  by 
Dr.  J.  B.  Solley,  Jr.  During  the  paroxysms  of  cough- 
ing the  distention  of  the  veins  was  much  more  marked, 
the  superficial  epigastric  being  three-eighths  to  one- 
half  an  inch  in  diameter. 

Heart:  There  was  visible  pulsation  of  the  whole 
anterior  portion  of  the  chest  wall,  which  showed 
marked  prominence,  especially  at  the  second  left  in- 
tercostal space  near  the  sternum,  where  a  mass  with 
distinct  expansile  pulsation  was  felt.  The  apex  beat 
was  diffuse.  The  area  of  cardiac  dulness  extended  to 
the  right  border  of  the  sternum;  above,  to  the  third 
intercostal  space.  There  was  also  an  area  of  dulness 
between  the  clavicles  and  second  ribs,  extending  to 
the  right  as  far  as  the  middle  of  the  right  clavicle, 
and  to  the  left  to  within  one  inch  of  the  left  mammil- 
lary  line.  The  aortic  and  pulmonic  second  sounds 
were  accentuated.  The  heart  sounds  were  obscured 
by  violent  respiration  and  coughing.  There  was  no 
thrill;  no  murmurs  were  heard.  Tracheal  tug  was 
obtained.  The  pulse  was  frequent,  regular,  small  in 
proportion  to  the  intensity  of  heart  action,  with  good 
tension. 

Lungs:  Over  the  upper  portion  of  the  right  chest 
behind  breathing  and  whisper  were  rather  amphoric: 
over  the  rest  of  the  right  chest  posteriorly  were  sibilant 
and  sonorous  breathing  and  subcrepitant  rales.  Over 
the  left  chest  beiiind  down  to  the  angle  of  the  scapula 
the  breathing  approached  an  amphoric  character;  be- 
low the  angle,  it  was  diminished  and  high-pitciied. 

Abdomen:    Slightly  distended  and  tympanitic. 

Liver  and  spleen  :    Normal. 

Extremities:  Normal  except  for  cyanosis  and  dila- 
tation of  veins  as  stated  above. 

Course  of  disease:  The  rectal  temperature  rose, 
soon  after  admission,  to  104°  F.,  and  subsequently 
varied  between  100  and  io2~'  F, ;  respirations,  24  to 
36;  pulse,  80  to  124.  Urine:  specific  gravity  1.031, 
acid,  orange,  turliid,  no  sugar,  albumin  gm.  '4  to  the 
litre;  passed  daily  twenty-four  to  thirty-eight  ounces; 
there  were  a  few  uric-acid  crystals. 

DyspncL-a  continued  severe  and  cough  frequent  and 


August  4,  1900] 


MEDICAL   RECORD. 


197 


troublesome.  The  patient  slept  only  in  the  sitting 
position.  On  April  17th  there  was  found  from  the 
angle  of  the  left  scapula  down  dulness  increasing  to 
flatness  toward  the  base,  with  nearly  absent  fremitus, 
voice  and  breath  sounds. 

At  7:15  A.M.  on  April  i8th  the  patient  became 
cyanosed  and  covered  with  cold  perspiration,  and  the 
pulse  was  very  weak.      He  died  at  7  :4o  a.m. 

Treatment  consisted  merely  in  the  administration 
of  potassium  iodide  in  doses  of  gr.  .\v.  three  times 
a  day,  and  the  alleviation  of  cough  by  appropriate 
remedies. 

Autopsy  by  Dr.  L.  A.  Conner,  assistant  pathologist, 
showed  aneurism  of  ascending  and  transverse  portions 


of  the  arch  of  the  aorta;  obliteration  of  both  innomi- 
nate veins;  ulcer  of  the  stomach;  secondary  pneu- 
monia. 

Inspection:  Poorly  nourished,  muscular;  slight 
oedema  of  ankles;  the  superficial  veins  of  both  sides  of 
the  neck,  chest,  and  especially  of  the  abdomen  are  tor- 
tuous and  greatly  distended,  some  of  them  having  the 
diameter  of  a  lead  pencil;  slight  prominence  of 
second  intercostal  space  on  either  side  of  sternum. 
The  peritoneum  and  pericardium  are  normal.  The 
diaphragm  is  at  the  fifth  rib  on  the  right  side,  and  at 
the  sixth  intercostal  space  on  the  left. 

Pleuras:  The  left  pleural  cavity  contains  600  c.c.  of 
serous  fluid. 

The  heart  is  displaced  somewhat  downward  and  to 
the  left;  the  valves  are  competent ;  the  muscle  is  light- 
colored  and  rather  soft. 

Aorta:  The  entire  anterior  mediastinum  is  occupied 
by  an  aneurismal  mass  vihich  is  firmly  adherent  to, 
and  has  partially  eroded,  the  manubrium  sterni.  The 
sac  also  projects  through  the  second  intercostal  space 


on  either  side  of  the  sternum.  For  a  distance  of  3 
cm.  above  the  aortic  valves  the  aorta  has  a  diameter 
of  about  3  cm.;  beyond  this  it  suddenly  widens  into 
a  great  sac  12  to  15  cm.  in  diameter.  This  sac  is  in 
some  places  lined  with  laminated  clot,  i  to  2  cm. 
thick,  and  in  other  places  is  quite  free  from  clot.  The 
innominate  artery  is  given  off  from  the  sac  at  about 
the  middle  of  its  upper  surface;  the  left  carotid  artery, 
from  its  left  wall.  Immediately  beyond  this  the  aorta 
suddenly  assumes  its  normal  calibre,  and  just  at  this 
point  the  left  subclavian  is  given  off.  The  trachea 
and  bronchi  are  apparently  not  greatly  compressed, 
although  firmly  adherent  to  the  aneurism. 

Superior  vena  cava:  This  vessel  runs  up  along  the 
right  wall  of  the  aneurism,  gradually  diminishing  in 
calibre  until  it  becomes  a  small  vein  which  communi- 
cates in  a  tortuous  way  with  the  right  subclavian  vein. 
Both  innominate  veins  traced  from  above  are  lost  and 
obliterated  in  the  aneurismal  wall. 

Azygos  veins:  ISoth  of  these  are  much  dilated  and 
engorged,  as  are  also  the  oesophageal  veins. 

Lungs:  The  lower  lobe  of  the  left  lung  is  com- 
pletely consolidated,  of  light  reddish  color,  rather 
tough  consistence,  and  shows  scattered  throughout 
many  small  yellowish  or  whitish  areas  which  may  be 
foci  of  suppuration.  A  similar  condition  exists  in 
the  middle  lobe  of  the  right  lung.  The  bronchi  con- 
tain much  muco-purulent  secretion.  Microscopic  ex- 
amination shows  the  consolidated  area  to  be  a  some- 
what unusual  type  of  broncho-pneumonia,  in  which 
foci  of  suppuration  alternate  with  areas  of  consolida- 
tion chiefly  fibrinous  in  character. 

The  kidneys  show  congestion  and  some  evidences 
of  chronic  change. 

The  liver  has  a  slight  degree  of  chronic  congestion. 

The  stomach  shows  in  its  lesser  curvature  5  cm. 
from  the  pylorus  a  large  old  ulcer  which  has  perforated 
but  is  shut  ofT  by  adhesions  from  the  general  peritoneal 
cavity.     There  is  chronic  gastritis. 

The  other  organs  show  only  slight  changes. 

The  obliteration  of  the  right  and  left  innominate 
veins  obviously  necessitated  the  return  of  all  venous 
blood  which  they  would  naturally  convey  to  the  heart, 
with  the  possible  exception  of  a  small  amount  carried 
from  the  riglit  subclavian  vein  by  the  narrow  and  tor- 
tuous remnant  of  the  right  innominate,  by  anastomotic 
branches  connecting  the  innominate  veins  with  branches 
of  the  inferior  vena  cava.  This  was  effected  chiefly 
by  the  intercostal  branches  of  the  internal  mammary 
veins,  which  by  anastomosis  with  the  superficial  epi- 
gastric veins  established  a  communication  through 
the  saphenous  openings  with  the  femoral  vein?,  and 
thus  transmitted  the  blood  from  the  upper  extremities 
and  head  through  the  iliac  veins  and  inferior  vena 
cava  to  the  heart.  The  presence  of  a  large  gastric 
ulcer  which  had  perforated  without  giving  symptoms 
sufficiently  severe  to  be  remembered  by  the  patient  is 
a  feature  of  interest. 

New  Vukk  Hospital. 


DERMOGRAPHIA   AND    ANIDROSIS. 
Bv   E.    V.    MOCK,    M.D., 

CAMBRIDGE,    ILL,, 

LATE    SIRGEON    TO   THE    ALMS-     AND      WORKHOl'SK    HOSPITAI-S,     BLACKWELL'S 
ISLAND,   NEW    YORK. 

A  CASE  of  peculiar  interest  having  recently  come  under 
my  observation,  I  present  a  photograph  and  short  his- 
tory of  it. 

William   F ,  thirty-five  years  old,  born   in   the 

United  States,  of  Irish  parents,  married,  with  healthy 
children,  weighs  one  hundred  and  seventy-four  pounds. 
Th;  family  history  is  good,  the  only  disease  being  a 
slight  eczema  on  the  father's  side  in  the  latter  years 


198 


MEDICAL   RECORD. 


[August  4,  1900 


of  his  life.  The  patient  has  never  been  ill  since 
childhood,  and  is  a  muscular  man  as  shown  by  the 
photograph.  For  a  great  many  years  it  has  been  his 
custom  to  plunge  into  a  pool  of  cold  spring  water  in 
the  summer,  and  this  often  while  he  was  e.xcessively 
hot  from  farm  labor.  About  six  j-ears  ago  he  noticed 
a  diminution  of  perspiration,  and  in  summer  suffered 
unusually  from  the  heat.  About  three  years  ago  lie 
noticed  that  a  slight  contusion  of  the  skin,  over  the 
areas  where  perspiration  was  diminished,  would  pro- 
duce a  welt,  and  that  the  patches  were  enlarging; 
which  they  did  until  his  entire  body  was  in  that  con- 
dition. Objectively  there  is  no  perspiration  of  the 
skin  of  the  entire  body,  but  there,  are  no  other  symp- 
toms, and  the  patient  suffers  nothing  but  from  his  non- 
resistance  to  heat.  The  welts  shown  in  the  photo- 
graph are  about  one-half  inch  wide  and  one-fourtli 
inch  deep.  They  were  produced  by  tracing  on  the 
skin  with  the  blunt  end  of  a  wooden  penholder  and 
were  photographed  about  ten  minutes  later.  They 
remain  distinct  for  about  two  hours,  and  at  the  end  of 
three  hours  there  is  no  trace  of  them. 

On  account  of  not  perspiring  and  the  resultant  non- 
resistance  to  heat,  the  patient  applied  at  the  Presby- 


developed.     The  entire  body  up  to  the  neck  was  nor- 
mal, except  the  spine.     The  posterior  arches  and  spines 


of  the  vertebra;  were  absent  down  to  the  sacrum.  The 
defect  was  covered  with  a  thin  membrane  for  an  inch 
on  each  side  of  the  spinal  cord  in  place  of  the  skin, 
and  at  the  edge  of  this  membrane  on  the  skin  was  a 
narrow  fringe  of  hair  an  inch  or  more  long,  extending 
down  to  the  ninth  dorsal  vertebra.  The  cord  was  only 
rudimentary  and  ran  along  under  the  membrane.  The 
neck  was  absent,  and  the  cord  ran  over  the  anterior 
part  of  the  foramen  magnup,  all  of  the  posterior  part 
of  the  foramen  and  the  occipital  bone  being  absent, 
as  were  also  the  parietal  and  frontal  bones. 

The  superciliary  ridge  and  all  that  goes  to  make  up 
the  roof  of  the  orbit  were  absent,  the  lesser  wing  of  the 
sphenoid  being  the  highest  bony  point.  The  ethmoid 
bone  ran  forward  and  connected  it  with  the  nasal 
bones.  The  palatine  arch  was  cleft.  No  traces  of 
the  cerebrum,  cerebellum,  or  medulla  existed,  al- 
though what  appeared  to  be  nerves  ran  across  the  bone 
where  the  foramen  magnum  should  be,  and  over  the 
bony  tissue.  The  accompanying  illustration  is  from 
a  photograph  showing  the  posterior  aspect  of  the 
monster. 

I  could  get  no  history  of  any  previous  illness  of  the 
mother,  and  she  appeared  to  be  the  picture  of  health. 
She  stated  that  she  always  had  an  excessive  amount 
of  fluid  while  carrying  her  children.  She  also  stated 
that  she  felt  life  up  to  the  morning  when  the  foetus 
was  born. 


^lU'Liical    ^uijiricsticins. 


terian  Hospital,  Chicago,  for  treatment,  and  was  ad- 
mitted at  the  clinics  of  the  Rush  Medical  College  and 
other  places,  but  no  diagnosis  was  made. 


AN    ACRANIAL    MONSTER. 
By  AI.HERT   S.    PAYNE,    M.I)., 

MANISTEE,    MICH. 

0>i  March  25,  1900,  I  was  called  to  see  Mrs.  C , 

aged  forty  years,  multipara.  She  says  she  was  never 
sick.  She  is  the  mother  of  four  living  children  and 
has  had  nine  miscarriages  and  abortions,  one  at  two 
months,  three  months,  five  months,  six  months;  two 
at  seven  months;  two  at  eight  months,  and  the  one  I 
was  called  to  attend  at  seven  and  one-half  months.  I 
found  an  excessive  amount  of  liquor  amnii.  The 
head  presented,  and  the  woman  was  delivered  in  three 
hours  of  a  monster.  The  fa-tus  weighed  four  and  one- 
half  pounds,  and  was  a  female  with  sexual  organs  well 


Ingrowing    Nail I'ack    the    side   of  the   nail    with 

cotton  soaked  in — 

IJ  Liq.  potassce 3  i. 

Cocaine  sol.  (4  percent.) 0  iij. 

Apply  plaster  strips  to  draw  the  soft  tissue  away  from 
the  nail  margin,  .\ever  cut  the  side  of  the  nail. — Afedi- 
cal  Times. 

Sprained  Ankle. — Apply  very  hot  water  followed 
by  a  rubber  bandage. 

Chronic  Cervical  Metritis. — 

IJ   I'otass.  idd., 

I'otass.  brom aa  gr.  xx. 

Tr.  iodi 3  ss. 

Aquoe 3  ij ■ 

Inject  into  the  hyperplastic  tissue  by  means  of  a  long 
syringe. 

Pruritus Electric  souffle:  The  point  of  the  elec- 
trode may  be  slowly  passed  over  the  affected  region 
for  twelve  to  fifteen  minutes. — Monell. 


August  4,  1900] 


MEDICAL    RECORD. 


'99 


Anaesthetic  Haemostatic  Solution — 

^  Gelatin,  pur 2.0 

Sodii  chloridi 0.7 

Acidi  carbol.  cryst 01 

Eucain.  hydrochlor.  h 0.7 

Cocain.  hydrochlor 03 

Aqux  destill ad  100. o 

M.      S.    To  be  used  as   in    the   Schleich    infiltration  anes- 
thesia. 

— Le  Grand. 
Hypodermic  Cure  of   Hernia. — The  lluid.s    are  as 

follows  : 

^  Zinc  sulphate gr.  x.\. 

Creosote  (b.  w. ) gtt.  w. 

Hamamelis 3  iij. 

(Uycerin 3  iij. 

Cocaine  hydrochlorate(4  percent.  sol.)q.s.  ad  J  i. 
M.     S.  Inject  five  to  twenty  minims. 

^  Zinc  chloride gr.  xx. 

Sodium  chloride 3  i- 

Cocaine  hydrochlorate gr.  x. 

Glycerin, 

.-Vqua:  dest aa  q.s.  ad  31. 

M.     S.    Inject  four  to  forty  minims. 

If  the  patient  is  a  male,  invaginate  the  scrotum  upon 
the  index  finger  of  the  right  hand,  tind  the  external 
ring;  have  him  draw  up  his  feet  until  his  thighs  form 
a  right  angle  with  his  body,  holding  the  knees  closely 
together.  Pass  the  finger  now  into  the  canal.  If  the 
sac  has  not  followed  the  bowel  into  the  peritoneal 
cavity,  press  it  upward  and  outward.  Locate  the  outer 
margin  of  the  internal  ring,  and  inject  six  to  ten  drops 
at  the  necessary  depth.  Apply  a  truss  before  the  pa- 
tient rises.  Repeat  in  two  days  on  opposite  side  of  the 
ring,  avoiding  the  epigastric  artery  and  vein.  Three 
days  later  repeat  half-way  down  the  canal  on  the  side 
of  Poupart's  ligament.  Further  injections  may  be  re- 
quired.— \V.  N.  Wo-LS\YJi~,\x\  Eclectic  Medical  Journal. 

Simple  Chronic  Nasal  Catarrh.  —  Hygiene: 
Cleanse  with  alkaline  solution,  and  apply  two  or  three 
times  a  week : 

If  lodi gr   V 

Potass,  iod gr    xv. 

Glycerini      5  i. 

Then  apply  as  a  protective: 

IJ  i\[enthoI gr.  v. 

Camphor.x gr.  xx. 

Albolene 3   i j . 

— E.  B.  Gleason. 
Toothache. — 

If  Chloroform, 
Linim.   aconiti, 
Tr.  capsici    aa  30 

01.  caryophylli, 

Camphora- aa  20 

M.     S.   Apply  a  few  drops  on  a  pledget  of  cotton. 

— Bull.  Gen.  ile  Tlier.,  June  23d. 
Contusions. — 

If  Menthol 3 

Collodion 27 

M.      S.   Paint  on  once  or  twice  a  day,  but  not  over  joints. 

Stings  and  Bites.— 

If  Ac.  salicylic i 

CoUod.  elastic 10 

M.      S.   Apply  at  once  to  prevent  inflammation. 

Boils,  Carbuncles,  and  Felons 

If  01.  oliv.  opt 3  XV. 

Plumbi  oxidi 3  iij.  -j-  3  vi. 

01.  lavandulte 3  ij. 

This  is  Hebra's  diachylon  ointment,  which  may  be 
applied  instead  of  employing  the  knife. — Bulklev. 

Cholaemic  Bleeding — (i)  A  solution  of  gelatin 
increases  the  coagulability  of  healthy  and  pathologi- 
cal blood,  (2)  This  occurs  after  local  application 
and  subcutaneous  administration,     (3)  It  is  harmless 


if  antiseptic  precautions  are  carefully  carried  out. 
(4)  It  can  be  used  in  all  cases  of  bleeding  from  the 
most  various  causes,  (5)  Its  value  as  a  prophylactic 
before  operation  can  be  established  only  after  further 
experience,  (6)  For  subcutaneous  injection,  a  one- 
or  two-per-cent,  solution  is  best;  for  local  applica- 
tion, a  five-  to  ten-per-cent,  solution  at  a  temperature 
of  98^  to  100"  F,  (7)  It  must  be  sterilized.  (8) 
Heart  and  kidney  disease  contraindicate  its  use, — 
Kehr. 

To  Loosen  Adhering  Dressing  pour  on  peroxide-of- 
hydrogen  solution. 

In  Inoperable  Uterjne  Cancer Make  an  opening 

into  the  rectum  for  the  fetid  discharges  so  that  they 
are  under  the  control  of  the  sphincter  ani. — Kuestner. 

Styptic  for  Bleeding  Gums.— 

if  Tr.  kranicria'     3  i- 

Chloroform!    ill  viij. 

he  tannic, 

Menthol aa  gr.  iv. 

Aq.  destill     3  ij. 

—  VlAU. 

Bone  Grafts. — Ricard's  plan  is  preferable  to  the 
use  of  metallic  substances.  Bone  is  finally  absorbed 
and  replaced  by  firm  fibrous  tissue.  Bone  taken  from 
an  animal  is  better  than  that  from  the  patient. — Ber- 

GER, 

Abortion,  whether  threatened,  complete,  or  incom- 
plete, requires  artificial  dilatation  and  emptying  of 
the  uterus  whenever  its  cavity  becomes  the  source  of 
septic  intoxication  as  indicated  by  rise  in  pulse  and 
temperature  and  foul  secretions. — Fothergill. 

Gall  Stones  — Introduction  of  cannula,  probing, 
withdrawing  fiuid  from  the  gall  bladder,  and  massage 
for  getting  rid  of  stones  are  dangerous  practices  com- 
pared with  the  good  accomplished.  Surgical  opera- 
tions present  the  only  safe  and  radical  cure. 

Infected  Wounds  are  best  cleansed  with  a  new 
hydrogen  peroxide  (thirty  per  cent,  by  weight)  equiva- 
lent to  one  hundred  per  cent,  by  volume.  .\  one-per- 
cent, solution  may  be  used  for  irrigation  and  applica- 
tion on  compresses. — Bruxs. 

Aneurism In  nine  cases  injected  with  gelatin  no 

patient  was  cured;  only  one  was  considerably  im- 
proved, but  pressure  symptoms  were  generally  relieved, 
and  the  treatment  affords  sufficient  amelioration  to 
make  it  deserving  of  further  trial, — Futcher. 

Cancer  of  Uterus.—  Curettage,  Divide  the  vagina 
on  all  sides  an  inch  below  the  diseased  area.  Bring 
down  the  uterus  and  bisect  it.  Cut  the  most  affected 
half  in  two  horizontally  at  the  cervical  junction. 
Clamp  the  uterine  artery  and  remove  the  quadrants, 
commencing  with  the  upper,  including  ovary  and  tubes, 
— Kelly. 

Anaesthesia. — In  all  combination  of  anaesthetics 
the  patient  is  subjected  to  the  bad  effects  of  all. 
These  admixtures,  therefore,  possess  no  advantages, 
since  all  the  bad  effects  are  exerted  upon  the  heart  or 
kidneys, — R,  C.  Ke.mp. 

Divided  Bowel  in  the  course  of  operation  is  closed 
in  the  simplest  manner  by  cutting  across  just  beyond 
the  clamp;  the  bowel  being  separated  for  from  2  to 
3  cm,  from  its  mesentery,  A  purse-string  suture  is  in- 
serted through  the  serous  and  muscular  coats  just 
above  the  clamp.  The  clamp  being  removed,  the 
divided  end  of  the  bowel  is  pushed  into  the  lumen 
while  the  circular  suture  is  tightened  and  knotted. — 
Centralbl.  fiir  Cliirurg.,  May  19,  igoo. 


200 


MEDICAL   RECORD. 


[August  4,  1900 


^tcdtcal  Jtcms. 

Cheap  Dwellings  for  Workingmen  in  France. — 
The  Revue  ties  Revues  for  April  has  a  paper  on  cheap 
dwellings  for  workingmen,  by  M.  de  Novion.  The 
question  of  the  housing  of  laborers  and  cheap  means  of 
transit  for  them  is  of  lirst  importance  in  England  and 
in  France.  Industrial  building-societies  have  been 
formed  not  only  in  the  suburbs  of  Paris  but  at  Mar- 
seilles, Lyons,  IJordeau.x,  and  almost  all  the  large  cen- 
tres of  French  industry.  These  societies  have  built 
near  the  towns  groups  of  cottages  surrounded  by  gar- 
dens, in  which  workmen  may  live  cheaply  and  health- 
ily. 

Horse  Sickness. — A  possible  method  of  prevention 
of  horse  sickness,  which  is  endemic  in  the  Orange 
River  colony,  Transvaal,  Rhodesia,  and  Bechuana- 
land,  and  also  occasionally  in  Cape  Colony,  is  de- 
scribed in  the  Cape  Times  by  Dr.  G.  C.  Purvis. 
Fortified  serum  derived  from  immune  horses  almost 
invariably  produces  fatal  ha'moglobinuria  when  in- 
jected into  horses  suffering  from  horse  sickness.  Dr. 
Purvis  finds,  however,  that  if  the  animal  is  gradually 
accustomed  to  the  to.xin  until  it  can  receive  an  injec- 
tion of  100  c.c.  or  200  c.c.  of  serum,  virulent  blood 
can  be  injected  without  any  danger.  It  appears  that 
fortified  serum  is  a  useful  agent  if  used  in  the  proper 
way,  and  that  it  is  capable  of  preventing  the  onset  of 
horse  sickness.  Moreover,  if  in  spite  of  precautions 
an  animal  acquires  the  disease,  judicious  treatment 
with  the  serum  will  assist  in  bringing  about  a  cure. 

Saloons  and  Tuberculosis. — Dr.  J.  VVheatley,  medi- 
cal officer  of  health,  Blackburn,  England,  in  his  annual 
report  just  issued  states  that  no  places,  excluding  the 
workrooms  of  some  trades,  are  more  favorable  to  the 
spread  of  tuberculosis  than  saloon  parlors  and  other 
frequented  rooms  of  saloons.  This  is  not  to  be 
wondered  at  when  one  considers  the  filthy  habits  as 
to  expectoration  too  common  among  those  who  frequent 
these  places,  and  the  neglect  of  cleanliness  that  often 
obtains  with  the  people  in  charge  of  the  lower  class 
drinking-places.  He  urges  most  scrupulous  cleanliness 
in  the  management  of  these  places. — Lancet. 

Ages  of  Immigrants  to  this  Country  of  the  Lead- 
ing Nationalities. — It  is  an  interesting  fact  that  nine- 
teen per  cent,  of  the  total  number  of  immigrants  who 
came  to  the  United  States  from  the  principal  countries 
of  Europe  during  the  twenty  years  closing  with  June 
30,  1898,  were  under  fifteen  years  of  age;  that  71.5 
per  cent  were  between  fifteen  and  forty  years  of  age, 
and  that  9.5  per  cent,  were  over  forty  years  of  age. 
Considered  as  to  nationalities  it  appears  that  Germany 
has  sent  the  largest  percentage  of  children,  as  24.2  per 
cent,  of  those  who  came  from  that  country  were  under 
fifteen  years  of  age.  Next  in  proportional  order  are: 
Russia  and  Poland,  23.2  per  cent.;  Scotland,  21.5 
per  cent.;  England,  21.1  percent.;  Austria,  18.3  per 
cent.;  Norway  and  Sweden,  16.4  per  cent.;  Italy,  14.4 
percent.;  Hungarj',  12.1  percent.;  Ireland,  11. 7  per 
cent.  Ireland,  Hungary,  Norway,  and  Sweden  have 
supplied  during  the  period  mentioned  above  the  lar- 
gest percentages  of  immigrants  between  the  ages  of 
fifteen  and  forty  years,  being  81.6,  79,  and  76.5  per 
cent,  respectively.  The  next  highest  proportionately 
is  Italy  with  72.1  per  cent.  Then  follow  Austria, 
with  72  per  cent.;  Russia  and  Poland,  68.9  per 
cent.;  Scotland,  68.6  per  cent.;  England,  68.1  per 
cent.;  Germany,  65.3  per  cent.  In  the  twenty  years 
Italy  has  furnished  the  maximum  percentage  of  the 
immigrants  over  forty  years  of  age,  or  those  who  have 
passed  the  prime  of  life,  this  proportion  being  13.5 
per  cent.     The   lowest  proportion   was  in   the  immi- 


gration from  Ireland,  it  being  6.7  per  cent.  England's 
proportion  was  10.8  per  cent.;  Germany's,  10.5  per 
cent.;  Scotland's,  9.9  per  cent.;  Austria's,  9.7  per 
cent.;  Hungary's,  8.9  per  cent;  Russia  and  Poland's, 
7.9  per  cent.;  Norway  and  Sweden's,  7.1  percent. — 
Bureau  of  Lal'Or  Statistics. 

Health  Reports. — The  following  cases  of  smallpox, 
yellow  fever,  cholera,  and  plague  have  been  reported 
to  the  surgeon-general  of  the  United  States  Marine- 
Hospital  service  during  the  week  ended  July  26, 
1900 : 

Cases.    Deaths. 

Smallpox— United  States. 

Alaska.  Cape  Nome June  20th  to  July  10th 5  • 

i>istrict  of  Culumbia,  Wash- 
ington     .July  14th  to  2ist I 

Indiana,  Michigan  City July  14th  to  21st i 

Kansas.  Wichita July  I4lh  to  21SI x 

Kentucky,  Covington '.  .July  9th  to  15th 3 

Louisiana,  New  Orleans  ....July  14th  to  2ist  . ..    8                  a 

Massachusetts,  Fall  River  .  .July  14th  to  21st 2 

Lowell July  14th  to  21st 2 

Minnesota,  Minneapolis.      .   June  30th  to  July  14th 23 

N.  Hampshire.  Manchester. .July  14th  to^ist ...  3 

Ohio,  Cincinnati July  6th  to  20th 7 

Cleveland July  14th  to  21st 20 

Utah.  Salt  Lake  City July  14th  to  21SI  4 

*  On  vessels. 

Smallpox — Foreign. 

Austria.  Prague June  23d  to  30th 10 

Krazil,  Rio  de  Janeiro May  19th  to  June  22d 18 

China,  Hong  Kong June  8lh  to  23d i 

Egypt,  Cairo J  une  3d  to  lolh 5 

England,  Liverpool June  30th  to  July  7th 3  2 

London June  3Qth  to  July  7th 17 

France,  Lyons June  23d  to  30th i 

Paris June  30th  to  July  7th 4 

Gibraltar July  1st  to  8th  . '. i 

Greece.  Athens June  30th  to  July  7th 2  2 

India,  Bombay June  12th  to  26th 12 

Karachi June  loth  to  24th 8  5 

Mexico,  Vera  Cruz July  7th  to  14th 4 

Russia,  Moscow June  i6th  to  23d 17  5 

Odessa June  23d  to  30th 5 

St,  Petersburg   June  23d  to  30th 3  8 

Warsaw June  23d  to  30th 7 

Siberia, Vladivostock. May  1st  to  31st 9 

Scotland,   Glasgow July  6th  to  13th 68  2 

Straits     Settlements,    Singa- 
pore  May  26th  to  June  i6th i 

Yellow  Fever. 

Brazil,  Rio  de  Janeiro May  iBth  to  June  2d 

Columbia,  Cartagena June  30th  to  July  7th 9 

Panama July  9th  to  16th 3 

Costa  Rica,  Port  Limon  . . .  .July  17th 1  ^ 


34 
7 


Cuba,  Cienfuegos July  21st it 

Havana July  4th  to  11th 21 

Sagua        July  5th 2 

Mexico,  \'era  Cruz July  7th  to  14th 

*  Suspicious  case.  +  Among  soldiers. 

Cholera. 
India.  Bombay June  12th  to  26th. 


Madras June  2d  to  22d  . 

Japan,  Osaka June  25d  to  30th i 

Plague— Foreign  and  Insular. 

Arabia,  Aden : June  23d  to  30th. 

China,  Hong  Kong June  2d  to  23d  . . 

India,  HomNay June  12th  to  26th 

Karachi June  loth  to  17th i; 

Japan,  ( )saka June  19th  to  30th. 

Sakai June  19th  to  30th. 

Shidzuoka  Ken June  19th  to  30th. 

Tamsui June  1st  to  14th 76 

Korea,  Seoul . . .  June  8th  to  i6th Endemic. 

Philippines,  Manila May  26th  to  June  7th 4 


i8s 
1S5 
16 


IVttile  the  Medical  Record  is  pleased  to  receive  all  new pub- 
lieaiiotis  which  niav  be  sent  to  it,  and  an  acknowledgment  will  be 
promptly  made  0/ their  receipt  under  this  heading,  it  must  be  -with 
the  distinct  understanding  that  its  necessities  are  such  that  it  can- 
not be  considered  under  obligation  to  notice  or  rez'ie-o  any  publica- 
tion received  by  it  which  in  the  judgment  of  its  editor  will  not  be 
of  interest  to  its  readers. 

Essentials  of  Medical  and  Clinical  Chemistry.  By 
Sainiiel  E.  Woody,  M.D.  i2ino,  243  pages.  Illustrated.  I'. 
Blakiston's  Son  i.\:  Co.,  Philadelphia. 

The  Refraction  of  the  Eye.  By  A.  Edward  Davis, 
M.I).  Svo,  413  pages.  Illustrated.  The  Macmillaii  Company, 
New  York. 

Real-Encyci.opadie  der  gesammten  Meilkundk.  Svo, 
665  pages.  Illustrated.  Volume  xxiv.  Urban  &  Schwarzen- 
berg,  Berlin. 

Transactions  of  the  American  MiCRoscoricAL  Society. 
Svo,  275  pages.  Illustrated.  Twenty-second  annual  meeting 
at  Columbus,  Ohio. 


Medical  Record 

A    IVeekly  younial  of  Medicine  and  Surgery 


Vol.  58,  No.  6. 
Whole  No.  1553. 


New  York,  August   ii,    1900. 


$5.00  Per  Annum. 
Single  Copies,  loc. 


AMERICAN    MEDICINE.' 
By   a.    JACOBI,    M.D.. 

NEW    YORK. 

It  is  the  purpose  of  this  address  to  contribute  to  your 
knowledge  of  transatlantic  medicine  and  medical  men. 
That  is  why  I  have  to  ask  the  pardon  of  both  my 
countrymen  and  all  of  you,  but  mainly  that  of  the 
French  gentlemen  here  assembled,  for  using  (or,  per- 
haps, misusing)  a  language  not  my  own,  but  better 
known  to  most  of  you  than  mine. 

The  first  advisers  in  cases  of  sickness,  all  over  New 
England  at  least,  were  the  clergymen.  Indeed  the  first 
news  we  have  of  diphtheria  in  that  region  came  from 
them.  John  Rogers  and  John  Fisk  are  known  to  have 
been  preachers  and  doctors.  John  Foster,  of  Boston, 
wrote  the  first  medical  treatise  published  in  America 
in  1677  ("Rule  to  Guide  the  Common  People  of  New 
England  How  to  Treat  .  .  .  Smallpocks  or  Measels '"). 
What  might  have  been  expected  when  real  doctors  took 
possession  of  the  field  occupied  by  the  clergy  did,  how- 
ever, not  occur.  For  a  long  time  the  latter  remained 
the  staunch  friend  of  the  medical  practitioner.  The 
Rev.  Cotton  Mather  in  172 1  strongly  favored  the  in- 
oculation of  smallpox,  and  defended  and  protected  Dr. 
Boylston,  who  was  persecuted  by  the  mob  of  Boston 
for  having  a  mortality  of  two  per  cent,  among  those 
inoculated  compared  with  one  of  fourteen  per  cent, 
among  those  suffering  from  genuine  smallpox.  That 
is  different  now,  when  there  is  no  trade  or  profession 
more  fond  of  sectarian  medicine  and  medical  dilet- 
tanteism  than  the  clergy. 

The  first  physicians  in  the  colonies  came  from 
abroad.  Wooton  in  1607,  Russell  in  1608,  appear  to 
have  stayed  but  a  short  time,  for  it  is  reported  that 
when  John  Smith  was  wounded  he  had  to  go  to  Eng- 
land to  be  treated.  The  name  of  Lamontagne  is  men- 
tioned in  1637,  John  Clark,  of  Boston,  in  1638,  Child  in 
1644.  There  was  but  very  little  opportunity  to  learn 
in  the  seventeenth  century.  We  know  of  no  lectures 
except  those  of  Dr.  Giles  Firmin,  who  lectured  in  Har- 
vard in  1647  o"  human  osteology.  At  that  time  med- 
ical practice  was  learned  in  apprenticeships;  young 
men  would  serve  and  study  with  a  practitioner  from 
three  to  seven  years,  the  same  time  that  Jacob  slaved 
for  Rachel  without  getting  her  after  all.  This  system 
of  apprenticeship  was  continued  with  more  or  less 
modification  until  recently.  Indeed,  most  medical 
schools  would  until  lately  accept  the  apprenticeship 
with  a  preceptor  in  lieu  of  a  year's  college  course. 
But  in  those  early  times  those  who  had  the  means,  and 
the  ambition  of  learning,  went  abroad  to  Leyden,  Paris, 
Padua,  or  Great  Britain. 

Our  first  information  in  regard  to  medical  lectures 
refers  to  those  on  anatomy.  Evidently  that  subject 
struck  the  imagination  of  chroniclers  most  forcibly. 
Dr.  Thomas  Cadwallader  instructed  Philadelphia  stu- 
dents between   1745  and  1751,  so  did  Dr.  John  Bard 

'Abstract  of  an  address  delivered  before  the  Thirteenth  Inter- 
national Medical  Congress,  Paris,  August  2-9,  1900. 


and  Peter  Middleton  in  1750  in  New  York,  Dr.  Wil- 
liam Hunter  in  1752  in  Newport,  R.  I.,  and  Dr.  William 
Shippen  in  Philadelphia  in  1762,  until  1765,  when 
the  Medical  College  of  Philadelphia  was  founded. 
He  lectured  on  anatomy  and  midwifery,  in  agreement 
with  the  time  which  did  not  abhor  the  incompatibility 
of  anatomy  and  obstetrics.  Historical  justice  com- 
pels me  to  add  right  here  that  it  was  a  professor  of 
anatomy  in  Harvard  University,  our  famous  poet  Dr. 
Oliver  Wendell  Holmes,  who  in  1843,  long  before 
the  unhappy  Semmelweis,  proclaimed  the  contagious- 
ness of  puerperal  fever  and  the  incompatibility  of  the 
lying-in  room  and  the  dissection  table.  It  was  the 
same  Shippen  who  tried  to  establish  a  school  of  mid- 
wifery. There  were  two  medical  schools  established 
before  the  War  of  Independence,  one  in  Philadel- 
phia in  1765  and  one  in  New  York  in  1768.  The 
first  degree  conferred  in  medicine  was  that  of  bache- 
lor of  medicine  in  1768;  the  first  degrees  of  doctor 
in  medicine  were  given  in  New  York  to  S.  Kis- 
sam  and  Robert  Tucker  in  1770.  Before  1776,  when 
the  war  suspended  them,  these  two  institutions  con- 
ferred fifty-one  degrees.  The  Medical  School  of  Har- 
vard was  founded  in  1782,  Dartmouth,  N.H.,in  1797, 
and  Lexington,  Ky.,  in  1799.  Thus  in  1800  there 
were  five  medical  schools  in  what  then  was  the  United 
States.  In  New  York  the  names  of  the  professors 
were  Richard  Bailey,  John  R.  B.  Rogers,  Wright  Post, 
William  Hammersley,  Samuel  L.  Mitchell,  and  David 
Hosack.' 

The  Medical  School  of  King's  College  in  New  York 
(the  name  formerly  carried  by  Columbia)  was  discon- 
tinued, but  in  i860  the  College  of  Physicians  and 
Surgeons,  which  was  founded  in  1807  simultaneously 
with  the  School  of  Medicine  of  the  University  of 
Maryland,  took  its  place  as  a  nominal,  a  few  years 
ago  as  an  actual,  part  of  Columbia  University.  Of 
the  156  medical  schools  which  exist  at  the  present 
time,  3  date  from  1765  to  i8oo,  12  from  1801-1825, 
22  between  1826  and  1850,33  between  1857  and  1875, 
and  86  since.  How  many  more  have  been  so  good  as 
to  disappear  from  the  face  of  the  American  earth  no- 
body cares  to  learn  or  to  know ;  if  we  knew,  we  should 
shed  no  tears. 

In  1899  there  were  156  medical  schools  in  the 
United  States  with  24,119  students;  the  latter  have 
increased  one  hundred  and  forty-two  per  cent,  in 
twenty-one  years.  Of  the  156  schools  21  call  them- 
selves homoeopathic,  with  1,833  students,  7  eclectic 
with  582,  3  physio-medical  with  85  students.  I  hope 
nobody  will  ask  me  for  an  explanation  of  the  three 
last  terms,  in  this  year  1900;  for  I  could  not  give  one. 
Of  the  156,  74  are  departments  of  colleges  and  uni- 
versities, 82  are  separate  institutions,  and  152  grant 
degrees.  In  addition  to  these  156  there  are  10  medi- 
cal schools  for  graduates,  who  come  to  the  larger 
cities,  mostly  New   York,  for  the  purpose  of  taking 

'  David  Hosack  graduated  in  Philadelphia  in  1791,  and  after- 
ward studied  abroad.  He  brought  home  with  him  a  cabinet  of 
minerals,  and  a  herbarium.  He  helped  in  founding  the  Historical 
Society  of  New  York  in  1804,  and  maintained  the  Elgin  Botani- 
cal Gardens  between  Forty-seventh  and  Fifty-first  streets,  and 
Fifth  and  Sixth  avenues,  which  now  forms  part  of  the  valuable 
property  of  Columbia  University  (Sidney  H.  Carney,  in  the  Medi- 
cal News,  February  17,  1900). 


202 


MEDICAL    RECORD. 


[August  1 1,  1900 


courses  mostly  in  specialties.  In  1899  these  10 
schools  had  1,916  students,  of  whom  75  were  women. 

Of  the  10  graduate  schools,  3  are  in  Illinois,  i  in 
Louisiana,  4  in  New  York,  and  2  in  Pennsylvania. 
Less  than  2,000  physicians  are  taught  in  these  insti- 
tutions annually,  most  of  them  in  short  courses.  They 
employ  300  professors  and  3,811  adjuncts  and  instruc- 
tors. There  can  be  no  doubt  as  to  two  effects:  first,  a 
good  many  practitioners  of  the  country  have  a  more  or 
less  brief  opportunity  to  improve  themselves;  sec- 
ondly, a  good  many  practitioners  of  the  large  city  bask 
in  the  sunshine  of  the  professorial  dignity.  Some- 
times it  seems  as  if  plain  doctors  were  scarce  at  pres- 
ent.    But  there  are  some  left. 

At  the  time  of  the  War  of  Independence  there  were 
probably  3,500  physicians  among  the  three  millions  of 
inhabitants  of  the  colonies.  It  is  estimated  that  400 
had  received  medical  degrees.  In  1798  16  doctors  of 
New  York  died  of  what  was  called  the  plague;  there 
were  94  in  New  York  in  1800.'  At  present  we  have 
probably  120,000  practitioners  in  the  United  States. 

The  ratio  of  physicians  to  population  is  less  than  1 
to  600  in  our  country,  while  in  Great  Britain  it  is  i  to 
1,100,  and  in  Russia  i  to  8,500.  Proportionately  we 
have  four  times  as  many  physicians  as  France,  five 
times  as  many  as  Germany,  six  times  as  many  as 
Italy,  and  six  times  as  many  medical  schools  as  either 
of  these  countries.  Medical  teaching,  however,  will 
be  better,  and  more  uniform,  and  more  in  accordance 
with  the  real  requirements  of  the  people,  when  our 
one  hundred  and  fifty-six  schools  will  have  been  re- 
duced to  twenty-five,  and  each  of  them  will  be  con- 
nected with  a  university  as  its  medical  department. 

The  earliest  law"  relating  exclusively  to  physicians 
was  passed  by  Virginia  in  1639,  but  like  the  later  act 
of  1736  it  was  designed  mainly  to  regulate  their  fees. 
The  act  of  1736  made  concessions  to  physicians  who 
held  university  degrees.  In  only  two  of  the  thirteen 
colonies  were  well-considered  laws  enacted  to  define 
the  qualifications  of  physicians.  The  General  Assem- 
bly of  New  York  in  1760  decreed  that  no  person  should 
practise  as  physician  or  surgeon  in  the  city  of  New 
York  till  examined  in  medicine  and  surgery  and  ad- 
mitted by  one  of  His  Majesty's  council,  the  judges  of 
the  supreme  court,  the  king's  attorney-general,  and  the 
mayor  of  the  city  of  New  York.  Such  candidates  as 
were  approved  received  certificates  conferring  the  right 
to  practise  throughout  the  whole  province.  A  simi- 
lar act  was  passed  by  the  General  Assembly  of  New 
Jersey  in  1772. 

In  1840  law's  had  been  enacted  by  the  legislatures 
of  nearly  all  the  States  to  protect  citizens  from  the  im- 
position of  quacks.  Between  1840  and  1S50,  how- 
ever, most  of  these  laws  were  either  repealed  or  not 
enforced,  as  a  result  of  the  cry  that  restrictions  against 
unlicensed  practitioners  were  designed  only  to  create 
a  monopoly. 

The  power  to  confer  degrees  differs  in  the  various 
schools  of  the  forty-five  States  composing  the  Union. 
Low  standards  in  many  professional  sciiools"  are  due 
to  a  failure  to  subject  the  degree-conferring  power 
to  strict  State  supervision.  In  New  York  and  Penn- 
sylvania the  laws  now  prevent  an  abuse  of  the  power 
to  confer  degrees.  A  similar  bill,  strongly  advocated 
by  educators,   was  defeated  in  Illinois  through   the 

'  Dr.  Sidney  H.  Carney  tells  us  that  about  that  time  the  gold- 
headed  cane  was  still  pretty  universal,  but  small  clothes  disap- 
peared rapidly  and  pantaloons  took  their  place.  He  also  tells  us 
something  of  their  pay.  In  Bellevue  Hospital  the  attendants  on 
plague  cases  received  20  shillings  daily  ;  at  that  time  the  hospital 
was  three  miles  out  of  town.  A  visit  among  the  people  cost  Si. 
a  visit  and  dose  of  medicine  St. 25,  pills  12  cents  ;  for  going  a 
mile  out  of  town  $1  extra  was  charged,  to  Brooklyn  S3,  to  Staten 
Island  Sio.      .\  venesection  was  paid  with  $1  to  S5. 

■•'  Henry  L  Taylor  (under direction  of  James  Russell  Parsons), 
"  Professional  Educ.ition  in  the  United  States,"  p.  362. 

'  "  Professional  Education,"  by  James  Russell  Parsons,  Jr. 


efforts  of  politicians  and  others  in  favor  of  low  stand- 
ards. In  Ohio  and  Nebraska  the  statutes  require  only 
the  nominal  endowment  of  $5,006  for  a  degree-confer- 
ring institution.  In  other  States  and  Territories,  as 
a  rule,  any  body  of  men  may  form  an  educational  cor- 
poration with  power  to  confer  degrees,  without  any 
guaranty  whatever  that  the  privilege  will  not  be 
abused;  from  all  of  which  you  infer  that  it  is  impos- 
sible to  judge  of  the  Union  from  a  single  State. 

The  power  of  every  medical  school  to  give  the 
license  to  practise  together  with  its  degree  of  doctor 
in  medicine,  led  to  the  furnishing  of  the  country  vi'ith 
low-grade  practitioners.  It  is  true  that  mainly  in  the 
Eastern  States  a  few  colleges  gradually  improved  their 
methods  of  teaching  and  lengthened  their  curricula, 
but  they  were  exceptions  to  the  rules.  On  the  other 
hand,  some  of  the  schools  in  our  very  New  York  op- 
posed bitterly  every  attempt  at  progress.  This  prog- 
ress is  due,  not  to  the  schools  themselves,  but  to 
the  influence  of  the  medical  profession  that  forced  the 
schools  to  improve  their  medical  instruction.  As 
early  as  1837  in  Philadelphia,  and  1839  in  the  Medi- 
cal Society  of  the  State  of  New  York,  it  was  re- 
solved that  teaching  and  licensing  should  be  sepa- 
rated. This  movement  resulted  in  a  call  for  a 
convention  of  delegates  from  all  medical  schools  and 
societies  in  the  United  States.  This  convention  of 
1846  led  to  the  formation  of  the  American  Medical 
Association,  and  was  the  forerunner  of  many  attempts 
at  giving  us  better  doctors  and  better  schools.  The 
Association  of  American  Medical  Colleges  that  w-as 
founded  in  1890,  the  American  Institute  of  Homoe- 
opathy of  1844,  the  National  Confederation  of  Eclectic 
Medical  Colleges  of  187 1,  and  the  Southern  Medical 
College  Association  of  1892  deserve  credit  for  earnest 
efforts  in  that  direction.  The  greatest  difficulty  is 
found,  as  I  have  said,  in  the  different  standards  of  the 
people  of  our  vast  territory.  Indeed  every  century  and 
every  people  has  exactly  the  doctors  it  deserves,  just 
as  it  has  the  rulers  it  deserves.  That  is  why  it  is  so 
difficult  to  arrive  at  a  uniform  standard  all  over  the 
United  States,  and  to  arrange  a  reciprocity  between  the 
single  States  which  would  allow  the  doctor  of  one 
State  to  settle  in  another. 

Instruction. — The  course  of  instruction  has  under- 
gone great  changes.  A  few  dozen  years  ago  the  so- 
called  seven  branches  of  medicine  were  taught  in  didac- 
tic lectures,  repeated  annually,  to  unprepared  young 
men.  There  was  no  laboratory,  and  but  little  clinical 
work.  At  present  the  curriculum  of  all  good  schools 
extends  over  four  years,  and  includes  systematic  and 
compulsory  work  in  laboratories,  chemical,  patholog- 
ical, histological,  and  bacteriological,  and  furnishes 
better  clinical  instruction,  no  longer  exclusively  to 
large  classes  with  no  means  of  independent  examina- 
tions on  the  part  of  the  student.  Moreover,  the  studies 
are  graded,  progressive  from  year  to  year,  and  in  many 
schools  the  students  are  examined  from  year  to  year 

Forty  or  fifty  years  ago  hardly  any  systematic 
clinical  instruction  was  given  in  the  best  of  our 
schools.  Now,  together  with  obligatory  laboratory 
work,  clinical  teaching  bids  fair  to  assume  the  leading 
part  in  our  instruction.  But  we  are  far  from  having 
European  facilities.  For  what  governments  do  for 
you.  we,  who  have  but  very  few  endowed  medical 
schools,  have  to  rely  on  the  efforts  of  the  profession 
and  the  benevolence  of  those  who  appreciate  the  good 
that  is  done  to  mankind  by  medicine  and  the  medical 
profession.  Until  a  few  years  ago  all  sorts  of  educa- 
tional institutions  were  benefited  by  philanthropists  to 
the  exclusion  of  medicine.  Some  change  has  taken 
place  in  that.  From  1894  to  189S  the  most  notable 
gifts  and  bequests  amounted  to  $2,63 1,000  for  medical 
schools  and  $16,593,701  for  hosjiitals.  The  new  med- 
ical school,  situated  in  New  York,  of  Cornell  Univer- 


August  1 1,  igcx)] 


MEDICAL    RECORD. 


203 


sity,  has  been  presented  with  $1,500,000  by  a  single 
benefactor.  In  the  city  of  New  York  alone  the  names 
of  Vanderbilt,  Sloane,  Carnegie,  Ottendorfer,  Woeris- 
hoffer.  Seth  Low,  Payne,  and  Pierrepont  Morgan  are 
not  the  only  ones  that  should  be  mentioned  and  never 
forgotten.  This,  however,  is  not  all.  Only  two  years 
ago  an  unknown  benefactor  presented  Columbia  Uni- 
versity with  a  fund  wherewith  to  establish  a  ward  in 
Roosevelt  Hospital  for  the  bedside  instruction  in  the 
diseases  of  children,  for  the  medical  students. 

Benevolence  is  even  more  special  than  this.  Mrs. 
Caroline  Brewer  Croft  left  $100,000,  which,  however, 
were  reduced  by  the  English  heirloom  tax,  to  Harvard 
University  on  the  condition  that  the  income  thereof 
should  be  spent  on  res"  arches  on  the  etiology  and  cure 
of  cancer;  the  same  purpose  Tor  wliich  the  legislature 
of  the  State  of  New  York  has,  for  some  years  past,  spent 
a  large  sum  annually  to  be  used  by  Roswell  Park  of 
the  University  of  Buffalo.  Special  hospitals  are  either 
endowed  or  benefited  in  a  similar  manner.  The  can- 
cer hospital  of  New  York  was  established,  or  strength- 
ened, by  money  given  by  Mrs.  CoUum  and  Mrs.  Astor 
many  years  ago. 

Teaching. — Who  were  the  teachers.''  In  by-gone 
times  a  few,  mostly  seven,  practitioners  would  com- 
bine to  form  a  school;  legislative  approval  could  be 
had  for  the  asking;  they  were  our  "  professors."  That 
position  gave  them  prominence  in  public  and  in- 
creased their  private  practice;  that  is  why  the  sala- 
ries, if  there  were  any  connected  with  their  places, 
were  commensurate  with  their  possibilities  to  make 
money  outside.  Now  and  then  the  anatomist  got  more 
because  his  office  took  more  of  his  time.  Thus  it  hap- 
pened that  medical  teaching  was  considered  subordi- 
nate to  other  occupations  even  in  good  schools.  There 
are  but  few  men  of  those  times  who  are  remembered 
because  they  were  teachers;  my  old  friend  Alonzo 
Clark,  one  of  the  most  learned,  intelligent,  and  elo- 
quent professors  the  College  of  Physicians  and  Sur- 
geons ever  had,  was  almost  forgotten  before  he  died, 
not  twenty  years  ago,  and  Austin  Flint  is  better  re- 
membered by  his  text-book  than  by  his  personal 
teaching. 

The  systematic  study  of  pathological  anatomy  and 
other  so-called  exact  branches  of  medicine,  histology, 
bacteriology,  etc.,  is  comparatively  young.  After  all 
they  are  young  all  over  the  world.  Fifty-two  years 
ago,  when  in  Germany  and  wanting  to  learn  something 
about  pathological  anatomy,  I  had  to  go  to  Gottingen 
to  listen  to  Frerichs,  the  only  man  who  taught  it  in 
Germany  besides  Virchow  in  Wurzburg,  and  Roki- 
tansky  in  Vienna  (then  belonging  to  Germany). 
These  studies  began  in  our  America  at  a  very  oppor- 
tune time.  T.  Mitchell  Prudden  and  William  H. 
Welch  had  each  a  small  pathological  laboratory  in 
New  York  in  connection  with  tlie  medical  schools  to 
which  they  belonged  more  than  twenty  years  ago,  but 
the  systematic  study  and  teaching  commenced  with  the 
first  development  of  the  ideal  of  a  university.  This 
ideal  was  first  realized  by  the  Johns  Hopkins  Univer- 
sity, at  Baltimore.  From  that  time  on  remarkable 
changes  took  place  in  the  configuration  of  most  of  our 
medical  schools.  Pathological  anatomy  became  of 
fundamental  importance;  full  professorships  of  that 
branch  were  established  in  most  great  schools,  and, 
moreover,  dozens  of  laboratories  both  for  teaching  and 
for  research.  Besides,  many  of  the  hospitals  were  sup- 
plied with  pathological  and  clinical  laboratories  which 
vie  with  those  of  Europe,  assistantships  and  fellow- 
ships were  increased,  and  the  students  were  taught  to 
appreciate  the  new  opportunities  given  and  demanded 
by  modern  medicine.  As  far  as  T.  Mitchell  Prudden 
in  New  York  is  concerned,  the  volumes  of  publications 
emanating  from  the  beautiful  laboratory  of  the  Col- 
lege of  Physicians  and  Surgeons  prove  his  enthusiasm 


and  successes;  and  never  was  there  a  more  influential 
teacher  than  Welch,  who  in  two  brief  decades  suc- 
ceeded in  disseminating  exact  research  all  over  the 
States  through  his  students  and  followers,  who  have 
been  called,  one  by  one,  to  Philadelphia,  Chicago,  Al- 
bany, or  Boston.  Dozens  of  them  combined  lately  to 
celebrate  on  the  4th  of  May,  1900,  the  twenty-fifth  an- 
niversary of  his  graduation  as  doctor  in  medicine  by 
a  precious  volume  cor.caining  original  contributions  of 
the  very  highest  order,  an  honor  to  the  famous  master 
and  an  ornament  of  medical  literature.  There  are  in 
our  recent  American  literature  two  more  such  dedica- 
tory volumes  of  similar  import,  one  containing  ana- 
tomical papers  contributed  by  his  pupils  in  honor  of 
Professor  Wilder,  of  Cornell  University,  in  1893,  the 
other  mostly  clinical,  written  both  by  pupils  and  by 
American  and  European  colleagues  in  favor  of  a  New 
York  teacher.  In  the  face  of  such  results,  and  such 
enthusiasm,  and  such  love  of  work,  who  is  there  that 
looks  still  down  on  American  medicine  and  American 
medical  men?  I  am  not  given  to  vanity,  but  proud — 
that  is  what  I  am. 

Literature.— According  to  E.  H.  Bradford,'  while 
the  best  physicians  of  the  colonies  and  the  young 
States  acquired  their  knowledge  in  Great  Britain,  their 
books  were  English.  No  books  grow  on  the  stumps 
of  the  forest  primeval.  When  the  War  of  Independ- 
ence began  in  1774,  there  were  i  book,  3  reprints,  and 
20  pamphlets  by  American  medical  men.  To-day 
there  are  7,000  American  books  and  reprints  and  a 
countless  number  of  pamphlets;  there  are  annually 
300  books  and  pamphlets  and  5,000  journal  articles. 
In  one  year,  1879-1880,  the  United  States  published 
10,334,  Great  Britain  7,476  books  and  articles.  In 
the  catalogue  of  Harvard  University  of  1875-76  44 
foreign  and  13  American  medical  books  were  recom- 
mended to  the  students;  among  the  latter  there  was 
none  on  medical  chemistry,  obstetrics,  and  surgery; 
in  the  catalogue  for  1898-99  there  are  recommended 
71  foreign  and  American  books. 

The  first  regular  publication  of  a  journal  dates  from 
1790.  It  carries  the  following  title:  A  Journal  oj  Ihe 
Practice  oJ  Aledicine  and  Surgery  and  Pharmacy  in  the 
Military  Hospitals  oJ  France,  and  contains  absolutely 
nothing  but  translations.  For  another  half-century 
France  was,  together  with  Great  Britain,  almost  the 
exclusive  fountain  from  which  the  thirst  of  American 
medical  men  was  quenched.  The  first  original  jour- 
nal was  7he  Medical  Repository,  which  existed  from 
1797  to  1824.  Not  long  afterward  the  first  quarterly, 
then  monthly,  American  Journal  oJ  the  Medical  Sciences 
was  founded  by  Dr.  Isaac  Hays.  These  seventy  years  • 
it  has  preserved  its  reputation  for  its  scientific  spirit, 
industry,  and  conscientiousness.  Much  that  was  new, 
much  that  is  new  may  be  found  in  its  volumes. 

Of  the  large  number  of  quarterlies,  or  monthlies,  I 
may  be  permitted  to  mention  the  University  Medical 
Monthly,  of  Philadelphia,  the  Albany  Medical  Journal, 
of  Albany,  the  Post-Graduate,  of  New  York,  and  the 
Therapeutical  Gazette,  of  Philadelphia,  not  to  speak  of 
special  journals,  such  as  the  Annals  oJ  Surgery,  the 
Archives  of  Pediatrics,  the  Journal  oJ  Obstetrics  and  the 
Diseases  of  Women  and  Children,  the  Archives  oJ 
Ophthalmology  a?td  Otology,  the  Journal  nj  Ctitaneous 
and  Genito-  Urinary  Diseases,  the  Journal  oJ  Nen'ous 
and  Mental  Disease,  and  many  others,  some  of  which 
are  now  and  then  quoted  in  Europe,  all  of  which  de- 
serve more  attention  than  they  have  hitherto  com- 
manded. 

There  are,  in  every  nation,  some  publications  which 
in  their  individual  spheres  demonstrate  the  very  best 
that  can  be  accomplished,  and  by  which  the  intellect 
and  industry  of  a  people  should  be  measured.  Such 
proofs  of  the  achievements  in  medicine  in  America  are 
'  Boston  Medical  and  Surgical  Journal,  June  29,  1899. 


204 


MEDICAL    RECORD. 


[August  1 1,  1900 


contained  in  the  Ametican  Journal  oj  Experimental 
Aledicine,  edited  by  Welch,  and  the  American  Journal  oJ 
Physiology,  edited  by  Bowditch  and  others.  They  are 
the  prides  of  those  of  us  who  have  lived  through  the 
most  important  period  of  the  development  of  American 
medicine,  and  equal  any  of  the  European  productions 
of  similar  claims.  I  know  they  have  met  with  the 
unstinted  praise  and  applause  of  European  masters. 

As  an  unavoidable  contrast  to  so  much  excellence, 
one  cannot  help  noticing  the  hundreds  of  piedical  jour- 
nals which  appear  all  over  the  States.  Many  are 
printed  with  honest  intentions,  others  for  the  purpose 
of  advertising  their  editors  or  of  puffing  proprietary 
articles.  The  growing  commercialism  of  the  end  of 
the  century  grasps  every  opportunity,  and  medical,  like 
every  other,  literature  is  prostituted  in  the  interest  of 
social,  professional,  or  financial  egotism.  That  is  why 
the  three  hundred  medical  or  alleged  medical  journals 
of  the  United  States  could  well  be  reduced  to  fifty.  If 
that  were  done,  both  medical  knowledge  and  ethics 
and  the  independence  of  medical  journalism  would  be 
served  to  better  advantage.  Under  the  present  cir- 
cumstances the  medical  publications  live  more  on  ad- 
vertisements than  on  subscribers;  and  both  the  pub- 
lisher and  the  editor  soothe  their  ethical  and  scientific 
conscience,  if  it  ever  existed,  with  the  glitter  of  gold. 
I  have  been  told,  and  have  read,  mainly  in  the  med- 
ical magazines  both  of  France  and  of  Germany,  that 
the  same  occurs  in  your  countries.  I  speak,  however, 
of  what  I  know,  and  I  am  best  informed  of  what  is 
going  on  in  mine. 

Among  the  most  important  instructors  of  the  med- 
ical profession  in  our  country  are  the  great  weekly 
journals  which  appear  mostly  in  the  large  cities.  New 
York,  Philadelphia,  Boston,  and  Chicago.  Most  of 
them  have  a  large  number  of  subscribers  and  have  ex- 
isted long.  The  Boston  Medical  and  Surgical  Journal 
has  reached  its  one  hundred  and  forty-second,  the 
New  York  Medical  Journal  its  seventy-first,  the  Medi- 
cal News  its  seventy-sixth,  the  Medical  Record  its 
fifty -seventh  volume.  The  Journal  oJ  the  American 
Medical  Association,  which  has  appeared  these  eigh- 
teen years,  takes  the  same  place  in  relation  to  the 
American  Medical  Association  that  is  occupied  by  the 
British  Medical  Journal  in  relation  to  the  British  Med- 
ical Association.  It  was  founded  to  publish  the  proceed- 
ings of  the  Association,  which  from  1848  to  1882  had 
published  thirty-three  volumes.  The  Philadelphia  Medi- 
cal Journal  was  founded  by  a  society  of  medical  men 
desiring  to  be  independent  of  the  medical  publishers. 
Contributions  to  the  literature  of  medicine,  not  of 
equal  rank,  are  furnished  by  the  large  societies,  par- 
ticularly of  the  States.  Many  of  them  publish  annual 
reports.  The  American  Medical  Association  pub- 
lished thirty-three  volumes  before  its  transactions 
were  collected  in  its  journal.  The  New  York  Acad- 
emy of  Medicine  has  furnished  nineteen  volumes  since 
1847,  which  are  found  in  many  libraries  of  Europe; 
the  College  of  Physicians  of  Philadelphia  twenty-nine 
since  1787.  The  very  best,  certainly  among  the  best, 
are  the  productions  of  fourteen  special  national  asso- 
ciations which  were  founded  at  a  period  in  the  life  of 
the  American  Medical  Association  when  its  results 
did  not  satisfy  the  expectations  of  those  who  had  no 
time  to  spare  for  entertainments,  excursions,  medico- 
political  wrangling,  and  other  pastimes.  These  men, 
most  of  them  of  a  specialistic  turn  of  mind,  and  bent 
upon  filling  their  time  with  work,  congregated  into 
special  associations  whose  members  were  recruited 
from  the  vast  territory  of  the  United  States.  The  old- 
est of  these  seceding  associations  is  the  Ophthalmo- 
logical,  which  was  founded  in  1864.  The  majority 
have  a  limited  membership.  The  Association  of 
American  Physicians  had  originally  one  hundred,  now 
one  hundred  and  twenty-five;    the  Pediatric  Society 


forty,  now  sixty  members.  The  object  was  to  select 
the  working  members  of  the  profession  only.  Thus 
it  has  happened  that  their  contributions  to  literature 
are  very  valuable  indeed. 

The  Ophthalmological  Association  has  published 
until  the  beginning  of  this  year  eight  volumes  since 
1864,  the  Otological  six  since  1868,  the  Neurological 
twenty-two  since  1875,  the  Gynaecological  twenty- 
three  since  1879,  the  Surgical  sixteen  since  1881,  the 
Climatological  fourteen  since  1886,  the  Association  of 
American  Physicians  thirteen  since  1886,  the  Ortho- 
padic  eleven  since  1889,  the  Pediatric  ten  since  1889, 
the  Anatomical  eight  since  1888.  The  Association 
of  Genito-Urinary  Surgeons  and  the  Dermatological 
Association  publish  their  transactions  in  the  Journal 
0/  Cutaneous  and  Genito-  Urinary  Diseases,  the  Phys- 
iological in  the  Atnerican  Journal  oJ  Physiology. 

In  addition  to  these  there  are  volumes  of  unusual 
excellence  containing  the  proceedings  of  the  "Ameri- 
can Congress  of  Physicians  and  Surgeons."  The  his- 
tory of  this  Congress  is  creditable  to  Mastin,  Pepper, 
Weir  Mitchell,  and  others  who  founded  it.  It  is  as  fol- 
lows: When  all  of  those  fourteen  special  national  as- 
sociations had  existed  more  or  less  long,  and  when 
among  the  most  comprehensive  and  philosophical 
minds  of  the  nation  the  fear  of  unchecked  specialism 
became  more  terrifying,  it  was  resolved,  among  univer- 
sal applause,  that  the  ^'disjecta  membra"  should  unite 
once  every  three  years  into  a  congress  whose  meetings 
were  to  be  held  in  Washington,  while  the  selection  of 
the  time  and  place  of  the  two  intervening  annual  meet- 
ings of  the  individual  societies  was  left  to  their  own 
discretion.  In  this  way  the  union  and  unity  of  medi- 
cine were  recognized  and  re-established. 

Books  are  numerous  and  of  about  the  same  nature 
as  in  Europe.  Text-books  for  students  on  aii  possible 
subjects,  some  of  them  masterpieces,  some  indifferent, 
some  catechisms  which,  with  their  questions  and  an- 
swers, appear  to  be  compounded  by  idiots  for  the  use 
of  idiots — ''que  c'est  un  plaisir  de  se  voir  imprime'," 
says  Moliere — they  all  appear  to  find  a  market.  It  is 
perhaps  invidious  to  select,  but  I  may  here  say  in  a 
general  way  that  some  of  our  text-books  in  medicine, 
obstetrics,  materia  medica,  diagnosis,  embryology,  and 
many  other  branches  compare  favorably  with  yours. 
Monographs  we  have  not  so  many  as  you ;  probably 
for  the  reason  that  the  number  and  the  variety  of  our 
many  weekly  and  monthly  journals  devour  whatever 
monographic  essays  have  been  prepared.  Cyclopae- 
dias we  have  like  you.  It  is  very  fortunate  that  the 
publishers,  who  mostly  were  the  first  to  give  the  idea, 
had  no  power  over  their  contents.  Those  edited  by 
Pepper,  Keating,  Loomis  and  Thompson,  Mann,  and 
Stedman  deserve  as  high  praise  as  those  published  in 
Europe.  A  pleasant  feature  in  medical  bookmaking  is 
the  occasional  participation  of  the  Congress  of  the 
United  States.  Indeed,  nearly  every  State  of  the 
Union  publishes  frequently,  at  the  expense  of  the  peo- 
ple, papers  and  books  of  common  interest,  mostly 
geological,  geographical,  and  agricultural.  Medicine 
owes  to  the  appropriations  of  the  National  Congress, 
not  always  given  with  equal  liberality,  six  volumes  of 
the  "Medical  and  Surgical  History  of  the  War,"  two 
of  "  Medical  Statistics,"  seventeen  of  the  "  Subject 
Catalogue  "  of  the  surgeon-general's  library  with  its 
continuations,  and  the  library  itself.  The  "Index 
Medicus"  was  not  a  government  publication;  at  first 
printed  by  an  ambitious  and  enthusiastic  publisher,  it 
was  afterward  secured  by  a  small  number  of  subscrib- 
ers willing  to  pay  a  big  price.  Its  final  collapse,  after 
twenty  years'  strenuous  labor  on  the  part  of  Drs.  Bil- 
ling.s  and  Fletcher,  is  not  a  creditable  leaf  in  the  his- 
tory book  of  the  profession  of  the  United  States. 

There   is,  I   believe,  no  country  with  a  greater  con- 
sumption   of    journals    and    books    than    the    United 


AugruSt    I  T, 


1900] 


MEDICAL    RECORD. 


205 


States.  There  is  probably  no  village  doctor  anywhere 
that  has  not  a  library,  buys  a  book  or  cyclopadia 
from  time  to  time,  and  takes  one  or  more  journals. 
What  Colonel  Stoffel  called  thirty  years  ago  the  in- 
stinct of  labor  in  the  German  government  employee, 
is  applicable  in  some  other  way  to  the  American 
medical  student  and  practitioner.  They  waste  no 
time,  are  industrious  workers  and  voracious  readers. 

Medical  libraries  were  founded  at  an  early  time. 
The  oldest  is  that  of  the  Pennsylvania  Hospital  in 
Philadelphia;  it  began  in  1762.  The  library  of  the 
New  York  Hospital  was  founded  in  1776  and  trans- 
ferred to  the  New  York  Academy  of  Medicine  two 
years  ago;  it  then  had  twenty-three  thousand  num- 
bers. That  of  the  College  of  Physicians  in  Philadel- 
phia, established  in  1788,  has  about  fifty-six  thousand 
numbers;  that  of  Boston  about  thirty  thousand.  The 
largest  medical  library  of  our,  perhaps  of  any,  country 
is  that  of  Washington,  in  charge  of  the  surgeon-gen- 
eral of  the  army;  it  contains  more  than  one  hundred 
thousand  numbers,  well  selected  and  in  excellent 
order,  accessible  to  the  medical  men  of  the  vast  coun- 
try, who  I  know  avail  themselves  eagerly  of  the  prof- 
fered opportunities.  It  was  founded  by  William  A. 
Hammond  during  our  Civil  War,  continued  and  ex- 
tended by  John  S.  Billings,  and  is  at  present  in  charge 
of  Dr.  Huntington.  Next  in  order  is  that  of  the  New 
York  Academy  of  Medicine,  with  about  sixty  thousand, 
with  duplicates  included  eighty  thousand,  volumes. 
It  increases  rapidly,  partly  through  purchases  out  of 
the  income  of  its  library  fund  of  §56,000,  partly 
through  donations,  and  partly  through  the  accumula- 
tions of  seven  hundred  medical  journals  on  the  shelves 
of  its  reading-rooms.  Our  brethren  of  the  Kings 
County  Medical  Society  in  Brooklyn  have  just  fin- 
ished a  new  building  in  which  their  rising  library  has 
been  stored.  Smaller  medical  libraries  have  been  es- 
tablished in  at  least  thirty  cities,  as  far  as  I  know. 
Large  libraries  are  also  in  possession  of  private  piiy- 
sicians.  A  year  ago  Dr.  N.  Senn,  of  Chicago,  pre- 
sented his  collection  of  thirty  thousand  books  to  the 
Rush  Medical  College.  I  have  knowledge  of  one 
library  in  the  possession  of  a  New  York  physician,  of 
about  fifteen  thousand  volumes. 

Ethics. — The  ethical  conscience  of  the  physicians 
of  the  United  States  is  exhibited  in  a  great  many  ways. 
It  is  considered  unethical  for  a  doctor  to  own  a  drug 
store  or  a  part  of  it;  ever  to  take  a  patent  on  any  in- 
vention of  his  own;  ever  to  recommend  over  his  name 
a  patented  instrument,  a  proprietary  food,  or  medicine, 
or  mineral  water.  That  is  illustrated  by  what  hap- 
pened to  the  famous  Morton  after  his  successful  dem- 
onstration of  the  anaesthetic  effect  of  ether  in  the 
Massachusetts  Hospital.  After  having  extracted  a 
tooth  on  September  30,  i8a6,  without  giving  the  pa- 
tient any  pain,  he  applied  immediately  for  patent 
rights  and  sold  individual  otfice  rights.  Moreover,  he 
kept  his  composition,  which  he  called  '"  letheon,"  a 
secret.  It  was  then  that  the  profession  turned  against 
him  and  forced  him  to  admit  that  his  "  letheon  "  was 
sulphuric  ether  disguised  by  some  aromatic  oil.  A 
medical  man  in  America  is  forbidden  ever  to  adver- 
tise his  name,  or  office  hours,  or  his  specialty  in  a 
newspaper  or  lay  magazine;  ever  to  announce  his 
specialty,  if  any  he  have,  on  his  cards.  If  reports 
of  cases  or  operations  of  the  same  physician  appear 
repeatedly  in  the  public  press,  it  is  taken  for  granted 
that  it  has  not  been  without  his  knowledge,  consent, 
or  prompting.  All  of  these  things  impair  a  medical 
man's  professional  standing;  they  render  him  an  im- 
proper candidate  if  ever  he  applies  for  membership 
in  a  medical  society,  or  make  him,  if  he  be  a  member, 
the  subject  of  discipline. 

Many  of  the  rules  accepted  by  American  medical 
men  are  contained   in  a  book   compiled  by  an  Eng- 


lishman, Percival,  in  1807.  It  wa^  received  as  the 
code  of  ethics  of  the  American  Medical  Association 
in  1847,  and  is  still  obeyed  by  those  who  know  the 
book  or  who  do  not  know  it,  or  even  by  those  who  never 
knew  of  its  existence.  One  of  the  regulations  of  the 
code  forbids  consultations  with  homoeopaths. 

It  is  hardly  necessary  to  say  to  those  of  you  for  whom 
the  practice  of  medicine  is  not  only  diagnosis  and 
autopsy,  but  the  treatment  and  cure  of  the  patient  in 
whose  behalf" a  consulfation  is  to  be  held,  that  when 
medicinal  treatment  is  in  question  you  cannot  agree 
with  a  homceopath  who  is  a  Hahnemannian ;  and  you 
do  not  want  to  meet  a  homa-opath  who,  because  the 
name  is  still  fashionable  and  for  a  portion  of  the  mis- 
informed public  the  subject  of  an  almost  religious 
fanaticism,  employs  that  title  for  meretricious  pur- 
poses. Still  there  are  cases  in  which  it  would  be  in- 
human to  refuse  a  consultation.  Not  only  were 
such  consultations  held  from  olden  times,  but  even 
in  large  cities  exceptions  to  the  rule  have  always 
been  frequent,  indeed  too  frequent  in  my  opinion. 
Moreover,  whoever  is  acquainted  with  smaller  cities 
and  villages,  where  a  homoeopath  is  the  only  rival  or 
companion  of  the  regular  ph)'sician,  knows  that  for 
either  it  would  be  suicidal  to  refuse  a  consultation. 
Only  lately  one  of  the  medical  men  most  widely  known 
for  his  wisdom,  in  the  American  Medical  Association 
and  the  profession  at  large.  Dr.  S.  C.  Busey,  of  Wash- 
ington, proclaimed  that  the  rule  forbidding  such  con- 
sultations should  be  so  modified  or  explained  as  to 
permit  them  in  cases  of  emergency.  This  is  exactly 
what  the  Medical  Society  of  the  State  of  New  York 
made  its  ofificial  policy  in  1882.  We  considered  it 
more  honest  to  admit  by  law  what  was  constantly  be- 
ing done,  and  to  decree  precisely  that  for  reasons  of 
humanity  and  in  an  urgent  case  a  consultation  should 
not  be  refused.  For  this  sin  we,  the  body  of  the  Med- 
ical Society  of  New  York,  ware  expelled  from  the 
American  Medical  Association. 

It  would  not  be  proper  to  dismiss  the  subject  of  the 
position  of  medical  men  without  referring  to  them  as 
sanitarians.  It  is  to  be  taken  for  granted  that  all 
family  physicians  are  sanitarians  in  the  families  they 
have  charge  of.  In  their  societies  public  hygiene  is 
frequently  the  subject  of  discussion.  Practical  work 
in  that  direction  is  evidenced  by  the  Sanitary  Com- 
mission of  the  Civil  War,  the  effective  labors  of  the 
New  York  Academy  of  Medicine  in  the  reconstruction 
of  the  quarantine  islands  in  the  harbor  of  New  York, 
and  its  defensive  work  at  cholera  times;  the — it  is 
true,  futile — efforts  of  all  the  large  societies  of  the 
country  in  favor  of  the  re-eslablishment  of  the  Na- 
tional Board  of  Health,  which  perished  because  a 
shortsighted  Congress  refused  the  required  appropria- 
tion; and  the  intelligent  activity,  under  the  direction 
of  medical  men,  of  our  municipal  boards  of  health. 
It  is  true  they  are  hampered  by  the  greed  of  poli- 
ticians. Imagine  that  in  New  York  the  president  of 
the  board  of  health  must  not  be  a  physician !  Whether 
that  is  more  sad  or  more  ludicrous  does  not  matter. 
The  only  consolation  the  citizens  of  a  republic  have, 
when  they  contemplate  such  an  anachronism,  is  that 
they  have  nobody  to  blame  for  it  and  have  nobody  to 
correct  it  but  themselves. 

But  I  do  not  wish  you  to  believe  that  we  American 
doctors  are  altogether  angelic.  Wings  have  not  grown 
from  our  scapulae  yet.  We  are  not  such  good  citizens 
as  you  may  believe  from  what  I  had  to  praise.  In- 
deed, there  is  no  class  of  citizens  that  take  less  inter- 
est in  municipal  and  political,  other  than  sanitary, 
affairs  than  doctors.  It  is  true,  their  vocation  takes 
all  their  time  and  is  exhausting;  but  the  examples  of 
European  parliaments,  in  which  good  medical  men  are 
representing  the  people,  should  not  be  lost  on  us. 
With  us,  however,  most  of  the  medical  men  in  State 


2o6 


MEDICAL    RECORD. 


[August  1 1,  1900 


legislatures  are  not  the  best  representatives  of  the 
profession  from  which  they  claim  they  came,  and 
whenever  there  is  a  medical  man  in  the  Congress  of 
the  United  States,  you  would  not  know  he  was  one  un- 
less you  were  told.  There  is  at  present  a  senator  of 
the  United  States — think  of  Rome  and  of  .^^.milius 
Paulus  and  of  Calo,  think  of  France  and  Arago  and 
Ne'laton,  of  Germany  and  of  Virchow — who  calls 
himself  a  homoeopathic  physician — no;  a  homceo- 
pathic  doctor — and  is  the  staunchest  adv'ersary  of  the 
medical  profession  and  the  solidest  champion  of  the 
anti-vivisectionists. 

Societies. — In  democratic  communities  the  freewill 
of  the  collective  individuals  takes  the  place  of  govern- 
ment dicta.  In  place  of  orders  coming  from  above, 
rules  are  obeyed  that  are  universally  agreed  upon  by 
co-operating  individuals.  That  explains  the  early 
formation  of  medical  societies  in  our  thinly  settled 
country.  Two  were  formed  during  Colonial  times, 
viz.,  the  Medical  Society  of  the  State  of  New  Jersey 
in  1766, of  Delaware  in  1776;  in  1876  there  was  only 
one  State  in  the  whole  Union  that  did  not  have  a 
State  medical  society.  Affiliated  with  the  State  Med- 
ical society,  and  sending  delegates  to  it,  there  are 
societies  in  many  of  the  thirty  to  sixty  or  more  coun- 
ties of  a  State.  The  State  societies  hold  mostly  an- 
nual meetings,  the  county  societies  monthly  or  quar- 
terly, according  to  their  membership,  isolation,  and 
distances.  All  of  these  societies  are  represented  in 
the  American  Medical  Association,  which  was  formed 
in  1847,  with  the  exception  of  the  Medical  Society  of 
our  great  State  of  New  York,  which  has  been  deprived 
of  its  membership  since  1882  for  a  reason  to  which  I 
have  referred. 

I  should  state  here  that  the  homoeopathic  and  the 
eclectic  practitioners  of  the  States  are  legally  recog- 
nized as  separate  bodies  like  ourselves,  and  are  simi- 
larly organized.  It  should  also  be  known  that  there 
is  a  certain  relation,  legally  established,  between  most 
of  the  State  medical  societies  and  the  legislatures  of 
their  States.  This  legal  position  is  not,  however,  pos- 
sessed by  the  American  Medical  Association.  Yet 
the  voice  of  that  body,  powerful  through  its  numbers 
and  the  character  of  its  membership,  is  frequently 
raised  in  connection  with  public  questions.  So  is 
that  of  other  large  societies.  The  New^  York  Academy 
of  Medicine,  for  instance,  has  often  been  the  adviser 
and  co-operator  of  the  official  bodies  of  New  York 
City  and  State,  though  originally  it  was  not  meant  to 
exercise  any  such  influence.  Other  societies  which  in 
large  cities  are  formed  for  special  scientific  purposes 
have  no  such  influence  or  activity,  and  do  not  claim  it. 

The  number  of  medical  societies  in  large  cities  has 
probably  become  too  large.  There  are  many  practi- 
tioners who  are  members  in  many  more  than  one  so- 
ciety. Besides  the  legalized  society  of  the  county — I 
now  speak  of  New  York  City — having  about  fifteen 
hundred  members,  there  is  the  "  Association  of  the 
County,"  with  about  eight  hundred,  and  a  third  one 
lately  formed,  viz.,  the  Society  of  Greater  New  York. 
If  our  brethren  would  only  remember  that  there  is 
more  strength  in  forceful  consolidation  than  in  fanci- 
ful expansion  or  multiplicity!  but  then  it  is  not  always 
strength  and  harmony  that  some  men  are  after,  but 
egotistic  self-assertion  and  envy  of  the  success  of 
others.  Besides,  we  have  many  societies  limited  to 
certain  neighborhoods  on  account  of  the  great  dis- 
tances, and  special  societies  such  as  the  pathological, 
neurological,  opiithalmological,  dermatological,  ob- 
stetrical; also  a  large  and  active  German  Medical  So- 
ciety; and  last,  but  by  no  means  least,  the  New  York 
Academy  of  Medicine,  which  I  mentioned  before. 
Let  me  say  a  few  words  about  it,  for  it  illustrates 
some  of  the  differences  between  America  and  F,urope. 

When   our  New    York  Academy  of   Medicine  was 


founded  in  1847,  •'  ^^^  ^'^"  understood  that  it  was  to 
differ  materially  from  what  is  called  an  Academy  of 
Medicine  in  F.urope.  The  latter  is  always  a  govern- 
ment institution,  and  in  some  way  or  other  supported 
by  centralized  national  means  or  accumulated  funds. 
Its  members  comprises  the  intellectual  and  sometimes 
the  social  heads  of  the  profession  only.  Young  faces 
are  but  seldom  seen  among  its  fellows.  Membership 
is,  as  a  rule,  obtained  after  a  long  life  of  successful 
scientific  pursuits  only.  Their  labors  and  efforts  are 
not  always  intended  for  immediately  practical  aims  or 
objects,  but  they  become  beneficent  by  the  action  of 
that  logical  force  which  ordains  that  there  is  no  scien- 
tific result,  no  truth  ever  so  abstruse,  that  will  not 
finally  terminate  in  some  tangible  application. 
Though  all  this  be  true,  the  limitation  and  exclu- 
siveness  of  membership  result  in  a  sort  of  aristo- 
cratic estrangement  from  the  masses  of  the  medical 
profession,  and  still  more  from  the  community  at  large. 

The  New  York  Academy  of  Medicine  has  a  broader 
democratic  basis.  The  high  and  the  lowly,  the  old 
and  comparatively  young,  the  mature  and  the  youth- 
fully ambitious  combined  for  the  same  purpose.  The 
Academy  is  not  connected  with  any  school  or  college. 
It  is  self-supporting,  and  carried  on  in  the  interest  of 
the  whole  profession,  whether  members  or  not.  There 
are  no  fees  or  emoluments  of  a  private  or  individual 
nature.  It  is  a  democratic  community,  with  equal 
duties  and  rights.  It  is  not  subsidized  by  the  State 
or  municipal  corporation.  Its  aims  are  the  elevation 
of  the  profession  to  a  higher  scientific  standard  for  in- 
creased public  usefulness.  Having  been  a  member 
these  forty-three  years,  I  have  known  it  when  it  was 
small,  and  have  followed  its  growth  with  grateful  and 
hopeful  eyes  until  it  was  established  in  its  present 
palace,  with  its  ever-increasing  public  medical  library, 
second  in  size  and  importance  in  the  country;  its  ab- 
sence from  medico-political  fights  about  the  advisa- 
bility or  superfluousness  of  a  written  code  of  ethics; 
its  impartial  and  non-political  interest  and  co-opera- 
tion in  all  public  sanitary  questions;  with  its  labors 
in  matters  of  quarantine,  cholera,  and  watershed;  with 
its  generosity  to  members  and  non-members  alike; 
with  its  rooms  taken  up  by  many  large  and  small 
special  societies  so  as  to  form  the  medical  head-centre 
of  the  metropolis;  and  with  its  ten  sections  in  con- 
stant working  order.  These  have  given  the  young 
and  deserving  men,  during  more  than  a  dozen  years, 
the  opportunity  for  legitimate  competition,  for  obtain- 
ing a  hearing  and  making  their  reputations,  which  are 
due — next  to  themselves  and  their  honest  work — to  the 
New  York  x\cademy  of  Medicine.  Ask  me,  ladies  and 
gentlemen,  for  a  medical  institution,  democratic,  en- 
lightened, independent,  generous,  and  progressive,  the 
daughter  of  a  country  free,  independent,  progressive, 
— and  I  shall  give  you  the  name  of  the  New  York 
Academy  of  Medicine. 

Some  Facts  on  Men  and  Institutions. — During 
the  time  of  the  War  of  Independence  there  lived  Bard, 
whose  papers  on  diphtheria  are  to-day  examples  of  good 
observation  and  elegant  diction,  and  Rush,  one  of  the 
signers  of  the  Declaration  of  Independence,  a  fertile 
writer  and  famous  teacher;  a  little  later  Dunglison  the 
lexicographer,  Drake,  the  author  of  the  "  Diseases  of 
the  Mississippi  Valley,"  and  Mitchell;  then  men  like 
Wormley,  whose  "  Microchemistry  of  Poisons"  ap- 
peared in  1867.  Contemporaneously  there  were  Bige- 
low,  the  inventor  of  litholapaxy,  and  Oliver  Wendell 
Holmes,  who  wrote  on  the  contagiousness  of  puerperal 
fever  in  1843;  then  came  Harry  P.  Bowditch,  Meigs, 
Clark,  Flint,  I.  W.  Draper,  and  Beard.  Remember,  I 
speak  of  the  dead,  of  some  of  the  dead  only.  Of 
modern  times  I  shall  mention  no  names;  but  the  many 
studies  on  malaria,  amceba-,  blood,  and  diagnosis  in 
general,  commend  themselves  to  the  studious  expert. 


August  1 1 ,  1 900] 


MEDICAL    RECORD. 


207 


The  literature  of  these  few  generations  is  very  fertile; 
even  smaller  men  did  meritorious  work.  In  1835  '' 
was  Fisher,  of  Boston,  who  discovered  the  fontanelle 
murmur,  and  in  1832  it  was  a  country  doctor  in  Can- 
andaigua  that  gave  the  first  plausible  explanation  of 
the  crepitant  rales  of  incipient  pneumonia.  What 
should  always  be  remembered  is  this,  that  all  the  men 
I  mentioned  were  engaged  in  the  practical  work  of 
their  profession;  and  that  some  of  them  had  enjoyed 
no  other  instruction  than  what  the  insufficient  schools 
of  the  country  could  furnish. 

Thus  it  appears  that  no  faulty  system  of  teaching, 
no  defectiveness  of  schools,  hamper  a  man  whose 
stimulus  is  necessity  from  within,  and  an  ideal. 
Sometimes  this  alone  is  sufficient  for  unusual  results. 
Think  of  Marion  Sims,  and,  in  spite  of  his  insuffi- 
ciency as  a  pathologist,  of  the  impetus  his  genius  gave 
to  gynaecology. 

But  this  is  not  what  is  best  known  in  Europe  about 
us.  What  we  are  principally  credited  with  is  the  in- 
troduction of  anaesthesia  into  practice. 

Dr.  Long,  of  Jefferson,  in  the  State  of  Georgia,  re- 
moved a  tumor  under  ether.  But  it  was  a  dentist, 
William  Jennings  Morton,  who  successfully  gave  ether 
to  a  patient  on  whom  Dr.  J.  Collins  Warren  operated 
for  a  tumor,  in  the  Massachusetts  General  Hospital  in 
Boston,  on  October  16,  1846.  Before  this  assembly 
of  medical  men  and  laymen  I  confine  myself  to  what 
Lecky  says  in  his  "  History  of  European  Morals  '' :  "  It 
is  probable  that  the  American  inventor  of  the  first  anaes- 
thetic has  done  more  for  the  real  happiness  of  man- 
kind than  all  the  philosophers  from  Socrates  to  Mills." 
Nothing  remains  to  be  said  e.xcept  that  not  only  was 
the  discovery  made  in  America,  but  even  the  name 
anaesthesia  was  coined  by  an  American,  Oliver  Wen- 
dell Holmes,  great  as  an  anatomist,  as  a  physician,  a 
poet,  and  a  scholar. 

Our  perfect  ambulance  system  has  been  largely  imi- 
tated in  Europe;  to  a  small  extent  also  the  night  medi- 
cal service  for  the  poor. 

Thus,  for  the  humane  purpose  of  medicine  you  will 
admit  America  exhibits  a  good  record.  In  many  other 
respects  it  does  not  excel,  but  equals  Europe.  Its 
hospitals  and  operating-rooms  are  like  yours;  many,  I 
have  been  told,  better  than  yours.  There  is  no  coun- 
try in  which  the  demands  of  antisepsis  and  asepsis  are 
more  scrupulously  obeyed  than  ours.  The  medical  at- 
tendance on  hospitals,  however,  is  capable  of  improve- 
ment. In  Europe  a  distinguished  man  is  known  for 
his  lifelong  connection  with  a  special  hospital.  That 
is  less  so  with  us.  The  ambition  to  be  on  a  hospital 
staff,  the  democratic  tendency  of  the  authorities  to  be 
fair  to  the  greatest  possible  number,  are  the  reasons 
why  the  hospital  staffs  are  unduly  large,  and  the  year 
is  divided  up  into  alternating  temporary  services,  and 
men  are  compelled,  in  order  to  have  hospital  services 
through  the  wJiole  year,  to  seek  them  in  different  insti- 
tutions. The  improprieties  and  drawbacks  of  this  ar- 
rangement have  so  long  been  felt  that  the  establish- 
ment of  permanent  services,  mostly  of  a  special 
nature,  has  been  resorted  to  in  some  hospitals.  One 
particular  disadvantage  of  our  system  of  cutting  up 
our  hospital  services  you 'may  have  noticed  is  this, 
that  our  hospitals,  while  being  a  source  of  constant 
improvement  to  the  lucky  incumbents  of  the  medical 
places,  have  not  contributed  to  medical  literature  in 
the  shape  of  special  scientific  reports,  with  the  excep- 
tion of  the  last  few  years. 

The  assistantships  are  in  almost  every  case  in  the 
hands  of  young  graduates  who  obtain  their  places 
after  competitive  examinations.  Their  terms  of  ser- 
vice range  from  one  and  one-half  to  two  or  two  and 
one-half  years,  in  semi-annual  advances  from  grade 
to  grade.  This  method  affords  a  great  many  young 
physicians  an  opportunity  for  more  or  less  independ- 


ent work,  guided  by  their  superiors,  who  make  their 
gratuitous  daily  visits  during  their  term  of  service. 
That  is  how  the  people  of  the  United  States  derive 
immense  benefits  from  the*facilities  afforded  to  a  very 
large  number  of  young  graduates  before  they  enter 
into  private  practice. 

no  West  THiKTV-FofKTH  Street. 


THE  CARE  OF  PATIENTS  DURING  SURGI- 
CAL OPERATIONS;  WITH  SOME  METH- 
ODS OF  PREVENTING  SHOCK  AND  IN- 
FECTION.' 

By   FENTON    B.    TURCK,    M.D., 

CHICAGO. 

Surgery  has  reached  that  stage  of  perfection  in  asep- 
tic, antiseptic,  and  operative  technique,  that  it  seems 
there  is  little  room  for  improvement.  Nevertheless,  in 
spite  of  our  most  painstaking  and  apparently  perfect 
precautions,  occasionally  some  disturbing  element 
gains  an  entrance  and  death  results.  In  many  of  the 
cases  terminating  fatally,  supposedly  from  infection, 
the  surgeon  is  perplexed  in  his  search  for  the  true 
cause  or  source  of  the  infection.  Far  too  often  we 
hear,  "The  operation  was  successful,  but  the  patient 
died."  In  these  obscure  cases,  the  cause  of  death  is 
sometimes  infection,  sometimes  shock,  and  many 
times  the  two  combined.  Shock  and  infection  do 
sometimes  occur  in  cases  in  which  all  the  ordinary  and 
usual  preventive  measures  have  been  taken,  the  cus- 
tomary precautions  being  usually  found  amply  suffi- 
cient to  protect  the  ordinary  case. 

I  shall  lay  stress  on  a  few  facts  which  call  atten- 
tion to  some  of  the  more  insignificant  (as  they  are 
unusual)  but  subtle  sources  of  wound  infection,  and 
at  the  same  time  present  some  few  methods  which 
may  tend  to  diminish  the  potency  of  these  occasional 
factors  as  carriers  and  sources  of  infection. 

In  the  preparation  for  an  operation,  as,  for  instance, 
a  laparotomy,  all  instruments,  suture  material,  sheet 
and  dressings — in  fact,  inanimate  objects — may  be 
rendered  completely  sterile  by  means  of  dry  or  moist 
heat.  But  the  animate  structures  which  take  part  in, 
or  come  in  contact  with,  the  wound  cannot  be  made 
absolutely  sterile.  That  the  skin  of  operator  or  pa- 
tient is  not  capable  of  absolute  sterilization  without 
producing  death  of  the  tissue  cells,  has  been  conclu- 
sively demonstrated  by  many  investigators,  notably 
Welch  of  Johns  Hopkins  L'niversity.  Complete  an- 
nihilation of  surface  bacteria  on  the  hands  of  operator 
and  assistants,  as  well  as  on  the  field  of  operation,  is 
vastly  important.  In  order  to  attain  this  perfection 
in  technique,  it  has  become  necessary  that  we  have  a 
more  thorough  knowledge  of  the  bacteria  present  in  or 
on  the  normal  skin.  Much  study  and  investigation 
have  been  devoted  to  this  subject  by  such  men  as  I'iz- 
zozero,  Bordone-Uffreduzzi,  Unna,  Maggiora,  Mitt- 
mann,  Fiirbringer,  Preindlsberger,  Robb  and  Ghriskey, 
and  Welch. 

The  skin,  owing  to  its  location,  is  constantly  coming 
in  contact  with  some  form  of  contamination  from  ex- 
ternal objects.  Many  species  of  bacteria  find  on  its 
surface  a  place  for  development  and  reproduction. 
Mittmann  mentions  seventy-eight  different  species,  of 
which  fifty-six  viere  cocci.  Preindlsberger  describes 
thirty-two  species,  of  which  twenty-eight  were  coccL 
Maggiora  isolated  twenty-nine  micro-organisms,  of 
which  twenty-two  were  bacteria,  three  budding  fungi, 
and  four  moulds.  Bizzozero  isolated  and  described 
the  so-called  bacillus  epidermidis  which  he  obtained 
from  the  skin  between  the  toes.  Along  this  line,  the 
following  experiments  were  carried  out  by  the  author: 

'  Paper  presented  to  the  Thirteenth  International  Medical  Con- 
gress, Paris,  August  2-9,  1900. 


208 


MEDICAL    RECORD. 


[August  11,1 900 


Towels  used  with  the  laparotomy  sheet  were  taken 
after  the  operation  was  completed,  and  small  pieces  re- 
moved. The  small  portion  of  towel  was  dropped  into 
bouillon,  and  the  bacteria  were  allowed  to  grow. 
Three  such  tubes  were  made  from  different  cases. 

The  skin  was  e.xamined  in  six  cases,  as  follows: 
After  the  usual  preparation  of  the  site  of  operation, 
the  skin  was  roughly  scraped  until  a  mass  of  epithelial 
cells  was  freed.  These  separated  epithelial  cells  were 
inoculated  in  bouillon  and  in  gelatin,  sterile  cultures. 
During  the  course  of  the  operation,  small  pieces  of 
skin  were  cut  out  of  the  wound  margin.  These  pieces 
were  dropped  into  bouillon  tubes  and  the  bacteria  al- 
lowed to  grow.  The  growths  in  all  these  tubes  were 
practically  identical,  being  composed  of  a  short  ba- 
cillus, the  staphylococcus  pyogenes,  and  other  cocci. 
■Cultures  of  these  bacteria  were  inoculated  into  animals 
not  in  shock  and  found  to  be  non-pathogenic ;  while  in 
animals  in  which  shock  was  artificially  produced  by 
exposure  and  manipulation  of  the  viscera,  they  were 
found  to  be  pathogenic.  Details  of  these  experiments 
will  be  found  later  on  in  this  article. 

The  exposed  surface  is  not  usually  the  seat  of  abun- 
dant growth  of  bacteria,  but  indentations  and  folds 
especially  predispose  to  their  rapid  growth,  as  in  the 
axilla,  groin,  umbilicus,  between  fingers  and  toes,  and 
under  the  nails — this  latter  location  teaches  a  lesson 
as  to  the  need  of  surgical  cleanliness. 

Welch,  in  1891,  was  the  first  to  call  attention  to  one 
bacterial  species,  named  by  him  staphylococcus  epi- 
dermidis  aibus,  which  he  regarded  as  the  inhabitant 
of  the  normal  skin,  owing  to  the  regularity  with  which 
it  was  found  in  cultures  from  the  skin.  It  is  practi- 
cally similar  to  the  staphylococcus  pyocyaneus  albus. 
It  liquefies  gelatin,  slowly  coagulates  milk,  and  is 
feebly  pyogenic.  It  is  found  along  hair  shafts  in  the 
follicle,  in  which  situation  it  is  able  to  withstand  the 
ordinary  process  of  disinfection,  and  remain  in  place 
unchanged,  in  cases  in  which  cultures  from  surface 
skin  will  give  a  negative  result. 

Robb  and  Ghriskey'  examined  stitches  in  thirty 
laparotomies  and  fifteen  perineorrhaphies.  In  thirty- 
three  of  these  cases  pure  cultures  of  staphylococcus 
epidermidis  albus  were  obtained,  and  in  other  cases 
were  found  staphylococcus  pyogenes  aureus,  staphy- 
lococcus flavus,  and  streptococcus  pyogenes;  and  in 
conclusion  he  says :  "  We  have  no  sure  and  absolute 
method  of  rendering  the  field  of  operation  entirely  free 
from  organisms,  owing  to  the  impracticability  of  de- 
stroying the  superficial  layers  of  skin.  The  staphylo- 
coccus epidermidis  albus  is  found  in  the  skin  with 
such  regularity  that  the  latter  situation  may,  for  all 
practical  purposes,  be  regarded  as  its  natural  habitat, 
and  our  methods  are  not  successful  in  reaching  those 
bacteria  in  the  depth  of  the  structure.''  It  is  usually 
innocuous  and  is  often  found  in  wounds  in  which  heal- 
ing by  first  intention  has  been  perfect.  But  Welch 
looks  upon  it  as  the  cause  in  cases  in  which  slight 
■elevation  of  temperature  and  moderate  suppuration 
have  been  present;  and  as  the  most  common  cause  of 
stitch  abscess.  Robb  and  Ghriskey  claim  that  the 
number  of  bacteria  is  increased  by  use  of  the  drainage 
tube  or  other  foreign  body,  too  tight  ligatures  or  su- 
tures, and  by  the  presence  of  any  necrotic  tissue. 
They  also  call  attention  to  the  fact  that  germs  are 
more  prone  to  multiply  if  catgut  is  used  than  if  other 
suture  material  is  employed. 

Among  the  other  important  bacteria  found  in  or  on 
the  skin  might  be  mentioned  other  white  and  yellow 
cocci,  and,  unless  careful  study  is  made  of  the  growth, 
some  of  the  white  cocci  mav  be  mistaken  for  the  sta- 
phylococcus pyogenes  aureus  (this  later  being  found 
rarely  anywhere  but  on  the  hands  of  surgeons,  sur- 
geons' assistants,  and  masseurs).  Also  bacillus  pyo- 
'  Bulletin  of  the  Johns  Hopkins  Hospital,  April,  iS<j2. 


cyaneus  and  bacillus  coli  communis  are  found  rarely 
in  the  skin. 

The  skin  of  the  hand  of  the  surgeon  may  be  pro- 
tected during  the  course  of  an  ordinary  operation  by 
gloves  made  of  thin  rubber.  These  are  capable  of 
absolute  sterilization,  are  water-proof  and  germ-proof. 
But  the  skin  of  the  patient  at  and  surrounding  the  site 
of  the  wound  still  contains  germs  deeply  situated. 
An  attempt  should  be  made  to  prevent  infection  from 
this  portion  of  skin  coming  in  contact  with  the  wound 
or  from  any  article  or  substance  which  in  turn  might 
come  in  contact  with  the  wound,  as  effectually  as  in- 
fection from  the  skin  of  the  operator's  hands  is  now 
prevented.  The  usual  laparotomy  sheets  and  towels, 
while  far  superior  to  having  the  skin  uncovered,  are 
capable  when  wet.  of  transmitting  infection  from  the 
surrounding  skin  area  to  the  wound  margin,  or  even 
to  the  peritoneum  or  peritoneal  cavity;  from  them 
infection  may  be  transmitted  to  the  sponge,  instru- 
ments, or  hand  which  may  be  placed  in  contact  with 
them  at  such  times.  Again,  in  cases  of  resection  of 
bowel,  or  when  pus  is  evacuated,  the  ordinary  lapar- 
otomy sheet  is  little  or  no  protection  to  the  surround- 
ing skin.  The  infectious  matter  is  absorbed  by  the 
cloth,  and  it  remains  in  contact  with  the  skin  and  per- 
haps the  edges  of  the  wound  for  a  greater  or  less 
length  of  time,  thus  rendering  the  entire  and  perfect 
removal  of  infectious  germs  almost  an  impossibility, 
and  those  remaining  act  in  the  future  as  a  source  of 
infection.  During  the  course  of  the  operation,  these 
laparotomy  sheets  become  wet  with  warm  water,  which 
soon  becomes  cold,  and  the  body  heat  is  lowered 
considerably  by  evaporation,  thus  greatly  increasing 
the  danger  of  shock,  and,  in  turn,  of  infection. 

To  obviate  the  above  objections  to  the  usual  meth- 
ods of  procedure,  and  also  to  reduce  to  some  slight 
extent  the  danger  of  shock  and  infection,  it  is  recom- 
mended, after  the  usual  steps  in  cleansing  the  field 
of  operation  are  taken,  to  place  over  it  a  sheet  of 
thin  rubber  which  extends  around  and  fits  closely  to 
the  body,  being  held  in  place  by  straps  and  buckles.' 
This  is  made  in  different  sizes,  each  with  an  opening 
which  may  be  placed  directly  over  the  site  of  incision, 
or  it  can  be  left  to  be  opened  by  the  surgeon  as  an 
artificial  skin.  It  fits  closely  and  does  not  interfere 
with  the  field  of  operation.  The  usual  linen  lapar- 
otomy sheet  may  be  used  in  addition  over  this,  if  the 
operator  so  desires.  This  rubber  protective  has  the 
following  advantages:  ( i )  It  diminishes  the  danger 
of  infection  from  the  skin;  (2)  it  prevents  contami- 
nation of  the  skin ;  (3)  it  reduces  the  tendency  to 
shock  by  protecting  the  exposed  area  of  the  body  and 
thus  preventing  the  loss  of  heat  by  evaporation. 

The  precautionary  measure  taken  by  some  surgeons 
of  securing  the  peritoneum  to  the  skin  by  means  of  a 
few  stitches,  which  leave  the  intervening  edges  ex- 
posed, does  not  afford  complete  protection  to  the 
wound  margin.  If  this  central  opening  in  the  rubber 
sheet  is  cut  in  flaps,  these  can  be  folded  over  the 
wound  margin  and  into  the  peritoneal  cavity,  and  held 
in  place  by  means  of  a  self-retaining  retractor.  In 
this  way  less  time  is  consumed,  while  the  skin  and 
wound  margins,  as  well  as  the  peritoneum,  are  excluded 
from  the  field  of  operation. 

Having  isolated  the  skin  and  wound  margins,  it  is 
necessary  to  consider  further  protection  to  the  abdomi- 
nal cavity  and  the  wound  edges  from  possible  contami- 
nation arising  from  the  opening  of  a  viscus  or  false 
cavity.  In  order  to  make  clear  tlie  metiiod  for  pre- 
venting this  infection,  the  operation  of  gastro-enter- 
ostomy  may  be  regarded  as  the  most  typical  for  il- 
lustration. 

A   square  sheet  of   rubber  dam   is   made   with  two 

'  "  Improved  Methods  during  Surg.  Oparations,"  Journal  of 
the  .American  Medical  .Association. 


August  1 1,  1900] 


MEDICAL    RECORD. 


209 


small  openings  which  are  reinforced  by  a  rubber  band 
forming  a  collar,  these  openings  being  from  three  to 
six  inches  distant  from  each  other.  This  protector  is 
laid  over  the  abdominal  wound,  and  that  portion  of  the 
stomach  to  be  incised  is  drawn  through  one  of  the 
openings  and  a  loop  of  intestine  for  anastomosis  through 
the  other.  This  portion  of  viscera  thus  excluded  from 
the  abdominal  cavity,  and  the  constriction  band  around 
each,  retard  any  undue  escape  of  contents,  and  at  the 
same  time  keep  the  contaminating  material  on  the 
outside  where  it  can  be  easily  removed  from  the  rub- 
ber cloth  by  flushing  or  other  means,  and  at  no  time 
can  it  come  in  contact  with  the  peritoneal  cavity  or 
other  viscera.  At  the  completion  of  the  operation, 
this  shield  is  readily  removed  by  dividing  it  with 
scissors,  thus  freeing  the  anastomosis,  which  is  care- 
fully dropped  back  into  the  abdominal  cavity  and  the 
latter  closed  as  the  operator  prefers. 

The  steps  in  an  end-to-end  anastomosis  w-ould  be 
about  the  same  as  those  above  mentioned.  For  chole- 
cystotomy  or  a  similar  operation,  a  protective  with 
but  one  opening  would  be  necessary.  In  an  emer- 
gency, or  when  a  special  protective  shield  cannot  be 
had,  one  might  be  improvised  for  the  occasion  from 
rubber  dam,  puncturing  small  round  holes  where  de- 
sired. But  in  this  case  the  constriction  at  the  rings 
or  openings  would  not  be  so  diffused  nor  so  uniform 
as  in  the  one  specially  made.  It  is  obvious  that  by 
the  use  of  this  shield  the  following  advantages  are 
gained : 

(i)  Absolute  exclusion  of  the  abdominal  cavity 
from  the  danger  of  infection  ((?)  by  escape  of  visceral 
contents;   (/')   through  outside  influences. 

(2)  Prevention  of  excessive  escape  of  visceral  con- 
tents. 

(3)  Partial  if  not  perfect  control  of  hemorrhage,  by 
the  pressure  exerted  by  the  rubber  band  or  collar. 

(4)  Reduction  of  the  liability  to  trauma  of  the  vis- 
cera by  handling:  (<?)  Being  covered  with  rubber,  they 
are  less  liable  to  injury.  {/')  The  "  collar  "  holds  them 
simply  in  position  and  there  is  no  need  of  tugging 
and  pulling. 

(5)  Minimizing  of  the  tendency  to  shock:  (a)  By 
being  covered,  the  viscera  escape  the  evil  effects  of 
handling.  (/')  Non-exposure  of  the  viscera  prevents 
evaporation,  and  in  consequence  there  is  no  desiccation 
or  loss  of  heat. 

In  abdominal  operations,  even  when  we  have  used 
every  precaution  against  infection,  there  is  still  an- 
other important  factor,  namely,  shock.  The  use  of 
the  word  shock  may  appear  unscientific,  inasmuch  as 
if  represents  such  a  di\ersity  of  etiological  factors 
and  pathological  conditions,  with  a  most  complex 
symptomatology.  What  is  sometimes  considered  to 
be  shock  following  an  operation  may  be  a  form  of  in- 
fection obscured  by  the  symptoms  of  shock.  Accord- 
ing to  Kiister,'  vaginal  methods  are  less  dangerous 
than  abdominal,  but  though  the  chief  danger  of  the 
latter  is  attributed  to  shock,  as  a  matter  of  fact  infec- 
tion of  the  peritoneum,  even  when  there  are  no  clini- 
cal or  post-mortem  signs  of  peritonitis,  is  very  often 
the  real  cause  of  death.  Autopsies  of  fatal  cases 
ought  to  include  bacteriological  examination  of  the 
secretions  of  the  cavity. 

It  is  well  recognized  clinically  that  susceptibility 
to  infection  is  acquired  through  the  shock  following 
serious  operations.  The  experiments  on  animals  by 
Canalis  and  Morpurgo,"  also  by  Tizzoni  and  Cattani, 
establish  the  above  clinical  observations,  and  in  even 
mild  forms  of  shock  the  subject  is  more  susceptible  to 
the  infection  that  occurs  during  ordinary  abdominal 
operations.  Natural  immunity  to  infection  seems  less- 
ened or  suspended,  according  to  the  degree  of  shock. 

'  British  Gyna-cological  Journal.    iSgg-igoo. 

^  Fortschritte  der  Medicin,  1S90,  Nos.  iS  and  ig. 


Aside  from  the  questions  of  virulence,  the  po.nt  of  in- 
oculation, and  the  dose  of  infection,  we  are  confronted 
with  the  problem  of  susceptibilit}  or  non-susceptibil- 
ity of  the  case  undergoing  operation.  Pasteur  im- 
mersed a  hen  in  cold  water,  causing  her  to  lose 
resistence  to  anthrax.  Pertuschy  kept  a  frog  at  a 
temperature  of  25°  and  35°  C,  causing  it  to  become 
susceptible  to  anthrax  infection,  which  resulted  in 
death.  In  my  previous  experiments  upon  dogs  in  the 
study  of  surgical  shock,"  I  observed  that  when  shock 
was  artificially  produced,  the  animal  was  subject  to 
infection  following  the  symptoms  of  shock.  Ani- 
mals in  which  surgical  shock  was  reduced,  as  by  the 
use  of  heat  applied  within  the  abdominal  cavity,  and 
also  within  the  stomach,  such  as  the  hot-water  bag,' 
rarely  died  from  infection.  These  observations  led 
to  a  most  interesting  series  of  experiments  to  de- 
termine how  far  high  temperatures  applied  to  the  ab- 
dominal cavity,  and  also  within  the  stomach,  would 
stimulate  the  vessels  and  tissue  cells  and  prevent  the 
growth  of  pathogenic  micro-organisms  introduced  into 
the  abdominal  cavity.  Cobbet  and  Melsome  found  a 
comparative  local  immunity  to  streptococcus  erysipe- 
latis  produced  by  the  presence  of  hyperasmic  exudate 
in  a  rabbit's  ear,  from  previous  inflammatory  attacks. 
Metchnikoff  and  IssaelT'  found  that  by  first  injecting 
sterile  bouillon  into  the  peritoneal  cavity  of  guinea- 
pigs,  no  infection  would  take  place  when  cholera 
vibrios  or  pneumococci  were  inoculated  the  follow- 
ing day;  but  when  no  such  stimulation  of  the  .peri- 
toneum had  taken  place,  the  animals  died  from  the 
infection.  Walther  and  Ravighi,  cited  by  Lowy  and 
Richter,'  rendered  the  animal  hyperthermic  and  less- 
ened susceptibility  to  infection.  This  was  also  done 
by  Filehne.'  Walther  found  that  artificial  heat  ap- 
plied to  the  surface  prevented  infection:  Ravighi, 
that  artificial  warming  prolonged  the  life  of  rabbits 
infected  with  bacilli  of  rabbit  septica-mia  and  an- 
thrax bacilli.  Lowy  and  Richter  came  to  similar  con- 
clusions by  producing  hyperthermia  by  cerebral  punc- 
ture. The  following  experiments  made  by  the  author 
seem  to  indicate  that  the  application  of  heat  by  the 
methods  soon  to  be  described  not  only  prevented  shock 
and  reduced  shock  when  present  in  the  animals  ex- 
perimented upon,  but  markedly  increased  the  immu- 
nity to  infection,  while  animals  in  shock,  not  so 
stimulated  by  the  action  of  heat  applied  to  the  ab- 
dominal cavity  or  within  the  stomach,  showed  in- 
creased susceptibility  to  infection. 

In  cotliotomies,  especially  operations  on  the  up- 
per abdominal  area,  in  liver,  stomach,  and  intestinal 
surgery,  this  factor  of  shock  followed  by  infection 
is  one  of  the  most  important  sources  of  danger  to 
the  life  of  the  patient.  In  the  above-described  meth- 
ods, I  have  called  attention  to  the  manner  of  prevent- 
ing injuries  in  handling  the  viscera  and  methods  for 
preventing  desiccation  of  exposed  viscera  and  loss  of 
heat.  The  application  of  heat  to  the  viscera  is  for  the 
purpose  of  stimulation,  and  it  is  usual  to  apply  hot 
sponges  for  this  purpose.  The  heat  in  the  wet 
sponges  is  soon  dissipated,  and  instead  of  supplying 
heat  the  sponge  abstracts  it  from  the  viscera  and  sur- 
rounding tissues.  The  sponges  cannot  be  changed  fre- 
quently enough  to  keep  up  the  temperature.  To  avoid 
this,  I  have  placed  within  a  gauze  pad  a  small,  thin, 
rubber  hot-water  bag.  These  are  made  in  different 
shapes  and  sizes  for  various  uses."     In  some  cases  the 

'  Journal  of  the  .American  Medical  Association,  June,  1897.  p. 
1 160. 

''Ibid.,  January  11,  1896,  p.  -g. 

''■  Annales  de  I'lnst.  Pasteur,  vol.  vii..  1S93,  and  other  papers  in 
the  same  publication. 

*  Virchow's  Archiv,  1 896,  vol.  cxiv. 

^Proceedings  of  Physiological  Society,  August  11,  1894; 
Journal  of  Physiology.  1S94. 

*  Journal  of  the  American  Medical  Association.  June  9,  igoo. 


2IO 


MEDICAL    RECORD. 


[August  1 1,  1900 


gauze  is  not  needed  for  absorptive  purposes,  but  sim- 
ply for  holding  back  the  viscera.  The  hot-water  bag 
alone  may  then  be  inserted  into  the  abdominal  cavity 
in  the  shape  of  a  ring,  to  act  as  a  coffer-dam  for  the 
operative  field.  The  rubber  bags  may  be  rendered  ab- 
solutely sterile,  and  then  be  partially  filled  with  ster- 
ile water  and  heated  in  a  receptacle  or  bath  to  the 
desired  temperature.  The  degree  of  temperature 
which  I  found  most  useful  is  about  48'  C. 

The  value  of  heat  obtained  by  the  introduction  of 
hot  water  into  the  abdominal  cavity  is  well  known; 
also  that  it  is  necessary  to  maintain  heat.  U'here  are 
many  objections  to  the  placing  of  water  directly  with- 
in the  abdominal  cavity.  The  danger  of  spreading 
infection  is  especially  important,  and  it  has  been 
claimed  that  some  of  the  evil  results  following  this 
method  have  been  due  to  "  flooding"  the  endothelial 
layers  of  the  peritoneum;  and  it  is  impossible  to 
maintain  the  heat  for  any  considerable  length  of 
time,  as  it  is  so  quickly  absorbed  that  it  no  longer 
acts  as  a  stimulant  to  the  end  nerves.  With  the  hot- 
water  rubber  pads  or  bags,  we  possess  all  the  advan- 
tages in  preventing  shock  by  heat  stimulation,  with 
none  of  the  above-mentioned  disadvantages. 

There  must  be  a  distinction  made  in  the  measures 
resorted  to  in  the  prevention  of  shock  when  it  is  im- 
minent, and  those  when  profound  shock  is  present. 
Of  all  measures  for  preventing  shock,  the  application 
of  heat  is  one  of  our  most  valuable  agents.  In  pre- 
vious contributions  on  this  subject,'  I  have  shown 
that  splanchnic  congestion  in  shock  is  most  readily 
reduced  by  the  application  of  heat  to  the  splanchnic 
area. 

The  advantages  of  hot-water  pads  are  :  ( i )  The  con- 
tinuous application  of  heat  at  the  required  tempera- 
ture. (2)  They  are  soft  and  yielding  like  a  water- 
bed.  (3)  They  can  be  changed  at  will  and  can  be 
removed  through  a  small  opening.  (4)  At  the  end  of 
an  operation,  before  the  abdominal  cavity  is  closed,  a 
hot-water  rubber  pad  is  placed  under  the  line  of  clos- 
ure and  covered  with  a  small  gauze  pad  to  catch  any 
blood  or  discharge.  This  bulges  the  walls  upward 
sufficiently  for  the  more  accurate  closing  of  the  ab- 
dominal wound.  In  removal,  the  pad  is  partially 
pulled  through  the  small  opening  at  the  end  of  the 
wound,  the  water  enters  the  extracted  portion,  and  the 
bag  is  easily  withdrawn,  far  more  easily  than  gauze 
can  be  dragged  out. 

Experiments Experiment  I.  Dogs  Nos.  i  and  2, 

brothers;  black  mongrels  nine  months  old;  weight 
respectively  8  and  9  kgm.  The  animals  were  pre- 
pared with  the  usual  aseptic  precautions. 

Dog  No.  I  :  The  abdomen  was  opened  and  exposed 
to  a  draught  of  air  at  a  temperature  of  15°  C,  for  one 
hour.  The  viscera  were  drawn  out  and  subjected  to 
the  insult  of  manipulation,  care  being  taken  not  to 
produce  any  visible  trauma.  Profound  shock  resulted, 
shown  by  the  pallor,  slow  pulse,  coldness  of  the  skin, 
low  temperature,  the  respiratory  and  vascular  failure, 
'i'here  was  marked  visceral  disturbance.  One  loop  of 
pure  culture  of  virulent  staphylococci  pyogenes  aureus 
was  inoculated  along  the  upper  viscera  by  stroke  culture 
and  along  the  stomach  and  upper  intestines.  Another 
loop  was  applied  similarly  over  the  lower  intestinal 
walls.  A  mixture  of  one  loop  and  sterilized  water 
was  sprinkled  over  the  viscera.  The  abdomen  was 
closed  in  the  usual  way.  The  animal  still  remained 
in  profound  shock.  On  being  placed  in  a  warm  room, 
reaction  took  place. 

Result:  General  peritonitis  and  death  on  the  fourth 
day.     Post-mortem    showed    multiple    absces.ses,  and 

'  Journal  of  the  American  Medical  Association,  June  11,  iSgfi  ; 
ibid..  June  19,  1897.  Also  Proceedinf;s  of  the  Am.  (lastro-Ent. 
Association,  ig^,  "  Splanchnic  Circulation  in  Relation  to  the 
Stomach  and  Intestines." 


bacteriological  examination  showed  staphylococci  pyo- 
genes aureus. 

Dog  No.  2  :  The  abdomen  was  opened  and  exposed  to 
a  draught  of  air,  and  the  viscera  were  handled  as  in  the 
case  of  the  first  dog.  Small  rubber  hot- water  bags  con- 
taining 100  c.c.  of  water  were  sterilized  and  placed  in 
the  upper  and  lower  portions  of  the  abdominal  cavity. 
The  temperature  of  water  in  the  bags  was  50^^  C.  In- 
stead of  the  bluish  congestion  of  the  veins  observed 
in  the  first  animal,  they  retained  more  the  purple 
shade,  and  the  viscera  assumed  the  bright  crimson 
shade  of  simple  hypereemia.  Although  the  viscera 
were  exposed  freely  to  the  air,  there  was  no  marked 
embarrassment  of  tiie  heart  and  circulation,  or  of  res- 
piration. The  body  temperature  at  the  end  of  the 
experiment  (one  hour  and  fifteen  mini-tes)  had 
reached  40°  C,  rectal  temperature.  The  bags  were 
removed  from  the  abdominal  cavity,  and  a  loop  of  pure 
virulent  culture  of  a  staphyloccus  pyogenes  aureus  was 
inoculated  into  the  upper  portion  of  the  abdominal 
cavity  and  a  small  loop  into  the  lower  portion  of  the 
abdominal  cavity.  A  loop  of  virulent  culture  in  10 
c.c.  water  was  sprinkled  in  the  abdominal  cavity.  The 
abdomen  was  closed,  no  shock  being  evident. 

Kesult:  There  was  no  peritonitis;  no  infection. 
The  stitches  were  removed  on  the  tenth  day.  In  three 
weeks  the  abdomen  was  again  opened  and  a  gastro- 
enterostomy performed.  A  few  adhesions  were  found 
at  the  site  of  the  old  operation,  but  no  evidences  of 
infection.     Bacteriological  examination  was  negative. 

E.xPERi.MENT  II.  Scotch  terrier  mixture;  weight  6 
kgm.  The  abdomen  was  opened,  and  the  viscera  were 
exposed  to  a  draught  of  air  for  one  hour  and  ten  min- 
utes. The  viscera  were  handled  under  aseptic  precau- 
tions. Evidences  of  shock  were  present.  I  introduced 
hot-water  bags  into  the  abdominal  cavity  and  observed 
an  increase  in  the  action  of  the  heart  and  circulation 
within  five  minutes.  .The  bluish  condition  of  the 
tongue  improved,  and  a  change  was  noticeable  in  the 
mouth.  Respiration  was  still  markedly  shallow.  A 
hot-water  bag  containing  water  at  50°  C.  was  then 
placed  in  the  .stomach.  This  hot-water  bag  was  at- 
tached to  a  double  recurrent  tube,  and  water  was  al- 
lowed to  play  through  it  continuously  at  a  temperature 
of  55°  C.  As  the  bag  was  introduced  into  the  stomach 
and  hot  water  was  forced  into  the  bag,  it  stimulated  the 
circulation  at  once,  and  more  chloroform  was  demanded 
to  increase  anjesthesia.  When  all  of  the  symptoms  of 
shock  were  reduced,  virulent  staphylococci  were  intro- 
duced into  the  upper  and  lower  portions  of  the  abdomi- 
nal cavity;  10  c.c.  of  four  days' growth  in  bouillon  was 
also  introduced  into  the  abdominal  cavity.  The  abdo- 
men was  closed.  No  evidences  of  shock  were  present. 
Soon  after  coming  out  from  the  anaesthetic,  the  animal 
was  able  to  run  about  without  any  evident  distress. 

Result:  No  infection  occurred,  and  no  increase  in 
temperature,  and  at  the  end  of  one  month  a  second 
operation  was  performed  on  the  same  animal,  and  the 
bacteriological  examination  was  negative. 

ExPKRiMENT  III.  Yellow  mougrel,  weighing  10 
kgm.  The  abdoment  was  eviscerated  under  aseptic 
precautions,  with  an  exposure  of  one  and  one-half 
hours.  The  animal  showed  shallow  respirations,  pal- 
lor, slow  heart  beat,  low  temperature,  cold  surface. 
All  the  evidences  of  shock  were  present.  Pure  cul- 
tures of  streptococci  pyogenes  were  introduced  into  the 
abdominal  cavity  over  the  walls  as  well  as  over  the 
visceral  layers.  The  abdomen  was  closed.  The  ani- 
mal remained  in  profotmd  shock  for  several  hours. 
Upon  being  placed  in  a  warm  room,  a  gradual  reac- 
tion took  place. 

Result:  Marked  septicaemia  followed,  with  diffuse 
peritonitis;  the  animal  died  on  the  fifth  day.  Post- 
mortem showed  streptococci  in  the  abdomen  and  also 
in  the  heart. 


August  1 1,  1900] 


MEDICAL   RECORD. 


21 1 


Experiment  IV.  Black-and-white  dog,  weighing 
1 1  kgm.  The  viscera  were  exposed  and  roughly 
handled.  Hot-water  bags  were  placed  within  the  ab- 
dominal cavity  in  the  upper  and  lower  portions  of  the 
abdomen — three  or  four  small  bags  at  one  time. 
These  were  changed  at  intervals  of  about  ten  minutes, 
or  as  soon  as  the  temperature  of  the  water  fell  below 
50°  C.  The  temperature  of  the  animal  rose  to  40"^ 
C. ;  respirations  were  deep,  and  the  circulation 
showed  peripheral  injection  of  the  arterioles,  and  hy- 
peremia of  all  the  abdominal  viscera  as  the  result  of 
the  heat  stimulation.  Virulent  cultures  of  streptococci 
were  introduced  into  the  upper  and  lower  portions  of 
the  abdomen;  also  a  bouillon  culture  was  distributed 
throughout  the  abdomen.  The  abdomen  was  then 
closed  under  aseptic  precautions  and  sealed.  There 
was  no  shock  evident,  and  the  following  day  the  animal 
ate  meat,  and  seemed  to  be  well.  The  animal  lived 
for  one  year  after  that,  with  no  evidence  of  infection. 

E.XPERI.MENT  V.  Rabbit  weighing  1.500  gm.  The 
viscera  were  exposed  to  a  cold  draught  of  air  for  one 
hour.  I  then  introduced  .staphylococci  pyogenes  and 
sealed  the  abdomen. 

Result:   Diffuse  peritonitis  with  localized  abscesses. 

Experiment  VI.  Rabbit  weighing  2,000  gm.  The 
abdomen  was  opened  and  the  viscera  were  exposed ; 
hot-water  bags  were  placed  in  the  abdominal  cavity 
for  one  hour;  temperature  of  water  in  bags  50°  C. 
Hyperemia  of  the  viscera  with  well-established  pe- 
ripheral circulation  took  place.  Staphylococci  were 
introduced  into  the  abdominal  cavity. 

Result:  The  animal  recovered  without  infection. 

Experiment  VH.  White-and-gray  rabbit,  weight 
1,800  gm.  The  viscera  were  exposed.  Hot-water 
bags  were  introduced  into  the  abdominal  cavity  for 
one  hour;  temperature  of  the  water  in  bags  50"^  C. 
Inoculation  was  with  streptococci  pyogenes. 

Result:  General  diffuse  peritonitis;  septicemia; 
death.  Bacteriological  examination  revealed  strepto- 
cocci. 

Experiment  VIII.  Black-and-white  rabbit,  weight 
2,400  gm.  The  viscera  were  exposed  for  one  hour. 
A  hot-water  bag  was  placed  in  the  abdominal  cavity 
during  this  time  and  changed  as  the  temperature  of  the 
water  in  the  bags  decreased.  Streptococci  were  placed 
in  the  upper  and  lower  portions  of  the  abdominal  cav- 
ity.    The  abdomen  was  then  closed. 

Result:  No  infection;  no  peritonitis.  Post-mortem 
was  made  one  month  after  and  no  evidences  of  the  in- 
oculations were  present. 

Experiment  IX.  Brown-and-white  guinea-pig 
weighing  500  gm.  The  abdomen  was  opened,  shock 
produced,  and  inoculation  made  with  staphylococci. 

Result:   Death. 

Experi.ment  X.  Red-and-white  guinea-pig.  The 
viscera  were  exposed,  and  small  hot-water  bags  were 
introduced  into  the  abdominal  cavity.  Exposure  was 
made  for  three-quarters  of  an  hour.  Inoculation  was 
made  with  staphylococci.     Xo  shock  was  present. 

Result:  The  animal  died  next  day. 

Experiment  XI.  White  -  and  -  black  guinea-pig. 
Shock  was  produced  and  the  animal  inoculated  with 
staphylococci. 

Result:  Death. 

Experiment  XII.  Guinea-pig,  weight  750  gm. 
Death  occurred  after  shock,  after  infection  with  strep- 
tococci. 

Experiment  XIII.  Guinea-pig.  Exposure  of  vis- 
cera was  done  and  a  hot-water  bag  introduced  into  the 
cavity.     The  animal  was  inoculated  with  streptococci. 

Result:  The  animal  died  same  night. 

Experiment  XIV.  Guinea-pig.  The  viscera  were 
exposed  and  hot- water  bags  were  introduced  for  one 
hour.  It  was  inoculated  with  staphylococci  in  the  ab- 
dominal cavity. 


Result:  No  infection.  Post-mortem  in  one  week 
revealed  no  foci.  Bacteriological  examination  was 
negative. 

Experiment  XV.  Guinea-pig.  The  abdomen  was 
opened;  also  the  stomach  exposed,  and  the  intestines 
were  drawn  out.  Desiccation  was  allowed,  and  a  hot- 
water  bag  was  introduced;  the  temperature  of  the  ani- 
mal rose  two  degrees. 

Result:  No  shock;  no  infection. 

E-XPEriment  XVI.  Guinea-pig.  The  viscera  were 
exposed  and  a  hot-water  bag  was  kept  constantly  in 
the  stomach.  I  introduced  mi.xed  culture  of  staphy- 
lococci and  streptococci. 

Resujt:  No  shock  and  no  infection. 

Experiment  XVII.  Small  yellow  guinea-pig, 
weighing  500  gm.  I  opened  the  abdomen  and  applied 
heat;  iieat  also  was  applied  to  the  stomach  internally. 
A  mixed  culture  of  staphylococci  and  streptococci  was 
introduced. 

Result:  The  animal  died  same  evening. 

Experiment  XVIII.  Guinea-pig  weighing  600  gm. 
The  viscera  were  exposed  and  a  hot-water  bag  was 
placed  in  the  abdominal  cavity  and  in  the  stomach; 
this  was  continued  for  forty-five  minutes.  A  mixed 
culture  of  streptococci  and  staphylococci  was  intro- 
duced. 

Result:  No  shock  and  no  infection.  Examination 
at  end  of  two  weeks  bacteriologically  was  negative. 

Experiment  XIX.  Under  aseptic  conditions,  the 
abdomen  of  a  dog  was  opened  and  the  viscera  were 
exposed  for  one  hour.  Staphylococcus  albus  cultures 
taken  from  the  skin  of  patients  who  had  been  asepti- 
cally  prepared  for  operation  were  introduced  into  the 
upper  and  lower  portions  of  the  abdomen. 

Result:  The  animal  died  the  third  day,  evidently 
from  shock  and  infection.  Examination  showed  small 
foci  of  growths,  which  proved  to  be  staphylococci  albus, 
similar  to  those  introduced. 

Experiment  XX.  Scotch  terrier,  mixed.  The  ab- 
domen was  exposed  for  an  hour,  and  hot-water  bags 
were  introduced  into  the  stomach  and  abdominal  cav- 
ity. Staphylococci  albus  taken  from  cultures  from  skin 
of  patients  before  operation  were  used,  after  aseptic 
preparation. 

Result:   No  shock  and  no  infection. 

Same  animal  one  month  later:  'i'he  abdomen  was 
opened  and  shock  produced,  followed  by  attempts  at 
resuscitation  with  hot-water  bags. 

Result:  The  animal  died  ne.xt  day  from  shock  and 
infection. 

Experiment  XXI.  Large  black  mongrel.  Hem- 
orrhage of  600  c.c.  was  induced.  Cannula;  were  placed 
in  the  femoral  artery  and  jugular  vein  to  measure  blood 
pressure.  The  venous  pressure  was  not  sufficient  to 
raise  mercury.  There  was  the  characteristic  pressure 
of  shock  induced  by  exposure  of  viscera.  The  blood 
pressure  fell  to  57  mm.  A  hot-\Vater  bag  was  intro- 
duced into  the  stomach,  the  water  at  55'^  C.  At  the 
end  of  three  minutes  the  blood  pressure  was  raised  to 
75°  C;  at  the  end  of  five  minutes  it  reached  100°  C., 
and  at  the  end  of  ten  minutes  had  reached  130°  C. 
with  an  accelerated  respiration.  The  hot-water  bag 
was  withdrawn,  and  the  animal  was  allowed  to  go  un- 
der shock  again.  Observed  at  the  end  of  half  an  hour, 
the  pressure  had  fallen  to  80  mm.,  but  upon  introduc- 
tion of  the  hot-water  bag  it  rose  to  140  mm.  The  bag 
was  again  withdrawn  for  a  short  time,  when  the  press- 
ure fell  to  75  mm.  The  animal  was  then  infused 
intravenously  with  saline  solution,  400  c.c.  The 
abdominal  cavity  was  then  infected  with  staphylo- 
cocci. 

Result:  The  animal  died  next  morning  in  shock. 

Experi.ment  XXII.  Mongrel  dog  fairly  well 
nourished.  Gastro-enterostomy  was  performed.  The 
viscera  were  exposed  and  the  skin  and  edges  of  the 


212 


MEDICAL    RECORD. 


[August  1 1,  1900 


wound  covered  in  with  rubber  dam.  A  rubber  bag 
containing  water  at  48°  C.  was  introduced  into  tiie 
abdominal  cavity,  this  acting  as  hot  pad  or  sponge  to 
prevent  shoci<.  The  exposed  viscera  being  protected 
with  rubber  dam,  small  openings  were  cut  in  the  rub- 
ber, and  the  viscera  to  be  operated  upon  were  drawn 
through  these  openings.  At  the  same  time,  constric- 
tions were  made  with  rubber  around  that  portion  of 
the  stomach  which  was  operated  upon.  The  corre- 
sponding portion  of  the  jejunum  was  covered  in  the 
same  way,  it  being  drawn  through  a  similar  aperture 
in  a  portion  of  the  rubber  dam.  The  edges  of  the 
dam  covered  entirely  the  abdominal  opening.  These 
excluded  air  from  the  abdominal  cavity  and  prevented 
any  injury  to  the  exposed  viscera.  The  operation 
lasted  two  hours,  the  time  being  purposely  prolonged. 
The  jejunum  was  joined  to  the  stomach  by  double  su- 
ture. The  rubber  dam  was  found  wholly  to  protect 
the  viscera  from  contamination  from  the  stomach  con- 
tents or  the  contents  of  the  bowel,  and  at  the  same 
time  to  prevent  loss  of  heat  and  desiccation  of  the  vis- 
cera, thus  preventing  shock.  The  rubber  dam  also 
prevented  leakage  from  the  stomach  and  intestines, 
and  hemorrhage  was  averted.  After  suturing  the  vis- 
cera, the  rubber  dam  was  slit  and  removed.  A  hot- 
water  bag  was  then  placed  underneath  the  abdominal 
wall.  This,  pressing  upward  against  the  abdominal 
wall,  held  it  in  place  tor  suture,  and  at  the  same  time 
lessened  the  danger  of  the  viscera  coming  in  contact 
with  the  needle.  As  soon  as  the  suture  joined  nearly 
to  the  upper  angle  of  the  wound,  a  portion  of  the  bag 
was  drawn  out  through  this  small  opening  and  the 
fluid  in  the  bag  forced  into  the  extruded  portion.  The 
bag  was  then  easily  withdravv'n.  The  abdominal  cav- 
ity was  then  closed. 

Result:  The  animal  showed  no  symptoms  of  shock 
or  infection.  It  was  fed  meat  the  following  day,  and 
the  stomach  showed  remarkable  digestive  activity. 

Experiment  XXIII.  Scotch  terrier.  The  abdo- 
men was  opened  and  the  viscera  were  exposed,  and 
hot-water  bags  were  placed  in  the  abdominal  cavity. 
The  temperature  of  the  bags  was  55°  and  58°  C.  Ex- 
posure lasted  one  hour  and  twenty  minutes.  The 
animal  was  inoculated  with  virulent  cultures  of  sta- 
phylococcus pyogenes  albus.  The  high  temperature 
produced  definite  stimulation.  After  closure  of  the  ab- 
domen and  sealing  of  the  wound,  the  animal  escaped 
and  ran  four  blocks  before  capture.  The  exertion 
caused  the  animal  to  vomit  bile,  and  show  signs  of  ex- 
haustion. 

Result:  The  dog  died  at  the  end  of  twenty-four 
hours.  The  post-mortem  revealed  a  marked  hyper- 
asmia  of  the  stomach  and  intestines,  exudate  extend- 
ing over  the  upper  and  lower  portions  of  the  abdomen, 
and  mucus  at  different  points.  Upon  the  intestines 
were  found  what  appeared  to  be  blebs  following 
burns.  Cultures  were  made  from  the  exudates,  from 
the  duodenum,  and  from  the  small  intestines. 

Experiment  XXIV.  Mongrel  weighing  7J2  kgm. 
The  viscera  were  exposed  and  hemorrhage  of  400 
c.c.  was  induced.  Profound  shock  followed.  An 
injection  of  500  c.c.  of  saline  solution  was  made  sub- 
cutaneously,  and  the  animal  was  sewed  up,  after  in- 
oculation with  colon  bacilli. 

Result:  The  animal  recovered  from  shock,  but  died 
in  one  week.  Colon  bacilli  were  found  in  the  spleen. 
There  was  general  peritonitis.  Death  was  the  result 
of  infection  following  shock. 

Experiment  XXV.  Dog  weighing  8  kgm.  The 
viscera  were  exposed  and  a  hemorrhage  of  400  c.c.  was 
induced.  The  hot-water  bags  were  placed  in  the  ab- 
dominal cavity  and  stomach,  and  the  animal  was  in- 
fused intravenously  with  hot  saline  solution.  It  was 
then  inoculated  with  fresh  cultures  of  colon  bacilli 
above  and  below,  and  the  wound  sutured. 


Result:  No  evidences  of  shock  and  no  infection. 

One  month  later  the  same  animal  was  subjected  to 
gastro-enterostomy.  Bacteriological  examination  at 
this  time  was  negative.     The  animal  recovered. 

Experiment  XXVI.  Large  setter.  I  exposed  the 
abdomen  and  performed  gastro-enterostomy.  The  ani- 
mal was  then  inoculated  with  cultures  of  staphylococci 
albus  made  from  the  skin  of  patients  after  preparation 
for  operation. 

Result:  Shock  from  which  the  animal  did  not  re- 
cover; it  died  on  the  sixth  day  of  general  peritonitis. 
Staphylococci  albus  were  found  which  liquefied  gelatin 
in  culture. 

.ExPERiMEXi  XXVII.  Large  black  mongrel.  I  ex- 
posed the  viscera  and  removed  one  and  one-half  feet  of 
intestine,  following  this  with  anastomosis.  Operation 
was  prolonged  one  and  one-half  hours,  with  frequent 
manipulation  of  viscera  and  exposure.  Shock  was 
produced.  Staphylococci  albus  obtained  from  skin  of 
patients  before  surgical  operation  were  introduced. 

Result:  The  animal  died  on  the  fourth  day. 

Experiment  XXVIII. .  Dog  weighing  6  kgm. 
Evisceration  was  done. 

Result:  The  animal  lived  three  hours.  It  had  not 
been  inoculated. 

Experiment  XXI^.  Dog.  It  was  placed  on  a  hot- 
water  bed,  and  the  abdomen  opened  and  exposed  to 
a  draught  of  air.  The  viscera  were  exposed  to  the  air 
for  forty-five  minutes.  Tortuous  veins  stood  out  in 
dark  relief  upon  a  livid  background.  There  was  a 
marked  fall  in  temperature,  and  reflexes  were  absent. 
The  anx'Sthesia  was  withdrawn,  as  none  was  required. 
The  breathing  was  shallow,  pulse  rapid  and  weak,  and 
tongue  pale.  The  abdomen  was  closed  at  the  end  of 
one  hour  and  fifteen  minutes.  The  operation  was 
carried  out  under  aseptic  precautions. 

Result:  The  animal  died  in  three  days. 

Experiment  XXX.  Dog.  It  was  placed  upon  hot- 
water  bag,  and  the  viscera  were  exposed  to  the  air  un- 
til profound  shock  was  produced.  Notwithstanding 
the  heat  from  the  hot-water  bag,  which  was  120°  C, 
there  was  marked  visceral  congestion  with  anemia  of 
the  surface,  shallow  breathing,  and  loss  of  reflexes, 
even  after  withdrawal  of  the  anaesthetic.  The  animal 
was  in  evident  collapse.  A  hot-water  bag  was  placed 
in  the  stomach,  at  a  temperature  of  53°  C.  The  water 
was  forced  into  the  bag  by  a  double  tube  so  that  the 
temperature  did  not  vary,  and  its  application  was  fol- 
lowed by  stimulation  of  the  respiratory  centre,  heart, 
and  circulation.  Hot-water  bags  were  also  placed 
in  the  abdominal  cavity.  The  viscera  regained  color 
and  lost  appearance  of  venous  congestion.  The  heart 
became  more  rapid,  the  surface  warm,  and  shock  was 
reduced.  At  the  end  of  an  hour  and  fort3'-five  minutes 
the  viscera  were  returned  and  the  abdomen  was  closed. 

Result:  The  animal  completely  recovered. 

Experiment  XXXI.  Black  dog,  weighing  13  kgm. 
The  field  of  operation  was  prepared  aseptically,  as  in 
all  the  other  experiments.  The  viscera  were  manip- 
ulated with  rubber  gloves.  Shock  was  produced 
with  evidences  of  collapse;  400  c.c.  of  physiological 
saline  solution  was  injected  intravenously.  The  ab- 
dominal cavity  was  inoculated  with  bacilli  taken  from 
the  skin  of  patient  over  the  field  of  operation  after  its 
having  been  prepared  for  operation. 

Result:  The  animal  died  on  the  fifth  day  of  peri- 
tonitis. Bacteriological  examination  showed  a  mixed 
infection. 

Experiment  XXXII.  Dog  weighing  14J4  kgm. 
The  viscera  were  exposed.  It  was  inoculated  with 
staphylococci  taken  from  the  skin  of  a  patient  over 
the  field  of  operation.  The  animal  was  infused  sub- 
cutaneously  with  salt  solution. 

Result:  The  animal  died  on  the  fourth  day.  Bac- 
teriological examination  showed  staphylococcus. 


August  1 1 ,  1 900] 


MEDICAL    RECORD. 


213 


Experiment  XXXIII.  Dog  weighing  12  kgm.  It 
was  infused  subcutaneously  with  salt  solution  and  in- 
oculated with  staphylococcus  pyogenes  aureus. 

Result:  The  animal  died  in  two  days  of  peritonitis. 
No  cultures  were  made. 

E.xi'ERiMENT  XXXIV.  Dog  Weighing  13  kgm. 
The  viscera  were  exposed  and  shock  was  induced.  It 
was  infused  subcutaneously  with  saline  solution,  after 
a  hemorrhage  of  400  c.c.  had  been  induced. 

Result:  The  animal  died  on  the  second  day. 

Experiment  XXXV.  Black-and-white  guinea-pig. 
The  viscera  were  exposed  and  shock  was  induced.  It 
was  inoculated  with  staphylococci  taken  from  the 
skin. 

Result:  The  animal  died  on  the  second  day  of  gen- 
eral peritonitis. 

Experiment  XXXVI.  Gray  rabbit.  It  was  placed 
upon  a  hot-water  bed;  temperature  of  water  in  bed, 
45^  C.  It  was  then  inoculated  with  virulent  colon 
bacilli.     The  operation  lasted  for  one  hour. 

Result:  The  animal  died  of  general  peritonitis. 
Colon  bacilli  were  found. 

Experiment  XXXV^II.  Dog.  It  was  placed  on  a 
hot-water  bed.  and  the  abdomen  was  opened  in  a  warm 
room.  The  viscera  were  exposed  and  the  animal  was 
inoculated  with  a  mixed  culture  of  bacteria  and  cocci 
taken  from  the  skin. 


Result:  The  animal  died  on  the  third  daj . 

Experiment  XXXVIII.  Dog  weighing  14  kgm. 
The  viscera  were  exposed  and  manipulated.  It  was 
inoculated  with  mixed  cultures  of  colon  bacilli  from 
faces  and  staphylococci  albus  and  other  cocci  taken 
from  the  skin  of  a  patient  before  operation.  A  hot- 
water  bag  was  placed  in  the  abdominal  cavity. 

Result:  The  animal  died  the  following  day. 

Experiment  XXXIX.  —  Gray-and-white  rabbit. 
The  abdominal  wall  was  cleansed  as  usual  and  a  large 
median  incision  was  made.  Hot-water  bags  were  in- 
troduced into  the  abdominal  cavity,  beginning  with 
water  at  temperature  48°  C.  and  raised  to  50"  C.  for 
forty-five  minutes.  The  stimulation  to  the  viscera  was 
well  marked.  The  peritoneum  was  inoculated  with 
virulent  staphylococcus  pyogenes  albus.  The  abdomen 
was  closed  and  sealed. 

Result:  No  shock,  no  infection ;  recovery. 

ExPERi.MENT  XL. — Gray  rabbit  for  control.  It  suc- 
cumbed under  anesthesia. 

Experiment  XLI. — White  and-yellow  guinea-pig. 
I  opened  the  abdomen  and  inserted  hot-water  bags 
into  the  abdominal  cavity.  Temperature,  48°  C, 
raised  to  50°  C.  Time,  forty-five  minutes.  Evi- 
dence of  marked  stimulation  was  shown.  The  ani- 
mal was  inoculated  with  virulent  mixed  staphylococ- 
cus culture,  and  the  abdomen  was  closed. 


Shock  Prevented — Inoculation. 


1 

Animal. 

Stimulation. 

Inoculated  with 

Length 

of 

Operation. 

it 

■s 

■q 

C3       J! 

•c-o  c 

s§-S 

U   jj  B 

3  =  0. 

Remarks, 

I 

nog  

Rabbit 

do 

do 

Guinea-pig  . . 

do. 

do. 

do. 

do. 

do. 
Doe 

Hot-water  bags. . 
do. 

do. 
do. 
do. 
do. 
do. 
do. 
do. 
do. 
do. 
do. 

Staph  

1  h.  J5  m. 

1  h 

ih 

Hh':':::. 

J 

Strep. . 

None, 
None. 

I 
1 
I 

I 

I 

None.. 

None. 

None, 
do. 

None. 

Bacteriological  examination  negative. 

3 

4 
5 

Strei> 

Diffuse  peritonitis. 

do."^ :::::.:: : 
St^Ph 

I 
9 
10 

Staph 

I  h 

Strep,  anti  staph... 

do. 

do. 
Staph     

ii]} 

I  h 

=  h 

I  h.  2om.. 

Hh '..'.'.'.'.. 

Kh 

Died  of  shocli  and  infection,  second  operation. 
Kscapcd,  and  ran   four  blocks  after    operation; 
died  of  peritonitis. 

do 

do 

do 

Rabbit        ... 
Guinea-pig  . . 

■3 
'4 
■5 
16 

do.            . .    Staph,  pyog,  albus. 

Hot-water  bed  ...    Mi.\ed  cultures 

Hot-water  bags..    Staph,  pyog.  albus. 

do.            ..    Virul.  mixed  staph. 

Shock  Induced — Inoculation — Infectio.n. 


0 

1 
'p. 

Animal, 

Method  of 
Resuscitation. 

Inoculated 
with 

Length 

of 

Operation. 

i1 

0 

•a' 

Bacteriolog- 
ical Ex- 
amination. 

•CO  C 

-  g.S 
^2§ 

s    .1 

'^          C 

Remarks. 

J 

Dog 

None 

Hot-water  bags 

None 

Staph 

do.     . . 

Strep  

do 

ih 

70  m 

ij^  h.    .. 

Staph 

Strep." ..'.'.'.'. 

None! 

None. 

Gen.  peritonitis  witli  abscesses. 
Bacteriological  cxatnination  negative. 

2 

3 
4 

do 

do 

do 

Rabbit      ..    . 

Guinea-pig... 

do,     ... 

do       ... 

do.     ... 

Hot-water  bags 

Lived  for  one  year  ;  no  trace  of  infection. 
Diffuse  peritonitis. 

Staph 

do. 

I  h.   .. 

do 

Staph,  a. 

7 

8 

do 

do 

do    

Strep  

q 

Hot-water  bags 

None 

Hot-water    bags    and 

saline  solution. 

Saline  solution 

Hot-water  bags 

None 

do 

Stapil 

do 

... 

I  h.... 
I'Ah.... 

do 

do 

Subjected  three  limes  to  shock  during  operation. 
General  peritonitis, 
do. 

Colon  bac 

Staph 

Mixed    infec. 
Staph. 

>3 
'4 
'S 

do 

do 

do 

do.     ..   . 
Staph 

do 

do 

17 

in 

do 

Placed  on    hot-water 

bed. 
Placed    on     hot-water 
bags   and  hot-water 
bag  in  cavity. 

Saline  solution 

do 

do 

do 

do. 

do 

Mixed  bac... 

,'Ah  ... 
iHh  ... 

I 

'9 

do 

do 

21 

do.  ... 

do    

do 

Colon  bac 

Guinea-pig... 
Rabbit 

Dog 

24 

Placed   on    hot- water 

bag. 
Hot-water  bag 

Colon  bac. . . , 

Mixed  cocci,. 
Mixed  staph. 

ih 

10  m 

General  peritonitis. 

76 

Guinea-pig  . . 

Acute  peritonitis. 

Summary  o^  Tables. 

Animals  inoculated  after  shock  without  heat  stimulation  applied  to  the  splanchnic  area  :    Dogs,  14  ;  died.  13.    Guinea-pigs,  7  ;  died,  6.     Rabbits,  4;  died,  4. 
Animals  inoculated  after  application  of  heat  stimulation  10  splanchnic  area  to  [  revent  shock  :    Dogs,  9  ;  died,  2.     Rabbits,  4  ;  died,  1.     Guinea-pigs,  8  ;  died,  3 


214 


MEDICAL    RECORD. 


[August  1 1,  1900 


Result:  No  shock  or  infection;  recovery. 

ExPKRiMENT  XLII.  —  Control,  black-and-yellow 
guinea-pig.  The  abdomen  was  opened  the  same  as  in 
No.  XLI.  Stimulation  by  hot-water  bags  was  omitted. 
The  viscera  were  t-.xposcd  for  ten  minutes.  Inocula- 
tion was  made  with  staphylococcus,  as  in  No.  XLI. 

Result:  Death.  Post-mortem  showed  acute  peri- 
tonitis. There  were  no  other  marked  pathological 
changes. 

In  these  experiments  it  is  difficult  to  e.xplain  the 
mode  of  action  of  the  hot-water  bags  placed  in  the  ab- 
dominal cavity  and  within  the  stomach.  Heat  stimu- 
lation thus  applied  to  the  splanchnic  area  for  a  definite 
length  of  time  seems  to  be  not  only  anti-bacterial  but 
also  antitoxic  in  its  action.  It  is  not  altogether  clear 
whether  this  result  is  due  simply  to  the  effect  of  heat 
acting  directly  upon  the  tissues,  producing  chemical 
changes,  or  to  the  physiological  increase  in  the  circu- 
lation, or  through  nerve  influence  acting  upon  both  tis- 
sue cells  and  circulation.  It  is  evident  that  blood 
changes  are  produced.  Experiments  seem  to  indicate 
that  molecular  chemical  changes  are  produced — that 
the  "side  chains"  in  the  albumin  molecule  are  al- 
tered. It  is  a  significant  fact  that  heat  applied  to  the 
external  surface  does  not  result  in  the  same  effect  pro- 
duced by  heat  applied  internally. 

In  connection  with  the  above  experiments  the  fol- 
lowing report  of  surgical  cases  may  be  of  interest,  in 
which  similar  precautions  were  taken  against  infec- 
tion and  shock: 

Case  I. — Mrs.   J.  P. ;  operation  for  carcinoma 

of  the  pylorus,  a  gastro-enterostomy  being  performed 
and  anastomosis  secured  by  means  of  the  Murphy  but- 
ton. The  e.xposure  of  the  viscera  to  air  was  followed 
by  marked  congestion  of  the  viscera.  In  thirty  min- 
utes there  was  apparent  collapse.  The  anasthesia 
was  withdrawn  and  artificial  respiration  attempted,  but 
without  resuscitation.  A  hot-water  bag  was  placed  in 
the  stomach,  which  stimulated  respiration,  the  heart, 
and  circulation.  The  viscera  changed  from  the  blu- 
ish shade  of  congestion  to  mild  hypera;mic  tints. 
The  surface  grew  warm,  perspiration  appeared  upon 
the  forehead  and  body,  and  a  restoration  of  the  circu- 
lation peripherally  showed  in  the  return  of  color  to  the 
finger-nails,  and  signs  of  shock  disappeared.  Recov- 
ery was  complete,  the  patient  leaving  the  hospital  and 
living  for  one  year  afterward. 

Case    II. — Mrs.    McG ,    aged   forty-five  years; 

hemorrhage  from  bowels;  estimated  loss  of  blood 
from  bowels  over  one  quart.  All  signs  of  shock  were 
present,  including  anesthesia,  disturbance  of  vision, 
thirst,  cold  surface,  blue  lips;  the  face  wore  an  anx- 
ious expression.  The  patient  experienced  a  feeling 
of  impending  death.  The  intra-gastric  resuscitator 
(hot-water  bag)  was  introduced  into  the  stomach,  and 
within  twenty  minutes  the  symptoms  has  disappeared, 
with  the  exception  that  the  hands  and  feet  were  cold; 
at  the  end  of  forty-five  minutes  these  were  warm.  No 
other  treatment  for  reduction  of  shock  was  used.  This 
was  repeated  the  following  day,  and  the  patient  felt  so 
well  after  treatment  that  she  requested  a  daily  treat- 
ment, which  was  instituted  for  one  week. 

Case  III. — A.  C ,  aged  fifty-two  years;  gastro- 
enterostomy and  gastrostomy  were  performed  for  cancer 
of  the  oesophagus,  middle  portion.  The  patient  was 
anaesthetized  with  ether.  Upon  opening  of  the  ab- 
domen and  seizing  of  the  stomach,  the  patient  ceased 
to  breathe.  Artificial  respiration  was  employed.  While 
saline  solution  was  being  prepared  for  infusion  subcu- 
taneously,  three  hot-water  bags  were  placed  in  the  ab- 
dominal cavity,  one  in  the  upper  portion  near  the  dia- 
phragm, one  in  the  lower  portion,  and  the  third  in 
the  side.  These  stimulated  respiration  at  once.  The 
blue,  cyanotic  appearance  of  the  patient  gave  way  to 
natural  color.     So  great  was  the  improvement  in  his 


condition  that  the  saline  solution,  when  ready,  was 
not  considered  necessary,  but  was  held  in  readiness 
should  signs  of  collapse  reappear.  The  author's  valve 
operation  for  gastrostomy  was  performed,  and  just  be- 
fore closure  of  the  abdomen  the  bags  were  withdrawn. 

Result:  The  patient  recovered  without  shock;  the 
temperature  did  not  rise,  and  the  patient  lived  six 
months. 

Case  I\'. — J.  I.  L ,  aged  fifty-eight  years;  car- 
cinoma of  the  pylorus,  atrophic  cirrhosis  of  the  liver, 
and  insufficiency  of  the  kidneys.  A  hot-water  bag 
was  placed  in  the  stomach  during  the  entire  operation, 
which  lasted  one  hour  and  forty-five  minutes.  No 
shock  was  apparent  and  no  infection  followed.  The 
patient  lived  four  months. 

Case    V. — Mrs.    \V ,  aged    seventy-two   years; 

operation  for  benign  stenosis  of  the  pylorus.  There 
was  also  insufficiency  of  the  kidneys.  Gastro-enteros- 
tomy was  performed.  A  hot-water  bag  was  placed  in 
the  abdomen  and  one  in  the  stomach;  temperature  of 
water  in  the  bag  in  the  stomach,  53°  C,  and  of  that 
in  the  bag  in  abdomen,  48°  C.  No  shock  and  no  in- 
fection followed.  The  patient  lived  six  months,  and 
subsequently  died  of  ura-mia. 

Case  VI. — William  J.  K ,  agd  forty-seven  years. 

Exploratory  operation.  A  large  tumor  occupying  the 
entire  epigastrium  and  a  portion  of  the  umbilical  re- 
gion was  found.  Diagnosis:  Pancreatitis  hremor- 
rhagica  and  peripancreatitis.  The  patient  went  into 
profound  shock  with  congestion  of  all  the  vessels 
that  were  exposed;  there  was  anaemia  of  the  surface, 
and  collapse  was  imminent.  A  hot-water  bag  was 
placed  in  the  stomach,  the  temperature  of  the  water 
contained  in  the  bag  being  53°  C.  In  fifteen  minutes 
the  patient  was  completely  restored  from  the  shock 
and  there  was  no  evidence  of  collapse;  respiration 
was  restored,  as  were  the  heart  and  circulation.  The 
abdomen  was  closed,  and  the  following  day  the  pa- 
tient again  showed  marked  symptoms  of  shock.  A 
hot-water  bag  was  again  placed  in  the  stomach  at  the 
same  temperature  as  on  the  previous  day,  and  com- 
plete restoration  followed.  The  patient  lived  one 
month,  and  died  from  the  above  pathological  lesions. 

Case  VII. — Mrs.    M.    B ,  thirty-six  years   old; 

operation  for  appendicitis  and  oophoritis  by  a  promi- 
nent gynaecologist.  In  a  preliminary  curettage,  the  uter- 
us was  accidentally  punctured,  and  when  the  abdomen 
was  opened  it  was  found  that  the  fundus  was  completely 
lacerated  and  some  of  the  contents  had  escaped  into  the 
peritoneal  cavity.  After  cleansing  away  the  de'bris 
from  this  accident,  an  ovariotomy  was  performed  and 
also  an  appendectomy.  The  patient  showed  marked 
symptoms  of  shock;  there  was  marked  anannia  of  the 
surface,  with  very  shallow  breathing,  tachycardia, 
small  and  almost  imperceptible  pulse,  and  collapse 
seemed  unavoidable.  I  chanced  to  be  in  the  hospital 
at  the  time  the  operation  was  going  on,  and  was  called 
in  to  resuscitate  the  patient.  Placing  a  rubber  bag 
with  a  double  tube  in  the  stomach,  I  introduced  water 
into  the  bag  at  a  temperature  of  53°  C.  This  was 
allowed  to  remain  in  the  stomach,  and  a  continuous 
current  was  kept  playing  through  the  bag,  about  500 
c.c.  of  water  remaining  in  the  bag  all  the  time,  for 
about  one-half  hour.  This  resulted  in  a  complete  res- 
toration from  shock  and  collapse.  The  following 
morning  the  patient  exhibited  signs  of  shock,  and  I 
was  again  called  and  carried  out  a  similar  procedure. 
At  the  end  of  twenty-five  minutes  there  was  complete 
restoration,  and  from  this  time  tlie  patient  made  an 
uneventful  recovery,  without  shock  or  infection. 

Case  VIII. — J.  J.  S— — ,  aged  forty-one  years; 
operation  upon  the  cystic  duct;  operator  I)r.  Newman. 
.A.  case  of  atrophic  cirrhosis  of  the  liver,  and  atrophic 
gall  bladder.  The  gall  bladder  was  opened,  the  stone 
removed,  and  the  wound  packed.     Shock  was  present. 


August  1 1 ,  1 900] 


MEDICAL    RECORD. 


215 


but  reduced  by  the  use  of  a  hot-water  bag  in  the  stom- 
ach. The  patient  died  on  the  fourth  day,  of  shock  or 
infection,  or  both. 

Case    IX.  — Mrs.     B.    A.    C ■,   aged     forty-three 

years;  chronic  enteritis  of  seven  years' standing,  and 
contracted  liver.  I  opened  the  abdomen  and  placed 
hot-water  bags  in  the  abdominal  cavity  and  also  in- 
troduced one  into  the  stomach.  The  gall  bladder  was 
drained  for  four  weeks.  The  patient  suffered  no  shock 
or  infection  or  signs  of  exhaustion  from  the  operation. 
She  completely  recovered. 

Case  X. — K.  J.  K ,  aged  forty-eight  years;  re- 
ferred by  Dr.  Beveridge  of  South  Dakota.  She  suf- 
fered from  benign  stenosis  of  the  pylorus,  resulting 
from  cicatricial  ulcer.  There  was  an  immense  dila- 
tation occupying  the  epigastric  and  umbilical  regions 
and  the  great  curvature  reaching  into  the  hypogastric 
region.  The  patient  weighed  but  one  hundred  and  four 
pounds,  having  lost  sixty-eight  pounds  since  the  ill- 
ness began,  and  was  very  weak,  stenosis  of  the  pylorus 
being  complete.  Hot-water  bags  were  placed  in  both 
the  abdominal  cavity  and  the  stomach,  and  a  gastro- 
enterostomy performed.  In  this  patient,  a  rubber  dam 
was  placed  over  the  abdominal  opening  and  one 
spread  over  the  abdomen  below  the  wound  to  prevent 
infection.  The  stomach  was  drawn  through  a  small 
aperture  in  the  rubber  dam  and  a  loop  of  the  jejunum 
drawn  through  another  small  aperture  in  the  rubber 
dam.  This  was  done  for  the  purpose  of  preventing 
any  escape  of  stomach  contents  into  the  abdominal 
cavity,  and  also  to  prevent  hemorrhage  by  the  con- 
striction of  the  viscera  drawn  through  the  small  aper- 
tures. Anastomosis  was  made  by  a  double  row  of 
sutures.  The  rubber  dam  was  then  cut,  and  the  vis- 
cera were  freed  and  replaced  in  the  abdominal  cavity, 
and  the  wound  was  sutured.  There  was  no  shock 
following  the  operation  and  no  apparent  exhaustion. 
The  patient  was  fed  the  following  day  and  continued 
to  improve,  to  gain  in  weight,  and  was  discharged  in 
four  weeks.  At  the  last  report,  two  years  and  one 
month  since  operation,  the  patient  had  gained  in 
weight  (60  lb.)  and  strength  and  continued  his  work 
regularly  on  the  farm. 

Case  XI. —  I.  J.  H ;  operation  for  stenosis  fol- 
lowing duodenal  ulcer  in  the  first  portion  of  the  duo- 
denum, just  beyond  the  pylorus;  periduodenitis,  with 
adhesions.  Hot-water  bags  were  placed  in  the  ab 
dominal  cavity  after  being  opened  and  rubjer  dams 
adjusted,  as  in  Case  X.  The  stomach  was  drawn 
through  an  aperture  in  the  rubber,  and  the  intestines 
were  drawn  through  another  slit.  Gastroenterostomy 
was  done,  with  anterior  suture.  The  operation  lasted 
one  hour  and  twenty-five  minutes.  Hot-water  bags 
were  changed  at  intervals,  keeping  the  temperature  of 
the  water  at  48'  C.  There  were  no  infection  and  no 
shock.  The  patient  was  fed  the  following  day,  and 
he  made  an  uneventful  recovery. 

Case    XII. — J.    G.    T ,    aged  forty-four   years; 

stenosis  of  the  pylorus  with  gastric  dilatation.  Gastro- 
enterostomy was  performed.  Hot-water  bags  were 
placed  in  the  stomach  and  also  in  the  abdominal  cav- 
ity. The  operation  lasted  one  hour  and  fifteen  min- 
utes.    The  patient  recovered. 

Case   XIII. — J.    G,    F ,   aged    fifty-one    years, 

complained  of  gastric  disturbance,  icterus,  and  general 
emaciation.  Examination  showed  a  contracted  liver, 
contraction  of  the  stomach,  insufficiency  of  the  kidney, 
and  general  fibrosis.  The  operation  was  exploratory. 
A  contracted  gall  bladder  was  found,  which  was 
opened  for  drainage. 

Result :  The  patient  died  on  the  fourth  day.  Death 
was  the  result  of  "exhaustion,"  probably  infection. 

Case   XIV.— Mrs.    B.    A.    J ,    aged    thirty-one 

years,  complained  of  constant  vomiting  and  occasion- 
ally vomited  small  quantities  of  blood;  she  also  com- 


plained of  icterus.  The  liver  area  was  contracted  and 
the  urine  contained  albumin.  The  stomach  was 
markedly  contracted.  Preparation  for  the  operation 
was  made  in  the  usual  manner  and  tiie  incision  made, 
after  which  the  rubber  protectors  were  adjusted,  hot- 
water  bags  having  been  placed  in  the  abdominal  cav- 
ity. The  gall  bladder  was  distended  and  the  rubber 
shield  pulled  around  it.  The  gall  bladder  was  then 
opened  and  exploration  for  stone  made,  which  proved 
negative.  The  gall  bladder  was  then  sutured.  Dur- 
ing the  operation,  the  bags  in  the  cavity  were  changed 
frequentl}'.  The  abdomen  was  then  closed,  but  drain- 
age of  the  gall  bladder  was  continued  for  four  weeks. 
The  patient  made  an  uneventful  recovery. 

Case  XV. — Mrs.  J.  L ,  forty-one  years  old,  pre- 
sented condition  of  cicatricial  stenosis  in  the  rectum, 
due  to  an  ulcer.  During  the  operation,  the  patient 
went  into  collapse,  following  apparent  shock.  I  in- 
troduced a  hot-water  bag  into  the  stomach  at  a  tempera- 
ture of  53°  C.  This  resulted  in  resuscitation  after 
five  minutes,  and  the  operation  was  completed.  The 
patient  made  an  uneventful  recovery. 

Case  XVI. — Mrs.  P.  McC^ — ,  thirty-nine  years 
old,  suffered  from  chronic  diarrhoea,  with  blood  dis- 
charges. Examination  of  the  faeces  showed  tubercle 
bacilli.  Upon  opening  of  the  abdomen,  tubercle  infec- 
tion of  the  ileum  and  a  small  portion  of  the  ascend- 
ing colon  was  revealed.  Hot-water  bags  were  placed 
in  the  abdominal  cavity.  A  part  of  the  ileum,  the 
cajcum,  and  a  portion  of  the  ascending  colon  were 
drawn  through  apertures  in  the  rubber  protector  and 
a  resection  was  made,  with  anastomosis  between  the 
ileum  and  colon.  The  patient  experienced  no  shock 
and  no  secondary  infection,  and  was  discharged  from 
the  hospital  five  weeks  later,  apparently  much  im- 
proved. 

Case  XVII. — F.  L.  R — ■• — ,  thirty-six  years  old,  com- 
plained of  frequent  vomiting  and  emaciation.  Ex- 
amination showed  dilatation  of  the  stomach  with 
obstruction.  The  usual  aseptic  precautions  were 
taken  ;  the  abdomen  was  opened,  hot-water  bags  were 
placed  in  the  abdominal  cavity,  and  the  rubber  pro- 
tector was  adjusted.  Examination  showed  cicatrical 
stenosis  just  beyond  the  pylorus.  Gastro-enterostomy 
was  decided  upon.  The  stomach  and  intestine  were 
drawn  through  slits  in  the  abdominal  protector;  the 
stomach  was  opened  and  the  mucous  membrane 
everted.  A  long  longitudinal  incision  was  made  in 
the  intestine.  The  stomach  was  invaginated  into  this 
large  opening  in  the  intestine,  and  the  intestine  su- 
tured transversely  to  the  long  axis  of  the  bowel,  mak- 
ing the  intestinal  opening  of  sufficient  size  to  accom- 
modate the  stomach.  The  remaining  portion  of  the 
intestinal  incision  was  sutured  in  the  following  man- 
ner; At  the  upper  extremity  of  the  everted  mucosa,  the 
intestine  and  stomach  were  united  by  two  rows  of  su- 
tures, the  first  including  the  intestine,  the  everted  por- 
tion of  the  stomach,  and  the  serous  coat  of  the  stomach. 
The  second  row  was  the  ordinary  Lembert  stitch,  thus 
causing  sero-serous  apposition,  the  everted  mucosa 
of  the  stomach  acting  similar  to  the  ileo-cnscal  valve. 
This  large  opening  prevented  stenosis  or  spur,  the 
valve  preventing  regurgitation  and  the  everted  portion 
preventing  closure  of  the  gastric  opening.  From  this 
operation  there  resulted  no  shock,  no  infection,  and  no 
vomiting.  The  patient  made  an  uninterrupted  recov- 
ery; he  was  able  to  take  liquid  food  the  following  day 
and  was  given  chopped  meat  on  the  fifth  day. 

Case  XVIII. — J.  B.  P— — ,  fifty-one  years  old;  car- 
cinoma of  the  cesophagus;  alcoholic  for  twenty-five 
years,  atrophic  cirrhosis  of  the  liver  and  interstitial 
nephritis.  I  opened  the  abdomen  and  introduced  hot- 
water  bags  in  the  abdominal  cavity.  Temperature  of 
the  water  in  the  bags  was  48°  C.  Turck's  valve  gastro- 
enterostomy was  performed.  Before  the  complete  sutur- 


2l6 


MEDICAL   RECORD. 


[August  11,1 900 


ing  of  the  stomach  to  the  peritoneal  wall,  the  bags  were 
withdrawn  through  a  small  aperture.  The  operation 
covered  one  hour  and  fifteen  minutes.  There  were  no 
shock,  no  infection,  and  no  evidence  of  e.xhaustion  fol- 
lowing the  operation.  The  patient  was  fed  at  once 
through  the  fistulous  opening.  Seven  months  after 
operation  he  was  still  alive. 

Conclusions. — I.  Pathogenic  and  non-pathogenic 
bacteria,  found  on  and  in  the  skin  before  and  during 
surgical  operations,  may  produce  infection. 

II.  The  skin,  especially  in  abdominal  operations,  is  a 
source  of  infection  that  may  cause  death,  though  all 
usual  precautions  are  particularly  taken.  Suscepti- 
bility to  infection  is  produced  in  cases  of  lowered 
vitality  and  weakened  condition;  or  incases  in  which 
shock  is  present,  from  whatever  cause,  in  a  mild  or 
severe  form. 

III.  The  present  methods  yet  in  use,  of  towels  and 
laparotomy  sheets,  do  not  sufficiently  protect  the  field 
of  operation. 

IV.  The  use  of  the  rubber  protector  which  is  made 
to  fit  close  to  the  skin  more  thoroughly  prevents'  the 
danger  of  infection  from  the  skin,  and  also  lessens  the 
liability  of  the  skin  becoming  contaminated  from  the 
escape  of  visceral  contents,  pus,  or  other  infected  ma- 
terial occurring  during  the  operation. 

V.  The  peritoneum  may  become  infected  from  the 
escape  of  visceral  contents  or  from  any  infected  cavity 
opened  during  surgical  operations  in  the  abdomen. 
Infection  may  result,  even  after  the  most  careful  pre- 
cautions are  taken,  notwithstanding  the  use  of  gauze 
and  careful  packing,  now  in  common  use. 

VI.  When  death  occurs  from  supposed  "shock"  or 
"exhaustion,"  especially  when  the  viscera  have  been 
exposed  to  dangers  of  infection  by  the  escape  of  vis- 
ceral contents,  the  death  is  probably  due  more  to  the 
infection  than  to  "shock"  or  "exhaustion." 

VII.  Whenever  practicable,  the  viscera  may  be  drawn 
through  the  small  openings  of  the  protective  rubber 
shield  overlapping  the  abdominal  wound,  as  described 
in  this  paper,  and  absolute  protection  to  the  abdomi- 
nal cavity  is  secured. 

VIII.  Exposed  viscera  may  be  covered  with  a  rub- 
ber hood,  kept  warm  by  small  rubber  hot-water  bags, 
thus  preventing  contamination  as  well  as  lessening 
susceptibility  to  infection. 

IX.  Animals  naturally  immune  to  certain  bacteria 
are  rendered  susceptible  by  exposure  of  the  viscera  to 
air  for  one  hour  or  more. 

X.  Susceptibility  can  also  be  produced  in  an  ani- 
mal naturally  immune,  by  long  manipulation  of  the 
abdominal  viscera,  notwithstanding  all  ordinary  pre- 
cautions are  taken.     Visible  trauma  is  not  essential. 

XI.  In  animals  in  which  susceptiblity  is  not  arti- 
ficially produced,  only  slight  effects  are  observed  after 
intraperitoneal  inoculation  of  microorganisms  taken 
from  the  skin  before  surgical  operations. 

XII.  When  an  animal  is  rendered  susceptible  by 
exposure  of  the  viscera  to  air,  pathogenic  and  many 
non-pathogenic  micro-organisms  inoculated  may  cause 
infection  followed  by  death. 

XIII.  Subcutaneous  or  intravenous  infusion  of 
physiological  salt  solution  does  not  materially  render 
the  animal  less  susceptible,  after  the  exposure  and 
manipulation  of  the  viscera. 

XIV.  When  heat  at  48  or  50"  C.  is  applied  within 
the  abdominal  cavity  during  the  time  corresponding  to 
the  exposure  and  manipulation  of  the  viscera  (about 
one  hour),  inoculation  by  pathogenic  or  non-patho- 
genic germs  seldom  results  in  infection  and  death. 

XV.  If  infection  does  occur,  death  is  delayed,  or 
seems  prevented,  as  a  result  of  the  procedure  de- 
scribed. Susceptibility  to  infection  is  not  materially 
decreased  by  the  external  application  of  heat. 

XVI.  Hot-water  bags  placed  in  the  abdominal  cav- 


ity during  an  operation  prevent  shock  or  collapse,  and 
also  produce  a  modified  immunity  or  lessen  the  sus- 
ceptibility to  infection. 

X\TI.  In  severe  operations,  when  extreme  shock  or 
collapse  is  present,  resuscitation  is  best  accomplished 
by  the  application  of  heat  within  the  stomach  and 
abdominal  cavity,  by  the  methods  already  described. 


AFTER-PAINS     FROM     EXTRACTION     OF 
TEETH. 

By   CHARLES   B.    IS.A.ACSOX,    M.D., 

NEW    VORK. 

There  is  no  condition  which  is  brought  oftener  to 
the  attention  of  the  medical  practitioner  than  what  is 
called  "after-pains"  from  extraction.  There  is  no 
subject  in  dentistry  which  has  been  touched  upon  less, 
or  to  which  so  little  special  attention  has  been  given, 
than  this  condition.  Here  and  there,  in  a  desultory 
way,  suggestions  of  methods  and  remedies  have  been 
made,  but  in  all  of  them,  as  far  as  my  research  goes, 
there  has  never  been  any  direct  attempt  to  fathom  the 
causes  and  to  approach  the  condition  radically. 

This  condition  of  after-pains  generally  arises  one 
or  two  days,  or  even  a  week,  after  the  offending  mem- 
ber has  been  extracted.  The  symptoms  vary  in  in- 
tensity from  causes  which  I  shall  proceed  to  enu- 
merate. 

The  average  practitioner,  when  called  upon  to  re- 
lieve patients  suffering  with  after-pains,  or  as  the 
Germans  call  it,  "  Zahnliickenschmerz,"  is  generally 
puzzled  how  to  proceed,  not  knowing  the  exact  nature 
of  the  condition  presented  to  him,  the  appearance 
being  so  unusual,  the  swelling  so  intense,  with  un- 
doubted signs,  in  a  large  majority  of  cases,  of  pus 
burrowing  under  and  through  the  tissues,  that  the  first 
impression  is  the  indefinite  expression  "blood  poison- 
ing," which  in  ninety-nine  cases  I  look  upon  as  a 
snapshot  diagnosis. 

The  direct  physico-pathological  causes  are  dimly 
recognized,  and  relief  is  sought  by  the  usual  antiseptic 
measures,  which,  in  minor  insignificant  cases,  may  be 
successful. 

The  local  application  of  cocaine  in  solution  to 
highly  inflamed  tissues  I  hold  to  be  reprehensible; 
for  tissues  in  that  condition  do  not  absorb  the  medica- 
ment, and  the  danger  of  a  harmful  quantity  of  the 
drug  being  swallowed  is  great.  Again,  I  cannot  dep- 
recate too  strongly  what  I  may  call  the  wanton  use 
of  hot  poultices  on  the  face;  it  seems  as  if  the  inter- 
vening thickness  of  the  facial  muscles  is  entirely 
ignored,  while  the  result  obtained  is  only  the  further 
infiltration  of  pus,  and  the  extension  of  the  intlamma- 
tion  to  tissues  which  had  been  entirely  normal,  thus 
causing  the  original  trouble  to  be  exacerbated. 

In  some  cases  it  may  be  necessary  to  use  heat  in 
order  to  lessen  the  tension,  but  surely  it  is  only  logical 
to  apply  the  heat  directly  to  the  parts  affected,  which 
can  be  very  easily  done  by  using  pledgets  of  cotton  or 
pieces  of  gauze,  folded  to  a  sufficient  size,  steeped  in 
hot  water  (one  or  two  per  cent,  solution  of  carbolic 
acid  is  suggested)  or  a  hot  infusion  of  chamomile  flow- 
ers. The  heat  is  thus  applied  directly  where  it  is 
wanted.  I  have  always  found  cold  packs  contraindi- 
cated. 

I  wish  to  enumerate  the  possible  causes  of  after- 
pains,  and  at  the  same  time  venture  to  suggest  the 
means  of  relieving  the  same:  ( i )  the  retention  of  the 
pyogenic  membrane  in  the  socket;  (2)  expansion  of 
the  osseous  walls;  (3)  fracture  of  the  alveolus;  (4) 
sundering  of  the  maxillary  process  and  alveolus,  with 
accompanying  lacerations  of  the  tissues;  (5)  the  re- 
tention  of  roots  and  spicula  in  the  socket;   (6)  that 


Au 


gust 


1 1,  I 


900] 


MEDICAL    RECORD. 


117 


particular  condition  of  the  alveolus  and  septum  from 
which  the  gum  tissues  have  been  denuded  by  the  en- 
croaching of  salivary  calculi ;  (7)  the  inflammation 
of  the  tissues  and  the  undermining  of  the  alveolus 
from  perforation  by  pus  from  long-standing  pyorrhceal 
discliarges  or  alveolar  abscesses  from  old  roots. 

1.  The  retention  of  the  pyogenic  membrane  is  gener-. 
ally  followed  by  acute  pain.  When  a  tooth  with  septic 
pericementitis  is  extracted,  the  pericementum  may  or 
may  not  be  attached  to  the  root.  As  there  is  an  in- 
tense inflammation  with  plastic  exudations,  the  chances 
are  that  the  pericementum  will  still  adhere  to  the 
lining  membrane.  In  order  to  relieve  this  condition, 
it  is  necessary  to  remove  all  clots,  and  to  curette  the 
socket.  For  this  a  small,  blunt  curette,  or  preferably 
a  rose  burr  in  the  dental  engine,  should  be  used.  As 
a  soothing  application,  I  have  found  the  following  pre- 
scription very  effectual,  used  on  a  tampon  in  the  socket : 

^  Mentholi, 

Acidi  carbolici, 

Tinct.  iodi aa  3  i. 

Ether.. 

Chloroform aa  j  ss. 

M.     S.    External  use. 

Of  course,  after  the  curetting  it  is  necessary  to  irri- 
gate the  socket  with  a  solution  of  hydrogen  peroxide, 
plus  any  antiseptic,  optional  with  the  practitioner. 

2.  The  expansion  of  the  osseous  walls.  This  con- 
dition will  require  careful  examination,  and  is  usually 
met  with  when  the  tooth  has  been  difficult  to  extract 
on  account  of  the  unyielding  walls,  and  is  generally 
most  noticeable  when  the  lower  wisdom  teeth  have 
to  be  excised  from  the  thickened  alveolus.  In  a 
large  number  of  these  cases,  the  outer  or  the  inner 
wall  has  been  bent,  and  possibly  slightly  fractured. 
In  many  such  cases  I  have  found  the  usual  methods 
of  irrigating  and  packing  of  little  or  no  avail.  The 
suffering  is  usually  intense,  while  the  swelling  inter- 
feres with  deglutition,  and  the  pocket  becomes  a 
veritable  receptaculum  for  mucus,  food,  and  unhealthy 
granulations.  In  these  cases  I  have  managed  to  ob- 
tain relief  in  a  very  short  time  by  using  the  rose  burr 
and  cutting  away  the  bent  ridge,  burring  away  all  the 
irregular  edges,  making  the  parts  as  smooth  as  pos- 
sible. This  is  to  be  followed  by  irrigating  and  pack- 
ing, and,  I  believe,  with  signal  success.  In  minor 
cases,  in  which  the  alveolus  has  been  bent  out  of 
shape,  compression  of  the  parts,  with  thorough  cleans- 
ing of  the  cavity,  will  answer.  I  have  always  been 
suspicious  of  cases  in  which  the  alveolus  has  been 
luxated,  and  always  feel  more  confident  when  I  have 
removed  that  part. 

3.  Fracture  of  the  alveolus.  This  would  require 
the  removal  of  the  fractured  part,  smoothing  of  all 
the  irregular  points,  the  usual  thorough  irrigation  and 
antiseptic  treatment. 

4.  Sundering  of  the  maxillary  process  and  alveolus, 
together  with  laceration  of  tissues.  This  will  present 
to  the  practitioner  the  appearance  of  a  large  surface, 
intensely  inflamed,  caused  by  the  gum  contracting 
over  the  serrated  edges  (for,  like  all  tissues,  the  gum 
forms  a  cicatrix,  which  exerts  considerable  pressure). 
The  gum,  in  trying  to  contract  over  these  sharp  points, 
becomes  intensely  inflamed,  the  pus  burrows  under- 
neath, forming  pockets  along  the  whole  ridge,  and 
owing  to  the  sack-like  condition  is  generally  in  a  sep- 
tic condition. 

The  treatment  in  this  case  is  to  relieve  the  condition 
by  one  or  more  incisions  parallel  to  the  axis  of  the 
maxillary;  then  with  the  curette,  or  still  better  with 
the  burr,  all  irregularities  of  the  alveolus  and  maxillary 
should  be  cut  away,  so  that  the  surface  is  absolutely 
smooth.  A  thorough  irrigation  of  the  parts  and  pack- 
ing them  with  antiseptic  gauze  will  bring  about 
desired  results.     In  deeper  cavities   I   have   used   al- 


most every  remedy  recommended,  but  have  found  that 
none  possessed  the  analgesic  properties  of  iodoform, 
and  though  this  is  so  objectionable  by  reason  of  its 
odor,  it  seems  to  do  its  work. 

5.  When  there  is  retention  of  the  root,  and  spicula 
are  in  the  pocket,  the  cavity  is  to  be  cleansed  of  the 
spicula;  and  if  the  root  cannot  be  removed  by  for- 
ceps or  is  too  small  to  be  grasped,  it  can  be  burred 
out. 

6.  This  condition  is  a  peculiar  one,  but  easily 
recognized  and  diagnosticated.  This  occurs  mostly 
with  teeth  which  have  become  elongated  from  want  of 
antagonism;  the  roots  are  more  or  less  exposed;  de- 
posits take  place  on  them,  pushing  the  tissues  farther 
up  from  the  alveolar  wall,  leaving  it  and  the  septum 
denuded.  After  extraction  (these  teeth  are  often 
pulled  out  by  the  patient  himself),  the  gum  refuses  to 
cover  the  necrotic  wall  and  septum — hence  painful 
consequences  follow. 

Relief  in  this  case  is  very  easily  obtained  by  cutting 
away  the  dry,  friable,  necrotic  bone  until  the  healthy 
bone  is  reached.  The  usual  antiseptic  treatment  and 
irrigation  are  in  order. 

7.  Perforation  of  the  alveolus  from  an  invasion  of 
pus.  When  repeated  perforations  have  taken  place  in 
the  alveolar  wall,  it  may  be  assumed  that  the  nutri- 
tion of  this  bone  has  been  largely  interfered  with^ 
impaired,  or  arrested,  and  that  the  wall  thus  under- 
mined really  becomes  a  sequestrum.  The  appear- 
ance of  such  a  condition  would  be  a  large  pocket,  a 
bulla  of  pus  outside  the  ridge,  considerable  swelling, 
and  possibly  the  burrowingof  pus  in  several  directions. 
This  condition,  I  have  noticed  in  a  large  number  of 
cases,  takes  place  long  after  extraction.  The  treat- 
ment for  the  same  would  be  a  crucial  incision,  removal 
of  the  necrotic  wall  or  sequestrum,  and  a  smoothing 
of  the  parts,  irrigation  and  packing  as  in  the  preceding 
cases. 

As  these  cases  come  under  the  observation  of 
physicians  who  are  called  in  to  correct  the  blood- 
poisoning,  which  the  patient  is  always  supposed  to 
have,  and  as  a  great  deal  of  censure  is  given  to  the 
dentist  for  having  extracted  the  tooth  so  brutally  or 
so  unskilfully,  I  wish  to  say  that  I  have  sufficient 
respect  for  the  ability  of  my  confreres  to  know  that 
these  conditions  are  never  produced  intentionally,, 
and  that  they  are  due  to  causes  which  may  be  beyond 
their  ken,  and  which  arise  unexpectedly.  Much  may 
be  ascribed  to  the  neglect  of  the  patient.  The  medi- 
cal practitioner,  not  being  familiar  with  the  mouth, 
resorts  to  general  antiseptic  treatment,  whereas  these 
conditions,  as  before  mentioned,  can  be  known  only 
to  the  dental  practitioner  and  oral  surgeon,  and  should 
be  handed  over  to  the  dental  practitioner  instead  of 
worrying  the  patient  with  a  long  course  of  treatment, 
futile  in  the  end  and  generally  accompanied  by  a 
liberal  dose  of  opium. 

In  performing  these  operations,  I  have  found  it 
more  advisable  to  do  so  by  the  aid  of  ethylic  chloride 
or  the  injection  of  cocaine.  The  use  of  nitrous-oxide 
anaesthesia  I  have  found  impracticable  on  account  of 
its  short  duration  and  the  danger  of  using  the  dental 
burr  in  a  hurry.  Of  course,  in  some  cases,  anjesthesia 
by  ether  or  chloroform  is  absolutely  necessary  to  per- 
form the  operation  thoroughly. 

I  have  not  mentioned  the  possible  inoculation  from 
unclean  instruments.  Such  cases  have  to  be  diagnosti- 
cated/^a-  sc'.  I  have  omitted  to  mention  the  pains 
which  may,  and  often  do,  arise  in  neurasthenic  patients ; 
pains  which  persist  in  syphilitic  patients;  and  finally 
the  vagaries  of  the  female  nervous  system  during 
pregnancy  and  the  catamenia.  These  require  the 
careful  attention  of  the  medical  practitioner  for  con- 
stitutional treatment,  with  the  advisable  collabora- 
tion of  a  dental    surgeon.     Every  practitioner  fastens 


2l8 


MEDICAL   RECORD. 


[August  1 1 ,  1 900 


upon  some  remedy  which  has  proved  faithful  to  him; 
so  the  selection  of  any  preparation,  from  mercuric 
bichloride  down  to  boric  acid  and  formalin  solutions, 
is  purely  optional. 

To  conclude,  I  \  ish  to  convey  the  idea  that  such 
pains  are  caused  only  by  foreign  substances,  whether 
they  are  spicula,  sequestra,  tissue,  clots,  mucus,  or  food 
retained  in  the  socket;  and  the  removal  of  these  is 
paramount  in  any  local  treatment  that  can  be  used. 

101  East  Sixtieth  Street. 


A  New  Method  of  Catheterization  of  the  Eusta- 
chian Tube G.   Ostino,  noting  that  when   the  letter 

"  e  "  is  pronounced  the  soft  palate  raises  itself  and  the 
Eustachian  cushion  approaches  the  median  line,  sug- 
gests the  following  method:  A  mark  is  made  on  the 
curve  of  the  catheter  7  cm.  from  its  tip.  The  catheter 
is  then  passed  in  the  usual  manner  until  the  mark  is 
opposite  the  entrance  of  the  nose,  this  distance  of  7 
cm.  being  the  average  distance  between  the  anterior 
and  posterior  nares.  The  patient  then  phonates  "e" 
(English)  in  a  continuous  tone,  at  which  moment  the 
catheter  is  rotated  externally.  Ostino  claims  that  this 
manoeuvre  will  positively  engage  the  tip  of  the  catheter 
in  the  pharyngeal  orifice  of  the  tube. — Archivo  Italiano 
di  Otologia,  etc.,  x.,  i,  1900. 

Curable  Forms  of  Hydrophobia  in  Man. — G.  Daddi 
reports  the  case  of  a  young  surgeon  who  was  bitten  by 
a  dog  in  the  left  popliteal  region ;  the  wounds  were  not 
deep,  and  were  cauterized  with  pure  ammonia.  The 
patient  came  to  the  Anti-hydrophobic  Institute  in 
Florence  for  treatment  merely  as  a  precautionary  meas- 
ure, being  firmly  convinced  that  the  dog  was  not  mad. 
An  examination  of  the  dog's  head  proved  that  it  had 
rabies,  but  the  patient  was  kept  in  ignorance  of  the 
fact.  He  developed  fever,  paralysis  of  the  detrusor 
urinae,  paraplegia  with  abolition  of  patellar  reflexes, 
and  pains  in  the  lower  limbs;  but  the  symptoms 
finally  subsided,  and  complete  recovery  ensued.  By 
a  process  of  exclusion,  the  author  comes  to  the  con- 
clusion that  the  complex  of  symptoms  was  due  to  in- 
oculation with  the  virus  from  a  rabid  dog. — Rivista 
Critica  di  Cliiiica  Alcdica,  June  30,  1900. 

Colic  Pains — Lucke  analyzes  the  various  possibil- 
ities involved  in  the  etiology  of  colic,  concluding  that 
the  painful  seizure  is  always  the  result  of  tension,  and 
that  muscular  spasm,  though  often  a  predisposing  or 
aggravating  factor,  is  not,  as  usually  thought,  to  be 
considered  the  prime  cause.  When  the  increase  in 
pressure  is  so  gradual  that  dilatation  can  keep  pace 
with  it,  no  colic  results,  as  is  true  of  the  cases  of  pain- 
less hydrops  of  the  gall  bladder;  when  tlie  stoppage 
is  sudden,  however,  as  when  it  is  due  to  an  impacted 
gall  stone,  the  pressure  rises  rapidly  and  the  tension 
produces  severe  pain.  Intestinal  colic  and  the  pain 
clue  to  impaction  of  a  renal  calculus  in  the  ureter  are 
explicable  on  the  same  grounds.  Pure  renal  colic 
unaccompanied  by  the  existence  of  stones  is  due  to 
an  intense  and  sudden  congestion. —  Wiener  klinische 
Wocheiischrijt,  July  5,  1900. 

The  Roentgen  Rays  in  Diseases  of  the  Nose, 
Throat,  and  Neighboring  Organs. — John  Maclntyre, 
who  has  done  more  work  in  this  special  direction  than 
any  one  else,  makes  a  strong  plea  for  the  systematic 
examination  of  cases  with  the  .r-rays  in  order  to  ob- 
tain accurate  information  as  to  the  relative  value  of 
these  and  other  methods  of  diagnosis.  In  the  major- 
ity of  cases  of  traumatic  lesions,  aneurism,  malignant 
disease,  glandular  enlargement,  fluid  effusions,  de- 
posits in  the  lung,  etc.,  other  signs  are,  as  a  rule, 
present,  and  the  shadows  obtained  by  the  A--rays  have, 


therefore,  only  a  place  among  the  different  aids  to 
diagnosis;  but  in  a  minority  of  cases  he  has  been  able 
to  obtain  by  the  rays  information  which  otherwise 
could  not  have  been  obtained.  He  believes  that  in 
the  hard  tissues  we  may  profitably  use  the  rays  in  the 
study  of  the  anatomy  of  the  nose,  antrum,  and  spine, 
and  may  detect  fractures  and  injuries  of  the  nose  and 
maxillary  walls  and  tumors.  In  the  soft  tissues  we 
may  be  able  to  make  out  cardiac  enlargement,  trans- 
position of  the  viscera,  mediastinal  gland  enlargement, 
malignant  and  other  neoplasms  of  the  jaw  and  chest, 
abscesses,  collections  of  fluid  in  the  chest,  deposits  in 
the  lung,  etc.  Moreover,  we  can  ascertain  the  pres- 
ence of  foreign  bodies  in  the  antrum,  nose,  pharynx, 
upper-air  tract  generally,  and  in  the  oesophagus. — 
Journal  oj  Laryngology,  July,  1900. 

A  Case  of  Acetanilid  Habit — G.  W.  Gaines  writes 
that  some  four  years  ago  acetanilid  was  prescribed  for 
a  negro  adult  suffering  from  rheumatism.  He  found 
that  he  was  relieved  by  its  administration,  but  on 
leaving  off  the  medicine  for  a  few  days  the  pain  re- 
turned. So  he  began  taking  it  constantly  each  day. 
Now  he  uses  two  ounces  each  week  and  has  been  do- 
ing this  for  some  months.  It  is  not  stated  whether 
the  man  suffers  any  ill  effects  of  his  habit. — New 
Orleans  Medical  and  Surgical  Journal,  July,  1900. 

Abscess  of  the  Cerebellum. — M.  Dieulafoy  de- 
scribes a  case  with  the  details  of  the  post-mortem  find- 
ings. Abscess  of  the  cerebrellum  is  nearly  always 
due  to  otitis.  The  symptoms  which  it  causes  are  oc- 
cipital headache,  vertigo,  ictus,  loss  of  equilibrium, 
titubation,  vomiting,  nystagmus,  cervical  contracture, 
optic  neuritis,  muscular  asthenia,  somnolence,  torpor 
closely  allied  to  coma.  Facial  paralysis  and  paralysis 
of  the  external  oculomotor  nerve  may  occur,  as  in  the 
case  described.  In  abscess  of  the  cerebrum  the  motor 
disorders,  the  paresis,  contractures,  and  spasms  are  on 
the  side  opposite  to  the  lesion  and  to  the  otitis,  and 
word-blindness  and  hemianopsia  further  constitute  the 
differential  diagnosis.  Tumors  of  the  cerebellum,  as 
glioma,  gliosarcoma,  etc.,  give  the  same  complex  of 
symptoms,  but  rarely  in  so  simple  a  form,  as  their  ten- 
dency to  invade  surrounding  parts  causes  the  addition 
of  other  symptoms.  Surgical  intervention  is  the  only 
form  of  treatment  possible  in  cases  of  cerebellar  ab- 
scess.— Bulletin  dc  l' Academic  de  Aledecine,  June  26, 
1900. 

The      Varicose     Osteo-Hypertrophic      Naevus. — 

Klipper  and  Trenaunay  under  this  title  describe  a 
congeries  of  symptoms  which  they  consider  sufficient- 
ly constant  to  be  grouped  as  a  specific  disease.  In 
the  light  of  their  own  observations  and  of  many  cases 
culled  from  the  literature,  they  would  establish  the 
following  as  the  characteristic  tripos  of  the  sympto- 
matology: (i)  A  naivus  covering  the  lower  extremity 
and  metameric  in  its  distribution;  (2)  varicosities 
limited  to  the  diseased  side  and  congenital,  or  dating 
from  early  infancy;  (3)  hypertrophy  of  all  the  tissues 
of  the  diseased  side,  but  involving  particularly  the 
bony  structures,  which  are  increased  in  length, 
breadth,  and  thickness.  In  addition  to  these  there 
are  many  other  less  important  and  more  variable  le- 
sions. The  skin  may  be  wrinkled  and  dry,  show  scars 
of  old  ulcers,  or  be  covered  with  desquamating  patches 
resembling  ichthyosis;  sometimes  elephantiasis  is  a 
complication,  or  the  cutaneous  surface  may  be  indurated 
and  scaly.  The  hair  is  usually  absent  in  the  neigh- 
borhood of  the  nffivus.  The  nails  are  striated,  brittle, 
and  deformed.  Hyperidrosis  may  exist,  and  frequently 
the  deformity  is  increased  by  the  hypertrophy  of  the 
cellular  and  fatty  tissue,  which  may  produce  more  or 
less  circumscril)t-(l  tumors. — Archives  Generales  dt 
Midecine,  June,  1900. 


August  11,1 900] 


MEDICAL   RECORD. 


219 


Medical   Record: 

A    Weekly  Journal  of  Medicine  and  Snrgeiy. 
GEORGE    F.    SHRADY,    A.M.,    M.D.,  Editor. 

I'lBLISHERS 

WM,   WOOD   &.  CO.,  51    Fifth   Avenue. 


New  York,  August  11,  1900. 


ANTITYPHOID    INOCULATION. 

The  question  as  to  whether  inoculation  against  ty- 
phoid fever  is  a  successful  means  of  either  prevention 
or  cure,  or  of  both,  is  of  the  utmost  importance  to 
this  country  as  well  as  to  almost  all  the  countries  of 
Europe  in  the  present  unfortunate  combination  of 
events  in  the  Far  East.  China  is  a  land  in  which 
sanitation  is  at  a  notoriously  low  ebb,  and  whose  in- 
habitants wholly  disregard  the  ordinary  laws  of  hygiene 
as  understood  by  Western  people.  This  being  so, 
judging  from  the  experience  gained  in  former  wars, 
disease  will  doubtless  figure  more  largely  in  the  death 
roll  among  the  troops  engaged  in  the  task  of  bringing 
about  order  in  the  Celestial  Empire  than  will  injuries 
produced  by  shot  and  shell. 

Of  all  the  maladies  which  strike  down  the  soldier 
in  the  field  none  claims  so  large  a  share  of  victims  as 
does  enteric  fever.  This  is  a  truism.  Even  in  lands 
where  sanitation  is  carried  out  in  a  more  or  less  effec- 
tive manner,  there  have  as  yet  been  discovered  no 
absolutely  sure  methods  of  preventing  this  disease  or 
of  staying  its  spread  when  it  has  once  broken  out  and 
has  gained  headway  among  a  large  body  of  men. 
This  fact  was  plainly  demonstrated  in  the  military 
camps  formed  in  this  country  during  our  war  with 
Spain.  It  is  true  that  typhoid  fever  is  classed  as  a 
preventable  disease,  but  it  is  an  extremely  difficult 
matter  to  prevent  it  under  all  the  conditions  of  war, 
and  infinitely  more  difficult  to  check  its  ravages  when 
its  germs  are  being  disseminated  within  the  confines 
of  a  camp. 

Undoubtedly  strict  sanitary  supervision  and  care 
will  go  far  toward  preventing  an  outbreak  of  this  dis- 
ease and  toward  nipping  in  the  bud  a  threatened  epi- 
demic. But  when  all  has  been  said  that  is  to  be  said 
on  the  subject,  it  must  be  acknowledged  that  much  yet 
remains  to  be  learned  concerning  the  etiology  and  the 
most  efifective  mode  of  fighting  and  controlling  the 
disease.  It  is  therefore — and  especially  in  view  of 
the  crisis  in  China — with  feelings  of  the  liveliest  and 
most  serious  interest  that  the  reports  of  the  results  of 
the  serum  treatment  of  enteric  fever,  to  which  many 
British  soldiers  now  in  South  Africa  were  subjected,  are 
being  watched  by  scientific  and  medical  men  through- 
out the  world.  Although  inoculation  against  typhoid 
fever  has  been  practised  in  the  British  army  in  India 


for  a  few  years,  and  although  Professor  Haffkine  de- 
clares that  it  has  been  successful  in  reducing  the  mor- 
tality there  to  a  very  large  extent,  the  statistics  to  hand 
are  not  sufficiently  convincing  altogether  to  uphold 
this  statement,  and  the  method  may  to  all  intents  and 
purposes  be  said  to  be  now  on  its  trial.  Opinions  of 
the  medical  men  serving  with  the  British  army  in 
South  Africa  are  conflicting.  Sir  William  MacCormac 
says;  "No  decided  opinion  can  yet  be  given  on  this 
point,  since  there  are  no  sufficient  data  for  statistics. 
The  observations  made  seem  to  show  that  those  inocu- 
lated are  less  apt  to  take  the  disease,  or  if  they  are 
attacked  they  have  it  in  a  milder  form;  but  the  ques- 
tion is  still  sul>  jiidice."  TJr.  Conan  Doyle  writes 
in  the  most  eulogistic  strain  in  regard  to  the  immuniz- 
ing or  rather  the  protective  properties  of  the  serum. 
He  says:  "There  is  one  mistake  we  have  made 
which  I  think  will  not  be  repeated  in  any  subsequent 
campaign.  Inoculation  for  enteric  fever  was  not  made 
compulsory.  If  it  had  been  so  I  believe  that  we 
should  (and,  what  is  more  important,  the  army  would) 
have  escaped  from  most  of  its  troubles.  No  doubt 
the  matter  will  be  fully  threshed  out  in  statistics,  but 
our  strong  impression  from  our  own  experience  is  that 
although  it  is  by  no  means  an  absolute  preventive  it 
certainly  modifies  the  course  of  the  disease  very 
materially.'"  Surgeon-General  Jameson,  as  was  men- 
tioned in  the  Medical  Record  of  July  21st,  does 
not  seem  to  be  very  enthusiastic  in  respect  to  anti- 
typhoid serum  as  an  immunizing  agent,  although  he 
naturally  speaks  in  somewhat  guarded  terms. 

A  correspondent  of  the  Lancet  from  the  front  gives 
his  views  as  follows:  "At  present  it  is  perhaps  too 
early  to  condemn  inoculation  against  typhoid  fever. 
It  certainly  does  not  prevent  a  person  from  con- 
tracting the  disease,  and  it  seems  doubtful  whether 
the  inoculated  person  will  show  any  greater  immunity 
than  the  non-inoculated  person.  Slight  attacks  have 
occurred  in  both  classes  of  patients,  and  two  in  this 
hospital  have  succumbed  to  the  disease.  On  a  priori 
grounds  one  would  hardly  expect  that  a  preventive- 
serum  treatment  would  be  successful  in  a  disease 
which,  after  it  has  existed  for  something  like  three 
weeks,  cannot  protect  a  person  from  a  relapse.  More- 
over, second  attacks  are  by  no  means  unknown,  and 
one  patient  had  a  most  severe  second  attack  of  typhoid 
fever  from  which  he  died;  so  that  a  previous  attack 
does  not  seem  either  to  protect  from  the  disease  or  to 
lessen  its  severity.'" 

Again,  to  judge  from  the  statistics  relating  to  the 
action  of  the  serum  during  the  siege  of  Ladysmith, 
the  conclusion  one  would  arrive  at  is  that,  while  in- 
oculation affords  a  measure  of  protection  from  attack, 
those  inoculated  suffer  more  severely  when  seized  with 
enteric  fever  than  those  not  inoculated.  Nevertheless, 
if  Dr.  Conan  Doyle  and  others  are  right  in  claiming 
for  antityphoid  inoculation  protective  properties  how- 
ever modified,  a  most  valuable  discovery  has  been 
surely  made.  Further  and  more  accurate  statistics 
from  Africa  will  be  needed  to  elucidate  the  matter, 
and  until  that  time  no  decided  opinion  regarding  the 
value  of  the  serum  can  be  formulated. 


220 


MEDICAL    RECORD. 


[August  1 1 ,  1 900 


FISTULA    AFTER    OPERATIONS  FOR 
APPENDICITIS. 

When  a  fistula,  with  mucous  or  fecal  discharge, 
persists  after  an  operation  for  appendicitis  we  have  to 
deal  with  a  situation  always  awkward  for  us,  and  un- 
comfortable or  dangerous  for  the  patient.  We  know 
that  a  fistula  is  most  likely  to  result  in  those  cases  in 
which,  in  the  presence  of  suppuration  and  necrosis  of 
tissue,  operation  is  deferred,  and  least  likely  to  occur 
in  cases  in  which  the  appendix  is  removed  while  the 
inflammatory  process  is  confined  to  the  interior  of  that 
organ,  and  the  wall  of  the  caecum  is  in  healthy  condi- 
tion. This  gives  us  a  good  idea  of  some  of  the  local 
conditions  which  are  followed  by  fistula,  and  enables 
us  to  lay  down  rules  which  do  not  favor  delay  in  the 
operative  treatment  of  the  disease. 

When  we  find  the  cacum  swollen  and  oedematous, 
with  purplish  or  even  black  or  dark-green  spots  in  its 
wall  in  the  neighborhood  of  a  more  or  less  gangre- 
nous and  sloughing  appendix,  we  know  that  a  fistula  is 
not  infrequently  the  sequel,  and  we  also  know  that  the 
local  conditions  mentioned  are  seen  in  those  cases  in 
which  operative  intervention  has  been  delayed  beyond 
safe  limits.  Some  of  these  fistuljE  heal  spontaneously 
after  longer  or  shorter  intervals  even  when  they  are 
left  severely  alone,  and  others  pursue  a  course  of  ex- 
treme vexation  to  patient  and  surgeon.  The  best  treat- 
ment for  them  does  not  seem  to  be  settled,  if  we  can 
judge  by  a  recent  discussion  at  the  meeting  of  the 
American  Medical  Association,  but  there  is  certainly 
no  doubt  that  the  only  cure  is  by  operation,  which  is, 
however,  attended  with  considerable  mortality.  Some 
fistulte  appear  as  practically  straight  tracts  lined  wdth 
granulation  tissue  and  leading  to  the  caecum  at  or  near 
the  original  insertion  of  the  appendix.  Such  fistute 
will  at  various  times  discharge  mucus,  gas,  pus,  or 
fecal  matter  in  varying  proportions.  In  addition  to 
straight  fistulas  like  these,  there  may  also  be  present 
various  degrees  of  tortuosity  and  complexity,  and  there 
may  be  branches  running  into  various  parts  of  the 
iliac  and  pelvic  connective  tissue  which  can  add  con- 
siderably to  the  difficulty  of  an  attempt  at  operative 
cure. 

We  may  also  sometimes  see  fistulae  which  are  caused 
by  the  presence  of  a  larger  or  smaller  remnant  of  the 
appendix  wilh  its  mucous  membrane,  which  goes  on 
secreting  and  thus  furnishes  the  discharge.  This  sort 
of  fistula  is  apt  to  be  most  amenable  to  the  milder 
forms  of  surgical  work,  but  is  not  likely  to  undergo  a 
permanent  spontaneous  cure.  The  chances  of  spon- 
taneous cure  in  the  other  form  is  not  great  if  the  con- 
dition has  shown  that  it  will  not  heal  within  eight  or  ten 
weeks  from  the  operation  for  the  acute  disease,  and 
something  of  a  radical  nature  will  probably  have  to 
be  done.  The  operation  which  will  be  found  to  give 
the  best  results  is  one  started  as  an  exploration  follow- 
ing the  tract,  and  developing  its  sinuosities  and  gen- 
eral character,  and  then  proceeding  as  conditions  de- 
mand. If  we  arrive  in  this  way  at  the  ca;cal  wall  and 
find  a  more  or  less  ragged  opening  through  it,  without 
much  change  in  the  iliac  connective  tissue,  or  even  if 
there  is  considerable,  a  suture  may  be  successful      In 


order  to  be  so,  however,  it  must  be  done  with  great  exact- 
ness, and  we  must  remember  that  we  have  no  longer 
the  advantage  oft'ered  by  the  quick  adhesion  of  fresh 
peritoneum  to  depend  upon,  but  that  we  are  working 
in  more  or  less  refractory  connective  and  muscular 
tissue.  The  sutures  should  be  applied  as  is  done  in 
the  case  of  wounds  of  the  bladder,  and  it  seems  a  good 
plan  to  treat  the  more  superficial  parts  of  the  wound 
to  some  extent  at  least  by  the  open  method.  Great 
care  is  necessary  to  prevent  some  of  the  secondary 
tracts  from  estaping  our  attention.  If  some  such 
attempt,  perhaps  necessarily  repeated,  is  made  in  these 
cases  of  fistula,  it  will  probably  very  rarely  be  necessary 
to  perform  the  much  more  serious  operation  of  intes- 
tinal resection,  wliich  is  decidedly  not  free  from  risk. 


SATURNINE  INTOXICATION  THROUGH  THE 
USE   OF    LEAD  OINTMENT. 

Too  much  emphasis  cannot  be  laid  on  the  injunction, 
in  the  treatment  of  a  given  condition,  to  seek  the 
cause  and  direct  therapeutic  measures  against  it, 
although  it  is  appreciated  that  it  is  necessary  at  times 
to  give  consideration  to  individual  symptoms.  Thus, 
in  the  treatment  of  aniemia  or  of  glottic  spasm  or  of 
convulsions,  it  is  of  the  utmost  importance  to  deter- 
mine the  underlying  factors,  for  unless  these  are  re- 
moved a  permanent  curative  result  cannot  be  hoped 
for.  The  convulsive  seizure  that  sometimes  attends 
the  onset  of  acute  febrile  disorders  can  scarcely  be 
looked  upon  as  a  physiological  manifestation;  else  it 
would  be  more  common  than  it  is.  Under  such  cir- 
cumstances a  careful  study  of  the  family  history  may 
reveal  some  predisposing  influence.  When  the  ten- 
dency to  convulsions  is  thus  well  defined  it  may  some- 
times be  counteracted  by  the  timely  administration  of 
a  sedative,  such  as  the  bromides.  If,  for  instance,  it  is 
known  that  a  child  is  generally  seized  with  convulsions 
as  a  result  of  febrile  disturbance,  the  attack  may  often 
be  aborted  by  prompt  treatment  with  bromides  at  the 
time.  Less  is  certainly  to  be  feared  from  this  sporadic 
administration  of  the  sedative  than  from  the  convul- 
sive seizures  themselves. 

A  febrile  convulsion  may  be  epileptic  or  uraemic  or 
due  to  auto-intoxication,  or  possibly  to  poisons  intro- 
duced from  without.  Some  observations  bearing  upon 
the  last-named  mode  of  origin  are  recorded  by  Hahn 
{Archh<  Jiir  Kindcrheilkunde,  B.  28,  H.  3  u.  4,  1900), 
who  briefly  records  two  cases  in  childreii  under  treat- 
ment for  eczema  of  the  scalp  with  lead  ointment,  in 
which  convulsions  occurred  and  saturnine  intoxication 
was  suspected,  and  a  third  case  of  similar  kind,  also 
attended  with  convulsions,  in  which  death  resulted 
and  the  existence  of  plumbism  was  determined 
chemically.  This  last  case  occurred  in  a  child  nine 
months  old,  presenting  an  old  and  neglected  eczema 
of  the  Jace  and  head,  for  the  relief  of  which  an  oint- 
ment containing  lead  oxide  was  prescribed,  the  mother 
being  carefully  instructed  to  return  at  short  intervals. 
This  injunction  was,  however,  not  obeyed,  and  after 
the  lap.se  of  four  months  the  little  patient  was  found 
in  convulsions,  without  fever  and  with  a  hard,  running 


August  1 1 ,.  1 900] 


MEDICAL    RECORD. 


221 


pulse.  In  spite  of  removal  of  the  ointment,  the  appli- 
cation of  sulphur,  and  the  administration  of  bromides, 
the  convulsive  attack  was  repeated,  and  the  child 
subsequently  became  comatose.  A  dark  line  was 
found  on  the  gums  around  one  of  the  teeth.  The 
fontanelle  was  bulging;  the  knee  jerks  were  increased; 
the  eye-grounds  were  normal.  The  urine  contained 
a  trace  of  albumin,  and  uric  acid  in  large  amounts. 
Lumbar  puncture  was  performed,  and  20  c.c.  of  clear 
fluid  permitted  to  escape.  The  child,  however,  failed 
to  rally,  and  death  resulted.  Histological  examina- 
tion failed  to  disclose  any  degeneration  of  the  gan- 
glion cells  of  the  cerebral  cortex,  and  chemical  examina- 
tion revealed  the  presence  of  lead  in  the  brain  tissue. 
It  is  pointed  out  that  the  diagnosis  in  this  case  might 
have  been  overlooked  if  it  had  not  so  happened  that  the 
condition  was  being  eagerly  searched  for.  The  con- 
vulsions were  not  distinctive,  and  the  subsequent  coma 
might  have  been  due  to  uraemia  or  to  persistent  cere- 
bral pressure.  Urjemia  was,  however,  excluded  by  the 
results  of  examination  of  the  urine,  and  a  number  of 
cerebral  disorders  by  the  results  of  lumbar  puncture. 


THE  THIRTEENTH  INTERN.A.TIONAL  MEDI- 
CAL   CONGRESS. 

The  Paris  Congress,  a  full  report  of  which,  cabled 
by  the  special  correspondents  of  the  Medic.vl  Record, 
is  presented  to  our  readers  in  this  issue,  will  undoubt- 
edly be  looked  back  upon  as  one  of  the  more  notable 
of  this  series  of  international  gatherings — notable  for 
its  numerous  attendance  if  not  for  its  scientific  im- 
portance. The  attraction  of  \.\\&fin-de-siecle  Exposition 
doubtless  drew  many  whose  scientific  ardor  might  not 
otherwise  have  impelled  them  to  travel  so  far  to  take 
part  in  a  purely  medical  meeting.  The  large  attend- 
ance of  the  Germans  sufficed  to  offset  the  absence  of 
the  English,  who  were  kept  away  partly  because  of  the 
not  very  cordial  political  relations  between  France 
and  their  country,  and  also  by  the  fact  that  the  meet- 
ing of  the  British  Medical  Association  at  Ipswich  was 
held  at  the  same  time.  The  Americans  were  in  greater 
force  than  at  any  previous  international  medical  con- 
gress, except,  of  course,  the  one  at  Washington,  and 
ihey  were  not  only  present  but  took  a  prominent  part 
in  the  proceedings  of  several  of  the  sections.  Dr. 
Jacobi,  in  his  well-meant  though  rather  unnecessarily 
apologetic  address,  presented  the  claims  of  American 
medicine  to  recognition  by  the  world  at  large;  but  if 
the  physicians  and  surgeons  of  the  United  States  will 
speak  for  themselves  at  future  congresses  as  they  did  at 
this,  there  will  hereafter  be  no  more  need  of  apologists 
for  American  medicine  than  there  is  now,  we  take  the 
liberty  of  reminding  our  eminent  fellow-citizen,  of 
apologists  for  American  politics.  Full  as  is  our  special 
report  of  the  scientific  work  of  the  congress,  it  is  im- 
possible to  judge  from  it  of  the  real  importance  of  the 
work  done  at  Paris,  and  it  will  be  necessary  to  wait  for 
the  more  complete  mail  reports  in  order  to  form  a  just 
estimate  of  the  congress  on  its  scientific  side.  That  it 
would  be  a  success  socially  was  a  foregone  conclusion. 
The  Frenchman  as  a  host  is  unapproachable. 


2>eius   of  tTte  'QxEcefe. 

Sanitary  Reforms  in  Manila.  —  Dr.  J.  J.  Curry, 
recently  in  the  Philippines,  is  reported  in  an  interview 
on  the  health  conditions  of  the  islands  as  follows: 
"The  hygienic  conditions  are  greatly  improved.  The 
board  of  health  has  made  a  new  city  of  Manila.  The 
people  seemed  to  know  nothing  of  sanitary  laws,  and 
did  not  know  what  sanitation  meant.  The  lepers  have 
been  rounded  up,  and  are  kept  in  a  large  roomy  hospital 
with  spacious  grounds,  which  was  formerly  a  convent. 
A  tent  quarantine  has  been  established  for  plague  and 
other  diseases.  Native  and  Chinese  inspectors  have 
charge  of  tiieir  respective  quarters,  and  have  done 
efficient  work.  The  general  condition  of  the  troops 
is  very  good,  considering  their  hard  work  and  long 
marches.  The  supplies,  both  food  and  medical,  are 
plentiful,  even  in  the  interior,  although  they  have  to 
be  drawn  for  miles  and  miles  in  bull  carts.  Hospitals 
are  established  all  over  the  islands  and  in  every 
garrison  town.  In  the  larger  hospitals  there  are  trained 
women  nurses  in  addition  to  the  hospital-corps  men. 
The  convalescent  hospital  at  Corregidor  Island  is  a 
splendid  institution,  beautifully  situated  on  the  crest 
of  a  hill,  where  it  receives  the  cool  breezes  of  the 
China  Sea." 

Erratum. — In  a  report  of  the  meeting  of  the  Amer- 
ican Association  of  Genito-Urinary  Surgeons,  pub- 
lished last  May,  Dr.  Chismore  was  credited  with  rec- 
ommending a  particular  preparation  of  urotropin. 
He  writes  that  he  was  incorrectly  reported,  not  hav- 
ing recommended  the  preparation  in  question,  but 
having  inquired  what  the  experience  of  others  with  it 
had  been. 

Yellow  Fever.— Several  cases  of  this  disease  were 
discovered  on  August  2d  at  Tampa,  Fla.,  which  are 
supposed  to  have  been  imported  from  Cuba.  On  Au- 
gust 3d  Dr.  Weedon,  of  the  State  board  of  health,  is- 
sued a  statement  announcing  that  there  had  been  one 
death  there  from  yellow  fever,  and  that  there  were  two 
other  cases  known  to  exist  in  the  city  at  that  time.  In 
Havana,  despite  stringent  sanitary  precautions,  yellow 
fever  is  now  on  the  increase,  fifty  cases  being  under 
treatment  on  Tuesday  of  this  week.  The  mortality  has 
been  thus  far  usually  low.  This  disease  is  also  re- 
ported to  be  on  the  increase  in  Pinar  del  Rio.  The 
Louisiana  board  of  health  decided  on  August  2d  to  en- 
force a  quarantine  of  five  days  against  all  Central 
American  fruit  vessels  carrying  passengers.  The 
Louisiana  inspector  at  Port  Limon,  Costa  Rica,  has 
reported  several  cases  of  suspicious  fever  and  one  of 
acknowledged  yellow  fever,  and  it  is  believed  the 
board  has  information  of  the  presence  of  the  disease 
at  others  of  the  Central  American  ports.  The  United 
States  Consul  at  Progreso,  Mexico,  reports  that  yellow 
fever  in  malignant  form  prevails  at  Merida,  Yucatan, 
and -that  the  epidemic  is  spreading. 

Dr.  S.  A.  Knopf,  of  this  city,  has  received  the  in- 
ternational prize  of  4,000  marks  offered  by  the  Berlin 
Tuberculosis  Congress  for  the  best  popular  essay  on 


222 


MEDICAL    RECORD. 


[August  1 1 ,  1 900 


"Tuberculosis  as  a  Disease  of  the  Masses  and  How  to 
Combat  it."  The  committee  of  award  was  composed 
of  some  of  the  best-known  clinicians  and  sanitarians 
of  Germany,  among  tiiem  being  Leyden,  B.  Fiiinkel, 
Gerhardt  and  Leuthold.  There  were  eighty -one  com- 
petitors. .\ccording  to  the  terms  of  the  competition, 
the  German  committee  for  the  erection  of  sanatoria 
for  the  tuberculous  will  publish  the  essay  in  a  cheap 
form  for  popular  distribution.  Dr.  Knopf  already  tn- 
joys  a  wide  reputation  as  a  worker  in  this  field,  and  to 
him  was  awarded  in  1898  the  Alvarenga  prize  of  the 
College  of  Physicians  of  Philadelphia  for  an  essay  on 
"  Pulmonary  Tuberculosis,  its  Modern  Prophylaxis  and 
Treatment  in  Special  Institutions  and  at  Home." 

Dr.  G.  E.  Morrison,  the  Peking  correspondent  of 
the  London  1'imcs,  is  a  physician  who  received  his 
medical  education  in  Melbourne  and  London.  He  is 
thirty-six  years  old  and  an  Australian  by  birth. 

An  Ambulance  Wrecked. — An  ambulance  of  the 
Harlem  Hospital,  in  which  were  seated  Dr.  Levy  and 
the  driver,  was  struck  by  a  trolley  car  of  the  Second 
Avenue  line  on  Saturday.  The  ambulance  was  thrown 
against  an  elevated  railroad  pillar  and  badly  wrecked. 
Dr.  Levy  was  thrown  out  and  received  some  injury. 

The  Physicians  of  Lake  Keuka.— The  second  an- 
nual meeting  of  the  physicians  of  the  Lake  Keuka 
(N.  Y.)  region  will  be  held  at  the  Grove  Springs  Hotel 
in  that  resort,  on  August  14th  and  15th.  The  pro- 
gramme contains  twenty-nine  titles  of  papers  to  be 
read  at  the  meeting.  The  secretary  of  the  association 
is  Dr.  W.  W.  Smith,  of  Avoca,  N.  Y. 

The  Prince  of  Wales  was  elected  an  honorary  fel- 
low of  the  Royal  College  of  Surgeons  on  the  occasion 
of  the  centenary  of  the  society's  foundation  on  July 
26th.  His  Royal  Highness  is  now  a  full-fledged,  all- 
around  honorary  medical  man,  the  Royal  College  of 
Physicians  having  made  him  an  honorary  fellow  some 
time  ago.  We  believe  he  still  lacks  the  honorary 
M.D.,  but  he  can  buy  that  in  Chicago  for  a  pound  or 

tW'O. 

The  International  Congress  of  Deontology  and 
Professional  Medicine  was  held  in  Paris  on  July  23d 
to  27th.  Many  subjects  relating  to  medical  ethics 
and  to  the  dispensary  and  hospital  abuse  were  dis- 
cussed, but  most  of  the  papers  were  of  local  interest, 
dealing  with  conditions  peculiar  to  France  and  hap- 
pily unknown  as  yet  in  our  own  country.  Some  of  the 
points  of  medical  eticjuette  discussed  were  amusing  in 
their  triviality,  and  gave  occasion  to  the  exercise  of 
an  amount  of  casuistry  that  would  have  delighted  a 
medieval  theologian.  Concerning  the  word  "  deontol- 
ogy," Dr.  Grasset  said  it  was  created  by  Bentham,  the 
British  jurist,  who  published  in  1747  a  work  entitled 
"  Deontology,  or  the  Science  of  Duty."  Dr.  Lereboul- 
let.  the  president  of  the  congress,  defined  medical  deon- 
tolog)  as  the  science  of  the  duty  of  the  medical  man 
to  the  public,  to  his  patients,  and  to  his  professional 
colleagues.  Deontology  sprang  from  the  soul.  It  fol- 
lowed the  principles  of  equity ;   it  engendered  a  sense 


of  refinement;  it  produced  harmony;  it  obliterated 
strife;  and,  though  the  most  vague,  it  was  the  most 
powerful  force,  directing  the  life  and  the  daily  acts  of 
the  physician. 

Recognition    of    a    Predecessor    of    Pasteur. — A 

monument  has  been  erected  at  La  Teste  de  Buch,  in 
the  Department  of  the  Gironde,  France,  to  Dr.  Jean 
Hameau,  the  humble  practitioner  whose  study  of 
viruses,  published  in  1836,  partly  anticipated  the  dis- 
coveries of  Pasteur. 

Sir  William  MacCormac  was  unanimously  re-elected 
president  of  the  Royal  College  of  Surgeons  of  England 
for  the  fifth  time  at  its  centenary  meeting  on  July  26th. 
Sir  William  Savory  was  president  for  three  years  in 
succession,  but  Sir  William  MacCormac  holds  the  rec- 
ord for  length  of  service. 

The  Lunacy  Exhibit  at  Paris. — Secretary  T.  E. 
McGarr,  of  the  State  commission  in  lunacy,  has  been 
awarded  the  first  prize  at  the  Paris  Exposition  for  the 
best  exhibit  showing  the  progress  made  during  the 
past  hundred  years  in  the  care  of  the  insane.  Mr. 
McGarr's  exhibit  of  photographs,  statistics,  and  work- 
ing models  collected  from  all  parts  of  the  country  form 
a  complete  presentation  of  the  progress  in  the  therapeu- 
tics of  insanity  in  the  United  States  during  this  cen- 
tury. 

A  Leper  Colony  in  the  Philippines. — A  board  con- 
sisting of  Major  Louis  M.  Maus,  surgeon,  Capt.  George 
P.  Ahren,  Ninth  Infantry,  and  Capt.  W.  E.  Horton,  as- 
sistant quartermaster,  has  been  convened  by  General 
McArthur  in  Manila  to  select  an  island  in  the  Philip- 
pine archipelago  for  the  segregation  of  lepers,  to  pre- 
pare plans  and  estimates  for  suitable  buildings  thereon, 
and  estimates  of  salaries  for  the  necessary  officials  and 
employe's.  The  board  is  also  charged  with  fixing  the 
ration  and  other  allowances  for  the  support  of  such 
leper  colony. 

The  Medical  Work  in  China The  army  medical 

staff  of  the  Department  of  California  has  begun  prep- 
arations for  the  care  of  sick  and  wounded  in  China, 
initiating  its  work  by  sending  out  twelve  ambulances 
and  fifty  hospital  tents.  Some  uneasiness  has  been 
caused  by  the  breaking  out  of  glanders  among  the 
twelve  hundred  horses  at  the  Presidio  stables  belong- 
ing to  the  various  cavalry  regiments  and  awaiting 
shipment  to  China.  As  soon  as  the  presence  of  glan- 
ders was  discovered,  the  eight  infected  animals  were 
shot,  and  it  is  hoped  an  epidemic  may  be  averted. 

Sewage  in  the  Seine.  —  Despite  the  rapid  succes- 
sion of  congresses  on  medicine  and  hygiene  in  Paris 
this  summer,  the  health  conditions  of  that  city  are  far 
from  satisfactory.  The  water-supply  is  so  limited  that 
it  is  shut  off  a  large  portion  of  each  day,  and  it  is 
feared  that  an  actual  water  famine  may  be  experienced. 
Then  the  sewer  system  seems  to  iiave  broken  down, 
and  vast  quantities  of  filth  are  poured  into  the  Seine 
because  tiie  territories  at  a  few  miles'  distance  from 
Paris  which  were  to  receive  it  for  agricultural  purposes 
are  not  sufficiently  extensive.     The  manufacturing  dis- 


August  II.  1900] 


MEDICAL    RECORD. 


22' 


tricts  close  to  the  capital  have  apparently  no  sewerage 
system  at  all,  with  the  consequence  that  below  Paris, 
all  along  that  picturesque  bend  of  the  Seine  which  ex- 
tends as  far  as  St.  Germain,  the  river  is  charged  with 
filth  of  all  sorts  and  sends  forth  horrible  emanations. 

Davos. — The  health-resort  companies  at  Davos- 
Platz  and  Davos-Dorf  have  combined,  and  the  two  re- 
sorts will  be  conducted  under  one  management  to  be 
known  as  the  "  Kurverein  Davos." 

The  Study  of  Tropical  Medicine.— It  is  stated  in 
The  LiJihct  that  the  Liverpool  Sciiool  of  Tropical  Medi- 
cine has  received  a  communication  from  the  expedition 
which  was  despatched  last  month  to  America  en  route 
for  Brazil,  to  the  effect  that,  at  the  suggestion  of  Sur- 
geon-General Sternberg,  the  expedition  had  joined  for 
a  short  period  the  official  yellow-fever  expedition 
which  the  government  has  just  despatched  to  Cuba. 

The  Plague  in  London  and  Hamburg. — Four  cases 
of  plague  were  discovered  on  a  steamer  arriving  at 
London  from  the  East  the  first  of  this  month.  The 
disease  was  among  the  Lascars  in  the  crew,  and  two  of 
those  affected  died.  A  case  has  also  been  discovered 
on  a  ship  recently  arrived  at  Hamburg  from  the  Orient. 
In  both  cities  all  possible  precautions  have  been  taken 
to  prevent  the  spread  of  the  disease. 

Dr.  Frederick  E.  Potter,  of  Portsmouth,  was  unani- 
mously nominated  for  governor  of  New  Hampshire  by 
the  Democratic  State  convention  on  August  1st.  Dr. 
Potter  is  a  graduate  of  the  medical  department  of  the 
University  of  Vermont  in  i860.  As  elections  usually 
go  in  New  Hampshire,  there  is  not  much  danger  that 
the  candidate  will  be  forced  to  give  up  his  practice  in 
order  to  discharge  gubernatorial  duties. 

Gagging  the  Contract  Surgeons.— An  interesting 
fact  has  come  to  light  in  connection  with  the  inquiry 
which  the  British  government  has  instituted  into  the 
hospital  management  during  the  war.  The  civilian 
surgeons  employed  in  the  military  hospitals  have  been 
required  by  the  British  Army  Medical  Department  to 
sign  a  contract  not  to  divulge  in  any  way  what  their 
impressions  may  be  on  hospital  matters. 

The  Cecil  County  (Md.)  Medical  Society.— At  a 
meeting  held  August  2d,  Dr.  William  T.  Skinner,  of 
(ilasgow,  Del.,  read  a  paper  on  "  Typhoid  Fever  with 
Particular  Reference  to  the  Temperature  Range."  Dr. 
Howard  Bratton,  of  Elkton,  Md.,  presented  a  commu- 
nication on  "  Some  of  the  Unusual  Manifestations  of 
Typhoid  Fever."  Dr.  A.  Robin,  of  Newark,  Del.,  read 
a  paper  on  "TheW'idal  Test,  with   Demonstrations." 

The  Lehigh  Valley  Medical  Association.— The 
twentieth  annual  meeting  of  this  association  will  be 
held  at  the  Neversink  Mountain  Hotel,  near  Reading, 
on  Thursday,  August  i6th.  The  programme  in- 
cludes: (i)  The  president's  address,  "Relation  of 
Medical  Professions  to  the  Physical  Culture  of  Chil- 
dren," by  Dr.  Israel  Cleaver,  of  Reading,  (2)  the  ad- 
dress upon  invitation  of  the  Berks  County  Society,  by 
Dr.  J.  Milton  Duff,  of  Pittsburg,  on  "Modern  Obstet- 
rics"; (3)  the  annual  address  before  the  Lehigh  Val- 


ley Medical  Association,  by  Dr.  F.  A.  Harris,  of  Pat- 
erson,  N.  J.,  on  "Certain  Pathological  Conditions  of 

the  Fallopian  Tubes  of  Interest  to  the  General  Practi- 
tioner." 

The  Eyesight  of  School-Children.— Dr.  Wallace 
Pyle,  who  was  commissioned  by  the  Jersey  City  board 
of  education  to  examine  the  eyes  of  the  pupils  of  Pub- 
lic School  No.  1,  has  submitted  a  report  of  his  investi- 
gation. He  examined  three  hundred  and  fifteen 
pupils.  Of  these  only  sixty-nine  had  perfect  eves, 
and  seventy-one  of  the  whole  number  were  in  danger 
of  permanent  injury  because  of  neglect  to  provide 
them  with  glasses.  In  the  majority  of  cases  the  de- 
fect was  slight  and  capable  of  correction  by  glasses. 
There  were  nine  cases  of  trachoma. 

Navy  Department,  Bureau  of  Medicine  and  Sur- 
gery, Washington,  D.  C. — Changes  in  the  medical  corps 
of  the  L'nited  States  navy  for  the  week  ending  August 
4,  1900.  July  28th. — Medical  Director  G.  W.  Woods 
detached  from  the  naval  hospital,  New  York,  August 
18th,  and  ordered  home  and  to  wait  orders.  Medical 
Director  H.  J.  liabin  ordered  to  duty  in  charge  of  the 
naval  hospital.  New  York,  August  i8th.  Passed  As- 
sistant Surgeon  L.  L.  von  Wedekind  detached  from  the 
Indiana  and  ordered  to  the  naval  hospital,  Chelsea, 
Mass.,  for  treatment.  Assistant  Surgeon  M.  K.  Elmer 
ordered  to  the  Boston  navy  yard,  August  ist.  July 
31st. — Pharmacist  F.  T.  Gordon  warranted  pharmacist 
from  July  25,  1900.  August  ist. — Passed  Assistant 
Surgeon  T.  W.  Richards  detached  from  the  Alachias 
when  put  out  of  commission,  and  ordered  to  the  Indi- 
ana. Assistant  Surgeon  C.  H.  Delancy  ordered  to  ad- 
ditional duty  at  the  naval  hospital,  Newport,  R.  I. 
Assistant  Surgeon  A.  Stuart  detached  from  the  Yank- 
ton and  ordered  to  temporary  duty  on  the  tug  Fortune 
at  the  New  York  navy  yard,  August  4*11. 

Obituary  Note.s. — Dr.  Elisha  Chenerv  died  at  his 
home  in  Boston  on  August  ist.  He  was  born  in  Liver- 
more,  Mass.,  on  August  23,  1829.  He  began  the 
study  of  medicine  at  Bowdoin  College,  and  afterward 
entered  Harvard  Medical  School,  from  which  he  was 
graduated  in  1853.  In  1862  he  passed  for  a  surgeon 
in  the  army,  and  started  for  the  front,  but  soon  after 
was  taken  ill,  and  compelled  to  resign.  After  thirteen 
years  of  practice  in  Maine,  he  went  to  Massachusetts, 
residing  three  years  in  Cambridge,  and  since  1870  in 
Boston.  He  was  a  member  of  the  Maine  Medical  As- 
sociation, also  a  fellow  of  the  Massachusetts  Medical 
Society,  and  a  member  of  the  American  Medical  As- 
sociation. 

Dr.  Frederick  W.  Hulseberg  was  killed  recently 
by  a  Filipino  sniper  near  Majajay,  fifty-five  miles 
from  Manila.  He  had  been  in  charge  of  the  hospital 
there  for  several  months.  He  was  born  in  India,  but 
came  to  this  country  from  England  while  a  boy.  He 
was  in  the  insurance  business  in  this  city  for  several 
years,  and  then  entered  the  Yale  Medical  School. 
Cpon  graduation  he  was  appointed  on  the  house  sta.ff 
of  the  Connecticut  General  Hospital  in  New  Haven, 
but  resigned  to  enter  the  army  as  acting  assistant  sur- 
geon, and  was  sent  immediately  to  the  Philippines. 


224 


MEDICAL    RECORD. 


[August  1 1,  1900 


S 


progress  of  HXctlical  J>cieuce. 


Journal  of  /he  Am,- run  11  Medical  Ass'n.   Aug.  4.  igoo. 

Four  Cases  of  Malaria  Associated  with  Acute  Abdominal 
Pain.— J.  A.  Capps  reports  a  number  of  cases  from  the 
Massachusetts  General  Hospital,  in  all  of  which  (1)  there 
were  intermittent  fever,  nausea  and  vomiting,  and  en- 
largement of  the  spleen;  (21  there  was  acute  abdominal 
pain  of  such  intensity  that  exploratory  laparotomy  was 
considered  by  men  of  experience  ;  (3)  the  acute  pain  sub- 
sided along  with  the  fever  and  with  the  other  symptoms 
after  the  administration  of  quinine  ;  (4)  typical  intracellu- 
lar forms  of  the  tertian  parasite  of  malaria  with  motile  pi.g- 
meiit  granules  were  present  in  the  peripheral  blood,  but 
were  never  very  numerous  ;  (5)  leucocytosis  was  invaria- 
blv  absent ;  (6)  a  considerable  degree  of  anjemia  of  the  sec- 
ondary tvpe  existed.  The  pain  was  attributed  to  some  co- 
existing disease  or  to  neuralgia  from  malarial  poison,  or  to 
both  combined.  Multiple  neuritis  in  malarial  subjects,  su- 
pra-orbital and  intercostal  neuralgias,  cardialgia,  enteral- 
gia,  etc.,  are  discussed  with  the  pathology  of  the  condition. 
Periodicity,  enlargement  of  the  spleen,  and  especially  the 
finding  of  organisms  in  the  blood,  lead  to  the  diagnosis  in 
cases  of  abdominal  pain  of  obscure  origin. 

Myomectomy  per  Vaginam.— J.  Riddle  Goflfe  points  out 
the  value  of  myomectomy  as  contrasted  with  hysterectomy 
for  fibroids,  and  the  superiority  of  the  vaginal  method,  car- 
rying out  his  conservatism  in  gyuEecological  surgery.  He 
believes  in  removing  the  diseased  portions  but  saving  the 
uterus  Three  illustrative  cases  are  reported,  in  which  the 
general  rule  is  followed  that  uteri  presenting  small  fibroid 
tumors  are  usually  retroverted.  He  believes  that  the  dis- 
placement affords  the  necessary  conditions  for  the  develop- 
ment of  the  tumors,  and  that  the  origin  is  very  close  to  in- 
terference with  the  circulation  as  a  cause.  The  facility 
afforded  by  the  vaginal  method  of  approach  for  the  cure  of 
the  retroversion  is  an  additional  factor  in  its  favor.  There 
is  also  less  danger,  convalescence  is  smoother  and  simpler, 
there  are  no  visible  scar  and  no  danger  of  hernia. 

Myofibroma  Uteri.— H.  J.  Boldt  finds  the  greatest  num- 
ber of  these  tumors  to  be  encapsulated  and  readily  enu- 
cleated. He  believes  that  fibromyomata  arise  from  the 
muscularis  of  the  capillaries.  The  greatest  number  of  ad- 
enomyomata,  however,  have  their  origin  m  the  Wolffian 
body.  The  various  changes  which  may  occur  in  hbromy- 
oma  are  discussed.  Sarcoma  is  to  be  suspected  if  a  tumor 
long  stationary  begins  to  give  rise  to  complex  symptoms. 
Abdominal  hysterectomy  in  the  hands  of  an  expert  should 
not  give  a  greater  mortality  than  simple  ovariotomy. 
There  is  a  limited  field  for  electricity,  but  only  for  pallia- 
tive treatment,  and  it  is  indicated  only  m  interstitial 
growths  of  moderate  size.  Ligation  of  the  uterine  arteries 
is  a  method  which  does  not  bear  the  test  of  time. 

Arrhythmia  Cordis  Complicating  Fibromata  Uteri.— J.  W. 
Bovee  concludes  as  follows  :  (i )  Arrhythmia  cordis  is  not 
yet  well  understood  ;  (2)  as  a  complication  of  fibromata 
uteri  it  is  exceedingly  rare  ;  (3)  it  has  a  serious  import,  the 
degree  of  which  depends  upon  the  condition  causing  it ;  (4) 
its  presence  as  a  complication  of  conditions  requiring  sur- 
gical operations  necessitates  a  careful  inquiry  into  its  cause 
before  the  operation  is  performed  ;  (5)  it  is  a  contraindica- 
tion of  more  or  less  influence  in  all  cases  requiring  surgical 
operation  ;  (6)  if  not  due  to  a  severe  pathological  lesion 
other  than  that  for  which  the  operation  is  to  be  performed, 
its  presence  does  not  necessarily  prohibit  operation,  but 
offers  an  additional  obstacle  to  the  patient's  recovery. 

Improved  Technique  in  Major  and  Minor  Surgery  of  the  Fe- 
male Generative  Organs.— By  H.  R.  Newman. 

The  Value  of  Section  Work  and  how  to  Advance  it.— By 
Edwin  Rosenthal. 

The  Angiotribe  in  Abdominal  Surgery.— By  H.  M.  Taylor. 

r/w  Xe-o  York  Mcdiial  Journal.  August  4,  /goo. 
Hysteria  ;  its  Nature  and  Etiology.— C.  L.  Mix  believes 
that  hysteria  in  its  local  manifestations  is  limited  to  psy- 
chical processes.  Although  the  disturbed  centre  is  m  the 
cerebral  cortex,  still  all  the  manifestations  of  hysteria^ap- 
pear  in  all  possible  territories  of  the  nervous  system.  The 
nature  of  the  disturbance  of  the  cerebral  cortex  may  be  one 
of  three  types  :  (i)  There  may  be  a  deadening  of  the  sen- 
sory excitability  of  the  cerebral  cortex  resulting  in  symp- 
toms of  hypresthesia,  anaesthesia,  hypalgesia.  and  anal- 
gesia ;  or  a  deadening  of  the  cortical  motor  discharge, 
resulting  in  paVesis  and  paralvsis.  (2)  There  may  be  an 
iutensifi'catiou  of  the  perception  of  the  entering  impulse 
manifested  by  hyperalgesia  and  hypersesthesia ;  or  an  in- 
tensification of  the  energy  of  the  motor  discharge,  resulting 
in  spasms  and  convulsions,  often  reflex  in  character.  (3) 
There  may  be  confusional  interpretation  of  entering  im- 


pulses, manifested  by  symptoms  of  parjesthesia  ;  or  confii- 
sion  in  the  motor  discharge  of  cortical  cells,  resulting  in 
hysterical  ataxia,  and  in  such  contractures  as  are  due  to 
the  imperlect  distribution  of  motor  impulses  to  groups  of 
opposing  muscles.  Predisposing  causes  include  herediiy, 
age,  sex,  protracted  and  exhausting  diseases,  .sexual  dis- 
orders, and  faulty  home-training.  Exciting  causes  are 
psychical  and  physical  trauma,  suggestion,  and  various 
toxaemias. 

Appendicitis  ;  When  to  Operate.— J.  H.  Carstens  advises 
to  operate  when  the  diagnosis  is  made,  except  when  the 
environment  is  bad,  when  no  experienced  opera  tor  or  prop- 
er facilities  are  at  hand,  and  in  mild  first  attacks.  As 
regards  diagnosis,  he  says  that  if  we  bear  in  mind  that  in 
most  cases  the  patient  first  complains  of  pain  in  the  region 
of  the  stomach  with  more  or  less  nausea,  and  has  a  high 
temperature,  but  notice  that,  as  often  hapjjens  in  such 
cases,  the  pain  in  the  region  of  the  stomach  and  the  nausea 
subside  within  twenty-four  hours,  and  that  the  only  sore- 
ness complained  of  is  in  the  region  of  the  appendix  (always 
assuming  that  opium  has  not  been  given),  then  we  shall 
not  make  a  mistake  very  often  in  diagnosticating  appen- 
dicitis. 

On  the  Treatment  of  Metacarpal  Fracture.— Carl  Beck  be- 
lieves that  metacarpal  fragments  can  be  invariably  held 
in  place  by  elastic  pressure.  For  this  purpose  two  rubber 
drainage  tubes  of  moderate  size  are  chosen,  which  are 
lightly  pressed  into  the  adjoining  interosseous  spaces  so 
that  they  fill  them  up  to  a  certain  extent.  They  are  kept 
in  situ  by  adhesive-plaster  strips.  Thus  the  recurrence  of 
the  displacement  is  prevented.  The  whole  is  surrounded 
then  by  a  moss  splint,  a  material  which,  after  being 
dipped  in  cold  water,  adapts  itself  to  the  contours  of  the 
hand  like  a  plaster-of-Paris  splint,  over  which  it  possesses 
the  great  advantages  of  being  absorbent  and  much  lighter. 
Glandular  Complications  of  Acute  Follicular  and  Acute  Sup- 
purative Amygdalitis  when  Accompanied  with  Grippe.  — ^\■.  C. 
Phillips  has  found  this  class  of  cases  quite  frequent  during 
the  past  year.  The  disease  has  in  some  cases  involved  the 
superficial,  in  ethers  the  deep,  glands.  The  cases  generally 
present  the  usual  tvpe  of  grippe  symptoms  with  follicular 
tonsillitis,  the  patient's  apparent  recovery  being  followed 
by  pain  in  the  side  of  the  neck,  a  very  extensive  swelling, 
and  a  rise  of  temperature.  Suppuration  has  occurred  in 
his  experience  in  about  half  the  cases.  In  one  instance, 
long  streptococci  were  found  in  the  pus. 

A  Case  of  Enlargement  of  the  Liver  and  Spleen  Succeeding 
Chronic  Catarrhal  Cholangeitis.— By  S.  S.  Cornell. 

The  Present  State  of  "the  Galvano-Caustic  Operation  of  Bot- 
tini  for  Ischuria.— By  Grenville  MacGowan. 
Vulvo-Vaginitis  in  Children.— By  H.  B.  Sheffield. 

Boston  Medical  and  Surgical  Journal,  August  2,  igoo. 
The  Transportation  of  Disease  by  Dust.— Harold  C.  Ernst 

says  that  of  the  irritant  action  of  dust  upon  the  respiratory 
apparatus  there  can  be  no  doubt,  as  is  illustrated  by  the 
photomicrographs  of  the  dust  from  the  streets,  which  show 
a  variety  of  minute  jagged  particles  of  mineral  and  vege- 
table origin.  This  material  also  carries  living  forms  of  the 
higher  bacteria.  E.  Germano  has  thoroughly  studied  the 
subject  of  the  possibility  of  the  transmission  of  pathogenic 
bacteria  by  dust.  He  concludes  that  it  is  a  settled  matter 
that  they  must  be  dry  to  render  their  transportation  by 
dust  at  all  probable.  The  bacteria  of.  typhoid,  cholera, 
plague,  influenza,  and  gonorrhoea  resist  drying  for  so  long 
a  time  that  their  chances  of  transmission  are  slight.  The 
streptococci,  piieumococci,  and  diphtheria  bacillus  may  be 
carried  by  dust,  as  they  show  great  variation  in  their  re- 
sistance to  drying.  The  diplococcus  intracellularis,  the 
staphylococcus  of  suppuration,  and  the  bacillus  of  tubercu- 
losis are  still  more  resistant  to  drying,  and  the  spore-pro- 
ducers—anthrax, malignant  oedema,  tetanus,  etc.— may 
resist  drying  for  an  'indefinite  period.  The  conclusion 
would  seem  to  be  that  the  danger  from  dust  is  greater  from 
its  direct  irritant  qualities  than  from  the  chance  of  trans- 
portation of  any  infectious  disease. 

The  Effects  of  Dust  on  the  Upper  Respiratory  Tract.— 
Samuel  W.  Langmaid  says  that  for  many  years  he  has  ob- 
served that  whenever  a  dust-storm  occurred  there  was  an 
outbreak  of  sore  throats.  Recovery  from  swelling  and 
ulceration  of  the  larynx  in  tuberculosis  of  the  throat  is 
made  much  more  diflicult  by  the  irritating  effects  of  a  dusty 
atmosphere.  The  author  scores  the  senseless  way  in  winch 
macadamized  streets  are  cleaned  ;  the  constant  watering, 
with  almost  no  swcepin.g.  together  with  the  attrition  of  tin 
surface  by  passing  vehicles,  soon  pulverizes  the  surface 
and  leaves  a  layer  of  dirt  which  is  again  wet  down,  to  be 
later  transformed  into  clouds  of  dust  under  the  influence  of 
strong  winds.  Better  pavements  should  be  put  down  in 
the  beautiful  and  expensive  city  of  Boston,  where  probably 
more  irritating  dust  can  be  found  in  the  atmosphere  than 
in  any  other  region  east  of  the  Mississippi  River. 


Augtist  1 1,  1900] 


MEDICAL    RECORD. 


225 


Effects  of  Dust  upon  the  Lungs. — Vincent  Y.  Bowditcli 
iir.ijes  agitation  in  Boston  in  regard  to  obtaining  an  abate- 
ment of  the  "  dust  nuisance. "  He  recalls  g<K)d  work  already 
done  by  medical  men  in  reference  to  street  watering,  but 
says  that  in  consequence  of  the  lack  of  proper  pavements 
the  citizens  of  Boston  have  had  to  endure  in  this  open  win- 
ter a  vile  atmospheric  condition.  He  has  patients  with 
delicate  throats  and  lungs  who  have  to  be  housed  ab.solutcly. 
when  with  the  streets  in  proper  condition  they  could  enjoy 
the  mild,  bracing  air  out-of-doors.  Asphalt  is  not  an  ideal 
pavement,  but  with  proper  <-are  and  regulation  to  prevent 
its  being  constantly  torn  up  or  replaced  by  inferior  mate- 
rial, it  has  thus  far. proved  in  our  American  cities  the  one 
which  possesses  the  greatest  advantages  and  the  fewest 
disadvantages  of  all  pavements  used  here. 

Asphalt   Pavements  ;   their  Nature  and   Desirability.  —  By 
Clillord  Richardson.  e.\])evt  on  ns])halt,  New  York. 
Recurrent  Luxation  of  the  Ulnar  Nerve. — By  F.  J.  Cotton. 

PIdladelphia  Medical  /ouriiat,  August  4,  ic/00. 

Antistreptococcic  Serum :  a  Case  in  Which  it  Was  Used 
with  Apparently  Remarkable  Results.  —  U.  H.  (ialloway  re- 
ports the  case  of  a  young  woman  sufiering  from  a  large 
swelling,  believed  to  be  an  abscess,  in  the  neck.  The  pa- 
tient's condition  was  critical,  but  an  operation  was  deemed 
inadvisable.  Antistreptococcic  serum  was  administered  in 
a  dose  of  10  c.c,  and  repeated  the  following  day  and  again 
two  days  later,  as  the  supposed  abscess  was  diminishing 
m  size.  Six  doses  in  all  were  given.  There  was  no  jjosi- 
tive  proof  that  the  swelling  in  the  neck  was  a  streptococcic 
abscess.  If  it  was,  however,  the  author  thinks,  there  could 
be  little  doubt  that  the  antistreptococcic  serum  saved  the 
patient's  life,  for  neither  of  the  consultants  believed  she 
would  survive  either  with  or  without  an  operation. 

Congenital  Tuberculosis. — Benjamin  F.  Lyle  reports  the 
case  of  a  child  born  at  term,  of  a  mother  who  w-as  practi- 
cally moribund  of  tuberculosis  at  the  time.  The  child  was 
evidently  ill  from  the  time  of  its  birth  ;  its  temperature  was 
subnormal  during  the  first  four  weeks,  then  for  twelve 
days  was  slightly  above  normal,  and  finally  hyperpyrexia 
ensued.  The  appetite  was  good  until  the  second  week  be- 
fore death,  which  occurred  about  ten  weeks  after  birth. 
Post-mortem  examination  showed  tuberculous  deposits  it; 
the  lungs,  liver,  spleen,  kidneys,  and  bronchial  glands. 
The  author  thinks  the  case  was  one  of  congenital  tuber- 
culosis. 

A  Case  of  Conjunctival  Burn ;  Recovery  Without  Sym- 
blepharon. — By  Howard  1'.  Hansell. 

Morbid  Conditions  Caused  by  the  Bacillus  Aerogenes  Cap- 
sulatus.— I'.y  William  II.  Welch. 

The  Early  Recognition  of  Ectopic  Pregnancy. — By  DeWitt 
G.  Wilcox. 

Mcdudl  W-ii's.   August  4,  tgoo. 

The   Treatment   of   Summer   Diarrhcea  in  Infants. — C.   G. 

Kerley  says  the  true  nature  of  summer  diarrhoea  is  not  ap- 
preciated by  the  rank  and  file  of  the  profession.  If  we  can 
bear  in  mind  that  in  so-called  "summer  diarrhoea"  vve  have 
a  disease  due  to  virulent  organisms,  much  will  be  accom- 
plished. The  child  is  poisoned.  Cholera  infantum  is  due 
to  direct  infection.  There  is  a  tendency  for  summer  diar- 
rhcea  to  get  well  if  left  to  itself.  The  treatment  is  simple, 
consisting  chiefly  in  elimination  and  diet.  Irrigation  is  of 
value  by  means  of  a  soft  catheter,  No.  14  English.  The 
writer  has  discarded  the  white  of  egg  in  milk  in  favor  of 
dextrinized  barley.  Opium  must  be  used  with  great  cau- 
tion. The-utmost  cleanliness  must  be  observed  in  prepar- 
ing the  infant's  food. 

The  Consumptive  in  Los  Angeles. — William  H.  Duckman 
saiys  many  patients  with  phthisis  come  annually  to  Los 
Angeles.  Many  arrive  exhausted  and  gasping  for  breath, 
only  to  die  within  a  few  days.  The  family  physician  is 
too  often  responsible  for  permitting  this.  There  is  no  ap- 
proach to  a  specific  remedy.  Country  life  in  the  open  air, 
easily  digested  food,  precautions  against  negligence,  and 
striving  to  get  well  are  the  essentials. 

The  Methods  of  Closure  of  Abdominal   Incisions.  — By  M. 

H.  Richardson. 

'T Iw  Lancet,  July  28.  igoo. 

Carbohydrates  and  Disease.— E.  Pritchard  and  E.  H.  Col- 
beck  enumerate  as  the  chief  methods  on  which  the  organ 
ism  relies  for  the  disposal  of  supplies  not  requisite  for  ordi- 
nary physiological  p  ocesses :  (i)  Complete  metabolism 
by  the  tissues,  with  removal  by  the  excretory  organs 
(luxus  consumption)  ;  (2)  loss  of  appetite,  vomiting,  diar- 
rhoea, and  protective  coating  of  the  absorbing  surfaces 
with  excess  of  mucus  :  (3)  the  metabolism  of  the  food  into 
incompletely  oxidized  end  products  and  their  removal  from 
the  body  with  more  or  less  detriment  to  the  organism  ;  (4) 
growth  of  normal  tis.snes  (hypertrophy) ,  and  g^ow'th  of  de- 
generate tissues  (mucoid,  amyloid,  adepoid)  ;  new  growths 


(tumors,  granulations),  and  leucocytosis  ;  (5)  loss  of  tis- 
sues, discharges  (purulent,  mucous,  .serous,  etc.),  and 
hemorrhage  ;  (6)  active  metabolism  with  the  production 
of  heat  (fevers)  ;  (7)  development  of  kinetic  energy,  rest- 
lessness, spasms  (tonic  and  clonic)  ;  (S)  parasites.  They 
study  especially  certain  clinical  problems  suggested  by  the 
third  heading  of  the  foregoing  list.  They  believe  that  an 
excess  of  carbohydrates  is  responsible  for  many  diseased 
conditions  such  as  rachitis,  rheumatism,  and  diabetes. 
This  condition  of  carbohydrate  excess  they  designate  as 
glycosachthicmia.  The  article  goes  quite  extensively  into 
certain  problems  in  physiological  chemistry  which  cannot 
be  followed   here. 

Tachycardia  Following  Enteric  Fever. — C.  Burland  treated 
tW'O  hundred  and  si.\ty-five  cases  of  enteric  fever  on  one  of 
the  transports  returning  from  South  Africa  to  Southamp- 
ton. The  lowest  pulse  rate  in  this  series  was  72  per  minute 
and  the  highest  was  150.  an  average  exactly  of  98.25.  In 
fifty-six  per  cent,  the  pulse  rate  was  80:  in  twenty-five 
per  cent,  it  was  gj  ;  in  ten  per  cent,  it  was  100  :  in  five  per 
cent,  it  was  no  ;  and  in  four  percent,  it  was  from  120 to  140. 
All  the  cases  were  in  the  convalescent  stage  when  seen  lay 
the  writer,  whose  attention  was  attracted  l;y  the  uniformly 
rapid  pulse  rate.  He  thinks  this  may  have  been  due  to  the 
great  privations  to  which  the  patients  h.ad  been  subjected 
previous  to  their  illness.  The  treatment  was  simple,  con- 
sisting of  free  stimulation  with  brandy  and  champagne, 
while  digitalis,  carbonate  of  ammonia,  and  strychnine  were 
the  drugs  chiefly  relied  uiion.  the  latter  being  administered 
hy])odermically  in  several  extreme  cases. 

A  Case  of  Abscess  of  the  Parotid  Gland  Presenting  Unusual 
Symptoms. — In  a  boy  aged  ten  years,  under  the  care  ot'  W. 
J.  Beveridge,  the  helix  of  the  ear  was  tilted  forward  by  an 
abscess  situated  in  the  groove  behind;  the  position  of  the 
zygoma  was  marked  by  a  hard  groove,  below  which  there 
were  cedema  and  deep  fluctuation  ;  and  there  was  consid- 
erable fi'dema  over  the  temporal  region  and  extending 
down  to  the  mastoid  process.  Both  tonsils  were  slightly 
swollen.  The  pus  sac  behind  the  ear  was  opened,  and  in 
twenty-four  hours  an  incision  was  made  into  the  parotid 
and  a  gauze  drain  inserted.  Considerable  pus  came  away 
in  the  course  of  a  few  days,  and  the  cedema  gradually  sub- 
sided. 

A  Further  Note  on  the  Influence  of  the  Temperature  of 
Liquid  Hydrogen  on  Bacteria. — A.  Macfayden  and  S.  Row- 
land find  that  no  appreciable  effect  is  produced  on  the 
vitality  of  such  organisms  as  bacilli  acidi  lactici.  typhosus, 
diphtheria,  anthracis,  coli  communis,  and  staphylococcus 
pyogenes  aureus,  etc.,  by  immersing  them  in  tube  cultures 
in  liquid  hydrogen,  in  which  for  about  ten  hours  thev  are 
ex])osed  to  a  temperature  of  — 252'  C.  The  hydrogen  was 
contained  in  a  vacuum-jacketed  vessel  immersed  in  liquid 
air. 

Addison's  Disease  and  Leucoderma. — Samuel  W'ilks,  who 
was  a  pupil  of  Addison,  says  that  many  cases  of  leuco- 
derma have  been  sent  to  him  during  the  last  half-century 
as  supposed  cases  of  Addison's  disease,  but  in  no  single 
case  has  this  assumption  proved  to  be  true.  The  paper  is 
in  the  main  a  historical  study  of  the  status  in  clinical  med- 
icine of  Addison's  disease,  and  a  repudiation  of  certain 
views  concerning  its  relation  to  leucoderma  which  the 
writer  asserts  have  been  wrongly  attributed  to  him. 

Pancreatitis  with  Special  Reference  to  Chronic  Pancreatitis, 
its  Simulation  of  Cancer  of  the  Pancreas,  and  its  Treatment  by 
Operation,  with  Illustrative  Cases. — Clinical  lecture,  by  Mayo 
Robson. 

The  Present  Position  of  Pharmacy. — Presidential  address 
before   the    British    Pharmaceutical   Conference,  by  E.  M. 

Holmes. 

Notes  on  Thrombosis  of  Cerebral  Veins  Occurring  in  a  Case 
of  Chlorosis. — By  E.  F.  M.  Neave. 

Hammer-Toe  and  Hallux  Valgus  and  Rigidus. ^Clinical  lec- 
ture, by  W.  Hawcud. 
The  War  in  South  Africa ;  Jottings  in   Burghersdorp. — By 

H.  Caiger. 

A  Case  of  Actinomycosis. — By  E.  T.  Jones. 

T he  Ilritish  Mcilical  /nurnal,  July  2S,  /goo. 
Oral  Sepsis  as  a  Cause  of  Disease. — William  Hunter  says 
that  for  every  case  of  gastric  or  other  affection  traceable  to 
pyorrhoea  alveolaris  a  hundred  are  found  associated  with 
other  dental  and  oral  conditions  of  sepsis.  All  the  various 
stomatitides  are  septic  in  nature  and  often  connected  with 
bone  disease  (teeth),  and  no  pus  organisms  are  so  virulent 
as  those  grown  in  connection  with  bone  necrosis.  Mouth 
asepsis  is  to  be  secured  by:  (i)  the  direct  application  to 
the  diseased  tooth  or  inflamed  gum  of  carbolic  acid  (i  .  20) , 
repeated  daily  for  just  so  long  a  period  as  the  patient  will 
persist  in  keeping  his  necrosed  tooth  or  fang  ;  still  better 
(2)  the  removal  of  all  diseased  useless  stumps  .  (3)  the 
most  scrupulous  daily  sterilizing  by  boiling  of  every  tooth- 


226 


MEDICAL    RECORD. 


[August  1 1,  fgoo 


plate  worn  ;  and  (4)  on  the  part  of  dentists  the  avoidance  of 
too  much  conservative  dentistry  and  of  the  use  of  contriv- 
ances like  "  bridges  "  which  cannot  jjossibly  be  kept  aseptic. 

A  Case  Bearing  upon  the  Pathology  of  Acromegaly.— 
P.  G.  Lodge  relates  a  history  in  which  there  was  stiffness 
of  the  right  knee,  which  wore  off  gradually  during  the  day. 
but  soon  became  constant.  There  were  swelling,  promi- 
nent veins,  and  pain  on  motion.  Nine  months  after  am- 
putation for  round-celled  sarcoma  the  hands  began  to  en- 
large, and  enlargement  of  the  other  knee  occurred.  The 
patient  died.  It  was  thought  that  secondary  deposits  might 
have  involved  the  pituitary  body  and  thus  caused  enlarge- 
ment of  the  hands.     No  autopsy  was  made. 

Hysteria  in  the  Male. — W.  T.  Greene  relates  the  following 
case.  During  a  paroxysm  of  pain  from  ingrowing  toe-nail 
there  was  complaint  of  severe  heart-pam,  and  the  patient 
slid  from  the  chair  to  the  Hoor  and  was  seized  with  violent 
paroxysms,  throwing  himself  about,  striking  the  head,  and 
snapping  with  the  teeth  at  friends  who  tried  to  restrain 
him.  On  recover}'  there  was  no  recollection  of  what  had 
occurred.  The  single  attack  was  attributed  to  nervous  ex- 
haustion as  a  result  of  severe  pain  in  the  toe. 

Dark  Sclerotics  and  Fragilitas  Ossium.— A.  Eddowes  has 
observed  the  tendency  to  broken  bones  in  those  having 
very  dark  sclerotics.  At  the  recent  meeting  of  the  Der- 
matological  Society  of  Great  Britain  he  showed  such  a  case 
and  mentioned  others.  Surgeons  seem  not  to  have  noted 
the  association.  The  transparency  of  the  sclerotics  indi- 
cates a  lack  of  fibrous  tissue  in  the  framework  of  various 
organs,  and  might  explain  the  want  of  toughness  in  the 
bones  of  these  individuals. 

A  Case  of  Aneurism  of  the  Abdominal  Aorta  Pointing  Pos- 
teriorly, in  which  the  Initial  Symptoms  Were  those  of 
Chronic  Colitis. — A.  Ernest  Maylard  gives  a  case  of  a  pa- 
tient who  showed  a  marked  pulsating  swelling  in  the  back 
close  tf>  the  spine,  which  was  for  a  longtime  puzzling.  '1  he 
patient  died  suddenly  by  probable  internal  rupture  of  the 
aneurism. 

An  Address  of  Welcome. — Delivered  by  the  president  of 
the  Roval  College  of  .Surgeons,  Sir  William  ^lacCormac, 
Bart.,  k.C.V.O. 

An  Account  of  Some  Researches  into  the  Nature  and  Ac- 
tion of  Snake  Venom. — By  Capt.  Robert  Henry  Elliott. 

On  the  Physiological  Action  of  Senecio  Jacoboea. — By  J. 
L.  Bunch. 

Fibromyoma  of  the  Vagina. — Bv  Lieut. -Col.  Patrick  A. 
Weir. 

Case  of  Inversio  Uteri. — By  D.  M.  McVeagh. 

Berlinc}'  klinische  ]\'oLlienschriJt,  July  ib,  igoo. 

Functional  Diagnosis  of  Kidney  Disease. — L.  Casper  and  P. 
F.  Richtev  advocate  the  use  as  a  test  of  phloridzin  followed 
by  ureteral  catheterization.  They  find  that  upon  the  in- 
troduction of  this  substance  the  body  reacts  through  the 
separation  of  a  sugar  whose  place  of  origin  is  in  the  kid- 
nej's.  After  the  introduction  subcutaneously  of  a  quantity 
of  phloridzin,  it  is  found  that  healthy  kidneys  excrete 
within  one-half  an  hour  to  one  hour  equal  quantities  of 
sugar.  A  damaged  kidney  will  excrete  less  than  its 
healthy  neighbor.  If  the  disease  is  far  advanced  the  ex- 
cretion of  sugar  is  reduced  to  a  minimum  or  is  entirely 
absent.  The  authors  believe  that  further  experiments 
along  this  line  will  enable  us  to  make  the  diagnosis  of 
renal  affections  more  accurately  than  has  hitherto  Ijeen 
possiljle. 

Methods  of  Identification  of  the  Tubercle  Bacillus,  with  Dem- 
onstrations and  Practical  Employment. — Max  Wolff  enumer- 
ates three  methods  of  idenlirtcation,  namely,  the  micro- 
scopical, cultivation  in  media,  and  inoculation  of  healthy 
organisms  with  a  pure  culture.  The  latter  may  be  done 
subcutaneously,  through  the  abdominal  cavity,  in  the  an- 
terior chamber  of  the  eye,  and  by  inhalation.  The  various 
details  of  all  these  methods  are  fully  set  forth.  Finally  he 
says  that  inoculation  may  occur  through  the  digestive 
tract,  as  can  be  experimentally  proven,  and  also  we  can 
inject  directly  into  the  blood.  The  article  contains  nothing 
especially  new,  but  is  an  excellent  i-esKiiii:  of  current  meth- 
ods of  experimentation. 

The  Etiology  and  Therapy  of  Tabes  Dorsalis.— By  P.  K.  Pel. 

Tissue  Change  in  Diabetes  Insipidus. — By  G.  Vannini. 

The  Pathology  of  Morbid  Growths.— By  O.  Israel. 

Mihichener  medicinische  Wochenschrift,  July  ij.  igoo. 

A  Hitherto  Unrecognized  Property  of  Alcohol  in  the  Steriliza- 
tion of  the  Hands.  —  Kraatz  comments  on  the  two  views  that 
have  been  taken  regarding  the  role  played  by  the  alcohol 
which  is  so  prominent  a  factor  in  most  of  the  methods  of 
hand-disinfection.  It  is  maintained  by  some  that  it  is 
mainly  through  its  property  of  dissolving  fat  that  it  is  use- 
ful, for  in  this  way  the  corrosive-sublimate  solution  is  en- 


abled to  come  into  closer  contact  with  the  skin,  while  other 
observers  claim  for  it  great  intrinsic  antiseptic  power.  It 
is  a  fact,  liowever,  that  other  substances,  such  as  ether, 
which  are  better  solvents  of  fat  than  alcohol,  or  bodies 
which  surpass  it  in  germicidal  power,  alike  fail  to  produce 
the  same  good  results,  and  we  are  furthermore  between  the 
horns  of  the  dilemma,  since  the  more  nearly  absolute  the 
alcohol  IS,  the  greater  is  us  fat-dissolving  faculty,  while 
the  more  water  it  contains,  withm  limits,  the  better  it  acts 
as  an  antiseptic.  The  author  endeavors  to  clear  up  the 
matter  by  advancing  the  theory  that  it  is  in  abstracting 
air  from  the  pores  and  hssures  of  the  skin  that  the  true 
value  of  the  application  lies  ;  a  previous.treatment  with  al- 
cohol enables  subsequent  aqueous  solutions  to  penetrate 
much  more  thoroughly  and  completely  into  all  the  macro- 
scopic and  microscopic  interstices  of  the  cutaneous  surface. 

The  Early  Diagnosis  of  Tabes. — Erb  emphasizes  the  neces- 
sity for  watclifulness  to  avoid  overlooking  incipient  or 
atyphical  forms  of  this  malady.  In  evidence  of  the  pro- 
tean character  of  the  disease  he  cites  five  case  histories  in 
which  there  were  practically  no  objective  symptoms  at 
all,  and  even  subjectively  the  disturbances  present  were 
of  the  slightest,  consisting  variously  of  ob.scure  lancinating 
pains,  slight  hyp-  or  hyper-Eesthesia,  lassitude,  diminished 
sexual  vigor,  headache,  etc.  ;  pupillary  sluggishness  or  in- 
action was.  however,  noted  in  several  instances.  On  the 
other  hand,  a  case  is  reported  in  which  the  patient  was  not 
suffering  from  any  subjective  symptoms  whatever,  and 
yet  on  examination  was  found  to  have  lost  his  tendon  re- 
flexes and  to  give  both  Romberg's  and  Westphal's  symp- 
toms. In  doubtful  cases  the  author  considers  the  presence 
or  absence  of  a  syphilitic  history  as  of  the  greatest  impor- 
tance :  when  preceded  by  a  specific  infection  symptoms 
which  otherwise  would  be  negligible  assume  the  gravest 
significance.  It  is  in  the  recognition  of  these  anomalous 
types  of  the  disease  (the  formes  frustes  of  French  observers) 
exhibiting  a  tendency  to  run  a  sluggish  course  or  even 
apparently  lie  dormant  for  years,  that  the  greatest  care  is 
needed,  for  these  are  precisely  the  cases  which  seem  most 
amenable  to  treatment. 

Alcohol  Dressings. — Graeser  has  found  permanent  appli- 
cations of  strong  (ninety-per-cent.)  alcohol  of  great  service 
in  combating  all  inflammatory  conditions  in  which  there  is 
a  tendency  toward  suppuration.  The  explanation  offered 
is  that  the  alcohol  by  the  chemical  irritation  produced 
causes  a  local  dilatation  of  the  blood-vessels,  and  the  richer 
blood-supply  means  an  increased  formation  of  ale.xins  and 
consequent  greater  capacity  for  resisting  the  spread  of  in- 
fection. The  technique  employed  consists  in  the  applica- 
tion of  thick  layers  of  gauze  which  are  saturated  with  alco- 
hol and  then  covered  with  some  impervious  material,  such 
as  gutta-percha  paper.  The  dressing  is  left  in  place  for 
days  at  a  time,  but  about  once  every  twelve  hours  it  is 
necessary  to  resaturate  it  with  alcohol. 

Comparative  Observations  on  the  Value  of  the  Mechanical 
and  Ahlfeld's  Alcohol  Disinfection  as  Opposed  to  Mercury 
Disinfection,  Especially  that  with  Mercury  Ethylendiamin. — 
By  Kriinig  and  Bluml^erg. 

A  Method  of  Determining  the  E.xact  Size  of  Objects  by 
Means  of  their  Roentgen-Ray  Shadow,  and  the  Determination 
of  the  Size  of  the  Heart  by  this  Method. — By  Jloritz. 

Experimental  Observations  on  Disinfection  of  the  Hands. 
IV. — By  Paul  and  Sarwey. 

The  Antiseptic  Value  of  Oxycyanide  of  Mercury. — By 
Sicherer. 

The  Clinical  Diagnosis  of  Diaphragmatic  Hernia. — By 
Hirsch. 

Diabetes  Insipidus. — By  Strubell. 

Dculsclie  iniuUiiiiischi:   W'lh  Iwitsi  hrift ,  /itly  rg.  igoo. 

The  Preparation  of  a  Bubonic-Plague  Serum  from  the 
Peritoneal  Exudate  of  Infected  Animals. — Terni  and  Bandi 
empliasize  the  disadvantages  and  dangers  connected  with 
the  preparation  and  use  of  the  serum  made  according  to 
Hafl'kine's  method.  It  is  necessary  to  have  very  virulent 
cultures  of  the  bacteria.  It  is  difficult  to  obtain  the  serum 
in  any  quantity  and  the  immunity  produced  does  not  mani- 
fest itself  until  ten  or  twelve  days  have  elapsed,  while  if 
the  individual  inoculated  has  already  been  infected  the 
treatment  would  only  serve  to  aggravate  the  severity  of 
his  disease.  With  the  idea  of  producing  a  serum  that 
might  be  obtained  in  large  quantities  in  a  short  space  of 
time,  and  in  which  there  should  be  present  substances  ca- 
pable of  conferring  on  the  organism  a  passive  immunity, 
making  it  able  to  resist  infection  until  the  moment  when 
active  immunity  should  have  been  caused,  they  experi- 
mented with  the  peritoneal  exudate  of  ral)bits  into  whose 
abdominal  cavities  virulent  cultures  of  plague  bacilli  had 
been  injected.  This  serum  contains  pure  cultures  in  abun- 
dance, and  after  fractional  sterilization  and  the  addition  of 
small  quantities  of  carbolic  acid,  sodium  carbonate,  and 
sodium  chloride,  it  is  ready  for  use.     No  disadvantages  at- 


August  1 1,  1900] 


MEDICAL    RECORD. 


227 


tend  its  employment ;  it  may  be  readily  obtained  in  consid- 
erable quantities  ;  the  determination  of  the  dose  for  each 
individual  lot  of  serum  is  easily  and  quickly  effected  ;  ex- 
periments on  man  and  animals  show  that  no  local  or  gen- 
eral disturbances  are  produced,  and  immunity  appears 
earlier  and  is  of  longer  duration  than  is  the  case  with  the 
serum  of  Haflfkine. 

The  Theory  of  the  Pasteur  Inoculations  for  Rabies. — Mai-.\ 
formulates  his  belief  as  follows:  The  virus  of  rabies  is 
modilied,  but  not  killed,  by  its  passage  through  rabbits. 
On  subsequent  injection  into  man,  in  consequence  of  its 
diminished  activity  it  is  killed  before  it  can  reach  the  cen- 
tral nervous  system.  The  constituents  of  the  disorganized 
microbes  are  thus  set  free,  and  by  their  presence  the  neces- 
.sary  stimulus  is  given  to  those  organs  which  produce  the 
specific  anti-bodies  for  rabies.  E.xperiments  on  monkeys 
showed  that  while  they  promptly  succumbed  to  injections 
of  the  virus  of  street  rabies,  they  were  resistant  to  virus 
that  had  been  passed  through  the  bodies  of  rabbits.  When 
the  infection,  instead  of  being  made  subcutaneously  or  in- 
tramuscularly, was  effected  by  injection  into  the  chambers 
of  the  eye  the  monkeys  died  with  characteristic  symptoms. 

Clinical  Contributions  to  the  Occurrence  of  Tetany  and  the 
Other  Tonic  Spasms  in  Gastric   Dilatation. — By  Ury. 

A  Report  on  the  Influenza  Epidermic  of  February,  1900, 
in  the  Obstetrical  Clinic  at  Greifswald.  —  By  Mollcr, 

Investigations  on  the  Parasitical  Nature  of  Eczema. — By 
.Scholtz- 

Frciuh  Jottriiixh. 

Nectrianine. — Mongour  and  Gentes  describe  experiments 
carried  out  with  nectria  ditissima  in  cancer.  The  drug 
nectrianine  is  derived  from  the  parasitic  fungus  of  the  so- 
called  cancer  of  trees.  The  external  aspect  of  these  vege- 
table cancers  is  often  strikingly  similar  to  the  appearances 
of  cancer  in  the  human  being.  Cultures  of  the  fungus 
show  cylindrical  conidiae,  an  illustration  of  a  pure  culture 
being  shown.  The  following  conclusions  are  drawn  from 
the  first  communication  of  Bra  and  Mongour  and  from  the 
present  observations:  (i)  Injections  of  nectrianine  are 
without  danger.  (2)  In  none  of  the  patients  affected  with 
cancer  did  the  treatment  arrest  the  evolution.  (3)  It  did 
not  i;revent  the  production  of  tumors  at  a  distance,  nor 
modify  the  'glandular  enlargements.  (4)  The  normal 
course  was  pursued.  (5)  In  most  cases  hemorrhage  was 
decreased  and  there  was  less  fetid  discharge.  Most  of  the 
cases  had  already  reached  an  advanced  .stage.  Further 
tests  are  justifiable  in  spite  of  the  unfavorable  showing.^ 
Le  Ihilletin  Medical.  July  i3,  tgoo. 

Salt  in  the  Alimentation  of  Epileptics. — Edw.  Toulouse 
gives  a  resume  of  his  observations  and  experiments  which 
go  to  show  that  by  diminishing  the  amount  of  salt  in  the 
food  of  epileptics  the  therapeutic  action  of  the  bromides  is 
in  a  large  measure  increased.  The  previous  work  of  Ch. 
Richet  and  himself  in  this  direction  is  referred  to.  Tables 
give  the  results  of  tests,  showing  the  effects  of  increased 
and  <Iiminished  salt  supply  in  reference  to  the  result  ob- 
tained from  bromide  medication.  The  author  thinks  the 
fact  established  that  decrease  in  salt  supply  intensifies  the 
effect  of  the  bromides,  and  that  the  bromide  of  sodium 
seems  to  be  the  least  toxic  and  to  approach  more  closely 
in  nature  the  sodium  chloride  which  it  should  replace.-^ 
Gazelle  dcs  Hopilaii.x,  July  21,  1900. 

Pneumonia  in  the  Obese. — H.  Huchard  believes  that  in 
the  prognosis  of  pneumonia  we  cannot  regard  the  degree 
of  virulence  of  the  microbe  by  itself.  Among  other  ele- 
ments to  be  reckoned  with  is  that  of  obesity.  In  treat- 
ment of  pneumonia  in  fatty  subjects  we  can  employ;  (i) 
.bleeding,  either  local  or  general  ;  (2)  digitalis,  not  witli  the 
aim  of  introducing  a  cardiac  tonic  and  not  with  the  end  in 
view  of  meeting  a  morbid  intoxication  with  a  remedial  in- 
toxication :  (3)  milk  diet  and  diuretics  (theobromine)  ;  (4) 
chloride  of  sodium. — /oiirnal  i/cs  Praticiens,  July  21, 
1900. 

A  New  Sign  of  Alcoholism. — Maridort  describes  a  sign 
which  he  learned  from  the  late  Professor  Quinquaud.  It 
consists  in  a  series  of  quick  tappings  or  the  sensation  of 
slight  shocks  made  by  the  phalanges  when  the  patient's 
fingers  are  spread  apart  and  extended  and  pressed  perpen- 
dicularly against  the  p:ilm  of  the  experimenter.  It  is  only 
after  a  few  seconds  that  the  phalangeal  shock  is  felt,  ani 
then  only  in  case  the  subject  is  an  alcoholic. — La  Medecine 
Modcrne,  July  iS,   igoo. 

American  Journal  of  the  Medical  Sciences.  August,  igoo. 

Clinical    Notes    of    Cases    of    Pernicious  Anxmia. — F.    P. 

Henry  finds  in  well-marked  cases  of  this  disease  (i)  a  re- 
duction of  the  number  of  the  red  corpuscles  to  a  degree 
that  is  normal  in  the  cold-blooded  animals.  It  is  the  rule 
to  find  in  this  disease,  when  well  advanced,  less  than 
1,000,000  corpuscles   per  cubic   millimetre.     Figures   like 


these  are  normal  in  the  cold-blooded  animals.  (2)  In  per- 
nicious aneeniia"niaay  of  the  corpuscles  are  much  increased 
in  size,  so  much  so  that  they  have  received  the  name  of 
megalocytes.  Many  of  them  are  quite  as  large  as  the  cor- 
puscles of  the  lizard  and  eel.  (3)  They  often  show  a  ten- 
dency to  assume  an  oval  outline,  which  is  that  of  the  cor- 
puscles of  the  cold-blooded  animals.  (4)  Finally,  to  make 
the  resemblance  com])lete,  nucleated  red  corpuscles  are 
commonly  present  in  the  blood  of  pernicious  ana:mia.  The 
clinical  facts  brought  out  in  the  paper  are  evident  from  the 
following  ca.se-headings ;  Case  I. — Profound  anaemia, 
with  all  the  characteristics  of  the  pernicious  type  ;  periph- 
eral neuritis,  with  paralysis  of  extensors  ;  bronzing  of  skin, 
with  freckle-like  spots  upon  its  surface.  Result  fatal. 
Case  II. — Profound  anasmia  following  repeated  epistaxis; 
characters  of  the  blood  as  regards  number  of  red  corpuscles 
and  percentage  of  Hb.  the  same  as  those  of  pernicious 
ana;mia  ;  convulsions  following  transfusion,  the  giver  of 
the  blood  being  epileptic;  continued  fever;  death.  Ca.se 
III.  —  Extreme  ana-mia,  with  percentage  of  color  higher 
than  tljat  of  number;  marked  gastro-intestinal  disorder; 
.great  improvement  under  the  use  of  arsenic  and  orexine. 
Case  IV. — ^Under  observation  six  years,  during  which 
there  have  been  several  slight  and  two  severe  relapses, 
chronic  gastro-intestinal  catarrh,  with  marked  exacerba- 
tions preceding  and  during  the  relapses  ;  complete  restora- 
tion to  health.  Case  V.  —  Extreme  amemia  of  less  than 
one  year's  duration  ;  pleuritic  effusion  of  left  side  ;  death 
from  erysipelas. 

Pernicious  Anaemia ;  a  Study  of  One  Hundred  and  Ten 
Cases. —  R.  C.  Cabot  gives  the  results  of  his  examination  of 
these  cases,  including  blood  counts.  From  this  analysis  he 
makes  up  a  composite  symptomatology  as  follows:  (i) 
a  slow,  insidious  onset  without  recognizable  cause;  (2) 
remarkable  freedom  from  pain  :  (3)  striking  absence  of  ema- 
ciation (in  most  cases)  ;  (4)  the  frequent  presence  <jf  symp- 
toms suggesting  disease  of  the  spinal  corcf ;  (5)  i)aroxys- 
mal  attacks  of  diarrhoea  and  vomiting,  occurring  without 
any  obvious  relation  to  diet  or  to  treatment,  preceded  and 
followed  by  periods  in  which  digestion  and  absorption  were 
performed  without  apparent  difficulty  ;  (6)  the  tendency  to 
great  spontaneous  imjjrovement  in  all  the  symptoms,  fol- 
lowed by  rapid  and  inevitable  relapse;  (7)  a  reduction  in 
the  red  corpuscles  to  a  point  below  2,000,000  per  cubic  mil- 
limetre, without  a  corresponding  reduction  in  the  ha;mo- 
globin  ;  a  reduction  in  the  number  of  leucocytes,  and  espe- 
cially in  the  number  of  polymori)honuclear  neutrophiles ; 
the  presence  of  large  numbers  of  oversized,  well-stained 
red  corpuscles,  some  of  them  containing  nuclei  (megalo- 
blasts),  together  with  a  tendency  to  abnormal  staining  re- 
actions and  to  an  oval  shape  in  the  red  corpuscles. 

The  distinctive  features  in  the  diagnosis  of  secondary  or 
symptomatic  ana-mia  are  :  ( i )  the  presence  of  a  well-recog- 
nized cause  ;  (2)  the  steady  progress  of  the  symptoms, 
especially  in  malignant  disease.  If  gastro-intestinal 
symptoms  are  present  they  seldom  improve  spontaneously  ; 
(3)  emaciation  :    (41  the  blood. 

Minor  Form  of  Cardiac  Dilatation. — Beverley  Robinson 
finds  this  condition  in  anaemic  girls  just  past  the  age  of 
puberty.  They  suffer  from  menorrhagia.  constipation, 
and  flatulence.  The  cardiac  fluttering  so  often  seen  in 
these  cases,  and  generally  considered  functional,  he  be- 
lieves to  be  due  to  actual  organic  change  requiring  iron 
and  oxygen,  rest  and  massage,  and  restricted  hours  of 
mental  effort.  But  they  also  require,  and  in  the  beginning 
of  treatment  it  is  absolutely  essential,  small  repeated  doses 
of  strychnine  and  digitalis  until  their  hearts  sufficiently 
respond  to  enable  us  to  make  satisfactory  use  of  other 
means  to  restore  bodily  activity.  In  these  cases  the  action 
is  as  a  rule  rapid,  and  the  first  sound  is  exaggerated  and 
seemingly  irrital)le.  Our  best  results  come  from  the 
strychnine  and  digitalis  in  moderate  doses  for  a  week  or 
two,  to  be  followed  by  a  prolonged  course  of  iron. 

Experimental  Research  Showing  that  Uric-Acid  Secretion 
is  Not  Regularly  Diminished  in  the  Periods  Preceding  Epi- 
leptic Seizures. — J.  J.  Putnam  and  F.  Pfaft'  examined  the 
twenty-four  hours'  urine  from  two  patients,  the  test  being 
made  twenty-nine  times.  The  tabulated  results  cannot  be 
said  to  bear  out  the  statements  which  have  been  so  em- 
phatically made,  either  as  regards  the  low  excretion  before 
the  epileptic  attacks  or  the  high  excretion  after  them. 

Endothelioma  of  the  Skin  Developing  in  the  Scar-Tissue 
of   Lupus  Vulgaris ;    Angiosarcoma   of    the  Skin. — By  J.   A. 

Fordyce. 

A  Comparative  Study  of  Digitalis  and  its  Derivatives. — By 

John  P.  Arnold  and  Horatio  C.  Wood,  Jr. 

A  Clinical  Summary  of  the  Literature  on  the  Inoculability 
of  Carcinoma.  —  By  Joseph  Sailer. 

Multilocular  Cystoma  of  the  Pancreas. — By  Reginald  H. 

Fitz. 


228 


MEDICAL    RECORD. 


[August  1 1,  1900 


Olorvcsponclcuce. 


OUR   LOXDON    LETTER. 

'  (From  our  Special  Correspondent.) 

SOl'TH  AFRICAN  HOSPITAL  COMMISSION — SPECIAL  KXTRAORDI- 
NAKY  MEETING  OK  THE  HRITISH  MKDICAL  ASSOC! ATION  ;  AT- 
TEMPT OF  THE  COUNCIL  TO  DISFRANCHISE  ME.MIIERS  AND 
CAPTURE  THE  FUNDS  AND  MANAGEMENT  OF  THE  ASSOCIA- 
TION—  LEAD  AS  AM  ABORTIFACIENT — FINSEN's  TREATMENT 
BY  LIGHT— COMMISSIONS  AND  GUARDIANS — NATIONAL  HOSPI- 
TAL   FOR     PARALYSIS. 

London,  July  20.  1900. 
On  Tuesday  Jlr.  Balfour  was  able  to  give  the  uanies  of  the 
additional  members  he  had  agreed  to  place  on  the  commis- 
sion of  inquiry  into  the  army  hospitals  in  South  Africa. 
The 'gentlemen  chosen  are  Sir  David  Richmond,  ex-lord 
provost  of  Glasgow,  and  Mr.  Frederick  Harrison,  general 
manager  of  the  London  and  Northwestern  Railway  Com- 
pany— our  largest  railway.  Both  men  have  experience  of 
the  sort  likely  to  prove  useful,  Sir  David  in  administra- 
tive affairs,  and  Mr.  Harrison's  knowledge  must  be  most 
important  in  considering  transport.  But  Mr.  Burdett- 
Coutts  was  not  satisfied,  and  gave  another  demonstration 
of  his  want  of  that  common-sense  recommended  by  Lord 
Roberts.  Mr.  Coutts  endeavored  to  controvert  the  rifling 
of  the  speaker  and  renew  his  attack  on  Professor  Cunning- 
ham, but  he  was  put  into  his  place  by  the  Speaker,  to  the 
delight  of  a  chuckling  House.  Only  one  other  person  in- 
dorsed the  silly  notion  that  an  examiner  of  army  surgeons 
in  anatomy  must  be  a  tool  of  the  War  Office. 

On  Wednesday  the  extraordinary  general  meeting  of 
the  British  Medical  Association,  called  to  pass  the  new 
regulations  framed  by  the  Council,  was  held  in  Exeter 
Hall,  and  most  emphatically  refused  to  sanction  the  alter- 
ations and  by  implication  condemned  the  Council  and  all 
its  works.  The  hostile  tone  of  the  meeting  was  evi- 
dent from  the  first.  The  chairman.  Dr.  Ward  Cousins, 
was  scarcely  equal  to  the  occasion,  genial  and  popular 
though  he  be.  At  times  the  meeting  might  be  described  as 
uproarious.  The  proceedings  began  by  objection  being 
taken  to  the  presence  of  the  solicitor  to  the  Council,  who 
was  not  a  member  of  the  association,  Mr.  Victor  Horslev 
and  Dr.  Brierly  pointing  out  that  actions  for  libel  (.f/Vi 
might  arise.  On  a  vote  he  was  directed  to  withdraw.  Sir. 
Brown  demanded  that  the  opinion  of  counsel  (Mr.  Beau- 
fort Palmer),  under  which  the  council  of  the  association 
were  acting,  be  read.  This  was  done.  Complaint  was 
made  that  amendments  of  which  due  notice  had  been 
given  had  not  been  put  upon  the  agenda  paper.  To  this 
the  secretary  replied  that  counsel  had  advised  tliat  the 
wording  of  the  notice  of  meeting  precluded  any  amend- 
ment being  moved  (a  smart  move  that  on  behalf  of  the 
Council  I)  After  a  suggestion  of  adjournment  in  order 
that  the  notice  might  be  amended  had  been  negatived,  the 
chairman  introduced  the  resolution.  He  much  regretted 
that  the  solicitor  had  been  excluded.  He  and  Mr.  Fowke 
were  the  best  friends  the  association  had.  Amid  much 
laughter  and  cries  of  "No!"  he  proceeded  to  draw  a  pa- 
thetic picture  of  these  two  officials  toiling  for  the  common 
good,  while  the  members  who  laughed  were  comfortably 
asleep  rolled  up  in  their  blankets.  He  said  that  the  new 
articles  were  only  aimed  at  the  removal  of  discrepancies 
and  contradictions,  and  that  there  was  very  little  real  dif- 
ference between  the  existing  and  proposed  new  articles. 
The  powers  of  the  annual  meeting  would  remain  unaltered 
by  the  new  articles.  From  this  the  chairman  seems  to 
liave  been  completely  hoodwinked. 

Dr.  Robert  Thompson  described  the  origin  of  the  new 
articles.  He  pointed  out  the  absurdity  of  the  association's 
being  ruled  by  an  annual  meeting  at  which  often  only 
thirty  members  were  present. 

Dr.  Bernard  O'Connor  said  the  new  articles  would  take 
away  all  power  from  the  meml)ers  and  make  the  council 
absolute.  This  was  done  by  what  he  would  not  call  chi- 
canery, but  verbal  subtlety. 

Dr.  Rentoul  advocated  that  limited  proxy-voting  should 
be  allowed  at  general  meetings  ;  no  per.son  to  be  proxy  for 
more  than  fifty  members,  and  such  proxy  voting  to  be 
allowed  only  on  motions  of  amendment. 

He  also  proposed  that  the  representation  of  branches 
should  be  equalized  and  the  Council  reduced  from  one  hun- 
dred and  one  to  forty-seven  members. 

Dr.  Douglas  complained  that  members  had  for  years 
maintained  that  the  Council  acted  illegally  in  ignoring  res- 
olutions passed  in  annual  meeting,  and  now  this  was  ad- 
mitted to  be  the  case.  The  Council  meant  well,  but  did 
badly. 

Mr.  'Victor  Horsley,  who  was  received  with  loud  ap- 
plause, said  he  himself  had  been  ruled  out  of  order  under 


an  interpretation  of  the  articles  that  was  now  admitted  to 
be  illegal,  but  no  apology  was  forthcoming.  He  urged  tlie 
rejection  of  the  resolution  and  the  reorganization  of  the 
association  after  careful  .study  of  its  needs,  by  a  special 
committee  if  necessary. 

Dr.  Ritchie  also  opposed  the  resolution.  He  said  that  in 
drawing  up  these  regulations  the  Council  had  ignored  the 
recommendations  of  a  committee  appointed  to  consider  the 
subject.     The  unattached  members  were  not  considered. 

On  the  resolution  being  put,  it  was  declared  that  the 
three  fourths  majority  necessary  to  pass  it  was  not  ob- 
tained. Apparently  an  absolute  majority  of  those  present 
voted  against  it. 

From  the  foregoing  you  will  see  that  the  little  plot  laid 
by  the  Council  to  capture  the  absolute  control  of  the  associ- 
ation and  the  disposal  of  its  funds  has  been  frustrated. 
For  once  the  members  have  seen  through  the  scheme  and 
taken  the  trouble  to  refuse  assent  to  changes  in  the  articles 
of  as.sociation  which  might  open  the  door  to  years  of  litiga- 
tion or  throw  away  all  the  rights  of  present  and  future 
members.  A  more  barefaced  attempt  could  scarcely  be 
imagined.  A  special  meeting  called  at  Exeter  Hall  to'cou- 
sider  some  amendments  of  the  articles  worded  in  such  a 
way  as  to  require  close  attention  to  grasp  their  efi^ect — then 
if  that  passed  without  comment  the  confirmation  could  be 
secured  next  week  at  Ipswich  by  one  of  the  old  dodges  by 
which  the  Council  has  too  often  secured  the  passing  of  its 
proposals.  It  is  desirable  that  the  general  meetings  at 
Ipswich  should  be  fully  attended,  lest  some  fresh  pettifog- 
ging move  be  attempted. 

Professor  Wright,  of  Netley,  has  been  permitted  by  the 
director-general  to  publish  the  official  statistics  concerning 
the  anti-typhoid  inoculations  of  the  Ladysmith  garrison. 
There  were  1,705  inoculated:  of  these  35  had  typhoid,  i  in 
487,  and  the  deaths  numbered  8,  or  i  in  213.'  The  non- 
inoculated  numbered  10,529:  of  these,  1,489  contracted  ty- 
phoid, or  1  in  7.07.  the  deaths  being  329,  or  i  in  32.  These 
figures  at  first  sight  seem  to  speak  well,  but  have  to  be  dis- 
counted by  various  considerations.  Taking  the  proportion 
of  deaths  to  the  total  number  of  attacks  in  the  two  groups, 
we  find  it  to  be  i  in  4,52  in  the  non-inoculated  and  i  in  4.4 
in  the  inoculated.  The  case  mortality,  therefore,  was  not 
influenced  much,  if  at  all,  by  inoculation,  but  this  point  is 
of  less  import  than  the  reduction  in  incidence.  It  is  hardly 
possible  to  determine  at  present  the  protective  power  of  in- 
oculation, and  there  seems  a  probability  that  different 
preparations  have  been  used.  But  on  the  whole  Professor 
Wright  regards  the  results  as  encouraging  in  animals,  in- 
asmuch as  they  show  that  the  proportion,  on  the  one  hand, 
of  attacks  and,  on  the  other  hand,  of  deaths  from  typhoid 
fever  was  seven  times  smaller  in  the  inoculated  than  in  the 
uninoculated.  It  may,  too,  be  borne  in  mind  that  the  fig- 
ures would  have  been  more  favorable  if  those  who  had  previ-  j 
ously  suffered  from  typhoid  could  have  been  subtracted  ■ 
from  the  number  of  uninoculated.  " 

Those  who  are  less  hopeful  than  Dr.  Wright  cannot  say 
that  so  far  statistics  are  discouraging,  and  the  enormous 
importance  of  typhoid  seems  abundantly  to  justify  any  rea- 
sonable experiment.  The  fact  tliat  anti-typhoid  inocula- 
tion has,  I  believe,  never  been  followed  by  serious  results 
should  induce  any  one  exposed  to  its  dangers  to  submit  to 
the  procedure. 

Cases  have  been  published  in  the  journals  during  the  last 
few  years  in  which  lead-poisoning  has  occurred  from  di- 
achylon or  some  other  preparation  being  taken  with  the 
intention  of  producing  abortion.  Dr.  Ran.soni,  of  Notting- 
ham, has  added  three  cases  in  which  cerebral  symptoms 
were  ])rominent,  and  says  his  experience  leads  him  to  be 
lieve  that  the  use  of  diachylon  as  an  abortifacient  is  a  fast- 
growing  evil.  Further,  he  has  obtained  from  others  state- 
ments of  their  experience  which  quite  corroborate  this  con- 
clusion, and  he  thinks  diachylon  should  be  classed  with 
poisons. 

Finsen's  "  light  treatment  "  is  being  tried  rather  fully  at 
the  London  Hospital,  where  a  department  has  been  fitted 
up  for  the  purpose  with  all  necessary  appliances. 

The  local  government  board  has  warned  other  guardians 
that  the  irregularities  at  St.  Pancras  as  to  commissions 
may  have  occurred  in  their  districts,  and  stating  that  re- 
lieving officers  who  had  been  guilty  of  such  practices  should 
not  be  allowed  to  continue  in  office. 

The  board  of  the  National  Hospital  for  the  Paralyzed 
and  Epileptic  has  replied  to  the  complaints  of  the  staff  in 
a  most  feeble  defence.  It  declares  that  the  question 
arises  because  the  staff  do  not  approve  of  the  board  allow- 
ing patients  who  can  aff'ord  to  pay  to  participate  in  the 
charity  of  the  hosjjital.  "Supposing  that  were  true."  when 
a  board  asserts  a  right  to  sell  the  services  of  the  honorary 
staff  to  those  who  can  afford  to  pay,  it  is  high  time  for  the 
staff  to  say  No. 

Malaria Methylene  blue  may  be  given  with  con- 
fidence whenever  quinine  is  indicated. ^Smithwick. 


August  1 1 .  1 900] 


MEDICAL   RECORD. 


229 


Jiocictij  ^leports. 

THIRTEENTH     INTERNATIONAL     MEDICAL 
CONGRESS. 

Held  in  Paris,  August  2,j,  4,  5,  6,  7,  8,  and  g,  igoo, 

(Special  Cable  Report  to  the  Medical  Record.) 
GENERAL  SES.SIONS. 

First  Day — Thursday,  August  2d. 

The  first  general  session  of  the  Thirteenth  Inter- 
national Medical  Congress  was  largely  attended,  nearly 
all  of  the  si.x  thousand  members  of  the  Congress  and 
their  ladies  being  present.  The  opening  session  was 
held  in  the  enormous  Salle  des  Fcles  at  the  end  of 
the  Champ  de  Mars  in  the  Exposition  grounds.  This 
great  hall,  which  had  been  constructed  from  the  old 
Machinery  Hall  of  the  Exposition  of  1889,  is  said 
to  have  a  seating  capacity,  when  all  its  space  is  util- 
ized, of  about  fifteen  thousand.  Its  expanse  of  roof, 
covering  an  area  of  about  one  hundred  thousand 
square  feet,  is  unbroken  by  a  single  column,  and  were 
its  acoustic  properties  perfect  it  would  be  unrivalled 
among  the  assembly  buildings  of  the  world.  The 
hall,  large  as  it  is,  was  completely  filled,  and  the 
gala  dresses  of  the  ladies  and  the  glittering  uniforms 
of  the  many  dignitaries  and  military  surgeons  present 
made  a  brilliant  scene.  The  hour  appointed  for  the 
opening  of  the  Congress  was  two  o'clock,  but  it  was 
long  after  this  time  when  the  loud  rapping  of  the 
president's  gavel  hushed  the  roar  of  conversation 
which  was  filling  the  auditorium. 

Addresses  of  Welcome. — M.  Loubet,  the  President 
of  the  French  Republic,  who  was  to  have  opened  the 
Congress,  was  unable  to  do  so,  and  the  pleasant  task 
was  delegated  to  the  Minister  of  Justice.  He  dwelt 
upon  the  satisfaction  which  Paris  and  all  France 
felt  when,  at  Moscow  three  years  ago,  the  represen- 
tatives of  the  medical  profession  throughout  the  civil- 
tzed  world  united  in  accepting  the  invitation  of  the 
French  delegates  to  hold  the  thirteenth  triennial  ses- 
sion in  Paris,  during  the  continuance  of  the  Exposi- 
tion which  marked  the  close  of  the  most  progressive 
century  the  world  has  ever  seen.  Officially  as  an 
officer  of  the  Government  of  France  and  as  the  ap- 
pointed delegate  of  the  President  of  the  Republic, 
and  personally  as  a  humble  citizen  of  Paris  and  of 
France,  he  extended  a  hearty  welcome  to  the  mem- 
bers of  the  Congress  and  to  the  ladies  who  accom- 
panied them.  He  was  sure  their  deliberations  would 
result  in  the  advancement  of  the  sublime  healing-art, 
and  he  confidently  hoped  that  their  stay  would  be  a 
pleasant  one — if  it  was  not  it  woald  not  be  the  fault 
of  their  hosts — and  that  they  would  always  look  back 
upon  the  Paris  Congress  as  one  of  the  greatest  of  the 
illustrious  series  of  medical  reunions. 

Address    of    the     President M.    Lanxelongue, 

president  of  the  Congress,  then  delivered  his  address, 
taking  as  his  theme  the  importance  and  the  value  of 
international  congresses,  particularly  of  those  called 
to  discuss  medical  subjects.  They  tended  to  promote 
international  intercourse,  to  break  down  national 
prejudices,  and  to  cement  the  bonds  of  a  common 
humanity.  Whatever  the  nationality  of  the  individual, 
each  and  all  belonged  to  the  one  great  profession  of 
medicine,  and  this  great  fact  was  exemplified  and  em- 
phasized in  no  better  way  than  by  these  international 
assemblages  of  medical  practitioners. 

After  this,  the  presidents  of  the  national  committees 
of  the  various  countries  were  presented  to  the  con- 
gressists  and  spoke  briefly  in  acknowledgment  of  their 
introduction.  \\\  were  received  with  applause,  but 
among  them  Lord  Lister  was  conspicuous  by  reason 


of  the  volume  and  duration  of  the  acclamation  ac- 
corded him.  Von  Bergmann,  of  Berlin,  representing 
Germany,  made  a  few  most  enthusiastically  received 
remarks  in  glorification  of  France,  which  he  said  was 
the  cradle  of  surgery  and  of  pathological  anatomy. 
He  recalled  the  names  of  some  of  the  great  surgeons 
of  France  and  of  tlie  pioneers  in  that  country  in  the 
study  of  patholog}-,  whose  labors  had  established  the 
foundation  upon  which  the  great  medical  structure  was 
now  being  erected.  Kitasato,  of  Japan,  was  among 
the  speakers. 

Traumatism  and  Infection Prof.  Rudolf  Vir- 

CHOW  delivered  the  first  of  the  general  addresses,  taking 
as  his  subject  the  relation  of  bacterial  infection  and 
traumatism.  A  trauma,  he  said,  became  harmful  to  the 
organism  wiien  it  opened  a  jiortal  for  the  admission  of 
pathogenic  micro-organisms,  and  when  it  so  weakened 
the  individual  cells  of  the  tissues  that  they  were  un- 
able to  overcome  the  microbes.  All  was  not  over  when 
the  specific  bacteria  had  invaded  the  organism,  for 
then  began  the  struggle  between  them  and  the  vital 
cells  of  the  body,  a  struggle  which  was  called  disease. 
If  the  intruders  were  too  strong,  either  absolutely  by 
reason  of  their  invincible  virulence  or  of  their  over- 
whelming numbers,  or  relatively  because  of  the  weak- 
ened resisting-power  of  the  cells,  the  latter  were  more 
or  less  speedily  overpowered,  the  organism  succumbed 
in  the  unequal  contest,  and  disease  resulted  in  death. 
If,  on  the  other  hand,  the  micro-organisms  were  present 
in  attenuated  form  or  in  small  numbers,  and  the  cells 
were  in  the  enjoyment  of  their  normal  vital  activity 
and  had  not  been  paralyzed  by  the  shock  of  the  initial 
injury,  then  the  invading  bacteria  were  vanquished 
and  infectious  disease  was  at  an  end.  The  province 
of  medicine  was  to  aid  these  cells  in  repelling  the  as- 
saults of  the  invading  hordes  by  whatever  would 
strengthen  the  cells  or  weaken  the  microbes. 

This  address  was  regarded  by  Virchow's  hearers  as 
a  full  recognition  by  the  great  pathologist  of  the  part 
played  by  bacteria  in  the  pathogenesis  of  disease. 

At  the  conclusion  of  \"irchow's  address,  which  was 
marked  by  great  applause,  the  president  announced 
that,  owing  to  the  lateness  of  the  hour,  Professor  Pav- 
loff's  address,  which  was  on  the  programme  for  this 
day,  would  be  postponed  to  the  second  general  session 
to  be  held  on  Monday. 

The  opening  session  of  the  Congress  was  then  ad- 
journed. 

The  President's  Reception On    Friday  evening 

M.  Lanxei,o.\gl"E  gave  a  reception  to  the  members 
of  the  Congress  and  their  ladies.  The  occasion  was  a 
brilliant  one.  It  was  marked  by  an  excellent  concert 
and  the  usual  buffet  supper.  Many  men  of  inter- 
national reputation  were  present,  among  them  I'otain, 
Pozzi,  Dieulafoy,  Virchow,  von  Bergmann,  Waldeyer, 
Weigert,  Ehrlich,  Ewald,  Boas,  Kitasato.  Sforza,  Yer- 
sin,  Surgeon-General  Van  Reypen,  U.S.N.,  Weir, 
Keene,  Jacobi,  Janeway,  Maragliano,  Babes,  Baginsky, 
Marfan,  and  others. 

Second  Day — Monday,  August  6th. 

The  second  general  session  was  held  on  Monday, 
the  fifth  day  of  the  congress,  in  the  grand  amphitheatre 
of  the  Sorbonne,  the  proceedings  being  opened  soon 
after  2  p.m.  by  M.  Lannelongue,  the  president  of  the 
congress.  It  was  announced  that  the  total  number  of 
registration  of  members  of  the  congress  was  6,170. 
Of  this  number  no  less  than  412  were  Americans,  the 
United  States  being  fourth  as  regards  attendance  in 
the  list  of  nations,  France  of  course  being  first. 

Experimental  Therapy  as  an  Aid  to  Physio- 
logical Research.  —  Profes.sor  Pavloff,  the  delivery 
of  whose  address  was  postponed  from  Thursday,  was 
unfortunately  unable  to   be   present  on    account   of  a 


230 


MEDICAL    RECORD. 


[August  1 1,  1900 


sudden  indisposition,  and  his  oration  was  therefore 
read  by  Dr.  Likhatcheff.  The  address  was  entitled 
"  Experimental  Therapy  as  a  New  and  Extremely 
Fecund  Method  of  Physiological  Research."  The 
author  presented  numerous  illustrations  of  the  solu- 
tion of  physiological  problems,  mainly  effected  through 
the  light  thrown  upon  the  subject  by  the  results  of 
therapeutic  measures.  Physiologists  were  for  a  long 
time  greatly  embarrassed  in  their  attempts  to  explain 
why  death  occurred  after  section  of  the  vagus  nerve  in 
animals.  This  was  due  partly  to  the  complex  dis- 
tribution and  function  of  the  nerve.  Three  solutions 
were  offered:  (i)  It  was  assumed  that  dissolution 
occurred  from  suffocation  in  consequence  of  paralysis 
of  the  laryngeal  muscles  supplied  by  the  recurrent 
branch  of  the  pneumogastric  nerve;  (2)  others  be- 
lieved that  apncea  resulted  from  hypera;mia  and  cedema 
of  the  lungs  following  upon  the  disturbances  of  pul- 
monary circulation  and  of  respiratory  function  caused 
by  loss  of  cardiac  and  pulmonary  control;  (3)  others 
again  attributed  the  fatal  result  to  distention  of  the 
stomach  and  decomposition  of  its  contents.  These 
suppositions  were  based  upon  the  well-known  results 
of  division  of  the  nerve.  There  was  a  loss  of  sensa- 
tion and  of  power  in  the  larynx,  cardiac  action  was  at 
first  accelerated  and  then  impeded,  the  respiratory 
movements  of  the  chest  wall  were  retarded,  the  bcsoin 
tie  respirer  was  dulled,  and  the  pulmonary  capillaries 
became  distended,  the  mucous  membrane  was  con- 
gested, and  inflammatory  appearances  were  noted  in 
the  lung  tissue;  finally  the  secretory  activity  of  the 
peptic  glands  was  checked,  the  cardiac  orifice  of  the 
stomach  was  paralyzed,  food  stagnated  and  decom- 
posed in  the  viscus,  and  the  organ  became  distended. 
Now,  however,  all  these  supposed  inevitable  changes 
could  be  prevented  by  appropriate  treatment,  and 
animals  in  which  the  tenth  nerve  had  been  divided  no 
longer  of  necessity  died.  The  death  of  the  organism, 
this  association  of  individual  organs,  was  found  not  to 
be  necessitated  by  the  abolition  of  function  of  any 
organ,  except,  of  course,  a  vital  one  such  as  the  heart. 
We  were  able  to  treat  successfully  each  organ  as  an 
individual,  and  upon  early  recognition  of  the  disturbed 
function  we  might  correct  it  or  supplement  it  by  a 
vicarious  action  in  some  other  organ;  indeed  the 
machinery  of  the  organism  often  adapted  itself  to  the 
new  requirements  without  our  aid.  As  an  example  of 
experiment  therapy,  the  results  of  which  had  con- 
tributed greatly  to  advance  the  science  of  physiology, 
the  speaker  referred  to  the  treatment  of  niyxoedema 
and  of  cretinism  by  means  of  preparations  of  the 
thyroid  gland. 

Some  Pathological  Problems  of  the  Present  Day. 
■ — Prof.  Burdon  Sanderson,  of  Oxford,  then  deliv- 
ered an  address  with  this  title.  He  passed  in  review 
the  history  of  the  cellular  theory  of  morbid  action, 
citing  the  experiments  and  teachings  of  Schwann, 
Robin,  Kolliker,  Cohnheim,  and  Virchow  down  to  the 
beginning  of  the  bacteriological  epoch  in  1878. 
Pathologists  were  formerly  interested  chiefly  in  the 
study  of  inflammatory  processes,  since  this  study 
seemed  best  adapted  to  bring  out  into  clearer  view  the 
cellular  theory  and  to  elucidate  some  of  its  unsolved 
problems.  Now,  Jiowever,  the  attention  of  all  was 
concentrated  upon  the  study  of  micro-organisms  as 
the  active  agents  in  the  excitation  of  morbid  processes. 
This  devotion  to  micro-biology  had  resulted  in  good 
in  other  directions.  For  example,  it  iiad  contributed 
not  a  little  to  progress  in  histology,  having  led  among 
others  to  the  discoveries  of  Golgi  and  Cajal  concern- 
ing the  minute  anatomy  of  the  nerve  structures — dis- 
coveries which  might  revolutionize  neural  pathology 
and  therapeutics.  It  had  also  led  to  a  plausible  ex- 
planation of  cell-function — that  is  to  say,  of  the  differ- 
ences in  function  exhibited  by  cells  of  similar  appear- 


ance and  of  the  chemical  action  of  cells  upon  each 
other — this  explanation  being  that  the  action  of  the 
cell  was  dependent  upon  the  presence  of  a  special  fer- 
ment developed  within  the  cell  itself  as  a  result  of  its 
metabolic  activity.  The  author's  theory  of  inflamma- 
tion was  that  it  was  a  morbid  process  resulting  from 
injury  to  the  tissues  caused  by  chemical  noxa,  but  that 
these  were  not  necessarily  of  bacterial  production. 
He  believed  in  the  existence  of  two  types  of  morbid 
action — toxic  and  biotic.  In  the  first  the  poison  was 
the  exciting  cause  of  the  pathological  process,  in  the 
second  this  was  the  result  of  the  vital  action  of  the 
infecting  micro-organism. 

American  Medicine — Prof.  A.  Jacohi,  of  New 
York,  then  delivered  an  address  entitled  "  La  Mede- 
cine  et  les  Medecins  dans  les  Etats-Unis  "  (see  p.  201 ). 
The  distinguished  speaker  was  greeted  warmly  by  the 
audience,  in  which  were  many  citizens  of  his  adopted 
country.  Upon  the  conclusion  of  this  oration  the 
second  general  session  was  adjourned.  The  third  and 
closing  general  session  of  the  congress  will  be  held 
on  Thursday  afternoon. 

Reception  by  the  Ladies'  Committee — On  Monday 
evening  a  reception  was  given  by  the  French  com- 
mittee of  ladies  to  the  members  of  the  congress  and 
their  families  in  the  Palace  of  the  Luxembourg.  The 
reception  was  a  brilliant  one,  but  the  crowd  was  too 
great  for  comfort. 

Third  Day —  Thursday,  August  gth. 

The  closing  session  of  the  congress  was  held  in  the 
amphitheatre  of  the  Sorbonne  under  the  presidency 
of  M.  Lannelongue.  The  attendance  was  not  so  large 
as  it  had  been  at  the  two  previous  general  sessions, 
and  those  present  were  attracted  chiefly  by  the  desire 
to  learn  the  name  of  the  recipient  of  the  Moscow  prize. 

The  Architecture  of  the  Bones  of  Man  and 
Animals  was  the  title  of  an  address  delivered  by 
Professor  Albert.  The  speaker  showed  how  nature, 
in  shaping  the  skeleton  so  as  best  to  bear  the  weight 
it  was  obliged  to  support  in  the  different  vertebrates, 
had  followed  the  same  rules  as  those  man  had  evolved 
through  long  experience  in  the  construction  of  his 
buildings.  In  other  words,  the  rules  of  architecture 
were  those  of  nature. 

Award  of  the  Moscow  Prize. — At  the  opening 
session  of  tlie  Twelfth  International  Medical  Congress 
in  Moscow  in  1897,  Prince  Gallitzin,  the  mayor  of 
Moscow,  in  his  address  of  welcome  announced  the 
foundation  by  that  city  of  a  prize  to  be  awarded  at 
each  succeeding  congress  to  the  person  who  in  the 
period  elapsed  since  the  preceding  meeting  had  done 
that  medical  work  deemed  to  have  been  of  the  greatest 
benefit  to  humanity.  The  value  of  the  prize  was  5,000 
francs  ($1,000),  and  it  had  been  established  by  the  city 
as  the  most  fitting  expression  of  its  appreciation  of  the 
honor  bestowed  upon  it  in  its  selection  as  the  place  of 
assembly  of  the  Twelfth  International  Medical  Con- 
gress. The  first  prize  was  awarded  at  the  Moscow 
congress,  on  the  motion  of  Professor  Virchow,  to  M. 
Henri  Dunant,  the  founder  of  the  Red  Cross  Society, 
who  was  then  living  in  straitened  circumstances  in 
Geneva.  The  second  award  was  made,  M.  Lan- 
nelongue announced,  to  Sefior  Ramchi  )■  Cajal,  of 
Madrid,  for  his  great  work  in  the  study  of  the  nervous 
elements,  the  possible  benefits  of  which  to  mankind 
were  incalculable. 

The  Fourteenth  Congress,  the  president  then  said, 
would  be  held  in  Madrid  in  1903,  the  medical  faculty 
of  the  University  of  Madrid  being  charged  with  the 
arrangements  for  the  meeting.  This  announcement 
was  greeted  with  loud  and  prolonged  applause,  at  the 
subsidence  of  which  Professor  Fernandez,  the  repre- 
sentative of  Spain,  rose  and  thanked  the  members  of 


August  11,1 900] 


MEDICAL   RECORD. 


231 


the  congress  in  his  own  name,  and  that  of  his  country 
and  the  city  of  Madrid,  for  the  honor  which  had  been 
done  them  in  the  selection  of  the  capital  of  Spain  as 
the  meeting-place  of  the  next  congress. 

The  president  then  announced  the  closure  of  the 
Thirteenth  Congress  in  a  brief  speech,  expressing  his 
appreciation  and  that  of  his  colleagues  of  the  honor 
the  congressists  had  done  them  in  responding  in  such 
numbers  to  the  invitation  extended  to  them  three  years 
ago.  

THE   WORK  OF   THE   .SECTIONS. 

On  Friday  the  session  of  the  Section  on  Medicine 
(Pathologie  Interne)  was  devoted  entirely  to  a  dis- 
cussion of  diseases  of  the  stomach  and  intestind. 

Gastric  Ulcer. — Dieulakov  read  a  paper  on  this 
subject.  The  size  of  such  ulcers,  he  said,  might  vary 
from  a  mere  point  to  a  solution  of  continuity  of  the 
area  of  a  silver  dollar.  After  a  brief  review  of  the 
symptoms  and  complications  common  to  all  forms  of 
gastric  ulcers,  he  referred  at  some  length  to  certain 
special  types.  The  smallest  of  tiiesewas  the  so-called 
erosion  which  occurred  in  the  form  of  bleeding  points. 
Those  might  be  numerous  and,  despite  their  small 
size,  might  give  rise  to  an  abundant  haematemesis. 
Sometimes  one  or  more  solutions  of  continuity  of 
greater  size  were  formed  in  the  gastric  mucous  mem- 
brane, to  which  the  author  gave  the  name  of  exulcera- 
tio  simplex.  Although  usually  superficial,  these  ero- 
sions might  extend  to  the  arterioles  lying  beneath 
the  muscularis  mucosa;  and  result  in  violent  and  even 
fatal  hibinatemesis.  The  simple  ulcer  was  the  type  of 
chronic  gastric  ulcers  with  a  tendency  to  perforation. 
Finally  there  were  the  specific  syphilitic  or  tuberculous 
ulcerations,  which  might  also  lead  to  hemorrhage  or 
perforation.  It  was  not  rare  to  see  cancer  engraft  it- 
self on  an  ulcer  of  the  stomach. 

The  subject  was  further  discussed  by  Ewai.d  and 
BouRGET,  the  latter  dwelling  especially  upon  the 
surgical  aspect  of  gastric  ulcer  and  emphasizing  the 
importance  of  operation  in  cases  of  threatening  or 
actual  perforation.  Cohnheim  read  a  paper  in  which 
he  described  his  new  oil  treatment  of  gastralgia,  Eix- 
HORN  presented  a  communication  on  idiopathic  dila- 
tation of  the  ctsophagus,  and  Hem.metf.r  one  on  in- 
testinal peristalsis. 

Muco-membranous  Enteritis  was  discussed  at 
some  length.  MAxWAiiERc;,  of  Vienna,  said  that  a 
distinction  should  be  made  between  membranous 
enteritis  and  mucous  colic,  the  former  being  a  sub- 
acute or  chronic  catarrhal  affection  of  the  large  intes- 
tine accompanied  by  evacuations  especially  rich  in 
mucus,  the  latter  being  a  morbid  condition  character- 
ized by  paroxysmal  crises  of  colic  followed  by  the 
evacuation  of  masses  of  mucus.  The  former  was 
simply  a  catarrh  of  the  large  intestine,  the  latter  was 
a  neurosis  associated  usually  with  hysteria  or  neuras- 
thenia. Some  of  the  exciting  causes  of  mucous  colic 
were  affections  of  tiie  genital  organs  (male  or  female), 
psychical  disturbances,  constipation,  and  organic  in- 
testinal disorders.  It  was  often  accompanied  by  achylia 
gastrica,  nervous  dyspepsia,  or  enteroptosis.  The 
pathological  anatomy  of  membranous  enteritis  was 
the  same  as  that  of  enteritis  in  general,  but  in  mucous 
colic  there  were  no  appreciable  lesions  of  the  intes- 
tine. 

Boas,  of  Berlin,  said  that  muco-membranous  colitis 
was  a  peculiar  catarrhal  affection  marked  by  a  ten- 
dency to  the  formation  of  mucous  casts  of  the  colon. 
Alongside  of  this,  the  more  common  form,  there  was 
another  in  which,  in  the  interval  of  the  paroxysms, 
there  was  no  special  trouble  except  constipation;  this 
latter  affection  was  called  mucous  colic.  The  symptoms 
of  muco-membranous  colitis  were  constipation,  colic, 


spasmodic  atony  of  the  intestine,  the  presence  of 
mucous  or  membranous  masses  in  the  stools,  and  a 
general  neurotic  state.  'J"he  clinical  course  of  muco- 
membranous  colitis  was  absolutely  parallel  with  that 
of  habitual  constipation,  and  measures  which  would 
cure  the  one  would  cure  also  the  other. 

Mathieu,  of  Paris,  discussed  this  subject  chiefly 
from  a  therapeutic  standpoint.  Constipation,  he  said, 
was  at  once  the  cause  and  the  effect,  and  presented  the 
chief  indication  for  treatment.  In  combating  it,  it 
was  necessary  to  employ  measures  which  would  not 
increase  the  secretions,  the  pain,  or  the  tendency  to 
spasm;  castor  oil,  large  enemata,  and  belladonna  were 
the  best  remedies.  The  former  might  be  given  in 
small  doses  with  the  morning  coffee.  The  injections 
should  be  made  slowly  with  but  little  pressure,  the 
fluid  being  at  a  temperature  of  about  40°  C,  and  from 
a  pint  and  a  half  to  two  pints  and  a  half  in  amount. 
Simple  boiled  water,  solutions  of  borax  or  salicylate 
of  sodium,  or  a  weak  solution  of  the  neutral  ichthyolate 
of  ammonium  might  be  used.  Belladonna  was  often 
given  with  good  results.  Warm  local  applications 
and  warm  baths  often  exercised  a  beneficial  effect. 
The  general  neurotic  condition  should  be  treated  with 
nerve  sedatives  and  hydrotherapy.  The  patients  being 
often  weak  and  emaciated,  tonics  and  a  generous  diet 
were  indicated. 

Pulmonary  (Edema. — On  Saturday  in  the  same 
section  the  question  of  ordema  of  the  lungs  was  dis- 
cussed. VoM  Ijasch,  of  Vienna,  said  that  cedema 
was  due  to  an  arrest  of  the  capillary  circulation  in  the 
pulmonary  alveoli,  resulting  from  the  increased  blood 
pressure  in  the  left  auricle,  and  to  the  afflux  of  blood 
from  the  right  heart.  The  mechanical  consequences 
of  these  two  conditions  were  a  dilatation  of  the  alveoli 
and  an  increased  resistance  of  the  alveolar  walls.  In 
addition  there  was  a  transudation  into  the  alveoli  in 
consequence  of  the  stasis  in  the  pulmonary  circulation. 
Dependent  upon  these  morbid  conditions  occurred  a 
mechanical  obstruction  to  respiration  and  imperfect 
aeration  of  the  blood,  wiience  arose  dyspncca.  Exuda- 
tion alone  without  dilatation  and  intra-alveolar  tension 
would  not  cause  dyspncta  in  any  such  degree  as  was 
generally  supposed;  indeed,  the  dyspnora  and  cardiac 
asthma  might  be  developed  in  the  prodromal  stage  of 
pulmonary  cedema  prior  to  the  occurrence  of  alveolar 
exudation. 

Masiijs,  of  Liege,  held  that  pulmonary  oedema  was 
of  the  same  nature  and  pathogenesis  as  oedema  in 
general,  its  special  characteristics  being  the  result 
primarily  of  its  location.  He  recognized  three  forms 
—  inflammatory,  static,  and  toxic — the  second  of 
which  was  by  far  the  most  frequent. 

Teissier  said  that  there  was  clinically  a  special 
morbid  syndrome  to  which  the  term  acute  cedema,  or 
serous  apoplexy  of  the  lung,  might  justly  be  applied. 
This  condition  should  be  carefully  distinguished  from 
other  forms  of  pulmonary  cedema  of  slow  evolution 
and  mechanical  origin.  It  was  characterized  by  a 
premonitory  tickling  in  the  throat  or  a  painful  intra- 
thoracic tension,  by  violent  dyspncta,  accompanied  by 
a  cough  and  often  by  a  pinkish,  frothy  expectoration, 
and  by  a  multitude  of  fine  rales  all  over  the  tedematous 
region.  For  the  occurrence  of  acute  pulmonary 
cedema  a  previous  infection  (rheumatism,  influenza, 
typhoid  fever,  pneumonia),  or  intoxication  (Bright's 
disease,  less  frequently  alcoholism)  was  necessary. 
Another  essential  to  its  production  was  some  lesion  of 
the  heart  at  its  base,  in  the  region  of  the  coronary 
arteries  or  in  the  left  ventricle,  the  exciting  cause  be- 
ing something  (a  cold,  strong  emotion,  excessive 
fatigue)  which  produced  cardiac  spasm  or  failure. 
Under  this  influence,  a  rapid  elevation  of  pressure  in 
the  pulmonary  vessels  being  produced,  the  already  ex- 
isting blood  changes  favoring  serous  exudation,  and 


232 


MEDICAL   RECORD. 


[August  1 1 ,  1 900 


the  concomitant  vasomotor  troubles  favoring  stasis, 
acute  cedema  of  the  lungs  would  readily  occur.  Those 
three  pathogenic  conditions  were  typically  existent  in 
cases  of  interstitial  nepiiritis,  in  which  pulmonary 
cedema  was  of  frequent  occurrence.  The  therapeutic 
measures  which  the  speaker  favored  were  bloodletting, 
revulsives,  atropine,  aniyl  nitrite,  and  in  some  cases 
rectal  injections  of  carbonic  acid  gas. 

Treatment  of  Pneumonia. — Vaill.\rd  discussed  the 
treatment  of  infectious  pneumonia,  the  main  indication 
in  which  was  the  expulsion  from  the  system  of  the 
metabolic  products  of  the  pathogenic  bacteria.  This 
could  best  be  accomplished  by  blood-washing — copi- 
ous venesection  combined  with  intravenous  injec- 
tions of  a  decinormal  saline  solution,  or  artificial 
serum.  The  elimination  of  the  toxins  and  the  increase 
in  the  resisting-powers  of  the  body  were  also  favored 
by  the  cold  pack  and  other  forms  of  hydrotherapy. 

Gastro-Enteric  Infections  in  Infancy This  was 

the  subject  of  discussion  in  the  Section  on  the  Medi- 
cal Diseases  of  Children. 

EscHERiCH,  of  Graz,  read  a  paper  on  "  The  Role  of 
Micro-Organisms  in  the  Gastro-Intestinal  Diseases 
of  Nursing  Infants."  After  referring  to  a  number  of 
examinations  made  by  him  and  his  assistants  deter- 
mining the  presence  of  microbes  in  the  stools  of 
infants,  he  said  that  the  introduction  of  any  micro- 
organisms other  than  those  normally  present  in  the 
intestine,  whether  the  new-comers  were  pathogenic  or 
not,  might  cause  fermentation  of  the  intestinal  con- 
tents. 

Baginsky,  of  Berlin,  divided  these  affections  into 
functional  (acute  dyspepsia)  and  organic.  Of  the 
latter  he  distinguished  the  following:  (i)  Lesions 
of  a  catarrhal  nature:  (a)  subacute  dyspeptic  catarrh, 
(f>)  superacute  catarrh,  cholera  infantum,  (<)  chronic 
gastro-intestinal  catarrh,  and  (it')  intestinal  atrophy, 
intestinal  cachexia,  or  athrepsia.  (2)  Lesions  local- 
ized in  the  follicles:  (a)  simple  follicular  enteritis, 
(/>)  grave  infectious  follicular  enteritis,  dysentery. 
The  functional  troubles  as  well  as  those  accompanied 
by  anatomical  alterations  were  caused  by:  (i)  Endo- 
genous infections  or  intoxications:  (<?)  the  direct 
action  of  the  normal  intestinal  microbes,  the  virulence 
of  which  is  exalted  by  certain  conditions  of  high 
temperature,  etc. ;  (/')  the  action  of  the  toxic  products 
elaborated  from  the  alimentary  substances  under  the 
influence  of  these  virulent  microbes.  (2)  Ectogenous 
infection  or  intoxications:  (a)  the  action  of  saprophy- 
tic microbes  or  those  Common  infections  introduced 
with  the  food  and  becoming  virulent  by  the  favoring 
circumstances  of  high  temperature,  etc.;  (/')  toxic 
substances  already  present  in  the  ingested  food. 

Fede,  of  Naples,  read  a  paper  dealing  chiefly  with 
the  symptoms  and  treatment  of  the  chronic  forms  of 
gastro-enteritis  in  infancy.  A  brief  consideration  of 
the  anatomical  and  physiological  imperfections  of  the 
digestive  apparatus  of  the  new-born,  he  said,  would 
suffice  to  prevent  surprise  at  the  frequency  of  catarrhal 
gastro-enteritis,  particularly  the  chronic  forms  in 
infancy.  The  chief  symptoms  were  an  obstinate 
diarrhcea,  rectal  prolapse,  vomiting,  fermentation  of 
the  gastric  contents,  and  dilatation  of  the  stomach. 
Among  the  general  symptoms  we  see  pyrexia  due  to 
auto-toxEemia  of  intestinal  origin,  debility,  cachexia, 
marasmus,  and  various  respiratory,  glandular,  nervous, 
renal,  and  cutaneous  complications.  Among  the 
sequelae  were  Parrot's  athrepsia,  rickets,  Riga's  dis- 
ease, and  tuberculosis.  The  primary  indications  in  the 
management  of  chronic  gastro-enteritis  of  infants  were 
for  the  institution  of  hygienic  measures  and  an  appro- 
priate diet — that  is  to  say,  breast-milk.  Elimination 
and  disinfection  of  the  intestinal  contents  were  very 
important,  and  among  the  remedies  most  suitable  for 
these  purposes  were  castor  oil,  calomel,  benzonaphthol, 


and  lavage  of  the  stomach  and  intestine  with  solutions 
of  boric  acid,  carbolic  acid,  creolin,  etc.  For  the 
diarrhcea,  when  too  profuse,  lactic  or  hydrochloric 
acid,  preparation  of  bismuth,  tannin,  or  other  astrin- 
gents were  indicated.  In  cases  of  pain  and  nervous 
excitement,  poultices,  calmatives  (belladonna  or  even 
opium),  and  baths  were  indicated.  When  depression 
was  marked,  aromatic  baths,  quinine,  caffeine,  ether, 
asafoetida,  musk,  and  injections  of  artificial  serum 
might  be  employed. 

Marfan,  of  Paris,  followed  with  a  communication 
on  the  etiology  and  pathogenesis  of  these  affections. 
He  divided  them,  according  to  their  exciting  causes, 
into  (i)  dyspeptic  gastro-enteritis  resulting  from  a 
faulty  elaboration  of  the  food,  whether  from  over-feed- 
ing or  from  too  early  weaning;  (2)  primary  infectious 
gastro-enteritis  following  the  introduction  of  patho- 
genic microbes  into  the  digestive  tract  by  way  of  the 
mouth;  (3)  primary  toxic  gastro-enteritis  resulting 
from  the  introduction  into  the  digestive  canal  of  some 
chemical  poison;  and  (4)  secondary  gastro-enteritis 
which  might  follow  any  of  a  number  of  diseases.  The 
action  of  the  causes  enumerated  might,  the  speaker 
added,  be  intensified  by  extraneous  influences,  such 
as  summer  heat,  catching  cold,  dentition,  etc. 

The  subject  was  further  discussed  by  Vargas,  of 
Barcelona,  and  Epstein,  of  Prague. 

Artificial  Feeding. — Jacobi,  of  New  York,  read  a 
paper  on  this  subject.  Human  milk,  he  said,  being 
of  variable  composition,  it  was  impossible  to  manu- 
facture an  exact  equivalent,  and  the  demand  for  it  had 
no  justification.  Water  was  a  necessary  addition  to 
the  infant's  artificial  food.  A  decoction  of  cereals 
was  the  proper  diluent  for  the  casein  of  cow's  milk. 
Enough  milk-sugar  was  contained  naturally  in  cow's 
milk,  and  the  added  sugar  should  be  cane — for  one 
reason,  because  there  was  a  ferment  in  the  intestinal 
tract  of  the  infant  which  rendered  cane  sugar  assimi- 
lable. There  was  no  necessity  for  adding  fat  to  cow's 
milk.  Finally  common  salt  must  be  added  to  the  in- 
fant's artificial  food.  Sterilized  cow's  milk  was  not  a 
curative  remedy  nor  an  equivalent  of  human  milk, 
but  it  was  indispensable  in  cities  and  wherever  pure,  11 
fresh  milk  could  not  be  obtained.  ■ 

Radiography  in  the  Study  of  Fractures  and 
Dislocations  was  the  subject  of  a  discussion  in  the 
Surgical  Section.  E.  von  Bergmann,  of  Berlin,  re- 
ferred to  certain  of  the  causes  of  non-union  after 
fracture,  such  as  the  interposition  of  muscular  fibres 
between  the  ends  of  the  fractured  bone.  Unfortunately 
we  could  not  diagnose  this  condition  positively  by 
means  of  the  Roentgen  rays,  but  we  might  be  justified 
in  assuming  its  presence  when  the  image  on  the  fluor- 
escent screen  siiowed  the  ends  of  the  bone  separated 
by  a  more  or  less  wide  interval,  which  was  always  of 
the  same  width  in  whatever  position  the  limb  was  ex- 
amined. Certain  other  causes  of  non-union,  however, 
could  be  accurately  revealed  by  the  .r-rays.  In  fracture 
of  the  patella,  for  example,  we  might  discover  by  this 
means  three  obstacles:  (i)  Inequality  in  size  of  the 
two  fragments,  (2)  multiple  fracture,  (3)  rotary  dis- 
placement of  one  of  the  fragments.  In  three  cases 
radioscopy  rendered  incalculable  service  by  revealing 
the  danger  of  non-union  and  thus  enabling  the  surgeon 
to  institute  ajipropriate  operative  measures.  The 
speaker,  thus  forewarned,  had  obtained  bony  union  in 
more  than  twenty-five  cases  of  this  nature.  Another 
service  which  radioscopy  had  rendered  was  in  reveal- 
ing various  fractures  of  the  metatarsal  and  tarsal 
bones  which  were  not  recognized  formerly,  being  re- 
garded as  simple  sprains  of  the  foot,  and  mistreated 
by  massage. 

G.  Manourv,  of  Chartres,  said  that  in  cases  of 
simple  fracture  radioscopy  was  of  invaluable  service 
in  showing  us  the  number  of  fragments,  their  form, 


August  I  I,  1900] 


MEDICAL    RECORD. 


233 


position,  extent  of  overriding,  and  the  location  of  de- 
tached splinters.  In  order  to  obtain  a  sufficient 
knowledge  of  the  disposition  of  a  fracture,  we  must 
radiograph  it  at  two  dilferent  angles — usually  in  front 
and  in  profile,  but  no  precise  rules  could  be  formu- 
lated in  this  respect,  for  each  fracture  called  for  its 
own  angle  of  observation.  The  clinical  diagnosis  of 
a  fracture  had  lost  none  of  its  value  since  the  intro- 
duction of  radioscopy,  but  the  latter  served  to  fortify 
or  sometimes  to  correct  the  former.  Although  this 
method  of  examination  was  useful  in  all  cases  of 
fracture,  there  were  certain  ones  in  which  it  was  espe- 
cially important,  such  as  those  of  the  upper  end  of  the 
humerus,  the  lower  end  of  the  radius,  the  leg  (espe- 
cially those  involving  the  tibio-tarsal  articulation), 
the  astragalus,  and  the  metatarsal  bones.  Radio- 
graphy was  no  less  useful  in  the  treatment  than 
in  the  diagnosis  of  fractures,  for  it  enabled  us  better 
to  reduce  the  fracture  and  to  determine  how  far  this 
reduction  was  possible,  to  rectify  any  malposition 
before  the  callus  became  so  firm  as  to  necessitate  re- 
fracture,  and  finally  to  determine  the  degree  of  per- 
fection of  the  result  of  our  treatment.  It  furnished 
us  also  with  a  means  of  estimating  the  relative  value 
of  the  different  forms  of  apparatus  employed.  In 
cases  of  complicated  fracture,  the  necessary  operative 
measures  could  be  instituted  much  more  intelligently, 
and  we  could  determine  in  advance,  in  cases  of  im- 
paction, whether  and  in  what  direction  it  would  be 
necessary  to  saw  the  fragments  in  order  to  obtain  free- 
dom and  apposition.  The  Roentgen  rays  were  of 
much  less  value  to  us  in  the  diagnosis  and  treatment 
of  dislocations,  yet  even  here  they  often  rendered  most 
valuable  service.  Unfortunately,  however,  radio- 
scopy often  failed  to  reveal  the  obstacles  to  the  reduc- 
tion of  a  luxation,  since  these  were  commonly  in  the 
soft  parts.  In  the  study  of  congenital  dislocation  of 
the  hip  and  of  the  luxations  occurring  in  the  course  of 
malum  coxk,  on  the  other  hand,  the  .r-rays  had  been 
exceedingly  serviceable. 

Among  other  subjects  of  interest  discussed  in  the 
various  sections  on  Saturday  were :  "Tuberculosis  in 
the  Italian  Army,"  bySforza;  "Tuberculosis  in  the 
French  Army  "  by  Arnaud;  "  Men  of  War  in  Time  of 
War,"  by  Surgeon-General  Van  Reypen,  L'.S.N.;  the 
"  Bacteriology,  Symptomatology,  Prophylaxis,  and 
Orrhotherapy  of  Plague,"  by  Simond,  Yersin,  and 
others;  "Infection  and  Immunity,"  by  Fe're,  Babes, 
Chantemesse,  Maragliano,  Xocard,  Bernheim,  and 
Ehrlich;  "Toxins  and  Antitoxins,"  by  Roux,  Ehrlich, 
Pane,  Vaillard,  Vincent,  and  others;  "Etiology  of 
Yellow  Fever,"  by  Geddings  of  the  United  States 
Marine-Hospital  service;  "General  Infections  in 
Gonorrhoea,"  by  Taylor,  Lassar,  and  Tommasoli; 
"  Notes  on  Recent  Methods  in  the  Surgery  of  Frac- 
tures, with  Special  Reference  to  Massage  and  Mobili- 
zation," by  Pickett;  "Treatment  of  Puerperal  Eclamp- 
sia by  Lavage  of  the  Blood  (Repeated  Venesections 
and  Injections  of  Artificial  Serum),"  by  Seytre. 

Gotit.  —  In  the  Section  on  Medicine  there  was  an 
interesting  discussion  on  the  pathogeny  of  gout. 

Sir  Dvce  Duckworth,  of  London,  said  that  an 
inherent  vice  of  nutrition  was  at  the  bottom  of  gout, 
this  vice  being  expressed  by  faulty  metabolism  in 
various  organs  such  as  the  liver  and  kidneys.  This 
trophic  vice  resulted  in  the  formation  of  uric  acid  in 
excess  and  its  occasional  retention  in  the  blood.  The 
nutritional  fault  might  be  acquired  or  inherited,  and 
when  acquired  might  be  transmitted  to  the  descendants. 
The  gouty  paroxysms  were  marked  by  the  precipita- 
tion of  crystals  of  sodium  biurate  in  the  joints  and 
other  parts  of  the  body.  The  influence  which  con- 
trolled these  paroxysms,  determining  their  location 
and  their  metastases,  was  nervous,  probably  bulbar. 
Articulations  or  tissues  which  had  been  weakened  by 


injury  or  overuse  were  those  which  were  most  prone 
to  be  the  seat  of  the  gouty  deposits,  but  the  neurosis 
was  the  essential  feature  in  the  pathogenesis  of  gout. 
The  presence  of  uric  acid  in  the  blood  was  in  itself 
alone  unable  to  produce  a  paroxysm  of  gout.  The 
deposit  of  urates  was  usually  permanent,  but  it  might 
sometimes,  especially  when  in  the  more  vascular 
tissues,  be  removed  by  appropriate  treatment.  That 
the  pain  of  gout  was  not  caused  by  the  uratic  deposit 
alone  was  shown  by  the  fact  that  enormous  deposits 
might  occur  in  gouty  individuals  without  exciting  any 
pain  whatever.  Gout  was  to  be  regarded  as  both  a 
blood  and  a  nerve  disease,  both  hamic  and  tropho- 
neurotic changes  being  shown  to  act  as  pathogenic 
factors. 

Prof.  Wilhelm  Erstein,  of  Gottingen,  held  that 
gout  was  a  more  or  less  chronic  malady,  the  fundamental 
substratum  of  which  was  an  hereditary,  usually  con- 
genital morbid  tendency  to  which  had  been  given  the 
name  of  the  uric-acid  diathesis.  One  could  only  theor- 
ize as  to  the  true  cause  of  this  diathesis.  The  close  re- 
lations existing  between  the  nucleins  and  uric  acid 
made  it  probable  that  one  had  to  do  with  an  abnormal 
condition  of  the  cellular  nuclei  or  protoplasm.  The  in- 
dividual predisposition,  whatever  this  might  be.  which 
could  often  be  traced  through  generations,  was  of  the 
greatest  importance  in  the  uric-acid  diathesis.  Certain 
conditions  might  arise  which  were  capable  of  convert- 
ing this  diathesis  into  actual  gout.  Among  these 
might  be  mentioned  the  following:  (i)  Other  things 
being  equal,  gout  developed  the  earlier  and  the  more 
surely,  the  more  pronounced  was  the  uric-acid  dia- 
thesis; (2)  luxury,  idleness,  and  the  abuse  of  alco- 
hol favored  the  development  of  gout;  (3)  certain 
intoxications,  acute  or  chronic,  often  excited  an  attack 
of  gout  in  the  presence  of  the  uric-acid  diathesis; 
among  these  might  be  mentioned  bacterial  poisons, 
lead,  and  the  toxic  principles  of  rheumatism,  influenza, 
and  syphilis;  (4)  contagion,  which  Boerhaave  regards 
of  such  importance,  was  a  negligible  factor;  (5)  and 
finally  climate  appeared  also  to  have  no  influence  in 
the  production  of  gout.  Uric  acid  was  the  gouty 
Y>o\son par  cxce/knce,  but  whether  other  products  belong- 
ing to  the  alloxur  or  nuclein  bases  were  also  concerned 
"in  the  production  of  the  disease,  it  was  as  yet  unable 
to  determine.  The  offending  uric  acid  was  probably 
that  formed  from  the  nucleinic  substances  of  the 
organism  and  not  that  formed  from  the  nucleins  of 
the  food.  An  excess  of  uric-acid  formation  seemed 
not,  in  itself,  to  be  responsible  for  the  gouty  attack, 
for  an  enormous  formation  of  this  body  was  often  noted 
in  leuka;mia  without  gouty  symptoms.  The  inflam- 
matory and  necrotic  changes  in  the  tissues  were  the 
result  of  the  presence  of  uric  acid,  and  when  the  tissues 
were  completely  necrosed — but  not  before — there 
occurred  a  deposit  of  sodium-biurate  crystals.  Gout 
might  be  divided  clinically  into  primarily  articular  and 
primarily  renal;  the  first  form  was  the  more  common 
and  was  not  incompatible  with  long  life,  the  second 
was  a  more  serious  malady  due  to  retention  of  uric 
acid  in  consequence  of  an  organic  lesion  of  the  kidney. 

M.  P.  Le  Gendre.  of  Paris,  reviewed  the  various 
theories  held  at  the  present  day  regarding  the  patho- 
genesis of  gout,  and  said  that  against  each  of  them 
might  be  raised  certain  chemical,  physiological, 
or  pathological  objections.  Statistics  proved  that 
gout  was  associated  very  often  with  the  so-called 
arthritic  diseases,  those  due  to  a  vice  of  nutrition, 
in  the  individual  or  his  family;  the  most  common  of 
these  associated  maladies  were  diabetes  and  obesity. 
Diabetes  consisted  in  an  inability  of  the  tissues  to 
consume  the  sugar,  to  carry  to  its  final  equation  the 
transformation  of  the  carbohydrates,  and  it  was  most 
probable  that  there  was  in  the  gouty  an  inability 
to  elaborate  completely  the   nitrogenous   principles. 


234 


MEDICAL    RECORD. 


[August  1 1,  1900 


Among  the  consequences  of  this  incomplete  destruction 
of  albumin  was  a  loading  of  the  system  with  certain 
acids,  which  diminished  the  solubility  of  the  uric  acid 
present  (not  necessarily  in  excess)  in  the  blood,  and 
with  certain  organic  bodies  the  toxic  action  of  which 
might  cause  some  of  the  symptoms  of  gout.  Clini- 
cally there  was  seen  also  a  morbid  affinity  between  gout 
and  interstitial  nephritis.  In  cases  of  acquired  gout 
the  nutritive  vice  of  the  cells  was  brought  about  by  a  de- 
fective hygiene  (abuse  of  nitrogenous  food  and  alcohol, 
insufficient  exercise  and  mental  overwork)  or  by  a 
poison  such  as  lead. 

Autotoxaemia. — On  Wednesday  there  was  an  ani- 
mated discussion  on  autointoxication,  participated  in 
by  Bouchard,  Ewald,  Albu,  Gautier,  and  lirouardel. 
The  majority  of  the  speakers  accepted  provisionally 
the  theories  of  Bouchard  regarding  the  pathogenesis 
of  this  condition.  Two  interesting  papers  on  "  Ex- 
trabuccal  Alimentation'"  were  read  by  Leube  and  Ewald 
(the  latter  will  appear  in  the  next  issue  of  the  Medical 
Record).  Chantemesse  discussed  the  influence  for 
good  or  ill  of  an  exclusive  meat  diet  upon  the  course 
of  pulmonary  tuberculosis.  Blum  described  a  new 
method  applicable  to  the  recognition  and  treatment  of 
systemic  intoxications.  Menetrier  presented  a  com- 
munication in  which  he  traced  the  relation  of  adeno- 
mata to  ulcer  and  carcinoma  of  the  stomach. 

Arloing  read  a  paper  dealing  with  the  history  of  the 
attempts  at  orrhotherapy  in  combating  tuberculosis,  and 
describing  the  various  researches,  from  Koch's  to 
Maragliano's,  made  with  the  aim  of  producing  a  really 
efficacious  and  safe  anti-tuberculous  serum. 

Among  the  communications  presented  by  Americans 
in  the  various  sections  were  the  following:  "Non- 
tabetic  Lesions  of  the  Spinal  Cord,"  by  Dana ;  "  Treat- 
ment of  Hypertrophied  Prostate,"  by  Ramon  Guiteras; 
"Ischaemia  and  Atrophy  of  Muscles  due  to  Tight 
Bandaging,"  by  Bernays;  "Surgery  of  the  Lungs,"  by 
J.  B.  Murphy;  "  Report  of  a  Case  of  Ligation  of  the 
Abdominal  Aorta,"  in  which  the  patient  survived  the 
operation  forty-eight  hours,  by  Keen;  "Study  of 
Tuberculosis  in  the  United  States,"  by  de  Schweinitz, 
of  Washington;  "A  New  Operation  for  Acute  Ap- 
pendicitis," by  Weir. 


^Iterapeutic  pints. 

Rachitis. — 

R  Phosphor! gr.  ss. 

01   amygJai.  dulc 31. 

Pulv.  acaci.L-, 

Pul V.  sacch    alb aa  |  ss. 

AquDe  destil 1  iss. 

M.      S.    Shake  and  give  one  to  three  tablespoonfuls  daily. 

— Kassowitz. 
Painful  Menses. — 

^  Codein gr.  i. 

Chloral, 

Ammon.  brom aa  gr.  xv. 

Aq.  caniphor.x- 5  '• 

M.     S.    I'rom  a  quarter  to  half  the  quantity  before  retiring. 
Repeat  as  indicated. 

Creosote  Wine. — 

H  Creosote 3  ss. 

linct.  gentian |  i. 

Spir.  vini  rect |  viij. 

Vini  xerici q.s.  ad  O  ij. 

In  tuberculosis  a  dessertspoonful  several  times  a  day  unless 
mu  h  fever  is  present. 

— Nouvcaux  Remides. 

Lupus  Erythematosus. — Strong  alcohol  containing 
a  little  menthol.  'I"he  patient  carries  about  a  vial  and 
applies  a  few  drops  every  half-hour  or  so. —  Hall. 


Dysentery  in  Childhood. — 

V,  Cocain    muriat 05  cgm. 

Ergotin 50     " 

Ext.  opii 10     " 

Aristol 25     " 

01.  theobrom q.s. 

M.  ft.  supposit.  No.  X.     S.    One  every  two  to  three  hours. 

— Meilical  Times  and  Hospital  Gazette,  June  9. 

Pruritus. — .\lkaline  baths;  starch  and  linseed  meal 
baths;  the  continuous  bath;  Turkish  and  vapor  baths. 

Vf  Ac.  carbol.  liq 3  i. 

Liq.  potassse 3  ss. 

.•Vqua; ad  |  viij. 

M.    ft.  lotio.     S.   Apply  as  required. 

— Evans. 
Urticaria. — 

I?  Sodii  phosphat 3  i- 

M.     S.    Every  three  hours. 

— Wolff. 

Hyper-Excitability  of  the  Stomach  with  pyloric 
spasm,  diarrhoea,  etc. 

B  Hydrat.  chloral gr.  xv. 

Aqure 3  iss. 

From   fifteen  to  thirty  drops  in  half  a  glass  of  vifater  after 
each  meal. 

— Rosen  BACH. 
Gastric  Catarrh — 

B  .\c.  hydrochl.  (C.  P.) 2.5  gm. 

Ac.  azotic 0.8  dgm. 

Spt.  vini  rect 18.    gm. 

Aq.  font 150. 

Syr.  limonis 100. 

M.     S.   Teaspoonful  in  half  a  glass  of  water  after  meals. 

Basedow's  Disease  in  Childhood. — 

B  Strontii  brom 6  gm. 

Strontii  iod 12     " 

Aq.  destil 40     " 

Aq.  menth.  pip 20     " 

Syr.  menth.  pip 20     " 

M.      S.   Teaspoonful  three  times  a  day. 

Pertussis. — 

B   Pulv.  bellad.  rad gr.  ^ 

Pulv.  1  )overi gr.  ss. 

Sulphur,  sublim., 

Sacch.  alb aa  gr.  viij. 

M.      S.   At  dose.      Repeat  from  two  to  ten    times   a  day, 
p.  r.  n. 

Ringworm  of  the  Scalp. — Cut  the  hair  short  with 
scissors,  and 

B  Chrysophanic  acid gr.  xv. 

Chloroform |  ss. 

Tie  a  piece  of  absorbent  cotton  on  the  end  of  a  probe 
and  apply  to  the  dry  scalp  (do  not  wash  the  part),  sat- 
urating the  ringworm.  One  application  will  often 
cure.  The  ringworm  will  peel  off  in  scales  about  the 
third  day,  and  the  second  application  is  certain  to 
complete  the  cure. — Bascom  Lvn.\.  • 

Heat-Stroke  and  Sun-Stroke — Local  and  general 
refrigerants.  Friction  and  other  m-^asures  aiming  at 
restoration  of  consciousness.  To  control  the  thermo- 
genic centres  give  antipyrin  in  drachm  doses  prefer- 
ably by  hypodermic  injection. — MoussoiR. 

Infant  Feeding After  the  first  two  days  the  infant 

should  be  fed  at  regular  intervals  of  two  hours,  and 
from  one  to  one  and  a  half  ounces  at  each  feeding. 
About  the  third  month  the  intervals  should  be  length- 
ened to  two  and  one-half  hours,  feeding  three  and  one- 
half  ounces  each  time.  The  intervals  should  be 
constantly  lengthened,  until  at  the  ninth  to  the  twelfth 
month  feeding  should  be  three  and  one-half  hours 
apart,  and  seven  to  nine  and  one-half  ounces  in  quan- 
tity. Ifntil  the  sixth  week  two  feedings  during  the 
night  should  be  allowed;  one  from  the  sixth  week  to 
the  sixth  month,  when  all  night-feeding  should  be  dis- 
continued.—  ROWELL. 


August  1 1,  1900] 


MEDICAL    RECORD. 


'■6:) 


(Clinical   ^Department. 

REPORT    OF    A    CASE    OF    CESAREAN 
SECTION. 

Bv    DAVID   ST.    JOHN,    M.D., 

VISITING      I'HY^ICIAN      AND     SUKGEON      TO     HACKENSACK      HOSPITAL,     HACKEN- 
SACK,    N.   J. 

Mrs.  H.  O ,  aged  twenty-five  years,  American,  en- 
tered Hackensack  Hospital  on  September  18,  1899, 
in  tiie  ninth  month  of  gestation,  and  feared  labor 
owing  to  marked  spinal  curvature  existing  from  in- 
fancy. Her  general  health  was  good  ;  she  was  under- 
sized, of  dark  complexion,  weight  one  hundred  pounds. 

The  following  measurements  were  determined  by 
Dr.  St.  John  and  confirmed  by  Doctors  White  and 
Conover : 

External  between  crests  of  ilium,  9.^  inches;  ex- 
ternal between  anterior  superior  spines,  :o  inches; 
external  between  trochanters,  11  inches;  external 
conjugate,  6  inches;  diameter  of  outlet,  only  2  inches. 

Since  it  was  evident  that  the  foetus  could  not  be 
born  "per  vias  naturales,"'  Cesarean  section  was  ad- 
vised. 

The  patient  was  placed  upon  nutritive  diet;  tlie 
bowels  were  regulated,  daily  baths  were  given,  and 
the  abdomen  was  thoroughly  asepticized.  Urinary 
analysis  showed  alkaline  reaction,  specific  gravity 
1. 01 4,  no  albumin. 

.-\t  intervals  for  several  days  the  patient  complained 
of  some  pains  in  the  back  and  suprapubic  region. 

On  September  25th,  at  2  -.^o  p.m.,  labor  pains  be- 
ginning, the  patient  was  taken  to  the  operating-room, 
catheterized,  and  the  abdomen  was  again  thoroughlj- 
cleansed  with  green  soap,  bichloride  solution,  al- 
cohol, and  ether  freely.  The  operation  was  performed 
by  Dr.  St.  John,  assisted  by  Doctors  Neer,  Conover, 
Conrad,  Swayze,  and  Scott,  with  the  hospital  nurses. 
A  hot  vaginal  douche  having  been  given,  the  cervix 
was  dilated,  and  the  vagina  was  loosely  filled  with 
iodoform  gauze.  Abdominal  incision  was  then  made 
in  the  median  line,  six  inches  long;  there  was  no 
hemorrhage.  The  wall  was  thin,  and  the  intestines 
were  not  in  the  way.  The  uterus  was  lifted  out  and 
surrounded  by  warm,  sterile  gauze.  A  longitudinal  in- 
cision was  made  in  the  uterus  five  and  one-half  inches 
long:  the  amnion  was  punctured,  and  the  opening  en- 
larged with  scissors.  The  child  was  grasped  by  the  foot, 
lifted  out,  and  handed  to  Dr.  Conover  to  be  cared  for. 
The  cord  was  clamped  and  cut.  Uterine  contractions 
immediately  set  in.  The  placenta  having  been  loos- 
ened and  delivered,  the  uterus  was  then  cleared  of 
remaining  membranous  shreds  and  loosely  packed 
with  strips  of  iodoform  gauze,  a  strip  for  drainage 
having  first  been  run  through  the  cervix. 

Dr.  Conrad  controlled  uterine  hemorrhage  by  com- 
pressing the  uterine  arteries  with  his  hands.  Thirty 
minims  of  aseptic  ergotal  was  given  hypodermically 
as  soon  as  the  uterus  was  emptied. 

The  uterine  incision  was  then  closed  by  two  sets  of 
sutures,  the  deep  with  No.  4  silk  two-fifths  of  an  inch 
apart,  the  superficial  with  No.  2  silk.  The  gauze  was 
removed  from  the  uterus  before  the  sutures  were  tied. 
The  uterus  was  cleaned  of  blood  and  returned  to  the 
abdomen.  The  pelvic  cavity  was  mopped  out,  though 
this  was  little  needed,  for  it  had  been  well  protected 
by  sterile  gauze  and  towels.  The  abdominal  incision 
was  closed  with  extra  heavy  silk.  No  drainage  was 
used.  The  time  under  ether,  which  was  given  by  Dr. 
Neer,  was  twenty-nine  minutes;  the  time  from  the  be- 
ginning of  the  first  incision  in  the  abdomen  until  the  last 
suture  was  tied,  twenty-four  minutes.  There  was  verj- 
little  hemorrhage.  She  bore  the  anaesthetic  well.  The 
dressings  used  were  iodoform,  iodoform  gauze,  sterile 


cotton,  and  binder.  Sterile  salt  solution  was  used 
during  the  operation. 

The  cervical  drainage  was  removed  on  the  27th. 
The  lochia  were  normal.  Seven  days  after  the  opera- 
tion the  dressing  was  changed.  Tiie  wound  was  clean 
and  dry.  The  stitches  were  removed  on  the  21st  day; 
the  incision  had  perfectly  united. 

Twenty-five  days  after  operation  the  patient  sat  up 
for  a  few  minutes.  After  the  first  few  days,  during 
which  time  the  patient  was  restless,  requiring  very  care- 
ful nursing  and  stimulation,  she  regained  strength 
rapidly,  and  was  discharged  from  the  hospital  on 
November  6th,  six  weeks  after  the  operation. 

Mother  and  child  are  both  well  now.  The  child 
weighed  seven  pounds  at  birth. 

Some  authorities  advise  dilating  the  cervix  after 
the  uterus  is  emptied,  but  why  should  any  time  be 
lost  during  this  important  step  in  the  operation,  when 
it  can  be  done  so  readily  and  with  no  need  of  haste, 
just  before  the  abdomen  is  opened? 

.\lthough  it  is,  advised  to  bring  the  uterus  out  of 
the  abdomen  before  incising  in  all  cases  in  which 
sepsis  is  suspected,  it  would  seem  to  be  better  to  do  so 
in  other  cases  as  well,  owing  to  greater  ease  of  hand- 
ling. Uterine  hemorrhage  can  be  effectually  con- 
trolled by  an  assistant  grasping  the  uterus  firmly  low 
down  near  the  neck  with  both  hands,  thus  avoiding 
the  dangers  of  subsequent  atony  or  post-partum  hemor- 
rhage so  apt  to  follow  when  a  rubber  ligature  is  thrown 
around  the  uterus. 


FARADIC    ELECTRICITY'    IN    RENAL    COLIC. 
Bv   C.A.KL   D.    S.    FrUh,    M.D., 

PHILADELPHIA,    PA. 

Henry  H ,  aged  forty-eight  years,  was  taken  se- 
verely ill  on  June  22,  1900,  with  pains  in  the  left  kid- 
ney. He  gave  a  history  of  three  previous  attacks  in 
which  the  pains  were  so  bad  that  he  went  into  convul- 
sions. The  regulation  treatment  with  morphine  and 
atropine  failed  here  even  to  give  more  than  momen- 
tary relief.  He  was  then  placed  on  his  side  with  the 
sore  kidney  up,  the  hip  and  legs  elevated,  and  a  fara- 
dic  current  interrupted  sixty  to  eighty  times  per  minute 
was  applied  to  the  front  and  back  of  the  organ.  One 
half-hour  of  this  gentle  tapping  of  the  kidney  eased  the 
pain  coni|)letely.  The  patient  passed  water  freely  and 
was  completely  relieved  by  this  treatment. 

July  2,  1900. 


A    LARGE    OV^•\RIAN    CYST. 
By    W.    C.    fisher     M.D., 

CLARINDA,    IOWA. 

In  January,  1900,  in  my  capacity  of  county  physician 

I  was  called  to  see  Mrs.  T ,  eighteen   years  old, 

married  almost  two  years.  Her  family  history  was 
good.  Her  mother  and  grandmother  were  still  living. 
About  eighteen  months  previously  she  had  noticed 
pains  in  the  region  of  the  left  ovary.  Menstruation 
was  irregular  and  painful.  She  noticed  a  tumor  in 
that  region,  but  did  not  think  seriously  of  it.  This 
continued  with  varied  treatment  until  the  summer  of 
1899,  when  a  diagnosis  of  ovarian  cyst  was  made  and 
operation  was  advised.  At  this  period  she  fell  in 
with  the  faith  healers  and -was  sent  to  Chicago,  where 
she  received  "spiritual  treatment"  for  some  time,  but 
the  tumor  continued  to  grow.  She  returned  from  Chi- 
cago and  continued  tiie  "absent  treatment"  plan  until 
June  16,  1900,  when  I  was  asked  to  operate.  I  called 
to  see  the  patient  and  found  her  suffering  from  short- 
ness of  breath,  caused  by  the   abdominal  distention. 


236 


MEDICAL    RECORD. 


TAugust  1 1,  1900 


The  cervix  uteri  was  partially  prolapsed  through  the 
vulva. 

The  woman  was  taking  but  little  nourishment,  be- 
cause anything  more  caused  vomiting.  Her  weight 
was  about  one  hundred  and  sixty  pounds.  The  meas- 
urement around  the  waist  was  fifty-five  inches,  her  pre- 
vious measurement  having  been  twenty-one  inches. 
She  had  been  in  the  habit  of  sitting  with  the  lower 
£nd  of  the  ftimor  resting  on  a  woven-wire  cot. 

I  informed  the  friends  that  there  was  very  little  to 
hope  from  an  operation,  but  it  was  the  only  hope,  and 
•f  it  was  their  wish  I  would  operate.  On  June  20th, 
at  their  request,  assisted  by  Urs.  Torrens,  Cokenower, 
and  English,  of  this  city,  I  operated.  Upon  opening 
the  peritoneum  I  came  upon  a  fibrinous  mass  filling 
the  entire  pelvic  cavity,  which  had  to  be  divided  be- 
fore I  could  bring  it  through  the  opening,  which  was 
about  nine  inches  in  length.  After  removing  this 
portion  I  came  upon  a  large  cyst  entirely  filling  the 
upper  part  of  the  abdomen  and  adherent  to  the  peri- 
toneum and  diaphragm.  This  was  filled  with  a  dark- 
brown,  syrupy  tiuid.  After  tying  the  pedicle  and 
removing'the  sack,  I  flushed  the  abdomen  with  steril- 
ized water,  sutured  with  silkworm  gut,  and  dressed  in 
the  usual  manner.  The  patient  recovered  promptly 
from  the  shock,  and  her  mental  condition  was  clear. 
She  did  well,  with  no  fever  and  a  normal  pulse  (72) 
until  Friday  morning  the  2 2d,  when  she  suddenly  col- 
lapsed and  died  in  a  few  minutes.  Upon  opening  the 
abdomen  after  death  I  found  everything  in  nice  shape; 
the  stump  was  in  good  condition,  there  had  been  no 
bleeding,  and  the  abdominal  wound  was  healing  rapid- 
ly.    The  tumor  weighed  seventy-five  pounds. 


familiar  with  their  properties,  and  anything  empha- 
sizing the  fact  ought  to  be  mentioned.  This  is  the 
reason  I  have  reported  my  little  experience. 


ALCOHOL  AS  AN 


ANTIDOTE  TO  CARBOLIC 
ACID. 


By   GEORGE   W.   SARGENT,    M.D., 

SENECA    CASTLE,    N.    Y. 

A  GOOD  deal  has  been  written  of  late  in  regard  to  car- 
bolic acid,  notably  a  paper  by  Dr.  Seneca  D.  Powell, 
in  the  Medical  Record  of  March  11,  1899.  Powell 
says  that  carbolic  acid  may  be  applied  to  the  skin  in 
full  strength  without  harm;  that  one  may  dip  his 
hands  in  ninety-five-per-cent.  carbolic  acid  with  im- 
punity if  he  rinses  them  promptly  in  ninety-five-per- 
cent alcohol. 

A  short  time  ago  I  involuntarily  verified  these 
statements  to  my  own  perfect  satisfaction  and  that  of 
several  witnesses.  I  had  on  a  table  with  other  things 
two  two-ounce  bottles,  labelled  and  filled,  respectively, 
with  carbolic  acid  and  alcohol.  Having  washed  my 
hands  I  purposed  to  rinse  them  in  alcohol,  and  pick- 
ing up  one  of  the  bottles  rubbed  a  liberal  amount  of 
the  contents  over  my  hands  as  in  the  act  of  washing. 
I  was  not  a  little  amazed  to  find  by  the  oily  sensa- 
tion and  silvery  color  of  the  skin  that  I  had  washed  in 
the  carbolic  acid.  I  at  once  drenched  well  with  alco- 
hol from  the  other  bottle,  and  was  well  pleased  to  see 
the  normal  color  and  feeling  return. 

Some  cases  have  been  reported  in  which  diluted 
alcohol— and  one  recently  in  which  pure  alcohol — 
was  poured  into  the  stomach  in  carbolic-acid  poison- 
ing, with  successful  results. 

I  have  learned  that  stronger  ammonia  acts  similarly 
to  alcohol  as  a  local  application,  but  it  would  hardly 
answer  for  internal  use  or  for  use  on  ulcerating  sur- 
faces or  in  suppurating  cavities.  Dr.  Powell  has 
proven  that  in  such  cases  as  the  latter  alcohol  makes 
it  possible  to  use  carbolic  acid  in  full  strength  with 
very  beneficial  results. 

Carbolic  acid  and  alcohol  being  so  commop,  and  so 
pow^erful  for  good  or  evil,  it  behooves  every  one  to  be 


RECURRENT    TRANCE. 

By    C    I.    PAGE,    M.D., 

LITCHFIELD,    CONN. 

The  following  case,  which  has  been  under  my  observa- 
tion for  a  number  of  years,  is  such  a  peculiar  one  in 
many  ways,  that  I  believe  a  repoit  will  be  of  inter- 
est.    Mrs.   C.   E- ,  aged  ninety-one  years,  widow, 

mother  of  three  children.     There  is  no  insanity  in  the 
family.     In   October,   1875,   she   was   thrown   from   a 
wagon,  striking  her  head  on  the  edge  of  a  plank.     On 
examination   a  small  scalp  wound  was  found  directly 
under  the  occipital  protuberance.     There  were  no  in- 
dications of  fracture.     She  was  taken  home  in  a  semi- 
conscious condition,  and  she  remained  so  for  several 
days,  with  symptoms  of  concussion  of  the  brain.     At 
the  end  of  two  w'eeks  she  was  able  to   perform   her 
usual  household  duties  and  appeared  to  have  fully  re- 
covered.    About  two  months  afterward,  while  reading, 
she  remarked  to  her  daughter :    "  I   have  a  headache 
and  feel  sleepy,  so  will  retire  for  the  night."     The 
next   morning  she  was  found  in  a  deep    sleep.     On 
being  shaken  she  awoke  for  a  few  seconds  and  an- 
swered questions,  but  directly  was  asleep  again.     She 
presented  the  appearance  of  being  under  the  influence 
of  morphine  or  an  anesthetic.     She  would  not  ask  for 
food  or  water,  but   if  either  were  placed  to  her  lips 
she  would  eat  and  drink,  but  if  not  continually  urged 
would  stop.     She  did  not  evacuate  the  bowels  or  blad- 
.  der  unless  kept  awake  and  requested  to  do  so.     The 
superficial  reflexes  were    diminished,  eyelids  closed, 
pupils    dilated.       There    was    no    muscular    rigidity. 
This  trance  continued  for  five  days.     She  then  awoke, 
and  for  a  few  hours  there  was  a  mild  delirium.     After 
this  she  seemed  perfectly  rational,  but  could   not  re- 
member people  she  had  seen,  or  conversation  w^hich 
had  taken  place  during  the  trance.     She  did  not  men- 
tion her  condition,  but  if  it  was  mentioned  she  would 
discuss  it  freely.     She  then  remained  awake  contin- 
ually for  four  days,  and  would  sit  all  night  reading, 
sewing,  or  in  conversation  with  her  attendant.     At  the 
end  of  this  time  she  would  again  sleep.     In  this  man- 
ner she  lived  for  twenty-five  years,  asleep  five  days, 
then  awake  four.     This  condition  of  wakefulness  and 
sleep  would  come  with  such   clock-like  regularity  that 
her  attendants  could  tell  almost  to  the  hour  when  she 
would  awake   or   sleep.     As   to   this  condition   being 
genuine  there  cannot  be  the   least   doubt.     The  wo- 
man's mental  powers  while  she  was  awake  were  much 
better  than  those  of  the  average  person  at  seventy-five 
years  of  age.     In  April  last  she  developed  bronchitis 
and  while  in  a  trance  died.     An  autopsy  was  refused. 


MIX- 


A    DEATH     FROM     THE      SCHLEICH 
TURE. 

By    R.    M.    stone,    M.D., 


It  becomes  my  painful  duty  to  report  a  death  in  my 
practice  from  the  use  of  the  Schleich  solution.  As 
yet  I  have  not  seen  one  recorded  in  the  .\merican  ex- 
perience with  the  solution.  As  anesthetist  of  the 
Presbyterian  Hospital,  it  fell  tome  to  give  the  solution 
to  a  young  woman  aged  twenty-three,  well  nourished 
and  fairly  robust  in  appearance  ;  the  heart  sounds  were 
not  clear  and  sharp,  but  there  was  no  valvular  lesion. 
She  took  it  kindly  and  had  corneal  ance-sthesia  in  six 
minutes  and  surgical  anesthesia  in  two  more;  she  was 


August  II,  1900] 


MEDICAL    RECORD. 


carried  to  the  operating-room,  and  the  last  preparation 
was  complete  in  about  three  minutes  more.  She  was 
to  be  operated  upon  for  chronic  appendicitis,  having 
recently  recovered  from  her  second  attack. 

After  these  eleven  minutes,  the  pupils  were  very 
small,  the  lower  jaw  was  relaxed,  and  anaestiiesia  was 
apparently  profound  as  it  usually  is  in  my  experience 
with  the  Schleich  solution.  The  surgeon  asked  if 
she  was  ready,  to  which  I  said  she  was.  He  made 
the  incision,  to  which  there  was  a  very  small  reflex; 
when  he  separated  the  muscles,  there  was  a  little 
more.  During  all  this  time,  I  had  continued  the 
dropping  of  the  solution  at  an  increased  rate  because 
of  the  flinching.  The  surgeon  had  removed  the  ap- 
pendix, when  the  following  sequence  of  events  took 
place.  (It  should  first  be  said  that  the  incision  and 
separation  of  the  muscles  had  not  caused  sufficient 
reflex  to  dilate  the  pupils;  they  were  still  siriall,  and 
the  pulse  and  color  were  good.) 

The  pulse  then  became  weak,  irregular,  intermittent, 
and  then  ceased;  the  respiration,  which  had  been 
regular,  became  very  rapid  for  six  or  eight  respira- 
tions; while  the  pulse  was  failing,  but  before  it  had 
ceased  the  pupils  were  observed  to  be  small;  instant- 
ly they  dilated  widely,  and  death  was  present.  Efforts 
at  resuscitation  were  continued  for  an  hour,  with  no 
response  whatever.  Death  had  taken  place  from 
paralysis  of  the  heart  centre,  followed  by  that  of  the 
respiratory. 

No  more  horrible  experience  can  happen  to  a  physi- 
cian than  this.  It  is  a  dreadful  shock  to  him,  and 
causes  him  to  review  his  work  most  carefully  and  to 
criticise  himself  harder  than  any  of  his  enemies  will 
dare  to.  Having  done  this,  I  can  say  that  my  four 
hundred  and  forty-one  administrations  of  the  Schleich 
solution,  with  serious  symptoms  in  only  thirteen,  and 
death  in  but  one,  still  allow  me  to  think  that  its  ad- 
ministration gives  more  quiet,  more  freedom  from 
nausea  and  vomiting  during  and  after,  and  greater 
safety,  than  either  ether  or  chloroform. 


A   CASE   OF    DOUBLE    FACIAL    PARALYSIS. 
By   GEORGE   J.    PRESTON,    M.D., 

PROFESSOR     OF     NEIROLOGY,     COLLEGE    OP    fBYSICIAHS    AND    SURGEONS, 
BALTIMORE. 

Paralysis  of  both  facial  nerves,  occurring  simulta- 
neously, is  sufficiently  rare  to  warrant  the  recording 
of  the  following  case:  The  patient,  a  widow  aged 
sixty-five  years,  had  always  enjoyed  excellent  health. 
She  was  very  well  nourished,  and  her  organs  were  all 
normal.  A  few  days  prior  to  my  visit  she  had  an  at- 
tack of  what  her  family  physician  pronounced  bron- 
chitis, accompanied  by  cough,  slight  fever,  and  general 
neuralgic  pains.  It  is  important  to  note  that  there 
was  at  this  time  a  mild  epidemic  of  grippe  prevailing. 
The  patient's  symptoms  were  not  such,  however,  as  to 
warrant  a  diagnosis  of  influenza.  I  saw  her  on  June 
2Sth  and  found  that  she  had  a  marked  facial  paralysis 
of  the'  peripheral  type,  involving  both  upper  and,lower 
branches  of  the  left  nerve ;  the  face  was  strongly  drawn 
to  the  right,  the  tongue  was  protruded  to  the  left,  the  left 
eye  could  not  be  closed,  etc.  There  was  no  impair- 
ment of  sensation  either  general  or  special.  On  the 
27th,  or  two  days  later,  I  saw  the  patient  again  and 
found  that  the  right  nerve  had  become  involved.  The 
face,  which  had  been  strongly  drawn  to  the  right,  was 
now  perfectly  straight,  but  practically  motionless  and 
without  expression,  a  veritable  mask.  The  patient 
was  unable  to  close  either  eye,  and  there  was  a  very 
distressing  flow  of  tears.  Speech  was  much  affected, 
and  the  movements  of  the  tongue  were  limited.  There 
was  no  disturbance  of  taste,  smell,  or  hearing,  and  gen- 
eral sensation  was  entirely  normal.     A  careful  exami- 


nation showed  no  trace  of  the  involvement  of  any  other 

nerves,  cranial  or  spinal. 

The  paralysis  gradually  improved  under  strychnine 
in  increasing  doses  and  the  galvanic  current.  In  a 
couple  of  months  the  left  side  was  practically  well  and 
the  right  was  much  improved.  I  saw  this  patient  a 
year  and  a  half  after  the  attack,  and  her  general  health 
was  excellent.  She  said  that  the  right  side  of  her  face 
was  not  yet  natural,  but  there  was  hardly  any  paraly- 
sis remaining.  As  was  said  above,  the  paralysis  was 
of  the  peripheral  type,  and  there  was  absolutely  no 
local  cause,  such  as  otitis  or  trauma.  Possibly  the 
patient  may  have  had  grippe,  or  a  slight  rheumatic 
diathesis  may  have  been  responsible. 

There  is,  of  course,  no  reason  why,  in  cases  of 
facial  paralysis  due  to  a  distinct  neuritis,  both  nerves 
should  not  be  involved;  in  fact,  it  is  hard  to  explain 
why  only  a  single  nerve  becomes  involved  in  cases  of 
neuritis  supposedly  due  to  some  general  systemic 
cause.  However  this  may  be,  double  facial  paralysis 
is  a  rare  occurrence. 


A    CASE    OF    GLANDULAR     FEVER    IN     AN 
ADULT. 

By   ABRAHAM    MAYER,    M.D., 

NEW    VORK. 

Since  Pfeiffer,  in  1899,  first  described  the  affection 
known  as  glandular  fever  {Drueserifiebcr),  little  has 
been  written  which  has  added  anything  to  our  knowl- 
edge of  this  disease.  In  this  country  J.  Park  West  in 
1896,  in  an  excellent  article  in  the  Archives  of  Pedia- 
Irics,  described  an  extensive  epidemic  occurring  in  a 
small  hamlet  in  Ohio,  where  ninety-six  cases  occurred 
in  forty-six  families,  all  between  the  ages  of  seven 
months  and  thirteen  years.  Dawson  Williams  de- 
scribes the  disease  in  Volume  XIV.  of  the  "Twentieth 
Century  Practice  of  Medicine,''  and  is  also  the  author 
of  a  similar  article  in  Allbutt's  "System."  On  ac- 
count of  the  scanty  literature  on  this  subject,  it 
seems  well  to  collect  and  report  observations  on  cases 
which  may  come  under  our  notice.  This  is  the  more 
important  as  the  etiology  of  this  affection  is  still  ob- 
scure, and  the  classification  still  unsettled. 

Of  the  various  observers  of  this  affection,  Heubner, 
von  Starck,  Rauchfuss,  and  Hesse  consider  it  a 
special  infectious  disease  of  benign  character,  while 
others  have  doubted  the  existence  of  this  disease />iv 
se.  Faidherbe,  in  a  recent  article  in  the  BuUetin  tie  la 
Societe\ScientiJique  de  Bnixelles,  cowixAnxi  it  an  un- 
usual form  of  influenza.  It  has  also  been  suggested  that 
it  may  belong  to  the  exanthemata,  in  which  the  eruption 
is  absent.  But  as  the  symptoms  are  of  the  classical 
kind  generally  seen  with  infections,  we  may  at  least 
consider  it  an  infectious  malady  due  to  the  invasion 
of  some  micro-organism,  the  nature  of  which,  be  it 
staphylococci,  streptococci,  bacilli,  or  an  organism  sui 
generis,  has  not  yet  been  determined.  Bacteriological 
examinations  have  been  made,  but  nothing  definite 
has  been  found  as  the  etiological  factor.  It  is  a  spe- 
cific disease,  and  its  clinical  syndrome,  in  the  absence 
of  evidence  of  other  specific  affections,  stamps  it  as 
distinct  in  itself.  Its  sudden  onset  with  headache, 
malaise,  sometimes  vomiting,  constipation,  etc.,  and 
rise  of  temperature — these  symptoms  in  connection 
with  enlargement  of  special  glands  characterize  it  as 
an  acute  infectious  fever.  It  is  at  least  reasonable  to 
consider  it  such,  rather  than  an  obscure  affection 
associated  with  enlargement  of  cervical  glands.  It 
affects  children  usually  under  the  age  of  thirteen 
years;  rarely  adults.  The  lymph  glands  most  com- 
monly affected  are  those  beneath  and  in  front  of  the 
sterno-mastoid  muscle;   occasionally  the  axillary,  in- 


238 


MEDICAL    RECORD. 


[August  1 1,  1900 


guinal,  and  mesenteric  glands  become  the  seat  of  an 
adenitis.  Pharyngitis  or  tonsillitis  rarely  is  present. 
In  most  cases  no  local  conditions  are  evident,  which 
makes  the  theory  a  fact  that  the  enlargement  of  the 
cervical  glands  is  due  to  an  infection  from  the  mucous 
membrane  of  the  mouth  or  pharynx.  Nor  have  inves- 
tigations proved  that  the  enlargement  of  mesenteric 
glands  sometimes  found  in  these  cases  is  due  to  an 
infection  from  the  bowels.  This  would  lead  one  to 
believe  that  the  adenitis  seems  to  be  the  primary  le- 
sion, since  it  has  not  yet  been  established  where  the 
true  porta  invasionis  lies.  Although  the  relationship 
of  clinical  symptoms  of  this  fever  to  other  diseases  of 
an  infectious  character  must  be  considered,  and  not- 
withstanding evidence  to  the  contrary,  the  early  infec- 
tion of  the  anterior  cervical  lymphatic  glands  makes 
it  probable  that  the  infection  first  finds  its  seat  of  en- 
trance through  the  mucous  membrane  of  the  mouth  or 
pharynx.  This  was  exemplified  partially  in  the  case 
about  to  be  described,  in  which  a  culture  from  the 
throat  exhibited  streptococci.  It  has  been  noticed 
that  in  most  cases  constipation  was  a  prominent  symp- 
tom in  the  onset,  and  von  Starck  suggested  that  the 
primary  seat  of  infection  was  in  the  intestines  whence 
the  toxins  were  absorbed,  and  the  mesenteric  glands 
were  the  first  to  become  enlarged;  and  from  here  the 
infective  agent  travelled  through  the  thoracic  duct  and 
at  its  termination  on  the  left  side  affected  the  lymph- 
atic glands  there  sooner  than  on  the  right  side.  This 
latter  conjecture  was  advocated  by  Koplik.  It  is  logi- 
cal and  reasonable  to  assume  that  such  may  be  the 
case,  just  as  clinical  experience  has  shown  that  often 
in  an  acute  osteomyelitis  the  premonitory  symptoms 
pointed  to  the  gastro-intestinal  canal  as  the  porta  in- 
vasionis (Kocher). 

All  observers  agree  that  the  disease  is  rare  in  adults. 
It  has  been  my  good  fortune  to  observe  a  typical  severe 
case  in  a  young  lady  during  the  fall  of  1899,  Miss 
X ,  blonde,  twenty  years  old,  family  history  excep- 
tionally good.  The  patient  suffered  few  of  the  ills  of 
childhood  and  had  never  been  sick  until  November 
28,  1899.  On  the  day  in  question  she  was  suddenly 
seized  with  a  severe  headache  and  chill  which  forced 
her  to  go  to  bed.  Her  temperature  rose  within  twenty- 
four  hours  to  104°  F.,  pulse  correspondingly  high,  over 
100.  She  had  nausea,  vomiting,  and  anorexia;  the 
tongue  was  not  coated ;  she  was  constipated.  There 
was  no  pain  anywhere  except  a  slight  rigidity  of  the 
neck.  The  pharynx  was  only  slightly  reddened,  other- 
wise the  mouth  and  throat  were  normal.  These  symp- 
toms continued  for  several  days,  and  the  aspect  and 
condition  of  the  patient  suggested  a  commencing 
typhoid.  The  urine  showed  a  trace  of  albumin,  but 
no  kidney  elements.  About  the  fourth  day  a  glandu- 
lar enlargement  was  noticed  on  the  left  side  of  the 
neck,  in  front  of  the  sterno-mastoid  muscle.  The  fol- 
lowing day  two  or  more  glands  on  the  same  side  be- 
came involved,  with  great  stiffness  of  the  neck.  There 
was  complete  loss  of  appetite.  The  temperature  was 
103°  F.  The  neck  was  extremely  sensitive;  there  was 
pain  on  palpation,  and  the  pressure  on  the  surround- 
ing parts  caused  pain  on  movement  and  consequently 
stiffness  of  the  head.  The  spleen  was  much  enlarged, 
the  liver  only  slightly  so.  Except  the  above-mentioned 
symptoms  there  was  nothing  to  indicate  the  nature  of 
the  disease.  The  blood  had  been  examined  up  to  this 
stage  (the  sixth  day  of  the  disease)  four  or  five  times, 
and  with  the  exception  noted  below  nothing  abnormal 
was  found.  Various  specimens  were  examined  for 
Widal  reaction,  with  negative  results.  Cultures  from 
the  throat  were  constantly  being  made,  one  of  which 
showed  the  presence  of  streptococci.  There  was 
slight  cough  without  expectation.  No  abdominal 
tenderness  was  present,  and  as  far  as  could  be  judged 
from  repeated  examinations  there  was  no  involvement 


of  the  mesenteric  glands;  but  constipation  was  marked 
and  the  bowels  had  to  be  moved  daily  by  enemata. 
These  symptoms  lasted  about  seven  days,  with  a  grad- 
ual amelioration  and  decline  of  temperature.  On  the 
eighth  day  the  glands  on  the  right  side  of  the  neck  be- 
came perceptible.  There  was  again  an  increase  of 
temperature  to  103°  F.,  and  a  more  decided  enlarge- 
ment of  the  spleen,  which  was  now  painful  on  palpa- 
tion. A  solitary  gland  at  the  angle  of  the  jaw  on  the 
right  side  was  decidedly  enlarged  and  caused  exces- 
sive pain. 

Successive  involvement  of  different  glands  of  the 
neck  prolonged  the  pyrexia  (which  was  of  an  irregular 
type)  and  also  the  other  symptoms  for  several  weeks 
until  January  20,  1900,  when  the  temperature  first 
became  normal  and  remained  so.  During  the  course 
of  the  disease  the  highest  temperature  recorded  was 
when  the  glands  reached  their  maximum  enlargement; 
the  last  two  weeks  showed  a  range  of  temperature  be- 
tween 100°  and  101.5°  F.  The  pulse  was  rapid  during 
the  height  of  the  fever,  and  was  seldom  below  80. 
The  complications  noticed  were  a  slight  cough  in  the 
beginning  of  the  disease,  which  lasted  a  few  days,  and 
a  slight  albuminuria  which  cleared  up  in  a  week.  But 
there  ensued  a  gradual  and  continued  constitutional 
depression  and  a  rather  decided  anemia.  At  the  end 
of  the  fifth  week  of  the  disease  an  anaemic  murmur  was 
heard  at  the  apex,  which  extended  toward  the  base  of 
the  heart.  The  blood,  which  had  been  repeatedly  ex- 
amined, showed  the  proportion  of  red  to  white  cells 
to  be  normal;  but  the  eosinophiles  were  trebled  in 
number,  were  larger  than  usual,  and  their  granula- 
tions were  coarser.  The  erythrocytes  were  pale  and 
exhibited  a  deficiency  of  hemoglobin. 

In  making  a  diagnosis  of  this  case  I  was  puzzled  at 
first,  and  only  by  taking  into  consideration  the  history 
and  circumstances  of  the  case  could  a  positive  diagno- 
sis be  made.  I  had  to  exclude  a  secondary  adenitis 
from  lesions  of  the  tonsils  and  pharynx,  typhoid  fever, 
tuberculosis,  and  specific  infection.  The  treatment  of 
the  case  had  been  purely  symptomatic  and  sustaining. 
Nothing  seemed  to  affect  the  course  of  the  disease. 

The  total  duration  of  the  disease  was  eight  weeks, 
and  convalescence,  once  begun,  continued  uninter- 
ruptedly, and  the  enlargement  of  glands,  spleen,  and 
liver  gradually  disappeared. 

After  the  case  was  recognized  as  one  of  glandular 
fever,  repeated  cultures  were  made  from  secretions  of 
the  throat  and  blood  in  hopes  of  finding  a  specific  or- 
ganism. Unfortunately  they  all  proved  negative  with 
the  exception  of  a  single  culture  from  the  throat 
which  showed  the  presence  of  streptococci.  It  ap- 
peared not  unlikely  that  the  micro-organism  of  this 
disease  would  be  found  in  the  glands  affected.  I  am 
sorry  to  say  that  a  bacteriological  examination  of  the 
infected  glandular  tissue  was  not  permitted.  No  fatal 
case  of  this  disease  has  yet  been  reported. 

40  East  Sixtieth  Strest. 


PJ.ACENTA    PREVIA   WITH    TWINS. 
By    M     F.    HUSSEY.    M.D., 

SIDNEY,    OHIO. 

In  the  Medical  Record  of  June  2d,  there  was  an 
article  on  placenta  praevia  with  twins.  Owing  to  the 
rarity  of  it,  I  desire  to  add  one  to  the  four  or  five  other 
cases  on  record. 

The  case  occurred  in  the  practice  of  Dr.  Peebles,  of 
Hardin,  Ohio,  June  28th,  but  as  the  latter  had  at  that 
time  a  case  of  puerperal  sepsis  under  his  care,  he  re- 
ferred the  case  without  examination  to  me. 

Mrs.  T ,  aged  thirty-five  years,  is  the  mother  of 

six  living  children,  all  of  whose  births  were  normal. 
She  menstruated  last  on  November  i,  1899.     During 


August  1 1 ,  1 900] 


MEDICAL   RECORD. 


239 


the  present  pregnancy  she  was  as  well  as  usual,  doing 
her  own  work.  June  13th,  without  warning  she  had  a 
slight  hemorrhage.  She  gave  but  little  attention  to 
this,  and  next  day  resumed  her  domestic  duties.  On 
June  25th  she  had  another  hemorrhage,  more  severe 
than  the  last,  but  again  the  next  day  resumed  her 
work.  On  June  28th,  while  she  was  in  the  garden,  a 
severe  bleeding  started  with  so  much  severity  as  to 
cause  her  to  take  to  bed  and  send  for  a  physician. 
When  I  arrived  I  found  her  seemingly  almost  blood 
less.  There  had  been  no  hemorrhage  for  some  little 
while  before  my  arrival.  Upon  examination  I  found 
a  marginal  adherent  placenta  on  the  left  side.  I  sent 
immediately  for  Dr.  Peebles,  with  the  request  that  he 
disinfect  himself  and  hasten  to  my  aid.  I  remained 
constantly  with  the  patient  until  his  arrival,  during 
which  time  I  had  used  my  fingers  as  dilators,  control- 
ling the  flow. 

We  pierced  the  placenta  and  ruptured  the  mem- 
branes. The  head  came  down,  stopping  all  hemorrhage. 
The  birtii  of  the  first  child  was  followed  immediately 
by  the  breech  of  the  second  one,  with  but  very  little 
flooding.  Both  children  were  dead.  The  woman 
made  an  uneventful  recovery. 


^edical  |tcms. 

Character   of   Modern    Chinese The  following   by 

no  means  flattering  estimate  of  the  Chinese  character 
is  given  by  one  who  has  lived  in  their  country  for 
years  and  should,  therefore,  be  qualified  to  judge.  He 
says:  "The  modern  Chinaman  we  know  is  the  most 
selfish  of  mankind,  callous  as  an  animal,  with  only  a 
relic  of  conscience;  disinclined  to  fight  because  he 
thinks  of  himself  first,  and  utterly  corruptible  because 
money  is  to  him  the  supreme  protection  ;  but  neverthe- 
less a  strong  man  with  a  clear  head  for  affairs  and  with 
a  strong  faith,  though  it  is  in  his  civilization  and  not 
in  any  creed  .  .  .  He  is  the  most  accomplished  liar 
in  the  world,  but  he  does  not  love  lying  as  a  Hindoo 
does  as  a  pleasurable  intellectual  excitement,  but  lies 
exactly  up  to  the  point  where,  as  his  native  shrewdness 
tells  him,  lying  is  convenient  for  his  interests." 

Lepers  in  France. — It  is  estimated  that  there  are 
about  four  hundred  lepers  in  France,  many  of  whom 
are  missionaries  and  nurses  who  have  contracted  the 
disease  caring  for  sufferers  in  distant  countries,  and 
also  soldiers  and  officials  from  the  colonies.  They 
are  now  scattered  about  in  Brittany,  in  the  Pyrenees, 
on  the  shores  of  the  Mediterranean,  and  in  Paris, 
where  there  are  one  hundred  and  fifty.  A  committee 
has  been  formed  at  the  instigation  of  Dom  Santon,  a 
member  of  the  Benedictine  community  of  Liguge,  and 
also  a  doctor  of  medicine,  to  further  measures  for  the 
care  of  lepers  in  France,  and  to  prevent  further  spread 
of  the  disease.  Dom  Santon  has  studied  leprosy  for 
a  number  of  years  in  the  course  of  his  travels  about 
the  world  for  this  purpose,  and  his  plans  to  deal  with 
the  disease  in  France  have  received  the  approval  of 
the  French  government.  He  has  acquired  property 
in  the  Vosges,  where  he  purposes  to  establish  an  asy- 
lum for  lepers,  to  be  called  the  St.  Martin  Sanatorium. 

British   Army   Medical   Report    for    1898.— The 

London  Times,  in  reference  to  this  report,  says :  "  As 
usual  the  annual  report  on  the  health  and  sanitary 
condition  of  the  army  loses  much  of  its  interest  and 
value  by  reason  of  its  belated  appearance.  There 
seems  no  sufficient  reason  for  the  double  delay  which 
occurs  in  forwarding  the  report  from  the  medical 
division  of  the  War  Office  to  the  secretary  of  state  for 
war  and  in  subsequently  passing  it  through  the  press. 


Apart  from  this  the  report  is  full  of  interest  and  on 
the  whole  may  be  classed  as  satisfactory.  Taking  the 
average  strength  of  the  European  troops  at  home  and 
abroad  as  202,166,  the  returns  show  a  ratio  of  9,819 
admissions  to  hospital  per  1,000  strength  ,  on  a  strength 
of  203,980  which  includes  detached  men  not  shown  in 
the  returns  the  death  rate  is  10.82  per  1,000.  Among 
the  troops  in  the  I'nited  Kingdom  the  admission  and 
mortality  rates  were  somewhat  higher  than  in  1897, 
but  compaie  favorably  with  the  average  of  the  previ- 
ous ten  years.  The  chief  point  noted  is  the  increase 
in  enteric  fever  owing  to  the  Khartum  expedition, 
ninety  cases  and  ten  deaths  having  occurred  after  the 
arrival  home  of  the  troops.  In  Canada  the  ratios  of 
sickness  were  much  higher  than  in  1897,  but  in  the 
West  Indies  there  was  a  marked  improvement,  no 
cases  of  yellow  fever  having  been  recorded  and  ven- 
ereal affections  being  much  less  prevalent.  The  latter 
remark  applies  also  to  South  Africa,  wiiere  the  general 
ratios  of  sickness  and  mortality  differed  but  little  from 
those  of  the  previous  year  and  the  average  of  the  pre- 
vious decade.  Enteric  fever  was  very  prevalent,  as- 
suming epidemic  proportions  in  Natal,  where  there 
was  also  much  sickness  from  dysentery.  In  China 
there  was  a  marked  decline  in  malarial  fevers.  Plague, 
which  was  epidemic  among  the  civil  population,  only 
caused  eight  admissions  and  one  death  among  the 
troops.  In  India  there  was  a  decline  in  the  admission 
and  'constantly  sick'  rates.  The  chief  causes  of 
sickness  were  as  usual  malarial  fevers  and  venereal 
diseases,  which  together  caused  55.4  per  cent,  of  the 
admissions  from  all  causes.  Malarial  fevers  and  en 
teric  fever  were  more  prevalent,  but  the  admission 
rates  for  cholera,  dysentery,  and  malarial  disease  were 
less  than  in  1897,  the  decline  in  venereal  disease  be- 
ing equal  to  more  than  one-quarter  of  the  ratio  for  the 
previous  year.  There  were  again  a  few  cases  of  plague 
in  the  Bombay  command." 

Summer  Mortality.— 7V/^  Evening  Post  recently 
published  the  following,  dated  Albany,  July  30th  :  "  An 
article  contained  in  a  bulletin  just  issued  by  the  State 
board  of  health  furnishes  some  instructive  data  on  the 
subject  of  summer  mortality.  The  summer  months  in 
New  York  State  appear  to  be  the  unhealthy  season  of 
the  year.  According  to  the  State  board  of  health's 
bulletin,  the  summer  months  show  in  addition  to  a 
large  total  mortality  a  great  relative  preponderance  of 
mortality  from  the  sometimes  called  preventable  dis- 
eases and  of  deaths  in  early  life.  Of  the  local  dis- 
eases the  deaths  reported  from  diseases  of  the  diges- 
tive organs  are  increased.  Diseases  of  the  nervous 
system  have  a  larger  mortality  than  in  the  autumn  and 
less  than  in  spring  and  winter.  Consumption  has 
fewer  deaths  in  summer.  Cancer  showed  no  maternal 
variation.  There  are  fewer  deaths  from  old  age  in 
summer.  The  deaths  from  accidents  and  violence  are 
much  increased,  thirty-three  per  cent,  occurring  in 
these  months;  the  increase  is  chiefly  due  to  drowning 
and  the  effects  of  heat." 

Hospitals  in  Roumania. — In  the  Archives  Orien- 
tales  de  Aledecine  et  de  Chiriirgie  Dr.  Cosma  de  Ploiesti 
gives  some  statistics  which  appear  to  show  that  Rou- 
mania is  more  liberally  supplied  with  hospitals  than  are 
most  countries  of  larger  size.  For  a  total  population 
of  5,000,000  there  are  188  hospitals  with  an  aggregate 
number  of  7,334  beds.  All  patients  are  treated  gratui- 
tously without  distinction  of  nationality,  and  the  for- 
eigners from  neighboring  countries  admitted  every 
year  to  the  hospitals  of  Roumania  are  numbered  by 
thousands.  The  hospitals  are  kept  up  by  the  state  or 
by  the  communes,  or  by  the  private  administrative 
bodies,  called  "ephorias,"  which  manage  special 
funds  bequeathed   by  charitable  persons.     The  hos- 


240 


MEDICAL    RECORD. 


[August  II,  19CX) 


pital  establishments  are  subdivided  as  follows:  53 
departmental  or  district  hospitals,  with  1,355  beds; 
26  communal  hospitals,  with  756  beds;  22  rural  hos- 
pitals, with  1,602  beds;  10  belonging  to  the  Bucharest 
ephoria,  with  1,016  beds;  11  under  the  Jassy  ephoria, 
with  683  beds;  10  maintained  out  of  private  funds, 
with  591  beds;  11  maintained  b)' Jewish  communities, 
with  289  beds;  5  lunatic  asylums,  with  749  beds;  11 
homes  for  the  infirm,  with  405  beds;  i  hospital  for 
sufferers  from  pellagra,  with  40  beds:  16  homes  for 
aged,  with  324  beds;  2  night  refuges,  with  60  beds. 
In  addition  to  these  there  are  6  nursing-homes,  with 
137  beds,  for  paying  patients. — British  Aledical  Jour- 
nal. 

Health  Reports. — The  following  cases  of  smallpox, 
yellow  fever,  cholera,  and  plague  have  been  reported 
to  the  surgeon-general  of  the  United  States  Marine- 
Hospital  service  during  the  week  ended  August  4, 
rgoo: 

Cases.    Deaths. 
Smallpox — United  States. 

Alaska.  Cape  Nome July  ist. 17 

Kansas,  Wichita J"'y  21st  to  28th 4 

Louisiana,  New  Orleans July  21st  to  28th 7                  4 

Massachusetts,  Lowell July  21st  to  28th 4 

Michigan,  Au   Sable  Town- 
ship   July  14th  to  2ist I 

Durano July  14th  to  21st 2 

Grand  Rapids July  14th  to  21st 2 

Hersey July  14th  to  21st i 

Walter  Township July  14th  to  21st    i 

SpringAVell  Township. July  14th  to  2ist     8 

N.  Hampshire.  Manchester..  July  2ist  to  28th 3 

Ohio,  Cincinnati July  20th  to  27th    i 

Cleveland July  21st  to  28th     l8 

Utah,  Salt  Lake  City July  21st  to  28th 3 

Smallpox — Foreign  and  Insular. 

Austria,  Pragrue ..  June  30th  to  July  14th 8 

Belgium,  .Antwerp June  30th  to  July  7th i 

Brussels June  30th  to  July  7th   .      i 

England,  Liverpool July  7th  to  14th i  i 

London  ...    July  7th  to  t4th 17 

France,  Lyons....,    .    June  30th  to  July  7th 4 

Paris July  7th  to  14th  .    ..    3 

Germany.    Frankfort  on    the 

Main June  23d  to  30th 1 

Kbnigsberg June  30th  to  July  7th i  1 

Gibraltar July  1st  to  15th i 

Greece,  Athens July  7th  to  14th i  4 

India,  Bombay June  26th  to  July  3d 3 

Calcutta June  23d  to  30th 27 

Karachi...    June  24th  to  July  1st 3  2 

Mexico,  Vera  Cruz. .    July  14th  to  2TSt 5 

Philippines,  .Manila June  8th  to  16th i 

Russ^  Moscow June  23d  to  July  7th 12  7 

'Odessa June  30th  to  July  7th 5  i 

St.  Petersburg  June  3cth  to  July  14th 76  25 

Scotland.  Glasgow July  13th  to  20th 52  i 

Spain,  Madrid    June2dt023d 43 

Straits    Settlements,    Singa- 
pore  June  2d  to  9th   2 

Switzerland,  Geneva June  23d  to  30th 2 

Yellow  Fever — United  States. 
Florida,  Hillsboro  County ..  .August  2d 2 

Yellow  Fever — Foreign. 

Colombia,  Barranquilla July  1st  to  14th 5 

Bocas  del  Toro  .  .July  26th  to  31st 4  1 

Costa  Rica,  Port  Limon  , . . .  J  uly  19th 1  ♦ 

Cuba,  Cienfuegos July  17th it 

Havana July  16th  to  23d _. .     ..  9 

Matanzas July  26th " ij 

Santa  Clara July  21st 2 

Mexico,  Vera  Cruz July  14th  to  21st 7 

Salvador,  San  Salvador June  27th Present. 

Venezuela,  Cartagena June  1st  to  30th 16 

•Suspicious.  +  On  transport  .S'^d'^rtv/c/t.  $  In  barracks. 

Cholera. 

China,  Hong  Kong June  i6th  to  23d i  1 

India,  Bombay...., June  24th  to  July  3d 109 

Calcutta June  23d  to  30th 55 

Madras June  23d  to  29th 1 

Plague. 

England,  London August  3d 4  2* 

India.  Bombay June  26t1i  to  July  3d 49 

Calcutta June  23d  to  30th  2  t^ 

Karachi June  24th  to  July  ist 2  x 

Philippines,  Manila June  8th  to  16th  6  3 

Turkey,  Beirut July  2d Present. 

•  On  P.  &  O.  steamer  Romt. 

The  British  Soldier's  Daily  Diet.— In  Pearson's 
Magazine  for  May  an  account  is  given  of  the  daily  ra- 
tions of  the  British  soldier.  They  are  as  follows  ;  One 
pound  of  fresh,  salt,  or  preserved  meat;  one  and  one- 
quarter  pounds  of  bread,  or  one  pound  of  biscuit,  or  one 


pound  of  flour ;  one-sixth  of  an  ounce  of  tea,  one-third  of 
an  ounce  of  coffee,  three  ounces  of  sugar,  four  ounces 
of  jam,  one-half  an  ounce  of  salt,  one-thirty-sixth  of 
an  ounce  of  pepper,  one-half  a  pound  of  fresh  vege- 
tables, when  procurable,  or  one  pound  of  compressed 
vegetables,  one  three-hundred-and-twentieth  of  a  gal- 
lon of  lime  juice,  with  one-quarter  of  an  ounce  of 
sugar,  on  days  when  fresh  vegetables  are  not  issued; 
one-half  of  a  gill  of  rum,  at  the  discretion  of  the  gen- 
eral commanding,  on  the  recommendation  of  the  med- 
ical officer.  Beer  is  not  issued  to  troops  on  service, 
but  tobacco  is  provided  on  payment.  Careful  calcu- 
lations given  the  writer  by  a  high  official  in  the  War 
Office  reveal  that  the  200,000  who  are  being  fed  at  the 
time  of  writing  on  home  provisions  consume  in  six 
months  16,000  tons  of  preserved  meats,  16,000  tons  of 
biscuit,  170  tons  of  tea,  3,000  tons  of  sugar,  340  tons 
of  coffee,  4,000  tons  of  jam,  500  tons  of  salt,  30  tons 
of  pepper,  8,000  tons  of  vegetables, 

Julian  Ralph  on  the  British  Army  Scandals  in 
South  Africa. — Julian  Ralph  says  in  the  London  Daily 
Mail:  "  I  am  able  to  bear  out  much  of  the  worst  Mr. 
Burdett-Coutts  has  written  about  tiie  sick  and  wounded 
with  the  army  in  South  Africa.  All,  however,  tend  to 
confirm  the  results  of  his  experience.  In  Bloemfon- 
tein  there  were  twenty-five  hundred  enteric  patients 
when  I  left,  and  they  were  in  a  large  proportion  left  to 
lie  on  the  ground  and  be  nursed  by  ignorant  and 
slovenly  '  Tommy  '  attendants.  They  lay  in  the  water, 
they  were  rained  on,  and  the  sanitary  arrangements 
were  such  that,  at  least  in  some  hospitals,  they  had  to 
leave  their  blankets  at  the  risk  of  death.  All  the  time 
I  was  at  Bloemfontein  I  was  haunted  by  the  horror  of 
the  neglect  of  and  cruelty  to  the  sick.  When  I  was  at 
Kimberley,  some  of  the  local  physicians  were  similarly 
horror-stricken  by  the  condition  in  which  the  wounded 
came  to  them,  trundled  over  the  bad  roads  all  the  way 
from  Paardeberg  in  ox  wagons.  I  have  no  hesitation 
in  saying  that  I  considered  the  treatment  of  the  sick 
and  wounded  (especially  after  the  main  advance  from 
Modder  River)  primitive,  cruel,  and  almost  barbaric, 
as  well  as  needless  and  inexusable." 


While  the  Medical  Record  is  f  leased  to  receive  all  new  pub- 
lications which  may  be  sent  to  it,  and  an  acknowledgment  will  ie 
promptly  made  of  their  receipt  under  this  heading,  it  must  be  with 
the  distinct  understanding  that  its  necessities  are  such  that  it  can- 
not be  considered  under  obligation  to  notice  or  review  any  publica- 
tion received  by  it  which  in  the  judgment  of  its  editor  will  not  ie 
of  interest  to  its  readers. 

Beneath  Hawaiian  Palms  and  Stars.  By  E.  S.  Goodbue. 
i2mo,  248  pages.  Illustrated.  The  Editor  Publishing  Com- 
pany, Cincinnati,  Ohio. 

A  Mani;al  of  Personal  Hygiene.  By  Walter  L.  Pyle, 
M.D.  i2mo,  344  pages.  Illustrated.  W.  B.  Saunders  &  Co. , 
Philadelphia,  Pa.     Price,  $1.50  net. 

Atlas  and  Epitome  of  Diseases  Caused  by  Accidents. 
By  Ed.  Golebiewski.  i2mo,  549  pages.  Illustrated.  \V.  B. 
Saunders  &  Co.     I'rice,  $4  net. 

Atlas  and  Epitome  of  GYNyEcoi-oGV.  By  Dr.  Oskar 
Schaeffer.  i2mo,  272  pages.  Illustrated.  \V.  B.  Saunders  & 
Co.     Price,  $3. 50  net. 

Clinical  Examination  of  the  Urine  and  Urinary 
Diagnosis.  By  J.  Bergen  Ogden.  8vo,  418  pages.  Illustrated. 
W.  B,  Saunders  &  Co.     Price,  $3  net. 

A  Text-Book  of  Practical  Medicine.  By  William 
Oilman  Thompson,  M.D.  8vo,  loil  pages.  Illustrated.  Lea 
Brothers  &  Co.,  Philadelphia,  Pa. 

Cancer  of  the  Uterus.  By  Thomas  -Stephen  CuUen.  8vo, 
593  pages.     Illustrated.     D.  Appleton  &  Co.,  New  York. 


Medical  Record 

A    Weekly  jfournal  of  Medicine  and  Surgery 


Vol.  58,  No.  7. 
Whole  No.  1554. 


New  York,  August   18,    1900. 


$5.00  Per  Annum. 
Single  Copies,  loc. 


©Ktflitiat  Jtrticles. 

EXTRABUCCAL    FEEDING.' 
By  C.    a.    EWALD,    M.D., 


Every  disease  of  the  digestive  system  making  the  ad- 
ministration of  food  by  the  natural  channel  impossible, 
or  in  which  the  assimilation  of  the  ingesta  is  impaired 
to  a  greater  or  less  degree,  confronts  the  physician 
with  the  question  whether  it  is  not  possible  by  some 
other  avenue  to  supply  the  organism  with  sufficient 
nutriment  to  sustain  life  and  to  rehabilitate  the 
damaged  nutrition. 

This  is  not  the  place  for  an  enumeration  of  the 
various  conditions  which  may  result  in  such  a  state  of 
restricted  receptive  poweror  imperfect  food  absorption. 
The  methods  of  feeding  through  the  oesophagus  by 
means  of  the  stomach-tube  also  lie  outside  the  limits 
of  the  present  discussion.  It  is  a  question  rather  of 
(i)  rectal  feeding  by  means  of  nutritive  enemata; 
(2)  feeding  through  the  cutaneous  surface  by  means 
of  subcutaneous  or  intravenous  injections  of  food 
stuffs;  and  (3)  feeding  after  gastrostomy. 

While  so-called  nutrient  enemata,  dys7nata  nutrienta, 
have  been  used  by  the  profession  of  old,  although  very 
different  degrees  of  value  have  been  accorded  them  by 
individual  physicians  and  in  different  times,  the  two 
latter  procedures  are  distinctly  productions  of  later 
date. 

At  the  outset  of  my  discussion  I  must  premise,  that 
none  of  the  above-mentioned  means  is  capable  of  sup- 
porting life  indefinitely,  and  that  under  no  circum- 
stances can  any  of  them  be  regarded  as  able  to  answer 
the  demands  of  the  metabolism  of  the  normal  healthy 
individual.  Under  favorable  circumstances  it  is  possi- 
ble through  the  exclusive  use  of  extrabuccal  feeding 
to  maintain  for  some  time  the  nutritive  balance  of 
those  who  in  consequence  of  their  sickness  exhibit  a 
greatly  decreased  metabolic  activity,  in  other  words 
those  in  a  very  much  depreciated  physical  condition, 
as  I  years  ago  demonstrated  by  experiment.' 

In  most  instances,  however,  a  state  of  under-nutri- 
tion  supervenes,  in  which  the  body  gives  off  more  than 
it  receives  through  the  medium  of  the  extrabuccal 
feeding.  The  result  of  the  measure  is  therefore  merely 
to  reduce  this  deficit  to  a  smaller  margin  than  would 
otherwise  be  the  case,  and,  furthermore,  it  is  only  a 
question  of  a  temporary  expedient  and  not  of  a  perma- 
nent form  of  feeding.  Therefore  the  method  is  of  real 
value  only  in  those  cases  in  which  it  plays  the  part  of 
makeshift,  tiding  the  patient  over  certain  critical 
stages  of  his  disease,  or  when  it  is  resorted  to  for 
some  definite  therapeutic  purpose,  as  in  the  treatment 
of  gastric  ulcer,  hysterical  vomiting,  dilated  stomach, 
etc.,  or  when  employed  as  "supplementary  feeding" 
in  cases  of  deficient  nutrition  per  os.  In  other  cases 
one  must  rest  satisfied  with  having  prolonged  life  for 

'  A  paper  read  at  the  Thirteenth  International  Medical  Con- 
J^ress,  Paris,  Aug.  2-q.  igoo. 

C.  A.  Ewald  ;  "  Ueber  die  Ernahrung  mit  Pepton  u.  Nahr- 
klystieren."     Zeitschr.  f.  Iclinische  Med.,  1887,  p.  407. 


a  certain  length  of  time  and  with  its  effect  of  affording 
the  patient  some  degree  of  moral  comfort. 

I.  Rectal  Feeding. — It  may  safely  be  accepted  that 
the  secretion  of  the  large  intestine  is  devoid  of  all 
peptonizing  power  and  possesses  only  very  slight 
amylolytic  properties.  Hemmeter'  has  shown  that  the 
aqueous  extract  of  the  rectal  contents  obtained  under 
aseptic  precautions  is  capable,  in  weakly  alkaline  so- 
lution, of  dissolving  36.5-50  per  cent,  of  dried  serum 
albumin  in  three  hours  and  of  converting  as  much  as 
fifteen  per  cent,  of  starch  into  maltose,  but  is  without 
steatolytic  power.  Nevertheless,  these  properties  of 
the  faeces,  inasmuch  as  the  action  of  bacteria  was  ex- 
cluded in  Hemmeter's  experiments,  are  ascribable 
solely  to  the  admixture  of  pancreatic  juice  which  at 
different  times  and  under  various  conditions  is  prob- 
ably a  very  variable  quantity.  As  it  is  customary, 
however,  before  the  administration  of  nutritive  enemata 
to  cleanse  the  rectum,  this  ferment  component  of  the 
faeces  cannot  enter  into  the  question.  There  are  to  be 
considered,  therefore,  only  those  quantities  of  pancre- 
atic juice  which  trickle  down  to  the  enema  during  its 
sojourn  in  the  intestine,  and  the  effect  of  the  intestinal 
bacteria  which,  to  be  sure,  exhibit  a  certain  amount 
of  albumin-splitting  power.  The  production  of  the 
Leube-Rosenthal  "pancreatic-meat  enemata"  through 
the  addition  of  pancreatic-tissue  substance  to  the  al- 
bumin was  only  the  logical  outcome  of  the  formerly 
prevalent  idea  that  for  absorption  through  the  rectal 
mucosa  a  previous  peptonization  of  the  albumin  and 
conversion  of  the  starch  was  requisite.  Experiment 
showed  that  almost  the  entire  amount  of  nitrogen  suf>- 
plied  to  the  body  in  the  "  meat-pancreatic  enemata  " 
was  absorbed. 

Still  it  must  not  be  disregarded  that  the  preparation 
and  application  of  such  mixtures  are  inconvenient  for 
both  the  physician  and  patient.  From  personal  ex- 
perience I  know  that  the  obtaining  of  the  gland  sub- 
stance and  the  proper  preparation  of  the  mass  to  be 
employed  in  the  enemata  both  present  difficulties  that, 
especially  in  private  practice,  are  not  easily  overcome. 
The  temptation  was  therefore  great,  in  view  of  the 
advances  that  had  been  made  in  the  commercial  produc- 
tion of  artificial  foods  and  soluble  peptone  and  albu- 
mose  preparations,  to  employ  these  instead  of  the  "  pan- 
creatic-meat "  mixture.  No  doubt  this  has  been  widely 
done  without  attracting  especial  comment;  at  any  rate 
I  myself  have  frequently  made  use  of  such  peptone  and 
albumose  solutions,  and  particularly  as  additions  to 
the  egg-enemata  to  be  described  below. 

Contrary  to  a  statement  of  v.  Leube's,^  however,  I 
must  observe  that  even  small  quantities  of  peptone, 
i.e.,  50-60  gm.  dissolved  in  200-250  gm.  of  water,  oc- 
casionally produce  marked  evidence  of  irritation  and 
are  speedily  expelled.  Still  this  apparently  depends 
somewhat  on  the  nature  of  the  peptone,  for  I  have 
noticed  that  peptones  of  different  sorts  behave  differ- 
ently in  this  respect.  This  much  is  certain,  that  ac- 
cording to  my  experience  peptone  solutions  are  well 
absorbed  and  can  cause  an  excretion  of  nitrogen,  and 

'  Hemmeter  :  "  Diseases  of  the  Stomach,"  1897,  p.  207. 

'  W.  V.  Leube  :  "  Ueber  kunstliche  Ernahrung."  "  Handbuch 
der  Emahrungs-Therapie,"  herausgegeb.  von  E.  von  Leyden, 
Abth.  i. ,  Bd.  ii.,  p.  ^(joff. 


242 


MEDICAL    RECORD. 


[August  1 8,  1900 


that  Kohlenberger'  and  von  Leube  never  found  al- 
bumose  or  peptone  in  the  urine  after  the  administration 
of  such  enemata,  a  proof  that  these  bodies  had  actu- 
ally undergone  metabolic  transformation. 

The  composition  of  nutritive  enemata  was  greatly 
simplified  after  Eichhorst's^  experiments  on  the  dog 
and  mine  on  man  had  shown  that  even  native  albumin 
in  the  form  of  egg  emulsion  and  the  casein  of  milk 
was  absorbable  without  preliminary  peptonization. 
The  absorbability  is  greatly  increased,  as  Eichhorst 
had  already  found,  by  the  addition  of  table-salt.  In 
the  light  of  these  facts,  which  have  been  fully  sub- 
stantiated by  later  observations  of  my  own  and  others, 
the  use  of  albumose  and  peptone  preparations  has  fall- 
en more  and  more  into  disrepute  until  at  present  they 
are  hardly  employed  at  all. 

As  a  matter  of  fact,  the  esteem  in  which  peptones  are 
held  as  constituents  of  nutrient  enemata  rests,  as  I 
maintained  in  1887,'  on  the  setting  up  of  a  fallacious 
analogy  with  the  conditions  obtaining  in  the  stomach. 
While  we  supply  this  viscus,  when  it  is  diseased  and  im- 
paired in  function,  with  peptones  and  albumoses  with 
the  (at  present  also  contested)  intention  of  relieving 
it  of  a  portion  of  its  work,  we  should  never  think  of 
treating  the  rectal  mucous  membrane,  no  matter  how 
much  diseased,  in  a  similar  way. 

Here  we  have  to  do  with  a  healthy  mucous  mem- 
brane which  is  to  assume  the  functions  of  the  higher 
portions  of  the  digestive  tract.  Inasmuch  as  my  ob- 
servations have  given  evidence  that  the  peptonization 
of  albumin  or  the  use  of  the  peptones  on  the  market  is 
not  needed  for  absorption  from  the  rectal  mucosa,  and 
that  this  itself  cannot  convert  albumin  into  albumose 
or  absorb  it  in  other  ways,  the  employment  of  peptone 
enemata  becomes  unnecessary.  Simple  egg  enemata 
accomplish  just  as  much,  and  in  addition  furnish  about 
twelve  per  cent,  of  fat,  which  effects  a  saving  to  the 
organism  through  its  fuel  value. 

Only  in  later  times  has  the  fact  of  albumin  absorp- 
tion in  the  colon  met  with  controversy.  Plantenga' 
has  published  a  series  of  experiments  yielding  very 
unfavorable  results  regarding  the  absorptive  power  of 
this  membrane  for  nitrogenous  bodies.  In  one  in- 
stance in  which  70  gm.  of  nitrogen  was  administered 
per  rectum  during  the  course  of  the  observation,  an 
average  of  only  0.375  g"^-  P^''  *^''y  ^^'^^  absorbed,  and 
in  another  in  four  days  only  r.43  gm.  was  taken  up. 

I  have,  therefore,  had  a  new  series  of  investigations 
made  by  Rost,  which  have  confirmed  the  old  dictum 
that  very  considerable  amounts  of  the  nitrogenous  sub- 
stances administered  by  the  rectum,  under  favorable 
conditions  ninety  to  ninety-five  per  cent.,  are  absorbed." 

At  this  juncture  the  query  might  arise  whether  we 
are  actually  dealing  in  these  cases  with  an  absorption 
of  albumin  or  nitrogenous  substances  of  actual  service 
in  the  economy  of  the  organism,  or  whether  the  nitro- 
gen reappearing  in  the  urine  does  not  represent  further 
decomposition  and  putrefactive  products  qf  ammonia- 
cal  nature  found  in  the  urine.  This  seems  to  me  not 
to  merit  consideration,  since  it  is  never  possible  to 
find  considerable  amounts  of  ammonia  in  the  expelled 
portions  of  the  enemata  by  means  of  the  Schlossing 
method,  and  a  well-marked  odor  of  putrefaction  is 
present  only  in  the  fewest  cases.  Besides,  it  is  possi- 
ble to  anticipate  any  such  fennentative  change  by  the 
addition  to  the  enema  of  small  amounts  (0.1-0.3  gm. 
to  each  injection)  of  some  such  substances  as  thymol, 
menthol,  or  lysol.     Like  the  soluble  egg-albumen  the 

'  Kohlenberger  :  "  Zur  Frage  der  Resorption  der  Albumose  im 
Mastdarm."     Munch,  med.  Wochenschr. ,  l8g6,  No.  97. 

"  H.  Eichhorst:  "  Ueber  die  Resorption  der  Albuminate  ini 
Dickdarm."     PfiUger's  Archiv,  Bd.  iv. ,  1871. 

»  Loc.  fit. 

^Plantenga:   Inaug.  Dissert..   Freiburg,  1898. 

'  C.  .\.  Ewald  .  "Ueber  die  Ernahrungs-Clysmata. "  I)u 
Bois-Reymond's  Archiv  f.  Anat.  u.  Physiol.,  1899,  p.  160. 


albumin  of  milk  also  undergoes  absorption.  Experi- 
ments on  the  value  of  milk  for  this  purpose  were  con- 
ducted by  Eichhorst  as  long  as  thirty  years  ago,  but 
Brandenburg'  has  lately  shown  that  more  than  one- 
third  of  the  casein  of  milk  is  never  absorbed,  and  von 
Leube  justly  says  that  even  in  relatively  large  quanti- 
ties, one-half  litre  of  milk  to  the  enema,  under  the  most 
favorable  conditions  hardly  100  calories  are  taken  up, 
and  even  this  only  under  the  supposition  that  com- 
plete absorption  of  the  carbohydrates  takes  place.  But 
the  probabilities  are  that  the  actually  effective  amount 
is  appreciably  smaller  than  this. 

Of  late,  as  is  well  known,  a  number  of  preparations 
have  been  put  upon  the  market  which  contain  the  al- 
bumin in  part  converted  into  albumoses,  in  part  in 
an  undecomposed  but  readily  soluble  state.  These 
preparations  do  not  present  any  especial  advantages 
for  the  preparation  of  nutritive  enemata.  They  irritate 
the  intestinal  mucosa,  and,  according  to  the  researches 
of  Kuhn  and  Volker,  Brandenburg,  Strauss,  and  others 
undergo  imperfect  absorption,  so  that  jap  to  sixty  per 
cent,  of  the  material  employed  remains  unused. 

As  regards  the  nitrogenous  bodies  we  are  therefore 
constantly  driven  to  revert  to  the  native  egg-albumen 
and  milk. 

What  now  are  the  facts  concerning  the  application 
of  the  carbohydrates  in  nutritive  enemata.' 

Primarily,  from  physiological  considerations  solu- 
tions of  grape  sugar  would  be  found  to  serve  best,  and 
the  other  varieties,  especially  cane  sugar,  should  also 
be  investigated,  while  enemata  of  starch  decoction 
(flour  paste)  are  less  suitable  for  the  purpose,  since 
the  advantage  they  possess,  following  von  Leube,  of 
causing  a  slow  formation  of  sugar  and  a  consequently 
diminished  amount  of  irritation,  is  offset  by  the  greater 
possibility  of  decomposition  and  fermentation  induced 
by  that  very  fact. 

The  experiments  of  Schonborn"  have  proved  that 
very  considerable  quantities  of  grape  sugar  (up  to 
ninety-five  per  cent.)  may  be  absorbed  from  the  intes- 
tine, but  the  solution  must  not  be  too  concentrated 
nor  be  injected  in  too  great  quantity,  otherwise  irrita- 
tion, diarrhcea,  and  the  secretion  of  mucus  are  caused. 
This  coincides  with  my  own  experience,  and  I  recom- 
mended years  ago  that  not  more  than  10-20  gm. 
of  grape  sugar,  that  is,  about  100  c.c.  of  a  correspond- 
ing solution,  should  be  used.  Whether  cane  sugar  is 
absorbable  to  the  same  degree  as  glucose  is  a  mooted 
point,  but  according  to  Plantenga  it  is  less  irritating. 
Lactose  has  been  shown  by  Strauss'  to  be  well  ab- 
sorbed and  to  be  converted  into  grape  sugar,  though 
from  a  practical  standpoint  it  hardly  needs  considera- 
tion. 

In  an  overwhelming  majority  of  cases  the  rectal  in- 
jection of  sugar  solutions  is  not  followed  by  the  ex- 
cretion of  sugar  in  the  urine.  As  Strauss  has  shown, 
the  same  relations  obtain  here  as  in  the  administration 
of  the  same  amounts  of  grape  sugar,  etc.,  by  the  mouth. 
Since  the  hemorrhoidal  veins  empty  their  contents 
directly  into  the  vena  cava,  thus  excluding  the  liver 
and  portal  system,  such  a  glycosuria  is  not  to  be  dis- 
counted a  priori.  However,  the  results  of  my  observa- 
tions, read  before  the  Naturforscherversammlung  at 
Frankfort  in  1896,  taught  the  contrary,  since  as  low  as 
6  to  7  cm.  from  the  anal  orifice  there  are  anastomoses 
between  the  superior  and  middle  hemorrhoidal  veins 
through  which  blood  reaches  the  portal  vein. 

Recently  von  Leube  has  shown  that  such  a  glycosuria 
may  be  produced  if  access  to  the  upper  part  of  the 

'Brandenburg;  "Ueber  die  Emahrung  mil  Casein-Prepara- 
tcn."     Deutsch.  Archiv  filr  klinische  Med.,  Bd.  58. 

'  Schonborn  :  "Zur  Frage  der  Resorption  von  Kohlehydraten 
im  menschlichen  Rectum,"  Wur^burg,  1S97. 

^H.  Strauss:  "  Untersuchuiigen  iiber  die  Resorption  und 
.\usscheidung  von  Zucker  bei  rectaler  Zuckerzufuhr."  Charite- 
Annalen,  22  Jahrg.,  1897. 


August  1 8,  1900] 


MEDICAL    RECORD. 


243 


rectum  be  cut  off  by  the  introduction  of  a  colpeurynter 
before  injection  of  the  solution,  and  its  absorption  be 
therefore  restricted  to  the  inferior  hemorrhoidal  veins. 
The  same  observer  has  stated  that  breaking  down  into 
lactic  acid,  acetic  acid,  etc.,  through  the  growth  of  fungi 
does  not  occur  to  a  noteworthy  degree,  for  the  absorption 
of  the  sugar  takes  place  so  rapidly  (in  the  first  hour 
from  sixty  to  ninety  per  cent,  of  the  injected  amount) 
that  no  time  is  given  for  any  appreciable  decomposition. 

Starch  decoctions  of  twenty-  to  thirty-per-cent. 
strength  yield  approximately  the  same  results  as  are 
obtained  with  sugar  solutions.  A  portion  of  the  starch, 
varying  in  different  cases,  is  hydrolized  and  absorbed, 
while  the  remainder,  amounting  to  from  four  to  twenty- 
five  per  cent,  of  the  total  quantity,  is  expelled  in  an 
undigested  state  after  a  longer  or  shorter  period  of 
time.  Evidences  of  irritation  are  less  than  with  sugar 
injections,  but  are  not  wholly  wanting. 

It  is  in  the  administration  of  fats  per  rectum  thai 
the  greatest  difficulties  are  presented.  Complementing 
the  voluminous  discussions  of  former  times  on  the 
value  of  fats  in  the  preparation  of  nutritive  enemata 
the  work  of  Dencher,'  Stiive,"  and  Strauss'  on  injec- 
tions of  olive-oil  emulsion  has  shown  that  under  the 
most  favorable  conditions  not  more  than  10  gni.  a  day 
can  be  absorbed.  If,  however,  after  the  method  of 
von  Leube  the  fat  is  mixed  with  pancreatic-gland  sub- 
stance before  its  introduction,  ninety  per  cent,  or  even 
more  may  be  taken  up.  But  here  also  there  is  no 
constant  relationsliip,  and  especially  the  simultaneous 
administration  of  starch,  fat,  and  pancreatic  substance 
seems  to  be  badly  borne,  premature  expulsion  of  the 
enema  resulting. 

From  what  has  been  said  it  follows  that  in  practice 
it  is  wisest  to  make  use  of  all  the  food-stuffs  in  ques- 
tion, and  to  vary  the  composition  of  the  enemata  ac- 
cording to  the  exigencies  of  each  individual  case,  that 
is,  the  degree  of  tolerance  exhibited  for  their  various 
components. 

Guided  by  my  extensive  experience,  I  still  believe 
that  the  following  combination  is  the  one  to  be  most 
recommended:  Two  tablespoonfuls  (40  gm.)  of  wheat 
flour  are  stirred  into  150  c.c.  of  lukewarm  water  or 
milk,  and  to  this  mass  one  or  two  eggs  with  a  pinch 
of  salt  (3  gm.)  are  added,  and  the  whole  is  beaten  up 
with  50  to  100  c.c.  of  a  fifteen-  to  twenty-per-cent. 
glucose  solution.  The  addition  of  a  small  amount  of 
alcohol,  e.g.,  in  the  form  of  a  glass  of  claret,  acts  as 
an  analeptic.  Such  an  enema  corresponds  to  about 
450  calories,  of  which,  to  be  sure,  only  a  portion  fulfil 
their  physiological  destiny.  It  goes  without  saying 
that  the  nutritive  value  of  such  a  combination  may  be 
increased  by  varying  its  constituents  and  adding  some 
peptone  preparation,  for  example,  one  of  the  newer  food 
products,  such  as  eulactol  or  plasmon.  But  it  must 
not  be  forgotten  that  the  more  complicated  the  com- 
position of  an  enema  the  greater  the  difficulty  of  its 
application  in  private  practice,  and  the  more  probable 
the  production  of  irritation  of  the  intestinal  mucosa 
and  its  early  expulsion.  Finally  there  remain  to  be 
mentioned  the  nutritive  enemata  in  concentrated  form 
consisting  of  suppositories  of  peptonized  meat  or 
peptonized  milk. 

The  well-known  method  of  administration  of  such 
enemata  I  shall  not  discuss.  As  in  everything  of  this 
nature,  a  certain  amount  of  practice  is-necessary,  simple 
as  the  matter  seems,  and  the  more  experienced  the 
physician  and  nurse  the  longer  will  the  enema  be 
retained  and  the  less  discomfort  will  it  cause. 

II.  Feeding  by  Means  of  Subcutaneous  Infusion. 
— It  is  not  to  be  denied  that  nutritive  enemata  do  not 

'  Dencher  ;   "  Ueber  die  Resorption  des  Fettes  aus  Clystieren." 
Deutsch.  Archiv  f.  klin.  Med.,  1S97,  Bd.  83,  p.  210. 
'StUve:  Berliner  klin.  Wochenschr. ,  1896,  No.  20. 
*  Strauss  :  Loc.  cit. 


fulfil  all  the  demands  we  have  to  make  on  an  extra- 
buccal  method  of  feeding.  Disregarding  the  varia- 
tions in  the  actual  nutritive  effect  produced,  the  irrita- 
tive disturbances  attendant  on  their  long-continued 
use,  and  their  impracticability  in  certain  diseases  of 
the  gut  itself  and  in  persons  mentally  deranged,  greatly 
limit  their  sphere  of  usefulness.  There  exists,  there- 
fore, a  need  for  some  other  manoeuvre  which  shall  be 
free  from  these  objections,  and  as  such  the  intravenous 
and  subcutaneous  injection  of  food-stuffs  is  to  be 
considered.  It  is  particularly  to  von  Leube  that 
credit  must  be  given  in  this  regard,  for  it  was  he  who, 
after  various  tentative  efforts  in  tiiis  direction  had 
been  made,  furnished  the  clinical  and  experimental 
evidence  of  the  feasibility  of  the  method. 

As  early  as  1850  Hodder  made  intravenous  injec- 
tions of  milk  into  cholera  patients  in  collapse,  and 
such  injections  and  similar  ones  of  peptone  solution 
were  in  consequence  often  repeated,  and  with  appar- 
ently favorable  results.  In  addition  subcutaneous  in- 
jections of  milk,  peptonized  milk,  and  defibrinated 
blood  have  been  recommended  and  carried  out. 

At  the  very  outset,  however,  it  is  clear  that  in  such 
attempts  the  injection  of  every  sort  of  albumin  solu- 
tion, either  in  the  natural  state  or  to  a  greater  or  less 
degree  peptonized,  must  be  avoided.  The  necessary 
sterilization  is  impossible,  and  on  account  of  the  well- 
known  toxic  effect  of  the  albumoses  and  peptones  they 
are  useless  for  the  purpose  in  view. 

The  subcutaneous  injection  of  glucose  solutions  has 
also  not  given  any  encouraging  results;  persistent 
pain,  even  inflammation  and  necrosis,  are  said  to  be 
easily  caused.  Still  Voit '  did  not  observe  any  evil 
effects  from  the  subcutaneous  infusion  of  a  ten-per- 
cent, glucose  solution,  of  which  up  to  i  litre  was  thrown 
into  the  thigh  within  twenty  to  twenty-five  minutes, 
and  when  given  in  small  quantities  it  was  found  never 
to  be  excreted  in  the  urine.  Only  after  100  gm.  of 
sugar  had  been  given  was  2.6  gm.  excreted  by  the 
kidneys.  Since  100  gm.  of  sugar  corresponds  to  410 
calories,  that  is,  nearly  a  third  of  the  amount  required 
by  a  resting  person  in  a  depreciated  state  of  health, 
such  a  result  should  be  counted  as  a  distinct  gain. 
It  is  evident  that  if  it  were  possible  to  infuse  a  like 
amount  of  oil  a  very  much  greater  calorie  value  would 
accrue  to  the  organism,  for  50  gm.  of  oil  corresponds 
to  465  calories,  so  that  one  might  either  use  a  less 
quantity  of  oil  or  by  giving  more  contribute  a  con- 
siderably larger  amount  of  fuel  values. 

Von  Leube^  has  shown  in  repeated  communications 
that  this  infusion  of  oil  presents  no  technical  diffi- 
culties, and  has  also  proved  by  ingenious  experimenta- 
tion that  the  fat  really  is  consumed.  He  injected 
butter  in  a  state  of  solution  into  dogs  and  determined 
the  following: 

A  dog,  brought  to  a  state  of  leanness  by  feeding  on 
fat-free  horse-meat,  received  in  fifty  days  3.50  kgm.  of 
butter  subcutaneously  and  in  this  time  gained  2.4 
kgm.  The  chemical  examination  of  his  abdominal 
fat  showed  this  to  consist  of  pure  butter;  the  dorsal 
fat  was  one-third  and  the  pericardial  fat  one-sixth 
butter.  A  second  experiment  was  begun  by  doing  a 
laparotomy  on  a  fat-free  dog,  showing  that  the  mesen- 
tery was  almost  and  the  skin  entirely  devoid  of  fat. 
In  the  course  of  the  next  three  weeks  he  was  given 
subcutaneously  about  1,400  gm.  of  butter.  A  second 
laparotomy  showed  that  the  skin  of  the  abdomen  now 
contained  abundant  fat  masses  composed  of  two-thirds 
of  butter  and  one-third  of  dog-fat,  while  the  fat  of  the 
now  richly  adipose  mesentery  was  almost  pure  dog-fat. 
The  animal  was  now  returned  to  his  fat-free  diet  till 

'  Voit:  "  Ueber  subcutane  Einverleibungvon  Nahrungstoffen. " 
Munch,  med.  Wochenschr.,  1896,  p.  31. 

*  Von  Leube:  "Ueber  subcutane  Ernahrung."  XXXIII. 
Congr.  f.  inn.  Med.,  1895,  and  loc,  cit. 


244 


MEDICAL    RECORD. 


[A 


ugust 


1 8,  1900 


he  gradually  became  reduced  to  his  former  weight. 
He  was  then  killed  and  found  to  be  absolutely  fat-free. 

The  experiment,  therefore,  shows  that  a  fat-free  dog 
can  be  made  to  accumulate  dog-fat  through  subcutane- 
ous injections  of  butter,  and  that  this  may  undergo 
complete  metabolistic  consumption.  Further  researches 
by  Knoll '  on  rabbits  demonstrated  that  the  absorption 
of  fat  takes  place  slowly  from  the  site  of  the  injection, 
and  that  the  albumin  consumption  is  diminished  in 
the  usual  way,  the  coefficient  in  an  oil-treated  animal 
being  only  about  fifty  per  cent,  of  the  corresponding 
value  in  a  control  animal. 

The  accuracy  of  these  results  has  been  confirmed 
in  various  quarters,  and  also  by  observations  on  man 
most  comprehensively  and  carefully  by  L)u  Mesnil 
de  Rochemond,'  who  lays  great  stress  on  slowness  in 
the  rate  of  injection  of  the  oil,  and  has  devised  a 
somewhat  complicated  pressure  apparatus  for  this 
purpose. 

I  myself  make  use  of  the  following  very  simple 
method.  I  employ  a  large  wash-bottle  holding  about 
I  litre,  such  as  is  used  in  the  sulphuretted-hydrogen 
apparatus,  and  consisting,  as  is  well  known,  of  a  glass 
jar  through  whose  upper  constricted  portion  a  glass 
tube  passes  air-tight  to  the  bottom,  while  at  the  side 
a  second  horizontal  tube  is  fused  into  place.  If  a 
rubber  tube  bearing  a  hoUov/  needle  with  a  lumen  of 
about  I  mm.  is  affixed  to  the  longer  tube,  and  the 
horizontal  one  is  connected  to  a  double-acting  bellows 
of  good  size,  and  200-300  c.c.  of  oil  placed  in  the  jar, 
by  the  aid  of  the  bellows  the  air  contained  in  the  flask 
may  easily  be  compressed  to  such  a  degree  that  the  oil 
is  forced  up  the  perpendicular  tube  and  out  through 
the  rubber  tubing  and  cannula.  The  rate  of  flow  may 
be  accurately  controlled  by  means  of  a  pinch-cock  on 
the  tube,  and  a  scale  affixed  to  the  jar  determines  the 
amount  of  oil  used.  The  apparatus  may  be  readily 
taken  apart  for  disinfection,  and  the  air  which  is  forced 
in  does  not  come  in  contact  with  the  lower  layers  of 
oil,  though  it  might  easily  be  purified  by  the  interpo- 
lation of  a  small  filter  of  cotton.  I  have  never  had 
occasion  to  do  this,  however.  After  having  introduced 
the  needle  into  the  subcutaneous  connective  tissue 
under  the  usual  antiseptic  precautions  the  apparatus 
may  be  left  at  the  patient's  bedside  without  supervision  ; 
the  pressure  once  established  lasts  for  a  half-hour  or 
so,  and  may  be  regulated  so  that  in  this  length  of  time 
80-100  c.c.  of  oil  enters  the  tissues. 

Unfortunately  the  procedure  is  not  entirely  free 
from  pain.  A  certain  degree  of  tension  and  redness 
of  the  skin  is  caused,  which  lasts  for  hours  even  if  the 
oil  is  diffused  as  much  as  possible  by  massage.  Other 
inconveniences,  such  as  abscess  formation,  necrosis,  or 
fat  embolism  have  not  come  under  my  observation; 
oil  is  not  excreted  in  the  urine. 

Nevertheless  the  manoeuvre  involves  troublesome 
preparations,  and  in  sensitive  individuals  cannot  be 
carried  on  for  any  length  of  time.  Another  disad- 
vantage which  places  the  oil  injection  below  the  nutri- 
ent enema  in  the  scale  of  utility  lies  in  the  fact  that 
by  this  means  the  introduction  of  water  into  the  body 
is  not  possible.  But  this  is  a  point  of  highest  im- 
portance precisely  in  those  cases  in  which  extrabuccal 
feeding  is  indicated.  For  in  this  the  administration 
of  water  per  os  is  not  possible,  either  because  access  to 
the  stomach  is  cut  off,  or  the  dilated  stomach  is  in- 
capable of  absorbing  water,  or  finally  it  is  speedily 
vomited.  But  the  prevention  of  this  diminution  in 
water-supply  is  of  great  significance  in  these  condi- 
tions, and  as  my  pupil  Dr.  Rost '  has  shown,  the  sup- 

'  E.  Knoll  :  "  Diesubcutane  Fetternahning."  Ilabilit.  Schr. , 
WUrzburg,  1897. 

'  Du  Mesnil  de  Rochemond  ;  "  Die  subcutane  Ernahrung  mil 
OlivenOel."     Deutsch.  Arch,  f   klin.  Med.,  Bd.  60,  p.  474. 

•  Rost :  "  Ueber  Verwendung  ausschliesslicher  Rectalernah- 
rung."    Berl.  klin.  Wochenschr. ,  1899,  Nos.  30,  31. 


plying  of  water  is  sometimes  even  more  necessary  or 
at  any  rate  just  as  important  as  the  giving  of  food.  Of 
course  the  possibility  remains  of  giving  nutrient  ene- 
mata  in  connection  with  the  oil  injections,  as  von 
Leube  has  mentioned,  but  according  to  my  experience 
it  would  be  difficult  to  find  patients  willing  to  consent 
to  this  method  more  than  once  or  twice. 

In  every-day  practice,  therefore,  the  nutrient  ene- 
mata  will  have  the  advantage  over  the  oil  injections, 
especially  as  they  do  not  off'er  the  risk  of  infection 
which  is  always  present  with  the  latter. 

III.  Feeding  Through  the  Gastric  Fistula Since 

gastric  fistulce  are  made  only  under  circumstances  in 
which  access  to  the  stomach  per  vias  naturales  is  per- 
manently blocked,  and  every  sort  of  fluid  food  may  be 
introduced  through  the  opening,  it  is  in  these  cases 
not  so  much  a  question  of  the  character  of  the  nutri- 
tive mixture  to  be  used  as  of  whether  its  digestion 
and  absorption  by  the  stomach  are  possible.  It  is 
essential  to  consider  the  conditions  which  have  made 
the  establishment  of  the  fistula  necessary.  In  cases 
of  benign  cicatricial  strictures  of  the  oesophagus,  the 
digestive  function  of  the  stomach  is  not  materially 
impaired,  and  I  have  seen  patients  who  continued  in 
an  excellent  state  of  nutrition  after  the  operation.  If 
the  matter  injected  through  the  fistula  was  again  with- 
drawn after  a  suitable  lapse  of  time,  the  normal  altera- 
tions in  character  were  recognizable. 

Quite  the  reverse  is  the  case  when  malignant  new 
growths  are  in  question.  Here  the  functional  activity 
of  the  stomach,  as  I  must  maintain  contrary  to  other 
opinions,  is  wholly  abrogated,  and  digestion  takes 
place  not  in  the  stomach  but  only  in  the  intestine. 
The  use  therefore  of  the  native  albumins  and  carbo- 
hydrates is  not  indicated,  but  it  is  preferable  to  em- 
ploy the  more  or  less  predigested  albumose  and  peptone 
preparations  and  glucose  solutions,  and  to  locate  the 
fistula  as  near  to  the  pylorus  as  possible,  as  I  have 
already  indicated  in  former  years,  so  that  it  may  be 
possible  to  introduce  the  food  directly  into  the  intes- 
tine by  means  of  a  tube  passed  through  the  gastros- 
tomy wound.  Unfortunately  in  most  cases  the  con- 
ditions are  so  unfavorable  that  a  protracted  and 
satisfactory  feeding  cannot  be  accomplished. 

Conclusions. — i.  Extrabuccal  feeding  does  not 
completely  replace  feeding  by  mouth,  and  is  not  per- 
manently capable  of  answ-ering  the  demands  of  meta- 
bolism. In  most  cases  in  which  this  method  exclu- 
sively is  resorted  to  a  state  of  malnutrition  sets  in  from 
the  outset.  An  exception  to  this  rule  occurs  in  those 
cases  of  gastric  fistula  in  which  the  operation  was 
necessitated  by  a  benign  stricture  of  the  oesophagus. 

2.  For  a  short  time,  in  weakened  individuals  whose 
metabolism  is  below  normal,  it  may  be  possible  through 
extrabuccal  feeding  to  increase  the  nitrogen  conversion 
and  even  to  cause  an  accumulation  of  nitrogenous 
substance  and  fat. 

3.  The  best  results  are  obtained  when  it  is  a  ques- 
tion of  a  temporary  replacement  of  the  natural  feeding 
per  OS,  or  when  extrabuccal  feeding  is  resorted  to  as 
an  accessory  measure  to  the  former. 

4.  Nutritive  eneniata  are  to  be  preferred  to  the  sub- 
cutaneous injection  of  oil.  The  applicability  of  the 
latter  lies  rather  in  isolated  cases  than  as  a  measure 
adapted  to  widespread  use  in  practice. 


Luxation  of  the  Acromion. — Bore  directly  through 
the  acromion  with  the  longest  and  strongest  drill  at 
hand,  and  also  bore  lengthwise  into  the  clavicle  a 
distance  of  5  cm.  The  drill  is  left  in  for  eighteen 
days,  the  apparatus  holding  the  bones  in  normal  posi- 
tion during  the  drilling  having  been  removed. — K. 
BOdinger. 


August  1 8,  1900] 


MEDICAL    RECORD. 


245 


MIGRATED     OVARIAN     AND     PAROVARIAN 
TUMORS." 

By   GEORGE    M.    EDEBOHLS,    A.M.,    M.U., 

NEW    YORK. 

L>Y  migrated  ovarian  and  parovarian  tumors  we  under- 
stand such  growths  as  have  become  entirely  detached 
from  their  former  connection  with  the  broad  ligament, 
and  which  either  lie  free  in  the  peritoneal  cavity  or  are 
united  by  new  attachments  to  organs  and  tissues  other 
than  those  from  which  they  were  originally  derived. 

Various  names  have  been  proposed  for  this  class  of 
tumors.  Migratory  and  migrant,  the  latter  suggested 
by  Stone,  denote  emigration  not  as  yet  completed,  and 
consequently  do  not  correspond  with  the  condition 
usually  encountered.  Almost  equally  with  the  terms 
wandering,  errant,  and  vagrant,  they  might  be  made  to 
apply  to  a  tumor  with  a  very  long  pedicle  permitting 
of  extensive  excursions.  The  term  parasitic  has  long 
been  pre-empted  for  tumors  due  to  parasites,  and  this 
pre-emption  should  be  respected.  To  call  them  ecto- 
pic tumors  would  tend  to  confusion  with  tumors  due 
to  extra-uterine  fobtation.  They  are  often  designated 
as  detached  tumors,  but  this  term  applies,  strictly 
speaking,  only  in  those  exceptional  instances  in  which 
the  tumor  lies  entirely  free  in  the  peritoneal  cavity. 
Of  the  more  admissible  designations,  such  as  alien, 
expatriated,  exiled,  transplanted,  self-amputated,  and 
migrated  tumors,  I  prefer  the  last  named. 

Torsion  of  the  pedicle  of  the  tumor  up  to  complete 
strangulation  and  division,  with  implantation  of  the 
tumor  upon  neighboring  organs,  selectively  and  most 
frequently  upon  the  omentum,  either  before,  during,  or 
after  detachment  from  its  original  site,  represents  in 
the  majority  of  instances  the  processes  by  which  an 
ovarian  or  parovarian  tumor  qualifies  as  migrated. 
Tension  or  traction  upon  the  pedicle  no  doubt  fre- 
quently assists  torsion  in  effecting  complete  separa- 
tion, a  combination  of  which  forces  I  have  seen  active 
in  one  of  my  own  cases. 

As  an  outcome  or  final  result  of  these  processes,  the 
ovary  or  ovarian  or  parovarian  tumor  occupies  a  new 
habitat,  while  the  adnexa  of  the  corresponding  side 
are  generally  represented  by  a  more  or  less  short 
stump  of  Fallopian  tube  and  ovarian  ligament  which 
remains  attached  to  the  uterine  cornu.  The  Fallopian 
tube  and  ovarian  ligament  may,  on  the  other  hand,  be 
twisted  or  pulled  in  their  entirety  out  of  the  uterus,  so 
that  the  differentiation  between  congenital  aplasia  of 
the  uterine  adnexa  on  the  one  hand  and  their  disap- 
pearance as  a  result  of  pathological  processes  on  the 
other  may  become  very  difficult,  or  even  impossible. 
In  doubtful  cases  the  determination  of  the  presence  or 
absence  of  the  interstitial  part  of  the  tube  may  be 
needed  to  decide  the  question.  Braun,^  as  quoted  by 
Kossmann,'  describes  and  pictures  a  case  of  complete 
detachment  of  the  ovary  in  which,  after  the  lapse  of  a 
few  years,  all  trace  of  a  scar  or  other  indication  of  the 
former  site  of  attachment  had  disappeared  from  the 
broad  ligament.  In  my  o\v,n  Case  II.  detailed  below, 
the  same  result  has  by  this  time  undoubtedly  obtained. 

That  the  new  pedicle  of  attachment  of  a  migrated 
ovarian  tumor  is  liable  to  the  same  accidents  of  tor- 
sion and  rupture  as  the  original  pedicle  is  shown  by  the 
case  of  Chalot. 

Stone'  and  Coe"  have  recently  well  covered  the  sub- 

'  Read  before  the  American  Gynecological  Society,  Washing- 
ton.  May  I,  IQOO. 

''  "  Ueber  die  Abschniirung  der  Ovarien."  Inaug.  Diss.,  Gies- 
sen.  1896. 

^  .\.  Martin  :  "  Krahkheiten  der  weiblichen  Adne.xorgane, "  vol. 
ii..  n.  ni. 

*"  Migrant  Tumors  of  the  Uterus  and  Ovary."  Trans.  Am. 
Gyn.  Soc,  1S9S.  x.Niii.,  4ti--a2i. 

'  "  Detached  or  Parasitic  Tumors  of  the  Uterus  and  Ovary." 
Am.  Gyn.  and  Obst.  Journ.,  !r)00,  xvi.,  210-216. 


jects  denoted  by  the  titles  of  their  respective  articles. 
The  present  paper  is  offered  more  as  a  clinical  con- 
tribution, since  I  find  myself  in  a  position  to  add  four 
further  cases  to  the  hitherto  reported  twenty-five  or 
thirty  cases  operated  upon  for  migrated  ovarian  or 
parovarian  tumors.  My  own  cases,  perhaps,  in  addi- 
tion to  furnishing  the  largest  individual  contribution 
to  the  subject,  possess  the  merit  of  having  been  more 
closely  observed  and  of  being  more  accurately  de- 
scribed than  the  majority  of  those  reported.  I  have 
no  doubt,  however,  that  there  are  on  the  note-books  of 
a  considerable  number  of  operators  records  of  similar 
experiences,  the  publication  of  which  may  be  stimu- 
lated, as  has  obtained  in  my  own  instance,  by  the  re- 
cent papers  of  Stone  and  Coe. 

Case  I. — Gangrenous  monocyst,  presenting  all  the 
characteristics  of  a  migrated  paro\arian  cyst,  removed 
from  the  omentum   by  operation;  cure.     Mrs.   M.   E. 

F ,  aged  thirty-seven  years,  married,  a  patient  of 

Dr.  G.  J,  Moser,  was  admitted  to  St.  Francis  Hospital, 
April  20,  1893,  suffering  from  a  painful,  fluctuating, 
globular  tumor,  20  cm.  in  diameter,  located  in  the  cen- 
tral part  of  the  abdomen,  immediately  behind  the  um- 
bilicus. The  uterus  and  right  adnexa,  normal  in  size, 
could  be  palpated  below  the  lumor;  the  left  adnexa 
could  not  be  recognized.  Caliotomy,  April  21,  1893, 
revealed  a  monocyst,  presenting  all  the  characteristics 
of  a  parovarian  cyst,  attached  by  a  pedicle  10  cm.  wide 
and  2  cm.  thick  to  the  lower  free  edge  of  the  omentum. 
There  were  no  other  attachments  whatsoever.  The  con- 
tents of  the  cyst,  a  bloody,  grumous  fluid,  measuring 
two  litres,  were  evacuated;  the  omentum  pedicle  was 
tied  off  and  the  cyst  removed.  The  cyst  wall  opposite 
the  attachment  to  the  omentum  was  gangrenous  over  a 
circular  area  15  cm.  in  diameter,  and  the  inner  layers 
of  the  cyst  were  studded  with  innumerable  points  of 
ecchymosis.  The  uterus,  both  tubes,  and  ovaries  were 
found  perfectly  normal.  The  abdomen  was  cleaned 
and  closed  without  drainage.  There  were  uneventful 
convalescence  and  primary  union.  She  left  the  hos- 
pital May  10,  1893,  and  has  remained  well  to  date. 

I  have  classed  this  tumor  as  a  migrated  parovarian 
cyst  because  it  presented  all  the  characteristics  of  the 
latter  and  none  of  those  common  to  tumors  originating 
in  the  omentum.  The  fact  that  the  uterus  and  tubes 
presented  nothing  abnormal  does  not  militate  against 
my  view  of  the  case,  since  Braun  has  shown,  and  my 
own  experience  bears  him  out,  that  an  ovary  may  be 
twisted  off  and  Jeave  no  trace  to  indicate  the  site  of  its 
former  attachment  to  the  broad  ligament. 

The  detachment  of  a  parovarian  cyst,  leaving  intact 
the  tube  and  ovary  of  the  same  side,  can  be  readily 
understood.  That  a  parovarian  cyst,  however,  in 
twisting  itself  free,  may  carry  with  it  the  tube  and 
ovary  of  the  same  side,  is  proven  by  the  following  case  : 

Case  II. — Large,  strangulated  left  parovarian  cys- 
toma free  in  the  abdominal  cavity,  its  pedicle  having 
just  been  completely  severed  by  torsion;  left  ovarian 
ligament  and  left  Fallopian  tube  completely  pulled  out 
of  uterine  cornu;  coexistence  of  umbilical  hernia; 
parovariotomy    and     radical     herniotomy;     cure.     T. 

H ,  aged   thirty-three   years,   single,   came   under 

observation  March  26,  1892.  For  a  year  previously 
she  had  known  of  an  abdominal  enlargement,  which 
had  caused  her  no  special  annoyance  or  apprehension 
until  within  the  past  two  days,  during  which  she  has 
suffered  from  persistent  abdominal  pains,  vomiting, 
rapid  pulse,  and  slight  elevation  of  temperature. 

Examination  showed  a  globular,  sensitive,  elastic 
tumor  filling  the  lower  half  of  the  abdomen  from  pubis 
to  umbilicus.  The  tumor  displaced  the  uterus  down- 
ward and  backward,  and  although  situated  mainly  on 
the  right  side  appeared  to  be  connected  by  a  thick, 
tense  band  with  the  left  adnexa.  The  diagnosis  was 
made  of  strangulated  left  ovarian  cystoma.     Tempera- 


246 


MEDICAL    RECORD. 


[August  18,  1900 


ture,  101°  F.;  pulse,  100.  A  large  umbilical  hernia 
was  also  present. 

The  operation  was  done  at  St.  Francis  Hospital, 
March  28,  1S92,  four  days  after  the  commencement  of 
symptoms  of  strangulation  of  the  cyst.  On  incision 
of  the  abdomen  a  black  cyst  presented,  with  its  rather 
thick  walls  still  unruptured,  though  uniformly  pur- 
plisli-black  from  incipient  gangrene  and  diffuse  extra- 
vasations of  blood.  The  peritoneal  cavity  in  the  neigh- 
borhood of  the  pedicle  of  the  tumor  contained  about 
100  gm.  of  fluid  blood  and  clots  which  were  mopped 
out.  The  cyst  was  punctured  and  one  litre  of  port- 
wine-colored,  bloody  fluid  was  drawn  off  by  aspiration. 
Further  exploration  showed  the  cyst  to  be  entirely 
free,  having  no  attachments  whatsoever.  The  stump 
of  its  former  pedicle,  which  still  remained  attached  to 
the  left  inferior  aspect  of  the  cyst  wall,  was  in  a  stran- 
gulated condition,  deep  black,  friable,  and  contained 
in  its  substance  blood  clots  in  beginning  disintegra- 
tion. The  free  blood  in  the  peritoneal  cavity  came 
from  the  ruptured  pedicle  which  was  still  in  condition 
and  position  to  demonstrate  at  least  two  complete 
twists,  from  left  to  right,  upon  its  own  axis.  The  left 
tube  and  the  left  ovarian  ligament  were  completely 
torn  out  cf  the  cornu  of  the  uterus,  leaving  no  vestige 
there  of  their  former  presence.  The  entire  left  tube 
and  the  left  ovary  were  found  in  beginning  disintegra- 
tion in  the  stump  of  the  pedicle  of  the  self-amputated 
cyst.  The  right  ovary  and  tube  were  perfectly  normal. 
Tension  or  stretching  of  the  pedicle  no  doubt  greatly 
aided  torsion  in  effecting  complete  separation;  the 
tumor,  although  originating  from  the  left  parovarium, 
being  locked  in  the  right  half  of  the  abdomen  by  spas- 
tic contraction  of  the  recti  abdominis  muscles.  The 
peritoneal  investment  of  the  intestines  as  well  as  of 
the  parietes  adjacent  to  the  tumor  showed  signs  of  in- 
cipient inflammation  with  plastic  deposits.  After 
thorough  mopping  with  damp  sublimate  gauze,  the  ab- 
dominal incision  was  extended  upward  to  embrace  the 
umbilical  hernia.  Radical  herniotomy  was  done,  with 
complete  closure  of  the  abdomen  without  drainage. 
There  was  an  uneventful  convalescence  ;  primary  union 
took  place.  She  was  discharged  from  the  hospital 
three  weeks  after  operation. 

Remarks:  Had  the  patient  survived  without  opera- 
tion, the  incipient  peritonitis  would  probably  have 
provided  for  the  attachment  and  continued  sustenance 
of  the  tumor  separated  from  its  original  source  of  nu- 
trition. Possibly  the  cyst  contents  would  have  es- 
caped, after  rupture  of  the  cyst  wall,  and  have  been 
absorbed  by  the  peritoneum.  The  cyst  wall  itself 
might  have  disappeared  by  absorption  or  organic  in- 
corporation with  the  adjacent  parts,  or  by  both  these 
processes  combined.  An  abdominal  section  or  an 
autopsy  after  these  changes  were  completed  would 
have  demonstrated  entire  absence  of  the  left  ovary 
and  tube.  All  of  which  goes  to  show  that  complete 
absence  of  one  ovary  and  tube  may  be  the  result  of 
self-amputation  as  well  as  of  congenital  aplasia,  and 
that  the  diagnosis  of  the  latter  condition  is  not,  as  has 
heretofore  laeen  assumed,  unequivocally  established  by 
finding  no  vestige  of  the  tube  and  ovary  of  one  side. 

Case  HI. — Self-amputation  of  left  ovarian  cyst  and 
tube;  intraligamentous  right  ovarian  cystoma;  chronic 
metritis  and  appendicitis;  ca;lio-obphoro-salpingo- 
hysterectomy ,     inversion     of     appendix;     cure.      E. 

S ,  aged  thirty-six  years,  married,  mother  of  five 

children,  was  admitted  to  St.  Francis  Hospital,  May 
24,  1898,  with  a  history  of  atypical  metrorrhagia, 
leucorrhoea,  bearing-down  sensations,  and  dyspareu- 
nia.  Examination  showed  chronic  metritis,  a  tumor 
about  8  cm.  in  diameter  of  the  right  ovary,  chronic  ap- 
pendicitis, movable  right  and  left  kidneys. 

Operation  was  done  May  27,  1898.  When  the  ab- 
domen was  opened  there  were  found  a  large  and  heavy 


uterus,  an  intraligamentous  right  ovarian  cystoma, 
hen's  egg  in  size,  and  far  advanced  appendicitis  ob- 
literans. The  left  ovary  was  entirely  absent;  the  left 
tube  also  being  missing,  with  the  exception  of  a 
twisted  stump,  2  or  3  cm.  long,  which  remained  at- 
tached to  the  uterine  cornu.  The  free  end  of  the 
twisted  tubal  stump  was  sealed  and  smoothly  rounded. 
The  left  round  ligament  was  intact.  Attached  to  the 
entire  posterior  aspect  of  the  uterus  and  to  a  portion 
of  the  left  broad  ligament  was  a  firm  membrane  of 
irregular  thickness,  which  on  subsequent  examination 
proved  to  be  part  of  the  sac  of  a  former  left  ovarian 
cyst.  The  operation  consisted  of  excision  of  the 
uterus,  right  ovarian  cyst,  right  tube,  and  stump  of  the 
left  tube,  with  inversion  of  the  vermiform  appendix. 
Complete  closure  was  done  without  drainage.  There 
was  uneventful  convalescence;  primary  union  took 
place.     She  was  discharged  well,  June  22,  1898. 

Remarks:  The  conditions  found  and  described 
above  leave  no  doubt  that  a  former  left  ovarian  cyst 
had  at  some  time  twisted  itself  free,  carrying  with  it 
the  greater  part  of  the  left  tube.  The  cyst  contents 
had  escaped  and  been  absorbed  together  with  a  part 
of  the  cyst  wall.  The  remainder  of  the  cyst  wall  had 
become  adlierent  to  the  back  of  the  uterus  and  left 
broad  ligament,  and  had  thus  maintained  its  vitality. 
There  was  nothing  in  the  patient's  history  to  indicate 
at  what  period  of  life  the  self-amputation  of  the  left 
ovarian  cyst  had  occurred.  The  period  of  occurrence 
of  a  like  event,  however,  was  well  marked  in  the  his- 
tory of  the  next  case. 

Case  IV. — Migrated  dermoid  of  right  ovary;  left 
ovarian  cystoma;  bilateral  ovariotomy ;  amputation  of 

omentum;    inversion  of  appendix;    cure.     E.  A , 

aged  thirty-six  years,  married,  never  pregnant  was  sent 
to  me  by  Dr.  Dayton  L.  Kathan,  of  Schenectady,  N.  Y. 
The  only  events  of  importance  in  her  previous  history 
were  two  attacks  of  acute  peritonit's,  the  first  twelve 
and  the  second  ten  years  ago,  each  attack  having  con- 
fined her  to  bed  for  five  weeks.  With  these  exceptions 
she  was  well  until  about  a  year  ago,  since  when  she 
had  noticed  progressive  enlargement  of  the  abdomen. 

Examination  showed  a  normal-sized  uterus  doubled 
forward  upon  itself  underneath  a  fluctuating  tumor 
diagnosticated  as  an  ovarian  cystoma,  the  cyst  enlarg- 
ing the  abdomen  to  a  size  and  shape  corresponding  to 
a  normal  pregnancy  near  term. 

Operation  was  performed  May  29,  1897,  at  the  Post- 
Graduate  Hospital.  When  the  abdomen  was  opened  a 
large  monocyst  of  the  left  ovary  presented,  and  was 
tapped  and  removed.  Further  examination  showed 
complete  absence  of  the  right  ovary  and  of  all  but  2  cm. 
of  the  right  tube,  which  with  an  equal  length  of  the  right 
ovarian  ligament  formed  a  stump  attached  to  the  right 
uterine  cornu.  The  right  round  ligament  was  intact. 
The  lower  free  end  of  the  omentum  was  enormously 
thickened  and  wrapped  completely  around  a  tumor,  15 
cm.  in  diameter,  which  proved  to  be  a  dermoid  of  the 
right  ovary  containing  teeth,  hair,  and  sebum.  The 
dermoid  had  absolutely  no  other  attachments  except  to 
the  posterior  surface  of  the  omentum,  which  completely 
enveloped  ii  and  from  which  it  received  its  sustenance 
by  means  of  numerous  small  vessels,  none  of  them  large 
enough  to  require  ligation.  The  tumor  was  simply 
peeled  out  of  the  omentum  without  any  bleeding.  The 
greater  part  of  tiie  hypertrophied  omentum  was  removed 
by  amputation,  the  appendix  vermiformis  inverted,  and 
the  abdomen  closed.  There  was  a  smooth  convales- 
cence.    She  was  discharged  three  weeks  after  operation. 

Remarks:  Torsion  of  the  pedicle  of  the  right  ova- 
rian dermoid  without  detachment 'probalily  occurred 
in  the  first  attack  of  peritonitis  twelve  years  previ- 
ously, while  complete  detachment  of  the  tumor  coin- 
cided with  the  peritonitic  attack  of  two  years  later. 
The  tumor  then  became  engrafted  upon  and  drew  its 


August  1 8,  1900] 


MEDICAL    RECORD. 


247 


further  sustenance  from  the  omentum,  in  which  it  was 
found  completely  wrapped. 

I  have  collected  from  the  literature  and  tabulated 
the  following  forty-three  pertinent  cases,  fourteen  of 
them  referring  to  post-mortem  findings,  and  twenty- 
nine  observed  on  the  operating-table: 

Migrated    0\arif.s    and   Ovarian   Tumors    Found    Post 
Mortem. 


Il 

Author. 

Reference. 

Nature  of  Tumor. 

Atlee,  \V.  I 

I 

"  Diagnosis     of    Ovarian 
Tumors,'"  Philadelphia, 
1873.  p.  188. 

Dermoid  of  left  ovary. 

Baumgarten 

2 

Arch.    f.    path.    Anat.  u. 

One  free  right  and  one  free 

Phys.,  1884,  xcvn.,  p.  j8. 

left  ovary 

Fraenkel,  E  . . . . 

^ 

Arch.    f.    path.    Anat.   u. 
Phys.,  1885,  xci.,  p.  519. 

Dermoid  of  right  ovary. 

HeschI 

1 

Oesterr.  Ztschr.  f.  prakt. 
Heilkunde,    1862,    vjii.. 

Free  cyst  of  right  ovary  in 
child  of  three  weeks. 

P-  377- 

Malin!i,  E 

I 

Lancet,  London,  1883,  i. , 
587.     Case  IL 

Cyst  of  right  ovary. 

Rokitansky 

7 

Allg.  Wiener   med.  Ztg., 

Five  dermoids,  two  ovarian 

i860,  v..  pp.  g,  17,  25. 

cysts,  six  teft-sided,  one 
nght-sided. 

Turner,  W 

I 

Edinburgh     Med.    Jour., 
1861,  vi.,  pt.  ii.,  p.  698. 

Cyst  of  left  ovary. 

Migrated  Ovarian   and   Parovarian   Tumors— Operative 
Cases. 


5  Si 

Author. 

13 

Reference. 

Nature  of  Tumor. 

Barrat  

Trans.  Path.    Soc. ,   Lon- 
don, 1866,  xvii.,  p.  197. 

Doubtful   case,     Multilocu- 

tar     omental     cyst,     pro- 

nounced   by    pathologists 

an    ovarian    cyst.     Ova- 

ries and  uterus  present  and 

normal. 

Chalot 

Annates  de  Gynec,  1887. 

Cyst   of    left   ovary.       Par- 

xxvii., 161  ;  xxviii.,  31, 

tial  rupture  of  new  pedi- 
cle attaching  migrated 
cyst  to  epiploon. 

Doran.  A 

Trans.     Med.-chir.  Soc, 
London,  1885,  2  S.,  L. 

Dermoid  of  left  ovary. 

F.debohls,  G.  M. 

2.1 5- 

I.  Parovarian  cyst,  side  not 
determinable.       2.   Left 

parovarian    cyst.     3.   Left 

ovarian  cyst.    4.  Dermoid 

of  right  ovary. 

Hofmeier,  M  . . . 

Zeitschr.  f.  Geb.  u.  Gyn., 
1880.  v..  pp.  96-111. 

Two  left  ovarian  cysts. 

Heurtaux 

Bull,  et  mem.  de   Soc.  de 
Chir.,    Paris,    1886,  xii. 
P-  75t- 

Left  ovarian  cyst. 

Keith,  S 

Edinburgh     Med.    Jour., 
1886,   xxxi.,    pt.    ii.,   p. 
838. 

"Operative  Gynaecology," 

Left  ovarian  cyst. 

Kelly,  H.  A  .... 

Left   ovarian   cyst,    not    re- 

1898, vol.  ii.,  p.  250. 

moved  in  the  presence  of 
general  peritoneal  carci- 
nosis. 

l-oebkei,  C 

Arch.  f.  Gyn.,  1879.  xiv., 

Cysto-sarcomaof  left  ovary. 

Malins,  £ 

p.  447. 
Lancet.  London,  1883,  i., 

Cyst   of    right    ovary.     M. 

P-  587. 

reports  three  other  cases 
in  which  separation  was 
not  as  yet  completed  at 
time  of  operation. 

Olshausen,  R  . . 

*'  Krankheiten  der  Ovari- 

Ovarian      cyst ;      side     not 

en,"  Stuttgart,  1887,   p. 

stated. 

269. 

Peaslee,  E 

Amer.    Journ.    of    Obst., 

Ovarian     cyst ;     side     not 

1878.  xi.,  p.  766. 

stated. 

Pfannenstiel.  J.. 

Veit's*'Handbuch  derGy- 
nakologie,"    Wiesbaden. 
1898,  pt.  iii.,  p.  421. 

Cyst  of  left  ovary. 

Ruge,  P 

Berliner  Klinik,  Heft  30. 
p.  3  ;  Ztschr.  f.  Geb.  u. 
Gyn.,  xxi.,  p.  210. 

Dermoid  of  left  ovary. 

Saenger,  M 

A.  Martin  :  '*  Krankheiten 

Dermoid  of  right  ovary  in 

d.     weiblichen    Adnex- 

both  cases. 

organe,"  ii.,  pp. 685-687. 

Smith,  H 

Trans.   Obst.    Soc,  Lon- 

Ovarian     cyst;      side      not 

don,  i88t,  xxiii.,  p.  104. 

stated. 

Stone,  I.  S 

Trans.   Am.    Gyn.    Soc, 
1898.  xxiii.,  pp.  411-421. 

Dermoid  of  left  ovary. 

Sutton,  J.  B... 

"  Surgical  Diseases  of  the 

Parovarian   cyst ;    side    not 

Ovaries    and    Fallopian 

stated,  nor  whether  opera- 

Tubes."    Philadelphia, 

tive   case.       The    ovarian 

1892,  p.  108. 

cyst,  figured  on  page  141, 
was  not  completely  de- 
tached. 

Tauffer,  W.    ... 

Wien.  med,  Wochenschr,, 

Cyst  of  left  ovar>-. 

TerriUon 

1885,  XXXV.,  p.  67. 

Rev.   de   chir.,    1886,  \'i.. 

Cyst,     Neither  side,  nor  na- 

p. 950- 

ture  of  cyst,  nor  any  de- 
tails stated. 

Thornton,  K  . . . 

Trans.   Obst.    Soc,    Lon- 
don, 1881,  xxiii.,  p.  104 

Dermoid  of  left  ovary. 

Veit,  J 

Archiv     f.    Gynak.,   1878. 

Free  left  ovary.     A  case  of 

xiii.,  p    4<;9. 

Schroeder. 

Wells,  S 

2 

"  Diseases    of    the    Ova- 

I. Dermoid;  side  not  stated. 

ries."  New  York,  1873. 

2.  Multilocular  cyst;    side 

p.  84. 

not  stated. 

I  find  in  the  literature  one  case  each  attributed  to 
Amann,  Jr.,  Boxall,  Braun,  Koeberle,  Pozzi,  and  Pul- 
teney.  Some  of  the  references  given  I  have  found  in- 
correct, and  in  the  case  of  the  remainder  I  do  not  hap- 
pen to  have  access  to  the  original  publications.  I 
have,  therefore,  preferred  to  omit  altogether  these 
cases,  rather  than  to  quote  them  at  second-hand. 

I  append  a  summary  of  the  above-noted  cases  of 
migrated  ovaries  and  ovarian  and  parovarian  tumors; 
3  free  ovaries,  i  right,  2  left;  3  parovarian  cysts,  i 
left,  2  side  not  stated;  21  ovarian  cysts,  3  right,  12 
left,  6  not  stated;  15  ovarian  dermoids,  5  right,  9  left, 
I  not  stated ;   i  cystosarcoma  of  left  ovary. 

59  West  Kortv-ninth  Street. 


POSTERIOR  COLPOCCELIOTOMY  FOR  LE- 
SIONS OF  THE  ADNEXA  AND  UTERUS; 
ITS    INDICATION    AND    TECHNIQUE.' 

Bv   CH.A.RLE.S    GREENE    CUMSTOX.    M.D., 

ItOSTON,    MASS, 

In  February  of  this  year  I  had  the  honor  of  reading  a 
paper  on  posterior  colpotomy  for  acute  suppurative  le- 
sions in  the  female  pelvis,  before  the  Gynaecological 
Section  of  the  Suffolk  District  Medical  Society,  and 
on  this  occasion  I  would  like  to  consider  this  excellent 
operation  for  the  removal  of  diseased  appendages  and 
certain  neoplastic  productions  of  the  uterus.  I  have 
always  upheld  that  when  an  abdominal  incision  could 
be  avoided,  and  still  a  thorough  operation  be  done 
through  the  vagina,  the  latter  should  be  the  preferred 
route,  and  the  experience  of  several  years  in  vaginal 
work  has  led  me  to  feel  more  strongly  on  this  point 
than  ever.  I  trust  that  these  remarks,  coming  as  they 
do  from  a  general  surgeon,  and  not  a  specialist,  may  be 
received  kindly,  and  although  in  this  paper  the  writer 
does  not  wish  it  to  be  understood  that  he  believes  the 
vaginal  route  is  the  only  one  to  select  in  gyntecologi 
cal  cases,  still  he  feels  certain  that  many  women  may 
be  relieved  of  their  infirmities  without  going  through 
the  rest  of  their  lives  with  a  weak  abdominal  wall  and  a 
scar. 

The  vaginal  route  is  at  the  present  time  no  longer 
limited  to  simple  puncture  and  drainage,  or  to  total 
vaginal  hysterectomy,  and  its  field  of  usefulness  has 
become  extended  for  the  treatment  of  a  large  number 
of  pelvic  lesions,  thanks  more  especially  to  the  mod- 
ern and  improved  technique.  In  a  recent  and  very 
excellent  article  on  vaginal  cceliotomy  by  Dr.  J.  Rid- 
dle Goffe,  which  appeared  in  the  J\lcdical  Neius  of  Oc- 
tober 7,  1899,  this  authority  goes  so  far  as  to  say  that 
ninety  per  cent,  of  pelvic  affections  may  be  treated 
through  the  vagina,  but  this  I  believe  to  be  some- 
what of  an  exaggerated  statement. 

In  the  Wiener  klinische  Wochenschrijt  of  February 
I,  1900,  is  to  be  found  a  very  exhaustive  and  profound 
article  from  the  pen  of  Professor  Schauta,  entitled 
"Ueberdie  Einschriinkung  der  Laparotomie  zu  Gun- 
sten  der  vaginalen  Coliotomie,"  in  which  the  author  re- 
ports his  experience,  amounting  to  1,112  vaginal  coe- 
liotomies  and  hysterectomies  and  1,279  abdominal 
sections  performed  for  various  lesions  of  the  uterus 
and  adnexa,  including  the  removal  of  one  or  both 
tubes  for  salpingitis,  ectopic  gestation,  enucleation  of 
fibroid  growths,  ovarian  tumors,  hysteropexy,  etc. 
Death  directly  due  to  the  operation  shows  for  the 
vaginal  method  2.8  per  cent.,  and  5.9  per  cent,  for  the 
abdominal.  As  to  vaginal  cceliotomy  for  lesions  of 
the  adnexa  and  uterus,  when  the  condition  of  the  lat- 
ter organ  did  not  necessitate  it's  removal,  we  find  51 
cases  of  single  ovariotomy,  i    case  of  double  ovari- 

'  Read  before  the  New  Hampshire  State  Medical  Society,  May 
31.  1900. 


248 


MEDICAL    RECORD. 


[August  18,  1900 


otomy,  26  cases  of  removal  of  one  tube  for  iiiHamma- 
tory  lesions,  i  case  of  removal  of  both  tubes  for  in- 
flammatory lesions,  6  cases  of  removal  of  an  ectopic 
gestation  sac.  7  cases  of  enucleation  of  fibroid  growths, 
and  178  cases  of  hysteropexy,  making  a  total  of  270 
cases.  Of  these,  three  patients  died,  and  all  three 
were  operated  upon  for  inflammatory  lesions  of  the 
adnexa.  This  makes  a  mortality  of  a  trifle  over  one 
per  cent. 

In  another  recent  and  important  paper  on  posterior 
colpocceliotomy  for  lesions  of  the  adnexa  and  tumors 
of  the  small  pelvis  which  was  read  before  the  Seventh 
Congress  of  Russian  Physicians  by  Dr.  P.  Y.  Teplor, 
the  author  mentions  184  cases,  51  of  which  are  his 
own.  Among  these  cases  there  were  48  operations  for 
neoplasms  and  136  for  lesions  of  the  adnexa.  The 
neoplasms  may  be  divided  as  follows:  34  cysts  of  the 
ovary  (24  serous  c)'sts,  7  dermoid  cysts,  3  parovarian 
cysts),  10  proliferating  cystomata,  2  cases  of  sarcoma 
of  the  ovary,  i  case  of  fibroid  tumor  of  the  broad  liga- 
ment, and  I  case  of  cyst  of  the  mesentery.  In  13  cases 
the  neoplasm  was  alone  removed,  while  in  35  others 
removal  of  the  adnexa  was  performed  on  account  of 
inflammatory  lesions  present.  None  of  the  neoplasms 
was  larger  in  size  than  a  fcetal  head.  For  the  cases 
of  inflammatory  lesions  of  the  adnexa,  the  following 
operations  were  performed:  23  cases  of  removal  of  the 
ovaries  and  tubes  on  both  sides;  65  cases  of  removal 
of  the  adnexa  on  the  one  side;  3  cases  of  removal  of 
both  ovaries;  4  cases  of  removal  of  one  ovary;  i  case 
of  bilateral  removal  of  the  tubes;  18  cases  of  unilat- 
eral salpingectomy;  9  cases  of  bilateral  extirpation 
of  the  tubes  and  removal  of  one  ovary;  4  cases  of 
bilateral  removal  of  the  tubes  with  partial  excision  of 
the  ovaries ;  9  cases  of  conservative  incision  of  the 
posterior  cul-de-sac. 

In  fourteen  per  cent,  of  these  cases,  suppurative  le- 
sions were  present,  and  in  7  cases  there  was  also 
present  a  retro-uterine  hematocele.  In  2  cases  an 
ectopic  gestation  was  found  with  the  foetus  in  a  macer- 
ated condition.  In  29  cases  there  was  a  retrodevia- 
tion of  the  uterus  accompanying  the  lesion  of  the 
adnexa.  Adhesions  were  met  with  in  only  two  cases. 
The  mortality  was  3.8  per  cent.,  and  in  55  per  cent,  of 
the  cases  the  post-operative  convalescence  was  apy- 
retic.  In  twenty-six  per  cent,  of  the  cases  there  was 
no  complication  after  the  operation.  In  4  cases  an  en- 
tero-vaginal  fistula  occurred,  but  which  rapidly  healed. 
In  42  cases  certain  complications  were  noted  after  the 
operation,  such  as  a  prolonged  rise  of  temperature, 
bronchitis,  pneumonia,  parotiditis,  urticaria,  etc.  The 
age  of  the  patients  varied  betw-een  eighteen  and  sixty 
years;  15  were  below  the  age  of  twenty  years,  no  be- 
tween the  ages  of  twenty  and  thirty  years,  51  between 
the  ages  of  thirty  and  forty  years,  while  8  were  be- 
tween forty  and  sixty  years.  Among  these  patients 
there  were  38  nuUiparous  females,  or  in  other  words 
about  twenty  per  cent. 

There  have  been  a  certain  number  of  objections 
raised  against  colpocceli otomy  by  numerous  surgeons. 
In  the  first  place,  it  has  been  said  that  it  was  a  slow 
operation.  Now  I  admit  that  in  a  certain  number  of 
cases,  and  these  form  a  small  proportion,  it  takes  some 
little  time  to  draw  the  adnexa  down  and  form  a  proper 
pedicle,  but,  generally  speaking,  the  operation  may  be 
performed  in  from  twenty  to  thirty  minutes. 

It  has  :ilso  been  asserted  that  the  clamps  placed  on 
the  pedicle  act  as  a  very  serious  encumbrance,  but  in 
reply  to  this  I  would  say  that  when  the  adhesions  are 
not  extensive  the  clamps  should  not  be  applied  until 
a  pedicle  has  been  fcjrmed  and  the  ovarv'  and  tubes  are 
ready  to  be  removed.  In  the  vast  majority  of  cases 
one  pair  of  clamps  is  quite  sufficient,  and  it  will  rare- 
ly be  necessary  to  employ  as  many  as  three.  If  we 
are  to  remove  the  adnexa  on  both  sides  the  clamps 


that  have  been  placed  on  one  side  first  may  perhaps 
cause  a  little  diflnculty  when  being  placed  on  the  op- 
posite side,  but  I  have  never  yet  operated  on  a  case  in 
which  this  could  be  counted  as  any  hindrance  to  the 
performance  of  the  operation. 

The  opponents  of  the  vaginal  route  insist  that  it  is 
a  blind  method.  On  this  point  I  can  say  that  in  all 
cases  which  are  suited  to  posterior  colpotomy,  the  field 
of  operation  is  as  readily  accessible  to  the  sight  as 
through  an  abdominal  incision.  Vou  can  always  draw 
the  adnexa  down  and  examine  them  carefully  before 
proceeding  to  their  removal.  The  only  part  of  the 
operation  which  is  beyond  the  reach  of  the  eye  is 
when,  before  the  pedicle  has  been  formed,  the  finger 
breaks  down  adhesions  and  frees  the  adnexa.  But 
with  a  finger  well  trained  to  abdominal  surgery,  we 
can  feel  the  loops  of  the  intestine  and  work  with  per- 
fect ease  and  without  danger.  When  the  pedicle  has 
been  formed,  the  clamps  are  always  applied  under  the 
entire  and  sole  guidance  of  the  eye.  The  use  of  an 
exaggerated  Trendelenburg  position  is  of  great  value 
in  vaginal  work,  and  even  if  we  are  dealing  with  a 
large  cyst  which  bursts  and  empties  its  contents  into 
the  general  peritoneal  cavity,  we  run  less  risk  by  the 
vaginal  route  than  by  the  abdomen,  because  we  can 
get  far  more  efficient  drainage  through  the  posterior 
cul-de-sac  than  from  above. 

The  intestinal  coils  and  the  folds  of  the  mesentery 
are  so  complex  that  even  a  most  careful  toilet  of  the 
peritoneal  cavity  may  sometimes  leave  behind  a  drop 
or  two  of  infectious  fluid  which  will  later  result  in 
sepsis,  but  the  perfect  drainage  which  is  obtained 
through  the  vagina  will  in  most  instances  prevent  this 
from  occurring.  I  purposely  say,  "  in  most  instances," 
because  I  had  the  misfortune  to  lose  a  case  last  month 
from  a  most  virulent  streptococcic  peritonitis,  so  virulent 
in  fact  that  the  patient  died  in  thirty-six  hours  from 
the  time  of  the  operation.  In  this  case  the  posterior 
cul-de-sac  was  opened  and  a  large  number  of  adhesions 
were  broken  down;  the  pehic  cavity  was  packed  with  , 
iodoform  gauze,  but  as  there  was  considerable  oozing 
from  the  vaginal  incision  the  vagina  was  also  tightly 
packed.  On  account  of  the  vaginal  packing  drainage 
was  imperfect,  as  is  proven  by  the  disastrous  result 
which  followed,  but  out  of  the  iifty-nine  cases  of  colpo- 
cceliotomies  which  I  have  now  done  for  most  varied 
affections  of  the  uterus  and  adnexa,  this  is  the  only 
case  that  I  have  lost. 

It  has  also  been  said  that  it  is  difficult  to  perform 
conservative  surgery  through  the  posterior  vaginal  in- 
cision, but  here  again  I  cannot  agree.  A  partial 
resection  of  the  ovary  can  be  performed  in  many 
cases,  and  a  hydrosalpinx  may  be  opened  and  drained. 
Lawson  Tait  has  said  that  an  operation  done  through 
the  vagina  is  always  incomplete,  but  I  would  here 
point  out  that  those  instances  in  which  a  complete 
operation  cannot  be  done  through  the  vaginal  incision 
are  just  the  ones  that  should  be  operated  on  through 
the  abdomen. 

As  to  the  argument  that  there  is  not  sufficient  space 
in  which  to  work  with  ease,  I  would  say  that  in  my 
experience  I  have  never  yet  met  with  a  case  in  which 
the  size  of  the  vagina  was  any  hindrance  to  the  perfect 
result  of  the  operation;  but  should  this  be  found  to 
exist,  two  lateral  incisions  in  the  perineum  should  be 
made,  as  is  done  in  obstetrical  practice  to  avoid  lacer- 
ation when  the  head  is  passing  thrcigh.  If  we  wish 
to  ligate  the  pedicle  instead  of  using  clamps,  it  can  be 
done  with  as  much  ease  as  through  the  abdominal  in- 
cision, and  as  far  as  secondary  hemorrhage  is  con- 
cerned it  is  no  more  likely  to  occur  when  the  opera- 
tion has  been  done  through  the  vagina  than  wiicn  an 
abdominal  incision  has  been  resorteti  to. 

Another  objection  which  has  been  raised  to  the 
vaginal  route  is  that  antisepsis  and  asepsis  cannot  be 


August  1 8,  1900] 


MEDICAL    RECORD. 


249 


carried  out  to  their  fullest  extent.  Now  as  to  this 
point  I  would  say  that  the  vagina  can  be  rendered 
quite  as  sterile  as  the  abdominal  wall,  and  when  the 
peritoneal  cavity  has  been  opened  asepsis  and  antisep- 
sis can  be  carried  out  just  as  well  as  through  an  ab- 
dominal incision.  If  we  are  dealing  with  an  ovarian 
cyst  which  has  undergone  septic  infection,  and  the 
purulent  liquid  escapes  into  the  peritoneal  cavity,  it 
will  remain  in  the  pelvis  and  can  be  removed  by 
sponges  mounted  on  clamps  just  as  well  as  through  an 
abdominal  incision,  and  here  again  the  drainage  being 
more  perfect,  on  account  of  the  natural  inclined  plane 
formed  by  the  anatomical  structures,  the  patient  is 
placed  in  less  danger  than  when  this  accident  occurs 
during  an  operation  through  the  suprapubic  incision. 

It  has  also  been  said  that  when  we  have  once  begun 
to  operate  through  a  vaginal  incision  it  is  ditficuh  to 
stop  if  the  condition  of  affairs  is  not  found  suited  to 
this  method.  Now  in  the  first  place  I  believe  that 
posterior  colpotomy,  and  for  that  matter  anterior  col- 
potomy,  is  and  always  should  be  considered  at  the 
beginning  as  an  exploratory  operation.  An  organ 
should  never  be  removed  if  it  appears  normal  and  if 
it  has  never  given  rise  to  any  symptomatic  phenomena. 
A  purulent  collection  in  the  culde-sac  of  Douglas  may 
be  mistaken  for  a  prolapsed  cystic  salpingitis,  but 
when  once  the  cul-de-sac  has  been  opened  the  explor- 
ing finger  readily  discovers  the  error,  and  there  is 
nothing  simpler  than  to  empty  the  pocket  and  drain. 

As  to  the  occurrence  of  a  post-operative  vaginal 
enterocele,  I  can  simply  say  that  I  have  never  seen 
it  occur  in  any  of  my  patients,  and  all  the  cases  I 
have  operated  on,  both  for  pus  in  the  pelvis  or  for  the 
removal  of  the  adnexa  through  the  vagina,  have  always 
presented  a  few  months  after  the  operation  an  almost 
imperceptible  firm  cicatrix  behind  the  cervix  through 
which  it  would  be  impossible  for  any  of  the  intestinal 
contents  to  form  a  hernia. 

Post-operative  intestinal  occlusion,  either  acute  or 
chronic,  has  never  been  reported  after  extirpation  of 
the  adnexa  by  the  vaginal  route,  as  far  as  I  know. 
I  believe  that  in  comparison  to  the  abdominal  in- 
cision removal  of  the  adnexa  through  the  vagina  is 
far  less  serious,  that  it  results  in  a  complete  cure  and 
avoids  a  suprapubic  cicatrix,  thus  freeing  the  patient 
from  any  danger  of  ventral  hernia. 

There  is  still  another  advantage  in  colpocceliotomy. 
When  one  of  these  very  persistent  fistula;  arises  which 
will  occasionally  occur  after  laparotomy,  they  are  very 
difficult  to  heal  and  very  annoying  for  the  patient. 
Now  in  the  case  of  the  vaginal  operation,  if  by  chance 
a  fistula  does  result,  it  is  much  more  agreeable  for  the 
patient  to  have  it  in  the  vagina  than  in  the  abdominal 
wall. 

When  ligatures  are  not  used  on  the  pedicle,  I  of 
course  resort  to  clamps,  which  are  left  in  place  from 
two  to  three  days,  and  during  this  time  the  patient 
will  complain  of  considerable  pain,  due  probably  to 
torsion  of  the  broad  ligament,  but  these  pains  can  be 
easily  controlled  by  the  judicious  use  of  morphine  un- 
til the  clamps  are  removed,  when  they  will  disappear 
as  if  by  magic.  The  pain  should  never  be  considered 
a  sufficient  reason  to  condemn  the  use  of  the  clamps, 
because  in  many  cases  the  patients  do  not  suffer  any 
more  than  after  an  ordinary  laparotomy  in  which  liga- 
tures have  been  used. 

In  those  cases  in  which  there  is  an  inflammatory 
lesion  of  both  adnexa  the  uterus  is  always  consider- 
ably diseased,  because  it  is  the  primary  focus  of  the 
infectious  process,  the  inflammation  of  the  endome- 
trium extending  by  direct  continuity  to  the  mucous 
membrane  of  the  tubes.  Now  if  we  remove  the  ad- 
nexa in  these  cases,  the  uterus  may  be  treated  and  its 
lesions  cured,  but  if  the  parenchyma  of  the  organ  is 
thoroughly  diseased,  it  should  be  removed  along  with 


the  adnexa — in  other  words,  a  total  vaginal  hysterec- 
tomy should  be  done.  On  the  other  hand,  the  uterus 
may  be  perfectly  normal,  although  there  may  be  a  le- 
sion of  the  tubes,  such  as  a  hydrosalpinx,  or  an  en- 
cysted haematosalpinx  which  has  been  produced  by  an 
unruptured  tubal  gestation  which  is  undergoing  ab- 
sorption, and  consequently  in  these  cases  the  uterus 
should  not  be  meddled  with. 

Anterior  colpotomy  is  also  useful  in  certain  cases, 
such  as  the  removal  of  fibroid  tumors'  situated  in  the 
anterior  wall  of  the  uterus,  or  for  the  performance  of  a 
cuneiform  exsection  on  the  anterior  wall  of  the  uterus 
for  cases  of  retroflexion  of  the  organ.'  The  incision 
is  made  transversely  in  the  anterior  cul-de-sac  just  as 
is  done  in  vaginal  hysterectomy,  and  then  may  be  in- 
creased in  size  by  carrying  a  longitudinal  incision  down 
perpendicularly  to  the  first,  and  this  latter  incision 
should  extend  the  whole  length  of  the  anterior  vaginal 
wall  just  as  is  done  in  Mackenrodt's  operation  for 
retroflexion  of  the  uterus,  which  will  be  described 
further  on.  The  bladder  is  separated  from  the  uterus 
as  well  as  the  vaginal  mucous  membrane  for  the  extent 
of  from  2.1  to  3  cm.  on  each  side  of  a  longitudinal  in- 
cision. The  opening  thus  gained  is  quite  sufficient 
for  any  radical  or  conservative  operation  we  may  wish 
to  perform  on  the  uterus  or  adnexa.  I  have  never 
witnessed  any  disturbances  of  the  bladder  in  the  few- 
operations  I  have  done  through  the  anterior  cul-de- 
sac,  and  this  is  also  the  experience  of  Goffe,  whose 
paper  I  have  already  referred  to.  In  cases  of  simple 
retroversion  of  the  uterus  without  adhesions,  the  uterus 
is  easily  reduced  and  maybe  brought  into  the  vaginal 
incision,  and  then  the  adnexa  maybe  examined.  Next 
the  round  ligaments  are  shortened  by  folding  them  on 
themselves,  and  are  held  in  this  position  by  a  few  cat- 
gut sutures.  In  a  sim;;'.e  case  of  this  description  the 
vaginal  incision  may  be  closed  with  catgut,  and  in  a 
few  weeks  after  the  operation  it  is  almost  impossible 
by  inspection  to  see  that  an  operation  has  been  per- 
formed. 

In  a  certain  number  of  cases  the  posterior  incision 
may  be  combined  with  anterior  colpotomy,  which  will 
very  greatly  facilitate  matters.  Very  recently  Stratz' 
has  described  an  operation  which  he  terms  lateral 
colpotomy  which  I  have  so  far  performed  on  two  oc- 
casions. It  is  very  true  that  the  lateral  incision  is  the 
shortest  through  which  to  reach  the  parametrium,  and 
in  certain  cases  I  believe  that  it  is  simpler,  quite  as 
easy,  and  less  dangerous  than  anterior  or  posterior 
colpotomy.  The  great  advantage  that  it  has  over  the 
two  latter  operations  is  that  the  peritoneum  is  avoided, 
and  as  to  wounding  the  uterine  artery,  or  the  ureter, 
the  mishap  is  easy  to  avoid.  To  perform  this  opera- 
tion properly,  two  long  lateral  retractors  are  placed,  one 
in  the  anterior  and  one  in  the  posterior  cul-de-sac;  the 
uterine  artery  is  then  recognized  by  its  pulsation,  and 
just  behind  it,  and  parallel  to  its  course  a  transverse 
incision  is  made  measuring  from  5  to  8  cm.  in  length, 
commencing  at  the  posterior  and  lateral  aspect  of  the 
cervix.  Through  this  incision  the  finger  can  easily 
attain   the   parametrium,  decorticate  it   in   its  entire 

'  For  further  details  see  Dr.  J.  Riddle  Goffe:  "  The  Enucleation 
of  Fibroids  by  Incision  of  the  Anterior  Vaginal  Wall."  Medi- 
cal Record,  February  17,  1900,  p.  304. 

''  Cuneiform  resection  of  the  uterus  for  retroflexion  or  ante- 
flexion, devised  by  Jonnesco.  of  Bucharest,  can  be  successfully 
performed  through  the  vagina.  If  the  flexion  is  anterior,  pos- 
terior colpotomy  should  be  done,  while  if  we  are  dealing  with  a 
retroflexion  anterior  colpotomy  must  be  selected.  If  the  uterus 
is  retroverted  as  well  as  retrofle.xed,  cuneiform  resection  should 
be  completed  by  a  Mackenrodt's  operation  or  by  intra-abdominal 
shortening  of  the  round  ligaments. 

See  also  an  interesting  paper  by  Dr.  G.  Ruggi,  "  Delia  isterec- 
tomia  cuneiforme  vaginale  eseguita  in  alcuni  special!  casi  di 
flessione  della  matrice,"  in  Archivio  Italiano  di  Ginecologia, 
Annoii  ,  No.  i. 

*H.  Stratz:  "  Kolpotomia lateralis."  Centralblatt  fiir  Gynak., 
No.  38,  1899. 


250 


MEDICAL    RECORD. 


[August  18,  1900 


height,  and  then  the  uterine  artery,  the  ureter,  and  the 
lesions  existing  in  the  adnexa  are  easily  recognized. 
By  the  use  of  long,  narrow  retractors  to  keep  the  oper- 
ative wound  well  open,  it  is  quite  possible  to  work 
under  the  control  of  the  eye,  and  the  lesions  may  be 
separated  from  their  adiiesions  and  the  whole  brought 
down  through  the  incision  into  the  vagina.  In  most 
cases  the  peritoneum  is  out  of  danger  because  it  es- 
capes in  front  of  the  finger,  and  consequently  it  is  not 
opened.  Hemorrhage  is  here  practically  nothing,  and 
the  vaginal  wound  is  so  dilatable  that  Stratz  affirms  a 
fibroid  measuring  from  12  to  15  cm.  in  diameter  can 
be  removed  through  the  opening. 

It  will  be  perhaps  not  out  of  place  here  to  mention 
Mackenrodt's  operation  for  retroversion  of  the  uterus, 
because  it  has  appeared  to  me  that  the  technique  has 
not  been  well  understood  by  a  number  of  surgeons. 
It  is  as  follows:  The  cervix  having  been  drawn  down 
by  two  stout  bullet  forceps,  a  third  one  is  then  placed 
at  about  the  middle  of  the  anterior  vaginal  wall,  which 
is  then  pulled  upon  so  as  to  raise  up  and  render  tense 
the  anterior  cul-de-sac.  It  is  then  incised  in  its  en- 
tire length  from  the  point  marked  by  the  forceps  in 
the  anterior  vaginal  wall  down  to  the  cervix;  at  this 
point,  a  second  incision  is  made  transversely  and  thus 
two  triangular  flaps  are  formed  that  are  dissected  off 
and  pushed  back  on  each  side.  The  bladder  is  then 
peeled  back  and  held  out  of  the  way  by  a  retractor, 
and  a  transverse  incision  is  made  in  the  peritoneal 
cul-de-sac. 

Through  this  incision  a  pair  of  bullet  forceps  is  in- 
troduced, guided  by  the  index  finger  of  the  other  hand, 
and  the  anterior  wall  of  the  uterus  is  seized  at  about 
1^4  or  2  cm.  above  the  level  of  the  internal  orifice; 
a  second  pair  of  forceps  seizes  and  pulls  up  the  vesi- 
cal flap  of  the  peritoneal  cul-de-sac.  We  now  remove 
the  bullet  forceps  which  raises  the  cervix,  and  by  the 
aid  of  the  finger  the  latter  is  pushed  backward,  while 
with  the  bullet  forceps  placed  on  the  corpus  uteri  the 
fundus  is  gently  drawn  forward  and  downward. 

It  should  be  understood  that  the  finger  which  ex- 
plores the  pelvic  excavation  has  already  recognized 
and  broken  down,  as  much  as  possible,  any  adhesions 
which  may  bind  down  the  adnexa.  When  the  uterus 
has  been  brought  forward,  the  forceps  which  holds  the 
peritoneal  flap  which  is  adherent  to  the  bladder  pulls 
this  flap  against  the  anterior  wall  of  the  corpus  uteri, 
exactly  above  the  point  where  the  forceps  which 
brought  the  uterus  forward  has  been  placed.  The 
flap  is  next  sutured  to  the  wall  of  the  uterus  by  a  sin- 
gle catgut  suture.  The  peritoneal  cul-de-sac  is  thus 
closed  and  at  the  same  time  is  brought  about  2  cm. 
higher  than  normal,  and  it  thus  results  that  below 
it  is  left  bare  about  i  J2  cm.  of  the  anterior  wall  of 
the  uterus,  and  it  is  on  this  very  part  that  the  bullet 
forceps  which  aided  in  bringing  the  uterus  forward 
was  placed.  A  large  catgut  suture  is  next  passed  into 
the  parenchyma  of  the  anterior  wall  of  the  uterus  just 
underneath  the  last-mentioned  pair  of  forceps,  and  the 
two  ends  are  tied,  and  only  at  this  point  should  the 
bullet  forceps  be  removed  and  then  be  placed  on  the 
anterior  lip  of  the  cervix,  which  is  again  drawn  down. 

Next,  the  transverse  incision  of  the  vaginal  cul-de- 
sac  is  closed  by  sutures  beginning  at  the  middle  and 
going  to  the  ends.  There  now  only  remains  the  lon- 
gitudinal incision,  whose  upper  angle  allows  the  long 
catgut  suture,  which  has  been  passed  into  the  anterior 
wall  of  the  uterus,  to  pass  out  through  it.  Each  one 
of  the  ends  of  this  suture  is  now  threaded  on  a  needle 
which  is  made  to  pass  through  a  corresponding  border 
of  the  longitudinal  vaginal  incision  near  its  upper 
angle,  sometimes  also  a  little  lower  according  to  the 
length  of  the  cervix.  Before  the  two  ends  arc  tied,  the 
vaginal  incision  should  be  carefully  brought  together 
by   interrupted  sutures,  and   it   is  only  after  this  has 


been  done  that  the  uterus  is  held  in  position  by  tightly 
tying  the  catgut  suture  which  goes  through  both  ante- 
rior walls  of  the  two  organs.  The  operation  is  now 
finished,  and  all  that  is  necessary  is  to  pack  some 
iodoform  gauze  in  the  vaginal  cul-de-sac,  which  by 
pushing  the  cervix  backward  will  hold  the  corpus 
uteri  in  its  new  position  until  cicatrization  has  be- 
come complete. 

Vaginal  fixation  performed  according  to  this  tech- 
nique usually  gives  satisfactory  results.  The  pelvic 
organs  retain  their  normal  situation,  and  are  in  no  way 
adherent  to  the  pelvis  or  to  the  abdominal  walls.  The 
uterus  is  in  good  anteversion  and  perfectly  normal ;  the 
corpus  and  fundus  are  absolutely  free  in  the  abdomi- 
nal cavity,  having  their  normal  relations  with  the  other 
viscera,  and  the  bladder  is  only  slightly  pushed  up- 
ward. The  author  of  this  method  claims  that  the  or- 
gan is  so  solidly  held  in  place  that  neither  labor  nor 
pregnancy  can  in  any  way  modify  its  position.  Why 
I  have  described  vaginal  fixation  of  the  uterus  is, 
because  in  many  instances  along  with  the  deviation  of 
the  organ  will  be  found  lesions  of  the  adnexa  which 
can  be  easily  removed  by  the  incision  necessary  for 
the  correction  of  the  position  of  the  uterus.  Gener- 
ally speaking,  however,  the  diseased  tube  or  ovary  has 
a  tendency  to  prolapse  into  the  posterior  cul-de-sac, 
and  consequently  posterior  colpocceliotomy  will  be 
the  proper  operation  to  select,  because  the  adnexa  are 
most  readily  reached  in  this  way. 

When  a  patient  presents  symptoms  indicating  the 
presence  of  some  lesion  of  the  adnexa  which  requires 
a  radical  operation,  we  should  consider  which  is  the 
better  route  for  the  given  case,  and  in  order  to  deter- 
mine this  point  as  correct  a  diagnosis  as  possible 
must  be  made.  The  difficulty  is  always  to  distin- 
guish the  predominating  symptomatic  elements,  and 
to  discover  their  pathogenesis  so  as  to  attack  the  cause 
directly.  W'hen  once  this  has  been  determined,  we 
may  then  resort  to  etiological  therapeutics,  which  are 
the  only  ones  that  can  have  any  pretension  of  being 
radical.  In  order  to  obtain  this  end,  the  personal 
and  hereditary  antecedents  of  the  patient  should  be 
gone  over,  and  all  the  viscera  should  be  carefully 
examined.  The  genital  organs  should  be  the  object 
of  our  special  attention,  and  all  the  means  of  diagno- 
sis which  are  used  should  be  employed,  such  as  digital 
examination  of  both  rectum  and  vagina,  bimanual  pal- 
pation, percussion,  and  auscultation. 

When  it  is  necessary  to  distinguish  a  uterine  or  a 
peri-uterine  tumor,  a  differential  diagnosis  with  all 
those  diseases  which  may  possibly  arise  in  the  female 
pelvis  should  be  considered,  and  a  correct  diagnosis 
will  thus  be  arrived  at,  and  this  is  absolutely  nec- 
essary in  order  to  avoid  any  error  in  diagnosis.  If 
these  precautions  are  not  taken,  an  incarceration  of  a 
pregnant  uterus  may  be  mistaken  for  a  fibroid,  or  a  re- 
troflexion may  be  diagnosed  as  some  tumefaction  lo- 
cated in  the  posterior  cul-de-sac.  In  many  instances, 
especially  when  the  patient  is  very  fleshy,  it  is 
absolutely  necessary  to  employ  general  anresthesia, 
and  this  should  always  be  resorted  to  when  any  doubt 
exists  as  to  the  exact  condition  of  affairs  in  the  pelvis. 

When  the  nature  of  the  disease  in  the  pelvis  has 
been  well  established,  as  well  as  the  necessity  of  do- 
ing something  for  its  relief,  we  should  consider 
whether  or  not  the  case  is  one  for  operation.  If  the 
patient  is  very  weak,  and  unless  the  condition  re- 
quires an  urgent  operation,  the  intervention  should  be 
delayed.  During  an  attack  of  pelvic  peritonitis,  we 
should  not  try  to  remove  an  adherent  organ;  a  pto- 
lapsed  ovary,  no  matter  how  painful,  should  never  be 
removed  during  pregnancy,  but  on  the  contrary,  if  we 
are  dealing  with  a  pregnancy  complicated  by  a  fibroid 
tumor  of  the  uterus,  the  neoplasm  should  always  be 
removed  by  either  the  abdominal  or  vaginal  route,  and 


August  1 8,  1900] 


MEDICAL    RECORD. 


251 


the  choice  of  the  operation  will  be  settled  by  its  posi- 
tion, size,  etc.  Generally  speaking,  every  tumor 
which  is  larger  than  a  good-sized  apple,  or  which  can- 
not be  reduced  to  this  dimension,  should  be  removed 
by  abdominal  incision,  but  when  it  is  below  this  size 
the  vaginal  route  is  the  one  which,  in  my  opinion,  is 
the  best  to  select. 

For  the  removal  of  the  adnexa  through  the  vaginal 
incision,  they  must  be  movable,  or,  if  adherent,  to 
only  such  an  extent  that  they  will  not  be  prevented 
from  being  drawn  down  into  the  incision.  If,  on  the 
contrary,  they  are  immobilized  by  adhesions,  and  are 
situated  high  up  beyond  the  reach  of  the  finger  intro- 
duced into  the  vagina,  they  would  better  be  removed 
by  abdominal  section.  When  the  adne.xa  are  adherent 
to  the  uterus  alone,  the  uterus  itself  must  be  movable 
so  that  it  can  be  drawn  well  down  in  order  to  make 
them  removable  by  posterior  colpotomy.  But  when 
these  conditions  are  not  present,  either  anterior  or  lat- 
eral colpotomy  is  to  be  selected.  In  order  to  determine 
the  exact  condition  of  affairs  in  cases  of  adherent 
adnexa,  examination  under  ether  is  usually  necessary. 

I  would  here  like  briefly  to  consider  those  cases 
in  which  removal  of  adnexa  through  the  vagina  is  in- 
dicated. A  painful,  prolapsed,  and  sclerocystic  ovary 
is  one  of  the  most  frequent  conditions,  and  is  recog- 
nized by  the  very  sharp  pain  produced  by  vaginal  pal- 
pation; these  ovaries  may  be  so  movable  that  they  can 
be  pushed  around  in  the  posterior  cul-de-sac,  and  will 
slip  away  from  the  fingers  like  marbles.  Another  con- 
dition in  which  the  posterior  vaginal  incision  is  indi- 
cated is  in  certain  cases  of  suppurating  or  parenchyma- 
tous ovaritis.  This  also  applies  to  small  fibromas  of 
the  ovary  which  are  characterized  by  their  slow  de- 
velopment, their  usually  small  size,  and  non-malig- 
nant character.  We  can  also  open  and  drain  cysts  of 
the  broad  ligament,  and  partially  extirpate  them. 

Diseases  of  the  tubes  may  also  be  treated  through  the 
posterior  vaginal  incision,  although  their  differential 
diagnosis  is  far  from  being  easy  in  a  large  number  of 
cases,  and,  in  the  absence  of  exact  diagnosis,  the  gravity 
of  the  symptoms  and  the  general  condition  of  the  pa- 
tient should  be  our  guide.  There  are  many  cases  of 
catarrhal  salpingitis  in  which  pain  is  very  severe,  and 
which  resist  every  kind  of  treatment  employed,  but  in 
which  an  abdominal  section  is  considered  a  pretty 
severe  operation,  in  view  of  the  slight  importance  of 
the  lesion  ;  posterior  colpotomy  may  here  be  employed 
to  advantage.  Hydrosalpinx,  hematosalpinx,  and 
chronic  hypertrophic  parenchymatous  salpingitis  are 
easier  to  enucleate  than  a  pyosalpinx.  This  latter 
lesion  is  so  often  accompanied  by  very  tough  and  thick 
adhesions  connecting  the  tube  with  the  surrounding  or- 
gans that  inmost  instances  the  suprapubic  route  should 
be  preferred.  If,  however,  the  tube  forms  a  purulent 
pocket,  it  may  be  opened  through  a  posterior  vaginal 
incision  and  drained,  a  treatment  which  in  many  cases 
results  in  a  complete  recovery,  usually  a  permanent 
one,  especially  when  the  lesion  is  unilateral. 

To  sum  up  the  lesions  which  may  be  removed 
through  the  posterior  vaginal  incision,  I  would  say 
that  we  have:  (1)  inflammatory  affections  of  the  ad- 
nexa with  prolapsus  in  the  cul-de-sac  of  Douglas;  (2) 
cysts  of  the  adnexa  of  small  dimensions;  (3)  neo- 
plasms situated  high  up  in  the  pelvis,  but  which  are 
movable  and  can  be  drawn  down;  (4)  large  cystic 
tumors,  provided  that  they  are  not  adherent  and  that 
by  digital  examination  through  the  vagina  the  finger 
can  easily  reach  the  lower  pole  of  the  neoplasm;  (5) 
solid  neoplasms  of  the  recto-uterine  cul-de-sac  w^hich 
do  not  exceed  the  breadth  of  the  posterior  vaginal  cul- 
de-sac;   (6)   extra-uterine  pregnancy. 

Vaginal  salpingectomy  is  indicated  in  that  condi- 
tion known  as  encysted  salpingitis.  In  this  variety 
the  adnexa,  whether  cystic  or  not,  are  contained   in  a 


secondary  cyst  which  is  formed  of  the  remains  of  a 
former  pelvic  peritonitis.  They  are  either  bound 
down  or  are  floating  in  a  pocket  which  contains  a  se- 
rous, seropurulenl,  or  purulent  liquid,  as  the  case  may 
be.  The  upper  wall  of  the  secondary  cyst  has,  as  a 
characteristic,  its  being  always  made  up  of  loops  of 
intestine  solidly  agglutinated.  The  other  walls  are 
variable  in  structure.  If  the  adnexa  are  in  Douglas' 
pouch,  the  walls  of  this  depression  and  the  utero-sa- 
cral  ligaments  compose  them.  If  they  are  in  the  retro- 
ovarian  fossa,  the  anterior  wall  of  the  pocket  is  made 
up  of  the  broad  ligament,  while  the  external  and  pos- 
terior walls  become  intermingled  wilh  the  structures 
of  the  side  of  the  pelvis,  the  internal  wall  having  for 
substratum  the  utero-lumbar  and  the  utero-sacral  liga- 
ments. The  cyst  formation  may  also  take  place  in 
front  of  the  broad  ligament  in  the  paravesical  fossa; 
but  no  matter  what  variety  of  cystic  formation  of  this 
type  we  may  be  dealing  with,  its  vault  is  always  the 
same,  that  is,  composed  of  an  agglomeration  "of  ag- 
glutinated coils  of  intestine. 

Encysted  salpingitis  is  usually  better  dealt  with  by 
posterior  colpotomy  than  by  any  other  method,  and 
most  of  it  can  be  removed  through  the  incision,  and 
what  is  left  will  be  eliminated  by  drainage. 

I  believe  that  retro-uterine  hematocele  can  be 
best  treated  by  the  vaginal  route,  provided  that  all 
symptoms  of  hemorrhage  have  ceased,  and  that  the  col- 
lection of  blood  has  become  encysted,  but  I  will  not 
insist  further  on  this  point,  as  it  has  been  discussed 
in  my  paper  already  alluded  to.  The  treatment  of 
tuberculous  peritonitis  by  posterior  colpotomy  as  re- 
commended by  Lohlein  does  not  appear  to  me  to  pre- 
sent the  advantages  possessed  by  abdominal  section. 

Generally  speaking,  posterior  colpotomy  is  contra- 
indicated  in  those  cases  which  do  not  present  any  of 
the  conditions  already  mentioned,  and  the  knowledge 
of  the  indication  will  be  sufficient  to  determine 
whether  the  vaginal  route  is  the  proper  one  to  select 
or  not.  The  contraindication  may  be  due  to  the  gen- 
eral condition  or  the  local  condition.  An  extreme 
debility,  an  acute  disease,  or  pregnancy  would  nat- 
urally lead  us  to  defer  the  operation  excepting  when 
the  case  is  one  of  emergency. 

The  contraindications  given  by  the  local  condition 
are  far  more  numerous  and  important.  To  operate 
for  the  removal  of  an  ovary  during  an  acute  attack  of 
pelvic  peritonitis  would  naturally  be  a  very  serious 
mistake,  excepting  in  those  cases  in  which  the  inflam- 
mation of  the  tube  is  due  to  direct  infection  from  an 
adherent  appendix  which  is  acutely  inflamed,  but  in 
these  cases  the  usual  incision  for  appendicitis  on  the 
right  side  of  the  abdomen  is  the  proper  one  to  select. 
If  a  cystic  purulent  salpingitis  which  is  adherent  to 
the  wall  of  the  vagina,  and  filling  out  the  cul-de-sac, 
is  present,  it  is  not  the  removal  of  this  condition  that 
should  be  undertaken,  but  a  simple  incision  followed 
by  drainage  is  all  that  is  necessary,  and  to  attempt 
anything  else  would  be  both  difficult  and  dangerous. 
In  other  cases  in  which  the  lesions  of  tiie  adnexa  are 
extensive  and  situated  on  both  sides,  the  adhesions  set 
up  by  a  chronic  pelvic  peritonitis  are  very  numerous. 
There  are  in  this  case  a  perimetro-salpingitis  and  a 
cellulitis,  and  consequently  we  should  remove  every- 
thing which  binds  up  these  collections;  in  other  words, 
a  total  vaginal  hysterectomy  should  be  done.  Except- 
ing in  the  case  of  encysted  salpingitis,  abdominal  in- 
cision should  be  preferred  on  account  of  the  intestinal 
adhesions,  because  when  we  try  to  break  them  down 
the  intestine  may  be  torn,  and  this  mishap  is  very 
difficult,  if  not  to  say  impossible,  to  repair  through  the 
vaginal  incision. 

It  is  very  true  that  a  diagnosis  of  the  presence  of 
intestinal  adhesions  is  difficult  to  make,  but  there 
are  certain  signs  which  will  at  least  lead  us  to  sus- 


252 


MEDICAL    RECORD. 


[August  1 8,  I  goo 


pect  their  presence.  Disturbances  in  defecation  and 
digestion,  intestinal  dyspepsia,  colics,  chronic  intes- 
tinal occlusion,  or  the  presence  of  gas  felt  when  a 
certain  point  of  the  tumor  is  palpated,  are  all  symp- 
tomatic of  intestinal  adliesions,  but  in  spite  of  all  these 
symptoms  they  are  oftentimes  not  suspected.  Conse- 
quently if,  after  having  opened  the  posterior  cul-de- 
sac,  this  condition  of  afifairs  is  found,  the  surgeon 
should  proceed  with  caution,  and  if  he  is  well  trained 
in  abdominal  surgery  his  finger  will  readily  ascertain 
how  far  the  operation  may  be  carried.  If  the  tumor 
is  tightly  bound  down,  and  abdominal  incision  cannot 
accomplish  more  than  the  vaginal  route,  the  posterior 
cul-de-sac  should  be  opened  and  the  tumor  incised  and 
drained. 

To  sum  up,  it  may  be  said  that  extensive  adhesions 
are  a  contraindication  to  the  removal  of  these  patho- 
logical conditions  even  by  the  abdominal  route,  but 
unfortunately  in  many  instances  we  are  not  aware  of 
the  condition  until  the  parts  are  explored  by  the  fin- 
ger. A  very  high  position  of  the  adne.xa  in  the  pel- 
vis, and  more  especially  the  impossibility  of  bringing 
them  down  low  enough  to  be  within  reach,  are  abso- 
lute contraindications  for  posterior  colpotomy,  and  the 
abdominal  route  should  then  be  selected.  A  high 
position  of  the  uterus,  in  which  it  cannot  be  drawn  down 
without  difliculty,  enters  into  the  same  class.  If  the 
adnexa  are  adherent  in  the  paravesical  fossa,  anterior 
colpotomy  is  the  operation  to  select;  and  the  last  con- 
traindication to  which  I  would  call  attention  is  a 
malformation  of  or  a  very  tight  vagina. 

The  technique  of  the  operation  I  have  discussed 
very  fully  in  the  paper  already  alluded  to,  so  I  will 
not  refer  to  it  here.  Suffice  it  to  say  that  the  patient 
is  placed  in  the  lithotomy  position  with  the  thighs 
well  flexed  on  the  abdominal  wall.  I  always  use  an 
exaggerated  Trendelenburg's  position  in  these  cases, 
and  for  this  purpose  there  is  no  table  equal  to  that 
devised  by  Pryor  of  New  York.  The  use  of  ligatures 
or  of  clamps  will  depend  entirely  upon  the  preference 
of  the  operator,  but  personally  I  prefer  the  latter  in 
many  cases.  I  have  never  seen  any  advantage  in  clos- 
ing the  vaginal  incision  with  sutures  after  the  removal 
of  non-suppurating  lesions,  and  rather  prefer  to  insert 
a  wick  of  gauze  which  is  removed  in  three  or  four  days, 
and  within  a  week  or  ten  days  from  the  time  of  the 
operation  the  incision  will  be  found  to  have  completely 
closed. 

871  Beacon  Street. 


H^MATOMYELIA,    WITH    REPORT   OF 
THREE    CASES.' 

Bv    W,    F.    BECKER,    M.D., 

MILWAUKEE,    WIS,, 
CONSL'LTINC.   NEUKOLOCIST,   MILWAUKEE  COUNTY   HOSPITAL. 

Spinal  hemorrhage,  even  excluding  that  incidental  to 
vertebral  traumatism,  is,  perhaps,  not  so  uncommon 
as  is  generally  supposed,  the  opinion  expressed  only 
about  twenty-five  years  ago  being  that  it  did  not  exist 
in  its  primary  non-traumatic  form.  Mild  cases  im- 
prove and  do  not  come  to  autopsy,  others  no  doubt  are 
masked  under  the  diagnosis  of  spinal  meningitis  or 
myelitis.  Compared,  however,  to  cerebral  hemorrhage, 
it  is  of  course  quite  rare.  This  is  owing,  no  doubt, 
to  the  longer  and  more  tortuous  course  of  the  spina! 
blood-vessels,  their  smaller  size,  and  the  less  frequent 
changes  in  the  blood  pressure  therein.  Thus  we  find 
no  miliary  aneurisms  in  the  cord,  which  in  the  brain 
are  the  forerunners  of  liemorrhage. 

The  text-book  distinction  of  hi:matomyelia  or  has- 
matorrhachis,  according  as  the  bleeding  is  in  the  cord 

'  Read    before   the   Milwaukee    Medical    Society,    December 
12,  1899. 


or  membranes,  seems  to  be  more  anatomical  than 
clinical.  Though  it  has  some  theoretical  justification 
in  the  blood  supply,  it  is  certainly  not  entitled  to  the 
same  weight  as  the  same  distinction  in  cranial  hemor- 
rhage. While  the  existence  of  pain  points  to  the 
membranous  form  it  is  not  a  reliable  discriminator, 
as  will  be  seen  in  one  of  the  cases  here  reported. 
Bleeding  in  the  cord  is  more  apt  to  take  place  in  the 
gray  matter,  where  the  vessels  are  more  numerous,  have 
less  support,  and  are  probably  subjected  to  more 
changes  in  lumen  than  in  the  white  matter. 

The  causes  of  spinal  hemorrhage  of  the  primary 
kind,  with  which  only  we  are  here  concerned,  are  ob- 
scure. Anamia  in  its  protean  forms  has  been  asso- 
ciated with  many  cases;  so  also  severe  exertion  of  the 
muscles  of  the  back,  as  in  a  case  that  took  place  dur- 
ing excessive  coitus,  and  in  one  here  reported  in  which 
the  patient  was  engaged  in  the  prolonged  use  of  the 
sewing-machine  at  the  time.  In  both  of  these  the 
lesion  was  in  the  portion  of  the  cord  innervating  the 
muscles  engaged  (lumbar  enlargement),  which  may 
have  some  bearing  on  the  matter.  Such  possible 
bearing  is  not  to  be  identified  with  the  instances  in 
which  general  convulsive  seizures  produce  the  com- 
monly found  punctate  hemorrhages.  These  are  more 
properly  classified  as  traumatic,  and  are  often  in  pro- 
portion to  the  violence  of  the  spasm. 

The  symptoms  of  spinal  hemorrhage  are  attributable 
to  varying  degrees  of  interference  with  the  motor,  sen- 
sory, trophic,  and  reflex  functions  of  the  particular 
spinal  segments  afifected.  P^ach  segment  of  the  cord, 
it  will  be  recalled,  is  not  only  engaged  in  conducting 
motor  and  sensory  impressions  to  and  from  parts  be- 
low it,  but  by  virtue  of  its  gray  matter  and  anterior 
and  posterior  nerve  roots  innervates  a  given  muscular 
area,  presides  over  its  nutrition,  and  receives  sensory 
impressions  of  a  given  cutaneous  area,  and  looks  after 
the  trophic,  reflex,  and  vasomotor  functions  of  the 
same.  Each  of  these  segments  contains  groups  of 
cells  which  preside  over  certain  "movements'"  rather 
than  muscles,  thus  differing  from  the  distribution  of 
peripheral  nerves,  which  often  supply  adjacent  muscles 
which  may  have  opposite  actions.  These  groups  of 
cells,  which  often  overlap,  rarely  occupy  only  a  single 
segment,  and  usually  extend  through  several,  so-  that 
certain  muscles,  probably  according  to  their  various 
actions,  and  also  to  their  size,  receive  their  innerva- 
tion from  a  varying  number  of  segments.  Thus  the 
biceps,  which  is  a  supinator  as  well  as  a  flexor,  indeed 
first  a  supinator,  as  one  may  easily  prove  byfaradizing 
it,  has  three  segments.  The  supinator  longus,  which 
is  a  flexor  as  well  as  a  supinator,  and  perhaps  more  of 
a  flexor,  has  its  group  of  innervating  cells  extending 
through  two. 

I  shall  not  speak  of  spinal  localization  except  to 
say  that  I  have  found  it  useful  to  picture  the  body  in 
the  quadruped  position,  when  it  will  be  found  that 
there  is  a  fairly  regular  correspondence  between  the 
segments  and  the  muscles  supplied  by  them  from 
before  backward.  Thus  the  deltoid  and  biceps  are 
supplied  before  the  teres  major  and  triceps,  which 
are  more  posterior  in  this  position;  the  radial  side  of 
the  arm  sooner  than  the  ulnar  side;  the  psoas-iliacus 
sooner,  i.e.,  from  a  higher  segment,  than  the  quadriceps 
extensor,  and  this  in  turn,  lying  more  anterior  than 
the  hamstrings,  is  supplied  by  a  higher  segment.  The 
perineal  muscles  being  most  caudal  in  this  position 
are  supplied  by  the  lowest  segments.  The  same  gen- 
eral sequence  will  be  found  to  prevail  even  more  per- 
fectly in  regard  to  the  sensory  distribution.  Thus 
a  lesion  in  the  lowest  segment  ]5roduccs  anresthesia  at 
the  very  caudal  extremity;  a  little  higher  and  the  pos- 
terior part  of  the  thighs  and  legs  are  afifected,  and  so 
on.  I  have  also  found  it  convenient  for  localization 
to  single  out  only  the  chief  muscles,  those  whose  con- 


August  1 8,  1900] 


MEDICAL    RECORD. 


253 


dition  is  easily  determined  as  affected  either  by  par- 
alysis or  atrophy,  or  in  response  to  electrical  stimula- 
tion, and  to  make  a  diagram  on  such  a  basis.  Such  a 
treatment,  however,  of  a  complicated  subject,  which  is 
largely  yet  a  terra  incognita,  may  be  regarded  as  only 
roughly  convenient,  and  must  not  be  used  to  the  sac- 
rifice of  accuracy  or  to  a  more  detailed  study  in  par- 
ticular cases. 

In  determining  the  exact  point  corresponding  to  the 
affected  segment  I  may  be  e.xcused  for  recalling  two 
important  things:  First,  that  a  given  segment  lies 
higher  than  its  corresponding  vertebra.  This  rela- 
tively higher  position  of  the  segment  to  its  vertebra 
increases  as  we  go  down  the  cord,  and  so  the  nerves 
as  they  emerge  from  each  segment  to  reach  the  inter- 
vertebral foramina  of  the  corresponding  vertebra  have 
an  increasingly  longer  intra-medullary  course  as  we 
go  down,  and,  the  cord  ending  at  the  first  lumbar,  all 
nerves  destined  for  intravertebral  foramina  below  this 
(lumbar,  sacral,  and  coccygeal)  must  leave  the  cord  at 
this  point.  Secondly,  we  must  remember  that  the 
spinous  processes  of  the  vertebra,  which  are  our  only 
guide  to  their  localization,  do  not  always  lie  opposite 
their  bodies.  This  is  distinctly  true  in  the  dorsal 
region,  where  from  about  the  second  to  the  eleventh 
the  spinous  processes  project  markedly  downward  so 
as  to  lie  over  the  body  of  the  vertebra  next  below  and 
even  lower.  To  illustrate  these  points,  a  horizontal 
line  passing  in  from  the  seventh  dorsal  spine  w-ould 
pass  through  the  lower  part  of  the  eighth  dorsal  body 
and  go  through  the  ninth  dorsal  segment.  Or,  putting 
it  contrariwise,  the  ninth  dorsal  segment  lies  opposite 
the  body  of  the  eighth  dorsal  vertebra,  which  lies  op- 
posite the  spinous  process  of  the  seventh. 

In  regard  to  localization  in  the  cervical  region  it 
should  be  remembered  that  the  first  vertebra  has  no 
spinous  process,  that  the  spinous  process  of  the  second 
is  very  large  and  distinct,  and  that  in  the  third,  fourth, 
and  fifth  the  spines  are  sometimes  absent  and  are 
generally  bifurcated,  which  makes  it  difficult  to  dis- 
tinguish them;  the  sixth  is  also  inconspicuous,  and 
the  vertebra  prominens,  instead  of  being  the  seventh 
cervical,  is  generally  the  first  dorsal. 

The  least  equivocal  picture  of  spinal  hemorrhage  is 
the  sudden  onset  of  paralysis  and  ana;sthesia  without 
loss  of  consciousness,  the  paralysis  reaching  its  maxi- 
mum intensity  in  a  short  time,  then  receding  early 
to  a  greater  or  less  extent  pari  passu  with  relief  of 
pressure  by  shrinkage  of  clot  or  subsidence  of  shock 
(the  continuance  of  improvement  depending,  of  course, 
upon  the  destructive  or  compressive  nature  of  the 
lesion)  ;  the  presence  of  pain  or  other  sensation  in  the 
back;  the  disturbance  of  the  bladder  and  rectum;  the 
flaccid  nature  of  the  paralysis  of  the  muscles  inner- 
vated by  the  affected  segments,  with  a  loss  of  their 
deep  reflex  activity  and  a  quantitative  change  to  fara- 
dism  and  galvanism,  and  later  qualitative  changes  to 
galvanism  with  R.  D.  and  atrophy;  and  the  spastic  na- 
ture of  the  muscles  below  the  affected  segment,  owing 
to  injury  of  the  conduction  paths,  with  an  increase  of 
their  deep  reflexes  and  absence  of  electric  changes; 
the  girdle  sensation  with  an  area  of  hyperaesthesia  at 
about  the  level  of  the  affected  segment;  the  absence 
of  the  superficial  reflex  of  the  segment  involved, 
though  its  presence  is  a  better  sign  of  the  integrity  of 
the  segment  than  its  absence  is  an  indication  of  the 
involvement  thereof. 

While  such  might  be  a  clinical  picture  of  a  trans- 
verse lesion  produced  by  a  large  hemorrhage,  a  smaller 
hemorrhage,  by  virtue  of  its  predilection  for  the  gray 
matter,  is  apt  to  produce  a  symptom  complex  which 
has  come  to  have  almost  pathognomonic  significance, 
namely,  a  dissociated  anaesthesia,  i.e.,  a  loss  of  tem- 
perature and  pain  sense  with  a  retention  of  the  tactile 
sense.     Through  the  study  of  syringomyelia  and  other 


means,  we  have  come  to  locate  the  conduction  paths 
of  pain  and  temperature  in  the  gray  columns,  while 
the  tactile-sense  paths  are  in  the  posterior  white 
columns.  A  smaller  lesion,  therefore,  is  thus  apt  to 
affect  only  the  pain  and  temperature  sense  of  the  gray 
matter,  leaving  undisturbed  the  tactile  sense,  and  this 
has  been  observed  to  be  so  clinically  corroborated  in 
a  number  of  cases  as  to  make  it  a  very  characteristic 
symptom  of  ha;matomyelia. 

As  in  other'  nervous  disea.ses,  however,  aberrant 
forms  are  perhaps  more  common  than  the  typical. 
Much  in  diagnosis  depends  upon  the  reliability  of  the 
symptoms  gathered,  the  returns  of  examinations  often 
being  ambiguous.  It  is  usually  more  difficult  to 
gather  exact  data,  making  due  allowance  for  sub- 
normal variations,  than  to  interpret  the  same.  Young 
and  lean  persons  furnish  the  least  equivocal  data,  the 
young  because  of  the  greater  reliability  of  the  sensory 
and  reflex  functions,  the  lean  because  of  the  easier 
reading  of  the  musculature. 

Antecedent  cord  disease  in  which  hemorrhage  may 
be  incidental  should  always  be  suspected  in  a  case 
supposed  from  its  sudden  on.set  to  be  spinal  hemor- 
rhage. Even  post  mortem  it  may  be  difficult  to  know 
whether  a  hemorrhage  was  primary  to  the  softening  of 
contiguous  myelin  or  secondary  to  a  myelitis.  On 
the  other  hand  various  paresthesia;,  which  may  be  brief 
forerunners  of  hemorrhage,  must  not  be  construed  as 
indicating  antecedent  cord  disease.  Gliomata,  too, 
may  bleed  in  the  cord,  as  thej'  commonly  do  in  the 
brain.  Their  softness  and  imperfect  differentiation 
from  adjacent  nerve  tissue  make  it  possible  for  them 
to  exist  without  decided  symptoms,  though  for  mechan- 
ical reasons  this  is  less  true  in  the  cord  than  the  brain, 
where  I  have  found  extensive  gliomatosis  of  the  right 
hemisphere  without  any  brain  symptoms  whatever. 
Pott's  disease,  also,  may  pre-exist  (though  not  so 
likely  to  be  unsuspected),  and  symptoms  caused  by 
the  pressure  of  broken-down  tissue  may  come  on  sud- 
denly enough  to  simulate  hemorrhage. 

Spinal  hemorrhage  is  not  so  easily  confusable  with 
cerebral  hemorrhage,  though  they  have  in  common  the 
sudden  onset  of  paralysis.  Those  cases,  however,  in 
which  the  apoplectic  insult  in  the  cord  is  accompanied 
by  reeling  or  faintness  due  to  shock,  may  easily  be 
mistaken  for  that  form  of  cerebral  hemorrhage  in 
w^hich,  because  of  the  position  or  severity  of  the  lesion, 
consciousness  is  but  little  disturbed,  especially  were 
the  paralysis  more  hemi-  or  monoplegic  than  para- 
plegic. 

More  confusable,  perhaps,  are  cases  of  multiple 
neuritis,  in  which  atrophy  and  electrical  changes  may 
be  the  same,  as  well  as  motor  and  sensory  disturbance 
and  a  fairly  sudden  onset.  The  absence  of  bladder 
and  rectal  disturbance,  the  very  characteristic  pain 
along  affected  nerves  and  muscles,  the  probably 
irregular  distribution  of  the  paralysis  and  anaesthesia, 
particularly  the  latter,  the  p.seudo-tabetic  symptoms 
arising  from  the  disturbances  of  muscular  sense,  as- 
sociated with  pain,  and  the  absence  of  girdle  sensation 
and  myostatic  irritability  of  muscles  below  the  lesion, 
and  the  absence  of  dissociated  anaesthesia,  favor 
neuritis  as  against  hemorrhage. 

Hysterical  or  functional  paralysis  of  the  spinal  type 
will  often  come  to  mind  in  explanation  of  the  symp- 
toms produced  by  spinal  hemorrhage.  Each  may  come 
on  in  anaemia,  and  with  considerable  suddenness  affect 
motion  and  sensation  with  flaccid  or  spastic  type  of 
paralysis.  In  discriminating  between  them  the  ab- 
sence of  hysterical  stigmata,  psychic  or  nervous,  must 
not  carry  too  much  negative  weight;  at  the  same  time 
it  is  an  easy  snare  when  symptoms  are  bizarre  and 
coupled  with  a  few  stigmata  to  lay  them  to  hysterical 
or  functional  causes  and  give  a  good  prognosis. 
While   globus,    tremor,   spasm,    deep   hemianalgesia, 


254 


MEDICAL    RECORD. 


[August  1 8,  1900 


sentimentality,  suggestibility,  and  want  of  inhibition 
have  due  weight,  we  are  more  and  more  learning,  as 
Seguin  pointed  out  years  ago,  that  organic  disease 
and  hysteria  often  coexist,  the  gross  lesion  provoking 
latent  hysieroid  symptoms  in  a  potential  hysteric.  In 
discriminating,  the  irregular,  bizarre  nature  of  the 
symptoms  which  cannot  easily  be  explained  by  a  focal 
lesion;  the  fact  that  the  paralysis  often  affects  "com- 
bined "  movements  rather  than  individual  muscles, 
producing  a  disability  of  walking  rather  than  of  mov- 
ing the  leg  muscles,  or  of  writing  rather  than  paralysis 
of  individual  arm  muscles;  the  fact  that  a  mental 
strain,  notably  worry  and  fatigue,  has  preceded;  that 
convulsive  seizures  of  a  general  character  and  not  con- 
fined to  the  muscles  to  be  presently  paralyzed,  as  in 
organic  lesions,  have  occurred;  that  the  special  senses 
are  affected;  that  there  maybe  decided  fluctuations  in 
the  symptom  complex — all  of  thesemust  favor  hysteria. 
Many,  however,  may  be  absent,  and  the  diagnosis  not  be 
so  easy,  for  even  atrophy  of  muscles,  bedsores  (small) 
and  bladder  disturbances  are  not  necessarily  absent 
in  either  hysterical  or  functional  paralysis,  and  the 
generally  described  sudden  disappearance  of  hysterical 
paralysis  is  the  exception  rather  than  the  rule,  accord- 
ing to  men  of  large  experience,  Mitchell,  Bastian,  and 
Charcot. 

Case  I. — My  first  case  is  that  of  a  married  woman 
aged  thirty  years,  aneemic  and  "run  down,"  who,  while 
sewing  for  a  protracted  time  at  her  machine,  started 
to  walk  across  the  room,  when  she  felt  faint  and  sank 
to  the  floor.  Unable  to  rise,  though  still  able  to  move 
her  legs  slightly,  she  was  lifted  to  a  couch,  when  the 
paralysis  soon  become  complete.  Hot  water  was  then 
applied  to  her  legs,  which,  being  thermo-ana;sthetic, 
were  thereby  severely  scalded.  When  I  saw  the  pa- 
tient a  fortnight  later  there  was  complete  paraplegia; 
the  muscles  were  flaccid,  the  knee  jerks  absent;  blad- 
der and  rectum  were  affected,  the  voluntary  sphincteric 
control  being  lost  so  that  they  emptied  themselves 
without  central  authority.  Tactile  sense  was  but 
slightly  diminished  over  the  lower  extremities  including 
the  lower  abdominal  region,  but  pain  and  temperature 
sense  were  abolished  over  the  same  parts.  The  epi- 
gastric, abdominal,  and  plantar  reflexes  were  intact. 
The  deplorable  state  of  the  patient  was  magnified  by 
the  fact  that  she  was  now  in  the  fifth  month  of  preg- 
nancy. 

After  about  two  weeks  from  the  onset  it  was  noticed 
that  some  motion  had  returned  to  the  right  foot,  the 
patient  being  able  to  flex  the  toes  slightly.  This  was 
not  accompanied  with  any  improvement  in  sensation, 
or,  if  so,  it  was  so  slight  as  to  be  unreliable.  The 
bladder  and  rectum  continued  incontinent,  and  not- 
withstanding catheterization  the  residual  urine  soon 
developed  cystitis.  In  spite,  also,  of  attention  to  the 
trophic  condition  of  the  skin  a  small  bedsore  soon  ap- 
peared on  the  foot,  and  the  injury  sustained  by  the 
scalding  of  the  legs  did  not  heal.  No  particular  atro- 
phy of  the  muscles  developed. 

Symptoms  pointing  to  the  death  of  the  fcttus  led  to 
the  induction  of  labor,  though  the  child  was  found 
viable.  No  anasthetic  was  required  for  the  forcible 
dilatation  of  the  os,  which  was  entirely  painless,  nor 
was  there  any  pain  in  expulsion  of  the  foetus,  the 
uterine  contractions,  however,  being  firm  and  potent, 
and  no  bad  after-effects  followed  the  operation. 

The  patient  soon  become  worse ;  bedsores  developed 
which  could  not  be  checked,  and  one  of  great  size  over 
the  sacrum  produced  general  infection  which  rendered 
cutting  away  of  the  slough  necessary,  and  languishing 
in  this  way  she  died,  after  having  lived  about  six 
weeks  without  once  having  her  mind  obscured  to  her 
condition. 

The  position  of  the  spinal  hemorrhage  as  it  was 
inferred  to  be,  no  autopsy  having  been  granted,  was 


in  the  lumbar  enlargement  somewhere  between  the 
abdominal  reflex  arc  above  (eleventh  and  twelfth  dor- 
sal) and  the  plantar  reflex  arc  below  (first  sacral),  both 
of  which  were  intact.  The  involvement  of  the  knee- 
jerk  centre  (third  lumbar)  and  the  flaccid  nature  of 
all  the  paralyzed  muscles  place  the  lesion  in  the  lum- 
bar segments  and  probably  greatest  in  the  upper 
ones.  The  improvement  in  the  foot  and  the  escape 
of  the  direct  bladder  and  rectal  reflex  arc  (those  or- 
gans suffering  only  from  an  interference  with  volun- 
tary control  from  above  and  not  from  a  breach  in  their 
reflex  centre,  in  which  case  there  would  have  been 
paralysis  of  the  detrusor  with  retention,  or  of  the 
sphincter  with  constant  incontinence),  show  the  escape 
of  the  sacral  segments.  Though  the  lesion  was  prob- 
ably large  it  does  not  require  so  very  extensive  a 
lesion  to  affect  all  the  lumbar  segments,  as  these  seg- 
ments lie  quite  closely  superimposed  here.  That  the 
lesion  was  chiefly  in  the  gray  matter  is  apparent  by 
the  flaccid  nature  of  the  paralysis.  If  the  white  con- 
duction paths  were  involved,  and  they  are  compara- 
tively few  here  (the  sensory  ones  having  not  yet  been 
gathered  in  for  their  brainward  course,  and  those  des- 
tined for  muscles  having  been  largely  distributed 
above  this  point),  the  spasticity  accompanying  such 
involvement  of  the  lateral  tracts  may  have  been  coun- 
teracted by  the  greater  and  more  vertically  extensive 
anterior  cornual  lesion.  That  there  was  no  marked 
atrophy  under  these  circumstances  seems  anomalous, 
(the  greater  adipose  of  a  woman's  legs,  however,  easily 
conceals  lesser  degrees  of  muscular  atrophy).  Though 
the  separate  existence  of  motor  and  trophic  cells  in 
the  gray  matter  is  probable,  it  is  not  likely  that  the 
latter  would  escape  in  such  an  extensive  lesion  as  this, 
which  practically  destroyed  the  independent  function 
of  the  cord  in  several  segments  as  well  as  its  conduc- 
tive function,  allowing  nothing  but  a  small  degree  of 
tactile  sense  to  penetrate  upward.  That  the  lesion 
was  destructive  rather  than  compressive  is  shown  by 
the  little  or  no  improvement.  All  of  these  inferences 
must,  however,  go  unverified  by  post-mortem  diagnosis. 

The  behavior  of  the  uterus  is  of  interest  in  this 
case.  The  strong  contractions  seem  anomalous,  es- 
pecially in  the  absence  of  sensation  necessary  to 
awaken  the  reflex  function.  This  anesthesia,  however, 
was  probably  only  that  of  the  pain  sense,  which,  trans- 
mitted through  the  cord  by  way  of  the  sacral  segments, 
was  interrupted  by  the  lesion,  while  the  tactile  or 
other  sensation  in  the  uterus  necessary  to  excite  the 
reflex  arc  through  the  hypogastric  plexus  was  uninter- 
rupted and  requisite  to  engage  the  uterine  mechanism, 
the  probable  centre  for  which  Onuf  has  recently  shown 
to  be  in  the  so-called  vegetative  cell  column  of  the 
third  sacral  segment,  which  was  here  inviolate. 

As  possible  causative  agents  it  may  be  mentioned 
that  the  woman  Jiad  taken  many  doses  of  an  unknown 
oxytocic  to  effect  abortion ;  also  the  fact  that  there 
was  more  or  less  anx-mia  (though  no  blood  count  was 
made),  and  the  fact  of  the  prolonged  innervation  of 
the  lumbar  segments  in  the  protracted  use  of  the  sew- 
ing-machine. There  was  no  nephritic  or  alcoholic 
history,  thougii  a  syphilitic  one  could  not  be  entirely 
excluded. 

Case  II.— Mr.  P ,  aged  thirty-eight  years,  with 

alcoholic  and  syphilitic  history;  the  patient  is  ad- 
dicted to  absinthe.  Coming  home  one  night,  not  in- 
toxicated, he  reeled  and  partly  fell  down  a  step  or  two 
leading  to  the  basement  of  his  house.  He  was  helped 
to  a  chair  and  found  himself  unable  to  move  the  left 
arm  or  leg.  Soon  he  dropped  from  the  chair  to  the 
floor,  and  then  his  right  side  was  found  immovable  as 
well.  There  was  no  disturbance  of  consciousness,  no 
deviation  of  head  or  eyes.  When  I  saw  him  a  few 
hours  later  there  was  complete  paraplegia  from  the 
shoulders  down;  no  facial   or  ocular  paralysis.     The 


August  1 8,  1900] 


MEDICAL    RECORD. 


255 


tongue  deviated  to  the  right  (which  was  probably, 
however,  a  normal  deviation);  his  mind  was  clear; 
there  was  severe  pain  over  the  post-cervical  region, 
where  there  was  no  sign  of  trauma,  but  where  pressure 
elicited  tenderness;  the  arm  paralysis  was  Haccid  ;  the 
legs  were  spastic,  the  knee  jerks  being  exaggerated, 
though  no  ankle  clonus  was  present.  There  was  little  or 
no  disturbance  of  sensation  or  superficial  reflexes. 
There  was  vomiting,  probably  due  to  medicine.  There 
was  apnoea  which  gradually  increased.  Later,  loss  of 
voluntary  bladder  control  was  manifest ;  the  respiratory 
difficulty  increased,  and  the  patient  died  about  thirty- 
eight  hours  after  the  onset,  with  mind  clear  almost 
beyond  the  threshold  of  death.  .\n  autopsy  was  re- 
luctantly granted,  and  only  the  upper  portion  of  the 
cord  was  removed.  Exudate,  probably  post-mortem, 
was  found  around  the  cord,  the  precaution  not  having 
been  taken  to  lay  the  body  prone  as  is  desirable  when 
the  cord  is  to  be  examined.  On  section  of  the  re- 
moved cord  there  was  found  a  red  hemorrhagic  area 
which  might  in  its  fluid  state  have  been  about  two  tea- 
spoonfuls  of  blood.  It  occupied  the  middle  of  the 
fourth  cervical  segment  and  extended  to  about  the 
middle  of  the  sixth.  The  clot  was  found  to  be  in 
the  gray  matter  and  chiefly  of  the  ventral  horns,  and 
greatest  on  the  left  side,  corresponding  to  the  initial 
paralysis.  The  clot  was  largest  at  the  fifth  segment 
and  on  the  left  side,  which  was  probably  nearest  to 
the  bleeding  vessel,  which  vessel  could  not  be  found. 
It  encroached  upon  the  lateral  tracts  chiefly  by  press- 
ure. The  membranes  were  unaffected,  which  fact 
leaves  the  pain  unaccounted  for  (see  figure). 

Coming  on  suddenly  in  the  form  of  hemiplegia  the 
symptoms  at  the  outset  in  this  case  might  have  been 
regarded  as  cerebral,  especially  with  the  deviation  of 
the  tongue  to  the  right  and  the  vomiting.  The  early 
supervention  of  the  paralysis  on  the  other  side,  how- 
ever, and  the  absence  of  involvement  of  speech,  face, 
or  consciousness,  would  have  cleared  away  any  doubt, 
especially  the  apncea,  indicating  paralysis  of  the 
phrenic  nerve.  Though  the  situation  of  the  clot  was 
mostly  below  the  chief  innervation  of  that  nerve,  the 
largest  mass  of  it  was  in  the  fifth  segment,  which  sends 
a  communicating  branch  to  the  phrenic.  Death  from 
apncea  might  have  come  sooner  had  it  not  been  for 
this  escape  of  a  large  part  of  the  phrenic  innervation. 
Though  it  has  been  established  that  paralysis  of  the 
diaphragm  alone  without  involvement  of  the  auxiliary 
muscles  of  respiration,  such  as  the  intercostals  and 
scaleni,  is  not'  fatal,  the  lesion  in  this  case  was  low- 
enough  to  enable  the  scaleni  and  sterno-mastoid  to  be 
in  active  play  as  auxiliaries.  From  some  recent  ex- 
periments on  the  faradization  of  the  phrenic  nerve  in 
the  neck  to  maintain  artificial  respiration,  it  is  not  too 
much  to  claim  that  in  lesions  like  this  in  which  the  clot 
just  edged  upon  the  phrenic-nerve  origin,  such  fara- 
disni  of  the  diaphragm  might  be  a  useful  therapeutic 
measure,  pending  wliatever  restitution  of  diaphrag- 
matic function  there  may  have  been  through  shrink- 
ing of  the  clot  or  subsidence  of  the  shock.  The 
respiratory  difficulty  in  this  case  was  very  character- 
istic. It  could  not  be  mistaken  for  dyspnoea,  either 
inspiratory  or  expiratory,  for  there  was  no  air  with 
which  to  breathe;  the  patient  would  open  his  mouth, 
and  jerk  his  head  forward  as  if  to  bite  off  pieces  of  the 
atmosphere  which  refused  to  enter  where  the  paralyzed 
diaphragm  made  no  vacuum. 

The  lesion  involving  the  innervation  of  the  brachial 
plexus  directly  through  the  gray  matter,  and  the  mus- 
cles below  indirectly  by  pressure  on  the  lateral  columns, 
explains  the  flaccid  nature  of  the  paralysis  of  the  arms 
with  diminished  myotatic  irritability  (and  also  changed 
electrical  reactions  with  atrophy  had  there  been  time 
to  develop  these),  and  the  spastic  paralysis  of  the  legs 
with  increased  knee  jerk.     That  sensation  should  re- 


main unaffected  in  this  case  makes  the  lesion  and 
symptom  group  a  curious  parallel  to  that  chronic 
spinal  disease,  amyotrophic  lateral  sclerosis,  in  which 
there  is  a  paralysis  of  the  upper  extremity  of  the 
peripheral  neuron  type,  with  atrophy,  R.  D.,  fibrilla- 
tion, and  of  the  lower  extremity  due  to  affection  of  the 
central  neuron,  with  increased  myotatic  irritability. 

Case  III. —  This  is  a  case  of  a  young  married  woman 
who  has  had  one  child  and  had  always  enjoyed  fair 
health,  having  no  syphilitic,  alcoholic,  or  neuropathic 
history.  About  one  year  ago  without  warning  she  had 
pain  in  her  back,  and  dragged  herself  to  a  couch, 
where  in  less  than  an  hour  her  legs,  as  she  said, 
"went  to  sleep,"  and  became  completely  immovable. 
Soon  after  that  she  had  no  restraining  influence  over 
the  bladder.  The  paralysis  seemed  to  reach  its  height 
at  once  and  straightway  began  to  improve,  some  mo- 
tion of  the  legs  being  possible  on  the  following  day. 
I  saw  the  patient  for  the  first  time  nearly  four  months 
after,  when  she  was  just  beginning  to  trust  herself  to 
step.     At  that  lime  her  movement  was  stiff,  the  mus- 


J3A 


occ/     ctrffY 


cles  of  both  legs  were  weak,  and  the  knee  jerks  were 
much  increased,  which  increase  was  more  marked  on 
the  right  side,  where  there  was  also  slight  ankle  clonus 
(about  eight  contractions);  there  was  also  some 
atrofjjiy  of  the  right  leg,  which  measured  three-quar- 
ters of  an  inch  less  than  the  left.  About  the  same 
relative  difference  existed  in  the  thighs.  As  there 
was  little  adipose  tissue,  and  the  legs  were  normally 
small,  even  such  a  slight  degree  of  atrophy  was  im- 
portant, particularly  on  the  right  side.  Electrical  re- 
action showed  quantitative  changes  in  faradism  and 
galvanism  on  the  right  side,  but  no  R.  D.  Slight 
tactile  anesthesia  existed,  greater  on  the  right  side 
and  increasing  toward  the  extremities.  Pain  sense 
was  also  affected  in  the  same  manner,  but  there  was 
no  thermo-antesthesia.  Both  extremities  were  sub- 
jectively and  objectively  cold,  the  right  more  than  the 
left.  The  superficial  reflexes  were  not  abnormal. 
These  symptoms  were  probably  due  to  hemorrhage  of 
the  cord,  small  in  extent,  and  greatest  upon  the  right 
side,  and  having  little  or  no  destructive  character,  as 
subsequent  improvement  showed.  It  is  a  little  diffi- 
cult to  understand  how-  a  lesion  could  press  upon  both 
lateral  columns  without  doing  more  damage  to  the  in- 
tervening gray  matter.  Two  ways  are  open  to  explain 
this:  one  is  the  morphological  anomaly  by  which  there 
is  little  pyramidal  decussation,  the  tracts  of  both  sides 
lying  contiguous  in  the  anterior  columns  (Tiirck's), 
where  a  lesion  might  easily  affect  them  both  as  well 
as  damage  the  right  anterior  horn;  or,  what  is  more 
probable,  that  originally  the  gray  matter  had  been 
damaged  transversely  to  the  extent  of  affecting  the 
lateral  tracts,  which  damage,  however,  had  been  largely 
remedied  four  months  after,  when  my  examination  was 
made.  For  want  of  early  observation  the  precise 
position  of  the  lesion  is  not  determinable,  though 
probably  in  the  upper  lumbar  segments.  No  other 
theory  of  diagnosis  is  as  tenable  as  hemorrhage.  An 
adult  form  of  acute  anterior  cornual  myelitis,  though 


256 


MEDICAL    RECORD. 


[August  18,  1900 


having  the  fairly  sudden  onset  and  the  characteristic 
coldness  of  the  limb,  is  negatived  by  the  presence  of 
the  knee  jerk,  the  bladder  disturbance  (which  is  very 
rare  in  poliomyelitis),  and  the  presence  of  sensory 
disturbance,  however  slight.  Hysterical  or  functional 
paralysis  might  be  read  into  some  features  of  the  case, 
but  the  patient  is  a  sensible,  cheerful,  happily  married 
and  favorably  situated  woman,  and  worry  and  fatigue 
are  wanting.  Neither  could  it  be  the  common  para- 
plegia of  alcoholic,  syphilitic,  or  metallic  poisoning, 
which,  excepting  the  syphilitic,  are  peripheral  in  their 
nature,  although  we  are  more  and  more  losing  the 
sharp  distinction  that  has  always  been  made  between 
peripheral  and  anterior-horn  lesions.  That  there  is 
no  progressive  system  disease  of  the  cord  is  shown  by 
the  fact  that  no  symptoms  antedated  the  onset  and  that 
there  has  been  progressive  improvement  since.  This 
has  continued,  at  first  rapidly,  later  more  slowly, 
under  faradism,  massage,  strychnine,  etc.  She  soon 
became  able  to  walk  about  the  street  without  support, 
later  to  go  up  and  down  stairs,  although  the  feeling  of 
stiffness  remained;  the  legs  and  thighs  improved  in 
nutrition  and  warmth,  until  examination  a  few  days 
ago  showed  no  atrophy,  the  legs  and  thighs  measuring 
the  same.  The  right  knee  jerk  was  no  longer  greater 
than  the  left,  though  they  were  both  still  exaggerated. 
Tactile  and  pain  sensations,  which  had  been  in  arrears 
in  former  examinations,  were,  if  diminished  at  all, 
very  slightly  so.  The  bladder  irritability  had  disap- 
peared within  a  few  weeks,  but  the  rectal  trouble,  in 
the  nature  of  diminished  expulsive  power,  from  which 
she  had  suffered  since  the  beginning,  continued.  Be- 
lieving that  this  had  no  relation  to  the  lesion,  but  was 
due  to  the  sedentary  life  which  she  was  obliged  to 
live,  and  the  constant  resort  to  cathartics  necessary, 
the  patient  was  recently  advised  to  discontinue  their 
use  and  allow  the  rectum  to  regain  its  reflex  activity 
even  at  the  cost  of  much  constipation.  Under  this  the 
patient  would  at  first  go  for  more  than  a  week  without 
bowel  movement,  during  which  she  suffered  headache 
and  other  discomfort,  but  on  persevering  the  normal 
evacuations  came  oftener,  until  now  they  take  place 
about  every  two  days.  The  subjective  sense  of  slight 
stiffness  continues,  and  also  a  slight  spasticity  in  her 
gait,  which  is  not  noticeable  unless  looked  for,  and 
with  the  exception  that  she  cannot  indulge  a  fondness 
for  dancing,  or  hurry  after  a  street  car,  she  is  almost 
as  well  as  before  her  trouble  a  year  ago. 

If  the  lingering  stiffness  is  the  result  of  some  de- 
generation in  the  so-called  inhibitory  fibres  of  the 
motor  tract  from  some  destruction  therein,  we  have, 
on  the  one  hand,  the  unfavorable  precedent  in  which 
the  section  of  monkeys'  cords  was  followed  by  little 
or  no  restoration  of  function,  and,  on  the  other  hand, 
the  favorable  precedent  in  the  great  improvement  of 
the  spasticity  in  Pott's  disease  when  regular  mechan- 
ical treatment  is  applied,  as  conflicting  features  as  to 
the  ultimate  integrity  of  the  patient's  cord.  That  there 
has  already  been  considerable  improvement  in  this  is 
a  fair  ground  for  expecting  more. 


Facial  Paralysis  in  the  Course  of  Acute  Catarrh 
of  the  Middle  Ear. — L.  Bar  reports  three  cases:  In 
the  first,  that  of  a  girl  aged  nine  years,  an  otitis  follow- 
ing influenza  was  accompanied  by  a  paretic  state  of  the 
facial  muscles;  puncture  of  the  drum  quickly  relieved 
all  untoward  symptoms.  The  second  case  was  in  a  boy 
aged  eight  years,  with  adenoids,  and  presented  similar 
symptoms,  with  the  same  happy  result  following  punc- 
ture: the  power  of  the  facial  muscles  in  both  was  re- 
stored inside  of  twenty-four  hours.  'l"he  third  case, 
occurring  in  a  woman,  was  of  longer  duration,  and  in- 
volved the  muscles  of  the  tongue  as  well  as  those  of  the 


face.  Later  history  showred  the  involvement  of  the  mas- 
toid. Opening  of  the  latter  was  followed  in  the  course  of 
a  week  by  gradual  improvement,  which  was  complete 
so  far  as  muscular  power  was  concerned  five  days  later. 
— Revue  Uelniomadaire  de  La/yiigo/of^ie,  etc.,  June  16, 
1900. 

Affections  of  the  Eye  Associated  with  Lesions 
in  the  Kidney. — VV.  O.  Moore  describes  albuminuric 
retinitis,  amaurosis  ura;mica,  and  alludes  to  paralysis 
of  the  ocular  muscles,  stating  that  the  abducens  is  the 
muscle  most  frequently  affected.  The  retinitis  is  at 
times  unilateral.  The  pathological  change  in  the 
retina  is  not,  according  to  Moore,  an  inflammatory  one, 
but  is  a  tissue  metamorphosis  which  produces  per- 
manent changes  in  the  retina  and  is  brought  about  by 
the  changes  in  the  vascular  system  generally,  which 
in  turn  are  caused  by  the  circulation  in  the  blood  of 
effete  material  due  to  imperfect  elimination  by  the 
kidneys.  This  material  maybe  urea  alone  or  in  com- 
bination with  other  substances.  The  prognostic 
significance  of  this  retinal  change  is  bad,  death  fol- 
lowing as  a  rule  inside  of  two  years. — 7'he  Post-Gradu- 
afe,  July,  igoo. 

The  Use  of  Opium  in  the  Summer  Diarrhoeas 
of  Children. — F.  M.  Crandall  says  that  opium,  under 
the  conditions  specified,  is  contraindicated  (i)  in  the 
first  stages  of  acute  diarrhcea,  before  the  intestinal 
canal  has  been  freed  from  decomposing  matter;  (2) 
when  the  passages  are  infrequent  or  of  bad  odor;  (3) 
when  there  is  a  high  temperature  or  cerebral  symp- 
toms are  present;  (4)  when  its  use  is  followed  by  ele- 
vation of  temperature  or  the  passages  become  more 
offensive.  It  is  indicated  (i)  when  the  passages  are 
very  frequent,  with  pain;  (2)  when  the  passages  are 
excessively  frequent,  large,  and  watery;  (3)  in  dysen- 
teric diarrhoea  preceded  by  castor  oil  or  a  saline;  (4) 
in  late  stages,  with  small,  frequent,  nagging  passages; 
(s)  when  the  passages  consist  largely  of  undigested 
food,  and  the  bowels  act  as  soon  as  food  is  taken  into 
the  stomach. — International  Medical  Magazine,  July, 
1900. 

The  Etiology  of  Congenital  Dislocation  of  the  Hip. 

— Bode,  in  studying  the  causative  agencies  at  work  in 
producing  this  deformity,  groups  them  under  three 
heads:  { i )  Those  involving  the  ftetus  alone;  (2)those 
emanating  from  conditions  in  the  environment  of  the 
foetus;  (3)  those  resulting  from  a  combination  of  these 
two.  In  conducting  a  series  of  investi'gations  on  this 
subject  by  means  of  the  Roentgen  rays  he  found  that 
only  the  first  set  of  these  factors  was  susceptible  of 
study  in  this  way;  skiagraphs  of  the  foetus  in  utero  are 
still  too  imperfect  to  be  of  any  assistance.  Accord- 
ingly, the  hip  joints  of  one  hundred  and  fifty  children 
(including  fifty-six  fcetuses)  were  radiographed,  two 
hundred  and  six  of  these  being  diseased  and  ninety- 
four  normal.  Owing  to  the  comparatively  late  date  at 
which  the  acetabuUmi  and  the  head  and  neck  of  the 
femur  ossify,  the  plates  prepared  from  the  fcetuses  do 
not  show  anything  of  value,  but  careful  pelvic  measure- 
ments were  made.  In  twenty-five  per  cent,  of  the  chil- 
dren sufTering  from  unilateral  congenital  dislocation 
the  supposedly  normal  side  was  found  to  exhibit  the 
typical  lesions  to  a  slight  degree.  In  general,  the 
change  found  consisted  in  an  increased  breadth  of  the 
acetabular  cavity,  in  flattening  of  its  upper  margin,  in 
lateral  thickening  of  its  wall,  or  in  asymmetrical 
atrophy  and  altered  growth  tendencies  of  the  femoral 
head.  The  conclusion  is  that  congenital  dislocation 
is  the  direct  result  of  morbid  processes  of  unknown 
etiology  and  dating  from  the  earliesfperiods;  if  these 
pathological  changes  are  slight,  no  deformity  results; 
if  they  are  well-marked,  a  dislocation  takes  place. — 
Centra Iblatt  Jiir  Chirurgie,  July  14,  1900. 


August  1 8,  1900] 


MEDICAL    RECORD. 


257 


Medical  Record: 

A    Weekly  Journal  of  Medicine  and  Surgery. 


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


Publishers 


WM.  WOOD  &.  CO,  51    Fifth  Avenue. 


New  York,  August  18,  1900. 


THE      SIGNIFICANCE     OF     DEGENERATION 
OF    RED    ELOOD    CORPUSCLES. 

Import.ant  additions  have  been  made  in  the  past  dec- 
ade to  our  knowledge  especially  of  the  morphology 
of  the  blood,  but  we  are  without  an  explanation  fo 
many  of  the  phenomena  observed.  It  is,  besides, 
difficult  to  state  whether  some  of  the  peculiarities  are 
the  result  of  regenerative  or  of  degenerative  processes, 
and  a  ready  means  by  which  a  correct  decision  could 
be  reached  would  be  a  useful  addition  to  our  clinical 
resources.  Valuable  therapeutic  suggestions  might, 
further,  be  obtained  from  a  knowledge  whether  the 
essential  disturbances  occur  in  the  plasma,  in  the  red 
cells,  or  in  the  white  cells — apart  from  the  prophylac- 
tic significance  a  more  thorough  etiological  knowledge 
would  possess.  In  a  recent  communication  Grawitz 
{Berliner  klinisehe  Wochensclirijt,  1900,  No.  9)  dis- 
cusses at  length  the  pathological  significance  of  cer- 
tain basophilous  granulations  that  he  has  found  under 
certain  circumstances  in  red  blood  corpuscles,  even  in 
the  absence  of  other  signs  of  anasmia  in  the  blood,  and 
that  he  considers  with  certainty  as  indicative  of  a 
degenerative  process.  When  present,  these  can  be 
demonstrated  in  dry  preparations  by  staining  with 
methylene  blue  after  fixation  with  alcohol.  Granular 
red  blood  corpuscles  have  been  noted  in  cases  of  per- 
nicious anamia  by  several  observers,  who  have  con- 
sidered them  as  the  remains  of  dissolved  nuclei. 
Grawitz,  however,  has  found  such  corpuscles  in  the 
total  absence  of  nucleated  red  corpuscles,  and  also  red 
corpuscles  with  intact  nuclei  but  containing  likewise 
many  granulations.  Unlike  the  nuclei  themselves  the 
granular  matter,  further,  cannot  be  stained  with  meth- 
ylene green.  Granular  red  corpuscles  are  not  found 
in  the  bone-marrow  in  any  greater  number  than  in  the 
general  circulation,  as  they  would  be  if  they  were  in- 
dicative of  karyolysis.  In  aggravated  cases  of  per- 
nicious anaemia  erythrobiasts  with  fibrillated  nuclei 
and  constricted  portions  of  the  nuclei  may  rarely  be 
found,  but  the  appearances  of  these  are  unlike  those 
of  the  granular  degeneration  under  consideration. 

The  granular  red  cells  are  particularly  numerous  in 
cases  of  pernicious  anemia.  They  are  found  frequently 
also  in  cases  of  carcinoma,  and  especially  when  the 
new  growth  is  so  situated  as  to  favor  absorption  of 
toxic  products,  as  in  the  digestive  tract.  They  have 
likewise  been  observed  in  cases  of  advanced  leukaemia 


and  in  association  with  septic  processes.  The  gran- 
ules are  remarkably  numerous  in  the  blood  in  cases 
of  lead-poisoning.  This  is  all  the  more  noteworthy 
because,  in  spite  of  the  pallor  present,  morphological 
alterations  in  the  blood  are  usually  absent  in  cases  of 
this  kind.  The  absence  of  these  peculiar  granules  is 
considered  not  less  significant  than  their  presence, 
tending  to  exclude  the  action  of  a  blo'od  poison.  The 
granules  have  not  been  found  in  cases  of  chlorosis,  and 
this  evidence  seems  to  confirm  the  view  that  the  dis- 
ease is  not  of  toxic  origin,  but  due  perhaps  to  vaso- 
motor disturbances.  The  granules  are  not  found  in 
cases  of  pulmonary  tuberculosis  free  from  excavation 
and  hectic  fever,  nor  in  cases  of  syphilis,  chronic 
parenchymatous  and  interstitial  nephritis,  and  cirrho- 
sis of  the  liver.  These  granules  are  looked  upon  as 
evidence  of  a  degenerative  process  due  to  the  action 
of  blood  poisons.  It  is  possible  to  cause  their  ap- 
pearance in  mice  by  exposure  to  a  temperature  of  be- 
tween 98.6°  and  104"  F.,  and  the  presence  of  iron 
granules  in  greater  amount  in  the  liver  is  accepted 
as  an  indication  of  increased  destruction  of  ha-moglo- 
bin.  In  this  connection  it  is  suggested  that  some 
forms  of  tropical  ansemia  may  have  a  like  mechan- 
ism. The  granules  under  consideration  cannot  be  re- 
garded as  distinctive  of  any  given  disease,  but  simply 
as  a  degenerative  manifestation  of  varied  origin.  Their 
importance  resides  in  the  fact  that  they  may  be  pres- 
ent in  considerable  number  before  other  symptoms  of 
anasmia. 

PLACENTAL    TRANSMISSION. 

The  placenta  stands  between  the  fcetal  and  the  mater- 
nal organism,  selecting  from  the  blood  of  the  latter 
the  materials  that  are  necessary  for  the  grov/th  and  de- 
velopment of  the  embryo,  and  from  the  blood  of  the 
former  those  that  are  no  longer  useful  and  require  to 
be  eliminated.  It  may,  therefore,  be  looked  upon  es- 
sentially as  the  respiratory  and  the  nutritive,  as  well 
as  the  circulatory,  organ  of  the  fcetus.  It  is,  however, 
probably,  also  the  medium  through  which  infection  is 
occasionally  conveyed  to  the  fcetus  from  the  mother, 
and  through  which  the  physiological  effects  of  drugs 
administered  to  the  mother  are  operative.  From  a 
review  of  the  literature  of  the  subject,  Dorland  (Amer- 
ican Gyncecological  and  Obstetrical  Journal,  June,  1900) 
in  a  recent  communication  formulates  the  conclusion 
that  while  many  drugs  may  be  administered  to  the 
mother  without  any  noticeable  effect  upon  the  foetus, 
there  are  certain  substances  that  show  a  special  ten- 
dency to  traverse  the  placenta,  and,  entering  the  foeto- 
piacental  circulation,  exert  a  positive  influence  for 
good  or  evil,  according  to  the  conditions  that  may  be 
present  in  the  given  instance.  Maternal  medication, 
therefore,  is  indicated  under  certain  circumstances, 
either  in  order  to  prevent  the  development  of  a  simi- 
lar condition  in  the  foetus,  or  to  counteract  the  effect 
of  germs  and  their  toxins  already  introduced  into  the 
foetal  economy.  The  drugs  that  have  been  found  to 
affect  the  foetus  in  utero  are  notably  opium,  mercury, 
copper,  lead,  arsenic,  and  the  iodides.  In  appropriate 
doses  they  may  be  administered  to  the  mother  in  the 


258 


MEDICAL    RECORD. 


[August  1 8,  1900 


presenseof  suitable  pathological  conditions,  with  bene- 
ficial results  to  both  mother  and  child.  Any  morbific 
influence  acting  upon  the  mother,  either  acutely,  as  in 
the  case  of  the  exanthemata,  or  more  slowly,  as  in  the 
case  of  tuberculous  and  syphilitic  infection,  will  react 
deleteriously  upon  the  product  of  conception,  and 
either  destroy  it  through  its  overwhelming  toxic  ac- 
tion, or  render  it  feeble  and  less  resistant  to  subse- 
quent and  post-natal  invasion,  or  the  disease  will  run 
an  atypical  course  in  utero  with  or  without  apparent 
vestiges  at  birth.  The  entrance  into  the  fcttal  struc- 
tures is  accomplished  through  the  agency  of  the  foeto- 
placental  circulation.  It  is  probable  that  access  is 
gained  through  bacterial  action,  the  germs  rendering 
the  placental  villi  less  resistant  to  invasion,  whereby 
both  the  microbes  and  their  toxins  pass  tlie  natural 
barrier  at  the  chorio-decidual  junction.  As  a  rule,  the 
infectious  diseases  do  not  manifest  their  characteristic 
lesions  in  the  foetus,  probably  because  of  the  passivity 
of  its  organs  during  antenatal  existence.  The  germs, 
however,  may  be  detected  in  large  numbers  by  bac- 
teriological and  microscopic  examination. 


PRIVATE  HOSPITALS  FOR    TRANSMISSIBLE 
DISEASE. 

Many  large  cities  are  provided  with  public  institu- 
tions to  which  it  practically  compels  to  be  sent  those 
suffering  from  contagious  disease  and  unable  to  insure 
adequate  isolation  and  disinfection  at  their  homes. 
In  other  cities  no  provision  at  all  is  made  for  cases 
of  this  kind,  or  they  must  be  sent  to  general  hospitals, 
or  even  be  kept  at  home.  There  is  in  every  commu- 
nity a  not  inconsiderable  number  of  persons  whom, 
when  seized  with  one  of  the  diseases /lamed,  it  would 
be  desirable,  if  it  be  not  absolutely  necessary,  to  send 
to  some  institution  in  which  the  appropriate  treatment 
shall  be  carried  out,  and  who  are  both  willing  and  able 
to  pay  for  the  service  rendered.  The  public  has  be- 
gun to  recognize  that  many  ailments  and  many  pa- 
tients can  often  be  better  managed  and  better  treated 
in  well-regulated,  well-organized,  and  well-disciplined 
hospitals  than  in  private  dwellings,  however  capa- 
cious and  however  sumptuous,  and  many  are  constantly 
availing  themselves  of  the  boon  thus  afforded  by  the 
private  rooms  of  such  institutions.  Most  general 
hospitals  will  not  receive  cases  of  contagious  disease 
under  any  conditions,  and  there  is,  therefore,  urgent 
need  for  such  institutions  as  will  admit  those  unfor- 
tunate enough  to  be  thus  attacked  in  hotels  and 
boarding-houses,  or  while  visiting  in  the  homes  of 
friends,  and  who  do  not  wish  and  have  no  need  to  go 
to  a  public  hospital.  Hospitals  of  this  special  class 
are  already  in  operation  in  Boston  and  New  York,  and 
a  movement  is  on  foot  looking  to  the  establishment  of 
a  pay-hospital  for  contagious  diseases  in  Philadelphia. 
The  objects  to  be  fulfilled  by  this  enterprise  are  so 
laudable  and  in  such  thorough  harmony  with  current 
hygienic  and  preventive  notions  that  there  should  be 
no  difficulty  in  securing  its  speedy  effectuation. 
The  movement  is,  therefore,  one  to  be  most  heartily 
encouraged,  as  it  is  also  deserving  of  general  emulation. 


ITtcius  of  the  'miccU. 

Deaths  from  Heat. — During  the  excessive  Iieat  of 
the  greater  part  of  last  week  there  were  one  hundred 
and  twenty-five  deaths  of  adults  attributed  directly  to 
insolation,  and  the  infant  mortality  was  markedly  in- 
creased. 

First  International  Congress  of  the  Medical  Press. 
— This  congress  was  held  in  Paris  on  July  26th,  27th, 
and  28th.  The  opening  ceremonies  took  place  in  the 
Press  Pavilion  in  the  Exposition  grounds,  Professor 
Cornil  presiding.  In  his  opening  address  he  referred 
especially  to  Virchow,  who  was  present,  as  the  dean 
of  medical  editors,  who  had  been  in  harness  for  sixty 
years  and  had  published  in  his  Air/uT  much  of  the 
cream  of  German  medical  literature.  He  said  that 
there  were  over  three  hundred  medical  journals  pub- 
lished in  France.  M.  Millerand,  the  Minister  of 
Commerce,  made  a  brief  address  welcoming  the  for- 
eign representatives  of  medical  journalism.  M.  Lan- 
douzy  then  spoke  upon  the  history  and  the  province 
of  the  medical  press,  and  was  succeeded  by  Virchow, 
who  congratulated  the  Association  of  the  French  Med- 
ical press  on  having  taken  the  initiative  in  organizing 
an  international  congress.  He  hoped  that  the  creation 
of  an  international  association  might  result  from  the 
congress,  and  said  it  was  more  in  accordance  with 
the  dignity  of  medical  journalism  that  it  should  have 
international  congresses  distinct  from  the  medical 
congresses,  and  should  not  be  relegated  to  an  insig- 
nificant place  as  one  of  a  multitude  of  sections  of  the 
triennial  congress.  The  serious  work  of  the  congress 
was  taken  up  the  second  day.  The  official  delegates 
were  presented  and  made  short  addresses:  Drs.  Pos- 
ner  for  Germany,  Ehlers  for  Denmark,  Hansen  for 
Norway,  Gallet  for  Belgium,  Brossi  for  Italy,  Diaka- 
noff  for  Russia,  and  Mendizabal  for  Mexico.  Dr, 
Marcel  Baudouin  described  his  method  of  indexing 
original  articles  published  in  the  medical  press 
throughout  the  world,  as  exemplified  in  his  new  publi- 
cation designed  to  take  the  place  of  the  Index  Medi- 
cus.  The  following  papers  were  read  and  discussed: 
"  The  Legitimacy  of  Medical  Advertising,"  by  Archam- 
baud;  "Free  Medical  Journals,"  by  Laborde  and 
Romme;  "  Uniform  Terminology  for  Scientific  Classi- 
fication," by  de  Maurans;  "Reproduction  of  Photo- 
graphs in  Medical  Journals,"  by  Doyen  and  Aragon; 
"The  Decimal  System  of  Indexing,"  by  Richet;  "  Re- 
lations between  the  Medical  and  the  Political  Press," 
by  Rossi ;  "  The  French  Law  of  Literary  Property  in 
its  Relation  to  the  Medical  Press,"  by  Pouillet,  Ro- 
cher,  and  de  Maurans;  "Property  in  the  Idea  and  in 
the  Expression  of  the  Idea  in  Medical  Journalism," 
by  Baudouin.  On  Saturday,  July  <:8th,  the  following 
papers  were  read:  "History  of  the  Greek  Medical 
Press,"  by  Foustanos;  "The  Medical  I'ress  of  Cuba," 
by  Juan  S.  Fernandez;  "  History  of  the  Belgian  Med- 
ical Pre.ss,"  by  limile  Gilson;  "  American  Medical 
Journalism,"  by  ('.  W.  F'assett;  "The  Ethics  of  Med- 
ical Journalism  in  London,"  by  Sprigge;  "The  Ger- 
man  Medical   Press,"  by  Spatz;  "The  Right  of  Re- 


August  1 8,  1900] 


MEDICAL    RECORD. 


!59 


production  of  Illustrations,"  by  F.  Alcan ;  "  Medical 
Copyright,"  by  Podoysotski;  "The  Right  of  Reply  in 
the  Medical  Press,"  by  Jayle  and  Pistre;  "Profes- 
sional Solidarity  in  the  Medical  Press,"  by  J.  Xoir; 
"  The  Abuse  of  the  Pseudonym  Preceded  by  the  Title 
Dr.  in  Medical  Advertisements,"'  by  G.  Levy;  "The 
Expediency  of  Founding  an  International  Association 
of  the  Medical  Press,"  by  J.  V.  Laborde;  "Interna- 
tional Association  of  the  Medical  Press,"  by  Posner. 
After  some  discussion  it  was  decided  to  establish  an 
International  Association  of  the  Medical  Press,  and 
to  hold  the  next  congress  in  jgoi  in  Brussels,  on  a 
date  to  be  determined  by  the  standing  committee  of 
the  association. 

The  Danger  of  Disease  in  China. — Dysentery  is 
the  most  dreaded  of  the  diseases  to  which  our  troops 
in  China,  as  well  as  in  the  Philippines,  are  exposed. 
The  water  is  everywhere  polluted,  yet  it  is  almost  im- 
possible to  prevent  troops  on  the  march  from  drinking 
it  unboiled  and  unfiltered. 

"Sport." — A  slugging-match  between  two  brutes 
took  place  last  week  in  this  city,  and  the  beaten  man 
lay  insensible  for  nearly  five  hours.  It  was  briefly 
noted  in  the  newspaper  report  "  that  the  blow  which 
the  man  received  when  his  head  struck  the  stage  at 
the  time  of  the  knockout,  together  with  the  plexus 
blow  and  other  severe  body  punishment,  had  brought 
him  to  a  state  of  collapse,  but  that  no  serious  results 
would  be  likely  to  occur.""  In  the  mean  time  the  vic- 
tor was  receiving  the  homage  of  his  devoted  admirers. 
Evidently  the  "  boxers  "  are  not  all  in  China. 

The  American  Therapeutic  Society  was  organized 
May  I,  1900,  in  Washington  during  the  session  of 
the  Congress  of  American  Physicians  and  Surgeons. 
"  Reputable,  physicians,  who  are  engaged  in  the  regu- 
lar active  practice  of  medicine,  and  who  are  interested 
in  the  study  of  materia  medica  and  therapeutics,  in 
any  or  all  their  branches,  and  such  reputable  physi- 
cians not  engaged  in  active  practice  but  who  are  en- 
gaged in  legitimate  experimental  therapeutic  research, 
shall  be  eligible  for  active  membership."  The  officers 
for  1900  are:  FrcsUent,  Dr.  Horatio  C.  Wood,  of  Phil- 
adelphia; First  Vice-President,  Dr.  Howard  H.  Barker, 
of  Washington;  Second  Vice-President,  Dr.  Reynold 
W.  Wilcox,  of  New  York;  Third  Vice-President,  V>\. 
Eli  H.  Long,  of  Buffalo;  Secretary,  Dr.  Noble  P. 
Barnes,  of  Washington;  Recorder,  Dr.  William  M. 
Sprigg,  of  Washington;  Treasurer,  Dr.  John  S.  Mc- 
Lain,  of  Washington.  Applications  for  membership 
should  be  made  to  the  secretary. 

The  Mississippi  "Valley  Medical  Association. — 
The  twenty-sixth  annual  meeting  of  this  association 
will  be  held  at  Asheville,  N.  C,  October  9,  10,  and 
II,  1900,  under  the  presidency  of  Dr.  Harold  N. 
Moyer,  of  Chicago.  Dr.  I.  N.  Love,  of  St.  Louis,  will 
deliver  the  address  in  medicine,  and  Dr.  C.  A.  Wbeat- 
on,  of  St.  Paul,  Minn.,  the  address  in  surgery.  Ne- 
gotiations are  in  progress  by  which  the  members  of 
the  association  may  obtain  a  one-fare  rate  for  the 
round  trip  for  this  meeting.  The  association  will  not 
be  divided  into  sections  at  this  meeting.     The  head- 


quarters will  be  at  the  Battery  Park  Hotel,  at  which 
place  the  sessions  will  be  held.  Those  who  intend  to 
read  papers  are  requested  to  send  the  title  together 
with  a  brief  synopsis  of  the  paper  to  the  secretary.  Dr. 
Henry  E.  Tuley,  1 1 1  West  Kentucky  Street,  Louis- 
ville, Ky. 

The  Congress  of  Spanish  Surgeons,  which  was  to 
have  been  held  in  September  of  the  present  year,  has 
been  postponed  until  1901. 

More  Honors  for  the  Prince  of  "Wales. — At  the 
meeting  of  the  British  Medical  Association  at  Ipswich, 
the  Prince  of  Wales,  having  already  the  double  hon- 
orary qualifications  of  F.R.C.P.  and  F.R.C.S.,  was 
elected  an  honorary  member  of  the  association. 

A  Pediatric  Society  in  Great  Britain. — The  Soci- 
ety for  the  Study  of  Disease  in  Children  was  inaugu- 
rated at  a  meeting  held  on  July  24th  at  the  rooms  of 
the  Royal  Medical  and  Chirurgical  Society  in  Han- 
over Square,  London.  The  chair  was  taken  by  Dr. 
A.  E.  Sansom.  There  was  a  fair  attendance  of  those 
interested  in  the  movement.  The  secretaries  of  the 
new  society  are  Mr.  Sydney  Stephenson  and  Dr. 
Charles  H.  Willey,  and  the  treasurer  is  Mr.  Clement 
Lucas.     The  society  numbers  about  eighty  members. 

Rabies  in  Paris.— The  annual  report  on  h)-dropho- 
bia,  which  has  just  been  presented  to  the  council  of 
public  hygiene  by  Prof.  Adrien  Proust,  inspector- 
general  of  the  board  of  health,  shows  by  statistics  that 
the  number  of  mad  dogs  in  Paris  and  the  Department 
of  the  Seine  is  steadily  increasing.  The  Pasteur  In- 
stitute treated  two  hundred  and  ninety-four  persons 
who  had  been  bitten  by  rabid  animals  between  Janu- 
ary I  and  June  8,  igoo. 

Names  of  Scientists  and  Medical  Men  for  the 
Hall  of  Fame.— The  Senate  of  the  New  York  Uni- 
versity has  submitted  to  the  judges  of  the  Hall  of 
Fame  a  list  of  two  hundred  and  thirty-four  nomina- 
tions, from  which  the  final  selection  of  one  hundred 
names  is  to  be  made.  The  scientists  whose  names 
have  been  presented  are  John  James  Audubon,  Spen- 
cer F.  Baird,  Alexander  D.  Bache,  Nathaniel  Bow- 
ditch,  William  Chauvenet,  Henry  Draper,  James  P. 
Espy,  Asa  Gray,  Robert  Hare,  Joseph  Henry,  Edward 
Hitchcock,  Isaac  Lea,  Matthew  Fontaine  Maury,  Maria 
Mitchell,  Benjamin  Peirce,  David  Rittenhouse,  Ben- 
jamin Silliman,  Benjamin  Thompson,  and  John  Tor- 
rey.  The  physicians  and  surgeons  are  Valentine 
Mott,  Benjamin  Rush,  James  Marion  Sims,  Ephraim 
McDowell,  and  Jolin  Collins  Warren. 

Another  Suit  for  Injuries  Received  in  Hospital. 
— An  amateur  athlete  living  in  Brooklyn  has  brought 
suit  for  Sio,ooo  against  the  New  York  Hospital.  He 
complains  that  while  he  was  undergoing  an  operation 
under  ether  at  the  Hudson  Street  House  of  Relief  his 
left  heel  was  burned  by  the  application  of  an  over- 
heated hot-water  bag.  He  entered  the  hospital  No- 
vember I,  and  because  of  the  injury  to  his  heel,  he 
alleges,  was  kept  there  until  late  in  November.  He 
says  that  he  was  dismissed  from  the  hospital  before 
his  heel  was  really  well,  and  that   it   became  much 


26o 


MEDICAL    RECORD. 


[August  1 8,  1900 


worse  and  is  still  in  such  a  state  that  he  is  not  able 
to  run  races.  The  attorney  for  the  hospital  has  filed 
an  answer  in  whicii  he  says  that  in  submitting  to  treat- 
ment in  a  charitable  institution  the  patient  waived  all 
claims  for  damages  resulting  from  purely  accidental 
injury. 

A  Doctor  Sued  for  an  Automobile  Accident.— A 
well-known  physician  in  New  Jersey  has  been  sued 
for  $25,000  damages  for  having  caused  the  death  of  a 
woman  by  running  into  the  wagon  in  which  she  was 
driving,  with  his  motor  carriage. 

Mr.  Treves'  Diagnosis  of  Genius. — In  an  address 
recently  made  to  the  students  of  the  London  Hospital, 
Mr.  Frederick  Treves  said  that  genius  was  nothing 
else  than  some  form  of  neurosis,  an  untabulated  ner- 
vous disease.  Genius,  he  averred,  never  accomplished 
anything,  but  hard  work  would  do  all  things,  and  if 
there  was  one  profession  in  which  geniuses  were  not 
wanted  it  was  that  of  medicine. 

Affairs  at  Home. — It  is  reported  that  there  is  a 
temporary  improvement  in  the  health  of  Cape  Nome, 
the  smallpox  epidemic  having  been  arrested,  though 
there  is  still  much  sickness,  chiefly  pneumonia.  It  is 
feared,  however,  that  this  betterment  is  for  only  a 
short  time,  for  there  are  four  thousand  stranded  gold- 
seekers  there  who  will  be  unable  to  get  home  w-ithout 
government  assistance,  and  if  they  remain  during  the 
coming  winter  few  will  probably  live  to  return  in  the 
late  spring  or  summer. 

"Revista  de  Medicina  Tropical"  is  the  name  of 
a  new  monthly  journal  of  Havana,  published  under 
the  editorial  management  of  Dr.  John  Guite'ras,  for- 
merly of  the  University  of  Pennsylvania,  and  Dr. 
Emilio  Martinez,  assisted  by  Drs.  Charles  Finlay,  Rai- 
mundo  Menocal,  Vicente  de  la  Guardia,  and  Enrique 
Saladrigas.  The  first  number,  dated  July,  1900,  con- 
tains an  introduction  by  Dr.  Guitdras  and  some  ab- 
stracts from  foreign  journals,  but  no  original  articles. 

Phototherapy  in  Russia The    dowager  empress 

of  Russia,  who  is  by  birth  a  Dane,  has  founded  an  in- 
stitute in  St.  Petersburg  for  the  treatment  of  lupus 
and  other  affections  of  the  skin  by  means  of  light.  It 
is  modelled  after  Finsen's  institute  in  Copenhagen,  and 
is  under  the  charge  of  a  Russian  physician  who  was 
sent  by  the  empress  to  study  the  technique  of  photo- 
therapy under  Finsen  himself.  The  matron  is  a  Da- 
nish woman  who  has  been  a  nurse  in  Finsen's  institute 
and  is  thoroughly  familiar  with  his  methods. 

Debt  and  Prosperity  for  Hospitals.  — Sir  William 
MacCormac  said  recently  that  no  hospital  can  be  sat- 
isfactorily carried  on  unless  it  is  in  debt,  as  there 
would  then  be  no  scope  for  charitable  feelings  and 
manifestations. 

Scarlet  Fever  and  Hotel  Bills.— A  man  wiio  had 
rented  an  apartment  for  himself  and  family  in  one  of 
the  large  family  hotels  in  this  city  recently  vacated 
it,  alleging  that  he  was  constructively  evicted  by  the 
occurrence  of  scarlatina  in  the  house.  The  hotel 
company  sued  him  for  the  unpaid  rent  and  has  recov- 


ered in  the  supreme  court.  It  was  not  shown,  the 
court  said,  that  the  management  had  been  negligent 
in  the  case,  but  it  had  been  demonstrated  that  all 
possible  precautions  had  been  taken  to  prevent  the 
spread  of  the  disease.  It  could  not,  therefore,  be  held 
that  there  was  an  eviction  in  fact  or  in  law. 

Navy  Department,  Bureau  of  Medicine  and  Sur- 
gery, Washington,  D.  C. — Changes  in  the  medical 
corps  of  the  United  States  navy  for  the  week  ending 
August  II,  1900.  August  3d.— Assistant  Surgeon  C. 
A.  Crawford  detached  from  the  Eagle  and  ordered  to 
the  Chesapeake.  August  6th. — Assistant  Surgeon  C. 
H.  Delancy  detached  from  the  Coiistellation  August 
13th,  and  ordered  to  the  Bancroft  August  14th. 
August  9th. — Passed  Assistant  Surgeon  \V.  C.  Braisted 
detached  from  the  Massachusetts  and  ordered  to  the 
Topeka  August  isth.  Assistant  Surgeon  W.  M.  Gar- 
ton  detached  from  the  Nc-w  York  and  ordered  to  tem- 
porary duty  on  the  Massachusetts.  Passed  Assistant 
Surgeon  James  Stoughton,  U.S.X.,  was  drowned  at 
Shanghai,  China,  August  5,  1900. 

Obituary  Notes. — Dr.  John  Francis  Burns,  vis- 
iting surgeon  of  St.  John's  Hospital  in  Long  Island 
City,  died  in  that  institution  August  gth,  of  spinal 
meningitis,  aged  thirty-seven  years.  Dr.  Burns  was 
born  in  New  York  City  and  graduated  from  the  Uni- 
versity of  New  York  in  1889.  Three  years  later  he 
opened  an  office  in  Long  Island  City. 

Dr.  Cortland  Van  Rensselaer  Creed,  a  well- 
known  negro  physician  of  New  Haven,  died  suddenly 
on  August  8th,  of  Bright's  disease.  He  was  graduated 
from  the  Yale  Medical  School  in  the  class  of  1857. 
He  was  about  sixt)'-seven  years  old. 

Dr.  Elias  B.  Harris  died  recently  at  Virginia 
City,  Nev.,  at  the  age  of  seventy-five  years.  He  was 
born  at  Richmond  Plains,  N.  Y.,  and  was  graduated 
from  the  medical  department  of  the  New  York  Uni- 
versity in  the  class  of  1847. 

Dr.  Samuel  H.  Gish  died  at  his  home  in  Janes- 
ville.  Wis.,  on  August  2d,  at  the  age  of  seventy-nine 
years.  He  was  born  in  Lancaster  County,  Pa.,  and 
was  graduated  from  the  Philadelphia  Medical  College 
in  185 1.  He  practised  for  several  years  in  Elizabeth- 
town,  Pa.,  and  then  took  up  the  study  of  dentistry  and 
practised  the  same  in  Janesville  to  within  a  few  weeks 
of  his  death. 

Dr.  Carl  M.  Kellev,  coroner  of  Pike  County,  Pa., 
fell  dead  at  his  home  in  Matamoras  on  August  iith, 
of  heart  trouble.  He  was  born  at  Scranton  thirty- 
eight  years  ago.  He  was  graduated  from  the  Col- 
lege of  Physicians  and  Surgeons  in  Baltimore  in 
1883,  and  entered  Bellevue  Hospital,  New  York.  He 
practised  in  Scranton,  then  in  New  York,  and  settled 
in  Matamoras  two  years  ago.  His  father  was  Dr. 
Thomas  Kelley,  of  Scranton,  and  both  of  his  grand- 
fathers were  physicians.  He  had  five  brothers  in  the 
medical  profession,  two  of  whom  are  living. 

Dr.   Henry   J.   Costello,  of   Philadelphia,  killed 
himself  on   August   13th   at   Eaglesmere,  by  hanging.        1 
He  had  suffered  for  a  long  time  from   insomnia.     He 
was  twenty-eight  years  old  and  W'as  a  graduate  of  the 
Jefferson  Medical  College  in  the  class  of  1895. 


August 


1 8,  1900] 


MEDICAL    RECORD. 


261 


^euiexus  and  ^loticea. 


Nf.i-roma  and  Nf.i-rokibromatosis.  By  Alexis  Thomson, 
M  D.,  F.R.C.S.E.  16S  pages  quarto;  twenty  plates. 
Edinburgh  ;  Turnbull  &  Spears.     1900. 

TnK  author  of  this  book  is  certainly  to  be  congratulated  for 
this  interesting  contribution  to  medical  literature.  The 
subject-matter  is  clearly  and  conci.sely  treated,  and  in- 
creased value  is  given  to  the  work  by  the  citation  of  numer- 
ous clinical  records  of  this  disease.  The  illustrations  are 
numerous  and  particularly  apt  and  good. 

"Festschrift  "  in  Honor  of  Abraham  Jacobi.  M.D.,  LL.D., 
to  Commemorate  the  Seventieth  Anniversary  of  His 
Birth.     New  York  :  The  Knickerbocker  Press,     igoo. 

An  American  jubilee  volume  of  international  contributions 
to  medical  literature  is  among  the  rarest  of  rare  things  that 
come  to  the  editor's  table.  The  one  before  us  does  the 
highest  credit  to  all  those  who.  in  its  conception  and  exe- 
cution, had  a  part  in  presenting  to  the  profession  a  work 
which,  while  it  honors  Professor  Jacobi,  reflects  honor  upon 
themselves.  Scientific  contributions  from  all  parts  of  the 
world  are  published  in  English,  German,  and  French. 
There  are  a  number  of  good  illustrations.  The  frontis- 
piece, a  portrait  of  Dr.  Jacobi,  especially  made  for  this 
work  by  the  celebrated  etcher  James  D.  Smillie,  is  truly 
a  work  of  art  and  a  most  excellent  likeness. 

Thf.  Rf-FRaction  of  thf.  Eve  :  A  Manual  for  Students. 
By  GirsTAVi's  Haktridc.k,  F.R.C.S.,  Senior  Surgeon  to 
the  Royal  Westminster  Ophthalmic  Hospital ;  Ophthal- 
mic Surgeon  and  Lecturer  on  Oi)hthalmic  Surgery  to  the 
Westminster  Hospital ;  Ophthalmic  Surgeon  to  St.  Bar- 
tholomew's Hospital,  Chatham  ;  Consulting  Ophthalmic 
Surgeon  to  St.  George's  Dispensary.  Hanover  Square. 
etc.  With  one  hundred  and  five  illustrations.  Tenth 
edition.     Philadelphia:  P.  Blakiston's  Son  &  Co.     1900. 

The  revised  tenth  edition  of  this  excellent  work  forms  a 
volume  of  two  hundred  and  sixty-seven  pages ;  it  is  care- 
fully written  and  treats  the  subject  in  quite  a  comprehen- 
sive manner.  The  language  is  simple  and  direct  and  of  a 
nature  readily  understood  by  the  student.  Illustrations 
are  found  wherever  they  can  serve  to  elucidate  the  text. 
Cases  presenting  the  various  problems  in  refraction  are 
given  as  required.  The  dioptric  system  of  lens  nomencla- 
ture is  used  throughout  the  work,  the  relative  value  of  the 
inch  systems  being  given  in  an  appendix.  A  creditable 
series  of  test  types  is  added.  This  work  has  few  equals  as 
a  guide  for  the  student  in  the  study  of  refraction  ;  its  teach- 
ings are  thoroughly  trustworthy. 

The  Ophthalmic  Patient.  Manual  of  Therapeutics  and 
Nursing  in  Eye  Disease.  By  Percy  Friedenkerg,  M.D. . 
Ophthalmic  Surgeon  to  the  Randall's  Island  and  Infants' 
Hospitals  ;  Assistant  Surgeon.  New  York  Eye  and  Ear 
Infirmary.    New  York :  The  Macmillan  Company.     1900. 

This  little  volume  of  three  hundred  and  eleven  pages  is  a 
comprehensive  treatise  on  ophthalmic  nursing,  and  is  de- 
signed "to  serve  as  a  practical  guide  to  physicians,  stu- 
dents, and  nurses  who  lack  special  training  in  the  care  of 
ophthalmic  cases."  The  contents  include  instructions  re- 
garding the  construction  of  eye  wards  ;  method  of  taking 
histories;  diet  and  dress  of  patients;  remedies  used  in 
ophthalmic  practice;  asepsis  and  antisepsis;  preparation 
of  patients  for  operation,  and  post-operative  care  ;  ana;s- 
thetics  ;  the  care  of  instruments,  dressings,  and  bandag- 
ing, etc.  The  language  is  sufficiently  devoid  of  technical 
terms  to  be  readily  comprehended  by  one  who  has  not  had 
a  medical  education.  The  work  is  admirably  adapted  to 
the  use  of  nurses  and  contains  much  that  is  of  value  to 
every  practitioner  of  medicine. 

Injuries  to  the  Eve  in  their  Medico-Legal  Aspect. 
By  S.  Baidrv,  M.D.,  Professor  in  the  Faculty  of  Medi- 
cine, University  of  Lille.  France,  etc.  Translated  fro'm 
the  Original  by  Alfred  James  Ostheimek.  Jr.,  M.D..  of 
Philadelphia,  Pa.  Revised  and  Edited  by  Charles  A. 
Oliver,  A.M.,  M.D..  Attending  Surgeon  to  the  Wills 
Eye  Hospital  ;  Ophthalmic  Surgeon  to  the  Philadelphia 
Hospital ;  Member  of  the  American  and  French  Oph- 
thalmological  Societies,  etc.  With  an  Adaptation  of  the 
Medico-Legal  Chapter  to  the  Courts  of  the  United  States 
of  America,  by  Ciiaiu.es  Sixkler,  Esq.,  member  of  the 
Philadelphia  Bar.     The  F.  A.  Davis  Company.     1900. 

This  small  volume  of  one  hundred  and  sixty-one  pages  is 
divided  into  four  parts.  Parts  I.  and  II.  are  devoted  to  an 
enumeration  and  brief  description  of  the  injuries  that  may 
occur  to  the  eyeballs  and  adnexa.  and  their  treatment. 
Part.  III.  treats  of  the  simulated  and  exaggerated  affec- 


tions of  the  eye  and  fully  describes  the  methods  for  their 
detection.  Part  IV.  contains  a  description  of  medico-legal 
expert  testimony,  with  a  brief  discussion  of  the  subject  and 
some  illustrative  cases.  A  fairly  comprehensive  bibliog- 
raphy is  appended. 

A  Pr.vcticai.  Treatise  on  the  Sexual  Disorders  of  the 
Male  and  Female.     New  (second)   edition.     By  Robert 
W.   Taylor,   M.D.,  Clinical  Professor  of  Venereal  Dis- 
eases in  the  College  of  Physicians  and  Surgeons,  New 
York.     In  one  handsome  octavo  voUime  of  435  pages, 
with  91  illustrations  and   13  plates   in  colors  and  mono- 
chrome.    Philadelphia  and  New  York  :  Lea  Brothers  & 
Co.     i9<x). 
The  author  is  to  be  congratulated  upon   the   popularity 
which  exhausted  his  first  edition  so  promptly.     This  issue 
has  been  carefully  revised  and  some  new  matter  added, 
especially  in  chapters  dealing  with  female  diseases,  includ- 
ing vaginismus,    kraurosis  vulva;,  etc.      To   the  original 
illustrations  some  additions  have  been   made,  so  that  in 
it5  present  form  it  will  be  more  than  ever  valuable  to  those 
in  search  of  knowledge  in  these  departments. 

Atlas  and  Epitome  of  Special  Pathological  Histolocv. 
By  DocENT  Dr.  Hermann  Di'rck,  Assistant  in  the  Path- 
ological Institute  ;  Prosector  to  the  Municipal  Hospital 
L.  I.  in  Munich.     Authorized  Translation  from  the  Ger- 
man.    Edited   by  Lidvig  Hektoen,  M.D.,  Professor  of 
Pathology  in  Rush  Medical  College,  Chicago.     Circula- 
tory  Organs;     Respiratory   Organs;    Gastro-Intestinal 
Tract.     With    sixty-two  colored   plates.     Philadelphia ; 
W.  B.  Saunders.     1900. 
The  author  of  this  volume  gives  in  a  concise  manner  the 
main  points  to  be  noted  in  the  different  diseases  of  the  cir- 
culatory,  respiratory,   and  digestive  organs.     The   plates 
are  good,  made  from  the  original  specimens  of  the  author, 
and  are  particularly  selected  as  best  illustrating  the  topics 
under  discussion. 

Fractures.     By  Carl  Beck,  M.D.,  Visiting  Surgeon  to  St, 
Mark's  Hospital  and  to  the   New  Y'ork   German    Poli- 
kliuik ;     formerly     Professor    of    Surgery,    New     York 
School  of  Clinical  Medicine  ;  Consulting  Surgeon.  Shel- 
tering Guardian  Society  Orphan  Asylum,  etc.     With  an 
Appendi.x  on  the  Practical  Use  of  the  Roentgen  Rays. 
Philadelphia :  W.  B.  Saunders  &  Co.     1900. 
This  work  is  important  chiefly  as  being  the  first  attempt  to 
bring  before  the  profession  in  a  systematic  way  the  .study 
of  fractures  by  means  of  the  Roentgen  rays.     The  author 
has  shown  by  skiagrams,  chiefly  original,  all  the  common 
and  many  of  the  rare  forms  of  fractures.     The  use  of  the 
Roentgen  rays  with  its  full  technique  is  fully  explained, 
and  the    practical  points    (especially  the  errors  liable  to 
cause  misinterpretations)  are  brought  out  with  a  thorough- 
ness which  merits  high  praise.     To  any  one  who  intends 
to  deal  with  fractures  and  has  the  privilege  of  an  .i-ray  ap- 
paratus, the  work  can  be  recommended  as  useful  and  trust- 
worthy.    There  are  one  hundred  and  seventy-eight  illus- 
trations. 

A  Treatise  on  Appendicitis.  By  John  B.  Deaver.  M.D., 
etc.  Second  edition,  revised  and  enlarged.  Illustrated 
with  twenty-two  full-page  plates.  Philadelphia ;  P. 
Blakiston's  Son  &  Co.  1900. 
This  volume  is  an  enlarged  and  revised  edition  of  the  au- 
thor's work  of  four  years  ago.  He  is  more  than  ever  con- 
vinced that  the  treatment  of  appendicitis  is  a  purely  surgi- 
cal question,  and  he  maintains  the  correctness  of  his  very 
radical  views  with  considerable  success.  The  chapters  on 
the  pathologj'  of  the  disease  in  question  are  instructive, 
and  that  on  differential  diagnosis  is  complete  and  useful. 
The  sul)ject  of  medical  treatment  is  given  some  space,  and 
we  are  warned  in  this  connection  that  surgical  treatment 
is  at  any  time  likely  to  be  imperatively  demanded  by  the 
occurrence  of  threatening  symptoms.  This  is,  of  cour.se, 
entirely  true,  and  only  shows  what  a  makeshift  the  medical 
treatment  of  appendicitis  is.  The  plates  in  this  volume 
are  verv  well  executed  and  its  general  appearance  is  excel- 
lent. 

A  Manual  of  Clinical   Diagnosis   bv  Mea.ns   of   Micro- 
scopic AND  Chemical  Methods,  for  Students.  Hospital 
Physicians,  and  Practitioners.     By  Charles   E.   Si.mon, 
M.D.,  Late  Assistant  Resident  Physician,  Johns  Hop- 
kins Hospital,  Baltimore  ;  Fellow  of  the  American  Acad- 
emy of   Medicine.     Third  edition,    thoroughly   revised. 
Illustrated  with  one  hundred  and  thirty-six  engravings 
and  eighteen  plates  in  colors.     Philadelphia  and  New 
York  :  Lea  Brothers  &  Co.     1900. 
The  third  edition  of  this  valuable  work  is  brought  thor- 
oughly up  to  date.     The  most  approved  modern  methods 
are  described  comprehensively,   yet  clearly  and   simply. 


262 


MEDICAL    RECORD. 


[August  18,  1900 


The  section  on  the  study  of  the  blood  has  been  elaborated, 
and  the  whole  work  has  been  carefully  revised,  much  new 
material  being  added.  The  subject-matter  comprises  the 
examination  of  the  blood,  the  secretions  of  the  mouth,  the 
gastric  juice  and  contents,  the  fa;ces.  the  nasal  secretion, 
the  s])Utura,  the  urine,  transudates  and  exudates,  cystic 
contents,  cerebro-spinal  fluid,  the  semen,  the  vaginal  dis- 
charge, and  milk.  The  text  is  embellished  throughout 
■  with  excellent  illustrations, 

Les  San.vtoria.  Traitement  et  Prophylaxie  de  la  Phtisie 
Pulmonaire.  Par  S.  A.  K.nopf,  de  la  Faculte  de  Paris  et 
de  Bellevue  Hospital  Medical  College  (New  York). 
Medecin  du  Departement  Pulmonaire  du  New  York 
Throat  and  Nose  Hospital  ;  Ancien  Assistant  du  Pro- 
fesseur  Dettweiler  an  Sanatorium  de  Falkenstein  ;  Mem- 
bre  de  I'Academie  de  Medecine  de  New  York  ;  Laureat 
de  I'Academie  de  iledecine  de  Paris.  Deuxieme  edi- 
tion.    Paris  :    Georges  Carre  et  C.  Nand.     1900. 

The  second  revised  and  greatly  enlarged  edition  of  this 
work,  which  was  originally  the  author's  graduation  thesis 
at  the  University  of  Paris,  is  an  attractive  treatise  of  four 
hundred  and  eighty-five  pages,  profusely  illustrated  and 
handsomely  bound— indeed,  a  veritable  edition  de  luxe. 
The  author  emphasizes  the  importance  of  hygienic  and 
dietetic  measures  in  the  treatment  of  tuberculosis,  and  he 
lays  great  stress  on  prophylaxis  in  this  disease.  In  the 
chapter  on  aerotherapy  there  is  a  detailed  description  of 
the  pneumatic  cabinet.  The  most  important  sanatoria  in 
the  different  countries  are  described  with  illustrations.  The 
last  two  chapters  deal  with  maternity  sanatoria,  hospitals 
and  schools  for  tuberculous  children,  And  sanatoria  for  the 
poor.  Dr.  Knopf  is  the  author  of  an  American  publication 
on  the  same  subject,  to  which  was  awarded  in  1S9S  the 
Alvarenga  prize  of  the  College  of  Physicians  of  Philadel- 
phia, and  he  has  just  received  a  prize  established  by  the 
Berlin  Congress  of  Tuberculosis  for  a  treatise  on  the  best 
method  of  combating  tuberculosis  among  the  poor;  this 
will  be  published  by  the  committee  of  award  m  Berlin,  so 
the  author  will  enjoy  the  unique  distinction  of  having  writ- 
ten and  published  three  books  in  three  different  countries, 
of  which  two  have  been  officially  proclaimed  by  competent 
judges  the  best  of  their  class. 

Die  angeborene  Luxation  des  Huftgelenkes.  Von  Geh. 
Med. -Rath  Prof.  Dr.  Max  Schede  (Bonn).  26  pages 
quarto,  with  S  i^lates.  Hamburg  :  Lucas  GrJife  &  Sillem. 
1900. 

This  short  monograph  is  certainly  a  most  valuable  addi- 
tion to  the  subject  of  congenital  hip-joint  dislocation.  A 
number  of  points  brought  out  by  the  author  differ  radically 
from  what  have  been  the  hitherto  accepted  notions  con- 
cerning this  subject.  First,  the  author  insists  that  bj*  far 
the  most  frequent  type  of  congenital  hip-joint  dislocation 
is  the  supra-cotyloid,  and  not  the  iliac  ;  thereby  differing 
from  traumatic  hip-joint  dislocations.  This  difference  is 
due  to  the  fact  that  the  femur  head  in  congenital  disloca- 
tions leaves  the  cotyloid  cavity  at  the  upper  aspect  of  the 
capsule  instead  of  at  the  posterior  inferior  aspect,  as  it 
usually  does  in  traumatic  dislocations.  In  an  excellent 
chapter,  "On  the  Changes  in  the  Head  and  Upper  Ex- 
tremity of  the  Femur,"  the  author  has  drawn  especial  at- 
tention to  an  anteversion  of  the  head,  which  is  present  in 
most  of  these  cases.  In  virtue  of  this  anteversion  the 
head  no  longer  lies  medially  to  the  trochanter,  but  in  front 
or  even,  in  extreme  cases,  external  to  it.  This  change  in 
the  upper  end  of  the  femur  interferes  with  tlie  success  of 
reposition  and  final  healing,  if  these  are  carried  out  in  a 
manner  applicable  to  traumatic  cases  of  hip-joint  disloca- 
tion. Tlie  author  has  therefore  modified  the  method  of  re- 
position and  after-treatment.  His  method  may  be  sum- 
marized as  follows:  (i)  By  palpation  and  Roentgen 
photography  in  various  positions  of  the  hip  joint,  the 
extent  of  anteversion  of  the  up])cr  femur  end  is  determined. 
(2)  Reposition  is  accomiilishd  by  traction  (sixty  to  one 
hundred  pounds) ,  and  while  pressure  over  the  trochanter 
is  l)eing  made,  tlie  limb  is  abducted  and  rotated  inward. 
When  the  anteversion  of  Ihc  upper  femur  end  is  very 
slight,  outward  instead  of  inward  rotation  is  made.  In- 
ward rotation  is  maintained,  the  extent  of  the  rotation 
depending  on  the  amount  of  the  anteversion.  (3)  The 
limb  is  immoliilized  in  the  position  of  abduction  and  in- 
ward rotation  for  from  two  to  tliree  months,  and  then  to 
prevent  a  reluxation,  which  usually  follows  when  outward 
rotation  is  assumed,  an  osteotomy  of  the  femur  through  its 
lower  third  is  performed.  The  lower  fragment  can  thus  be 
brought  into  Us  normal  anterior  (losition,  while  the  upjier 
fragment  is  kept  inwardly  rotated — healing  occurs  in  this 
position.  (4)  After  the  osteotomy  has  healed  the  jiatient 
is  required  to  wear  a  plaster-of-Paris  splint  for  from  three 
to  six  months.  The  monograph  is  excellently  illustrated 
by  numerous  Roentgen  photographs. 


grogvcss  ot 


l^acdiciil 


.science. 


^Wti'  \'o>l-  Miciicii/  /oiiriiii/.  .hii^iis/  11,  ic)oo. 

The  Relation  of  Seminal  Vesiculitis  to  Impotence. — Ramon 

Guiteras  says  that  seminal  vesiculitis  results  from  prostatic 
trouble  due  to  acute  prostatitis,  in  which  the  ejaculatory 
ducts  are  pressed  upon  by  ;in  exudate  in  the  gland  ;  pros- 
tatic abscess,  during  the  healing  of  which  the  ducts  may 
be  caught  and  pinched  in  the  scar  tissue,  and  any  growth 
or  enlargement  of  the  gland  m  so  far  as  it  presses  upon 
them.  Pressure  from  any  of  these  causes  interferes  with 
the  function  of  the  vesicles,  and  causes  inflammation  of 
them,  in  much  the  same  way  that  an  obstruction  of  the 
urethra  gives  rise  to  cystitis.  Cases  generally  present  a 
stage  of  sexual  excitation  followed  by  depression.  The 
vesicles  are  sensitive  to  touch.  They  may  be  dilated  and 
in  a  condition  which  might  be  termed  spermatic  retention 
due  to  an  atonic  condition  of  the  walls  associated  with 
pressure  ;  at  other  times  they  are  dilated,  but  feel  soft  and 
pasty  :  again  there  may  be  an  acute  inflammation  of  these 
structures,  or  the  condition  may  be  one  of  atrophy.  The 
method  of  treatment  may  be  outlined  as  follows  :  Internal 
remedies  to  neutralize  the  urine  in  cases  of  over-acidity ; 
rectal  irrigation  every  night,  with  decinormal  salt  solution 
or  strained  flaxseed  tea  at  a  temperature  of  105  to  120  F.. 
by  means  of  the  double-current  rectogenital  tube,  and 
massage  of  the  internal  genitals  every  five  days,  followed 
immediately  by  a  urethral  irrigation  whenever  there  is 
chronic  prostatitis  or  posterior  urethritis  associated  with 
this  condition.  The  patient  will  at  first  scarcely  be  able  to 
tolerate  the  gentlest  manipulation  of  the  vesicle  by  the 
finger,  but  after  several  seances  not  only  will  he  be  able  to 
endure  the  massage,  but  he  will  feel  much  benefited  and 
relieved  by  it.  After  the  S)-mptoms  of  inflammation  and 
irritation  have  been  relieved,  tonics,  such  as  strychnine  and 
iron,  can  be  used,  or  even  damiana  and  phosphorus.  Elec- 
tricity may  also  be  emploj'ed  \>y  means  of  the  rectal  elec- 
trode, using  the  galvanic  or  the  faradic  current  or.  better 
still,  the  galvanic  followed  by  the  faradic. 

The  Diagnostic  and  Therapeutic  Value  of  Insufflation  of 
the  (Esophagus,  Stomach,  and  Colon. — C.  D.  Spivak  de- 
scribes the  different  methods  of  producing  insufflation,  and 
gives  the  differential  diagnosis  of  the  various  conditions  it 
is  used  to  detect.  The  procedure  has  been  recommended 
in  obstruction  of  the  bowel,  especially  in  invagination  and 
volvulus,  in  chronic  atony  of  the  bowel,  etc.  Spivak  is  ex- 
perimenting with  the  introduction  of  hot  air  into  the  stom- 
ach for  various  gastric  disorders,  but  is  not  yet  ready  to 
rejjort  results. 

The  Spectacle  and  Eyeglass  Habit. — A.  W.  Herzog  criti- 
cises severely  an  article  which  recently  appeared  in  the 
Journal  from  the  pen  of  N.  B.  Jenkins.  The  tone  of  the 
article  in  the  present  issue  is  not  pleasant,  although  the 
author  evidently  means  well.  Jenkins'  contention  was  in 
the  main  that  glasses  were  often  worn  when  there  was  no 
necessity  for  them.  Herzog  maintains  that  glasses  are 
worn  not  alone  for  imperfect  vision,  but  relieve  many  reflex 
neuroses,  such  as  headache,  nervousness,  chorea,  etc. 

An  Investigation  into  the  Causes  of  So-Called  Uric-Acid 
Lesions  and  a  Rational  Therapeusis  of  the  Uratic  Diathesis. 
—  By  A.  C.  Crofton. 

The  Etiology  of  Diphtheria  and  the  Value  of  Antitoxin ; 
A  Further  Criticism  of  Dr.  Herman's  Views. — By  A.  Robin. 

Obstetrical  "Don't  Fails."— By  C.  I.  Page. 

Medical  Xl-il's,  August  1  i ,  igoo. 

Anastomosis  of  Ureters  with  Intestine. — Reuben  Peter- 
son, basing  his  paper  on  experimental  work,  reviews  in 
c.xlcnso  the  literature  of  the  subject.  The  most  striking 
fact  revealed  by  such  study  is  the  exceptional  lii.gh  mortal- 
ity accompanying  the  operation.  Primary  mortality  is 
large  by  all  methods  ;  twenty-eight  uretero-intestinal  im- 
plantations show  a  primary  mortality  of  thirty-two  per 
cent.  The  general  conclusions  are  as  follows,  (i)  The 
primary  mortality  of  uretero  intestinal  anastomosis  both 
in  experimental  work  on  animals  and  in  man  is  exceed- 
ingly high.  (2)  The  best  technique  is  that  requiring  the 
least  amount  of  suturing  of  the  ureters  themselves.  (3) 
All  efforts  to  prevent  a.scending  renal  infection  in  animals 
or  in  man  when  the  ureter  has  been  implanted  without  its 
vesical  orifice  have  proved  futile.  (4)  It  is  impossible  to 
determine  in  advance  the  extent  of  the  infection  which  will 
result  from  uretero-intestinal  anastomosis.  The  patient 
may  die  in  a  few  days  of  a  pya'mui  or  in  a  short  time  of 
])yelonephritis,  or.  in  rare  cases,  may  recover  from  the  in- 
fection with  resulting  contracted  kidneys.  (5)  Hence  the 
operation  is  unjustifiable,  either  for  the  purpose  of  making 
the  patient  more  comfortable,  iis  in  exstrophy  of  the  blad- 
der, vesico-vaginal  or  uretero-vaginal  fistula,  or  for  malig- 
nant disease  of  the  bladder.      (0)   The  results  ot  uretero- 


August  1 8,  1900] 


MEDICAL    RECORD. 


26: 


intestinal  anastomosis  through  the  formation  of  vesico- 
rectal fistulas  have  not  been  favorable  up  to  the  present 
time.  (7)  The  success  of  Frank's  experimental  work  in 
vesico-rectal  anastomosis  justifies  the  expectation  that  the 
future  results  of  this  operation  will  be  more  satisfactory. 
(S)  The  primary  mortality  of  uretero-trigono-intestinal 
anastomosis  is  low  for  an  operation  of  this  magnitude,  (y) 
While  it  cannot  be  denied  that  ascending  renal  infection 
may  occur  after  this  operation,  the  infection  as  a  rule  is  of 
such  a  type  that  the  chances  of  the  individual's  overcom- 
ing it  are  good.  (10)  Hence,  the  operation  of  implanting 
the  vesical  flap  with  its  ureteral  orihces  into  the  intestine 
is  a  justifiable  surgical  procedure.  (11)  There  is  no  valve 
guarding  the  vesico-ureteral  orifice  ;  nor  does  the  circular 
muscle-layer  of  the  ureter  nor  the  bladder-muscles  them- 
selves act  as  a  sphincter.  (12)  It  has  been  abundantly 
demonstrated  by  experimental  and  clinical  work  that  the 
rectum  tolerates  the  presence  of  urine  and  acts  as  a  good 
substitute  for  the  bladder,  and  that  good  control  over  the 
anal  sphincter  will  be  maintained. 

Chronic  Enteritis  and  Tuberculous  Enteritis  Treated  with 
Hypodermic  Injections  of  Arsenic. — Louis  Kolipinski  says 
patliological  anatomy  recognizes:  (i)  a  hyperplastic  in- 
flammation of  the  mucous  membrane;  (2)  an  atrophic 
form  ;  (3)  ulceration  of  the  mucosa  may  coexist.  Injec- 
tions are  given  once  a  week  in  chronic  enteritis  ;  a  o.  5-pcr- 
cent.  salt  solution  being  used  as  a  menstruum.  If  good 
results  are  not  to  be  noted  within  fourteen  days,  the  injec- 
tions may  be  abandoned.     The  c<mclusions  quoted  are : 

(1)  The  arsenical  injection  is  safe,  painless,  and  effective. 

(2)  The  dose  is  very  small.  From  gr.  j'j  to  gr.  ,'j  of 
sodium  arsenite  is  sufficient.  (3)  One,  two,  or  three  injec- 
tions per  week  will  cure  in  'the  milder  cases.  (4)  Other 
internal  medication  is  avoided,  and  the  patient  has  no 
daily  routine  of  dosing.  (5)  Greater  latitude  in  diet  can 
be  allowed  without  detriment. 

Vaccination  Eruptions.— Jacob  Sobel  makes  a  sharp  dis- 
tinction between  eruptions  incidental  to  the  period  follow- 
ing vaccination  and  those  due  to  the  inoculation  pure  and 
simple.  The  paper  deals  mainly  with  generalized  vaccina- 
tion eruptions.  The  material  studied  was  that  of  Dr.  C. 
\V.  Allen's  skin  clinic  during  three  years,  in  which  there 
were  out  of  4, 160  vaccinations  5S3  sequelae  or  complications, 
of  which  So  were  generalized  eruptions  of  one  kind  or  an- 
other, or  about  two  in  every  hundred.  Illustrations  of  the 
urticarial  bullous  and  vesico-buUous  types  accompany  the 
article.  The  most  common  generalized  eruption  after  vac- 
cination is  the  urticarial,  occurring  from  the  fifth  to  the 
fifteenth  day. 

The  Automobile  in  Country  Practice.— By  A.  D.  Hard. 

School  Break-Down. — By  J.  Henry  Bartlett. 
Boston  Miulii'al  mul  Sin\i(!Ciil  foiiriuil,  August  g.  /goo. 

Acute  Dilatation  of  the  Heart  in  Influenza  of  Children. — 
F.  Forchheimer  describes  two  forms  of  this  affection,  as 
seen  in  epidemics  of  influenza,  a  severe  and  a  mild  form. 
The  dominant  symptoms  are  on  the  part  of  the  heart,  with 
a  peculiar  respiration  which  the  author  has  seen  in  only 
two  other  conditions — in  pericardial  effusion,  and  the  fugi- 
tive oedcmatous  condition  of  lung  that  frequently  precedes 
pneumonic  consolidation  in  influenza  without  cardiac 
change.  He  believes  that  we  are  justified  in  assuming 
that  one  form  of  heart  dilatation  is  produced  by  the  action 
of  the  toxin  upon  the  nervous  system  of  the  heart  and  pos- 
sibly upon  the  myocardium ;  this  form,  according  to  the 
observations  made  by  West,  may  end  fatally.  The  second 
form  occurs  when  the  outflow  of  the  blood  is  materially  in- 
terfered with  by  mechanical  conditions.  This  lasts  much 
longer  than  the  first,  but  in  children  has  a  tendency  to 
recovery. 

Norfolk  District  Records  and  Reminiscences,  1350-1900. — 
By  C.  Ellery  Stedinan. 

The  Progress  of  Medicine.— By  Harold  C.  Ernst. 

7 /le  I'liilaiL-ipiiia  Mcilical  Journal,  August  //,  igoo. 

Puerperal  Eclampsia. — J.  B.  Todd  says  that  headache 
during  labor  and  the  two  following  days  is  a  danger  sig- 
nal of  coming  eclampsia.  In  the  treatment  he  places  little 
reliance  on  diuretics,  but  gives  hydragogue  cathartics, 
preferably  elaterium,  to  effect  the  elimination  of  the  poison. 
Morphine  in  doses  of  gr.  ss.-iss.  is  given  hypodermically 
to  control  the  convulsions,  the  injection  being  repeated 
whenever  the  patient  complains  of  severe  pain  in  the  iiead. 
The  cathartic  is  followed  by  a  mixture  of  one  grain  of  corro- 
sive sublimate  and  one  ounce  of  tincture  of  the  chloride  of 
iron,  twelve  drops  being  given  in  a  capsule  every  four 
hours.  The  writer  reports  briefly  ten  cases  which  occurred 
in  his  practice. 

Clinical  Report  of  Two  Cases  of  Paralytic  Dementia  Occur- 
ring in  the  Negro.— By  W.  K.  Walker 

Transmission  of  Tuberculosis  through  the  Meat  and  Milk 
Supply.— By  John  J.  Repp. 


Miitter  Lectures  of  the  College  of  Physicians  of  Philadel- 
phia.-By  John  B,  Roberts. 

Report  of  a  Case  of  Rupture  of  the  Perineum  in  Coitus. — 
By  R.  Abrahams. 

Military  Surgery. — By  W.  C.  Borden. 
Journal  of  the  American  Medical  Ass'  n,  August  11,  igoo. 

The  Treatment  of  Acute  Alcoholism  by  Large  Doses  of 
Digitalis. — W.  S.  I.oomis  finds  it  interesting  to  note  that  a 
drug  the  use  of  which  even  in  moderation  is  supposed  to 
be  attended  with  some  danger  can  be  given  in  dose  of  one- 
half  ounce  of  the  tincture  in  alcoholism  without  producing 
any  of  the  ordinary  symptoms  of  poi.soning.  From  a  study 
of  cases  treated  by  this  method  the  following  conclusions 
are  drawn:  (i)  The  indiscriminate  use  of  large  doses 
(half-ounce)  of  digitalis  in  acute  alcoholism  is  fraught  with 
danger.  (2)  The  cases  in  which  it  should  be  given  are  the 
strong,  robust,  those  in  early  life,  with  no  complications, 
and  those  with  violent  delirium.  In  these  cases  the  result 
will  be  exceptionally  favorable.  The  patients  become 
quiet  and  go  to  sleep  with  a  certainty  and  promptness  ob- 
tained by  no  other  methods  with  which  the  author  is  famil- 
iar. (3)  If  after  three  doses  no  narcotic  effect  is  noted,  he 
would  not  advise  a  continuance  of  the  remedy.  He  believes 
in  the  above  class  of  cases  it  can  be  u.sed  with  perfect  safe- 
ty for  a  limited  number  of  doses.  (4)  The  failures  among 
the  writer's  cases  were  in  the  chronic  alcoholic  subjects,  in 
those  in  middle  and  advanced  life,  in  the  ana;mic,  and  in 
those  with  bad  nutrition.  (5)  One  fact  noted  which  showed 
marked  results  from  the  treatment  was  that  when  the  pa- 
tients recovered  and  awoke  from  their  sleep  they  were  in 
such  good  condition  that  they  were  able  to  leave  the  hospi- 
tal at  once.  This  is  an  unusual  experience,  as  ordinarily 
convalescence  is  delayed  for  two  or  three  days. 

New    Sources  of    Danger  in  the    Use    of   Opium.— T.    D. 

Crothers  refers  to  his  former  paper  bearing  on  the  ques- 
tion of  diftering  effects  of  opium  in  dift'erent  individuals 
and  the  tendency  created  in  some  persons.  He  finds  the 
stimulating  effect  fascinating  to  the  alcoholic,  necessitating 
watchful  care  in  the  use  of  any  form  of  opium  in  these  or 
other  subjects.  The  facts  to  make  prominent  are:  (i) 
The  use  of  opium  continuously  for  any  possible  purpose  is 
dangerous,  in  that  it  may  impress  the  organism  in  some 
unknown  way  and  leave  a  diathesis  and  susceptibility  to 
resort  to  it  again  in  after-life.  (2)  The  condition  called 
opium  addiction,  in  which  the  drug  is  used  for  its  narcotic 
and  pleasing  effects,  is  one  of  organic  disease  whose  origin 
is  preventable  by  a  study  of  the  conditions  and  peculiarities 
of  the  person  in  early  life.  (3)  When  opium  is  used  with 
but  little,  if  any,  irritant  effects,  there  exists  a  predisjjosi- 
tion  to  its  continuous  use  and  the  development  of  an  addic- 
tion. (4)  When  its  poisonous  effects  are  marked  in  the 
irritations  and  exaltations  which  follow  its  use,  there  is 
great  danger  of  organic  changes  and  diseases  with  tatal 
results.  (5)  The  psychic  element  in  these  cases  furnishes 
very  suggestive  hints  of  the  derangements  which  follow 
the  mental  perversions  and  disturbances  of  reason  and 
judgment,  and  gives  some  idea  of  the  profound  organic 
changes  which  take  place. 

Scrofulous  Keratitis. — H.  Gradle  makes  observations  on 
the  etiology  and  treatment  of  this  condition,  especially  by 
salicylate  of  sodium.  They  define  the  conditions  gener- 
ally included  under  the  term  by  writers,  and  give  the  pres- 
ent clinical  conception  of  scrofula.  The  exciting  cause  of 
phlyctenular  eruptions  is  unknown,  but  their  peculiarities 
are  dwelt  upon.  Salicylate  of  sodium,  best  given  in  five- 
grain  tablets,  shows  its  good  effects,  if  at  all,  within  two 
days.  Its  value  was  most  marked  in  cases  accompanied 
by  much  suffering. 

Fracture  and  Dislocation  of  the  Spine. — S.  P.  Kramer 
gives  a  report  of  a  case  of  gunshot  wound  of  the  spine, 
pointing  out  the  difficulties  and  describing  measures  for 
the  restoration  of  function  in  the  cord.  Non-operative 
treatment  is  not  favorably  considered,  extension  is  too 
risky,  while  the  need  of  early  operation  to  remove  pressure 
is  urgent. 

Secondary  Glaucoma. — W.  C.  Posey  and  E.  A.  Shumway 
give  a  clinical  and  pathological  report  of  three  cases  repre- 
senting different  types  of  the  disease.  They  define  sec- 
ondary glaucoma  and  give  report  on  the  microscopic  find- 
ings, calling  attention  to  points  of  special  interest. 

The  Medical  Profession.  The  Necessity  of  and  Benefits 
from  its  more  Complete   Organization. — By  J.   C.   Bierwirth. 

Materia   Medica,    Pharmacy,  and   Therapeutics.— Address 

of  chairman,  Leon  L.  Solomon. 

The   Therapeutic   Properties  of  the  Suprarenal  Capsule. — 

By  W.  H.  Bates. 

Section  on  Ophthalmology. — Address  of  chairman,  H.  V. 
Wurdeman. 


264 


MEDICAL    RECORD. 


[August  18,  1900 


The  Lancet.  A  lit;  list  4.  iqoo. 

Some  Remarks  upon  the  Xechiiique  of  Operations  Designed 
to  Cure  Radically  Oblique  Inguinal  Hernia.— F.  IJ.  Bird  lays 
stress  on  the  following  points  ;  the  skin  incision  to  l)e  made 
well  above  Poupart's  ligament  and  well  away  from  the 
pubes,  the  separation  of  the  fibres  of  the  external  oblique 
aponeurosis  at  a  suitable  spot,  the  separation  being  carried 
well  toward  the  muscular  portion  :  the  sparing  of  the  ex- 
ternal ring  ;  the  dislocation  but  partial  of  the  cord  from  its 
bed,  and  the  elimination  of  the  sac  from  above  and  there- 
fore the  preservation  of  the  nerves,  the  whole  to  be  accom- 
plished with  little  or  no  bleeding — an  advantage  to  be  at- 
tained with  great  gentleness  and  the  use  of  dissecting 
forceps.  Apart  from  the  unworkmanlike  appearance  of  a 
sloppy  operation  area,  bleeding  much  inconveniences  the 
surgeon  and  damages  the  tissues.  It  obscures  the  view, 
necessitates  constant  sponging,  and  irritates  the  delicate 
areolar  planes,  which  become  more  or  less  loaded  with 
blood  not  capable  of  being  removed.  The  serous  exudation 
is  much  greater  and  the  tissues  are  much  weaker  and  sod- 
den. In  addition  to  these  immediate  disadvantages  there 
is  the  grave  though  unlikely  occurrence  of  thrombosis  in 
the  veins  of  the  cord  with  its  possibilities  of  pneumonia 
and  other  distant  disasters.  The  absence  of  the  deep  su- 
tures is  a  gain  in  two  directions :  the  unimpeded  mu.scle 
acts  as  nature  meant  it  to,  and  there  is  no  foreign  body  at 
all  in  the  depths  of  the  wound,  no  silk  with  tension  on  it, 
and  no  over-chemicalized  catgut. 

A  Note  of  the  Safest  Method  of  Removal  of  the  Appen- 
dix.— A.  A.  Warden  advocates  Doyen's  method,  which  he 
describes  as  follows  :  The  little  mesentery  of  the  appendix 
is  first  ligatured  with  a  small  silk  ligature  to  free  the  ap- 
pendix laterally.  Then  (i)  the  base  of  the  appendix  is 
gently  crushed  with  Doyen's  small  clamp.  Almost  any 
forceps  suffices  for  this  purpose  if  strong  enough  and  broad 
enough  completely  to  occlude  the  appendix  for  a  breadth 
of,  say,  a  quarter  of  an  inch ;  (2)  a  fine  silk  ligature  is 
thrown  round  the  base  of  the  appendix  in  the  furrow  left 
by  the  clam]) ;  (3)  the  appendix  is  then  removed  by  the 
thermo-cautery  cutting  clase  to  the  ligature  ;  (4)  a  purse 
suture  is  then  made  in  the  serous  covering  of  the  cscum 
close  round  the  base  of  the  appendix  (as  this  purse-stitch 
is  drawn  tight  the  little  stump  is  invaginated  so  that  all  is 
completely  closed)  ;  (5)  for  safety  a  second  fine  silk  purse- 
stitch  is  made  and  the  little  pucker  of  the  first  stitch  ig 
similarly  invaginated  and  the  ligature  is  gently  tightened. 
The  result  technically  is  perfect,  and  certainly  this  is  the 
most  aseptic  method  of  removing  the  appendix. 

A  Case  of  Meningo-Myelitis  with  Bacteriological  Examina- 
tion of  the  Spinal  Cord. — G.  R.  Murray  and  W.  Hardcastle 
report  this  case.  The  pa\ient  was  a  single  man  aged 
twenty-nine  years,  who  died  seven  and  a  half  weeks  after 
admission  to  the  hospital.  The  attack  seemed  to  have 
been  precipitated  by  wetting,  exposure,  and  fatigue.  The 
characters  of  the  micro-organisms  obtained  from  the  spinal 
cord  are  .summarized  as  follows :  A  short  oval  motile  ba- 
cillus which  stains  readily  by  aniline  dyes,  the  stain  in 
many  cases  showing  a  much  stronger  aftinity  for  the  ends 
than  for  the  centre  of  the  bacillus.  It  can  with  care  be 
stained  by  Gram's  method,  and  was  found  in  large  num- 
bers in  the  pia  mater  and  also  in  lesser  numbers  in  the 
substance  of  the  cord.  Pure  cultures  of  the  bacillus  were 
obtained  both  from  the  meninges  and  also  from  the  sub- 
stance of  the  cord  itself.  Subcutaneous  inoculation  caused 
rapid  general  infection  in  the  guinea-pig  and  a  local  infec- 
tion in  the  rabbit.  The  bacillus  grows  readily  on  the  ordi- 
nary nutrient  media  in  both  the  hot  and  cool  incubators. 
It  liquefies  gelatin. 

A  Blood  Reaction  in  Diabetes  Mellitus ;  its  Cause  and 
Diagnostic  Value. — R.  T.  Williamson  says  that  a  drop  of 
blood  taken  from  the  linger  of  a  diabetic  decolorizes  a  warm 
alkaline  solution  of  methylene  blue  when  mixed  in  certain 
proportions  (details  given),  while  blood  from  healthy  jier- 
sons  or  fromjindividuals  sick  with  other  diseases  causes  un- 
der the  same  test  conditions  no  such  decolorization.  The 
action  is  due  to  the  glucose  in  the  blood.  The  test  is  avail- 
able in  coma  when  the  bladder  may  be  empty,  and  may 
be  of  medico-legal  value  in  ascertaining  the  cause  of  death 
in  a  doubtful  case.  It  has  been  made  with  positive  results 
si.xteen  hours  after  death. 

.  A  Case  of  Sudden  Death  Shortly  After  Operation. — W.  B. 

Thompson  operated  for  adenoids  and  enlarged  tonsils  on  a 
child  aged  twelve  years,  chloroform  being  used.  The  child 
did  well  for  a  few  minutes,  when  it  began  to  be  cyanotic 
with  weak  pulse,  dilated  pupils,  and  feeble  respiration. 
The  usual  restoratives,  lingual  traction,  and  finally  trache- 
otomy were  all  made  use  of.  but  without  avail.  There  was 
no  attempt  at  rallying,  and  heart  sounds  and  breathing 
ceased  for  some  time  after  artificial  respiration  was  aban- 
doned, after  about  one  and  one-half  hours.  Death  was 
ascribed  to  gradual  cardiac  ])aralysis. 


The  Etiology  of  Scurvy. — 'W'.  E.  Home  suggests  that 
scurvy  is  essentially  an  infection  of  the  mouth  with  micro- 
organisms out  of  decayed  food,  antagonized  by  lime-juice 
and  fresh  vegetables  which  act  as  antiseptics,  this  infection 
of  the  mouth  being  most  apt  to  occur  in  times  of  hardship 
when  cleanliness  is  least  within  our  reach. 

On  the  Limitation  of  Physical  Methods  in  the  Investiga- 
tion of  the  Physiological  and  Psychical  Phenomena  of  Sight. 
—By  F.  W.  Eldridge-Grecn. 

Medicine  as  a  Science  and  Medicine  as  an  Art. — Annual 
address  before  the  British  Medical  Association,  by  Philip 
Henry  Pye-Smith. 

The  Surgeon  in  the  Nineteenth  Century. — Address  before 
the  British  Medical  Association,  by  Frederick  Treves. 

Notes  on  Two  Cases  of  Pernicious  Ansemia  Treated  with 
Hommel's  HEematogen. — By  H.  Meggitt. 

Imperial  British  Pharmacopoeia.  Notes  on  Some  Indian 
Drugs. — By  William  Mair. 

Berliner  klinische  WochenscJiriJt,  July  23  and  j-o,  iqoo. 

The  Etiology  and  Therapy  of  Tabes  Dorsalis. — Concern- 
ing the  relation  of  syphilis  to  tabes,  P.  K.  Fels  takes  the 
view  that  the  former  makes  a  predisjiosition  for  the  latter, 
or  that  the  latter  may  be  regarded  as  a  para-syphilitic 
affection  comparable  to  the  paralysis  following  diphtheria. 
The  exact  relation  of  the  two  affections  is,  however,  still 
undetermined.  Tabes  more  often  follows  syphilis  when 
the  manifestations  of  the  latter  have  been  mild,  and  it  does 
not  occur  until  from  five  to  fifteen  years  after  the  specific 
infection.  It  is  not  a  continuance  of  the  original  syphilis. 
Concerning  treatment  Fels  says  that  the  best  treatment  is 
the  prophylactic — not  to  become  syphilitic.  Any  plan  of 
therapy  should  aim  at  putting  the  general  nervous  system 
into  the  best  possible  condition.  Mercury  is  to  be  given 
not  as  a  routine  but  only  in  selected  cases.  It  is  indicated 
(I)  in  cases  showing  specific  evidence;  (2)  when  tabes 
comes  on  only  a  few  years  after  infection  and  when  previ- 
ous treatment  has  been  without  result ;  (3)  in  cases  show- 
ing an  unusual  clinical  course  which  gives  evidence  that 
the  cord  and  brain  are  involved.  For  bladder  and  sexual 
weakness,  Fels  recommends  strychnine  given  subcutane- 
ously  in  the  general  region  of  th:  bladder.  He  regards  the 
effect  of  the  chloride  of  gold  and  sodium  as  problematical. 
Protargol  is  of  service.  He  also  enumerates  the  various 
other  remedies  and  plans  of  treatment  which  have  been  at 
various  times  tried. 

The  Recognition  and  Treatment  of  the  Ansemias. — H.  Sen- 
ator calls  attention  to  the  much  wider  signification  given 
to  the  term  "anannia  "  in  recent  years,  and  alludes  in  brief 
to  the  different  conditions  now  included  under  this  clinical 
term.  In  arriving  at  the  etiology  of  a  given  case  we  should 
never  omit  to  examine  both  macroscopically  and  micro- 
scopically the  stools  with  reference  to  the  presence  of  para- 
sites and  of  blood.  In  all  severe  cases,  the  blood  should 
be  examined  with  reference  to  departures  of  cell  contents 
from  the  normal.  Finally,  we  may  find  the  cause  of  some 
cases  to  reside  in  impairment  of  the  chemical  and  motor 
functions  of  the  stomach.  In  many  cases  of  chlorotic 
anaemia,  the  use  of  the  alkaline  salts  will  give  far  better 
results  than  to  begin  at  once  with  iron  preparations.  When 
the  time  for  the  latter  may  arrive,  combinations  with  the 
organic  acids  as  lactic,  citric,  acetic,  etc.,  will  answer  bet- 
ter than  the  metallic  compounds,  for  they  are  less  liable  to 
upset  the  stomach  and  to  constipate.  He  places  much  con- 
fidence also  in  the  "sweat-cure  "  by  means  of  internal  rem- 
edies and  water,  sand,  and  air  baths.  He  also  alludes 
to  essential  pernicious  anaemia,  and  to  that  form  which 
comes  from  residence  in  mountainous  regions. 

Systemic  Infection  in  Diseases  of  the  Urinary  Organs. — 
Posner  and  J.  Cohn  exposed  the  ureter  in  rabbits, 
and  injected  into  the  central  portion  cultures  of  various 
organisms.  The  wound  was  then  carefully  closed  un- 
der strict  antisepsis.  In  seventeen  cases  peritonitis  re- 
sulted three  times.  Out  of  the  remaining  fourteen,  three 
inoculations  with  the  bacillus  anthracis  all  proved  fatal  ; 
negative  results  were  obtained  with  the  bacillus  prodigi- 
osus  in  some  cases,  while  in  two  cases  resulting  fatally 
from  peritonitis  there  was  a  general  infection.  The  sta- 
phylococcus aureus  and  albus  and  the  streptococcus  gave 
in  every  instance  positive  evidences  of  infection,  except  in 
one  instance  of  inoculation  with  the  latter,  in  which  the 
authors  ascribe  the  failure  to  a  faulty  technique. 

Phenylhydrazin  in  Anamia. — S.   Kaminer  and   R.  Rohii- 

stein  discuss  the  question  as  to  whether  or  not  pernicious 
anaemia  is  a  true  ha-moglobintemia,  and  claim  that  in  the 
muriate  of  phenylhydrazin  we  have  a  substance  which  in 
experimentation  on  animals  produces  blood  disturbances 
identical  with  those  of  Biermcrs  anjemia.  The  article  is 
devoted  to  a  recital  of  the  work  done  by  the  authors  along 
the  line  indicated,  and  a  detailed  account  is  given  of  the 
blood  changes  as  tound  by  them. 


August  1 8,  1900] 


MEDICAL    RECORD. 


365 


Surgical  Opening  of  New  Collateral  Channels  for  the  Blood 
of  the  Portal  Vein.  — By  S.  'J'alnia. 

The  Systematic  Struggle  Against  Tuberculosis  in  Germany. 
—  By  Ur.  Faiiwitz. 

Migraine  with  Recurring  Paralysis  of  the  Ocular  Muscles. 
—By  W.  SeiUcT. 

The  Pathology  of  Morbid  Growths. — By  O.  Israel. 

Hsmolysin. — By  P.  Elirlich  and  J.  Morgenroth. 

Deutsche  inedicinische  Wochetischrift,  July  26.  igoo. 

Contributions  to  Tetanus  Intoxication. — Sliyanioto  desciibes 
a  form  of  death  caused  by  tetanus  infection  which  does  not 
run  the  usual  course.  Rabbits,  when  inoculated  under 
some  conditions,  do  not  exhibit  the  characteristic  cerebral 
and  spinal  manifestations  of  the  destructive  action  of  the 
poison  on  the  nervous  elements,  but  gradually  succumb 
to  a  progressive  niarasmic  emaciation.  This  moditication 
of  the  pathological  picture,  to  which  the  name  of  "tetanus 
sine  tetano  "  has  been  given,  might  seem  explicable  on  the 
ground  of  tlie  theory  advanced  by  Ehrlich  that  the  lo.xin 
produced  by  the  specific  micro-organism  is  made  up  of  two 
components.  To  one  of  these,  "  tetanospasmin,"  the  con- 
vulsive symptoms  are  due,  while  the  other  has  the  prop- 
erty of  destroying  red  blood  cells  and  has  been  named 
"  tetano-lysin. "  That  the  "  tetanus  sine  tetano  "  is  not  due 
to  the  action  of  this  latter  body  is,  however,  shown  by  the 
author's  experiments  with  an  old  specimen  of  the  tetanus 
toxin  which  produced  the  marasmic  form  of  the  disease, 
but  did  not  liave  the  property  of  modifying  red  blood  cells. 
The  conclusion  is,  therefore,  drawn  that  the  modified  teta- 
nus produced  was  the  result  of  a  double  decomposition  of 
both  toxic  elements,  accompanied  by  the  formation  of  a 
third  poisonous  "toxon  "  body. 

Are  Spontaneous  Fractures  of  the  Metatarsus  to  be  Regarded 
as  Accidents? — .Muskat's  article  has  reference  to  a  point  in 
dispute  between  claimants  for  damages  and  accident  insur- 
ance companies.  Even  when  none  of  the  predisposing 
causes  to  spontaneous  fracture  are  present,  such  as  bony 
atrophy  either  senile  or  occurring  in  youthful  individuals 
as  a  result  of  wasting  disease  or  maladies  ot"  the  central 
nervous  system,  particularly  tabes  and  paralysis,  acute 
osteomyelitis,  terminating  either  in  abscess  or  necrosis, 
caries  (tuberculous),  rachitis,  osteomalacia,  sarcoma,  car- 
cinoma, enchondromata  and  cysts,  echinococcus,  syphilis 
(rare) ,  scurvy  (rare) .  or  hereditary  tendency  without  known 
cause,  sudden  e.xertion  or  strain  in  jumping,  alighting  from 
street-cars,  etc.,  may  produce  a  slight  incomplete  fracture 
of  one  of  these  bones,  well  protected  as  they  seem.  This 
slight  injury  usually  passes  unnoticed  till  at  some  other 
time  the  break  suddenly  becomes  complete,  and  what  is 
apparently  a  spontaneous  fracture  is  produced.  It  is,  how- 
ever, evident  that  this  is  not  truly  so,  and  that  the  case  is 
properly  to  be  considered  as  one  of  accident,  for  which  in- 
surance may  be  collected. 

Two  Cases  of  Cerebellar  Tumor. — Schede  discusses  the 
complicated  symptomatology  attending  growths  in  this  sit- 
uation, and  concludes  that  definite  location  of  the  neoplasm 
with  a  view  to  operation  is  as  yet  impossible.  The  fact 
that  the  tumor  is  situated  in  the  cerebellum  may  usually 
be  determined  without  especial  difficulty,  but  we  are  still 
unable  to  predicate  with  accuracy  on  which  side  the  skull 
should  be  laid  open.  The  only  sign  which  appears  to  be 
even  relatively  useful  is  that  in  many  cases  the  tendency 
seems  to  be  for  the  staggering  gait  to  be  most  pronounced 
toward  the  side  opposite  to  that  occupied  by  the  new 
growth.  The  literature  contains  records  of  eleven  ca.ses 
operated  on  ;  of  these  patients  five  succumbed  to  hemor- 
rhage and  shock,  two  survived  the  operation  but  manifested 
no  signs  of  improvement,  and  only  two  permanent  cures 
are  chronicled.  The  author  describes  two  cases  operated 
on  by  himself  with  apparently  complete  relief  of  the  symp- 
toms in  one,  while  the  other  patient,  owing  to  the  fact  that 
complete  ren'oval  was  impossible,  died  of  the  primary 
growth  m  a  short  time. 

Clinical  Contributions  to  the  Occurrence  of  Tetany  and 
Other  Tonic  Spasms  in  Gastric  Dilatation. — By  Ury. 

Contributions  to  the  Early  Diagnosis  of  Intestinal  Carci- 
noma  (Heredity  and  Skin  Changesi. — By  Hollander. 

Investigations  on  the  Parasitical  Nature  of  Eczema. — By 
Scholtz. 

Miinclu-ner  mcilicinisch:  WocJu-nscltrift.  /uly  24.  rgoo. 
The  Newer  E.xperimentally  Determined  Methods  for  the 
Diagnosis  and  Treatment  of  Diseases  Caused  by  Auto-intox- 
ication.— Blum  publishes  the  following  conclusions,  (i) 
Certain  definite  poisons  are  continually  being  generated 
within  the  organism  and  are  normally  destroyed  by  the 
thyroid  .gland.  (2)  These  poisons  originate  in  the  intes- 
tinal canal,  and  in  their  character  and  quantity  depend,  on 
the  one  hand,  on  the  nature  of  the  decomposing  albumins 
present,  and,  on  the  other,  on  the  bacteria  of  decomposition. 

(3)   If  the  activity  of  the  thyroid  gland  is  impaired  and 


these  entero-toxins  are  able  to  act  unhindered  on  the  or- 
ganism, severe  disturbances  accompanied  by  anatomical 
changes  are  produced.  (4)  Such  animals  as  either  with  or 
without  treatment  remain  well,  or  recover  from  illness  after 
removal  of  the  thyroid  gland,  jwssess  in  their  blood  bodies 
protective  against  these  entero-toxins.  (5)  The  entero- 
toxins  which  are  taken  up  in  their  passage  through  the 
thyroid  gland  are  deposited  there  as  thyreotoxalbumin  and 
gradually  rendered  harmless.  (6)  There  is  both  a  natural 
(pre-existing)  and  an  acquired  immunity  for  these  thyreo- 
toxalbumins  which  normally  never  enter  the  circulation. 
(7)  The  immunities  to  entero-toxins  and  to  thyreoalbumins 
are  entirely  distinct  and  exhibit  no  interrelationship.  (8) 
The  results  of  animal  experimentation  make  it  probable 
that  a  greater  number  of  diseases  than  is  supposed  depend 
on  intestinal  phenomena  and  insufficiency  of  the  thyroid 
gland.  (9)  Therapeutic  measures  may  al.so  be  deduced 
from  these  observations. 

Contributions  to  the  Physiology  of  Nutrition  in  Infants. — 
Bendix,  in  studying  the  effect  of  menstruation  and  preg- 
nancy on  the  character  of  the  milk-supply  of  nursing 
women,  and  its  influence  on  the  nutrition  of  the  infant, 
concludes  as  follows  :  The  mere  fact  of  the  inauguration 
of  menstruation  is  not  an  indication  for  weaning  the  child, 
even  when  a  direct  effect  upon  the  milk  appears  to  be 
produced,  such  as  an  increase  or  diminution  in  quantity, 
apparent  thinning,  color  changes,  or  slight  intestinal  disor- 
ders of  the  child  during  the  days  of  the  flow.  Such  devia- 
tions from  the  normal  speedily  readjust  themselves  and  do 
the  infant  no  permanent  harm.  If  the  child  ceases  to  gain 
in  weight,  and  there  is  evidence  of  involution  in  the  breast, 
which  sometimes  takes  place  in  the  days  following  the  first 
period,  weaning  or  a  wetnurse  is  to  be  advised.  In  cases 
in  which  a  second  pregnancy  begins  during  lactation  the 
author  advises  careful  consideration  of  the  strength  of 
the  mother  and  nursling  and  the  amount  of  milk  formed, 
and  believes  that  it  is  justifiable  to  wait  for  some  evidence 
of  inadequate  feeding  or  overstrain  on  the  mother  liefore 
weaning  the  infant. 

Comparative  Observations  on  the  Value  of  the  Mechanical 
and  Alcohol  Disinfection  of  the  Hands  as  Opposed  to  that 
with  Mercury  Salts,  Especially  with  Mercury  Ethylendiamin 
(Conclusion) . — Krtinig  and  Blumberg  draw  these  conclu- 
sions ( 1 )  The  purely  mechanical  methods  of  disinfection 
with  water,  soft  soap,  and  brush,  or  with  Schleich's  soap 
give  only  very  unsatisfactory  results.  (2)  -•^hlfeld's' 
method  of  treating  the  luinds  for  five  minutes  with  water 
and  soap,  and  five  minutes  with  ninety-six-per-ccnt.  alco- 
hol, is  also  inadequate.  (3)  These  methods  are  surpassed 
in  point  of  efficacy  by  a  combination  of  mechanical  disin- 
fection with  water,  soft  soap,  and  brush,  and  subsequent 
treatment  with  a  solution  of  some  mercury  salt.  (4)  In 
place  of  the  usually  employed  i  :  i.ckxj  sublimate  solution 
it  is  preferable  to  use  an  aqueous  3 :  1,000  solution  of  mer- 
cury ethylendiamin  citrate.  This  does  not  irritate  the  cu- 
taneous surface,  does  not  precipitate  albumin  or  blood,  and 
has  great  penetrating  power. 

Butyric  Acid  Bacilli  and  their  Relations  to  Gaseous  In- 
flammation ito  be  Concluded)  .—By  Schattenfroh  and  Grass- 
berger. 

The  Normal  Respiratory  "Liver  Flexion"  and  the  Origin 
of  the  So-called  Expiration  Furrows  of  the  Liver.— By  Walz. 

Experimental  Observations  on  Disinfection  of  the  Hands 
(V.I.  —  By  Paul  and  Sarwey. 

The  Question  of  Sanatoria  for  Consumptives. — By  Rumpf. 

An  Outfit  for  Stomach  Examinations. — By  Schilling. 

The  Laryngoscope,  July  and  August,  tgoo. 
The  Spoke-Shave  in  the  Removal  of  Septal  Spurs.— J.  G. 

Wishart  says  that  he  has  largely  given  u])  the  use  of  the 
nasal  saw  in  the  removal  of  those  projections  springing 
from. the  nasal  septum  which  present  (a)  the  appearance 
of  horns,  such  as  occur  usually  far  back  in  the  nasal  cavity, 
are  bony  in  character,  and  impinge  against  a  small  area  of 
the  mucous  covering  of  the  inferior  or  middle  turbinated 
surfaces;  or  (/')  the  appearance  of  shelves,  usually  more 
anterior  in  situation,  partly  cartilaginous  and  partly  bony 
in  character,  and  in  length  anywhere  from  one-quarter  to 
one  inch,  and  lying  parallel,  or  almost  parallel,  to  the  floor 
of  the  inferior  meatus.  He  applies  to  the  site  of  operation 
pledgets  of  aseptic  cotton  moistened  with  a  solution  con- 
taining cocaine  four  per  cent.,  extract  of  suprarenal  cap- 
sule ten  per  cent.,  and  trinkresol  twelve  percent.  When 
all  is  ready  for  operation,  the  surgeon  places  the  left  hand 
upon  the  patient's  forehead  and  with  the  right  draws  the 
loop  of  the  instrument  rapidly  and  firmly  forward,  thus  re- 
moving the  obstruction.  He  claims  for  this  procedure  the 
following  advantages:  (i)  the  absence  of  bleeding  till  the 
operation  is  accomplished,  with  the  advantage  of  non-ob- 
struction to  the  vision  ;  (2)  great  saving  of  time  in  operat- 
ing :  (3)  the  almost  entire  absence  of  pain  or  fear  to  the 
patient ;   (4)  the  satisfactory  course  pursued  in  healing. 


266 


MEDICAL    RECORD. 


[August  1 8,  1900 


Fibroma  Involving  the  Tjrmpanic  Cavity.— A  case  of  fibroma 
at  this  unusual  site  is  reported  by  E.  W.  Fleming  as  occur- 
ring in  a  man  aged  forty  years.  One  mouth  before  coming 
under  observation  the  man  noticed  an  increasing;  sensation 
of  fulness  in  the  left  ear,  later  a  discharge  of  pus  and  a 
solid  Heshy  mass  nearly  tilling  the  ear.  In  order  to  effect 
its  removal  the  auricle  was  detached  and  a  wire  loop  slipped 
over  the  growth.  Granulation  tissue  necessitated  (in  the 
course  of  three  weeks)  a  thorough  curettage.  The  patient 
then  had  an  attack  of  rheumatism.  Si.x  months  after  the 
aural  operation  the  following  note  was  made  ot  the  ear 
condition  :  With  the  e.\ception  of  a  small  sinus,  through 
which  issues  stringy  muco-pus,  the  external  auditory  canal 
is  closed.  The  obstructing  tissue  appears  to  be  fairly  or- 
ganized granulation  tissue  having  none  of  the  characteris- 
tics of  the  original  growth.  There  are  small  pouting  gran- 
ulations at  the  orifice  of  the  sinus.  The  patient  is  now 
gaining  strength  rapidly,  and  says  he  has  at  no  time  expe- 
rienced any  ear  pain  or  other  head  symptoms.  The  special 
points  of  interest  in  the  case  are,  first,  the  nature  of  the 
tumor;  second,  its  extreme  vascularity  and  rapid  growth 
after  partial  removal,  pointing  alike  to  possible  malig- 
nancy :  and,  third,  its  unusual  location. 

Strong  Carbolic  Acid  Used  by  Mistake  as  a  Throat  Spray. 
— D.  H.  Galloway  treated  a  man  with  severe  tonsillitis  and 
pharyngitis,  and  desired  to  use  peroxide  of  hydrogen.  The 
patient' s  wife  brought  the  bottle,  which  was  labelled  as 
above,  and  about  one  ounce  of  the  contents  was  poured 
into  an  atomizer  and  sprayed  into  the  throat.  The  patient 
coughed  and  choked,  and  the  doctor,  getting  a  view  of  the 
mucous  membrane  of  the  mouth,  saw  that  it  was  white  and 
smelled  the  odor  of  carbolic  acid.  Examination  of  the  bot- 
tle showed  that  the  original  label  of  the  acid  had  been 
partly  covered  over  by  that  of  the  pero.\ide.  The  atomizer 
was  immediately  rinsed  out  with  hot  water  and  filled  with 
equal  quantities  of  alcohol  and  water,  which  was  sprayed 
into  the  patient's  throat  and  mouth  and  repeated  ten  or  a 
dozen  times  in  the  next  fifteen  or  twenty  minutes.  During 
most  of  this  time  the  patient  was  choking  and  strangling, 
almost  suffocated  and  quite  cyanotic.  When  he  was  able 
to  breathe  with  some  freedom  a  mucilage  of  slippery-elm 
bark  was  freely  sipped.  The  patient  recovered  in  about  a 
week.  The  accident  was  caused  primarily  by  the  druggist 
pasting  the  carbolic-acid  label  over  the  original  label,  a 
thing  which  druggists  seldom  do  and  which  should  never 
lie  done. 

The  Physiology  of  Voice  Production. — In  an  article  on  this 
subject.  W.  Scheppegrell  says  that  the  speaking  voice 
should  be  placed  as  low  as  the  voice  will  permit,  so  that  it 
can  be  used  without  undue  strain  of  the  muscles  of  the 
vocal  cords  and  accessory  muscles,  at  the  same  time  not 
being  so  low  as  to  prevent  changes  in  the  inflections  of  the 
voice  in  giving  expression  to  speech.  Very  frequently  it 
is  placed  several  tones  above  this,  .so  that  the  con.stant 
strain  from  speaking  places  the  subject  in  the  same  posi- 
tion as  one  who  has  ametropic  vision  and  who  feels  the  con- 
stant strain  unless  assistance  is  given  by  glasses.  Fortu- 
nately, in  this  case,  the  correction  is  a  more  natural  one, 
and  the  error  being  recognized  and  the  subject  placed  un- 
der the  care  of  one  who  understands  the  correct  principles 
of  elocution  and  the  proper  placing  of  the  voice,  the  fault 
may  he  entirely  corrected.  Many  cases  of  the  so-called 
"clergyman's  sore  throat,"  chronic  laryngitis,  and  other 
irritations  of  the  throat  are  due  to  this,  and  unless  thecau.se 
is  removed  recurrences  will  naturally  be  frequent  until 
eventually  the  voice  maj'  be  permanently  injured. 

Auricular  Cataphoresis. ^Determined  to  give  this  mode  of 
therapy  a  trial,  G.  Ferreri  made  the  following  experiments. 
He  used  a  silver-chloride  battery  of  ten  elements  develop- 
ing a  current  of  five  milliamperes,  and  in  circuit  with  a 
commutator.  Evidence  of  absorption  was  estimated  by 
the  effect  on  the  pupil.  As  myotics  eserine  and  pilocarpine 
were  used,  and  for  mydriatics  hyoscyamine,  scopolamine, 
atropine,  duboisine,  homatropine,  ephedrine,  and  cocaine 
were  used.  The  results  of  his  experiments  were  extremely 
disappointing,  for  notwithstanding  various  arrangements 
of  his  apparatus,  he  was  unable  to  demonstrate  any  absorp- 
tion of  the  substances  used.  He  believes  that  auricular 
therapy  cannot  count  galvanic  cataphoresis  among  its  effica- 
cious resources. 

The  Journal  of  'Tropical  Mcdiiinv,  July,  h/oo. 
Camp  Fevers  as  seen  at  Massowah  by  Italian  Observers. 
— Filippo  Rho  says  that  in  Massowah,  a  region  ab.solutely 
free  from  malaria,  there  is  an  extraordinary  number  ot 
cases  of  fevers  breaking  out  in  extensive  epidemics,  espe- 
cially in  the  less  dry  and  less  torrid  season.  They  declared 
themselves  suddenly,  mostly  without  shiverings,  the 
symptoms  being  ])aiiis  in  foreliead,  loins,  and  eyes,  a  foul 
but  never  dry  nor  cracked  tongue,  loss  of  ap])etite,  and 
constipation  ;  dry  or  perspiring  skin,  according  to  the  tem- 
perature, which  hovered  between  3S  and  40  C.  A  measly 
rash  .sometimes  appeared  about  the  neck,  chest,  back,  and 


extensor  surface  of  the  limbs.  Rarely  diarrhoea  occurred. 
There  was  a  slow  convalescence,  with  exhaustion  dispro- 
portionate to  the  brevity  of  the  malady.  The  author  gives 
his  reasons  for  considering  these  fevers  as  belonging  to  the 
diseases  of  a  typhoid  order.  In  hot  climates,  typhoid  fever 
usually  runs  a  less  dangerous  course  than  with  us.  He  be- 
lieves that  many  fevers  of  tropical  and  temperate  climes, 
which  are  being  attributed  to  various  causes  and  called  cli- 
matic, must  be  ascribed  to  typhoid  infection. 

Circumscribed  Cutaneous  (Edema  in  Brazil. — W.  G.  Tot- 
tenham Posnett  describes  six  cases  noted  by  him  while  he 
was  serving  as  ship's  surgeon  to  Brazil.  It  was  charac- 
terized by  swellings  which  appeared  on  the  dorsum  of  feet 
and  hands,  shins,  back  and  front  of  thi.ghs,  buttocks,  back 
of  the  shoulder,  and  dorsal  aspect  of  the  forearms — never 
on  the  face.  The  swellings  were  never  round,  but  oval  ;  in 
the  limbs  the  long  axis  of  the  swelling  was  always  in  the 
long  axis  of  the  part  ;  those  on  the  buttocks  and  shoulders 
had  a  direction  downward  and  outward,  seldom  inward. 
The  onset  was  sudden,  accompanied  by  slight  malaise  ; 
the  swellings  appearing  in  the  morning,  persisting  from  a 
few  hours  to  several  days,  and  causing  a  tingling  or  burn- 
ing sensation.  This  appears  to  be  a  comparatively  com- 
mon aft'ection  among  the  English  in  Brazil,  but  rarely  at- 
tacks Portuguese  or  Brazilians.  The  etiology  is  not  known. 
Treatment  consisted  in  a  mixture  of  potassium  bicarbonate, 
magnesium  carbonate,  and  magnesium  sulphate,  which 
was  useful  in  one  case.  Sodium  sulphate  seemed  to  be 
more  useful  in  another  case. 

Anchylostomiasis  in  the  Leeward  Islands. — William  M. 
McDonald  says  that  in  his  report  to  the  government  he 
drew  attention  to  this  disease  for  the  following  reasons : 
(I)  That  up  to  that  time  anchylostomiasis  was  not  recog- 
nized and  not  treated  in  Antigua  ;  (2)  its  great  prevalence 
throughout  Antigua :  (3)  the  severity  of  its  sy^mptoms  in 
all  the  cases  reported  by  him  ;  (41  its  response  to  treat- 
ment if  attended  to  early.  He  thinks  the  cases  that  har- 
bor the  parasites,  and  that  do  not  show  symptoms,  just  as 
important  as  those  .suffering  from  anchylostomiasis,  for  a 
large  proportion  of  those  that  show  marked  symptoms  are 
"past  praying  for,"  and  go  down  hill,  whatever  the  treat- 
ment. On  the  other  hand,  those  that  harbor  the  parasite 
without  any  definite  symptoms,  with  vigorous  treatment 
are  prevented  from  becoming  chronic  invalids,  a  nuisance 
to  themselves  and  their  relations,  a  burden  to  the  State,  a 
serious  loss  to  their  employer,  and  a  source  of  great  dan- 
ger to  their  neighbors. 

Leucoderma  in  Indian  Natives. — Frederick  Pearse  de- 
scribes a  case,  illustrated  by  a  photograph,  of  a  disease 
common  among  Indian  natives.  It  is  characterized  by 
irregular  loss  of  pigment  forming  piebald  areas  of  skin  on 
all  parts  of  the  bod\-.  The  disease  is  popularly  called 
white  leprosy,  but  has  no  relation  to  the  true  kind.  It 
occurs  in  children  and  in  old  people  as  well.  Some  of  the 
natives  lose  nearly  all  their  color,  others  lose  it  in  patches 
only.  The  author  does  not  know  whether  the  lost  pigment 
is  ever  recovered. 

Upon  the  Part  Played  by  Mosquitos  in  the  Propagation  of 
Malaria;  a  Historical  and  Clinical  Study  (Continued). — By 
George  H.  F.  Xuttall. 

A  Sanitary  Corps  for  the  British  Army. —  By  Samuel  Os- 
born. 

A  Case  of  Cirrhosis  of  Hanot. — By  Fernandes  Figueira. 

The  Recent  Discoveries  in  Paludism. — By  J.  Guiart. 

A  'Note   on  Albinos. — By  Frederick  Pearse. 

Notes  from  South  Africa. — By  M.  J.  Tarr. 

University  Medical  Magazine,  July.  tgoo. 

Experience  an  Essential  of  Satisfactory  Radiography. — A. 

W.  Goodspeed  says  that  to  make  a  radiogram  of  a  normal 
hand,  for  example,  in  such  a  way  as  to  show  a  shadow  of 
the  bones  on  a  photographic  plate,  is  such  an  easy  matter 
that  any  intelligent  person  can  accomplish  the  result  with 
a  very  little  experience,  provided  the  apjiaratus  is  .set  up. 
adjusted,  and  in  good  working  order.  The  event  is  far 
different,  however,  if,  for  instance,  an  obscure  case  of  hip 
disease  is  brought  to  be  radiographed,  and  when  a  correct 
diagnosis  and  proper  treatment  arc  dependent  not  only 
upon  a  good,  clear,  and  undistorted  jiicture,  but  upon  a 
logical  and  intelligent  interpretation  of  the  same.  As  an 
almost  indispensable  aid  to  correct  diagnosis  Goodspeed 
believes  that  a  very  complete  .set  of  standard  normal  pic- 
tures of  the  various  parts  of  the  anatomy,  taken  under  con- 
ventional and  well-defined  conditions,  should  be  a  part  of 
every  equipment.  Careful  comparison  of  |)athoIogical  pic- 
tures with  first-class  standards,  if  the  former  were  well 
executed,  should  not  lead  an  experienced  operator  into  seri- 
ous error. 

The  Relation  of  Artificial  Feeding  to  the  Gastro-Intestinal 
Diseases  of  Infants.  — D.  11.  Bergey  discusses  the  various 
phases  of  this  question,  summarizing  his  views  as  follows: 


August 


1 8,  1900] 


MEDICAL    RECORD. 


267 


The  continued  hif^li  death  rate  from  gastro  intestinal  dis- 
eases among  infants  under  one  year  of  age  should  cause  us 
to  put  forth  our  best  efforts  to  combat  this  scourge.  All 
known  preventive  measures  should  be  employed,  such  as 
sanitary  inspection  and  control  of  the  production  and  sale 
of  milk  intended  for  infant  feeding  ;  the  pasteurization  of 
all  milk  used  for  infant  feeding  by  heating  to  75  C.  for  ten 
minutes,  and  then  rapidly  cooling  it  and  preserving  it  in 
the  ice  chest  until  used  ;  the  rigid  exclusion  of  all  adulter- 
ants of  whatever  nature  ;  gratuitous  sujjply  of  pasteurized 
milk,  and  ice.  to  the  poor  of  our  large  cities;  the  careful 
instruction  of  the  laity  in  the  process  of  rational  infant 
feeding,  especially  of  the  great  danger  of  feeding  infants 
under  eighteen  months  to  two  years  of  age  on  anything 
but  properly  prepared  milk  without  the  consent  and  direc- 
tion of  the  family  jihysician  ;  the  inculcation  of  the  idea 
that  the  gastro-intestinal  diseases  of  infants  are  frequently 
communicable  to  other  infants  brought  in  contact  with 
such  cases. 

Osteoarthritis  of  the  Spine  and  Hip  Joints :  Rhizomelic 
Spondylosis. — Two  cases  of  this  diseases  are  described  by 
C.  H.  Frazier.  The  name  was  suggested  by  Marie,  and 
refers  to  a  condition  in  which  tlie  osteoarthritis  involves 
the  spine  and  joints  adjacent  to  the  trunk  to  the  exclusion 
of  other  articulations,  particularly  those  of  the  hands  and 
feet.  Several  illustrations  are  given  of  the  characteristic 
attitudes  assumed  by  the  patients,  and  the  matter  of  differ- 
ential diagnosis  is  thoroughly  discussed.  No  cause  has 
yet  been  discovered  for  this  jieculiar  localization  of  the 
lesion.     No  specific  internal  treatment  has  vet  been  found. 

A  Study  of  the  Physiological  Action  of  Phenacetin. — H.  C. 
Wood,  Jr.,  presents  tlie  following  conclusions:  (i)  The 
moderate  dose  of  phenacetin  is  without  any  distinct  action 
on  any  vital  organ.  (2)  Large  doses  lessen  reflexes  by  a 
direct  action  on  the  spinal  cord.  (3)  Doses  of  0.5  gm.  per 
kilo  of  body  weiglit  (equivalent  to  a  little  less  than  one 
ounce  for  a  man  weighing  one  hundred  and  fifty  pounds) 
kill  by  aiTest  of  respiration.  (4)  Doses  even  up  to  0.5  gm. 
per  kilo  had  no  distinct  effect  on  the  circulation. 

Some  of  the  Developments  and  Demands  of  Modern  Public 
Hygiene. — By  A.  C.  Abb'itt. 

Coxa  Vara  ;  Ankylosis  of  the  Hip.— By  Da  Forest  Willard. 
Mt-uiuine,   Audits/,  igoo. 

Ankle    Sprains. — Edward    H.     Ochsner    recommends    a 

method  of  treatment  which  consists  in  careful  and  system- 
atic strapping  with  rubber  adhesive  straps.  These  are  cut 
from  half  to  three-quarters  of  an  inch  in  width,  and  the 
proper  length,  the  width  depending  upon  the  size  of  the 
limb.  The  foot  is  held  at  slightly  less  than  a  right  angle 
and  a  trifle  everted.  One  end  of  a  long  strap  is  applied  to 
the  inner  surface  of  the  foot  near  its  posterior  end,  brought 
under  the  heel,  and  u])on  the  outer  posterior  surface  of  the 
leg  to  within  a  few  inches  of  the  knee.  At  the  lower  end 
this  falls  into  the  depression  just  posterior  to  the  external 
malleolus.  A  shorter  strap  is  now  applied  by  placing  one 
end  to  the  inner  surface  of  the  heel  near  the  sole  of  the 
foot,  then  bringing  it  around  over  the  tendo  Achillis  to  the 
outer  surface  of  the  foot,  making  it  cover  the  first  strap  at 
a  right  angle,  and  passing  along  parallel  to  the  under  bor- 
der of  the  sole  of  the  foot,  then  over  the  dorsum  of  the  lit- 
tle toe.  Another  long  one  is  now  applied,  anterior  to  the 
first,  overlapping  it  about  one-lhird  of  its  width  ;  then  a 
short  one,  and  so  on  alternately  until  the  outer  anterior 
aspect  of  the  ankle  is  reached.  A  hard-rolled  bandage  is 
placed  over  all,  and  the  patient  directed  to  lie  still  "with 
the  foot  elevated  until  the  warmth  of  the  body  has  caused 
the  plaster  to  adhere  firmly.  As  a  rule,  the  patient  can 
walk  with  reasonable  comfort  after  a  few  hours. 

The  Examination  of  Sputum  for  Tubercle  Bacilli.— Carl 
Weidner  emphasizes  the  necessity  for  a  positive,  infallible 
method  of  making  a  differential  diagnosis  between  the 
tubercle  bacilli  and  other  bacilli  that  may  be  similar  to 
them  in  appearance  or  in  staining-reaction.  He  describes 
in  detail  the  method  of  staining  taught  and  practised  by 
CJuenther.  Several  preparations,  instead  of  one  only, 
ought  always  to  be  made.  The  absence  of  tubercle  or  tu- 
bercle bacilli  may  not  be  positive  proof  of  the  absence  of 
tuberculosis.  The  repeated  absence,  however,  of  bacilli 
m  purulent  sputum  nearly  all  authorities  consider  to  be 
positive  proof  of  the  absence  of  tuberculosis.  The  number 
of  bacilli  is  of  no  value  in  giving  a  clew  to  the  progress  or 
prognosis  of  a  case.  The  author  lays  stress  upon  the  point 
that  we  should  always  use  a  controlling  stain  whenever 
we  are  in  doubt.  We  ought  to  have  several  preparations 
and  use  two  methods  in  order  to  make  the  procedure  safe. 

The  Treatment  of  Abortion.— Henry  B.  Stehman  outhnes 
the  principles  underlying  this  treatment  as  follows :  (i) 
The  rendering  of  the  vulva,  vagina,  and  uterus  aseptic 
and,  so  far  as  possible,  maintaining  them  so  ;  (2)  arresting 
of  hemorrhage,  either  by  use  of  the  tampon  in  the  cervix 
or  vagina,  or  by  directly  emptying  the  uterus ;   (3;  in  in- 


evitable abortion,  the  ovum,  or  any  part  of  the  product  of 
conception,  should  be  removed  as  early  as  possible;  (4) 
intelligent  curettage  is  invariably  indicated  whenever  a 
vestige  of  placental  <lecidua  remains,  or  any  suspicion  (jf 
infection  is  in  evidence,  and  a  bacteriological  differentia- 
tion is  necessary  both  from  the  standpoint  of  prognosis 
and  treatment  ;  (51  when  circumscribed  local  infection  is  a 
complication,  evacuate  the  pus  as  earlv  as  possible  and  by 
the  shortest  route. 

Conjunctivitis  and  its  Treatment ;  with  Especial  Reference 
to  the  Use  of  Nuclein  Solution,  five  per-cent.,  in  Conjunctivitis 
I.ymphatica.  — Uy  J.  Ivimey  Dowlmg. 

Chloretone  as  a  Hypnotic  and  Local  Anaesthetic— By  Free- 
man F.  Ward. 

.l/iiui/s  11/  Si/>\i;,-)y.  Aiiici'sf.  rgoo. 

Note  on  the  Relation  of  the  Os  Magnum  to  Tuberculosis  of 
the  Wrist  Joint.— In  three  cases  of  the  disease  D.  E.  Mun- 
dell  noted  from  skiagraphs  that  the  disease  had  started  in 
the  OS  magnum  or  at  least  had  made  greatest  progress  in 
this  bone.  Tubercle  bacilli  manifest  themselves  in  bone 
by  a  process  of  rarefaction  ;  hence  that  bone  most  rarefied 
would  in  all  probability  be  the  one  in  which  the  process  is 
most  active.  Oilier  has  emphasized  the  inijiortance  of 
juxta-epiphyseal  strain  in  the  production  of  tuberculosis  of 
long  bones;  and,  on  the  same  principle,  repeated  strains  on 
any  bone  may  favor  tuberculosis  on  account  of  minute  foci 
of  inflammation  resulting  from  the  "jarring  "  of  the  trabec- 
ulse.  Such  conditions  obtain,  JIundell  believes,  in  the  case 
of  the  OS  magnum,  and  he  describes  at  length  the  mechan- 
ical conditions  which  come  into  play  with  reference  to 
this  bone  both  in  health  and  in  injuries.  It  is  the  main 
bone  in  the  wrist  and  is  the  first  to  ossify  ;  it  is  so  situated 
as  to  receive  the  effects  of  injuries  from  three  metacarjial 
bones  ;  it  performs  more  movement  in  flexion  and  exten- 
sion than  the  other  bones ;  in  these  movements  greater 
strain  is  thrown  on  it  than  on  the  other  carpal  bones,  from 
the  numerous  ligaments  connected  with  it  and  resisting 
such  movements  ;  the  cancellated  structure  of  the  os  mag- 
num is  uneven  ;  that  portion,  the  inner,  which  has  the 
wider  spaces,  and  is  therefore  less  strong,  has  a  richer 
blood  supply.  For  the  above  reasons,  vibrations  tlie  result 
of  traumatisms  would  affect  the  os  magnum  more  often 
than  the  other  carpal  bones,  and  especially  that  portion  of 
it  referred  to  above  which  consists  of  less  numerous  tra- 
beculse.  The  pain  has  been  described  by  patients  as  of  a 
burning,  aching  character,  and  is  the  result,  in  the  early 
stage  of  the  disease  at  least,  of  pressure  on  the  synovia'l 
membrane  between  the  os  magnum  and  trapezium,  be- 
cause these  two  are  more  closely  bound  to.gether  than  any 
of  the  other  bones  ;  hence  the  enlargement  of  the  os  mag- 
num from  the  tuberculous  process — though  this  enlarge- 
ment would  be  very  slight,  for  tuberculosis  of  bone  is  ac- 
companied by  very  little  increase  in  size— will  be  sufficient 
to  "nip"  the  synovial  membrane  between  it  and  the  trape- 
zium. 

Malignant  Disease  of  the  Stomach  and  Pylorus.— W.  J. 
Mayo  takes  the  position  that  cancer  at  this  site  is  a  surgi- 
cal disease.  Surgery  offers  the  only  hope  of  cure,  and  a 
suspicion  of  gastric  cancer  should  cause  the  physician  to 
send  the  patient  to  the  surgeon  for  exi)loratory  incision  to 
complete  the  examination.  The  main  difficulty  is  in  the 
direction  of  early  diagnosis.  The  curability  of  cancer  of 
the  stomach  depends  upon:  (i)  the  histological  structure 
of  the  neoplasm  ;  (2)  its  location  ;  (3)  its  extension  to 
neighboring  structures;  (4)  lymphatic  infection;  (5)  the 
general  condition  of  the  patient.  It  is  essential  that  the 
relative  value  of  the  manifestation  of  the  malignant  proc- 
ess be  studied,  for  upon  a  correct  appreciation  of  the  con- 
ditions i)resent  depends  the  whole  question  of  treatment. 
The  author  then  elaborates  the  foregoing  propositions  and 
describes  the  various  operations  which  have  been  devised 
for  the  removal  of  the  malignant  growth  at  this  site,  going 
into  considerable  detail  as  to  the  technique  of  the  opera- 
tions, proper  preparation  of  the  jiatient,  etc.  He  con- 
cludes by  saying  that  the  exploratory  incision  for  sus- 
pected cancer  of  the  stomach,  instead  of  being  a  last 
resource,  should  be  one  of  the  first,  and  be  promptly  un- 
dertaken if  the  condition  cannot  be  proved  to  be  non-malig- 
nant.  Complete  removal  of  the  stomach  has  won  a  foot- 
hold, but  to  what  extent  the  future  only  can  determine. 
The  more  radical  believe  that  even  if  the  disease  has 
affected  only  a  limited  and  apparently  excisable  portion  of 
the  stomach,  the  whole  organ  should  be  removed ;  that 
pylorectomy  and  partial  gastrectomy  are  not  based  on  cor- 
rect principles,  and  the  large  percentage  of  local  recur- 
rences after  partial  operations  certainlv  give  color  to  this 
view. 

Tetanus ;  a  Study  of  the  Nature,  Excitant  Lesions,  Symp- 
tomatology, and  Treatment  of  the  Disease,  with  a  Critical 
Summary  of  the  Results  of  Serum  Therapy.— By  A.  V.  Mos- 
chowitz  (a  continued  article  ;  abstract  later) . 


268 


MEDICAL    RECORD. 


[August  1 8,  1900 


The  Pathology  of  Fractures  of  the  Lower  End  of  the  Ra- 
dius.— By  F.  J.  Cotton  la  continued  article  to  be  abstracted 
later). 

Report  of  a  Case  of  Irreducible  Backward  Dislocation  of 
the  Bones  of  the  Leg  at  the  Knee  Joint. — By  L.  C.  Hull. 

The  Best  Method  of  Collecting  the  Urine  from  the  Ureters 
for  Diagnostic  Purposes. — By  M.  L.  Harris. 

Report  of  a  Case  of  Strangulated  Obturator  Hernia.— By 
J.  M.  Elder. 

A  Method  of  Excision  of  the  Shoulder  Joint.— By  J.  F. 
Binnie. 

A  Critical  Survey  of  Ureteral  Implantations. — By  J.  \V. 
Bovee. 

Archives  Generalcs  de  Mt'ciecinc,  May  aiuf  Jn/y.  igoo. 

Hemorrhages  of  the  Suprareual  Capsules. — Francois  Arnaud 
gives  the  symptomatology  of  this  condition,  as  observed  in 
eighty  cases :  (i)  In  forty-.six  out  of  seventy-nine  cases 
there  were  no  appreciable  signs.  (2)  In  five  cases  there 
was  a  voluminous  hematoma  or  abdominal  tumor  that  could 
be  perceived  by  palpation.  The  diagnosis  was  made  in 
one  case  only  during  life.  (3)  There  were  peritoneal  symp- 
toms in  six  ca^es,  all  accompanied  by  tearing  of  the  cap- 
sule with  hemorrhage.  (4)  There  were  symptoms  of  cap- 
sular insufficiency  in  eight  cases.  (5)  In  fifteen  cases 
there  was  sudden  death,  or  death  after  three  days  at  the 
most,  sometimes  accompanied  by  delirium,  convulsions, 
contractures,  coma,  hypothermia,  and  syncope.  In  more 
than  half  of  the  cases,  therefore,  the  hemorrhages  remain 
latent  and  apparently  without  effect  upon  the  organism. 

Diffuse  Muscular  Atrophy  following  Slight  Traumatism  of 
the  Extremities. — Gilbert  Ballet  and  Henri  Bernard  thus 
sum  up  their  conclusions:  (i)  Following  a  superficial  cu- 
taneous lesion,  or  exceptionally  an  articular  lesion,  there 
may  be  a  complex  of  symptoms  characterized  by^  a  spe- 
cial form  of  muscular  atrophy.  (2)  This  amyotrophia 
affects  all  the  muscles  of  the  limb  to  the  same  e.xtent ; 
it  is  an  atrophy  en  masse,  or  diffuse  atrophy.  It  is  slight, 
the  circumference  of  any  part  of  the  limb  rarely  being 
diminished  more  than  2  or  3  cm.  It  is  not  accompanied 
by  any  reaction  of  degeneration.  (3)  These  symptoms 
cannot  be  due  to  a  true  ascending  neuritis,  nor  to  a  de- 
generation of  the  axis.  They  must  be  related  to  a  slight 
diffuse  lesion,  or  to  some  slight  nutritional  disorder  of  the 
medullary  cells  of  the  anterior  cornua. 

Malarial  Household  in  Meaux ;  Role  Played  by  House 
Plants. — M.  Vicente  describes  three  cases  ot"  malaria 
(proved  to  be  such  by  an  examination  of  the  blood,  and  by 
the  reaction  to  quinine)  in  the  mother  and  two  children  of 
a  family  living  in  a  house  so  situated  as  to  be  apparently 
free  from  malarial  infection,  and  in  winter.  There  were 
three  oleander  bushes  in  the  house,  a  plant  which  in  Al- 
geria is  supposed  to  give  malaria.  This  bush  harbors  an 
insect  which  plays  the  part  so  frequently  played  by  nios- 
quitos  in  transporting  the  malarial  germ  from  the  swamps 
to  man.  There  were  innumerable  colonies  of  this  "flea" 
on  the  plants  above-mentioned,  and  on  the  furniture  and 
floor,  and  the  clothe-;  and  hair  even  of  persons  in  the  hou.se. 

The  Pancreas  in  Cirrhosis. — E.  Lefas  having  examined 
the  pancreas  at  the  autopsy  of  a  number  of  persons  who 
died  of  cirrhosis,  gives  the  following  results  of  his  observa- 
tions ;  In  atrophic  cirrhosis,  the  pancreas  is  enlarged,  with 
some  sclerosis  of  the  splenic  extremity,  and  cells  in  fatty 
degeneration.  In  hypertrophic  biliary  cirrhosis,  there  is  no 
increase  in  volume,  but  increase  in  interlobular  connective 
tissue.  In  cardiac  cirrhosis,  there  are  no  special  changes 
in  the  pancreas,  but  occasional  changes  in  the  blood-ves- 
sels. In  hypertrophic  pigmentary  cirrhosis,  the  author  has 
not  found  special  alterations  in  the  pancreas,  dut  Hanot 
and  Chauffard  found  considerable  peri-lobular  sclerosis. 

Acute  Fecal  Intoxication. — M.  Deschamps  says  that  it  has 
been  demonstrated  that  the  sudden  admixture  of  fecal  mat- 
ters with  water  used  for  drinking  may,  in  addition  to  sjie- 
cial  acci<lents,  produce  troubles  that  can  be  divided  into 
two  distinct  clinical  types.  The  first  are  characterized  by 
toxic  gastro-entcritis.  the  phenomena  being  tliose  of  int<«- 
ication  ratherthan  of  infection,  and  resemblingthose  which 
follow  the  ingestion  of  putrefied  food.  The  .second  are 
choleriform  in  nature,  or  in  some  severe  cases  choleraic. 

Hysterical  Laryngeal  Hypokinesis. — C.  Chauveau  describes 
a  case  in  which  hysteria  was  caused  l)y  grippe  and  affected 
the  air  jnissages,  the  larynx,  and  finally  the  nerve  centres 
presiding  over  the  motor  functions  of  the  larynx,  -giving 
hypokinesis,  with  hemiplegic  motor  and  sensory  troubles 
of  the  same  side  of  the  body  and  of  the  velum  palati. 

Thirteen  Cases  of  Softening  or  Hemorrhage  of  the  Cere- 
bellum, the  Pons,  and  the  Crura.-  -H\-  K.  Touche. 

Jackson's  Epilepsy.     Cerebral  Tumor  of  Difficult  Diagnosis, 
Probably  Parasitic. — By  K.  Apcrt  and  Ch.  Ciandy. 
Gastro-Intestinal  Surgery. — By  Henri  Hartmanu. 


Olovvcspourtcnce. 


OUR    LONDON    LETTER. 

(From  our  Special  Correspondent.) 

THE  HEAT  VVAVE— CENTENARY  OF  THE  ROYAL  COLLEGE  OF 
SURGEONS  OK  ENGLAND — WAR  HOSPITALS  COMMISSION — PRO- 
FESSOR OSLER  AT  THE  POST-GRADUATE  COLLEGE — THE  IN- 
GLEBY    LECTURES. 

London-,  July  27,  1900. 

The  London  season — as  interpreted  by  the  votaries  of 
fashion — closes  to-day,  and  next  week  we  shall  hear  that 
Mayfair  is  empty,  although  many  of  its  most  useful  inhab- 
itants will  remain.  The  season  goes  out  with  a  marked 
change  of  weather.  The  heat-wave  which  has  been  so 
oppressive  for  the  last  three  weeks  appears  likely  to  pass 
by.  .-^  fall  of  10'  or  12  in  the  thermometer  yesterday  por- 
tended a  change,  and  this  afternoon  we  had  a  thunder- 
storm with  copious  rain.  Next  week  we  shall  have  an  ex- 
odus of  many  doctors  as  well  as  of  society  people. 

The  ceremony  of  conferring  honorary  fellowships  in  cele- 
bration of  the  centenary  of. the  Royal  College  of  Surgeons 
of  England  was  the  occasion  of  a  gathering  far  more  bril- 
liant to  the  eye  than  such  functions  usually  ai'e  with  us. 

The  costumes  of  the  numerous  ladies  present  and  the 
British  and  foreign  doctors'  gowns  lit  up  the  theatre  of  the 
London  University  gayly.  Few  people  recognized  Mr. 
Treves  in  the  dashing-looking  officer  in  a  hussar  uniform 
who  occupied  one  of  the  seats  on  the  platform.  Xot  the 
least  imposing  figure  was  that  of  the  Prime  Minister  in  the 
gold-barred  robes  of  Chancellor  of  the  University  of  Ox- 
ford. Lord  Rosebery,  too,  was  conspicuous  in  his  Cam- 
bridge doctor's  robes.  Both  these  statesmen  received 
honorary  fellowships,  as  did  some  thirty  distinguished 
European,  American,  and  colonial  surgeons,  including  von 
Bergmann,  Lannelongue,  Albert,  Oilier,  Keen,  Warren, 
and  others. 

Professor  Keen,  who  was  received  with  great  applause, 
made  a  speech  distinguished  by  its  excellence  of  matter 
and  manner.  Referring  to  the  improvements  in  surgery, 
he  said  Warren  and  Lister  had  made  them  possible  by 
their  discoveries  of  anaesthesia  and  antisepsis. 

The  ceremony  took  place  in  the  theatre  of  Burlington 
House,  lately  the  abode  (if  such  a  disembodied  spirit  can 
have  been  said  to  have  an  abode)  of  the  late  London  Uni- 
versity. Always  a  picturesque  figure,  the  president.  Sir 
William  MacCormac,  showed  to  advantage  in  his  brilliant 
surroundings  and  conferred  the  fellowships  with  impressive 
dignity.  His  reception  was  the  more  cordial  because  the 
company  appreciated  his  services  in  South  Africa — services 
which  were  gracefully  referred  to  by  Professor  Keen. 

Before  the  actual  celebration  a  deputation  from  the  Coun- 
cil waited  on  the  Prince  of  Wales  to  present  the  diploma 
of  the  honorary  fellowship  to  His  Royal  Highness.  The 
Prince,  having  accepted  the  diploma,  signed  his  name  and 
so  began  the  roll  of  this  new  honorary  fellowship.  The 
diploma  says,  "We,  the  Royal  College  of  Surgeons  of  Eng- 
land, do  hereby  admit, "  etc.  This  does  not  express  the 
fact  that  the  college  consists  of  th<rasands  of  members  who 
have  no  vote  in  appointing  the  twenty-four  gentlemen  who 
constitute  the  Council,  and  who  thus  arrogate  to  themselves 
the  name  of  the  college.  It  should  read,  "  We,  the  Council, " 
etc. 

There  was  a  conversazione  at  the  college  on  Wednesday 
evening,  when  the  guests  were  received  by  the  president 
and  vice-presidents.  On  Wednesday  and  Thursday  dem- 
onstrations were  given  illustrating  the  work  of  the  labora- 
tory, and  each  morning  Professor  Stewart,  conservator, 
conducted  visitors  round  the  museum  and  gave  a  demon- 
stration of  some  of  the  chief  objects  of  interest. 

The  address  of  welcome  by  the  president  was  an  effective 
one,  and  it  is  said  will  be  published  together  with  bio- 
graphical notices  of  the  sixty-one  masters  and  jiresidents 
who  have  held  office  during  the  last  hundred  years.  The 
address  itself  .goes  further  back,  for  the  president  attempted 
a  sketch  of  the  progress  of  the  art  of  surgery  from  about 
the  close  of  the  second  century. 

The  commission  on  the  war  hospitals  held  its  first  sit- 
ting on  Tuesday,  when  some  evidence  was  taken  as  to  the 
state  of  preparation  prior  to  the  outbreak  of  war.  It  would 
seem  that  there  was  in  store  very  inadequate  provision, 
and  that,  of  course,  the  necessary  provision  could  not  be 
obtained  without  lime,  but  further  evidence  will  be  forth- 
coming. The  commission  will  shortly  sail  for  the  Cape, 
and  on  its  return  will  perha])s  take  more  evidence  in  this 
country.  Mr.  Burdett-Coutts  has  made  himself  still  more 
ridiculous  by  insinuating  in  Parliament  that  the  commis- 
sioners will  not  be  impartial.  Then  he  declared  that  civil 
surgeons  at  the  front  were  bound  down  not  to  disclose  hos- 
pital secrets  or  scandals.  Mr.  Wyndham,  Under-Secre- 
tary for  War.  being  questioned  as  to  this  by  Dr.  Farquhar- 


August  1 8,  1900] 


MEDICAL    RECORD. 


269 


son.  was  able  to  deny  it.  Mr.  Coutts  further  urged  that 
the  truth  could  not  be  obtained  without  special  protection 
being  afforded  to  all  who  gave  evidence.  Mr.  Balfour  de- 
clared that  the  precautions  taken  by  the  commission  which 
would  be  made  royal,  were  ample,  and  the  suggestion  made 
conveyed  an  uncalled-for  insult  on  officers  and  others. 

You  know  that  we  have  recently  established  a  post-grad- 
uate college  here.  The  promoters  have  secured  some  ex- 
cellent lecturers,  and  the  institution  seems  likely  to  be  of 
service.  At  the  opening  of  the  museum  lately  Prof.  Wil- 
liam Osier  delivered  an  address  in  which  he  ably  advo- 
cated a  resort  to  study  at  intervals  in  order  to  avoid  be- 
coming fossilized,  and  told  us  how  widely  polyclinics  and 
post-graduate  courses  were  appreciated  in  America.  He 
gave,  too,  some  particulars  of  his  own  work  in  this  depart- 
ment, and  said  it  was  superfluous  to  dwell  upon  the  great 
advantages  London  offers  for  study  by  graduates  and  prac- 
titioners, considering  that  here  are  collected  more  sick  peo- 
ple than  in  any  city  m  the  world.  The  unequalled  facili- 
ties afforded  by  our  special  hospitals  and  their  elaborate 
equipments  he  thought  quite  counterbalanced  the  absence 
of  concentration  of  material  so  convenient  in  Vienna.  The 
organization  necessary  is  no  longer  lacking  since  the  es- 
tablishment of  this  college.  The  value  of  the  museum 
as  a  means  of  practical  instruction  was  first  illustrated 
by  John  Hunter,  and  the  college  is  indebted  to  a  man 
with  a  truly  Hunterian  mind — Mr.  Jonathan  Hutchin- 
son, to  whom  Dr.  Osier  paid  a  high  tribute,  in  the  course 
of  which  he  said  that  when  anything  turns  up  on  which 
text-books  are  silent  and  cyclopaedias  dumb  he  advised  his 
students  to  look  up  the  "Archives  of  Surgery."  as,  if  not 
there  mentioned,  it  must  be  something  very  much  out  of 
the  common.  He  then  drew  an  amusing  picture  of  the 
routinist  and  the  rationalist  practitioner.  No  one,  he  said, 
needs  more  renovation  than  teachers  ;  upon  none  does  in- 
tellectual staleness  steal  more  relentlessly,  and  the  profes- 
sion has  suffered  sorely  from  intellectual  old-fogyism. 
Then  he  went  on  to  say  that  men  above  the  age  of  forty  are 
rarely  pioneers,  rarely  creators  in  science  or  literature. 
Over  that  age  men  are  in  dan.ger  of  premature  senility. 

Professor  Osier  is  thought  so  much  of  on  this  side  that  it 
may  seem  heterodox  to  interpose  a  awcat,  and  yet  much 
work  has  been  done  for  the  world  by  older  men.  I  might 
claim  some  of  them  as  scientific,  but  science  is  essentially 
modern  and  its  work  appropriate  for  the  younger  men — 
though  they  will  carry  it  on  to  the  next  generation.  In 
older  branches  of  intellectual  work  surely  older  men  have 
accomplished  much.  Take  literature,  which  Dr.  Osier 
mentioned — one  example  will  suffice;  Milton  was  old  and 
blind  when  he  produced  "Paradise  Lost." 

The  Ingleby  lectures  at  Birmingham  were  this  year  de- 
livered by  Dr.  O.  J.  Kauffmann,  who  devoted  them  to  the 
neuroses  of  children,  confining  his  attention  to  the  more 
common  forms.  Among  the  practical  observations  which 
marked  the  lectures  was  a  distinction  between  migraine 
and  recurrent  paroxysmal  headaches.  The  sensory  symp- 
toms of  migraine,  the  unilateral  commencement  of  pain, 
and  t!ie  sickness  and  vomiting  are  tlie  prominent  marks, 
but  other  headaches  may  alternate  with  migraine.  More- 
over, the  vasomotor  symptoms  and  the  fluctuations  in  the 
blood-pressure  so  pronounced  in  typical  migraine  are  sel- 
dom, if  ever,  quite  absent  from  recurrent  headaches  of  a 
simple  kind,  and  both  are  produced  by  exactly  the  same 
causes.  In  these,  and,  indeed,  in  most  of  the  neuroses, 
constipation  and  other  digestive  disorders  are  pretty  con- 
stant, and  Dr.  Kauffmann  laid  stress  on  the  tox^emic  con- 
dition that  might  thus  arise.  Overfeeding  or  faulty  feed- 
ing was  accordingly  blamed.  Excessive  amount  ot  meat 
is  quite  liable  to  set  up  a  state  of  epileptic  tension.  Undi- 
gested food  is  not  merely  irritant ;  it  is  often  the  source  of 
a  toxa;mia.  particularly  when  constipation  exists  and  has 
probably  begun  such  a  process.  The  first  remedy,  then,  is 
proper  diet.  Beyond  this  medicines  to  get  the  bowels  into 
a  regular  and  healthy  action  must  be  employed.  These 
are  aperients,  alteratives,  and  antiseptics.  These  are  far 
superior  to  tonics,  which  are  of  only  slight  utility,  and 
when  there  is  any  degree  of  auto-intoxication  are  injurious. 


LETTER  FROM  NEW  ZEALAND. 

(From  Our  Special  Correspondent.) 

A   C.\SE   OF     SUSPECTED     PL.AGl'E — DESPOTIC     POWERS     OF     THE 
PREMIER — THE   PLAGUE   IN   AUSTRALIA. 

Auckland,  N.  Z.,  July  9,  iqoo. 
On  Sunday,  June  19th.  a  man  who  had  been  at  work  all 
the  previous  week  was  taken  ill  with  febrile  symptoms 
and  vomiting,  headache,  etc.  As  he  was  a  member  of  a 
club,  his  wife  sent  for  the  club  doctor.  He  continued  ill 
all  the  week  until  Tliursday.  the  doctor  stating  that  it  was 
a  bad  case  of  "blood  poisoning."     No  restrictions   were 


placed  on  visitors,  no  disinfectants  were  employed  in  the 
house.  On  Thursday  a  trained  nurse  w;.s  obtained,  who 
took  the  patient's  temperature  at  S  p.m.  It  was  then  loi' 
K..  pulse  120.  respiration  32.  That  evening  he  read  the 
newspaper  in  bed.  Xext  morning,  temperature  kkj.S  F., 
pulse  100.  respiration  36.  Ordered  whiskey  ji.  every  two 
hours.  The  temperature  rose  on  Friday  afternoon  to 
104.4  P..  pulse  120:  respiration  to 44.  52,  56,  and  about  7:30 
P.M.  he  died.  In  the  afternoon  a  second  medical  man  was 
called  in.  The  patient  had  been  in  bad  health  for  months, 
with  blotches  and  pimples  on  his  face.  He  drank  quietly 
and  unknown  to  his  wife  a  good  deal  of  beer.  He  had  been 
cleaning  out  a  drain  on  the  Saturday  before  he  was  at- 
tacked, and  had  a  small  sore  on  a  toe  of  the  left  foot. 
There  was  an  enlargement  of  the  femoral  glands  on  the 
left  side  with  red  streaks  of  inflamed  lymphatics.  The  two 
doctors  declared  it  to  be  a  case  of  bubonic  plague,  and  gave 
a  certificate  accordingly.  The  people  in  the  house  were  all 
quarantined,  and  three  houses  besides,  in  which  were  per- 
.sohs  who  had  l)ecn  in  contact  with  the  sick  man.  The  pa- 
tient died  on  Friday.  June  24th.  and  on  Saturday,  July  7th, 
the  inmates  of  the  house  were  released  from  quarantine,  no 
case  of  sickness  of  any  kind  having  occurred  among  them. 
Altogether  twenty-five  "contacts  "  were  quarantined;  six 
others  (doctors  and  undertakers)  who  had  been  in  contact 
with  the  corpse  were  allowed  at  large,  and  among  the 
thirty-one  there  was  not  a  single  case,  even  suspicious, 
after  a  fortnight  s  quarantine  '.  Obviously  the  conclusion 
is  that  this  was  either  not  a  case  of  bubonic  plague,  or  that 
plague  is  not,  in  our  climate  and  to  our  population,  an  in- 
fectious disease.  I  believe  the  case  to  have  been  one  of 
simple  septicaemia,  probably  by  the  introduction  of  septic 
matter  through  the  sore  on  the  toe. 

The  case  has  created  great  excitement  in  New  Zealand 
and  great  indignation  here,  as  exceptional  legislation  was 
passed  in  order  to  meet  the  emergency.  We  have  a  pre- 
mier here,  with  a  large  majority,  and  he  rules  us  with  a 
rod  of  iron.  By  the  new  act  anybody  can  be  shut  up.  any 
property,  including  houses,  can  be  taken  and  destroyed, 
without  compensation,  and  all  sueJi  acts  are  declared  to  be 
outside  the  jurisdiction  of  the  courts  of  law.  The  plague 
is  dying  out  in  Sydney,  but  spreading  to  other  Australian 
towns.  The  death  rate  in  Sydney  is  below  the  average  in 
spite  of  plague. 


A.  WORD  THROUGH  THE  FAMILY  PHYSI- 
CTAN  TO  THE  MOTHERS  OF  DEAF  CHIL- 
DREN. 

To   THE    F-DITOR    OF  THE    MeDICAI.   ReCORD. 

Sir  :  I  am  moved  to  write  you  under  the  above  title  by 
the  frequent  instances  that  come  to  my  notice  in  which  a 
timely  word  from  the  family  physician  to  the  mother  of  a 
deaf  child  would  have  made  him  a  genuine  benefactor. 

Every  physician  some  time  during  his  practice  meets  with 
a  case  of  total  deafness  or  imperfect  hearing  in  a  child. 
In  nine  cases  out  of  ten  the  deafness,  whether  partial  or 
total,  was  not  noticed  by  him  on  first  seeing  the  child,  and 
was  not  accepted  as  a  fact  by  the  parents  for  a  long  time 
after  the  doctor's  suspicions  were  aroused  and  expressed. 
I  have  known  many  cases  in  which  the  child  was  four  years 
old,  and  more,  before  the  parents  were  convinced  that  it 
was  so  deaf  as  to  need  special  attention.  The  result  is 
that  much  valuable  time  is  lost  which,  if  properly  used, 
would  have  had  a  most  beneficial  effect  upon  the  future 
welfare  of  the  child. 

It  is  not  generally  realized  by  either  physicians  or  parents 
how  great  a  handicap  even  slight  deafness  is  to  a  child  in 
hindering  tlie  acquisition  of  language  and  such  general  in- 
formation as  comes  from  the  ordinary  conversation  of  those 
around  him.  If  the  truth  was  known,  many  so-called  stu- 
pid children  are  only  hard  of  hearing  and  have  been  so  from 
infancy. 

If  the  child's  hearing  is  imperfect,  the  fact  should  be 
known  as  early  as  possible,  and  steps  taken  to  determine 
the  nature  of  the  difficulty,  and  what  means  should  be  em- 
ployed to  develop  the  hearing,  when  possible,  or  to  train 
the  other  senses  if  there  is  little  hope  of  improvement  in 
the  hearing. 

The  first  step,  of  course,  is  to  determine  whether  the  sus- 
picion of  deafness  is  correct,  and  if  so,  to  what  extent  the 
hearing  is  impaired  :  and  this  is  not  so  simple  a  thing  as  it 
might  seem.  In  fact,  there  are  not  many  more  puzzling 
things  than  to  determine  satisfactorily  these  facts  in  the 
case  of  a  child  at  the  age  of  two  years.  Slowness  in  learn- 
ing to  talk  may  be  an  indication,  but  many  children  of  nor- 
mal hearing  are  slow  in  beginning  to  speak.  Direct  tests, 
such  as  calling  when  the  child's  back  is  turned,  or  clapping 
the  hands,  are  apt  to  be  misleading,  for  often  a  child  with 
perfect  hearing  will  pay  no  attention  to  such  things  if  his 
mind  happens  to  be  occupied  with  something  el.se.  and  I 
have  frequently  seen  deaf  children  turn  on  such  an  occasion, 


270 


MEDICAL    RECORD. 


[August  1 8,  1900 


either  as  a  coincidence  or  from  pcictiving  vibration,  to 
which  they  are  often  surprisingly  sensitive.  Deafness 
also  presents  so  many  peculiarities  in  relation  to  pitch  as 
to  add  ditHcufty  to  the  task.  I  have  had  instances  iu  which 
sounds  of  a  certain  pitch  were  entirely  unheard,  while  for 
other  notes  the  hearing  was  almost  acute.  I  have  known 
instances  of  inability  to  hear  certain  vowels,  while  others 
were  heard  with  considerable  distinctness. 

There  are  al.so  certain  mental  defects  that  simulate  deaf- 
ness very  closely,  but,  of  course,  require  very  diflferent 
treatment.  These  and  many  other  possibilities  have  to  be 
known  and  taken  into  account  in  pronouncing  upon  the 
deafness  of  a  child  and  in  determining  what  course  is  best 
to  pursue. 

In  general  it  may  be  said  that  if  a  child  is  slow  in  begin- 
ning to  express  itself  in  words,  passes  its  second  birthday, 
we  will  say.  without  having  surely  uttered  any  words  ex- 
cept "papa"  and  "mamma,"  which  words  are  generally 
spoken  even  by  de'af  children  simply  in  imitation  of  the 
movements  of  the  mother's  lips,  then  it  is  time  to  prcJve 
that  deafness  is  or  is  not  the  cause. 

In  the  case  of  even  a  totally  deaf  child,  the  laugh  and 
cry  are  perfectly  natural,  a  thing  which  often  deceives  both 
mother  and  physician.  If  the  child  is  wholly  or  partially 
deaf,  but  in  every  other  I'espect  physical  and  mental  is 
normal,  there  have  probably  been  many  little  occurrences 
before  its  second  birthday  to  cause  the  mother  to  wonder  if 
there  may  not  be  something  wrong.  But  this  suspicion  is 
seldom  strong  enough  to  lead  to  a  consultation  with  a  spe- 
cialist, though  the  matter  may  be  mentioned  to  the  family 
physician,  and  he  should  either  carefully  test  the  child 
himself  or  have  the  parents  consult  some  one  for  the  pur- 
pose. 

It  is  no  very  unusual  thing  for  an  aurist  to  declare  that 
a  child  is  totally  deaf  who  has  really  only  some  form  of 
tonal  deafness,  and  possesses  enough  perception  of  sound 
to  be  of  great  service  if  _it  was  properly  educated  and  de- 
veloped. But  the  dictum  of  the  specialist  is  accepted  as 
final  and  the  latent  hearing-power  is  allowed  to  lie  dor- 
mant until  it  is  too  late  .to  do  much  in  the  way  of  awaken- 
ing and  educating  it.  But  even  if  an  aurist  is  not  always 
of  service  in  determining  the  state  of  the  child's  hearing, 
he  should  certainly  be  consulted  at  once  in  regard  to  the 
state  of  the  child's  ears,  as  soon  as  the  fact  of  deafness  is 
suspected. 

Every  mother,  of  course,  wishes  the  child  to  speak  and 
understand  the  speech  of  others,  and  to  be  as  intelligent  as 
other  children.  It  is  for  the  purpose  of  bringing  this  about, 
so  far  as  it  is  possible  in  the  case  of  a  deaf  child,  that  an 
early  knowledge  of  the  deafness  is  desirable.  Few 
mothers  realize,  even  after  they  are  certain  that  their  child 
is  deaf,  that  the  first  thing  they  should  do,  if  they  wish 
him  to  become  as  proficient  as  possible  in  speech  and  the 
understanding  of  speech,  is  to  consult  some  competent  au- 
thority on  the  subject  of  the  oral  education  of  the  deaf,  and 
put  themselves  under  the  guidance  of  such  a  person  in  their 
dealings  with  the  child.  In  this  way  they  can  often  save 
years  of  time  in  the  later  stages  of  the  child's  education, 
and  at  the  same  time  attain  results  which  would  be  impos- 
sible if  the  beginning  had  not  been  made  so  promptly.  A 
word  to  this  effect  from  the  family  physician  would  have 
great  weight  and  would  l:>e  the  means  of  conferring  an  in- 
calculable beneht  upon  both  parent  and  child. 

John  D.  Wright. 

42  West  76th  Street. 


AN    EARLY    EXPERIENCE  WITH    THE   RAIN 
BATH. 

To  THE  Editor  of  the  Medical  Record. 

Sir  ;  I  have  no  desire  to  enter  the  lists  in  the  controversy 
of  a  mooted  question,  viz.,  that  of  priority  in  having 
brought  to  public  notice  in  this  country  the  advantages  of 
the  rain  bath.  However,  recently  I  recalled  that  a  number 
of  years  ago,  when  post-bellum  literature  referring  to  the 
Civil  War  w-as  still  popular,  I  had  read  somethin.g  which, 
despite  facetious  narration,  bears  upon  the  subject. 

Junius  Henri  Browne,  war  correspondent  and  author  of 
"  Four  Years  in  Secessia,"  relates  in  the  last-named  volume 
his  experience  in  Missouri  while  with  Fremont's  army. 
In  one  place  he  speaks  with  fervor  of  some  evils  of  camp- 
life,  animate  and  other.  One  hot  night,  having  shed  his 
garments  for  good  cause,  he  resolves  upon  a  certain  line  of 
action,  which  is  described  as  follows:  "A  few  minutes 
after,  a  storm  which  had  been  gathering  burst  with  fierce 
lightning,  heavy  thunder,  and  torrents  of  rain.  A  happy 
idea  seized  me.  I  caught  up  my  saddle  and  bridle  and 
placed  them  on  my  sable  steed,  Festus,  which  stood 
neighing  to  the  tempest,  a  few  feet  from  camp.  I  mounted 
the  fleet-footed  horse  and.  nude  as  Apollo  Bel videre..  cried 
'go !  '  to  the  restive  animal,  and  off  we  sped,  to  the  amaze- 
ment of  the  sentinels,  throii.gh   the  darkness  and   storm. 


Every  few  minutes  the  lightning  blazed  around  us  with  a 
lurid  sheen,  as  we  went  like  the  wind  through  the  tem- 
pestuous night.  Festus  enjoyed  it,  as  did  his  rider,  and 
six  swift-speeding  miles  were  passed  ere  I  drew  the  rein 
upon  the  neck  of  the  panting  beast  covered  with  white 
llecks  of  foam.  1  paused  and  felt  the  fleas  had  been  left 
behind.  The  pelting  rain  and  rushing  blast  had  been  too 
much  for  them  ;  while  the  exercise  had  made  my  attireless 
body  glow^  into  a  pleasant  warmth.  Festus  galloped  back, 
and  soon  I  was  in  the  tent,  rolled  so  closely  in  a  blanket 
that  no  new  attack  could  reach  me.  ...  So  ended  that 
memorable  nochc  trisic,  an  exemplification  of  the  Scrip- 
tural declaration,  '  The  wicked  flee  when  no  man  pursu- 
eth. '" 

It  will  be  noted  in  the  above  that  both  the  stimulating 
and  the  cleansing  effects  of  the  rain  were  realized,  therefore 
in  a  sense  priority  in  employment  of  this  method  of  hydro- 
therapeutics  was  established  with  a  vengeance.  And  who 
will  not  say  that  thirty-nine  years  ago  a  layman's  inspira- 
tion conceived  and  at  once  brought  into  practical  effect  all 
the  benefits  of  a  natural  spray  bath? 

Bernard  Oetti.nger. 

Denver,  Colo.,  Aug.  2,  igoo. 


THE    SPECTACLE   AND    EYEGLASS    HABIT. 

To  THE  Editor  of  the  Medical  Record. 

Sir:  Your  issue  of  August  4th  contains  an  abstract  from 
an  article  by  N.  B.  Jenkins,  which  appeared  in  the  Xew 
York  Medical  Journal  of  July  2Sth,  entitled  "The  Spec- 
tacle and  Ej-eglass  Habit."  The  following  expressions  the 
writer  deems  strange,  if  not  absurd,  in  view  of  the  facts 
and  truths  that  are  to-day  incontrovertilih'  established: 
"The  wearing  of  spectacles  or  eyeglasses  out-of-doors  is 
always  a  disfigurement,  often  an  injury,  seldom  a  neces- 
sity. The  old  rule,  '  Wear  glasses  all  the  time, '  should  be 
changed  to  '  Wear  glasses  just  as  little  as  possible. '  " 

As  concerns  the  disfigurement,  it  suffices  to  say  that 
much  of  this  can  be  obviated  by  the  proper  regard  for  cos- 
metic effects.  There  is  no  doubt  that  a  face  can  be  made 
to  look  ludicrous  or  comely,  the  effect  produced  depending 
chiefly  on  the  oculist's  knowledge  of  symmetry,  harmony, 
and  the  angular  or  pleasing  relation  of  lines  and  forms. 
But  the  statement  that  glasses  are  "seldom  a  necessity  "  is 
inexcusable.  It  is  incorrect  and  could  be  excused  only  on 
the  grounds  that  the  author  wrote  from  the  standpoint  of 
a  layman,  or  one  who  deals  with  old  and  settled  facts  as  if 
he  were  discoursing  on  the  nebular  hypothesis  or  other 
questions  of  undoubted  controversial  category.  It  is  not 
necessary  to  state  that  an  anomalous  or  ametropic  eye, 
which  cannot  be  restored  by  operative  or  other  means  to  a 
normal  state,  needs  a  support  as  much  as  a  short  leg  needs 
a  high  heel,  etc.,  and  what  is  more  potent  and  true  is,  that 
it  needs  it  as  long  as  that  abnormality  exists  ;  in-doors  or 
"out-of-doors,"  or  wherever  vision  is  desired.  It  cannot  be 
doubted  that  an  eye  having  the  proper  correction  will  feel 
strained  when  the  correcting  lens  is  removed,  as  would  the 
short  leg  when  the  heel  is  removed  from  the  boot ;  Init  this 
Dr.  Jenkins  declares,  with  an  unheard-of  sweeping  state- 
ment, to  be  "because  they  have  wrong  glasses."  "The 
right  glasses,"  he  states,  "can  be  put  on  and  taken  off  at 
any  time  with  ease,  and  no  more  discomfort  will  follow 
than  when  putting  on  or  taking  off  a  hat." 

As  far  as  the  physical  exertion  of  taking  off  and  putting 
on  is  concerned,  this  is  true,  but  in  no  other  sense.  In  fact, 
it  is  possible  only  when  eyes  are  not  properly  corrected. 
Even  an  incorrectly  fitted  glass  you  can  t.ike  oft'  and  get 
much  relief.  It  is  an  accepted  fact  that  when  you  correct 
an  astigmatism  of  i  D,  you  relieve  the  strain  that  the  pa- 
tient makes  in  trying  to  obtain  clear  vision.  Take  this 
lens  of  I  D  cylinder  and  put  it  on  a  normal  eye,  and  that 
eye  will  encounter  the  trouble  that  the  patient  with  i  D  of 
astigmatism,  without  a  lens,  encounters,  habit  excepted. 
To  say  that  a  lens  correcting  an  error  of  refraction,  a 
heterophoria,  or  any  anomaly  is  onlv  temporarily  neces- 
sary, is  reversing  not  only  pure  logic,  Init  turns  topsy-turvy 
the  laws  upon  which  hygiene,  sanitation,  and  healing  are 
based. 

The  individual  with  healthy  normal  eyes  can  as  consist- 
ently and  with  as  much  comfort  put  on  3  D-j-  lenses  when 
he  goes  into  the  street  as  the  3  D  hyperope  can  remove  his 
when  he  goes  out-of-doors,  barring  what  of  custom,  disre- 
gard, and  disuse  habit  may  have  established.  The  indi- 
vidual with  4  or  5  of  exophoria  can  gain  but  little  by  .suf- 
fering in  "bits  "  when  his  comfort  is  complete  and  continual 
by  wearing  prisms  constantly. 

The  individual  with  a  marked  congenital  refractive  trou- 
ble of  one  eye  liaving  caused  an  amlilyopia.  should  be  told 
to  wear  liis  glasses  all  the  lime,  and  educate  and  develop 
his  defective  vision.  T.  T.  Blaise,  M.D. 

Mason  City,  Iowa. 


August  1 8,  1900] 


MEDICAL    RECORD. 


271 


^Ixerapcutic  glints. 

Cystitis.— 

^  Liquor  potassse 3  ij. 

Mucil.  acacift- §  i. 

Tinct.  hyoscyami ad  3  iv. 

M.     S.   Teaspoonful  every  four  hours. 

— BuRNSiDE  Foster. 

Pruritus  Ani. — 

ii  Sodii  hyposulphit 30  parts. 

Acid,  carbol 5       " 

Glycerini 50 

.'Xqiine 4;iJ 

Apply  frequently  by  means  of  wet  compresses. 

— Practitioner. 

Summer  Diarrhoea  in  Children. — Salol  is  to  be  em- 
ployed when  symptoms  indicate  an  implication  of  the 
upper  bowel ;  naphthalin,  however,  is  to  be  used  when 
the  colon  appears  to  be  chiefly  involved.  None  of  the 
bismuth  preparations  is  superior  to  the  subnitrate. 

H,  Bismutlii  subnit "  iss. 

Bismuth!  salicylatis gr.  .\v. 

Tinct.  rhei  aromat 3  ss. 

Aqua;  destill ad  3  ij. 

M.     S.   Teaspoonful  every  three  hours. 

— Hayward  and  Butler. 

Amyl  Nitrite  inhalations  cautiously  made  quiet 
severe  after-pains. — VVinterburx. 

Rachitis  and  Chronic  Malnutrition 

Vlf  Yolk  of  egg No.  ij. 

Glycerini 3  ss. 

01.  oliv 3  iij. 

.Add  one  minim  of  creosote  to  each  two  drachms. 
M.  ft.  emuls.      S.   Teaspoonful  after  food  three  times  a  day. 

— Practitioner. 
Mouth  Wash  and  gargle  for  sweetening  the  breath: 

iJ  .■\cid.  salicylici, 

Sodii  bicarb., 

Sacchari aa  gr.  ,\v. 

Spt.  vini  rect ' 5  i. 

Spt.  menth.  pip gtt.  x. 

M.      S.   Teaspoonful  in  a  small  cupful  of  hot  water. 

— Pal.mer. 
Gonorrhoeal   Arthritis. — 

H  Syr.  ferri  iodidi 3  ss. 

S.    At  dose  gradually  increased. 

— Wilson. 
Chorea. — 

I^  O!.  gaultherias J  i j. 

S,    .Apply     3  ss.    to     3  ii'    to    the   skin    with    friction    until 
systemic  effects  are  noted. 

— LuiGI. 

Hemorrhoids. — 

Q  Chrysarobin gr.  xij. 

lodoformi gr.  v. 

E.xt.  bellad gr.  viij. 

Petrolati 31. 

M.      S.   Apply. 

— Journ.  dc  Mid. 
Senile  Bronchitis 

1(  .\mmon.  carb gr.  v.-x. 

In  three  ounces  of  milk  several  times  daily. 

—Ex. 

Tuberculous  Laryngitis  in  the  later  stages  may  be 
best  treated  by  insufflation,  the  patient  himself  using 
a  bent  glass  tube  for  the  purpose. 

R  Iodoform 8 

Cocain,ii  hydrochlor 0.08 

Morphin.  hydrochlor 0.04 

The  pain  is  greatly  relieved  and  the  voice  may  be 
restored. — Leduc. 

Tuberculous  Joints — A  sun-bath  of  several  hours' 
duration  each  day  should  be  given.  A  firm  bandage 
over  wool  dressing  should  be  used  during  intervals. — 

MiLLIOZ. 


The  Mask  of  Pregnancy. — For  uterine  chloasma 
apply : 

'S,  Zinci  oxidi 0.20 

llydrarg.  ammoniat. ; o.  10 

01.  theobrom., 

01.  ricini aa  10. 

Essen,  rosx gtt.  x. 

M.  ft.  ung. 

Erysipelas. — Apply  mercurial  ointment  either  in  its 
full  strength  or  diluted  with  other  ointments  according 
to  the  nature  of  the  case. —  De.matteis. 

Measles  with  unconsciousness,  delirium,  carpologia, 
involuntary  evacuations,  etc.,  was  markedly  improved 
by  an  injection  of  10  c.c.  of  antistreptococcus  serum. 
—  Edgar  Oillrie. 

Myocarditis. — Caffeine  in  small  dose  varying  from 
day  to  day  may  be  kept  up  for  years  with  benefit  in  a 
great  variety  of  chronic  heart  affections.  It  is  espe- 
cially indicated  in  weakness  due  to  disturbance  of 
pulmonary  circulation. — Lemoine. 

Eclampsia. — In  coma  introduce  a  stomach  tube  and 
inject  a  solution  of  chloral  (gr.  xlv.  to  Ix.)  directly 
into  the  stomach.  If  given  by  the  rectum  it  is  often 
expelled.  When  the  mouth  cannot  be  opened,  pass 
through  the  nasal  fossse. —  Fochier. 

Chorea. — The  good  effect  of  belladonna  is  most 
marked  in  recent  cases.  Arsenic  may  be  combined 
with  it  in  rheumatic  cases.  Thirty  minims  or  more 
of  the  tincture  may  be  given  to  a  child  in  a  hospital 
ward,  every  four  hours  for  ten  days  or  more. — Over- 
end. 

Morphine  is  depended  upon  at  the  Willard  Parker 
Hospital  to  maintain  the  heart's  strength  in  diphtheria. 
Small  doses  hypodermatically  (gr.-iV --['„)  are  given. 
Strychnine,  alcohol,  and  nitroglycerin  are  also  em- 
ployed. 

Reflex  Cough  in  Children. — Treat  the  cause. 
Hacking  night-coughs  are  mostly  due  to  nasopharyn- 
geal obstruction.  Paroxysmal  hacking  cough  in 
emaciated  children  with  normal  temperature  is  held 
by  Warner  of  London  to  be  due  to  unbalanced  central 
nerve  action. — Pediatrics. 

Enteric  Fever   with  Excessive   Diarrhoea. — Give 

compound  tincture  of  benzoin,  beginning  with  ni^  v.  in 
water  every  two  hours,  and  double  the  dose  if  the 
diarrhoea  does  not  markedly  decrease  within  twelve 
hours.  Besides  the  antiseptic  there  is  supposed  to 
be  an  antipyretic  action. — J.  C.  Potter. 

To  Bring  on  Labor. — The  use  of  the  Krause  sound 
or  the  Farnier  balloon  are  means  largely  employed. 
They  prepare  for  rather  than  provoke  labor.  The 
Farnier  divulsor  at  times  gives  good  results  when  the 
part  presses  upon  the  neck.  Manual  dilatation  is  the 
method  of  choice,  for  it  permits  of  complete  and  rapid 
dilatation  and  should  be  adopted  in  all  cases  in  which 
it  becomes  necessary  to  terminate  labor  quickly. — 
Leon  Weill. 

Nitrogen  Gas  by  Intra-Pleural  Injection. — (i)  It 
will  have  a  permanent  place  in  the  treatment  of  pul- 
monary tuberculosis.  (2)  Bad  results  or  unpleasant 
effects  following  the  injections  have  not  been  person- 
ally observed.  (3)  No  patient  under  my  care  has 
been  cured  by  the  method,  although  a  great  many  have 
been  distinctly  benefited,  with  a  marked  recession  of 
all  the  active  svmptoms.  (4)  The  local  improvement 
is  not  so  marked  as  the  constitutional.  (5)  A  decided 
gain  in  the  bodily  weight  was  noted  in  every  case 
subjected  to  this  treatment.  (6)  It  has  never  failed 
promptly  to  stop  hemorrhages  from  the  lungs,  even  in 
severe  cases. — H.  P.  Loomis. 


272 


MEDICAL    RECORD. 


[August  18,  1900 


J»acictvj  5>epovts. 

THE  BRITISH  MEDICAL  ASSOCIATION. 

Sixty-eig/itk  Annual  Meeting,  Held  at  Jpswicit,  July  ji, 
and  August  i,  2,  and  j,  /goo. 

GENERAL  SESSIONS. 
(Special  Report  for  the  Medical  Record.) 

J^trsf  Day — Tuesday,  July  jTsi. 

At  eleven  o'clock  the  members  of  the  association  as- 
sembled in  the  church  of  St.  Mary-le-To\ver  to  take 
part  in  the  usual  opening  service.  The  church  was 
well  filled  with  the  members  and  their  families,  and 
the  mayor  and  aldermen  of  Ipswich,  who  were  pres- 
ent in  state,  attended  by  the  bearers  of  sword  and 
mace.  The  sermon  was  preached  by  the  Right  Rev. 
John  Sheepshanks,  Lord  Bishop  of  Norwich,  who  took 
for  his  text  Ecclesiasticus  xxxvii.  13,  14,  15,  and  16: 

"  Honor  the  physician  with  the  honor  due  unto  him,  for  the 
use  ye  may  have  of  him,  for  the  Lord  hath  created  him. 

"  For  of  the  Most  High  cometh  healing,  and  he  shall  receive 
honor  of  the  king. 

'■  The  skill  of  the  physician  shall  lift  up  his  head,  and  in  the 
sight  of  great  men  he  shall  be  in  admiration. 

"The  Lord  hath  created  medicines  out  of  the  earth,  and  he 
that  is  wise  shall  not  abhor  them. " 

At  three  o'clock  the  opening  general  session  was 
held  in  the  Higher-Grade  School  hall,  the  members  in 
attendance  (less  than  two  hundred)  being  called  to 
order  by  the  retiring  president,  Dr.  John  Ward  Cousins. 

Resolutions  of  Sympathy — He  began  by  propos- 
ing a  resolution  of  sympathy  by  the  association  with 
the  Queen  and  all  the  members  of  the  royal  family  in 
the  death  of  the  Duke  of  Edinburgh,  the  reigning 
prince  of  Saxe-Coburg  Gotha,  whose  demise  froin  can- 
cer had  recently  occurred.  This  resolution  having  been 
unanimously  adopted,  the  president  delivered  a  short 
address  upon  retiring  from  the  chair.  He  said  that  the 
membership  in  the  association  was  steadily  increasing, 
there  being  now  18,382  members  of  the  parent  asso- 
ciation and  of  its  various  branches  in  the  colonies. 
There  were  still,  however,  too  many  non-members 
among  the  medical  men  of  the  United  Kingdom,  and 
he  would  urge  upon  them  the  duty  and  the  advantage  of 
enrolling  themselves  in  this  great  representative  body. 
He  spoke  of  the  work  of  the  medical  men  in  South 
Africa,  and  expressed  confidence  that,  whtn  all  the 
testimony  concerning  the  alleged  hospital  mismanage- 
ment was  in,  it  would  be  found  that  no  blame  attached 
to  the  army  medical  corps.  There  ought,  he  said,  to 
be  specialists  in  the  medical  department  of  the  army. 
There  should  be  surgeons  to  treat  the  wounded,  physi- 
cians to  treat  the  sick,  and  sanitarians  to  prevent  sick- 
ness. After  referring  to  the  all  too  premature  death 
of  his  predecessor  in  office,  Sir  Thomas  Grainger 
Stewart,  he  introduced  his  successor,  Dr.  William  Al- 
fred EUiston,  tiie  president-elect  for  1900-1901. 

After  tlie  applause  which  greeted  him  had  subsided. 
Dr.  Elliston  said  that  his  first  pleasant  duty  as  presi- 
dent of  the  association  was  the  nomination  for  hon- 
orary membership  of  H.R.H.  the  Prince  of  Wales, 
K.G.,  Hon.  F.R.C.r.,  Hon.  F.R.C.S.  The  nomina- 
tion was  seconded  by  Dr.  Thomas  G.  Roddick,  of 
Montreal,  who  said  Canadians  were  very  much  at- 
tached to  the  Prince  of  Wales  and  would  all  be  glad 
to  learn  that  it  was  now  permitted  to  him  to  practise 
medicine  and  surgery  throughout  the  British  domin- 
ions. The  honor  the  association  was  about  to  bestow 
upon  him  w^as  shared  by  a  Canadian,  Lord  Strathcona 
and  Mount  Royal,  and  the  speaker  hoped  both  hon- 
orary members  would  attend  some  future  meeting  of 


the  association   in  Canada.     The  election  was  unani- 
mous. 

A  vote  of  thanks  to  the  retiring  president  was  then 
passed. 

Report  of  the  CounciL — A  motion  calling  for  the 
adoption  of  the  report  of  the  Council  and  of  the  treas- 
urer's statement  was  the  signal  for  the  usual  dispute 
over  matters  of  little  general  and  no  scientific  inter- 
est. In  the  course  of  the  wrangle  Mr.  Victor  Horsley 
called  attention  to  an  article  in  7/ic  British  Medical 
Journal  which  had  displeased  him,  and  accused  the 
editor  of  dishonesty,  and  to  emphasize  his  disapproval 
he  moved  that  the  following  paragraph  be  omitted 
from  the  report  of  the  Council:  ■'The  Council  has 
every  reason  to  believe  that  the  journal  has  proved 
increasingly  useful  to  members.  The  publication  of 
the  proceedings  of  the  last  annual  meeting  and  of  its 
sections  was  commenced  immediately  after  the  con- 
clusion of  the  meeting,  and  was  completed  before  the 
end  of  November.'' 

Dr.  Dawson  Willia.ms,  editor  of  The  Journal,  in 
a  straightforward  speech  disproved  Mr.  Horsley's 
charges,  and  maintained  that  he  had  written  the  ob- 
jectionable leader  in  good  faith,  with  no  thought  either 
of  suppressio  veri  or  of  suggcstio  Jalsi.  The  offended 
member  of  the  Council  then  agreed  to  w  ithdraw  his 
motion  of  censure  on  condition  that  his  remarks  and 
those  of  the  editor  be  printed  verbatim  in  The  Jownal. 

The  general  session  was  then  adjourned  to  reconvene 
at  8:30  in  the  Lyceum  Theatre.  After  another  reso- 
lution of  sympathy  with  the  Queen  and  royal  fam- 
ily in  their  loss  had  been  passed,  the  mayor  of  Ipswich 
welcomed  the  members  ot  the  association  to  the  town, 
and  spoke  of  the  pleasure  the  citizens  of  Ipswich  had 
experienced  in  the  selection  of  their  fellow-townsman, 
Dr.  Elliston,  as  president  of  this  representative  body 
of  British  medical  men. 

The  President's  Address. — Dr.  William  Alfre» 
Elliston  tiien  delivered  an  address  entitled,  "  Some 
Incidents  in  the  Evolution  of  the  Modern  Physician." 
During  the  Dark  Ages,  he  said,  men  of  learning  had 
spent  their  time  in  translating  and  repeating  what  the 
Greeks  had  taught,  until  at  last  they  had  come  to  believe 
that  Ptolemy,  Galen,  and  Aristotle  had  settled  most 
of  the  scientific  questions,  and  that  no  one  iiad  any 
right  to  doubt  their  decisions.  The  one  exception  to 
this  apathy  to  science  on  the  part  of  Englishmen  was 
Roger  Bacon.  Thomas  Linacre  introduced  what  was 
termed  the  "new  learning"  from  Italian  universities, 
and  Sir  Thomas  More,  in  his  "  Utopia,"  showed  the 
effect  upon  health  of  pure  water,  the  structure  and 
ventilation  of  the  house,  tlie  garden  at  the  back,  the 
width  of  the  street,  cleanliness,  isolation  of  the  in- 
fected sick,  care  of  cliildren,  abattoirs,  etc.  The  great 
event  of  the  sixteenth  century,  so  far  as  medicine  was 
concerned,  was  the  success  of  Thomas  Linacre  in  per- 
suading the  king  to  grant  a  charter  to  a  small  body  of 
medical  graduates,  who  were  thenceforth  called  the 
Royal  College  of  Physicians.  It  gave  them  the  sole 
power  to  license  to  practise  physic  in  London  or 
within  seven  miles'  radius,  with  other  privileges 
which  were  confirmed  by  a  statute  of  Henry  \T1I., 
and  extended  to  the  whole  of  England.  Soon  after  the 
birth  of  the  new  learning,  the  work  of  Vesalitis,  aided 
by  his  contemporaries  Fallopius  and  Eustachius, 
raised  anatomy  to  a  science  based  upon  the  dissection 
of  the  human  body  itself,  in  addition  to  that  of  ani- 
mals, but  this  scientific  advance  did  not  exercise  its 
infiuence  at  once,  as  might  be  seen  from  the  records 
of  highly  esteemed  practitioners  of  the  day.  In  the 
sixteenth  century  there  were  already  established  physi- 
cians, surgeons,  and  apothecaries,  the  first  being  men 
of  education,  the  others  with  a  few  exceptions  belong- 
ing to  the  les.s-educated  classes  until  the  rise  of  the 
nineteenth  century.     At  the  beginning  of  the  seven- 


August  1 8,  igooj 


MEDICAL    RECORD. 


273 


teenth  century  the  original  researches  of  Gilbert  and 
Harvey  completely  altered  the  position  of  Great  Brit- 
ain in  scientific  advance,  and  from  that  time  to  this 
Englishmen  have  taken  a  conspicuous  part  in  the  so- 
lution of  the  many  scientitic  problems  and  discoveries 
of  the  last  three  centuries.  Gilbert  established  the 
magnetic  nature  of  the  earth,  and  conjectured  that 
terrestrial  magnetism  and  electricity  were  two  allied 
emanations  of  a  single  force.  He  described  the  propn 
erties  of  the  magnet.  Harvey's  name  was  immortal- 
ized in  the  annals  of  medicine  for  his  discovery  of  the 
circulation  of  the  blood,  the  results  of  his  observa- 
tions were  the  more  remarkable  when  the  scanty  in- 
struments and  appliances  then  available  were  consid- 
ered. In  1645  ^  small  body  of  students  assembled  at 
Oxford,  who  in  1662  were  to  be  known  as  the  Koyal 
Society,  which  was  the  oldest  scientific  society  in 
Great  Britain  and  one  of  the  oldest  in  Europe.  Soon 
after  its  incorporation  the  society  published  papers 
by  Malpighi,  who  by  the  microscope  revealed  the  mi- 
nute infinite  particles  of  living  bodies.  A  little  ear- 
lier Boyle  and  John  Mayow  anticipated  some  of  the 
great  discoveries  in  chemistry  and  physiology  a  cen- 
tury later.  Practical  medicine  was  developing  in  this 
century;  a  pharmacopceia  had  been  issued,  cinchona 
bark  was  introduced,  botanical  gardens  were  estab- 
lished. In  surgery  the  growth  was  slow,  but  Nathan- 
iel Highmore  discovered  the  cavity  in  the  superior 
ma.xillary  bone,  and  Thomas  Wharton  the  duct  of  the 
maxillary  gland.  In  the  early  part  of  the  eighteenth 
century  Boerhaave,  of  Leyden,  shared  with  Dr.  Hales, 
the  great  English  chemist,  the  honor  of  founding  the 
science  of  organic  chemistry.  At  this  time  there  was 
no  systematic  medical  training  in  the  British  isles; 
but  there  were  isolated  attempts  at  special  instruction. 
The  study  of  anatomy  increased,  but  there  was  a  great 
amount  of  popular  prejudice  against  dissection.  Wil- 
liam Hunter  was  the  first  great  teacher  of  anatomy  in 
London,  and  was  selected  and  advanced  by  Dr.  James 
Douglas,  who  discovered  Douglas'  pouch.  The  most 
remarkable  scientific  advance  was  in  the  science  of 
chemistry.  Black,  Priestly,  Cavendish,  and  Ruther- 
ford discovered  respectively  carbonic  acid,  oxygen, 
hydrogen,  and  nitrogen.  In  practical  medicine  Dr. 
Richard  Mead  communicated  to  the  Royal  Society 
Borrow's  discovery  of  the  acarus  scabiei.  Dr.  James 
Lind  published  a  treatise  on  scurvy,  suggesting  the 
use  of  fruit  and  vegetables  and  lemon  juice.  He  also 
discovered  that  the  steam  of  salt  water  was  fresh. 
Toward  the  end  of  the  century  Sir  Edward  Jenner 
completed  his  observations  upon  the  prophylactic 
power  of  cowpox  against  the  virulence  of  smallpox. 
Dr.  Baillie  published  his  "  Morbid  Anatomy,"  which 
was  the  first  book  on  the  subject  in  Plnglish.  He  de- 
scribed ulcers  of  the  stomach  and  of  typhoid,  the 
changes  of  the  liver  in  cirrhosis,  abdominal  cysts,  and 
other  pathological  conditions.  The  scanty  means  of 
education  possible  in  London  and  the  absence  of  med- 
ical societies  in  the  eighteenth  century  were  remark- 
able. Surgeons  and  apothecaries  were  supposed  to  be 
able  to  pick  up  a  sufficient  smattering  of  their  work 
by  attending  a  hospital  for  a  few  months,  and  physi- 
cians were  educated  elsewhere.  The  education  of 
Edinburgh  was  far  ahead  of  London;  medical  socie- 
ties and  periodicals  flourished  there  before  coming 
south.  In  London,  in  1783,  there  were  five  lecturers 
on  anatomy,  three  lecturers  on  surgery,  and  three  lec- 
turers on  the  practice  of  medicine.  The  eighteenth 
century  closed  with  an  immense  advance  all  round  in 
general  science,  particularly  in  chemistry  and  elec- 
tricity. Of  the  physicians  and  surgeons  in  active 
practice  early  in  the  nineteenth  century  there  were 
many  of  great  distinction — Lettsom,  Matthew  Baillie, 
Edward  Jenner,  James  Gregory  the  younger,  Edward 
Grigby,    Cline,    Abernethy,    Sir   Astley    Cooper,    Sir 


Charles  Bell.  The  long  roll  of  eminent  surgeons  of 
later  days  began  with  several  distinguished  pupils  of 
John  Hunter.  Abernethy  and  Cooper  had  great  fame 
as  lecturers  and  bold  and  philosophic  surgeons.  To 
Charles  Bell  were  owed  anatomical  and  physiological 
discoveries  of  the  highest  importance  in  connection 
with  the  nervous  system.  The  important  legislation 
of  the  nineteenth  century  was  the  .Apothecaries  Act  of 
1815.  Previous  to  this  act  the  education  of  the  med- 
ical practitioners  of  England  and  VVales  was  entirely 
optional  on  their  part.  About  1850  a  preliminary  ex- 
amination in  arts  was  instituted  as  a  necessary  and 
independent  requirement  before  proceeding  to  the 
medical  curriculum.  In  1858  the  Medical  Act  be- 
came law.  Women  were  admitted  to  practise  in  1876. 
In  187S  the  pharmaceutical  chemists  were  licensed  by 
act.  In  1832  the  Anatomy  Act  afforded  facility  for 
the  practical  study  of  anatomy,  and  did  away  with 
"  body-snatching."  The  growth  of  the  medical  press 
began  with  the  efforts  of  William  Sharman,  M.D., 
who  in  18 10  edited  a  journal  called  The  JSkio  Medical 
Physical  Journal,  or  Annals  of  Medicine,  Natural  His- 
tory,and  Chemistry.  In  18 1 5  Thomas  Wakley  founded 
The  Lancet,  with  the  primary  object  of  disseminating 
much-needed  information  hitherto  regarded  as  the  ex- 
clusive property  of  members  of  the  London  hospitals, 
and  also  with  the  view  of  exposing  the  family  in- 
trigues that  influenced  the  appointments  in  the  Lon- 
don hospitals  and  the  medical  corporations.  It  was 
fiercely  opposed  for  ten  years.  The  brilliant  work 
done  by  physicians  and  surgeons  in  this  century 
would  take  too  long  to  enumerate;  but  the  speaker 
alluded  to  Bright's  discoveries  in  the  pathology  of 
kidney  disease,  Hodgkin's  observations  on  the  lym- 
phatic glands  and  the  spleen,  and  Addison's  publica- 
tions in  regard  to  the  relationship  between  anaemia 
and  disease  of  the  suprarenal  capsules.  Sir  William 
Gull,  Graves,  Gerhard,  Hughes  Bennett,  and  many 
other  great  names  swelled  the  list.  In  surgery,  more 
than  in  medicine,  the  tendency  had  been  to  special- 
ize. Dentistry,  ophthalmology,  and  aural  surgery 
were  branches  of  the  science.  The  most  brilliant  ad- 
vances had  been  in  abdominal  surgery,  and  operations 
that  forty  years  ago  were  deemed  unjustifiable  were 
now  performed  with  success  in  every  hospital,  thanks 
to  Sir  Spencer  Wells,  Keith,  Clay,  Greig  Smith,  and 
Lister.  William  Jeaffreson,  of  Eramlingham,  was  the 
first  surgeon  in  England  to  perform  the  modern  opera- 
tion of  ovariotomy  by  a  small  central  incision.  The 
treatment  of  mental  affections  had  greatly  improved 
in  this  century,  great  thanks  being  due  to  William 
Tuke,  Sir  John  Bucknill,  and  others.  The  two  great 
discoveries  of  the  nineteenth  century  in  connection 
with  medicine  and  surgery  were  the  antiseptic  treat- 
ment (due  to  Lord  Lister)  and  the  use  of  anasthetics. 
Robert  Liston  was. the  first  surgeon  in  the  country  to 
use  ether,  which  was  discovered  by  Faraday.  Parkes 
was  the  founder  and  first  teacher  of  military  hygiene, 
and  was  a  great  factor  in,  if  not  the  founder  of,  the 
science  of  modern  hygiene.  The  special  departments 
which  concerned  the  surroundings  of  man  had  been 
the  subjects  of  legislation  during  the  present  century. 
State  raadicine  as  an  organized  department  of  admin- 
istration was  of  modern  growth.  The  first  act  in  this 
direction  was  the  Towns  Improvement  Act  of  1847, 
and  in  1848  a  general  Public  Health  Act,  embracing 
the  whole  of  England  except  the  metropolis,  was 
passed.  The  Local  Government  Board  was  created 
in  187  I,  and  in  1875  the  existing  laws  were  digested 
into  the  Public  Health  Act  of  1875.  In  conclusion 
the  president  alluded  to  the  fact  that  medical  educa- 
tion was  the  most  costly  of  all  the  modern  profes- 
sions, which  was  due  to  the  long  period  of  time  re- 
quired for  the  medical  curriculum,  and  to  the 
multiplication  of  qualifications,  which  he  regarded  as 


2  74 


MEDICAL   RECORD. 


[August  1 8,  1900 


a  fashionable  absurdity.  There  was  necessity  for  the 
highest  mental  training,  but  the  elements  of  science 
should  be  more  generally  taught  in  school  life. 

At  the  conclusion  of  the  address  a  vote  of  thanks 
was  proposed  by  Mr.  Howard  Marsh,  seconded  by 
Dr.  I.  H.  Cameron,  of  Toronto,  and  carried  unani- 
mously. 

Greeting  to  Colonial  and  Foreign  Representa- 
tives.—  Dr.  John  Ward  Cousins  then  spoke  a  few  words 
of  welcome  to  the  foreign  and  colonial  guests,  to  which 
Drs.  Nicolaysen,  of  Christiania,  and  Roddick,  of  Mon- 
treal, responded. 

Second  Day —  JVediwsiiay,  August  ist. 

The  second  general  session  was  held  in  the  hall  of 
the  High  Grade  School. 

The  Meeting  of  1901. — After  a  list  of  names  of 
the  new  and  retiring  members  of  the  council  had  been 
read,  the  president  of  the  council.  Dr.  Roberts  Thom- 
son, announced  that,  upon  invitation  of  the  Gloucester 
branch,  the  council  suggested  that  the  ne.xt  meeting 
of  the  association  would  be  held  in  Cheltenham  under 
the  presidency  of  Dr.  George  Bagot  Ferguson.  This 
recommendation  was  adopted  by  a  vote  of  the  associa- 
tion, with  thanks  to  the  members  of  the  Gloucester 
branch  for  their  courteous  invitation. 

Address  in  Medicine. — Dr.  Philip  H.  Pve-Sjiith 
then  delivered  the  annual  address  in  medicine,  taking 
as  his  subject  "  Medicine  as  a  Science  and  Medicine  as 
an  Art."  He  said  that  medicine  was  defined  by  Aris- 
totle as  the  art  of  healing  and  the  art  of  curing,  and  to 
this  might  be  added  the  art  of  preventing  disease. 
Nevertheless,  as  the  art  of  agriculture  rested  on  botany, 
geology,  and  vegetable  physiology,  so  the  art  of  medi- 
cine depended  on  the  science  of  pathology,  the  prac- 
tice of  physic,  and  the  principles  of  physic.  It  must 
never  be  forgotten  that  it  was  an  art.  Theories,  or 
what  seem  to  be  logical  deductions,  or  explanations, 
or  statistics,  or  authority,  must  never  be  allowed  to 
take  the  place  of  observation  and  experience.  The 
disease  must  never  be  treated  without  considering  the 
patient.  There  need  be  no  wonder  if  vast  knowledge, 
profound  learning,  and  the  best  scientific  training 
sometimes  failed  to  make  a  successful  practitioner,  for 
besides  adequate  knowledge  and  a  strenuous  effort  to 
do  the  best  for  each  individual  patient  there  was  am- 
ple room  for  the  personal  qualities  which  insured  suc- 
cess in  every  department  of  life — power  of  observation 
and  insight — the  personal  influence  by  which  a  strong 
character  would  secure  obedience  and  inspire  hope, 
the  judgment  which  divined  what  kind  of  remedies 
were  suited  to  each  patient,  and  the  sympathy  which 
put  one  in  the  patient's  place,  and  not  only  met  but 
anticipated  his  wants.  If.  however,  medical  science 
without  art  was  inefficient,  medical  art  without  science 
was  not  only  unprogressive.  but  almost  always  became 
quackery.  As  soon  as  patients  were  treated  by  rule  of 
thumb,  by  tradition,  by  dogmas,  or  by  metaphysical 
axioms,  injury  was  done  to  the  physician  and  to  the 
patient.  Ronesetters  ignorant  of  anatomy,  wise  women 
who  cured  by  charm,  were  irrational;  the  indiscrimi- 
nate use  of  "  tonics"  was  as  irrational  as  that  of  hydro- 
therapy, of  alcoholic  stimulation,  or  of  electricity. 
There  was  no  such  thing  as  a  tonic  or  strengthening 
medicine:  the  sole  source  of  strength  was  oxidizable 
food,  and  bitter  medicines  could  only  give  strength  by 
improving  the  appetite.  The  last  of  the  systems  of 
medicine  founded  on  a  dogma  was  homceopathy. 
Apart  from  these  exploded  systems  of  treatment,  our 
profession  had  often  suffered  from  lack  of  the  scien- 
tific, inquiring,  sceptical  spirit,  and  had  been  led  too 
easily  by  authority,  by  tradition,  and  by  fashion — as 
witness  the  past  abuse  of  venesection  and  of  mercury. 
The  important  and  constantly  growing  branch  of  med- 


icine which  dealt  with  the  prevention  rather  than  the 
cure  of  disease  also  depended  upon  science,  for  trac- 
ing the  dependence  of  one  event  upon  another  was  the 
essence  of  inductive  science.  How  closely  natural 
science  was  related  to  preventive  medicine  was  shown 
by  the  history  of  Jenner,  who  was  a  naturalist,  and 
Pasteur,  who  was  a  chemist.  We  ought  to  give  up  the 
perfunctory  explanations  which  so  often  did  duty  for 
investigation,  and  not  ascribe  every  inflammation  to 
cold,  every  doubtful  symptom  to  gout,  disease  to  over- 
work and  worry;  modern  life  was  easier  and  safer  and 
smoother  than  it  was  a  hundred  years  ago,  and  young 
men  and  maidens  were  healthier,  bettergrown,  less  emo- 
tional than  their  great-grandparents.  The  duty  of  a 
physician  was  not  to  flatter  the  selfishness  of  neurotic 
patients,  but  to  inspire  fortitude,  and  to  prescribe  reg- 
ular and  steady  work  as  the  best  cure  for  a  thousand 
nervous  ailments.  There  was  another  temptation — ■ 
and  that  was  to  assume  that  because  many  diseases 
were  now  proved  to  depend  upon  the  presence  of  bac- 
teria this  must  be  true  of  all.  Science  did  not  antici- 
pate, but  waited  for  proof.  Another  important  branch 
of  medicine — prognosis — depended  as  an  art  upon  ex- 
perience and  insight.  Yet  here  also  rational  prognosis 
rested  on  the  science  of  statistics.  Statistics  must  be 
based  upon  cases  which  were  both  numerous  and  accu- 
rate. It  was  only  after  hundreds  of  cases  had  been 
observed  that  it  was  learned  that  infantile  paralysis 
sometimes  befell  adults,  and  that  osteo-arthritis  might 
occur  in  children.  This  paucity  might  be  remedied  by 
time,  but  the  defect  of  inaccuracy  was  without  remedy. 
If  diagnosis  was  perfunctory  or  careless,  and  nomen- 
clature arbitrary  and  inconstant,  the  more  cases  were 
observed  the  less  did  they  teach.  The  necessity  for 
experiments  for  the  progress  of  pathology  and  for  the 
cure  and  prevention  of  disease  was  too  important  to  be 
omitted.  As  its  objects  and  methods  were  better  un- 
derstood, it  would  secure  the  enlightened  patronage  of 
all  who  desired  the  improvement  of  human  knowledge 
and  the  increase  of  human  happiness.  The  cure  of 
disease  rested  upon  science,  but  even  in  its  practical 
carrying  out  we  were  bound  to  take  with  us  a  scientific 
spirit.  Some  men  prescribed,  and  never  saw  that  the 
prescriptions  or  directions  were  carried  out.  How 
could  success  be  expected  in  treating  an  obscure  ner- 
vous affection  if  galvanism  was  applied  to  the  spine 
without  making  sure  of  any  physiological  effect — nay, 
sometimes  without  making  sure  that  a  current  was 
passing  through  the  electrodes;  or  if  a  patient  was 
sent  to  drink  the  waters  of  a  fashionable  watering- 
place  without  the  physician  remembering  that  there 
were  two  or  perhaps  three  springs,  one  of  them  inert 
and  another  possibly  injurious.'  What  success  could 
be  anticipated  if  ointment  was  ordered  for  a  weeping 
eczematous  patch  when  it  floated  on  the  secretion  and 
never  reached  tiie  inflamed  tissue,  or  if  a  lotion  was 
prescribed  to  be  applied  twice  a  day  to  a  skin  well 
protected  by  its  sebaceous  secretion  ?  Much  ineffectual 
treatment  again  depended  upon  want  of  confidence  in 
one's  diagnosis.  If  syphilis  was  only  suspected,  rem- 
edies would  be  given  in  inadequate  doses.  Another 
source  of  failure  in  therapeutics  was  the  legion  of  new 
remedies.  It  was  astonishing  to  find  apparently  ra- 
tional men  forsaking  the  drugs  which  had  been  proved 
effectual  by  the  experience  of  long-past  time  in  all 
nations,  to  take  up  with  remedies  the  composition  of 
which  was  often  unknown,  the  use  of  which  they  had 
never  learned,  and  of  which  the  value  rested  upon  the 
interested  or  credulous  assertions  of  those  who  were 
trying  to  sell  them.  A  scientific  spirit  siiould  also  be 
more  freely  admitted  in  treatment  by  baths  and  waters. 
Was  a  bath  different  in  its  effects  because  it  came 
heated  from  the  earth  rather  tiian  from  a  kettle,  or  did 
salts  act  differently  when  occurring  in  natural  solution 
than  when  dissolved  in   the  same  proportion   in  the 


August  1 8,  1900] 


MEDICAL    RECORD. 


275 


druggist's  shop?  It  should  be  frankly  acknowledged 
that  benefit  was  derived  by  change  of  air  and  scene, 
by  early  hours,  regulated  rest,  exercise,  diet,  and  copi- 
ous draughts  of  water.  VVas  it  not  also  a  mistake  to 
prescribe  made-up  drugs,  and  thus  lead  patients  to 
ascribe  their  recovery  not  to  the  doctor's  skill,  but  to 
this  or  that  pill  or  tablet?  As  to  the  physician's  just 
recognition,  his  patients  could  not  be  expected  to  un- 
derstand the  scientific  basis  of  medicine,  nor,  as  his 
services  were  to  tiie  individual  and  not  to  the  com- 
munity, could  he  expect  the  rewards  given  to  states- 
men, generals,  or  judges;  but  he  did  as  a  rule  receive 
the  trust,  the  honor,  and  the  gratitude  which  he  had 
earned,  for  patients  understood  personal  character, 
honesty,  sense,  kindness  and  sympathy,  liberality,  and 
benevolence  to  rich  and  poor. 

Award  of  the  Middlemore  Prize. — After  a  vote  of 
thanks  to  Dr.  Pye-Smitii  had  been  passed,  the  presi- 
dent announced  that  the  Middlemore  prize,  of  the 
value  of  ;^5o,  had  been  awarded  for  research  in  oph- 
thalmology to  Dr.  Krnest  Maddox,  of  Lournemouth. 

Reform  in  the  Association The   reports   of   the 

parliamentary  bills  committee,  of  the  scientific  grants 
committee,  of  the  general  practitioners  and  ethical 
committee,  of  the  ansesthetics  committee,  and  of  the 
therapeutic  committee  having  been  presented  and 
adopted,  Mr.  Victor  Horsley  presented  a  resolution, 
"That  a  committee  be  appointed  to  consider  and  re- 
port upon  the  best  means  of  reorganizing  the  constitu- 
tion of  the  British  Medical  Association,  such  commit- 
tee to  furnish  a  provisional  report  to  the  branches  by 
March  i,  1900."  In  speaking  upon  the  motion  he 
sketched  the  reforms  which  he  thought  necessary,  and 
read  a  list  of  twenty-three  names  of  men  viho,  he  said, 
ought  to  constitute  the  committee.  After  the  mem- 
bers had  recovered  their  breath  they  decided  tiiat  Mr. 
Horsley  was  not  the  whole  association,  and  that  the 
others  should  have  some  voice  in  the  matter.  It  was 
then  decided  that  the  committee  should  consist  of 
twenty-four  members,  twelve  to  be  nominated  by  the 
council  and  twelve  by  the  general  body,  and  that  the 
appointment  should  be  made  at  the  next  general  ses- 
sion. The  resolution  was  then  carried,  the  date  for 
the  provisional  report  being  advanced  to  February  ist, 
in  order  to  allow  time  for  consideration  of  the  proposed 
changes  by  the  Australian  branches. 


SECTION    OK   SURGERY. 
First  Day —  Wednesday,  August  ist: 

President's  Address — Mr.  Howard  Marsh,  of 
London,  in  opening  the  work  of  the  section,  said  that, 
in  accordance  with  a  general  agreement,  he  would 
make  no  formal  address,  but  would  briefly  call  atten- 
tion to  the  work  which  had  been  planned  for  this 
meeting.  An  effort  had  been  made  to  limit  the  num- 
ber of  papers,  and  so  prevent  the  congestion  that  usu- 
ally occurred  and  allow  time  for  the  intelligent  dis- 
cussion of  the  subjects  introduced.  There  would  be 
two  set  discussions,  one  on  subphrenic  abscess,  the 
other  on  fractures.  It  might  be  thought  that  one  of 
these  conditions  was  too  uncommon,  the  other  too 
common  to  merit  formal  discussion  by  the  members 
of  the  section,  but  this  was  not  so.  Subdiaphragmatic 
abscess  was  not  such  a  rare  condition  as  was  gener- 
ally supposed,  and  there  had  been  many  improve- 
ments in  the  diagnosis  and  treatment  of  fractures  in 
recent  years  which  would  well  bear  discussion  at  the 
present  day. 

Subdiaphragmatic  Abscess. — Mr.  Rick^ian  J. 
GoDLEE,  of  London,  opened  the  discussion  with  a 
long  and  carefully  considered  paper.  The  condition, 
he  said,  was  not  a  disease  but  a  symptom,  and  he 
would  define  it  as  "a  collection  of  pus,  with  or  with- 


out gas,  between  the  diaphragm  and  the  structures  in 
contact  with  it."  There  were  no  pathognomonic  symp- 
toms of  the  affection,  a  pleuritic  stitch  and  hiccough 
being  perhaps  the  most  common.  If  there  was  no  gas 
present,  the  percussion  note  would  be  dull  when  the 
abscess  was  near  the  surface,  but  in  cases  of  subdia- 
phragmatic pneumothorax  (as  the  condition  had  been 
called  when  gas  was  present)  the  note  would  be  tym- 
panitic. The  respiratory  movements  of  the  chest  were 
seldom  interfered  with,  and  the  normal  pulmonary 
sounds  were  generally  audible — signs  of  value  in  the 
differential  diagnosis.  The  speaker  then  presented 
an  etiological  classification  of  the  different  forms  of 
subphrenic  abscess,  in  which  he  said  he  had  followed 
Maydl  quite  closely.  This  was  as  follows:  (i)  Stom- 
ach.—In  cases  of  sudden  perforation  of  a  gastric  ulcer 
the  pus  might  escape  into  the  general  peritoneal  cav- 
ity or  into  the  smaller  sac,  but  in  either  case  it  was 
not  uncommon  to  find  it  localized.  In  other  cases  in 
which  the  perforation  of  the  stomach  walls  was  grad- 
ual, adhesions  were  almost  always  formed  with  the 
diaphragm  or  adjacent  viscera,  and  a  strictly  circum- 
scribed subphrenic  abscess  was  sometimes  the  result. 
More  often,  however,  these  abscesses  burrowed  widely, 
and  in  such  cases  a  diagnosis  of  empyema  (espe- 
cially if,  as  not  infrequently  happened,  there  was  a 
coincident  pleural  serous  effusion)  was  often  made. 
(2)  Intestine. — Subdiaphragmatic  abscesses  of  intes- 
tinal origin  were  the  result  of  perforation  of  ulcers  of 
the  duodenum  or  transverse  colon.  In  such  cases  gas 
was  mingled  with  the  pus  and  the  note  elicited  by 
percussion  was  tympanitic,  tiiough  if  the  patient  were 
made  to  stand,  some  dulness  might  be  obtained  at  the 
lower  portion  of  the  collection.  (3)  Appendix. — A 
subphrenic  abscess  might  result  from  the  migration 
of  a  perityphlitic  abscess.  In  such  cases  there  was 
tirst  a  swelling  in  the  iliac  fossa,  which  usually  sub- 
sided as  the  signs  of  a  subdiaphragmatic  collection 
became  pronounced.  The  abscess  might  be  on  the 
left  side,  though  naturally  it  was  more  commonly  on 
the  right.  (4)  Hydatids. — Suppuration  might  occur 
in  an  hydatid  cyst  of  the  liver  or  spleen.  (5)  Liver. — 
As  would  be  expected,  many  subdiaphragmatic  ab- 
scesses owed  their  origin  to  disease  of  the  liver  or 
gall  tracts,  a  perihepatic  abscess  being  a  not  very  un- 
common affection.  (6)  Kidneys. — Occasionally  a  peri- 
renal abscess  was  formed  between  the  kidney  and  the 
diaphragm,  and  sometimes  a  subphrenic  abscess  was 
simulated  by  a  pyonephrosis  of  large  size.  (7)  Sub- 
cutaneous Injuries. — Cases  were  on  record  in  which  a 
subdiaphragmatic  abscess  had  followed  a  blow  with- 
out a  wound  of  the  skin,  but  it  was  probable  that  in 
such  instances  an  ulcer  of  the  stomach  or  intestine  had 
been  present  and  the  blow  caused  perforation.  (8) 
Wounds. — Septic  material  might  be  introduced  in  the 
case  of  a  penetrating  wound  of  the  abdomen  and  lead 
directly  to  the  formation  of  an  abscess.  (9)  Me- 
tastases.—  Maydl  had  this  division  in  his  classifica- 
tion, but  the  speaker  was  inclined  to  regard  the  ab- 
scesses grouped  under  this  head  as  due  in  reality  to 
direct  extension  of  pus  from  some  lesion  in  the  neigh- 
borhood. (10)  Ribs. — Cold  abscesses  resulting  from 
necrosis  or  caries  of  the  ribs  might  burrow  through  the 
muscular  tissues  and  become  subphrenic  in  location. 
(11)  Thorax. — The  pus  of  an  empyema  or  that  re- 
sulting from  Pott's  disease  or  mediastinitis  might  pass 
down  beneath  the  diaphragm.  (12)  Various  Causes. 
— This  was  Maydl's  last  group,  and  included  luber- 
culosis,  pancreatitis,  peritonitis,  and  actinomycosis. 
The  last-named  condition  was  seemingly  not  so  rare 
as  was  generally  supposed,  for  the  speaker  had  seen 
no  fewer  than  thirteen  cases  in  the  past  five  years. 
The  matter  forming  the  contents  of  the  so-called  ab- 
scess in  cases  of  actinomycosis  was  not  true  pus.  The 
progress  of  these  cases  was  very  slow,  and   the  treat- 


276 


MEDICAL    RECORD. 


[August  18,  1900 


ment  was  not  entirely  satisfactory  in  its  results.  In 
those  cases  in  which  the  subdiaphragmatic  abscess  re- 
sulted from  perforation  of  a  gastric  or  intestinal  ulcer  it 
was  often  necessary  to  close  the  opening  in  the  viscus, 
though  sometimes  simple  drainage  of  the  abscess  cav- 
ity was  sufficient. 

Mr.  Bruce  Clarke,  of  London,  spoke  of  the  diag- 
nosis, which  he  said  was  usually  difficult  and  could 
often  be  made  only  by  e.xclusion.  Among  the  causes 
he  regarded  a  perforating  ulcer  of  the  stomach  or  in- 
testine as  by  far  the  most  common.  He  agreed  with 
Mr.  Godlee  that  it  was  incorrect  to  speak  of  metastasis 
as  one  of  the  causes  of  subdiaphragmatic  abscess,  and 
preferred  the  term  "septic  condition."  He  favored 
the  making  of  an  incision  in  the  abdomen  large  enough 
to  admit  the  hand  for  exploratory  purposes,  before  cut- 
ting directly  into  the  abscess. 

Mr.  Leox.^rd  a.  Bidwell,  of  London,  reported  six 
cases  of  subphrenic  abscess,  in  four  of  which  a  diag- 
nosis of  empyema  had  been  made.  Gastric  ulcer 
was  the  cause  in  three  cases  and  ulcer  of  the  transverse 
colon  in  one.  He  spoke  of  the  odor  of  the  pus  in 
cases  of  subphrenic  abscess,  which  was  peculiarly 
offensive  and  served  as  a  diagnostic  point  in  the  differ- 
entiation from  empyema. 

Mr.  Edw.\rd  Barx.\rd  Fl'ller,  of  Cape  Town, 
said  that  a  bacteriological  examination  of  the  pus  re- 
moved by  an  exploratory  aspiration  was  often  of  great 
service  in  the  way  of  diagnosis,  the  presence  of  the 
colon  bacillus  pointing  with  almost  absolute  certainty 
to  the  intestinal  origin  of  the  abscess  and  consequently 
establishing  the  diagnosis  of  subphrenic  abscess  as 
opposed  to  empyema. 

Interesting  cases  of  subdiaphragmatic  abscess  were 
reported  by  Mr.  James  Stanley  Boyd  and  Mr.  Noble 
Smith  of  London,  Dr.  Cameron  of  Canada,  Dr.  Len- 
nander  of  Upsala,  Mr.  Firmin  Cuthbert  of  Gloucester, 
and  Mr.  R.  C.  Chicken  of  Nottingham. 

Pyloroplasty Mr.  Leo.vard  A.  Bidwell,  of  Lon- 
don, reported  a  number  of  cases  of  non-malignant  ste- 
nosis of  the  pylorus  in  which  he  had  performed  pylo- 
roplasty with  excellent  results,  and  he  regarded  the 
operation  in  such  cases  as  one  attended  with  compara- 
tively slight  risk. 

Prof.  John  Berg,  of  Stockholm,  said  his  experi- 
ence with  pyloroplasty  had  not  been  entirely  satisfac- 
tory, retraction  of  the  stenosis  having  occurred  in 
about  half  of  his  cases.  He  was  obliged  to  resort  to 
gastro-enterostomy  in  these  cases,  and  usually  now  had 
recourse  to  this  operation  in  the  first  instance  as  being 
the  more  sure  in  its  results  and  not  much  more  danger- 
ous. He  said  it  was  not  safe  to  tabulate  the  results  of  a 
pyloroplasty  within  three  years  of  the  operation,  since 
recurrence  of  the  stricture  was  sometimes  very  late. 

Cholecystocolostomy. — -Mr.  Hexrv  Betham  Rob- 
inson, of  London,  reported  a  case  of  jaundice  due  to 
obstruction  of  the  ductus  communis  choledochus  by  a 
syphilitic  formation.  An  anastomosis  was  established 
betw'een  the  colon  and  the  gall  bladder,  and  potassium 
iodide  was  administered.  The  patient  made  a  good 
recovery,  and  the  stricture  was  eventually  relieved. 

Oophorectomy  in  Mammary  Carcinoma.— Mr.  J. 
Stanley  Boyd  read  a  paper  in  which  he  had  collected 
the  statistics  of  thirty-eight  cases  of  this  operation — • 
all  of  which  he  could  find  mention  in  the  literature  up 
to  the  present  time.  In  seventeen  of  these  cases 
(nearly  forty-five  per  cent.)  the  operation  had  been 
followed  by  improvement  in  the  condition  of  the  breast. 
In  some  of  the  cases  thyroid  feeding  had  also  been  re- 
sorted to,  but  the  speaker  did  not  think  there  was  any 
evidence  of  benefit  from  this.  The  operation  was  still 
siili  Jiiiiii-c,  but  enough  had  been  learned  to  show  that  it 
was  useless  to  resort  to  it  after  the  menopause. 

Stricture  of  the  Rectum — Mr.  Frederick  Charles 
Wallis,  of  London,  read  a  paper  on  the  etiology  and 


treatment  of  non-cancerous  stenosis  of  the  rectum.  In 
almost  all  of  these  cases,  he  said,  some  toxa;mic  con- 
dition was  present,  as  shown  by  the  frequent  coinci- 
dence of  arthritis.  Excision  of  the  strictured  portion 
of  the  gut,  with  pulling  down  of  the  mucous  membrane 
and  suture  to  the  anus,  was  a  method  of  treatment  to 
which  he  had  resorted  with  most  satisfactory  results 
in  two  cases,  the  histories  of  which  he  narrated. 

Mr.  Frederick  Treves,  of  London,  said  that  the 
operation  of  excision  was  of  use  only  in  cases  of 
fibrous  stenosis  of  the  rectum,  but  in  selected  cases  it 
was  often  of  great  benefit.  He  believed  that  many 
cases  of  rectal  stricture,  although  not  recognized  until 
later  in  life,  were  really  of  congenital  origin. 


SECTION   OF   GENERAL    MEDICINE. 
First  Day —  Wedfiesday,  August  Tst. 

The  medical  section  met  in  the  Art  Gallery, 
Wednesday  forenoon,  under  the  presidency  of  Dr. 
Thomas  Buzzard.  The  president  said  that  com- 
plaints were  often  heard  that  the  chairman's  introduc- 
tory address  took  up  too  much  time  that  might  more 
profitably  be  devoted  to  the  scientific  work  of  the  sec- 
tion, and  he  would  therefore  content  himself  with  a 
few  informal  remarks. 

Influenza  as  it  Affects  the  Nervous  System. — 
The  set  discussion  on  this  subject  was  opened  by 
Dr.  Judson  S.  Bury,  of  JManchester.  He  said  that  in- 
fluenza was  such  a  protean  disease  that  it  was  almost 
impossible  to  picture  any  typical  syndrome,  and  while 
four  general  forms  might  be  recognized  according  as 
the  symptoms  were  referable  chiefly  to  the  respiratory, 
the  gastro-enteric,  the  cardiac,  or  the  nervous  appara- 
tus, yet  in  all  the  nervous  system  was  a  special  suf- 
ferer from  the  action  of  the  toxin.  Of  the  nervous 
form/(7/'  excellence  there  were  two  divisions,  embracing 
(i)  cases  in  which  the  brain  was  chiefly  affected,  and 
(2)  those  in  which  the  symptoms  were  of  a  mental,  neu- 
rasthenic, or  paralytic  order.  Cases  in  the  first  group, 
in  which  the  most  characteristic  symptom  was  deli- 
rium or  coma,  occurred  during  the  pyrexia,  those  of  the 
second  group  were  not  marked  by  fever.  The  differ- 
ence between  the  influenza  and  the  diphtheria  toxins, 
as  regarded  their  influence  upon  the  nervous  system, 
was  that  the  former  seized  upon  no  special  part  of  the 
nervous  system,  but  affected  now  one.  now  another  por-  J 
tion,  seemingly  at  haphazard.  In  the  polyneuritis  of  \ 
influenza  he  thought  it  possible  that  the  active  agent 
might  be  a  streptococcus  or  some  other  as  yet  unrecog- 
nized pathogenic  agent,  the  influenza  bacillus  acting 
only  as  a  forerunner  preparing  the  soil  for  the  specific 
germ.  He  reported  .several  cases  of  nervous  influenza 
in  illustration  of  the  various  points  brought  out  in  his 
communication. 

Sir  Willia.m  Broadbent,  of  London,  thought  a  dis- 
tinction should  be  made  between  the  direct  action  of 
the  bacilli  upon  the  tissues  and  that  of  their  toxins. 
The  more  serious  forms,  the  comatose  and  delirious 
types  of  the  preceding  speaker,  were  jjrobably  due  to 
the  direct  action  of  the  bacilli,  being  analogous  to 
pernicious  malarial  fever  of  cerebral  type  in  which 
were  found  plasmodial  and  leucocytic  emboli  in  the 
vessels.  In  the  neuritic  and  neurasthenic  cases,  on 
the  other  liand,  the  symptoms  were  probably  the  effect 
of  the  toxin  of  the  disease  acting  upon  some  already 
weakened  spot.  The  speaker  reported  several  inter- 
esting cases:  one  of  acute  dementia  following  influ- 
enza, six  of  the  acute  comatose  form,  and  one  of  poly- 
neuritis in  which  death  occurred  after  involvement  of 
the  respiratory  muscles.  In  one  case,  probably  of 
thrombosis  of  the  cerebral  vessels  of  the  right  side, 
the  patient  suffered  from  hemiplegia  of  gradual  onset 
and  still  more  gradual  decline;  the  attack  occurred 


August  1 8,  1900] 


MEDICAL    RECORD. 


277 


ten  years  ago,  and  now  the  hemiplegia  had  almost  en- 
tirely disappeared.  In  another  case,  which  had  ended 
in  recovery,  there  were  very  severe  unilateral  convul- 
sions, without  paralysis. 

Sir  Peter  Eade,  of  Norwich,  was  unable  to  agree 
with  Sir  William  Gowers,  who  had  said  that  the  influ- 
enza poison  affected  chiefly  the  motor  nerves,  and  be- 
lieved that  its  incidence  was  rather  on  the  sensory 
apparatus.  The  medulla  oblongata  was  the  part 
mainly  attacked,  and  in  this  the  speaker  saw  an  ex- 
planation of  the  frequent  cardiac  complications.  He 
thouglit  it  incorrect  to  call  the  nervous  symptoms 
sequelae,  for  he  believed  the  implication  of  the  ner- 
vous system  began  during  the  primary  attack.  He 
remarked  upon  the  unexampled  duration  of  the  pres- 
ent pandemic  of  the  disease,  which  had  now  lasted  ten' 
years. 

Dr.  T.  Clifford  Allbutt,  of  Cambridge,  said 
that  many  cases  were  called  influenza  incorrectly,  and 
he  insisted  upon  the  necessity  for  accuracy  in  diagno- 
sis. One  sign  of  value  in  this  respect  was  the  sudden 
onset  of  the  disease.  He  thought  the  anterior  part  of 
the  brain  was  the  most  frequently  attacked,  but  whether 
certain  areas  here  were  more  liable  to  involvement  than 
others  he  could  not  say,  though  it  would  be  well  to 
determine  this  point.  In  cases  in  which  the  symp- 
toms pointed  to  lesions  of  the  central  nervous  system 
he  advocated  lumbar  puncture  in  order  to  render  pos- 
sible a  bacteriological  diagnosis.  He  thought  the 
prognosis  of  nervous  influenza  was  not  favorable.  He 
related  a  case  i  1  which  there  had  been  aphasia  and 
paralysis;  the  latter  had  disappeared  completely,  but 
the  patient  suffered  from  aphasia  whenever  he  at- 
tempted to  talk  fast. 

Dr.  Newton  Pitt,  of  London,  questioned  whether 
the  meningitis  and  other  severe  nervous  affections  as- 
sociated with  influenza  were  due  to  the  direct  effect 
of  the  specific  bacillus.  He  had  seen  several  cases 
in  w'hich  typhoid  fever  followed  an  attack  of  influ- 
enza, but  no  one  would  claim  that  the  typhoid  lesions 
were  influenzal;  the  influenza  bacilli  had  doubtless 
overcome  the  resisting  power  of  the  organism,  which 
had  then  become  vulnerable  to  the  action  of  the  ty- 
phoid germ,  and  it  might  be  the  same  in  the  so-called 
influenzal  meningitis.  He  had,  however,  found  Pfeif- 
fer's  bacillus  in  a  couple  of  cases  in  which  the  inflam- 
mation had  crept  up  through  the  nasal  sinuses.  He 
held  that  the  cardiac  forms  of  influenza  were  really 
nervous,  the  heart  suffering  through  its  nerve  supply 
and  not  from  myocardial  implication.  In  many  cases 
also  the  symptoms  referable  to  the  heart  were  really 
secondary  to  gastric  disturbances.  In  polyneuritis  of 
influenzal  origin  facial  paralysis  was  a  common  symp- 
tom. 

Dr.  Frank  M.  Pope,  of  Leicester,  thought  it  not 
improbable  that  the  incidence  of  the  influenzal  poison 
might  often  be  determined  by  trauma,  and  related  a 
case  of  comatose  type  seeming  to  support  this  assump- 
tion. He  remarked  upon  the  fact  that  the  nervous 
forms  of  influenza  were  more  common  at  the  beginning 
of  the  epidemic  than  now,  and  thought  this  was  due 
to  the  fact  that  those  whose  nervous  system  was  vulner- 
able speedily  fell  victims,  thus  showing  that  the  disease 
attacked  the  weak  spots.  He  referred  to  cases  of  anos- 
mia as  being  of  unfavorable  prognosis,  and  explained 
this  by  the  fact  that  the  olfactory  centre  was  so  close 
to  the  nasal  mucous  membrai^e,  the  portal  of  entry  of 
the  disease,  that  it  received  a  large  dose  of  the  poison. 

Dr.  J.  M.  MacCormac,  of  Belfast,  said  that  one 
spoke  always  of  the  influenza  bacillus,  and  of  influenza 
as  a  specific  entity,  but  he  questioned  very  much 
whether  such  a  protean  disease  as  that  called  influ- 
enza could  really  be  due  to  the  action  of  only  one 
form  of  bacillus. 

Dr.  S.  K.  Mullick,  of  London,  thought  influenza 


was  primarily  a  disease  of  the  nervous  system,  the 
other  organs  and  apparatus  being  secondarily  affected, 
and  of  the  nervous  system  the  motor  nerves  were  more 
commonly  involved  than  the  sensory. 

Dr.  S.  E.  Solly,  of  Colorado  Springs,  reported  a 
case  of  influenzal  hemiplegia  terminating  in  recovery. 

Dr.  R.  Saundby,  of  Birmingham,  spoke  of  diabetes 
following  influenza,  which  he  said  was  exactly  com- 
parable to  diabetes  following  any  other  acute  infec- 
tious malady,  and  was  not  improbably  due  to  a  chronic 
interstitial  pancreatitis  set  up  by  the  toxin  of  the  dis- 
ease. 

Dr.  Garrett  Anderson,  of  London,  agreed  with 
Dr.  Clifford  Allbutt  as  to  the  necessity  for  accurate 
diagnosis,  and  said  that  influenza  was  too  often  used 
as  a  convenient  term  to  cover  ignorance.  She  re- 
ported two  cases  of  influenzal  diabetes.  Referring  to 
the  interesting  series  of  cases  reported  by  Sir  William 
Broadbent,  six  of  which  occurred  on  a  training-ship, 
she  said  that  the  poison  was  intensified  by  crowding; 
and  she  herself  had  observed  similar  aggregations  of 
cases  in  the  servants'  quarters  of  great  houses  and  in 
schools. 

Dr.  John  Haddon,  of  Hawick,  believed  that  influ- 
enzal pneumonia  was  due  to  an  early  implication  of 
the  vagus  centres. 

Dr.  William  Ewart,  of  London,  spoke  of  the  dif- 
ferential diagnosis  of  the  influenzal  imitation  of  the 
system  diseases  (such  as  tabes  dorsalis,  Friedreich's 
ataxia,  and  spastic  paraplegia)  and  system  diseases 
with  organic  lesions.  In  the  former  the  symptoms 
were  of  sudden  onset,  the  disease  appeared  at  once  in 
full  intensity  and  then  began  to  subside  gradually;  in 
the  true  disease  the  beginning  was  insidious  and  the 
symptoms  increased  very  gradually  in  intensity.  He 
recommended  especially  a  study  of  the  nervous  forms 
of  influenza,  for  he  thought  we  might  through  this  in- 
crease our  knowledge  of  the  mode  of  action  of  the  vari- 
ous toxins  upon  the  brain  and  spinal  cord.  In  certain 
cases  of  recurring  influenza  or  of  nervous  symptoms 
appearing  some  time  after  the  subsidence  of  the  pri- 
mary attack,  the  speaker  thought  it  possible  that  the 
bacilli  might  be  persisting  in  the  nasal  mucous  mem- 
brane or  elsewhere  and  giving  forth  continually  fresh 
supplies  of  toxin. 

Sir  John  William  Moore,  of  Dublin,  said  that  in 
his  opinion  many  cases  of  so-called  influenzal  nervous 
disorders  were  purely  imaginary.  Influenza  frequently 
induced  a  peculiar  psychical  state  in  which  the  pa- 
tients became  hypochondriacal  and  imagined  them- 
selves the  subject  of  various  serious  diseases,  when, 
as  a  matter  of  fact,  they  had  no  organic  lesions  what- 
ever. As  to  the  cardiac  form  of  influenza,  he  agreed 
with  Dr.  Newton  Pitt  that  the  symptoms  were  more 
often  of  nervous  than  of  myocardial  origin. 

Dr.  St.  Clair  Thomson,  of  London,  referred  to 
influenzal  anosmia,  and  said  he  did  not  regard  the 
prognosis  as  especially  unfavorable.  He  advocated 
cleansing  of  the  nasal  mucous  membrane,  but  d(  ubted 
the  utility  of  strong  antiseptic  solutions.  He  spoke 
also  of  influenzal  paralysis  of  the  larynx  and  of  the 
pharyngeal  hypersesthesia  occurring  in  this  disease. 

Dr.  Thomas  Buzzard,  of  London,  the  president  of 
the  section,  said  that  we  ought  to  distinguish  between 
the  symptoms  actually  due  to  influenza  and  those  of 
the  diseases  which  were  pre-existing  and  had  only 
been  brought  to  light  by  the  influenzal  attack.  As  an 
example  of  the  latter,  he  reported  a  case  of  locomotor 
ataxia  in  which  the  symptoms,  previously  slight,  were 
greatly  intensified  after  an  attack  of  influenza.  Sim- 
ilarly in  many  cases  of  influenzal  mania  and  melan- 
cholia there  was  doubtless  mental  disease  smouldering 
beneath  the  surface  and  only  needing  the  disturbing 
influence  of  the  acute  infection  to  burst  into  flame. 
He  referred  to  some  earlier  writings  in  which  he  had 


278 


MEDICAL   RECORD. 


[August  18,  1900 


noted  the  bizarre  arrangement  of  the  symptoms  of 
syphilis  of  the  nervous  system,  such  as  paralysis  of  a 
leg  and  an  arm  on  opposite  sides  of  the  body,  an  ar- 
rangement which  was  now  recognized  as  the  result  of 
the  action  of  toxins.  This  same  bizarre  arrangement 
was  seen  in  the  symptoms  of  nervous  influenza,  show- 
ing that  they  were  the  expression  of  a  toxa;mia.  In 
illustration  of  this  the  speaker  reported  several  cases 
of  unusual  interest.  One  patient  had  double  optic 
neuritis,  nystagmus,  paralysis  of  both  arms  and  both 
legs,  intention  tremor  of  one  arm,  and  absence  of  the 
patellar  phenomenon.  He  said  the  nomenclature  of 
nervous  influenza  was  too  cramped  and  a  wider  vocab- 
ulary was  needed.  Toxasmic  nervous  affections  had 
largely  increased  of  late,  and  this  was  in  great  meas- 
ure due  to  the  influenza  pandemic. 

Dr.  Bury  closed  the  discussion,  giving  several  il- 
lustrations of  the  value  of  debates  of  this  sort,  show- 
ing how  they  added  to  the  sum  of  the  store  of  medical 
knowledge. 

{To  be  Continued.'^ 


ptcdical  Items. 

Plague    in    Oporto Dr.   Albert  Chalmette,  writing 

in  the  Nori/'i  American  Review,  July,  on  the  plague  in 
Oporto  says  :  "  The  experiments  initiated  by  the  French 
mission,  and  conducted  with  the  aid  of  the  Portuguese 
and  foreign  doctors  present  at  Oporto,  prove  unexcep- 
tionally  that  with  energetic  measures  intelligently  ap- 
plied it  is  easy  to  arrest  the  spread  of  the  disease  in  a 
district  or  city.  The  experiments  were  first  of  all 
directed  toward  the  prevention  of  the  plague  among 
animals  susceptible  to  it  and  among  mankind.  The 
international  committee  appointed  to  verify  this  by 
the  president  of  the  Portuguese  council  of  ministers 
affirmed  that  every  one  who  will  submit  to  the  inocu- 
lation of  5  c.c.  of  the  anti-plague  serum  of  the  Pas- 
teur Institute  would  by  such  vaccination  be  protected 
against  the  plague  for  a  period  of  about  three  weeks, 
and  that  it  would  be  of  the  greatest  value  if  this  vac- 
cination were  made  obligatory  .  .  .  The  measures 
that  the  French  scientific  mission  recommended  to  the 
sanitary  authorities  of  Oporto  were  these:  (i)  Isola- 
tion and  the  obligatory  transportation  of  those  stricken 
to  a  special  hospital;  (2)  compulsory  vaccination  of 
all  persons  who  have  been  in  contact  with  the  sick  or 
who  inhabit  the  same  house;  (3)  the  building  of  tem- 
porary huts  to  lodge  for  a  period  of  twenty  days  all 
persons  who  have  inhabited  a  house  where  a  case  of 
plague  has  occurred;  (4)  complete  disinfection,  airing 
and  abandoning  for  a  space  of  twenty  days  a  house 
where  a  case  of  plague  has  been  observed;  (5)  the  or- 
ganization as  at  Bombay,  if  (as  almost  always  happens) 
the  population  conceals  cases,  of  search  committees 
composed  of  doctors,  nurses,  litter  bearers,  and  police, 
which  committees,  arranged  for  districts,  should  visit 
twice  a  day  all  dwelling-places  in  their  quarter  and 
satisfy  themselves  that  no  case  of  illness  exists  in 
them;  (6)  the  methodical  destruction  of  rats  and  mice 
in  the  shops,  houses,  and  sewers;  (7)  liberty  of  circu- 
lation outside  the  town  for  all  persons  who  have  been 
vaccinated  against  the  plague  within  a  period  of  not 
less  than  forty-eight  hours,  nor  more  than  fifteen  days, 
after  such  vaccination;  (8)  the  burning  of  buildings 
of  small  value  where  many  cases  of  the  disease  have 
occurred." 

New  Air-Ship.— According  to  a  cablegram  in  the 
daily  papers,  the  first  authoritative  report  on  Count 
Zeppelin's  airship  was  made  on  July  loth  at  a  meeting 
of  the  Society  for  the  Promotion  of  Aerial  Navigation 
by  experts  who  either  shared  in  or  watched  the  recent 


experiments.  They  declared  that  improvements  in  the 
steering  apparatus  were  necessary,  the  one  used  at 
present  having  been  thrown  out  of  gear  on  one  side  of 
the  balloon,  rendering  its  proper  guidance  and  return 
to  the  starting-point  impossible.  The  steering-rods 
running  upward  from  the  car  were  too  weak  and  be- 
came bent.  The  screw-blades  consequently  did  not 
respond  properly.  The  air-pressure  motors  failed,  but 
it  was  difficult  to  say  whether  this  was  caused  by  a  de- 
fect or  by  bad  handling.  The  method  of  transmitting 
power  to  the  screws  will  need  great  improvement  to 
enable  the  airship  to  contend  against  even  a  light 
wind.  During  the  recent  ascent  the  wind  had  a  veloc- 
ity of  three  metres  to  the  height  of  one  hundred  metres, 
and  against  this  the  vessel  sailed  well;  but  at  a  height 
of  from  one  hundred  and  fifty  to  two  hundred  metres 
the  balloon  was  evidently  driven  before  the  wind.  It 
must  be  remembered,  however,  that  this  was  when  one 
of  the  rudders  was  out  of  gear.  If  the  speed  of  the 
screws  cannot  be  increased,  the  blades  must  be  en- 
larged. Another  defect  was  the  continual  escape  of 
gas,  necessitating  constant  filling  up  of  the  receptacle 
up  to  the  moment  of  starting.  This  defect  alone  will 
prevent  the  achievement  of  the  idea  of  remaining  in 
the  air  for  eight  consecutive  days,  as  a  single  filling 
costs  1,000  marks.  Already  more  than  1,000,000 
marks  has  been  spent  on  the  machine  and  experi- 
ments, of  which  amount  Count  Zeppelin  furnished 
about  500,000  marks. — Science. 

Mr.  Treves  on  Wounds  in  War. — Mr.  Treves, 
lecturing  recently  in  London  on  his  South  African  ex- 
periences, concludes  that  operations  upon  the  wounded 
in  battle  should  be  performed  under  the  following  cir- 
cumstances: (i)  If  the  patient  is  seen  before  seven 
hours  have  elapsed;  (2)  if  the  patient  has  had  a  short 
and  easy  transport ;  (3)  an  empty  stomach.  In  antero- 
posterior wounds  of  the  abdomen  above  the  umbilicus 
it  is  a  sine  qua  no?i  that  the  bullet  should  have  escaped. 
He  judges  that  the  circumstances  against  operation 
are:  (i)  As  a  general  rule,  if  the  patient  is  not  seen 
till  more  than  seven  hours  after  the  wound;  (2)  if 
there  has  been  a  long  and  arduous  transport;  (3)  all 
cases  of  transverse  or  oblique  wounds  above  the  um- 
bilicus, because  it  is  practically  impossible  to  do  all 
that  is  required,  the  openings  in  the  bowel  and  the 
wounds  of  other  structures  being  so  numerous;  (4)  all 
cases  of  retained  bullet;  it  is  impossible  in  the  field 
to  start  on  a  search  for  the  bullet,  a  procedure  that 
would  require  bringing  the  viscera  out  of  the  ab- 
domen; (5)  all  cases  of  wounds  of  the  liver,  of  the 
spleep,  and  of  the  kidney;  (6)  most  cases  of  wound 
below  the  umbilicus,  because  they  do  all  right  if  let 
alone;  (7)  cases  in  which  the  colon  alone  is  impli- 
cated (perhaps  excepting  the  transverse  colon),  be- 
cause these  cases  do  very  well  if  let  alone. 

British  Army  Contract  Scandals.— So  much  was 
written  at  the  time  of  our  war  with  Spain  concerning 
the  shortcomings  of  our  army  commissariat  department 
that  it  is  perhaps  somewhat  excusable  on  our  part  not 
to  be  too  greatly  distressed  to  find  that  the  conduct  of 
the  same  department  of  the  British  army  has  not  been 
above  reproach;  London  Truth  says  in  reference  to 
this  matter:  "Evidence  of  a  most  interesting,  not  to 
say  sensational,  character  was  given  at  a  late  sitting  of 
the  committee  on  army  contracts.  The  story  of  the 
boots  supplied  to  the  company  of  the  Second  V.  B. 
Worcestershire  regiment  formed  for  service  in  South 
Africa  reads  like  a  chapter  from  the  history  of  the 
Crimean  war.  Not  only  were  these  boots  delivered 
seventeen  or  eighteen  days  after  the  troops  ought  to 
have  sailed,  but  after  being  tried  during  a  route  march 
to  .Mdershot  were  found  to  be  useless  rubbish,  and  on' 
hundred  and  fifty  pairs  out  of  two  hundred  and  twent\ 


August  1 8.  1900] 


MEDICAL    RECORD. 


279 


six  were  actually  condemned  after  being  opened  and 
inspected  by  the  representatives  of  the  middleman  who 
took  the  contract.  The  worst  feature  of  the  case  is 
that  for  these  precious  goods  the  regiment  had  paid 
considerably  more  than  the  usual  government  contract 
price.  Within  the  past  few  months  I  have  been  in 
direct  communication  on  this  subject  with  two  or  three 
firms  who  have  had  a  large  experience  of  such  con- 
tracts. All  of  them  agree  that  in  execution  of  an  army 
contract  it  is  the  necessary  and  usual  course  to  bribe 
subordinate  oflicials  chiefly  for  two  purposes — the  pass- 
ing of  the  work  and  the  passing  of  accounts.  For  in- 
stance, one  contractor  told  me  that  he  had  an  enor- 
mous sum — reckoned  in  tens  of  thousands  of  pounds — 
long  outstanding,  and  his  only  chance  of  getting  his 
accounts  settled  up  in  reasonable  time  was  to  grease 
the  palms  of  the  military  foreman  of  works,  who  other- 
wise could  and  would  delay  the  payment  for  an  indefi- 
nite time.  One  contractor  told  me  that  I  might  take 
it  as  certain  that,  whatever  tender  is  accepted,  from  ten 
to  fifteen  per  cent,  has  been  added  to  the  price  for  the 
purpose  of '  backsheesh.' " 

Inhuman  Experiments. — The  Berlin  correspondent 
of  the  British  Medical  Journal  narrates  the  following 
experiments  performed  on  a  human  being  in  Germany. 
He  says:  "Gross  abuses  in  any  profession  should  not 
be  hushed  up,  but  should  rather  be  made  public  as 
freely  as  possible,  so  as  to  rouse  public  opinion  against 
them  and  thus  render  their  repetition  or  spread  impos- 
sible; and,  therefore,  we  have  reason  to  thank  the 
Social  Democrat  paper  Vorwdrts  for  dragging  into 
light  the  'experiments'  made  by  Dr.  Stubell  (first  as- 
sistant in  Professor  Stinzing's  clinic  at  Jena)  on  pa- 
tients suffering  from  diabetes  insipidus,  and  published 
by  him  in  the  Anliiv  Jiir  klinische  Medizin.  Dr.  Stu- 
bell there  tells  how  he  kept  one  of  his  patients  in  an 
attic  with  barred  windows,  the  doorof  which  he  locked, 
putting  the  key  in  his  pocket;  how  the  patient,  who 
was  allowed  only  a  very  small  amount  of  liquid,  in 
his  torturing  thirst,  which  is  a  symptom  of  the  disease, 
drank  his  washing-water;  how  one  night  in  his  agony 
he  drank  about  1,400  c.c.  of  his  own  urine;  how 
another  night  he  wrenched  off  one  of  his  window 
bars,  climbed  over  the  roof  to  another  small  window, 
through  which  he  crept,  thus  finding  his  way  to  a 
water-tap,  where  he  was  captured  and  brought  back  to 
his  prison.  Dr.  Stubell  calmly  states  that  his  patient 
must  have  endured  '  frightful  tortures '  one  night,  and 
gives  the  following  account  of  his  condition  in  the 
morning:  'The  patient  was  quite  collapsed,  his  face 
seemed  dried  up,  eyes  and  cheeks  deeply  sunken,  pulse 
almost  imperceptible,  a  great  deal  of  pain,  joints 
stiff.'  The  whole  medical  profession  must  reprobate 
cruelties  such  as  these  perpetrated  in  the  name  of 
science." 

A  Noble  Doctor — The  London  Globe  recently  pub- 
lished a  letter  from  a  correspondent  in  the  Orange 
River  Colony  telling  the  following  story  concerning 
one  of  the  medical  officers  to  the  British  forces  in 
South  Africa:  "  I  wanted  to  tell  about  our  doctor.  He 
is  a  splendid  chap,  named  Martin.  I  believe  the  fel- 
lows simply  swear  by  him.  For  instance,  the  other 
morning  I  took  some  men  of  my  command  down  to  see 
him,  and  after  looking  at  the  sick  report,  he  said: 
'  Oh,  yes!  Jerkins,  chap  with  rheumatics  in  the  right 
leg.'  '  Yuss,  doctor,  pains  horful,'  says  Jorkins. 
Jorkins  is  a  London  cockney,  good  soldier,  and  par- 
ticular friend  of  mine.  '  Well,  look  here,  Jorkins,  you 
must  have  something  warm  over  you  at  night;  take 
this  overcoat;  you  must  go  into  hospital  when  we 
reach  camp.'  This  overcoat  I  noticed  was  the  doctor's 
own  private  property,  and  I  thought  what  a  good  soul 
he  was.     Next  came  Walker.     '  Let  me  see ;   Walker, 


bad  chest;  still  painful,  eh? '  '  Shockin','  tersely  an- 
swered Walker.  Said  the  doctor,  diving  into  a  kit  bag, 
'  take  this,'  producing  a  fine  woollen  shirt,  worth  its 
weight  in  gold  out  here.  '  Rip  it  up  and  wrap  it 
round  your  chest  every  night,  and  here's  some  more 
cough  mixture  for  you.  I  can't  do  anything  more  for 
you  just  now.'  I  was  walking  just  behind  these  two 
as  they  returned  to  their  lines.  '  Proper  toff,  ain't  'e,' 
says  Jorkins.  '  'E's  wot  I  call  the  fine  root ' ;  and  when 
a  soldier  dubs  a  man  the  '  fine  root '  it  means  a  lot." 
— Fhysician  and  Surgeon. 

State    Care    of    Dependent   Children Henrietta 

Christian  Wright  contributed  a  "well-written  article  on 
the  above  subject  to  the  July  number  of  the  North 
American  Review,  in  which  she  points  out  that  the 
methods  in  vogue  in  New  York  State  and  in  other 
States  of  the  Union  of  grappling  with  the  problem  of 
how  best  to  deal  with  indigent  children  are  both  un- 
intelligent and  harmful.  She  is  in  favor  of  the  board- 
ing-out system,  and  cites  Massachusetts  as  a  striking 
example  of  this  mode  of  procedure  carried  out  success- 
fully. Referring  to  this  State,  Miss  Wright  says: 
"Massachusetts,  with  a  population  to  the  square  mile 
exceeding  that  of  New  York,  and  in  which  the  artificial 
conditions  of  living  are  practically  the  same,  has  no 
dependent  children,  technically  speaking,  in  institu- 
tons  supported  by  the  State.  Largely  affected  by  the 
problem  of  immigration  and  under  the  strain  produced 
by  great  centres  of  population  engaged  in  mill  and 
factory  work  and  so  removed  from  the  more  healthful 
influences  of  smaller  village  and  country  life,  this  State 
has  yet  so  successfully  solved  the  problem  of  juvenile 
pauperism,  that  out  of  a  population  of  two  and  a 
half  millions  it  has  only  twenty-eight  hundred  and 
fifty-two  wards  to  support.  The  State  has  a  nursery 
at  Roxbury,  where  destitute  infants  are  cared  for  while 
requiring  medical  or  surgical  treatment,  and  where 
children  boarded  out  are  brought  for  treatment  when 
necessary.  The  nursery  is  a  temporary  home  only  in 
the  strictest  sense  of  the  word,  boarding-out  being  the 
end  in  view.  There  is  also  a  temporary  boarding-place 
at  Arlington  with  a  capacity  for  only  twenty  children, 
and  a  home  for  wayward  boys,  with  a  capacity  for  sev- 
enteen. The  State  has  two  industrial  schools,  the 
Lyman  school  for  boys  and  the  State  industrial  school 
for  girls,  which  together  cared  for  three  hundred  and 
ninety-one  boys  and  girls  during  the  year  1896.  There 
are  also  two  reform  schools,  having  three  hundred  and 
ninety-seven  children  in  charge.  With  these  excep- 
tions the  dependent  children  of  Massachusetts  are 
placed  or  boarded  out." 

Conan  Doyle  upon  Enteric  Fever  among  the  Brit- 
ish Troops  in  South  Africa. — Conan  Doyle,  writing 
to  the  British  Medical  Journal,  says:  "  The  outbreak  of 
enteric  fever  among  the  troops  in  South  Africa  was  a 
calamity  the  magnitude  of  which  had  not  been  fore- 
seen, and  which  even  now  is  imperfectly  appreciated. 
We  naturally  did  not  dwell  too  much  upon  it  while  the 
war  was  in  progress,  but  it  was  appalling  in  its  sever- 
ity both  in  quantity  and  quality.  I  know  of  no  in- 
stance of  such  an  epidemic  in  modern  warfare.  I  have 
not  had  access  to  any  official  figures,  but  I  believe  that 
in  one  month  there  were  from  ten  thousand  to  twelve 
thousand  men  down  with  this  most  debilitating  and  lin- 
gering of  continued  fevers.  I  know  that  in  one  month 
six  hundred  men  were  laid  in  the  Bloemfontein  ceme- 
tery. A  single  day  in  this  one  town  saw  forty  deaths. 
There  is  one  mistake  we  have  made  which  will  not,  I 
think,  be  repeated  in  any  subsequent  campaign.  In- 
oculation for  enteric  fever  was  not  made  compulsory. 
If  it  had  been  so,  I  believe  that  we  should  (and  what 
is  more  important,  the  army  would)  have  escaped  from 
most  of   its  troubles.     No  doubt  the  matter  will  be 


28o 


MEDICAL   RECORD. 


[August  1 8,  1900 


fully  threshed  out  in  statistics,  but  our  strong  impres- 
sion from  our  own  experience  is  that,  although  it  is  by 
no  means  an  absolute  preventive,  it  certainly  modifies 
the  course  of  the  disease  very  materially.  We  have 
had  no  death  yet  {al>sit  omen)  from  among  the  inocu- 
lated, and  more  than  once  we  have  diagnosed  the  in- 
oculation from  the  temperature  chart  before  being 
informed  of  it.  Of  our  own  personnel,  only  one  in- 
oculated man  has  had  it,  and  his  case  was  certainly 
modified  very  favorably  by  the  inoculation." 

The  Female  Army  Nurses  now  number  one  hun- 
dred and  forty-five,  practically  all  of  whom  are  either 
in  the  Philippines,  stationed  at  the  hospitals  of  the 
various  garrisons  throughout  the  archipelago,  or  on 
their  way  there. 

A  Natural  History  Note.— A  physician  of  Dyers- 
ville,  Iowa,  now  on  his  travels,  writing  to  The  Com- 
mercial of  that  place  a  description  of  an  ocean  trip, 
says:  "We  have  met  several  ships  and  have  seen  lots 
of  flying-fish,  which  are  three  to  four  feet  long  and 
longer.  When  they  jump  from  the  ocean,  they  look 
more  like  a  hog  than  a  fish." 

Plague  Infection  by  Fleas. — The  danger  of  infec- 
tion by  fleas  exists,  to  those  near  the  sick,  but  this 
insect  does  not  infest  man  in  great  numbers,  and  be- 
sides it  can  gorge  itself  with  bacilli  only  in  the  last 
days  of  the  disease,  since  until  then  these  do  not 
appear  in  the  blood.  The  most  frequent  cases  of  con- 
tagion are  those  of  physicians  who  have  made  post- 
mortem examinations,  doubtless  from  coming  in  con- 
tact with  the  blood  and  with  organs  infected  by  the 
microbes.  Two  of  Kitasato's  assistants  acquired  the 
plague  in  Hong-Kong  in  this  way. — Dr.  Montenegro 
on  Bubonic  Plague. 

A  New  Terror  of  Courtship  has  been  developed  in 
the  case  of  an  Indiana  brunette.  For  some  days  she 
had  been  suffering  from  a  supposed  attack  of  pleurisy, 
but,  when  Dr.  S.  F.  Bordman  was  called  in,  he  found 
that  one  of  the  young  lady's  ribs  was  fractured.  After 
much  questioning,  the  girl  blushingly  admitted  that 
her  best  beau  had  inflicted  the  injury  while  giving  her 
his  usual  tender  embrace  before  parting  on  his  last 
visit.  The  occurrence  of  the  accident  was  marked  by 
a  sharp  pain  in  the  side,  "  a  catch  in  her  breath,"  and 
a  sudden  relaxation  of  her  hold. —  Chicago  Medicai  Re- 
corder, July,  1900. 

Power  of  the  Eye. — "  We  often  hear,"  writes  Hiram 
M.  Stanley,  "  people  say  that  they  can  merely  by  a 
steady  gaze  affect  a  person  at  a  distance,  who  is  not 
looking  at  them,  and  some  say  that  they  are  able  to 
make  one  sitting  in  front  turn  the  head  in  this  way. 
Mr.  Bell  in  his  '  Tangweera  '  mentions  this  feeling 
when  he  says:  '  Presently  I  felt  as  if  some  one  was 
looking  at  me,  and  raising  my  head  I  saw  a  large  puma 
standing  ten  yards  away.'  To  the  physiologist  it  may 
seem  uncalled-for  to  investigate  a  manifest  absurdity, 
but  it  has  at  least  a  practical  value  to  explode  a 
common  error  by  direct  experiment.  I  asked  a  young 
man,  who  is  very  confident  of  his  powers,  to  stand  un- 
known to  reagent  A  behind  a  bookcase  and  look 
through  a  carefully  concealed  peep-hole.  I  gave  him 
the  best  opportunity,  placing  A  about  four  feet  from 
the  hole  directly  facing  him,  and  I  engaged  A  in 
mechanical  writing.  To  the  young  man's  confessed 
disgust  and  irritation  he  was  unable  to  disturb  A. 
My  few  experiments  were  negative  in  results.  How- 
.ever,  it  may  be  that  telepathic  influence  is  exerted 
under  certain  conditions,  and  experiments  with  twins 
and  others  constantly  en  rapport,  especially  when  under 
emotional  stress  and  at  critical  junctures,  might  be 
worth  trying.     If  there  is  nervous  telepathy,  this  is 


perhaps  as  simple  and  common  a  form  as  any.  If  dis- 
turbance arose  subconsciously  the  test  would  be  that 
the  tracings  from  an  instrument,  to  show  nervous  con- 
ditions, should  show  large  fluctuations  coincidently 
with  the  times  when  the  agent  regards  himself  as 
successful," 

The  Heat  in  Paris — The  long  uninterrupted  spell 
of  tropical  heat,  unprecedented  in  Paris  during  the 
present  century,  is  producing  most  deplorable  results. 
The  list  of  persons  who  succumb  in  the  streets  is 
lengthening  every  day,  and  all  the  inhabitants  and 
guests  in  the  French  capital  are  suffering  real  incon- 
venience from  the  high  temperature.  At  the  same 
time  the  water-supply  is  running  short,  and  the  ice 
manufacturers  find  it  impossible  to  satisfy  the  demands 
of  all  their  customers.  There  is,  however,  a  yet  more 
serious  effect  of  the  prolonged  heat  and  drought.  The 
water  in  the  Seine  is  not  only  very  low  but  has  just 
below  Paris  become  absolutely  putrid.  A  few  days 
ago  all  the  fish  in  the  river  died,  it  was  alleged  from 
the  heat  of  the  water.  Efforts  were  made  to  collect 
their  dead  bodies  and  to  bury  them;  but  they  were  so 
numerous  that  though  they  were  carted  away  by  wagon- 
loads  those  which  remained  floating  on  the  water 
rendered  life  in  the  suburban  villas  almost  impossible. 
Together  with  the  sewage  which  flows  into  the  Seine 
at  St.  Ouen  these  dead  fish  have  transformed  the  Seine 
at  Argenteuil,  Bougival,  Marly,  Croissy,  and  Chalons 
into  a  veritable  cloaca.  The  river  inspectors  have 
declared  that  nothing  can  be  done  to  improve  the 
situation  but  to  wait  patiently  for  a  heavy  fall  of  rain 
to  raise  the  waters  of  the  Seine  and  to  increase  the 
current  which  will  carry  away  the  putrid  matter. — 
Public  Opittion, 

Health  Reports. — The  following  cases  of  smallpox, 
yellow  fever,  cholera,  and  plague  have  been  reported 
to  the  surgeon-general  of  the  United  States  Marine- 
Hospital  service  during  the  week  ended  August  10, 
1900 : 

Cases.    Deaths. 
Smallpox — tJNiTED  Statbs. 


Louisiana,  New  Orleans July  28th  to  August  4th 4 

Massachusetts.  Lowell July  28th  to  August  4th 5 

Nebraska,  Omaha July  28th  to  August  4th i 

N.  Hampshire,  Manchester.. July  28th  to  August  4th 2 

Ohio,  Cincinnati July  27th  to  August  3d i 

Cleveland July  28th  to  August  4th 6 

Washington,  Tacoraa July  21st  to  28th x 

Smallpox — Foreign. 

Belgium,  Antwerp July  7th  to  21st 

Egypt,  Cairo June  23d  to  30th 

England,  London July  7th  to  21st 

France,  Lyons July  7th  to  14th 

Gibraltar July  15th  to  22d i 

India,  Bombay July  3d  to  loth 

Calcutta June  30th  to  July  7th 

Karachi  July  ist  to  8th 4 

Madras June  30th  to  July  6th 

Mexico,  Vera  Cruz July  21st  to  28th 

Russia,  Moscow July  7th  to  14th 8 

Odessa July  7th  to  21st 8 

W'arsaw July  7th  to  14th 

Scotland,  Glasgow July  igth  to  27th r 48 

Switzerland,  Geneva June  30th  to  July  7th 5 


31 


4 
18 


Yellow  Fever. 


.June  16th  to  30th. 
.Ju 


Africa,  Goree  Dakar. . 

Rufisque June  30th Several. 

Colombia,  Barranquilla July  14th  to  21st 3 

Bocas  del  Tore. .  .July  29th 2 

Cartac;ena July  7th  to  14th 3 

Panama July  23d  to  30th 4 

Cuba,  Cardenas August  3d i^ 

Matanzas July  2sth 

Santa  Clara July  24th z 

*  Suspicious.  t  tJnitcd  States  Volunteera. 


India,  Bombay  . 
Calcutta. 
Karachi  . 
Madras.. 


Cholera. 

to  loth. 


30th  to  July  7th. 

5t  to  8th    

13d  to  29th 


Plague. 


Australia,  Sydney June  14th  to  30th 18 

F,gypt.  Port  Said April  20th  to  July  gtb  .   .   .- 90 

India,  Bombay July  3d  to  10th 

Calcutta June  30th  to  July  7th 

Japan.  Formosa,  Tamsui, .  ..June  14th  to  2i5t 33 

Philippines,  Cavitc June  i6th  to  23d  x 

June  x6tb  to  93d » 


'75 
37 


3 

t 
7" 


Medical  Record 

A    IVeekly  youmal  of  Medicine  and  Surgery 


Vol.  58,  No.  8. 
Whole  No.  1555. 


New  York,  August  25,    1900. 


$5.00  Per  Annum. 
Single  Copies,  loc. 


©riotnat  ^rttctcs. 

ERRORS  CAUSED  BY  THE  FALSE  INTER- 
PRETATION OF  THE  ROENTGEN  RAYS, 
AND   THEIR    MEDICO-LEGAL  ASPECTS.' 

By  carl  15ECK,  M.D., 

NEW    VORK. 

Since  the  Roentgen  rays  began  their  triumphant 
march  from  the  modest  town  on  the  Main  throughout 
the  world,  our  knowledge  of  the  obscurer  ailments 
has  been  greatly  enlarged,  and  our  methods  of  treat- 
ment have  been  revolutionized.  It  may  safely  be 
said  that  treatises  on  fractures,  for  instance,  which  were 
written  before  the  Roentgen  era,  have  ceased  to  be 
regarded  as  authoritative.  The  proofs  of  the  immense 
usefulness  of  the  Roentgen  rays  in  surgery  are  so 
overwhelming,  indeed,  that  to  discuss  them  would  be 
carrying  owls  to  Athens. 

Unfortunately  the  strangeness  of  the  subject  soon 
attracted  many  imaginative  and  speculative  minds, 
that  .drew  unwarranted  conclusions  and  spread  errone- 
ous impressions.  The  ease  with  which  some  of  the 
small  bones  of  the  human  body  can  be  reproduced  by 
the  rays  on  a  photographic  plate  led  many  medical 
novices  and  even  ignorant  laymen  to  the  indiscrimi- 
nate use,  or  rather  abuse,  of  the  new  discovery.  Little 
wonder  that  tlie  consequences  of  such  abuse  of  the 
rays  were  soon  heralded  and  misapplied  by  officious 
friends,  inconsiderate  and  malicious  confreres,  and 
last,  but  not  least,  by  shyster  lawyers.  It  naturally 
shared  the  fate  of  other  inventions,  as  did  anaesthesia 
and  asepsis,  and  as  still  do  many  new  remedial 
measures. 

The  public  mind  was  deplorably  disturbed  by  re- 
ports of  extensive  dermatitis  and  gangrene  of  the 
skin.  But  while  in  some  individuals  a  peculiar 
trophoneurotic  idiosyncrasy  may  exist,  predisposing 
to  dermatitis,  in  the  great  majority  of  cases  the  burns 
of  the  skin  were  caused  either  by  the  ignorance  of  the 
unskilful  operator,  the  tube  often  being  too  near  the 
object,  or  by  too  prolonged  and  too  often  repeated 
exposures.  Such  accidents  are  not  surprising  so  long 
as  laymen,  such  as  opticians  and  instrument  makers, 
who  understand  nothing  of  the  anatomy  and  physiology 
of  the  skin,  are  intrusted  with  "the  manufacture  of 
skiagrams."  As  in  many  other  respects,  the  question 
of  "  proper  dosage  "  must  also  here  be  perfectly  under- 
stood by  the  operator.  A  person  who  irradiates  a 
patient  suffering  from  sycosis,  for  instance,  every  day 
intensely  for  a  whole  hour,  irrespective  of  the  reaction 
following  such  a  radical  procedure,  so  that  gangrene 
occurs,  is  as  much  qualified  to  do  skiagraphic  work  as 
is  a  shoemaker  to  prescribe  morphine. 

Since  February,  i8g6,  I  have  made  nearly  three 
thousand  skiagraphs,  and  have  never  observed  the 
slightest  irritation  of  the  skin  in  any  case  in  which 
the  rays  were  used  for  diagnostic  purposes.  In  but 
two  cases  did  circumscribed  depilation  supervene. 
In  both  skiagraphy  of  the  skull  was  required  frequently 

'  Read  before  the  Society  of  Medical  Jurisprudence  of  Xew 
York,  May  4,  igoo. 


and  at  short  intervals.  In  the  first  case  depilation 
began  after  the  fifth,  and  in  the  second  case  after  the 
sixth,  exposure.  Within  three  weeks  the  depilated 
spots  had  recovered  their  hair.  In  addition  to  such 
misadventures,  crass  ignorance  is  responsible  for 
many  distorted  Roentgen-ray  pictures,  which  caused 
such  fatal  errors  that  even  medical  men  felt  much 
discouraged  by  such  results.  But  in  considering  these 
errors  more  closely,  it  becomes  evident  that  the  Roent- 
gen rays  never  lie,  but  that  it  is  entirely  our  own  im- 
perfections which  induce  us  to  err  under  peculiar 
circumstances. 

In  order  to  avoid  errors,  it  should  in  the  first  place 
never  be  forgotten  than  a  so-called  Roentgen-ray 
picture  is  by  no  means  an  ordinary  photograph  of  an 
object,  but  a  silhouette  only  (skiagraph  1 — that  is,  a 
photograph  of  its  shadow.  To  interpret  such  shadows 
properly,  a  thorough  know  ledge  of  the  normal  anatomi- 
cal relations  of  the  tissues,  especially  of  the  bones, 
that  produce  such  shadows,  is  required.  As  the  most 
minute  gradation  of  density  is  registered,  it  is  impor- 
tant to  be  thoroughly  acquainted  with  the  anatomical 
relations  of  the  bones  producing  the  doubtful  shadow. 
The  question,  then,  would  be  whether  the  supposed 
shadow  is  normal  or  not.  On  certain  portions  of  the 
skeleton  the  muscles  and  tendons  would  naturally 
cause  obscure  shadows.  The  carpus  is  especially 
likely  to  produce  such  errors  in  the  skiagraph;  the 
tuberosities  of  the  trapezium,  the  scaphoid,  the  hamu- 
lus ossis  hamati,  the  os  pisiforme,  and  the  eminentia 
carpi  volaris,  radialis,  and  ulnaris  double  up  the  thick- 
ness of  the  carpus,  thereby  causing  dark  shadows, 
which  might  be  mistaken  for  foreign  bodies.  Similar 
considerations  and  similar  cautions  apply  to  the  other 
diagnostic  opportunities  offered  by  the  rays. 

If  a  skiagraph  of  the  human  hand,  for  instance,  is 
taken,  the  plate  will  show  the  least  light  where  the 
bones  rest,  while  the  soft  tissues  appear  opaque. 
There  is  also  a  difference  of  opacity  according  to  the 
thickness  of  the  tissues,  their  blood-supply,  and  their 
air-capacity.  The  foot,  while  easily  skiagraphed  in 
the  direction  of  the  dorsum  toward  the  planta  pedis, 
from  the  toes  up  to  the  upper  third  of  the  metatarsus, 
presents  an  obstacle  farther  backward  in  the  first  and 
third  cuneiform  bones  and  the  scaphoid,  so  that  it  is 
necessary  also  to  skiagraph  the  foot  on  these  portions 
transversely  by  having  the  outer  face  rest  on  the 
support.  It  is  by  this  procedure  only  that  the  isolated 
shadows  of  the  astragalus,  the  calcaneum,  the  os 
cuboidum,  the  scaphoid,  and  the  fourth  and  fifth  meta- 
tarsal bones  can  be  distinctly  outlined,  so  that  false 
interpretations  may  be  excluded.  In  the  early  era  of 
the  Roentgen  rays  the  normal  sesamoids  were  also 
sometimes  incorrectly  interpreted. 

How  important  the  knowledge  of  minute  anatomical 
details  is,  especially  of  non-pathological  abnormalities, 
will  be  evident  from  the  fact  that  the  os  intermedium 
cruris  (os  trigonum  tarsi)  has  been  mistaken  for  a 
fragment  severed  from  the  astragalus.  This  bone  is  a 
typical  part  of  the  tarsus  of  all  mammalia,  and  its 
frequency  is  estimated  at  from  seven  to  eight  per  cent. 
Shepherd,  who  mistook  this  bone  for  a  fractured  frag- 
ment, says:  "The  fact  that  this  fracture  is  not  men- 
tioned in  any  of  the  text-books  of  surgery  or  in  special 


282 


MEDICAL    RECORD. 


[August  25,  1900 


treatises  on  fractures  would  easily  be  accounted  for  by 
its  only  being  discovered  by  dissection;  it  causes  no 
deformity,  and  the  symptoms  it  would  give  rise  to 
during  life  would  probably  be  obscure."  The  same 
author   tried   to   produce   this  fracture  artiticially  on 


pr-" 


Flu.  I.— Us  Trigonum  Tarsi  in  a  Man  Forty  Years  Old. 

the  cadaver,  but  "  in  every  case."  he  says.  "  where  this 
manoeuvre  was  performed,  I  failed,  even  when  the 
greatest  force  was  used,  to  break  off  the  little  process 
of  bone  mentioned  above."  Pfitzner  regards  the  os 
trigonum  tarsi  as  an  integral  part  of  the  posterior 
process  of  the  astragalus  in  the  adult,  which  is  analo- 
gous to  the  OS  intermedium  antibrachii. 

The  practical  significance  of  this  bone  is  evident 
from  a  case  described  by  Wilmans,  which  is  also 
highly  interesting  from  a  medico-legal  standpoint:  A 
laborer  claimed  that  he  was  injured  by  an  iron  bar  on 
January  20.  1897,  but  was  able  to  work  during  the 
whole  day.  On  the  following  day  he  called  on  Dr. 
Wilmans,  complaining  of  intense  pain  at  his  internal 
malleolus.  He  limped  and  asserted  his  inability  to 
work.  Wilmans  found  a  slight  swelling  below  the 
right  internal  malleolus.  Ecchymosis  of  the  skin 
being  absent,  the  swelling  was  attributed  to  the  pres- 
ence of  a  considerable  degree  of  talipes,  from  which 
the  laborer  suffered  at  the  same  time.  The  leg  was 
elevated  and  fomentations  were  applied  for  several 
days.  The  patient  still  complaining  of  great  pain,  it 
was  decided  to  transfer  him  to  a  hospital  for  observa- 
tion. When  discharged,  after  several  weeks  of  treat- 
ment, the  laborer  made  an  effort  to  resume  work,  but 
at  once  declared  that  he  was  unable  to  keep  it  up. 
He  was  therefore  admitted  to  another  hospital,  where 
he  repeated  this  manoeuvre  several  times  during  a 
period  of  si.x  months.  Finally  he  claimed  damages 
for  having  been  crippled  by  the  injury  sustained  on 
January  20,  1897,  but  in  view  of  the  negative  objective 
condition  found  by  Dr.  Wilmans,  the  society  decided 
not  to  grant  any  claims.  The  consequence  was  that 
the  man  was  transferred  to  the  surgical  division  of  a 
third  hospital  for  further  observation.  There  he  com- 
plained that  he  had  continuous  pains  below  the  right 


external  malleolus,  even  while  in  the  recumbent  posi- 
tion. The  pain  increased  during  walking  or  sitting. 
Stepping  on  the  right  heel  he  also  declared  to  be  im- 
possible. By  distracting  his  attention,  however,  it 
was  noticed  that  he  could  stand  well  on  his  heel,  and 
he  would  undoubtedly  have  been  declared  a  malingerer, 
had  not  the  Roentgen  rays  come  to  his  rescue,  at  least 
temporarily.  A  skiagraph  showed  a  bone-fragment  at 
the  junction  of  the  astragalus  with  the  posterior  surface 
of  the  calcaneum.  On  the  strength  of  this  skiagraphic 
"proof"  Dr.  Wilmans,  although  still  mistrusting,  was 
forced  to  modify  his  original  opinion,  and  certified 
that  the  patient  suffered  from  "  fracture  of  the  astraga- 
lus, in  consequence  of  which  he  was  damaged  for  life." 
The  laborer  therefore  received  an  annuity  of  thirty 
per  cent.,  in  proportion  to  the  estimated  curtailing  of 
his  wages.  Soon  afterward  the  laborer  was  discovered 
by  Dr.  Wilmans  carrying  a  heavy  load  without  any 
apparent  pain,  while  formerly  he  had  claimed  to  be 
unable  to  walk  without  a  cane  or  a  crutch.  Now  Dr. 
Wilmans  insisted  upon  a  second  irradiation,  this  time 
also  skiagraphing  the  uninjured  left  foot.  The  skia- 
graph showed  the  "  severed  bone  fragment,"  which  had 
first  been  regarded  as  a  sesamoid  of  the  musculus 
flexor  longus  hallucis,  but  which  was  now  recognized 
as  a  normal  os  intermedium  cruris.  The  society  of 
course  refused  the  annuity,  and  the  German  supreme 
assurance  court,  to  which  the  man  had  appealed,  not 
only  sustained  the  verdict  of  the  society,  but  also 
decided  that  the  laborer  must  return  the  annuity 
which  he  had  unjustifiably  enjoyed  for  eighteen  months. 

The  practical  significance  of  the  os  trigonum  tarsi 
is  also  evident  from  the  case  of  a  laborer  forty  years 
of  age,  who  reported  to  me  that  he  broke  his  ankle  by 
falling  from  a  stairway.  After  four  months' treatment 
in  a  mining  district  of  Pennsylvania  he  still  com- 
plained of  considerable  pain  in  the  ankle,  the  intensity 
of  which  increased  when  he  stepped  on  the  foot.  Limp- 
ing was  also  present  to  a  great  extent.  The  protuber- 
ance of  the  left  external  malleolus  and  the  well- 
marked  tenderness  at  this  region  pointed  to  a  fracture 
of  the  external  malleolus,  united  in  a  deformed  posi- 
tion. On  the  internal  side  but  little  swelling  and 
considerable  tenderness  could  be  noted.  A  skiagraph, 
(Fig.  1)  taken  in  the  antero-posterior  direction  with  a 
slight  lateral  turn,  showed  a  dehiscence  to  the  extent  of 
Yt.  cm.  on  the  external  malleolar  side.  The  gap  was 
partially  filled  with  callus.  On  the  internal  malleolar 
side  tlie  marked  evidence  of  a  separation  of  a  small 
bone  fragment  could  be  seen,  just  as  it  is  observed  in 
Pott's  fracture.  It  appeared  to  be  displaced  downward 
to  the  extent  of  '2  cm.  and  its  upper  surface  looked  so 
much  like  the  lower  surface  of  the  internal  malleolus, 
that  it  seemed  to  be  almost  certain  that  the  two  surfaces 
belonged  to  each  other  and  had  only  recently  been 
separated  by  external  violence.  Consequently  I  as- 
sumed that  there  was  a  typical  case -of  Pott's  fracture, 
and  that  the  pain  in  the  sphere  of  the  internal  malleo- 
lus was  due  to  the  pressure  caused  by  the  displaced 
fragment.  While  considering  its  removal,  I  studied 
a  second  skiagraph  in  the  lateral  position,  and,  to  my 
great  surprise,  recognized  the  integrity  of  the  internal 
malleolus.  Now  it  became  clear  to  me  why  there  was 
no  callus  formation  around  the  alleged  bone  fragment 
and  why  at  the  same  time  the  connection  with  the 
astragalus  was  so  close.  Ky  skiagraphing  the  healthy 
foot  a  normal  os  trigonum  tarsi  was  found.  This 
showed  that  the  patient  had  sustained  a  fibular  fracture 
only,  which  became  united  in  a  deformed  position,  and 
that  the  alleged  fragment,  which  had  misled  me  at  the 
first  exposure,  repre.sented  the  intact  os  trigonum  tarsi. 

The  same  considerations  apply  to  normal  muscular 
sesamoids,  heretofore  unrecognized.  This  I  found  a 
sesamoid,  belonging  to  the  seniitendinosus  muscle,  in 
the  popliteal  space,  in  the  same  percentage  (8). 


August  25,  1900] 


MEDICAL    RECORD. 


283 


The  significance  of  a  skiagraph  for  the  purpose  of 
estimating  the  degree  of  functional  disability  is  not 
always  conclusive.  A  skiagraph  (Figs.  2  and  3)  may 
show  a  considerable  degree  of  bony  deformity  after  a 
fracture,  and  still  the  function  may  hardly  be  disturbed 
at  all.  Skiagraphic  test  has  shown  that,  as  a  whole, 
even  our  best  functional  results  show  by  no  means  an 
ideal  union.  An  unscrupulous  patiefit  who  secures 
possession  of  a  skiagraph  of  his  own  case,  which  shows 
considerable  deformity,  may,  although  there  is  no  func- 
tional disturbance,  strongly  appeal  to  a  jury  on  tht- 
strength  of  his  skiagraph,  if  he  succeeds  in  simulating 
great  impairment.  On  the  other  hand,  there  may  be 
but  little  evidence  of  bone  injury  on  the  skiagraph,  but 
there  may  be  severe  impairment  of  function  on  account 
of  the  injury  to  the  soft  tissues  (circulatory,  trophic, 
or  inflammatory  disturbances),  which  can  be  repre- 
sented only  faintly,  if  at  all.  This  shows  the  necessity 
of  considering  all  the  other  clinical  symptoms  in 
connection  with  the  skiagraph. 

While  it  is  easy,  even  for  a  layman,  to  understand 
the  significance  of  most  skiagraphs,  there  are,  as 
alluded  to,  injuries  the  correct  interpretation  of  which 
presupposes,  besides  thorough  anatomical  knowledge, 
the  greatest  care  and  a  vast  amount  of  e.xperience  as 
to  the  different  modes  of  delineation  in  various  pro- 
jection planes.  The  greatest  diagnostic  difficulties 
are  offered  by  the  joints.  The  more  complicated  a 
joint  is,  the  more  complicated  the  skiagraphs  of  its 
various  positions  will  naturally  appear.  It  is  espe- 
cially the  elbow  joint  and  hip  joint  which  are  kept  in 
view.  First  of  all,  the  interpretation  of  the  displace- 
ment caused  by  supracondylar  fracture  of  the  humerus, 
and  the  deformities  resulting  from  it  later  on,  may  tax 
the  power  of  discrimination  considerably.  The  older 
the  fracture,  the  less  conspicuous  the  fracture  line  will 
appear,  since  it  will  be  more  or  less  overshadowed  by 
the  callus.  In  old  fractures  the  lines  cannot  be 
represented  as  such,  and  it  is  only  in  case  of  union  in 
a  displaced  position  tliat  its  features  can   be  guessed. 


Fig-  s.— Vicious  LTnion  of  Oblique  Fracture  of  Femur,  showing  riding  of 
divergent  fragments,  in  a  boy  four  years  of  age,  seien  weeks  after  the  in- 
jur}-. 

In  the  case  of  a  lady  aged  seventy  years,  for  instance, 
a  second  skiagraph,  taken  three  years  after  a  supra- 
malleolar fracture  was  sustained,  showed  essentially 
the  same  features  as  the  first,  which  had  been  taken 
four  weeks  after  the  injury. 


Fig. 


Case  Illustrated  by  Kig.  i.  showing  less 
deformity  and  loss  of  functional  ability  than 
should  be  guessed  from  the  skiagraph. 


In  case  of  the  entire  absence  of  displacement  it  is 
only  a  very  distinct  skiagraph  that  shows  the  line 
clearly.  It  is  natural  that  in  such  cases  there  is  no 
skiagraphic  evidence  after  recovery — that  is,  in  from 
four  to  ten  weeks,  according  to  the  type  of  the  fracture. 

Should    a   court,  

for  instance, 
doubt,  in  such  an 
event,  that  there 
liad  been  a  frac- 
ture, a  skiagraph 
taken  after  such 
a  period  might 
show  a  negative 
result,  although 
there  surely  was 
a  fracture.  In 
this  boy  whom  I 
present  to  you  to- 
night, the  very 
distinct  skia- 
graph, taken  only 
t*vo  months  after 
he  had  sustained 
a  subtrochanteric 
fracture  of  the 
thigh,  showed  no 
signs  of  a  frac- 
ture. Had  this 
case  not  been 
skiagraphed 
shortly  after  the 
injury,  no  evi- 
dence of  the  frac- 
ture could  have 
been  subse- 
quently obtained.  When  no  displacement  existed, 
only  a  faint  fracture-line  will  show,  but  the  presence 
even  of  small  amount  of  callus  leaves  no  doubt  as  to 
the  previous  existence  of  a  fracture. 

On  the  other  hand,  callus  formation  may  be  so 
abundant  that,  in  spite  of  the  absence  of  displacement, 
the  fullest  evidence  of  fracture  may  still  be  furnished 
after  months.  In  one  of  my  cases,  callus  formation 
was  so  excessive  that  the  attending  physician  was 
accused  of  malpractice,  and  it  was  the  skiagram  only 
which  convinced  the  patient  that  his  physician  had 
treated  him  correctly,  the  bones  being  in  perfect  ap- 
position, and  which  thus  exonerated  the  practitioner. 

The  intra-articular  fracture  types  offer  the  greatest 
diagnostic  difficulties,  inasmuch  as  the  fracture  line  is 
also  often  obscured  by  the  callus  formation.  If,  how- 
ever, a  skiagraph  of  the  other  joint  is  made  at  the 
same  time,  in  the  same  position,  and  in  the  same 
projection,  the  various  delineations  of  the  shadows 
will  be  correctly  understood  and  interpreted. 

A  normal  skeleton  should  also  always  be  compared 
with  the  skiagraph.  It  should  particularly  be  remem- 
bered that  certain  pathological  conditions,  such  as 
rachitis,  for  instance,  influence  the  outlines  of  the 
bones  and  may  deceptively  be  supposed  to  represent  a 
portion  of  an  injury.  In  such  an  event  the  skiagram 
of  the  fellow-extremity  will  set  matters  right.  In  very 
young  children  the  eminentia  capitata  appears  as  if 
entirely  severed  from  the  humerus,  although  the  rela- 
tions are  absolutely  normal.  The  explanation  of  this 
very  important  phenomenon  is  that  the  epiphyseal 
tissues  are  not  sufficiently  ossified  to  produce  a  shadow- 
on  the  plate.  If  these  points  are  not  thoroughly 
considered,  a  displaced  fracture  fragment  might  be 
erroneously  diagnosticated.  Union  between  the  epi- 
physis and  the  diaphysis  of  the  head  of  the  humerus 
is  not  perfect  before  the  twentieth  year.  The  lower 
epiphysis  of  the  humerus  consists  of  four  nuclei, 
which  ossify  from  the  eighth  to  the  seventeenth  year. 


284 


MEDICAL    RECORD. 


[August  25,  1900 


The  epiphyses  of  the  trochlea  as  well  as  of  the  olec- 
ranon ossify  between  the  seventh  and  twelfth  years, 
which  explains  why  an  osseous  nucleus  that  is  still 
connected  with  its  neighboring  epiphyseal  nuclei  and 
the  diaphysis  by  cartilaginous  tissue  appears  as  an 
isolated  piece  of  bone  which  might  erroneously  be 
taken  for  a  fragment.  The  acromio-clavicular  junction 
sometimes  shows  in  the  skiagraph  a  hiatus  of  the 
width  of  a  finger,  so  that  a  diastasis  of  the  joint  might 
be  assumed.  But  since  our  knowledge  on  this  new 
subject  has  increased,  we  know  that  this  apparent 
diastasis  is  by  no  means  pathological,  and  that  there 
is  a  normal  gap  between  the  osseous  ends  of  the  acro- 
mion and  the  acromial  end  of  the  clavicle.  The  upper 
epiphysis  and  the  diaphysis  of  the  radius  unite  be- 
tween the  seventeenth  and  the  eighteenth  year,  and  its 
lower  epiphysis  and  the  diaphysis  join  in  the  twentieth 
year.  During  the  early  Roentgen  era  the  translucent 
space  above  the  epiphyseal  cartilage  in  children  was 
erroneously  taken  for  a  fracture  line.  The  head  of  the 
femur  unites  with  the  diaphysis  at  the  eighteenth  or 
nineteenth  year,  and  the  lower  epiphysis  follows  after 
the  twentieth  year.  The  upper  epiphysis  of  the  tibia  , 
unites  with  the  diaphysis  in  the  twentieth  or  twenty- 
second  year,  while  the  lower  tibial  epiphysis  unites 
with  the  diaphysis  between  the  eighteenth  and  the 
nineteenth  year. 

For  the  thorough  interpretation  of  skiagraphs  in 
children,  it  is  important  to  know  that  at  birth  the 
diaphyses  of  the  radius,  the  ulna,  the  metacarpal 
bones,  and  the  phalanges  are  ossified,  while  their 
epiphyses,  as  well  as  the  whole  carpus,  are  still  carti- 
laginous. It  is  not  before  the  seventh  year  that  an 
osseous  nucleus  shows  at  the  lower  epiphysis  of  the 
ulna.  Union  with  the  diaphysis  sometimes  begins 
with  the  twelfth  year,  but,  as  a  rule,  not  before  the 
fifteenth.  Even  then  a  small  epiphyseal  disc  remains, 
which  does  not  disappear  before  the  seventeenth  year 
in  the  female,  and  not  before  the  nineteenth  year  in 
the  male. 

The  osseous  nuclei  of  the  carpus  show  at  different 
periods — viz.,  at  the  os  capitatum  at  the  fourth  month  ; 
at  the  hamatum  at  the  fifth  month  ;  while  the  triquetrum 
shows  its  nucleus  between  the  second  and  the  third 
year,  the  lunatum  between  the  third  and  fifth,  the  navic- 
ulare  between  the  fifth  and  the  seventh,  the  trape- 
zium and  the  trapezoid  between  the  sixth  and  the 
seventh  year,  and  the  os  pisiforme  between  the  eleventh 
and  the  fifteenth  year.  After  five  years  the  capitatum, 
hamatum,  and  triquetrum  have  assumed  their  regular 
shapes,  while  the  others,  with  the  exception  of  tiie  pisi- 
forme, are  perfectly  developed  at  the  twelfth  year. 

The  osseous  nuclei  of  the  epiphyses  of  the  metacarpal 
bones  show  at  the  second  year,  their  synostosis  with 
the  diaphysis  taking  place  between  the  twelfth  and 
the  seventeenth  year  in  the  female,  and  at  the  age  of 
nineteen  in  the  male.  The  epiphyseal  nuclei  of  the 
phalanges  are  ossified  between  the  fourth  and  the  fifth 
year,  their  synostosis  with  the  diaphysis  taking  place 
at  the  same  age  as  that  of  the  metacarpal  bones  (from 
the  twelfth  to  the  seventeenth  year  in  the  female,  and 
between  the  sixteenth  and  the  nineteenth  year  in  the 
male). 

Regarding  the  elbow-joint,  it  must  be  considered 
that  an  osseous  nucleus  appears  at  the  medial  side  of 
the  capitulum  humeri  between  the  second  and  the  third 
year,  another  one  in  the  internal  epicondyleat  the  fifth 
year,  a  third  in  the  trochlea  between  the  eleventh  and 
the  twelfth  year,  and  soon  afterward  a  fourth  in  the 
external  epicondyle.  The  nucleus  of  the  internal 
epicondyle  unites  with  the  diaphysis  between  the  six- 
teenth and  the  twentieth  year;  but  the  other  three 
nuclei  form  a  synostosis  among  themselves  at  the 
seventeenth  year,  and  then  form  the  uniform  osseous 
epiphysis,  which  completes  its  synostosis  with  the  dia- 


physis at  about  the  twentieth  year.  In  the  capitulum 
radii  an  osseous  nucleus  appears  between  the  fifth  and 
seventh  year,  and  in  the  olecranon  between  the  sixth 
and  the  eighteenth  year,  both  uniting  with  the  diaphy- 
sis between  the  twentieth  and  the  twenty-fifth,  and  be- 
tween the  sixteenth  and  the  twentieth  year. 

Regarding  the  knee-joint  it  must  be  considered  that 
the  lower  femoral  epiphysis  contains  an  osseous  nucleus 
at  birth,  while  the  nucleus  in  the  tibial  epiphysis 
shows  shortly  afterward.  At  the  fourth  year  both  these 
epiphyses  have  completed  their  development,  but  they 
do  not  unite  with  the  diaphysis  before  the  fifteenth 
year.  The  anatomical  text-books  say  that  union  takes 
place  between  the  seventeenth  and  the  twenty-fourth 
year,  but  skiagraphic  experience  points  to  an  average 
period  of  only  sixteen.  The  osseous  epiphyseal  nu- 
cleus of  the  fibula  appears  beween  the  second  and 
the  fifth  year,  and  unites  with  the  diaphysis  between 
the  eighteenth  and  the  twenty-fifth  year;  but  skia- 
graphy dates  this  period  earlier,  viz.,  the  fifteenth 
year.  The  osseous  nucleus  in  the  tibial  spine  appears 
between  the  eighth  and  the  tenth  year;  the  epiphyseal 
line  between  it  and  the  diaphysis  disappears  at  the 
fifteenth  year. 

As  to  the  bones  of  the  foot,  it  may  be  said  that  the 
lower  epiphyses  of  the  tibia  and  fibula  show  their 
osseous  nuclei  in  the  first  and  second  years,  and  unite 
with  the  diaphysis  between  the  eighteenth  and  the 
twenty-fifth  year;  according  to  skiagraphs,  as  early  as 
before  the  eighteenth  year.  The  osseous  nucleus 
of  the  astragalus  and  calcaneum  appears  in  utero, 
that  of  the  cuboid  shortly  before  or  after  birth,  that 
of  the  cuneiform  bones  between  the  first  and  the  fifth 
year,  and  that  of  the  os  naviculare  from  the  first  to  the 
fifth  year.  The  osseous  nuclei  of  the  metatarsal  bones 
and  of  the  phalanges  appear  from  the  second  to  the 
tenth  year,  and  unite  with  the  diaphyses  between  the 
sixteenth  and  the  twenty-second  year. 

In  elbow-joint  fractures  occurring  in  childhood  it  is 
necessary,  therefore,  to  take  at  least  two  skiagraphs  in 
different  projection  planes  and  to  compare  them 
thoroughly  with  the  normal  fellow.  In  a  case  of 
fracture  of  the  femoral  head,  for  instance,  the  deform- 
ity had  appeared  three  times  as  large  as  it  actually 
was,  on  account  of  inappropriate  projection.  The 
degree  of  shortening  of  the  limb  was  overestimated 
accordingly.  This  shows  the  necessity  of  considering 
the  other  clinical  symptoms  and  data  in  connection 
with  the  skiagraph. 

In  fractures  of  childhood  it  should  also  be  remem- 
bered that  the  process  of  ossification  is  influenced  by 
various  affections  of  the  bone,  as,  for  instance,  by 
rickets. 

How  important  the  question  of  projection  is  be- 
comes evident  when  we  consider  that^grave  errors  may 
sometimes  occur  even  if  all  the  preliminary  conditions 
required  for  a  thorough  understanding  of  the  case 
seem  to  be  fulfilled.  This  will  appear  from  the  follow- 
ing experience,  which  has  probably  not  been  paralleled 
in  the  literature  of  this  subject  (compare  Nejc  Y'ork 
Medical  Journal,  January  6,  igoo). 

A  boy  four  years  of  age,  while  playing  in  the  street, 
fell  against  an  iron  bar.  Being  unable  to  rise  again, 
he  was  taken  up  and  carried  to  St.  Mark's  Hospital, 
where  in  the  first  instance  moderate  pain  was  noted  be- 
sides the  functional  disturbance.  There  was  neither 
any  difference  in  level  or  any  other  deformity,  nor 
any  shortening  or  the  typical  equinus  position.  A 
photograph  taken  two  days  after  the  injury  only  showed 
a  very  moderate  and  uniform  swelling  of  the  leg. 
Abnormal  mobility  and  crepitus,  in  accordance,  could 
be  produced  only  by  very  rough  manipulations. 

On  the  day  following  the  injury  two  skiagraphs 
were  made  in  different  positions;  one  of  them  in  the 
dorsal  and  the  other  in  the  lateral  position.     To  my 


August  25,  1900] 


MEDICAL    RECORD. 


285 


surprise,  the  one  which  had  been  skiagraphed  by  a 
direct  irradiation,  the  centre  of  the  platinum  disc  of 
the  tube  being  perpendicular  to  the  anterior  surface  of 
the  leg,  did  not  show  the  slightest  indication  of  a 
fracture,  while  the  one  which  represented  the  leg  irra- 
diated from  the  outer  aspect  of  the  tibia  showed  a 
marked  fracture  line.  The  fracture  presented  the 
typical  oblique  type  in  the  middle  of  the  tibia,  the 
fracture  line  running  from  below  anteriorly  to  above 
posteriorly,  the  upper,  tapering  fragment  overlapping 
the  lower  end.  No  sideward  displacement  having 
been  present,  it  can  be  understood  why  the  rays  reach- 
ing the  long  axis  of  the  tibia  in  a  vertical  direction 
did  not  show  the  fracture  line.  A  very  slight  change 
in  position,  when  the  inclination  toward  the  fibular 
direction  amounted  to  less  than  i  mm.,  brought  out 
the  fracture  distinctly. 

Now  if  I  had,  as  is  the  custom  in  general,  taken  a 
skiagraph  in  the  antero-posterior  direction  only,  and  if 
the  manipulations  made  during  the  first  examination 
were  carried  out  as  gently  as  they  properly  should  be, 
the  fracture  might  have  been  overlooked  entirely. 
And  if,  in  view  of  the  local  pain  and  tenderness,  the 
swelling,  and  the  functional  disturbance,  the  possibil- 
ity of  a  fracture  had  been  seriously  considered,  the 
skiagraph  might  have  silenced  the  uneasy  conscience. 

If  the  case  had  been  brought  before  a  jury,  the  expert 
might  there  on  the  strength  of  the  first  skiagraph  have 
testified  in  good  faith  that  there  was  no  fracture. 

This  experience  teaches  the  necessity  of  adopting 
the  principle  of  always  taking  at  least  two  skiagraphs 
in  two  different  positions  in  all  cases  of  suspected 
fracture. 

In  taking  skiagraphs  of  foreign  bodies  it  must  be 
considered  that  their  size  varies  according  to  the  dis- 
tance from  the  tube.  In  oblong  bodies  great  errors 
as  to  their  extent  may  be  committed.  Once  I  was  very 
much  surprised  in  a  case  in  which  a  needle-fragment 
had  entered  the  palm  of  the  hand  in  a  perpendicular 
direction.  The  plate,  while  indicating  the  presence 
of  the  needle,  distinctly  created  the  impression  that 
the  fragment  was  only  about  2  mm.  in  length.  When 
extracted  it  was  found  to  be  more  than  an  inch  long, 
the  rays  having  reached  the  hand  in  a  perpendicular 
direction  so  that  the  circumference  of  the  fragment 
was  reproduced  rather  than  its  length.  A  side  view, 
of  course,  would  have  cleared  up  the  error  at  once. 

Misinterpretations  have  also  arisen  from  unavoid- 
able mechanical  and  chemical  defects,  causing  mark- 
ings in  the  photographic  plate,  the  significance  of 
which  must  be  well  known  to  the  skiagraphic  inter- 
preter. Blemishes  may  also  be  produced  by  spots 
caused  by  pus  from  wounds  or  by  perspiration. 

In  the  location  of  foreign  bodies,  especially  in  the 
skull,  many  errors  were  and  are  still  committed. 
Their  avoidance  will  be  considered  in  a  special  article. 

The  case  of  the  German  malingerer  is  a  striking 
illustration  of  the  significance  of  the  Roentgen  rays, 
which  for  a  time  proved  a  protection  on  account  of 
erroneous  interpretation,  but  showed  the  case  in  its 
true  light  when  assisted  by  better  anatomical  knowl- 
edge. Soon  after  the  discovery  of  the  Roentgen  rays 
the  courts  were  in  a  position  to  grant  damages  to 
patients,  especially  veteran  soldiers,  who  claimed  to 
have  been  damaged  by  bullets  and  were  unjustly  re- 
jected by  medical  experts  as  malingerers.  The  pres- 
ence of  the  bullet,  shown  on  the  photographic  plate, 
cannot  be  denied,  and  a  patient  who  harbors  a  piece 
of  cold  metal  in  any  part  of  his  body  has,  as  a  rule,  a 
good  reason  to  complain.  On  the  other  hand,  an  im- 
postor, who  pretends  to  have  been  shot  and  simulates 
functional  disability,  will  be  exposed  by  a  distinct 
skiagraph,  which  would  show  the  absence  of  the 
alleged  bullet. 

It  is  a  question  to  be  solved  by  my  colleagues  of 


the  other  faculty,  whether  the  court  has  a  right  to 
censure  a  surgeon  for  not  having  used  the  Roentgen 
rays  in  a  suitable  case,  and  furthermore  whether  it  can 
compel  a  patient  in  a  doubtful  bullet — or  fracture — 
case  to  submit  to  an  exposure  to  the  rays. 

A  distinct  skiagraphic  plate  will  always  tell  the 
truth.  If  accompanied  by  the  registration  of  the  de- 
tails of  operation,  viz.,  the  source  of  the  current 
(whether  battery,  static  machine,  or  street),  the  length 
of  spark  of  the  induction  coil,  the  intensity  of  the  tube, 
tiie  distance  of  the  platinum  disc  of  the  tube  from  the 
photographic  plate,  the  position  of  the  object,  the  kind 
of  plates,  and  the  time  of  exposure,  it  will  be  a  valid 
document,  intelligible  to  every  expert.  And  together 
with  the  anatomical  and  clinical  knovvledge  of  the 
expert  it  should  be  evidence  in  court. 


THE  PRESENCE  OF  VIRULENT  TUBERCLE 
BACILLI  IN  THE  HEALTHY  NASAL  CAV- 
ITY   OF    HEALTHY    PERSONS. 

By   NOIiLE    W.    JONES,    M.D.. 

CHICAGO,    ILL. 

(FROM    THE    PATHOLOGICAL     LABORATORV    OP     RUSH    MEDICAL     COLLEGE, 
CHICAGO.) 

It  cannot  at  present  be  stated  that  the  methods  of  in- 
fection of  tuberculosis  are  well  understood.  Since  the 
discovery  of  the  bacillus  tuberculosis  in  1882  much 
work  of  a  various  nature  has  been  done  to  throw  light 
upon  this  important  subject.  Some  of  this  has  been 
most  thorough  and  painstaking;  much,  on  the  other 
hand,  has  been  of  a  purely  miscellaneous  character. 
Assuming  the  purely  parasitic  nature  of  the  tubercle 
bacillus,  this  work  has  naturally  tended  toward  the 
study  of  the  micro-organism  in  its  relation  to  the 
bodies  and  excretions  of  animals  affected  with  tuber- 
culosis, and  the  atmosphere  and  the  dusts  which  have 
been  supposed  to  contain  portions  of  these  materials  as 
component  parts.  The  former  belief  of  a  universal  at- 
mospheric contamination  was  first  disproved  by  the 
work  of  Cornet,  who  has  shown  that  virulent  tubercle 
bacilli  are  not  to  be  found  in  atmospheres  unfrequented 
by  consumptives.  This  has  since  been  verified  by  the 
works  of  many  other  investigators.  The  question  of 
the  infectiousness  of  dust,  on  the  other  hand,  is  far 
more  important  in  that  all  recent  researches  show  more 
or  less  causative  relations  existing  between  infected 
dust  and  the  various  forms  of  the  disease,  particularly 
inhalation  tuberculosis. 

Briefly  reviewing  some  of  the  literature  bearing  on 
this  subject,  it  is  to  be  noted  that  Klebs'  does  not  be- 
lieve infected  dust  to  be  a  potent  factor  in  the  causa- 
tion of  the  pulmonary  disease.  Cornet '  agrees  that 
the  dust  of  the  street  is  not  of  much  importance  in  its 
production,  because,  as  he  has  shown,  the  bacillus 
loses  its  virulence  within  a  few  hours  under  the  action 
of  the  direct  rays  of  the  sun,  although  Marpmann' 
claims  to  have  found  virulent  bacilli  in  this  material. 
Indeed,  Heron  and  Chaplin,'  of  London,  state  that 
dust  that  has  come  in  contact  with  the  e.xcretaof  tuber- 
culous patients  does  not  play  a  very  important  role  in 
the  carrying  of  this  infectious  germ.  Their  series  of 
one  hundred  inoculation  tests  with  guinea-pigs,  using 
dust  collected  from  six  important  hospital  rooms,  in- 
cluding wards,  laboratory,  waiting-rooms,  etc.,  show 
but  two  dead  of  tuberculosis.  The  clinical  statistics 
of  the  London  hospitals  during  a  period  of  twenty 
years  prior  to  1894,  as  summarized  by  Theodore  Wil- 
liams,^ also  seem  to  point  to  a  like  conclusion.  On 
the  other  hand,  the  more  recent  work  of  Cornet'  in 
Berlin  shows  positively,  he  believes,  that  the  factor  of 
infected  dust  is  an  important  and  dangerous  one,  es- 
pecially to  those  in  attendance  upon  tuberculous  pa- 


286 


MEDICAL    RECORD. 


[August  25,  1900 


tients.  The  source  of  greatest  infection,  according  to 
his  work,  is  tuberculous  sputum  that  has  become  dry. 
The  mucous  contents  of  the  nasal  cavities  is  less  in- 
fectious for  obvious  reasons.  The  spread  of  tubercle 
bacilli  througii  the  urine,  the  fajces,  or  tuberculous  pus 
is  of  but  slight  importance,  because,  first,  they  are 
present  in  small  numbers  only;  secondly,  they  die  on 
decomposition  of  these  substances.  And,  finally,  the 
expired  air  from  the  patient,  when  not  laden  with  fine 
droplets  of  mucus  and  saliva  thrown  out  by  cough- 
ing, speaking,  or  forced  breathing,  contains  no  tuber- 
cle bacilli  whatever,  as  has  also  been  demonstrated  by 
numerous  observers,  namely,  Buchner,  Weinich,  F. 
Miiller,  Straus,"  etc.  In  all,  Cornet  collected  one  hun- 
dred and  forty-nine  samples  of  dust  from  various  places 
frequented  by  tuberculous  patients,  namely,  hospitals, 
insane  and  orphan  asylums,  prisons,  private  rooms  in 
which  such  patients  lived,  surgical  wards,  streets,  etc., 
and  made  inoculations  into  three  hundred  and  ninety- 
two  animals.  Fifty-nine  animals  became  tuberculous, 
representing  forty  samples  of  the  dust,  or  a  percentage 
of  26.8.  On  the  other  hand,  twenty-nine  animals  in- 
oculated with  dust  from  non-infected  places  remained 
healthy. 

An  interesting  series  of  experiments  has  recently 
been  made  by  R.  Sticker,"  under  the  direction  of 
Fliigge,  in  Breslau,  with  the  direct  object  in  view  of 
showing  the  infectiousness  of  dust  bearing  dry  pow- 
dered sputum.  In  the  first  place,  three  attempts  were 
made  by  blowing  fine,  sterile  dust  into  the  faces  of 
guinea-pigs,  and  with  negative  results.  He  then 
treated  twenty-nine  guinea-pigs  in  a  similar  manner 
with  infected  dust.  Of  the  first  eleven  experiments 
in  which  comparatively  strong  currents  of  air  were 
used — i.e.,  a  rate  of  one  metre  per  second — seven  gave 
positive  results.  Of  the  succeeding  eighteen  experi- 
ments with  weaker  currents  of  air  none  resulted  posi- 
tively, that  is,  in  producing  inhalation  tuberculosis, 
but  in  the  latter  case  he  was  able  to  obtain  bacilli  on 
receptive  plates  (  Vorlagcn').  He  concludes  that  viru- 
lent tubercle  bacilli  can  be  disseminated  in  dust  under 
the  influence  of  strong  currents  of  air,  as  above  indi- 
cated, and  also  that  highly  dried  sputum,  under  the 
influence  of  weaker  currents,  can  carry  bacilli  when 
mi.xed  with  the  finest,  lightest  dust;  but  the  number 
is  dependent  {a)  upon  the  strength  of  the  air  stream, 
and  {b)  upon  the  absence  of  moisture.  Such  condi- 
tions must  necessarily  more  or  less  limit  the  operation 
of  this  factor  in  general  infection,  for,  as  Fliigge"  well 
says,  such  conditions  cannot  be  applied  to  the  condi- 
tions actually  surrounding  persons.  Again,  the  danger 
of  the  use  of  handkerchiefs  by  phthisical  patients,  and 
the  dissemination  of  tubercle  bacilli  in  dust  therewith, 
are  referred  to  by  Cornet,'  Laschtschenko,'  and  Be- 
ninde.'"  The  latter  has  shown  experimentally  that 
particles  of  mucus  laden  with  bacilli  can  be  blown 
from  wet  handkerchiefs  by  strong  currents  of  air, 
w'hile  weaker  currents  are  entirely  unable  to  do  this. 
On  the  other  hand,  when  the  handkerchief  is  dry, 
weaker  currents  are  also  able  to  disseminate  bacilli. 
But  Fliigge,"  again,  maintains  that  practically  such  a 
condition  of  dryness  is  never  obtained,  and,  although 
agreeing  with  Cornet  that  such  a  condition  is  possible, 
he  believes  it  to  be  a  doubtful  factor. 

There  is  not,  to  the  same  degree,  this  uncertainty 
surrounding  the  experiments  with  coughed,  sneezed,  or 
sprayed  sputum  that  one  notes  in  the  case  of  dust  ex- 
periments. Quite  all  writers  are  agreed  that  fine  drop- 
lets of  mucus  laden  with  tubercle  bacilli  have  been 
shown  experimentally  to  play  an  important  role  in  the 
dissemination  of  this  microorganism.  In  recent  years 
great  stress  has  been  laid  upon  this  factor  by  Fliigge 
and  his  pupils.  Laschtschenko"  has  shown  that  on 
moderate  speaking,  sneezing,  and  coughing,  growths 
could  be  obtained  on  agar  plates  when  the  mouth  had 


been  washed  with  a  solution  containing  Bacillus  pro- 
digiosus.  Not  so,  however,  in  the  case  of  ordinary 
breathing.  Out  of  nine  attempts  with  phthisical  pa- 
tients, four  guinea-pig  inoculations  resulted  posi- 
tively, and  of  a  second  series  three  experiments  gave 
two  positive  results.  In  these  experiments  the  pa- 
tients, washed  and  dressed  in  sterilized  clothing,  were 
placed  in  a  glass  cage,  which  previously  had  been  dis- 
infected, and  were  allowed  to  remain  in  it  for  some 
time  in  order  that  mucous  droplets  thrown  out  on 
coughing,  speaking,  etc.,  might  fall  into  dishes  con- 
taining sterilized  salt  solution,  which  in  turn  was 
used  for  the  inoculation.  Heymann"  has  in  a  some- 
what different  manner  obtained  the  same  results.  He 
caused  phthisical  patients  to  cough  through  a  tube  into 
a  sterile  box  containing  guinea-pigs,  and  out  of  six 
series  of  experiments  in  which  were  used  twenty-eight 
animals,  six  became  tuberculous,  representing  four  of 
the  series.  Similar  results  have  been  obtained  by  von 
Esmarch,"  Hiibner,"  and  V.  Weissmayr.'' 

In  all  cases  the  elements  of  distance  and  duration 
of  exposure  play  most  important  parts.  Heymann 
shows  that  at  a  distance  of  50  cm.  there  is  marked  dis- 
tribution of  bacilli  on  the  slides;  that  this  continu- 
ally decreases  up  to  a  distance  of  1.5  metres,  when  the 
slides  remain  free,  and  also  that  it  is  necessary  to  col- 
lect 10  cubic  metres  of  air  at  this  distance  to  obtain 
occasional  positive  results.  It  is  quite  apparent  that 
such  experiments  as  these  teach  us  certain  limitations  of 
the  infectiousness  of  tuberculosis  by  these  methods  of 
dissemination  also.  It  is  quite  true  that  many  phthisi- 
cal patients  probably  do  not  distribute  bacilli  at  all,  or 
again  only  at  certain  periods  of  the  day,  or  at  certain 
stages  of  their  disease,  so  that  it  is  reasonable  to  be- 
lieve that  the  thorough  employment,  on  the  part  of  the 
patient  himself,  of  the  ordinary  prophylactic  measures 
now  used  in  hospitals  would  restrict  enormously  the 
spread  of  the  dis'ease.  Fliigge  concludes  a  review  of 
the  present  status  of  our  knowledge  of  tuberculous  in- 
fection by  stating  that  infection  will  result,  first,  in 
those  places  in  which  tuberculous  sputum  has  been  al- 
lowed to  dry  on  the  floor  and  fixtures,  and  in  which 
the  air  is  filled  with  a  visibly  coarse  dust;  such  dust 
being  scattered  by  the  walking  about  of  persons,  the 
continuous  vibration  of  machinery,  railroad  coaches, 
etc.  But  even  under  these  conditions  the  probability 
of  infection  is  brought  about  only  by  a  person's  re- 
maining in  such  places  continuously  for  a  relatively 
long  time.  Secondly,  concerning  the  spread  of  bacilli 
through  fine  droplets  of  mucus,  infection  is  practically 
possible  only  when  repeated  approximation  to  coughing 
patients  takes  place  within  a  distance  of  one  metre, 
such  as  may  occur  in  the  case  of  nurses,  or  occupants 
of  factories,  counting-rooms,  \v6rkshops,  and  the  like, 
where  the  workers  are  closely  crowded;  and  this  dan- 
ger, Fliigge  believes,  could  well  be  obviated  by  the 
use  of  proper  prophylactic  measures. 

In  1894  Straus,'"  of  Paris,  proved  that  the  presence 
of  virulent  tubercle  bacilli  could  be  demonstrated  in 
the  nasal  cavities  of  those  who,  being  non-tubercuious 
themselves,  were  in  more  or  less  constant  attendance 
upon  tuberculous  patients.  His  experiments  num- 
bered twenty-nine  in  all,  and  were  made  upon  hospital 
attendants,  internes,  and  patients  suffering  ,vith  chronic 
maladies  other  than  tuberculosis.  The  dirt,  solid  par- 
ticles, and  mucous  contents  of  the  nasal  cavities  were 
removed  by  sterile  cotton  swabs,  washed  into  sterile 
bouillon  or  water,  and  the  total  solution  was  injected 
intraperitoneally  into  guinea-pigs  by  means  of  a  large 
hypodermic  syringe  or  small  trocar.  The  result  of 
this  series  of  experiments  was  as  follows:  Seven  ani- 
mals died  within  a  few  days  of  septica'mia,  or  acute 
peritonitis;  nine  animals  died,  in  times  varying  from 
twelve  to  thirty-three  days,  of  tuberculosis  of  the 
omentum,  mesenteric  glands,  spleen,  and  occasionally 


August  25,  1900] 


MEDICAL    RECORD. 


287 


the  lungs  and  liver.  The  remaining  thirteen  animals 
were  killed  or  died  from  causes  non-tuberculous,  after 
having  lived  a  sufficient  length  of  time  for  tuberculous 
lesions  to  have  developed  if  bacilli  had  been  intro- 
duced. In  four  of  the  nine  animals  showing  positive 
results  there  were  found  caseous  abscesses  in  the  ab- 
dominal wall  at  the  point  of  inoculation.  These  tests 
show  the  presence  of  bacilli  in  the  enormous  number 
of  40.9  per  cent,  of  all  persons  experimented  upon,  the 
seven  animals  dead  of  septicemia  and  peritonitis  hav- 
ing been  deducted  from  the  total  number  because  of 
their  early  deaths. 

In   view  of   what   has   been    previously  related,  the 
questions  naturally  arise:    (1)  Are  tubercle  bacilli  to 
be  found  in  the  nasal  cavities  of  healthy  individuals 
following  the  ordinary  vocations  of  life?     (2)  Are  they 
to  be  found  in  such  proportions  as  Straus'  work  would 
show  in  the  case  of  those  in  more  or  less  intimate  re- 
lations with  the  tuberculous;  and  if  not  in  such  pro- 
portions, in  what  numbers  can  we  expect  them  to  be 
present,  bearing  in  mind  the  variations  which  differ- 
ent conditions  and   modes  of   life  would   necessarily 
produce.'     As   tending  to   answer  these   questions,  I 
wish  to  narrate  the  results  of   the   following  experi- 
ments.    My  object   was  to   demonstrate,  if   possible, 
virulent  tubercle  bacilli  in  the  nasal  cavities  of  those 
who   were  free   from   tuberculous  processes,  and  were 
subjected  only  to  the  ordinary  amount  of  infection  to 
which  every  dweller   in  a  large  city  must  submit.     I 
failed   in  the  effort  to  study  public-school  children  as 
I  had  desired,  and,  therefore,  relied  upon  my  fellow- 
students  to  furnish  me  with  this  material.     I  am  quite 
aware  that  an  objection  may  here  be  raised  concern- 
ing the  environment  of  such  persons.     This  was  met 
as   best  it   might,  by  choosing  mostly  men  who  were 
in  good    physical    health,  and  who  were   not    haunt- 
ers  of   laboratories  or  clinics.     Thg    technic  of    the 
experiments  was  as  follows:     The  entire  contents  of 
the  nasal  cavities,  particles  of  dirt,  of  crusts,  and  of 
mucus  were  removed  by  five  or  six  sterilized  cotton 
swabs,  made  by  spinning  cotton  on  wires  of  suitable 
length,  by  carrying  them  back  as  near  the  pharynx  as 
possible  and  cleansing  the  cavities  from  within  out- 
ward.    The  nose  and  face  were  not  previously  washed 
or  prepared  in  anyway.     These  swabs  were  washed  in 
test-tubes  containing  10  c.c.  of  sterilized  normal  salt 
solution,   by  rotating   them   rapidly  in    the  solution. 
The  animals  were  then  prepared  in  the  usual  manner. 
The  hair  covering  the  lower  abdomen  was  removed  by 
shaving  and  by  a  depilatory,  and  the  surface  scrubbed 
with  soap  and  water  and  again  with  a  ten-per-cent.  for- 
malin  solution.     The  skin,  fascia,  and   muscles  were 
then  nicked  with  sterile  scissors,  and  the  solution  with 
its  solid  contents,  measuring  5  c.c.  or  6  c.c.  in  amount, 
was  introduced  into  the  peritoneal  cavity  by  quickly 
plunging  the  point  of  a  large  glass  capillary  tube  con- 
taining  it  through   the   remaining  fascia  and  perito- 
neum.    The    wound    then    was    closed    by    collodion 
dressings.     Thirty-one   inoculations  were   made,  and 
briefly  the  results  are  tabulated  below. 

It  is  desirable  to  describe  somewhat  in  detail  the 
tuberculous  cases. 

Case  VIII.— The  nasal  contents  of  No.  8,  a  mer- 
chant by  occupation,  forty  years  of  age,  was  inoculated 
into  a  guinea-pig  intraperitoneally  November  9,  1899. 
The  animal  died  fifty-nine  days  later,  and  on  post- 
mortem examination  showed  the  following:  The  ani- 
mal was  large  and  well  nourished;  wound  had  healed 
by  primary  union.  The  omentum  showed  a  large 
caseated  mass  on  the  external  surface;  the  lungs,  liver, 
and  kidneys  showed  no  visible  tuberculous  lesions. 
From  the  omentum  the  staphylococcus  aureus  was  ob- 
tained by  smears  and  cultures,  and  the  micrococcus 
tetragenus  from  the  liver  and  lungs.  Cultivations 
from   the   spleen  remained   negative.     Histologically 


a  u  = 

K    =    - 


II 

III 


Date  of 

Inoculation. 


Kov.    1,  1899. 


VI 
VII 

vni 


IX 


XI 


XII 

xni. 

XIV. 
XV 


XV.a, 
XVI 

XVII 

xviri. 

XIX 
XX. 

XXI. 


do. 


do. 


.899. 


Anatomical  Diagnosis. 


Bacteriolu(^ical 
Examination. 


N'ov. 
Nov. 


7.  1899. 
do. 
9, 1899. 


Nov.  ji,  1899, 


do. 


Nov.  13, 1899. 


Nov.  16, 1899 

do. 

do. 
Nov.  25, 1899 


Dec.    2,  1899 
Nov.  25,  1899. 


do. 


do. 


Dec.     6, 1899. 


do. 


Lobular      pneumonia     ufl  Xc^aiive. 

both  lungs  ;  acute  infec-j 

tious  changes  of  all  vis-' 

ceral  organs, 
do. 
Double  lobar  pneumonia  ; 

infectious      changes     as 

above. 
Lobular    pneumonia    and 

hypostatic  c<)n>;esiion  of 

both    lungs :    acute    vis- 
ceral changes  as  above. 
Lobular    pneumonia    and 

acute  visceral  changes  as 

above. 

do. 

do. 

Tuberculosis  of  omentum 

and  spleen  ;  passive  con- 
gestion  of    lungs,    liver, 

spleen,  and  kidneys. 


do. 
do. 


do. 


do. 


do. 
do. 


XXIII 

XXIV 

XXV 

XXVI. 


XXVII 
XXVIII, 


XXIX 


XXX 


XXXI 


do. 


Feb.  : 


do. 
do. 


do. 


do. 


do. 


hrs. 


Lobular  congestion 
lungs ;  the  usual  acute 
changes  of  visceral  or 
gans. 

Multiple  small  abscess  for- 
niationsof  splten  ;  acute 
infectious  lesions  of 
lungs,  liver,  and  kidneys 

Lobular  pneumonia  and 
the  usual  visceral 
changes. 

do. 
do. 
do. 

Tuberculosis  of  omentum; 
lobular  congestion  and 
emphysema  of  both 
lungs. 

Tuberculosis  of  spleen ; 
miliary  tuberculosis  of 
liver  and  lungs. 

Lobular  congestion  and 
emphysema  of  both 
lungs  ;  passive  conges- 
tion of  liver,  spleen,  and 
kidneys. 

Lobular  congestion  of 
both  lungs;  the  usuall 
acute  infectious  changes 
of  visceral  organs. 

Abscess  formation  of 
spleen  ;  metastatic  ab- 
scesses of  lungs  and  Uver, 


Lobular      pneumonia     of 
both  lungs,  and  the  usual 
visceral  changes. 
Lobular    and     hypostatic 
congestion  of  both  lungs, 
and    the    usual    visceral 
lesions. 
Abscess  formations  of  rec 
tus    abdominis    muscle ; 
metastatic    abscesses   of 
liver  ;  the   usual  inflam- 
matory changes   of   vis- 
ceral organs. 
Tuberculosis  and   abscess 
formations     of     spleen  ; 
miliary  tuberculosis  and 
metastatic    abscesses  of 
liver  and  lungs  ;  passive 
congestion  of    kidneys, 
lungs,  and  liver. 
Lobular  congestion  of  both 
lungs,  and  the  usual  vis- 
ceral lesions. 
Acute  septicarmia 


Staphylococcus  au- 
reus from  omen- 
tum. ^J  icrococcus 
tetragenus  from 
liver  and  iungs. 

Negative. 


Staphylococcus  au- 
reus from  spleen. 


Negative. 


do. 

do. 

do. 
Micrococcus    tetra- 
genus from  heart's 
blood. 


Negative. 


do. 


do. 


Staphylococcus  au- 
reus from  spleen  ; 
Micrococcus  tetra- 
genus from  kid- 
neys. 

Negative. 

do. 


Staphylococcus  au- 
reus from  rectus 
abscess. 


Staphylococcus  au- 
reus from  spleen  ; 
Bacillus  coh  com- 
munis from  spleen 
and  liver. 


Passive  congestion  and 
hemorrhagic  infarction 
of  lungs. 

Lobular     congestion      of 
lungs  and   passive   con- 
gestion of  spleen,  liver, 
and  kidneys. 
do. 

Diffuse  purulent  peritoni- 
tis. 

Lobular  congestion  of 
lungs ;  passive  conges- 
tion of  liver,  spleen,  and 
kidneys. 

Lobular  congestion  of 
lungs  ;  ana:mic  infarction 
of  kidneys  ;  marked  gas- 
trectasis ;  passive  con- 
gestion of  liver. 

Lobular  congestion  of 
lungs ;  passive  congeS' 
tion  of  liver  and  kid- 
neys. 


Negatii 


Streptococcus  pyo- 
genes from  intra- 
peritoneal fluid. 

Negative, 


do. 

Staphylococcus  au- 
reus from  intra- 
peritoneal  fluid. 

Negative. 


do. 


do. 


the  omental  mass  revealed  tubercle  formations  with 
typical  giant  cells.  There  were  congestion  and  diffuse 
miliary  tuberculosis  of  the  spleen.  No  tuberculous 
lesions  were  found  in  the  liver,  lungs,  or  kidneys. 


288 


MEDICAL    RECORD. 


[August  25,  1900 


Case  XV. — A  guinea-pig  was  inoculated  November 
25,  1899,  intraperitoneally  with  tlie  nasal  contents 
from  No.  15,  a  student  twenty-seven  years  of  age. 
The  animal  died  eight  days  later.  On  e.\aniination 
the  wound  was  found  apparently  healed  by  primary 
union.  Six  to  eight  small  yellowish  masses  were 
found  on  the  omentum  underneath  the  cardiac  end  of 
the  stomach.  There  were  no  mesenteric  adhesions. 
The  lungs,  liver,  spleen,  and  kidneys  were  free  from 
visible  lesions.  The  lungs,  however,  showed  areas  of 
lobular  congestion  and  emphysema.  Cultures  and 
smears  from  the  yellowish  tuberculous  masses  re- 
mained negative.  The  micrococcus  tetragenus  was 
isolated  from  the  heart's  blood.  Histologically  the 
omental  tubercles  showed  an  aggregation  of  lymphoid 
cells  with  areas  of  necrosis  near  one  surface.  The  re- 
maining organs  appeared  as  above  described. 

Case  XVa. — A  control  animal  was  inoculated  De- 
cember 2,  1899,  subcutaneously  in  the  groin  with 
three  of  the  yellowish  masses  found  on  the  omentum 
of  Case  XV.  The  animal  lived  twenty-si.\  days,  when 
it  died  in  an  emaciated  condition.  On  post-mortem 
examination  the  wound  was  found  to  be  healed  by 
primary  union.  There  was  no  swelling  of  the  inguinal 
lymph  glands.  The  omentum  and  mesenteric  glands 
were  free  from  change.  The  spleen  w-as  enlarged  and 
congested;  it  contained  several  large  caseous  masses, 
the  largest  being  the  size  of  a  bean.  No  further  tuber- 
culous lesions  were  found.  Smears  and  cultures  from 
the  spleen  resulted  negatively.  A  bacteriological  ex- 
amination of  the  remaining  organs  was  not  made.  His- 
tologically tubercle  formations  were  demonstrated  in 
the  spleen,  but  they  contained  no  typical  giant  cells.  A 
miliary  tuberculosis  of  the  liver  and  lungs  was  present. 
Case  XXH. — A  guinea-pig  was  inoculated  in  a 
similar  manner  December  6,  1899,  ^^''^'^  ^^^  nasal 
contents  from  No.  22,  a  student  aged  twenty-six 
years,  and  died  fourteen  days  later  greatly  emaciated. 
Post-mortem  examination  showed  the  wound  to  have 
healed  by  primary  union.  The  omentum  possessed  sev- 
eral yellowish  punctate  bodies;  as  also  did  the  under 
surface  of  the  left  lobe  of  the  liver.  The  mesenteric 
glands  were  not  swollen.  The  spleen  was  large,  con- 
gested, and  filled  with  large,  yellow,  caseated  masses. 
The  liver,  lungs,  and  kidneys  showed  the  usual  acute 
infectious  changes.  Bacteriologically  the  staphylo- 
coccus aureus  was  obtained  from  the  caseous  masses 
of  the  spleen,  and  the  colon  bacillus  from  the  tissues 
of  the  spleen  and  liver.  The  omental  nodules  ap- 
peared histologically  as  lymphoid  tissue  which  had 
undergone  partial  necrosis.  There  were  typical  tuber- 
cle formations  with  giant  cells  and  also  local  abscess 
formation  in  the  spleen  and  metastatic  abscesses  of 
the  liver  and  lungs. 

The  following  cases  are  also  of  interest:  Cases 
XXVI.,  XXVII.,  XXIX.,  and  XXXI.  These  animals 
were  inoculated  February  22,  1900,  as  usual  with  the 
nasal  contents  from  students.  The  animals  lived  from 
thirteen  to  twenty  days,  and  on  examination  practi- 
cally the  same  conditions  were  found  in  each,  so  that  a 
description  of  Case  XXVI.  will  suffice  for  all.  The 
animal  died  after  twenty  days.  It  had  lost  some 
weight.  The  inoculation  wound  had  healed  by  pri- 
mary union.  On  the  omentum  were  found  two  opaque 
grayish  bodies,  the  size  of  half  a  split  pea.  The  mes- 
enteric glands  were  swollen  and  of  the  same  color. 
The  spleen,  liver,  and  kidneys  showed  marked  ])assive 
congestion,  and  the  lungs  lobular  areas  of  congestion. 
Smears  and  cultures  of  the  swollen  glands  remained 
negative,  as  also  did  the  lung  cultivations.  Histologi- 
cally, the  omental  and  mesenteric  glands  showed  a 
hyperplasia  and  partial  necrosis  of  lymphoid  cells. 
There  were  no  unequivocally  tuberculous  lesions  any- 
where. The  remaining  visceral  organs  revealed  the 
usual  acute  infectious  changes. 


Briefly  summarizing  the  records,  we  note  the  follow- 
ing facts:  Of  the  thirty-one  animals  inoculated,  one 
died  within  a  few  hours  of  septicemia,  and  another  in 
three  days  of  acute  peritonitis;  twenty-two  died  from 
acute  pulmonic  lesions  of  unknown  origin,  as  all  at- 
tempts to  isolate  micro-organisms  from  the  lungs  re- 
sulted negatively;  and  it  is  significant  that  nearly  all 
of  these  deaths  occurred  during  the  extreme  cold  nights 
of  the  past  winter  months.  The  swollen  mesenteric 
glands  found  in  Cases  XXVI.,  XXVII.,  XXIX.,  and 
XXXI.  of  this  group  are  to  be  explained  by  the  acute 
infection,  as  neither  lesions  resembling  tuberculosis 
were  found,  nor  was  the  presence  of  bacilli  in  the  tissues 
demonstrated.  Three  animals  died  of  staphylococcus 
aureus  infection  with  multiple  abscess  formation  of 
the  spleen  and  liver  after  several  weeks.  One  animal 
(No.  XXV.)  was  drowned  on  the  seventeenth  day,  and 
three  died  of  or  with  tuberculosis  in  fourteen,  twenty- 
six,  and  fifty-nine  days  respectively.  The  lesions 
found  in  these  last  cases  are  from  a  histological  stand- 
point positively  tuberculous.  In  Case  XV.,  this  was 
further  proven  by  re- inoculation  of  the  omental  tuber- 
cles into  another  animal  with  resulting  tuberculous 
lesions  of  the  spleen.  Very  many  most  careful  at- 
tempts were  made  to  obtain  the  bacilli  in  the  tissues, 
without  success,  but  because  of  the  technical  difficul- 
ties so  frequently  encountered  in  finding  them  in  tuber- 
culous tissues  in  general,  and  in  view  of  the  positive 
histological  and  re-inoculation  findings  cited  above,  I 
do  not  hesitate  to  give  these  as  positive  results,  mak- 
ing it  possible  to  state  that  in  this  series  of  experi- 
ments three  out  of  twenty-nine  cases  developed  tuber- 
culosis, or  a  percentage  of  10.3. 

It  is  to  be  noted  that  Fliigge's  conditions  necessary 
for  infection  are  not  to  be  applied  to  these  cases.  In 
the  case  of  No.  VIII.,  a  dealer  in  second-hand  furni- 
ture, the  physical  examination  showed  him  to  be  free 
from  visible  tuberculosis.  He  is  not  subject  to  the 
continuous  breathing  of  visible  dust,  nor  does  he  asso- 
ciate with  tuberculous  patients.  The  other  two  cases, 
those  of  students,  are  likewise  not  subject  to  these  con- 
ditions, though,  no  doubt,  from  the  nature  of  their 
work  they  are  somewhat  more  prone  to  infection  than 
the  average  person.  In  order  to  explain  these  findings 
we  must,  I  believe,  accept  a  wider  range  of  possible 
infection  than  the  experimental  researches  of  Fliigge 
and  his  conjreres  would  allow,  and,  to  my  mind,  the 
conclusions  of  Cornet  as  to  the  general  infectiousness 
of  contaminated  dust  satisfy  these  conditions  in  a 
more  liberal  way. 

On  taking  up  this  work  it  was  my  intention  to  make 
further  researches  than  I  have  recorded,  but  circum- 
stances prevent  it.  I  believe  the  question  justifies 
further  observations — observations  which  should  be 
exhaustive  and  differentiative.  It  would  be  interest- 
ing, for  instance,  to  determine  whether  or  not  the  ba- 
cillus is  limited  to  the  purely  respiratory  portion  of 
the  nasal  cavities.  Its  occurrence  on  the  pharyngeal 
mucous  membrane,  in  the  lacrymal  secretions,  in  the 
external  auditory  passages,  etc.,  should  be  studied. 
These  are  all  matters  that  have  some  bearing  upon 
the  spread  of  tuberculosis. 

In  general  we  may  conclude  as  follows:  F'irst.  that 
virulent  tubercle  bacilli  are  to  be  found  in  the  nasal 
cavities  of  healthy  persons  in  the  ordinary  walks  of 
life,  as  nearly  as  this  series  will  represent  this  class; 
and,  secondly,  they  are  not  to  be  found  so  frequently 
in  these  persons  as  in  those  who  have  the  care  of  the 
tuberculous. 

I  wish  to  express  my  thanks  to  Dr.  Ludvig  Hektoen 
for  advice  and  aid,  and  to  Dr.  T.  R.  Crowder  for  ex- 
amining physically  a  number  of  the  persons. 
REFERENXES   CITED. 
I     C.  Cornet     Nothnagel's  Specielle  Path.  u.  Therapie,  i8g<). 
xiv.,  iii.,  4;. 


August  25,  1900] 


MEDICAL    RECORD. 


289 


E.  Klebs  ;  Chicago  Medical  Record,  1898,  xv.,  172. 
Marpmann  :  Cited  by  Cornet,  loc.  cit. 
Heron  and  Chaplin  :   London  Lancet.   1894.  i.,  it. 
Williams:  Cited  by  E.  C.  Beale,  London  Lancet,  1894.  i. 


Cited  by  Cornet, 


2. 
3- 
4- 
5- 
470. 

6.  Buchner,  Weinich,  F.  Muller.  Straus,  etc. 
loc.  cit. 

7.  R.  Sticker  ;  Zeitschr.  f .  Hygiene  u.  Infektionskrankheiten, 
1899,  .\x.\..  103. 

8.  C.  FUigge  :   Ibid.,  107. 

9.  Laschtschenko  :  Ibid.,  105. 

10.  M.  Beninde  :  Ibid.,  193. 

11.  B.  Heymann  :  IbiJ.,  139. 

12.  V.    Esmarch  :    Deutsche  Vierteljahrsschrift    f.   offentliche 
Gesundheitspflege.  iSgS,  xx.x.  156. 

13.  Hlibener  :  Zeitschr.  f.  Hygiene  u.   Infektionskrankheiten, 
1898,  xxviii.,  348. 

14.  V.  Weissmayr  :  Wiener  klinische  Wochenschrift,  1896,  ix., 
131,  150. 

15.  M.    Straus:  Bull,   de  I'.^cademie  de  Med.,   Paris,   1S94, 
xxxii.,ii.,   18. 


ing  passed  urine  she  became  alarmed.  One  of  her 
daughters  told  me  that  her  mother  constantly  kept  on 
talking  of  her  condition  and  spoke  even  to  neighbors 
of  it.     She  had  constantly  iu  her  mind  the  idea  that 


ANURI.A     FOLLOWED     BY     RETENTION     OF 
URINE    IN    A    CASE   OF    HYSTERIA. 

By   ALFRED   GORDON,    M.D., 

PHILADELI'HIA,    I'A   , 

ASSISTANT      IN     THE      NEUROLOGICAL      DEPARTMENT,      JEFFERSON      COLLEGE 
HOSPITAL. 

Mrs.  S ,  forty-five  years  of  age.  had  eight  children, 

four  living.  At  the  age  of  thirty-five  she  had  typhoid 
fever,  and  since,  she  says,  she  has  not  been  feeling 
very  strong.  Her  menses  were  regular,  every  twenty- 
eight  days.  Her  present  trouble  began  ten  days  after 
her  married  daughter  was  taken  ill  with  scarlet  fever; 
two  days  later  her  daughter's  children  took  scarlet 
fever.  Immediately  previous  to  her  daughter's  illness 
her  son  underwent  an  operation  for  appendicitis. 
The  patient,  being  very  much  attached  to  her  family, 
became  so  much  alarmed  and  affected,  that  a  few  days 
following  her  grandchildren's  illness  she  developed 
the  symptoms  of  anuria.  When  I  first  saw  her,  she 
affirmed  that  she  passed  a  teaspoonful  of  urine  in 
twenty-four  hours.  After  questioning  her  again  and 
again,  she  repeatedly  assured  me  of  the  truthfulness 
of  her  assertion.  I  immediately  catheterized  her, 
but  could  obtain   only  a  few  drops  of   urine.     Palpa- 


RiGHT  Eye 


Fig.  3 


tion  and  percussion  of  the  region  of  the  bladder  did 
not  reveal  any  dulness.  The  patient  seemed  to  be 
perfectly  normal.  There  was  no  complaint  of  head- 
ache or  of  pain  in  any  part  of  the  body.  She  passed 
a  comfortable  night.     On  the  following  day,  not  hav- 


Left 


Fig.  2. 

she  could   not   live  without   urinating,   and  that  her 
kidneys  were  undoubtedly  affected. 

Knowing  the  family  for  a  tonsiderable  length  of 
time,  I  was  aware  of  the  fact  that  all  the  members  of 
it  were  neurasthenic.  The  treatment  on  the  first  day 
consisted  of  abundant  drinks,  especially  milk,  hot 
applications  to  the  region  of  the  kidneys,  and  strych- 
nine. At  my  third  visit  I  was  informed  that  the 
patient  passed  about  two  teaspoonfuls  of  urine,  and 
with  another  catheterization  I  obtained  again  a  tea- 
spoonful  of  urine.  VVhat  appeared  to  me  remarkable, 
was  that  there  was  no  vomiting,  and  the  patient  had 
no  headache  and  apparently  no  suffering.  The  lum- 
bar region  was  not  sensitive;  the  abdomen  was  soft; 
the  patient's  bowels  moved  as  usual,  and  in  spite  of 
two  quarts  of  milk  and  two  glasses  of  water  a  day  she 
did  not  urinate.  The  only  inconvenience  the  patient 
experienced  was  a  perspiration  during  one  night,  and 
she  affirmed  that  it  had  the  odor  of  urine.  She  be- 
came very  much  alarmed  and  begged  me  to  save  her, 
as  she  expressed  herself,  because  she  was  told  by  a 
friend  she  would  not  be  able  to  urinate  by  herself, 
but  she  must  ask  her  doctor  to  make  her  do  so. 

After  excluding  all  possibilities  of  anything  organic 
which  could  interfere  with  the  function  of  the  kidneys, 
and  being  somewhat  struck  by  the  comparatively  non- 
suffering  appearance  of  the  patient,  I  began  imme- 
diately an  investigation  in  regard  to  hysterical 
symptoms.  Of  all  stigmata  that  we  usually  find  in 
hysteria  there  were  only  two:  complete  anjesthesia  of 
the  plantar  region  of  the  right  foot,  and  a  very  marked 
concentric  narrowness  of  the  visual  field  in  both  eyes 
(Figs.  I  and  2).  While  the  normal  field  of  vision  is 
93'  for  temporal  region,  55"  nasal,  65-  lower,  and  55" 
upper,  in  this  case,  as  is  seen  by  the  charts,  it  was  far 
below  normal.  These  were  the  only  symptoms  of  hys- 
terical character  which  I  found  in  my  patient. 

I  have  always  been  of  the  opinion  that  it  is  an  error 
to  think  that  only  cases  of  true  insanity  are  accom- 
panied by  physical  stigmata  of  degeneration.  I  firmly 
believe  that  physical  stigmata  of  degeneration  lead 
very  frequently  to  psychical  degeneration,  and  not 
only  in  serious  organic  psychoses,  but  also  in  many 
functional  neuroses,  such  as  hysteria,  epilepsy,  chorea, 
neurasthenia.  A  person  affected  with  any  of  these 
neuroses  should   always  be    watched   closely,  for  al- 


290 


MEDICAL   RECORD. 


[August  25,  1900 


though  of  slight  character,  they  might  some  day  turn 
into  a  serious  psychosis.  I  scarcely  ever  fail  to  de- 
tect more  or  less  physical  signs  of  degeneration  in 
cases  of  chorea,  neurasthenia,  and  hysteria,  whether 
it  is  of  the  head,  face,  palate,  hands,  or  feet.  The 
early  recognition  of  physical  and  psychical  stigmata 
of  degeneracy  is  of  the  highest  importance  in  diagno- 
sis. In  examining  any  case  of  nervous  disorder  I 
make  it  a  rule  to  look  invariably  for  stigmata  of  this 
character,  for  their  nature  is  of  great  value  as  to  the 
future  of  the  patient. 

In  the  present  case  I  could  detect  the  following 
signs  of  degeneracy:  ogival,  deep  palatine  vault,  one 
ear  larger  than  the  other,  the  second  being  almost  per- 
pendicular to  the  head ;  three  bony  elevations  on  the 
head,  which  was  of  square  shape;  a  vestige  of  a  super- 
numerary finger  on  the  left  hand.  The  deeper  I  went 
into  my  investigation  the  clearer  appeared  to  me  the 
cause  of  my  patient's  anuria.  I  was  therefore  con- 
vinced that  I  had  to  deal  with  a  degenerate,  who  sub- 
sequent to  an  emotion  due  to  diseases  in  the  family 
to  which  she  was  so  much  attached,  developed  anuria. 
This  anuria  was  not  originated  by  any  lesion  bearing 
upon  the  functions  of  the  kidneys,  but  was  one  of  the 
symptoms  of  hysteria.  My  presumption  w'as  com- 
pletely verified  by  subsequent  events  in  the  course  of 
the  disease. 

I  persuaded  the  patient  that  she  was  really  ill  (any 
other  course  would  never  make  her  believe  me);  that 
the  trouble  was  in  her  kidneys,  and  that  a  special 
external  application  over  the  region  of  the  kidneys 
would  undoubtedly  cure  her.  She  was  enchanted  with 
my  announcement,  which  I  made  most  emphatically. 
Accordingly  I  prescribed  a  lotion  composed  of  chloro- 
form and  alcohol,  and  advised  her  to  rub  it  over  the 
lumbar  region  for  one  minute  every  three  hours.  I 
told  the  patient  to  be  as  quiet  as  possible,  this  being 
a  necessary  element  of  the  treatment;  to  carry  out  my 
instructions,  and  she  would  positively  urinate  the 
following  day.  My  next  visit  was  exactly  twenty-four 
hours  after  the  previous  one.  The  patient  and  her 
daughter  met  me  with  a  happy  smile,  and  appeared  to 
be  glad  to  see  me.  To  my  satisfaction  I  learned  that 
my  instructions  had  been  followed  to  the  letter,  and 
she  had  urinated  a  little  more  than  a  pint.  She  was 
very  much  encouraged,  felt  contented,  and  with  a 
reaffirmation  on  my  part  felt  sure  she  was  recovering. 
This  time  again  I  told  the  patient  that  to-morrow  she 
would  urinate  just  as  much  as  anybody  else,  and  she 
would  not  have  any  more  trouble.  This  suggestion 
worked  remarkably  well.  Early  on  the  following  day 
the  patient  sent  me  word  not  to  come,  as  she  was  en- 
tirely well;  she  urinated  five  times  during  the  day 
and  three  times  during  the  night;  she  began  to  eat 
full  meals,  and  felt  happy. 

Four  days  later  I  was  called  in  haste  to  see  my 
patient  again.  I  learned  that  she  suffered  intense 
pain  in  the  lower  part  of  the  abdomen,  and  had  not 
urinated  for  ten  hours,  but  felt  the  desire  to  do  so 
and  could  not.  On  uncovering  the  patient  I  found 
a  swelling  above  the  pubis  which  was  evidently  the 
distended  bladder.  Immediate  catheterization  brought 
a  large  amount  of  urine  of  very  strong  ammoniacal 
odor.  The  patient  informed  me  that  she  rubbed  over 
the  abdomen  the  same  lotion  I  prescribed  for  her  pre- 
vious anuria,  but  it  did  not  give  her  any  relief.  I 
stated  then  that  the  lotion  was  a  special  remedy  for 
the  kidneys,  but  this  retention  of  urine  was  due  to 
some  disturbance  of  the  bladder,  and  I  could  cure 
this  disease  with  another  lotion  specially  for  this 
case,  but  I  preferred  to  wait  until  evening.  In  the 
evening  I  called  again  and  found  exactly  what  I  ex- 
pected. The  patient  had  not  urinated  since  the 
catheterization ;  she  was  expecting  me  with  the  great- 
est impatience  to  obtain   "  the  great  remedy  "  for  her 


bladder.  I  immediately  prescribed  alcohol  with 
some  laudanum.  The  patient  hurried  her  daughter 
to  send  for  the  remedy  at  once.  Upon  leaving  I  said 
to  her  that  she  would  be  entirely  well.  She  blessed 
me  in  her  old-fashioned  way  and  looked  pleased  with 
my  promise.  The  following  morning  her  daughter 
reported  that  her  mother  urinated  after  the  first  rubbing 
with  that  remedy,  which  my  patient  called  "  wonder- 
ful." Since  then  I  heard  that  she  had  not  had  any 
more  trouble,  but  she  kept  copies  of  the  prescriptions, 
on  which  she  marked  in  German  which  was  for  kid- 
ney and  wiiich  for  bladder.  I  happened  to  be  in  her 
house  three  weeks  later  to  attend  one  of  her  children. 
I  took  the  trouble  to  examine  her  again  in  regard  to 
those  hysterical  stigmata  I  mentioned  above.  The 
visual  field,  although  not  entirely  normal,  was  con- 
siderably enlarged;  not  having  with  me  a  perimeter 
this  time,  I  could  not  obtain  the  exact  field.  The 
plantar  anesthesia  disappeared  entirely.  Instead  she 
developed  a  pharyngeal  anaesthesia. 

It  is  four  months  since  the  patient  recovered,  and 
she  has  not  had  a  relapse,  but  there  is  no  assurance  that 
she  will  not  have  one.  A  patient  who  is  a  degenerate 
and  has  once  developed  hysterical  symptoms  is  liable 
to  have  repeated  attacks  of  functional  disorders  and 
even  to  develop  other  neuroses. 

This  case  appeared  to  me  to  be  of  great  interest  in 
regard  to  the  rarity,  character,  peculiarities,  diagnosis, 
and  treatment.  Perhaps  there  is  no  disease  of  which 
there  has  been  so  much  written  as  hysteria.  The 
number  of  s\mptoms  and  the  peculiarities  of  the  case 
are  so  striking  that  it  seems  the  subject  can  hardly  be 
exhausted.  It  is  extremely  interesting  in  making  a 
diagnosis  and  applying  a  proper  treatment  in  order 
to  obtain  the  proper  results.  And  the  more  there  is 
written  on  the  subject,  the  more  one  feels  anxious  to 
study  each  case. 

Anuria  of  course,  as  well  as  oliguria  and  ischuria, 
has  been  observed  in  hysteria,  but  contrary  to  the 
opinion  of  some  writers  I  believe  it  is  rather  a  rare 
symptom.  During  the  three  years  I  spent  in  La 
Salpe'triere,  where  the  number  of  hysterical  subjects 
is  legion,  I  had  an  opportunity  to  observe  but  three 
cases  of  anuria.  In  looking  up  the  literature  for  the 
last  five  years  at  my  disposal  I  could  find  but  one 
case  reported  by  Guisy.'  His  case,  however,  differs 
in  many  points  from  mine,  and  resembles  those  re- 
ported by  the  older  writers.  Guisy's  case  can  be 
summed  up  thus:  The  patient  could  urinate  only  half 
a  cupful  of  urine;  he  was  permeated  with  the  odor  of 
urine;  his  eyes  and  nostrils  were  congested,  swollen, 
and  red;  they  discharged  a  fluid  of  ammoniacal  odor; 
examination  of  this  fluid  showed  urea,  pus,  and 
mucus.  The  patient  vomited,  and  the  vomited  fluid 
had  the  odor  of  urine  and  contained  urea.  There  was 
also  paresis  of  the  left  superior  and  inferior  mem- 
bers. Hysterical  symptoms  were  prese.it.  The  anuria 
lasted  twelve  days. 

The  present  case,  as  one  can  readily  see,  differed 
much,  and  there  is  the  extreme  interest  in  it  that  there 
was  no  vomiting,  no  odor  of  urine  around  the  patient, 
no  fluid  from  the  eyes  or  nostrils,  indeed  nothing  but 
a  slight  perspiration  during  one  night,  so  that  I  could 
not  even  examine  the  sweating  fluid.  In  addition  to 
this  a  vesical  retention  followed.  When  the  physician 
is  not  prepared  for  such. an  emergency  and  does  not 
bear  in  his  mind  the  possibility  of  hysteria,  he  will 
feel  greatly  embarrassed  for  lack  of  symptoms  from 
which  to  make  a  diagnosis.  If  the  diagnosis  of 
similar  cases  is  so  interesting,  their  treatment  is  still 
more  striking.  In  fact,  what  did  I  do  to  relieve  the 
patient.'  Merely  and  simply  suggestion.  It  is  use- 
less to  mention  that  it  was  not  the  chloroform  or  the 
alcohol.  The  patient  was  hysterical,  whicii  condition 
'  I'rogres  Medical,  1898,  vii.,  3  s.,  p.  S4. 


August  25,  1900] 


MEDICAL    RECORD. 


291 


is  rather  a  psychical  one,  or  a  disease  sine  materia, 
which  is  of  superior  functional  disturbance.  It  is 
therefo're  rational  to  apply  a  treatment  which  shall 
bear  upon  the  patient's  psychic  centres.  The  result, 
as  has  been  seen,  was  satisfactory.  It  is  curious  to 
see  how  complex  and  at  the  same  time  simple  is  the 
human  cerebral  condition,  at  least  in  hysteria.  One' 
feels  attracted  by  the  study  of  this  great  and  exceed- 
ingly interesting  functional  neurosis.  Let  us  see 
what  we  know  about  its  pathoijeny,  and  whether  the 
most  recent  discoveries  in  the  domain  of  neuropathol- 
ogy give  a  key  to  explain  the  nature  of  this  disease, 
and  why  suggestive  therapeutics  give  often  the  best 
results. 

First  of  all,  how  and  by  what  mechanism  can 
anuria  and  vesical  retention  be  the  result  of  hysteri- 
cal disorder?  It  is  a  well-known  fact  that  intense 
moral  impressions  increase  and  decrease  or  suppress 
altogether  tiie  glandular  secretions  through  the  nerves 
of  the  cerebrospinal  and  sympathetic  system,  which 
nerves  produce  a  reriex  action  upon  the  contraction  or 
dilatation  of  the  blood-vessels,  and  through  them  upon 
the  excretory  glands.  The  vaso-constrictors  or  vaso- 
dilators have  their  centres  in  the  medulla  and  spinal 
cord.  Any  intense  moral  impression  acts  first  upon 
the  cerebral  hemispheres,  whence  a  relie.x  reaction 
takes  place  in  the  medulla  and  spinal  cord,  in  which 
is  situated  the  centre  for  the  vasomotor  nerves;  these 
last  send  through  the  sympathetic  system  fibres  to  the 
renal  plexus,  which  in  its  turn  sends  fibres  to  the 
muscular  walls  of  the  blood-vessels  of  the  kidneys  and 
contracts  them ;  hence  diminishes  and  even  suppresses 
urinary  secretion.  The  centre  for  the  vaso-constrictor 
nerves,  particularly  of  the  kidneys,  is  situated  in  that 
portion  of  the  gray  substance  of  the  spinal  cord  which 
is  between  the  last  dorsal  vertebra  and  third  lumbar 
vertebra.  But  this  centre  is  dependent  upon  the  vaso- 
motor centre  situated  in  the  medulla.  This  is  exactly 
what  took  place  in  this  case.  The  mental  tension  pro- 
duced by  repeated  attacks  of  illness  in  her  family,  to 
which  she  was  very  much  attached,  broke  down  the 
patient,  and  the  reaction  appeared  in  the  urinary  ap- 
paratus, first  tiie  kidneys  and  then  the  bladder,  or 
rather  the  sphincter  of  the  neck  of  the  bladder.  This 
last  muscle,  like  other  similar  muscles,  is  always  in  a 
state  of  permanent  semi-contraction  whicii  is  called 
tonicity.  This  is  due  to  the  '  .ct  that  the  muscular 
fibres  of  the  sphincter  are  united  by  nervous  fibres 
with  the  motor  centre  of  the  sphincter,  which  is  placed 
in  the  spinal  cord  between  the  fourth  and  sixth  lum- 
bar vertebra  (Budge).  Any  excitement  of  the  centre, 
direct  or  indirect,  makes  the  sphincter  contract.  In 
this  case  the  impression  was  conceived  by  the  cerebral 
hemispheres,  and  through  a  reflex  reaction  it  was 
transferred  to  that  portion  of  the  spinal  cord  which 
contains  the  centre  of  Budge;  the  motor  nerves  going 
from  this  centre  to  the  sphincter  being  put  in  action, 
produced  the  contraction  of  the  muscle. 

From  this  short  discussion  we  can  learn  only  of 
the  mechanism  which  puts  in  action  different  cen- 
tres reacting  upon  the  organs.  But  how  explain  the 
initial  factor,  and  in  which  way  are  the  superior 
centres  influenced  in  hysteria?  Charcot  said  that  we 
must  consider  hysteria  as  a  disease  essentially  of 
psychical  order;  of  the  whole  vast  nervous  apparatus 
it  is  the  brain  that  is  especially  affected.  At  any 
rate,  if  there  is  an  anatomical  lesion,  which,  however, 
escapes  as  yet  our  investigations,  we  can  say  that  this 
lesion  is  of  a  dynamic  order,  for  we  know  that  the 
most  tenacious  of  hysterical  manifestations  are  liable 
to  disappear  almost  always  and  instantaneously  from 
a  psychical  influence,  as,  for  instance,  from  an  intense 
emotion.  Therefore  the  basis  for  the  treatment  of 
hysterical  accidents  will  consist  of  psychical  pro- 
cedures.    The    mental   state  of   hysterical   people   is 


characterized  by  its  aptitude  to  be  under  the  influence 
of  suggestion.  And  this  we  mean  not  only  during 
hypnotic  sleep,  but  also  in  waking  state.  As  we 
have  seen  in  our  case,  suggestion  interrupts  the  state 
of  consciousness  and  develops  other  ideas.  Our 
patient  previously  to  the  treatment  was  positive  that 
she  was  affected  with  a  grave  disease,  spoke  of  it 
everywhere  and  to  everybody.  It  was  therefore  es- 
sential that  the  state  of  consciousness  in  regard  to  her 
trouble  siiould  be  removed  and  a  new  idea  developed. 
Of  course,  suggestion  requires  certain  conditions, 
outside  of  which  it  cannot  exist.  A  mind  which  has 
not  a  certain  degree  of  w'eakness  will  not  be  over- 
powered by  suggestion.  Suggestion  requires  a 
disease  of  the  personality.  This  explains  the  fixed 
ideas  of  the  hysterical,  which  ideas  are  by  themselves 
spontaneous  suggestions,  or  at  least  they  are  auto- 
matic phenomena  developed  independently  of  will  and 
under  the  influence  of  accidental  causes.  What  is 
the  cause  of  such  a  state  of  the  nervous  system  in 
which,  under  the  influence  of  a  moral  emotion, 
functional  disorders  take  place,  and  why,  under  the 
influence  of  suggestion,  do  those  disorders  disappear? 
Of  all  the  theories  there  is  one  which  has  for  basis 
the  most  recent  studies  of  neuro-pathology,  i.e.,  the  the- 
(jry  of  neurons.  Waldeyer  was  the  first  who  suggested 
the  idea  of  neurons.  It  is  now  admitted  that  the 
neuron  is  a  unity  consisting  of  a  nervous  cell  with 
all  its  ramifications;  while  the  dendrites,  which  are 
identical  in  their  composition  with  the  cell,  are  un- 
equal to  each  other  in  their  diameter  and  length,  the 
ramifications  of  the  axons  are  almost  always  dichoto- 
mous.  Ramon  y  Cajal  discovered  that  the  neurons 
are  independent  of  each  other  and  are  not  continuous, 
so  that  two  cells  are  in  relation  with  each  other  through 
the  ramifications,  the  ends  of  which  are  onlv  in  prox- 
imity but  not  in  actual  contact.  Since  it  has  been 
proven  that  the  nervous  elements  are  not  a  continuous 
chain  and  do  not  present  a  closed  circle,  a  belief 
naturally  arises  that  in  order  to  give  passage  to  a 
nervous  current  it  is  necessary  that  they  should  be  in 
contact  sometimes,  and  for  this  it  is  supposed  that 
the  ends  of  the  ramifications  possess  amoeboid  move- 
ments. Rabl  Ruckhard  first  suggested  aniceboid 
movements  of  cells  in  ganglions  in  vertebrata.'  Later 
Wiedersheim,  basing  his  belief  on  W'eissmann's  ob- 
servations concerning  the  movements  of  certain  cere- 
bral cells  in  leptodora  hyalina,  became  a  partisan  of 
this  theory.'^  In  1894  Lt^pine,  in  1895  Mathias  Duval 
applied  the  theory  of  amceboism  to  the  intellectual 
phenomena.  Dercum  in  1896  adapted  the  same  theory 
and  ingeniously  explained  the  phenomena  of  hysteria. 
At  the  present  time  this  hypothesis  has  made  great 
progress,  and  many  phenomena  can  be  explained  by  it. 
Take  for  instance  acts  of  habit:  in  order  to  acquire 
a  habit,  frequently  repeated  efforts  are  indispensable; 
this  brings  often  the  ends  of  the  neurons  together, 
and  as  soon  as  relation  of  contact  is  established,  then 
automatic  action  takes  place.  In  senility  the  aptitude 
of  amceboism  is  greatly  diminished,  for  the  neurons 
lose  their  power  of  expansion;  the  interval  between 
them  is  large,  the  habit  of  contact  and  the  transmission 
of  nervous  influence  are  difficult,  hence  cerebral  or 
spinal  memory  becomes  slow.  'J'he  amceboism  of 
nervous  elements  gives  us  the  key  of  many  phenomena, 
physiological  as  well  as  pathological.  If  the  rami- 
fications are  simply  near  each  other,  but  not  continu- 
ous, we  can  readily  understand  why  under  any  psychi- 
cal influence  an  insignificant  displacement  of  them 
is  apt  to  destroy  their  contact.  On  the  other  hand, 
the  contact  can  be  restored  under  the  influence  of  will, 
or  of  a  new  psychical  influence,  as  suggestion.  For 
example,  in  our  case  of  hysterical   anuria  and  vesical 

'  Neurolog.  Centralblatt,  iSfjo,  No.  7. 
'  Anat.  Anz.,  December,  1890. 


292 


MEDICAL    RECORD. 


[August  25,  1900 


retention  a  psychical  influence,  namel)-,  mental  ten- 
sion and  worry,  broke  the  normal  equilibrium  of  the 
neurons  in  the  cerebrum  and  the  spinal  cord;  some 
perturbation  took  place  among  them,  the  normal  con- 
tact in  some  of  them  was  interrupted,  and  the  neurons 
in  the  neighborhood  became  so  disturbed  locally  as 
to  produce  a  reflex  reaction  upon  the  renal  centre  and 
the  centre  of  the  vesical  sphincter;  then  the  above- 
mentioned  morbid  manifestations  took  place.  A  new 
psychical  phenomenon  appeared,  /'.(•.,  suggestion, 
which  re-established  the  loss  of  equilibrium  and  har- 


FlG.  3. 

monious  contact   of  the   nerve  elements,  the   patient 
recovered. 

It  is  interesting  also  to  know  how  the  contact  be- 
tween the  neurons  is  formed.  Numberless  histological 
researches  have  been  made  to  elucidate  this.  The 
most  recent  are  those  of  Stefanowska,  who  observed 
that  the  dendrites  are  provided  at  their  ends  with  en- 
largements of  ovoid  shape  (Fig.  3).  Of  course  the 
appendices  will  increase  considerably  the  surface  of 
the  free  ends  of  the  dendrites,  and  consequently  help 
the  contact.  S.  Soukhanoff  corroborated  the  results 
of  Stefanowska's  researches,  reporting  his  observa- 
tions in  \hii  Journal  de  J)}eurologie  de  Bnixellcs,  \.-^x\\, 
1898,  p.  147. 


WHAT   ARE    NECESSARY    AND    DESIRABLE 
DATA    UPON     HEALTH    RESORTS? 

By    EDWARD   O.    OTIS,   M.D., 


The  physician  who  has  frequent  occasion  to  advise 
his  patients  regarding  a  change  of  climate  and  the 
selection  of  a  health  resort  is  often  baffled  in  his 
search  for  data  sufficient  to  enable  him  to  decide  intel- 
ligently upon  the  applicability  of  any  resort,  under 
consideration,  to  the  patient  he  is  purposing  to  send 
away.  There  may  have  been  much  written  about  the 
region  by  both  residents  and  visitors,  but  the  state- 
ments are  in  many  cases  vague  and  unverified,  and  the 
real  essential  facts  are  wanting.  Some  have  written 
with  a  genuine  desire  to  state  the  truth;  while  others 
have  exaggerated  the  advantages  and  ignored  the 
disadvantages  of  a  resort  from  a  desire  to  make  it 
popular.  Those  who,  with  the  best  intent,  have 
attempted  to  describe  a  resort  have  often  woefully 
failed  to  apprehend  what  were  the  necessary  and 
desirable  data  — climatic,  regional,  and  hygienic— to  be 
determined  from  the  point  of  view  of  a  health  resort. 

I  would  make  a  classification  of  the  facts  and  data 
necessary  to  be  known  in  order  to  give  a  clear  and 
working  description  of  a  health  resort  under  two  heads, 
the  natural  and  the  artificial.  Under  the  former  would 
be  included  the  meteorological  or  climatic  data;  the 
elevation  and  distance  from  the  sea;  the  configuration 
of  the  land,  whether  mountainous,  hilly,  flat,  or  un- 
dulating; the  existence  or  not  of  water  in  the  form  of 
river,  jiond,  or  lake;  the  character  of  the  soil  and 
subsoil,  whether  dry,  sandy,  clayey,  moist,  or  marshy; 


the  character  of  the  vegetation,  and  the  varieties  of 
tree,  shrub,  and  plant;  whether  wooded  or  npt;  the 
animal  and  insect  life — the  presence  of  mosquitos,  for 
instance,  would  be  a  serious  objection  to  some  persons, 
and,  according  to  the  new  theory,  might  mean  malaria. 

Under  the  head  of  artificial  facts  would  be  included 
the  population ;  the  system  of  drainage  and  water 
supply;  the  existence  or  not  of  a  board  of  health  and 
its  efficiency;  the  characteristics  of  the  town  as  to 
streets,  buildings,  churches,  public  buildings,  etc.;  the 
amusements  and  attractions;  the  roads  and  their 
conditions;  the  accommodations,  including  the  char- 
acter of  the  hotels  and  boarding-houses,  the  food, 
sanitary  arrangements,  bathing  facilities,  expense; 
manner  of  reaching  the  resort,  and  the  time  and  dis- 
tance from  one  or  more  great  cities;  then  the  preva'- 
lent  diseases  and  mortality,  and  whether  reliable  and 
skilful  medical  service  can  be  obtained;  and  finally, 
what  are  the  diseases  upon  which  the  resort  is  said  to 
exercise  a  favorable  influence;  and,  if  the  reporter 
is  a  resident  physician,  what  has  been  his  personal 
experience  in  the  observation  and  treatment  of  these 
diseases. 

The  reader  may  suggest  other  points,  but  if  one  is 
in  possession  of  the  above  facts — their  accuracy  being 
assured — he  will  be  able,  I  believe,  to  form  a  pretty 
reliable  estimate  of  the  resort  and  judge  intelligently 
as  to  its  applicability  to  any  case  under  consideration. 

To  examine  in  detail  some  of  the  above-enumerated 
facts:  Under  climate,  various  and  differing  data  are 
included,  or  omitted,  by  those  describing  a  resort,  and 
generally,  in  the  writer's  experience  and  opinion,  either 
too  much  or  too  little  is  given.  Elaborate  charts  of 
climate  are  more  or  less  perplexing  to  the  ordinary 
reader  and  do  not  convey  so  much  definite  knowledge 
as  fewer  data,  which  should  be,  as  far  as  possible,  self- 
explanatory.  I  may  add  here,  that  in  order  to  appre- 
ciate any  statement  of  climate,  a  knowledge  of  that  of 
the  reader's  residence  is  essential  in  order  to  compre- 
hend fully  by  the  comparison  the  differences  of  that 
of  the  region  under  consideration. 

The  following  plan,  suggested  by  Dr.  Phillips  of 
the  United  States  Weather  Bureau,  appears  to  the 
writer  to  be  simple  and  plain  and  yet  to  convey  the 
main  climatic  facts  of  any  region : 


Climatic  Data. 

Temperature  : 

Average  or  normal 

Average  daily  range 

Mean  of  warmest  (mean  ma.^imum) 

Mgan  of  coldest  (mean  minimum)    . 

Highest  or  maximum 

Lowest  or  minimum 

Humidity  : 

Average  relative 

Average  absolute 

Precipitation  : 

Average  in  inches 

Wind  : 

Prevailing  direction 

Average  hourly  velocity 

Weather  : 

Average  number  clear  days 

Largest         "  "       "    

Smallest        "  "       "    

Average  number  fair  days 

L.irgest         "         "      "  

Smallest        "         "      "  

Average  number  cloudy  days 

Largest  "  "  *"    

Smallest         "  "  "    

Averrjge  number  rainy  days 

Smallest         "  "        "    

Largest  "  "        "    


I 


si 
e 


As  to  the  temperature,  we  want  to  know,  first,  whaf^ 
is  the  average  daily  temperature  for  the  season  it 
which  one  visits  the  health  resort:  for  instance,  if  ill 


August  25,  1900] 


MEDICAL    RECORD. 


293 


is  a  resort  in  Florida,  the  winter  temperature;  if 
Mount  Desert,  the  average  summer  one.  If  an  all- 
the-year  resort  like  Colorado  or  Saranac,  we  want  the 
temperature  for  the  whole  year.  Next,  it  is  important 
to  know  the  average  diurnal  range,  from  which  we 
obtain  an  idea  of  the  equability  of  the  temperature — 
for  instance,  how  much  colder  it  is  at  night  than  dur- 
ing the  day,  or  w-hen  the  sun  is  overcast  than  when  it 
is  clear.  The  mean  of  warmest  temperature  is  the 
average  daily  maximum  of  all  the  days  of  any  given 
month  throughout  the  entire  period  of  observation,  be 
it  one  year  or  ten;  for  example,  the  mean  of  warmest 
temperature  of  Baltimore  for  thirteen  years  for  the 
month  of  January  is  40.5^  F.,  which  means  that  in  the 
403  (13  X31)  January  days,  the  highest  which  the  maxi- 
mum thermometer  may  be  expected  to  reach  on  each 
of  these  days  is  40.5'  F.,  this  representing  the  maxi- 
mum temperature  of  a  normal  January  day.  In  the 
same  way  the  mean  of  the  coldest,  or  the  minimum 
temperature  of  a  normal  day  for  any  month,  is  obtained ; 
and  subtracting  the  one  from  the  other  we  have  the 
average  daily  variation  or  range  referred  to  above. 
The  highest  or  absolute  maximum  temperature  is  the 
highest  reached  upon  any  day  of  the  given  month  in 
any  year  of  the  period  of  observation;  and  the  lowest 
or  absolute  minimum  is  the  lowest  temperature 
reached. 

These  extremes,  as  Dr.  Huntington  Richards  has 
sententiously  remarked,  are  the  "chances  the  invalid 
has  got  to  take  in  any  resort;  they  do  not  indicate 
what  temperature  he  may  expect,  but  what  it  may  be 
his  good  or  evil  fortune  to  encounter."  A  severe  frost 
is  the  "  chance "  in  Florida,  for  instance;  it  is  not 
expected,  but  occasionally  it  comes,  and  the  orange- 
trees  are  frozen. 

Next  in  importance  to  the  purity  of  the  air  comes, 
perhaps,  the  question  of  moisture,  whether  the  air  is 
damp  or  dry.  The  average  relative  humidity  is  the 
best  indicator  of  this,  and  is  determined  by  oividing 
the  absolute  humidity  by  the  amount  of  vapor  that 
might  exist  if  the  air  was  saturated.  Both  the 
temperature  and  soil,  as  well  as  distance  or  proximity 
to  large  bodies  of  water,  have  a  direct  influence  upon 
the  humidity.  The  average  rainfall  is  of  obvious 
importance,  and  this  factor  should  be  considered  in 
connection  with  the  character  of  the  soil,  for  if  the 
latter  is  dry  and  porous,  quickly  absorbing  moisture, 
the  amount  of  the  rainfall  is  of  less  importance  than 
if  the  soil  was  clayey  and  held  the  water. 

The  direction,  regularity,  and  velocity  of  the  wind 
are  extremely  important  facts  to  be  noticed.  From 
one  direction  the  wind  brings  dampness,  like  the  east 
wind  on  the  Atlantic  seaboard;  from  £(nother  dryness, 
like  the  sirocco  of  southern  Italy,  or  the  winds  from 
the  great  Australian  plains.  From  one  direction  it 
come  fresh  and  pure,  blowing  over  forest  expanses  or 
from  the  hills;  from  another,  laden  with  dust  and 
germs,  exhausted  of  its  ozone  and  deficient  in  oxygen. 
Sudden  and  frequent  changes  of  the  wind  are  generally 
undesirable,  though,  for  instance,  the  sudden  appear- 
ance of  a  cool  sea-breeze  at  the  sea-shore  on  a  hot  day 
is  wholesome  and  refreshing.  Although  every  region 
has  its  prevailing  winds,  absolute  and  continued  reg- 
ularity is  found  only  in  the  region  of  the  trade  winds 
at  such  resorts  as  Nassau  or  Barbadoes,  W.  I. ;  here  the 
northeast  '"  trades "'  can  be  depended  upon  to  blow- 
daily  as  certainly  as  the  sun  to  rise.  No  resort  is  de- 
sirable where  high  winds  are  frequent,  especially  for 
pulmonary  tuberculosis ;  hence  the  importance  of  know- 
ing the  frequency  and  velocity  of  the  wind. 

Under  weather  data  we  have  the  average  number  of 
clear,  fair,  and  cloudy  days,  as  well  as  the  rainy  ones. 
This  enables  us  to  determine  the  amount  of  sunshine 
we  are  to  expect  at  the  resort,  and  the  degree  to  which 
one  can  enjoy  out-door  life.     Some  observers  note  the 


number  of  hours  of  sunshine  duiing  the  season,  which 
perhaps  is  raither  more  accurate.  The  largest  and 
smallest  number  of  days  of  the  different  kinds  of 
weather  are  again  the  "chances,"  above  referred  to, 
which  we  have  to  take;  for  in  almost  all  resorts  there 
are  exceptionally  bad  seasons,  as  well  as  extraordi- 
narily good  ones.  It  is  obviously  of  high  importance 
to  be  sure  of  a  large  proportion  of  fair  and  clear  days 
at  a  health  resort,  for.  whatever  tlie  disease,  it  is  the 
out-door  life  which  is  desired.  On  the  other  hand, 
occasional  rains  are  desirable  to  cool  and  purify  the 
air.  If  the  resort  described  is  one  in  the  northern 
latitudes,  like  Saranac  or  Liberty,  or  of  the  high 
altitudes  like  Davos,  it  is  essential  to  know  the  amount 
of  snowfall,  and  the  length  of  time  snow  lies  continu- 
ously on  the  ground,  and  when  it  begins  to  melt  in  the 
spring.  The  elevation  above  sea-level,  if  at  all  con- 
siderable, is  accompanied  with  especial  climatic  con- 
ditions which  are  to  be  noted. 

Again  the  configuration  of  the  land  often  modifies 
the  climate,  sometimes  detracting  from  otherwise  fa- 
vorable climatic  conditions,  and  sometimes  neutraliz- 
ing certain  unfavorable  ones;  for  example,  a  hill  or 
mountain  may  afford  protection  from  high  winds  or 
those  blowing  from  an  injurious  quarter;  or  if  the 
resort  is  in  a  valley  the  daily  amount  of  sunshine 
may  be  reduced.  ^loderate  a.scents  are  often  of  value 
for  exercise,  as  Brehmer  utilized  them  at  Gorbersdorf 
for  his  consumptives,  or  as  they  are  used  in  the  Oertel 
"cur  de  terrain." 

A  hilly  or  undulating  country  is  less  tiresome  to 
look  upon  than  a  dead  level;  it  is  pleasant  to  wonder 
what  is  beyond  the  hills. 

Under  vegetation,  we  want  to  know,  in  the  first 
place,  whether  the  region  is  well  wooded  or  not,  and 
the  extent  and  character  of  the  forests,  if  they  exist. 
The  fir,  pine,  spruce,  and  other  evergreen  trees  are 
generally  considered  an  advantage  to  a  health  resort 
on  account  of  their  balsamic  exhalations,  their  shade, 
and  the  aisthetic  effect.  Arcachon  in  France,  Bourne- 
mouth in  England,  Lakewood  and  the  southern  pine 
belt  in  this  country  are  illustrations  of  resorts  in  the 
midst  of  pines.  Gorbersdorf  in  Germany  and  the 
Adirondacks  are  in  the  region  of  the  fir  and  spruce. 

Second,  some  account  of  the  other  forms  of  vegeta- 
tion should  be  given,  especially  the  flora.  The  invalid 
may  happen  to  be  a  botanist,  and  a  rich  and  varied 
flora  may  afford  him  unending  delight.  If  he  is  a  suf- 
ferer from  hay  fever,  a  knowledge  of  the  plant  life  is 
important ;  if  an  entomologist  or  zoologist  he  will  want 
to  know  something  of  the  insect  and  animal  life  to  be 
found  there. 

It  is  evident  that  dryness  of  soil  and  subsoil  is  desir- 
able, and  that  any  large  amount  of  stagnant  water  in 
marsh,  lake,  or  pond  is  undesirable,  on  account  of  the 
increased  humidity  and  the  possibilities  of  malaria. 

After  a  consideration  of  the  natural  conditions  of 
a  health  resort,  we  have  to  examine  next  the  artificial 
ones,  as  I  have  termed  them.  What  facilities  exist 
for  comfortable  living,  without  which  the  best  of 
climatic  conditions  are  likely  to  prove  elusive?  The 
invalid  requires  good  food,  properly  cooked ;  a  well- 
ventilated  and  sunny  bedroom  and  a  comfortable  bed; 
suitable  and  sufficient  attendance,  good  sanitary 
arrangements;  facilities  for  sitting  or  reclining  out  of 
doors,  if  the  open-air  "Liegekur"  is  to  be  taken;  and 
if  it  is  a  resort  for  pulmonary  tuberculosis  some  assur- 
ance that  his  neighbors  will  properly  dispose  of  their 
sputum.  He  must  be  sure  of  obtaining  pure  drinking- 
water,  and  know  that  the  sewage  is  safely  disposed  of, 
that  the  risk  from  the  zymotic  diseases  may  be  avoided. 
An  intelligent  and  efficient  local  board  of  health  is 
quite  indispensable  at  a  health  resort;  for  instance, 
hotels,  boarding-houses,  or  rented  cottages,  receiving 
consumptives,    should   be   under   the    supervision    of 


294 


MEDICAL   RECORD. 


[August  25,  1900 


such  a  board,  by  application  to  which  one  can  be 
sure  that  a  room  or  cottage  which  has  been  occupied 
by  a  consumptive  has  been  satisfactorily  renovated 
and  disinfected.  At  Cannes,  France,  the  health 
authorities,  in  conjunction  with  the  physicians,  do  this. 
In  many  other  ways  the  invalid  can  be  protected  by  a 
capable  health  board  from  avoidable  dangers  of  con- 
tagion. 

The  amusements  and  diversions  the  resort  affords 
should  receive  mention,  and  not  be  exaggerated  as  is 
too  often  the  case.  One  cannot  live  by  climate  alone, 
but  must  have  something  to  occupy  his  mind  when 
away  from  the  sweet  influences  of  home  and  the  usual 
routine  of  life,  and  depressed  by  illness.  The  out- 
door diversions  are  the  ones  to  which  especial  atten- 
tion should  be  given,  for  in  the  majority  of  cases  the 
invalid  is  e.xpected  to  spend  the  greater  portion  of  his 
time  in  the  open  air.  The  amusements  of  the  quieter 
kind  will  be  the  ones  most  applicable  to  the  patient — 
driving,  walking,  shooting,  fishing,  etc.  The  condi- 
tion and  extent  of  the  roads  are  also  to  be  mentioned. 
Is  there  a  library;  and  are  there  schools?  What  are 
the  churches?  P'or  many  prefer  to  go  where  a  church 
of  their  own  denomination  is  to  be  found.  A  most 
important  and  in  many  cases  decisive  fact  to  be 
known  is  the  probable  expense;  about  what  will  it  all 
cost?  For  what  price  can  one  obtain  comfortable  ac- 
commodations, and  what  are  the  other  necessary  ex- 
penses? No  resort  should  be  recommended  whicli 
does  not  contain  one  or  more  good  physicians,  known 
either  by  reputation  or  personally  to  the  physician 
sending  the  patient  there,  and  to  whom  the  invalid 
should  be  referred  by  a  note  of  introduction,  briefly 
stating  the  case. 

If  the  results  of  cases  treated  at  a  resort  can  be 
presented  by  physicians  practising  there,  they  will  in- 
dicate, as  nothing  else  can,  the  actual  benefits  to  be 
expected  from  a  residence  at  the  resort,  for  whatever 
disease  its  climate  is  recommended.  The  careful  re- 
sults published  by  the  late  Dr.  Geddings,  of  Aiken, 
those  of  Dr.  Trudeau,  of  Saranac,  and  of  Drs.  Fiske 
and  Solly,  of  Colorado,  are  admirable  illustrations 
of  this.  Simply  to  make  the  statement  that  such  a 
resort  is  beneficial  in  such  and  such  diseases,  without 
facts  and  results,  carries  but  little  weight,  when  one 
considers  how  inconsiderately  this  claim  is  often  made. 

The  writer  is  well  aware  that  to  obtain  all  the  data 
and  facts  enumerated  above,  with  accuracy  and  a  strict 
adherence  to  truth,  requires  long  experience  with  a 
health  resort,  and  painstaking  observations.  Indeed 
some  of  the  data  can  be  collected  only  by  observations 
which  must  extend  over  a  series  of  years,  like  those  of 
climate;  but  others  are  always  at  hand,  like  those  rel- 
ative to  the  soil  and  vegetation.  It  is,  however,  some 
such  plan  as  here  suggested  which  should  be  kept  in 
view,  and  every  year  of  experience  will  add  something 
toward  the  completeness  of  the  record. 

The  therapeutic  value  of  a  change  of  climate,  and  the 
many  advantages  of  health  resorts,  are  becoming  more 
and  more  appreciated  by  the  profession.  With  this 
greater  appreciation,  however,  comes  the  greater  desire 
to  be  in  possession  of  sufficient  and  definite  knowledge 
of  the  various  health  resorts,  so  that  they  can  be  pre- 
scribed with  something  of  the  same  accuracy  with  which 
one  prescribes  a  drug  or  other  treatment.  If  one  has 
a  new  remedy  to  offer,  its  composition,  physiological 
action,  and  the  effects  of  its  use  in  the  disease  for 
which  it  is  advocated,  are  given.  So  it  must  be  with 
a  health  resort,  so  far  as  the  intrinsic  conditions  will 
allow.  At  all  events,  while  the  knowledge  is  accumu- 
lating to  render  such  a  description  possible,  let  not 
hasty  and  unproved  generalizations  be  given  for  facts. 
State  what  is  known,  and  wait  for  more  evidence  and 
the  results  of  more  extended  -  oservations  and  longer 
experience. 


TUMOR    ALBUS." 
By   frank    E.    I'ECKIIAM,    M.D., 

ORTHOPEDIC  SURGEON,    RHODE    ISLAND   HOSPITAL. 

Tumor  albus,  or  white  swelling,  is  a  term  applied  to 
a  chronic  tuberculosis  of  the  knee  joint.  This  process 
may  first  attack  the  epiphysis  of  the  long  bones  either 
above  or  below  the  joint.  It  may  attack  the  patella, 
or  it  may  first  appear  in  the  synovial  membranes. 

In  1898  Dr.  Nichols,  of  Boston,  presented  a  very 
elaborate  paper  before  the  American  Orthopedic  As- 
sociation, proving  that  in  over  one  hundred  and  twenty 
tuberculous  joints  examined  by  him  the  disease  had 
begun  in  the  epiphysis.  From  this  he  reasoned  that 
in  all  probability  this  was  the  original  point  of  attack 
in  the  majority  if  not  all  cases.  This  was  rather 
difficult  to  believe,  because  clinicall)'  joints  had  been 
opened,  the  gelatinous  tuberculous  material  removed, 
the  bone  found  to  be  in  many  cases  not  seriously  if 
at  all  damaged,  and  the  operation  of  arthrectomy 
(sometimes  spoken  of  as  erasion)  being  entirely  suffi- 
cient to  limit  the  progress  of  the  disease.  Since  that 
time  clinical  experience  has  become  still  more  defi- 
nite, and  the.v-ray  photographs  have  begun  to  show  that 
undoubtedly  there  are  many  cases  that  do  not  begin  in 
the  epiphysis,  but  rather  in  the  synovial  membranes 
or  joint  surfaces. 

The  symptoms  of  this  disease  come  on  very  slowly, 
and  tlie  most  prominent  ones  are  heat,  swelling,  ten- 
derness, and  the  presence  of  fluid  causing  distention. 
When  fluid  is  not  present  and  the  joint  is  enlarged  it 
has  a  peculiar  boggy  feeling  to  the  touch,  and  the  tis- 
sues are  raised  above  the  patella.  When  the  joint  is 
opened  this  is  found  to  be  due  to  the  presence  of  a 
gelatinous  tuberculous  condition  of  the  membranes, 
and  this  is  quite  characteristic  of  tuberculous  knees 
in  the  early  and  acute  stages,  whether  with  or  without 
the  presence  of  fluid.  The  inner  condyle  is  very  apt 
to  be  more  enlarged  than  the  outer,  causing  a  condi- 
tion similar  to  knock-knee.  These  symptoms  coming 
on  also  cause  lameness,  which  may  be  intermittent  in 
the  very  early  stages.  With  increasing  irritability  the 
flexor  muscles  slowly  become  contracted,  causing  flex- 
ion and  subluxation,  two  characteristic  deformities. 
The  muscles  above  and  belpw  the  knee  become  atro- 
phied. In  this  stage  of  the  disease  there  is  very  apt 
to  be  an  actual  lengthening  of  the  leg  due  to  an  over- 
growth, the  epiphysis  being  stimulated  to  greater  ac- 
tivity for  a  time.  The  temperature  of  the  joint  is 
elevated,  the  difference  between  the  two  knees  being 
perceptible  to  the  sense  of  touch.  At  first  when  the 
patient  is  still  bearing  weight  on  the  leg  there  is 
slight  pain,  whjch  becomes  more  and  more  aggravated 
and  may  be  excruciating  if  treatment  is  delayed.  The 
face  also  begins  to  be  an  index  to  the  general  condi- 
tion, becoming  anxious  and  careworn,  and  sleep  may 
be  interfered  with,  although  the  "night  cries"  of  hip 
disease  are  absent.  If  treatment  be  delayed  then 
the  constitutional  symptoms  appear — fever,  debility, 
emaciation,  loss  of  appetite,  and  loss  of  flesh.  Ab- 
scesses may  complicate  knee-joint  disease,  but  usually 
in  the  more  acute  forms  or  in  the  neglected  cases. 

Without  entering  into  an  exhaustive  differential 
diagnosis,  I  shall  mention  two  or  three  diseases  which 
most  commonly  give  trouble  in  ruling  out.  Synovitis 
in  the  early  stages,  particularly  if  the  general  physical 
condition  is  a  little  run  down,  may  be  difficult  or  even 
im|iossible  to  distinguish  absolutely.  In  synovitis  the 
patella  can  be  depressed  until  it  is  felt  to  strike  the 
femur  beneath,  while  in  tuberculosis  the  swelling  is  a 
boggy  thickening  surrounding  the  patella  rather  than 
floating  it  as  fluid  would  do.  In  synovitis  motion  is 
not  interfered  with  so  much,  and  atrophy  is  not  pres- 
ent. 

'  Read  before  the  Providence  Clinical  Club,  May  2,   lyoo. 


August  25,  1900] 


MEDICAL    RECORD. 


295 


In  acute  articular  rheumatism  tliere  is  a  sudden  on- 
set with  fever,  and  other  joints  may  become  involved, 
while  ordinarily  white  swelling  is  an  insidious 
affair.  In  the  chronic  forms  of  rheumatism  greater 
care  is  necessary  in  differentiating,  and  it  may  be 
even  impossible  to  do  so  clinically. 

Rheumatoid  arthritis  is  another  affection  which  may 
closely  stimulate  white  swelling.  With  this  disease 
the  enlargement  at  the  joint  is  bony  and  is  more  apt 
to  be  of  a  spindle-shape.  The  ends  of  the  bones  be- 
come more  or  less  eroded,  and  motion  is  liable  to 
cause  a  grating  which  can  be  felt  when  the  hand  is 
placed  upon  the  knee,  and  in  many  cases  the  sound  is 
audible.     More  than  one  joint  is  liable  to  be  affected. 

Hysterical  joints  may  give  trouble  at  times,  but 
careful  examination  at  different  limes  should  reveal 
the  true  nature  of  the  affection. 

The  treatment  of  tumor  albus  naturally  resolves 
itself  into  conservative  and  operative.  The  conserva- 
tive method  includes  a  general  tonic  treatment  which 
would  be  of  value  in  any  wasting  disease.  The 
mechanical  part  of  the  treatment  includes  fixation  and 
protection.  Fixation  is  best  obtained  by  a  plaster-of- 
Paris  bandage  extending  from  the  ankle  to  the  groin, 
and  in  some  of  the  more  sensitive  cases  even  the  foot 
should  be  included.  Other  materials  may  be  used, 
and  the  leg  may  be  splinted,  but  when  one  becomes 
thoroughly  accustomed  to  the  use  of  plaster  of  Paris 
there  is  nothing  which  gives  such  complete  satisfac- 
tion. Later  in  the  disease  and  during  convalescence 
a  leather  corset  may  be  fitted,  lacing  up  in  front,  thus 
giving  a  much  lighter  support  and  one  that  can  be  re- 
moved and  the  skin  cleansed  every  day. 

Protection  is  accomplished  by  keeping  the  weight 
from  the  diseased  leg.  The  patient  in  a  great  many 
cases  will  get  along  with  just  the  plaster  of  Paris  and 
a  pair  of  crutches,  swinging  the  leg  during  the  act  of 
walking.  A  high  sole  may  be  applied  to  the  shoe  of 
the  well  leg,  thus  raising  the  patient  up  two  inches. 
At  the  same  time  a  splint  may  be  applied  to  the  dis- 
eased leg,  thus  transferring  the  weight  to  the  perineum 
when  walking.  This  splint  may  be  worn  over  the  plas- 
ter of  Paris  or  leather  corset,  and  during  convalescence 
the  splint  alone  may  suffice. 

In  the  early  stages  various  external  applications 
were  recommended  in  the  text-books,  but  I  never  yet 
saw  any  good  results  from  such  treatment,  and  I  fail 
to  see  how  anything  applied  externally  can  have  any 
effect  whatever  upon  tubercle  bacilli  deep  within  a 
joint.  If  such  a  thing  were  possible,  certainly  the 
treatment  in  other  tuberculous  affections,  such  as  tuber- 
culous meningitis,  should  show  better  results. 

Operative  procedures  become  necessary  in  the  cases 
that  do  badly  under  conservative  treatment.  The 
operation  which  I  most  frequently  do,  especially  in 
children,  is  arthrectomy.  The  joint  is  thoroughly 
opened  by  a  circular  incision  extending  through  the 
ligamentum  patellae,  a  flap  being  formed  which,  when 
elevated,  exposes  the  supra-patellar  space.  With  this 
free  opening  every  portion  of  the  joint  can  be  in- 
spected and  every  portion  of  tuberculous  material  re- 
moved, and  if  the  bone  is  found  to  be  seriously  dis- 
eased everything  is  already  thoroughly  exposed  for 
an  excision,  and  no  time  need  be  lost.  In  doing  a 
simple  arthrectomy  my  experience  is  that  the  curette 
is  of  very  little  value,  as  it  slips  over  the  tough,  gelat- 
inous-like material  without  taking  off  very  much  of 
ic;  but  with  a  pair  of  mouse-tooth  forceps  and 
curved  scissors  it  can  be  removed  with  much  greater 
facility.  The  semilunar  cartilages  will  usually  be 
found  diseased,  and  the  space  above  the  patella  and 
beneath  the  rectus  muscle  must  always  be  thoroughly 
explored,  and  will  usually  be  found  filled  with  tuber- 
culous material.  It  is  impossible  to  know  in  any 
given  case  whether  all  disease  has  been  removed,  but 


a  thorough  operation  must  be  done.  The  ligamentum 
patella,  which  is  divided  in  this  operation,  readily 
unites,  as  is  demonstrated  in  cases  operated  upon  a 
second  time. 

If,  on  opening,  the  bone  is  found  to  be  extensively 
invaded  and  the  patient  is  an  adult,  excision  should 
be  done  immediately,  while  in  children  oftentimes  the 
curette  will  be  sufficient.  In  the  adult  the  bone  has 
attained  its  growth,  and  so  saving  the  epiphysis  is  not 
of  such  importance  as  in  a  child. 

Arthrectomy  is  the  most  usual  operation,  excision 
coming  next,  while  amputation  would  be  necessary 
only  as  a  life-saving  measure. 

I  shall  now  submit  a  few  illustrative  cases: 

Case  I. — The  first  patient,  a  little  girl,  A.  G , 

now  aged  seven  years,  first  came  under  observation 
November  21,  1896.  The  disease  had  been  present 
then  six  months,  and  had  involved  both  knees  and 
both  ankles.  There  were  beginning  contractures  of 
the  hamstring  muscles,  with  swelling  of  knees  and  an- 
kles. She  was  unable  to  walk  on  account  of  pain ; 
the  child  was  crying  out  at  night,  and  considerable 
loss  of  flesh  had  taken  place.  This  case  has  been 
treated  through  the  whole  course  of  the  disease  as  an 
out-patient  at  the  hospital,  and  plaster  of  Paris  has 
been  the  only  method  used.  All  treatment  ceased 
December  30,  1899,  about  three  years  in  duration,  and 
the  patient  now  attends  school.  There  is  no  thicken- 
ing about  the  joint;  there  is  normal  motion  at  the 
ankles,  while  at  the  knee  flexion  is  possible  up  to  a 
right  angle,  which  allows  her  to  sit  down  easily.  In 
walking  about  the  room  nothing  unusual  is  observed. 

Case  II. — The  next  patient   is  K.  McL ,  now 

aged  nine  years.  She  first  came  under  observation 
November  5,  1896,  the  disease  having  already  existed 
one  year.  This  case  did  not  do  well,  and  early  in 
1898  arthrectomy  was  done,  followed  by  plaster-of- 
Paris  splint  until  June,  1899,  when  all  treatment  was 
omitted,  almost  one  year  ago.  The  knee  is  stiff  and 
slightly  flexed,  and  the  diseased  leg  measures  now 
three-eighths  of  an  inch  longer  than  the  sound  leg. 
She  walks  and  runs  easily. 

Ca.se  III. — This  result  is  also  an  excellent  one. 
This  boy,  J.  H ,  aged  ten  years,  came  under  obser- 
vation November  10,  1896,  the  disease  having  existed 
for  four  months.  Two  operations,  both  of  them  ar- 
threctomies,  have  been  done ;  the  first  one  early  in  1898, 
and  the  second  one  in  the  fall  of  1898.  Plaster  of 
Paris  was  omitted  in  the  early  fall  of  1899,  and  the 
boy  has  been  walking  on  the  leg  ever  since.  The  knee 
is  slightly  flexed  in  this  case  also. 

I  wish  now  to  speak  of  two  cases  in  adult  life  in 
which  arthrectomy  was  entirely  sufficient.  There  are 
a  number  of  these  cases,  but  two  will  be  sufficient,  and 
they  are  interesting  as  well  as  the  cases  of  the  chil- 
dren, showing  that  the  disease  in  many  cases  must  be- 
gin in  the  synovial  membranes  and  not  in  the  epiphy- 
sis. 

Case  IV. — M.  M- ,  aged  twenty-four  years,  came 

under  observation  November  3,  1897.  His  knee  had 
been  troublesome  for  over  a  year  on  account  of  pain, 
and  at  times  the  joint  would  become  "  locked."  In 
March,  1897,  a  piece  of  floating  cartilage  had  been 
removed,  and  in  the  latter  part  of  October  the  joint 
had  been  aspirated.  As  the  joint  looked  bad  an 
arthrectomy  was  done  November  8,  1897,  and  a  large 
quantity  of  sero-purulent  fluid  was  found  in  addition 
to  the  usual  gelatinous  condition.  The  bone  w'as 
only  superficially  involved,  and  hence  an  excision  was 
not  done.  The  joint  was  drained  and  continued  to 
discharge  a  small  quantity  of  serous  fluid  until  May, 
1898,  when  it  closed  and  was  apparently  perfectly 
solid.  The  man  works  at  present  in  a  coal -yard, 
shovelling,  and  says  he  has  had  no  trouble  since  leav- 
ing the  hospital  three  years  ago. 


296 


MEDICAL    RECORD. 


[August  25,  1900 


Case  V. — O.    T ,    a  man    twenty-one   years  of 

age,  came  under  observation  February  19,  1900,  with 
the  history  of  a  tuberculous  knee  of  four  years'  dura- 
tion. He  had  been  walking  about  on  it  all  this  time, 
but  it  had  become  so  painful  that  he  had  to  give  up 
and  go  to  bed.  On  March  5,  1900,  the  joint  was 
opened,  the  tuberculous  material  all  cleaned  out,  and 
the  bone  found  perfectly  healthy ;  consequently  only 
an  arthrectomy  was  done.  The  wound  was  closed 
practically  without  drainage.  There  was  no  trouble 
whatever  with  healing,  and  the  patient  was  discharged 
on  .April  14th,  with  a  perfectly  solid  joint.  Plaster 
will  be  continued  for  a  short  while,  when  the  leg 
should  be  all  right  without  any  further  treatment. 


A  FURTHER  REPORT  UPON  THE  USE  OF 
PURE  CARBOLIC  ACID  IN  THE  TREAT- 
MENT OF  MASTOID  WOUNDS  AND 
CHRONIC  SUPPURATION  OF  THE  MID- 
DLE   EAR.' 

By  WENDELL   C.   PHILLIPS,    M.U., 

SURGEON  TO  THE  MANHATTAN  EYE  AND  EAR  HOSPITAL,  AURAL  DEPARTMENT  ; 
PROFESSOR  OF  DISEASES  OF  THE  EAR  IN  THE  NEW  VOKK  POST-GRADUATE 
MEDICAL    SCHOOL   AND    HOSPITAL. 

At  the  fifth  annual  meeting  of  this  society  I  called 
your  attention  to  the  use  of  pure  carbolic  acid  in  mas- 
toid wounds  and  in  chronic  suppurations  of  the  mid- 
dle ear.  The  paper"  gave  a  short  resume  of  Powell's 
article  on  "  Carbolic  Acid  in  Surgery,'"  wherein  he 
had  demonstrated  that  a  ninety-five-per-cent.  solution 
of  the  crystals  of  carbolic  acid  could  be  rubbed  freely 
on  the  hands  and  allowed  to  remain  for  a  few  seconds 
with  no  unpleasant  effects,  providing  the  hands  were 
rinsed  with  pure  alcohol ;  in  other  words,  he  had  shown 
that  alcohol  is  a  perfect  antidote  for  carbolic  acid. 

At  the  time  the  previous  paper  was  presented,  I  had 
made  use  of  this  drug  for  three  months  only  in  the 
treatment  of  mastoid  wounds  and  chronic  suppurative 
otitis  media  in  which  necrosis  existed,  and  in  the 
sinuses  so  often  found  in  mastoid  wounds  which  are 
so  difficult  to  heal;  I  also  presented  a  convenient  ato- 
mizer for  spraying  the  acid  when  it  was  required  in 
attic  cases. 

Several  of  the  cases  presented  at  that  time  had  re- 
sisted all  methods  of  treatment,  but  with  the  use  of 
carbolic  acid  healing  rapidly  took  place.  From  the 
number  of  cases  in  which  it  bad  been  used,  six  were 
reported,  in  all  of  which  the  patients  have  remained 
well  up  to  the  present  date.  During  the  past  year  I 
have  continued  the  use  of  carbolic  acid  both  in  private 
and  hospital  practice,  and  am  able  to  give  a  fuller 
report  as  to  its  benefits.  My  cases  have  been  about 
the  same  as  those  reported  before,  excepting  that  I 
have  used  it  upon  the  denuded  surfaces  after  ossicu- 
lectomies and  also  in  burrowing  pus  sacs  accompany- 
ing mastoid  suppurations.  Some  of  these  pus  sacs 
extended  well  down  into  the  sterno-cleido-mastoid 
muscle,  and  others  had  burrowed  downward  and  back- 
ward upon  the  external  surface  of  the  cranium.  I 
have  used  it  freely  in  these  latter  cases,  and  cannot 
say  too  much  as  to  the  favorable  results  obtained. 
After  emptying  the  pus  cavities  freely  I  used  the 
carbolic  acid  with  considerable  freedom,  making  use 
of  a  cotton  carrier  and  leaving  the  cotton  rather  loose 
at  the  point.  I  swab  out  these  cavities  with  the  acid. 
One  improvement  in  its  use  in  this  connection  seems 
to  have  been  obtained  from  leaving  the  acid  a  longer 
time  in  contact  with  the  tissues  before  using  the  alco- 
hol.    I  often  leave  the  carbolic  acid  for  from  thirty 

'  Read  before  the  American  Laryngological,  Khinological,  and 
Otological  Society  at  its  sixth  annual  meeting. 

'  I'nblished  in  the  Mriucai.  Record,    Septembers,  1899. 
^Mkdicai.  Record,  March  11.  1899. 


to  sixty  seconds  before  resorting  to  the  alcohol.  This 
seems  to  me  to  be  the  more  rational  method,  giving 
the  carbolic  acid  more  time  to  produce  its  effect  upon 
the  necrosed  tissues  with  which  it  comes  in  contact. 

In  the  pus  sacs  in  which  I  have  used  the  carbolic 
acid,  I  have  not  in  any  single  instance  been  obliged 
to  make  any  operation  for  secondary  abscesses.  At 
this  moment  I  can  recall  four  ossiculectomies  in 
which  I  have  made  use  of  carbolic  acid  to  destroy  any 
resultant  necrosis.  I  might  state  here  that  I  never 
perform  ossiculectomy  except  in  those  chronic  suppura- 
tions which  have  resisted  all  forms  of  local  medication 
for  a  reasonable  period  of  time. 

In  all  these  cases  I  believe  pure  carbolic  acid  has 
had  a  beneficial  effect,  although  I  am  fully  aware  that 
many  of  these  patients  recover  as  a  result  of  the  removal 
of  the  ossicles  alone;  at  least  I  have  seen  no  ill  effects 
from  its  use  in  this  class  of  cases,  and  I  have  come 
to  believe  that  there  is  a  more  rapid  healing  when 
carbolic  acid  is  employed.  I  might  further  add  that 
in  no  instance  has  the  use  of  carbolic  acid  in  the  cases 
above  described  been  followed  by  any  unfavorable 
reaction  or  any  untoward  symptoms,  so  that  if  applied 
even  with  considerable  freedom  one  need  have  no  fear 
of  doing  harm,  of  course  bearing  in  mind  the  fact 
that  the  acid  is  thoroughly  destroyed  by  the  subsequent 
free  application  of  alcohol. 

I  have  the  following  note  from  Dr.  Parker,  house 
surgeon  to  the  Manhattan  Eye  and  Ear  Hospital, 
giving  in  a  few  words  the  result  of  his  experience 
with  the  acid.  Dr.  Parker  gives  his  experience  in 
effect  as  follows:  He  has  used  pure  carbolic  acid, 
followed  by  alcohol,  for  the  past  six  months  in  about 
twenty  cases  that  have  been  operated  on  for  mas- 
toiditis, and  has  observed  that  the  discharge  has  been 
markedly  lessened  by  its  use  in  cases  in  which  other 
cauterizing  agents  had  failed.  To  quote  his  words: 
"  Under  its  use.  areas  of  necrosed  bone  have  taken 
on  a  healthy  healing-process,  sluggish  granulations 
have  been  stimulated  to  healthy  activity,  and  in  many 
cases  secondary  operations  have  been  avoided.  It  has 
been  particularly  valuable  when  used  by  means  of  the 
spray;  in  discharge  of  the*middle  ear,  many  cases  of 
persistent  discharge  have  been  entirely  stopped." 


Experiments  on  the  Resistant  Powers  of  the 
Plague  Bacillus  to  Cold.— H.  Noguchi,  of  the  Gen- 
eral Hospital  in  New-Chwang,  China,  has  found  that 
the  plague  bacillus  is  not  devitalized  by  a  three 
weeks'  exposure  to  a  temperature  of  24°  C.  below  zero. 
This  bacillus  can  develop  slowly  but  steadily,  at 
a  temperature  of  from  20^  C.  to  37°  C.  Near  the 
freezing-point  it  remains  inert.  Chinese  houses,  with 
their  bad  ventilation  and  other  unhygienic  conditions, 
furnish  favorable  conditions  for  the  development  of 
the  plague  bacillus.  Mice  and  some  other  animals 
(excepting  birds  and  swine,  which  are  immune)  help 
to  propagate  the  plague.  It  is  difficult  to  enforce 
sanitary  measures  in  China,  where  legislation  and  po- 
lice protection  give  no  assistance,  and  the  author 
thinks  it  safer  for  foreigners  to  isolate  themselves 
than  to  try  to  isolate  the  Chinese.  Their  houses 
should  be  under  strict  sanitary  inspection,  and  a  public 
market  should  be  started  for  their  provisions  ap.yt 
from  the  town. —  T/ic  Sei-i-Kic>ai Mtiliialjounial,  Tokio, 
May  31,  1900. 

The  Occurrence  of  a  P«culiarly  Altered  Blood 
Pigment  in  the  Urine  of  Paroxysmal  Hemoglobi- 
nuria.— Jolles  relates  the  case  of  a  patient  who  for 
eight  years  has  suffered  from  occasional  attacks  of 
ha-moglobinuria.  These  never  occur  in  summer,  but 
only    in    cold  weather,  when   they  are   ushered   in   by 


August  25,  1900] 


MEDICAL    RECORD. 


297 


painful,  chilly  sensations  in  the  extremities  and  a  sense 
of  oppression,  which  symptoms  are  speedily  followed 
by  the  characteristic  discoloration  of  the  urine.  In  ex- 
amining this  the  author  found  a  body  which  does  not 
give  the  spectroscopic  field  typical  of  any  of  the  blood 
pigments  hitherto  studied,  and  which  on  boiling 
coagulates  without  undergoing  decomposition  and 
yields  crystals  of  hajmin.  It  is  also  precipitated  un- 
changed by  ethyl  alcohol,  amyl  alcohol,  and  ether, 
w'hile  acetic  and  hydrochloric  acids  act  by  splitting  it 
into  two  components,  one  of  which,  a  peptone-like  sub- 
stance, goes  into  solution,  while  the  other,  containing 
iron  and  phosphorus,  is  thrown  down  and  does  not 
yield  the  Teichmann's  ha:min  crystals. —  Wiener  k!i- 
uische  Rundschau,  July  8,  1900. 

A  Channel  of  Infection  in  Man — Aron  endeavors 
to  explain  the  variations  in  indi\idual  susceptibility 
to  infection  by  the  zymotic  diseases  by  giving  the  ton- 
sils an  important  role  as  portals  of  entry  for  the  con- 
tagium.  Accepting  this  view  it  is  easy  to  believe  that 
greater  or  less  resisting-power  to  invasion  by  disease 
goes  more  or  less  hand-in-hand  with  differences  in  the 
structure  and  conformation  of  those  organs.  It  is  par- 
ticularly the  tonsillar  crypts  that  furnish  suitable  lurk- 
ing-places for  bacteria  of  all  sorts,  and  it  is  well 
known  that  in  some  persons  these  are  abnormally  num- 
erous and  deeply  placed.  It  seems  well  proven  that 
from  this  point  infectious  material  can  find  its  way 
directly  into  the  blood  stream  without  first  having  had 
to  pass  through  the  successive  filter-beds  existing  in  the 
shape  of  the  numerous  cervical  lymph  nodes. —  Wiener 
klinische  Rundschau,  July  8,  1900. 

Diagnosis  of  Tuberculosis  in  Chronic  Aural  Sup- 
purations.— G.  Ferreri  lays  down  the  following  propo- 
sitions: (i)  It  is  necessary  from  a  diagnostic  as  well 
as  a  therapeutic  point  of  view  to  determine  the  true 
nature  of  a  chronic  suppuration  of  the  ear  when  there 
is  a  suspicion  of  tuberculosis.  (2)  As  a  careful  and 
exact  means  of  establishing  the  existence  of  an  os- 
seous caries  an  opinion  from  a  dermatologist  may  be  of 
the  greatest  value.  (3)  As  the  presence  of  caries  is 
not  absolute  testimony  in  favor  of  the  existence  of  a 
specific  tuberculous  lesion,  we  ought  to  call  in  to  our 
aid  all  other  possible  means  of  research.  (4)  In  the 
present  uncertainty  of  our  knowledge  the  best  course 
to  follow  is  to  make  ihe  tuberculin  test,  and  to  remove 
for  microscopic  examination  the  pre-mastoid  lymphatic 
ganglion. — Archivio  Italiano  di  Otologia,  etc.,  July  7, 
1900. 

Clinical  Forms  of  Purulent  Rhinitis ;  their  Pa- 
thology and  Treatment. — C.  de  Rossi  says  that  the 
essential  principle  of  treatment  is  comprehended  in 
the  words  ''  non  nocere."  The  mucosa  invaded  by  pus 
germs  is  easily  vulnerable.  If  one  touches  the  mucosa 
too  roughly,  it  bleeds  easily,  and  if  the  young  epithelia 
which  are  forming  are  detached,  a  new  channel  is 
opened  for  the  micro-organisms;  moreover  hemor- 
rhage, however  slight,  interferes  with  the  exact  and 
efficient  application  of  topical  agents.  The  circum- 
scribed forms  of  purulent  rhinitis,  which  lead  to  ulcer- 
ations, perichondritis,  septal  abscess,  carious  or  necro- 
tic osteitis,  etc.,  require  surgical  treatment.  Ordinarily 
the  removal  of  necrotic  portions  and  the  application 
of  the  electro-cautery  are  sufficient  to  effect  this. — Ar- 
chivio Italiano  di  Olo/ogia,  etc.,  Jul)'  7,  1900. 

Ulcerations  of  the  Tonsils.— Brindel  and  Raoult 
divide  these  into  primarj'  (such  as  ulcerative  lacunar 
tonsillitis,  pseudo-diphtheritic,  gangrenous,  ulcero- 
membranous, etc.),  secondary  (infectious  maladies  as 
diplitheria,  typhoid,  the  exanthemata,  and  tuberculo- 
sis), symptomatic  (as  those  of  lupus,  syphilis,  and  scrof- 
ula), and  ulcerations  of  malignant  tumors.     The  term 


ulceration  denotes  a  loss  of  substance  at  least  of  the  epi- 
thelium, and  more  often  of  the  basement  membrane 
and  underlying  tissue.  Ulcerations  should  be  distin- 
guished from  mere  erosions.  The  particular  class  to 
which  a  given  case  belongs  requires  a  consideration 
of  the  entire  history  of  the  case  and  a  careful  watch- 
ing of  the  progress  of  the  lesion  in  its  different  stages. 
—  Re'ue  Hehdomadaire  de  Laryngohgie,  etc.,  June  23, 
1900. 

The  Etiology  of  Malignant  Tumors.— Ziem  re- 
ports a  series  of  cases  of  malignant  tumors  of  the 
upper  air  tract,  all  having  the  common  features  of 
traumatism  and  the  antecedent  existence  of  a  puru- 
lent discharge.  He  believes  that  this  combination  of 
factors  is  the  frequent  cause  of  the  development  of 
malignant  growths  in  the  upper  air  passages  at  least. 
The  likelihood  of  their  development  is  still  further  in- 
creased if  with  the  existence  of  the  discharge  there  is 
an  infectious  complication,  such  as  syphilis,  erysipe- 
las, inHuenza,  typhoid,  and  possibly  also  malaria. — 
Revue  Hehdomadaire  de  Laryngologie,  etc..  May  9,  igoo. 

Septic  Pyohaemic  Otitis. — G.  Laurens  lays  down 
the  following  rules  for  guidance  in  treatment:  Given 
a  pyaemia  in  the  course  of  an  acute  otitis  without  any 
localization  in  the  mastoid,  and  without  grave  infec- 
tious symptoms,  we  should  puncture  the  drum  so  as  to 
provide  for  perfect  drainage  and  care  for  the  general 
condition;  if  mastoiditis  is  present,  the  apophysis 
must  be  opened  and  the  sinus  uncovered  preparatory 
to  examination;  finally,  if  tiie  pyaemia  runs  its  course 
without  involving  the  mastoid,  but  with  grave  symp- 
toms of  severe  general  infection,  we  must  open  the 
antrum,  and  if  it  is  healthy  we  should  proceed  as  in 
the  case  of  the  sinus;  if  the  exploring  needle  with- 
draws blood,  abstain  from  opening;  if  there  is  throm- 
bosis, incise  the  sinus  after  previous  ligation  of  the 
jugular. — Revue  Hehdomadaire  de  Larytigologie,  etc., 
July  7,  1900. 

The  Treatment  of  Burns. — G.  S.  Armstrong  thus 
summarizes  the  appropriate  treatment  for  burns,  he 
having  in  the  past  two  years  treated  one  hundred  and 
seventy-six  cases,  chiefly  of  the  second  degree,  one 
caused  by  boiling  oil,  and  all  the  others  by  flying 
metal.  Water  or  solutions  containing  water  are  bad; 
vaseline  acts  badly;  the  application  of  cotton  lint, 
gauze,  or  any  dressing  witli  a  rough  surface  is  inex- 
cusable. (1)  Cut  away  with  particular  care  every 
portion  of  every  bleb,  even  the  smallest.  See  that  no 
margin  is  left  under  which  burrowing  may  take  place. 
(2)  Apply  castor  oil  ninety-five  per  cent,  and  balsam 
of  Peru  five  per  cent.,  or  lanolin.  (3)  Cover  this 
with  gutta-percha  or  oiled  silk,  perforated  or  not.  (4) 
The  molecular  death  and  separation  of  tissues  will 
cause  an  accumulation  under  the  gutta-percha,  which 
must  be  removed  each  day  by  gentle  mopping  with  ab- 
sorbent cotton.  This  is  easily  done,  without  disturb- 
ing the  granulations  or  causing  bleeding.  (5)  A 
small  portion  of  cases  improve  more  readily  during  the 
later  stages  under  dry  boric  acid. — Medical  Sentinel, 
July,  1900. 

Acute  Mastoiditis  Following  Infectious  Diseases. 
— J.  W.  Murphy  says  that  about  twenty  per  cent,  of  the 
children  suffering  from  an  infectious  disease  have,  at 
some  time  during  the  course  of  the  disease,  an  infec- 
tion of  the  mucous  membrane  lining  the  tympanum 
and  mastoid  antrum.  If  toward  the  close  of  an  attack 
of  one  of  the  infectious  diseases  there  is  a  sudden  rise 
of  temperature,  with  restlessness,  especially  marked 
at  night,  it  indicates  some  new  focus  of  infection. 
The  drum  membrane  may  be  found  inflamed,  and 
pain  on  pressure  over  the  mastoid,  or  swelling  in  that 
region,  will  point  to  involvement  of   the  middle  ear. 


298 


MEDICAL    RECORD. 


[August  25,  1900 


One  of  the  most  reliable  symptoms  of  involvement  of 
the  pneumatic  spaces  of  the  mastoid  is  swelling  or 
bogginess  of  the  posterior  superior  wall  of  the  exter- 
nal auditory  canal,  near  its  junction  w-ith  Schrapnell's 
membrane.  If  after  the  continuous  action  of  heat  or 
cold  (not  poultices)  for  thirty-six  hours  there  are  still 
much  pain  and  tenderness  over  the  mastoid,  we  should 
not  wait  longer,  but  open  up  the  mastoid  cells  by 
means  of  Schwartze's  mastoid  operation — opening  the 
antrum  and  pneumatic  spaces  of  the  mastoid. —  Colum- 
bus Medical  Journal,  July,  igoo. 

Experimental  Researches  on  the  Latero-Iateral 
Anastomoses  of  the  Vas  Deferens. — Enrico  Trocello 
has  conducted  experiments  with  a  view  of  determining 
the  best  treatment  for  establishing  the  continuity  and 
permeability  of  the  vas  deferens  in  cases  of  com- 
plete transverse  wounds  of  the  duct.  He  finds  that 
the  indications  are  met  by  means  of  a  latero-lateral 
anastomosis  of  the  two  stumps  and  closure  of  the  end 
of  the  duct.  He  describes  the  methods  adopted,  and 
claims  that  the  results  are  excellent. — /I  Folitliiiito, 
June  15,  1900. 

The  Treatment  of  Movable  Kidney. — D.  Biondi 
in  eleven  cases  of  nephrorrhaphy  has  made  an  incision 
in  Petit's  triangle  between  the  posterior  margin  of  the 
oblique  and  latissimus  dorsi  muscles.  In  this  situa- 
tion all  that  is  needed  is  to  cut  down  on  the  anterior 
margin  of  the  quadratus  lumborum  through  the  anterior 
and  posterior  folds  of  the  aponeurosis  of  the  transver- 
salis,  to  reach  the  adipose  capsule  of  the  kidney.  He 
then  removes  the  adipose  and  fibrous  capsule,  corrects 
any  antefiexion  of  the  kidney,  and  puts  it  in  place, 
where  he  keeps  it  by  tampons  of  gauze,  which  are 
stuffed  into  the  space  below  the  kidney.  When  the 
gauze  is  withdrawn  six  to  eight  days  later,  the  kidney 
is  found  to  be  firmly  fixed  in  place.  The  operation  is 
innocuous  and  efficacious. —  La  Riforma  Alcdica,  July 
10,  1900. 

Non-Tabetic  Lesions  of  the  Posterior  Columns  of 
the  Spinal  Cord.  —  E.  A.  Home'n  divides  these  affec- 
tions into  three  groups:  (i)  Those  caused  directly  by 
neuritis,  due  either  to  purely  anatomical  nerve  lesions, 
or  to  noxious  agents  such  as  toxins  or  microbes;  (2) 
those  co-ordinated  to  neuritis,  that  is  to  say,  those  in 
which  the  same  noxious  agent  can  affect  the  intrame- 
dullary tract,  as  well  as  the  peripheral  portions,  or  else 
both  at  once;  (3)  those  entirely  independent  of  neurons 
or  of  fibres,  but  in  close  relation  to  the  blood-vessels. 
In  chronic  alcoholism  there  may  be  affection  of  exo- 
genous sensory  fibres  of  Goll's  column,  with  peripheral 
neuritis.  In  eleven  cases  of  cancer  there  was  rarely 
alteration  of  the  posterior  extra-medullary  roots,  but 
there  was  of  the  intra-medullary.  In  grave  anaemia  the 
lesions  are  most  pronounced  in  the  posterior  columns; 
in  senile  marasmus  there  is  thickening  of  the  neuro- 
glia, with  corresponding  atrophy  of  the  nerve  fibres, 
principally  in  the  posterior  columns  and  around  blood- 
vessels. Myelitic  lesions  in  acute  infections  and 
purely  syphilitic  lesions  of  the  spine  show  no  special 
predilection  for  the  posterior  columns  of  the  cord. — 
lunska  Liikaresallskapcts  Haiidlhigar,  June,  1900. 

An    Unusual  Case  of    Prolonged  Intubation — \). 

Tanturri  describes  a  case  in  which  intubation  was  |mo- 
longed  to  one  hundred  and  thirty-six  days.  In  his 
conclusions  he  states  that  a  possible  complication  of 
croup  may  be  a  peri-tracheal-laryngeal  abscess,  fol- 
lowed perhaps  by  partial  necrosis  of  the  cricoid.  In 
acute  laryngeal  stenosis  of  long  duration  intubation  is 
a  valuable  resource.  The  tube  may  be  left  for  a  long 
time  in  the  larynx  without  harm,  provided  that  it  is  of 
the  proper  size  and  material  and  that  the  surgeon  bear 
in  mind  the  delicacy  of  the  structures  upon  which  he 


is  working.  O'Dwyer's  fenestrated  tube  is  of  the 
greatest  value  in  granulations  of  the  cricoid.  Ichlhyol 
with  gelatin  is  an  excellent  medicament  for  the  larynx 
in  cases  of  intubation.  Meat  gelatin  is  a  good  food 
in  these  cases. —  Gioniale  Jntcrnazionale  delle  Scknze 
Alcdiche,  June  30,  1900. 

The  Effect  of  Fatigue  in  Modifying  the  Minute 
Structure  of  Kidneys  and  Liver.— Guido  Guerini 
by  experimentation  upon  animals  has  found  that  as  an 
effect  of  great  exertion  the  protoplasm  of  many  cells  of 
the  convoluted  tubules  become  homogeneous  and  gran- 
ular. The  cells  increase  in  size.  Still  greater  fatigue 
causes  them  to  break  down  and  fill  the  lumen  with  a 
fine  detritus.  The  changes  in  the  liver  cells  are  very 
similar,  consisting  in  the  first  place  of  turbidity  and 
increase  in  size  of  the  cell  contents,  and  under  greater 
stress  of  rarefaction  and  sponginess.  The  cells  con- 
tain much  bile  pigment.  —  La  Rijorma  Aledica,  July  9, 
igoo. 

Gout  as  a  Function-Failure. — S.  W.  Macllwaine 
enters  a  protest  against  the  narrow  view  so  frequently 
expressed  that  gout  finds  its  essential  expression  in 
joint  disturbance.  We  should  rather  take  a  broader 
view  and  look  upon  it  as  a  failure  of  the  metabolic 
functions  under  conditions  that  produce  no  such  un- 
toward results  in  the  majority  of  people.  The  essence 
of  the  disease  is  the  production  of  imperfectly  soluble 
waste  products  difficult  of  elimination.  The  cause  of 
gout  is  therefore  function  failure.  It  is  intrinsic  in 
origin,  and  treatment  must  be  directed  to  the  individual, 
to  the  re-establishment  of  his  deranged  functions. 
Roughly  speaking,  the  bulk  of  the  metabolism  occurs 
in  the  muscles;  further,  the  commencing  channels  of 
excretion  are  emptied  by  vigorous  muscular  contrac- 
tion. Exercise  flushes  the  joints  with  their  viscid  and 
sluggish  fluids.  Experience  teaches  us  that  a  man  on 
a  rational  diet,  and  in  the  enjoyment  of  exercise 
necessitating  the  daily  vigorous  use  of  all  his  muscles, 
does  not  suffer  from  gout. — Mtdical Press a/id Cncular, 
July  18,  1900. 

The  Pathology  and  Etiology  of  Acute  Articular 
Rheumatism. — J.  C.  Young  discusses  this  question 
from  the  standpoint  of  the  elf  ect  of  the  disease  as  bear- 
ing on  the  question  of  life  insurance.  His  inferences 
are  as  follows:  (i)  If  the  disease  has  occurred  in  the 
ancestor  and  not  in  the  applicant  it  need  not  be  con- 
sidered, for  heredity  can  be  traced  only  in  about  thirty 
per  cent,  of  the  cases  anyhow;  and  if  a  parent  has  had 
rheumatism,  it  by  no  means  follows  that  his  child  must 
suffer  from  it.  On  the  other  hand,  if  such  an  applicant 
has  himself  had  an  attack  already,  the  probability  of 
recurrence  is  thereby  greatly  enhanced.  (2)  As  a  rule, 
the  earlier  the  age  at  which  a  primary  attack  occurs, 
the  greater  the  likelihood  of  repeated  attacks,  the 
greater  their  severity,  and  the  greater  the  probability 
of  cardiac  complications.  The  later  the  age,  the  less 
the  danger  to  be  apprehended  from  the  consequences 
which  the  disease  engenders.  (3)  Occupations  call- 
ing for  great  muscular  exertion,  with  consequent 
fatigue  and  free  perspiration,  and  particularly  when 
tlie  applicant  is  exposed  to  sudden  chilling,  produce 
more  than  half  the  cases,  and  if  he  has  already  had  an 
attack,  persistence  in  such  occupation  greatly  increases 
the  risk.  {4)  Conditions  of  living  which  favor  a  low- 
ering of  tone  of  tile  nervous  system,  or  produce  a  uric- 
acid  diathesis,  or  serve  to  enfeeble  the  muscular 
system,  increase  the  susceptibility  of  the  individual 
and  augment  the  chances  of  recurrencce.  So,  too, 
with  diseases  which  lower  bodily  resistance.  (5)  A 
combination  of  two  or  more  of  these  elements  just  so 
far  increases  the  probability  of  recurrence  and  impairs 
a  risk  in  the  same  proportion. — Mcdiial  Examiner  and 
J'raililioncr,  July,  1900. 


August  25.    ICjOOj 


MEDICAL   RECORD. 


299 


Medical   Record: 

A    Weekly  Journal  of  Medicine  and  Surgery. 


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


PUBLISHERS 


WM     WOOD  &  CO     51    Fifth  Avenue. 


THE 


New  York,  August  25,  1900. 


PROGNOSIS     OF     GLYCOSURIA     AND 
DIABETES. 


The  interpretation  applied  to  the  presence  of  sugar  in 
the  urine  depends  essentially  upon  whether  it  is  to  be 
looked  upon  as  a  simple  glycosuria  or  as  a  syinpiom  of 
diabetes.  On  the  one  hand,  a  transitory  failure  on  the 
part  of  the  sugar-assimilative  functions  of  the  organ- 
ism may  be  concluded  to  exist,  while,  on  the  other,  the 
manifestation  is  to  be  looked  upon  as  a  symptom  of 
an  incurable  disease.  The  prognosis  must  necessa- 
rily vary  in  accordance  with  the  pathology  of  the  mor- 
bid process  in  operation.  On  the  basis  of  a  considera- 
ble personal  experience,  Hirschfeld  {Berliner  klinischc 
Woehenschrijt,  1900,  Nos.  25  and  26)  expresses  dissent 
from  the  prevailing  view  with  regard  to  the  curability 
of  diabetes.  Improvement,  he  maintains,  is  frequently 
observed,  even  in  severe  cases  of  diabetes,  and  it  may 
at  times  reach  a  degree  sufficient  to  transform  a  severe 
into  a  mild  case. 

From  observations  in  some  two  hundred  and  fifty 
cases  of  diabetes,  Hirschfeld  was  impressed  with  the 
variability  of  the  glycosuria,  improvement  taking  place 
far  more  commonly  than  aggravation.  This  was  es- 
pecially marked  in  mild  cases  and  less  so  in  severe. 
In  analyzing  the  cases  an  attempt  was  made  to  deter- 
mine in  how  far  prognostic  conclusions  could  be 
reached  from  the  severity  of  the  functional  disturbance 
in  the  individual  case.  Associated  conditions,  such 
as  the  presence  of  nervous  symptoms  or  complications, 
afford  no  indication  of  the  severity  of  the  diabetes. 
Only  from  the  degree  of  the  glycosuria  itself  does  the 
prognosis  as  to  the  severity  of  the  diabetes  seem  pos 
sible.  In  this  connection  the  question  arises,  When 
can  such  a  degree  of  improvement  be  hoped  for  that 
the  urine  will  remain  permanently  free  from  sugar? 
The  improvement  that  follows  the  withdrawal  of  car 
bohydrates  sets  in  only  in  the  course  of  a  few  months, 
although  the  assimilative  power  is  increased  immedi 
ately  afterward.  Improvement,  further,  is  less  com- 
monly to  be  expected  if  the  disease  is  of  long  stand- 
ing, and  it  may  be  assumed  that  under  such  conditions 
the  curative  effects  of  antidiabetic  diet  are  to  a  certain 
degree  exhausted.  Nevertheless,  transitory  improve- 
ment in  assimilative  power  may  be  brought  about  by 
temporary  rigid  restriction  of  the  diet  and  active 
muscular  exercise.  In  general,  it  may  be  said  that  if 
in  a  case  of  long  standing  such  conditions  cannot  be 


established,  in  spite  of  restriction  of  carbohydrates, 
permanent  improvement  cannot  be  hoped  for.  Exac- 
erbations are  due  principally  to  overloading  the  or- 
ganism with  an  excess  of  carbohydrates.  Such  exacer- 
bations develop  slowly,  i.e.,  in  the  course  of  months 
or  even  of  years,  in  contradistinction  from  changes  due 
to  extraneous  circumstances.  At  times,  it  is  true,  the 
disease  increases  in  severity  without  external  cause. 
Such  conditions  are  present  principally  in  young  pa- 
tients, and  rarely  after  the  thirtieth  year. 

In  addition  to  glycosuria,  there  may  be  an  increased 
elimination  of  acetone.  In  severe  cases  there  is  an 
increased  amount  of  acid  present  in  the  urine.  It  is  a 
debatable'  question  whether  diabetic  coma  is  to  be 
looked  upon  as  an  acid  intoxication.  In  mild  cases 
the  elimination  of  acetone  is  but  little,  if  at  all,  in 
creased.  If  the  amount  is  large,  diacetic  acid  also  is 
usually  demonstrable  by  the  ferric-chloride  reaction. 
Progressive  increase  in  acetonuria  is  of  unfavorable 
prognostic  significance.  The  patient  may  feci  well, 
but  coma  is  readily  induced,  as,  for  instance,  by  physi- 
cal effort  or  inanition.  It  is  of  general  prognostic  im- 
portance that  acetonuria,  in  contrast  with  glycosuria, 
more  frequently  exhibits  a  tendency  to  spontaneous 
increase.  In  some  cases,  it  is  true,  the  exacerba- 
tions are  also  induced  by  unfavorable  external  condi- 
tions and  by  disease  states  that  exert  an  unfavorable 
influence  upon  the  glycosuria.  A  third  metabolic  dis- 
turbance is  to  be  taken  into  consideration,  viz.,  defi- 
cient absorption  of  the  food.  This  of  itself  renders 
the  prognosis  unfavorable,  as  with  imperfect  utiliza- 
tion of  proteids  and  fats  maintenance  of  the  bodily 
weight  is  difficult. 

Among  extraneous  conditions  capable  of  increasing 
glycosuria,  intercurrent  disease  especially  is  worthy  of 
mention.  Exhausting  disease  at  times,  though  not 
always,  to  a  certain  degree  displaces  the  glycosuria. 
Disease  of  the  kidneys,  especially,  exerts  such  an  in- 
fluence. On  the  other  hand,  the  opposite  effect  also 
is  sometimes  observed.  The  hyponutrition  attending 
most  diseases  causes  diminution  in  the  glycosuria  in 
a  large  majority  of  cases  of  diabetes.  In  Hirschfeld's 
experience,  however,  the  majority  of  febrile  diseases 
were  without  any  influence  on  the  glycosuria.  To 
this  rule  influenza  constitutes  an  exception  in  many 
cases,  often  causing  increase  in  the  glycosuria  and 
coma.  Painful  attacks  of  colic,  with  transitory  diar- 
rhoea or  constipation,  may  make  their  appearance 
early  in  cases  subsequently  attended  with  deficient 
absorption.  A  directly  deleterious  effect  is  exerted 
also  by  those  disorders  considered  peculiar  to  diabetes, 
viz.,  furuncle,  carbuncle,  gangrene.  In  some  cases, 
however,  the  excretion  of  sugar  is  slight.  Psychic  in- 
fluences, particularly  severe  fright,  have  a  bad  effect 
on  diabetes,  as  have  also  painful  affections,  biliary 
calculi,  renal  calculi,  hypochondriacal  delusions. 

Cardiac  enfeeblement  may  be  a  manifestation  of 
diabetes,  and  it  will  under  such  circumstances  be  re- 
lieved by  antidiabetic  diet.  An  appearance  of  well- 
preserved  nutrition  is,  as  a  rule,  an  indication  that  the 
disease  is  not  progressing;  but  to  this  there  are  numer- 
ous exceptions.  Increase  in  polyuria  is  sometimes 
indicative  of  aggravation   of   diabetic   functional  dis- 


300 


MEDICAL    RECORD. 


[August  25,  1900 


turbance.  In  Hirschfeld's  opinion,  alcoholism  or 
alcoholic  intoxication  can  scarcely  be  considered  a 
factor  in  the  etiology  of  diabetes.  He  holds  that  the 
essential  point  to  be  borne  in  mind  is  that  in  cases  of 
diabetes  glycosuria  is  a  most  variable  symptom,  with 
a  tendency,  especially  in  recent  cases,  to  undergo 
spontaneous  improvement,  unless  the  organism  be 
overwhelmed  with  carbohydrates.  As  to  the  recogni- 
tion of  alimentary  glycosuria  as  a  distinct  affection,  its 
brief  duration,  and  the  lower  percentage  of  sugar,  as 
well  as  the  absence  of  characteristic  symptoms,  such 
as  polyuria  and  nervous  manifestations,  can  no  longer 
be  considered  as  decisive,  while  the  evidence  goes  to 
show  that  its  clinical  course  is  identical  with  that  of 
diabetes.  Finally,  Hirschfeld  prefers  to  speak  of  rel- 
ative, rather  than  absolute,  recovery  or  cure,  and  this 
he  considers  accomplished  if  the  patient  can  tolerate 
constantly  200  gm.  of  carbohydrates  daily  without  the 
appearance  of  sugar  in  the  urine.  ' 


CLIMATE   AND    DISEASES    OF    CHINA. 

If  the  war  now  being  waged  by  the  civilized  world 
against  China  should  be  a  lengthy  one,  it  will  be  in- 
cumbent upon  the  governments  of  the  several  powers 
engaged  to  pay  particular  attention  to  the  numbers, 
composition,  and  equipment  of  the  medical  and  nurs- 
ing staff.  By  neglect  of  this  most  necessary  branch 
of  the  military  service  serious  results  are  certain  to 
follow.  This  has  been  recently  evidenced  in  a  con- 
clusive manner  among  the  British  troops  in  South 
Africa. 

The  climate  of  China  is,  according  to  trustworthy 
accounts,  and  especially  in  those  portions  in  which 
American  soldiers  will  be  called  upon  to  operate,  de- 
cidedly insalubrious  to  men  of  the  white  race.  In  the 
region  in  which  are  situated  Peking,  Tien-Tsin,  and 
Chefoo,  the  heat  in  the  summer  season  is  tropical, 
while  during  three  winter  months  the  thermometer 
goes  down  as  low  as  15  degrees  Centigrade  below 
zero.  These  extremes  of  temperature  are  character- 
istic of  this  part  of  the  Middle  Kingdom  and  pecul- 
iarly so  of  Peking,  and  consequently  very  trying  to 
those  not  acclimatized.  Rain  never  falls  in  winter, 
and  snow  but  on  rare  occasions.  As  a  matter  of  fact 
the  rainfall  in  and  about  Peking  is  slight.  The  great- 
est extremes  of  climate  are  exhibited  in  Shan-Si  and 
portions  of  Shan-Tung.  The  rivers  and  streams  in 
these  districts  are  deeply  frozen,  as  is  the  Gulf  of  Pechi- 
11  along  the  coast  line  to  eight  or  ten  miles  from  shore. 
The  change  from  heat  to  cold  and  vice  versa  is  ex- 
tremely sudden,  and  is  therefore  certain  to  have  a  bad 
effect  upon  the  health  of  foreigners. 

The  New  York  Herald  of  August  12th  says,  in  an 
article  referring  to  the  diseases  of  Northern  China, 
"that  on  account  of  the  extreme  character  of  the 
climate,  the  diseases  follow  the  seasons  in  a  well- 
marked  order.  During  winter,  besides  the  direct 
results  of  the  action  of  cold,  such  as  acute  affections 
of  the  lungs  and  rheumatism,  typhoid  epidemics  are 
noted,  as  well  as  typhus  fever  and  diphtheria;  their 
development  is  due  evidently  to  the  confinement  to 


which  the  rigors  of  winter  condemn  the  population, 
which  is  shut  up  in  narrow  houses,  generally  in 
overheated  air,  where  the  disease-carrying  microbes 
find  favorable  conditions  for  development.  On  the 
other  hand,  when  the  temperature  becomes  milder,  the 
inhabitants  leave  their  houses  to  live  very  much  in  the 
open  air,  and  typhoid  disappears  almost  absolutely. 
Soon,  however,  under  the  inrluence  of  the  heavy  rain- 
falls of  the  months  of  July  and  August,  the  soil  of  the 
cities  impregnated  with  filth  exhales  miasma,  which 
gives  rise  to  poisoning,  manifested  under  form  of 
fevers,  sometimes  dangerous,  of  diarrhoea  and  dysen- 
tery." 

Smallpox  is  the  greatest  and  most  deadly  scourge  of 
China,  the  disease  alw-ays  being  present  to  a  greater  or 
less  extent.  This  fact  is  undoubtedly  due  to  the  dis- 
gustingly filthy  sanitary  conditions  in  which  the  vast 
majority  of  the  Chinese  people  live.  The  three  dis- 
eases, then,  with  which  an  invading  army  must  con- 
tend in  China  are  typhoid  fever,  dysentery,  and  small- 
pox. Every  care  should  and  doubtless  will  be  taken 
to  ward  off  and  effectually  to  fight  these  maladies.  It 
need  scarcely  be  said  that  one  of  the  most  important 
protective  measures  to  be  enforced  will  be  the  provid- 
ing of  efBcient  means  of  sterilizing  water.  Another 
point  only  second  in  importance  to  that  just  mentioned 
is  the  necessity  of.  revaccinating  the  soldiers  and  sail- 
ors whose  duties  will  call  them  to  the  far  East.  Chi- 
na has  not  agreed  to  the  Geneva  convention,  and  the 
Red  Cross  Society  is  not  represented  in  its  army. 
The  allied  forces  must  be  equipped  to  meet  any  con- 
tingency, as  the  w-ounded  who  may  fall  into  the  hands 
of  the  Chinese  will  not  receive  the  care  always  given 
them  among  civilized  nations.  The  disastrous  results 
from  an  inadequate  medical  and  nursing  staff  has 
lately  had  so  striking  an  object  lesson  in  the  South 
African  campaign  that  there  can  be  no  excuse  for 
pleading  ignorance  in  this  respect,  and  if  the  govern- 
ment of  the  United  States  does  not  profit  by  the  ex- 
eprience  so  dearly  bought  by  the  British,  the  reckoning 
at  the  hands  of  the  American  public  win  surely  be  a 
heavy  one. 


DR.  JACOBI    ON    MEDICAL   JOURNALISM. 

In  common,  doubtless,  with  many  of  those  who  have 
read  his  address,  we  can  but  regret  that  the  American 
orator  at  the  International  Medical  Congress  in  Paris 
should  have  chosen  as  his  theme  an  apoloi;ia  pro patria 
instead  of  selecting  some  scientific  subject  which  he 
is  so  well  fitted  to  handle.  Had  he  delivered,  as  he 
so  easily  could,  a  brilliant  address  embodying  the  te- 
sults  of  original  research  or  the  fruits  of  his  ripe  ex- 
perience, he  would  have  brought  much  more  honor  on 
the  country  of  his  adoption  than  he  has  by  this  timid 
presentation  of  her  claims.  But  it  is  not  in  criticism 
of  the  address  as  a  whole  that  we  would  write;  we 
desire  only  to  call  attention  to  an  insult  to  a  few 
hard-working  members  of  the  medical  profession  in 
America  and  a  few  business  men,  of  which  the  author 
of  the  address  was  guilty.  In  speaking  of  medical 
journalism.  Dr.  Jacobi  asserted  that  "the  policy  of  a 


August  25,  1900] 


MEDICAL   RECORD. 


;oi 


journal,  the  selection  of  the  advertisements,  sometimes 
even  the  admission  of  articles  more  or  less  scientific 
or  quackish,  is  to  a  greater  or  lesser  extent  in  the 
hands  of  the  publisher.-  It  takes  an  editor  of  unusual 
character  or  prudence  either  to  hold  his  place  or  to  be 
removed  unceremoniously.  But  the  publisher  gets 
rich;  that  is  what,  in  his  opinion,  medical  science,  art, 
and  quackery  are  made  for."  The  sentence  referring 
to  the  editor  is  obscure,  but  we  take  it  to  mean  that  the 
editor  must  always  do  as  the  publisher  tells  him  or 
be  dismissed.  If  that  is  what  the  speaker  intended  to 
say,  we  can  only  reply  that  of  our  personal  knowledge 
it  is  not  true.  As  to  the  publishers  of  medical  jour- 
nals, we  have  no  doubt  that  they  are  inspired  by  a 
desire  to  make  money,  but  we  believe  that  other  men, 
even  physicians  far  removed  from  the  corrupting  in- 
fluence of  publishers,  are  not  averse  to  accepting  a 
just  compensation  for  their  labor.  But  that  the  editor 
of  a  reputable  journal  was  ever  constrained  by  its  pub- 
lisher to  accept  an  article  which  the  editor  regarded  as 
unfit  we  do  not  believe.  That  the  publisher  has  con- 
trol of  the  admission  of  advertisements  is  true  enough, 
and  natural  and  proper  enough,  but  a  comparison  of 
tiie  advertising  pages  of  the  journals  owned  by  lay 
publishers  and  those  controlled  wholly  by  medical 
men  is  by  no  means  to  the  disadvantage  of  the  former. 
Dr.  Jacobi  owes  an  apology  to  American  medical 
editors  and  American  medical  publishers,  for  he  has 
recklessly  charged  the  latter  with  dishonesty  and  the 
former  with  what  is  no  less  despicable — a  truckling 
subserviency,  and  in  both  cases  he  has  spoken  rashly 
and  with  insufficient  knowledge. 


^cius   of  the  '<!3ilcck.  • 

America   as   a   Field   for    Post-Graduate  Study. — 

In  an  address  delivered  at  the  opening  of  the  Museums 
of  the  Medical  Graduates'  College  and  Polyclinic  in 
London  recently,  Dr.  Osier,  after  dwelling  on  the  im- 
portance of  post-graduate  study,  the  value  of  museums 
as  a  means  of  profitable  instruction,  the  desirability 
of  change  in  one's  teachers  from  time  to  time,  and 
pointing  out  the  silent  revolution  that  has  taken 
place  in  the  educational  field  in  the  United  States 
during  the  past  quarter  of  a  century,  suggested  to 
students  who  wish  to  have  the  best  the  world  offers 
that  ''the  lines  of  intellectual  progress  are  very 
strongly  toward  the  West,"  and  made  the  interesting 
prediction  that  in  the  twentieth  century  "young  Eng- 
lish physicians  will  find  their  keenest  inspiration  in 
the  land  of  the  setting  sun." 

Hot-Weather  Mortality  Statistics  of  Philadel- 
phia.—  For  the  week  ended  August  i8th  there  were 
reported  to  the  Philadelphia  bureau  of  health  550 
deaths— 98  more  than  for  the  preceding  week,  and 
169  more  than  for  the  corresponding  week  of  the 
previous  year.  The  principal  causes  of  death  were  as 
follows:  Sunstroke  56,  pulmonary  tuberculosis  54, 
cholera  infantum  42,  heart  disease  40,  marasmus  27, 
inanition  24,  inflammation  of  the  stomach  and  bowels 
24. 


Sir  William  Stokes,  who  went  out  to  South  Africa 
some  time  ago  as  one  of  the  consulting  surgeons  to  the 
British  forces,  died  at  Durban  on  August  19th.  He 
was  born  in  Dublin  in  March,  1839,  and  received  his 
education  at  the  University  of  Dublin.  He  was  presi- 
dent of  the  Pathological  Society  in  188 1,  president  of 
the  Royal  College  of  Surgeons  in  Ireland  in  1887, 
and  honorary  president  of  the  International  Medical 
Congresses  at  Berlin  in  1890,  Rome  in  1894,  Moscow 
in  1897,  and  Paris  in  1900.  He  held  the  office  of 
surgeon  in  ordinary  to  the  Queen  in  Ireland. 

The  British  Congress  on  Tuberculosis It  is  an- 
nounced in  the  British  Alediial  Journal X\iZX.  a  Congress 
on  Tuberculosis  will  be  held  in  London  during  the 
last  week  of  April,  under  the  presidency  of  the  Prince 
of  Wales.  Among  the  vice-presidents  are  the  Duke  of 
Fife,  the  Marquis  of  DufTerin,  Earl  Spencer,  Lord 
James  of  Hereford,  Lord  George  Hamilton,  Lord  Reay, 
Lord  Lister,  Sir  John  Burdon  Sanderson,  Sir  Her- 
mann Weber,  the  presidents  of  the  Royal  Colleges  of 
Physicians  and  Surgeons,  the  president  of  the  Royal 
College  of  Veterinary  Surgeons,  the  director-general 
of  tlie  Medical  Department  of  the  Navy,  and  the  chair- 
man of  the  London  County  Council.  The  president 
of  the  organizing  committee  is  the  Earl  of  Derby; 
the  chairman,  Sir  William  Broadbent;  the  honorary 
treasurers.  Lord  Avebury  and  Sir  James  Blyth ;  the 
chairman  of  the  general  purposes  committee,  Pro- 
fessor Clifford  Allbutt;  and  the  honorary  secretary- 
general,  Mr.  Malcolm  Morris.  The  Prince  of  Wales 
has  consented  to  open  the  congress  in  person.  In 
order  to  make  tlie  congress  as  comprehensive  as  pos- 
sible, every  colony  and  dependency  in  the  empire  will 
be  asked  to  send  representatives,  and  distinguished 
guests  will  be  invited  from  Europe,  Asia,  and  America. 
Authorities  in  these  and  other  countries  will  be  in- 
vited to  take  an  active  part  in  the  work  of  the  con- 
gress. It  is  hoped  that  the  congress  will  be  able  to 
adopt  practical  resolutions  which  will  serve  to  indi- 
cate the  measures  best  adapted  for  the  suppression  of 
tuberculosis.  The  work  of  the  congress  will  be 
divided  into  sections  as  follows:  Section  i  (state  and 
municipal)  :  president.  Right  Hon.  Sir  Herbert  Max- 
well; secretaries.  Dr.  Bulstrode,  Dr,  Arthur  News- 
holme,  Dr.  James  Niven.  Section  2  (pathological, 
including  bacteriology)  :  president,  Professor  Sims 
VVoodhead ;  secretaries.  Dr.  Wethered,  Professor 
Rubert  Boyce,  Dr.  E.  J.  McWeeney.  Section  3  (tuber- 
culosis in  animals):  president.  Sir  George  Brown; 
secretaries,  Professor  Hobday,  Royal  Veterinary  Col- 
lege; Messrs.  Harold  Sessions,  Stuart  Stockman 
(Glasgow),  Frank  Leigh  (Bristol).  Section  4  (clini- 
cal and  therapeutical,  including  climatology  and  sana- 
toria) :  president.  Sir  R.  Douglas  Powell ;  secretaries. 
Sir  Hugh  Beevor,  Dr.  Hector  Mackenzie,  Dr.  R.  W. 
Philip,  Dr.  William  Calwell  (Belfast). 

Medical  Reciprocity  in  Canada — For  several 
years  past  there  has  been  a  movement  on  foot,  ini- 
tiated, we  believe,  by  Dr.  Roddick,  of  Montreal,  look- 
ing to  the  creation  of  a  central  medical  examining- 
board  for  the  Dominion  of  Canada,  the  object  being 
a   uniform   standard    of   medical  licensure.     Such   a 


392 


MEDICAL    RECORD. 


[August  25,  1900 


board  will  not  conflict  with  any  of  the  existing  pro- 
vincial boards  or  colleges.  Under  Dr.  Roddick's  plan 
a  physician  possessing  a  diploma  conferring  the  right 
to  practise  in  one  province  of  the  Dominion  may  reg- 
ister it  with  the  central  board  and  receive  from  this 
board  the  right  to  practise  in  any  other  part  of  Canada 
without  further  local  examination.  A  similar  move- 
ment is  under  consideration  in  this  country,  and  was 
the  subject  of  discussion  at  the  meeting  of  the  National 
Confederation  of  Medical  Examining  and  Licensing 
Boards  in  Atlantic  City  in  June. 

The  Geneva  (N.  Y.)  City  Hospital  will  receive 
$10,000  by  the  will  of  the  late  Judge  Francis  O. 
Mason.  Upon  the  death  of  two  sisters  of  the  deceased, 
it  will  also  receive  $80,000  additional. 

A  New  Yellow-Fever  Serum? — A  despatch  to  the 
daily  papers  from  Vera  Cruz  states  that  the  most 
severe  cases  of  yellow  fever  there  are  being  treated 
with  Bellinzaghi's  serum  and  seem  to  improve  won- 
derfully. The  patients  are  quickly  relieved  of  black 
vomit  and  revived  from  their  lethargy. 

Smallpox  has  broken  out  among  the  Indians  on 
the  Turtle  Mountain  reservation  in  North  Dakota  near 
the  Canadian  line.  There  are  about  twelve  hundred 
Indians  on  the  reservation,  and  among  them  were  some 
thirty  cases  of  smallpox,  when  the  outbreak  was  re- 
ported the  middle  of  this  month. 

Dr.  T.  M.  Lippitt,  assistant  surgeon  U.S.N.,  who 
was  in  charge  of  the  marines  sent  to  Pekin  to 
guard  the  United  States  legation  there,  was  wounded 
in  the  thigh.  The  femur  was  fractured,  but  the  leg 
was  saved,  and  he  is  now  reported  convalescent.  He 
was  thought  at  one  time  to  have  been  killed. 

Dr.  Thomas  G.  Roddick  and  Sir  William  Hings- 
ton,  of  Montreal,  were  among  those  elected  honorary 
fellows  of  the  Royal  College  of  Surgeons  of  England 
at  the  centenary  celebration  in  July. 

The  Plague  in  Manila. — The  record  of  the  plague 
in  Manila  for  the  two  weeks  ending  on  July  7th,  as 
just  reported  to  the  Marine-Hospital  service,  was  seven 
new  cases  and  five  deaths.  Of  the  new  cases  four  were 
Filipinos  and  three  Chinese. 

High    Mortality   Rate  in    Porto  Rico Assistant 

Surgeon  King  of  the  Marine-Hospital  service  reports 
that  in  Ponce  City  and  surrounding  country,  for  the 
two  weeks  ending  July  28th,  there  were  two  hundred 
and  sixteen  deaths,  against  seventy  births  during  the 
same  period.  An  investigation  into  this  remarkable 
mortality  is  being  conducted  by  the  superior  board  of 
health  of  the  island. 

Yellow  Fever  in  Havana. — During  July  there  were 
thirty  deaths  from  yellow  fever  in  Havana.  The  aver- 
age July  mortality  record  for  the  decade  from  1885-94 
was  thirty-four.  The  principal  unfavorable  factor  at 
present  is  the  number  of  non-immunes.  Last  year  up- 
ward of  twenty-five  thousand  inimii^rants  came  to 
Havana,  or  three  times  the  normal  number.  The  nor- 
mal death  rate  from  yellow  fever,  estimated  from  the 
statistics  of  1885-90,  is  4.2  per  1,000.  Last  year  it 
was  only  about   1.2  per   1,000.     When  the  enormous 


increase  in  the  number  of  non-immunes  is  taken  into 
account,  the  rate  of  mortality  for  1899,  as  well  as  the 
rate  for  July  of  this  year,  is  much  below  what  might 
have  been  expected. 

Mortality  of  Ofl&cers  and  Privates  in  War.— 
The  official  table  of  casualties  in  the  British  army  in 
Soutli  Africa  shows  a  curious  discrepancy  in  the  rel- 
ative mortality  from  disease  and  that  from  bullets,  of 
the  officers  and  men.  The  figures  are :  Killed  in 
action  and  died  of  wounds,  344  officers,  3,183  men. 
Died  of  disease,  141  officers,  4,836  men.  That  is  to 
say,  that  for  every  one  officer  killed  in  battle  nine 
men  die,  but  for  every  officer  dying  of  disease  thirty- 
four  men  die. 

Navy  Department,  Bureau  of  Medicine  and  Surgery, 
Washington,  D.  C. — Changes  in  the  medical  corps  of 
the  United  States  navy  for  the  week  ending  August 
18,  1900.  August  nth. — Assistant  Surgeon  M.  K. 
Elmer  commissioned  assistant  surgeon  from  July  18, 
igoo.  August  13th. — Surgeon  C.  H.  T.  Lowndes 
commissioned  surgeon  from  June  7,  1900.  August 
15th. — Assistant  Surgeon  W.  M.  Garton  detached  from 
the  Neiv  York  and  ordered  to  the  jMassachiisctts  im- 
mediately, temporarily,  by  the  commander-in-chief  of 
the  North  Atlantic  Station.  August  i6th. — Passed 
Assistant  Surgeons  C.  D.  Costigan,  G.  A.  Lung,  and 
J.  T.  Kennedy  ordered  to  the  Alonadnock  for  additional 
duty  with  regiment  jf  marines.  Assistant  Surgeon  E. 
Davis  ordered  to  the  Yorktowii.  Passed  Assistant  Sur- 
geon A.  R.  Alfred  ordered  to  the  Castine. 

Obituary  Notes. — Dr.  Edwin  Evans  died  at  his 
home  in  Rome,  N.  Y.,on  August  i6th,  of  heart  disease, 
at  the  age  of  fifty-five  years.  He  was  a  graduate  of 
the  College  of  Physicians  and  Surgeons,  New  York,  in 
the  class  of  1870.  He  was  very  prominent  in  Masonic 
circles. 

Dr.  John  H.  W.  Chestnut,  of  Philadelphia,  died 
at  Dutch  Harbor,  Alaska,  on  August  5th,  of  cancer  of 
the  stomach.  He  was  born  in  Philadelphia  in  1846, 
and  was  a  graduate  of  the  medical  department  of  the 
University  of  Pennsylvania  in  1871. 

Dr.  Fr.anklin  Booth,  of  Elmhurst,  borough  of 
Queens,  died  at  St.  John's  Hospital,  Long  Island  City, 
on  August  19th,  at  the  age  of  sixty-three  years.  The 
night  before  his  death,  while  on  the  way  to  visit  a 
patient,  he  was  run  over  by  a  trolley  car  and  both  legs 
were  badly  mangled.  Before  the  ambulance  arrived 
he  gave  directions  to  one  of  the  passengers  how  to 
apply  a  tourniquet  improvised  from  a  bit  of  rope  so  as 
to  arrest  the  hemorrhage.  One  leg  was  so  badly  in- 
jured that  it  was  amputated  at  once;  the  knee  of  the 
other  leg  was  resected  after  Dr.  Booth  reached  the  hos- 
pital. He  rallied  well  at  first,  and  it  was  hoped  he 
might  recover,  but  he  soon  sank  and  died  about  twenty- 
four  hours  after  the  injury  was  received.  Dr.  Booth 
was  a  graduate  of  the  Bellevue  Hospital  Medical  Col- 
lege in  the  class  of  1864. 

Dr.  Hkrhert  Park,  surgeon  on  the  Red  Cross  l,ine 
steamship  Grangense,  died  suddenly  at  sea  on  August 
nth.  He  was  twenty-three  years  old,  and  was  born 
in  Wigan,  England.      He  was  buried  at  sea. 


August  25,  1900] 


MEDICAL    RECORD. 


303 


^rotjvcBS  of  pictlical   s,cicnce. 

T/ic  Philadclphhi  Medical  Journal,  August  /S;  /goo. 

Military  Surgery. — W.  C.  Borden  continues  the  paper  on 
this  subject,  in  which  he  discusses  wounds  of  bones  and 
other  parts  caused  by  bullets  of  various  kinds. 

The  other  original  articles  in  this  issue  are  the  opening 
remarks  of  the  presidents  of  the  sections  on  tropical  medi- 
cine, patliology.  ])harmacnl()gy  and  theraiJeutics,  state  med- 
icine, surgery,  and  army,  navy,  and  ambulance,  rejirinted 
from  the  British  Mctiical  Journal. 

Boston  Mi'ilical  aiul  Surgical  Journal,  .lugust  /b,  /900. 

Purgation  with  Opium. — J.  W.  Wainwright  reports  a  case 
of  intestinal  obstruction,  without  pain,  in  a  child  aged  five 
years,  in  which  high  enemata  with  massage,  under  chloro- 
form, had  absolutely  no  effect,  and  operation  was  thought 
imperative  by  the  consultants,  but  ol)jected  to  by  the 
father,  a  physician.  Another  consultant  advised  the  fol- 
lowing treatment,  which  was  carried  out;  A  quantity 
each  of  tinctura  opii  deodorata  and  tinctura  l)eUadonn;c 
was  procured,  and  two  drops  of  the  tinctura  opii  was  given 
on  the  tongue  with  a  medicine-dropper  every  half-hour. 
This  was  kept  up  until  there  was  complete  coma  with  ster- 
torous breathing.  This  condition  was  maintained  for  two 
hours,  during  which  there  were  contracted  pupil,  insensible 
conjunctiva,  threatened  paralysis  of  the  inuscles  controlling 
the  tongue,  etc.  At  the  e.Kpiration  of  the  two  hours  the 
patient  was  allowed  to  recover  from  the  effects  of  the  drug, 
taking  about  four  more  hours,  with  the  aid  of  small  quan- 
tities of  tinctura  belladonn;e,  which  had  been  held  as  an 
anti<lote  to  tiie  effects  of  the  opium  if  needed.  His  first 
words  upon  regaining  consciousness  were  to  ask  for  "his 
chair."  when  there  was  a  free  stool.  A  knuckle-shaped 
mass  was  found,  which  proved  to  be  cheese.  The  patient 
made;  an  uninterrupted  recovery.  The  cathartic  action  of 
the  opium  was  rather  the  complete  muscular  relaxation 
which  chloroform  had  not  succeeded  in  bringing  about,  ex- 
tending to  the  muscular  coat  of  the  intestines,  thus  allow- 
ing the  mass  to  pass  through  the  ileocascal  valve  by  gravi- 
tation. 

'  The  Psychic  Factor  in  Disease.— Robert  W.  Greenleaf  l;y 

'  means  of  cases  elaborates  the  following  propositions:  (i) 
That  some  cases  of  illness  are  simply  neuroses  without  ap- 
preciable pathological  lesions ;  (2)  that  causes  capable  of 
producing  such  neuroses  may  act  while  disease  is  present 
and  should  be  guarded  against ;  (3)  purely  psychic  causes, 
as  shock,  grief,  and  the  like,  may  pave  the  way  for.  if  not 
directly  cause,  profound  pathological  disturbance ;  (4)  at- 
tention to  the  ps)-chic  is  capable,  under  some  conditions,  of 
so  turning  the  scale  to  health  that  it  may  arrest,  even 
perhaps  cure,  otherwise  fatal  pathological  conditions  ;  (5) 
attention  to  the  psychic  should  be  considered  a  routine 
measure  in  the  treatment  of  delirium  from  toxic  causes,  as 
alcohol,  belladonna,  ether,  and  the  like  ;  (6)  it  should  also 
be  considered  a  routine  measure  in  the  treatment  and  in 
the  prevention  of  delirium  in  febrile  states,  as  of  typhoid  : 
(7)  nurses  should  be  able  to  enter  into  psvchic  relation 
with  their  patients  :  otherwise  the  value  of  their  services  is 
much  lessened  and  may  be  harmful. 

Surgical  Pain.— G.  Ryder  says  that  simple,  uninfected 
trauma  of  the  viscera  causes  comparatively  little  pain,  and 
this  soon  subsides.  Contractile  pain,  of  which  examples 
are  afforded  by  any  abdominal  viscus,  is  typical  in  its  re- 
currence, and  is  rhythmical  in  character.  At  times  it  is 
intense,  paroxysmal,  and  colicky.  Inflammatory  pain  is 
most  .severe  when  due  to  the  colon  communis  and  strepto- 
coccus bacilli.  Neuralgic  jjain  is  paroxysmal,  with  inter- 
missions, lightning-like  and  lancinating.'  Hysterical  pain 
is  usually  burning  and  may  occupy  any  part  of  the  abdo- 
men and  its  contents.  Charcot's  stigmata  will  differentiate 
it  from  other  pains.  Obstruction  pains  of  .the  abdomen 
come  with  a  sudden  onset,  are  colickv  and  constant,  and 
cause  vomitin.g.  In  peritonitis  the  pain  is  localized  at 
first,  but  soon  becomes  diffused  and  constant.  All  abdom- 
inal emergencies  characterized  by  inflammation  have  one 
common  and  timely  feature,  that  pain  is  increased  bv 
pressure. 

A  Brief  Report  of  a  Case  of  Cerebral  Abscess  of  Otitic 
Origin;  Operation;  Death.  — By  George  L.  Riehanis. 

A  Case  of  Volvulus  Complicated  by  Peritonitis  ;  Operation  ; 
Recovery.- By  W.  P.  Giddings. 

Journal  of  the  American  Medical  Ass' n.  Aug.  iS.  rgoo. 

Therapeutics  of  Travel  and  Change  of  Scene  ia  Nervous 
and  Mental  Diseases.— Richard  Dewey  finds  that  the  dan- 
gers (if  travel  predominate  over  the  benefits  in  the  case  of 
neurotic  and  insane  patients,  citing  cases  from  practice  in 
support  of  this  view.     Travel  and  change  of  scene  for  men- 


tal and  nervous  maladies  cannot  be  judiciously  prescribed 
except  by  careful  consideration  of  the  individual  case. 
Travel  may  be  good  in  one  stage  and  bad  in  another  of 
the  same  di.sease.  If  the  patient  grows  worse  by  travel, 
this  does  not  prove  the  treatment  bad,  for  some  cases  will 
grow  worse  whatever  is  done.  It  may  even  be  necessary 
to  make  a  careful  experiment  before  the  question  can  be 
settled.  Another  fact  regarding  travel  is  that  a  great  deal 
depends  upon  the  manner  of  its  regulation.  Patients  who 
can  command  every  facility  for  comfort  an<l  safety  and  an 
experienced  medical  escort  could  travel  when  such  a 
course  would  be  injurious  and  dangerous  for  one  of  mod- 
erate means. 

Medico-Legal  Relations  of  Opium  Inebriety  and  the  Neces- 
sity for  Legal  Recognition.— T.  1).  Crothers  discusses  the 
character  of  crime  committed  by  the  morphinist,  showing 
petty,  stealthy  criminal  acts  to  predominate.  He  finds 
need  for  the  medico-legal  study  of  morphinism.  All  state- 
ments of  the  opium  inebriate  should  be  open  to  doubt  and 
regarded  as  worthless  so  far  as  the  witness-stand  is  con- 
cerned, unless  confirmed  by  other  facts  and  strong  circum- 
stantial evidence.  Crime'  is  often  purposeless.  There 
should  be  no  question  of  the  incapacity  of  opium-takers  to 
execute  bills  and  contracts.  Further  study  must  be  made 
above  all  theories  and  based  solely  on  facts  and  conditions 
present. 

Interstitial  Gingivitis  from  Indigestion  Auto-intoxication.— 

E.  .S.  Talbot  discusses  the  phase  of  auto-into.xication  due 
to  indigestion  or  disturbance  of  the  gastro-intestinal  tract. 
A  factor  in  auto-intoxication  is  non-performance  of  the 
process  of  elimination.  Another  is  the  formation  of  toxic 
products  in  such  quantities  as  to  prevent  their  destruction 
by  organs  like  the  liver  and  consequent  elimination.  Peo- 
ple of  sedentary  habits  do  not  require  excessive  nitrogen- 
ous or  starchy  diet,  and  if  they  receive  it  auto-intoxication 
with  inflammation  of  the  gum  and  alveolar  process  occurs 
and  absorption  takes  place. 

Syphilitic  Locolosis  Alveolaris. — G.  Lenox  Curtis  discusses 
under  this  title  pynrrhcjca  alveolaris,  which,  he  says,  is 
generally  regarded  as  incurable.  .It  is  a  disease  of  the 
peridental  membrane  aggravated  by  calcareous  deposits 
with  resulting  decalcification  of  the 'alveolar  tissue.  The 
cause  of  the  disease  is  discussed,  and  syphilis  is  found  to 
be  a  ]irevalenl  condition,  but  (me  often  overlooked.  When 
specific  treatment  is  pushed  these  patients  get  well  and 
recurrences  are  not  noted. 

Morphinism  from  the  Standpoint  of  the  General  Practi- 
tioner.— T.  J.  Hap])el  points  out.  first,  the  increase  in  the 
consumption  of  opium,  and  goes  on  to  discuss  how  the 
habit  is  acquired  by  patients  and  physicians.  The  effects 
produced  up<m  the  child  in  utero  a'nd  u])on  fertility  are 
considered.  This  vice  will  have  to  be  faced  and  fought  in 
the  twentieth  century  as  never  before.  The  question  of 
heredity  in  relation  to  morphinism  is  considered. 

Neurotic  Affections  of  Interstitial  Gingivitis. — J.  G.  Kier- 
nan  says  falling  of  the  teeth  and  similar  affections  may  oc- 
cur not  only  from  constitutional  neuroses,  but  from  disturb- 
ances of  the  cranial  and  spinal  nerves,  and  after  injury 
to  these  nerves,  epilepsy,  neurasthenia,  and  hysteria. 

Treatment  of  Morphinism.— A.  J.  Pressey  points  to  the 
necessity  for  a  more  universal  knowledge  of  morphinism, 
and  reports  a  case.  It  is  not  a  mere  habit,  to  be  broken  by 
the  will,  and  still  it  is  not  incurable.  The  jiatient  is  as 
grateful  for  relief  as  are  the  friends. 

The  Treatment   of  Keratoconus  with  Galvano-Cautery. — By 

Herman  Knapp. 

The  Surgical  Treatment  of  Conical  Cornea.— By  Robert 
Sattler. 

The  Therapeutic  Uses  of  the  Thymus  Gland.— By  S.  Solis- 
Cohen. 

The  .\'e7e  ]'orl:  .\ledual Journal,  .lugust,  iS,  iqoo. 

Congenital  Dislocation  of  the  Shoulder.— John  Lincoln  Por- 
ter relates  a  case  of  this  condition  occurring  in  a  boy.  The 
birth  was  normal,  in  head  presention,  but  labor  was 
terminated  witli  the  aid  of  forceps  after  four  hours,  because 
of  the  haste  of  the  physician  to  go  to  another  case.  The 
author  finds  sixteen  cases  reported  in  the  literature  in 
addition  to  twelve  noted  by  Scudder  in  iSyo,  making  with 
the  present  one  a  total  of  t'wenly-nine  cases.  The  conclu- 
sions at  which  the  author  arrives  from  his  study  of  congen- 
ital luxation  of  the  shoulder  are.  (i)  It  is  of  fundamental 
importance  to  discriminate  between  traumatic  and  devel- 
opmental cases.  (2)  The  pathology  of  the  congenital  cases 
is  not  sufficiently  known  to  indicate  the  most  promising 
line  of  treatment.  (3)  Sufficient  operations  have  not  been 
done  to  establish  a  successful  method  of  operative  treat- 
ment or  add  much  to  our  pathological  knowledge.  (4) 
In  cases  determined  to  be  developmental  by  the  history 
and  measurements,  remembering  the  probable  deficiency 
of  development  of  one  or  both  articular  surfaces,  an  early 


304 


MEDICAL    RECORD. 


[August  25,  1900 


ojieration,  before  the  humeral  head  has  formed  a  new- 
articular  facet  under  the  spine  and  has  itself  become  de- 
formed, offers  tlie  best  results. 

The  Treatment  of  the  Morphine  Habit— Can  it  be  Cured  ? 
— James  il.  McBridc  believes  that  few  people  addicted  to 
the  use  of  morphine  or  opium  are  permanently  cured  of  the 
habit.  They  may  be  apparently  cured,  but  this  is  as  a  rule 
temporary  only.  The  habit,  he  says,  is  but  half  cured 
when  the  u.se  of  the  drug  is  stopped,  and  in  order  that  the 
cure  may  be  lasting  the  patient  should  be  under  control 
for  months  or  a  year  before  he  is  allowed  to  return  to  his 
occupation.  The  craving  for  morphine  is  often  strong  for 
a  long  time  after  its  use  has  been  stopped,  and  the  patient 
should  be  under  control  as  long  as  the  desire  for  the  drug 
continues  or  until  he  is  strong  enough  to  resist  the  desire. 
To  treat  the  morphinist  successfully  means  not  only  to  help 
him  to  get  rid  of  the  drug  habit,  but  it  means  to  restore  if 
possible  a  shattered  nervous  system  to  a  normal  condition, 
and  this  involves  prolonged  seclusion  and  aljsence  of  temp- 
tation. He  advocates  institutional  treatment  under  legal 
restraint. 

A  Study  of  the  Action  of  Gelsemium  upon  the  Nuclei  of 
the  Motor  Cerebral  Nerves. — By  R.  H.  Whitehead. 

Some  Observations  upon  the  Ocular  Sjrmptoms  in  Loco- 
motor Ataxia. — By  Paul  Turner  \'aughan. 

On  the  Use  of  Suprarenal  Extract  in  Diseases  of  the  Nose 
and  Throat. — By  Seymour  Oppenheinier. 

A  New  Hypnotic. — By  Warren  B.  Hill. 

Enterocolitis.— By  William  E.  Fitch. 

The  Lancei,  August  //,  iqoo. 

The  Remote  Results  of  Structural  Lesions  ("Interventions 
Sanglantes  ")  in  Urethrostenosis. — Reginald  Harrison  sums 
up  as  follows  a  paper  read  at  the  thirteenth  international 
congress  on  August  Sth  :  (i)  There  is  evidence  to  show- 
that  in  peri-urethral  strictures  of  the  deep  urethra  the 
effects  of  divulsion  as  practised  in  Perreve's  and  Holt's 
operations  may  be  limited  to  rujjturing  the  dense  stricture 
bands  in  the  submucosal  of  the  urethra,  while  the  mucous 
membrane  itself  escapes  an)-  serious  injury  or  laceration 
and  is  merely  restored  by  stretching  to  its  original  dimen- 
sions. Here  a  permanent  cure  may  result.  On  the  other 
hand,  when  the  mucous  membrane  Ss  in  itself  the  seat  of 
stricture  and  forms  part  of  the  latter  structurally,  it  is  nec- 
essarily torn  or  lacerated  by  the  process  ofa  sudden  divul- 
sion, and  the  pathological  condition  consequently  becomes 
assimilated  with  thatof  traumatisms  of  the  urethra  from  ex- 
ternal violence  accidentally  applied  which  are  followed  by 
strictures  of  the  most  contractile  and  recurrent  form.  (2) 
There  is  evidence  to  indicate  that  w-hen  the  entire  thick- 
ness of  a  stricture  can  be  included  within  an  incision  of 
moderate  dimensions  made  by  an  internal  urethrotome  the 
normal  calibre  of  the  urethra  may  be  completely  and  per- 
manently restored.  When  this  happens  it  may  be  con- 
cluded that  all  the  fibres  of  contraction  constituting  the 
stricture  were  divided  at  the  time  of  operation  ;  and  fur- 
ther, that  the  conver.se  is  equally  true.  There  is  al.so  evi- 
dence to  show  that  the  absence  of  recurrence  under  such 
circumstances  is  not  necessarily  dependent  on  the  use  of  a 
bougie,  though  the  latter  is  a  precautionary  measure  which 
should  invariabl)'  be  ad\-ised.  (3)  In  the  case  of  multiple 
strictures  or  strictures  of  tlic  deep  urethra  of  considerable 
dimensions  either  in  their  length  or  thickness  treated  by 
an  internal  incision  of  corresponding  proportions,  apart 
from  other  considerations,  the  tendency  to  recontraction 
and  recurrence,  with  an  additional  amount  of  cicatricial 
material,  is  frequent ;  the  latter  being  probably  due  to 
the  circumstances  under  which  healing  takes  place  in 
wounds  of  these  dimensions  so  situated.  (4)  Lesions  of 
the  urethra  demonstrate  in  various  ways  the  poisonous 
effects  that  unprotected  and  confined  urine  is  capable  of 
exercising  both  on  the  body  generally  and  on  the  tissues 
in  contact  with  it,  and  the  liability  to  such  effects  is 
greatly  diminished  when  drainage  and  irrigation  render 
these  conditions  of  the  urine  unlikely.  (5)  In  the  case  of 
recurring  strictures  previously  treated  by  incision  and  in 
primary  strictures  of  such  length  or  extent  as  to  require  an 
internal  section  of  a  corresponding  size,  or  as  to  which 
there  might  be  doubt  as  to  whether  it  would  be  safely  pos- 
sible so  to  include  them,  for  the  purposes  of  the  operation 
and  its  results  such  wounds  should  be  made  with  due  re- 
gard to  other  surgical  princii'>lcs  in  addition  to  the  one  per- 
taining to  the  division  of  the  contraction.  (6)  There  is 
direct  evidence  to  show  that  the  tendency  to  recontraction 
and  recurrence  of  stricture  after  internal  urethrotomy  is 
largely  diminished  by  the  concurrent  employment  of  sys- 
tematic and  efficient  urine  and  wound  drainage  such  as  the 
combination  of  external  urethrotomy  or  perineal  puncture 
affords. 

The  Indications  of  Th3rrotomy. — Sir  Felix  Semon  says 
that  while  in  the  nature  of  things  thyrotomy  can  never  be 
an  everyday  operation,  il  has  in  the  past  been  anything 


but  a  popular  one.  The  time  has  now  fully  come  when 
everybody  should  be  capable  of  forming  an  opinion  on  this 
question,  and  if  the  results  obtained  be  scrutinized  with 
an  unbiassed  mind  he  has  no  doubt  that  the  chief  indica- 
tion for  the  employment  of  thyrotomy  will  in  future  be 
found  in  early  intrinsic  malignant  disease  of  the  larynx. 

A  New  Disease  with  a  Specific  Urinary  Reaction. — N.  F. 
Surveyor  describes  a  vesicular  eruption  of  the  face,  in  the 
region  of  the  eye,  ear,  etc.,  coming  on  after  a  wound  of  the 
thumb,  some  vesicles  subsequently  appearing  near  the  seat 
of  injury.  The  urine  assumed  a  bright  pinkish-purple  col- 
or on  adding  a  drop  of  strong  caustic-soda  solution  to  the 
centrifugalized  deposit.  This  was  not  due  to  any  drugs 
taken,  as  shown  by  tests.  In  a  record  of  one  hundred  and 
ninety-five  urine  analyses  no  such  reaction  had  been  pre- 
viously seen. 

The  Sympathetic  Origin  oi!  Post-Enteric  Tachycardia. — P. 
C.  Fenwick  advances  a  theory  of  sympathetic  origin  of  the 
cardiac  phenomena  in  military  convalescents.  Cardiac 
irritability  may  be  due  to  sympathetic  disturbance  arising 
in  the  superior  mesenteric  plexus  and  thence  transmitted 
to  the  cardiac  ganglia  and  ple.xus. 

A  Case  of  Puerperal  Septicaemia  Treated  by  Anti-strepto- 
coccic  Serum,  and  Complicated  by  Phlegmasia  ;  Recovery. — 
By  A.  Hamilton  Wood. 

Eczema  and  the  Allied  Diseases  :  an  Outline  of  their  Eti- 
ology, Pathology,  and  Treatment. — By  W.  'J'.  Freeman. 

The  Maternal  Mortality  in  Childbed.— By  William  J. 
Smyly. 

On  the  Prevention  of  Insanity. — By  R.  Percy  Smith. 

JMiinchencr  mcdkiiiiscJie   ]]'ocl!cnschrift,  July  jt,  igoo. 

Some  Clinical  Aspects  of  the  Plague  as  Observed  in  Oporto 
in  1899. — Reiche  says  that  the  typical  invasion  of  plague 
is  accompanied  by  headache,  chills,  great  prostration,  and, 
in  many  cases,  diarrhoea  and  vomiting:  The  temperature 
is  high  and  fluctuating,  the  abdomen  tender,  and  the 
spleen  enlarged  ;  the  bubo  is  most  frequently  found  in  the 
inguinal  region,  the  axilla  being  the  second  site  of  elec- 
tion. Both  sexes  are  affected  with  equal  frequency  :  the 
fever  presents  nothing  characteristic,  being  either  continu- 
ous or  remittent,  and  terminating  by  lysis  or  crisis.  The 
cerebral  symptoms  also  are  of  all  degrees  of  severit)-,  vary- 
ing from  tiie  normal  to  well-marked  delirium.  The  buboes 
are  in  nearly  all  cases  the  most  typical  symptom  and  are 
usually  present  from  the  earliest  days  of  the  disease. 
Sometimes  but  a  single  group  Of  glands  is  affected,  but 
more  often  secondary  involvement  in  other  regions  is 
observed.  The  size  and  number  of  the  buboes  are  very  va- 
riable, but  no  conclusions  as  to  the  probable  clinical  course 
are  to  be  deduced  from  these  factors.  In  pronounced  cases 
the  diagnosis  offers  no  difficulty  and  may  always  be  con- 
firmed by  aspiration  and  bacteriological  examination  of 
the  contents  of  the  bubonic  absces.ses  ;  in  mild  cases,  how- 
ever, and  those  in  which  the  glandular  manifestations  are 
late  in  appearing,  the  true  nature  of  the  disease  is  often 
long  in  doubt.  It  is  to  be  hoped  that  some  serum  reaction 
will  be  devised  to  make  positive  diagnosis  possible  in  the 
early  stages.  The  therapy  includes  isolation  in  clean,  well- 
ventilated  rooms  and  internally  tonics  and  intestinal  anti- 
septics. The  value  of  Calmette's  method  Of  injection  with 
Yersin's  serum  is  still  sub  jiiiikc. 

Experimental  Observations  on  Disinfection  of  the  Hands  (Con- 
clusion).— The  results  of  Paul  and  Sarwey 's  series  of  articles 
may  l)e  summed  up  as  follows  :  (i)  Neither  of  the  three  me- 
chanical methods  of  hand  sterilization,  viz.,  w-ashing  with 
green  soap  and  brush  in  hot  w-ater,  with  Schleich's  marble 
soap  or  Sanger's  sand  soap  is  sufficient  to  effect  a  satisfac- 
tory freedom  from  germs.  On  the  contrary,  even  when  the 
cleansing  jirocess  is  continued  for  some  time,  the  disinfec- 
tion is  still  very  imperfect,  and  even  hands  that  have  been 
artificially  infected  are  not  to  be  purified  with  certainty  by 
these  means.  (2)  It  is  not  possible  by  purely  mechanical 
means  to  secure  as  high  a  degree  of  sterilization  as  is  ])os- 
sible  by  the  use  of  chemicals.  (3)  Green  .soap  (sapo  ka- 
linus  vernalis)  on  account  of  its  high  percentage  of  free 
alkali  is  d;imaging  to  the  skin  and  not  to  be  recommended 
for  cleansing  tlie  hands.  (4)  From  a  cosmetic  standpoint 
Schleich's  marl)le  soap  is  very  suitable  for  constant  use 
but  it  is  not  yet  certain  whether  it  makes  an  advantageous 
precursor  to  chemical  disinfection.  (?)  Sanger's  sand- 
soap  is  well  adapted  for  habitual  use  and  leaves  the  skin 
in  good  condition  for  the  subsequent  action  of  chemical 
disinfectants. 

The  Treatment  of  Infected  Perforating  Wounds  of  the  Eye- 
ball.— (llaiining  recommends  highly  ICverslnisch's  proce- 
dure of  performing  i>araccntesis  of  the  anterior  chamber  by 
means  of  the  galvaiio-cautery.  The  advantages  of  this 
method,  as  corroborated  by  the  clinical  histories  of  a  num- 
ber of  cases  cited,  are  that  (i|  the  infected  aqueous  humor 
is  allowed  to  drain  away,  a  continuous  How  being  possible 


August  25,  1900] 


MEDICAL    RECORD. 


305 


much  longer  through  an  opening  made  by  the  galvano-cau- 
tery  than  through  a  simple  incision  the  edges  of  which 
quickly  agglutinate  ;  (2)  this  is  replaced  by  freshly  secreted 
and  not  at  all  or  only  slightly  infectious  fluid  ;  (3)  through 
the  diminislied  tension  the  vascular  supply  of  the  organ  is 
greatly  favored,  and  a  larger  amount  of  blood  rich  in  the 
properties  needed  to  combat  infection  gains  access  to  the 
damaged  area. 

A  Case  of  Congenital  Hernia  Cerebri. — Behm  reports  the 
successful  cure  by  operation  of  a  congenital  hernia  of  brain 
substance.  The  tumor  was  situated  between  the  posterior 
fontanelle  and  the  occipital  tuberosity,  and  was  connected 
with  the  cranial  cavity  by  its  pedicle  through  a  palpable 
opening  in  the  bony  skull.  It  was  of  the  size  of  a  lien's 
egg,  was  fluctuating.  n(m-pulsating,  and  did  not  increase 
in  volume  when  the  infant  cried.  On  the  tenth  day  the 
mass  was  tied  off  by  multiple  ligature  and  amputated  with- 
out narcosis.  Recovery  was  uneventful,  and  six  months 
later  the  patient  was  apparently  perfectly  well  and  pre- 
sented only  a  fluctuating  mass  of  the  size  of  a  cherry  at  the 
site  of  tile  former  tumor. 

A  Case  of  Spontaneous  Intraocular  Hemorrhage  followed  by 
Rupture  of  the  Globe. —  Hauenschild  describes  an  unusual 
termination  for  the  not  uncommon  intraocular  bleeding. 
The  patient  was  a  woman  aged  twenty-eight  years,  whose 
past  history  presented  nothing  of  importance  e.xcept  a 
slight  neurotic  tendency.  On  the  day  of  the  hemorrhage 
she  e.Kperienced  only  a  feeling  of  lassitude  and  a  slight 
headache.  Suddenly  there  was  a  spasm  of  pain  and  blood 
spurted  from  between  the  lids  of  the  right  eye.  Examina- 
tion of  the  urine  and  blood  gave  negative  results. 

Butyric-Acid  Bacilli  and  their  Relationship  to  Gaseous  In- 
flammation (Conclusion).  —  By  Schattenfroh  and  Grass- 
berger. 

Therapeutic  Results  with  "  Unguentum  Argenti  Colloidalis 
Crede." — By  Strohniayer. 

A  Forgotten  (?)  Heroic  Poison  Plant  of  Madagascar. — By 
Model. 

Deutsilie  niedicinische  IVoc/tenschri//,  August  2,  igoo. 

Metatraumatic  Alimentary  Glycosuria. — Haedke  took 
twenty-five  patients  wlio  had  suffered  severe  traumatism 
of  some  sort,  either  accompanied  by  injury  to  the  head  or 
involving  severe  concussion  of  the  entire  body  such  as  is 
produced  by  falls  from  a  height,  and  endeavored  to  estab- 
lish a  causative  relationship  between  the  injury  and  the 
production  of  temporary  glycosuria.  This  was  done  by 
giving  each  patient  on  the  day  after  the  accident  100  gm. 
of  pure  grape-sugar  in  watery  solution,  previous  examina- 
tion having  shown  the  absence  of  sugar  or  albumin  in  the 
urine.  In  cases  in  which  chloroform  had  been  given  a  clay 
was  allowed  to  elapse  before  the  e.xperiment  was  made. 
Alcoholism,  lead  poisoning,  etc.,  were  also  carefully  ex- 
cluded. The  result  was  that  in  sixty  per  cent,  of  the  cases 
an  alimentary  glycosuria  lasting  in  some  instances  as  long 
as  a  week  was  produced,  and  although  this  observation 
brings  nothing  of  distinct  value  iu  regard  to  the  etiology 
or  therapy  of  diabetes,  still  the  author' considers  that  it  in 
some  sense  bridges  the  gap  between  simple  trauma  and 
post-traumatic  diabetes. 

The  Quantitative  Proportions  of  the  Carbohydrates  in  Dia- 
betic Urine. — Rosin  has  made  a  series  of  observatious  im 
the  carbohydrates  other  than  glucose  present  in  the  urine 
of  diabetics  and  their  quantitative  relation  to  the  amount 
of  the  latter  found.  Those  bodies  are  mostly  he.xoses,  be- 
longing to  the  same  group  as  the  grape-sugar,  and  one 
other,  viz.,  a  pentose.  By  fermentation  with  yeast  it  is 
possible  completely  to  eliminate  the  glucose  and  leave  tl'.e 
other  members  of  the  group  behind,  and  by  a  further  treat- 
ment with  benzoyl  chloride  there  may  be  formed  from  these 
a  series  of  benzoic-acid  esters  which  possess  a  definite 
relationship  to  the  amount  of  the  carbohydrates.  By 
means  of  this  method  the  author  was  able  to  determine  that 
diabetic  urine  in  addition  to  its  charge  of  grape-sugar  con- 
tains other  carbohydrates  in  proportions  varying  from  five 
to  thirty  times  the  normal,  and,  furthermore,  that  there  is 
no  constant  ratio  between  the  relative  amounts  of  glucose 
and  the  other  carbohydrates. 

A  "  Cured"  Case  of  Diabetes  Mellitus.— Zaudy  reports  the 
case  of  a  diabetic  whose  sugar  excretion  at  times  went  as 
high  as  274  gm.  to  4,5700.0.  of  urine.  He  was  put  upon 
the  usual  diet  and  given  i  gm.  of  salol  four  times  a  day. 
Under  this  treatment  the  sugar  gradually  diminished  until 
after  about  a  month  and  a  half  Fehling's  reaction  gave 
a  constantly  negative  result,  which  state  of  affairs  contin- 
ued even  on  the  patient's  return  to  carbohj-drate  diet. 
The  general  condition  was  in  every  way  improved  and 
various  secondary  troubles  were  greatly  relieved.  A  year 
after  his  discharge  the  patient  returned  suffering  from  joint 
pains.  He  had  been  on  every-day  diet  during  this  time, 
and  it  was  found  that  his  urine  was  free  from  sugar,  albu- 
min, and  acetone,  and  was  even  slightly  below  normal  in 


quantity.  While  the  author  does  not  deny  the  possibility 
of  a  relapse,  he  considers  the  effect  of  the  salol  sufficiently 
remarkable  to  justify  further  experiment  with  its  use. 

The  Utility  of  the  Newer  Saccharometers  in  the  Quantita- 
tive Estimation  of  Glucose  in  Urine.  -By  Spaelht. 

Benzoyl  Esters  and  Carbohydrates  in  Normal  and  Diabetic 
Urine.  — By  -Mfthan. 

French  Journals. 

Parasitic  Origin  of  Eczemas. — L.  Brocq  presented  the  first 
paper  in  the  skin  section  at  the  Paris  congress,  followed 
by  reports  by  Unna,  Jadassohn,  and  Galloway,  and  dis- 
cussed by  Kaposi,  Sabourand,  Neisser,  Hallopeau,  and 
others.  Inoculations  in  the  dog  produced  an  eruption 
analogous  to  that  of  man  and  presenting  the  five  histobacte- 
riological  symptoms  which,  according  to  Unna,  are  pathog- 
nomonic— parakeratosis,  formation  of  serous  vesicles  with 
spongy  transformation  of  the  Malpighian  layer,  acanthosis, 
proliferation  of  connective-tissue  cells  of  the  superior  layer 
of  the  derma,  and  the  presence  of  masses  of  cocci  in  the  se- 
rous crusts.  A  resiiinc  of  the  experiments  is  presented. 
Unna  finds  that  among  the  numerous  micro-organisms 
which  have  been  found  in  eczema,  there  are  several  which 
when  inoculated  reproduce  eczema.  Eczema  is  contagious, 
and  under  certain  circumstances  epidemic.  Galloway  says 
the  morococcus  described  by  Unna  belongs  to  the  class  of 
organisms  giving  white  cultures  but  not  yet  capable  of 
separation  from  the  staphylococcus  pyogenes  albus.  The 
local  infeotivity  and  the  chronicity  of  eczema  are  chiefly 
due  to  the  presence  of  micro-organisms.  Kaposi  says  ex- 
perimentation sliows  that  eczema  may  be  caused  by  chem- 
ical and  physical  external  agencies.  Clinical  experience 
repudiates  absolutely  the  conception  of  an  eczema  of  para- 
sitic origin. — La  Prcsse  Medicale.  August  7,  igoo. 

Gastric  Ulcerations. — Dieulafoy  concludes  his  paper  read 
in  the  section  of  pathology  of  the  Paris  congress  with  a  de- 
scription of  the  various  forms  of  ulceration  of  the  stomach, 
from  the  simple  erosion  which  is  the  smallest  to  losses  of 
substance  of  greater  or  lesser  extent ;  the  simi)le  ulcer  be- 
ing the  type  of  ulcer  of  chronic  evolution  with  tendency  to 
perforation.  Specific  ulceration  in  tuberculosis  and  syph- 
ilis and  cancer  engrafted  upon  previous  ulcer  are  conditions 
discussed.  Treatment  is,  according  to  the  case,  medical, 
specific,  or  surgical. — La  Prcssc-  Medicalc,  August  4,  1900. 

Hot  Air  in  the  Treatment  of  Affections  of  the  Upper  Air 
Passages. — Lermoyez  and  Mahn  review  the  question  of  su- 
perheated air  as  a  remedial  measure,  and  give  the  theory 
of  their  procedure  with  description  of  apparatus  and  method 
of  producing  and  ajjplying  the  air.  It  is  found  useful  in 
congestive  spasmodic,  vasomotor,  and  simple  chronic  cory- 
zas  ;  in  subacute  tubal  catarrhs,  otalgia,  etc.  Contraindi- 
cations are  also  given. — La  Prcsse  Mcduah',  July  25,  igoQ 

Chronic  Sciatica  Cured  by  a  Viper's  Bite.— Pom merol  re- 
lates the  curious  result  of  a  viper  bite  upon  the  heel  of  a 
woman  w'ho  had  suffered  for  five  or  six  years  from  sciatica. 
There  were  shrinking  of  the  tissues  of  the  leg  and  a  limp- 
ing gait.  From  the  time  of  the  injury  all  pain  disappeared 
and  by  degrees  a  permanent  cure  of  the  disability  and  de- 
formity, etc.,  took  place. ^Cfti^fZ/f  des  Hopitau.x,  August 
2,  I  goo. 

Two  Cases  of  Contusion  of  the  Liver. — A.  Gosset  relates 
the  history  of  two  injuries  from  the  kick  of  a  horse  in 
which  the  liver  was  injured  and  in  which  immediate  lapa- 
rotomy was  performed,  in  one  instance  with  success. 

.Irc/uvcs  of  PcdiatriiS.  AugKSt,  /goo. 

Naso-Pharyngeal  Disease  in  Pediatric  Practice. — Francis 
Huber  discusses  the  subject  from  the  side  of  the  specialist 
as  well  as  from  that  of  the  general  practitioner.  The  main 
functions  of  the  nose  are  respiratory,  olfactory,  to  give  res- 
onance to  the  voice,  and  to  act  as  a  regulator  of  the  aera- 
tion of  the  middle-ear  and  of  the  accessory  air  chambers  in 
the  ethmoidal  and  sphenoidal  bones.  Patency  and  healthy 
mucous  membranes  are  essential  to  proper  performance  of 
the  work.  In  summing  up.  the  writer  says  ;  (i)  The  re- 
moval of  the  lymplioid  hypertrophies  in  the  naso-  and  oro- 
pharynx, with  the  cure  of  the  associated  naso-pharyngeal 
catarrh,  will  restore  the  patency  and  permeability  of  the 
nose.  If  done  early,  many  local  pathological  changes  may 
be  avoided.  (2)  The  general  health  will  be  more  or  less 
improved.  (3)  The  mental  faculties  and  general  intelli- 
gence will  be  improved.  (4)  Defects  in  speech  and  in 
hearing  due  to  nasal  troubles  will  disappear.  (5)  Deaf- 
mutism  may  be  relieved.  (6)  The  functions  of  taste  and 
smell  will  be  restored.  (7)  Reflex  neuroses  of  various 
kinds  will  be  modified  or  cured.  (8)  Nasal  and  supposed 
pulmonary  hemorrhages  will  disappear.  (9)  Thoracic  de- 
formities will  be  relieved  or  cured.  (10)  The  tendency  to 
acute  rhinitis,  pharyngitis,  laryngitis,  bronchitis,  and 
pneumonia  becomes  less  and  less  with  the  restoration  of 
normal  respiration.  (11)  The  dangers  attending  the  pres- 
ence of  enlarged  cervical  lymph  nodes  will  be  avoided. 


3o6 


MEDICAL   RECORD. 


[August  25,  1900 


(12)  The  invasion  of  various  infectious  diseases  is  less 
likely  when  the  nasal  mucous  membrane  is  in  a  healthy 
state.  (13)  The  danger  of  meningeal  infection  from  the 
naso-pharynx  will  be  lessened.  (14)  Ear  complications  in 
general,  and  particularly  those  incidental  to  the  infectious 
diseases,  will  be  avoided  or  rendered  less  dangerous. 

Intussusception  in  an  Infant  Four  Months  Old,  Relieved  by 
Injection. — Alfred  Hand,  Jr.,  relates  an  instance  of  intus- 
susception showing  the  value  of  opium,  which  prevented 
an  increase  of  the  intussusception  and  possibly  showed  a 
reducing  effect  at  the  start  of  recurrence.  The  case  illus- 
trated the  fact  that  with  reduction  the  patient  is  by  no 
means  cured,  but  that  the  secondary  and  very  likely  also 
the  causal  primary  enteritis  is  capable  of  giving  rise  to 
many  anxious  moments. 

Three  Cases  of  Head-Nodding  and  Head-Rotation  in  Ra- 
chitic Infants.— By  D.  J.  Milton  Miller. 

Perforation  of  a  Tuberculous  Lymph  Node  into  the  Trachea 
-^Sudden  Death.— By  A.  Caille. 

The  Practitioner,   August,  igoo. 

Recent  Experimental  Contributions  to  the  Pathology  of 
Diabetes. — J.  R.  Bradford  says  the  fundamental  fact  in  the 
pathology  of  diabetes  is  unquestionably  that  the  blood 
contains  an  excess  of  sugar.  Theoretically  this  may  be 
due  to  a  number  of  causes :  too  great  ingestion  of  sugar, 
excessive  formation  of  sugar,  lack  of  oxidation  by  the  tis- 
sues of  the  amounts  of  sugar  normally  ingested  or  produced. 
There  might,  too,  be  a  primary  disintegration  of  the  tis- 
sues with  the  formation  of  sugar.  The  great  bulk  of  cases 
at  the  present  time  are  considered  to  be  either  of  hepatic 
or  of  pancreatic  origin.  Biedl's  experiments  are  quoted  as 
confirmatory  evidence  that  the  pancreas  secretes  some 
substance  into  the  lymph  stream  and  so  into  the  circula- 
tion, the  absence  of  which  is  followed  by  glycosuria.  Tuck- 
ett's  observations  are  quoted  showing  that  lympli  from  the 
thoracic  duct  when  injected  into  the  portal  vein  will  cause 
glycosuria  of  vifrying  intensity. 

Glycosuria  and  Diabetes  in  Relation  to  Life  Assurance. — 
Hector  Mackenzie  finds  in  the  growing  mortality  from  dia- 
betes, and  the  fact  that  victims  are  largely  from  the  ujjper 
and  middle  strata  of  society,  a  cause  for  rigid  examination 
for  sugar  in  insurance  risks.  A  case  is  quoted  to  illustrate 
the  importance  of  testing  for  minute  quantities  of  sugar. 
Fehling's  test  with  boiling  is  considered  the  best.  Trust- 
worthy results  are  obtained  from  Williamson's  modifica- 
tion of  HoS^mann  and  Ultzmann's  method.  When  doubt 
remains  the  fermentation  test  may  be  applied.  True  dia- 
betes should  always  be  declined  by  the  company  even  on 
short-term  policies. 

Some  Points  in  the  Present-Day  Treatment  of  Diabetes. — 

The  standard  diet  of  von  Noorden's  clinic,  kevulose,  phos- 
phate of  lime,  thj-roid  extract,  uranium  nitrate,  hepatic 
extract,  antipyrin,  boracic  acid,  spermin,  etc.,  are  remedies 
discussed  pro  and  con. 

Clinical  Tests  lor  Sugar  in  the  Urine.  — By  R.  T.  William- 
son. 

Heredity  and  Immunity. — By  G.  A.  Reid. 

Norsk  Magazin  for  LiFgei'iiiens/caben,  fu/y,  igoo. 

lodo-Parotiditis. — K.  Gron  reports  the  case  of  a  syphilitic 
patient,  who  after  the  administration  of  potassium  iodide 
had  parotiditis  eight  times  out  of  sixteen.  A  small  dose 
affected  him  in  .some  cases,  and  a  large  dose  in  others,  but 
sometimes  he  took  as  much  as  240  gm.  without  effect.  No 
other  symptoms  of  iodism  were  observable,  except  on  one 
occasion,  when  he  had  headache  and  catarrh  of  the  nasal, 
pharyngeal,  and  ocular  mucous  membranes.  The  author 
is  unaljle  to  explain  the  phenomena  except  by  the  term 
idiosyncrasy. 

The  Actual  Condition  of  the  Question  of  Acetone. — H. 
Chr.  Geelmuyden  holds  tliat  tlie  necessary  condition  for 
the  production  of  acetonuria  is  an  insufficient  decomposi- 
tion of  hydrocarbons,  either  from  their  absence  in  the  diet, 
or  from  impaired  jiowers  of  decomposition  on  the  part  of 
the  organism  (diabetes).  In  advanced  diabetes  acetonu- 
ria is  a  grave  symptom,  threatening  coma.  This  coma 
may  be  delayed  by  the  administration  of  large  doses  of 
sodium  bicarbonate.  The  author  iliscusses  the  theories 
which  have  been  advanced  in  regard  to  the  physiology  of 
the  bodies  of  the  acetone  series,  their  origin,  seat  of  forma- 
tion, etc.  It  is  probable  that  they  are  formed  in  consider- 
able quantity  in  the  organism,  to  disappear  completely 
later.  They  doubtless  represent  links  in  a  continuous 
series  of  transformations  in  which  oxybutyric  acid-,;?  is  the 
primordial  term. 

A  Case  of  Spontaneous  Development.— By  Dr.  Drejer. 
Diet  in  Gastric  Disorders. — By  Olaf  Krich. 
Oil  Stoves.— By  Edward  Kaurin. 


@0rrcspoucIcuce. 


OUR    LONDON    LETTER. 

(From  our  Special  Correspondent.) 

IPSWICH — WAR  HOSPITALS  INQUIRY— HOSPITAL  FOR  PARALYSIS 
AND  EPILETSY  SCANDAL — SCHOOLS  OK  TROPICAL  MEDICINE — 
COLLEGE  CENTENARY — EMBALMING — POISONOtS  "  HEADACHE 
POWDERS" — WEATHER  —  N.\TIONAL  HOSPITAL  SCANDAL  — 
IPSWICH  ECHOES — PLAGUE — SALE  OK  POISONS — WAR  HOSPI- 
TAL  COM.MISSION. 

I-nNDON,  August  3.   1900. 

A  GOODLY  number  of  doctors  have  put  in  an  appearance 
at  Ipswich,  and  a  considerable  proportion  have  returned 
already,  while  more  are  e.xpected  to-morrow.  Not  a  few 
will  make  the  meeting  the  starting-point  for  their  holiday. 
Some  went  late  and  left  early,  others  ran  down  to  be  ready 
to  read  a  paper  in  their  section  or  join  in  a  discussion,  and 
returned  the  same  day.  Those  of  us  who  remain  take  a 
languid  interest  in  the  proceedings.  All  seem  elated  that 
the  a/li-iitat  of  the  Coundil  at  Exeter  Hall  was  rejected 
with  Ignominy,  and  a  few  are  nervous  lest  some  trick  may 
be  played  on  this  last  day  of  the  meeting.  Of  the  actual 
doings  you  will  be  fully  informed  by  your  own  reporters. 

The  War  Hospitals  (Commission  has  had  some  more  ex- 
citing evidence  this  week  than  last,  when  it  was  very  dull. 
On  Tuesday  Mr.  Burdett-Coutts  was  examined,  and  ex- 
plained that  in  using  the  word  "inhumanity  "  he  did  not 
mean  to  reflect  on  the  medical  corps,  but  on  the  deficien 
cies  of  the  supplies.  He  said  no  special  effort  was  made  to 
get  fresh  milk.  He  said  the  Royal  Army  Medical  Corps 
ought  to  get  rid  of  their  rooted  objection  to  female  nurses. 
Perhaps  this  remark  gi%-es  the  key  to  his  own  conduct. 
We  have  heard  of  the  "plague  of  women"  in  the  South 
African  hospitals — not  trained  and  capable  nurses,  but 
society-seekers  after  new  excitements.  The  doctors  were 
hampered  in  many  ways  by  these  meddlesome  women  who 
knew  nothing  of  nursing,  and  when  they  were  excluded 
they  started  a  campaign  of  misrepresentation,  pretending 
that  the  doctors  dared  not  let  them  see  the  state  of  the  hos- 
pitals. Poor  Mr.  Coutts  seems  to  have  been  made  a  cat's- 
paw  by  some  of  these  spiteful  .society  women. 

After  him.  Sir  William  MaaCormac  was  examined,  and 
repeated  what  he  has  already  stated  as  to  the  hospitals  he 
visited.  Lady  C.  de  Crespigny  said  she  saw  soldiers  Iving 
about  outside  the  tents  of  the  military  hospital  at  Kimber- 
ley,  and  at  the  Victoria  at  Bloemfontein  food  was  short. 

But  on  Wednesday  more  interest  was  excited,  for  Rud- 
yard  Kipling  told  the  commission  that  he  had  got  into 
some  hospitals  by  the  back  door,  pajamas,  drugs,  etc.,  at 
the  request  of  nurses,  just  to  save  time  and  circumvent 
red-tape.  He  said  that  he  was  told  there  were  drugs  in  the 
hospital,  but  when  a  man  is  ill  you  cannot  wait  for  routine. 
This  seems  very  well  as  to  pajamas  and  flannels,  but 
surely  it  was  not  for  nurses  to  say  what  drugs  were  wanted. 
Perhaps  they  were  not  properly  trained  nurses. 

The  distribution  of  /^  50,000  of  the  Hospital  .Sunday  Fund 
was  arranged  at  the  meeting  of  the  Council  this  week.  In 
consequence  of  the  scandal  in  connection  with  the  Hospital 
for  the  Paralyzed  or  Epileptic  that  institution  receives  no 
award.  The  manager,  who  is  dubbed  "the  secretary- 
director,"  appeared  before  the  committee,  which  invited 
the  board  and  the  staff  also  to  be  present.  The  result  of 
what  passed  is  '  no  award,"  and  the  public  will  accept  the 
decision  as  a  condemnation  of  the  board  of  management. 
Last  year  there  was  ample  warning  given  that  the  hospital 
would  not  receive  further  award  until  harmony  with  the 
medical  staff  was  restored.  This  would  seem  impossible 
with  the  present  board  in  office  guided  by  the  "secretary- 
director,"  and  the  sooner  the  governor  dismis.ses  the  board 
and  ajipoints  men  of  common  sense  to  manage  the  hospital, 
the  better  it  will  be  for  the  reputation  of  tlie  institution  and 
the  welfare  of  the  patients.  On  Saturday  Tiu-  Tiiiws  ])ub'- 
lished  a  letter  signed  by  the  medical  staff,  demanding  an 
independent  inquiry  into  the  administration  of  the  liospi- 
tal.  The  revelations  that  have  already  been  made  fully 
justify  this  course,  and  unless  the  governors  take  it  the 
scandal  will  spread,  for  1  hear  there  is  much  more  to  come 
out,  and  tliat  of  a  kind  which  the  public  can  appreciate,  for 
the  welfare  and  comfort  of  the  jiatients  are  involved  in  the 
mismanagement  alleged  to  be  .going  on. 

Dr.  Nocht,  port  medical  officer  of  Hamburg,  and  director 
of  the  School  of  Tropical  Diseases  about  to  be  opened  there, 
has  come  over  to  study  the  methods  of  the  London  and 
Liverpool  schools  of  this  department  of  medicine.  Major 
Ronald  Ross,  in  an  interview,  said  the  three  schools  would 
work  together  in  the  effort  to  lower  the  death  rate  ot  tropi- 
cal climates,  concerning  which  England  has  been  too  lax. 
The  west  coast  of  Africa  may  be  cited.  The  great  prob- 
lem there,  said  Major  Ross,  is  not  the  Ashantis,  but  ma- 
laria.    Do  away  with  that  and  you  have  a  .second  India,  a 


August  25,  1900] 


MEDICAL    RECORD. 


307 


fact  recognized  by  the  Liverpool  merchants  and  by  Mr, 
Chamberlain.  Malaria  germs  were  discovered  twenty 
years  ago,  but  the  discovery  has  been  practically  ignored. 
Germs  which  may  cause  dysentery  have  not  been  properly 
studied,  and  the  disease  has  caused  much  havoc  in  .South 
Africa.  Major  Ross  seemed  to  indorse  Professor  Wright's 
discovery  of  anti-typhoid  inoculation,  and  held  that  much 
might  have  been  done  to  avert  the  disease  in  Africa  had 
the  method  been  fully  followed.  Naturally  enough  he  felt 
deeply  the  neglect  to  follow  up  tlie  revelations  about  tlie 
mosquito.  That  malaria  is  propagated  by  it,  he  said,  has 
been  proved  in  India,  in  Italy,  and  elsewhere,  and  the 
French  Academy  has  recognized  the  discovery  ;  while  Eng- 
land only  sends  out  a  couple  of  expeditions  to  inquire,  in- 
stead of  taking  practical  measures  on  the  lines  suggested 
by  the  discovery. 

Continuing  the  account  of  the  College  of  Surgeons'  cen- 
tenary celebrations.  I  may  say  that  some  three  hundred 
and  fifty  persons  sat  down  to  the  festival  dinner  on  Tliurs- 
day  evening.  The  Prince  of  Wales  was  present,  and  in 
returning  thanks  for  the  toast  of  the  royal  family  exjiressed 
tlianks  also  that  his  diploma  of  honorary  fellow  would  not 
permit  him  to  practise  surgery.  Lords  Salisbury  and  Rose- 
bery  were  equally  amazed  to  find  themselves  made  a  part 
of  a  College  of  Surgeons.  They  might  add  tlieir  influence 
as  honorary  fellows  to  the  demands  of  members  for  the 
franchise.  On  Friday  the  official  reception  by  the  lord 
mayor  and  lady  mayoress  at  the  Mansion  House  was  fol- 
lowed by  a  conversazione,  which  some  go  so  far  as  to  pro- 
nounce the  pleasantest  function  of  the  centenary  celebra- 
tion. 

I  am  told  that  Professor  Renouard  is  coming  over  from 
your  side  to  instruct  undertakers  and  others  in  the  art  of 
embalming.  In  Europe  this  is  usually  done  by  medical 
men.  But  the  practice  is  not  general,  as  I  understand  it 
is  with  you. 

A  child  has  been  poisoned  by  a  "headache  jjowder " 
bought  at  a  grocer's.  It  contained  a  heavy  adult  dose  of 
acetanilid.  And  our  legislators  permit  such  poisons  to  be 
sold  by  grocers  and  stores  as  freely  as  carbolic  acid  and 
others!  Verdict — accident.  But  what  if  a  doctor  accident- 
ally poisoned  a  patient? 


London,  Aujjust  10,  1900. 

The  "heat-wave"  you  sent  us  was  succeeded  by  cold, 
rain,  thunder  storms,  and  cyclones.  Day  after  day  the 
papers  were  filled  with  accounts  of  floods  and  other  catas- 
trophes caused  by  the  storms,  to  say  nothing  of  the  deaths 
of  men  and  cattle.  The  svidden  fall  of  some  30'  in  the 
tliermometer  set  men  talkin,g  about  arctic  severity,  which, 
of  course,  was  mere  exaggeration,  for  the  instrument  per- 
sistently pointed  at  temperate.  XevertheLess,  many  were 
glad  to  liglit  fires  again,  although  in  August.  Then  came 
cajjles  saying  you  were  having  another  heat-wave,  and  as 
our  clerk  of  the  weather  often  takes  his  cue  from  yours  we 
be.gan  to  feel  that  we  should  yet  have  some  more  summer. 
But  here  we  are  still  waiting  for  a  share  of  your  heat-wave 
which  does  not  come,  and  I  write  by  a  fire  ! 

The  long-standing  dispute  at  the  National  Hospital 
should  soon  be  settled.  The  staff  have  signed  a  letter  for 
puljlication  exposing  the  breach  of  faith  of  the  committee 
and  the  autocratic  conduct  of  the  director.  They  have 
further  shown  the  administrative  evils  of  committing  all 
power  to  one  man,  and  the  absurd  position  of  a  board 
which  has  become  the  tool  of  its  paid  servant.  The  con- 
demnation by  the  Sunday  Fund  committee,  which  with- 
holds its  award  this  year,  should  be  enough  to  settle  the 
matter,  but  the  director  does  not  seem  disposed  to  resign. 
The  staff  declare  they  "are  unanimous  in  their  resolve  to 
put  an  end  to  the  evils  of  the  present  system."  On  the 
appearance  of  this  protest  the  board  called  a  meeting  of 
the  governors  for  to-morrow.  This  looks  as  if  they  delib- 
erately chose  a  time  when  very  few  are  in  town,  and  the 
staff  decline  to  be  a  party  to  anything  of  the  kind  and  re- 
peat their  demand  for  a  full  and  independent  inquiry. 

Echoes  from  Ipswich  are  loud  and  persi,stent.  They  are 
jubilant  in  tone,  too,  for  though  the  atmosphere  of  debate 
was  as  changeable  and  stormy  as  the  weather  outside,  the 
association  scored  a  triumph  over  the  Council  respecting 
the  disgraceful  attempt  to  cheat  the  members  out  of  their 
slender  rights  and  grasp  the  control  of  the  funds.  The 
Council  should  have  understood  their  position  under  their 
"articles  of  association"  when  these  were  framed  and  the 
society  was  incorporated  under  the  Limited  Liability  Acts, 
Finding,  however,  that  the  apathy  of  members  could  be 
generally  counted  on,  they  attempted  their  coup  d'c'/a/  at 
Exeter  Hall,  intending  to  liave  it  ratified  at  Ipswich.  But 
the  scheme  was  defeated  at  the  outset.  No  one  who  looked 
at  it  could  help  seeing  that  it  was  an  attempt  to  condone 
illegality  in  the  pa.st  and  to  hand  over  every  authority  to 
the  Council  with  all  the  funds,  and  .so  erect  these  would-be 
despoilers  into  another  petty  medical  oligarchy.  We  have 
too  many  such  "authorities  "  not  to  see  how  they  are  likely 
to  act,  and  the  Council  have  only  themselves  to  thank  for 


this  disgrace  they  have  reaped  from  their  barefaced  at- 
tempt. 

Dr.  Pye-Smith's  address  seems  to  have  given  much  sat- 
isfaction, judging  by  the  pithy  examples  brought  away  and 
handed  round  liere.  Take  a  sample  or  two;  "To  say  a 
man  died  of  apoplexy  or  paraplegia  is  to  state  a  fact  within 
the  practitioner's  knowledge;  to  say  he  died  of  cerebral 
hemorrhage  or  of  myelitis  is  only  a  doubtful  inference  un- 
less a  post-mortem  has  shown  it.  .  A  man  who  believes 
everything  about  the  action  of  remedies  in  Garrod  or  Wood 
or  in  the  assertions  of  advertising  druggists  is  apt  to  end 
in  unbelief  in  opium  and  is  sure  to  be  unsuccessful.  Is  it 
not  a  pity  to  prescribe  made-up  pills  and  mixtures  of  manu- 
facturers, and  so  lead  patients  to  ascribe  their  recovery  to 
the  special  cure  instead  of  our  skill?  How  can  statistics 
be  useful  when  made  up  of  the  cases  of  one  disease  under 
curious  names?  I  see  many  patients  suffering  from  idle- 
ness, few  from  hard  work.  Worry  or  nerve  prostration  is 
generally  only  a  veil  for  drink  and  gambling.  Steady 
work  is  the  best  cure  for  a  thousand  nervous  ailments," 

During  the  discussions  warm  words  were  sometimes  ex- 
changed, as  when  the  jiresident  of  the  Council  said  to  Mr. 
Horsley,  "Your  amendment  comes  to  the  same,"  and  was 
promptly  told,  "No,  it  doesn't,  and  you  know  it,"  thus  pro- 
voking, "Don't  question  our  don ct  /ii/ts,"  and  extracting 
the  retort,  "The  proposal  has  been  shelved  the  same  way 
before.  " 

When  Professor  Byers  suggested  that  there  was  too 
much  centralization  in  the  bestowal  of  scientific  grants. 
Dr.  Saundby  was  up  in  a  moment,  and  a  lively  bit  of  dia- 
logue ensued.  Dr.  Haddon  joined  in  and  declared  much 
money  allowed  for  grants  was  really  frittered  away.  He 
preceded  to  remark  that  he  had  previously  spoken  on  this 
subject,  and  was  shouted  down  with  cries  of  "You  have — 
you  have." 

Now  and  then  two  or  three  .gentlemen  were  speaking  at 
once  with  considerable  excitement,  and  that  at  times  they 
seemed  to  be  passing  doubtful  compliments,  but  it  was 
hardly  possible  to  be  sure  of  the  words.  Nor  were  these 
amenities  confined  to  the  general  meetings.  Even  the  sec- 
tions were  occasionally  lively.  In  one  a  gentleman  dis- 
claimed responsibility  for  a  paper  he  read  for  an  absent 
member,  when  the  speaker  he  had  interrupte«i  remarked, 
"I  didn't  say  anything  of  you  in  particular,"  and  was 
answered,  "No,  sir:  but  you  shook  your  fist  at  me,"  to  the 
intense  amusement  of  the  audience. 

The  dinner  went  off  successfully— at  least  those  who 
were  jjresent  say  so,  though  some  who  stayed  away  afi'ect 
to  think  nothing  of  it.  The  president  presided,  and  here  as 
throughout  seems  to  have  given  great  satisfaction.  The 
toast  of  the  army,  navy,  and  volunteers  naturally  drew 
out  applause.  In  responding,  Surgeon-General  Hamilton 
referred  to  the  "hysterical  allegations  of  Jlr.  Burdett- 
Coutts,"  and  knowing  the  difficulties  of  the  country  de- 
clared that  it  was  impossible  to  imagine  more  could  have 
been  done  than  was  done  for  the  sick  and  wounded.  There 
was  nothing,  he  said,  the  field-marshal  would  not  have 
done  to  have  saved  a  single  man  an  hour  of  suffering. 
When  he  remarked  that  the  medical  service  had  been  for 
years  impressing  on  the  War  Office  the  importance  of  un- 
derstanding, .some  one  interrupted  with  a  cry  of  "They 
can't,"  and  the  remainder  of  the  sentence  was  drowned  in 
laughter. 

Sir  John  Moore  proposed  "The  Mayor  and  Town  of  Ips- 
wich," and  the  mayor  responded  in  a  witty  speech  provok- 
ing much  laughter  and  applause. 

Sir  C.  Dalrymple,  in  proposing  the  Association,  was  not 
much  behind  when  he  admitted  he  had  not  heard  one  of 
the  addresses,  but  the  rapidity  of  communication  in  these 
days  was  such  that  he  read  it  in  his  newspaper  in  the  train 
before  it  was  delivered. 

The  president's  toast  elicited  enthusiasm,  and  was  re- 
plied to  with  hearty  thanks. 

While  the  dinner  was  proceeding  there  was  a  smoking 
concert  at  another  place,  and  in  the  museum  a  soiree  was 
given  by  the  ladies  of  the  locality,  which  was  attended  by 
some  eight  hundred  people. 

I  hear  that  the  garden  parties  and  other  out-door  enter- 
tainments were  as  successful  as  the  weather  permitted. 
The  museums  offered  shelter  in  heavy  rain  to  those  who 
fled  the  sections.  The  Pathological  Museum  had  some  in- 
teresting specimens  from  the  Norfolk  and  Cambridge  hos- 
pitals, and  a  series  of  slides  from  the  London  Tropical 
School  illustrating  malaria,  etc.  The  drug  and  apparatus 
museum  was  of  the  usual  character — a  few  novelties  at- 
tracting attention. 

The  landing  of  four  cases  of  plague  at  the  docks  caused 
some  trouble  to  our  health  department.  They  were  quickly 
isolated,  and  the  medical  officers  of  health  profess  to  be 
quite  ready  to  deal  with  any  other  cases  that  may  be  landed 
on  our  coasts. 

Another  death  from  headache  powders  is  reported.  At 
last  carbolic  acid  is  to  be  scheduled  as  a  poison.  Why  not 
other  poisons  too? 


;o8 


MEDICAL    RECORD. 


[August  25,  1900 


^ocutQ  Reports. 

THE   BRITISH    MEDICAL    ASSOCIATION. 

Sixty-eigkt/i  Annual  Meeting.  Held  at  Jps-tvicli.  July  31, 
and  August  /,  2,  and  j,  igoo. 

(Special  Report  for  the  Medical  Record.) 
GENERAL   SESSIONS. 

(Continued ^rom  /agf  278.) 

T/iird  Day —  Thursday,  August  2d. 

The  third  general  session,  held  in  the  central  hall  of 
the  Higher  Grade  School,  was  called  to  order  by  the 
president  at  2  :3o  p.m. 

Address  in  Surgery Mr.  Frederick  Treves,  of 

London,  then  delivered  the  annual  address  on  surgery, 
taking  as  his  title  "The  Surgeon  in  the  Nineteenth 
Century."  He  began  by  drawing  a  picture  of  England 
as  it  was  one  hundred  years  ago — the  life  mostly  spent 
in  little  villages,  when  travelling  was  a  lu.\ury  limited 
to  the  few.  London  was  not  one-fourth  of  its  present 
size;  no  railway  terminus  flaunted  its  structures  in  the 
city's  midst;  there  were  no  telegraph  and  no  telephone. 
The  postal  system  was  without  form  and  void.  Educa- 
tion among  the  mass  of  the  people  was  a  matter  of  lit- 
tle account,  and  was  to  a  great  extent  actually  non- 
existing.  As  to  the  surgeon,  he  was  but  a  sorry 
element  in  social  life.  In  the  great  towns  and  cities 
there  were  esteemed  practitioners  of  surgery  who  were 
eminent  by  reason  of  their  scientific  work  and  their 
successful  practice,  but  their  numbers  were  few.  In 
the  country  the  surgeon  or  common  practitioner  was 
usually  ignorant,  illiterate,  sordid,  not  without  a  sus- 
picion of  dishonesty  and  of  a  leaning  toward  the  bot- 
tle. He  was  to  a  large  extent  a  mere  retailer  of  physic, 
and  in  the  public  eye  he  ranked  with  the  quacks  and 
nostrum  sellers  with  whom  he  competed.  In  noting 
the  advances  made  by  the  surgeon  during  the  centuiy, 
the  first  matter  to  be  dealt  with  concerned  his  position 
as  an  adviser  to  his  patient.  Sick  men  demanded 
knowledge  from  their  physicians.  In  the  past  the  sur- 
geon had  to  make  up  by  fiction  what  he  lacked  in 
fact.  The  surgeon  of  the  present  day,  as  an  adviser, 
was  in  a  position  which  is  so  greatly  improved  that 
it  could  hardly  have  been  imagined  by  his  forebears  of 
a  hundred  years  ago.  He  had  in  the  first  place  to 
deal  with  a  more  enlightened  public,  and  in  tiie  sec- 
ond place  the  additions  made  to  surgical  lore  had  been 
so  substantial  that  in  many  departments  surgery  had 
reached  to  the  status  of  an  exact  science.  There  was 
no  longer  need  to  call  upon  invention  to  fill  up  the 
gaps  of  the  unknown.  One  said  that  at  present  nothing 
was  known  of  the  nature  and  causes  of  cancer,  and  the 
patient  was  satisfied,  whereas  at  the  beginning  of  the 
century  he  should  have  been  told  that  it  was  "  a  dis- 
eased hardness''  or  a  "  scirrhous  degeneration."  Doc- 
tors still,  to  be  sure,  talked  of  the  constitution,  of  sup- 
porting the  system,  of  poverty  of  blood,  diminished 
vitality,  sympathetic  inflammation,  tonics,  galacta- 
gogues,  alteratives,  strengthening  the  lungs,  giving 
tone  to  the  stomach,  etc.,  but  the  modern  surgeon 
could  dispense  with  these  empty  forms.  As  a  man  of 
learning,  the  surgeon  of  a  century  ago  knew  nothing  of 
the  causes  of  infiammation  and  of  the  dangers  to  open 
wounds.  He  had  no  glimmer  of  the  possibilities  of 
asepsis;  lie  had  no  anresthetic,  no  hypodermic  syringe, 
no  clinical  thermometer,  no  practical  means  of  inves- 
tigation in  clinical  chemistry.  The  very  name  bac- 
teriology did  not  exist,  and  the  treatment  of  disease 
by  prepared  serums  would  have  seemed  to  him  a  wild 
dream.  The  microscope  played  no  part  in  iiis  equip- 
ment;   he  had  no  laryngoscope  nor  ophthalmoscope. 


and  his  acquaintance  with  otology,  skin  affections,  and 
diseases  of  women  was  but  rudimentary.  Conservative 
surgery  and  plastic  operations  were  unknown.  There 
was  no  systematized  medical  education;  the  training 
of  the  surgeon  was  paltry,  casual,  and  inefficient. 
During  the  nineteenth  century,  the  surgeon,  as  an 
operator,  passed  through  a  rapid  metamorphosis,  and 
had  now  reached  the  level  of  the  unexpected.  He 
possessed  some  qualities  which  were  now  falling  into 
abeyance,  and  which  could  not  pass  away  quite  unre- 
gretted.  The  success  of  his  craft  depended  largely 
upon  his  daring,  upon  the  alertness  of  his  eye,  the 
steadiness  of  his  nerve,  and  the  rapidity  of  his  move- 
ments. In  spite  of  moans  for  mercy  the  knife  had  to 
move  on  its  way  steadily,  and,  undeterred  by  struggles 
and  bursts  of  hemorrhage,  the  blade  must  needs  pass 
without  faltering  or  sign  of  hesitancy.  At  present  the 
surgeon's  hand  could  move  with  leisurely  precision, 
and  the  operating  theatre  had  changed  from  a  sham- 
bles to  a  chamber  of  sleep.  The  operator  had  less 
need  for  dashing  qualities,  but  he  had  gained  much 
in  the  sympathetic  handling  of  his  patient.  Beyond 
these  general  changes  in  the  attitude  of  the  operator 
there  had  been  special  advances  in  the  surgeon's  art. 
Prominent  among  these  might  be  mentioned:  ( i )  an 
improved  knowledge  of  anatomy ;  (2)  a  readier  method 
of  arresting  hemorrhage;  (3)  the  employment  of  anaes- 
thetics; (4)  the  introduction  of  antiseptic  measures. 
The  science  of  anatomy  was  well  advanced  at  the  be- 
ginning of  the  century,  but  it  was  not  taught  to  the 
common  student.  Hemorrhage  was  expected  in  opera- 
tions, tourniquets  were  employed  freely  and  with  harsh- 
ness, raw  surfaces  were  bathed  with  styptic  solutions 
which  were  destructive,  or  at  least  opposed,  to  primary 
healing.  The  ecraseur  was  employed  for  the  removal 
of  growths  of  various  kinds.  At  the  present  day  the 
surgeon  had  little  dread  of  hemorrhage;  bleeding  was 
often  anticipated  by  applying  a  temporary  or  perma- 
nent ligature  to  a  main  artery  before  a  part  supplied 
by  that  vessel  was  excised.  With  an  anesthetized  pa- 
tient, a  surgeon  could  proceed  with  slowness.  Press- 
ure forceps,  moreover,  had  brought  a  great  assurance 
of  security  and  had  done  much  to  extend  the  area  of 
safe  operation.  The  value  of  ana:sthesia  was  too  well 
understood  to  call  for  comment.  It  had  not  only  ex- 
tended surgery,  but  had  engendered  surgeons.  Anti- 
septic measures,  and  the  changes  wrought  by  them, 
were  also  well  known.  The  surgeon  had  learned  to 
be  clean,  and  had  become  aware  of  the  potency  of  lit- 
tle things.  As  to  the  surgeon  of  the  future,  the  days 
of  the  great  operator,  of  the  one  man  to  whom  all 
came  who  could,  were  rapidly  passing  away.  The 
practice  of  pure  surgery  was  now  becoming  common  to 
the  many.  The  man  who  excelled  conspicuously  as 
an  operator  would  always  attain  such  eminence  as  his 
ability  deserved,  but  the  exclusiveness  of  the  practice 
of  surgery  was  quietly  vanishing  with  the  century. 
The  change  was  well.  Some  undesirable  develop- 
ments there  were;  men  w'ho  were  not  qualified  might 
occasionally  perform  major  operations.  We  were  also 
in  danger  of  passing  from  the  policy  of  doing  too  lit- 
tle to  the  policy  of  doing  too  much.  So  many  were  the 
artificial  aids  to  clinical  investigation  that  it  was  a 
question  whetiier  the  natural  acumen  of  the  surgeon 
would  not  deteriorate  in  proportion  as  he  failed  to  en- 
courage that  particular  learning  which  clung  to  the 
finger-tips  of  all  great  diagnosticians.  The  skiagraph 
embodied  a  substantial  gain,  but  it  was  to  be  dis- 
counted by  the  loss  of  tiie  great  element  in  education 
which  it  was  slowly  replacing.  An  abdominal  swell- 
ing was  brought  under  notice.  Its  features  were  ob- 
scure, but  much  of  the  uncertainty  of  outline  could  be 
dissipated  by  a  cultured  hand  which,  with  infinite 
patience  and  repetition,  had  learned  to  construct  a 
reality  out  of  a  shadow.     It  might  be  said  that  it  was 


August  25,  1900] 


MEDICAL    RECORD. 


309 


needless  to  persist  in  bringing  this  much-elaborated 
means  of  inquiry  to  further  perfection,  since  the  prob- 
lem was  at  once  to  be  solved  by  an  exploratory  lapa- 
rotomy. By  such  little  operation  a  great  advantage 
was  gained,  but  an  opportunity  to  add  to  one  of  the 
most  refined  forms  of  learning  was  lost.  The  value 
of  the  e.xploratory  incision  was  beyond  question,  but 
among  the  signs  of  the  times  it  was  impossible  not  to 
notice  a  tendency  to  resort  too  readily  to  this  means 
of  solution.  There  were  cases  which  presented  symp- 
toms hard  to  interpret  at  any  superficial  inquiry.  V\'as 
it  worth  while  in  such  to  undertake  an  e.\haustive  crit- 
ical research  and  to  submit  the  whole  to  a  trained 
judgment  ?  The  quest  would,  no  doubt,  develop  habits 
of  observation  and  powers  of  weighing  evidence;  but 
the  process  was  slow,  and  an  inquiry  carried  out  in 
a  bacteriological  laboratory  would  clear  up  all  doubts, 
and  at  the  same  time  dispense  with  the  efforts  of  a 
cultured  sense.  Those,  therefore,  who  were  concerned 
with  the  education  of  the  surgeon  of  the  future  would 
do  well  to  cherish  still  this  ancient  power,  and  to  fos- 
ter a  memory  of  the  fact  that  surgery  was,  in  its  very 
essence,  a  handicraft,  and  that  in  all  that  he  did  the 
surgeon's  great  endeavor  should  be  to  make  his  own 
hands  self-sufficing.  It  was  sad  to  think  that  this 
hardly  acquired  faculty  died  with  the  possessor  of  it. 
An  individual  loss  did  not,  however,  hinder  the  gen- 
eral tide  of  progress.  Advance  in  such  a  work  as  ours 
depended  upon  the  uneventful  w^ork  of  the  whole  body 
and  was  only  accentuated  by  the  achievements  of  the 
prominent  few.  The  movement  was  the  movement  of 
a  multitude  in  which  individuality  was,  at  a  distance 
•of  time,  little  to  be  distinguished,  and  in  which  per- 
sonal eminence  contributed  a  smaller  factor  than  the 
present  was  willing  to  acknowledge.  Those  who  stood 
forth  as  the  leaders  of  the  advance  were  merely  the 
elect  of  the  common  body  and  the  representatives  of  a 
wide  intellectual  franchise.  F.ven  he  who  startled  the 
world  as  a  discoverer  had  often  done  little  more  than 
give  e.xpression  to  what  was  already  nascent  in  the 
multitude.  So  as  one  great  surgeon  after  another 
dropped  out  of  the  ranks  his  place  was  rapidly  and 
imperceptibly  filled,  and  the  advancing  line  moved  on 
with  still  the  same  solid  and  unbroken  front. 

After  the  usual  vote  of  thanks  to  the  orator  the  sub- 
ject of  reorganization  was  resumed.  The  president  of 
the  Council  presented  one  list,  and  Mr.  Horsley  pre- 
sented the  other,  as  had  been  arranged.  The  meeting 
accepted  the  two  lists  and  appointed  the  gentlemen 
named  in  them  the  committee,  as  follows:  Nominated 
by  the  Council:  Surgeon-General  Hamilton,  South 
Africa;  Mr.  J.  Cantlie,  India  and  Eastern  Archi- 
pelago; Sir  John  William  Moore,  Ireland;  Dr.  J.  C. 
McVail,  Scotland;  Dr.  J.  Roberts-Thomson,  Mr.  T. 
Jenner-Verrall,  Dr.  S.  Woodcock,  Dr.  R.  Saundby, 
Mr.  .-Andrew  Clark,  Dr.  J.  Ward  Cousins,  Dr.  H.  Rad- 
cliffe  Crocker.  Mr.  H.  T.  Butlin,  England.  By  Mr. 
Horsley:  Dr.  Buist,  Dundee;  Dr.  Byers,  North  of  Ire- 
land; Dr.  Gooding,  West  Indies;  Dr.  Morier,  Austral- 
asia; Dr.  Bateman,  Dr.  A.  Co.x,  Dr.  Gordon,  Dr.  Mil- 
burn,  Dr.  Browne-Ritchie,  Dr.  Whitaker,  Mr.  Victor 
Horsley,  England;   Mr.  Edmund  Owen,  Canada. 

Dr.  O'Conxor  said  that  in  accordance  with  the 
rules  observed  in  royal  commissions  the  meeting 
should  appoint  the  chairman,  and  he  therefore  pro- 
posed Mr.  Horsley. 

Dr.  a.  Co.x  supported  this,  amid  cries  of  "  No,  no!  " 
and  the  president  said  he  must  rule  the  motion  out  of 
order,  whereupon  Dr.  O'Connor  declared,  amid  laugh- 
ter, that  the  ruling  was  unconstitutional,  and  the  pres- 
ident provoked  renewed  laughter  by  saying,  "  It  is  my 
ruling." 

Dr.  Sarat  Mullick  brought  forward  a  motion,  of 
which  he  had  given  due  notice,  on  the  system  of  filling 
professorial  chairs  in  India.     These  appointments,  he 


said,  were  given  more  by  virtue  of  grade  rank  in  the 
Indian  medical  service  than  by  special  ability  of  can- 
didates, and  he  proposed  a  sub-committee  to  inquire 
and  report  to  the  council  on  the  subject. 

Mr.  Horsley  seconded.  Colonel  McLeod  and  others 
opposed. 

Eventually  it  was  agreed  to  refer  the  subject  to  the 
parliamentary  bills  committee. 

Mr.  R.  B.  Anderson  brought  forward  a  motion  of 
which  he  had  given  due  notice,  condemning  the  Coun- 
cil for  repudiating  its  subordination  to  the  general 
meetings,  contrary  to  the  articles  of  association,  and, 
further,  his  resolutions  embodied  a  plan  for  securing 
a  change. 

The  President  of  the  Council  rose  to  order,  and 
said  Mr.  Horsley's  motion  was  placed  in  the  forefront 
of  the  business,  by  arrangement,  for  the  purpose  of 
dealing  with  and  covering  all  questions  relating  to  the 
constitution  of  the  association. 

Mr.  Anderson  said  he  was  not  a  party  to  such  ar- 
rangement, and  claimed  the  right  to  move  his  resolu- 
tion. 

The  President  interposed,  and  said  such  had  been 
the  general  understanding,  and  he  should  rule  the 
motion  out  of  order. 

Mr.  Anderson  thereupoi  gave  formal  notice  of 
protest  against  this  ruling,  and  that  he  reserved  all 
his  rights  on  the  question. 

A  member  warmly  supported  Mr.  Anderson,  but  the 
president  was  firm. 

It  was  agreed  to  pay  the  expenses  of  the  constitu- 
tional committee,  and  that  the  provincial  members 
should  be  allowed  a  guinea  a  day  for  hotel  expenses. 


Fourth  Day — Friday,  August  jd. 

The  closing  meeting  was  called  to  order  by  the 
president  at  the  usual  hour. 

Address  in  Obstetrics. — This  was  delivered  by  Dr. 
^^'lLLIAM  J.  Smvlv.  who  took  for  his  subject  "The 
Maternal  Mortality  in  Childbirth.'"  He  said  that  the 
improvement  in  the  death  rate  did  not  take  place 
gradually  as  the  light  of  science  slowly  dawned  upon 
our  art.  but  occurred  suddenly  in  the  seventh  decade 
of  the  present  century.  In  the  Paris  Maternity,  for 
example,  the  mortality  dropped  in  one  year  from  eight 
per  cent,  to  four  per  cent,  and  in  1881  to  one  per  cent., 
and  has  since  improved,  and  in  all  the  hospitals  of 
Europe  a  similar  change  occurred.  As  to  private 
practice  it  was  impossible  to  give  any  facts  founded 
upon  reliable  statistics.  The  statistics  of  the  Rotunda 
Hospital  from  1870-1876  (the  period  immediately 
preceding  the  introduction  of  antiseptics)  gave  8,092 
women  delivered,  of  whom  169  died,  or  i  in  45.5. 
During  the  time  from  1890-1896  there  were  9,085, 
with  50  deaths,  or  i  in  181. 7,  a  saving  of  about  200 
maternal  lives  in  every  lo.ooo  deliveries.  Similar 
results  were  shown  by  hospitals  generally.  The 
greatest  improvement  was  noticed  in  puerperal  fever, 
or  septic  infection.  In  the  beginning  of  the  century 
obstetricians  were  ignorant  of  the  nature  of  this  chief 
cause  of  childbed  mortality,  and  were  helpless  to  pre- 
vent or  to  cure  it.  Epidemics  became  more  frequent 
and  more  virulent,  and  obstetricians  endeavored  by 
clinical  observation  and  post-mortem  examination  to 
discover  its  nature;  but  unfortunately  both  these 
roads  to  knowledge  were  pursued  by  the  same  indi- 
viduals, and  with  disastrous  results.  In  1872  Dr. 
Churchill  reflected  the  general  ignorance  when  he 
published  in  the  sixth  edition  of  his  well-known  work 
his  opinion  that  puerperal  fever  was  due  to  mental 
emotion,  cold,  putrefaction  of  portions  of  retained 
placenta,  gastro-enteric  irritation,  the  state  of  the  at- 
mosphere, epidemic  influences,  and  contagion.  With 
regard  to  the  latter,  he  felt  compelled  by  the  evidence 


3IO 


MEDICAL    RECORD. 


[August  25,  1900 


to  admit  the  possibility  of  its  being  conveyed  and 
communicated  or  excited  by  those  who  liad  attended 
midwifery  cases  after  being  employed  in  dissection  or 
post-mortem  examination,  or  who  were  much  in  con- 
tact with  fever  patients;  but  in  all  other  cases  he  at- 
tributed its  occurrence  to  epidemic  influence.  Toward 
the  end  of  the  last  century  Dr.  White,  of  Manchester, 
published  a  remarkable  work  in  which  he  attributed 
puerperal  fever  to  the  absorption  of  putrid  matter  by 
the  lymphatics  and  vessels  of  the  womb.  .At  this 
conclusion  he  arrived  by  observing  the  similarity  in 
causation  and  symptoms  in  putrefactions  occurring  in 
other  parts  of  the  body.  He  further  observed  that 
when  a  putrid  wound  was  cleansed,  the  symptoms 
abated.  His  treatment  was  therefore  directed  toward 
the  prevention  of  putrefaction,  and  elimination  of 
putrid  matter  should  it  have  already  formed.  To  these 
ends  he  advocated  thorough  ventilation,  cleanliness, 
and  drainage.  Free  and  even  cold  air  should  pervade 
the  apartment,  and  clean  linen  be  supplied  every  day. 
The  lochia,  if  permitted  to  stagnate  in  the  vagina, 
would  soon  become  putrid,  for,  he  said,  it  was  well 
known  that  the  mildest  humors  in  the  human  body,  if 
suffered  to  stagnate,  became  acrid  as  soon  as  the  air 
had  access  to  them.  He  therefore  encouraged  his  pa- 
tients to  sit  up  several  I'mes  a  day,  or  even  to  leave 
their  beds  so  as  to  prevei.t  a  lodging  of  offending 
matter  in  the  vagina,  uterus,  intestines,  or  bladder. 
"I  must  not  omit  to  mention,"  he  said,  "the  good 
effects  I  have  experienced  from  emollient  or  antiseptic 
injections  into  the  uterus  by  means  of  a  large  ivory 
syringe  or  elastic  vegetable  bottle  in  those  cases  in 
which  the  lochia  have  become  acrid  or  putrid.  ...  I 
have  by  this  means  known  the  fever  to  be  much  as- 
suaged and  in  many  cases  wholly  extinguished."  One 
could  not  but  wonder  at  White's  independence  of 
opinion  and  the  general  correctness  of  his  views. 
Ignorance,  prejudice,  obstinacy,  were  the  forces 
against  which  he  combated  in  vain,  and  not  until 
fifty  years  later  did  another  champion  take  the  tield 
against  them,  to  perish  in  the  attempt.  This  champion 
was  Ignatz  Philipp  Semmelweis.  In  1846  he,  a  young 
man  of  twenty-eight  years,  was  appointed  assistant  to 
Professor  Klein  in  the  maternity  department  of  the 
Vienna  Hospital.  His  observant  mind  was  struck  by 
the  fact  that  the  mortality  in  childbed  was  immensely 
greater  in  the  department  attended  by  students  who 
also  attended  posi-mortems,  than  in  the  department 
reserved  for  pupil  midwives.  He  concluded  that  the 
cause  of  puerperal  fever  must  be  an  infection  from 
without,  due  to  the  transportation  of  poison  by  the 
fingers  and  instruments  of  attendants,  and  by  ordering 
disinfection  of  hands,  instruments,  and  air,  he  reduced 
the  mortality  from  5.3  per  cent,  to  1.27  per  cent. 
Jealousy  and  unbelief  thwarted  him  in  Vienna  and  in 
Buda-Pesth,  and  he  retired  from  practice  to  write  a 
work  on  "The  Nature  and  Prophylaxis  of  Puerperal 
Infection."  In  his  endeavors  to  impress  upon  others 
the  importance  of  his  life-saving  truths  he  fretted  and 
fumed  his  life  away,  and  finally  died  in  an  insane 
asylum,  of  septic  infection.  Had  he  had  more  patience 
he  might  have  observed  that  the  seed  he  was  sowing 
had  taken  root.  His  views  were  adopted  by  Michaelis, 
Lange,  and  Simpson,  and  Pasteur's  wonderful  discov- 
eries set  them  upon  a  firm  scientific  footing.  Lister 
in  1 86-1.  astonished  the  world  by  the  wonders  of  anti- 
septic surgery.  Stadfeld,  Bischoff,  Fritsch,  Schroeder, 
Breisky,  and  Lucas  Championnil-re  were  the  pioneers 
in  the  movement  for  applying  antiseptic  principles  to 
obstetric  practice.  Soon  the  spray  was  replaced  by 
the  douche,  and  the  vagina  was  douched  with  antiseptic 
fluids  before  and  after  every  labor;  the  uterus  was 
soon  included  in  the  process.  Accidents  and  deaths 
occurred,  however,  due  to  the  injection  of  air  and 
fluids  into  the  veins.     Leopold  showed  that  by  thor- 


oughly disinfecting  the  external  parts  and  avoiding 
unnecessary  examinations  better  results  were  obtain- 
able than  by  prophylactic  douching.  The  whole 
question  of  the  value  of  prophylactic  douching  re- 
solved itself  into  the  probability  or  even  possibility 
of  auto-infection.  That  the  vaginal  discharges  often 
contained  germs,  many  of  which  were  apparently 
aseptic  or  saprophytic,  was  undeniable,  but  were  these 
germs  really  dangerous  to  the  patient,  and  could  they 
be  removed  by  antiseptic  measures?  These  were  the 
two  important  questions.  Kronig  injected  cultures 
of  various  bacilli  into  the  vagina,  and  found  that  they 
were  all  eliminated  within  twenty-four  hours.  In 
cases  in  which,  after  injecting  the  micro-organisms, 
he  at  once  thoroughly  scrubbed  out  the  vagina  with  a 
one-per-cent.  solution  of  corrosive  sublimate  or  lysol, 
they  had  not  entirely  disappeared  at  the  end  of  thirty- 
six  hours.  The  douche,  therefore,  not  only  failed  to 
dislodge  them,  but  so  altered  or  removed  the  natural 
discharges  that  for  at  least  twelve  hours  the  normal 
bactericidal  action  of  the  vagina  was  annihilated. 
The  speaker  believed  that  unless  nurses  could  be 
trusted  to  preserve  perfect  asepsis,  vaginal  prophylactic 
douching  w'as  productive  of  more  harm  than  good- 
The  teaching  of  Semmelweis  and  Sir  James  Simpson, 
that  infection  was  carried  chiefly  by  the  hands  of  at- 
tendants, was  now  the  generally  accepted  opinion. 
Experience  proved  that  an  absolutely  aseptic  condi- 
tion of  the  hands  could  not  be  insured  by  any  known 
process,  and  from  this  is  learned:  (1)  to  avoid  as 
far  as  possible  septic  contamination;  (2)  to  spare  no 
pains  to  render  the  hands  as  innocuous  as  possible; 
y)  to  restrict  local  interference  within  the  narrowest, 
bounds.  The  last  of  these  rules  included  not  only 
unnecessary  operative  interference,  but  also  needless 
vaginal  examinations.  Next  to  antiseptics,  the  author 
considered  the  substitution  of  external  for  internal  ex- 
aminations the  most  important  advance  in  modern 
midwifery.  By  whom  it  was  introduced  he  did  not 
know,  but  its  systematization  and  popularity  were  owed 
to  Pinard.  Crede,  and  Leopold.  By  its  means  it  can 
be  ascertained  whether  the  woman  is  pregnant,  the 
period  of  pregnancy,  the  position  and  presentation  of 
the  ftetus,  whether  it  was  living,  dying,  or  dead,  and 
whether  there  was  one  child  or  more  in  the  uterus. 
The  presence,  course,  and  progress  of  labor  could  be 
told;  and  pelvic  deformity  and  many  other  conditions 
could  be  diagnosed.  External  examination  was  safer, 
gave  more  information  to  the  examiner,  and  was  easier 
and  more  reliable.  In  the  Rotunda  Hospital,  students 
made  more  mistakes  with  the  vaginal  than  with  the 
abdominal  method.  Two  things  could  be  made  out 
only  by  vaginal  examination  —  the  condition  of  the  os 
uteri,  and  a  prolapse  of  the  umbilical  cord.  A  fat  or 
rigid  abdomen  on  the  part  of  the  patient  also  neces- 
sitated an  internal  examination.  The  speaker  seldom 
examined  more  than  once  in  the  course  of  a  normal 
labor,  and  then  as  soon  as  possible  after  full  dilata- 
tion of  the  OS,  as  indicated  by  a  rupture  of  the  mem- 
branes or  a  change  in  the  character  of  the  labor  pains. 
Disinfection  of  the  hands  should  be  thorough.  In 
the  treatment  of  the  disease  when  once  established, 
local  disinfection  by  antiseptic  douching,  the  curette, 
abdominal  section,  and  ablation  of  the  infected  organs 
had  all  been  employed  with  success.  The  general 
treatment  with  which  he  had  met  most  success  was 
that  introduced  by  Runge  in  1886.  and  consisted  in 
cool  bathing,  nourishing  diet,  avoidance  of  internal 
antipyretics,  and  free  administration  of  alcohol. 

A  vote  of  thanks  was  moved  by  Proi'kssgr  Byers, 
who  particularly  alluded  to  the  address  as  one  full  of 
information,  and  full  of  another  quality  which  he  re- 
gretted was  so  rare,  viz.,  the  elfacement  of  self. 

The  motion  was  seconded  by  Dr.  Griffith  and  car- 
ried unanimously. 


August  25,  1900] 


MEDICAL    RECORD. 


311 


Afterward  votes  of  thanks  were  unanimously  passed 
to  the  mayor  of  Ipswich  and  a  number  of  others  who 
had  contributed  to  the  success  of  the  meeting,  con- 
cluding with  one  to  Dr.  EUiston,  the  president,  which 
was  suitably  acknowledged,  and  thus  the  annual  meet- 
ing came  to  an  end. 


SECTION   OF   OBSTETRICS   .\X1)   GVX.KCOLOGV. 

First  Day —  Wednesday,  August  ist. 

President's  Address — Dr.  VV.  S.  A.  Griffith,  of 
London,  in  the  course  of  a  brief  introduction,  said 
that  the  subject  chosen  to-day  for  discussion  had  never 
been  discussed  before,  and  that  there  was  no  subject 
more  thorny;  the  subject  chosen  for  the  second  dis- 
cussion, viz.,  uterine  fibroids,  was  one  about  which 
there  were  very  different  opinions  held,  and  the  reason 
that  the  subject  of  the  treatment  of  post-partum  hem- 
orrhage was  chosen  for  the  third  discussion  was  that, 
although  it  was  so  well  worn,  yet  letters  frequently 
appeared  in  the  medical  papers  asking  for  guidance 
as  to  the  best  method,  and  it  was  felt  that  sorne  au- 
thoritative pronouncement  would  do  good. 

Puerperal  Fever  in  Relation  to  Notification — Dr. 
Rkrrv  Hart,  of  l^dinburgh,  opened  the  discussion  on 
this  subject.  He  said  that  notification  of  scarlet  fever 
and  typhoid  was  accepted  as  desirable  by  all,  but  that 
there  were  difficulties  in  the  way  of  the  general  ac- 
ceptance of  the  notification  of  puerperal  fever.  Sta- 
tistics showed  that  the  mortality  of  puerperal  fever 
was  not  diminishing.  The  evident  objections  to 
notification  were;  First,  the  difficulty  of  defining  what 
was  puerperal  fever;  second,  the  risk  of  misleading 
statistics;  third,  the  reluctance  of  the  practitioner  to 
notify.  With  regard  to  the  first,  he  would  define  puer- 
peral fever  as  any  form  of  puerperal  septicemia.  By 
septiceemia  he  understood  an  acute  disease  from  the 
entrance  of  organisms  through  the  genital  tract;  these 
pathogenic  organisms  spread  along  the  lymphatics  to 
the  body,  and  it  was  this  spread  which  marked  the 
disease  as  notifiable.  The  case  had  usually  to  be 
diagnosed  on  clinical  conditions.  He  recognized 
(1)  an  acute  rapid  form;  (2)  the  ordinary  lymphatic 
form;  (3)  the  rare  venous  form.  The  second  form 
was  the  usual  one,  and  under  this  head  would  be  in- 
cluded cases  of  sapraemia.  The  third  variety  taxed 
the  practitioner's  skill  most.  It  originated  in  the  in- 
fection of  a  uterine  clot  inside  the  uterus,  and  the 
infection  passed  along  the  blood  channels.  These 
cases  were  the  most  tedious,  trying,  and  difficult  to 
diagnose.  Serum  reaction  now  eliminated  typhoid. 
He  considered  that  the  origin  of  puerperal  fever  from 
drain  poison  was  not  proven.  Some  of  the  rashes  of 
septica;niia  closely  resembled  scarlet  fever,  and  before 
the  diagnosis  of  the  latter  disease  was  accepted  its 
source  should  be  clearly  proven.  Notification  was 
not  necessary  in  localized  pelvic  inflammation,  nor  in 
gonorrhceal  cases,  nor  cases  of  that  rare  disease,  puer- 
peral tetanus.  Gonorrhceal  inflanmiation  may  come  on 
late  in  the  puerperium,  and  gonococci  will  be  found 
in  the  discharge.  With  reference  to  the  unwillingness 
to  notify,  he  found  that  it  was  not  so  general  as  would 
be  supposed.  He  found  on  examining  the  statistics 
of  many  large  towns  that  the  notifications  consider- 
ably exceeded  the  deaths.  In  regard  to  prevention,  he 
thought  that  the  most  important  point  was  the  correct 
management  of  the  third  stage.  The  advantages  of 
notification  were:  (i)  that  it  showed  the  frequency  of 
occurrence — this  was  not  diminishing;  (2)  that  it 
would  help  in  prevention  by  putting  the  medical  officer 
of  health  on  the  track  of  dangerous  midwives.  The 
municipality  should  provide  hospital  accommodation 
for  these  cases,  as  they  required  special  local  treat- 
ment and  most  careful  nursing.     He  was  not  optimis- 


tic with  regard  to  the  treatment  of  bad  cases.  Notifi- 
cation would  also  improve  our  knowledge  of  the  disease. 
The  literature  of  the  subject  was  principaljy  repre- 
sented by  Boxall,  .Allingworth,  Olshausen,  and  Nau- 
mann. 

Dr.  S.mvly,  of  Dublin,  spoke  of  the  great  importance 
of  obtaining  statistics  of  the  mortality  in  private  prac- 
tice. It  was  impossible  to  obtain  that  until  a  record 
was  got  of  all  tfie  deaths  occurring  after  childbirth, 
whatever  the  cause.  The  returns  of  the  registrar- 
general  divided  deaths  after  childbirth  into  three 
classes:  (i)  Cases  of  metria;  (2)  deaths  due  to  causes 
directly  dependent  on  the  labor;  (3)  deaths  due  to 
causes  not  connected  with  labor.  Under  the  latter 
head  were  many  cases  certified  as  pneumonia,  scarlet 
fever,  etc.,  which  were  really  puerperal.  He  deplored 
the  perpetuation  of  the  term  puerperal  fever.  He  re- 
ferred to  the  difficulty  of  determining  what  should  be 
notifiable.  Dr.  Berry  Hart  said:  "Notify  systemic 
infection  but  not  local  inflammations."  The  speaker 
would  ask,  why  not?  For  scientific  purposes  notifica- 
tion would  not  be  of  much  use,  but  it  would  be  useful 
for  saving  life.  It  damaged  a  man's  practice  to  use 
the  word  pberperal  fever,  and  he  would  like  to  see 
some  other  name  adopted. 

Dr.  Cami'bell,  of  Belfast,  said  that  there  were  two 
great  sources  of  puerperal  fever:  (i)  the  midwife;  (2) 
the  patient.  He  believed  in  auto-infection  as  from 
gonorrhoea.  A  great  advantage  of  notification  would  be 
that  there  would  then  be  supervision  of  midwives.  It 
would  increase  public  interest  in  the  training  of  mid- 
wives,  and  improve  the  quality  of  monthly  nurses, 
raising  them  more  to  the  level  of  surgical  nurses. 

Dr.  Boxall,  of  London,  had  investigated  the  statis- 
tics of  the  mortality  from  childbirth  up  to  the  end  of 
1898,  and  found  that  since  the  publication  of  his  pre- 
vious investigations  in  1894  the  returns  showed  no 
improvement.  In  1880  the  registrar-general  instituted 
a  system  of  inquiry  into  all  cases  returned  under 
doubtful  headings  such  as  peritonitis,  and  the  pro- 
ceeding had  raised  the  mortality  of  puerperal  fever  by 
one-twelfth.  Statistics  showed  a  serious  state  of 
affairs.  We  now  knew  that  puerperal  fever  is  a  pre- 
ventable disease.  In  lying-in  hospitals  the  mortality 
was  formerly  fearful.  Now  puerperal  fever  was  prac- 
tically abolished;  e\en  when  septic  cases  had  been 
brought  in  from  outside  the  spread  of  the  disease 
could  be  absolutely  prevented.  Mere  tabulation  could 
do  no  good,  and  he  did  not  think  that  it  was  necessary 
to  remove  these  patients  to  an  isolation  hospital.  He 
doubted  previous  auto-infection  of  the  patient  as  a 
cause,  giving  as  his  reason  that  if  that  were  so  there 
would  be  more  cases  in  strictly  conducted  lying-in 
hospitals  tiiandid  arise,  and  he  agreed  with  Dr.  Smyly 
that  all  serious  cases  of  illness  should  be  notified. 
He  would  not  attempt  a  definition  of  what  was  puer- 
peral fever. 

Dr.  Macan,  of  Dublin,  was  entirely  opposed  to 
notification.  He  advised  that  a  practitioner  should 
refuse  to  attend  cases  unless  a  nurse  was  employed  of 
whose  knowledge  of  asepsis  he  felt  assured. 

Professor  Bvers,  of  Belfast,  approved  of  notifica- 
tion. It  would  enable  the  physician  to  see  where  the 
disease  was,  and  to  find  its  cause,  and  in  the  end 
would  lead  to  prevention.  We  must  not  oppose  it  be- 
cause it  might  injure  the  practitioner;  that  was  an 
unscientific  and  selfish  position  to  take  up.  There  was 
great  difficulty  in  definition.  We  must  accept  fever 
after  delivery,  face  the  facts,  and  boldly  say  that  it 
must  be  notified.  He  advocated  bacteriological  exam- 
ination of  the  discharges,  and  disbelieved  in  auto- 
infection.  He  would  teach  students  and  midwives 
to  make  as  few  vaginal  examinations  as  possible. 

Dr.  Bru.mme;,  of  South  .Australia,  said  that  the  law 
in  that  country  provided  for  the  notification  not  only 


;i2 


MEDICAL    RECORD. 


[August  25,  1900 


of  puerperal  fever  but  also  of  phlegmasia  dolens,  cel- 
lulitis, etc.  He  pointed  out  the  difficulty  in  notifying 
when  there  was  a  rise  of  temperature  which  might  turn 
out  to  be  temporary. 

Dr.  Targett,  of  London,  said  that  recently  at 
Guy's  Hospital  three  beds  in  an  isolation  ward  had 
been  set  apart  for  cases  of  puerperal  fever  which 
might  arise  in  the  out-door  maternity.  The  cases  ad- 
mitted had  done  so  remarkably  well  as  to  show  that 
there  would  be  an  advantage  in  isolation  hospitals. 

Dr.  Helme,  of  Manchester,  strongly-  opposed  the 
teaching  that  the  doctor  was  always  responsible.  The 
public  were  already  too  much  disposed  to  take  that 
view,  and  this  constituted  one  of  the  chief  difficulties 
in  notification. 

The  President  drew  attention  to  the  absolute  differ- 
ence between  the  notification  of  puerperal  fever  and 
that  of  other  infectious  diseases.  No  one  blamed  the 
doctor  for  the  occurrence  of  smallpo.x  or  scarlet  fever, 
but  in  connection  with  puerperal  fever  the  man,  be  he 
consultant  or  general  practitioner,  always  suffered. 
That,  however,  should  not  stand  in  the  way  of  his  tell- 
ing the  plain  truth,  as  the  alternative  of  deliberate 
concealment  entailed  far  worse  results.  In  the  speak- 
er's opinion,  when  a  regular  temperature  record  was 
kept  it  was  shown  that  all  severe  cases  began  within 
twenty-four  hours. 

Dr.  Berry  H.art,  in  reply,  said  that  some  seemed 
to  think  that  if  they  kept  their  hands  clean  that  was 
all  that  was  required,  but  he  thought  the  management 
of  the  third  stage  of  labor  was  equally  important,  and 
was  of  opinion  that  the  Crede  method  had  done  much 
harm  through  leading  to  premature  and  hasty  interfer- 
ence with  the  normal  mechanism. 

On  the  motion  of  Dr.  Box.\ll  the  following  resolu- 
tion was  carried  nem.  con.:  "That  it  be  a  recommenda- 
tion to  the  council  of  the  association,  that  in  the  opin- 
ion of  this  meeting  it  is  desirable  that  the  notification 
of  puerperal  fever  (septicaemia)  should  be  adopted  gen- 
erally." 

Cephalotripsy  for  the  After-coming  Head. — Dr. 
Targett,  of  London,  read  a  paper  with  tiiis  title.  In 
the  case  recorded  the  conjugate  diameter  was  two  and 
three-fourths  inches.  Cassarean  section  was  refused. 
The  head  was  perforated  behind  the  ear.  One  blade 
of  the  cephalotribe  was  passed  through  the  hole  made 
by  the  perforator  and  the  other  blade  applied  over  the 
face,  and  the  head  was  easily  delivered.  Attention 
was  particularly  drawn  to  tiiis  method  of  applying  the 
instrument. 

A  Human  Placentation  in  its  Second  Stage. — 
Dr.  Catharixe  vox  Tussenbrock,  of  Amsterdam, 
read  this  paper.  This  embodied  a  series  of  prolonged 
microscopical  examinations  of  the  placental  structures, 
which  were  illustrated  by  diagrams,  and  among  other 
things  she  proved  that  at  the  sixth  month  the  reflexa  had 
perished  by  simple  necrosis  due  to  pressure  of  the 
growing  ovum. 

Second  Day — Thursday.  August  2d. 

Natural  History  of  Fibroids  and  Recent  Improve- 
ments in  their  Treatment. — Mr.  Aldan  Doran,  of 
London,  opened  the  discussion,  saying  that  we  did 
not  know  the  pathological  relation  of  fibroids  to  the 
ovaries  nor  were  we  certain  of  the  precise  significance 
of  menorrhagia  in  certain  cases,  'rhe  growth  of  these 
tumors  was  very  variable  and  the  prognosis  as  to 
growth  extremely  uncertain.  As  a  rule,  they  got 
smaller  at  the  menopause,  but  there  were  many  excep- 
tions. As  regarded  treatment,  most  of  them  required  no 
operative  treatment.  He  would  put  aside  broad- liga- 
ment fibroids  in  an  entirely  separate  class.  They 
always  tended  to  grow  to  a  large  size,  and  should  al- 
ways be  removed.     They  seldom  caused  enlargement 


of  the  uterus,  but  the  uterus  was  thin  and  flattened  out 
over  the  growth,  and  the  operation  for  their  removal 
differed  from  any  form  of  hysterectomy,  and  these 
tumors  should  not  be  included  in  statistics  of  hyster- 
ectomy. In  the  operation  for  fibroid  of  the  broad 
ligament  the  risk  of  hemorrhage  was  greater,  that  of 
septicaemia  less.  Fibroids  of  the  uterus  were  really 
myomata  composed  of  plain  muscular  fibre,  and  ergot 
acted  on  the  latter,  but  he  thought  that  the  action  of 
the  ergot  depended  rather  on  the  fact  that  the  tumor 
was  uterine  than  on  the  fact  that  it  consisted  of  mus- 
cular fibre.  Heart  disease  was  a  contraindication  to 
the  use  of  ergot.  No  definite  change  was  ever  de- 
tected in  the  ovaries  connected  with  fibroids,  that 
would  account  for  the  growth  of  the  fibroid.  Removal 
of  the  ovaries  in  uncertain  cases  checked  bleeding. 
On  the  whole,  oophorectomy  was  not  followed  by  sat- 
isfactory results,  and  when  failure  occurred  one  could 
never  be  certain  that  the  entire  ovary  had  been  re- 
moved, as  ovarian  tissue  was  sometimes  found  extend- 
ing along  the  ovarian  ligament  right  up  to  the  uterine 
wall.  Oophorectomy  was  practically  discarded.  It 
was  difficult  to  be  clear  as  to  the  nature  of  the  hemor- 
rhage observed  in  fibroids;  in  subserous  ones  there 
was  no  hemorrhage  whatever.  The  distinction  be- 
tween menorrhagia  and  metrorrhagia  was  not  easily 
determined.  There  was  no  rule  as  to  prognosis  of 
rate  of  growth.  Slow  spontaneous  disappearance 
might  occur;  rapid  disappearance  was  doubtful,  and 
he  thought  cases  recorded  under  the  latter  had  been 
instances  of  error  in  diagnosis.  Abdominal  measure- 
ments were  useless  for  determining  the  growth  of  the 
tumor  unless  the  skin  was  stretched  by  the  growth, 
and  the  sound  fallacious.  The  menopause  was  de- 
ferred. It  was  very  difficult  to  be  assured  that  hemor- 
rhage was  not  menstrual.  The  majority  of  fibroids 
ceased  to  trouble  after  the  menopause.  The  usual  indi- 
cation for  operation  was  bleeding.  He  drew  attention 
to  the  close  connection  which  had  been  shown  to  exist 
between  fibroids  and  heart  disease.  An  improvement 
in  expectant  treatment  had  been  the  introduction  of 
chloride  of  calcium  and  salines.  Simple  fibroids 
producing  no  symptoms  could  often  be  extirpated 
easily,  but  this  was  not  surgery.  If  operation  was 
decided  on,  then  the  following  were  the  latest  methods: 

(1)  The  serre-nceud  was  still  allowed  to  be  used  in 
cases  of  fibroids  complicating  labor  or  pregnancy, 
when  speed  in  the  operation  was  desirable.  (2)  Myo- 
mectomy. (3)  Pan-hysterectomy.  (4)  Retroperito- 
neal hysterectoni)'.  This  latter  was  the  more  popular 
method  in  the  country;  there  was,  however,  a  danger 
in  the  sutures  which  were  left  in  the  cervix.  As  re- 
garded the  removal  of  the  ovaries,  it  had  been  shown 
that  removal  of  the  uterus  led  to  atrophy  of  the  ovaries, 
and  his  own  experience  was  that  removal  of  the  ova- 
ries was  not  essential.  He  thought  retroperitoneal 
hysterectomy  was  the  best  operation. 

Dr.  Berry  Hart,  of  Kdinburgh,  thought  that  if  con- 
servative opinion  was  founded  on  experience  of  the 
clamp  operation,  it  was  not  to  be  relied  on.  The 
effect  of  the  menopause  was  not  always  so  favorable 
as  was  generally  slated.  The  two  great  improvements 
in  operation  were:  (i)  The  arrest  of  hemorrhage  by 
ligature  of  arteries,  not  on  the  tissue  of  the  cervix; 

(2)  the  Trendelenburg  position. 

Dr.  Smyly,  of  Dublin,  thought  it  very  difficult  to 
advise.  For  himself  in  the  past  he  thought  that  he 
had  operated  too  little  rather  than  too  much.  There 
was  now  very  little  difference  between  pan-hysterec- 
tomy and  the  subperitoneal  method.  Personally  he 
adopted  Doyen's  method  of  operation  and  found  it 
best. 

Mr.  Harrison  Cripps,  of  London,  said  the  ques- 
tion of  operation  depended  on  (i)  What  is  the  fatality 
if  left  alone?    (2)  What  is  the  fatality  of  operation.' 


August  25,  1900] 


MEDICAL    RECORD. 


.13 


It  was  very  difficult  to  make  a  statement  as  to  tiie  rirst 
c|uestion.  Champneys  had  shown  from  the  post- 
mortem records  of  St.  Bartholomew's  that  in  eighteen 
hundred  cases  of  women  at  the  fibroid  age  one  hun- 
dred and  forty  had  fibroids,  and  that  among  the  num- 
ber death  was  directly  attributable  to  the  fibroid  in 
three  cases.  In  his  opinion  the  three  greatest  im- 
provements in  operation  were:  (i)  Improved  antiseptic 
methods;  (2)  intraperitoneal  treatment  of  the  pedicle; 
(3)  the  Trendelenburg  position.  As  regarded  anti- 
sepsi  a  noticeable  improvement  at  "  Barts  '  had  fol- 
lowed the  introduction  of  the  use  of  a  solution  of 
biniodide  of  mercury  in  spirit,  r  :  500,  for  the  sterili- 
zation of  the  hands. 

Dr.  Macan,  of  Dublin,  pointed  out  that  a  very 
large  number  of  fibroid  tumors  were  never  suspected, 
and  consequently  did  not  enter  into  any  statistics. 

Dr.  Cameron,  of  Toronto,  estimated  that  fifty  per 
cent,  of  negro  women  had  fibroids.  He  agreed  that  it 
was  impossible  to  prognose  the  course  of  a  fibroid. 
He  adopted  Kelly's  method.  One  could  avoid  liga- 
ture by  using  forci pressure.  A  pressure  of  two  thou- 
sand pounds  could  be  obtained. 

Dr.  Roger  \Villiam.s,  of  Bristol,  said  that  statistics 
showed  that  not  more  than  one  in  two  thousand  women 
died  from  fibroid.  There  were  no  statistics  available 
on  which  to  estimate  the  frequency  of  fibroids.  Some 
foreign  observers  had  said  that  twenty  per  cent,  of 
women  had  them.  He  calculated  that  there  were  one 
million  women  in  the  United  Kingdom  suffering  from 
fibroids. 

.  Dr.  Stanmore  Bishop,  of  Manchester,  thought 
medical  treatment  of  fibroids  absolutely  useless,  but 
did  not  think  that  any  surgeon  would  recommend  re- 
moval of  every  fibroid.  He  thought  that  the  two  great 
improvements  in  their  removal  were  the  abandonment 
of  the  extraperitoneal  clamp  operation  and  of  the 
drainage  tube. 

Dr.  Campbell,  of  Belfast,  had  regretted  advising 
non-interference.  He  had  found  that  chloride' of  cal- 
cium and  hydrastis  had  a  good  effect  in  checking 
hemorrhage.  He  had  a  good  opinion  of  vaginal  hys- 
terectomy for  small  multiple  fibroids  giving  rise  to 
serious  hemorrhage.  He  favored  pan-hysterectomy  in 
preference  to  retroperitoneal,  as  the  latter  left  the 
cervix  with  its  blood  supply  partially  cut  off. 

Dr.  Macxaughton  Jones,  of  London,  had  seen 
women  with  fibroids  become  lunatics,  and  also  die 
from  uramia,  sloughing,  or  heart  disease.  In  all  cases 
in  which  fibroids  were  producing  any  symptoms  he 
advised  hysterectomy. 

Dr.  St.^nley  Boyd,  of  London,  asked  what  was  the 
effect  of  the  salpingitis  which  so  frequently  accom- 
panied fibroids  on  the  production  of  hemorrhage.  She 
said  that  the  only  way  of  estimating  the  growth  of 
fibroids  was  by  careful  bimanual  examination  both 
per  vaginam  and  per  rectum.  She  asked  if  atrophy  of 
the  ovaries  which  followed  hysterectomy  had  the  same 
effect  on  the  woman  as  removal  of  the  ovaries  by 
operation.  It  was  sometimes  difficult,  when  the  fibroid 
grew  low  down  in  the  uterus,  to  avoid  leaving  some  of 
the  uterus  in  doing  the  retro-peritoneal  operation. 

Dr.  Scharlieb,  of  London,  pointed  out  that  in  cases 
in  which  a  fibroid  became  frequently  incarcerated  in 
the  pelvis,  of  which  she  gave  an  instance,  removal  was 
needed;  and  in  these  and  similar  cases  the  question 
of  operation  should  be  fairly  put  before  the  patient. 
Since  the  serre-nceud  was  abolished  Champneys'  sev- 
enteen per  cent,  mortality,  which  was  based  on  that 
operation,  was  fallacious.  She  thought  it  important 
not  to  introduce  any  chemical  antiseptic  into  the  peri- 
toneal cavity.  She  had  removed  a  fibroid  tumor  by 
myomectomy  from  a  girl  fifteen  years  of  age.  She 
thought  that  the  results,  both  immediate  and  remote, 
were  better  if  the  ovaries  were  left  in  doing  hysterec- 


tomy. She  never  used  the  elastic  ligature  or  trans- 
fixed the  stump  with  a  ligature. 

Dr.  Giles,  of  London,  said  he  had  no  faith  in  drugs 
or  electricity.  He  agreed  that  it  was  better  to  leave 
the  ovaries. 

Dr.  Briggs,  of  Liverpool,  would  add  to  the  indica- 
tions for  operation  injury  to  the  fibroid  from  mechani- 
cal violence,  of  which  he  gave  an  instance. 

Dr.  Skene  Keith,  of  London,  had  known  only  one 
case  in  which  a  fibroid  had  grown  after  the  menopause. 
He  would  put  the  date  of  the  latter  in  bleeding 
fibroids  at  the  age  of  fifty-two  to  fifty-four.  He  be- 
lieved in,  and  practised,  Apostoli's  method. 

The  President  said  that  all  were  agreed  that  in  seri- 
ous conditions  one  should  operate.  Cases  on  the  bor- 
derland were  the  difficult  ones  in  which  to  decide.  No 
means  existed  of  estimating  the  mortality  of  fibroids, 
but  hospital  records  showed  that  it  was  not  high.  The 
question  of  operative  interference  could  not  be  settled 
by  discussion,  but  must  be  left  to  individual  discre- 
tion. He  agreed  with  the  general  tendency  of  the 
discussion.  It  was  exceptional  for  a  fibroid  not  to 
cause  menorrhagia,  and  very  rare  for  it  to  be  associ- 
ated with  amenorrhcea.  The  large  majority  of  fibroids 
ceased  to  cause  any  trouble  after  the  menopause.  To 
say  that  medical  treatment  did  no  good  was  gross  ex- 
aggeration. He  would  ask  how  many  women  were 
kept  in  comfort  for  years  by  rest  at  the  periods  and 
drugs.  He  believed  in  chloride  of  calcium,  combined 
with  iron,  in  ana;mic  cases. 

iMr.  Doran,  in  reply,  protested  against  the  idea  that 
operation  should  be  advised  because  complications 
might  ensue  which  would  kill  the  patient  later.  In 
some  of  the  older  cases  in  which  diseased  appendages 
were  removed  by  oophorectomy,  the  good  result  which 
followed  was  due  to  the  fact  that  the  symptoms  de- 
pended on  the  salpingitis  and  not  on  the  fibroid.  He 
had  used  the  Trendelenburg  position,  but  twice  with 
stout  patients  he  had  had  difficulty  with  the  ansesthetic 
with  the  patient  in  that  position. 

Vaginal  Hysterectomy,  its  Immediate  and  Re- 
mote Results. — Dr.  Scharlieb,  of  London,  read  a 
paper  with  this  title.  She  gave  details  of  forty-six 
cases;  in  thirty-five  of  these  the  operation  was  done 
for  malignant  growth.  In  these  thirty-five  cases  four 
patients  died  within  a  month,  one  from  kidney  disease, 
one  from  shock,  and  two  from  sepsis.  These  were  all 
the  deaths  in  the  whole  forty-six  cases.  Of  the  thirty- 
five  cases  of  cancer  seventeen  patients  were  now  alive 
and  free  from  recurrence.  The  known  recurrence  had 
been  seven  per  cent.  Theaverage  age  of  the  patients 
was  forty-seven  years. 

Vaginal  Enucleation  versus  Vaginal  Hysterec- 
tomy in  the  Treatment  of  Some  Fibroids  of  the 
Uterus,  with  Notes  of  Cases.— Dr.  Briggs,  of  Liver- 
pool, read  this  paper.  The  largest  fibroid  removed  by 
this  method  weighed  four  pounds  ten  ounces.  He 
pointed  out  how  much  better  vaginal  operations  were 
borne  than  abdominal  operations. 


Third  Day — Friday,  August  3d. 

Por-t-Partum  Hemorrhage,  its  Prevention  and 
Treatment — Dr.  Bvers,  of  Belfast,  opened  the  dis- 
cussion in  the  unavoidable  absence  of  Dr.  Dakin,  of 
London.  He  said  that  with  respect  to  the  definition 
of  post-partum  hemorrhage  one  could  not  fix  the 
amount  of  blood  lost.  Some  had  said  one  pound  of 
blood  and  upward  should  be  considered  to  be  post- 
partum hemorrhage,  but  patients  varied,  and  one  must 
judge  by  the  constitutional  effect  produced  and  by  the 
presence  of  relaxation  of  the  uterus.  One  of  two  path- 
ological conditions  was  present  in  cases  of  hemor- 
rhage: (1)  open  vessels  in  the  placental  area — uterine 
atony;   (2)  a  wound  of  the  parturient  tract.     He  would 


314 


MEDICAL    RECORD. 


[August  25,  1900 


discuss  to-day  particularly  the  first.  One  of  the  pre- 
disposing causes  was  hemorrhage  in  previous  labors; 
this  was  important  especially  in  the  poor,  when  preg- 
nancy had  occurred  too  frequently.  In  the  well-to-do, 
want  of  exercise,  too  much  food,  and  alcohol  were  pre- 
disposing causes.  Other  clearer  causes  were  over-dis- 
tention  of  the  uterus,  albuminuria,  and  extreme  men- 
tal depression.  He  liad  seen  some  severe  cases  in 
which  the  patient  had  been  depressed  owing  to  death 
of  the  husband  during  the  pregnancy.  During  delivery 
predisposing  conditions  were  any  condition  of  high 
vascular  excitement  attended  with  a  pulse  of  over  100, 
and  sharp,  quick,  inefficient  pains  in  the  second  stage. 
With  regard  to  chloroform  he  did  not  believe  that  it 
caused  hemorrhage  except  through  the  hurry  and  in- 
efficient attention  to  the  third  stage,  which  were  fre- 
quently associated  with  its  use.  As  to  prophylaxis,  in 
every  case  one  should  never  deliver  in  the  absence  of 
pains.  Forceps  were  very  dangerous  in  cases  of  sec- 
ondary uterine  inertia.  In  the  management  of  the 
third  stage  the  conditions  must  be  understood;  the 
nature  of  the  natural  separation  of  the  placenta  must 
be  studied.  It  was  bad  management  to  squeeze  it  off 
the  uterine  wall,  but  the  uterus  must  be  followed  down 
as  the  child  is  born  and  the  hands  kept  on  the  uterus, 
never  letting  it  go.  The  woman  should  be  turned  on 
her  back  as  soon  as  the  child  was  born,  and  then  one 
should  wait  until  the  placenta  was  separated,  twenty 
minutes  or  longer.  One  could  tell  when  the  placenta 
was  separated  by  the  fundus  uteri  rising  and  the  lower 
segment  appearing  distended  on  abdominal  inspection, 
and  resembling  the  distended  bladder.  He  made  a 
practice  of  tying  the  second  ligature  on  the  cord  just 
at  the  vulva,  and  then  one  would  readily  see  when  the 
cord  descended  still  farther.  As  soon  as  it  was  clear 
that  the  placenta  was  separated,  with  the  next  pain  one 
should  gently  squeeze  out  the  placenta.  He  did  not 
believe  in  pads,  saucers,  or  books  on  the  abdomen. 
In  cases  in  which  there  had  been  previous  post-partum 
hemorrhage  he  advised  slow  extraction,  and  rupture  of 
the  membranes  early  in  labor.  For  the  treatment  of 
actual  hemorrhage  he  advised  (i)  uterine  massage; 
(2)  the  injection  of  hot  water.  He  spoke  strongly 
against  putting  any  mercurial  preparation  in  the 
water.  It  was  not  good  practice  to  introduce  the  hand 
unless  one  felt  sure  from  an  examination  of  the  pla- 
centa and  membranes  that  a  portion  was  left  behind. 
He  discountenanced  iron,  but  spoke  strongly  in  favor 
of  plugging  the  uterus  by  Diihrssen's  method,  which 
he  regarded  as  very  useful.  The  bimanual  method  he 
considered  to  be  tedious  and,  as  it  involved  the  intro- 
duction of  the  hand,  dangerous,  and  he  would  rather 
pack.  If  packing  failed  it  should  be  withdrawn,  fol- 
lowed by  douching  and  repacking.  If  that  failed 
Schauta  had  advised  forcible  inversion  of  the  uterus 
and  the  tying  of  a  piece  of  gauze  round  its  neck,  leaving 
it  on  for  six  hours.  In  one  case  he  had  arrested  the 
hemorrhage  by  forcibly  drawing  down  the  uterus  with  a 
vulsellum.  flemorrhage  from  wounds  in  the  parturient 
canal  had  been  described  as  hemorrhage  from  a  con- 
tracted uterus.  The  diagnosis  was  made,  in  the  case 
of  wound  of  the  vulva,  by  inspection;  if  the  '.vound 
was  in  the  cervix  the  bleeding  would  go  on  in  spite  of 
contraction  of  the  uterus,  and  if  a  Hozeman's  catheter 
was  used  to  wash  out,  blood  would  be  seen  in  the 
uterine  stream.  The  treatment  of  the  wound  was,  in 
the  vulva,  ligature;  in  the  vagina  or  cervix,  ligature 
or  packing.  The  treatment  of  the  anxmia  following 
hemorrhage  consisted  in:  (i)  Keeping  quiet;  (2) 
saline  injections,  which  were  of  the  greatest  advantage 
(he  infused  underneath  the  breast);  (3)  strychnine  in- 
jections hypodermically;   (4)  feeding. 

Dr.  Boxall,  of  London,  said  that  he  would  consider 
the  amount  of  blood  to  be  lost  to  make  a  case  one  of 
post-partum  hemorrhage  as  upward  of  twenty  ounces, 


but  of  course  much  depended  on  the  individual,  and  a 
better  standard  would  be  the  weight  of  the  blood  lost 
compared  with  the  weight  of  the  patient's  body.  Some 
cases  of  hemorrhage  were  due  to  the  retention  of  a 
clot  the  result  of  an  ante-partum  hemorrhage.  In  the 
General  Lying-in  Hospital,  London,  out  of  ten  hun- 
dred and  fifty-eight  cases  there  was  a  loss  of  twenty 
ounces  or  more  in  ninety-four  patients,  and  in  twenty 
of  these  there  was  undue  retention  of  placenta  or 
membranes;  in  eight  an  ante-partum  clot  had  formed. 
Auvard  had  described  what  he  called  the  '"collarette" 
placenta  as  a  cause  of  hemorrhage;  this  consisted  in 
a  circular  reduplication  of  the  chorion,  usually  at  the 
edge  of  the  placenta,  and  at  this  reduplication  the 
chorion  was  rotten  and  easily  gave  way ;  in  the  Lying- 
in  Hospital  this  year  out  of  two  hundred  and  ninety 
patients  twenty-two  lost  twenty  ounces  of  blood  or 
more,  and  of  these  fifteen  were  found  to  have  a  col- 
larette placenta.  He  found  that  women  addicted  to 
alcohol  were  very  prone  to  have  post-partum  hemor- 
rhage. He  believed  in  early  rupture  of  the  mem- 
branes as  a  preventive.  The  forceps  would  ward  off 
hemorrhage  if  judiciously  applied  so  as  to  save  the 
uterus  from  becoming  tired,  but  in  many  cases  the 
forceps,  from  being  used  injudiciously  and  to  save 
the  time  of  the  practitioner,  produced  hemorrhage. 

Mr.  Stanmore  Bishop,  of  Manchester,  advocated 
compression  of  the  abdominal  aorta  so  as  to  stop  the 
hemorrhage  while  the  uterus  was  resting  and  recover- 
ing contractile  power. 

Dr.  Scharlieb,  of  London,  had  worked  for  some 
time  in  India,  and  had  found  post-partum  hemorrhage 
frequent  among  European  women  there  and  found 
that  the  administration  of  quinine  during  pregnancy 
was  in  those  cases  a  prophylactic. 

Dr.  Campbell,  of  Belfast,  had  found  drawing  down 
the  uterus  with  a  vulsellum  useful,  and  used  hot  water 
through  a  Hushing  curette. 

Dr.  Smvly,  of  Dublin,  said  the  uterus  might  be  re- 
laxed and  no  hemorrhage  take  place;  in  that  case  it 
should  be  left  alone.  He  had  found  this  especially 
the  case  after  using  chloroform. 

Dr.  Briggs,  of  Liverpool,  also  approved  of  pulling 
down  the  uterus  with  a  vulsellum.  This  proceeding 
gave  aid  in  plugging,  and  by  its  means  the  use  of  a 
very  large  amount  of  gauze  was  avoided. 

The  President  said  that  the  uterus  must  be  emptied. 
It  was  a  difficult  thing  in  practice  to  be  sure  that  all 
membrane  was  removed.  He  disapproved  of  the  in- 
troduction of  the  hand  into  the  uterus.  He  always 
managed  the  third  stage  with  the  patient  on  her  back, 
and  found  it  easier  to  detect  lacerations  of  the  peri- 
neum in  this  position.  As  regarded  anaesthetics,  he 
believed  that  cjsloroform  interfered  with  uterine  con- 
traction; ergot  had  an  opposite  effect,, and  he  had 
made  a  practice  of  giving  a  dose  of  ergot  before  ad- 
ministering chloroform.  For  plugging  the  uterus  when 
no  gauze  was  at  hand  he  advised  clean  linen  rags 
soaked  in  some  spirits. 

Dr.  Bvers  made  a  brief  reply,  in  which  he  said  that 
he  was  glad  to  find  that  there  was  so  general  an  agree- 
ment with  the  linesof  treatment  that  he  had  laid  down. 

Conservative  Surgery  of  the  Tubes  and  Ovaries. 
—  Dr.  Stanlkv  Bovn,  of  London,  read  a  paper  on  this 
subject.  She  gave  an  account  of  twenty-two  cases 
with  one  death;  in  ten  there  was  recurrence  of  inflam- 
matory symptoms,  and  in  three  further  operation  be- 
came necessary:  in  six  there  was  a  good  result,  and  in 
three  pregnancy  followed  the  operation.  She  found 
that  a  better  result  was  obtained  from  this  kind  of 
operation  on  the  ovary  than  on  the  tube. 

Dr.  Scharlieb  found  that  operating  in  gonorrhceal 
cases  was  of  very  little  good  while  active  inflammation 
was  still  going  on. 

The    President  would   emphasize    the    danger    of 


August  25,  1900] 


MEDICAL    RECORD. 


315 


gonorrhoea  in  women,  especially  with  reference  to 
the  marriage  of  men  who  were  suffering  from  that  dis- 
ease in  a  latent  form.  If  part  of  an  ovary  was  re- 
moved when  pus  was  present  there  was  always  a  dan- 
ger of  further  trouble. 

An  Account  of  a  Case  of  Complete  Inversion  of 
the  Uterus  of  Three  Years'  Duration — Dr.  Pars- 
low,  of  Birmingham,  read  this  paper.  The  case  re- 
sisted all  efforts  at  reduction,  and  amputation  was  per- 
formed. The  uterus  was  split  from  front  to  back, 
opening  the  peritoneal  cavity,  and  the  broad  ligaments 
were  transfixed  and  tied  before  amputation  of  the 
uterus.  The  author  believed  that  this  metiiod  of  trans- 
fixing and  tying  the  broad  ligaments  had  not  been  de- 
scribed before. 

This  concluded  the  business  of  the  section. 


SECTION    OK   SURGERY. 
Second  Day — Thursday,  August  2d. 

Discussion  on  Fractures. — Mr.  \V.  H.  Bennett, 
of  London,  read  a  paper  on  the  methods  at  present  in 
use  in  the  treatment  of  simple  fractures.  In  order  to 
obtain  information  on  the  methods  of  treatment  usu- 
ally adopted  by  surgeons  who  were  in  the  habit  of 
seeing  a  large  number  of  simple  fractures,  Mr.  Ben- 
nett had  sent  out  to  some  three  hundred  hospital,  in- 
firmary, and  colliery  surgeons  in  Great  Britain  a  list 
of  questions  as  follows :  (i)  \\'hat  is  the  method  you 
usually  adopt  in  the  treatment  of  fractures  of  the 
bones  of  the  extremities?  (2)  Do  you  use  massage  or 
passive  movements;  if  so,  at  what  period  after  the  re- 
ceipt of  the  injury  do  you  adopt  either  or  both  of  these  ? 
(3)  What  is  about  the  average  time  which  elapses  in 
your  practice  after  the  occurrence  of  the  injury  before 
the  patient  is  allowed  to  resume  his  ordinary  calling, 
in  simple  fracture?  (4)  Have  you  had  experience  of 
the  immediate  treatment  of  simple  fractures  by  wiring, 
screwing,  etc.  ?  If  so,  what  is  your  opinion  of  the 
method,  especially  with  regard  to  the  scope  of  its  ap- 
plication and  to  the  risks  entailed  by  its  use,  and  its 
results?  (5)  Assuming  that  you  treat  the  majority, 
or  at  all  events  some,  of  your  cases  of  fracture  of  the 
patella  or  olecranon  by  wiring,  screwing,  etc.,  what 
treatment  do  you  use  in  cases  which  you  do  not  treat 
by  operation?  (6)  In  cases  of  fracture  of  the  patella 
treated  by  wiring,  when  do  you  commence  passive 
movement  at  the  knee,  and  how  long  is  it,  as  a  rule, 
before  the  patients  can  return  to  their  ordinary  callings 
with  free  movement  at  the  joints?  (7)  In  cases  of 
fracture  of  the  patella  treated  by  immediate  suture, 
have  you  any  experience  of  results  which  are  defective, 
as  partial  stiffness  of  the  knee,  complete  stiffness,  or 
suppuration?  (8)  Have  you  had  experience  of  the 
treatment  of  fractures  by  the  immediate  use  of  massage 
and  passive  movement?     If  so,  what  is  your  opinion? 

The  answers  received  respectively  may  be  briefiy 
summarized  as  follows: 

(i)  The  treatment  adopted  by  nearly  half  the 
surgeons  in  question  ( forty-seven  per  cent.)  was  the  ap- 
plication of  removable  splints,  and  plaster  of  Paris  was 
not  used  at  any  period  throughout.  Several  prac- 
titioners stated  that  they  had  given  up  plaster  of  Paris 
on  account  of  the  slow  recovery  following  its  use. 
Plaster  of  Paris  or  other  fi.xed  arrangements  were  more 
used  in  the  Provinces  and  in  Scotland  than  in 
London.  Twenty-six  per  cent,  used  removable  splints 
first  and  plaster  of  Paris  later.  Twenty-two  per  cent, 
advocated  the  use  of  plaster  of  Paris  from  the  first. 

(2)  Sixty-three  per  cent,  used  passive  movement 
without  massage ;  twenty-five  per  cent,  used  both ; 
twelve  per  cent,  neither.  In  London  sixty  per  cent. 
of  those  who  used  passive  movement  at  all  reserved 
passive  movement  with  or  without  massage   to  those 


cases  in  which  joints  were  involved  in  the  injury.  Out 
of  London  eighty  per  cent,  of  the  surgeons  followed 
this  course.  The  periods  at  which  passive  movement 
was  started  varied  largely.  Thus  in  London  thirty-five 
per  cent,  used  it  from  the  first,  twenty-six  per  cent, 
after  firm  union;  while  in  the  country  only  thirteen 
per  cent,  used  it  from  the  first,  and,  speaking  gen- 
erally, the  time  at  which  it  was  started  was  later  than 
in  London.  But  in  Edinburgh  and  GlasgoV,  like 
Lonr  jn,  the  practice  of  early  passive  movement  seemed 
followed. 

(3)  From  a  comparison  in  detail  of  the  answers 
given  to  question  No.  2,  and  the  returns  given  to  this 
question,  it  followed  that  the  quickest  recoveries  oc- 
curred in  cases  in  which  movements  active  and  passive 
were  earliest  used.  Thus  in  fracture  of  the  femur,  in 
London  fifty  per  cent,  returned  to  their  calling  in  less 
than  twelve  weeks;  in  the  provinces  only  twenty-five 
per  cent.  In  London  six  weeks  was  the  usual  time 
lost  by  a  patient  for  simple  fracture  of  both  leg  bones, 
in  the  country  eight. 

(4)  In  answer  to  question  No.  4,  half  those  who  re- 
plied had  had  experience  of  the  operative  treatment, 
and  half  iiad  not.  Of  those  who  had,  only  five  per 
cent,  expressed  unqualified  approval;  thirty  per  cent, 
operated  in  a  few  special  cases,  as  spiral  and  oblique 
fractures  of  the  tibia;  sixty-five  per  cent,  entirely  dis- 
approved unless  the  case  was  absolutely  unmanage- 
able without. 

(5)  In  answer  to  question  No.,  5,  when  wiring  of 
the  patella  was  not  done  owing  to  the  fragments  being 
in  apposition  or  nearly  so,  the  age  or  health  of  the 
patient,  or  because  the  surgeon  was  opposed  to  the 
operation,  twenty-five  per  cent,  used  fixation  by  splints 
with  arrangements  of  strapping;  seventeen  per  cent, 
used  removable  splints  of  wood,  leather,  poroplastic 
felt,  etc.,  giving  facilities  for  early  passive  movement: 
sixteen  per  cent,  fixation  by  splints  plus  elastic  traction, 
fifteen  per  cent,  immediate  use  of  plaster  of  Paris, 
eight  per  cent,  the  inclined  plane,  five  per  cent.  Mal- 
gaigne's  hooks,  two  per  cent.  Thomas'  knee  splints. 
Of  the  total  number  sending  returns  six  per  cent,  as- 
pirated effused  blood.  The  majority  of  those  who 
operated  did  not  do  so  at  once,  but  in  from  three  to 
twenty-one  days.  In  the  case  of  the  olecranon  the 
majority  were  adverse  to  operation,  and  the  favorite 
treatment  was  splinting  in  the  extended  position. 

(6)  After  wiring  the  patella,  in  London  twelve  per 
cent,  commenced  passive  movement  at  once,  fifteen  per 
cent,  in  seven  days,  fifteen  per  cent,  in  fourteen  days, 
twenty  per  cent,  in  twenty-one  days;  the  average  time 
before  patients  were  ready  to  resume  work  was  eight 
weeks.  In  the  provinces  the  figures  indicated  that 
passive  movement  was  begun  later,  and  the  average  time 
before  patients  were  ready  to  resume  work  was  nine 
weeks. 

(7)  As  to  the  adverse  results  in  operations  on 
fractured  patella,  one  hundred  and  eleven  surgeons 
sent  replies.  Twenty-eight  had  experienced  suppura- 
tion ;  in  eight  cases  amputation  had  been  necessary. 
Three  others  had  had  fatal  results.  Twelve  had  ex- 
perienced stiffness  with  material  disability.  In  five 
the  wire  had  cut  through  the  bone  during  attempts  at 
restoring  movement. 

(8)  In  answer  to  question  No.  8,  only  forty  replies 
were  received.  Of  these  thirty-three  surgeons  had  had 
personal  experience  of  it,  and  thirty-one  were  in  favor 
of  the  treatment. 

Mr.  Bennett's  own  experience  was  against  screws  or 
ivory  pegs  as  a  means  of  fixing  fragments.  He  pre- 
ferred wire,  but  even  wire  sometimes  acted  as  an  irri- 
tating foreign  body.  Of  course  operations  were  open 
to  the  general  objection  that  they  were  not  suited  to 
the  general  body  of  practitioners  unless  great  care  was 
taken  in  maintaining   asepsis.      He   thought   that  the 


3i6 


MEDICAL    RECORD. 


[August  25,  1900 


disability  following  fracture  was  rather  due  to  the  mat- 
ting of  parts,  and  not  to  the  bad  union.  It  was  astonish- 
ing how  often  sailors  with  very  badly  united  fractures 
were  seen  in  whom  no  serious  incapacity  followed. 
He.  tiierefore,  advocated  earl)'  and  methodical  passive 
movements  to  prevent  matting  and  fixation.  The 
sooner  the  joints  above  and  below  the  fracture  moved, 
the  sooner  would  the  patient  recover.  Of  course  the 
bones  Should  be  kept  in  position  as  much  as  possible, 
but  moderate  displacement,  if  not  rotatory,  netJ  not 
necessarily  impair  the  use  of  the  part.  \o  one  method 
could  be  insisted  on  for  all  cases.  The  value  of  the 
operative  treatment  must  be  restricted  to  certain  cases, 
and  operations  on  the  patella  were  not  so  free  f'om  risk 
as  had  been  thought. 

Mr.  Margle  thought  systematic  investigation  as  to 
the  exact  time  at  which  union  did  take  place  was 
needed.  He  felt  sure  he  had  seen  a  humerus  firmly 
united  in  three  weeks.  He  had  wired  the  patella  as  a 
routine  practice  and  never  saw  any  harm  come  of  it. 
That  surgeons  had  neglected  the  value  of  manipulations 
in  the  past,  the  records  of  the  successes  of  bone-setters 
clearly  showed. 

Mr.  Keetlev  thought  the  paper  had  a  slight  ten- 
dency to  make  one  underestimate  the  value  of  getting 
the  bones  back  into  their  exact  position.  Care  must 
be  taken  in  drawing  inferences  as  to  the  times  given. 
Patients  were  notoriously  given  to  prolonging  the 
period  of  convalescence  for  "  compensation  ''  reasons. 
The  three  points  that  interested  him  were  pinning,  wir- 
ing, and  massage.  Pinning  he  considered  most  valuable 
for  fracture  of  a  diaphysis  not  easily  kept  in  position. 
He  used  rectangular  or  L-shaped  pins,  inserted  some 
distance  from  the  fracture  (otherwise  they  would  not 
hold).  The  one  arm  of  the  pin  being  inserted  into 
the  one  fragment,  and  the  corresponding  arm  of  the 
other  pin  into  the  other  fragment — the  fracture  having 
first  been  carefully  reduced — the  free  arms  of  the  pins 
were  made  to  overlap  and  were  lashed  together  (so 
that  two  L's  became  a  U).  Wood-wool  pads  and  ban- 
dages were  all  that  was  needful.  He  believed  he  had 
seen  a  femur  unite  in  two  weeks.  For  fractures  near 
joints,  f.^.,  a  condyle,  or  the  head  of  the  fibula  no 
mode  of  treatment  other  than  wiring  would  answer  at 
all.  A  distinction  should  be  definitely  made  between 
active  movement  and  massage.  What  harm  could 
result  from  two  weeks'  rest?  And  he  could  see  no  ad- 
vantage in  disturbance  earlier. 

Mr.  Robert  Jones  disagreed  with  both  Mr.  Keetley 
and  the  president.  Mr.  Marsh.  He  believed  union 
took  much  longer  than  either  of  them  stated,  in  fact 
longer  than  the  text-books  stated.  He  believed  the 
so-called  "ambulatory"  treatment,  /'.e.,  keeping  the 
parts  in  place  by  apparatus  and  letting  the  patient  get 
about  before  union  was  firm,  must  result  in  shortening. 
Some  years  ago  he  had  been  in  the  habit  of  measur- 
ing all  fractured  femurs  when  the  patients  were  dis- 
charged from  the  infirmary  as  cured,  and  then  measur- 
ing them  again  after  the  patients  had  been  about  some 
time.  He  generally  found  some  further  shortening 
on  the  second  measurement.  This  he  took  to  mean 
that  the  bones,  although  united,  were  not  firmly 
enough  knit  to  stand  the  constant  thud  of  walking,  but 
were  driven  in  together  in  some  degree.  If  there  was 
one  place  he  would  not  operate,  it  would  be  in  frac- 
tures of  the  condyles  into  the  elbow-joint.  It  was  a 
very  serious  matter  to  make  a  compound  fracture  of 
the  elbow-joint.  And  these  cases,  if  put  up  in  the 
flexed  position  to  make  sure  that  flexion  would  not  be 
lost,  did  remarkably  well.  In  Colles'  fracture  the  want 
of  thorough  reduction  was  the  trouble,  not  the  length 
of  time  the  bones  were  kept  fixed.  As  to  wiring  the 
patella  he  had  been  unfortunate.  He  had  done  twelve 
cases,  and  one  of  these  patients,  in  whose  case  the 
joint  was  supposed   not  to  have  been   opened,  died. 


Another  came  back  at  a  later  date  with  abscess  from 
the  wire  causing  irritation. 

Mr.  Eve  said  that  he  had  operated  on  four  cases  of 
fractured  leg  bones  for  various  reasons  since  October 
last.  He  thought  wiring  the  patella  was  an  operation 
which  rested  with  the  conscience  of  the  surgeon.  If 
he  could  be  sure  of  asepsis  the  procedure  was  ideal, 
and  could  be  pressed  on  the  patient  because  the  func- 
tional results  were  better.  Passive  movement  should 
be  commenced  in  about  two  weeks.  He  agreed  with 
other  speakers  that  screws  were  useless,  and  very 
liable  to  break  away.  In  many  cases  of  Pott's  frac- 
ture the  malposition  of  the  bones  was  the  cause  of  the 
trouble,  and  adhesions  were  not.  He  had  recently 
operated  on  one  such  case,  and  found  a  fragment  of 
bone  displaced  between  the  tibia  and  fibula,  which  ex- 
plained the  difficulty  experienced  in  keeping  the  foot 
in  position.  He  did  not  approve  of  early  passive 
movement,  because  adhesions  were  not  likely  to  be 
formed  under  seven  to  ten  days. 

Mr.  Jonathan  Hutchinson,  Jr.,  advocated  wiring 
the  patella  plus  open  operation  because  any  blood 
clot  present  in  the  joint  could  be  removed.  It  was 
most  important  to  get  absolute  bony  union,  and  only 
wiring  could  obtain  that.  He  doubted  if  massage 
and  galvanism  could  prevent  wasting  of  the  quadriceps, 
and  was  sceptical  as  to  the  value  of  early  and  immediate 
massage.  In  injuries  around  the  elbow  joint  fixation 
should  be  adopted  for  three  weeks,  after  accurate  re- 
placement had  been  made;  then  slight  active  move- 
ments should  follow.  Massage  used  early  for  fracture 
of  the  surgical  neck  of  the  humerus  would  probably 
cause  non-union.  Too  much  must  not  be  claimed  for 
it;   it  might  even  cause  compound  fracture. 

Mr.  F.  F.  Burghard  adviBcated  im.mediate  operation 
in  every  case  of  fractured  patella,  and  used  no  splint 
from  the  first,  only  cotton  wool  and  a  bandage.  In 
three  weeks'  time  a  splint  was  put  on,  and  the  patient 
allowed  to  get  up.  In  Pott's  and  Colles'  fractures  he 
thought  massage  was  useful.  The  less  splinting  was 
used  the  better.  If  any  fracture  could  not  be  reduced, 
or  kept  reduced,  it  should  be  cut  down  on  and  wired. 
He  believed  matting  of  muscles  had  a  lot  to  do  with 
the  ill  results  met  with.  Screws  held  only  for  a  few 
hours,  and  speedily  caused  softening.  He  used  wire 
whenever  possible. 

Mr.  Bennett,  in  reply,  denied  being  an  enthusiast 
for  massage.  He  said  his  object  was  rather  to  elicit 
information  than  to  lay  down  any  views  of  his  own. 

Removal  of  Large  Vesical  Calculi.— Mr.  H.  S. 
Burton  read  a  paper  on  the  removal  of  large  stones 
from  the  bladder.  He  gave  the  notes  of  a  case  in 
which  he  removed  by  suprapubic  lithotomy  a  stone 
weighing  ten  ounces  five  drachms.  The  patient  lived 
for  four  months  and  then  died  from  pyelitis.  The 
operations  at  one's  disposal  for  deal'ng  with  large 
stones  were  reviewed,  and  the  main  points  of  the 
suprapubic  operation,  litholapaxy,  and  median  and 
lateral  perineal  lithotrity  were  discussed.  He  him- 
self advocated  the  suprapubic  operation,  because  the 
bladder  could  be  opened  freely  and  thoroughly  ex- 
plored, and  stones  of  any  size  removed.  The  only 
disadvantage  he  saw  was  that  the  wound  left  might 
be  long  in  healing. 

Mr.  p.  Frever  had  done  a  large  number  of  opera- 
tions for  stone,  chiefly  in  India,  and  strongly  advo- 
cated Bigelow's  method  in  all  possible  cases.  When- 
ever that  operation  could  be  done,  it  was  immensely 
superior  to  any  other.  In  his  last  four  hundred  cases 
he  had  adopted  cutting  operations  only  thirteen  times. 
The  difliculty  was.  what  to  do  with  large  stones.  What 
was  a  large  stone?  He  should  say  one  of  two  ounces 
or  over  in  an  adult.  The  mortality  of  the  suprapubic 
operation  was  very  high,  probably  fifty  per  cent.  He 
should  say  a  cutting  operation  should  be  selected   if 


August  25,  1900] 


MEDICAL    RECORD. 


317 


stricture  was  present  and  the  stone  large,  in  some 
cases  of  enlarged  prostate  if  the  bladder  was  so  con- 
tracted that  sufficient  antiseptic  solution  could  not  be 
introduced  to  enable  litholapaxy  to  be  safely  done,  or 
if  the  stone  was  so  hard  that  the  instrument  failed  to 
crush  it.  He  showed  his  specially-made  giant  litho- 
trites  for  dealing  with  large  stones,  and  maintained 
that  in  proportion  as  he  had  abandoned  cutting  opera- 
tions so  had  his  results  improved. 

Mr.  Cadge  believed  that  if  general  surgeons  ven- 
tured to  deal  with  such  large  stones  as  the  specimens 
shown   by  Mr.   Freyer,  by  Bigelow's  method,  disaster 
was  sure  to  follow.      He  thought  Mr.  Freyer  had  had 
too  much  success.     He  meant  that  litholapaxy  was  an 
operation  requiring  much  practice,  especially  in  deal- 
ing with   large  stones,  and  that  because  one  surgeon 
had  acquired  great  dexterity  in  doing  these  cases,  all 
must  not  be  encouraged  thereby  to  expect  such  good 
results.     He  could  remember  Sir  Henry  Thomson's 
advocacy  of  the  suprapubic  operation  as  the  cutting 
method  against  any  other.     But  in  these  days  perineal 
lithotrity  had  not  been  introduced.     He  took  it  that 
the  question  was  narrowed  to  a  comparison   between 
the   suprapubic   operation    and  the  various  forms  of 
perineal  lithotrity.      Experts  would  do  just  the  opera- 
tion they  felt  competent  to  do,  but   it  did  not  follow 
that  such  operation  was  most  suitable  for  the  average 
surgeon.     The  suprapubic  method  was  easy  of  execu- 
tion, although  too  much  stress  must  not  be  laid  on  the 
ease  with  which  it  could  be  done.     No  vessels  of  any 
size  could  be  cut,  or  hemorrhage   would  follow;   the 
parts  could  be  easily  seen,  and  the  bladder  digitally 
exposed  in  every  part.     The  advantage  was  manifest 
if  the  stone  was  encysted  or  fixed.     What  could   be 
said    against    it?     The   mortality,  and  the    fact    that 
ready   and   complete  healing  did  not   always  follow. 
But  the  technique  and  details  had  not  yet  been  alto- 
gether settled,  and  as  time  went  on  much  improvement 
in  the  mortality  and  general  results  might  be  expected. 
As  far  as  he  could  see,  there  was  no  one  particular 
danger  to  which  it  was  liable.     The  alternatives  were 
perineal   lithotrity,  median  or  lateral,  and  combined 
with  the  use  of  giant   lithotrites  as  in   India,  and   by 
Mr.  Milton,  of  Cairo,  or  Mr.  Harrison's  method.      In 
the  first  place  no  comparison  was  to  be  made  between 
Indian,  and  he  presumed  Egyptian,  practice  and  Eng- 
lish.    Eastern    natives  were    notoriously  tolerant    of 
major  operations,  and  the  stones  met  with  were  much 
softer.     He    did  not    believe  that    even   one  of    Mr. 
Freyer's  giant  lithotrites  would  crush  a  six-  or  eight- 
ounce  East  Anglian   pure  uric-acid  stone.      Many  of 
theirs  in   Norfolk  were  uric  acid,  not   friable  urates. 
He  had  warped  instruments  made  by  the  best  London 
makers  in  cases  which  the  stones  were  only  one  and  a 
half   ounces    in   weight.     He    thought    Milton's    and 
Harrison's  methods  liable  to  give  rise  to  much  lacera- 
tion.    His  conclusion  was  that  for  the  generality  of 
surgeons  the  suprapubic  method  was  safer  for  large 
stones. 

Professor  Nicolaygow,  of  Christiania,  said  he  had 
failed  in  attempting  to  cru.sh  a  hard  stone  by  the  lateral 
perineal  method,  and  had  had  to  do  a  suprapubic.  He 
thought  it  was  easy  of  execution,  and  very  safe  if  done 
"a  deux  kmps,"  the  bladder  being  opened  after  adhe- 
sion had  taken  place. 

Mr.  Reginald  Harrison's  experience  of  perineal 
lithotrity  was  not  large,  but  it  had  been  successful. 
The  reasons  for  its  adoption  had  been  large  stones  or 
complications.  Milton  and  himself  had  done  fifty 
cases  with  only  one  death.  He  had  no  objection  to 
the  suprapubic  method  per  se  ;  but  he  had  seen  recur- 
rent stone  fixed  to  the  hard  cicatrix  left  after  that 
operation. 

Mr.  Keegan  confined  his  remarks  to  cases  of  very 
large  stones.     In  these  he  would  select  perineal  litho- 


trity, because  the  mortality  of  the  supraputjic  was  fifty 
per  cent.  In  India  the  natives  died  of  the  suprapubic 
operation  the  same  as  here.  Their  mortality  had  been 
42.17  per  cent.  That  of  the  median  and  lateral  peri- 
neal methods  was  much  less. 

Mr.  Chicken  referred  to  a  case  in  which,  although 
symptoms  of  stone  were  present  in  a  lady,  no  stone 
could  be  felt  by  sounding.  He  dilated  the  urethra 
and  digitally  examined  the  bladder,  felt  a  stone  en- 
cysted, and  extracted  it  per  urethram.  It  weighed  810 
grams.     No  incontinence  of  urine  followed. 

Mr.  Freyer  pointed  out,  in  reply,  that  it  was  inter- 
esting to  hear  from  Mr.  Keegan's  statistics  that  natives 
of  India  did  sometimes  die  after  operations.  Some 
people  seemed  to  believe  that  in  India  operations  were 
so  pleasant  and  free  from  risk  that  the  natives  under- 
went them  merely  to  while  away  the  monotony  of  ex- 
istence. Did  these  people  believe  that  the  genito- 
urinary tract  of  the  Indian  had  been  rendered  so 
aseptic  by  the  constant  imbibition  of  the  pure  water 
from  the  Himalayas  or  the  sacred  fluid  from  the 
Canges  that  operations  could  be  undertaken  on  his 
bladder  with  impunity?  Anyhow,  that  had  not  been 
his  happy  experience. 

Third  Day — Friday,  August  3d. 

Roentgen-Ray  Methods.— Dr.  J.  Mackenzie  Da- 
vidson read  a  paper  and  gave  a  demonstration  on  re- 
cent progress  in  the  use  of  the  Roentgen-ray  methods 
in  surgery.  He  illustrated  how  misleading  the  use 
of  the  rays  might  be  as  ordinarily  used,  if  proper 
precaution  was  not  taken,  since  the  picture  was  a 
shadow  picture  and  liable  as  all  shadows  to  distor- 
tion. To  obviate  this  he  devised  the  method  of  tak- 
ing two  photographs,  with  the  tubes  6  cm.  apart,  and 
then  viewing  the  two  photographs  in  a  VVheatstone's 
stereoscope.  The  distance  thus  chosen  was  about  the 
distance  between  the  centres  of  the  two  pupils.  Thus, 
suppose  an  observer  wished  to  locate  a  bullet  in  a  leg, 
and  suppose  him  looking  at  the  leg  from  a  distance  of 
two  feet.  If  he  were  gifted  with  Roentgen-ray  vision, 
he  would  see  the  bullet  in  three  dififerent  positions  with 
regard  to  the  leg  bones,  accordingly  as  he  looked  with 
the  right  eye,  left  eye,  or  both  together.  But  bi- 
nocular vision  would  give  him  the  most  accurate  in- 
formation. Dr.  Davidson  then  would  take  a  point 
two  feet  away,  representing  the  observer's  nose,  move 
the  tube  3  cm.  to  one  side,  then  3  cm.  to  the  other, 
and  take  an  .v-ray  photograph  in  each  case.  By  com- 
bining the  two  thus  obtained  in  VVheatstone's  stereo- 
scope very  accurate  localization  could  be  obtained. 

Open  Incision  for  Club-Foot Dr.  A.  M.  Phelps, 

of  New  York,  read  a  paper  on  "The  Open  Incision 
for  Club-Foot;  its  Indications  and  Abuses."  He  said 
that  in  1878  he  did  his  first  operation  by  open  incision 
on  a  case  of  relapsed  club-foot.  From  then  until  1897 
he  operated  in  five  hundred  and  thirty-eight  cases.  Al- 
together up  to  the  presen  the  had  operated  in  some  six- 
teen hundred  and  fifty  cases.  He  maintained  that  the 
mortality  was  nil;  that  any  foot  at  any  age  could  be 
straightened;  that  the  results  were  better  than  by 
other  methods  of  operation,  and  that  relapses  were 
rare.  These  good  effects  were  obtained  in  a  few 
weeks,  and  the  weight  of  the  body  kept  the  foot  in 
good  position  afterward.  In  America  tenotomies  and 
the  use  of  retention  apparatus  were  being  largely 
abandoned.  The  means  at  the  surgeon's  disposal  in 
dealing  with  club-foot  (varus)  were,  according  to  the 
severity  of  the  case:  (i)  Manual  manipulation;  (2) 
subcutaneous  tenotomy;  (3)  open  incision  (Phelps' 
operation) ;  (4)  open  incision  plus  linear  osteotomy 
of  the  neck  of  the  astragalus;  (5)  same  as  the  preced- 
ing (4)  plus  removal  of  a  V-shaped  piece  of  os  calcis; 
(6)  amputation.     In  the   infant,  aged  from   three  to 


3i8 


MEDICAL    RECORD. 


[August  25,  1900 


four  months,  mature  experience  enabled  him  to  pre- 
sent a  method  which  should  cover  all  operative  pro- 
cedures for  club-foot.  The  soft  parts  caused  the  chief 
trouble,  and,  that  being  so,  were  we  justified  in  such 
an  operation  as  osteotomy  or  tarsectomy  with  a  mor- 
tality of  five  per  cent.?  No.  On  the  other  hand.  Dr. 
Phelps  spoke  vigorously  and  emphatically  against  the 
prolonged  use  of  orthopedic  instruments  and  appli- 
ances and  traction.  His  plan  was,  excluding  all  those 
cases  in  which  manual  reposition  was  possible,  to  cut 
all  the  contracted  parts  that  offered  resistance  to  re- 
placement, beginning  with  the  tendo  Achillis,  and  go- 
ing as  deep  and  as  far  as  the  peroneus  longus  tendon. 
The  cut  must  be  at  right  angles  to  the  long  axis  of  the 
foot.  The  operator  should  not  cease  his  efforts  until 
the  foot  was  over-corrected,  going  on  if  needful  to 
linear  osteotomy  of  the  neck  of  the  astragalus  and 
wedge  osteotomy  of  the  os  calcis.  Of  course  the 
operation  should  be  antiseptically  performed,  and 
perhaps  Esmarch's  bandage  should  be  used.  Older 
patients  should  be  treated  in  the  same  w'ay,  age  itself 
being  no  bar  to  the  operation.  The  only  exceptions 
should  be  those  cases  in  which  the  foot  could  be 
manually  replaced,  or  those  curable  by  tenotomy  only. 
In  dressing,  the  organization  of  the  blood  clot  in  the 
wound,  or  filling  with  chipped  catgut,  helped  to 
abridge  the  healing-process.  Plaster  of  Paris  was  the 
only  retention  apparatus  he  used,  with  in  some  cases 
hooks  in  the  bandage  and  lacing  to  keep  the  foot  in 
position.  The  cases  would  need  looking  after  for 
months  and  years.  Of  his  first  one  hundred  and 
sixty-one  cases  six  per  cent,  relapsed;  since  then  re- 
lapses had  been  rare.  His  conclusions  were  that  all 
feet  at  any  age  after  four  months,  with  shortened  skin 
and  ligament,  should  be  operated  on  by  the  open 
method,  and  that  club-foot  shoes  of  every  name  and 
nature  should  be  discarded. 

Mr.  Jackson  Clarke,  while  thanking  Dr.  Phelps 
for  his  paper,  felt  that  he  must  dissent  from  him  from 
every  point  of  view.  What  were  the  results  of  his 
early  cases?  Unless  these  patients  were  seen  in  adult 
life,  no  idea  at  all  could  be  formed  as  to  the  value  of 
the  proceeding,  and  unless  they  had  been  thus  watched 
figures  as  to  relapses  were  valueless.  He  himself 
years  ago  had  gone  in  for  this  type  of  procedure,  and 
very  thoroughly,  but  had  now  entirely  given  it  up. 
He  mentioned  cases  of  double  varus  in  which  one  foot 
had  been  operated  on  by  Dr.  Phelps'  method,  the  other 
by  tenotomies  as  in  the  older  method.  That  done  by 
the  open  incision  failed,  the  tenotomized  foot,  how- 
ever, being  satisfactory.  Young  club-feet  should  be 
guided  in  growth,  not  mutilated.  If  it  went  abroad 
to  the  medical  world  that  a  big  operation  was  needed 
in  these  cases,  many  thousands  of  feet  would  be 
ruined.  He  had  no  fault  at  all  to  find  with  the  older 
methods.  He  was  quite  satisfied  with  Mr.  Adams'  re- 
sults, and  his  treatment  was  based  on  the  least  po.s- 
sible  surgical  interference.  Most  cases  required  noth- 
ing more  than  division  of  the  tendo  Achillis,  and  then 
the  wearing  of  a  simple  inside  upright  and  guiding 
strap.  As  to  Dr.  Phelps'  denunciation  of  apparatus, 
did  he  not  himself  explain  his  method  of  hooks  and 
lacing  and  plaster  of  Paris?  And  this  was  quite  right 
too.  A  judicious  surgeon  ought  to  use  all  the  possible 
means  at  his  disposal  for  his  patient's  benefit.  He 
believed  much  of  the  present  unfortunate  state  of 
affairs,  that  is,  the  resorting  to  large  operations  on 
these  feet,  was  due  to  the  much  too  general  ignorance 
of  orthopedics  and  of  the  results  of  orthopedic  meth- 
ods of  treatment. 

Mr.  a.  H.  Tubry  was  especially  pleased  to  have 
heard  from  Dr.  Phelps  exactly  his  method  of  proce- 
dure. Mr.  Tubby  had  thought  the  operation  consisted 
in  the  division  of  the  soft  parts  only  on  the  inner  side 
of  the  foot — at  all  events,  that  was  the  description  ac- 


cepted up  to  now.  But  now  he  heard  from  Dr.  Phelps 
that  he  went  on  to  bony  operations  as  well.  He  quite 
agreed  with  the  remarks  of  the  last  speaker,  and  he 
believed  the  operation  to  be  a  bad  surgical  procedure. 
The  result  looked  well  on  the  table,  but  did  not  stand 
the  test  of  lime.  It  stood  to  reason  that  in  a  large 
gap,  like  that  formed  in  this  operation,  a  scar  must 
develop.  That  scar  would  contract  and  an  incurable 
varus  result.  His  own  feeling  was  that  he  preferred 
to  be  driven  into  such  open  operations,  and  not  to  take 
them  up  voluntarily.  Dr.  Phelps'  operation  of  open 
division  of  soft  tissues  he  condemned  from  his  own 
experience.  As  to  the  modification  of  that  operation 
by  bone  division  also  he  had  no  personal  knowledge. 
Dr.  Phelps  had  said  the  operation  was  often  indicated 
at  four  months  of  age.  He  had  never  yet  seen  a  foot 
at  this  age  which  required  any  operation  of  the  kind. 
On  the  other  hand,  he  had  seen  many  bad  results  of 
such  procedure.  He  should  say  that  no  open  opera- 
tion was  ever  needed  before  the  fourth  or,  more  often, 
sixth  year.  All  these  methods  were  designed  to 
shorten  the  time  taken  in  treatment.  Did  they  do  so 
in  the  end?  If  they  did,  which  was  doubtful,  the  re- 
sults by  the  older,  slower  methods  conscientiously  car- 
ried out  were  far  superior.  Then  After  the  open  opera- 
tion one  has  burnt  one's  boats,  and  if  the  result  was 
not  satisfactory  nothing  further  could  be  undertaken. 
But  in  fairness  to  Dr.  Phelps  it  must  be  acknowledged 
that  the  originator  of  any  operative  procedure  in  all 
probability  had  a  better  idea  of  the  nature,  scope,  and 
limitations  of  his  method  than  had  his  copiers;  and 
therefore  he  would  do  the  operation  better  than  they. 
So  that  instead  of  finally  and  absolutely  condemning 
the  open  method  from  the  results  seen  in  England,  he 
would  rather  hold  judgment  in  suspense  until  he  had 
paid  a  visit  to  America  and  seen  Dr.  Phelps'  own 
cases. 

Mr.  Noble  Smith  thought  that  the  points  in  dis- 
cussion so  far  resolved  themselves  into  matters  of  de- 
gree rather  than  divergence  of  principle.  Dr.  Phelps 
himself  says  he  would  exclude  all  cases  curable  by 
manipulation  and  tenotomy.  If  that  were  so  few  would 
be  left  for  open  methods.  Of  course  we  had  not  seen 
Dr.  Phelps'  cases,  but  we  had  seen  many  done  by  ex- 
cellent surgeons,  and  many  relapses  among  those. 
And  the  successful  cases,  or  those  exhibited  as  such  at 
the  various  societies,  certainly  showed  much  want  of 
elasticity.  He  showed  casts  taken  of  a  bad  case  of 
varus  in  early  infancy,  and  at  intervals  up  to  adult 
life,  and  maintained  that  the  case  showed  that  bad 
cases  of  varus  were  perfectly  curable  by  tenotomies  and 
the  usual  orthopedic  methods. 

A  member  said  that  at  the  City  Orthopedic  Hos- 
pital they  were  most  anxious  to  do  Phelps'  operation, 
and  that  for  the  last  seven  years  he  had  been  looking 
for  cases  suitable  for  it.  Unfortunately  he  had  been 
unable  to  find  them,  the  cases  they  saw  there  being 
perfectly  curable  by  less  heroic  measures.  Dr.  Phelps' 
method  was  certainly  fascinating  in  its  simplicity, 
and  in  the  description  of  its  results.  The  older 
methods  were  prolonged  in  carrying  out,  and  liable  to 
relapse.  But  was  the  open  operation  not  liable  to  re- 
lapse? Perhaps  it  would  be  maintained  that  the  very 
many  undoubted  relapses  they  saw  after  Dr.  Phelps' 
method  had  not  been  properly  done.  But  could  it  be 
believed  for  a  moment  that  the  many  good  surgeons 
who  did  these  cases  undertook  operations  for  which 
they  were  incompetent,  and  about  which  they  were 
ignorant?  He  did  not  for  a  moment  believe  so.  The 
operation,  not  the  surgeon,  was  at  fault.  Then  if  it 
became  generally  accepted  in  the  profession  that  such 
treatment,  apparently  so  simple,  as  Dr.  Phelps  de- 
scribed was  the  proper  course  to  follow,  they  would 
certainly  see  many  feet  hopelessly  ruined  by  surgeons 
attempting  the  operation  who  were  quite  ignorant  of 


August  25,  1900] 


MEDICAL    RECORD. 


319 


the  harm  that  might  result.  For  example  they  recently 
had  had  a  case  brought  in  of  a  foot  irrevocably  spoiled, 
in  which  the  house  surgeon  of  one  of  the  general  hos- 
pitals in  London  had  on  his  own  responsibility  done 
a  Phelps  operation,  badly  perhaps,  but  certainly  need- 
lessly. He  believed  that  everything  possible  should 
be  tried  before  resorting  to  the  operation. 

Dr.  Phelp-S,  in  reply,  did  not  agree  about  want  of 
elasticity  in  feet  after  his  operation.  He  maintained 
that  the  very  cases  on  which  his  paper  was  based  were 
those  which  had  been  treated  for  years  by  the  okkr 
methods,  and  treated  unsuccessfully.  As  to  .Mr.  .Smith's 
casts  he  did  not  consider  the  result  perfect;  the  tarsal 
arch  was  not  normal.  He  believed  the  relapses  seen 
so  often  in  London  were  due  to  the  surgeon's  not  go- 
ing on  far  enough,  but  stopping  before  over-correction 
was  obtained.  The  failure  to  divide  the  deltoid  liga- 
ment led  to  relapses  in  many  ca.ses.  How  could  a 
contracted  skin  or  the  deep  ligaments  be  dealt  with 
except  by  his  method  ?  As  to  the  scar  contracting,  ex- 
perience had  shown  that  such  did  not  occur.  Rather 
than  many  thousand  feet  being  ruined  by  the  adoption 
of  his  teaching.s,  he  believed  that  if  his  method  was 
not  adopted  many  thousand  more  patients  would  go  to 
their  graves  uncured.  .As  to  the  older  methods  he  had 
come  to  the  conclusion  that  they  were  unsatisfactory, 
after  years  of  careful  study.  For  fifteen  consecutive 
years  he  had  visited  Europe.  He  had  seen  Mr.  Adams' 
work  and  cases,  and  also  the  result  of  continental 
surgeons;  and  it  was  on  their  failures  that  his  views 
as  to  the  inefficiency  of  the  older  orthopedic  methods 
were  based. 

(To  be  Continued.) 


|]accUc<il  Items. 


Contagious   Diseases— Weekly   Statement Report 

of  cases  and  deaths  from  contagious  diseases  reported 
to  the  Sanitary  Bureau,  Health  Department,  for  the 
week  ending  August  18,  1900: 


Tuberculosis 

Typhoid  fever 

Scarlet  fever 

Measles 

Diphtheria 

Laryngeal  diphtheria  (croup) 
Cerebro-spinal  meningitis. . . . 

Chicken-po.\ 

Smallpox    


Treatment  of  Malaria  in  the  Roman  Campagna. 
—A  campaign  against  malaria  in  the  .\gro  Romano 
was  undertaken  at  the  beginning  of  this  summer  by 
the  bureau  of  hygiene  of  Rome.  Instructions  were 
issued  to  the  resident  physicians  and  special  medical 
officers  were  despatched  by  the  bureau  to  patrol  the 
Campagna,  distributing  quinine  tablets  and  impress- 
ing upon  the  farm  laborers  and  superintendents  the 
urgent  necessity  of  observing  certain  simple  prophy- 
lactic measures.  From  a  translation  of  the  official  in- 
structions issued  by  the  bureau  (published  in  The  Lan- 
cet of  July  7,  1900)  we  take  the  following  directions 
for  treatment  in  developed  cases: 

"  Primary  Attacks. — The  administration  of  quinine 
in  tablets,  each  containing  '_.  gm.  (gr.  viiss.)  of  the 
sulphate  should  be  recommended  during  the  subsi- 
dence or  at  the  end  of  the  febrile  attack.  The 
quantity  administered  should  be  2  gm.  daily  for 
three  successive  days  and  i  gm.  daily  for  other  four 
days.  Tabloids  sufficient  for  a  week's  treatment  are 
to  be  given  in  a  small  box  with  appropriate  directions 
to  each  patient.     After  the  remedy  has  been  suspended 


for  five  days,  it  will  be  well  to  follow  the  directions 
for  relapsing  cases,  even  although  there  be  no  return 
of  the  fever.  Hypodermic  injections  are  to  be  em- 
ployed only  in  exceptional  cases.  The  medical  officer 
is  recommended  to  supervise  the  treatment  of  primary 
aestival  infections  in  which  the  fever  of  the  first  attacks 
should  be  suppressed  as  far  as  possible,  experience 
having  proved  the  importance  of  prophylaxis  of  early 
treatment. 

"  Relapshi!^  A-ri-rj.— The  administration  of  sulphate 
of  quinine  should  be  carried  out  as  follows:  .After  the 
last  febrile  attack,  or  during  its  decline,  2  gm.  of  the 
quinine  in  four  tabloids  are  to  be  given.  The  follow- 
ing day,  the  same  doses  are  repeated.  During  the  next 
five  days  I  gm.  of  sulphate  of  quinine  in  two  tabloids 
is  administered,  after  which  the  treatment  is  to  be  sus- 
pended for  a  week.  The  following  week  the  adminis- 
tration is  to  be  resumed,  the  patient  being  supplied 
with  the  same  quantity  of  quinine  as  in  the  first  week, 
and  the  quantity  taken  regulated  as  before.  When  the 
fever  no  longer  returns,  the  daily  dose  should  be  re- 
duced by  one-half.  The  administration  is  then  to  be 
again  suspended  for  a  week.  In  the  fifth  week  the 
same  amount  is  to  be  given  in  the  same  way  as  in  the 
third  week,  and  so  also  during  the  seventh  week.  As 
a  rule,  it  is  not  necessary  to  continue  the  administra- 
tion beyond  the  seventh  week.  During  the  weeks  in 
which  the  quinine  is  suspended,  he  may,  if  he  thinks 
proper,  administer  'Bacelli's  mixture''  or  capsules 
and  tabloids  containing  iron.  For  convenience  of  ref- 
erence the  above  rules  may  be  stated  in  the  following 
tabular  form : 

Tables  for  tmk  Administration  of  Quinine. 

A — In   Primary  Malarial  Fevers. 

(Tabloids  of  50  cgm.) 

Tabloids 

Pirst  day  (near  end  of  febrile  attack)  ....  4 

Second  day . 

Third  day _j 

Fourth  day 2 

Fifth  day 2 

Si.\th  day 2 

Seventh  dav 2  t     " 

"  Suspend  the  administration  for  five  days,  then  con- 
tinue as  in  Table  B. 

B—/n  A'llapsiiig  Malarial  Fevers. 

Tabloids.        Total. 

First  day  (at  end  of  febrile  attack) 4  2  gm. 

Second  day 4  2     " 

Third  day ■  2     " 

Fourth  day 2  i*  " 

Fifth  day 2  i     " 

Sixth  day 2  i     " 

Seventh  day 2  I     " 

Second  week. — Suspend  quinine  ;  daily  observations,  etc.  (in 
an.Temic  persons  live  tablespoonfuls  of  "  Bacelli's  n)i.\ture  "). 

Third  week.  — Repeat  treatment  as  in  first  week,  but  if  no  re- 
turn of  fever  reduce  dose  by  one-half. 

Fourth  week.— Suspend  quinine;  dailv  observations  (in 
an.-emic  cases  four  tablespoonfuls  of  "  I3.icelli's  mixture  "). 

Fifth  week,— Repeat  (jeatment  as  in  third  week,  with  the 
same  precaution. 

Sixth  week— Suspend  quinine;  observations  (in  anaemic  cases 
four  tablespoonfuls  of  "  Hacelli's  mixture  "). 

Seventh  week.— Repeat  treatment  as  in  fifth  week.  End  of 
treatment  if  no  return  of  fever. 

*  If  on  the  fourth  day  after  commencing  treatment  the  fever  does  not  dis- 
appear continue  with  doses  of  2  gm.  In  exceptional  cases  use  hypodermic 
injections.  iv  ^ 

"The  treatment  of  the  fever,  whether  primary  or  sec- 
ondary, should  be  commenced  according  to  the  scheme 
laid  down,  even  when  the  last  attack  has  occurred  some 
days  previously.  Whenever  the  fever  asserts  itself  it 
is  best  to  recommence  the  treatment  as  for  the  first  day 
and  to  continue  according  to  the  rules  prescribed.     The 

Bacelli's  mixture  "  contains  the  following  ingredients  :  sul- 
phate of  quinine.  3  gm. ;  tartaric  acid,  3  gm, ;  arseniate  of  sodium. 
5  cgm. ;  distilled  water.  300  gm.  The  dose  for  an  adult  is  one 
tablespoonful. 


Total. 
2  gm. 

2  " 
I*  ■• 
I      ■' 


320 


MEDICAL    RECORD. 


[August  25,  1900 


total  dose  of  quinine  should  be  given  within  two  hours, 
i.e.,  at  intervals  of  half-hour,  three-quarters  of  an  hour, 
or  one  hour,  according  to  the  fractions.  A  glass  of 
water  should,  if  possible,  be  drunk  after  every  tabloid, 
acidulated  by  preference  with  lemon  or  vinegar.  In 
children  the  doses  should  be  reduced  in  proportion  to 
age. 

"  Hypodermic  and  IntraTenous  Injections. —  Hypoder- 
mic injections  are  reserved  for  cases  of  intolerance  of 
quinine  by  the  stomach  and  for  cases  of  pernicious 
fever.  In  these  cases  two  hypodermic  injections  are 
made,  each  of  i  gm.  of  the  bi-hydrochlorate  of 
quinine  dissolved  in  5  gm.  of  distilled  and  sterilized 
water.  A  large  syringe  is  employed,  the  lateral  re- 
gions of  the  abdomen  being  chosen  and  the  skin  washed 
with  gauze  and  absolute  alcohol.  The  needle  should 
also  be  sterilized  with  absolute  alcohol  or  by  boiling 
in  a  test  tube.  The  hypodermic  solution  in  sterilized 
vials,  each  containing  i  gm.  of  bi-hydrochlorate,  will 
be  supplied  to  the  medical  officer.  Tlie  patient  must 
then  be  conveyed  to  the  temporary  hospital  or  to  the 
city.  In  the  hospital  injections  of  camphorated  oil 
and  caffeine  will  be  made.  During  the  two  subse- 
quent days  2  gm.  of  quinine  must  be  given  daily  either 
by  injection  or  by  the  mouth  (one  tabloid  of  '_■ 
gm.  every  hour).  The  intravenous  injections  ac- 
cording to  Bacelli's  method  will  be  made  in  extreme 
cases  in  the  sanitary  station  hospital.  For  these  injec- 
tions boiled  solutions  of  neutral  hydrochlorate  of 
quinine  at  a  temperature  of  40°  C.  should  be  employed 
exclusively  in  doses  of  i  gm.  in  10  c.c.  of  chloride  of 
sodium  solution  (0.75  per  cent.)." 

Psychology  of  Crazes. — Professor  Patrick,  writing 
on  this  subject  in  Applehm's  Magazine,  says:  "If  we 
turn  to  the  behavior  of  the  normal  adult  man  in  men- 
tal epidemics  and  crazes  of  all  kinds,  from  the  crusades 
to  the  massacre  of  St.  Bartholomew,  from  the  tulip 
mania  in  Holland  to  the  Dewey  welcome  in  New  York 
City,  we  observe  that  his  behavior  is  to  some  extent 
similar  to  that  of  the  hypnotic  subject  and  the  child 
and  the  primitive  man.  The  general  character  of  men- 
tal action  in  epidemics  is  as  follows:  Men  become 
imitative  beings,  and  their  actions  are  determined  by 
suggestion  from  the  action  of  others.  Memory  and 
the  association  of  ideas  are  inactive,  and  there  is  an 
inability  to  reason  and  an  indisposition  toward  delib- 
eration and  calm  reflection.  Past  experiences  are  dis- 
regarded, remote  consequences  are  not  seen,  and  be- 
havior is  repulsive  and  spasmodic.  Feeling  is  very 
strong,  and  every  kind  of  emotion  is  apt  to  be  exagger- 
ated. Calm  observation  is  also  lacking,  and  mental 
images  maybe  mistaken  for  objective  reality,  as  in  the 
case  of  the  hallucinations  that  are  frequent  in  these 
phenomena." 

Mr.  Watson  Cheyne  on  Nursing  at  the  Front 
in  South  Africa. — In  the  course  of  a  long  letter  to 
the  London  Times,  describing  his  experiences  as  con- 
sulting surgeon  to  the  army  in  South  Africa,  Mr. 
Watson  Cheyne  alludes  to  the  question  of  nursing. 
He  "  strongly  agrees"  that  female  nurses  are  better, 
"especially  for  cases  of  typhoid  fever,"  than  males. 
.Admitting  that  women  could  not  go  forward  with  an 
advancing  army,  and  deprecating  their  employment 
in  field  hospitals,  he  holds  that  female  nurses  must  be 
limited  to  base  hospitals.  Mr.  Cheyne  proceeds: 
"  As  a  matter  of  fact  in  this  campaign  a  much  larger 
number  of  female  nurses  than  is  arranged  for  in  the 
army  regulations  was  employed.  My  belief  is  that 
a  still  larger  number  might  have  been  used  with  ad- 
vantage, but  even  if  the  authorities  had  taken  the  same 
view,  any  attempt  to  substitute  female  nurses  for  the 
orderlies  to  such  an  extent  as  is  the  case  in  a  civil 
hospital    would   have   dislocated   arrangements   most 


seriously,  and  would  have  meant  practically  the  re- 
organization of  the  base  hospital  system  in  the  middle 
of  the  campaign,  when  the  officials  were  already  very 
much  overworked.  This  is,  however,  I  think,  a  point 
which  should  be  kept  in  view  when  the  numerous 
lessons  taught  by  the  war  are  taken  into  consideration." 

Drs.   Sambon  and  Low's  Experiments The  hut 

in  which  Drs.  Sambon  and  Low  are  making  their 
experiments  to  see  whether  malaria  is  pre\  ented  by 
excluding  mosquitos  is  placed  on  a  site  about  two 
miles  from  Ostia,  on  the  edge  of  a  swamp  formerly 
part  of  the  royal  hunting  dornain  of  Castel  Fusano, 
and  left  undrained  to  preserve  the  wild  animals.  It 
is  one  of  the  most  fever-stricken  centres  of  the  Roman 
Campagna,  and  is  infested  with  innumerable  mosquitos 
of  the  malarial  variety. —  Science. 

The  Centenary  of  the  Royal  College  of  Surgeons 
of  England. — It  is  one  hundred  years  since  George 
III.  gave  to  the  surgeons  of  England  the  right  to  in- 
corporate themselves  into  a  Royal  College,  and  on 
Thursday,  July  26th,  the  centenary  of  this  incorpora- 
tion was  fittingly  celebrated.  Sir  William  MacCor- 
mac,  the  president  of  the  college,  delivered  for  the 
occasion  an  eloquent  address,  in  which,  after  welcom- 
ing the  surgeons  from  other  countries  who  had  been 
adjudged  worthy  of  receiving  the  honorary  fellowship 
of  the  college,  he  proceeded  to  give  a  short  but  interest- 
ing review  of  the  development  and  progress  of  surgery 
in  general,  and  of  British  surgery  in  particular.  Sir 
William  MacCormac's  speech  has  been  published  in 
book  form,  and  appended  to  it  is  a  brief  biographical 
sketch  of  each  master  and  president  of  the  college 
since  its  incorporation. 

Health  Reports. — The  following  cases  of  smallpox, 
yellow  fever,  cholera,  and  plague  have  been  reported 
to  the  surgeon-general  of  the  United  States  Marine- 
Hospital  service  during  the  week  ended  August  17, 
1900 : 

Smallpox— United  States. 

Kansas,  Wichita  August  4th  to  nth i 

Louisiana,  New  <")rleaiis  ..  ..August  4th  to  nth lo                  3 

Minnesota,  Minneapolis July  14th  to  .August  4th    22 

Winona July  20th  to  August  4th      a 

New  York,  New  York August  4th  to  nth x                  1 

Ohio,  Cleveland August  4th  to  nth 1 

Portsmouth August  4th  to  nth 4 

Utah,  Salt  Lake  City July  28th  to  August  nth..  11                  3 

Smallpox — Foreign. 

Eelgiutn,  Antwerp July  21st  to  28th 2 

lirazil,  Rio  de  Janeiro June  22d  to  29th 7 

England,  Liverpool July  21st  to  2Sth i 

London July  21st  to  28th 11 

Germany,    Frankfort  on   the 

Main July  14th  to  21st 1 

Mexico,  City  of  Mexico June  17th  to  August  5th,  .......     62  51 

Vera  Cruz July  28th  to  .Auj^ust  4th  .. 6 

Netherlands,  Rotterdam   ..   July  21st  to  28th. .  x 

Russia,  Moscow July  14th  lo  21st 3 

Odessa July  2ist  to  28th     x  i 

St    Petersburg     .       July  14th  to  21st     .       ...    69  15 

Warsaw July  ^4th  to  21st 4 

Straits    Settlements,     Singa- 
pore  June  2-^d  to  30th 2 

Swiuerland,  Geneva July  7tn  to  14th I 

Yellow  Fevkk. 

Brazil,  Rio  de  Janeiro June  22d  to  2Qth 4 

Colombia,  liarranquilla June  Z2d  to  29th 2 

Bocas  del  'I'oro  . .  July  26th 2 

Panama July  30th  to  August  6th 5  2 

Cuba,  Cienfuegos August  I4lh i* 

Havana July  2d  to  23d 9 

Matanzas July  23d  to  29th 1+ 

Mexico,  ^Ic^ida [uly  I4lh  to  21st 5  2 

Vera  Cruz July  28th  to  August  4th ig  6 

•  American  from  Matan/as.  f  Case  reported  July  ,ith. 

CllOLBRA. 

India,  Madras June  21st  to  29th 1 

Japan,  Yokohama July  12th      1  suspect. 

Plague. 

Brazil,  Rio  de  Janeiro June  2d  to  29th 40  '4 

F.gypt.  Port  Said April  20th  to  July  12th 22  38 

Japan,  Osaka July  5th  to  i6th 1 

Shidzuoka  Ken July  5th  to  i6th 1 

Philippines,  Manila June  23d  to  July  7th 7  5 

Syria,  Beirut July  14th  to  2xst 4 

Turkey,  Trebizonde  July  27th 1  suspect. 


Cases.    Deaths. 


Medical  Record 

A    IVeekly  yournal  of  Medicine  and  Surgery 


Vol.  58,  No.  9. 
Whole  No.  1556. 


New  York,   September   i,    1900. 


$5.00  Per  Annum. 
Single  Copies,  loc. 


©riotiiaX  Articles. 

THE  RELATIVE  BEARING  OF  THE  CON- 
JOINED TENDON  AND  THE  INTERNAL 
OBLIQUE  MUSCLfi  UPON  THE  RADICAL 
CURE   OF    INGUINAL    HERNIA.' 

V,\   JOSEPH    A.    BLAKE,    M.D.. 

ASSISTANT     DEMONSTRATOR     OF     ANATOMY.    COLUMBIA     UNIVERSITY  ;    ATTEND- 
ING  SURGEON    TO   THE    ST.    LUKE    ANO    HARLEM    HOSPITALS. 

My  chief  reason  for  presenting  this  subject  is  that  we 
are  in  danger  of  becoming  confused  in  our  descrip- 


pectineal  line  laterally  for  a  variable  distance  from 
the  rectus  insertion.  A  careful  dissection  of  this 
region,  especially  if  the  internal  oblique  be  well  de- 
veloped, reveals  that  as  a  rule  the  lowermost  fibres  of 
the  internal  oblique  do  not  enter  into  the  formation  of 
the  conjoined  tendon,  but,  arising  from  Poupart's  liga- 
ment, in  front  of  the  cord,  pass  parallel  with  the  liga- 
ment to  be  inserted  in  front  of  the  rectus  (Fig.  i).'  If 
the  internal  oblique  be  reflected  the  conjoined  tendon 
is  found  to  be  chiefly  derived  from  the  deeper  aspect 
of  the  internal  oblique,  and  slightly  from  the  transver- 
salis  where  these  muscles  are  inseparably  connected 
at  their  origin.     It  consists  mainly  of  a  few  scattered 


Ilio-hypogastric  nerve. 

Ilio-inguinal  nerve 
Spermatic  cord. 


I'.Mernal  oblique. 

IiUernal  oblique. 
Poupart's  ligament. 


—   -j'ne  of  pubis. 


.xternal  oblique 
(reflected). 


KlG. 


tionsof  the  operations  for  the  radical  cure  of  inguinal 
hernia.  The  danger  arises  from  the  misapplication 
of  the  term  "conjoined  tendon."  It  is  not  my  pur- 
pose to  enter  into  a  long  dissertation  upon  the  anatomy 
of  this  region,  but  only  to  give  enough  to  elucidate  the 
points  in  question.  It  may  seem  superfluous  to  review 
these  anatomical  details,  yet  if  they  were  understood 
by  all  the  present  ambiguity  would  not  have  arisen. 

The  conjoined  tendon  is  usually  understood  to  be 
the  insertion  of  the  lower  fibres  of  the  internal  oblique 
and  transversalis  muscles,  extending  along  the  ilio- 

'  Read  before  the  Surgical  Section  of  the  Academy  of  Medi- 
cine, New  York,  April  g,  igoo. 


muscular  fasciculi  arching  over  the  cord,  to  be  inserted 
to  the  ilio-pectineal  line  (Fig.  2). 

The  conjoined  tendon  is  thus  covered  by  the  lower 
part  of  the  internal  oblique  muscle,  and  also  it  lies  in 
front  of  the  main  aponeurosis  of  the  transversalis,  for 
the  fibres  of  the  latter  are  easily  demonstrated  as 
passing  behind  the  conjoined  tendon  to  unite  with  the 
internal  oblique  in  front  of  the  rectus  (Figs.  2  and  3). 
This  relation  is  usually  overlooked  on  account  of  the 
tenuity  of  the  transversalis  aponeurosis  in  this  region. 

'  The  illustrations  were  drawn  from  consecutive  dissections 
made  on  the  same  subject,  a  man  thirty  years  of  age,  of  moder- 
ate muscular  development. 


^22 


MEDICAL    RECORD. 


[September  i,  1900 


In  May,  1898,  Bloodgood  published  a  preliminary 
report  upon  an  operation  he  had  devised  and  practised 
for  the  radical  cure  of  hernia.  The  operation  was 
especially  designed  for  a  condition  which  he  calls 
"obliteration"  of  the  conjoined  tendon,  and  is  based 
upon  the  suture  of  the  lateral  border  of  the  rectus  ab- 
dominis to  Poupart's  ligament.  Bloodgood  explains 
the  use  of  the  term  "obliteration"  "in  that  the  ex- 
treme condition  is  more  likely  to  be  acquired  than 
congenital."  He  further  states  that,  in  cases  of  ob- 
literation of  the  conjoined  tendon,  the  whole  hand  can 
be  introduced  into  the  abdomen  after  division  of  the 
aponeurosis  of  the  external  oblique.  Obliteration  was 
found  by  him  to  occur  in  seven  per  cent,  of  herniee. 
He  also  mentioned  the  variable  development  of  the 
conjoined  tendon,  and  refers  to  the  statement  in 
Quain's  "  Anatomy  "  that  it  usually  extends  over  the 
inner  two-thirds  of  Hesselbach's  triangle,  but  may  ex- 
tend laterally  as  far  as  the  internal  abdominal  ring, 


on  reading  Quain's  description,  and  after  reading  Hal- 
sted's  discussion  of  Turck's  paper  on  "The  Surgical 
Anatomy  of  Hernia,"  '  I  found  it  to  be  the  case. 

How  this  error  arose  can  be  better  appreciated 
by  reviewing  the  structure  of  this  fascia  as  well  as 
the  literature  on  the  subject.  The  aponeurosis  of  the 
transversalis  muscle  passes  horizontally  across  the 
lower  part  of  the  abdomen,  and  in  this  region  is  in- 
serted with  that  of  the  internal  oblique  in  front  of  the 
rectus  muscle.  For  a  short  distance  above  Poupart's 
ligament  in  the  region  of  the  inguinal  canal  it  is  de- 
ficient, and  the  structure  already  referred  to  as  the 
transversalis  fascia  is  the  sole  protection  to  this  part.of 
the  abdominal  wall  after  removal  of  the  external  and 
internal  oblique  muscles  (Figs.  2  and  3).  This  fascia 
presents  aponeurotic  fibres,  which  near  the  rectus 
muscle  have  in  general  a  vertical  direction,  while  in 
the  region  of  the  internal  ring  they  have  a  curved 
direction,  passing  from  above  downward  and  curving 


Internal  oblique  (reflected). 


Transversalis  muscle 


External  oblique  (reflected). 


Transversalis  fascia. 


Internal  oblique  (reflected  j. 


Internal  oblique  (reflected). 


Internal  oblique  (deep  fibres'). 
Kpigastric  vessels. 

Transversalis  aponeurosis. 


I  Poupart's  ligament  (attached 
(  to  spine  of  pubis). 


F:g. 


which  would  be  a  distance  of  about  an  inch  and  a  half 
or  two  inches. 

My  impression  from  casual  observation  in  numerous 
dissections  had  been  that  the  conjoined  tendon  was 
more  or  less  of  a  myth,  and  it  seemed  to  me  to  be 
erroneous  to  attribute  so  much  importance  to  it.  In 
order  to  determine  this  point,  I  made  during  the  past 
fall  and  winter  a  series  of  observations  in  the  dissect- 
ing-rooms of  the  College  of  Piiysicians  and  Surgeons, 
Columbia  University.  In  observations  made  on  both 
sides  in  twenty-five  selected  muscular  subjects,  in 
which  the  parts  were  normal,  I  found  that  in  no  case 
did  the  conjoined  tendon  extend  for  more  than  five- 
eighths  of  an  inch  laterally  from  the  insertion  of  the 
rectus.  In  the  majority  the  extent  was  less  than  half 
an  inch,  and  in  some  subjects  its  extent  was  inap- 
preciable. In  all  cases  it  consisted  of  only  scattered 
muscular  or  tendinous  fibres.  There  was  uniformly, 
however,  a  distinct  dorsal  wall  to  the  inguinal  canal 
formed  by  the  tliickened  transversalis  fascia.  It  had 
not  occurred  to  me  at  first  that  the  Baltimore  surgeons 
referred  to  this  fascia  as  the  conjoined  tendon.     But 


sharply  around  the  cord  to  pass  laterally  below  that 
structure  with  a  direction  in  general  parallel  to  Pou- 
part's ligament.  These  latter  fibres  form  the  pillars 
of  the  internal  ring,  and  suspend  the  cord  above  Pou- 
part's ligament.  Between  the  vertical  inner  and  curved 
outer  portions  is  a  thinner  portion  through  wliich  di- 
rect herni.'E  are  said  to  occur  (^Fig.  3).  This  fascia  in- 
cluding tlie  aponeurotic  fibres  lies  on  the  dorsal  aspect 
of  the  transversalis  ajjoneurosis,  being  easily  separable 
from  it  at  its  lower  portion,  but  above  it  is  clo.sely 
connected  with  the  transversalis  and  a  separation 
becomes  artificial  (Fig.  3).  The  structure  is  best 
viewed  from  tlie  dorsal  surface  of  the  abdominal  wall, 
after  tiie  removal  of  the  peritoneum.  Often  in  muscu- 
lar subjects  muscular  fasciculi  from  the  transversalis 
and  sometimes  the  internal  oblique  may  be  seen  pass- 
ing into  it.  It  is  closely  connected  above  with  the 
extremities  of  the  fold  of  Douglas. 

Henle '  described  the  structure  as  fascia  transversalis, 
and  named  the  portion  consisting  of  the  fibres  curving 

'  Journal  of  the  Amcricin  Mctiicil  ■Vssocialion,  /Xpril  15,  1899. 
"  Henle  :   "  .Anatomic  des  Menschen — Muskellehre." 


September  i,  1900] 


MEDICAL    RECORD. 


323 


downward  to  form  the  inner  margin  of  the  internal 
ring  the  "  ligamentum  inguinale  mediale,"  wliile  to 
the  portion  below  and  lateral  to  the  ring  he  gave  the 
name  "  ligamentum  inguinale  laterale  "  (Fig.  3 ).  The 
curved  margin  is  also  known  as  the  "  plica  semilunaris 
fascia  transversalis."  '  The  curved  portion  internal 
to  the  ring  is  generally  known  as  the  ligament  of 
Henle;  the  outer  portion,  lying  below  the  inguinal 
ring  or  fossa  and  so  above  the  femoral,  is  often  called 
the"  "ligamentum  interfoveolare,"  or  ligament  of 
Hesselbach. 

Douglass"  describes  the  whole  fascia  as  properly  an 
aponeurosis,  inasmuch  as  it  is  closely  combined  with 
the  transversalis  aponeurosis  above  and  also  is  con- 
nected to  both  internal  oblique  and  transversalis 
muscle  by  muscle  fibres.  He  also  states  that  a  fascia 
that  lies  between  it  and  the  peritoneum  is  the  true  trans- 
versalis fascia.  No  doubt  the  supposition  that  it  is 
conjoined  tendon  has  arisen  on  account  of  his  descrip- 
tion of  the  insertion  to  it  of  muscle  fibres  from  both 


the  name  of  falx  inguinalis  or  ligament  of  Henle  has 
been  given." 

Unless  we  call  this  fascia  conjoined  tendon  we  can- 
not accept  Bloodgood's  term  "  obliteration  of  the  con- 
joined tendon."  It  is  entirely  distinct  from  the 
historic  conjoined  tendon,  being  separated  from  it  by 
the  main  aponeurosis  of  the  transversalis.  Although 
forming  the  main  support  of  this  region  it  has  nothing 
to  do  with  the  operation  for  radical  cure,  except  in  so 
far  as  to  determine  an  operative  method,  inasmuch  as 
only  structures  that  lie  in  front  of  it  are  sutured.  The 
true  conjoined  tendon  is  ordinarily  such  a  weak  affair 
that  it  is  negligible  in  operative  juocedures.  It  is  only 
exceptionally  that  either  it  or  the  transversalis  are  in- 
cluded in  the  sutures  in  the  Bassini  operation,  ex- 
cepting that  the  sutures  placed  in  the  neighborhood  of 
the  internal  ring  may  include  the  transversalis.  Our 
main  reliance  in  radical  cure  is  the  internal  oblique, 
and  our  efforts  should  be  to  restore  the  normal  paral- 
lelism of  its  fibres  to  Poupart's  ligament.     This  may 


Internal  oblique  (reflected^ 


Transversalis  (refiectedj. 


Transversalis  fascia  dig.  ( 
inguinalis  nicdiale).      \ 

(Lig.  inguinalis  laterale) 


Puupart's  ligament. 
Genito-crural  nerve. 


Spermatic  cord  (cut  and  I 
reflected).  I 


F.xternal  oblique  (reflected). 

Internal  oblique  (reflected). 
Iransversalis  (reflected). 


»  1  ransversalis  fascia  (inner 
'1  vertical  fibres). 

(Thinner  portion;. 


Conjoined  tendon. 


Fig. 


transversalis  and  internal  oblique.  However,  I  can- 
not gather  from  his  article  that  he  calls  it  conjoined 
tendon.  The  description  in  Quain  is  based  upon 
Douglass'  article,  and  refers  to  this  fascia  or  aponeu- 
rosis as  a  part  of  the  conjoined  tendon.  Bloodgood's 
position  is  evidently  taken  from  Quain. 

Quain's  words  are:'  "The  conjoined  tendon  varies 
greatly  in  its  development.  In  many  cases  it  is  very 
slight  and  scarcely  to  be  distinguished,  while  in  others 
its  deeper  portion,  derived  from  the  transversalis 
muscle,  covers  the  whole  breadth  of  the  triangle,  reach- 
ing outward  along  the  deep  femoral  arch  as  far  as  the 
internal  abdominal  ring.  Sometimes  the  outer  part  is 
detached  from  the  rest,  and  forms  a  band  which  has 
been  designated  ligamentum  interfoveolare  or  ligament 
of  Hesselbach,  while  to  the  remaining  inner  portion 

'  [oessel  ;  "  Topographisch-chirurgische  Anatomic,"  zweiter 
Theil. 

*M.  Douglass;  "The  Anatomy  of  the  Transversalis  Muscle 
and  its  Relation  to  Inguinal  Hernia."  Journal  of  Anatomy  and 
Physiology,  vol.  xxiv.,  1890. 

*  Quain's  "Anatomy,"  Appendix,  p.  56. 


be  done  in  nearly  all  cases  by  separating  the  internal 
oblique  for  a  short  distance  upward  from  the  transver- 
salis fascia  and  the  transversalis  aponeurosis,  and  then, 
thus  having  loosened  it,  it  may  be  drawn  down  by  the 
sutures  to  Poupart's  ligament.  As  a  rule  it  is  futile 
to  attempt  to  draw  down  the  transversalis  aponeurosis, 
since  this  structure  is  normally  deficient  for  a  consid- 
erable distance  above  the  ligament  (Fig.  2).  The 
normal  arrangement  of  the  lower  fibres  of  the  internal 
oblique  is  well  shown  in  Fig.  i.  It  shows  that  they 
form  a  considerable  part  of  the  anterior  wall  of  the 
inguinal  canal,  the  lowermost  fibres  arising,  as  a  rule, 
from  Poupart's  ligament  for  a  considerable  distance  to 
the  inner  side  of  the  internal  ring.  Turck  '  has  con- 
firmed this  relation  in  a  number  of  observations. 

The  method  of  inserting  the  suture  as  employed  by 
Coley'  restores  in  a  great  measure  this  normal  arrange- 
ment.     Coley  employs  the  Bassini  method  with  the 

'  R.  C.  Turck  ;  "  Surgical  Anatomy  of  Hernia."  Journal  of 
the  American  Medical  Association,  April  15,  iSgg. 

'\V.  B.  Coley:  "The  Radical  Cure  of  Hernia."  Montreal 
Medical  Journal,  September,  iSgg. 


324 


MEDICAL    RECORD. 


[September  i,  1900 


exception  that  the  first  suture  is  placed  outside  of  the 
cord.  Bassini's  and  Coley's  results  are  ample  proof, 
it  seems  to  me,  that  this  method  is  the  best  we  have. 
Bassini's  statistics  give  less  than  three  per  cent,  of 
relapses  and  Coley's  only  five  relapses  in  five  hundred 
and  forty-nine  cases.  Methods  which  are  based  upon 
the  division  of  the  muscle  and  the  transplantation  of 
the  cord  between  the  cut  fibres  do  not  give  such  bril- 
liant results.  Although  the  cord  is  transplanted  to  a 
place  where  the  muscle  fibres  are  more  abundant,  yet 
relapses  occur  chietly  along  the  cord.  According  to 
the  statistics  at  the  Johns  Hopkins  Hospital,  over  six 
per  cent,  of  the  cases  had  relapses  at  this  point.'  It 
seems  to  me  that  there  are  two  reasons  for  this — first, 
that  the  cut  ends  of  the  muscle  fibres  retract  away  from 
the  cord,  and  secondly,  that  the  incised  transversalis 
aponeurosis  and  fascia  are  not  properly  repaired. 
Thus  arises  a  muscular  dimple  which  is  a  more  im- 
portant etiological  factor  in  the  occurrence  of  hernia 
than  a  mere  peritoneal  dimple.  In  order  to  obviate 
the  relapses  along  the  cord,  the  operators  have  dimin- 
ished the  size  of  the  cord  by  either  excising  the  veins, 
which  sometimes  causes  atrophy  of  the  testicle,  or  by 
transplanting  only  the  vas  deferens  to  the  intra-muscu- 
lar  position,  which  it  seems  to  me  is  simply  trying  to 
make  the  anatomical  structure  fit  the  operation  instead 
of  vice  versa. 

In  regard  to  the  suturing  of  the  border  of  the  rectus 
muscle  to  Poupart's  ligament,  the  procedure  cannot  be 
said  to  be  a  new  one,  inasmuch  as  Bassini  '■'  in  his 
original  article  recommended  it  in  some  cases.  It  was 
also  advocated  by  Wofier  in  1892,''  who  incised  its 
sheath,  and  Slajmer,'  in  1898,  reported  one  hundred 
and  fifty  cases  treated  by  Wofler's  method. 

Incision  of  the  sheath  of  the  rectus  on  its  anterior 
aspect,  as  practised  by  Wofler,  severs  the  insertion  of 
the  internal  oblique  and  transversalis  and  thus  weakens 
the  abdominal  wall.  Bloodgood  overcomes  this  by 
opening  the  sheath  behind  and  then  transplanting  the 
muscle. 

Bloodgood  at  first  employed  the  transplantation  of  the 
rectus  only  in  those  cases  in  which  the  transversalis 
fascia  (conjoined  tendon?)  was  obliterated.  In  four- 
teen such  cases  operated  upon  by  this  method  there 
were  no  relapses  at  the  lower  angle  of  the  wound, 
while  sixty-two  per  cent,  of  similar  cases  treated  by 
the  Halsted  method  without  this  modification  relapsed. 
When  the  transversalis  fascia  is  obliterated,  scarcely 
any  additional  traumatism  is  caused  by  Bloodgood's 
procedure,  but  it  necessitates  the  sacrifice  of  this 
fascia  if  it  be  well  developed.  For  this  reason  it  does 
not  seem  to  be  indicated  as  a  routine  procedure. 


Tumor  of  the  Soft  Palate. — Noquet  reports  the 
case  of  a  boy  three  months  old  who  was  troulaled  with 
attacks  of  sufiEocation  becoming  more  frequent  and 
often  occurring  when  he  was  asleep.  Nursi.ig  was 
interfered  with,  but  between  the  attacks  the  cry  was 
perfectly  normal.  Kxamination  showed  a  pedicled 
growth  attached  to  the  left  free  border  of  the  palate 
and  reaching  to  the  base  of  the  tongue.  Excision  was 
easily  done  with  traction  forceps  and  scissors,  and 
while  there  was  no  bleeding,  the  fibrous  character  of 
the  pedicle  led  Noquet  to  pass  a  ligature  around  it  as 
a  matter  of  precaution.  All  symptoms  quickly  disap- 
peared. The  mass  removed  was  found  to  be  a  fibro- 
myxoma. — Revue  Hebdomadaire  de  Larytigologie,  July 
21,  1900. 

'  Joseph  C.  Bloodgood :  Johns  Hopkins  Hospital  Reports, 
vol.  vii. 

■'  Bassini  :  Archiv  fUr  klinische  Chirurgie,  Bd.  x!.,  p.  429,  1890. 

'  Wufler  :   Heitragc  zur  Chirurgie,  i8c)2. 

*D.  Slajmer :  Archiv  fUr  klinische  Chirurgie,  Bd.  Ivi.,  1898, 
p.  893. 


THE     SIGNIFICANCE     OF      THE     BACILLUS 
COLI    COMMUNIS    IN    DRINKING-WATER.' 

By  J.    H.    LINSLEV,  M.D., 

AND 

13.    H.    STONE,  A.B..  M.D., 

DIRECTOR  AND  ASSISTANT  BACTERIOLOGIST,    LABORATORY  OF    HYGIENE,    VER- 
MONT  STATE    BOARD   OF    HEALTH,    BURLINGTON.    VT. 

The  bacteriological  examination  of  water  has  in  the 
last  few  years  undergone  something  of  an  evolution. 
With  the  first  flash  of  knowledge  of  micro-organisms 
as  etiological  factors  in  disease,  and  the  wave  of  scien- 
tilic  enthusiasm  which  followed,  it  seemed  that  in  this 
discovery  lay  a  direct  method  for  the  prevention  or 
cure  of  all  disease.  This  branch  of  water  analysis  as- 
sumed perhaps  an  exaggerated  importance  to  the  slight- 
ing of  the  older  chemical  methods.  Great  significance 
was  attached  to  the  number  of  micro-organisms,  and  it 
was  asserted  by  some  that  a  water  which  contained 
over  three  hundred  bacteria  to  the  cubic  centimetre  was 
to  be  condemned.  Gradually  a  reaction  has  come, 
and  the  pendulum  has  swung  back  to  more  nearly  its 
true  resting-place,  we  may  assume. 

Now  much  less  significance  is  attached  to  the  num- 
ber of  organisms  per  cubic  centimetre,  and  the  efforts 
of  the  bacteriologist  are  centred  on  a  determination 
of  the  kind  of  germs  present. 

The  presence  of  certain  species  is  accepted  as  a 
proof  that  the  water  has  been  exposed  to  conditions  of 
the  greatest  importance  in  connection  with  its  fitness 
for  drinking-purposes.  The  object  of  the  present  sys- 
tem is  to  bring  into  accord  the  chemical  and  bacterial 
examination.  W'ith  the  chemical  is  compared  the  bio- 
logical, which  seeks  to  ascertain  the  facts  required  for 
a  just  conception  of  the  general  bacterial  history  of 
the  water,  and  by  a  careful  balancing  of  the  two  re- 
sults it  seems  possible  to  form  a  just  judgment  of  the 
sanitary  value  of  the  water  supply,  and  to  learn  whether 
it  contains,  or  is  liable  in  the  future  to  contain,  poi- 
sonous substances  or  the  contagia  of  disease. 

The  important  questions  to  be  answered  are:  (i) 
Whether  the  water  has  been  polluted  with  sewage,  and 
(2)  in  case  there  are  many  bacteria  present,  whence 
they  are  probably  derived. 

In  water  which  has  been  freely  exposed  to  the  at- 
mosphere, there  are  often  a  large  number  of  organisms 
present,  but  these  are  derived  from  the  air,  are  not  as 
a  rule  pathogenic,  and  consequently  are  of  little  im- 
portance. The  numerical  determination  is  of  value  if 
it  can  be  carried  on  systematically,  a  daily  or  weekly 
record  of  the  numbers  being  kept  as  a  standard.  Any 
sudden  and  great  variation  from  this  standing  will 
then  suggest  some  contamination. 

In  the  search  for  the  pathogenic,  the  germ  most 
often  isolated  is  the  bacillus  coli  communis.  Before 
gaining  any  idea  of  the  significance  of  the  presence 
of  this  germ  we  must  have  a  clear  view  of  what  we 
mean  by  the  bacillus  coli  communis.  But  here  unfor- 
tunately we  meet  with  much  confusion.  .As  its  name 
indicates,  this  bacillus  is  a  common  inhabitant  of  the 
colon,  and  is  present  in  the  fecal  discharges  of  man 
and  many,  if  not  all,  of  the  animals.  It  is  commonly 
described  as  answering  to  a  certain  nimiber  of  con- 
stant features  in  regard  to  motility,  size,  and  growth 
upon  artificial  media.  It  is  sluggishly  motile  or,  ac- 
cording to  some  observers,  motionless;  2-3  microns  in 
length;  and  its  most  important  cultural  characteristics 
are  the  production  of  gas  in  glucose  solutions,  the 
power  of  curdling  milk,  and  of  producing  indol  by  its 
growth  in  peptone  solution.  These  growth  traits  serve 
to  distinguish  it  from  the  typhoid  bacillus,  which  it  re- 
sembles in  many  other  points.  But  unfortunately  for 
our  classification  we  find  in  water  often,  and  in  excre- 

'  I'aper  read  at  School  of  Instruction  for  Health  Officers.  Bur- 
lington, Vt. ,  May  24,  1900. 


September  i,  1900] 


MEDICAL    RECORD. 


325 


tions  sometimes,  a  number  of  bacilli  which  apparently 
lie  between  these  two  groups.  Our  classification  of 
bacteria  is  at  best  an  artificial  one,  and  there  are  un- 
doubtedly a  number  of  undiscovered,  unnamed  species 
shading  into  each  other  and  filling  in  the  spaces  be- 
tween known  varieties. 

In  a  series  of  509  specimens  of  water  examined  at 
our  laboratory,  varieties  of  colon  bacilli  have  been 
found  as  follows:  56  which  give  every  typical  reaction; 
3  which  ferment  lactose  and  glucose  but  do  not  give 
indol;  i  which  ferments  lactose  and  glucose,  does  not 
coagulate  milk  but  does  give  indol;  3  which  ferment 
glucose  and  lactose,  but  do  not  coagulate  milk  or  give 
indol;  i  which  does  not  ferment  lactose  or  glucose, 
coagulates  milk,  but  does  not  give  indol ;  i  w'hich  does 
not  ferment  lactose  or  glucose,  and  does  not  coagulate 
milk.  These  varieties,  it  will  be  seen,  ap|3roach  nearer 
to  the  typhoid  bacillus  in  their  characteristics,  and  the 
question  has  been  seriously  discussed  whether  the  colon 
bacillus  may  not  under  certain  conditions  become  al- 
tered so  as  to  assume  all  the  properties  of  the  typhoid, 
and  these  pseudo-coli  or  typhoid  varieties  be  transi- 
tional forms.  Rou.x  and  Rodct  came  to  the  conclusion 
that  this  was  the  case,  and  that  the  bacillus  coli  com- 
munis when  grown  in  sewage,  etc.,  miglit  become  ex- 
tremely pathogenic  and  give  rise  to  typhoid  fever. 
Laboratory  experiments  upon  this  organism  have,  how- 
ever, failed  to  demonstrate  this. 

But  granting  that  the  two  varieties,  typhoid  and  co- 
lon bacilli,  are  entirely  distinct,  the  significance  of  the 
bacillus  coli  communis  in  w'ater  is  still  of  the  utmost 
importance:  First,  as  an  undeniable  evidence  of  sew- 
age pollution.  Here  it  is  ten  times  more  delicate  tiian 
any  chemical  tests,  for  a  mere  trace  of  sewage  contami- 
nation, so  small  that  there  is  no  appreciable  increase 
in  the  ammonia  or  chlorine,  will  infect  such  a  water 
with  a  germ  which  will  increase  to  an  extent  that  any 
careful  bacterial  examination  will  disclose  its  presence. 

In  our  examination  of  five  hundred  and  nine  speci- 
mens, the  bacillus  coli  communis  was  found  in  seventy- 
eight,  and  only  thirty-one  of  these  were  condemned  by 
the  chemical  findings.  In  a  report  on  this  subject  in- 
the  British  Medical  Journal,  Drs.  Klein  and  Houston 
emphasize  the  failure  of  chemistry  to  detect  pollution 
of  water  with  minimum  quantities  of  sewage.  Steril- 
ized distilled  water  was  infected  with  sewage  in  vary- 
ing degrees  representing  dilutions  ranging  between 
I  :  100  to  I  :  20,000.  Chemically  these  waters  would 
have  been  classed  as  at  least  organically  safe  for 
drinking-purposes,  but  in  every  one  the  bacillus  coli 
communis  w^as  detected.  Moreover,  the  detection  of 
this  organism  tells  something  about  the  contamination. 
The  colon  bacillus  will  not  live  indefinitely  in  water 
which  does  not  contain  so  high  a  per  cent,  of  organic 
matter  as  would  readily  be  detected  chemically.  (In 
experiments  carried  on  at  the  laboratory  this  germ  has 
been  found  to  live  two  months  in  distilled  water,  three 
months  in  tap  water,  and  four  to  six  months'  in  sewage- 
polluted  water.)  Hence  it  follows  that  the  presence  of 
a  colon  bacillus  indicates  that  the  contamination  is  of 
comparatively  recent  date,  and  it  also  shows  that  it 
came  probably  from  the  surface. 

If  at  Lawrence  five  feet  of  sand  can  remove  disease 
germs,  it  probably  can  do  the  same  in  Vermont.  It  is 
an  old  idea  that  if  there  is  a  cesspool  up  here  and  a 
well  a  little  lower  down,  a  figure  can  easily  be  traced 
on  the  blackboard  showing  how  the  filth  from  the 
cesspool  finds  its  way  to  the  bottom  of  the  well,  per- 
haps twenty  or  fifty  feet  away.  The  chemical  evidence 
of  sewage,  chlorine,  and  ammonia  may  reach  the  water, 
but  whenever  an  infected  well  is  found,  the  source 
of  the  trouble  should  be  first  looked  for  at  the  top. 
The  large  number  of  waters  showing  the  chemical  evi- 
dence of  sewage  alone  are  probably  cases  of  old  pol- 
'  Experiments  not  yet  completed 


lution  or  pollution  from  remote  ground  filtration,  and 
are  comparatively  harmless. 

So  much  for  the  presence  of  colon  bacillus  as  an  in- 
dicator; and  now  (second)  what  danger  does  it  carry 
in  itself? 

Much  too  little  significance  has  been  attached  to  the 
pathogenicity  of  this  germ.  Because  it  is  found  nor- 
mally in  some  parts  of  the  intestinal  tract  and  is  gen- 
erally harmless  when  found  there,  it  has  been  ignored 
more  or  less  as  a  dangerous  element.  The  bacillus 
coli  communis  may  be,  and  often  is,  the  etiological  fac- 
tor in  many  diseases,  as  cystitis,  nephritis,  pyone- 
phrosis, meningitis,  abscess,  sepsis,  pyaemia,  and  septi- 
ca;mia.  In  fact  it  is  one  of  the  most  obstinate  pus 
producers  we  know,  and  is  usually  the  infective  agent 
in  appendicitis  and  peritonitis. 

It  is  generally  conceded  that  there  are  two  great 
classes  of  dysentery:  one  due  to  faulty  digestion,  and 
one,  epidemic  dysentery,  caused  by  infection.  Aside 
from  the  rare  anicebic  form,  what  is  the  cause  of  epi- 
demic dysentery.'  Filthy  conditions,  infected  water 
are  the  usual  explanations.  Epidemic  dysentery  is, 
like  typhoid  fever,  a  filth  disease:  this  fact  has  been 
recognized  since  the  time  of  Hippocrates,  who  wrote  a 
lengthy  discussion  upon  the  subject.  U'e  in  northern 
climes  hardly  realize  what  this  means  until  we  stop  to 
think  that  this  is  one  of  the  four  great  epidemic  dis- 
eases of  the  world  in  regard  to  its  mortality.  And  we 
can  in  this  age  hardly  doubt  that  the  trouble  comes 
from  micro-organisms  in  the  sewage-polluted  water; 
and  the  germ  concerned  is  undoubtedly  the  bacillus 
coli  communis.  This  is  too  generally  admitted  to 
need  much  argument.  Sternberg  in  his  description  of 
the  etiology  of  diarrhoea  says:  "  Probably  the  bacilli 
of  the  colon  and  proteus  group  are  more  frequently 
than  any  others  responsible  for  these  gastro-intestinal 
troubles.  They  are  widely  distributed  and  multiply 
with  great  rapidity  in  favorable  conditions.''  Jensen 
has  investigated  a  fatal  infectious  disease  of  calves 
characterized  by  diarrhcea,  and  concludes  that  it  is 
due  to  a  bacillus  which  corresponds  to  the  bacillus 
coli  communis  in  all  respects  except  in  its  increase  in 
virulence.  In  the  contents  of  the  intestine  of  calves 
which  have  recently  succumbed  to  the  malady,  the  ba- 
cillus is  found  in  almost  pure  culture ;  also  in  inflamed 
mucous  membrane,  in  hyperamic  mesenteric  glands,  in 
blood  and  various  organs.  Calves  fed  with  a  culture 
of  the  bacillus  invariably  died  within  two  or  three 
days,  and  the  bacilli  were  found  in  almost  pure  culture 
in  the  contents  of  the  intestines  and  in  great  numbers 
in  the  blood  and  organs.  Subcutaneous  injection  of 
4  c.c.  of  bouillon  culture  caused  fatal  septicemia. 
Drefus  finds  a  decided  difference  in  the  pathogenic 
virulence  of  colon  bacilli  from  healthy  individuals 
and  those  sutTering  from  intestinal  disorders.  Is  it 
not  entirely  possible  also  that  some  of  the  groups  of 
colon  bacilli  set  up  a  case  of  enteritis  in  some  suscep- 
tible person  who  has,  let  us  say,  recently  moved  into 
the  community;  and  that  these  germs,  increased  in 
virulence  by  passing  through  a  susceptible  individual 
and  again  into  the  sewage-polluted  water,  infect  others, 
and  thus  produce  some  of  the  cases  of  pseudo-typhoid 
enteritis  which  do  not  give  the  Widal  reaction  with 
the  laboratory  standard  typhoid  culture?  It  would 
seem  that  such  might  be  the  case;  and  if  so  theoreti- 
cally, the  blood  from  such  a  person  should  give  VVi- 
dal's  reaction  with  the  germ  if  it  can  be  isolated. 

And  at  this  point  let  us  digress  to  explain  this  se- 
rum, or  so-called  Widal,  reaction.  The  principle  of 
this  phenomenon  as  used  in  laboratory  diagnosis  is,  we 
presume,  more  or  less  familiar  to  most  of  those  pres- 
ent, yet  as  it  is  the  method  constantly  employed  in  the 
identification  of  bacteria,  and  will  be  referred  to  fre- 
quently in  this  paper,  it  is  essential  that  it  be  clearly 
understood. 


326 


MEDICAL    RECORD. 


[September  i,  1900 


It  was  noted  a  few  years  ago  that  the  fluid  serum  of 
an  animal  immunized  against  the  bacillus  pyocyaneus 
caused  the  diffuse  turbidity  of  a  culture  of  this  germ 
in  a  fluid  medium  to  assume  a  clotted  appearance,  the 
lumps  or  clots  gradually  settling  to  the  bottom  of  the 
tube,  leaving  the  fluid  above  clear.  Microscopically 
the  germs,  instead  of  swimming  about  actively  as  they 
did  normally,  showed  a  great  tendency  to  group  them- 
selves together  in  large  bunches  and  to  cease  their  mo- 
tions. Later  it  was  discovered  that  the  principle  held 
true  with  the  serum  of  animals  immunized  with  ty- 
phoid, plague  bacillus,  and  the  bacillus  coli  communis 
— in  short  any  pathogenic  motile  organism.  Finally 
it  was  proven  that  not  only  the  body  fluids  of  animals 
rendered  immune,  but  the  same  fluids  from  patients 
suffering  from  any  infectious  disease,  possessed  the 
same  property,  and  further  that  the  reaction  occurred 
only  between  the  serum  of  the  patient  suffering  from 
or  rendered  immune  to  the  disease  and  the  germ  of  that 
particular  disease.  The  principle  is  simple  enough, 
viz.,  that  the  germ  in  its  growth  produces  a  toxin 
which  is  disseminated  through  the  blood  and  when 
sufficiently  concentrated  is  fatal  to  the  organism  itself. 
It  was  the  same  reason  which  caused  the  soldier  boys 
when  confined  at  Chickamauga  Park  for  a  long  time 
to  sicken  and  die,  poisoned  by  their  ow-n  excretions. 
The  same  principle  is  made  use  of  in  a  practical  way 
in  the  production  of  diphtheria  antitoxin. 

The  phenomenon  above  described  is  used  for  two 
purposes:  (i)  the  diagnosis  of  disease;  (2)  the  iden- 
tification of  micro-organisms. 

To  return  to  these  cases  of  enteritis  resembling  ty- 
phoid but  failing  to  give  Widal's  reaction  with  the 
typhoid  bacillus.  It  was  our  good  fortune  to  be  able 
to  investigate  the  etiology  of  several  such  cases  a  short 
time  ago.  A  gentleman  came  to  the  laboratory  in  the 
hoped  finding  the  source  of  infection  of  several  cases 
of  enteric  fever  which  had  occurred  in  his  household. 
The  cases,  which  were  at  that  time  three  in  number, 
were  of  a  mild  character,  lacking  the  delirium  of  ty- 
phoid. The  family  had  recently  moved  from  New 
York  City  to  this  place,  their  summer  home  on  the 
lake  shore.  At  our  suggestion  samples  of  water,  milk, 
butter,  and  vegetables  were  furnished  and  subjected  to 
bacteriological  examination.  Nothing  which  could 
possibly  be  considered  pathogenic  was  found  in  any 
of  these  specimens  with  the  exception  of  the  milk,  but 
from  this  was  isolated  an  exceedingly  motile  bacillus, 
apparently  belonging  to  the  colon  family,  but  differing 
from  the  ordinary  bacillus  coli  communis  in  its  ex- 
treme motility,  its  failure  to  coagulate  milk,  and  its 
tendency  to  produce  a  diffuse  growth  in  Hiss'  medium. 
These  variations  from  the  normal  bacillus  of  the  colon 
seem  to  place  it  between  this  and  Eberth's  bacillus. 

The  question  arose  as  to  wiiether  this  might  not  be 
the  cause  of  the  trouble,  and  if  so  how  infection 
reached  the  milk.  With  a  view  to  investigate  the 
former  suggestion,  specimens  of  blood  from  the  cases 
were  procured  and  gave  Widal's  reaction  with  this 
germ  and  also  with  the  laboratory  culture  of  typhoid, 
though  only  slightly.  Later  the  temperature  charts 
with  an  explanation  from  the  attending  physician  gave 
evidence  along  this  same  line.  These  showed  that 
when  the  milk  was  not  used  for  some  time  the  symp- 
toms were  ameliorated,  but  upon  its  re-use  the  temper- 
ature again  went  up,  suggesting  a  re-infection.  When 
the  suspected  cause  was  removed  no  more  cases  oc- 
curred. These  facts  seemed  sufficiently  good  ground 
for  deeming  the  milk  the  source  of  infection.  The 
next  question  was,  Whence  did  the  infection  gain  en- 
trance to  the  milk?  Milk  was  delivered  directly  from 
the  cow  into  the  sterilized  bottles  and  found  sterile 
upon  examination,  excluding  this  source. 

Further   inquiry  showed  that  the  milk  pails,  cans, 
etc.,  were  rinsed,  after  being  washed  and  scalded,  in 


water  from  an  old  well  which  had  not  been  used  for 
some  time,  and  an  examination  of  the  water  from  this 
well  disclosed  the  identical  bacillus  which  was  found 
in  the  milk.  The  well  was  situated  where  it  could  re- 
ceive the  drainage  of  the  barnyard,  and  had  not  been 
used  by  the  family  of  the  farmer  for  drinking-purposes 
for  some  time.  No  ill  effects  had  been  produced  upon 
the  people  who  had  been  drinking  this  milk  for 
months,  but  when  a  family  unaccustomed  to  the  sur- 
roundings commenced  using  it,  the  trouble  began. 

Table  Showing  Comparative  Reactio.vs  of  Bacillus  Typhosus, 
Bacillus  Coli  Communis,  and  the  Germ  Found  in  the  Milk  and 
Well-Water. 


Morphology  and 
Growth  Reactions. 


Morphology  in  brol^h 


.Motility 

Growth  in  reference 
to  air. 

Stain      by      Gram's 

method. 
Growth  at  37°  C.  in: 
(0    Smith's    glu- 
cose solution  24 
hours. 
(2^  Litmus  milk  24 
hours. 

(3)  Dunham's  pep- 
tone solution  48 
hours. 

(4)  Plain  bouillon 
24  hours. 

(5)  Agar-agar  24 
hours. 

(6)  Acid  potato  24 
hours. 


(7)  Loefiler's  blood 

serum. 
Widal's    reaction 

with ; 
(i)  Blood    from 

these  cases. 
(2)   Blood    from  a 

known     typhoid 

case. 


Bacillus 
Typhosus. 


Well-marked  rods 
five  or  si.K  times 
as  long  as  broad, 
with  longer  in- 
dividuals and 
thread  forms. 


Actively  motile  . . 
Aerobic  and  facul- 
tative anaerobic 


Decolorized . 


Turbidity  in  clos-  30  per  cent.  gas. 
ed  arm  ;  no  gas. 

Reddened,  not  co-  Ditto  with  bacil- 
agulated.  lus  typhosus 

Indol  rarely  pro-  Indol  produced 
duced. 


Bacillus  X. 


Bacillus  Coli 
Communis. 


Ditto   with   ba 
cillus  typhosus 


Actively  motile. 

Aerobic  and 
facultative  an- 
aerobic. 

Decolorized.. . . 


General  turbidity, 
slight  increase 
in  acidity. 

Slight  whitish 
film. 

Luxuriant  but  in- 
visible gro\rth 
so  m  etimes 
slightly  yellow. 

Yellowish  -  white 
fairly  luxuriant. 


Slight... 
Positive  , 


Ditto   with   ba- 
cillus typhosus 

More   luxuriant 

than     bacillus 

typhosus. 
More    luxuriant 

than     bacillus 

typhosus. 

Ditto    with   ba- 
cillus typhosus 


Short  rods  two  or 
three  times  as  long 
as  broad,  often 
nearly  ovoid; 
longer  individuals 
occur  much  more 
rarely  than  with 
bacillus  typhosus. 

Sluggishly  motile. 

Aerobic  and  faculta- 
tive anaerobic. 

Decolorized. 


20  to    30  per  cent, 
gas. 

Reddened    and   co- 
agulated. 
Indol  produced. 


Ditto   with   bacillus 
typhosus. 

Luxuriant     yellow- 
ish-white growth. 

Luxuriant      yellow- 
ish-white. 


More  luxuriant  than 
bacillus  typhosus. 


Positive.. 
Slight  . . . 


Negative. 
Negative. 


In  this  case  you  will  notice  the  infection  came  di- 
rectly from  the'  milk  to  the  individual.  And  in  my 
mind  this  is  usually  the  case.  The  antiseptic  property 
of  the  stomach  secretions  is  sufficient  to  dispose  of  a 
small  invasion  of  a  mildly  pathogenic  germ,  but  when 
this  organism  gains  lodgment  in  a  soil  so  congenial  as 
milk,  it  increases  with  enormous  rapidity,  and  when 
millions  of  bacilli  are  repeatedly  poured  into  the 
stomach  of  an  individual  of  lowered  vitality  the  natu- 
ral resisting-power  is  overcome  and  infection  occurs. 

Another  case  along  this  same  line  has  recently  come 
under  our  observation.  A  physician  in  this  city 
brought  to  the  laboratory  a  specimen  of  blood  from  a 
case  of  suspected  typhoid  fever,  and  also  a  specimen 
of  milk  which  the  man  had  been  using.  The  blood 
gave  the  Widal  reaction,  but  no  typhoid  bacilli  were 
found  in  the  milk.  It  was,  however,  found  infected 
with  the  bacilli  coli  communis.  The  blood  also  gave 
a  reaction  with  this  germ.  The  physician  describes 
the  case  as  characterized  by  more  than  the  usual  tym- 
panites. At  about  this  time  the  dairy  from  which  the 
milk  came  became  afflicted  with  an  epidemic  charac- 
terized by  diarrluea,  and  a  number  of  cows  and  calves 
died  of  the  disease.  This  was  apparently  a  case  of 
double  infection,  as  the  blood  reacted  to  both  typhoid 
and  colon  cultures. 

Some  investigations  were  made  along  the  same  lines 
during  the  epidemic  of  typhoid  fever  in  Belfast,  with 
the  following  conclusions,  and  though  the  cases  in 
Belfast  were  mo.st  of  them  typical  typhoid,  there  was 
added  an  element  of  infection  due  to  the  bacillus  coli 
communis.       The    investigators  (Messrs.  Smith    and 


September  i,  1900] 


MEDICAL    RECORD. 


327 


Tennant)  discovered  that  fifty  per  cent,  of  these  cases 
which  were  diagnosed  typhoid  gave  the  Widal  reac- 
tion with  the  bacillus  coli  communis,  and  of  these 
there  were  a  number  which  reacted  in  the  highest  di- 
lution with  this  germ  alone.  In  these  cases  it  is  diffi- 
cult to  believe  that  this  reaction  from  the  first  was  due 
simply  to  the  invasion  of  the  typhoid  bacillus.  The 
more  natural  supposition  is  that  the  reaction  of  the 
bacillus  coli  communis  in  such  cases  is  due  to  some 
process  of  infection  for  which  it  is  itself  responsible, 
and  that  in  those  cases  in  which  there  is  a  reaction 
with  both  organisms  tliere  is  a  double  infection.  In 
fact  we  must  accept  this,  or  be  driven  to  the  other 
horn  of  the  dilemma  and  concede  that  the  two  germs 
are  very  closely  related. 

Furthermore,  the  occurrence  of  the  bacillus  coli 
communis  in  the  urine  in  these  cases  is  another  argu- 
ment for  this  independent  infection.  The  facts  that 
this  occurs  often  when  there  is  no  history  of  catheteriz- 
ation, and  that  there  are  a  number  of  cases  on  record  of 
a  pyonephrosis  proven  to  be  due  to  these  germs,  are  evi- 
dence that  the  infection  comes  by  way  of  the  kidneys 
in  the  process  of  elimination. 

In  investigating  the  water  supjily  of  a  certain  town 
in  the  .State,  traces  of  the  bacillus  coli  communis  have 
repeatedly  been  isolated,  but  never  at  any  time  have 
typhoid  germs  been  found.  In  this  town  during  the 
fall  and  winter  months  there  have' continually  been  a 
number  of  cases  of  a  mild  enteritis,  some  of  which 
have  and  some  of  which  have  not  given  Widal's  reac- 
tion with  our  laboratory  culture  of  typhoid  bacilli. 
Ten  of  these  cases,  which  never  gave  a  good  typhoid 
reaction,  have  been  e.xamined  in  reference  to  evidence 
of  an  infection  by  the  colon  bacillus.  Six  of  them 
have  been  found  to  give  a  positive  reaction  with  the 
bacillus  coli  communis,  using  the  ordinary  dilution 
and  time  limits.  The  urine,  in  the  only  one  of  these 
cases  in  which  it  was  e.xamined,  was  found  to  be  in- 
fected with  these  germs.  One  of  the  four  cases  which 
failed  to  respond  to  the  reaction  with  either  organism 
proved  to  be  pneumonia,  another  malaria. 

Otto  Lerch  reports  in  the  Medical  Record  vvliat 
he  believes  to  be  a  case  of  enteric  fever  caused  by  the 
colon  bacillus.  In  this  case  the  patient,  after  an  ill- 
ness somewhat  resembling  a  typical  typhoid  fever,  died 
suddenly  of  heart  failure. 

The  search  for  the  typhoid  bacillus  in  water  is  car- 
ried on  with  much  difficulty,  and  results  are  very  un- 
certain. This  is  due  to  the  fact  that  the  germ  does 
not  increase  to  any  extent  in  water,  and  so  the  rela- 
tively small  quantities  which  are  necessarily  handled 
in  an  examination  may  easily  contain  none  of  them, 
and  to  the  difficulty  encountered  in  separating  this 
germ,  when  present,  from  the  more  resistant  bacillus 
coli  communis.  We  cannot,  therefore,  rely  on  the 
failure  to  find  the  germ  in  water  as  a  positive  proof  of 
its  absence,  but  we  can  say  that  the  water  contains  no 
typhoid  if  it  fails  to  show  colon  bacilli.  In  the  labo- 
ratory experiments  we  have  not  succeeded  in  keeping 
the  more  virulent  germ  alive  in  water  over  four  weeks, 
while  the  colon  bacillus  will  live  a  much  longer  time 
and  is  much  more  easily  isolated. 

From  the  consideration  of  all  these  facts  we  are 
driven  to  conclude  that  waters  in  which  the  bacilli 
coli  communis  are  found  to  exist  for  any  length  of 
time  are  dangerous  to  the  public  health,  and  that  the 
only  safe  course  is  to  condemn  all  such.  An  example 
proving  this  is  the  recent  outbreak  of  typhoid  fever  in 
West  Burke.  From  the  first  there  seemed  good  reason 
for  suspecting  the  water  as  the  source  of  the  trouble, 
and  samples  were  sent  to  the  laboratory  and  examined. 
The  cases  in  this  town  were  undoubtedly  typhoid, 
but  no  typhoid  bacilli  were  found  in  the  water.  It 
was,  however,  found  infected  with  the  bacillus  coli 
communis.     If  the  water  had  been  examined  before 


the  outbreak  and  found  contaminated,  as  it  undoubt- 
edly was,  the  trouble  might  have  been  averted. 

In  reply  to  the  argument  which  is  sure  to  be  ad- 
vanced, that  people  have  drunk  the  waters  which  you 
condemn,  for  years,  and  are  still  living,  we  may  use 
Professor  Sedgewick's  words  in  answer  to  a  similar 
argument:  "Look  here,  did  you  ever  see  a  G.  A.  R. 
procession?  They  look  pretty  healthy.  Well,  then, 
war  isn't  a  bad  tiling,  judging  by  these  people."  Now 
the  point  is  the  same  in  both  cases.  These  are  the 
survivors.  We  don't  see  those  who  are  lying  in  the 
graveyards  hereabout  or  at  Arlington  or  elsewhere, 
and  because  you  and  I  and  a  half-dozen  others  have 
been  tough  enough  to  stand  all  of  these  things,  it  does 
not  follow  that  a  lot  of  people  have  not  died  of  them 
or  will  not  if  subjected  to  the  same  conditions. 

In  this  State,  when  so  large  a  per  cent,  of  our  waters 
are  pure,  it  is  perfectly  practical  and  will  be  highly 
profitable,  not  only  hygienically  but  financially  as 
well,  in  the  long  run,  to  discard  all  supplies  which 
are  permanently  infected  with  the  bacillus  coli  com- 
munis. 


PATHOLOGICAL  PHYSIOLOGY  OR  EXPERI- 
MENTAL PATHOLOGY,  ITS  SCOl'E  AND 
SIGNIFICANCE    IN    MEDICINE. 

By   IS.VAC   levin,    M.D., 

NKW    \OHK. 

1'he  ancient  notion,  that  a  disease  is  a  certain  inde- 
pendent entity  added  to  the  organism,  and  that  it  is 
only  the  disease,  and  not  the  organism  itself,  which 
tiie  physician  has  to  deal  with,  has  as  yet  a  strong 
hold  on  the  profession.  The  study  of  pathological 
physiology,  which  deals  with  the  abnormal  functions 
of  different  organs,  alone  can  show  that  nothing  is 
added  to  the  organism  in  disease,  but  that  it  is  only 
its  functions  that  are  changed.  The  science  of  patho- 
logical physiology  has  been  in  existence  nearly  a  cen- 
tury, and  its  importance  in  medicine  is  fully  recog- 
nized. Still  there  are  very  few  medical  schools  in 
existence  in  which  the  subject  is  systematically  taught. 
I  therefore  think  that  it  may  be  of  some  interest  to 
give  a  short  review  of  the  present  state  of  this  science. 
I  hope  that  my  readers,  after  the  perusal  of  the  fol- 
lowing pages,  may  see  clearly  that  medicine  is  not 
only  an  art,  but  a  science  in  the  full  meaning  of  the 
word,  that  the  logical  reasoning  on  a  scientific  basis 
of  observation  and  experiment  is  of  more  importance 
than  all  the  patented  and  other  nostrums,  and  also  that 
pathological  physiology  is  the  real  philosophy  of 
medicine.  By  this  I  do  not  mean  to  say  that  it  is  a 
science  which  attempts  to  explain  every  phenomenon 
of  a  disease  by  mere  force  of  abstract  argument,  but 
I  do  say  that  pathological  physiology  is  a  science 
which  analyzes  the  observations  of  the  clinic  and 
pathological  anatomy  and  chemistry,  and  verifies  by 
experiment  the  conclusions  derived  from  these  obser- 
vations. 

The  relation  between  tiiis  science  and  the  other 
branches  of  pathology  will  be  best  understood  after 
the  explanation  is  given  of  the  meaning  of  the  words 
"diseased  or  abnormal  state  of  the  organism." 

An  organism  is  normal  and  healthy  when  it  re- 
ceives the  greatest  possible  benefit  from  the  work  or 
functions  of  every  one  of  its  parts  or  organs.  It  is 
only  by  the  aid  of  the  work  of  these  organs  that  the 
organism  itself,  as  a  unit  in  the  external  world,  is  en- 
abled to  perform  those  life  functions  which  distinguish 
it  from  unorganized  objects.  If  the  work  of  its  organs 
ceases,  the  organism  becomes  an  inert,  unorganized 
body — it  dies.  But  it  may  also  happen  that  though 
one  or  more  organs  are  unable  to  give  the  required 
amount  of  assistance  to  the  organism,  the   latter  will 


328 


MEDICAL    RECORD. 


[September  i,  1900 


be  able  to  compensate  the  deticiency  in  one  way  or 
another,  and  continue  to  live.  Such  a  state  of  the 
organism  is,  however,  certainly  abnormal,  diseased, 
and,  as  already  stated,  the  organism  will  suffer  not 
only  through  the  deficiency  of  the  organs  primarily 
diseased,  but  also  through  its  consecutive  deleterious 
influence  upon  the  other  organs.  It  should  here  be 
added  that  the  function  of  a  certain  organ  may  be 
abnormal,  and  still  be  able  to  give  to  the  rest  of  tiie 
organism  the  necessary  assistance.  Such  a  state, 
though  abnormal,  will  not  be  pathological.  A  dis- 
eased state  of  an  organism  is  consequently  an  abnormal 
state,  in  which  tiie  functions  of  one  or  more  organs  are 
so  changed  that  they  are  not  only  unable  to  give  the 
organism  the  full  benefit  of  the  work  allotted  to  them, 
but  may  even  produce  a  deleterious  effect  upon  the 
rest  of  the  organism. 

It  follows  that  in  studying  a  diseased  organism  we 
shall  find  some  or  all  of  these  functions  changed;  in 
other  words,  no  matter  how  well  normal  physiology 
may  explain  the  functions  of  the  same  organism  in  its 
healthy  state,  we  shall  still  have  to  study  the  diseased 
organism  anew,  i.e.,  we  shall  have  to  develop  a  morbid 
or  pathological  physiology.  It  is  obvious  that  in  dis- 
ease the  structure  and  chemical  nature  of  an  affected 
organ  are  also  changed,  and  notwithstanding  the  per- 
fect knowledge  we  have  of  the  organism  in  its  normal 
state,  we  must  make  a  new  and  just  as  complete  study 
of  it  in  every  direction  in  its  diseased  state. 

Pathology  in  the  broadest  sense  of  the  word  may 
consequently  be  considered,  in  the  same  way  as  bi- 
ology, a  group  of  sciences,  studying  the  structure  of  a 
diseased  organism  (pathological  anatomy),  its  chemical 
composition  (pathological  chemistry),  and  its  func- 
tions (pathological  physiology). 

That  pathological  physiology  must  be  considered  a 
science  independent  of  either  pathological  anatomy 
or  chemistry  hardly  needs  elucidation.  A  change  of 
structure  of  the  same  character  may  produce  entirely 
different  functional  disorders  in  two  different  organs, 
and  consequently  have  an  entirely  different  influence 
on  the  entire  organism.  On  the  other  hand,  the  same 
functional  disorder  may  be  accompanied  in  one  case 
by  a  quite  characteristic  change  of  the  structure  of  a 
certain  organ,  while  in  another  case  we  shall  hardly 
be  able  to  discover  any  change  at  all. 

A  great  deal  nearer  are  the  relations  between  the 
pathological  and  normal  physiology.  They  both  deal 
with  functions  of  the  different  organs.  Pathological 
physiology  avails  itself  of  almost  the  whole  technique 
of  normal  physiology.  Still  the  nature  of  the  ques- 
tions with  which  these  two  sciences  are  concerned  are 
entirely  different;  many  methods  which  are  indispens- 
able in  pathological  physiology  would  be  superfluous 
for  the  purposes  of  normal  physiology. 

In  the  following  lines  I  shall  attempt  briefly  to 
outline  the  scope  of  pathological  physiology,  and  to 
show  that  the  subject-matter  of  that  science,  the  ques- 
tions it  has  to  solve,  and  its  methods  of  research  are 
different  from  those  of  the  otiier  medical  sciences,  and 
that  pathological  physiology  has  a  fundamental  im- 
portance for  medicine  as  well  as  for  biology. 

Morphologically  an  organism  consists  of  a  con- 
glomeration of  different  cells.  If  we,  therefore,  un- 
dertake to  study  the  pathological  changes  in  the  struc- 
ture of  an  organism,  i.e.,  the  pathological  anatomy,  we 
have  to  consider  the  cell  as  the  independent  unit  for 
investigation.  But  we  must  apply  a  different  method 
when  it  is  our  object  to  study  the  abnormalities  of  the 
functions  of  an  organism.  While  each  of  the  cells 
of  the  body  of  the  very  lowest  animal  can  perform  the 
same  work  as  any  other  of  its  cells,  the  cells  in  the 
animals  of  a  higher  development  are  greatly  differen- 
tiated. Not  only  is  every  cell  restricted  to  a  certain 
kind  of  work,  but  if  severed  from  the  rest  of  the  cells 


of  the  same  group,  from  the  organ  of  which  it  is  a 
part,  it  ultimately  dies;  consequently  a  certain  kind 
of  work,  a  certain  function  can  be  performed  only  by 
a  union  of  like  cells,  by  an  organ,  and  this  organ  only 
is  the  unit  for  examination  in  pathological  physiology. 

An  individual  thus  needs  a  certain  amount  of  ma- 
terial— food  and  oxygen,  which  it  receives  from  the 
outside,  through  its  lungs  and  alimentary  organs. 
The  food  after  having  undergone  certain  preliminary 
changes  in  those  organs  is  distributed  by  the  aid  of 
the  circulatory  system  all  over  the  body,  penetrating 
into  the  cells  in  which  it  undergoes  its  final  trans- 
formation. The  cells  again  discharge  into  the  circu- 
latory channel  whatever  is  eliminated  from  their  body 
during  the  process  of  assimilation  of  the  food,  or  some 
other  work  they  have  to  perform.  The  suh>stances  so 
eliminated,  either  having  undergone  some  subsequent 
changes  in  the  blood  or  unchanged,  leave  the  organism 
through  the  excretory  organs  (lungs,  which  conse- 
quently do  double  work,  skin,  and  kidneys).  Thus 
assimilated  food  is  the  source  of  a  certain  amount  of 
energy  existing  in  the  organism,  which  expresses  itself 
in  animal  heat,  and  in  the  work  of  the  muscular,  ner- 
vous, and  genital  systems. 

From  this  enumeration  of  the  functions  of  the  dif- 
ferent organs  it  is  easily  seen  that  there  is  the  closest 
relation  and  dependence  between  them,  and  that  an 
abnormality  of  one  of  them  must  affect  all  others. 
Consequently,  unlike  the  study  of  pathological  an- 
atomy, in  which  even  a  separate  study  of  a  certain 
part  of  the  body  may  give  us  some  results,  we  have  to 
study  in  pathological  physiology  not  only  the  abnor- 
mality of  the  function  of  a  certain  organ,  but  also  the 
influence  such  an  abnormality  has  upon  the  rest  of  the 
organism. 

The  abnormality  of  functions  may  be  of  two  kinds: 
quantitative, />.,  the  function  may  retain  its  character, 
but  may  increase  or  decrease  in  degree ;  or  qualitative, 
when  the  character  of  the  function  itself  is  changed. 

In  the  next  p.iges  will  be  given  a  brief  sketch  of  the 
scope  of  pathological  physiology.  I  shall  start  w-ith 
the  circulatory  system,  as  the  influence  of  this  upon 
the  life  of  the  whole  organism  is  most  manifest. 

Pathology  of  the  Circulation.— The  circulatory 
system  practically  consists  of  two  parts,  the  circu- 
latory system  proper  on  one  hand  and  the  blood  and 
lymph  on  the  other.  The  function  of  the  circulatory 
system  consists  in  propelling  the  blood  from  the  dif- 
ferent parts  of  the  body  to  the  lungs, where  it  comes 
into  close  contact  with  the  inhaled  air  and  gets  the 
necessaiy  amount  of  oxygen,  and  from  there  again  to 
the  different  organs.  The  heart  is  the  most  important 
propelling  power.  Its  increased  work  can  hardly  be 
considered  a  pathological  condition,  because,  no  matter 
how  much  the  quantity  of  blood  coming  to  a  certain 
organ  is  increased,  the  cells  do  not  take  from  the 
blood  nor  return  to  it  any  more  substances  than  they 
would  under  normal  conditions.  But  a  decreased  work 
of  the  heart,  its  weakening,  is  injurious  to  the  or- 
ganism not  only  because  the  supply  of  blood  to  the 
different  organs  is  decreased,  but  also  because  an  ab- 
normal quantity  of  blood  is  gathered  in  the  venous 
system,  which  in  its  turn  produces  secondary  changes 
in  the  organs. 

But  the  action  of  the  heart  may  also  undergo  quali- 
tative changes,  and  these  are  of  the  gravest  conse- 
quence to  the  organism  as  a  whole.  The  qualitative 
changes  are  caused  by  some  morphological  lesions  in 
the  openings  leading  from  the  auricles  to  the  ven- 
tricles, or  from  the  latter  to  the  arteries.  Those  open- 
ings are  provided  with  valves,  the  function  of  which 
is  to  prevent  the  blood  from  returning.  .Ml  those 
openings  may  become  narrowed,  stenotic,  or  the  valves 
may  be  unable  to  close  perfectly.  Let  hs  consider  the 
case  in  which  one  of  the  auriculo-ventricular  apertures 


September  i,  1900] 


MEDICAL    RECORD. 


329 


has  become  stenotic.  Onh-  part  of  the  blood  normall)- 
drawn  into  the  ventricle  during  the  diastole  will  find 
its  way  in;  another  part  will  be  left  in  the  auricle  and 
consequently  in  the  venous  system.  Should,  on  the 
other  hand,  the  bicuspid  or  tricuspid  valves  be  insuffi- 
ciently closed,  then  part  of  the  blood  during  the  systole 
will  return  to  the  auricle  and  consequently  again  over- 
fill the  venous  system.  In  a  word,  whichever  of  these 
openings  becomes  abnormal,  the  result  will  be  of  the 
same  character,  i.e.,  part  of  the  heart's  energy  will  be 
wasted.  The  heart  hypertrophies  and  is  thus  enabled 
for  a  certain  time  by  increased  energy  to  do  the 
amount  of  work  necessary  for  the  organism,  but  like 
every  muscle  the  heart  becomes  tired  out  by  overwork 
— it  does  not  propel  a  sufficient  quantity  of  blood  into 
the  arterial  system,  and  the  blood  consequently  stag- 
nates in  the  veins.  The  whole  organism  suffers,  on 
one  hand,  from  the  mechanical  and  chemical  influence 
of  the  accumulated  venous  blood,  and  on  the  other 
hand  from  an  insufficiency  in  the  supply  of  fresh  arte- 
rial blood;  the  different  cells  of  the  organs  degener- 
ate, the  parenchymatous  organs  become  congested  by 
the  increased  quantity  of  the  venous  blood,  which  also 
produces  a  hydrops.  It  may  be  here  added  that  for- 
merly when  we  made  an  autopsy  and  found  great  mor- 
phological changes  of  a  certain  nature  and  at  the  same 
time  a  certain  lesion  in  one  of  the  apertures  of  the 
heart,  it  was  a  very  tempting  hypothesis  that  the  latter 
was  the  cause  and  all  the  rest  only  the  sequence,  but 
it  was  no  more  than  a  hypothesis  until  experiments 
performed  on  animals  produced  on  the  latter  the  same 
lesions  in  the  apertures  of  the  heart,  and,  as  a  result, 
the  same  functional  disorders  and  the  same  morpho- 
logical changes  at  the  autopsy  which  we  met  with  in 
a  human  body. 

The  arteries  are  normally  assisting  the  heart's  work, 
and  if  their  walls  are  changed  by  some  disease  process 
and  lose  their  elasticity,  the  heart  has  to  perform  an 
increased  amount  of  work,  it  becomes  overworked; 
this  in  its  turn  inlluences  the  organism  in  the  manner 
previously  described. 

The  amount  of  blood  contained  in  an  organism  is 
not  sufficient  to  furnish  every  organ  with  the  quantity 
necessary  during  its  activity;  as  a  consequence  an  ac- 
tive organ  receives  a  larger  quantity  of  blood  than  an 
inactive  organ.  CI.  Bernard  has  shown  experiment- 
ally that  this  constant  change  between  a  local  physio- 
logical hyperaemia  and  anaemia  is  due  to  the  influence 
of  the  nervous  system.  If  the  quantity  of  blood  con- 
tained at  a  certain  time  in  some  part  of  the  organism 
is  increased  or  decreased  without  regard  to  the  require- 
ments of  the  normal  function  of  that  part,  such  a 
hyperaemia  or  ansmia  becomes  pathological.  A  local 
hyperaemia  is  called  "active"  when  the  quantity  of 
blood  is  increased  through  a  greater  influx  of  arterial 
blood.  Such  a  hyperreniia,  as  already  mentioned  be- 
fore, has  hardly  any  deleterious  influence  upon  the 
functions  of  the  organism.  It  is  true  that  inflamma- 
tion, which  is  also  accompanied  by  an  arterial  hyper- 
aemia, does  change  the  function  of  the  organ  which  it 
affects,  but  there  are  other  reasons  for  this.  In  the 
first  place,  in  inflammation  the  stream  of  blood  is  not 
accelerated  as  in  an  ordinary  arterial  hypersemia,  but 
on  the  contrary  it  is  even  slackened.  On  the  other 
hand,  the  causes  producing  the  inflammation  show 
their  influence  not  only  upon  the  circulatory  system, 
but  also  greatly  on  the  cells  of  the  affected  organ  itself 
and  thereby  only  they  injure  its  function. 

A  stronger  influence  upon  an  organ  is  exerted  by  a 
passive  or  venous  hyperaemia, />.,  a  condition  in  which 
the  influx  of  arterial  blood  is  normal,  but  for  some 
reason  or  other  the  organ  cannot  be  freed  from  its 
venous  blood.  This  blood  accumulating  in  increas- 
ing quantity  injures  the  organ,  first  by  the  mechanical 
pressure  it  produces  on  it,  and  then  by  the  poisonous 


action  of  the  venous  blood  on  the  cells  of  the  organ 
(this  will  be  better  understood  later). 

The  influence  of  a  local  anemia  on  an  organ  is  ob- 
vious: it  produces  inanition.  The  more  delicate  an 
organ  is  in  its  function  (the  brain,  for  instance)  the 
less  it  is  able  to  sustain  anaemia  without  injury.  Not 
only  may  the  quantity  of  blood  in  an  artery  be  de- 
creased but  the  artery  may  become  entirely  imperme- 
able at  some  point.  At  first  thought  we  should  expect 
that  the  part  of  an  organ  fed  by  this  artery  would  die, 
but  it  usually  does  not.  The  interchange  of  material 
between  the  cells  of  an  organ  and  the  blood  begins  in 
the  capillaries.  Before  an  artery  merges  into  its 
terminal  capillaries,  however,  it  usually  anastomoses 
at  frequent  intervals  with  the  arteries  of  the  neigh- 
boring regions,  and  such  an  anastomosing  artery  will 
always  exist  between  the  obstructed  part  of  the  artery 
and  its  capillaries.  This  anastomosing  artery  will 
also  supply  blood  to  the  capillaries  of  the  obstructed 
artery.  But  in  some  organs  (spleen,  kidneys,  brain, 
lungs,  retina)  the  arteries  do  not  have  an  anastomosis 
on  their  entire  length  (such  arteries  Cohnheim  called 
'•terminal  arteries").  Consequently  if  the  artery  be- 
comes obstructed  below  such  an  anastomosis,  the  cor- 
responding part  of  the  organ  becomes  necrotic  and  its 
function  ceases.  The  fact  that  an  obstruction  of  an 
artery  by  a  thrombus  or  embolus  produces  a  local 
necrosis  in  one  case  and  does  not  in  another  was 
known  long  ago,  but  its  explanation  could  be  found 
only  after  the  wonderful  experiments  of  Cohnheim, 
who  compressed  a  minute  artery  of  a  frog's  tongue  (a 
terminal  artery)  and  studied  the  results  under  the 
microscope. 

Blood  is  the  most  wonderful  organ  with  the  most 
complicated  and  manifold  functions,  some  of  which 
we  are  only  commencing  to  discover  now.  Like  any 
other  organ,  blood  consists  of  cells  endowed  with  cer- 
tain functions  and  an  intercellular  tissue,  but  while 
in  every  other  organ  the  latter  serves  only  as  a  sup- 
port for  the  cells,  the  blood  serum  has  a  great  many 
functions  to  perform,  and  this  not  only  as  transporting 
cells  as  well  as  diluted  substances  from  one  place  to 
another,  but  probably  also  as  an  agent  producing  some 
chemical  changes  in  these  substances. 

Of  the  blood  cells  we  are  most  familiar  with  the 
function  of  the  red  corpuscles.  Each  cell  contains  a 
certain  amount  of  a  substance  called  haemoglobin, 
which  coming  into  contact  with  the  air  in  the  lungs 
combines  loosely  with  its  oxygen,  then  turns  to  the 
tissues  of  the  body  and  just  as  freely  distributes  it 
among  the  cells  of  the  latter.  Now,  should  the  num- 
ber of  all  the  red  corpuscles  in  the  body,  or  the  quan- 
tity of  haemoglobin  in  each  cell,  decrease,  the  condi- 
tion of  the  whole  organism  will  in  either  case  become 
pathological,  as  every  cell,  every  organ  of  the  body 
will  suffer  from  lack  of  oxygen.  Such  state  of  the  or- 
ganism is  called  aneemia.  An  increased  number  of 
red  corpuscles  or  quantity  of  haemoglobin  is  hardly 
ever  to  be  met  with  and  is  not  injurious  to  the  organ- 
ism, as  no  cell  in  the  organism  consumes  more  oxygen 
than  it  really  needs. 

We  know  much  less  of  the  functions  of  the  other 
cellular  part  of  the  blood,  the  so-called  leucocytes. 
This  is  a  chapter  in  pathological  physiology  in  which 
we  have  no  normal  physiology  for  a  basis,  the  reason 
probably  being  that  the  most  easily  observed  function 
of  these  cells  begins  only  after  the  organism  has  be- 
come diseased. 

Metchnikoff  was  the  first  to  show  that  if  we  intro- 
duce into  an  organism  some  microbes,  we  will  soon 
find  them  inside  of  the  leucocytes  (in  a  degenerated 
state),  and  he  thereupon  developed  the  theory  of 
phagocytosis. 

The  leucocytes  are  consequently  for  him  analogous 
to  an  armv.  which  mechanically  destroys  any  parasite 


330- 


MEDICAL    RECORD. 


[September  i,  1900 


that  would  otherwise  injure  the  organism.  Further 
research  showed  that  this  function  of  the  leucocytes 
is  not  a  meclianical  one  only;  it  seems  that,  bacterial 
or  any  other  poison  being  present  in  the  blood  serum, 
the  leucocytes  produce  certain  substances,  eliminate 
them  also  into  the  blood  serum,  and  thereby  protect 
the  organism  against  injuries  from  the  poison.  It 
was  further  shown  clinically  as  well  as  experimentally, 
that  as  soon  as  a  certain  poison  is  introduced  into  the 
organism  the  number  of  the  leucocytes  is  greatly  in- 
creased. This  increase  occurs  in  so  short  a  time  after 
the  influence  of  a  poison  on  the  organism  commences, 
that  it  can  certainly  not  depend  upon  a  new  formation 
of  leucocytes.  Facts  seem  to  prove  that  the  increase 
is  due  to  the  so-called  chemotactic  inriuence  of  the 
poisons,  /.('.,  to  the  fact  that  the  poison  circulating  in 
the  blood  attracts  a  number  of  leucocytes  contained  as 
a  kind  of  a  reserve  force  inside  of  the  blood-forming 
organs  (spleen,  lymphatic  glands,  and  marrow  of  the 
bones).  Having  entered  the  blood,  these  supernum- 
erary leucocytes  begin  to  participate  in  the  work  of 
protecting  the  organism.  Further  e.\perimental  re- 
search in  this  line  throws  light  on  some  of  the  most 
puzzling  questions  of  pathology.  But  while  the  results 
accomplished  are  of  the  greatest  importance  and  bene- 
fit to  mankind,  the  field  of  work  opened  by  these  re- 
searches is  quite  une.Kplored  as  yet,  and  will  surely 
lead  to  innumerable  discoveries  of  the  greatest  im- 
portance. 

It  has  long  been  known  that  some  species  of  animals 
are  refractory,  immune  against  certain  diseases  of  other 
species;  further,  an  organism,  after  having  passed 
through  a  certain  disease,  may  remain  immune  against 
the  same  disease  for  some  time  or  even  its  whole  life. 
It  has  also  been  shown  by  the  wonderful  experiments 
of  Pasteur  and  others  that  by  subjecting  an  animal  to 
the  influence  of  the  attenuated  virus  of  a  certain  dis- 
ease, we  can  make  the  animal  artificially  immune 
against  it.  The  most  probable  explanation  of  natural 
as  well  as  acquired  immunity  is  the  following:  All 
cells  of  the  body,  and  chietiy  the  lymphocytes  and 
leucocytes  as  was  lately  shown,  produce,  most  probably 
by  their  nuclei,  some  substances,  alexins,  which  arrest 
the  growth  and  kill  the  invading  bacteria.  These  bac- 
teria are  consequently  not  pathogenic  for  the  organ- 
ism. On  the  other  hand,  if  pathogenic  bacteria  pene- 
trate into  the  organism,  they  produce  some  substances 
which  neutralize  the  alexins,  and  the  bacteria  are 
enabled  to  thrive  and  produce  toxins,  which  serve  as 
a  general  poison  to  the  organism.  If  the  organism 
has  recovered  from  the  elTect  of  an  invasion  of  patho- 
genic bacteria,  that  will  show  that  the  organism  has 
produced  more  alexins  than  it  usually  does,  and 
killed  the  bacteria,  or  else  produced  antitoxin  and 
with  it  neutralized  the  bacterial  toxins,  while  leaving 
the  bacteria  themselves  alive.  In  many  instances  an 
organism,  after  having  once  recovered  from  a  certain 
bacterial  invasion,  is  able  for  some  time  or  even  for 
the  whole  life  to  produce  such  an  amount  of  alexins 
as  to  be  immune  against  the  same  bacterial  invasion. 
Such  an  immunity  is  called  an  acquired  active  im- 
munity. An  artificially  acquired  active  immunity 
will  then  simply  mean  that  the  organism  was  trained 
to  produce  more  alexins,  not  by  having  passed  through 
a  certain  disease,  but  by  an  introduction  of  an  attenu- 
ated poison  of  certain  bacteria. 

If  the  blood  serum  of  an  immunized  animal  con- 
tains an  increased  amount  of  alexins  it  may,  if  in- 
troduced into  another  animal  suffering  from  the  same 
disease,  cure  it.  This  supposition  has  proved  to  be 
true  for  diphtheria  and  tetanus,  and  in  time  may  give 
us  many  more  therapeutic  acquisitions.  Such  an  im- 
munity, when  the  organism  is  not  trained  to  produce 
more  alexins  but  is  simply  given  an  extra  amount  of 
them,  is  called  passive  acquired  immunity. 


All  this  protective  work  is  probably  not  the  only 
function  of  the  leucocytes;  at  least  it  does  not  explain 
why  an  increase  in  the  number  of  the  leucocytes,  which 
ought  to  be  beneficial  to  the  organism,  is  the  most 
conspicuous  feature  of  a  grave  disease  (leukaemia)  al- 
ways leading  to  death,  though  here  also  the  leucocy- 
tosis  may  be  only  a  secondary  reaction  to  some  poi- 
soning of  the  organism  unknown  to  us.  Neither  the 
normal  nor  the  pathological  physiology  of  the  leuco- 
cytes can  therefore  be  considered  a  solved  problem. 

Blood  serum  has  for  its  function  the  transmission  to 
and  from  every  cell  of  the  body  of  different  substances 
of  its  metabolism,  consequently  the  abnormalities  of 
its  function  depend  upon  and  are  best  studied  with 
the  abnormalities  of  the  general  metabolism.  It  need 
only  be  stated  here,  that  the  function  of  the  blood 
serum  may  decrease  or  cease  entirely  in  a  certain  part 
of  the  body,  simply  through  the  change  of  its  density. 
Blood  may  coagulate  inside  of  the  blood-vessels,  ob- 
struct them,  and  thereby  produce  a  local  ana;mia. 

Pathology  of  Respiration. — Under  respiration  we 
understand  a  series  of  functions  as  a  result  of  which 
cells  of  an  organism  are  constantly  being  supplied 
with  an  amount  of  oxygen  necessary  for  their  metabo- 
lism and  eliminate  the  produced  carbonic  oxide.  The 
functions  accomplishing  this  work  are  the  following: 
The  lungs  receive  from  the  outside  atmosphere  the 
oxygen;  the  red  corpuscles  of  the  blood  come  in  near 
contact  with  this  oxygen,  combine  with  it,  and  then 
carry  it  to  the  different  cells  of  the  body.  These  cells 
receive  from  the  red  corpuscles  the  oxygen  and  transfer 
to  them  their  carbonic  oxide.  The  carbonic  oxide  is 
being  received  by  the  red  corpuscles  and  carried  to 
the  lungs,  where  it  is  being  eliminated.  I  have  al- 
ready analyzed  the  functions  of  the  red  corpuscles; 
of  the  use  which  the  cells  of  the  organism  make  of  the 
oxygen  I  will  treat  under  the  head  of  general  meta- 
bolism. What  concerns  us  now  is  the  work  of  the 
lungs  themselves,  or  the  so-called  external  respiration 
as  distinguished  from  the  other  respiratory  functions 
which  are  called  internal  respiration. 

The  function  of  the  respiratory  organ  may  be 
changed  in  one  of  the  following  three  ways:  Either 
the  air  tubes  leading  to  the  alveoli  may  be  obstructed 
(foreign  bodies,  tumors,  bronchitis,  and  so  on),  and 
then,  though  the  respiratory  movements  are  the  same, 
the  alveoli  do  not  receive  the  amount  of  air  necessary 
for  their  ventilation;  the  blood  consequently  receives 
less  oxygen  and  is  also  unable  to  free  itself  of  the  car- 
bonic oxide.  Or  the  alveoli  may  be  filled  with  some 
other  substance  than  air  (exudate  in  pneumonia,  fluid 
in  ttdema,  etc.);  then  the  blood  does  not  come  in 
natural  relationship  to  the  air  and  consequently  is 
unable  to  take  in  o.xygen  and  eliminate  its  carbonic 
oxide.  Or,  lastly,  tire  air  tubes  may  be  free,  but  the 
musculo-nervous  apparatus  (the  respiratory  muscles, 
vagus,  phrenicus,  the  respiratory  centre  in  the  medulla) 
and  the  respiratory  movenrents  are  changed.  Should 
the  obstruction  be  complete,  all  the  alveoli  filled,  or 
the  musculo-nervous  apparatus  cease  to  work — then  the 
w'irole  orgatrism  will  be  deprived  of  its  necessary  sup- 
ply of  oxygen  and  on  the  other  hand  be  overfilled  with 
carbonic  oxide,  which  is  poisonous,  and  the  organism 
must  consequently  die. 

On  the  other  iiand,  should  the  changes  be  partial, 
then  if  it  is  the  musculo-nervous  apparatus  which  is 
affected,  the  function  of  the  respiratory  organ  will 
change  accordingly.  But  the  result  becomes  more 
complicated  if  the  air  passages  are  partly  obstructed 
or  some  of  the  alveoli  are  filled  with  a  foreign  sub- 
stance. In  both  instances  the  arterial  blood  flowing 
from  the  lungs  will  contain  less  oxygen  and  more  car- 
bonic oxide  than  normally.  This  will  affect  the 
whole  organism,  but  first  of  all  the  respiratory  centre, 
which  will  become  irritated  and  will  increase  its  work 


September  i,  1900] 


MEDICAL    RECORD. 


331 


and  as  a  consequence  the  respiratory  movements. 
The  inspiration  becomes  deeper  and  more  frequent, 
the  expiration  becomes  active — i.e.,  not  only  is  the 
air  forced  out  by  the  elasticity  of  the  lungs  but  also 
by  active  muscular  work  (of  the  abdominal  and  some 
chest  muscles).  Such  an  increased  respiration  is 
called  "dyspnoea."  It  is  easily  seen,  then,  that  dysp- 
noea is  a  kind  of  a  compensatory  action  of  the  organ- 
ism against  a  decrease  of  work  by  the  respiratory  ap- 
paratus. As  a  matter  of  fact  it  has  been  proven 
experimentally  that  the  amount  of  oxygen  used  and 
carbonic  oxide  eliminated  during  dyspnoea  is  nearly 
the  same  as  that  during  normal  respiration  of  the  same 
organism.  The  inference  may  be  made,  tiiat  an  ab- 
normality in  the  function  of  the  respiratory  organ  is 
never  injurious  to  the  organism,  is  never  pathological. 
We  know,  however,  that  dyspnoea  injures  the  other 
organs  and  is  certainly  a  pathological  condition.  The 
reason  must  be  looked  for  in  the  fact  that  dyspnoea 
increases  the  gas  metabolism  by  the  aid  of  increased 
muscular  work,  and  such  an  increase  of  work  neces- 
sitates again  an  increase  in  the  amount  of  oxygen 
used  and  carbonic  oxide  eliminated.  Dyspnoea,  then, 
though  it  brings  the  amount  of  oxygen  and  carbonic 
oxide  to  a  normal  level,  is  unable  to  increase  the 
amount  sufficiently  for  an  animal  in  such  a  state.  The 
arterial  blood  leaves  the  lungs  with  a  normal  amount 
of  oxygen  and  carbonic  oxide,  but  it  goes  to  organs 
that  do  more  than  a  normal  amount  of  work;  conse- 
quently they  take  from  the  blood  more  oxygen  and 
give  it  more  carbonic  oxide  than  normally.  This 
venous  blood,  abnormally  rich  in  carbonic  oxide  and 
poor  in  oxygen,  cannot,  therefore,  receive  in  the  lungs 
the  necessary  amount  of  oxygen  and  eliminate  the 
necessary  amount  of  carbonic  oxide  to  become  normal 
arterial  blood,  though  the  work  of  the  lungs  is  normal. 
That  this  is  so  is  proven  by  the  fact  that  dyspnoea  pro- 
ducess  cyanosis,  a  state  in  which  even  the  arterial 
blood  contains  abnormally  little  oxygen  and  an  ex- 
cessive amount  of  carbonic  oxide.  But  in  order  to 
prove  the  above  supposition  we  should  have  to  show 
experimentally  that  there  really  is  a  difference  in  the 
amounts  of  oxygen  and  carbonic  oxide  in  the  blood 
of  a  normal  animal  and  of  one  in  a  state  of  dyspnoea. 
Such  experiments  have  not  been  made  yet,  though  the 
amount  of  oxygen  and  carbonic  oxide  in  the  blood  of 
a  normal  animal  has  been  determined. 

Pathology  of  Digestion. — The  food  which  a  higher 
organism  gets  from  outside  must  contain  albumen,  fat, 
carbohydrates,  salts,  and  water.  Ail  these  substances 
except  salt  and  water  have  to  undergo  certain  prelimi- 
nary changes,  chemical  as  well  as  physical,  before 
they  are  fit  to  be  used  as  food  by  the  cells  of  the  body. 
This  preliminary  work  is  allotted  to  the  digestive  ap- 
paratus. Beginning  with  the  mouth  and  ending  with 
the  anus,  this  apparatus  consists  of  a  series  of  organs, 
each  doing  its  part  in  the  digestive  function. 

Almost  every  kind  of  a  pathological  state  in  any  of 
these  organs  produces  the  same  influence  on  the  or- 
ganism. On  the  one  hand,  it  is  not  all  the  food  taken 
in  that  undergoes  the  necessary  preliminary  trans- 
formation, and  the  organism  suffers  from  partial  in- 
anition. On  the  other  hand,  parts  of  the  food  trans- 
formed and  untransformed  stagnate  in  the  digestive 
tract.  The  micro-organisms  that  are  always  swallowed 
with  the  food  have  a  better  opportunity  to  act  on  it 
and  split  its  chemical  substances  into  different  ones, 
which  may  prove  injurious  (poisonous)  to  the  organ- 
ism. 

Pathology  of  Metabolism.— The  assimilation  of 
food  or  metabolism,  as  we  have  seen,  consists  of  three 
acts — introduction  of  food,  assimilation  proper,  and 
the  elimination  of  the  remnants  of  the  food.  The 
same  three  divisions  we  must  follow  in  studying  the 
abnormalities  of  the  metabolism. 


The  food  may  be  introduced  into  the  organism  in 
an  abnormally  increased  quantity.  'J'he  influence  of 
such  an  increase  is  hardly  of  any  importance.  The 
quantity  of  food  taken  in  by  the  cells  of  the  organism 
does  not  depend  on  the  amount  of  the  supply  of  food 
on  hand,  but  upon  the  amount  of  substance  necessary 
for  the  cell  to  cover  its  expenditure,  consequently 
upon  the  amount  of  work  produced  by  the  cell.  The 
only  injury  an  organism  can  receive  from  overfeeding 
is  the  overloading  and  stagnation  of  food  in  the  diges- 
tive tract,  or  overexerting  of  the  excretory  organs. 

.V  great  deal  more  important  is  a  decrease  in  the 
amount  of  introduced  food  or  a  total  absence  of  food. 
Certain  functions  have  to  go  on  in  an  organism  so 
that  its  life  may  be  continued.  These  functions  will 
then  go  on  even  though  the  supply  of  food  has  ceased. 
At  first  the  cells  find  in  the  body  a  sufficient  amount 
of  stored  up  material  (fat,  carbohydrates),  by  which 
they  can  recuperate  their  loss.  But  when  this  is  all 
used  up,  the  cells,  w'hile  continuing  their  functions, 
lose  so  much  of  their  own  substance  that  they  are  un- 
able to  continue  them,  and  die.  In  this  instance  there 
manifests  itself  the  most  wonderful  capacity  of  the 
whole  organism  for  self-preservation.  Tor  those  cells 
which  are  of  the  greatest  necessity  to  the  whole  organ- 
ism (nerve  cells)  live  longer  than  the  rest,  and  most 
probably  feed  themselves  on  the  substance  of  less  im- 
portant cells  (fat). 

Now,  the  substances  introduced  into  the  organism 
can  also  differ  qualitatively  from  the  ordinary  food. 
A  priori  we  have  to  suppose  that  such  a  substance  in- 
troduced into  an  organism  (I  mean  by  it  not  only 
brought  in  the  digestive  tract,  but  also  absorbed  by 
the  blood)  will  be  eliminated  again  without  being 
taken  in  by  the  cells;  and  this  is  really  the  case  with 
some  substances.  But  there  is  a  large  class  of  sub- 
stances which,  when  introduced  into  the  organism,  are 
taken  in  by  the  cells,  and,  though  unable  to  serve  as 
food  in  rebuilding  the  cell,  these  substances  influence 
the  latter  so  that  its  function  is  either  improved,  im- 
paired, or  even  stopped  entirely.  To  the  first  class 
belong  the  medicative  agents,  to  the  latter  the  so-called 
poisons. 

The  study  of  poisons  has  now  acquired  such  a  pre- 
dominant place  in  the  whole  field  of  pathology  that  it 
would  be  impossible  for  me  to  give  here  even  the 
merest  outline  of  the  matter.  We  understand  a  poison 
to  be  a  substance  which,  when  introduced  into  the 
circulation,  produces  upon  some  cells  of  the  organism 
such  an  influence  that  the  function  of  these  cells  is 
either  interfered  with  or  stopped  entirely.  What  the 
nature  of  the  action  of  a  poison  is  we  are  absolutely 
unable  to  say.  Still  there  are  a  great  many  questions 
in  physiology,  normal  as  well  as  pathological,  which 
could  be  answered  only  through  the  study  of  the  action 
of  poisons,  and  a  great  many  more  that  will  probably 
be  answered  through  such  a  study  in  the  future.  The 
fact  that  a  great  many  mineral  substances  as  well  as 
substances  produced  by  or  derived  from  plants  or  ani- 
mals are  poisonous,  if  introduced  into  another  organ- 
ism, was  known  in  medicine  from  time  immemorial. 
But  poison  was  considered  a  factor  rather  subordinate 
in  pathology,  while  at  present  we  have  facts  enough 
to  prove  that  poisoning  plays  a  dominant  role  in  the 
whole  field  of  pathology.  The  etiology  of  the  most 
numerous  class  of  diseases,  the  so-called  infectious 
ones,  was  absolutely  unknown  until,  beginning  witli 
the  works  of  Pasteur  and  Koch,  it  was  shown  conclu- 
sively of  some  of  them  and  made  very  probable  for  the 
rest,  that  they  are  produced  by  the  influence  on  the 
organism  of  certain  well-defined  micro-organisms.  It 
has  been  further  proven,  as  just  stated,  that  this  in- 
fluence does  not  consist  in  a  mechanical  action  of 
these  microbes,  as  was  at  first  believed,  but  that  the 
micro-organisms  through  their  own  metabolism   pro- 


332 


MEDICAL    RECORD. 


[September  i,  igcx) 


duce  certain  substances,  which  when  absorbed  by  the 
blood  act  as  poisons  on  some  cells  of  the  organism. 

Even  normal  food,  in  case  it  stagnates  in  the  diges- 
tive tract,  may  become  a  source  of  poisoning.  Under 
the  influence  of  some  micro-organisms  which  may 
exist  there,  and  which  by  themselves  may  not  be  in- 
jurious to  the  organism,  the  food  produces  abnormal 
chemical  substances  which  also  act  like  poisons  when 
absorbed  by  the  blood.  The  most  wonderful  bio- 
logical facts  discovered  through  the  study  of  poison- 
ing are  in  the  first  place  the  inability  of  the  poison 
after  it  has  been  absorbed  by  the  blood  to  injure  all 
cells  of  the  organism.  It  seems  that  certain  poisons 
can  penetrate  and  injure  only  certain  cells  of  the  or- 
ganism. The  other  fact  is  that  the  same  cells  which 
were  susceptible  to  a  certain  poison,  can  under  cer- 
tain circumstances  be  made  to  withstand  the  same 
poison  (I  have  mentioned  it  in  the  section  on  blood). 
This  fact  is  true  in  the  case  of  bacterial  to.xins  as  well 
as  of  different  poisonous  alkaloids  (morphine,  cocaine). 
Though  the  nature  of  the  action  of  a  poison  on  a  cell 
is  unknown,  we  are  quite  familiar  with  the  manner  in 
which  a  given  poison  injures  a  certain  function;  but, 
as  already  stated,  it  is  impossible  to  go  here  into  any 
details  of  the  question. 

We  turn  now  to  the  study  of  the  abnormalities  of 
assimilation  of  food.  This  question  is  very  compli- 
cated. As  was  mentioned  before,  a  substance  which 
is  assimilated  by  one  cell  may  have  been  eliminated 
by  another.  We  are  unable  to  follow  the  course  of 
metabolism  of  each  cell  separately;  the  only  method 
left  to  us  is,  therefore,  to  follow  as  best  we  can  each 
component  of  food  from  the  time  it  has  been  absorbed 
by  the  blood  or  lymph  until  it  is  eliminated  from  the 
organism.  VVe  will  begin  with  the  proteids  of  the 
food.  They  leave  the  body  in  the  form  of  urea,  and 
other  substances  of  less  importance.  It  has  been 
shown  that  within  the  cells  the  final  products  of  de- 
composition of  proteids  are  most  probably  certain 
organic  acids  (lactic,  oxybutyric,  etc.)  and  alkali 
(NH3).  Normally  these  two  substances  form  a  salt. 
This  salt  is  transported  to  the  liver,  where  it  under- 
goes an  oxidation  into  ammonium  carbonate  [(NHJ„- 
COJ  which  is  then  transformed  synthetically  by  the 
liver  into  urea.  Should  this  function  of  the  liver  be- 
come impaired  by  some  pathological  process  (acute 
yellow  atrophy,  phosphorus  poisoning,  etc.),  experi- 
mental elimination  of  the  organ,  or  even  without  any 
apparent  morphological  change,  then  some  of  the  or- 
ganic acids  will  be  eliminated  without  their  preliminary 
transformation  into  urea.  This  fact  is  likely  to  be- 
come of  some  importance  in  pathology,  as  the  state  of 
coma  taking  place  in  the  course  of  diabetes,  carcinoma, 
and  some  other  pathological  processes  seems  to  be 
due  to  intoxication  by  the  organic  acids  circulating  in 
the  body. 

The  abnormality  in  the  metabolism  of  proteids  may 
go  further  yet  and  the  proteids  may  be  eliminated  be- 
fore they  split  into  a  nitrogenous  and  a  non-nitrogen- 
ous part.  This  takes  place  in  fevers,  carcinoma, 
phosphorus  poisoning,  acute  yellow  atrophy  of  the 
liver,  and  some  other  conditions,  when  the  proteids  are 
eliminated  in  the  form  of  albumoses.  Such  an  ab- 
normality in  the  metabolism  is  certainly  a  sign  of 
great  depression  in  the  functions  of  the  cells,  since 
the  albumoses  i)ractically  contain  the  same  amount  of 
potential  energy  as  the  proteids  themselves;  conse- 
quentlythe  cellsof  the  body  arein  a  stateof  inanition, 
though  the  supply  of  food  may  be  plentiful. 

Uric  acid,  which  in  birds  is  the  most  important 
product  of  elimination  of  proteids,  occupies  a  subordi- 
nate place  in  mammals.  It  has  been  shown  lately 
that  in  the  latter  uric  acid  is  a  product  of  elimination 
of  only  a  certain  kind  of  proteids,  the  so-called  nucle- 
ins  (a  constituent  part  of  the  nuclei  of  cells).     Some 


cells  in  the  organism  (leucocytes  for  instance)  are 
constantly  dying  off  and  undergoing  the  process  of 
decomposition.  There  is  consequently  always  ma- 
terial for  the  formation  of  uric  acid.  In  some  patho- 
logical processes,  when  leucocytosis  takes  place,  and 
also  in  leukaemia,  we  find  mostly  an  increased  amount 
of  eliminated  uric  acid.  This  tends  to  show  that  the 
increased  number  of  leukocytes  in  leuka;mia  is  due  not 
to  a  decrease  in  their  decomposition,  but  to  an  increase 
in  formation,  for  the  number  of  dead  leucocytes  must 
increase  so  that  the  amount  of  eliminated  uric  acid 
may  increase. 

There  is  a  disease  which  has  some,  though  not  well- 
defined  relations  to  the  uric-acid  formation,  and  this 
is  gout.  The  most  important  symptoms  of  the  disease 
are  painful,  inflammatory  swelling  near  some  joint, 
with  necrosis  of  the  tissue  and  precipitation  in  it  of 
uric  acid.  At  first  it  was  thought  that  the  uric  acid 
was  the  real  cause  of  the  disease.  There  is,  it  was 
thought,  an  increased  formation  of  uric  acid,  which 
accumulates  in  the  blood  and  then  precipitates  in  the 
tissues.  But  lately  with  the  help  of  improved  methods 
it  has  been  shown  that  in  gout  there  is  no  increase  of 
uric-acid  formation  in  the  whole  organism,  neither  is 
there  decreased  elimination.  The  more  plausible 
theory  seems  to  be,  therefore,  that  some  unknown 
cause  gives  rise  in  certain  parts  of  the  organism  to 
such  an  abnormal  state  of  the  cells  that  they  produce 
locally  more  uric  acid  than  the  blood  can  absorb. 

We  hardly  know  anything  about  assimilation  of  fat 
under  either  normal  or  abnormal  conditions.  It  has 
been  proven  experimentally  that  the  fat  absorbed 
with  the  food  can  be  not  only  oxidized,  but  also  de- 
posited as  fat  in  the  body.  On  the  other  hand,  an 
organism  which  does  not^receive  any  fat  with  the  food 
can  still  increase  the  amount  of  its  fat,  through  the 
splitting  of  albumin.  Now,  why  do  some  individuals 
have  an  abnormally,  even  pathologically  increased 
amount  of  fat.'  It  is  possible  that  the  cells  of  such 
an  organism  are  able  to  oxidize  only  an  abnormally 
small  amount  of  fat,  and  that  the  rest  is  deposited. 
We  may  suppose,  on  the  other  hand,  that  the  cells  split 
off  an  abnormally  great  amount  of  fat  from  the  proteids 
of  the  food  as  well  as  from  those  of  the  cells  them- 
selves. We  liave  not  sufficient  experimental  proof  to 
accept  either  of  these  possibilities. 

The  greatest  amount  of  work  in  metabolism  has 
been  done  on  the  question  of  the  assimilation  of  car- 
bohydrates, thanks  to  diabetes,  a  disease  which  has 
puzzled  and  interested  physicians  of  all  times.  It 
should  also  be  stated  that  we  have  received  a  clearer 
insight  into  the  normal  metabolism  of  the  carbohy- 
drates mostly  through  the  study  of  its  pathology;  still 
a  great  many  of  our  conceptions  of  the  matter  are  as 
yet  hypothetical.  Under  normal  conditions,  all  the 
carbohydrates,  after  being  formed  in  the  digestive 
tract  into  monosaccharids,  are  absorbed  by  the  portal 
venous  system,  and  carried  to  the  li\er.  The  cells  of 
the  liver  seem  to  transform  them  into  insoluble  gly- 
cogen, storing  the  latter  within  tiiemselves.  The  cells 
further  transform  the  glycogen  into  sugar  and  dis- 
tribute it  in  small  quantities  only  by  way  of  the  gen- 
eral circulation  to  the  other  parts  of  the  organism  ac- 
cording to  their  needs.  The  following  fact  may  serve 
as  proof:  If  we  feed  an  animal  witli  sugar,  we  find  an 
increased  amount  of  sugar  in  the  blood  of  tiie  portal 
vein,  while  in  the  blood  of  the  general  circulation  tlie 
sugar  is  taken  up  by  the  cells  and  after  having  under- 
gone some  preliminary  changes,  tiie  nature  of  which 
we  do  not  yet  know,  it  is  oxidized  into  carbonic  oxide 
and  water.  Now  when  an  abnormally  increased 
amount  of  carbohydrates  is  introduced  into  the  organ- 
ism, then  the  liver  will  receive  more  sugar  than  it  is 
able  to  transform  into  glycogen.  The  excess  of  this 
alimentary  sugar  will  be  absorbed  by  the  general  blood 


September  i,  1900] 


MEDICAL    RECORD. 


333 


circulation,  and  we  have  a  glyceemia.  Furthermore, 
as  all  the  sugar  from  the  blood  cannot  be  taken  in  by 
the  cells,  the  rest  of  it  will  be  eliminated  by  the  urine ; 
we  shall  have  then  a  glycosuria.  Such  a  glycosuria 
though  abnormal  is  not  pathological,  as  it  does  not 
interfere  with  any  function  of  the  organism.  A  gly- 
cosuria becomes  pathological  only  if  it  is  the  result 
of  a  decrease  in  or  cessation  of  the  glycogen-forming 
function  of  the  liver,  when  all  the  sugar  absorbed 
from  the  intestinal  tract  passes  into  the  general  circu- 
lation. i!ut  only  a  part  of  this  circulating  sugar  can 
be  oxidized  in  a  given  time;  the  rest  will  be  elimi- 
nated, and  the  organism  will  suffer  from  partial  in- 
anition. Now  is  pathological  glycosuria  or  diabetes 
simply  an  abnormality  of  the  glycogen-forming  func- 
tion of  the  liver?  The  e.xperiniental  study  of  the 
question  has  shown  it  to  be  a  great  deal  more  com- 
plicated, and  is  hardly  yet  able  to  give  a  definite  an- 
swer to  the  question.  It  has  been  shown  that  the  ex- 
tirpation of  the  pancreas  produces  in  an  animal  a 
severe  form  of  diabetes.  This  fact  shows  that  the 
pancreas  has  also  a  certain  influence  upon  the  assimila- 
tion of  carbohydrates.  VVhether  this  influence  con- 
sists of  the  formation  of  some  substance  which  is 
introduced  into  the  liver  and  assists  there  in  the 
transformation  of  sugar  into  glycogen,  or  of  something 
else,  cannot  as  yet  be  definitely  stated. 

There  are  also  facts  which  show  that  sugar  can  be 
transformed  into  glycogen  and  stored  not  only  in  the 
liver  but  in  the  other  organs  of  the  body,  and  first 
among  them  in  the  muscles.  The  assimilation  of  car- 
bohydrates takes  consequently  the  following  course: 
The  organs  receive  sugar  from  the  liver,  transform  it 
into  glycogen,  and  then  according  to  their  needs  trans- 
form the  glycogen  again  into  sugar.  Now,  should  the 
glycogen-forming  capacity  of  any  of  the  organs  be- 
come abnormally  decreased,  then  sugar  will  accumu- 
late in  this  organ  and  from  there  penetrate  in  abnormal 
quantities  into  the  blood.  We  shall  get  a  glycasmia 
and  glycosuria.  Another  striking  experimental  fact, 
which  complicates  the  question  still  more,  is  the  so- 
called  phloridzin  diabetes.  Phloridzin  is  a  chemical 
body,  which,  when  introduced  into  an  animal,  pro- 
duces a  glycosuria,  but  without  an  increase  in  the 
amount  of  sugar  in  the  blood.  Such  a  glycosuria  can 
be  explained  only  by  a  certain  influence  of  the  phlo- 
ridzin on  the  cells  of  the  kidneys.  It  has  been  further 
proven  that  an  injury  of  a  certain  place  in  the  brain 
also  produces  a  glycsmia  and  glycosuria.  It  seems, 
then,  that  pathological  glycosuria  or  diabetes  can  be 
the  result  of  dilTerent  lesions,  and  it  is,  therefore,  most 
likely  not  a  disease  siii  generis,  but  a  symptom  show- 
ing that  the  assimilation  of  carbohydrates  is  abnormal 
in  some  organ  of  the  body. 

The  mineral  substances  of  the  food  cannot  be  oxi- 
dized nor  in  any  other  way  assimilated  by  the  organ- 
ism. Still  they  are  of  vital  importance,  and  an  ani- 
mal which  receives  all  the  other  constituents  of  the 
food  except  the  mineral  substances  dies  sooner  than 
an  animal  in  a  state  of  complete  inanition.  As  yet 
we  are  unable  to  explain  tlie  mode  of  action  of  these 
substances.  They  are  most  likely  a  vital  part  not  only 
of  the  skeleton,  but  also  of  all  other  parts  of  the  body, 
and  as  some  part  of  the  mineral  substances  is  continu- 
ally eliminated,  the  loss  must  consequently  be  repaired 
by  the  food.  We  know  of  certain  diseases,  such  as 
scurvy,  rickets,  and  osteomalacia,  which  are  in  all 
probability  results  of  certain  abnormalities  in  the  as- 
similation of  one  or  another  mineral  substance.  But 
the  manner  in  which  these  states  are  produced  is  just 
as  little  known  to  us  as  is  the  nature  of  the  normal  as- 
similation of  these  substances. 

While  studying  the  functions  of  the  liver  and  pan- 
creas, we  have  met  with  the  fact  that,  besides  produc- 
ing and  eliminating  certain  secretions  through  their 


ducts,  they  perform  also  some  other  work,  the  so-called 
internal  secretion.  The  latter  is  of  the  greatest  im^ 
portance  to  the  organism,  and  consists  in  one  of  the 
following  two  kinds  of  functions:  Either  the  cells  of 
such  glands  take  up  some  nutritive  substances  from 
the  blood  and  transform  them  in  some  way.  and  then 
turn  them  to  the  blood  again,  or  the  cells  of  these 
glands  produce  by  themselves  certain  substances  and 
eliminate  them  into  the  blood,  l-'rom  the  blood  these 
substances  pass  into  other  organs  of  the  body  and  in- 
fluence there  in  one  way  or  another  tlieir  metabolism. 

Now  there  is  a  series  of  these  so-called  ductless 
glands  in  the  body,  such  as  the  thyroid,  the  pituitary 
body,  the  suprarenal  glands,  the  spleen,  the  lymphatic 
glands,  and  to  their  number  must  also  be  added  the 
marrow  of  the  bones.  What  is  their  function?  Normal 
physiology  was  utterly  unable  to  answer  this  question. 
It  was  thought  that  all  these  glands  had  some  connec- 
tion with  the  formation  of  blood,  but  practically  they 
were  hardly  considered  of  any  importance  in  the  or- 
ganism. It  was  left  for  pathology  to  elucidate  this,  as 
well  as  some  other  most  difficult  questions  of  normal 
physiology.  The  former  was  first  to  show  clinically, 
as  well  as  experimentally,  that  an  organism  cannot 
live  without  the  thyroid  and  dies  after  its  extirpation 
under  symptoms  of  poisoning.  These  symptoms  con- 
sist either  in  acute  irritation  of  the  nervous  system — 
tetanic  convulsions — or  in  slow  depression  of  nervous 
and  mental  functions  with  certain  characteristic 
changes  of  the  connective  tissue  (myxcedenia).  Ap- 
parently the  thyroid  is  also  an  important  factor  in  the 
general  metabolism  of  the  organism,  though  we  are  as 
yet  hardly  able  to  determine  the  mode  of  its  action. 
The  cells  of  the  thyroid  may  absorb  some  intermediate 
product  of  metabolism  poisonous  to  the  organism  and 
transform  it  into  a  non-poisonous  substance.  Or  the 
cells  of  the  thyroid  may  produce  some  substance  neces- 
sary for  the  general  metabolism.  \\'e  have  also  facts 
which  tend  to  show  that  the  same  kind  of  function  be- 
longs to  the  suprarenal  glands  and  the  pituitary  body. 
We  may  say,  then,  that  these  so-called  ductless  glands 
are  very  likely  some  kind  of  regulators  of  the  general 
metabolism,  and  any  pathological  state  of  the  former 
injures  the  whole  metabolism. 

Far  less  yet  are  we  able  to  explain  the  relation  to 
the  metabolism  of  the  spleen,  (he  lymphatic  glands, 
and  the  marrow  of  the  bones.  There  are  facts  which 
show  that  an  organism  may  continue  its  normal  life 
even  after  the  spleen  has  been  extirpated.  This  fact, 
however,  does  not  yet  preclude  the  possibility  that  the 
spleen  may  have  some  very  important  part  in  the 
metabolism.  Its  function  may,  for  instance,  consist  in 
neutralizing  or  transforming  some  bacteria  or  other 
poisons  introduced  from  outside,  and  this  will  explain 
the  fact  that  the  spleen  increases  so  often  in  size  dur- 
ing infectious  disease.  But  this  supposition  needs  a 
great  deal  of  additional  experimental  work  in  order  to 
become  even  a  theory. 

Pathology  of  Excretiou.  — It  has  been  already 
stated  that  as  the  last  stage  of  the  assimilation  of 
food  there  are  formed  in  the  organism  carbonic  oxide, 
water,  urea,  uric  acid,  some  other  product  of  decom- 
position of  proteids,  and  mineral  substances.  These 
last  products  of  the  metabolism  are  eliminated  by  the 
organism  through  its  excretory  organs.  Carbonic 
oxide  and  part  of  the  water  are  eliminated  by  the 
lungs,  the  excretive  function  of  which  we  have  al- 
ready studied.  All  the  other  substances  are  elimi- 
nated by  the  kidneys  and  the  skin. 

The  "kidneys  are  the  most  important  excretory  or- 
gans. Their  function  consists  in  absorbing  from  the 
blood  all  the  last  products  of  metabolism  (except  car- 
bonic oxide)  in  an  aqueous  solution  and  subsequently 
eliminating  them.  It  must  be  added  that  the  cells  of 
the  kidneys  are  also  able  to  change  the  structure  of 


'>  ->  A 

oj4 


00 


MEDICAL    RECORD. 


[September  i,  1900 


some  of  the  absorbed  substances,  an  instance  of  which 
we  can  see  in  the  formation  of  hippuric  acid.  IJoth 
kinds  of  function  may  certainly  become  abnormal. 
The  absorbing  power  of  the  kidneys  may  suffer  in  two 
ways:  on  the  one  hand,  from  causes  emanating,  as  a 
rule,  outsidt  the  kidneys,  the  latter  may  be  enabled 
to  absorb  from  the  blood  substances  which  they  could 
not  absorb  abnormally.  Among  these  substances  are 
sugar,  which  we  studied  already,  and  albumin.  It  has 
been  shown  lately  that  one  of  the  albumins  which 
appear  in  the  urine  under  pathological  conditions,  i.e., 
nucleo-albumin,  is  due  to  some  lesion  of  the  cells  of 
the  kidneys  themselves.  I!ut  in  most  cases  albumin 
is  eliminated  from  the  blood  as  a  result  of  some 
abnormality  either  of  the  blood  circulation  or  of  the 
filtering  properties  of  the  cells  of  the  kidneys,  or  of 
both.  The  elimination  of  albumin  through  the  kid- 
neys, I.e.,  albuminuria,  has  hardly  any  influence  upon 
the  rest  of  the  organism.  The  quantity  of  albumin 
eliminated  is  certainly  too  small  to  cause  the  organ- 
ism to  suffer  from  proteid  inanition.  Far  more  in- 
jurious to  the  organism  is  such  an  abnormal  condition 
of  the  kidneys  as  makes  it  impossible  for  them  to 
eliminate  all  the  substances  of  decomposition  from 
the  blood. 

In  the  course  of  different  diseases  of  the  kidneys 
there  may  develop  a  state  of  the  organism  called 
ursemia.  Uraemia  may  present  different  phenomena 
in  different  cases,  but  it  is  always  associated  with  a 
state  of  general  irritation  or  depression  of  the  central 
nervous  system,  and  always  shows  features  common  to 
general  intoxication.  The  explanation  of  the  nature 
of  uramia  has  always  interested  and  puzzled  physi- 
cians. At  first  it  was  thought  that  in  the  diseases  of 
the  kidneys  urea  accumulates  in  the  blood  and  is 
transformed  there  into  ammonium  carbonate,  which  is 
poisonous  to  the  organism.  Then  successively  salts 
of  potassium,  uric  acid,  and  creatin  were  considered 
the  poisons  that  produced  uraemia.  But  it  has  been 
proven  experimentally  that  none  of  these  substances, 
though  poisonous  to  the  organism,  is  able  to  produce 
all  the  symptoms  of  uraemia.  Neither  has  an  overac- 
cumulation  of  these  substances  in  the  blood  been 
found  in  cases  of  uraimia.  There  must  consequently 
be  some  other  substances  in  the  urine,  the  retention 
of  which  within  the  organism  produces  uremia.  The 
chemical  search  for  these  substances  has  so  far  not 
proven  successful.  Hut  we  have  experimental  proof 
that  even  normal  urine  is  poisonous  to  the  organism. 
It  has  been  shown  that  sterile  urine  of  a  normal  or- 
ganism, if  injected  intravenously  into  a  rabbit,  kills 
it  under  symptoms  very  like  those  of  uraemia.  The 
quantity  of  normal  urine  necessary  to  kill  a  rabbit  is 
always  nearly  the  same.  It  has  been  further  shown 
that  in  order  to  kill  a  rabbit  with  urine  taken  from  a 
diseased  organism  we  have  to  take  sometimes  a  greater 
and  sometimes  a  smaller  quantity.  The  latter  fact 
could  be  taken  as  a  proof  that  there  is  overproduction 
in  the  diseased  organism  of  those  toxic  substances 
that  exist  in  the  normal  urine.  The  former,  on  the 
other  hand,  would  show  that  there  is  retention  in  the 
organism  of  the  same  toxic  substances  which  exist  in 
the  normal  urine.  The  latter  fact  would  then  tend  to 
prove  that  ur.-emia  is  produced  by  retained  toxic  sub- 
stances which  are  normally  filtered  into  the  urine. 
Still  this  fact  alone  cannot  explain  uraemia.  We 
know  of  cases  in  which  there  is  a  complete  anuria  for 
a  few  days,  and  still  no  uraemia  follows.  The  most 
important  factor,  therefore,  is  probably  the  impaired 
power  of  the  kidney  cells  to  transform  some  toxic 
products  of  metabolism  into  non-toxic  ones. 

The  skin  is  also  able  to  secrete  the  greater  part  of 
those  substances  which  are  eliminated  by  the  kidneys, 
but  in  such  small  quantities  tliat  the  secretory  func- 
tion of  the  skin   is  hardly  of  any  importance  to  the 


organism.  An  extensive  injury  of  the  skin  may  damage 
or  even  kill  the  animal,  but  such  an  effect  then  will 
not  be  due  to  the  impaired  eliminative  function  of  the 
skin,  but  rather  to  the  disturbance  of  the  heat  economy 
caused  by  such  an  injury. 

From  the  study  of  general  metabolism  we  saw  that 
this  function  of  the  cells  of  the  organism  is  the  most 
important  and  extensive  one,  as  it  is  common  to  all 
the  cells  of  the  body.  The  abnormalities  of  this  func 
tion  result  in  partial  or  complete  inanition,  or  more 
frequently  in  some  kind  of  poisoning.  This  poison- 
ing from  causes  originating  within  the  organism  it- 
self, the  so-called  auto-intoxication,  is  gaining  a  pre- 
dominant place  in  pathology,  and  is  probably  the 
most  frequent  and  important  ultimate  cause  of  disease. 

Pathology  of  the  Heat  Economy. — The  tempera- 
ture of  an  organism  depends,  on  the  one  hand,  upon 
the  temperature  of  the  atmosphere,  and  on  the  other 
on  the  amount  of  heat  in  the  organism,  and  any  change 
in  either  factor  must  influence  its  temperature.  An 
organism  can  withstand  a  lower  atmospheric  tempera- 
ture only  up  to  a  certain  point,  and  then  its  own  tem- 
perature falls  gradually,  and  the  animal  dies  under 
symptoms  of  general  paralysis.'  A  so-called  "cold," 
or  an  influence  of  an  abrupt  decrease  of  an  atmospheric 
temperature  in  producing  different  diseases,  was  in 
former  years  considered  quite  an  important  factor,  but 
with  the  advent  of  bacteriology  its  significance  has 
been  entirely  underrated.  Lately  the  opinion  seems 
to  prevail  that  even  in  infectious  diseases  a  "  cold  " 
may  have  a  certain  influence  as  a  contributing  cause. 
It  is  interesting  to  note  in  this  connection  that  experi- 
ments have  been  made  which  show  that  an  animal 
previously  cooled  off  more  readily  yields  to  bacterial 
infection. 

Very  high  atmospheric  temperature  is  also  proven 
experimentally,  as  well  as  clinically  (insolation),  to 
be  injurious  to  an  organism.  The  temperature  of  an 
animal  rises  and  it  dies  under  symptoms  of  general 
paralysis.  The  cause  of  death  from  overheating  is 
not  yet  clearly  ascertained  ;  the  most  plausible  opinion 
seems  to  be  that  the  ultimate  cause  is  some  kind  of 
intoxication. 

A  decrease  of  the  temperature  through  causes  em- 
anating from  the  organism  itself  does  not  seem  to  be 
of  any  importance  in  pathology.  The  deaths  resulting 
from  an  extensive  injury  of  the  skin  have  to  be  ascribed 
to  this  cause. 

The  most  important  and  frequent  abnormality  in 
the  heat  economy  of  an  organism  is  the  increase  of 
the  temperature  emanating  from  internal  causes,  or 
the  so-called  fever.  There  is  still  much  difference  of 
opinion  as  to  what  the  term  fever  means.  There  is 
certainly  a  great  deal  of  difference  between  an  eleva- 
tion of  the  temperature  after  mechanical  overwork  and 
that  which  accompanies  septicaemia  or  some  other  dis- 
eases. Some  pathologists,  therefore,  do  not  consider 
every  elevation  of  the  temperature  a  febrile  one,  but 
say  that  in  fever  the  temperature  has  not  only  to  be 
raised  to,  but  also  levelled  on,  a  certain  point.  This 
means  the  following:  If  we  attempt  by  the  help  of 
some  agent  to  reduce  a  simple  elevation  of  the  tem- 
perature of  an  organism,  we  shall  succeed  in  reducing 
it  and  keeping  it  at  norm,  even  after  the  agent  has 
ceased  to  act,  while  if  we  do  the  same  with  an  indi- 
vidual having  fever  the  temperature  will  not  sink  en- 
tirely to  the  norm,  and  will  rise  again  to  the  former 
height  as  soon  as  the  agent  ceases  to  work.  Now,  this 
very  ingenious  theory  still  does  not  seem  to  introduce 
any  qualitative  difference  between  the  two  kinds  of 
elevation  of  the  temperature.  Let  us  suppose  that  in 
the  first  case  the  cause  which  produces  fever  gives  a 
certain  shock  to  the  regulative  mechanism  and  then 
ceases  its  action,  while  in  the  other  the  cause  acts 
continually.     It  is  evident,  then,  that  in  the  first  case 


September  i,  1900] 


MEDICAL   RECORD. 


335 


the  temperature  will  be  easily  reduced  to  the  norm, 
while  in  the  other  it  maintains  its  height,  because  the 
regulative  mechanism  gets  the  second  shock  before 
the  .uUipyretic  has  had  time  to  act.  But  as  long  as 
there  is  no  qualitative  differe-nce  between  the  different 
elevations  of  the  temperature,  it  is  more  convenient  to 
call  fever  every  elevation  of  the  temperature  due  to 
causes  originating  within  the  organism  itself. 

Now,  to  what  abnormality  in  the  heat  economy  is 
fever  due?  The  normal  temperature  of  an  organism 
depends  on  the  relative  amount  of  heat  produced  and 
distributed.  It  has  been  shown  e.xperimentally  that 
the  amount  of  heat  distributed  decreases  in  fever.  At 
the  same  time  the  amount  of  heat  produced,  which 
under  normal  conditions  would  also  decrease  under 
the  regulative  influence  of  the  nervous  apparatus,  now- 
even  increases.  The  main  factor  then  must  conse- 
quently be  the  abnormal  function  of  the  heat-regulating 
mech.inism,  which  works  in  fever  so  as  to  raise  the 
temperature  of  the  organism  above  the  normal.  Quite 
a  large  amount  of  experimental  work  has  been  done 
of  late,  which  tends  to  show  that  this  abnormality  in 
the  function  of  the  heat-regulating  mechanism  is 
brought  about  by  some  kind  of  intoxication  due  to  the 
so-called  alb.imoses  (derivates  of  cell  or  bacteria  pro- 
teids).  It  must  be  borne  in  mind,  however,  that  these 
substances  producing  fever  are  not  identical  with  the 
substances  producing  the  pathological  process  which 
is  accompanied  by  the  fever.  Undoubtedly  there  are 
also  cases  in  which  fever  is  produced  by  a  simple  re- 
flex action  through  some  peripheral  nerves  on  the  heat 
centres. 

From  all  that  has  been  said  we  can  see  that  beat 
economy  resembles  general  metabolism  in  so  far  as  it 
is  the  result  of  a  joint  work  of  many  organs  of  our 
body,  and  pathological  states  of  heat  economy  are  in 
most  instances  special  kinds  of  intoxication  by  some 
substances  not  yet  well  defined. 

Pathology  of  the  Nervous  System The  study  of 

all  the  manifold  functions  of  the  nervous  system  must 
go  hand-in-hand  with  tlie  study  of  the  functions  of  the 
other  organs  of  the  body.  The  nervous  system  may 
be  considered  the  organ  whicli  connects  the  inner  life 
of  the  organism  with  the  outside  world.  One  class  of 
nerve  cells  or  so-called  neurons  receives  its  impulses 
from  the  outside.  The  functions  of  these  neurons 
must  be  studied  together  with  the  functions  of  the 
organs  of  sense,  and  it  would  lead  us  too  far  to  under- 
take such  a  study  here.  Neither  can  we  dwell  here  en 
the  vast  domain  of  functions  of  that  part  of  the  ner- 
vous system  which  is  treated  by  the  science  cf  normal 
and  pathological  psychology.  Neurons  of  the  third 
kind  are  those  which  transmit  the  impulses  recei\ed 
from  the  other  neurons  to  the  different  organs  of  the 
body,  the  functions  of  which  we  had  occasion  to  study 
before.  We  shall  have  to  consider  here  only  the  func- 
tions of  the  locomotor  apparatus.  The  locomotion  of 
an  organism  is  brought  about  by  two  kinds  of  organs, 
the  passive  ones— bones  and  joints,  the  role  of  which 
is  mechanical  and  need  not  be  dwelt  upon  here,  and 
the  active  one— muscles,  the  various  contractions  of 
which  bring  the  bones  and  joints  into  motion.  The 
function  of  a  muscle  is  so  fully  dependent  upon  the 
nervous  system,  that  functionally  a  muscle  fibre  may 
be  considered  simply  a  continuation  of  the  axis- 
cylinder  process  of  a  neuron.  The  joint  function  of 
the  muscular  and  nervous  system  gives  rise  to  two 
kinds  of  muscular  action.  The  first  is  a  simple  re- 
flex action.  In  certain  pathological  states  of  the 
nervous  system  this  action  may  be  abnormally  increased 
or  decreased,  or  it  may  even  cease  entirely.  Much 
more  important  to  the  organism  is  the  second  kind  of 
muscular  action,  the  so-called  co-ordinate  movements. 
There  are  regions  in  the  brain  in  which  the  axis- 
cylinder  process  of  one  neuron   transmits  its  impulse 


to  the  protoplasmic  processes  not  only  of  one  but  of  a 
number  of  sefcondary  neurons.  The  axis-cylinder  proc- 
esses of  the  latter  pass  within  the  spinal  cord  and 
leave  it  to  approach  the  corresponding  muscles.  .As 
a  result  the  neurons  of  the  so-called  motor  regions 
transmit  the  impulse  not  to  one  but  to  several  muscles, 
and  these  muscles  are  so  combined  that  the  organism 
is  enabled  to  perform  certain  rational  movements.  If 
the  nervous  impulse  ceases  because  of  some  abnormal- 
ity of  the  nerve  cell  in  the  brain  or  the  loss  of  con- 
tinuity of  the  axis-cylinder  process  in  the  spinal  cord, 
then  the  function  of  the  muscles  also  ceases,  they  be- 
come paretic.  Again,  whenever  neurons  of  the  motor 
region  become  over-irritated,  then  the  corresponding 
muscles  will  produce  contractions  unnecessary  for  the 
economy  of  the  organism;  we  will  see  different  kinds 
of  convulsions.  Kpilepsy  is  a  result  of  some  kind  of 
irritation  of  all  the  motor  regions  of  the  brain. 

Besides  the  abnormalities  in  the  special  functions 
of  the  different  neurons,  there  are  conditions  when  the 
nervous  system  as  a  whole  is  affected,  as  in  ana;mia 
of  the  brain,  its  increased  pressure  or  commotion. 
.Such  states  have  always  a  general  influence  on  the 
organism;  tiiey  produce  fainting,  vomiting,  slackening 
of  the  pulse  and  respiration,  general  convulsions,  and 
so  on.  "What  the  nature  of  this  general  influence  of 
the  nervous  system  on  the  whole  organism  is,  is  a 
question  which  cannot  yet  be  positively  answered. 
Possibly  these  actions  impair  somehow  the  supply  of 
food  to  the  nerve  cells,  or  else  poison  the  cells  by  un- 
eliminated  products  of  their  metabolism. 

Conclusion. — From  the  perusal  of  the  foregoing 
pages  we  can  easily  see  that  the  subject-matter  of 
pathological  physiology  resembles  closely  that  of  nor- 
mal physiology.  Both  are  dealing  with  the  differ- 
ent functions  of  the  organism.  Still  these  sciences 
are  by  no  means  identical.  While  normal  physiol- 
ogy studies  only  one  normal  type  of  the  functions, 
pathological  physiology  has  to  study  every  variation 
of  the  same  function.  This  makes  the  science  of 
pathological  pliysiology  more  complicated,  not  only 
because  every  function  may  become  abnormal  in 
different  ways,  but  also  for  the  reason  that  every 
change  in  the  function  of  one  organ  is  usually  ac- 
companied by  functional  changes  in  the  rest  of  the  or- 
ganism. 

The  study  of  this  science  must  necessarily  be  ex- 
perimental. Deductive  reasoning  on  the  basis  of  facts 
acquired  in  the  clinic  or  from  the  study  of  pathological 
anatomy  or  chemistry  alone  can  hardly  wholly  en- 
lighten us.  Every  diseased  organism  we  meet  with  in 
the  clinic  presents  abnormalities  in  a  number  of  its 
organs,  and  in  most  instances  we  are  unable  to  say 
what  organ  it  was  which  primarily  became  abnormal 
and  how  it  influenced  the  others.  Pathological  an- 
atomy and  chemistry  may  show  that  a  given  disease  is 
followed  by  certain  lesions  in  certain  organs,  but  this 
makes  a  certain  relation  between  these  two  factors  only 
probable.  In  order  to  change  this  probability  into 
certainty,  we  must  prove  that  a  certain  morphological 
lesion  produced  on  a  healthy  organ  of  an  animal  will 
be  accompanied  by  the  same  functional  abnormality 
that  we  saw  in  the  clinic. 

Neither  is  it  always  necessary  to  produce  a  certain 
morphological  lesion  on  an  organ  in  order  to  change 
its  function,  for  there  are  various  factors  which,  though 
leaving  the  organ  morphologically  unchanged,  make 
its  function  abnormal.  Once  the  function  has  become 
abnormal,  we  can  compare  it  with  functional  abnor- 
mality which  we  met  in  the  clinic,  and  also  study  the 
influence  of  this  abnormality  on  the  rest  of  the  organ- 
ism. But  to  change  at  will  the  conditions  of  existence 
of  an  organism  means  to  experiment.  Pathological 
physiology  is  a  science  of  functions,  of  dynamic  proc- 
esses, and  experimentation   alone  can   solve  its  prob- 


336 


MEDICAL    RECORD. 


[September  i,  1900 


lems.     Pathological  physiology  and  experimental  pa- 
thology may  be  then  considered  synonymous. 

In  applying  the  results  of  pathological  physiology 
to  medicine,  a  further  ditficulty  arises  from  the  fact 
that  we  can  only  very  seldom  experiment  on  a  human 
being.  The  objection  is  always  liable  to  be  urged 
that  no  experiment  on  an  animal  can  be  compared  with 
the  pathological  process  in  the  human  being,  as  their 
organizations  are  different.  There  is  certainly  some 
truth  in  this  assertion,  as  there  are,  for  instance, 
pathological  processes  that  we  are  as  yet  unable  to 
produce  in  an  animal  (acute  exanthemata,  tumors, 
etc.).  Some  factors  producing  a  pathological  process 
on  a  human  being  do  not  affect  an  animal,  and  vice 
versa.  Still  in  most  instances  we  have  a  perfect  right 
to  transfer  the  results  of  an  animal  experimentation 
to  the  study  of  human  pathology.  The  cardinal  func- 
tions of  the  corresponding  organs  are  the  same  in  all 
animals  with  a  higher  organization  ;  the  morphological 
features  of  the  organs  also  resemble  each  other  very 
closely.  If  we  then  produce  in  an  animal  the  same 
lesion' which  we  met  in  a  human  cadaver,  and  notice 
the  same  symptoms  which  we  saw  on  the  patient  be- 
fore his  death,  we  can  no  doubt  compare  the  results. 
This  is  the  wav,  for  instance,  that  all  the  results  in 
bacteriology  have  been  achieved.  Neither  must  we 
strive  always  to  experiment  on  animals  which  stand 
nearest  the  human  being  by  the  complicated  and  high 
development  of  their  organization,  but,  on  the  con- 
trary, more  use  should  be  made  of  lower  animals  than 
has  hitherto  been  done.  The  less  complicated  an 
organism,  the  less  complicated  its  functions  and  the 
easier  it  is  to  study  their  nature  and  causes.  From 
these  studies  it  will  then  not  be  difficult  to  pass  over 
to  more  complicated  phenomena. 

As  was  stated  above,  the  experiment  in  pathological 
physiology  consists  in  introducing  new  factors  to  act 
on  a  certain  organ.  But  as  our  aim  is  to  compare  the 
abnormal  function  which  we  have  produced  artificially 
with  the  one  met  in  some  diseased  organism,  the  fac- 
tors which  change  the  function  must  also  coincide  in 
both  instances.  In  other  words,  before  we  are  able 
to  study  the  pathological  physiology  of  a  certain  dis- 
ease process,  we  must  know  its  etiology,  and  as  the 
latter  is  frequently  unknown  we  must  start  our  study 
with  it.  After  an  abnormality  in  the  function  of  a 
certain  organ  has  been  produced,  we  must  also  study 
its  changed  morphological  and  chemical  composition 
in  order" to  be  able  to  compare  it  fully  with  the  cor- 
responding organ  of  a  diseased  organism. 

We  see  then  that  pathological  physiology,  though 
resembling  the  normal,  has  its  own  problems  and  uses 
its  own  line  af  experimentation  to  solve  them.  Be- 
sides this,  it  employs  certain  technical  methods  used 
in  pathological  anatomy  and  bacteriology  for  instance, 
but  not  used  in  normal  physiology.  Like  every  branch 
of  medicine,  pathological  physiology  is  closely,  we 
may  say  originally,  united  with  the  other  branches  of 
medicine.  It  may  be  considered  a  connecting  link 
between  normal  physiology,  pathological  anatomy, 
bacteriology,  and  pathological  chemistry  on  the  one 
hand,  and  the  clinic  and  hygiene  on  the  other.  Fed 
and  strengthened  by  the  development  of  the  former, 
it  becomes  indispensable  in  its  turn  not  only  for  prog- 
ress in  the  treatment  of  diseases,  but  not  less  so  for 
the  achievement  of  the  highest  aim  of  medicine,  the 
art  of  preventing  diseases.  Prevention  of  epidemics, 
immunization,  hygiene  of  food,  and  innumerable  other 
subjects  could  not  have  been  properly  developed  with- 
out pathological  physiology. 

A  Christian  Science  Expert  recently  fell  ill  in  a 
boarding-house  in  this  city  and  tried  to  unthink  the 
thought  that  annoyed  her.  She  was  so  successful  that 
an  ambulance  was'  called,  and  she  was  carried  to  the 
hospital  in  a  raving  delirium. 


THE  DISCOVERY  OF  "  UREINE,"  THE  PRIN- 
CIPAL ORGANIC  CONSTITUENT  OF  URINE 
AND   THE   TRUE   CAUSE   OF    UREMIA.' 

By   WILLIAM    OVIU    MOOR,    M.IX, 

NEW    VOKK. 

About  one  year  ago  I  began  studies  regarding  certain 
substances  which  could  be  easily  oxidized,  and  which 
gave  as  a  proof  of  their  easy  oxidizability  the  same 
characteristic  blue  reaction  with  a  solution  of  ferrocy- 
anide  of  potassium  and  ferric  chloride  as  we  observe 
when  morphine  or  any  of   its  salts  is  brought  in   con- 
tact with  a  solution  of  these  two  salts  of  iron.     To  my 
great  astonishment  I  found  that  the  human  urine  con- 
tained a  large   quantity   of   some  organic  substance, 
which  gave  this  interesting  blue  reaction  in  a  very  in- 
tense manner.     Numerous    and    exact    investigations 
forced  me  to  the  conclusion  that  none  of  the  known 
organic  or  inorganic  componenls-of  urine  could  account 
for  this  intense  blue  reaction,  and  that  therefore  some 
chemical  body  until  the  present  unknown  must  be  the 
cause  of  this  strange  phenomenon.   For  the   last  three 
months  I   labored  in  vain  to  find  and  to  isolate  this 
mysterious  body,  and  almost  gave  up  the  task  as  a  hope- 
less one,  when  at  last,  on  the  fifth  day  of  July,  1900,  I 
discovered  that  the  human  urine  contained  a  liquid 
organic  body,  in  a  quantity  superior  to  urea.     I  wish 
to  state  here  at  once,  that  this  organic  liquid   is  the 
most  characteristic  component  part  of  urine,  and  that, 
therefore,    I   shall   henceforward   designate   it  by  the 
name  of  "ureine."     It  is  not  surprising  that  the  ex- 
istence of  a  metabolism-product  of  such  great  impor- 
tance should  until  the  present  have  escaped  our  knowl- 
edge, for  every  urinary  analysis  has  been  made  with 
the  firmly  rooted  idea  that  urine  is  a  liquid  composed 
of  water  and  of  inorganic  solid  ingredients.     For  ob- 
vious reasons  it  must  be  evident   that  the  principal 
scope  of  this  communication  will  be  a  description  of 
the  method  to  be  employed  for  the  isolation  of  ureine; 
an  accurate  knowledge  of   its  physical  and  chemical 
characteristics  and  of  its  clinical  significance  in   rela- 
tion to  the  pathological  conditions  of  the  body  can  be 
only  the  outcome  of  careful  and  assiduous  investiga- 
tions by  serious  workers  all  over  the  world. 

In  isolating  this  organic  liquid,  two  principal  rules 
should  be  kept  in  view:  (i)  High  temperatures  must 
be  avoided.  (2)  Chemicals  should  be  used  as  little 
as  possible. 

The  urine  to  be  examined  for  its  liquid  organic 
component,  ureine,  should  be  put  in  a  large,  shallow, 
flat  recipient  and  evaporated  at  a  temperature  of  not 
over  50°  C.  .\s  soon  as  v/e  observe  that  there  is  no 
more  vapor  ascending  from  the  recipient,  we  treat  the 
remainder  of  the  liquid  with  a  strong  solution  of  silver 
nitrate  until  no  more  precipitate  is  formed.  We  now 
cool  off  the  liquid  sufficiently  to  promote  the  separa- 
tion of  the  saline  and  earthy  phosphates,  and  then 
filter,  washing  out  the  filter  once  or  twice  with  water, 
until  the  liquid  comes  out  perfectly  colorless.  The 
filtrate  is  now  put  into  a  small  cup,  which  should  be 
rather  deep,  and  heated  to  65°  C,  in  order  to  evaporate 
the  remaining  water.  New^  aqueous  vapor  will  be 
formed  but  soon  the  formation  of  vapor  will  cease, 
though  the  evaporation  may  still  continue  invisibly. 

To  determine  accurately  whether  or  not  the  rest  of 
the  liquid  contains  a  considerable  percentage  of  water, 
the  following  delicate  test  is  indispensable: 

A  large  mercury  thermometer  is  placed  in  the  liquid 
and  rapidly  withd'rawn  just  at  65'  C;  we  will  prob- 
ably see  a  puff  of  vapor  ascending  from  the  mercury 
bulb,  which  is  an  indication  that  the  remainder  of  the 
urine  still  contains  an  undesirable  quantity  of  water. 
This   procedure   is   repeated   at   short    intervals,   and 

'  Communication  presented  to  the  Ihirteenlh  Internalional 
Medical  Congress,  Paris,  1900. 


September  i,  1900] 


MEDICAL    RECORD. 


337 


finally  we  shall  arrive  at  a  point  when  there  is  no 
more  vapor  ascending  from  the  mercury  bulb.  We  now 
measure  the  quantity  of  liquid  which  remained  and 
add  to  it  one-half  of  its  volume  of  absolute  alcohol 
together  with  powdered  pure  oxalic  acid,  i  gm. 
for  each  100  c.c.  of  urine  used,  and  after  having  al- 
lowed the  newly  formed  oxalate  of  urea — (CH,N.,) , 
CjHjOO, — to  settle  completely,  we  carefully  add  a 
concentrated  alcoholic  solution  of  oxalic  acid  (which 
is  prepared  by  dissolving  3  gni.  oxalic  acid  in  10  c.c. 
of  hot  absolute  alcohol)  until  no  further  precipitate  is 
formed.  The  alcoholic  liquid  thus  obtained  is  filtered, 
the  filter  is  washed  out  once  or  twice  with  absolute  al- 
cohol, and  the  whole  is  now  exposed  to  a  temperature 
of  about  55°  C.  (but  not  over)  for  about  one  hour  or 
an  hour  and  a  half,  being  stirred  once  in  a  while  with 
a  horn  spoon  or  with  a  glass  rod.  To  facilitate  the 
separation  of  sulphates  and  of  the  other  remaining  solid 
ingredients  from  the  liquid  organic  constituent  of 
urine — ureine — we  now  reduce  the  rest  of  the  liquid 
to  a  low  temperature  and  filter  the  same,  freely  using 
cold  absolute  alcohol  to  facilitate  filtration.  There  is 
finally  nothing  but  ureine,  together  with  coloring- 
matters  left  in  the  recipient  (besides  the  alcohol,  of 
course).  To  separate  the  coloring-matters  from  the 
ureine,  the  alcoholic  solution  containing  both  must 
be  treated  carefully  with  a  saturated  solution  of 
nitrate  of  mercury — Hg(NO,J, —  until  no  further  pre- 
cipitate is  formed,  and  neutralized  with  carbonate 
of  sodium.  (It  is  advisable  then  to  add  a  sutificient 
amount  of  sodium  carbonate,  so  as  to  render  the 
liquid  slightly  alkaline.)  Filter  again  and  evap- 
orate carefully,  resorting  to  a  temperature  of  not  over 
55°  C.  We  have  thus  obtained  ureine,  the  liquid 
organic  component  of  urine,  that  mysterious  chemical 
body  which  is  the  cause  of  the  intense  blue  reaction 
resulting  from  urine  and  a  solution  of  red  prussiate  of 
iron  and  perchloride  of  iron.  Ureine  resembles  in 
aspect  olive  oil,  is  of  a  pale  yellow  color,  of  a  slightly 
bitter  taste,  gives  to  the  touch  the  impression  of  a  fatty 
substance,  and  produces  on  paper  spots  resembling  fat 
spots,  though  not  so  marked  as  those  produced  by  fat. 
Its  specific  gravity  is  about  1.270;  it  is,  therefore, 
much  heavier  than  water  and  about  as  heavy  as  glycer- 
in. It  is  freely  miscible  in  all  proportions  with  water 
and  alcohol,  whether  these  latter  are  of  a  neutral,  acid, 
or  alkaline  reaction;  it  is  barely  soluble  in  ether.  Its 
own  reaction  is  very  slightly  alkaline,  almost  neutral. 
My  preliminary  investigations  have  led  me  to  the  con- 
clusion that  this  organic  metabolism-product  of  the 
human  body  belongs  to  the  group  of  alcohols  of  the 
aromatic  series;  at  a  temperature  of  about  80*^  C.  it  be- 
gins to  split  into  several  bodies  belonging  to  the  class 
of  aromatic  oxy-acids,  and  if  heated  to  about  150°  C. 
it  leaves  behind  pure  carbon.  This  organic  liquid 
has  a  characteristic  odor;  in  fact,  it  is  this  constituent 
of  urine  which  is  the  cause  of  its  specific  odor. 
Rubbed  into  the  skin  it  soon  produces  a  sensation  of 
slight  burning;  there  can  be  no  doubt,  therefore,  that 
it  is  the  principal  cause  of  the  irritating  qualities  of 
urine.  One  of  the  most  remarkable  characteristics 
of  ureine  is  its  ability  to  take  up  large  quantities  of 
oxygen  witu  great  facility.  The  quantity  of  50  c.c.  of 
the  average  human  urine  can  deoxidize  1  gm.  of  potas- 
sium permanganate,  and  one  sample  of  urine  taken 
from  a  woman  in  the  ninth  month  of  pregnancy  deoxi- 
dized with  great  rapidity  over  4  gm.  of  permanganate 
to  each  100  c.c.  of  urine;  this  urine  was  voided  about 
five  o'clock  in  the  aftefnoon,  was  of  an  intense  yellow- 
color,  and  of  a  specific  gravity  of  1.030;  it  contained 
about  2-'i  per  cent,  (by  volume)  of  ureine.  It  is  im- 
portant to  remember  that  the  power  of  urine  to  take  up 
oxygen  does  not  depend  only  on  the  quantity  of 
ureine  present,  but  to  a  greater  extent  on  the  quality 
of  the  ureine,  on  some  intrinsic  peculiar  force  inherent 


in  this  wonderful  organic  liquid;  I  have  seen  urine, 
containing  less  ureine  than  did  other  samples  of 
urine,  absorb  more  oxygen  than  did  the  latter  samples 
which  were  richer  in  ureine,  and  especially  strong  was 
this  power  of  absorption  in  the  urine  of  a  pregnant 
woman.  Urine  which  has  been  subjected  for  some 
length  of  time  to  a  temperature  of  7o°-8o"  C.  loses  in 
a  great  measure  its  capacity  of  taking  up  oxygen,  and 
when  exposed  to  90°  C.  for  about  half  an  hour  it  loses 
seventy-five  per  cent,  of  its  absorptive  power.  It  does 
not  take  up  all  at  once  all  the  oxygen  which  it  is  able* 
to  absorb,  but  does  so  with  great  avidity  in  the  begin- 
ning, and  gradually  takes  up  less  and  less  during 
equal  periods  of  time;  its  capacity  of  absorbing  oxygen 
is  not  wholly  extinguished  before  a  lapse  of  four  or 
five  weeks. 

Ureine  surpasses  urea  as  regards  quantity  ;  thus  far  I 
have  found  that  it  is  present  in  a  quantity  double 
that  of  urea.  The  greatest  amount  of  ureine  is  con- 
tained in  urine  voided  between  5  and  7  p.m.  On  July 
ir,  1900,  I  examined  the  urine  of  a  diabetic  woman 
and  found  six  per  cent,  of  ureine  and  only  2.1  per 
cent,  of  urea;  the  urine  was  voided  about  6  p.m., 
specific  gravity  1.025,  total  amount  in  twenty-four 
hours  1,250  c.c.  The  same  woman  gave  me  a  sample 
of  her  urine  on  July  i8th,  at  nine  o'clock  in  the  morn- 
ing; this  time  I  found  only  2.3  per  cent,  of  ureine. 
In  the  case  of  a  pregnant  woman  (eighth  month  of 
pregnancy)  I  found  on  some  days  only  one  per  cent.; 
on  other  days,  especially  when  she  had  worked  a  good 
deal  and  had  felt  unusually  well,  I  found  almost  three 
per  cent,  of  ureine;  on  one  occasion,  June  loth,  I  had 
found  only  0.6  per  cent,  of  urea  in  a  sample  of  her 
urine  voided  about  noon.  In  the  urine  of  an  elderly 
man  about  sixty  years  old,  I  found  four  per  cent,  of 
ureine  by  volume;  his  urine  was  markedly  yellow,  of 
a  rather  strong  odor,  of  a  markedly  acid  reaction,  and 
of  a  specific  gravity  of  1.030.  The  urine  of  a  middle- 
aged  man,  thirty-five  years  old,  suffering  from  polyuria, 
contained  two  per  cent,  ureine.  This  urine  was  voided 
on  July  i2th,  at  8:30  a.m.;  its  reaction  was  markedly 
acid,  its  specific  gravity  1.017  J2  ;  the  total  amount  of 
urine  formed  in  twenty-four  hours  was  3,500  c.c;  the 
entire  quantity  of  ureine  excreted  in  twenty-four  hours 
must  have  been  at  least  70  c.c.  but  was  probably  about 
80-90  c.c,  weighing  100-115  gm.  A  sample  of  urine 
from  the  same  man,  received  on  May  22d  about  9  p.m., 
contained  only  0.5  per  cent,  of  urea,  corresponding  to 
17-18  gm.  of  urea  in  twenty-four  hours. 

It  is  self-evident  that  the  enumeration  of  even  a 
greater  number  of  isolated  cases  can  afford  no  clew  as 
to  the  clinical  and  pathological  importance  of  ureine. 
The  more  gratifying  must  it  be  to  us,  as  physicians, 
that  at  least  in  one  respect  the  pathological  significance 
of  ureine  is  clearly  established.  It  was  to  be  expected 
a  priori  that  the  principal  organic  constituent  of  urine 
should  be  the  true  cause  of  those  complex  toxic  symp- 
toms which  have  been  designated  by  the  collective 
name  of  "  uramia,"  and  which  are  quite  frequently  in- 
cidental to  the  puerperal  state,  after  all  the  other  or- 
ganic and  inorganic  components  of  urine  failed  to  ac- 
count for  these  terrible  toxic  phenomena.  A  few 
exjjeriments  on  rabbits  have  fully  demonstrated  the 
truth  of  this  a  priori  conclusion.  Several  of  these 
animals,  each  weighing  over  i  kgm.,  have  succumbed 
after  three  to  eight  hours  from  subcutaneous  injections 
of  3J'2  to  4'j  c.c.  of  ureine.  For  the  present  I  shall 
give  the  results  of  only  one  of  these  experiments,  the 
others  closely  resembling  the  one  mentioned: 

On  July  22d,  at  4.10  p.m.,  I  injected  subcutaneously 
into  the  dorsum  of  a  lively  black  rabbit,  weighing  about 
I  kgm.,  3^  c.c.  of  ureine  obtained  from  the  urine  of  a 
pregnant  woman  in  the  ninth  month  of  her  pregnancy. 
Immediately  after  the  injection  the  animal  lay  motion- 
less for  several  minutes,  evidently  prostrated;   in  a  few 


338 


MEDICAL    RECORD. 


[September  i,  1900 


minutes  the  rabbit  made  slowly  a  few  steps;  it  seemed 
excited,  but  soon  afterward  was  again  prostrated;  it 
tried  to  hide  itself  with  the  head  resting  against  a 
pillar,  the  hind  legs  stretched  out,  and  the  ears  Hat; 
the  respirations  were  124  per  minute  (at  4:40  p.m.). 
At  5  P.M.,  the  animal  was  still  motionless,  ears  flat 
(as  in  cases  of  morphine  poisoning),  bladder  and  rec- 
tum relaxed.  At  5  :so  p.m.  the  animal  presented  a  pic- 
ture of  complete  prostration  ;  it  lay  flat  on  its  abdomen 
with  the  head  flat  on  the  floor,  eyes  closed,  forelegs 
'stretched  out ;  it  paid  no  attention  to  food  placed  by 
its  mouth,  did  not  stir  when  approached,  hut  twitched 
once  in  a  while;  the  respirations  were  88  per  minute, 
rather  labored.  At  6  p.m.  the  rabbit  lay  on  its  side; 
lOur  minutes  later  it  jumped  up  and  had  a  short  gen- 
eral convulsion,  turned  around  slowly  in  a  circle  twice 
or  three  times.  At  6  :o5  p.m.  the  animal  lay  on  its  right 
side,  evidentl)'  m  extremis.  At  6:17  the  respiration 
was  very  labored,  difficult;  now  and  then  convulsive 
movements  occurred.  At  6:25  the  respirations  were 
63  per  minute.  At  6:30  p.m.  the  animal's  eyes  were 
turned  for  one  moment,  the  white  of  the  eyes  only  be- 
ing visible;  the  aspect  of  the  animal  was  like  one 
dead,  except  for  slow,  shallow  respirations — a  perfect 
picture  of  urasmic  coma;  now  and  then  there  was  a 
spasmodic  twitching  of  the  legs.  About  6:45  p.m. 
there  were  long-continued  general  convulsions  with 
opisthotonos,  the  animal  being  stretched  out  in  a  semi- 
circle from  one  end  of  the  body  to  the  other.  After 
the  convulsion  the  animal's  respirations  were  30  per 
minute,  spasmodic;  it  opened  and  shut  its  mouth  with 
each  act  of  respiration,  gasping  for  breath.  At  7:06 
P.M.  it  gasped  at  long  intervals,  and  at  7:13  p.m.  the 
animal  was  dead. 

Lack  of  time  forces  me  to  conclude  this  paper,  but 
before  doing  so  I  wish  to  state  that  ureine  is  the 
principal  cause  of  the  ammonical  fermentation  of 
urine,  as  without  its  presence  urea  cannot  be  decom- 
posed into  ammonia  and  carbon  dioxide.  Neither 
Pasteur's  micrococcus  urea,  nor  Leube's  bacterium 
urea;,  nor  any  other  micro-organism  is  able  to  change 
urea;  in  fact,  in  many  respects  urea  is  just  as  inde- 
structible as  iron,  silver,  or  any  other  elements,  for 
the  strongest  mineral  acids  do  not  decompose  it,  but 
simply  combine  with  it.  Only  a  temperature  of  above 
130''  C,  perhaps  140°  C,  can  split  urea  into  ammonia 
and  carbon  dioxide.  Ureine  is  therefore  a  ferment, 
which  has  a  potential  energy  of  at  least  130°  C.  U'ith- 
out  ureine  all  organic  matter  would  become  converted 
into  urea,  which  would  remain  in  nature  without  any 
use,  and  thus  within  a  limited  period  of  time  all  vege- 
tation and  animal  as  well  as  human  life  would  cease. 

Truly,  this  wonderful  organic  fluid  deserves  our 
closest  attention  and  study,  and  I  hope  that  my  feeble 
efforts  will  give  some  impulse  toward  detailed  re- 
searches, which  may  in  the  near  future  bring  us  to  a 
full  understanding  of  ureine  and  of  its  significance  in 
relation  to  the  science  of  medicine. 

KoME,  Italy,  Piazza  Monte  Citorio,  121. 


Actual  Experience  with  Wounds  Inflicted  by 
Modern  Military  Projectiles  vs.  Theory.  — C.  B. 
Nancrede  disputes  the  conclusions  of  many  of  the 
recent  writers  on  this  subject,  some  of  whom  he 
claims  "never  set  foot  out  of  the  country,  and  who 
never  heard  a  bullet  whistle."  He  details  at  some 
length  his  views  as  to  theories  of  ballistics,  and  claims 
that  while  at  short  ranges  deflection  of  the  missile  is 
not  common,  yet  at  the  ranges  at  which  most  wounds 
are  received  it  does  occur  much  more  frequently  than 
is  usually  taught.  He  does  not  believe  that  results  ob- 
tained from  bullet  wounds  on  the  cadaver  are  the  same 
as  tho.se  produced  by  bullets  shot  into  living  tissues. 
It  is  a  palpable  mistake  to  suppose  that  a  bullet  fired 


into  a  deaii  body  necessarily  will  produce  the  same 
effects  as  when  living  tissues  are  concerned,  because 
the  liquid  fat  of  the  medulla  and  cellular  tissue  be- 
comes converted  into  a  soft,  solid  mass  by  the  loss  of 
the  body  heat,  the  skin  loses  its  elasticity  as  well  as 
support  afforded  by  the  dense  fascire  rendered  tense  by 
muscular  action,  while  other  patent  changes  also  oc- 
cur. The  lessened  mortality  in  recent  wars  is  due 
especially  to  the  "first-aid  "  package  with  which  the 
combatants  are  supplied.  \Vithout  this,  the  results 
now  would  be  practically  the  same  as  during  the  times 
before  the  packet  was  used.  When  distinct  indica- 
tions do  not  exist  for  meddling,  the  best  primary  treat- 
ment for  modern  ball  wounds  of  joints  is  antiseptic 
occlusion  and  fixation,  to  be  followed  by  antiseptic  in- 
cision, exploration,  removal  of  infected  foreign  bodies, 
fragments  of  bone,  etc.,  and  the  maintenance  of  free 
drainage,  when  the  occasion  requires,  not  merely  to 
meet  a  theoretical  possibility  which  may  never  mate- 
rialize.—  I'oledo  Medical  and  Surgical Kepoi'ler,  August, 
1900. 

Treatment  of  Fungoid  Otitis  Media. — A.  Bonain 
secures  local  anaesthesia  by  means  of  a  mixture  of 
mentho-phenol  cocaine,  observes  rigid  antisepsis,  and 
carefully  cleanses  the  ear.  The  fungosities  are  then 
removed  with  snare,  forceps,  and  curette.  The  field  of 
operation  is  then  re-ana;sthetized  and  carefully  dried. 
For  cauterization  he  employs  for  small  areas  pure 
chloride  of  zinc,  and  for  larger  ones  the  same  salt  in 
ten-  or  twenty-per-cent.  solution.  Following  cauteri- 
zation the  ear  is  irrigated  with  sterile  water  and  lightly 
packed  with  iodoform  gauze. — Rei'iie  Hcbdomadaire  de 
La ry/igo logic.  July  21,  igoo. 

Does  a  Cerebral  Abscess  of  Otitic  Origin  Ever 
Disappear  Spontaneously  ? — Koepke  sa}s  that  the 
course  of  an  otitic  cerebral  abscess  is  regularly  acute 
or  subacute.  In  many  cases  the  pus  opens  into  the 
ventricles  or  on  the  meninges  after  some  days  or 
weeks,  and  proves  fatal.  It  is  not  rare,  however,  that 
the  course  is  slow  and  that  the  purulent  formation 
ceases,  and  the  virulence  of  the  infection  may  then  be 
so  light  that  a  limiting  wall  will  form.  If  the  cerebral 
tissue  surrounding  the  abscess  is  in  nearly  a  normal 
condition,  absorption  can  occur,  although  a  case  pre- 
senting exactly  these  conditions  has  never  been  ob- 
served. The  membrane  limiting  the  purulent  focus 
may  undergo  calcareous  degeneration,  but  it  is  not 
known  whether  the  contents  of  the  abscess  undergo 
the  same  change  or  not.  Cysts  have  been  discovered 
in  the  brain  of  persons  who  have  had  purulent  otitis, 
and  certain  authors  have  considered  them  as  of  otitic 
origin. — La  L^ratiqiie  Medicale,  June  15,  1900. 

Myotherapy Nathan  Herman  holds  that  mas- 
sage is  indicated:  (i)  P'or  the  removal  of  exudates  or 
infiltrations,  wliich  it  does  by  causing  their  absorption, 
to  overcome  stases,  and  to  reestablish  a  more  active 
local  circulation ;  (2)  for  the  after-treatment  of  frac- 
tures; (3)  for  the  treatment  of  some  forms  of  paralysis. 
Various  forms  of  exercise  are  indicated  for  the  correc- 
tion of  deformities,  especially  of  the  spine,  t'horea, 
writer's  cramp,  cerebral  congestion,  indigestion,  con- 
stipation, neurasthenia,  anaemia,  chlorosis,  threatened 
or  incipient  phthisis,  malnutrition,  obesity,  rheumatism 
are  some  of  the  disorders  benefited  by  myotherapy. 
Gymnastics  and  athletics  offer  a  vast  field  and  an  end- 
less diversity  of  application,  especially  in  the  preven- 
tion of  disease  by  the  enhancement  of  vital  resistance. 
Especially  noticeable  among  the  efl'ects  of  exercise  are 
the  enlargement  of  the  thorax  and  the  increase  in 
costal  mobility,  thus  creating  conditions  which,  if 
they  do  not  preclude  pulmonary  diseases,  at  least 
render  their  attacks  less  nocuous  and  fatal. — Marylatui 
Medical  Journal,  August.  1900. 


September  i,  1900] 


MEDICAL    RECORD. 


339 


Medical  Record: 

A    Wcck/y  Journal  of  Medicine  and  Surgery. 


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


I'fBLISHERS 


WM,   WOOD  &.  CO,,  51    Fifth  Avenue. 


New  York,  September  i,  1900. 


RECENT      VIEWS      ON      THE     EFFECTS     OF 
ALCOHOL. 

The  conclusion  reached  by  Professor  Atwater,  as  a 
result  of  experiments  conducted  by  him  last  year  to 
determine  the  effects  of  alcohol  on  the  human  system, 
that  the  substance  taken  in  small  quantities  and  under 
certain  conditions  is  a  food,  has  given  rise  to  much 
and  bitter  discussion.  The  garbled  accounts  given 
in  the  newspapers  of  Dr.  .\t\vater's  findings  are 
chiefly  responsible  for  this  state  of  affairs.  Many  of 
these  journals  proclaimed  that  the  professor  had 
proved  alcohol  as  a  beverage  to  be  harmless,  whereas 
in  fact  he  went  no  f  irther  than  to  declare  that  it  is 
oxidized  in  the  same  manner  as  any  other  food  ma- 
terials, and  is  transformed  into  heat  and  muscular 
energy.  The  experiments  were  not  sufficiently  pro- 
longed to  demonstrate  what  the  effects  might  be  upon 
the  human  organism  of  the  habitual  use  of  alcohol,  nor 
was  any  attempt  made  to  show  that  such  use  would  be 
anything  but  harmful. 

Another  pronouncement  on  the  same  question  has 
been  recently  made  by  the  well-known  \'iennese 
clinician.  Prof.  Max  Kassowitz,  who  asserts  that  the 
dogma  concerning  the  nourishing  and  strengthening 
character  of  alcohol  is  one  of  the  fatal  errors  of  science. 
He  holds  the  view  that  the  majority  of  physicians 
take  up  an  inconsistent  position  with  regard  to  the 
use  of  alcohol,  for  the  reason  that  while  they  are 
well  aware  of  its  dangerous  and  poisonous  qualities, 
they  nevertheless  contribute  to  making  permanent  the 
false  ideas  concerning  the  value  and  effects  of  alcoiiol 
which  are  so  generally  disseminated.  Kassowitz  ex- 
plains these  inconsistencies  on  the  ground  that  the 
teaching  which  considers  alcohol  a  food  because  it  is 
burned  in  the  organism,  has  held  its  ground  in  spite 
of  many  disregarded  newer  investigations  which  have 
shown  its  indefensibility.  He  is  therefore  of  the 
opinion  that  the  assumption  ascribing  food  properties 
to  alcohol  based  on  simple  theoretical  consideration 
is  a  grave  scientific  error,  the  removal  of  which  is  the 
most  important  preliminary  condition  to  an  effectual 
battle  against  alcoholism. 

Dr.  Hermann  Blocher,  of  Basle,  .Switzerland,  in  an 
article  in  the  Internationale  Monatsscliriji  Jiir  die  Be- 
l;aiiipjung  der  Trinksitten  for  April,  comments  very 
favorably  upon  Professor  Kassowitz's  utterances,  and 
discusses  the  matter  from  the  standpoint  of  physiologi- 


cal experiment.  He  refers  to  the  investigations  of 
Miura,  which  indicate  that  alcohol  belongs  to  the 
same  group  of  substances  as  glycerin,  lactic  acid, 
butyric  acid,  and  so  forth,  which  are  indeed  burned  in 
the  animal  body,  but  which  nevertheless  are  not  fit, 
even  to  the  smallest  extent,  to  take  the  place  of  neces- 
say  food  in  the  preservation  of  the  body.  Miura 
found  that  the  addition  of  alcohol  to  the  food  before 
its  being  taken  not  only  causes  no  diminution  of  the 
nitrogen  output,  and  does  not  prevent  the  loss  of  body 
material  (as  is  the  case  with  the  addition  of  sugar 
or  fat),  but  that  on  the  contrary  the  nitrogen  output 
following  this  addition  of  alcohol  may  become  yet 
greater  than  it  had  been  without  this  addition. 

Professor  Atwater  did  not  pretend  in  his  experi- 
ments to  prove  the  innocuousness  of  alcohol  as  a  bev- 
erage, and  it  was  due  to  the  newspapers  that  such  a 
belief  was  disseminated.  Whether  alcohol  in  small 
amounts  and  used  with  discretion  is  harmful  has  yet 
to  be  clearly  proved. 


CONSERVATISM    IN    THE   TREATMENT    OF 
APPENDICITIS. 

Thkre  are  several  gradations  of  opinion  on  the 
question  of  when  to  operate  in  cases  of  acute  appendi- 
citis, and  whether  in  all  cases  operation  is  the  best 
treatment.  Those  who  hold  the  most  radical  views 
believe  that  an  operation  should  be  undertaken  as  soon 
after  the  diagnosis  is  made  as  is  possible,  and  various 
arguments  and  statistics  are  brought  to  bear  in  order 
to  justify  this  attitude.  .Another  group  of  observers 
believe  that  it  is  better  to  wait,  especially  in  first  or 
mild  attacks,  until  there  is  some  specific  reason  for 
operative  intervention,  of  which  several  may  exist 
when  the  patient  is  first  seen,  or  may  occur  during  the 
period   in    which   the   patient   is     under   observation. 

These  observers  are  of  the  opinion  that  practically 
every  case  of  appendicitis  must  sooner  or  later  come 
to  operation,  if  not  on  account  of  rapid  development 
of  threatening  symptoms  in  the  first  attack,  then  dur- 
ing a  recurrent  manifestation  or  in  the  period  of 
ciuiescence.  We  might  add  a  third  class  of  observers 
who  are  perhaps  fond  of  being  called  "conservative," 
and  who  think  tliat  at  least  a  fair  proportion  of  cases 
of  appendicitis  result  in  recovery  without  operation, 
and  that  an  appreciable  number  of  patients  do  not 
again  suffer  from  the  disease. 

-Accumulating  evidence,  clinical  and  pathological, 
has  very  nearly  driven  this  view  of  the  matter  into  its 
last  ditch,  and  it  is  hardly  necessary  to  say  more  than 
that  patients  who  have  had  appendicitis  are  never  cured 
without  operation,  though  they  may  be  free  from 
symptoms  for  a  long  time,  and  that  one  true  attack  of 
the  disease,  well  marked  enough  to  cause  definite 
symptoms,  invariably  leaves  the  appendix  in  a  condi- 
tion which  predisposes  to  subsequent  attacks.  The 
attitude  of  those  who  hold  the  views  outlined  in  our 
second  grouping  have  apparently  a  position  of  con- 
siderable justification,  both  from  the  evidence  of  the 
statistics  of  this  disease  and  from  the  state  of  mind, 
usually  present,  which  makes  us  assume  that  we  ought 


340 


MEDICAL    RECORD. 


[September  i,  1900 


to  relieve  our  patients  with  as  little  surgery  as 
possible,  as  a  matter  of  general  principle.  It  is,  how- 
ever, undoubtedly  a  fact  that  the  observers  who  are  in 
a  position  to  see  and  treat  most  cases  of  appendicitis 
are  more  and  more  coming  to  believe  thoroughly  that 
no  case  of  the  disease  which  results  in  recovery  from 
an  attack  without  operation  is  ever  safe  from  another 
attack ;  in  other  words,  as  we  have  noted  above,  that  true 
non-operative  cure  is  impossible,  and  furthermore  that 
in  many  instances  the  attacks  increase  in  severity.  It 
is  quite  true  that  many  attacks  can  be  tided  over  with- 
out operation,  but  this  does  not  cure  the  patients,  and 
what  passes  for  conservatism  is  then  too  often  timidity, 
indecision,  or  ignorance.  Those  who  are  most  radi- 
cal in  their  views  form  a  group  which  is  receiving  con- 
stant accessions  of  men  who  are  generally  inclined  to 
be  aggressive  in  their  advocacy  of  what  they  think  is 
right,  and  are  pretty  successful  in  supporting  them- 
selves with  logic  and  statistical  material.  Their 
position  involves  acceptance  of  the  following  state- 
ments: that  appendicitis  is  always  a  grave  and  im- 
portant disease;  that  it  is  never  cured  spontaneously ; 
that  the  attacks  are  very  apt  to  increase  in  severity ; 
that  the  course  of  an  individual  attack  involves  several 
important  elements  of  uncertainty;  that  there  is  no 
real  non-operative  treatment  of  the  disease,  though  the 
symptoms  can  be  mitigated  and  temporarily  removed; 
and  that  operative  treatment  in  competent  hands,  un- 
dertaken at  the  proper  time,  gives  an  exceedingly  small 
mortality  figure,  which  is  unquestionably  becoming 
still  smaller  and  is  unapproached  by  any  form  of  non- 
operative  treatment.  The  interval  between  the  begin- 
ning of  the  attack  and  the  operation  is  of  the  greatest 
importance  in  the  prognosis,  and  no  hard-and-fast  rule 
can  be  made,  but,  in  general  terms,  the  more  severe  the 
attack  the  sooner  should  an  operation  be  done.  The 
"proper"  time  may  be  within  two  or  three  hours  of  the 
attack,  and,  according  to  the  most  radical,  is  rarely 
beyond  twenty-four. 

Now  the  views  embodied  in  these  statements  seem 
at  first  sight  extremely  radical,  and  their  diffusion 
and  general  acceptance  are  encountering  a  good  deal 
of  the  inertia  of  "conservatism,"  but  this  is  bound  to 
be  gradually  overcome,  and  then  the  treatment  of  ap- 
pendicitis will  be  looked  upon  purely  as  a  surgical 
question,  with  the  details  of  time  and  place  to  be  de- 
cided promptly  by  tlie  surgeon.  When  we  reach  this 
state  of  affairs,  there  will  be  a  still  fupther  reduction 
in  the  mortality  figures  from  this  very  important  and 
common  disease,  fewer  operations  under  desperate 
conditions,  and  much  less  chance  of  ventral  hernias 
on  account  of  necessarily  large  incisions  in  these  same 
desperate  cases.  It  will  never  be  necessary  nor  wise 
to  try  to  promulgate  the  rule  that  all  cases  should  be 
operated  upon  within  twenty-four  hours  of  the  begin- 
ning of  the  attack,  for  there  are  often  cases  which  do 
not  demand  operation  so  immediately  and  so  strenu- 
ously; though  even  under  such  circumstances  the  idea 
must  not  be  to  avoid  operation  altogether,  but  to  choose 
the  most  favorable  time  at  which  to  operate,  either 
during  the  present  attack  in  the  period  of  quiescence, 
or  when  the  next  attack  occurs,  the  last  the  less 
desirable.     The  true  conservatism  in  treating  patients 


with  appendicitis  consists  in  knowing  when  to  operate 
upon  a  condition  which  sooner  or  later  is  certain  to 
demand  operative  intervention,  and  in  carrying  out 
this  intervention  promptly  and  intelligently.  It  is 
not  conservative  to  trust  to  luck  that  each  particular 
case  is  not  One  in  which  surgery  must  be  called  upon 
for  help,  and  to  make  an  inefficient  attack  upon 
the  symptoms,  hoping  that  somehow  the  patient  will 
survive. 


LUSTIG'S    PLAGUE   SERUM. 

A  Bo.MBAY  physician  reports  to  the  Lancef,  of  July 
28th,  a  series  of  observations  made  on,  and  the 
results  from  the  use  of,  Lustig's  plague  serum.  The 
first  series  of  observations  lasted  from  March  to 
November,  1898,  and  again  from  February  to  May, 
1899.  During  the  course  of  this  period  four  hundred 
and  three  patients  received  the  serum  treatment  and 
eleven  hundred  and  ninety  patients  were  treated  by 
ordinary  methods.  The  clinical  effects  of  the  serum 
were  watched  from  day  to  day,  and  although  in  some 
very  grave  and  advanced  cases  the  patients  ultimately 
succumbed,  the  immediate  effects  on  the  general  con- 
dition of  the  patients  were  extremely  well-marked,  in- 
dicating either  that  the  dose  of  the  serum  was  too 
small,  or  that  it  was  not  strong  enough,  or  that  the 
treatment  was  commenced  too  late.  On  the  whole, 
however,  the  improvement  was  quite  perceptible  and 
gratifying.  \\'hen  at  the  termination  of  these  observa- 
tions the  results  were  tabulated,  it  was  found  that  the 
serum-treated  cases  had  a  recovery  of  38.2  per  cent., 
whereas  that  in  those  not  so  treated  was  19.5  per  cent, 
only.  The  second  series  of  observations  was  com-' 
menced  in  May,  1899.  The  object  with  which  this 
series  >vas  started  was  to  determine  the  statistical 
value  of  the  serum,  and  hence  it  was  resolved  to  con- 
duct observations  on  one  thousand  cases  of  plague, 
five  hundred  to  be  treated  with  the  serum  and  five 
hundred  by  ordinary  methods,  the  latter  acting  as 
controls,  and  the  cases  were  to  be  taken  for  treatment 
alternately  in  the  order  of  admission  and  without  any 
attempt  of  exclusion  of  any  sort.  But  objection  to  this 
method  of  treatment  was  the  preponderance  of  either 
moribunds  or  convalescents  in  either  set  vitiating  the 
final  results.  It  was,  however,  anticipated  that  in  two 
such  large  sets  of  five  hundred  each  these  would 
equalize  at  the  end,  and  thus  no  undue  advantage 
would  accrue  to  one  side  or  the  other.  Further,  in 
order  to  arrive  at  strict  accuracy  and  to  eliminate  all 
errors,  some  standard  had  to  be  fixed  as  to  what  cases 
should  be  classed  as  moribunds  and  what  as  convales- 
cents. It  was  therefore  determined  to  fix  the  limit  for 
the  former  at  twent3'-four  hours,  and  all  patients  dying 
within  twenty-four  hours  of  admission  were  consid- 
ered moribund ;  but  as  it  was  subsequently  found  that 
a  large  number  died  between  twenty-four  and  twenty- 
seven  hours  of  admission,  twenty-seven  hours  was 
adopted  as  the  standard.  As  regards  convalescents 
all  those  that  had  gone  over  the  acute  stage  of  the 
disease  and  had  a  normal  temperature  or  thereabouts, 
and  had  suppurating  or  suppurated  open  buboes,  were 
considered  convalescents. 


September  i,  igoo] 


MEDICAL    RECORD. 


341 


The  results  of  these  observations  were  as  follows: 
Up  to  the  end  of  June  480  cases  had  been  treated  with 
serum  and  480  cases  had  become  controls.  Of  the 
serum  cases  328  patients  died,  152  recovered;  per- 
centage of  recovery  31.67.  Of  the  control  cases  382  pa- 
tients died  and  98  recovered;  percentage  of  recovery 
20.42.  The  showing  is  even  better  if  the  moribunds 
and  convalescents  are  eliminated  from  either  series. 
The  results  then  stand  thus :  Serum  cases,  313;  patients 
died,  189;  recovered,  124;  percentage  of  recovery, 
39.62.  Control  cases,  297;  patients  died,  237;  re- 
covered, 60;  percentage  of  recovery,  20.21,  showing  a 
difference  of  ig.o8  percent,  in  favor  of  serum.  These 
facts  are  vouched  for  by  the  chief  medical  officer  of 
one  of  the  Bombay  hospitals,  and  would  appear  to 
indicate  in  the  clearest  possible  manner  the  value  of 
the  serum  treatment  of  plague  in  general  and  of  the 
use  of  Lustig's  serum  in  particular. 


^eius  of  tttc  'Wicck. 

A  School  of  Embalming  is  about  to  be  established 

in  London,  "  under  American  patronage."  as  the  ad- 
vertisement reads. 

The  International  Language  of  the  Future. — A 
writer  in  the  Tribune  states  that  Dr.  Dietz,  of  the  Ber- 
lin University,  in  a  lecture  before  the  Prussian  Acad- 
emy of  Science,  has  declared  his  belief  that  English 
is  undoubtedly  the  world  language  of  the  future.  Ac- 
cording to  the  London  Daily  Neivs,  the  professor  points 
to  the  wonderful  diffusion  of  the  English  language 
through  Great  Britain  and  her  colonies  and  the  United 
States,  a  circumstance  which  in  itself  constitutes  a 
great  claim  to  a  still  more  pre-eminent  position  among 
the  languages  of  the  world.  But,  apart  from  its  politi- 
cal prestige,  English,  thinks  the  professor,  is  remark- 
ably adapted  by  its  very  structure  to  be  the  U'cll- 
spraclh-.  It  has  freed  itself  from  all  superfluous  ballast 
of  declensions  and  conjugations  and  genders.  By  its 
fusion  of  the  Germanic  and  Latin  elements  it  repre- 
sents "  two  principal  streams  of  culture."  "  The  young 
Englishman,"  says  Dr.  Dietz,  ''  unconsciously  from 
early  childhood  amalgamates  valuable  elements  of 
cultivation  dating  back  one  thousand  years  in  his 
Germanic-Roman  mixed  speech  which  every  other 
nation  only  acquires  with  great  pains  and  at  great  ex- 
pense." 

Quarantine  in  the  Philippines Passed  Assistant 

Surgeon  Perry,  chief  quarantine  officer  for  the  Philip- 
pine Islands,  has  recently  completed  an  inspection  of 
Philippine  ports  of  entry  with  reference  to  quarantine 
service.  As  a  result  of  the  investigation  he  recom- 
mends that  as  vessels  come  direct  from  Hong  Kong 
to  Iloilo,  and  the  distance  from  there  to  Manila  is 
thirty-six  hours,  a  small  station,  with  barrack  accom- 
modations for  one  hundred  people,  be  equipped  at 
Iloilo  as  soon  as  practicable.  This  station  would  be 
available  for  a  great  number  of  vessels  from  the  neigh- 
boring island  ports.  He  also  recommends  the  estab- 
lishment of  a  small  floating  and  disinfecting  plant  and 


barrack  accommodations  at  Cebu,  as  a  station  there 
would  be  convenient  for  the  disinfection  of  boats  com- 
ing from  the  groups  of  islands  to  the  east  and  south  of 
Luzon.  It  may  also  be  necessary  to  have  a  station  at 
Zamboanga  on  the  island  of  Mindanao,  as  it  is  pur- 
posed to  have  ships  from  Singapore  and  Australian 
ports  call  there.  Assistant  Surgeon  L.  D.  Pricks  has 
been  detailed  as  quarantine  officer  at  Iloilo,  and 
Assistant  Surgeon  H.  A.  Stansfield  at  Cebu. 

The  University  of  St.  Andrews  has  received  a  gift 
of  ;^2o,ooo  from  the  Marquis  of  Bute  to  establish  a 
chair  of  anatomy. 

The  Hospil;^!  Ship  "  Maine."— The  Anglo-Ameri- 
can hospital  ship  Maine,  which  rendered  such  effectire 
service  in  the  Boer  war,  both  as  a  hospital  station  at 
the  Cape  and  as  a  transport  for  sick  and  wounded 
soldiers  to  Netley,  has  been  sent  to  China.  Sne  ar- 
rived at  Hong  Kong  last  Saturday,  and  on  Friday  of 
this  week  proceeded  to  W'ei-hai-Wei. 

Tuberculosis  in  Hawaii.— The  Honolulu  health 
reports  show  a  progressive  increase  in  the  death  rate 
among  the  Japanese  and  native  Hawaiians  on  the 
island  of  Oahu.  The  greatest  increase  is  in  the  deaths 
from  tuberculosis,  and  the  board  of  health  is  discussing 
measures  for  restricting  the  immigration  of  consump- 
tives, of  whom  there  are  many  coming  to  the  island 
because  of  its  climate. 

Plague  in  Nicaragua?— A  report  from  Managua, 
dated  August  ist,  states  that  some  kind  of  dangerous 
epidemic  is  causing  the  death  of  rats  and  pigs  in 
that  place.  Hundreds  of  those  animals  are  found 
lifeless  in  the  streets  and  vacant  lots.  The  number  of 
pigs  that  have  died  from  the  unknown  malady  is  very 
large.  The  rats  are  also  very  numerous,  and  the  great 
mortality  among  them  is  evidently  connected  in  some 
way  with  that  among  the  hogs.  A  sanitary  commis- 
sion has  been  formed  which  is  endeavoring  to  discover 
the  cause  of  the  epidemic  and  to  put  a  stop  to  its 
ravages,  lest  it  should  prove  to  be  the  bubonic  plague 
and  attack  the  population. 

Leprosy  in  the  Philippines — Surgeon-General 
Sternberg  has  received  a  report  from  Major  Guy  L. 
Edie,  president  of  the  board  of  health  in  Manila,  stat- 
ing that  the  board  of  health  is  considering  a  plan  to 
segregate  all  the  lepers  on  one  island,  where  hospitals 
and  other  suitable  buildings  can  be  erected  for  their 
care.  The  report  states  that  leprosy  was  introduced 
in  the  Philippines  in  1633,  when  the  Emperor  of  Japan 
sent  one  hundred  and  fifty  lepers  to  the  islands.  Since 
then  the  number  has  increased  until  the  estimate  is 
that  there  are  thirty  thousand  lepers  in  the  archipelago, 
largely  in  the  Vasayas.  In  a  recent  inspection  of 
Manila,  one  hundred  lepers  were  found  concealed  in 
various  houses,  while  many  others  escaped  to  the 
country. 

The  Russian  Medical  Service  in  China  is  said  to 
be  better  than  that  of  the  other  European  nations.  The 
number  and  good  organization  of  the  Russian  ambu- 
lances should  afford,  it  is  said,  an  object  lesson  for  the 
other  powers.     At  Moscow  twelve  new  military  medi- 


342 


MEDICAL    RECORD. 


[September  i,  1900 


cal  corps  have  just  been  organized,  and  they  will 
shortly  start  for  the  East.  Each  of  these  corps  con- 
sists of  four  physicians,  four  Sisters  of  Charity,  and 
eighty-two  nurses. 

Carbolic  Acid  has  been  officially  declared  a  poison 
in  Great  Britain,  and  its  purchase  is  now  iiedged  about 
with  the  same  formalities,  meant  to  be  deterrent,  as 
that  of  other  deadly  drugs.  Special  provision  has, 
however,  been  made  to  facilitate  its  sale  for  agricul- 
tural purposes. 

A  Chilian  Medical  Congress  is  announced  for 
December  of  the  present  year.  This  ought  to  be  an 
additional  reason  for  the  postponement  of  the  Pan- 
American  Medical  Congress  to  some  more  convenient 
season  than  the  Christmas-tide. 

The  Bubonic  Plague  in  Glasgow Several  cases 

of  plague  have  been  discovered  in  Glasgow,  and  the 
families  of  the  sufferers,  as  well  as  those  of  persons 
who  have  come  in  contact  with  the  sick — forty  families 
in  all — have  been  quarantined.  Up  to  Wednesday  of 
this  week  there  had  been  five  deaths.  The  disease  was 
imported  in  a  ship  recently  arrived  from  the  Orient. 

A  Coroner's  Diagnosis A  physician  in  Philadel- 
phia who  attended  a  boy  six  years  old,  who  died  in 
convulsions,  believed  the  symptom's  to  be  those  of 
hydrophobia,  and  so  informed  the  coroner.  There 
was  a  history  that  the  child  was  bitten  by  a  dog  twenty- 
.six  days  previously,  and  that  he  died  in  convulsions 
resulting  therefrom.  The  coroner  instructed  the  jury 
that  he  discredited  the  hydrophobia  theory,  and  that 
his  opinion  was  that  death  was  due  to  the  excessive 
heat,  causing  the  convulsions.  The  jury  found  a  ver- 
dict accordingly. 

No  Base  Hospital  for  China. — With  a  probable 
recall  of  some  of  our  troops  in  China,  the  large  base 
hospital  that  was  projected  by  the  government  at  Na- 
gasaki, Japan,  has  been  abandoned,  and  the  wounded 
and  sick  from  China  who  would  have  gone  there  will 
be  brought  to  San  I-'rancisco  and  treated  in  the  general 
hospital  at  tiie  Presidio.  The  physicians  and  nurses 
who  had  been  ordered  to  Nagasaki  will  remain  in 
San  Francisco  until  it  is  definitely  decided  that  their 
services  will  not  be  required  in  China  or  the  Philip- 
pines. 

A  Royal  Lady's  Doctor's  Bill. — A  report  from 
Honolulu  states  that  Dr.  Charles  E.  English,  who  was 
ex-Queen  Liliuokalani's  physician  for  about  two  years, 
has  sued  her  for  $5,000.  He  declares  he  gave  up  all 
his  practice  to  attend  her,  for  which  he  was  to  receive 
$300  a  month,  with  a  bonus  of  $5,000  should  she  part 
with  his  services.  In  case  she  received  compensation 
for  the  crown  lands  he  was  to  get  §30,000.  In  July, 
he  says,  she  suddenly  told  him  that  his  attendance  was 
no  longer  required,  and  refused  to  pay  the  $5,000. 

The  Role  of  the  Mosquito  in  Filariasis We  re- 
cently noted  the  discovery  by  Dr.  George  G.  Low,  of 
London,  of  the  filaria  sanguinis  hominis  in  the  pro- 
boscis of  the  mosquito,  and  his  deduction  from  this 
that  man  might  receive  the  parasite  by  direct  inocula- 
tion instt-ad  of  by  drinking  water  in  which  the  worms 


had  been  deposited  on  the  death  of  the  mosquito. 
This  discovery  has  been  confirmed  by  the  members  of 
the  expedition  of  the  Liverpool  School  of  Tropical 
Medicine  now  at  Bonny  in  equatorial  Africa. 

Cholera  is  reported  to  be  prevailing  to  an  unusual 
extent  in  Bombay,  the  present  epidemic,  according  to 
JVw  Daily  Mail  of  London,  being  one  of  the  worst  on 
record.  The  bubonic  plague  is  for  the  time  being 
quiescent. 

Anti-Alcohol  Teaching  in  the   Public   Schools 

The  school  superintendent  of  Cincinnati  has  forbidden 
the  use  of  colored  pictures  showing  to  a  greatly  exag- 
gerated degree  the  effect  of  alcohol  upon  the  mucous 
membrane  of  the  stomach  and  upon  other  organs.  He 
says  the  pictures  are  unaesthetic  and  fill  the  minds  of 
the  children  with  unpleasant  impressions,  and  give 
them  false  notions  which  will  react  harmfully  on 
them  in  the  future.  He  favors  impressing  upon  the 
pupils  the  benefits  of  temperate  eating  and  drinking, 
and  not  dwelling  upon  the  horrors  of  an  intemperate 
use  of  alcohol.  He  says  he  is  in  favor  of  giving  in- 
struction in  hygiene  and  preventive  medicine,  and 
suggests  that  the  city  health  department  issue  circulars 
and  papers,  which  shall  be  used  as  the  teachers  see 
fit.  These  will  show  how  contagions  are  to  be  pre- 
vented, and  in  general  give  pupils  an  idea  of  how  best 
to  preserve  their  health. 

Second    Attacks    of    Typhoid    Fever.— Dr.  T.  J. 

Maclagan,  writing  in  the  British  Alcdical  Joitnial  re- 
garding preventive  inoculations  for  typhoid  fever,  says 
that  the  foundation  of  the  treatment  is  a  hypothesis 
which  is  inconsistent  with  fact.  The  idea  is  that,  as 
one  attack  of  typhoid  gives  immunity  from  a  second, 
temporary  if  not  lasting  immunity  might  be  acquired 
by  inoculation  with  an  attenuated  dose  of  the  poison. 
But  one  attack  of  typhoid  does  not  give  immunity  from 
a  second,  he  says.  Second  attacks  of  typhoid  are  as 
common  as,  by  the  ordinary  doctrine  of  chances,  they 
ought  to  be ;  more  common,  for  instance,  than  second 
attacks  of  pneumonia,  in  about  the  same  proportion 
that  first  attacks  are  more  common.  If  one  attack  of 
the  fully  developed  disease  does  not  give  immunity, 
he  concludes,  inoculation  with  an  attenuated  dose  of 
the  poison  can  scarcely  be  expected  to  do  so. 

Insanity    in    the    Philippines Dr.    Charles    H. 

Latimer  of  St.  Elizabeth's  Asylum,  Washington,  has 
been  commissioned  by  the  government  to  go  to  the 
J'hilippines  to  study  and  report  upon  the  effect  of  the 
climate  of  tliose  islands  upon  the  brain. 

Deaths  from  Rabies  in  New  York — A  boy  thir- 
teen years  old  died  a  few  days  ago  in  the  Harlem 
Hospital  of  hydrophobia.  He  was  attacked  while 
playing  in  the  street  by  a  dog  which  bit  his  nose  off. 
The  first  symptom  of  rabies  appeared  seventeen  days 
later.  It  is  stated  that  this  is  the  seventeenth  death 
from  rabies  reported  in  this  city  during  the  past  five 
years. 

Trouble  on  a  Hospital  Ship.  —  It  is  reported  th;'.t 
there  has  been  serious  trouble  on  the  hospital  ship 
RitieJ,   now   at   Nagasaki.     Thirteen  men   in  the  tn- 


September  i,  1900] 


MEDICAL    RECORD. 


343 


gineers'  department  and  several  officers  are  said  to 
havd  struck.  They  are  also  said  to  have  expressed 
the  determination  not  to  sign  new  service  contracts 
when  those  now  in  force  expire.  The  first  officer  of 
the  Grant  has  been  ordered  to  the  RelieJ  as  master. 

An  Obstetrical  Fraud. — A  French  contemporary 
relates  an  instructive  story  of  a  young  physician  who 
was  visited  by  a  woman  presenting  the  external  signs 
of  pregnancy.  She  engaged  him  for  the  approaching 
confinement  and  left.  A  few  months  Liter  the 
physician  was  summoned  to  his  patient,  to  find 
the  infant  not  only  born,  but  washed  and  dressed. 
He  was  gently  chided  for  his  slowness  in  responding 
to  the  summons,  and  was  requested  as  a  particular 
favor  to  call  at  the  registration  office  for  the  purpose 
of  registering  the  birth.  Anxious  to  re-establish  him- 
self in  the  good  graces  of  his  patient,  the  physician 
did  as  requested,  leaving  the  house  without  examining 
either  mother  or  child.  We  may  judge  of  his  surprise 
and  dismay  when,  some  time  after,  he  was  prosecuted 
by  the  state  for  aiding  and  abetting  in  a  fraud  by 
having  made  a  false  declaration  as  to  the  birth  of  a 
child.  It  turned  out  that  his  patient  had  not  been 
pregnant  and  consequently  had  not  borne  a  child;  but 
had  presented  her  physician  with  a  supposititious  one 
and  made  him  a  guileless  partner  in  her  attempt 
fraudulently  to  acquire  some  property.  P'ortunately 
for  the  young  man,  M.  Brouardel  interested  himself 
in  his  case,  and  the  prosecution  was  dropped. —  The 
Medical  Press. 

Navy  Department,  Bureau  of  Medicine  and  Surgery, 
Washington,  D.  C. — Changes  in  the  medical  corps  of 
the  United  States  navy  for  the  week  ending  August  25, 
1900.  August  20th. —  Passed  Assistant  Surgeon  L.  L. 
von  Wedekind  ordered  to  temporary  duty  at  the  head- 
quarters of  the  marine  corps,  Washington,  D.  C, 
August  2 2d,  and  then  to  the  Kichmoiul.  August  24th. 
— Medical  Inspector  J.  R.  Waggener  transferred  from 
the  naval  hospital,  Cavite,  P.  I.,  to  the  naval  hospital, 
Yokohama,  Japan,  for  treatment.  Surgeon  G.  Pickrell 
detached  from  the  naval  hospital,  Yokohama,  Japan, 
and  ordered  to  the  Cavite  naval  station.  Surgeon  O. 
D.  Norton  detached  from  the  Moiiocacy  and  ordered  to 
duty  with  the  marine  regiment  in  China.  August  20th. 
—  Pharmacist  S.  W.  Douglass  detached  from  the  Mas- 
snsoit  and  ordered  to  the  Key  West  naval  station 
immediately. 

The  Hospital  Charges  in  South  Africa A  Mrs.- 

Chamberlain,  sister-in-law  of  the  British  Secretary  of 
State  for  the  Colonies,  has  contributed  an  interview  to 
a  London  paper  in  which  she  declares  that  the  charges 
regarding  the  mismanagement  of  the  military  hospi- 
tals in  South  Africa,  recently  made  in  Parliament,  are 
literally  true.  She  says  that  hospital  supplies  were 
intentionally  withheld,  and  also  expresses  a  poor 
opinion  of  the  surgeons,  saying  that  "  with  few  excep- 
tions the  army  doctors  are  a  low  class  of  men.  Those 
in  South  Africa  neglected  their  patients.  Six  cases 
of  drunkenness  among  army  doctors  came  under  my 
observation.  After  these  people  had  come  into  con- 
tact with  the  police  they  were  sent  home  in  charge  of 


invalids.''  i'ossibly  Mrs.  Chamberlain,  who  had  been 
for  several  months  in  South  Africa,  was  one  of  the 
atoms  in  the  "plague  of  women  "  concerning  which 
Mr.  Frederick  Treves  spoke  so  feelingly.  In  that  case 
her  animosity  against  the  army  surgeons  receives  a 
ready  explanation. 

Danger  of  Yellow  Fever  from  Cuba. — Surgeon- 
General  Wynian  of  the  Marine-Hospital  service  has 
recently  received  a  report  from  the  chief  quarantine 
officer  at  Havana,  that  during  the  month  of  August,  up 
to  the  26th,  there  had  been  two  hundred  and  four 
cases  of  yellow  fever  reported  at  Havana,  and  thirty- 
four  deaths.  Many  of  the  cases  were  very  mild. 
There  were  eleven  new  cases  August  27th.  On  ac- 
count of  the  mildness  of  the  cases  and  their  short  dura- 
tion the  surgeon-general  has  notified  the  various  quar- 
antine stations  on  the  Atlantic  and  Gulf  coasts  to  use 
particular  care  to  prevent  an  importation  of  the  dis- 
ease. 

Obituary  Notes. ^Dr.  William  B.  Waterman  died 
at  his  home  in  Brooklyn  on  August  21st,  after  an  ill- 
ness of  several  months'  duration.  He  was  born  in 
Brooklyn  in  1862  and  was  graduated  from  the  Medi- 
cal Department  of  the  L'niversity  of  Mew  York  in  the 
class  of  1887,  taking  the  Mott  medal. 

Dr.  Ernst  Schmidt,  of  Chicago,  died  on  August 
25th.  He  was  born  in  Bavaria  in  1830,  and  was  a 
graduate  of  Wiirzburg  in  1852.  Soon  after  graduation 
he  came  to  this  country  and  settled  in  Chicago,  where 
he  practised  for  over  forty  years.  He  was  connected 
with  the  Alexian  Brothers'  Hospital  and  also  with  the 
Michael  Reese  Hospital. 

Dr.  Ferdinand  K.  Chatard,  of  Baltimore,  died  at 
Atlantic  Cit)'  on  August  27th.  He  came  of  a  line  of 
medical  men,  his  father  and  grandfather  both  having 
been  surgeons  of  prominence.  He  was  educated  at 
Mount  St.  Mary's  College,  Emmittsburg,  and  was 
graduated  in  medicine  from  the  L^niversity  of  Mary- 
land in  1S61.  After  a  period  of  study  abroad  he  re- 
turned to  Baltimore  and  became  associated  with  his 
father  in  practice.  One  of  his  brothers  is  the  Roman 
Catholic  bishop  of  Vincennes,  another  is  a  physician 
in  Washington. 

Dr.  Frank  Stephen  Milkurv  died  at  his  home 
i  1  Brooklyn  on  August  29th,  at  the  age  of  forty -three 
yc;ar.s.  He  was  born  in  Xew  Brunswick,  and  first  turned 
his  attention  to  dentistry,  practising  in  Nova  Scotia 
and  later  in  the  City  of  Mexico.  He  then  studied 
medicine  and  was  graduated  from  the  Cincinnati 
College  of  Medicine  and  Surgery  in  1888.  After  a 
period  of  post-graduate  study  in  Europe,  Dr.  Milbury 
entered  upon  practice  in  Brooklyn.  He  was  laryngolo- 
gist  and  otologist  to  the  Bedford  Hospital  and 
assistant  at  the  N'ew  York  Eye  and  Ear  Hospital. 

Rev.  Dr.  John  S.  Breckinridge,  superintendent  of 
the  Methodist  Episcopal  Hospital,  Brooklyn,  died  on 
August  28th  at  Stamford,  Conn.  He  was  about  sixty- 
three  years  old,  and  was  born  in  Pennsylvania.  He 
was  graduated  from  Wesleyan  University  in  1861. 
In  1887  he  was  appointed  superintendent  of  the 
Methodist  Episcopal  Hospital,  a  position  he  held  up 
to  the  time  of  his  death. 


544 


MEDICAL    RECORD. 


[September  i,  1900 


progress  of  |3tXc(Ucal  Science. 

Tlie  Medical  News,  August  2j,  igoo. 

The  Abortive   Treatment  of  Acute   Mastoiditis.— James   F. 

McKernon  says  that  when  a  case  conies  under  observation, 
if  there  is  not  sufficient  drainage  of  the  middle  ear  the  per- 
foration made  by  nature  in  the  drum  membrane  must  be 
enlarged,  and  if  the  upper  portion  of  the  middle  ear  or  attic 
is  infected  this  incision  is  extended  upwartl.  opening 
Shrapnell's  membrane,  and  still  continued  outward  and 
backward  through  the  tissues  of  the  superior  canal  wall, 
thus  making  what  has  sometimes  been  called  an  internal 
Wilde's  incision.  This  done,  the  patient  is  placed  in  bed 
and  kept  absolutely  quiet  on  a  fluid  diet ;  an  ice  coil  is  ap- 
plied snugly  over  the  mastoid  process,  a  free  purgative  is 
administered,  and  the  canal  is  irrigated  every  two  or  three 
hours  (depending  upon  the  character  of  the  discharge)  with 
a  warm  solution  of  bichloride  of  mercury,  1:4,000.  The 
coil  is  left  in  position  for  twenty-four  hours,  and  at  the  end 
of  this  time  we  usually  find  upon  its  removal  much  less 
tenderness  than  had  existed  before,  and  if  all  swellin.g  has 
not  entirely  disappeared  it  has  markedly  diminished. 
Usually  in  from  thirty-six  to  forty-eight  hours  convales- 
cence is  established  and  the  danger  of  mastoid  involve- 
ment is  over.  The  author  is  strongly  opposed  to  the  appli- 
cation of  moist  heat  to  the  mastoid  process  of  a  patient 
suffering  from  acute  middle-ear  disease. 

Medullary  Narcosis  during  Labor. — S.  Marx  reports  sev- 
eral cases  of  lumbar  cocainization  employed  to  mitigate 
the  pains  of  parturition.  He  says  the  report  is  only  pre- 
liminary, for  the  cases  are  too  few  to  warrant  any  wide  de- 
ductions as  to  the  ultimate  value  of  this  method.  As  far 
as  he  can  form  conclusions  from  the  few  experiments  he 
has  made,  he  says  he  feels  warranted  in  stating  that  in 
lumbar  cocainization  we  have  a  method  which  is  of  the 
greatest  value  in  producing  analgesia,  which  checks  almost 
entirely  the  pains  of  labor  without,  so  far  as  personal  ex- 
perience goes,  the  least  danger  to  mother  or  child.  "It  is 
very  astonishing  and  awe-inspiring  to  those  of  us  who  have 
seen  many  labors  and  heard  the  agonizing  and  maniacal 
shrieks  of  these  poor  women,  to  see  the  parturient,  under 
the  influence  of  cocaine,  lie  quietly  in  bed,  feeling  only 
some  indescribable  sensation,  but  without  pain,  bearing 
down  when  told  to,  and  giving  birth  to  her  child  without 
her  knowledge,  and  only  cognizant  of  the  fact  when  the 
first  cry  of  the  new-born  is  heard."  The  puncture  is  made 
between  the  third  and  fourth  or  fourth  and  fifth  vertebrae, 
the  point  of  the  needle  being  pushed  slowly  and  gently 
downward  until  the  spinal  fluid  is  seen  running  out.  An 
injection  is  then  made  of  ten  minims  of  a  solution  repre- 
senting gr.  ),  of  cocaine. 

The  Construction  and  Management  of  Small  Cottage  San- 
atoria for  Consumptives. — By  Arnold  C.  Klebs. 

Co-operation  of  the  Public  Schools  in  Teaching  "  Good 
Teeth,  Good  Health."— By  Richard  Grady. 

Tuberculosis  and  Modem  Methods  for  its  Prevention. — By 
H.  H.  Vinke. 

Boston  Medical  and  Surgical  Journal,  August  zj,  igoo. 

Hysterectomy  for  Myoma  in  America. — Ernest  W.  Gush- 
ing points  out  the  principal  contributions  of  Americans  to 
this  branch  of  surgery.  Up  to  iSg5,  in  the  transition  pe- 
riod, there  was  a  mortality  of  13.8  per  cent.  At  present, 
in  the  hands  of  good  operators,  there  is  often  a  series  of 
sixty  or  seventy-five  or  more  cases  without  a  death.  The 
change  of  methods  in  performing  hysterectomy  for  myoma 
may  be  briefly  summarized  as:  (1)  Entire  abandonment 
of  the  extra-abdominal  treatment  of  the  stump  by  serre- 
noeud  or  rubber  ligature  ;  (2)  the  wide  trial  and  substan- 
tial rejection  of  vaginal  hysterectomy,  as  an  operation  of 
election  in  cases  of  myoma  and  salpingitis;  (3)  the  estab- 
lishment of  indications  for  the  retention  of  the  cervix  uteri, 
as  compared  with  total  extirpation  of  the  uterus;  (4)  the 
adoption  of  a  method  substantially-  the  same  by  most  ope- 
rators ;  (5)  the  disuse  of  drainage  wherever  possible;  (6) 
the  common  employment  of  the  operation  by  general  prac- 
titioners operating  in  the  small  hospitals  which  are  s])ring- 
ing  up  in  all  towns  of  three  thousand  or  more  inhabitants. 
This  generalization  is  at  present  a  disadvantage,  but  by 
competition  and  training  tends  to  the  diffusion  of  good 
surgery  throughout  the  country. 

Repeated  Ectopic  Gestation  in  the  Same  Patient,  with 
Operation  in  Each  Case. — Malcolm  .Storer  and  M.  T.  Thur- 
ber  report  the  case  of  a  young  woman,  who  in  December, 
1898,  was  operated  upon  by  the  former  for  ectopic  preg- 
nancy, and  the  left  tube  and  ovary  were  removed.  In 
May,  1899,  Dr.  Thurber  again  found  tliat  the  patient  had 
an  extra-uterine  pregnancy,  and  Dr.  Storer  performed  a 
second  operation.     The  tube  was  removed,  but  most  of  the 


ovary  was  left  in  place  and  stitched  to  the  stump  of  the 
tube.  In  the  first  operation,  an  attempt  was  first  made  to 
use  the  vaginal  route,  but  this  had  to  be  abandoned  on  ac- 
count of  free  hemorrhage.  In  general  terms,  the  author 
would  confine  the  vaginal  operation  to  women  with  large 
pelves,  yet  even  in  them,  should  there  be  urgent  symptoms 
of  active  hemorrhage,  he  would  personally  prefer  the  ab- 
dominal route,  as  the  source  of  bleeding  could  more  e&sily 
be  found  and  controlled.  Should  the  operator  prefer  to 
begin  by  the  vaginal  route,  he  would  be  wise  to  have  every- 
thing ready  for  a  cieliotomy  in  case  he  should  find  it  neces- 
sary to  abandon  the  vagina  in  a  hurry. 

The  Mortality  of  Hysterectomy  for  Fibroids. — F.  H.  Dav- 
enport points  out  that  the  causes  of  danger  in  case  the 
tumor  is  left  alone  are:  (i)  hemorrhage,  which  may  be- 
come a  source  of  danger,  no  matter  what  the  size  of  the 
tumor  ;  (1)  pressure  from  a  large  tumor  causing  disease  in 
other  organs  ;  (3)  anjemic  necrosis  of  a  part  of  the  tumor;' 
(4)  the  development  of  malignant  disease  in  connection 
with  the  fibroid.  The  author  has  done  nineteen  hysterec- 
tomies for  fibroids.  Two  of  the  patients  died;  these  had 
large  tumors  which  presumably  could  have  been  success- 
fully removed  if  taken  earlier.  In  addition  to  these  two 
cases,  there  were  two  of  malignant  degeneration,  three  of 
anaemic  necrosis,  one  of  the  latter  presenting  malignancy 
as  well.  Therefore  out  of  nineteen  cases  there  were  six  in 
which  life  was  threatened  by  the  presence  of  the  growth. 
Tlie  author  strongly  advises  the  removal  of  fibroids  if 
symptoms  are  present. 

Immediate  Repair  of  Perineal  Tears. — E.  S.  Boland  says 
that  if  carefully  carried  out  the  immediate  operation  of 
suturing  ought  to  give  ninety  per  cent,  of  successes.  An 
anajsthetic  is  not  usually  necessary:  the  value  of  the 
prompt  restoration  of  the  perineal  body  does  not  depend 
wholly  on  the  after-results,  but  also  on  the  influence  it 
exerts  to  minimize  the  risks  of  septic  infection  in  the  puer- 
perium.  To  illuminate  the  vagina,  the  head  mirror  of  the 
laryngoscope  with  head-band  attached  will  be  absolutely 
satisfactory,  and  a  neighbor  or  the  patient  herself  can 
hold  the  lamp,  thus  obviating  the  necessity  of  an  assistant, 
which  in  poor  families  is  g  consideration. 

Medicine  as  a  Science  and  Medicine  as  an  Art. — By  Philip 
H.  Pye-Smith. 

The  Philadelphia  Medical  /ounial,  August  2<.  igoo. 

A  Contribution  to  the  Significance  of  Koplik's  Spots  in  the 
Diagnosis  of  Measles. — Jose  L.  Hirsh  reports  seven  cases, 
one  in  a  negro,  in  which  a  diagnosis  of  measles  was  made 
or  confirmed  by  the  observation  of  Koplik's  spots,  and  he 
formulates  the  following  conclusions:  (i)  An  eruption 
limited  to  the  buccal  and  labial  mucous  membrane  and 
characterized  by  the  presence  of  an  irregular  red  spot  with 
a  bluish-white  centre,  is  always  present  in  beginning 
measles.  (2)  These  spots  are  present  for  twelve  hours  to 
five  days  before  the  cutaneous  outbreak.  (3)  The  number 
of  these  spots  bears  no  relation  to  the  severity  of  the  attack. 
(4)  These  spots  will  be  found  in  no  other  condition  of 
heallh  or  disease. 

The  Psychoses  of  the  Menopause. — John  B.  Cliapin  says 
that  of  8,320  women  admitted  to  insane  asylums  in  1S99, 
18S,  or  22  in  1,000,  were  stated  to  have  become  insane  at 
the  menopause.  Many  women  who  ai'e  melancholy  or 
threatened  with  insanity  at  the  menopause  have  had  seri- 
ous neurotic  or  mental  symptoms  at  the  age  of  puberty. 
He  says  it  can  be  stated  as  a  clinical  conclusion  that  wo- 
men who  become  insane  at  the  menopause  as  a  rule  pos- 
sess a  neurotic  and  mental  heredity,  or  liave  already  suf- 
ered  fi'om  recurrent  insanities  during  the  menstrual  life. 
and  are  rendered  suitable  and  peculiarly  liable  to  a  fresh 
attack  at  any  crisis  in  their  lives. 

Physical  Diagnosis  in  its  Relation  to  the  Stomach  and  As- 
sociated Organs. — By  B.  C.  Loveland. 

Miitter  Lectures  of  the  College  of  Physicians  of  Philadel- 
phia.— By  John  P>.  Roberts. 

Two  Cases  of  Trichinosis  with  Eosinophilia. — By  William 
Watt  Kerr. 

An  Apparatus  for  Making  Roll-Cultures. — By  George  H. 
F.  Nut  tall. 

Military  Surgery. — By  W.  C.  Borden. 

Journal  of  the  American  Medical  Ass'  n,  August  z^,  igoo. 

Keratitis  Bullosa. — E.  O.  Sisson  reports  a  case  of  this  rare 
afi^ection,  which  is  usually  secondary  to  blindness  caused 
by  corneal  cicatrix,  iridocyclitis,  increased  tension,  etc. 
According  to  Fuchs,  the  lymphatic  stasis  of  glaucomatous 
eyes  protluces  an  interstitial  iiedema  of  the  epithelium, 
which  tends  to  the  production  of  vesicles,  etc.  The  contin- 
ual irritation  of  tlie  corneal  epithelium  alters  the  nutrition 
of  the  cells.  The  usual  treatment  of  opening  the  bullse  and 
touching  the  raw  spots  with  nitrate-of-silver  solution  was 
first  adopted.     This,  together  with  atropine,  was  fruitless. 


September  i,  1900] 


MEDICAL    RECORD. 


345 


Iridectomy  was  then  done  under  cocaine.  At  first  lliis 
promised  success,  but  suddenly  new  bulla;  appeared  and 
the  eye  was  enucleated,  a  procedure  which  the  patient  had 
pleaded  for  from  the  first.  In  this  case  the  condition, 
which  had  e.\isted  for  a  year,  was  secondary  to  cataract 
and  complete  posterior  synechia  of  the  iris.    ■ 

Chemical  Factors  in  Interstitial  Gingivitis. — \V.  L.  Baum 
says  that  since  the  gums  at  times  take  upon  themselves 
the.  function  of  excretion,  they  are  peculiarly  apt  to  be 
affected  by  chemical  action.  The  metals  and  phosphorus 
all  produce,  by  their  excretion  through  the  gums,  condi- 
tions of  oedema,  which  are  predisposing  factors  to  intersti- 
tial gingivitis.  Among  vegetable  alteratives  having  a  like 
action  are  colchicum,  guaiac,  salicylic  acid,  sarsaparilla, 
and  pilocarpine.  A  culture-medium  is  furnished  by  the 
oedema  produced.  In  a  case  of  mercurial  stomatitis  exam- 
ined, evidences  of  inflammation  were  found  in  the  gums, 
bacteria  being  absent,  and  it  was  thought  to  be  due  to  the 
chefflotactic  influence  of  the  mercury  in  process  of  excre- 
tion. Bacteriological  invasion  is  secondary  to  an  endar- 
teritis obliterans,  producing  an  anjemic  infarct,  which 
either  undergoes  absorption  or  becomes  necrotic. 

Cerebral  Localization. — Sydney  Kuh  speaks  of  cortical  lo- 
calization, cerebral  centres,  distribution  of  motor  centres, 
etc.  The  points  in  differentiating  Jacksonian  from  idio- 
pathic epilepsy  are :  the  spasm  is  limited  in  the  beginning 
of  the  attack :  loss  of  consciousness  occurs  late,  if  at  all ; 
the  epileptic  cry,  fall,  and  biting  of  the  tongue  are  usually 
absent  ;  post-epileptic  coma  is  slight,  of  short  duration,  or 
entirely  absent ;  and  in  the  t'tat  (?<;  Jiial  there  is  no  rise  of 
temperature.  The  history  and  age  aid.  The  diagnosis  of 
corpus  callosum  lesions  is  usually  impossible.  The  signs 
of  importance  are  enumerated.  Temporal  lobe,  basal  gan- 
glia, alternating  hemiplegia,  etc.,  are  considered. 

The  Constitutional  Treatment  of  Interstitial  Gingivitis. — 
J.  H.  Salisbury  says  that  besides  metallic  and  other  drugs, 
auto-intoxication  plays  a  part  in  pyorrhoea  alveolaris,  atro- 
phic changes  being  due  to  poisons  circulating  in  the  blood. 
Successful  treatment  depends  upon  the  discovery  of  the  tox- 
ieraia  by  which  the  condition  is  caused.  The  indications  to 
be  met  are  :  (t)  to  stimulate  the  eliminating  organs  ;  (2)  to 
fortify  the  system  against  the  action  of  the  poison  ;  (3)  to 
prevent  the  formation  of  the  poison. 

Local  Treatment  of  Interstitial  Gingivitis. — M.  H.  Fletcher 
quotes  Talbot  to  the  effect  that  the  exciting  cause  of  gingi- 
vitis is  tartar,  and  believes  with  Carpenter  that  without  a 
locally  exciting  cause  the  disease  would  not  e.xist.  He 
makes  an  acute,  a  chronic,  and  a  sloughing  stage.  He  ad- 
vocates soft-wood  toothpicks,  stiff  brushes,  and  tooth-pow- 
ders containing  no  gritty  substances. 

AnjBsthesia. — D.  H.  Galloway  reports  a  case  which  illus- 
trates the  value  of  nitrous  oxide  as  an  aid  to  anjesthesia 
when  ether  or  chloroform  is  em])loyed. 

How  to  Place  Lenses  Before  the  Eyes  so  that  Distance  of 
their  Respective  Anterior  Foci  Shall  be  the  Same. — By  JIark 
D.  Stevenson. 

The  Bacillus  of  Philippine  Dysentery. — Extract  of  a  report 
by  R.  P.  Strong  and  W.  E.  Musgrave. 

A  Few  Observations  on  the  Efficacy  of  Protargol  in  Pyo- 
genic Affections  of  the  Eye. — By  F.  C.  Hotz. 

Anteflexion  of  the  Uterus :  its  Causes  and  Treatment. — By 

Augustus  P.  Clarke. 
A    Simple  Operation    for  Divergent    Strabismus. — By   L. 

Webster  Fox. 

Parturition  as  a  Factor  in  Gynecological  Practice. — By  John 

Milton  I  Miff. 


Medicine  and  Medical  Men  in  the   United   States. 
Jacobi. 


-By  A. 


7  he  Xew  York  Medical  Journal.  August  ij,  rgoo. 

On  a  New  Method  of  Operation  for  Exstrophy  of  the  Blad- 
der.— Carl  Beck  reviews  the  various  procedures  devised  tor 
repair  of  this  most  distressing  condition,  and  gives  a  plan 
of  his  own  recently  modified  which  has  served  him  well. 
The  disadvantages  of  implanting  the  ureters  in  the  sig- 
moid flexure  are  discussed,  and  while  intestinal  implan- 
tation approaches  more  nearly  the  ideal  restitutio  ail  inte- 
grum, there  are  severe  risks  attending  it.  His  own  auto- 
plastic method  for  restoring  the  retentive  power  by  an 
anterior  muscular  wall  is  described,  and  cases  are  cited, 
showing  how  a  small  bladder  was  secured  and  protected 
by  a  firm  muscular  laver. 

A  Case  of  Murphy-Button  Anastomosis. — John  von  Aesch 
relates  an  instance  of  abdominal  injury  with  attempt  at 
suture  and  subsequent  insertion  of  the  button.  The  fea- 
tures are :  long  delay,  very  dirty  gut.  time  lost  in  vain 
attempt  to  suture,  and  passage  of  the  button  on  the  elev- 
enth day,  bringing  with  it  a  large  intestinal  worm  which 
had  been  caught  in  the  trap-like  opening  of  the  button. 


A  Case  of  Cyst  of  the  Epiglottis.— W.  L.  Bullard  relates 
a  case  of  this  rare  condition.  After  incision  of  a  filbert- 
sized  cyst  on  the  anterior  surface  of  the  epiglottis  and 
touching  with  strong  silver  solution,  there  was  recurrence. 
After  a  second  incision  with  discharge  of  gelatinous  fluid, 
and  touching  the  interior  of  the  sac  with  fused  chromic 
acid,  cure  was  permanent. 

The  Annual  Address  of  the  President  of  the  American 
Laryngological  Association. — By  Samuel  Johnston. 

Bladder  Incrustations,  Multiple  Phosphatic  Calculi ;  Median 
Lithotomy,  Irrigation,  etc. — By  J.  Coplin  Stinson. 

Secondary  Hemorrhage  following  the  Use  of  Suprarenal 
Extract. — By  Frederick  E.  Hopkins. 

Laryngitis  a  Provoking  Cause  of  the  Asthmatic  Paroxysm. 
— By  William  C.  Glasgow. 

The  Lancet,  August  tS,  rgoo. 

The  Hot-Air  Treatment  of  Eczematous,  Gouty,  Rheumatic, 
and  Other  Affections.— David  Walsh  describes  the  apparatus 
employed  in  the  application  of  hot  air.  The  method  is 
likely  to  do  good  in  painful  nervous  affections,  many  pain- 
ful and  stiffened  joints,  anjemia,  Bright's,  eczema'  rheu- 
matism, gout,  etc.  A  typical  case  of  gonorrhoeal  rheuma- 
tism treated  with  good  results  is  detailed.  It  is  here  shown 
that  cardiac  complications  need  not  necessarily  contra- 
indicate  the  application  of  the  Tallerman  treatment. 

Measles,  German  Measles,  and  the  "  Fourth  Disease." — 
Robert  Craik  relates  the  history  of  several  cases.  In  Case 
I.  a  scarlet-fever-like  rash  with  very  little  fever,  illness,  or 
desquamation  was  present  in  18(39.  I"  March,  1900,  the 
patient  had  measles,  and  in  May,  1900,  she  had  German 
measles.  Cases  II..  III.,  and  IV.  proved  to  be  the  first  of 
an  epidemic  of  German  measles.  The  reasons  for  not  re- 
garding the  cases  as  scarlatina  are  given. 

An  Unusual  Case  of  Scarlet  Fever. — A.  J.  Rice  Oxley 
relates  an  instance  of  scarlatina  in  which,  six  days  after 
desquamation  began,  and  two  days  after  the  patient  first 
sat  up,  the  cervical  glands  began  to  swell.  Five  days  later 
there  was  fever  (103  F. ),  and  ecchymo.ses  began  to  form 
on  various  parts  of  the  body,  and  then  large  extravasations 
followed  by  death.  The  reporter  is  at  a  loss  for  an  expla- 
nation. 

Preliminary  Rashes  in  Measles. — J.  H.  Thursfield  records 
a  case  and  speaks  of  scarlatiniform  rashes  which  were  pres- 
ent in  five  out  of  seven  cases  seen.  In  four  they  were  the 
earliest  manifestatiim  of  measles,  Koplik's  spots  not  being 
found.  The  scarlatiniform  premonitory  eruptions  are  apt 
to  mislead,  especially  since  text-books  do  notas  a  rule  men- 
tion them. 

An  Address  on  Professional  Organizations. — Delivered  be- 
fore the  Southwest  London  Medical  .Society  by  W,  G. 
Dickinson. 

Report  on  the  Physiological  and  Therapeutic  Action  of 
Digitalis  and  its  Active  Principles. — By  Sir  T.  Lauder  Brun- 
ton. 

A  Case  of  Dislocation  of  the  Shoulder  Joint  Produced  by 
Muscular  Action  Alone. —  By  J.  Grimmond  Smith. 

The  Danger  to  the  Community  of  the  Workmen's  Compen- 
sation Act,  1897. — By  Albert  Benthall. 

Note  on  a  Case  of  Strychnine  Poisoning. — By  Thomas 
Lettis. 

Some  Remarks  on  Cancer  of  the  Breast. — By  Skene  Keith. 
Miinchener  medicinische  Wochenschrift.  August  7,  igoo. 

The  Pathogenesis  of  Gout. — O.  Hager  discusses  the  v^ari- 
ous  theories  as  to  the  causation  of  this  disease,  and  con- 
trasts the  views  of  recent  continental  observers  with  those 
of  the  English  writers.  Garrod's  theory  is  that  owing  to 
dietary  excesses,  exposure,  exertion,  injury,  etc.,  an  attack 
of  gout  may  be  produced,  which  consists  in  the  deposit  of 
uric  acid  in  the  form  of  a  urate  in  the  joints  or  the  sur- 
rounding tissues,  in  anomalous  forms  also  in  the  internal 
organs.  Through  the  attack  the  blood  is  relieved  of  the 
excess,  and  the  deposit  in  the  joints  appears  as  a  sort  of 
safety-valve  for  the  escape  of  the  surplus.  Luff  regards  as 
materia  morbi  the  quadri-urate  of  soda,  and  explains  the 
formation  of  uric  acid  in  two  ways.  In  health  it  is  formed 
in  the  kidneys,  probably  from  urea  and  glycocin,  and  is 
immediately  excreted  by  the  urine.  If  as  a  result  of  some 
functional  or  organic  disturbance  this  process  is  impeded 
this  substance  is  taken  up  by  the  circulation  and  forms 
the  supply  which  furnishes  the  gouty  deposits.  In  dis- 
eases which  are  accompanied  by  leucocytosis  uric  acid  may 
originate  in  the  nuclein  of  the  leucocytes  in  the  spleen  and 
possibly  in  the  entire  body,  but  this  is  properly  taken  care 
of  by  the  kidneys,  which  are  supposably  in  a  normal  state. 
and  hence  no  gouty  deposits  are  found.  These  views  seem 
untenable  to  the  author,  who  advocates  the  following  the- 
ory :  Under  the  influence  of  heredity,  the  lymphatic  con- 
stitution, or  intoxication  of  some  sort,  and  sometimes  with- 


346 


MEDICAL    RECORD. 


[September  i,  1900 


out  any  recognizable  cause,  a  state  of  faulty  metaliolism  is 
inaugurated.  This  consists  in  the  retention  in  the  body  of 
a  considerable  quantity  of  nitrogen,  which  does  not  enter 
into  the  formation  of  new  albuminous  bodies.  These  re- 
tained substances,  which  are  not  demonstrable  as  uric  acid 
and  which  comprise  such  alloxur  bodies  as  adenin,  circu- 
late in  the  blood  and  eventually  produce  necrosis  of  certain 
tissue  cells.  These  necroses  constitute  a  decomposition 
which  leads  to  the  formation  of  allo.xur  bodies  and  an  in- 
creased amount  of  uric  acid  in  the  blood,  which  is  deposited 
in  the  damaged  areas,  and  so  the  gouty  circle  is  fulfilled. 

Nervous  Disturbances  in  the  Domain  of  the  Brachial  Plexus 
in  Angina  Pectoris. — L.  Loewenfeld  describes  the  accessory 
nervous  disturbances  accompanying  angina  pectoris  and 
illustrates  by  the  citation  of  a  case  history.  The  brachial 
symptoms  may  be  grouped  into  three  classes:  disturbances 
of  sensibility,  of  motility,  and  of  vasomotor  control.  As 
regards  their  bearing  on  the  angina  it  is  to  be  noted  that 
they  may  be  entirely  absent,  but  it  is  more  often  the  case 
that  they  are  concurrent  with  tlie  cardiac  seizure,  tlunigli 
there  is  no  definite  relationship  between  their  intensity 
and  the  severity  of  the  disease  proper.  Sometimes  it  is 
observed  that  the  accessory  symptoms  precede  the  main 
attack,  and  in  others  that  they  considerably  outla.st  it. 
This  is  especially  true  of  the  sensory  manifestations,  par- 
asthesias,  etc.  Finally  the  brachial  neuralgia  may  appear 
to  be  entirely  unrelated  to  the  cardiac  disease  and  run  an 
independent  course.  Under  these  conditions  there  seems 
to  be  no  common  causative  agency  for  the  two,  but  they 
mutually  aggravate  each  other. 

A  Case  of  Death  from  Starvation. — Hartmann  describes 
the  post-mortem  findings  in  a  man  aged  seventy-three 
years,  who  was  allowed  to  die  through  lack  of  food  in  the 
almshouse  of  a  small  village.  The  evidence  of  the  manner 
of  death  lay  in  the  emptiness  of  the  alimentary  tract,  the 
pi-esence  of  old  hard  fecal  masses,  the  loss  of  body  fat,  the 
anaemia  of  many  organs,  and  the  absence  of  any  other 
cause,  as  well  as  the  testimony  of  witnesses  which  showed 
that  for  twelve  days  he  had  received  no  food. 

The  Time  for  Surgical  Intervention  in  Extra-Uterine  Preg- 
nancy.— By  L.  Prochownik. 

Xeroderma  Pigmentosum. — By  Herxheimer  and  Hilde- 
brandt. 

The  Corset  and  Dress  Reform. — By  J.  Thiersch. 

The  Suture  of  Arteries. — By  R.  Seggel. 

Berline7-  kliiiische  IVoc/iensc/trif/,  August  6,  iqoo. 

Idiopathic  Evanescent  Clouding  of  Consciousness. — Placzek 
reports  two  cases  of  temporar\'  mental  aberration  wliich 
are  interesting  from  a  forensic  point  of  view.  The  first 
concerns  a  woman  aged  about  forty  years,  who  without 
warning  became  entirel)'  irrational  in  language  and  action 
for  a  period  of  six  hours,  after  which  she  returned  to  the 
normal  and  had  no  recollection  of  the  time  that  had  elapsed. 
The  other  case  is  that  of  a  man,  and  is  much  of  the  same 
type,  except  that  in  this  instance  the  recovery  took  place 
just  as  suddenly  as  the  onset  of  the  trouble,  while  in  the 
former  it  took  several  hours  for  a  clear  i-ealization  of  events 
to  be  re-established.  In  their  causation  the  author  thinks 
that  seizures  of  this  sort  are  referable  to  circulatory  dis- 
turbances in  the  cortex,  and  calls  attention  to  somewhat 
similar  phenomena  observed  in  those  resuscitated  after 
strangulation  by  hanging,  in  which  the  main  effect  is  the 
compression  of  the  carotids.  It  is  of  great  importance  from 
a  medico-legal  standpoint  to  recognize  the  possibility  of 
such  a  loss  of  emotional  control,  which  it  appears  may  occur 
quite  independently  of  any  epileptic,  hysteric,  traumatic, 
or  hereditary  taint. 

A  Contribution  to  the  Bacteriology  of  Whooping-Cough. — 
G.  Arnheim  corroborates  the  findings  of  Czaplewski  and 
Hensel  on  the  ground  of  forty-four  cases  of  the  disease  and 
three  autopsies  studied  by  him.  In  the  sputum  of  these 
patients  and  in  two  of  tlie  bodies  he  was  able  to  find  and 
grow  in  pure  culture  the  Czaplewski-IIensel  bacillus,  which 
is  described  as  occurring  singly  or  in  chains,  the  individ- 
uals appearing  to  be  divided  in  the  middle  owing  to  the 
fact  that  only  the  two  poles  take  up  the  stain.  Control 
experiments  on  patients  with  other  pulmonary  and  bron- 
chial diseases  gave  negative  results.  Taken  in  connection 
with  the  observations  of  other  authors,  the  number  of  cases 
in  which  this  bacillus  has  been  isolated  is  now  sufficiently 
large  to  leave  little  doubt  as  to  its  specific  nature,  and 
although  experiments  on  animals  have  not  been  successful, 
still  tlie  requirements  of  Koch's  law  as  to  constancy  of  spe- 
cies and  location  and  the  possibility  of  pure  culture  have 
been  complied  with. 

The  Nature  and  Significance  of  Alterations  in  the  Ganglion 
Cells,  especially  in  Psychoses.  —  By  E.  Meyer. 

The  Subject  of  Primary  Sarcoma  of  the  Stomach. — By  \V. 
Mintz. 

Observations  on  Diabetes  Insipidus.— By  H.   Rebensburg. 


Deutsche  medicinische  Wockenschrift,  August  8.  igoo. 

A  Typhoid-Like  Disease  Caused  by  a  Bacillus  Resembling 
that  of  Typhoid. — Schcittmiiller.  in  making  b;icteriological 
tests  of  llie  blood  of  fifty  typhoid  jiatients,  was  able  to  cul- 
tivate the  specific  bacillus  in  eighty  per  cent,  of  the  cases. 
One  of  these,  however,  while  running  the  typical  course  of 
a  rather  mild  typhoid,  yielded  cultures  of  a  bacillus  which 
differed  so  markedly  from  the  normal  that  there  is  no  doubt 
in  the  author's  mind  that  it  is  a  separate  variety.  In  its 
cultural  characteristics  it  corresponds  clo.sely  to  the  Koch- 
Eberth  bacillus,  but  in  addition  to  the  usual  properties  it 
possesses  the  entirely  irregular  ability  to  produce  fermen- 
tation in  sugar  bouillon.  The  patient's  blood  gave  no  re- 
spon.sc  whatever  to  the  Widal  reaction,  but  caused  the 
agglutination  of  cultures  of  its  own  atypical  bacilli  even  in 
the  dilution  of  i  :  loo.  The  converse  of  the  experiment  was 
then  tried  and  the  serum  of  four  typhoid  patients  that  re- 
acted with  typhoid  bacilli  at  a  dilution  of  i  ;  loo  allowed  to 
act  on  the  abnormal  bacilli,  with  the  result  that  even  at 
1 :  20  only  one  specimen  caused  clump  formation.  While 
the  regularity  with  which  the  typical  Widal  reaction  is  ob- 
tained is  sufficient  evidence  of  the  rarity  of  this  form  of  the 
disea.se,  the  author  thinks  that  those  not  altogether  uncom- 
mon cases  in  which  the  reaction  never  appears  are  explica- 
ble on  this  ground,  and  recommends  that  in  all  such  a  bac- 
teriological examination  of  the  blood  be  made. 

A  Contribution  to  the  Study  of  Polyneuritis  Puerperalis. — 
j\I.  llinkiewicz  describes  a  case  of  multiple  neuritis  begin- 
ning in  the  latter  half  of  pregnancy  and  undergoing  sud- 
den exacerbation  immediately  after  labor.  Neither  the 
history  nor  the  physical  examination  shed  any  light  on  the 
causation  of  the  disease,  which  first  involved  mainly  the 
lower  extremities  and  later  became  seated  in  the  arms. 
The  labor  was  a  perfectly  normal  one,  and  there  were  no 
signs  of  septic  infection  either  intra-  or  post-partum. 
Medication  seems  to  have  bad  no  effect  whatever  on  the 
course  of  the  trouble,  which  lasted  for  five  months,  at  the 
end  of  which  time  the  paiieut  made  an  apparently  perfect 
recovery. 

The  Physical  and  Medicinal  Analysis  of  Mineral  Waters. 
— By  H.  Koppe, 

Right-  and  Left -Handedness. — By  Hecht  and  Langstein. 

Is  Alcohol  a  Food  or  a  Poison  ? — By  Kassowitz. 

French  Journals. 

Operations  on  the  Prepuce. — S.  Beruheim  draws  the  follow- 
ing conclusions  from  the  experience  of  a  long  practice  :  ( i ) 
The  prepuce  is  an  organ  often  presenting  congenital  or  ac- 
quired malformations  of  very  irregular  form.  These  mal- 
formations, annoying  during  infancy,  may  become  the 
point  of  departure  in  tlie  formation  of  bad  habits  (mastur- 
bation) or  of  infirmities  (retention  or  incontinence  of  urine) . 
During  adult  life  they  constitute  an  impediment  to  sexual 
congress  and  favor  all  kinds  of  infectious  inoculations 
(chancroids,  syphilis,  blennorrhagia,  epithelioma,  tuber- 
culosis). At  times,  too,  they  are  the  direct  cause  of  steril- 
ity. It  is,  therefore,  well  to  examine  this  anatomical  organ 
in  all  new-born.  Preputial  adhesions  may  be  ruptured, 
the  preputial  orifice  may  be  dilated,  or  a  piece  excised  so 
as  to  permit  liberation  of  the  glans.  Circumcision  is  the 
most  salutary  procedure,  and  useful  from  different  moral 
and  material  points  of  view. — Journal  ilc  Meilecine  fte 
Paris,  August  I2,  1900. 

Pathology  of  the  Initial  Sclerosis  in  Syphilis. — Ehrmann, 
of  Vienna,  has  proved,  by  the  artificial  injection  of  the 
blood-vessels  and  lymphatics  in  chancre,  that  the  contagion 
advances  principally  by  way  of  the  lymphatics  coming  off 
from  tlie  region  contaminated.  The  virus  in  spreading  in 
the  lymphatics  produces  an  irritation  in  the  network  of 
blood  capillaries  surrounding  the  lymjiliatics,  and  causes 
the  latter  to  become  filled  with  lymph  cells  destined  to 
combat  the  virus.  In  consequence  of  these  observations 
the  writer  has  practised  upon  the  chancre  electric  diffusion 
with  corrosive  sublimate.  In  this  way  he  has  prevented 
the  production  of  secondary  symptoms  in  .some  cases  treated 
during  the  first  fortnight  following  contagion  and  before 
the  appearance  of  regional  adcnojiathy.  Electric  diffusion 
is  a  very  simple  procedure  applicable  to  all  cases  seen  early. 
— /.£■  Bulletin  Meilieal.  August  11,  ic;oo. 

Treatment  of  Neurasthenia.— He  Fleury,  in  a  report  upon 
the  treatment  of  nerve  prostration,  comes  to  these  conclu- 
sions :  (I)  In  the  genesis  of  the  symptoms  of  neurasthenia 
it  seems  proven  that  the  brain  initiates  and  that  the  other 
symptoms,  and  notably  the  gastric  symptoms,  are  secon- 
dary. The  gastric  state  does  not  cause  the  mental,  but  it 
aggravates  and  keeps  it  up.  (2)  The  brain  is  the  origin 
of  all  the  symiHoms,  but  not  the  brain  as  an  organ  of 
thought.  The  fixed  idea  is  not,  as  in  hysteria,  a  generator 
of  symptoms,  (3)  The  fatigue  of  the  nervous  centres  en- 
genders a  general  functional  paresis  which  has  its  reflec- 


September  i,  1900] 


MEDICAL    RECORD. 


347 


tion  in  the  feelings.  Treatment  must  be  based  upon  this 
conception. — Gazette  Hebdomadahe  de  Medecine  ct  de 
Chirurgie,  August  9,  1900. 

Bit  I  lei  ill  (>f  /o/i>is  Hopkins  Hospital,  /illy  and  ^i  iij^'-. ,  igoo. 

A  Comparative  Study  of  Some  Members  of  a  Pathogenic 
Group  of  Bacilli  of  the  Hog  Cholera  or  Bacillus  Enteritidis 
iGaertneri  Type,  Intermediate  between  the  Typhoid  and 
Colon  Groups. — Harvey  Cushing  describes  a  bacillus,  the 
bacillus  O,  which  is  intermediate  between  the  typhoid  and 
oloii  groups,  the  clinical  signiticance  of  which,  asadetinite 
Ivpe,  has  been  much  neglected.  It  possesses  the  morpho- 
logical and  motile  properties  of  Eberth's  bacillus,  but  dif- 
fers from  this  organism  in  the  fermentation  reactions,  pro- 
ducing gas  in  the  presence  of  glucose  and  other  more  easily 
fermentable  carbohydrates.  Its  chief  characteristic  differ- 
ence from  the  bacillus  of  Escherich  rests  upon  the  fact  that 
fermentation  in  various  media  made  from  milk  does  not  pro- 
duce sufficient  acidity  to  precipitate  the  casein,  but,  on  the 
contrary,  the  acid  jiroduction  is  but  a  transient  process  and 
is  followed  in  the  presence  of  air  by  a  prompt  (two  to  three 
days)  and  distinguishing  alkalinization  of  the  media,  which 
furnishes  a  ready  means  of  differentiation  from  both  the 
typhoid  and  colon  type.  The  author  demonstrates  that  tlie 
definiteness  of  the  serum  reactions,  pathogenicity,  and  per- 
petuation of  cultural  features  of  these  bacilli  justify  the 
placing  of  them  in  a  separate  group. 

I.  Primary  Carcinoma  of  the  Appendix  Vermiformis.  II. 
Carcinoma  of  the  Appendix  Secondary  to  Carcinoma  of  the 
Ovaries. — Elizabeth  llurdon  describes  two  cases.  The 
diagnosis  of  this  affection  is,  of  course,  extremely  diffi- 
cult, owing  to  the  absence  of  distinctive  symptoms  in  the 
early  stages.  Our  attention  is  first  directed  to  the  iliac 
region  by  the  onset  of  pain  and  the  presence  of  tume- 
faction, and  when  these  arc  manifest  the  growth  is 
usually  well  advanced.  There  is  ordinarily  no  interference 
with  the  digestive  function  until  the  growth  has  invaded 
the  ca.'cum  or  the  large  or  small  intestine.  The  diseases 
for  which  carcinomatous  appendix  is  most  apt  to  be  mis- 
taken are:  cyst  of  the  appendix,  calculi,  tuberculosis  of 
the  so-called  neo])lastic  form,  impacted  fa'ces  in  the  Ccecum 
or  small  intestine.  In  man)'  instances  only  an  exploratory 
section  will  enable  one  to  make  a  positive  diagnosis.  If 
the  appendix  is  found  to  be  the  seat  of  a  new  growth,  in 
order  to  secure  its  complete  removal  the  head  of  the  colon 
should  be  resected,  and  should  the  growth  have  visibly  ex- 
tended beyond  the  appendix  a  more  e.xtensive  resection 
may  be  indicated. 

A  Case  of  Transient  Spastic  Convergent  Strabismus. — 
Sainuel  Tlieoljald  reports  a  case,  due  in  all  probability  to. 
an  irritation  of  influenzal  origin  of  the  innervation  centre 
which  controls  the  associated  action  of  the  internal  recti 
muscles.  It  disappeared  under  the  influence  of  atropine, 
a  normal  muscle  balance  being  re-established  in  a  few  days. 

Charles  Frederick  Wiesenthal,  Medicinse  Practicus,  the 
Father  of  the  Medical  Profession  of  Baltimore. — By  Eugene 
F.  Cordell. 

On  the  Present  Status  of  Therapy  and  its  Future. — By 
Lewellys  F.  Barker. 

T/te  Edinburgh  Medical  Journal,  August,  igoo. 
The  Feeding  of  Phthisical  Patients  in  Relation  to  the 
Wasting  of  the  Body. — Vincent  Dormer  Harris  says  that 
the  object  we  should  aim  at  is  not  to  increase  the  weight 
of  the  patient  by  a  mere  deposition  of  fat,  but  rather  to  set 
up  a  more  healthy  metabolism  in  the  tissues,  and  espe- 
cially in  the  muscles,  in  which  so  much  of  the  active  metab- 
olism takes  place.  With  this  object  in  view,  it  would  seem 
to  be  unwise  to  increase  any  one  of  the  three  varieties  of 
food  stuff  to  any  large  extent,  at  the  e.xpense  of  the  others, 
but  if  any  is  to  be  increased  it  should  be  the  proteid.  Food 
should  be  given  in  the  most  appetizing  form  possible,  well 
cooked,  and  in  variety.  Preserves,  honey,  and  marmalade 
with  breakfast  are  good,  and  relishes  frequently  stimulate 
the  appetite.  Fat  may  be  given  as  cream,  fre.sh  or  clotted, 
bone  marrow,  yolk  of  eggs  in  wine,  caviar,  fish  roes,  etc. 
Frequent  small  meals  often  help  to  overcome  anorexia. 
The  author  has  little  confidence  in  increase  of  weight  ex- 
hibited by  patients  who  are  lying  down  and  inactive  mf  st 
of  the  day,  but  progressive  increase  in  weight,  maintained 
while  the  daily  amount  of  exercise  is  gradually  increased, 
appears  to  be  of  real  value  as  an  indication  of  improved 
tissue  metabolism. 

Suppression  of  Urine  Following  Cystitis.— J.  Lamond 
Lackie  reports  a  case  of  chronic  cystitis  ;  there  was  double 
infection  of  the  kidneys,  but,  strange  to  sav,  there  were  no 
symptoms  pointing  to  renal  affection  until  a  short  time  be- 
fore death,  when  complete  suppression  of  urine  occurred, 
and  even  then  the  patient  did  not  feel  especially  ill  until 
complete  anuria  had  existed  for  ten  days.  After  that  oc- 
currence, there  was  a  continuous  flow  for  eight  days,  and 
again  for  four  days  before  death  no  renal  secretion  occurred. 


The  Treatment  of  Simple  Goitre  in  Young  Adults.  —  George 

K.  Murray  calls  attention  to  the  satisfactory  results  ob- 
tained by  the  treatment  ol  some  forms  of  enlargement  of 
the  thyroid  gland  by  thyroid  extract.  Exophthalmic  goitre 
must  be  excluded,  for  its  symptoms  are  often  aggravated 
by  this  treatment.  Liquid  thyroid  extract  or  dry  thyroid 
may  be  given  ;  the  author  uses  the  officinal  preparations, 
giving  of  the  former  m  xv.  twice  or  thrice  a  day.  and  of 
the  latter  gr.  iii.  or  more  two  or  three  times  a  dav.  He 
reports  three  cases  which  illustrate  his  point. 

The  Action  of  the  Heart  in  Mitral  Stenosis.— C.  C.  Gibbes 
discusses  the  various  theories  held  in  regard  to  the  mechan- 
ism of  this  disease,  and  says  in  conclusion  that  he  considers 
the  predominant  feature  of  mitral  stenosis  to  be  a  want  of 
synchronism  in  the  action  of  the  two  ventricles,  the  right 
assuming  in  part  the  function  as  well  as  the  rhythm  of  the 
left  auricle. 

Points  of  Practical  Interest  in  Surgical  GynsBcology.  IV. 
— Conservatism  and  its  Influence  on  Operative  Technique. — 
By  H.  Macnaughton  Jones. 

Uretero-Vaginal  Fistula,  with  Notes  of  a  Case  for  which 
Uretero-Cystostomy  was  Performed. — By  E.  Arthur  Gibson. 

Remarks  on  the  Treatment  of  Dacryocystitis  and  Lacrymal 
Obstruction. — By  \V.  Ernest  Thomson. 

Duhlin  Medical  Journal,  August,  rgoo. 

Pemphigus  with  Erythema  Circinatum. — H.  C.  Drury  re- 
ports the  case  of  a  boy  aged  fourteen  years,  with  a  scanty 
eruption  on  the  face,  chest,  and  arms,  consisting  of  groups 
of  small  vesicles  for  the  most  part  the  size  of  boiled  sago 
.grains,  .some  few  being  the  size  of  small  peas  ;.  there  were 
a  few  on  the  eyelids  and  cheeks,  also  a  few  scattered  about 
the  chest  and  arms.  In  the  course  of  twenty-four  hours 
he  developed  a  most  extensive  gyrate  or  circinate  erythema 
over  the  entire  trunk  and  upper  parts  of  arms  and  legs. 
This  consisted  of  larger  and  smaller  circles,  sharply  marked 
off  from  the  healthy  skin  by  a  distinctly  raised  margin. 
These  circles  were  of  a  bright  red  color,  somewhat  paler  in 
the  centre  than  at  the  margins;  some  were  separate,  but 
many  coalesced,  forming  large,  irregular  gyrate  patches. 
The  vesicles  seen  on  the  previous  day,  though  still  for  the 
most  part  small,  were  a  little  larger  than  before.  On  the 
next  day  the  erythema  had  faded,  though  the  evidences  of 
it  had  not  disappeared.  The  whole  body  was  mapped  out 
by  gyrate  markings  ;  the  margin  still  could  be  felt  b)- the 
linger  to  be  distinctly  raised  ;  inside  this  the  patch  showed 
a  very  faint  brownish  discoloration,  which  when  viewed 
from  a  distance  was  distinctly  seen,  but  when  looked  at 
closely  could  hardly  be  said  to  be  different  from  the  healthy 
skin  outside  the  bounding  ridge.  In  addition  to  this,  how- 
ever, a  great  increase  had  occurred  in  the  size  and  number 
of  the  vesicles  and  bulhe.  For  six  or  seven  days  after  ad- 
mission the  bullaj  increased  in  number  and  size,  this  latter 
feature  being  due  partly  to  increas.e  in  individual  bulla;, 
but  chieflj'  to  the  coalescing  of  .several,  so  that  huge,  irregu- 
lar bags  of  fluid  were  formed,  measuring  in  some  cases  as 
much  as  three  inches  by  two  inches.  The  patient  did  well 
on  arsenic,  and  was  discharged  on  the  twenty-first  day  of 
treatment  in  good  condition,  though  not  entirely  well. 

Remarks  on  Dupuytren's"  Contraction  of  the  Palmar  Fascia. 

— J.  Knott  saw  five  cases  in  old  soldiers  whom  he  examined 
for  pensions.  Two  of  them  had  the  lesions  of  chronic 
rheumatic  arthritis.  In  all  the  contraction  engaged  the 
ring  finger  of  the  right  hand  and  passed  to  the  little  finger 
of  the  same  side.  The  corresponding  fingers  of  the  left 
hand  had  afterward  become  affected,  but  always  to  a 
slighter  degree.  Several  other  cases  are  also  alluded  to. 
Knott  gives  a  history  of  the  literature  of  this  affection,  and 
makes  an  interesting  digression  concerning  the  place  of 
the  ring  finger  in  classical  studies  on  the  hand.  In  every 
instance  he  has  examined  he  has  found  some  evidence  of 
the  coexistence  of  what  he  calls  the  fibroid  diathesis.  He 
believes  that  the  skin  is  involved  as  well  as  the  deeperstruc- 
tures.  The  relationship  of  the  palmar  fascia  to  the  over- 
lying skin  also  contributes  to  give  to  this  condition  some 
of  its  peculiar  features.  Anatomists  are  familiar  with  the 
fact  that  the  separation  of  the  skin  from  the  subjacent 
"deep  fascia  "  presents  special  difficulty  in  the  case  of  the 
palm  of  the  hand  and  sole  of  the  foot,  as  also  in  the  case 
of  the  scalp.  The  skin  in  these  localities  is,  so  to  speak, 
nailed  down  to  the  strong  fascia  beneath  by  vertical  pegs 
of  dense  fibrous  tissue.  This  arrangement  accounts  for  the 
fact  that  the  skin  cannot  be  pinched  up  in  these  places; 
also  that  the  subcutaneous  tissue  does  not  become  the  seat 
of  fatty  deposit  or  of  oedematous  infiltration  to  any  marked 
extent.  The  cirrhotic  process  had  had  the  effect  of  approx- 
imating the  surfaces  of  skin  and  fascia,  and  the  amount  of 
"granular  "  fat  normally  found  in  this  situation  was  reduced 
to  a  vanishing  quantity.  The  ring  finger  is  especially  in- 
volved because  it  is  a  place  of  least  resistance,  owing  to  the 
peculiar  arrangement  of  its  tendons. 


348 


MEDICAL    RECORD. 


[September  i,  1900 


The  Nose,  Cold  Feet,  "Tobacco"  Heart,  and  Convallaria 
Majalis. — H.  S.  Purdon  ascribes  the  cold  feel  and  redness 
of  the  uose  often  seen  in  smokers  to  the  weakened  action 
of  the  heart  from  tobacco  poisoning.  He  advises  conval- 
laria internally,  while  suggesting  calisthenic  exercises  with 
the  arms,  bending  the  body,  and  pressure  with  the  hands 
"off  and  on,"  over  the  epigastric  region,  which  help  to  re- 
store "tone"  to  the  heart.  For  the  cold  feet  and  in  all 
cases  of  any  redness  of  the  nose,  especially  in  tho.se  of  the 
female  sex,  no  matter  how  caused,  a  mustard  foot-bath  at 
night  for  ten  or  fifteen  minutes,  followed  by  brisk  friction, 
and  in  winter  a  "hot- water  bottle  "  in  bed,  is  most  useful  as 
well  as  comforting.  For  the  local  treatment  of  redness  of 
nose,  a  sulphur  and  calamine  lotion  rubbed  into  that  organ 
stimulates  the  skin  circulation  and  does  good  in  restoring 
a  natural  appearance  to  that  prominent  and  important 
organ. 

University  Medical  Magazine,  August,  igoo. 

Perichondritis  of  the  Larynx  in  Typhoid  Fever. — M.  How- 
ard Fussell  reports  two  cases,  both  occurring  during  con- 
valescence from  typhoid,  which  had  been  mild  in  one  case, 
severe  in  the  other.  In  both  the  laryngeal  symptoms  ap- 
peared after  some  sort  of  exertion  of  traumatism,  in  the 
one  swallowing  an  apple,  in  the  other  the  shock  of  opening 
a  rather  large  abscess.  In  both  the  severe  symptoms  came 
on  suddenly  and  threatened  life  in  a  very  few  hours.  In 
both  cases  there  was  early  some  slight  disturbance  of 
breathing,  in  one  some  hoarseness.  Operation  was  re- 
fused in  the  case  of  the  patient  who  swallowed  a  large 
piece  of  apple,  although  he  was  suffering  tortures  from  ste- 
nosis. He  died  in  three  days.  The  post-mortem  showed 
a  huge  abscess  of  the  cricoid  cartilage.  The  second  pa- 
tient recovered  after  tracheotomy.  He  wore  the  tube  con- 
stantly for  six  months.  The  patient^  remains  well,  with  a 
slight  stridor  in  breathing,  and  hoarseness  of  the  voice  and 
some  dyspnoea  on  exertion. 

A  Case  of  Migraine  with  Aphasia  and  Numbness  in  One 
Ann. — Samuel  McC.  Haniell  reports  the  case  of  a  young 
man  aged  twenty  years,  who  at  seventeen  years,  while 
preparing  for  the  final  e.xamination  of  his  college  year,  be- 
gan to  suffer  from  hemicrania.  At  the  beginning  of  the 
attacks  there  was  visual  disturbance,  with  a  peculiar  sensa- 
tion in  the  epigastric  region,  relieved  by  loosening  his  cloth- 
ing, then  numbness  with  loss  of  sensation,  first  in  the  little 
finger,  then  the  fingers  in  succession  and  the  thumb,  the 
hand,  and  the  forearm  to  the  elbow.  Following  this  there 
was  numbness  in  the  lip  and  one  side  of  the  nose,  and  on 
several  occasions  he  had  difficulty  in  speech.  The  head 
pain  began  very  shortly  after  these  phenomena,  gradually 
augmented,  became  very  severe,  and  subsided  in  from 
three  to  five  hours.  There  was  never  any  suggestion  of 
a  convulsive  seizure.  The  author  protests  against  the  view 
held  by  many  at  the  present  time,  that  migraine  is  closely 
allied  to  epilepsy. 

Malignant  Precocious  Syphilis. — H.  M.  Christian  has  seen 
eight  cases  during  the  past  two  years.  In  all  of  them  the 
precocious  type  of  the  disease  was  shown  by  the  early  ap- 
pearance of  ulcerative  and  pustulo-crustaceous  lesions, 
most  particularly  marked  upon  the  lower  limb.  Apart 
from  the  varying  forms  of  cutaneous  lesions  presented  by 
these  patients,  the  following  conditions  were  found  com- 
mon to  all ;  progressive  loss  of  flesh,  ansemia— the  result  of 
a  marked  leucocytosis — hectic  fever,  insomnia,  and  night 
sweats.  In  the  treatment  of  these  cases,  no  time  should 
be  lost  in  giving  mercury  by  the  mouth,  or  by  daily  inunc- 
tions, the  latter  being  the  more  suitable  method  of  em- 
ploying the  remedy.  Iodide  of  potassium  should  be  given 
in  ten-grain  doses  three  or  four  times  daily.  Tonic  and 
stimulating  methods  should  be  employed,  such  as  are  re- 
sorted to  in  the  treatment  of  any  wasting  disease. 

A  Case  of  Pneumonomycosis  due  to  the  Aspergillus  Fumi- 
gatus.  —  By  I^eonard  Pearson  and  Mazyck  Ravenel. 

Some    Personal    Observations  on   the  Plague. — By   H.    M. 

Miller. 

Revue  de  Medecine,  August  lo,  /goo. 

Diseases  of  the  Spinal  Cord  in  New-Born  and  Nursing  In- 
fants with  Hereditary  Syphilis. — iJe  Peters  gives  a  detailed 
study  of  eleven  cases,  in  which  various  forms  of  paralysis 
testified  to  affection  of  the  spinal  cord.  In  nine  cases  there 
was  the"  /•A^i.ftv/.f /(•//;/«;,'■,  "out  ward  deviation  of  the  wrists  ; 
in  two  paralysis  of  the  nucha  and  u]>per  extremities,  and 
in  nine  paralysis  of  the  upper  extremities  without  affection 
of  the  nucha.  The  author  gives  his  reasons  for  attributing 
the  paralyses  to  hereditary  syphilis.  Treatment  consisted 
in  friction  with  gray  ointment,  the  internal  use  of  calomel, 
and  tlie  administration  of  potassium  iodide  to  the  mother, 
and  was  followed  by  surprisingly  rapid  and  good  results. 

Acute  Dysenteric  Hepatitis. — Paul  Renilinger  concludes  a 
study  of  four  cases  of  this  affection  as  follows  ;     Dysentery 


is  capable  of  occasioning  either  acute  hepatitis  or  liver  ab- 
scess. The  diagnosis  between  these  two  affections  is  pos- 
sible, but  difficult.  Exploratory  puncture  will  solve  doubt 
and  will  precede  operation  in  the  case  of  abscess,  and 
bleeding  of  the  liver  in  the  case  of  hepatitis.  Whether  this 
bleeding  acts  simply  by  relieving  congestion,  or  by  with- 
drawing a  certain  number  of  micro-organisms  and  favoring 
leucocytosis,  it  is  followed  by  rapid  improvement  of  the 
local  and  general  conditions,  and  a  recovery  so  complete 
that  no  other  form  of  treatment  can  bear  comparison  with 
it. 

Simple  Persistence  of  the  Arterial  Canal. — By  G.  Gerard. 
A  continued  article. 

Sadism  at  Bullfights.— By  Charles  Fere. 


©ovrespondcncje. 

OUR   LONDON    LETTER. 

(From  our  Special  Correspondent.) 
WEATHER   CHANGES — ECHOES   FROM    IPSWICH. 

London,  August  17,  1900. 
We  are  still  awaiting  the  arrival  of  your  heat-wave.  Some 
of  the  weather-wise  say  it  has  been  turned  aside  by  the 
east  wind  from  Spain  ;  others  think  it  has  only  been  tem- 
pered thereby.  At  any  rate  we  have  had  a  week  of  de- 
lightful warm  summer  weather.  Yesterday  twelve  hours 
of  sunshine  at  a  bearable  temperature  has  made  us  forget 
the  wet  holiday  week,  and  to-day  is  nearly  as  fine,  though 
a  thunderstorm  seems  to  be  brewing. 

The  scandal  of  the  National  Hospital  for  Paralysis  and 
Epilepsy  advanced  a  stage  on  Saturday,  when  at  least  six- 
teen governors  seem  to  have  attended  the  meeting  ;  for  a 
resolution  of  the  boarc^  was  carried  by  fourteen  votes  to 
two,  that  "  it  is  inexpedient  to  grant  the  demand  of  the  staff 
for  direct  representation  on  the  board."  What  next?  I 
have  just  received  from  my  college  a  note  saying  that  on 
the  26th  ult.  it  was  resolved  to  circulate  again  a  resolution 
passed  on  the  25th  of  October,  iSSS,  in  the  following  terms  : 
"That  it  is  undesirable  that  any  fellow  or  member  of  the 
college  should  be  officially  connected  with  any  company 
having  for  its  object  the  treatment  of  disease  for  profit." 
It  seems  to  me  difficult  to  imagine  a  more  feeble  action  oa 
the  part  of  so  influential  a  college.  I  am  half  inclined  to 
think  it  an  impertinence  to  warn  nie  against  such  an  "un- 
desirable "  proceeding  ;  but  then  I  remember  there  are  some 
fellows  who  have  been  guilty. 

The  little  "odds  and  ends  "  gathered  from  conversations 
about  the  doings  at  Ipswich  are  sometimes  interesting  and 
often  reflect  floating  opinions  which  ma^-  not  find  other 
expression.  There  is  certainly  widespread  indignation  at 
the  amazing  eft'rontery  of  the  Council  in  endeavoring  to 
seize  all  the  authority  and  the  accumulated  funds  of  the 
association.  On  the  other  hand,  there  is,  perhaps,  an 
equally  widespread  indifference  as  to  what  the  wire-pullers 
may  do,  mingled  with  mild  contempt  for  everything  per- 
taining to  the  association,  except  in  relation  to  any  sign  of 
scientific  progress. 

A  curious  circumstance  connected  with  sectional  man- 
agement may  be  noticed.  In  some  sections  the  president 
announced  that  he  had  been  requested  not  to  deliver  a  for- 
mal address,  and  called  upon  the  openers  of  the  discussions 
to  proceed  with  their  papers  ;  in  other  sections  the  old  for- 
mality of  a  presidential  address  was  observed  without  re- 
mark ;  so  there  are  conjectures  as  to  whether  the  request 
was  general  or  partial,  and  inquiries  as  to  bj-  whose  author- 
ity the  requests  were  made.  Certainly  the  profession  has 
lately  had  a  surfeit  of  addresses,  and  the  time  of  the  sec- 
tions is  often  insufficient  for  adequate  discussion,  while 
sketches  of  what  has  been  done  are  of  little  interest  to 
audiences  supposed  to  be  devoted  to  the  departments  un- 
der review.  These  sectional  formalities  must  be  distin- 
guished from  the  three  addresses  before  the  whole  associa- 
tion, which  are  on  a  different  level.  I  gave  you  a  note  or 
two  on  that  in  medicine.  Dr.  Smyly's  address  in  obstet- 
rics should  interest  every  general  practitioner.  It  might 
well  be  summed  up  in  the  old  adage  against  "meddlesome 
midwifery,"  only  the  aphorism  was  thoroughly  applied  as 
to  every  up-to-date  measure. 

In  the  Psychological  Section,  Dr.  R.  P.  Smith  gave  an 
address  in  which,  admitting  the  increase  of  insanity  as  to 
which  so  much  has  been  said,  he  boldly  urged  the  neces- 
sity of  attacking  it  at  its  sources.  These  are  heredity,  alco- 
holism, and  syphilis.  Legislation  is  not  likely  to  forbid 
"  free  trade  in  marriage."  Probably  persons  who  have  even 
suffered  attacks  of  insanity,  will,  in  spite  of  the  risk,  con- 
tinue to  marry.  Many  have  done  so  with  disastrous  results. 
Others  who  have  not  actually  suffered  attacks  are  liable 


September  i,  1900] 


MEDICAL    RECORD. 


349 


through  heredity.  Then  there  are  the  cases  of  break-down 
after  marriage.  Further,  it  is  a  sad  fact  that  congenital 
imbeciles  and  chronic  epileptics  have  added  many  bad 
specimens  to  the  stock.  Should  |they  be  prevented  from 
marrying?  Dr.  Smith  would  say  yes,  but  how  to  do  it  is 
not  an  easy  problem.  The  second  most  powerful  cause  of 
insanity  is  alcoholism,  and  surely  it  would  be  easier  to 
deal  with  this  than  with  the  lirst,  but  though  the  subject 
is  ever  before  Parliament  no  really  practical  measure  has 
been  passed  restricting  the  influence  of  this  poison.  So 
we  go  on  building  new  asylums  at  enormous  cost  for  pre- 
ventable diseases,  and  no  doubt  shall  do  so  until  the  op- 
pressed rate-payer,  on  whom  are  heaped  the  costs,  rises  in 
his  might  and  insists  on  a  change.  The  third  source  of  the 
evil — syphilis — is  now  seen  to  be  more  active  than  was  sup- 
posed, and  it  is  unquestionably  more  difficult  to  restrict  it. 
Notification  is  the  popular  panacea  with  many,  but  I  doubt 
its  applicability  here.  Dr.  Smith  is  doubtful  'if  the  ensuing 
century  will  be  marked  by  an  arrest  of  insanity  in  these 
sources,  but  he  thinks  that  is  the  direction  in  which  our 
efforts  should  tend. 

In  the  Section  of  Diseases  of  Children,  Mr.  Muirhead 
Little  read  a  paper  dealing  with  one  hundred  and  fifteen 
cases  of  infantile  paralysis.  He  gave  full  details  of  the 
deformities  met  with  and  the  muscles  that  suffered.  These 
statistics  brought  out  the  fact  that  has  been  before  noted, 
that  the  left  lower  limb  is  more  often  attacked  than  the 
right  and  that  the  tibiales  anticus  and  posticus  were  far 
more  often  palsied  than  any  other  muscles,  and  the  quad- 
riceps e.xtensor  was  affected  twice  as  often  as  the  ham- 
strings. He  gave  details  of  eight  cases  in  which  teno- 
plasty was  performed,  and  of  four  in  which  he  had  stiffened 
the  ankle.  He  remarked  on  the  difficulty  of  deciding  how 
much  of  the  resulting  benefit  was  due  to  the  removal  of  the 
deforming  muscle  and  how  much  to  the  newly  constituted 
muscle.  In  the  discussion  which  followed  speakers  had 
nothing  to  say  on  the  statistical  part  of  the  paper,  but  con- 
fined themselves  to  di.scussing  the  operations.  The  gen- 
eral feeling  was  distinctly  in  favor  of  tenoplasty,  and  es- 
pecially of  Kicoladoni's  operation. 

As  we  are  engaged  in  war,  and  much  heart-searching 
as  to  our  preparations  for  it,  the  new  Section  on  Army, 
Navy,  and  Ambulance  naturally  attracted  attention.  The 
past,  present,  and  future  of  the  Royal  Army  Medical  Corps 
was  discussed.  So  was  the  volunteer  medical  organiza- 
tion. The  necessity  of  increasing  both  is  becoming  a  con- 
viction on  the  part  of  the  public.  A  motion  was  carried  by 
Surgeon-Captain  Cantlie,  asking  the  Council  to  appoint  a 
committee  to  draw  up  a  scheme  to  submit  to  the  govern- 
ment for  reorganizing  the  medical  services  of  the  auxiliar}- 
forces  on  the  basis  of  the  system  of  the  Royal  Army  Med- 
ical Corps,  and  bringing  into  unison  the  medical  services 
of  the  regular  and  auxiliary  forces. 

Your  reporters  have  no  doubt  told  what  took  place  about 
the  journal  of  the  association.  Some  talk  of  Mr.  V.  Hors- 
ley's  "attack  on  the  editor  "  as  if  it  were  a  personal  affair, 
but  he  disclaimed  any  such  intention.  Others  say  it  was 
time  some  one  spoke  out,  and  it  was  well  that  a  strong  man 
undertook  the  task.  The  position  of  the  editor  is  no  easy 
one,  with  the  Council  and  journal  committee  and  members 
to  cater  for.  You  will  no  doubt  sympathize  with  him,  as 
I  do,  for  an  editor  in  harness  and  driven  by  conflicting  in- 
fluences may  well  stumble.  But  Dr.  Dawson  Williams  has 
really  raised  the  tone  of  the  journal  since  he  took  the  reins. 
Any  blame  about  the  articles  concerning  the  Exeter  Hall 
attempt  should  be  put  on  the  shoulders  of  the  wire-pullers, 
who  seem  to  have  concealed  from  the  editor  their  full  inten- 
tions, just  as  they  must  have  done  from  Dr.  Ward  Cousins, 
for  he  is  not  the  man  to  have  willingly  cajoled  his  hearers. 
If  you  read  between  the  lines  of  Mr.  Horsley'  s  speech,  which 
has  been  published  in  full  in  the  journal,  you  will  see  that 
he  did  not  really  attack  the  editor  personally,  but  only  hit 
out  at  the  others  through  the  official,  and  the  editor's  de- 
fence was  satisfactory  so  far  as  he  was  himself  concerned. 


THE  PLAGUE    IX    BEYROUT. 

(From  our  Special  Correspondent.) 

Bevrout,  July  21,  1900. 

Thev  have  left  the  city  and  gone  to  the  mountains  this 
time  with  a  vengeance  ;  not  because  the  summer  is  upon 
us  in  full  force,  but  for  another  reason,  to  wit,  the  "  plague  " 
was  "declared  "  about  fifteen  days  ago— on  Friday,  the  6th 
of  this  month.  It  came  about  in  this  way :  Three  men 
and  a  boy  aged  fourteen  years,  who  used  to  work  in  a  pit, 
a  cellar,  or  a  charnel-house,  whichever  you  like  to  call  it — 
their  occupation  being  the  making  of  sweetmeats,  no  less, 
for  the  multitude— fell  ill  suddenly.  They  came  out  of 
their  residence  and  had  a  promiscuous  and  heavy  meal, 
composed  of  I  don't  know  what,  but  I  have  been  informed 


that  the  symposium  was  a  mixture  in  one  course  of  sweets 
(of  course),  vegetables,  cheese,  melon,  raw  cucumbers, 
and  some  dishes  the  composition  of  which  is  a  mystery, 
fining  up  the  details  with  bread  and  onions  raw.  They 
had  been  fasting,  no  doubt,  these  three  men  and  a  boy, 
and  being  a-hungered  ate  heartily.  Then  the  end  came! 
All  three  were  stricken  down  with  vomiting  and  diarrhoea 
and  collapse. 

The  quarantine  officer,  or  the  port  medical  officer  of 
health,  was  sent  for  and  "declared"  the  malady  to  be 
"plague."  Other  medical  men  were  sent  to  consult  with 
him,  and  the  case  hung  fire,  the  consulting  physicians  be- 
ing opposed  to  the  diagnosis  (quick  as  it  was)  of  the  san- 
itary officer.  He  held  his  ground,  however,  and  on  Satur- 
day evening,  the  7th  of  July,  the  declaration  of  plague  was 
confirmed  in  Beyrout.  Then  came  the  stampede.  The 
plague  was  a  subject  of  further  investigation.  A  rabbit 
was  inoculated  with  the  blood  of  one  of  the  victims.  It 
fell  sick  unto  death.  All  in  Beyrout  were  hanging,  so  to 
speak,  on  the  life  of  the  little  rodent,  and  when  it  died, 
seventy  hours  after  the  inoculation,  there  was  a  panic. 
Twenty-five  thousand  inhabitants  left  the  town  in  one  duy. 
The  road  for  twenty-one  kilometres  (fourteen  English 
miles)  was  one  line  of  carriages,  outriders,  muleteers, 
camels,  baggage  carts,  and  mules  in  abundance  laden  with 
household  property,  donkeys  ditto,  men,  women,  and  chil- 
dren on  foot  tramping  up,  all  (except  the  beasts  of  bur- 
den) terror-stricken,  to  the  shelter  of  the  hills.  Not  know- 
ing the  circumstances,  one  could  not  well  have  said  whether 
it  was  a  grand  funeral  procession  or  an  invading  army. 

Then  the  amusing  part  comes  in.  As  I  said,  "  la  Peste  " 
was  confirmed  on  Saturday  evening,  the  7th  inst.  Now  all 
the  merchants  here  send  their  families  to  "  the  mountains, " 
going  to  visit  them  from  Saturday  till  Mondav.  returning 
on  that  day  by  the  early  train  to  look  after  their  various 
businesses,  from  the  banker  to  the  man  who  sells  you  a  yard 
of  tape.  All  these  went  off  in  the  best  of  health  and  iii  the 
enjoyment  of  good  spirits  on  that  fatal  Saturday  afternoon 
— to  come  back  no  more.  On  the  night  or  evening  of  that 
fated  or  fatal  Saturday  all  communication  by  rail  or  road 
was  cut  off — no  one  and  nothing  was  allowed  to  cross  the 
frontier  to  the  highlands,  so  that  the  train  our  friends  were 
waiting  and  waiting  for  never  came.  It  was  lying  snugly 
without  a  sign  of  life  in  Beyrout  station.  It  used  to  be 
full  of  energy  early  of  a  morning,  puffing  its  little  .soul  out 
to  be  in  readiness  to  fetch  the  swarms  of  folks  from  Aleigh 
to  the  capital.  But  now  not  a  puff,  not  a  running  to  and 
fro — even  the  throttle  valve  was  silent ;  and  it  lay,  did  the 
little  engine,  stiff  and  stark  in  its  engine-shed.  The  news 
of  the  plague  surely  could  not  have  succeeded  in  putting 
out  its  fires  and  extinguishing  its  lights,  while  all  the 
multitude  waited  and  wept  for  it  in  breezy  Aleigh  with 
its  dust  by  day  and  its  fogs  by  night. 

On  the  top  of  this  came  the  "cordon  "  (of  course  Beyrout 
had  already  been  put  under  quarantine  to  outside  ports 
and  the  yellow  flag  hoisted) ,  by  which  we  mean  an  encir- 
cling line  of  armed  dragoons  surrounding  and  cutting  oft" 
the  town  and  suburbs  of  Beyrout  from  any  communication 
with  the  hills  of  Lebanon.  Did  it  end  there?  By  no 
means.  We  were  not  allowed  to  go  to  Lebanon,  and  Leb- 
anon was  not  allowed  to  come  to  us !  As  the  merchants 
could  not  come  down,  all  their  stores,  shops,  and  ware- 
houses are  closed,  or  most  of  them,  and  only  that  we  are 
not  enlivened  by  an  occasional  shell  from  above,  and  in 
that  we  have  the  sea  open  to  us,  upon  our  word  it  looks 
like  another  Ladysmith.  No  vegetables  in  the  market, 
very  good  mutton,  and  very  bad  beef.  Thank  goodness 
we  are  few,  so  the  supply  of  the  latter  is  good  and  the  price 
has  gone  up  verj-  little.  Flour  has  gone  up,  however,  17.5 
per  cent.,  which  is  a  very  bad  thing  for  the  poor  in  our 
midst,  bread  and  herbs  being  their  sheet-anchor  to  save 
them  from  starvation.  The  principal  streets  are  being  re- 
paired and  macadamized  at  a  furious  pace — the  dens  and 
purlieus  of  the  inner  circle  of  the  bazaars  are  more  un- 
kempt and  filthier  than  heretofore. 

Should  this  plague  scare  turn  out  a  fiasco,  as  I  think  it 
will,  there  "will  be  trouble  in  the  town."  Somebody — I 
think  it  was  a  Jesuit  father — claims  to  have  discovered  the 
real  true  and  undeniable  bacillus  of  "la  peste."  "It  is 
not,"  I  am  informed  he  saj-s,  "the  absolute  bacillus,  but 
that  of  the  third  degree."  Well,  what  could  he  have  more? 
All  this  on  account  of  four  men  and  a  boy  aged  fourteen  who 
shut  themselves  up  without  sunlight — the  only  sun  was 
tl^^ir  candle  or  lamp — and  of  fresh  air  there  was  none, 
coming  out  of  their  burrow  and  filling  themselves  to  reple- 
tion at  a  temperature  of  about  90'  F.  in  the  shade.  Busi- 
ness is  stagnant,  merchants  will  lose  a  vast  amount  of 
money,  the  ships  refuse  to  land  or  take  cargo,  we  are  a  be- 
leaguered city — and  all  on  account  of  four  men  and  a  little 
boy  of  fourteen,  who  are  doing  merrily  and  well  after  their 
fifteen  or  sixteen  days'  experience  of  the  "Forest  " — a  grove 
of  stately  pine-trees  outside  the  city  wall. 

No  case  has  been  "reported  "  since,  and  the  health  of  the 
town,  considering  the  season,  is  practically  good. 


350 


MEDICAL    RECORD. 


[September  i,  1900 


Varicose  Veins. — 

1}  liarii  chloridi 2 

Aqiue  destil q.s.  ut  ft.  sol. 

Lanolini 60 

01.  amygdala"  dulc i 

M.     S.    Use  three  times  daily  with  friction,  where  blue  veins 
shine  through  the  skin. 

— Alex.  Rixa. 
Pruritus  Ani. — 

H  Fluid  extract  of  hamamelis i 

Fluid  extract  of  ergot 2 

Fluid  extract  of  hydrastis 2 

Compound  tincture  of  benzoin 2        ' 

Carbolized  olive  or  linseed  oil  (5  per  cent.)   I 

M.      S.   Shake  well   and   inject  from  one  to  three  drachms 
daily 

Paint  with  a  solution  of  silver  nitrate,  using  a  two- 
per-cent.  cocaine  solution  to  prevent  excessive  pain. 
After  two  or  three  burnings,  apply  citrine  ointment, 
cover  with  cotton,  and  secure  with  T-bandage. — - 
Adloe. 

Bites  of  Fleas,  Mosquitos,  Gnats,  etc — ■ 

IJ  01.  chamomilla:  camphorat too  parts. 

Liq.  styracis 20 

Spt.  menth.  pip 5 

M.      S.   Apply. 

—  Brocq  and  Jacquet. 
Hemorrhoids. — 

1}  Carbolic  acid,  saturated  solution 3  i- 

01.  olivje 3  ij 

M.      S.    Inject  five  or  ten  drops  into  each  tumor,  injecting 
as  the  needle  is  withdrawn. 

Reinsert  into  any  part  that  does  not  turn  white. 
Treat  all  tumors  at  one  sitting.  Smear  with  vaseUne, 
press  well  inside,  and  put  patient  to  bed. — Monroe. 

Paraldehyde  and  Chloroform  given  together  do 
away  with  the  period  of  excitement  and  cause  anass- 
thesia  more  rapidly  and  with  less  chloroform  than 
when  the  latter  is  used  alone. — Cosimo  Noto. 

Closed  Inhalers  are  cumbersome,  unclean,  unscien- 
tific, and  dangerous.  The  best  inhaler  is  the  simplest; 
one  made  with  a  towel  or  an  "'  Allis  "  for  ether,  and  a 
folded  towel  for  chloroform. — H.  A.   Hare. 

Naevi,  Lupus,  and  Scar  Tumors  may  be  treated 
with  advantage  by  the  elastic  bandage.  The  good 
results  are  due  to  pressure,  warmth,  and  moisture,  and 
protection  from  external  irritation.  The  band  may  be 
removed  every  day  so  that  it,  as  well  as  the  skin,  can 
be  thoroughly  cleansed. — Serenin. 

Lupus. — Calomel  may  be  injected  or  Robins'  pills 
given : 

H  Hydrarg.  chl.  corros., 
-Sodii  chloridi, 

Vin.  thebaic aa  1 

Mic.  panis 5 

Cluten 2.5 

Cilycerin 2-3 

M.    ft.  pil.  No.  c.      S.  One  to  three  daily  with  meals. 

Bleeding  from  the  surface  of  an  internal  organ  or 
from  a  single  vessel  may  be  checked  by  directing 
against  the  seat  of  hemorrhage  a  current  of  hot  air 
(39°  at  5  mm.)  from  the  Hollander  apparatus. — Za 
Semaine  Medicalc. 

Nasal  Stenosis  from  Defective  Septa.  — Kriefly 
this  operation  consists  of  four  steps:  i.  I'.uttonhole 
the  septum  at  the  point  of  greatest  obstruction,  and 
incise  obstructing  ridges  or  convexities  in  the  line  of 
convexity.  2.  Break  with  forceps  all  fibrous  bands 
and  separate  the  cartilage  from  the  superior  maxillary 


spine  at  the  floor  of  the  nose.  3.  Overlap  cut  edges 
and  introduce  splints.  4.  Treat  antiseptically  for  tvi'o 
weeks.  It  restores  the  entire  septum  to  its  normal 
position,  corrects  slight  external  deformities,  and 
leaves  both  surfaces  of  the  septum  parallel.  It  is 
adaptable  to  all  forms  of  deformities  or  deflections. 
No  perforations  result,  no  granulation  tissue  is  left 
behind,  and  better  and  more  uniform  results  have  been 
obtained  by  me  than  by  other  methods. — Beaman 
Douglass,  in  the  Laryngscope,  June,  1899. 

Strabismus  should  be  treated  early  with  glasses  and 
parents  be  made  aware  of  the  following  dangers  of 
neglect  in  this  particular:  Permanent  cross-eyes, 
partial  blindness;  necessity  of  operation  in  after 
years  which  will  straighten  the  eyes  but  will  not  cure 
the  blindness. 

In  Resection  of  the  Gasserian  ganglion  the  sphe- 
noidal sinus  should  be  guarded  against  injury  and  in- 
fection which  might  have  fatal  results.  There  is  less 
danger  by  the  Krause-Hartley  than  by  the  pterygo- 
maxillary  route. — O.  Jacob. 

In  Heat-stroke  with  convulsions  and  oedema  of  the 
lungs,  the  patient  was  benefited  by  venesection. — C. 
Klein. 

Fracture  of  the  Nose  in  its  Upper  Portion.— 
Waste  no  time  in  an  attempt  to  replace  the  bones  from 
the  inside  nor  in  applying  plasters,  etc.,  externally, 
but  make  a  median  incision  and  replace  the  fragments, 
holding  them  in  place  with  fine  stitches. — Budinger. 

To  Preserve  Rubber  Articles  keep  them  in  a  one- 
per-cent.  solution  of  formol  or  zinc  chloride,  or  a  con- 
centrated solution  of  boric  acid.  They  should  never 
be  left  exposed  to  the  air  or  to  the  action  of  cold. — 
Krolikovski. 

Linen  is  entirely  unsuited  for  the  proper  application 
of  ointments  to  the  skin,  and  still  it  is  popularly 
thought  essential. 

Late  Union  is  more  apt  to  occur  in  fractures  of  the 
upper  third  of  the  humerus  than  elsewhere;  a  prog- 
nostic point  to  bear  in  mind. 

Iodoform  Odor  may  be  removed  from  the  hands  by 
thorough  washing  in  vinegar  after  the  use  of  soap  and 
water. 

Extemporized  Dressings. — Cheesecloth  cut  into 
strips  or  squares  is  rendertd  alkaline  by  boiling  for 
twenty  minutes  in  a  solution  of  washing  soda  (two 
ounces  to  a  quart),  then  wrung  out  and  boiled  again  in 
clear  water,  previously  boiled  and  allowed  to  settle. 
It  is  then  passed  through  a  bichloride  solution  ( i  :  200) 
and  packed  moist  in  jars  previously  sterilized  or 
washed  in  bichloride  solution  (1:200).  Just  before 
using  it  is  wrung  out  in  bichloride  solution  \\  :  2,000). 
—  The  Clinical  Jicvira'. 

Note  on  a  Case  of  Webbed  Penis. — L.  Grounauer 
mentions  a  case  of  deformity  of  the  penis  in  a  child 
aged  seven  years,  submitted  to  operation,  and  calls 
attention  to  the  extreme  rarity  of  the  condition.  '1  he 
penis  portion  was  attached  to  the  scrotum,  drawn  up 
and  separated  from  the  pubic  region  by  a  marked 
furrow  which  dipped  down  upon  either  side  in  the  arc 
of  a  circle  to  near  the  fr.-enum.and  showing  externally 
the  separation  between  the  penis  and  scrotum.  The 
penis  was  drawn  down  so  that  the  meatus  looked  down- 
ward by  the  combined  adhesion  to  the  scrotum  and  a 
marked  shortening  of  the  penile  portion  of  the  urethra. 
An  operation  separated  the  parts  successfully  and 
restored  the  penis  to  approximately  normal  conditions. 
— A'ftiu  Meditale  tic  la  Suisse  Komainle,  July  20,  1900. 


September  i,  1900] 


MEDICAL    RECORD. 


;5i 


THE    BRITISH    MEDICAL   ASSOCIATION. 

Sixty-eightli  Annual  Aleeting,  Held  at  Jps-wicli,  July  ji, 
and  August  I,  2,  and  j,  igoo. 

(.Special  Report  for  ihe  Medical  Record.) 
SECTION   OF   GENER.-VL   MEDICINE. 

( Concluded  front  page  Jiq. ) 

Second  Day — Thursday,  August  2d. 

The  Problem  of  Gastric  Ulcer.  —  This  discussion 
was  opened  by  Dr.  J.  F.  Pavne,  of  London,  who  said 
he  would  present  several  problems,  discussion  upon 
which  he  trusted  would  prove  of  interest.  He  first 
took  the  prevalence  and  mortality  of  gastric  ulcer  and 
showed  from  statistics  of  upward  of  six  hundred  cases 
spread,  over  a  period  of  thirty  years  that  the  disease 
was  apparently  increasing  both  in  prevalence  and 
mortality.  He  could  find  no  satisfactory  explanation 
for  this,  but  thought  it  was  suggestive  that  the  same 
held  true  for  other  abdominal  diseases.  He  had 
looked  up  the  records  of  appendicitis  for  twenty  years, 
and  there  seemed  to  be  an  enormous  increase  in  this 
disease,  which  he  put  down  to  better  methods  of  diag- 
nosis. He  said  that  cancer  of  the  digestive  organs 
had  increased  more  than  cancer  of  other  organs,  and  ty- 
phoid more  tiian  other  zymotic  diseases.  He  was  not 
prepared  with  an  explanation.  The  next  question  he 
brought  forward  was  that  of  diagnosis,  and  he  asked 
whether  all  cases  so  diagnosed  were  really  gastric 
ulcers.  He  reviewed  in  detail  some  of  the  main  symp- 
toms, and  pointed  out  that  the  principles  of  diagnosis 
were  with  one  exception  the  same  thirty  years  ago  as 
now.  The  only  new  symptom  of  importance  was  that 
of  hyperacidity  of  the  gastric  fluid,  of  which  he  would 
speak  later  on.  With  regard  to  the  typical  pain  in  the 
stomach  after  food,  circumscribed,  often  severe,  and 
associated  w'ith  circumscribed  tenderness,  he  had  found 
that  it  was  absent  in  the  majority  of  his  cases.  \'omit- 
ing  was  recorded  in  more  tiian  half.  He  was  surprised 
to  find  that  hemorrhage  was  often  absent  in  fatal  cases, 
whereas  it  nearly  always  took  place  in  the  non-fatal. 
He  supposed  that  the  rapidity  of  a  fatal  termination 
by  perforation  was  the  explanation.  This  raised  the 
question  of  correctness  of  diagnosis.  Hnematemesis 
was  fatal  apart  from  gastric  ulcer.  He  had  collected 
one  hundred  and  four  cases,  and  he  had  found  that 
chronic  alcoholism  and  cirrhosis  of  the  liver  were  the 
most  common  causes  in  males.  Aneurism  was  rare. 
He  believed  that  a  strain  might  be  the  starting-point 
of  a  gastric  ulcer,  and  he  instanced  several  cases.  He 
came  to  the  conclusion  that  hemorrhage  from  the 
stomach  in  grown  men  was  most  commonly  due  to 
alcoholism,  but  that  in  the  young  and  in  women  gas- 
tric ulcer  was  the  most  frequent  cause.  He  now  re- 
ferred to  the  symptom  of  hyperacidity  of  the  gastric 
fluid,  to  which  attention  had  been  drawn  by  German 
writers.  They  nearly  always  detected  hydrochloric 
acid  in  excess,  and  considered  it  of  such  value  that 
they  washed  out  the  stomach  in  all  suspected  cases. 
They  believed  this  hyperacidity  a  cause  of  gastric 
ulcer.  Others,  on  the  other  hand,  had  not  found  it, 
but  it  became  a  question  how  far  it  was  allowable  to 
wash  out  the  stomach.  The  next  problem  w-as,  could 
a  distinction  be  made  between  acute  and  chronic 
ulcers,  and  he  believed  that  only  in  fatal  cases  which 
were  brought  to  the  post-mortem  table  could  we  distin- 
guish for  certain.  In  forty-eight  fatal  cases  the  symp- 
toms in  thirty-six  had  lasted  over  one  month  and  the 
appearances  were  those  of  chronic  ulcer;  in  twelve 
the  appearances  were  of  acute  ulcer  and  the  symptoms 


had  lasted  less  than  one  month.  He  found  of  non- 
fatal cases  that  in  thirty-four  per  cent,  the  symptoms 
had  lasted  one  month  or  less,  and  in  sixty-six  per  cent, 
they  had  been  present  for  more  than  one  month. 
Among  the  former  were  only  twice  as  many  females 
as  males,  while  the  females  in  the  latter  were  four  and 
one-half  times  in  excess  of  the  males.  He  knew  these 
figures  did  not  accord  with  Dr.  William  Feiiwick's.  He 
asked  of  if  there  was  any  criterion  of  acute  disease,  or 
whether  a  chronic  ulcer  was  anything  more  than  an 
acute  ulcer  grown  older.  Coming  to  the  problem  of 
etiology  he  considered  that  of  the  many  factors  which 
had  been  brought  forward  as  possible  causes  of  gas- 
tric ulcer  he  believed  the  theory  of  auto-digestion 
ofTered  perhaps  the  best  explanation.  It  would  at  all 
events  account  for  the  persistence  and  chronicily  of 
the  disease.  'I'he  precedent  conditions  were,  liowever, 
still  unexplained,  and  he  did  not  think  that  bacteriol- 
ogy helped  us  very  much  at  present.  As  regarded 
sex,  his  tables  showed  that,  of  those  who  died,  the 
sexes  participated  nearly  equally,  and  he  was  able  to 
point  out  that,  although  the  disease  was  commoner  in 
women,  it  was  relatively  much  more  fatal  in  men. 
The  male  mortality  took  place  principally  in  the  later 
periods  of  life,  the  female  in  those  under  thirty  years. 
The  proportional  mortality  for  all  cases  in  later  life 
was  high.  It  had  been  said  that  the  disease  was  most 
common  in  young  women  of  the  poorer  classes. 
Considering  the  enormous  numerical  preponderance 
of  the  poor,  he  doubted  if  this  were  true.  As  to  prog- 
nosis he  had  little  to  say  at  that  time,  but  he  believed 
that,  speaking  briefly,  in  the  young  it  was  good,  in 
the  elderly  bad.  On  the  subjest  of  morbid  anatomy 
he  would  only  say  that  he  did  not  take  the  occluded 
vessels  with  coagulation  of  their  contents — a  condition 
not  infrequently  found — as  evidence  of  thrombosis. 
He  strongly  advocated  treating  the  disease  by  rectal 
injections.  He  admitted  that  that  was  a  process  of 
slow  starvation,  but  pointed  out  that  by  allowing  the 
patient  to  drink  small  quantities  of  water  this  method 
could  be  employed  for  two  weeks  or  more.  He  de- 
precated the  employment  of  lumps  of  ice.  He  re- 
marked that  acetonuria  had  been  observed  in  rectal-fed 
patients.  .Acetone  in  the  urine  was  decidedly  com- 
mon in  other  conditions  than  diabetes,  especially  in 
alcoholic  dyspepsia,  and  he  regarded  it  as  due  to 
starvation. 

Dr.  Habershon,  of  London,  displayed  some  interest- 
ing tables  drawn  up  from  his  late  father's  private  note- 
book. They  supported  much  that  Dr.  Payne  had  said, 
and  went  to  show  that  gastric  ulcer  was  not  uncommon 
in  young  women  of  the  upper  classes.  He  thought  that 
there  must  be  some  very  potent  cause  for  the  prevalence 
of  this  disease  in  young  women.  There  were,  he 
maintained,  three  classes  of  cases  in  which  the  diag- 
nosis was  often  extremely  difficult.  They  were,  first, 
those  occurring  in  young  women  with  no  history  of 
haematemesis;  secondly,  the  neurotic  class,  in  which 
there  was  extreme  hyperesthesia  often  located  in  such 
situations  as  gave  rise  to  grave  suspicion  of  gastric 
ulcer.  In  this  connection  he  related  what  had  been 
handed  on  to  him  as  a  "  tip  "  in  dealing  with  this  class, 
and  which  he  had  found  to  be  of  the  greatest  possible 
practical  assistance,  namely,  that  while  pressure  was 
made  over  the  epigastrium  with  one  hand,  firm  pressure 
should  be  made  upon  one  of  the  carotids  with  the 
other.  He  found  in  this  way  that  the  imaginary  pain 
fled  in  a  remarkable  manner.  He  was  unable  to  say 
how  this  came  about,  but  he  suggested  that  it  acted 
either  by  cutting  otY  some  of  the  circulation  through 
the  brain  or  by  direct  pressure  upon  the  pneumogas- 
tric  nerve.  The  third  class,  which  he  found  difficult 
to  diagnose,  were  those  in  which  the  pain  was  relieved 
by  food.  It  was  in  these  that  the  ulcer  was  found  near 
the  pylorus. 


352 


MEDICAL    RECORD 


[September  i,  1900 


Dr.  \V.  Gordon,  of  Exeter,  reviewed  the  many 
well-known  theories  as  to  the  etiology  of  the  disease, 
but  he  did  not  attach  value  to  any.  He  set  aside  the 
idea  of  either  thrombosis,  embolism,  or  simple  sub- 
mucous hemorrhages  with  subsequent  auto-digestion, 
and  regarded  such  causes  as  trophic  lesions,  scalding 
food,  tight  lacing,  or  wounds  as  most  unlikely.  He 
believed  the  explanation  would  be  found  in  some  organ- 
ism associated  with  alkaline  reaction  of  the  gastric 
fluid.  On  this  account  he  very  strongly  advocated  the 
systematic  bacteriological  examination  of  all  excised 
ulcers.  Eight  or  nine  years  ago  he  had  an  opportu- 
nity of  examining  a  very  typical  example  of  acute  per- 
forating gastric  ulcer.  The  specimen,  which  had 
been  some  time  in  spirit,  showed  a  clean  circular  hole 
punched  out  as  it  were  in  the  stomach  wall,  with  no 
evidence  of  induration  or  even  swelling  around  it. 
Sections  into  the  surrounding  tissue  starting  from  the 
edges  of  the  ulcer  were  made,  and  stained  with  methy- 
lene blue  showed  what  was  at  least  suggestive.  The 
edge  of  the  ulcer  was  confused  and  almost  structure- 
less, having  apparently  undergone  digestion.  A  little 
way  from  the  edge  there  was  indication  of  a  certain 
amount  of  inflammation  with  aggregation  of  leucocytes, 
and  (what  impressed  him  most  at  the  time)  beyond 
the  leucocytosis  and  reaching  for  some  distance  into 
the  stomach  wall  were  numerous  cells  stuffed  with 
micrococci,  and  free  groups  of  micrococci  were  scat- 
tered in  the  tissue.  On  the  free  edge  of  the  ulcer 
there  were  also  microbes,  but  they  were  various,  both 
bacilli  and  cocci.  He  had  not  pursued  the  investiga- 
tion at  the  time,  for  it  seemed  to  him  that  without 
fresh  specimens,  i.e.,  specimens  excised  in  life,  no 
useful  result  could  be  arrived  at,  and  eight  years  ago 
excision  of  the  >alcer  was  not  even  spoken  of.  Now  in 
certain  cases  the  material  had  becomS  available,  al- 
though he  himself  had  had  no  opportunity  of  making 
use  of  it. 

Dr.  Calwell,  of  Belfast,  addressed  himself  to  the 
question  of  whether  it  were  not  possible  to  prevent 
adhesions  forming  from  gastric  ulcer.  He  strongly 
urged  the  importance  of  treating  even  slight  cases  of 
acute  dyspepsia  with  this  end  in  view.  His  practice 
was  to  advise  bed  and  complete  rest  for  days,  and  he 
did  this  because  it  was  his  belief  that  many  patients 
suffering  from  acute  dyspepsia  had  as  a  matter  of 
fact  small  gastric  ulcers.  He  said  the  presence 
of  adhesions  had  been  denied,  but  he  had  evidence  of 
strong  adhesions  in  sixteen  cases  upon  v.hich  he  had 
operated.  One  of  these  patients  had  had  an  attack  of 
epigastric  pain  on  making  a  sudden  movement.  He 
related  a  case  of  acute  hemorrhagic  pancreatitis  in 
which  he  had  found  adhesions  to  the  pancreas. 

Dr.  Juli.\  Cock.,  of  London,  related  two  very  in- 
teresting cases  which  pointed  to  difficulty  in  diagnosis. 
In  both,  the  symptoms  simulated  gastric  ulcer.  The 
first  was  that  of  a  young  girl  ^ith  all  the  symptoms  of 
gastric  ulcer,  including  hasmatemesis,  which  was  severe 
and  for  which  she  was  admitted  to  hospital.  She  was 
under  observation  for  some  weeks,  lier  symptoms  be- 
ing always  such  as  to  suggest  gastric  ulcer.  The 
question  of  laparotomy  was  raised.  At  the  post-mor- 
tem there  was  subphrenic  abscess  with  pleurisy  and 
pneumonia  from  extension,  while  there  was  absolutely 
no  explanation  for  the  hemorrhage.  Miss  Cock 
thought  that  in  young  women  hasmatemesis  without 
ulcer  was  more  common  than  was  supposed.  The 
second  patient  was  an  older  woman,  and  her  symptoms 
spread  over  a  period  of  eight  years.  At  first  she  pre- 
sented the  typical  symptoms  of  gastric  ulcer,  having 
several  attacks  of  pain  and  hnematemesis;  she  was 
also  phthisical.  A  laparotomy  was  performed  for 
symptoms  of  perforation  and  the  stomach  was  found 
healthy.  An  interval  elapsed  which  was  followed  by 
recurrence  of  the  pain  which  now  became  constant.     A 


second  laparotomy  was  done  and  chronic  adhesions 
were  found  and  divided.  The  stomach  was  perfectly 
healthy. 

Dr.  Newton  Pitt,  of  London,  had  long  held  the 
view  that  ha;matemesis  in  young  women  was  not  neces- 
sarily due  to  gastric  ulcer.  He  had  been  struck  by 
the  wide  divergence  between  the  clinical  and  the  post- 
mortem evidence.  He  himself  had  made  two  autopsies 
on  patients  with  haematemesis  and  had  found  no  cause 
for  the  hemorrhage.  He  related  a  similar  case  to 
Miss  Cock's,  and  suggested  that  hasmatemesis  should 
be  the  diagnosis  until  there  was  positive  evidence  of 
gastric  ulcer.  On  the  other  hand,  hemorrrhage,  as 
shown  by  Dr.  Payne,  was  often  absent  in  fatal  cases. 

Mr.  \V.  Stuart  Low,  of  Kirkbank,  after  some  re- 
marks on  the  anatomical  relations  of  the  stomach,  said 
that  he  had  had  very  good  results  from  the  use  of 
mucin,  which  he  tried  in  ten  cases  of  acute  dyspepsia, 
the  pain  and  constipation  being  speedily  relieved. 
He  considered  this  to  be  a  logical  method  of  treatment 
when  the  position  of  the  mucous  secreting  glands  of 
the  stomach  was  remembered.  They  were  nearest  the 
surface  and  suffered  most.  He  dieted  his  patients 
carefully,  but  objected  to  peptonized  foods  and  rectal 
feeding. 

Dr.  Pye-Smith,  of  London,  remarked  on  the  differ- 
ence between  the  clinical  and  the  post-mortem  evidence 
in  respect  to  the  age  and  sex  incidence  of  the  disease 
under  discussion.  He  had  collected  cases  which  en- 
tirely bore  out  what  Dr.  Payne's  tables  show-ed.  He 
was  much  interested  in  Dr.  Gordon's  suggestion  as  to 
the  pathology,  and  agreed  that  a  bacteriological  in- 
vestigation of  the  freshly  excised  ulcer  was  likely  to 
help  us  to  an  explanation  of  the  exciting  cause.  He 
considered  that  it  was  important  to  bear  in  mind  the 
different  appearances  that  an  acute  perforating  ulcer 
and  a  chronic  funnel-shaped  ulcer  presented.  He  was 
familiar  with  these  cases  of  hjematemesis  occurring 
in  young  women  without  any  apparent  cause,  and 
likened  them  to  the  nose-bleedings  from  which  boys 
so  often  suffered.  He  regarded  hceniatemesis  without 
ulcer  as  an  epistaxis  of  the  stomach,  so  to  speak.  He 
took  a  favorable  view  of  the  prognosis  in  cases  of 
hasmatemesis.  He  believed  that  it  might  be  said  with 
truth  that  hsematuria  was  never  fatal,  hasmatemesis 
from  gastric  ulcer  very  rarely,  and  haemoptysis  only 
occasionally.  He  advocated  treatment  by  rectal  feed- 
ing, and  agreed  that  small  draughts  of  water,  and  espe- 
cially warm  water,  not  only  were  harmless,  but  he 
believed  they  were  of  distinct  advantage. 

Dr.  Sauxdrv,  of  Dirmingham,  said  he  was  quite  at 
one  with  those  who  laid  stress  on  the  difficulty  of 
diagnosing  gastric  ulcer.  He  had  always  been  in  the 
habit  of  pointing  this  out;  but  at  the  same  time  he 
would  not  go  so  far  as  Dr.  Pitt,  for  in  that  case  it 
came  to  never  diagnosing  the  disease  ai  all  during  life. 
His  practice  was  to  speak  of  anasmic  gastralgia  until 
hemorrhage  occurred,  when  he  thought  it  was  safe  to 
diagnose  gastric  ulcer.  He  was  inclined  to  be  scepti- 
cal about  the  value  of  the  statistics  which  had  been 
brought  forward,  for  he  could  not,  from  his  experience, 
agree  that  gastric  ulcer  was  more  fatal  in  elderly 
people.  He  was  sure  that  haematemesis  from  gastric 
ulcer  was  very  rarely  fatal.  In  a  long  experience  at 
the  Birmingham  General  Hospital  he  had  had  only 
one  fatal  case.  His  routine  treatment  consisted  of 
rectal  feeding  for  twenty-four  to  fort)'-eight  hours;  he 
then  gave  milk  and  lime-water  in  gradually  increas- 
ing quantities.  He  usually  prescribed  a  mixture  con- 
taining the  sulphates  of  magnesium  and  iron,  advising 
his  patients  to  continue  this  for  a  considerable  period. 

Dr.  Poi'E,  of  Leicester,  said  that  no  mention  of 
drugs  had  been  made  throughout  the  discussion  ex- 
cept by  the  last  speaker.  He  himself  was  in  the 
habit  of  giving  his  patients  resorcin  in  doses  of  gr.  v. 


September  i,  1900] 


MEDICAL    RECORD. 


353 


He  believed  the  pain  and  discomfort  were  materially 
relieved  by  this  method  of  treatment. 

Dr.  I'avne,  in  his  reply,  said  he  was  somewhat 
disappointed  that  the  problem  of  prevalence  had  not 
been  touched  upon  by  any  of  the  speakers.  He  was 
interested  to  hear  Dr.  Gordon's  remarks,  and  was  in- 
clined to  believe  in  the  theory  of  the  bacterial  origin 
of  the  disease.  In  support  of  this  opinion,  he  had 
seen  in  one  autopsy  two  ulcers  occupying  such  positions 
that  when  the  walls  of  the  stomach  came  in  contact 
the  ulcers  closely  approximated  in  a  way  that  he 
thought  was  suggestive. 

Intermittent  Pulse. — Dr.  Arthur  R.  Cushnv,  of 
Ann  Arbor,  Mich.,  read  a  paper  on  this  subject.  He 
differentiated  four  types  of  irregularity,  ascribing  them 
to  excessive  or  deficient  contraction  of  auricles  or 
ventricles. 


Third  Day — Friday, 


August  jd. 


Explanation  of  So-Called  Imperfect  Aeration  Symp- 
toms of  Post-Nasal  Adenoids. — Dr.  McKeow.v,  of 
Manchester,  read  a  short  paper  with  this  title.  Head- 
ache, bad  memory,  stunted  growth,  etc.,  were  usually 
attributed  to  imperfect  aeration  of  blood,  but  he  was 
of  opinion  that  this  explanation  was  not  warranted, 
and  he  mentioned  several  reasons  in  support.  Often 
the  growths  were  too  small  to  form  sutficient  obstruc- 
tion. During  sleep,  the  mouth  being  kept  open,  the 
intake  of  air  must  be  ample.  The  symptoms  were  as 
a  rule  immediately  relieved  by  operation.  He  re- 
ferred to  the  anatomical  relation  of  the  growths  to  the 
sphenoidal  and  other  sinuses,  and  pointed  out  that 
headache  was  not,  as  a  rule,  caused  by  imperfect 
aeration  of  blood.  These  considerations  had  led  him 
to  seek  some  other  explanation,  and  he  suggested  that 
it  might  be  found  in  reHex  action. 

Very  few  members  had  as  yet  arrived,  and  no  dis- 
cussion took  place. 

The  Diastolic  Expansion  Movement  of  the  Ven- 
tricles as  a  Factor  in  Compensation  for  Disease  of 
the  Mitral  Valve Dr.  St..\cey  Wilson,  of  Birming- 
ham, followed  with  a  long  but  interesting  and  carefully 
prepared  paper  on  this  subject.  Unfortunately  the 
time  limit  (fifteen  minutes)  did  not  give  Dr.  Wilson 
an  opportunity  of  reading  more  than  half  the  matter  he 
had  prepared,  most  of  which  was  demonstrated  by  a 
series  of  cardiograph  tracings.  The  following  short 
epitome  of  his  argument  does  poor  justice  to  a  valu- 
able communication.  He  contended  that  the  ventric- 
ular expansion  movement  during  diastole  was  due  to 
active  expansion  of  the  muscular  fibres  and  not  merely 
to  passive  dilatation.  Experimentally  it  had  been 
demonstrated  (i)  that  the  muscular  wall  of  the  ventri- 
cles remained  active  for  an  appreciable  time  after 
closure  of  the  valves,  and  (2)  Stefani  had  found  that 
after  section  of  the  vagus  less  torce  was  required  to 
prevent  diastolic  expansion  of  the  heart.  The  clinical 
evidence  was  scanty.  His  series  of  cardiographic 
tracings  showed  that  the  expansion  rise  was  so  great 
that  it  could  not  be  caused  by  a  mere  elastic  expan- 
sion;   it  must  be  muscular. 

The  President  regretted  that  time  did  not  allow  a 
satisfactory  elaboration  of  the  interesting  and  valuable 
paper  then  being  read.     There  was  no  discussion. 

Pathogenesis  of  Gout Dr.  Gore,  of  Whitchurch, 

read  a  paper  entitled  "  A  Toxin  Tiieory  of  the  Causa- 
tion of  Gout."  Gout  did  not  arise  in  all  cases  in 
which  uric  acid  was  found  in  excess  in  the  blood, 
and,  with  the  exception  of  the  deposits  in  the  joints, 
there  was  little  evidence  that  uric  acid  was  the  cause 
of  gout.  He  believed  that  the  various  manifestations 
of  gout  were  the  result  of  some  morbid  condition  of 
the  blood,  which  was  probably  brought  about  by  a 
toxin  developed  in  the  alimentary  canal  from  one  of 


the  bacilli  commonly  infesting  the  intestinal  tract. 
A  catarrh  set  up  by  the  ingestion  of  unsuitable  food 
would  induce  such  changes  as  would  enable  the  bacilli 
to  exert  their  morbid  influence  through  their  toxins. 
He  believed  this  theory  would  explain  many  of  the 
aspects  under  which  gout  presented  itself,  and  that  it 
suggested  a  line  of  treatment  aiming  at  the  flushing 
and  cleansing  of  the  gastro-intestinal  canal.  His 
supposition  would  explain  the  baneful  effects  of  lead 
which  constricted  the  blood-vessels.  He  explained 
the  concurrent  presence  of  uric  acid  as  due  to  the 
action  of  the  toxins  on  the  liver,  and  he  believed  that 
the  specific  alteration  produced  in  the  intestinal  secre- 
tion by  unsuitable  diet  was  assisted  by  hereditary  pre- 
disposition. 

Dr.  Sa.muel  Bartuw,  of  Norwich,  agreed  with  Dr. 
Gore  that  gout  must  be  due  to  some  other  cause  than 
lithic  acid,  and  he  had  always  felt  that.  In  his  neigh- 
borhood lithic-acid  calculus  was  extremely  common; 
gout,  on  the  other  hand,  very  unusual.  Therefore  he 
maintained  there  must  be  some  other  factor,  although 
he  believed  that  this  factor  came  into  play  only  when 
uric  acid  was  in  the  blood.  He  thought  gout  less 
common  now  than  formerly,  and  supposed  that  that 
was  due  to  people  knowing  better  how  to  manage  their 
diet. 

Dr.  Gordon,  of  Exeter,  said  that  in  Devonshire  an 
exactly  opposite  condition  of  things  obtained.  Gout 
was  common,  but  uric-acid  stone  almost  unknown. 
He  was  in  the  habit  of  prescribing  salicylic  acid  in 
some  form  for  those  irregular  symptoms  of  gout  such 
as  headache,  dyspepsia,  and  giddiness,  and  had  had 
good  results.  He  thought  this  supported  Dr.  Gore's 
contention. 

Dr.  Pope,  of  Leicester,  thought  that  the  fact  that 
colchicum  relieved  only  when  it  purged  also  bore  tes- 
timony to  the  correctness  of  Dr.  Gore's  theory. 

Dr.  Garrett-Anderson,  of  London,  found  it  im- 
possible to  accept  the  toxin  theory  for  gout.  She 
favored  the  chemical  theory. 

Subcutaneous  Saline  Injections  in  Pneumonia 

This  paper,  jointly  compiled  by  Dr.s.  Kwart  and  B. 
Percival,  of  London,  was  read  by  the  former.  He 
had  thought  it  well,  considering  that  treatment  had  as 
yet  not  reduced  the  mortality  of  pneumonia,  to  give  a 
trial  to  this  method,  which  had  been  introduced  by 
Dr.  Clement  Penrose,  of  Baltimore.  He  thought 
cases  might  be  roughly  divided  into  three  groups — 
those  likely  to  recover,  those  almost  certain  to  be 
fatal,  and  those  in  which  there  was  uncertainty.  It 
was  to  these  very  grave,  but  not  hopeless  cases  that 
he  had  applied  this  method.  It  was  not  strictly  em- 
pirical but  had  a  scientific  basis.  It  was  well  known 
that  saline  infusions  were  attended  by  success  in  cases 
of  severe  collapse.  In  pneumonia  they  were  dealing 
with  a  disease  in  which  sudden  change  for  the  worse, 
with  collapse,  often  took  place  about  the  third  or 
fourth  day.  This  suggested  applying  the  method  of 
treatment  which  formed  the  sulaject  of  that  paper. 
They,  however,  had  considered  it  best  to  transfuse 
earlier,  before  the  stage  of  possible  collapse  arrived, 
in  the  hope  of  supporting  the  system  against  its  effects. 
.\  pint  of  decinormal  saline  solution  was  injected  into 
the  chest  wall  twice  or  thrice  in  the  twenty-four  hours, 
each  operation  occupying  about  an  hour.  He  related 
six  cases,  only  one  of  which  appeared  to  benefit  from 
the  infusion.  This  case  improved  the  day  after  the 
first  injection  and  the  temperature  reached  normal 
three  days  after.  Of  the  other  cases,  all  of  which 
were  fatal,  one  was  complicated  by  typhoid,  another  by 
salpingitis  and  pleural  effusion,  two  by  alcoholism. 
Two  had,  in  addition  to  the  saline  solution,  ten  per 
cent,  peroxide  of  hydrogen.  In  none  did  the  infusion 
produce  any  apparent  favorable  result,  except,  perhaps, 
to  delay  the  fatal  termination.     They  considered  that 


354 


MEDICAL    RECORD. 


[September  i,  igoo 


they  could  come  to  the  following  partial  conclusions: 
that  the  infusions  were  not  followed  by  any  unfavorable 
consequence,  but,  on  the  contrary,  they  appeared  to 
delay  the  fatal  event;  that  possibly  tiie  bulk  of  saline 
solution  should  be  increased;  that  the  infusions  were 
powerless  to  check  fatal  cases  ;  that  there  was  no  effect 
on  the  changes  in  the  lung;  that  the  patients  did  not 
resent  the  treatment. 

No  discussion  took  place. 

Progress  in  the  Sanatorium  Treatment  of  Con- 
sumption in  England.  —  Dr.  Jane  Walker,  of  Lon- 
don, read  a  paper  with  this  title.  She  believed  that 
under  favorable  circumstances  consumption  could  be 
cured  in  any  climate,  and  advocated  that  the  sanatorium 
treatment  should  be  carried  on  in  the  climate  in  which 
the  patient  would  afterward  have  to  reside.  She  laid 
great  stress  on  the  importance  of  careful  medical 
supervision  in  sanatoria.  Those  possessed  of  strength 
of  will,  wisdom,  and  equanimity  of  temperament  did 
best.  It  was  often  very  hard  to  tell  people  they  were 
not  yet  well,  although  they  might  feel  well.  The  gen- 
eral standard  of  health  should  decide  the  length  of 
stay.  It  was  very  important  to  get  cases  early,  as 
the  chances  of  recovery  from  the  second  stage  were 
not  so  good.  She  regarded  inverse  type  of  temperature, 
e.vcessive  pulse  rate,  and  diarrhoea  as  indications  for 
bad  prognosis.  When  the  temperature  remained  down 
and  the  patient  gained  weight  she  regarded  the  prog- 
nosis good.  The  management  of  these  cases  resolved 
itself  into  the  exhibition  of  common  sense  on  the  part 
of  all  concerned.  She  held  that  Mr.  Gibson,  in  the 
Nineteenth  Century,  erred  in  giving  false  hope  to  many 
by  saying  that  all  could  be  cured  in  sanatoria.  She 
advocated  sanatoria  for  tuberculous  children  and 
tuberculous  pregnant  women.  Out  of  one  hundred 
and  seventy-seven  cases  passing  through  her  hands, 
forty-five  patients  were  cured  and  fifty-four  improved; 
thirteen  were  losing  ground,  and  seven  died;  twenty- 
nine  were  still  under  treatment,  and  she  had  lost  sight 
of  nine. 

Dr.  Chowry-Muthu,  of  Ilford,  advocated  open- 
air  treatment  for  all  infectious  diseases.  He  had 
seen  cases  of  scarlet  fever,  typhoid,  and  pneumonia  all 
treated  by  this  method  with  admirable  results.  With 
regard  to  consumption  he  considered  that  the  sana- 
torium treatment  gave  the  best  results  for  the  majority. 
Under  the  old  methods  patients  did  what  they  liked; 
now  they  placed  themselves  under  the  generalship  of  a 
medical  man,  and  he  believed  that  was  the  secret. 
Three  things  influenced  the  progress  of  these  cases 
especially,  vitiation  of  the  stomach  by  toxins,  bronchial 
catarrh,  and  strong  east  winds. 

Dr.  Burton-Fanning,  of  Norwich,  was  sure  that 
wisdom  on  the  part  of  the  patient  was  of  great  valne, 
and  was  glad  Dr.  Walker  had  drawn  attention  to  that. 
He  considered  no  thanks  were  due  to  Mr.  Gibson. 
The  latter,  in  his  article  in  the  Nineteenth  Century, 
spoke  of  cure  being  effected  in  three  months;  in  his 
experience,  one  year  was  the  shortest  stay  a  patient 
should  make.  Mr.  Gibson  spoke  of  ninety  per  cent,  of 
cures.  It  would  be  more  correct  to  say  ninety  per  cent, 
of  the  patients  improved.  He  believed  everything 
depended  upon  early  treatment,  and  for  this  reason  he 
considered  the  stethoscope  of  less  value  than  the  ther- 
mometer, the  laryngoscope,  and  staining  reagents. 
He  agreed  that  climate  was  of  little  importance,  and 
commended  Dr.  Walker's  statement  that  elaborate 
common  sense  was  what  was  of  most  value. 

Dr.  St.  Clair  Thomson,  of  London,  speaking  as 
an  official,  urged  the  importance  of  making  people 
understand  the  necessity  for  medical  supervision.  A 
retired  tradesman  had  written  to  him  and  said  he  had 
taken  two  roomy  cottages  and  had  placed  all  the  cases 
of  consumption  he  could  find  in  them;  was  there  any- 
thing else  he  could  do?     He  thought  that  cases  had 


sometimes  been  kept  too  long  in  sanatoria  to  the  detri- 
ment of  others.  A  wise  American  had  once  remarked 
that  we  must  not  get  hold  of  the  wrong  case  and  put  it 
in  the  wrong  place,  until  death  resulted;  but  we  must 
get  the  right  case,  and  put  it  in  the  right  place,  until 
recovery  took  place. 

Consanguinity  as  a  Factor  in  the  Etiology  of 
Tuberculosis. — Dr.  Charles  Davies,  of  the  Isle  of 
Man,  read  this  paper.  After  bringing  evidence  from 
various  authors  to  show  that  it  had  been  commonly 
known  and  observed  from  early  times  that  children 
sprung  from  in-and-in  marriages  were  of  inferior  energy, 
he  directed  attention  to  the  condition  of  things  exist- 
ing in  the  Isle  of  Man.  The  Manx,  an  isolated  being, 
resented  the  introduction  of  strangers,  and,  further,  the 
dwellers  in  the  north  not  only  held  the  southerners  of 
the  island  in  aversion,  but  there  were  natural  physi- 
cal conditions  which  formed  a  barrier  between  them. 
In  addition  it  was  rare  for  migration  from  village  to 
village  to  take  place.  The  consequence  was  that  un- 
doubtedly families  had  married  and  intermarried  with 
their  immediate  neighbors  again  and  again.  There 
was  no  exaggeration  in  saying  that  three  parts  of  the 
inhabitants  were  related  to  one  another.  The  Manx 
people  had  then  attained  to  a  very  high  degree  of  con- 
sanguinity. Did  ill-effects  result?  There  was  un- 
doubtedly a  high  phthisis  rate,  viz.,  25.7  per  10,000 
living,  and  he  believed  this  was  accounted  for  by  in- 
breeding. The  temperature  of  the  island  was  equable; 
fogs  were  unknown,  sunshine  was  abundant,  and  he 
considered  the  climate  to  be  eminently  suitable  for 
the  treatment  of  lung  diseases.  The  soil  was  fairly 
dry  and  well  drained,  the  natives  were  well  nourished 
and  happy  and  contented.  Their  principal  occupa- 
tions were  healthy.  The  dwellings  were  no  worse, 
from  a  sanitary  point  of  view,  than  those  of  their  class 
in  England.  He  was  driven,  therefore,  to  conclude 
that  there  must  be  something  in  the  constitutional 
idiosyncrasy  of  the  people  that  rendered  them  peculiarly 
liable  to  tubercle. 

Dr.  Sommerville,  of  London,  asked  if  the  same  re- 
sult had  been  noticed  among  the  royal  families  and 
nobility  of  Europe. 

Dr.  St.  Clair  Thomson  wished  to  thank  Dr.  Davies 
for  his  interesting  paper.  It  was  at  his  suggestion 
that  Dr.  Davies  had  come  from  the  Isle  of  Man  to 
make  that  contribution  to  the  etiology  of  phthisis. 

Dr.  Barton  thought  that  consanguinity /<vjv  might 
not  be  the  cause.  Was  it  not  rather -due  to  tubercle 
attacking  a  community  in  which  intermarriage  was 
common  ?  At  Clovilly,  where  there  was  much  inbreed- 
ing, there  was  no  tubercle. 

Dr.  Gore  suggested  that  the  condition  of  the  cot- 
tages might  have  an  influence,  as  he  believed  was  the 
case  in  Ireland. 

Orrhotherapy  of  Malignant  Endocarditis. — Dr. 
EwART  next  related  a  case  of  fatal  malignant  endo- 
carditis and  right  embolic  hemiplegia  apparently  due 
to  infection  from  dental  caries  and  stomatitis,  treated 
by  anti-streptococcic  serum  and  by  saline  infusions. 
A  man  aged  twenty-six  years  was  admitted  to  St. 
George's  Hospital  on  April  icth,  having  been  seized 
suddenly  with  apliasia  and  right-sided  paralysis.  On 
admission,  the  only  thing  noticed  after  careful  exam- 
ination was  a  systolic  mitral  murmur.  His  tempera- 
ture was  101°  P.,  and  he  had  albumin  in  his  urine. 
On  .\pril  13th  he  became  worse  and  died  suddenly. 
There  was  no  delirium,  but  the  man  was  nervous;  he 
understood  what  was  said  to  him,  but  had  difficulty  in 
making  his  wants  known.  The  cardiac  signs  had 
varied  since  admission.  A  diastolic  murmur  had  been 
heard  over  the  pulmonary  valves  and  a  double  mur- 
mur at  the  apex.  On  this  account  the  diagnosis  of 
ulcerative  endocarditis  was  made.  For  treatment  he 
was  at  first  placed  on  a  mixture  containing  perchloride 


September  i,  1900] 


MEDICAL    RECORD. 


355 


of  mercury.  Subsequently  five  injections  of  anti-strep- 
tococcus serum  were  administered  ,  and  he  was  given 
four  saline  infusions,  while  finally  large  doses  of  qui- 
nine were  tried.  A  question  of  source  of  infection 
had  been  before  their  minds,  and  a  very  thorough  in- 
vestigation was  therefore  made.  They  found  only 
stomatitis  from  decayed  stumps  with  very  intense 
fetor.  The  glands  were  not  enlarged.  A  post-mor- 
tem examination  was  made  forty-two  hours  after  death. 
The  aortic  valves  appeared  greatly  diseased  with 
ulcerative  vegetations,  the  liver  was  nutmeg,  there  was 
an  infarct  in  one  kidney.  There  was  an  embolism 
of  the  left  middle  cerebral  artery  with  softening  of  the 
brain  tissue.  Van  Jurgensen,  Ludwig.  Herzog,  and 
others  made  no  reference  to  any  portal  of  infection  in 
their  recorded  cases;  they  called  them  primary  ulcera- 
tive endocarditis.  Some  authors,  however,  in  report- 
ing cases,  had  mentioned  certain  septic  conditions  in- 
cidentally. Gibson,  for  example,  had  related  a  case  in 
which  middle-ear  disease  was  present.  Dreschfeld 
came  nearest  to  pointing  to  the  mouth  as  a  possible 
route  for  infection.  If  no  examination  had  been  made 
in  the  case  he  had  related  that  day,  he  supposed  it 
would  have  been  put  down  as  primary  disease  of  the 
valves;  but  he  believed  that,  having  excluded  all  other 
possible  sources,  that  case  depended  upon  an  organism 
existing  in  the  mouth. 

Dr.  C0LD.STREAM,  of  Florence,  remarked  that  he  had 
published  a  case  of  ulcerative  endocarditis  which  re- 
sulted fatally  on  the  fourth  or  fifth  day  after  a  gumboil, 
associated  with  a  bad  tooth,  had  been  incised. 

Dr.  Sommerville  referred  to  cases  which  led  him 
to  suppose  the  cause  of  infection  might  have  been  an 
unclean  condition  of  the  mouth. 

Dr.  Stacev  Wilson  mentioned  cases  associated  with 
middle-ear  disease  which  had  come  under  his  notice. 

With  Dr.  Ewart's  reply  the  proceedings  of  the  sec- 
tion terminated. 


SECTION'   OF   TROPICAL   DISEASES. 

First  Day — ■  Wednesday,  August  zst. 

President's  Address. — Col.  Kenneth  Macleod, 
president  of  the  section,  gave  an  opening  address 
on  "The  Scope  and  Aim  of  the  Section's  Work."  A 
knowledge  of  the  pathology  and  pathogenesis  of  dis- 
ease, he  said,  must  obviously  precede  and  guide 
preventive  and  curative  effort;  and  it  could  not  be 
too  loudly  proclaimed  that  this  knowledge  could  be 
obtained  only  by  systematic  scientific  research.  The 
days  of  casual  and  statistical  observations  and  disser- 
tations had  gone,  and  it  was  now  universally  under- 
stood that  nothing  would  avail  for  the  solution  of  patho- 
logical problems  except  the  undistracted  work  of 
trained  agents  provided  with  ample  opportunities, 
facilities,  and  appliances.  The  recent  history  of 
malariology,  he  continued,  was  a  signal  illustration 
of  the  dependence  of  sanitary  and  therapeutical  en- 
deavor on  pathological  discovery.  Laveran  in  1880 
furnished  the  key  to  the  morbid  processes  which  in 
malarious  disease  took  place  within  the  body  by  the 
discovery  of  the  Plasmodium  malariae.  Manson  and 
Ross  pioneered  the  brilliant  investigations  which  had 
revealed  one,  if  not  the  one,  means  by  which  this  or- 
ganism left  the  infected  subject,  lived  and  bred  in 
outer  nature,  thus  compassing  the  communication  of 
what  must  now  be  admitted  to  be  an  infective  disease. 
This  knowledge  was  being  at  the  present  time  turned 
to  practical  account,  and  it  explained  and  gave  pre- 
cision to  methods  of  prevention  and  cure  which  had 
previously  been  resorted  to  empirically.  Koch  had 
been  attacking  the  Plasmodium  within  the  human  host, 
and  claimed,  by  destroying  it  in  that  phase  or  stage 
of  its  existence,  not  only  to  cure  the  individual  but  to 


reduce  greatly,  or  altogether  abolish,  the  prevalence  of 
malarious  disease  in  the  community.  Sambon  and 
Low  in  Italy  were  addressing  themselves  to  the  extra- 
somatic  life  of  the  parasite,  and  endeavoring  by  special 
contrivances  and  precautions  to  cut  the  morbific  circuit 
outside  the  body.  The  results  of  their  labors  would 
be  eagerly  watched,  as  they  would  contribute  an  im- 
portant aid  to  the  solution  of  the  question  whether  the 
Anopheles  was  the  only  medium  of  malarious  infec- 
tion, and,  if  so,  whether  this  occurred  invariably  by 
inoculation.  That  typhoid  fever  existed  in  South 
Africa,  and  was  apt  to  prevail  in  South  African  towns 
and  cantonments  during  the  summer  months,  was  well 
known,  and  its  appearance  among  the  troops  engaged 
in  this  war  was  fully  anticipated;  but  the  excessive 
prevalence  of  the  disease  in  a  country  and  climate  with 
a  reputation  for  exceptional  healthiness  had  come,  he 
said,  as  an  unpleasant  surprise.  No  doubt  the  cir- 
cumstances and  exigencies  of  warfare  were  mainly  re- 
sponsible for  the  heavy  tribute  of  sickness  and  death 
which  the  fever  had  levied.  War  shared  with  famine 
the  malignant  power  of  enhancing  the  susceptibility 
to  whatever  infection  happened  to  be  present  at  the 
place  and  time.  Malaria,  cholera,  yellow  fever,  and 
dysentery  had  on  many  occasions  been  stimulated  into 
disastrous  activity  by  war.  So  with  famine;  malarious 
disease,  smallpox,  diarrhoea,  dysentery,  and  relapsing 
fever  had  attended  or  followed  it,  and  at  the  present 
time  cholera  and  plague  were  raging  among  the 
famine-stricken  in  India.  It  was  important  to  note,  the 
speaker  continued,  that  a  very  marked  contrast  existed 
between  the  ordinary  incidence  and  mortality  of  the 
disease  in  temperate  and  tropical  or  sub-tropical 
countries — in  Kngland  and  Canada  on  the  one  hand, 
and  in  India  and  F.gypt  on  the  other.  A  similar  con- 
trast appeared  in  the  French  army  stationed  in  France 
and  in  Northern  Africa.  How  much  of  this  great  ex- 
cess was  due  to  tropical  conditions,  topical  and 
climatic,  and  how  much  to  remediable  sanitary  de- 
fects, it  was  not  easy  to  say.  But,  side  by  side  with 
the  excessive  suffering  of  the  army  in  India,  we  were 
confronted  with  the  remarkable  fact  of  the  immunity 
of  the  native  population.  Whether  a  similar  immu- 
nity existed  among  indigenous  races  and  habitual  resi- 
dents in  South  Africa  was  an  interesting  question. 
Evidence  seemed  to  indicate  that  it  was  so.  The 
native  immunity  in  India,  though  not  absolute,  was 
undoubted;  its  cause  had  not  been  satisfactorily  ascer- 
tained. It  had  been  attributed  to  habituation  to 
minute  dosage  of  the  contagium,  to  protection  con- 
ferred by  attack  during  infancy  and  childhood,  and  to 
racial  resistance  acquired  in  the  course  of  generations 
through  both  tiiese  influences.  Some  experiments  by 
Freyer  and  others  indicated  that  natives  gave  positive 
reactions  to  Widal's  test;  but  more  extended  and  ex- 
act investigations  on  this  point  were  desirable.  It  was 
quite  certain  that  the  immunity  was  not  due  to  superior 
sanitary  conditions.  U'hether  a  similar  immunity — ■ 
temporary  or  permanent. — could  be  engendered  in 
European  subjects  by  a  process  of  inoculation  such  as 
had  been  devised  by  Professor  Wright,  of  Netley,  and 
practised  on  a  large  scale  among  soldiers  proceeding 
to  the  seat  of  war,  was  a  question  the  reply  to  which 
was  awaited  with  eager  anxiety.  Some  figures  ob- 
tained from  Ladysmith  had  been  published  by  Pro- 
fessor Wright,  which  seemed  to  show  that  some  im- 
munity was  conferred  by  these  inoculations,  but, 
though  encouraging,  they  were  by  no  means  demonstra- 
tive. The  persistence  of  plague  in  India  and  the 
appearance  of  the  disease  for  the  first  time  south  of 
the  equator — in  Mauritius,  South  Africa,  South  Amer- 
ica, and  Australia —  were  events  deserving  of  special 
notice.  The  disease  had  during  its  present  prevalence 
confined  itself  mostly  to  warm  and  hot  countries,  and, 
though  not  exclusively  a  tropical  disease,  nor  apt   in 


356 


MEDICAL    RECORD. 


[September  i,  1900 


the  tropics  to  be  at  its  worst  when  conditions  were 
most  typically  tropical,  it  appeared  to  find  in  tropical 
countries  and  circumstances  the  most  favoring  environ- 
ment. It  was  curious  to  remark  that,  while  in  India 
natives  appeared  to  be  readily  susceptible  to  the  infec- 
tion of  plague,  Europeans,  though  not  absolutely  in- 
susceptible, exhibited  a  comparative  immunity— the 
reverse  of  what  happened  as  regarded  typhoid  fever. 
The  work  of  this  section,  Dr.  Macleod  said,  in  con- 
cluding his  remarks,  had  to  do  not  only  with  exclu- 
sively tropical  diseases,  many  of  them  strangely  named 
and  imperfectly  investigated  and  understood,  which 
might  be  encountered  and  contracted  in  hot  places 
where  Europeans  were  compelled  to  reside  for  pur- 
poses of  protection,  administration,  or  commerce,  and 
which  were  not  as  a  rule  met  with  outside  of  the 
tropics.  More  important  were  those  diseases,  origin- 
ally or  essentially  tropical,  which  might  be  dissemi- 
nated by  intercourse  with  the  tropics,  and  might  prevail 
for  a  time  in  e.\tra-tropical  localities  in  which  they 
were  not  habitually  present.  And,  finally,  there  were 
the  diseases  which  were  not  specially  tropical,  but 
which  were  liable  to  be  aggravated  in  prevalence  or 
severity  by  tropical  conditions.  These  three  classes 
represented  a  wide  field  of  research,  and,  in  addition, 
interesting  questions  arose  regarding  diseases  which, 
common  elsewhere,  were  rare  or  unknown  in  tropical 
countries. 

Quinine;    its   Action   and   Value.— Dr.  Andrew 
Duncan  opened  a  discussion  upon  the  use  of  quinine 
as  a  prophylactic  and  as  a  curative  agent.     He  said 
that  in  the  hands  of   French  physicians  quinine  was 
found  to  be  of  some  prophylactic  value  in  the  milder 
forms  of  malarial  fever,  but  in  pernicious  varieties  it 
was  wellnigh  useless.     The  general    conclusions  ar- 
rived at  by   Russian  and  Austrian  military  surgeons 
were  that  quinine  had  but  little,  if  any,  value  as  a  pro- 
phylactic.     In  America  Dr.  Bryan  stated  that  cinchona 
preparations  had  a  markedly  prophylactic  action.  ^   The 
last  Surgeon-Major  Parke,  of  the  Stanley  expedition  in 
search  of  Livingstone,  gave  the  officers  four  grains  of 
quinine  daily  for  ten   days  before  entering  the  mouth 
of  the  Congo.     During  a  subsequent  journey  of  three 
hundred  and  fifty  miles  through  one  of  the  most  un- 
healthy regions  of  the   world  only   two  officers  con- 
tracted fever.     The  speaker's  own  experiences  in  India 
afforded  support  to  the  belief  that  the  giving  of  qui- 
nine was  a  preventive  to  malaria.     In  1896,    of    fifty 
men  of   the   Second   Goorkha   Rifles  who   took  three 
grains  of  quinine  daily  none  had  fever,  whereas  among 
the  men  who  took  no  drugs  6.5  per  cent,  had  malaria; 
in   1897   the  same  experiment  was  tried  again,  when 
the  results  were,  no  malaria  among  the  quinine  takers 
and  9.8  per  cent,  among  the  non-quinine  takers.      Dur- 
ing the  Malay  war  the  prophylactic  benefits  of  quinine 
were    not    marked.      West  African  experiences  were 
varied.     Harvey  found  that  the  sailors  who  took  qui- 
nine had  as  much  fever  as  the  men  who  did  not  take 
it.     During  the  Ashanti  wars  of  1893  and  1896  quinine 
as  a  prophylactic  proved  of  no  benefit.     An   inquiry 
in  connection  with  this  subject  was  promoted  by  Mr. 
Chamberlain  and   Dr.  Man.son   in  West  Africa.     The 
benefit  of  quinine  as  elicited  by  this  inquiry  seemed 
to  be  pronounced,  for  in  87.7  per  cent,  of  those  who 
used   it  as  prophylactic  it  was  efficacious.     Dr.  Dun- 
can then  reviewed  the  action  of  several  reputed  anti- 
malarial drugs.     Arsenic  us  a  prophylactic  afforded 
conflicting  evidence.     In  Italy  it  had  been  moderately 
successful,  in  India  it  had  proved  very  disappointing. 
The  most  eminently  successful  experiment  seemed  to 
have  been  made  by  Dr.  Ralph   Leslie   in  the  Congo 
Free  State,  where  arsenic  was    administered    during 
fifteen  days  every  six  weeks,  and  every  one  who  took 
it  was  rendered  immune  to  fever.     Narcotine  seemed 
of  little  value  as  a  prophylactic.     As  a  cure  for  mala- 


rial attacks  quinine  gave  by  far  the  best  results,  only 
2.05  per  cent,  of  failures.  Next  to  quinine  as  a  cura- 
tive came  nim  bark  in  doses  of  ;  i.  thrice  daily; 
failures  were  eighteen  per  cent.  Lerberis  had  fifty 
per  cent,  of  failures.  Narcotine,  kreat,  and  inderjas 
seemed  to  be  unreliable  as  either  prophylactic  or  cura- 
tive agents. 

^[.\J.  W.  J.  Buchanan  reported  an  experiment  on  a 
large  scale.  At  six  of  the  large  jails  of  India  the 
prophylactic  issue  of  quinine  had  been  tried  for  five 
years  past.  In  some  instances  the  results  had  been 
tested  by  control  experiments.  At  the  Mymensingh 
jail  the  result  was  "diminished  fever";  at  the  Rajah- 
mundri  jail,  one  of  the  most  malarial  jails  in  India, 
quinine  as  a  prophylactic  was  useful  in  the  case  of 
those  who  had  not  been  previously  exposed  to  malaria; 
those  who  contracted  fever  had  it  more  mildly;  the 
duration  was  shorter  and  the  recurrences  were  fewer 
when  the  drug  had  been  taken  previously  as  a  preven- 
tive. At  the  Rajshaye  jail  Lieutenant-Colonel  French 
reported  strongly  in  favor  of  quinine  as  a  prophylactic 
during  1896  and  1897,  but  he  changed  his  opinion  in 
consequence  of  the  experiences  gained  during  r8g8. 
At  the  Bankura  jail  the  prophylactic  issue  of  quinine 
had  distinctly  beneficial  results;  at  the  Huzaribagh 
jail,  Major  Maynard  gave  it  as  his  opinion  that  cin- 
chonidine  given  in  six-grain  doses  daily  was  useful  as 
a  prophylactic,- and  as  a  beneficial  agent  should  attacks 
of  fever  come  on  afterward.  Major  Buchanan's  ex- 
perience at  the  Bhagalpur  jail  proved  negative,  the 
quinine  takers  and  those  who  had  not  taken  the  drug 
being  equally  affected.  Major  Buchanan  had  never 
seen  hsemoglobinuria  or  other  evil  effects  from  taking 
quinine. 

Dr.  Fielding  Ould,  of  West  Africa,  said  that  since 
Koch's  statements  about  quinine  the  Europeans  on  the 
West  Coast  entertained,  many  of  them,  a  dread  of  the 
drug.  Quinine  acted  by  staying  the  development  of 
the  malarial  amceba;  it  might  do  so  by  binding  the 
oxygen  to  the  haemoglobin  more  closely  and  thus  de- 
priving the  parasite  of  the  oxygen  necessary  for  its 
growth.  Quinine  could  be  in  no  sense  a  preventive, 
it  could  deal  with  the  parasite  only  when  it  existed  in 
certain  stages  in  the  blood;  it  could  not  prevent  the 
entrance  of  the  parasite  into  the  blood.  He  quoted 
an  experiment  of  Bignami's  in  which  blood  rich  in 
parasites  but  impregnated  with  quinine  was  incapable 
of  reproducing  malaria  when  injected  into  a  healthy 
person.  Of  the  methods  of  administration  that  by  the 
mouth  was  perhaps  preferable  unless  gastric  catarrh  was 
present,  when  it  might  be  given  by  the  rectum  or  hypo- 
dermically.  The  prophylactic  use  of  quinine  was  in 
many  instances  harmful  by  upsetting  digestion;  and 
it  was  persons  who  suffered  from  gastric  catarrh  or 
hyper.-emia  of  the  liver  who  were  wont  to  be  most 
severely  attacked  by  malaria;  in  them  the  pernicious 
forms  of  malaria,  the  bilious  remittent  and  hemo- 
globinuria, were  apt  to  develop. 

Dr.  Patrick  Manson  said  that  the  reputed  prophy- 
lactic action  of  quinine  was  but  a  phase  of  its  thera- 
peutic action ;  it  was  the  application  of  the  drug  to 
the  parasite  :ind  not  an  immunizing  of  the  body  against 
the  parasite  that  characterized  the  action  of  quinine. 
Just  as  some  varieties  of  the  parasite  were  highly 
amenable  to  the  drug  given  therapeutically,  similarly  | 
its  prophylactic  power  would  be  greater  against  such.  II 
Dr.  Mans'on  recommended  that  future  experiments  in 
prophylaxis  be  made  with  the  aid  of  the  microscope,  , 
and  in  reference  to  the  particular  type  of  malarial  para- 
site it  was  used  against. 

LiEiTENANT-CoLONEL  MuRSDEN  Stated  that  he  had 
invariably  given  quinine,  both  as  a  prophylactic  and 
as  a  therapeutic  agent,  for  the  last  twenty  years,  and 
the  results  had  nearly  always  been  satisfactory.  He 
described  the  only  case  in  which  he  had  seen  quinine 


September  i,  1900] 


MEDICAL    RECORD. 


357 


cause  hasmoglobinuria  as  that  of  a  German  missionarv, 
who  every  time  he  took  quinine  declared  that  hasmo- 
globinuria supervened,  and  when  the  drug  was  admin- 
istered by  the  speaker  the  urinary  trouble  developed. 

Mr.  D.  C.  Rees,  of  London,  gave  his  experience  of 
quinine  as  a  prophylactic  in  Nigeria.  He  came  to 
the  conclusion  that  five  grains  administered  daily,  al- 
though it  did  not  reduce  markedly  the  number  of  attacks 
of  fever,  tended  to  lessen  the  severity  and  also  the 
case  mortality.  He  advocated  introducing  the  needle 
of  the  hypodermic  syringe  into  the  muscles  when  ad- 
ministering quinine  by  this  method;  when  introduced 
beneath  the  skin  only,  suppuration  was  apt  to  follow. 
Dr.  C.  F.  Harford-Baitersby,  of  London,  be- 
lieved strongly  in  the  prophylactic  value  of  quinine. 
Although  quinine  might  cause  hemoglobinuria,  he 
did  not  believe  it  could  cause  hasmoglobinuric  fever. 
He  held  that  there  were  many  minor  ailments  attrib- 
utable to  malaria,  such  as  vomiting,  neuralgia,  etc., 
which  quinine  would  relieve. 

M.AjoR  Wilson  did  not  find  in  the  Ashanti  expedi- 
tion of  1895-96,  nor  on  the  Sierra  Leone  coast,  that 
quinine  held  much  prophylactic  value.  He  had  used 
the  hypodermic  injection  of  quinine  in  many  instances 
without  causing  local  inflammation. 

Dr.  B.  S.  Ringer,  of  Canton,  China,  described  a 
case  of  quinine  blindness  (occurring  in  malaria), 
which  disappeared  by  treatment  with  ten-grain  doses 
of  potassium  iodide. 

Lt.-Col.  B.  C.  Maitland  asked  for  information 
concerning  the  use  of  methylene  blue  in  malarial 
fever.  During  an  outbreak  of  malaria  he  gave  it  in 
alternate  cases  with  quinine  and  found  methylene  blue 
gave  the  better  results.  He  found  little  danger  in 
giving  quinine  in  pregnancy,  and  he  had  administered 
it  without  inducing  aljortion  at  any  and  every  stage  of 
pregnancy. 

Mr.  James  Cantlie,  of  London,  related  a  case  of 
fever  in  a  child  four  months  of  age.  The  child  was 
born  in  England,  while  the  parents  were  at  home  on  a 
holiday  from  China.  The  fever  continued  for  six 
weeks,  and  it  was  only  when  the  mother,  who  was 
nursing  the  child,  and  the  child  took  quinine  that  the 
fever  disappeared. 

Dr.  Henderson,  of  Shanghai,  stated  that  the  benign 
tertian  was  the  usual  malarial  parasite  met  with  in 
Shanghai  practice,  and  that  it  readily  yielded  to  qui- 
nine. He  believed  quinine  to  be  a  decidedly  danger- 
ous drug  in  pregnancy,  and  he  had  seen  miscarriages 
traceable  to  its  administration.  With  opium,  or  better 
still  with  chlorodyne,  some  of  the  danger  of  quinine 
to  pregnant  women  might  possibly  be  minimized. 

Major  Ronald  Ross,  of  Liverpool,  drew  attention 
to  the  circumstance  that  in  old  cases  of  malaria  there 
might  be  a  secondary  form  of  fever,  due  to  enlarge- 
ment of  the  liver  and  spleen,  not  directly  due  to  the 
presence  of  parasites  and  not  amenable  to  quinine. 
Major  Ross  advocated  the  exhibition  of  quinine  for 
three  months  after  infection,  and  believed  the  best  form 
of  administration  was  in  solution  by  mouth. 

Dr.  Guthrie  Rankin,  of  London,  described  a  case 
of  ha;moglobinuric  fever  developing  in  about  fourteen 
months  after  settlement  in  Central  Africa.  The  man 
returned  to  England,  had  a  mild  attack  of  hemoglo- 
binuria, and  after  four  months  went  back  to  Africa. 
During  his  second  term  of  residence  there,  extending 
over  two  and  a  half  years,  he  took  quinine  daily  in 
teaspoonful  doses,  and  never  had  a  return  of  malarial 
fever. 

Lt.-Col.  Oswald  Baker,  of  London,  believed  the 
reason  of  quinine  failing  as  a  prophylactic  was  that 
It  was  not  given  in  sufficient  doses.  He  was  of  opinion 
that  the  prophylactic  dose  should  be  the  same  as  the 
curative  dose. 

Col.  H.  MACLEOD,  of  Netley,  pointed  out  the  im- 


portance of  using  the  microscope  as  a  guide  and  check 
during  the  administration  of  quinine.  It  had  been 
asserted  that  malarial  parasites  might  exist  in  the 
blood  without  causing  pyrexia,  and  it  was  necessary  to 
ascertain  the  infection  of  the  community  before  com- 
ing to  a  conclusion  as  regarded  the  prophylactic  use  of 
quinine.  Colonel  ALicLeod  referred  to  the  distinc- 
tion to  be  drawn  between  hemoglobinuria  and  hemo- 
globinuric  fever.  The  former  was  caused  by  many 
drugs,  but  the  latter  seemed  to  be  a  specific  disease. 

Notes  on  the  Etiology  of  Filariasis Lieuten- 
ant-Colonel Maitland  referred  to  the  observations 
made  by  Dr.  G.  C.  Low  concerning  the  presence  of  the 
filiarial  parasite  in  the  proboscis  of  the  mosquito,  and 
the  probability  of  the  infection  of  the  human  being  by 
the  bite  of  the  mosquito.  He  regarded  the  evidence 
in  favor  of  this  theory  as  presumptive  only  and  op- 
posed to  well-attested  evidence.  He  drew  attention  to 
the  extraordinary  immunity  of  Europeans  to  filariasis 
in  districts  where  the  natives  were  extensively  in- 
fected, and  regarded  the  fact  that  Europeans  boiled  or 
filtered  their  drinking-water  as  an  argument  in  favor 
of  water  being  the  medium  of  infection  in  filariasis. 
The  speaker  thought  it  quite  possible  that  the  young 
filaria  might  pass  from  the  mo.squito's  proboscis  into 
water  instead  of  directly  into  the  blood. 

Metamorphosis  of  the  Filaria  Sanguinis  Hominis 
in  Mosquitos — Capt.  T.  P.  James  read  a  paper  in 
which  he  drew  attention  to  the  difference  in  time  re- 
quired for  the  metamorphosis  of  the  filaria  in  mosqui- 
tos observed  by  Bancroft  and  Manson,  and  it  would 
appear  that  the  period  of  such  metamorphosis  was  not 
yet  determined  definitely.  In  Bancroft's  experiments 
and  in  those  undertaken  by  Captain  James,  the  female 
Culex  was  employed.  The  insects  were  bred  from 
larve  placed  under  the  mosquito  curtains  of  a  filari- 
ated  man's  bed,  and  when  caught  they  were  transferred 
to  bottles  in  which  ripe  bananas  were  hung.  Against 
the  water-borne  theory  of  infection  Captain  James 
advanced  the  argument  that  the  filaria  died  in  two 
and  a  half  hours  in  pure  water;  and  therefore  too  short 
an  existence  was  allowed  to  insure  continuance  of  the 
species.  The  speaker  favored  the  idea  that  the  filaria 
was  carried  to  the  human  being  by  the  bite  of  either 
the  Anopheles  or  Culex. 

Dr.  Manson  wished  to  state  that  the  discoveries  of 
Dr.  Low  and  Captain  James  were  made  independently 
of  each  other,  and  that  both  observers  were  entitled  to 
have  their  names  associated  with  the  establishment  of 
the  fact  that  the  filarial  worm  could  find  exit  by  way 
of  the  proboscis  of  the  mosquito.  He  regarded  the 
relative  immunity  of  Europeans  to  filarial  infection  as 
due  to  the  use  of  mosquito  nets  and  their  better  sani- 
tary surroundings  compared  with  those  of  the  poor 
natives.  The  process  of  richly  infecting  a  human 
being  by  filaria  probably  involved  a  considerable 
time;  the  individual  required  possibly  to  be  bitten 
many  scores  of  times  by  filaria  infected  mosquitos 
before  the  embryos  appeared  in  sufficient  numbers  to 
cause  pathologically  lesions  of  any  clinical  magni- 
tude. He  drew  attention  to  the  analogy  between  filari- 
asis and  malaria.  In  both  diseases  a  parasite  was  re- 
moved from  the  human  blood  by  the  mosquito;  they  ' 
both  developed  in  the  mosquito's  tissues,  both  prob- 
ably quitted  the  mosquito  via  the  proboscis,  both  were 
inoculated  by  the  mosquito  bite,  both  exhibited  a 
remarkable  periodicity  in  the  human  blood,  and  both 
gave  rise  to  recurring  fevers. 

Mr.  D.  C.  Rees  said  that  although  both  Dr.  Bancroft, 
of  Australia,  and  Captain  James  seemed  disinclined 
to  believe  that  filaria  nocturna  cast  its  sheath  in  the 
mosquito's  stomach,  he  thought  there  could  be  little 
doubt  that  it  did  do  so.  Several  specimens  in  his 
possession  showed  that  ecclysis  has  taken  place,  for 
the  filaria  and  its  sheath  could  be  seen  side  by  side. 


358 


MEDICAL    RECORD. 


[September  i,  igcx) 


Major  Ross  referred  to  the  case  of  an  F.nglishman 
living  in  the  West  Indies  who  suffered  from  elephan- 
tiasis which  he  ascribed  to  tlie  bite  of  a  mosquito. 

Hot-Weather  Diarrhoea  in  India. — Maj.  VV.  T. 
Buchanan  read  a  paper  drawing  attention  to  a  very 
severe  form  of  diarrhtca  which  was  not  cholera,  but 
in  many  cases  closely  resembled  it.  After  describing 
the  sudden  onset,  the  watery  stools,  the  collapse,  the 
cyanotic  appearance  of  the  patient,  occasional  suppres- 
sion of  urine,  etc.,  he  said  he  thought  the  disease  bore 
the  same  relation  to  cholera  in  India  as  did  summer 
diarrhcea  to  cholera  nostras  in  England.  He  suggested 
the  name  "thermic  diarrhoea"  for  the  complaint. 
The  disease,  especially  in  old  people,  was  occasionally 
fatal.  The  treatment  consisted  in  boiled  milk,  brandy, 
and  the  tinctura  chloroformi  et  morphinae  Co.  B.P. ;  as 
the  diarrhoea  subsided,  a  dose  of  castor  oil  hastened 
recovery. 

Colonel  Macleod  remarked  that  Major  Buchanan's 
paper  raised  two  questions:  First,  as  to  the  distinction 
between  cholera  nostras  and  cholera  Asiatica,  and, 
second,  what  the  organisms  or  toxins  were  which  gave 
rise  to  cholera  nostras.  The  form  of  diarrhoea  men- 
tioned was  very  common  among  children  in  India. 

A  Note  on  a  Case  of  Blackwater  Fever. —  Dr. 
George  Thin,  of  London,  reported  the  case  of  a  man 
who  died  of  blackwater  fever  in  Central  Africa. 
Specimens  were  forwarded  to  Dr.  Thin  by  Dr.  Douglas 
Gray  for  examination.  Dr.  Thin's  conclusions  were 
that  the  patient  died  of  acute  malarial  fever  in  which 
the  hasmoglobinuria  was  a  concomitant  symptom. 
The  presence,  condition,  and  extent  of  the  pigment  in 
the  liver  and  spleen  showed  the  recent  existence  of  the 
parasite  in  great  numbers  at  some  point  of  the  blood 
circulation. 

Dr.  Manson  remarked  that,  although  he  inclined 
to  the  belief  that  hamoglobinuric  fever  was  an  expres- 
sion of  malarial  fever,  he  did  not  think  we  were  justi- 
fied in  jumping  at  such  a  conclusion  merely  because 
the  malarial  parasite  was  found  in  a  haemoglobinuric 
patient's  blood.  It  would  be  strange  were  post-mortem 
evidence  of  malarial  infection  not  found  in  persons 
dwelling  in  so  highly  malarious  a  country  as  British 
Central  .Vfrica,  whatever  the  cause  of  death. 

Mr.  D.  C.  Rees  stated  that  he  had  examined  speci- 
mens from  the  same  patient  upon  which  Dr.  Thin  had 
reported,  and  he  had  come  to  an  exactly  opposite  con- 
clusion to  that  arrived  at  by  Dr.  Thin. 

The  Diseases  of  Goorkhas. — Dr.  Andrew  Duncan 
said  that  malarial  fever  of  an  intractable  form  seemed 
to  prevail  among  the  soldiers  of  the  Goorkha  regi- 
ments he  had  been  quartered  with.  He  found  admin- 
istration of  quinine  by  the  rectum  was  more  efficacious 
than  by  the  mouth.  Phthisis  seemed  also  to  run  a 
peculiar  course,  passing  from  mild  symptoms  to  a 
severe  and  suddenly  fatal  form.  Mumps,  measles,  and 
ophthalmia  were  prevalent.  Enteric  fever,  contrary 
to  popular  belief,  was  not  a  common  disease  among 
Goorkhas;  in  fact,  he  had  seen  only  one  case.  In 
reply  to  Mr.  Cantlie,  Dr.  Duncan  stated  that  he  had 
never  seen  scarlet  fever  among  Goorkhas. 


Second  Day — Thursday,  August  2d. 

Ankylostomiasis. — Major  G.  M.  Giles  opened  the 
discussion  on  ankylostomiasis  by  communicating  a 
paper  in  which  he  referred  to:  (i)  the  history  of  our 
knowledge  of  the  disease;  (2)  his  own  researches  into 
the  life  history  of  the  free  stage  of  ankylostomum,  by 
which  he  established  the  fact  that  the  rhalidites  can 
live  and  multiply  freely  in  fecal  matter;  in  other  words, 
that  it  was  a  case  of  heterogenesis  or  dimorphism. 
(3)  He  then  dealt  with  Dr.  Sonsino's  criticisms 
as  regards  the  accuracy  of  iiis  observations.  Dr. 
Sonsino  held  that  the  organisms  described  by  Major 


Giles  were  rhabdites  terricola  or  other  free  nematodes, 
and  that  the  appearances  were  really  the  free  form  of 
rhabdomena  intestinale.  To  these  criticisms  Major 
Giles  gave  a  distinct  negative  as  to  their  potency. 
(4)  Major  Giles  next  discussed  the  question  of  the 
harmful  versus  the  harmless  nature  of  the  ankylosto- 
mum. He  held  that  the  pai^asite  was  responsible  for 
a  formidable  mortality,  and  for  a  great  amount  of 
chronic  sickness. 

Capt.  a.  T.  Fearnside  continued  the  discus- 
sion. He  told  of  a  systematic  research  for  the  ova  of 
the  ankylostomum  parasite  among  the  convicts  and 
new  arrivals  in  the  central  prison  at  Rajahmundry  in 
India.  He  found  that  of  six  hundred  and  seventy- 
eight  new  arrivals  at  the  prison  four  hundred  and 
sixty-two.  or  68.1  per  cent.,  harbored  the  parasite.  In 
another  group  of  observations,  the  speaker  found 
seventy-two  per  cent,  infested,  yet  they  remained  in 
good  health.  About  thirty-five  per  cent,  harbored  the 
ankylostomum  and  ascaris  lumbricoides  simultane- 
ously. At  one  hundred  and  five  post-mortem  exami- 
nations at  the  jail,  74.3  per  cent,  revealed  the  presence 
of  the  ankylostomum.  He  held  that  post-mortem  evi- 
dence went  to  show  that  the  effects  of  the  ankylostoma 
were  for  the  most  part  secondary  and  not  primary,  and 
that  it  was  only  when  the  ankylostoma  attacked  a  per 
son  already  weakened  by  malaria  or  other  illnesses 
that  ankylostomiasis  developed. 

Dr.  Leonard  Rogers  read  a  paper  on  "The  Classi- 
fication and  Differential  Diagnosis  of  Ankylostomiasis 
with  Special  Reference  to  the  Type  of  the  Ana;mia." 
The  question  of  the  relation  of  kala-azar  to  ankylos- 
tomiasis was  discussed  by  Captain  Rogers,  and  he 
agreed  with  Major  Ross  that  kala-azar  had  a  malarial 
rather  than  an  ankylostomian  basis.  He  regarded 
ankylostomiasis  as  a  disease  characterized  by  anamia 
produced  by  long-continued  small  losses  of  blood 
through  thegastro-intestinal  mucous  membrane  caused 
by  the  presence  of  several  hundreds  of  ankylostoma 
acting  for  many  months,  or  by  still  larger  numbers 
acting  for  a  shorter  time. 

Lieut. -Col.  Oswald  Baker  described  the  condition 
induced  by  the  ankylostoma  in  severe  form  as  being 
practically  identical  with  that  of  a  person  bled  to  the 
verge  of  death.  He  established  the  fact  that  the  anky- 
lostomum was  extremely  prevalent  throughout  the  prov- 
ince, and  considered  the  prevalence  of  ankylostomiasis 
to  be  directly  and  indirectly  responsible  for  a  high 
mortality.  He  attributed  the  wide  distribution  of  the 
disease  to  be  due  to  the  habits  and  customs  of  the 
Burmese,  especially  as  regards  their  mode  of  eating 
their  food. 

Dr.  Manson  remarked  on  the  fact  that  the  rhab- 
domena intestinale  was  so  seldom  found  by  Major 
Giles  in  Assam,  considering  that  it  was  so  frequently 
associated  elsewhere  with  the  ankylostomum,  and  that 
the  climatic  and  other  physical  conditions  closely  re- 
sembled those  in  Cochin-Ciiina  where  the  parasite  was 
extremely  common.  The  speaker  had  twice  encoun- 
tered ankylostoma  in  the  stools  of  Englishmen  who 
had  returned  to  this  country  from  the  West  Indies. 
He  disagreed  with  a  remark  made  by  Dr.  Fearnside 
in  regard  to  the  inefficiency  of  thymol  as  an  anthel- 
mintic, and  stated  that  thymol  rarely  failed,  if  given 
in  adequate  and  rapidly  repeated  doses.  He  referred 
also  to  the  virtues  of  betel-nut  taken  by  the  natives  of 
.A.ssam,  Hurmah,  and  Malaya  as  a  prophylactic  against 
ankylostomum.  He  believed  that  the  parasite  was 
generally  acquired  by  way  of  the  food. 

Major  Ross  remarked  that  he  had  carefully  followed 
Major  Giles'  investigations  on  the  rhabditiform  stage 
of  the  parasite,  and  considered  his  conclusions  sound. 
He  regarded  the  well-known  fact  that  the  disease  was 
present  among  earth-workers  as  an  argument  in  favor 
of  Major  Giles'  statements.     He  scouted  the  idea  that 


September  i,  1900] 


MEDICAL    RECORD. 


359 


the  ankylosloma  parasite  was  harmless,  and  entered  a 
plea  for  the  much  more  o;eneral  use  of  the  microscope 
for  the  detection  of  the  ova  in  localities  where  the 
worm  was  prevalent. 

Mr.  Cantlie  stated  that,  stimulated  by  the  re- 
searches of  Dr.  Walker  in  Borneo  concerning  the  as- 
sociation of  the  ankylostomuni  with  beri-beri,  he  had 
carried  out  prolonged  examinations  in  Hong  Kong, 
but  failed  to  find  tlie  parasite  in  cases  of  beri-beri. 

Tropical  Abscess  of  the  Liver. — Col.  Kenneth 
Maci.eod,  of  W'tley,  read  a  paper  on  "The  Manage- 
ment of  Lung  Lesions  Consequent  on  Liver  Abscess." 
The  frequency  of  liver  abscess  pointing  in  the  direc- 
tion of  the  thorax,  and  opening  either  into  the  pleural 
cavity  or  into  the  lung,  was  referred  to.  When  such 
an  event  occurred  a  free  opening  into  the  pleural 
cavity  must  be  made,  with  resection  of  a  rib  if  neces- 
sary. He  pointed  out  the  futility  of  operating  upon 
an  abscess  of  the  liver  after  expectoration  of  liver  pus. 
In  all  such  cases  tiie  condition  ought  to  be  approached 
by  way  of  the  chest,  and  the  lung  treated  as  the  of- 
fending organ;  for  very  soon  after  the  pus  had  found 
evacuation  by  way  of  a  bronchus,  the  liver  abscess 
commenced  to  heal  and  was  not  infrequently  healed 
altogether,  the  patient  succumbing  to  the  lung  lesion. 
He  advocated  leaving  the  liver  to  take  care  of  itself 
in  such  cases,  and  the  treatment  should  be  confined  to 
the  relief  of  the  lung. 

Mr.  James  Cantlie,  of  London,  read  a  paper  on 
"  Subhepatic  .Abscess."  By  subhepatic  abscess  he 
meant  a  collection  of  pus  between  the  capsule  of  the 
liver  and  the  under  surface  of  the  liver  substance. 
The  abscess  tended  to  point  in  the  epigastrium,  and 
was  probably  due  to  a  lymphangitis,  and  was  not  asso- 
ciated with  either  dysentery  or  any  other  pronounced 
intestinal  lesion.  He  had  been  able  to  verify  the 
existence  of  subhepatic  abscess  in  a  case  in  which 
laparotomy  was  performed,  and  he  had  seen  two  or 
three  cases  in  which  the  clinical  evidence  was  pro- 
nounced. 

Dr.  W.  Johnson  Smith,  of  Greenwich,  continued 
the  discussion  with  a  paper  on  "The  Diagnosis  and 
Surgical  Treatment  of  Tropical  Liver  Abscess."  In 
regard  to  surgical  treatment,  he  said  he  preferred  ex- 
ploratory pinicture  to  laparotomy  as  a  means  of  diag- 
nosis. He  had  met  with  almost  invariable  success  by 
puncturing  the  liver,  and  had  never  seen  any  un- 
toward effects  from  it.  Laparotomy,  under  the  most 
favorable  circumstances,  had  certain  inconveniences 
and  after-troubles  when  employed  as  a  means  of  diag- 
nosis. When  treating  the  abscess  by  trans-pleural 
incision  there  was  great  danger  of  opening  the  cavity 
of  the  pleura.  When  the  diaphragm  was  so  pressed 
upward  as  to  bulge  into  the  wound,  the  pleural  layers 
might  be  so  approximated  that  one  did  not  gain  en- 
trance to  the  cavity,  a  most  fortunate  circumstance. 

Staff  Surgeon  P.  W.  Bassett  Smith,  of  Haslar, 
reported  a  case  of  abscess  of  the  left  lobe  of  the  liver, 
with  remarks  particularly  referring  to  its  amoebic  cau- 
sation. The  abscess  in  this  instance  occurred  in  a 
man  in  England  who  had  not  been  abroad  for  two  years. 
The  hepatic  abscess  followed  quickly  after  an  attack  of 
dysentery,  .\moebae  coli  were  abundantly  found  in  the 
pus,  to  the  exclusion  of  pyogenic  bacteria.  Owing  to 
the  existence  of  the  pus  in  the  left  lobe  of  the  liver 
the  abscess  was  not  found  by  exploratory  puncture 
until  quite  late  in  the  illness.  Post-mortem  an  ab- 
scess was  found  on  the  right  lung,  not  directly  com- 
municating with  the  liver  abscess  cavity. 

Dr.  Manson  referred  to  the  heroic  nature  of  the 
operation  for  liver  abscess  practised  by  most  surgeons 
in  England,  and  thought  that  by  the  trocar  and  cannula 
more  satisfactory  results  were  obtained.  He  did  not 
regard  the  presence  of  the  amceba  coli  in  the  sputum 
as  an  indication  of  pus  in  the  liver,  he  had  never  met 


with  it.  He  failed  to  understand  the  cause  of  the 
serious  hemorrhage  met  with  during  hepatic  puncture 
by  IJombay  surgeons. 

Major  Ross  had  seen  a  case  of  hepatic  abscess  in 
Liverpool  in  which  leucocythaemia  but  no  evidence  of 
malaria  was  present. 

Mr.  Cantlie  said  he  had  followed  Dr.  Manson's 
plan  of  treating  liver  abscess  by  the  trocar  and  cannula 
and  the  insertion  of  a  large  drainage  tube  into  the 
cavity,  with  success.  He  stated  that  he  had  studied 
the  dangers  from  hemorrhage  during  hepatic  explora- 
tion, and  had  from  a  frozen  section  of  the  body  come 
to  the  conclusion  that  in  a  chest  of  thirty-two  inches 
circumference  it  was  not  safe  to  penetrate  farther  into 
the  liver  in  a  vertical  direction  from  the  surface  than 
three  and  three-fourths  inches. 

Colonel  Maci.eod  agreed  with  Dr.  Manson  that 
the  plan  followed  by  most  surgeons  was  too  severe. 
He  mentioned  a  case  in  which  after  laparotomy  the 
surgeon  failed  to  find  pus  in  the  liver,  yet  the  abscess 
burst  into  the  bowel  within  three  days  after  the  opera- 
tion. The  trans-thoracic  incision,  with  the  removal 
of  a  rib  and  stitching  of  parts  together,  was  an  unnec- 
essary proceeding  unless  the  pus  was  actually  in  the 
pleural  cavity. 

The  Cyprus  Sphalangi  and  its  Connection  with 
Anthrax  was  the  subject  of  a  paper  communicated  by 
Dr.  Geori;e  A.  Williamson,  of  Cyprus.  He  said  that 
the  so-called  sphalangi  was  an  insect  resembling  an 
ant  belonging  to  a  genus  of  sting-bearing  hymenop- 
tera,  called  mutilla.  The  bite  of  this  insect  was  con- 
sidered in  Cyprus  to  be  the  means  of  carrying  anthrax 
to  human  beings  from  animals  dead  of  the  disease. 
After  stinging  the  local  symptoms  were  a  circum- 
scribed induration  and  widespread  cedema  with  toxic 
general  symptoms.  The  discharge  from  the  puncture 
had  been  found  to  swarm  with  anthrax  bacilli.  The 
treatment  consisted  in  destruction  of  the  indurated 
tissue  by  the  cautery  and  hypodermic  injections 
around  the  part  of  a  solution  of  mercuric  chloride  and 
potassium  iodide. 

Some  Suggestions  for  the  Improvement  of  Sani- 
tary Medical  Practice  in  the  Tropics  was  the  subject 
of  a  paper  by  Maj.  Ro.nald  Ross.  He  advocated 
(i)  the  formation  of  small  up-to-date  libraries  in  the 
large  towns  in  our  colonies;  a  better  supply  of  micro- 
scopes; (2)  the  necessity  for  improved  municipal  sani- 
tary regulations;  (3)  the  desirability  of  securing 
organization  in  the  matter  of  research;  (4)  the  im- 
portance of  establishing  a  central  scientific  authority. 

Dr.  Mullick,  of  London,  said  there  was  urgent 
necessity  for  the  appointment  of  specially  trained 
investigators  to  fill  the  chairs  in  the  medical  schools 
of  India. 

Colonel  Macleod  pointed  out  the  difference  be- 
tween a  teacher  and  an  investigator;  seldom  was  the 
power  of  imparting  knowledge  and  investigation  met 
with  in  the  same  individual,  and  the  first  thing  re- 
quired of  the  lecturers  in  our  schools  was  that  they 
should  be  good  teachers. 


Third  Day — Friday.  August  jd. 

Yaws — Mr.  Jonathan  Hitchinson  opened  the 
discussion  on  yaws.  He  showed  a  man,  a  European 
from  the  west  coast  of  Africa,  believed  to  have  con- 
tracted yaws.  He  regarded  yaws  as  the  parent  of 
syphilis,  and  adduced  many  arguments  in  favor  of  the 
contention.  In  Fiji,  where  yaws  prevailed,  there  was 
no  syphilis,  and  he  argued  that  the  presence  of  yaws 
prevented  infection  by  syphilis.  Mr.  Hutchinson  de- 
nied the  statement  that  there  was  no  primary  sore  in 
yaws.  He  believed  that  sailors  and  others  becoming 
infected  by  yaws  abroad  came  back  to  this  country 
with  the  signs  and  symptoms  of  syphilis,  the  cause  of 


36o 


MEDICAL    RECORD. 


[September  i,  igoo 


the  slight  differences  in  symptoms  being  probably  ac- 
counted for  by  climate. 

Dr.  Davies,  of  Samoa,  said  that  in  Fiji  children 
only  were  attacked  by  yaws,  and  he  failed  to  see  how 
the  disease  could  be  acquired  by  sailors.  In  Fiji  and 
Samoa  the  natives  considered  yaws  in  children  in  the 
same  light  as  we  in  Britain  regarded  measles — that  it 
was  almost  a  certainty  to  have  the  disease,  and  the 
sooner  it  was  got  over  the  better. 

Dr.  Manson  considered  Mr.  Hutchinson's  views  on 
yaws  open  to  question  and  thought  it  strange  that  in- 
oculation by  yaws  did  not  protect  one  from  syphilis, 
and  vice  versa,  if,  as  Mr.  Hutchinson  suggested,  the 
primary  poisons  were  identical.  Why  yaws  was  not 
seen  in  England  was  to  be  explained  in  the  same  way 
as  the  absence  of  many  other  skin  affections  of  tropi- 
cal origin,  viz.,  that  a  high  constant  temperature  was 
necessary  for  its  continuance  and  development. 

Mr.  C.  Rees  said  that  he  saw  syphilitic  cases  and 
cases  of  yaws  side  by  side  in  West  Africa;  that  in  the 
Hinterland  yaws  was  common  but  syphilis  unknown, 
and  that  the  natives  of  the  West  African  coast  re- 
garded syphilis  as  a  new  disease. 

Colonel  Macleod  stated  that  he  thought  the  case 
shown  by  Mr.  Hutchinson  was  a  case  of  syphilis,  and 
all  present  agreed  with  him. 


^ccUcal  Items. 

Contagious   Diseases — Weekly   Statement Report 

of  cases  and  deaths  from  contagious  diseases  reported 
to  the  Sanitary  Bureau,  Health  Department,  for  the 
week  ending  August  25,  1900: 


Tuberculosis 

Typhoid  fever 

Scarlet  fever 

Measles 

Diphtheria 

Laryngeal  diphtheria  (croup) 
Cerebro-spinal  meningitis. . .  . 

Chicken-pox 

Smallpox   


Deaths. 


89 

"5 

51 

14 

51 

3 

37 

5 

20 

28 

6 

4 

0 

7 

I 

0 

I 

Antivivisectors  in  Sheffield The  Sheffield  corre- 
spondent of  the  British  Medical  Jntirnal  says  :  "  The 
antivivisectors  after  a  lull  are  again  on  the  war-path. 
The  walls  and  hoardings  of  Sheffield  are  placarded  with 
'torture'  pictures  calculated  to  hold  the  medical  pro- 
fession up  to  opprobrium  and  possibly  to  arouse  the 
sympathies  of  the  ill-informed.  The  campaign  is 
fairly  launched  against  the  holding  of  a  license  at  the 
University  College.  An  ofifice  has  been  started,  and 
signatures  are  solicited  for  a  petition  for  the  with- 
drawal of  the  license.  An  active  canvass  is  also  being 
promoted  with  the  same  object  in  view." 

Climate  of  Pekin. — A  well-informed  journal,  re- 
ferring to  the  configuration  of  the  country  and  the 
weather  generally  experienced  in  the  neighborhood  of 
Pekin,  says:  "The  most  of  the  territory  east  and  west 
of  I'ekin  in  which  the  earlier  part  of  the  Chinese  cam- 
paign will  have  to  be  carried  on  is  fiat  and  low-lying, 
much  of  it  subject  to  yearly  devastation  by  the  over- 
flow of  the  rivers.  In  winter  the  cold  is  frequently 
very  severe,  more  so  than  in  New  York,  which  has 
nearly  the  same  latitude  as  Pekin,  and  it  is  probably 
in  anticipation  of  a  campaign  during  the  coming  cold 
season  that  the  British  government  called  for  tenders 
for  the  supply  of  fur  capes  for  a  considerable  number 
of  troops.  At  present  the  heat  in  the  flat  country  east 
of  Pekin  is  great,  and  the  season  rainy,  but  in  view  of 


a  prolonged  resistance  by  the  Chinese  it  seems  de- 
sirable that  the  same  preparations  should  be  made  for 
the  comfort  of  our  troops." 

Contagiousness  of  Smallpox — Smallpox  is  prob- 
ably more  contagious  than  any  other  disease.  As 
reported  in  the  British  Local  Government  Reports  for 
the  periods  1884-85,  it  was  found  by  Dr.  Power 
(the  now  chief  medical  officer  of  the  board)  that  the 
disease  was  liable  to  be  communicated  under  favoring 
conditions  at  the  distance  of  a  quarter  of  a  mile.  He 
showed  that  if  the  district  in  which  the  Fulham 
Hospital  was  situated  were  divided  into  zones  by 
means  of  circles  drawn  upon  a  map  of  the  locality, 
with  the  hospital  in  the  centre,  with  radii  of  a  quarter 
of  a  mile,  three-quarters  of  a  mile,  and  one  mile  dis- 
tant respectively,  and  an  enumeration  made  of  all 
the  houses  in  each  belt  and  also  of  all  houses  invaded 
by  smallpox,  the  proportion  of  invaded  houses  dimin- 
ished as  the  distance  from  the  hospital  increased,  and 
this  relation  held  good  in  each  "quadrant "  of  each 
zone.  Within  the  quarter-mile  zone  there  was  only 
one  approach  to  the  hospital,  and  this  was  in  the 
northwest  quadrant.  The  distribution  of  cases  in  the 
several  quadrants  was  not  such  as  to  suggest  any  re- 
lation to  lines  of  traffic  or  ambulance  routes.  He 
concluded  that  diffusion  occurred  only  when  acute 
cases  were  aggravated  and  perhaps  only  under  certain 
atmospheric  conditions. 

State  Sanatoria  for  Consumptives. — Dr.  Edward 
Otis  thinks  that  State  sanatoria  should  be  erected  by 
State  appropriation,  and  at  least  partially  maintained 
from  the  sfme  source.  A  portion  of  the  expense  could 
be  collected  in  some  cases  from  the  patient  through 
his  friends,  or  by  private  charity,  or  defrayed  by  the 
city  or  town  from  which  he  conies.  Of  course,  the 
entire  maintenance  could  be  provided  for  by  a  per- 
capita  tax  on  the  locality  from  which  each  patient 
comes,  as  suggested  by  the  New  York  board  of  health, 
but  in  the  opinion  of  Dr.  Otis  a  certain  yearly  appro- 
priation should  be  made  by  the  State,  if  not  directly 
for  maintenance  purposes  at  least  for  investigations 
in  bacteriology,  pathology,  and  treatment  of  tubercu- 
losis, which  would  indirectly  benefit  not  only  the 
State  but  the  public  generally. 

Arsenic  in  a  Popular  Purgative. — Some  little 
time  ago  a  rumor  was  made  public  in  Great  Britain 
which  caused  widespread  alarm.  The  report  ran  that 
a  large  firm  of  manufacturing  chemists  had  for  sev- 
eral months  been  sending  out  a  granular  phosphate  of 
soda  which  was  afterward  found  to  contain  a  danger- 
ous amount  of  arsenic.  The  firm  issued  a  circular  to 
chemists  stating  "  that  the  phosphate  of  soda  lately 
supplied  by  them  contains  a  dangerous  percentage  of 
an  arsenical  preparation."  They  further  admit  that 
this  defect  applies  to  all  phosphate  of  soda  supplied 
from  November  15,  1899,  until  the  end  of  April,  1900. 
The  Medical  Press  and  Circular,  commenting  upon  the 
matter,  says:  "The  prospect  thus  opened  up  of  whole- 
sale and  unsu-spected  poisoning  is  simply  appalling. 
Phosphate  of  soda,  as  most  persons  know,  is  a  mild 
aperient  extensively  used  among  babies  and  children. 
The  effect  of  arsenic  would  be  to  produce  cramps, 
vomiting,  purging,  watery  and  choleraic  stools — in 
short,  symptoms  like  those  of  summer  diarrhoea.  It 
is  almost  certain  that  any  death  so  caused,  in  the  ab- 
sence of  any  symptoms  pointing  to  arsenical  poison- 
ing, would  be  referred  by  the  medical  attendant  to  the 
disease  mentioned.  It  is  therefore  not  improbable 
that  during  the  past  few  months  many  deaths  of  chil- 
dren have  been  improperly  ascribed  to  diarrhoea, 
whereas  their  true  nature  was  acute  arsenical  poison- 
ing." 


Medical  Record 

A    IVeekly  yoiinial  of  Medicine  and  Surgery 


Vol.  58,  No.  10. 
Whole  No.  1557. 


Nkvv  York,   September  8,    1900. 


$5.00  Per  Annum. 
Single  Copies,  loc. 


©rigmal  Articles. 

DILATATION  OF  THE  CERVIX  BY  MEANS 
OF  A  MODIFIED  CHAMPETIER  DE  RIBES 
BALLOON.' 

By  JAMES  D.    VOORHEES,    A.M.,    M.D., 

ASSISTANT  ATTENDING  PHYSICIAN  TO  THE  SLOANE  MATEKNITV  HOSI'ITAL^  AND 
TUTOR  IN  OBSTETRICS  AT  THE  COLLEGE  OF  PHYSICIANS  AND  SURGEONS, 
NEW  YORK    CITY, 

The  normal  mechanism  of  dilatation  of  the  cervix 
means  the  manner  in  which  the  os  uteri  enlarges, 
when  the  waters  are  abundant  and  the  membranes  in- 
tact. The  initial  stages  are  in  reality  to  be  referred 
to  the  fact  that  the  lower  uterine  segment  possesses 
less  muscular  strength  than  the  upper  part  of  the 
uterus,  and  to  the  character  of  the  uterine  contrac- 
tions; this  lower  segment  therefore  tends  to  expand 
during  contraction  from  the  action  of  the  general  intra- 
uterine fluid-pressure.  Besides  this,  the  longitudinal 
fibres  of  the  uterus  open  up  the  os,  and  lastly,  by 
separation  and  descent  of  the  membranes  a  fluid 
wedge  bulges  through  the  cervix  and  enables  the 
intra-uterine  fluid-pressure  to  take  direct  effect  upon 
its  margins.  As  this  process  continues  the  internal  os 
becomes  effaced,  the  cervix  is  shortened,  and  finally 
the  external  os  is  in  direct  contact  with  the  membranes 
and  stands  the  pulling  of  the  longitudinal  fibres.  The 
membranes  bulge  more  and  more,  the  force  is  greater 
and  greater  with  the  convexity,  and  finally  the  cervix 
has  totally  disappeared. 

When  the  waters  partially  escape  from  a  high-up 
rupture  of  the  membranes,  the  presenting  part,  i.e.,  the 
head,  descends  against  the  cervix  and  acts  as  a  ball- 
valve.  In  such  cases  the  process  is  slow,  unless  the 
os  has  so  far  dilated  as  to  admit  nearly  the  greatest 
circumference  of  the  head,  when  it  dips  through  as  a 
wedge,  and  then  the  dilatation  is  rapid. 

When  all  the  waters  escape,  then  the  head  must 
dilate  the  os  by  contact,  assisted  by  the  uterine  longi- 
tudinal fibres.  Now  all  such  dry  labors  are  not  long, 
protracted  labors.  If  the  pains  are  strong,  the  pelvis 
is  normal,  the  occiput  anterior,  or  the  child  small,  but 
especially  if  the  cervix  is  soft,  such  labors  are  often 
the  shortest. 

One  of  the  greatest  bugbears  for  the  obstetrician  is 
the  care  of  a  case  in  which  such  happy  conditions  do 
not  exist.  In  some  cases  the  membranes  rupture,  the 
waters  drain  away,  and  the  pains  do  not  start.  The 
child  is  compressed,  the  cervix  is  tough,  oxytocics  are 
useless,  and  we  wonder  how  things  will  terminate.  In 
others  the  pains  start,  are  strong,  the  membranes  rup- 
ture or  do  not,  but  for  many  reasons  the  labor  is  long 
and  drawn  out.  Such  protraction  we  expect  in  cases 
of  posterior  positions,  small  pelves,  large  children, 
twins,  breech  presentation,  hydramnion  cases,  and  the 
like.  What  concerns  us  principally  is  delay  from  the 
cervix,  whether  from  spasm,  because  it  is  tough,  rigid, 
and  immature,  or  in  consequence  of  congenital  and 
pathological  changes.  Nature  takes  care  of  some  of 
these  cases;  with  strong  pains,  the  spasm  is  relaxed, 

'  Awarded  the  Stevens  Triennial  Prize  by  Columbia  University, 
June  13,  1900. 


or  the  cervix  lacerates  and  labor  terminates.  In  the 
others  there  is  no  progress.  These  cases,  if  not  helped 
in  some  way,  soon  show  bad  symptoms.  The  women 
are  tired  out  and  the  bodily  vigor  is  gone.  The  pulse 
runs  up  as  well  as  the  temperature.  The  tongue  is 
dry,  the  teeth  are  covered  by  sordes;  the  vagina  is 
dry;  the  uterus  is  not  contracting  or  is  approaching 
a  tonic  spasm.  These  conditions  must  be  prevented. 
For  such  a  state  of  the  cervix  many  measures  have 
been  recommended — for  weak  pains,  oxytocics;  for 
spasm  of  the  cervix,  locally  hot  douches,  cocaine  and 
belladonna,  also  opium  and  chloral.  Cases  are  re- 
ported to  have  been  benefited  by  all  of  these  measures. 
Undoubtedly  chloral  by  the  rectum  is  the  best  remedy. 
It  gives  sleep  and  rest,  and  restores  the  nervous  tone. 
It  does  not  diminish  the  force  or  frequency  of  the 
uterine  contractions,  and  relaxes  any  spasm  of  the  cer- 
vix.    Often  labor  terminates  quickly  after  its  use. 

Yox  true  rigidity  the  above  treatment  fails  and  some- 
thing mechanical  is  necessary.  Tents  ha\e  been  rec- 
ommended and  used.  They  are  now  obsolete.  Their 
action  is  slow,  painful,  and  uncertain.  The  danger  of 
infection  is  very  great. 

Manual  dilatation  of  the  cervix  has  a  wide  field  and 
is  the  only  method  used  by  many  men.  We  always 
have  our  hands  with  us,  which  is  a  very  important 
fact.  The  method  is  painful  and  demands  anasthesia. 
In  cases  of  emergency,  severe  hemorrhage,  placenta 
prsevia,  eclampsia,  prolapse  of  the  cord,  etc.,  other  pro- 
cedures are  too  slow.  Dilatation  is  readily  accom- 
plished in  cases  of  soft  cervix  before  a  resort  to  for- 
ceps or  version.  Yet  nature  acts  differently  ordinarily. 
When  the  hand  is  used  the  cervix  most  often  yields 
only  by  tearing. 

Incision  of  the  cervix  is  rarely  necessary.  It  is 
demanded  only  in  cases  of  cicatricial  and  organic 
changes  in  the  cervix,  and  when,  in  dilating,  a  tear 
has  started  on  one  side  of  the  os.  Diihrssen's  inci- 
sions made  at  other  points  make  smaller  rents — not  a 
deep  one  which  will  endanger  the  lower  uterine  zone. 

The  natural  dilator  of  the  cervix  is  a  fluid  wedge. 
If  we  can  imitate  it  we  respect  all  the  physiological 
requirements,  we  help  nature  after  her  own  dictates, 
and  exactly  to  the  measure  of  her  needs.  We  use  no 
violence,  and  such  a  measure  ought  to  be  very  effec- 
tive, 

Dr,  Robert  Barnes  thought  by  his  fiddle-shaped 
rubber  bags  to  have  solved  the  difficulty.  They  have 
been  in  use  since  i860.  They  are  certainly  of  ad- 
vantage in  many  cases,  but  their  field  of  usefulness 
is  limited.  They  expand  the  cervix  in  some  cases; 
gripped  in  the  os,  they  exert  an  eccentric  force  which 
might  wear  out  a  muscular  resistance.  They  often 
start  pains  and  accelerate  labor,  acting  as  an  intra- 
uterine irritant,  a  foreign  body.  They  will  induce 
labor,  but  not  surely.  They  will  soften  a  cervix,  pre- 
liminary to  a  resort  to  the  forceps  or  version,  but  not 
regularly.  They  might  stop  a  hemorrhage  in  placenta 
praevia,  but  not  certainly.  They  are  not  used  exten- 
sively, therefore,  and  why  ?  (i)  It  is  difficult  to  in- 
troduce them  into  a  cervix  admitting  less  than  two 
fingers;  there  is  so  much  bulk.  (2)  Their  shape  is 
incorrect.  It  is  of  a  sort  one  often  sees  in  a  breech 
or  shoulder  presentation — an  hourglass  constriction — 


362 


MEDICAL    RFXORD. 


[September  8,  1900 


which  does  not  dilate  the  cervix.  They  slip  either 
into  the  uterus  or  vagina  without  accomplishing  any- 
thing. (3)  The  material  is  wrong.  Nature's  bag  is 
inelastic.  They  are  very  distensible.  In  filling  them 
one  cannot  regulate  the  pressure.  The  dilatation  may 
be  too  forcible,  consequently  they  burst.     They  soon 


Fig.    1. — a,  Largest  bag ;  ^,  smallest  bag ;  one-quarter  actual  size;    c,  bag 
rolled  lip  in  the  introducing-forceps. 

crack  and  rot,  and  therefore  are  often  useless  in  an 
emergency.  (4)  They  are  not  reliable  in  induction 
of  labor.  (5)  They  are  too  slow  a  dilator  in  eclamp- 
sia. (6)  In  placenta  previa  they  do  not  surely  stop 
the  hemorrhage. 

Champetier  de  Ribes  in  his  early  experience  used 
a  rubber  bag  of  Tarnier,  a  small  ampulla  attached  to 
a  tube.  He  found  that  this  rubber  bag  did  well  as  a 
cervical  dilator  in  some  cases,  but  not  in  all.  He 
therefore  determined  to  make  a  better  one.  It  was  to 
be  longer,  conical,  impermeable,  and  inexpansible  be- 
yond a  certain  volume.  It  was  to  be  strong  to  resist 
uterine  and  abdominal  contraction,  and  long  enough 
to  fill  the  cervix.  He  devised  a  long  conical  balloon 
with  a  slight  constriction  forming  a  neck.  To  it  was 
attached  a  tube  in  which  was  a  stop-cock.  To  be  in- 
expansible  it  was  made  of  fine  silk,  and  to  be  imper- 
meable it  was  covered  with  thin  rubber. 

Champetier's  balloon  has  been  quite  extensively 
used  in  Europe,  but  not  very  much,  so  far  as  I  can 
learn,  in  this  country.  Pinard  has  used  it  in  forty 
cases  to  induce  labor,  with  most  rapid  results.  In 
twenty-three,  labor  was  completed  in  six  to  twelve 
hours;  in  seven,  in  seventeen  to  twenty-four  hours; 
and  in  ten,  in  twenty-four  to  forty-eight  hours.  Her- 
man and  Spencer  have  also  used  it  successfully 
to  induce  labor.  G.  F.  Blacker'  reports  twenty-two 
cases  in  which  the  balloon  has  been  used  in  placenta 
prsevia  with  good  results.  Of  these  one  mother  died, 
and  she  of  sepsis,  which  had  been  manifest  at  the  be- 
ginning of  the  labor;  of  the  children  fourteen  were 
alive;    of  the  still-births,  six  were  premature.     In  all 


Fic.  2. — rt,  Syringe;  h^  forceps  ;  one-quarter  actua 


cases  hemorrhage  was  controlled  by  traction  on  the 
balloon. 

All  of  the  above  men  used  Champetier's  large  bal- 
loon. Lately  he  has  made  them  of  six  different  sizes, 
ranging  from  a  cone  whose  base  is  3  cm.  in  diameter 

'  Transactions  of  the  Obstetrical  Society,  London,  iSgS,  vol. 
xxxi.x. 


to  one  whose  base  is  8  cm.  in  diameter.  These  are 
more  generally  convenient  and  easier  of  introduction 
when  the  os  is  small. 

In  the  fall  of  1897  Dr.  James  W.  McLane,  the  at- 
tending physician  to  the  Sloane  Maternity  Hospital, 
began  to  use  Champetier's  balloons.*  At  once  we  found 
that  they  were  not  so  strong  and  durable  as  they  were 
supposed  to  be.  They  would  hold  only  so  much  fluid 
and  no  more.  If  the  tension  was  too  great,  they  would 
burst  in  the  seams.  They  would  stand  but  little  trac- 
tion on  the  tube.  So  having  only  one  set,  my  supply 
soon  gave  out. 

The  balloons  were  expensive — $1.50  singly  and  $9 
the  set.  As  Colin's  in  Paris  was  the  only  place  where 
they  could  be  bought,  it  took  a  long  time  to  get  them. 
To  make  them  more  available  and  to  remedy  their 
faults,  I  suggested  to  a  rubber  manufacturing  company 
of  New  York  to  make  one  for  trial.  It  was  to  be  made 
of  thin  canvas  and  covered  by  a  thicker  rubber.  This 
was  done  and  a  sample  sent.  It  proved  very  satisfac- 
tory. This  original  one  is  now  intact  after  a  number 
of  trials  and  two  years  of  service.  A  set  of  four  was 
then  made.  Not  one  of  them  has  burst.  They  are  in- 
expensive— only  $1  a  set. 

Description  of  the  Balloon  and  Forceps. — (i)  The 
balloon  is  conical  in  shape.  For  best  results  it  must 
be  impervious  and  inexpansible.  It  must  be  strong 
enough  to  resist  uterine  and  abdominal  contraction, 
also  to  stand  traction  on  the  tube.  It  is  therefore 
made  of  thin  canvas,  firmly  sewed,  and  covered  by  a 
rather  thick  rubber,  carefully  cemented.  Everything 
must  be  of  such  material  as  can  be  readily  boiled  and 
then  kept  for  a  short  time  in  some  antiseptic  solution; 
also  a  material  which  will  stand  the  action  of  the 
liquor  amnii  and  vaginal  mucus. 

There  are  four  sizes:  No.  i,  diameter  of  base  of 
cone,  3  cm.;  capacity,  10  c.c.  No.  2,  diameter  of  base 
of  cone,  5  cm.;  capacity,  50  c.c.  No.  3,  diameter  of 
base  of  cone,  6  cm.;  capacity,  100  c.c.  No.  4,  diam- 
eter of  base  of  cone,  8  cm. ;  capacity,  200  c.c.  No.  i 
dilates,  therefore,  to  two  fingers  plus;  No.  2  to  three 
fingers;  No.  3  to  four  fingers;  No.  4  to  four  fingers 
plus — almost  five  fingers.  The  size  used  at  first  de- 
pends on  the  size  of  the  os.  The  balloons  are  best 
kept  in  talcum  or  lycopodium. 

(2)  The  Forceps  (see  F"ig.  i,  c ;  Fig.  ij>):  This  in- 
strument is  not  absolutely  necessary.  Any  dressing- 
forceps  or  sponge-holder  will  do,  or  one  can  use  the 
fingers  alone.  The  most  convenient  one  is  a  forceps 
with  a  clamp.  It  should  have  a  slight  pelvic  curve; 
the  blades  should  diverge  and  meet  again  at  the  tips. 
The  blades  should  be  smooth — no  serrations — so  as 
not  to  bring  out  the  bag  on  removal  of  the  forceps. 
A  small  fenestra  in  the  blades  holds  the  bag  firmly 
in  its  grasp.     The  length  is  25  cm. 

The  Operation. —  (i)  The  instruments  necessary 
are:  set  of  balloons,  introducing-forceps,  tape,  scissors, 
and  syringe. 

(2)  Solutions:  Some  antiseptic  solution  incase  the 
bag  ruptures,  e.g.,  lysol  (one-half  per  cent.),  carbolic 
acid  two  per  cent.,  bichloride  of  mercury  i :  5,000. 

(3)  Assistants:  One  to  inject,  the  operator  holding 
the  bag  in  position;  another  to  give  chloroform.  An 
anesthetic  is  not  necessary  but  makes  tiic  introduction 
easier.  If  the  woman  is  brought  down  to  the  edge  of 
the  bed  two  assistants  are  necessary  for  the  extremi- 
ties.    Yet  you  can  get  along  with  only  one. 

(4)  Preparation  of  the  instrument,  patient,  and 
operator:  (</)  The  balloon,  forceps,  scissors,  tape,  and 
syringe  are  boiled  for  five  minutes  and  then  kept  in 
carbolic-acid  solution  five  per  cent.,  or  in  lysol  solu- 
tion one-half  per  cen.t.  (/>)  The  patient  is  prepared 
as  for  induction  of  labor  or  for  delivery.  She  is  given 
a  cleansing  bath  and  an  enema.  The  vulva,  groin, 
and  thighs  are  scrubbed  carefully  with  green  soap,  and 


September  8,  1900] 


MEDICAL    RECORD. 


363 


then  irrigated,  first  witii  alcohol  and  after  with  bichlor- 
ide solution  1:5,000.  A  sterile  pad  is  put  on  the 
vulva  and  kept  there  until  time  of  introduction.  The 
woman  has  on  sterile  leggings.  She  is  brought  to  tiie 
edge  of  the  bed  or  table.  Under  her  buttocks  is  a 
perineal  or  Kelly  pad,  covered  by  a  sterile  towel,  and 
a  sterile  towel  is  placed  over  her  abdomen.  Assist- 
ants may  hold  the  extremities.  She  voids  her  urine 
or  is  catheterized.  The  vagina  is  thoroughly  irrigated 
and  cleansed  by  a  lysol  one-half-per-cent.  douche. 
Some  cases  need  an  anasthetic.  If  a  preliminary 
dilatation  by  means  of  a  divulsor  is  necessary,  if  the 
cervi.K  is  high  up,  if  the  patient  is  nervous  or  is  a 
primipara  with  a  small  vulvar  orifice,  light  chloroform 
narcosis  can  be  induced. 

(s)  The  operator:  His  hands  and  forearms  are 
thoroughly  sterilized.     He  has  on  a  sterile  gown. 

Method  of  introduction:  If  the  cervix  is  undilated, 
a  Goodell  dilator  or  the  finger  must  be  forced  through 
as  a  preliminar)'  measure.  Then,  if  the  membranes 
are  unruptured,  they  are  to  be  separated  as  much  as 
possible  about  the  os.  Remove  all  the  air  from  the 
syringe  and  fill  it  with  the  antiseptic  fluid.  Fill  the 
bag  first  to  see  that  it  is  intact.  The  balloon  to  be 
used  depends  upon  the  size  of  the  os.  Remove  all 
air  and  solution  from  the  bag.  Tuck  in  its  base,  roll 
it  up,  and  clamp  it  tightly  in  the  forceps  (see  Fig.  i,c). 
Then  dip  it  in  lysol.  Two  fingers  of  the  left  hand  are 
now  carried  into  the  vagina  as  far  as  theos.  On  them 
the  bag  in  the  forceps  is  guided  into  the  opening. 
With  the  base  well  inside  the  forceps  is  undamped 
and  removed.  The  bag  is  then  held  in  place  by  the 
fingers  while  an  assistant,  or  the  operator  with  the 
other  hand,  slowly  and  gradually  fills  it  with  Huid. 
The  amount  necessary  is  determined  by  the  resistance 
or  by  feeling  the  tension  of  the  bag.  The  tube  is 
securely  tied  by  the  tape  and  then  put  into  the  vagina. 
A  sterile  pad  is  now  put  over  the  vulva.  The  bag 
cannot  get  out  until  the  cervix  has  dilated  to  admit 
its  base.  If  the  pains  are  weak  and  infrequent  or  the 
dilatation  is  slow,  from  time  to  time  traction  can  be 
made  on  the  tube  until  the  balloon  comes  through. 
Then  if  things  are  not  progressing,  if  the  cervix  is 
unsoftened  and  the  pains  are  weak,  a  larger  balloon 
can  be  inserted.  Xo  balloon  should  be  left  in  longer 
than  eighteen  to  twenty-four  hours,  as  the  danger  of 
infection  is  great.  When  a  bag  comes  out  an  exam- 
ination should  be  made  to  see  that  the  cord  has  not 
come  down. 

Results. — I  publish  all  cases  in  which  the  balloons 
have  been  employed.  These,  seventy-two  in  number, 
are  not  selected.  They  are  those  in  which  the  indica- 
tion was  certain,  and,  in  almost  all,  other  methods  had 
been  tried  and  failed.  All  were  not  successful,  but 
certain  advantages  were  obtained  and  the  field  of  use- 
fulness of  the  bags  was  more  definitely  determined. 
The  cases  are  taken  from  2,113  during  the  past  two 
years  to  September  i,  1899,  in  the  writer's  experience 
at  the  Sloane  Maternity  Hospital.  I  did  not  insert 
all  the  balloons  myself.  Some  were  introduced  by 
my  assistants,  who  have  kept  exact  records. 

I.  Dry  Labors:  (a)  Vertex  cases;  no  pains.  Dur- 
ing this  time  there  were  three  hundred  and  fifty  dry 
labors,  but  the  bags  have  been  used  in  only  twenty- 
seven.  There  were  eleven  primiparsE  and  sixteen  mul- 
tipara; three  had  justo-minor  pelves;  one  a  flat  pelvis 
with  an  internal  conjugate  diameter  of  8.25  cm.;  the 
other  pelves  were  normal.  In  four  the  position  was 
jrosterior;  the  head  was  engaged  in  six;  in  twenty-one 
it  was  above  the  brim.  In  nineteen  oxytocics,  quinine 
and  strychnine,  had  been  given  without  starting  the 
pains.  The  time  from  rupture  of  the  membranes  until 
the  introduction  of  the  bag  varied  from  three  to  forty- 
eight  hours;  the  average  time,  eighteen  hours  one 
minute.     In  nineteen  cases  the  cervix  was  tough.     In 


one  case  three  bags  were  used;  in  three,  two  bags 
were  used;   in  twenty-three,  only  one. 

Pains  started  earliest — immediately;  latest,  after 
sixteen  hours  thirty  minutes;  average,  one  hour  one 
minute.  The  bag  was  in  the  cervix — longest,  thirteen 
hours  fifty-five  minutes;  shortest,  one  hour  five  min- 
utes; average,  four  hours  fifty-three  minutes.  In 
twenty-two  cases  pains  were  strong,  and  in  five  they 
were  weak.  The  cervix  admitted  three  fingers  when 
the  bag  came  out,  seven  times;  four  fingers,  fourteen 
times;  five  fingers  twice;  it  was  fully  dilated  four 
times. 

After  the  balloon  came  out,  the  cervix  was  found  to 
be  soft  in  twenty-five  cases.  The  longest  time  till 
complete  dilatation  after  the  introduction  of  the  bag 
was  fifteen  hours  thirty-eight  minutes:  shortest,  one 
hour  forty  minutes;  there  were  only  five  cases  over 
ten  hours;  average,  five  hours  forty  minutes. 

The  child  was  in  bad  condition  three  times  when 
the  bag  was  put  in;  six  children  were  asphyxiated  at 
birth,  three  slightly,  two  moderately,  one  deeply.  (3ne 
child  was  still-born;  the  cord  had  prolapsed,  and 
through  carelessness  it  was  detected  too  late.  There 
was  no  sepsis.  Four  patients  had  temperatures  from 
100°  to  :oo.8°  F. 

All  births  were  spontaneous  but  three;  one  was  a 
case  of  high-forceps  operation  in  the  flat  pelvis;  one 
of  a  medium  forceps;  and  the  other  of  a  low  forceps. 
The  last  was  done  to  deliver  quickly  in  the  case  in 
which  the  cord  prolapsed. 

(/')  Breech  cases :  During  the  two  years  there  were 
one  hundred  and  two  breech  cases,  and  the  bag  was 
used  in  only  six.  Two  were  primipara  and  four  mul- 
tipara;. One  had  a  flat  pelvis  with  previous  difficult 
births.  Two  were  over  time  and  had  large  children. 
In  two,  pains  had  started  but  were  weak.  In  one  the 
membranes  had  ruptured  thirty  hours  before  the  bag 
was  put  in.  In  two,  pains  started  immediately,  and 
in  two  after  thirty  and  forty-five  minutes  respectively. 
In  one  the  umbilical  souffle  was  present;  and  in  four 
the  fcetal  heart  was  slow  and  irregular.  Bags  were  in 
the  cervix  from  five  minutes  to  two  hours  forty  min- 
utes. Shortest  time  from  introduction  of  the  bag  until 
complete  dilatation,  one  hour  twenty  minutes;  longest, 
six  hours  thirty  minutes.  Four  children  were  deliv- 
ered spontaneously,  two  by  extraclion ;  four  children 
were  born  asphyxiated,  three  moderately.  There  were 
no  cases  of  high  temperature  in  the  puerperium.  The 
cervi.x  was  only  slightly  torn  in  all  cases. 

2.  Protracted  Labors:  In  the  two  years  at  the  hos- 
pital there  were  fifty-six  protracted  labors.  The  bal- 
loon was  used  in  twenty-two.  Ten  were  primipara;  and 
twelve  were  multipara.  There  were  ten  posterior 
positions.  In  only  three  cases  was  the  head  engaged 
at  the  beginning  of  labor.  Two  patients  had  flat 
pelves,  and  two  justo-minor.  In  fifteen  the  pains 
were  weak.  In  all  oxytocics  had  been  used;  in 
twelve,  chloral.  In  three  there  was  some  manual  dila- 
tation. In  all,  the  membranes  had  been  ruptured  be- 
fore the  bags  were  introduced.  The  shortest  time  of 
pains  before  the  bags  were  used  was  eight  hours; 
longest,  forty-eight  hours;  average,  twenty-three  hours 
thirty-nine  minutes.  The  cervix  admitted  one  finger 
plus  in  two  cases;  two  fingers  in  nine;  and  three  fin- 
gers in  eleven,  at  time  of  introduction.  The  cervix 
was  tough  in  all  but  one;  in  one  it  was  cicatricial, 
and  in  another  cartilaginous.  One  bag  was  used  in 
fifteen  cases;  two  bags  in  seven  cases.  The  shortest 
time  of  bags  in  the  cervix  was  one  minute;  longest 
time  seven  hours  thirty  minutes;  average,  two  hours 
fifty-five  minutes.  Dilatation  when  the  bags  came  out 
— cervix  admitted  three  fingers,  three  times;  four  fin- 
gers, eleven  times;  five  fingers,  eleven  times.  Short- 
est time  from  introduction  of  the  balloon  till  com- 
plete dilatation  was  thirty  minutes;    longest,  tTrenty- 


564 


MEDICAL    RECORD. 


[September  8,  1900 


three  hours  thirty-five  minutes;  average,  six  hours 
thirty-six  minutes;  one  never  fully  dilated  (cartila- 
ginous). 

The  condition  of  the  child  when  the  bag  was  intro- 
duced was  good  in  fourteen  cases.  There  was  an 
umbilical  souffle  in  one;  in  three  the  fcetal  heart  was 
slow  and  irregular;  in  one  the  child  was  passing 
meconium. 

Twelve  cases  terminated  spontaneously  ;  two  by  high 
forceps  (one  after  replacement  of  the  cord  and  the 
other  after  a  symphyseotomy);  four  by  a  medium  for- 
ceps; two  by  a  low  forceps;  one  by  a  version  and 
craniotomy. 

Only  one  child  was  still-born.  This  one  had  its 
after-coming  head  perforated,  as  a  cartilaginous  cervix 
held  it,  and  the  child  died.  Ten  children  were  not 
at  all  asphyxiated  at  birth,  four  slightly  so,  four  mod- 
erately, four  deeply;  but  in  all  cases  they  recovered 
and  survived. 

Five  women  had  fever;  one  had  a  temperature  of 
100°  F.  on  the  third  day,  due  to  the  breasts;  one 
101°  F.,  reactionary  after  symphyseotomy;  one  101° 
F.,  reactionary  after  a  severe  hemorrhage;  another 
101-103°  F.  for  seven  days,  due  to  a  cystitis  and  ure- 
teritis; and  one  died  of  a  virulent  sepsis  on  the  sixth 
day.  She  was  annemic,  underfed,  and  had  attempted 
abortion.  She  had  a  long,  dry  labor,  with  many  ex- 
aminations. Her  placenta  was  retained  and  she  had 
an  extensive  tear.  Autopsy  showed  a  suppurative 
metritis,  chronic  nephritis,  and  miliary  tuberculosis. 

3.  Induction  of  Labor:  In  the  2,113  cases,  labor 
was  induced  fifty-five  times,  a  bougie  being  the  method 
usually  adopted.  During  this  time  there  had  been 
twenty-six  cases  of  eclampsia — accouchement  force 
being  the  usual  method  of  treatment.  In  inducing 
labor,  the  bag  was  used  alone  in  eight  cases,  in  one 
after  rupturing  the  membranes,  and  in  seven  after  the 
bougie  had  practically  failed.  Seven  patients  were 
primiparx-  and  nine  multipara. 

The  indication  for  five  was  a  contracted  pelvis; 
three  were  cases  of  eclampsia;  two  had  albuminuria; 
two  were  cases  of  chronic  endocarditis;  one  had  a 
large  ovarian  cyst,  one  severe  asthma  and  emphysema, 
one  accidental  hemorrhage,  and  one  was  a  woman  who 
had  the  history  of  two  previous  still-births.  Four 
were  occipito-posterior  positions,  two  breech  presenta- 
tions, one  twins.  The  membranes  had  ruptured  in 
seven— the  shortest  time  twenty  minutes,  and  the  long- 
est fourteen  hours  fifty-seven  minutes.  All  the  chil- 
dren were  premature,  seven  and  three-fourths  to  eight 
and  three-fourths  months.  Pains  had  started  slightly 
in  two;  no  pains  in  fourteen;  in  seven  a  bougie  had 
been  in  the  uterus  from  five  hours  nineteen  minutes  to 
twenty-seven  hours.  All  the  cervices  were  tough,  five 
immature  and  long.  The  cervix  was  closed  in  one, 
admitted  one  finger  in  ten  cases,  two  fingers  in  five 
cases.  One  bag  was  used  in  four  cases,  two  in  ten 
cases,  three  in  four  cases.  The  shortest  time  a  bag 
was  in  the  cervix  was  one  hour  fifteen  minutes;  long- 
est, thirteen  hours  thirty-five  minutes;  average,  ten 
hours  fifteen  minutes.  Pains  started— shortest  time, 
immediately;  longest  time,  three  hours  thirty  minutes; 
average,  two  hours  twenty-seven  minutes.  There  were 
no  pains  in  one  case,  terminated  by  accouchement 
force  in  a  bad  case  of  eclamjisia.  The  time  from  in- 
troduction till  complete  dilatation  was,  shortest,  two 
hours  one  minute;  longest,  twenty-nine  hours  thirty- 
one  minutes;  average,  fourteen  hours  two  minutes. 

Nine  patients  were  delivered  spontaneously;  two 
breech  cases  by  extraction ;  one  by  version ;  two  by 
forceps;  ohe  by  basiotripsy,  as  the  forceps  failed  and 
the  child  died;  and  one  by  a  perforation  of  the  after- 
coming  head  after  the  child  had  died.  Nine  children 
were  not  asphyxiated  at  birtli,  two  were  moderately  so, 
and  three  deeply.     Three  were  still-born — two  were 


perforated   in  cases  of  eclampsia  as  above,  and  the 
third  was  the  second  child  of  twins. 

Four  women  had  fever.  One  had  102°  F.  on 
fourth  day,  the  cause  of  which  is  unknown.  The  other 
three  died;  two  were  cases  of  eclampsia,  and  the  third 
a  case  of  acute  yellow  atrophy  of  the  liver. 

4.  Placenta  J'raevia:    In  the  two  years  there  were 
fourteen  cases  of  placenta  prania,  but  the  balloons 
were  used  in  only  three.     All  were  of  multipara'.     One 
patient  had  had  three  hemorrhages  before  admission; 
she  was  very  anamic,  pulse  slow  but  small.     Another 
had  been  bleeding  continuously  for  four  days;  she  was 
anx'mic,  but  pulse  was  good.     Tlie  third  had  had  three 
hemorrhages,  but  her  condition  was  good.     The  first 
was  almost  at  term;    the  second,  seven  and  one-half 
months  along;  the  third,  seven  and  one-fourth  months. 
The  presentations  were  L.O.P.,  L.D.A.,  and  R.O.,  re- 
spectively.    No  pains   had  started.     The  cervix  was 
firm  in  one,  tough   in  the  other  two.     The  cervix  ad- 
mitted one  finger  in  all;    the  membranes  were  intact. 
Pains  started  almost  immediately  in  the  first,  in  twelve 
minutes  in  the  second,  and   in  seven  minutes  in  the 
third — after  the  introduction  of  the  bags.     Nos.  2,  3, 
and  4  were  used  in  the  first  case;    they  were  in  the 
cervix    thirty-one   minutes.     The  patient  lost  twenty 
ounces  of  blood  between  the  introductions.     In  the 
second,  Nos.  2   and  3  were  used.     They  were  in  the 
cervix   three    hours    forty   minutes.     Two   ounces   of 
blood  were  lost  between  the    introductions.     In    the 
third,  Nos.  2    and   4  were   used.     They  were   in   the 
cervix  three  hours  seventeen  minutes.     Two  ounces  of 
blood  were  lost  between  introductions.     There  was  no 
hemorrhage  while  the  balloons  were  in.     Tractions  on 
the   tube  were   used   in   all.     All   the    patients  were 
finally  delivered  by  version  and  extraction.     All  had 
pulses  below  100  after  delivery.     The  children  of  the 
second  and  third  were  deeply  asphyxiated.     The  first 
came  around  all  right,  but  the  other  was  very  prema- 
ture, weighing  three  pounds  thirteen  ounces,  and  lived 
only  seven  hours.     The  child  of  the  other  was  still- 
born.    The  cervix  gripped  the  neck  and  delayed  the 
delivery  enough  to  kill  it. 

The  first  patient  had  a  fever  of  101°  F.  on  the 
fourth  day— a  mild  absorption;  the  second,  101°  F. 
on  the  first  day — reactionary;  the  third,  no  elevation 
of  temperature. 

Action  of  the  Balloon — With  the  membranes  in- 
tact, the  distention  of  the  balloon  shoves  them  up  and 
separates  them  below  near  the  internal  os.  The  cone 
shape  keeps  the  bag  in  the  uterus.  The  apex  fills  the 
cervix.  It  cannot  get  out.  With  the  membranes  rup- 
tured, the  balloon  plugs  the  cervix,  taking  the  place  of 
the  natural  bag.  The  rest  of  the  liquor  amnii  cannot 
escape;  it  therefore  protects  the  child,  and  so  is  espe- 
cially advantageous  in  breech  cases.  The  bag  is  a 
foreign  body  in  the  uterus,  therefore  an  irritant  to 
uterine  contractions.  It  pushes  up  the  head  or  pre- 
senting part,  increasing  the  intrauterine  pressure.  In 
this  way  it  stimulates  the  uterus  to  contract.  The 
weight  of  the  child  drives  the  balloon  down  into  the 
cervix,  causing  an  eccentric  pressure  and  so  dilating 
the  cervix.  Again,  there  is  nothing  like  a  body  in  the 
cervix  to  start  labor  pains  reflexly. 

If  no  contractions  begin,  traction  on  the  tube  may 
start  them  and  at  the  same  time  dilate  the  cervix.  If 
the  uterus  contracts,  the  cone  is  driven  down  and  opens 
the  OS.  If  the  cervix  is  in  spasm,  the  constant  pressure 
of  the  bag  will  tire  the  muscle  and  it  will  relax. 
While  in  the  uterus,  it  also  causes  a  physiological 
softening.  If  the  cervix  is  long,  the  internal  os  is  first 
acted  upon. 

In  some  cases  the  pains  start  immediately,  ordina- 
rily in  three  or  four  hours.  They  may  be  weak  and 
infrequent  at  first,  and  later  strong;  or  they  may  be 
strong  and  frequent  from  the  beginning.     Often  when 


September  8,  1900] 


MEDICAL    RECORD. 


365 


successive  balloons  are  used,  in  the  interim  the  pains 
cease,  but  start  up  again  as  soon  as  the  next  size  of 
the  balloon  is  introduced.  Whether  the  pains  start 
soon  or  late,  or  are  strong  or  weak,  generally  depends 
on  the  time  of  pregnancy,  the  condition  of  the  os,  or 
the  duration  of  labor.  With  the  contractions  of  the 
uterus  and  dilatation  of  the  cervix,  the  bag  descends 
and  passes  through  the  os  into  the  vagina.  Sometimes 
the  bag  remains  there.  It  will  do  so  unless  the  vagina 
expels  it,  or  the  head,  in  its  advance,  drives  it  out  of 
the  vulva.  After  balloon  No.  4  comes  through  the 
cervix,  unless  the  brim  resists,  the  head  dips  into  it 
and  completes  the  dilatation.  The  labors  then  gen- 
erally terminate  spontaneously.  In  this  way  the  cer- 
vix is  gradually  opened  without  violence,  and  no  deep 
lacerations,  which  later  bother  the  patient,  result. 
Quite  different  is  a  cervix  after  a  manual  dilatation. 

In  dry  labors,  the  balloons  surely  start  pains  when 
oxytocics  fail.  They  dilate  the  cervix  rapidly  and 
diminish  foetal  mortality.  This  is  very  remarkable  in 
breech  cases.  In  them  you  do  not  have  to  pull  down 
a  foot  so  early,  and  thereby  save  the  child  from  pro- 
longed pressure.  The  bag  also  prepares  the  cervix 
for  the  after-coming  head. 

In  protracted  labors  the  birth  is  hastened,  saving 
the  mother  untold  sufifering.  The  balloons  dilate  the 
cervix  when  other  measures  fail,  and  many  labors 
terminate  spontaneously  which  otherwise  would  re- 
quire manual  dilatation,  with  laceration  of  the  cervix, 
and  instrumental  aid.  However,  if  forceps  or  version 
is  necessary,  the  cervix  is  softer  and  the  os  is  wider 
and  so  in  better  shape  for  these  operations. 

The  balloons  certainly  start  labor,  even  when  a 
bougie  has  failed.  They  are  especially  advantageous 
in  those  cases  in  which  the  membranes  have  ruptured 
early. 

In  cases  of  contracted  pelvis,  ordinarily  the  dilata- 
tion is  slow.  The  bag  makes  it  more  rapid,  allows 
the  head  to  engage,  and  sooner  prepares  the  case  for 
major  operations  if  they  are  necessary. 

In  albuminuria  and  eclampsia,  the  uterus  is  not 
very  irritable,  so  that  dilatation  is  slow.  Often  no 
pains  start  at  all,  and  the  only  advance  we  can  get  is 
by  traction  on  the  tube. 

In  placenta  previa  the  balloons  can  be  used  with 
the  membranes  intact  or  ruptured.  If  they  are  intact, 
they  perhaps  separate  the  placenta  a  little  more,  but 
as  few  attachments  are  directly  central,  this  makes 
little  difference.  The  bag  is  an  excellent  tampon  and 
will  stop  all  active  bleeding.  It  presses  directly 
against  the  bleeding  sinuses.  Again,  if  the  mem- 
branes are  intact,  a  subsequent  version  is  more  easily 
accomplished.  With  the  membranes  ruptured,  the 
bag  is  in  the  amniotic  cavity  and  presses  the  sepa- 
rated portion  of  the  placenta  against  the  uterine  wall. 
If  the  bag  itself  does  not  stop  the  hemorrhage  a  little 
traction  on  the  tube  w-ill  always  do  it.  By  starting 
uterine  contractions,  by  softening  and  dilating  the 
cer\'ix,  the  bag  accomplishes  much  in  placenta  previa. 

.\lso  by  not  being  required  to  use  the  child's  foot  to 
do  this  we  diminish  ftttal  mortality;  besides,  the  bag 
is  a  much  better  plug  for  the  cervix  than  the  half- 
breech.  Then,  with  the  cervix  so  prepared,  the  ease 
of  delivery  after  the  expulsion  of  the  largest  bag  is 
remarkable— quite  different  from  a  delivery  through  a 
tough  cervix  after  a  Braxton-Hicks  version. 

Advantages  of  the  Modified  Champetier  de  Ribes 
Balloons  over  Others,  i.e.,  Barnes'  Bags.— ( i )  They 
are  easier  to  introduce,  less  bulky.  (2)  The  shape  is 
more  like  that  of  nature's  bag.  (3)  They  are  inexpansi- 
ble  and  cannot  burst.  (4)  They  cannot  get  out  through 
the  cervix  without  dilating  it.  (5)  They  are  more  re- 
liable in  starting  labor  pains.  (6)  They  keep  in  the 
liquor  amnii.  (7)  They  do  not  rot.  (8)  Theysurely 
stop   hemorrhage   in   placenta   prasvia.     (9)  One  can 


pull  on  the  tube.     (10)   They  are  less  apt  to  displace 
the  presenting  part. 

Objections  to  the  Balloons.  — (1)  They  may  rupture 
the  membranes.  This  happens  rarely,  and  it  makes 
little  difference  if  they  do.  The  fatus  suffers  some, 
but  little,  as  the  waters  cannot  all  drain  away.  If  the 
fluid  does  escape,  the  dilatation  is  rapid  enough  to  do 
little  harm. 

(2)  They  may  separate  the  placenta — only  in  pla- 
centa pr.tvia.  But  the  bag  either  arrests  the  hemorrhage 
on  being  filled  or  when  traction  is  made  on  the  tube. 

(3)  They  may  increase  the  tension*  in  the  interior 
of  the  uterus.  It  is  not  great  and  no  harm  is  ever 
done.  It  is  not  painful  to  the  patient  and  never  rup- 
tures or  weakens  the  uterus. 

(4)  They  may  displace  the  presenting  part.  This 
is  possible,  but  by  slow  distention  of  the  bag  and  by 
watching  the  presenting  part  during  (he  distention,  we 
can  keep  it  in  place.  This  accident  occurred  only 
once  in  the  seventy-two  cases.  It  was  in  a  contracted 
pelvis,  and  perhaps  would  have  occurred  spontane- 
ously. If  it  does  occur,  it  can  be  easily  rectified,  for 
the  conditions  are  very  favorable  for  a  version. 

(5)  The  cord  may  prolapse.  For  this  accident  to 
occur,  the  cord  must  be  long  or  about  the  neck.  It 
happened  twice  in  my  cases.  In  one  it  was  imme- 
diately replaced,  forceps  applied,  and  a  living  child 
delivered.  In  the  other,  the  condition  was  not  dis- 
covered until  too  late — the  caput  was  in  sight  with  the 
cord.  The  bag  had  been  out  three  hours.  Although 
the  forceps  was  applied  and  the  child  quickly  deliv- 
ered, it  was  still-born. 

Rule:  Always  examine  v^heii  the  balloon  comes 
through  the  cervix. 

(6)  Sepsis.  Balloons  can  be  boiled.  If  the  aseptic 
technique  is  correct  there  should  be  no  infection.  In 
my  cases  ten  patients  had  high  temperatures;  one  had 
a  mild  sapra-mia;  one  died  of  a  virulent  sepsis.  She 
was  probably  infected  before  treatment.  She  had 
many  other  causes  than  the  bag  for  infection. 

Indications. — (i)  To  start  pains,  when  the  mem- 
branes have  been  long  ruptured,  especially  in  breech 
cases;  (2)  in  dry  labors  when  the  child  is  in  bad  condi- 
tion— there  is  an  umbilical  souffle,  or  it  is  passing 
meconium,  or  the  heart  is  slower  irregular;  (3)  in 
prolonged  and  protracted  labors,  oxytocics  and  chloral 
failing;  (4)  in  rigid  cervices  of  all  kinds;  (5)  in 
liydramnion,  when  it  is  necessary  to  rupture  the  mem- 
branes; (6)  in  cases  of  twins,  when  it  is  necessary  to 
rupture  the  membranes;  (7)  in  shoulder  presentations, 
w'hen  a  Braxton-Hicks  version  cannot  be  easily  done; 
(8)  to  induce  labor:  (<?)  In  cases  in  which  a  bougie 
fails  or  when  the  membranes  are  ruptured  in  its  intro- 
duction; (/')  in  albuminuria;  (r)  in  contracted  pelves 
— to  let  the  head  down  against  the  brim  to  engage;  or 
preparatory  to  forceps  or  version ;  (if)  in  case  of  a  dead 
fcetus;  («•)  in  chronic  endocarditis;  (9)  in  placenta 
pra;via,  especially  those  cases  in  which  the  cervix  is 
lough,  or  in  which  the  placenta  is  over  the  os  and  one 
cannot  turn  easily,  preparatory  to  version. 

Conclusions — i.  Dilatation  of  the  cervix  is  readily 
accomplished  by  a  hydrostatic  bag. 

2.  The  best  balloon  for  it  is  the  modified  Champe- 
tier de  Ribes — it  being  inexpansible,  impermeable, 
strong,  and  inejcpensive. 

3.  The  Barnes  bag  is  unsatisfactory. 

4.  The  operation  is  easy  and  not  dangerous. 

5.  The  dilatation  is  rapid. 

6.  The  uterine  contractions  always  start  after  its 
introduction  into  the  uterus. 

7.  Labor  is  hastened,  and  almost  always  terminates 
spontaneously  after  expulsion  of  the  balloon,  or  the 
easy  extraction  of  the  child  is  possible. 

8.  The  balloons  control  hemorrhage  in  placenta 
pravia,  and  diminish  foetal  mortality. 


366 


MEDICAL    RECORD. 


[September  8,  1900 


9.  The  balloons  meet  all  the  indications  before 
mentioned. 

BIBLIOCRAPHY. 

1.  Barnes:  Method  of  Inducing  Labor.  Medical  Times  and 
Gazette.  London.  iSog,  pp    392,446.  475,  499. 

2.  Pinard  :  De  I'accouchemcnt  provoque.  Annal.  de  Gyn., 
vol.  xx.xv. 

3.  Insertion  viceuse  du  placenta  sans  rupture  de  membranes, 
emploi  ballon  de  Champetier  de  Kibes ?  Qui.  La  Presse  Med., 
Paris,  1S94. 

4.  Varnier  :  De  I'emploi  du  ballon  de  thampetier  dc  Ribes 
dans  quelque  cas  d'insertion  viceuse  du  placenta.  Revue  pra- 
tique d'obstctrique  et  de  pcdiatrique,  t.  v.,  May.  1S92,  p.  130. 

5.  Duhrssen  :   Deutsche  med.  \\  ochenschrift.  1S94,  Ko.  20. 

6.  Lubusquitre  :  Ilcmorrhagies  par  insertion  viceuse  du  pla- 
centa.    Annales  de  Gynccologie,  January,  1S96. 

7.  G.  F.  Blacker  :  Treatment  of  Placenta  Pr.-evia  by  Champe- 
tier de  Ribes'  Balloon.  Transactions  of  the  Obstetrical  Society, 
London,  1S9S.  vol.  xxxix. 

8.  Bourder :  Insertion  viceuse  et  tamponnement  vaginale. 
These  de  Paris,   1895. 

9.  ."Kbd-el-Nour  :   Les  mefaits  du  vag.  tamp,  dans  plac.  prev. 
ID.    Pinard  :     Fonctionnement    de   la   maison   d'accouchement 

Baudeloque,  1S02-1895.     Steinheil. 

11.  Herman  Spencer  :  On  Induction  of  Labor  by  Champetier 
de  Ribes'  Bag.      British  Medical  Journal,  1S93. 

12.  Champetier  de  Ribes  :  Accouchement  provoque.  Annales 
de  Gynecologic,  1S88. 

13.  J.  Farrar  :  A  Speedy  Method  of  Dilating  the  Os  in  Parturi- 
tion.     British  Medical  Journal,  1S79,  vol.  ii. 

14.  R.  Barnes  :  Induction  of  Labor.  St.  George's  Hospital 
Report,  1S69. 

15.  Barnes:  Transactions  of  the  Obstetrical  Society,  London, 
1866,  vol.  vii. ,  p.  150. 

16.  Keiller  ;  Some  Modifications  of  Barnes'  Dilators.  Trans- 
actions Edinburgh  Obstetrical  Society,  vol.  xvi. 

17.  Morgan  :  A  New  Use  of  Barnes'  Dilators.  British  Medi- 
cal Journal,  January,  1872. 

18.  Barnes :  Induction  of  Labor.  British  Medical  Journal, 
1869.  vol.  i. 

19.  Barnes :  Induction  of  Labor.  British  Medical  Journal, 
1882,  vol.  ii. 

20.  Pyle  :  A  New  Bag  for  Emptying  the  Uterine  Cavity  by 
Artificial  Dilatation.      ^IEDICAL  Record,  1893. 

21.  Skene  :  Natural  or  .'Vrtificial  Dilatation  of  the  Os  in  Par- 
turition, either  Premature  or  at  Term. 

22.  .\ltheil  :  Mechanical  Dilatation  of  the  Os.  British  Medi- 
cal Journal,  1S72. 

23.  Miiller  :  Monatsschrift  fiir  Geburtshiilfe  und  Gynakologie, 
1895,  No.  2. 

24.  Eldridge  :  Tedious  Labor  from  a  Rigid  Os.  Transactions 
of  Rhode  Island  Medical  Society,  18S3.  vol.  ii. 

25.  Barnes  ;  System  of  Obstetrics,  Medical  and  Surgical,  1S85. 

26.  Playfair  :  System  of  Obstetrics. 

27.  Lusk  :  System  of  Obstetrics. 

28.  Hirst  :  System  of  Obstetrics. 
126  West  Fifty-Eighth  Street. 


OBSERVATIONS  OX  THE  GASTRIC  FUNC- 
TIONS BEFORE  AND  AFTER  G.^STRO- 
ENTEROSTOMY.* 

By   CHARLES   S.    FISHER,    Ph.D.,    M.D.  , 

NEW    YORK. 

The  cases  presented  in  this  paper  are  representative 
of  certain  benign  chronic  diseases  of  the  stomach  for 
the  relief  of  which  the  operation  of  gastro-enterostomy 
has  frequently  been  resorted  to  in  the  past  few  years. 
The  results  obtained  by  this  operation  in  such  cases 
have  formed  the  basis  for  much  discussion  and  many 
statistics. 

The  following  cases  are  few  in  number,  but  they 
have  the  advantage  of  having  been  carefully  studied 
for  periods  of  months  and  years  previous  to  operation 
and  for  the  same  length  of  time  afterward.  It  has 
been  pos.sible  to  note  the  very  gradual  changes  which 
took  place  in  the  motor  and  secretory  functions  of  the 
stomach  before  operation,  and  to  observe  the  effect  of 
operation  upon  these  functions.  The  apparent  tedious- 
ness  attendant  upon  the  presentation  of  so  many 
analyses  is  counterbalanced  by  the  necessity  of  their 

*  Re.id  before  the  American  Surgical  Association,  May  2,  1900, 
at  Washington,  D.  C 


presence  in  order  to  explain  the  causes  which  led  to 
operation  and  the  results  obtained  by  the  same.  All 
the  ordinary  symptomatology  has  been  eliminated  in 
these  cases,  for  as  clinical  types  they  are  well  known. 
These  observations  are  directed  entirely  to  the  func- 
tions of  the  stomach  and  its  size  and  position  before 
and  after  operation.  The  surgical  side  of  these  cases 
has  already  been  presented  by  Dr.  Robert  F.  Weir,' 
by  whom  all  the  operations  were  performed. 

Case  I.- — Benign  pyloric  stenosis  with  dilatation, 

peripyloritis,  posterior  gastro-enterostomy.    A.  P , 

cigarmaker,  aged  forty-one  years,  came  under  observa- 
tion in  December,  1895.  His  principal  symptom  at 
that  time  was  pain  of  such  an  intense,  spasmodic,  and 
remittent  character  as  to  simulate  hepatic  colic  at 
times.  At  other  times  it  resembled  a  crise  gastrique. 
It  occurred  independently  of  all  food  taken,  and  seemed 
to  be  more. or  less  dependent  upon  those  movements 
which  brought  into  play  the  abdominal  muscles.  The 
patient  suffered  from  no  gastric  symptoms  and  had 
been  perfectly  well  previously.  He  was  well  nourished, 
gave  no  specific  history,  no  objective  or  subjective 
symptoms  of  gall  stones,  but  had  suffered  from  an  at- 
tack of  peritonitis  some  years  before.  He  had  been 
troubled  with  constipation  for  one  year.  Several 
analyses  of  gastric  contents  and  physical  examinations 
were  made  with  the  following  results: 

December,  1895:  Trial  breakfast;  one  hour's  di- 
gestion. The  gastric  contents  were  normal  in  appear- 
ance and  character;  free  hydrochloric  acid,  0.7-1.0 
per  1,000;  total  acidity,  40-60;  organic  acid,  traces; 
albumen  and  starch  digestion,  normal.  Repeated  ex- 
aminations on  an  empty  stomach  revealed  the  size, 
location,  and  motility  of  the  organ  as  normal.  The 
greater  curvature  did  not  reacli  the  umbilicus. 

The  patient  was  kept  under  observation  for  a  time, 
but  finally  disappeared  until  October,  1897.  He  had 
been  treated  for  hepatic  colic  in  the  mean  time  with- 
out benefit.  His  pain  had  increased  in  intensity  and 
frequency,  and  in  addition  he  was  suffering  from  most 
pronounced  dyspeptic  symptoms.  The  following  re- 
sults were  obtained  by  repeated  examination : 

October,  1897:  Trial  breakfast;  one  hour's  di- 
gestion. The  gastric  contents  large  in  quantity,  fer- 
menting and  rancid;  free  hydrochloric  acid,  1.5  per 
1,000;  total  acidity,  120-140;  organic  acids  in  quan- 
tity; peptic  ferments  normal;  yeast  and  sarcina;  in 
abundance.  Physical  examinations  by  lavage  many 
hours  after  meals  always  revealed  large  quantities  of 
fermenting  food  residue,  and  the  greater  curvature 
was  located  two  inches  below  the  umbilicus. 

This  condition  of  pyloric  stenosis,  hyperacidity,  and 
dilatation  existed  practically  at  the  time  of  operation, 
March  26,  1898.  The  patient  made  a  good  recovery 
and  has  been  free  from  pain  ever  since.  He  has  had 
no  treatment  beyond  dietetic  precautions.  On  Feb- 
ruary 27,  1900.  I  began  the  following  .series  of  exam- 
inations: 

February  27.  1900:  Trial  breakfast;  one  hour's  di- 
gestion. Gastric  contents  normal  in  appearance  and 
consistency,  but  containing  considerable  bile;  free 
hydrochloric  acid,  2  per  1,000;  total  acidity,  86; 
organic  acids  in  small  quantities;  albumen  digestion, 
81  per  cent.;  starch  digestion  delayed;  no  yeast  or 
sarcina;. 

February  28th:  Riegel  meal;  two  and  one-half  hours' 
digestion.  Gastric  contents  normal  in  consistency, 
green  color;  free  hydrochloric  acid  0.5  per  i,ooo, 
combined  hydrochloric  acid  1.6  per  1,000,  total  hydro- 
chloric acid  2.1  per  1,000;  total  acidity,  92;  organic 
acids,  32;  albumen  digestion,  79  per  cent.;  starch  di- 
gestion normal ;  no  yeast,  etc. 

March  5th:  Trial  breakfast;  one  hour.  Gastric 
contents  of  normal  character  but  green ;  free  hydro- 
chloric acid,  1.8  per  1,000;  total  acidity,  84. 


September  8,  1900] 


MEDICAL    RECORD. 


36; 


March  6th:  Riegel  meal ;  three  and  one-half  hours' 
digestion.  Gastric  contents  green  and  well  digested; 
free  hydrochloric  acid,  1.4  per  1,000;  total  acidity,  93  , 
organic  acids,  traces;  albumen  digestion  normal. 

March  9th:  Physical  examination.  Leube'smeal; 
seven  hours.  The  stomach  contains  no  food  residue, 
but  50  c.c.  of  a  green,  acid  fluid;  free  hydrochloric 
acid,  1.3  per  1,000;  total  acidity,  96.  The  greater 
curvature  was  located  at  the  umbilicus. 

From  the  results  obtained  by  these  analyses  it  ap- 
pears that  the  hyperacidity  existing  at  the  time  of 
operation  has  not  disappeared  at  the  end  of  two  years. 
The  free  hydrochloric  acid  after  trial  breakfasts  ranges 
from  1.8  to  2  per  1,000,  with  a  fairly  constant  total 
acidity  (86-96).  The  free  hydrochloric  acid  for  Rie- 
gel meals  is  somewiiat  lower  (0.5-1.4  per  1,000), 
whereas  the  total  acidity  remains  stationary  (96). 
Bile  is  constantly  present.  The  motor  functions  have 
become  normal,  and  the  dilatation  has  been  reduced. 

Case  II.  —  Benign  pyloric  stenosis,  hypertrophic; 
gastro-enterostomy  and  entero-anastomosis  by  Gal  let's 
method.  In  this  patient,  I.  VV ,  tailor,  aged  thirty- 
five  years,  all  the  symptoms  of  pyloric  stenosis  were 
present  from  the  beginning.  Very  active  symptoms 
had  been  noticed  for  nine  months,  but  a  weak  stomach 
had  existed  for  years.  There  was  no  indication  in 
the  history  of  a  tumor.  The  following  examinations 
were  made : 

November  7,  1898:  Trial  breakfast;  one  hour. 
Gastric  contents  extremely  rancid;  free  hydrochloric 
acid,  0.8  per  1,000;  total  acidity,  79;  organic  acids, 
fair;  yeast  and  sarcin.t  abundant. 

November  9th:  Trial  breakfast;  one  liour.  Same 
general  character  as  before;  free  hydrochloric  acid, 
1.2  per  1,000;  total  acidity,  90;  organic  acids, 
marked. 

November  14th  :  Trial  breakfast,  one  hour.  Same  as 
before.  Free  hydrochloric  acid,  1.7  per  1,000;  total 
acidity,  100;  organic  acids  in  quantity;  albumen  and 
starch  digestion  normal;  yeast  and  sarcina;  in  abund- 
ance. 

December  9th:  Trial  breakfast.  Free  hydrochloric 
acid,  1.8  per  1,000;  total  acidity,  140;  marked  fer- 
mentation and  organic  acids  in  abundance. 

November  9th  and  i8th:  Physical  examinations  re- 
veal a  constant  large  food  residue  many  hours  after 
meals.  The  greater  curvature  was  located  two  and 
one-half  to  three  inches  below  the  umbilicus. 

Further  examinations  made  at  the  time  of  operation, 
December  15,  1898,  showed  the  free  hydrochloric  acid 
to  have  reached  2  per  1,000,  with  a  corresponding  in- 
crease in  the  severity  of  the  symptoms.  Diagnosis 
was  confirmed  by  the  operation,  and  the  patient  made 
a  good  recovery.  He  has  been  free  from  pain  and 
dyspeptic  symptoms  ever  since.  The  general  nutrition 
has  improved  and  he  has  been  able  to  work.  In  Feb- 
ruary, 1900,  fourteen  months  after  operation,  the  fol- 
lowing examinations  were  made: 

February  28,  1900:  Trial  breakfast,  one  hour. 
Gastric  contents  were  rancid  and  in  considerable 
quantity;  free  hydrochloric  acid.  1.3  per  1,000;  com- 
bined hydrochloric  acid,  1.9  per  1,000  (free  and  com- 
bined hydrochloric  acid,  3.2  per  1,000");  total  acidity, 
120;  organic  acids,  30;  albumen  digestion  complete; 
starch  digestion  retarded;  yeast  and  sarcinae  in  quan- 
tity. 

March  3d:  Riegel  meal;  three  hours.  Gastric 
contents  rancid;  free  hydrochloric  acid,  1.5  per  1,000; 
total  acidity,  120;  organic  acids,  fair  quantity;  al- 
bumen digestion,  73  per  cent.;  yeast  and  sarcinae. 

March  5th:  Trial  breakfast;  one  hour.  Gastric  con- 
tents same  as  before;  free  hydrochloric  acid,  1.6  per 
1,000;  total  acidity,  115;  organic  acids  abundant. 

March  7th:  Physical  examination  revealed  the 
motility  of  the  stomach  impaired.     Quantities  of  food 


were  found  when  the  organ  should  have  been  empty 
The  greater  curvature  was  located  at  the  umbilicus. 

It  appears  that  the  secretions,  which  at  the  time  of 
operation  were  in  a  condition  of  progressive  hyper- 
acidity, are  still  hyperacid,  fourteen  months  afterward, 
free  and  combined  hydrochloric  acid  is  present  to 
the  extent  of  3.2  per  1,00,  and  the  total  acidity  reaches 
120  for  both  trial  breakfast  and  Riegel  meal.  The 
motility  of  the  stomacii  is  still  impaired,  but  its  size 
has  been  reduced  markedly. 

Case  III. — Hyperacidity,  pyloric  spasm,  moderate 
dilatation,  gastro-enterostomy  with  entero-anastomosis; 
Braun's    method   w-ith    Gallet's    modification.       J.    F. 

S ,  salesman,  aged  forty-four  years,  came  under 

my  observation  in  April,  1899.  He  gave  a  history  of 
functional  hyperacidity  of  a  remittent  type  of  two  years' 
duration.  Recently  his  symptoms  had  become  more 
or  less  constant.  The  following  are  some  of  the  exam- 
inations made  at  intervals  from  May  1  to  December 
19,  1899: 

May  I,  1899:  Trial  breakfast;  one  hour.  Gastric 
contents  normal  in  appearance  and  consistency ;  free 
hydrochloric  acid,  2.3  per  1,000;  total  acidity,  88; 
organic  acids,  small  quantity;  yeast,  small  quantity. 

May  3d:  Physical  examination  reveals  normal  size, 
location,  and  motility  of  the  stomach. 

May  8th :  Trial  breakfast.  General  appearance  of 
contents  same  as  before;  free  hydrochloric  acid,  2.4 
per  1,000;  total  acidity,  96;  organic  acids,  negative; 
some  yeast. 

May  29th:  Trial  breakfast.  Gastric  contents  show 
evidence  of  fermentation;  free  hydrochloric  acid,  2 
per  1,000;  total  acidity,  86;  organic  acids,  fair ;  yeast 
in  fair  quantity. 

August  2d:  Trial  breakfast.  Gastric  contents  ran- 
cid; free  hydrochloric  acid,  2.1  jier  1,000;  total  acid- 
ity, 120. 

October  2d:  Trial  breakfast.  Gastric  contents 
very  rancid;  free  hydrochloric  acid,  2.6  per  1,000; 
total  acidity,  104;  organic  acids  abundant;  yeast 
abundant;  fat  crystals. 

October  iith:  I'hysica!  examination  reveals  im- 
paired motility  and  some  dilatation. 

November  29th  :  Trial  breakfast.  Very  rancid  con- 
tents. Free  hydrochloric  acid,  2.3  per  1,000;  total 
acidity,  112. 

These  were  the  conditions  at  the  time  of  operation, 
December  19,  1899.  The  hyperacidity  had  been  con- 
stant and  pyloric  spasm  had  supervened,  which  finally 
resulted  in  relative  impaired  motility  and  slight  di- 
latation. The  patient  recovered  rapidly  after  operation 
and  has  been  free  from  distress.  On  the  following 
dates  examinations  have  been  made: 

January  24,  1900:  Trial  breakfast ;  one  hour.  Gas- 
tric contents  normal  in  appearance  and  consistency; 
free  hydrochloric  acid,  1.6  per  1,000;  total  acidity, 
76;  organic  acids,  small  quantity;  albumen  digestion 
normal ;  retarded  starch  digestion  ;  some  yeast. 

January  31st:  Trial  breakfast.  Free  hydrochloric 
acid,  negative;  total  acidity,  60;  organic  acids  nega- 
tive. 

March  9th:  Trial  breakfast.  Contents  normal  in 
appearance;  free  hydrochloric  acid,  2.9  per  1,000; 
total  acidity,  136;  organic  aids,  traces;  albumen  di- 
gestion. 82  per  cent.;  yeast  in  small  quantities. 

March  12th:  Riegel  meal;  three  hours.  Free  hy- 
drochloric acid,  o.i  per  1,000;  combined  hydrochloric 
acid,  2.1  per  1,000  (free  and  combined  hydrochloric 
acid,  2.2  per  1,000);  total  acidity,  108;  organic 
acids,  44. 

March  i6th:  Trial  breakfast.  Free  hydrochloric 
acid,  I  per  1,000;  combined  hydrochloric  acid,  1.6 
per  1,000  (free  and  combined  hydrochloric  acid,  2.6 
per  1,000);  total  acidity,  80;  organic  acids,  8;  no 
yeast. 


368 


MEDICAL    RFXORD. 


[September  8,  1900 


March  20th:  Physical  examination  reveals  the  size 
and  location  of  the  stomach  as  normal  and  the  motility 
restored. 

In  this  case  the  functional  hyperacidity,  which  was 
constant  for  months  prior  to  operation,  has  resumed 
the  remittent  type  with  which  it  started.  For  six 
weeks  subsequent  to  operation  the  free  hydrochloric 
acid  ranged  from  normal  to  subacidity  (1.6  to  negative) ; 
total  acidity,  120-60.  On  March  9th,  five  weeks  later, 
the  patient  was  subjected  to  considerable  mental  dis- 
tress due  to  business  reverses,  and  upon  examination 
at  this  time  we  find  free  hydrochloric  acid,  2.9  per 
1,000,  with  a  total  acidity  of  136.  A  few  days  later, 
March  i6th,  we  find  that  the  free  hydrochloric  acid 
has  again  fallen  to  i  per  1,000,  with  a  total  acidity  of 
80.  There  were  no  symptoms  from  this  post-operative 
temporary  hyperacidity,  except  the  formation  of  some 
^as.  There  was  absolutely  no  reappearance  of  the 
pain. 

C.\SE  IV. —  Dilatation  of  stomach  without  pyloric 
obstruction  and  with  movable  kidney ;  gastro-enteros- 
tomy  and    entero-anastomosis.     Observations  on  the 

case  began  in  October,  1895.     Mrs.  B ^.aged  forty 

years,  had  been  suffering  for  years  from  what  was  ap- 
parently nervous  dyspepsia.  The  following  examina- 
tions were  made  at  the  time: 

October  27,  1895  :  Trial  breakfast;  one  hour.  Gas- 
tric contents  appear  normal ;  free  hydrochloric  acid, 
trace;  total  acidity,  51;  organic  acids,  trace;  peptic 
ferments,  normal. 

October  29th :  Trial  breakfast.  Same  gross  char- 
acteristics; free  hydrochloric  acid,  1.4  per  1,000; 
total  acidity,  69;  organic  acids,  traces;  physical  ex- 
aminations reveal  normal  motility,  somewhat  vertical 
position  of  the  stomach,  with  the  greater  curvature  one 
inch  below  the  umbilicus.  Repeated  examinations 
showed  a  constant  fiuctuating  character  in  the  secre- 
tions; free  hydrochloric  acid  ranged  from  subacidity 
to  slight  hyperacidity,  and  the  motility  was  constantly 
normal.  One  year  later  other  examinations  were 
made : 

October  28,  1896:  Trial  breakfast.  Fairly  normal 
gross  appearances;  free  hydrochloric  acid,  0.2  to  i.o 
per  1,000;  total  acidity,  50-60;  organic  acids,  traces; 
small  quantities  of  yeast.  Physical  examination  re- 
vealed the  size  and  position  unchanged.  There  was, 
however,  a  beginning  tendency  to  impaired  motility. 

From  these  and  other  examinations  it  appeared  that 
the  occasional  hyperacidity  had  disappeared.  Free 
hydrochloric  acid  ranged  from  subacidity  to  normal. 
The  beginning  impaired  motility  was  accompanied  by 
a  corresponding  increase  in  the  fermentative  organisms 
found.  From  this  time  on  the  atony  was  progressive, 
as  the  following  examination  will  show: 

March  15,  1897:  Trial  breakfast;  one  and  three- 
fourths  hours.  Gastric  contents  rancid,  fermenting; 
free  hydrochloric  acid,  0.7  per  1,000;  total  acidity, 
65 ;  organic  acids,  yeast,  and  sarcina;  in  abundance. 
Physical  examination  showed  increased  atony  and  the 
greater  curvature  extending  to  one  and  throe-fourths 
inches  below  the  umbilicus. 

February  4,  1898:  Trial  breakfast  and  physical  ex- 
amination. A  large  quantity  of  fermenting  material 
was  constantly  present;  free  hydrochloric  acid,  i.i 
per  1,000;  total  acidity,  57;  organic  acids  marked: 
increased  atony,  and  the  greater  curvature  more  than 
two  inches  below  umbilicus. 

These  conditions  were  progressive  until  the  time  of 
operation. 

March  7,  1899,  one  year  later:  At  this  time  free  hy- 
drochloric acid  ranged  from  o.t  to  I.I  peri, 000;  total 
acidity,  5.5  to  6.5;  peptic  ferments  normal;  organic 
acids  in  quantity;  abundance  of  yeast  and  sarcina?; 
marked  atony;  greater  curvature  two  and  one-half 
inches  below  the   umbilicus;  freely  movable  and  de- 


scended right  kidney;  considerable  general  emacia- 
tion. The  patient  made  a  good  recovery,  and,  with 
the  exception  of  occasional  attacks  of  fermentation, 
has  been  well  and  has  added  some  thirty  pounds  to 
her  weight.  One  year  later  I  had  the  opportunity  to 
make  the  following  examinations: 

November  22,  1899:  Trial  breakfast.  Free  hydro- 
chloric acid  negative;  total  acidity,  30. 

March9,  1900:  Trial  breakfast ;  one  hour.  Gastric 
contents  unchanged  in  appearance;  free  hydrochloric 
acid,  negative;  total  acidity,  44;  organic  acid,  traces; 
albumen  digestion,  42  per  cent.;  starch  digestion, 
normal;  yeast,  small  quantity;  marked  presence  of 
bile. 

March  i6th:  Riegel  meal;  three  hours.  Contents 
of  stomach  slightly  rancid;  free  hydrochloric  acid, 
negative;  combined  hydrochloric  acid,  o.i  per  1,000; 
total  acidity,  26;  organic  acids,  21;  some  yeast  and 
bile  present. 

March  17th  to  19th:  Phsyical  examinations  reveal 
some  slight  food  residue  seven  hours  after  a  meal. 
Upon  early  lavage  the  stomach  is  constantly  empty. 
The  greater  curvature  is  located  two  inches  below  the 
umbilicus.     The  right  kidney  is  still  freely  movable. 

In  this  case,  notwithstanding  the  very  evident  gen- 
eral improvement  in  the  physical  condition  of  the 
patient,  there  has  been  no  attempt  at  repair  on  the 
part  of  the  glandular  structures  of  the  stomach.  On 
the  contrary,  the  subacidity  seems  to  have  gone  on  to 
a  fair  state  of  achylia.  The  size  and  position  of  the 
stomach  remain  about  the  same.  The  motility  has 
apparently  improved  to  a  great  extent. 

It  would  be  manifestly  impossible  to  draw  very 
general  conclusions  from  this  limited  number  of  cases. 
It  can  only  be  said  of  them  that  they  represent  certain 
distinct  types  for  which  gastroenterostomy  is  per- 
formed, and  that  it  is  in  a  comparatively  small  number 
of  cases  only  that  patients  can  be  controlled  both  be- 
fore and  after  operation  so  as  to  render  the  observa- 
tions conclusive.  The  immediate  effect  of  gastro-en- 
terostomy  in  cases  of  benign  pyloric  stenosis  is  relief, 
which  relief,  coming  naturally  as  a  result  of  the  ces- 
sation of  the  spasm  of  the  sphincter  pylori,  is  apt 
to  produce  an  exaggerated  idea  of  the  ultimate  effect 
of  the  operation  upon  the  various  gastric  functions. 
Hence  tlie  real  value  of  this  operation  can  be  judged 
only  by  a  careful  study  of  those  cases  in  which  it 
has  been  possible  not  only  to  observe  the  functions  of 
the  stomach  for  a  protracted  period  after  operation, 
but  also  to  have  been  able  to  follow  the  very  gradual 
changes  which  occurred  in  these  functions  during  the 
months  which  preceded  the  operation.  On  the  other 
hand,  the  very  relief  experienced  by  the  patient  after 
operation  is  to  a  certain  extent  an  obstacle  to  a 
thorough  study  of  the  changes  which  take  place  in  the 
gastric  functions,  for  such  patients  are  very  apt  to 
overestimate  the  capabilities  of  their  stomachs,  and  so 
deliver  themselves  over  to  dietetic  excesses,  which 
latter  are  well  calculated  not  only  to  influence  the  ex- 
pected repair,  but  in  many  cases  to  retard  it.  Any 
temporary  return  of  dyspeptic  symptoms  in  these  cases 
is  very  likely,  however,  to  cause  the  most  intense  de- 
pression, especially  in  those  whose  mental  tone  has 
been  materially  undermined  by  years  of  suffering. 
This  mental  depression  is  very  antagonistic  to  the 
ultimate  repair  of  the  gastric  function  in  certain  cases. 
Hence  the  absolute  control  of  the  patient  is  most  de- 
sirable. 

'l"he  two  functions  of  the  stomach  which  are  pri- 
marily involved  in  this  discussion  are  the  secretion  of 
hydrochloric  acid  and  the  motility.  The  cause  for 
operation  in  a  large  proportion  of  cases  is  either  an 
abnorm.il  increase  of  the  one  or  a  decided  impairment 
of  the  other.  Of  the  two  functions  the  one  which  has 
engaged  the  attention  of  observers  most  is  the  secre- 


September  8,  1900] 


MEDICAL    RECORD. 


369 


tion  of  acid,  and  the  reports  and  statistics  of  clinics 
fiave  been  devoted  to  the  effect  of  gastro-enterostomy 
upon  hyperchlorhydria.  In  this  connection  a  closer 
study  of  the  first  three  cases  may  be  of  interest. 

In  Case  I.  there  are  many  reasons  to  believe  that 
the  cause  for  the  obstruction  was  located  e.Kternally  to 
the  pylorus  in  the  beginning.  Not  only  the  history  of 
the  case,  but  its  e.xceedingly  slow  course  and  the  find- 
ings at  the  operating-table,  are  indicative  of  this. 
The  examination  of  the  gastric  fvinctions  in  Decem- 
ber, 1895,  gave  nothing  abnormal.  The  figures  for 
free  hydrochloric  acid  at  that  time  showed  even  a 
tendency  to  subacidity  (0.7-1.0  per  1,000).  The 
other  functions  were  found  to  be  normal.  Their  con- 
ditions very  gradually  changed  until  October,  1897, 
when  the  examinations  revealed  a  pronounced  pyloric 
obstruction  with  hyperacidity  (free  hydrochloric  acid, 
1.5  per  1,000  and  over;  total  acidity.  120-140).  Dur- 
ing all  this  time  there  never  were  any  symptoms  sug- 
gesting ulcer  or  tumor.  Two  years  after  operation 
we  find  the  hyperacidity  still  present.  All  examina- 
tions give  quantities  for  free  hydrochloric  acid  rang- 
ing from  1.5  to  2.0  per  1,000,  and  for  total  acidity  from 
86  to  96,  both  for  trial  breakfast  and  Ricgel  meal. 
Only  on  one  occasion,  February  28,  1900,  did  the 
figures  for  free  hydrochloric  acid  indicate  subacidity 
(0.5  per  1,000);  but  the  combined  hydrochloric  acid 
reached  1.6  per  1,000,  and  the  total  acidity  92.  If 
there  was  any  doubt  on  this  score,  it  was  dispelled  by 
the  finding  of  a  small  quantity  of  acid  fluid  on  an 
empty  stomach,  which  gave  the  figures  1,3  per  1,000 
for  free  hydrochloric  acid  and  96  for  the  total  acidity. 
The  digestion  of  albumen  was  normal  (79-81  percent.). 

In  Case  II.  we  have  somewhat  similar  conditions, 
although  here,  both  from  the  history  of  the  case  and 
the  findings  at  the  operating-table,  a  primary  ulcer  at 
the  pylorus  might  be  suspected.  Actual  symptoms  of 
the  same  never  existed,  however.  From  the  compara- 
tive progressive  increase  of  the  acidity  ( free  hydro- 
chloric acid,  1.2  to  2.0  per  1,000;  total  acidity,  92  to 
130)  and  the  severity  of  the  symptoms  of  obstructions, 
it  could  be  inferred  that  the  former  was  due  to  the 
latter.  Fourteen  montlis  after  operation  it  is  found 
that  the  change  in  the  hyperacidity  has  not  kept  jjace 
with  the  general  improvement.  Free  hydrochloric 
acid  is  still  present  to  the  extent  of  1.3  to  1.5  per 
1,000,  figures  within  the  normal,  perhaps,  were  it  not 
that  the  combined  hydrochloric  acid  reaches  i.g  per 
1,000,  making  a  total  figure  for  hydrochloric  acid  of 
3.2  per  1,000.  The  total  acidity  was  correspondingly 
high  (120  for  trial  breakfast  and.  Riegel  meal).  The 
digestion  of  albumen  was  normal  (73  to  100  per  cent,). 

Case  III.  is  typical  of  those  conditions  in  which  the 
hyperacidity  is  primary  or  purely  functional.  The 
pyloric  obstruction  and  slight  dilatation  were  second- 
ary in  this  case.  Repeated  examinations  from  May  i 
to  December  19,  1899,  showed  this  plainly.  With  a 
constant  hyperacidity  of  2.3  per  1,000  for  free  hydro- 
chloric acid,  pyloric  spasm  and  obstruction  gradually 
supervened.  The  examinations  after  operation  are  in- 
teresting. The  hyperacidity  steadily  decreased  until 
January  31,  1900,  when  there  existed  a  condition  of 
subacidity  (free  hydrochloric  acid,  negative;  total 
acidity,  60).  Suddenly,  as  a  result  of  emotional  dis- 
turbances, we  again  find,  on  March  9,  1900,  a  most  de- 
cided hyperacidity  (free  hydrochloric  acid,  2.9  per 
1,000;  total  acidity,  136).  As  the  mental  excitement 
disappeared  a  decline  in  the  acidity  took  place,  until, 
on  March  12th,  we  again  have  normal  figures  (free  hy- 
drochloric acid,  0.1  per  1,000;  combined  hydrochloric 
acid,  2.1  per  1,000  after  a  Riegel  meal),  and  on  March 
16th  the  corresponding  figures  (free  hydrochloric  acid, 
i;  combined  hydrochloric  acid,  i.6  per  1,000;  total 
acidity,  80),  after  a  trial  breakfast.  The  acidity  after 
operation  in  this  case  depended  upon  the  general  ner- 


vous condition  of  the  patient  and  ranged  from  sub- 
acidity to  normal,  difTering  in  this  respect  essentially 
from  Cases  I.  and  II. 

The  observations  in  Case  IV.,  which  extended  over 
a  period  of  four  years  prior  to  operation,  made  it  pos- 
sible to  follow  the  very  gradual  changes  which  took 
place  in  the  functions  and  size  of  the  stomach.  The 
case  is  further  interesting  in  that  it  represents  a  class 
of  chronic  gastric  disease,  the  existence  of  which  has 
been  denied.  I  refer  to  simple  gastric  dilatation  as 
a  result  of  atony.  From  the  history  it  can  be  seen 
that  in  October,  1895,  there  existed  a  condition  of 
nen-ous  dyspepsia  with  varying  acidity  (free  hydro- 
chloric acid,  traces  to  1.4  per  1,000;  total  acidity,  51 
to  68),  and  a  tendency  to  gastroptosis.  This  state  of 
things  had  existed  for  a  long  time.  In  1896,  one  year 
later,  during  which  time  the  patient's  symptoms  in- 
creased in  severity,  the  acidity  had  changed  to  a  sub- 
acid condition  (free  hydrochloric  acid,  0,2-1,0  per 
1,000),  at  the  same  time  that  atony  of  the  muscular 
structures  began  to  show  itself.  The  changes  in  the 
size  and  motor  functions  of  the  stomach  were  progress- 
ive to  the  time  of  operation,  as  was  the  general  relaxa- 
tion in  the  abdominal  walls  and  ligaments  (freely 
movable  right  kidney).  Tiie  secretions  up  to  the 
time  of  operation  had  remained  stationary  (free  hy- 
drochloric acid,  0.1  to  i.i  per  1,000).  Notwithstand- 
ing the  general  improvement  in  the  condition  of  the 
patient  since  the  operation,  we  find  upon  examination 
one  year  later  that  the  dilatation  still  exists  and  that 
the  subacidity  has  progressed  to  a  fair  state  of  achylia 
(free  hydrochloric  acid,  negative;  combined  hydro 
chloric  acid,  o.i  per  1,000;  total  acidity,  21-44:  al 
bumen  digestion,  42  per  cent.).  The  decrease  in  the 
secretion  of  the  ferments  has  apparently  not  been  so 
rapid. 

The  motor  functions  appear  to  have  become  normal 
in  all  but  one  case.  The  same  can  be  said  of  the  size 
and  position  of  the  stomach.  In  Cases  I.,  Ill,,  and 
IV.  the  stomach  is  empty  upon  lavage  within  the 
necessary  time  limit.  In  Case  I.  a  small  quantity  of 
acid  and  green  fluid  was  constantly  found  after  all  food 
had  passed  into  the  intestine.  In  Case  II.  slight  atony 
still  remained  fourteen  months  after  operation,  which 
incomplete  restoration  can  be  traced  to  improper  hy- 
gienic surroundings,  indiscretions  in  diet,  and  the 
cramped  position  required  by  his  work,  that  of  tailor- 
ing. It  is  curious  that  in  this  case  also  the  size  of  the 
stomach  should  have  as  materially  decreased  as  in 
Cases  I.  and  III.,  in  all  of  which  the  greater  curva- 
ture was  located  at  the  umbilicus  by  repeated  and 
various  methods  of  examination.  In  one  case  alone 
(IV.)  did  the  dilatation  apparently  persist  after  opera- 
tion. The  greater  curvature  was  still  two  inches  below 
the  umbilicus  one  year  later.  Here,  however,  in 
marked  contrast  to  Case  II.,  the  motility  has  greatly 
improved.  This  improvement,  however,  is  probably 
more  passive  than  active,  and  the  location  of  the  greater 
curvature  need  not  necessarily  indicate  a  marked  de- 
gree of  dilatation,  as  the  stomach  in  this  case  was 
more  or  less  vertical  from  the  beginning.  The  de- 
scended and  freely  movable  right  kidney  still  remained 
as  before.  In  none  of  these  cases  is  it  possible  to 
note  the  hypermotility  claimed  by  some  to  exist  after 
operation.  The  stomachs  are  empty  within  the  nor- 
mal prescribed  time  limit  and  not  before.  On  the 
contrary,  in  Case  II.,  in  which  the  most  active  and 
visible  peristaltic  activity  existed  before  operation, 
the  motility  after  operation  is  the  most  backward  in 
repair. 

In  order  to  find  the  causes  wljich  produced  this 
variety  of  results,  it  is  only  necessary  to  examine 
closely  the  conditions  existing  before  operation.  We 
have  represented  in  these  cases  three  distinct  types  of 
benign   chronic  gastric  disease.     In  Cases  I.  and  II. 


370 


MEDICAL    RECORD. 


[September  8,  1900 


we  have  primary  pyloric  obstruction  with  secondary 
hyperacidity  and  dilatation.  In  Case  III.  we  have 
primary  functional  hyperacidity  with  secondary  pyloric 
spasm  and  dilatation.  In  Case  IV.  we  have  primary 
neurotic  atony  with  secondary  subacidity  and  dilata- 
tion. The  repeated  analyses  in  Cases  1.  and  II.  show 
the  hyperacidity  to  have  been  subsequent  to  and  pro- 
gressive with  the  obstruction.  In  Case  I.,  in  1895.  a 
normal  acidity  e.xisted.  The  increase  in  the  quantity 
of  free  hydrochloric  acid  could  be  observed  from  year 
to  year.  In  Case  III.  hyperacidity  was  constant  from 
April  to  December,  1899,  and  previous  to  that  there 
was  a  very  good  history  of  periodic  functional  hyper- 
acidity. In  the  first  two  cases  the  hyperacidity  was 
the  result  of  obstruction.  In  the  third  case  the  ob- 
struction was  the  result  of  the  hyperacidity.  In  the 
first  two  cases  we  have  great  dilatation  and  in  the  third 
comparatively  slight  dilatation. 

In  Cases  I.  and  II.  the  hyperacidity  has  persisted 
one  to  two  years  after  operation.  In  Case  I.  it  has 
even  increased  (free  hydrochloric  acid,  1.5-2  per 
1,000).  In  order  to  explain  these  results  it  will  be 
necessary  to  refer  to  the  investigations  of  Boas,"  Cohn- 
heim,' Hayem,'  Einhorn,''and  Hemmeter  on  prolifera- 
tive changes  in  the  gastric  mucous  membrane  in  hy- 
peracidity. Boas  speaks  of  a  gastritis  proliferus; 
Hayem  of  a  gastrite  parenchymateuse  hyperpeptique 
chloro-organique.  From  the  examinations  made  by 
Cohnheim,  Einhorn,  and  Hemmeter  of  particles  of 
mucous  membrane  it  was  found  that  glandular  prolif- 
eration existed  in  from  one-half  to  two-thirds  of  the 
cases  of  hyperacidity.  It  is  immaterial  in  this  con- 
nection to  know  whether  this  proliferation  is  in  the 
tubular  or  the  oxyntic  cells.  Of  greater  importance, 
however,  as  Kovesi "  properly  remarks,  would  have 
been  the  determination  of  the  nature  of  the  hyper- 
acidity—  whether  primary  or  secondary. 

This  explanation  of  the  nature  of  hyperacidity  in  a 
certain  class  of  cases  can  be  applied  to  our  own  cases. 
In  Cases  I.  and  II.  we  have  evidence  of  prolonged  ir- 
ritation of  the  mucous  membrane  of  the  stomach  be- 
fore operation.  That  this  irritation  should  have  led 
to  glandular  proliferation  is  probable,  and  that  the 
proliferation  should  persist  after  operation  is  natural. 
Hence  we  have  persistent  hyperacidity.  W'e  have  as 
facts  justifying  this  assumption  not  only  the  progress- 
ive increase  of  the  free  hydrochloric  acid  before  and 
its  persistency  after  operation,  but  also  the  very  sta- 
tionary and  constant  quantitative  results  obtained  by 
analyses  during  the  last  examinations  made.  These 
results  for  the  total  quantity  of  hydrochloric  acid  pro- 
duced were  the  same  for  both  slight  or  great  stimula- 
tion (carbohydrates  and  proteids).  This  constancy  in 
production  on  the  part  of  the  gastric  mucous  mem- 
brane is  fair  evidence  of  the  capabilities  of  that  mem- 
brane and  also  a  determining  factor  in  the  estimation 
of  its  structure. 

The  causes  which  led  to  and  produced  the  results 
obtained  by  operation  in  Cases  III.  and  IV.  are  of 
great  interest  to  the  internist,  for  lliey  represent  clini- 
cal types  in  which  the  question  of  operative  interfer- 
ence is  largely  one  of  expediency  and  not  of  necessity. 
We  have  here  represented  functional  disturbances  of 
secretion  and  motility,  which,  while  not  necessarily 
involving  the  life  of  the  patient,  serve  materially  to 
render  that  life  a  misery  and  a  burden.  It  is  in  these 
cases  that  the  advice  as  to  operation  depends  upon 
severe  judgment  not  only  of  the  actual  disease  itself, 
but  also  of  the  occupation,  social  surroundings,  and 
especially  the  mental  tendency  of  the  patient. 

In  the  absence  fjom  the  records  of  Cohnheim,  Hem- 
meter, etc.,  of  the  actual  causes  producing  the  hyper- 
acidity and  the  history  of  each  case,  it  will  be  necessary 
to  accept  those  cases  in  which  no  structural  changes 
were  found  as  purely  functional  conditions.     In  Case 


III.  we  have  such  a  condition.  Here  periodic  hyper- 
acidity led  to  chronic  hyperacidity,  which  finally  re- 
sulted in  pyloric  spasm  and  slight  dilatation.  The 
discussion  of  the  effect  of  gastro-enterostomy  upon 
such  cases  has  been  elaborate  and  has  involved  two 
questions  principally.  The  one  has  reference  to  the 
seniority  of  the  ])yloric  spasm  or  the  hyperacidity. 
The  other  deals  with  the  effect  of  operation  upon  the 
secretion  of  the  acid  itself.  Standing  for  the  defence 
of  hyperacidity  as  a  purely  functional  neurosis  we 
have  Bouveret,  Fleischer,  Schule,  Ewald,  Riegel,  and 
Pick.  On  the  other  side,  standing  for  the  spastic 
theory,  are  Hayem,  Roux,  Robin,  Doyen,  Carle,  and 
Fantino.  Midway  between  these  two  we  have  the  in- 
vestigations of  Jaworski,  Cohnheim,  Einhorn,  and 
Hemmeter  on  the  proliferation  of  the  gastric  cells. 
So  far  as  the  neurotic  and  proliferation  theories  for 
simple  hyperacidity  are  concerned,  it  is  conceded  by 
gastrologists  that  both  may  exist.  The  discussion  has 
been  greatest  in  regard  to  the  spastic  theory,  espe- 
cially in  connection  with  hypersecretion;  but  as  hy- 
persecretion and  hyperacidity  are  allied  diseases,  the 
facts  deduced  will  apply  to  both. 

It  will  be  observed  that  most  of  the  reasoning  on 
behalf  of  the  spastic  theory  has  resulted  from  obser- 
vations made  at  the  operating-table.  It  is  not  pos- 
sible, however,  to  draw  absolute  conclusions  from 
such  observations.  That  both  spasm  and  hyperacidity 
should  be  found  at  this  time  is  natural ;  that  the  spasm 
should  be  relieved  by  an  anasthetic  is  also  natural ; 
but  there  is  no  evidence  in  this  that  one  existed  be- 
fore or  produced  the  other.  Cases  of  simple  hyper- 
acidity do  not  reach  the  operating-table  until  sufficient 
time  has  usually  elapsed  for  changes  to  have  taken 
place  at  the  pylorus.  On  the  other  hand,  many  of  the 
observations  have  been  made  in  cases  in  which  actual 
tissue  change  had  occurred  ( I  refer  to  operations  for 
ulcer);  and  Cohnheim,'  in  a  recent  article,  goes  so  far 
as  to  assert  that  no  dilatation  exists  without  pyloric 
or  duodenal  obstruction,  however  slight  this  may  be. 

There  can  be  no  doubt  about  the  primary  or  func- 
tional character  of  the  hyperacidity  in  Case  lU.  Th's 
was  fully  established  by  long  observation  before  op- 
eration. If  any  doubt  still  existed  as  to  the  nature  of 
this  case  it  has  been  dispelled  by  the  results  obtained 
from  the  operation  itself.  By  reported  examinations 
we  find  that  the  free  hydrochloric  acid  gradually  de- 
creased for  six  weeks  after  operation  until,  on  January 
31,  1900,  it  was  decidedly  subacid.  Suddenly,  as  a 
result  of  emotional  disturbances,  it  again  becomes 
markedly  hyperacid.  This  hyperacidity  is  temporary 
and  slowly  disappars  as  the  mental  state  of  the  patient 
becomes  calmer.  It  is  hardly  possible  that  a  struc- 
tural change  has  taken  place  in  the  mucous  membrane 
of  the  stomach  with  this  history.  The  operation  had 
simply  removed  one  link  in  the  connecting  chain  of  a 
vicious  circle,  namely,  the  possibility  of  pyloric  spasm, 
and  the  patient,  so  far  as  the  gastric  secretions  are 
concerned,  is  placed  again  in  a  condition  of  neurotic 
and  periodic  hyperacidity,  without  pyloric  spasm,  how- 
ever. Had  the  examinations  in  this  case  been  made 
for  a  few  weeks  after  operations  only,  the  result  ob- 
tained would  have  been  erroneous. 

From  these  frequent  examinations  and  observations 
the  extreme  pertinacity  of  the  gastric  secretions  is 
demonstrated.  This  quality  is  not  limited  to  hyper- 
acidity, as  we  can  see  from  Case  IV.  It  is  generally 
agreed  that  subacid  conditions  remain  so  after  opera- 
tion. Here,  as  in  hyperchlorhydria,  we  have  primary 
and  secondary  subacidities.  Primary  or  neurotic  sub- 
acidity  does  not  reach  the  operating-table.  Secondary 
subacidity  is  the  result  of  the  chronic  inflammatory 
conditions  involving  atrophic  changes  in  the  mucous 
membrane,  and  these  do  not  come  to  operation  until 
sufficient    structural    damage    has    been    done   to  ex- 


September  8,  1900] 


MEDICAL    RECORD. 


37^ 


elude  a  possibility  of  repair.  The  investigations  of 
Einiiorn,  Hemmeter,  and  Martins"  have  demonstrated 
that  partial  atrophy  of  the  glandular  structure  of  the 
mucous  membrane  exists  in  from  one-half  to  two-thirds 
of  tlie  cases  of  achylia  gastrica,  even  in  those  cases  in 
which  no  very  active  dyspeptic  symptoms  are  present. 

It  was  not  to  be  expected,  then,  that  any  change  for 
the  better  would  take  place  in  this  case.  Of  interest, 
however,  is  the  fact  that  the  subacidity  existing  at  the 
time  of  operation  should  have  progressed  to  a  condition 
of  anacidity.  The  operation  appears  to  have  had  no 
influence  upon  the  degenerative  changes  taking  place 
in  the  gastric  mucosa.  These  structural  changes  un- 
doubtedly began  years  before,  as  the  history  of  the 
case  demonstrates.  In  1895  the  acidity  was  normal, 
even  hyperacid  at  times.  This  acidity, progressively 
decreased  at  the  same  time  that  loss  of  tone  in  the 
muscular  structures  and  deficiency  in  peptic  power  in- 
creased up  to  the  time  of  operation.  After  operation 
we  have  a  general  improvement  in  the  health  of  the 
patient  and  a  considerable  gain  in  weight  and  no  dys- 
peptic symptoms.  Vet  in  one  year  we  find  that  the 
changes  in  the  mucous  membrane  have  advanced  so 
far  as  to  give  a  fair  condition  of  achylia.  It  would  be 
impossible  to  explain  this  on  the  basis  of  continued 
irritation  due  to  food  stasis,  for  the  stomach  empties 
itself  within  a  reasonable  time.  The  simple  conclusion 
to  be  drawn  is  that  hypertrophic  or  atrophic  changes 
of  long  duration  may  be  progressive  after  operation. 

That  the  continuous  hyperacidity  and  subacidity  in 
these  cases  should  not  affect  the  general  health  of  the 
patients  is  not  surprising,  for  in  each  case  the  imme- 
diate cause  of  distress  has  been  removed  by  the  opera- 
tion. It  is  a  matter  of  common  experience  to  find  hy- 
peracidity and  subacidity  in  stomachs  which,  so  far 
as  any  subjective  symptoms  are  concerned,  are  ap- 
parently normal.  The  distress  which  may  be  produced 
by  these  conditions  is  purely  relative,  and  both  may 
exist  for  years  without  giving  rise  to  any  symptoms 
whatever.  In  case  of  hyperacidity  it  is  largely  a  ques- 
tion of  the  irritability  of  the  nervous  system,  both 
general  and  local.  In  cases  of  subacidity  freedom 
from  symptoms  depends  entirely  upon  the  activity  of 
the  muscular  structures.  On  the  other  hand,  it  is 
possible  to  have  pronounced  symptoms  of  hyperacidity 
in  cases  in  which  the  gastric  analysis  reveals  normal 
figures  for  the  secretions.  From  this  it  seems  almost 
right  to  assume,  with  some  of  the  French  authorities, 
that  the  normal  quantity  of  acid  secreted  constitutes 
hyperacidity  in  some  persons. 

The  results  obtained  for  the  digestion  of  albumen 
in  these  cases,  both  before  and  after  operation,  coin- 
cide with  those  obtained  by  other  recent  experimental 
investigations,  and  show  that  the  changes  which  take 
place  in  the  peptic  cells  need  not  be  proportional  to 
those  found  in  the  acid-secreting  cells.  In  Cases  I., 
II.,  and  III.  we  have  normal  results  throughout.  In 
Case  I.  two  years  after  operation  the  digestion  of 
albumen  does  not  exceed  81  per  cent,  with  a  free 
hydrochloric  acidity  of  2  per  1,000.  The  same  can 
be  said  of  Cases  II.  and  III.  for  both  trial  break- 
fast and  Riegel  meals.  In  Case  IV.  we  have  the 
same  relations.  Here  the  secretion  of  hydrochloric 
acid  one  year  after  operation  is  practically  ;//'/,  and 
yet  we  find  that  albumen  is  digested  to  the  extent 
of  42  per  cent.  It  would  be  difficult  to  state  from 
these  figures,  however,  whether  the  apparently  pre- 
served peptic  power  is  due  to  a  small  quantity  of  pep- 
sin of  good  quality,  or  to  a  large  quantity  of  poor 
quality.  It  is  impossible  to  judge  the  state  of  the 
gastric  mucous  membrane  from  digestion  tests  to  the 
same  extent  as  this  is  done  by  quantitative  acid  tests. 
The  action  of  the  acid  in  the  gastric  juice  is  directly 
proportional  to  its  quantity,  whereas  the  action  of  the 
pepsin   depends  to  a  considerable   extent    upon    the 


quality  of  the  ferment.  Hence  it  is  that  in  many  in- 
stances the  results  obtained  from  albumen  digestion 
are  not  proportional  to  those  found  for  free  hydro- 
chloric acid,  and  the  42  per  cent,  obtained  for  albumen 
digestion  in  Case  IV.  probably  means  that  a  certain 
quantity  of  pepsinogen  of  active  quality  is  still  being 
secreted  as  a  result  of  the  general  improvement  of 
nutrition  after  operation. 

The  same  principle  may  apply  to  the  conversion  of 
the  starches.  In  Cases  I.,  II.,  and  III.  we  have  de- 
layed digestion:  in  Case  IV.  there  is  complete  diges- 
tion so  far  as  this  is  possible  in  tiie  stomach.  These 
cases,  then,  have  followed  the  general  rule  in  this  re- 
spect, but  here  we  have  extreme  conditions  of  hyjDer- 
acidity  and  subacidity.  In  a  good  proportion  of  cases 
of  subacidity  it  will  be  found  that  the  conversion  of 
starch  does  not  pass  the  erythrodextrin  stage,  whereas, 
according  to  rule,  it  should  have  been  complete.  The 
contradiction  can  be  accounted  for  only  by  the  inac- 
tivity and  poor  quality  of  the  diastasic  ferment  secreted 
with  the  saliva,  especially  as  in  these  cases  it  will 
usually  be  found  that  the  peptic  power  of  the  gastric 
juice  is  reduced  and  the  general  nutrition  impaired. 

The  effect  of  gastro-enlerostomy  upon  the  size,  posi- 
tion, and  motility  of  the  stomach  in  these  cases  coin- 
cides with  the  observations  made  at  the  surgical  clinics. 
The  organ  returns  to  a  normal  condition  of  size  and 
motility  in  those  cases  in  which  the  enlargement  and 
impaired  muscular  activity  were  relative  and  due  to 
obstruction.  These  conditions  we  have  in  Cases  I., 
II.,  and  III.  The  reduction  of  the  dilatation  was  here 
accomplished  by  the  inherent  power  of  contraction 
which  still  existed  in  the  muscular  structures  of  the 
stomach  at  the  time  of  operation.  Given  an  opportu 
nity  to  do  so  by  the  removal  of  the  obstruction,  they 
were  fully  able  to  redeem  the  size  of  the  organ.  Only 
in  Case  II.  we  find  some  atony  still  present  at  the  end 
of  the  year.  This  patient,  however,  is  compelled  by 
his  occupation — that  of  a  tailor — to  assume  a  position 
which  is  entirely  antagonistic  to  good  motor  activity 
of  the  gastric  muscles,  'i'his  danger  existed  in  Case 
I.  also,  but  tiie  patient  gave  up  his  trade  as  a  cigar- 
maker,  and  thus  we  have  a  better  result.  In  Case  IV. 
the  size  of  the  stomach  has  not  been  affected  by  opera- 
tion. This  was  to  be  expected  from  the  conditions 
which  existed  at  the  time  of  operation.  The  enlarge- 
ment and  atony  were  positive  and  part  of  a  constitu 
tional  condition  which  had  existed  for  years.  There 
was  no  power  left  in  the  muscular  coats  to  contract; 
hence  the  repair  is  slow  in  this  case.  The  stomach, 
however,  even  in  this  case  empties  itself  fairly  well. 
This  improvement  in  motility  is  probably  more  ap- 
parent than  real,  and  due  to  a  large  extent  to  gravity. 
An  examination  of  themuscular  activity  of  the  stomach 
before  and  after  operation  by  the  introduction  of  a 
Hemmeter  intragastric  bag  would  be  of  interest. 

The  more  or  less  constant  presence  of  bile  in  the 
gastric  contents  after  operation  has  been  noticed  by 
most  observers.  It  is  generally  acknowledged  that  it 
causes  no  disturbance.  It  has  not  in  these  cases. 
According  to  Boas,  the  objectionable  feature  connected 
with  the  presence  of  bile  in  the  stomach  lies  in  its 
alkaline  reaction  and  in  the  danger  of  precipitation  of 
the  pepsin.  In  cases  of  hyperacidity  after  operation 
the  first  property  need  hardly  be  feared.  In  cases  of 
subacidity  the  conditions  are  somewhat  different. 
Here  the  neutralizing  effect  of  the  bile  might  be  offen- 
sive, but  is  counteracted  in  part  by  the  inhibitory 
action  upon  the  fermentation  to  which  these  cases  are 
prone,  especially  if  the  atony  is  persistent. 

The  regulation  of  the  action  of  the  intestines  is  one 
of  the  best  results  obtained  by  gastroenterostomy. 
This  effect  is  generally  reported  in  all  the  statistics. 
It  was  very  marked  in  our  own  cases.  The  reasons 
for  this  relief  from  pre-existing  constipation   vary  ac- 


572 


MEDICAL    RECORD. 


[September  8,  1900 


cording  to  the  conditions  at  the  time  of  operation. 
The  constipation  of  the  first  three  cases  of  pyloric  ob- 
struction was  spastic  in  its  nature.  It  was  due  not  so 
much  to  the  obstruction  in  the  passage  of  food  through 
the  pylorus  as  to  a  condition  of  tonic  spasm  induced 
all  along  the  intestinal  tract  by  the  spasm  at  the  py- 
lorus and  the  fixation  of  the  abdominal  muscles  as  the 
result  of  pain.  We  have  evidence  of  this  in  the  small 
lumpy  or  lead-pencil  character  of  the  stools  in  the  first 
three  cases.  It  was  a  condition  of  secondary  entero- 
spasm.  so  to  speak.  This  tonic  condition  was  removed 
by  the  elimination  of  the  pylorus  by  operation,  and  in 
a  short  time  the  stools  not  only  became  regular  but 
normal  in  size  and  consistency. 

In  Case  IV.  the  constipation  was  atonic.  It  was 
part  of  a  general  muscular  relaxation.  Here  the  stools 
were  large  in  calibre  and  occasionally  fermentative 
diarrhoeas  would  supervene.  After  operation  we  find 
normal  and  regular  stools,  due  to  the  general  improve- 
ment of  muscular  activity,  both  voluntary  and  invol- 
untary, the  result  of  the  improved  nutrition.  This' reg- 
ulation of  the  action  of  the  bowels  istone  of  the  most 
salutary  effects  of  the  operation  of  gastro-enterostomy, 
and  to  it  in  many  cases  can  most  of  the  benefits  of 
operation  be  ascribed. 

The  most  complete  reports  and  statistics  of  the  opera- 
tion of  gastro-enterostomy  have  come  from  the  clinics 
of  Czerny,"  Mikulicz,''  Hartmann  and  Soupault,"  Carl 
and  Fantino,'^  Doyen,''  Tricoms,"  and  others.  Prac- 
tically their  cases  may  be  divided  into  three  classes: 
ist,  operations  of  necessity;  2d,  operations  of  emer- 
gency; 3d.  operations  of  expediency.  By  far  the  great 
majority  of  the  cases  reported  has  belonged  to  the 
first  two  classes.  The  effect  of  operation  upon  the 
subsequent  secretory  functions  of  the  stomach  in  these 
cases,  however,  is  a  matter  of  secondary  importance. 
The  life  of  the  patient  is  involved,  and,  whatever  may 
be  the  ultimate  result,  the  pyloric  obstruction  or  gas- 
tric perforation  or  hemorrhage  must  receive  immediate 
attention. 

It  is  in  the  third  class  of  cases,  as  represented  in 
Cases  III.  and  IV.  of  this  paper,  that  very  definite 
rules  for  operating  are  desirable.  The  results  desired 
in  these  cases  are  remote,  not  immediate.  As  these 
results,  as  we  have  seen  in  some  cases,  depend  upon 
the  actual  condition  of  the  mucous  membrane  at  the 
time  of  operation,  and  also  the  course  of  the  disease 
for  a  long  time  before  operation,  it  now  appears  de- 
sirable to  eliminate  from  the  statistics  all  those  cases 
in  which  it  has  not  been  possible  to  ascertain  the  actual 
structural  condition  of  the  mucous  membrane  of  the 
stomach  by  repeated  analyses  for  months  prior  to  op- 
eration. It  is  unfortunate,  therefore,  that  we  should 
miss  from  many  of  the  reports  the  detailed  and  serial 
analyses  and  observations  of  the  internist  before  op- 
eration, for  it  is  only  in  this  way  that  a  definite  knowl- 
edge of  the  actual  condition  of  the  mucous  membrane 
can  be  obtained.  A  few  gastric  analyses  made  imme- 
diately before  operation  are  of  small  value  in  this 
respect,  especially  in  neurotic  cases.  The  stomach 
reacts  to  the  emotions  somewhat  like  a  lacrymal  gland. 
It  either  secretes  profusely  or  very  little.  It  is  for 
this  reason  that  I  have  come  to  discard  the  results  ob- 
tained by  a  first  analysis  of  the  gastric  contents.  They 
are  generally  erroneous.  In  most  cases  repeated  an- 
alyses at  stated  intervals  and  after  various  meals  are 
necessary  to  secure  sufficiently  accurate  figures  which 
may  be  used  in  diagnosis  and  prognosis.  Especially 
is  this  the  case  as  most  of  us  have  not  the  time  to 
look  for  or  the  courage  to  scrape  off  particles  of  mucous 
membrane  for  microscopical  examination. 

That  the  results  to  be  obtained  by  gastro-enter- 
ostomy and  the  prognosis  to  be  given  depend  upon 
this  knowledge  has  been  sufficiently  demonstrated. 
Whether  or  not  a  hyperchlorhydria   is  to  recede  after 


operation  depends  in  a  certain  proportion  of  cases 
upon  the  structural  changes  which  have  taken  place 
in  the  mucous  membrane.  It  has  even  been  shown 
that  it  may  increase,  and  this  brings  us  to  the  abso- 
lutely independent  character  of  the  gastric  secretions, 
and  the  progressive  nature  of  structural  changes  once 
begun,  even  though  the  cause  for  the  beginning  of 
these  changes  has  been  removed  by  operation.  In 
Cases  I.  and  IV.  we  have  diametrically  opposed  con- 
ditions. In  one  we  have  hyperacidity  due  to  cell  pro- 
liferation, and  in  the  other  progressive  subacidity  due 
to  cell  atrophy,  and  in  both  the  most  marked  improve- 
ment in  the  general  nutrition  and  local  distress;  yet 
in  both,  one  and  two  years  after  operation,  we  find 
that  the  abnormal  conditions  of  secretion  have  pro- 
gressed in  their  respective  directions.  This  obstinacy 
on  the  part  of  the  secreting  cells  of  the  gastric  mucous 
membrane  is  a  matter  of  common  observation  in  the 
treatment  of  a  considerable  proportion  of  chronic  gas- 
tric affections,  and  continues  after  the  active  dyspeptic 
symptoms  have  disappeared. 

It  would  be  impossible  to  draw  general  conclusions 
from  the  observation  of  this  limited  number  of  cases. 
It  can  only  be  said  that  they  have  been  closely  followed, 
and,  as  representative  of  certain  well-known  types  of 
chronic  gastric  diseases  to  which  gastro-enterostomy  is 
applied,  may  be  of  some  service  in  the  formation  of 
rules  for  prognosis  and  advice. 

BIBLIOGRAPHICAL   REFERE^XES. 

I  Medical  News,  June,  1898,  1899.  Philadelphia  Medical 
Journal,  February  19,  1900. 

2.  Diagnostik  der  Magen-Krankheiten.  Wiener  med.  \Yoch- 
enschrift,  i  and  2,  1895. 

3.  Archiv  fiir  Verdauungskrankheiten,  i. ,  p.  274. 

4.  Gazette  Hebdomadaire,  53,  54.  'S93. 

5.  Medical  Record,  June,  1S96. 

6.  Martius  and  Lubarsch  :  Achylia  Gastrica.    * 

7.  Archiv  fiir  Verdauungskrankheiten,  iv..  405. 

8.  Milnchener  med.  Wochenschrift,  1S9S,  p.   1081. 

9.  Beitrage  zur  klinischen  Chirurgie,  vol.  xxiii.,  i  and  399. 

10.  Mittheilungen  aus  den  GrAizgebieten,  vol.  iv.,  347. 

11.  Revue  de  Chirurgie,  1899. 

12.  Archiv  ftir  klinische  Chirurgie,  vol.  Ivi. 

13.  Revue  de  Chirurgie. 

14.  Thirteenth  Congress  of  Italian  Surgeons.  1898. 


A  NEW  PHYSICAL  SIGN  IN  DISLOCATION 
OF  THE  HEART;  GASTRECTATIC  DYSP- 
NCEA    AND    PSEUDO-ANGINA. 

By   albert    ABRAMS,    A.M.,    M.D., 

S.\N    FRANCISCO,    CAL. 

Acute  or  chronic  dilatation  of  the  stomach  is  a  fre- 
quent cause  of  dyspncea  and  even  asthma.  An  asthma 
of  gastric  origin  is  the  asthma  dyspepticum  of  some 
writers.  Asthma  of  gastric  genesis  is,  however,  caused 
less  often  by  gastrectasis  than  by  the  absorption  and 
irritation  of  products  the  result  of  gastric  indigestion. 
The  latter  observation  is  based  only  on  my  individual 
experience.  In  my  case-book,  I  have  records  of  a 
number  of  patients,  especially  children,  with  asthmatic 
symptoms  in  whom  gastrectasis  did  not  exist,  and  who 
were  cured  by  treatment  directed  solely  to  the  stomach 
— systematic  lavage  and  a  suitable  dietary.  I  have 
called  difficult  breathing  sequential  to  gastric  dilata- 
tion, gastrectatic  dyspnoea.  Many  sufferers  from  this 
form  of  dyspna-a  make  no  mention  of  dyspeptic  symp- 
toms, the  latter  being  masked  by  pressure  signs.  Such 
individuals  are  usually  recruited  from  the  ubiquitous 
neurasthenics.  Their  pneumatosis  is  sudden  in  origin 
and  attended  by  a  feeling  of  weight  or  pressure  in  the 
precordia  or  sternal  region.  Eructations  of  gas  mark 
the  relief  of  the  paroxysm.  In  some  instances  the 
symptoms  are  protracted,  the  patient  being  unable  to 
get  rid  of  the  gases  owing  to  spasm  of  the  sphincters 


September  8,  1900] 


MEDICAL    RECORD, 


373 


of  the  stomach.  Gastrectatic  dyspnoea  is  caused,  as  I 
have  assured  myself  after  examination  of  a  number  of 
patients,  by  dislocation  of  the  heart  upward  by  a 
dilated  stomach.  Some  years  ago,  I  reported  a  case' 
of  gastroptosis  and  merycismus  with  voluntary  disloca- 
tion of  the  stomach  and  kidney.  This  phenomenal 
case  taught  me  one  fact  in  particular,  viz.,  the  ease 
with  which  dislocation  of  tlie  heart  could  be  induced 
by  a  dilated  stomach.  The  individual  in  question 
could,  by  buccal  insufflation  of  the  stomach,  cause  his 
heart  to  disa|)pear  behind  the  lungs,  so  that  precordial 
percussion  yielded  absolutely  no  dulness.     This  case 


Flc.  X. — tlSect  of  Stomach  Insufflation  on  the  Heart  ;  x,  Radioscopic  appear- 
ance of  the  heart  ;  3,  Outline  of  the  fundus  of  the  stoniacn. 


directed  my  attention  to  a  correct  investigation  of  all 
individuals  presenting  themselves  for  the  treatment  of 
slight  dyspeptic  symptoms  in  whom  sternal  pressure 
and  dyspnoea,  especially  in  walking,  were  the  chief 
subjective  symptoms.  In  nearly  all  such  individuals, 
the  diminished  area  qi  cardiac  dulness  with  its  con- 
generic sign,  viz.,  enfeebled  heart  tones,  bore  a  dis- 
tinct relation  to  the  severity  of  the  pressure  symptoms. 
The  removal  of  the  ingesta  and  gases  from  the  stom- 
ach usually  restored  the  heart  to  its  normal  position 
and  the  feeble  heart  tones  became  strong.  To  detect 
quickly  a  dilated  stomach  encroaching  on  the  thoracic 
viscera,  the  percussion  method  of  Ferber'  is  highly 
recommended,  although  my  experience  with  this  pro- 
cedure has  often  been  negative.  Ferber  found  that 
the  circular  tympanitic  stomach-lung  region  formed 


Fic. 


I.  Radioscopic    appearance  of  the  heart   after  administration  of  a 
Seidlitz  powder  ;  2,  outline  of  the  fundus  of  the  stomach. 


by  the  stomach  beneath  the  lower  lobe  of  the  left  lung 
gradually  disappears  behind  the  axillary  line  if  the 
stomach  is  normal,  but  if  the  latter  is  dilated  i:  may 
be  traced  to  the  vertebral  column.     The  following  il- 

'  Medical  News,  April  13.  1895. 
'Ewald  :  "  Diseases  of  the  Stomach." 


lustrations  describe  more  full)  than  words  the  in- 
rtuence  of  a  dilated  stomach  on  the  position  of  the 
heart.  They  are  through  reproductions  from  the  fluoro- 
scopic picture.  In  the  average  examination  of  the 
chest  by  means  of  the  Roentgen  rays,  that  portion  of 


Fig.  3. 


-Patch  of    Dulness  in  Dislocation  of  the   Heart  Upward, 
in  the  erect  po<ulion'. 


Patient 


the  Stomach  which  is  in  direct  contact  with  the  chest 
wall,  occcupying  the  space  of  Traube,  is  obscured  by 
the  shadow  cast  by  the  spleen.  There  is  a  small  pro- 
portion of  cases  in  which  a  considerable  area  of  stom- 
ach-illumination is  shown  by  .skiascopy.  This  condi- 
tion is  engendered  by  the  favorable  position  of  the 
spleen,  which  does  not  lie  sideward  and  upward  from 
the  stomach  but  downward  and  outward  from  the  latter 
viscus.  It  has  been  my  good  fortune  to  have  met  with, 
in  my  skiascopic  examinations,  two  persons  in  whom 
the  illuminated  stomach  area  in  Traube's  space  corre- 
sponded with  the  normal  dimensions  of  the  stomach  in 
that  region,  a  condition  which  1  attributed  to  one  of  four 
things,  viz.,  favorable  location  of  the  spleen,  absence  or 
atrophy  of  the  spleen,  and  the  jjresence  of  rudimentary 
splenules.  In  the  examination  of  one  of  the  individ- 
uals, the  unusual  phenomenon  was  utilized  in  studying 
a  case  of  nervous  eructation.'     In  the  other  patient, 


Fig.  4.— Same  Case.    Patient  leaning  backward. 

artificial  distention  of  the  stomach  was  produced  by 
means  of  a  Seidlitz  powder.  The  illustrations  (Figs. 
I  and  2)  demonstrate  most  forcibly  how  sudden  death 
may  occur  after  a  heavy  meal  if  the  individual  is  a 
sufferer  from  indigestion  with  a  weak  heart.  Little 
or  no  detailed  reference  is  made  to  gastrectasis  in  the 
literature  as  an  etiological  factor  in  pseudo-angina 
pectoris,  although  in  my  own  experience  I  have  fre- 
quently encountered  cases  of  pseudo-angina  which 
were  cured  by  treatment  directed  solely  to  the  stomach 
'  Philadelphia  Medical  Journ.il,  A.ugust  12,  iSgg. 


374 


MEDICAL    RECORD. 


[September  8,  1900 


or  to  a  neurasthenic  condition  which  was  primarily  a 
factor  in  the  distention  of  the  stomach  by  gases.  The 
sign  of  Ferber  has  been  most  unsatisfactory  to  me  in 
detecting  a  dilated  stomach  fundus.  Repeated  exam- 
inations of  the  thorax  after  artificial  distention  of  the 
stomach  with  air  failed  in  a  number  of  instances  to 
contirm  the  constancy  of  this  sign.  Diminished  area 
of  cardiac  dulness  and  enfeebled  heart  tones  which 


b 


Fig.  5, — a.  Shadow  cast  by  normal  heart  ;  b,  shadow  of  dislocated  heart. 

assume  an  embryocardial    character    are  more  trust- 
worthy objective  symptoms. 

There  is  a  new  sign  to  which  I  wish  to  direct 
attention.  When  the  heart  is  dislocated  upward 
by  a  dilated  stomach,  a  patch  of  dulness  and  even 
flatness  may  be  detected  in  the  interscapular  region 
on  the  left  side,  about  midway  between  the  verte- 
bral column  and  the  internal  border  of  the  scapula. 
This  is  the  usual  site,  although  the  patch  of  dulness 
may  reach  a  point  on  a  level  with  the  spine  of  the 
scapula.  The  dull  area  may  vary  in  size  from  that 
of  a  silver  dollar  to  the  entire  space  between  the 
scapula  and  spine.  It  always  disappears  to  be  re- 
placed by  the  normal  lung  resonance  when  the  patient 
leans  forward,  reappears  when  the  erect  posture  is 
again  attained,  and  the  area  of  dulness  is  greatly  in- 
creased by  directing  the  patient  to  bend  backward. 
Over  the  area  of  dulness,  bronchial  respiration  is 
heard,  but  this  likewise  disappears  when   the  patient 


Fig.  6. — a,  Posterior  pericardial  patch  of  dulness;  5,  sign  of  Bamberger. 


bends  forward  or  becomes  increased  in  intensity  when 
the  patient  leans  backward.  The  accompanying  illus- 
trations (Figs.  3  and  4)  serve  to  exemplify  the  sub- 
ject-matter. The  cause  of  the  dulness  is  compression 
of  the  lung  by  a  dislocation  of  the  heart  upward.  This 
sign  is  constantly  present.  That  the  patch  of  dulness 
is  actually  caused  by  lung  compression  from  a  dislo- 
cated heart,  I   have  assured  myself  synthetically  by 


introduction  of  the  stomach  tube  into  the  stomach  and 
distending  the  latter  viscus  by  air,  by  which  means  I 
could  invariably  reproduce  the  clinical  phenomena, 
viz.,  dulness  in  the  left  interscapular  region  disappear- 
ing when  the  patient  leaned  forward,  increasing  area 
of  dulness  when  the  patient  leaned  backward.  Cor- 
responding to  the  percussional  sign,  bronchial  respira- 
tion is  heard  with  resumption  of  vesicular  breathing 
when  the  forward  attitude  is  assumed.  Withdrawal 
of  air  from  the  stomach  is  attended  by  a  disappearance 
of  the  phenomena.  One  may  follow  the  foregoing 
procedure  by  aid  of  the  Roentgen  rays,  and  note  the 
upward  dislocation  of  the  heart  by  the  distended 
stomach.  The  degree  of  heart  dislocation  viewed 
from  the  back  is  surprisingly  slight,  and  it  would 
appear  theoretically  to  be  unable  to  account  for  the 
lung  compression.  If  the  dislocation  is  protracted, 
it  will  be  found  difficult  to  differentiate  the  shadow 
cast  by  the  heart  and  the  compressed  lung.  Fig.  5 
represents  the  shadow  cast  by  the  normal  heart  on  the 
posterior  surface  of  the  thorax.  The  shaded  area  is 
the  dislocated  heart  after  artificial  distention  of  the 
stomach. 

The  patch  of  dulness  caused  by  upward  dislocation 
of  the  heart  may  be  confounded  w-ith  atelectatic  zones 
which  are  frequently  present  in  this  region.  I  have 
referred  elsewhere  to  these  zones.'  The  zones  of  ate- 
lectasis, however,  disappear  after  repeated  forced  vol- 
untary inspirations,  or  by  means  of  what  I  have  called 
the  lung  reflex,"  and  are  in  no  wise  influenced  by  the 
position  of  the  patient.  The  only  two  physical  phe- 
nomena in  any  way  associated  with  my  sign  are  the 
posterior  pericardial  patch  of  dulness  and  the  sign  of 
Bamberger,  signs  which  arise  in  pericarditis  with  efTu- 
sion  and  are  caused  by  the  exudate  compressing  the 
lung.  In  pericardial  effusion  the  sign  of  Bamberger 
is  important.  When  the  patient  is  in  the  erect  pos- 
ture, an  area  of  dulness  about  the  size  of  a  silver 
dollar  can  be  outlined  at  the  angle  of  the  scapula,  over 
w-hich  increased  fremitus  and  bronchial  breathing 
may  be  elicited.  If  the  patient  bends  forward,  the 
signs  disappear,  to  reappear  when  he  sits  upright. 


TWO  CASES  OF  INTESTINAL  OBSTRUC- 
TION FOLLOWING  VAGINAL  HYSTER- 
ECTOMY, AND  ONE  AFTER  PELVIC 
ABSCESS,  WITH  A  SECONDARY  OPERA- 
TION   IN    EACH    CASE.' 

By  a.    GOLDSPOHN,  M.D.. 

CHICAGO, 

PROFESSOR  OF  GVN.«C0L0GY,  CHICAGO  POST-GRADi:ATK  MEDICAL  SCHOOL  ; 
SENIOR  GVN.«COI.OGIST  TO  THE  GEK.MA.S  HOSI'ITAL,  AND  ATTENDING 
GVN,fiCOLOGIST  TO  THE  POST-GRADt'ATE  AND  THE  CHARITV  HOSI'ITALS 
OF   CHICAGO. 

A  VERY  good  and  recent  French  thesis  upon  post- 
operative intestinal  obstruction,  by  M.  le  Dr.  E.  Len- 
clos,'  enumerates  cases  of  ileus  as  follows:  57  after 
ovariotomy;  16  after  salpingectomy;  8  after  abdom- 
inal ablation  of  uterine  fibroids;  6  after  abdominal 
hysterectomy;  7  after  radical  cure  of  hernia;  4  cases 
after  cceliotomy  for  strangulated  hernia;  3  after  opera- 
tions for  appendicitis;  i  each  after  hysteropexy,  Caj- 
sarean  section,  and  transperitoneal  nephrectomy;  and 
37  cases  of  ileus  after  vaginal  hysterectomy.  Of  the 
last-named  number  evidently  the  largest  proportion  of 
cases  have  occurred  in  the  French-speaking  countries 
or  after  French   technique  of  vaginal   hysterectomy. 

'  rhiladelphU-i  Medical  Journal,  November  26,  1898  ;  the  Med- 
ical Standard,  Januar\',  1900. 

'  New  York  .Medical  Journal,  January  13,  1900. 

^  Read  at  a  meeting  of  the  Illinois  State  Medical  Society, 
at  Springheld,  HI.,   May  16,  Igoo. 

*  tiazette  hebdomadaire  de  medecine  et  de  chirurgie,  1900,  t. 
47.  pp    37-44- 


September  8,  1900] 


MEDICAL    RECORD. 


375 


But  the  following  isolated  and  interesting  cases,  among 
others,  in  the  literature  of  this  subject,  in  which  a 
secondary  operation  for  relief  of  the  obstruction  was 
performed,  are  certainly  also  included  in  that  collec- 
tion:  L.  Landau'  reported  a  case  in  1888  done  with 
clamp  forceps,  and  the  associated  intraperitoneal 
gauze  drain.  It  was  progressing  normally.  The  for- 
ceps were  removed  after  one  and  two  days.  The 
patient  got  up  on  the  fourth  day  and  walked  about  for 
a  drink.  Soon  after  symptoms  of  ileus  and  peritonitis 
followed,  and  progressed.  On  the  seventh  day  a  loop 
of  ileum  was  found  adherent  in  the  funnel  of  the 
wound,  and  was  liberated  by  abdominal  section.  But 
the  patient  died  next  day. 

r.  Reichel  •  records  three  cases  of  ileus  after  vaginal 
hysterectomy,  occurring  in  1887  and  1888,  in  Ols- 
hausen's  clinic.  Xo  clamps  were  used  in  these  cases, 
but  the  peritoneal  cavity  was  left  open  and  drained 
by  gauze.  In  two  of  these  a  secondary  coeliotomy  was 
done,  but  the  first  patient  died  on  the  table  on  the 
seventh  day,  and  the  second  one  died  twenty  hours 
after  the  operation  on  the  eighth  day.  Neither  of 
them  had  passed  gas  or  fajces,  aside  from  the  contents 
of  the  colon,  since  the  first  operation.  No  riiythmical 
colic  pains  were  mentioned,  nor  was  there  any  pyrexia 
or  marked  tenderness  of  the  distended  abdomen. 
The  first  had  a  rapid  pulse  from  the  beginning,  and 
both  were  nauseated  or  vomited  early. 

In  1887  A.  P.  Dudley"  (New  York)  did  a  vaginal 
hysterectomy  for  carcinoma.  Ha:mostasis  was  secured 
by  ligatures,  and  an  intraperitoneal  gauze  drain  was 
inserted.  Six  months  later,  while  exerting  herself,  the 
patient  felt  something  give  way  in  her  pehis,  and 
thereafter  suffered  from  intestinal  obstruction  of  varia- 
ble degrees  for  four  months,  until  a  fecal  fistula  into 
the  vagina  developed  spontaneously.  This  was  suc- 
cessfully cured,  one  year  after  the  vaginal  hysterectomy, 
by  abdominal  section  and  resection  of  the  injured  small 
intestine,  performed  by  a  California  surgeon. 

In  1889  H.  C.  Coe*  performed  vaginal  hysterectomy 
for  an  adherent  cancerous  uterus  associated  with  a 
small  ovarian  cyst.  Hcemostasis  was  secured  by  four 
pairs  of  forceps,  left  in  for  forty  hours,  and  an  intra- 
peritoneal and  vaginal  gauze  drain  was  placed.  The 
patient  took  fluids  by  mouth  from  the  beginning,  and 
was  in  good  condition  until  the  fourth  day,  when  dis- 
tention and  rise  of  temperature  occurred.  These  be- 
came less  the  next  day  after  cathartics  and  enemata, 
but  returned  more  severely,  together  w  ith  an  accelerated 
pulse,  on  the  sixth  day,  when  the  abdomen  was  opened 
and  a  portion  of  the  ileum  found  adherent  to  the  right 
edge  of  the  wound  and  severely  kinked.  There  was 
no  extensive  peritonitis.  The  intestine  was  liberated, 
the  abdomen  irrigated,  gauze  drainage  renewed  into 
the  vagina,  and  the  abdomen  closed.  The  patient 
died  next  morning  from  shock. 

In  1896  John  A.  Prince'  (Springfield,  111.)  did 
vaginal  hysterectomy  for  chronic  ovarian  and  tubal 
disease.  Hamostasis  was  secured  by  forceps,  removed 
on  the  second  day.  The  patient  passed  gas  freely 
from  the  first  day,  and  had  two  good  bowel  movements 
on  the  fourth  day.  But  tympanites  developed  on  the 
eighth  and  complete  obstruction  on  the  ninth  day. 
On  the  tenth  day  the  doctor  passed  his  hand  (in  nar- 
cosis) up  the  vagina,  and  the  fingers  into  the  pelvis, 
breaking  up  the  adhesions,  which  appeared  to  be  com- 
posed entirely  of  omentum.  He  came  upon  a  col- 
lapsed portion  of  small  intestine,  and  made  a  lateral 
anastomosis  between  this  and  an  adjacent  distended 
portion  of  small  intestine  by  means  of  a  Murphy  button 

'  Berliner  klinisclie  Wochenschrift,  1888,  No.  10. 
'Zeitschrift  fiir  Oeburts.  und  Cynak.,  Bd.  xv. .  S.  37. 
'New  York- 4Medical  Journal    July  y,  1S87,  p.  35. 
■*  .Vmerican  Journal  of  Obstetrics,  Februar)-.  1890,  p.   144. 
'  Medical  Record,  rSg6,  vol.  1.,  p.  209, 


within  the  vagina.  Natural  evacuations  followed, 
but  a  free  fecal  fistula  supervened.  However,  a  spon- 
taneous recovery  resulted  finally. 

In  a  somewhat  hasty  review  of  the  literature  of  the 
past  twelve  years,  I  have  found  only  this  one  case  (of 
I)r,  Prince),  in  which  a  secondary  operation  was  per- 
formed for  ileus  successfully  within  ten  days  after 
vaginal  hysterectomy,  and  not  merely  for  this  condition 
as  a  later  sequel  of  that  operation.  To  this  case  I  can 
add  another  successful  one  by  abdominal  section,  and 
also  two  unsuccessful  ones. 

Case    I. —  Mrs.    F.    S ,   aged   thirty-four  years, 

multipara;  total  vaginal  hysterectomy  for  chronic 
metritis  (fibrosis  uteri);  pyosalpinx  of  one  side,  and 
cystic  ovary  of  the  other  side.  The  uterus  was  high 
up,  anteverted,  and  the  broad  ligaments  were  difficult  of 
access.  Therefore  a  broad-ligament  forceps  was  left 
on  the  upper  portion  of  the  broad  ligament  of  one 
side,  but  in  its  base  and  in  the  entire  opposite  side 
preventive  or  antecedent '  ha-mostasis  was  secured  by 
ligatures,  with  dilliculty.  The  patient  bore  the  opera- 
tion well,  and  continued  to  be  in  a  satisfactory  con- 
dition for  two  days,  except  that  the  much-desired 
jiassages  of  gas  failed  to  come  after  the  usually  very 
effective  enemata  that  were  begun  after  twenty-four 
hours,  and  repeated  at  intervals  of  four  to  six  hours. 
The  forceps  was  removed  after  forty-eight  hours,  and 
about  ten  small,  hourly  doses  of  calomel  and  soda 
were  next  given,  followed  by  several  doses  of  magne- 
sium sulphate.  These  things  started  the  vomiting, 
but  did  not  secure  the  needed  evacuations  nor  reduce 
the  rising  tympanites.  There  were  no  decided  tender- 
ness of  the  distended  abdomen  at  this  time  (third  and 
fourth  days  after  operation),  and  no  colicky  pains, 
but  mtich  discomfort  from  the  distention.  The 
temperature  during  the  first  two  days  did  not  rise  over 
loi""  F.,  and  the  pulse  ranged  from  90  to  no.  After 
the  first  nausea  from  the  anaesthetic  passed  off,  there 
was  no  vomiting,  and  liquid  food  was  taken  satisfac- 
torily up  to  fifty-six  hours  after  the  operation,  when 
the  vomiting  began  and  continued,  with  growing  ten- 
derness of  the  tympanitic  abdomen,  with  some  rise  of 
temperature  and  a  greater  acceleration  of  pulse.  A 
high  and  somewhat  forcibly  retained  half-gallon  ene- 
ma of  water,  with  essence  of  peppermint,  afforded 
no  real  improvement.  Hot  fomentations  and  turpen- 
tine stupes  gave  only  slight  and  temporary  relief,  and 
did  not  improv",  i!:e  general  condition,  which  was 
rapidly  growing  worse,  with  the  signs  of  peritonitis 
supervening  upon  those  of  ileus.  Therefore  I  opened 
the  abdomen  eighty-four  hours  after  operation.  'I'he 
small  intestine  was  severely  distended  and  intensely  in- 
jected, with  loss  of  lustre,  and  some  threads  of  fibrin 
upon  the  loops  nearest  the  pelvis.  There  was  a  small 
amount  of  fluid  exudate.  A  loop  was  adherent  in  the 
bottom  of  the  cul-de-sac,  where  it  appeared  to  have 
been  compressed  by  the  gauze  drain,  but  it  was  not 
completely  occluded  and  was  easily  raised.  Through 
drainage  from  the  abdominal  incision  into  the  vagina 
was  introduced.  The  patient  was  now  severely  shocked, 
but  hypodermics  of  strychnine  and  camphorated  oil, 
given  alternately  and  liberally,  afforded  temporary 
improvement.  But  no  satisfactory  evacuations  from 
the  bowels  were  obtained,  notwithstanding  numerous 
colonic  flushings.  The  signs  of  general  peritonitis 
grew  continually,  and  terminated  in  death  about  thirty- 
six  hours  after  the  ventral  section. 

Case  II. — Mrs.  P.  P.  C ,  aged  forty-three  years. 

The  patient  was  fairly  nourished  and  vigorous,  but 
had  some  albumin  in  the  urine,  and  had  had  a  rise 
of  temperature  recently  from  the  intrauterine  septic 

'  .\ntecedent  as  distinguished  from  consequentive  hsemostasis, 
as  is  the  case  in  the  technique  of  Doyen,  in  which  the  uterus  is 
drawn  down  into  the  vulva  and  is  "  pedicled  "  upon  the  broad 
ligaments  before  the  latter  are  clamped  or  tied  off. 


376 


MEDICAL    RECORD. 


[September  8,  1900 


condition.  On  January  25,  1900.  a  large  metritic  and 
severely  adherent  uterus,  containing  a  necrotic  and 
suppurating  submucous  fibroid,  the  size  of  a  large 
hen's  egg,  was  removed  by  the  vagina,  together  with 
the  very  adherent  and  degenerated  adnexae  and  an 
ovarian  cyst  of  the  left  side.  (The  patient  had  had 
repeated  attacks  of  pelvic  peritonitis  previously.) 
The  uterine  arteries  were  secured  by  two  ligatures  on 
each  side,  and  the  upper  portion  of  each  broad  liga- 
ment and  the  ligamentum  infundibulo-pelvicum  beyond 
the  tube  and  ovary  of  each  side  were  secured  by  a 
curved  broad-ligament  forceps.  A  small  forceps  was 
also  allowed  to  remain  upon  a  branch  of  the  right 
uterine  artery,  tiiat  was  not  cauglit  in  the  ligatures. 
These  forceps  were  removed  after  forty-eight  hours. 
The  raw  wound  surface  in  the  pelvis  was  very  large, 
and  the  opening  in  the  vaginal  vault  was  carefully 
sponged  out,  while  the  patient's  body  was  placed  in  a 
moderate  Trendelenburg  position  to  cause  the  small 
intestines  and  omentum  to  recede,  and  not  to  become 
entangled  with  the  sponges  and  the  subsequent  gauze 
packing  or  drain  which  was  introduced  before  the 
patient  was  returned  to  the  horizontal  position,  thus 
giving  the  least  possible  chance  for  the  intestine  or 
omentum  to  bfcome  mingled  with  it.  The  general 
condition  of  this  patient  was  absolutely  perfect  for 
eight  days.  Very  satisfactory  passages  of  gas  and 
stool  came  after  enemata  after  twenty-four  hours,  and 
on  every  day  after  that  until  the  end  of  the  eighth  day. 
Up  to  that  time  her  pulse  ranged  between  75  and  90, 
and  the  temperature  between  98.6°  and  99.8"  F.,  reach- 
ing 100°  F.  only  once  in  the  first  forty-eight  hours, 
with  a  pulse  of  1 00.  The  excretion  of  urine  was  ample. 
After  the  immediate  effects  of  the  narcosis,  there  was 
no  vomiting,  and  the  amount  of  nourishment  taken 
and  relished  was  very  satisfactory.  But  with  the 
ninth  day  some  distention  and  rhythmic  colicky  pains 
and  some  tenderness  of  the  lower  abdomen  and  nausea 
and  vomiting  began,  with  a  rise  of  pulse  to  100,  and 
temperature  to  100.8°  F.  Asa  saline,  a  laxative,  vigor- 
ous high  enemata,  and  turpentine  stupes  secured  only 
a  temporary  improvement,  and  no  gas  had  been  passed 
for  thirty-six  hours,  while  the  abdominal  distention, 
colicky  pains,  and  vomiting  were  becoming  worse,  I 
fortunately  decided  to  wait  no  longer,  and  performed 
ventral  cceliotomyon  the  tenth  day,  although  the  pulse 
at  the  time  was  only  100  and  the  temperature  100.8° 
F.  per  rectum.  More  than  a  pint  of  free  fluid  peri- 
toneal exudate  at  once  escaped  from  the  incision. 
All  the  small  intestines  that  came  into  view  were 
intensely  injected,  and  the  peritoneal  lustre  was  absent 
over  extensive  areas  of  their  red  surfaces,  which  bore 
strands  of  fibrin,  chiefly  along  the  lines  of  junction  of 
two  opposed  surfaces.  Two  loops  of  ileum,  with  a  mass 
of  omentum,  were  adherent  to  the  posterior  edge  of  the 
vaginal  wound,  and  were  severely  kinked  and  drawn 
upon.  Detachment  wounded  their  serous  and  muscu- 
lar coats.  VVhen  these  surfaces  were  repaired  by  super- 
ficial stitches  of  fine  silk,  and  when  the  peritoneal 
exudate  had  been  sponged  out  and  the  most  suspicious 
parts  had  been  treated  with  peroxide  of  hydrogen,  the 
gauze  drain  into  the  vagina  was  renewed,  and  three 
gauze  drains  from  different  points  in  the  abdomen, 
so  placed  as  al.so  to  cover  the  sutured  areas,  were 
guided  out  of  the  abdominal  wound,  which  was  closed 
only  about  one-half.  The  patient  bore  the  operation 
very  well,  with  camphor  and  strychnine  hypoder- 
mically.  Satisfactory  evacuations  came  in  six  hours 
afterward.  The  pulse,  at  first  not  at  all  accelerated, 
rose  to  its  maximum  of  115  in  eight  hours,  when  the 
temperature  was  99.8°  F.  A  slight  rise  of  tempera- 
ture with  a  pulse  near  100  continued  for  about  five 
days.  A  large  amount  of  fluid  was  discharged  by  the 
vaginal  and  the  abdominal  gauze  drains.  The  abdom- 
inal wound  was  closed  completely  under  anaesthesia, 


about  twelve  days  after  it  had  been  made,  but  the 
gauze  drain  beneath  the  bladder  into  the  vagina  re- 
mained a  few  days  longer.  The  patient  left  the 
hospital  and  the  city  thirty-two  days  after  the  first 
operation,  with  all  wounds  closed,  and  in  the  best  of 
spirits. 

Case  III. — Mrs.   A.    J.    S ,    aged   twenty-seven 

years,  Ilpara,  ■with  one  induced  abortion  at  three 
months,  six  months  ago.  Before  that  she  had  been 
generally  healthy,  and  without  hereditary  taint.  The 
patient  submitted  to  instrumental  interference  on  the 
part  of  a  notorious  midwife,  for  supposed  pregnancy, 
soon  after  one  cessation  of  menses.  This  was  followed 
by  a  continuous  and  profuse  bleeding  for  three  weeks, 
with  constant  pain;  and  after  fever,  vomiting,  and 
persistent  constipation  had  supervened.  Dr.  H.  S. 
Barnard,  succeeding  a  former  attendant,  recognized  a 
large  pelvic  abscess  and  transferred  the  patient  to  the 
Fost-Graduate  Hospital.  On  March  9th  I  made  a 
two-and-a-half-inch  transverse  incision  in  the  posterior 
vaginal  vault,  back  of  the  uterus,  with  a  Paquelin 
cautery,  opened  into  the  large  multilocular  abscess 
with  my  fingers,  broke  down  some  septa,  and  evacu- 
ated at  least  a  gallon  of  pus.  The  abscess  cavity  and 
the  vagina  were  then  packed  with  sterilized  iodoform 
gauze,  which  was  renewed  in  the  vagina  every  second 
day,  and  was  all  removed  after  a  week,  when  a  double 
soft-rubber  drainage  tube  was  introduced  into  the 
abscess  cavity,  extending  within  the  vagina  almost  to 
the  vulva,  so  that  an  irrigator  tube  could  be  inserted 
into  one  of  its  terminal  openings,  and  the  cavity  irri- 
gated daily.  Sixteen  days  after  operation,  when  her 
general  condition  had  become  quite  normal,  although 
still  quite  feeble,  a  difficulty  arose  with  the  bowel 
evacuations.  Calomel  and  salines  were  followed  by 
nausea  and  vomiting,  and  the  high  enemata  were  often 
mostly  retained,  or  came  away  in  a  drizzling  manner, 
which,  together  with  the  contour  of  the  abdomen, 
suggested  a  filled  colon  and  an  obstruction  at  the 
sigmoid  flexure.  This  I  thought  to  be  the  trouble  and 
to  be  caused  by  some  involvement  of  the  sigmoid  in 
the  retracting  abscess  walls.  This  view  of  the  dis- 
order, and  the  fact  that  a  high  rectal  tube  could,  some- 
times at  least,  be  run  up  into  or  through  the  sigmoid, 
as  shown  by  digital  exploration  in  the  vagina  and  the 
cul-de-sac,  induced  me  to  delay  interference  for  about 
sixty  hours  after  faeces  were  first  vomited.  The  pulse 
during  this  time  ranged  from  104  to  130.  and  the 
temperature  from  98.4^  to  101°  F.  On  March  29th 
(twentieth  day )  1  made  an  incision  suitable  for  left 
inguinal  colostomy,  and  at  once  came  upon  a  greatly 
distended  and  inflamed  small  intestine,  which  led 
down  to  an  acutely  flexed  portion  whose  serous  coat 
was  pulled  out  in  form  of  a  band,  that  was  attached 
to  something  in  the  abscess  wall  below.  The  obstruc- 
tion was  almost  complete;  but  when  the  band  was 
severed  the  collapsed  and  strictured  portion  of  small 
bowel  could  be  again  distended  by  compression  of  the 
dilated  gut;  and  stitches  to  repair  the  wound  in  the 
serous  and  muscular  coats  were  all  that  were  needed. 
But  the  sutured  part,  as  well  as  all  the  rest  of  the  in- 
testine that  came  within  the  wound,  was  clearly  in- 
volved in  marked  peritonitis.  .As  there  was  no  liquid 
exudate,  I  placed  no  drain,  but  closed  the  wound 
entirely.  The  patient  rallied  from  the  severe  shock, 
and  satisfactory  bowel  evacuations  came  spontaneously 
after  five  hours.  Nevertheless,  coolness  of  skin  and 
extremities,  with  a  very  rapid  pulse  and  other  evidence 
of  severe  infection  and  general  peritonitis,  soon 
followed,  and  continued  until  death — seventy-two  hours 
after  the  ventral  section.  .Autopsy  by  Professor  Zeit. 
pathologist  of  the  Post-Graduate  Medical  School, 
twenty-four  hours  after  death,  showed  no  free  gas  in 
the  abdominal  cavity.  The  small  intestines  were 
greatly  distended  and  involved  in  general   peritonitis, 


September  8,  1900] 


MEDICAL    RECORD. 


377 


being  coated  with  purulent  fibrinous  exudate.  There 
was  no  apparent  leakage  of  the  ileum  at  the  point  of 
suturing,  which  looked  greenish-black,  and  was  sur- 
rounded with  a  purulent  necrotic  area.  After  the  in- 
testines were  taken  out  and  detached  from  their 
mesentery,  a  perforation,  the  size  of  a  small  colTee- 
bean,  was  found  six  and  a  half  feet  from  the  stomach 
end.  The  left  side  of  the  pelvis  contained  a  large 
abscess  cavity,  with  some  greenish-yellowish  pus  that 
had  an  ammoniacal  odor.  In  the  walls  of  this  cavity 
the  small  intestine  and  also  the  vermiform  appendix 
were  extensively  engaged.  Professor  Zeit  says  the 
operation  was  not  successful,  because  it  was  done  too 
late,  i.e.,  upon  structures  already  infected. 

Observations.  —  I .  According  to  the  showing  of 
Lenclos,  ileus  is  more  frequent  after  vaginal  hyster- 
ectomy than  after  other  abdominal  sections.  This  is 
as  we  could  expect,  chiefly  in  all  cases  in  which  the 
abdominal  or  pelvic  cavity  is  not  closed;  for  in  these 
cases  two  or  three  of  the  chief  causes  of  peritoneal  ad- 
hesions are  quite  generally  present,  i.e.,  (<?)  raw  sur- 
faces, (/')  infection,  and  {c)  a  foreign  body  (the  drain). 

2.  Inasmuch  as  we  know  that  the  physiological 
economy  of  the  abdomen  demands  tliat  the  different 
portions  of  tlie  small  intestines  shall  be  free  to  migrate 
from  place  to  place,  as  is  painfully  illustrated  by  my 
third  case,  therefore  any  opening  of  the  abdominal  or 
pelvic  peritoneal  cavity  is  deplorable,  that  engages 
any  portion  of  the  small  intestine  to  assist  in  closing 
the  opening  or  wound.  This  is  regularly  the  case  in 
vaginal  hysterectomy,  as  ordinarily  performed,  and  as 
is  necessarily  done  in  all  cases  of  this  operation  in 
which  there  are  extensive  abraded  surfaces,  or  in  which 
septic  features  are  present  in  the  case.  But  in  all 
other  cases  of  this  op)eration,  when  no  intraperitoneal 
drain  is  needed,  it  is  a  just  requirement  that  the  peri- 
toneal cavity  be  sealed  by  a  closure  of  the  wound  in 
the  peritoneum  by  coaptation  of  its  edges;  and  that 
the  use  of  ha;mostatic  forceps  or  clamps,  as  far  as  it 
interferes  with  such  closing  of  the  peritoneum,  should 
be  avoided  as  far  as  possible.  I  do  r.ot,  from  my  ex- 
perience, find  it  necessary  or  desirable  to  close  the 
opening  in  the  vaginal  vault,  but  prefer  to  let  this  and 
the  broad  ligament  wound  drain  into  the  vagina. 

3.  The  secondary  operation  for  the  relief  of  post- 
operative ileus,  to  be  successful,  must  be  performed 
early,  before  the  mechanical  obstruction  has  caused  in- 
fection and  paralysis  of  the  bowel  (peritonitis). 

4.  When  this  difficulty  arises  early — within  three 
to  four  days  after  an  abdominal  or  pelvic  operation, 
i.e.,  the  time  in  which  post -operative  peritonitis  can 
also  be  expected — it  will  often  be  difficult  to  exclude 
the  latter,  which  also  causes  similar  symptoms. 

5.  The  symptoms  and  signs  which  speak  mostly  for 
ileus  are:  Abdominal  distention  without  marked 
tenderness  to  touch  on  gentle  pressure;  the  presence 
of  rhythmical  colicky  pains;  a  slow  pulse  that  is  not 
wiry;  fecal  vomiting;  vermicular  motion  of  the  small 
intestine,  seen  or  felt  through  the  abdominal  wall; 
increased  proportion  of  indican  in  the  urine. 


Incipient  Insanity.— T.  Outterson  Wood  describes 
the  disorder  characterized  by  a  feeling  of  unhappiness, 
a  dampening  of  buoyancy  of  spirits  and  healthy,  hope- 
ful looking  forward,  with  a  loss  of  power  in  fighting 
against  the  weight  of  despondency.  The  expression 
of  the  patient's  face  is  that  of  unhappiness  and  un- 
certainty, and  the  attitude  of  the  body  is  that  of  list- 
lessness  and  want  of  energy,  showing  a  flaccid  condition 
which  distinguishes  it  from  the  well-known  condition 
of  flexion  so  typical  of  the  pronounced  melancholic. 
Another  striking  difference  between  this  state  of  de- 
pression and  melancholia  proper  is  that  in  melancholia 


there  is  a  characteristic  tendency  to  tears.  The  danger 
is  in  the  recurrence  and  persistence  of  attacks  of  de- 
pression until  they  gradually  drift  into  the  depths  of 
melancholia.  Drugs  are  useless.  The  general  health 
should  be  improved  and  a  healthy  action  of  the  vari- 
ous excretions  encouraged,  with  change  of  scene, 
change  of  daily  routine  and  work,  open-air  living, 
exercise,  and  cheerful  surroundings.- — Treatment,  ]w\^, 
igoo. 

A  New  Method  of  Treatment  of  Initial  Syphi- 
loma.— Leone  Levi  claims  that  his  method  is  new, 
the  means  used  for  its  application  not  being  new,  how- 
ever. He  cauterizes  the  syphiloma,  preferably  by 
means  of  the  galvano-cautery.  Certain  practitioners 
in  the  past  cauterized  a  syphiloma  perhaps  once:  the 
author  does  it,  if  necessary,  a  thousand  times,  until  the 
treatment  determines  an  intense  local  inflammation  of 
the  tissues.  This  makes  of  the  syphilide  a  mere  local 
infection,  preventing  constitutional  infection  with  all 
its  consequences.  He  describes  his  method  in  detail, 
and  claims  absolutely  successful  results  in  thirty-two 
cases. — La  Kijorma  Medica.  July  19,  1900. 

Concomitant  Measles,  Chickenpox,  and  Smallpox. 
— Otto  Lerch  relates  a  case  which,  so  far  as  his  search 
goes,  shows  no  parallel  in  literature.  A  twelve-year- 
old  boy,  after  fever,  chill,  etc.,  showed  a  crop  of 
vesicles;  five  days  later,  after  headache,  nausea,  and 
vomiting,  the  temperature  rose  from  normal  to  104° 
F.,  and  signs  of  measles  appeared.  In  another  in- 
stance there  was  coexistence  of  measles  and  varioloid, 
and  inonefamily  the  writer  observed  cases  of  measles, 
smallpox,  and  chickenpox,  and  he  believes  they  may 
all  coexist  in  one  individual. — Nets.'  Orleans  Medical 
and  Surgiea!  Joiirnat,  August,  1900. 

Pseudo-Membranous  Bronchitis. — \  case  of  this 
unusual  affection  is  reported  by  Joncheray,  whose  pa- 
tient was  a  man  aged  fifty-seven  years.  The  author  says 
that  it  is  necessary  to  distinguish  between  the  acute 
and  chronic  forms  of  the  disease.  The  membranes 
may  suggest  diphtheria,  and  we  must  examine  for  the 
Loefifler  bacillus,  look  after  the  lymph  nodes,  and  if 
necessary  make  use  of  serum  treatment  to  clear  up  the 
diagnosis.  Another  form  is  that  due  to  the  aspergillus 
fumigatus,  but  examination  will  reveal  the  parasite, 
and  it  can  be  cultivated  outside  the  body,  \^■hen  no 
membranes  have  appeared,  it  is  necessary  to  differen- 
tiate from  foreign  bodies,  ingestion  of  caustic  liquids, 
cicatricial  contraction,  tumors,  glottic  spasm,  and 
rarely  tracheal  ozana. — Revue  Hebdomadaire  de  Laryn- 
gologie,  July  28,  1900. 

Typhoid  Mastitis. — Luigi  Fornaca  reports  a  case 
in  a  woman  aged  forty  years.  On  the  twenty-ninth 
day  of  the  disease,  the  patient  being  convalescent, 
pains  appeared  in  the  right  breast  and  soon  became 
extreme,  and  on  the  following  day  the  breast  was 
greatly  swollen.  An  exploratory  puncture  five  days 
later  showed  the  tissues  to  be  hard  and  resistant;  three 
drops  of  a  sero-purulent  fluid  were  obtained,  and  cul- 
tivated in  ordinary  broth.  The  left  breast  became 
involved  sixteen  days  after  the  right,  and  both  tumors 
became  indolent,  although  remaining  enlarged  and 
hardened.  The  fluid  cultivated  on  bouillon  showed 
a  micro-organism  wliich  in  appearance,  reactions  to 
stains,  and  action  upon  guinea-pigs  in  every  way  re- 
sembled Eberth's  bacillus. — La  Rtjorma  Medica,  July 
27,  1900. 

Trinitrin  in  Melancholia.— Guiseppe  Paoli  has 
found  this  drug  to  be  of  great  service  in  the  type  of 
melancholy  characterized  by  attacks  of  "  anxiousness," 
the  agony  of  mind  seing  largely  due  to  vasomotor  dis- 
turbances. To  patients  who  are  periodically  subject 
to  grave  exacerbations  of  their  condition,  whose  pe- 


378 


MEDICAL    RECORD. 


[September  8,  1900 


ripheral  blood-vessels  are  evidently  in  a  spastic  state, 
which  becomes  much  aggravated  during  the  attack,  he 
gives  treatment  the  object  of  which  is  to  prevent  the 
attacks  and  to  overcome  the  permanent  constriction  of 
the  vessels.  Witli  this  object  in  view,  he  puts  them 
on  a  milk  diet,  and  prescribes  two  spoonfuls  a  day  of 
the  following  potion:  '"One-per-cent.  alcoholic  solu- 
tion of  trinitrin,  gtt.  30;  water,  300  gm.''  This  is 
given  for  the  first  ten  days  of  each  month,  a  mild 
iodine  treatment  being  given  the  other  twenty  days: 
"  Iodide  of  sodium,  10  gm.:  water,  300  gm.;  2  spoon- 
fuls a  day."'  Meanwhile  glycero-phosphates  with 
arseniate  of  strychnine  are  given  hypodermically  to 
counteract  the  action  of  the  treatment  on  the  blood 
corpuscles.  The  cardiac  and  renal  functions  are 
closely  watched  during  the  treatment. — La  Rijorma 
Medica,  July  28  and  30,  1900. 

A  Disease  Resembling  Acute  Leukaemia — Ste- 
phen reports  the  case  of  a  middle-aged  woman  who 
died  after  a  short  illness  with  every  evidence  of  great 
prostration,  but  no  focalizing  symptoms  or  physical 
signs.  The  microscopic  examination  of  the  blood  re- 
vealed a  diminution  of  the  red  cells  and  an  increase 
of  the  leucocytes;  the  small  lymphocytes  being  scanty, 
but  the  eosinophiles  present  in  abnormally  large  num- 
bers. Tlie  main  feature  of  interest,  however,  lay  in  tlie 
fact  that  though  many  of  the  red  cells  contained  what 
were  undoubtedly  nuclei,  others  exhibited  what  the  au- 
thor believes  to  be  amoeboid  parasites.  These  were 
also  to  be  found  in  some  numbers  lying  free  between 
the  cells,  and  Stephen  considers  himself  justified  in 
regarding  them  as  the  cause  of  the  disease,  to  which 
he  applies  the  name  of  proteosomiosis. —  Wiener  kli- 
nische  Rundschau,  July  22,  igoo. 

Subacute  Tuberculosis  of  the  Pharynx  in  Child- 
hood.— Carlo  Comba  reports  three  cases  of  this  affec- 
tion, which  is  rare  in  childhood,  only  fourteen  cases 
being  found  in  medical  literature.  In  these  three 
cases  the  process  was  secondary  to  tuberculosis  of  the 
air  passages  and  the  digestive  tract.  The  subjective 
symptoms  are  sharp  pains  in  the  affected  region,  which 
are  increased  during  deglutition,  so  that  swallowing  is 
sometimes  absolutely  impossible.  Should  the  soft 
palate  be  involved,  it  becomes  paralyzed.  An  exami- 
nation of  the  pharynx  in  the  early  stages  will  show 
grayish-yellow  nodules,  composed  of  soft  tissue  which 
easily  bleeds.  .\\.  a  later  stage  these  ulcerate  and 
leave  cavities  with  irregular  margins,  containing  a  de- 
tritus of  caseous  substance  and  muco-pus.  The  sur- 
rounding mucosa  is  swollen  and  red.  The  cervical 
glands  become  swollen  and  sometimes  suppurate. 
The  diagnosis  is  not  difficult,  especially  when  there 
are  marked  symptoms  of  tuberculosis  in  other  organs, 
and  will  be  materially  assisted  by  bacteriology. — Lo 
Sperimeiitale,  vol.  liv.,  No.  3,  1900. 

The  Hygiene  of  Obesity. — K.  von  Noorden  divides 
the  treatment  of  those  suffering  from  obesity  into  three 
headings.  First  and  perhaps  most  important  in  pre- 
venting and  removing  abnormal  deposits  of  fat  is  the 
matter  of  exercise,  but  tiiis  requires  careful  regulation 
and  adjustment  according  to  each  individual's  needs 
and  capabilities.  The  best  and  also  tiie  most  univer- 
sally applicable  form  of  exercise  for  this  class  of  pa- 
tients is  pedestrianisni.  and  especially  hill-climbing. 
It  is  easy  to  determine  the  length  of  walk  to  be  taken, 
the  character  of  the  ground  to  be  covered,  and  the 
length  of  time  consumed;  to  avoid  overtaxing  the 
heart,  thorough  ventilation  of  the  chest  by  deep  and 
regular  respiration  must  be  insisted  on.  The  second 
element  in  the  treatment  involves  the  care  of  the  skin. 
Fat  persons  are  especially  liable  to  some  forms  of 
skin  diseases,  notably  seborrhoeic  and  intertriginous 
eczema.     In  the  treatment  and   prophylaxis  of   these 


scrupulous  cleanliness  and  hydrotherapy  are  of  the 
greatest  value.  Regular  baths,  frictions,  and  cold 
douches  are  useful  for  the  hyperidrosis  commonly  ob- 
served;  if  these  are  insufficient,  Turkish  baths,  small 
doses  of  atropine,  and  restriction  of  the  fluids  imbibed 
are  indicated.  The  third  therapeutic  factor  to  be  con- 
sidered embraces  the  question  of  diet.  In  addition  to 
a  careful  selection  of  the  articles  of  food  allowed,  it 
is  of  greatest  service  to  make  each  meal  very  small  in 
quantity,  but  to  give  food  at  short  intervals,  viz.,  seven 
or  eight  times  a  day.  In  this  way  the  stomach  is  kept 
busy  and  the  feeling  of  hunger  does  not  become  trou- 
blesome, w'hile  at  the  same  time  the  sensation  of  faint- 
ness,  which  so  often  is  a  prominent  feature  in  women, 
and  depends  on  emptiness  of  the  stomach,  is  entirely 
obviated. — Z-eitschriJt Jiir  Krankeiipjlege,  July,  1900. 

An  Unusual  Form  of  Painful  Anaesthesia  of 
Hysterical  Origin.  — Guiseppe  Dagnini  reports  the 
case  of  a  young  woman  who  exhibited  the  following 
symptoms:  Total  loss  of  specific  sensibility  to  punc- 
ture of  the  skin  and  subjacent  tissues;  loss  of  cuta- 
neous sensitiveness  to  thermic  and  electric  stimula- 
tion, to  space,  to  recognition  of  the  quality  of  bodies 
touching  the  skin,  to  the  most  superficial  contact;  loss 
of  sense  of  position  of  the  knee-joint,  combined  with 
hyperalgia  to  the  slightest  pressure,  which  became  intol- 
erable pain  if  the  pressure  were  increased.  The  con- 
dition was  found  to  be  absolutely  of  hysterical  origin, 
and  was  cured  by  the  suggestion  that  the  evacuation 
of  an  abscess  (due  to  a  hypodermic  injection  of  mor- 
phine) done  under  chloroform,  would  give  relief. — 
Rivista  Critica  di  Cliiiica  Aledira,  July  7,  14,  and  21, 
1900. 

Five  Years'  Experience  with  the  Antiseptic 
Treatment  of  Typhoid  Fever — J.  A.  Crook  refers  to 
his  former  communications,  in  which  he  showed  that 
carbonate  of  guaiacol  was  not  taken  up  from  the  ali- 
mentary canal,  but  that  it  passed  through  as  taken  in, 
and  hence  reached  the  seat  of  disease.  He  believes 
this  drug  to  be  non-irritating  to  the  mucous  membrane 
of  the  stomach  or  bowels,  and  that  it  may  be  given  in 
doses  sutTiciently  large  to  cause  disinfection  without 
detriment  to  the  patient.  In  the  past  five  years  the 
writer  has  treated  one  hundred  and  nine  patients,  with 
four  deaths.  He  finds  that  the  strict  Woodbridge  and 
Brand  methods  necessitate  worry  and  annoyance  to 
the  patient  by  the  oft-repeated  small  doses  and  the  too 
frequent  use  of  the  cold  bath,  when  sponging  would 
accomplish  what  is  desired.  Intestinal  antiseptics  are 
rational  and  scientific;  the  course  of  the  disease  is 
shortened,  and  the  mortality  is  lessened. — Memphis 
Medical  Monthly,  August,   1900. 

Abnormal  Electrical  Storage  in  the  Human  Sys- 
tem.— Sir  James  Grant  says  that  for  many  years  he 
has  been  in  the  habit  of  treating  cases  of  supposed 
muscular  rheumatism  by  the  insertion  of  small  (No. 
8)  fine  steel  needles,  the  number  varying  according  to 
the  extent  of  the  affected  parts,  and,  as  a  general  rule, 
the  seat  of  pain  will  indicate  the  precise  place  and 
extent  to  which  the  needles  should  be  used.  They 
remain  stuck  into  the  muscles  for  from  one  to  two 
minutes,  'i'he  previous  hard,  tense  condition  approxi- 
mating one  of  tetany  relaxes,  the  needles  are  removed 
without  force,  and  the  patient  is  able  at  once  to  use  the 
muscles.  Experiments  point  to  an  abnormal  storage 
of  electricity  in  the  tissues.  It  may  be  stored  as  a 
result  of  sudden  draughts  and  cold.  When  the  in- 
serted needles  are  touched,  the  electrical  accumulation 
is  simultaneously  discharged,  passing  through  the 
body  of  the  operator  without  any  serious  result. 
There  is  almost  immediate  relief  in  lumbago  from  tiiis 
acupuncture.  Cases  are  cited. — Montreal  Medical 
Journal,  July,  1900. 


September  8,  igoo] 


MEDICAL    RECORD. 


579 


Medical   Record: 

A    IViikly  Journal,  of  Medicine  and  Surgery. 


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

I'lKl.ISHF.KS 

WM     WOOD  &  CO.,  51    Fifth   Avenue. 


New  York,  September  8,  1900. 

THE    EARLY    DIAGNOSIS    OE    CARCINOMA 
OF   THE   STOMACH. 

The  prospects  of  ever  attaining  comparative  success 
in  the  surgical  treatment  of  carcinoma  of  the  stomach 
have  come  to  depend  not  so  mucli  upon  surgical  skill 
and  technical  efficiency  as  upon  early  diagnosis,  and 
the  term  early  has  now  a  different  significance  from 
what  it  formerly  possessed.  At  present,  if  a  diagnosis 
is  to  be  designated  early,  it  must  be  made  very  much 
sooner  in  the  course  of  the  disease  than  would  have 
been  considered  early  a  few  years  ago,  when  a  diag- 
nosis made  before  a  tumor  could  be  palpated  was  not 
looked  upon  as  trustworthy.  The  surgical  side  of  the 
question  of  the  treatment  of  this  disease  is  now  in  a 
satisfactory  condition  as  far  as  technique  is  concerned, 
and  when  it  is  possible  to  operate  upon  patients  who 
are  in  reasonably  good  condition  the  immediate  re- 
sults can  fairly  be  called  excellent;  but  unfortunately 
very  few  patients  are  operated  upon  in  a  stage  of  the 
disease  which,  in  view  of  our  present  knowledge,  can 
be  called  the  most  suitable  and  most  promising  as  to 
final  result. 

It  is  safe  to  say  that  the  prospects  of  obtaining  a 
real  cure  when  a  tumor  is  palpable,  no  matter  how 
movable,  are  very  poor,  for  there  are  exceedingly  few 
patients  operated  on  under  such  circumstances  who 
have  survived  long  enough  to  be  looked  upon  as  safe 
from  recurrence,  and,  furthermore,  we  know  that  pa- 
tients may  reach  a  very  advanced  stage  of  the  disease, 
or  may  die,  without  ever  having  given  palpable  evidence 
of  a  tumor.  We  certainly  cannot  use  the  presence  of 
a  tumor  as  a  safe  means  of  diagnosis,  if  we  are  seek- 
ing information  to  guide  our  therapeutics  to  perma- 
nent success.  There  seems,  however,  to  be  hope  that 
we  may  arrive  at  a  state  of  knowledge  which  in  many 
cases  will  allow  us  to  make  a  diagnosis  of  strong 
probability  at  least,  at  a  much  earlier  stage  in  the 
disease  than  heretofore;  but  to  make  this  possible  the 
clinician  is  the  one  who  must  get  the  evidence  and 
draw  conclusions,  and  then  call  upon  the  surgeon  for 
the  performance  of  an  operation  which  may  be  only 
exploratory.  We  need  not  always  expect  to  make 
positive  early  diagnoses,  but  we  may  hope  to  collect 
enough  evidence  from  observation  and  experiment 
upon  which  to  base  a  diagnosis  of  such  strong  prob- 
ability that  under  reasonably  favorable  circumstances 
an  exploration  will  often  be  justifiable  and  perhaps 
be  followed  by  a  successful  operation  for  radical  cure. 


In  gathering  evidence  for  an  early  diagnosis,  one 
of  the  first  points  to  consider  is  the  age  of  the  patient, 
in  reference  to  which  we  may  say  that  most  cases  occur 
in  those  who  have  passed  the  age  of  forty-five  years, 
though  exceptions  to  this  general  rule  are  frequent 
enough.  Sex  does  not  seem  to  be  of  much  signifi- 
cance, though  if  anything  the  disease  occurs  oftener 
in  men  than  in  women.  A  history  of  chronic  gastri- 
tis or  dyspepsia  which  does  not  show  signs  of  amelio- 
ration under  treatment  is  always  suspicious,  and  when 
this  condition  is  associated  with  a  constantly  dimin- 
ished amount  of  free  hydrochloric  acid  we  may  make 
at  least  a  provisional  diagnosis  of  carcinoma  of  the 
stomach,  and  expect  by  further  investigation  to  dis- 
prove or  substantiate  it.  It  has  been  observed  that,  in 
connection  with  the  gastritis  occurring  in  the  presence 
of  carcinoma,  there  are  certain  irregularities  in  the 
life-processes  of  the  epithelial  cells  of  the  gastric 
mucous  membrane,  the  so-called  atypical  and  irregular 
mitoses  seen  in  these  cells  when  they  are  collected 
from  the  stomach  washing  either  with  or  without  the 
preliminary  scraping  of  the  mucous  membrane  with 
the  end  of  the  stomach  tube  in  order  thus  to  increase 
the  number  of  dislodged  cells.  These  appearances 
are  practically  always  demonstrable  and  occur  early  in 
the  disease,  before  the  mucous  membrane  is  actually 
involved  in  the  carcinomatous  process,  and  though 
perhaps  not  pathognomonic  are  certainly  of  great  im- 
portance. 

The  Oppler-Boas  bacillus  seems  to  occur  regularly 
in  stomachs  which  are  the  seat  of  carcinoma,  but,  as  a 
rule,  too  late  to  influence  the  making  of  a  really  early 
diagnosis,  and  the  presence  of  lactic  acid  has  about 
the  same  diagnostic  value.  It  does  occur  in  carcino- 
matous stomachs,  but  usually  too  late  in  the  disease  to 
be  of  assistance  in  making  the  kind  of  diagnosis  which 
will  be  of  much  use  to  the  patient.  However,  the 
presence  of  lactic  acid  and  of  a  tumor,  though  not  early 
signs,  does  not  necessarily  in  all  cases  preclude  the 
possibility  of  operative  cure,  though  the  chances  of 
real  cure  are  much  diminished  by  such  signs,  in  the 
case  of  the  first  because  the  functions  of  the  stomach 
must  be  gravely  disordered  if  it  is  constantly  present 
in  any  quantity,  and  in  the  case  of  the  second  because 
the  disease  must  have  reached  very  considerable  ex- 
tent if  it  is  possible  to  feel  a  tumor  through  the  ab- 
dominal walls.  Only  freely  movable  tumors  need  be 
considered  in  this  connection  at  all.  The  discovery 
of  true  carcinomatous  tissue  in  the  stomach  contents 
undoubtedly  makes  a  diagnosis,  but  not  an  early  one. 
A  point  to  remember  is  that  the  progress  of  a  case  of 
carcinoma  of  the  stomach  will  vary  according  to  the 
site  of  the  growth  in  the  gastric  wall  and  its  histo- 
logical character,  so  that  an  early  diagnosis  in  one 
instance  might  offer  a  quite  different  prospect  from 
what  it  would  in  another.  Fortunately,  the  so-called 
scirrhus  type,  intrinsically  least  malignant,  is  the  com- 
monest, and  is  most  frequently  located  in  the  pylorus, 
where  it  soonest  gives  symptoms.  Haematemesis  is 
undoubtedly  a  symptom  of  gastric  carcinoma,  but  there 
are  several  other  conditions  which  cause  vomiting  of 
blood,  sometimes  in  the  "coffee-ground  "  condition,  so 
that  at  best  its  presence  can  afford  us  only  corrobora- 


38o 


MEDICAL    RECORD. 


[September  8,  1900 


tion,  often  too  late  to  be  of  any  use,  in  outlining  our 
treatment.  The  great  aid  to  early  diagnosis  is  ex- 
ploratory incision,  though  even  this  does  not  enable 
us  to  say  positively  every  time  whether  carcinoma  is 
present,  but  it  does  give  us  evidence  as  to  whether  we 
are  called  upon  to  deal  with  a  lesion  amenable  to 
operative  treatment,  so  that  what  to  do  next  is  easily 
decided.  Just  when  and  upon  what  evidence  to  make 
an  exploratory  incision,  and  whether  to  proceed  at 
once  with  a  radical  operation,  are  questions  which  at 
present  must  be  answered  largely  from  individual  ex- 
perience and  opinion;  but  the  exploratory  incision  is 
gaining  in  favor  steadily,  and  justification  for  its  use 
is  sought  in  the  result  of  formulating  facts  such  as  we 
have  mentioned,  in  its  practical  freedom  from  danger, 
and  in  the  important  knowledge  which  we  gain  by  it. 
There  is  room  for  a  judicious  extension  of  its  use. 


CHYLOUS   ASCITES. 

An  effusion  of  fluid  into  the  peritoneal  cavity  may  ex- 
hibit a  milky  appearance  from  the  presence  of  fat  or 
of  chyle.  Fatty  ascites  has  been  observed  in  associa- 
tion with  tuberculosis  or  carcinoma  of  the  peritoneum, 
large  numbers  of  endothelial  cells  in  a  state  of  fatty 
degeneration  being  desquamated  and  partly  mixed  and 
partly  dissolved  in  the  fluid  poured  out.  Chylous 
ascites,  on  the  other  hand,  is  dependent  upon  obstruc- 
tion to  the  flow  of  chyle  or  rupture  of  a  lacteal,  the 
thoracic  duct,  or  the  receptaculum  chyli.  A  case  of 
the  latter  variety  has  recently  been  reported  by  Croon 
(^Lancet,  June  23,  1900).  The  patient  was  a  woman 
thirt}'-nine  years  old,  who  presented  symptoms  of  car- 
cinoma of  the  omentum  and  the  mesentery,  with  re- 
sulting ascites.  On  aspiration  three  hundred  and 
eighty  ounces  of  fluid  resembling  pus  were  removed. 
This  was  of  pale  yellov/  color,  and  at  first  quite  homo- 
geneous, but  on  standing  for  twenty-four  hours  a  slight 
creamy  layer  appeared  upon  the  surface.  The  fluid 
had  a  sweetish,  milky  odor.  It  was  found  to  consist 
partly  of  finely  emulsified  fat,  but  more  largely  of 
granular  de'bris,  constituted  mainly  of  leucocytes  in  a 
state  of  fatty  degeneration.  A  movable  tumor  was 
now  found  in  the  region  of  the  gall  bladder,  and  an 
indefinite,  irregular,  solid  mass  in  the  situation  of  the 
greater  curvature  of  the  stomach. 

Although  temporary  improvement  ensued,  the  fluid 
reaccumulated,  and  after  an  interval  of  some  three 
weeks  about  three  hundred  and  fifty  ounces  of  fluid 
were  additionally  removed.  Death,  however,  resulted 
in  the  course  of  a  few  days.  On  post-mortem  exam- 
ination, the  subpleural  lymphatics  were  found  studded 
with  minute  carcinomatous  nodules.  The  small  in- 
testine was  the  seat  of  commencing  peritonitis.  The 
mesenteric  glands  were  generally  enlarged  from  malig- 
nant infiltration. 

A  large  carcinomatous  neoplasm  grew  from  the  inner 
surface  of  the  anterior  wall  of  the  stomach,  extending 
from  an  inch  beyond  the  pylorus  for  four  inches  along 
the  lesser  curvature.  The  gall  bladder  was  distended 
with  bile,  and  the  glands  and  tissues  along  the  larger 
bile-ducts  and  in  the  portal  fissure  of  the  liver  were 


extensively  infiltrated  with  new  growth.  The  liver 
itself  contained  one  small  carcinomatous  nodule. 
The  small  intestine  was  thickened  and  contracted 
throughout  its  entire  length.  It  contained  an  im- 
mense number  of  small  carcinomatous  nodules  sur- 
rounding and  extensively  occluding  the  lacteals,  close 
to  the  mesenteric  attachment.  The  thoracic  duct  as 
well  as  the  receptaculum  chyli  was  healthy,  although 
a  mass  of  infiltrated  glands  was  found  lying  close  be- 
side and  pressing  on  it. 


HOSPITAL    ABUSE. 

That  abuse  of  the  privileges  intended  by  hospital  au- 
thorities only  for  the  worthy  poor  is  not  confined  to 
any  state  or  country  is  amply  shown  by  statements 
made  in  an  address  delivered  by  Thiery  {^Lancet,  July 
28,  1900)  at  the  First  International  Congress  on  Medi- 
cal Ethics  held  recently  at  Paris.  So  rapidly  is  the 
use  of  hospitals  by  those  who  can  afford  to  pay  for 
medical  attention  increasing  that  it  has  been  declared 
that,  in  spite  of  all  efforts  to  the  contrary,  the  time 
will  come  when  bread  and  medical  aid  will  be  given 
gratuitously  to  all  who  apply,  and  that  the  time  is  not 
far  distant  when  the  medical  practitioner  will  be  a 
paid  functionary  of  the  state.  The  following  instances 
of  hospital  abuse  were  cited:  That  of  a  jockey  who 
was  earning  $5,000  a  year  and  went  to  a  hospital  to 
be  treated  for  a  sprain;  a  lady  who  was  able  to  pay 
for  her  journey  from  America  in  order  to  obtain  advice 
at  the  same  hospital ;  a  cashier  in  a  commercial  house 
earning  a  salary  of  $4,000;  a  young  lady  from  Russia 
who  was  operated  on  gratuitously  at  a  hospital  and 
then  went  for  her  convalescence  on  a  journey  to  Italy; 
a  celebrated  singer  who  wanted  the  hospital  surgeon  to 
come  to  her  own  house  because  she  did  not  like  to  go 
to  the  hospital,  and  who  strongly  objected  to  paying- 
any  fee  whatever.  Further,  of  about  fifty  thousand 
births  that  occur  annually  in  Paris,  eighteen  thousand 
take  place  at  public  expense.  It  will  thus  be  seen  that, 
unless  the  predictions  made  are  to  be  verified,  some 
steps  will  be  necessary  to  curtail  an  abuse  that  has 
already  attained  enormous  proportions.  The  remedy 
proposed  is  that  clerks  or  janitors  at  hospitals  should, 
in  addition  to  taking  the  names  and  addresses  of 
patients,  make  inquiries  as  to  their  means  of  subsis- 
tence. An  inspector  should  then  institute  an  investi- 
gation for  the  purpose  of  verifying  the  statements 
made.  The  very  least  that  can  be  done  under  present 
conditions,  is  to  ask  each  applicant  for  gratuitous 
treatment  whether  he  can  afford  to  pay,  and  to  inform 
him  that  the  gratuitous  services  of  the  hospital  and 
dispensary  are  only  for  the  worthy  poor.  The  indi- 
vidual should  be  permitted  to  decide  for  himself  if  he 
wishes  to  be  made  an  object  of  charity. 


■  Typhoid  Fever  in  Newark,  N.  J.— Numerous 
cases  of  typhoid  fever  occurring  among  the  factory 
hands  in  several  thread  mills  have  been  traced  to  the 
use  of  well-water.  Examinations  of  the  water  of  the 
wells  in  the  mill  yards  have  shown  the  presence  of 
typhoid  bacilli. 


September  8,  1900] 


MEDICAL    RECORD. 


381 


^euis   of  the  ^IccU. 

The  Rocky  Mountain  Inter-State  Medical  Asso- 
ciation.— The  second  annual  meeting  of  this  associa- 
tion was  held  at  Butte,  Mont.,  on  Tuesday  and  Wed- 
nesday, August  28th  and  29th,  under  the  presidency  of 
Dr.  C.  K.  Cole,  of  Helena,  Mont.  There  was  an  in- 
teresting programme  of  papers.  A  luncheon  was  had 
at  Columbia  Gardens  on  Tuesday,  and  the  annual 
banquet  at  the  McDermott  Hotel  on  Wednesday. 
After  the  close  of  the  meeting  a  number  of  the  mem- 
bers joined  in  an  excursion  through  the  National  Park. 

Yellow  Fever  in  West  Africa.  — It  is  reported  in 
Paris  that  a  terrible  epidemic  of  yellow  fever  is  raging 
in  Senegal.  Nearly  all  the  French  troops,  the  physi- 
cians, the  nurses,  and  others  of  the  civil  population 
have  been  attacked,  and  since  the  rainy  season  set  in 
the  mortality  has  been  about  eighty-five  per  cent. 
The  churches  have  been  closed,  and  the  white  troops 
will  be  withdrawn  at  the  earliest  possible  date,  their 
place  being  taken  by  native  soldiers. 

Mortality  Statistics  of  Philadelphia. — For  the 
week  ended  September  ist  there  were  reported  to  the 
Philadelphia  bureau  of  health  413  deaths,  41  more 
than  for  the  preceding  week,  and  77  more  than  for  the 
corresponding  week  of  the  previous  year.  The  prin- 
cipal causes  of  death  were  as  follows:  Pulmonary 
tuberculosis  49,  cholera  infantum  42,  heart  disease 
35,  marasmus  24,  pneumonia  19,  inflammation  of  the 
stomach  and  bowels  17,  nephritis  15,  diphtheria  13. 
Seven  deaths  were  due  to  sunstroke. 

A  Ten-Thousand-Dollar  Fee — It  is  stated  that 
one  of  the  largest  fees  ever  paid  for  medical  services 
in  a  single  case  will  be  received  by  Dr.  J.  N.  McCor- 
mack  of  Bowling  Green  for  his  attendance  upon  Wil- 
liam Goebel,  of  Kentucky,  after  the  latter  was  shot  at 
Frankfort.  Arthur  Goebel,  brother  of  the  dead  gov- 
ernor, has  accepted  a  claim  against  the  estate  of 
Governor  Goebel  for  $i 0.000  for  Dr.  McCormack's 
ser\'ices.  It  is  said  that  Goebel's  life  was  prolonged 
by  Dr.  McCormack  until  the  legislature  could  meet 
and  elect  him  governor  of  the  State. 

Typhoid  Fever  in  Paris. — The  recently  published 
statistics  of  the  health  authorities  of  Paris  show  that 
typhoid  fever  prevails  in  an  almost  epidemic  form. 
There  were  recorded,  from  the  beginning  of  the  year 
to  August  13th,  thirty-one  hundred  and  forty-eight 
cases,  of  which  five  hundred  and  sixty-eight  re- 
sulted fatally.  This  is  a  considerable  increase  over 
the  records  of  previous  years.  Paris  is  never  free 
from  this  disease,  but  until  1898  the  number  of  cases 
for  the  corresponding  period  never  exceeded  seven 
hundred.  The  prevalence  and  spread  of  typhoid  fever 
are  attributed  entirely  to  bad  water.  One  of  the 
sources  from  which  Paris  is  furnished  is  known  to  be 
contaminated  with  the  typhoid  bacillus,  though  the 
water  from  all  the  others  is  comparatively  innocuous. 
The  authorities  say  they  are  obliged  to  furnish  the 
bad  water  with  the  good  owing  to  the  inadequacy  of 
the  supply,  and  the  only  remedy  they  suggest  is  that 


the   inhabitants   boil   all  the   water  they  use,  or  else 
drink  only  natural  mineral  waters. 

Prizes  for  Charitable  Institutions  and  Health 
Boards. — The  Department  of  Social  Economy  at  the 
Paris  Exposition  embraces  a  great  variety  of  exhibits, 
including  labor  unions,  charitable  organizations,  health 
boards,  department  stores,  etc.  The  awards  in  this 
section  have  been  announced,  and  we  learn  that  grand 
prizes  have  been  bestowed  upon  the  following:  Tene- 
ment-House Committee,  Associated  Charities,  New 
York  City;  State  Board  of  Health,  Massachusetts; 
State  Bureau  of  Charities  and  Correction,  Albany; 
State  Bureau  of  Charities,  Massachusetts;  Lunacy 
Commission,  State  of  New  York,  Albany;  St.  John's 
Guild,  New  York  City;  Charity  Organization  Society, 
New  York  City;  Association  for  Improving  Condition 
of  the  Poor,  New  York  City;  and  the  Children's  Aid 
Society,  New  York  City.  Gold  medals  have  been 
awarded  to  the  New  York  City  Street-Cleaning  Depart- 
ment; the  Loomis  Sanitarium  ;  the  Bureaus  of  Charities 
of  Michigan,  California,  Illinois,  Indiana,  Ohio,  Penn- 
sylvania, Wisconsin;  the  Public  Charities  and  Chari- 
ties Association  of  Boston  ;  the  Lunacy  Commission  of 
Massachusetts;  the  Massachusetts  General  Hospital, 
Boston;  St.  Marj's  Hospital  for  Children,  New  York 
City;  Johns  Hopkins  Hospital,  Baltimore;  Pennsyl- 
vania Hospital,  Philadelphia;  Presbyterian  Hospital, 
New  York  City;  Boston  City  Hospital,  Boston;  Hos- 
pital for  Aged  and  Married  Couples,  Boston;  Institu- 
tion for  the  Assistance  of  Children,  Glenmills,  Pa.; 
Columbia  Institution  for  the  Deaf,  Washington,  D.  C. ; 
New  York  Institution  for  the  Deaf,  New  York  City; 
Society  for  the  Assistance  o'!  Children,  Boston;  Five 
Points  House  of  Industry,  New  York  City;  Society 
for  Prevention  of  Cruelty  to  Children,  Brooklyn; 
State  Charities  Aid  Association,  New  York  City; 
Mount  Sinai  Hospital,  New  York  City,  and  the  Asso- 
ciation for  Improving  Condition  of  Poor,  Brooklyn; 
public  baths,  New  York  City.  Also  to  the  boards  of 
health  of  Brookline,'  Mass.,  Cambridge,  Mass.,  Chi- 
cago. New  York  City,  Philadelphia,  Pittsburg,  Provi- 
dence, Boston  ;  and  the  State  boards  of  health  of  Cali- 
fornia, Illinois,  Michigan,  New  York,  Pennsylvania, 
Rhode  Island,  and  Vermont.  The  following  received 
silver  medals:  public  baths  of  Boston  and  Brookline, 
Mass.;  the  boards  of  health  of  Baltimore,  Buffalo, 
Charleston,  N.  C,  Cincinnati,  Cleveland,  Detroit, 
Milwaukee,  Minneapolis,  Newark,  New  Orleans.  St. 
Louis,  St.  Paul,  San  Francisco,  Washington,  D.  C, 
VV'orcester,  Mass.;  and  the  State  boards  of  health 
of  Connecticut,  Delaware,  Florida.  Indiana,  Iowa, 
Kansas,  Kentucky,  Maine,  Maryland,  Minnesota,  Mis- 
souri, New  Hampshire,  New  Jersey,  Ohio,  Oklahoma. 
South  Carolina,  Wisconsin.  A  bronze  medal  was  given 
to  Dr.  W.  B.  Atkinson. 

A  Cattle  Disease  in  Eastern  Pennsylvania An 

epidemic  prevails  among  the  cattle  in  Monroe  and 
Wayne  Counties,  Pa.,  and  SuUi'an  County,  N.  Y., 
which  is  causing  the  death  of  large  numbers  of  animals. 
The  chief  symptoms  are  colic,  prostration,  and  petech- 
ial hemorrhages  on  the  mucous  membranes,  followed 
by  death  in  from  a  few  hours  to  several  days. 


382 


MEDICAL    RECORD. 


[September  8,  1900 


Dr.  Edwin  Klebs,  who  was  for  several  years  pro- 
fessor of  patholog)-  in  the  Rush  Medical  College  and 
director  of  the  pathological  laboratory  in  the  Post-Grad- 
uate  Medical  School  of  Chicago,  has  resigned  these 
places  and  has  returned  to  Germany  to  reside  perma- 
nently. 

Sanitary  Barber  Shops — At  a  labor  meeting  on 
Sunday  last  it  was  announced  that  an  agitation  for 
antiseptic  barbers'  shops  is  to  be  started  by  the  walk- 
ing delegate  of  the  Journeymen  Barbers'  Union,  who 
is  now  engaged  in  a  fight  to  have  the  Sunday-closing 
law  observed  in  the  barbers'  shops. 

Congratulations  to  Major  Ross The  Section  of 

Bacteriology  of  the  International  Medical  Congress 
in  Paris  during  its  sessions  sent  a  telegram  to  Major 
Ronald  Ross,  of  the  Liverpool  School  of  Tropical 
Medicine,  extending  to  him  hearty  congratulations  upon 
his  discoveries  regarding  the  parasitology  of  malaria. 

The  Cholera  in  India. — A  despatch  from  Bombay 
states  that  official  returns  show  that  there  were  seventy- 
nine  hundred  and  sixty-nine  deaths  from  cholera  in 
the  native  and  British  states  during  the  week  ended 
August  25th.  The  number  of  relief  works  is  decreas- 
ing and  the  numbers  receiving  gratuitous  relief  are 
increasing. 

The  New  Jersey  State  Board  of  Health Gov- 
ernor Voorhees,  of  New  Jersey,  has  appointed  Mr. 
George  P.  Olcott,  of  East  Orange,  to  succeed  the  late 
Dr.  Gauntt,  of  Burlington,  as  a  member  of  the  State 
board  of  health.  The  other  members  of  the  board  are 
physicians.  It  was  their  ivish  to  have  associated  with 
them  a  sanitary  engineer,  and  Mr.  Olcott  fulfils  this 
requirement. 

The  Plague  in  Glasgow  seemed  at  the  beginning  of 
this  week  to  have  got  beyond  the  control  of  the  health 
authorities,  but  later  reports  have  been  less  disturbing. 
One  hundred  and  three  suspects  were  under  observa- 
tion on  September  4th,  and  the  disease  had  spread  to 
Govan,  a  suburb  on  the  left  bank  of  the  Clyde.  The 
number  of  cases  of  the  disease  thus  far  is  sixteen. 
It  has  not  been  officially  determined  how  the  disease 
gained  a  foothold  in  the  city,  but  it  is  not  improba- 
ble that  an  efficient  quarantine,  against  which  British 
trade  rages  so  furiously,  might  have  prevented  the 
invasion.  Denmark,  Belgium,  and  .\ustria-Hungary 
have  declared  a  quarantine  against  Glasgow,  and  the 
port  authorities  at  Liverpool,  Southampton,  and  else- 
where in  England  have  instituted  a  special  medical 
inspection  of  vessels  from  the  Clyde.  A  report  was 
current  on  Tuesday  that  two  cases  of  the  plague  had 
been  discovered  in  the  vicinity  of  the  London  Docks. 
But  the  medical  officer,  when  questioned  on  the  sub- 
ject, said  he  knew  nothing  about  the  matter.  A  case  of 
plague  has  been  officially  reported  at  Buenos  Ayres. 

A  Commission  for  the  Study  of  Dysentery  and 
Typhoid  Fever — Drs.  W.  J.  R.  Simpson,  of  London, 
J.  Lane  Notter,  of  Netley,  and  David  Bruce,  of  the 
British  army,  have  been  commissioned  by  the  British 
government  to  proceed  to  South  .Africa  and  inquire 
into  the   nature,  causation,  pathology,  and   modes  of 


prevention  ('more  particularly  as  affecting  armies  in 
the  field)  of  dysentery,  and  its  connection,  if  any,  with 
typhoid  fever.  Dr.  Simpson  is  professor  of  hygiene 
at  King's  College,  London;  Dr.  Xolter  is  professor  of 
military  hygiene  at  Xetley;  and  Surgeon-Major  Bruce 
is  well  known  for  his  discoveries  regarding  Malta 
fever  and  the  tsetse-fly  disease.  It  is  hoped  that  some- 
thing more  practical  than  usually  comes  from  such 
official  investigations  will  be  the  result  of  the  labors 
of  this  commission. 

The  Sick  and  Wounded  in  China. — A  despatch  to 
the  surgeon-general  from  Major  Perley,  surgeon  in 
charge  of  the  American  army  hospital  at  Taku,  states 
that  there  are  one  hundred  and  twenty  sick  at  Pekin 
and  two  hundred  at  Tien-Tsin,  many  only  slightly  ill. 
.\11  the  wounded  have  been  brought  from  the  front,  and 
the  hospital  ship  Re/ief\\\\\  take  the  more  severe  cases. 

The  American  Ambulance  Corps  in  China. — A 
Japanese  paper  says  that  "  the  American  ambulance 
corps  has  done  some  excellent  work.  Their  stretchers 
are  the  best  in  the  field  and  show  the  wonderful  in- 
ventive faculty  of  the  Americans.  The  handles  of 
these  stretchers  are  so  arranged  that  they  can  be 
formed  at  once  into  supports  by  a  clever  mechanical 
contrivance,  so  that  the  stretchers  can  be  used  as  beds 
or  benches  for  surgical  operations.  The  advantages 
of  this  system  cannot  be  too  much  commended,  for  on 
ground  so  swampy  and  hot  as  the  soil  of  Pe-Chi-Li 
the  wounded  men  cannot  safely  lie  long  pending  the 
treatment  on  the  spot;  and  this  inconvenience  is  re- 
moved by  the  American  invention.  Sixty  men  were 
thus  treated  directly  where  they  fell,  who  otherwise 
would  have  died.  The  Japanese  medical  staff  refer  to 
the  fact  in  most  praiseworthy  terms." 

State  Hospitals  for  Consumptives. — No  less  than 
twenty-two  sites  for  the  proposed  hospital  for  tubercu- 
losis have  been  inspected  by  the  committee  without 
a  decision  having  been  reached  as  to  the  most  desir- 
able location. 

Examination  for  Senior  Assistant  Physician  at 
the  Government  Hospital  for  the  Insane,  Washing- 
ton, D.  C. — 'J'he  United  States  Civil  Service  Commis- 
sion announces  that  on  October  23  and  24,  1900,  an  ex- 
amination will  be  held  in  any  city  in  the  United  States 
where  it  has  a  local  board  of  examiners,  for  the  posi- 
tion of  assistant  physician,  senior  grade.  Government 
Hospital  for  the  Insane,  Washington,  D.  C.  The 
examination  will  consist  of  the  subjects  mentioned 
below,  which  will  be  weighted  as  follows:  i,  letter 
writing,  5;  2,  anatomy  and  physiology,  5;  3,  general 
and  special  pathology,  20;  4,  obstetrics  and  gynaecol- 
ogy, 10;  s,  surgery,  10;  6,  chemistry,  materia  medica, 
and  therapeutics,  10;  7,  bacteriology  and  hygiene,  15; 
8,  mental  diseases,  25.  It  is  desired  that  applicants 
shall  have  had  at  least  five  years'  actual  experience  in 
a  hospital  or  institution  for  treatment  of  the  insane. 
The  age  limit  is  tw^enty  years  or  over.  The  salary  of 
the  senior  physician  is  Si, 200  per  annum.  This 
examination  is  open  to  all  citizens  of  the  United 
States  who  are  graduates  of  reputable  medical  col- 
leges and  who  comply  with  the   requirements.     Per- 


September  8,  1900] 


MEDICAL    RECORD. 


383 


sons  who  desire  to  compete  should  apply  to  the  United 
States  Civil  Service  Commission,  Washington,  D.  C, 
for  application  forms  304  and  375. 

A  French  Hospital  Ship  in  China. — The  French 
Red  Cross  Societ)'  has  decided  not  to  send  any  ambu- 
lances with  the  French  troops  to  China,  and  has  con- 
fined its  energies  to  the  equipment  and  sending  out 
of  the  hospital  ship  Notre  Dame  de  Saint,  which  left 
France  for  China  on  August  loth.  The  medical  staff 
of  the  ship  consists  of  nine  surgeons,  two  apothecaries, 
and- twelve  hospital  orderlies.  Three  of  the  surgeons 
and  ten  of  the  nurses  belong  to  the  French  nav}-.  The 
vessel  has  accommodations  for  three  hundred  patients. 
The  amount  raised  by  the  Red  Cross  Society  for  the 
equipment  and  maintenance  of  the  vessel  was  upward 
of  1,000,000  francs. 

The  Clarence  Barker  Memorial  Hospital,  which 
was  erected  at  liiltniore,  N.  C,  in  memory  of  Clarence 
Barker  by  his  sisters,  was  formally  opened  on  Tues- 
day of  this  week.  A  fund  has  been  started  for  a 
permanent  endowment  of  the  hospital. 

Navy  Department,  Bureau  of  Medicine  and  Sur- 
gery, Washington,  D.  C. — Changes  in  the  medical 
corps  of  the  United  States  navy  for  the  week  ending 
September  1,  1900.  August  30th. — Medical  Inspector 
P.  M.  Rixey  commissioned  medical  inspector  from 
August  24,  1900.  Surgeon  G.  T.  Smith  commissioned 
surgeon  from  August  24,  igoo.  Passed  Assistant  Sur- 
geon A.  M.  D.  McCormick  detached  from  the  C/ikago 
and  ordered  to  the  Montgomery.  Assistant  Surgeon 
J.  R.  Whiting  detached  from  the  Montgomery  and 
ordered  to  the  Chicago.  August  27th. — Passed  As- 
sistant Surgeon  M.  R.  Pigott  ordered  to  the  Naval 
Academy  immediately.  Assistant  Surgeon  C.  A.  Craw- 
ford detached  from  the  Chesapeake  and  ordered  to  the 
Eagle.  August  30th. — Passed  Assistant  Surgeon  L. 
W.  Spratling  detaclied  from  the  naval  hospital,  Yo- 
kohama, Japan,  upon  reporting  of  relief,  and  ordered 
to  report  to  the  commander-in-chief  of  the  Asiatic 
station  for  such  duty  as  may  be  assigned.  Assistant 
Surgeon  F.  L.  Benton  detached  from  the  naval  hos- 
pital, Cavite,  P.  I.,  and  ordered  to  the  naval  hospital, 
Yokohama,  Japan,  for  duty. 

Mrs.  Fannie  Lamar  Rankin  has  been  chosen  as 
delegate  from  Georgia  to  the  annual  convention  of 
wholesale  druggists  to  meet  in  Chicago  September 
iSth.  This  is  the  second  time  that  she  has  been 
selected  for  this  duty. 

Promotion  for  British  Acting  Assistant  Sur- 
geons.— It  is  announced  that  the  civilian  surgeons  at 
present  serving  with  the  troops  in  South  Africa  are  to 
be  offered  commissions  in  the  Royal  Army  Medical 
Corps,  by  which  means  it  is  hoped  to  fill  some,  at  any 
rate,  of  the  numerous  vacancies  in  that  discredited 
service.  It  is  questionable  whether  the  vacancies  can 
be  filled  even  by  giving  the  positions  away  without  e.\- 
amination,  and  it  is  certain  that  the  prestige  of  the 
service  will  not  be  enhanced  by  introducing  possibly 
unfit  men. 


Another  Great  Question  Settled. — The  Interna- 
tional Congress  of  Animal  Protection  Societies  was 
held  in  Paris  in  July.  On  the  fourth  and  last  dav  of 
this  congress,  July  21st,  there  was  a  debate  on  the  sub- 
ject of  vivisection.  Almost  all  the  societies  represented 
opposed,  to  a  certain  e.\tent,  the  practice  of  vivisec- 
tion, and  were  willing  to  vote  in  favor  of  restrictive 
laws  tending  to  diminish  and  control  experiments  on 
living  animals.  But  the  antivivisectionist  societies 
were  in  the  majority,  and  a  resolution  was  passed  after 
an  acrimonious  debate  affirming  that  "  vivisection  is 
a  crime,  unwortiiy  of  the  toleration  of  any  people  call- 
ing themselves  civilized."  The  New  York  State  Anti- 
vivisection  Society  was  represented  at  the  congress  by 
a  Boston  man. 

Obituary  Notes.  —  Dr.  James  Stovghton,  surgeon 
United  States  navy,  was  drowned  on  August  5th  in  the 
harbor  of  Shanghai.  He  was  returning  to  the  United 
States  steamer  Castine\d.\.<i  in  the  evening,  and  in  step- 
ping into  a  sampan  he  slipped  and  went  overboard. 
A  strong  ebb  tide  was  running,  and  he  was  swept  under 
some  junks.  The  officer  with  him  dived  after  him,  but 
without  success.  The  body  was  recovered  the  follow- 
ing morning,  and  was  buried  in  the  cemetery  there. 

Dr.  Easton  Burchard,  assistant  surgeon  United 
States  army,  died  of  dysentery  on  September  2d  on  the 
transport  Grant  at  Nagasaki.  He  was  born  at  Bon- 
net's Mill,  Mo.,  on  March  29,  1865.  He  was  gradu- 
ated from  the  Kentucky  School  of  Medicine  in  Louis- 
ville in  the  class  of  1886,  and  practised  for  several 
years  in  Kansas  City.  He  entered  the  army  as  assist- 
ant surgeon  of  the  Fifth  Missouri  Volunteers  on  May 
4,  1898,  and  was  appointed  first  lieutenant  and  assist- 
ant surgeon  in  the  Fortieth  Infantry  on  August  17, 
'899-  

QDliituai'ij. 

WILLIAM    SPENCi:R    WARD,    M.D., 

NKWANK,    N     J. 

Dr.  VVilliam  Spencer  Ward,  who  died  at  the  home 
of  his  son  in  Newark  on  September  ist,  was  born 
in  Bloomfield,  N.  J.,  on  July  13,  1821.  He  was  the 
son  of  Dr.  Eleazar  Dodd  Ward.  The  father  prac- 
tised medicine  in  Bloomfield  for  a  period  of  fifty  years, 
and  his  son  had  been  in  active  practice  for  nearly  the 
same  length  of  time.  He  entered  Princeton  College 
in  1838,  and  was  graduated  in  184 1.  For  five  or  six 
years  after  graduation  he  was  classical  and  mathemati- 
cal preceptor  in  the  Bloomfield  Academy,  and  after- 
ward in  Montclair.  During  the  latter  portion  of  this 
time  he  commenced  the  study  of  medicine,  with  his 
father  as  preceptor,  and  entered  the  College  of 
Physicians  and  Surgeons,  in  New  York,  in  1847.  t)^" 
ing  graduated  from  it  in  the  class  of  1S49.  He  began 
his  career  as  a  physician  in  Newark  in  August  of  his 
graduation  year,  and  lived  there  continuously  in  active 
practice  up  to  about  two  years  ago.  During  the  Civil 
War  Dr.  Ward  was  in  the  government  service  as  an 
acting  surgeon,  and  was  stationed  at  the  Ward  Gen- 
eral Hospital,  in  Newark,  from  1863  to  1865.  He 
was  on  the  medical  staff  of  St.  Michael's  Hospital 
during  1877  and  1878,  and  from  1881  to  1S85  on 
that  of  St.  Barnabas'  Hospital.  He  was  also  attend- 
ing physician  to  the  Protestant  Foster  Home  for  over 
thirty  years. 


384 


MEDICAL    RECORD. 


[September  8.  igcxj 


^^rorji'css  of 


Itt^ctUcal 


s»cieuce. 


Boston  Mt-iiicti/  ixiiif  Siirgua/  Joitriia/,  August  jo,  iqoo. 

The  Injurious  Effects  of  Improperly  Constructed  School 
Chairs. — J.  S.  Stoiii;  s;iys  tliat  lateral  curvature  of  the  sjiiiie 
is  a  disease  originatinjj  almost  always  during  school  life. 
and  is  much  more  frequent  among  girls  than  among  boys. 
The  ordinary  type  of  lateral  curvature  is  that  of  the  writ- 
ing position.  In  Nuremburg  twice  as  many  incorrect  pos- 
tures jwere  found  among  |children  writing  the  oblique  as 
among  those  writing  the  vertical  script,  in  Munich  two  and 
a  half  times  as  many,  in  Fiirth  and  Wiirzburg  four  times 
as  many.  Tlie  chair  back  has  always  been  the  great  prob. 
lem.  There  are  two  essentials  to  a  proper  back.  In  the 
first  place,  the  shoulders  should  never  be  forced  forward, 
and  in  the  second,  the  physiological  anterior  lumbar  curve 
should  be  maintained.  It  has  been  found  a  matter  of  com- 
mercial value  to  provide  the  typewriter  with  an  adjustable 
automatic  spring  back  constructed  on  hygienic  principles.. 
Are  not  the  health  and  well-being  of  the  growing  children 
of  the  community  of  as  great  consequence  as  the  comfort 
of  the  tyjiewriters,  in  whom,  because  of  greater  age,  de- 
formities are  much  less  likely  to  occur?  No  attitude,  no 
matter  how  good  in  itself,  can  be  long  maintained  without 
fatigue.  Professor  Mille  has  devised  a  chair  to  allow  a 
change  of  distance,  to  allow  an  upright  and  a  reclining  po- 
sition, and  to  allow  for  some  changes  in  the  antero-poste- 
rior  curves  of  the  spine,  while  at  the  same  time  alwaj-s 
giving  a  firm  lumbar  support. 

Results  of  the  Operative  Treatment  of  Cancer  of  the  Breast. 

— Homer  Gage  says  that  although  the  results  are  by  no 
means  what  they  ought  to  and  might  be,  they  are  suffi- 
cient to  convince  him  that  in  the  thorough,  complete  re- 
moval of  the  cancerous  breast  we  have  a  means  of,  offering 
a  long  immunit)-  from  cancerous  infection  to  a  large  pro- 
portion of  the.se  patients,  and  a  considerable  hope  that  the 
immunity  maybe  permanent,  a  hope  which,  in  the  absence 
of  any  alternative,  is  so  strong  that  it  certainly  ought  not 
to  be  smothered  by  a  refusal  to  interfere.  '  To  have  reduced 
the  mortality  to  almost  nothing,  the  local  recurrences,  that 
is,  the  external  recurrences,  from  sixty-seven  per  cent,  to 
less  than  twenty  per  cent.,  and  to  have  increased  the  num- 
ber of  those  who  pass  the  three-year  limit  free  from  any  re- 
currence from  ten  per  cent,  and  fifteen  per  cent,  to  more 
than  forty  per  cent.,  would  seem  to  be  a  sufficient  justifica- 
tion for  the  operation.  But  it  must  be  remembered  that 
these  results  are  to  be  obtained  only  by  a  most  thorough 
and  extensive  operation,  and  it  is  fair  to  hope  that  if  such 
an  operation  can  be  performed  when  the  growth  is  discov- 
ered early,  while  the  external  manifestations  are  limited  to 
the  breast  itself,  even  better  results  may  be  expected. 

A  Case  of  Parovarian  Cyst  with  Twist  of  the  Pedicle  Oc- 
curring during  the  Fourth  Month  of  Pregnancy ;  Operation ; 
Recovery ;  Normal  Delivery  at  Term. — By  F.  B.  I^und. 

The  Surgeon  in  the  Nineteenth  Century. — By  Frederick 
Treves. 

The  Philadelphia  Medical  Journal,  Septetnber  i,  igoo. 

The  Etiology  of  Tropical  Dysentery. — Simon  Flexner  for- 
mulates the  following  conclusions  concerning  the  parasit- 
ology of  tropical  dysentery:  (i)  No  bacterial  species  yet 
described  as  the  cause  of  dy.sentery  has  an  especial  claim 
to  be  regarded  as  the  chief  micro-organism  concerned  in 
the  causation  of  the  disease.  (2)  It  is  unlikely  that  any 
bacterial  species  that  is  constantly  and  normally  present  in 
the  intestine  or  in  the  environs  of  man,  except  where  the 
disease  prevails  in  an  endemic  form,  can  be  regarded  as 
the  probable  cause  of  epidemic  dysentery.  (3)  The  rela- 
tions of  sporadic  to  epidemic  dysentery  are  so  remote  that 
it  is  improbable  that  the  two  diseases  are  produced  by  the 
same  organic  cause.  (4)  The  pathogenic  action  of  amceba 
coli  in  many  cases  of  tropical,  and  in  certain  examples  of 
sporadic,  dysentery  has  not  Ijeen  disproved  by  the  discov- 
ery of  amoeba;  in  the  normal  intestine  and  in  diseases  other 
than  dysentery.  While  amoeba  arc  commonly  present  and 
are  concerned  in  the  production  of  the  lesions  in  subacute 
and  chronic  dysentery,  they  h.ive  not  thus  far  been  shown 
to  be  equally  connected  with  the  acute  dysenteries  even  in 
the  tro])ics.  In  the  former  varieties,  bacterial  association 
probably  has  much  influence  upon  the  pathogenic  powers 
of  the  amrcbiE. 

On  the  Teaching  of  Pharmacology,  Materia  Medica,  and 
Therapeutics  in  Our  Medical  Schools.— By  John  J.  Abel. 

Comparative  Pathology  :  its  Relation  to  Biology  and  Med- 
icine.—  By  Theobald  Smitli. 

On  the  Practical  Clinical  Teaching  of  State  Medicine.  -By 
Wyalt  Johnston. 

The  Method  of  Teaching  Physiological  Chemistry.— By  R. 
H.  Chittenden. 


The  Master  of  Medicine  as   a   Teacher  of   Medicine.—  By 

Bayard  Holmes. 

The  Unit  System  of  Laboratory  Construction.— By  Charles 

S.  Mi  not. 

The  Teaching  of  Physiology. — By  William  Townsend  Por- 
ter. 

Methods  of  Teaching  Gynsecology.- By  Howard  A.  Kelly. 
Methods  of  Teaching  Hygien". — F^y  Victor  C.  Vaughan. 
The  Teaching  of  Anatomy. — By  William  Keiller. 
Teaching  Obstetrics. — By  J.  Whitridge  Williams. 
On  the  Teaching  of  Pathology.— By  J.  G.  Adami. 

Medical  Ncik's,  September  /,  iqoo. 

Differential  Diagnosis  of  Chronic  Rheumatism  —  J .  J 
Walsh  points  out  many  of  the  conditions  which  may  be 
and  are  confounded  with  chronic  rheumatism.  The  class 
to  which  the  name  really  belongs  shows  joint  lesions  which 
have  occurred  during  an  attack  of  rheumatism  and  persist 
even,  becoming  worse  by  reason  of  secondary  degenera- 
tive processes  extending  over  years.  Many  others  should 
be  called  cases  of  pseudo-chronic  rheumatism.  Flat-foot, 
writer's  cramp,  brachyalgia  from  carrying  loads,  umbrel- 
las, and  holding  up  heavy  skirts,  etc.,  are  forms  spoken 
of.  Traumatic  neuroses,  varico.se  veins,  meralgia  paraes- 
thetica, etc.,  are  some  of  the  conditions  the  writer  has 
found  being  treated  as  chronic  rheumatism. 

The  Essential  Conditions  for  Habitation  to  Develop  and 
Maintain  Healthful  Family  Existence. — Rosa  Engelmann 
makes  a  plea  for  the  detached  suburban  home  with  its 
wholesome  atmosphere  as  compared  with  even  the  model 
tenement  of  the  city.  No  parks,  public  baths,  or  play- 
grounds can  take  the  place  of  the  open  life  out  of  town. 
Rapid  and  cheap  transportation  is  one  of  the  crying  prob- 
lems of  the  day  and  should  be  made  a  political  issue  just 
as  much  as  are  sanitary  environment,  shorter  hours  of  la- 
bor, etc.  The  dwelling-places  of  the  poor  of  Chicago  are 
described  and  contrasted  with  what  might  be  offered  out- 
side the  city  and  its  slums. 

Gastroptosis  with  Special  Reference  to  a  New  Mechanical 
Support. — By  H.  W.  Lincoln. 

Improved  Technique  for  the  Cure  of  Ventral  Hernia. — By 
M.  M.  Johnson. 

The  Advances  in  Medicine. — By  Martin  M.  Kittell. 

Journal  of  the  American  Medical  Ass' n,  Sept.  /,  7900. 

The  Relation  of  Surgery  to  Diabetes. — C.  P.  Gildersleeve 
believes  that  in  aseptic  surgery  we  do  not  possess  the 
means  of  preventing  gangrene  after  operations  upon  dia- 
betic patients,  as  some  authors  teach.  Cases  are  cited. 
The  following  rules  are  observed  by  the  writer  .  (i)  He 
would  not  operate  on  any  patient  suffering  from  diabetes 
without  first  explaining  either  to  the  patient  or  some  one 
in  authority  the  possibilities  which  might  follow.  (2)  He 
w-ould  refuse  to  operate  on  an  elderly  diabetic  sttbject  for 
any  of  the  simple  affections,  such  as  benign  tumors,  etc., 
unless  there  was  some  special  reason  for  operating,  and  it 
is  certainly  a  good  rule  always  to  examine  the  urine  in  any 
case  of  gangrene  occurring  in  elderly  people.  (3)  In  the 
painful,  rapidly  spreading  gangrene  which  often  occurs  in 
these  cases,  and  which  is  bound  to  cause  death  if  left  alone, 
he  believes  in  prompt  and  high  aniputati(m.  As  a  rule,  he 
waits  until  a  line  of  demarcation  forms  ;  but  in  .some  cases, 
although  the  line  has  not  formed,  one  can  judge  fairly  well 
about  how  high  it  is  going  by  the  appearance,  and  in  such 
a  case  he  would  operate  before  the  line  had  actually  formed. 
Some  of  these  cases  are  inoperable  ;  there  may  be  com- 
plete gangrene  of  the  foot,  and  the  leg  maybe  in  good  con- 
dition. Again,  the  leg  may  be  indurated  and  boggy,  and 
this  condition  may  extend  as  high  as  the  knee  or  above  it, 
and  it  would  be  poor  judgment  to  operate  on  such  a  case. 
Another  class  of  cases  is  that  of  dry,  comparatively  painless 
gangrene  which  often  affects  the  toes.  These  cases  will 
often  run  their  course,  the  dead  parts  being  cast  off,  and 
as  a  rule  they  should  be  left  alone,  so  far  as  operations  are 
concerned. 

The  Physiological  Training  of  the  Feeble-Minded. — S.  J. 
Fort  reviews  the  history  of  American  institutions  and 
methods.  The  physiological  system  at  formulated  by 
Seguin  is  considered,  and  the  kindergarten  is  thought  to 
be  of  value.  There  seems  to  be  no  reason  to  doubt  the 
efficiency  of  physiological  training.  The  following  can  be 
urged  for  the  future;  (i)  The  State  owes  its  mental  de- 
fectives proper  care  and  training,  and  a  proper  considera- 
tion of  the  normal  and  subnormal  demands  life-guardian- 
ship of  those  unable  to  support  tliemselves  in  the  outside 
world  and  a  bond  on  the  ])art  of  the  well-to-do  tliat  pro- 
vision shall  be  made  for  tlie  support  of  their  feeble-minded 
progeny.  (2)  The  enormous  increase  in  the  number  of 
this  class  of  incompetents  urges  a  clo.ser  attention  to  tlie 
l^roper  enumeration  of  all  such  defectives  in  each  State. 


September  8,  1900] 


MEDICAL    RECORD. 


585 


their  registration  on  the  files  of  State  boards  of  health,  and 
penalizing  both  parties  to  a  marriage  contract  in  which 
one  is  known  to  be  feeble-minded. 

Fracture  of  the  Superior  Maxilla  in  a  Man  Seventy  Years 
Old,  with  Recovery. — V,  A.  Latham  finds  little  in  the  liter- 
ature relating  to  the  subject,  and  gives  cases  with  illustra- 
tions to  show  some  of  the  difficulties  in  treatment  and 
points  of  interest  to  the  general  as  well  as  to  the  dental 
surgeon. 

Pelvic  and  Nervous  Diseases.  The  Third  Element  in  Equa- 
tion between  Pelvic  and  Abdominal  Disease  in  Women  and 
Disturbance  in  the  Nervous  System.-  By  II.  A.  Tomlinsnii. 

The  Causal  Relation  Intra-Abdominal  Diseases  Bear  to 
Nervous  Disturbances  Recognized  by  Gynsecologlsts,  Ignored 
by  Neurologists. — Hy  Hi-nry  O.  Marty. 

Traumatisms  and  Malformations  of  the  l-'emale  Genital 
Apparatus,  and  their  Relation  to  Insanity. — By  George 
Henry  Noble. 

Pelvic  Disease  as  a  Factor  of  Cause  in  Insanity  of  Females 
and  Surgery  as  Factor  of  Cure. —  By  Eu;<cne  G.  Carpenter. 

Gall  Stones  and  Disease?  of  the  Gall  Bladder  and  Nervous 
Symptoms  Resulting  Therefrom.— By  Krhvin  Ricketis. 

Autointoxication  from  Defective  Menstruation. — By  Arthur 
W.  Jolinstone. 

Tubo-Ovarian  Adhesions — their  Reflexes. — By  A.  L.  Bea- 
han. 

.Vew   York  Medical  Journal,  September  /,  igoo. 

A  Case  of  Acute  Glaucoma  with  Sub-Hyaloid  Hemorrhage 
Supervening  upon  Unilocular  Retinitis  Albuminurica. — 1>. 
Webster  and  E.  S.  Thompson  report  the  case  of  a  man 
aged  fifty-six  years,  who  in  January  of  the  current  year 
began  to  have  difficulty  in  seeing  with  his  left  eye.  He 
was  treated  for  "cold"  without  benefit.  Three  months 
later  his  eye  began  to  swell,  and  an  oculist  found  all  tlic 
symptoms  of  acute  glaucoma.  Myotics  failed  to  give 
relief,  and  as  the  tension  of  the  eyeball  threatened  perma- 
nent loss  of  sight,  iridectomy  upward  was  done  under  co- 
caine and  suprarenal  extract.  Immediately  after  the  ex- 
cision of  the  iris  the  whole  pupillary  area  was  obscured  by 
blood,  which  also  spread  itself  over  the  anterior  surface  of 
the  iris.  He  remained  in  the  hospital  a  period  of  eighteen 
days,  during  which  he  had  treatment  with  a  view  to  get- 
ting rid  of  the  blood  in  the  anterior  chamber,  but  without 
effect.  The  hemorrhages  were  renewed  as  fast  as  the 
blood  was  absorbed,  and  the  anterior  chamber  was  always 
from  a  quarter  to  half  full  of  blood.  His  urine  was  exam- 
ined and  found  to  be  loaded  with  alljumin  and  with  casts 
of  various  kinds.  His  diet  was  regulated  accordingly,  and 
he  was  treated  locally  and  internally,  but  still  unsuccess- 
fully. Two  weeks  later,  inasmuch  as  all  perception  of 
light  was  lost,  and  the  eye  remained  painful  and  inflamed, 
enucleation  was  performed.  Some  bleeding  followed  a  few 
hours  after  the  operation,  but  was  controlled  by  pressure. 
He  was  discharged  in  about  ten  days  with  the  orbital  cav- 
ity in  good  condition  and  the  other  eye  unaffected. 

Fibroid   Tumors  of  the  Uterus  Complicating  Pregnancy.^ 

L.  S.  McMurtry  gives  a  brief  review  of  this  condition,  dis- 
cussing the  various  problems  which  it  presents.  The  clin- 
ical history  is  recorded  of  a  case  occurring  in  a  woman  aged 
thirty-four  years,  who  gave  the  evidence  of  a  pregnancy  of 
five  months'  duration  except  that  the  enlargement  of  the 
abdomen  corresponded  to  the  eighth  month.  Jluch  dithculty 
was  experienced  in  emptying  the  bladder  and  rectum. 
Vaginal  examination  showed  the  entire  pelvic  basin  to  be 
packed  with  a  hard  mass  ;  the  cervix  could  not  be  felt ;  the 
tumor  when  examined  tlirough  the  abdomen  was  soft  and 
yielding,  almost  to  the  impression  of  fluctuation  ;  diagnosis, 
pregnancy  with  fibromyomata  in  pelvis,  displacing  uterus 
upward.  A  hysteromyomectomy  was  done,  the  mass  being 
amputated  from  the  cervi.x  at  the  vaginal  junction,  the  cer- 
vical stump  stitched  and  dropped,  and  the  peritoneum 
closed  over  it  and  across  the  pelvic  floor  by  continuous  cat- 
gut suture.  The  abdomen  was  closed  in  the  usual  way 
without  drainage.  P>.  five-months'  fcxtus  was  removed 
from  the  uterus.  There  was  an  uninterrupted  recovery, 
the  patient  returning  home  from  the  hospital  in  four  weeks. 

Atrophic  Rhinitis.— J.  E.  Logan  reviews  the  various  theo- 
ries which  have  been  put  forth  to  explain  this  condition. 
He  is  personally  inclined  to  attach  much  value  to  the  views 
of  Michel  and  Griinwald,  who  attribute  to  accessory-sinus 
disease  the  principal  etiological  rdle  in  the  affection,  espe- 
cially suppuration  of  the  ethmoid  cells.  Illustrative  cases 
are  given. 

Report  of  a  Case  of  Nephrectomy  for  Ascending  Tubercu- 
losis, with  Some  Remarks  on  Cystoscopy  and  Catherization 
of  the  Ureters  in  Women. — By  H.  N.  Vineberg. 

The  Treatment  of  Tuberculous  and  Purulent  Joints  with 
Large-Glass-Speculum  Drainage  and  Pure  Carbolic  Acid  :  with 
a  Report  of  Seventy  Cases. — By  A.  M.  Phelps. 


The  Lancet.  August .?/.  igoo. 

The  Cellular  Pathology  of  To-Day.— J.  Burdon-Sanderson 
says  that  the  word  "cellular  "  has  now  a  wider  signification 
than  when  it  was  first  introduced  into  pathological  nomen- 
clature, for  it  comprises  not  merely  histological  changes, 
but  the  chemical  reactions  which  subsist  between  the  cell 
and  its  environment.  Formerly. we  regarded  each  kind  of 
cell  as  having  a  single  special  function  proper  to  itself,  but 
the  progress  of  investigation  has  taught  us  that  each  spe- 
cies of  cell  possesses  a  great  variety  of  chemical  functions 
and  that  it  may  act  on  the  medium  which  it  inhabits  and 
be  acted  upon  by  it  in  a  variety  of  ways.  Thus,  for  exam- 
ple, we  think  of  the  colorless  corpu.scles  of  the  blood  (or, 
as  we  now  call  them,  leucocytes)  not  merely  as  agents  in 
the  process  of  suppuration  or  as  typical  examples  of  con- 
tractile protoplasm,  but  rather  as  living  structures  possess- 
ing chemical  functions  indispensable  to  tlie  life  of  the 
organisn\.  Similarly  we  have  come  to  regard  the  blood 
disc,  which  formerly  we  thought  of  merely  as  a  carrier  of 
hajmoglobin,  as  a  living  cell  possessed  of  chemical  suscep- 
tibilities which  render  it  the  most  delicate  reagent  we  can 
employ  for  the  detection  of  abnormal  conditions  in  the 
blood. 

Diphtheria  in  the  Horse. — From  one  case  coming  under 
observation,  L.  Cobbctt  is  led  to  believe  that  it  is  perfectly 
possible  for  the  horse  to  suffer  from  nasal  and  laryngeal 
diphtheria.  This  fact  is  of  importance  because  it  shows 
another  possible  channel  of  contagion  to  man,  and  because 
it  has  a  direct  bearing  on  the  origin  of  antitoxin.  It  has 
been  shown  that  the  serum  of  a  horse  which  has  never  been 
immunized  with  the  diphtiieria  bacillus  or  its  products 
often  has  the  power  of  neutralizing  the  di])htheria  toxin. 
The  fact  that  all  horses  do  not  possess  this  natural  anti- 
toxin is  doubtless  to  be  explained  by  the  fact  that  it  is 
present  only  in  those  who  have  accidentally  contracted  the 
disease. 

The  Microscopic  Appearance  of  the  Motor  Ganglion  Cells 
in  Five  Cases  of  Peripheral  Neuritis. — The  exciting  cause  of 
the  neuritis  in  the  cases  reported  by  W.  K.  Hunter  was 
alcoholism  in  four  and  chronic  interstitial  nephritis  in  the 
fifth,  a  man  who  had  previously  suffered  from  lead  palsy. 
In  general  the  changes  consisted  in  a  granular  degenera- 
tion with  more  or  less  fatty  material,  giving  when  faint 
the  impression  of  a  mere  yellow  stain.  In  some  instances 
the  granular  contents  of  the  cells  had  almost  entirely  dis- 
appeared, leaving  the  cells  "ghost-like,"  and  in  many  the 
nucleus  was  peripheral.  Colloid  degeneration  was  fre- 
quently present  in  tlie  coats  of  the  vessels. 

Notes  on  One  Hundred  Cases  of  Enteric  Fever  Treated  at 
the  Military  Hospital  at  Naauwpoort,  South  Africa. — The 
point  of  special  interest  in  the  article  by  Derwent  Parker 
is  in  reference  to  the  value  of  anti-typhoid  inoculation. 
The  general  mortality  was  about  ten  per  cent.  It  was  2.3 
per  cent,  lower  among  the  inoculated  cases  than  among 
the  cases  uninoculated.  The  average  temperature  in  the 
first  group  was  nearly  a  degree  lower,  but  about  five  and  a 
half  days  elapsed  before  it  finally  became  normal.  All  the 
inoculations  were  recent,  none  being  more  than  six  months 
old. 

The  Increase  and  Distribution  of  Cancer  in  Eastern  Essex. 
—  By  G.  M.  Scott. 

The  Pathology  and   Therapeutics  of  Scurvy. — By   A.    E. 
Wright. 
The  Pathogeny  of  Gout. — By  Dyce  Duckworth. 
Eye  Disease  in  Egypt. — By  K.  Scott. 

MiincluJier  iiu-ilicinisclie  H'oc/iensc/iri/t.  August  14,  /goo. 

Furring  of  the  Tongue  in  Health  and  Disease. — J.  M  filler 
believes  that  the  coated  tongue  so  often  observed  in  per- 
fectly healthy  individuals  is  largely  due  to  excessive  pro- 
liferation of  the  hairlike  appendages  of  the  filiform  papillae 
rather  than  to  any  extraneous  deposit.  Some  persons  have 
a  greater  tendency  to  this  overgrowth  than  others,  and  it 
is  found  less  frequently  with  advancing  years.  In  disease 
it  is  not  to  be  regarded  as  an  indication  of  the  condition  of 
the  alimentary  tract  as  popularly  supposed,  though  it  is 
nearly  always  present  in  acute  diseases,  whether  involving 
the  digestive  system  or  not.  In  chronic  ca.ses  it  is  not 
nearly  so  constant,  being  often  absent  even  in  chronic  gas- 
tritis. On  examination  of  the  deposit  from  a  large  number 
of  cases  it  was  found  that  there  was  no  appreciable  varia- 
tion in  character  in  different  diseases,  and  that  the  average 
proportions  of  epithelial  cells,  bacteria,  mould,  portions  of 
food,  and  leucocytes  in  the  mixture  were  fairly  constant. 
In  two  diseases,  however,  viz.,  pulmonary  tuberculosis 
and  gastric  carcinoma,  the  number  of  leucocytes  is  uni- 
formly so  large  as  to  be  a  characteristic  sign.  The  causes 
for  the  formation  of  this  deposit  are  numerous.  The  me- 
chanical element  is  of  importance,  for  most  patients  are 
taking  greatly  decreased  amounts  of  nourishment  or  sub- 
sisting largely  on  fluids,  so  that  the  normal  scouring  of  the 


386 


MEDICAL    RECORD. 


[September  8,  1900 


tongue  through  mastication  and  deglutition  is  interfered 
with.  In  many  diseases  there  are  increased  formation  and 
death  of  epithelial  cells  as  a  result  of  local  congestion  and 
serous  infiltration — in  fact,  a  desquamative  catarrh  which 
contributes  largely  to  the  coating.  Changes  in  the  bacte- 
rial flora  of  the  mouth,  as  well  as  reflex  nutritive  and  vaso- 
motor impulses,  also  play  their  part,  and,  lastly,  individual 
idiosyncrasies  and  the  predisposition  to  increased  growth 
and  size  of  the  filiform  papiihe  must  be  taken  into  account. 

The  Suture  of  Arteries  (Conclusion). — R.  Seggel  is  of 
the  opinion  that  in  view  of  improvements  in  technique  and 
the  favorable  results  obtained  in  what  is  now  a  large  num- 
ber of  cases,  the  ligature  of  large  vessels  after  injury 
should  not  be  resorted  to  until  after  an  attempt  at  suture 
has  failed.  This  is  especially  the  case  in  wounds  of  the 
carotids,  when,  if  the  artery  be  tied,  everything  depends 
on  the  almost  instant  establishment  of  a  collateral  circula- 
tion, with  the  result  that  the  death  rate  is  thirty-one  per 
cent.,  the  fatal  termination  being  nearly  always  referable 
to  the  disturbance  of  the  cerebral  circulation.  It  is  much 
wiser  to  clamp  temporarily  the  vessel  above  and  below. 
and  close  the  wound  by  means  of  fine  sutures  of  silk,  or  if 
necessary  a  portion  may  be  resected  and  one  cut  end  in- 
vaginated  into  the  other  according  to  the  method  of  Mur- 
phy. In  a  case  of  attempted  suicide  which  involved  a 
good-sized  transverse  wound  of  the  carotid,  the  author  su- 
tured the  artery  with  three  fine  silk  sutures,  piercing  the 
adventitia  and  media  but  not  touching  the  intima.  The 
wound  was  packed  and  the  patient  made  an  uneventful 
recovery. 

Treatment  of  a  Typical  Case  of  Pachydermia  Laryngis 
with  Salicylic  Acid. — J.  Fein  reports  remarkably  good  re- 
sults m  the  treatment  of  this  refractory  condition  b\'  means 
of  twenty-per-cent.  alcoholic  solutions  of  salicylic  acid.  In 
the  case  cited  the  immediate  relief  to  the  subjective  symp- 
toms was  very  gratifying,  and  after  the  treatment  had 
been  continued  for  several  months  the  local  appearances 
had  so  far  approached  the  normal  as  to  obliterate  all  the 
diagnostic  features.  A  year  later  the  patient  returned  to 
be  treated  for  another  trouble,  when  it  was  found  that  the 
laryngeal  picture  was  still  the  same  as  at  the  last  observa- 
tion. 

The  Indications  for  Surgical  Interference  in  Extra-uterine 
Pregnancy  (Conclusion). — By  L.  Prochownik. 

A  Case  of  Echinococcus  of  the  Liver  with  Rupture  into 
the  Gall  Passages.— By  W.  Althaus. 

The  Establishment  of  Sanatoria  for  Tuberculous  Children. 
—By  A.  Baginsky. 

A  Case  of  Foreign  Body  in  the  Left  Bronchus. — By  Hecker. 

Deutsche  nieiiiiiiiisi/ie  W'ochcnschrift ,   August  i6.    /goo. 

A  Case  of  Gastric  Carcinoma  with  Unusual  Symptoms, 
and  a  Contribution  to  the  Question  of  (Esophageal  Atony. — 
R.  Schiitz's  patient,  a  woman  aged  seventy-Hve  years, 
gave  a  history  of  cachexia  and  emaciation  with  dysphagia, 
and  the  feeling  that  food  was  arrested  at  the  lower  end  of 
the  oesophagus.  During  the  entire  illness  no  vomiting  oc- 
curred, and  no  resistance  was  offered  to  the  passage  of 
oesophageal  bougies.  The  necropsy  revealed  a  pyloric 
cancer  which  had  so  far  invaded  the  neighboring  tissues 
as  to  have  transformed  the  stomach  into  a  thick-walled 
rigid  tube  about  six  inches  in  length,  and  which  was  held 
in  a  perfectly  perpendicular  position  by  peritoneal  adhe- 
sions. It  is  to  this  extensive  structural  change  that  the 
absence  of  the  usual  si.gns  of  dilatation  is  to  be  ascribed, 
while  an  increase  in  the  lumen  of  the  cesophagus  just 
above  the  cardia  had  undoubtedly  served  to  receive  a  por- 
tion of  the  food  for  which  there  was  no  room  in  the  verv 
contracted  stoniacli.  inducing  a  secondary  atrophy, 

A  Group  of  Clinically  and  Etiologically  Related  Cases  of 
Chronic  Disease  of  the  Upper  Air  Passages. — E.  Neisser  and 
Kahiiert  report  five  cases  of  disease  of  the  upper  respira'- 
tory  passages,  of  which  the  most  striking  feature  was  the 
essentially  chronic  course  and  the  tendency  to  remissions 
in  summer.  In  several  of  these  the  trouble  seemed  to  be 
secondary  to  some  acute  di.sease.  The  mucosa  of  the  entire 
naso-pharynx,  of  the  pharynx  down  to  and  into  the  larynx, 
and  of  the  upper  jjortions  of  the  nose  is  affected,  present- 
ing atrophy  and  swelling  of  the  follicles  with  a  tendency 
to  the  copious  production  of  mucus  and  subsequent  desicca- 
tion and  formation  of  crusts.  Hoarseness  and  dryness  of 
the  throat  amounting  almost  to  pain  are  the  principal  sub- 
jective signs.  A  bacteriological  examination  of  the  secre- 
tion revealed  the  jiresence  of  almost  pure  cultures  of  organ- 
isms resembling  diphtheria  bacilli  in  every  particular. 
The  I)lood  of  the  i)ationts  was  also  found  to  be  rich  in 
diphtheria  antitoxin. 

The  Symptomatology  and  Diagnosis  of  Membranous  Co- 
litis.—By  I.  Boas. 

Is  Alcohol  a  Food  or  a  Poison? — By  Kassowitz. 


Betliiier  klinische   Wochensclnift ,  August  /j,  /goo. 

Charcot-Leyden  Crystals  and  Spermin  Crystals. — Benno 
Levy  contrasts  these  two  microscopic  crystal  forms,  which 
are  considered  identical  by  many  observers.  In  his  opin- 
ion they  are  entirely  independent  of  each  other  and  have 
nothing  in  common  except  a  superficial  resemblance  in 
form  which  vanishes  on  closer  study,  for  then  it  is  seen 
that  they  represent  different  groups,  the  one  belonging  to 
the  monoclinie  system  and  the  other  to  the  hexagonal. 
They  also  differ  in  their  reaction  to  iodine,  which  imparts 
a  characteristic  violet  hue  to  spermin  crystals,  but  not  the 
Charcot-Leyden  form.  The  former  are  highly  refracting, 
the  latter  weakly  so,  while  the  Charcot-Leyden  cry.stals 
have  a  very  important  relation  to  the  eosinophile  cells 
which  is  not  observed  with  the  spermin  crystals,  for,  ac- 
cording to  the  author,  whenever  the  eosinophiles  are  in- 
creased there  will  also  be  found  Charcot-Leyden  crystals, 
and,  on  the  other  hand,  the  presence  of  the  cry.stals  is 
always  an  indication  of  eosinophilia. 

The  Stomach  Pump  as  a  Peristaltic    Stimulant. — Oswald 

Ziemssen  has  had  recourse  to  lavage  with  excellent  results 
in  cases  of  obstinate  constipation.  Within  one-half  to  one 
hour  it  is  usual  for  the  procedure  to  be  followed  by  one  or 
more  pultaceous  stools,  while  it  frequently  happens  that 
after  a  short  course  of  treatment  patients  who  formerly 
suffered  from  the  most  obstinate  constipation  have  a  regu- 
lar morning  movement  before  the  tube  is  introduced.  The 
cure  is  usually  permanent,  no  cathartics  being  required 
even  after  years  have  passed.  The  operation  should  be 
conducted  as  follows  :  the  tube  is  introduced  into  the  empty 
stomach  and  one  to  two  pints  of  water  are  allowed  to  flow 
in  and  quickly  siphoned  out  again,  the  manojuvre  being  re- 
peated fifteen  or  twenty  times.  The  treatment  is  given 
every  day  and  the  amount  of  water  used  increased  at  each 
sitting.  It  is  important  that  the  washing  be  done  with  a 
0,6  per  cent,  salt  solution  and  not  with  plain  water. 

Blood-Pressure  Estimations  with  Gaertner's  Tonometer.— 
By  Schiile. 

Neuro-Fibromata  of  the  Posterior  Cerebral  Fossa. — By 
Monakow. 

The  Therapy  of  Impotentia  Virilis. — By  J.  Zabhidowski. 

French  Journals. 

Aspergillosis. — Louis  Renon  treats  of  this  affection  as  a 
primary  disease  attacking  the  lungs,  due  to  the  action  of 
the  aspergillus  fumigatus  upon  the  respiratory  tract.  He 
reviews  his  early  work  and  the  confirmation  it  has  received 
from  subsequent  observations.  At  the  present  time  all 
that  is  known  about  the  affection  as  a  primary  disease  can 
be  encompassed  in  the  following  conclusions :  (i)  Asper- 
gillosis is  a  spontaneous  disease  common  to  man  and  ani- 
mals. (2)  In  animals  it  attacks  mammifers  and  birds  :  it 
develops  in  eggs  in  incubation  and  may  contaminate  the 
embryos  contained  in  these  eggs.  (3)  In  man  it  develops 
upon  the  cornea  or  the  skin,  but  has  its  special  evolution  in 
the  respiratory  apparatus,  creating  pulmonary  mycoses 
resembling  tuberculosis  and  pulmonary  gangrene,  but 
without  the  fetid  odor.  It  may  coexist  with  tuberculosis. 
Occasionally  it  is  fatal  after  the  formation  of  cavities  in 
the  lungs.  It  may  invade  the  bronchial  apjiaratus  alone, 
causing  membranous  bronchitis,  of  special  form  and  of 
long  evolution.  (4)  In  the  etiology  and  pathogeny  of  this 
mycosis,  contamination  by  grain  plays  a  capital  r6ie,  those 
handling  various  grains  being  much  more  likely  to  be  af- 
fected than  others.  (5)  E.xperimentally  in  animals  the 
lesions  are  almost  always  pseudo-tuberculous,  and  at  times 
necrotic  and  ulcerative.  (6)  Primary  aspergillosis  is  rel- 
atively frequent.  It  is  distinctive  and  absolutely  specific. 
— Jomnal  ties  Prntic/'eus,  August  18,  igoo. 

The  Erythemas  of  Tuberculosis.— Paul  Raymond  consid- 
ers it  an  error  at  the  present  day  to  look  upon  erythemas 
as  morbid  entities.  They  are  only  the  external  evidences 
of  generalized  toxic  infections.  The  various  infectious 
processes  in  which  such  skin  lesions  appear  are  cited,  and 
the  latter  are  regarded  as  the  effect  of  the  products  of  se- 
cretion. In  tuberculosis  we  have  all  the  forms,  macular, 
papular,  nodose,  and  jjolymorphous.  Examples  from  prac- 
tice are  given.  Generalized  erythematous  lu[)us  is  for  the 
writer  only  the  outbreak  of  ])ersistent  tuberculous  ery- 
thema, as  are  also  ])laques  of  Cazenave's  lupus.  Transition 
forms  show  that  erythematous  lupus,  the  persistent  ery- 
thema of  tuberculosis,  may  be  set  down  against  the  eva- 
nescent forms  mentioned.  He  agrees  with  Malcolm  Mor- 
ris that  lupus  erythematosus  is  an  erythema,  and  should 
not  be  classed  with  cutaneous  tuberculosis;  it  is  an  ery- 
thema of  tul)erculous  es.sence.  Cazenave's  lupus  should 
be  described  as  a  variety  of  erythema  in  tuberculosis  and 
placed  in  the  large  class  of  tuberculous  erythrodermias. — 
Le  /'rogres  .Medicnl.  August  iS,  i<)oo. 

Treatment  of  Hepatic  Colic— A.  Mesnard  gives  a  n'sumi 
of  modern  treatment,  and  concludes  that  the  best  plan  to 


September  8,  1900] 


MEDICAL    RECORD. 


387 


pursue  is,  first  of  all,  to  inject  morphine  from  a  solution  con- 
taining atropine,  then  to  cover  the  painful  region  with  a 
large  hot  poultice  sprinkled  with  laudanum,  then  to  give 
iSoOr  200  gm.  of  anisetted  olive  oil,  or  in  case  of  repug- 
nance two  soupspoonfuls  of  pure  glycerin.  If  the  crisis  is 
beginning,  admi nister  six  capsules  of  amyl-valerianic ether, 
two  at  a  time  at  three-hour  intervals.  If  the  crisis  is  es- 
tablished, from  time  to  time  a  soupspoonful  of  chloroform 
water  should  be  given.  For  persistent  vomiting  give  ice 
pills,  champagne  frappe ;  and  as  alimentation  iced  milk, 
vichy,  lemonade  with  seltzer,  cold  consomme,  all  in  small 
and  frequent  doses.  No  purgatives  should  be  given  and 
no  baths  taken  during  the  crisis.— /.<z  Presie  Medicalc, 
August  18,  igoo. 

American  /ournal  of  the  Meiitcal  Sciences.   Sep/.,  /goo. 

A  Case  of  Ligature  of  the  Abdominal  Aorta  Just  Below 
the  Diaphragm. — \V.  W.  Keen  operated  upon  a  man  for  rup- 
tured aneurism.  The  patient  survived  forty-eight  hours. 
The  author  gives  a  resume  oi  all  the  recorded  cases  of  li- 
gation of  the  aorta,  including  one  by  Tillau.K,  done  since 
his  own.  lie  proposes  an  instrument  for  the  treatment  of 
aneurisms  of  the  abdominal  aorta  by  temporary  compres- 
sion, and  describes  one  which  avoids  all  danger  of  i)res- 
sure  on  the  thoracic  duct,  and  requires  only  the  opening  of 
the  abdomen  and  its  application  to  the  vessel.  It  is  possi- 
ble that  the  patient  might  not  have  to  be  ana;sthetized  dur- 
ing the  entire  sitting.  Very  possibly,  when  the  aorta  has 
been  occluded,  the  amcsthetic  might  be  withheld  and  re- 
newed only  when  the  instrument  has  to  be  withdrawn. 
With  the  modern  antiseptic  methods  he  believes  it  would 
be  possible  to  retain  the  instrument  in  position  for  two  or 
three  days,  and  reapply  the  pressure  at  any  time,  remov- 
ing the  instrument  entirely  when  the  attempt  has  either 
been  successful  or  would  be  best  abandoned.  The  author 
describes  experiments  upon  animals  with  the  instruments 
just  described. 

Idiopathic  Dilatation  of  the  (Esophagus. — Max  Einhorn  by 
this  term  means  those  conditions  in  which  there  is  dilata- 
tion of  the  oesophagus  without  any  mechanical  obstacle 
within  or  outside  of  the  oesophageal  walls  or  cardia.  He 
describes  ten  cases  seen  by  him,  and  refers  to  two  seen 
previously.  The  condition  may  be  the  result  of  paralysis 
(or  atony)  of  the  oesophagus,  spasmodic  contraction  of  the 
cardia,  or  a  lack  in  the  rcHex  relaxation  or  opening  of  the 
cardia  during  the  act  of  swallowing.  It  will  be  diagnosti- 
cated when  dysphagia  of  long  standing  exists,  the  swal- 
lowing sound  is  found  absent,  no  organic  stricture  is  en- 
countered, and  the  oesophagus  is  found  partly  filled  with 
unaltered  food.  Prognosis  is  good  as  to  life,  but  bad  as 
regards  complete  recovery.  Treatment  should  consist 
of  liquid,  semi-liquid,  and  solid  foods  rich  in  nutriment. 
After  each  meal  the  patient  should  perform  exercises  com- 
pressing the  chest  after  deep  insitirations  for  a  few  minutes  ; 
this  forces  the  food  down.  The  (esophagus  should  be 
emptied  and  washed  by  means  of  a  tube  every  evening. 
Bromides,  iron,  and  arsenic  may  be  of  benefit. 

Myositis  Ossificans. — Lydia  M.  DeWitt  reports  two  cases 
of  this  comparatively  rare  disease.  Miinchmeyer  has  de- 
scribed it  as  a  constitutional  affection  of  slow  course  with 
periodical  exacerbations.  There  is  first  infiltration  of  the 
intermuscular  connective  tissue,  then  a  stage  of  connective- 
tissue  induration,  and  finally  ossification,  which  begins  in 
the  centre  of  the  affected  mu.scle,  in  the  connective-tissue 
ground  substance.  The  disease  usually  begins  in  the 
neck  and  back  muscles,  spreading  and  producing  ever  in- 
creasing deformity.  The  etiology  is  very  obscure.  Cold, 
unsanitary  surroundings,  trauma,  and  irritation  have  all 
been  held  to  be  exciting  causes,  but  these  are  often  so 
slight  and  trivial  that  they  cannot  be  sufficient  to  produce 
the  disease  in  a  normal  individual.  Virchow  believes  in 
an  o.isifying  i)redisposition  in  these  individuals  :  others 
ascribe  it  to  a  congenital,  not  hereditary  predisposition. 
Maunz  suggests  a  disturbance  of  embryonic  development. 
Brennsohu  and  others  suggest  the  idea  that  the  di-sease  is 
due  to  atavistic  influence.  The  author  gives  reasons  for 
non-belief  in  these  various  hypotheses. 

Granular  Degeneration  of  the   Erythrocytes,  and   its  Sig- 
nificance in  Clinical  Pathology. —  By  Ernst  (Jrawitz. 
Sarcoma  of  the  Small  Intestine.— By  E.  Libman. 

7  lie  Journal  of  7  ropical  Medicine,  Auj^iist,  igoo. 

Cerebro-Spinal  Fever  on  an  Emigrant  Ship.— C.  P.  Lucas 
forwards  an  extract  from  a  report  by  the  immigration 
agent-general,  dated  May  i6,  1900.  There  were  six  deaths 
on  the  ship  Clyde,  due  chiefly  to  cerebro-spinal  fever. 
There  was  nothing  in  the  weather,  so  far  as  the  surgeon 
could  see,  to  cause  the  disease.  There  was  not  the  slight- 
est evidence  of  contagion.  There  was  no  relationship  or 
communication  between  the  people  affected,  and  as  soon 
as  a  case  was  discovered  it  was  isolated  in  the  hospital, 
and  the  place  previously  occupied  disinfected  with  perchlo- 


ride  solution.  There  was  no  sanitary  defect  on  the  Clyde, 
which  was  well  ventilated,  not  overcrowded,  and  was 
cleaned  and  disinfected  daily.  Treatment  in  this  disease 
is  discouraging.  If  ice  could  be  had  it  would  do  much 
good,  aijplietl  to  the  head.  In  treating  the  symptoms  bro- 
mide of  potassium  in  large  doses  and  morphine  hypo- 
dermically  afford  most  relief.  In  reference  to  the  ques- 
tion of  ice,  in  iSSO  the  surgeon-superintendent  of  the  ship 
.-///£v;j'/;<jri;' expressed  the  following  opinion  in  connection 
with  an  epidemic  of  cerebro-spinal  fever  which  occurred 
during  a  voyage,  with  a  result  of  ten  deaths  :  "One  of  the 
modern  small,  inexpensive  ice  machines  would  probably 
have  saved  several  lives." 

Bilateral  Typhoid  Gangrene. — M.  T.  Sarr,  writing  from 
Bloemfonlein.  says  thai  there  has  been  a  case  in  the  hospi- 
tal due  to  enteric  fever.  As  only  eight  cases  of  this  disease 
from  this  cause  are  on  record,  he  describes  it  in  full.  The 
patient  was  a  weakly  man,  aged  twenty-three  years,  whose 
fever  ran  a  moderate  course.  Convalescence  appeared  to 
be  established  when  he  began  to  be  troubled  with  cold  feet. 
On  examination,  the  right  lower  extremity  was  found  to 
be  of  corpse-like  cf)ldness  up  the  junction  of  the  middle  and 
lower  third  of  the  thigh,  without  the  slightest  pulsation  in 
any  part ;  the  left  lower  extremity  was  cold  as  high  as  the 
middle  of  the  leg:  a  feeble  pulsation  could  be  felt  in  the 
femoral  artery  down  to  Scarpa's  angle,  none  in  Hunter's 
canal  or  below.  Operation  was  out  of  the  question,  as  it 
was  evident  that  the  blood  clot  extended  far  into  the  right 
external  iliac  artery.  The  patient  died  about  four  days 
after  the  onset  of  the  gangrene.  At  the  autopsy  the  right 
femoral  artery  was  found  filled  with  blood  clot,  which  ex- 
tended up  the  external  and  common  iliac  to  the  aorta :  the 
left  was  filled  with  clot  uj)  to  within  an  inch  of  Poupart's 
ligament ;  no  sign  of  endarteritis  could  be  detected,  but 
the  case  was  evidently  thrombosis,  not  embolism. 

A  Contribution  on  the  Question  of  Yaws  and  Syphilis. — 
A.  B.  iJuprey  luilds  that  yaws  is  not  a  form  of  syphilis,  and 
has  nothing  in  common  with  it.  When  calm  judgment  and 
a  critical  professional  mind  are  brought  to  bear  on  the  sub- 
ject, there  is  no  reason  at  all  why  the  malady,  however 
horrible  it  may  appear  to  the  sight,  should  be  thought  con- 
tagious. Mistakes  do  occur,  especially  with  papular  yaws, 
but  under  the  lens  the  pajiulcs  are  seen  to  be  different  in 
apjiearance  from  those  of  syphilis.  The  author  suggests 
that  the  cause  of  yaws,  as  the  disease  is  known  in  the 
West  Indies,  is  the  abuse  of  a  mango  diet.  Arsenic  is  the 
drug  whieii  answers  best   in   the  tieatnient  of  this  disease. 

Upon  the  Part  Played  by  Mosquitos  in  the  Propagation  of 
Malaria   iContinuedi.  —  By  ("leorge  H.  F.  Xuttall. 

On  Peculiar  Conditions  of  the  Hair. — By  Irving  P.  Lyon. 

Goundou  or  Anakhre   iGros  Nez). — By  John  C.  Graham 

Notes  from  Lagos,  West  Africa.— By  Henry  Strahan. 

Camp  Fevers. — By  Filippo  Rho. 

Pinta. — By  James  Cran. 

Zciischrifl  J.  'I uberkulose  u.  Heilstdlten'U'esen.July,  igoo. 

The  Early  Diagnosis  of  Tuberculosis. — S.  A.  Knopf  writes 
an  interesting  article  under  this  heading,  and  discusses 
l)riefly  the  various  means  at  hand  for  early  recognition  o£ 
the  disease.  The  bacteriological  examination  of  the  spu- 
tum when  it  gives  positive  results  is  conclusive,  but  it  is 
precisely  in  the  early  cases  in  which  the  expectoration  is 
scanty  that  it  is  hardest  to  find  the  bacilli ;  the  tuberculin 
reaction  is  unreliable  and  not  free  from  risk,  the  fluoroscope 
as  yet  is  not  able  to  reveal  anything  not  appreciable  to  the 
educated  ear.  and  the  latest  aid,  the  agglutination  reaction 
of  Arloing  and  Courmont,  gives  far  too  contradictory  re- 
sults to  be  relied  on  ;  so  that  it  is  still  the  physical  exam- 
ination that  must  bear  the  crux  of  the  diagnosis.  The 
author  considers  the  various  predisposing  factors,  the 
jjoints  of  importance  in  the  history,  and  finally  calls  atten- 
tion to  several  comparatively  little-known  physical  signs 
which  are  of  help  in  making  an  early  diagnosis. 

Syphilis  and  Tuberculosis. — Portucalis  draws  the  follow- 
ing conclusions  from  an  extended  period  of  clinical  obser- 
vation :  (I)  Sy])hilis  when  it  is  contracted  by  a  phthisical" 
patient  arrests  the  course  of  the  earlier  di.sease.  (2)  When 
contracted  by  a  patient  already  suffering  from  phthisis, 
syphilis  runs  a  mild  course.  (3)  The  antagonism  between 
the  microbes  of  these  two  diseases  produces  a  neutraliza- 
tion of  their  toxins.  (4)  When  the  microbe  of  syphilis  has 
been  discovered  and  its  cultivation  made  possible,  we  shall 
be  able  to  prepare  a  serum  with  which  consumptives  may 
be  inoculated  and  their  disease  arrested.  (5)  Inoculation 
with  the  blood  serum  of  syphilitics  in  the  third  stage  would 
be  of  great  advantage  to  consumptives. 

Education  in  the  Sanatorium. — In  Moeller's  opinion  the 
beneficial  results  of  sanatorium  treatment  are  entirely  due 
to  the  summation  of  many  minor  curative  measures,  each 
of  which  taken  by  itself  has  but  slight  effect,  but  combined 
with  others  may  be  productive  of  greatest   good.     This 


388 


MEDICAL    RECORD. 


[September  8,  1900 


means  that  the  patient  must  follow  implicitly  his  physi- 
cian's directions  to  the  minutest  detail,  and  involves  a  re- 
lationship of  absolute  trust  and  confidence  between  the 
two,  to  establish  which  should  be  the  physician's  first  aim. 
It  js  important  to  keep  the  patient  constantly  busy  doing 
nothing,  i.e.,  to  occupy  all  his  time  without  allowing  him 
any  definite  pursuit  which  might  tend  to  cause  excitement 
or  fatigue. 

The  Prevention  of  Infection  with  Tubercle  Bacilli  in 
Schools,  the  Public  Highways,  and  Railroad  Cars  (Conclu- 
sion!. — Mdsler's  article  is  a  plea  for  greater  care  in  the 
disposition  of  tlie  sputum  of  consumptives.  Experience 
has  shown  that  this  is  dangerous  only  when  allowed  to 
desiccate  and  be  diffused  tlirough  the  air  as  dust,  hence 
adequate  provision  should  be  made  in  all  jiublic  places  for 
its  reception  in  suitable  vessels  containing  water.  Rail- 
roads should  furnish  special  cars  for  the  transportation  of 
invalids,  and  these  should  not  l)e  allow^ed  to  make  use  of 
the  cars  in  general  use. 

Preliminary  Report  upon  the  Use  of  Palladium  Chloride 
(PdCU)  Internally  in  the  Treatment  of  Tuberculosis.— Co- 
hen reports  favorably  u])on  the  use  of  this  drug,  which  he 
was  led  to  investigate  on  account  of  its  great  affinity  for 
hydrogen  and  its  consequent  oxidizing  and  antiseptic 
power.  Patients  to  whom  it  was  administered  for  a  long 
period  improved  in  weight,  and  in  a  number  of  cases  there 
was  disappearance  of  the  fever  and  cough  with  physical 
signs  of  active  destruction  of  lung  tissue.  The  dose  for  an 
adult  is  gtt.  v.-x.  of  a  three-per-cent.  solution,  well  diluted. 

A  New  Diagnostic  Sign  in  Pulmonary  Tuberculosis. — Fer- 
ran  descrilies  a  saprophytic  form  of  the  tubercle  bacillus 
which  accompanies  its  growth  in  the  lungs  and  generates 
spermin  in  sufficient  quantities  to  be  recognizable  by  its 
characteristic  odor.  Experimenting  with  this,  he  has  found 
that  it  groW'S  best  in  the  serum  of  sheep  at  about  37'  C. 
The  presence  of  this  odor  in  cultures  made  from  sputum 
is  sufficient  to  confirm  a  diagnosis  of  pulmonar)-  tuber- 
culosis even  if  the  bacilli  themselves  cannot  be  found. 

Some  Remarks  on  the  Rest  and  Open-Air  Treatment  of 
Consumptives  (Conclusion) . — Dettweiler  sketches  briefly  the 
history  of  the  development  of  the  out-door  treatment  for  tu- 
berculous patients,  and  recapitulates  the  benefits  resulting 
from  it.  Properly  graduated  breathing  and  gymnastic  ex- 
ercises form  an  important  factor. 

The  Early  Diagnosis  of  Pulmonary  Tuberculosis. — Klynens 
and  Van  Bogaert  discuss  the  symptoms  and  signs  of  the 
early  stages  of  the  malady  and  the  various  other  aids  to 
diagnosis,  such  as  the  tuberculin  reaction,  the  Roentgen 
rays,  and  the  serum  reaction  of  Arloing  and  Courmont. 

Tuberculous  Gastric  Ulcer,  with  a  Case  of  Chronic  Ulcerative 
Tuberculosis  of  the  Stomach  with  Fatal  Perforation  Peri- 
tonitis.— By  Struppler. 


©ovvcspoudcucc. 

OUR   LONDON   LETTER. 

(From  our  Special  Correspondent.) 

PUBLIC  HEALTH — WAR  HOSPITALS  COMMISSION — THE  PRINXE'S 
CONVALESCENT  HOME — ECHOES  FROM  IPSWICH — DEATHS  OF 
SIR  WILLIAM  STOKES,  DRS.  SIMPSON,  O'CALLAGHAN,  AND 
ANDEKSON. 

London,  August  24,  1900. 

The  weather  has  not  settled  down  since  the  storms  I  men- 
tioned, so  we  did  not  get  a  share  of  your  hot  wave,  but 
have  had  some  fine  warm  days  with  the  proverbial  thun- 
der to  follow.  The  public  health  does  not  seem  to  have 
been  alTected  by  the  unsettled  meteorological  conditions. 
The  diseases  prevalent  are  those  of  our  summer  and  their 
incidence  is  about  the  same  as  the  average.  Tlie  mortality 
returns  include  a  death  from  glanders  at  Guy's  Hospital. 
It  is  a  year  since  the  last  death  from  this  cause  was  regis- 
tered. A  death  also  is  registered  from  typhus — the  first 
of  the  kind  since  February,  1899.  Two  deaths  are  also  re- 
corded from  ana;sthetics.  making  twenty  of  these  fatalities 
this  year.  The  London  death  rate  has  crept  up  to  20.5; 
that  of  the  provincial  towns  is  20.2.  The  increased  rate  is 
largely  due  to  zymotic  diseases. 

The  commission  on  the  war  hospitals  has  arrived  in  South 
Africa,  and  already  has  begun  to  take  evidence,  notes  of 
which  reach  us  by  telegraph.  Professor  Dunlop  told  them 
that  the  soldiers  in  the  Wynberg  hospital  were  as  well 
treated  as  his  own  patients  in  the  Glasgow  Royal  Infirma- 
ry. He  was  perfectly  satisfied  with  the  arrangements,  but 
said  there  was  too  much  red  tape.  Professor  Chiene,  who 
has  inspected  all  the  military  hospitals  during  his  stay  in 
Soutli  Africa,  also  expressed  satisfaction  with  everything. 


especially  in  the  Natal  hospitals,  which  were  almost  per- 
fect. Generally  the  evidence  shows  a  lack  of  complaints. 
Professor  Chiene  has  made  a  proposal  for  the  creation  of  an 
imperial  medical  reserve,  consisting  of  one  thousand  sur- 
geons with  a  due  complement  of  nurses  and  other  officials. 
He  thinks  hundreds  now  in  South  Africa  would  be  glad  to 
join  such  a  reserve  and  bind  themselves  to  serve  whenever 
or  wherever  wanted,  without  pay. 

The  invalided  officers  who  are  enjoying  their  sojourn  in 
the  convalescent  home  established  at  Sandringham  by  the 
Prince  and  Princess  of  Wales  have  much  to  be  thankful 
for.  They  drive  about  in  the  royal  wagonettes  and  dog- 
carts, play  billiards  on  the  prince's  table,  or  repose  in 
comfortable  lounge-chairs  in  the  smoking-room.  The 
home  was  specially  established  for  colonial  officers,  and 
before  leaving  for  the  continent  the  prince  and  princess 
personally  satisfied  themselves  that  every  comfort  was 
provided. 

The  lime  limit  is  an  important  element  in  considering 
papers  for  such  assemblies  as  the  British  Medical's  annual 
outing.  Discussions  of  a  light  nature  pass  off  easily 
enough,  but  others  are  apt  either  to  bore  or  empty  the  room. 
A  man  should  not  attempt  to  do  more  than  make  a  short 
communication  and  one  that  can  easily  be  grasped  on  hear- 
ing it  read.  Illustrations  of  this  have  been  given  me  by 
those  who  attended  different  sections.  Thus  Dr.  Stacey 
Watson's  paper  was  too  long  and  too  intricate  to  secure 
proper  attention.  He  had  fifteen  minutes  and  required 
probably  forty-five.  He  had  to  sit  down  after  furnishing 
his  facts  and  compressing  them  into  an  impossibly  small 
space.  In  some  otherpapers  elaborate  statistics  were  sub- 
mitted, a  consideration  of  w-hich  restricted  to  a  few  min- 
utes might  perhaps  "prove  anything." 

Much  regret  and  some  disgust  have  been  expressed  to  me 
at  the  attack  on  Professor  Cushny's  paper  by  Dr.  Barr.  It 
is  certain  that  the  professor  would  not  resent  fair  criticism, 
but  anytliing  like  acrimony  should  be  eschewed,  especially 
toward'  a  visitor  who  had  honored  the  as.sociation  by  his 
presence  and  by  submitting  his  paper.  Xot  improbably 
the  paper  will  re'ceive  the  more  attention  when  it  is  pub- 
lished in  full. 

The  report  on  scientific  grants  called  forth  a  little  criti- 
cism as  to  their  distribution.  One  member  moved  that 
these  grants  be  di.scontinued,  and  the  money  be  devoted  to 
prizes  for  work  already  done.  As  the  motion  found  no 
seconder,  it  may  be  presumed  the  meeting  was  satisfied 
with  the  present  plan.  A  distribution  of  prizes  for  work 
done  does  not  offer  an  ideal  method  of  encouraging  re- 
search or  securing  impartiality. 

Prof.  Walter  Smith  in  presiding  over  the  therapeutical 
section  took  the  opportitnity  of  denouncing  the  rubbish  ad- 
vertised among  new  drugs  and  preparations,  "used  chiefly 
by  those  who  do  not  know  how  to  employ  the  old  ones." 
Each  new-comer  is  soon  elbowed  out  b)'  a  fresh  arrival. 
He  protested  against  the  manner  and  matter  of  the  adver- 
tisements that  appear  in  our  journals,  and  thfeir  plausible 
pretence  of  original  work  and  offers  of  "full  literature." 
But  these  find  their  way  to  the  waste-paper  basket.  He 
further  objected  to  the  visits  of  agents  of  drug  firms  as  a 
growing  practice  "which  should  be  stamped  out  by  the 
profession."  Many  will  applaud  him  for  this,  but  more 
will  probably  still  be  ready  to  receive  the  canvassers.  I 
do  not  object  to  advertisements  of  drugs  in  the  journals, 
but  there  are  too  many  other  announcements  which  de- 
grade our  periodicals. 

The  death  of  Sir  William  Stokes  was  announced  on  Mon- 
day as  having  taken  place  on  Saturday  at  Pietermaritz- 
burg.  He  went  out  as  consulting  surgeon  to  our  forces, 
and  was  chiefly  at  work  in  Natal,  where  for  six  months  his 
services  have  been  greatly  ap])reciated.  He  was  one  of 
the  most  distinguished  Dublin  surgeons,  surgeon  to  the 
Queen  in  Ireland,  ami  has  for  many  years  held  a  leading 
position.  In  1S61  he  was  awarded  the  gold  medal  of  the 
Pathological  Society  and  three  years  later  was  appointed 
surgeim  to  the  Meath  Hospital.  In  due  time  he  presided 
over  the  society  which  in  earlier  days  gave  him  the  gold 
medal.  As  president  of  the  Dublin  College  of  Surgeons  he 
had  a  hapjjy  time  in  the  Queen's  jubilee  year,  1SS7.  He 
was  the  son  of  the  eminent  physician,  William  Stokes, 
whose  name  you  will  remember  in  connection  with  his 
work  on  diseases  of  the  chest.  Other  members  of  the  fam- 
ily have  also  achieved  distinction  in  medicine,  literature, 
and  science.  The  late  Sir  William  Stokes  was  jirofessor 
of  surgery  at  the  College  of  Surgeons,  Dublin,  for  some 
thirty  years.  His  pupils  are  scattered  over  the  world,  and 
all  will  feel  on  hearing  of  his  deatli  that  an  able  exiiouciit 
of  their  art  and  an  upright  gentleman  has  passed  away. 

Dr.  P.  .\.  Simpson,  emeritus  profes.sor  of  forensic  med- 
icine in  Glasgow  University,  died  on  the  nth  inst.,  aged 
sixty-three  years. 

Surgeon-General  D.  J.  O'Cullaghan  died  on  the  12th, 
aged  eighty-five  years. 

Dr.  John  Anderson,  who  died  on  the  15th,  did  not  prac- 
tise medicine  but  devoted  himself  to  natural  history.     He 


September  8,  1900] 


MEDICAL    RECORD. 


389 


was  professor  in  Edinburgh  and  also  in  India.  He  was 
employed  in  %'arious  scientific  expeditions,  his  report  on 
that  to  Western  China,  published  in  1S71  by  the  Indian 
government,  being  especially  valuable.  '  He  retired  from 
the  Indian  service  in  1877.  He  was  M.D..  LL.D.,  and 
F.R.S.  Edin.,  and  received  various  other  honors. 


LETTER    FROM    KASHMIR. 

(From  our  Special  Correspondent.) 

PREVALE  DISEASES — SANITARY      IMPROVEMENTS — MEDICAL 

INSTITUTIONS — SURGICAL   WORK. 

Kashmir.  July  15,  1900. 
Kashmir  is  on  the  whole  wonderfully  free  from  sickness 
dependent  on  climate.  Great  tracts  of  the  country  lie  per- 
manently under  water  and  many  large  areas  are  exposed 
to  annual  floods.  During  the  summer  months  the  valley 
is  little  more  than  an  alluvial  plain  covered  with  rice  fields 
and  swamps.  Mosquitos  abound  ;  and  yet,  owing  to  the 
altitude,  malarial  disease  is  quite  rare.  The  Kashmiris 
hardly  sutler  from  it  at  all.  Diseases  of  the  eye  are,  how- 
ever, very  numerous,  especially  ophthalmia  and  entropion. 
Cataract  is  much  less  common  than  in  the  plains.  Diseases 
of  the  skin,  especially  those  which  are  parasitic,  simply 
abound.  Scabies,  for  instance,  is  universal.  Digestive 
affections  are  extremely  common  and  are  often  due  to  the 
great  excess  of  starch  consumed  in  a  diet  which  consists  so 
largely  of  rice.  Dilated  stomach  is  of  frequent  occurrence. 
In  the  winter,  respiratory  complaints,  especially  bronchi- 
tis, abound,  and  rheumatism  is  very  prevalent.  There  is 
a  fairly  representative  series  of  the  general  diseases  with 
which  we  meet  in  America  or  Europe.  But  the  variety  is 
more  limited,  and  some  affections  are  conspicuous  by  their 
absence,  t'..?".,  scarlet  fever  and  diphtheria.  Phthisis  is 
comparatively  rare  and  chiefly  confined  to  those,  such  as 
shawl  weavers,  who  lead  indoor  lives,  in  impure  atmos- 
phere. Pneumonia  and  pleurisy  are  seldom  met  with  ; 
rickets  is  rare. 

During  the  recent  appalling  distress  from  famine  and 
plague  in  India,  Kashmir  has  escaped  untouched.  The 
cultivation  is  carried  on  chiefly  by  irrigation,  and  owing  to 
the  proximity  of  the  snow  mountains  the  water  supply  is 
abundant.  Our  immunity  from  plague  is  partly  due  to 
distance.  Should  the  Punjab  become  generally  affected, 
Kashmir  will  be  in  great  danger.  The  filthiness  of  the 
city  of  Grinagar  is  notorious.  Twice  recently  we  have 
been  visited  by  epidemicsof  cholera,  viz..  in  18SS  and  1892. 
Each  time  the  mortality  e.xceeded  ten  thousand.  The  soil 
of  the  city  and  in  the  villages  is  sodden  with  the  accumu- 
lated filth  of  ages,  to  which  fresh  additions  are  being  made 
daily.     Enteric  fever  is  very  common. 

After  the  last  cholera  epidemic  a  most  important  sanitary 
improvement  was  effected  in  the  introduction  of  a  new  and 
abundant  supply  of  pure  water,  brought  in  pipes  from  a 
neighboring  mountain  stream.  Among  other  improve- 
ments may  be  mentioned  the  construction  of  a  large  num- 
ber of  public  latrines,  a  systematic  attempt  to  remove  filth 
from  the  city,  the  levelling  and  metalling  of  many  roads, 
and  efforts  to  control  cow-houses,  slaughter-houses,  and 
offensive  trades.  An  attempt  has  been  made  to  do  syste- 
matic vaccination.  A  good  deal  has  been  done,  but  more 
efficient  control  of  the  public  vaccinators  and  of  the  calf- 
lymph  stations  is  urgently  required. 

There  are  five  medical  institutions  in  Kashmir.  Of 
these,  the  oldest  is  the  Kashmir  Mission  Hospital.  This 
contains  one  hundred  and  twenty  beds  and  draws  patients 
not  only  from  the  valley  of  Kashmir  but  from  all  the  dis- 
tricts around,  Poonch,  Kishtiwar,  Ladakh,  and  Baltistan. 
The  total  number  of  out-patient  visits  last  year  was  41,628. 
The  state  leper  hospital  with  ninety  beds  is  also  under 
the  superintendence  of  the  mission  surgeons.  The  other 
three  hospitals  are  the  state  hospital,  the  Diamond  Jubi- 
lee hospital  for  women,  and  a  small  hospital  for  the  for- 
eign community.  In  several  of  the  larger  towns  and  vil- 
lages there  are  state  dispensaries. 

It  is  astonishing  to  how  large  an  extent  out-patient  prac- 
tice in  Kashmir  is  surgical.  And  the  proportion  of  surgi- 
cal patients  requiring  operative  treatment  is  equally  sur-, 
prising.  Last  year,  in  the  Kashmir  mission  hospital  4, 146 
operations  were  performed.  Of  these  856  were  for  entro- 
pion, 240  for  pterygium,  93  for  cataract,  and  250  for  bone 
disease;  304  tumors  were  excised  (including  2  ovarioto- 
mies). There  were  29  cases  of  epitheliomata  of  the  thigh 
and  15  of  the  abdominal  wall.  Those  which  are  due  to 
burns  and  subsequent  irritation  from  the  heat  of  the  por- 
table brazier  (kangri),  which  the  people  carry  under 
their  clothes  in  the  winter,  are  in  the  early  stages  abso- 
lutely curable.  They  are  often  of  slow  growth,  but  sooner 
or  later  the  lymph  glands  become  affected.  The  case 
then  assumes  a  much  more  serious  aspect.  The  imme- 
diate risk  from  operation  is  small    (of    more  than  three 


hundred  operations  for  epithelioma  performed  by  Drs. 
Arthur  and  Ernest  Neve  since  1S90,  only  one  proved  fatal). 
Experience  has  shown  that  it  is  inadvisable  to  do  very 
sweeping  operations  when  the  glands  are  extensively  in- 
volved or  the  skin  over  them  is  brawny. 

A  very  cheap  dressing  is  used  in  the  Mission  Hospital, 
consisting  of  muslin  bags  of  various  shapes  and  sizes  filled 
with  cedar  sawdust.  Before  use  these  are  sterilized  by 
heat.  Usually  a  deep  dressing  of  Lister's  double  cyanide 
gauze  is  placed  underneath  each  bag.  The  economy 
effected  in  a  large  hospital  by  the  u.se  of  these  bags  instead 
of  expensive  medicated  cotton  wool  is  astonishing. 


THE    SOLDIER     IN     THE    TROPICS. 

To  THE  Editor  of  the  NIedical  Record. 

Sir;  Not  long  ago  I  had  the  privilege  of  stating  in  your  col- 
umns my  views  regarding  the  acclimation  of  the  white 
man  in  the  tropics.  I  adhere  to  what  I  said  and  indorse 
every  word  uttered  by  Capt.  Charles  E.  Woodruff,  M.D.. 
in  a  recent  paper  on  "Medicine  in  the  Tropics."  It  is 
true  that  the  white  man  can  live  in  the  tropics  if  he  is  able 
to  surround  himself  with  many  precautions;  but  that  is 
not  the  kind  of  life  characteristic  of  the  white  man  and  ex- 
pected of  him  ;  that  is,  not  being  acclimated,  he  vegetates 
and  his  offspring  will  be  degenerates.  If  that  is  true  of 
the  white  man  in  general  and  of  the  colonist  especially,  it 
is  much  more  true,  and  necessarily  so,  of  the  soldier, 
whose  calling  imposes  on  him  extraordinary  hardships  and 
exertions;  and  there  will  always  be  a  great  distinction  to 
be  made  between  the  soldier  in  garrison  and  in  campaign. 
The  three  points  to  be  considered  in  making  life  possible 
in  the  tropics  are  feeding,  clothing,  and  housing. 

About  housing  not  much  need  be  said.  In  garrison  suit- 
able barracks  will  be  provided  for,  and  in  campaign  the 
soldier  must  take  it  as  it  is.  Tents  will  be  quite  neces- 
sary. 

With  regard  to  clothing  I  wish  to  say  that  cases  of  sun- 
stroke are  of  rare  occurrence  among  the  people  of  tropical 
countries,  because  they  are  not  foolish  enough  to  walk  in 
the  hot  sunshine,  to  use  tight  clothing,  to  wear  heavy  cov- 
ering for  the  head,  or  to  carry  weights  which  oppress  the 
chest.  The  commanders  of  troops  are  responsible  for  neg- 
lect of  these  points.  We  all  know  that  soldiers,  when  they 
have  to  march  or  to  fight  in  the  hot  sunshine,  gradually 
throw  away  everything  that  oppresses  them,  such  as  knap- 
sacks and  coats  ;  and  they  would  soon  throw  off  their  caps 
or  helmets  if  they  were  able  to  get  straw  hats  instead. 
The  tropical  helmet  may  be  very  good,  but  I  think  that 
straw  hats  would  be  most  welcome  to  the  soldier  in  cam- 
paign during  the  hot  season  or  in  hot  countries.  There 
must  come  a  day  when  the  question  will  be  not  so  much 
how  pretty  the  soldier  looks  as  how  he  feels  and  how  far 
he  is  able  to  do  his  duty.  Heat  weakens  man  by  excessive 
perspiration,  loss  of  appetite,  and  loss  of  sleep ;  but  it  is 
my  belief  that  the  most  dangerous  hours  of  the  day  in  the 
tropics  are  not  the  hottest  ones,  but  the  early  hours  in  the 
morning  before  the  sun  rises,  when  the  air  is  often  decid- 
edly chilly.  How  many  Mexicans  have  I  seen  travelling 
without  any  other  protection  against  the  lower  morning 
temperature  than  a  silk  handkerchief  wrapped  round  the 
neck !  Abdominal  bandages  are  not  necessary,  and  the 
men  will  soon  throw  them  away. 

Finally  comes  the  most  important  item  of  feeding.  Lately 
there  has  been  much  said  and  written  on  this  subject,  and 
a  "soldier's  ideal  ration  "has  been  invented  and,  I  am  told, 
has  already  proven  a  failure.  Suppose  now  that  the  home 
ration  of  the  United  States  soldier  were  all  right,  when  the 
troops  are  sent  to  the  tropics  some  change  may  be  convenient 
in  regard  to  quality,  not  to  quantity.  If  the  soldier  is  fur- 
nished something  he  will  not  eat  and  is  expected  to  sell 
part  of  it  and  buy  something  he  will  eat,  that  is  not  the 
so-called  "ideal  ration."  Besides,  even  if  that  expedient 
is  admissible  in  garrison,  it  becomes  at  once  impossible  in 
campaign. 

The  .soldier  in  the  tropics  ought  to  have  more  fat  than  at 
home,  perhaps  a  trifle  less  meat,  and  some  alcohol.  So  far 
as  the  latter  is  concerned,  I  should  prefer  wine  to  whiskey, 
and  much  more  so  if  the  men  can  be  prevailed  upon  to 
take  their  share  of  wine  mixed  half  and  half  with  water. 
It  is  shocking  to  all  foreigners  to  see  what  quantities  of 
fat  Mexicans  eat  with  their  meals. 

For  the  soldier  in  campaign  we  cannot  rely  upon  fresh 
provisions.  We  must  furnish  the  men  with  food  easily 
transportable,  not  too  voluminous,  palatable,  and  quickly 
made  eatable.  If  the  men  are  tired,  they  will  do  as  the 
horses  do — drink  and  lie  down  and  sleep  rather  than  eat 
or  wait  for  their  food  to  be  cooked. 

We  must,  to  a  certain  extent,  rely  on  canned  things. 
The  use  of  canned  beef  is  necessarily  limited,  as  the  men 
soon  get  tired  of  it,  and  salt  dry  pork  or  beef  will  be  found 


39° 


MEDICAL    RECORD. 


[September  8,  1900 


more  acceptable.  1  wonder  why  dry  cheese  is  not  more  ex- 
tensively used,  if  it  is  true  that  272  gm.  of  cheese  are  equiv- 
alent to  iiS  gm.  of  albumen,  and  if  1.160  gm.  of  cheese 
represent  31S  gm.  of  carbon  I  I  believe  that  for  expedi- 
tions of  a  few  days  soldiers  will  be  satisfied  if  they  get 
ham.  cheese,  hardtack,  .some  alcohol,  and  coffee. 

Now,  as  to  quantities.  A  man  who  is  doing  heavy 
work,  such  as  a  .soldier  during  a  campaign,  ought  to  have 
somewhat  more  than  when  he  is  at  home  and  in  garrison. 
The  white  soldier  in  the  tropics,  as  long  as  he  is  in 
good  health,  will  not  eat  noticeably  less  than  he  does  in 
his  native  country.  The  war  ratio  required  for  the  Ger- 
man troops  in  France  was:  Bread  750  gm.,  meat  500  gm.. 
bacon  250  gm.,  coffee  30  gm.,  tobacco  60  gm.  (or  five 
cigars),  wine  500  gm.  (or  beer  i.ooo  gm.,  or  brandy  200 
gm.).  Dr.  Semeleder.  . 

Cordoba,  State  of  Vera  Cri'z,  Mexico, 
August,  1900. 


was  begun  seven  years  earlier.  To  Leopold  belongs  the 
credit  of  having  in  recent  years  emphasized  the  possibility 
of  avoiding  vaginal  infection  by  a  thorough  carrying  out 
of  abdominal  examination  of  pregnant  and  parturient 
women  to  the  large  exclusion  of  vaginal  touch,  certainly 
a  great  merit,  but  in  no  wise  original. 

But  to  Richardson,  Chadwick.  and  myself,  I  think,  be- 
longs the  credit  of  having  first  written  up  and  popularized 
the  method  of  external  examination  of  pregnant  and  par- 
turient women  for  an  English-speaking  public,  and  of 
these  articles  mine  alone  can  lay  claim  to  comj)leteness,  as 
it  was  exhaustive  and  covered  the  whole  subject,  while  the 
others  were  only  short  papers.  Of  course.  I  do  not  impute 
to  Dr.  Smyly  any  intention  in  omitting  our  names,  and  I 
am  sure  he  would  gladly  rectify  the  omission  were  it  still 
in  his  power  to  do  so.  I  trust,  Mr.  Editor,  that  you  will 
pardon  my  tran.sgressing  so  greatly  on  your  valuable  space 
for  a  personal  matter.  Paul  F.  Munue.  M.D. 

Hotel  New  Frontenac,  Thousand   Islands, 
August  27,  igoo. 


EXTERNAL  ABDOMINAL  EXAMINATIONS 
DURING  PREGNANCY  AND  LABOR. 

To  THE  Editok  of  the  IMedical  Record. 

Sir:  I  notice  in  the  very  interesting  "Address  in  Obstet- 
rics, "  by  Dr.  William  F.  Smyly,  delivered  before  the  Brit- 
ish Medical  Association  at  its  recent  meeting,  and  reported 
in  the  Medical  Record  for  August  25,  on  page  310,  a 
statement  which  I  consider  unjust  and  to  which  I  desire  to 
take  exception. 

The  report  says :  "  Next  to  antiseptics,  the  author  con- 
sidered the  substitution  of  external  for  internal  examina- 
tions the  most  important  advance  in  modern  midwifery. 
By  whom  it  was  introduced  he  did  not  know,  but  its  sys- 
tematization  and  popularity  were  owed  to  Pinard,  Crede, 
and  Leopold  "  ;  and  then  the  report  goes  on  to  give  the  now- 
well-known  advantages  and  uses  of  external  abdominal 
manipulations  and  examinations  during  pregnancy  and 
labor. 

Now,  Mr.  Editor,  I  do  not  care  so  much  for  the  point 
of  original  priority  in  this  matter,  tor  I  personally  have  no 
such  claim  to  make  regarding  the  discovery  and  systema- 
tization  of  this  most  beneficent  method  of  obstetric  prac- 
tice. But  I  do  protest  against  being  left  "out  in  the  cold," 
together  with  several  other  colleagues  and  contemporaries, 
when  the  question  of  having  contributed  to  the  "popular- 
ity "  of  the  method  is  considered.  Who  originated  the 
practice  of  determining  the  position  of  the  child  in  utero 
by  external  (abdominal)  examinations,  I  do  not  know;  that 
it  did  not  originate  witi;  Pinard,  Crede.  or  Leopold  is, 
however,  certain.  Wigand,  d'Outrepont.  and  Busch  (all 
Germans)  were  generally  credited  with  having  first  intro- 
duced e.xtefnal  version  into  obstetrics  ;  Braxton  Hicks  and 
Wright  certainly  originated  "bipolar  "  version;  Crede  un- 
doubtedly devised  his  method  of  expressing  the  placenta. 
But  neither  Pinard  nor  Leopold,  so  far  as  I  know,  con- 
tributed anything  original  or  new  to  these  methods ;  nor 
did  L  Mr.  Editor. 

But  these  methods  were  well  known  and  universally 
practised  and  taught  in  all  the  maternity  hospitals  and 
obstetric  clinics  in  Germany  when  I  became  assistant  to 
Professor  von  Scanzoni,  at  Wiirzburg,  in  1S67,  then  the 
greatest  authority  on  obstetrics  and  gynaecology  in  Ger- 
many. For  three  years  I  taught  these  methods  to  the  stu- 
dents at  Wiirzburg,  and  no  pregnant  or  parturient  woman 
was  ever  examined  per  vaginam  in  those  days  until  the 
usual  routine  external  exploration  had  lieen  made  ;  and  so 
much  was  I  impressed  by  the  simplicity,  utility,  and 
safety  of  this  practice  that,  while  in  Vienna  in  the  winter 
of  1871  to  1S72,  I  began  to  write  a  paper  on  the  subject  for 
publication  in  America,  where  I  knew  the  metliod  was  not 
understood,  appreciated,  or  practised.  This  pajjer  was  not 
finished  at  the  time,  as  I  left  Vienna  and  travelled  for 
about  a  year  ;  and  in  the  mean  while  my  friends,  Drs.  Wil- 
liam L.  Richardson  and  James  R.  Chadwick.  of  Boston, 
who  had  first  seen  and  learned  tlie  metliod  in  Vienna  in 
1871,  each  wrote  a  short  article  on  it,  and,  if  I  remember 
correctly,  a  Louisville  physician  also,  whose  name  I  do 
not  recollect— all  about  the  same  time.  Reminded  by  these 
articles  of  my  unfinished  paper,  I  at  once  resumed  work  on 
it,  and  ])ublished  it  in  The  Anwriiiiii  /oiirnal  of  Obstet- 
rics for  July  and  August,  1S79,  and  April,  18S0,  under  the 
title  of  "Obstetric  Palpation:  the  Diagnosis  and  Treat- 
ment of  Obstetric  Cases  by  External  (Alxlominal)  Exami- 
nation and  Manipulation."  from  which  it  was  rejirintcd  as 
a  bound  monograph  of  about  one  hundred  and  twenty 
pages,  with  illustrations.  Unfortunately,  the  edition  was 
small,  only  one  hundred  copies,  and  was  soon  exhausted, 
but  even  up  to  within  a  few  years  there  have  been  calls 
for  it. 

Pinard's  very  elaborate  work  on  the  same  subject  ap- 
peared almost  simultaneously  with   mine,  although  mine 


^i'uiaus  and  Notices. 

A    Manual    of    Obstetrics.     By  A.   F.  A,    King,    A.M., 
M.D..  Professor  of  Obstetrics  and  Diseases  of  Women 
and  Children  in  the  Medical  Department  of  the  Colum- 
bian University,  Washington,  D.  C,  and  in  the  Univer- 
sity of  Vermont,  etc.     Eighth  edition,   revised  and  en- 
larged.    With  2G4  illustrations.     Philadelphia  and  New 
York  :  Lea  Brothers  &  Co.     1900. 
It  is  only  two  years  since  the  appearance  of  the  seventh 
edition  of  King's  Manual.     The  best  recommendation  any 
work  can  have  is  the  rapid  exhaustion  of  its  edition.     And 
when  a  work  has  been  before  the  public  for  nearly  twenty 
years,  and  this  rapid  exhaustion  still  continues,  nothing 
further  need  be  said  as  to  the  quality  of  the  book.     Materi- 
ally enlarged  in  every  direction,  it  can  contrast  with  any 
of  the  larger  standard  works.     We  have  no  criticism  to  offer 
and  no  major  corrections  to  be  made  but  one ;  and  that  is 
a  false  interpretation  of  the  Walcher  position  so  far  as  the 
plate  .showing  this  posture  is  concerned.     The  plate  is  faulty 
in  so  far  as  the  patient  is  not  can-ied  suflicientl)'  over  the 
edge  of  the  table.     We  thank  the  author  for  his  painstak- 
ing revision  of  his  work. 

A   Manual   of   Obstetrical   Technique,    as  Applied    to 
Private  Practice  ;  with  a  Chapter  on  Abortion,  Prem- 
ature Labor,  and  Curettage.     By  Joseph  Brown  Cooke, 
M.D.,  New  York,  Late  Attending  Physician  St.  Mary's 
Free  Hospital  for  Children,  Out-Door  Department ;  Late 
Attending  Physician  Northwestern  Dispensary.  Depart- 
ment of  Diseases  of  Children  ;   etc.     Philadelphia  and 
London:  J.  B.  Lippincott  Company.     1900. 
The  little  volume  before  us  can  be  recommended  to  the  stu- 
dent during  his  first  year's  course  as  well  as  to  the  mid- 
wife, but  it  is  certainly  not  a  book  for  the  practitioner.     It 
cannot  compare  with  the  many  we  have  had  the  pleasure 
to  review.     The  plates  are  good,  but  many  are  unneces- 
sary. 

Guide  Pratique  d'Electrothekapie  Gvnecologique.    Par 

LE  Dr.  E.  Ali)ert-Weii.,  Licencie  es-Sciences  Pliysiques 

et  Chimiques,  Ancien  Interne  de  Saint-Lazare,  Prepara- 

teur  Adjoint  a  la  Faculte  de  Medecine  de  Paris,  Mede- 

cin-Electricien.     Paris :  B.  Bailliere  et  Fil.s.     1900. 

In   the   tendency   to   resurrect   electro-gyueecology  at  the 

present  time,  we  welcome  this  work,  though  small  in  size, 

as  a  useful  appendix  to  the  larger  and  older  works.     The 

pictures  ex])lain   very  thoroughly  what  the  text   fails   to 

make  quite  clear.     It  makes  very  pleasant  reading,  and  no 

more  profitable  hour  could  be  spent  than  in  its  perusal. 

CiiiRUKGiE  Du  Rein  et  de  l'Ureteke.  Par  V.  Rochet, 
Chirurgien  de  1' Antiquaille,  etc.  Paris:  G.  Steinheil. 
lyoo. 
This  is  a  u.seful  and  systematically  arranged  little  volume 
on  the  subject  of  the  surgical  diseases  of  the  kidneys  and 
.ureters,  and  the  treatment  of  these  conditions.  There  are 
an  introductory  chapter  upon  the  anatomy  of  the  urinary 
organs,  and  then  a  series  of  chapters  containing  descrip- 
tions of  the  ])athological  conditions  which  are  met  with  in 
them,  with  detailed  accounts  of  the  various  forms  of  treat- 
ment. There  are  enough  statistical  and  bibliographical 
references  to  give  the  book  considerable  value  as  a  work 
of  reference,  and  some  useful  explanatory  illustrations. 

Transactio.ss  ok  the  New  York  State  Medical  Associa- 
tion FOR  the  Year   1899.     Vol.  XVI.     Edited  by  M.  C. 
O'BuiKN.  M.D.     Published  by  the  Association. 
The  volume  opens  with  the  address  of  welcome  by  Fred 
erick   W.    Wiggin,  chairman,  followed  by  the  address  of 


September  8,  1900] 


MEDICAL    RECORD. 


391 


the  president,  Joseph  D.  Bryant.  About  sixty  papers  fill 
the  greater  part  of  the  remainrler  of  nearly  nine  hundred 
pages,  neatly  bound  to  match  former  reports.  A  very  val- 
uable feature  is  the  alphabetically  arranged  comments  on 
the  materia  medica,  pharmacy,  and  therapeutics  of  the  year, 
prepared  by  E,  H.  Squibb,  Jr.  It  takes  in  over  two  hun- 
dred of  the  8S7  pages  contained  in  the  whole  report. 

Essentials   ok  Medical   and    Clinical   Chemistry,    with 
Laboratory   Exercises,    by   Samuel    E.    Woodv,    A.M., 
M. U.     Fourth  edition,  revised  and  enlarged.     Philadel- 
phia: P.  Blakiston's  Son  &  Co.     igoo. 
This  little  work  has  long  been  regarde.d  as  one  of  the  best 
of  our  text-books  on   medical  chemistry,   and  it  has  last 
none  of   its   value   in   the   present  revision.     The  author 
states  that  it  has  lieen  largely  rewritten  and  much  new 
matter  has  been  added.     The  laboratory  exercises  are  in- 
serted as  foot-notes.     There  are  seventy-six  illustrations. 

Golden  Rules  ok  Oi-htmalmic   Practice.     By  Gustavus 
Hakiridge,    F.K.C.S.,     Senior    Surgeon    Royal     West- 
minster 0]>hthalniic  Hospital  ;  Ophthalmic  Surgeon  and 
Lecturer   on    Oplithalmology,     AVestminster    Hospital. 
"Golden  Rules"  Series  No.  V'H.     John  Wright  &  Co., 
Bristol  ;  Simpkin,  Marshall  Hamilton,  Kent  &  Co.,  Lim- 
ited, publishers,  London. 
This  book  is  about  two  by  three  inches  in  size  and  con- 
tains sixty-nine  pages.     There  are  a  few  paragraphs  de- 
scriptive of  the  physiological  and  pathological  conditions 
of  the  eye,  and  some  short,  pithy  admonitions  regarding 
the  treatment  of  ophthalmic  cases. 

Ori<;inal  Contributions  Concerning  the  Glandular 
Structures  Aim'ertaining  to  the  Human  Eye  and  its 
Appendages.  By  Adoi.k  Alt,  M.D.  ,  Professor  of  Oph- 
thalmology in  Beaumont  Hospital  Medical  College,  St. 
Louis.  St.  Louis  American  Journal  of  (Ophthalmology, 
Publisher,      igoo. 

This  monograph  is  a  most  valuable  anatomical  study  of 
the  glands  of  tlie  orbit,  lids,  and  conjunctiva.  It  contains 
only  twenty-three  pages  of  text,  but  is  illustrated  by 
thirty-six  excellent  plates  made  from  photographs  taken 
by  the  author. 

Encvki.op.edie  dkk  Teikkapie.     Hcrausgegeben  von  Oscar 
LiEiiREicii,    Dr.    Med.,    Geheimcr    Medicinalrath,   o.    ii. 
Profes.sor  der  Heilmittellehre  an  der  Friedrich-Wilhelms- 
Universitat.     Unter  Mitwirkung  von  Martin   Mendel- 
sohn,  Dr.   Med..   Universitiits-Professor,   Priv.-Doc.  der 
Inneren  Medicinan  der  Friedrich-Wilhelms-Universitat, 
und  Arthur  Wurzhurg,   Dr.  Med.,   Kgl.    Sanitiitsrath, 
Bibliothekar  im  Kaiserlichen  Gesundheitsamte.     Berlin: 
August  Hirschwald.     k/x). 
This,  the  third  fasciculus  of  the  third  volume,  completes 
the  e.xcelleut  encyclopedia  of  therapeutics,  the  ajjpearance 
of  the  successive  parts  of  which  we  have  noted  from  time 
to  time  in  these  columns.     This  number  caiTies  the  titles 
from  Secale  Corautum  to   Zyniotische    Krankheiten,   and 
includes  such  important  subjects  as  medicinal  soaps,  sep- 
ticaemia,  scirrhus,   spectrum    analysis,   sputum,   sterility, 
metabolism,  strychnine,  syphilis,  tetanus,   inebriety,  ure- 
mia,   mastoid  disease,   water,  childbirth,   and  teeth.     An 
index,  which  is  wonderfully  complete  for  a  foreign  book, 
adds  greatly  to  the  value  of  the  work,  especially  for  a  non- 
German  reader  who  is  sometimes  at  a  loss  for  the  German 
name  of  a  disease  and  who  can  find  it  in  the  index  under 
its  Latin  name. 

A  Manual  ok  Surgical  Treatment.  Bv  W.  Watson 
Cheyne,  M.B.,  F.R.C.S..  F.R.S.,  etc.,  aiid  F.  F.  Burg- 
hard,  M.D.,  and  M.S.  (Loud.),  F.R.C.S.,  etc.  Inseven 
volumes.  Volume  IH.  :  The  Treatment  of  the  Surgical 
Affections  of  the  Bones.  Amputations.  Philadelphia 
and  New  York  :  Lea  Brothers  &  Co.  1900. 
We  have  before  us  now  the  third  volume  of  this  excellent 
work,  and  we  might  say  here  that  we  should  be  glad  to 
have  the  remaining  four  volumes  appear  at  shorter  inter- 
vals than  has  so  far  been  the  case  with  the  first  three. 
This  section  contains  the  subject  of  fractures  and  their 
treatment,  and  descriptions  of  the  surgical  diseases  of  the 
bones.  As  in  the  previous  instalments  of  the  work,  it  has 
been  the  aim  of  the  authors  to  limit  themselves  in  the  dis- 
cussion of  treatment  to  what  they  consider  best  and  most 
suitable,  leaving  many  methods  merely  mentioned  or  ig- 
nored entirely.  This  method  has  made  possible  a  concise- 
ness and  practicalness  which  could  not  otherwise  have 
been  attained,  and  has  obviated  much  prolixity.  The 
treatment  of  compound  fractures  is  considered  in  an  excel- 
lent chapter,  and  minute  directions  are  given  for  securing 
asepsis  at  the  site  of  the  injury.  The  authors  are  believers 
in  the  use  of  silver  wire  for  maintaining  apposition  of  frag- 
ments both  in  compound  and  in  some  forms  of  simple  frac- 
ture, notably  of  the  patella,  in  which  condition  they  believe 
that  operation  is  indicated  unless  some  reason  exists  for  the 


avoidance  of  any  kind  of  operative  intervention.  The  ob- 
jections to  the  use  of  silver  wire,  in  the  jjatella  especially, 
are  recognized,  but  the  good  points  of  catgut  are  not  men- 
tioned. Tumors  of  bone  do  not  receive  perhaps  quite  all 
the  attention  which  the  importance  of  the  subject  Seems  to 
demand,  but  the  subjects  of  inflammation  of  various  kinds 
in  bone,  and  its  sequela;,  are  well  covered.  There  are 
many  illustrations  showing  the  methods  of  treating  differ- 
ent forms  of  fracture.  The  last  part  of  the  book  is  devoted 
to  the  subject  of  amputations,  and  here,  too.  the  illustra- 
tions are  very  good.  Descriptions  of  useless  and  obsolete 
methods  have  been  omitted,  and  some  space  has  been 
g^ven  to  a  satisfactory  discussion  of  the  general  considera- 
tions of  anijiutations.  Lister's  tourniquet  and  Davy's 
lever  are,  we  think,  wisely  condemned  in  disarticulations 
at  the  hip. 

Diseases  ok  the  Chest,  Throat,  and  Nasal  Cavities.  By 
E.  Fletcher  Ingals.  A.M.,  M.D.  Fourth  Edition.  Il- 
lustrated by  254  Cuts  and  a  Plate  in  Colors.  New  York  . 
William  Wood  and  Comjiany.  1900. 
This  work  possesses  a  distinct  advantage  over  most  trea- 
tises on  diseases  of  the  nose  and  throat  in  that  it  treats  of 
bronchial,  pulmonary,  and  cardiac  affections  as  well,  em- 
bracing therefore  the  diseases  of  the  entire  respiratory 
tract  together  with  the  mutually  dependent  heart  troubles. 
The  book  is  doubtless  familiar  in  one  of  its  earlier  editions, 
but  the  present  edition  surpasses  the  others  in  that  it  has 
been  brought  fully  up  to  date,  much  important  matter,  es- 
especially  regarding  pulmonary  affections,  having  been 
added.  Dr.  Ingals  has  a  clear  style,  and  his  descrijitions 
are  to  the  point  and  not  too  verbose,  yet  sufficiently  full  to 
meet  the  needs  even  of  the  student.  The  illustrations  are 
good  and  sufficiently  numerous. 

Atlas   and  Epitome  ok  Diseases  Caused  by  Accidents. 
By  Dr.  E.  Golehiewski,  of  Berlin.     Authorized  Trans- 
lation  with    Editorial   Notes  and  Additions  by  Pearce 
Baii.k.v,  M.D.,  Neurologist  to  St.  Luke's  Hosjjital,  etc.. 
New  York.     Philadelphia :  W.  B.  Saunders  &  Co.     1900. 
This  volume  is  upon  an  important  and  only  recently  sys- 
tematized subject,  which  is  growing  in  extent  all  the  time. 
Accidents  are  coming  to  form  such  a  considerable  propor- 
tion of  the  causes  of  human  ills  that  the  study  of  their 
effects  is  almost  a  sejiarate  specialty,  and  the  Germans 
have  invented  a  special  term  for  it,  "  Unfallheilkunde. " 
This  book  contains  much  useful  information  upon  the  na- 
ture and  effects  of  various  forms  of  accidental  injury,  and 
upon  i)ercentages  of  disability  as  estimated  under  German 
law.     It  ought  to  be  useful  as  a  guide  to  our  own  examin- 
ing physicians  and  adjusters.     The  work  of  the  translator 
and  of  the  editor  has  been  carefully  done,  and  the  pictorial 
part  of  the  book  is  very  satisfactory. 

A  Te.\t-Book  ok  Practical  Medicine.  By  Willia.m  Gil- 
man  Thompson,  M.D.,  Professor  of  Medicine  in  the  Cor- 
nell University  Medical  College.  New  York  City;  Phys- 
ician to  the  Presbyterian  and  Bellevue  Hospitals,  New 
York.  Illustrated  with  Seventy-nine  Engravings.  New 
York  and  Philadelphia  :  Lea  Brothers  &  Co.  1900. 
The  first  thought  that  comes  to  the  mind,  as  one  sees  the 
announcement  of  a  new  te.xt-book  of  general  medicine,  is: 
"What's  the  use  of  another?"  But  the  answer  to  this  de- 
pends largely  ujjon  the  authorship  of  the  new  work.  When 
the  writer  is  one  of  the  rijie  experience  in  practice  and  in 
teaching  and  of  the  scholarly  attainments  of  Dr.  Thomp- 
son, then  there  can  be  no  que.stion  of  the  utility  of  issuing 
the  work.  Every  man  has  some  special  knowledge  of  his 
own,  acquired  through  observation  and  not  from  books,  and 
he  does  a  service  to  his  fellows  when  he  shares  this  knowl- 
edge with  the  world  and  so  adds  to  the  sum  of  general  in- 
formation. For  this  reason  Dr.  Thomp.son's  book  is  wel- 
come. The  weak  point  in  the  book  is  one  on  which, 
curiously  enough,  the  author  lays  special  stress  in  his 
preface,  and  that  is  the  treatment  of  disease.  In  this  de- 
partment, so  far  as  the  reviewer  has  been  able  to  discover 
after  a  pretty  careful  search,  there  is  little  or  nothing  that 
is  not  already  the  common  property  of  the  medical  profes- 
sion, and  many  methods  vouched  for  as  more  or  less  effica- 
cious by  competent  and  trustworthy  observers  are  utterly 
ignored.  For  example,  nothing  is  said  of  Baccelli's  treat- 
ment of  tetanus,  of  warm  baths  in  the  treatment  of  cere- 
brospinal fever,  of  the  salicylates  and  of  sudation  in  pneu- 
monia, or  of  the  so-called  eliminative  treatment  of  typhoid 
fever,  and  the  section  on  the  treatment  of  neuralgia  is 
brief  and  unsatisfactory.  In  other  places,  however,  it  is 
only  fair  to  say  that  the  therapeutic  recommendations 
are  excellent,  'fhe  descriptions  of  the  individual  diseases 
are  clear  and  concise,  and  the  value  of  the  work  is  greatly 
enhanced  by  the  incorporation  of  the  results  of  the  au- 
thor's experiments  and  studies  in  his  hospital  and  private 
practice.  The  work,  even  with  the  drawbacks  mentioned, 
is  a  welcome  addition  to  our  literature  and  reflects  credit 
upon  American  medicine. 


392 


MEDICAL 


Intestinal  Meteorism  in  Infants.^ 

^  Sodii  siilpho-carbolat 0.25-0.50  cgm. 

Syr.  aurantii  corl.  amar 5  gm. 

Aq.  menth.  pip.  dest 25    " 

M.     S.   Take  a  teaspoonful  three  times  a  day  for  two  con- 
secutive days. 

— Frevberger, 
Painful  Pharyngitis. — 

If  Morph.  sulphat 0.20  cgm. 

Acidi  carbol., 

Tannin   aa     2  gm. 

Glycerin. , 

Aq.  destil aa  15    " 

M.     S.   Apply  to  the  throat. 

— Fletcher  Ingals. 
Chloroanaemia. — 

If  Artemisine o.ooi  mgm. 

Quassine  (crystal.) o.ool 

Ferri  protoxalat o.  10  cgm. 

M.     One  capsule.      S.   Two  twice  a  day  before  eating. 

— Ze  Progris  Medical,  August  1 1,  1900. 

Rosacea. — Apply  with  a  brush  for  three  da)'s; 
after  the  paint  peels  off  about  the  sixth  day,  reapply: 

If  Resorcin i 

Ichthyol 2 

Collod.  flex 30 

^Petrini  and  Galsaz. 
Conjunctivitis  (simple  catarrhal). — 

I?  .Vc.  boric gr.  xl. 

Sodii  chl gr.  vi. 

Aq.  camphor. , 

Aq.  destil aa  3  ij. 

M.      S.   Apply  every  two  hours. 

—  Can.  Fract.  and  Rev. 
Endometritis  (chronic). — 

If  Solutio  iodi  (  Lugol)  fort S  iij. 

Ac.  carbol.  (crystal. ) 3  i. 

Glycerini 3  iv. 

M.     S.   Apply  through  the  cervical  canal. 

— Spangler. 
Chronic  Coryza  in  Infants — 

If  Bismuth,  salicylic, 

Bismuth,  benzoat aa  4. 

Sodii  benzoat • i .  50 

Orthoform o.  50 

Menthol o.  50 

Talci 10. 

M.      S.    Insufflation. 

— Le  Progris  Midical,  July  14th. 

Terpin  Mixture 

if  Elix.  terpin., 

Terpin aa  20 

Spt.  vini  rect.  (ninety  per  cent. ) 300 

Glycerin,   (thirty  per  cent. ) 670 

Tinct.  vanill.T; ID 

Dissolve  the  terpin  in  alcohol.      Add  the  tincture  of  vanilla 
and  then  the  glycerin. 

— Journai  des  Pratidens.  July  28,  1900. 

Hay  Fever. — To  ward  ofif  or  to  mitigate  the  attack 
in  rheumatic  patients: 

if  Brucina;  pliosphat gr.  iij. 

Ext.  hyoscyami gr.  xv. 

Quinina;  valerianat 3  i- 

Camphorre gr.  xxx. 

M.   ft.  caps  No.  xxx.      S.    One  four  times  a  day. 

Tablet  pul v.  adrenals  (desiccated) aa  gr.  v. 

No.  xxiv.     S.   One  dissolved  in  the  mouth  four  times  a  day. 

This  gives  great  relief  during  the  attack. — SoLis- 

COHEN. 

Craving  for  Whiskey  is  overcome  by  dropping  a 
few  drops  of  tincture  of  cinchona  far  back  on  the 
tongue. 


RECORD.  [September  8.  1900 

Itching  Conjunctivae  in  hay  fever,  etc. — 

If  Sodii  biborat    gr.  viiss. 

Aqua;  camphorar J  i . 

M.     S.   Bathe  the  eyes  as  necessary,  and  drop  in   one  or 
two  drops  several  times  daily. 

Teething  Powder. — 

If  Calomel |  i. 

Carmine gr.  x. 

Sugar I  iv. 

Sugar  of  milk J  iij. 

M.     S.  From  three  to  six  months  of  age,  gr.  vi.;  from  six 
to  twelve  months,  gr.  viii.  ;  from  one  to  three  years,  gr.  x. 

Dipsomania.  — 

If  ,\pomorphina; gr.  iij. 

Tr.  calumbx |  i. 

Tr.  capsici ni  xv. 

Tr.  nuc.  vom \\. 

Tr.  cinch,  comp \  iss. 

M.     S.   Small  teaspoonful  after  meals  in  water. 

—  Cronica  Medica. 
Bronchitis.— 

If    Terpinol., 

Sodii  benzoat aa  gr.  ij. 

Sacch.  lact q.s. 

For  one  pill.      S.    From  six  to  twelve  daily. 

—  The  Med.  Times  and  Hasp.  Gaz.,  July  4.  1900. 

Seasickness — Codeine  gr.  '4  in  an  effervescing 
mixture.      Useful  in  vomiting  from  any  cause. 

If  Menthol o.  I 

Cocaine o.  1 5 

Syr.  simp 30. 

Spir.  vini  rect 60. 

M.      S.   Teaspoonful  every  half-hour. 

Neurasthenic  Headache. — 

If  Zinci  valerianat. , 

Ferri  sulphat. , 

Ext.  rhei, 

Asafietidiv aa  gr.  xviij. 

M.   ft.  pil.  No.  XX.     S.   One  t.i.d. 

Strychnine  in  large  dose  after  hemiplegia  increases 
blood  pressure  and  may  lead  to  second  rupture  of  the 
weakened  artery.  It  is  likewise  contraindicated  in  all 
forms  of  hemiplegia,  and  tabes.- — Medicine. 

Digitalis  is  unsatisfactory  and  uncertain  because 
its  action  cannot  be  controlled.  Strophanthus  is 
greatly  superior,  being  more  prompt  and  more  per- 
manent.— Upshur. 

Freckles. — Lactic  acid  and  glycerin  in  equal  parts. 

Butter  in  considerable  quantities  added  to  the  food 
is  the  best  means  of  preventing  constipation  in  infants. 
— Doerfler. 

As  a  substitute  for  cod-liver  oil  in  the  treatment  of 
children's  diseases. — V\'irschillo. 

Substitute  for  the  Poultice — 

If  Kaolin 1 ,000  parts. 

Glycerin 1,000      " 

Ac.  boric 100      " 

01.  menth.  pip i      " 

01 .  gaultheria- i 

01.  eucalypti 2      " 

Heat  the  kaolin  to  212^  F.  for  an  hour  to  make 
sterile.  Add  the  glycerin  and  heat  for  forty  minutes. 
Stir  in  other  ingredients  and  keep  in   air-tight  jars. 

—  WlI.I'.ERT. 

Ozaena  of  atrophic  rhinitis.  Cleanse  with  an  alka- 
line solution,  then  with  peroxide,  and  again  with  the 
alkaline  wash.     Apply  by  insufflation: 

If  Ac.  citric 75  parts. 

Sacch.  lactis 25 

— SOMERS. 


September  8,  1900] 


MEDICAL    RECORD. 


393 


Trifacial  Neuralgia. — Introduce  inio  the  external 
auditory  meatus  pledgets  of  cotton  soaked  in  chloro- 
form and  covered  with  dry  cotton  wool  before  inser- 
tion.— BOSE. 

Craving  for  Morphine  or  Spirits. — 

Q  .Vramon.  bromidi gr.  v. 

E.\t.  bellad.  fld.. 

Ext.  nuc.   vom.  fld., 

Ext.  cannabis  ind.  fld aa  ni  ij. 

Aqu?e ad   3  ij. 

At  dose  four  times  a  day. 

— L.  V.  Weathers. 

Parenchymatous  Nephritis  (chronic). — 

H    Tinct.  canlliarid "l  xxiv. 

Liq.  ferri  et  animon.  acetat q  s.  ad  3  iij. 

M.     S.   Teaspoonful  every  four  hours. 

— Salinger. 

Stop  Coughing  by  taking  in  a  long  breath  and  hold- 
ing it  as  long  as  possible.  The  procedure  is  said  to 
have  a  soothing  effect  on  the  air  cells. —  Virginia  Medi- 
cal Semi-Monthly. 

Chancroid. — Cleanse  with 

"B,  Ac.  boric 1 

Aquse 30 

Spir.  vini  rect 60 

Apply  for  twenty-four  hours: 

V,  Zinci  chl i 

Zinci  oxid 10 

.Aqua;  dest q.s. 

Ut  ft.  pasta. 

. — Hallopeau  axd  Lerrede. 

Tremor  of  paralysis  agitans  is  notably  diminished 
by  one  or  two  injections  daily  of  hydrobromate  of 
hyoscine  gr.  jj-j^. — Erb. 

Threatened  Uraemia. — To  stimulate  cutaneous  per- 
spiration in  Liright's  disease: 

'B,  I'ilocarpin.  hydrochlor o.oi  cgm. 

Muc.  gum.  acac 100.      gm. 

M.     S.   From  three  to  six  dessertspoonfuls  daily. 

This  small  dose  acts  without  causing  the  incon- 
veniences 'of   larger   quantities  of   pilocarpine. — Le- 

MOINE. 

Creosote  Pills — 

If  Heechwood  creosote 30  %a\. 

01.  amygd.  dulc 10    " 

.\xungia; 10    " 

Magnes.  calcin.  lev 10   " 

Mix  together  the  creosote  and  oil,  add  the  axungia 
in  a  mortar  and  then  the  magnesia.  Stir  occasionally 
during  the  next  twenty-four  hours  and  put  into  a  re- 
ceptacle.— Delestrac. 

Ovarian  Neuralgia. — 

"S,  Ext.  bellad 0.25  cgm. 

ExL  stramonii 0.30     " 

I.actophenin 6.       gm. 

M.  div.  in  pil.  xx.     S.   Two  or  three  daily. 

— C.  S.  Martin. 

Addison's  Disease. — Suprarenal  extract  in  dose  of 
gr.  ix.  produced  rapid  improvement  in  a  case.  In 
forty-three  collected  cases  so  treated  there  was  im- 
provement in  thirteen,  recovery  in  nine,  death  in 
eleven ;  no  improvement  in  three,  and  in  seven  the 
result  is  not  recorded. — W.  W.  Johnston. 

Resorcin  in  Rodent  Ulcer There  can  be  no  doubt 

as  to  the  value  of  resorcin  in  rodent  ulcer.  I  have 
lately  had  a  typical  case,  which  was  cured  in  five  or 
six  weeks  by  rubbing  in  the  powder  every  night  after 
removing  the  crusted  covering,  and  ceasing  the  appli- 
cation when  the  reaction  was  excessive.— J.  E.  Blo.m- 

FIELD. 


(fJUnical  gcpavtment. 

LIGHTNING    STROKE    WITH    RECOVERY. 
By   C.    LDWAKDS   SHARP,    M.n., 

COLl'MBUS,   OHIO. 

On  May  i8th — the  eighteenth  anniversary  of  the  pa- 
tient's birth — during  a  spring  shower,  Miss  L.  W 

went  to  the  attic  on  the  third  tioor  of  her  home  to  close 
the  windows.  •  h.  flash  of  lightning  struck  her,  and 
she  was  found  with  her  clothing  ablaze  and  lying  un- 
conscious on  the  lloor  of  the  apartment.  Strange  to 
state,  the  building  did  not  catch  fire,  but  a  two-by-six 
rafter  in  the  gable  roof  was  badly  splintered  and  a 
hole  was  made  through  the  floor  of  the  attic  as  if  a 
gun  loaded  with  buckshot  had  been  used.  Another 
member  of  the  family  on  the  second  floor  of  the  build- 
ing was  momentarily  stunned  by  the  stroke.  I  was 
called  and  reached  the  patient  about  ten  minutes  after 
the  flash,  to  find  Dr.  A.  O.  Bonnet  in  attendance,  but 


we  had  very  slight  hope  of  recovery,  and  he  soon  left 
the  case.  The  patient  was  found,  as  previously  stated, 
in  an  unconscious  condition;  the  pupils  were  widely 
dilated,  there  was  stertorous  and  irregular  breathing, 
but  the  pulse  was  apparently  unaffected  or  slightly 
accelerated.  The  face  was  burned  and  the  hair 
singed.  The  flesh  on  the  chest  between  the  nipples, 
that  covering  the  anterior  surface  of  the  abdomen  and 
mens  veneris,  the  anterior  surface  of  the  thighs,  and 
the  right  foot  were  burned.  For  a  space  just  above 
the  knee  to  the  top  of  the  shoe  on  the  right  side  no 
marks  of  injury  were  visible.  The  shoe  on  the  right 
foot  was  burst  open  as  shown  in  the  accompanying 
photograph.  The  crossings  of  the  shoe-lacing  were 
burned  on  the  flesh,  probably  because  the  lacing  was 
damp.  The  lacing  itself  was  entirely  missing. 
Otherwise  the  foot  escaped  injury  and  the  left  foot 
and  leg  were  uninjured. 

After  this  hasty  examination  the  patient  began  to 
jerk  spasmodically — first  the  right  arm  and  left  leg. 
Morphine  and  bromide  of  potassium  were  adminis- 
tered. The  patient  was  then  removed  to  a  bed  on  the 
second  floor.  The  spasmodic  contractions  increased 
and  more  morphine  was  injected.  I  summoned  Dr.  I. 
C.  Edwards  to  the  case,  and  he  soon  arrived;  Dr.  H. 
W.  Whittaker  also  assisted  for  a  few  minutes.  The 
pulse  remained  excellent,  and  a  little  chloroform  soon 
quieted  the  tendency  to  spasm.  The  pupils  now  con- 
tracted to  pin-head  size,  possibly  due  to  the  morphine. 

The  burns  were  dressed  with  carron  oil,  after  the 
charred  clothing  had  been  carefully  removed. 

The  patient  continued  in  a  comatose  condition  till 
about  6  -A.M.  the  following  morning,  when  she  feebly 
called  for  her  father.  Upon  being  informed  of  the 
nature  of  her  injuries,  she  said  that  she  remembered 
nothing  about  the  cause  of  her  condition.  She  grad- 
ually rallied  from  the  shock. 

The  burns  were  dressed  antiseptically.  The  tem- 
perature at  one  time  was  102.5°  F-  'ri  the  afternoon, 
but  on  closer  attention  to  the  dressings  was  controlled. 
The  patient  urinated  more  than  usual,  probably  due  to 
the  impaired  function  of  the  skin  of  the  burned  sur- 
faces. 


394 


MEDICAL    RECORD. 


[September  8,  1 900 


The  bowels  were  constipated,  and  cathartics  and 
enemata  were  given.  But  on  the  afternoon  of  May  23d 
a  moderate  diarrhcca  set  in  with  bloody  or  tar-like 
passages.  The  temperature  at  this  time  was  99  F., 
and  pulse  rate  104.  This  bowel  trouble  yielded 
happily  to  treatment,  and  the  patient  at  the  present 
time  is  well  both  mentally  and  physically,  except  for 
the  burns  which  are  healing  rapidly. 

570  East  Livingston  .\\knue. 


SARCOMATOSIS  OF  THE  VERTEBR/E  SIM- 
ULATING TUBERCULOUS  OSTEITIS  IN  A 
CASE   OF    PULMONARY   TUBERCULOSIS. 

By    T.    H.VLSTED    MVERS,    M.D., 

NEW    YORK. 
ATTENDING    ORTHOPEDIC    SURGEON,    ST.     LI'KE's    HOSPITAL. 

PATHOLOGICAL    REPORT    BY 
F.    C.    WOOD,    M.D., 

PATHOLOGIST  TO  ST.    LUKS's   HOSPITAL. 

On  December  25,  1899,  I  was  asked  by  Dr.  Le  Fevre 
to  examine  the  spine  of  a  man  in  the  phthisical  ward  at 
St.  Luke's  Hospital.  I  report  the  case  as  a  contribu- 
tion to  differential  diagnosis.  He  was  forty  years  old, 
and  as  he  lay  in  bed  was  unable  to  sit  up  or  even  turn 
without  severe  pain  in  the  interscapular  region.  There 
was  neither  kyphosis  nor  curvature,  but  marked  mus- 
cular rigidity  in  the  upper  dorsal  and  cervical  regions. 
There  was  also  tenderness  over  the  fourth  dorsal  verte- 
bra, together  with  some  pain  in  the  left  mammary 
region  and  lower  end  of  the  sternum.  The  ribs  were 
almost  motionless  and  the  respiration  was  abdominal. 
There  were  signs  of  old  pleurisy  on  both  sides  and  of 
consolidation  of  the  lower  lobes  of  the  right  lung. 
Tubercle  bacilli  had  been  found  in  the  sputum  on 
every  examination.  The  man  was  emaciated,  losing 
weight  and  strength  rapidly,  and  had  a  hectic  temper- 
ature. There  were  no  symptoms  of  pressure  on  the 
spinal  cord.  Malignant  disease  was  at  once  suspected, 
on  account  of  the  marked  local  pain  and  tenderness; 
but  as  malignant  disease  of  the  vertebree  is  nearly  al- 
ways secondary,  as  we  could  discover  no  primary  fo- 
cus, as  there  was  a  good  family  history,  and  as  active 
tuberculous  disease  did  exist  in  the  lungs,  the  diag- 
nosis was  reserved,  as  it  seemed  possible  that  an  ab- 
scess about  to  point  posteriorly  might  explain  the  local 
symptoms.  A  week  later,  examination  showed  a  slight 
projection  of  the  fourth  dorsal  spine  and  more  pain 
along  the  intercostal  nerves,  but  there  was  the  same 
persistence  of  local  tenderness  and  muscular  rigidity. 
As  every  motion  was  exquisitely  painful,  a  spinal 
brace  was  ordered.  The  patient  now  failed  rapidly 
and  the  support  was  never  applied,  but  it  was  not  un- 
til February  23d,  two  days  before  death,  that  the  diag- 
nosis was  made  certain  by  the  discovery  of  a  nodule 
on  the  anterior  surface  of  the  liver. 

In  a  paper  on  "Non-Tuberculous  Infianunations  of 
the  Spine,''  '  I  found  that  carcinoma  and  sarcoma  are 
present  in  about  equal  frequency;  that  both  may  be 
primary,  but  are  usually  metastatic.  Kyphosis  is  usu- 
ally not  present.  The  disease  may  occur  at  any  age, 
but  the  average  is  forty-five  years.  The  average 
length  of  life  after  the  onset  of  vertebral  symptoms, 
Amidon  found  to  be  eight  months.  I'ain  has  been  a 
prominent  symptom  in  all  these  cases,  motor  paralysis 
less  constant.  The  cachexia  at  times  did  not  appear 
till  late.  The  spinal  nerves  are  often  involved  in  the 
new  growth.  .Vs  Hodenpyl  has  said,'  speaking  of  the 
association  of  malignant  disease  with  tuberculosis: 
"The  lesions  are  not  antagonistic,  though  they  usually 
occur  at  different  periods  of  life.     Carcinoma  may  be 

'  Medical  New.s.  .May  27.   iSgi). 

'  Transactions  of  New  York  Pathological  Society,  1896,  p.  20. 


grafted  on  an  old  tuberculosis,  and  a  tuberculous 
lesion  may  act  as  a  predisposing  cause  in  locating  this 
deposit  just  as  a  traumatism  might."  This  probably 
would  apply  to  sarcomata  as  well.  This  patient  had 
pleurisy  four  years  ago.  Acute  pulmonary  symptoms 
began  four  months  ago. 

From  a  point  of  view  of  pure  pathology,  the  case  is 
interesting  because  of  the  unusual  distribution  of  the 
sarcomatous  nodules  and  the  impossibility  of  a  certain 
determination  of  the  situation  of  the  primary  growth. 
The  kyphosis  mentioned  above  was  quite  marked  post 
mortem,  the  most  prominent  vertebral  spine  being  the 
fourth.  Just  at  this  level  and  3  cm.  to  the  left  of  the 
spine  was  a  tumor  mass  lying  in  the  muscles  and 
roughly  oval,  measuring  3x2x7  cm.  This  mass 
was  quite  soft  and  made  the  kyphosis  more  prominent 
by  its  bulk.  The  middle  and  lower  lobes  of  the  right 
lung  were  converted  into  a  cavity  half  filled  with  puru- 
lent sputum.  The  bronchial  lymph  nodes  were  enor- 
mously enlarged,  partly  tuberculous  and  partly  invaded 
by  the  new  growth.  The  lymph  nodes  in  the  medias- 
tinum were  enlarged  by  tumor  invasion,  and  many 
small,  bean-shaped  sarcomatous  masses  were  scattered 
over  the  inner  surface  of  the  pleural  cavity,  lying  just 
under  the  costal  pleura  and  easily  movable.  The  liver 
was  10  cm.  below  the  costal  arch  in  the  mammary  line. 
On  its  anterior  surface  was  a  tumor  mass  of  moderate 
hardness,  8  cm.  in  diameter,  and  considerably  raised 
above  the  surface  of  the  viscus.  Throughout  the  whole 
organ  were  numerous  smaller  nodules  of  sarcoma. 
The  stomach  showed  no  metastases,  though  its  mucous 
membrane  was  covered  with  small  polypoid  growths  a 
few  millimetres  long,  and  at  one  place  was  a  small 
fragment  of  a  pancreas  about  tlie  size  of  a  pea  just 
under  the  mucosa,  both  of  which  conditions,  though 
interesting,  will  not  be  further  described,  as  they  were 
not  pertinent  to  the  main  lesion. 

The  spleen  contained  two  moderately  large  metas- 
tases. The  left  suprarenal  body  contained  numerous 
small  nodules  which  resembled  very  closely  miliary 
tubercles,  as  did  also  small  scattered  metastases  in 
both  kidneys.  The  left  kidney  also  had  two  nodules, 
measuring  about  i  cm.  in  diameter,  lying  just  under 
the  capsule.  In  the  head  of  the  pancreas  was  a  lafge 
tumor,  about  5  cm.  in  diameter,  paler  than  the  sur- 
rounding pancreatic  tissue  and  shading  off  gradually 
into  normal  gland.  There  was  no  capsule  or  evidence 
of  delimitation  of  the  growth  from  the  gland  tissue. 
Two  other  nodules  lay  midway  between  the  head  and 
tail  of  the  pancreas,  each  measuring  about  1.5  cm.  in 
diameter,  and  sharply  marked  oflf  from  the  surrounding 
gland  tissue  by  the  color  and  texture.  The  pancreatic 
duct  was  patent.  The  retroperitoneal  and  portal 
lymph  nodes  were  greatly  enlarged  and  sarcomatous. 
Tlie  body  of  the  fourth  dorsal  vertebra  was  softened 
and  dislocated  backw'ard  several  centimetres,  the  new- 
growth  having  invaded  and  softened  it  and,  to  a  less 
extent,  the  bodies  of  the  third  and  fifth  vertebra;.  The 
spinal  cord  was  compressed  sliglitly,  but  no  changes 
could  be  made  out  microscopically.  The  spinal 
nerves  at  their  exit  from  the  canal  were  surrounded  by 
the  new  growth. 

The  microscopical  examination  of  all  these  growths 
showed  them  to  be  spindle-celled  sarcomata. 

Primary  and,  to  a  less  degree,  secondary  sarcoma  in 
the  pancreas  is  of  great  rarity.  Not  over  eight  pri- 
mary cases  are  on  record.  The  rarity  of  secondary 
growths  is  said  to  depend  on  two  seemingly  rather  in- 
sufficient causes:  that  the  pancreatic  arterial  supply  is 
derived  from  small  lateral  branches,  chiefly  from  the 
splenic,  and  the  metastatic  particles  are  carried  by  in 
the  main  current;  and  secondly,  that  metastases  may 
occur,  but  do  not  find  suitable  soil  for  development. 
The  same  peculiarity  has  al^■o  been  observed  in  mili- 
ary tuberculosis;    the  spleen  is    very  commonly,  the 


September  8,  1900] 


MEDICAL    RECORD. 


595 


pancreas  very  rarely,  invaded,  though  both  are  fed 
from  the  same  vessel.  The  question  of  soil  is  impor- 
tant here  also,  for  the  rarity  of  tuberculosis  in  similar 
glandular  organs,  the  parotid  and  submaxillary,  is  well 
known. 

Spindle-celled  sarcomata  arising  from  the  perios- 
teum are  not  rare,  and  the  probable  course  in  this  case 
was  a  growth  from  the  periosteum  of  the  fourth  verte- 
bra with  subsequent  invasion  of  the  bone  marrow,  and 
thence  a  flooding  of  the  general  circulation  with  me- 
tastatic particles,  and  a  secondary  invasion  of  the  pan- 
creas, liver,  and  other  organs. 


EMBOLUS    AND    HEMIANOPSIA.' 
By   GEORGE   DACRE   BLEVTIilNG,    M.D., 

NEW    YORK. 

Mrs.  C.   M.  B ,  aged  fifty-seven  years,  married. 

On  May  24,  1898,  I  was  called  to  this  patient,  who 
made  a  statement  of  finding  herself  two  evenings  be- 
fore, in  playing  a  game  of  backgammon,  unable  to  put 
her  hand  directly  on  her  pieces  or  dice,  her  sight  fail- 
ing to  guide  her  as  to  the  location  of  the  object  sought. 
This  became  so  annoying  that  she  left  the  game  and 
walked  about,  opened  an  outside  door  and  stood  in 
the  air,  and  then  returning  and  finding  that  she  was 
not  relieved,  she  gave  up  the  game  and  went  to  bed. 
She  had  previously  at  times  been  troubled  with  float- 
ing objects  in  the  field  of  vision,  which  disappeared 
after  a  dose  of  calomel,  and  she  felt  no  special  con- 
cern at  these  symptoms. 

The  following  day  slie  took  her  purgative,  but  on 
the  second  day  sent  for  me  and  narrated  this  e.xperi- 
ence,  with  the  additional  statement  that  she  could  not 
read,  as  the  page  was  interrupted  by  black  bars. 

Her  general  condition  was  found  to  be  fair;  the 
pulse,  however,  was  intermittent,  and  upon  examina- 
tion the  heart  was  found  to  have  extensive  valvular 
disorganization.     There  was  an  aortic  direct  murmur. 

The  patient  had  suffered  from  dyspnoea  upon  exer- 
tion for  some  time — a  year  or  more — and  now  com- 
plained of  headache  localized  about  the  right  eye  and 
through  the  head  to  the  occiput.  Ophthalmic  exami- 
nation showed  no  degeneration  of  the  retina,  but  the 
test  of  the  visual  field  discovered  a  distinct  hemianop- 
sia of  the  right  eye,  on  the  temporal  side. 

The  patient  was  put  to  bed  with  orders  for  quiet, 
light  food,  and  a  shaded  room— the  last  for  relief  from 
the  impression  of  the  marked  limitations  of  the  visual 
field. 

With  slight  fluctuations  as  to  digestion,  gastric  and 
intestinal,  and  of  sleeping,  the  patient  improved  dur- 
ing May  and  June,  the  disorder  of  vision  becoming 
less.  The  improvement  was  not  alone  from  the  patient's 
becoming  accustomed  to  and  ignoring  the  limitations, 
but  the  use  of  the  perimetric  test  showed  an  actually 
diminished  area  of  insensitive  retina.  The  right  eye 
showed  slight  outward  deflection. 

On  July  2d  Dr.  H.  H.  Seabrook  saw  the  patient  and 
made  the  following  report :  "There  is  at  present  rapid 
exhaustion  of  the  macular  portion  of  the  retina  when 
the  eyes  are  used,  with  rather  indefinite  complaints  of 
metamorphopsia  which  must  be  due  to  cerebral  causes, 
as  examination  of  the  refraction  and  ocular  muscles 
shows  :  V  O.I).  =  .6  with  cylinder  +  .50  axis  90°=  .8 
at  20  feet.  Orthophoria  — abduction  6".  Jaeger  N'o.  i 
from  8  to  12  inches  with  spherical  -[-3.50.  Field  nor- 
mal, with  the  exception  of  10°  at  periphery  of  tempo- 
ral boundary  of  field  of  right  eye." 

Dr.  M.  .\llen  Starr  saw  the  patient  in  consultation 
on  May  27th.  His  diagnosis  was  central  embolism 
(i)  of  the  post-cerebral  artery,  involving  occipital 
'  Read  before  Lennox  Medical  Society. 


lobe;  (2)  of  the  middle  cerebral  artery,  involving  the 
internal  capsule'  and  the  motor  speech  area. 

The  prognosis  was  recurring  emboli  with  an  ulti- 
mately fatal  result. 

As,  however,  the  hemiopia  almost  disappeared,  and 
there  was  for  a  time  no  repetition  of  the  former  symp- 
toms, I  hoped  for  long  relief  from  the  detachment  of 
growths  and  recurrent  arterial  occlusion;  and  on  June 
25th  I  left  town  for  the  summer,  coming  once  a  week 
only  to  see  my  patients. 

When  1  returned  on  August  9th  I  found  the  patient 
under  the  ministration  of  Dr.  J.  Lee  Morrell.  Two 
days  before  she  had  attempted  a  bath,  had  fallen  in 
the  tub,  and  was  unable  to  say  whether  a  vertigo  had 
caused  the  fall,  or  whether  she  had  slipped  and  the 
shock  of  the  fall  had  induced  cerebral  symptoms. 
The  fall  had  been  heavy  and  her  ribs  were  injured  by 
contact  with  the  tub.  Except  for  pain  in  respiration, 
no  trouble  followed  this  accident. 

So  through  August  and  September  such  improve- 
ment in  the  general  condition  took  place  that  the  pa- 
tient became  restive,  and  finally  so  depressed  from 
confinement  in  the  apartment  that  she  was  permitted 
to  go  down-stairs  every  evening  when  she  felt  disposed 
to  dine  with  the  family. 

On  October  20th  she  was  taken  to  her  daughter's 
house  in  the  suburbs  for  a  change,  and  experienced 
little  fatigue  from  the  effort;  on  the  contrary,  she  had 
increased  appetite  and  better  spirits. 

The  hemianopsia  now  ceased  to  be  troublesome; 
the  patient  read  and  played  cards  and  backgammon 
with  ease. 

On  November  29th  she  came  home,  showing  distinct 
loss  of  power  in  her  right  arm  and  hand.  It  was  de- 
scribed as  coming  so  gradually  that  she  had  not  no- 
ticed a  change  from  day  to  day,  but  felt  now  that  it 
liad  begun  about  two  weeks  before.  This  paralysis 
showed  that  the  blood  supply  of  the  motor  areas  was 
cut  off  by  a  new  embolus,  or  that  softening  had  super- 
vened upon  the  first  embolus  and  slowly  extended. 

On  December  2d  I  was  summoned  early  in  the  day 
to  the  patient,  who  had  difficulty  in  calling  words  and 
was  herself  greatly  alarmed  at  the  symptoms.  All 
signs  of  cerebral  impairment  now  increased,  the  right 
leg  becoming  involved  and  the  power  of  speech  being 
gradually  entirely  lost. 

During  this  time  the  patient  was  in  an  increasing 
degree  emgtional,  and  upon  the  first  appearance  of 
the  various  failures  of  functions  showed  mental  dis- 
tress, but  at  no  time  lost  consciousness,  with  the  pos- 
sible exception  of  the  time  of  the  fall  in  the  bath. 
The  hemianopsia  and  the  aphasia  only  were  sudden 
in  their  onset. 

On  December  21st  Dr.  Starr  again  saw  the  patient, 
and  his  prognosis  giving  no  hope,  a  daughter-in-law 
urged  the  services  of  her  physician,  who  was  a  homoe- 
opath, and  I  withdrew  from  the  case. 

I  was  so  interested  in  the  patient  as  a  friend  and 
anxious  for  the  best  treatment  for  her,  that  I  met  the 
doctor  and  explained  the  case,  the  theory  we  had  gone 
upon,  and  the  treatment,  giving  symptoms  as  they  had 
occurred,  but  leaving  the  new  attendant  to  make  his 
diagnosis.  He  saw  her,  felt  her  pulse,  looked  at  her 
tongue,  and  without  further  examination  of  heart,  urine, 
vision,  or  sensation,  left  the  room  with  me  and  pro- 
nounced the  case  "  sclerosis."     He  informed  me  the 

'  The  internal  capsule  consists  of  white  fibres  passing  between 
the  caudate  nucleus  of  the  thalamus  opticus  and  the  lenticular 
nucleus.  The  anterior  portion  consists  of  fibres  from  the  anterior 
lobe,  and  the  posterior  portion  of  motor  fibres  from  the  opercu- 
lum on  their  way  to  the  anterior  pyramid  of  the  medulla  oblon- 
gata. The  lenticular  nucleus  of  the  corpus  striatum  is  the 
largest  portion  and  is  lodged  within  the  white  substance  of  the 
hemisphere,  being  separated  from  the  caudate  nucleus  by  a  layer 
of  white  matter — the  internal  capsule.  The  caudate  portion  is  in 
the  lateral  ventricle. 


396 


MEDICAL    RECORD. 


[September  8,  1900 


case  was  hopeless,  and  he  had  taken  it  only  at  the 
solicitation  of  his  patient. 

His  prognosis  was  verified  four  days  later.  There 
was  no  autopsy. 

Undoubtedly  the  first  lesion  in  this  case  was  in  the 
cortex  of  the  calcarine  fissure,  now  proved  to  be  the 
site  of  the  primary  visual  centres,  and  showing,  as  Dr. 
Starr  had  declared,  that  some  branch  of  the  posterior 
cerebral  artery  passing  into  the  base  of  the  occipital 
lobe  was  the  seat  of  the  embolus.  The  median  cere- 
bral artery  (or  a  branch)  supplying  the  inferior  frontal 
convolution  (Broca's  convoUition),  now  localized  as 
the  speech  centre,  must  also  have  been  in  turn  oc- 
cluded, as  softening  would  not  extend  from  the  poste- 
rior to  the  anterior  lobe  of  the  brain.  The  centre  for 
movements  of  lips  and  tongue  is  placed  in  that  rela- 
tion to  the  fissure  of  Sylvius. 

The  portion  of  hemisphere  overlapping  the  central 
lobe  is  called  the  operculum  or  lid.  The  fissure  of 
Sylvius  forms  the  boundary  of  this  opercular  lobe, 
which  includes  the  central  fissure  of  Rolando,  and  is 
demonstrated  to  be  the  controlling  centre  of  the  move- 
ments of  the  limbs  and  is  likewise  nourished  by  the 
middle  cerebral  artery. 

This  case  is  one  of  few  reported,  and  is  interesting 
in  its  comparative  novelty  and  also  important  in  its 
suggestion,  in  the  early  history,  of  apoplexy  without 
paralysis  of  limbs  or  impairment  of  locomotion.  Dr. 
M.  A.  Starr  has  reported '  several  such  cases  of  apo- 
plexy— one  similar  to  the  one  here  narrated.  As  Dr. 
Starr  demonstrates,  slight  cerebral  hemorrhages  are 
often  overlooked. 

I  have  a  case  now  under  observation,  belonging  to 
that  class  in  which  numbness  of  the  arm  has  been  at- 
tributed to  position  in  sitting  or  in  sleeping,  but  which 
has  been  undoubtedly  the  result  of  slight  cerebral 
hemorrhage. 

I  will  quote  Dr.  Starr's  case  of  hemianopsia :  "  Male, 
aged  sixty-two  years,  who  has  a  well-marked  mitral  re- 
gurgitant murmur  and  extremely  rigid  arteries,  sufi'ered 
in  1893  from  a  slight  attack  of  left  hemiplegia  which 
passed  away  gradually,  leaving  a  disagreeable  and 
permanent  sensation  of  numbness  in  the  left  hand. 
During  the  summer  of  1896  he  had  an  attack  in  which 
he  noticed  a  headache,  a  sensation  of  vertigo,  and  a 
sudden  obscuration  of  vision  in  the  left  eye.  This 
was  attended  by  a  condition  of  prostration,  in  which 
he  was  seen  by  Dr.  W.  C.  Campbell,  who^  found  his 
heart  very  weak  and  intermittent,  but  his  mind  per- 
fectly clear.  There  were  no  anxiety,  no  aphasia,  no 
paralysis,  but  an  examination  showed  that  the  sup- 
posed dimness  of  vision  in  the  left  eye  was  really  a 
bilateral  left  hemianopsia.  In  the  course  of  two 
weeks  the  general  symptoms  subsided  under  appropri- 
ate treatment,  and  since  that  time  he  has  been  attend- 
ing to  business.  The  left  homonymous  hemianopsia 
remains,  a  careful  perimetric  diagram  of  the  visual 
fields  taken  in  October,  and  again  in  December,  1896, 
showing  the  blindness  in  the  left  half  of  both  eyes."' 

27  East  Eighty-first  Stkeet. 


TWO    CASES    OF    SELF-CASTRATION. 
By  J.    E.   COURTNEY,  M.D., 

I'OUGHKEErSIE,    N.    V. 

Two  remarkable,  if  not  unique,  cases  of  this  rare  form 
of  self-mutilation  have  come  under  my  observation. 
I  think  they  deserve  recording  on  account  of  both 
their  psychological  and  their  surgical  interest.  There 
is  something  at  once  grimly  dramatic  and  repulsive 
in  an  act  of  this  sort,  and  the  literature  of  such  patients, 
especially  in  modern  times,  is  small.  The  motive, 
the  premeditation,  the  psychological  condition,  the 
'  Mf.ijicai.  Recokd,  November  13,  1897. 


rough  technique,  and  the  ready  recovery  of  the  patients 
are  notable.  One  patient  was  a  religious  fanatic  and 
conceived  the  act  from  his  reading;  the  other  could 
not  have  read  of  any  precedent.  I  have  read  of  but 
one  case  nearly  similar  to  these  two;  that  is  recorded 
in  Tuke's  "Dictionary  of  Psychological  Medicine." 

Neither  patient  was  imbecile  nor  had  any  anasthe- 
sia. 

Case  I. — John  C ,  aged  twenty-six  years,  under 

commitment  for  burglary,  was  transferred  to  a  State 
hospital  for  the  insane.  He  was  quiet  and  worked 
about  the  grounds.  He  removed  one  testicle  under 
the  following  circumstances:  He  sharpened  an  old 
knife  used  for  peeling  potatoes,  and  made  a  little  ret- 
icule bag  in  which  to  put  the  testicle,  secured  a  sew- 
ing-needle and  ordinary  spool  of  thread,  and,  excusing 
himself  a  moment  from  his  attendant,  cut  out  the  tes- 
ticle and  sewed  up  the  scrotum.  He  asked  the  atten- 
dant to  take  him  to  the  doctor,  but  gave  no  reasons. 
When  seen,  he  was  somewhat  pale  and  laboring  under 
suppressed  excitement,  and  taking  the  writer  aside  he 
announced  what  he  had  done,  saying  that  his  "nerve 
failed  him  ""  as  to  taking  out  the  other.  There  was 
little  time  for  incredulity.  With  the  utmost  sang- 
froid he  produced  from  his  vest-pocket  the  little  pouch 
containing  the  testicle.  The  scrotum  was  greatly  dis- 
tended with  blood.  The  crude  sutures  were  removed 
and  the  wound  was  dressed.  The  man  quickly  recov- 
ered. He  explained  that  his  purpose  was  to  cure  him- 
self of  masturbating,  to  which  habit  he  attributed  his 
crime  and  all  of  his  troubles;  he  claimed  later  that  he 
was  "  almost  cured." 

Case  II. — O.  P.  F ,  aged  forty-six  years,  shortly 

before  coming  under  my  care  removed  one  testicle, 
and  had  no  medical  attention  until  the  second  day 
after  the  act.  I  am  indebted  to  Dr.  Bird,  of  Hyde 
Park,  N.  Y.,  for  the  following  account :  "  I  was  called  to 

see  O.  P.  F two  days  after  he  operated  on  himself, 

removing  one  testicle.  There  had  been  oozing  of 
blood,  and  it  was  on  this  account  that  I  was  called.  I 
introduced  one  suture.  He  said  his  object  was  to  de- 
stroy venereal  passion,  and  that  if  the  loss  of  one  tes- 
ticle did  not  suffice  he  would  remove  the  other.  He 
said  it  did  not  hurt  much.     He  recovered  promptly." 

This  case  was  one  of  paranoia  with  hallucinations 
and  delusions  pertaining  mostly  to  religious  subjects. 
The  line  of  argument  leading  to  the  act  was  that  the 
original  sin  was  sexual;  that  there  were  eunuchs  who 
had  made  themselves  eunuchs;  "if  the  eye  oiTend, 
pluck  it  out  ";  that  "the  old  dispensation  was  founded 
on  two  tablets,  two  stones,  the  new  on  Peter,  a  rock, 
one  stone,"  etc.  He  was  quite  clever  in  defending  the 
act  from  the  predication  of  insanity,  and  published  a 
pamphlet  in  which  he  elaborated  his  arguments. 


Intestinal  Paralysis   in   Typhoid  Fever. — E.    P. 

Benoit  reports  a  case  which  convinced  him  that  the 
specific  lesions  of  typhoid  fever,  while  locally  very 
dangerous  and  often  determining  fatal  complications, 
may  frequently  cause  but  a  slight  ulceration  of  the 
intestinal  wall  and  yet  induce  grave  alterations  in  the 
coats  of  the  organ  by  creating  an  entrance  for  the 
toxins  of  Eberth's  bacillus.  The  danger  to  the  intes- 
tine in  such  cases  comes,  not  from  the  local  ulcera- 
tion, but  from  general  infection,  and  the  patient  who 
has  escaped  death  from  hemorrhage,  perforation,  and 
peritonitis  may  succumb  to  intestinal  paralysis.  The 
author  thinks  that  there  is  no  way  to  avert  the  fatal 
issue.  Electricity  and  other  measures  may  be  of  use 
when  the  paralysis  is  due  to  defective  nerve  force,  or 
to  great  intra-intestinal  pressure,  but  the  function  of 
the  organ  can  scarcely  be  restored  if  the  muscular 
tissue  is  degenerated.  One  might  as  well  attempt  to 
overcome  fatty  degeneration  of  the  heart  by  digitalis. 
— L' Union  Aledkak  du  Canada,  July,  1900. 


September  8,  1900] 


MEDICAL    RECORD. 


397 


lew  ^Hstrximciits. 


A   NFAV    NASAL-DUCT    IRRIGATOR. 
I5v   HUGH    E.    JONES.  M.R.C.S., 

SURGEON   TO  THE   LIVERPOOL  EVE   AND   RAK   INFIRMARY,  LIVERPOOL,   ENGLAND. 

The  accompanying  woodcut  represents  a  cannula  for 
irrigating  tlie  lacrymal  sac  and  nasal  duct.  It  has 
been  used  in  its  present  form  for  two  years  and  has 
given  [lerfect  satisfaction.  The  chief  points  about  the 
instrument  are  the  following: 

1.  It  is  made  of  silver. 

2.  The  cannula  is  closed  at  the  distal  end  and  two 


catheter  eyes  are  cut  as  near  the  end  as  possible.  In 
this  way  the  use  of  the  stylet  is  avoided,  while  it  is 
practically  impossible  to  injure  the  delicate  mucous 
membrane  of  the  duct  while  passing  the  cannula. 

3.  The  outside  diameter  does  not  exceed  that  of 
Bowman's  original  No.  6  probe,  so  that  it  is  neces- 
sary to  divide  only  half  the  length  of  the  canaliculus 
in  order  to  pass  the  instrument. 

4.  There  is  a  tap  at  the  proximal  end  of  the  instru- 
ment whereby  the  flow  from  the  irrigator  (which  should 
be  at  least  six  feet  above  the  patient's  head)  may  be 
controlled  by  the  hand  which  handles  the  instrument. 
If  preferred  the  cannula  can  be  obtained  without  the 
tap,  and  a  clamp  used  on  the  irrigator  tube. 


A   NEW    CURETTE. 
By  E.    W.    rEERV,    M.D., 


RURAL    RETREAT.    VA. 


The  instruments  now  in  use  for  curetting  the  uterus 
are  inconvenient  and  unsatisfactory.  They  are  incon- 
venient because  the  patient  has  to  be  placed  before  a 
light,  a  speculum  must  be  adjusted,  and  often  it  is  nec- 
essary to  call  assistance.  The  methods  are  unsatis- 
factory because,  in  using  them,  the  hand  is  some  dis- 
tance from  the  uterine  cavity  and  the  sense  of  touch  is 
necessarily  in  great  measure  lost;  after  the  operation 
one  is  not  sure  that  all  retained  portions  have  been 
removed;  and  in  cases  of  uterine  flexure  it  is  almost 
impossible  to  reach  and  curette  the  whole  endome- 
trium. One  is  really  groping  about  for  the  retained 
portions  of  placenta,  and  the  scraping  process  is 
usually  prolonged  by  the  operator  so  that  he  may  feel 
more  certain  of  the  complete  removal  of  adherent 
portions.  This  is  likely  to  cause  injury,  especially 
when  the  sharp  curette  is  used.  For  these  reasons 
most  physicians  remove  retained  portions  with  the 
finger  when  it  can  be  done,  and  it  is  only  in  ca.ses  in 
which  this  is  not  possible  that  the  long-handled  cu- 
rettes and  forceps  are  used. 

The  curette  here  shown  is  more  efficient  than  the 
finger,  and  it  has  not  the  disadvantages  of  the  long- 
handled  curettes.  This  instrument  is  to  be  worn  on 
the  finger,  and  may  be  used  in  those  cases  in  which 
the  cervical  canal  is  already  open,  or  after  its  dila- 
tation. While  the  instrument  is  especially  useful  in 
cases  of  incomplete  and  induced  abortion,  it  may  also 
be  used  in  cases  of  fungous  and  decidual  endometritis, 
in  cases  of  multiple  polypi  of  small  size,  and  of  poly- 
pi arising  from  placental  tissue;  in  obstetrical  cases 
to  remove  portions  of  placenta,  and  in  the  puerperal 
state  to  curette  the  uterine  cavity  when  there  are  symp- 
toms demanding  such  a  procedure. 


The  advantages  claimed  for  this  little  instrument 
are  these :  i .  As  the  blade  is  broad  and  round,  and 
the  cutting  edge  semi-sharp,  as  the  sense  of  touch  is 
better,  and  as  the  finger  is  within  the  uterine  cavity 
gauging  its  depth,  there  is  not  so  much  danger  of  in- 
juring the  parts. 

2.  lieing  placed  on  the  finger,  it  enables  the  opera- 
tor to  reach  easily  the  fundus  uteri,  and  the  retained 
portions  or  other  abnormal  tissues  hanging  from  tiiis 
or  other  parts  of  the  uterine  walls  arc  easily  scraped 
away. 

3.  By  its  use  the  finger  is  lengthened  so  that  the 
fundus  can  be  reached  in  most  cases  by  introducing 
two  fingers,  and  in  every  case  can  be  easily  reached  by 
inserting  the  four  fingers  up  to  or  a   little  above  the 

metacarpo-phalangeal  joints,  so  that 
the  whole  hand  need  not  be  intro- 
duced; consequently  there  is  not  so 
much  stretching  of  the  vaginal  walls, 
and  therefore  less  pain. 

4.  It  enables  the  physician  to  do 
the  work  in  half  the  time  required  without  it,  thus  less- 
ening the  danger  of  prolonged  hemorrhage  and  the 
sufTering  of  the  patient. 

5.  IJy  its  use  portions  of  decidua  which  may  adhere 
high  up  in  one  or  the  other  cornu  can  be  removed 
more  easily  than  by  any  other  means  at  our  command. 

6.  The  finger-nail  which  must  enter  the  cavity  of 
the  womb  is  practically  sealed,  doing  away  with  an- 
other possible  source  of  infection. 

7.  It  not  only  separates  the  adherent  decidua  or 
placenta  easily,  quickly,  and  safely,  but  the  cup-like 
portion  makes  it  easy  to  withdraw  pieces  from  the 
uterine  cavity,  which  is  often  diflicult  with  the  finger 
alone,  especially  in  cases  of  unyielding  or  of  hour- 
glass contraction. 

8.  Its  employment  does  not  necessitate  the  use  of 
speculum  and  light,  and  as  a  consequence  a  certain 
amount  of  exposure  which  every  woman  dislikes. 

We  see,  then,  that  this  little  instrument,  applied  lo 
the  finger,  supplies  a  long-felt  want,  and  is  a  most  effi- 
cient means  of  curetting  in  nearly  all  cases.  We  also 
see  that  it  has  great  advantages  over  the  old  curette, 
even  in  cases  in  which  the  latter  can  be  most  efliicient- 
ly  used.  Then  we  meet  some  cases  in  which  the  older 
instruments  are  almost  entirely  useless.  In  cases  of 
abortion  when  the  womb  is  flexed  or  impacted  below 
the  sacral  promontory,  it  is  almost  impossible  to  reach 
adherent  parts  with  them.  With  the  finger-curette 
they  can  be  easily  reached  and  separated,  regardless 
of  the  position  of  the  womb. 

Soon  after  parturition  it  is  often  necessary  to  cu- 
rette the  placental  site,  but  as  the  uterus  usually  is 


bent  on  itself,  the  long  curettes  cannot  be  used  satis- 
factorily, and  often  are  of  no  service  at  all;  while 
with  this  instrument  on  the  finger  any  curvature  may 
be  followed ;  consequently  the  work  is  done  with  ease 
and  certainty. 

One  should  first  pass  the  finger  into  the  uterine  cav- 
ity and  note  its  size;  also  the  size  and  position  of 


398 


MEDICAL    RECORD. 


[September  8,  1900 


fungosities  or  retained  portions  of  placenta;  then  the 
instrument  may  be  placed  on  either  the  fore  or  mid- 
dle finger,  but  it  is  most  easily  introduced  on  the  fore- 
finger. With  the  curette  on  this  finger  and  resting 
against  the  palmar  surface  of  the  middle  finger,  the 
two  fingers  should  be  passed  into  the  vagina,  and  then, 
using  the  middle  finger  as  a  guide,  the  operator  will 
find  the  cervix  and  pass  the  forefinger  around  with  the 
curette  into  the  uterine  cavity.  The  other  hand  should 
be  placed  over  the  upper  pelvic  strait,  pressing  the 
womb  down  and  supporting  it  while  the  curetting  is 
being  done.  In  using  this  curette  one  need  not  e.xpect 
to  feet  the  adherent  portions  as  he  would  with  the  fin- 
ger alone,  but  he  sl-.ould  boldly  sweep  the  instrument 
around  with  sufficient  force  to  detect  the  firm  uterine 
wall.  This  is  not  hard  to  recognize,  and  one  need 
have  no  fear  of  doing  damage  when  this  curette,  which 
is  semi-sharp,  is  used. 


Among  the  affections  are  primary  putrefaction  of  the 
cord,  fungous  growth,  tetanus,  erysipelas,  blennorrha- 
gia,  ulcer,  abscess,  phlegmon,  phlebitis,  and  arteri- 
tis.— AUDION. 

A  Chloroform  Mask  is  preferable  to  a  piece  of  lint 
or  towel  end,  because  of  the  possibility  of  burning  the 
nose  and  lips  with  the  latter. — Gardner. 


Surgical  J>uoocstioii5. 

Burns  not  exceeding  degree  of  vesication. — 

IJ  Tannin, 

Alcohol aa  I  part 

Sulphuric  ether S  parts 

— NiKOLSKY. 

To  Prevent  Sloughing. — Cover  by  means  of  a  brush 
the  parts  threatened,  with  two  coats  daily  of  : 

IJ  Gutta-percha 4 

Chloroform 30 

Balsam  of  Peru I 

Iodine  Ointment  which  does  not  irritate  the  skin: 

^  Amyli  iodidi 3  gm. 

Lanolin 30    " 

Spir.  canella; gtt.  iij. 

M.     S.   For  external  use. 

— Verbitzky,  Gaz.  Hebd.,  August  12,  1900. 

Hay  Fever. — Cauterize  repeatedly  the  hyperaesthetic 
areas. — Roe. 

Myomectomy  for  submucous  fibroid  was  done  by 
Rraithwaite  in  an  almost  bloodless  manner.  The 
drainage  tube  was  removed  in  twenty-four  hours. 
There  was  uninterrupted  recovery. — Scalpel. 

Shock. — Horizontal  position,  hot  bottles  to  epigas- 
trium and  feet,  warm  affusion  to  the  head,  and  warmth 
generally.  Frictions,  stimulants  (brandy,  ammonia), 
and  galvanism  to  the  precordia.^ — Medical  Siiinviary. 

Fissured  Nipple — Bathe  the  nipple  daily  during 
the  last  month  of  pregnancy  with  tincture  of  quinine. 
Avoid  all  ointments. 

Early  Tapping  is  now  advocated  as  giving  relief 
to  the  patient  and  lending  to  prolong  life  in  the  ascites 
of  cirrhosis.  It  is  better  than  to  employ  purgatives 
and  diuretics.  Aseptic  precautions  do  away  with  the 
dread  of  infective  peritonitis. 

For  Disinfecting  the  Hands — Tests  with  spiritus 
saponis  (P.  G.)  have  confirmed  its  efficacy  in  the  dis- 
infection of  the  hands.  It  renders  them  as  free  from 
germs  as  it  is  possible  to  have  them  with  our  present 
methods,  while  it  has  no  injurious  effect  on  the  skin. 

H.^NEL. 

Umbilical  Infection  in  the  new-born  is  a  not  infre- 
quent cause  of  death.  The  wound  may  have  appeared 
healed  several  days  before  death  occurs.  It  is  never 
possible  to  affirm  that  an  umbilicus  is  entirely  healed 
until    from    fifteen  days   to    three    weeks  after  birth. 


^cclicat  5tcms. 

Typhoid  in  South  Africa — A  correspondent  writ- 
ing to  the  London  Lancet  from  South  Africa  says: 
'■  Hy  far  the  largest  number  of  our  patients  are  suffer- 
ing from  typhoid  fever  of  a  very  severe  type.  The 
chief  strain  seems  to  fall  upon  the  circulatory  ap- 
paratus, and  weak  running  pulses  of  from  130  to  144 
are  not  uncommon.  The  reason  for  this  seems  to  be 
that  the  patients  before  contracting  the  disease  have 
had  excessively  hard  work  to  do,  riding  and  marching 
for  many  hours  every  day,  and  this  has  no  doubt  weak- 
ened the  resisting-power  of  the  heart  in  a  disease 
which  is  known  to  severely  attack  the  muscular  struc- 
tures throughout  the  body.  Liberal  quantities  of 
champagne  and  brandy  with  digitalis  and  strychnine 
have  to  be  given  to  tide  the  patient  over  his  difficulties.'' 

Increase   of   Insanity    in    Great    Britain. ^There 

can  be  little  doubt  that  insanity  is  on  the  increase 
not  only  in  Great  Britain  but  throughout  the  civilized 
world.  Dr.  VV.  VV.  Ireland,  a  British  lunacy  expert, 
has  recently,  says  the  Medical  Press,  addressed  a  series 
of  questions  to  a  number  of  leading  men  in  the  coun- 
try in  order  to  ascertain  whether  they  have  observed 
an  increase  in  the  relative  frequency  of  diseases  of  the 
nervous  system.  Several  doctors  give  their  opinion 
that  nervous  diseases  are  on  the  increase,  and  their 
testimony  is  quoted  as  having  an  important  bearing 
on  the  lunacy  problem.  Undoubtedly  there  is  a  great 
deal  of  common  sense  in  this  view,  and  there  can  be 
but  very  little  question  that  nervous  diseases  come 
more  under  notice  than  formerly.  Professor  Erb  gives, 
as  among  the  factors  producing  nervous  diseases,  irri- 
tation and  depression,  the  greater  anxiety,  hurry,  men- 
tal toil  of  life,  overwork  at  school,  and  so  forth.  It  is 
probable  that  lunacy  is  really  more  on  the  increase 
than  authorities  will  admit. 

Ruskin's  Dislike  of  Bicycling. — A  few  days  be- 
fore Ruskin's  death  a  New  \'ork  editor  despatched  his 
London  representative  to  interview  the  sage  of  Brant- 
wood  on  the  beauties  and  benefits  of  bicycling.  Rus- 
kin,  following  his  usual  custom,  gave  the  newspaper 
man  so  cold  a  reception  that  the  latter  lost  no  time 
in  making  his  return  trip  to  London.  A  few  days 
later  the  correspondent  received  a  letter  from  Ruskin 
in  which  he  said:  "Some  time  ago  I  put  myself  on 
record  as  an  antagonist  of  the  devil's  own  toy,  the 
bicycle.  I  want  to  reiterate  with  all  the  emphasis  of 
strong  language  that  I  condemn  all  manner  of  bi-,  tri-, 
and  4-,  5",  6-,  or  7-  cycles.  Any  contrivance  or  in- 
vention intended  to  supersede  the  use  of  human  feet 
on  God's  own  ground  is  damnable.  Walking,  running, 
leaping,  dancing  are  the  legitimate  and  natural  joys 
of  the  body,  and  every  attempt  to  stride  on  stilts, 
dangle  on  ropes,  or  wriggle  on  wheels  is  an  affront  to 
the  Almighty.  Vou  can't  improve  on  God's  appointed 
way  of  walking  by  substituting  an  improved  cart- 
wheel. " —  Current  J.iteraturc. 

The  Antituberculous  Movement  in  France. — In 
consequence  of  the  publication  in  the  Revue  Generate 
drs  Sciences  of  some  articles  by  Dr.  Romme  on  sana- 
toria, he  was  asked  not  long  ago,  says  the  British 
Medical  Journal,  to  deliver  a  lecture  at  Versailles  on 


September  8,  1900] 


MEDICAL    RECORD. 


399 


the  same  subject  to  a  number  of  foremen,  tradesmen, 
and  employees.  So  successful  was  he  in  impressing 
them  witli  the  practical  importance  of  the  question 
that  they  resolved  to  take  immediate  steps  in  the  mat- 
ter. They  approached  the  municipal  council,  then  on 
the  eve  of  a  new  election,  and  the  reply  they  got  was 
that  means  would  be  sought  for  the  creation  of  a  dis- 
trict sanatorium  for  necessitous  tuberculous  patients. 
This  reply  being  considered  somewhat  vague,  three 
hundred  and  sixty  electors,  represenitng  all  shades  of 
political  opinion,  demanded  a  more  explicit  pledge, 
taking  the  precaution  to  make  the  demand  public  by 
placarding  it  all  over  the  town.  In  deference  to  this 
wish  the  council  replied  with  a  placard  to  the  follow- 
ing effect:  "Certain  electors  ask  us  to  give  formal 
promises  on  the  question  of  a  district  sanatorium  for 
tuberculous  patients.  Had  it  not  been  our  intention 
to  carry  out  the  measure  proposed  we  should  have 
passed  it  over  in  silence.  In  promising  to  seek  for 
means  to  realize  it,  we  have,  as  is  fitting,  a  firm  in- 
tention of  finding  them;  but  a  preliminary  inquiry, 
for  which  we  will  without  delay  collect  materials,  is 
necessary."  At  the  same  time  one  of  the  political 
parties  opposed  to  the  outgoing  council  expressed  its 
adhesion  to  the  manifesto  of  the  advocates  of  the 
sanatorium,  and  the  leading  members  of  another  local 
party,  certain  of  whom  had  signed  the  manifesto,  indi- 
vidually pledged  themselves  in  the  same  sense.  This  is 
said  to  be  the  first  time  in  France  that  the  feelings  of 
a  municipal  electorate  have  found  expression  on  the 
question  of  sanatoria.  It  is  to  be  hoped  that  the  ex- 
ample of  Versailles  will  be  followed  in  other  parts  of 
France. 

Sins  of  Commission  are  charged  against  certain 
Chicago  physicians  by  a  Chicago  editor.  Dividing 
the  specialist's  or  surgeon's  fee  with  the  family  physi- 
cian who  refers  the  case  is  not  looked  upon  as  ethical 
or  strictly  honest  by  New  York  physicians  in  general. 

The  Proper  Time  to  Begin  the  Treatment  of 
Cross-Eyes. — \'ard  H.  Hulen  makes  a  plea  for  early 
attention  in  strabismus,  pointing  out  the  danger  of 
altered  vision  and  incurable  defects  resulting  from 
neglect  in  the  hope  that  time  will  cure  the  squint.  It 
is  a  common  and  grave  error  to  suppose  that  nothing 
can  be  done  until  the  child  is  six  or  seven  years  of 
age.  Many  patients  can  be  cured  without  resort  to 
operation  if  seen  early. —  Oaidcuial  Aledical  Times. 
August,  1900. 

Hospital  Scandals  in  South  Africa The  follow- 
ing remarks  in  the  London  Daily  Graphic  express  the 
opinion  of  the  British  public  with  regard  to  the  charges 
brought  against  the  methods  of  caring  for  the  sick  in 
the  Transvaal  campaign:  "Amid  the  conflict  of  evi- 
dence from  South  Africa  on  the  question  of  the  hospi- 
tal scandals,  two  points  seem  clear  beyond  dispute: 
first,  that  the  individual  members  of  the  Army  Medi- 
cal Corps  worked  with  untiring  devotion;  and  sec- 
ondly, that  the  corps  as  an  organization  was  incapable 
of  dealing  adequately  with  the  heavy  work  suddenly 
sprung  upon  it.  The  breakdown  is  variously  attributed 
to  War  Office  red  tape,  to  the  want  of  independent 
transport,  and  to  the  necessary  difficulties  of  warfare 
in  a  huge  and  generally  barren  country.  It  is  impos- 
sible, however,  not  to  feel  that  beyond  these  causes 
there  is  also  a  deficiency  in  the  composition  of  the 
corps  itself.  Every  one  is  aware  of  the  difficulty  that 
the  War  Office  has  experienced  in  recent  years  in  fill- 
ing up  vacancies  in  army  medical  service.  In  spite  of 
concessions  with  regard  to  title  and  military  rank,  the 
best  medical  men  have  steadily  refused  to  enter  the 
army.  The  reasons  are  obvious:  in  the  army  a  medi- 
cal man  finds  neither  good  professional  experience  nor 
good  pay.     Why,  then,    should    he    sacrifice   all    the 


chances  which  civilian  life  offers?  The  mere  pleasure 
of  filling  up  War  Office  returns  which  nobody  reads  is 
not  sufficient  to  attract  the  man  who  loves  his  work  or 
the  man  who  loves  his  leisure.  If  the  army  wishes  to 
get  better  doctors,  it  must  pay  them  better,  give  them 
larger  opportunities  of  civilian  practice  and  of  return- 
ing to  civilian  life,  and  must  worry  them  less  with  the 
tomfoolery  of  the  red-tape  system." 

Mosquitos  and  Malaria.— Dr.  Irving  C.  Rossesays: 
"During  a  considerable  residence  in  Southern  France 
and  in  Italy,  I  had  frequent  occasion  to  study  this 
(|uestion.  Monte  Carlo  is  most  prominently  associ- 
ated in  my  mind  with  broken  sleep  caused  by  mosqui- 
tos during  an  autumnal  visit.  Yet  among  those  of 
my  personal  acquaintance  with  the  same  experience, 
none  has  since  shown  the  slightest  trace  of  malaria. 
A  similar  remark  applies  to  Leghorn  and  to  Rome, 
where,  owing  to  the  most  important  changes  in  public 
hygiene  that  Europe  has  ever  witnessed,  malarial  fever 
is  seldom  seen  except  among  the  poorer  classes.  Eng- 
lishmen and  Americans,  w-ho  constitute  two-thirds  of 
the  foreigners  in  Rome,  now  reside  there  for  years 
without  an  attack  of  malaria,  in  spite  of  mosquitos 
and  of  what  the  Italians  consider  their  eccentric  and 
independent  habits.  The  old  tradition  of  applying  to 
almost  every  ailment,  from  a  cold  to  enteric  fever,  the 
general  term,  '  Roman  fever,'  a  vague  disease  that  has 
no  place  on  the  nosological  table,  has  created  a  pre- 
vailing notion  hard  to  correct.  As  a  matter  of  fact, 
the  study  of  mortuary  statistics  and  the  sanitary  con- 
dition of  Rome,  where  I  spent  some  time  as  sanitary 
inspector  for  the  government,  show  that  with  the  ex- 
ception of  London  it  is  the  best-watered,  the  best- 
drained,  and  the  healthiest  capital  in  Europe;  and  that 
a  European  or  native  of  New  England  runs  greater  risks 
of  contracting  malarial  fever  in  Washington,  where  it 
is  more  prevalent  and  where  Anopiieles  are  equally 
aggressive.  The  latest  medical  information  from 
South  .\frica  shows  the  entire  absence  of  malaria  in 
many  localities  where  mosquitos  are  most  trouble- 
some. An  old  and  experienced  practitioner  of  New 
Orleans  tells  me  that  the  same  is  true  of  Louisiana, 
notably  among  residents  of  the  salt  marshes,  extending 
from  six  to  fifteen  miles  inland  from  the  Gulf.  On 
the  other  hand,  I  am  told  that  malarial  fevers  are  com- 
mon in  the  foothills  of  Virginia,  as  at  Charlottesville, 
where  mosquitos  are  such  a  negligible  quality  as  to 
be  almost  unknown." 

Lord  Lister  in  Paris. — A  pleasing  and  striking 
proof  has  recently  been  afforded  in  Paris  that  race  ani- 
mosity has  no  place  in  the  realms  of  science.  Not- 
withstanding the  bitter,  not  to  say  rancorous,  feeling 
displayed  by  a  portion  of  the  French  people  and  press 
against  everything  English,  the  reception  of  the  Brit- 
ish men  of  science  who  took  part  in  the  International 
Medical  Congress  was  hearty  to  a  degree.  Lord  Lis- 
ter, indeed,  was  the  hero  of  the  meeting,  and  the  wel- 
come he  recei.-ed  at  the  hands  of  his  French  brethren 
could  hardly  have  been  excelled  in  warmth  and  spon- 
taneity. Dr.  Fleury.  in  Lc  Figaro,  comments  as  fol- 
lows upon  the  appearance  and  character  of  Lister: 
"Very  tall,  with  a  fine  large  head,  white  curling  hair, 
gray  whiskers,  a  smooth  upper  lip  and  chin,  magnifi- 
cently clear  eyes  which  are  at  the  same  time  dreamy 
and  merry,  like  the  eyes  of  a  child;  calm,  courteous, 
and  good-natured.  Such  is  the  impression  which  the 
inventor  of  the  antiseptic  treatment  made  on  me  when 
I  happened  to  see  him  at  the  removal  of  the  ashes  of 
Pasteur.  He  came  then  at  the  head  of  an  important 
delegation  of  English  savants  to  pay  homage  to  his 
real  master,  thanks  to  whom  it  had  been  possible  for 
him  to  save  hundreds  of  thousands  of  human  lives  and 
to  increase  tenfold  the  domain  of  reparative  surgery. 
He  is  seventy-three  years  of  age.     If  he  seems  now 


400 


MEDICAL    RECORD. 


[September  8,  1900 


somewhat  aged  and  broken  since  the  last  few  months, 
it  is  because  he  has  lost,  after  a  short  illness,  the  ad- 
mirable companion  who  was  in  every  sense  of  the  word 
the  half  of  his  life,  the  dimidium  anhiuc  si/u\  Let  us 
honor  and  fete  Joseph  Lister.  The  opportunity  offered 
us  will  not  be  soon  repeated.  Innovators  who  bring 
to  a  branch  of  our  activity  such  complete  and  magnifi- 
cent reforms  are  rare.  The  work  of  this  scientific  son 
of  Pasteur  is  of  incalculable  scope.  Scientific  surgery 
dates  from  him." 

Alleged  Poisonous  Bullets.— On  examining  some 
of  the  alleged  poisonous  bullets  brought  to  England 
by  Sir  W.  MacCormuc  which  the  Hoers  were  reported 
to  have  used,  it  was  found  that  the  charge  was  totally 
untrue.  The  green  coating  complained  of  was  not 
verdigris  but  a  comparatively  harmless  product  of  the 
reaction  of  the  metallic  casing  of  the  cartridge  upon 
a  wa.K  coating  used  to  prevent  damp  and  wet. —  7i/- 
Bt/s. 

Corporal  Punishment  in  Schools. ^The  question 
of  corporal  punishment  in  schools  has  been  much  dis- 
cussed lately  in  Germany  and  Switzerland,  and  the 
Canton  Berne  has  come  to  a  decision  in  the  matter. 
3'/ie  Ethical  World  considers  the  new  law  a  compro- 
mise between  the  ilagellants  and  anti-flagellants.  It 
prescribes  the  use  of  the  cane  for  "  grave  faults  "  such 
as  indicate  moral  perversion;  repeated  lying  is  given 
as  an  instance,  and  it  is  expressly  forbidden  to  punish 
for  want  of  ap])lication.  Girls  are  not  to  be  punished 
physically  at  all. 

Delusions. — The  fact  that  emotions  often  form  the 
starting-point  of  primary  delusions  furnishes  an  im- 
portant indication  as  to  treatment.  As  long  as  we  are 
unable  to  e.xert  any  direct  influence  on  the  functional 
disorder  itself,  i.e.,  on  the  nervous  retro-action,  our 
efforts  must  be  directed  toward  the  possible  source, 
the  emotion.  Every  one  who  is  obliged  to  deal  with 
paranoiacs  knows  by  experience  that  the  best  way  to 
get  along  with  these  unfortunate  patients  consists  in 
a  careful  avoidance  of  all  exciting  agents,  whether 
they  come  from  within  or  without,  and  that  these  pa- 
tients will  do  best  if  their  minds  are  absorbed  by 
some  mechanical  occupation  which  will  guard  the 
moods  from  injurious  fluctuation.  The  beneficial  re- 
sult of  this  purely  empirical  treatment  furnishes,  there- 
fore, a  further  support  to  the  theory  of  nervous  retro- 
action.— "  Psychical  Mechanism  of  Delusion,"  by 
Dr.  Hirsch. 

Death   from  Apoplexy,  Not   Nitrous   Oxide.— At 

the  discussion  on  anaesthetics  before  the  New  York 
County  Medical  Association,  a  report  of  which  ap- 
peared in  the  Medical  Record,  vol.  57,  page  438, 
Dr.  Hobart  A.  Hare,  of  Philadelphia,  alluded  to  a 
case  in  his  city  in  which  death  had  resulted  from 
the  inhalation  of  nitrous-oxide  gas.  It  appears  that 
this  case  occurred  in  the  [iractice  of  Dr.  John  D. 
Thomas,  who  took  occasion,  at  a  recent  meeting  of  the 
New  York  Odontological  Society,  to  explain  how  the 
case  had  been  misreported  in  medical  literature.  This 
death  should  not  have  been  attributed  to  nitrous  oxide, 
according  to  Dr.  Thomas,  who  writes: 

"This  was  not  a  case  of  death  under  nitrous  oxide 
at  all.  The  gentleman  was  a  personal  friend  of  mine, 
and  had  taken  the  gas  upon  three  previous  occasions, 
and  there  was  no  apparent  indication  that  he  should 
not  take  it  again.  The  gas  was  given,  and  the  right 
upper  second  and  third  molars  were  extracted.  His 
recovery  was  complete  in  the  usual  time,  and  he  rinsed 
his  mouth  with  a  tumbler  of  water  while  sitting  in  the 
chair.  1  had  gone  to  my  desk  in  another  part  of  the 
room;  and  he  arose  from  the  chair  and  walked  to  the 
■vashstand,  ten  feet  away,  filled  the  glass  and  returned 


to  the  cuspidor  beside  the  chair,  and  continued  rinsing 
the  mouth  while  standing,  conversing  with  me  in  the 
mean  time.  This  he  repeated  until  he  had  used  three 
glasses  of  water,  occupying  at  least  twenty-five  minutes, 
after  which  he  stood  before  the  mirror  and  with  his 
right  hand  drew  back  his  lips  and  endeavored  to  see 
where  the  teeth  had  been  taken  from.  As  he  removed 
his  hand  he  looked  at  it  and  said:  ' 'i'hat  hand  feels 
numb.'  He  looked  a  little  pale,  and  as  my  first 
thought  was  that  looking  at  the  wounds  had  made  him 
feel  faint,  I  directed  him  to  lie  down  upon  the  couch 
while  1  proceeded  to  get  him  some  brandy;  and  then 
I  realized  that  his  speech  was  thick  and  indistinct. 
Physicians  were  immediately  summoned  and  every- 
thing was  done  to  save  him,  but  he  died  about  four 
hours  afterward.  The  coroner's  jury  gave  the  verdict 
of  death  from  apople.xy,  and  stated  that  the  gas  was 
not  the  cause  of  it,  in  accordance  with  the  medical 
testimony  given  there.  The  gentleman  was  certainly 
in  such  a  physical  condition  that  any  exciting  cause 
might  have  produced  the  same  effect,  and  his  taking 
the  gas  was  but  an  incident  leading  to  that  effect. 
When  we  think  of  the  many  cases  of  sudden  death 
with  people  in  apparently  good  health  which  occurs 
on  the  street,  on  the  cars,  or  in  their  homes,  and  take 
into  consideration  the  nervous  condition  in  which  the 
many  thousands  who  are  to  take  the  gas  approach  the 
dentist,  it  is  really  wonderful  that  there  have  not  been 
numerous  deaths  either  before  or  after  the  operation. 
I  once  made  an  appointment  to  go  to  a  gentleman's 
house  one  morning  at  nine  o'clock  to  administer  the 
gas,  and  he  died  during  the  night  preceding.  Another 
man  came  to  my  office  while  suffering  from  grippe,  and 
I  refused  to  give  the  ana:sthetic,  but  advised  his  return 
home,  and  promised  to  go  to  his  house  in  a  few  days, 
when  his  physician  was  to  be  present.  He  died  the 
next  day.  I  have  notes  of  another  almost  precisely 
similar  case." 

Health  Reports. — The  following  cases  of  smallpox, 
yellow  fever,  cholera,  and  plague  have  been  reported 
to  the  surgeon-general  of  the  United  States  Marine- 
Hospital  service  during  the  week  ended  August  31, 
1900 : 

Cases.    Death./ 
Smallpox— Unitbd  States. 

.Maska,  Cape  Nome From  beginning  of  outbreak  to 

August  23d 33 

Colorado,  Denver August  nth  to  isJh 3 

Ciarficld  Co August  4th i 

Las  Animas  Co.  ..August  7th i 

Louisiana,  New  Orleans .\ugU5t  iSth  to  25th 9  a 

New  York,  New  York August  i8th  to  25th I 

Ohio,  Cleveland August  18th  to  25th 4 

Ilayton August  18th  to  2Slh I 

Portsmouth August  18th  to  sslh 1 

Smallpox — Forsign. 

Austria,  Prague July  28th  to  August  ist 8 

Belgium,  .\ntwerp July  28th  to  August  4th 2 

i\gypt,  Cairo July  22d  to  29th i 

England,  London August  4th  to  nth S 

France,  Lyons July  28th  to  August  4th 2 

(jermany,  Berlin August  loth 3 

Gibr.iltar August  5th  to  12th 2 

India,  Bombay July  24th  to  31st 2 

Russia,  Moscow July  28th  to  August  4th a  a 

Odessa July  28th  to  August  nth 108  29 

Wars;iw July  28th  to  August  4th 7 

Ybllow  Fever. 

Colombia,  Barranquilla August  5th  to  12th i 

Panama August  13th  to  20th 4 

Costa  Rica,  Port  Limon August  22d 1* 

Cuba,  Hav,-ina August  4th  to  nth to 

Matanzas August  26th 1 

France,  Havre August  nth „''',... 

August  13th Several.* 

Mexico,  Merida July  3d 7  4 

Tampico August  1 6th i 

•Steamer  CuHard^  from  Colon. 

+  St.amcr  C,irn-;iHas.  from  Lorenzo  Marques,  via  Senegal. 

X  Steamer  Santa  /•<■,  from  Lorenzo  Marques,  via  Senegal. 

Cholera. 

India,  Bombay July  22d  to  31st 

Madras July  21st  to  27th 

Plague. 

Australia,  Sydney To  July  28th .102 

India,  Bombay July  24lh  to  31st 

Scotland August  31st ■ 

Turkey,  Smyrna From  outbreak  lo  August  olh  . . .     23 


379 
S 


102 
45 


Medical  Record 

A    Weekly  Journal  of  Medicine  and  Surgery 


Vol.  58,  No.  II. 
Whole  No.  1558. 


New  York,  September   15,    1900. 


$5.00  Per  Annum. 
Single  Copies,  loc. 


©ricjiiTaX  gtrtictcs. 

POISONOUS   SNAKES  AND   SNAKE    POISON.' 
By   c;IjSTAV   LANGMANN,   M.D., 

NEW    VORK, 

PROM     THE    DEPARTMENT    OV     PATHOLOCV,    COLLEGE      OP    PHYSICIANS     AND 
SURGEONS,    COLUMBIA    UNIVERSITY,    NEW   YORK. 

The  zoological  order  Ophidia  is  popularly  divided  into 
non-poisonous,  or  liarmless,  and  poisonous  snakes. 
Such  division  appears  quite  natural,  yet  it  is  neither 
practical  nor  is  it  based  on  anatomy  or  biology ;  for 
in  practice  it  is  impossible  to  distinguish  an  innocent 
snake  from  a  similar  poisonous  one  by  easily  recog- 
nized characteristics.  The  law  of  mimicry  is  quite 
extensively  displayed  in  reptiles,  so  that  even  experts 
after  a  hasty  examination  have  been  subject  to  fatal 
mistakes.  Harmless  and  some  poisonous  snakes  have 
certain  anatomical  features  in  common. '^ 

You  may  remember  from  the  study  of  comparative 
anatomy  that  snakes  are  provided  with  two  rows  of 
palatal  teeth  besides  tlie  usual  marginal  teeth  of  the 
upper  and  lower  jaws;  both  run  almost  parallel.  The 
teeth,  solid  pointed  hooks,  are  curved  backward;  they 
r  .e  used  for  hooking  the  prey  rather  than  for  purposes 
of  attack  or  defence.  When  the  very  dilatable  mouth 
is  repeatedly  opened,  the  teeth  are  at  the  same  time 
thrown  forward  so  that  the  prey  is  gradually  dragged 
down  into  the  widely  distensible  asophagus.  In  the 
innocent  snakes  the  teeth  in  both  jaws  extend  back 
a. most  to  the  commissure  of  the  mouth;  in  the  poison- 
ous snakes,  however,  the  strength  of  the  whole  row  of 
marginal  teeth  of  the  upper  jaw  is,  as  it  were,  concen- 
trated into  one  powerful  tooth,  the  poison  fang,  which 
projects  at  the  distal  end  of  the  maxilla.  It  is  true, 
you  will  often  find  two  or  three  teeth  at  this  point; 
these  are  succedaneous  teeth,  which  fix  themselves  into 
place  when  the  snake  has  broken  the  main  fang  or  lost 
it  while  shedding  its  skin.  Such  a  fang  is,  as  a  rule, 
replaced  by  a  new  one  about  every  six  weeks;  the  old 
one  is  loosened  by  odontoclasts  in  Howship's  lacuna-, 
just  as  are  the  milk  teeth  of  an  infant.^  The  fangs  are 
firmly  inserted,  standing  immovable  in  one  family  of 
the  venomous  snakes,  the  Colubridae  venenosae,  to 
which  the  cobras  and  hydrophids  belong;  in  the  other, 
the  Viperida;,  including  the  true  vipers  and  pit-vipers, 
they  are  erected  for  biting  and  are  folded  like  a  pocket- 
knife  when  at  rest.  This  mechanism  works  in  this 
way:  the  pterygoid  muscles  act  on  the  shortened  and 
vertically  situated  maxilla  in  which  the  fang  is  firmly 
fixed. 

Another  division  is  sometimes  made  by  classifying 
the  snakes  according  as  they  have  short,  cone-shaped, 
furrowed  fangs,  or  are  provided  with   long,  pointed, 

'  Read  before  the  .\cademy  of  Medicine,  New  York,  May  17, 
Igoo.  It  is  impossible  to  condense  the  extensive  material  regard- 
ing this  topic  into  the  paper  of  one  evening  The  paper  must 
necessarily  show  many  gaps  and  deficiencies,  and  as  such  is  to  be 
considered  merely  as  an  introduction  to  the  study  of  snake  poison. 

*  A  fact  which  is  indicated  by  the  usual  division  of  snakes  into 
Colubrida',  comprising  all  harmless  snakes,  Colubridas  venenosa- 
and  Viperidae. 

•  Kathariner  :  Wurzburg.  Sitzungsber. ,  i8g6. 


tubular  ones.  This  condition  is  brought  about  devel- 
opmentally  in  the  first  instance  by  the  folding  of  the 
dentine,  which  leaves  a  longitudinal  furrow  along  the 
anterior  surface;  and  in  the  second  by  a  complete  ap- 
proximation, which  produces  a  perfect  tube.  To  the 
first  class,  the  Proteroglypha,  belong  the  Hydrophids 
and  Elapidaj,  or  cobras;  the  latter  class,  the  Soleno- 
glypha,  comprises  the  vipers  and  pit-vipers.  The  in- 
tensity of  a  poisonous  bite  is  not  dependent  upon  the 
shape  of  the  fangs,  except  that  a  longer  tooth,  such  as 
that  of  the  viperine  snakes,  is  capable  of  injecting 
the  poison  to  a  greater  depth;  indeed,  the  viperine 
poison  apparatus  is  the  most  perfect  of  any  in  the 
venomous  snakes. 

We  have  to  consider  a  third  class  of  poisonous  ser- 
pents, the  so-called  Opisthoglypha,  the  furrowed  fangs 
of  which,  as  the  name  indicates,  are  situated  to- 
ward the  rear  of  the  mouth.  There  has  long  been  a 
doubt  as  to  whether  they  should  be  classed  among 
the  poisoners;  and  for  this  reason  they  were  grouped 
together  under  the  name  of  "  suspecti."  Recent  inves- 
tigations, however,  have  proven  to  a  certainty  that 
they  also  poison  their  prey,  which  mostly  consists 
of  small,  cold-blooded  animals.  Catching  them  first 
with  the  innocuous  front  teeth,  they  push  them  gradu- 
ally backward  into  the  reach  of  the  poison  in  the  back 
teeth,  to  the  action  of  which  they  soon  succumb. 

The  poison  apparatus  is  completed  by  the  addi- 
tion of  the  poison  gland,  which  is  closely  in  contact 
with  either  side  of  the  skull,  directly  behind  the  eye, 
and  is  under  the  influence  of  the  overlying  masseter 
muscle.  In  some  small  East  India  snakes,  Callophis, 
the  elongated  glands  extend  into  the  abdomen,  so  that 
they  are  emptied  by  a  vigorous  contraction  of  the 
muscles  of  the  whole  body.  The  efferent  duct  of  the 
gland  does  not  lead  directly  into  the  hollow  of  the 
fang;  if  it  were  so,  every  shedding  of  a  fang  would 
necessitate  the  formation  of  a  new  duct;  the  glandular 
secretion  flows  into  a  groove  of  the  mucous  membrane, 
which  adapts  itself  directly  to  the  base  of  the  fang. 

Poisonous  snakes  are  found  in  all  countries  of  the 
temperate  and  more  so  of  the  tropical  zone.  Numer- 
ous genera  of  the  Hydrophids,  elegant  swimmers,  with 
a  laterally  compressed  tail,  swarm  through  the  whole 
intertropical  part  of  the  Pacific  Ocean;  their  bite  is 
justly  dreaded.  The  tropical' islands,  however,  and 
tropical  countries  of  the  old  continent,  are  haunted  by 
the  worst  kind  of  snakes,  the  Elapidae.  A  large  num- 
ber of  genera  and  innumerable  types  of  every  genus 
render  parts  of  those  countries,  and  especially  of  the 
islands,  almost  uninhabitable.  The  chief  representa- 
tives of  this  genus  are  the  cobra  di  capello  (Naja  tri- 
pudians)  and  the  somewhat  smaller  though  not  less 
dangerous  krait  (Bungarus  fasciatus),  both  living 
throughout  the  whole  of  East  India.  The  most  for- 
midable is  the  king-cobra  or  hamadryas  (Ophiophagus 
elaps),  the  largest  of  all  poisonous  snakes;  it  attains 
a  length  of  fourteen  feet,  and  it  alone  enjoys  the  rep- 
utation of  attacking  and  even  pursuing  man.  Its 
nearest  relative,  the  aspis  of  Cleopatra  (Xaja  naje), 
the  symbol  of  the  Egyptian  kings,  lives  throughout 
almost  the  whole  of  Africa.  In  the  western  world  this 
genus  is  represented  by  the  beautiful  coral  snakes 
alone-    one   of   them,    Elaps   fulvius,    lives    in    our 


402 


MEDICAL    RECORD. 


[September  15,  1900 


Southern  States,  where  it  is  little  feared,  on  account 
of  its  alleged  good-nature,  or  rather  its  lack  of  irrita- 
bility; its  poison  is,  however,  as  active  as  that  of 
its  East  Indian  relative.  Snakes  are  very  numerous 
in  Australia.  Two-thirds  of  these  are  poisonous, 
and  they  belong  exclusively  to  the  family  Klapidx-; 
the  tiger  snake,  Hoplocephalus  curtus,  and  the  black 
snake,  Pseudechis  porphyriacus,  have  a  fearful  reputa- 
tion. Europe  has  none  but  various  species  of  vipers: 
the  well-known  common  viper,  Pelias  berus,  lives  in 
Germany,  England,  and  chiefly  in  France  (Viaud 
Grand  Alarais  counted  in  the  departments  of  Vendue 
and  Loire  Infcrieure  alone  in  six  years  three  hun- 
dred and  twenty-one  cases  of  bites  with  sixty-two  deaths, 
in  Auvergne  fourteen  with  six  deaths') ;  in  the  south, 
around  the  Mediterranean  the  sand  viper  (Vipera  am- 
modytes)  is  found.  East  India  again  has  one  of  the 
most  formidable  vipers,  the  chain  viper  (Daboja  Rus- 
selii);  and  Africa  there  is  the  very  sluggish  but  very 
poisonous  puff-adder  (Clotho  arietans).  The  greatest 
number  of  species  of  vipers  are  found  in  America,  most 
of  them  belonging  to  the  sub-family  of  the  Crotalidee 


or  pit-vipers,  so  called  from  a  deep  pit  lying  between 
the  nostril  and  the  eye. 

The  object  of  this  pit,  which  sinks  into  a  cavity  of 
the  maxilla — as  it  were,  a  reversed  maxillary  sinus — 
is  entirely  unknown.  Leydig,  of  Bonn,  calls  it  the 
seat  of  a  sixth  sense,  which  means  nothing  else  but 
that  he  has  no  explanation.  I  have  been  able  to  in- 
vestigate this  pit  to  some  extent.  The  bottom  of  the 
pit  is  covered  by  a  thin  membrane,  the  continuation 
of  the  external  integument.  Under  this  membrane, 
which  shows  abundant  ramifications  of  nerves,  there  is 
a  cavity  which  opens  by  a  duct  at  the  anterior  margin 
of  the  orbit.  According  to  the  careful  investigations 
of  my  friend.  Dr.  PoUitzer,  who  followed  it  up  by  se- 
rial sections,  the  nerve  connects  with  the  auditory 
nerve.  Pricking  or  any  other  irritation  did  not  pro- 
duce any  reaction,  nor  did  the  destruction  of  one  or 
both  membranes  have  any  effect  upon  the  movements 
or  the  hearing  of  the  snake. 

The  chief  representatives  of  tiie  pit-vipers  in  the 
United  States  are  the  rattlesnakes.  The  banded  rat- 
tlesnake (Crotalus  horridus)  is  present  throughout  the 
whole  territory  from  tiie  Atlantic  to  the  Rocky  Moun- 
tains and  far  into  Canada.  Of  the  remaining  six  spe- 
cies of  rattlesnakes  we  have  to  note  the  largest  of  all 
our  snakes,  tiie  diamond-back  (Crotalus  adamanteus) 
of  Florida  and  the  South,  and  the  swift  prairie-rattler 
(Crotalus  confluentus)  in  the  Mississippi  valley  and 
the  great  Western  basin;  finally  the  smallest  of  all, 
the  massasauga  or  ground-rattler.  To  the  same  sub- 
family belong  tlie  southern  water-snakes,  the  moccasin 
{"Ankistrodon  piscivorus) — sluggish  animals  which  are 


not  a  little  dreaded  by  the  negroes  working  in  the  rice- 
fields;  and  finally  the  beautiful  copperhead  (.\nkistro- 
don  contortrix),  which  is  not  at  all  rare  in  the  whole 
East — in  fact,  lives  almost  in  the  same  expanse  as  tlie 
banded  rattlesnake.  In  the  tropics  almost  all  species 
grow  to  a  larger  size;  thus  the  copperhead  is  repeated 
in  the  larger y."/- ^/^  lance  (Bothrops  lanceolatus)  of  the 
West  Indies ;  the  rattlesnakes  of  Central  America  grow 
larger,  just  as  does  the  Crotalus  durissus;  and  in  the 
Orinoco  valley  there  lives  the  bushmaster  of  the  Dutch 
settlers  (Lachesis  mutus),  next  to  the  Hamadryas  the 
largest  of  all  poisonous  snakes. 

Let  us  now  consider  tiie  poison  apparatus.  The 
poison  glands,  button-,  tube-,  or  almond-shaped,  with 
anterior  elongated  duct,  are  situated  behind  either 
eye,  and  when  extraordinarily  developed,  as  in  the 
Crotalids,  give  to  the  head  that  triangular  shape 
which  was  erroneously  considered  the  characteristic 
of  all  poisonous  snakes,  and  which  gave  to  some 
species  the  name  Trigonocephalus.  The  glands  are 
the  homologues  of  the  common  parotid;  of  the  latter 
it  is  also  well  known  that  it  alone  produces  an  albu- 
minous secretion.  As  to  structure,  they  belong  to  the 
compound  racemose  glands  with  elongated  acini;  the 
glandular  substance  has  columnar,  the  duct  pavement 
epitlielium.  They  respond  to  the  action  of  belladonna 
exactly  like  any  parotid  gland. 

A  slight  thickening  of  the  duct  is  caused  by  a  cir- 
cular constrictor  muscle,  so  that  the  snake  is  able  to 
retain  its  secretion  at  will;  and  indeed  it  may  be  thus 
tretained  and  not  used  for  months.  While  the  mouth 
opens,  nothing  flows  out,  and  only  when  the  mas- 
seters  in  closing  the  jaw  compress  the  glands  a  fine 
stream  squirts  out  of  the  pointed  teeth.  The  secretion 
of  tiie  other  salivary  glands  and  of  the  mouth  is  alka- 
line, while  the  poison  is  always  acid.  The  color  of 
the  latter  varies  from  a  straw  or  greenish-yellow  to  a 
deep  orange.  The  viscous  fluid,  either  clear  or  turbid 
(bitter  in  Naja),  is  not  odorless  as  often  asserted;  it 
has  a  specific  smell  for  every  species,  which  is  not 
easy  to  describe,  but  easy  to  recognize,  thus  the 
odor  of  crotalus  poison  may  be  called  "  mousy '" ;  its 
specific  gravity  varies  from  1.030  to  1.077;  ^^^  solids 
are  variously  stated  as  from  twelve  to  sixty-seven  per 
cent. ;  my  own  samples  are  mostly  dried  down  to 
twenty-five  or  twenty  per  cent,  of  the  original  weight. 
The  dry  poison  cracks  in  scaly  translucent  chips  of  a 
light  yellow  or  deep  brown  color,  and  also  has  a  char- 
acteristic odor.  .  Fresh  poison  under  the  microscope 
shows  nothing  but  a  few  scaly  epithelia  and  a  number 
of  finely  granulated,  amorphous,  albuminoid  masses, 
which  undergo  no  change  in  a  hanging  drop,  even 
after  a  long  while.'  It  was  often  and  even  is  to-day 
asserted  that  bacteria  or  cocci  exist  in  the  poison.  To 
establish  this  positively,  I  sterilized  my  collecting  ap- 
paratus thoroughly,  and  not  the  least  sign  of  bacterial 
life  was  seen  in  broth  or  gelatin  cultures  of  the  fresh 
poison;  also  in  acid  media  in  which  the  experiments 
were  repeated  no  trace  of  life  was  to  be  found.  In 
order  to  determine  whetlier  the  poison  which  itself 
destroys  life  might  for  that  reason  be  free  from  mi- 

'  It  may  be  of  interest  to  describe  my  method  of  collecting 
poison.  It  ought  to  be  said  in  advance  that  poisonous  snakes, 
as  a  rule — at  least  those  of  our  country — are  of  a  timid  and  re- 
tiring, rather  than  of  an  aggressive  disposition.  They  are  taken 
out  of  their  cage  with  a  curved  stick  on  which  they  remain  hang- 
ing, afraid  to  fall.  Then  they  are  laid  upon  a  table  or  upon  the 
door,  and,  while  they  arc  stretching  out  to  crawl  aw.^.y,  their  head 
is  tightly  pinned  down  to  the  table  with  the  stick.  The  index 
finger  and  tliumb  thereupon  grasp  the  neck  of  the  snake  behind 
its  head  so  lirnily  that  it  cannot  be  turned.  .\  funnel  over  which 
a  chamois  skin  or  thin  rubber  is  tightly  drawn  is  held  in  front  of 
the  snake,  which  throws  both  of  its  fangs  through  the  cover  of 
the  funnel  ;  the  poison  drops  out  of  the  fangs  into  the  funnel  and 
into  a  glass  beneath  the  latter.  While  the  snake  is  holding  on 
its  glands  may  be  compressed  in  squee/e  out  the  last  drop.  The 
liquid  poison  is  either  mi.xed  with  equal  parts  of  glycerin  or  it 
is  dried  under  a  bell-glass  with  sulphuric  acid  or  calcium  chloride. 


September  15,  1900] 


MEDICAL    RECORD. 


403 


crobes,  I  mixed  fresh  poison  with  bacillus  subtilis  and 
bacterium  coli  for  one-half  hour  and  then  inoculated 
it  on  gelatin.  The  growth  was  lively,  even  more  lively 
than  in  the  control  plates,  probably  because  the  gela- 
tin was  liquefied  at  the  points  of  contact  with  the 
poison.'  A  bacterial  action,  therefore,  cannot  be  as- 
sumed; the  rapidity  alone  with  which  the  poison  acts 
in  the  system  would  exclude  bacterial  influence. 
VVhat,  then,  is  its  active  constituent?  The  first  chem- 
ical analysis  was  made  in  1843  by  Prince  Lucien 
Bonaparte,  who  established  the  albuminous  nature  of 
viper  poison  and  called  the  poison  "  viperin."  Almost 
twenty  years  later,  1861,  W'tir  Mitchell  found  a  similar 
proteid  in  crotalus  poison,  which  he  named  "crotalin." 
Other  investigators  claimed  to  have  found  alkaloids  or 
ptomains,  when  Weir  Mitchell  again,  in  conjunction 
with  Reichert,  published  in  1883  the  results  of  their 
studies,  that  the  active  principle  of  snake  poison  was 
an  albuminoid,  but  instead  of  one  they  had  discovered 
two.  One  of  them,  easily  dialyzable  and  coagulable 
by  heat,  was  called  venom-peptone;  the  other,  not 
dialyzable  and  not  coagulable  by  heat,  venom-globulin. 
The  proportions  of  both  were  not  alike  in  cobra  and 
crotalus  poison  ;  even  among  the  Crotalidre  they  found 
wide  differences.  Thus  cobra  poison  had  ninety-eight 
per  cent,  of  peptone  and  two  per  cent,  of  globulin,  but 
moccasin  venom  had  ninety-two  per  cent,  of  peptone 
and  eight  per  cent,  of  globulin,  diamond-back  only 
seventy-five  per  cent,  of  peptone  and  twenty-five  per 
cent,  of  globulin.  Besides  the  proteid  there  are  a 
coloring  substance,  several  salts,  and  some  fat. 
Mitchell's  report  was  mainly  corroborated  in  1886  by 
Wolfenden  in  P^ngland,  who  discovered  globulin  and 
several  albumins  in  variable  proportion  in  the  poison 
of  cobra  and  daboja;  one  of  the  latter  he  designated 
serum-albumin;  the  other,  corresponding  to  Mitchell's 
peptone,  syntonin  or  albumose.  Kanthack's  analy- 
ses likewise  demonstrated  the  presence  of  a  proto- 
and  hetero-albumose  in  cobra  poison.  Martin  and 
McGarvey  Smith  found  also  a  harmless  albumin  and 
two  very  toxic  albumoses  in  the  poison  of  the  Aus- 
tralian snakes.  It  may  be  asserted  that  in  no  instance 
has  a  definitive  analysis  of  any  poison  been  worked  out 
to  this  day,  but  all  investigations  centre  in  this  one 
fact,  that  the  active  principle  in  all  snake  poisons  is 
some  form  of  albumose.' 

In  default  of  accurate  analyses,  I  will  use  the  con- 
venient terms,  venom  peptone  and  globulin,  in  our 
further  discussion.  Not  only  do  the  various  poisons 
differ  in  the  percentage  of  peptone  and  globulin,  but 
also  in  the  toxicity  of  the  constituents  themselves.' 
The  venoms  retain  their  efficacy  for  long  periods  of 
time  under  suitable  conditions;  poison,  when  dried  or 
mixed  with  glycerin,  has  proved  itself  as  active  as  fresh 
poison,  even  after  a  lapse  of  twenty-two  and  twenty 
years  respectively.  Freezing  continued  through  weeks 
does  not  alter  it;  putrefaction  destroys  it  after  a  long 
time,  but  it  is  soon  changed  by  heating  when  the  tem- 
perature is  raised  to  different  iieights,  according  to  the 
different  chemical  composition.  The  easier  coagula- 
ble globulins  are  rendered  innocuous  at  80°  C,  while 

'  E.itperiments  carried  out  by  Dr.  A.  V.  Moschcowitz  with  sterile 
snake  poison  have  demonstrated  that  it  liquefies  gelatin  like  some 
digestive  ferments,  ^..i,'.,  trypsin.  Wehrmann  (Annales  Pasteur. 
i8q8)  finds  that  it  peptonizes  fibrin  weakly  and  does  not  sac- 
charify amylum. 

•  It  is  well  known  that  albumoses,  the  products  of  the  hydra- 
tion of  albumin  formerly  called  propeptones  and  accurately 
defined  by  KUhne  and  Chittenden  in  18S4,  differ  widely  as  to 
their  to.Kicity.  While  our  modern  means  do  not  allow  yet  a 
chemical  differentiation  of  those  albumoses  generated  by  super- 
heated steam,  by  gastric  digestion,  by  bacilli,  or — as  in  our 
case — by  the  parenchyma-cell  of  a  gland,  the  varying  reaction 
of  the  more  sensitive  living  organism  toward  them  demonstrates 
decisively  their  different  nature. 

'  Gastric  digestion  does  not  influence  snake  poison  ;  the  action 
of  the  bile,  however,  and  of  the  pancreatic  juice  destroys  it. 


the  peptones  are  destroyed  only  by  applying  heat  for 
hours.  The  coagulated  proteids  are  inert  in  this  con- 
dition, but  they  regain  their  toxicity  when  redissolved. 
It  is  the  more  or  less  evident  capability  of  chemicals  to 
coagulate  proteids  which  determines  their  relative  power 
of  destroying  the  efficacy  of  venoms,  when  they  are 
mixed  with  the  poison  in  a  test  tube  for  experimen- 
tal purposes.  Alcohol  renders  it  inert  for  a  time 
only.  Absolute  alcohol  seems  to  coagulate  all  poison- 
ous ingredients,  but  the  presence  of  an  infinitesimal 
part  of  water  is  sufficient  to  retain  the  toxicity  of  the 
supernatant  fluid.  Poisonous  serpents,  when  preserved 
in  alcohol,  have  to  be  handled,  even  after  years,  with 
the  greatest  care,  as  has  been  demonstrated  by  a  fatal 
accident  to  an  assistant  in  the  St.  Petersburg  Museum. 

The  physiological  effects  of  both  ingredients  named, 
whenever  they  are  tested  separately  in  animals,  are 
widely  different.  The  peptone,  though  causing  some 
local  oedema,  is  more  productive  of  general  symptoms, 
which,  commencing  as  irritation,  twitching,  and  con- 
vulsions, finally  end  in  paralysis;  paralysis  of  the  re- 
spiratory centre  is  especially  characteristic.  The  glo- 
bulin, on  the  contrary,  incites  a  violent  local  reaction 
with  hemorrhages  around  the  point  of  injection,  hemor- 
rhages of  the  mucous  membranes,  and  destruction  of 
the  coagulability  of  the  blood.  The  latter  phenome- 
non recalls  to  us  the  results  of  experiments  performed 
on  animals  with  pure  peptones  and  albumoses  of  diges- 
tion. Kiihne,  Pollitzer,  Schmidt-Mulheim,  Shore,  and 
Matthes  found  in  a  large  number  of  these  experiments 
not  only  characteristic  hemorrhages  and  necroses,  but 
also  paralyses,  the  intensity  of  which  was  in  corre- 
spondence with  the  higher  hydrolysis  of  the  albumoses. 

You  will  perceive  from  what  has  been  said  that  dif- 
ferent cases  of  snake  poisoning  cannot  have  an  identical 
course,  and  that  the  numerous  contradictions  of  the 
mostly  incomplete  records  of  snake  bites  are  to  be  ex- 
plained only  when  we  consider  each  type  of  poisoning 
separately.  Leaving  aside  the  cases  of  almost  instan- 
taneous death  which  are  due  to  general  thrombosis,  es- 
pecially when  the  venom  has  been  accidentally  injected 
into  a  large  blood-vessel,  we  usually  see  about  the  fol- 
lowing symptomatology.  We  will  consider  first  the 
less  complicated  picture  of  the  effects  of  a  cobra  bite: 
two  small,  scarcely  visible  punctures  in  the  skin  are 
found,  whence  radiates  a  burning  and  stinging  pain 
with  gradually  extending  ctdema.  Within  an  hour, 
on  an  average,  the  first  constitutional  symptoms  appear 
— a  pronounced  vertigo,  like  that  of  drunkenness, 
quickly  followed  by  weakness  of  the  legs,  which  is  in- 
creased to  paraplegia,  ptosis,  falling  of  the  lower  jaw 
with  paralysis  of  the  tongue  and  epiglottis,  inability 
to  speak  and  swallow,  with  fully  preserved  sensorium. 
A  mass  of  viscous,  frothy  saliva  is  constantly  drib- 
bling from  the  open  mouth;  nausea  and  vomiting  set 
in;  the  paralysis  becomes  general,  the  patient  lies  mo- 
tionless. The  pulse,  a  little  accelerated,  is  somewhat 
weaker  in  the  beginning,  but  keeps  a  moderate  strength 
until  even  a  few  minutes  after  the  cessation  of  respira- 
tion. The  latter,  also  accelerated  in  the  beginning, 
soon  becomes  slower,  labored,  and  more  and  more 
superficial,  until  it  dies  out  almost  imperceptibly. 
The  pupils,  somewhat  contracted,  react  up  to  the  last 
moment.  Slight  convulsions,  which  we  are  accus- 
tomed to  see  in  asphyxia,  sometimes  occur  shortly  be- 
fore death.  Absorption  is  exceedingly  rapid;  al- 
ready after  thirty  seconds  a  distinct  areola  is  visible 
around  the  bite.  Death  occurs  at  the  latest  within 
fifteen  hours,  in  thirty-two  per  cent,  in  the  first  three 
hours.  When  the  patients  do  not  die  of  paralysis, 
they  recover  remarkably  quickly  and  without  later  con- 
sequences. The  autopsy  reveals  no  changes  in  the 
skin  at  the  point  of  injection  ;  the  subcutaneous  tissue, 
however,  is  thickly  infiltrated  with  reddish  serum;  the 
surrounding  blood-vessels  are  congested.     All  the  in- 


404 


MEDICAL    RECORD. 


[September  15,  1900 


ternal  organs  are  hyperKmic,  and  the  bronchi  are  filled 
with  frothy  mucus  and  perhaps  with  fluids  which  have 
been  forced  into  the  patient's  throat.  The  blood  is 
mostly  liquid  and  dark. 

After  the  bite  of  a  rattlesnake  the  local  disturbance 
is  most  pronounced:  violent  pains  at  the  bleeding 
wound,  hemorrhagic  discoloration  of  its  surroundings, 
and  later  also  of  more  distant  parts;  bloody  exudations 
on  all  the  mucous  membranes,  nose,  mouth,  conjunc- 
tiva, and  hcematuria  or  rather  ha;moglobinuria.  Usu- 
ally somewhat  later  than  after  cobra  poisoning,  but 
possibly  within  fifteen  minutes,  constitutional  symp- 
toms may  develop,  great  prostration  with  nausea  and 
vomiting.  A  continuous  fall  of  blood  pressure  is 
noticed.  Respiration,  in  the  beginning  accelerated, 
grows  slow  and  stertorous.  After  a  temporary  increase 
of  retlexes,  which  in  susceptible  animals  and  after 
large  doses  may  rise  to  convulsions,  opisthotonos,  and 
tetanus,  paresis  supervenes,  with  paraplegia  of  the 
lower  e.xtremities,  which  progresses  in  an  upward  direc- 
tion, ending  in  complete  paralysis.  Albuminuria  ap- 
pears after  about  six  hours.  In  such  a  condition 
death  may  come  inside  of  twelve  hours.  If  the  patient 
recovers  from  the  paralysis,  a  septic  fever  may  develop 
in  consequence  of  the  enormous  and  multiple  hemor- 
rhages, to  which  he  may  succumb  after  a  lapse  of  time. 
Eventual  recovery  sets  in  very  suddenly,  even  in  the 
most  desperate  cases.  Not  rarely,  however,  suppurat- 
ing wounds  remain,  which  granulate  poorly,  break  open 
repeatedly,  and  may  lead  later  on  to  deep  necrosis, 
even  of  the  bones.'  The  autopsy  shows  a  deep  bloody 
infiltration  at  the  bite,  down  into  the  necrotic  muscles, 
hemorrhages  of  distant  muscles,  particularly  of  the 
intercostals;  all  serous  membranes,  chiefly  the  endo- 
cardium and  the  peritoneum,  are  completely  covered 
by  ecchymoses  of  all  sizes;  the  lungs  show  subpleural 
ecchymoses  and  infarctions;  the  kidneys  are  hemor- 
rhagic in  the  glomeruli  and  pelvis,  and  there  is  cloudy 
swelling  of  the  epithelium  of  the  canaliculi.  Hemor- 
rhages have  been  observed  also  in  the  serosa  and  in  the 
substance  of  the  central  nervous  system.  The  blood 
is  fluid,  and  does  not  clot,  even  after  a  long  time. 

If  it  is  permissible  to  illustrate  and  fix  the  symp- 
toms, which  I  could  but  sketch  roughly,  in  a  well- 
known  and  familiar  complex,  I  might  call  the  se- 
quelas  of  a  cobra  bite  an  acute  bulbar  paralysis  of 
the  most  furious  and  vehement  type.  Also  for  the 
second  type,  that  of  viper  poisoning,  we  have  an  anal- 
ogy in  acute  ascending  spinal  paralysis,  the  last  stage 
of  which  exhibits  alike  bulbar  symptoms  and  in- 
hibition of  respiration.  We  may  remember  here  that 
the  common  ascending  spinal  paralysis  is  also 
ascribed  to  an  infection.  Yet,  whereas  in  the  two  dis- 
eases named  the  development  of  the  nervous  symptoms 
is  very  gradual,  and  they  may  take  years  or  at  least 
weeks  to  advance  to  a  fatal  exitus,  in  snake  poisoning 
the  effect  is  almost  instantaneous.  It  may,  therefore, 
be  considered  as  firmly  established  that  snake  venoms 
affect  the  motor  ganglia  of  the  anterior  horns  and 
chiefly  the  medulla  oblongata.  There  exist  records  of 
few  accurate  microscopic  examinations  of  all  organs 
after  snake  poisoning.  In  general  they  resemble  the 
changes  which  we  are  wont  to  find  in  all  kinds  of 
poisoning  of  whatever  origin,  especially  by  the  toxins 
of  zymotic  diseases,  c.^'.,  fatty  degeneration  of  the  liver 
with  inflammation  of  the  bile  ducts,  acute  parenchy- 
matous nephritis,  disseminated   pneumonic   patches, 

'  It  is  remarkable  that  in  some  cases  a  periodical  relapse  of 
inflammation  anil  suppuration  of  tfie  old  cicatrices  is  reported 
almost  at  the  same  time  every  year.  Leon  Stejneger,  in  "  The 
Poisonous  Snakes  of  North  America,  "p.  353,  relates  the  case  of 
the  draughtsman  of  the  Smithsonian  Institution.  After  a  bite 
of  a  coral  snake,  swelling  and  indammation  of  a  linger  with  loss 
of  the  nail  are  said  to  have  recurred  in  ten  successive  years  almost 
to  the  (late  of  the  bite.  A  cure  was  finally  eflected  by  means  of 
the  herb  Micania  guacho. 


etc.  Of  the  pathological  changes  in  the  central  ner- 
vous organs,  which,  to  judge  from  the  symptoms,  we 
may  expect  to  find,  no  reliable  records  have  been 
published.  I  am  glad  to  say,  therefore,  that  several 
gentlemen  of  this  city  have  been  working  up  some 
cases  of  snake  poisoning,  and  tiiey  will  give  us  later 
an  analysis  of  their  investigations.  In  the  mean  time, 
I  may  be  permitted  to  state  the  substance  of  the  results 
as  a  pronounced  affection  of  the  ganglion  cells 
throughout  the  central  nervous  system,  especially  in 
the  medulla;  the  chromatic  structure  and  cyto-retic- 
ulum  have  almost  disappeared,  as  well  as  the  den- 
drites; the  nucleus  and  nucleolus  are  not  affected. 

The  question,  then,  whether  snake  venom  is  a 
nerve  or  blood  poison  seems  to  be  definitely  settled: 
it  is  both.  We  have,  however,  in  this  connection 
to  consider  separately  some  remarkable  phenomena 
in  the  blood  and  circulation.  In  like  manner  the 
multiple  hemorrhages  might  point  to  a  disturbance 
of  the  vasomotor  centre,  and  some  investigators 
ascribe  them  to  an  enormously  increased  diapedesis. 
Fresh  poison  added  to  blood  in  a  test  tube  or  admin- 
istered hypodermically  causes  the  blood  corpuscles  to 
swell  and  allows  the  ha?moglobin  to  escape  into  the 
plasma.  The  hiemoglobin  itself  is  not  changed,  the 
spectrum  remaining  normal.  Local  application  of 
poison  to  a  capillary  area  incites  a  vigorous  diapedesis, 
as  some  consider  it,  while  others  think  it  to  be  a  real 
rupture  of  the  capillary  wails.  The  blood  cells  escape 
and  are  destroyed  to  such  an  extent  that  a  few  hours 
after  the  injection  of  poison  but  one-half  of  the  nor- 
mal blood  corpuscles  are  counted.  Finally,  however — 
and  this  point  has  been  creating  a  most  lively  discus- 
sion— the  coagulability  of  the  blood  is  materially  in- 
fluenced. Formerly  it  was  an  accepted  dogma  that 
cobra  venom  increased  and  viper  venom  inhibited 
clotting;  recently,  however,  the  investigations  of 
Heidenschild,  and  more  so  the  careful  experiments  of 
Martin,  of  Sydney,  have  cleared  up  the  matter.  It  is 
true  that  viper  venom  has  a  more  pronounced  influence 
upon  the  circulation,  yet  the  doses  and  the  mode  and 
the  rapidity  of  introduction  are  matters  of  the  greatest 
importance.  As  a  rule  coagulation  is  inhibited  for 
a  long  period.  A  small  dose  injected  intravenously 
causes  a  positive  phase  of  coagulability  of  two  or  three 
minutes,  which  is  followed  by  a  negative  phase  of  lon- 
ger duration.  A  second  larger  injection  brings  on  the 
same  positive  and  a  much  longer  negative  phase.  A 
third  still  larger  injection,  which  is  borne  remarkably 
well,  destroys  coagulability  for  a  long  period.  At  the 
same  time  the  leucocytes  disappear  almost  entirely 
from  the  circulating  blood;  they  are  massed  in  the 
liver,  lungs,  and  bone  marrow,  and  reappear  only  when 
the  blood  regains  its  coagulability  (or  perhaps  inverse- 
ly). A  hypodermic  injection,  and  therefore  the  major- 
ity of  all  snake  bites,  acts  in  the  same  way  as  a  small 
intravenous  injection.  Immediate  introduction  of  a 
larger  quantity  of  poison  into  a  blood-vessel  may  cause 
a  sudden  complete  clotting  of  the  whole  mass  of  blood, 
with  the  exception  of  that  in  the  pulmonary  veins 
and  the  left  heart.  Many  contradictory  reports  of  the 
blood  pressure,  sudden  stoppage  of  respiration,  etc., 
are  explained  by  the  sudden  massive  thrombosis. 
The  immediate  cause  of  coagulation  is  probably  a  nu- 
cleo-albumiii,  analogous  to  tlie  fibrinogenic  substance 
of  Wooldridge,  also  a  nucleo-albumin.  It  is  not  pre- 
formed in  the  venom,  but,  as  Martin  has  it,  is  liberated 
instantaneously  by  the  action  of  the  poison  from  the 
stroma  of  tiie  destroyed  erythrocytes  and  the  endothe- 
lium of  the  blood-vessels,  and  it  brings  on  extensive 
thrombosis  at  one  stroke. 

Another  important  effect  of  snake  venom  is  the  loss 
of  the  germicidal  property  of  the  blood  plasma.  It  is 
well  known  that  most  normal  blood  serum  destroys 
micro-organisms,    or    at    least    retards    their    growth. 


September  15,  1900]  MEDICAL 

Ewing,  of  Washington,  was  the  first  to  show  in  1894 
that  this  faculty  was  annihilated  in  the  blood  of  ani- 
mals killed  by  crotalus  poison,  and  Martin  has  con- 
firmed it  for  the  venom  of  the  Australian  black-snake. 
This  explains  both  the  well-known  rapid  putrefaction 
of  the  poisoned  organs  and  the  danger  of  subsequent 
decomposition  of  the  extravasated  blood  and  the  re- 
sulting sepsis  during  convalescence.  We  can  create  a 
closer  similarity  of  the  two  types  of  poison  in  an  arti- 
ficial way.  Viper  venom,  when  heated  to  80'  C,  loses 
its  intense  action  upon  the  circulation  and  approaches 
cobra  venom  in  character.  The  Australian  snakes 
occupy  in  this  regard  an  intermediate  position,  for 
besides  a  prominent  cobra  effect  they  produce  moder- 
ate hemorrhage  and  always  hajmoglobinuria.  Persons 
poisoned  by  the  East  Indian  Bungarus  exhibit  some- 
times a  peculiar  course  of  disease.  Some  cases  can- 
not be  distinguished  from  cobra  poisoning,  yet  in 
others  a  certain  chronicity  of  symptoms  is  seen,  which 
can  be  compared  only  to  the  incubation  period  of  infec- 
tious diseases.  From  two  to  six  days  may  have  elapsed 
after  the  bite  without  any  symptoms,  when  unexpect- 
edly a  general  debility  sets  in,  with  albuminuria  and 
a  sanious  discharge  from  the  eyes,  nose,  and  rectum. 
The  patient  invariably  succumbs  within  a  siiort  time.' 
A  disproportionate  swelling  is  to  be  noted  in  poison- 
ing by  the  European  viper;  it  sometimes  extends  over 
the  whole  body.  The  poison  of  the  African  viper, 
the  puff-adder,  acts  in  a  stupefying  manner  from 
the  very  beginning;  the  animal  stricken  stands  with- 
out motion  or  reaction,  as  if  the  whole  cerebral  cortex 
was  eliminated;  complete  sensory  and  motor  para- 
plegia ascends  gradually  with  sharply  defined  limits. 
In  briefly  summarizing  the  mode  of  dying  from  snake 
poison  we  might  say:  Death  occurring  within  a  few 
minutes  is  due  to  general  thrombosis;  a  patient  who 
dies  within  twenty-four  hours  may  succumb  in  the 
first  hours  to  paralysis  of  the  respiratory  centre,  later 
to  general  paralysis ;  lethal  exitus  later  than  this  time, 
days  or  even  weeks  after  the  bite,  may  be  the  result 
of  sepsis. 

It  may  be  appropriate  now  to  say  a  few  words  about 
the  relative  dangerousness  of  a  snake  bite.  Statistics 
cannot  give  us  an  adequate  idea  as  regards  this  point. 
Not  all  cases  are  reported,  and  not  all  bites  reported 
are  those  of  venomous  snakes.  Moreover,  chance 
plays  an  important  role  in  the  sequelae,  e.g.,  in  what 
condition  was  the  snake  when  biting?  Were  one  or 
both  fangs  deeply  implanted,  or  was  the  skin  merely 
scratched?  How  old  and  in  what  condition  of  health 
was  the  bitten  individual?  India,  as  is  generally 
known,  has  the  largest  mortality  from  snake  bites; 
this  is  easily  explained  by  the  enormous  number  of 
snakes,  and  these  the  most  deadly  of  all,  the  cobras. 
Neverthelesss,  indolence  and  superstition  of  the  pop- 
ulation may  increase  the  number  of  fatal  accidents 
considerably.  Those  may  be  right  who  consider  the 
smaller  number  of  deaths  in  America  and  Australia 
as  due  to  the  greater  intelligence  of  the  people,  be- 
cause a  rational  treatment  is  instituted  in  time,  es- 
pecially the  early  application  of  a  ligature.  In  default 
of  reliable  analyses,  the  only  way  to  decide  this  point 
has  been  shown  by  Calmette  to  be  that  of  comparative 
experiments.  After  carefully  graded  hypodermic  in- 
jections to  determine  how  much  poison  may  kill  a  kilo 
of  animal  (mostly  rabbits),  the  following  table  has 
been  worked  out : 

I  gm.  of  cobra  and  aspis  kills 4,000  kilo  of  rabbit. 

I        "      hoplocephalus  kills 3.45° 

I        "      fer  de  lance  and  pseudophis  kills. . .       800       " 

I       "      Crotalus  horridus  kills 600 

I       "       Pelias  berus  kills 250 

'  Tliese  observations  should  be  further  confirmed,  for  the 
general  impression  given  is  that  of  ordinary  wound  infection  with 
subsequent  sepsis. 


RECORD. 


405 


But  even  this  method  has  not  yet  yielded  undisputed 
results,  for  Martin  claims  for  hoplocephalus  4,000 
and  for  pseudophis  2,000  kilo.  At  any  rate  the  tox- 
icity of  snake  venom  is  exceedingly  high.  A  com- 
parison with  the  toxins  of  infectious  diseases  as  calcu- 
lated to  this  date  shows  that  only  that  of  diphtheria 
conies  up  to  4,000  kilos,  toxopeptone  to  3  kilos,  and 
the  albumose  of  anthrax  to  not  more  than  80  gm. 
Besides  the  high  toxicity,  it  is  also  the  extremely  rapid 
absorption  and  consequent  early  appearance  of  grave 
'symptoms  which  distinguish  snake  venom  from  other 
toxins. 

Leaving  out  the  most  serious  cases,  e.g.,  when  both 
fangs,  and  especially  those  of  a  large  tropical  snake, 
have  thrown  their  full  dose  of  poison  into  the  tissues, 
the  prognosis  is  not  so  bad  as  is  generally  believed. 
\\'eir  Mitchell  gives  the  mortality  of  crotalus  bites  in 
one  place  as  twenty-five  per  cent.,  in  another  as  not 
more  than  twelve  per  cent.;  that  of  the  Australian 
snakes  is  said  to  be  only  seven  per  cent.  It  has  been 
mentioned  how  quick  an  amelioration  may  set  in  even 
after  the  most  serious  nervous  symptoms  have  preceded. 
This  is  undoubtedly  a  reason  why  so  many  remedies 
have  gained  the  undeserved  reputation  of  being  a  sure 
cure.  Most  of  the  patients  would  ha\e  reco\ered  with- 
out them. 

This  leads  me,  then,  to  the  treatment  of  snake  bites. 
It  is  not  my  object  to  pass  in  review  all  the  reme- 
dies recommended  and  used.  It  would  take  the  whole 
evening  merely  to  read  a  complete  list  of  them.  Be- 
sides the  whole  pharmacopoeia  of  minerals,  vegetables, 
and  chemicals,  there  have  been  at  all  times  all  possi- 
ble substances  in  use  which  had  the  temporary  reputa- 
tion of  being  infallible.  Such  an  array  of  remedies 
has  forever  been  the  proof  of  our  utter  helplessness — 
an  example  which,  to  our  regret,  is  not  without  paral- 
lel in  other  ailments.  The  object  of  treatment  is 
fourfold:  first,  to  prevent  absorption  of  the  poison; 
second,  to  destroy  or  neutralize  it;  third,  to  accelerate 
its  elimination;  fourth,  to  treat  .symptoms  of  imminent 
danger.  If  the  wounded  limb,  e.g.,  a  finger,  cannot  be 
amputated  quickly,  at  least  the  circulation  should  be 
checked  or  retarded  by  a  ligature  as  practised  since 
time  immemorial.  A  ligature  is  ap[)lied  as  tight  as 
possible,  not  only  at  one,  but  at  two  or  three  places; 
e.g.,  when  a  finger  has  been  bitten,  round  the  finger  it- 
self, at  the  wrist,  and  at  the  elbow.  The  experienced 
Wall  is  so  convinced  of  the  advantages  of  Esmarch's 
bandage  that  he  not  only  recommends  every  physician 
in  India  to  have  one  in  readiness,  but  wants  to  see  it 
in  every  well-regulated  household.  The  ligature  is 
relaxed  at  intervals  of  some  hours  to  prevent  gangrene, 
but  is  applied  again  as  soon  as  practicable. 

It  has  been  an  often-recommended  custom  to  suck 
the  wound  with  the  lips  or  to  apply  cups.  The  result 
of  such  a  measure  is  at  least  doubtful,  because  of  the 
finely  punctured  bites;  the  sucking  ought  to  be  pre- 
ceded by  a  long  scarification  into  the  deeper  "tissues. 
It  is  still  safer  to  excise  a  large  area  of  these  tissues 
or  destroy  them  with  the  actual  cautery.  Wall,  taught 
by  long  experience,  recommends  proceeding  in  the  most 
ruthless  manner.  By  these  means  the  absorption  of 
poison  can  be  limited  to  a  possible  minimum  so  that 
that  the  system  shall  gain  time  to  overcome  the  whole 
quantity  at  intervals.  How  reliable  a  good  ligature 
may  be  is  demonstrated  by  a  case  reported,  in  which 
the  effect  of  a  fatal  dose  was  arrested  for  sixteen 
hours,  but  after  the  ligature  was  loosened  death  oc- 
curred within  two  hours.' 

The  next  question  is:  Are  we  able  to  render  innocu- 
ous the  poison  in  the  tissues  surrounding  the  bite? 
This  leads  us  to  a  whole  series  of  specifics,  which  owe 
their  reputation  partly  to  old  traditions,  partly  to  ex- 
periments in  the  test  tube.     The  majority  of  these  spe- 

'  Weir  Mitchell  :  Smithsonian  Contribution,  1861,  p.  3. 


4o6 


MEDICAL    RECORD. 


[September  15,  1900 


cifics,  which,  it  is  true,  neutralize  the  poison  in  vitro 
after  a  shorter  or  longer  period  (carbolic  acid,  e.g.,  only 
after  twenty-four  hours),  destroy  all  tissues  to  such  an 
extent  that  it  seems  preferable  to  apply  the  cautery. 
Even  the  much-praised  permanganate  of  potassium, 
recommended  especially  by  Lacerda,  of  Rio,  has  not 
fulfilled  the  high  expectations,  for  neither  locally  ap- 
plied in  a  one-per-ccnt.  solution  nor  injected  intrave- 
nously has  it  the  elective  faculty  to  single  out  snake 
venom  for  o.\idation  in  presence  of  other  proteids. 
One  per  cent,  of  chromic  acid  has  gained  somewhat  of 
a  reputation  ;  it  does  not  destroy  the  tissues  simulta- 
neously with  the  poison,  but  it  merely  makes  them 
shrink.  Calmette  has  frequently  tested  hypochlorite 
of  lime  in  a  solution  of  i :  60;  he  found  both  its  local 
and  repeated  hypodermic  application  as  well  as  its 
internal  administration  of  good  effect;  not  less  so  a 
one-per-cent.  solution  of  chloride  of  gold  as  a  local 
remedy. 

Ammonia,  extensively  used  internally  and  externally, 
is  notliing  but  a  stimulant.  Feoktistow  actually  ad- 
vises against  it,  because  he  thinks  he  has  seen  after  its 
use  increasing  hemorrhages  caused  by  higher  blood 
pressure.  Neither  has  alcohol  any  local  effect  as  a 
coagulating  medium;  it  is  to  be  rated  also  as  a  mere 
stimulant.  It  has  always  met  with  appreciation  on 
the  part  of  the  real  or,  more  so,  of  the  alleged  victim. 
Indeed,  the  use  of  this  infallible  specific  has  often 
been  carried  to  such  an  extent  that  it  was  impossible 
to  decide  whether  the  patient  succumbed  to  snake 
venom  or  to  an  acute  alcoholism.  It  is,  moreover,  a 
fact  that  intoxicated  persons,  when  bitten  in  this  state, 
have  not  proved  to  be  better  protected  against  snake 
bites  than  sober  people ;  and  the  enormous  doses  which 
we  often  hear  of  as  having  been  administered  deserve 
nothing  but  condemnation. 

If,  then,  the  chances  of  neutralizing  the  poison  /// 
loco  are  limited,  we  may  ask  if  we  can  hasten  the  ex- 
cretion of  the  injurious  substance.  The  kidneys  are 
attacked  to  a  greater  or  lesser  degree  by  the  poison, 
especially  that  of  vipers;  hence  it  is  doubtful  whether 
we  should  be  permitted  to  increase  their  activity. 
The  vicarious  excretion  by  perspiration,  stimulated  by 
diaphoretics,  has  also  had  dubious  results.  It  has 
been  demonstrated,  however,  that  part  of  the  poison 
is  excreted  by  the  stomach.  Alt,  of  Munich,  found 
that  alkaloids,  chiefly  morphine,  after  hypodermic  use 
were  excreted  by  the  stomach  almost  to  one-half  of 
their  amount.  When  he  tried  the  same  method  for 
snake  venom,  it  was  discovered  that  the  animals  whose 
stomachs  were  washed  out  were  saved,  whereas  the 
controls  died ;  at  the  same  time  the  washed-out  fluid 
was  again  poisonous  to  other  animals.  Hence  it  is 
probable  that  the  use  of  the  stomach  pump  may  be  of 
good  service.  Those  of  you  who  have  read  a  minute 
description  of  or  have  personally  witnessed  the  snake- 
dance  of  the  Moki  and  Zuni  Indians  of  Arizona,  will 
remember  that  after  the  performance  the  dancers  who 
are  sometimes  bitten  by  the  snakes  receive  a  potion 
prepared  by  the  priests,  which  contains  an  emetic. 
Then  the  whole  crowd  stand  around  a  certain  part  of 
the  parapet  to  empty  their  stomachs  freely.  This  cus- 
tom has  undoubtedly  been  sanctioned  by  long  experi- 
ence. 

Finally  to  settle  upon  a  definite  method  of  rational 
treatment,  it  will  be  necessary  to  proceed  in  a  regu- 
lar clinical  way,  in  order  to  find  the  proper  indi- 
cations for  therapy.  What  are  the  prominent  morbid 
changes  which  threaten  life?  Are  they  irremediable 
or  are  they  transient.^  That  they  are  not  irreme- 
diable is  proved  by  the  many  individuals  who  survive 
a  snake  bite  in  spite  of  the  gravest  symptoms.  We 
have  seen  that  the  poison  exerts,  first,  a  iiremolytic  ac- 
tion; second,  a  destructive  influence  upon  the  cells  of 
the  medulla.     We  know  at  present  of  no  pharmaceuti- 


cal remedy  which  will  arrest  either  the  escape  of  the 
hamoglobin  into  the  plasma  or  the  rupture  of  the  ca- 
pillaries. Maragliano,  in  his  experiments  with  the 
blood  in  infectious  diseases,  found  that  a  globulicidal 
faculty  had  developed  in  the  plasma  (/.t-.,  that  erythro- 
cytes were  easily  dissolved  in  such  bloodj,  and  that 
this  probably  depended  upon  a  diminution  of  the  pro- 
portion of  salts  in  the  plasma.  If  these  results  be  di- 
rectly applicable  to  our  question,  it  is  to  be  expected 
that  tiie  intravascular  introduction  of  chloride  of  so- 
dium would  be  of  some  value  in  desperate  cases  of 
haemolysis.  It  is  worth  a  trial  not  only  in  future  ex- 
periments, but,  on  account  of  its  relative  innocuous- 
ness,  in  any  case  of  fresh  rattlesnake  bite.  The 
effective  remedy,  however,  which  we  now  possess  will 
be  spoken  of  in  conjunction  with  the  other  groups  of 
symptoms  to  which  we  proceed  directly.  These  symp- 
toms we  have  found  to  be  due  to  the  toxic  action  upon 
the  central  nervous  system.  The  changes  in  the  gan- 
glion cells,  the  dissemination  and  disappearance  of 
the  Nissl  granules,  whatever  this  may  mean,  must  be 
fully  reparable,  since,  as  we  have  seen,  rehabilitation 
takes  place  rather  suddenly.  If  we  are  not  able,  there- 
fore, to  re-establish  their  function  immediately,  could 
we  not  at  least  tide  over  the  dangerous  period  of  deep 
depression?  One  method  suggests  itself  to  a  medical 
mind,  /.<■.,  artificial  respiration.  The  heart-beat  ceases 
several  minutes  later  than  respiration,  and  in  one  ex- 
periment Fayrer  succeeded  in  keeping  up  the  circula- 
tion for  eight  hours  longer  by  artificial  respiration. 
Fayrer  and  Lauder  Brunton  strenuously  recommend 
that  it  be  continued  not  only  for  hours  but  for  days, 
with  or  without  a  tracheal  cannula.  This  advice  seems 
to  have  fallen  somewhat  into  oblivion,  especially  since 
Martin  claims  that  in  poisoning  by  Australian  snakes 
he  saw  no  good  results  from  artificial  respiration, 
death  occurring  in  spite  of  it  in  fifteen  minutes  after 
the  heart  stopped.  Notwithstanding  some  failures  we 
are  justified  in  trying  it  for  an  extended  time,  always 
keeping  in  mind  that  an  abrupt  change  may  set  in  in 
the  most  desperate  cases. 

In  this  connection  we  have  to  consider  a  remedy 
which  even  recently  has  been  praised  with  certain  per- 
sistency as  a  specific;  I  mean  strychnine.  First  used 
by  Pringle  in  Australia,  it  was  tested  in  India,  and  in 
spite  of  the  little  encouraging  reports  was  enthusias- 
tically championed  by  Dr.  Muller,  of  Sydney.  He 
declared  the  failures  were  due  to  insufficient  doses, 
and  he  began  with  a  dose  of  at  least  0.0 1  gm.,  repeated 
several  times  until  slight  tetanic  symptoms  appeared.' 

Many  cases  in  Australia  have  been  treated  with 
strychnine,  and  upon  the  advice  of  the  government, 
Indian  surgeons  have  also  used  it  quite  extensively. 
Nevertheless,  the  results  are  not  so  convincing  that 
we  could  rely  upon  this  drug  as  a  specific.  The 
experiments  of  Kanthack  and  Feoktistow  were  nega- 
tive; interesting,  however,  is  the  latter's  positive  ex- 
periment that  artificial  tetanus  brought  on  by  strych- 
nine was  arrested  by  snake  venom.  Roux"  states  that 
tetanus  antitoxin  has  a  certain  influence  u])on  snake 
poison,  but  not  inversely.  Atropine  has  been  recom- 
mended as  a  stimulant  for  the  respiratory  centre.  I 
do  not  find  many  instances  of  its  use  recorded,  but 
fail  to  see  why  it  should  not  be  resorted  to  as  well  as 
stryciinine. 

This  prompts  me  to  relate  the  few  instances  in 
which  snake  poison  has  been  used  therapeutically. 
Dr.  Amaden,  of  Glens  Falls,  near  Lake  George,  a 
country  abounding  in  rattlers,  cured  a  man  aged  twenty- 

'  The  tolerance  toward  strychnine  seems  to  be  quite  extraor- 
dinary in  these  cases  :  thus  gr.  §  was  used  in  the  case  of  a  boy 
thirteen  years  of  as:e  within  three  and  tliree  i)uartcr  hours,  gr.  \ 
in  five  and  one-half  hours,  gr.  J  in  four  and  one-half  hours,  gr. 
Ij^d  in  seven  liours.  gr.  4  in  si.t  days. 

''  .\nnales  I'asteur,   l8().|. 


September  15,  1900] 


MEDICAL    RECORD. 


407 


five  years  with  unmistakable  tetanus  by  two  injections 
of  one  drop  of  fresh  rattlesnake  poison.  It  should  be 
mentioned  that  snake  venom  has  been  used  in  an  un- 
systematic way  for  several  other  diseases,  e.g.,  yellow 
fever,  of  course  without  success.  Recently  it  has  been 
asserted  that  during  the  plague  in  India  some  success- 
ful inoculations  of  cobra  poison  (,'„  and  j',  V\)  were 
made,  and  that  some  similar  e.xperiments  in  monkeys 
gave  equally  good  results.  Later  correspondence,  how- 
ever, is  silent  regarding  these  experiments. 

The  therapeutics  of  snake-bite  were  in  this  state  of 
hopelessness  when  a  few  years  ago  Calmette,  and 
almost  simultaneously  Fraser,  of  Edinburgh,  surprised 
both  the  scientific  and  the  lay  world  with  an  antiven- 
omous  serum.  It  is  to  serum  therapy  and  immuniza- 
tion, as  we  shall  presently  see,  that  we  have  to  look 
for  the  successful  treatment  of  snake-bites. 

Regarding  this  topic  the  question  first  arises:  Are 
there  animals,  as  often  atifirmed,  which  are  immune  to 
snake  poison?  In  East  India  the  mongoose,  a  kind 
of  weasel,  the  deadly  enemy  of  the  cobra,  has  the  rep- 
utation of  immunity;  and  in  Europe  the  droll,  bris- 
tled hedgehog  (Erinaceus  europaeus)  is  considered  the 
natural  destroyer  of  the  viper.  More  accurate  observ- 
ers have  shown  that  the  mongoose  owes  its  apparent 
immunity  to  a  certain  low  susceptibility,  but  more  to 
its  agility,  and  that  the  hedgehog  is  partly  protected 
by  its  spinous  coat;'  it  possesses,  however,  a  higher 
resistance  to  snake  poison  than  other  animals,  and 
from  my  own  investigations  I  might  figure  a  resistance 
of  about  four  times  that  of  a  rabbit  of  equal  weight. 
A  relative  immunity  toward  various  toxins  is  well 
known  to  exist  in  different  animals.  The  poisonous 
snakes  themselves  possess  a  perfect  immunity  against 
their  own  poison, •  the  species  with  weaker  poison  a 
relative  immunity  toward  those  with  stronger  venom, 
and  even  the  non-poisonous  snakes  enjoy  a  certain 
security  against  the  bites  of  the  poisonous  ones.'  This 
faculty  is  ascribed  to  internal  secretion,  to  the  inces- 
sant influx  of  toxin  into  the  circulation.  A  discovery 
of  Phisalix  corroborates  this  theory;'  he  found  in  the 
common  Tropidonatur  natrix  a  supralabial  gland  with- 
out a  duct,  which  contained  a  poisonous  secretion.  The 
king-snakes  of  our  Southern  States,  which  are  the  ene- 
mies and  destroyers  of  our  poisonous  serpents,  seem 
to  enjoy  a  perfect  immunity.' 

The  idea  of  immunization  is  by  no  means  a  modern 
one.  Even  in  antiquity  we  hear  of  it,  and  among  sav- 
age tribes  of  ancient  and  modern  times,  wherever 
poisonous  snakes  abound,  attempts  at  protection 
against  snake  venom  are  made  under  various  forms, 
sometimes  connected  with  mystic  ceremonies.  The 
poison  is  either  taken  internally  in  the  fresh  state  or 
parts  of  the  dried  poison  glands  are  eaten  (as  practised 
in  South  Africa).  A  shepherd,  immunized  in  this 
way,  admitted  that  the  dried  gland  of  the  cobra  had 
an  intoxicating  effect,  which  he  compared  to  that  of 
Indian  hemp,  only  that,  whereas  the  latter  lost  its 
effect  gradually,  the  action  of  the  first  was  not  im- 
paired by  habit.  Or  it  is  used  as  an  inoculation 
(Serpa  Pinto).  Sometimes  one  of  the  reputed  an- 
tidotes is  employed,  as,  e.g.,  the  eiirados  de  culehras  of 
Mexico  employ  a  composite  plant,  Micania  guacho. 

Sewall,  of  Vnn  Arbor,  Mich.,  was  the  first  to  intro- 
duce methodical  inoculation  of  snake  venom  with  the 

'  Calmette  :   "  l>e  venin  des  serpents,"  1896. 

•'  Weir  Mitchell  finds  that,  at  least  in  some  cases,  crotalus  is 
not  immune  against  its  own  poison. 

^  Kayrer  ;  "  Thanatophidia  of  India.  "  I!ancroft:  Australasian 
Medical  Gazette.   1893. 

'  Societe  de  biologie,  December  26.  1S96. 

*  I  have  injected  a  king-snake  (Ophibolus  getulus)  of  Florida, 
of  700  gm.  weight,  with  i  gm.  of  fresh  moccasin  poison,  a 
quantity  which  can  never  be  injected  by  a  single  bite  of  the  larg- 
est venomous  snake.  With  the  exception  of  a  pronounced  local 
swelling  and  some  apparent  sick  feeling  for  a  few  days,  the  snake 
survived  this  experiment  well. 


idea  of  immunization.  His  experiments,  in  which,  by 
gradually  increased  doses,  he  made  his  pigeons  secure 
against  seven  times  the  lethal  dose  of  massasauga  poi- 
son, were  published  in  1887.  Calmette,  director  of 
the  Pasteur  Institute  of  Lille,  France,  after  a  series  of 
failures  succeeded  in  securing  immunity  and  at  the 
same  time  in  elaborating  a  protective  serum,  anti- 
venene,  which,  in  spite  of  some  weighty  opposition, 
must  be  considered  to-day  as  the  only  reliable  anti- 
dote to  the  deadly  action  of  snake  poison.  Calmette 
manufactures  antivenene  by  inoculating  with  cobra 
venom  or  with  a  mixture  of  cobra,  crotalus,  viper, 
and  hoplocephalus  venoms,  in  both  of  which  the 
hamolytic  agent  has  first  been  eliminated  by  heating 
to  80"  C.  The  inoculation  of  horses  has  been  carried 
on  for  three  successive  years.  Antivenene  acts  as  a 
full  protective  in  a  dose  of  from  5  to  20  c.c,  when  in- 
jected even  one  and  one-half  hours  after  the  introduc- 
tion of  venom.  A  number  of  reports  from  different 
parts  of  the  world  attest  the  curative  power  of  Cal- 
mette's  antivenene:  it  has  been  used  with  beneficial 
effect  in  East  India,  in  Egypt,  Africa,  and  in  the  VVest 
Indies  against  the  different  serpents  of  those  countries. 
Fraser,  who  worked  independently  of  Calmette  for  six 
years'  on  the  same  subject,  does  not  agree  on  all  points 
with  Calmette;  in  fact,  the  latter's  statements  have 
not  been  thoroughly  confirmed  by  the  Indian  physi- 
cians and  by  Martin,  of  Sydney.'  Not  only  has  con- 
troversy arisen  as  to  the  curative  value  of  antivenene, 
but  also  other  questions  have  been  stirred  up  in  rela- 
tion to  the  chemical  and  physiological  action  of  toxin 
and  antitoxin,  which  promise  to  be  of  the  greatest  im- 
portance in  settling  this  vital  problem  of  therapeutics. 
I  cannot  refrain  from  going  into  some  details  in  the 
controversy. 

First,  it  was  objected  that  Calmette  asserted  his 
antivenene  to  be  equally  effective  against  all  kinds 
of  venom,  in  direct  opposition  to  Behring's  law, 
that  every  toxin  requires  a  specific  antitoxin.  It 
should  be  noticed  that  Calmette's  horses  are  immu- 
nized with  a  venom  in  which  the  haemolytic  element 
has  been  destroyed.  Hence  while  he  may  work  out 
an  antitoxin  to  the  more  important  constituent,  the 
nerve  poison,  he  neglects  the  other  agent  entirely. 
Nevertheless,  experiments  seem  to  prove  that  the 
blood  is  acted  upon  as  well.' 

Another  objection  was  made  that  the  curative  power 
w-as  entirely  overrated,  since  Calmette  used  as  a  test 
for  estimating  its  value  only  the  minimum  test  dose 
of  poison.  Fraser  thus  calculates  that  for  a  man 
weighing  60  kilos  a  dose  of  330  c.c.  of  antivenene 
would  be  required — an  amount  which  because  of  its 
bulk  and  its  price  would  preclude  its  practical  employ- 
ment. Statistics  and  calculations  do  not,  however, 
bear  out  this  objection,  for,  with  rare  exceptions,  not 
more  than  the  lethal  dose  is  injected  by  the  snake  in 
the  average  instance.  At  the  same  time,  man  has 
more  resistance  than  the  animals  mostly  experimented 
upon — a  fact  which  may  be  considered  an  established 
law  is  that  the  larger  the  animal  the  less  susceptible 
it  is,  weight  for  weight. 

The  discrepancies  between  the  experience  of  Cal- 
mette and  that  of  Martin,  of  Sydney,  may  probably  be 
explained  by  the  difference  of  Australian  and  Indian 
snake  venom,  so  that  an  antivenene  elaborated  with 
.\ustralian  venom  may  have  more  curative  power  in 
Australia.  It  is  less  easy  to  account  for  the  many 
failures  of  the  Indian  surgeons  with  the  serum,  al- 
though good  reports  are  not  lacking.  An  experi- 
mental investigation  carried  out  by  Semple  and  Lamb 

'  Fraser  dries  his  antivenomous  serum,  in  which  state  it  is  said 
to  keep  indefinitely. 

•'  Intercolonial  .Medical  Journal  of  Australasia.  1897,  1898. 

'  Stephen  and  Myers  :  Journal  of  Physiology,  vol.  xxiii.,  p.  i. 
Stephen  :  Ibid.,  vol.  vi.,  p.  273. 


4o8 


MEDICAL    RECORD, 


[September  15,  1900 


at  the  medical  school  at  Netley  has  also  confirmed  the 
value  of  antivenene.' 

Another  point  of  contest  is  the  mode  of  action  of 
the  antivenene,  whether  it  is  chemical  or  physiological. 
\\hereas  C'almette  with  Roux  and  Buchner  insists  that 
antitoxin  elicits  or  stimulates  the  resistance  of  tissues, 
Fraser  and  Martin  assert  with  Behring  that  the  action 
can  be  only  chemical.  The  experiments  with  snake 
poison  and  its  antidote  point,  in  my  opinion,  positively 
to  chemical  action.  For  instance,  a  certain  amount  of 
antivenene  counteracts  a  minimal  lethal  dose  when  in- 
jected on  separate  points  of  the  skin,  whereas  j^L-  of 
this  quantity  mixed  with  the  venom  in  vitro  and  then 
injected  has  the  same  effect.  An  experiment  which 
was  negative  in  Calmette's  laboratory,  but  has  been 
decided  positively  by  the  accurate  Martin,  is  the  fol- 
lowing: A  certain  amount  of  venom  and  antivenene 
mixed  in  vitro  is  injected  without  injurious  conse- 
quences. Then  the  same  mixture  heated  to  68°  C.  (a 
temperature  which  renders  the  antivenene  inert,  but 
not  the  venom)  is  injected,  and  acts  as  if  no  antiven- 
ene had  been  added.  Only  when  the  mixture  is 
allowed  to  stand  at  least  twenty  minutes  is  the  venom 
neutralized,  and  heating  no  longer  arrests  the  effect 
of  the  antitoxin. 

Fraser-  recommends  the  introduction  of  antivenene 
into  the  bitten  limb  rather  than  into  distant  parts, 
and  its  administration  in  repeated  doses  instead  of  one 
large  dose.  Martin  advocates  intravenous  injection 
because  he  thinks  that,  whereas  venom  is  rapidly  ab- 
sorbed, antivenene,  probably  on  account  of  its  large 
molecular  size,  enters  the  circulation  slowly;  a  recom- 
mendation which  for  that  reason  he  extends  also  to  the 
use  of  antitoxin  in  severe  cases  of  diphtheria  or  tetanus. 

A  new  light  has  apparently  been  shed  upon  this 
topic  by  the  researches  of  Phisalix,  of  Paris,  who, 
while  experimenting  exclusively  with  viper  venom, 
has  found  many  substances  which  exhibit  a  decided 
antitoxic  action.  First  he  discovered  in  the  blood 
serum  of  eels  a  substance  which,  according  to  Mos- 
so's  researches,  has  a  similar  effect  to  that  of  snake 
venom,  only  that  larger  doses  are  required,  and  in 
the  poison  of  the  Japanese  salamander  ingredients 
which  serve  to  immunize  against  viper  venom.  Still 
more  surprising  was  the  similar  action  of  cholesterin, 
separated  from  biliary  calculi  and  from  carrots,  or 
that  of  tyrosin,  separated  from  bulbs  of  the  well- 
known  dahlia  and  also  from  mushrooms.  All  these 
bodies,  partly  of  vegetable  origin,  had  a  decided  im- 
munizing effect  against  viper  venom,  and  the  blood 
serum  of  animals  into  which  these  substances  had 
been  injected  had  an  exactly  similar  effect.  Very 
likely  we  have  to  add  to  these  many  vegetable  reme- 
dies which  have  had  more  or  less  established  reputa- 
tion as  snake  cures,  as,  c.,^.,  the  before-mentioned  Mi- 
cania  guacho.  All  these  substances,  however,  are 
capable  of  raising  the  resisting-power  of  the  organism 
but  little  above  the  minimal  lethal  dose  of  venom; 
they  have  no  effect  whatever  when  injected  simultane- 
ously with  the  poison,  but  if  introduced  at  least  twenty- 
four  hours  previously  they  create  an  immunity  of  some 
duration.  It  must  be  noted  that  all  these  substances 
are  the  highest  final  products  of  proteid  metabolism. 
I  must  not  forget  to  mention  the  similar  antitoxic  in- 
fluence of  the  suprarenal  glands,  the  administration  of 
which  is  a  therapeutic  measure  recently  come  into 
prominence;  their  cortical  substance  seems  to  be  more 
efficacious,  and  it  may  be  of  interest  to  know  that  the 
guinea-pig,  which  is  the  animal  most  susceptible  to 
snake  venom,  has  almost  no  suprarenal  cortex.'  It  is 
to  be  hoped  that  the  action  of  these  proteid  substances 
may  lead  us  to  a  definite  solution  of  the  relation  between 

'  British  Medical  Journ.-il,  1899,  i. 
'  British  Medical  Journal,  1895,  i. 
'Myers:  Lancet,  1898,  i.,  ii. 


toxin  and  antitoxin;  and  snake  poisons,  as  Martin 
points  out,  are  particularly  well  adapted  for  these  in- 
vestigations. They  have  the  great  advantage  of  being 
less  sensitive  than  other  toxins  to  light  and  heat,  and 
of  being  comparatively  easy  to  obtain  in  a  form  which 
preserves  a  remarkably  constant  composition. 

To  sum  up,  then,  the  most  commendable  treatment 
would  be : 

One  or  several  tight  ligatures  should  be  made  above 
the  wound,  followed  perhaps  by  deep  scarifications; 
then  injection  of  antivenene,  if  at  hand.  If  the  latter 
cannot  be  had,  injections  should  be  made  of  a  solution 
of  hypochlorite  of  lime,  i  to  60,  at  several  points  near 
the  bite  and  elsewhere.  Stimulation,  if  necessary,  by 
either  strychnine  or  atropine  or  alcohol;  hypodermo- 
clysis  of  physiological  saline  solution;  lavage  of  the 
stomach;  artificial  respiration  for  hours;  and,  not  least 
of  all,  continuous  encouragement  of  the  victim,  for  a 
deep  mental  prostration  goes  together  with  the  physical 
depression  of  the  nervous  centres. 

It  affords  me  great  pleasure  to  acknowledge  at  this 
place  my  obligation  to  Dr.  T.  M.  Prudden  for  many 
courtesies  bestowed  during  my  studies  on  this  subject. 

The  reports  of  Drs.  James  Ewing  and  Fred.  R. 
Bailey  regarding  the  changes  in  the  central  nervous 
organs  are  herewith  appended.  Both  gentlemen  were 
to  take  part  in  the  discussion  of  this  paper,  but,  having 
been  prevented  from  being  present,  they  sent  in  the 
following  statements: 

Dr.  James  Ewing :  The  changes  in  the  ganglion  cells 
of  the  rabbit  into  which  was  injected  moccasin  poison, 
I  found  by  Nissl's  stain  to  be  of  a  somewhat  specific 
type  and  of  extreme  grade.  The  appearance  of  the 
cells  was  that  of  general  disintegration  of  chromatic 
bodies  without  marked  loss  of  the  total  amount  of  the 
chromatic  substance.  The  outlines  of  the  Nissl  bod- 
ies were  completely  obscured ;  the  substances  had  been 
redeposited  in  finely  granular  form  all  over  the  cell 
body  and  even  in  the  pericellular  lymph  space.  In 
the  majority  of  the  large  stichochrcmes  neither  formed 
bodies  nor  reticulum  could  be  distinguished.  It  was 
evident  that  the  lesions  went  much  deeper  than  the 
chromatic  substance,  affecting  the  underlying  cyto- 
reticulum,  which  was  granular,  disintegrated,  in  places 
completely  destroyed.  The  nuclei  were  very  opaque, 
and  the  nucleoli  often  swollen  or  subdivided.  The 
dendrites  were  often  irregular,  shrunken,  or  detached. 
These  changes  constitute  a  true  acute  degeneration 
of  the  cell,  in  contradistinction  to  the  simple  disturb- 
ances of  chromatic  substance,  which  may  be  entirely 
physiological. 

I  think  the  changes  which  I  found  in  this  rabbit 
were  the  most  violent  in  the  whole  list  of  conditions 
included  in  my  experience  with  degeneration  of  gan- 
glion cells. 

Dr.  Fred.  R.  Bailey:  Rabbit  No.  i;  snake  poison, 
rapid  action.  The  cells  showing  changes  were  con- 
fined to  the  anterior  horn  of  the  spinal  cord.  Most  of 
these  cells  are  normal.  A  small  number  of  cells  pre- 
sent those  modifications  in  their  chromatic  elements, 
which  probably  evidence  the  early  stages  of  a  begin- 
ning acute  degeneration,  /.«•..  an  increase  in  the  gran- 
ularity of  the  chromophilic  bodies  and  a  fraying  out  at 
their  edges,  with  some  distinct  loss  in  chromatic  sub- 
stance. The  cyto-reticulum  is  normal.  The  nucleus 
may  be  normal,  or  there  may  be  an  intensification  of 
the  surrounding  membrane  and  a  thickening  of  the 
strands  of  the  nucleo-reticulum.  A  few  cells  are  found 
in  which  there  is  much  greater  loss  of  chromatin,  the 
cell  bodies  appearing  extremely  pale  and  no  distinct 
chromophilic  bodies  being  present. 

Rabbit  No.  2;  snake  poison,  long  action.  The 
character  of  the  lesion  is  the  same  as  in  the  preceding, 
but  much  more  advanced  and  involving  a  much  greater 
number  of  cells.      Changes  were  found  in  the  cells  of 


September  15,  1900] 


MEDICAL    RECORD. 


409 


the  (i)  cortex,  (2)  cerebellum,  (3)  olfactory  lobe,  mi- 
tral cells,  (4)  basal  ganglia,  (5)  medullary  nuclei,  (6) 
anterior  horn,  and  (7)  spinal  ganglia.  The  cells 
showing  the  most  marked  changes  were  the  anterior- 
horn  cells  and  the  Purkinje  cells  and  the  mitral  cells 
of  the  olfactory  lobe.  The  changes  were  those  of  later 
stages  of  acute  degeneration. 

Rabbit  No.  3;  heloderma,'  rapid  action.  The 
changes  were  almost  identical  with  those  found  in  rab- 
bit No.  I. 

Technique:  The  material  was  placed  in  a  four-per- 
cent, aqueous  solution  of  formalin  for  twenty-four 
hours,  then  passed  through  graded  alcohols.  Sections 
were  cut  in  celloidin  and  stained  by  Held's  modifica- 
tion of  the  Nissl  method,  i.e.,  erythrosin-methylene 
blue. 


A     FEW     CASES     OF      EROSIONS     OF     THE 
STOMACH. 

By    EDWARD   QUINTARD,    M.D., 

NEW    YORK. 

Under  the  heading  of  "Gastritis  ulcerosa  chronica 
anachlorhydrica  "  in  Xht  An/ii-f.  Verdauungs-Krank- 
heitcii,  vol.  vi.,  No.  i.  Dr.  Luigi  Sansoni,  of  'I'urin, 
describes  three  cases,  the  salient  features  of  each  of 
these  being  as  follows: 

When  the  stomachs  of  these  patients  were  washed 
out  during  a  fasting  condition  the  wash-water  was 
found  to  contain  little  pieces  of  mucous  membrane, 
and  furthermore  it  was  found  that  after  a  test  break- 
fast the  gastric  filtrate  of  such  patients  gave  either  a 
neutral  reaction  or  else  a  very  slight  acidity.  Again 
there  was  an  absence  of  free  hydrochloric  acid  and  a 
negative  or  doubtful  reaction  in  reference  to  lactic 
acid,  but  the  motility  of  the  stomach  was  good  and  in 
other  respects  the  stomach  was  normal.  From  a  con- 
sideration of  the  clinical  facts  above  named.  Dr. 
Sansoni  comes  to  the  conclusion  that  a  constant 
presence  of  these  pieces  of  superficial  mucous  mem- 
brane in  the  stomach  washings  existing  along  with  a 
hypo-  or  anachlorhydria — cancer  being  excluded — 
sigiiifices  a  chronic  superficial  ulceration  of  the 
stomach,  a  condition  which  he  would  describe  as 
'■gastritis  ulcerosa  chronica  anachlorhydrica." 

In  the  Medical  Record,  June  23,  1894,  Dr.  Max 
Einhorn  of  this  city,  in  a  pajjer  entitled  ''Clinical 
Observations  on  Erosions  of  the  Stomach  and  their 
Treatment,"  described  seven  of  these  cases  clinically. 
Previous  to  this,  although  such  "hemorrhagic  ero- 
sions "  h.id  been  observed  as  a  frequent  anatomico- 
pathological  occurrence,  notably  such  investigators  as 
R.  Virchow,  D.  Gerhardt,  C).  Hartung,  Langerhans, 
Ewald-Boas,  Jaworski,  and  Korcynzski  having  called 
attention  to  them — yet  to  Einhorn  belongs  the  credit 
of  having  first  grouped  these  cases  clinically,  at  the 
same  time  giving  their  history,  symptoms,  and  treat- 
ment. Dr.  Einhorn's  paper  was  followed  by  very  in- 
teresting ones  on  the  subject.  So  far  as  we  know 
these  papers  appeared  in  the  following  order:  P. 
Cohnheim,"  L.  Sansoni,'  Curt.  Pariser.'  Einhorn,'  L. 
Sansoni.' 

Let  us  refer  briefly  to  Dr.  Sansoni's  first  paper  on 
the  subject,  a  paper  entitled  '"  Sull'  importanza 
diagnostica  dei  frammenti  di  mucosa  gastrica  estratti 

'  The  saliva  of  Meloderma  horridum,  a  poisonous  lizard,  had 
been  used  for  poisoning  rabbit  No.  3. 

*  Archiv  fiir  Verdauungfs-Krankheiten,  Bd.  i.,  p.  274. 

'  Giornale  della  Reale  Accademia  di  Medicina  di  Torino,  Tanu- 
ar)-  15,  iSq;. 

■■  Medicinische  Revue  fur  interne  Medicin  und  Therapie.  Wien, 
April,  1S97. 

'The  Journal  of  the  American  Medical  Association,  Mav  20. 
iSgg. 

'  Archiv  fUr  Verdauungs-Krankheiten,  Bd.  vi.,  vol.  i. 


dallo  stomaco  digiuno."  In  this  article  Dr.  Sansoni 
describes  two  cases  in  which  he  found  small  particles 
of  mucosa  in  the  stomach  washings,  one  being  the  case 
of  a  young  woman  aged  twenty-six  years,  the  other  that 
of  a  man  aged  forty-two.  In  both  these  cases  ulcers 
were  believed  to  exist.  Furthermore  these  ulcers  were 
supposed  to  have  been  the  round  or  peptic  ulcer  in 
contradistinction  to  that  more  superficial  solution  of 
continuity  known  as  erosion,  for  Dr.  Sansoni  distinctly 
says,  in  speaking  of  the  case  of  the  young  woman  aged 
twenty-six,  after  discussing  whether  it  was  an  ulcer  or 
an  erosion:  "Taking  into  consideration  that  the  pain 
was  circumscribed  and  that  there  were  exacerbations  of 
this  pain  after  the  ingestion  of  food,  especially  if  it 
were  irritating  or  coarse  in  its  nature  (wine,  bread), 
the  diagnosis  of  ulcer  seemed  to  us  the  more  rational, 
and  as  such  it  was  treated."  And  again,  in  speaking 
of  the  man  aged  forty-two.  Dr.  Sansoni  says:  "The 
diagnosis  of  gastric  ulcer  is  certain  at  least  clini- 
cally." We  wish  to  emphasize  the  fact  that  in  these 
two  cases  it  was  evidently  the  round  ulcer  that  was 
meant,  as  we  wish  to  refer  to  this  statement  again. 
The  study  of  these  two  cases  leads  Dr.  Sansoni  to  con- 
clude that  "the  finding  of  such  pieces  of  mucosa  is 
not  only  a  symptom  of  mucous  gastritis  or  of  simple 
erosion  of  the  stomach,  as  claimed  by  the  authors 
above  quoted,  but  in  my  opinion  it  has  a  still  deeper 
significance  in  rendering  probable  a  case  of  suspected 
ulcer,  or  in  confirming  a  clinical  diagnosis."  ulcer  in 
this  case  again  evidently  signifying  the  round  or  peptic 
variety  of  ulcer.  Granting,  however,  that  in  these  two 
cases  there  existed  a  round  ulcer,  which,  after  carefully 
reading  their  histories,  does  not  appear  to  us  at  all 
certain,  this  by  no  means  signifies  that  the  finding  of 
such  small  pieces  of  mucous  membrane  in  the  stomach 
washings  speaks  for  ulcer.  It  would  merely  go  to 
show  that  from  time  to  time  in  the  stomach  washings 
of  patients  suffering  from  ulcer,  as  in  the  stomach 
washings  of  patients  suffering  from  a  variety  of  other 
pathological  conditions  of  the  stomach,  we  find  frag- 
ments of  the  mucosa.  But  why  Dr.  Sansoni  should 
have  arrived  at  such  a  conclusion  at  all  is  what  we 
fail  to  comprehend,  because  in  Dr.  Einhorn's  paper, 
mentioned  by  Dr.  Sansoni  in  this  very  article  of  his 
from  which  we  quote,  we  are  given  a  history  of  seven 
cases  of  erosions,  in  only  one  of  which,  and  that  a  very 
doubtful  case,  was  there  even  so  much  as  a  suspicion 
of  ulcer;  in  fact  they  were  proven  distinctly  to  be  not 
cases  of  ulcer,  but  of  erosion.  And  here  we  ourselves 
must  state  as  nearly  as  possible  what  we  mean  by  the 
term  erosion  in  contradistinction  to  the  term  ulcer. 
When  hereafter  in  this  article  we  speak  of  erosion  we 
shall  mean  a  superficial  solution  of  continuity  in  the 
gastric  mucous  membrane,  never  extending  as  deep  as 
the  submucosa  and  whose  edges  never  present  the 
elevated  indurated  margins  of  that  special  form  of 
ulceration  frequently  named,  after  the  author  who  was 
the  first  to  describe  it  graphically,  the  Cruveilhier 
ulcer,  or,  in  other  words,  the  round,  peptic,  or  hyper- 
peptic  ulcer.  This  statement  must  by  no  means  be 
construed  as  implying  that  we  mean  that  an  ulcera- 
tion and  an  erosion  are  two  different  processes  patho- 
logically, for  unfortunately  the  etiology  and  pathology 
of  such  lesions  are  at  present  most  vexed  and  undeter- 
mined. We  use  the  terms  as  distinct  in  order  to 
facilitate  the  clinical  description  of  such  cases. 

When  in  the  Archiv  Jiir  Verdauun<;s-Krankluiien  we 
come  to  read  Dr.  Sansoni's  second  paper  on  the  sub- 
ject, it  must  be  confessed  we  are  somewhat  confused. 
For,  in  this  last  paper  of  his,  we  find  before  reading 
very  far  that  what  Dr.  Sansoni  now  means  by  ulcer  is 
something  altogether  different  from  what  he  meant  in 
his  first  paper.  For  we  will  remember  that  in  his  first 
paper  Dr.  Sansoni,  in  reaching  a  diagnosis  in  the  case 
of  the  young  woman,  says :   "  There  was  reason  for  the 


4IO 


MEDICAL    RECORD. 


[September  15,  1900 


suspicion  that  at  the  very  least  there  was  a  solution  of 
continuity  in  the  stomach,  and  hence  an  ulcer,  or  at 
least  a  simple  erosion  of  the  mucous  membrane." 
Mark  you,  in  Dr.  Sansoni's  mind  at  this  particular 
time  there  vvas  a  distinction  to  be  made  between  an 
ulcer  and  an  erosion.  Three  years  back  when  he 
spoke  of  ulcer  he  meant,  as  we  have  already  shown, 
the  peptic  ulcer,  and  he  did  not  apply  the  term  of 
ulceration  to  erosion.  Let  us  now  see  wiiat  he  says  in 
this  second  paper  of  his.  After  describing  these  cases 
in  which  fragments  of  mucosa  were  found  in  the 
stomach  washings,  he  says:  "  Die  constante  Anwesen- 
heit  von  Schleimhautstiickchen  im  Wasser  der  im 
niichternen  Zustande  vorgenommenen  Magenausspii- 
lung  mit  Bestimmtheit  fiir  einen  ulcerativen  Process 
im  Magen  spricht.  Ueber  diesen  Gegenstand  bereitet 
jedoch  Herr  I'oggio,  ein  Schiiler  der  Klinik,  eine 
Arbeit  vor,  in  welcher  er  darthun  wird,  dass  die  mit 
dem  Spiilwasser  aus  dem  Magen  extrahierten  Schleim- 
hautstiickchen nicht  immer  durch  die  Sonde  losgelost 
werden,  wie  manche  behaupten,  soiidern  in  der  Mehr- 
zahl  der  Fiille  in  der  Magenhohle  schon  losgelost 
vorkommen  und  wirklich  eine  Continuitatstrennung 
der  Magenschleimhaut  anzeigen."  We  quote  in  full 
because,  in  the  first  place,  it  shows  that  what  Dr. 
Sanson!  now  means  by  ulcer  is  altogether  different 
from  what  he  meant  three  years  previously,  and  in  the 
second  place  to  state  that  the  hypothesis  which  his 
pupil  Herr  Poggio  conceived,  as  regards  the  exfolia- 
tion of  these  small  pieces  of  mucosa  in  these  cases,  is 
the  same  as  was  given  by  Dr.  Einhorn  in  his  original 
paper  on  the  subject  six  years  ago,  the  very  title  of 
which  paper  Dr.  Sansoni,  unfortunately  for  himself, 
seems  to  have  forgotten,  for  we  look  all  in  vain  for 
the  name  of  the  able  clinician  who  first  classified  the 
cases  clinically. 

We  learn,  then,  that  Dr.  Sansoni  to  all  practical 
purposes  has  come  to  regard  the  terms  erosion  and 
ulceration  as  interconvertible.  We  shall  not  dispute 
his  right  to  do  so,  and  we  really  should  think  nothing 
more  of  the  fact  were  it  not  for  the  last  paragraph  in 
this  second  article  of  his.  We  quote  again  :  "  Deshalb 
miisste  man  zwei  Formen  von  chronischer  ulceroser 
Gastritis  unterscheiden :  eine  mit  Hyperchlorhydrie 
und  eine  mit  Hypo-  oder  Anachlorhydrie.  Bei  der 
ersteren  liegt  das  typische  Cruveilhier's  che  Geschwiir 
vor,  bei  der  letzteren  handeltes  sich  um  obertlachliche 
Ulcerationen,  die  meistens  in  Tiefe  nicht  iiber  die 
Schleimhaut  hinaus  gehen,  jedoch  imponierende 
Hamatcmesen  und  vielleicht  auch  Perforation  herbei- 
fiihren  konnen.  Zu  dieser  letzteren  Form  diirften  die 
von  Dieulafoy  unter  dem  Namen  Exulceratio  simplex 
beschriebenen  Frille,  die  hamorrhagischen  Erosionen, 
wahrscheinlich  viele  der  von  den  Autoren  beschrie- 
benen Fiille  von  Magengeschwiir  mit  Hypo-  oder 
Anachlorhydrie  und  die  von  mir  beschriebenen  drei 
Falle  gehoren,  welche  letzteren,  wenn  sie  durch  weitere 
Untersuchungen  besonders  in  anatomischer  Hinsicht 
bestatigt  werden  sollten,  eine  besondere  Bedeutung 
haben  diirften.  Denn  auf  Grund  der  bei  ihnen  ange- 
troffenen  objectiven  Symptome,  niimlich;  i.  constantes 
Vorhandensein  von  diinnen  Magenschleimhautstiick- 
chen  im  Wasser  der  im  niichternen  Zustande  vor- 
genommenen Magenausspiilung;  2.  nicht  an  eine 
Geschwulst  in  der  Magengegend  und  Krebskachexie 
gebundene  Hypo-  oder  Anachlorhydrie,  ware  eine 
Diagnosticierung  der  Krankheit  intra  vitam  moglich, 
wahrend  sie  bisher  erst  bei  der  Autoj^sie  gemaciit  wurde. 
Diese  Form  verdient  wirklich  den  Namen  Gastritis 
ulcerosa  chronica  anachlorhydrica."  Let  us  take  the 
last  part  of  this  paragraph  first.  We  have  just  seen 
that  Dr.  Sansoni  uses  the  terms  erosion  and  ulcer  as 
interconvertible — in  other  words,  what  Dr.  Einhorn 
and  other  investigators  describe  as  erosions  Dr. 
Sansoni  describes  as  ulcers.     So  far  so  good  ;  but  why, 


pray,  anachlorhydrica?  What  about  the  seven  cases 
described  in  Dr.  Einhorn's  first  article —article  and 
author  so  unfortunately  forgotten  by  Dr.  Sansoni? 
Among  the  seven  cases  we  find  four  with  hypochlor- 
hydria,  two  which  might  be  termed  normal,  /,<•.,  total 
acidity  =  60;  and  one  of  hyperchlorhydria.  Again 
in  Dr.  Paul  Coiinheim's  cases — cases  it  is  true  viewed 
for  the  most  part  pathologically — yet  of  these  cases 
in  which  fragments  of  mucosa  were  found  in  the  wash 
water,  seven  presented  a  normal  acidity,  and  six 
hyperacidity.  Again,  in  the  very  able  article  by  Dr. 
Curt.  Pariser,  "  Ueber  hemorrhagische  Erosionen  der 
Magenschleimhaut,'"  '  an  article  as  yet  evidently  unseen 
by  Dr.  Sansoni,  in  only  one  case  was  there  hypo-acid- 
ity ;  in  both  others  the  acidity  was  normal.  Finally,  in 
Dr.  Einhorn's  last  report,  we  find  among  sixteen  cases 
one  of  hyperacidity,  three  of  normal  acidity,  seven  of 
hypo-acidity,  and  two  of  anacidity.  Now,  are  we  to 
suppose  for  an  instant — and  from  what  Dr.  Sansoni 
says  we  judge  that  this  is  his  idea — that  in  those  cases 
in  which  we  have  hyperacidity  we  have  to  deal  with 
the  Cruveilhier  ulcer,  and  that  in  the  cases  of  hypo- 
or  anacidity  we  are  dealing  with  cases  not  of  round 
ulcer  but  with  a  form  of  ulceration  absolutely  distinct, 
and  to  which  the  term  "gastritis  ulcerosa  chronica 
anachlorhydrica"  is  scientifically  applicable?  We 
say  emphatically.  No!  To  begin  with,  from  what  we 
have  said  the  term  employed  by  Dr.  Sansoni  is,  we 
believe,  a  manifest  misconception  of  the  case.  We  all 
know  that  the  round  ulcer  from  time  to  time  appears 
without  an  accompanying  hyperchlorhydria,  and  in  the 
cases  reported,  when  along  with  the  finding  of  the  frag- 
ments of  mucosa  there  existed  hyperacidity,  in  only 
one  case,  and  that  one  reported  by  Dr.  Paul  Cohnheim, 
was  there  even  a  suspicion  of  a  round  ulcer.  We  see, 
then,  that  these  fragments  of  mucosa  in  the  wash  water 
are  found  in  patients  when  the  secretion  varies  from 
that  of  hyper-  to  that  of  anacidity.  This  again  leads 
us  to  repeat  that  the  pathological  etiology  of  the 
various  forms  of  ulcerations  and  erosions  met  with  in 
the  stomach  is  as  yet  a  matter  of  much  controversy. 
It  is  quite  impossible  at  present,  it  would  seem,  to  say 
whether  the  forms  of  ulcerations  and  erosions  described 
by  Laine,  Dieulafoy,  Nauwerk,  Marfan,  etc.,  are  all 
one  and  the  same  lesion  in  different  states  of  evolu- 
tion, or  the  same  lesion  as  seen  under  different  patho- 
logical surroundings.  Wliat  we  can  say,  however,  is 
this,  that  clinically  there  is  a  difference.  In  fact,  we 
can  probably  say  that  ulcerative  and  eroding  processes 
are  met  with  under  the  following  clinical  aspects: 

(i)  The  patients  who  suffer  from  tuberculosis 
(mostly  in  the  terminal  gastritis  of  such  patients), 
puerperal  eclampsia,  alcoholic  gastritis,  atrophic  cir- 
rhosis, and  ursmia.  These  cases,  unless  hamatemesis 
or  perforation  supervenes,  run  as  a  rule  without  defi- 
nite gastric  symptoms,  and  for  the  most  part  have 
been  described  at  autopsy. 

(2)  The  patients  who  with  no  past  history  of 
stomach  trouble  suddenly  develop  a  terrific  hemorrhage, 
and  at  the  operation  or  autopsy  there  may  be  found  by 
careful  search  erosions  so  tiny  that  for  the  most  part  they 
are  best  seen  by  the  aid  of  a  magnifying  lens.  These 
little  erosions,  one  to  several  in  number,  are  very  super- 
ficial and  never  reach  the  submucosa,  the  cause  of  the 
"hemorrhagic  foudroyani  "  in  these  cases  being  the 
eroded  arteriole  running  at  the  base  of  the  erosion. 
This  is  the  exulceratio  simplex  so  beautifully  and 
graphically  described  by  the  great  clinician  Dieulafoy. 

(3)  The  round  ulcer  first  described  by  Cruveilhier 
with,  as  a  rule,  its  train  of  classical  symptoms. 

(4)  Cases  in  which  small  pieces  of  the  mucosa  are 
found  in  the  wash  water,  thus  showing  erosions,  a  defi- 
nite clinical  class  first  described  by  Einhorn. 

'  Medicinisclie  Kevue  fiir  interne  Medicin  und  Tlierapie,  Wien, 
April,  1897. 


September  15,  1900] 


MEDICAL    RECORD. 


411 


(5)  Primary  ulcers  from  known  specific  and  con- 
stitutional infections,  such  as  tuberculosis,  syphilis, 
etc.     These  ulcers  run  a  varying  course. 

(6)  Ulcers  appearing  after  serious  burns  of  the 
skin.  These  are  for  the  most  part  intestinal  and 
present  very  few  gastric  symptoms,  the  general  lesion 
masking  the  same. 

(7)  Ulcers  due  to  irritant  chemical  poisons,  car- 
bolic acid,  etc. 

As  the  following  cases  of  erosions  of  the  stomach 
came  under  my  personal  observation,  and  as  the  sub- 
ject is  quite  new,  it  will  be  of  interest  to  report  them 
in  full: 

Case  I. — October,  1897.  R.  H.  M ,  aged  thirty- 
five  years,  machinist,  of  good  habits  and  temperate. 
P'or  the  last  eighteen  months  he  has  not  chewed 
tobacco,  but  previous  to  this  he  used  fi\e  packages  a 
week.  He  has  naso-pharyngeal  catarrh.  He  has 
complained  of  gastric  troubles  for  the  past  three  years, 
and  has  a  bad  taste  in  the  mouth  all  the  time.  He 
feels  bloated  and  full  after  eating.  There  are  slight 
pains  after  meals,  but  the  quality  of  food  makes  no 
material  difference.  He  has  no  dizzy  attacks.  The 
bowels  are  constipated.  For  the  past  four  or  five 
months  there  has  been  an  exacerbation  of  these  symp- 
toms, and  the  patient  has  lost  several  pounds  in  weight. 

Status  pr.TKsens:  The  patient  is  somewhat  pale  and 
pinched.  'I'he  tongue  is  very  slightly  coated.  The 
thoracic  organs  are  normal.  There  is  some  pain  on 
pressure  over  the  epigastrium.  A  splashing  sound  is 
heard  just  below  the  navel. 

E.xamination,  C)ctober  7,  1897,  in  fasting  condition  : 
The  wash  water  contains  mucus,  and  entangled  in  the 
mucus  are  two  small  pieces  of  pale  gastric  mucosa 
(examined  microscopically)  and  one  loose  piece.  The 
wash  water  is  slightly  tinged  with  blood. 

October  8th:  Practically  the  same  results,  and  three 
pieces  of  gastric  mucosa;  the  water  is  slightly  tinged 
with  blood.  Later  gave  test  breakfast,  Ewald-Koas. 
Result:  hydrochloric  acid,  total  acidity  40;  no  lactic 
acid.  The  stomach  was  washed  with  warm  water  and 
sprayed  with  nitrate-of-silver  solution  2  :  1,000,  using 
the  Einhorn  atomizer. 

October  loth:  After  test  breakfast,  Ewald-Boas, 
hydrochloric  acid,  total  acidity  40.  The  wash  water 
contains  mucus,  but  no  particles  of  mucosa. 

October  i  2th  :  The  wash  water  contains  some  mucus, 
but  no  fragments  of  mucosa.  The  stomach  was  sprayed 
with  2  :  1,000  nitrate  of  silver.  From  this  time  on  the 
patient  felt  much  better.  He  gained  in  weight  several 
pounds,  but  the  belching  and  the  fulness  continuing, 
probably  owing  to  the  slightly  atonic  condition  of  the 
stomach,  cold  ablutions,  bitter  tonics,  and  exercises 
were  ordered  with  most  beneficial  results. 

Case  II. — J.  O ,  1897-99,  man  aged  forty-seven 

years,  a  chronic  drinker  for  years.  In  this  case 
Dr.  Einhorn  was  called  in  consultation,  and  the 
patient's  condition  is  described  under  No.  6  of  his 
last  series  of  cases.  The  following  facts  were  interest- 
ing in  this  patient's  case :  A  prolonged  or  desperate 
drinking-bout  invariably  ended  in  an  acute  attack  of 
gastritis.  Such  an  attack  would  last  from  three  days 
to  one  week  before  the  symptoms  would  subside.  As  a 
rule  gastric  lavage  was  practised  during  these  acute 
attacks,  and  although  mucus  was  always  found  in  the 
wash  water,  mucosa  fragments  were  not  always  present. 
Once,  however,  just  as  Dr.  Einhorn  and  myself  had 
gotten  this  patient  in  a  very  fair  condition — in  other 
words,  just  after  he  had  been  treated  for  erosions 
and  to  all  appearances  had  been  cured — he  again 
indulged  in  large  quantities  of  alcohol,  with  the  result 
that  the  mucosa  fragments  appeared  the  next  day  in 
the  wash  water.  It  was  interesting  to  note  that  when- 
ever such  pieces  of  mucosa  were  found  in  the  wash 
water  the  patient's  symptoms  were  more  aggravated 


than  at  any  other  time.  He  would  begin  to  lose 
weight,  and  his  face  became  pinched  and  at  times 
quite  haggard;  he  would  complain  that  his  food  hurt 
him,  of  great  weakness  on  exertion,  and  he  would  be- 
come much  more  nervous.  Finally,  whenever  the  spe- 
cial symptoms  described  manifested  themselves,  we 
would  wash  out  his  stomach,  with  the  result  that  we 
would  find  one  to  three  tiny  pieces  of  mucosa  in  the 
wash  water.  These  symptoms  extended  over  a  period 
of  several  years,  w  ith  intervals  of  several  weeks  between 
them,  and  at  times  when  the  patient  had  abstained 
several  weeks  from  alcohol ;  yet  it  must  be  remarked 
that  this  patient,  as  a  rule,  no  sooner  was  made  better 
than  he  again  succumbed  to  the  desire  for  drink,  and 
this  left  his  gastric  mucous  membrane  in  a  more  or 
less  constant  state  of  inllammation.  The  gastric 
spray  of  2:1,000  nitrate-of-silver  solution,  combined 
with  proper  diet  and  hydrotherapeutic  measures,  al- 
ways resulted  in  a  cure  so  far  as  the  erosion  went. 
Another  peculiarity  was  that  the  total  acidity  of  this 
patient's  gastric  filtrate  varied  greatly  from  time  to 
time.  As  a  rule  it  was  about  47-50,  but  at  times  as 
low  as  30  and  again  as  high  as  80,  the  hydrochloric 
acid  being  always  present.  The  blood  never  registered 
below  80  H.;  and  as  a  rule  registered  between  85  and 
go.  In  other  respects  there  was  absolutely  nothing 
abnormal.  The  urine  at  times  showed  evidences  of 
renal  hypera;mia,  i.f.,  a  trace  of  albumin  and  casts. 
The  albumin  and  the  casts  appeared  at  times  when  the 
indican  was  in  excess  and  when  the  normal  ratio  be- 
tween urea  and  uric  acid  or  between  the  mineral  and 
ethereal  sulphates  was  disturbed.  The  patient  finally 
died  following  the  effects  of  a  prolonged  debauch. 

Case  III. — May,  1898.     J.  A.  H ,  student,  aged 

twenty-one  years.  He  has  complained  for  two  years  of 
gastric  disturbances.  He  is  a  cigarette  smoker  and 
uses  alcohol  moderately.  During  the  past  six  months 
symptoms  have  become  worse.  He  complains  that 
food  hurts  him,  and  that  he  feels  weak;  at  times  he  has 
nausea,  and  if  indiscreet  in  diet  he  vomits  as  a  rule  on 
the  morning  of  the  following  day.  He  has  lost  con- 
siderably in  weight  during  the  past  few  months. 

Status  praesens:  The  patient  is  thin  and  pale,  and 
his  cheeks  are  somewhat  hollow.  The  heart  is  ir- 
regular and  somewhat  forcible,  what  might  be  called 
a  "smoker's  heart."  Lungs,  liver,  and  spleen  normal. 
There  is  some  tenderness  on  pressure  over  epigastrium. 

May  7th:  Test  breakfast,  Ewald-ljoas — total  acidity 
37,  hydrochloric  acid  -|-  ;  a  good  deal  of  mucus. 

May  8th  :  Lavage  in  the  fasting  condition.  Result: 
two  pieces  of  mucous  membrane  in  wash  water. 
Spray,  2  :  1,000  nitrate  of  silver. 

May  10th:  Lavage  in  the  fasting  condition.  One 
small  fragment  of  mucosa  and  some  mucus.  Spray, 
2  :  1,000. 

May  nth:  Lavage  in  the  fasting  condition.  Some 
mucus,  but  no  pieces  of  mucosa.  No  more  fragments 
were  observed,  but  as  there  was  every  evidence  of 
chronic  catarrhal  gastritis  the  patient  was  treated  for 
such  and  recovered. 

Through  the  great  courtesy  of  Dr.  Alexander  Lambert 
of  this  city,  I  have  the  following  ca.se  to  report: 

Man,  aged  fifty-two  years,  merchant.  He  began  to 
feel  weak  and  lose  flesh  last  January.  He  complains 
of  a  dull  oppression  back  of  the  sternum.  The  pain 
did  not  seem  to  be  increased  particularly  after  eating, 
but  it  was  worse  after  exertion,  and  again  the  pain 
seemed  worse  after  eating  if  the  patient  had  been  tired 
just  before. 

Status  praesens:  The  patient  is  slightly  anaemic. 
The  lungs  are  normal.  The  heart  is  slightly  enlarged 
toward  the  left,  but  nothing  more  than  exercise  would 
account  for.  There  is  a  slight  increase  of  the  second 
aortic  sound  with  a  slight  systolic  murmur  at  the  aortic 
area.     The   urine  is  normal,  with  a  normal  amount  of 


412 


MEDICAL    RECORD. 


[September  15,  1900 


urea.  A  week  latei,  a  double  murmur  was  found  at 
the  aortic  area,  which  sliowed  he  liad  atheroma  of  the 
valves.  He  was  given  potassium  iodide  gr.  v.  t.i.d., 
and  also  general  tonics.  The  patient  did  only  fairly 
well,  his  heart  souml  became  much  better,  the  diasto- 
lic murmur  disappearing  entirely  and  only  a  very  faint 
systolic  remaining,  and  the  e.xaggerated  snap  of  the 
valves  being  much  less  marked.  His  general  strength 
and  his  anaemia  were  better,  but  he  was  losing  tlesh, 
and  his  pain  back  of  the  sternum  persisted.  Under 
bitter  tonics  and  nux  the  symptoms  improved  some- 
what, but  by  no  means  disappeared.  The  patient  still 
felt  weak,  and  the  pains  still  persisting  back  of  the  ster- 
num, and  the  patient  not  having  regained  his  weight, 
a  carcinoma  was  susi^ected,  and  an  Ewald-Boas  test 
breakfast  was  given  and  expressed  an  hour  and  a  half 
afterward.  The  result  of  the  chemical  analysis  was  as 
follows:  Free  hydrochloric  acid  absent;  combined  hy- 
drochloric acid,  0.0548  per  cent.;  organic  acid  and 
acid  salts.  0.0730  per  cent.;  total  acidity,  0.1278 
per  cent.  Lactic  acid  (Boas  test)  presented  strong  re- 
action. This  was  followed  by  lavage.  In  the  wash 
water  were  found  three  small  pieces  of  gastric  mucous 
membrane,  which  being  sent  to  Dr.  Harlow  Brooks 
were  on  examination  found  to  be  absolutely  normal. 
After  this  the  stomach  was  washed  out  every  other  day 
for  four  days  with  a  dilute  soda  solution.  At  the  end 
of  ten  days  another  test  was  given,  the  chemical  report 
being:  Total  acidity,  0.264  per  cent.;  total  hydro- 
chloric acid,  0.085  P^'"  cent.;  combined  hydrochloric 
acid,  0.080  per  cent. ;  organic  acid  and  salts,  0.090 
per  cent. ;  trace  of  lactic  acid.  At  this  date  the 
patient  felt  much  improved;  the  pain  was  less,  he  felt 
much  stronger,  and  there  were  no  fragments  of  mucosa 
found  in  the  wash  water. 

June  8th  :  The  patient  returned  with  some  of  his  old 
symptoms.  He  feels  weak,  and  suffers  some  pain  and 
discomfort  back  of  the  sternum.  His  stomach  was 
washed  out  and  there  were  found  three  pieces  of 
mucosa.  The  stomacli  was  sprayed  with  a  solution  of 
nitrate  of  silver. 

June  itth:  Two  pieces  of  mucosa  were  found  in 
the  wash  water.  The  stomach  was  again  sprayed  with 
nitrate  of  silver. 

June  13th:  The  \va.sh  water  contained  one  piece  of 
mucosa.  The  treatment  with  nitrate  of  silver  was  con- 
tinued. 

June  15th:  The  wash  water  contains  no  pieces  of 
gastric  mucosa.  The  patient  expresses  himself  as 
practically  well. 

These  cases  reported  by  me  resemble  in  their 
principal  points  those  described  by  Einhorn;  that 
is  to  say,  in  these  cases  there  were  the  loss  of  flesh, 
the  pain  after  eating  not  very  intense,  the  exhaustion 
on  exertion,  the  pinched  and  more  or  less  haggard  look 
at  times,  and  finally  that  which  rendered  the  diagnosis 
positive,  namely,  the  repeated  finding  in  the  wash 
water  of  little  pieces  of  gastric  mucosa.  So  far  as 
treatment  is  concerned  it  would  seem  that  excellent 
results  are  to  be  ha<l  with  the  solution  of  nitrate  of 
silver  of  the  strength  of  2  :  1,000  or  stronger,  sprayed 
by  means  of  an  Einhorn  atomizur,  this  being  done 
every  other  day.  In  the  cases  reported  it  can  be  seen 
that  after  two  or  three  applications  of  the  nitrate-of- 
silver  solution  the  fragments  of  mucosa,  as  a  rule, 
ceased  to  appear  in  the  wash  water,  and  in  conjunction 
with  this  the  subjective  symptoms  and  the  general 
condition  of  the  patient  improved.  In  a  recent  con- 
versation with  Dr.  Einhorn  on  the  subject,  he  told  me 
that  of  late  he  has  been  using  with  seemingly  good  re- 
sults five  grains  of  the  extract  of  suprarenal  gland, 
powdering  the  stomach  with  this  amount  while  the 
latter  organ  was  in  the  fasting  condition. 

Our  conclusions,  similar  to  those  of  Drs.  Einhorn 
and  Pariser,  are  as  follows: 


(1)  That  from  time  to  time  we  see  patients  in 
whose  stomach  washings  are  repeatedly  found  small 
fragments  of  the  gastric  mucous  membrane;  on  an 
average  one  to  four  of  such  pieces  are  found  in  a 
washing,  their  size  varying  from  2  to  7  cm.  long  and 
about  2  to  3  cm.  wide;  that  the  repeated  finding  of 
such  pieces  of  mucosa  in  the  wash  water  shows  that 
we  are  dealing  with  a  case  of  erosion. 

(2 )  That  such  erosions  occur  under  varying  patho- 
logical conditions,  and  that  as  a  consequence  the  func- 
tional signs  vary  accordingly. 

(3)  That  the  exact  etiology  and  pathology  of  such 
erosions  are  at  present  not  definitely  known;  that  in 
the  great  majority  of  cases  at  least  where  such  tiny 
fragments  of  mucous  membrane  are  found  in  the  wash 
water  the  patient  gives  a  definite  and  peculiar  clinical 
history  distinct  from  that  of  round  ulcer  or  from  the 
exulceratio  simplex  described  by  Dieulafoy. 

(4)  That  as  a  consequence  these  cases  should  be  re- 
garded as  a  distinct  class  clinically  and  treated  as 
such. 


THE    RADICAL  TREATMENT  OF    TUBERCU- 
LOSIS  OF   THE   TESTIS. 

By   ALEXIS   V.    MOSCHCOWITZ,    M.D.. 

ADJfNXT  ATTENDING  SUKGEON,   MOl'NT  SINAI    HOSPITAL,   NEW   YOKK. 

It  is  a  well-recognized  and  universally  accepted  surgi- 
cal rule  that  when  dealing  with  cases  of  surgical  tu- 
berculosis a  thorough  and  far-reaching  removal  is  an 
essential  which  must  under  no  consideration  be  over- 
looked. Whenever  such  a  thorough  removal  is  not 
feasible,  either  on  account  of  the  involvement  of  vital 
organs  or  on  account  of  technical  difficulties  impos- 
sible to  overcome,  recurrence  of  the  tuberculous  proc- 
ess may  be  looked  for  with  almost  absolute  certainty. 

It  would  carry  me  far  beyond  the  scope  of  this  short 
communication  to  go  into  the  details  of  the  pathologi- 
cal anatomy  of  genital  tuberculosis,  but  for  a  thorough 
understanding  of  my  reasons  for  advocating  a  more 
radical  procedure  in  the  treatment  of  tuberculosis  of 
the  testicle,  I  may  be  permitted  to  recapitulate  briefly 
so  much  of  the  pathological  course  and  progress  of 
this  malady  as  goes  to  prove  the  correctness  of  this 
aim. 

It  has  not  as  yet  been  definitely  decided  whether  or 
not  there  can  be  a  primary  tuberculosis  of  the  genital 
tract  without  the  coexistence  of  a  tuberculous  focus  in 
some  other  part  of  the  body;  suffice  it  to  say,  for  the 
purposes  of  this  paper,  that  we  not  infrequently  see 
patients  who  consult  us  with  that  peculiar  nodule  in 
the  epididymis  which  experience  has  taught  us  to 
recognize  as  tuberculosis.  No  matter  whether  this  be 
a  primary  or  secondary  focus,  the  subsequent  course  of 
this  nodule  in  the  epididymis  will  be  mainly  as  fol- 
lows :  in  the  course  of  a  few  days,  or  at  the  most  a  few 
weeks,  the  tubercle  bacilli  will  be  carried  by  the  sem- 
inal secretion  into  the  corresponding  vas  deferens  and 
will  infect  this  at  first  in  its  scrotal  portion;  in  course 
of  time  the  infection  gradually  but  surely  travels  up- 
ward into  the  inguinal  and  abdominal  portions,  until 
the  entire  vas  deferens  up  to  the  seminal  vesicles  is  in- 
volved; very  soon  this  is  also  infected  and  becomes 
tuberculous.  The  next  step  is  the  infection  of  the 
corresponding  lobe  of  the  prostate. 

Up  to  this  stage  the  tuberculosis  has  run  an  insidi- 
ous and  a  more  subacute  or  even  chronic  course,  and 
has  not  as  yet  involved  any  of  the  vital  organs.  Un- 
less early  recognized  and  properly  treated,  the  process 
may  subsequently  very  readily  extend  to  the  posterior 
urethra  and  bladder,  with  secondary  infection  of  one 
or  both  ureters  and  kidneys.  The  testicle  itself  is  but 
rarely  involved,  and  if  so  only  by  contiguity  from  the 
affected  epididymis. 


September  15,  1900] 


MEDICAL    RECORD. 


41; 


In  exceptional  instances  the  progress  of  the  disease 
takes  place  in  the  opposite  direction;  that  is,  the  pri- 
mary focus  is  to  be  found  in  the  seminal  vesicle,  while 
the  disease  involves  only  secondarily  the  vas  deferens 
and  epididymis,  in  a  direction  opposite  to  the  one 
quoted. 

If  this  progress  and  extension  of  the  process  of  tu- 
berculous epididymitis  are  borne  in  mind,  it  does  not 
require  very  much  argument  to  prove  the  futility  of 
the  procedure  for  its  supposed  cure — namely,  castra- 
tion below  the  inguinal  ring,  or  castration  combined 
with  evulsion  of  a  part  of  tiie  intra-abdominal  portion 
of  the  vas  deferens,  as  recommended  by  Biingner," 
which  has,  with  very  few  exceptions,  been  the  practice 
up  to  the  present.  I  do  not  speak  of  the  various  pal- 
liative measures  in  use,  which  make  pretence  to  be 
radical.  Xo  one,  of  course,  will  deny  that  castra- 
tion alone  may  also  be  radical  at  the  beginning  of 
genital  tuberculosis — that  is,  at  that  stage  when  the 
entire  process  is  still  confined  exclusively  to  the  epi- 
didymis; unfortunately,  however,  the  disease  is  so  in- 
sidious in  its  onset  as  to  escape  the  attention  of  tlie 
affected  individual  at  this  stage.  It  is  self-evident, 
therefore,  that  a  method  for  more  radical  treatment  is 
clearly  indicated. 

Authorities  and  men  of  experience  differ  very  much 
regarding  the  extent  of  the  procedure  which  may  be 
termed  radical.  To  my  mind  we  can  then  only  speak 
of  radicality  when  we  may  be  reasonably  sure  that  we 
have  removed  every  portion  of  the  tuberculous  tissue, 
so  that  there  is  no  opportunity  given  for  a  subsequent 
development  of  new  tuberculous  foci.  In  view  of  what 
has  been  said,  it  is  but  natural  to  conclude  that  the 
radical  treatment  of  tuberculous  orchitis,  so  called, 
would  have  to  include,  besides  extirpation  of  the 
testis,  also  extirpation  of  the  entire  vas  deferens,  to- 
gether with  the  corresponding  seminal  vesicle.  Of  the 
various  procedures  possible,  I  take  the  liberty  to  rec- 
ommend the  following: 

Castration  is  performed  by  the  usual  method  and 
through  the  usual  scroto-inguinal  incision,  with  the  ex- 
ception tiiat  the  vas  deferens  is  primarily  not  divided 
at  the  level  of  the  vessels,  but  is  carefully  isolated 
from  the  other  structures  of  the  spermatic  cord  and 
left  in  connection  with  the  testicle;  then  as  mucli  of 
the  vas  deferens  is  pulled  out  of  the  inguinal  canal  as 
can  be  done  without  running  the  danger  of  tearing  it  off. 
After  placing  a  ligature  around  it,  it  is  divided,  and 
the  proximal  end  is  carefully  seared  with  a  Paquelin 
cautery,  so  that  in  the  subsequent  manipulation  no  op- 
portunity shall  be  given  for  any  exuded  material  to 
infect  the  ciiannel  of  the  vas  deferens,  between  the 
peritoneum  and  tlie  bladder.  After  removal  of  the 
testicle  the  external  incision  is  closed,  with  or  without 
drainage,  depending  upon  individual  cases.  The  pa- 
tient is  then  placed  in  the  lithotomy  position,  a  sound 
is  introduced  into  the  bladder  to  serve  as  a  guide,  and 
a  curved  incision  is  made  in  front  of  the  anus,  extend- 
ing from  one  tuberosity  of  the  ischium  to  the  other — • 
the  so-called  prerectal  incision  of  Zuckerkandl,  or, 
more  preferably,  Kocher's  "pointed  arch"  incision; 
after  division  of  the  superficial  and  deep  perineal  fas- 
cia, and  of  the  tendinous  union  between  the  bullio- 
cavernosus  muscle  and  the  external  sphincter  of  the 
anus,  the  urethra  being  held  to  the  front  by  a  blunt 
retractor,  the  space  between  the  rectum  and  urethra  is 
deepened  by  blunt  dissection,  until  the  levator  ani,  or 
more  particularly  its  anterior  portion,  the  so-called 
levator  prostata;,  is  reached.  Tliis  is  then  divided  by 
a  pair  of  scissors,  the  divided  muscle  retracts,  and  the 
prostate  and  the  diseased  seminal  vesicle  are  reached 
by  the  palpating  finger.  The  finger  of  the  left  hand 
is  now  introduced  into  the  rectum,  and  hooked  over 
the  upper  border  of  the  prostate;  traction  is  exerted, 
and  it   is  surprising  how   much  of  the  prostate  and 


seminal  vesicle  can  thus  be  brought  into  view.  Should 
this,  however,  be  impossible  on  account  of  adhesions, 
the  seminal  vesicle  may  be  grasped  by  a  clamp  and 
gentle  traction  and  manipulation  may  then  be  made  to 
liberate  it  further.  Proceeding  in  this  manner,  the 
entire  unruptured  seminal  vesicle  and  the  remaining 
portion  of  the  intra-abdominal  part  of  the  vas  deferens 
are  brought  into  view  (that  the  entire  vas  deferens  is 
being  extirpated  can  be  recognized  by  the  attached 
ligature  and  the  seared  surface).  The  seminal  vesicle 
and  vas  deferens  are  by  this  time  attached  only  by  the 
ejaculatory  duct,  which  can  be  readily  cut  off.  Tam- 
ponade of  the  wound,  and  possibly  the  insertion  of  one 
or  two  sutures  into  each  angle  of  the  perineal  incision, 
terminate  the  operation. 

I  have  had  occasion  to  operate  on  but  one  case  by  this 
method,  and  must  confess  that  at  the  time  of  the  op- 
eration it  was  unknown  to  me  that  other  surgeons  had 
operated  by  similar  methods.  Though  the  duration  of 
the  operation  was  somewhat  prolonged,  because  of  its 
novelty  to  me,  I  was  very  much  impressed,  not  only 
by  its  feasibility,  but  particularly  by  the  ease  with 
which  the  extirpation  of  the  seminal  vesicle  can  be 
effected  by  tliis  method. 

B.  \V ,  thirt3'-five  years  of  age,  married,  a  native 

of  Roumania,  barkeeper  by  occupation,  was  admitted 
to  Mt.  Sinai  Hospital  on  August  18,  1899.  There 
was  no  history  of  hereditary  tuberculosis;  he  denies 
lues,  but  confesses  to  potus.  The  patient  complains 
since  four  months  of  pain  in  the  left  testicle,  at  which 
time  he  also  noticed  a  small  nodule,  which  gradually 
became  larger  and  harder;  there  was  pain  also  in  the 
left  groin.  He  had  no  sexual  impairment.  There 
was  considerable  loss  of  flesh  and  strength.  Physical 
examination  led  me  to  suspect  the  integrity  of  the  left 
lung,  but  there  were  no  definite  symptoms  of  a  tuber- 
culous affection.  The  left  testicle  was  of  normal  size 
and  consistence ;  within  the  epididymis  a  hard  nodular 
tumor  was  found,  about  the  size  of  a  walnut,  painful 
on  pressure,  but  not  markedly  tender ;  the  vas  defer- 
ens could  be  distinctly  traced  up  to  the  inguinal  ring, 
firmer  than  normal,  and  about  the  thickness  of  a  small 
pencil.  Rectal  examination  showed  the  left  seminal 
vesicle  to  be  the  size  of  a  thumb,  and  bulging  nipple- 
like into  the  rectum.  The  genital  organs  of  the  right 
side  were  normal.  The  examination  of  the  sputum 
and  of  the  expressed  secretion  from  the  seminal  vesicle 
and  prostate  gland  for  tubercle  bacilli  proved  nega- 
tive. 

Operation  was  done  on  August  22d,  under  chloro- 
form narcosis.  An  incision  was  made  in  the  left  in- 
guinal region,  extending  a  short  distance  downward 
upon  the  scrotum.  As  the  patient  was  averse  to  los- 
ing the  testicle,  and  as  at  the  time  of  the  operation  it 
appeared  to  be  perfectly  healthy,  I  contented  myself 
with  the  extirpation  of  the  epididymis.  In  other  re- 
spects the  operation  was  finished  as  above  described, 
Kocher's  prerectal  incision  being  used.  It  is  to  be 
regretted  that,  possibly  through  inadvertence,  the 
sound  introduced  as  a  guide  into  the  bladder  was  dur- 
ing the  operation  found  to  have  perforated  the  urethra; 
the  rent,  however,  was  immediately  sutured,  and  a 
permanent  catheter  was  introduced  into  the  bladder. 
The  duration  of  the  entire  operation  was  one  hour  and 
fifty  minutes. 

Dr.  Mandlebaum,  pathologist  to  the  hospital,  was 
good  enough  to  examine  microscopically  the  specimens, 
and  confirmed  the  clinical  diagnosis  of  tuberculosis  of 
the  extirpated  parts  in  every  respect. 

The  subsequent  course  was  uneventful,  marred  only 
by  persistent  vomiting,  due  to  a  marked  alcoholic  gas- 
tritis. The  patient  was  discharged  five  weeks  later  with 
a  minute  urinary  fistula,  which  subsequently  closed 
spontaneously.  He  presented  himself  to  me  in  No- 
vember of  the  same  year  for  examination,  entirely  cured 


4H 


MEDICAL    RECORD. 


[September  15,  1900 


as  regards  the  local  tuberculosis,  but  with  well-marked 
symptoms  of  tuberculosis  of  the  left  apex,  to  which  he 
succumbed  four  months  later. 

A  research  of  the  literature  pertaining  to  the  sub- 
ject has  shown  to  nie  that  the  e.vtirpation  of  the  sem- 
inal vesicles  for  tuberculosis  has  been  carried  out  a 
limited  number  of  times,  viz.: 

Ullmann"  was  the  first  surgeon  to  extirpate  tiie  sem- 
inal vesicle  for  tuberculosis.  After  having  performed 
castration  for  right-sided  tuberculous  epididymitis,  he 
was  enabled  to  watch  the  progressive  development  of 
tuberculous  vesiculitis;  hence  five  weeks  after  the  cas- 
tration he  extirpated  through  a  Zuckerkandl  incision 
the  right  seminal  vesicle  with  the  abdominal  portion 
of  the  vas  deferens,  and  also  the  affected  left  seminal 
vesicle,  but  not  the  left  vas  deferens;  incidentally  he 
also  extirpated  a  paa-sized  tuberculous  abscess  from 
the  right  prostate.  The  patient  was  discharged  with 
a  perineal  urethral  fistula,  which,  however,  closed 
spontaneously. 

Villeneuve,  quoted  by  Guelliot'  in  a  communica- 
tion to  the  Congress  for  Advancement  of  Sciences, 
Marseilles,  1 891,  reports  a  case  of  extirpation  of  the 
epididymis,  vas  deferens,  and  seminal  vesicle  by  an 
extensive  incision  in  the  inguinal  region  and  pushing 
back  the  posterior  layer  of  the  peritoneum  toward  the 
median  line. 

Roux,  of  Lausanne,*  reports  two  cases  of  extirpation 
of  the  seminal  vesicle  and  vas  deferens  for  tubercu- 
losis, by  a  perineal  incision  similar  to  Wolfler's  para- 
rectal incision;  after  division  of  the  pedicle  of  the 
seminal  vesicle,  he  sutured  the  overlying  structures, 
so  as  to  avoid,  if  possible,  the  formation  of  a  urinary 
fistula.  One  patient  recovered,  while  the  other  died 
shortly  afterward  of  tuberculous  basilar  meningitis. 

Routier,  quoted  by  Guelliot,'  extirpated  through  a 
Kraske  incision  a  tuberculous  seminal  vesicle,  which 
caused  compression  of  the  rectum,  and  obtained  a  cure. 

Schede*  tells  briefly  of  two  cases  of  extirpation  of 
the  seminal  vesicles  for  tuberculosis,  with  temporary 
resection  of  the  sacrum  by  Rydygier's  method,  and  ob- 
tained a  complete  cure  in  both  cases.  Incidentally  he 
criticises  Biingner's  method  of  castration  with  evulsion 
of  the  vas  deferens,  as  he  believes  that  the  vas  deferens 
is  more  likely  to  tear  off  just  at  a  weak  tuberculous 
infiltration  and  not  in  healthy  tissue. 

Weir'  relates  a  case  of  double  castration  and  com- 
plete extirpation  of  the  vesiculae  seminales  and  vasa 
deferentia  for  tuberculosis.  On  the  right  side,  while  he 
was  trying  to  extirpate  the  seminal  vesicle,  apparently 
by  Villeneuve's  method,  the  peritoneum  was  torn,  but 
was  immediately  sutured.  The  operation  was  finished 
by  a  prerectal  incision.  The  patient  was  discharged 
with  a  urinary  fistula,  which  closed  spontaneously  in 
seven  weeks. 

A.  G.  Gerster"  extirpated  at  the  Mount  Sinai  Hos- 
pital in  1894  a  seminal  vesicle  for  tuberculosis, 
through  a  Villeneuve  incision,  and  obtained  a  good 
result.  The  patient  died  two  years  later  of  pulmonary 
phthisis. 

Fenger'  is  reported  to  have  extirpated  the  seminal 
vesicle  and  vas  deferens  for  tuberculosis,  together  with 
a  small  abscess  in  the  prostate,  through  a  perineal  in- 
cision after  Roux.     The  patient  was  cured. 

Guelliot'  gives  an  excellent  account  of  the  surgery 
of  the  seminal  vesicles  and  reports  two  cases  of  extir- 
pation for  tuberculosis.  In  the  first  case  a  complete 
cure  was  obtained  by  high  castration  and  extirpation  of 
the  seminal  vesicle,  through  a  perineal  incision  which 
encircled  the  anus  for  about  two-thirds  of  its  circum- 
ference. In  the  second  case,  involving  both  sides,  the 
following  were  the  operative  steps:  ( i)  Castration  on 
the  right  side;  (2)  incision  and  curettage  of  left  epi- 
didymis; (3)  extirpation  of  the  right  seminal  vesicle 
by  morcellement,  through  a  perineal  incision;  (4)  tes- 


ticular prothesis.  The  patient  retained  a  urinary  fis- 
tula, and  died  two  and  a  halt  months  after  the  opera- 
tion, of  acute  phthisis. 

Moullin"  reports  two  cases  of  excision  of  the  seminal 
vesicle  for  tuberculosis  through  a  perineal  incision, 
and  obtained  a  complete  cure  in  both  cases.  The  sec- 
ond case  was  complicated  by  a  urinary  fistula,  which, 
however,  closed  spontaneously. 

From  these  reported  cases  it  will  be  seen  that  the 
seminal  vesicle  may  be  attacked  surgically  by  three 
different  methods:  (1)  ISy  the  inguinal  route;  (2)  by 
the  sacral  route;  (3)  by  the  perineal  route.  A  com- 
parison of  the  three  methods  will,  I  believe,  result 
very  favorably  for  the  perineal  route,  as  it  has  certain 
undeniable  advantages  over  the  others,  which  cannot 
be  underestimated.  Operation  by  the  inguinal  route 
appears  to  me  to  be  very  difficult,  and  the  extensive 
stripping  off  of  and  not  impossible  injury  to  the  peri- 
toneum cannot  be  an  indifferent  matter;  furthermore, 
the  extreme  depth  in  which  the  operation  has  to  be 
carried  out  bars  an  inspection  and  treatment  of  the  pos- 
sibly infected  prostate.  The  sacral  route  in  any  of  its 
numerous  modifications,  with  or  without  resection,  or 
by  a  parasacral  incision,  certainly  does  expose  the  parts 
in  question  in  a  most  beautiful  manner,  but  the  opera- 
tion and  dissection  are  necessarily  so  extensive  as  not 
to  be  entirely  devoid  of  complications  and  dangers. 
Finally,  there  remains  only  the  perineal  route,  which, 
as  already  pointed  out,  is  devoid  of  many  if  not  all  of 
the  dangers  inherent  to  the  other  methods,  is  compar- 
atively simple  and  easy  of  execution,  and  exposes  the 
parts  in  question  in  a  perfect  manner. 

In  the  performance  of  this  operation  there  may  arise 
many  circumstan.res  which  may  necessitate  slight 
modifications  in  the  technique;  but  as  by  this  method 
the  parts  are  fully  exposed,  it  is  but  proper  to  individ- 
ualize. It  may,  for  instance,  not  be  necessary  to  ex- 
tirpate the  testicle  (and  there  are  some  patients — for 
instance,  as  in  the  case  above  reported — who  are 
averse  to  losing  this  organ,  though  it  may  have  become 
unnecessary  and  not  functionating,  through  the  extir- 
pation of  its  efferent  duct),  particularly  when  it  is  tak- 
en into  consideration  that  the  testis  proper  is  involved 
but  very  late  in  the  disease,  and  even  then  not  by  me- 
tastasis, but  by  contiguity  from  the  epididymis.  I  can 
well  see  that  in  such  cases  it  might  be  permissible  to 
extirpate  only  the  epididymis  with  the  vas  deferens 
and  leave  in  place  the  testicle.  When  in  doubt  re- 
garding the  testicle,  we  may  go  one  step  further  and 
bisect  it,  so  as  to  bring  its  stroma  to  inspection.  It 
is  perhaps  needless  to  add  that  in  those  cases  in  which 
the  testicle  is  not  extirpated,  care  must  be  taken  not 
to  injure  the  spermatic  artery  and  veins  within  the 
cord,  as  in  either  instance  the  nutrition  of  the  testicle 
will  be  so  much  impaired  that  its  removal  may  become 
imperative. 

A  decided  advantage  of  this  operation  is  that  it  en- 
ables us  to  inspect  and  palpate  the  corresponding  lobe 
of  the  prostate;  a  localized  nodule  witliin  the  sub- 
stance of  the  gland  may  be  extirpated;  abscesses  may 
be  incised,  curetted,  and  drained. 

The  advantages  I  therefore  claim  for  this  operation 
are  its  ready  execution  and  the  possibility  of  remov- 
ing radically  all  the  diseased  tissues.  The  disadvan- 
tages of  the  operation  are  only  such  as  can  be  readily 
overcome  by  any  one  versed  in  the  general  surgical 
rules  of  procedure.  The  only  disadvantage  inherent 
to  the  operation  is  the  possibility  of  a  urinary  fistula 
arising  through  the  division  of  the  ejaculatory  duct, 
but  even  this  closes  in  a  majority  of  instances  sponta- 
neously. The  indications  and  contraindications  for 
the  operation  are  those  generally  observed  and  recom- 
mended for  tuberculosis  of  the  testicle. 

Although  at  the  time  of  the  operation  (.August, 
1899)  it  was  unknown  to  me  that  a  radical  operation 


September  15,  1900] 


MEDICAL    RECORD. 


415 


for  tuberculosis  of  the  testicle  had  been  attempted  by 
the  perineal  route,  it  is  far  from  me  to  claim  the  least 
bit  of  originality  for  this  procedure,  my  only  claim, 
if  it  can  be  honored  by  so  dignified  a  name,  is  a  slight 
improvement  in  its  technique.  In  concluding,  I  would 
express  the  hope  that  this  operation  may  be  given  a 
more  extended  trial  than  is  vouchsafed  me,  with  the 
limited  genito-urinary  service  in  the  surgical  division 
of  my  chief.  Dr.  A.  G.  Gerster,  to  whom  also  I  am 
gratefully  indebted  for  this  case. 

BIIU.IOCRAl'HY. 

1.  Bungner  :  Centralblatt  fur  Chirurgie,  No.  46,  1S93. 

2.  Ullmann     Centralblatt  fur  Chirurgie.  No.  8,   1890. 

3.  Guelliot      La  Presse  medicale.  April  20,  1898. 

4     Roux  :  Congres  franijais  de  Chirurgie,  1891,  p.  668. 

5.  Schede  .    Deutsche    niedicinische  Wochenschrift,  February 
15.  1894. 

6.  Weir:   Mf.dicai.  Rfcokd,  August  11,  1894. 

7.  Fenger  .  Senn's  Tuberculosis  of  the  Genito-urinary  Organs, 
Philadelphia,   1897. 

8.  Moullin  :   Lancet.  January  13.  1900. 
Q.    Personal  com..iunication. 

350  Wbst  Fifty-eighth  Street. 


A  CLINICAL  STUDY  OF  THK  LIVER  AS  A 
FACTOR  IN  ELIMIN.VriOX.  AND  IX  THK 
PRODUCTION    OF    .NEPHRITIS.' 

Bv    GEORGE   E.    DAVIS,    Mi)., 

LAWRENCEBt'RG.    KV., 
VICE-fRESlDENT   OF    THE    K'ENTICKV    STATE    M  F.DIC  Al.  ^OCIE  I  S'. 

At  Maysville,  in  May,  1898,  I  presented  a  paper  to 
this  society  entitled,  "The  Physiology  of  the  Liver 
and  the  Role  it  Plays  in  Digestion  and  Nutrition." 
You  may  deem  it  strange  that  I  make  another  inven- 
tory of  the  functions  of  the  liver,  and  small  wonder, 
when  we  remember  the  triteness  of  the  text.  If,  how- 
ever, there  is  a  lack  of  interest  manifested  in  paying 
our  respects  to  so  esteemed  a  friend,  our  indifference 
may  be  attributed  not  so  much  to  a  blunted  sense  of 
obligation  for  services  rendered,  but  rather  to  our  ig- 
norance of  the  mysterious  ways  he  works  his  wonders 
to  perform. 

Digestion,  nutrition,  and  elimination  constitute  met- 
abolism. Metabolism,  therefore,  comprises  those  nat- 
ural functions  and  processes  whereby  living  organ- 
isms maintain  vitality  and  being,  and  resist  the  im- 
pressions of  time  and  disease.  Thus  the  dynamics  of 
life,  beginning  with  the  cell,  are  the  chemical  and 
physical  activities  required  in  the  transformation  of 
energy,  involved  in  the  processes  of  digestion,  nutri- 
tion, elimination,  growth,  reproduction,  and  heredity. 

The  simple  cell,  as  well  as  the  differentiated  cell  of 
the  higher  or  complex  organism,  acting  under  normal 
conditions,  has  the  capacity  of  responding  to  tiie  pres- 
ence of  food  material  by  appropriating  it  to  its  own 
growth  and  multiplication,  and  of  oxygen  by  yielding 
to  disintegration  or  waste.  The  primary  and  inherent 
function  of  all  life  is  a  constant  change,  produced  by 
an  affinity  for  such  material  as  by  addition  constitutes 
nutrition  or  growth  on  the  one  hand,  and,  on  the 
other,  a  similar  affinity  for  oxygen,  by  which  oxidation 
and  disintegration  are  constantly  taking  place." 

Under  these  conditions  the  processes  and  functions 
are  termed  physiological.  However,  these  cells,  act- 
ing under  abnormal  circumstances,  as  the  presence -of 
micro-organisms,  are  cap.ible  of  responding  in  an  ex- 
aggerated manner  in  protecting  themselves  individu- 
ally, or  the  organism  of  which  they  are  a  component, 
against  the  toxic  influences  of  said  micro-organisms. 
This  capacity  of  the  cells  for  increased  activity  under 

'  Read  before  the  Kentucky  State  Medical  Society,  convened 
at  Georgetown.  May  9,  lo.  and  11,  1900. 

•Journal  of  the  American  Medical  Association,  July  i,  1899. 


adverse  circumstances  is  the  vis  medicatrix  naturae. 
Under  such  conditions  the  processes  and  functions  are 
termed  pathological. 

Therefore,  if  we  would  discover  the  secrets  of  the 
doctrine  of  organic  evolution  and  heredity,  and  under- 
stand the  functions  of  the  widely  differentiated  and 
closely  co-ordinated  cell  collections  composing  the 
several  organs  of  the  body,  we  are  admonished  to  study 
them  in  the  light  obtained  from  the  observation  of  the 
functions  of  the  simple  cell,  acting  under  physiologi- 
cal and  pathological  conditions. 

The  single  cell  is  the  simplest  form  of  organized 
life.  Its  existence  is  perpetuated  by  its  capacity  for 
selecting  and  imbibing  such  material  as  is  fit  for  its 
nutrition  and  growth  and  rejecting  that  which  is 
detrimental.  This  constitutes  cell-metabolism.  The 
human  body  is  an  aggregation  of  these  minute  organ- 
ized bodies  or  cells  into  a  variety  of  forms  or  struc- 
tures, each  having  some  special  function.  The  great 
structural  differentiation  attained  by  the  human  organ- 
ism opens  up  new  avenues  for  invasion  by  pathogenic 
agents,  however,  physiological  division  of  labor  has 
kept  pace  and  provides  special  functions,  not  only  to 
protect  the  organism  from  toxic  influences,  but  to  sus- 
tain and  nourish  it.  This  capacity  of  sustenance,  of 
selection  and  rejection,  of  assimilation  and  elimina- 
tion constitutes  body-metabolism. 

Therefore,  the  maintenance  of  the  natural  functions 
of  animal  life  and  its  vital  resistance  to  toxic  agents, 
resulting  eitiier  from  pathogenic  bacteria  introduced 
from  without,  or  from  the  retention  of  excrementitious 
products  of  tissue  disintegration  within,  depends  on 
the  activity  and  efficiency  of  metabolism,  or  the  proc- 
esses involved  indigestion,  nutrition,  and  elimination. 

The  agents  essential  for  normal  metabolism  in  the 
development  and  nutrition  of  the  blood  and  body  tis- 
sues are  wholesome  food,  pure  water,  and  fresh  air, 
and  the  proper  mechanism  of  suitable  organs  not  only 
to  elaborate  these  agents,  but  to  eliminate  from  the 
system  the  waste  products  evolved  in  their  elaboration. 
The  quality  and  quantity  of  the  blood  depend  on  the 
quality  and  quantity  of  the  food  material  and  air,  and 
on  the  efliciency  of  the  digestive,  respiratory,  and  elim- 
inative  organs.  The  blood  is  the  vehicle  by  which 
the  food  material,  after  it  has  been  elaborated,  is  dis- 
tributed to  all  the  tissues.  When  wholesome  food 
and  pure  air  have  been  supplied  and  the  digestive  and 
respiratory  mechanism  has  been  normal,  the  blood 
truly  is  the  life.  But,  as  the  blood  is  also  the  recipi- 
ent of  the  waste  products  of  disintegration,  nature  has 
provided  special  organs  for  the  elimination  of  said 
waste  products  or  other  harmful  agents  that  may  have 
gained  entrance  into  the  circulation.  The  kidneys 
are  specially  constructed  for  the  elimination  of  the 
waste  products  of  disintegration  from  the  blood,  which, 
if  retained,  would  poison  the  blood  and,  through  it,  all 
the  tissues;  and  in  this  instance  the  blood  becomes 
the  death.  .\nd  thus,  in  the  blood,  we  note  that  life 
and  death  tread  so  close,  their  paths  needs  must  touch. 

The  laws  of  physiology  decree  that  the  integrity  and 
vitality  of  the  body  and  its  different  organs,  in  the 
performance  of  their  several  functions,  are  dependent 
on  proper  blood  supply,  and  in  turn  the  blood  supply 
is  dependent  on  the  proper  functions  of  the  organs  in- 
volved in  metabolism,  and  though  elimination  is  the 
last  step  in  metabolism  it  is  not  the  least  important. 

I  have  purposely  dwelt  at  some  length  on  the  differ- 
ent steps  in  metabolism  in  order  to  emphasize  their  mu- 
tual interdependence  and  the  intimate  relation  between 
the  digestive  and  eliminative  organs.  Proper  elimi- 
nation is  dependent  on  proper  nutrition,  and  proper 
nutrition  is  dependent  on  proper  digestion.  Anything 
that  disturbs  digestion  will  disturb  nutrition,  which  in 
turn  will  pervert  elimination;  and  whatever  aids  di- 
gestion  favors  nutrition   and  facilitates    elimination. 


4i6 


MEDICAL    RECORD. 


[September  15,  1900 


Digestion,  nutrition,  and  elimination  constitute  a  cy- 
cle in  physiology,  and  since  digestion  is  the  first  step 
in  this  cycle,  it  is  most  liable  to  primary  derange- 
ments and  usually  is  the  origin  of  faulty  metabolism 
around  the  whole  circle;  though,  on  account  of  the 
intimate  relation  of  these  processes,  the  converse  may 
occasionally  prove  true.  The  derangements  of  diges- 
tion e.xplain  the  genesis  of  most  derangements  of  eli- 
mination, both  of  an  acute  and  of  a  chronic  character, 
and  affords  a  key  to  the  study  of  their  symptoms  and 
treatment.  The  liver  is  the  largest  and  most  complex 
gland  of  our  complex  body,  and  since  it  is  especially 
endowed  with  important  metabolic  functions  I  seek  to 
establish  its  intimate  relation  as  connecting-link  be- 
tween digestion  and  elimination. 

In  my  Maysville  paper,'  after  reviewing  the  physi- 
ology of  the  liver,  I  made  the  declaration,  "  that  the  liver 
is  the  most  important  digestive  organ  of  the  body," 
basing  the  claim,  first,  on  its  biliary  function  in  prepar- 
ing fats  for  absorption  and  digestion ;  and,  again, 
while  the  stomach,  pancreas,  and  intestines  perform 
the  primary  digestion  of  proteids  and  carbohydrates, 
the  liver  performs  the  secondary  digestion  and  elabo- 
ration of  these  materials;  truly  a  most  important  func- 
tion, for  it  has  been  shown  by  many  reliable  investi- 
gations that  the  normal  products  of  primary  digestion 
act  as  toxins,  or  foreign  bodies,  when  introduced  di- 
rectly into  the  general  circulation.  With  equal  plau- 
sibility, however,  I  could  have  made  the  declaration 
that  the  liver,  if  not  directly  through  the  bile,  is  indi- 
rectly the  most  important  eliminative  organ  in  the 
body,  if  we  are  to  accept  the  current  teaching  of  the 
physiology  of  the  liver  in  its  capacity  of  transforming 
the  products  of  disintegration  and  completing  the  re- 
trograde change  of  the  substances  from  non-diffusible 
colloids  into  crystalloid,  dialyzable  materials  before 
they  pass  into  the  kidneys  for  final  excretion.  jVIany 
investigations,  physiological  and  pathological,  make 
it  clear  that  the  hepatic  and  renal  functions  are  inti- 
mately connected,  the  chief  object  of  the  kidneys  be- 
ing to  excrete  certain  products  secreted  by  the  liver. 
Urea  is  thus  formed  by  the  liver,  which  is  returned  to 
the  blood  to  be  finally  eliminated  by  the  kidneys. 
And  since  urea  represents  the  greater  portion  of  the 
nitrogen  taken  into  the  body  in  the  way  of  food,  there- 
fore an  analysis  of  the  urine  should  be  a  good  test  of 
the  hepatic  condition.  Urea,  then,  in  a  measure,  con- 
stitutes a  fair  expression  of  the  retrograde  change  in 
nitrogenous  tissue  metabolism  and  to  tiiat  degree  pos- 
sesses definite  clinical  value. 

Renal  insufficiency,  therefore,  proclaims  preceding 
hepatic  insufficiency — disturbed  nutrition  and  auto- 
intoxication intervening.  Renal  inadequacy,  func- 
tional and  organic,  has  its  origin  most  frequently,  if 
not  invariably,  in  primary  hepatic  inadequacy  in  elab- 
orating the  products  of  both  constructive  and  destruc- 
tive metabolism.  The  kidneys  first  suffer  functional 
disturbance  because  said  imperfect  products  are 
brought  to  them  in  a  form  chemically  unable  to  pass 
through  them,  organic  change  supervening  as  a  result  of 
the  long-continued  irritation  occasioned  by  these  in- 
completed products  of  metabolism.  Especially  is  this 
liable  to  happen  to  those  who  indulge  in  over-feeding 
and  lack  of  exercise,  or  overwork,  mental  and  physical, 
producing  excessive  somatic  change,  and  lack  of  fresh 
air,  resulting  in  imperfect  oxidation,  which  further  em- 
barrass the  hepatic  functions.  Thus  we  can  easily 
conceive  how  the  blood,  overloaded  with  food  products 
imperfectly  elaborated  for  nutrition  and  products  of 
retrograde  change,  some  of  whicii  are  not  completely 
reduced  for  elimination,  will  act  as  an  irritant  to  the 
kidneys,  finally  producing  nephritis  with  albuminuria 
— thus  interfering  with  elimination  and  later  resulting 
in  auto-intoxication. 

'  Medical  Record.  September  17,  i8g8. 


And  need  the  hepatic  origin  of  renal  insufficiency 
and  degeneration  hardly  tax  our  credulity  when  we 
remember  the  intimate  relation  of  the  liver  through  its 
nerve  supply,  sympathetic  and  spinal,  not  only  with 
the  digestive  and  eliminative  organs,  but  also  with  the 
vital  processes  of  respiration  and  circulation.''  More- 
over, in  view  of  said  intimate  relation  of  the  hepatic 
functions  with  both  the  digestive  and  eliminative  or- 
gans, we  more  nearly  appreciate  the  prime  importance 
of  the  liver  in  metabolism,  and  understand  how  the 
pathology  of  Bright's  disease,  with  albuminuria,  may 
be  traced  to  hepatic  derangements,  which  cause  degen- 
eration as  a  consequence  of  the  long-continued  elimi- 
nation of  products  of  faulty  digestion,  resulting  from 
derangements  of  the  nutritive  and  disintegrative  proc- 
esses in  which  the  liver  plays  so  important  a  part; 
and  in  many  instances,  if  not  all,  the  liver  seems  pri- 
marily at  fault.  Again,  diabetes  mellitus  furnishes 
positive  clinical  evidence  of  faulty  elimination  of 
hepatic  origin,  and  I  need  hardly  remind  you  that  sac- 
charine urine  is  not  due  to  any  morbid  condition  of 
the  kidneys.  What  I  seek  to  emphasize  is,  that  sugar 
in  the  urine  indicates  functional  hepatic  derangement. 
However,  chronic  degeneration  of  the  kidneys,  with 
albuminuria,  may  prove  a  sequel  to  diabetes  as  a  con- 
sequence of  the  constant  irritation  of  the  saccharine 
urine. 

The  pathology  of  faulty  renal  elimination  has  its 
etiology,  then,  most  often  in  primary  functional  de- 
rangements of  the  liver  interfering  with  digestion,  nu- 
trition, and  disintegration,  but  the  deleterious  effects 
of  retained  products  of  imperfect  metabolism  are  man- 
ifested not  only  in  derangements  of  the  kidneys,  but 
in  derangements  of  the  nervous  system,  in  derange- 
ments of  the  organs  of  circulation  and  respiration,  and 
in  abnormal  conditions  of  the  skin,  etc.  Some  of  the 
remote  effects  of  the  functional  derangements  of  the 
liver  may  be  noted  in  impairment  of  the  voice;  as  wit- 
ness the  recent  retirement  of  Calve  from  the  stage,  on 
account  of  her  liver,  whose  functional  disturbance  has 
jarred  the  tones  of  a  voice  instinct  with  melody  divine 
— the  world  and  art  the  losers. 

The  indications  for  treatment  in  renal  insufficiency, 
then,  are  to  aid  digestion  and  nutrition  and  promote 
disintegration.  A  careful  regulation  of  the  diet  and 
free  supply  of  oxygen  by  fresh  air  are  of  the  first  im- 
portance. The  former  corrects  digestion  and  nutri- 
tion, and  the  latter  promotes  disintegration.  After 
these  come  cholagogues  and  alteratives,  which  favor 
digestion  and  promote  disintegration.  Often  the  best 
diuretic,  aside  from  water,  is  the  drug  that  touches  the 
liver  and  arouses  it  to  the  performance  of  both  its  di- 
gestive and  disintegrative  functions. 

The  liver,  primarily  by  its  digestive  functions  in 
completing  and  perfecting  the  elaboration  of  the  food 
materials  for  the  development  and  nutrition  of  the 
blood  and  tissues,  and  secondly  by  transforming  the 
waste  products  of  disintegration  into  soluble  or  dia- 
lyzable forms  for  elimination,  is  the  beginning  and  the 
end,  the  alpha  and  omega  in  the  cycle  of  metabolism 
— constructive  and  destructive — embracing  digestion, 
nutrition,  and  elimniation. 

With  tlie  presentation  of  the  arguments  I  have  briefly 
stated  I  submit  the  plausibility  of  my  claims — "that 
the  liver  is  the  most  important  digestive  organ  of  the 
body,"  and,  "  if  not  directly  through  the  bile,  indi- 
rectly through  urea  is  the  most  important  eliminative 
organ  of  the  body." 


Individual  Communion  Cups  have  been  introduced 
into  a  Congregational  church  in  Ipswich,  Kngland. 
Whether  or  not  this  hygienic  innovation  is  a  result  of 
the  recent  meeting  of  the  British  Medical  Association 
in  Ipswich  is  not  stated,  but  it  is  the  first  instance  of 
the  sort  in  England. 


September  15,  1900] 


MEDICAL    RECORD. 


417 


Asepsis  in  Obstetric  Practice.— James  U.  Bamhill 
says  that  before  the  days  of  antiseptics  the  death  rate 
in  the  Maternity  Hospital  of  Paris  from  i860  to  1864 
was  eleven  per  cent.  In  the  New  Vork  Maternity 
Hospital,  where  antiseptics  were  first  introduced,  it 
was  for  the  nine  years  preceding  1883  4.17  per  cent. 
The  great  value  of  strict  antisepsis  in  obstetrics  is 
insisted  upon,  as  is  the  necessity  for  observing  all  rules 
which  apply  to  aseptic  surgery.  Rules  for  disinfec- 
tion are  indicated.  It  is  suggested  that  societies  fol- 
low the  example  of  the  obstetric  section  of  the  New 
•York  Academy  and  adopt  resolutions  to  the  effect 
that  it  is  the  duty  of  every  obstetrician  to  surround 
the  parturient  woman  confined  in  her  home  with  the 
same  safeguards  against  infection  that  are  being  used 
in  hospitals. — An?ia/s  oj  Gynecology  atid  Pediatry,  Au- 
gust, 1900. 

Tonsillar  Obstruction  in  the  Fauces  and  Phar- 
ynx.— A.  W.  Francis  emphasizes  the  importance  of 
early  recognition  and  treatment  of  tonsillar  affections. 
Prominent  symptoms  formerly  attributed  to  the  faucial 
tonsil  are  now  known  to  be  due  to  adenoid  growths  in 
the  pharynx.  The  most  important  feature  of  these 
growths  is  the  relation  to  deafness  from  mechanical 
pressure  and  frequent  attacks  of  otitis.  The  main 
symptoms  are  a  sensation  of  a  foreign  body  or  lump  in 
the  throat,  frequent  ineffectual  efforts  to  swallow  some- 
thing beyond  reach,  sensation  of  constriction  about 
the  throat,  globus  hystericus,  frequent  "  clearing  of  the 
voice,"  voice  fatigue  after  moderate  effort,  evening 
hoarseness,  ill-defined  uneasiness  in  the  throat,  loud 
brassy  cough  at  puberty,  reflex  nervous  symptoms, 
palpitation  of  the  heart,  and  spasmodic  asthma.  The 
treatment  is  surgical. — Aiuials  of  Gynecology  and  Pedi- 
atry, August,  1900. 

Albuminuria  in  Young  Men H.W.  Syers  claims 

that  in  the  case  of  young  men  between  the  ages  of 
fifteen  and  twenty  or  twenty-five  years,  albuminuria  is 
often  found  which  is  not  a  symptom  of  renal  disease. 
As  albuminuria  can  be  induced  in  perfectly  healthy 
and  robust  individuals  by  exposure  to  cold,  the  author 
holds  that  many  of  these  cases  are  due  to  chilling  of 
the  surface  of  the  body,  as  in  open-air  bathing.  Why  al- 
bumin should  appear  more  readily  in  the  urine  in  some 
cases  than  in  others  in  which  the  same  exciting  cause 
is  present  can  be  explained  only  on  the  same  principle 
as  the  well-known  tendency  of  some  people  to  catarrh 
on  the  least  exposure.  When  examination  shows  en- 
tire absence  of  the  renal  heart  (hypertrophy of  the  left 
ventricle,  reduplication  of  the  first  or  accentuation  of 
the  entire  second  sound),  a  pulse  of  normal  tension, 
and  no  cedema  or  dyspna-a,  then,  if  there  are  no  casts, 
it  is  in  the  highest  degree  probable  that  the  kidne3's 
are  perfectly  sound.  Of  course  it  is  possible  that  if 
the  patient  is  likely,  from  carelessness  or  necessity, 
to  be  repeatedly  subjected  to  the  chilling  process, 
what  is  at  first  merely  an  ordinary  stasis  in  the  kid- 
ney might,  by  constant  repetition,  become  a  renal  in- 
flammation.—  The  Clinical  Journal,  August  i,  1900. 

Psychoses  Accompanying  Chorea. — Krafft-Ebing 
divides  the  mental  disturbances  sometimes  attend- 
ing Sydenham's  chorea  as  follows:  (i)  Elementary 
psychic  disturbances.  These  are  seldom  wholly  ab- 
sent, and  may  be  ascribed  in  part  to  the  general  neu- 
ropathy and  the  psjxhically  irritating  effect  of  the 
choreic  movements  and  in  part  to  direct  stimulation 
of  the  diseased  cortex.  They  comprise  variability  of 
temper,  nightmares,  evanescent  visual  hallucinations, 
etc.  (2)  Fleeting  fever,  delirium  of  light  grade.  (3) 
Symptoms  of  psychic  fatigue  evidenced  by  forgetful- 
ness,  impaired  cerebration,  lack  of  concentration, 
apathy,  incoherence,  deficient  food  absorption,  fever, 
etc.     (4)   Psychoses  in  the  stricter  sense,  originating 


from  the  same  infectious  source  as  the  chorea,  and 
presenting  simple  or  hallucinatory  confusion  going  on 
to  stupor  or  dementia.  (5)  Complicating  psychoses 
due  to  the  same  mental  condition  as  the  chorea  or 
arising  independently. —  Wiener  klinische  Rundschau, 
July  29,  1900. 

Gall  Stones — Dudley  P.  Allen  reports  ten  cases 
and  urges  various  considerations,  the  object  being  to 
establish  the  following  three  propositions:  (i)  That 
in  cases  of  continued  distress  in  the  epigastrium,  when 
a  physician  skilled  in  modern  methods  of  investiga- 
tion, both  clinical  and  physical,  can  make  no  positive 
diagnosis  and  give  no  relief,  an  exploratory  operation 
is  advisable.  How  it  is  to  be  completed  must  de- 
pend upon  what  is  found.  (2)  Oix;ration  under  such 
conditions  frequently  results  in  the  removal  of  gall 
stones,  or  the  setting  free  of  adhesions,  and  entirely 
relieving  the  patient's  suffering.  (3)  Such  opera- 
tions should  not  be  too  long  delayed,  since  the 
formation  of  dense  adhesions,  such  as  are  found  not  in- 
frequently, may  greatly  enhance  the  difficulty  of  op- 
erating and  endanger  the  life  of  the  patient. — Cleve- 
land Journal  oJ  Medicine,  August,  1900. 

A  Contribution  to  the  Statistics  and  Treatment 
of  Umbilical  Infection — Theodor  Escherich  regards 
it  as  of  great  importance  in  preventing  infection  in 
infants  by  way  of  the  umbilical  wound,  that  the  cord 
be  cut  close  to  the  body  and  only  a  very  short  stump 
left.  A  second  point  is  the  omission  of  the  full  bath 
until  the  stump  has  dropped  off.  In  his  experience 
no  untoward  results  have  been  noted,  and  the  chances 
of  infection  are  lessened.  A  suitable  covering  for  the 
stump  is  difficult  to  devise,  especially  for  use  in  in- 
stitutions in  which  time  and  expense  are  objects.  It 
should  be  easily  and  quickly  removable  and  cheap. 
\  form  he  recommends  consists  of  a  square  of  gauze 
fastened  around  the  body  by  a  pair  of  tapes  and  kept 
from  slipping  out  of  place  by  a  third  band  passing 
around  the  neck.  For  inspection  and  renewal  of  the 
dressing  it  is  simply  necessary  to  undo  the  lower  tape, 
and  the  flap  may  be  lifted,  uncovering  the  whole  um- 
bilical region.  If  the  stump  is  long  in  dropping  off 
or  does  not  desiccate  as  it  normally  should,  it  fur- 
nishes a  most  favorable  medium  for  the  growth  and 
development  of  infectious  organisms.  Simple' ampu- 
tation of  such  a  remnant  leaves  an  open  wound  which 
is  also  dangerous;  'hence  the  author  advises  removal 
of  the  persistent  portion  of  cord  with  the  Paquelin 
cautery.  This  disposes  of  the  offending  tissue  and 
also  seals  the  wound,  which  receives  a  dry  dressing  of 
airol. —  Wiener  klinische  Jiuttdschau,  July  29,  1900. 

The  Treatment  of  Necrotic  Acne  with  Sea-Water. 
— Linthlen  describes  as  acne  necrotica  a  form  charac- 
terized by  a  chronic  course,  frequent  relapses,  and  the 
formation  of  a  localized  induration  which  eventually 
develops  a  dark-colored  parchment-like  crust  lying  on 
a  level  with  the  skin.  If  this  be  removed  a  loss  of 
substance  is  revealed  extending  far  into  the  corium 
and  healing  into  a  deeply  sunken  scar.  Its  most  fre- 
quent site  is  on  the  face  in  the  bearded  region  or  at 
the  junction  of  forehead  and  scalp,  while  its  painful- 
ness  and  the  disfiguring  scars  produced  make  it  a 
really  serious  trouble.  None  of  the  remedies  gener- 
ally recommended  is  useful  for  this  form,  and  the 
author,  prompted  by  the  observation  of  one  of  his  pa- 
tients that  his  lesion  always  receded  in  summer  when 
he  bathed  frequently  in  the  ocean,  made  the  experi- 
ment of  trying  sea-water  as  a  local  application.  Com- 
presses saturated  with  a  one-half-per-cent.  solution  of 
the  sea-salt  of  commerce  was  left  on  over  night,  and 
by  day  a  lanolin  ointment  of  the  same  strength  was 
applied.  The  results  were  most  satisfactory;  the  ne- 
crosis was  promptly  checked,  healing  of  the  existing 


4i8 


MEDICAL   RECORD. 


[September  15,  1900 


lesions  was  promoted,  and  the  formation  of  new  ones 
apparently  permanently  prevented. —  H  icncr  kliuisc/n: 
Wocltensihrijt,  August  2,  1900. 

The  Abortive  Treatment  of  Bubo. — H.  M.  Chris- 
tian sa)s  two  methods  claim  attention,  the  abortive 
and  the  operative.  Too  little  attention  is  paid  to 
counter-irritation  and  pressure  as  a  means  of  averting 
a  cutting  operation.  It  must  be  applied  early  before 
pus  is  present.  It  is  useless  to  attempt  to  abort  a  tu- 
berculous adenitis.  Thirty  to  forty  drops  of  a  two-per- 
cent, carbolic-acid  solution  may  be  injected  into  the 
gland,  or  two  syringefuls  of  a  one-per-cent.  solution  of 
benzoate  of  mercury  with  sodium  chloride  3:1,000 
added.  The  best  results  are  obtained  at  the  Philadel- 
phia Polyclinic  by  the  application  of  equal  parts  of 
mercurial  and  belladonna  ointments,  lanolin  and  ich- 
thyol,  and  a  spica  bandage.—  Therapeutic  Gazette, 
August,  1900. 

Double  Heart  Beat.— G.  D.  Giuranna  says  that  a 
duplicated  beat  is  produced  by  an  abnormal,  super- 
numerary beat,  which  may  be  diastolic  or  systolic. 
(I.)  When  diastolic,  it  may  be  due  to  an  exaggerated 
wave  owing  to  overfilling  of  the  ventricles.  In  mitral 
stenosis  it  may  occur  because  of  the  increased  force 
with  which  the  blood  descends  at  the  beginning  of 
diastole  of  the  left  heart,  the  left  side  being  overfilled 
and  the  ventricle  drawing  in  the  blood  with  greater 
energy.  In  aortic  insufficiency  the  blood  regurgitates 
with  abnormal  force  into  the  left  ventricle,  striking 
against  the  walls  of  the  ventricle  and  raising  the  in- 
ternal pressure.  Double  diastolic  beat  may  in  mitral 
stenosis  be  the  expression  of  an  exaggerated  systole 
of  the  auricle,  in  which  case  it  will  be  presystolic. 
(II.)  When  systolic,  the  double  beat  may  be  due  to 
low  arterial  tension  in  proportion  to  the  systolic  en- 
ergy of  the  ventricle,  the  simple  muscular  contractions 
which  form  the  wave  not  blending  as  harmoniously  as 
usual.  This  form  of  double  beat  is  produced  in  the 
second  period  of  systole. — Giornale  Internazionale  delle 
Scienze  Aledkhe,  July  31,  1900. 

Ocular  Headaches. — W.  A.  Brailey  says  that  while 
the  great  majority  of  headaches  are  of  course  indepen- 
dent of  the  eyes,  it  is  a  matter  of  general  acceptance 
that  ocular  errors  produce  headaches,  though  by  no 
means  in  all  cases.  Muscular  errors  are  the  most  im- 
portant class  concerned  in  their  production.  Accom- 
modative movements  are  bound  up  with  a  great  num- 
ber of  ocular  headaches.  As  a  general  rule,  the  larger 
the  ocular  error  the  less  the  effect  produced  on  the  head, 
the  reason  being  that  a  great  defect  of  accommodative 
power  leads  to  its  abandonment,  the  patient  seeing  as 
iDest  he  can  without  it.  Low  degrees  of  hypermetropia 
and  hypermetropic  astigmatism  are  often  causes  of 
headache;  so  is  a  moderate  inequality  of  refraction, 
especially  if  astigmatic.  .Another  potent  factor  in 
headaches  is  the  tendency  to  binocular  vision,  and 
here  we  have  another  rule :  the  stronger  the  tendency 
to  binocular  vision  the  more  headache  produced  by  an 
error  of  the  recti  and  obliqui  muscles.  Ocular  head- 
aches are  most  frequent  between  the  ages  of  ten  and 
forty-five  years ;  women  are  the  greatest  sufferers,  and 
Americans  appear  to  be  more  affected  than  the  Eng- 
lish.—  The  Medical  Press,  August  15,  1900. 

The  Treatment  of  Hay  Fever.  —  K.  H.  Gleason 
says  that  liishop  has  called  attention  to  the  fact  that 
the  neurotic  condition  of  the  patient  and  the  hyper- 
sensitiveness  of  the  nasal  passages  are  often  due  to  an 
excess  of  uric  acid  in  the  blood.  Horsford's  acid 
phosphates  in  one-half  to  teaspoonful  doses  in  a  tumbler 
of  water  at  each  meal  gave  very  satisfactory  results. 
The  author  has  prescribed  nitro-muriatic  acid  in  doses 
of  three  to  five  drops  of  the  freshly  prepared  concen- 


trated acid  after  meals,  and  sometimes  also  at  night. 
The  dose  should  be  diluted  with  a  half-tumblerful  of 
water,  and  the  patient,  after  taking  the  medicine,  should 
rinse  out  his  mouth  and  swallow  another  half-tumbler- 
ful of  water.  The  hay-fever  symptoms  are  usually  re- 
lieved in  forty-eight  hours,  but  not  a  single  dose  must 
be  omitted,  or  some  symptoms  will  return.  Hyper- 
aesthetic  areas  upon  the  respiratory  portion  of  the  nasal 
mucous  membrane  should  be  touched  with  a  ten-per- 
cent, solution  of  chromic  acid,  after  cocainizing  the 
nose,  temporary  relief  may  be  obtained  during  the 
worst  stages  of  the  attack  by  spraying  the  nose  with  a 
weak  alkaline  one-per-cent.  solution  of  cocaine,  and 
afterward  with  fluid  vaseline  as  a  protective.  Good 
results  have  been  reported  from  the  local  use  of  a  ten- 
per-cent.  solution  of  the  extract  of  suprarenal  capsule. 
— International  Medical  Alagazine.  August,  1900. 

The  Treatment  of  Epilepsy  by  Fleisig's  Method 

J.  Seglas  and  Heitz  subjected  twenty-two  patients  to 
this  treatment,  which  consists  in  first  administering 
opium  in  progressive  doses  (up  to  i  gm.  daily  on  the 
twelfth  day)  for  six  weeks,  and  then  replacing  it  by 
potassium  bromide  7  gm.  a  day,  gradually  diminished 
to  2  gm.  The  authors  believe  that  only  a  limited 
number  of  patients  can  bear  this  treatment.  Its  ad- 
ministration requires  such  care  and  such  constant 
supervision  that  the  patient  must  be  placed  where  he 
can  be  under  observation  ;  even  under  these  conditions 
the  treatment  is  difficult  and  even  dangerous.  These 
drawbacks  are  far  from  being  compensated  by  the  ad- 
vantages of  the  method,  and  the  authors  much  prefer 
the  simple  bromide  treatment. — Archi-es  de  Neurologie, 
August,   1900. 

Prophylaxis  in  Malaria,  by  Protection  from 
Mosquitos. — Eugenio  di  Mattel  reports  the  result  of 
an  experiment  carried  out  upon  five  persons,  himself 
and  four  workmen.  A  hut  situated  in  an  extremely 
malarial  region,  infested  by  mosquitos,  was  chosen, 
and  here  the  five  slept  for  thirty-two  nights.  Their 
work  during  the  day  was  arduous,  their  food  scanty, 
their  accommodations  were  uncomfortable;  they  took 
no  quinine  or  other  medicament,  but  their  hut  was  so 
completely  protected  by  wire  gauze  that  no  mosquitos 
were  able  to  obtain  access.  No  one  of  the  five  con- 
tracted malaria,  although  other  workmen,  sleeping  in 
the  neighborhood  and  unprotected  from  the  mosquitos, 
suffered  from  grave  forms  of  the  disease. — Archirio 
per  le  Scienze  Mediche,  vol.  xxiv.,  Xo.  2,  1900. 

Toxic  Paralysis  of  the  Pharynx. — Patrick  Wat- 
son Williams  says  that,  excluding  the  purely  myo- 
pathic paralyses,  toxic  paralyses  are  due  to  inflamma- 
tory degeneration  of  the  neuron,  that  is,  in  its  wider 
sense,  neuritis,  and  may  be  divided  into  two  distinct 
pathogenic  groups:  (1)  Infective  neuritis,  commonly 
occurring  in  the  course  of  diphtheria,  less  frequently 
observed  in  typhoid,  typhus,  scarlatina,  morbilli.  influ- 
enza, rheumatism,  tuberculosis,  syphilis,  and  pneu- 
monia; (2)  toxic  neuritis,  most  frequently  due  to  lead 
poisoning,  but  also  reported  to  have  occurred  in  poi- 
soning by  arsenic,  copper,  antimony,  phosphorus,  alco- 
hol, atropine,  and  morphine.  The  treatment  of  these 
toxic  laryngeal  paralyses  may  be  thus  summed  up:  {a) 
appropriate  general  treatment  of  the  infective  disease, 
and  measures  directed  to  removal  of  the  poison  in  the 
circulation  and  tissues  in  the  case  of  organic  or  metal- 
lic poisons;  (/')  intra-laryngeal  applications  of  the 
faradic  or  galvanic  current,  combined  with  the  internal 
exhibition  of  strychnine  in  considerable  doses  either 
by  the  mouth,  or  directly  into  the  affected  muscles 
when  feasible;  (<)  the  relief  of  dyspnea  and  threat- 
ened asphyxia  in  cases  of  bilateral  abductor  paralysis 
by  intubation  or  tracheotomy. —  The  Medical  Tress, 
August  1  5,  1900. 


September  15,  1900] 


MEDICAL    RECORD. 


419 


Medical  Record: 

A    Weekly  Journal  of  Medieine  and  Surgery. 


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

I'lBLlSHERS 

WM,  WOOD  &  CO  .  51    Fifth  Avenue. 
New  York,  September  15,  1900. 

PERFORATING   ULCER   OF   THE    STOMACH. 

The  history  of  modern  operative  experience  with  per- 
forated ulcer  of  tiie  stomach  is  comparatively  short ; 
in  fact,  it  is  only  within  the  last  eight  or  nine  years 
that  successful  cases  have  been  recorded.  Finney,  in 
the  Annals  of  Surgery,  July,  1900,  has  a  paper  in 
which  there  is  a  general  review  of  the  subject  with  a 
collection  of  cases  gathered  from  the  most  recent  med- 
ical literature,  bringing  the  total  of  reported  operations 
up  to  nearly  three  hundred.  There  is  also  given  a 
comprehensive  analysis  of  the  statistics  of  the  subject, 
many  of  which  are  interesting,  though  perhaps  not 
very  novel.  According  to  various  authors  the  fre- 
quency of  perforation  is  estimated  at  from  6.5  per 
cent,  to  eighteen  per  cent,  of  all  cases  of  gastric  ulcer, 
pretty  wide  variations,  with  the  chances  of  accuracy, 
we  should  say,  in  favor  of  the  smaller  figure.  The 
most  important  factors  in  the  pathological  anatomy  of 
the  condition  are  the  presence  of  adhesions  and  the 
location  of  the  perforation.  A  large  majority  of  ulcers 
are  situated  upon  the  posterior  wall  of  the  stomach, 
but  in  this  region  comparatively  very  few  of  them  per- 
forate, while  the  converse  is  true  in  regard  to  those 
upon  the  anterior  aspect  of  the  organ.  The  presence 
of  adhesions  of  course  modifies  the  symptoms  and 
prognosis,  when  perforation  occurs,  in  ways  which  at 
once  suggest  themselves.  In  about  one-fifth  of  all 
cases  of  perforated  ulcer,  it  is  important  to  remember 
that  the  perforation  is  multiple,  so  that  in  operating 
we  should  always  be  on  the  lookout  for  such  a  state 
of  afTairs. 

Most  general  interest  on  this  subject  naturally  at- 
taches to  the  question  of  symptoms  and  treatment,  and 
in  many  ways  our  knowledge  has  made  important  ad- 
vances in  the  last  few  years.  When  an  intelligent  his- 
tory can  be  obtained,  and  when  the  patient  is  seen 
early,  the  diagnosis  is  often  easy,  but  under  other  cir- 
cumstances we  may  have  to  be  satisfied  with  the  con- 
clusion that  we  are  dealing  with  a  grave  abdominal 
lesion,  and  allow  our  incision  to  disclose  exactly  what 
has  occurred.  Many  cases  of  perforation  have  been 
observed  in  women  before  the  age  of  thirty,  while 
when  men  are  the  victims  the  condition  occurs  most 
often  after  forty;  but  ulcer  of  the  stomach  is  abso- 
lutely much  more  frequent  in  women  than  in  men. 
The  physical  signs,  it  is  hardly  necessary  to  say.  are 
those  of  air  and  fluid  in  the  peritoneal  cavity  and  later 


the  signs  of  general  peritonitis.  A  history  of  previous 
gastric  troubles  of  various  kinds  can  be  elicited  in 
nearly  all  cases,  and  is  useful  as  confirmatory  evidence. 
The  treatment  of  the  condition,  though  it  involves 
some  questions  which  are  not  answered  by  all  in  pre- 
cisely the  same  way,  is  of  course  entirely  surgical. 
Whether  to  use  opium  or  morphine  is  one  such  ques- 
tion, the  answer  to  which  is  probably  best  given  by 
advocating  a  middle  course,  always  keeping  in  mind 
the  objections  to  the  use  of  such  drugs  in  patients  who 
must  undergo  severe  abdominal  operations.  Finney's 
conclusion  is  undoubtedly  just,  that  nothing  is  to  be 
gained  by  waiting  for  the  disappearance  or  ameliora- 
tion of  the  shock  which  is  usually  present  for  some 
time  after  the  perforation  has  taken  place,  but  we 
should  also  emphasize  the  fact  that  at  the  same  time 
every  possible  means  for  combating  shock  should  be 
used.  A  point  noted  by  some  writers  with  words  of 
commendation  is  the  use  of  cocaine  anaesthesia  in 
some  cases  of  this  class.  Those  who  have  used  it  will 
be  satisfied  with  it  and  will  often  feel  that  one  source 
of  danger  to  a  patient,  almost  always  in  a  desperate 
condition,  has  been  avoided.  This  method  deserves 
more  attention  than  it  usually  gets,  for  the  risks  of 
ether  or  chloroform  ana;sthesia  in  patients  with  dan- 
gerous abdominal  conditions,  often  accompanied  by 
much  distention,  is  either  not  appreciated  or  too  often 
disregarded.  The  incision  to  reach  a  supposed  per- 
foration of  the  stomach  is  almost  always  in  the  mid- 
dle line  of  the  epigastrium,  and  need  not  at  first  be 
very  extensive,  though  enlargement  may  be  necessary, 
and,  when  a  perforation  is  found,  the  plan  which  can 
be  carried  out  with  the  greatest  celerity  consistent  with 
safety  is  the  one  which  should  be  adopted.  The  ab- 
dominal cavity  must  be  thoroughly  cleansed  and  all 
foreign  material  carefully  removed.  The  question  of 
drainage  will  usually  have  to  be  decided  according  to 
the  apparent  requirements  of  each  case.  When  we  are 
dealing  with  a  perforated  gastric  ulcer,  the  most  im- 
portant point  to  remember  is  that  the-  patient's  chances 
of  recovery  are  diminishing  at  the  rale  of  about  eight 
per  cent,  an  hour  from  the  occurrence  of  perforation 
to  the  time  of  operation  (unless  we  are  dealing  with  a 
case  in  which  protective  adhesions  are  present),  so 
that  the  indication  for  immediate  radical  treatment  is 
peremptory. 

A  FATAL  CASE  OF  EXOPHTHALMIC  GOITRE. 

Although  it  is  not  uncommon  for  exophthalmic 
goitre  to  set  in  abruptly,  especially  after  psychical  or 
physical  shock,  and  while  at  times  the  symptoms  may 
attain  a  profound  degree  of  intensity,  a  fatal  issue 
is  quite  rare.  It  is  in  fact  rather  remarkable  that  the 
results  of  more  autopsies  have  not  been  placed  on 
record,  and  although  exophthalmic  goitre  is  not  an  ex- 
ceptional disease  it  does  not  often  figure  in  the  death 
lists.  The  disease  is  further  most  common  at  or  about 
the  thirtieth  year  of  life.  In  view  of  the  foregoing 
considerations  a  case  of  exophthalmic  goitre  in  a  girl 
eleven  years  old,  reported  by  Armstrong  {Lherpool 
Medko-Chinirgical  Journal,  February,  1900),  must  be 
looked    upon   as   unique.      The   patient  was   an   only 


420 


MEDICAL   RECORD. 


[September  15,  igcxj 


child,  and  her  parents  were  dead,  of  influenza  and 
pulmonary  tuberculosis  respectively.  She  had  had  an 
attack  of  measles  and  one  of  chickenpox.  Six  months 
prior  to  death  the  child  began  to  suffer  from  palpita- 
tion of  the  heart  and  became  nervous,  and  at  the  same 
time  protrusion  of  the  eyeballs  was  first  noticed.  She 
was  large  and  well  formed  for  her  age,  but  behaved 
in  an  infantile  manner,  crying  hysterically  for  hours 
after  her  friends  had  left.  Menstruation  had  not  yet 
appeared.  Exophthalmos  was  marked.  The  thyroid 
gland  was  slightly  but  perceptibly  enlarged.  There 
was  no  thrill,  but  a  systolic  bruit  was  heard  on  aus- 
cultation over  the  goitre..  The  action  of  the  heart  was 
rapid,  132  in  the  minute,  and  regular,  and  the  sounds 
were  clear.  There  were  pretty  general  tremors.  The 
temperature  was  normal,  with  a  single  slight  exception. 
The  treatment  consisted  of  rest  in  bed,  and  tincture 
of  belladonna  TTl  iii.,  potassium  bromide  gr.  x.,  thrice 
daily.  Nausea  and  vomiting  set  in,  a  little  blood  and 
some  coffee-ground  material  being  evacuated  on  several 
occasions.  The  condition  of  the  patient  grew  gradually 
worse,  and  death  resulted  from  exhaustion.  Most  un- 
fortunately, an  autopsy  could  not  be  secured.  Of 
course,  it  is  difificult  to  say  in  this  case  to  what  causes 
death  is  to  be  attributed,  and  to  determine  what  part 
if  any  the  exophthalmic  goitre  played  in  bringing 
about  the  fatal  issue.  The  opinion  is  expressed  that 
gastric  ulceration  did  not  exist,  but  the  grounds  for 
this  exclusion  are  not  entirely  obvious. 


INTERNATIONAL  MEDICAL  PRESS  CON- 
GRESS IN  PARIS. 

One  of  the  most  distinctive  features  of  the  International 
Medical  Congress  just  ended  in  Paris  was  the  meeting 
of  medical  journalists  from  all  parts  of  the  world, 
f  his  reunion  of  medical  scribes  may  on  the  whole  be 
regarded  as  a  success.  Neither  the  United  States  nor 
Great  Britain  was  conspicuous  so  far  as  numbers 
were  concerned,  but  the  papers  read  by  Dr.  Fassett, 
editor  of  the  American  Medical  Journalist,  and  by  Dr. 
Squire  Sprigge,  of  The  Lancet,  were  excellent  in  qual- 
ity. Dr.  P'assett  gave  a  sketch  of  the  origin  and  rise 
of  American  medical  journalism,  stating  that  the  first 
paper  devoted  to  medical  matters  was  founded  in  this 
country  at  the  end  of  the  last  century,  and  that  at  the 
present  time  there  were  two  hundred  and  seventy-eight 
medical  journals  in  the  United  States,  a  sufficiently 
convincing  proof  of  enterprise.  Dr.  Fassett  insisted 
that  medical  journals  should  avoid  sensational  news 
and  the  discussion  of  vague  theories,  and  should  also 
be  written  so  as  to  be  intelligible  to  general  practi- 
tioners who  are  not  specialists.  The  paper  read  by 
Dr.  Sprigge  was  exceptionally  interesting,  and  was 
recognized  as  perhaps  the  most  suggestive  submitted 
to  the  congress.  In  it  was  given  a  history  of  the  early 
struggles  of  T/te  Lancet  and  of  the  successful  attempts 
of  its  editor  to  combat  the  nepotism  prevalent  at  the 
hospitals  and  at  the  medical  schools  in  those  days. 
The  financial  situation  of  The  Lancet  and  British 
Medical  Journal  was  described,  showing  that  the  pros- 
perous condition  of  these  papers  rendered  them  entirely 


independent  and  able  to  supply  freely  the  means  to 
make  original  researches  and  investigations,  to  depute 
experienced  technicians  to  follow  armies  on  the  field, 
to  study  epidemics  in  all  parts  of  the  world,  and  to 
analyze  all  sorts  of  food-stuffs.  The  results  of  these 
investigations  had  been  most  beneficial  in  their  effect 
on  the  laws  of  the  country  with  regard  to  medical  edu- 
cation, public  health,  adulteration  of  food,  etc. 

A  paper  was  read  by  Dr.  Alban  on  the  right  of  re- 
production of  scientific  illustrations.  This  paper  pro- 
voked much  discussion,  but  no  definite  conclusion  on 
the  matter  was  reached.  A  committee,  however,  was 
elected  to  discuss  the  question  with  publishers,  med- 
ical men,  and  legislators,  and  to  study  generally  the 
question  of  literary  property  from  a  medical  point  of 
view.  It  would  appear  that  the  work  of  tlie  Interna- 
tional Medical  Press  Congress  should  be  productive  of 
much  good  in  the  future. 


PLEA    FOR    A    MEDICAL    DEFENCE    UNION 
IN    THE   UNITED    STATES. 

TsE  medical  profession  has  many  difficulties  with 
which  to  contend,  and  one  that  undoubtedly  weighs 
heavily  upon  its  members  is  the  disadvantages  under 
which  they  labor  in  defending  malpractice  suits.  An 
action  of  this  description  brought  against  a  physician 
does  not  only  affect  him  personally,  but  upon  his  vic- 
tory or  defeat  depend  to  a  certain  extent  the  good 
name  and  financial  position  of  his  medical  brethren 
at  large.  This  being  so,  it  is  reasonable  to  expect  that 
every  effort  will  be  put  forth  by  the  accused  to  win  his 
suit,  as  he  is  as  a  matter  of  fact  fighting  in  the  inter- 
ests of  the  entire  medical  profession.  But  unfortu- 
nately it  often  happens  that  the  money  necessary  to 
employ  the  best  measures  to  insure  success  is  lack- 
ing, and  that  consequently  irreparable  injury  is  done 
to  physicians  throughout  the  country. 

Dr.  Donald  B.  Pritchard,  writing  in  the  St.  Paul 
Medical  Journal,  July,  proposes  that  a  medical  de- 
fence union,  formed  on  the  lines  of  that  now  in  exist- 
ence in  England,  should  be  established  in  this  coun- 
try. His  idea  is  to  organize  a  mutual  association,  the 
membership  of  which  should  be  confined  to  those  who 
belong  to  the  State  or  some  properly  organized  medi- 
cal society.  In  order  that  the  organization  might  be 
of  the  highest  standing,  it  would  not  be  proper  to  de- 
fend one  guilty  of  gross  malpractice.  That  this  might 
be  accomplished,  every  case  sliould  be  submitted  to  a 
standing  committee,  who  after  a  thorough  examina- 
tion would  decide  whether  or  not  it  would  be  proper  for 
the  association  to  defend.  If  the  decision  is  not  sat- 
isfactory to  the  member,  then  a  board  of  arbitration 
should  decide  the  matter.  When  the  association  un 
dertakes  the  defence,  the  member  involved  should  be 
pledged  to  be  absolutely  guided  by  it  in  the  conduct 
of  the  case,  and  that  it  should  not  pay  any  part  of  the 
verdict,  simply  incurring  liability  for  all  expenses  of 
the  trial.  Dr.  Pritchard  says  that  he  has  communi- 
cated with  a  number  of  well-known  law3'ers,  and  that 
they  all  say  that  tliere  is  no  legal  bar  to  such  an  asso- 
ciation, and  that  there  is  no  more  likelihood  of  juries 


September  15,  1900] 


MEDICAL   RECORD. 


421 


being  adversely  influenced  than  in  the  case  of  any  other 
corporation.  The  suggestion  is  at  least  worthy  of 
consideration,  and  the  good  work  done  by  the  English 
Medical  Defence  Union  should  act  as  encouragement 
for  the  establishment  of  a  similar  organization  in  this 
country. 


^cius  ot  tttc  "uxEcch. 

A  Roosevelt  Hospital  Ambulance  was  run  into  on 
Sunday  evening  by  an  Eighth  Avenue  car  and  over- 
turned. The  driver  and  a  policeman  riding  on  the 
ambulance  were  severely  injured,  the  surgeon  received 
a  scalp  wound,  but  the  patient,  who  had  shortly  before 
fallen  from  a  third-story  window,  received  no  further 
injury.  Another  ambulance  was  called  and  gathered 
up  the  entire  party  and  took  them  to  the  hospital. 

The  Zeta  Phi  of  Syracuse  University. — During 
the  past  year  the  women  of  Syracuse  University  Col- 
lege of  Medicine,  have  organized  Zeta  Phi  (letters 
which  might  appropriately  stand  for  "Zeuxis  phi- 
Ion "),  the  first  and  only  women's  medical  fraternity 
in  this  country.  Dr.  Elizabeth  Blackwell  has  con- 
sented to  become  a  charter  member,  she  having  been 
graduated  from  this  college  and  the  first  woman  to  re- 
ceive the  degree  of  M.D.  in  America.  The  purpose 
of  the  fraternity  is  to  bring  the  women  of  the  medical 
profession  into  closer  touch  with  one  another. 

Dr.  John  B.  Murphy  has  accepted  a  professorship 
in  surgery  and  clinical  sui^ery  in  the  Northwestern 
University  Medical  School  (Chicago  Medical  Col- 
lege). Dr.  Murphy  has  also  been  appointed  surgeon- 
in-chief  of  Mercy  Hospital  with  the  direction  of  the 
surgical  teaching  in  that  hospital.  He  will  give  two 
clinics  each  week  at  the  hospital.  The  hospital  now 
contains  two  hundred  and  sixty  beds,  with  abundance 
of  clinical  material.  A  new  amphitheatre  with  a  seat- 
ing capacity  of  three  hundred  is  in  progress  of  con- 
struction. 

The  American  Electro-Therapeutic  Association. 
— The  tenth  annual  meeting  of  this  association  will 
be  held  in  this  city  in  the  hall  of  the  Academy  of 
Medicine  on  September  2slh,  26th,  and  27th.  The 
headquarters  of  the  association  will  be  at  the  Hotel 
Bristol,  Forty-second  Street  and  Fifth  Avenue.  There 
is  a  programme  of  sixty-two  titles,  many  of  them 
containing  the  promise  of  great  interest.  In  addi- 
tion to  the  reading  and  discussion  of  papers,  visits 
are  planned  to  the  Electric  Vehicle  Transportation 
Company's  barns,  the  central  station  of  the  Xew 
York  Telephone  Company,  the  power  house  of  the 
Metropolitan  road.  Ninety-sixth  Street  and  First  Ave- 
nue, the  cable  machinery  of  the  Brooklyn  Bridge, 
Columbia  College  library  and  laboratories,  and  St. 
Luke's  Hospital.  The  ladies'  auxiliary  committee 
have  planned  excursions  to  visit  the  Stock  Exchange, 
Trinity  Church,  and  the  Aquarium;  Central  Park 
East,  the  Obelisk,  and  the  Metropolitan  Museum  of 
Art;  Central  Park  West  and  the  Museum  of  Natural 
History;  and  Columbia  College,  St.  Luke's  Hospital, 


Morningside  Park,  and  Riverside  Drive.  The  officers 
of  the  association  are:  President,  Dr.  Walter  H.  White, 
of  Boston  ;  Vice-Presidents,  Drs.  D.  Percy  Hickling,  of 
Washington,  and  Charles  O.  Files,  of  Portland,  Me.; 
Secretary,  Dr.  George  E.  Bill,  of  Harrisburg,  Pa.; 
Treasurer,  Dr.  R.  J.  Nunn,  of  Savannah.  The  chair- 
man of  the  committee  of  arrangements  is  Dr.  Robert 
Newman,  148  West  Seventy-third  Street,  New  York 
City.  All  members  of  the  medical  profession  are  in- 
vited to  attend  the  meetings. 

Nurses  in  the  Spanish  War. — A  society  to  be 
called  the  Spanish-American  War  Nurses'  Association 
was  organized  in  this  city  last  week  at  a  reunion  of 
some  sixty  army  nurses  who  had  served  in  the  Span- 
ish war.  The  meeting  was  held  at  the  New  York 
Hospital.  The  constitution  adopted  makes  only  those 
who  were  in  actual  ser\'ice  not  less  than  one  month 
during  the  Spanish  war  eligible  to  membership.  Of 
these  there  are  at  least  five  hundred.  The  following 
officers  were  elected:  President,  Dr.  Anita  Newcomb 
McGee,  acting  assistant  surgeon  United  States  army, 
Washington;  Vice-Presidents,  Dr.  L.  A.  Hughes,  Bos- 
ton; Miss  Hibbard,  Manchester,  N.  H.;  Dr.  Isabel 
Cowan,  Presidio  Reservation,  California;  Miss  Hob- 
son,  New  York;  Miss  McCloud,  now  serving  in  the 
Philippines;  Miss  Walton,  New  York;  Miss  Misel- 
back,  now  serving  in  Santiago,  Cuba;  Miss  Robbins, 
Miss  Dreyer,  now  in  the  Philippines;  Miss  Read,  Bal- 
timore; Recording  Secretary,  Miss  Lela  Wilson,  Bos- 
ton ;  Corresponding  Secretary  and  Treasurer,  Mrs. 
George  Lounsbury,  Charleston,  S.  C.  The  association 
will  meet  in  Washington  next  year. 

Sickness  and  Destitution  in  Alaska According 

to  a  report  recently  submitted  by  the  captain  of  the 
revenue  cutter  Bear  to  the  chief  of  the  revenue  cutter 
service  in  Washington,  a  most  deplorable  condition 
of  affairs  exists  among  the  natives  on  the  Alaska  coast 
north  of  Nome  and  also  on  the  Siberia  coast.  The 
Bear  sailed  along  the  north  coast  of  Siberia  as  far 
west  as  Kolutchin  Bay.  When  off  Sinrock  an  officer 
and  a  surgeon  were  sent  ashore  and  reported  an  epi- 
demic of  measles  and  pneumonia,  with  many  of  the 
natives  sick.  Medicines  were  left  and  the  vessel 
proceeded  to  Port  Clarence.  Here  there  was  found  to 
be  much  sickness,  and  many  deaths  had  occurred 
among  the  natives.  The  surgeon  prescribed  and  med- 
icines were  left.  The  same  conditions  prevailed  at 
Cape  York,  Whalen,  King's  Island,  and  all  the  other 
places  touched  at  in  Siberia.  At  St.  Lawrence  Bay 
there  had  been  thirty-six  deaths  out  of  a  total  popula- 
tion of  two  hundred  and  ninety-three.  This  unusual 
prevalence  of  epidemic  disease  has  thoroughly  demor- 
alized the  natives.  Instead  of  busying  themselves  in 
laying  in  the  winter's  supply  of  food,  as  they  are 
always  obliged  to  do  at  that  time,  they  remained  in 
their  huts  consuming  what  little  food  was  left  them. 
The  Bear  has  returned  to  that  coast  carrying  a  large 
quantity  of  supplies  for  the  destitute  natives.  At 
Teller,  Alaska,  the  Esquimaux  are  suffering  greatly 
from  influenza,  fully  one-half  of  those  near  the  station 
having  died.     In  some  cases  whole  families  have  dis- 


422 


MEDICAL    RECORD. 


[September  15,  1900 


appeared,  both  parents  and  children  being  dead.  In 
others  the  parents  and  some  of  the  children  have  died, 
leaving  young  children  orphans  with  no  near  relatives 
to  feed  or  care  for  them.  The  salmon  are  running  in 
their  waters,  but  there  are  not  sufficient  numbers  of 
well  people  to  catch  them,  and  thus  provide  for  the 
present  and  for  next  winter.  The  ravages  of  the  dis- 
ease have  been  so  great  that  a  panic  has  seized  the 
native  population,  and  the  dead  are  left  unburied  in 
their  homes.  It  is  said  that  the  records  for  the  last 
half-century  show  no  such  distress  among  the  natives 
as  that  which  is  now  prevalent  along  the  whole  Be- 
ring Sea  coast. 

The  Heat  Mortality  in  New  York  City.— One 
hundred  and  fifty-two  deaths  were  caused  in  this  city 
last  July  by  sunstroke,  according  to  the  bulletin  of  the 
State  board  of  health.  The  State  is  now  free  from 
smallpox  for  the  first  time  in  some  months.  There 
were  eight  hundred  and  fifty-six  deaths  from  accident 
and  sunstroke  in  the  State  in  July,  five  occurring  from 
lightning  strokes. 

A  New  Dispensary  Building. — Plans  have  been 
submitted  to  the  department  of  buildings  for  a  six- 
story  and  basement  dispensary  building  to  be  erected 
by  St.  Bariholoniew's  Episcopal  Church  at  an  esti- 
mated cost  of  $200,000  on  East  Forty-second  Street, 
adjoining  the  mission  house  built  by  the  church.  The 
first  story  of  the  building  will  be  of  Indiana  limestone 
and  the  superstructure  of  brick. 

Dr.  Smith  Ely  Jelliffe  assumed  editorial  control 
of  the  Medical  yews  on  September  ist,  succeeding  Dr. 
J.  Riddle  Goffe,  who  has  so  ably  conducted  the  jour- 
nal ever  since  its  transfer  from  Philadelphia  to  this 
city.  Dr.  JellifTe  has  been  for  some  time  on  the  edi- 
torial staff  of  the  Ncii's,  and  may  be  trusted  to  main- 
tain the  high  standard  established  by  Dr.  Goffe. 

Women  in  the  British  Association. — Previous  to 
the  opening  of  the  annual  meeting  of  the  British  As- 
sociation for  the  Advancement  of  Science  at  Bradford 
on  September  5th,  the  general  committee  debated  the 
motion  of  Professor  Hartop  that  women  should  be  ad- 
mitted to  membership  in  the  association.  Sir  Henry 
Roscoe,  vice-chancellor  of  the  University  of  London, 
and  others  supported  the  proposition,  but  Sir  John 
Evans,  former  president  of  the  association,  counselled 
caution.  It  was  decided  finally  to  admit  women, 
making  membership  of  the  general  association  a  prec- 
edent to  election  to  membership  in  the  sections. 

Yellow  Fever  in  Havana. — Although  the  general 
health  of  Havana,  thanks  to  American  sanitary  meth- 
ods, is  better  than  ever  before,  yellow  fever  has  pre- 
vailed quite  extensively  this  summer,  fifty  deaths  from 
this  cause  having  been  reported  in  August.  This  is, 
according  to  the  consensus  of  testimony,  due  almost 
entirely  to  the  large  immigration  of  non-immunes. 
Seventy-five  per  cent,  of  the  total  number  of  cases  were 
among  immigrants  from  .Spain  who  had  been  in  Ha- 
vana less  than  a  year.  Since  July,  1899,  twenty-six 
thousand  immigrants  have  arrived  in  Havana  and  ten 
thousand  are  expected  during  the  next  two  montlis. 


Many  of  these  come  to  Havana  on  the  mere  chance  of 
finding  work.  They  accept  the  first  employment  that 
offers,  often  taking  very  small  pay,  instead  of  going  to 
the  country  districts,  where  more  men  are  needed  and 
the  rate  of  w-ages  is  better.  Many  of  them  remain  in 
unhealthful  conditions,  and  as  nearly  all  are  non-im- 
munes, yellow  fever  increases.  Governor-General 
Wood  has  recently  appointed  a  board  of  immigration 
consisting  of  Drs.  Gorgas  and  Havard  and  two  Cuban 
physicians,  and  they  will  draw  up  regulations  con- 
cerning immigrants.  Cheap  but  healthful  barracks 
will  be  built  on  the  other  side  of  the  harbor,  where 
the  immigrants  may  have  free  lodgings.  A  small  sum 
will  be  charged  them  for  board.  The  board  of  immi-  ■ 
gration  will  interest  itself  in  obtaining  employment 
for  the  immigrants,  placing  as  many  of  them  as  possi- 
ble in  the  provinces. 

The  Plague  in  Glasgow,  which  was  thought  at  the 
end  of  last  week  to  have  been  checked,  has  broken  out 
afresh.  Up  to  Thursday  last  the  total  number  of  cases 
was  sixteen,  and  one  hundred  and  fourteen  suspects 
were  under  surveillance.  There  has  been  a  recrudes- 
cence of  the  disease  in  India,  over  one  thousand  deaths 
from  plague  having  occurred  there  last  week. 

The  Cholera  in  India. — A  telegram  received  in 
London  from  the  Viceroy  of  India  states  that  the 
deaths  from  cholera  for  the  week  ending  September 
1st  were  1,930  in  the  native  states  and  4,021  in  the 
British  districts. 

Electric  Ambulances.- — Roosevelt  Hospital  will 
soon  have  two  electric  ambulances  which  have  been 
given  to  the  institution,  one  of  them  by  a  physician. 
The  ambulances,  which  will  have  a  maximum  speed 
of  sixteen  miles  an  hour,  are  seven  and  one-half  feet 
long,  and  can  carry  three  patients  at  one  time.  The 
only  other  electric  ambulance  in  the  city  is  one  be- 
longing to  St.  Vincent's  Hospital,  but  two  others  are 
now  under  construction — one  for  the  New  York  and 
one  for  the  Presbyterian  Hospital. 

The  Horror  at  Galveston.— In  the  frightful  storm 
which  visited  Galveston  and  other  Gulf  towns  last 
Saturday,  the  large  buildings — asylums,  hospitals,  and 
school-houses,  which  had  been  sought  out  as  places  of 
refuge  suffered  more  than  frailer  buildings.  An  orphan 
asylum,  containing  many  children  and  numbers  of  ref- 
ugees, collapsed,  as  an  eye-witness  expressed  it,  "  like 
a  house  of  cards,"  and  most  of  the  inmates  perished. 
St.  Mary's  Infirmary  was  completely  demolished,  and 
all  the  sisters  and  ninety  patients  and  other  inmates 
were  drowned.  The  Catholic  orphan  asylum  is  also 
reported  to  have  been  destroyed,  all  the  ciiildren  and 
sisters  being  drowned.  A  home  for  aged  women  fell, 
and  a  school-house  near  it  was  also  destroyed,  burying 
in  the  ruins  numbers  of  persons  who  had  taken  refuge 
there.  Two  physicians  were  killed  while  on  the  way 
to  see  their  patients.  One  was  drowned,  the  other 
struck  by  a  falling  beam  or  other  heavy  object. 

The  New  Brunswick  and  the  Maritime  Medical 
Associations. — The  twentieth  annual  meeting  of  the 
New  Brunswick  Medical  Society  was  held  at  St.  John, 


September  15,  1900] 


MEDICAL    RECORD. 


423 


N.  B.,  on  Tuesday,  July  17,  1900.  The  meeting  was 
called  to  order  by  the  vice-president,  Dr.  R.  L.  Bots- 
ford,  of  Moncton,  N.  B.,  who  explained  that  the  society 
had  been  called  togetlier  to  transact  business,  after 
which  the  sessions  would  merge  into  those  of  the  tenth 
annual  meeting  of  the  Maritime  Medical  Association. 
The  meeting  of  this  association  was  held  on  July  i8th 
and  19th.  The  election  of  officers  of  the  New  Bruns- 
wick Medical  Society  resulted  as  follows:  PresuUnt. 
Dr.  G.  T.  .Smith,  of  Moncton;  Vice-President,  Dr.  S. 
C.  Murray,  of  Albert;  Treasurer,  Dr.  C.  G.  Melvin,  of 
St.  Joiin ;  Corresponding  Secretary,  Dr.  J.  H.  Scam- 
mell,  of  St.  John  ;  Recording  Secretary,  Dr.  W.  Leonard 
Ellis,  of  St.  John;  Trustees,  Drs.  J.  C.  Mott,  Murray, 
and  Bridges.  The  next  annual  meeting  will  be  held 
at  Moncton.  The  election  of  officers  of  the  Maritime 
Medical  Association  resulted  as  follows:  President, 
Dr.  W.  S.  Muir,  of  Truro;  Vice-Presidents,  for  Nova 
Scotia,  Dr.  T.  Tretiaman,  of  Halifax;  for  New  Bruns- 
wick, Dr.  P.  R.  Inches,  of  St.  John;  for  Prince  Ed- 
ward Island,  Dr.  A.  Ross,  of  Alberton  ;  Treasurer,  Dr. 
T.  D.  Walker,  of  St.  John;  Secretary,  Dr.  G.  M.  Camp- 
bell, of  Halifax. 

The  Study  of  Psychology.— One  of  the  subjects 
discussed  at  the  International  Congress  of  Psychology 
held  in  Paris  during  the  present  summer  was  the 
establishment  of  a  permanent  institute  for  psychical 
research.  The  board  appointed  to  deal  with  the 
matter  contains  MM.  Ribot,  Richet,  Janet,  Fe'lix  Al- 
can,  d'Arsonval,  Bouchard,  Duclaux,  Marey,  Fouillce, 
Bergson,  Sarde,  and  St-ailles,  for  France;  Sir  William 
Crookes,  Frederic  Myers,  Prof.  James  Sully,  Prof. 
Oliver  Lodge,  and  Oswald  Murray,  for  England; 
and  Profs.  \\'illiam  James,  of  Harvard,  and  Mark 
Baldwin,  of  Princeton,  for  the  United  States. 

Navy  Department,  Bureau  of  Medicine  and  Sur- 
gery, Washington,  D.  C. — Changes  in  the  medical 
corps  of  the  United  States  navy  for  the  week  ending 
September  8,  1900.  August  31st. — Assistant  Surgeon 
E.  V.  Armstrong  granted  sick  leave  for  one  month. 
September  ist. — Passed  Assistant  Surgeon  C.  M.  De 
Valin  ordered  to  additional  duty  at  the  navy  yard, 
Portsmouth,  N.  H.  September  3d. — (Orders  issued 
by  commander-in-chief  of  Asiatic  station.)  Assistant 
Surgeon  A.  G.  Grunwell  detached  from  the  Monocacy 
and  ordered  to  the  Brooklyn.  September  4th. — Assis- 
tant Surgeon  T.  M.  Lippitt  detached  from  the  Newark 
and  ordered  to  the  Monocacy.  September  6th. — Sur- 
geon A.  C.  H.  Russell  detached  from  the  naval  hos- 
pital, Yokohama,  Japan,  and  ordered  to  proceed  home 
and  to  wait  orders. 

Obituary  Notes — Dr.  Samuel  F.  Gilbert,  of  Elys- 
burg,  Northumberland  County,  Pa.,  died  August  30, 
1900,  aged  fifty-five  years.  He  was  a  graduate  of  the 
University  of  Pennsylvania,  receiving  his  diploma  in 
1872.  He  located  first  at  Sunbury,  then  at  .\ugusta. 
from  which  place  he  removed  to  Elysburg  about 
twenty-five  years  ago.  Dr.  Gilbert  was  born  August  7, 
1845,  near  Halifax,  Pa. 

Dr.  Joseph  Washington  Clowes,  one  of  the  old- 
est and  best-known  dentists  of    New  York,  and  the 


last  surviving  member  of  the  first  class  graduated 
at  the  Baltimore  College  of  Dental  Surgery,  died  at 
his  home  in  this  city  on  September  9th,  at  the  age  of 
seventy-nine  years.  He  began  the  study  of  dentistry 
in  1838  in  the  office  of  Dr.  J.  Smith  Dodge.  The 
following  year  he  entered  the  Baltimore  College  of 
Dental  Surgery.  In  1842  he  opened  an  office  in  New 
London,  Conn.,  and  came  to  New  York  in  1850,  re- 
maining in  practice  here  until  about  a  year  ago,  when 
he  retired  on  account  of  ill  health. 

Dr.  Dennis  Dowlino  Mulcahev  died  on  Septem- 
ber iith,  at  his  home  in  Newark,  N.  J.,  after  an  ill- 
ness of  a  few  days.  He  was  born  in  Tipperary,  Ire- 
land, in  1848,  and  began  the  study  of  medicine  before 
coming  to  this  country,  but  took  his  degree  from  the 
College  of  Physicians  and  Surgeons  in  this  city  in 
1872.  During  the  Fenian  uprising  of  March  7,  1867, 
he  went  from  Killmaltock  to  the  aid  of  the  wounded 
at  Limerick  Junction,  and  was  picked  up  by  the  con- 
stabulary and  imprisoned  for  a  year  and  a  half.  Upon 
his  release  he  came  to  this  country  and  found  a  friend 
in  Dr.  William  O'Gorman,  of  Newark,  in  whose  office 
he  completed  his  studies.  He  was  known  as  one  of 
the  best  Irish  historians  in  this  country,  and  possessed 
a  very  valuable  library  of  books  on  Irish  history  and 
kindred  subjects.  He  was  himself  a  vigorous  writer 
and  his  pen  was  always  at  the  ser-ice  of  his  native 
island. 


JACOB    M.    DaCOSTA,    M.D.,    LL.D., 


rHILADELPHIA. 


Dr.  Jacob  M.  DaCosta  died  suddenly  on  Tuesday 
evening,  September  iith,  at  his  country  home  in  Vil- 
lanova  near  Philadelphia.  He  had  but  recently  re- 
turned from  York  Harbor,  Me.,  where  he  had  been 
passing  the  summer,  and  was  apparently  in  excellent 
health.  Cardiac  disease  was  the  cause  of  his  death. 
Dr.  DaCosta  was  born  on  the  island  of  St.  Thomas, 
West  Indies,  February  7,  1833.  He  received  his  lit- 
erary and  classical  education  in  Germany  and  pursued 
his  medical  studies  at  the  Jefferson  Medical  College 
in  Philadelphia,  from  which  he  was  graduated  in  1852. 
The  following  two  years  he  spent  in  study  in  the  hos- 
pitals and  schools  of  Paris  and  Vienna,  and  in  1854 
returned  to  Philadelphia  and  established  himself  in 
practice.  He  soon  made  for  himself  a  reputation  as 
a  diagnostician  of  more  than  ordinary  acumen,  and 
though  always  regarding  himself  as  a  general  practi- 
tioner he  was  by  preference  drawn  to  a  special  study  of 
diseases  of  the  thoracic  organs.  His  contributions  to 
medical  literature  have  been  large  and  upon  a  variety 
of  subjects,  but  he  was  perhaps  best  known  as  the 
author  of  a  classical  work  on  "Medical  Diagnosis," 
the  first  edition  of  which  appeared  in  April,  1864,  and 
the  ninth  and  last  only  a  few  weeks  ago. 

In  1864  Dr.  DaCosta  was  appointed  lecturer  on 
clinical  medicine  at  Jefferson  Medical  College,  in 
1872  was  elected  to  the  chair  of  the  theory  and  prac- 
tice of  medicine  in  the  same  institution,  and  a  few 
years  ago  was  retired  at  his  own  request,  being  made 
emeritus  professor  of  the  practice  of  medicine  and  of 
clinical  medicine.  He  was  at  different  times  attend- 
ing physician  to  the  Episcopal,  the  Pennsylvania,  and 
the  Philadelphia  hospitals.  He  was  a  fellow  of  the 
College  of  Physicians  of  Philadelphia,  and  for  several 
years  its  president. 


424 


MEDICAL   RECORD. 


[September  15,  1900 


'^voQVcss  of  I^Xcdical  J>cicnce. 

Boston  Medical  aiiii  Surgical  Journal,  September  0,  igoo. 

Notes  on  the  Treatment  of  Ataxic  Patients  by  Co-ordination 
Exercises,  with  Demonstration  of  Two  Patients. — James  J. 
Putnam  says  that  in  the  treatment  by  this  method  several 
points  should  be  strictly  borne  in  mind:  (i)  It  is  skill,  not 
strength  that  it  is  sought  to  develop.  (2)  It  is  necessary 
to  begin  with  relatively  elementary  motions,  such  as  draw- 
ing the  leg  up  and  down  in  bed,  or  moving  the  finger  from 
one  spot  to  another.  The  patient  should  be  called  ujjon  to 
perform  them  with  promptness  and  accuracy  and  at  the 
word  of  command.  (3)  Dulness,  monotony,  and  fatigue, 
on  the  one  hand,  and  superficiality  on  the  other,  are  the 
rocks  to  be  avoided,  both  by  the  introduction  of  sufficient 
variety  into  the  exercises,  and  by  giving  them  something 
of  the  entertainment  of  games  of  skill.  (4)  It  is  not  well 
to  let  the  patient  get  on  without  an  instructor,  using  a  pre- 
scribed set  of  exercises.  The  necessity  for  obedience  to 
the  word  of  command,  which  calls  for  close  attention  and 
for  movements  which  come  to  have  something  of  the  char- 
acter of  involuntary  reflexes,  is  a  great  help  in  stimulating 
both  the  conscious  and  the  sub-conscious  attention  and  the 
power  of  instinctive  control.  (5)  Weak,  anasmic  patients, 
and  those  suffering  constantly  from  pains  and  crises,  those 
with  atrophy,  rupture  of  tendons,  cardiopathy,  aneurism, 
obesity,  arthritis,  laxity  of  ligaments,  or  severe  arthropathy 
are  not  good  subjects  for  the  treatment. 

Notes  on  Dermatitis  Venenata. — George  F.  Harding  says 
that  this  term  is  used  to  indicate  forms  of  inflammation  or 
irritation  of  the  skin  produced  by  the  action  of  substances 
applied  externally.  The  number  of  these  substances  is 
very  large,  including  familiar  garden  plants  and  wild 
flowers,  drugs  applied  to  the  skin  therapeutically,  sub- 
stances used  in  trade,  or  found  in  articles  of  clothing, 
household  articles,  etc.  There  are  also  animal  irritants. 
The  form  of  dermatitis  produced  is,  as  a  rule,  of  the  ery- 
thematous or  eczematous  type,  but  occasionally  deeper 
grades  of  inflammation  are  seen.  Itching,  burning,  and 
pricking  are  usual,  and  sometimes  there  is  numbness.  The 
author  takes  up  a  number  of  irritating  substances  and  dis- 
cusses them  in  detail,  also  reporting  a  number  of  cases. 

Two  Cases  of  Abnormal  Sexual  Development. — George  G. 
Sears  describes  the  case  of  a  boy  in  whom  there  was  im- 
perfect development  of  the  genital  organs,  accompanied  by 
dwarfism  and  feminism  :  and  the  case  of  a  girl  in  whom 
the  failure  of  the  genitals  to  develop  was  associated  with 
a  tendency  to  gigantism  and  the  assumption  of  male  char- 
acteristics.    The  thyroid  gland  was  not  felt  in  either  case. 

The  Scope  and  Aim  of  the  Section's  Work. — By  Col.  Ken- 
neth Macleod,  president  of  the  Section  of  Tropical  Diseases 
of  the  British  Medical  Association. 

New   York  Medical  Journal,  September  S,  igoo. 

Feeding  the  Infants  of  the  Poor  with  Unsterilized  Cow's 
Milk. — (i.  T.  Palmer  enumerates  the  objections  to  sterili- 
zation, and  .states  that  in  one  of  the  Chicago  institutions 
the  following  method  was  adopted :  A  certified  milk  was 
obtained  and  the  method  of  dilution  and  of  addition  of 
cream  and  milk  and  sugar  carried  out  as  laid  down  in  nu- 
merous text-books.  Palmer  began  with  rather  a  larger 
percentage  of  proteids  and  decreased  as  the  age  of  the 
child  increased.  The  milk  thus  prepared  was  packed  in 
sterile  jars  and  placed  in  large  buckets  of  ice,  in  which 
way  it  is  carried  home  by  the  mother.  If  placed  in  a  cel- 
lar or  in  some  way  protected  from  heat,  this  ice  will  pre- 
serve the  food  the  greater  part  of  the  day.  Each  morning 
the  infant  is  brought  to  the  kitchen  for  inspection  and  the 
weight  and  character  of  the  stools  are  regularly  noted.  At  . 
the  same  time  the  nursing  bottles  and  nipples  are  inspected 
and  the  parents  are  repeatedly  warned  and  advised  regard- 
ing the  proper  method  of  feeding.  Aside  from  this,  it  is 
customary  to  have  the  superintendent  and  nurses  call  at 
the  homes  of  the  patients  to  see  that  directions  are  carried 
out.  During  the  summer  about  seven  hundred  applica- 
tions for  food  and  medical  care  have  been  made,  invariably 
for  babies  more  or  less  ill ;  for  so  long  as  the  infant  is  com- 
paratively well  these  people  sec  no  necessity  of  asking  as- 
sistance.    Tlic  total  mortality  has  been  three. 

The  First-Aid  Packet  in  Civil  Practice  and  the  Organiza- 
tion of  First-Aid  Societies. — M.  J.  Shields  gives  his  expe- 
rience in  organizing  a  society  of  the  kind  named  among 
the  mining  population  of  one  of  the  Pennsylvania  dis- 
tricts. He  makes  a  plea  for  the  extension  of  this  work  in 
localities  where  men  are,  from  their  occupation,  particu- 
larly liable  to  accidents. 

A  Plea  for  the  Early  Naked-Eye  Diagnosis  and  Removal 
of  the  Entire  Organ,  with  the  Neighboring  Areas  of  Possible 
Lymphatic  Infection,  in  Cancer  of  the  Larynx.  —  Hy  J.  N. 
Mackenzie. 


Report  of  a  Case  of  Nephrectomy  for  Ascending  Tubercu- 
losis, with  Some  Remarks  on  Cystoscopy  and  Catheteriza- 
tion of  the  Ureters  in  Women. — By  II.  N.  Vineberg. 

Severe  Operations  on  the  Throat  and  Nose ;  Report  of  Five 
Cases.— By  A.  A.  Bliss. 

The  Surgical  Treatment  of  Laryngeal  Cancer.— By  J. 
Solis-Cohen. 

Philadelphia  Medical  Journal,  September  S,  igoo. 

Rheiunatic  Fever. — J.  Kewton  Hunsberger  believes  that 
the  multiplicity  of  cases  at  times  encountered  is  due  entirely 
to  atmospheric  conditions.  He  has  observed  most  cases  in 
autumn.  Heredity  plays  a  distinct  role.  It  was  shown 
in  seventy-five  per  cent,  of  cases.  A  case  is  given  show- 
ing the  eti'ect  of  an  overproduction  of  urates,  and  another  to 
illustrate  the  effect  of  a  le.ssened  excretion.  In  treatment 
four  indications  must  be  met ;  (i)  To  prevent  fresh  chill- 
ing of  parts;  (2)  to  keep  them  at  rest ;  (3)  to  modify  the  conr 
dition  of  the  blood  and  neutralize  the  poison  ;  (4)  to  prevent, 
if  possible,  inflammation  of  the  en<locardium  and  pericar- 
dium. Rules  of  treatment  are  laid  down,  and  as  much 
more  than  a  gallon  of  water  a  day  as  the  patient  can  be 
made  to  take  is  advised.  Water  meets  most  of  the  indica- 
tions. He  regards  salicylic  acid  and  its  various  combina- 
tions to  be  absolutely  contraindicated. 

Prostatic  Calculus. — John  C.  Spencer  says  a  distinction 
should  be  drawn  between  essential  and  adventitious  or 
exotic  calculus  of  the  prostate.  The  latter  may  enlarge  by 
accretion  of  urinary  salts,  and  invade  the  gland  paren- 
chyma, protruding  into  the  prostatic  urethra  to  a  small 
extent.  The  paper  treats  chiefly  of  the  essential  form. 
The  origin  is  to  be  found  in  the  protoplasm  of  degenerated 
gland  epithelia  about  which  colloid  material  is  deposited. 
The  symptoms  become  manifest  only  when  the  calculus 
may  have  eroded  through  into  the  urinary  passages,  or  by 
its  size  either  paralyzes  the  vesical  sphincter,  causing  in- 
continence, or  produces  vesical  irritation  and  tenesmus, 
or  is  an  obstruction  to  the  outflow  of  urine.  The  latter 
was  the  case  in  an  instance  recorded  by  the  writer. 

Legal  and  Judicial  Disagreement  and  the  Shortcomings  of 
Medical  Witnesses. — By  Irving  C.  Rosse. 

Note  on  the  Frequency  of  Renal  Casts  without  Albumi- 
nuria.— By  C.  F.  Martin  and  F.  B.  Jones. 

Heroin  in  the  Treatment  of  Phthisical  Cough  and  Whoop- 
ing-Cough. — By  M.  Loewenthal. 

A  New  Forceps  for  Holding  Slides  in  Staining. — By 
Thomas  S.  Kirkbride.  Jr. 

The  Etiology  and  Pathology  of  Empyema. — By  Joseph 
McFarlaud. 

Medical  News,  September  S,  /goo. 

Trophic  Changes  in  Consumption :  a  Contribution  to  the 
Symptomatology  of  this  Disease. — Henry  Herbert  considers 
scrofulosis  as  having  a  certain  analogy  to  syphilis  in  that 
it  constitutes  the  primary  and  secondary  stages  of  tuber- 
culosis, and  reappears  as  tuberculosis  of  the  lungs  or  of 
other  organs  like  the  tertiary  lesions  of  syphilis.  He  is 
not  a  believer  in  the  hereditary  theory  of  consumption,  but 
fully  agrees  with  the  most  radical  views  regarding  the  infec- 
tiousness of  the  disease.  The  writer  illustrates  by  the  re- 
lation of  cases  the  curious  coincidence  of  the  side  on  which 
the  trophic  signs  occur  and  that  in  which  tlie  lung  is  dis- 
eased. His  researches  show  the  possibility  of  recognizing 
the  early  and  latent  stages  of  consumption  sooner  than  with 
the  present  means  or  methods,  and  of  ascertaining  the 
side  affected,  if  physical  examination  does  not  give  satis- 
factory evidence.  The  side  primarily  affected  is  indicated 
by  the  occurrence  of  trophic  disturl)ances  on  that  side. 

The  Effect  of  Flashes  of  Electric  Light  on  the  Eye.— Dun- 
bar Roy  believes  there  have  been  more  cases  observed 
than  reported  of  temporary  injury  to  the  eye  through  in- 
tense electric  flashes.  The  danger  of  the  electric  light  is 
illustrated  by  a  series  of  examples  from  practice.  In  a 
number  of  instances  cessation  from  school  work  has  had 
to  be  ordered  because  of  the  injurious  incandescent  lights  ; 
and  in  other  cases  student's  lamps  had  to  be  substituted. 
Electric  ophthalmia  is  discussed.  It  seems  probable  that 
domestic  lights  are  injurious  to  the  eye  in  proportion  to  the 
amount  of  ultra-violet  rays  they  contain.  The  Wclsbach 
gas  light  seems  less  injurious  as  a  light  by  which  to  read 
and  work  than  others.  There  should  always  be  an  under 
shade  to  mitigate  the  li.ght. 

The  Physiology  of  Sleep. — H.  H.  Stoner  goes  over  the 
various  theories  whicli  have  been  advanced  from  time  to 
time  to  account  for  the  phenomena  of  sleep.  Recent  dis- 
coveries in  anatomical  construction  and  the  jihysiological 
action  of  the  nervous  system  give  a  clearer  insight  into  the 
manner  in  which  sleep  is  produced.  Neurons  and  their 
relations  and  functions  are  entered  into.  Sleep  is.  accord- 
ing to  the  theory  advanced,  not  the  result  of  an  outside 


September  15,  1900] 


MEDICAL    RECORD. 


425 


influence  exerted  upon  the  brain  as  a  whole,  but  is  due  to 
metabolic  changes  which  take  place  in  the  body  of  the 
nerve  cell  as  the  result  of  normal  fatigue. 

The  Status  of  General  Anaesthesia  in  igoo. — By  JI.  L. 
Maduro. 

Graves'  Thyroid  Disease.— By  O.  T.  Osborne. 

/<>iiii!al  0/  //ii:  Aiiiericait  Medical  Ass'  n,  Sepl.  S.  igoo. 

Traumatic  Insanity. — E.  G.  Carpenter  reports  a  case  and 
calls  attention  to  injury  of  the  cranium  as  one  of  the  rare 
causes  of  insanity.  An  injury  producing  irritation  of  mem- 
branes to  the  degree  of  causing  spasms,  contractures,  and 
paralysis  could  also  disturb  cell  elements  of  the  cortex  so 
as  to  induce  insanity.  He  concludes  that  conditions  al- 
ready present  may  predispose  to  the  causing  of  insanity  by 
an  injury.  The  insanity  should  speedily  follow  the  in- 
jury. The  extent  of  the  concussion  may  be  a  determining 
factor.  The  locality  on  the  cranium  may  be  an  important 
consideration. 

Exophthalmic  Goitre. — F.  W.  Higgins  discusses  symp- 
toms, theories  of  pathology,  the  toxiemic  theory,  functions 
of  the  thvroid,  myxcedema,  and  indications  for  treatment. 
There  is  probably  a  fright  centre  as  well  as  a  speech  cen- 
tre, and  this  may  be  congenitally  weakened.  A  physical 
manifestation  in  the  thyroid  in  a  predisposed  person  may 
assume  a  permanent  character  from  an  inherent  predispo- 
sition. Thus  the  thyroid  is  still  recognized  as  a  prime 
factor,  but  only  as  one  of  a  chain,  and  treatment  is  di- 
rected to  the  breaking  of  the  chain  at  its  most  vulneraljle 
point. 

Typhlitis,  Perityphlitis,  and  Appendicitis  in  Infancy  and 
Childhood. — J.  H.  Byrne  discusses  first  the  causation  and 
relative  frequency  and  reviews  the  teachings  of  the  past 
as  they  indicate  the  original  seat  of  inflammation.  The 
anatomy,  etiology,  and  predisposing  causes  are  studied, 
and  a  case  is  given  in  which  hardened  fecal  masses  were 
expressed  by  digital  manipulation  with  very  satisfactory 
results. 

Pseudo,  Modified,  or  True  Smallpox — Which  is  it? — Bv  H. 
M.  Bracken. 

Measurement  of  Chicago  School  Children. — By  W.  S.  Chris- 
topher. 

Serum-therapy  in  Croupous  Pneumonia. — By  J.  C.  Wilson. 

Pseudo   (?)   or  Modified  (?j   Smallpox. — By  T.  J.  Happel. 

Bnlish  Medical  Journal,  September  /,  igoo. 

A  Discussion  of  the  Enlargements  of  the  Spleen  in  Chil- 
dren.—Samuel  West  calls  attention  to  the  course  and  dura- 
tion of  splenic  enlargement  of  infants  and  its  relation  to 
rickets  and  syphilis.  He  finds  an  enlarged  spleen  in  fifty 
per  cent,  of  all  cases  of  congenital  syphilis  and  still  more 
frequently  in  still-bora  syphilitic  foetuses.  Enlargement 
is  not  constant  in  rickets,  and  there  is  no  relation  between 
the  size  of  the  viscus  and  the  degree  of  the  rickets.  Nei- 
ther the  syphilis  nor  the  rickets  is  the  sole  cause,  and  prob- 
ably not  the  cause  at  all  except  perhaps  indirectly  by 
means  of  the  ill  health  to  which  either  leads.  As  to  the 
relation  which  exists  between  the  splenic  enlargement  and 
the  profound  anaemia  so  often  associated  with  it,  three  al- 
ternatives present  themselves  :  the  enlargement  may  cause 
the  anfemia,  may  be  caused  by  it,  or  both  may  result  from 
some  common  cause. 

Congenital  Hjrpertrophic  Stenosis  of  the  Pylorus. — J.  H. 
NicoU  finds  records  of  some  thirty  undoubted  cases.  His 
own  case  was  that  of  a  baby  aged  six  weeks,  who  from 
the  .second  week  after  birth  v'omited  the  stomach  contents 
fifteen  or  twenty  minutes  after  each  meal.  Vomiting 
was  not  preceded  or  accompanied  by  hiccough,  nausea, 
pain,  or  difficulty.  Between  attacks  the  child  seemed  to 
be  perfectly  comfortable  until  hunger  induced  another 
meal,  when  the  same  results  would  happen.  Emaciation 
naturally  followed.  A  Loreta's  operation  was  done  with 
perfect  success.  The  child  was  living  and  healthy  a  year 
after. 

An  Explanation  of  the  Cause  of  Infantile  Scurvy,  with 
Suggestions  as  to  its  Prevention. — C.  E.  Corlette  advances 
the  theory  that  the  sterilization  and  to  a  less  extent  the 
pasteurization  of  milk  deprive  it  of  its  normal  citric-acid 
contents,  and  that  it  is  this  deficiency  which  is  the  cause 
of  scurvy  symptoms.  He  advises  along  with  milk  the  ad- 
dition of  lime-juice  or  a  citrate,  and  gives  his  formula  for 
this  procedure.  The  article  is  well  worthy  of  perusal  by 
all  interested  in  the  matter  of  infant  feeding. 

Ambidexterity:  a  Plea  for  its  General  Adoption.  —  E. 
Noble  Smith  traverses  familiar  ground,  calling  attention 
to  the  possible  influence  of  one-sided  use  of  the  body  in 
the  production  of  deformities. 

Mtinchencr  medicinische  Wochenschrift,  August  21,  iqoo. 

Pneumonia  following  Laparotomies  in  the  Neighborhood  of 

the  Diaphragm. — In  the  opinion  of  George  Kelling  this  is 


the  most  serious  of  the  complications  attending  operations 
of  this  sort,  especially  those  performed  on  the  gastro-intesti- 
nal  canal.  From  its  causation  it  may  be  divided  into  :  (i) 
Aspiration  pneumonia,  due  to  inhalation  of  vomitus,  and 
which  is  particularly  infectious  in  cases  of  oesophageal  or 
gastric  carcinoma  when  breaking  down  has  taken  place; 
(2)  pneumonia  due  to  pulmonary  infarcts  resulting  from 
emboli  originating  from  the  vessels  ligated  ;  (3)  hypostatic 
pneumonia,  observed  in  the  aged  and  secondary  to  imper- 
fect aeration  of  the  lungs  and  impaired  heart  action  ;  (4) 
pneumonia  occuring  during  epidemics.  In  addition  to 
these  there  is  a  set  of  cases  which  give  the  impression  that 
the  infection  was  conveyed  at  the  time  of  operation,  and 
as  other  factors  can  usually  be  excluded  the  author  believes 
that  this  often  takes  place  through  the  contact  of  the  ailr 
with  the  interior  of  the  abdominal  cavity.  To  guard  against 
this  danger  the  operating-room  must  be  kept  as  dust-free 
as  possible,  with  which  object  frequent  wiping  with  moist 
cloths,  filtration  of  the  air  admitted  for  purposes  of  venti- 
lation, and  flooding  of  the  floor  with  water  are  recom- 
mended. 

Infection  through  the  Conjunctival  Sac. — Mayer  performed 
a  large  number  of  experiments  on  animals,  demonstrating 
the  possibility  of  bacterial  invasion  of  the  circulation  and 
generalized  infection  through  the  medium  of  the  conjunc- 
tiva. This  takes  place  with  great  rapidity  after  inocula- 
tion with  anthrax,  jjest,  chicken  cholera,  mouse  typhus,  in 
small  animals  with  glanders  and  psittacosis  (Nocard). 
Pseudo-tuberculosis  gives  a  subacute  course  ;  in  larger  ani- 
mals psittacosis,  glanders,  and  tuberculosis  are  very 
chronic.  Tetanus  and  diphtheria  are  fatal  through  the 
formation  of  to.xins;  diphtheria  and  the  staphylococcus 
pyogenes  aureus  produced  local  infections,  while  the  organ- 
isms of  cholera,  typhoid,  and  actinomycosis  were  not  able 
to  invade  the  system,  the  tears  appearing  to  have  a  special 
inhibiting  effect  on  cultures  of  the  former  two,  while  on  the 
contrary  the  growth  of  the  diphtheria  bacillus  was  encour- 
aged. 

The  Occurrence  of  Rhodan  in  the  Nasal  and  Conjunctival 
Secretion. — U.  Muck  tested  the  nasal  secretion  for  this  con- 
stituent of  saliva  by  introducing  cotton  tampons  moistened 
with  diluted  ferric-chloride  solution  acidulated  with  hydro- 
chloric acid.  A  reddish  or  yellowish  brown  was  produced 
where  the  nasal  secretion  came  in  contact  with  the  re- 
agents. As  a  corroborative  reaction  chemically  clean  filter 
paper  was  saturated  with  a  mixture  of  concentrated  hydri- 
odic  acid,  dilute  sulphuric  acid,  and  starch  solution,  and 
dried.  When  this  is  applied  to  the  nasal  secretion  a  blue 
spot  is  produced,  showing  that  iodine  has  been  .set  free,  ow- 
ing to  the  reducing  properties  of  the  rhodan  base. 

Sugar  as  an  Oxytocic. — Max  Madlener  has  had  good 
results  with  sugar  solution  in  cases  of  insufficient  labor 
pains.  He  gives  one  ounce  of  sugar  dissolved  in  eight 
ounces  of  water,  repeating  if  necessary.  If  more  accept- 
able to  the  palate  the  draught  may  be  flavored  with  tea  or 
rum.  Xausea  is  never  produced.  In  from  one-half  to  one 
hour  after  administration  the  effect  is  manifest,  the  uter- 
ine contractions  being  greatly  stimulated,  while  the  physi- 
cal pain  is  somewhat  diminished. 

My  "Position  Treatment"  in  Abnormalities  of  Form,  Po- 
sition, and  Size  of  the  Uterus. — By  Beckers. 

The  Alexander-Adams  Operation  in  Retroflexio  Uteri  Mo- 
bilis. — By  Carl  Peters. 

Deutsche  medicinische  Wochenschrift,  August  2s.  igoo. 

Is  Alcohol  a  Food  or  a  Poison  ? — Kassowitz  maintains 
that  it  is  not  so  much  a  question  as  to  whether  alcohol /^r  se 
is  toxic  or  nutritive,  for  it  can  hardly  be  denied  that  it  is  an 
active  poison  capable  of  causing  the  death  of  any  animal  or 
vegetable  protoplasm  with  which  it  comes  in  contact,  but 
rather  as  to  whether  in  spite  of  these  injurious  properties 
it  can  still  be  of  value  to  the  organism  and  serve  to  sus- 
tain it.  A  food-stuff  to  be  classed  as  such  must  not  only 
be  capable  of  supplying  the  organism  with  energy  to  be 
dissipated  as  heat  and  in  the  performance  of  work,  but 
must  also  under  proper  conditions  enter  into  the  bodily 
structure  and  replace  tissue  that  has  become  worn  out. 
Recent  investigation  has  shown  clearly  enough  that  alco- 
hol is  easily  and  abundantly  oxidizable  in  the  human 
body,  but  the  mere  proof  that  a  substance  is  consumed  in 
this  way  does  not  entitle  it  to  rank  as  a  food,  and  still  less 
can  this  supposition  be  entertained  if  in  addition  it  at  the 
same  time  causes  decomposition  and  destruction  of  living 
protoplasm.  That  alcohol  does  this  is  not  to  be  doubted 
in  view  of  the  present  knowledge  of  metabolic  processes, 
and  this  granted,  it  is  evident  that  a  substance  capable  of 
destroying  body  tissue  cannot  also  at  the  same  time  serve 
to  build  it  up  and  replace  damaged  parts.  Therefore  the 
position  that  alcohol  may  play  the  double  role  of  food  and 
poison  is  untenable,  and  the  sooner  it  is  dropped  from  the 
list  of  drugs  for  internal  administration  the  better  it  will 
be  for  physician  and  patient. 


426 


MEDICAL    RECORD. 


[September  15,  1900 


What  is  the  R81e  of  the  Tube  in  the  Therapeutic  Applica- 
tion of  the  Roentgen  Rays  ?— Strater  dividt.s  tlie  tubes  used 
therapeutujally  into  hard  and  soft,  with  intermediate  de- 
grees, basing  the  jjradations  on  the  degree  of  penetration 
into  the  tissues  exhibited.  Soft  tubes  are  those  whose  rays 
manifest  their  activity  principally  in  tlie  skin  and  muscle, 
while  those  that  penetrate  tlie  overlying  structures  and  are 
only  partially  blocked  even  by  the  bone  are  designated  as 
hard.  These  differences  may  be  estimated  by  the  use  of 
the  fluorescent  screen,  on  which  the  intensity  of  the  rays 
is  commensurate  with  the  degree  of  illumination  and  the 
hardness  proportionate  to  the  sharpness  of  contrast  be- 
tween the  illuminated  object,  r.o-.,  the  hand,  and  the  sur- 
rounding tield  :  thus  the  harder  the  tube  the  less  plainly 
will  the  soft  parts  show  and  the  less  intense  will  be  the 
shadow  of  the  bones.  Therapeutically  soft  tubes  arc  to  be 
used  when  it  is  intended  to  confine  tlie  remedial  action  to 
the  upper  layers  ;  hard  ones  when  deeper  structures  are  to 
be  influenced. 

A  Fatal  Case  of  Septicsemia  Beginning  as  Angina  FoUicu- 

laris.— The  case  described  by  Xultenius  began  apparently 
as  a  simple  tonsillitis  contined  to  the  left  side.  At  the  same 
time  tliere  was  a  slight  redness  of  the  skin  on  the  opposite  ' 
side,  which  gradually  increased  in  extent  and  the  skin  be- 
came somewhat  swollen  and  painful.  The  local  symptoms 
in  the  throat  became  more  severe  and  simulated  a  diph- 
theritic infection,  so  that  antitoxin  was  injected.  The 
treatment  was  not  effective,  and  the  patient  had  a  daily 
afternoon  temperature  of  102.5=  P-  with  morning  remis- 
sions. On  the  eighth  day  the  left  calf  and  both  forearms 
became  intensely  painful  and  gave  evidence  of  a  well- 
marked  lympliangitis,  and  tlie  temperature  went  up  to 
103.5"  F-.  continuing  higli  until  the  patient's  death  four 
days  later  from  cardiac  weakness.  The  case  is  interesting 
as  affording  proof  of  the  possibility  of  a  general  infection 
taking  place  through  the  medium  of  the  tonsils. 

The  Treatment  of  Aneurisms  by  Electrolysis  through  the 
Introduction  of  Wire.— By  A.  Bernheim. 

The  Dbubtful  Value  of  Antitussin  as  a  Remedy  in  Whoop- 
ing-Cough.— By  P.  Krause. 

Fifth  Report  of  the  Malarial  Expedition.— By  R.  Koch. 

Berliner  klinische  Wochenschrift.  August  20,  igoo. 

Therapeutic  Trials  with  Alternating  Currents  of  High  Fre- 
quency and  Tension  (Tesla  Cun-ents) .— Tobv  Cohn  describes 
a  series  of  experiments  made  by  himself  alone,  which  were 
similar  to  those  made  by  himself  and  Loewv.  He  arrived 
at  practically  the  same  conclusions.  He  could  not  make 
out  any  change  in  blood  pressure  or  in  tissue  change. 
There  were  some  subjective  sensations  which  made  the  pa- 
tients say  they  felt  better,  especially  in  regard  to  ability  to 
sleep  well.  Cohn  thinks  that  the  current  may  have  a  sug- 
gestive influence,  and  that  to  this  are  due  all  the  reported 
benefits. 

The  Effect  of  Tesla  Currents  on  Metabolism.— A.  Loewy 
and  Toby  Cohn  made  a  series  of  experiments  on  person's 
subjected  to  the  influence  of  the  Tesla  currents  by  inci- 
sure within  large  .solenoids,  and  by  the  estimation  of  oxy- 
gen absorbed  and  carbonic  acid  gas  given  off.  They  were 
unable  to  determine  that  the  conditions  of  the  experiments 
produced  any  effect  whatever. 


A  Contribution  to  the  Critical  Examination  of  Milk  Prepa- 
rations.—By  W.  Caspari. 

Contributions  to  the  Derivation  of  Sugar  from  Albumin  — 

By  J.  Wohlgemuth. 

French  Journals. 
The  Parasitic  Origin  of  Eczema.— L.  Brocq  concludes  a 
clinical  lecture:  («)  In  the  present  state  of  our  knowledge 
the  existence  of  a  specific  microbe  pathogenic  of  eczema 
remains  still  to  be  demonstrated.  The  microbe  may  exist, 
but  it  has  not  been  proven.  {(6)  Pure  primary  lesion.s 
(closed  vesicles)  of  true  vesicular  eczema  do  not  contain 
any  microbe  discoverable  by  procedures  now  known  in  bac- 
teriology, (c)  The  various  microbes  (and  in  particular  the 
staphylococcus)  which,  exist  in  abundance  upon  the  oozing 
or  crusted  surfaces  of  eczema  constitute  secondary  infec- 
tions, wdiose  direct  effect  ujKjn  pure  eczema  begins  to  be  sus- 
pected, but  their  presence  does  not  explain  its  nature. 
These  microbes  are  the  cause  of  most  of  the  complications 
and  of  the  polymorphous  erui)lions  which  so  often  change 
the  typical  evolution  of  pure  eczema.— /r«/;;/,?/  des  Pra- 
ticiens.  August  25,   lyoo. 

Entero-Colitis.— P.  Froussard.  in  a  clinical  study  of  muco- 
membranous  entero-colitis  concludes  with  a  consideration 
of  the  dermatoses  in  its  course.  A  certain  number  of  cuta- 
neous manifestations  of  the  polymorphous  erythema  type 
appear,  esi)ecia!ly  after  paroxysmal  crises,  whicli  are 'ac- 
companied by  infectious  phenomena,  and  which  ought  to 
be  attributed  to  the  latter.  There  are  other  dermatoses  of 
remittent  or  chronic  course :  urticaria,  prurigo,  pruritus, 
eczema,  and  seborrhcea,  which  pursue  an  equal  course  with 


the  entero-colitis.  Especial  attention  is  directed  to  a  mil- 
iary pustular  recurrent  eruption  of  the  face,  especially  seen 
in  women  who  suffer  from  gastro-intestinal  troubles  as  well 
as  from  nervous  antecedents.— £<;  Presse  Medicate  Au- 
gust 2q,  1900. 

The  Pathogeny  of  Pellagra.- Professor  Babes  says  pella- 
gra is  on  the  increase  in  Roumaiiia.     He  gives  a  resume 
of    histological    researches    in    collaboration    with    Sion 
which  point  to  the  action  of  a  toxic  substance  in  pellagra' 

This  substance,  formed  in  the  blood,  has  the  property  of 
suppressing  the  toxic  action  of  the  extract  of  altered  ma'ize 

I  his  substance  can  be  found  in  the  blood  serum  of  subjects 
of  pellagra  who  have  been  cured  or  improved  It  pos- 
sesses the  specific  features  of  action  upon  the  toxic  ex- 
tracts of  spoiled  maize  coming  from  pellagra-infected  re- 
gions, while  other  serums  experimented  with  do  not  have 
this  action.— /,,;  Mededne  Modernc,  August  22,   1900. 

Organization  of  the  Fight  against  the  Plague  in  Russia.— 
Loris  Mehkoff  describes  the  precautions  taken  along  the 
Russian  frontier  to  keep  out  the  plague  from  Asiatic  coun- 
tries. The  energetic  efforts  of  the  Prince  of  Oldenbourg, 
it  would  seem,  have  overcome  almost  insurmountable  difli- 
culties  and  made  it  possible  for  Europe  to  consider  herself 
free  from  invasion  from  the  side  of  Russia.— Z,?  Bu/le/in 
Medical,  August  2g,  1900. 

Medicine,  September,  igoo. 
Suggestion  without  Hypnotism  as  a  Therapeutic  Agent.— 

Harold  N.  Moyer  believes  that  suggestion,  well  directed 
and  above  all  patiently  and  systematically  applied,  forms 
a  very  important  element  in  the  treatment  of  many  dis- 
ea.sed  states.  Hypnosis,  on  the  contrary,  has  many  ob- 
jectionable features.  It  is  by  no  means'  easily  induced 
excepting  in  individuals  with  very  unstable  nervous  sysl 
tems,  and  in  these  it  is  quite  certain  that  the  effects  are 
harmful.  There  is  not  a  little  evidence  that  goes  to  show- 
that  suggestion  may  be  invoked  just  as  efficiently  without 
hypnosis  as  with  it,  but  it  would  seem  that  the  more  self- 
consciousness  is  in  abeyance  the  more  efficient  the  sug- 
gestion. However,  when  the  patient's  own  consciousness 
comes  to  the  aid  of  the  person  making  the  suggestion,  there 
IS  a  possibility  that  suggestion  may  be  more  efficient  with- 
out the  hypnotic  state.  If  an  individual  comes  to  a  physi- 
cian, for  examjjle,  in  the  full  belief  that  the  physician  is 
in  possession  of  a  remedy  or  a  treatment  that  will  infal- 
libly cure  a  certain  trouble,  undoubtedly  the  effect  on  the 
patient's  mind  of  suggestion  along  the  lines  of  this  thought 
IS  more  efficient  when  the  person  is  conscious  than  if  he 
were  in  a  hypnotic  state.  On  the  contrary,  if  the  patient 
were  opposed  to  the  suggestion,  it  is  self-evident  that  hyp- 
nosis, if  it  can  be  induced,  would  lend  additional  aid'  in 
making  the  suggestion  operative. 

Bone  Food.— B.  T.  Whitmore  suggests  the  ingestion  of 
bone  flour  as  a  reparative  food  or  means  of  supplying  the 
phosphates  needed  to  repair  the  phosphatic  elements 
which  are  wasted  in  the  economy  of  life.  It  is  prepared 
from  the  larger  bones  of  sound  be'ef  cattle.  The  bones  are 
thoroughly  cleaned  of  all  muscular  and  tendinous  tissue, 
dried,  and  ground.  The  resulting  product  is  a  line  pow- 
der devoid  of  taste  and  odor,  which  will  keep  indefinitely. 
It  is  given  in  admixture  with  other  foods  in  such  propo'r- 
tion  as  will  serve  to  bring  them  up  to  the  standard  phos- 
phatic supply.  It  may  be  mixed  with  any  food  article 
sufl!iciently  glutinous  to  hold  it  in  admixture,  or  it  may  be 
taken  in  suspension  in  milk  or  water.  It  is  not  intended 
to  take  the  place  of  the  various  hypophosphites  as  a  rem- 
edy, but  as  a  dietetic  agent  is  w'ill  frequently  make  the 
administration  of  the  hypophosphites  unnecessary. 

Decinormal  Salt  Solution  in  the  Treatment  of  Hemorrhage 
in  Typhoid  Fever.— C.  H.  Anderson  reixirts  in  full  one  case 
out  of  five  which  were  treated  with  transfusions  of  deci- 
normal salt  .solution  in  the  United  States  General  Hospi- 
tal at  Fortress  Monroe.  In  this  case,  of  a  corporal  of  the 
Illinois  Volunteer  Infantry,  transfusion  was  performed 
several  times,  when  the  patient  had  collapsed  from  hem- 
orrhages. He  rallied  well  after  each,  and  finally  recov- 
ered. The  author  says  that  the  mortality  from 'typhoid 
fever  accompanied  by 'hemorrhage  is  very  g'reat,  and  trans- 
fusion should  be  done  in  every  case.  In  the  case  reported  it 
was  done  in  a  tent,  without  antiseptic  and  asejitic  material, 
and  with  no  conveniences  with  which  to  do  careful  work. 

Pregnancy    Complicated    by    Suppuration    of    Fibroids.— 

By  Charles  Greene  Cuniston. 

Treatment  of  Tuberculosis  of  the  Lungs.— By  C.  J.  Whalen. 

Zeit.uli.  f.  Diatct.  u.  riiysik.  Tiierap..  vol.  /?■..  Xo.  4.  rgoo. 
The  Weather,  Sunshine,  and  Infectious  Diseases. — J.  Ruhe- 
mann  divides  the  meteorological  conditions  influencing 
disease  curves  into  two  general  groups  (i)  Those  acting 
principally  on  the  individual,  involving  mainly  the  ques- 
tion of  heat  abstraction  and  comprising  the  atmospheric 
temperature,  absolute  and  relative  humidity,  the  direction 


September  15,  1900] 


MEDICAL    RECORD. 


427 


and  rate  of  air  currents,  and  the  rain-  and  snow-fall  ;  (2) 
The  element  of  sunshine,  which  is  the  factor  having  most 
to  do  with  ectogenous  bacterial  growth.  Barometric  press- 
ure is  not  mentioned,  for  although  not  without  its  eflfect 
on  man  it  does  not  hold  any  directly  causative  relationship 
to  disease.  Of  these  two  groups  the  latter  is  by  far  the 
most  important,  and  to  a  very  marked  degree  controls  the 
activity  of  bacterial  life,  so  that  the  law  may  be  laid  down 
that  the  average  of  hours  of  sunshine  for  any  .season  is  in 
inverse  proportion  to  the  amount  of  infectious  disease. 
This  relation  is,  however,  not  synchronous  but  post])oned, 
owing  to  the  fact  that  allowance  must  be  made  for  the  pe- 
riods of  incubation,  and  in  comparing  statistics  the  periods 
contrasted  must  be  taken  from  corresponding  seasons  of 
the  year.  Thus  a  week  in  March  may  show  the  same  sun- 
shine factor  as  one  in  October  and  yet  the  disease  coeffi- 
cient be  much  higher,  since  all  winter  long  the  weather  has 
been  dark,  and  therefore  the  conditions  have  been  more 
favorable  for  the  bacterial  flora  than  during  the  light,  sun- 
shiny summer  montlis. 

Hydrotherapy  in  Gynaecological  and  Obstetrical  Practice. — 

Odiin  Tuszkai  employs  hydrotherapy  under  four  different 
forms  in  the  treatment  of  acute  and  chronic  disease  of  the 
female  pelvic  contents.  These  are  sitz-baths,  irrigations, 
packs  or  compresses,  and  continuous  application  of  heat  or 
cold  by  means  of  water  coils.  Of  these  the  sitz-bath  is  the 
most  widely  applicable  and  u.seful ;  the  portion  immersed 
should  be  from  the  middle  of  the  thighs  to  the  umbilicus. 
The  effect  of  such  a  cold  bath  is  to  produce  plethora  of  the 
cerebral  vessels  with  attendant  eye  symptoms,  buzzing  in 
the  ears,  dizziness,  increased  respiratory  and  cardiac  ac- 
tivity, with  a  pulse  first  rapid  and  irregular  and  then  slow. 
The  cause  of  these  symptoms  is  the  strong  vaso-constric- 
tion  due  to  reflex  stimulation  of  the  splanchnic  nerves  and 
which  produces  a  local  drop  in  temperature  and  reduced 
blood  current  at  the  surface,  with  the  opposite  effects  at  the 
periphery  and  in  the  interior.  This  is  the  result  of  a  bath 
of  short  duration  (five  or  six  minutes),  which  is  indicated 
in  all  conditions  of  atony,  relaxation,  etc.,  when  there  is 
no  inflammation  ;  if,  however,  it  be  continued  for  from  fif- 
teen to  twenty  minutes,  contraction  of  the  deep  vessels  and 
hypericmia  of  surface  take  place.  Warm  sitz-baths  produce 
superficial  congestion  and  anaemia  of  the  pelvic  viscera, 
but  here  the  reaction  sets  in  much  sooner  than  with  the 
cold  applications  and  a  state  of  great  relaxation  supervenes, 
which  contraindicates  the  procedure  in  any  conditions 
in  which  congestion  or  hemorrhage  is  to  be  feared. 

Russki  Arkhiv  lie  Patulogii,  i^Iay  31  and  June  30,  igoo. 

The  Effect  of  Repeated  Injections  of  Toxins  upon  Nutritive 
Exchanges. — K.  Dmitrievski  obtained  the  following  results 
by  experimentation:  (i)  Pyocyanic  toxin.  In  animals 
previously  starved,  nitrogen,  urea,  phosphorus,  and  chlo- 
rine were  considerably  increa.sed  after  the  first  and  slightly 
increased  after  the  second  and  third  dose.  The  first  dose 
caused  a  notable  loss  of  weight,  the  second  and  third  a 
lessened  diminution  and  for  a  lessened  duration.  In  ani- 
mals ])reviously  well  nourished,  four  to  five  doses  produced 
a  condition  of  immunization,  the  modifications  in  weight 
and  in  the  amount  of  nitrogen  becoming  less  and  less 
marked  after  each  injection.  (2)  Toxin  of  bacillus  coli 
communis.  The  modifications  in  weight,  nitrogen,  phos- 
phoric oxide,  and  chlorine  are  about  the  .same  as  in  the 
case  of  pyocyanic  toxin.  (3)  Diphtheritic  toxin.  In 
starved  animals  the  first  dose  causes  a  loss  of  weight  and 
an  increase  in  disassimilation  with  hyperazoturia  and 
hyperphosphaturia.  The  increase  of  nitrogen  and  phos- 
phoric oxide  is  less  than  in  the  preceding  experiments. 
Chlorine  is  increased.  After  the  second  and  third  injec- 
tions, the  percentage  of  nitrogen  and  phosphoric  oxide  is 
not  increased  so  much  as  before,  but  the  chlorine  is  aug- 
mented in  amount.  In  well-fed  animals  the  modifications 
of  nitrogen  become  less  and  less  marked.  Hyperleucocy- 
tosis  was  found  after  eacli  injection. 

Cutaneous  Hypaesthesia  in  Tabes. — Dr.  Grebner.  from  the 
result  of  the  examination  of  fifty-two  patients,  states  that 
hypaesthesia  always  originates  in  two  foci,  corresponding 
to  the  third  dorsal  and  the  first  sacral  nerves,  and  is  lim- 
ited to  the  peripheral  distribution  of  the  posterior  roots. 
From  these  two  foci  the  affection  is  propagated  above  and 
below  to  the  neighboring  posterior  roots.  The  upper  focus 
is  the  one  most  frequently  affected.  The  upper  roots  of 
the  nuchis  (from  the  fifth  cervical  nerve)  are  unaffected, 
even  in  advanced  stages  of  the  disease.  This  regularity 
in  the  occurrence  and  distribution  of  the  hypassthesia  de- 
pends upon  the  structural  differences  in  the  segments  of 
the  spinal  cord.  Wherever  there  is  ataxia,  hypaesthesia  is 
found.  The  skin  covering  the  ata.xic  articulations  is  not 
necessarily  hypaesthetic.  The  author  found  no  improve- 
ment of  articular  hypjesthesia  in  cases  in  which  improve- 
ment of  the  ataxia  had  been  brought  about  by  retraining 
of  the  muscles. 


A  Study  of  Immunity. — Professor  Savchenko  instituted 
a  number  of  experiments  with  a  view  of  ascertaining  the 
correctness  of  M.  Gabritschewsky's  statement  that  the  nat- 
ural immunity  of  animals  iguinea-pigs)  against  the  spiril- 
lum is  due  to  the  rapid  formation  of  specific  bactericidal 
substances  at  the  seat  of  inoculation.  The  experiments 
appear  to  disprove  this  statement,  for  the  spirilla  disappear 
as  a  result  of  a  slow  phagocytosis,  the  uninuclear  cells 
almost  exclusively  performing  the  part  of  phagocytes. 
Even  in  vitro  we  can  see  that  leucocytes  containing  immu- 
nizing substances  are  endowed  with  energetic  properties 
of  positive  chemotaxis  toward  spirilla.  The  latest  experi- 
ments demonstrate  that  immunizing  substances  mav  exist 
in  the  blood,  without  acting  directly  upon  the  spirilla,  the 
action  being  throu.gh  the  agency  of  cells. 

Clinical  Study  of  Gout.— A.  Svoechotoff  holds  that  gout 
is  due  to  auto-intoxication  by  the  abnormal  products  of 
metabolism.  The  bases  are  probably  clo.sely  allied  to  uric 
acid.  The  amount  of  urine  and  of  urea  diminishes,  and 
that  of  uric  acid  increases  during  an  attack.  The  vaso- 
motor system  probably  undergoes  modifications  during  an 
attack  :  there  is  spasmodic  contraction  of  the  smaller  ves- 
sels. Uric  acid  appears  in  the  affected  joints  in  the  form 
of  needle-shaped  crystals  of  the  biurate  of  sodium,  and  not 
in  the  form  of  globules.  During  the  disease  the  kidneys 
may  allow  albumin  to  filter  through  without  clinically  ap- 
pearing to  affect  the  renal  tissue.  The  seat  of  the  gouty 
deposits  probably  depends  upon  nutritional  changes  in  the 
tissues  and  enfeebled  circulation.  Surgical  intervention 
is  often  imperative  in  gout. 

Mycotic-Embolic  Aneurism. — Oscar  Ling  describes  the 
case  of  a  youth,  aged  nineteen  years,  suffering  from  cryp- 
togenic septico])ya,'mia  and  septic  endocarditis.  A  pulsat- 
ing tumor  was  found  at  the  left  elbow,  and  after  the  patient's 
death  it  was  examined  and  judged  to  be  a  mycotic-embolic 
aneurism  formed  after  a  rupture.  An  embolus  was  found 
at  the  point  of  division  of  the  artery  ;  there  were  destruction 
of  the  internal,  the  elastic,  and  the  median  muscular  coats, 
rupture  of  the  adventitia,  and  dilatation,  and  the  mass  of 
micrococci  foramed  in  the  aneurism  was  similar  to  those 
found  in  the  valves  of  the  heart. 

The  Structure  and  Transformations  of  the  Plasmadiophora 
BrassiccB  Woron  during  its  Intracellular  Development. — By 
S.  Navachin. 

Some    Parasites   of    Man    as    yet    Little    Studied    in   the 

Orient.— By  P.  SsokoU.ff. 

Change  in  Weight  of  Nursing  Infants  in  Phthisis. — By  A. 

P.  Morkovitin. 

The    Combustion    and    Disinfection    of    Rubbish. — By   F. 

Erismann. 

Two  Cases  of  Lymphosarcoma. — By  A.  I.  Kostkevits. 
Pericarditis. — By  B.  M.  Schaposchnikoff. 

Revue  de  Chirurgie,  July  10  and  August  10,  igoo. 

Anatomical  Researches  in  Regard  to  the  Ceecum  and  its 
Appendi.x. — Giullauo  Peronidi,  from  the  study  of  the  ca;cal 
region  in  fifty  cadavers,  reaches  the  following  conclusions: 
that  the  caecum  in  eighty-three  per  cent,  of  the  cases  is  sit- 
uated in  the  lower  part  of  the  right  iliac  fossa.  Next  in 
order  of  frequency,  its  situation  is  in  the  middle  or  superior 
third  of  the  iliac  fossa  ;  and  next  in  the  pelvic  cavity.  In 
three  cases  it  was  in  the  umbilical  region,  in  one  in  the  lum- 
bar fossa.  Its  direction  is  usually  the  following:  its  axis 
is  obliquely  to  the  right,  upward,  and  backward.  In  three 
cases  it  was  vertical,  in  two  transverse.  Its  serous  cover- 
ing was  complete  in  seventy-five  per  cent,  of  the  cases  ;  its 
length  varied  from  6  to  10  cm.,  its  breadth  from  3  to  10  cm. 
The  appendix  was  in  the  majority  of  cases  cylindrical,  ver* 
tical,  and  within  the  caecum.  In  ten  cases  it  was  retro- 
caecal ;  its  average  length  was  7.(1  cm.  and  breadth  5  cm. 
In  one  case  tlie  me.so-appendi.x  formed  a  pouch  ;  in  one,  the 
ileo-appendicular  fold  was  greatly  developed  :  in  one  this 
fold  was  absent  and  its  place  taken  by  a  rounded  depres- 
sion. The  author  claims  to  be  the  first  per.son  to  call  atten- 
tion to  these  interesting  characteristics. 

Osteoplastic  Amputations. — Z.  Samfirescu  describes  a  proc- 
ess to  be  used  111  the  case  of  amputations  in  the  continuity 
of  the  long  bones  of  the  extremities.  It  consists  in  the  for- 
mation of  an  osteo-periosteal  .segment  which  is  closely  ap- 
plied to  the  surface  of  the  amputated  bone,  and  which  un- 
doubtedly becomes  joined  to  it  later,  in  the  same  way  that 
soft  tissues  unite  together.  The  adaptation  and  consolida- 
tion of  such  a  diaphyseal  segment  at  the  extremity  of  the 
amputated  limb  will  make  a  stump  as  solid  as  the  limb 
itself,  with  tissues  equally  diaphyseal.  The  author  claims 
that  in  the  case  of  children  the  bone,  if  treated  in  this  way, 
will  not  grow  after  amputation  ;  as  all  surgeons  know,  the 
growth  of  bone  beyond  the  soft  tissues  in  the  end  of  the 
stump  is  an  inconvenient  occurrence  which  frequently 
takes  place.     The  stump  after  this  process  can  at  once  be 


428 


MEDICAL    RECORD. 


[September  15,  1900 


placed  in  an  artificial  limb,  and  it  will,  moreover,  not  be 
sensitive  to  changes  of  temperature,  as  are  stumps  formed 
according  to  the  classic  methods. 

Pneumotomy  with  Resection  of  Ribs. — Michel  Christovitch 
describes  the  case  of  a  young  man  in  whose  hing  had  lodged 
the  bullet  from  a  revolver.  On  the  sixth  day  after  receiv- 
ing the  wound  his  condition  was  so  grave  that  an  operation 
was  decided  on.  An  exijloratory  puncture  in  the  seventh 
left  intercostal  space  showed  an  effusion  of  blood  and  pus. 
Three  centimetres  of  the  sixth  rib  were  resected,  and  tlie 
ball  was  felt  by  the  finger  introduced  into  the  wound.  The 
fifth  and  sixth  ribs  were  then  re.sected,  the  pleura  and  lung 
incised,  and  the  bullet  was  removed  together  with  blood, 
pus,  and  three  sphacelated  pieces  of  lung  tissue.  Ab- 
sorbent gauze  stopped  the  hemorrhage,  drainage  was  se- 
cured, the  wound  sutured  and  dressed,  and  ether  and  arti- 
ficial serum  injections  were  administered  and  repeated  for 
two  days.  The  operation  lasted  twenty  minutes  only.  The 
patient  was  completely  cured  at  the  end  of  two  months, 
with  no  fistula. 

Abdominal  _Iysterectomy. — E.  Quenu  and  L.  Louquet  thus 
sum  up  tneir  study  of  the  subject :  Total  abdominal  cas- 
tration for  neoplasms  of  the  appendages  is  legitimate,  and 
not  dangerous.  It  possesses  great  technical  advantages, 
and  prevents  many  post-operative  accidents,  such  as  intes- 
tinal occlusion.  It  is  indicated  in  cases  of  ovarian  cysts 
and  tumors  complicated  by  uterine,  peri-uterine,  and  tubal 
inflammatory  lesions,  or  those  complicated  by  neoplastic 
degeneration  of  the  uterus,  and  in  bilateral  ovarian  cysts 
and  tumors,  when  the  size,  friability,  or  situation  of  the 
pedicle  presents  difficulties  as  to  hsemostasis.  It  is  contra- 
indicated  in  cases  of  unilateral  cyst  in  a  young  woman  ; 
when  the  uterus  is  healthy,  and  the  manipulation  of  the 
pedicles  easy  ;  in  cases  of  bilateral  lesions  of  the  appen- 
dages, and  in  cases  in  which  a  good  treatment  of  the  pedicle 
can  be  obtained  by  some  easier  process. 

Familial  Symmetrical  Lipoma  of  the  Plantar  Arch. — Charles 
Fere  describes  the  occurrence  of  tumors  of  the  feet  in  two 
women,  cousins.  This  cannot  be  ascribed  to  heredity,  but 
must  be  classed  as  "familial."  There  was  an  arthritic  and 
cancerous  family  history,  and  in  both  cases  a  markedly 
nervous  previous  personal  history.  In  one  patient  the/e 
was  herpes  zoster  of  the  lower  part  of  the  left  leg  and  outer 
side  of  the  foot,  and  this  affection,  in  fact,  was  the  occasion 
of  the  physician's  attention  being  drawn  to  the  lipoma  of 
the  plantar  arch,  which  the  patient  asserted  had  been  there 
for  twenty  years.  Her  sister  had  a  similar  growth  on  her 
foot. 

Perforation  of  Stomach,  Colon,  and  Diaphragm  by  a  Bul- 
let ;  Suture  ;  Recovery. — By  O.  Laurent. 

Cancer  of  the  Large  Intestine,  Excepting  the  Rectum.— By 
R.  de  Bovis.     A  continued  article. 

A  Study  of  Rhabdomyoma,  especially  of  a  Malignant  Na- 
ture.— By  Edouard  Genevet. 

A  Case  of  Voluminous  Sebaceous  Adenoma  of  the  Face. — 
By  G.  Curtis  and  Lambret. 

The  Interstitial  Cells  in  the  Adult  Testicle.— By  B.  Cuneo 
and  P.  Lecene. 

Exclusion  of  the  Intestine. — By  F.  Terrier  and  A.  Gosset. 

Revue  de  Medecine,  July  lo,  igoo. 

Gastro-Intestinal  Affections  due  to  Neuroses. — M.  Dubois 
writes  of  cases  of  gastro-intestinal  dypsepsia,  due  to  purely 
nervous  conditions.  In  hundreds  of  these  cases  he  has  ob- 
tained a  cure  by  making  tlie  patients  abandon  the  restricted 
diet  upon  which  they  had  been  placed,  sending  them  to  bed 
in  a  sort  of  rest  cure,  keeping  them  upon  a  milk  diet  for  a 
few  days,  and  then  suddenly  causing  them  to  return  to 
three  full  meals  a  day  of  food  chosen  haphazard,  or  accord- 
ing to  taste.  The  chief  thing  is  to  convince  them  that  their 
troul)le  is  cerebral,  and  does  not  come  from  gastro-intes- 
tinal disease,  and  their  recovery  is  then  immediate.  The 
gastro-intestinal  tract  is  peculiarly  under  the  influence  of 
the  nervous  system,  and  in  psychotherapy  is  found  the 
best  treatment  for  the  greater  part  of  disorders  supposed 
to  indicate  local  lesions. 

The  "  Coup-de-Foudre." — Charles  Fere  writes  of  the  coup- 
de-foudre  or  "  tliunderbolt,"  a  term  used  in  French  litera- 
ture to  signify  what  we  might  translate  "  love  at  first  sight.  " 
were  it  not  that  love  in  its  higher  manifestations  would 
appear  to  be  absent.  The  autlior  gives  examples  of  tlie 
condition,  which  seems  to  be  a  symptom  of  degeneracy,  of 
hallucinations  of  memory,  and  in  especial  of  ei)ile]isy  and 
of  neurasthenia.  This  explosive  form  of  affection  lie  thinks 
should  be  considered  a  symptom  of  morbid  emotion,  of 
nervous  disorder,  rather  than  a  celestial  inspiration  to  be 
followed  at  all  hazards. 

The  Nasal  Crisis  in  Tabes. — Henri  Jullian  describes  this 
condition,  which  is  characterized  by  an  attack  of  sneezing 
with  nasal  parjesthesia,  preceded  by  subjective  symptoms 


in  the  region  of  the  fifth  nerve,  consisting  in  a  strange 
sensation  of  constriction  and  stiffness  of  the  cheek  and 
neck.  The  nostril  of  the  same  side  suddenly  appears  to  be 
occluded,  and  the  sneezing  follows.  There  is  no  especial 
increase  of  secretion.  The  crisis  is  undoubtedly  due  to  the 
tabes. 

Tuberculosis  and  its  Open-Air  Treatment  in  Normandy. — 
By  Raoul  Brunon. 

Archives  Gcnerales  de  Midecine,  Augiisf,  igoo. 

Is  Scorbutus   an   Infectious  and  Contagious  Disease?— H. 

Turner  says  that  in  Russia,  in  iSgcj.  during  an  outbreak  of 
this  disease,  physicians  were  struck  by  the  following  facts 
which  seem  to  point  to  contagion :  The  epidemic  character 
of  the  malady  ;  its  presence  in  certain  villages  and  its  ab- 
sence from  other  villages,  not  far  removed,  but  haying  no 
communication  with  the  first ;  the  large  number  of  persons 
in  easy  circumstances  attacked  by  the  disease,  who  either 
were  obliged  to  live  in  the  midst  of  the  epidemic  or  to  come 
in  daily  contact  with  the  sick.  The  author  adduces  a  num- 
ber of  cases  and  facts  which  tend  to  prove  that  the  disease 
is  infectious,  that  isolation,  even  without  special  hygienic 
precautions,  prevents  its  spread,  and  that  salt  meat  and 
absence  of  vegetable  diet  are  not  the  only  causes.  The 
microscope  has  not  as  yet  discovered  a  specific  agent  for 
scorbutus,  but  it  may  do  so  with  improved  technique  :  and 
meanwhile  there  is  every  reason  to  isolate  the  patients. 
Writers  of  the  sixteenth  and  seventeenth  centuries  thought 
the  disease  contagious.  The  Nansen  party  escaped  it  en- 
tirely, in  spite  of  cold,  insufficient  diet,  and  absence  of 
fresh  food  for  sixteen  mouths. 

Spontaneous  Dilatations  and  Ruptures  of  the  Gall  Bladder 
in  Adhesive  Supra-Umbilical  Peritonitis. — A.  Machard  re- 
ports a  case  of  this  fatal  accident.  Obstruction  of  the  cys- 
tic canal  or  ductus  cholodechus  by  foreign  bodies  is  not  a 
necessary  condition  to  dilatation  of  the  gall  bladder ;  in 
the  case  under  discussion  it. was  produced  by  peritoneal 
adhesions  which  had  obstructed  the  cystic  canal.  Hy- 
drops of  the  gall  bladder  occurred,  and  the  walls,  weak- 
ened by  infection  due  to  stasis  caused  by  the  peritonitis, 
were  unable  to  resist  the  internal  pressure,  and  were  rup- 
tured. The  best  treatment  for  this  condition  is  cholecys- 
tostomy  with  abouchement  outside  of  the  gall  bladder. 
This  insures  drainage,  and  permits  of  direct  antisepsis. 
It  is  also  a  rapid  procedure.  There  is,  to  be  sure,  the  draw- 
back of  a  biliarj-  or  mucous  fistula,  but  cholecystectomy  or 
suture  of  the  walls  can  be  performed  later  when  all  danger 
of  infection  is  over. 

Researches  in  Regard  to  Arterial  Pressure  in  Chloroform 
and  Ether  Anaesthesia. — Simon  Duplay  and  Louis  Hallion 
hold  that  death  under  ansesthesia  is  due  to  a  fall  in  arte- 
rial pressure.  Hence  it  would  be  of  the  utmost  importance 
to  be  able  to  estimate  the  degree  of  pressure  at  every  step 
of  the  anjEsthesia  ;  for,  that  known,  it  would  be  easy  to  di- 
rect the  proper  amount  of  intoxication  and  keep  it  within 
the  limits  of  safety.  In  dogs,  which  are  more  liable  to  ac- 
cidents under  chloroform  than  are  human  beings,  the  an- 
aesthetic can  be  given  with  absolute  safety  provided  that  a 
manometer  be  placed  on  an  artery  and  carefully  watched. 
The  authors  hope  soon  to  be  able  to  show  that  an  exact 
estimation  of  arterial  pressure  during  anaesthesia  is  not 
only  desirable  but  very  possible. 

A  Study  of  the  Geographical  Distribution  of  Goitre  in 
France. — By  Lucien  Mayet. 

A  Case  of  Cerebral  Tumor. — By  Maurice  Patel  and  Lucien 
Mayet. 


Olot'vcspontlcncc. 


OUR   PARIS    LETTER. 

(From  Our  Special  Correspondenl.) 
THE    THIKTKENTH    MED1C.\L   CONGRESS. 

Paris,  August  i8,  1900. 

The  Thirteentli  International  Medical  Congress  in  Paris  is 
now  a  thing  of  the  jiast,  and  yet  it  is  hard  to  form  as  yet  a 
just  appreciation  of  the  work  accomplished  by  its  mem- 
bers. Dr.  Chauffard's  report,  which  was  read  at  the  open- 
ing session  held  lu  the  Salic  des  Fetes  on  tlie  Cliamp  de 
Mars,  indicated  that  tlicre  were  6,000  members  and  dele- 
gates;  2,000  Frenchmen,  750  Russians,  570  Germans,  350 
Americans,  330  Italians,  220  Spaniards.  Though  Dr. 
Chauffard  does  not  seem  to  have  mentioned  the  number 
of  the  English  contingent,  it  was  220  strong,  a  very  small 
number  comparatively,  due,  however,  to  the  condition  of 
affairs  in  the   British' empire  and  to  the  slight  degree  of 


September  15,  1900] 


MEDICAL   RECORD. 


429 


tension  existing  between  the  two  nations.  There  were  250 
reports  inscribed  to  be  read,  and  1.200  communications,  a 
great  many  of  which  are  signed  by  the  most  illustrious 
names  in  tlie  medical  line.  Dr.  Chauffard  spoke  also  of 
the  difference  between  this  congress  and  the  first  one  held 
in  Paris  in  1S67,  when  there  were  333  French  members  and 
589  foreigners. 

This  opening  session  was  to  have  been  honored  by  the 
presence  of  President  Loubet,  but  on  account  of  the  assas- 
sination of  the  King  of  Italy  he  did  not  come.  The  Salle 
des  Fetes  is  a  large,  circular  hall,  gaudily  decorated,  erected 
inside  the  Palais  des  Machines,  a  relic  of  the  iSSg  exliibi- 
tion,  and  its  size  prevented  one  from  hearing  most  of  the 
speeches.  The  first  was  by  Professor  Lannelongue,  the 
president  of  tlie  congress,  who  spoke  well  and  was  much 
applauded.  I  happened  to  be  seated  next  to  one  of  his 
former  colleagues  of  the  internate,  an  honorary  surgeim  of 
the  hospitals,  and  he  told  me  that  in  his  youth  Dr.  Lanne- 
longue had  been  somewhat  like  Demosthenes,  afflicted 
with  a  slight  impediment  in  his  speech.  No  trace  of  it  ex- 
ists at  present,  and  his  voice  was  heard  better  than  any 
other.  Dr.  Lannelongue  paid  a  tribute  to  the  wonderful 
progress  made  in  recent  years  in  determining  tlie  causes  of 
disease,  and  then  compared  the  result  of  recent  efforts  to 
the  discovery  of  those  mysterious  undulations  of  rays 
which  exist  in  the  solar  spectrum  from  the  red  to  and  beyond 
the  ultra-violet.  Science  was  slowly  transforming  the  civ- 
ilization of  the  present  day,  and  to  bring  forth  its  best 
fruits  the  seeker  should  not  remain  alone  and  isolated,  but 
all  should  ]nit  their  shoulders  to  the  wheel  and  work  to- 
gether. One  of  the  great  principles  of  modern  medical 
science  was  the  cultivation  of  man's  bodily  health,  and  in 
the  seeking  after  the  knowledge  needful  to  this  it  was  nec- 
essary to  be  guided  b)'  a  light  akin  to  that  of  the  miner  in 
his  progress  through  subterranean  passages.  Modern  proc- 
esses of  investigation,  more  perfect,  more  accurate,  would 
replace  little  by  little  the  older  forms;  a  new  nomenclature 
of  diseases  and  medical  terms  would  render  the  inter- 
change of  ideas  more  easy,  though  a  universal  language 
could  not  as  yet  be  established. 

Dr.  Lannelongue  concluded  by  welcoming  the  various 
delegates  and  foreign  members,  and  ended  his  speech  by 
citing  the  words  that  the  celebrated  Bouillaud,  the  heart 
specialist,  spoke  at  the  first  congress:  "Thanks  to  you, 
my  whole  life  has  received  at  last  its  crown.  I  carry  you 
henceforth  in  my  heart,  and  you  will  live  there  till  it  stops 
beating." 

Dr.  von  Bergmann,  German  delegate.  Dr.  Albert  from 
Austria,  Dr.  Preisz  from  Hungary,  Surgeon-General  Stern- 
berg, delegate  from  the  United  States,  Sir  William  Mac- 
Cormac,  delegate  from  Great  Britain,  and  Dr.  Reverdin.  of 
Geneva,  made  speeches.  The  last  address  made  was  by 
Professor  Virchow  who  spoke  on  "  Infection  and  Trau- 
matism." 

On  Friday  evening  Dr.  Pinard.  president  of  the  Obstet- 
rical section,  and  Professor  Terner  of  the  Gynaecological 
section  gave  a  dinner  to  one  hundred  and  twenty  members 
of  those  two  sections,  at  the  Grand  Hotel.  All  the  notable 
men  in  these  specialties  were  present,  and  speeches  and 
toasts  were  made  in  French,  English,  German,  and  Ital- 
ian. After  the  dinner,  which  took  place  in  the  apartment 
called  the  Zodiac  Hall,  a  reception,  to  which  the  ladies  had 
been  invited,  was  held. 

Dr.  Lannelongue's  reception  was  the  great  social  festiv- 
it)-  of  the  congress.  The  number  of  invitations  was, 
however,  limited,  not  more  than  twelve  hundred  of  these 
being  sent  out,  so  far  as  I  could  judge.  This  reception 
took  place  on  Friday  at  the  Galerie  des  Champs  Elysees, 
and  a  musical  entertainment  was  furnished.  The  close  of 
the  evening  was  a  dance  called  the  "  Danse  des  Nations," 
undertaken  by  four  young  pupils  of  the  opera,  dressed  re- 
spectively as  a  Breton  peasant,  an  Italian,  a  Spanish  girl, 
and  a  Russian  peasant.  Some  thirty  or  forty  American 
physicians  were  present  with  their  wives  and  daughters. 

Professor  Landouzy  gave  a  dinner  to  the  therapeutists 
at  the  Marguery  restaurant,  a  place  which  is  famous  the 
world  over  for  its  excellent  cooking.  The  dinner  took 
place  in  the  large  hall  reserved  for  such  festivities.  Mme. 
Alme,  of  the  Francjais,  sang  some  delightful  old  French 
songs  of  the  sixteenth,  seventeenth,  and  eighteenth  cen- 
turies. Professor  Landouzy  made  a  speech  which  was 
very  much  applauded.  He  said  he  had  thought  it  well 
that  therapeutists  should  pass  from  theory  to  practice  ; 
that  this  dinner  was  a'Megon  de  choses, "  a  practical  les- 
son, whereby  the  needs  of  the  inner  man  could  be  satisfied. 
He  spoke  a  few  words  about  vegetarian  diet,  and  showed 
how  the  menu  was  a  complete  refutation  of  the  principles 
of  the  vegetarians. 

On  Mondaj-  night  asocial  gathering  offered  by  the  mem- 
bers of  the  committee  was  to  take  place  in  the  gardens  of 
the  Luxembourg,  but  on  account  of  the  weather  it  was  re- 
solved to  hold  it  in  the  palace.  Eight  thousand  invitations 
had  been  sent  out,  and  as  a  certain  number  of  members 
brought  their  families,  and  even  acquaintances  it  would 


.seem,  the  result  was  that  there  was  an  awful  crush,  and  a 
certain  number  of  notable  medical  men,  who  should  have 
had  reserved  seats,  left  the  place  in  sheer  disgust.  A 
musical  and  theatrical  programme  had  been  gotten  up  by 
Dr.  Pozzi,  and  there  was  singing  bj-  Fougere,  of  the  Opera 
Comique,  who  rendered  "  Les  Saisons,"l3y  Masse.  Mme. 
Litvinne,  of  the  Opera,  sang  an  air  from  "Tristan  and 
Isolde";  M.  Renaud,  also  of  the  Opera,  sang  "The  Wil- 
lows are  Weeping,"  by  Erliinger,  and  Mounet-Sully  recited 
some  poems.  The  entertainment  was  certainly  most  bril- 
liant. 

On  Friday  afternoon  the  reception  of  the  President  of  the 
Republic  took  place  at  the  Elysee.  A  large  crowd  had 
gathered  in  the  Faubourg  St.  Honore.  and  only  a  few  were 
allowed  to  enter  at  one  time.  The  back  of  the  garden, 
which  fronts  on  the  Avenue  Gabriel  and  the  Champs  Elj'- 
sees,  had  been  transformed  into  a  sort  of  stage,  and  dances 
of  different  epochs  were  given  by  ballet-dancers  from  the 
Opera.  The  effect  was  striking.  The  weather  was  not, 
however,  very  propitious,  and  a  slight  shower  would  every 
now  and  then  dampen  everybody's  spirits.  There  was 
such  a  large  gathering  in  the  gardens  that  it  was  difficult 
to  get  near  the  stage.  The  dances  given  were  those  of 
different  epochs — the  barbarian,  the  Greek,  the  Roman,  and 
so  forth. 

On  Saturday  the  Municipal  Council  received  the  mem- 
bers at  the  Hotel  de  Ville  in  the  apartments  intended  for 
festivities. 

On  Thursday,  the  9th  of  August,  the  last  general  as- 
sembly took  place  in  the  amphitheatre  of  the  Sorbonne. 
The  second  general  meeting  had  been  but  scantily  at- 
tended, but  this  time  there  was  a  large  gathering.  Dr. 
Lannelongue  presided,  having  at  his  right  Dr.  Callejd, 
dean  of  the  Faculty  of  Medicine  of  Madrid,  and  on  his  left 
Professor  Virchow.  Dr.  Lannelongue  introduced  Professor 
Albert,  of  Vienna,  who  read  a  discourse  on  the  architecture 
of  the  bones  of  man  and  animals.  The  prize  of  5,000 
francs,  which  had  been  offered  at  the  Congress  of  Moscow 
to  the  author  of  the  best  work  done  in  medicine  or  hygiene 
of  recent  years,  was  awarded  to  Dr.  Ramon  y  Cajal,  of 
Madrid,  whose  work  on  neurology  has  been  so  extensive 
and  important.  It  was  next  definitely  announced  that  the 
fourteenth  congress  would  be  held  in  Madrid  in  the  spring 
of  1903.  The  Spanish  national  hymn  was  then  played ; 
Dr.  Callej^  spoke  a  few  words,  and  Professor  Costojorena, 
a  member  of  the  official  Spanish  delegation,  thanked  the 
Congress  on  behalf  of  Madrid  for  having  chosen  that  city. 


LETTER    FROM    JAPAN. 

(From  our  Special  Correspondent.) 

THE  PLAGUE — HOSPITAL  SHIPS  OF  THE  JAPANESE  RED  CROSS 
— REPORT  OK  THE  SURGEON-GENERAL  OF  THE  JAPANESE 
NAVY — ADDRESS    OF   DR.    H.    L.  WOOD   TO   THE   NURSES. 

ToKvo,  August  16,  2900. 

The  pest  has  been  practically  stamped  out,  and  the  more 
stringent  measures  have  now  been  superseded  by  the  usual 
precautionary  ones.  Great  credit  is  due  to  the  govern- 
ment, and  especially  to  the  sanitary  bureau,  in  this  emer- 
gency. Dr.  Kitasato's  Bacteriological  Institute,  or  Insti- 
tute for  the  Investigation  of  Infectious  Diseases,  has  fur- 
nished a  corps  of  well-trained  medical  men  who  have 
given  scientific  and  painstaking  assistance  in  different  parts 
of  the  country.  Japan  will  undoubtedly  require  to  keep 
constant  and  vigilant  watch  upon  her  borders,  especially 
in  the  open  ports,  as  she  is  now  in  such  intimate  commu- 
nication with  endemic  sources  of  infection  from  the  plague 
and  cholera,  both  of  which  have  proven  so  virulent  and 
fatal  in  Japan,  as  well  as  on  account  of  her  proximity  to 
the  field  of  military  operations  in  China,  and  her  being  the 
asylum  of  so  many  refugees  from  all  over  that  country. 

Japan  is  now  having  a  good  opportunity  of  making  use 
of  the  two  fine  Red  Cross  hospital  ships,  the  Hakiiai  Marit 
and  Kosai  Mam,  both  of  which  have  been  commissioned 
for  service  in  connection  with  the  war  in  China.  The 
Hakiiai  Mani  sailed  some  time  since  and  has  already 
made  one  or  two  trips.  Dr.  Iwai,  of  the  Red  Cross  Hospi- 
tal in  Tokyo,  is  in  charge,  while  Dr.  S.  Suzuki  is  in  charge 
of  the  K'osai  Man/.  These  ships  are  thoroughly  equipped, 
up-to-date  vessels,  and  no  doubt  will  prove  a  great  boon 
to  the  suffering  wounded  of  other  nations  as  well  as  of 
Japan.  In  placing  these  vessels  at  the  service  of  the  allied 
fleets  and  army,  Vice-Admiral  Toya  stated  that  these  ves- 
sels are  under  the  control  of  the  war  and  navy  depart- 
ment, being  equipped  and  maintained  entirely  at  the  ex-  • 
pense  of  the  Japanese  Red  Cross  Societ)-,  and  that  the 
regulations  of  the  Hague  Convention  of  July,  1S99,  relat- 
ing to  the  Geneva  Conference  of  August,  1864,  as  far  as 
circumstances  would  allow  should  be  observed.     This  act 


430 


MEDICAL    RECORD. 


[September  15,  1900 


lias  been  highly  appreciated  by  the  different  admi  '.Is  iii 
command,  among  whom  Rear-Admiral  KemijtV,  of  the 
United  States  navy,  has  expressed  special  appreciation. 
Thus  far  the  number  of  wounded  has  not  been  so  great  as 
to  tax  the  resources  at  the  disposal  of  the  united  tleets,  but 
should  the  disturbance  extend  up  the  Vang-tze  valley  and 
throughout  other  parts  of  China  it  is  probable  that  all  the 
resources,  including  those  of  the  Japanese,  will  scarcely 
prove  sufficient.  Sascho,  in  the  southern  coast,  is  the 
present  hospital  base. 

There  are  already  large  numbers  of  refugees  in  Na- 
gasaki, Kobe,  and  Yokohama,  while  the  mountain  and 
seaside  resorts  have  also  received  considerable  numbers. 

The  health  of  the  various  ports  of  Japan  at  the  present 
time  is  good,  and  the  same  may  be  said  of  the  health  of  the 
refugees. 

The  annual  report  of  the  health  of  the  Japanese  navy 
for  1897  has  just  made  its  appearance,  and  though  refer- 
ring to  conditions  existing  three  years  ago  is  none  the  less 
of  considerable  interest.  The  total  mean  daily  force  in  the 
service  was  14.964,  and  the  ratio  of  cases  of  disease  and 
injury  per  1,000  of  the  force  was  822.  The  number  of  days' 
sickness  per  man  was  20.38  and  24.78  days'  sickness  per 
patient,  while  the  number  of  deaths  was  S.37  per  1,000. 
Among  the  various  classes  of  diseases  tabulated,  venereal 
diseases  were  the  highest,  being  167.4  per  1,000,  diseases 
cf  the  digestive  system  being  151. i.  while  those  of  the  re-' 
spiratory  system  were  95.36. 

The  follovviug  extracts  are  of  interest.  The  "monime" 
is  about  a  drachm  in  weight,  120  tn.  being  equal  to  one 
pound  avoirdupois. 

"DisE.\SF.s  OF  THE  RESPIRATORY  SYSTEM. — The  number  of 
cases  comprised  under  this  nomenclature  was  1,427,  which 
is  in  the  ratio  of  95.36  per  1,000  of  force,  showing  an  in- 
crease of  49.04  per  1,000  as  compared  with  the  previous 
year.  The  deaths  numbered  thirty,  giving  a  ratio  of  2.00 
per  1,000  of  force,  which  is  a  decrease  of  0.S4  per  1,000  in 
comparison  with  the  previous  year.  The  number  of  inval- 
idings  was  139,  the  ratio  being  9.29  per  1,000  of  force,  and 
shows  an  increase  of  4. 38  per  1,000  in  comparison  with  the 
previous  year.  Cases  of  phthisis  under  this  heading  have 
increased  year  by  year  and  many  lives  have  been  sacri- 
ficed to  this  disease.  An  instruction  for  the  prevention  of 
phthisis  was,  therefore,  issued  in  June  of  this  year  and  the 
proper  method  of  prevention  was  carried  out,  but  the  cases 
have  increased  in  frequency  since  former  years. 

"CoNscRH'TiON. — The  total  number  of  volunteers  who 
receive  the  physical  e.xamination  as  seamen-candidates 
levied  in  this  year  reached  5.664  persons  (e.xcluding  sea- 
men temporarily  levied).  Of  the  above  number,  2,155 
persons  passed  the  e.xamination  and  the  remaining  3.509 
persons  were  dismissed.  The  result  of  examination 
shows  a  ratio  of  38  per  100  of  persons  qualified,  while  that 
of  persons  non-qualified  gives  a  ratio  of  62  per  100. 

"Food. — The  average  daily  amount  of  food  supplied  to 
each  person  was  391.29  momine,  being  an  increase  of  6.39 
m.  .IS  compared  with  the  previous  year.  Taking  each  arti- 
cle of  food  in  detail,  it  will  be  found  that  the  amount  of 
bread  given  was  increased  by  10. 84  tn..  fresh  meat  by  2.43 
in.,  fresh  fish  by  2.9  ;«.,  rice  by  0.4S  ;//.,  fresh  vegetables 
by  8.66  in.,  soy  by  0.03  w.,  and  vinegar  by  0.07  ?«.,  while 
the  amount  of  hard  biscuit  diminished  by  7.74  ;«.,  pre- 
served meat  by  3.01  ;«. ,  preserved  fish  by  2.72  in.,  beans 
by  0.29  in.,  wheat  flour  by  2.19  in.,  dried  vegetables  by 
1.84  in.,  dried  fruits  by  0.46  in.,  roasted  barley  by  0.16  in., 
sugar  by  0.43  in.,  oil  by  0.03;/;..  common  salt  by  o.  11  in.,  and 
fat  by  o.  12  ;//.  The  amount  of  albumens  for  each  person 
decreased  by  0.60  in.,  fat  by  0.25  in.,  and  carbohydrates 
by  1.34  in.  as  compared  with  the  previous  year.  [The  cost 
per  jjerson  a  day  was  9  cents  United  States  gold.] 

"  Bodv-Weioht. — The  average  body-weight  of  14,000 
persons  taken  in  March  and  15,271  per.sons  taken  in  Sep- 
tember, of  cadets,  petty  officers,  and  men  was  15,630 
tnoniinc,  being  an  increase  of  120  in.  as  conijjared  with 
15,510  in.  of  the  previous  year,  and  also  being  an  increase 
of  520///.,  over  what  has  been  the  average  body-weight 
15,110  m.  of  each  person  during  the  last  thirteen  years. 
Thus  it  shows  an  increase  of  40  in.  even  compared  with 
the  average  weight  I5,590  7«.  of  the  year  1S96,  which  was 
the  highest  average  since  the  year  18S4,  when  an  estimate 
of  the  body-weight  was  first  made." 

.•\mong  the  many  distinguished  visitors  to  Japan  this 
year  we  have  been  favored  with  the  presence  of  Dr.  H.  C. 
Wood,  of  the  University  of  I'ennsylvania.  who  with  his 
wife  and  daughter  are  spending  some  weeks  in  sight-see- 
ing. iJr.  Wood  while  in  Tokyo  attended  the  graduating 
ceremony  of  the  Murses'  Training-School  of  the  Akasaku 
Hospital,  of  which  Dr.  W.  N.  Whitney  is  the  founder  and 
present  head.  Dr.  Wood's  address  was  characteristic  and 
helpful.  He  pointed  out  the  importance  of  the  nurses'  call- 
ing and  of  exactness  and  ])unctuality  in  the  performance 
of  her  duties.  Miss  Letsu  Ito,  a  graduate  of  the  Methodist 
Ei>iscopal  Training-Home  of  Philadelphia,  is  in  charge  of 
the  school. 


THE   HOSPITAL  FOR  SCARLET  FEVER 
DIPHTHERLA.    PATIENTS. 

To  THE  Editor  of  the  Medical  Record. 


AND 


Sir;  During  the  past  winter  we  have  received  many  let- 
ters of  inquiry  in  regard  to  the  methods  of  quarantine  and 
disinfection  used  at  the  Hos])ital  for  Scarlet  Fever  and 
Diphtheria  Patients,  and  it  has  occurred  to  me  that  the 
be.st  way  of  reaching  those  interested  in  our  work  is 
through  the  columns  of  your  journal. 

A  brief  description  of  the  general  arrangement  of  the 
institution  is  essential  to  the  understanding  of  our  meth- 
ods. The  hospital  is,  as  many  of  your  readers  are  aware, 
situated  at  tire  foot  of  East  Sixteenth  Street,  the  grounds 
extending  on  two  sides  to  the  water's  edge.  Many  physi- 
cians believe  this  hospital  to  be  connected  with  the  city 
institutions  for  the  treatment  of  contagious  diseases,  but 
such  is  not  the  case.  It  is  a  i>rivate  corporation,  controlled 
by  its  own  board  of  governors,  and  is  not  connected  with 
any  other  institution.  The  president  of  the  board  of  health 
and  one  of  the  health  commissioners  are  e.x-officio  mem- 
bers of  the  board.  There  is  a  regular  visiting  staff,  but 
physicians  in  general  are  allowed  to  attend  cases  which 
they  send  to  the  hospital. 

There  are  two  pavilions  separated  from  each  other  at 
their  nearest  point  by  a  distance  of  thirty  feet,  the  work- 
ings of  which  are  entirely  distinct.  Each  employs  a  sepa- 
rate medical  staff,  corps  of  nurses,  cooks,  chambermaids, 
etc.,  and  has  its  own  kitchen,  dormitory,  and  nurses'  rooms 
and  office  for  the  use  of  the  phj-sician  in  charge,  in  connec- 
tion with  which  there  is  a  well-equipped  laboratory  and 
drug  room,  and  an  observation  room  where  doubtful  cases 
can  be  isolated.  The  patients'  quarters  consist  of  a  num- 
ber of  light,  well-ventilated  rooms  communicating  with  a 
long  corridor,  at  the  end  of  which  there  is  a  sun-room. 
There  is  no  ward,  so  that  each  patient  has  a  private  room. 
Convalescents  can  enjoy  the  open  air  from  the  roof,  which 
is  arranged  to  accommodate  them.  The  laundry  is  in  a 
building  bj-  itself  The  disinfecting  plant  is  also  separated 
from  the  hospital  and  consists  of  a  steam  tank  and  formal- 
dehyde chamber.  In  the  former  the  steam  is  raised  under 
pressure  to  a  temperature  of  230'  F.  and  kept  turned  on  for 
half  an  hour.  If  formaldehj-de  is  used,  the  articles  to  be 
disinfected  are  exposed  to  the  gas  continuously  for  twelve 
hours. 

Patients  are  carefully  examined  before  being  admitted, 
and  if  tliere  is  any  question  in  regard  to  diagnosis  they  are 
placed  in  the  observation  room  of  the  scarlet  fever  or  dipli- 
theria  pavilion.  The  resident  physician  before  entering 
the  presence  of  the  patient  is  required  to  wash  his  hands 
thoroughly  with  soap  and  water,  followed  by  immersing 
them  in  bichloride  solution  1:2,000.  A  gown  is  supplied 
which  buttons  closely  around  the  neck,  covering  the  collar 
and  enveloping  the  body  completely,  just  clearing  the 
ground  below.  With  this  goes  a  cap  arranged  to  cover  the 
head  and  neck,  exposing  only  the  face.  This,  with  a  pair 
of  rubber  overshoes,  completes  the  uniform.  When  he 
leaves  the  pavilion,  the  hands  and  face  are  disinfected  thor- 
oughly, and  the  mouth  is  cleansed  with  boric-acid  solution. 
The  attending  physicians,  whether  of  the  regular  hospital 
staff  or  specially  employed  by  the  patient,  follow  the  same 
routine,  and  this  is  required  of  all  visitors.  Ladies,  if  ad- 
mitted at  all,  are  also  required  to  remove  their  outer  skirts 
before  putting  on  the  uniform. 

The  patients  are  not  allowed  to  leave  until  free  from 
contagion.  Scarlet-fever  cases  are  examined  repeatedly, 
particular  attention  being  given  to  the  feet,  which  are 
sometimes  slow  and  troublesome  in  desquamating.  The 
scalp  requires  watching,  as  does  also  the  external  auditory 
meatus,  which  is  often  found  filled  with  desquamated  epi- 
thelium in  cases  otherwise  free  from  contagion.  For  the 
diphtheria  cases  we  require  two  clear  cultures  on  succes- 
sive days  before  they  are  considered  ready  to  discharge. 
The  disinfection  is  the  same  in  both  pavilions,  except  that 
.scarlet-fever  i>atients,  during  the  week  previous  to  time  of 
probable  discharge,  have  their  ears  irrigated  with  bichlo- 
ride solution  I  :  S.ocraand  the  scalp  shampooed  on  alternate 
days. 

On  the  day  of  discharge  the  following  routine  is  adopted 
for  all  adults  unless  there  is  some  contraindication  (for 
children  special  instructions  are  given  in  each  case)  :.(i) 
The  ears  are  irrigated  with  bichloride  solution,  i  :  8, 000. 
(2)  The  scalp  is  shampooed  with  soap  and  water.  (3) 
The  scalp  is  shampooed  with  bichloride  .solution,  i  :  2,000. 
(4)  A  tub  bath  is  given  of  soaj)  and  water.  (5)  A  tub 
bath  is  given  of  bicliloride  solution,  1:8,000,  for  twenty 
minutes.  (6)  A  sponge  bath  is  given  of  bichloride  solu- 
tion, I  :  2,000.  (7)  The  bichloride  is  sponged  off  with  ster- 
ile water.  (8)  A  nasal  spray  is  given  of  bichloride  solu- 
tion, I  :  8, 000.  (9)  The  mouth  is  cleansed  with  saturated 
solution  of  boric  acid. 

For  convenience  is  used  a  suite  of  three  communicating 
rooms  known   as  the   discharge  rooms  Nos.   i,  2,  and  3. 


September  15,  1900] 


MEDICAL   RECORD. 


431 


The  first  room  is  entered  from  the  corridor,  and  here  the 
hospital  clothing  is  left.  In  No.  2  the  patient  is  subjected 
to  ihe  process  of  disinfection.  In  No.  3  he  puts  on  his 
frt-shly  disinfected  clothing.  There  is  a  "discharge  door" 
ill  this  room  .so  arranged  that  he  can  leave  the  hosjiital 
without  again  passing  through  the  corridor. 

All  clothing  that  can  be  washed  is  disinfected  with 
steam.  For  articles  that  will  not  stand  this  treatment  is 
used  formaldeliyde  gas.  Books  and  papers  are  subjected 
to  steam,  although  it  is  necessary  first  to  remove  the 
leather  covers  from  the  former.  Beyond  a  slight  blurring 
of  the  writing  no  damage  is  done.  Toilet  articles  are 
treated  in  the  same  way,  but  jewelry,  such  as  rings,  pins, 
etc.,  are  disinfected  with  pure  carbolic  acid.  Watches  are 
exposed  to  formaldehyde  gas,  which  disinfects  therp  satis- 
factorily. 

So  far  as  we  are  able  to  learn  no  case  of  contagion  has 
ever  been  traced  to  patients  that  have  been  discharged 
from  our  institution,  and  it  is  quite  certain  that  never  in 
the  history  of  the  hosjiiial  has  a  case  of  scarlet  fever  de- 
veloped in  the  diphtheria  pavilion  or  vice  versa. 

Edw.\rii  L.  Kki.i.oc.g,  M.D.. 

Resident  Physician. 
New  York. 


THE    SPECTACLE    AND    EYEGLASS    HABIT. 

To   THE    EdITOK  of   THE    MeDICAL    ReCORD. 

SiK  :  In  the  Medical  Record  of  August  4th  was  an  e.xtract 
from  an  article  by  me,  entitled  "The  Spectacle  and  Eye- 
Glass  Habit."  In  the  issue  of  August  iSth.  L)r.  T.  T. 
Blaise,  of  Mason  City,  la. .  criticises  the  ideas  expressed  in 
that  article,  finding  them  unorthodox. 

Dr.  Blaise  objects  to  the  statement :  "  Wearing  spec- 
tacles and  eye-glasses  out  of  doors  is  always  a  disfigure- 
ment, often  an  injury,  seldom  a  necessity  "  ;  and  says  ;  "As 
concerns  the  disfigurement,  it  suffices  to  say  that  much  of 
this  can  be  obviated  by  the  proper  regard  for  cosmetic  ef- 
fects. There  is  no  doubt  that  a  face  can  be  made  to  look 
ludicrous  or  comely,  the  effect  produced  depending  chiefly 
on  the  oculist's  knowledge  of  symmetry,  harmony,  and  the 
angular  or  pleasing  relation  of  lines  and  forms. " 

In  spite  of  what  Dr.  Blaise  says  every  practitioner  knows 
that  glasses  are  and  always  will  be  a  disfigurement,  and 
that  most  young  and  middle-aged  women  seriously  object 
to  any  kind  of  them.  Spectacles  are  a  constant  butt  for 
the  caricaturists,  a  cause  of  mirtli  to  the  thoughtless,  and 
the  prevailing  and  widespread  degeneracy  of  the  spectacle 
habit,  particularly  in  children,  invites  the  jirofound  ])ity 
and  inquiry  of  the  thoughtful  and  observing,  for  the  fail- 
ings and  imperfections  of  the  eye  are  more  quickly  and 
certainly  transmitted  throngh  heredity  than  those  of  any 
other  part  of  the  body,  and  the  worst  of  this  is  that  it  hurts 
most  the  intellectual,  the  very  top  of  civilization.  If  the 
generally  accepted  teachings  of  ophthalmology  are  true, 
then  the  eyes  of  Christendom  are  in  a  parlous  state. 

Dr.  Blaise  says  :  "  It  is  not  necessary  to  state  that  an 
anomalous  or  ametropic  eye,  which  cannot  be  restored  by 
operative  or  other  means  to  a  normal  state,  needs  a  sup- 
port as  much  as  a  short  leg  needs  a  high  heel,  etc..  and 
what  is  more  potent  and  true  is,  that  it  needs  it  as  long  as 
that  abnormality  exists  ;  indoors  or  out  of  doors,  or  wher- 
ever vision  is  desired." 

The  doctor  probably  means :  All  persons  with  farsight- 
edness, nearsightedness,  or  astigmatism  should  wear 
glasses  all  the  time,  just  as  every  man  with  a  short  leg 
needs  a  high  heel. 

About  ninety-nine  out  of  a  hundred  persons  are  ame- 
tropic, ha%-e  some  imperfection,  when  properly  e.xaniined. 
About  eighty  or  ninety  of  these  are  farsighted,  to  say  noth- 
ing of  those  with  astigmatism  and  nearsightedness.  Now, 
if  Dr.  Blaise  is  right,  nearly  everybody  ought  to  wear 
glasses  all  the  time. 

Dr.  Blaise  has  confused  function  with  structure.  If  an 
eye  is  imperfect  or  ametropic  the  focussing  mechanism  is 
proportionately  strong  and  usually  makes  functional  com- 
pensation. Nothing  of  this  kind  can  take  ])lace  in  a  leg 
structurally  short.  It  is  useless  to  discuss  such  a  compar- 
ison, for,  the  basic  fact  in  the  problem  of  fitting  glasses 
is  one  of  function  rather  than  of  structure,  although  it  does 
concern  both.  The  imperfections  of  the  eye  give  trouble 
more  like  a  tired,  weak  leg  than  like  a  short  one. 

Tlie  doctor  says  :  "  It  cannot  be  doubted  that  an  eye  hav- 
ing the  proper  correction  will  feel  strained  when  the  cor- 
recting lens  is  removed,  as  would  the  short  leg  when  the 
heel  is  removed  from  the  boot  ;  but  this  Dr.  Jenkins  de- 
clares, with  an  unheard-of  sweeping  statement,  to  be  "be- 
cause they  have  wrong  glasses." 

On  page  63  of  volume  Iv.  of  the  Medical  Record,  the 
editor  of  that  journal  comments  on  Hartridge  recommend- 
ing hyperopes  to  leave  their  glasses  off  when  not  reading. 


Another  statement  by  Dr.  Blaise:  "To  say  that  a  lens 
correcting  an  error  of  refraction,  a  heterophoria.  or  any 
anomaly  is  only  temporarily  necessary,  is  reversing  not 
only  pure  logic,  but  turns  topsy-turvy  the  laws  upon  which 
hygiene,  sanitation,  and  healing  are  based." 

What  are  the  laws  spoken  of  with  such  definite  certainty 
as  though  the  principle  and  laws  of  gravitation  in  astron- 
omy were  under  discussion  ?  Medicine  is  still  an  inexact 
science,  somewhat  like  agriculture  or  meteorology  :  obstet- 
rics and.  to  an  e.xtent,  surgery  excepted. 

Dr.  Blaise  says  further:  "The  individual  with  healthy 
normal  eyes  can  as  consistently  and  with  as  much  comfort 
put  on  3  D-}-  lenses  when  he  goes  into  the  street  as  the 
3  D+  hyperope  can  remove  his  when  he  goes  out-of-doors, 
barring  what  of  custom,  disregard,  and  disuse  habit  may 
have  established." 

The  boot-heel  again.  Now,  if  "the  individual  with 
healthy  normal  eyes  '  puts  on  such  glasses  as  Dr.  Blaise 
speaks  of  and  "goes  into  the  street,"  he  will  have  vertigo, 
nausea,  and  be  miserably  sick  in  a  few  hours,  if  not  sooner. 
If  a  man  is  farsighted  and  is  jierfeclly  fitted  for  reading 
with  such  glasses  as  Dr.  Blai.se  sjieaks  of,  he  can  read  with 
them  with  comfort  and  be  comfortable  without  them  while 
on  the  street  or  out-of-doors.  In  this  I  am  with  Hartridge. 
The  focussing  muscles  of  eyes  with  farsightedness  of  3  U 
are  stronger  and  need  much  more  work  than  those  of  per- 
fect eyes.  If  the  focussing  muscles  do  not  get  their  right 
exercise  they  will  become  weak  or  will  atrophy.  I  take  it 
that  the  error,  "3  D-j- hyperope, "  is  a  typographical  one; 
again,  that  the  writer  means  -f-  3  D.S.  lenses. 

Dr.  Blaise  is  evidently  following  the  antiquated  and  er- 
roneous tables  in  the  standard  text-books,  and  seems  not 
to  have  studied  recent  tables.  The  old  tables  are  founded 
on  the  teaching  that  a  perfect  eye  needs,  for  reading,  an 
active  focussing  power  of  4.5  D.  It  needs  3  D.,  possibly 
less.      (See  Oplitlialiiiic  Rcciini,  February,  191X),  page  8g.) 

The  fundamental  and  misleading  error  which  pervades 
Dr.  Blaise's  criticism  is  that  his  elementary  facts  are 
wrong  and,  since  it  concerns  one  of  the  most  useful  and 
beautiful  of  the  eternal  verities,  space  will  not  be  wasted 
in  clearing  his  mistake,  which  is,  indeed,  a  widespread 
one.  He  confuses  function  with  structure  in  comjiaring 
spectacles  to  a  raised  boot-heel.  Now  spectacles  are  not 
essentially  a  prosthetic  ajjpliance,  except,  perhajis,  after 
cataract  operations.  They  are  more  orthopaedic  than  pros- 
thetic, for  glasses  correct  rather  than  substitute.  Do  they 
not  compensate,  correct,  and  strengthen  weakness  and  de- 
formity? Glasses  add  and  exalt,  project  and  extend,  our 
greatest  sense,  are  its  chief  auxiliary.  The  telephone  and 
microphone  are  also  sensory  aids.  The  lelesco])e  and  mi- 
croscope are  but  other  forms  of  spectacles.  The  compari- 
,son  of  spectacles  to  a  lengthened  boot-heel  is  decidedly 
oulrc  ;  as  well  think  a  telesco]>e  is  like  a  high  stilt.  Such 
conceptions  <if  glasses  robs  refraction  of  both  professional 
and  scientific  dignity,  makes  it  now  an  art,  shortly  to  be- 
come a  handicraft.  To  fit  glasses  properly  one  should  well 
know  the  relationships  of  the  eye  to  the  other  parts  of  life 
and  their  habits  in  both  disease  and  health.  Lack  of  this 
is  the  organic  failing  of  many  modern  specialists. 

The  eye  is  so  lively,  nervous,  and  sentient  that  it  really 
is  not  comparable  to  any  other  function  excejit  itself  or  the 
mind.  It  and  its  sight  are  so  complex  and  so  closely  re- 
lated to  and  intimate  with  the  brain  and  thought  that  it 
seems  of  them,  so  much  so  that  deep  meditation  on  the  eye 
and  its  function  becomes  philosophic  rather  than  scientific. 

The  best  ophthalmology  is  yet  to  be  achieved,  lies  before 
and  not  behind  us,  and  slavishness  to  authority  and  the 
past  will  not  bring  it.  Medical  science  needs  workers  who 
see  and  think  for  themselves,  men  with  clear  vision  antici- 
pating wi.sdom  ;  those  who  know  what  to  do  and  how  to  do 
it.  rather  than  they  who  know  what  has  been  done  and 
who  did  it.  We  must  be  whole-souled  doubters,  for  many 
things  which  pass  current  are  but  falsehoods  and  counter- 
feits. We  too  readily  believe  authorities.  Scientific 
thought  should  be  used  on  all  questions  alike.  This  can 
be  done  only  by  those  schooled  in  using  thought  in  a  sci-' 
entific  way.  "  Prove  all  things  and  hold  fast  that  which 
is  good."  NoRiiURNE  B.  Jenkins,  M.D. 

Chicago. 


An  African  Remedy  for  Dysentery — The  Kafirs 
and  Zulus  make  use  of  the  root  of  the  geranium,  of 
which  there  is  said  to  be  a  number  of  varieties,  all, 
however,  of  equal  therapeutic  efficacy,  in  South  Africa, 
in  the  treatment  of  dysentery.  They  simply  chew  the 
root,  but  the  British  army  surgeons  give  it  in  the  form 
of  a  decoction  in  milk.  The  remedy  is  reported  by 
those  who  have  employed  it  to  be  a  real  specific,  no 
failure  to  cure  within  thirty-six  or  forty-eight  hours 
being  recorded. 


432 


MEDICAL    RECORD. 


[September  15,  1900 


^Iicvapciitic  Jliuts. 

Epileptiform  Convulsions  due  to  auto-intoxication. — 

B  Ext.  chirett.T! gr.  ij. 

Leptandrin gr-  ss. 

I'odophyllin gr.  ^. 

Kuonymin gr.  ss. 

Creosote  (beechwood) gr.  ss. 

M.  ft.  pil.  No.  I.     S.   One  such  after  each  meal. 

—Hare. 
Tooth  Powder. — 

^  Pulverized  cereal "5  parls. 

Sodium  borate i  S 

I'otassium  chlorate 7 

-Saccharin q.  s. 

Flavor  to  taste. 

— Fletcher. 
Emulsion  of  Castor  Oil — 

If  Ol.  ricini 3  i. 

tium  acaciii; §  ss. 

Elix.  saccharin TH  xx. 

01.  amygdal "l  ij. 

01.  carui ni  ij. 

Aq.  destil ad  3  ij. 

M.    Dissolve  the  ijum   in  water,  add  the  oil  gradually,  and 
lastly  the  flavoring. 

— Medical  Times  aud  Hospital  Gazette,  August  1 1 ,  1 900. 
Seminal  Emissions  without  marked  erection. — 

If  Strychninii;  sulph gr.  i. 

Ac.  phosphorici  dil 3  ij. 

M.     S.   Gtt.  -Nxv.  in  water  after  meals. 

• — B.    K.    TwiTCHELL. 

Smoker's  Gingivitis. — 

'S,  Salol I 

Tinct.  catechu 4 

Spir.  menth.  pip ad   120 

M.  ft.  lotio.      S.   Teaspoonful  in  half  a  glass  of  tepid  water 
as  mouth  wash. 

Hair  Tonic. — 

If  Pilocarpin.  hydrochlorat gr.  v. 

Ott.  rosce Ill  viij. 

01.  rosmarini 3  iv. 

Lin.  cantharidis 3  iv. 

Glycerini  puri |  i. 

01.  amygdala;  dulc 3  iij. 

Spir.  camphors I  "j- 

M.     S.    Kub  well  in,  morning  and  night. 

— Whitla. 
Phthisical  Cough. ^ 

V,  Codein gr.  iv. 

Ac.  hydrochl.  dil 3  ss. 

Spir.  chloroformi 3  iss. 

Syr.  limonis 3  i. 

Aquam ad  3  iv, 

M.  ft.  emuls.     S.   Teaspoonful  at  frequent  intervals 

— MURRELL. 

Amenorrhoea  in  debilitated  and  anaemic  states. — 

If   Hydrarg.  chl.  corros., 

.Sodii  arsenit., 

Strych.  sulphat aa  gr.  i. 

Potass,  carbonat., 

t'erri  sulphat aa  gr.  xxx. 

M.  ft.  pil.  No.  ix.      S.   One  after  each  meal. 

—  LUTAUD. 

Tuberculous  Laryngitis.^ 

If   Menthol.. 

Ether,   sulphurici, 
01.  pini  sylvestris, 

Tinct.  iodi  aa  3  ij. 

Tincture  benzoini  co ad  |  ij. 

M.     S.   Ten  drops  on  an  oro-nasal  inhaler,  to  be  worn  as 
much  of  the  time  as  possible. 

— W.    I'OWI.ER. 

Epistaxis.  — Puff-ball  applied  freely. — Whitla. 

Suprarenal  extract  capsule  will  probably  be  found 
useful.  It  lessens  bleeding  during  nasal  operations. 
Hot  water  (no'  F.)  is  useful  either  injected  or  ap- 


plied as  a  swab.  Peroxide  of  hydrogen  may  be  left  in 
position  on  a  swab  for  fifteen  minutes.  In  hemophilia 
give  calcium  chloride  and  in  purpura  turpentine. — 
William  Lamb. 

Urticaria. — 

If  Etliyl  alcohol, 
Sulphuric  ether. 

Chloroform i&  30.      gm. 

Menthol o.  10  cgm. 

M.      S.    .\pply  as  lotion. 

— Gaucher. 
Menthol  Vinegar. — 

If  .Menthol 3  gm. 

.Vcid.  acetici  (crystal) 8    " 

Spt,  vini  rect.   (sixty  per  cent. ) 100   " 

M.  Dissolve  the  menthol  in  the  alcohol  and  add  the  acid. 
S.  Half  a  teaspoonful  in  a  wineglass  of  tepid  water  as  a  mouth 
wash  or  gargle. 

Carious  Teeth. — 

If  Menthol 2.       gm. 

Camphor I.        " 

Cocaine o.  50   " 

M,  Triturate  to  liquefaction.  S.  Introduce  into  the  cavity 
a  pledget  of  cotton  wet  with  the  solution  every  half-hour  till  relief. 

Antineuralgic  Lotion. — 

If  Menthol 1.50  gm. 

Cocaine  hydroch o.  50    " 

Chloral  hydrat 10.        " 

— Galezowski. 
Caffeine  Mixture. — 

If  CatTeina:, 

.Sod.  salicylat aa     i.       gm. 

Spartein.  sulphat o.  40    " 

Amnion,    acetat I.         ** 

Aquje  destil 50.        " 

M.     S.   Teaspoonful  undiluted  or  in  a  little  spirits. 

— Capitan. 
Rebellious  Intermittent  Fever — 

If  (Juininje  sulpliat 4.        gm. 

Ferro-potass.  tartrat 10. 

Acid,  arsenosi o.  10  cgm . 

Aquce  destil 300.         gm. 

M.  S.  The  day  following  the  attack  a  dessertspoonful  of 
this  solution  is  given  every  hour,  the  following  day  every  three 
hours,  and  so  on. 

— Baccelli. 
Amenorrhoea. — 

If  Strychnin.-e  sulphat o.  1 2  cgm. 

Acidi  oxalici o.  60    " 

Ferri  peptonat., 

Manganesii  lactat aa  8.         gm. 

Ext.  colocynth.  comp 2.  " 

M.  ft.  cachets  No.  60.      S.   One  after  each  meal. 

— H.  C.  Bloom. 
Delirium  Tremens. — 

If   Methylal 5  gm. 

Aq.  destil 20    " 

M.  S.  Inject  a  syringeful  three  or  four  times  a  day,  subse- 
quently twice  daily  for  live  or  six  days. 

—  FiSCHER. 

Anaemia  in  Phthisis. — 

\\  Sulphur,   loti lo  gm. 

-Sacch.  lact 20 

M.      S.   A  pinch  at  beginning  of  each  meal. 

If  Pulv.  digitalis  fol., 

Ferri  lactat Sa  2  gm. 

Ext.  gentian q.s. 

M.  ft.  pil.  No.  xxx.      S.    Two  pills  daily. 

—  Von  Szekelv. 
Blennorrhagic  Dysuria — 

"S,  Sod.  salicylat 10.       gm. 

Ext.  bellad 0.30  cgm. 

Aqua; 195.       gm. 

Tinct.  aurant.  cort.  amar 5.         " 

M.     S.    Dessertspoonful  every  two  to  three  hours. 

— E.  Gerrert. 

Migrating  Erysipelas  in  a  child  aged  four  years 
was  cured  in  three  weeks  by  tepid  baths  (120'  F.). — A. 
Halipr^. 


September  15,  1900] 


MEDICAL    RECORD. 


433 


To  Cause  Sleep. — Inject  per  rectum: 

Q  Chloralamid .    gr.  xlv. 

Ac.  hydrochl.  dil git.  ij. 

Spt.  vini  rect gtt.  xv. 

Aqux  destil 3  iij. 

— Agenda  Therapeiitica. 
Dysmenorrhcea. — 

I^  Asafcetida; gr.  ij. 

Ext.  valerian gr.  i. 

Ext.  cannabis  ind gr.  ){ 

M.      For  one  pill.      S.    One  three  times  a  day. 

— Lyon. 

Pruritus  Ani. — Inject  into  the  bowel  for  several 
days  in  succession  from  one  to  two  and  a  half  drachms 
of  the  following: 

1(  Ext.  hamamelidis  fid §  i. 

Ext.  ergota;  fid 3  ij- 

Ext.  Hydrastis  fld 3  ij- 

Tinct.  benzoini  co 3  ij- 

Olei  carbolisat.  (five  percent.) 3  i. 

M.      S.   Shake  well  before  using- 

Nasal  Spray  in  acute  catarrhal  conditions. — 

1$  .Ac.  carbol gr.  viiss. 

Ichthyol 3  i. 

Spir-  vini  rect 3  iiss. 

Aq.  destil ad  3  iij. 

M.     S.    Use  two  or  three  times  a  day. 

In  Stomach  Washing. — 

1}  Sodii  biborat 3  ij- 

Ac.  salic §  ss. 

Ac.  borici ad  |  iv. 

M.      S.   Add  a  dessertspoonful  to  a  quart  of  warm  water. 

Anaphrodisiac  in  gonorrhcea. — 

"S,  Ext.  ergot;i;  fld ill  xv. 

Tinct.  gelsemii lU  v. 

Potass,  bromidi gr.  xx. 

Tinct.  hyoscyami HI  xxx. 

Syr.  aurantii q.  s.  ad  §  ss. 

M.     S.   Shake  and  take  a  dose  at  bedtime. 

- — Lydston. 
Rachitis. — 

IJ  Phosphori gr.  \. 

Solve  in  ol.  oliv 3  iiss. 

Pulv.  gummi  arab gr.  Ixxv. 

Syr.  simplicis ill  Ixxv. 

Aq.  destil 3  iiss. 

.\I.     S.   One  teaspoonful  daily. 

— Stewart. 
Emphysema. — 

1}  Potass,  iod 10 

.\qu.i.'  destil 3(j<j 

M.      S.    Teaspoonful  at  each  meal  for  twenty  days  of  each 
month. 

IJ  Sodii  arsenitis o.  10 

Aquie  destil 300. 

M.      S.   Teaspoonful  three  times  a  day  for  the  other  ten  days. 

— /oiirn.  tie  Med. 
Chronic  Alcoholism 

Vf  Zinci  oxidi 3  i. 

Piperina: 3i. 

M.  ft.  pil.  No.  XX.     S.   One  three  or  four  times  a  day. 

— Chapmam. 
Ac'-'te  Alcoholism.^ 

If  Tinct.  capsici. 

Tinct.  zingiberis aa  3  i. 

Tinct.  valerian,  ammon, . 

Tinct.  gentiance  co iia  3  i. 

M.     S.  Dessertspoonful  in  a  cup  of  hot  water  three  or  more 
times  a  day- 

— Gerhard. 

Anaphrodisiac. — Lupulin  in  gram  doses  at  bedtime. 
— Medical  Times  and  Hospital  Gazette. 

Thinness. — Avoid  condiments,  acids,  sour  fruits, 
salads,  cabbage,  coffee,  turnips,  sour  wines,  hot  drinks, 
tobacco;  take  fatty  meats  and  fatty  foods,  the  crust  of 
bread,  pastry,  beans,  peas,  nuts,  sugars,  honey,  water; 


reside  in  the  country  and  secure  rest  of  mind  as  well 
as  of  body;  take  Fowler's  solution  in  gradually  in- 
creasing dose  up  to  twenty  drops. — Le  Roy. 

Tuberculosis  of  the  Kidneys.— 

If   Ichthyol., 

.•Vq.  destil Sa  20 

M-      S.   Ten  drops  increased  up  to  seventy,  taken  in  water 
after  eating,  to  be  continued  for  a  long  period. 

— Goldberg. 
Adynamia  from  withdrawing  alcohol  in  habitue's. — 

If  Spir.  ammon.  aromat 3  ss. 

Strychninie gr.  ^ 

-At  dose-      Repeat  every  hour- 

— Tyson. 


Uraemic  Asthma. - 

Rl.VGER. 


-Morphine  hypodermatically.- 


Pelvic  Neuralgias. — Salicin  gr.  v--xv.  three  times 
a  day  in  cachet  or  capsule  after  meals,  followed  by  a 
glass  of  water. — Jourti.  de  mot.  Ue  Paris. 

Gout In  addition  to  the  regular  diet  one  and  one- 
half  pound  of  cherries,  one  pound  of  strawberries,  or 
two  pounds  of  grapes.  Quinic  acid  acts  by  diminish- 
ing uric  acid.— J.  Weiss. 

Post-Syphilitic  Tabes.  —  Electrization  of  the  spine 
and  medulla  oblongata;  cauterization  of  the  spine 
with  the  I'aquelin  every  tenth  to  fourteenth  day. 
Strychnine  pills,  atropine  and  morphine  for  the  lan- 
cinating pains. — Tschiriekf. 

Pneumonia  complicating  influenza. — In  the  con- 
gestive stage  give  quinine  and  mercury  with  chalk; 
also  fluid  extract  of  ergot  in  doses  of  V\  xx. ;  in  the 
exudative  stage  quinine,  digitalis,  tincture  of  iron,  and 
dilute  hydrochloric  acid;  give  stimulants  for  asthenic 
symptoms. — Latchford. 

Sciatica. — Apply  each  night  along  the  painful  areas 
strong  hydrochloric  acid  by  means  of  a  glass  rod ;  then, 
when  dry,  cotton  and  a  loose  bandage;  omit  if  redness 
or  irritation  ensues. — Bayliss. 

Whooping-Cough. — Spray  the  nasal  mucous  mem- 
brane with  cocaine,  and  apply  to  the  nose  and  naso- 
pharynx a  two-  or  four-per-cent.  solution  of  nitrate  of 
silver;  wash  with  a  mild  alkaline  and  antiseptic  spray. 

—  H.  COGGESHALL. 

Juvenile  Obesity — Thyroid  extract  gr.  iiss.  three 
times  a  day,  gradually  increased  to  gr.  vi.  four  times 
daily,  for  a  boy  of  eight  years,  weighing  one  hundred 
and  thirty  pounds. — J.  A.  Love. 

Bronchial  Adenopathy. — Each  morning  some  sul- 
phurated water  with  w-arm  milk.  Cod-liver  oil ;  ar- 
senate of  sodium  (gr.  Tr4  "Va)  with  meals,  followed  in 
fifteen  days  by  phosphates.  Two  or  three  drops  of 
tincture  of  belladonna  and  the  same  amount  of  alco- 
holic extract  of  aconite  root  as  a  calmative. 

Asthma. — For  the  threatening  attack  paint  the  nasal 
mucous  membrane  as  far  back  as  possible  with  cocaine 
solution  (i  :  20).  If  the  attack  is  at  its  height,  in- 
ject half  a  syringeful  of  a  one-per-cent.  morphine  solu- 
tion. Should  the  attack  persist,  repeat  this  injection. 
The  remedies  for  the  diathesis  are  potassium  iodide, 
belladonna,  and  arsenic. — Dieulafoy. 

Mercolint  is  the  name  of  the  material  recommended 
for  shirts  to  be  worn  by  anamic  or  weakly  subjects  of 
syphilis,  pregnant  women,  and  infants  who  need  a  mer- 
curial course.  The  cloth  is  impregnated  with  an  oint- 
ment of  ninety  per  cent,  mercury,  and  each  shirt  con- 
tains from  ten  to  fifty  grains. — Blaschko. 


434 


MEDICAL    RECORD. 


[September  15,  1900 


Ctinicat  jpcpartmciit. 

MALARIA  COEXISTING  WITH  TYPHOID 
FEVER. 

By  J.    G.    HANSON,    M.D., 

NEW   VORK. 

The  coexistence  of  malarial  and  typhoid  fever  has  been 
tie  subject  of  much  discussion.     \V.  G.  Thompson,  in 


RESPIRATION 

PULSE 

TEMPERATURE 

S5 

1^ 

Ps?S5i^g^.  ssssossiiilssss-,  g.qs  i^  s  1  s^  1^  1  i  ?. 

■  1 

^ 

, 

\ 

^ 

S 

c 

IV '  L" 

o 

s 

> 

-=2! 

^ 

X 
in 

«  'i 

- 

> 

tD 

< 

-' 

< 

■*fc, 

S 

^ 

tv 

;3 

o 

-1 

« 

^ 

< 

i. 

« 

S 

2 

\ 

< 

> 

s 

- 

=?* 

o 

■fe 

T 

» 

/ 

< 

■> 

£ 

*i 

1:. 

• 

- 

Z 

\ 

■^ 

^ 

5 

-r, 

Zi 

o 

-fo- 
ol 

1 

-=j 

— 

—l 

. 

E 

« 

*^ 

- 

^ 

< 

£ 

0 

01 

IS 

VE 

Y  ( 

JLI 

=: 

» 

£ 

^ 

Cs 

- 

' 

1 

L-, 

£ 

jr 

-• 

_)"* 

^ 

^ 

, 

S 

M 

■X 

« 

f 

C^ 

L, 

£ 

Z 

-J 

^- 

y 

J 

> 

5 

— 

s 

s 

< 

"= 

m. 

-= 

^ 

£ 
m 

Ci 

n 

^^ 

( 

"=• 

5, 

£ 

t; 

til 

o 

/ 

"=3 

. 

Z 

-St 

w 

o 

— 

=: 

u 

0 

■^ 

o 

\ 

=: 

£ 

1% 

0 

en 

« 

DEL 

IRK 

US 

SLI 

jH7 

— 

— ^ 

£ 

10 

Ci 

to 

" 

' 

~ 

£ 

*? 

n 

o" 

'■ 

• 

r 



"" 

— 

— 

E 

':?   7 

I 

- 

= 

=_ 

£ 

!i 

3 

CA 

PM 

L.0 

GY 

= 

— 

l__ 

Z 

s 

§ 

=• 

^ 

- — 

= 

^ 

X 
m 

1^ 

li 

„" 

SU 

35  U 

Tl. 

ST 

:nd 

NUI 

n 

*"■ 

■^ 

— 

r^ 

E 

ivli 

a 

QUI 

NIN 

■  10 

OR, 

Hi 

0. 

< 

> 

^ 

1= 



^ 

£ 

X     i5 

^ 

■• 

» 

_ 

^ 

— ■ 

£ 

L4|£ 

o 

< 

-> 

- 

~ 

^ 

. 

I 

m 

cT* 

" 

< 

■ 

^ 



£ 

II 

o 

" 

< 

> 

u 

=C 

^ 

£ 

J* 

" 

■ — 

5 

^ 

* 

n  X 

o 

" 

- 

, 

£ 

NO 

QU 

NIN 

* 

n 

c'l  H 

" 

■■ 

A 

■>■ 

£ 

H 

= 

o 

" 

" 

■* 

in 

s 

- 

5rf 

o 

" 

" 

■=- 

— 

■*- 

Z 

IXt 

" 

■■ 

-7 

-fd 

> 

£ 

M 

M 

O 

ou 

NIN 

■  15 

OR 

f— 

/ 

a. 

■-~ 

-^ 

rt 

4« 
0 

4- 

" 

C 

■?■ 

;< 

C 

£ 

4* 

C» 

o 

NO 

QU 

NIN 

<c 

< 

'    ' 

£ 

It  '* 

o 

" 

" 



— 

» 

— 



= 

=*■ 

£ 

o 

" 

" 

^ 

-' 

■ 

<: 

'' 

i 

i .  ^' 

!=^ 

QU 

NIN 

=.  c 

OCK,  2 

01 

^ 

_ 

_,_ 

- 

— 

-^ 

— 1 

n 

^!"-= 

-:» 

— • 

"^ 

» 

■^ 

— 

' 

E 

»a 

• 

1 

0 

/ 

1/ 

^9 

< 

S 

= 

\ 

» 

*• 

<, 

i 

o 

=, 

<, 

£ 

cT' 

y 

9 

<^ 

£ 

° 

QU 

NIK 

e  1 

OR 

^ 

^ 

< 

s 

£ 

o 

\ 

se 

T  U 

9  Bi 

0 

v> 

^ 

C 

o 

< 

1     1        1 

'    ' 

HO 

IR 

0 

< 

^ 

£ 

o 

r 

i 

.  .,  , 

'    2 

■ 

s 

< 

SO 

.ID 

FO 

D 

£ 

^ 

;> 

'    4 

= 

< 

o 

h 

.    .[oh 

AIR 

1   ' 

5 

< 

Z 

- 

N 

* 

,  ,f 

■■ 

4  ' 

' 

u 

■i 

^ 

; 

' 

£ 

o 

QU 

Nl^ 

E2 

GR 

< 

CL 

OTh 

ES 

ON 

= 

< 

' 

C 

o 

< 

■■ 

" 

s 

< 

£ 

^ 

< 

" 

5 

< 

£ 

«» 

<; 

s- 

" 

" 

r, 

< 

• 

£ 

J" 

^ 

w/ 

(.K 

^0 

95 

< 

S 

C 

iv 

o 

ik.lN  BE 

0 

0 

s= 

» 

E 

Si -'I 

QU 

Nl 

12 

OR 

< 

'' 

U 

P 

s 

< 

■) 

£ 

o 

\ 

< 

Y 

C 

< 

V 

C 

Si 

0 

s 

< 

^ 

C 

s 

■< 

> 

£ 

7 

■- 

1 

n 

iC^ARC 

EO 

1 

/ 

_ 

e 

■■^;'-" 

1893,  writing  of  typho-malarial  fever  says:  "The  name 
typho-malarial  fever  must  not  imply  a  specific  disease, 
but  rather  a  combination  or  coexistence  of  two  diseases, 
typhoid  fever  and  malarial  fever,  in  the  same  patient." 
While  allowing  that  these  diseases  may  coexist  he 
further  says:  "To  produce  this  fever  there  must  be  a 
double  infection  with  the  typhoid  bacillus  and  the  ma- 
larial Plasmodium.  Unfortunately,  positive  evidence 
that  these  two  germs  can  coexist  in  the  same  individual 
has  not  yet  been  obtained, 
since  the  natural  history  of 
both  germs  has  been  studied 
for  only  a  brief  decade.'' 

More  recent  investigation 
has  given  positive  evidence 
that  the  diseases  coexist,  and 
in  a  recent  article  on  typhoid 
fever  Brannan  says:  "Mala- 
rial fever  and  typhoid  fever 
may  exist  in  the  same  pa- 
tient, but  this  association  is 
rare'';  and  Kwing,  from  re- 
cent observations  in  camp, 
where  several  of  the  above 
cases  were  under  treatment, 
says:  "The  malarial  infec- 
tion frequently  outlasts  the 
typhoid  infection,  and  makes 
itself  manifest  during  con- 
valescence." 

The  following  case,  under 
my  observation  throughout  its 
course,  will  be  of  interest  in 
that  it  demonstrates  positively 
the  coexistence  of  malarial 
fever  with  typhoid  fever,  and 
bears  evidence  that  the  ma- 
larial element,  while  not 
wholly  inactive  during  the 
period  of  typhoid  infection, 
did  not  materially  affect  the 
course  of  the  disease,  but 
made  itself  more  manifest 
during  convalescence. 

The  patient,  a  male  nurse, 
twenty-three  years  of  age,  of 
robust  health  and  phlegmatic 
temperament,  became  ill  dur- 
ing an  epidemic  of  typhoid 
fever.  He  was  the  possessor 
of  a  fixed  idea  that  if  he 
should  ever  take  to  his  bed 
because  of  sickness  he  would 
never  recover,  and  he  there- 
fore carefully  concealed  his 
early  symptoms.  His  dull 
and  apathetic  condition  ex- 
cited suspicion,  and  after 
much  persuasion  I  succeeded 
in  getting  his  temperature; 
it  registered  102°  I'.  He  was 
taken  off  duty,  but  refused  to 
go  to  bed.  The  following 
day,  however,  his  temperature 
was  104^  P.,  and  he  was  forced 
to  yield  to  treatment  and 
obey  the  physician's  orders. 
He  presented  the  typical  ty- 
phoid symptoms:  the  head- 
ache, pain  in  the  lumbar  re- 
gion, the  ciiaracteristic  tongue, 
the  mental  hebetude,  and 
later  the  low,  muttering  delir- 
ium and  subsultus  tendinum. 
On     the     seventh    day    the 


September  15,  1900] 


MEDICAL    RECORD. 


435 


Widal  reaction  was  present.  The  wide  ranges  of  tern 
peraturc  in  (.•ach  twenty-four  hour.s,  noticeable'throiigh- 
out  the  disease,  accompanied  with  sweating  at  fairly 
regular  intervals,  led  to  a  belief  that  a  malarial  element 
might  be  present,  though  several  careful  blood  exami- 
nations during  the  first  three  weeks  failed  to  disclose 
the  malarial  organism.  On  the  twenty-seventh  day  of 
the  disease,  however,  the  plasmodia  malaria  of  the 
tertian  form  were  found  in  abundance.  Up  to  this 
date  the  treatment  had  been  as  follows:  sweeping  out 
the  intestinal  tract  with  calomel  and  salines;  salol  in 
gr.  viii.  doses  every  four  hours  as  an  intestinal  anti- 
septic; baths  at  68'  F.,  to  reduce  the  temperature  and 
strengthen  the  heart ;  and,  for  nourishment,  liquid  food 
every  five  hours. 

On  tiie  day  the  malarial  organisms  were  found,  qui- 
nine in  gr.  X.  doses  was  substituted  for  salol,  and  con- 
tinued a  week,  then  stopped.  During  the  time  it  was 
given  the  temperature  fell  by  lysis.  Four  days  after 
quinine  was  discontinued  the  temperature  went  up  to 
101.4°  F.,  falling,  to  rise  on  the  second  day  following 

to  101.5°  P-j  ^^^  °"  ''^'•''  ''^y  g""-  ^^'-  *^f  quinine  was 
given,  and,  as  seen  by  the  chart,  the  evening  tempera- 
ture fell,  being  nearly  at  normal  on  the  forty-second 
day  of  the  disease. 

The  next  day  (forty-third)  the  evening  temperature 
registered  104°  F.,  the  patient  having  the  chill,  hot 
stage,  and  the  sweating  of  malaria.  An  examination 
of  the  blood  eight  hours  after  the  chill  showed  the 
malarial  organisms  in  abundance. 

In  order  better  to  observe  the  case,  quinine  was  with- 
held, and  after  the  usual  interval  in  the  tertian  form  of 
malaria,  the  temperature  again  went  to  103' F.  Qui- 
nine was  then  given  after  Dock's  method,  with  most  fa- 
vorable results,  the  slight  rise  on  the  sixty-third  day  of 
the  disease  being  due  to  indiscretion  in  diet.  The 
patient  was  discharged  as  recovered  sixty-nine  days 
after  admission. 

Typhoid  fever  was  the  initial  disease,  and  its  symp- 
toms predominated  throughout  its  usual  course,  but 
with  the  period  of  defervescence  we  saw  the  malarial 
element,  which  had  been  masked,  appearing  in  typical 
form;  and  while  we  are  positive  that  it  was  present 
during  the  latter  part  of  the  attack,  there  is  strong 
presumptive  evidence  that  it  developed  early  in  the 
disease. 

The  accompanying  chart  gives  the  morning  and 
evening  temperatures,  with  the  condition  of  the  circu- 
latory, respiratory,  and  intestinal  apparatus  during  the 
course  of  the  disease. 


LARGE  SUBDUR.AL  ABSCESS  AND  ABSCESS 
OF  THE  BRAIN  FOLLOWING  A  PENE- 
TRATING WOUND,  WITH  BUT  SLIGHT 
PRESSURE    SYMPTOMS. 

3y   LOUIS  J.    >L-\NDEL,    M.D., 

DROOKLV.S-, 
HOUSE  SURGEON  TO  THE   GERMAN    HOSPITAL  OF   BROOKLYN. 

C.  B ,  a  male  infant,  was  brought  to  the  hospital 

on  August  28th,  by  his  mother,  complaining  of  partial 
paralysis  of  the  left  arm,  of  irritability  of  temper,  and 
of  progressive  loss  of  flesh  and  strength.  There  was 
a  tumor  mass,  ovoid  in  shape  and  about  the  size  of  a 
robin's  egg.  on  the  right  side  of  the  skull,  about  one 
and  one-half  inches  above  the  external  auditory  mea- 
tus, corresponding  about  to  the  anterior  inferior  angle 
of  the  parietal  bone. 

On  questioning  the  mother,  the  following  history 
was  obtained:  The  family  history  was  negative,  both 
parents  and  other  members  of  the  immediate  family  be- 
ing in  good  health;  the  patient  was  the  youngest  of  a 
family  of  seven  children.  The  child  was  bottle-fed. 
and  his  mother  says    he    always    had    been   in   good 


health  up  to  the  time  of  the  accident.  About  three 
and  a  half  weeks  before  admission  to  the  hospital 
the  patient  fell  out  of  bed,  striking  the  door  with 
considerable  force,  and  landing  head  first  upon  a 
large  wire  nail,  which  entered  his  skull.  The  mother 
and  the  older  sister  of  the  child,  attracted  by  its 
cries,  rushed  into  the  room,  picked  up  the  child,  with- 
drew the  nail,  and  carried  the  boy,  who  was  bleed- 
ing quite  freely,  to  the  office  of  a  neighboring  phy- 
sician. According  to  the  mother's  story,  the  physician 
made  an  examination  of  the  child,  assured  i.er  that 
the  skull  was  not  fractured,  and  that  the  injury  was 
but  a  slight  one.  He  then  washed  the  wound  and 
applied  a  piece  of  adhesive  plaster,  instructing  her, 
she  says,  to  return  in  the  course  of  the  week.  She 
called  again  about  a  week  later,  and,  after  having  again 
washed  the  child's  scalp,  the  physician  informed  her 
that  the  wound  was  perfectly  healed,  and  discharged 
the  infant  as  cured. 

The  mother  states  that  the  child  ever  since  the  acci- 
dent has  progressively  lost  flesh  and  strength  and  grown 
more  and  more  irritable.  She,  however,  regarded  these 
phenomena  lightly,  attributing  them  to  the  heat,  and 
it  was  not  until  three  days  ago,  when  there  simultane- 
ously appeared  the  symptoms  of  a  tumor  on  the  right 
side  of  the  head,  of  vomiting,  and  of  paralysis  of  the 
left  upper  extremity,  that  she  regarded  the  condition 
of  the  child  as  serious  and  consulted  her  regular  medi- 
cal attendant.  After  an  examination  of  the  child,  the 
physician  recommended  operative  interference  as  the 
only  treatment  for  the  relief  of  the  symptoms.  Three 
days  after  this  consultation  with  her  regular  attendant 
the  mother  presented  herself  and  child  at  the  hospital. 

The  child  was  admitted  to  the  children's  ward  of 
the  hospital,  and  a  physical  examination  showed  the 
following:  The  general  condition  is  poor,  the  patient 
is  very  much  emaciated,  the  conjunctiva;  and  mucous 
membranes  are  pale,  the  patient  vomits  immediately 
after  the  ingestion  of  food,  the  bowels  are  constipated, 
and  the  child  has  an  apathetic  and  stupid  appearance. 

Thorax:  The  ribs  are  prominent,  the  intercostal 
spaces  deep,  and  palpation  reveals  a  slightly  devel- 
oped rachitic  rosary.  The  heart  and  lungs  are  nor- 
mal; the  pulse  and  respiration  are  regular,  being  re- 
spectively 125  and  25;  the  temperature  is  100°  F. 
The  abdomen  is  prominent  and  distended,  otherwise 
the  examination  of  this  part  gives  negative  results. 
Extremities:  The  muscles  are  atrophied  and  flabby. 

The  head  is  normal  in  size ;  the  anterior  fontanelle  is 
prominent  and  pulsating  though  of  normal  size.  There 
is  a  tumor  mass,  ovoid  in  shape,  about  the  size  of  a 
robin's  egg,  situated  one  and  one-half  inches  above 
the  external  auditory  meatus  about  at  the  anterior  in- 
ferior angle  of  the  parietal  bone.  The  tumor  is  sur- 
rounded by  an  area  of  a-dematous  tissue  one-half  inch 
in  width,  and  gives  an  impulse  when  the  child  cries, 
increasing  at  such  times  to  one  and  a  half  times  its 
normal  size,  the  overlying  skin  becoming  tense  and 
shining.  The  tumor  can  readily  be  reduced  into  the 
cranial  cavity,  when  there  is  felt  a  small,  round  hole  in 
the  bone,  about  three-eighths  of  an  inch  in  diameter 
and  occupying  approximately  the  centre  of  the  tumor 
mass.  The  skin  overlying  the  tumor  shows  the  scar 
of  the  former  wound,  which  has  an  unhealthy  appear- 
ance. The  pupils  are  both  dilated,  the  right  more  so 
than  the  left.  The  left  pupil  slowly  reacts  to  light, 
the  right  does  not.  The  left  upper  extremity  is  para- 
lyzed and  anjesthetic.  There  is,  however,  good  func- 
tion of  the  lower  extremity  on  this  side  and  only  slight 
impairment  of  sensation  of  this  limb  and  of  the  trunk 
on  this  side.  There  is  no  stitTness  or  rigidity  of  the 
muscles  of  the  neck  or  back,  and  there  is  no  hyperses- 
thesia.  The  skin  is  exceedingly  hot  and  dry,  and 
there  is  a  marked  difference  in  temperature  between 
the  paralyzed  limb  and  its  unaffected  fellow. 


436 


MEDICAL    RECORD. 


[September  15,  1900 


Upon  the  history  thus  obtained  and  upon  the  find- 
ings of  the  physical  examination,  a  diagnosis  was  made 
of  primary  compound  depressed  fracture  of  the  skull, 
with  subsequent  necrosis  of  the  depressed  fragment, 
and  abscess  formation,  this  abscess  being  both  intra- 
and  extra-cranial,  the  two  parts  communicating  with 
each  other  by  means  of  the  puncture  wound  in  the 
bone;  by  its  pressure  upon  the  motor  cortical  area  this 
abscess  has  caused  paralysis  of  the  opposite  half  of  the 
body;  the  greatest  amount  of  pressure  was  in  that 
portion  which  controlled  the  motion  of  the  upper  ex- 
tremity. 

An  unfavorable  prognosis  as  to  the  success  of  oper- 
ative interference  in  the  present  condition  of  the  pa- 
tient was  given,  but  at  the  urgent  request  of  the  pa- 
rents that  the  child  be  given  this,  its  only  chance  of 
recovery.  Dr.  Weisbrod,  one  of  the  visiting  surgeons, 
assisted  by  the  house  staff,  trephined  the  infant's  skull 
under  chloroform  narcosis.  The  skin  flap  was  three- 
fourths  of  an  inch  in  diameter,  its  base  pointing  down- 
ward and  backward  and  its  circumference  encircling 
the  base  of  the  tumor.  As  soon  as  the  flap  was  dis- 
sected back,  pus  in  great  quantity  began  to  well  out 
of  the  hole  in  the  bone.  A  trephine  one-half  inch  in 
diameter  was  set,  and  a  button  of  bone  was  removed 
with  great  difficulty,  the  underlying  thickened  dura 
being  a  great  deal  more  adherent  than  normally  in  a 
child  of  this  age.  The  button  of  bone  having  been 
separated  from  the  dura,  the  hole  in  the  membrane 
was  increased  in  size,  and  the  pus,  which  was  fairly 
thick  and  creamy,  flowed  freely,  in  all  about  fourteen 
ounces  of  pus  being  removed.  The  abscess  cavity  was 
drained  with  a  strip  of  plain  hemmed  gauze,  and  the 
child  was  placed  in  bed  on  its  right  side  so  as  to  favor 
drainage. 

On  removal  from  the  operating-room  the  child's  tem- 
perature was  gg.2^F.;  pulse,  140;  respiration,  24. 
The  child  had  also  regained  complete  control  over  the 
movements  of  the  paralyzed  limb  and  in  every  way 
seemed  greatly  improved,  it  being  able  to  retain  some 
liquid  food  which  was  fed  to  it  in  drachm  doses;  its 
pupils  became  regular  and  it  seemed  brighter  and 
more  cheerful.  The  wound  was  dressed  fifteen  hours 
after  operation,  the  drain  being  removed,  and  six 
ounces  of  pus  was  drained  from  the  cavity  as  the  child 
was  held  on  its  right  side. 

The  rally  of  the  child  was  only  transitory,  for  it 
soon  began  to  grow  worse  again,  refusing  to  take  food  ; 
the  palpebral  fissures  became  widely  dilated,  marked 
nystagmus  developed,  and  tiie  child  emitted  sharp, 
short,  penetrating  shrieks.  The  respirations  became 
irregular,  the  pulse  rose  rapidly,  and  the  temperature 
was  correspondingly  high,  these  being  just  before 
death  respectively  50,  180,  and  106'  F.  The  child 
died  at  5  p.m.  August  29th,  twenty-two  hours  after  the 
operation. 

The  autopsy  disclosed  the  dura  to  be  greatly  thick- 
ened and  the  calvarium  was  removed  with  difficulty, 
efforts  at  separating  the  dura  from  the  bone  being  fu- 
tile, so  that  it  had  to  be  taken  away  with  the  skull 
cap.  The  brain  thus  exposed  showed  a  large  area  of 
depression  over  the  superior  frontal  and  a  portion  of 
the  anterior  central  convolutions,  the  area  occupied  by 
the  subdural  abscess.  The  brain  tissue  was  greatly 
thinned  and  softened,  and  there  was  an  abscess  in  the 
posterior  portion  of  the  superior  frontal  convolution 
which  communicated  with  the  lateral  ventricle  on  the 
right  side,  w-hich  ventricle  was  greatly  distended  and 
filled  with  pus.  Just  anterior  to  this  abscess  there 
was  a  puncture  wound  made  by  the  entrance  of  the 
nail  into  tiie  skull. 

From  the  above  history,  the  results  of  the  physical 
examination,  and  the  disclosures  of  the  autopsy,  it  is 
probable  that  early  trephining  and  proper  and  careful 
treatment  of  the  wound  might  have  resulted  in  the  re- 


covery of  the  child;  for,  as  was  clearly  brought  out  at 
the  autopsy,  the  abscess  in  the  brain  did  not  commu- 
nicate witii  the  wound  in  its  substance,  nor  did  this 
wound  communicate  with  the  subdural  abscess,  from 
which  it  was  walled  o(f  by  stout  adhesions. 

The  lesson  of  this  case  is  that  it  is  the  duty  of  every 
practitioner  to  examine  thoroughly  under  aseptic  pre- 
cautions every  scalp  wound  and  to  satisfy  himself  be- 
yond the  shadow  of  a  doubt  that  there  is  no  fracture; 
or  in  case  there  is  a  fracture,  he  should  see  to  it  that 
it  receives  careful  treatment  at  the  hands  of  a  surgeon. 


A   CASE   OF 


PERVERSION 
INSTINCT. 


OF   SEXUAL 


By    A.     C.    P.\XTON,    M.D., 

I'ORTLA.VD,   OREGON. 

The  following  strange  case  presented  itself  lately  in 
my  service  at  Good  Samaritan  Hospital  of  this  city: 
The  patient  was  a  farmer,  aged  sixty-eight  years,  family 
and  personal  history  good.  He  was  a  soldier  during  the 
Civil  War,  and  was  married  in  1865  to  a  woman  who 
bore  him  four  children.  But  love  took  wings  when 
poverty  entered  the  household,  and  the  couple  separated 
in  1883,  the  husband  settling  on  a  farm  where  he  lived 
alone. 

For  four  years  nothing  unusual  took  place  in  his 
life  (so  he  says),  but  thirteen  years  ago,  in  order  to 
gratify  an  abnormal  sexual  passion,  he  was  prompted 
to  perform  a  surgical  operation  upon  himself.  He 
thereupon  sharpened  his  pocket-knife,  and,  with  a 
slash,  divided  his  scrotum  into  two  lateral  halves  up 
to  the  penis.  During  his  military  career  he  had  seen 
a  surgeon  sewing  a  wound,  so,  bearing  in  mind  the 
method,  he  took  a  needle  and  common  cotton  thread, 
and  with  interrupted  sutures  united  the  divided  skin 
of  the  front  and  back  of  the  left  half  of  his  scrotum, 
and  repeated  the  same  operation  on  the  right  side,  with 
the  result  that  each  testis  now  had  a  separate  scrotal 
investment.  Ho  did  not  wash  the  wound,  but  "tied 
it  up  in  the  blood,""  and  went  on  with  his  farming. 
Everything  seems  to  have  healed  as  kindly  as  if  done 
under  modern  surgical  asepsis. 

After  this  first  experience,  the  knife  with  which  this 
devotee  sacrificed  to  Eros  was  in  frequent  requisition. 
As  a  rule,  a  small  incision  of  one  or  other  scrotum,  or 
of  the  skin  about  the  root  of  the  penis,  satisfied  his 
cravings;  but  eight  years  ago  he  indulged  in  a  star- 
tling and  unique  departure,  in  that  he  made  a  free  in- 
cision into  his  right  scrotum  and  inserted  therein  a 
glass  marble  or  alley,  about  one  inch  in  diameter, 
suturing  tiie  tissues  over  it.  The  operation  was  a 
success,  the  wound  uniting  firmly,  but  as  time  ad- 
vanced, owing  to  its  weight,  this  addition  became 
pendulous,  and,  as  seen  in  the  accompanying  illus- 
tration, hung  from  a  pedicle  about  an  inch  in  length. 
It  seems,  however,  to  have  been  quite  satisfactory  to 
its  owner,  who  continued  at  intervals  to  incise  himself, 
sometimes  losing  his  self-control  and  cutting  himself 
more  freely  than  his  cooler  judgment  would  have  ap- 
proved. This  last  fact  led  to  his  coming  under  my 
notice.  On  July  2olh  last,  he  was  brought  to  the  hos- 
pital suffering  from  a  severe  wound  of  the  left  scrotum 
two  inches  long  and  two  inches  deep,  upward  toward 
the  pubes,  accompanied  by  such  bleeding  that  he  tied 
some  cloths  tightly  about  the  mangled  parts.  But  the 
scrotum  became  distended  with  blood,  which  again 
burst  forth,  and  he  removed  his  first  bandage  and  ap- 
plied tighter  ones.  This  time  the  blood  flowed  no 
more,  but  his  left  scrotum  became  gangrenous. 

When  I  first  saw  him  his  condition  seemed  rather 
desperate,  as  he  was  suffering  from  .septic  fever  and 
the  parts  involved  were  in  a  foul  and  sloughing  con- 


September  15,  1900] 


MEDICAL    RECORD. 


437 


dition.  I  had  the  wound  dressed  with  hot  boracic- 
acid  solution,  and  put  the  man  on  supportive  treat- 
ment. 

It  was  with  great  difficulty  that  I  obtained  the  pre- 
ceding history.  For  some  days  he  maintained  that  the 
hard  mass,  which  turned  out  to  be  a  marble,  was  a 
testicle  that  had  been  there  all  his  life.  But  finally 
he  confessed  the  truth,  and  stated  that  the  pains  whicii 
he  had  endured  from  these  mutilations  were  enjoyable 
to  him. 

In  a  week  the  sloughs  had  separated  and  the  swelling 
had  subsided,  and  believing  that  it  was  not  imperative 


to  make  a  supreme  effort  to  save  his  left  testis,  I  re- 
moved it,  and  also  his  glass  alley,  which  was  firmly 
encapsulated,  and  which  being  cut  down  upon  was 
found  to  be  a  thing  of  beauty,  with  an  elaborate  spiral 
of  red,  green,  and  yellow  colors  in  its  interior. 

It  is  remarkable  that  this  humble  operator  with  his 
dirty  old  jack-knife,  dirty  glass  alley,  etc.,  had  such 
immunity  from  sepsis  throughout  a  series  of  mutila- 
tions extending  over  a  period  of  thirteen  years. 


J'livijkal   J>uotjcstions. 

To  Keep  Cocaine. — 

1^  Cocain^e  hydrochl gr.  iv. 

Acidi  salicylici gr.  ss. 

AquK  destil 3  ii j . 

— Joiiin.  de  Affii.  de  Paris. 
Vulvitis  in  Young  Girls — 

If  Salol gr.  ij. 

Ol.  tlieobr gr-  xv. 

To  make  a  crayon  3  mm.  in  diameter.  This  is  intro- 
duced without  aid  of  speculum  twice  or  three  times  a 
week  till  a  cure  results. — Comby. 

Vulvitis 

1}  Liq.  plumbi  subacet 3  i. 

Tinct.  hyoscyami 3  ij- 

Aqux  camphora; q.s.  ad  3  viij. 

M.      S.    Apply. 

— Medical  Standard. 

Rubber  Gloves  have  in  their  favor  the  matter  of 
convenience  and  the  fact  that  they  are  more  easily 
sterilized  than  the  more  absorbent  skin  of  the  hands. 

—  E.  WoRiMSER. 

To  Sterilize  Gloves.— Wash  thoroughly  with  soda 
solution,  inside  and  out,  and  hold  for  a  minute  or  two 
over  a  gas  flame  or  heater  to  dry.     Dust  the  inside 


with  sterilized  soapstone;  wrap  each  pair  in  a  double 
layer  of  gauze.  Lay  on  a  towel  and  place  in  formic 
aldehyde  sterilizer  for  two  hours.  Four  or  five  sets 
may  be  prepared  at  a  time.  After  putting  on,  dip  in 
sublimate  solution  \  :  1,000  for  five  minutes. — C.  H. 
Richardson,  in  Albany  Medical  Annals,  July,  1900. 

Chilblains. — 

I(  Spir.  chloroformi 3  'j. 

Lin.  bellad J  ss. 

Tinct.  benzoini  co 3  ij. 

Lin.  saponis ;  iij. 

M.     S.   Saturate  a  piece  of  sheet  lint  and  apply. 

— Joum.  A.  M.  A. 
Cholesteatoma. — 

"Bf  Papain 3  i. 

Ac.  hydrochl.  dil iH  xv. 

Aquam ad  3  i. 

M.     S.   Instill  into  the  earand  retain  (or  at  least  half  an  hour. 

— Yearsley. 

Air  Cauterization  is  the  best  treatment  for  inoper- 
able na:-vi.  The  hot-air  current  should  be  passed  over 
the  tumor  until  incision  shows  the  blood  spaces  to  be 
empty  and  tiie  part  mummified. — Hollander. 

Instruments  after  use  should  be  cleaned  with  brush 
and  sapolio,  then  boiled  in  plain  or  soda  solution  just 
before  using.  They  should  be  kept  under  water  to 
prevent  exposure  to  the  air. — C.  H.  Richardson. 

Angina  Epiglottidea  Anterior  is  very  often  pri- 
mary. Early  scarification  is  advised,  and  iced  ich- 
thyol  spray  is  of  value  in  relieving  the  acute  pain  and 
reducing  the  inflammation.  Steam  inhalations  are  of 
service  when  iced  sprays  cannot  be  used. — C.  F. 
Theisen. 

The  Gall  Bladder  is  very  tolerant  of  surgical  ma- 
nipulation. Over  ninety  per  cent,  of  primary  cancer 
of  the  organ  is  due  to  gall  stones.  Early  operation 
reduces  the  mortality. —  Roheson  and  Kehr. 

Mortality  of  the  wounded  is  greatly  lessened  by  the 
modern  small-calibre,  small-arm  projectile  which  now 
produces  ninety  per  cent,  of  battle-field  injuries. — 
Borden. 

Aneurism  of  the  entire  right  subclavian,  of  egg  size, 
was  cured  by  ligation  of  the  axillary  under  the  clavi- 
cle and  of. the  common  carotid  close  to  the  innominate 
trunk. 

Lingual  Tonsillar  Abscess  is  a  condition  of  extreme 
discomfort  simulating  oedema  of  the  glottis.  The 
swelling  is  at  first  hard,  then  fluctuating.  Incision 
gives  relief  even  when  pus  is  not  reached. — Froth- 
ingham. 

Femoral  Fracture  in  an  infant  was  treated  by  flex- 
ing the  limb  on  the  abdomen,  the  foot  being  over  the 
shoulder  and  retained  by  bandages.  A  loop  ot  band- 
age was  carried  around  the  ankle  and  fastened  to  the 
rail  of  the  cot.     A  good  result  followed. — J.  D.  Rice. 

Cancer  of  the  Vagina. — Pryor's  radical  operation 
has  a  surgical  basis  in  the  following  principles:  ((7) 
The  preliminary  and  preventive  ha;mostasis  renders 
the  field  of  operation  comparatively  dry.  and  there  is 
less  danger  of  transplantation  of  cancer-cells  during 
the  subsequent  manipulations;  (b)  avoidance  of  in- 
jury to  the  cancerous  field  until  haemostasis  is  secured 
and  the  cancer  charred;  (c)  there  is  removal  of  all 
organs  in  which  recurrence  is  apt  to  take  place  from 
above  downward;  [d)  establishment  of  an  artificial 
anus  near  the  normal  site.— B.  F.  Kingsley. 

The  Technique  of  Lumbar  Puncture. — The  loca- 
tion for  entering  should  fulfil  three  requirements;  (i) 


438 


MEDICAL    RECORD. 


[September  15,  1900 


where  the  needle  could  find  a  ready  entrance;  (2)  the 
tip  should  point  in  sucii  a  way  as  least  likely  to  pro- 
duce damage;  (3)  tiie  fluid  obtained  should  be  rich  in 
sediment.  Any  one  of  the  three  lower  lumbar  spaces 
should  be  chosen.  At  the  lumbo-sacral  space  the  fluid 
should  be  riciier  in  sediment.  The  patient  should  as- 
sume the  sitting  position,  but  in  the  delirious,  or  coma- 
tose, there  is  greater  difficulty  in  operating  in  this 
position.  The  upright  position  is  generally  confined 
to  small  children.  An  essential  point  to  remember  is 
that  the  greatest  degree  of  flexion  should  be  main- 
tained; if  the  child  is  sitting  it  should  be  bent  well 
forward;  the  operator  should  stand  on  the  right  side 
of  the  patient  and  bend  over  the  body.  — L.  A.  Connor. 


depressed.  The  narrowest  vertical  surface  is  intro- 
duced first  and  as  far  back  as  possible,  with  the  oblique 
surface  inferior.  The  props  are  united  in  pairs  by 
narrow  tape  knotted  on  the  opposite  side  of  the  per- 
foration through  the  centre. 

225  Wbst  Fortv-fifth  Street. 


^cxti  Instritmmxts. 

DESCRIPTION  OF  NEW  INSTRUMENTS: 
(_i)  LIP  RETRACTOR;  (2)  INTERDENTAL 
MOUTH    PROPS. 

By   S.    ORMOND   GOLDAN,    M.D., 

NEW   YORK. 

The  lip  retractor  was  devised  to  overcome  a  mechan- 
ical obstruction  to  breathing  not  infrequently  met  with 
when  administering  anesthetics  to  old  patients.  This 
is  due  to  atrophy  of  the  alveoli  and  atony  of  the  mus- 
cles about  the  cheek 
and  lips.  These 
subjects,  in  expira- 
tion, balloon  the 
cheeks  and  lips,  but 
do  not  effectually 
separate  them ;  dur- 
ing inspiration  the 
lips  are  drawn  to- 
gether, valve -like, 
without  air  entering 
the  oral  cavity. 

The  retractor  is 
of  two  sizes  and 
made  of  light-weight 
rigid  wire,  twisted 
into  supports  for 
the  upper  and  lower 
lips  and  a  lateral 
support    united    a  t 

the  centre,  which  fits  the  cheek  externally  and  inter- 
nally at  the  angle  of  the  lips,  and  permits  the  retractor 
to  remain  in  place  during  the  entire  narcosis.  Breath- 
ing is  unimpaired,  and  the  ansesthetic  may  be  ad- 
ministered without  any  interference  with  the  close 
adaptation  of  the  face-piece  of  the  inhaler. 

Mouth  Props.  Certain  types  of  patients  develop 
during  the  administration  of  anesthetics  a  respiratory 
obstruction  due  to  abnormally  small  air  passages,  not 
discoverable  before  the  administration  of  the  anes- 
thetic. This  is  also  frequently  met  with  in  mouth 
breathers.  When  ordinarily  the  patient  is  subjected 
to  the  mouth  gag  and  barbarous  tongue  forceps,  this  is 
entirely  avoided  by  slight  separation  of  the  lower 
jaws  and  the  insertion  of  one  of  the  smaller  props: 
breathing  continues  uninterruptedly  throughout  the 
anaesthesia,  the  prop  remaining  in  place. 

The  larger  sizes  for  adults,  and  the  smaller  ones  for 
children,  are  particularly  useful  in  dental  and  oral 
operations.  The  props  are  made  of  four  sizes,  eitiier 
hard-rubber  or  metal,  and  are  so  designed  that  a  rul)- 
ber  band  encircles  the  prop,  making  a  rubber  cushion 
over  the  serrated  surfaces,  upon  which  the  teeth  rest. 
The  upper  surface  is  horizontal,  the  lower  oblique, 
conforming  perfectly  with  the  lower  jaw  when  it  is 


FRONT. 


Vertical  Items. 

School  of  Tropical  Diseases  for  Germany.  —  A 
school  of  tropical  diseases  similar  to  those  already  in 
existence  in  London  and  Liverpool  is  about  to  be 
opened  at  Hamburg.  Dr.  Nocht,  the  port  medical 
officer  of  Hamburg,  has  been  visiting  the  English 
schools  for  the  purpose  of  studying  the  work  in  each 
establishment,  since  the  Hamburg  school  will  work  in 
co-operation  with  the  two  Flnglish  schools.  Dr.  Nocht 
has  had  an  interview  with  Mr.  Chamberlain,  the  Eng- 
lish colonial  secretary,  who  is  intensely  interested  in 
the  subject.  It  is  contended  that  once  malaria  is  sup- 
pressed in  West  Africa  the  country  will  become  a  sec- 
ond India. 

Mortality  of  Typhoid   Fever  in  South  Africa. — 

There  has  been  much  futile  discussion,  says  7'/ie  Lon- 
don PrairtHio)ier,z.%  to  the  mortality  of  typhoid  fever  in 
South  Africa,  and  statistics  have  been  compiled  from 

all  available  sources 
to  show,  according 
to  the  controversia- 
list's point  of  view, 
that  the  death  rate 
i  n  Lord  Roberts' 
army  has  been  nor- 
mal or  that  it  has 
been  excessive. 
Military  statistics 
are  to  be  distrusted 
in  the  matter  of  ty- 
phoid fever.  The 
twenty-one  per  cent, 
of  deaths  admitted 
b  y  Lord  Roberts 
will  doubtless,  when 
the  official  report  of 
the  war  comes  to  be 
written,  be  reduced 
to  an  infinitesimal  fraction  by  dilution  scanidum  artem 
with  cases  of  "continued  fever."  Already  the  employ- 
ment of  his  process  has  been  foreshadowed  by  Bennett 
Burleigh  in  his  account  of  an  interview  with  Lord 
Roberts  published  in  The  Daily  Telegraph  of  July  2d. 

Poisons  and  Poisoners. — Italy  was  the  sapient 
nurse  of  the  finer  arts  of  the  poisoner.  In  the  fifteenth, 
sixteenth,  and  seventeenth  centuries  professional  poi- 
soners were  common  in  Italy  and  found  a  large  sphere 
of  practice.  Poison  was  recognized  by  churchmen  as 
a  means  of  preferment,  by  statesmen  as  a  useful  politi- 
cal instrument,  and  even  by  governments  as  an  engine 
of  diplomacy.  Poison  was,  in  fact,  the  common  means 
of  getting  rid  not  only  of  a  dangerous  enemy  and  an 
inconvenient  rival,  but  of  a  troublesome  husband  or 
a  wealthy  relative  who  lagged  too  long  "  superfluous 
on  the  stage  of  life."  The  character  of  the  Italan 
mind  made  it  prefer  the  subtle  instrument  of  poison  to 
the  grosser  methods  of  murder  practised  by  more  bar- 
barous races.  It  is  largely  its  historical  association 
with  poison  that  gives  the  name  of  Borgia  its  sinister 
celebrity.  In  this  particular  respect  more  has  been 
laid  to  the  charge  of  the  members  of  that  unscrupulous 
family  than  the  evidence  fully  justifies;  nevertheless, 


September  15,  1900] 


MEDICAL    RECORD. 


439 


on  ne prete  gtt'aux  riches.  But  the  poisoned  gloves  and 
flowers,  which  are  said  to  have  been  instruments  of 
death  in  their  hands,  are  almost  certainly  mythical. 
Such  legends,  however,  show  the  fear  which  the  black 
art  of  the  poisoner  had  bred  in  the  public  mind. 
The  toxic  agent  chiefly  used  by  professional  poisoner.^ 
in  antiquity  and  in  the  Middle  Ages  was  arsenic. 
This  remained  the  poison  most  in  favor  up  to  the 
present  century.  The  famous  "aqua  tof ana  "  was  a 
solution  of  arsenious  acid  in  distilled  cymbalaria 
water,  to  which  was  added  some  alcoholic  preparation 
of  cantharides.  Arsenic  from  the  poisoner's  point  ot 
view  has  the  advantage  that  the  symptoms  produced 
by  it  when  skilfully  administered  are  not  very  charac- 
teristic, and  may  easily  simulate  natural  illness.  Ex- 
amples of  this  have  been  afforded  by  the  history  of 
several  celebrated  criminals  of  modern  times.  It  was 
the  poison  most  used  by  Madame  de  Brinvilliers,  who 
said  of  it,  "  //  n'en  Jaut  pas  dormer  trop  a  /a  Jots  afni 
que  Fori  ne  s'aper(oit pas,  et  que  cclaji'it  trop  precipile.'' 
Being  tasteless  it  was  easily  given  in  food  and  drink. 
But  when  the  fear  of  poison  got  hold  of  men's  minds 
this  simple  plan  was  difficult  to  carry  out.  Recourse 
was  then  had  to  such  devices  as  poisoned  shirts,  slip- 
pers, gloves,  etc.,  or  the  inside  of  the  cup  itself  was 
coated  with  poison. — J'ractitioner. 

The  Antarctic  Regions — Dr.  Frederick  Cook,  of 
Brooklyn,  who  has  the  unique  distinction  of  being  the 
only  man  who  has  been  in  both  the  .\rctic  and  Antarctic 
regions,  has  just  published  a  book  relating  his  expe- 
riences. Dr.  Cook  was  the  surgeon  and  anthropolo- 
gist of  the  Belgian  Antarctic  expedition  which  passed 
the  season  of  1898-99  in  South-polar  waters.  The 
Be/^ica,  the  name  of  the  ship  in  which  he  sailed,  spent 
thirteen  months  frozen  in  the  pack.  The  Sun,  com- 
menting on  Dr.  Cook's  book,  says:  "The  effects  of 
the  Antarctic  night  upon  the  health  of  the  men  were 
serious.  They  suffered  from  anaemia  in  a  more  severe 
form  than  Dr.  Cook  met  in  his  Arctic  experiences,  or 
than  is  recorded  in  the  literature  of  polar  exploration. 
Of  the  eighteen  men  on  shipboard  one  officer  died  and 
another  barely  escaped  death.  The  men  became  pale, 
the  heart  action  grew  feeble,  and  the  stomach  and 
other  organs  were  sluggish  and  refused  to  work. 
There  was  difficulty  of  respiration  if  the  slightest  ex- 
ercise was  taken.  All  these  unfavorable  conditions 
disappeared  when  the  summer  day  fairly  returned." 

A  Case  of  Mould  Infection  in  Man.— Ophiils  and 
Moffitt  describe  a  mould  parasite  from  the  case  of  a 
farm  laborer  who  died  after  an  illness  characterized 
by  pleuritis  and  inflammatory  swelling  of  the  joints, 
with  high  temperature,  cough,  slight  rigors,  and  pro- 
fuse sweating.  In  the  pus  of  various  abscesses  which 
were  found  after  death,  a  number  of  protozoon-like 
bodies  were  identified  which  appeared  to  correspond 
with  the  description  given  by  others  of  a  species  of 
sporozoon  coccidioides  immitis  pyogenes.  From  pus 
containing  these  bodies,  however,  a  mould  parasite 
developed  on  artificial  media  after  forty-eight  hours' 
incubation.  After  three  subcultures  had  been  carried 
out,  a  rabbit  was  inoculated  with  the  mould.  The 
rabbit  w-as  killed  three  weeks  after  the  inoculation, 
and  a  number  of  small  white  nodules  were  found  in 
the  lungs  and  kidneys.  No  mould  mycelium  was 
present  in  the  nodules,  but  there  were  a  number  of 
the  protozoon-like  bodies  which  had  been  found  in 
the  original  pus.  The  authors  conclude,  therefore, 
that  these  bodies  are  not  protozoa  at  all  but  represent 
a  stage  in  fructification  of  the  mould  parasite. — Public 
Health. 

Railway  Accidents. — According  to  the  report  of 
the  Interstate  Commission,  the  total  number  of  cas\i- 
alties  to  persons  on  account  of  railway  accidents  dur- 


ing the  year  ending  June  30,  1899,  was  51,743.  The 
aggregate  number  of  persons  killed  as  a  result  of  rail- 
way accidents  during  the  year  was  7,123,  and  the  num- 
ber injured  was  44,620.  Of  railway  employees  2,210 
were  killed  and  34,923  were  injured  in  the  course  of 
the  year.  The  number  of  passengers  killed  in  the 
same  period  was  239,  and  the  number  injured  was 
3,442.  Corresponding  figures  for  the  previous  year 
were  221  killed  and  2,945  injured.  The  total  number 
of  persons  other  than  employees  and  passengers  killed 
was  4,674;  injured,  6,255.  The  total  number  of  per- 
sons killed  at  highway  crossings  was  693;  injured, 
1,125.  "^^^  number  of  persons  killed  at  stations  was 
443;  injured,  3,306.  The  summaries  containing  the 
ratio  of  casualties  show  that  1  out  of  every  420  em- 
ployees was  killed  and  i  out  of  every  27  employees 
was  injured.  One  passenger  was  killed  for  every 
2,189,023  carried  and  i  injured  for  every  151,998  car- 
ried. 

Gender  of  Automobile The  question  of  the  gen- 
der of  the  word  "  automobile  "  has  just  come  up  for  ad- 
judication by  the  F'rench  Academy,  and  the  "Immor- 
tals" have  decided  to  make  it  masculine.  Many 
French  purists  disagree  with  the  Academy.  Still  it 
seems  eminently  proper  to  make  the  rattling  combina- 
tion of  iron  and  fire  or  electricity  masculine. — Scien- 
tific American. 

A  Tax  for  the  Benefit  of  the  Tuberculous The 

Paris  correspondent  of  The  Lancet  says  that  at  the 
Congress  of  Hygiene  Dr.  Phicque,  physician  in 
charge  of  the  sanatorium  in  Agincourt,  proposed  the 
establishment  of  an  additional  tax  upon  alcohol,  of 
which  the  profits  should  be  applied  to  the  expenses  of 
the  fight  against  tuberculosis.  An  additional  penny 
{decime)  to  the  present  tax  of  156  francs  per  hectolitre 
would  bring  in  25,000,000  francs  per  annum.  The 
French  duties  were  at  present  much  lower  than  the 
American,  245  francs;  the  Dutch  252  francs,  and.  above 
all,  the  British  477  francs  per  hectolitre.  The  crea- 
tion of  the  "  tubercle  duty  "  upon  alcohol  would,  ac- 
cording to  Dr.  Phicque,  be  perfectly  justifiable,  for 
alcoholism  is  the  principal  cause  of  pulmonary 
phthisis.  With  the  25,000.000  francs  which  the  duty 
would  bring  in,  sanatoria  could  be  built,  and  all  the 
expenses,  which  are  very  high,  of  disinfecting  un- 
wholesome houses  could  be  defrayed. 

Physique  of  Chinese.  —  Commander  Webster, 
U.S.N.,  says  that  in  physical  apjDearance  the  natives 
of  China  vary  widely  from  extreme  north  to  south. 
While  our  experience  in  the  United  States  leads  us  to 
think  that  the  race  is  small  and  undersized,  a  brief  resi- 
dence in  the  northern  provinces  of  the  empire  will  go 
far  to  dispel  this  impression.  At  Chefu,  Taku,  and 
Tien-Tsin  one  is  struck  by  the  stalwart  appearance  and 
height  of  the  natives.  At  the  first-named  port  large 
numbers  of  the  men  are  six-footers,  and  among  the 
boatmen  of  Chefu  it  is  no  uncommon  thing  to  see  a 
native  over  six  feet  in  height  weighing  nearly  or  quite 
two  hundred  pounds.  In  the  South,  however,  the 
average  is  more  nearly  accordant  with  the  specimens 
we  encounter  as  laundrymen,  gardeners,  and  coolies 
generally  in  the  United  States.  The  cue  or  pigtail  by 
which  Chinamen  have  become  so  well  known  is  the 
visible  mark  imposed  by  their  Manchurian  conquerors 
in  1644.  Notwithstanding  the  length  of  years  since 
the  imposition  of  this  mark  of  subjection,  there  are 
large  numbers  who  resent  the  cue. — Scientific  American. 

The  Antagonism  of  Diseases. — According  to  Hah- 
nemann, his  colleagues,  when  they  happened  to  cure  a 
patient,  did  so  by  introducing  another  and  antagonistic 
disease — that  is,  by  allopathy.  This  is  now  what  is 
definitely  aimed  at  in  many  cases,  and  it  is  interesting 


440 


MEDICAL    RECORD. 


[September  15,  1900 


to  find  that  it  was  also  definitely  aimed  at  by  our  re- 
mote predecessors.  Rufus  of  Ephesus,  for  example,  a 
contemporary  of  Galen,  has  a  chapter  on  the  antag- 
onism of  diseases  which  is  preserved  in  Oribasius, 
and  which  may  be  condensed  as  follows:  "  Fevers  are 
catarrhs  and  spasmodic  affections,  and  burn  up  morbid 
humors.  Certain  Africans  use  the  goat's  urine  to  pro- 
voke fevers,  as  did  also  the  Greek  physician,  Evenor. 
Quartan  ague  will  cure  epilepsy  and  asthma,  also 
obstinate  leprous  eruptions  and  fevers,  which  last  also 
cure  it.  Chronic  dysentery  will  cure  epilepsy  and  ver- 
tigo. Hemorrhoids  are  good  for  melancliolia  and 
mania,  epilepsy  and  vertigo,  and  protect  against  pleu- 
risy, pneumonia,  and  acute  fevers.  Varicose  veins  act 
similarly,  but  less  strongly.  Therefore  the  cure  of 
either  piles  or  varix  is  not  always  safe."  There  may 
be  some  truth  in  the  above,  though  we  should  now  re- 
duce the  list,  and  it  omits  a  notable  case  of  supposed 
antagonism,  viz.,  that  between  phthisis  and  mitral  dis- 
ease or  emphysema.  This  was  discovered  at  the 
Naples  Congress  on  Tuberculosis  by  Drs.  Fazio  and 
Stefanile,  who  collected  twenty  cases  of  aortic  and 
fifty-nine  of  mitral  disease,  only  two  of  which  were 
tuberculous,  and  thirty-five  patients  with  emphysema, 
one  of  whom  only  was  phthisical.  They  conclude 
that  the  antagonism  of  the  two  latter  diseases  to 
phthisis  merits  further  consideration. — Medical Maga- 


Health  Reports. — The  following  cases  of  smallpox, 
yellow  fever,  cholera,  and  plague  have  been  reported 
to  the  surgeon-general  of  the  United  States  Marine- 
Hospital  service  during  the  week  ended  September  8, 
1900 : 


Smallpox— United  States. 


Cases.    Deaths. 


39 


Alaska,  Nome Aug^ust  nth 

Louisiana,  New  Orleans    ...  August  26th  to  September  ist.. 

Minnesota,  Minneapolis August  i8lh  to  25th 

Winona August  21st  to  28th 

Ohio,  Cleveland   August  2fith  to  September  ist . . 

Portsmouth August  26th  to  September  ist.  . 

Utah,  Salt  Lake  City August  igth  to  September  ist. . 

Smallpox — Foreign. 

Austria.  Prague August  nth  to  i8th 

Brazil,  Pernambuco July  ist  to  15th 

England,  Liverpool August  nth  to  i8th 

France.  Paris August  sih  to  18th 

Gibraltar August  12th  to  igth  

India,  Calcutta July  28th  to  August  4th 

Madras July  28th  t()  August  3d 

Japan,  Formosa June  ist  to  30th 

Mexico,  City  of  Mexico  . . .  .August  19th  to  26th 0 

Vera  Cruz August  igih  to  September  1st 

Russia.  Moscow August  5th  to  nth 4 

Odessa August  nth  to  18th 8 

Warsaw August  4th  to  nth 

Scotland,  Dundee August  iqth  to  25th 1 

Glasgow August  17th  to  a4th 28 

Spain,  Corunna August  nth  to  i8th 

Madrid July  28th  to  August  nth 

Yellow  Fevhr. 

Colombia,  Bocas  del  Toro  .  .September  ist   ..    i 

Cartagena August  3d  to  17th 3 

Panama August  20th  to  27th 3 

Cuba,  Batabano August  i8th  to  25th 

Havana. . .    August  15th  to  20th 

Mexico,  (-ity  of  Mexico  .    .  .  August  iqth  to  26th 

Vera  Cruz August  19th  to  September  rst 

West  Africa,  Dakar August  15th 14 

St.  Louis August  isth 34 

Cholera. 

India,  Calcutta July  28th  to  August  4th 

Madras July  27th  to  August  3d 

Japan,  Yokohama July  23th  to  August  4th 1 


Plague. 

China,  Amoy July  7th  to  28th 

Hong-Kong July  i4^h  ^^  28th 

India,  Calcutta July  28th  to  ,\ugust  4th 

Japan,  Formosa June  ist  to  July  z^ith 167 

Philippines,  .Manila Ju'y  ^oih  to  17th 

Straitit    Settlements,    Singa- 

apore July  ^4^^  to  aist 


4' 

■35 


the  air  of  rooms.  One  of  his  principal  results  is  that 
gas,  either  as  a  heating  or  lighting  agent,  should  be 
used  as  little  as  possible  if  the  air  of  the  room  is  to 
be  kept  pure.  Taking  as  the  standard  of  purity  an 
atmosphere  containing  not  more  than  thirteen  parts  of 
carbonic  acid  in  10,000,  the  only  combination  for 
lighting  and  heating  an  ordinary  room  on  an  average 
winter  day  was  found  to  be  that  of  a  coal  fire  and 
electric  light.  This-  did  not  raise  the  carbonic  acid 
to  more  than  12  parts,  whereas  a  coal-fire  with  gas 
speedily  ran  up  the  average  to  27  parts.  A  gas  cook- 
ing-stove, even  though  provided  with  a  fiue  lead- 
ing into  the  chimney,  increased  the  carbonic  acid 
up  to  40  parts  per  1,000,  and  while  the  burners  on  the 
top  were  in  use  up  to  84  parts.  What  must  the  condi- 
tion of  the  atmosphere  be  when,  as  is  often  the  case, 
there  is  no  flue?  The  humidity  of  the  air  is  also  re- 
duced by  gas  fires.  One  noticeable  point  in  the 
pamphlet  deserves  the  attention  of  those  who  in  car- 
rying out  the  ordinary  quantitative  examination  for 
carbonic  acid  take  the  most  elaborate  precautions 
against  possible  errors  in  experiment.  Mr.  Jones 
declares  that  he  never  quite  succeeded  in  obtaining  air 
free  from  moisture  and  carbon  dioxide. — Medical  Mag- 
azine. 


The  Air  of  Rooms. — Mr.  Francis  Jones,  F.C.S.,  of 
the  Manchester  grammar  school,  England,  has  com- 
pleted a  most  useful  piece  of  research  work  on  the 
effects  of  various  methods  of  lighting  and  heating  on 


While  the  Medical  Record  is  pleased  to  receive  all  new  pub- 
lications which  may  be  sent  to  it,  and  an  acknowledgment  will  be 
promptly  made  of  their  receipt  under  this  heading,  it  must  be  with 
the  distinct  understanding  that  its  necessities  are  such  that  it  can- 
not be  considered  under  obligation  to  notice  or  review  any  publica- 
tion received  by  it  which  in  the  Judgment  0/ its  editor  will  not  be 
of  interest  to  its  readers. 

International  Clinics.  By  Henry  W.  Cattell,  M.D. 
Vol.  II.  8vo,  2q5  pages.  Illustrated.  J.  II.  Lippincott  Com- 
pany, Philadelphia. 

Braithwaite's  Retrospect  of  Medicine.  Vol.  CXXI. 
l2mo,  447  pages.      Illustrated.     Simpson  cS:  Co.,  London. 

The  Kansas  University  Quarterly.  Vol.  IX.  8vo,  100 
pages.  Illustrated.  Published  by  the  University,  Lawrence, 
Kan.      Price,  50  cents. 

Annual  Report  of  the  Health  of  the  Imperial  Navy 
FOR  1897.     Svo,  126  pages.      Tokyo,   1S9S. 

The  Medical  Directory  of  New  York.  New  Jersey, 
and  Connecticut.  New  York  State  Medical  Association, 
Vol.  II.      i2rao,  894  pages. 

Practical  Urinalysis  and  Urinary  IJiaonosis.  By 
Charles  \V.  Purdy.  Svo,  392  pages.  Illustrated.  F.  A. 
Davis  Company,  New  York. 

Medical  Diseases  of  Infancy  and  Childhooi).  By 
Dawson  Williams,  M.D.  Svo.  542  pages.  Lea  Brothers  & 
Co.,  Philadelphia. 

A  Manual  of  Pathology.  By  \V.  M.  Late  Coplin,  M.D. 
8vo,  846  pages.  Illustrated.  P.  Blakiston's  Son  &Co.,  Phila- 
delphia. 

Transactions  of  the  Southern  Surgical  and  Gvn^xo- 
LOGICAL  Association.     Svo,  394  pages.     Illustrated. 

Medical  Diagnosis  with  Special  Reference  to  Practical 
Medicine.  By  J.  M.  Da  Costa,  M.D.  8vo.  966  pages.  Illus- 
trated.    J.  B.  Lippincott  Company,  Philadelphia. 

The  Water  Supply  of  the  City  of  New  York.  By  the 
Merchants'  .Association  of  New  York.      Svo,  627  pages. 

The  Law  in  its  Relation  to  Physicians.  By  Arthur  N. 
Taylor.      l2mo,  550  pages.      D.  Appleton  &  Co.,  New  York. 

Air,  Water,  and  Food,  from  a  Sanitary  Standpoint. 
By  Kllen  H.  Richards  and  A.  G.  Woodman.  Svo,  226  pages. 
Illustrated.      John  Wiley  &  Sons,  New  York. 

Mortality  Records  of  the  Mutual  Life  Insurance 
Company.  By  Elias  J.  Marsh  and  Granville  M.  White,  M.D. 
4to,  24  5  pages. 


Medical  Record 

A    Weekly  youmal  of  Medicine  and  Surgery 


Vol.  58,  No.  12. 
Whole  No.  1559. 


N-\T  c  $5.00  Per  Annum. 

Ew  York,   September  22,    1900.    sfngie  Copies,  loc. 


©rioiuaX  Articles. 

THE  PHKLPS  OPKRATION  FOR  HERNTA 
AND  MKTHOD  UF  CLOSURE  OF  ABDOMI- 
NAL   WOUNDS." 

liY    A.    M.     rilEI.PS,    A.M.,    M.D., 

NEW    VOKK, 

IRESIDENT  OF  THE  .NEW  YORK*  STATE  MEDICAL  SOCIETV  ;  TRESIDENT  np 
THE  AMEKICA.N  OKTHOP/KDIC  ASSOCIATION  FOR  t8q4  ;  MEMBER  OF  THE 
NEW  yORK  ACADEMY  OF  MEDICINE  AND  THE  NEW  YORK  COUNTY  MEDI- 
CAL SOCIETY;  VISITING  SURGEON  TO  THE  NEW  YORK  CITY  HOSFITAL  ; 
PROFESSOR  OF  ORTHOP.KD1C  SURGERY  AND  VISITING  ORTHOPEDIC  SUR- 
GEON TO  THE  NE%V  YORK  POST-GRADUATE  SCHOOL  AND  HOSPITAL; 
PROFESSOR  OP  SURGERY  IN  THE  .MEDICAL  DEPARTMENT  OF  THE  UNI- 
VERSITY   OF    VERMONT,    ETC. 

In  1892  I  became  thoroughly  convinced  that  the  rea- 
son why  relapses  occurred  after  operation  for  hernia, 
and  why  hernias  so  frequently  followed  abdominal 
operations,  was  because  the  scar  tissue  stretched  after 
the  operation.  I  was  perfectly  familiar  with  the  fact 
that  the  profession  had  for  more  than  a  hundred  years 
used  silver  wire  in  various  surgical  operations;  that 
it  had  been  used  for  wiring  fractures,  and  had  been 
introduced  to  the  profession  by  J.  Marion  Sims  more 
than  forty  years  ago  in  gynaecological  work,  and  by 
other  operators.  I  also  became  convinced  from  my 
clinical  observations  that  the  reason  why  silver  wire 
used  by  the  method  taught  by  the  great  masters  fre- 
quently gave  disturbances  requiring  its  subsequent  re- 
moval, was  because  it  was  improperly  used. 

These  two  propositions  forced  themselves  upon  my 
mind,  and  led  to  a  very  careful  investigation,  the  re- 
sults of  which  started  important  experimental  work  in 
the  New  York  City  Hospital  in  1892  and  1893.  The 
results  of  that  work  in  hernia  were  reported  to  the 
New  York  Academy  of  Medicine  in  April,  1894,  and 
published  in  the  Neni  York  State  Medical  Jviiriutl  in 
September  of  the  same  year.  Subsequent  to  these 
dates,  I  have  repeatedly  offered  to  this  same  medical 
body,  and  also  to  the  New  York  State  Medical  So- 
ciety, communications  upon  the  subject. 

Since  1892,1  have  operated  upon  two  hundred  and 
si.xteen  cases  of  hernia;  forty-six  were  relapsed  Bas- 
sinis,  and  fifty-one  from  other  operations,  chiefly  that 
of  McBurney,  and  all  abdominal  wounds  I  have  closed 
with  silver  wire,  and  fortified  after  a  method  which  is 
original  so  far  as  I  know,  after  looking  up  the  litera- 
ture upon  the  subject. 

It  is  a  well-known  clinical  fact  that  scar  tissue  will 
stretch,  and  it  is  immaterial  whether  the  wound  unites 
by  primary  union  or  not;  a  certain  amount  of  scar 
tissue  must  be  the  result,  and  the  stretching  of  this 
leads  to  the  hernias  following  abdominal  work.  I'o 
obviate  this,  I  introduce  a  continued  suture  of  fine 
silver  wire  which  becomes  encysted,  and  remains  so 
during  the  natural  life  of  the  patient.  In  extremely 
thin  abdominal  walls,  in  addition  to  this,  a  mattress 
of  loops  of  silver  wire  is  introduced  over  the  trans- 
versalis  fascia,  and  underneath  all  of  the  muscular 
coats  of  the  abdominal  walls.  This  wire  becomes 
encysted  in  the  granulation  tissue,  preventing  subse- 

'  Read  before  the  Surgical  Section  of  the  Thirteenth  Inter- 
national Congress  at  Paris,  August,  1900. 


quent  stretching.  So  far  as  I  know,  silver  wire  has 
always  been  introduced  into  tissues  as  an  interrupted 
suture,  the  fear  being  that  it  might  cause  disturbances 
and  could  be  easily  removed.  If  this  wire  is  sewn 
into  the  tissue  with  continued  suture,  it  always  be- 
comes encysted  and  causes  no  disturbance  whatever. 

Now,  in  hernia  operations,  I  take  advantage  of  this 
idea,  and  fortify  the  inguinal  canal  with  a  mattress 
of  wire,  stitching  the  muscular  layers  over  it,  entirely 
obliterating  tlie  inguinal  canal,  bringing  the  cord  out 
underneath  the  skin,  and  cutting  the  aponeurosis  of 
the  muscles  so  as  to  prevent  strangulation  of  the  cord. 


t  iG.  I. — Mouth  of  the  Sac  after  it  has  been  Cut  Away.  A  continued  suture 
of  wire  closes  it  precisely  as  is  done  in  any  laparotomy.  The  cord  is  re- 
tracted with  gauze. 

Relapses  in  oblique  hernia  take  place  at  the  inter- 
nal abdominal  ring,  or,  in  otiier  forms  of  hernia,  at 
the  external.  One  of  the  very  serious  mistakes  made 
by  all  operators  is  the  ligation  of  the  sac.  Frequent- 
ly— and  I  have  observed  it  post  mortem — after  a  liga- 
tion of  the  sac,  retraction  takes  place  of  the  perito- 
neum and  transversalis  fascia,  leaving  a  large 
surface,  varying  from  three-fourths  of  an  inch  to  two 
inches  in  diameter,  which  is  not  covered  by  the  fibrous 
tissue  and  natural  support  of  the  abdominal  walls. 
Then,  to  obviate  this  accident,  I  cut  off  the  sac  and 
retract  it  from  the  operation  precisely  as  I  would  from 
any  other  abdominal  operation,  stitching  up  the  peri- 
toneum and  transversalis  fascia  with  a  continued  su- 
ture of  silver  wire,  as  seen  in  Figs,  i,  2,  3,  and  4. 
Over  the  transversalis  fascia  and  peritoneum  a 
mattress  of  fine  silver  wire  is  placed  (Fig.  2),  and  the 
deep  layer  of  muscles  stitched  over  it  with  continued 
suture  of  silver  wire.  A  small  glass  drainage  tube  is 
inserted  down  to  the  wire  mattress  for  the  purpose  of 
drainage.     If  a  large  hernial  opening  is  to  be  stopped, 


442 


MEDICAL    RECORD. 


[September  22,  1900 


and  tliere  is  very  much  attenuation  of  the  muscular 
coats  of  the  abdominal  walls,  a  second  mattress  of 
wire  is  placed  between  the  layers  of  muscles  and  a 


Fig.  a. — Shows  the  stitching  together  of  the  deep  layer  of  muscles  from  the 
spine  of  the  pubis  to  one  inch  beyond  the  internal  abdominal  rin^.  I'he 
mattress  of  silver  wire,  the  finest  made,  is  looped  or  knotted  and  finally 
matted  totrether  and  placed  over  the  transversalis  fascia,  covering  the  entire 
inguinal  canal  to  one  inch  external  to  the  internal  abdominal  ring.  It  can 
be  seen  in  the  figure  partially  covered  by  the  muscles  which  are  beini,' 
stitched  over  it.  The  cord  is  retracted  with  gauze.  This  is  the  second 
step  of  the  operation. 


more  danger  from  the  operation  than  from  any  other. 
There  is  no  danger  from  any  irritation  of  the  wire. 
The  mortality  in  my  series  of  cases  is  nil,  and  the 
possibilities  of  relapse  are  nothing.  For  these  rea- 
sons, if  for  no  other,  the  method  should  commend  it- 
self to  every  operator.  The  method  has  been  ac- 
cepted by  Professor  Schede,  of  Bonn,  Germany,  and 
by  other  distinguished  surgeons  of  that  country.  It 
has  been  accepted  by  many  of  the  leading  surgeons  of 
the  I'nited  States.  And,  speaking  personally,  I  can- 
not too  strongly  urge  the  profession  to  adopt  this  pro- 
cedure in  preference  to  all  others. 

In  my  original  article,  I  devoted  much  space  to  the 
treatment  of  tlie  sac,  believing  this  was  one  of  the  fer- 
tile sources  of  relapse  in  hernia,  but  I  am  now  fully 
convinced  that  the  sac  should  be  dealt  with  by  radical 
methods,  and  a  hernia  operation  should  be  converted 
into  a  small  laparotomy  to  secure  the  best  possible 
chances  of  success.  As  a  matter  of  fact,  when  we  ex- 
amine into  the  etiology  of  oblique  inguinal  hernia,  we 
must  become  thoroughly  convinced  from  the  time  of 
the  descent  of  the  testicle  behind  the  kidney  during 
fcetal  life  to  its  future  repository  in  the  scrotum,  that, 
to  a  certain  extent,  the  abdominal  walls  in  this  part 
of  the  anatomy  must  necesarily  be  weakened. 

And  then  again,  the  distention  which  follows  hernia 
still  further  absorbs  the  muscular  and  fibrous  tissue, 
resulting  in  a  great  loss  of  substance.  And  the  only 
way  to  secure  a  strong  resisting  point  at  this  weak- 
ened portion  of  the  abdominal  walls  is  by  reproducing 
a  large  amount  of  inflammatory  material,  and  prevent- 
ing its  stretching  by  a  material  that  will  not  absorb, 
and  so  elastic  that  it  will  bend  with  every  motion  of 
the  body. 

Silver  wire  answers  this  purpose.  The  use  of  cat- 
gut, silkworm  gut,  kangaroo  tendon,  or  any  other  ma- 


superficial  layer  of  muscles,  together  with  the  aponeu- 
rosis stitched  over  it  (Fig.  2).  The  cord  is  brought 
out  from  the  inguinal  canal  externally  and  inferior  to 
the  internal  abdominal  ring.  A  notch  made  by  cut- 
ting with  scissors  in  the  aponeurosis  of  the  muscles 
prevents  strangulation,  and  the  cord  lies  directly  un- 
der the  skin  in  its  course  to  the  scrotum  (Fig.  3). 

My  paper,  presented  to  the  New  York  Academy  of 
Medicine  in  1894,  giving  the  results  of  my  work  from 
1892,  was  a  preliminary  one.  Before  taking  up  all  of 
the  steps  herein  enumerated,  and  a  great  many  others 
which  experience  lias  demonstrated  to  me  are  entirely 
useless,  for  the  reason  that  I  did  not  wish  to  present 
to  the  profession  an  incomplete  method  of  operating 
on  hernias,  I  have  deferred  presenting  anything  on 
this  subject  until  more  mature  observation  and  experi- 
ence in  hundreds  of  cases  might  verify  any  statement 
which  I  might  make. 

I  am  now  prepared  to  urge  the  profession  to  adopt 
the  operation  which  I  here  present  for  hernia  in  any 
form,  and  for  the  purpose  of  preventing  relapses  in 
any  abdominal  operation  of  any  name  or  nature.  The 
operations  upon  the  relapsed  Bassinis  which  I  have 
performed  are  of  very  great  interest,  or  should  be,  to 
the  profession.  The  primary  operations  had  been 
performed  in  our  best  hospitals,  and  also  in  private 
practice,  by  the  best  surgeons  that  the  United  States 
of  America  can  furnish,  and  I  predict  that  the  day  is 
not  far  distant  when  Bassini's  operation,  and  all  others 
except  the  one  that  I  here  propose,  will  be  abandoned 
by  every  operator. 

It  is  very  important  to  the  surgeon  in  private  prac- 
tice to  know  that  he  can  state  truthfully  to  his  patient 
that  he  can  operate,  and  guarantee  that  there  will  not 
be  a  relapse.  The  operation  which  I  here  propose 
places  the  surgeon  exactly  in  that  position.  I  know  of 
no  other  operation  for  hernia  that  safeguards  the  opera- 
tor against  the  possibilities  of  relapse.     There  is  no 


~1 


1             '  jf     : 

Aji 

P/^^^^-  ,^j 

/rd/ 

^ 

r-'.^..  '  '  '■^:\ 

'  v-^ 

^ 

Zji^-'-'i 

i^ 

p! 

mF-M 

JKi,  f ' 

f                   gSW 

'^       ' 

%!'      ■ 

'%        \ 

JU 

m^  < 

^* 

k^          1 

Fig.  3.— Superficial   Layer  of  Muscles  and  Aponeurosis  Stitched  with  a  con- 
tinued Suture  of  Wire.     The  cord  is  retracted  and  the  aponeurosis  notched. 


terial  which  will  be  absorbed,  defeats  the  very  object 
at  which  we  aim.  The  use  of  silk  is  positively  con- 
traindicated,  on  account  of  the  dangers  of  infection. 
Silver  wire,  taken  from  pure  carbolic  acid,  heated  to  a 
red  heat  with  an  alcoliol  lamp  before  its  introduction 
into  the  wound,  furnishes  us  a  material  which  is 
thoroughly  sterilized  and  cannot  possibly  produce  ir- 
ritation, and  all  the  dangers  of  infection  are  avoided. 


September  22,  1900] 


MEDICAL    RECORD. 


443 


In  two  hundred  and  sixteen  operations,  I  have  had 
infection  at  the  seat  of  the  wire  mattress  sixteen 
times. 

The  question  naturally  arises  in  the  mind  of  the 
operator:  "What  will  you  do  when  infection  takuh 
place  in  this  mattress  of  wire?     Will  you  remove  it?  "' 


Fig. 


-Shows  the  wound   closed  linally  with  a  continuous  suture  of  catgut 
which  includes  only  the  skin 


Most  certainly  not.  Lay  the  wound  open  with  a  fine 
curette,  curette  out  all  of  the  infected  portion,  and  fill 
the  wound  with  pure  carbolic  acid,  afterward  wash  it 
out  with  alcohol,  which  is  a  perfect  antidote  to  the 
corrosive  effects  of  carbolic  acid,  and  allow  tlie  wound 
to  heal  by  granulation.  In  every  one  of  the  cases  so 
treated,  not  one  single  case  has  relapsed,  and  that  por- 
tion of  the  abdominal  walls  is  the  strongest  part. 

Cases  with  sinuses  have  been  discharged  from  the 
City  Hospital  by  the  incoming  staff  before  the  sinuses 
were  closed.  .Such  sinuses  should  have  been  opened 
and  treated  before  they  left  the  hospital.  When  the 
patients  were  admitted  to  other  hospitals  the  surgeon 


Fig.  s  is  the  entire  inguinal  canal  removed  from  a  patient  who  died  two  and 
one-half  yearsafler  the  operation  for  hernia,  from  a  hysterectomy.  It  shows 
the  wire  perfectly  encysted  and  the  mass  of  new  tissue  held  together  with 
the  wire,  which  prevented  stretching.  The  inguinal  canal  was  completely 
obliterated  and  was  the  thickest  and  strongest  part  of  the  abdominal  walls 
No  inconvenience  was  ever  felt  from  the  wire  by  the  patient. 

has  removed  the  wire  instead  of  following  the  plan 
which  I  always  resort  to,  mentioned  above — leaving 
the  wire  in.  The  results  in  the  infected  cases  are 
equally  as  good  as  in  the  non-infected. 

Another  application  of  this  method  of  using  silver 
wire   is  in   large  cranial  wounds  with   much  loss  of 


bony  structure,  and  also  in  the  restoration  of  ruptured 
and  lacerated  muscles.  The  opening  in  the  skull  I 
close  by  stitching  across  it  fine  wire,  including  the 
aponeurosis  and  periosteum  on  the  other  side  of  the 
wound.  The  stitching  in  the  second  row  is  at  right 
angles  to  the  first  across  the  wound;  this  forms  a  net- 
work which  prevents  the  cicatricial  tissue  from  con- 
tracting and  making  pressure  upon  the  brain.  This 
method  also  prevents  hernia  cerebri.  In  rupture  of 
muscles  or  in  loss  of  muscular  tissue  from  injury,  I 
stitch  the  muscle  together  with  a  continued  suture,  and 
when  there  is  loss  of  muscular  substance  the  wire  is 
stretched  across  from  end  to  end  of  the  muscle,  care 
being  taken  that  the  wire  shall  be  in  the  centre  of  the 
muscle  with  no  ends  projecting  when  reproduction  has 
taken  place.  Such  muscles  are  as  strong  after  repro- 
duction as  before  the  injury,  and  the  scar  tissue  be- 
tween the  end  of  ruptured  muscles — for  instance,  the 
quadriceps  extensor  femoris  or  the  biceps  flexor  cu- 
biti — will  not  stretch  because  the  encysted  wire  will 
prevent  it.  There  are  many  other  instances  in  which 
wire  can  be  used  in  our  surgical  procedures,  and  when 
introduced  as  I  have  already  suggested  it  will  never 
occasion  disturbance.  Suppuration  is  never  produced 
by  the  wire  unless  the  germs  of  infection  are  intro- 
duced with  it;  then  when  suppuration  does  occur  it  is 
always  an  accident  which  might  have  been  avoided. 


TO  WHAT  EXTENT  DOES  "RHEUMATIC 
AND  GOUTY  DIATHESIS"  ENTER  INTO 
TRAUMATIC  Jt)INTS  (SPR.AINS  AND 
BRUISES),  SEPTIC  AND  GONORRHtEAL 
JOINTS,  ACUTE  ARTICULAR  RHEUMA- 
TISM, NEUROPATHIC  JOINTS.  ARTHRITIS 
DEFORMANS  (OSTEOID,  RHEUMATOID), 
AS  AN  ETIOLOGICAL  FACTOR?  WHAT  IS 
THE  SCIENTIFIC  BASIS  FOR  SUCH  A 
TERM  ?  ' 

By   WII,LI.\M    henry    PORTER,    M.D., 

PROFESSOR  OF  GENERAL  MEDICINE  AND  rATHOLOOV  AT  THE  NEW  VOBK 
POST-GRADl'ATE  M  BDICAL  SCHOOL  AND  HOSPITAL;  ATTENDING  PHYSICIAN 
AT   THE    NEW    VOKK    POST-GRADUATE    HOSPITAL,    ETC. 

Of  the  six  subdivisions  propounded  for  discussion 
under  the  common  subject,  "  Diseases  of  the  Joints 
Often  Diagnosed  as  Rheumatic  or  Complicated  with 
Rheumatism."  the  one  given  above  was  assigned  to 
me  by  your  committee.  The  (juestion  is  composed  of 
two  distinct  parts,  the  last  of  which  calls  for  elucida- 
tion before  the  first  can  be  logically  considered. 

Taking  up  first  the  question  as  to  the  scientific  basis 
of  the  two  terms  "rheumatic'"  and  "gouty  diathesis" 
before  we  can  decide  their  true  position  in  connection 
with  scientific  medicine,  we  are  at  once  forced  to  an- 
alyze the  origin  and  literal  meaning  of  these  terms  in 
the  light  of  our  present  chemico-physiological  and 
pathological  knowledge.  Take,  for  instance,  the  term 
"  diathesis  '" ;  what  is  its  true  significance  in  relation  to 
the  chemistry  of  the  human  economy?  For  years  the 
term  "  diathesis  "  has  been  used  to  indicate  that  some- 
thing has  been  handed  down  from  generation  to  gen- 
eration, but  what  that  something  is  has  never  been 
made  clear  to  the  science  of  medicine.  Taking  the 
literal  meaning  of  the  word  diathesis  from  its  Greek 
origin  and  applying  it  to  the  chemistry  of  the  body,  it 
must  indicate  sim]ily  and  only  that  there  is  a  tendency 
on  the  part  of  the  animal  economy  to  arrange  the 
chemical  phenomena  of  the  system  in  certain  and  defi- 
nite directions.  This,  however,  does  not  justify  the 
supposition  that  the  individual  is  of  necessity  born  to 
develop  finally  those  symptoms  recognized  as  consti- 
tuting the  conditions  so  long  known  under  the  terms 

'  Read  before  the  Massachusetts  Medical  Society,  Boston,  June 
13,  1900. 


444 


MEDICAL    RECORD. 


[September  22,  igoo 


"gout"  and  "rheumatism."  Therefore,  the  term 
"diatliesis"  as  it  is  commonly  applied  has  neither 
fact  nor  foundation  to  rest  upon;  for  all  the  evidence 
at  our  disposal  tends  to  prove  that  all  diseased  condi- 
tions, with  the  possible  exception  of  syphilis,  are  ac- 
quired after  birth.  All  are  abnormal  chemical  states 
of  the  system  which  can  be  either  fed  into  or  fed  out 
of  the  human  race,  so  to  speak.  This,  however,  is  as- 
suming a  very  high  and  almost  theoretically  ideal 
position;  nevertheless,  it  is  one  that  can  be  practi- 
cally accomplished,  provided  we  can  succeed  in  attain- 
ing the  highest  perfection  in  the  hygienic  and  dietetic 
conditions  influencing  animal  life.  Thus  we  find, 
without  going  further  into  exhaustive  details,  that 
there  is  no  real  scientific  basis  for  the  term  "  diathesis  " 
as  it  has  been  commonly  used  in  the  past.  In  fact,  it 
would  be  better  if  this  term  were  dropped  entirely 
from  medical  literature. 

In  like  manner,  the  terms  "gout  "and  "rheuma- 
tism," when  viewed  from  a  purely  scientific  basis,  are 
almost  as  meaningless  as  is  diathesis.  Naturally,  with 
this  statement  before  us,  the  first  question  that  arises 
is,  VVhat  is  this  so-called  "gout"  and  "rheumatism"' 
that  we  hear  and  talk  so  much  about?  Turning  back 
to  the  derivation  of  the  word  "gout  "  we  find  that  it 
comes  from  the  Latin  \vord^'«//(7,  meaning  a  drop.  Ac- 
cording to  Dunglison's  "  Medical  Dictionary  '" :  "  Gout 
received  its  name  from  the  French  j^out/i:,  drop,  because 
believed  to  be  produced  by  a  liquid  which  is  distilled 
drop  by  drop  on  the  diseased  part.  The  name  was 
first  used  about  1270."  Hence,  gout  is  the  drop  dis- 
ease. This,  however,  gives  no  insight  into  the  etio- 
logical factors  entering  into  the  production  of  the 
pathological  conditions  so  long  honored  by  this  name. 
Nor  does  it  give  any  suggestion  as  to  the  disturbances 
of  the  chemistry  of  the  body,  which  ultimately  bring 
about  the  pathological  changes  and  symptoms  so  well 
recognized  under  the  name  "gout."  We  might  possi- 
bly strain  a  point  and  say,  in  a  similar  manner  to 
what  lias  been  said  in  the  past,  that  the  term  "gout"  was 
coined  to  indicate  the  dropping  of  the  uric-acid  rad- 
ical into  the  protoplasmic  structures  of  the  various  tis- 
sues of  the  body  as  the  result  of  the  final  and  vicarious 
oxidation  of  the  proteid  molecule  in  the  tissues  already 
made  pathological  by  the  prolonged  disturbances  in 
the  chemical  activities  of  the  animal  economy,  vica- 
rious oxidation  being  synonymous  with  the  term  "dis- 
tillation "  of  the  ancient  writers,  referred  to  in  Dungli- 
son's definition  of  the  disease,  .\ccepting  this  more 
modern  interpretation,  there  might  be  some  justifica- 
tion for  considering  the  term  "gout"  as  a  word  based 
upon  our  present  scientific  data.  On  the  other  hand, 
as  this  vicarious  oxidation  of  the  proteid  molecule  in 
the  already  pathological  structures  of  the  body  is  but 
one  little  factor  in  the  great  and  complex  chemical 
problem  constituting  the  condition  so  long  known  by 
the  name  "gout,"  there  is  no  logical  reason  for  regard- 
ing the  term  as  one  resting  upon  a  clearly  elucidated 
and  perfectly  scientific  basis.  F"urtherniore,  the  con- 
dition known  as  gout,  as  commonly  defined,  is  said  to 
be  one  in  which  there  is  a  production  of  uric  acid  in 
the  blood,  a  condition,  however,  that  never  occurs,  be- 
cause chemistry  forbids  tlie  separate  presence  of  an 
active  acid  in  a  strongly  alkaline  solution  without  the 
formation  of  a  salt  of  that  acid;  at  least  it  cannot  oc- 
cur unless  all  chemical  laws  are  suspended  in  connec- 
tion with  the  blood.  So  far  as  my  observation  and 
researches  have  carried  me,  there  is  nothing  to  war- 
rant the  assumption  that  the  well-known  laws  of  chem- 
istry have  been  suspended,  so  that  uric  acid  exists  as 
such  in  the  blood  and  does  not  result  in  the  formation 
of  a  salt.  Furthermore,  it  can  be  asserted  tliat  uric  acid 
does  not  exist  in  the  blood,  for  the  reason  that  the  salts 
of  uric  acid  have  never  been  found  there,  as  must  have 
been  the  case  had  uric  acid  entered  the  blood  stream. 


The  definition  above  mentioned  further  affirms  that 
the  phenomena  recognized  under  the  term  "gout"  are 
due  to  the  non-elimination  of  the  uric  acid  from  the 
blood  stream,  and  its  subsequent  discharge  from  the 
blood  as  uric  acid  into  the  protoplasm  of  tlie  various 
structures  of  the  body,  by  preference  into  the  cartilage 
cells  of  certain  joints.  Jiut  this  explanation  does  not 
tell  why  the  acid  refuses  to  attack  the  sodium  and  cal- 
cium compounds  in  the  blood  stream,  but  seizes  upon 
them  with  intense  activity  as  soon  as  it  is  discharged 
into  the  semi-solid  protoplasmic  structures.  Thu^  we 
find  that  the  whole  theory  of  gout  is  developed  largely 
without  any  reliable  scientific  foundation,  at  least  so 
far  as  the  name  is  concerned,  and  it  also  disregards, 
almost  from  beginning  to  end,  the  well-known  and  in- 
Hexible  laws  of  chemistry,  as  we  understand  them  to- 
day. The  only  indisputable  fact  in  connection  with 
the  whole  theory  of  gout,  as  it  is  commonly  given,  is 
the  final  deposition  of  the  insoluble  salts  of  calcium, 
together  with  some  urate  of  sodium  crystals,  in  the 
various  structures  of  the  body.  Therefore,  it  can  very 
justly  be  stated  that  there  is  no  well-grounded  scien- 
tific basis  for  the  term  "gouty  diathesis.'" 

VVhen  we  come  to  the  term  "  rheumatism  '"  or  "  rheu- 
matic diathesis,'"  the  mystery,  so  far  as  the  derivation 
of  the  name  is  concerned,  is  greater  even  than  is  the 
case  with  gout.  There  is  absolutely  no  scientific  basis 
for  the  term.  Yet  under  the  term  "  rheumatism "  is 
included  a  very  great  complexity  of  disturbed  physio- 
logical phenomena.  If  we  attempt  to  secure  any  infor- 
mation through  the  derivation  of  the  word,  we  are  led 
still  farther  away  from  any  scientific  basis  for  it.  Tak- 
ing its  Greek  origin,  lUuiuiTinnn^^  from  //"i'Vc/.  or  /■/(«, 
and  translating  it  literally  "  rheumatism,'"  would  mean 
a  fluxion,  or  flow,  but  of  what  or  in  what  direction  we 
are  in  total  ignorance.  The  more  modern  definitions 
are  almost  as  vague  and  uncertain  as  those  based  upon 
the  old  and  long  since  discarded  humoral  theory  of 
rheumatism.  If  there  is  no  scientific  basis  for  these 
terms,  it  is  difficult  to  see  how  their  relation  to  the  topics 
under  discussion  can  be  elucidated  or  explained  from 
a  scientific  standpoint.  On  the  other  hand,  the  nat- 
ural inference  is  that  botii  "rheumatism'"  and  "gout" 
are,  in  a  measure  at  least,  connected  with  some  of  these 
joint  affections  under  discussion.  Before  we  can  dis- 
cuss any  etiological  relationship  between  "  rheumatic  " 
and  "  gouty"  conditions  and  the  joint  affections  enumer- 
ated, we  must  first  have  some  fixed  and  definite  con- 
ception of  the  chemico-pathological  phenomena  that 
are  to  be  included  under  these  terms.  The  weight  of 
evidence,  however,  both  chemico-physiological  and 
clinical,  points  clearly  to  defective  oxidation  on  the 
part  of  the  system  as  the  chief  predisposing  factor  in 
bringing  about  these  two  dissimilar  conditions. 

In  tlie  majority  of  instances  the  ciiief  cause  for  a 
suboxidation  state  of  the  system  is  the  ingestion  of 
more  oxidizable  food  than  there  is  oxygen  absorbed 
through  the  lungs  to  reduce  completely  the  proteid 
constituents  to  the  normal  end-products.  In  other  in- 
stances, diminution  in  the  food  supply,  together  with 
that  of  a  poor  quality,  may  so  deteriorate  the  nutritive 
activity  of  the  system,  tiiat  a  pronounced  anaemia  is 
produced,  thus  cutting  down  the  intaking  capacity  of 
the  animal  economy  for  oxygen  to  such  an  extent  that 
there  is  not  sufficient  oxygen  absorbed  tiirough  the 
lungs  to  oxidize  perfectly  the  little  proteid  that  is 
taken  in  the  limited  supply  of  food.  Hence,  too  lit- 
tle or  too  much  food  may  act  as  determining  factors  in 
producing  an  imperfect  oxidation  of  tlie  jiroteid  con- 
stituents. It  matters  little  whether  the  proteid  be  de- 
rived from  the  vegetable  or  the  animal  kingdom.  Its 
imperfect  oxidation,  and  the  toxic  ]3roducts  developed 
in  consequence  of  incomplete  oxidation  transmutation, 
are  the  factors  which  excite  the  symptoms. 

Attributing  these  pathological  conditions  to  a  sub- 


I 


September  22,  1900] 


MEDICAL    RECORD. 


445 


oxidation  state  of  the  system  does  not  fully  explain 
why  in  the  one  instance  the  result  is  "■  rheumatism  " 
and  in  the  other  "gout."  This  was  at  one  time  at- 
tempted by  assuming  from  the  general  clinical  history 
that  those  individuals  who  partook  freely  of  starches 
and  saccharine  substances  developed  "rheumatism," 
while  those  who  lived  largely  upon  an  animal  class  of 
foods  and  used  alcoholic  beverages  freely  as  a  rule 
developed  the  condition  called  "gout."  This  was 
during  the  period  in  which  lactic  acid  was  supposed 
to  be  developed  from  the  incomplete  oxidation  reduc- 
tion of  the  saccharine  elements,  and  when  uric  acid 
was  supposed  to  be  the  product  of  an  animal  diet  only. 
That  both  uric  acid  and  lactic  acid  do  result  from  the 
imperfect  utilization  of  the  proteid  constituents  de- 
rived from  the  vegetable  as  well  as  from  the  animal 
kingdom  is  a  well-established  fact.  With  this  under- 
standing of  the  oxidation  problem  it  is  easy  to  compre- 
hend how  both  "rheumatism  "  and  "gout"  can  be  de- 
veloped from  an  excessive  diet  of  either  vegetable  or 
animal  food.  It  does  not  explain  fully,  however,  why 
a  liberal  vegetable  diet  is  more  likely  to  produce  the 
condition  called  "  rheumatism, ""  and  the  liberal  ani- 
mal diet  is  more  likely  to  produce  the  condition  called 
"gout."  At  the  same  time  it  must  be  clear  to  every 
one  who  has  observed  many  cases  clinically  that  cer- 
tain kinds  of  diet  have  a  decided  influence  in  deter- 
mining the  nature  of  the  suboxidation  processes.  It 
should  further  be  remembered  that  none  of  these  in- 
complete end  products  found  in  the  excreta  is  to  be 
considered  as  constituting  the  disease  any  more  than 
urea  constitutes  normal  nutrition.  They  should  be  re- 
garded only  in  the  light  of  results,  or  indicators  by 
which  the  different  types  of  suboxidation  can  be  rec- 
ognized and  differentiated. 

The  development  of  the  so-called  rheumatic  condi- 
tion cannot  be  explained  as  it  was  at  one  time  by  as- 
suming that  lactic  acid  is  the  chief  etiological  factor 
in  producing  the  disease,  and  that  this  so-cailed  lactic 
acid  or  rheumatic  condition  is  due  to  the  imperfect 
oxidation  of  the  starches  and  sugar  alone,  while  the 
gouty  condition  is  due  to  imperfect  oxidation  of  the 
proteid  constituents.  Assuming  that  such  a  condition 
is  true  from  a  chemical  standpoint,  it  does  not  explain 
the  development  of  the  rheumatic  condition  so  called 
in  those  who  live  almost  exclusively  upon  an  animal 
diet,  in  which  there  is  no  excess  of  the  starch  and  sugar 
to  undergo  imperfect  oxidation  reduction.  Therefore, 
such  a  theory  is  absolutely  untenable  both  from  the 
chemico-physiological  and  clinical  data  at  our  com- 
mand. Hence,  we  are  forced  to  the  assumption  that 
in  the  so-called  lactic  or  rheumatic  condition,  as  in 
the  so-called  uric-acid  or  gouty  state  of  the  system,  all 
the  toxic  products  found  within  the  system  and  all  the 
abnormal,  products  found  in  the  excreta  are  due  to  the 
imperfect  oxidation  reduction,  or  faulty  isomeric  trans- 
formation of  the  proteid  constituents  contained  in  the 
animal  economy.  This  fact  accepted,  our  theories  can 
easily  be  made  to  fit  all  the  clinical  facts  met  with. 
Now,  we  can  readily  understand  how  it  is  that  over- 
indulgence in  the  starches  and  sugars  is  so  prone  to 
excite  imperfect  oxidation  of  the  proteid  constituents. 
The  starches,  sugars,  and  fats,  all  being  easily  and 
quickly  oxidized  into  their  complete  end  products,  if 
taken  in  inordinate  quantities  will  overtax  the  oxy- 
genating capacity  of  the  system,  and  there  will  not  be 
left  sufficient  oxygen  to  complete  the  more  difficult 
task  of  perfectly  oxidizing  the  proteid  constituents. 
In  this  manner  they  act  as  verypotent  factors  in  bring- 
ing about  the  imperfect  oxidation  of  the  proteid  ele- 
ments. Further  than  this,  their  oxidation  being  dif- 
ferently effected  from  that  of  the  proteids,  it  is  easy  to 
understand  how  their  excessive  utilization  may  have  a 
result  upon  the  system  different  from  that  of  an  exces- 
sive use  of  the  proteid  constituents,  thus,  in  a  measure. 


explaining  why,  in  the  one  instance,  we  are  mora  likely 
to  have  "rheumatism,"  and  in  the  other  the  "gouty" 
condition. 

As  there  seems  to  be  so  much  confusion  in  the 
minds  of  many  in  regard  to  the  true  position  and 
meaning  of  these  imperfect  products  of  proteid  oxida- 
tion, and  especially  in  reference  to  the  most  common 
of  all,  namely,  uric  acid,  it  may  not  be  unprofitable  to 
enter  a  little  more  into  the  detail  of  the  formation  of 
uric  acid  and  its  significance  in  connection  with 
health  and  diseased  conditions.  Uric  acid  is  one  of 
the  substances  by  which  nitrogen  is  eliminated  nor- 
mally from  the  system.  It  is  an  almost  insoluble  and 
very  stable  substance.  It  was  first  separated  from 
human  urine  by  Scheele  in  1776.  It  is  a  dibasic  acid, 
having  two  replaceable  hydrogen  atoms,  one  of  which 
is  easily  substituted  by  sodium,  forming  an  acid  urate, 
or  biurate,  of  sodium.  Both  of  the  replaceable  hydro- 
gen atoms  can  be  substituted  by  sodium,  but,  so  far  as 
is  known,  only  the  acid  salt  is  a  product  of  the  animal 
economy.  This  urate  is  relatively  soluble.  Uric  acid 
is  formed  by  the  oxidation  of  the  proteid  molecule  or 
its  derivatives,  and  is  a  lower  oxidation  product  than 
urea,  in  the  same  manner  that  urea  is  a  lower  oxida- 
tion product  than  ammonia  and  carbon  dioxide  and 
water,  which  are  the  final  products  of  proteid  oxidation, 
chemically  speaking.  Why  urea  is  the  final  oxidation 
product  in  man  instead  of  ammonia,  carbon  dioxide, 
and  water  has  never  been  explained,  further  than  to 
state  that  it  is  according  to  the  original  plan  of  na- 
ture. 

It  has  been  claimed  by  some  that  uric  acid  is  not 
an  oxidation  product,  and  they  base  their  claim  on  the 
fact  that  this  acid  and  its  salts  are  the  normal  and 
complete  excrementitious  products  in  birds,  reptiles, 
etc.,  in  which  animals  the  oxidation  powers  are  said  to 
be  exceedingly  high.  However,  there  is  nothing  to 
prove  the  capacity  of  birds,  reptiles,  etc.,  to  take  in 
o.xygen,  or  of  the  blood  to  distribute  this  oxygen,  and 
of  their  system  to  utilize  it,  and  that  it  is  sufficient  to 
oxidize  all  the  assimilated  hydrocarbons  and  proteid 
compounds  into  their  final  and  complete  products.  At 
any  rate,  to  draw  such  an  inference  is  begging  the 
question.  The  chemical  fact  remains  that  their  ex- 
creta, as  compared  with  those  of  the  higher  order  of 
animals,  are  products  of  a  lower  proteid  oxidation,  just 
as  urea  is  lower  than  the  final  product  ammonia. 
Why  in  the  one  species  the  chemico-physiological  ap- 
paratus of  the  animal  economy  is  so  constructed  that 
uric  acid  and  its  urates  are  the  final  excretory  product, 
while  in  another  it  is  urea,  is  just  as  mysterious  and 
absolutely  unfathomable  as  are  the  phenomena  of  life 
and  death.  In  what  follows  I  shall  endeavor  to  show 
that  in  man  the  production  of  uric  acid  in  quantities 
above  the  normal  is  due  to  a  condition  of  suboxida- 
tion. 

The  two  most  prominent  theories  advanced  to  ex- 
plain the  genesis  of  uric  acid  in  the  system  are:  (i) 
That  it  is  an  oxidation  product  manufactured  in  the 
renal  cells;  (2)  that  it  is  made  in  some  manner  in 
the  liver,  spleen,  etc.,  but  chiefly  in  the  liver.  Min- 
kowski,' Schroder,"  Horbaczewski,'  are  among  the 
more  recent  defenders  of  the  latter  theory,  while  Gar- 
rod'  is  generally  credited  with  the  former.  The  lat- 
ter view  is  the  one  that  has  been  accepted  generally 
and  on  the  following  grounds:  First,  that  uric  acid  is 
found  in  the  blood;  second,  that  in  gout  it  is  found 
in  the  tissues;  third,  that  after  extirpation  of  the  kid- 
neys uric  acid  continues  to  be  formed;  and,  fourth, 
that  at  the   height  of   digestion,  when   the  liver  and 

'  Minkowski:  -Vrch.  e.xp.  Path.  u.  Pharmak..  xxi. 

•  Schroder :  Summar)-  of  his  views  in  Ludwig's  Festschrift, 
I  537.  p.  8q. 

•  Horbaczewski  :  Monatshefte  f.  Chem.,  x.,  624. 

■•  Garrod  :  Lumleian  Lectures.  Lancet,  vol.  i.,  18S3. 


446 


MEDICAL    RECORD. 


[September  22,  1900 


spleen  are  most  active,  uric  acid  is  most  abundant  in 
the  urine.  In  this  connection  it  maybe  remarked  that 
in  all  the  experiments  which  have  been  brought  for- 
ward to  sustain  the  theory  that  uric  acid  is  formed 
outside  the  kidneys,  or  in  the  liver,  there  have  been 
produced  profound  abnormal  or  pathological  states  of 
the  systum.  Therefore  they  should  be  completely  dis- 
carded from  a  physiological  standard,  as  all  deductions 
founded  thereon  are  upon  a  purely  pathological  basis, 
and  not  normal. 

The  claim  that  is  so  commonly  made  that  free  uric 
acid  is  found  in  the  blood  is  not  tenable,  as  we  have 
already  seen;  for,  on  coming  into  close  relation  with 
the  alkali  metals,  salts  of  the  same  are  immediately 
for.'ned.  Therefore,  if  this  nitrogenous  organic  acid 
were  in  the  blood,  it  would  be  in  the  form  of  a  urate 
only,  and,  as  already  stated,  such  a  salt  has  never  been 
found  in  the  blood.  The  statement  that  uric  acid 
does  exist  in  the  blood  is  based  upon  Haycraft's' 
method  for  detecting  uric  acid,  or  upon  others  of  a 
similar  nature;  as  they  all  admit  of  a  possibility  of 
oxidizing  the  proteid  elements,  and  thus  producing 
uric  acid  in  the  process  for  detecting  this  compound, 
they  cannot  be  relied  upon  as  proving  the  existence  of 
uric  acid  in  the  blood.  Some  have  claimed  to  obtain 
good  results  from  this  method.  On  the  other  hand, 
Salkowski'  regards  the  process  as  of  little  value  even 
in  solutions  known  to  contain  uric  acid,  as  the  com- 
position of  the  silver  urate  formed  is  not  constant; 
this  opinion  is  further  supported  by  Gossage." 

On  the  other  hand,  it  has  been,  and  is  still,  dis- 
tinctly affirmed  that  free  uric  acid  and  its  biurate  salts 
do  exist  in  the  blood;  and  the  method  called  upon 
to  explain  the  possible  presence,  in  some  form,  of  uric 
acid  in  the  blood  is  by  the  so-called  ''quadurate" 
(quadriurate)  theory.  The  following  statement  made 
by  Roberts,'  the  author  of  this  theory,  in  his  descrip- 
tion of  his  method  for  obtaining  the  quadriurate,  tends 
to  prove  that  the  quadriurate — if  it  really  has  a  chem- 
ical existence — is  an  accidental  rather  than  a  constant 
product,  for  he  says:  "  To  obtain  a  product  of  uniform 
composition  by  this  process  requires  a  somewhat  nice 
adjustment  of  the  reaction.  If  the  quantity  of  alkaline 
carbonate  added  be  faint,  the  precipitate,  on  cooling,  is 
apt  to  be  contaminated  with  free  uric  acid.  On  the 
other  hand,  if  the  alkaline  carbonate  be  added  too  free- 
ly, and  the  resulting  alkalescence  be  excessive,  the  pre- 
cipitate is  apt  to  be  contaminated  with  biurate.  These 
risks  are  greatly  minimized  by  using  the  alkaline  ace- 
tates instead  of  the  alkaline  carbonates."  From  this 
it  appears  tiiat  Roberts  failed  to  obtain  the  quadriurate 
with  the  regular  uniformity  necessary  to  establish  his 
theory;  in  fact,  the  nice  adjustment  of  the  reagents 
required  for  the  precipitation  of  the  quadriurate  might 
lead  one  to  believe  that  with  this  test  the  precipitate 
was  a  mixture  of  biurate  and  uric  acid  in  quantities 
to  satisfy  the  theoretic  demands  for  the  quadriurate. 

In  Watts' '"  Dictionary  of  Chemistry"  is  the  follow- 
ing: "NaHO  -f  /^  -Aq.  (dried  at  100)  =  crystalline 
powder.  Occurs  as  an  amorphous  urinary  deposit." 
This  statement,  together  with  the  fact  that  the  alleged 
quadriurate  is  an  amorphous  deposit  and  very  unstable, 
makes  it  appear  highly  probable  that  the  biurate  is 
still  the  form  of  urate  most  commonly  found  in  the 
urine.  It  is  not  necessary  to  find  a  more  soluble  form 
of  urate  than  the  acid  urate,  for  it  is  well  known  that 
the  disodic  monohydrogen  phosphate,''  which  is  often 

'  Haycraft :   British  Medical  Journal,  December,  1885. 

'  Sallcowski  :  Zeit.  pliysiol.  Cliem.,  xiv.,  31. 

'Gossage:  Proceedings  of  Royal  Society,  xliv. ,  284. 

■•Roberts:  Proceedings  of  the  Medico-Chirurgical  Society, 
iSqo,  p.  85. 

'Watts:  "  Dictionary  of  Chemistry,"  vol.  iv  ,  p.  83^,  edition 
1884. 

"  liunge  :  "  Te.\t-book  of  Physics  and  I'alliology,"  London, 
1890,  p.  332. 


present  in  the  urine  in  abundance,  will  hold  large  quan- 
tities of  uric  acid  in  solution.  It  is  also  known  that 
the  uric  acid  in  the  urine,  and  in  the  absence  of  any 
newly  added  chemical  agent,  steadily  attacks  the  di- 
sodic monohydrogen  phosphate,  so  that  when  the  acid 
phosphate,  which  will  not  hold  the  uric  acid  in  solu- 
tion, has  replaced  the  neutral  phosphate,  the  uric  acid 
is  precipitated — all  of  which  occurs  naturally  and  with- 
out adding  anything  to  the  urine  as  is  required  for  the 
demonstration  of  the  presence  of  the  quadriurate  ac- 
cording to  Roberts' theory.  The  one  occurs  naturally, 
and  the  other  requires  very  nicely  adjusted  reagents 
for  its  demonstration.  This  method,  which  may  be 
called  the  natural  one,  of  precipitating  uric  acid  in 
urine  which  apparently  contains  no  excess  of  the  acid, 
can  be  artificially  quickened  by  a  very  simple  proced- 
ure. This  is  best  done  by  filling  a  test-tube  with  urine 
and  bringing  the  upper  stratum  to  the  boiling-point; 
then  adding  a  drop  or  two  of  a  four-per-cent.  solution 
of  acetic  acid  and  setting  the  tube  aside  in  a  cool  place. 
At  the  end  of  a  few  hours,  if  there  is  an  abnormal  amount 
of  uric  acid  contained  in  the  sample  and  held  in  solu- 
tion, as  already  described,  the  heat  and  the  acetic  acid 
will  excite  chemical  action  between  the  uric  acid  and 
the  disodic  monohydrogen  phosphate,  with  a  rapid  for- 
mation of  the  monosodic  dihydrogen  phosphate,  thus 
destroying  the  solvent  power  of  the  urine  for  the  uric 
acid.  Now  the  uric  acid  will  rapidly  be  crystallized 
out,  and  the  amount  so  formed,  when  collected  on  a 
filter  and  weighed,  will  give  the  exact  percentage  of 
uric  acid  in  excess  of  the  normal  amount.  In  this 
manner  and  in  a  few  hours  the  exact  quantity  of  uric 
acid  can  be  estimated.  When  the  amount  of  uric  acid 
is  normal  in  the  urine,  no  precipitation  of  the  acid  can 
be  effected  by  this  method.  It  then  requires  the  use 
of  a  considerable  quantity  of  one  of  the  stronger  min- 
eral acids,  sufficient  to  decompose  the  normal  urates, 
and  thus  set  free  the  uric  acid  otherwise  held  in  com- 
bination with  the  sodium,  before  its  presence  is  de- 
monstrated. 

The  quadriurate,  as  has  been  said,  is  a  very  unstable 
compound,  and  one  that  is  easily  broken  up  by  wash- 
ing with  water.  This  being  the  case,  its  decomposi- 
tion and  the  subsequent  demonstration  of  the  uric  acid 
and  the  biurate  in  the  blood  should  be  easily  accom- 
plished. No  mention  is  made,  however,  of  finding  the 
so-called  quadriurate  in  the  blood,  but  it  is  introduced 
artificially  into  the  blood  serum  and  synovia;  and 
from  this  it  has  been  claimed  that  it  can  exist  in  the 
blood,  but  failure  to  demonstrate  its  presence  directly 
in  the  normal  blood  stream  is  not  a  proof  that  it 
does  not  exist  in  that  medium.  The  production  of  the 
quadriurate  in  the  system  necessitates  first  the  produc- 
tion of  uric  acid.  So  far,  in  connection  with  the 
quadriurate  theory,  we  are  in  total  ignorance  as  to 
the  point  where  the  uric  acid  is  manufactured,  also  as 
to  where  it  attacks  the  sodium  compounds  to  form  the 
theoretical  salt,  and  where  the  latter  finally  gains  ac- 
cess to  the  blood.  Until  these  doubtful  points  have 
been  cleared  up  satisfactorily,  the  quadriurate  theory 
is  one  grand  speculative  problem  which  does  not  ex- 
plain the  facts  as  developed  by  clinical  observation. 
I'nlcss  our  theories  can  be  made  of  practical  value  in 
the  study  and  management  of  the  case  at  the  bedside, 
they  are  of  no  real  value. 

From  all  the  preceding,  it  can  be  justly  deduced 
that  uric  acid  and  its  urates  have  not  as  yet  been 
clearly  demonstrated  in  the  normal  blood  stream. 
That  uric  acid  and  its'  urates  are  found  in  the  tissues 
in  pathological  conditions  is  true.  This,  however, 
does  not  necessitate  the  assumption  that  uric  acid  or 
its  urates  existed  in  the  blood  stream  in  defiance  of 
all  the  known  laws  of  chemistry.  l!ut  it  does  demand 
the  hypothesis  that,  as  a  result  of  a  faulty  nutrition, 
there  is  developed  an   imperfect  and  abnormal  trans- 


September  22,  1900] 


MEDICAL    RECORD. 


44; 


mutation  of  the  proteid  compounds;  that,  as  a  result, 
these  substances  are  oxidized  at  an  abnormal  position, 
instead  of  in  the  renal  cells  as  normally  occurs;  that 
when  this  is  the  case  there  is  a  sudden  production  of 
uric  acid  and  tiie  formation  of  urates  in  the  protoplas- 
mic masses,  and  that  when  this  happens  all  the  symp- 
toms are  those  which  indicate  a  profound  irritation  and 
an  increased  chemical  activity.  Thus,  by  assuming  a 
vicarious  production  of  uric  acid,  a  theory  which  holds 
true  in  many  other  abnormal  and  pathological  condi- 
tions in  tiie  body,  the  presence  of  uric  acid,  or  rather 
the  urates,  in  the  tissues  is  explained  by  simple  chem- 
ical phenomena,  and  without  deviating  from  any  well- 
defined  law  of  chemistry.  All  this  can  be  done  with- 
out predicating  that  uric  acid  or  its  urates  are  present 
in  the  blood. 

The  pathological  condition  which  is  produced  by 
extirpation  of  the  kidneys  will  admit  of  the  formation 
of  uric  acid  by  the  vicarious  oxidation  of  the  proteid 
substances  in  the  protoplasm  of  cells  other  than  those 
of  the  renal  gland,  upon  the  same  principle  as  given  in 
the  foregoing  example. 

Upon  the  theory  that  uric  acid  is  due  to  a  defi- 
ciency in  the  quantity  of  oxygen  reaching  the  body  as 
a  whole,  and  the  renal  cells  in  particular,  the  manu- 
facture of  uric  acid  by  the  kidneys  should  normally 
be  greatest  during  digestion  and  least  during  the  in- 
terval; for,  during  digestion,  the  carbohydrates,  fats, 
and  proteids  are  being  introduced  into  the  circulation 
in  large  quantities.  The  two  former  are  rapidly  oxi- 
dized, the  one  in  the  liver  and  the  other  in  the  lungs, 
tending  to  use  up  the  oxygen  supply,  so  that  a  defi- 
cient amount  of  oxygen  reaches  the  kidneys  and  a  less 
perfect  transmutation  of  the  proteid  in  the  renal  cells 
is  the  result,  while  the  output  of  uric  acid  is  aug- 
mented. Thus,  a  normal  physiological  phenomenon, 
which  is  called  upon  to  explain  the  production  of  uric 
acid  in  the  liver  instead  of  the  renal  glands,  when 
viewed  in  this  light,  makes  it  appear  quite  plain  that 
no  such  deduction  is  justified.  It  rather  strengthens 
the  theory  which  points  to  the  renal  cell  as  the  true 
source  of  the  uric-acid  production,  except  in  patholog- 
ical states  of  the  system,  when  it  can  be  made  at  ab- 
normal points  by  the  vicarious  action  of  the  protoplas- 
mic masses. 

This  theory  of  uric-acid  production  by  the  oxida- 
tion of  the  proteid  substances  in  the  protoplasm  of  the 
renal  cells  is  by  far  more  logical,  is  best  sustained  by 
all  the  points  in  evidence,  and  fits  most  accurately  all 
the  known  facts  and  conditions.  This  formation  of 
uric  acid  is  one  method  for  the  elimination  of  nitrogen 
from  the  system.  It  is  absolutely  necessar)-  to  have 
this  acid  produced  at  this  particular  point  and  poured 
into  the  uriniferous  tubules;  for  by  its  action  upon 
the  disodic  monohydrogen  phosphate  in  tiie  urinifer- 
ous tubules  the  monosodic  dihydrogen  phosphate  is 
produced,  and  the  production  of  this  acid  phosphate 
of  sodium  is  absolutely  necessary  to  hold  in  solution 
the  otherwise  insoluble  phosphate  of  calcium,  thus 
preventing  the  formation  of  this  form  of  calculi  in  the 
urinary  passages. 

The  theory  that  the  uric  acid  is  produced  in  the 
renal  cells  in  the  manner  described  above  is  further 
substantiated  by  the  steady  presence  of  this  acid  or 
the  urates  in  urine,  and  by  their  absence  from  the 
blood. 

When  uric  acid  is  herein  contrasted  with  urea  as  a 
suboxidation  product,  it  is  not  meant  to  intimate  that 
uric  acid  is  the  direct  antecedent  of  urea.  On  the 
contrary,  it  is  one  of  the  complete  end  products  of  pro- 
teid oxidation  so  far  as  the  animal  economy  is  con- 
cerned, just  as  much  as  urea,  carbon  dioxide,  and 
water  are  final  products.  Chemically,  less  oxygen  has 
been  utilized  to  produce  this  particular  form  of  com- 
pound than  is  required  to  produce  urea  and  the  other 


higher  oxidation  products.  Physiologically,  when  pro- 
duced in  excess,  it  is  a  suboxidation  product,  for  it 
is  found  that  the  output  of  uric  acid  is  always  aug- 
mented by  anything  which  interferes  with  the  utiliza- 
tion of  the  full  amount  of  oxygen  by  the  system,  as 
compared  with  the  quantity  of  food-stuffs  absorbed. 
A  prolonged  high  tension  of  the  arterial  system,  under 
the  intlut;nce  of  digitalis,  for  instance,  causes  the  blood 
to  be  driven  through  the  capillary  blood-vessels  so 
rapidly  that  sufficient  oxygen  cannot  be  taken  up  from 
the  blood  and  utilized  for  the  complete  transmutation 
of  the  proteid  elements  of  the  food.  As  a  result,  sub- 
oxidation occurs,  and  the  manufacture  and  output  of 
uric  acid  by  the  renal  cells  are  increased.  The  same 
is  true  with  every  condition  of  the  system  which  pro- 
duces a  prolonged  high  tension  of  the  vascular  system 
and  a  rapid  pulse  rate.  When  the  intaking  capacity 
of  the  lungs  for  oxygen  is  diminished  by  mechanical 
defects  in  the  heart,  or  by  pneumonia,  pleurisy,  em- 
physema, etc.,  the  oxidation  of  the  proteid  substances 
falls  to  an  abnormally  low  degree,  the  excretion  of 
urea  decreases  and  that  of  uric  acid  increases,  the  lat- 
ter often  to  a  marked  degree.  When  the  carbohydrates 
or  fats  are  taken  in  excessive  quantities,  and  especially 
the  former,  the  o.xygenating  capacity  of  the  system  is 
exceeded,  the  more  difficult  task  of  oxidizing  the  pro- 
teid elements  is  imperfectly  performed,  suboxidation 
ensues,  and,  as  a  result,  uric  acid  increases  in  the 
urine,  while  the  urea  output  decreases.  When  an  ex- 
cessive amount  of  tiie  proteid  substance  is  taken,  either 
alone  or  in  combination  with  the  carbohydrates  and 
fats,  the  oxygenating  capacity  of  the  system  is  ex- 
ceeded in  a  similar  manner,  and  the  proteids  are  im- 
perfectly oxidized  as  before. 

When  the  uric  acid  rises  above  the  normal,  it  is 
simply  a  symptom  found  in  the  urine,  which  indicates 
an  imperfect  state  of  proteid  oxidation  and  a  general 
condition  of  malnutrition.  This  suboxidation  may  be, 
in  a  measure,  caused  by  many  different  conditions,  act- 
ing singly  or  in  combination,  causes  which  may  arise 
either  in  the  nervous,  digestive,  circulatory,  or  in  the 
respiratory  system.  In  every  instance  there  is  more 
or  less  profound  impairment  in  the  glandular  activity 
and  nutritive  tone  throughout  the  wiiole  system.  In 
some  instances  one  organ  or  tissue  will  suffer  more 
than  another,  and  thus  the  symptomatic  manifestations 
are  varied  and  irregular  in  their  development.  When 
the  renal  cells  temporarily  cease  to  act,  thus  failing  to 
produce  uric  acid,  the  associated  defective  state  of  nu- 
trition results  in  many  instances  in  the  various  masses 
of  protoplasm  throughout  the  body,  which  are  now  in 
an  abnormal  physiological  state,  assuming  an  abnormal 
or  vicarious  action.  In  this  manner  the  proteid  sub- 
stances are  oxidized  into  uric  acid  in  the  cells  of  the 
tissues,  with  the  immediate  production  of  the  urate  of 
sodium.  This  abnormal  oxidation  may  occur  in  any 
protoplasmic  mass  which  is  in  this  state  of  malnutri- 
tion, but  it  is  most  commonly  met  with  in  the  carti- 
lage cells  of  the  metatarso-phalangeal  articulation  of 
the  great  toe.  It  does,  however,  occur  in  other  parts 
of  the  body  and  in  other  tissues  than  the  cartilaginous 
structures.  This  development  of  uric  acid  in  the  car- 
tilage cells,  or  at  other  points  of  the  body,  results  in 
its  immediate  precipitation  at  such  points  as  a  urate 
of  sodium.  This  abnormal  deposit  acts  as  an  intense 
chemical  irritant,  and  excites  a  local  inflammatory 
process  by  which  a  fibro-plastic  exudate  is  thrown 
around  this  foreign  body  until  the  urates  are  finally 
incapsulated,  and  gradually  all  the  local  symptoms  sub- 
side. 

The  problem  has  further  been  very  much  simplified 
by  the  fact,  now  generally  recognized,  that  all  the  non- 
nitrogenous  food  products,  such  as  starch,  sugar,  and 
fats,  are  directly  oxidized  into  their  end  products,  car- 
bon dioxide  and  water,  and  that  they  do  not  yield  any 


448 


MEDICAL    RECORD. 


[September  22,  1900 


toxic  by-products  to  the  system.  Therefore  we  are 
left  to  deal  chiefly  with  proteid  constituents  as  the 
etiological  factors  in  the  production  of  these  toxic  and 
suboxidation  conditions  of  the  system.  This  much 
established,  we  still  have  no  clear  and  complete  ex- 
planation for  the  dift'erent  degrees  and  forms  of  sub- 
oxidation  processes  which  constitute  the  various  dis- 
eases, such  as  so-called  rheumatism,  so-caHed  gout, 
etc. 

Strenuous  attempts  have  been  made  in  this  bacterio- 
logical age  to  associate  a  specific  germ  with  all  patho- 
logical problems,  and  in  many  instances  this  has  ap- 
parently been  successfully  accomplished.  Still,  the 
declaration  of  the  presence  of  a  specific  germ  as  the 
causative  factor  in  the  production  of  disease  does  not 
explain  in  full  the  special  and  characteristic  features 
of  the  pathological  lesions  found,  or  the  symptoms  by 
which  the  different  diseases  are  characterized.  Work- 
ing along  these  lines,  a  considerable  number  of  observ- 
ers profess  to  have  found  a  specific  germ  as  the  causa- 
tive factor  in  the  production  of  so-called  rheumatic 
conditions  of  the  system.  Among  this  number  maybe 
mentioned  von  Schueller,'  Buss,-  Brunner,^  Buday,' 
Petrone,''  Hlava,"  Tizzoni,'  Goldscheider,"  Loeffler," 
Boulloche,"  Mantle,"  P.  Guttmann,"'  Fleischhauer," 
Waibel,"  FJouchard,"  Sahli,"  Lucatello,"  Leyden," 
Singer,'"  Chvostek,""  Humphrey,"'  and  Young. '■'  All 
of  these  observers  have  given  more  or  less  attention  to 
this  subject.  Buss  states  that  he  considers  it  highly 
probable  that  acute  articular  rheumatism,  so-called,  is 
in  many,  perhaps  in  the  majority,  of  cases,  caused  by 
attenuated  pyogenic  micro  organisms,  among  which  he 
includes  the  Friedlander  pneumo-bacillus  and  the 
diplococcus  of  Frankel-Weichselbaum.  Sahli"'  culti- 
vated streptococci  from  the  blood  and  contents  of  af- 
fected joints  in  cases  of  so-called  acute  articular  rheu- 
matism. Singer"'  made  bacteriological  examinations 
in  seventeen  cases  of  so-called  articular  rheumatism, 
and  secured  positive  results  in  sixteen  instances.  In 
ten  cases  he  found  staphylococcus  albus,  in  one  staphy- 
lococcus aureus,  in  three  streptococci,  in  two  staphy- 
lococcus albus  and  streptococci.  He  further  argued 
from  his  observations  that  the  constancy  of  the  occur- 
rence of  the  micro-organisms  in  the  urine,  and  the 
fact  that  the  number  of  the  colonies  obtained  dimin- 
ished in  number  as  the  symptoms  improved,  were  suffi- 
cient evidence  for  considering  a  coccus  infection  as  the 
exciting  cause  of  the  disease.  Chvostek,  on  the  other 
hand,  made  repeated  observations  in  twelve  cases  of 
so-called  rheumatic  affections  of  the  joints.  In  one  of 
these  cases  he  found  the  diplococcus  urea;;  in  another, 
in  which  the  urine  was  not  drawn  with  a  catheter,  staphy- 
lococcus albus;  and  in  a  third,  large  cocci,  which  have 

'Von  Schueller:  Berlin,  klin.  Woch. ,  1893,  No.  36.  Also 
Fluegge  ;   "  Die  Mikroorganismen."  3te  Auf.,  ii.,  p.  2S7. 

-Buss:   Deutsches  .Vrch.   f.  klin.   Med.,  liv.,  p.  35. 

'  Brunner  :  Correspondenzblatt  fur  Schweizer  Aerzte,  1S92, 
No.  12. 

■•Buday:  Centralblatt  ftlr  Baktericlogie.  x..  189I. 

'  Petrone  :  Virchow-Hirsch's  Jahresbericht,  1886. 

^  Hlava  :   Baumgartcn's  Jahresbericln  fUr  Bakteriologie,  1SS8. 

'Tizzoni:   Riforma  .Medica.  1891,  No.  100. 

*  Goldscheider  :   Zeitsclirift  ftir  klinische  Medicin,  xxi. 

'  I.oelller  :     Mittlicilungen    aus  deni   kaiserlichen  Gesundheits- 
amte.  ii. ,  1S84,  p.  421. 
'"  Boulloclie  :  Arch,  de  med.  exp.,   1891,  p.  252. 
"  Mantle:  British  Medical  Journal,  June  25,  1SS7. 
'^  P.  (luttmann  :    Deutsche  "med    Woch.,  l386,  p.  809. 
"  Fleischhauer  :  Virchow's  Archiv,  Ixii. 
'MVaibel  :   MUnch    med.  Woch..  1892,  No.  5. 
'°  Bouchard  :   La  Semaine  medicale.   1S91,  No.  47. 
"  Sahli  :  Correspondenzblatt  ftir  Schweizer  Aerzte.  xxii.     Also 
Deutsches  Arch.  f.  klin    Med.,  Ii..  p.  451  ;  liv..  p.  38. 
"I.ucatello:   Lancet,  December  17,   1S92. 
'"Von  Leyden;   Deutsche  med.  Woch.,  1894,  p.  913. 
"Singer:  Wien.  klin.  Woch  ,  1S95,  No.  25. 
■-"  F.  Chvostek:   Wien.  klin.  Woch.,   1S95.  p.  469. 
■'  Humphrey  :   Medical  Tress  and  Circular,  cxi.,  No,  19, 
•Mvrause  :  Wien.  med.  Woch.,  iSo^.  p.  472. 
"  /Hd.  ■■■'  //,U 


not  yet  been  described,  but  which  probably,  according 
to  Chvostek,  are  derived  from  the  urethra.  In  this 
connection  it  should  be  remembered  that  Krause'  has 
shown  that  bacteria  are  often  excreted  in  the  urine 
during  infectious  diseases,  which  have  no  connection 
whatever  with  the  particular  infection  from  which  the 
patient  is  suffering,  and  which  must  not,  therefore,  be 
regarded  as  the  exciting  cause  of  the  disease.  Among 
these  bacteria  the  staphylococcus  albus  jslays  an  im- 
portant part.  And  this  is  the  form  of  micro-organism 
that  has  most  frequently  been  described  in  connection 
with  these  rheumatic  conditions.  Krause  further  says 
that  these  bacteria  are  no  longer  found  in  the  urine 
when  all  the  signs  of  disease  have  vanished,  simply, 
as  he  argues,  because  the  conditions  of  the  system  nec- 
essary for  their  growth  have  been  removed. 

Chvostek  °  extended  his  examinations  and  made  ex- 
aminations of  the  blood,  urine,  and  articular  fluids,  in 
cases  of  so-called  acute  and  chronic  articular  rheuma- 
tism as  well  as  in  cases  of  other  infectious  diseases  in 
which  an  acute  swelling  of  the  joint  takes  place.  The 
results  which  he  obtained  from  his  examination  of  the 
articular  fluids  were  negative  in  all  his  cases,  except 
in  the  changes  in  the  joints  that  arose  directly  in  the 
course  of  a  sepsis  or  a  gonorrhoea.  Chvostek  sought 
further  to  discover  whether  the  bacteria  which  are  pres- 
ent in  the  blood  entered  the  joints  during  the  life  of 
the  patient,  and,  if  so,  the  conditions  necessary  for 
their  transit  through  the  wall  of  the  blood-vessels. 
In  this  connection  it  may  be  mentioned  that  his  ex- 
periments on  animals  showed  that  certain  alterations 
in  the  nutritive  composition  of  the  vascular  wall  must 
be  produced  before  the  passage  of  the  micro-organism 
could  be  effected.  He  also  demonstrated,  to  his  own 
satisfaction,  that  the  construction  cf  the  synovial 
membranes  and  that  of  their  contained  blood-vessels 
resisted  to  a  high  degree  tliis  nutritive  change  that 
makes  possible  the  passage  of  the  germs,  thus  render- 
ing it  very  difficult  for  the  micro-organisms  to  pass 
through  the  walls  of  the  blood-vessels  and  gain  access 
to  the  joints.  This  is  not  the  case,  however,  with  the 
vascular  walls  of  the  kidneys.  Hence  the  bacteria,  if 
they  appear  at  all  in  the  joints,  will  do  so  at  a  much 
later  period  than  they  are  excreted  by  the  kidneys. 

That  micro-organisms  have  been  found  in  the  urine, 
and  in  some  instances  in  the  blood,  and  in  the  fluid 
accumulations  in  tiie  joints,  and  in  various  structures 
of  the  body,  in  connection  with  the  varying  conditions 
which  have  been  described  under  the  common  term 
rheumatism,  cannot  be  denied.  We  may  even  go  fur- 
ther and  state  that  the  prevailing  organism,  when  de- 
scribed at  all,  is  most  frequently  of  the  coccus  type. 

From  the  great  diversity  of  results  obtained,  and 
from  the  fact  that  no  one  form  of  micro-organism  is 
found  with  any  degree  of  regularity  in  connection  with 
these  so-called  rheumatic  conditions,  the  consensus  of 
opinion  is,  that  the  pathological  conditions  and  symp- 
toms classed  as  rheumatic  are  not  to  be  attributed  to 
the  direct  and  intrinsic  bacterial  invasion  of  the  struc- 
tures of  the  body,  as  is  the  case  in  connection  with 
some  of  the  well-known  and  undisputed  microbic  dis- 
eases. Nevertheless,  it  is  reasonable  to  suppose  that 
in  conjunction  with  over-feeding  and  with  under-feed- 
ing, and  tile  consequent  suboxidation  state  of  the  sys- 
tem, the  action  of  the  micro-organism  and  the  toxic 
products  that  are  developed  as  a  direct  result  of  their 
presence  in  the  alimentary  canal  are  largely  responsi- 
ble for  the  different  forms  and  degreesof  suboxidation 
included  vmder  the  terms  gout,  rheumatism,  etc.  The 
micro-organism  in  all  these  instances  acts  by  its  pres- 
ence in  the  alimentary  canal,  and  by  its  disturbing  in- 
fluence upon  the  digestive  process,  and  not  by  its  in- 
herent presence  within  the  intrinsic  structures  of  the 
system. 

'  /diJ.  '  Ibid. 


September  22,  1900] 


MEDICAL    RECORD. 


449 


To  understand  this  proposition  thoroughly,  it  must 
be  remembered  that  the  presence  of  certain  kinds  of 
bacterial  life  is,  in  all  probability,  absolutely  essential 
to  a  perfect  performance  of  the  digestive  function.  In 
this  connection  it  must  also  be  remembered  that  only 
a  few  years  ago  Nuttall  and  Thierfelder,'  in  a  series 
of  experiments  in  which  they  used  young  guinea-pigs, 
apparently  proved  that  the  alimentary  canal  could  be 
kept  free  from  all  bacterial  influences,  and  a  perfect 
nutrition  at  the  same  time  be  maintained.  In  opposi- 
tion to  this  is  the  fact  that  in  almost  all  instances  the 
alimentary  tract  at  all  times  contains  various  micro- 
organisms. Added  to  this  are  the  more  recent  experi- 
ments of  J)r.  M.  Schottf  lius."  Dr.  Schotlelius' series 
of  experiments  was  carried  out  in  a  manner  similar  to 
those  of  Nuttall  and  Thierfelder,  but  instead  of  select- 
ing the  guinea-pig,  hens  and  their  eggs  were  utilized 
for  the  experimental  work.  Two  sets  of  eggs  were 
taken,  one  in  wliich  the  surface  of  the  eggs  was  made 
absolutely  free  from  bacteria  by  washing  with  a  strong 
solution  of  bicliloride  of  mercury,  the  remaining  set 
remaining  contaminated  by  micro-organisms.  The 
first,  so  far  as  tiieir  exterior  is  concerned,  will  be 
called  for  convenience  sterilized  eggs,  while  the  other 
batcii  will  be  designated  as  non-sterile  eggs.  The 
former  were  introduced  into  a  sterile  incubator,  while 
the  others  were  not.  When  the  chickens  were  hatched, 
tiiose  from  the  steriljzed  incubator  were  carefully  fed 
upon  sterilized  food,  while  those  of  the  control  experi- 
ment were  given  ordinary  food.  The  faeces  were  care- 
fully examined  in  both  instances.  In  tiie  first  set,  or 
the  so-called  sterile  chickens,  the  faces  were  found  to 
be  absolutely  free  from  all  forms  of  bacterial  life, 
while  the  reverse  was  found  to  be  the  case  in  the  con- 
trol experiment.  At  the  end  of  a  certain  period  of 
time  the  non-sterile  batcli  of  chickens  were  found  to 
have  gained  in  weight  much  more  rapidly  than  the 
sterile  batch.  Tiie  gain  was  two  hundred  and  fifty 
per  cent,  greater  in  those  in  which  the  bacteria  gained 
access  to  the  alimentary  tract.  Further  than  this,  all 
ot  the  so-called  sterile  chickens  died  within  three 
weeks  after  they  were  hatched,  while  the  control 
chickens  lived  on  as  usual.  Thus  it  would  seem  to  ^ 
be  clearly  proved  that  for  the  most  perfect  working  of 
the  digestive  function  in  the  alimentary  tract,  and  also 
for  assimilation,  the  presence  of  certain  kinds  and 
amounts  of  bacterial  life  and  their  chemical  products 
in  the  alimentary  canal  are  absolutely  essential. 

To  determine  which  form  of  bacterial  life  is  essen- 
tial for  the  maintenance  of  a  perfect  piiysiological 
state  will  require  a  long  series  of  experiments,  in  which 
the  composition  of  the  food  is  accurately  determined 
before  being  ingested.  At  the  same  time  the  excreta, 
representing  the  utilization  of  the  foodstuffs  and  tis- 
sue waste,  must  be  accurately  studied.  Then  the  vari- 
ous kinds  of  micro-organisms  at  work  in  the  contents 
of  the  alimentary  tract  must  be  determined  through  a 
study  of  the  bacterial  life  found  in  the  faeces.  With 
this  there  must  also  be  associated  an  isolation  of  the 
various  kinds  of  bacteria  found  in  the  contents  of  the 
alimentary  canal  in  connection  witii  the  condition  rec- 
ognized ordinarily  as  the  normal  state.  Then  the 
action  of  the  bacteria  should  be  carefully  studied  on 
the  normal  sterilized  and  non-sterilized  foodstuffs 
outside  the  body;  and  this  must  be  done  with  the  bac- 
teria singly  and  in  combination.  Their  action  should 
also  be  studied  upon  the  food  in  the  presence  of  the 
various  digestive  ferments.  VVhen  all  this  has  been 
accomplished,  a  very  fair  knowledge  of  the  action  of 
germs  in  the  digestive  process  in  the  normal  state  will 
be  secured.  Then,  in  a  similar  manner,  their  action 
upon  the  digestive  process  could  be  studied  in  connec- 
tion with  the  conditions  designated  as  intestinal  indi- 

'  Nuttall  and   Thierfelder:  Zeits.  f    phys.  Chem..  xxi. .  p.  log. 
•  M.  Schottelius  :  .Vrch.  f.  Hygiene,  xxxi.,  p.  240. 


gestion,  and  also  in  connection  with  all  the  patholog- 
ical processes  which  appear,  in  a  large  measure  at 
least,  to  take  their  origin  in  an  imperfect  digestion 
and  assimilation,  and  in  which  an  incomplete  oxida- 
tion is  a  leading  feature  of  the  disease,  as  occurs  in 
the  so-called  gout,  rheumatism,  Uright's  disease,  dia- 
betes, etc. 

While  all  this  desirable  information  is  not  as  yet  at 
our  command,  there  is  a  sufficient  evidence  at  hand  to 
warrant  the  assertion  that  the  varying  degrees  and 
kinds  of  suboxidation  met  with,  such,  for  instance,  as 
the  so-called  gout  and  rheumatism  and  a  host  of  other 
conditions,  are  the  result  of  some  special  kind  of 
micro-organism  acting  in  the  alimentary  canal;  or 
they  may  be  the  result  of  two  or  more  varieties  acting 
together;  or  may  it  not  be  that  tlie  absence  of  certain 
kinds  of  bacterial  life  is  the  determining  factor  in  the 
production  of  the  disease  process?  In  either  instance 
it  maybe  assumed  that  abnormal  or  toxic  products  are 
produced  in  the  alimentary  canal,  which,  when  intro- 
duced into  the  circulation  with  the  foodstuffs,  act  as 
the  direct  and  determining  factor  in  establishing  the 
special  degree  or  form  of  suboxidation  that  we  know 
by  these  time-honored  names,  "gout,"  "rheumatism," 
etc.  By  assuming  the  development  of  a  variety  of 
toxic  products  it  easily  explains  the  great  variety  in 
the  clinical  picture  as  witnessed  under  the  so-called 
rheumatic  condition. 

This  line  of  argument  is  sustained,  so  far  as  the 
symptoms  are  concerned,  by  the  fact  that  with  the  in- 
troduction of  certain  chemical  compounds  into  the  sys- 
tem definite  symptoms  follow,  as  when  morphine, 
strychnine,  atropine,  pilocarpine,  etc.,  are  introduced. 
Why  morphine,  strychnine,  atropine,  pilocarpine,  etc., 
are  always  followed  by  a  pretty  uniform  train  of  symp- 
toms depending  upon  the  special  one  used  has  never 
been  absolutely  explained.  Yet  no  one  attempts  to 
deny  the  fact.  In  a  similar  manner  it  is  reasonable 
to  suppose  that  the  symptoms  of  disease  are  the  result 
of  the  introduction  into  or  development  within  the 
system  of  definite  chemical  compounds;  that  these 
chemical  products  either  emanate  directly  from  the 
micro-organism  or  are  produced  from  the  proteid  con- 
stituents in  which  the  bacteria  grow,  liy  the  action  of 
the  bacteria  u|)on  the  proteid  molecule.  This  latter 
view  appears  to  be  the  more  probable,  taking  all  things 
into  considera'tion.  The  modification  of  the  physiolog- 
ical phenomena  by  the  introduction  of  the  varying 
toxic  products  can  also  be  made  to  explain  the  varying 
pathological  conditions  met  with;  just  the  same  as  the 
introduction  of  chemical  compounds  can  be  made  to 
modify  pathological  phenomena,  and  thereby  enable 
the  system  to  be  brought  back  into  a  more  nearly 
physiological  condition.  In  all  these  suboxidation 
diseases  the  action  of  the  bacteria  is  on  the  proteid 
constituents  as  they  exist  in  the  chyme  rather  than 
upon  those  which  exist  as  integral  parts  of  the  body. 

Thus  we  find  that  the  two  great  predisposing  factors 
in  the  development  of  so-called  gout  and  rheumatism 
are  the  prolonged  intake  of  a  larger  amount  of  nutri- 
tive pabulum  than  the  system  can  perfectly  oxidize,  or 
conditions  tiiat  so  reduce  the  oxygenating  capacity  of 
the  animal  economy  that  the  small  amount  of  food 
taken  cannot  be  perfectly  oxidized.  Added  to  this,  as 
the  exciting  and  determining  factors  in  the  production 
of  the  special  type  encountered,  are  the  action  of  the 
bacteria  on  the  proteids  in  the  alimentary  canal  and 
tlie  formation  and  absorption  into  the  system  of  toxic 
products  in  conjunction  with  the  food  products  ab- 
sorbed. These  two  factors  acting  together  determine 
the  form  of  the  suboxidation,  the  nature  of  the  patho- 
logical lesions,  the  character  of  the  symptoms,  and  the 
abnormal  and  by-products  that  are  found  in  the  ex- 
creta. It  is  largely  by  the  latter  that  we  are  enabled 
to  differentiate  accurately  between  the  diilerent  forms 


450 


MEDICAL    RECORD. 


[September  22,  1900 


of  these  suboxidation  conditions  that  afflict  humanity. 
In  conjunction  with  the  two  predisposing  factors  and 
the  exciting  factor  in  the  production  of  these  suboxi- 
dation conditions  there  are  a  few  other  things  that 
must  not  be  overlooked,  as  they  often  exert  a  decided 
influence  in  determining  the  linal  result.  They  are 
the  varying  changes  in  the  temperature,  hygienic  sur- 
roundings, nervous  disturbances,  etc.,  for  they  are  all 
very  important  factors  and  help  to  disturb  the  perfect 
working  of  the  glandular  system.  Just  how  the  modus 
operandi  of  this  bacterial  factor  working  in  the  ali- 
mentary canal  can  best  be  absolutely  determined  is 
the  question  that  is  still  pressing  for  an  answer  from 
the  physiological  chemists.  Until  it  lias  been  fully 
solved,  the  absolute  etiology  of  these  suboxidation 
processes  under  discussion,  so-called  gout  and  rheu- 
matism cannot  be  absolutely  elucidated  except  in 
theory.  But  even  in  the  absence  of  this  much-desired 
complete  verification,  this  explanation,  as  here  given, 
adheres  more  closely  to  all  the  facts  thus  far  known 
to  modern  science  than  any  explanation  previously  ad- 
vanced. 

With  this  conception  of  the  chemical  conditions  that 
are  at  work  within  the  system,  when  affected  with  so- 
called  gout  and  rheumatism,  the  etiological  relation  of 
these  conditions,  if  any  exists,  can  be  applied  to  the 
various  diseases  that  are  under  discussion.  It  is 
nevertheless  difticult  to  comprehend  how  false  feed- 
ing, the  action  of  the  micro-organisms  in  the  alimen- 
tary canal,  and  a  toxic  infection  of  the  system  there- 
from, can  in  any  manner  be  looked  upon  as  a  primary 
etiological  factor  in  the  production  of  a  traumatism  to 
a  joint,  a  sprain  or  a  bruise.  Therefore,  it  must  be 
asserted  in  the  very  beginning  that  there  is  no  direct 
primary  etiological  relationship  between  the  so-called 
rheumatic  condition  of  the  system  and  traumatic  lesions 
of  the  joints.  .  On  the  other  hand,  it  is  equally  true  that 
the  abnormal  chemical  condition  of  the  system  which 
produces  that  state  of  the  animal  economy  classed 
as  "rheumatism"  and  "gout,"  will  assert  itself,  and 
modify  the  whole  course  of  the  pathological  problem 
in  connection  with  a  traumatism.  This  does  not  war- 
rant the  supposition,  however,  that  the  so-called  rheu- 
matic state  of  the  system  in  any  manner  acts  as  a  pri- 
mary etiological  factor  in  producing  the  traumatism  of 
the  joint  structures.  Penetrating  a  little  more  deeply 
into  this  intricate  problem,  we  find  that  the  products 
absorbed  from  the  alimentary  canal,  and  which,  if 
retained  in  the  system,  are  the  determining  factors  in 
producing  the  special  type  of  suboxidation  that  excites 
the  lesions  and  symptoms  classed  as  rheumatic,  will 
influence  the  pathological  changes  following  a  trau- 
matic injury  to  the  joint.  This  is  assuming,  however, 
that  there  have  been  false  habits  of  feeding,  micro- 
organisms at  work  in  the  alimentary  canal,  absorption 
of  toxic  products  into  the  system,  and  that,  in  conse- 
quence thereof,  the  animal  economy  has  been  or  is  on 
the  verge  of  the  suboxidation  state  called  rheumatism 
prior  to  the  receipt  of  the  injury.  In  other  words, 
after  a  mechanical  or  macroscopic  traumatism  to  the 
joint  structures,  the  nutrition  in  the  injured  parts,  in 
one  who  is  sutfering  from  this  characteristic  chemical 
state  of  suboxidation  of  the  system,  which  just  precedes 
and  makes  possible  the  so-called  rheumatic  condition, 
will  undergo  changes  different  from  those  occurring  in 
a  more  normal  state  of  the  system.  When  this  term 
toxic  product  is  used  in  connection  with  the  diseases 
under  discussion,  it  is  understood  that  one  of  two  con- 
ditions exists:  either  the  system  contains  one  or  more 
by-products  which  have  resulted  from  an  incomplete 
oxidation  reduction  of  the  proteid  elements,  or  the 
system  contains  proteid  molecules,  which,  instead  of 
pursuing  their  normal  isomeric  transformation  course, 
have  been  deflected  therefrom.  When  this  latter  oc- 
curs, the  proteid  molecule  is  so  changed,  isomerically. 


that  it  becomes  toxic  in  its  character,  yet  it  still  re- 
mains an  unoxidized  proteid  body.  This  irregular 
isomeric  transformation  of  the  proteid  bodies  and 
their  change  into  a  toxic  form  easily  explains  the 
toxicity  of  the  system.  It  further  shows  the  difliculty, 
if  not  the  absolute  impossibility,  of  detecting  the  pres- 
ence of  these  toxic  proteid  bodies  as  they  circulate  in 
the  blood  and  lymph  stream.  In  whatever  manner 
produced,  the  toxic  product  which,  prior  to  the  injury, 
was  eliminated  from  the  system  without  exciting  any 
active  symptoms,  will  often  aid  in  intensifying  the 
pathological  changes  and  symptoms  resulting  directly 
from  the  traumatism.  Lesions  and  symptoms  which 
would  not  have  developed  in  the  absence  of  the  trau- 
matism are  produced  by  virtue  of  the  presence  of  the 
suboxidation  and  toxic  condition  of  the  system  called 
"rheumatic."  On  the  other  hand,  they  would  not 
have  occurred  in  the  presence  of  the  traumatism  in  a 
system  perfectly  free  from  so-called  gouty  and  rheu- 
matic conditions.  In  instances  of  this  character,  the 
so-called  gouty  and  rheumatic  states  of  the  system  can 
be  looked  upon  as  etiological  factors  in  the  production 
of  some  of  the  pathological  changes  and  symptoms 
which  follow  direct  traumatisms  to  the  joint  structures. 
They  are,  however,  always  secondary  and  never  pri- 
mary. 

This  relationship  of  the  so-called  gouty  and  rheu- 
matic condition  of  the  system  shpuld  always  be  taken 
into  consideration  in  connection  with  every  traumatism 
that  implicates  the  joints.  If  such  a  state  of  the  sys- 
tem is  found  to  be  present,  it  must  be  given  due  con- 
sideration in  the  general  management  of  the  case; 
otherwise  recovery  will  be  greatly  retarded. 

In  one  instance  that  came  under  my  observation,  a 
severe  wrench  to  one  of  the  great  toes  liad  occurred  in 
a  gentleman  past  fifty  years  of  age.  This  injury  was 
followed  by  all  the  characteristic  symptoms  common 
to  an  ordinary  attack  of  so-called  subacute  or  chronic 
gout.  So  long  as  the  case  was  treated  as  one  of  sim- 
ple traumatism,  which  was  the  method  pursued  before 
he  came  under  my  care,  there  was  no  pronounced  or 
permanent  improvement.  From  the  moment  the  con- 
dition was  regarded  as  being  primarily  traumatic  in 
its  origin,  and,  in  a  large  measure,  secondarily  kept  in 
motion  by  the  gouty  suboxidation  condition  of  the  sys- 
tem which  preceded  the  traumatism,  and  that  the 
treatment  was  modified  in  accordance  with  this  latter 
view,  improvement  was  steady,  and  a  permanent  cure 
was  speedily  effected.  Here  the  traumatism  precipi- 
tated the  so-called  gouty  attack,  if  I  may  so  state  it, 
and  the  only  line  of  treatment  that  could  be  effectual 
was  one  directed  toward  removing  the  suboxidation 
state  of  the  system.  This  is  only  one  of  many  cases 
that  could  be  cited  in  illustration  of  this  principle. 
The  same  holds  true  in  connection  witli  the  so-called 
rheumatic  conditions.  On  the  other  hand,  we  fre- 
quently meet  with  instances  in  which  slight  fractures 
running  into  the  joint  and  dislocations  of  the  carpal 
and  tarsal  bones  are  diagnosticated  as  so-called  rheu- 
matic affections.  Thus  we  find  that  there  may  be  a 
commingling  of  the  two  conditions,  both  acting  as 
etiological  factors,  even  in  connection  with  simple 
traumatic  injuries  of  the  joints.  Therefore,  each  and 
every  case  examined  must  be  carefully  analyzed  by 
itself,  and  due  consideration  given  to  the  traumatism 
and  to  the  possible  inthience  that  a  previously  exist- 
ing suboxidation  state  of  the  system  may  at  the  time 
exert  in  the  production  of  the  lesions  and  symptoms. 
When  this  is  systematically  done,  treatment  will  be 
more  scientifically  applied  and  the  restoration  of  the 
involved  joint  to  its  normal  functional  activity  be 
more  speedily  effected. 

With  the  septic  and  gonorrhoea!  affections  of  the 
joints,  all  that  has  been  said  as  to  the  relation  of  so- 
called  gouty  and  rheumatic  conditions  of  the  system  to 


September  22,  1900] 


MEDICAL    RECORD. 


451 


a  traumatism  can  similarly  be  applied  to  these  two 
diseases.  The  so-called  gouty  and  rheumatic  stales  of 
the  system  are  in  no  sense  primary  etiological  factors 
in  the  production  of  a  septic  or  so-called  gonorrhital 
joint.  Both,  however,  may  play  a  secondary  part  in 
determining  the  nature  of  the  lesions  and  the  character 
of  the  symptoms  as  in  the  simple  traumatic  affections 
of  the  joints;  but  their  influence  will  not  be  so  well 
marked  as  it  is  in  the  former  instance.  This  is  es- 
pecially true  in  connection  with  a  septic  joint,  in  which 
the  intensity  of  the  suppurative  process  and  its  symp- 
toms mask  all  those  of  a  minor  character,  and  also  be- 
cause death  usually  occurs  early  in  the  disease.  The 
same  may  be  said  in  connection  with  so-called  gonor- 
rhceal  infections  of  the  joints;  for  it  is  still  an  open 
question  whether  the  acute  joint  symptoms  developed 
during  the  course  of  the  gonorrhcea,  or  following  as 
sequela-,  are  not  due  to  a  direct  septic  infection  instead 
of  a  gonococcus  invasion  of  the  joint.'  With  so-called 
gonorrhceal  rheumatism,  which  develops  many  months 
after  the  acute  gonorrha-al  attack,  the  subo.vidation 
state  and  the  to.\ic  involvement  of  the  system  througii 
the  alimentary  canal  are  in  all  probability  more  largely 
responsible  for  the  pathological  changes  and  symp- 
toms than  is  the  gonorrhctal  infection.  Thus  the  so- 
called  rheumatic  condition  may  play  a  large  part  in 
the  development  of  tiie  lesions  and  symptoms  in  so- 
called  gonorrhceal  affections  of  the  joints;  but  it  is  al- 
ways a  secondary  and  never  a  primary  cause.  Still, 
in  the  management  of  all  these  cases  it  must  be  care- 
fully considered  and  the  treatment  directed  accordingly 
if  the  best  results  are  to  be  attained. 

When  we  come  to  the  consideration  of  those  condi- 
tions commonly  classed  as  acute  articular  rheumatism, 
we  for  the  first  time  reach  a  point  in  which  the  errors 
in  diet,  the  action  of  bacteria  in  the  alimentary  canal, 
and  the  absorption  or  the  development  of  the  toxic 
products  directly  traceable  to  their  presence,  act  when 
they  are  introduced  into  the  system  as  the  direct  etio- 
logical factors  in  determining  the  special  type  of  sub- 
O-xidation.  In  this  manner  we  can  further  look  upon 
the  subo.\idation  and  toxic  invasion  of  the  system  from 
the  alimentary  canal  as  the  direct  and  exciting  cause 
of  the  so-called  gouty  and  rheumatic  affections.  The 
great  variety  of  toxic  products  which  can  be  produced 
in  this  manner  in  the  alimentary  canal  and  that  can  be 
developed  within  the  system,  as  well  as  those  absorbed 
from  tiie  alimentary  tract,  can  be  made  to  explain  the 
varying  degrees  and  types  of  suboxidation  encountered. 
They  can  also  be  made  to  explain  all  the  different 
forms  and  types  of  so-called  rheumatic  affections  that 
are  encountered  clinically.  This  theory  of  the  produc- 
tion of  these  lesions  is  well  supported  by  that  of  Wei- 
gert  ■  in  his  explanation  of  the  various  kinds  and  types 
of  renal  lesions  that  are  known  to  exist.  As  yet,  how- 
ever, we  are  not  sufficiently  familiar  with  the  micro- 
organisms and  the  toxic  products  to  trace  fully  the 
modus  opcraiiili  from  the  point  of  origin  of  the  etiolog- 
ical factor  to  the  final  result.  If,  as  seems  quite  proba- 
ble, many  of  the  toxic  products  are  simply  isomeric 
forms  of  the  normal  proteid  molecule,  it  will  be,  as  be- 
fore stated,  a  very  difficult  matter  to  trace,  isolate,  and 
identify  them.  At  the  same  time,  from  the  data  at 
our  command,  it  seems  reasonable  to  assume  that  con- 
tinued errors  in  diet,  the  action  of  various  kinds  of 
micro-organisms  in  the  alimentary  canal,  and  the  pro- 
duction of  an  almost  endless  variety  of  these  toxic 
products  can  easily  be  made  to  explain  the  many  forms 
and  types  of  the  so-called  rheumatism,  even  from  the 
slightest  myalgia  to  the  most  extensive  destruction  of 
the  joint  structures.  Even  the  so-called  neuropathic 
joint  affections  can  be  elucidated  upon  this  theory  of 

'  Young :  Welch's  Festschrift,  p.  677-707.  igoo. 
*  Weigert :  Volkmann's  Sammlung  klinischer  Vortrage,    1879, 
Nos.  162,  163. 


a  disturbance  of  the  nutritive  functions  of  the  animal 
economy  as  they  can  in  no  other  way.  When  one  kind 
of  toxic  product  affects  the  system,  it,  like  some  of  the 
well-known  drugs  already  mentioned,  will  influence 
the  chemistry  of  the  body  in  its  special  manner,  and 
a  certain  definite  train  of  lesions  and  symptoms  will 
follow.  The  introduction  of  still  other  kinds  will  pro- 
duce their  special  results,  and  an  almost  endless  variety 
of  examples  might  be  mentioned.  In  the  one  instance 
the  abnormal  and  toxic  condition  may  result  in  a  sim- 
ple congestion  only  of  the  intermuscular  planes  with 
an  undue  pressure  upon  the  nerve  endings  distributed 
to  that  particular  part.  Then  we  have  the  condition 
called  muscular  rheumatism.  In  another  instance  the 
abnormal  and  toxic  condition,  by  virtue  of  a  difference 
in  the  toxic  product,  will  implicate  the  central  or  the 
peripheral  nervous  system  and  give  rise  to  that  class 
of  cases  which  are  known  as  neurotic  and  in  which 
there  is  no  very  pronounced  joint  lesions.  In  still 
others  the  toxic  elements  will  cause  a  more  profound 
disturbance  of  the  peripheral  nervous  mechanism,  and 
thereby  the  action  of  the  so-called  trophic  centres  will 
be  so  profoundly  disturbed  that  actual  and  pronounced 
destructive  changes  in  the  joint  structures  are  pro- 
duced, such  as  are  found  in  Charcot's  disease.  The 
more  common  lesions,  however,  that  occur  as  the  re- 
sult of  this  special  type  of  suboxidation  and  toxic  in- 
fection of  the  system  classed  as  rheumatism,  is  one  in 
which  the  vascular  areas  in  and  around  the  joints  be- 
come congested,  and  are  followed  by  a  pronounced 
cedematous  swelling  of  the  soft  structures  in  and  around 
the  joints  affected.  In  all  these  cases  it  is  the  lowered 
nutritive  activities  and  the  action  of  the  toxic  products 
within  the  system,  acting  either  upon  the  central  or 
the  peripheral  nervous  system,  that  cause  the  disturb- 
ance in  the  vascular  and  nutritive  supply  to  the  parts 
affected,  and  thus  give  rise  to  the  anatomical  changes 
and  symptoms.  In  the  vast  majority  of  instances  the 
injury  to  the  structures  involved  in  the  so-called  rheu- 
matism is  not  sufficiently  great  to  excite  the  phenomena 
characteristic  of  a  true  inllammatory  process.  Hence, 
with  tiie  removal  of  the  cause  and  an  improvement  in 
the  general  as  well  as  in  the  local  nutrition,  there  is 
perfect  restoration  of  the  implicated  joints  to  their  nor- 
mal state.  In  a  few  instances  the  primary  injury  from 
the  toxic  infection  maybe  sufficiently  great  to  excite  a 
truly  infiammalory  process  with  all  the  changes  char- 
acteristic of  inliammation.  In  all  these  cases  there  is 
a  tendency  to  more  or  less  permanent  damage  to  the 
structures  in  and  around  tiie  joints  involved.  The 
amount  and  permanency  of  the  damage  to  the  joint 
will  depend  entirely  upon  the  intensity  of  the  primary 
injury  and  the  duration  of  the  actual  inffammatory 
process. 

The  most  extensive  damage  to  the  joints,  however,  is 
met  with  in  those  cases  which  are  not  inflammatory, 
but  in  which  there  is  a  long-continued  general  suboxi- 
dation state  of  the  system  together  with  its  peculiar 
type  of  toxic  infection.  In  these  instances  the  contin- 
ual augmented  vascular  supply  to  one  area  with  a  de- 
fective supply  to  another  adjacent  zone,  but  in  both 
instances  of  material  poor  in  quality  and  also  toxic  in 
its  nature,  causes  a  very  irregular  distribution  of  the 
nutritive  pabulum  with  which  to  carry  on  the  functions 
in  and  around  the  joints.  So  great  and  varied  is  this 
abnormal  distribution  of  the  nutritive  pabulum,  that 
almost  all  grades  of  new  formations  are  met  with  in 
and  around  the  joints.  These  vary  from  sim|)le  swell- 
ings consisting  of  atrophied  librillated  connective  tis- 
sue infiltrated  with  a  watery  exudate  into  its  meshes, 
to  well-defined  enlargements  composed  of  dense  fibril- 
lated  connective  tissue  almost  as  firm  and  well  devel- 
oped as  the  normal  tendon  tissue.  These  new  forma- 
tions are  located  chiefly  in  the  ligamentous  structures 
and  around  the  ends  of  the  bones  at  the  point  of  the 


452 


MEDICAL   RECORD. 


[September  22,  1900 


attachment  of  the  ligaments  and  tendons.  This  newly 
formed  tissue  in  some  cases  is  infiltrated  with  the  in- 
soluble salts  of  calcium  and  the  urates,  but  it  differs 
from  the  so-called  gouty  deposits  in  position  rather 
than  in  kind.  In  the  hitter  the  salts  are  deposited  by 
preference  in  the  cells  of  the  cartilage  structures,  while 
in  the  condition  under  consideration  it  is  outside  the 
joints  and  in  the  newly  formed  tissue. 

In  some  rare  instances  there  maybe  developed  both 
a  carious  condition  and  the  formation  of  new  bone 
in  and  around  the  joint.  These  two  latter  conditions 
are  very  rare  and  always  suggest  the  possibility  of  a 
syphilitic  infection  as  an  accessory  etiological  factor. 
In  all  but  this  latter  class  this  compie.\  chemical 
suboxidation  problem,  with  its  associated  toxic  condi- 
tion of  the  system  which  has  for  so  many  years  been 
included  under  the  so-called  rheumatic  condition,  can 
be  looked  upon  as  the  direct  etiological  factor  in' pro- 
ducing the  lesions  and  sj-mptoms  of  so-called  acute 
articular  rheumatism  in  all  its  varied  forms,  also  the 
neuropathic  joints,  and  some  of  the  forms  of  arthritis 
deformans.  This  is  especially  so  in  all  cases  in  which 
the  joints  become  enlarged  and  distorted  by  the  undue 
and  irregular  position  of  newly  formed  connective  tis- 
sue. 

In  the  osteoid  types  and  in  those  cases  in  which  a 
certain  amount  of  caries  occurs,  it  is  highly  probable 
that  other  etiological  factors  must  be  taken  into  con- 
sideration in  explaining  the  loss  of  bone  and  the  de- 
velopment of  new  bone.  As  already  mentioned,  it  is 
highly  probable  that  syphilis  plays  a  decided  part  in 
producing  graver  changes,  as  it  is  well  known  that 
syphilis  causes  a  decided  tendency  on  the  part  of  the 
system  to  bring  about  a  carious  state  of  the  bone  and 
a  tendency  to  the  formation  of  new  bone. 

This  method  of  explaining  the  phenomena  that  oc- 
cur in  connection  with  the  condition  of  the  system  so 
long  known  under  the  names  "gout"  and  "rheuma- 
tism "  places  us  in  a  much  better  position  to  prevent 
their  development,  and  to  displace  them  from  the  sys- 
tem when  they  have  developed.  It  further  shows  in 
which  of  the  diseases  under  discussion  the  "gouty" 
and  "rheumatic"  condition  of  the  system  acts  as  a 
direct  etiological  factor,  and  also  in  which  its  influ- 
ence is  only  of  a  secondary  nature. 


PRIMARY 


CARCINOMA    OF 
RIUM. 


THE    PAROVA- 


Bv   B.  S.  TALMEY,  M.D. 


For  the  pathologist,  says  Doran,  the  parovarium  should 
be  of  great  interest,  as  it  plays  such  a  prominent  part 
in  the  pathology  of  cystic  tumors  of  the  broad  liga- 
ments. The  vertical  tubes  of  the  parovarium  have  a 
tendency  to  develop  solid  growths.  When  they  com- 
nience  in  the  ovary  they  first  appear  in  the  tissue  of 
the  hilum,  where  rudiments  of  the  Wolffian  body  exist. 
For  the  better  understanding  of  the  epithelial  struc- 
tures of  the  urogenital  organs,  I  think  it  would  not  be 
amiss  to  review  the  embryonic  development  of  these 
organs. 

The  urinary  secretion  is  effected  throughoui  the  ani- 
mal kingdom  by  three  systems,  the  pronephros  or  head- 
kidney,  mesonephros  or  primitive  kidney,  or  Wolffian 
body,  or  "  Urniere,"  and  metanephros  or  true  kidnev 
The  pronephros  must  be  regarded  as  the  phylogene't- 
ically  oldest  part,  since  only  traces  of  it  are  found  in 
the  human  embryo.  Here  in  the  earlier  stages  of  em- 
bryonic development  the  Wolffian  body  is  the  organ 
for  the  urinary  secretion.  The  Wolffian  body  appears 
as  two  longitudinal  protuberances  on  either  side  of 
the  mesentery,  along  the  spinal  column,  the  ducts  run- 


ning alongside  the  abdominal  aorta.  The  transverse 
excretory  tubules  or  nephridia  open  into  these  prone- 
phric  ducts.  Nephridia  and  ducts  are  lined  by  a  high 
cylindrical  epithelium,  ^■ery  soon  a  small  longitu- 
dinal ridge  of  the  genital  fold  appears  on  the  ventral 
side  of  the  Wolffian  body  with  the  free  surface  toward 
the  cctlom  or  body  cavity.  The  Mullerian  duct,  the 
primitive  female  duct,  arises  from  the  mesothelium  of 
the  Wolffian  body  and  lies  close  alongside  of  the 
Wolffian  duct  on  its  medial  side.  At  the  caudal  end 
of  the  abdomen  both  the  Wolffian  and  the  Mullerian 
ducts  open  into  the  cloaca  or  hind  end  of  the  alimen- 
tary tract.  The  metanephros  or  true  kidney  appears 
first  as  an  epithelial  or  renal  evagination  of  the 
Wolffian  duct  on  its  dorsal  side  near  its  opening  into 
the  intestinal  canal  (cloaca).  This  bud  grows  for- 
ward on  the  dorsal  side  of  the  Wolffian  body  and  be- 
comes a  long  narrow  tube  (ureter),  while  the  blind 
end  changes  into  the  kidney.  The  Wolffian  bodv  is 
now  replaced   in   its  function  by  the  true  kidney  and 


— .^-^ l€ 


.  1 J'. 


@i 


.« 


>ii-;v.->i 


^'^'Jk7M^  iAfJ'f"'^  '"  "'^  ""^'S*"  °'  ">'  "ladder.  Embryo  three 
weeks  old.  .1/  Mesoderm  ;  „.  ureter  ;  fr.  excavatio  recto-uterina  •  /  intes- 
tine ;  ,«rf,  Mul  er,an  duct  ;  r,.rf,  Wolffian  duct  ;  ^,  genital  f old  •  "t '  ei«va- 
tio  utero-vesicalis  ;  /.,  bladder.  i,<:"iu.i  loia  ,  cu,  exca\a- 

enters  into  special  relation  with  the  sexual  organs. 
The  genital  folds  are  transformed  into  the  indifferent 
genital  glands  and  appear  as  two  protuberances  into 
the  ca;lom.  In  the  female  sex  the  genital  glands  or 
ovaries  soon  become  bean-shaped  with  a  free  surface 
on  the  one  side,  the  other  being  attached  by  the  meso- 
varium,  the  later  ligamentum  latum.  While  the  devel- 
opment of  the  ovaries  is  thus  going  on.  the  Mullerian 
ducts  unite  at  the  caudal  end  into  the  vagina  and  ute- 
rus, the  upper  blind  ends  diverge  and  form  the  Fallo- 
pian tubes.  The  Wolffian  tubules  and  ducts  lying 
between  the  Fallopian  tubes  and  ovaries  degenerate'! 
The  relics  of  the  tubules,  lined  by  a  16//  high  cylin- 
drical epithelium,  are  called  parovarium.  While  the 
epithelial  elements  of  the  ovary,  the  genital  epithelium, 
"Keimepithel,"  as  well  as  the  follicular  epithelium' 
arecubical,  the  epithelium  of  the  parovarium  is  a  high 
cylindrical  one  (compare  Figs.  1-4). 

Kpithelial  tumors,  even  larger  ones,  embracins;  the 
ovary,  parovarium,  and  ligamentum  latum  show,  there- 
fore, their  origin  by  the  shape  of  their  epithelium. 
The  erroneous  conception  of  the  possibility  of  a  meta- 
plasia of  flattened  epithelium  into  columnar  is  scarcely 
shared  nowadays  by  any  earnest  observer.  Columnar 
epithelial  tumors  of  the  adnexa,  not  starting  from  the 
tube,  must  therefore  by  necessity  arise  from  the  re- 
mains of  the  Wolffian  body.  This  thought  especially 
led  me  to  declare  the  tumors  in  our  case  as  of  parova- 
rian origin.  'J'he  specimen  to  be  described  came  from 
a  woman,  forty-three  years  of  age,  who  died  in  June, 
1899,  after  having  been  operated  upon  for  a  cancer  of 
the  pylorus  several  weeks  previouslv.  The  autopsy 
was  performed  in  the  pathological  institute  of  the  Uni- 
versity of  Zurich.  The  following  are  the  notes  made 
of  the  autopsy  of  the  genital  organs : 


September  22,  1900] 


MEDICAL    RECORD. 


453 


Bladder  empty;  its  mucous  membrane  pale  and 
smooth.  Vagina  wide  and  smooth.  Introitus  e.xter- 
nus  of  the  cervi.x  fissured.     Uterus  of  the  size  of  a 


i/^...v/j| 


Fig.  2. — Genital  Gland  of  a  Human  Embr>'0  Forty  Days  Old.  gp.  Genital 
gland  ;  a'rf,  Wolffian  duct  ;  «•<*,  Wollfian  body  ;  <»,  allantois  ;  aw,  arteria 
umbilicalis ;  7'm,  vena  umbilicalis. 


small  apple,  its  muscles  firm,  mucosa  witliout  particu- 
lar alteration.  Left  ovary  changed  into  a  tumor  of 
the  size  of  an  apple.  On  the  cut  surface  yellow  and 
gray  transparent  nodules  are  noticed.  Peritoneum 
intact.  ,  Right  ovarian  tumor  of  the  size  of  a  fist. 
The  cut  surface  shows  a  partly  opaque  and  partly 
transparent  yellow  appearance.  Numerous  minute 
cysts  varying  in  size,  with  clear  bright  yellow  contents, 


Fig.  3.-^.1/,  .Appendix  vcsicuIo-MorgaRni  ;  ;!/</,  Mullerian  duct;  P.  par- 
ovarian tubules;  (>.  ovary;  PO,  par-oophoron ;  ltd,  WolfTian  duct;  «, 
uterus  ;  5"/,  Gartner's  duct. 

are  seen  on  the  surface.  In  the  rectum  nothing  note- 
worthy.    No  implication  of  the  Hoor  of  the  pelvis. 

Clinical  diagnosis:  Carcinoma  pylori. 

Pathological  diagnosis:  Peritonitis  fibrinosa  uni- 
versalis perforativa,  carcinoma  ovarii. 


The  next  day  Professor  Ribbert  handed  me  the  in- 
ternal genital  tract  for  the  microscopical  examination. 

Uterus,  vagina,  bladder,  peri-  and  parametrium  are 
without  any  changes.  A  careful  examination,  particu- 
larly of  the  parametrium,  showed  nothing  patholog- 
ical. I  failed  to  discover  any  enlargement  of  the 
lymphatic  glands.  The  Fallopian  tube  runs  alongside 
the  upper  boundary  of  the  left  tumor.  The  fimbriated 
extremity  is  somewhat  enlarged*  The  fimbrix-  arc 
well  developed.  About  4  cm.  beneath  the  tube  a  small 
oval  outgrowth,  measuring  3  cm.  long  and  2  cm.  wide, 
projects  from  the  main  tumor  by  a  small  pedicle. 
This  polypus-like  appendix  shows  in  its  interior  a 
circular  Hattened  nodule  of  i  cm.  diameter.  At  the 
right  larger  tumor  the-  Fallopian  tube  is  not  quite  so 
distinctly  limited  as  on  the  left  side.  A  great  many 
fimbria;  are  here  also  preserved.  Three  to  four  cen- 
timetres below  ti)e  Fallopian  tube  a  polypus  similar  to 
that  on  the  left  side  is  attached  to  the  main  tumor  by 
a  broad,  short  pedicle.     In  its  interior  a  similar  nodule 


Fig.  4.- 


,  Ovary  ;  /,  Fallopian  lube  ;  tu.  Wolffian  body  ;  w.  mesovariuro  ; 
ligamentum  teres  uteri ;  «,  uterus.     (--Vftcr  KoUmann.) 


to  that  on  the  left  side  is  found.  Both  tumors  were 
fixed  in  Zenker's  fluid,  hardened  in  alcohol,  cut  partly 
in  paraffin,  partly  in  celloidin,  stained  with  ha.-matonin 
Van  Gieson  and  hamatonin-eosin,  and  mounted  in  Can- 
ada balsam.     The  left  tumor  was  first  examined. 

The  microscopic  examination  showed  the  main  mass 
of  the  growth  to  be  composed  of  various  irregular 
spaces  lined  with  a  single  layer  of  high  cylindrical 
epithelium  within  a  richly  cellular  stroma.  The 
luniina  are  oval  or  spherical  and  have  a  glandular 
aspect.  They  are  sometimes  occluded  with  broken- 
down  epithelium.  The  cylindrical  cells  lie  in  a  regu- 
lar row,  with  the  oval-shaped  nuclei  at  the  base.  The 
protoplasm  toward  the  lumen  is  three  to  four  times 
longer  than  the  nucleus.  The  contents  of  some  lumina 
have  a  cystic  appearance.  At  other  points  of  the  tu- 
mor the  meshes  are  very  small,  containing  only  two  to 
five  single  epithelial  cells  in  regular  rows  and  appear- 
ing to  be  on  the  point  of  forming  an  alveole,  though  I 
failed  to  find  any  cells  in  the  state  of  mitosis.  Some- 
times single  epithelial  bodies  are  found  in  the  midst 
of  the  stroma,  and  then  the  cylindrical  character  of  the 
cell  is  not  easily  determined.  The  stroma  contains 
numerous  enlarged  vessels  with  thickened  walls  and 
oval-shaped  nuclei.  Solid  nests  of  epithelial  cells  are 
not  rare,  and  even  these  cells  are  cylindrical  in  shape. 
Often  nucleolated  nuclei  are  observed.  Some  epithe- 
lial cells  show  at  the  top  distinct  vacuoles. 

Examining  under  the  microscope  sections  of  the 
above-mentioned  appendix,  I  found  normal  ovarian 
tissue  with  well-formed  Graafian  follicles  lined  with  a 


454 


MEDICAL   RECORD. 


[September  22,  1900 


cubical  epithelium.  The  stroma  of  the  ovary  has  the 
normal  amount  of  vessels.  Cellular  infiltration  is 
nowhere  to  be  seen,  but  there  is  a  distinct  incre.ise  of 
the  fixed  connective-tissue  cells.  At  the  border  of  the 
above-mentioned  nodule  within  the  ovary  the  mutually 
intergrowing  of  the  connective-tissue  and  epithelial 


-^5^ 

[         ,.    V 

•-i^: 


Fig.  5.— Cut  through  the  Left  Cancer,  a.  Stroma  ;  b,  alveoles  lined  with  a 
single  layer  of  epithelial  cells  ;  c,  cell  nests  ;  rf,  broken-down  epithelium 
within  the  alveoles. 


cells  can  be  noticed.  Single  epithelial  cells  are  sur- 
rounded by  connective  tissue.  A  little  farther  the 
epithelial  cells  become  very  numerous,  and  the  tissue 
gives  the  appearance  of  being  infiltrated  by  epithelial 
cells.  They  are  now  often  lying  in  a  regular  row,  are 
cylindrical  in  shape,  and  begin  to  assume  a  glandular 
appearance.  Soon  the  meshes  become  larger  and  are 
lined  with  columnar  epithelium.  They  are  not, 
though,  round  or  oval  as  in  the  larger  tumor,  and  ap- 
pear more  like  enlarged  lymphatic  spaces.  The  epi- 
thelial cells  are  not  so  high  as  in  the  main  tumor,  and 
where  they  are  lying  single  the  nucleus  is  not  dis- 
tinctly recognizable.  The  hilum  appears  normal. 
Old  corpora  lutea  are  noticed.  Often  the  epithelial 
cells  show  a  distinct  degeneration,  being  more  homo- 
geneous and  having  lost  their  nuclei. 

In  the  right  tumor  the  conditions  are  similar.  The 
tumor  has  an  adenomatous  structure,  and  can  be  classed 
among  those  growths  which  have  been  often  called 
cylindrical  epithelioma  or  malignant  adenoma.  The 
alveoles  are  of  irregular  size  and  lined  with  a  high 
columnar  epithelium.  The  larger  alveoles  contain  a 
cystic  mass,  the  smaller  appear  empty.  Some  epithelial 
cells  are  found  in  semilunar  rows.  Here  and  there 
solid  epithelial  nests  are  found.  The  tumor  is  sharply 
limited  toward  the  ovarian  tissue.  The  ovary  contains 
some  Graafian  vesicles  and  corpora  lutea,  and  resembles 
in  every  respect  normal  ovarian  tissue. 

The  microscopical  examination  corroborates  the  as- 
sumption that  the  appendices  represented  the  preserved 
ovaries.  The  invasion  of  the  ovarian  tissue  by  the 
cancerous  process  has  already  begun.  But  the  partly 
preserved  ovaries  show  that  the  tumor  is  not  of  ovarian 
origin.  The  intact  hilum,  as  well  as  the  high  cylin- 
drical epithelium  of  the  alveoles,  shows  its  parovarian 
origin.  For  granting  even  the  correctness  of  the  for- 
mer generally  accepted  view  of  columnar  epithelial 
cells  being  able  to  change  into  flattened  epithelium,  it 
is  hard  to  understand  liow  and  why  cubical  and  flat- 
tened epithelium  should  first  change  into  the  higher 
organized  columnar  epithelium,  when  already  doomed 
to  destruction.  The  metaplastic  theory,  as  well  as  the 
assumption  of  a  primary  penetration  of  epithelial  cells 
into  the  surrounding  tissue,  presupposes  a  change  of 
the  cells,  for  which  we  iiave  no  reason.  However,  we 
often  see  that  various  external  or  internal  irritations 
cause  a  proliferation  of  connective  tissue.  The  favor- 
ite organs  for  the  cancer,  on  the  other  hand,  are  also 
those  which  are  often  exposed  to  such  irritations. 
Hence  Ribbert's  theory  ascribes  the  histogenesis  of 
cancers  to  a  primary  proliferation  of  the  connective  tis- 


sue, which,  penetrating  between  the  epithelial  cells, 
separates  them  from  their  continuity  and  encloses  a 
variable  number  of  them.  The  isolated  celLs,  sepa- 
rated from  their  organic  connection,  continue  their 
normal  proliferating  tendency  within  the  connective 
tissue,  dislodging  and  supplanting  the  latter  and  giv- 
ing rise  to  a  cancerous  growth.  They  do  not  change 
their  character,  and  less  so  do  they  alter  their  shape. 
This  theory  of  Ribbert  became  a  subject  of  debate. 
His  most  conspicuous  opponent,  Hauser,  ascribes  the 
growth  and  spreading  of  the  primary  cancer  to  a  con- 
tinual ingrowing  of  the  proliferating  epithelial  cells 
into  the  connective  tissue.  The  passing  downward  of 
single  or  rows  of  epithelial  cells  into  the  changed 
stroma  is  due  to  the  faculty  of  the  cancerous  cells  to 
perform  amoeboid  movements.  But  the  question  re- 
mains the  same,  how  a  primary  columnar-celled  cancer 
could  originate  in  an  organ  possessing  normally  only 
cuboidal  epithelium.  Now  the  main  mass  of  our 
tumor  is  situated  between  the  ovaries  and  the  Fallo- 
pian tubes,  where  normally  the  pronephric  relics  are 
found,  that  in  an  early  emjjryonic  stage  are  lined  with 
a  cylindrical  epithelium.  Our  tumors  are,  therefore, 
certainly  of  parovarian  origin. 

That  tliese  growths  are  metastases  of  the  carcinoma 
pylori  is  scarcely  to  be  thought  of.  The  formerly 
widely  accepted  view,  that  cancerous  cells  could  drop 
down  from  the  stomach  into  the  pelvis  and  continue 
their  proliferation  in  the  broad  ligaments,  is  not  shared 
nowadays  by  any  earnest  observer.  The  cancerous 
cells  could,  therefore,  reach  the  broad  ligaments  only 
by  the  way  of  the  lymphatics  or  blood-vessels.  But  it 
is  scarcely  probable  that  the  cells  on  their  long  way 
from  the  pylorus  to  the  pelvis  would  pass  all  the  lym- 
phatic glands  without  causing  any  metastasis  anywhere, 
as  in  the  liver  and  the  easily  affected  mesenteric 
glands.  If  the  cells  had  passed  the  vena  porta,  they 
would  surely  have  left  some  changes  in  the  liver. 
There  is  no  plausible  reason  why  the  cancerous  cells 
should  just  settle  in  the  broad  ligaments.  In  what 
relation  does  the  epithelium  of  the  pylorus  stand  with 
that  of  the  parovarium  or  ovary?  The  shape  of  the 
epithelial  cells  in  our  case  is  also  against  the  assump- 


I-m;.  6.  — P.rti   [1  .1  11.;.  5  more  highly  magnified. 

tion  of  our  tumors  to  be  metastases  of  the  carcinoma 
pylori.  If  Ribbert's  account  of  the  origin  of  cancers 
be  correct — and  I  fail  as  yet  to  find  any  better  theory- 
there  is  no  possibility  of  epithelial  cells  changing 
their  character,  and  the  structure  of  the  metastasis  must 
be  the  same  as  that  of  the  primary  cancer.  The  cylin- 
drical cancers  of  the  pylorus  are  generally  solid,  true 


September  22,  1900] 


MEDICAL    RECORD. 


455 


cancers,  the  alveoles  being  filled  with  epithelial  cells. 
In  our  case  the  alveoles  are  lined  by  a  single  layer  of 
high  columnar  epithelium.  The  tumor  is  the  true 
adeno-carcinoma  as  described  by  Ziegler,  and  it  is  im- 
probable that  a  primary  simple  cancer  will  set  up  a 
metastasis  of  an  adeno-carcinoma. 

I  am  therefore  led  to  the  conclusion  that  the  right 
parovarian  growth  is  certainly  a  primary  cancer.  As 
to  the  left  growth  it  is  difficidt  to  decide.  The  path 
by  tlie  lymphatics  could  be  excluded,  since  the  para- 
metrium is  in  no  way  affected.  There  is  no  direct 
path  across  the  uterus  from  one  parovarium  to  the 
other.  I  would,  therefore,  rather  incline  to  the  belief 
that  both  tumors  are  two  independent  growths  excited 
alike  locally  by  a  lower  vitality  and  called  into  ex- 
istence by  a  morbid  substance  existing  tiiroughout  the 
body.  Similarly  Williams,  in  accord  with  Sir  James 
Paget,  declares  in  a  case  of  his  the  cancers  of  botli 
thighs  to  be  independent  of  one  another.  Other  writ- 
ers also  have  observed  multiple  primary  cancers  in  the 
same  person.  Mandry  saw  two  cases,  one  of  two  pri- 
mary cancers  of  both  thighs,  and  the  other  of  the  ex- 
ternal part  of  both  ears.  Johannowsky  saw  two  cases 
of  carcinoma  ovarii  bilaterale.  Volkmann  describes 
primary  cancers  of  both  thighs.  Bruns  affirms  the  ex- 
istence of  deposits  of  cancerous  masses  on  two  or  more 
remote  points  of  the  body  in  one  and  the  same  person, 
which  lie  beyond  the  anatomical  reach  of  the  primary 
cancer,  so  tliat  the  younger  growth  could  not  have 
arisen  from  the  primary  tumor  by  a  structural  continu- 
ity of  the  cancerous  masses.  Hutchinson  describes  a 
case  of  two  separate  growths  of  epithelial  cancer  de- 
veloped almost  simultaneously  on  the  opposite  sides 
of  the  tongue.  13ucher  in  describing  two  cases  of  pri- 
mary cancers  of  the  stomach  and  intestines  says: 
'"With  our  present  knowledge  we  are  not  justified  in 
assuming  another  path  for  the  metastasis  of  tumors 
than  by  continued  proliferation  of  the  cell-elements  to 
the  other  points."  Billroth  answers  the  question, 
whether  in  a  given  case  the  multiple  cancers  are  pri- 
mary or  secondary,  by  demanding  that,  (i)  the  cancers 
should  have  a  different  anatomical  structure;  (2;  that 
one  cancer  could  not  be  derived  histologically  from 
the  epithelium  of  the  primary  growth;  and  (3)  that 
every  cancer  should  set  up  its  own  metastasis.  Of 
these  tliree  requirements  the  third  is  the  least  impor- 
tant, as  we  often  see  single  primary  cancers  that  do 
not  set  up  any  metastases.  The  other  two  conditions 
are  given  in  the  present  case.  VVe  are  therefore  jus- 
tified in  assuming  in  our  case  a  primary  carcinoma  of 
both  parovaria. 

A  few  words  will  now  suflSce  to  show  how  any  con- 
nective-tissue proliferation  in  the  broad  ligaments 
could  give  rise  to  cancerous  growths.  The  old  authors 
have  long  given  to  the  connective  tissue  an  important 
part  in  the  origin  of  cancers.  Thiersch  is  of  the  opin- 
ion that  any  weakening  change  of  the  connective  tis- 
sue enables  the  naturally  energetic  epithelial  cells  to 
penetrate  into  the  deeper  layers.  Waldeyer  also  be- 
lieves that  epithelial  remains,  when  enclosed  in  con- 
nective tissue  and  thus  disturbed  in  their  natural 
growth  and  function,  often  begin  to  proliferate  in  an 
abnormal  way,  and  give  rise  to  cancerous  growths. 
Klebs  demands  as  the  characteristic  features  of  the 
cancer  a  metastasis  of  the  epithelial  cells  within  the 
connective  tissue  at  the  outset.  Boll  finds  also  at  first 
proliferation  of  the  connective-tissue  cells,  which  then 
give  rise  to  the  formation  of  emljryonic  vascular  germ 
tissue.  The  resulting  struggle  for  mastery  between 
the  connective  tissue  and  the  epithelium  leads  to  an 
invasion  of  one  another's  territory,  i.e.,  to  a  cancer- 
ous growth.  Recently,  as  above  mentioned,  Ribbert 
claims  as  the  main  cause  for  the  origin  of  a  cancer 
always  the  proliferation  of  the  connective  tissue  ele- 
ments resulting  in  a  separation  of  the  epithelial  cells 


from  their  organic  coherence  and  their  implantation 
within  the  connective  tissue.  At  the  beginning  of  the 
cancerous  proliferation  a  distinct  boundary  line  of  the 
two  tissues  cannot  always  be  made  out;  instead  a 
gradual  transition  of  epithelium  into  connective  tissue 
is  always  observed.  It  gives  one  the  impression  of 
the  epithelium  and  connective  tissue  rushing  pell-mell 
into  the  combat  — no  arrangement  of  cells  of  the  for- 
mer, rather  small  groups  or  even  single  cells.  The 
isolated  cells  arc  not  inert,  however.  The  isolation 
of  the  epithelial  cells  once  accomplished,  they  begin 
to  proliferate  within  the  connective  tissue  and  form 
the  alveoles,  the  epithelium  growing  in  the  line  of  the 
least  resistance.  The  malignant  metastasis  of  a  priori 
benign  growth  {e.g..,  adenoma  struma)  furnishes  us  the 
best  proof  for  Ribbert's  contention,  that  cells  in  other 
respects  unchanged,  once  separated  from  their  organic 
union,  continue  their  proliferating  tendencies  in  other 
organs  under  more  favorable  conditions  and  give  rise 
to  malignant  growths.  Ribbert  has  since  completed 
his  theory  of  the  origin  of  flattened  epithelial  cancers 
from  columnar  epithelial  growths.  The  increased 
proliferation  of  the  connective  tissue  causes  a  kind  of 
amputation  of  the  lower  ends  of  the  glands.  These 
separated  ends  do  not  always  undergo  cystic  degenera- 
tion, but  following  the  natural  tendency  of  normal 
glands  they  jienetrate  incessantly  into  the  deeper  lay- 
ers. In  short,  Ribbert  attributes  the  origin  of  growths 
to  an  intra-  or  extra-uterine  separation  of  the  tissue- 
germs  from  their  organic  union.  The  isolated  cell 
aggregations,  withdrawn  from  the  influence  of  their 
organic  continuity,  continue  to  increase  on  their  own 
account  and  lead  to  atypical  growths. 

In  our  case  there  was  from  the  start  a  natural  metas- 
tasis of  epithelial  cells  within  a  connective  tissue. 
The  relics  of  the  Wolffian  body  are  parts  of  an  embry- 
onic organ  which  has  lost  its  function,  and  which  in 
the  female  is  doomed  to  degeneration.  Now  Zahan's 
experiment  shows  that  non-embryonic  tissue  grafted 
from  one  animal  upon  another  becomes  encapsulated 
and  inert,  while  embryonic  tissue  continues  to  prolif- 
erate. In  our  case  the  metastatic  cells  were  of  embry- 
onic origin.  Leopold  says:  "If  a  superfluous  or  for- 
eign heap  of  cells  occurs  within  another  tissue,  ho- 
mologous or  not,  this  cell  heap,  in  accordance  with  its 
embryonic  nature,  has  tiie  faculty  to  increase  enor- 
mously, needing  only  an  increased  blood  supjjly,  as  is 
found  in  the  human  body  during  puberty  or  menstru- 
ation." Ribbert  says:  "  Every  mechanical  stretching 
and  every  hypera-mia  of  the  tissue  which  causes  an 
increase  in  size  of  an  organ,  and  in  that  way  a  sepa- 
ration of  the  individual  parts  of  the  tissue  from  one 
another,  can  also  effect  an  abnormal  proliferation."  In 
our  case  we  have  a  natural  metastasis  of  embryonic 
epithelial  cells  in  the  connective  tissue  of  the  broad 
ligaments,  that  are  certainly  often  exposed  to  nat- 
ural changes  of  the  blood  supply  and  to  various 
chronic  irritations.  If  by  any  causv  the  tissue  of  the 
broad  ligament  undergoes  modification,  then  all  the 
conditions  for  the  development  of  a  cancer  are  present. 
The  slumbering  embr)'onic  cells  are  again  awakened 
to  a  new  existence,  and  a  tumor  is  the  result. 

Parovarian  tumors  are,  therefore,  not  so  rare.  If 
all  the  so-called  ovarian  tumors  were  systematically 
examined  under  the  microscope,  a  great  part  of  them 
would  certainly  be  found  to  be  of  parovarian  origin. 

BIBLIOGKAl'HV. 

Doran  :  Transactions  of  the  Pathological  Society  of  London, 
vol.  34. 

Ribbert  :  Virchow's  Archiv.  vols.  195  and  I4r. 
Ribbert:  Miinchener  med.  Wochenschr.,  iSgS.  No.  25. 
Hauser  :  Virchow's  .Archiv.  vol.  13S. 
Williams:   British  Medical  Journal,  1887. 
Mandry  :   Bruns'  Beitrage  zur  Chirurg. .  vol.  viii. 
Johannowsky:   Prager  raed.  Wochenschr.,  1S77. 


456 


MEDICAL    RECORD. 


[September  22,  1900 


Volkmann  :   Samml.  klin.  Vortrage,  334.  335. 

Bruns  :   Handbuch  der  pract.  Chirurg..  1S59. 

Hutchinson  :  Transactions  of  the  Pathological  Society  of  Lon- 
don, 1S75. 

Bucher  :  Ziegler's  Beitrage.  vol.  xiv. 

Billroth  :   Allgem.  chirurg.  Pathol,  u.  Therapie. 

Waldeyer  :  Virchow's  Archiv,  vol.  41. 

Klebs  ;  Allgemeine  Pathologic,  vol.  ii. 

Zahan  :  Sur  le  sort  du  tissu  implante  dans  I'organisme. 
Protocol  du  Congr^s  mcd.  interne  de  Geneve,  187S. 

Leopold  ;  Virchow's  Archiv,  vol.  85. 


SnrPLE  FR.-\CTURE  OF  THE  SHAFT  OF 
THE  FEMUR,  WITH  REPORT  OF  TWO 
CASES    OF    DELAYED    UNION.' 

By   WILLIAM    H.    SHIPPS,    M.D.. 

BOKDENTO'WN,    N.    J. 

The  successful  treatment  of  fractures  of  the  bony  frame- 
work not  only  embraces  union  of  the  broken  fragments, 
but  restoration  of  function  as  well,  and  only  when  the 
two  conditions  are  realized  can  it  be  said  that  we  have 
achieved  a  perfect  result. 

Even  under  the  most  favorable  circumstances,  insur- 
ing the  exercise  of  the  highest  skill,  this  is  not  always 
possible,  and  the  results  thus  attained,  while  not  so 
satisfactory  either  to  patient  or  surgeon,  in  no  sense 
militate  against  the  skill  or  watchfulness  of  the  latter, 
but  in  a  majority  of  cases  are  due  to  causes  over  which 
he  has  no  control.  Fortunately  the  cases  are  rare  in 
which,  if  the  proper  skill  and  care  are  exercised,  the 
results  are  entirely  unsatisfactory. 

Apparently  there  is  nothing  specially  brilliant  in 
the  setting  of  a  broken  bone  or  conducting  the  case  to 
a  successful  issue.  If  we  obtain  satisfactory  results, 
well  and  good;  nothing  else  is  tolerated  by  our  pro- 
fessional brethren,  while  the  laity  at  large  look  upon 
the  healing  of  a  broken  bone  as  an  everyday  occur- 
rence for  which  the  surgeon  is  entitled  to  no  special 
commendation,  and,  as  a  rule,  he  neither  gets  nor  ex- 
pects it.  Once  in  a  while,  however,  the  results  are  not 
just  what  he  had  hoped  for,  and  he  is  then  not  infre- 
quently cheered  by  the  kindly  criticisms  of  his  breth- 
ren in  the  profession,  especially  by  that  member  who 
has  been  uniformly  successful  in  every  case  he  was 
called  to  treat.  We  all  have  met  this  personage — I 
know  I  have — and  have  seen  specimens  of  his  handi- 
work, too. 

I  well  remember  when  years  ago  a  student  of  medi- 
cine attending  the  lectures  of  that  skilful  surgeon  and 
prince  of  clinicians,  D.  Hayes  .^gnew,  hearing  him 
lecture  upon  the  subject  of  fractures  in  general.  "  Gen- 
tlemen," he  said,  "no  class  of  cases  coming  under  your 
notice  in  after-life  will  give  you  more  anxiety  or  at 
times  call  for  the  exercise  of  greater  judgment  and 
skill  than  the  diagnosis  and  treatment  of  fractured 
bones,  and  especially  when  they  involve  the  neighbor- 
hood of  the  joints."  "VVith  all  my  experience,"  he 
added,  "I  to  this  day  never  approach  a  fracture  of  the 
elbow  joint  without  realizing  I  am  dealing  with  a  grave 
injury,  the  outcome  of  which  I  cannot  with  certainty 
predict."  Wiien  a  surgeon  of  Agnew's  attainments 
gives  utterance  to  sentiments  such  as  these,  who  will 
justify  the  indilTerence  with  which  the  general  practi- 
tioner sometimes  approaches  this  class  of  injuries? 

And  now  just  a  word  upon  the  medico-legal  aspect  of 
the  subject.  This  always  annoying  complication  may 
never  have  appealed  to  you,  but  it  is  likely  to  thrust 
itself  upon  you  when  least  expected:  consequently  it 
is  not  amiss  to  devote  to  it  brief  consideration. 

As  before  stated,  notwithstanding  our  best  efforts, 
occasionally  deformity  or  more  or  less  loss  of  function 
is  the  unpleasant  sequela  of   injuries  of  the  kind  to 

'  Read  before  the  IJurlington  County  .Medical  Society,  June 
19,  19OU. 


which  we  allude,  and  too  often  the  surgeon  in  charge 
is  unjustly  held  responsible.  It  behooves  us,  then,  as 
physicians  and  surgeons  to  exercise  the  greatest  char- 
ity in  our  criticisms  of  these  untoward  results. 

Unfortunately  the  tendency  is  to  take  advantage  of 
our  brother's  misfortune,  if  such  it  be,  and  not  infre- 
quently by  look  or  word  furnish  the  pretext  for  a  legal 
action  that  may  be  productive  of  untold  evil  to  our 
medical  associate.  I  have  made  it  a  point  for  years 
when  requested  to  pass  upon  the  treatment  of  a  frac- 
tured bone,  to  avoid  all  semblance  of  unfavorable  criti- 
cism even  when  it  would  seem  circumstances  justi- 
fied it. 

Years  ago  a  noted  surgeon  said :  "  It  has  been  my 
invariable  rule  to  discourage  in  the  most  emphatic 
manner  possible  any  criticisms  reflecting  upon  the 
skill  of  a  professional  brother."  Only  recently  he 
added:  "A  man  came  to  my  office  with  a  decided 
limp,  the  result  of  a  fractured  thigh  that  had  solidly 
healed,  but  with  marked  deformity  and  shortening. 
Divining  that  his  purpose  was  merely  to  obtain  an  ex- 
pression from  me  as  to  the  treatment  of  the  case,  I  pro- 
ceeded to  examine  the  limb  carefully;  which  accom- 
plished, I  said  to  him:  '  You  should  be  very  grateful 
at  making  so  good  a  recovery.'  As  a  result  he  left  my 
office,  disappointed  with  the  verdict  perhaps,  but  cer- 
tainly with  a  very  different  feeling  toward  his  attend- 
ing physician  than  he  had  previously  entertained." 

I  would  that  all  of  us  exercised  the  same  charity; 
were  this  the  rule  malpractice  suits  would  be  rarely 
heard  of.  Probably  nine  such  cases  out  of  ten  owe 
their  origin  to  the  dishonesty  of  the  patient,  a  dishon- 
orable or  thoughtless  action  of  some  member  of  our 
profession,  and  the  cupidity  of  a  shyster  lawyer. 
These  constitute  the  trinity  that  have  to  do  with  most 
of  the  cases  that  find  their  way  into  our  courts  seek- 
ing fictitious  damages. 

I  will  say  to  the  younger  men  here  present,  watch 
your  fracture  cases  most  carefully.  In  most  instances 
it  is  better  far  to  call  in  some  medical  friend  to  assist 
at  the  first  dressing;  he  will  not  only  be  of  great  as- 
sistance at  the  time,  but  may  be  of  even  greater  ser- 
vice later  on.  The  fracture  cases  I  am  most  wary  of, 
and  in  which  I  almost  invariably  call  in  outside  aid, 
are  those  in  the  transient  guests,  who  are  with  you  to- 
day but  away  perhaps  to-morrow,  then  to  pass  into  the 
hands  of  some  other  surgeon  or  physician,  who,  in  case 
of  any  untoward  result  follow'ing,  is  quite  likely  to  at- 
tribute the  same  solely  to  the  treatment  instituted  at 
the  first  dressing.  But  all  this  is  a  digression,  a  par- 
donable one  I  trust,  from  the  subject  proper  of  this 
paper,  delayed  union  in  fracture  of  the  shaft  of  the 
femur. 

In  private  practice  probably  not  more  than  three  j 
per  cent,  of  all  fractures  we  are  called  to  treat  will  f 
be  fractures  of  the  femur.  Of  1,712  cases  of  frac- 
ture treated  in  the  Pennsylvania  Hospital,  256  or  fif- 
teen per  cent,  were  fractures  of  the  femur.  Of  51,938 
cases  treated  in  the  London  Hospital,  covering  a  period 
of  twenty-five  years,  3,243,  or  more  than  six  per  cent., 
were  fractures  of  the  thigh.  Edward  Martin,  of  Phila- 
delphia, in  an  article  published  in  The  'J'heiapeuiic 
Gazette  for  May.  1900,  gives  some  exceedingly  inter- 
esting statistics  upon  the  subject  of  fractures  of  the 
femur,  and  from  the  results  following  treatment  of  the 
same  draws  conclusions  for  the  most  part  not  at  vari- 
ance with  tiiose  of  Holthouse,  of  London,  Hamilton, 
Buck,  and  Manley,  of  New  York,  and  Agnew,  of  Phila- 
delphia, and  calculated  to  make  those  of  us  in  private 
practice  who  achieve  good  results  triumphant,  and 
somewhat  comforted  when  we  are  less  successful. 

To  quote  from  Martin's  paper:  "In  the  hope  of  de- 
termining with  some  degree  of  accuracy  the  ultimate 
prognosis  of  simple  fracture  of  the  shaft  of  the  femur 
when   treated  by  skilful  surgeons  and  in  accordance 


September  22,  1900] 


MEDICAL   RECORD. 


457 


with  generally  approved  methods,  I  have  had  a  list 
made  from  the  leading  hospitals  of  the  city,  compris- 
ing all  the  cases  treated  in  the  wards  of  these  institu- 
tions from  1890  to  1899.  An  effort  was  then  made  to 
find  each  patient  in  the  list  and  to  determine  by  direct 
examination  the  seat  of  his  fracture,  the  method  of 
treatment,  the  period  of  total  disability,  the  period  of 
partial  disability,  the  amount  of  shortening  or  other 
aeformity,  and  the  amount  of  ultimate  crippling." 

Out  of  a  list  of  several  hundred,  one  hundred  care- 
ful observations  were  made.  Of  the  100  cases.  45 
were  in  children  and  55  in  adults,  85  male  and  15 
female.  In  30  cases  occuring  in  childhood  the  frac- 
ture involved  the  middle  third  of  the  bone,  in  10  cases 
the  upper  third,  in  5  cases  the  lower  third.  Nineteen 
of  these  patients  were  totally  disabled  for  two  months, 
15  for  two  and  a  half  months,  10  for  three  months,  1 
for  five  months.  There  was  a  further  partial  disabil 
ity  averaging  two  months.  In  14  cases  there  was  no 
shortening;  in  2  the  shortening  was  '2  cm.;  in  18  the 
shortening  was  1  cm.;  in  8  the  shortening  was  1.5  cm.; 
in  3  the  shortening  was  10  cm.  There  was  no  disabil- 
ity in  30,  but  II  of  these  suffered  from  slight  limp, 
stiffness,  and  pain  in  wet  weather.  There  was  slight 
permanent  crippling  in  7.  There  were  2  cases  of  de- 
layed union. 

In  the  series  of  55  cases  occurring  in  adult  life,  2 
were  double  fractures.  In  32  the  fracture  involved  tlie 
middle  third;  in  17,  the  upper  third;  in  8,  the  lower 
third.  In  2  cases  there  was  no  shortening.  In  the 
remaining  53  cases,  the  shortening  ranged  from  1.5  to 
7  cm. 

In  12  cases  there  was  no  permanent  disability;  in 
43  cases  there  was  permanent  crippling,  the  limp,  stiff- 
ness, pain,  and  swelling  being  so  great  as  seriously  to 
interfere  with  ordinary  activity.  The  period  during 
which  these  patients  were  bedridden  was  from  two  to 
twenty-four  months,  or  longer. 

The  cases  were  in  tlie  main  treated  by  sand  bags 
and  extension,  secured  by  weights  attached  to  the  leg 
and  thigh  by  adhesive  strips,  the  foot  of  the  bed  being 
raised  to  secure  counter-extension. 

From  a  study  of  the  one  hundred  cases,  which  Martin 
says  are  too  few  to  justify  dogmatic  assertion,  the  fol- 
lowing conclusions  seem  tenable: 

In  children  the  average  period  of  treatment  in  bed 
with  crutches,  splints,  and  bandages  is  five  months. 
In  about  one-third  of  the  cases  there  will  be  no  short- 
ening; in  about  one-half  a  shortening  of  i  cm.;  the 
remainder  will  show  a  shortening  of  between   i  and 

2  cm. 

In  adults  the  average  period  of  treatment  is  eight 
months.  In  four  per  cent,  there  may  be  no  shortening; 
in  five  per  cent,  a  shortening  of  i  cm.;  in  nine  per 
cent,  a  shortening  of  1.5  cm.;  in  twenty-six  per  cent, 
a  shortening  of  2  cm.;  in  nineteen  per  cent,  a  shorten- 
ing of  2.5  cm. ;  in  seventeen  per  cent,  a  shortening  of 

3  cm.;  in  twelve  per  cent,  a  shortening  of  from  3  to  4 
cm.;  and  in  the  remainder  an  even  greater  shortening. 

An  ultimate  shortening  of  less  than  2  cm.  after  frac- 
ture of  the  shaft  of  the  femur  in  an  adult  is  the  excep- 
tion, and  in  men  past  the  age  of  twenty-one  years  will 
not  occur  in  more  than  one  case  out  of  ten.  An  ulti- 
mate shortening  of  from  2.5  to  4  cm.  is  so  commonly 
observed  after  skilful  treatment  of  simple  fracture  of 
the  shaft  of  the  thigh  that  this  circumstance  is  in  itself 
not  even  suggestive  of  carelessness  or  improper  treat- 
ment on  the  part  of  the  surgeon.  Martin  makes  no 
reference  to  the  fact  so  emphatically  urged  and  so 
clearly  demonstrated  by  Thomas  G.  Morton,  that  in 
most  cases  careful  measurement  of  the  human  skeleton 
shows  an  almost  constant  deviation  from  bilateral  sym- 
metry. A  man  with  limbs  of  equal  length  is,  accord- 
irig  to  Morton,  the  exception;  this  he  first  demon- 
strated in  one  of   his  patients  as  far  back  as   1873, 


when  on  measuring  the  two  limbs  it  was  found  that 
the  fractured  limb  was  slightly  longer  than  its  fellow. 
This  led  to  further  investigation,  and  a  series  of  meas- 
urements of  different  individuals,  including  those  who 
had  suffered  injury  of  the  thigh  and  those  who  had 
not,  justified  the  conclusion  that  asymmetry  as  to  length 
in  the  lower  extremities  of  the  same  person  is  the  rule 
and  perfect  symmetry  the  exception. 

"Not  more  than  one  man  in  five  who  has  sustained 
a  simple  fracture  of  the  thigh  will  never  again  be  able- 
bodied;  the  other  four  will  suffer  from  weakness  and 
swelling  of  the  leg  and  harassing  pain,  and  if  labor- 
ing-men will  be  debarred  from  their  usual  work." 

In  speaking  of  treatment,  Martin  says  that  the  un- 
satisfactory results  following  the  weight-extension 
treatment  of  fractures  of  the  thigh  suggest  that  this 
method  is  either  inadequate  in  itself  or  is  unskilfully 
applied,  or  that  the  ambulant  treatment  of  fractured 
•femur  after  consolidation  of  the  bone  is  not  sufficiently 
guarded.  If  with  all  the  appliances  of  modern  sur- 
gery, such  as  every  hospital  affords,  the  results  are  as 
described  by  Martin  and  confirmed  by  such  authori- 
ties as  Agnew,  Hamilton,  liigelow,  and  others,  those 
of  us  in  private  practice,  so  far  as  my  limited  observa- 
tion goes,  have  no  special  cause  for  humiliation. 

One  of  the  complications,  if  so  it  can  be  termed, 
sometimes  following  fracture  of  the  shaft  of  the  femur 
is  what  is  known  as  delayed  union,  differing  from  non- 
union in  that  consolidation  eventually  takes  place. 
Granted  that  the  fragments  are  in  good  apposition  and 
the  subsequent  treatment  combines  all  that  modern  sur- 
gery approves,  it  is  difficult  to  explain  why  in  some 
instances  prompt  union  fails  to  take  place.  In  such 
cases  I  believe  the  cause  can  generally  be  traced  to 
some  constitutional  vice  or  fault,  which,  when  recog- 
nized and  prompt  treatment  instituted,  is  followed  by 
good  results. 

In  support  of  this  proposition  I  ask  your  attention 
to  the  following  cases  occurring  in  my  practice: 

Case  I. — On  January   20,  1893,  S.  L ,  a  young 

woman  seventeen  years  of  age,  unmarried,  while  coast- 
ing was  violently  thrown  from  a  sled  against  a  tree, 
sustaining  a  fracture  of  the  right  femur  at  about  the 
junction  of  its  middle  and  lower  third.  She  was  at 
once  carried  to  her  home,  placed  upon  a  firm  mattress, 
and  sand  bags  and  extension  by  weight  and  pulley  were 
employed. 

The  patient,  an  exceedingly  nervous  but  intelligent 
girl,  recognized  from  the  start  the  importance  of  keep- 
ing the  fragments  in  position,  and  labored  in  every 
possible  way  to  avoid  disturbance  of  the  limb;  so  de- 
termined was  she  in  this  respect  that  she  avoided  in 
so  far  as  possible  a  regular  evacuation  of  the  bowels, 
although  assured  of  the  folly  of  such  a  course.  Hav- 
ing a  most  capricious  appetite,  it  was  difficult  for  the 
first  six  weeks  to  get  her  to  take  a  sufficient  quantity 
of  nourishment,  although  the  necessity  for  this  impor- 
tant aid  in  bone  repair  was  constantly  urged  upon  her. 
At  the  end  of  four  weeks  the  dressings  were  removed 
and  the  limb  was  carefully  inspected.  No  shortening 
was  detected,  but  to  my  chagrin  no  attempt  at  union  had 
taken  place,  notwithstanding  the  parts  were  in  perfect 
apposition.  The  dressings  were  carefully  reapplied. 
On  March  20th,  two  months  after  the  injury,  an  ex- 
amination showed  entire  absence  of  bony  union.  At 
this  juncture  I  requested  Dr.  Thomas  G.  Morton,  of 
Philadelphia,  to  see  the  case  with  me.  It  was  agreed 
to  resort  to  daily  massage  of  the  entire  limb,  especially 
in  the  vicinity  of  the  fracture  and  to  lessen  the  amount 
of  the  extension,  the  weight  at  no  time  exceeding  eight 
pounds.  The  limb  was  also  incased  in  a  firm  dress- 
ing made  of  two  Russia-felt  splints,  carefully  moulded 
to  the  limb — a  posterior  one  extending  from  the  great 
trochanter  to  within  six  inches  of  the  ankle;  an  ante- 
rior one  extending  the  entire  length  of  the  thigh,  firmly 


458 


MEDICAL    RECORD. 


[September  22,  1900 


held  in  place  by  a  roller  bandage.  Four  weeks  later 
the  patient  was  allowed  to  get  out  of  bed  daily  and 
walk  about  on  crutches,  care  being  taken  that  no 
weight  be  borne  upon  the  limb.  This  plan  of  treat- 
ment, together  with  the  daily  use  of  the  hypophosphites 
of  lime  and  soda,  was  faithfully  carried  out;  the  appe- 
tite of  the  patient  in  the  mean  time  materially  im- 
proved. In  the  course  of  three  weeks  the  circumfer- 
ence of  the  limb  had  visibly  increased  and  an  evident 
attempt  at  bony  union  was  noticed.  From  this  on  the 
limb  gradually  improved  in  size  and  strength,  until  at 
the  expiration  of  eight  weeks  from  the  commencement  of 
massage,  or  sixteen  weeks  from  the  date  of  injury,  con- 
solidation w^as  complete.  The  dressings  were  contin- 
ued for  a  few  weeks  longer,  when  a  roller  bandage  took 
the  place  of  splints.  Careful  measurement  of  the  two 
limbs  failed  to  show  any  appreciable  shortening.  Ul- 
timately no  evidence  of  the  injury  was  apparent  to  the 
observer. 

Case    II. — February    6,     1897.     C.    L ,    male, 

twenty-six  years  of  age,  weight  one  hundred  and  sixty 
pounds,  while  working  in  a  rubber  mill  had  occasion 
to  move  a  heavy  roll  of  rubber  belting  from  a  platform 
to  a  truck  below.  In  some  way  he  slipped  to  the 
floor,  the  roll  falling  upon  his  right  thigh,  causing 
fracture  of  the  bone  both  at  its  upper  and  middle 
thirds.  He  was  conveyed  to  his  home,  a  distance  of 
eight  miles.  With  the  assistance  of  Dr.  Macfarland, 
of  Bordentown,  the  patient  was  etherized  and  reduc- 
tion of  the  fracture  was  made.  The  treatment  in  this 
instance  was  essentially  like  that  employed  in  Case  I., 
except  that  the  limb  was  encased  in  the  felt  splint  at 
the  initial  dressing,  and  for  the  outer  sand  bag  w'as 
substituted  a  well-padded  wooden  splint,  long  enough 
to  extend  from  four  or  five  inches  below  the  axilla  to 
about  five  inches  below  the  heel,  four  and  one-half 
inches  wide  by  one-half  inch  in  thickness.  At  the 
lower  extremity  of  the  splint  was  attached  a  cross- 
piece,  two  feet  long  by  three  or  four  inches  wide  and 
half  an  inch  thick;  the  object  being  to  prevent  tilting 
of  the  splint  and  consequent  reversion  of  the  limb. 
This  splint  is  recommended  by  Hamilton,  of  New- 
York,  for  all  fractures  of  the  thigh,  and  is,  I  think, 
superior  to  the  sand  bag  as  an  outside  splint.  The 
case  apparently  progressed  satisfactorily.  In  this  in- 
stance, as  in  the  first  case,  the  patient  was  of  a  very 
nervous  temperament,  but  possessed  of  a  fairly  good 
appetite  and  digestion. 

On  removing  the  dressings  at  the  end  of  four  weeks 
no  union  whatever  had  taken  place.  The  bandages  were 
reapplied,  and  two  weeks  later  the  limb  was  again  exam- 
ined; still  no  union.  Two  weeks  later  there  seemed 
to  be '  a  slight  attempt  at  consolidation  in  the  upper 
fracture,  but  none  in  the  lower.  I  now  began  the  use 
of  hypophosphites  of  lime  and  soda,  together  w'ith 
daily  massage.  In  the  course  of  three  or  four  weeks 
longer  I  was  gratified  to  note  l)ony  union  through- 
out. The  patient  was  now  allowed  to  get  about 
on  crutches,  the  massage  and  hypophosphites  being 
meanwhile  continued.  What  gave  me  more  or  less 
concern  was  a  feature  that  played  no  part  in  Case  I., 
namely,  almost  complete  ankylosis  of  the  knee  joint. 
Not  to  prolong  the  history  of  the  case,  the  patient  in 
about  four  months  from  the  time  of  accident  was  able 
to  bear  some  weight  upon  the  injured  limb;  but  itw^as 
fully  nine  months  before  he  ventured  without  the  sup- 
port of  a  cane.  Ultimately  he,  too.  made  a  good  re- 
covery, save  for  about  three-quarters  of  an  inch  siiort- 
ening  and  some  remaining  stiffness,  both  of  whicli 
cause  a  perceptible  limp,  but  in  no  sense  interfering 
'.vith  his  ability  to  do  a  hard  day's  work. 

These  cases  teach  several  lessons:  (i)  Delayed 
union  is  possible  notwithstanding  the  conditions  for 
repair  are  apparently  every  way  favorable;  (2)  consoli- 
dation is  readily  effected  by  systematic  employment  of 


massage  and  the  use  of  the  hypophosphites;  (3)  the 
advisability  of  the  early  employment  of  massage  in 
thigh  fractures,  say  as  early  as  the  fourth  week,  both 
for  the  purpose  of  facilitating  consolidation  by  im- 
proving the  nutrition  of  the  parts  and  to  prevent  knee 
stiffness  or  ankylosis,  a  not  infrequent  accompani- 
ment of  such  injuries;  (4)  the  early  use  of  the  hypo- 
phosphites of  lime  and  soda  in  all  cases  of  fracture 
when  there  exists  doubt  of  prompt  bony  union. 


The  Use  of  Inflammation-Producing  Agents  in 
the  Treatment  of  Wounds — G.  Meyer  takes  the 
stand  that  absolute  asepsis  is  impossible,  and  that,  no 
matter  how  nearly  perfect  the  operative  technique, 
there  will  still  inevitably  be  some  infection  of  the 
wound.  Inflammation  is  now  univer.sally  regarded  as 
a  conservative  process,  and  its  production  in  a  mild 
degree  means  an  increased  power  of  resistance  of  the 
organism  through  the  more  active  formation  of  bac- 
tericidal toxins.  Arguing  along  these  lines  he  advo- 
cates the  use  of  some  mildly  irritant  application  to  the 
neighborhood  of  the  wound;  tincture  of  iodine  answers 
every  purpose,  and  gives  the  requires  stimulus  without 
in  any  way  jeopardizing  asepsis. —  Caitialblatt  Jiir 
Chirurgie,  August  ii,  1900. 

Subphrenic  Abscess  following  Appendicitis. — J. 
F.  Baldwin  reports  two  cases,  which  make  the  forty- 
fourth  and  forty-fifth  on  record.  In  the  first  case,  that 
of  a  w'oman  aged  forty-nine  years,  the  appendix  was 
removed  by  inversion  in  June,  1S99.  Convalescence 
was  satisfactory,  but  in  two  weeks' time  pain  and  sore- 
ness reappeared  above  the  location  of  the  appendix. 
On  July  20th  a  large  abscess  pointing  on  the  right 
side  at  about  the  tip  of  the  twelfth  rib  was  opened, 
and  gave  exit  to  an  enormous  amount  of  pus.  In  the 
second  case,  that  of  a  young  girl  aged  sixteen  years, 
a  gangrenous  and  perforated  appendix  was  removed 
on  July  26th,  and  convalescence  was  uninterrupted. 
From  August  i6th  to  28th,  however,  the  patient  had 
irregular  fever,  with  rapid  pulse  and  profuse  perspi- 
ration. There  was  no  bulging,  but  the  septic  condi- 
tion called  for  interference.  An  exploratory  incision 
showed  a  pus  cavity  back  of  the  suspensory  ligament 
of  the  liver,  which  was  evacuated  and  drained.  Re- 
covery was  prompt,  abscess  and  wound  healing  in 
about  two  weeks. —  Ckvelaiiit  Joiinial  of  Jlcdiiiiie,  Au- 
gust, 1900. 

A  Case  of  Anthrax  Successfully  Treated  by 
Local  Injections  of  Pure  Carbolic  Acid. — W.  E. 
Fisher  relates  an  instance  of  anthrax,  which  he  con- 
siders a  comparatively  rare  disease  in  this  country. 
The  lesion  developed  on  the  forearm  seven  days  after 
a  punctured  wound.  On  the  eighth  day  swelling  was 
followed  by  a  bluish-colored  bleb  one-eighth  inch  in 
diameter.  Cultures  showed  the  anthrax  bacillus.  The 
temperature  was  104'^  F.  The  lymphatics  of  the  ax- 
illa were  not  painful  or  enlarged.  Nausea,  malaise, 
and  the  same  high  temperature  persisted  under  wet  bi- 
chloride dressing  till  the  next  day,  and  new  blebs  of 
bluish  color  formed  about  the  site  of  puncture.  One 
drachm  of  ten-per-cent.  carbolic  solution  was  now  in- 
jected into  and  around  the  eschar.  Pure  carbolic  acid 
in  draciim  doses  was  continued  for  six  days,  and  the 
conditions  improved,  while  no  carbolic  acid  was  de- 
tected in  the  urine.  After  the  third  injection  the  tem- 
perature fell  to  normal,  and  after  tiie  fifth  the  eschar 
ceased  spreading.  Jarnovsky  reports  seventy-two 
cases  treated  in  this  manner  in  which  cure  resulted. 
Other  forms  of  treatment  recommended  are  bichloride 
injections,  the  internal  use  of  large  doses  of  ipecac, 
and  excision. —  Therapeutic  Gazette,  August,  1900. 


September  22,  190c 


MEDICAL    RECORD. 


459 


Medical   kecord: 

A    Weekly  Journal  of  Medicine  and  Surgery. 


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

Publishers 

WM,   WOOD  &  CO.,  51    Fifth  Avenue. 


New  York,  September  22,  1900. 


EARLY    DI.AGXOSIS    OF    PULMONARY 
TUBERCULOSIS. 

There  is  hardly  need  to  emphasize  the  importance  of 
early  recognition  of  pulmonary  tuberculosis  in  order 
that  appropriate  treatment  may  be  promptly  instituted. 
Tuberculosis  is  no  longer  properly  synonymous  with 
consumption  or  phthisis,  for  we  have  learned  that  res- 
toration to  health  takes  place  in  a  large  number  of 
cases,  sometimes  with,  sometimes  without  the  interven- 
tion of  therapeutic  art.  It  is  true  that  for  practical 
purposes  one  must  make  a  distinction  in  this  connec- 
tion between  anatomical  and  clinical  recovery.  The 
latter  implies  subsidence  of  activity  on  the  part  of  the 
morbid  process  and  cessation  of  clinical  symptoms. 
It  may  be  associated  with  fibroid  changes  in  and  en- 
capsulation of  the  tuberculous  lesions,  in  which,  how- 
ever, tubercle  bacilli,  while  perhaps  not  actually  de- 
stroyed, are  rendered  innocuous,  for  the  time  being  at 
least. 

The  good  that  can  be  accomplished  by  treatment 
must  be  effected  early  for  the  attainment  of  the  most 
satisfactory  results,  and  existing  records  siiould  stimu- 
late the  physician  to  his  best  endeavors  to  bring  about 
such  a  desired  end.  The  diagnostic  difficulties  are 
by  no  means  inconsiderable,  inasmuch  as  the  disease 
may,  and  often  does,  have  a  most  insidious  beginning, 
and  it  may  have  progressed  considerably  before  ordi- 
nary physical  signs  and  symptoms  become  obvious. 
Some  of  the  more  important  and  valuable  of  these  are 
dwelt  upon  by  Strauss  (Berli/ier  klinische  Wochen- 
schrijt,  1900,  Nos.  25  and  26)  in  an  address  delivered 
a  short  time  ago  before  the  Association  of  German 
Railway  Surgeons.  It  was  pointed  out  that  inspec- 
tion should  be  general  as  well  as  local.  The  preser- 
vation of  the  general  nutrition  is  of  less  importance 
than  its  impairment,  and  the  absence  of  the  tuberculous 
habitus  than  its  presence.  Comparative  inspection  of 
the  upper  part  of  the  chest  on  both  sides,  particularly 
with  reference  to  its  length  and  breadth  and  the  re- 
spiratory expansion  at  the  apices  and  in  the  infracla- 
vicular region,  is  more  important  than  a  consideration 
of  the  general  conformation  of  the  chest.  In  some 
persons  predisposed  to  pulmonary  tuberculosis  the 
acromial  extremity  of  one  clavicle,  generally  the 
right,  occupies  a  lower  level  than  that  of  its  fellow. 

Percussion  frequently  does  not  yield  so  much  infar- 
mation  as  auscultation.     The  topographic   are   more 


important  here  than  the  qualitative  results,  and  are 
obtained  by  exact  determination  of  the  expansion  of 
the  apices  upward  (by  percussion  from  above  down- 
ward) and  outward  (by  percussion  anteriorly  from  the 
acromion  toward  the  middle  linej.  High-pitched  tym- 
pany is  of  considerable  diagnostic  significance.  All 
of  the  signs  yielded  by  percussion,  as  well  as  by  aus- 
cultation, are,  however,  of  value  only  when  considered 
in  association  with  other  signs.  The  significance  of 
the  auscultatory  phenomena  is  all  the  greater  the  more 
they  are  confined  to  one  apex,  especially  the  posterior 
portion  of  the  right  apex.  In  some  cases,  however, 
symptoms  of  diffuse  bronchitis  predominate,  especially 
in  persons  who  have  been  exposed  to  the  inhalation  of 
dust.  Nor  does  the  presence  of  emphysema  or  of  dis- 
ease of  the  heart  necessarily  exclude  the  existence  of 
tuberculosis.  Occasionally  auscultatory  phenomena 
indicative  of  tuberculosis  are  found  in  other  portions 
of  the  lung  than  the  apex,  as,  for  instance,  just  below 
the  clavicle  or  at  the  base  between  the  mammillary 
and  the  anterior  axillary  line,  while  percussion  of  the 
anterior  aspect  of  the  chest  often  yields  better  results. 
The  reverse  is  true  of  auscultation.  Muscle-murmurs 
or  physiological  crepitation  on  deep  inspiration  should 
not  be  mistaken  for  rales.  It  is  of  great  importance 
to  find  that  the  abnormal  physical  signs  are  always 
present  in  the  same  situation  on  repeated  examination. 
Auscultatory  phenomena  may  be  rendered  more  obvi- 
ous by  cough  or  by  the  administration  of  small  doses 
of  potassium  iodide  for  the  purpose  of  increasing  the 
secretion  of  an  already  irritated  bronchial  mucous 
membrane. 

Evidence  of  active  disease  will  be  afforded  by  the 
presence  of  certain  constant  symptoms,  especially  pro- 
gressive loss  of  weight  and  fluctuations  in  temperature, 
and  also  anaemia  or  chlorosis  and  their  sequelae,  symp- 
toms of  irritability  or  of  exhaustion  of  the  nervous 
system,  especially  of  the  cardiac  nervous  apparatus, 
and  signs  of  digestive  derangement.  Of  especial  sig- 
nificance are  certaiti  symptoms  that,  while  not  arising 
directly  from  the  lungs,  point  to  disease  in  the  air- 
passages,  such  as  persistent  hoarseness,  which  should 
lead  to  laryngoscopic  examination.  Night-sweats, 
transitory  flushing  of  one  cheek,  chest-pains,  radiating 
pains  in  the  muscles  of  the  shoulder,  should  likewise 
suggest  examination  of  the  lungs.  Especial  consid- 
eration should  be  given  to  haemoptysis  or  to  pleurisy, 
present  or  past.  The  former  should  be  considered 
a  symptom  of  pulmonary  tuberculosis  until  proved 
otherwise,  and  the  latter  is  always  highly  suspicious, 
as  about  cne-half  of  the  cases  of  pleural  effusion  of 
obscure  origin  are  tuberculous.  In  order  to  establish 
the  diagnosis  some  of  the  Huid  obtained  on  exploratory 
puncture  should  be  injected  into  the  peritoneal  cavity 
of  a  guinea-pig,  and  the  results  that  take  place  in  six 
weeks  awaited. 

In  the  history  some  importance  is  to  be  attached  to 
hereditary  influences,  to  general  and  local  lowering  of 
the  powers  of  resistance,  and  to  association  with  tuber- 
culous patients.  No  one  or  all  of  the  symptoms  men- 
tioned are  definitely  conclusive  as  to  the  existence  of 
pulmonary  tuberculosis.  For  this  the  demonstration 
of  tubercle  bacilli  in  the  sputum  is  necessary.     Fail- 


460 


MEDICAL   RECORD. 


[September  22,  1900 


ure  to  detect  the  bacilli  does  not,  of  course,  exclude 
the  existence  of  tuberculosis,  as  the  micro-organisms 
can  appear  in  the  sputum  only  when  communication 
exists  between  a  softened  tuberculous  focus  and  the 
bronchial  apparatus.  Should  tubercle  bacilli  not  be 
demonstrable  in  the  presence  of  other  symptoms  of 
tuberculosis,  the  tuberculin  test  should  be  employed; 
but  it  should  be  borne  in  mind  that  a  reaction  will  be 
obtained  whatever  the  situation  of  the  tuberculous 
lesion. 


THE  PRESENT  STATUS  OF  BACTERIOLOGY. 

Though  one  of  the  youngest  of  the  medical  sciences, 
bacteriology  has  had  a  most  rapid,  yet  withal  lusty 
growth  in  recent  years.  It  is  true  that  great  and  many 
changes  in  hypothesis  and  theory  have  been  necessary 
with  advances  in  knowledge,  but  this  is  a  natural  evo- 
lutionary process.  Great  progress  in  etiology  and 
prophylaxis  has  been  made,  and  the  promise  of  thera- 
peutic success  has  been  |in  part  fulfilled;  but  many 
problems  yet  remain  to  be  solved,  many  obscure  points 
to  be  cleared  up.  Of  the  present  status  of  bacteriol- 
ogy a  most  interesting  summary  is  given  in  a  didactic 
article  by  Baumgarten  {Berliner  klinische  Wochai- 
schrijt,  1900,  Nos.  27  and  28).  He  points  out  that 
bacteria  are  still  classified,  not  in  conformity  with  the 
principles  of  natural  history,  but  in  accordance  with 
their  morphological  appearances.  Such  classification 
is,  however,  based  upon  more  than  the  external  charac- 
teristics, in  so  far  as  the  several  forms,  apart  from  minor 
variations,  never  pass  one  into  another.  Nor  does  the 
knowledge  that  bacteria  that  under  natural  conditions 
exert  definite  effects,  and  should,  therefore,  be  desig- 
nated specific,  under  artificial  conditions  exert  effects 
approximately  those  of  other  species  ju.stify  the  as- 
sumption that  the  individuals  of  one  species  pass  over 
into  those  of  another.  It  is  true  that  atypical  cultures 
can  be  maintained  under  certain  conditions,  but  a  re- 
turn to  the  normal  takes  place  when  these  conditions 
are  removed. 

The  bacterial  cell  is  a  more  or  less  solid  structure, 
consisting  of  a  protoplasmic  body  (by  some  tliought  to 
be  a  nucleus)  contained  within  a  membrane,  and  sur- 
rounded by  a  more  or  less  distensible  sheath  (by  some 
considered  to  be  the  cell  body).  It  is  generally  free 
from  chlorophyl,  only  a  few  containing  an  allied  pig- 
ment (bacterio-purpurin).  In  addition  to  molecular 
movement,  bacteria  may  be  propelled  by  fiagella. 
Multiplication  takes  place  by  fission;  perpetuation 
through  spores  occurs  only  as  the  result  of  a  provision 
of  nature  in  case  of  necessity,  in  order  to  defer  pro- 
liferation to  a  more  propitious  time,  when  the  mature 
cells  are  surrounded  by  conditions  not  favorable  to 
multiplication. 

A  study  of  the  vital  conditions  of  bacteria  has  shown 
that  it  is  their  function  to  convert  the  refuse  of  the 
organic  world  so  that,  eliminated  from  the  living,  it 
shall  be  adapted  to  enter  the  sphere  of  life  again, 
and  that  which  never  possessed  life  is  introduced  into 
organic  life.  The  bacteria  induce  in  the  products  of 
organic  life,  in  organic  but  not  organized  substances, 
not  dead  but  not  living,  in  which  the  molecules  have 


reached  a  state  of  relative  rest,  movements  or  activi- 
ties that  constitute  the  distinctive  feature  of  ferments 
or  zymotic  bodies.  Others  invade  active  life,  being 
naturally  true  parasites,  and  thus  pathogenic,  entering 
the  animal  body  and  vegetating  therein.  In  order  that 
the  latter  result  shall  take  place,  the  bacteria  must  find 
the  necessary  conditions  for  their  existence.  The  ab- 
sence of  these  constitutes  natural  immunity. 

If  the  bacteria  find  lodgment  and  undergo  multipli- 
cation, they  induce  disease,  which  is  an  expression  of 
the  reaction  of  the  body  to  irritating  influences.  Some 
of  the  resulting  symptoms,  such  as  fever  and  inflam- 
mation, are  due  alike  to  various  bacteria,  but  in  gen- 
eral each  micro-organism  gives  rise  to  a  peculiarly 
characteristic  and  distinctive  symptom  complex  and 
course.  Bacteria  constitute  the  specific  cause  for  a 
number  of  specific  diseases:  the  diseases  are  specific 
because  the  bacteria  are  specific.  The  infecting  micro- 
organisms and  their  injurious  effects  may  remain  con- 
fined to  the  site  of  invasion,  or  the  products  of  their 
activity  may  be  taken  up  and  distributed  by  the  circu- 
lating fluid.  A  number  of  bacteria,  however,  prolif- 
erate only  in  the  blood  or  in  remote  parts,  or  simul- 
taneously at  the  site  of  inoculation  and  in  both  of 
these.  The  bacteria  whose  effects  are  due  principally 
to  the  poison  to  which  they  directly  or  indirectly  give 
rise  have  long  been  designated  toxic,  in  contradistinc- 
tion from  those  that  give  rise  to  symptoms  by  reason 
of  their  enormous  multiplication  within  the  body,  and 
which  are  designated  infective. 

The  bacteria  live  and  multiply  at  the  expense  of  the 
cells  and  the  tissues,  and,  without  diminution  in  the 
volume  of  the  plasma,  they  so  alter,  the  chemical  con- 
stitution of  the  molecules  by  selective  action  that  the 
cell  or  its  derivatives  are  starved  and  die  in  conse- 
quence of  disintegration  of  the  plasma,  or  are  stimu- 
lated to  the  formation  of  cells  that  are  incapable  of 
performing  the  specific  function  of  the  mother  cell. 
The  elimination  of  a  large  number  of  important  cells 
from  the  economic  apparatus  of  the  living  body  in  this 
manner  or  their  perverted  functions  may,  in  accordance 
with  the  parts  affected,  be  manifested  in  various  forms 
of  disease.  As  in  the  cells,  bacteria,  when  they  mul- 
tiply in  the  blood,  would  be  capable  of  harm  not  only 
through  impoverishment  of  the  blood,  by  the  taking 
up  of  nutritive  matters,  but  also  by  interfering  with 
the  organic  associations  of  these  substances  at  innu- 
merable points.  A  mechanical  factor  may  also  be 
present,  the  bacteria  surrounding  the  blood  corpuscles, 
occluding  the  capillaries,  giving  rise  to  thrombi,  pre- 
venting interchange  between  the  blood  and  the  cells. 

The  bacteria  are  capable  through  their  secretions  of 
converting  nutrient  material  into  poisons,  which  are 
sent  to  all  parts  of  the  body,  where  they  enter  into  re- 
lations with  parts  for  whicii  they  have  chemical  affin- 
ity, giving  rise  to  nutritional  changes  and  functional 
disturbances  and  thus  to  the  characteristic  outlines  of 
the  clinical  picture. 

In  addition  to  these  specific  poisons  there  occur  also 
substances  derived  from  them  and  not  possessing  sim- 
ilar activity — so-called  toxins;  and  others  that  are 
common  to  various  bacteria  and  cause  similar  eflfects, 
such  as  fever  and   inflammation.     Then  also  certain 


September  22,  1900] 


MEDICAL    RECORD. 


461 


effects  are  attributable  to  absorption  of  substances  gen- 
erated in  considerable  amount  from  decomposition  of 
the  nutrient  substratum.  The  symptoms  of  intoxica- 
tion are  thus  due  to  several  factors  and  are  accordingly 
variable.  The  assumption  of  a  multiplicity  of  poi- 
sons generated  by  specific  bacteria  affords  an  explana- 
tion not  alone  of  the  variability  in  virulence  of  epi- 
demic bacterial  diseases,  in  accordance  with  the 
amount  of  the  specific  poison,  but  also  of  the  charac- 
ter peculiar  to  almost  every  epidemic. 

As  the  bacteria  find  the  conditions  for  their  prolif- 
eration only  where  they  can  enter  into  interchange 
with  the  nutrient  medium,  so  the  possibility  of  activity 
on  the  part  of  the  poisons  produced  by  them  presumes 
a  reciprocal  relation  between  the  poison  and  the  part 
attacked;  that  is,  the  bacterial  poisons  are  not  injuri- 
ous everywhere  or  to  all  of  the  tissues  of  the  body; 
they  are  not  omnipotent.  Upon  this  exclusiveness  of 
action  upon  certain  cell-territories  is  in  part  dependent 
the  claim  of  specificity  for  the  bacteria.  It  is  believed 
that  the  poisons  enter  into  chemical  combination  with 
the  structure  of  the  cell,  rather  than  that  they  merely 
cause  injury  to  the  cell  without  entering  into  its  struc- 
ture, by  inhibition  of  its  functional  activity  througli 
simple  contact.  The  poison  is  neutralized,  probably 
in  some  instances  at  least,  not  by  substances  generated 
by  the  bacterium  itself  or  from  its  own  transformation 
but  through  the  activity  of  the  invaded  body,  which  is 
stimulated  to  the  production  of  a  counter-poison. 

Active  immunization,  i.e.,  the  conferring  of  protec- 
tion against  fatal  amounts  of  bacteria  or  their  toxins, 
not  only  has  been  of  great  service  in  practical  thera- 
peutics, but  it  has  also  shed  much  light  upon  the 
causation  of  the  immunity  induced  naturally  or  arti- 
ficially by  recovery  from  disease.  Artificial  active 
immunization  may  be  looked  upon  as  the  analogue  or 
successful  experimental  imitation  of  natural  immunity, 
the  antitoxin  being  prepared  by  the  cells  of  the  body 
as  a  result  of  influences  exerted  by  the  toxin.  Recov- 
ery from  disease  with  the  final  elimination  of  the  bac- 
teria is  thought  to  take  place  through  a  process  of 
bacteriolysis  by  the  action  of  a  ferment  set  free  in  the 
blood  through  cellular  activity. 


^cius  of  the  'Smccli. 

Dr.  EUwood  R.  Kirby  has  been  appointed  by  the 
mayor  of  Philadelphia  a  member  of  the  bureau  of 
charities  and  correction. 

The  Dangerous  Celluloid  Comb A  young  woman 

in  a  town  near  Philadelphia  was  recently  burned  about 
the  head  from  the  combustion  of  celluloid  combs  worn 
in  the  hair.  The  accident  resulted  from  the  practice, 
in  itself  not  free  from  danger  and  scarcely  to  be  com- 
mended, of  putting  burning  joss-sticks  in  the  hair  for 
the  purpose  of  keeping  away  mosquitos. 

A  Parsee  Woman  Physician.— The  first  Eastern 
lady  admitted  to  the  licenses  of  the  Royal  College  of 
Physicians  and  Surgeons  in  Ireland,  and  the  first,  ac- 
cording to  the  belief  of  the  Medical  Press,  to  be  ad- 


mitted to  any  qualification  in  Great  Britain,  received 
her  diplomas  recently.  The  lady  is  a  Parsee  named 
Miss  Aunnie  M.  Treausurywala,  and  she  appeared  at 
the  capping  ceremonial  in  the  full  costume  of  her 
caste.  She  made  a  most  brilliant  examination  for  her 
final,  having  been  the  only  candidate  who  passed  with 
honors. 

An  Edict  Against  Long  Skirts.— The  local  board 
of  health  in  one  of  the  districts  of  Vienna  has  placed 
placards  in  all  the  public  gardens  and  parks,  directing 
the  women  who  visit  these  places  to  hold  up  their 
skirts  if  they  trail  upon  the  ground.  The  notice 
states  tliat  as  tliese  enclosures  are  devoted  to  the  rec- 
reation of  persons  desirous  of  escaping  from  the  dusty 
town,  the  authorities  forbid  dust  to  be  swept  there  into 
heaps  by  trailing  skirts. 

The  Royal  Disease.— Dr.  Bachmann,  of  Shanghai, 
has  recently  stated,  in  a  letter  to  the  Gegenwarl,  that 
Emperor  Kwang-Su  suffers  from  cancer  of  the  throat, 
and  is  unable  to  reign.  The  same  view  is  taken  by  Dr. 
Dethere,  a  French  physician,  and  by  Dr.  Sheng  Lian 
Feng,  both  of  whom  have  examined  the  emperor.  This 
seems  to  be  the  disease  to  which  rulers  are  specially 
prone. 

Threatened  Famine  in  Ireland.— Fears  of  a  potato 
blight  and  failure  in  the  grain  harvest  in  Ireland  are 
beginning  to  be  expressed,  and  priests  recently  re- 
turned from  that  country  say  that  the  outlook  for  the 
natives  of  the  Green  Isle  this  winter  is  fast  becoming 
as  serious  as  that  of  the  famine  years  of  1846  and  1847, 
when  nearly  two  million  people  died  as  the  result  of 
the  blight  of  the  potato  crop. 

Anti-Rabic  Inoculations  in  Paris. — During  the 
years  1886-99,  o''  since  the  Pasteur  Institute  in  Paris 
was  founded,  23,245  persons,  sufTering  or  supposed  to 
be  suffering  from  the  bites  of  rabid  animals,  have  been 
treated  there  by  means  of  preventive  inoculations.  Of 
this  number  only  103  died.  The  figures  for  each  year 
are  as  follows: 


Year. 

Number  of 
Persons  Treated. 

Number 
of  Deaths. 

Rate  of  Mortality. 
Per  Cent, 

18S6 

2,6-1 
1,770 
1,622 
1.830 
1.540 
1.559 
1,790 
1,64s 

1,387 
1,520 
1,308 
1,521 
1,465 
1,614 

25 
14 

9 
7 

5 
4 
4 
6 

7 
5 
4 
6 

3 

4 

•94 
•79 

•  55 
.38 
.32 

•25 

1887 

l883 

1880 

1 800 

iSqi 

1802 

1893 

1804 

.36 
.50 
•33 
.30 
•39 
.20 

ISO'S 

1806 

1807 

i8qS 

I  3qq 

.25 

Protest  against  Vaccination. — A  report  from  Ber- 
lin states  that  owing  to  the  unusually  heavy  passenger 
traffic,  as  well  as  to  the  reduction  in  number  of  pas- 
senger steamers,  many  American  citizens  have  recently 
been  compelled  to  take  steerage  passage  in  returning 
to  the  United  States.  The  physicians  of  the  North 
German  Lloyds  Steamship  Company  have  very  proper- 
ly insisted  upon  vaccinating  all  these  to  meet  the  re- 


462 


MEDICAL    RECORD. 


[September  22,  1900 


quirements  of  the  United  States  laws.  Recently  an 
American  filed  objections  with  the  United  States  con- 
sul at  Bremen,  who  wrote  to  Washington  for  instruc- 
tions, meanwhile  forbidding  the  physicians  in  question 
to  vaccinate  Americans  in  the  steerage  on  the  ground 
that  the  law  was  intended  to  apply  to  immigrants  only. 
We  do  not  know  whether  or  not  an  American  consul 
has  the  right  to  set  up  his  authority  against  the  law 
of  his  country,  but  in  any  case  it  is  cruel  to  deprive 
any  man  of  the  security  afforded  by  vaccination  just  be- 
cause lie  happens  to  be  an  American  citizen. 

Dr.  Archibald  Church  has  been  recently  appointed 
professor  of  nervous  and  mental  diseases  and  head  of 
the  neurological  department  in  the  Northwestern  Uni- 
versity Medical  School  (Chicago  Medical  College). 

The  Southern  Surgical  and  Gynaecological  Asso- 
ciation.—  The  ne.\t  annual  meeting  of  this  association 
will  be. held  in  Atlanta,  on  November  13th,  14th,  and 
15th,  under  the  presidency  of  Dr.  A.  M.  Cartledge,  of 
Louisville.  Members  of  the  medical  profession  are 
invited  to  attend. 

The  Woman's  Medical  College  of  Philadelphia. 
— Dr.  W.  L.  Rodman  has  been  appointed  professor  of 
the  principles  and  practice  of  surgery  at  the  Woman's 
Medical  College  in  Philadelphia,  and  Dr.  W.  V.  Laws 
has  been  appointed  professor  of  operative  and  clinical 
surgery  at  the  same  institution. 

Dr.  William  C.  Woodward  has  been  reappointed 
health  officer  of  the  District  of  Columbia,  and  the  or- 
der of  1894,  limiting  the  term  of  office  to  three  years, 
has  been  suspended.  This  secures  to  Washington  the 
services  of  a  particularly  efficient  commissioner  of 
health. — Maryland  Medical  Journal. 

Tuberculosis  has  now  been  declared  officially  to  be 
a  disease  subjecting  the  sufferer  to  quarantine.  \\\ 
the  case  of  a  Japanese  with  tuberculosis  recently  ar- 
rived at  San  Francisco,  the  Commission  of  Lnmigration 
has  decided  that  the  disease  is  contagious  and  that  the 
sufferer  cannot  land  and  must  return  to  the  port  whence 
he  sailed. 

Dr.  Julian  Calleja  y  Sanchez,  professor  of  de- 
scriptive anatomy  and  embryology  at  the  University 
of  Madrid,  has  been  chosen  president  of  the  Fourteenth 
International  Medical  Congress,  which  will  meet  in 
Madrid  in  1903,  and  Dr.  Fernandez  y  Caro,  inspector- 
general  of  the  Spanish  navy,  has  been  appointed  secre- 
tary general  of  the  congress. 

A  Vegetarian  Colony. — The  president  of  the  Veg- 
etarian Society  of  America  is  in  the  South  looking  for 
a  suitable  place  where  members  of  the  society  can 
establish  a  colony.  Association  with  meat-eaters  is 
said  to  become  disagreeable  to  real  (no-egg,  no-milk) 
vegetarians,  and  so  they  wish  to  flock  by  themselves. 
They  want  to  go  to  a  place  where  all  sorts  of  fruits 
and  vegetables  can  be  grown,  and  if  a  suitable  one  is 
found  many  of  the  members  of  the  society  will  go 
there  and  engage  in  fruit  and  vegetable  farming  and 
in  the  manufacture  of  preserved  fruits  and  peanut 
butter. 


Phosphorus  in  Oysters.— Some  French  chemists 
have  recently  made  very  e.xtensive  analyses  of  several 
varieties  of  oysters  in  order  to  ascertain  the  quantity 
and  form  of  phosphorus  which  exists  in  these  tooth- 
some bivalves.  They  found  that  a  dozen  Portuguese 
oysters  contain  about  six  grains  of  phosphoric  acid, 
which  represents  about  fifteen  grains  of  the  tribasic 
phosphate  of  lime.  About  four  grains  per  dozen  was 
obtained  from  French  oysters. 

Typhoid  Fever  at  the  Children's  Asylum  in 
Syracuse. — The  annual  epidemic  of  typhoid  fever  has 
broken  out  in  the  State  Custodial  Asylum  for  Feeble- 
Minded  Children  at  Syracuse,  and  twelve  persons  are 
down  with  the  fever,  including  the  resident  physician. 
Every  year  it  has  been  thought  that  the  cause  of  the 
disease  had  been  eradicated,  but  its  recurrence  again 
has  led  the  State  board  of  health  to  undertake  a  thor- 
ougii  investigation  of  the  origin  of  the  infection. 

An  Alleged  Death  from  X-Ray  Burns — A  death 
certificate  recently  presented  to  the  St.  I^aul  board  of 
health  stated  that  the  deceased  came  to  his  death  in 
consequence  of  burns  received  during  an  examination 
by  means  of  the  Roentgen  rays.  The  man  met  with 
a  street-car  accident  last  winter,  and,  it  is  said,  de- 
sired to  have  .v-ray  photographs  taken  of  his  injuries 
for  use  as  evidence  in  a  suit  for  damages.  The  doc- 
tor who  took  the  radiographs  denies  that  the  patient 
was  burned  so  seriously  as  to  cause  fatal  injuries. 

A  Medicine  Man's  Failure. — The  penalties  for  in- 
success  in  therapeutics  are  somewhat  severe  at  times 
among  the  aborigines  as  well  as  in  civilized  commu- 
nities. Not  long  ago  Illowaho,  an  aged  medicine 
man  and  chief  of  the  Yakima  tribe,  in  the  State  of 
Washington,  was  stoned  to  death  in  his  tent  by  an  In- 
dian named  John.  He  had  been  called  to  save  John's 
child,  who  was  sick,  and  went  through  the  usual  for- 
malities, with  no  more  success  than  a  "Christian  sci- 
entist." The  child  died,  and  the  enraged  father  went 
to  the  medicine  man's  tent  and  stoned  him  to  death. 

The  Standardization  of  Antitoxins.  —  A  firm  of 
manufacturing  chemists  in  England  having  applied 
for  a  license  to  perform  experiments  upon  living 
animals  for  the  purpose  of  standardizing  antitoxins, 
the  Royal  College  of  Physicians  was  requested  to  give 
an  opinion  as  to  the  advisability  of  granting  the  license. 
The  reply  of  the  college  was  that,  while  these  experi- 
ments were  absolutely  necessary  to  the  advance  of 
pharmacology,  the  granting  of  such  licenses  to  com- 
mercial firms  was  very  undesirable.  The  standardiza- 
tion of  antitoxins  should  be  done  in  a  government 
laboratory,  into  which  the  question  of  money-making 
did  not  enter. 

An  Unfortunate  Decision. — A  judge  in  Towanda, 
a  Pennsylvania  town,  has  just  reversed  a  judgment  by 
which  §2,  the  penalty  for  non-attendance  at  school, 
was  recovered  by  the  school  board  from  a  Christian 
Scientist  who  declined  to  have  his  son  vaccinated,  in 
consequence  of  which  the  latter  was  refused  admission 
to  the  school.  The  judge  expressed  the  opinion  that 
the  vaccination   law  is  not   mandatory,  but   optional, 


September  22,  1900] 


MEDICAL    RECORD. 


463 


and  that  the  parent  did  all  the  law  required  in  send- 
ing his  son  to  school,  although  the  latter  was  refused 
admission.  This  opinion  is  opposed  to  that  expressed 
recently  by  a  learned  Philadelphia  judg",  who  declared 
in  favor  of  the  validity  of  the  compulsory  vaccination 
law. 

Fatal    Hemorrhage  from  Ritual  Circumcision 

The  death  is  reported  at  Philadelphia  of  a  Jewish 
child,  fifteen  days  old,  as  a  result  of  hemorrhage  follow- 
ing the  performance  of  circumcision  as  a  religiousrite. 

The  American  Academy  of  Railway  Surgeons 
met  in  seventh  annual  session  in  St.  i'aul  on  Septem- 
ber 5tii  and  6th,  under  the  presidency  of  Dr.  Charles 
A.  Wheaton,  of  that  city.  The  election  of  ofificers  for 
the  ensuing  year  resulted  in  the  following  choice: 
President,  Dr.  D.  S.  Fairchild,  of  Clinton,  la.;  First 
Vice-President,  Dr.  W.  L.  Estes,  of  South  Bethlehem, 
Pa. ;  Second  Vice-President,  Dr.  \V.  J.  Mayo,  of 
Rochester,  Minn. ;  Secretary  and  Treasurer,  Dr.  T.  B. 
Lacey,  of  Council  Bluffs,  la.  The  next  meeting  will 
be  held  in  Chicago. 

The  British  Hospitals  in  South  Africa. — The 
testimony  which  is  gradually  coming  in  regarding  the 
conditions  of  the  medical  relief  service  in  the  Eoer 
war  tends  to  offset  the  e.xaggerated  statements  of  Bur- 
dett-Coutts,  Kipling,  and  others.  Medical  men  and 
laymen  who  were  on  the  spot,  and  saw  with  their  own 
eyes  what  they  describe,  admit  that  at  Bloemfontein 
and  Kroonstad  there  was  some  extra  suffering  when 
the  pressure  became  great,  owing  to  the  lack  of  skilled 
orderlies,  but  there  was  nothing  to  warrant  Mr.  Bur- 
dett-Coutts'  statements.  During  Roberts'  march 
there  was  some  difficulty  in  coping  with  the  sick  and 
wounded.  For  the  first  sixteen  days  the  Bloemfontein 
supply  trains  that  arrived  were  insufficient  for  the 
daily  requirements.  Then  they  began  slowly  to  ac- 
cumulate a  reserve  until  they  had  forty-five  days' stock 
when  they  moved  forward.  The  wounded  were  sent 
back  with  the  least  possible  delay.  General  Roberts 
frequently  visited  the  hospitals  and  was  satisfied  that 
the  surgeons  did  their  duty.  The  commissioner  of 
the  Red  Cross  Society  at  Cape  Town  reported  only 
recently  that  he  had  visited  the  hospitals  at  Pretoria, 
Johannesburg,  and  other  centres  of  operations,  and  had 
found  the  arrangements  for  the  care  of  patients  excel- 
lent and  the  hospital  supplies  abundant.  Dr.  Ryerson, 
who  was  the  Canadian  Red  Cross  commissioner  in 
South  Africa,  stated  a  few  weeks  ago  that  the  hospital 
arrangements  could  not  have  been  more  admirable. 
In  war,  one  could  not  expect  the  same  comforts,  hos- 
pital and  otherwise,  as  in  peace,  but  nothing  that  was 
deemed  necessary  was  wanting.  What  astonished  him 
especially.  Dr.  Ryerson  said,  was  the  testimony  of 
Kipling  that  medicine  had  been  taken  into  the  hos- 
pitals by  the  back  door.  There  was  no  necessity  for 
taking  it  in  surreptitiously,  he  asserted,  and  no  reason 
why  the  surgeons  should  have  so  received  it. 

Conjunctivitis  is  very  prevalent  in  New  York,  and 
the  eye  clinics  are  reported  to  be  thronged  with  suffer- 
ers from  this  unpleasant  malady.  It  is  attributed  by 
some  to  contagion  acquired  in  the  public  baths. 


A  Congress  of  Polish  Medical  Men  was  recently 
held  at  Cracow.  Tiie  opening  address  was  delivered 
by  Professor  Kostanecki,  who  took  as  his  theme  the  ^ 
universality  of  medical  science.  The  two  principal 
subjects  discussed  during  the  general  sessions  were 
the  means  of  combating  tuberculosis  and  alcoholism. 
The  work  of  the  congress  was  divided  among  twenty- 
four  sections,  and  there  was  a  large  attendance  of 
physicians  from  the  three  divisions  of  Poland. 

Vacancies  in  the  Naval  Medical  Service. — A  board 
for  the  examination  of  candidates  for  admission  to  the 
medical  corps  of  the  navy  is  in  session  at  the  Naval 
Laboratory,  Brooklyn,  X.  V.,  and  will  remain  in  session 
for  several  months.  There  are  now  seventeen  vacan- 
cies in  the  list  of  assistant  surgeons.  Congress  at  its 
last  session  passed  a  law  taking  assistant  surgeons  out 
of  the  steerage  and  making  them  ward-room  officers  as 
soon  as  they  entered  the  service,  giving  them  the  rank 
of  junior  lieutenants  and  the  pay  of  assistant  surgeons 
in  the  army.  Candidates  must  be  between  the  ages  of 
twenty-one  and  thirty  years.  A  circular  of  informa- 
tion can  be  obtained  on  application  to  the  surgeon- 
general  of  the  navy.  Navy  Department,  Washington. 

The  <' Maine"  at  Wei-hai-Wei.— The  medical 
officer  on  the  hospital  ship  Maine,  which  was  equipped 
for  service  in  South  Africa  through  the  contributions 
of  Americans  and  afterward  went  to  China,  cables  to 
the  London  committee  under  date  of  Wei-hai-Wei, 
September  13th,  that  the  vessel  has  been  ordered  to 
remain  at  that  port  and  await  the  arrival  there  of  sick 
and  wounded. —  The  Sun. 

The  State  Hospital  for   Tuberculosis The  New 

York  board  of  pensions  recently  passed  a  resolution 
recommending  that  the  State  Hospital  for  Consump- 
tives be  erected  at  Dannemora.  This  place,  where 
there  is  already  a  penitentiary,  is  in  the  Adirondack 
region.  The  hospital  commission  has  a  number  of 
sites  under  consideration. 

The  Marine-Hospital  Station  at  Biloxi,  on  the 
Gulf  of  Mexico,  concerning  the  safety  of  which  grave 
fears  were  entertained  at  the  time  of  the  Galveston 
disaster,  escaped  all  damage  from  the  hurricane. 

A  Nevir  Epileptic  Colony  in  England.— The  David 
Lewis  Trustees,  who  have  the  disposal  of  a  large  sum 
of  money  left  for  public  charities,  are  engaged,  the 
British  Medical  Journal  states,  in  completing  arrange- 
ments for  a  munificent  gift  to  the  public,  representing 
a  sum  which  may  possibly  approach  _;£'ioo,ooo.  There 
were  negotiations  a  year  or  two  ago  between  the  trus- 
tees and  authorities  of  the  Southern  and  St.  Mary's 
hospitals,  Manchester,  with  a  view  to  the  presentation 
to  the  city  of  a  hospital  for  women,  which  was  to  cost 
about  ^60,000.  These  negotiations  fell  through,  but 
the  trustees  have  now  decided  to  purchase  a  considerable 
estate  at  Warford,  near  Manchester,  where  preparations 
are  being  made  for  the  erection  of  extensive  buildings 
for  the  accommodation  and  treatment  of  epileptics. 
Every  effort  will  be  made  to  produce  a  thoroughly 
efficient  modern  institution  in  which  the  most  ad- 
vanced scientific  treatment  may  be  given.     The  new 


464 


MEDICAL   RECORD. 


[September  22,  1900 


colony  will  not  be  designed  for  the  reception  of  pauper 
patients,  and  will  be  distinct  from  the  undertaking  of 
a  joint  committee  of  the  Manchester  and  Chorlton 
unions,  which  is  said  to  contemplate  the  erection  of 
a  hospital  to  accommodate  about  one  thousand  epi- 
leptics and  imbeciles. 

Health  Conditions  in  Havana The  mortality  re- 
port of  Havana  for  August,  including  deaths  from  all 
causes,  shows  a  lower  total  than  for  any  previous 
August  in  ten  years,  the  figures  being  559  as  against 
620  in  1899  and  1,078  in  1898.  The  death  rate  for 
August  was  2.76,  yellow  fever  furnishing  49  victims 
and  tuberculosis  65.  On  September  13th  there  were 
78  cases  of  yellow  fever  in  the  city.  La  Hahana 
Aledica  says  that  the  gravity  of  the  present  epidemic  of 
yellow  fever  in  the  city  is  truly  alarming.  In  1895 
the  number  of  cases  was  greater,  but  the  general  char- 
acter of  the  disease  was  fairly  mild.  This  year,  how- 
ever, the  gravity  of  the  fever  is  marked,  the  mortality 
exceeding  thirty  per  cent.  Thus  yellow  fever  con- 
tinues to  dominate  among  the  local  diseases,  while 
other  diseases  are  decreasing  with  the  improvement 
in  hygiene.  Our  contemporary  despairs  of  controlling 
the  disease  by  hygienic  measures  only,  and  says  that 
it  can  be  conquered  by  some  effective  specific  remedy, 
which  as  yet  is  wanting. 

Report  of  Cholera  in  Madrid. — An  alarming  de- 
spatch from  Madrid  was  sent  out  last  week  stating 
that  Asiatic  cholera  had  appeared  in  tliat  city.  In- 
vestigation, however,  showed  that  the  disease  was 
simply  cholera  nostras,  of  which  numerous  cases  occur 
every  summer. 

The  Congress  of  Spanish  Surgeons  was  to  have 
held  its  second  meeting  in  Barcelona  in  September, 
but  in  vievi'  of  the  meeting  of  the  Thirteenth  Inter- 
national Medical  Congress  at  Paris  this  summer  the 
organizing  committee  decided  to  postpone  the  meet- 
ing until  the  autumn  of  1901. 

Fire  in  City  Hospital. — A  defective  flue  on  the 
fourth  floor  of  Charity  Hospital  on  Blackwell's  Island 
caused  a  small  fire  there  one  afternoon  last  week. 
The  call  brought  a  lot  of  fire  apparatus  to  the  foot  of 
East  Twenty-sixth  Street,  and  a  steamboat  was  all 
ready  to  hurry  it  over  to  the  island,  when  a  telephone 
message  was  received  saying  that  the  fire  was  out. 
There  was  no  damage  and  little  alarm  was  caused 
among  the  patients. 

British  Mortality  in  the  Boer  War. — A  careful 
analysis  of  the  statistics  shows  that  of  the  British  offi- 
cers in  South  Africa  72.1  per  thousand  have  been 
killed  or  have  died  from  wounds,  and  30.6  per  thou- 
sand have  died  from  disease.  Of  the  men,  19  per 
thousand  have  been  killed  or  died  from  wounds,  and 
31.8  per  thousand  have  died  from  disease.  These 
statistics  show  that,  while  the  officers  and  men  suffered 
nearly  equally  from  disease,  the  risks  of  the  officers  in 
action  were  greatly  disproportionate. 

The  Plague  in  Glasgow  continues  with  an  occa- 
sional new  case,  the   number  of   suspects   being  one 


hundred  and  sixteen,  and  of  declared  cases  twenty- 
two.  On  September  17th  five  new  cases  were  discov- 
ered. They  were  in  the  persons  of  the  wife  and  two 
children  of  a  hospital  worker  and  his  mother  and 
sister.  It  seems  tiiat  they  had  been  in  constant  con- 
tact with  suspected  plague  cases  since  August  22d, 
and  had  been  ill  without  the  knowledge  of  the  authori- 
ties. The  family  comes  from  tlie  neighborhood  where 
the  plague  appeared  at  first.  This  new  outbreak  has 
caused  some  uneasiness  in  the  public  mind,  as  it  sug- 
gests that  the  health  authorities  are  not  completely  in 
control  of  the  situation.  In  Hong  Kong  the  epidemic 
has  abated  by  the  efforts  of  the  health  authorities  or 
has  exhausted  the  soil  upon  which  it  formerly  thrived. 
For  the  first  week  in  September  four  cases  and  four 
deaths  were  reported. 

The  Search  for  the  Missing  Link. — It  is  stated 
in  Science  that  Mr.  George  Vanderbilt  is  defraying  the 
expenses  of  an  expedition  to  Java  by  Mr.  David  J. 
Walters  of  New  Haven,  who  purposes  to  search  for 
remains  of  Pithecanthropus  erectus. 

Navy  Department,  Bureau  of  Medicine  and  Sur- 
gery, Washington,  D.  C. — Changes  in  the  medical 
corps  of  the  United  States  navy  for  the  week  ending 
September  15,  1900.  September  7th. — Assistant  Sur- 
geon C.  A.  Crawford  detached  from  the  Eagle  and 
ordered  to  the  Dixie.  September  8th. ^Surgeon  M. 
F.  Gates  detached  from  the  naval  hospital,  Norfolk, 
Va.,  September  12th,  and  ordered  to  the  Atlanta, 
September  15th.  Passed  Assistant  Surgeon  A.  M.  D. 
McCormick  ordered  to  the  naval  hospital,  Norfolk, 
Va.,  for  duty,  when  detached  from  the  Aloiitgotnery. 
September  lath.^ — Passed  Assistant  Surgeon  L.  Morris 
detached  from  the  Bcdtiviore  when  put  out  of  com- 
mission, and  ordered  home  and  to  wait  orders.  Phar- 
macist J.  Pearson  detached  from  the  Wheeling  and 
ordered  home  and  to  wait  orders.  September  13th. — 
Assistant  Surgeon  W.  E.  G.  High  detached  from  the 
naval  hospital,  Yokohama,  and  ordered  to  the  Oregon. 


©bituainv 

HUNTER    McGUIRE,    M.D., 

RICHMOND,    VA. 

Dr.  Hunter  McGuire,  of  Richmond,  Va.,  died  Sep- 
tember 19th,  at  his  country  residence  near  Richmond, 
Va.,  as  the  result  of  exhaustion  from  hemiplegia,  with 
which  he  was  attacked  six  months  ago. 

For  a  long  period  he  maintained  the  proud  position  of 
the  leading  surgeon  of  the  Soutli,  and  his  loss  to  the  pro- 
fession and  his  numerous  friends  and  admirers  is  irrep- 
arable. Identified  with  all  matters  tending  to  the  ad- 
vancement of  the  interests  of  his  calling,  a  writer  of 
authority,  and  a  leading  and  distinguished  educator,  he 
exerted  an  infiuence  for  good  along  many  and  varied 
lines,  which  can  scarcely  be  overestimated.  He  was  born 
at  Winchester,  Va.,  October  11,  1835,  his  father  being 
Dr.  Hugh  H.  McGuire  of  that  place.  His  early  edu- 
cation was  in  his  native  town,  where  he  also  com- 
menced his  medical  studies,  completing  them  in  the 
Winchester  Medical  College  in  1855,  and  the  follow- 
ing year  in  J'hihuklphia.  He  first  located  in  Win- 
chester, assisting  his  father  in  practice,  and  occupying 


September  22,  1900] 


MEDICAL    RECORD. 


465 


the  chair  of  anatomy  at  Winchester  Medical  College. 
In  1858  he  resided  temporarily  in  Philadelphia,  and 
after  distinguished  service  in  the  Confederate  army  as 
chief  medical  officer  on  Gen.  Stonewall  Jackson's  staff, 
he  settled  in  1865  in  Richmond.  Here  his  success  in 
practice  and  his  influence  as  a  leader  of  medical 
thought  became  assured  from  the  first,  and  in  1869  he 
was  made  president  of  the  Richmond  Academy  of 
Medicine.  He  was  also  president  of  the  Association 
of  Confederate  Officers,  and  was  one  of  the  vice-presi- 
dents of  the  International  Medical  Congress  of  1876. 

His  voluminous  and  varied  writings  on  surgical 
subjects  proved  him  a  thorough  scholar,  a  skilled  anat- 
omist, and  a  judicious  and  conservative  counsellor. 
As  an  occasional  contributor  to  general  periodical  lit- 
erature he  took  a  high  rank,  which  was  well  deserved 
after  his  admirable  and  touching  history  of  the  death 
wounds  of  Stonewall  Jackson. 

He  was  a  hard  and  constant  worker,  but  his  main 
ambition  centred  in  the  foundation  and  prosperity  of 
the  University  Medical  College  of  Richmond,  with 
which  he  was  so  long  and  honorably  identified. 


Obituary  Notes. — Dr.  John  McMahon  Brown 
died  of  cardiac  trouble  at  his  home  in  this  city  on 
September  12th.  He  was  born  in  Ireland  fifty-five 
years  ago,  and  was  graduated  in  medicine  from  the 
University  of  Dublin  in  1868.  He  practised  for  many 
years  in  Dublin  and  later  in  London,  and  came  to  this 
country  in  188S.  He  was  a  visiting  physician  to  the 
Metropolitan  Dispensary. 

Dr.  Frank  C.  Merriam  of  this  city  died  at  Water- 
ford,  Conn.,  on  September  i6th,  at  the  age  of  forty-six 
years.  He  was  a  graduate  of  the  University  Medical 
College  in  1880.  He  had  been  in  poor  health  for 
over  a  year. 


^roflvcss  of  pXalical  Jicicnce. 

Boston  Medical  and  Surgical  /onrnal,  Sept.  ij,  igoo. 

Actinomycosis. — Charles  Allen  Porter  reports  eight  cases 
with  tlie  object  of  attracting  attention  to  the  possibility 
that  a  proportion  of  the  cases  ranking  as  alveolar  abscesses 
may  be  due  to  the  specific  organism  of  this  disease. 
Though  it  cannot  be  a  rare  affection,  he  says,  few  cases 
enter  the  hospital  with  advanced  actinomycosis  of  the  jaw, 
and  it  seems  therefore  certain  that  many  recover  after  sim- 
ple incision  of  the  abscess,  and  even  through  a  natural 
rupture  of  it.  Simple  opening,  curetting,  and  drainage 
have  proved  sufficient  in  many  cases  ;  though  recurrences 
may  be  frequent,  healing  eventually  takes  place.  When 
possible,  excision  of  the  inner  half  of  the  abscess  wall  or 
sinus  is  the  best  treatment.  The  danger  from  swallowing 
the  granules,  when  the  discharge  empties  into  the  mouth. 
is  hard  to  estimate.  Certain  cases  of  generalized  disease 
in  the  lungs,  intestinal  tract,  liver,  etc.,  occur  in  which  the 
organism  gained  entrance  through  the  food,  or  was  swal- 
lowed, and  therefore  the  surgeon  should  aim  at  making 
external  drainage. 

Tendon  Suture. — Edward  S.  Hatch  describes  the  case  of 
a  patient  who  plunged  his  right  hand  through  a  window 
and  cut  the  anterior  part  of  his  WTist  on  the  ulnar  side. 
The  tendons  of  the  palmaris  longus,  flexor  carpi  ulnaris, 
and  flexor  sublimis  digitorum  were  found  to  be  divided. 
The  ulnar  artery  and  the  median  nerve  were  also  found  to 
be  cut.  The  ulnar  nerve  was  cut  about  half-way  through 
its  structure.  The  tendons  and  nerves  were  united  with 
tine  silk  sutures.  The  ulnar  ai'tery  was  tied,  both  the 
proximal  and  distal  ends.  No  attempt  was  made  to  unite 
the  tendon  sheaths.  The  skin  wound  was  united  with  in- 
terrupted silkworm-gut  sutures.  The  results  of  the  opera- 
tion were  excellent.  At  the  present  time,  seven  months 
later,  the  patient  has  normal  flexion  and  extension,  with 
normal  sensation  over  the  distribution  of  the  median  nerve. 
He  can  separate  the  fiugers  and  draw  them  together  again 
with  perfect  ease. 

The  Radical  Cure  of  Hernia.— J.  Collins  Warren,  urging 
the  radical  operation  rather  than  the  wearing  of  a  truss. 


gives  statistics  of  a  series  of  ninety-eight  cases  operated 
ujjon  between  iSSS  and  igoo,  showing  in  a  striking  way  the 
marked  change  which  the  improvement  in  asejitic  tech- 
nique has  brought  about  in  the  prognosis  of  the  healing  of 
the  wound.  Prior  to  1S95  there  were  thirty-three  cases 
operated  upon,  of  which  sixteen,  or  forty-eight  percent., 
were  septic :  whereas,  after  1895.  of  si.xty-five  cases  oper- 
ated upon,  nine,  or  sixteen  per  cent,  only,  were  septic.  The 
term  "septic"  includes  all  cases  that  did  not  heal  by  first 
intention  throughout  the  wound.  The  slightest  infection 
of  a  stitch  would  place  it  under  the  above  heading.  When 
silk  was  used  for  sutures  only  seventeen  per  cent,  of  the 
wounds  were  septic,  but  in  the  case  of  catgut  septic  condi- 
tions were  found  in  forty  per  cent.  The  author  describes 
several  points  in  the  technique  of  the  operation. 

Four  Cases  of  Actinomycosis. — John  C.  Munro  reports  four 
cases,  in  one  of  which  the  tumor  was  situated  below  the 
angle  of  the  scapula.  The  three  face  cases  showed  inva- 
sion of  the  soft  tissues  only,  the  bone  being  free.  In  none 
of  them  could  any  definite  trace  of  the  original  affection  be 
found.  All  the  patients  were  given  iodide  of  potassium, 
and  the  wounds  were  treated  with  peroxide,  tincture  of 
iodine  in  full  strength  or  solution,  and  packed  in  iodoform 
gauze  until  all  evidence  of  presence  of  the  fungus  had 
disappeared. 

A  Method  of  Teaching  Practical  Medicine. — By  Thomas 
F.  Harrington. 

7 lie  Medical  News,  September  /j,  rgoo. 
Post-Apoplectic  Temperature   and  Disturbances  of  the  Ali- 
mentary  Tract:    their    Management. — Hcnrj'    Lyle   Winter 

believes  that  a  continued  high  temperature,  at  times  irreg- 
ular in  its  fluctuations,  and  various  disturbances  of  the 
digestive  organs,  usually  of  the  fermentative  type,  which 
occur  frequently  after  cerebral  apoplexy,  may  be  depend- 
ent entirely  upon  the  absorption  of  the  infective  material 
in  the  alimentary  canal.  Hitherto  these  symptoms  have 
been  met  with  small  doses  of  calomel,  but  the  writer  thinks 
hydrogen  dioxide  much  more  effective.  After  its  admin- 
istration he  has  found  that  it  not  only  improved  the  condi- 
tion of  the  alimentary  tract,  but  that  the  temperature  sub- 
sided. It  has  been  his  practice  to  give  the  drug  combined 
with  an  equal  quantity  of  chemically  pure  glycerin. 

In  What  Relation  does  Occupation  Stand  to  Tuberculosis? 
— In  studying  the  statistics  of  tuberculosis  as  related  to 
occupation,  W.  Freundenthal  notes  one  striking  fact,  viz., 
the  extraordinary  large  number  of  tailors  and  those  with 
similar  occupations  who  suffer  from  this  disease.  The 
writer  finds  the  causes  for  this  condition  of  things  in  lack 
of  exercise,  bad  ventilation,  overwork,  undernutrition,  and 
lack  of  all  hygienic  precautions,  resulting  in  that  condition 
christened  by  Bouchardat  "physiological  misery."  His 
general  conclusions  are  in  accordance  with  Flint's,  "that 
occupation  has  an  agency  in  the  etiology  of  pulmonary 
tuberculosis,  in  so  far  as  it  is  sedentary  and  involves  con- 
finement within  doors." 

A  Simple  and  Efficient  Treatment  of  Talipes  Calcaneus 
Paralyticus  in  Young  Children. — Ur.  \'.  P.  Gibney  rcjiorts 
several  cases  evidencing  the  efficacy  of  prolonged  and  un- 
interrupted extension  of  the  foot.  The  writer  prefers  a 
plaster-of-Paris  dressing,  but  says  that  almost  any  appli- 
ance which  is  worn  night  and  day,  the  management  of 
which  is  taken  completely  out  of  the  patient's  hands, 
should  bring  about  like  results.  He  has  not  resorted  to 
the  method  in  older  patients,  for  the  reason  that  it  is  diffi- 
cult to  keep  plaster  of  Paris  on  a  limb  sufficiently  long  to 
secure  a  good  position. 

Multiple  Traumatic  Hemorrhages  of  the  Liver  Associated 
with  Multiple  Pulmonary  Emboli  of  Liver  Cells  and  Giant 
Cells  Resembling  Bone-Marrow  Cells. — By  Alfred  Scott 
Warthin. 

Xew  York  Medical  Journal,  September  ij,  iqoo. 

The  Treatment  of  Tuberculous  and  Purulent  Joints  with 
Large  Glass  Speculum  Drainage  and  Pure  Carbolic  Acid; 
with  Report  of  Seventy  Cases. — A.  M.  Phelps  summarizes 
his  results  in  the  following  statements:  in  the  seventy 
cases  there  have  been  twenty  excisions.  In  all  the  other 
cases  the  joints  have  been  freely  opened  and  portions  of 
bone  and  cartilage  which  were  found  dead  in  the  joint  re- 
moved in  nearly  every  one.  In  fifteen  of  the  cases  the 
head  of  the  bone  was  found  separated  from  the  neck  and 
lying  as  a  sequestrum  in  the  joint.  In  thirty  cases  the 
disease  was  confined  to  the  acetabulum,  with  some  second- 
ary infection  of  the  neck  of  the  bone.  In  twelve  cases  the 
abscess  had  burrowed  into  the  iliac  fossa,  necessitating  an 
operation  there.  In  forty  cases  the  capsule  had  ruptured 
anteriorly  into  the  iliac  muscle,  finding  its  way  into  the 
iliac  fossa  or  into  Scarpa's  triangle.  In  two  cases  the  ab- 
scess had  gone  through  the  thigh  from  Scarpa's  triangle 
and  had  appeared  in  the  gluteal  fold  posteriorly.  Fifteen 
patients  who  had  been  subjected  to  excision  of  the  hip  left 
the  hospital  with  their  splints  on  four  weeks  from  the  day 


466 


MEDICAL    RECORD 


[September  22,  1900 


of  the  excision ;  three  left  the  hospital  at  the  end  of  two 
months;  two  required  subsequent  operations,  and  one  of 
these  left  the  hospital  at  the  end  of  four  months,  and  the 
other,  with  extensive  disease  of  the  pelvis,  has  been  in  the 
hospital  Jive  months  and  will  be  discharged  within  a  week 
or  two  ;  and  three  more  are  reported  as  having  been  oper- 
ated on  last  week.  In  all  the  cases  requiring  excisions  or 
extensive  bone  operations  the  patients  were  discharged 
from  the  hospital  in  an  average  of  three  weeks  from  the 
time  of  the  operation,  wearing  hip  braces  or  using  crutches. 
The  wounds  were  firmly  closed  in  all  the  cases,  except 
those  reported  as  not  closed,  and  remain  so. 

The  Lingual  Tonsil. — Robert  Levy  says  that  depending 
upon  ilic-  prominence  with  which  certain  individual  symp- 
toms exist,  one  may  class  these  cases  into:  (i)  those  of 
simple  discomfort ;  (2)  those  of  severe  cough  ;  (3)  those  of 
vocal  distress  ;  (4)  those  of  respiratory  distress  ;  (5)  those 
of  distress  in  swallowing ;  (6)  hemorrhagic  cases.  The 
symptoms  referable  to  these  various  conditions  are  con- 
sidered in  detail.  He  offers  a  word  of  caution  and  warn- 
ing to  the  effect  that  many  individuals  present  compara- 
tively large  lingual  tonsils,  but  that  they  are  not  responsible 
for  any  symptom,  and,  moreover,  it  is  not  always  safe  to 
conclude  that  because  certain  peculiar  nervous  symptoms 
are  relieved  by  the  application  of  the  galvano-cautery  to 
the  base  of  the  tongue,  these  symptoms  were  the  direct 
results  of  disease  at  this  situation.  In  certain  highly  neu- 
rotic patients  the  effect  of  counter  irritation  or  the  pro- 
found mental  impression  made  by  rather  severe  and.  to 
some,  formidable  local  treatment,  cannot  be  excluded. 

Generalized  Tuberculous  Lymphadenitis,  with  the  Clinical 
and  Anatomical  Picture  of  Pseudoleukeemia  :  the  Study  of 
a  Case. — By  T.  R.  Cmwder. 

A  Consideration  of  the  Statistics  of  Operations  for  the  Re- 
lief of  Malignant  Disease  of  the  Larynx. — By  D.  Bryson 
Delavan. 

Were  these  Unusual  Cases  of  Partial  Paralysis  of  the  Vocal 
Bands  Caused  by  Over-Use  of  the  Telephone  ? — By  Clarence 
C.  Rice. 

The  Philadelphia  Mediial  Journal,  September  /j,  igoo. 

Mental  Disturbances  after  Operations  upon  the  Eye. — Wil- 
liam Campbell  Posey  reports  twenty-four  cases  in  which 
delirium  followed  various  operations  upon  the  eye.  The 
delirium  was  of  the  same  character  in  all,  beginning  with 
mild  restlessness  and  developing  into  active  delirium  witli 
hallucinations  and  ideas  of  persecution,  but  passing  rapidly 
under  control  by  the  proper  administration  of  narcotics; 
permanent  affection  of  the  brain  was  not  remarked  in  a 
single  instance.  The  writer  is  convinced  from  a  critical 
study  of  the  subject  that  the  cause  of  this  delirium  is 
largely  psychic,  and  he  agrees  with  Parinaud  that  it  is  due 
to  the  preoccupation  upon  the  part  of  the  patients  prior  to 
and  after  the  operation  ;  this  is  still  further  favored  by  the 
constraint  of  the  supine  position  and  the  unusual  stillness 
of  the  surroundings.  Treatment  consists  in  the  free  and 
repeated  administration  of  chloral  and  the  bromides. 
There  is  no  reason  to  discontinue  the  employment  of  atro- 
pine. Constant  oversight  and  judicious  and  tactful  nurs- 
ing are  most  essential. 

Resolution  as  an  Etiological  Factor  in  Post-critical  Temper- 
ature of  Lobar  Pneumonia  in  Children. — By  William  N. 
Fisher. 

Post-diphtheric  Paralysis  of  Both  External  Recti  Muscles ; 
Report  of  a  Case. — By  Harry  FricdcnwaUI. 

A  Few  Cases  of  Diphtheria  and  What  They  Taught  Me. 
—  By  John  Luvcrctt. 

Inversion    of    Uterus ;    Uterine    Inertia ;    Short   Cord. — By 
Edward  K.  Bacon. 
Neurasthenia. — By  J.  T.  Eskridge. 

Journal  of  the  Anieriean  Medical  Ass' n,  Sept.  /j.  iqoci. 

Some  Facts  Medical  and  Surgical  about  Appendicitis. — J. 
H.  Carstens  sums  up  his  conclusions  as  follows:  (i)  It 
ought  to  be  a  general  rule  to  operate  on  every  case  of  ap- 
pendicitis as  soon  as  the  diagnosis  is  made,  but  when  it  is  a 
first  attack  and  mild,  or  no  proper  facilities  are  at  hand  for 
operation  or  subsequent  care  of  the  patient,  it  is  often  good 
policy  to  wait  and  watch  the  case.  (2)  In  cases  of  second 
or  subsequent  attacks,  however,  the  patient  should  be  sent 
to  a  hospital,  even  if  it  is  at  quite  a  distance — unless  good 
facilities  can  be  had  at  home — and  an  operation  promptly 
performed.  (3)  Statistics  of  cases  operated  on  as  they 
come  along,  good,  Ijad.  and  indifferent,  by  exi>erienced  sur- 
geons, give  a  mortality  of  only  eight  per  cent.  (4)  Statis- 
tics collected  by  geneial  practitioners  who  are  able  and  up 
to  date,  and  who  advocate  surgical  interference,  show  that 
medically  treated  cases  have  a  death  rate  of  at  least  fifteen 
to  twenty  per  cent.  ;  that  at  least  sixty  per  cent,  have  re- 
currences ;  while  in  the  cases  operated  on  the  patients  are 
absolutely  cured. 


Cutaneous  Manifestations  in  Diabetes  Mellitus.— S.  Sher- 
well  gives  the  following  list,  made  out  in  the  order  of  rela- 
tive frequency:  (i)  Xeroderma,  or  a  condition  of  dry 
skin  ;  (2)  pruritus,  without  any,  or  at  least  any  note- 
worthy, objective  lesions,  the  genital  regions  in  both  sexes 
apparently  suffering  most ;  (3)  eczemas,  partly  neurotic, 
at  other  times  catarrhal  ;  (4)  furunculosis,  often  general 
in  character,  but  sometimes  regional;  (5)  conditions  of 
erysipelatous  manifestations  and  gangrene  ;  (6)  xanthoma 
diabeticorum,  a  disease  accompanied  by  formation  of  xan- 
thomatous new  growths,  often  in  immense  quantities,  and 
more  particularly  over  extensor  surfaces  of  body  and  limbs  : 
(7)  possibly,  the  recently  recognized  and  not  much  inves- 
tigated "blastomycetic  dermatitis,"  in  which  tumors  look- 
ing like  verrucous  lupus,  or  the  so-called  "tuberculosis 
verrucosa  cutis,"  become  fungoid  in  character,  and  on  mi- 
croscojiical  examination  are  found  to  be  filled  with  the 
fungi  (if  saccharine  fermentation  ;  (8)  dermatitis  herpeti- 
formis— Duhring's  disease. 

Diabetes  Mellitus  in  Children. — Henry  Dwight  Chapin 
gives  the  following  conclusions  as  to  this  disease  in  chil- 
dren :  First,  it  is  exceedingly  rare.  Sec<md,  it  is  a  disease 
exceedingly  fatal  to  young  children,  although  this  writer 
cannot  tell  wh}'.  In  the  two  cases  he  rejjorts  there  was  no 
evidence  of  assimilative  disturbance,  and  the  children  had 
been  in  a  state  of  good  nutrition.  Third,  this  disease  in 
children  is  accompanied  by  very  rapid  emaciation.  The 
author  believes  that  whenever  a  child  is  brought  to  the 
physician  with  a  rapid  atrophy,  he  should  examine  the 
urine  for  sugar. 

Improved  Lantern  for  Testing  Color  Perception. — By 
Charles  H.  Williams. 

Improved  Method  of  Testing  Color  Perception.  — By  Wil- 
liam Thomson. 

Influence  of  Sea-Air  and  Sea-Water  Baths  on  Disease. — 
By  W.  Blair  Stew  art. 

The  Identification  of  Dextrose  in  Human  Urine. — By  Hein- 
rich  StL'in. 

Measurements  of  Chicago  School  Children. — By  W.  S. 
Christo|)lier. 

Infantile  Cerebral  Palsy.  Classification  of  Twenty-five 
Cases,  with  Illustrations. — By  A.  C.  Cotton. 

The  Milk-Control  in  the  Kaiser  und  Kaiserin  Friedrich 
Hospital,  Berlin. — By  Sommerfeld. 

The  Milk-Supply  in  the  Kaiser  und  Kaiserin  Friedrich 
Hospital,  Berlin. — By  A.  Bagmsky. 

The  Relative  Value  of  Homatropine  as  a  Cycloplegic :  a 
Clinical  Study.— By  E.  C.  Ellett. 

Hrittsli  Medical  Journal,  September  S,  iqoo. 

Yellow-Fever  Expedition  of  the  Liverpool  School  of  Tropi- 
cal Medicine. — In  these  preliminary  notes  Herbert  E.  Dur- 
ham and  Walter  Myers  say  it  appears  certain  that  neither 
the  handling  of  or  contact  with  yellow-fever  patients  nor 
the  performance  of  necropsies  is  capable  per  se  of  convey- 
ing the  disease  to  uon-immunes.  It  also  appears  probable 
that  .general  ships'  cargoes  and  the  fomites  of  patients  are 
not  directly  infective,  although  the  evidence  as  to  this 
point  is  not  conclusive.  It  seems  to  be  fairly  definitely 
established  that  a  patient  may  become  a  danger  by  "  infect- 
ing the  house"  in  which  he  is  placed.  Given  that  a  house 
is  "infected,"  a  visit  by  a  non-immune  person  entails  con- 
siderable risk  of  contracting  the  malady.  Complete  and 
absolute  immunity  is  not  acquired  by  a  single  attack, 
though  second  attacks  are  usually  comparatively  mild,  or 
at  any  rale  of  a  recoverable  type.  The  statement  .so  fre- 
quently reiieated  in  text-books,  to  the  effect  that  colored 
people  and  natives  never  suffer  from  the  disease,  seems 
not  to  be  true.  The  writers  saw  one  negro  during  the 
course  of  a  typical  attack,  and  although  Cubans  and  Cu- 
ban doctors  assert  that  the  Cuban  system  is  incapable  of 
contracting  yellow  fever,  they  are  known  to  suffer  from  a 
disease  called  "borras"and  also  from  "pernicious  mala- 
rial fever,"  the  symptomatology  and  pathological  anatomy 
of  which  are  very  suggestive  of  yellow  fever.  In  "  borras  " 
there  is  sometimes  black  vomit  with  suppression  of  urine, 
and  the  lesions  of  yellow  fever  are  said  to  be  present  in 
fatal  cases. 

On  the  Treatment  of  Blisters.— Arthur  H.  Ward  advo- 
cates the  following:  The  blister  is  incised  and  the  raised 
epidermis  cut  completely  away  with  sharp  scissors;  no 
overla]ii)ing  fragment  beneath  which  microbes  might  de- 
velo])  is  left.  The  surface  is  then  carefully  dried  and 
painted  with  several  layers  of  salicylated  collodion.  A 
circular  piece  of  soft  linen  is  cut  rather  larger  than  the  ex- 
posed surface,  and  this  is  jilastcred  on  with  more  collodion, 
which  is  worked  well  into  the  meshes  of  the  material.  Sev- 
eral more  coats  of  collodion  are  put  over;ill.  This  makes 
a  strong  protection  to  the  abraded  surface,  and  the  patient 
can  at  once  walk  with  comfort.  If  a  blister  has  been  neg- 
lecte<l  and  is  inflamed  it  should  be  treated  with  antiseptic 
lotions  for  a  day  or  two  before  the  method  is  applied. 


September  22,  1900] 


MFDICAL    RECORD. 


467 


Hay  Fever. — George  H.  R.  Dabbs  says  that  not  for  many 
years  has  he  been  free  from  hay-fever  symptoms  until  this 
summer.  This  immunity  he  thinks  may  possibly  be  due 
to  the  use  of  an  ointment  of  the  liquor  carbouis  detergens  as 
strong  as  it  can  be  made,  with  benzoated  lard,  and  not  too 
thick  to  be  easily  painted  on  the  inside  of  the  nostrils  and 
snuffed  up  well  from  the  loaded  brush. 

Two  Cases  of  Amputation  at  the  Hip-Joint  for  Gunshot 
Fracture  of  the  Thigh  during  the  Intermediate  Stage,  fol- 
lowed by  Recovery  in  One. — By  F.  J.  \V.  i'orler. 

Diphtheria  and  its  Treatment  by  Antitoxin. — By  R.  W. 
Marsdun. 

Cervello's  Treatment  of  Phthisis.— By  Nevell  E.  Norway. 

Splint  for  Fractured  Humerus.— Bv  Richard  Francis 
Tol.in. 

Obstruction  of  Steno's  Duct  Caused  by  Stomatitis. — By 
Chichcle  Xourse. 

A  Case  of  Supposed  Foreign  Body  in  the  (Esophagus.— Bv 
G.  P.  Xewbolt. 

'J he  Lanci-t,  Srf'tt-inih-y  S,  /goo. 
Expectancy  of  Life  in  Cases  of  Cancer  of  the  Breast.— 
Arthur  E.  Barker,  in  a  clinical  lecture,  after  dwelling  on 
the  present  methods  of  radical  and  extensive  removal  of 
not  only  the  breast  but  surrounding  parts,  goes  into  figures 
and  gives  statistical  tables  grouped  as  follows  :  Group  I. 
includes  cases  of  i)atients  known  to  have  died  long  after 
excision,  presumably  from  recurrence,  though  one  certainly 
died  from  calculous  [jyelitis  without  recuiTence,  and  pos- 
sibly others.  Fifty-two  patients  have  died  at  intervals 
ranging  from  two  months  to  over  seven  years.  Group  II. 
comprises  cases  of  excision  of  the  breast  in  which  the 
patients  were  known  to  be  alive  at  the  intervals  given, 
grouped  with  those  alive  and  without  recurrence  respec- 
tively ten  years  and  one  month,  one  year  and  seven 
months,  and  one  year  and  two  months  when  last  heard  of 
more  than  a  year  ago.  Of  these  twenty  were  known  to  be 
alive  at  the  intervals  given,  and  of  these  fifteen  are,  or 
were,  alive  over  three  years.  Group  III.  includes  cases  of 
patients  known  to  have  died,  taken  together  with  those 
still  alive  and  examined  as  to  duration  of  life.  Trom  this 
it  will  be  seen  that  sixteen  per  cent,  lived  over  five  years 
and  33.7  per  cent,  over  tliree  years.  These  figures  appear 
to  justify  the  hojje  that  the  expectancy  of  life  is  improving 
as  time  goes  on.  It  is  clear  that  over  thirty-three  per  cent, 
of  patients  live  more  than  three  years  after  the  operation, 
which  has  suggested  to  .some  surgeons  that  such  cases 
should  be  regarded  as  permanent  cures.  But  some  of  the 
cases  (26.9  per  cent.)  have  resulted  fatally,  most  likely 
from  recurrence,  in  all  but  one  after  an  "interval  of  immu- 
nity of  over  three  years,  so  that  such  a  presumption  is 
unwarranted.  Another  interesting  point  comes  out  from 
this  analysis — namely,  that  only  seven  suffered  from  local 
recurrence.  Those  in  whom  the  disease  has  returned  have 
shown  it  in  internal  parts.  This  is  another  good  feature 
of  the  modern  ojierations,  local  recurrence  being  most  de- 
pressing and  jjainful,  while  internal  generalization  is  often 
not  so.  The  entire  set  of  figures  is  based  on  one  hundred 
consecutive  cases. 

Some  Remarks  upon  the  Treatment  of  Heart  Disease,  with 
Special  Reference  to  the  "Hill  Heart."— H.J.  Campbell 
speaks  of  the  physics  of  the  Xauheim  system,  calling  at- 
tention to  the  fact  that  while  it  is  most  excellent  in  its  re- 
sults, and  that  while  Oertel's  system  of  graduated  walking 
exercises  is  of  service,  both  presuppose  a  heart  which  has 
nmscle  substance  capable  of  either  exerting  more  force 
under  increased  stimulation,  of  increasing  its  power  on 
contraction  as  the  result  of  its  hypertrophy,  or  at  least  of 
recovering  itself  if  nutrition  is  favorable.  The  difiicult 
cases  are  those  in  which  the  heart  muscle  is  so  degenerated 
that  it  is  unable  to  react  to  the  means  employed  for  its 
relief.  Here  an  endeavoi- must  be  made  to  lessen  the  work 
the  heart  has  to  do.  Another  set  of  cases  is  found  in  which 
the  heart  acts  very  well  under  normal  circumstances,  but 
does  badly  under  any  sudden  strain.  Here  there  are 
alarming  and  dangerous  attacks.  These  may  cause  only 
distress,  dyspnoea,  or  anginal  pain,  or  they  may  induce 
syucope,  or  even  lead  to  seizures  of  an  epileptiform  or  ajio- 
plectiform  character,  and  may.  and  not  infrequently  do. 
terminate  in  almost  sudden  death.  Illustrative  histories 
are  given  of  the  different  varietiesof  cases.  As  to  therapy, 
the  author  lays  stress  on  balneology  and  gymnastics, 
which,  however,  must  be  interdicted  in  any  advanced  stage 
of  arteriosclerosis. 

Case  of  Diffuse  Suppurative  Peritonitis  from  Gangrene  of 
the  Appendix;  Laparotomy;  Recovery.— H.  A.  Duffet  gives 

some  statistics  bearing  on  the  subject,  and  details  the  his- 
tory of  a  boy  aged  fourteen  years  treated  for  acute  pain 
and  abdominal  distention,  with  vomiting  and  constipation. 
The  symptoms  of  peritonitis  gradually  developed,  and  the 
abdomen  was  opened  by  a  four-inch  incision  below  the 
umbilicus.     Free  offensive  pus  was  found  in  the  pelvis, 


with  a  gangrenous  appendix.  No  concretion  was  seen. 
The  patient  did  well  for  five  days,  when  the  temperature 
rose  with  symptoms  suggesting  a  recrudescence  of  the 
peritonitis.  A  fresh  abdominal  incision  disclosed  a  small 
pus  pocket  in  the  right  iliac  fossa.  Thereafter  the  boy  did 
well,  though  healing  of  the  incisions  was  slow. 

A  Note  on  Pathology  and  Treatment  of  Gastric  Ulcer. — 
W.  Stuart-Low  believes  that  .gastric  ulcer  is  favored  by  the 
deficient  secretion  of  the  glands  of  the  alimentary  tract, 
more  especially  the  mucous  secretion.  He  consequently 
orders  in  such  cases  mucin  in  ten-grain  doses.  It  is  pre- 
pared in  cachets  from  animal  bile  and  is  given  in  doses  of 
gr.  X.  along  with  an  equal  amount  of  sodium  bicarbonate 
just  before  meals,  with  a  little  water.  Diet  and  other 
measures  are  as  usual. 

The  Removal  of  Septic  Effusions  from  the  Cavities  of  the 
Human  Body. — Edward  Arniitage  advocates  the  use  of  mer- 
curial ointment,  believing  tliat  this  time-honored  remedy 
has  fallen  into  an  undeserved  disuse. 

Some  Aspects  of  Biology. — Presidential  address  by  Sir 
William  Turner  before  the  British  Association  for  the  Ad- 
vancement of  Science. 

Note  on  a  Case  of  Acute  Glaucoma,  the  Result  of  an  Oper- 
ation for  Secondary  Cataract. — By  C.  B.  Taylor. 

Tracheotomy  with  Antitoxin  in  Laryngeal  Diphtheria. — 
By  \V.  Blair  Bell. 

On  the  Pathology  and  Therapy  of  Angina  Pectoris. — By 
T.  Schott. 

A  Case  of  Malignant  Disease  of  the  Ovaries. — Bv  P.  J. 
Baily. 

Prussia  Acid  in  Sweet  Cassava. — By  Professor  Carmody. 

Berliner  klinische  WochenschriJI,  August  zy,  igoo. 

The  Treatment  of  Antral  Empyema.— Max  Halle  advo- 
cates the  procedure  followed  in  Krause's  clinic  in  Berlin. 
The  antrum  is  opened  by  a  trocar  in  the  interior  nasal  me- 
atus and  its  contents  are  evacuated  by  syringing  through 
the  opening  thus  made,  out  through  the  natural  opening 
in  the  middle  meatus.  By  means  of  the  syringe  an  air 
douche  is  driven  through  the  antrum  and  it  is  again 
syringed.  The  air  douching  is  again  resumed  until  the 
interior  of  the  cavity  has  been  made  fairly  dry.  Iodoform 
is  then  freely  insufflated  into  it.  No  packin.g  whatever  is 
used.  Halle  claims  that  this  plan  of  treatment  (the  dry 
method)  is  not  difficult,  can  be  done  without  narcosis. 
avoids  all  communication  with  the  mouth,  relieves  the 
patient  from  the  disagreeable  taste  of  iodoform  packing, 
as  is  so  often  necessary  in  operations  through  the  canine 
fossa,  and  produces  healing  in  less  time  than  by  other 
methods. 

The  Especial  Danger  of  Acute  Purulent  Middle-Ear  Inflam- 
mations in  Advanced  Life. — Heine  gives  a  study  of  sixty- 
three  fatal  cases  of  meningitis  following  middle-ear  trou- 
ble, in  which  the  antecedent  history  was  one  of  acute  or 
subacute  ear  inrtammation  in  thirty-one,  and  of  chronic 
trouble  in  thirty-two.  Of  the  latteronly  five  cases  occurred 
in  patients  over  forty  years  old,  but  of  the  former  no  less 
than  sixteen  fell  in  this  category.  He  is  disposed  to  ex- 
plain this  fact  by  the  late  disclosure  of  meningeal  trouble 
in  this  last-named  class,  a  result  due  in  turn  to  the  fact 
that  in  later  years  the  bone  surrounding  the  inflammatory 
area  becomes  hardened  and  even  eburnated  so  that  exter- 
nal escape  of  the  inflammatory  products  is  rendered  dif- 
ficult. Necessity  for  operation  is  consequently  not  so 
evident,  and  meningeal  infection  occurs  before  the  true 
condition  is  recognized. 

Affections  of  the  Nose  in  their  Relations  to  General  Affec- 
tions.— A.  Seifert  reviews  familiar  ground,  calling  special 
attention  to  the  fact  that  various  cardiac  neuroses  are  de- 
pendent on  intranasal  conditions.  Chlorotic  .girls  often 
suffer  from  a  dryness  of  the  nares.  and  in  the  various  l)lood 
di.seases,  so-called,  bleeding  from  the  nares  is  a  frequent 
occurrence.  The  no.se  is  often  the  channel  of  entrance  of 
the  infective  agents  in  many  contagious  diseases,  such  as 
scarlatina,  diphtheria,  tetanus,  etc.  The  same  observation 
holds  true  with  reference  to  the  chronic  infectious  mala- 
dies such  as  tuberculosis  and  lupus.  The  article  contains 
nothing  new. 

Kidney  Operations  in  Cases  in  which  One  Kidney  is  Absent 
or  Diseased. — By  Mankiewicz. 

Deutsclie  iiieiiicinischc  Woclicnscliril I,  August 30,  /goo. 

Queirolo's  Method  of  Determining  the  Stomach  Boundaries. 
—  Edel  and  Volhard  have  experimented  with  this  method 
to  determine  its  accuracy  and  utility.  The  apparatus  de- 
vised by  Queirolo  and  Landi  consists  of  a  stomach  tube, 
the  lower  extremity  of  which  is  closed  bj'  a  distensible  bal- 
loon, while  the  free  end  is  provided  with  two  pieces  of 
tubing.  One  of  these  is  connected  to  a  Marey's  tambour, 
while  the  other  is  simply  closed  by  a  stop-cock.     After  in- 


468 


MEDICAL   RECORD. 


[September  22,  1900 


troduction  of  the  tube  the  balloon  is  lightly  inflated  through 
the  open  tube,  and  the  membranes  of  the  tambour  are  thus 
made  tense.  On  now  gently  percussing  the  abdomen  and 
watching  the  index  of  the  registering  apparatus,  an  excur- 
sion of  the  lever  is  observed  as  soon  as  the  stomach  is 
reached,  while  it  stays  at  rest  so  long  as  only  the  intestine 
is  being  percussed.  The  inventor  claims  that  by  this 
means  much  greater  exactness  of  diiignosis  in  stomach  dis- 
eases will  be  made  possible,  and  that  our  ideas  of  the  nor- 
mal limits  may  have  to  undergo  change.  In  order  to  test 
the  method  the  authors  first  determined  and  marked  out 
the  gastric  boundaries  by  means  of  the  instrument,  and 
then  inflated  the  stomach  with  carbonic-acid  gas  and  re- 
peated the  percussion.  It  was  found  that  the  results  of  the 
two  methods  were  identical,  though  some  skill  is  necessary 
in  interpreting  the  movements  of  the  registering  index. 
For  i-outine  use  the  instrument  offers  no  advantages  over 
the  far  simpler  and  equally  accurate  inflation  with  air  or 
carbonic-acid  gas,  and  gives  no  information  not  obtainable 
by  the  customary  methods  of  diagnosis. 

A  Myxomatous  Endothelioma  of  the  Soft  Palate. — H. 
Cordes  reports  a  case  of  this  rather  unusual  new  growth 
and  discusses  its  pathological  aspects.  Only  one  hundred 
and  thirty-eight  cases  of  tumor  in  this  situation  are  to  be 
found  mentioned  in  the  literature,  and  of  these  nearly  one- 
half  are  eitlier  sarcoma,  carcinoma,  or  adenoma,  only  four 
being  endotheliomata.  These  tumors  originate  in  the  en- 
dothelial lining  of  the  tissue-clefts  or  lymph  and  blood- 
.vessels,  and  are  characterized  by  a  strong  tendency  to 
degenerative  changes.  Colloid,  hyaline,  or  myxomatous 
metamorphosis  nearly  always  is  found  to  a  greater  or  less 
extent,  which  greatU'  enhances  the  difficulties  of  a  micro- 
scopical diagnosjis.  The  clinical  manifestations  are  slight, 
and  after  years  of  growth  the  tumor  may  be  discovered 
only  by  accident.  Even  when  of  large  size  these  tumors 
are  painless  and  give  rise  only  to  mechanical  symptoms, 
dysphagia,  aphasia,  or  dyspnoea  through  pressure  on  the 
epiglottis.  In  general  they  are  non-malignant  in  type, 
having  no  tendency  to  the  formation  of  metastases,  and 
when  removed  in  seasun  do  not  recur. 

Can  Roentgen-Ray  Transillumination  Differentiate  Aortic 
Aneurism  from  Intrathoracic  Tumor? — E.  Gebauer  answers 
this  question  in  the  negative,  and  in  illustration  cites  a 
case  in  which  the  fluoroscopic  diagnosis  and  post-mortem 
findings  did  not  agree.  The  symptomatology  and  physical 
signs  gave  evidence  which  might  be  interpreted  as  indicat- 
ing either  aneurism  of  the  aorta,  pulmonary  phthisis  with 
considerable  glandular  infiltration,  or  an  intrathoracic  new 
growth.  On  .i-ray  examination  a  mass  was  made  out  just 
above  the  heart  and  exhibiting  very  distinct  pulsation,  so 
that  the  diagnosis  of  aneurism  seemed  assured.  The  ne- 
cropsy revealed  a  carcinomatous  growth  of  the  oesophagus, 
which  had  spread  to  the  lungs  and  broken  down  in  places  ; 
the  pulsation  observed  was  apparently  purely  transmitted. 

The  Examination  of  the  Thorax  with  the  Roentgen  Rays 
and  Some  Results. — By  Levy-Dorn. 

Haematological  Investigations. — By  E.  Becker. 
Alunchener  medicinische  VVochenschrift,  Aiigxist 2S,  igoo. 

Immunity. — Buchner  divides  the  general  subject  into  two 
headings,  natural  immunity,  or  preferably  resistance,  and 
specific  immunity  either  acquired  by  chance  or  produced 
experimentally.  Regarding  the  former  our  views  are 
changing  somewhat,  and  it  is  being  recognized  that  in  ad- 
dition to  the  phagocytic  power  of  tlie  leucocytes  they  pos- 
sess at  least  one  other  property  of  use  in  fortifying  the 
organism.  This  is  the  faculty  of  producing  alexins,  which 
by  many  observers  are  supposed  to  appear  only  on  the  death 
of  the  cells  themselves.  The  author  differs  from  this  view, 
however,  and  emphatically  affirms  that  the  leucocyte  is  not 
the  easily  destructible  thing  it  is  usually  considered,  and 
that  even  during  its  life  if  the  proper  stimulus  be  present 
alexin  secretion  can  take  place.  We  can  no  longer  rely  on 
the  microscope  alone  in  our  study  of  this  subject,  and  ad- 
vance is  to  be  made  along  chemical  rather  than  histologi- 
cal lines.  In  di.scussing  the  subject  of  specific  immunity 
the  greatest  difficulties  are  encountered  owing  to  the  hope- 
lessly confused  state  of  the  terminology.  A  simple  and 
logical  nomenclature  would  be  to  make  the  two  grou])s  of 
alexins  and  anti-bodies,  and,  kccijing  the  general  ]irefix 
anti-,  to  subdivide  the  latter  into  antiha-matins,  antitoxins, 
etc.,  according  to  their  specific  nature. 

Traumatic  Tetanus  Complicated  by  Intestinal  Obstruction. 
—  Krey  and  Sarauw  were  called  to  treat  a  boy  twelve  years 
old  giving  the  typical  clinical  picture  of  intestinal  obstruc- 
tion. Soon  after  coming  under  observation  characteristic 
convulsions  and  rigidity  set  in,  whicli  were  ascribed  to 
tetanic  infection  of  a  scalp  wound.  A  laparotomy  revealed 
the  cause  of  obstruction  as  an  intussusception  of  the  small 
intestine,  which  was  readily  reduced  and  the  abdominal 
symptoms  were  relieved.  Tetanus  antitoxin  was  not  avail- 
able, but  under  symptomatic  treatment  the  patient  did 
well  and  was  discharged  cured  in  a  month.     No  definite 


connection  between  the  tetanus  and  the  intestinal  condition 
could  be  established. 

Observations  on  the  Prognostic  Significance  of  the  Diazo 
Reaction  in  Tuberculosis. — F.  Becker  finds  that  a  positive 
diazo  reaction  does  not  always  indicate  a  bad  prognosis  in 
phthisis.  Temporary  and  imimportant  complications  may 
cause  the  phenomenon  quite  independently  of  the  main 
trouble.  If  the  reaction  ajipears  in  cases  in  which  it  is 
usually  ab.sent,  a  complication  of  infectious  nature  is  to  be 
looked  for.  In  some  cases  the  reaction  is  doubtful,  and  a 
positive  interpretation  cannot  be  made.  Usually  the  ap- 
pearance of  a  green  precipitate  after  the  solution  has  stood 
twenty-four  hours  is  taken  to  indicate  a  positive  reaction, 
but  sometimes  this  coloration  is  observed  also  in  negative 
cases. 

The  Treatment  of  Tetanus  Uteri. — Jacob  describes  a  case 
of  transverse  presentation  in  which  version  was  accom- 
plished with  great  difficulty,  and  the  child  was  extracted 
as  far  as  the  head.  The  uterus  spasmodically  contracted 
on  this,  but  finally  relaxed  under  the  prolonged  application 
of  hot  compresses  to  the  abdomen.  The  delivery  of  the 
head  was  followed  by  copious  hemorrhage  and  atony  of 
the  uterus.  This  was  controlled  by  traction  on  the  anterior 
lip  of  the  cervix  with  Museux's  forceps,  massage,  and 
ergot.  Attempts  at  ex])ression  of  the  placenta  by  Crede's 
method  failed,  and  its  removal  was  not  effected  till  the  fol- 
lowing day,  when  it  was  extracted  by  digital  curettage. 

Antitoxin  Treatment  of  Tetanus. — Renter's  case  forms  an 
interesting  pendant  to  the  one  reported  by  Krey  and  Sa- 
rauw, in  which  a  severe  tetanic  infection  was  recovered 
from  withovit  any  specific  treatment.  In  the  present  in- 
stance death  resulted  though  antitoxin  was  promptly  given, 
and  in  spite  of  the  fact  that  tlie  slow  onset  of  the  symptoms 
made  the  case  seem  a  favorable  one  for  treatment.  Never- 
theless the  convulsive  seizures  steadily  increased  in  sever- 
ity and  reached  their  acme  forty-four  hours  after  the  first 
injection,  and  death  followed  sixteen  hours  later. 

A  Case  of  Gonorrhceal  Metastases  in  the  Joints  and  Skin 
Secondary  to  Blennorrhoea  Neonatorum. — Paulsen  says  tliat 
although  joint  affections  of  gonorrhceal  etiology  are  fre- 
quent enough  after  genital  infection,  it  is  very  rare  for 
metastases  to  follow  specific  ophthalmia.  He  reports  a 
case  in  which  both  knees  and  one  wrist  of  an  infant  ten 
days  old  became  inflamed  secondarily  to  the  eye  disease. 
Gonococci  were  found  m  the  joint  fluid  and  also  in  the 
secretion  obtained  from  vesicles  forming  a  well-marked 
eruption  on  the  face,  body,  and  limbs. 

A  Further  Contribution  to  the  Origin  of  Cutaneous  Emphy- 
sema after  Laparotomy. — By  Hcil. 

A  Failure  with  Dflhrssen's  Tamponade  in  Atonia  Uteri. — 
By  Spaeth. 

The  Topography  and  Diagnosis  of  the  Stomach.  —  By 
Rosenfekl. 

Acute  Osteomyelitis  of  the  Atlas. — By  Eichel. 

The  Tonometer. — By  Gaertner. 

Bulletin  of  the  Johns  Hopkins  Hospital,  September,  igoo. 

The  Distribution  of  Connective  Tissue  in  New  Growths. — 

W.  C.  White  concludes  that  elastic  fibres  are  frequently 
present  in  new  growths,  in  the  stroma,  among  the  cells, 
around  the  blood-vessels,  and  in  breast  tumors  around  the 
lactiferous  ducts  which  have  been  included  and  invaded 
by  the  growth.  They  are  usually  in  connection  with  pre- 
existing elastic  tissue  elements  in  the  original  tissue  in 
which  the  tumor  has  grown.  New  formation  probably  oc- 
curs. Sarcomata  present  a  large  increase  in  connective 
tissue  and  possess  a  fine  intercellular  network  similar  in 
structure  to  tlie  reticulum  present  in  normal  glandular 
tissue.  Carcinomata  possess  a  stroma  of  white  fibrous  tis- 
sue outlining  the  cell  .spaces,  but  have  no  intercellular 
network.  The  digestion  methods  present  a  possible  means 
of  diagnosis  between  carcinomata  and  sarcomata  in  doubt- 
ful cases.  Uterine  myomata  have  a  large  amount  of  both 
white  fibrous  and  reticular  connective  tissue,  possessing  a 
connective-tissue  capsule  for  each  miiscle-ccU  ;  and  they 
would  be  more  correctly  termed  fibromyomata. 

A  Contribution  to  the  Study  of  Malignant  Tumors  Arising 
in  Congenital  Moles. — R.  H.  Whitehead  says  that  among 
the  widely  differing  ojiinions  one  finds  it  difficult  to  reach 
a  definite  conclusion  as  to  the  nature  of  the  [na-vus  cells, 
but  the  pictures  of  Scheuber  and  of  Gilchrist  are  sugges- 
tive, and  one  may  be  permitted  to  hold  the  view  that  in 
some  moles,  at  least,  the  groups  of  cells  are  modified  epi- 
thelial cells  of  epidermal  origin.  Should  a  tumor  spring 
from  such  cells,  we  should  naturally  expect  it  to  follow  the 
tyix-  of  carcinoma.  This  expectation,  however,  is  not 
always  realized.  Nine  tumors  of  this  class,  which  the 
author  has  been  alile  to  examine,  had  that  histological 
structure  which  most  pathologists  have  agreed  to  call  alve- 
olar sarcoma,  and  were  so  pronounced  by  competent  ob- 
servers.    The  author  reports  two  cases  in  which  the  tumors 


September  22,  1900] 


MEDICAL    RECORD. 


469 


springing  from  congenital  moles  represent  the  same  proc- 
esses as  those  going  on  in  the  melanotic  tumors,  with  the 
exception  that  they  totally  lack  true  melanotic  pigment. 

On  the  Eistology  of  the  Islands  of  Langerhans  of  the  Pan- 
creas.— Eugenu  L.  Opie  reaches  the  following  conclusions; 
(i)  The  islands  of  Langerhans  are  composed  of  cells  hav- 
ing the  same  origin  as  those  of  the  glandular  acini,  but 
forming  structures  which  are  independent  of  the  secreting 
apparatus  and  in  intimate  relation  with  the  vascular  sys- 
tem. (2)  In  the  splenic  end  of  the  cat's  pancreas  they 
have  a  definite  position  within  the  lobule,  each  of  which 
contains  one  of  these  structures.  (3)  In  the  human  pan- 
creas they  are  more  numerous  in  the  sjjlenic  extremity  or 
tail  than  elsewhere.  (4)  Prolonged  stimulation  of  the 
gland  does  not,  as  claimed  by  Lewaschew,  transform 
groups  of  acini  into  islands  of  Langerhans. 

On  the  Relation  of  the  Electrical  Conductivity  of  Blood 
Serum  to  its  Alleged  Bactericidal  Power. — By  ICmnia  Lootz 
and  Alice  Weld  Tallant. 

Morbid    Conditions    Caused   by  Bacillus  Aerogenes   Capsu- 
latus.— By  William  H.  Welch. 
The  Sterilization  of  Catgut. — By  G.  Brown  Miller. 
Inorganic  Ferments. — By  Harry  C.  Jones. 

Archives  of  I'c'dialrics,  September,  igoo. 

Typhoid  Fever  in  Childhood. — A.  I).  Blackader  analyzes 
the  features  of  one  hundred  consecutive  cases  occurring  in 
children  under  fifteen  years  of  age.  Concerning  the  use  of 
the  bath  he  finds  that  the  nervous  system  of  the  child  re- 
sponds more  quickly  and  energetically  to  the  cool  bath 
than  does  that  of  the  adult,  and  the  amount  of  response 
has  to  some  extent  an  inverse  proportion  to  the  age.  It  is 
therefore  unnecessary  and  undesirable  that  as  low  temper- 
ature should  be  employed  in  the  case  of  a  young  child  as 
in  the  case  of  an  adult.  He  believes  it  to  be  a  great  shock 
to  a  young  child  to  plunge  it  at  the  outset  into  a  bath  of  68' 
or  even  75  F.  ;  while  a  bath  of  go°  cooled  to  85  and  re- 
peated regularly  for  the  first  few  days  of  the  attack  gives 
rise  to  neither  resistance  nor  signs  of  shock  or  collapse  on 
the  part  of  the  child.  Later  on  in  the  disease  lower  tem- 
peratures may  be  employed  if  found  necessary.  Even 
after  the  pyrexia  falls  below  102'  K.,  he  believes  that  the 
regular  use  of  the  cool  bath  once  or  twice  a  day  strengthens 
the  heart  action  and  tends  to  a  more  rapid  convalescence. 

General  Subcutaneous  Emphysema. — A.  C.  Cotton  reports 
the  case  of  a  child  aged  seven  and  a  half  years  who,  during 
hard  coughing  incident  to  a  severe  bronchitis,  developed 
a  ridge  over  the  right  clavicle  from  which  point  extension 
took  place  in  all  directions.  Examination  of  the  surface 
showed  great  distention  about  the  neck  and  chest,  com- 
pletely obliterating  clavicular  depressions,  and  extending 
downward  over  the  trunk,  especially  in  the  dorso-Iumbar 
region  along  each  side  of  the  spine.  Pressure  elicited  dis- 
tinct crepitation  and  left  no  pitting.  Respirations  were 
shallow  and  rapid  (50  per  minute)  ;  the  pulse  was  rapid 
and  barely  perceptible;  temperature  102°  F.  During  the 
six  subsequent  days  of  life,  infiltration  of  the  subcutaneous 
tissue  extended,  involving  both  upper  and  lower  extremi- 
ties with  the  exception  of  palms  and  soles,  the  skin  becom- 
ing tense  and  shiny.  The  paroxysms  of  coughing  increased 
in  frequency,  being  nearly  continuous  the  last  twenty-four 
hours.  There  were  increasing  dyspnoea  and  deepening 
cyanosis. 

Two  Cases  of  Fatal  Lead  Poisoning. — Allen  Eaines  men- 
tions as  a  characteristic  symptom  of  thiscondition  in  child- 
hood a  very  pronounced  dark  blue  circle  about  the  anus, 
more  marked  in  his  two  cases  from  the  fact  that  the  chil- 
dren were  of  fair  complexion.  The  meals  of  the  family  of 
his  patients  were  cooked  with  firewood  procured  from  the 
staves  of  old  barrels  which  had  contained  white  lead,  so 
that  the  fumes  of  lead  not  only  entered  the  food  but  per- 
meated the  atmosphere.  The  children  affected  were  broth- 
ers. Urine  examination  showed  the  presence  of  lead.  In 
both  convulsions  were  a  prominent  feature. 

A  Case  of  Hysteria  with  Laryngeal  Manifestations  in  a 
Eo/  Aged  Eleven  Years. — By  C.  Herman. 

Exclusive  Soup  Diet  and  Rectal  Irrigation  in  Typhoid 
Fever.— -By  A.  Seibert. 

Annals  oj  Siiti^ery,  Septcnihcr,  igoo. 

Massage  in  the  Treatment  of  Recent  Peri-Articular  Fractures. 
— G.  Woolsey  reviews  the  arguments  advanced  in  favor  of 
this  form  of  treating  fractures,  stating  that  the  claim  is  made 
that  a  certain  amount  of  motion  is  favorable  to  the  repair 
of  bone,  and  that  massage,  in  addition  to  furnishing  this, 
prevents  atrophy  of  the  muscles,  reduces  swelling,  and  re- 
stores the  circulation.  In  this  and  other  less  clearly  known 
ways  it  causes  the  repair  of  bone  to  be  rapid  and,  in  com- 
bination with  passive  motion,  prevents  the  stiffness  of  the 
neighboring  joints.     He  has  followed  this  plan  in  Pott's 


cases,  in  fracture  of  the  patella,  obtaining  in  one  case  firm 
union  and  almost  perfect  motion  in  twenty-four  days,  and 
in  fractures  about  the  elbow-joint.  He  sees  no  advantage 
in  discarding  splints  in  the  early  period  of  the  treatment. 
Their  use  gives  confidence  to  the  patient  and  the  surgeon 
alike,  and  a  sense  of  security  that  no  displacement  is  likely 
to  occur.  Particular  attention  should  be  paid  to  the  [Josi- 
tion  of  the  limb  by  carefully  reducing  any  deformity,  and 
keeping  it  reduced  during  massage  and  between  the 
periods  of  massage,  when  the  limb  is  in  a  splint.  If  this 
is  not  possible  from  the  outset,  after  a  preliminary  mas- 
sage, plaster  should  be  applied,  and  kept  on  for  from  eight 
to  fourteen  days,  and  then  massage  commenced.  The 
result  in  these  cases  is  better  as  far  as  position  is  concerned, 
equally  good  functionally,  and  nearly,  if  not  quite,  as 
quickly  obtained  as  when  massage  is  employed  from  the 
first.  If,  again,  after  mas.saging  for  some  time,  the  posi- 
tion is  found  to  be  imperfect,  or  if.  after  three  weeks,  quite 
firm  union  has  not  taken  place,  Woolsey  believes  in  using 
a  plaster  splint  for  eight  to  fourteen  days,  though  the  func- 
tional result  is  thereby  delayed.  The  application  of  mas- 
sage and  passive  motion  is  easy.  It  relieves  pain  and 
swelling,  hastens  callus  formation  and  solidification,  and 
prevents  atrophy  of  the  muscles  and  stiffness  of  the  joints 
and  tendons. 

The  Ileo-Caecal  Orifice  and  its  Bearing  on  Chronic  Consti- 
pation ;  with  Report  of  Two  Cases  Relieved  by  Operation. — 
\V.  J.  Mayo  believes  that  a  narrowing  of  the  ilc<i-c;ecal 
valve  is  the  cause  of  certain  cases  of  obstinate  constipa- 
tion. In  a  case  requiring  removal  of  the  appendix,  he 
noticed  that  the  calibre  at  this  point  of  the  bowel  was 
markedly  reduced,  having  almost  the  appearance  of  con- 
striction by  a  string.  There  was  no  evidence  of  previous 
disease  or  ulceration.  Obstinate  constipation  of  the  pa- 
tient led  the  doctor  to  expose  the  valve  and  make  an  inci- 
sion two  and  a  half  inches  in  length  at  right  angles  to  the 
ileo-cacal  junction,  having  its  centre  at  that  point,  and  so 
to  suture  the  wound  transversely  as  considerably  to  in- 
crease the  calibre  of  the  valvular  opening.  Recovery  was 
uneventful,  and  the  constipation  practically  disappeared. 
The  writer  advances  the  following  theory  as  explaining 
the  good  results  obtained:  The  secretions  in  the  small 
bowel  are  alkaline,  in  the  large  bowel  slightly  acid,  and  in 
the  production  of  this  change  gases  are  evolved  which 
materially  aid  the  passage  of  fecal  matter  along  the  large 
bowel.  The  thinness  of  the  mu.scular  coat  of  the  large 
bowel  and  its  sacculation  make  it  evident  that  flatus  is  a 
necessary  adjunct  to  fecal  progress.  It  becomes  a  question, 
also,  as  to  whether  or  not  the  greater  amount  of  absorjition 
which  takes  place  in  the  small  bowel  under  such  circum- 
stances leaves  the  contents,  when  passed,  in  a  condition 
less  favorable  to  stimulate  the  peristalsis  and  production 
of  gases  in  the  large  bowel. 

The  Results  of  Castration  and  Vasectomy  in  Hypertrophy 
of  the  Prostate  Gland. — This  is  a  statistical  article  by  A.  C. 
Wood,  who  has  collected  the  records  of  all  ascertainable 
cases  since  the  date  of  the  papers  on  the  same  topic  by 
White  and  Cabot.  Wood  has  gathered  the  records  of  one 
hundred  and  fifty-nine  additional  cases  of  castration  and 
of  one  hundred  and  ninety-three  additional  cases  of  vasec- 
tomy. In  the  former  series  there  were  thirteen  deaths 
from  sepsis  ilue  to  pyuria,  pyelonejihritis,  suppression,  em- 
physematous phlegmon,  pneumonia,  exhaustion,  etc.  The 
results  in  general  were  as  favorable  as  in  the  previously 
reported  cases :  of  the  vasectomies,  general  improvement 
followed  the  operation  in  sixty-seven  per  cent,  of  the  cases. 
There  were  thirteen  deaths,  from  about  the  same  general 
run  of  causes  as'  above  stated.  Dr.  Wood's  article  is  a 
most  valuable  contribution  to  the  literature  of  this  subject. 

On  the  Influence  of  Anaesthesia  on  the  Effect  Produced  on 
the  Circulation  and  Respiration  by  Irritation  of  a  Sensory 
Nerve. — S.  1*.  Kramer  notes  that  in  ex])erimenls  on  dogs 
there  was  in  each  instance  a  stage  of  narcotization  at  which 
the  irritation  of  the  central  end  of  the  crural  nerve  pro- 
duced a  fall  in  blood-pressure.  The  conclusion  may  be 
drawn  from  these  experiments  that  severe  vasomotor  shock 
is  more  liable  to  follow  operations  done  under  partial  anjes- 
thesia  than  such  as  are  done  under  complete  insensibility. 

Tetanus  :  a  Study  of  the  Nature,  Excitant,  Lesions,  Symp- 
tomatology, and  Treatment  of  the  Disease,  with  a  Critical 
Summary  of  the  Results  of  Serum  Therapy. — By  A.  V.  Jilosch- 
cowitz.     A  continued  article. 

Cubitus  Varus;  or,  "Gunstock"  Deformity  following  Frac- 
ture of  the  Lower  End  of  the  Humerus. — By  L.  A.  Siimson. 

Hernia  of  the  Bladder  through  the  Pelvic  Floor  from  the 
Traction  of  a  Subperitoneal  Fibroma.— By  F,  B.  Harrington. 

The  Pathology  of  Fracture  of  the  Lower  Extremity  of  the 
Radius.— By  F.  J.  Cotton. 

Excision  of  the  Wrist  by  a  Modification  of  Mynter's  Method. 
—By  W.  J.  Taylor, 


470 


MEDICAL    RECORD. 


[September  22,  1900 


Scottish  Medical  and  Surgical  Journal.  September,  igoo. 

A  Case  of  Erythema  Induratum  Scrofulosorum. — The  pa- 
tient of  O,  S.  liuughty  was  a  yirl  av;L-d  twenty  years  with 
pulmonary  tuberculosis,  who  did  well  on  open-air  treat- 
ment with  full  feeding  and  guaiarol  carbonate  and  creosote 
internally.  Seen  again  a  few  months  later,  she  was  found 
in  bed  complaining  of  aching  all  over  the  body  but  espe- 
cially in  her  legs,  on  which,  she  said,  there  were  spots. 
Her  temperature  was  100.4  F-  :  '^er  pulse  somewhat  quicker 
than  usual.  A  careful  examination  of  her  chest  failed  to 
reveal  any  return  of  the  former  mischief.  There  was  no 
cough  and  no  expectoration  could  be  got  for  examination. 
On  the  lower  two-thirds  of  the  calves  of  her  legs  there 
were  several  nodules,  more  numerous  on  the  left  leg  than 
on  the  ri,ght.  These  nodules  were  of  various  sizes  and 
mostly  of  a  purple  violet  color,  some  darker  than  others. 
In  one  or  two  of  them  there  was  a  small  hole  in  the  centre 
from  which  exuded  a  slight  discharge.  Some  which  were 
not  visible  to  the  eye  could  be  felt  under  the  skin. 
Doughty's  first  impression  was  that  the  lesion  was  syphi- 
litic. Sodium  salicylate  was  given,  followed  by  the  iodide. 
The  latter  gave  no  evident  benefit.  The  case  ran  an  indo- 
lent course,  the  nodules  growing  less  in  size  and  color  but 
not  entirelv  disappearing  as  long  as  the  case  was  under 
observation. 

On  Transfusion. — T.  Annandale  concludes  as  follows  re- 
garding this  therapeutic  measure:  (i)  It  may  be  a  valu- 
able aid  in  saving  life  in  the  case  of  patients  suffering  from 
serious  loss  of  blood,  provided  they  show  no  signs  of  re- 
action after  the  ordinary  means  have  been  carefully  tried. 
(2)  The  best  form  of  transfusion  for  ordinary  use  is  the 
injection  of  human  blood  mixed  with  a  solution  of  phos- 
phate of  .sodium,  and  kept  at  a  proper  temperature,  so  as  to 
prevent  clotting.  (3)  If  the  former  method  cannot  be 
properly  caiTied  out,  the  injection  into  a  vein  of  saline 
solution  (chloride  of  sodium)  is  the  next  best  procedure. 
Both  of  these  procedures  must  be  carried  out  with  the  most 
strict  and  careful  antiseptic  i:)recautions.  {4)  Intra-peri- 
toneal  injections  of  warm  water,  or  of  warm  saline  solu- 
tions, are  most  likely  to  be  useful  in  cases  in  which  the  abdo- 
men has  already  been  opened,  for  without  an  opening  there 
is  always  a  risk  of  injuring  the  intestines  or  other  internal 
organs  with  the  trocar  and  cannula.  (5)  Injections  of 
warm  water  or  of  warm  saline  solutions  into  the  rectum,  or 
into  the  cellular  tissues,  is  a  safe  and  simple  procedure, 
which  maybe  usefully  employed  in  any  sudden  emergency. 

The  Importance  of  Accurate  and  Detailed  Diagnosis  in 
Abdominal  Cases. — Three  cases  illustrating  the  importance 
of  this  proposition  are  described  by  William  Russell. 
Tneir  titles  are  respectively;  Gastric  Ulcer  with  Appen- 
dicitis simulating  Perforating  Gastric  Ulcer  ;  Dyspepsia 
with  Chronic  CEsophageal  Ulcer  simulating  Chronic  Gas- 
tric Ulcer;  Calculus  in  the  Lower  Extremity  of  the  Ureter 
simulating  Appendicitis. 

Inflammation  of  the  Uterine  Appendages. — A  clinical  lec- 
ture by  A.  H.  Freeland  Barbour. 

A  Case  of  Csesarean  Section  followed  by  Subperitoneal 
Hysterectomy. — By  N.  T.  Brewis. 

Ti:e  Ediiibi/ri;Ii  Medical  Journal.  September,  iqoo. 
Can  the  Period  of  Infectiveness  of  Diphtheria  be  Shortened 
and  its  Tendency  to  Spread  Diminished? — William  Ewart 
urges  thorough  disinfection  of  the  nasal  cavities  and  naso- 
pharyn.x  in  all  cases  of  diphtheria,  before  children  are  al- 
lowed to  return  to  the  companionship  of  others.  Whatever 
the  method  adopted,  it  should  be  applied  early  during  the 
attack,  and  perseveringly  and  continuously  during  the 
period  of  convalescence.  At  St.  George's  Hospital  it  is  the 
author's  practice  to  have  all  cases  of  diphtheria  under  his 
care  receive  local  treatment  for  the  nose  and  naso-pharynx 
by  the  introduction  of  carbolized  oil  twice  daily  throughout 
their  stay  at  the  hos])ital,  with  a  view  not  only  to  relieve 
local  discomfort  or  lesions,  and  to  prevent  the  spread  of  the 
latter,  but  also  to  insure,  if  ])Ossible,  in  all  cases  a  grad- 
ual cleansing  and  disinfection  of  the  entire  mucous  surface. 
by  the  spreading  upward  of  the  oil,  which  is  dro])pcd  in 
with  a  camel's-hair  brush,  with  the  patient's  head  thrown 
back. 

Jacksonian  Epilepsy  due  to  Cerebral  Abscess  following  upon 
Typhoid  Fever. — Andrew  Cassels  Brown  reports  a  case 
which  is  of  interest:  (i)  Because  it  followed  ai)parently 
upon  an  attack  of  typhoid  fever.  Presumably  the  same 
pyogenic  organisiris  gained  access  to  the  system  by  means 
of  the  intestinal  ulcerations  and  were  depositee!  in  the 
brain,  becoming  foci  for  the  abscess  which  resulted.  {2) 
Because  of  the  position  of  the  abscess.  It  was  situated  in 
the  Rolandic  area  of  the  right  side,  extending  ])ractically 
all  over  the  ascending  parietal  and  ascending  frontal  con- 
volutions, involving  the  u])per,  middle,  and  lower  thirds  of 
the  motor  area.  {3)  Becau.se  of  the  difficulty  of  making  a 
correct  diagnosis  of  the  exact  nature  of  the  lesion.  Ab- 
scess, in  fact,  was  excluded,  and  the  diagnosis  of  a  rapidly 


growing  tumor  was  made.  (4)  Operation  was  performed, 
and  was  entirely  successful.  The  ]>atient  has  entirely  re- 
coveied  the  use  of  her  leg,  and  to  a  certain  extent  of  her 
arm.  She  is  well,  and  much  pleased  with  the  results  of 
the  treatment. 

Clinical  Lectures  on  Circulatory  Disorders :  II.  The  Cause 
of  the  Presystolic  Murmur.-  By  Jnhn  Orr. 

A  Contribution  to  the  Mechanism  of  Articulate  Speech.— 
By  S.  W.  Carruthers. 

Two  Cases  of  Poisoning  by  Cannabis  Indica. — By  James 
Foulis. 

Norsk  Magaziii  Jor  Laegevideiiskahen.  Sef<teinber.  /goo. 

A  Case  of  Intoxication  from  Camphorated  Naphthol. — Sind- 
ing-Larsen  reports  the  case  of  a  girl  aged  twelve  years,  suf- 
fering from  white  tumor  of  the  knee.  An  injection  of  5 
c.c.  of  camphorated  naphthol  was  made  into  the  articulation 
on  Fel)ruary  Sth,  with  no  bad  results.  Eight  days  later 
another  injection  was  made  with  some  diflicully,  owing  to 
beginning  obliteration  of  the  joint.  Only  4  c.c.  was  ad- 
ministered, when  suddenly  the  patient  had  epileptiform 
convulsions,  delirium,  and  symptoms  of  cerebral  weakness 
(weak  pulse,  cyanosis,  pulmonary  oedema).  The  expired 
breath  two  minutes  after  the  injection  had  a  strong  odor 
of  camphor.  The  cramps  and  the  delirium  ceased  in  aboitt 
ten  minutes,  but  the  symptoms  of  cerebral  weakness  con- 
tinued for  twenty-four  hours,  and  did  not  entirely  disap- 
pear for  several  days.  The  author  advises  caution  in  the 
use  of  the  remedy,  and  believes  that  an  injection  should 
not  be  forced  when  obstacles  are  met  with,  as  in  cases  of 
obliterated  articulations  and  sclerosed  glands. 

The  Etiology  of  Chorea  Minor. — Theodor  Frolich  reports 
forty-seven  cases  in  children  from  three  to  sixteen  years 
old.  In  twenty-four  of  these  there  was  a  family  history 
of  rheumatism  or  of  psychical  trouble.  Fifteen  of  the  pa- 
tients had  had  acute  rheumatism.  In  sixteen  the  chorea 
was  ushered  in  or  accompanied  by  febrile  symptoms  with 
angina,  articular  affections,  or  erythema  nodosum.  These 
sixteen  cases  the  author  considers  to  be  infections.  In 
four  patients  the  chorea  followed  other  infectious  diseases 
— scarlatina,  influenza,  and  epidemic  muscular  rheuma- 
tism. In  twelve  cases  there  was  no  previous  infection, 
but  three  of  them  had  cardiac  lesions.  On  the  whole,  the 
author  holds  that  in  S0.S5  per  cent,  of  the  cases  infection 
was  proved,  and  not  proved  in  ig.  15  per  cent. 

Milk  Diet  in  the  Treatment  of  Stationary  Scotomatous 
Atrophy  of  the  Optic  Ners-e  and  Special  Alexia,  in  Spite  of 
Good  Visual  Perception  (Central  Annular  Scotoma:  after 
Relative  Cure  of  the  Affection.— By  S.  llolth. 

A    Case    of    Color-Blindness    following    Beri-beri. — By    F. 

Tillier. 


CCox'vcsponclcucc. 


OUR   LONDON   LETTER. 

(From  our  Special  Correspondent.) 

CLIMATIC  FRE.^KS — BUBONIC  PL.tGUE  IN  GI.ASOOW — EUTHANA- 
SIA ADVOCATED  BY  "A  PHYSICIAN" — THE  WAR  HOSPITALS 
— MR.    BUKDETT-COUTTS   CONTRADICTED — THE   COMMISSION. 

London,  Auj^ust  24,  1900. 
Ag.\in  W'C  have  been  having  a  cold  snap  while  reading 
telegrams  of  your  sufferings  under  another  heat-wave. 
The  thermometer  marking  barely  60  F.  in  August  made 
us  feel  tliat  autumn  if  not  winter  had  really  set  in.  Last 
year  at  the  same  time  it  was  in  the  eighties.  On  Monday 
and  Tuesday  it  was  quite  curious  to  see  men  going  about 
in  overcoats  with  collars  turned  up  and  ladies  in  sealskins 
and  muffs.  The  shops,  too,  were  suddenly  transformed, 
for  the  windows  were  dressed  with  winter  garments. 
Yesterday  the  rigor  had  relaxed  and  the  thermometer 
was  in  the  seventies.  But  the  sky  was  overcast  and  we 
had  only  forty  minutes  of  clear  sunshine.  To-day  is  just 
the  same.  The  meteorologists  are  divided  as  to  whether 
we  areentering  a  period  of  summer  or  must  first  pass 
through  storms. 

Glasgow  has  had  a  week  of  an.xiety  on  account  of  a  visit 
of  the  plague.  A  suspicious  death  occurred  in  hospital  on 
Mpnday,  and  precautions  were  at  once  taken,  while  exper- 
iments were  being  carried  out  by  Professor  Muir.  The 
result  of  these  is  that  to-day  the  medical  othcer  of  health 
officially  announces  that  the  death  was  cau.scd  by  plague. 
One  or  two  other  suspicious  deaths  have  occurred.  You 
must  not  think  the  last  few  days  have  been  passed  without 
great  activity  on  the  pari  of  the  sanitary  staff,  which  has 
been  doubled.     It  is  believed  that  the  outbreak  will  be 


September  22,  1900] 


MEDICAL   RECORD. 


471 


soon  stamped  out.  There  are  nine  suspected  cases  being 
carefully  watched  in  the  hospital,  and  fifty-tive  contacts 
have  been  isolated,  and  one  is  under  observation.  The  san- 
itary offices  will  be  kept  open  night  and  day.  The  Paris 
Pasteur  Institute  has  supplied  serum.  Quarantine  regu- 
lations will  no  doubt  affect  Glasgow  and  the  Clyde  ports, 
but  the  Scottish  local  government  board  does  well  to  let 
the  truth  be  known  and  to  .second  the  efforts  of  sanitary 
offices  to  limit  the  outbreak. 

An  unfounded  report  that  two  ships  in  Dublin  harbor 
had  cases  of  plague  on  board  gave  rise  to  no  little  fear  on 
Thursday,  when  the  city  was  full  of  visitors  to  the  great 
horse-show. 

lu  this  country  suicide  is  criminal,  and  persons  are  often 
brought  before  the  magistrates  for  attempting  it.  Unless 
under  very  exce])tional  circumstances  the  act  is  generally 
regarded  as  cowardly  or  disgraceful.  Nevertheless,  there 
have  never  been  wanting  those  who  hold  it  to  be  justiti- 
able.  To  assist  another  in  putting  an  end  to  his  life  might 
lead  to  a  charge  of  being  an  accomplice  in  murder.  And 
yet  the  question  has  often  been  raised,  whether  the  pro- 
motion of  euthanasia  is  justifiable  by  the  medical  attend- 
ant in  hopeless  cases.  Discussion  of  tlie  point  has  been 
started  again  by  a  letter  in  a  provincial  newspaper  signed 
"A  Physician."  The  writer  starts  with  the  assumption 
that  suicide  is  justifiable— nay,  may  often  be  honorable 
and  brave.  From  this  he  goes  on  to  argue  that  as  a  man 
has  a  right  to  determine  his  own  life,  it  may  be  equally 
right  for  the  physician  to  assist  him  in  thus  ending  the 
sufferings  of  a  patient  whose  case  is  hopeless.  He  would 
limit  this  course  to  those  cases  in  which  a  rapid  but  pain- 
ful end  is  near,  and  says  he  has  in  a  number  of  cases 
closed  them  with  chloroform.  Religious  or  moral  objec- 
tions he  considers  it  the  business  of  the  sufferer  to  settle. 
As  to  the  legal  questions  he  might  find  it  awkward  to  make 
this  confession  to  a  magistrate,  and  he  does  well  to  write 
anonymously  lest  the  nearest  policeman  should  fail  to  ap- 
preciate his  logic.  An  academical  discussion  on  the  moral- 
ity of  promoting  euthanasia  may  be  very  well  in  a  medical 
]Ournal^though.  often  as  the  question  has  been  raised,  the 
profession  has  invariably  repudiated  the  thought  of  be- 
coming a  party  to  taking  or  shortening  life. 

The  statements  made  by  Mr.  Burdetl-Coutts  respecting 
the  sick  and  wounded  have  been  contradicted  by  another 
of  our  consulting  surgeons  in  Soutli  Africa,  and  one,  too, 
who  had  the  opportunity  of  knowing  the  facts  at  Bloem- 
fontein,  for  he  was  there  at  the  time  covered  by  Mr. 
Coutts'  letters  to  The  Times.  This  surgeon  is  Mr.  Ken- 
dall Franks,  who  was  attached  to  the  army  headquarters 
and  accompanied  Lord  Roberts  in  his  famous  march.  His 
testimony  is  therefore  of  special  value.  "I  confess,"  he 
writes  in  Tlic  fi-/t\srrap/i,  "I  have  not  been  able  to  locate 
the  especial  field  hospital  described  by  Jlr.  Coutts, "  and 
then  he  slyly  suggests  that  perhaps  he  was  "  not  able  to 
recognize  it  under  the  description  given  by  that  gentle- 
man." He  says,  although  he  has  seen  overcrowding  which 
was  unavoidable,  and  even  men  lying  on  the  ground  be- 
cause every  available  stretcher  and  bed  was  occupied,  he 
never  saw  "  in  any  hospital,  field  or  otherwise,  anything 
resembling  the  state  of  aft'airs  described  by  Mr.  Coutts." 
Mr.  Franks  further  denies  that  funerals  were  going  on 
"from  morning  to  night,"  or  that  the  dead  were  buried  in 
"unknown  crowded  graves,"  as  asserted  by  Mr.  Coutts. 
He  says  the  funerals  took  place  between  2  and  5  p.m.,  and 
declares  on  the  authority  of  tlie  chaplain  on  the  head- 
quarters staff  that  every  body  had  its  own  grave,  every 
grave  being  numbered  and  the  names  and  numbers  regis- 
tered in  the  cathedral  books.  This  seems  a  facer  for  Mr. 
Coutts, \vliose  "hysterical  word-painting"  is  once  more  ex- 
posed. Mr.  Franks  explains  why  some  supplies  had  to 
wait — it  was  because  "to  supply  the  troops  with  ])roper 
and  sufficient  food  was  the  most  humane  precaution  to 
prevent  the  spread  of  disease,"  and  he  declares  that  Lord 
Roberts  should  be  shielded  by  the  public  "from  the  unfair 
and  carping  criticism  of  an  irresponsil)le  itinerant."  As 
to  Mr.  Coutts'  sensational  account  of  the  appearance  of 
the  troops  on  arrival  at  Bloemfontein,  Mr.  Franks  says,  "  It 
is  not  a  true  picture ;  it  is  not  exaggerated — it  is  false." 

On  the  other  hand,  Mrs.  Dick  Chamberlain  has  returned 
and  been  interviewed.  She  says:  "Every  word  that  Mr. 
Burdett-Coutts  has  said  with  regard  to  the  dreadful  mis- 
management of  the  hospitals  is  true. "  Perhaps  the  com- 
mon report  is  correct  that  Mrs.  Dick  Chamberlain  got  hold 
of  Mr.  Coutts  and  through  him  vented  her  revenge  for 
being  excluded  from  the  hospitals  as  u.seless  and  in  the 
way.  If  so  she  would  have  been  well  advised  to  take  the 
hint  of  Sir  A.  Milner  and  return  to  the  excitements  of  Lon- 
don Society  (with  a  capital  S).  She  told  her  interviewer 
that  "the  army  doctors,  with  but  few  exceptions,  were  an 
inferior  class  of  men. "  Perliaps  some  of  them  will  retort 
that  wouid-be  fashionable  ladies  are  an  inferior  class  of 
women.  She  further  said  six  cases  of  drunkenness  among 
them  came  under  her  observation,  and  after  coming  in 
contact  with  the  police  were  sent  home  in  charge  of  in- 


valids on  transports.  This  statement  should  be  capable  of 
support  or  otherwise  by  the  police  records.  I  pass  by 
other  allegations  more  difficult  of  disproof  and  whicli  will 
probably  be  contradicted  in  due  course.  So,  too,  anony- 
mous statements  are  not  worth  repeating. 

But  it  appears  that  there  will  be  evidence  submitted  to 
the  commission  on  the  defects  noticed  by  competent  ob- 
servers, and  we  may  well  awaft  their  testimony.  The 
commi.ssioners  are  quite  qualified  to  weigh  the  evidence. 
They  have  already  visited  Wynberg  and  taken  the  evi- 
dence of  Colonel  Anthonisz,  who  has  been  in  charge  for  the 
last  ten  months.  He  denies  Mrs.  Dick  Chamberlain's  alle- 
gations and  attributes  them  to  spite.  Professor  Dunlop, 
who  was  there  for  six  months,  has  nothing  to  complain  of 
except  excessive  red  tape. 


THE  DISCOVERY  OF  "UREIXE."  THE 
PRINCIPAL  ORGANIC  CONSTITUENT  OF 
URINE. 

To  THE  Editor  of  the  Medical  Record. 

Sir  :  Kindly  permit  me  to  add  the  following  remarks  as  a 
postscript  to  the  paper  recently  published  under  the  above 
title  in  the  Mf.okai.  Rkcokh: 

In  order  not  to  weaken  the  toxic  qualities  of  ureine  by 
exposing  it  to  a  high  temperature,  and  also  to  sini])lify  the 
method  of  its  isolation,  I  have  found  the  following  pro- 
cedure to  be  preferable  to  the  one  recommended  in  my 
paper :  We  evaporate  the  urine  at  a  temperature  of  50-55" 
C.  until  we  are  certain  that  no  more  evaporation  takes 
place.  Then  we  reduce  the  temperature  of  the  liquid,  if 
possible  to  o'  C,  and  add  a  convenient  quantity  of  cold 
absolute  alcohol  to  facilitate  filtration.  We  now  separate 
the  urea  present  by  adding  pulverized  pure  oxalic  acid, 
until  no  further  precipitate  is  formed,  and  then  we  filter 
the  alcoholic  liquid  and  evaporate  it  at  50-55  C.  The 
ureine  resulting  from  this  method  is  sufiicienlly  i)ure  to 
satisfy  all  exigencies  of  clinical-medicine  and  of  physiol- 
ogy, for  it  is  evident  that  the  presence  of  some  .saline  mat- 
ter cannot  influence  the  qualities  of  ureine,  and,  further- 
more, I  have  convinced  myself  that  the  presence  or 
absence  of  urinary  coloring- matters  does  not  alter  the 
symptoms  observed  in  experiments  upon  animals.  If  we 
wish  to  isolate  the  ureine  for  chemical  purposes,  we  continue 
the  above  procedure  by  treating  the  alcoholic  liquid  suc- 
cessively with  barytes.  to  remove  the  sulphates  and  phos- 
phates, with  nitrate  of  silver  to  separate  the  chloride  of 
sodium,  and  finally  with  mercuric  nitrate  to  remove  the 
coloring-matters  of  the  urine  ;  it  is  better  not  to  neutralize 
subsequently  with  sodium  carbonate.  There  is  one  rather 
important  point  which  I  have  ob.served  since  the  pre]>ara- 
tion  of  my  paper.  If  we  add  nitric  acid  to  ureine.  a  solid, 
wax-like  mass  will  be  formed  at  once,  and  this  is  a  fact 
worth  remembering,  as  otherwise  one  might  think  that 
this  solid,  wax-like  substance  was  the  result  of  a  chemical 
combination  of  nitric  acid  and  urea. 

WiLi.iAM  Ovid  Moor,  M.D. 

121  Monte  Citorio,  Ro.me,  August  13,  1900. 


^cuicius  and  ijloticcs. 

A  Memoir  of  Henry  J.vcoii  Bicki.ow,  A.M.,  M.D..  LL.D., 
who  was  Emeritus  Professor  of  Surgery  in  Harvard 
University  and  a  member  of  many  home  and  foreign 
scientific  societies.  Boston  :  Little.  Brown  &  Company. 
1900.  Together  with  three  volumes ;  one  devoted  to 
orthopaedic  surgery  and  medical  papers  ;  one  to  surgical 
anaesthesia,  addresses,  and  other  papers,  and  one  con- 
taining: I.  The  Jlechanism  of  Dislocations  and  Frac- 
ture of  the  Hip  ;  and,  II.,  Litholapaxy,  or  Rapid  Lithotrity 
with  Evacuation. 

The  first  volume,  which  contains  portraits  of  Dr.  Bigelow, 
taken  in  1S41-1S72,  and  an  excellent  likeness  as  a  frontis- 
piece from  a  photograph  taken  in  1SS8,  is  devoted  to  a  re- 
production of  written  monographs,  addresses,  and  inter- 
views, contributed  by  friends  and  admirers  at  the  time  of 
this  distinguished  surgeon's  death.  There  is  a  vigorous 
biographical  memoir  by  Prof.  Oliver  Wendell  Holmes,  and 
graphic  sketches  by  Professor  Fitz,  Dr.  Cabot.  Mr.  Lee: 
reminiscences  by  Drs.  Derljy,  Beach,  and  other  intimate 
friends  and  associates.  The  miscellaneous  papers  repro- 
duced in  the  next  volume  relate  mostly  to  surgery,  and  in- 
clude the  more  important  of  Dr.  Bigelow's  contributions  to 
medical  journals,  including  the  Boylston  prize  disserta- 
tion. The  interesting  and  vastly  important  discovery  of 
surgical  anaesthesia,  with  which  the  subject  of  these  me- 


472 


MEDICAL   RECORD. 


[September  22,  1900 


moirs  was  closely  identified,  is  gone  over  liere  in  chrono- 
logical order  l)y  a  reproduction  of  the  publications  and 
addresses  of  Dr.  Bigelow  bearing  upon  the  questions  in- 
volved. The  first  portion  of  the  fourth  volume  is  a  reprint 
of  a  treatise  on  the  "  Mechanism  of  Dislocations  and  Frac- 
ture of  the  Hip,"  for  a  long  time  out  of  print.  The  second 
part  includes  published  articles  on  rapid  lithotrity,  un- 
nioditied  e.xcept  by  the  author's  own  annotations.  Taken 
together  this  set  of  works  makes  a  fitting  tribute  to  the 
memory  of  one  who  did  so  much  to  advance  surgical  sci- 
ence in  various  ways  and  to  add  to  the  lustre  of  American 
medicine. 

GrUNDRISS      DER      ORTHOpXdISCHEN     ChIRURGIE      I-tiR     PRAK- 

TiscHE  Aerzte  uxd  Studierende.  Von  Dr.  Max  David, 
Berlin.  Mit  129  Abbilduugen.  Berlin  ;  S.  Karger.  1900. 
This  is  a  condensed  te.xt-book  on  orthopedic  surgery  ar- 
ranged so  as  to  be  especially  viseful  for  the  student.  The 
illustrations  are  suitable,  though  some  of  them  are  crude, 
and  the  text  meets  the  requirements  of  the  student  class, 
to  whom  we  can  recommend  the  book. 

The  Year  Book  of  the  Nose,  Throat,  anb  Ear.     Edited 
by  G.   P.   Head  and  A.  H.  Andrews,  Professors  in  the 
Post-Graduate    Medical     School    of    Chicago.     Chicago 
Medical  Book  Company.     1900. 
The  scope  of  this  new  venture  includes  a  statement  of  the 
essential  points  made  in  journal  articles  in  the  depart- 
ments covered,  which  have  appeared  during  the  year.     It 
is  convenient  for  reference,    and   though  not  exhaustive 
may  be  improved  in  succeeding  issues.     The  work  is  di- 
vided into  chapters,  and  the  articles  taken  at  random  are 
referred  to  the  bibliographic  list  by  number  and  date  on 
which  thearticle  appeared.     The  field  is  fairly  well  covered, 
and  the  specialist  in  these  branches  will  find  something 
-about  most  of  the  advances. 

The  Criminal  :   His  Personnel  and  Environment ;  A  Scien- 
tific  Study.     By  August    DkAhms,    Resident   Chaplain 
State  Prison,  San  Quentin  Prison,  California.     AVith  an 
introduction  by  Cesare  Lombroso,  Professor  of  Psychi- 
atry, University  of  Torino,  Italy.     New  York  ;  The  Mac- 
millan  Company.     1900. 
We  find  here  a  result  of  several  years'  observation,  from 
the  near  point  of  vision,  by  a  practical  worker  among  the 
class  described.     The  personal  and  social  aspects  of  the 
question  are  chiefly  considered.     The  field  is  surely  large, 
and   no  one  can  successfully  maintain  that  it  has  been 
overworked.     The  present  contribution  to  the  moral,  so- 
cial, political,  and  economic  aspects  of  the  condition  are  of 
value  as  an  aid  in  the  solution  of  some  of  the  important 
■questions  involved. 

International  Clinics:  A  Quarterly  of  Clinical  Lectures 
and  Especially  Prepared  Articles.  Edited  by  Henry 
W.  Cattell,  A.m.,  M.D.,  with  the  collaboration  of  John 
Asiihurst,  Jr.,  Charles  H.  Reed,  and  James  T.  Whit- 
taker.  With  regular  correspondents  in  Jlontreal,  Lon- 
don, Paris,  Leipsic,  and  Vienna.  Vols.  I.  and  II.  Tenth 
series.  Philadelphia  :  J.  B.  Lippincott  &  Co.  igoo. 
With  the  change  in  editorial  management  of  this  well- 
known  quarterly  there  have  come  some  modifications  and 
alterations  in  the  general  construction,  and  a  new  staff  of 
assistants  has  replaced  the  old.  It  does  not  always  or  of 
necessity  follow  that  a  change  is  for  the  best,  or  that  be- 
cause of  a  new  editor  the  reader  and  subscriber  are  going 
to  benefit.  In  the  present  instance,  however,  one  must 
admit  that  the  captain  has  taken  the  wheel  as  though  he 
were  quite  familiar  with  the  craft,  the  waters,  and  all  the 
reefs  and  rocks,  whether  they  arc  down  on  the  chart  or 
not.  In  selecting  contributors  for  these  two  volumes  the 
editor  has  been  (juite  happ)-,  aiul  such  names  appear  as 
Brieger,  Dieulafoy,  Flexner,  Gamier,  Lassar  (who  has  an 
interesting  illustrated  lecture  on  lepra) ,  T.  G.  Morton, 
Victor  Vaughan,  C.  J.  Aldrich,  C.  W.  Allen,  Ballantyne, 
Bishop,  Katzenbach,  R.  T.  Morris,  J.  B.  Murphy,  Senator. 
Skene,  Souchon,  G.  L.  Walton,  J.  C.  Wilson,  and  others 
equally  well  known.  The  literary  and  scientific  quality  of 
the  lectures  and  special  articles  is  of  a  high  order,  and  the 
illustrations  are  well  made.  The  date  upon  the  back  has 
wisely  been  omitted,  since  it  was  more  apt  to  confuse  than 
otherwise.  The  new  editor,  wlio  has  himself  contributed 
an  interesting  article  to  each  of  these  issues,  is  to  be  con- 
gratulated upon  the  good  impression  which  the  initial 
volumes  cannot  fail  to  make. 

The  Law  in  its  Rel.vpions  to  Physicians.  By  Arthur 
N.  Taylor,  LL.B.,  of  the  New  York  Bar.  New  York ; 
D.  Appleton  &  Company.  1900. 
In  the  preface  to  this  useful  little  handbook  the  author. 
iin])lying  that  there  are  no  similar  treatises,  says  that  the 
need  of  revealing  to  physicians  their  legal  relations  broke 
tipon  him  when,  casually  looking  over  the  pages  of  a  cur- 
rent legal  journal,  his  attention  was  caught  by  the  case  of 


a  physician  who  had  been  cast  in  substantial  damages  for 
having  violated  well-established  legal  jirinciples.  Mr.  Tay- 
lor, however,  has  had  predecessors.  Ordronaux's  scholarly 
lectures  on  the  jurisprudence  of  medicine,  Glenn's  excel- 
lent manual  of  the  laws  affecting  medical  men,  McClel- 
lan's  "Civil  JIalpractice,"  Rogers'  book,  "The  Law  and 
Medical  Men,"  Field's  "  Medical  Guide,"  are  all  small  books 
covering  more  or  less  Mr.  Taylor's  limits.  More  recently 
Hamilton's  "System  of  Legal  Medicine  "  covers  the  same 
field  in  a  special  article,  and  the  treatises  of  Becker  and 
Witthaus  and  other  writers  on  medical  jurisprudence  deal 
with  the  same  topics  ;  and  foreign  books  in  the  field  are 
not  lacking.  The  lack  of  a  table  of  cases,  which  is  usually 
found  in  law  books,  renders  it  difficult  to  compare  Mr. 
Taylor's  work  with  that  of  his  predecessors  as  a  collection 
of  authorities.  Turning  the  pages  we  find  the  familiar 
cases  cited  in  other  books  and  some  of  later  date.  Prob- 
ably the  treatise  is  not  intended  to  be  an  exhaustive  collec- 
tion of  authorities,  for  under  the  important  heading,  "What 
Constitutes  the  Practice  of  Jledicine? "  we  do  not  find  Un- 
derwood -.'.  Scott,  Wood  ?'.  Kelly,  Harding?'.  People.  Al- 
cott  ''.  Barber,  Musser's  Executors  v.  Chase,  and  other 
cases  cited  in  the  brief  for  medical  prosecutions  issued  by 
Treat  two  years  ago  ;  nor  do  we  find  State  71.  Paul,  holding 
that  one  cannot  practise  under  the  guise  of  an  assistant,  a 
principle  of  importance  especially  under  the  dental  law  : 
for  in  this  State  many  men  have  been  convicted  of  practis- 
ing dentistry  unlawfully  who  have  been  defended  upon  the 
ground  that  they  were  assistants  of  licensed  men.  We  do 
not  find  any  discussion,  by  the  way,  of  the  very  interest- 
ing question  whether  dentistry  is  or  is  not  a  specialty  of 
medicine,  although  there  are  a  number  of  reported  cases 
upon  that  topic  which  one  would  expect  to  find  cited  under 
the  definition  of  physician  or  dentist.  Upon  the  important 
question  whether  a  physician  registered  in  one  coui  ty  may 
practise  in  another  without  registration,  Martino  ?'.  Kirk 
is  cited,  without  noting  that  its  rule  was  based  upon  the 
law  of  iSSo,  which  had  been  repealed  before  the  case  was 
decided.  Wiel  •?■.  Cowles  is  cited  to  the  effect  that  an  un- 
licensed practitioner  may  be  required  to  disclose  confiden- 
tial communications  of  a  patient ;  but  we  do  not  find  the 
recent  holding  of  Mr.  Justice  McAdam  (McGillicuddy  ?'. 
F.  L.  &  P.  Co.)  that  a  licensed  physician  not  legally  qual- 
ified to  practise,  because  unregistered,  may  not  be  com- 
pelled to  make  such  disclosure — the  privilege  being  the 
patient's  and  not  his.  There  seems  to  be  no  note  of  the 
many  cases  decided  of  late  years  under  excise  laws,  espe- 
cially in  the  West,  South,  and  Southwest,  whereby  the 
ability  of  thirsty  gentlemen  to  evade  the  law  through  a 
physician's  prescription  is  harshly  circumscribed.  Thus 
it  was  held  in  North  Carolina,  when  a  dentist  prescribed  a 
pint  of  whiskey  on  Sunday  for  an  aching  tooth,  that  a  den- 
tist was  not  a  doctor  within  the  meaning  of  the  law — a 
decision  said  to  be  necessary  in  view  of  the  fact  that  every 
normal  citizen  of  North  Carolina  has  thirty-two  teeth  that 
might  possibly  ache  at  once.  There  seems  to  be  no  men- 
tion of  the  line  of  cases  holding  medical  men  or  their  pa- 
tients liable  for  defamation  in  making  disparaging  remarks 
of  one  another  ;  nor  of  the  very  important  topic  of  medical 
societies,  the  obligation  to  join  them,  and  the  rights  of 
members  ;  nor  yet  of  the  right  of  colleges  and  hospitals  to 
dismiss  members  of  the  staff  (People  f.v  ?•<•/.  Kelsey  v.  N. 
Y.  P.  G.  M.  S.  &  H.,  29  App.  Div.  244).  There  is  no  dis- 
cussion of  expert  testimony  or  even  of  that  important  ques- 
tion— as  to  which  two  rules  obtain — whether  a  physician  is 
bound  to  testify  as  an  expert  for  an  ordinary  witness'  fee. 
For  taking  a  wrong  position  upon  this  point  Dr.  Dixon 
found  himself  in  contempt  of  court  (Di.xon  ?'.  The  People, 
i63  Illinois,  129).  It  maybe  that  some  of  these  topics  have 
been  touched  upon  so  that  one  who  reads  from  cover  to 
cover  might  find  them  ;  but  we  have  found  no  clew  to  them 
in  the  iude.x  or  table  of  contents.  This  only  means,  how- 
ever, that  the  book  is  not  exhaustive  and  does  not  entirely 
supply  the  place  of  other  treatises  the  existence  of  which 
it  does  not  indicate.  It  may  be,  nevertheless,  a  useful 
little  book  for  the  practitioner,  who  will  bear  in  mind  that 
any  book  of  the  kind  can  only  be  for  the  physician  what  a 
"Household  Doctor"  or  pamphlet  on  "  F'irst  Aid  to  the  In- 
jured "  would  be  in  a  lawyer's  family.  The  subject  was 
suggested  some  time  ago  by  the  Medical  Record  as  one 
which  might  be  profitably  included  in  the  curriculum  of  all 
medical  colleges. 

Sixth    International    Otologicai.    Congress,     Held    in 
London,  August,  1S99,  under  the  Presidency  of  Pro- 
fessor   Uriian    Pritchari).      Transactions,     edited    by 
E.  Cresswell  Bauer.     London:  The  Southern  Publish- 
ing Company.     1900. 
This  somewhat  bulky  volume  of  nearly  five  hundred  pages 
contains  the  iiroceedings  of  the  congress  above  named.     It 
has  the  peculiarity  of  presenting  the  various  contributions 
in  the  respective  languages  in  which  they  were  delivered  ; 
so  we  find  pages  in  English,  French.  German   and  Italian. 
It   is  a  most  admirable  example  of  the  ideal  volume  of 


September  22,  1900] 


MEDICAL    RECORD. 


473 


scientific  proceedings  and  of  careful  editing.  Tiie  various 
papers  and  discussions  have  been  abstracted  in  manv  cur- 
rent journals  during  the  past  year  and  call  for  no  special 
mention  here. 

The  Water   Supi'lv   oi-   the   City   of   New  York.     Au- 
gust, 1900. 

This  large  volume  contains  the  result  of  an  inquiry  into 
the  conditions  relating  to  the  water  supply  of  this' city, 
undertaken  by  the  Merchants'  Association  of  New  \\,vk, 
Tlie  immediate  occasion  was  the  attempt  to  bind  the  city 
to  the  payment  of  an  immense  sum  of  money  to  the  Ram- 
ai)r)  Water  Company  for  water  which  the  city  can  obtain 
tiirough  its  own  efforts  for  a  fraction  of  the  amount.  'J'hu 
report  shows  conclusively  that  there  is  no  danger  of  a 
water  famine,  and  that  the  city  can  always  obtain  all  the- 
water  it  needs  without  having  resource  to  a  private  com- 
pany. 

SiRGiCAL  A.natomv.  A  Treatise  on  Human  Anatomy  in 
its  Application  to  the  Practice  of  Medicine  and  Surgery. 
By  John  B.  Deavek,  M.D.,  Surgeon-in-Chief  to  the  Ger- 
man Hospital,  Philadelphia.  Vol.  n.  Philadelphia:!'. 
Blakiston's  Son  &  Co.     igoj. 

The  second  volume  of  this  really  superb  work  is  concerned 
with  the  anatomy  of  the  neck,  mouth,  pharynx,  nose,  orbit, 
eyeball,  organ  of  hearing,  brain,  male  perineum,  and 
female  perineum.  These  parts  are  illustrated  by  one  luin- 
dred  and  seventy  large  plates  and  described  in  three  hun- 
dred and  thirty-seven  pages  of  te.\t.  An  index  of  thirty 
pages  makes  all  this  material  readily  accessible  to  the  in- 
quirer. As  an  illustration  of  the  thoroughness  with  which 
the  author  treats  his  subject,  we  may  analyze  the  section 
dealing  with  the  organ  of  hearing.  Each  division  is  taken 
up  in  turn  and  described  in  all  its  parts  from  the  surface 
inward  ;  the  diseases  affecting  it,  so  far  as  they  have  any 
relation  to  the  anatomy,  are  mentioned,  and  the  anatomi- 
cal bearings  of  operations  in  the  neighborhood  are  touched 
upon.  This  tills  nineteen  pages  of  text.  The  plates  in 
this  section  are  twelve  in  number,  as  follows:  Pinna,  in- 
trinsic muscles  of  pinna,  e.^ternal  and  middle  ear,  anterior 
vein  of  right  tympanum,  membrana  tympani  and  its  incli- 
nation, external  view  of  membrana  'tvmpani  of  left  ear, 
internal  view  of  right  tympanum,  cxtcnial  view  of  bonv 
labyrintli,  or  cochlea  and  semicircular  canals,  interior  of 
osseous  labyrinth  of  left  internal  ear.  interior  of  os.seous 
))ortion  of  cochlea,  section  of  osseous  portion  of  cochlea, 
and  diagram  of  membranous  labyrinth.  The  appearance 
of  the  third  and  concluding  volume  of  Dr.  Deaver's  un- 
equalled work  will  be  eagerly  looked  for  by  those  fortunate 
enough  to  possess  the  first  two  volumes. 

.\  Text-Book  of  the  Medical  Treat.ment  of  Diseases 
AND  Symptoms.  By  Nestor  Tfrard.  M.D.  London. 
.  F.R.C.P.,  Professor  of  the  Princi))les  and  Practice  of 
Medicine,  King's  College,  London  ;  Physician  to  King's 
College  Hospital  ;  Examiner  in  Materia  Medica  to  the 
Conjoint  Board  of  England.  Adapted  to  the  United 
States  Pharmacopoeia  by  E.  Qvis  Thornton,  M.D.,  Dem- 
onstrator of  Therapeutics,  Pharmacy,  and  Materia  Mtd- 
ica,  Jefferson  Medical  College,  Philadelphia.  Philadel- 
phia and  New  York  :  Lea  Brothers  &  Co.     1900. 

It  is  a  curious  fact  that  most  medical  writers,  whether  of 
monographs  or  of  general  treatises,  while  acknowledging 
that  the  end  of  medicine  is  the  prevention  and  cure  of  dis- 
ease, usually  devote  but  little  space  to  therapeutics.  It  is 
this  neglect  of  the  most  important  branch  of  medicine  that 
gives  an  excuse  for  works  like  the  one  before  us.  Dr. 
Tirard  takes  up  the  several  affections  of  the  circulatory, 
respiratory,  digestive,  and  nervous  systems  in  turn,  and 
discusses  both  the  general  management  of  these  diseases 
and  the  various  measures  adapted  to  the  relief  of  the  spe- 
cial symptoms  as  they  arise.  The  work  is  probably  not  in- 
tended to  be  encyclopedic,  yet  we  think  the  author  has 
erred  somewhat  on  the  side  of  conservatism  in  refusing  to 
discuss  such  methods  as  the  use  of  carbolic  acid  in  the 
treatment  of  tetanus  or  the  serum  treatment  of  pneumonia. 
Such  important  affections  as  epidemic  cerebrospinal  men- 
ingitis, multiple  neuritis,  beriberi,  round  ulcer  of  the  duo- 
denum, arteriosclerosis,  and  oza:na  are  ignored,  or  at  least 
are  not  discoverable  on  careful  perusal  of  the  index  and 
patient  search  through  the  body  of  the  book.  Certain  of 
the  author's  recommendations  are  unsound  :  as,  for  exam- 
ple, when  he  advises,  without  any  qualification  whatever, 
a  resort  to  quinine  in  the  treatment  of  malarial  h«moglf>- 
binuna.  Despite  these  imperfections  and  omissions,  how- 
ever, theiook  is  one  that  can  be  safely  recommended,  for 
Its  blemishes  are  outweighed  by  its  merits.  The  author 
has  wliat  medical  teachers  sometimes  lack— common  sense 
and  practicality— and  his  discussion  of  such  common  but 
distressing  complaints  as  dyspepsia  and  constipation  i<; 
worthy  of  all  commendation. 


NEW  YORK   NEUROLOGICAL  SOCIETY. 
Staled  Meeting,  June  j,  /goo. 

The   President,    Frederick.    Peterson,    M.D.,    in 
THE  Chair. 

Exophthalmic   Goitre   Treated  by  Intestinal    Anti- 
septics—  1)K.  Makv  i'LTNAM  Jacoiu  reported  a  case 

of  tliis  nature.     B.  D ,  aged  twenty-two  years,  was 

first  seen  I-ebruary  8,  1899.     She  had'been  well  until 
the  age  of  twenty  years,  when  she  began  to  work  in  a 
shop  for  making  infants'  clothing.     She  worked  from 
8  A..M.  until  5  P.M.  on   buttonholes  and  feather-stitch- 
ing.    She  began  to  suffer  much  from  constipation,  re- 
lieved  by   frequent   purgation    with    licorice    powder. 
At  the  end  of  a  year  menstruation  ceased,  i.e.,  in  July, 
1897.     Six  months  later  the  eyeballs  began  to  be  promi- 
nent; at  the  same  time  there  were  flushings  of  heat 
all  over  the  body,  palpitations,  headache,  and  weak- 
ness, tremor  of  the  hands  and  feet,  especially  on  rising 
in  the  morning,  and  frequent  distress  in  the  stomach. 
In  the  summer  of  1898  constipation  was  replaced  by 
chronic  diarrhcea.     In  P'ebruary  of  this  year  she  had 
a  severe   attack   of   diphtheria,   for  the  treatment   of 
which  she  entered  Mt.  Sinai   Hospital.     On  recovery 
from   this  the  patient   felt   for  a  while  much   better. 
The  thyroid  gland  was  only  moderately  enlarged  and 
appeared  to  be  slightly  larger  in  the  morning,  at  the 
same   time   that  the  tremor  and   diarrhoea   occurred. 
There    was    marked    accentuation    of    both    cardiac 
sounds   over   the   tricuspid,  but    none  at   the    mitral 
valve.     No  cardiac  murmurs  were  audible,  but  there 
was  a  systolic  murmur  over  the  carotid  artery.     The 
pulse  was    120;    respiration   24.      The   sphygmogram 
\yas  regular,  rapid,  with  normal  dicrotism."  The  pa- 
tient complained  of  constant  aching  in  the  upper  dor- 
sal region  between  the  shoulder  blades,  in  the  region 
of  the  columns  of  Clarke.     An  attempt  at  a  complete 
milk  diet  rendered  the  patient  very  weak  and  miser- 
able and   increased   the   tachycardia  to  such  a  point 
that  the  pulse  could  not  be  counted.     The'  urine  was 
examined  by  Bouchard's  method  once  in  February  and 
again  in  March.     On  the  first  occasion  the  toxic  co- 
elhcient  was  5.79;  on  the  second,  .712.     The  patient 
had  been  treated  with  various  nerve  and  vascular  tonics 
without   material  benefit,  before  she  came  under  the 
speaker's  care,  so  that  line  of  medication  was  aban- 
doned altogether  and  attention  was  directed  to  disin- 
fection of  the  intestinal  canal.     Various  disinfectants 
were  used  at  dififerent  times;  for  a  long  period,  bis- 
muth, salityl,  and   beta-naphthol   were   given,  associ- 
ated with  a  daily  flushing  of  the  colon  with  two  quarts 
of  water.     Under  this   treatment,  and   especially  the 
colon   flushing,   the   diarrhcea   was  arrested    and    the 
patient  grew  steadily  stronger,  and   the  menstruation 
returned  on   April   15,  1899,  after  an   amenorrhoea  of 
twenty-two  months.     The  week  before  this  happened 
a  third  examination  of  the  urine  gave  a  urotoxic  co- 
efficient of   1.426,  nearly  double  the  toxicity  found  in 
March.     On  April   21st  the  patient  was  feeling  very 
weak,  with    much    headache    and    anorexia,  and   the 
urotoxic  coefficient  was  .388,  the  only  time  at  which 
it  was  subnormal  or  other  than  excessive.     On  March 
27th.  after  an  experiment  with  thymus  gland,  the  co- 
efficient was  1.662.     Menstruation  occurred  three  days 
later,  but  after  this  it  was  absent  until  January,  1900, 
when    it    returned    and    has    recurred    regularly    ever 
since.     The  last  urinary  examination  was  made  May 
22,  1900,  and  the  coefficient  was  then  nearly  normal, 
being  .432.     The  pulse  remained  at  120  or  over  with 


474 


MEDICAL    RECORD. 


[September  22,  1900 


scarcely  an  exception  for  eleven  months;  then,  on 
January  24th,  it  became  100  and  did  not  change  in 
spite  of  an  attack  of  diarrhcea  and  insomnia.  On  the 
7th  of  February,  1900,  the  medication  was  changed  to 
salicylate  of  sodium,  of  which  from  gr.  Ix.  to  gr.  Ixxx. 
were  given  a  day.  After  ten  days  the  pulse  was  found 
at  93,  ten  days  later  at  92,  on  April  4th  at  90;  the 
day  before  the  report  was  made  it  was  93. 

Dr.  E.  D.  F"isher  said  that  the  case  showed  a  very 
vascular  condition  of  the  thyroid  gland.  He  did  not 
absolutely  agree  with  Dr.  Jacobi  in  the  use  of  intesti- 
nal antiseptics.  He  had  had  success  with  the  use  of 
strophanthin  for  long  periods.  That  treatment  might 
be  carried  out  in  a  case  of  this  kind. 

Dr.  U'illi.\m  H.  Porter  said  that  he  had  seen  re- 
cently two  cases  of  a  similar  nature  treated  by  anti- 
sepsis of  the  alimentary  canal,  and  this  had  given 
better  results  than  have  been  obtained  under  other 
treatment  for  that  class  of  cases. 

Dr.  William  H.  Caswell  said  that  glycerophos- 
phate of  sodium,  gr.  xv.  three  times  a  day,  had  been 
given  in  a  case  of  this  kind,  and  the  improvement  had 
been  very  marked.  The  pulse  had  fallen  from  130  or 
140  to  84  or  88,  and  had  remained  so  for  the  last  two 
months.  All  constitutional  symptoms  were  very  much 
improved,  although  the  exophthalmos  had  not  disap- 
peared, nor  was  there  any  decrease  in  the  size  of  the 
thyroid.  The  patient  was,  however,  better  and  was 
still  doing  well. 

Dr.  Jacobi  replied  that  this  question  of  the  uro- 
toxic coefficient  interested  her,  although  she  had  paid 
no  systematic  attention  to  it.  She  had  noted  that 
when  the  urotoxic  coefficient  was  in  excess  of  normal, 
the  patient  was  better.  Once  it  fell  below  normal 
and  she  was  decidedly  weaker  with  symptoms  of  more 
constitutional  poisoning,  this  confirming  the  idea  that 
poison  circulating  in  the  blood  and  excess  of  urine 
toxicity  coexisted  with  the  effort  of  the  organism  to 
throw  it  out.  When  the  toxicity  was  high,  the  patient 
was  better;  when  subnormal  the  patient  was  worse. 

Congenital  Hydrocephalus  of  Non-Inflammatory 
Type. — Dr.  Joseph  Fraexkel  presented  this  case. 
He  said  he  thought  it  worth  while  to  bring  the  pa- 
tient, as  the  case  seemed  unusual  in  its  clinical  pathol- 
ogy, and  he  was  in  doubt  as  to  the  correct  diagnosis. 
The  child'was  twenty-six  months  old;  it  was  born  at 
full  term  without  difficulty.  The  father  was  thirty- 
six  years  old,  the  motiier  thirty;  they  were  Russian 
Hebrews.  Both  were  perfectly  free  from  taint  of 
chronic  disease.  They  had  three  other  living  chil- 
dren, all  perfectly  well.  One  miscarriage  occurred 
prior  to  birth  of  this  child.  Immediately  after  birth 
the  child  w-as  noticed  to  be  abnormal.  It  did  not 
hold  its  head  up  and  gave  no  evidences  of  mind  or 
brain  development.  The  symptoms  had  since  become 
accentuated.  At  no  time  had  it  walked,  talked,  or 
shown  any  signs  of  mental  vigor.  Obstinate  consti- 
pation had  existed  since  birth.  All  examinations  had 
given  a  negative  result.  There  were  no  evidences  on 
the  skeleton  pointing  to  rachitis.  The  upper  and 
lower  extremities  were  rigid  and  permanently  con- 
tracted, but  the  contracture  could  be  overcome,  and 
the  reflexes  were  present.  There  was  no  ankylosis, 
and  the  reflexes  were  not  exaggerated  as  would  be 
expected.  The  child  vomited  at  limes  and  had  had 
three  or  four  general  convulsions.  After  the  last  one 
reported,  the  child  lost  its  voice  for  three  or  four 
days.  Sensation  in  so  far  as  it  could  be  determined 
was  normal.  The  head  was  somewhat  large,  46  an- 
thropometers  in  circumference,  though  not  so  large  as 
in  hydrocephalic  infants  usually.  The  fontanelles  were 
not  closed.  The  child  was  put  on  iodide  of  potas- 
sium and  iodide  of  iron,  and  was  thought  to  have  im- 
proved, but  objective  examination  showed  no  improve- 
ment.    The  speaker  could  make  no  diagnosis  except 


that  of  hydrocephalus,  but  the  history  of  the  case  was 
not  in  keeping  with  the  general  experience  of  that 
disease. 

Dr.  Fisher  agreed  with  Dr.  Fraenkel's  diagnosis 
of  hydrocephalus,  non-inflammatory  type,  congenital. 
One  case  which  he  had  seen  showed  a  congenital  con- 
dition of  interference  with  liie  circulation  through  the 
fontanelles. 

Dr.  Fraexkel  said  he  had  made  the  diagnosis  of 
hydrocephalus  with  some  hesitation,  and  he  was  dis- 
satisfied with  it.  In  other  cases  he  had  seen,  he  had 
not  noticed  this  constant  rigidity  and  throwing  back 
of  the  head.  Taking  into  consideration  the  severity 
of  the  symptoms,  the  head  was  comparatively  small. 

Dr.  Jacobi  asked  whether  there  might  not  be  a  cor- 
relation between  the  small  head  and  the  severity  of 
the  symptoms.  For  some  reason  the  head  had  not 
yielded,  causing  greater  intercranial  pressure  than  in 
ordinary  cases  in  which  the  skull  was  large  and  neces- 
sarily the  pressure  was  less. 

Dr.  Lewis  A.  Connor  said  this  question  of  in- 
creased intercranial  pressure  could  be  determined  by 
puncturing  and  the  use  of  the  manometer  measuring 
resistance.  A  manometer  might  be  readily  improvised 
by  means  of  a  bent  glass  tube  with  a  short  horizontal 
arm  and  a  long  perpendicular  one,  attached  by  a  piece 
of  rubber  tubing  to  the  cranium. 

Dr.  Petersox  said  that  it  seemed  to  him  the  fact 
of  the  fontanelles  being  open  would  show  that  there 
was  not  unusually  great  pressure.  The  case  did  not 
look  like  one  of  congenital  hydrocephalus.  In  that 
disease  there  should  be  an  unusual  growth  of  the 
head.  He  had  seen  this  rigidity  resulting  from  basi- 
lar hemorrhage  occurring  during  the  birth  of  the 
infant. 

Dr.  Fraenkel  replied  that  in  this  case  the  labor 
was  distinctly  noted  to  have  been  normal. 

Multiple  Neuritis  Following  Pneumonia. — Dr. 
Lewis  Connor  presented  a  case  of  this  kind.  He 
said  he  wanted  to  show  the  patient,  not  because  the 
condition  was  unusual,  but  because  of  its  unusual 
association  with  another  disease.  The  man,  forty-one 
years  of  age,  came  to  the  Hudson  Street  Hospital  on 
November  7th  with  a  lobar  pneumonia  of  five  days' 
standing,  typical  in  history  and  physical  signs.  The 
consolidation  involved  the  left  upper  and  lower  lobes 
and  the  disease  ran  a  normal  course  up  to  the  point  of 
defervescence.  Instead  of  clearing  up  at  the  end  of 
the  seventh  or  ninth  day,  although  temperature  fell, 
the  consolidation  remained,  the  case  presenting  the 
ordinary  picture  of  delayed  resolution,  lasting  two 
weeks  beyond  the  allotted  time.  During  that  time 
the  patient  gave  no  evidence  of  any  other  trouble. 
Just  at  the  end  of  this  period  of  consolidation,  three 
weeks  from  the  beginning  of  the  attack  of  pneumo- 
nia, it  was  noticed  that  his  legs  were  weak  and  that 
there  was  some  discomfort  in  moving  them,  and  the 
left  arm  extensors  were  also  paretic.  In  the  course  of 
a  week  the  following  picture  was  developed:  Exten- 
sive, almost  complete  paresis  of  the  extensors  of  the 
leg,  tibialis  group,  and  peroneal  muscles,  and  exten- 
sors of  the  left  arm,  and  slight  loss  of  power  in  the 
right  arm;  no  anaesthesia;  some  numbness  of  the  tips 
of  the  fingers  and  an  area  of  hyperajsthesia  over  the 
crests  of  the  ilia  on  both  sides;  almost  no  pain  except 
girdle  sensation  ;  very  slight  tenderness  over  the  calves 
of  the  legs  and  the  arms.  The  diaphragm  was  not 
moving  properly,  and  in  about  a  week  from  the  begin- 
ning of  symptoms  of  paralysis  there  was  complete  loss 
of  function  of  the  diaphragm  with  either  forced  or 
natural  respiration.  It  was  a  severe  multiple  neuritis 
which  ran  a  course  of  five  weeks  before  any  improve- 
ment could  be  noticed.  The  patient  could  now  walk 
about  and  had  recovered  very  largely  the  use  of  his 
left  hand.     It  was  six  weeks  from   the  lime  of  disap- 


September  22,  1900] 


MEDICAL    RECORD. 


475 


pearance  of  function  in  the  diaphragm  before  tlic  first 
contraction  could  be  recognized.  So  severe  a  neuri- 
tis was  very  unusual  in  lobar  pneumonia;  it  was  recog- 
nized as  a  possible  complication,  but  an  unusual  one, 
and  in  those  cases  in  which  the  speaker  had  found  it 
the  neuritis  had  been  local  or  else  of  a  mild  type. 
As  to  frequency  of  involvement  of  the  diaphragm  in 
these  cases  of  functional  neuritis,  he  had  not  seen 
anytliing  in  the  literature  of  the  subject,  but  his  im- 
pression was  that  it  was  not  common.  He  had  neg- 
lected to  say  that  the  man's  history  was  good  so  far 
as  syphilis  or  tuberculosis  went.  He  had  been  accus- 
tomed to  drink  three  or  four  glasses  of  beer  or  ale  in 
the  course  of  the  day,  and  two  or  three  times  a  week 
a  glass  of  whiskey.  The  picture  was  not  that  of  alco- 
holic neuritis,  nor  were  the  sensory  symptoms  less 
marked  than  they  usually  were  in  these  cases. 

Dk.  CuN^'IN(;H.\^r  asked  what  the  state  of  the  pulse 
was  during  this  attack,  and  whether  there  was  any 
involvement  of  the  vagus. 

Dr.  Connor  replied  that  the  pulse  remained  nor- 
mal.    Only  the  pupils  were  involved. 

Dr.  ('uNNixr.H.vM  said  that  in  alcoholic  neuritis  the 
vagus  invariably  was  affected  several  days  before  the 
diaphragm  was  involved. 

Dr.  Jacori  asked  whether  it  was  thought  that  there 
was  any  infection  by  continuity  of  inflammation  from 
the  leg  to  the  diaphragm,  affecting  the  motility  of  the 
phrenic. 

Dr.  Connor  said  that  his  idea  was  that  it  was 
purely  a  matter  of  to.vism ;  delayed  resolution,  long 
maintained  condition  of  consolidation  with  continued 
growth  of  the  specific  bacterium.  This  was  a  cause 
of  to-\ism  sufficient  to  produce  this  result,  taken  in 
conjunction  with  the  damaged  condition  of  the  nerves 
from  the  man's  alcoholic  habit. 

Dr.  Peterso.n  said  that  a  case  such  as  the  one  just  re- 
ported was  quite  unusual ;  it  certainly  was  one  of  simple 
multiple  neuritis  following  pneumonia.  The  moderate 
alcoholism  might  not  have  been  sufficient  to  produce 
neuritis,  but  the  added  to.vic  condition  of  the  blood 
caused  by  the  pneumonia  was  sufficient  to  bring  it  about. 

Progressive  Muscular  Atrophy. — Dr.  Caswell 
reported  a  case  of  this  nature.  A  young  woman, 
twenty-one  years  of  age,  came  to  the  Vanderbilt  clinic 
seeking  treatment  for  weakness  in  the  hands.  She 
was  a  maker  of  artificial  flowers.  Five  or  si.x  months 
ago  her  hands  began  to  fail,  and  she  could  not  work 
so  easily  as  before.  The  speaker  found  upon  investi- 
gation that  from  the  time  she  was  a  young  girl  she 
had  had  difficulty  in  closing  her  eyes,  and  she  did  not 
smile  and  use  her  lips  and  mouth  as  other  children 
did.  She  was  not  conscious  of  this,  and  had  com- 
plained only  for  the  past  few  months  that  her  hands 
failed  at  work.  He  examined  her  and  found  a  case 
which  in  almost  every  particular  conformed  to  the 
type  of  primary  progressive  dystrophy  described  by 
Landouzy-Dejerine,  beginning  in  the  face  with  no 
hypertrophy,  the  atrophy  showing  later  in  the  upper 
e.\tremities.  The  lower  extremities  were  fairly  well 
developed  for  a  thin  girl.  The  arms  from  the  elbows 
to  the  fingers  were  not  atrophied.  From  the  elbows 
to  the  shoulders  there  was  marked  atrophy  on  both 
sides.  The  pectoral  muscles  about  the  triangles  of 
the  neck  were  decidedly  wasted  and  fallen  away. 
When  the  arms  were  turned  backward  the  superior 
angles  of  the  scapulae  went  into  the  triangles  of  the 
neck  on  both  sides;  when  the  hands  were  put  forward, 
the  scapulae  were  winged.  This  was  due  to  the 
atrophy  and  weakness  of  the  lower  portions  of  the 
trapezius  and  deltoid.  The  face  was  myopathic.  The 
onset  of  this  disease,  Dr.  Caswell  said,  was  very  in- 
sidious. Until  the  patient  noticed  something  which 
interfered  with  the  daily  employment  or  manual  la- 
bor, she  did  not  seek  treatment. 


Dr.  1'kteks(jn  said  that  he  had  considered  the  Lan- 
douzy-Dejerine t)pe  very  rare  up  to  two  years  ago, 
rarer  than  the  F.rb  juvenile  form,  but  within  the  past 
two  years  he  had  seen  four  cases  with  perfectly  typical 
syndromes.  The  history  was  usually  indefinite  except 
as  to  the  eyes.  The  patients  never  remembered  being 
able  to  close  the  eyes.  This  would  lead  the  speaker 
to  suggest  that  some  cases  occasionally  met,  of  bilat- 
eral lagophthalmos,  might  turn  out  to  be  this  disease. 
Several  years  ago  he  thought  this  form  a  variation  of 
the  F.rb  juvenile  type.  Now  he  thought  it  a  different 
syndrome  with  a  different  pathological  basis. 

Progressive    Muscular  Atrophy Dr.    Leopold 

Stieglitz  reported  a  case  of  a  man,  thirty-three  years 
of  age,  born  in  Germany,  who  came  to  this  country 
four  years  ago;  his  father  died  of  heart  disease,  his 
mother  was  living.  He  had  one  brother  and  four  sis- 
ters, and  said  none  of  them  had  a  trouble  similar  to 
his.  He  could  not  state  exactly  when  his  present 
trouble  began.  He  had  noticed  for  some  years  weak- 
ness in  the  legs  and  inability  to  lift  them  properly 
from  the  ground;  in  consecjuence  of  this  he  had  diffi- 
culty in  walking  and  tired  easily.  This  condition 
became  steadily  worse.  The  speaker  saw  the  patient 
four  years  ago  at  Mt.  Sinai  Dispensary.  Upon  exami- 
nation he  found  very  profound  atrophy,  no  disturbance 
of  sense,  and  slight  signs  of  reaction  of  degeneration. 
The  case  was  entered  as  one  of  the  peroneal  type  of 
progressive  muscular  atrophy.  Last  February  the  pa- 
tient returned  to  the  dispensary  complaining  of  weak- 
ness in  the  arms.  Upon  examination  it  was  found 
that,  besides  the  condition  in  the  legs,  there  was  a 
very  pronounced  typical  condition  of  progressive  mus- 
cular atrophy  of  the  body.  The  atrophy  involved  also 
the  gastrocnemius  muscles  of  the  calf  and  to  a  certain 
extent  the  muscles  of  the  thighs.  On  both  sides  there 
were  atrophy  of  the  pectoral,  hypertrophy  of  the  del- 
toids, wasting  away  of  the  upper  arms,  typical  drop- 
foot,  and  atrophy  of  the  lower  extremities.  The  diag- 
nosis was  the  peroneal  and  juvenile  types  of  progres- 
sive muscular  atrophy  or  dystrophy.  The  electrical 
reactions-,  however,  did  not  correspond  to  those  one 
would  expect  in  a  case  of  this  kind.  They  were  nor- 
mal in  the  upper  extremities  and  absent  entirely  in  the 
lower.  The  patient  had  winged  scapula;,  protruding 
abdomen,  and  kyphosis — all  indicative  of  progressive 
muscular  dystrophy. 

Dr.  Fisher  said  that  there  w'as  a  fine-drawn  dis- 
tinction between  the  juvenile  and  peroneal  types. 
From  the  conjunction  of  the  two  in  the  same  patient, 
it  would  seem  that  they  might  belong  to  the  same 
family. 

Dr.  Fraenkel  said  the  three  types  of  dystrophy 
were  shown  in  this  patient.  The  remarkable  feature 
was  the  absence  of  any  heredity.  This  condition  was 
unusual,  he  said,  so  late  in  life. 

Dr.  Peterson  agreed  with  Dr.  Stieglitz  that  it  was 
the  juvenile  type.  He  thought  there  was  a  marked 
distinction  between  the  juvenile  and  the  Charcot- 
Marie-Tooth  forms.  The  two  syndromes  were  not 
alike.  One  peculiarity  in  Dr.  Stieglitz's  case  was 
that  the  legs  below  the  knees  were  affected.  He 
could  not  see  why,  in  the  Erb-juvenile  form,  other 
muscles  were  not  involved  besides  the  shoulder  girdle. 

Dr.  Stieglitz  said  that  the  unusual  feature  was  the 
commencement  of  the  disease  in  the  lower  extremities. 
He  had  looked  into  the  literature  of  the  subject  and 
could  find  nothing  that  exactly  corresponded  with  this 
case.  The  involvement  of  the  lower  legs  was  not  so  un- 
usual, and  in  this  case  simply  the  muscles  below  the 
thigh  sequence  were  involved.  Atrophy  of  the  muscles 
of  the  thigh  was  common  in  progressive  muscular  dys- 
trophy. He  thought  a  distinction  should  be  made 
between  the  Charcot-Marie-Tooth  and  the  Landouzy- 
Dejerine  types  on  account  of  the  difference  in  pathol- 


4/6 


MEDICAL    RECORD. 


[September  22,  1900 


ogy.  The  former  was  a  disease  of  lliu  cord,  the 
Landouzy-Uejerine  type  was  a  pure  myotrophia.  On 
that  account  we  should  not  try  to  connect  the  two  syn- 
dromes. Unless  the  family  history  was  carefully  in- 
vestigated we  might  be  misled,  for  the  disease  might 
be  hereditary  without  its  being  found  out  from  the 
statements  of  the  patient. 

Hereditary    Cerebellar    Ataxia.  — Du.    M.   Mail- 
house  presented   a  case   of   this  alieciion   so-called. 

The  patient,  F.  F ,  was  admitted  to  the  New  Haven 

Hospital  January  13,1900,  with  the  following  history  : 
Age,  thirty-two  years;  single;  birthplace  United 
States;  occupation,  postal  clerk;  thefather and  mother 
were  living  and  well;  he  had  five  sisters  living,  all  in 
good  health.  One  sister  died  of  pulmonary  tubercu- 
losis and  another  died  in  infancy  of  some  cause  not 
stated.  The  mother's  mother  also  died  of  pulmonary 
tuberculosis.  A  sister  of  his  mother  was  at  present 
an  inmate  of  the  Connecticut  Asylum  for  the  Insane. 
Both  mother  and  father  have  had  muscular  rheumatism. 
The  patient  had  scarlet  fever  and  diphtheria  at  fifteen 
years  of  age.  When  a  boy  he  had  rheumatism  of  mild 
degree.  In  1887  he  had  a  sunstroke  which  left  him 
confined  to  his  bed.  He  never  had  syphilis,  alcohol- 
ism, or  tuberculosis.  According  to  the  history  taken 
on  his  admission  to  tlie  hospital,  the  patient  first 
noticed  in  1S87  a  dragging  of  his  toes  on  walking  and 
that  his  shoes  curled  up,  and  were  worn  at  the  toes; 
he  did  not  walk  with  a  stamping  gait  and  could  direct 
his  feet  anywhere  without  trouble.  The  legs  did  not 
cross  in  walking.  On  closing  his  eyes  while  standing 
he  was  unablQ  to  keep  his  balance.  He  had  no  pain 
in  the  legs,  but  considerable  backache.  Then  his 
hands  began  to  tremble  (1888),  and  his  legs  shook  on 
walking.  These  symptoms  increased  and  he  had  to 
use  two  canes  in  walking  in  18S8  ,  in  18S9  he  used  a 
crutch  and  one  cane,  and  in  1S90  two  crutches.  He 
had  lost  fifty-seven  pounds  in  weight  within  the  past 
ten  years.  He  had  headaches,  off  and  on,  not  severe. 
He  also  stated  that  when  twenty-one  years  of  age  he 
noticed  an  inability  to  run ;  he  could  walk,  but  when 
he  ran  his  legs  got  mixed  up  as  though  they  were 
playing  cross-tag  with  one  another.  For  the  past  four 
or  five  years  erections  had  been  incomplete,  and  at 
one  time  he  had  frequent  urination.  In  his  present 
state  he  appeared  to  be  a  man  above  medium  height, 
of  good  frame  but  somewhat  emaciated.  A  striking 
feature  as  he  stood  supported  by  his  two  crutches  was 
the  nodding  tremor  of  his  head;  this  was  aggravated 
by  walking.  There  was  marked  asymmetry  of  the 
head,  a  flattening  of  the  occiput,  and  pronounced  slop- 
ing of  the  forehead,  with  considerable  flattening  over 
the  left  parietal  region.  There  was  some  facial  asym- 
metry also,  as  was  evidenced  by  a  greater  prominence 
of  the  right  supraorbital  arch  than  of  the  left.  The 
nose  was  directed  toward  the  riglit,  and  the  left  pal- 
pebral fissure  was  smaller  than  the  right.  His  gait 
was  markedly  ata.\ic;  he  was  able  to  get  about  fairly 
well  on  a  level  with  the  aid  of  crutches,  but  lost  his 
balance  readily  on  attempting  to  ascend  steps.  There 
was  absolutely  no  muscular  weakness  in  his  legs. 
The  knee  jerks  were  present,  but  not  e.xaggerated. 
There  was  no  ankle  clonus.  The  Ronilierg  symptom 
was  present,  and  the  patient  was  supported  with  diffi- 
culty when  he  stood  with  closed  eyes.  There  was  no 
impairment  of  sensation  of  any  one  of  the  forms,  from 
head  to  toe.  His  mo\ements  were  ciuickly  performed, 
jerky,  as  was  observed  when  he  attempted  to  touch 
the  tip  of  his  nose  with  the  index  finger,  the  eyes  be- 
ing closed.  The  ataxia  of  the  upper  extremities  was 
much  less  evident  than  that  in  the  legs.  His  speech 
was  noticeably  affected,  but  changed,  being  sometimes 
scanning  or  staccato  and  at  other  times  characterized 
by  indecision  and  unsteadiness  in  the  muscles  of  vocal 
expression;   it  was  decidedly  an  ataxic  speech.     The 


pupils  reacted  neither  to  light  nor  to  accommodation. 
There  was  marked  lateral  nystagmus,  and  when  the 
patient  looked  upward  a  rotatory  nystagmus  occurred; 
when  the  eyes  were  at  rest  there  was  no  oscillation. 
There  were  no  contractures  and  no  scol  iosis.  The  grasp 
of  the  hands  was  strong  and  the  muscles  of  the  arms 
showed  no  loss  of  power.  The  pectoral  muscles  were 
wasted,  otherwise  no  atrophies  were  present.  There 
were  no  optic  atrophy  and  no  limitation  of  the  visual 
fields,  but  the  man  was  myopic,  requiring  a  lens  of 
seven  diopters.  The  superficial  reflexes  were  present, 
the  plantar  being  very  active.  The  urine  presented 
no  abnormality.  The  handwriting  was  like  that  of  a 
tabetic.  A  review  of  the  symptoms,  Dr.  Mailhouse 
said,  revealed  the  marked  ataxia  of  the  whole  muscular 
sytsem  without  any  paralytic  phenomena.  The" case 
resembled  one  of  Friedreich's  ataxia  in  its  mode  of 
development  and  general  appearance,  but  dift'ered  from 
the  typical  disease  in  its  later  onset,  in  the  retained 
knee-jerks,  in  the  late  and  mild  affection  of  the  arms, 
in  the  loss  of  the  ocular  reflexes,  and  in  the  absence 
of  contractures  or  paralysis ;  the  man  had  been  afflicted 
twelve  years  and  there  was  no  paralysis  or  contracture 
present.  The  question  might  arise  as  to  the  disease 
being  multiple  sclerosis,  but  the  speaker  believed  that 
this  affection  could  be  ruled  out  by  the  mode  of  onset, 
it  being  ataxic  rather  than  paraplegic,  by  the  normal 
refle.xes  and  sensory  phenomena,  and  by  the  absence 
of  intention  tremor.  Furthermore  the  long  duration 
of  the  illness  without  any  paralysis,  ocular  or  corporal, 
would  militate  against  such  a  diagnosis.  The  case 
was  presented  not  as  an  argument  in  favor  of  the  type 
of  hereditary  cerebellar  ataxia,  but  rather  as  a  clinical 
example  of  ataxia  presenting  such  a  symptom  complex. 

Dr.  Caswell  said  that  in  the  form  of  ataxia  de- 
scribed the  fundus  was  generally  affected;  there  was 
more  or  less  neuritis  and  the  knee  jerks  were  increased, 
and  in  this  way  discrimination  was  made  between 
cerebellar  and  ordinary  ataxia. 

Dr.  Fisher  thought  the  sunstroke  might  have  been 
an  etiological  factor  in  this  case.  He  said  he  remem- 
bered a  case  of  sunstroke  followed  by  symptoms  of 
this  type,  resembling  compound  or  multiple  sclerosis, 
not  conforming  strictly  to  either.  Taking  that  as  an 
etiological  factor,  there  w'ere  ordinarily  some  menin- 
gitis, some  change  affecting  the  cortex  of  the  brain 
leading  to  the  ataxic  symptoms;  accordingly  ataxia 
was  seen  with  inco-ordination  of  the  muscles,  a  spastic 
condition — a  degenerative  condition  secondary  to 
some  such  lesion  as  that  caused  by  the  action  of  the 
sun. 

Dr.  Fraenkel  said  there  was  a  great  difference  be- 
tween cerebellar  ataxia  and  ataxia  produced  by  disease 
of  any  other  parts  of  the  co-ordinatory  system. 

Dr.  Peterson  said  he  had  examined  the  man  be- 
fore the  meeting  and  thought  the  diagnosis  lay  between 
multiple  sclerosis  and  cerebellar  ataxia.  He  was  in- 
clined to  think  Dr.  Mailhouse  was  right  in  his  diag- 
nosis of  cerebellar  hereditary  ataxia,  on  account  of  the 
pupillary  condition— no  reaction  to  light — and  because 
the  man  had  more  of  an  ataxia  than  tremor  of  the 
ordinary  multiple-sclerosis  type. 

Dr.  Wm.lia.m  K.  Pritchard  asked  whether  tliere 
was  anytiiing  of  note  in  the  subjective  history  of  the 
case  as  regards  vision,  hearing,  or  persistence  of  ver- 
tigo or  headaches,  that  added  to  the  data. 

Dr.  Mailhousf.  said  there  were  no  subjective  sym|> 
tonis  at  all,  except  backache  and  difficulty  of  manipu- 
lating the  legs.  The  man  was  strongly  myopic,  but 
there  was  no  eye-strain. 

Raynaud's  Disease  of  a  Gangrenous  Type. — Dr. 
William  H.  PoRri.R  presented  a  case  of  this  kind. 
The  man  came  to  this  country  some  years  ago;  for  a 
year  or  so  he  was  a  hod  carrier,  then  went  into  an  iron 
foundry,  where  he  had  worked  since.     He  had  a  very 


September  22,  1900] 


MEDICAL    RECORD. 


477 


pronounced  alcoholic  habit,  and  used  tobacco  to  a 
considerable  extent.  In  the  middle  of  April  he  no- 
ticed that  the  fingers  of  both  hands  were  very  whiii.- 
and  icy  cold.  This  lasted  for  two  weeks  and  was  fol- 
lowed by  superficial  gangrene,  discoloration  and 
Islackness  of  the  four  fingers  of  both  hands,  a  little 
discoloration  of  the  left  ear,  and  a  spot  on  the  opposite 
ear.  This  condition  lasted  for  ten  days  before  he 
came  to  the  hospital.  He  suffered  intolerable  pain 
and  got  very  little  sleep.  The  urine  showed  sligiit 
traces  of  albumin,  a  decrease  in  urea,  and  a  large 
amount  of  indican.  The  patient  had  a  very  higli 
pulse  and  was  given  doses  of  nitroglycerin  with  strych- 
nine and  caffeine  to  improve  the  circulation.  Lead 
and  opium  dressing  was  applied  and  gave  relief. 

Dr.  Pritchari)  said  that  the  patient  had  been  under 
his  care  for  three  or  four  weeks.  At  that  time  the 
man  had,  in  addition  to  the  symptoms  mentioned,  ex- 
treme (tdema  of  the  hand,  extending  beyond  the  wrist. 
He  had  almost  the  national  combination  of  colors — 
blue  finger  tips,  red  hand,  white  arm.  He  was  not 
relieved  by  the  lead  and  opium  applications  made  in 
varying  strength,  and  by  other  local  means.  He  ad- 
mitted a  rather  gross  alcoholic  history,  and  those  who 
saw  him  at  the  time  were  of  the  opinion  that  that  was 
an  etiological  factor  of  some  importance,  possibly  in- 
tensified by  the  extremes  of  heat  and  cold  to  which  he 
had  been  exposed.  His  sufferings  were  horrible. 
Opiates  were  given  in  moderate  quantities,  only  to 
modify  the  extremity  of  pain. 


m 


cdical  Jtcms. 


Contagious   Diseases — Weekly   Statement.^Report 

of  cases  and  deaths  from  contagious  diseases  reported 
to  the  Sanitary  Bureau,  Health  Department,  for  the 
week  ending  September  15,  rgoo: 


Tuberculosis 

Typhoid  fever 

Scarlet  fever 

Measles 

Diphtiieria 

Laryngeal  diphtheria  (croup) 
Cerebro-spinal  meningitis. . . . 


Cases. 


223 

128 

116 

28 

45 

3 

2b 

5 

1 11 

20 

3 

I 

0 

6 

Bionchitis  in  Children. — Oppenheim  says  that  in 
the  treatment  of  bronciiitis  in  children  the  parents 
must  by  all  means  free  themselves  from  certain  time- 
honored  beliefs  which  should  be  called  superstitions. 
Children  suffering  from  this  disease  need  not  be 
swathed  in  blankets  and  pads  until  they  resemble 
mummies;  they  need  not  be  kept  unwashed  during  the 
course  of  the  sickness,  and  they  will  not  be  killed  Ijy 
a  breath  of  fresh  air.  On  the  contrary,  they  should 
be  kept  comfortably  warm  but  not  hot;  they  may  with 
advantage  have  a  warm  bath  morning  and  night;  ami 
the  sick-room  should  always  be  kept  well  ventilated. 
One  should  keep  in  mind  that  most  of  these  cases  are 
examples  of  germ  infection,  and  that  they  require  a 
vigorous  excretion,  a  satisfactory  stimulation,  and  a 
bland  soothing  of  the  cough  and  pain. 

Hints  to  Contributors  to  the  Medical  Press. 
Professor  Virchow,the  editor  of  the  Archiv  Jiir  patlio- 
logische  Anatomie,  has  addressed  some  words  of  coun- 
sel to  the  contributors  to  that  periodical  and  to  med- 
ical authors  generally,  explaining  several  points  which 
it  is  desirable  that  writers  for  the  medical  press  should 
always  keep  in  mind.  It  would  be  difficult  to  find  a 
higher  authority  on  this  subject  than  Professor  Vir- 
chow,  the  patriarch  of  the  savants  and  editors  of  Ger- 


many. His  remarks  are  not  intended  for  authors  of 
books,  who  are  at  liberty  to  write  as  they  like;  they 
have  been  published  exclusively  for  the  benefit  of  con- 
tributors to  medical  weekly,  monthly,  or  quarterly  jour- 
nals. He  says  that  it  is  one  of  the  elementary  princi- 
ples of  journalism  that  the  successive  numbers  of  a 
journal  must  be  issued  at  a  certain  time  and  in  a  cer- 
tain size.  Contributors  must  therefore  endeavor  to 
write  concisely,  taking  up  as  little  space  as  possible 
and  avoiding  all  superfiuous  matter.  Descriptions  of 
cases,  experiments,  and  necropsies  when  sent  to  editors 
for  publication  are  often  so  voluminous  that  it  is  im- 
possible to  use  them  without  serious  inconvenience. 
The  publication  of  series  of  cases,  etc.,  in  the  form 
of  tables  is  a  great  annoyance  for  the  editor,  the 
printer,  and  the  readers.  Controversies  as  to  priority 
are  often  offensive  in  style  and  lacking  in  the  courtesy 
due  to  professional  brethren.  Finally,  contributors 
ought  to  abandon  the  custom  of  quoting  long  passages 
from  other  authors  with  the  object  only  of  showing 
their  knowledge  of  medical  literature.- —  T/ie  Lancet. 

The  Earliest  Signs  of  Tuberculosis — Professor 
Bozzalo,  of  Turin,  in  a  paper  read  at  tiie  recent  inter- 
national (Jongress  on  Tuberculosis  at  Naples,  has  con- 
veniently summarized  the  following  eleven  important 
points  which  are  of  assistance  in  forming  a  diagnosis 
of  pulmonary  phthisis  inits  earliest  stages.  They  are 
as  follows:  (i)  Albuminuria  alternating  with  phos- 
phaturia;  {2)  a  p.seudo-chlorosis  distinguishable  from 
true  chlorosis  by  the  slighter  degree  of  reduction  of 
the  ha:nioglobin  and  by  the  less  marked  vascular  and 
cardiac  disturbances  (palpitation,  soft  pulse,  pulsating 
arteries,  etc.);  (3)  the  presence  of  gastric  disturbances 
like  gastralgia,  anorexia,  nausea,  and  vomiting;  (4) 
tachycardia  in  the  absence  of  fever;  (5)  diminution 
of  blood-pressure;  (6)  a  rise  of  temperature  follow- 
ing bodily  or  mental  exertion  above  the  slight  lise 
proper  to  health;  in  women  a  rise  of  from  0.3°  to  0.4'' 
tJ.  is  observable  before  the  onset  of  each  menstrual 
period;  {7)  an  undue  tendency  to  sweat  after  exer- 
tion, mental  or  bodily,  also  night  sweats;  (8)  pain  in 
the  supra-orbital  regions  and  in  the  neck;  (9)  a  slight 
inequality  of  the  pupils  with  a  tendency  to  dilatation 
(^mydriasis) ;  ( i  o)  the  occurrence  of  herpes  zoster ;  ( 1 1 ) 
enlargement  of  the  spleen.  Of  these  the  first  seven 
symptoms  are  the  most  frequently  met  with  and  possess 
considerable  diagnostic  value. —  T/ie  Lancet. 

The  Hospital  Ship  "  Maine."— Following  is  an 
account  of  the  work  of  the  American  hospital  ship 
Maine,  now  in  Chinese  waters,  written  by  Mrs.  Kinni- 
cutt,  one  of  the  hospital  officials  of  the  State  of  New 
York,  and  published  in  77ie  Tiiliuiie  : 

"The  American  hospital  ship  Maine  arrived  in 
Chinese  waters  on  Saturday,  August  25th.  So  little 
is  known  in  the  I'nited  States  of  her  mission,  either 
present  or  past,  that  I  ask  leave  to  acquaint  your  read- 
ers with  what  she  has  accomplished  and  what  she  still 
aims  to  do  for  the  relief  of  suffering  humanity  and  for 
the  credit  of  our  country  in  distant  parts  of  the  world. 
The  idea  of  a  hospital  ship  originated  with  an  Ameri- 
can woman,  the  wife  of  an  American  long  resident  in 
South  Africa.  This  ship,  generously  loaned  by  the 
Atlantic  Transport  Company,  through  its  president, 
Bernard  Baker,  of  Baltimore,  equipped  and  maintained 
at  the  cost  of  Americans,  and  in  charge  of  American 
doctors,  started  on  an  errand  of  mercy  in  December 
last  for  Cape  Town,  to  give  aid  to  the  sick  and 
wounded  in  the  South  African  war.  As  a  volunteer 
ship,  supplementary  to  the  government  relief  ships, 
she  was  fitted  out  with  many  comforts  and  luxuries 
such  as  cannot  be  demanded  in  times  of  stress  from 
an  overtaxed  War  Office.  In  the  harbors  of  Cape 
Town  and  Durban  the  Maine  received  both  the  British 
and  the  Boer  wounded,  and  returned  in  April  to  South- 


478 


MEDICAL    RECORD. 


[September  22,  1900 


ampton,  Eng.,  with  a  full  complement  of  invalided 
British  soldiers.  The  number  of  patients  received 
on  board  was  three  hundred  and  fifty-four,  including 
those  treated  in  port.  Re-equipped  and  re-victualled 
in  nine  day.s,  she  sailed  directly  back  to  South  Africa 
to  bring  home  another  shipload  of  disabled  soldiers. 
On  this  her  second  return  voyage,  in  July,  I  was  one 
of  those  who  sailed  out  from  Southampton  to  welcome 
her.  For  me  it  was  the  first  and  nearest  approach  to 
the  horrgrs  of  war,  and  I  found  them,  even  in  this 
their  second  stage,  sad  and  grim.  As  our  boat  ap- 
proached the  incoming  Maine — this  moving  hospital, 
larger  in  its  number  of  beds  than  most  of  the  large 
hospitals  of  New  York — we  saw  her  sides  and  decks 
crowded  with  eager  faces;  men  everywhere  in  invalid 
chairs,  on  stretchers  and  on  crutches;  with  legs  gone, 
arms  gone,  heads  bandaged,  and  all  in  motley  ar- 
ray. No  gay  trappings  of  dress  parade,  only  here  and 
there  a  cap,  a  Glengarry  or  a  fatigue  jacket,  to  indicate 
the  soldier's  uniform.  We  boarded  the  Maiin\  and 
during  the  two  hours  before  we  reached  the  dock  at 
Southampton  there  was  ample  opportunity  to  examine 
her.  Descending  into  the  first  ward — named  after 
Mrs.  VVhitelaw  Reid — we  found  a  number  of  patients 
in  the  cots.  It  was  unnecessary  to  ask  the  nature  of 
their  trouble,  for  the  pale  faces  and  emaciated  bodies 
bore  the  unmistakable  stamp  of  enteric  fever — that 
deadliest  of  camp  followers.  The  ward  was  bright  and 
well  ventilated,  the  bed-linen  fresh  and  white,  and 
everything  scrupulously  clean.  Over  each  bed  was 
suspended  the  name  of  its  American  donor — men  and 
women  with  svmpaihies  broad  enough  to  stretch  forth 
into  the  unknown  for  the  unknown.  The  ward  capac- 
ity of  the  Maine  is  two  hundred  and  ten  beds.  The 
surgeons  and  physicians,  all  of  them  first-rank  men 
from  our  best  American  hospitals;  the  nurses  from 
the  Mills  Training-School,  and  the  orderlies,  were  a 
strong,  sturdy  band,  truly  a  staff  upon  which  to  lean. 
Despite  the  comparatively  cramped  quarters,  modern 
scientific  treatment  had  been  carried  out  in  the  form 
of  tub  baths  for  the  cases  of  enteric  fever  with  gratify- 
ing results.  By  means  of  an  admirable  Roentgen-ray 
apparatus  sent  out  from  New  York  valuable  assistance 
had  been  obtained  in  the  treatment  of  gunshot  inju- 
ries, and  in  a  well-equipped  laboratory  diagnoses  in 
doubtful  cases  had  been  made  by  bacteriological  ex- 
aminations. A  strange  and  a  happy  fact  to  be  re- 
corded was  that  during  the  three  weeks'  voyage  of  this 
hospital  ship  not  a  single  death  had  occurred.  The 
patients  below  deck,  as  well  as  above,  were  in  excel- 
lent spirits,  despite  their  disabilities,  and  one  and  all 
seemed  grateful  for  what  they  termed  their  good  luck 
in  having  been  consigned  to  the  '  Yankee  ship.'  At 
Madeira  a  few  newspapers  had  been  obtained  telling  of 
the  outbreak  of  trouble  in  China,  and  all  were  eager 
for  the  latest  war  news.  '  Soon  we'll  be  fighting  to- 
gether out  there,'  a  bright-faced  Irishman  said  to  me, 
with  evident  impatience  to  be  himself  in  the  fray. 
When  I  expressed  my  preference  for  soldiers  as  guar- 
dians of  peace  rather  than  as  forces  for  war,  he  looked 
quite  disgusted,  and  said:  '  Hut,  ma'am,  what  would 
we  be  afther  doin'  without  a  bit  of  a  stir-u])  oncet  in  a 
while?' — truly  a  characteristic  race  point  of  view  of 
the  interest  and  pleasures  of  life.  As  we  approached 
Southampton  the  Maine  received  a  hearty  welcome 
from  the  American  training-ship  I.ancaskr,  whose 
yards  were  manned  with  lusty  lads.  Across  the  end 
of  the  Southampton  dock  a  large  sign  was  stretched, 
'Telegrams  sent  free,'  and  soon  every  soldier  on  deck 
was  scribbling  a  home  message.  It  had  been  the  in- 
tention of  the  London  executive  committee  of  the 
Maine — all  of  whom  are  women  of  American  birth, 
whose  energy,  efficiency,  and  devotion  are  deserving 
of  home  recognition — again  to  send  her  back  to  South 
Africa,     liut  the  crisis  in  China  had  become  so  acute. 


the  provision  for  many  sick  and  wounded  of  the  allied 
forces  so  urgent,  with  no  hospital  ship  as  yet  under 
way,  that  the  committee  decided  that  the  need  for 
their  ship  was  now  greater  in  the  far  East  than  in  the 
far  South.  A  proposal  to  this  effect  met  with  cordial 
ajjproval  at  the  British  War  Office,  and  on  July  12th 
the  Maine  set  sail  for  Chinese  waters.  She  was  re- 
ported on  August  25th  as  having  arrived  at  Hong 
Kong,  on  her  way  to  her  northern  station  to  receive 
the  wounded.  Directly  after  the  departure  of  the  Maitie 
the  committee  notified  the  United  States  govern 
ment  at  Washington  of  her  intended  destination,  and 
ofTered  a  welcome  and  all  possible  aid  to  our  sick  and 
wounded  countrymen.  The  American  ambassadors 
at  the  courts  of  the  allied  Powers  were  also  informed 
of  the  departure  of  the  Maine  for  China,  and  asked  to 
notify  the  governments  to  which  they  were  accredited 
that  their  wounded  would  receive  a  cordial  welcome 
on  the  American  ship.  Prompt  and  appreciative  ac- 
knowledgment has  been  received  from  Germany,  Italy, 
Austria-Hungary,  and  the  other  powers.  A  check  for 
^1,000 — a  most  timely  and  welcome  gift — was  also 
received  from  Mrs.  Corning  Clark  soon  after  the  de 
parture  of  the  Maine.  Mrs.  Clark  asked  that  the  sum 
be  used,  if  possible,  to  aid  the  men  of  the  Ninth 
United  States  Infantry — the  first  American  regiment 
to  suffer  in  the  field.  J.  P.  Morgan  &  Co.,  No.  23 
Wall  Street,  are  the  treasurers  of  the  Alaine  fund  in 
New  York. 

"This  is  the  history,  so  far,  of  the  American  hospi- 
tal ship  Maine.  If  with  this  name  is  to  be  linked  the 
word  'remember,'  may  it  be,  in  the  future,  with  this 
sister  ship  of  mercy,  whose  activities  and  sympathies, 
true  to  her  Red  Cross  flag,  are  world-wide  and  world- 
embracing," 

The  Plague  Bacillus. — Dr,  H,  Noguchi  has  been 
conducting  some  experiments  at  Newchwang,  China, 
with  the  plague  bacillus,  to  determine  its  resistant 
power  against  cold  in  dry  conditions  and  in  frozen 
liquid  media.  His  results,  which  are  tabulated  in 
the  report  of  the  United  States  Marine-Hospital  ser- 
vice for  July  13th,  are  as  follows:  "That  the  plague 
bacilli  are  not  devitalized  by  the  temperature  of  24° 
C.  below  zero  even  after  being  submitted  to  this  tem- 
perature for  the  space  of  three  weeks.  The  peculiar- 
ity possessed  by  the  plague  bacillus  is  the  limit  of 
temperature  for  its  multiplication,  not  like  other  path- 
ogenic germs.  It  can  grow  uniformly,  slowly  but 
steadily,  from  20°  1037°  C.  which  is  rarely  observed 
in  other  bacteria.  .  .  .  The  plague  bacilli  if  laid  near 
the  freezing-point  stop  their  growth  and  remain  for  a 
long  time  inert  waiting  for  further  chances  of  good 
hosts.  .  .  .  From  the  several  reports  published  by  the 
German  plague  commission  to  Bombay,  I  have  learned 
that  the  pneumonic  forms  are  comparatively  few  while 
the  ofiicial  report  of  the  sanitary  board  of  Germany 
showed  that  the  majority  of  cases  in  Odessa  were  of 
pneumonic  form.  Of  course  the  nature  of  an  epi- 
demic is  influenced  by  the  climate  and  the  resistance 
of  the  plague  bacilli  on  one  side,  and  it  also  depends 
greatly  upon  the  customs  of  the  nation,  ...  In  India, 
where  the  hot  air  and  dry  soil  are  very  unfavorable  to 
the  tloating  bacteria  to  retain  their  lives  even  for  a 
few  minutes,  the  pneumonic  forms  are  produced  by 
the  direct  contagion  with  fingers,  or  pipes,  etc.,  of  the 
patient,  or  particles  of  sputum.  ...  In  contrast  to 
India,  Chinese  houses  are  furnished  w-ith  favorable 
conditions  for  the  plague  bacillus — bad  ventilation, 
little  direct  sunlight,  a  heaping  of  human  excrements, 
etc.,  especially  the  earthen  Hoor  must  be  regarded 
as  a  most  dangerous  source  of  infection.  .  .  .  Chinese 
people  do  not  use  spittoons  in  their  rooms,  and  spit 
anywhere;  indeed  I  have  seen  that  the  jjiieumonic  pa- 
tients were  spitting  their  bloody  sputum   on  the  beds, 


September  22,  1900] 


MEDICAL    RECORD. 


479 


windows,  walls,  or  floor  at  the  agonal  stages,  and  the 
relatives  trampled  the  sputum  into  powder  within  a 
few  minutes." 

Demand  for  Antitoxin — At  the  recent  meeting  of 
the  British  Royal  Institution  of  Public  Health  at 
Aberdeen,  Dr.  Dean,  who  lias  charge  of  the  farm 
where  the  antitoxin  is  manufactured  for  the  Jenncr 
Institute,  referred  to  the  seasonal  fluctuation  in  the 
demand  for  antitoxin.  He  used  the  facts  of  his  ex 
perience  at  the  Jenner  Institute  to  show  that  the  sup 
ply  of  antitoxin  varied  according  to  the  seasons  much 
in  the  same  way  as  the  deatiis  from  diphtheria.  The 
curve  shown  on  a  chart  was  formed  on  the  basis  of  the 
number  of  doses  sent  out  each  month  of  the  year. 
This  was  correlated  with  the  corresponding  one  of 
diphtheria  deaths  in  the  registrar-general's  returns, 
and  altiiough  tliey  did  not  show  an  exact  correspond- 
ence, the  variation  was  sufficiently  slight  to  justify  the 
conclusion  that  the  supply  of  antitoxin  was  a  real  in- 
dication of  the  sea.sonal  variations  in  the  prevalence 
of  diphtheria.  Taking  the  average  of  the  last  twenty 
years  they  were  lowest  in  the  month  of  May  and  high- 
est in  the  month  of  November,  while  in  precisely 
the  same  months  the  supply  of  antitoxin  was  highest 
and  lowest  respectively. 

Mortality  in  War — In  the  London  Tim:s  of  Sep- 
tember ist,  an  interesting  comparison  is  drawn  be- 
tween the  rates  of  mortality  which  prevailed  among 
officers  and  men  during  the  Franco-German  war,  and 
those  incurred  by  the  British  army  in  South  Africa. 
The  mean  strength  of  the  British  army,  including  all 
forces,  may  be  taken  to  have  been  5,266  officers  and 
188,000  non-commissioned  officers  and  men.  The 
deaths  have  been:  officers  killed  or  died  of  wounds 
380,  died  of  disease  160,  total  540;  non-commis- 
sioned oflicers  and  men  killed  or  died  of  wounds 
3,580,  died  of  disease  5,980,  total  9,560.  The  rates 
of  mortality  were  as  follows;  of  the  officers  72.1  per 
1,000  were  killed  or  died  of  wounds,  and  30.6  per 
1,000  died  from  disease;  total  102.7  P*^""  i.ooo.  Of 
the  non-commissioned  officers  and  men  19  per  1,000 
perished  in  battle  or  died  of  wounds,  and  31.8  per 
1,000  died  of  disease;  total  50.8  per  i,ooo.  In  the 
Franco-German  war  official  figures  show  the  fortunes 
of  a  mean  strength  of  25,960  officers  and  862,800  men 
who  took  part  in  that  campaign.  Battle  and  wounds 
accounted  for  1,650  officers  and  26,627  men,  while 
144  officers  and  10,942  men  met  their  deaths  from 
disease.  The  rates  of  mortality  were:  officers  65.5 
per  1,000  killed  or  died  of  wounds;  and  8.9  per 
1,000  died  from  disease  and  other  causes;  total  74.4 
per  1,000.  Non-commissioned  officers  and  men  killetl 
or  died  of  wounds,  30.9  per  1,000,  died  from  disease, 
etc.,  14.2  per  1,000;  total  45.1  per  1,000.  As  witii 
British  forces  in  South  Africa  we  see  a  large  discrep- 
ancy between  the  number  of  oflicers  and  of  men  killed 
in  battle,  but  while  in  the  Franco-German  war  an 
officer  had  a  double  chance  of  being  killed  as  com 
pared  with  his  men-,  in  South  Africa  the  British 
officer  had  to  face  three  and  a  half  chances.  As  re- 
gards the  men,  the  risks  in  the  Franco-German  war,  as 
compared  with  those  in  the  South  African  compaign, 
were  50  per  cent,  greater  of  being  killed  in  battle, 
and  less  than  half  as  great  of  dying  of  disease. 
When  every  allowance  is  made  for  the  conditions 
under  which  the  Franco-German  war  was  carried  on, 
the  highly  civilized  and  thickly  populated  country, 
and  the  ease  with  which  medical  comforts  and  assist 
ance  could  be  commanded,  it  is  remarkable  how  low 
the  death  rate  was  from  disease.  In  South  Africa 
officers  and  men  have  died  of  disease  at  the  rate  of 
31.7  per  1,000.  while  the  rate  for  officers  and  men  in 
the  Franco-German  war  was  only  12.5  per   1,000,  that 


of  officers  alone  being  as  low  as  8.9  per  1,000.  In- 
deed the  Franco-German  disease  rate  was  some  points 
less  than  the  ordinary  rate  of  15  per  1,000,  experi- 
enced by  British  troops  on  foreign  service  in  time  of 
peace. 

German  Military  Expedition  to  China — The  care 
of  the  troops  embarked  tor  China  has  been  an  object 
of  great  solicitude  to  the  military  authorities,  and  all 
the  officers  have  received  a  small  pamphlet  containing 
hygienic  rules  to  be  observed  on  board  ship  and  in  the 
far  East.  The  pamphlet  is  written  in  a  style  intelli- 
gible to  the  ordinary  reader,  and  the  officers  have  been 
ordered  to  give  their  men  instruction  in  the  subjects 
dealt  with  in  it.  This  is  the  more  necessary  as  the 
China  expedition  is  the  first  in  which  German  troops 
have  been  engaged  on  a  large  scale  out  of  Europe. 
The  troops  have  been  provided  with  difTerent  uniforms 
for  the  hot  and  cold  seasons;  the  summer  uniform  con- 
sisting of  khaki  and  a  straw  hat,  the  winter  uniform 
of  stout  cloth  and  furs.  With  a  view  to  prevent 
scurvy  and  similar  disease  great  quantities  of  pre- 
served vegetables  and  anti-scorbutics  have  been  sent 
to  China.  .Apparatus  for  the  sterilization  of  drinking- 
water  by  boiling  and  by  bromine,  as  suggested  by  Dr. 
Schumberg,  has  also  been  provided.  Army  medical 
officers  specially  trained  in  bacteriological  work  have 
been  sent  with  the  army,  and  it  will  be  their  duty  not 
only  to  examine  the  food  and  the  drinking-water,  but 
also  to  investigate  any  conditions  which  might  have  a 
significance  in  connection  with  an  outbreak  of  disease. 
The  army  medical  corps  is,  of  course,  much  more 
numerous  than  in  a  European  war;  army  medical 
officers  being  sent  for  each  129  men.  The  special 
medical  staff  consists  of  a  bearer  company  and  of  four 
field  hospitals  for  200  patients  each.  For  the  erec- 
tion of  .stationary  hospitals  one  hundred  and  twenty- 
seven  tents  and  fifteen  barracks  have  been  sent  with 
all  the  necessary  stafT  and  material.  Two  hospital 
ships  have  been  chartered  from  the  North  German 
Lloyd  for  the  conveyance  of  sick  and  wounded  sol 
diers  to  Europe. —  The  Lancet. 

Strong  Solution  of  Tar  in  Eczema.— Jonathan 
Hutchinson's  favorite  prescription  for  almost  all 
forms  of  eczema  is  a  combination  of  liquor  carbonis 
detergens  and  liquor  plumbi  subacetatis.  A  tea- 
spoonful  of  each  to  a  pint  of  warm  water  is  a  common 
prescription  which  should  be  used  not  only  as  a  wash, 
but  kept  constantly  applied  on  lint.  But  in  some 
cases  a  more  convenient  method  is  to  apply  a  very 
much  stronger  preparation  for  only  a  few  minutes  at  a 
time.  The  undiluted  liquor  carbonis  alone  is  often 
effectual  for  the  relief  of  pruriginous  affections  It 
stings  at  the  moment  of  application,  but  it  relieves 
the  itching  and  does  not  cause  smarting  afterward. 
A  surgeon  for  whom  the  writer  prescribed  found  that 
equal  parts  of  the  liquor  plumbi  and  liquor  carbonis 
applied  undiluted  always  killed  eczematous  patches. 
— Arclihes  oj  Surgery,  vol.  xiv..  p.  345. 

Adulteration  of  Coffee  and  Tea  on  the  European 
Continent.— James  Du  Bois  says  that,  if  all  the  sub- 
stances that  pass  through  a  continental  coffee-grind- 
ing machine  during  the  year  should  be  written  in 
alphabetical  order,  A  would  begin  the  list  with  acorns, 
and  W  would  end  it  with  wormwood,  sprouts  of  which 
are  sometimes  used  to  give  the  debased  coffee  a  slight 
aromatic  bitter  taste.  Adulteration  occurs  largely  in 
the  cotTee  that  is  sold  in  the  ground  form.  Several 
cofTee-berry  factories  have  been  discovered  in  Europe 
which  are  doing  a  large  and  profitable  business  by 
moulding  an  admixture  of  tan  bark,  stove  rust,  clay, 
sawdust,  chicory,  coffee  sediment,  and  cofl^ee  meal  into 
a  neat  berry  by  the  aid  of  some  agglutinant,  and  these 


48o 


MEDICAL   RECORD. 


[September  22,    1900 


berries  were  so  well  made  that  the  deception  was  not 
discovered  for  a  long  time.  This  production  had  a 
large  sale  among  the  lower  classes  of  Russia  and 
Poland,  and  mixed  with  the  genuine  coffee  berry  its 
sale  was  quite  lively  in  other  parts  of  Europe.  Un- 
roasted  coffee  berries  are  often  made  from  oat  and  rye 
flour  and  corn  meal.  The  natural  aroma  of  these 
grains  is  destroyed  by  some  process,  and  after  the 
proper  amount  of  coffee  aroma  is  added  the  berries 
are  formed  and  caused  to  maintain  their  shape  by 
some  adhesive  substance.  The  test  usually  employed 
to  discover  this  deception  is  to  place  the  beans  in  a 
receptacle  containing  water;  this  will  dissolve  them 
in  a  few  hours.  The  debasement  of  tea  is  a  growing 
industry.  Twenty-five  years  ago  the  tea-drinking 
habit  was  confined  to  Holland,  Kussia,  and  England, 
but  the  beverage  is  now  popular  in  almost  every  con- 
tinental country.  This  new  condition  increases  the 
demand,  and  the  adulterators  thus  have  the  opportu- 
nity to  ply  their  nefarious  trade  with  success.  Take  a 
handful  of  ordinary  tea  and  place  it  in  lukewarm 
water,  and  when  the  leaves  are  thoroughly  saturated 
open  and  spread  them  out,  and  three  chances  in  six 
you  will  find  a  quantity  of  strawberry,  linden,  sage, 
and  other  leaves  in  the  collection.  But  should  it  be 
found  that  all  of  the  leaves  belong  to  the  tea  plant 
that  will  be  no  proof  that  adulteration  has  not  taken 
place,  for  the  clever  Chinese  have  a  trick  of  using  the 
old  leaves  of  brewed  tea  for  the  export  trade,  and 
some  of  the  tea  dealers  of  Europe  have  discovered  the 
deception  and  are  utilizing  the  trick  by  preparing 
these  leaves  themselves. — The  Sanitarian. 

Production  of  Ipecacuanha. — One  of  the  most 
widely  used  of  all  vegetable  drugs  is  the  powerful 
emetic  ipecacuanha,  which  is  obtained  from  a  Brazil- 
ian shrub.  The  French  conseiller  de  commerce  at 
Cuyaba,  state  of  Matto  Grosso,  gives  in  a  recent  re- 
port an  interesting  account  of  this  plant,  which  has  in 
that  state  and  the  neighboring  district  its  only  habitat. 
The  drug  is  obtained  from  plants  which  attain  a 
height  of  from  twelve  to  sixteen  inches.  The  leaves 
are  oval,  dark  green,  and  sharply  ribbed,  and  tlie 
white  flowers  give  place  to  an  ovoid  fruit  containing 
black  seeds.  Besides  the  ipecacuanha  cephoelis  or 
the  "white  ipecacuanha,"  as  it  is  generally  known, 
there  are  several  other  varieties  which  are  somewhat 
different,  but  all  are  used  for  the  same  purpose,  and 
are  distinguished  as  brown,  black,  and  striated  ipe-^ 
cacuanha.  The  drug  is  obtained  from  the  root  of  the 
plant,  where  it  occurs  in  quantities  about  the  size  of 
a  quill  between  the  layers.  The  state  of  Matto  Gros- 
so, which,  as  before  observed,  is  the  habitat  of  the 
plant,  is  one  of  the  richest  in  Brazil,  among  its  many 
natural  products  being  gold  and  diamonds,  rubber, 
sarsaparilla,  jalap,  jaborandi,  and  copaiba.  Ipeca- 
cuanha is  found  in  the  north  and  northwest  of  the  San 
Luiz  de  Caceres,  formerly  in  the  Villa  Maria  region, 
and  its  habitat  covers  an  immense  area  between  a  net- 
work ui  rivers  in  Brazil,  ]iolivia,  and  Paraguay.  The 
dense  foliage  of  the  forests  of  this  region  provides  the 
dank  and  humid  conditions  which  favor  the  growth  of 
the  shrub.  The  Brazilian  product  is  known  as  Rio 
ipecacuanha,  and  the  product  procured  from  similar 
shrubs  in  other  countries  passes  under  the  name  of 
the  port  whence  it  is  shipped.  Attempts  have  been 
made  to  transplant  the  shrub  and  to  cultivate  it  in 
British  colonies  in  various  parts  of  the  world,  but 
without  success,  and  Brazil  continues  to  be  the  only 
source  of  supply  for  the  best  grade. — Scientific  Ameri- 
can Supp/inicnt. 

Yerba  Mat6  Tea.— Some  of  the  British  consuls  in 
South  America,  says  the  London  Times,  refer  in  their 
last  reports  to  the  virtues  ascribed  to  the  tea  made 


from  yerba  matd,  a  herb  which  takes  the  place  to  some 
extent  of  tea  and  coffee,  and  which  is  derived  from 
the  leaves  of  the  Ilex  Faraguaensis,  a  tree  of  from 
twelve  to  twenty  feet  in  height.  *rhe  consul  in  Para- 
guay says  this  tea  is  consumed  by  a  large  proportion 
of  the  populations  of  Brazil,  the  Argentine,  Uruguay, 
Chili,  and  Paraguay.  The  leaves  are  gathered  every 
two  or  three  years  and  dried  over  a  slow  fire;  they  are 
then  pounded  in  mortars  on  the  ground,  and  finally 
packed  in  fresh  skins  and  dried  in  the  sun.  The  tea 
is  made  by  pouring  boiling  water  on  the  leaves,  which 
serve  for  several  infusions.  The  taste  is  bitter  but 
not  unpleasant,  and  the  effects  are  asserted  to  be  in- 
vigorating. It  is  said  that  it  would  be  valuable  as  a 
restorative  to  troops  on  the  march,  and  the  French 
government  has  ordered  a  shipment  of  mate  for  the 
coloied  troops.  Some  samples  have  also  been  sent  to 
Germany  for  experimental  purposes.  An  attempt  is 
also  being  made  to  introduce  it  into  the  United  States 
as  a  suitable  beverage  for  the  working  classes.  When 
analyzed  the  tea  is  shown  to  contain  caffeine  and 
caft'eotanic  acid  in  important  proportions.  The  con- 
sul-general at  Rio  also  refers  to  the  subject  as  one  of 
commercial  interest.  It  is  claimed  on  behalf  of  the 
tea  that  it  possesses  superior  stomachic  properties  to 
tea  and  coffee,  in  that  while  it  is  refreshing  and  in- 
vigorating, and  favorable  alike  to  mental  and  physical 
exertion,  it  does  not  disturb  the  nervous  system.  But 
even  Brazilians  are  not  agreed  as  to  its  merits,  some 
alleging  that  by  its  aid  the  most  arduous  work  can  be 
done,  such  as  forced  marches  on  short  rations;  others 
asserting  that  in  war  coffee  has  proved  much  more  sus- 
taining. However  this  may  be,  it  is  largely  consumed 
in  South  American  countries,  where  the  price  of  low- 
grade  China  teas  is  too  high  to  admit  of  their  ship- 
ment to  South  America,  and  it  is  therefore  possible 
that  it  has  some  good  qualities  to  recommend  it. — 
Science. 

Health  Reports. — The  following  cases  of  smallpox, 
yellow  fever,  cholera,  and  plague  have  been  reported 
to  the  surgeon-general  of  the  United  States  Marine- 
Hospital  service  during  the  week  ended  September  15, 
1900 : 

Cases.    Deattis. 
Smallpox— United  States. 

Alaska,  Nome August  i8th 3 

Colorado,  Jefferson  Co August  aStli  to  September  ist.. .  11 

Las  .Animas  Co  ..August  28th  to  September  1st .. .  1 

Kansas,  W'jchita September  ist  to  8th z 

Louisiana,  New  Orleans  . . .   September  ist  to  8th 3 

Minnesota,  Minneapolis September  ist  to  8th I 

Winona AuKust  28th  to  September  4tli  ..  3 

Ohio,  Cleveland September  ist  to  8th 3 

Dayton September  ist  to  Bth i 

Texas,  Eagle  Pass  (in  Mexi- 
can portion  of  town) September  7th 1 

Utah,  tjgden August  ist  to  31st 3 

Salt  Lake  City. September  ist  to  8th    i 

West  Virginia,  Wheeling. . .  .September  isC  to  8th i 

Smai.i.I'OX — Foreign. 

Austria,  Prague August  i8th  to  25th 3 

lielgium,  .Antwerp August  i8th  to  25th i 

Brazil.  Kio  de  Janeiro July  13th  to  30th 38  10 

England,   Liverpool August  18th  to  2sth 6 

London August  18th  to  7Sth i 

India,  liombay August  ist  to  14th 6 

Calcutta  August  4th  to  nth 7 

Karachi August  5th  to  I2th 1  1 

Mexico,  City  of  Mexico  ,... August  26th  to  September  2d  ...      4  5 

Russia,  Moscow August  nth  to  i8tJi  6 

Odessa August  i8th  to  25th i 

St.  t*ctersburg August  1  ith  to  25th 96  11 

Warsaw August  nth  to  i8th 10 

Switzerland,  Zurich August  11th  to  i8th i 

Vli.low  Fkvek. 

Brazil,  Rio  de  Janeiro July  Mth  to  20th 10 

Colombia,  Harranquilla.    ....August  19th  to  26th i 

Panama August  27th  to  September  ist. . .       3  i 

Cuba,  Cientuegos September  8tli i 

Havana August  2d  to  September  ist 215  57 

Cholera. 
India,  Bombay August  1st  to  14th 


Calcutta August  4th  to  nth 

Plague. 

India,  Bombay August  ist  to  14th 

Calcutta August  4th  to  t ith 

Philippines,  ('cbu July  14th  to  21st 1 

Manila July  14th  to  21st 4 

Turkey,  Constantinople Augu.st  27th i  * 

♦On  steamer  Nigrr  from  coast  of  Asia  Minor. 


693 

35 


los 


Medical  Record 

A    IVeekly  Journal  of  Medicine  and  Surgery 


Vol.  58,  No.  13. 
Whole  No.  1560. 


New  York,   September  29,    1900. 


$5.00  Per  Annum. 
Single  Copies,  loc. 


©riginaT  5ivttctcs. 

SOME  PERSONAL  OBSERVATIONS  ON  THE 
EFFECTS  OF  INTRAPLEURAL  INfECTIONS 
OF  NITROGEN  GAS    IN    TUBERCULOSIS.' 

hy  henry  p.  loom  is,  m.d., 

NEW    YORK. 

In  such  a  disease  as  tuberculosis  we  herald  with  avid- 
ity anything  which  seems  to  abate  one  jot  of  its  viru- 
lence, or  wliich  seems  to  assist,  in  any  way,  the  proc- 
esses of  nature  toward  restoration  to  health. 

In  looking  back  over  professional  work  it  is  un- 
doubtedly the  e.\perience  of  many  that  certain  cases 
stand  out  in  the  memory  with  prominence  and  dis- 
tinctness, especially  those  that  have  an  unusual  cul- 
mination. Such  a  case,  occurring  several  years  ago  in 
my  practice,  made  a  deep  impression  upon  me.  It  was 
that  of  a  man  with  advanced  tuberculosis  of  one  lung, 
who,  losing  flesh  rapidly,  had  apparently  but  a  few 
months  to  live.  The  patient  was  confined  to  his  room 
with  all  the  constitutional  symptoms  of  advanced  tuber- 
culosis. Suddenly  the  pleural  cavity  on  the  affected 
side  became  filled  with  serous  efTusion.  I  was  sur- 
prised to  notice  at  once  a  marked  change  in  the  pa- 
tient's condition.  All  the  constitutional  symptoms 
improved  and  he  began  to  gain  in  flesh,  and  at  the 
end  of  two  months  was  able  to  return  and  take  charge 
of  an  active  business.  He  remained  apparently  well, 
until,  at  the  end  of  four  months,  as  the  Huid  seemed 
so  thoroughly  to  fill  his  pleural  cavity,  I  decided  to 
withdraw  it.  After  tapping  he  became  worse  at  once, 
and  finally  died.  The  inference  is  that,  had  I  left  the 
Huid  alone,  the  man  would  have  continued  in  his  im- 
proved condition,  and  I  have  no  doubt  that  many 
observers  can  recall  cases  in  which  ordinary  apical  tu- 
berculosis suddenly  starts  to  improve,  and  the  patient, 
from  being  in  a  desperate  condition,  becomes  compar- 
atively well,  this  change  following  a  filling  of  the 
chest  cavity  of  the  affected  side  with  the  effusion,  the 
result  of  tuberculous  pleurisy. 

It  has  been  estimated  that  three-fourths  of  the  cases 
of  primary  pleurisy  are  tuberculous,  these  statistics 
being  based  upon  the  future  histories  of  cases  of  pleu- 
risy with  effusion;  and  it  has  been  found  that  months 
or  years  afterward  pulmonary  tuberculosis  develops  on 
the  side  where  the  pleurisy  had  been.  May  not  the 
explanation  at  least  of  some  of  these  pleurisies  be 
that  they  have  developed  secondarily  to  a  slight  pul- 
monary lesion  of  the  lung,  which  is  quickly  rendered 
quiescent  and  possibly  cured  by  the  pressure  of  the 
effusion,  and  later  this  pulmonary  lesion  lights  up, 
not  as  secondary  to  the  pleurisy  but  really  as  the  pri- 
mary condition  preceding  the  effusion?  Clinical  ex- 
perience has  proved  that  the  results  upon  pulmonary 
tuberculosis  when  empyema  develops  upon  the  affected 
side  are  much  more  favorable  than  when  there  is  a 
serous  effusion.  In  one  hundred  and  sixty-four  cases 
of  empyema  operated  upon  by  Koenig,  Cabot,  and 
Runeberg,  one  hundred  and  forty-four  resulted  in  re- 

'  Read  before  the  American  Climatological  Association,  Wash- 
ington, D.  C,  May  2,  1900. 


covery.  This  shows  what  a  favorable  termination 
empyema  may  have.  Considering  that  it  is  proven  to 
be  secondary  to  tuberculosis  in  eighty-three  per  cent. 
of  all  cases,  it  certainly  speaks  favorably  for  its  cura- 
tive effect  upon  the  lungs.  The  explanation  of  this 
fact  is  no  doubt  that  in  an  empyema  the  compres- 
sion of  the  lung  is  maintained  for  a  much  longer 
time  and  is  even  more  or  less  permanent,  on  ac- 
count of  thickening  and  the  adhesion  which  prevents 
the  expansion  of  the  lung.  The  curative  effect  upon 
tuberculosis  by  this  compression  impresses  upon  us 
the  fact  that  tapping  and  drainage  should  be  resorted 
to  only  after  careful  consideration,  and  only  when 
special  indications  arise,  for  statistics  collected  by 
Czernicki  and  Boumber  have  proven  conclusively  that 
quiescent  tuberculosis  of  a  lung  compressed  by  empy- 
ema may  be  aroused  to  activity  by  such  expansion  as 
follows  every  thoracotomy  or  aspiration. 

Again,  it  is  a  well-known  clinical  fact  that  pneu- 
mothorax developing  in  the  course  of  pulmonary 
tuberculosis  produces  salutary  changes  in  the  tubercu- 
lous process  which  not  only  arrest  the  course  of  the 
disease,  but  ameliorate  the  general  symptoms  and 
sometimes  produce  a  cure.  Osier  and  Pepper  both 
call  attention  to  this  fact,  and  I  think  all  of  us  have 
been  surprised  at  times  at  the  unexpected  improvement 
in  cases  of  phthisis  following  upon  the  development  of 
a  perforation  and  the  filling  of  the  pleural  cavity  with 
air.  Dr.  \V.  F.  Hamilton,  of  Montreal,  reports  six  cases 
of  pneumothorax  occurring  during  the  course  of  pulmo- 
nary tuberculosis.  All  these  patients  were  failing  grad- 
ually before  the  perforation.  After  it  occurred  two 
died  in  a  short  time,  one  lived  for  seven  months,  and 
the  other  three  recovered. 

In  those  cases  of  pulmonary  tuberculosis  reported  as 
ending  in  complete  recovery,  the  perforation  becomes 
healed  and  the  effusion  is  absorbed  as  well  as  the 
contained  air  or  gas,  and  the  lung  again  performs  its 
function,  depending,  however,  somewhat  upon  the 
degree  of  infiltration  of  the  tissues  present.  What- 
ever may  be  the  explanation  of  the  phenomenon,  the 
clinical  fact  remains  that  compression  of  the  lungs — 
as  occurs  in  the  three  classes  of  cases  which  I  have 
just  mentioned — has  a  beneficial  effect  on  pulmonary 
tuberculosis.  As  is  well  known,  the  most  brilliant 
successes  in  the  treatment  of  tuberculosis  have  been 
in  the  cure  of  tuberculosis  of  the  joints.  The  treat- 
ment which  gives  this  result  is  simply  immobilization 
and  the  enforced  physiological  rest  to  the  joint.  May 
this  not  be  the  explanation  of  the  fact  that  in  those 
cases  of  pleurisy  with  effusion,  empyema,  or  pyo- 
pneumothorax, the  compression  of  the  lung  brings 
about  a  condition  somewhat  similar  to  that  which  is 
obtained  by  the  surgical  treatment  of  the  joints? 

The  enforced  rest  of  the  lung  as  a  respiratory  ap- 
paratus aids  in  the  encapsulation  and  favors  the  cica- 
trization of  the  tuberculous  foci.  It  does  more:  it 
enforces  drainage  of  secondary  deposits  through  the 
bronchi,  aids  the  healing  of  cavities  by  approximation 
of  their  walls  so  that  the  condition  is  brought  about 
which  is  sought  for  every  day  by  the  surgeon  in  the 
healing  of  abscesses — the  emptying  of  the  cavity  and 
the  drawing  together  of  its  walls.  Possibly  the  most 
important  element  in  favoring  the   elimination   and 


482 


MEDICAL   RECORD. 


[September  29,  igoo 


final  cure  of  the  tuberculous  areas  in  those  lungs  ren- 
dered quiescent  by  compression  is  a  gradually  dimin- 
ished lymphatic  circulation.  This  lessens  at  once  the 
danger  of  the  most  common  complication  of  phthisis, 
namely,  the  dissemination  of  the  tuberculous  products 
along  the  lympliatic  vessels. 

The  quiescent  condition  of  the  lungs  also  stops 
almost  completely  the  transmission  of  infection  into 
uninfected  bronchi,  and  yet  all  the  time  the  circulation 
is  not  interfered  with  to  any  extent,  and  fibrosis  is 
favored — an  ideal  condition  for  the  healing  of  pul- 
monary tissue,  it  seems  to  me.  Dr.  Lemke,  of  Chi- 
cago, cites  an  interesting  case  in  this  connection.  It 
was  a  case  of  miliary  tuberculosis  involving  the  whole 
lung  with  the  exception  of  one  lobe,  which  escaped 
the  infection  entirely,  and  this  lobe  was  compressed 
by  a  pleuritic  inllammation. 

Nature,  when  she  heals  tuberculosis  by  this  princi- 
ple of  immobilization  and  enforced  rest,  as  is  seen  in 
cases  of  empyema,  causes  a  contraction  of  the  chest 
wall  in  proportion  to  the  amount  of  tissue  involved. 
Moreover,  successful  operations  for  empyema  are  de- 
pendent on  thorough  resection  of  the  ribs  so  as  to 
favor  complete  collapse  of  the  lung  and  obliteration 
of  the  empyeinic  cavities.  Post-mortem  examinations 
which  have  been  made  when  the  lung  from  any  cause 


has  been  compressed  for  a  long  time  show  that  a  cer- 
tain degree  of  fibrosis  has  developed.  Kokitansky 
has  proven  this  by  a  number  of  pathological  investi- 
gations. 

If  clinical  experience  proves,  as  it  seems  to  me  to 
do,  that  compression  of  the  lung  favors  the  healing  of 
a  tuberculous  process,  what  means  have  we  to  bring 
about  this  artificially?  It  has  been  proposed  to 
apply  a  plaster  jacket  to  the  whole  of  the  affected  side 
so  as  to  obtain  immobilization  of  the  thorax.  Mige- 
lion,  in  La  Alcdccine  JModcnie,  reports  thirty  cases  of 
phthisis  which  he  treated  in  this  way.  He  states  that 
the  jacket  was  worn  in  all  cases  excepting  two,  with- 
out discomfort.  He  reports  favorable  results.  Again, 
upon  the  same  principle,  others,  such  as  Dr.  Stewart 
Tiday  and  Dr.  Dennison,  recommend  strapping  the 
chest.  It  hardly  seems  to  be  probable  that  much 
compression  can  be  brought  about  by  this  means. 
Others  have  proposed  resecting  a  portion  of  bone  over 
a  cavity  or  extensive  pulmonary  lesion,  and  so  causing 
a  falling  in  of  the  chest  at  that  point,  producing  a 
localized  compression.  Turban'  reports  the  case  of  a 
young  man  twenty-one  years  of  age  with  extensive  in- 
volvement of  the  left  lung,  this  being  almost  entirely 
destroyed.  He  did  an  extensive  resection  of  the 
fourth,  fifth,  sixth,  and  seventh  ribs  without  entering 
the  pleural  cavity.  The  chest  contracted  gradually. 
He  did  a  second  operation  and  removed  more  of  the 
sixth  and  seventh  ribs  and  also  portions  of  the  eighth 
and  ninth  ribs.  The  symptoms  ameliorated  and  tiie 
patient  recovered  (.'). 

All  these  methods  seem  to  me  to  be  crude  and  in- 
effectual. After  my  experience  with  the  case  referred 
'  Berliner  klinische  Wochenschrifl,  May  22,  1899. 


to  at  the  beginning  of  this  article,  which  showed  such 
improvement  on  the  development  of  pleurisy,  I  carried 
on  a  series  of  experiments  for  a  number  of  months,  en- 
deavoring to  fill  the  chest  cavity  with  some  fluid  which 
would  remain  and  cause  collapse  of  the  lungs.  In 
experimentation  on  animals  I  was  unable  to  find  any 
liquid  that  was  safe  to  use  and  which  would  remain 
for  any  length  of  time  in  the  chest  cavity  without 
being  absorbed  or  causing  suppuration.  I  found  th?.t 
cacao  butter  was  the  most  effective,  as  it  would  re- 
main in  the  pleural  cavity  of  a  dog  and  cause  com- 
pression, but  I  never  felt  warranted  in  injecting  it  into 
a  patient.  All  other  substances  which  I  used  were 
ineffectual. 

In  the  spring  of  1898  Dr.  J.  K  Murphy,  of  Chicago, 
read  a  paper  before  tlie  American  Aledical  Associa- 
tion, in  Denver,  on  "The  Surgery  of  the  Lungs,  '  in 
which  he  reported  a  number  of  cases  of  phthisis  which 
had  shown  marked  improvement  from  injections  of 
nitrogen  gas  into  the  pleural  cavity  He  found  that  the 
pleural  cavity  could  be  filled  with  nitrogen  gas,  and 
that  this  gas  would  remain  for  a  number  of  weeks  or 
months  without  being  absorbed  In  cases  of  pneu- 
mothorax the  composition  of  the  air  contained  in  the 
pleural  ca\ity,  as  subjected  to  analysis  by  Dory,  Bou- 
veret,  Le  Conte,  Ewald,  and  others,  seems  to  differ 
little  in  composition  from  the  outside  atmosphere.  If, 
however,  the  pneumothorax  becomes  closed,  the  oxy- 
gen steadily  diminishes  and  finally  disappears,  the 
carbon  dioxide  decreases,  and  the  last  element  to  dis- 
appear is  the  nitrogen.  This  apparently  proves  theo- 
retically the  claim  of  Dr.  Murphy.  It  has  been  said 
that  Prof.  Carlo  Forlanini  has  used  nitrogen-gas  in- 
jections into  the  pleural  cavity  for  pulmonary  tubercu- 
losis for  the  past  ten  j^ears,  but  I  am  unable  to  ascer- 
tain that  he  more  than  suggested  its  use  before  the 
International  Medical  Congress  in  Rome,  in  1894, 
and  that  he  had  no  practical  experience  in  its  use. 

After  reading  Dr.  Murphy's  article  I  decided  to  give 
this  treatment  a  thorough  test,  and  I  have  made  these 
injections  during  the  past  two  years  in  eighteen  se- 
lected cases;  and  it  is  to  the  report  of  the  results 
which  I  obtained  and  the  uses  and  limitations  of  this 
nietiiod  of  treatment  that  I  will  ask  your  attention  for 
a  few  moments  more.  I  might  say  here  that  the  longer 
I  employed  this  method  the  more  favorably  I  became 
impressed  with  its  efficacy  in  certain  cases.  If  one 
intends  to  use  this  treatment  there  are  two  things 
which  it  is  advisable  to  do-  First,  to  obtain  the  spe- 
cial apparatus  as  recommended  by  Dr  Murphy  for  in- 
jecting the  gas  (see  cut);  second,  to  see  that  the  ni 
trogen  gas  used  is  pure.  Most  of  the  nitrogen  gas  on 
the  market  is  nothing  but  compressed  air. 

Operation. — The  gas  is  best  injected  with  the  pa- 
tient sitting  in  bed,  although  I  have  performed  the 
injection  with  the  patient  sitting  in  a  chair  At  the 
point  where  the  needle  is  to  be  inserted  the  chest  is 
sterilized  by  the  ordinary  method  Tlie  point  of  the 
insertion  of  tiie  needle  varies  somewhat  in  eacii  indi- 
vidual. Personally  I  have  obtained  the  best  result  by 
inserting  the  needle  behind  the  posterior  axillary  line 
in  about  tiie  eighth  interspace,  although  Dr  Murphy 
generally  makes  the  insertion  in  the  fifth  interspace 
in  the  anterior  axillary  line.  If  it  be  a  middle  or 
lower  lobed  tuberculosis  the  injection  should  be  made 
over  liie  upper  lobe,  preferably  in  tiie  third  interspace 
just  outside  the  mammary  line.  Chloride  of  ethyl  may 
be  used  as  a  local  anesthetic.  'i"he  trocar  attached 
to  the  rubber  tube  connected  with  the  gas  retort  is 
easily  inserted.  It  gives  hardly  more  pain  than  an 
ordinary  hypodermic  injection.  The  stylet  in  the 
trocar  should  be  withdrawn  when  the  rib  is  reached. 
The  gas  should  now  be  turned  on.  The  trocar  should 
then  be  pushed  in  close  to  the  margin  of  the  rib. 
'  British  Medical  Journal,  October  22.  i8g8 


September  29.  1900] 


MEDICAL    RECORD. 


483 


When  the  parietal  pleura  is  punctured  the  trocar  ad- 
vances rapidly  and  the  gas  is  seen  to  flow  by  the 
dropping  of  the  upper  portion  of  the  gas  retort,  first 
slowly  and  then  more  rapidly.  If  the  gas  does  not 
How  readily  at  first  the  trocar  is  moved  back  and  forth, 
and  on  the  least  indication  of  the  gas  flowing  the 
trocar  should  be  held  still.  If  adhesions  arc  present 
the  gas  will  not  How;  the  trocar  should  then  be  re- 
moved and  inserted  in  the  same  manner  in  another 
place.  When  the  gas  is  running  freely  into  the  pleural 
cavity  it  is  found  that  from  one  to  five  cubic  inches 
will  pass  in  with  each  inspiration.  The  quantity  of 
gas  to  be  injected  will  vary  considerably,  and  will 
range  from  fifty  to  two  hundred  cubic  inches.  The 
amount  to  be  injected  will  vary  with  each  case  accord- 
ing to  the  dyspmta,  distress,  irregularity  of  the  heart, 
and  displacement  of  the  mediastinal  contents.  My 
experience  has  been  that  people  vary  a  good  deal  in 
the  way  in  which  they  take  the  injection.  I  have 
never  seen  any  bad  results  whatever  follow  the  injec- 
tion. If  the  patient's  discomfort  should  suddenly  be- 
come very  great,  the  current  of  gas  can  at  once  be 
reversed  by  raising  the  cylinder  and  withdrawing  part 
or  all  of  the  gas  from  the  chest.  Having  injected  as 
much  gas  as  possible,  the  trocar  should  be  withdrawn 
and  the  puncture  covered  with  cotton  wet  with  collo- 
dion, and  a  firm  compress  placed  over  the  puncture 
and  a  broad  band  of  adhesive  plaster  over  the  com- 
press. 

If  one  hundred  or  more  cubic  inches  of  the  gas  have 
been  injected,  the  respiratory  sounds  upon  the  injected 
side  will  be  completely  suppressed,  the  heart  will  be 
displaced,  and  if  the  injection  is  on  the  left  side  the 
apex  will  be  carried  as  far  as  the  median  line.  It  is 
astonishing  how  few  unpleasant  effects  follow  these 
injections.  I  have  injected  a  number  of  times  two 
hundred  cubic  inches  of  nitrogen  gas,  completely  com- 
pressing the  lung  and  markedly  displacing  the  heart, 
and  had  the  patient  in  a  few  minutes  put  on  his  coat 
and  walk  about  without  any  apparent  discomfort. 
The  respirations  are  always  increased  after  the  injec- 
tions. The  pulse  rate  is  generally  lowered,  and  the 
patients  complain  often  of  a  "  tightness "  about  the 
chest.  One  of  the  earlier  cases  I  injected  presented 
peculiar  symptoms  from  the  gas  leaking  through  the 
trocar  puncture  and  tilling  the  subcutaneous  tissue  of 
the  chest.  This  subcutaneous  emphysema  persisted 
for  a  number  of  days,  and  the  patient  showed  constitu- 
tional effects  of  the  gas  by  an  excited  and  talkative 
condition  which  lasted  for  about  twelve  hours  after 
the  injection.  That  the  gas  fills  the  chest  cavity  can 
be  proven  not  only  from  a  physical  examination  of  the 
lungs,  but  also  by  the  placing  of  the  heart,  and,  as  I 
have  done  a  number  of  times,  by  examining  the  pa- 
tient with  the  .v-ray  after  the  injection.  The  radio- 
graph shows  conclusively  the  lung  compressed,  the 
diaphragm  immovable,  and  the  heart  displaced.  My 
experience  leads  me  to  believe  that,  to  obtain  any 
marked  and  permanently  beneficial  results,  the  lungs 
should  be  kept  quiescent  for  from  three  to  six  months 
or  even  longer.  The  more  gas  injected  the  longer  it 
will  remain  and  the  less  frequent  need  be  the  injec- 
tion. I  have  seen  the  gas  in  a  number  of  cases  re- 
main three  or  four  months  without  any  apparent 
diminution.  In  other  cases  the  gas  will  have  to  be 
injected  at  the  end  of  from  four  to  six  weeks.  Physi- 
cal examination  can  easily  decide  when  a  second  in- 
jection is  necessary. 

One  of  the  most  constant  elTects  noted  after  injec- 
tions is  that  there  will  be  a  marked  increase  in  the 
expectoration  during  the  first  twenty-four  hours,  some- 
times an  increase  of  tenfold  over  the  ordinary  amount 
expectorated  per  day.  After  the  first  few  days  expec- 
toration diminishes  rapidly.  The  gain  in  weight  of 
the  patients  is  so  constant  and  often  so  excessive  after 


the  injections  that  one  is  astonished  and  almost  at  a 
loss  sufficiently  to  account  for  it.  I  have  not  noticed 
any  sudden  fall  of  temperature  following  the  injec- 
tions as  reported  by  Dr.  Lemke  and  Dr.  Murphy,  of 
Ciiicago.  In  many  cases  the  teniperature  gradually 
declines,  but  it  did  not  seem  to  be  due  to  the  effect  of 
the  injection.  L'pon  the  temperature  the  injections 
seemed  to  have  less  effect  than  upon  any  of  the  other 
constitutional  symptoms.  In  one  ca.se  the  patient  was 
suddenly  seized  with  a  severe  stitch-like  pain  on  the 
afTected  side,  which  as  suddenly  disap|)eared;  this  was 
probably  due  to  tearing  of  adhesions  by  the  gas.  N  ight 
sweats  were  unaffected  except  in  so  far  as  they  grad- 
ually disappeared  as  the  patient's  general  condition 
improved.  In  looking  over  the  carefully  kept  record 
of  my  cases  I  am  impressed  with  this  thing,  viz.,  the 
marked  improvement  in  the  subjective  symptoms  fol- 
Icjwing  the  injections,  such  as  diminution  in  the  cough 
and  expectoration,  rapid  gain  in  weight  and  strength, 
stoppage  of  hemorrhages  and  night  sweats,  and  im- 
proved appetite. 

It  does  not  seem  to  me,  however,  that  the  physical 
changes  noted  in  the  lungs  show  such  an  improvement 
as  the  subjective  symptoms  would  suggest.  When  the 
gas  is  absorbed  and  the  lung  can  once  more  be  exam- 
ined, in  the  majority  of  cases  no  greatly  marked  im- 
provement of  the  lesion  can  be  noted.  I  am  convinced 
that  if  permanent  results  are  to  be  expected  the  chest 
cavity  must  be  kept  filled  with  gas  for  six  months  at 
least.  The  two  cases  that  gave  me  the  most  satisfac- 
tory results  were  watched  carefully  for  four  months, 
and  the  compression  was  kept  up  by  repeated  injec- 
tions. 

Dr.  Murphy,  in  his  original  article,  makes  no  men- 
tion of  the  effects  of  these  injections  upon  pulmonary 
hemorrhages.  I  was  first  tempted  to  use  the  injections 
in  these  cases  on  theoretical  grounds.  The  results 
astonished  me.  Hemorrhages  of  all  varieties,  from 
the  daily  spitting  of  blood-streaked  sputum  to  pro- 
fuse hamoptyses,  were  at  once  controlled,  and  in  al- 
most all  the  cases  there  was  no  return  of  the  bleed- 
ing. These  results  were  especially  astonishing  in  one 
or  two  cases  of  persistent  bleeding  in  which  it  was 
imjiossible  to  control  this  by  any  of  the  usual  means 
such  as  absolute  quiet  and  rest  with  hypodermics  of 
morphine  every  four  hours.  The  hemorrhages  stopped 
at  once  after  the  injections.  It  is  diflicult  to  explain 
why  these  injections  should  have  such  a  pronounced 
effect  on  pulmonary  hemorrhages,  but  that  they  do  ^ 
am  thoroughly  convinced. 

Kind  of  Cases  Benefited. — Theoretically,  cases  of 
apical  unilobar  tuberculosis  in  the  early  stages  with 
lungs  free  from  adhesions  would  be  the  ones  in 
which  we  should  expect  the  best  results  from  this 
treatment.  These  are  the  cases  in  which  the  most 
compression  is  possible.  The  localized  cavity  at  the 
apex  is  another  class  of  cases  which  presents  favorable 
conditions  for  treatment.  One  of  the  most  remarkable 
results  which  I  obtained  was  in  Case  III.,  in  which  a 
slight  pulmonary  lesion  of  the  apex  was  complicated 
by  a  general  tuberculous  pleurisy.  The  separation  of 
tlie  two  pleural  surfaces  at  once  cured  the  pleurisy 
and  relieved  marked  constitutional  symptoms. 

The  more  I  have  used  the  gas  the  more  I  have  been 
tempted  to  use  the  injections  in  advanced  and  appar- 
ently hopeless  cases.  I  find  that  it  relieves  the  patient 
and  stops  many  of  the  distressing  symptoms.  The 
only  objection  to  its  use  that  practical  experience  has 
taught  me  is  that  these  injections  cannot  be  made  in 
many  cases  on  account  of  the  inability  to  force  the 
nitrogen  gas  into  the  pleural  cavity  on  account  of  the 
adhesions.  My  experience  has  been  somewhat  differ- 
ent from  Dr.  Murphy's  in  this  respect.  He  has  been 
able  to  inject  into  the  pleural  cavity  of  almost  all  of 
his  patients.     In  a  number  of  cases  apparently  favor- 


484 


MEDICAL    RECORD. 


[September  29,  1900 


able  for  treatment  I  have  had  to  abandon  the  method 
on  account  of  adhesions.  In  no  way  except  by  prac- 
tical test  can  we  discover  whether  there  are  enough 
adhesions  to  make  the  method  of  treatment  imprac- 
ticable. 

Analysis  of  Cases  Injected.— 

1.  Total  number  of  cases.     Eighteen. 

2.  For  pulmonary  hemorrhages.     Eight  cases. 

3.  Eor  effect  on  lungs.     Ten  cases. 

4.  Effects  on  hemorrhage.     Stopped  at  once. 

5.  Effect  on  lung  condition.  In  the  majority  of 
cases  the  physical  signs  remained  the  same  except 
that  rales  diminished  or  disappeared.  Only  one  case 
showed  a  marked  improvement.  Pleurisy  was  con- 
trolled at  once. 

6.  Number  of  cases  gained  in  weight.     Sixteen. 

7.  Number  of  cases  lost  in  weight.     None. 

8.  Average  gain  in  weight  per  patient.  Seven  and 
one-half  pounds. 

9.  Number  of  injections  given.     Twenty-nine. 

10.  Average  amount  of  gas  injected.      107,'j  c.c. 

11.  Number  of  cases  in  which  improvement  was 
noted.     In : 

(i)  Cough,  thirteen  cases;    three  slightly  and 

temporarily. 
(2)    Expectoration,  eleven  cases. 
(3'!   Fever,  four  cases. 

12.  Number  of  cases  during  the  past  year  in  which 
the  injections  were  tried  and  failed  owing  to  the  in- 
ability to  introduce  the  gas  (adhesions,  etc.),  eight. 

Remarks  on  Treatment. — I  am  convinced  that  in- 
trapleural injections  of  nitrogen  gas  will  have  a 
dermanent  place  in  the  treatment  of  pulmonary 
tuberculosis. 

1.  It  is  a  treatment  that  has  a  future;  I  would  ad- 
vise its  more  extended  use;  only  in  this  way  can  we 
ascertain  the  kinds  of  cases  to  which  it  is  best  ap- 
plied. 

2.  I  have  never  seen  any  bad  results  or  even  un- 
pleasant effects  following  the  injections. 

3.  I  have  seen  no  cases  result  in  absolute  cure  of 
the  disease. 

4.  I  have  certainly  seen  the  apparent  arrest  of  the 
disease  in  two  cases,  and  the  disappearance  of  such 
constitutional  symptoms  as  expectoration,  fever,  and 
cough  in  a  number  more.  Sufficient  time  has  not  yet 
elapsed  to  say  whether  in  even  the  most  favorable 
cases  the  activity  of  the  disease  may  not  return. 

5.  The  local  improvement  is  not  so  apparent  as  the 
constitutional. 

6.  A  marked  gain  in  weight  is  found  in  every  case 
injected.  This  is  so  universal  as  to  be  astonishing, 
especially  as  the  cases  have  had  no  other  treatment 
and  many  of  them  have  been  in  hospital  wards  and 
under  anti-hygienic  surroundings;  yet  the  gain  in 
weight  has  followed  almost  immediately  after  injec- 
tions, and  when  a  patient  had  been  losing  weight  be- 
fore the  injections  he  suddenly  began  to  gain.  It  is 
very  difficult  to  explain  this  effect,  except  by  the 
marked  effect  upon  the  pulmonary  lesion. 

7.  That  this  method  of  treatment  will  stop  pulmo- 
nary hemorrhages  I  am  thoroughly  convinced.  I  have 
never  seen  it  fail  even  in  one  of  the  most  desperate 
cases  upon  which  it  was  tried.  If  these  nitrogen-gas 
injections  have  no  other  place  in  the  treatment  of  pul- 
monary tuberculosis,  it  seems  to  me  that  their  ability 
to  arrest  pulmonary  hemorriiage  gives  them  a  place 
which  no  other  method  we  have  at  the  present  time 
can  occupy. 

Synopsis  of  Cases  Injected  with  Nitrogen  Gas  for 
Pulmonary  Hemorrhage. — 

("ask  I.  -  John  N — — ,  aged  thirty-eight  years. 
Duration  of  disease,  three  years.  Pulmonary  condi- 
tion, consolidation  with  fibroid  changes  at  both  apices 
— moderate  at  left,  and  involving  entire  upper  lobe  on 


right  side.  Number  of  hemorrhages  before  injection, 
continuous  for  eight  days.  Extent  of  hemorrhage, 
very  severe.  Number  of  hemorrhages  after  injection, 
none.  Number  of  injections,  one.  Amount  of  gas  in- 
jected, 193  c.c.  Weight  before  injection, one  hundred 
and  four  pounds.  Weiglit  after  injection,  one  hun- 
dred and  eighteen  pounds  (end  of  four  months).  Ef- 
fect of  injections  on  (i)  cough,  diminished ;  (2)  ex- 
pectoration, decreased;  (3)  fever,  temperature  normal 
after  three  weeks. 

Remarks:  In  1898  the  patient  was  injected  for  his 
general  condition  once.  The  improvement  in  weight, 
etc.,  followed  this  injection.  In  1899  the  injection 
was  given  to  stop  the  most  profuse  hemorrhages  I  have 
ever  seen. 

Case    II. — John     F" ,    aged    thirty-four    years. 

Duration  of  disease,  five  months.  Pulmonary  condi- 
tion, consolidation  involving  the  upper  portion  of  the 
left  lung  with  large  and  small  rales.  Number  of 
hemorrhages  before  injection,  many.  Extent  of  hem- 
orrhage, slight;  sputum  streaked  with  blood  for  a 
number  of  months.  Number  of  hemorrhages  after  in- 
jection, none.  Number  of  injections,  two.  Amount 
of  gas  injected  (approximate),  114  c.c.  and  80  c.c. 
Weight  before  injection,  one  hundred  and  forty-seven 
pounds.  Weight  after  injection,  one  hundred  and 
fifty-seven  pounds  (two  months  after).  Effect  of  in- 
jections on  (i)  cough,  diminished;  (2)  expectoration, 
none;  (3)  fever,  none. 

Remarks :  This  case  shows  the  favorable  effects  of 
the  injections  on  continuous  bleedings,  also  at  the 
same  time  on  the  pulmonary  condition  and  the  pa- 
tient's general  health. 

Case  III. — William  H ,  aged  twenty-four  )'ears. 

Duration  of  disease,  five  months.  Pulmonary  condi- 
tion, very  slight  consolidation  localized  at  the  right 
apex.  Number  of  hemorrhages  before  injection,  two 
severe;  constant  spitting  of  blood-streaked  sputum. 
Extent  of  hemorrhage,  severe.  Number  of  hemor- 
rhages after  injection,  none;  blood-stained  sputum 
stopped  within  six  hours.  Number  of  injections,  one. 
Amount  of  gas  injected  (approximate),  120  c.c. 
Weight  before  injection,  one  hundred  and  fifty-four 
pounds.  Weight  after  injection,  same  (only  seen  two 
weeks).     Effect  of  injections  on  (i)  cough,  decreased; 

(2)  expectoration,  decreased;   (3)  fever,  had  none. 
Remarks:    Stopped  at  once  moderate  bleeding  that 

had  lasted  for  eight  days  and  had  resisted  ordinary 
treatment. 

Case  IV. — Adam    S- ,    aged    thirty-four   years. 

Duration  of  disease,  two  years  ten  months.  Pulmo- 
nary condition,  incipient  involvement  of  right  apex  and 
left  upper  lobe.  Number  of  hemorrhages  before  in- 
jection, repeated  ha;moptyses.  F^xtent  of  hemorrhage, 
slight  but  continuous.  Number  of  hemorrhages  after 
injection,  none.  Number  of  injections,  three.  Amount 
of  gas  injected  (approximate),  80  c.c.  (average). 
Weiglit  before  injection,  one  hundred  and  fifty-four 
pounds.  Weight  after  injection,  one  hundred  and 
fifty-eight  and  one-half  pounds.  Effect  of  injections 
on  (i)  cough,  decreased;    (2)  expectoration,  decreased; 

(3)  fever,  had  none. 

Remarks:  A  number  of  small  injections  were  nec- 
essary to  control  the  bleedings  completely;  when 
stopped  tiiey  remained  so.  The  patient  had  had 
slight  but  continuous  bleedings  for  a  number  of 
months. 

Case  V. — John  L ,  aged  forty-three  years.  Pul- 
monary condition,  consolidation  and  softening  at 
upper  portion  of  left  lung;  beginning  changes  at  right 
apex.  Number  of  hemorrhages  before  injection,  nu- 
merous. Extent  of  hemorrhage,  slight.  Number  of 
hemorrhages  after  injection,  none.  Number  of  injec- 
tions, one.  .Vmount  of  gas  injected  (approximate), 
1 10  c.c.     Weight  before   injection,  one   hundred  and 


September  29,  igoo] 


MEDICAL    RECORD. 


485 


sixty-two  pounds.  Weight  after  injection,  one  hun- 
dred and  seventy-three  pounds.  Effect  of  injections 
on  (i)  cough,  none;  (2)  expectoration,  none;  (3) 
fever,  none. 

Remarks:  The  patient's  general  condition  is  im- 
proved but  not  his  pulmonary.  He  had  laryngeal 
tuberculosis,  which  was  unaffected. 

Case  VI. — Harry  A ,  aged  twenty  years.  Dura- 
tion of  disease,  more  than  a  year.  Pulmonary  contli- 
tion,  consolidation  at  right  apex;  left  upper  and  middle 
lobe  also  affected.  Number  of  hemorrhages  before 
injection,  numerous.  Extent  of  hemorrhage,  severe. 
Number  of  hemorrhages  after  injection,  none.  Num- 
ber of  injections,  one.  Amount  of  gas  injected,  135 
c.c.  Weight  before  injection,  one  hundred  and  thirty- 
eight  pounds.  Weight  after  injection,  one  hundred 
and  thirty-six  pounds.  Effect  of  injections  on  (i) 
cough,  none;  (2  j  expectoration,  none;   (3)  fever,  none. 

Remarks:  The  injections  had  no  effect  on  the  prog- 
ress of  the  disease,  but  stopped  at  once  the  hemor- 
rhages. 

Case  VH. — Mrs.  C.  A ,  aged  thirty-eight  years, 

Duration  of  disease,  about  sixteen  months.  Pulmo- 
nary condition,  consolidation  and  small  cavity  at  left 
apex;  slight  changes  at  right  apex.  Number  of  hem- 
orrhages before  injection,  six.  Extent  of  hemorrhage, 
two  severe.  Number  of  hemorrhages  after  injection, 
none.  Number  of  injections,  one.  Amount  of  gas 
injected  (approximate),  60  c.c.  Weight  before  injec- 
tion, one  hundred  and  eighteen  pounds.  Weight  after 
injection,  one  hundred  and  eighteen  pounds.  Effect 
of  injections  on  (1)  cough,  none;  (2)  expectoration, 
none;   (3)  fever,  had  none. 

Remarks:  Owing  to  adhesions  only  a  small  quan- 
tity of  gas  could  be  injected.  The  gas  remained  in 
the  pleural  cavity  only  seven  days. 

Case  VIII. — Adeline    C ,   aged    twenty    years. 

Duration  of  disease,  six  years  intermittently.  Pul- 
monary condition,  infiltration  of  right  upper  lobe  and 
left  apex.  Number  of  hemorrhages  before  injection, 
numerous.  Extent  of  hemorrhage,  severe.  Number 
of  hemorrhages  after  injection,  one  after  first  injection. 
Number  of  injections,  two.  Amount  of  gas  injected 
(approximate),  120  c.c,  iio  c.c.  Weight  before  in- 
jection, one  hundred  and  thirty-seven  pounds.  Weight 
after  injection,  one  hundred  and  fifty-one  pounds. 
Effect  of  injections  on  (i)  cough,  greatly  decreased; 
(2)  expectoration,  greatly  decreased;  (3)  fever,  nor- 
mal temperature  after  a  time. 

Remarks:  Although  the  injections  were  given  for 
the  hemorrhages,  there  was  a  marked  improvement  in 
the  patient's  general  and  pulmonary  condition. 

Synopsis  of  Cases  Injected  with  Nitrogen  Gas 
for  Effect  on  the  Lungs. — 

Case     I. — .Stella    W ,    aged     nineteen    years. 

Duration  of  disease,  four  weeks.  Pulmonary  condi- 
tion, slight  consolidation  at  left  apex;  fine  crepita- 
tions all  over  left  chest.  Number  of  injections,  one. 
Amount  of  gas  injected,  160  c.c.  Weight  before  injec- 
tion, one  hundred  and  three  pounds.  Weight  after 
injection,  one  hundred  and  fourteen  pounds  (end  of 
eight  weeks).  Effect  of  injections  on  (i)  cough, 
marked  diminution  ;  (2)  expectoration,  decreased  ;  (3) 
fever,  dropped  from  105°  to  101°  in  the  first  twenty- 
four  hours;  (4)  general  condition,  greatly  improved. 
Effects  of  injections  on  pulmonary  condition:  Fine 
crepitations  (pleuritic)  at  once  disappeared;  in  eight 
weeks  the  patient  was  under  observation  consolidation 
remained  the  same. 

Remarks:  This  case  was  at  first  supposed  to  be 
one  of  acute  pulmonary  tuberculosis,  but  the  results 
show  that  the  pulmonary  changes  were  only  in  the 
pleura. 

Case    II. —  Mary    B ,    aged    thirty-three    years. 

Duration   of  the   disease,   nine    months.     Pulmonary 


condition,  consolidation  of  left  lung,  with  rales,  from 
apex  to  middle  of  scapula.  Number  of  injections, 
two.  Amount  of  gas  injected,  58  c.c.  and  70  c.c. 
Length  of  time  gas  remained  in  chest,  two  months 
and  over.  Weight  before  injections,  one  hundred  and 
twenty-eight  pounds.  Weight  after  injections,  one 
hundred  and  forty-one  pounds  (end  of  two  months). 
Effect  of  injections  on  (i)  cough,  none;  (2)  expecto- 
ration, none;  (3)  fever,  after  ten  days  reached  normal. 
Effects  of  injections  on  pulmonary  condition  :  consoli- 
dation not  affected;  rales  disappeared. 

Remarks:  There  was  a  marked  gain  in  weight. 

Case  III.— Owen    L ,    aged    thirty-four    years. 

Duration  of  disease,  not  known.  Pulmonary  condi- 
tion, evidences  of  consolidation  over  middle  of  left 
lung,  witii  crepitations  and  rales  below.  Number  of 
injections,  one.  -Amount  of  gas  injected,  87  c.c. 
Length  of  time  gas  remained  in  chest,  while  under 
observation.  Weight  before  injections,  one  hundred 
and  forty-six  pounds.  Weight  after  injections,  one 
hundred  and  forty-three  pounds.  Effect  of  injections 
on  (i)  cough,  slight  improvement;  (2)  expectoration, 
none;  (3)  fever,  marked  diminution  ;  (4)  general  con- 
dition, improved.  Effects  of  injections  on  pulmonary 
conditions,  none. 

Remarks:  This  case  was  supposed  at  first  to  be 
lobar  pneumonia;  later  it  w-as  diagnosed  as  localized 
tuberculosis  with  accompanying  tuberculous  pleurisy. 

Case  IV. — Joseph    F ,  aged   thirty-four  years, 

Duration  of  disease,  twenty  months.  Pulmonary  con- 
dition, chronic  tuberculous  changes  at  both  apices,  left 
extensively  involved  ;  no  softening.  Number  of  injec- 
tions, two.  Amount  of  gas  injected,  130  c.c.  and  130 
c.c.  Length  of  time  gas  remained  in  chest,  two 
months.  \\'eight  before  injections,  one  hundred  and 
fifty-seven  pounds.  Weight  after  injections,  one  hun- 
dred and  sixty-five  pounds.  Effect  of  injections  on 
(i)  cough,  greatly  improved;  (2)  expectoration,  first 
increased,  then  diminished;  (3)  fever,  none;  (4)  gen- 
eral condition,  unchanged.  Effects  of  injections  on 
pulmonary  condition,  none. 

Remarks:  Ten  days  after  first  injection  the  patient's 
weight  increased  eight  pounds  and  remained  the  same 
eight  months  afterward. 

Case  V. — Christian  M ,  aged  forty-three  years. 

Duration  of  disease,  one  year.  Pulmonary  condition, 
consolidation  of  upper  lobe  of  right  lung  with  infiltra- 
tion and  some  softening.  Number  of  injections,  one. 
Amount  of  gas  injected,  150  c.c.  Length  of  time  gas 
remained  in  chest,  six  weeks.  Weight  before  injec- 
tion, one  hundred  and  twenty-nine  pounds.  Weight 
after  injection,  one  hundred  and  thirty-five  pounds. 
P^ffect  of  injections  on  (i)  cough,  marked  diminution; 
(2)  expectoration,  disappeared;  (3)  fever,  none;  (4) 
general  condition,  improved.  Effects  of  injections  on 
pulmonary  condition,  none. 

Remarks:  The  patient  attended  to  his  work  with 
the  gas  in  the  pleural  cavity. 

Case  VI. — Eugene  P — — ,  aged  twenty-six  years. 
Duration  of  disease,  one  year.  Pulmonary  condition, 
very  slight  involvement  of  right  upper  lobe;  pleuritic 
thickening  in  lower  lobe  of  left  lung.  Number  of 
injections,  two.  Amount  of  gas  injected,  not  noted. 
Length  of  time  gas  remained  in  chest,  about  six  days 
each  injection.  Weight  after  injections,  gained  one 
and  one-half  pounds.  Effect  of  injections  on  (i) 
cough,  slight  improvement;  (2)  expectoration,  slight 
improvement;  (3)  fever,  had  none.  Effects  of  injec- 
tions on  pulmonary  condition,  none. 

Remarks:  After  the  first  injection  most  of  the  gas 
escaped  into  the  cellular  tissue,  causing  intoxication. 
After  the  second  injection  the  gas  had  to  be  withdrawn 
owing  to  continued  dyspncea. 

Case    VII. — Bertha   W ,  aged    nineteen  years. 

Duration  of  disease,  five  months.     Pulmonary  condi- 


486 


MEDICAL    RECORD. 


[September  29,   1900 


tion,  advanced  involvement  of  upper  portion  of  right 
lung;  cavity.  Number  of  injections,  three.  Amount 
of  gas  injected,  each  time  about  60  c.c.  Length  of 
time  gas  remained  in  chest,  one  montii.  Weight  be- 
fore injections,  ninety-nine  pounds.  Weight  after  in- 
jections, one  hundred  and  live  pounds.  Effect  of  in- 
jections on  (i)  cough,  none;  (2)  expectoration,  none; 
(3)  fever,  none;  (4)  general  condition,  none.  Effects 
of  injections  on  pulmonary  condition,  improved  while 
gas  remained  in  chest. 

Remarks:  Injections  given  to  close  up  cavity  were 
successful  wliile  the  gas  remained,  hut  the  gas  appeared 
to  be  quickly  absorbed. 

Case    VIII.— Mrs.     C.    Z ,    aged    thirty-eight 

years.  Duration  of  disease,  fourteen  months.  Pul- 
monary condition,  cavity  at  left  apex,  surrounded  by 
fibrous  tissue  with  adhesions.  Number  of  injections, 
two.  Amount  of  gas  injected,  not  noted.  Length  of 
time  gas  remained  in  cliest,  six  weeks.  Weight  be- 
fore injection,  one  hundred  and  fifteen  pounds.  Weight 
after  injections,  one  hundred  and  eighteen  pounds. 
Effect  of  injections  on  ( i )  cough,  lessened  for  a  time 
only;  (2)  expectoration,  lessened  for  a  time  only,  (3) 
fever,  diminished  temporarily,  (4)  general  condition, 
slightly  improved.  Effects  of  injections  on  pulmo- 
nary condition,  unable  to  close  cavity  on  account  of 
adhesions. 

Remarks:  Injection  was  made  under  .x--ray,  results 
were  unsatisfactory. 

Case     IX.  —  Leonard    C ,    aged    forty    years. 

Duration  of  disease,  about  two  years.  Pulmonary 
condition,  cavity  with  softening  at  upper  portion  of 
left  lung;  slight  infiltration  at  right  apex.  Number 
of  injections,  two.  Amount  of  gas  injected,  100  c.c. 
and  1 10  c.c.  Weight  before  injections,  one  hundred 
and  thirty-eight  pounds.  Weight  after  injections,  one 
hundred  and  forty-four  pounds.  Effect  of  injections 
on  (i)  cough,  lessened  at  first,  then  increased;  (2) 
expectoration,  lessened  at  first;  (3)  fever,  none;  (4) 
general  condition,  improved.  Effects  of  injections 
on  pulmonary  condition,  unable  to  close  cavity  on  ac- 
count of  dense  adhesions. 

Remarks:  During  first  injection,  some  adhesions 
were  torn  as  evinced  by  sudden  sharp  pain  in  the 
side. 

Case  X. — Miss    H ,    aged    twenty-two    years. 

Duration  of  disease,  two  months.  Pulmonary  condi- 
tion, slight  consolidation  at  right  apex.  Number  of 
injections,  one.  Amount  of  gas  injected,  171  c.c. 
Length  of  time  gas  remained  in  chest,  one  month. 
Weight  before  injections,  one  hundred  and  twenty-two 
pounds.  Weight  after  injections,  one  hundred  and 
thirty-one  poimds.  Effect  of  injections  on  (i)  cough, 
decreased;  (2)  expectoration,  decreased;  (3)  fever, 
had  none;  (4)  general  condition,  improved.  Effects 
of  injections  on  pulmonary  condition,  none. 


The  Vitality  of  Certain  Pathogenic  Micro-organ- 
isms in  the  Juices  of  the  Organs  of  Healthy  Ani- 
mals.—  Andrea  Ciaccio  from  experimentation  con- 
cludes: (i)  that  in  the  extracts  of  organs  kept  at  a 
temperature  of  37°  C.  (98.6^  E.)  micro-organisms  were 
able  to  develop;  (2)  that  the  juices  of  the  brain,  liver, 
heart,  spleen,  lungs,  and  muscles  of  guinea-pigs  and 
sheep  possess  antibacterial  properties,  quite  inde- 
pendently of  temperature;  (3)  muscular  tissue  in  es- 
pecial possesses  bactericidal  properties.  The  value 
of  the  administration  of  raw  meat  in  certain  affections 
is  well  known,  as,  for  instance,  in  tuberculosis,  (4) 
the  addition  of  certain  other  substances  to  the  ex- 
tracted juices  appears  to  influence  their  properties, 
for  instance,  dog's  serum  and  sodium  chloride  increase 
their  bactericidal  powers.  —  A'iissej:^/iij  Inkniazionale 
delhi  Medicirta  Moderna,  August  15,  1900. 


ELECTRICITY  IN  GVN^:COL0GV  AND  THE 
PRESENT  RELUCTANCE  OE  GYN.-I-XOLO- 
GISTS    TO    USE    ELECTRICITY.' 

By   ROBERT   NEWMAN,    M.D, 

NKW  YORK, 

CONSULTING  SURGEON  TO  HACKENSACK  AND  BAVONNE  HOSPITALS,  N  J,, 
M'DONOL'GH  MEMORIAL  HOsIMTAL,  GERMAN  DISHBNSARV,  WEST  SIDE, 
N.  v.;  FOKMEKLV  I'ROSECTOR,  LONG  ISLAND  COLLEGE  HOSPITAL  ;  COR* 
RESfONDINC   ME.MDER    OP    THE    GVN.ECOLOGICAL    SOCIETV,    BOSTON.  ETC. 

In  looking  over  the  bibliography  of  the  subject  an 
abundant  evidence  of  tiie  successful  therai^eutic  use 
of  electricity  in  almost  every  disease  peculiar  to 
woman  is  found  in  text-books,  addresses,  and  papers 
by  the  best-known  gynaecologists.  The  list  includes 
particularly : 

Uterus — Abrksion  of  the  os  uteri,  stenosis  of  the 
OS  and  uterine  canal,  endometritis,  cervical  catarrh, 
amenorrhcea,  dysmenorrhoea,  menorrhagia,  metror- 
rhagia, flexions,  subinvolution,  hyperplasia,  fibroid 
neoplasm,  prolapsus,  procidentia,  polypi,  and  carci- 
noma. Tumors — Fibroid,  ovarian.  Appendages — 
oophoritis,  cysts,  salpingitis,  pyosalpinx,  and  ha:ma- 
tosalpinx.  Pelvis — adhesions,  cellulitis,  pelvic  hema- 
toma, h;tniatocele.  Urethra  —  stricture.  Bladder— 
neuroses,  papilloma,  benign  and  malignant  tumors. 
Rectum — stricture.  Vulva  —  growth,  cysts.  Extra- 
uterine pregnancy,  etc. 

The  successful  treatment  by  gynecologists  must  be 
a  fact,  if  they  tell  it  themselves  and  have  it  recorded 
in  the  literature  on  the  subject.  Naturally  the  ques- 
tion arises,  why  the  same  gentlemen  in  a  body  by  a 
vote  denounce  electro-therapeutics  as  a  failure.  An 
investigation  for  facts  and  truth  may  not  be  pleasant, 
and  it  is  not  my  desire  to  elicit  unpleasantness  hence 
let  us  cover  with  professional  love  all  differences. 
Only  one  inquiry  of  the  writer  may  be  noted  here, 
which  gives  one  of  the  many  reasons.  One  of  the 
staff  of  a  special  hospital  was  asked  why  his  col- 
leagues had  denounced  the  use  of  electricity  in  gyne- 
cology, while  there  were  recorded  so  many  successes. 
He  answered:  "We  have  an  excellent  electro-thera- 
peutist on  the  hospital  staff,  and  cases  which  were  re- 
ferred to  him  he  often  did  not  cure.  On  the  contrary, 
we  often  found  adhesions  when  laparatomy  was  per- 
formed after  an  electrical  treatment." 

The  electro-therapeutist  in  question  then  was  in- 
terviewed and  said :  "  There  is  some  truth  in  the 
former  statement.  I  have  cured  cases  and  have  had 
success  with  electro-therapeutics,  but  some  cases  are 
either  tedious  or  incurable.  Next  I  had  no  choice  in 
the  selection  of  the  patients  suitable  for  a  successful 
treatment.  Some  patients  not  wanted  by  the  oper- 
ating staff  nor  by  myself  were  referred  to  me,  and 
nolens  volens  I  had  to  treat  them,  even  though  I  knew 
they  were  not  suitable  for  a  successful  treatment  by 
electricity." 

The  very  same  thing  hapjjens  to  other  electro-thera- 
peutists on  the  staff'  of  other  hospitals.  Tliey  have  to 
treat  unsuitable  cases  against  their  wishes,  and  no 
protest  changes  the  matter,  but  even  then  often  they 
succeed.  Concerning  adhesions,  our  ex-president.  Dr. 
Lapthorn  Smitli,  remarked  once  in  a  discussion:  "I 
think  it  is  unjust  and  unfair  for  my  friend  Dr.  Joseph 
Price  and  others  to  lay  all  the  blame  of  adhesions  on 
electricity,  when  they  know  as  well  as  I  do  that  these 
complications  are  met  with  in  cases  which  have  never 
been  touched  with  electricity,  while,  on  the  contrary, 
they  know  that  c.ises  which  have  been  treated  for  a 
year  with  electricity  were  found  at  the  operation  to  be 
absolutely  free  from  adiiesion." 

Injudicious  treatment  and  particularly  too  strong  a 
current  may  cause  adhesions,  but  the  therapeutic  agent 

'  I\e.ici  .It  the  meeting  of  the  American  Electro-Therapeutic 
.Vssociation.  .September  26,  1900,  held  at  the  Academy  of  Medi- 
cine. New  Nork. 


September  29,  1900J 


MEDICAL    RECORD. 


487 


/ 


cannot  be  held  responsible  for  the  mistakes  of  the 
operator.  Mistakes  of  doctors  and  druggists  may  have 
killed  people,  but  it  never  has  been  known  that  opium 
or  any  other  drug  had  been  condemned  on  that  account. 

The  writer  has  treated  successfully  with  electricity 
most  of  the  diseases  above  enumerated.  There  was 
a  series  of  cases  of  prolapsus  uteri,  in  some  of  which 
the  uterus  was  outside  and  entirely  irreducible.  The 
high-tension  current  cured  in  every  case,  and  it  could 
be  seen  how  the  electricity  caused  contraction  and 
diminished  the  size  of  the  organ,  so  that  it  was  re- 
duced and  pulled  back  to  its  normal  place  without  the 
use  even  of  the  hand,  and  solely  by  the  action  of  the 
electric  current.  But  let  us  adhere  entirely  to  our 
text,  the  use  of  the  continuous  current. 

In  many  cases  electrolysis  has  been  used,  which 
means  that  the  galvanic  current  is  applied  in  such  a 
manner  that  by  chemical  decomposition  compound 
bodies  or  salts  are  reduced  to  their  component  parts. 
Thereby  the  current  reabsorbs  pathological  formations 
not  alone  polar  but  interpolar,  and  the  fact  explains 
also  how  we  cause  the  reabsorption  of  fibroids. 

Fibroid  tumors  of  the  uterus  may  be  peritoneal, 
interstitial,  or  submucous.  Nobody  would  advocate 
the  use  of  electricity  in  peritoneal  fibroids,  and  it 
seems  that  many  operations  for  them  are  unnecessary, 
as  we  often  find  on  autopsies  large  peritoneal  fibroids, 
which  in  life  never  had  troubled  the  bearer.  With 
the  other  two  varieties  the  writer  has  had  invariable 
successes. 

Formerly  needles  were  used,  partly  as  galvano- 
puncture  under  strong  currents.  Dr.  J.  N.  Freeman, 
of  Brooklyn,  read  a  paper  on  January  20,  1885,  before 
the  Medical  Society  of  Kings  County,  in  which  he 
reported  three  successful  cases  of  fibroid  tumors  treated 
by  galvano-puncture.  Freeman  operated,  with  the 
patient  under  an  anaesthetic,  with  needles  and  with 
strong  currents.  Freeman's  memory  as  a  pioneer  in 
this  line  should  go  down  to  posterity.  During  his 
life  the  Brooklyn  profession  could  not  comprehend 
his  arduous  work  and  success.  Almost  at  the  same 
time  our  lamented  honorary  member,  G.  Apostoli,  in 
establishing  his  method  of  treatment  by  electricity, 
labored  assiduously  in  Europe  and  America,  was  suc- 
cessful, and  made  many  friends,  but  also  met  bitter 
opposition  and  was  more  abused  than  appreciated. 

Meniere  in  Paris  with  six  cases,  and  J.  T.  Everett, 
Clyde,  Pa.,'  with  seventeen  cases,  came  next,  and  were 
followed  by  Franklin  Martin,'  VV.  E.  Stevenson,^  E. 
Cutter,'  Semeleder,'  A.  H.  Buckmaster,  W.  F.  Hutch- 
inson, A.  Lapthorn  Smith,'  J.  H.  Kellogg.'  Massey, 
Schavoir,  and  many  others  too  numerous  to  mention. 
During  a  discussion  on  "Fibroids,"  at  the  last  meet- 
ing of  the  British  Medical  Association,  our  honorary 
fellow.  Dr.  Skene  Keith,  said  he  believed  in  and 
practised  Apostoli's  method." 

The  art  in  applying  electrolysis  successfully  in 
gj'naicology  consists  in;  (i  )  using  the  correct  strength 
of  the  galvanic  current;  (2)  applying  the  poles  at  the 
right  place;  (3)  selecting  the  size  and  material  of 
the  electrodes;  (4)  timing  the  duration  and  intervals 
of  the  se'ances. 

Electrolysis  applied  with  a  mild  current  will  cause 
absorption  only,  while  a  strong  current  will  burn,  cau- 
terize, and  even  destroy  tissues.  Therefore  the  opera- 
tor must  know  what  effect  he  wishes  to  produce,  and 
then  graduate  the  strength  of  the  current  accordingly. 
Very  strong  currents  have  been  used,  but  the  writer 

'  New  York  Medical  Journal,  .April  iS.  18S5. 

•  Journal  of  the  .American  Medical  .Association,  April  23,  l33-. 

'British  Medical  Journal,  October  I,  1S87. 

■"  Transactions  of  the  Ninth  International  Medical  Congress. 

'  Wien.  klin.  Wochenschrift.  October,   18S8. 

'  Journal  of  Electro- Therapeutics,  January-,   1S9O. 

'  Times  and  Register,  Februar)-  7,  1891. 

'  Medical  Record,  August  25,  1900. 


:urrents  a 
is  under-  l—k 
le  patient  /   / 


has  always   advocated   weak   currents,  and  has   been 
successful   in  his  cases.     This  is  a  practical  point  in 
the    argument,  but    his    theoretical    reasons    are    that        , 
strong  currents  may  cause  serious  intlammations  and       / 
destruction  of  healthy  tissues  while  the  current  tra- 
verses living  tissues  in  all  directions,  interpolar,  but 
mostly  polar.     It  has  been  shown   in   a  series  of  ex- 
periments that  currents  of  great  electro-motive  force 
became    uncontrollable  when   traversing   animal    tis- 
sues.    The  writer  has  always  succeeded  better  with 
mild  currents,  and  prefers  to  use  the  mild  currents  a 
longer  time  if  necessary.     By  mild  currents 
stood  a  strength  which  can  be  tolerated  by  the 
without  being  painful.     A  fixed  amount  of  amperage 
cannot  be  stated.     Applying  the  correct  pole  in   the 
right  place  means  particularly  using  the  positive  pole  " 
for  stopping  hemorrhages,  while  the  negative  pole  will  7 
absorb  the  fibroid  tissues.  '' 

In  selecting  the  material  and  size  of  electrode  the 
writer  does  not  use  needles,  but  generally  makes  his 
way  into  the  uterus  with  a  blunt  platinum  sound,  and 
always  pushes  this  by  degrees  into  the  tumor,  some- 
times to  the  depth  of  eight  and  ten  inches.  For  the 
abdominal  electrode  nothing  suits  better  than  pottery 
clay,  which,  however,  must  be  kept  warm,  smooth,  and 
moist;  its  size  should  be  about  twelve  by  twenty  inches. 

The  duration  and  intervals  of  the  se'ances  must  be 
regulated  according  to  indications.  The  time  for  a 
cure  of  a  fibroid  tumor  cannot  be  exactly  staled,  but 
depends  on  the  nature  and  size  of  the  tumor,  the  compli- 
cations, and  the  constitution  and  pluck  of  the  patient. 

Interstitial  tumors  may  be  either  diffused  in  the 
uterus,  or  circumscribed  in  one  locality.  If  the  latter, 
which  is  usually  the  case,  the  electric  current  is  di- 
rected toward  the  tumor.  These  tumors  are  more  or 
less  adherent  to  the  wall  of  the  uterus,  and  often  they 
are  encapsulated.  The  treatment  by  electrolysis  con- 
sists in  possible  absorption  of  the  tumor,  or  at  least  in 
making  it  smaller,  cutting  off  its  nutrition,  and  leaving 
it  small  in  a  dormant  state,  when  it  will  do  no  harm. 
Sometimes  it  may  do  good  to  rupture  the  capsule. 
Then  one  of  two  things  may  happen.  The  tumor  may 
slough  off,  which  takes  some  time,  and  then  the  elec- 
tric current  may  do  harm,  and  great  care  should  be 
taken  to  prevent  sepsis,  and  to  keep  up  the  vitality  of 
the  patient.  In  one  case,  in  which  the  tumor  was 
very  large  and  of  eleven  years'  standing,  the  writer 
operated  in  the  way  just  described  during  more  than 
three  months,  using  the  blunt  platinum  electrode.  The 
patient  was  very  weak  and  often  in  collapse,  but  finally 
made  a  good  recovery.  The  diagnosis  was  first  made 
by  Dr.  E.  M.  Moore,  of  Rochester.  Another  patient 
was  brought  to  the  writer's  office,  who  had  lost  so 
much  blood  by  active  hemorrhage  that  her  life  was  in 
danger.  Therefore  she  had  to  remain  at  his  house, 
as  she  could  not  be  moved,  and  be  treated  for  the 
hemorrhage,  as  she  was  almost  bloodless.  She  made 
a  good  recovery.  She  was  heard  from  twelve  years 
afterward,  when  she  was  alive  and  well. 

Sometimes  after  the  capsule  has  been  ruptured  the 
tumor  may  be  pulled  out  of  the  uterus,  somewhat  like 
enucleation,  and  if  the  adhesion  is  small  and  pedun- 
culated the  tumor  may  be  removed  in  its  entirety  at 
the  pedicle  with  the  galvano-cautery  platinum  wire,  or 
with  an  ecraseur. 

Submucous  tumors  are  almost  always  hanging  by 
a  pedicle  in  the  uterine  cavity  and  cause  the  most 
trouble  by  hemorrhage.  The  best  treatment  is  the  re- 
moval of  the  tumor  by  galvano-cautery  under  antisep- 
tic precautions. 

The  writer  has  always  treated  his  cases  of  fibroid 
tumor  successfully  by  electricity,  and  never  has  lost  a 
case.  Sometimes  the  tumor  has  not  entirely  disap- 
peared, but  was  small  and  lay  dormant,  without  caus- 
ing any  trouble  or  inconvenience. 


488 


MEDICAL    RECORD. 


[September  29,  1900 


Now  a  few  words  as  to  the  diagnosis  of  these  cases, 
which  has  been  always  verified  by  good  authorities,  or 
made  before  the  patient  came  under  treatment.  In 
some  cases  I  have  selected  a  good  surgeon  of  unques- 
tionable standing,  who  was  believed  to  be  prejudiced 
against  electricity,  to  examine  the  patient,  confirm  the 
diagnosis,  and  locate  the  fibroid  tumor.  The  same 
surgeon  was  again  invited  toe.\amine  the  same  patient 
after  the  electric  treatment,  and  was  then  obliged  to 
acknowledge  that  the  tumor  could  no  longer  be  found, 
and  that  therefore  the  electrolysis  must  have  caused 
its  absorption. 

Some  may  ask,  why  these  cases  have  not  been  pub- 
lished before.  My  answer  is  that  I  have  had  my  share 
of  abuse  for  praising  electrolysis,  and  therefore  would 
leave  some  criticism  for  others;  besides,  I  did  not  wish 
to  encroach  so  far  on  the  work  and  glory  of  the  gynae- 
cologists. Other  diseases  of  the  uterus  have  been 
treated  with  various  results.  Is  there  a  man  who  can 
assert  that  he  has  cured  all  cases  of  uterine  catarrh  by 
any  routine?  Ovarian  tumors  cannot  be  expected  to 
yield  under  any  electric  treatment,  because  they  are 
mostly  multilocular  cysts,  and  the  piercing  of  the 
tumor  by  a  needle  may  cause  peritonitis  and  adhe- 
sions. 

Pelvic  cellulitis  may  be  cured  by  electrolysis  judi- 
ciously and  carefully  applied.  The  writer  has  had 
among  other  cases  a  very  bad  one,  with  adhesions 
which  held  the  uterus  retrofiexed  and  adherent  in  the 
peritoneal  cavity.  A  consulting  gyneecologist  con- 
firmed the  diagnosis  and  considered  the  adhesions 
permanent.  The  writer  treated  the  case  by  persistent 
electrolysis,  using  the  negative  pole  in  Douglas'  cul- 
de-sac,  pushing  the  instrument  backward  and  upward. 
The  adhesions  were  thereby  removed  and  the  patient 
was  cured.  This  was  eighteen  years  ago,  and  the 
patient  was  seen  only  recently  and  was  found  to  have 
remained  well  since  that  time.  Several  other  similar 
cases  are  in  the  writer's  notes,  but  none  with  such 
bad  prognosis. 

Peritonitis  has  been  cured  by  Dr.  \V.  E.  Ford,  of 
Utica.' 

In  peri-uterine  hiematocele  Apostoli ''  has  had  excel- 
lent results  by  means  of  negative  galvanic  puncture. 
He  says  that  it  is  applicable  alike  to  haematocele, 
abscess,  fibromata,  interstitial  myomata,  and  extra- 
uterine cysts. 

Strictures  of  the  female  urethra  are  rare,  but  they 
occur,  occasionally  and  are  readily  cured  by  electroly- 
sis.    The  writer  has  reported  some  of  his  cases.' 

Oophoritis  and  salpingitis  are  intimately  connected, 
say  our  modern  authors.  Cases  appear  in  different 
stages;  some  are  very  difficult  to  manage  and  no  treat- 
ment will  positively  cure.  I  have  had  some  cures  by 
electrolysis,  having  notes  of  cases  treated  from  1872 
to  1887.  One  acute  case  was  treated  successfully  in 
fivese'ances.  I  have  generally  used  the  negative  metal 
electrode  in  the  vagina,  and  a  positive  pad  on  the  ab- 
domen over  the  ovary. 

In  one  case  in  private  practice  the  patient,  who  was 
very  poor,  had  been  treated  medically,  the  case  being 
regarded  almost  hopeless.  Friends  applied  for  her 
admission  to  hospital,  and  in  every  institution  the 
surgeon  in  charge  insisted  on  laparotomy  and  removal 
of  the  uterus  and  appendages.  The  writer  objected 
to  such  harsh  measures,  and  after  quieting  tlie  patient 
with  morphine  took  her  to  a  hospital  out  of  town  to 
which  he  is  attached  as  consulting  surgeon.  There 
the  patient  was  curetted,  drainage  was  established, 
and  she  made  a  good  recovery.  I  have  seen  her  only 
very  recently.     No  electricity  was  used. 

In  bladder  neuroses,  papilloma,  and  other  tumors, 

'  The  Medical  Press  of  Western  New  York,  April,  iSSS. 

'  American  Journal  of  Obstetrics,  .Vpril,  iSS6 

'American  journal  of  the  Medical  .Sciences,  October,  1875. 


electrolysis,  after  the  diagnosis  has  been  made  by  the 
cystoscope,  is  certainly  indicated.  The  writer  has  re- 
moved papillomata  with  the  galvano-cautery,  and  tu- 
mors by  means  of  electrolysis  with  needles.  A  paper 
in  which  cases  of  tiiis  kind  were  reported  was  read  be- 
fore tills  association  in  Chicago  in  1893.' 

Strictures  of  the  rectum  are  more  successfully  treated 
by  electrolysis  than  by  any  other  method.  The  writer 
has  had  considerable  experience  with  cases  of  stric- 
ture of  the  rectum,  and  read  a  paper  on  this  subject 
before  the  American  Medical  Association  at  Newport 
in  1S89."  Most  of  the  cases  were  successfully  treated; 
in  some  recovery  could  not  be  expected.  One  woman, 
who  subsequently  underwent  a  surgical  operation  in  a 
hospital,  died  soon  afterward. 

The  vulva  has  sometimes  growths  or  cysts  which 
can  be  removed  either  by  surgical  operation  or  by 
electrolysis. 

In  extra-uterine  pregnancy  the  profession  is  divided 
as  to  the  best  treatment,  and  some  surgeons  prefer 
laparotomy.  However,  we  have  reports  of  successful 
treatment  by  electricity  by  eminent  men,  of  whom  the 
following  may  be  mentioned:  Drs.  A.  D.  Rockwell," 
E.  G.  Landes.'  Nathan  Bozeman,'  H.  J.  Garrigues,'  \V. 
Goodell,'  Eli  Van  de  Warker,-  Reeve,  T.  Lusk,"  A.  H. 
Buckmaster,'"  Matthews  Duncan,"  Percy  Boulton,'-'  and 
W.  E.  Stephenson.'"  The  modus  opcraiidi  differs,  but 
it  seems  electrolysis  is  mostly  used.  One  method  is 
to  have  one  pole  in  the  vagina  or  rectum,  the  other 
pole  on  the  abdomen. 

Basing  my  conclusion  on  my  own  experience  and 
on  reports  contained  in  the  literature  on  the  subject,  I 
may  say  that  we  obtain  better  results  from  treatment 
by  electricity  than  by  other  means,  and  the  reluctance 
of  gynecologists  to  apply  electricity,  or  at  least  to  rec- 
ommend it,  has  not  been  explained. 

W'e  need  a  means  for  a  better  education  of  the  med- 
ical men  in  electro-therapeutics,  and  should  strive  to 
see  the  establishment  in  New  York  of  a  school,  labor- 
atory, hospital,  and  clinic  in  electro-therapeutics. 

148  West  Seventv-third  Street 


A  CURE  OF  A  CASE  OF  HYPERTROPHIC 
ALCOHOLIC  CIRRHOSIS  OF  THE  LIVER, 
WITH    REMARKS.* 

Bv   M     LUZZATTO,    M.D., 

NEW    YORK. 

G.  A •,  aged  fifty-five  years,  a  carpenter  by  occupa- 
tion. Family  history  good ;  his  parents  both  died  of 
old  age.  Past  history:  Twenty-six  years  ago,  while 
residing  in  a  malarial  district,  he  developed  intermit- 
tent fever,  from  which  he  suffered  at  times  for  a  pe- 
riod of  ten  months.  Eight  years  later  he  had  another 
attack  of  malaria,  lasting  for  about  one  month.  With 
these  exceptions  he  has  always  felt  well,  although 
since  boyhood  he  has  been  subject  to  attacks  of  nose- 
bleed, which  were  finally  controlled  by  venesection 
practised  every  four  months.  The  patient's  habits, 
however,  have  not  been  good,  as  since  the  age  of  sev- 

'  Times  and  Register.  Philadelphia.  November  II,  1S93 
-Journal  of  the  .Vmerican  Medical  Association,  May  17,  1S9O. 
■'Mkdii'al   Rkcokl),  February  17.  1SS3. 
■*  Medical  News.  April  S.  1S82. 

^  Transactions  of  the  New  \'ork  State   Medical  Association, 
1884. 
'  Gyn!Bcological  Transactions,  vol.  vii.,  18S3 
■■  Union  Medical  Magazine,  Philadelphia,  l)ecember.  1SS8. 
'■  (lynrvcological  Transactions,  vol.  xii..  p    2g(). 
' -American  lournal  of  Obstetrics,  xiv.    329,  18S1. 
'»  Medical  News,  July  21.  1SS8. 
"  St,   Hartholomew's  Hospital  Reports,  vol.  xix. 
'-'  British  Medical  Journal,  April  30,  1888. 
'■'British  .Medical  .Association,  18S6 

»  Read  before  the  Italian  Medical  Society  of  New  York.  June 
27.  iqoo. 


September  29,  1900] 


MEDICAL 


enteen  years  he  has  been  constantly  increasing  his 
amount  of  stimulants.  When  a  boy  of  seventeen  he 
drank  two,  three,  or  four  glasses  of  wine  a  day,  but 
when  over  twenty  he  increased  this  amount,  and  on 
Sunday  was  in  the  habit  of  taking  two  quarts  of  wine, 
when  thirty-two  he  was  taking  twelve  drinks  of  whis- 
key and  three  or  four  pints  of  beer  every  day.  At  the 
age  of  fifty  years,  after  eighteen  years  of  hard  drink- 
ing, during  which  time  he  ate  very  little  and  worked 
very  hard,  he  was  obliged  to  give  up  drinking  spirits, 
as  it  seemed  to  produce  attacks  of  dyspncca  and  vom- 
iting. 

About  September  15,  1894,  he  began  to  feel  bad, 
and  two  months  later  (November  g,  1894)  he  consulted 
me  about  his  condition.  He  then  complained  of  diffi- 
culty in  breathing,  sticking  pains  in  the  right  side  of 
the  chest  low  down,  and  a  tenderness  over  the  right 
side  of  the  abdomen.  (Jn  examination  1  found  that 
he  had  a  temperature  of  100°  F.,  a  pulse  of  80,  hydro- 
thorax  on  both  sides,  and  a  beginning  pulmonary 
oedema.  He  also  had  ascites  and  a  reducible  hernia 
on  both  sides,  which  could  in  no  way  be  retained 
within  the  abdominal  cavity,  even  with  the  truss.  His 
abdomen  measured  thirteen  inches  from  the  ensiform 
cartilage  to  the  pubis;  thirty-five  and  one-half  inches 
in  circumference  at  the  level  of  the  umbilicus,  and 
thirty-seven  and  one-half  inches  at  the  point  of  its 
maximum,  which  was  about  two  inches  above  the  um- 
bilicus. The  abdominal  veins  (subcutaneous  collater- 
al circle)  were  very  much  enlarged.  A  diagnosis  of 
alcoholic  hypertrophic  cirrhosis  of  the  liver  was  made. 

Treatment:  The  patient  was  put  on  a  milk  diet  of 
four  and  one-half  pints  a  day.  His  condition,  how- 
ever, grew  rapidly  worse,  and  the  ascites  increased. 
A  consultation  with  Dr.  A.  Loomis  was  accordingly 
held,  and  the  diagnosis  was  confirmed.  After  the 
consultation  it  was  decided  to  put  the  patient  on  the 
following  powders:  Calomel,  gr.  i. ;  pulv.  digitalis, 
gr.  i. ,  pulv.  squill,  gr.  iii.;  to  be  taken  four  times  a 
day.  In  addition  to  which  a  teaspoonful  of  Kpsom 
salts  was  given  every  morning,  and  a  milk  diet  was 
instituted.  The  condition  of  the  patient  at  the  begin- 
ning of  the  treatment  was  as  follows: 

November  26,  1894:  Milk  taken  daily,  2,2500.0.; 
urine  passed,  500  c.c.  Abdominal  measurements: 
vertical  13  inches;  circumferences — umbilical,  35'.- 
inches;  at  its  maximum,  37 'j  inches.  Pulse,  80, 
temperature,  morning  100',  evening  101°  F. 

After  three  days  of  this  treatment  the  patient  could 
no  longer  endure  a  milk  diet,  so  he  was  allowed  solid 
food.     His  condition  then  was  as  follows: 

November  29th:  Urine  passed,  300  c.c;  abdominal 
measurement — vertical,  14  inches,  circumferences, 
38 '2  and  37, '2  inches.  Pulse,  83  ;  temperature,  morn- 
ing 100.5^,  evening  102.5^  F. 

.\t  the  end  of  twelve  days  (December  loth)  his 
temperature  had  dropped  to  normal;  urine  was  750 
c.c.  a  day;  and  his  abdominal  measurements  were 
13' J  inches  vertically  and  37 ^<4  and  36^  inches  cir- 
cumferentially. 

December  loth:  As  there  were  some  signs  of  stom- 
atitis present  the  powders  were  discontinued  and  the 
patient  was  put  on  nitrate  of  potassium,  ;  i.  a  day, 
and  iodide  of  potassium,  gr.  xv.  twice  daily  in  a  liquid 
potion.  After  eleven  days  of  this  treatment  without 
improvement  it  was  noticed  that  the  lower  lobe  of  the 
left  lung  was  consolidated.  Accordingly  all  medi- 
cines were  cut  off  and  he  was  put  on  a  milk  diet  again 
with  somatose,   3  iii.  a  day. 

Beginning  December  20th  with  500  c.c.  of  milk  a 
day,  in  two  weeks  (January  5,  1895)  he  had  run  the 
amount  up  to  3,000  c.c,  and  at  the  same  time  it  was 
noticed  that  the  amount  of  urine  passed  had  also  in- 
creased from  500  to  3,000  c.c.  a  day,  his  abdominal 
measurements  were:    vertical,   12)^   inches;    the  cir 


RECORD.  489 

cumferences,  38  and  37  inches.     Accordingly  the  fol- 
lowing mixture  was  ordered: 

If  I'owd.  digitalis gr    viij. 

Make  hot  infusion ad  |  iij. 

Potassium  acetate 3  ij 

Syr.  of  squill §1. 

S.  Tablespoonful  every  two  hours. 

January  23d  (seventeen  days  later)  he  was  taking 
2,000  c.c.  of  milk;  urine  passed,  1,700  c.c. ,  abdominal 
measurements  still  less,  viz.,  vertical,  12  inches,  cir 
cumferences,  36 ;-4  and  36 '3  inches.  As  he  complained 
of  a  little  stomach  trouble,  the  milk  was  now  cut 
down,  and  b«ef-tea  added  to  the  diet.  His  other 
medicines  were  also  stopped  except  Epsom  salts, 
which  WMS  given  every  morning  in  3  i.  dose  for  a  few 
days,  after  which  the  diuretic  was  again  administered. 

From  January  24th  to  February  nth  the  milk  was 
continued  in  the  quantity  of  1,500  c.c.  a  day  .  the  urine 
passed  was  1,500  c.c.  (normal),  the  abdominal  meas 
urements  went  down  to  10^2  inches  (vertical)  and 
34  inches  both  circumferences.  In  view  of  the  fair 
condition  of  the  patient  the  milk  was  left  off  alto- 
gether, but  after  three  days  without  milk  it  was  found 
that  the  amount  of  urine  had  decreased,  and  that  the 
abdominal  measurements  were  increasing  It  was 
therefore  thought  expedient  on  February  14th  to  put 
the  patient  back  on  2,000  c.c.  of  milk  a  day,  when  the 
urine  again  increased  in  amount.  The  fluid  in  the 
chest  was  now  completely  absorbed,  so  that  friction 
sounds  and  vocal  fremitus  could  be  obtained  over  both 
lungs.  A  blister  was  applied  for  the  sticking  pain  in 
the  side,  and  the  diuretic  mixture  discontinued  for  a 
few  days,  but  again  given  when  the  amount  of  urine 
was  seen  to  be  decreasing. 

Two  weeks  later  (February  28th)  the  amount  of 
urine  was  still  normal  (1,500  c.c.  a  day).  The  abdo- 
men was  regular  in  shape,  tympanitic,  with  no  sign  of 
fluctuation,  and  measured  vertically  10^2  inches  and 
circumferentially  33;'{(  and  32;^/)^  inches.  The  subcu 
taneous  abdominal  veins  could  no  longer  be  noticed, 
and  the  pain  in  the  chest  was  gone,  although  a  few 
friction  sounds  and  rales  were  evident  on  auscultation. 

The  liver  could  now  be  mapped  out,  and  it  was 
found  that  its  absolute  dulness  was  limited  along  the 
mammary  line,  above,  by  the  fourth  intercostal  space; 
below,  by  the  costal  arch.  At  the  parasternal  line  it 
reached  2  cm.  below  the  arch.  Its  limits  posteriorly 
were  normal.  The  spleen  was  moderately  increased 
in  size.  One  week  later  (March  6th)  pleurisy  reap- 
peared on  the  left  side  posteriorly,  together  with  slight 
fever.  Salicylate  of  sodium,  gr.  xxx.  a  day,  was  or- 
dered, diuretics  were  discontinued. 

March  9th:   Pleurisy  improved,  no  fever 

March  20th:  Friction  sounds  still  persisted  Sali- 
cylate of  sodium  was  continued.  Diuretic  potion  v.as 
again  administered,  with  gr.  viii  of  iodide  of  potas- 
sium, besides  3  ss  of  cod-liver  oil  with  Tf],  viiss.  of 
syrupus  ferri  iodidi  twice  a  day. 

From  March  ist  to  March  6th  he  took  1,000  c.c. 
of  milk  a  day.  Urine  passed,  1,000  c.c.  Measure- 
ments of  the  abdomen,  lo'.-  inches  vertically .  33  and 
32 '2  inches  circumferentially. 

From  March  6th  to  March  31st  1,000  c  c.  of  milk  a 
day.  Urine  passed,  1,250  c.c.  Measurements,  ver 
tical  10I/2  inches,  both  circumferences  32  inches. 

March  31st:  Weight,  one  hundred  and  thirty  eight 
pounds  (his  normal  weight  when  in  health).  There 
was  no  fluid  in  the  pleural  cavity,  friction  sounds 
could  be  noted  all  over  the  left  and  posterior  parts  of 
the  chest.  Respiratory  murmur  normal  except  at  the 
lowest  part  of  the  right  chest,  where  it  is  replaced  by 
fine  crepitant  rales.  The  patient  has  a  good  appeitte 
and  eats  macaroni,  meat,  eggs,  and  vegetables  in  ad- 
dition to  his  1,000  c.c.  of  milk  a  day. 


490 


MEDICAL    RECORD. 


[September  29,  1900 


April  7th:  Tincture  of  iodine  was  painted  over  ihe 
chest,  where  the  friction  sounds  were  present. 

April  15th:  Milk  reduced  to  500  c.c.  a  day;  urine 
passed,  still  2,000  c.c.  a  day.  Abdominal  measure- 
ments, lo'i  and  32  inches.  Friction  sounds  on  left 
side  were  less  marked.  Weight,  one  hundred  and 
thirty-nine  pounds.  The  daily  amount  of  diuretic 
mixture  was  reduced  to    -  i. 

April  27th:  Friction  sounds  less;  ordered  iron  and 
arsenic. 

May  3d  :  Friction  sounds  disappearing.  Patient  is 
allowed  to  go  out.  A  liberal  diet  was  given  besides 
500  c.c.  of  milk  a  day.  Diuretic  was  stopped.  Urine, 
still  1,500  c.c.  Abdominal  measurements,  io,'i  and 
32  inches. 

May  24th:  No  more  friction  sounds;  few  rales  on 
right  side  of  chest  low  down;  weight,  one  hundred 
and  forty  pounds.  The  patient  feels  well  and  strong, 
and  is  able  to  work.  I  forbade  him  to  work  again  in- 
side of  two  years,  but  he  did  not  heed  my  advice,  and 
went  back  to  his  trade.  After  working  for  a  number 
of  weeks,  he  noticed  that  his  hernia,  which  he  could 
not  keep  up  with  a  truss,  seemed  to  be  growing  larger. 
Examination  showed  a  hydrocele  from  which  about 
eight  ounces  of  straw-colored  fluid  was  obtained  by 
puncture.  This  I  continued  tapping  at  intervals, 
thinking  that  it  might  gradually  disappear.  The 
fluid,  however,  instead  of  diminishing  in  quantity,  in- 
creased and  finally  became  bloody,  until  at  the  end  of 
August  about  a  gallon  of  bloody  fluid  was  withdrawn 
from  the  right  side.  It  was  noticed  also  that  the  ab- 
dominal measurements  were  increasing.  On  examin- 
ing the  patient  when  lying  down  it  was  found  that  the 
fluid  had  disappeared  from  the  scrotum.  It  was  thus 
evident  that  the  fluid  in  the  tunica  vaginalis  came 
from  the  abdominal  cavity.  This  condition  had  not 
been  noticed  during  his  first  sickness,  as  he  was  first 
seen  in  bed,  and  was  never  allowed  out  of  bed  until 
he  was  well  and  the  ascites  had  disappeared.  In  view 
of  the  fact  that  the  fluid  in  the  scrotal  sac  thus  pointed 
to  a  return  of  his  ascites,  puncture  of  the  scrotum  was 
discontinued,  and  the  patient  again  put  upon  milk 
diet  (September  21st). 

September  21  St :  Milk,  2,000  c.c. ;  urine,  2,000  c.c. ; 
abdominal  measurements,  34  inches. 

October  12th:  Milk,  1,500  c.c;  urine,  2,000  c.c; 
abdominal  measurements,  32 'g  inches. 

November  4th:  Milk,  i.ooo  c.c;  urine,  2,000  c.c; 
abdominal  measurements,  33' 8  inches. 

The  treatment  was  then  discontinued. 

December  27th:  Abdominal  measurements,  33 
inches;  weight  of  body,  137  pounds. 

January  12,  1896:  Abdominal  measurements,  31 -'a 
inches;  weight  of  body,  135  pounds. 

April  27th:  Abdominal  measurements,  31  inches; 
weight  of  body,  137  pounds. 

At  this  time  the  patient  was  well  and  attending  to 
his  business.  His  diet  was  general,  and  he  drank  a 
little  wine  with  his  meals,  but  no  spirits. 

The  liver  was  mapped,  and  its  limits  of  absolute 
dulness  were:  In  the  mammary  line — above,  at  the 
inferior  border  of  the  sixth  rib;  below,  two  inches 
above  border  of  ribs.  In  tlie  parasternal  line — above, 
at  the  superior  border  of  the  fifth  rib;  below,  one  inch 
below  costal  arch. 

June  30th;  Abdominal  measurements,  31  inches. 
The  limit  of  absolute  liver  dulness  was,  in  the  mam- 
mary line— above,  superior  border  of  the  fifth  rib; 
below,  one  inch  above  the  border  of  ribs;  in  the  para- 
sternal line — above,  at  the  superior  border  of  the 
fifth  rib;  below,  one  inch  below  border  of  ribs.  The 
abdominal  veins  were  normal. 

July  1 8th:  The  abdominal  measurement  was  31 'j 
inches. 

Remarks  on  Cirrhosis   of   the   Liver. —  Etiology: 


The  cirrhosis,  originally  described  at  length  by  Laen- 
nec,  and  named  by  him  "  gin-drinker's  liver,"  by  no 
means  depends  alone  for  its  causation  upon  over-indul- 
gence in  alcohol.  In  fact,  many  other  etiological  fac- 
tors have  been  noted  by  writers  since  his  time,  viz., 
syphilis,'  tuberculosis,"  malignant  growth"  of  the  organ, 
malaria,'  traumatism,"  diabetes,'  ptomain  poisoning,' 
obstructive  valvular  diseases  of  the  heart,"  other  car- 
diac conditions,'  fright,'"  chronic  lead  poisoning,"  and 
chronic  poisoning  from  sulphuric  ether,"  both  experi- 
mentally produced,  alcohol  and  malaria  together"  (our 
case),  and  possibly  a  specific,  but  as  yet  imperfectly 
understood  infectious  disease."  as  well  as  an  inherited 
tendency  or  special  dyscrasia,"  chronic  peritonitis," 
and  obstruction  of  biliary  ducts.'" 

Nevertheless,  there  can  be  no  doubt  that  alcoholic 
excess  is  the  most  common  cause  of  cirrhosis  of  the 
liver,'"  and  this  is  due,  it  appears  to  me,  not  to  any 
special  selective  action  of  alcohol  upon  the  liver,  but 
because  alcohol  is  the  most  common  toxic  agent  to 
which  human  beings  expose  themselves,  and  because, 
furthermore,  the  liver  is  the  first  important  organ  to 
receive  and  filter  all  toxins  absorbed  from  the  gastro- 
intestinal tract. 

In  the  case  herewith  presented  two  etiological  ele- 
ments were  present:  a  malaria  from  which  the  patient 
had  suffered  at  one  time  for  ten  months,  and  alcohol- 
ism of  eighteen  years'  standing.  Only  two  similar 
cases  in  the  literature  of  the  past  six  years  has  been 
presented,  by  Mirinescu  {toe.  at.)  and  A.  Cardarelli 
(tp,-.  at.). 

Diagnosis. — The  large  size  of  the  abdomen,  the  ab- 
sence of  lancinating  pains  of  the  peritoneum,  the  fact 
that  the  urine  was  free  from  albumin  and  casts:  the 
presence  of  the  fever  only  for  a  few  days  in  the  begin- 
ning of  the  disease;  the  non-existence  of  organic  dis- 
ease of  the  heart  or  cedemas,  taken  in  conjunction  with 
the  well-marked  abdominal  venous  circle  (caput  me- 
dusas), were  sufficient  to  point  to  an  hepatic  rather  than 
to  a  renal,  cardiac,  peritonitic,  or  hydremic  origin  of 
the  ascites,  without  excluding  a  secondary  element  in 
the  malarial  enlargement  of  the  spleen.  The  relatively 
large  size  of  the  liver  before  treatment  and  its  marked 
reduction  thereafter  tend  to  confirm  the  diagnosis  of 
alcoholic  hypertrophic  cirrhosis  of  the  liver. 

Course  of  the  Disease  as  Influenced  by  the 
Treatment. — .\  careful  study  of  the  above-described 
course  of  the  disease  will  show  the  influence  exerted 
by  the  milk  diet  upon  the  flow  of  urine.  Before  the 
steady  ingestion  of  milk  the  patient  was  passing  a 
relatively  small  amount  of  urine.  This  amount  grad- 
ually increased  as  time  went  on,  till  he  was  excreting 
by  way  of  the  kidney  an  even  larger  amount  of  fluid 
than  he  was  taking  in.  During  the  period  throughout 
which  treatment  was  suspended  (May  4th  to  September 
2  I  St),  the  amount  of  urine  gradually  fell,  coming  up 
again  with  the  renewed  application  of  the  milk  diet 
and  remaining  permanently  high  in  spite  of  tiie  low- 
ering of  the  quantity  of  milk  ingested.  This  would 
seem  to  indicate  two  things:  (i)that  the  treatment 
was  in  the  first  instance  suspended  too  soon;  (2)  that 
the  milk  diet  was  the  true  factor  in  the  cure. 

The  abdominal  measurements  are  seen  to  drop  pro- 
portionately to  the  rise  in  the  amount  of  urine.  The 
body  weight  drops  with  the  rise  of  the  urine  curve; 
this  indicates  that  the  loss  of  weight  in  this  period  of 
time  is  due  to  the  disappearance  of  the  ascitic  fluid. 
The  highest  point  of  it  corresponds  with  the  premature 
suspension  of  the  milk  diet  (May  24th)  and  is  per- 
manently kept  to  the  average  weight  of  the  patient 
when  in  health  after  the  final  suspension  of  the  treat- 
ment. To-day,  about  five  years  since  the  treatment  was 
stopped,  the  patient  is  perfectly  .well,  having  a  good 
appetite,  digesting  the  strongest  kind  of  food,  and 
attending  to  the  heaviest  labor  of  his  trade.     He  has. 


September  29.  1900] 


MEDICAL    RECORD. 


491 


however,  entirely  abandoned  the  use  of  whiskey,  and 
is  abstemious  in  regard  to  other  alcoholic  drinks. 

Curability  of  Cirrhosis  of  the  Liver — Quite  a 
number  of  cases  resulting  in  cure  have  been  recorded  in 
the  literature.  Fritz"  reports  an  apparently  hopeless 
case  quickly  cured  by  daily  doses  of  strychnine,  i  cgni.. 
together  with  4  gm.  of  potassium  iodide,  and  though  he 
does  not  pretend  to  explain  the  reason  for  the  cure, 
he  says  that  physicians  should  never  give  up  hope  in 
the  treatment  of  cirrhosis. 

Rendue""  reports  cure  in  a  case  after  fourteen  para- 
centeses, during  which  two  hundred  and  eighty  pints 
of  fluid  were  withdrawn. 

A.  L.  Romain,"'  a  case  of  cure  by  milk  diet  and  iodide 
of  potassium. 

Croisier,''  five  cases  cured  by  repeated  paracenteses. 

Soucerotte""  reports  a  cure  after  four  months'  treat- 
ment and  quotes  cures  at  the  hands  of  others  (Fereol, 
Descurt  et  Vulpian,  and  Richard)  as  the  result  of 
treatment  ranging  in  length  from  two  months  to  two 
years.  He  cites  a  patient  of  his  father  who  lived 
thirty  years  after  being  cured. 

Senator,'"'  a  case  of  cure  in  four  months. 

Wirsing,'"  besides  reporting  a  case  of  his  own,  col- 
lects nianv  others  from  the  literature. 

D.  I)e  Buch  et  L.  De  Moor,'"  Beerens,''  B.  C.  Senn- 
et H.  Delageniere,"  among  the  more  recent  authors, 
report  cases  of  cirrhosis  of  the  liver  resulting  in  cure. 

Budd,"  Cornil,"  Rendue, ""  Frerichs,  '  Cirelli,"  and 
others  of  the  older  writers  had  no  faith  in  the  curabil- 
ity of  cirrhosis  of  the  liver,  believing  that,  when  asci- 
tes has  once  developed,  nothing  can  be  done  beyond 
amelioration  of  the  symptoms. 

As  will  appear  from  the  dates  in  the  bibliography, 
it  is  the  more  recent  writers  who  have  advanced  a 
more  hopeful  view  and  have  brouglit  forward  cases  to 
support  it.  It  not  mfrequently  happens  that  experi- 
ence and  theory  fail  to  harmonize;  and  in  view  of  the 
clinical  facts  and  of  the  newer  cytology  we  must  con- 
clude that  the  reasoning  of  the  older  writers  was  based 
upon  an  imperfect  conception  of  the  effect  of  toxins. 
In  fact,  the  very  existence  of  such  products  was  hardly 
suspected. 

In  the  present  case,  after  about  five  years  during 
which  treatment  was  stopped,  the  patient  displays  no 
evidence  of  his  former  trouble.  An  enlargement  of  the 
spleen  existed,  but  that  was  undoubtedly  of  malarial 
origin,  since  only  the  atrophic  form  of  cirrhosis  can 
produce  splenic  hypertrophy. 

A  most  interesting  fact,  and  one  which  should  have 
considerable  value  as  showing  the  changes  in  volume 
that  the  liver  may  undergo  during  the  course  of  a  cir- 
rhosis, will  appear  upon  examining  the  measurements 
taken  at  different  tim^s  during  the  course  of  the  dis- 
ease. 

The  vertical  diameter  reached  its  maximum  on 
February  28,  1895,  its  minimum  on  April  27,  1896, 
and  with  a  marked  improvement  of  the  symptoms, 
on  June  30,  1896,  had  returned  to  a  point  between 
these  two  extremes. 

Wide  variations  in  the  size  of  the  liver  during  the 
course  of  a  cirrhosis  have  been  noted  by  Duncan," 
Senator,"  H.  W.  Webber,"  Debove,  '  .A.  A.  Eshner,'' 
and  a  unique  case  was  reported  by  Markvall,"  in 
which  the  autopsy  showed  in  some  points  of  the  liver 
atrophic  tissue,  in  other  points  of  the  same  hypertro- 
phic tissue  in  the  form  of  round  masses  of  newly  built 
hepatic  parenchyma,  as  was  proved  by  the  microscop- 
ical examination.  Hanot  and  Gilbert"  also  report  a 
case  of  atrophic  cirrhosis  of  the  livei'  in  which,  at  the 
autopsy,  besides  an  atrophic  lesion  a  process  of  regen- 
eration of  hepatic  tissue  was  found.  Remarks  on  this 
process  of  regeneration  were  also  in  the  last  decade 
published  by  D.  Nasse,"  J.  B.  Gibbon,"  V.  Hanot." 

It   is   not   surprising,    therefore,  that  a  case  which 


ended  in  recovery  should  present  the  changes  in  size 
that  were  noted.  The  final  increase  in  volume  par- 
allel with  the  improvement  of  the  symptoms  would 
seem  to  point  to  a  regenerative  process  in  the  organ, 
and  we  may  even  assume  that  this  regeneration  was 
the  sine  qua  iioii  of  recovery.  Nor  have  we  any  reason 
to  believe  that  such  a  process  is  confined  to  the  liver, 
but  rather  that  this  same  regeneration  of  damaged  cells 
takes  place  during  recovery  of  any  organ  from  disease. 
The  Infectious  Nature  of  Cirrhosis The  follow- 
ing facts  tend  to  show  that  certain  forms  of  cirrhosis 
of  the  liver  may  be  due  to  a  special  infection  : 

1.  Cirrhosis  is  not  peculiar  to  the  liver,  but  can 
affect  any  organ. 

2.  Many  cases  have  followed  a  very  rapid  course." 

3.  In  many  cases  the  state  of  the  blood  is  much  de- 
praved, as  evidenced  by  hemorrhage"  (which  was  pres- 
ent also  in  this  case  in  form  of  bloody  ascitic  serum), 
although  said  hemorrhage  can  be  produced  even  by 
varicose  veins"  complicating  a  dyscrasic  condition  of 
the  blood. 

4.  C'ertain  known  infectious  diseases'"  cause  cir- 
rhosis. 

5.  Microparasites  have  been  found  in  cirrhotic  liv- 
ers.'" 

6.  Coma"  and  delirium"  have  been  noticed  during 
the  course  of  certain  forms  of  cirrhosis. 

The  subject  is  too  extensive  to  be  more  than  touched 
upon  in  this  place,  but  possesses  rich  material  for  dis- 
cussion. 

Treatment. — As  to  the  treatment  of  this  case,  the 
therapy  consisted  of  milk,  iodide  of  potassium,  and 
diuretics.  The  milk  was  administered  from  start  to 
finish;  the  iodide  of  potassium  and  the  diuretics, 
though  not  used  till  late,  seemed  to  contribute  in  con- 
siderable degree  to  the  cure.  The  milk  sustained  the 
patient  without  throwing  work  upon  the  liver  as  would 
have  been  the  case  if  the  patient  had  been  allowed 
fatty  or  starchy  food,  while  at  the  same  time  its  diu- 
retic properties  were  of  exceeding  benefit. 

The  iodide  of  potassium  probably  acted  as  a  solvent 
upon  the  hypertrophic  connective  tissue,  and  probably 
as  an  antiseptic,  while  the  diuretics  were  selected  from 
those  that  would  not  only  assist  in  eliminating  the 
waste  from  the  body,  but  so  strengthen  the  heart  and 
blood-vessels  as  to  restore  the  hydraulic  equilibrium. 

General    Remarks    on    Other    Treatment Very 

many  therapeutic  measures  have  been  adopted  in  the 
treatment  of  alcoholic  cirrhosis  of  the  liver:  Copaiba 
either  alone''  or  with  milk  and  iodide  of  potassium" 
with  good  results;  calomel  gr.  iii.  daily  with  mouth 
wash  of  chlorate  of  potash;  '  milk,  Vichy  water, 
potassium  iodide,  and  nux  vomica,  '  without  result. 
Paracentesis,  when  repeated  often  enough,  sometimes 
completely  relieves  the  ascites.  '  Lecanu  performed 
it  upon  a  single  patient  eight  hundred  and  eighty-six 
times  during  fifteen  years. 

Milk,  diuretics,  and  potassium  iodide,"  with  result- 
ing cure.  Milk  and  puncture,"  case  resulting  in  cure. 
Milk  and  potassium  iodide  with  resulting  cure  by 
Lancereaux"  and  by  Semmola,' '  who  says  that  milk, 
if  used  long  enough  in  large  doses,  will  cure  cirrhosis. 
Milk  and  calomel,"  with  result  in  death  due  to  an  in- 
fectious condition  of  the  blood. 

Strychnine  and  potassium  iodide,''  i  cgm.  of  the 
first  and  i  gm.  of  the  second  daily,  caused  rapid  re- 
covery through  diuresis  after  \'ichy  water,  potassium 
iodide,  nux  vomica,  and  puncture  had  been  employed 
without  result. 

Laparotomy"  in  a  cirrhotic  for  diagnostic  purpose 
resulted  in  cure. 

Drainage,"  invariably  resulting  in  death  sooner  or 
later. 

Packing  of  the  abdominal  cavity,"  constantly  result- 
ing in  death. 


492 


MEDICAL   RECORD. 


[September  29,  1900 


Milk  and  gin,"  death  following. 

Calomel  and  puncture,"'  witii  no  good  result. 

More  recent  authors  (Villemin  and  Chresteu  de 
Monpellier,  quoted  by  Uujardin-Beaumetz,  Ferreira, 
De  Renzi,  and  Senimola)  registered  cases  of  patients 
cured  of  cirrhosis  of  the  liver,  having  used  diuretics, 
drastics,  iodine  preparations,  and  above  all  milk. 

IJearens  (/iv.  cit.)  reports  a  case  of  a  cure  with 
repeated  paracenteses  and  application  of  a  caustic 
(Vienna  paste)  in  the  hepatic  region.  Klemperer  {/oc. 
cit.)  cured  a  patient  with  milk  and  urea  as  diuretic. 
Verstraeten  (loc.  cit.)  cured  one  with  Vienna  paste  and 
eleven  paracenteses,  by  which  he  drew  9)2  litres  of 
fluid.  Of  these  various  remedies  the  greatest  num- 
ber of  favorable  results  seems  to  have  been  obtained 
by  the  plentiful  use  of  milk  combined  with  potassium 
iodide  or  rarely  with  tapping,  this  last  part  of  the 
treatment  being  purely  symptomatic,  and  though  use- 
ful at  times,  e.xtremely  dangerous  if  often  repeated. 
For,  besides  the  danger  of  ill  effect  from  traumatism 
of  the  peritoneum  and  of  possible  infection,  an  amount 
of  albumin  is  drawn  off  which  takes  a  long  time 
for  the  blood  to  recover,  and  which  a  patient  in  a  low 
state  can  ill  afford  to  lose.  Milk  therefore  should 
be  our  mainstay  in  the  treatment  of  this  disease,  and 
though  it  takes  a  long  time  for  it  to  perfect  a  cure,  in 
a  disease  of  such  importance  we  can  afford  to  make 
haste  slowly. 

Summary. — ^i.  This  was  a  true  case  of  hypertrophic 
cirrhosis  of  tiie  liver  due  to  alcoliolism. 

2.  The  patient  was  entirely  cured  with  milk,  potas- 
sium iodide,  and  diuretics. 

3.  The  cure  probably  depended  upon  a  regeneration 
of  the  damaged  cells  of  the  organ. 

4.  For  the  complication  that  arose,  i.e.,  sero-fibrin- 
ous  double  pleurisy  with  partial  consolidation  of  the 
left  lobe,  only  local  treatment  was  used  in  addition  to 
the  regular  treatment  for  cirrhosis,  and  yet  these  con- 
ditions were  entirely  cured. 

A  study  of  this  case,  together  with  the  cases  reported 
in  the  bibliography  below,  will  give  prominence  to 
three  facts: 

1.  Alcoholism  is  by  no  means  the  only  cause  of  cir- 
rhosis of  the  liver. 

2.  Alcoholic  cirrhosis  of  the  liver  is  curable;  the 
hypertrophic  form  more  often,  but  the  atrophic  form 
also. 

3.  Cirrhosis  very  often  shows  symptoms  character- 
istic of  an  infectious  disease. 

BIBLIOGKAPIIV. 

1.  Corni!  :  Diet,  encyclop.  des  sc.  med.,  Paris,  1876,  xvii., 
489-523-— Tonkoff,  V.  N.;  Vrach.  St.  I'etersb..  iSgs,  vi. ,  1201- 
1236,  1266.— Hebb,  R.  G.  :  Tr.  Pathol.  Soc,  London,  1896-97, 
xlv.,  vii.,  117.— Adami.  J.  G.  :  Canad.  Pract. .  Toronto,  189S, 
xxviii.,  3S5-400. 

2.  Devic  et  Lepin  :  Province  med.,  Lyon,  1S96,  x. ,  292,  301. 
— Kelynack",  T.  N.  :  Med.  Chronicle,  Manchester,  1S96-97,  vi., 
262.— Pcrone,  A.  R.  ;  Soc.  de  Biol.,  Par.,  1898,  10  s. ,  v.  394- 
396. 

3.  Pennato.  P.  :  Arch.  it.  di  el.  med.,  Milano,  l8g6,  xxxv. , 
245-271.— Senna,  K.  :  Gazzetta  degli  ospedali,  Milano,  1896, 
xvii.,  708-711.— Workman,  C:  Glasgow  Med.  J.,  1808,  xlix., 
184-187,  187-189. 

4.  Lancereaux  :  Wien.  med.  Presse.  1887,  xxviii.,  827.  — Laure 
et  Ilonorat  (from  Legry).  Arch.  gen.  de  mod.,  I'ar.,  1894,  80- 
9-1.  •• 

5.  Grasset :  Rev.  gen.  de  therap..  18S7,  pp.  162-164.— 
Ilanot,  J.  :  Societe  Anatomique,  1874-75, — Duncan:  Middlesex 
Hosp.  Rep.,  1892,  p.   185. 

6.  Paul  Reymond  :  Gaz.  des  hop.  de  Par.,  1887,  p.  875. — 
Hanot  et  ChaufTert :  Rev.  de  med.,  1882.  — Lctulle  :  .Soc.  mid. 
des  Hop.,  1SS5.— Ilanot  and  Schachman  :  Arch,  de  Physiol., 
18S6.— Schmey,  F.  :  Allg.  med.  Centr.-Ztg.,  Berl.,  1897,  Ixvi., 
521. 

7.  Legry.  loc.  cit.;  Laure  et  Ilonorat,  loc.  cit. 

8.  Perry  Kidd  :   Trans.  Path.  Soc,  I.ond.,  1893. 

9.  Queirolo,  G.  1!.  :  Clinica  medicadi  Pi.sa,  1896,  ii.,  224-227. 
10.   Senator:    Charite-Ann.,    Kerl.,   xviii,,    328-333. — Potain : 

Semaine  med..  Par.,  1896,  xvi  ,  161. 


11.  Lafitte  :  1S92  (from  A.  Letienne),  La  med.  mod..  Par., 
1894.  p.  227. 

12.  De  Grandmaison  (from  A.  Letienne),  loc.  ^it. 

13.  Mirinescu  :  Rev.  des  malad.  de  I'enfance.  1S94,  p.  560. — 
Cardarelli  :  Giorn.  internaz.  di  sc.  med.,  Napoli,  1S96,  n.  s., 
xviii.,  260-264. 

14.  Alexander  Crombie  :   Internat.  Med.  An.,  1891,  p.  323. 

Soucerotte  :  Gaz.  hebd..  18S6,  No.  34.— A.  Jula  :  The  Lancet, 
I.ond..  1S87,  ii.,  413.— Debove:  Bull,  et  mem.  de  Soc  med. 
des  116p.  de  I'ar..  1SS7,  3  s.,  iv.,  333,  334. —  K.  Penrose  'Irans. 
of  Pathol.  Soc,  I.ond.,  1893,  p.  93.— Gilbert,  A.,  et  L.  Four- 
nier:  Soc.  de  Biol,  de  Par.,  1S97,  10  s.,  iv.,  692-695.- .M.  Le- 
tulle  :  .^rch.  des  sc.  med.  Bucarest,  Par.,  1897,  ii..  111-149. — 
Kirikoff,  N.  :  Zeitschr.  f.  kl.  Med.,  Berl.,  1898-99,  xxxvi., 
444-473 —Kenvers;  Il>id.,  jif^-siS.  — P.  Haushalter :  Rev. 
med.  de  Test,  Nancy,  189S,  xxx.,  97,  iii..  i  pi.— Boinet:  Gaz. 
d.  hop..  Par.,  189S,  ixxi..  445  —Adami.  J.  G. :  Lancet,  Lond., 
1S98,  ii.,  396-400,  I  pi.;  also,  Montreal  M.  J.,  1S9S,  xxvii., 
485-4S9.— Gilbert,  A.,  et  A.  Grenet  :  .Soc  de  Biol,  de  Par., 
1896,  10  s.,  iii.,  107S-10S1.— Macdonald,  W.  T. :  Albany  Med. 
-■Xn.,  1S97,  xviii.,  29-32. — Letulle  :  Bull,  et  mem.  Soc.  nied.  des 
Hop.,  Par. ,  iSg7,  3  s. ,  xiv. ,  205-216. 

15.  Hutinel  :   La  France  med.,  18S1. — TonkofT,  V.  N.,  loc.  cit. 

16.  Caporali  :  Riforma  medica,  Napoli,  189S,  xiv.,  pt.  3a, 
149,  160,  — Deguy:  .'\rch.  gen.  de  med. ,  Par.,  1S98,  i.,  670-695. 

17.  Weber,  F.  P.  :  Brit.  Med.  J.,  Lond.,  1S96.  1027-1030. 

18.  Charcot:  Progr.  med.,  Par.,  1S76,  v.,  668,679,  ^'9°.  703, 
715.— Cornil.  loc.  cil.,  p.  519.— Paul  Olivier:  L'Un.  med.,  xvii., 
p.  402. — MM.  Perrin,  Lallemand,  et  Durray  (from  Legrj'),  loc. 
cit.,  1867,  p.  31. — Wunderlich  (from  Niem'ever,  Inn.  Pathol.), 
Par.,  1S66,  i.,  746.— Senator:  Med.  Press  and  Circ,  Lond., 
1893,  vii.,  p.  575.— Mirinescu,  loc.  cit.— A.  Letienne  (La  med. 
mod.,  1894,  p.  227),  who  quoted  also  the  following  authors  on 
the  subject:  Dahlstrom  (1S52)  ;  Duckok  (1S53):  Perrin,  Lalle- 
mand, and  Durray  (i860) ;  Kremiansky  (1S68)  ;  Magnan  (1S69); 
Ruge  (1S70);  Dujardin-Beaumetz  et  Audige  (1SS6);  Straus  and 
Belocq  (1SS7);  Lafitte  (1S92).— Curtis  ;  Rev.  Bull.  Soc.  Centr. 
de  Med.  de  Lille,  1S97,  2s.,  i.,  49-55.— P.  Desoil  :  Bull.  Soc. 
Centr.  de  Med.  du  Nord,  1897,  2  s..  i.  34-48.— Gilbert,  A.,  et 
Gamier  :  .Soc.  de  Biol.,  Par.,  1897,  10  s. ,  iv.,  637-640. — Lubet- 
Barbon  :  Arch,  internat.  de  laryng..  Par.,  1897,  x..  471. — 
Saingery,  H,  :  Gaz.  d.  hop.,  Par.,  1S97,  Ixx.,  810.— E.  Lance- 
reaux :  IliiJ.,  1057-1059.— J.  V.  I.aborde:  Bull.  ac.  med., 
Par.,_  1S97,  3  s. ,  xxxviii.,  334-390.— E.  \'allin  :  J/'id.,  2S5-298. 
— Renon  :  Rev.  gen.  de  clin.  et  de  therap..  Par.,  1S97,  xi., 
737.  739-— C'ilbert  et  Garnier,  M.:  //';'(/.,  1899,  10  s.,  vi.,  59-62. 
— Rendue  :  Bull.  ac.  de  med.,  Paris.  1898,  3  s.,  xxxix.,  255- 
259.— A.  Riche:  /Hit.,  304-313.  362-3f'6-  — Portes  ■  Gaz.  hebd. 
des  sc.  mt'd.  de  Bordeaux,  iSgS,  xix.,  172. — T.  Rovighi ;  La 
med.  mod..  Par.,  1S9S,  ix. ,  236. —J.  Mollard  et  C.  Bonne: 
Bull,  med..  Par.,  iSgS,  xii.,  601-C05.— Haushalter  et  Richon  : 
Arch,  de  med.  des  enf..  Par.,  iSgg,  ii.,  129-133.  —  Devic  et 
Lepin,  loc.  cit.~V.  Hanot:  Bull,  et  mem.  de  la  Soc.  med.  d. 
Hop.  de  Par.,  1896,  3  s.,  xiii.,  595.— Marfan  :  Bull.  med..  Par.. 
1897,  xi. ,  57-60.— Kelynack,  T.  N.:  Edinburgh  Med.  J.,  1897, 
n.  s..  i.,  1S7-1S9. 

ig.   Gaz.  hebd.,  xxiii..  18S6.  No.  36. 

20.  Quoted  by  Fereol  :  Bull,  et  mem.  d.  Soc.  med.  des  Hop. 
de  Par..  1SS7,  3  s. ,  iv. .  p.  8. 

21.  Arch,  de  med.  et  pharm.  mil..  Par..  1886.  viii.,  p.  389. 

22.  Gaz.  hebd.  demed..   Par.,  1886,  2  s.,  xxiii.,  830. 

23.  Ihitt.,  Nos.  34,  36. 

24.  Loc.  cit. 

25.  Verhandlungen  der  Wurzburger  physiol.-med.  Gesell., 
xxvi.,  1S92. 

26.  Belgique  med.  (land,  Haarlem,  i8g6,  iii.,  Tii-Tfi. 

27.  .An.  Soc.  de  Me'd.  de  Gand.  iSg6,  Ixxv.,  31-40. 

28.  Indian  Medical  Gazette.  Calcutta,  lSg7,  xxxii. ,  146. 
2g.    Rev.  de  Chir.,  Paris,  i8g7.  xvii.,  433. 

30.  Medical  Times.  Lond.,  1851,  n.  s.,  ii.,  253. 

31.  Diet.  Kncycl.  d.  sc.  med..  Par.,  1875,  xvii.,  p.  522. 

32.  Ihid.,  1879. 

33.  1862. 

34.  Morgagni,  1894,  xxxvi.,  183-185. 

35.  Middlesex  Hospital  Reports,  1892,  Lond..  p.  185. 

36.  /('(•.  cil. 

37.  Lancet,  Lond.,  1894,  i. ,  p.  1000. 

38.  Bull,  et  mem.  de  .Soc.  med.  des  Hop.,  Par.,  18S7,  3  s., 
iv..  333-336. 

39.  Proc   Pathol.  Soc,  Phihid.,  i897-g8,  n.  s.,  i.,  295-298, 
40    Virchow's  .\rch.,   1894,  cxxxv.,  p.  292. 

41.  Soc.  med.  des  Ilup.,  x. ,  7. 

42.  I.angenbeck's  .Archiv  f.  clin.  Chlrurg.,  1S94,  xlviii.,  885. 

43.  Indian  Lancet,  Calcutta,  iSg6,  vii.,  426-429. 

44.  Hull,  et  mem.  Soc.  med.  des  Hop.,  Par.,  1896,  3  s.,  xiii., 
595  ;  also,  Gaz.  des  Hop.,  Par.,  iSg6,  Ixix.,  897-900. 

45.  Debove,  loc.  cit..  333-336;  Hanot,  loc.  cit.;  Senator,  he. 
cit. — Vincent:  Virginia  Medical  Monthly,  xx. ,  1893-94,  p, 
1305.— Faltut,  P.  :  Bull.  .Soc  Anat.,  Par.,  1897,  Ixxii.,  58-61.— 
M.  Loeb;  Deutsch.  Arch.  f.  kl.  Med.,  Leipzig,  i8g6,  liii.,  475- 
484. — Cardarelli.  A.:  La  clinica  medica  di  Pisa.  1S97.  iii.,  2S5. — 
Bruns,  C:  Deutsche  med.  Wochcnschr..  Leipzig  u.  Berl.,  1898, 
xxiv.,  220.  — Fwald:  Perl.  kl.  Wochenschr  ,  1897.  xxxiv.,  1106. 
— Markl.  G. :  Wien.   med.  Wochenschr.,  1898,  xlviii.,  3S9-392. 


September  29,  1900] 


MEDICAL    RECORD. 


493 


46.  Charcot,  loc.cit.,  p.  717;  Senator,  he.  (it  ,  p.  326-333. — 
J.  S.  Musser;  The  Med.  and  Surg.  Kep.,  18S7,  pp.  339-342.— 
H.  W.  Webber  Lancet,  Lond.,  1894,  i.,  p.  1000.— Bruns.  loc. 
cit. — Renvers,  loc.  cil. — Thomas:  Rev.  gen.  de  cl.  et  de 
therap. ,  Par..  i8g6,  x. ,  162.— F.  Barjou  et  L.  Henry:  Lyon 
med.    i8q8.  Ixxxviii.,  258-266. 

47.  Lubet-Barbon,  loc.  cit. — Marchiafava,  E. :  Supplem.  al 
policl.  di  Roma,  1897-gS,  iv. ,  242-244.— J.  MoUar  et  C.  Bonne: 
Bull,  med..  Par.,  1898,  xii. ,  601-605. — Dreyfuss  :  .Mtinch.  med. 
Wochenschr. ,  iSgS,  xiv. ,  1022.  —  Marchiafava:  Boll.  d.  See. 
Lancisiana  d.  Osp.  di  Roma(iS97),  1S9S,  xviii..  314. — P.  M. 
Menetrier  ;  Bull,  et  mem.  Soc.  med.  d.  Hop.  de  Par..  1S96,  3 
s.,  xiii.,  847-S50. — Garland,  J.  NL  :  Boston  Medical  and  Surgical 
Journal,  1896  (xxxv.),  277-2S0. 

43     Legry,  loc.  cil.  ;  I.aure  et  Honorat,  loc.  cit. 

49.  Zwaademaker:  Nederl.  mit  geneesk.  Arch.,  etc.,  Utrecht, 
1887,  .xi.,  121. — Straus  Soc.  de  Biol.,  Par.,  1S87.  8  s..  iv..  p. 
470. — Senator:  Medical  Press  and  Circular,  London,  1S93,  vii., 
p  575. — F.  Penrose  .  .Medical  Chronicle,  1S93-94,  p.  307. — 
Adami.  J.  G. ,  loc.  cit.,  4S5-4S9,  565-5S1. 

50.  Weidner.  C. :  Louisville  Medical  Monthly,  1896-97,  iii., 
405-407. 

51.  Jaccoud  ;  Bull.  med..  Paris,  189S.  xii.,  ii?7.  1195. 

52.  Ghcorgirsky  :  Prov  Med.  Journ.,  May,  1S92.  and  Inter- 
nal   Med.  An.,  1893,  p.  360. 

53.  Dujardin-Beaumetz  :  Gaz.  med   de  Montreal,  July,  lSg2, 

54.  Paul  de  Palma :  Internal.  Med.  An.,  1S94. 

55.  Fritz,  loc.  cit..  Xo.  36. 

56.  M.  P'ereol,  loc.  cit.,  pp.  6-S ;  M  Rendue.  loc  cit  — 
Saucerotte  ,  Gaz.  hebd. ,  18S6.  Nos.  34-36. — Macdonnell  ;  Can- 
ada Medical  and  Surgical  Journal,  Montreal,  1886-87.  xv. ,  p.  736. 

57.  \.  L.  Romain,  loc    cit. 

58.  Croisier,  loc.  cit. 

59.  Gaz,  des  hop..  Paris.  1887.  pp.  869-S76  (quoted  by  ^^ 
Paul  Reymond). 

60.  Quoted  by  Senator :  Berl  kl.  Wochenschr.  1893,  pp. 
1232  and  1238. 

61.  Charrin  :  Soc.  de  Biol.  Par.  1893,  9  s.,  v.,  pp  1057- 
lOSg. 

62.  Fritz,  loc.  cit. 

63.  Duncan,  loc.  cit. 

64  Gaspare  d'Urso  :  Giornale  Internationale  delle  scienze 
mediche,  Napoli,  18S7,  n.  s. .  ix. .  631-65; 

65.  Lanini  Lo  sperimentale,  .\pril,  1SS5,  p.  404.  —  Llewellyn 
Eliot:  New  York  Medical  Journal,  June  26.  1SS6. — D".\ntona  ; 
Giornale  Internationale  delle  scienze  mediche,  anno  viii. 

66.  Budd,  loc.  cit 
ill.   Senator,  loc    cit. 

I  6  King  Street 


THE  CO-OPERATION  OF  THE  MEDICAL 
PROFESSION  OF  THE  UNITED  STATES 
WITH  THE  NATIONAL  CONFEDERATION 
OF  STATE  MEDICAL  EXAMINING  AND 
LICENSING  BOARDS,  IN  ESTABLISHING 
INTERST.\TE  RECIPROCITV  FOR  THE 
LICENSE   TO    PRACTISE   MEDICINE,' 

By   EMIL   AMBERG,    M.D., 
detroit,  mich. 

It  was  with  a  feeling  of  embarrassment  that  I  ac- 
cepted the  kind  invitation  to  read  a  paper  before  this 
confederation.  There  certainly  cannot  be  anything 
new  that  I  may  be  able  to  present;  however,  since  the 
committee  of  the  Wayne  County  Medical  Society,  of 
Detroit,  has  become  a  kind  of  a  centre  for  the  ex- 
change of  opinions  along  the  line  of  interstate  reci- 
procity for  the  license  to  practise  medicine,  it  may  be 
of  interest  to  hear  some  of  the  ideas  which  were  fur- 
nished to  this  committee  and  stimulated  the  move- 
ment. 

Before  entering  into  the  subject  proper,  I  take  great 
pleasure  in  expressing  my  thanks — and  I  am  sure  our 
committee  and  our  society  are  in  accord  with  me — to 
all  the  medical  boards  and  medical  State  officials  in 
the  United  States.  In  fact,  the  movement  is  partly 
based  on  the  willingness  of  these  authorities  and  on 
the  interest  they  take  in  the  matter.  The  question 
might  be  raised  why  the  whole  movement  might  not 
better  be  left  to  the  National  Confederation  instead  of 
enlisting  the  whole  medical  profession   in   the  same. 

'  Read  before  the  National  Confederation  of  State  Medical 
Examining  and  Licensing  Boards,  June  4,  I900,  at  Atlantic 
City,  N.  J. 


We  can  answer  that  the  aim  of  the  National  Confed- 
eration of  State  Medical  Examining  and  Licensing 
Boards,  their  efforts  and  their  works  are,  no  doubt, 
highly  appreciated  by  the  medical  profession.  Two 
points,  however,  make  it  desirable  that  the  whole 
medical  profession  stand  shoulder  to  shoulder  with 
the  boards:  First,  the  feeling  of  equal  citizenship, 
and,  second,  the  fact  that  the  changes  toward  an  im- 
provement have  to  go  through  the  legislative  bodies. 

Concerning  the  first  point,  we  must  consider  the 
peculiarity  of  our  country  and  our  form  of  government. 
As  to  the  second  point  we  know  that  the  laws  neces- 
sary for  our  purpose  must  be  enacted  voluntarily.  If 
it  can  be  expected  from  every  citizen  that  he  under- 
stands why  he  expresses  his  will  on  the  proper  occa- 
sion, it  must  with  right  be  taken  for  granted  that  the 
learned  members  of  the  medical  profession  know  why 
they  will  depart  from  the  old  rules  and  why  they  will 
assist  the  members  of  the  various  boards  in  their 
efforts  toward  an  improvement 

There  exists  no  doubt  that  the  advancement  of  med- 
ical science  in  any  country  demands  a  progress  in 
medical  education,  and,  if  it  were  only  for  this  reason, 
a  standstill  cannot  be  tolerated.  But  let  us  consider 
whether  we  must  not  improve,  if  it  were  only  for  the 
purpose  of  reaching  that  point  which  would  place  the 
medical  profession  in  the  United  States  on  an  equal 
footing  with  those  in  the  most  advanced  countries. 
Physicians  are  the  products  of  the  medical  schools; 
therefore  we  may  speak  at  the  same  time  of  the  medi- 
cal schools.  Permit  me  to  quote  from  quite  a  num- 
ber of  authors,  because  I  think  in  repeating  their  re- 
marks we  will  have  a  good  idea  of  the  opinion  of  the 
medical  profession  on  the  subject. 

Mr.  James  Russell  Parsons,  Jr.  in  his  monograph 
on  education  in  the  United  States,  gives  the  number 
of  medical  colleges  in  the  year  1899  as  one  hundred 
and  fifty-six,  excluding  post-graduate  schools,  with 
twenty-four  thousand  one  hundred  and  nineteen  stu- 
dents. The  Medic.-vl  Record  (March  17,  1900), 
quoting  Mr.  Parsons,  says:  ".A.  foreigner,  reading  this 
statement,  and  unacquainted  with  the  facts  of  the  case, 
would  come  to  the  conclusion  that  the  medical  educa- 
tion in  this  country  was  in  a  particularly  healthy  con- 
dition. If,  however,  he  were  of  a  curious  disposition 
and  would  dive  more  deeply  into  the  matter,  his  opin- 
ion would  assuredly  undergo  a  radical  change."' 

It  is  evident  that  the  standards  of  one  hundred  and 
fifty-six  medical  schools  vary  a  good  deal.  Their  suf- 
ficiency at  present  must  be  tested  by  the  boards.  The 
Philadelpliia  Medical  Joitnial  says  well  (in  the  issue  of 
.\pril  14,  1900)  :  "  Medical  examining  boards  have  a 
distinct  power  and  well-defined  duties  in  regard  to 
these  matters;  they  can  refuse  to  recognize  the  diplo- 
mas of  colleges  that  give  insufficient  instruction. 
Every  examining  board  should  have  an  '  inspection 
that  inspects'  every  school  whose  diplomas  they  agree 
to  recognize." 

I,  for  my  part,  go  even  further;  I  do  not  believe 
in  private  medical  schools  at  all.  It  is  the  duty  of 
the  State  to  provide  for  the  education  of  physicians 
through  first-class  medical  institutions.  The  State 
can  do  this  through  boards  which  are  independent  of 
party  politics.  Parsons,  in  speaking  of  the  meagre 
endowment  of  medical  schools  corresponding  to  those 
made  to  other  educational  institutions,  says:  "For- 
tunately, the  closing  year  of  this  century  seems  to  in- 
dicate a  change  in  the  attitude  of  philanthropists 
toward  medical  schools."  In  my  mind  there  ought 
not  to  be  any  necessity  for  the  medical  schools,  insti- 
tutions of  vital  importance  for  the  people,  to  be  de- 
pendent upon  alms.  Dr.  Roosa,  president  of  the  New 
York  Post-Graduate  School,  is  reported  to  have  said: 
"  I  hold  that  the  State  ought  to  furnish  sufficient  funds 
for  the  adequate  and  thorough   instruction  of  all  the 


494 


MEDICAL    RECORD. 


[September  29,  1900 


pupils  in  every  medical  institution  already  legally 
organized,  and  for  such  others  as  the  increase  of  popu- 
lation may  cause  to  be  established  under  the  regula- 
tion of  the  State."  Contrary  to  Dr.  Roosa,  I  hold 
that  the  State  has  not  the  right  to  support  private  cor- 
porations at  the  expense  of  all  citizens.  If  the  differ- 
ent political  divisions  would  take  charge  of  the  medi- 
cal schools  there  would  be  a  decrease  in  the  number 
and  an  improvement  in  the  quality.  I  naturally 
admit  that  we  have  some  good  private  medical  schools; 
this,  however,  does  not  change  the  aspect  and  does 
not  excuse  a  system  which  has  detrimental  effects  upon 
the  medical  profession  and  upon  the  public.  Condi- 
tions at  present  equal  a  hazard  game.  It  is  not  nec- 
essary for  me  to  indulge  at  length  on  this  subject 
before  this  body.  I  may  be  permitted  to  quote  only 
tile  remarks  made  by  the  Bostflii  Medical  and  Surgical 
Journal  (October  12,  1899).  which,  in  speaking  of 
"  uniformity  requirements,"  says:  "We  need,  first,  to 
reform  our  medical  education,  and,  when  that  is  satis- 
factorily done,  uniformity  of  standard  will  be  attained 
without  recourse  to  legislation.  We  are,  therefore, 
strongly  of  the  opinion  that  the  real  question  at  issue 
is  to  regulate  the  character  and  attainments  of  the  men 
who  are  about  to  study  medicine,  rather  than  to  attempt 
to  legislate  into  positions  of  respect  men  who,  from 
the  beginning,  were  unfitted  for  the  duties  and  respon- 
sibilities of  tlieir  profession.'' 

In  establishing  reciprocity,  the  question  of  prelim- 
inary and  medical  education  is  of  paramount  impor- 
tance, and  there  cannot  be  an  independent  member  of 
the  medical  profession  who  would  not  admit  that 
uniform  training  is  the  foundation  of  uniform  rights 
in  all  States  and  Territories.  We  fully  agree  witii 
Dr.  William  Warren  Potter  when  he  says  under  the 
heading,  "  Equality  of  Standards  a  Basis  for  Reci- 
procity "  :  '  "  The  only  equitable  basis  upon  which  reci- 
procity can  be  established,  that  appears  both  feasible 
and  practicable,  is  that  of  equality  of  standards  for 
admission  to  the  study  and  practice  of  medicine. 
This  implies  an  equalization  of  the  preliminary  re- 
quirements of  medical  students  and  a  uniformity  of 
applying  the  tests,  a  uniform  period  of  collegiate 
training,  including  uniformity  of  methods  of  teaching, 
and,  finally  an  absolute  similarity  in  the  method  of 
conducting  State  examinations  and  granting  licenses." 
Dr.  Potter's  ideas  are  known  to  you.  no  doubt.  I  wish 
they  were  known  to  the  whole  medical  profession  in 
the  United  States. 

I  might  mention  here,  that  it  is  distinctly  under- 
stood by  all  parties  that  it  is  not  expected  that  any 
board  lowers  the  standard  of  requirements.  Also  some 
other  points  should  be  considered.  I  may  be  per- 
mitted to  quote  part  of  a  letter  which  I  received  from 
the  Maryland  State  Board.  It  reads:  "The  board  is 
not,  at  present,  disposed  to  enter  into  reciprocal  rela- 
tions with  other  States  without  receiving  some  power 
by  exercise  of  which  an  undesirable  physician  could 
be  kept  out  of  Maryland;  a  man  might  be  all  right 
when  he  received  your  license,  and  subsequently  be- 
come very  bad."  This  letter  I  regard  as  very  impor- 
tant. The  board  acknowledges  the  necessity  of  exer- 
cising some  kind  of  a  control  of  the  moral  character 
of  a  physician,  if  I  understand  the  letter  rigiit.  There 
does  not  exist  any  doubt  that  such  a  control  is  very 
desirable,  even  necessary.  In  this  respect  the  answer 
is  very  suggestive  to  all  boards  and  legislators.  On 
the  other  hand,  I  cannot  understand  that  this  question 
touches  directly  upon  the  interstate  reciprocity  agree- 
ment. If  a  man  is  undesirable  in  one  State  he  cer- 
tainly is  undesirable  in  all  States — not  less  so  in  his 
own  State.     We  have  here  to  deal  with  two  questions 

'  "  Reciprocity  in  Medical  Licensure;  a  Plea  for  Interstate 
Indorsement."  The  Bulletin  of  the  American  Academy  of  Medi- 
cine, vol.  iii,,  No.  I. 


which  are  practically  independent  one  of  another,  and 
the  disapproval  of  existing  conditions  concerning  one 
point  does  not  excuse  the  refusal  to  co-operate  in  an- 
other. 

There  is  also  a  letter  from  another  board  in  my 
hand,  the  contents  of  which  will  be  of  great  interest. 
It  reads,  in  part:  "We,  as  a  board,  have  made  it  a 
rule  to  issue  no  license  to  practitioners,  except  in 
compliance  with  the  requirements  of  our  own  laws. 
Owing  to  the  fact  that  some  States  which  have  good 
medical  laws  seem  to  have  boards  that  are  very  lax  in 
enforcing  their  requirements,  we  have  deemed  this 
course  not  only  advisable  but  absolutely  necessary  in 
regulating  this  matter  in  our  own  State.  So  long  as 
the  authority  for  authorizing  a  license  is  invested  in 
the  members  of  the  board  to  the  degree  that  it  is  in 
many  of  the  States,  we  do  not  feel  that  we  can  consist- 
ently enter  into  any  interstate  reciprocity,  even  if  we 
had  liie  legal  power  to  do  so.  This  board  has  just 
received  a  personal  recommendation  from  the  presi- 
dent of  the State  board  of  medical   examiners, 

in  behalf  of  a  man  whose  sole  claim  for  recognition 
was  a  diploma  issued  by  one  of  the  most  disreputable 
"mills"  in  the  country.  As  long  as  State  boards  are 
so  entirely  indifferent  in  performing  their  duties  as 
the  one  above  mentioned  (the  applicant  is  a  registered 

practitioner  in  ■ ),   we    are    distinctly  opposed    to 

reciprocity  with  such  people.  It  is  needless  to  say 
that  the  applicant  was  refused  a  certificate.'' 

My  remarks  made  before  apply  also  to  this  letter. 
Nobody  expects  that  any  board  recognize  diplomas  of 
diploma  mills.  The  boards  can  agree  upon  a  few 
colleges  the  diplomas  of  which  they  will  recognize, 
without  including  the  others.  It  should  not  be  diffi- 
cult to  select  some  medical  schools  which  require  a 
high  preliminary  education  and  which  guarantee  a 
thorough  medical  training. 

Although  we  recognize  the  commendable  work  done 
by  the  Association  of  the  American  Medical  Colleges, 
the  boards,  in  my  mind,  cannot  recognize  all  the  col- 
leges of  the  same.  The  association  may  be  a  very 
necessary  institution,  but  as  far  as  the  profession  in 
general  is  concerned,  and  also  the  public  and  the 
boards  which  form  the  connective  link  between  the 
public  and  the  profession,  there  does  not  exist  a  close 
connection  between  them. 

As  I  expressed  it  on  another  occasion,  in  establish- 
ing interstate  reciprocity  the  process  of  evolution  has 
to  be  followed,  in  order  to  have  a  sound  development. 
There  is  no  doubt  in  my  mind  that  by  steady  work 
and  perseverance  the  desired  results  will  be  attained 
in  the  course  of  time.  The  question,  however,  arises, 
whetiier  anything  can  be  done  immediately  toward  the 
end  in  view.  It  appears  to  me  that  we  may  answer 
this  question  in  the  affirmative.  In  a  communication 
to  the  Alcdical  E.\ami>ter,  of  New  York,  I  took  occasion 
to  state  my  view  concerning  the  temporary  division  of 
States  into  six  groups,  taking  as  a  basis  the  prelimi- 
nary education,  the  medical  education  proper,  and  the 
final  State  examination.  This  view  was  commented 
upon  by  the  New  York  Medical  Journal  oi  January  20, 
igoo.  ['arsons,  in  his  work,'  says:  "The  present 
needless  multiplication  of  standards,  however,  is  most 
unfortunate.  Instead  of  a  separate  standard  for  each 
political  division,  two,  or  at  most  three,  standards 
should  answer  for  all." 

It  assuredly  would  be  preferable  to  have  two  or 
three  groups  instead  of  six,  hut  I  doubt  whether  such 
an  advanced  step  can  be  taken  at  present.  I  admit 
that  six  groups  are  a  little  numerous,  but  six  are  pref- 
erable to  fifty-one  or  more  groups.  There  is  no  doubt 
that  the  formation  of  groups  would  not  only  benefit  a 
great  part  of  the  medical  profession  immediately,  but 
also  would  help  toward  the  final  aim.  No  better  proof 
'  Loc.  lit. ,  p.  45. 


September  29,  1900] 


MEDICAL    RECORD. 


495 


can  be  brought  forward  in  favor  of  this  view  than  the 
welcome  and  timely  action  of  the  boards  of  the  New 
England  States.  There  was  a  meeting  held  at  the 
State  House  at  Boston,  on  February  i,  1900,  which, 
in  my  mind,  is  of  fundamental  importance  in  the  his- 
tory of  medicine  in  the  United  States.  Not  too  much 
praise  can  be  given  to  the  originator  of  the  meeting 
and  to  those  who  participated  in  the  same.  V\'e  read 
in  the  report  that  "the  object  of  the  meeting  was 
presented  by  the  president,  who  stated  that  it  was  gen- 
erally conceded  that  reciprocity  would  be  desirable, 
and  suggested  the  need  of  discovering  the  best  means 
of  guiding  the  legislation  in  order  to  unify  the  laws 
governing  medical  practice  in  the  different  States. 
Efforts  should  be  made  to  secure  like  standards,  uni- 
form severity  of  examinations  and  markings,  like  dura- 
tion of  examinations,  like  subjects,  the  same  fees,  the 
same  rules  as  to  conditions,  etc.,  and  the  same  fre- 
quency of  meetings  in  the  various  States." '  The 
medical  profession,  I  think,  is  e.\pecting  to  see  other 
groups  formed.  I  know  that  the  great  majority  of  the 
boards  have  not  the  right  to  enter  reciprocity  until  the 
laws  of  the  respective  States  and  Territories  have 
been  changed. 

Experience  teaches  us  that  it  requires  great  efforts 
on  the  part  of  the  medical  profession  to  educate  the 
law-makers  and  the  ])ub!ic,  in  order  to  convince  them 
of  the  usefulness  and  necessity  of  changes.  L'nfortu- 
nately,  it  seems  that,  for  some  reason  or  other,  the 
law-makers  are  sometimes  more  influenced  by  the  ad- 
versaries of  the  general  good  than  by  the  friends  of 
the  same.  We  fully  agree  with  Dr.  William  W.  Potter 
wnen  he  bitterly  complains  of  this  fact. 

Also  another  step  forward  can  be  made  without 
much  delay  and  trouble.  The  secretary  of  the  Ameri- 
can Academy  of  Medicine,  Dr.  Mclntire,  offers  the 
following  commendable  suggestion  in  the  Bulletin 
of  the  .American  Academy  of  Medicine  (December. 
1899)  :  "To  hasten  the  desired  result  it  would  be  well 
if  the  various  licensing  bodies  would  take  cognizance 
of  the  fact  that  the  legal  minimum  requirements  are 
more  severe  in  some  States  than  in  others,  even  though 
the  board  may,  at  its  own  volition,  keep  the  standard 
higher  than  the  minimum  requirements  specified  by 
law,  and  where  any  State  has  minimum  requirements 
less  exacting  than  those  of  another  State,  if  it  would 
accept  the  licenses  from  another  State  having  the 
higher  legal  requirements  without  reciprocity  it  would 
work  no  harm  to  its  own  physicians  and,  at  the  same 
time,  show  a  good  will  that  could  not  but  help,  in  the 
course  of  time,  to  aid  in  the  general  exchange  of 
licenses."  I  fully  agree  with  the  doctor,  and  I  think 
it  is  an  injustice  to  make  reciprocity  dependent  upon 
the  condition  that  the  certificates  of  the  weaker  States 
are  accepted  by  the  stronger  States.  It  seems  to  me 
that  the  boards  should  not  place  a  tariff  on  knowledge 
and  skill.  If  the  weaker  divisions  are  unable  to  fur- 
nish a  sufficiently  good  education,  the  boards  should 
welcome  the  licentiates  from  the  stronger  divisions. 
This  will  work  as  a  stimulus  to  the  weaker  divisions, 
and  is  justifiable  from  a  moral  and  humane  point  of 
view. 

Concerning  the  relation  of  the  medical  profession 
in  general  to  the  National  Confederation,  in  the  efforts 
toward  interstate  reciprocity,  we  readily  see  that  their 
work  is  interwoven.  I  may  be  permitted  to  call  at- 
tention to  some  other  points  in  connection  herewith. 
We  know  that  it  is  the  aim  and  the  object  of  the 
National  Confederation  of  the  State  Mediqal  Examin- 
ing and  Licensing  Boards  to  establish  the  standard  of 
medical  education  in  all  its  details.  We  know  also 
of  the  good  work  the  Confederation  is  doing,  and  are 
already  convinced  that  its  efforts,  in  general,  are  in 
the  right  direction.  Therefore,  it  appears  to  me  that 
'  Rhode  Island  Monthly  Bulletin,  February.   1900,  p.  45. 


the  medical  profession  can  heartily  indorse  the  work 
of  the  Confederation  and  pledge  their  support  in  pur- 
suing the  same. 

The  co-operation  of  the  medical  profession  at  large 
is  shown,  and  can  still  more  be  shown,  in  the  follow 
ing  ways  which  are  familiar  to  you.  In  the  first  place, 
it  is  advisable  that  the  medical  profession  constantly 
keep  in  touch  with  the  work  and  with  the  intentions 
of  the  Confederation.  In  this  way  the  profession  will 
be  aware  of  the  progress  of  the  work  I  may  suggest, 
in  this  place,  that  a  journal,  perhaps  a  bi  monthly 
journal,  be  edited  by  the  Confederation  in  co-opera- 
tion with  the  profession  at  large.  It  might  treat  all 
subjects  in  connection  with  interstate  reciprocity  and 
higher  medical  education  The  profession  could  thus 
become  more  thoroughly  acquainted  with  all  the  de- 
tails of  the  question. 

Furthermore,  the  medical  profession  can  materially 
assist  the  boards  in  helping  to  establish  and  to  change 
the  laws  in  the  different  political  divisions  This, 
I  think,  can  be  regarded  as  the  most  important  assist- 
ance on  the  part  of  the  profession  It  appears  to  me 
that  in  this  time  of  unsettled  affairs  a  public  spirited 
citizen,  even  if  he  be  a  physician,  has  the  duty  to  do 
all  in  his  power  to  instruct  and  to  educate  the  public 
concerning  these  subjects  Can  we  expect  otherwise 
to  accomplish  anything,  and  who  else  could  do  this 
work  if  the  medical  profession  will  not  do  it?  I  can- 
not believe  that  law-makers  have  not  the  intention  to 
work  for  the  good  of  the  people  If  they  sometimes 
are  more  inclined  to  follow  the  advice  of  the  enemies 
of  the  welfare  of  the  community,  this  fact  certainly 
can  be  explained,  in  most  cases  if  not  in  all,  by  the 
lack  of  understanding.  I  think  that  the  medical  pro- 
fession itself  is  to  blame  for  this  to  a  great  extent. 
The  medical  profession  should  furnish  to  the  law 
makers  the  necessary  knowledge  We  have  a  powerful 
profession  in  the  United  States,  and  if  all  members, 
or  the  great  majority  of  the  same,  would  be  a  little 
more  aware  of  their  duties  as  citizens  and  use  their 
inffuence,  uniting  their  efforts  toward  an  improvemer.t, 
there  would  be  a  speedy  change  It  has  recently  been 
seen  in  Michigan  vihat  the  medical  profession  can  do. 
There  is  no  doubt  that  the  physicians  under  proper 
guidance,  have  a  great  influence  upon  public  opinion, 
and  nothing,  it  seems  to  me,  has  greater  weight  upon 
the  law-makers  than  the  latter.  Individually  and  col 
lectively  the  medical  profession  should  stand  by  the 
Confederation  in  this  respect. 

The  Jcurncil  of  the  American  Medical  Association 
(May  12,  1900),  speaking  of  the  Ohio  medical  law, 
says  (on  page  1205):  "The  passage  of  this  amended 
law  is  full  of  fruition  of  the  dreams  of  many  years  of 
the  leading  Ohio  members  of  the  profession,  and  it 
required  the  most  assiduous  and  most  self  sacrificing 
labor,  on  the  part  of  the  legislative  committee  of  the 
State  Medical  Society,  assisted  by  committees  of  the 
local  societies.  The  result,  however,  clearly  demon 
strates  that  when  the  medical  profession  shows  itself 
to  be  determined  in  its  requests  to  the  politicians  it 
can  overcome  all  opposition," 

Also  another  important  factor  should  be  considered. 
We  know  that  the  public  opinion  is  largely  influenced 
by  the  daily  press.  I  think  it  is  commendable  to  in- 
terest the  daily  press  and  to  furnish  the  individual 
editors  with  material.  They  will  draw  the  proper 
conclusions  themselves.  It  affords  me  great  satisfac 
tion  to  state  that  the  people  of  Michigan  are  greatly 
indebted  to  the  daily  press  in  our  State  for  their  new- 
law.  I  am  especially  familiar  with  the  assistance  of 
the  press  in  Detroit.  With  great  interest  the  press 
watched  the  work  of  the  better  part  of  the  profession. 
After  becoming  convinced  of  the  necessity  of  changes, 
it  worked  for  them  with  unceasing  efforts,  and  could 
see  its  work  crowned  with  success.     Independent  of 


496 


MEDICAL   RECORD. 


[September  29,  1900 


one  another  in  their  ways,  combined,  however,  by  the 
general  principles  of  humanity,  the  press  and  the  pro- 
fession in  Michigan  have  worked  together  for  the  ben- 
efit of  all,  and  I  sincerely  hope  that  both  will  continue 
to  do  so  in  the  future.  The  greater  part  of  the  work 
is  still  before  us  (I  may  mention  tiiat  at  that  time  there 
did  not  exist  a  State  board  in  Michigan;  it  has  been 
created  since  then  by  united  efforts).  Should  the  lay 
press  in  all  sections  of  the  United  States  follow  the 
ex.imple  set  by  the  papers  in  Detroit,  conditions  all 
over  the  country  would  improve  more  quickly. 

The  co-operation  of  the  medical  profession  with  the 
boards,  to  their  mutual  benefit,  can  also  be  shown  in 
a  way  wliich  suggests  itself  to  me  through  a  communi- 
cation by  Dr.  John  S.  Lewis,  president  of  the  Dubuque 
Medical  Society.  Dr.  Lewis  says,  partly  quoting  from 
another  source : 

"  State  boards,  from  the  manner  of  their  appoint- 
ments, are  transient  not  only  as  to  their  constitution 
but  as  to  their  character.  They  are  often  creatures  of 
a  political  system,  with  which  barter  and  sale,  and 
compromises,  and  pledges  have  haq  to  do,  and  they 
owe  debts;  the  result  is  that  some  of  them  will  be 
efficient  and  some  will  not  and  that  the  element  of 
stability  in  their  judgments  will  be  lacking.  State 
pride  of  a  very  poor  quality  will  influence  a  certain 
order  of  minds  to  favor  the  product  of  their  own  State 
institutions,  and  it  is  not  inconceivable  that  even 
worse  motives  may  actuate  them.  Besides  this,  who 
is  going  to  judge  of  the  standing  of  the  various  State 
boards  and  assign  them  to  their  proper  places  in  the 
si.x  classes  you  propose  ?  " 

I  may  answer  that  we  should  consider  that  we  are 
obliged  to  start  the  work  with  our  present  material. 
The  State  boards  will  improve,  no  doubt,  in  the  same 
degree  as  the  profession  in  general.  Both  will  co- 
operate with  each  other  for  their  mutual  improvement. 
Concerning  the  si.x  groups  and  the  assigning  of  the 
various  boards  to  their  places  I  should  like  to  say  that 
the  formation  of  groups  should  not  be  based  on  the 
quality  of  the  boards  so  much  as  on  the  sufficiency  of 
the  laws.  There  exists  little  doubt  in  my  mind  that 
the  members  of  the  various  groups  will  e.xercise  a 
sharp  control  among  themselves. 

There  is  still  another  way  in  which  the  individual 
physician  can  help  to  purify  the  medical  profession 
and  at  the  same  time  help  the  cause  under  considera- 
tion;  I  am  thinking  of  the  duty  of  a  physician  to 
withdraw  his  support  from  advertising  medical  jour- 
nals. It  has  been  said  we  have  two  hundred  and  fifty 
medical  journals  in  the  United  States.  A  great  many 
of  these  journals  are  certainly  not  only  superfluous  but 
they  are  absolutely  detrimental  to  a  higher  medical 
education  and  to  the  profession.  Furthermore,  the 
medical  profession  can  work  in  the  behalf  of  interstate 
reciprocity  and  higher  medical  education  by  con- 
stantly keeping  in  mind  that  medical  schools,  with 
greater  benefit  to  all,  should  be  public  institutions,  as 
I  mentioned  before.  In  connection  herewith  permit 
me  to  add  part  of  an  editorial  of  the  Philadclpliia 
Medical  Journal  oi  May  5,  1900,  which  comments  upon 
the  ideas  of  Dr.  Bowditch,  of  Boston,  expressed  in  his 
paper,  "The  Medical  School  of  the  Future."  The 
Journal  sSiys,  among  other  things: 

"These  suggestions  are  of  the  greatest  importance 
for  the  future  of  American  medicine;  the  introduction 
of  the  university  idea,  the  laboratory  method  of  in- 
struction, the  practical  examination  to  test  the  stu- 
dent's real  fitness  for  practice,  and  even  the  Harvard 
arrangement  of  courses  in  due  sequence,  are  all,  ap- 
parently, past  the  experimental  stage.  Kvery  member 
of  the  profession  should  use  his  influence  to  support 
such  schools  as  are  working  for  these  ideals,  and  the 
entire  profession,  through  its  societies,  should  organ- 
ize to  support  sucii  schools  and  to  use  the  profession's 


best  influence  to  crush  the  inefficient  diploma  mills 
which  exist  in  such  numbers  in  almost  all  parts  of 
our  country.  Aside  from  the  more  ideal  motive  of 
striving  for  that  which  is  best  in  medical  progress, 
there  is  the  very  practical  motive  which  must  appeal 
to  every  practitioner,  that  the  profession  is  daily  be- 
coming more  and  more  crowded  with  inefficient  men. 
According  to  the  Bulletin  on  Projcssional  Ei/u cation, 
of  the  University  of  Xew  York,  there  is  already  one 
doctor  to  about  six  hundred  inhabitants  in  most  sec- 
tions of  the  country,  and  if  this  increase  continues 
an  honorable  living  in  the  medical  profession  will  be 
almost  impossible." 

In  following  out  this  principle  the  co-operation  of 
the  medical  profession  with  the  Confederation  will 
not  only  serve  the  purpose  mentioned,  but  will  also 
more  or  less  improve  the  conditions  of  which  we  con- 
stantly read,  viz.,  the  overcrowding  of  the  medical 
profession,  unethical  advertising,  the  catering  to  igno- 
rant and  incompetent  pretenders,  the  question  of  the 
different  pathies,  the  leaning  toward  Christian  scien- 
tists and  toward  patent  medicines,  the  question  of 
specialism,  the  position  of  medical  experts,  the  dark 
sides  of  medical  journalism  which  I  mentioned  be- 
fore, of  lodge  practice,  the  abuse  of  free  dispensaries 
on  the  part  of  the  profession  and  the  public,  the  social 
standing  of  the  medical  profession  in  general,  etc.  At 
present  we  are  moving  in  a  ''  circulus  vitiosus."  United 
efTortsof  the  Confederation  and  of  the  medical  profes- 
sion should  create,  instead  of  it,  a  "  circulus  nobilis." 

That  a  greater  part  of  the  medical  profession  all 
over  the  United  States  understands  its  position  is 
clearly  shown  by  the  great  interest  which  the  medical 
press,  medical  societies,  and  individual  physicians 
take  in  the  work  aiming  at  interstate  reciprocity.  Also 
the  laity  is  beginning  to  take  interest  in  the  question. 
In  order  to  further  the  movement  I  venture  to  suggest 
that  an  interstate  reciprocity  committee  be  appointed 
by  the  National  Confederation  of  State  Medical  Ex- 
amining and  Licensing  Boards,  which  may  keep  in 
touch  with  all  other  interstate  reciprocity  committees 
which  may  be  appointed  by  other  bodies,  and  also 
that  this  or  a  separate  committee  may  be  authorized 
to  publish  an  Interstate  Reciprocity  Journal  ^ex\\3.-ps  in 
connection  with  the  medical  profession  at  large — if  it 
sees  fit  to  do  so. 

In  conclusion,  permit  me  to  say  that  the  movement 
is  important  also  for  another  reason.  It  seems  to  me 
that  the  next  century  will  witness  tiie  greatest  progress 
in  the  history  of  mankind  in  regard  to  hygienic  meas- 
ures. It,  perhaps,  will  be  called  the  "  hygienic  century." 
A  hundred  years  hence  the  then  living  generation  will 
be  entitled  to  name  it  so,  if  only  the  facts  discovered 
in  this  century  will  have  more  generally  been  used  for 
the  ad\ancement  and  happiness  of  the  human  race. 
We  have  reason  to  believe  that  this  will  be  done. 
With  unusual  activity  all  civilized  nations  are  taking 
part  in  the  fight  against  the  ravages  of  diseases,  e.g., 
tuberculosis.  It  is  the  duty  of  the  National  Confeder- 
ation of  State  Medical  Examining  and  Licensing 
Boards  to  provide  for  a  well-prepared  medical  profes- 
sion which  will  be  leading  in  the  march  of  progress, 
and  it  is  the  desire  of  the  medical  profession  of  to-day 
to  do  all  in  their  power  to  help  the  Confederation  to 
this  end.  Afay  every  single  member  of  the  profession 
contribute  his  share. 

Even  a  superficial  study  of  the  question  will  con- 
vince every  citizen  of  the  United  States,  be  he  a  phy- 
sician or  not,  that  the  establishment  of  interstate  re- 
ciprocity for  tlie  license  to  practise  medicine  is  in  the 
interest  of  all. 

Woman's   Medical    Rights    in   Austria.— Women 

are  now  empowered  to  practise  medicine  and  pharmacy 
in  Austria  on  the  same  conditions  as  men. 


September  29,  1900] 


MEDICAL    RECORD. 


497 


TREATMENT    OF    FRACTURED    PATELL.-E. 
By   WILLIAM   B.    TRIMBLE,    M.D., 

INSTRUCTOR    IN  CLINICAL  St" RGERV  (NEW   YORK  L'NIVERSITv),  UNIVERSITY  AND 
BELLEVUB    HOSPITAL  MEDICAL    COLLEGE. 

Realizing  fully  that  this  subject  has  been  very  widely 
discussed  and  is  somewhat  time-worn,  it  is  my  desire 
to  give  a  short  re'sume  of  the  different  ideas  of  treat- 
ment in  cases  of  fractured  patella,  and  to  speak  briefly 
in  advocacy  of  the  wire-suture  method,  reporting  three 
cases  operated  on  by  me  in  this  manner. 

The  causes  of  fractured  patellaj,  like  those  of  frac- 
tures elsewhere,  are  direct  violence  and  muscular  ac- 
tion. Direct  violence  usually  produces  comminuted 
fracture,  and  past  writings  upon  this  subject  show 
quite  conclusively  that  bony  union  in  this  variety  of 
cases  is  a  frequent  result;  one  accountable  reason  for 
this  is  that  the  comminution  and  multiplicity  of  frag- 
ments produce  a  larger  extent  of  raw  surface;  hence 
more  callus  is  formed.  However,  we  must  guard  against 
ankylosis,  which  is  often  a  serious  source  of  trouble 
in  these  cases.  All  fractures  of  the  patella;  from 
muscular  action  are  transverse,  and  as  this  variety  is 
the  one  most  frequently  encountered  by  the  surgeon, 
this  article  is  confined  more  or  less  to  a  consideration 
of  cases  of  simple  transverse  fracture  of  the  patella;. 

To  get  bony  union  is  the  aim  of  all  our  efforts,  and 
to  do  this  the  fragments  are  to  be  brought  together 
and  held  (with  the  accent  on  the  held)  in  direct  ap- 
position. Surgeons  of  the  present  day  do  not  expect 
union  from  non-opt^rative  treatment,  and,  although  it 
may  happen  in  rare  instances,  it  is  a  surgical  curi- 
osity. 

From  a  palliative  standpoint,  numerous  splints  and 
appliances  have  been  devised;  all  of  which  have  the 
same  end  in  view,  viz.,  direct  apposition,  bony  union, 
etc. 

A  few  of  the  best  of  these  methods  will  here  be 
enumerated.  A  time-honored,  popular,  and  excellent 
method  is  that  with  adhesive  or  rubber  plaster  strips. 
A  posterior  wooden  splint,  padded,  should  be  applied, 
extending  from  the  middle  of  the  thigh  to  the  tendo 
Achillis;  a  compress  is  placed  just  above  the  upper 
fragment;  and  over  this,  in  an  oblique  direction, 
should  be  placed  a  strip  of  adhesive  plaster  about  one 
or  one  and  a  half  inches  wide,  which  is  carried  down- 
ward encircling  the  leg  and  splint  below  the  lower 
fragment;  the  lower  fragment  should  be  treated  in  the 
same  manner,  and  the  strip  of  plaster  carried  upward 
and  attached  to  the  splint  and  thigh  above  the  upper 
fragment;  a  roller  bandage,  carried  from  the  instep  to 
the  middle  of  the  thigh,  completes  the  dressing.' 

Agnew's  splint  may  also  be  employed;  it  consists 
of  a  posterior  wooden  splint  with  pegs,  to  wliich  tlie 
ends  of  the  rubber  plaster  are  fastened.  It  is  a  modi- 
fication of  the  foregoing,  and  tlie  end  in  view  is  identi- 
cal. Other  splints,  such  as  Manning's,  Thomas',  etc., 
have  been  put  forward  by  their  originators,  and  have 
their  followers,  but  time  and  space  prevent  a  full  de- 
scription of  them;  however,  as  said  before,  they  like 
the  others  have  the  same  objective  point. 

All  splints  should  be  worn  from  six  to  eight  weeks, 
during  which  time  the  foot  is  kept  elevated  to  relax 
the  quadriceps  as  much  as  possible;  after  this,  a 
plaster-of-Paris  dressing,  split  down  the  centre  to 
facilifate  removal  and  passive  motion,  is  worn,  the 
length  of  time  being  left  to  the  attending  surgeon  in 
each  individual  case. 

We  now  come  to  what  may  be  called  the  semi- 
operative  treatment,  and  under  this  head  will  be 
placed  Malgaigne's  hooks,  the  long  steel  pins  of  Mayo 

'  The  case  of  Harriet  C was  treated  by  the  author  in  this 

manner.  She  was  seen  almost  immediately  after  injur)-,  and  as 
the  quadriceps  had  not  contracted  there  was  practically  no  sepa- 
ration of  the  fragments.     A  beautiful  result  was  obtained. 


Robson,  and  the  circumpatellar  subcutaneous  suture 
of  Mr.  Barker. 

Malgaigne's  hooks  have  been  justly  called  instru- 
ments of  torture,  owing  to  the  severe  pain  and  exces- 
sive irritability  that  they  produce,  and  oftentimes  the 
complaints  of  the  patient  will  be  so  forcible  that  it 
will  be  found  inexpedient  to  use  them;  however,  it 
must  be  said  in  their  favor  that  they  come  nearer  to 
accomplishing  the  purpose  sought  than  most  appliances. 
In  treating  a  fractured  knee-cap  by  this  method, 
thorough  antisepsis  should  be  resorted  to,  and  the 
punctures,  four  in  number,  are  first  made  down  to  the 
bone  with  a  tenotome;  the  hooks  are  then  inserted, 
first  in  the  lower  and  then  in  the  upper  fragment,  and 
the  parts  are  brought  together  by  turning  the  approxi- 
mating screw. 

The  treatment  by  long  steel  pins  is  usually  credited 
to  Mayo  Robson,  of  England;  they  have  been  used  to 
some  extent  and  have  undoubtedly  some  favorab'e  re- 
sults. The  writer  first  saw  this  method  demonstrated 
by  Dr.  James  E.  Kelly,  of  this  city.  It  consists  in 
passing  two  steel  pins  each  about  six  inches  long  close 
to  the  fragments,  one  through  the  tendon  of  the  quad- 
riceps and  the  other  through  the  ligamentum  patellse; 
the  ends  are  then  wrapped  in  a  figure-8  manner  with 
heavy  silk  or  silver  wire  to  draw  the  fragments  to- 
gether. An  addition  to  the  technique  of  the  above 
plan  was  to  take  the  third  pin,  plunge  it  in  one  side 
of  the  joint,  between  the  fragments,  but  not  allowing 
it  to  emerge  through  the  skin  of  the  opposite  side,  and 
an  upward  and  backward  sawing  motion  was  gone 
through  with,  as  the  pin  was  withdrawn ;  it  was  sug- 
gested in  the  hope  that  any  interposed  tissue  might  be 
lifted  from  between  the  pieces.  The  idea  is  some- 
what far-fetched  and  not  practical. 

The  best  of  the  semi-operative  procedures  to  be  dis- 
cussed here  is  the  circumpatellar  subcutaneous  suture 
of  Mr.  Barker;  the  technique  is  somewhat  similar  to 
the  subcutaneous  operation  for  varicocele,  viz.,  the 
long  curved  needle  is  passed  through  the  ligamentum 
patellse,  close  to  the  lower  border  of  the  lower  frag- 
ment, under  the  patellfc,  and  brought  out  through  the 
tendon  of  the  quadriceps  and  skin,  and  then  threaded 
with  heavy  silk  or  silver  wire  and  withdrawn;  the 
needle  is  again  inserted  through  the  original  puncture, 
this  time  going  over  the  broken  bone,  and  threaded 
with  the  other  end  of  the  suture  ;  the  ends  are  then  tied 
tightly  into  several  knots.  The  originator  lays  claim 
to  many  good  results,  and  the  method  is  steadily  grow- 
ing in  favor  in  England. 

Very  recently,  that  is,  within  the  past  year,  several 
cases  of  fractured  patellae  treated  by  the  so-called 
massage  treatment  were  presented  at  the  Academy  of 
Medicine;  it  developed  during  the  discussion  that 
the  treatment  consisted  in  putting  up  the  injury  with 
the  posterior  splint  and  adhesive  plaster  strips,  it  be- 
ing daily  taken  down,  and,  while  the  surgeon  strongly 
held  the  fragments,  a  masseur  manipulated  the  injured 
limb,  beginning  at  the  hip  and  working  down  to  the 
knee. 

The  writer  does  not  wish  to  criticise  massage  ad- 
versely in  any  way,  as  it  undoubtedly  has  its  advan- 
tages, viz.,  relieving  pain,  increasing  the  circulation, 
removing  exudate,  and  acting  as  a  form  of  passive 
motion,  etc. ;  but  we  are  forced  to  agree  with  one  of 
the  gentlemen  in  the  discussion,  that  the  term  "mas- 
sage treatment"  is  somewhat  of  a  misnomer,  as  the 
cases  referred  to  had  been  previously  treated  by  the 
surgical  appliances  used  by  most  medical  men. 

Numerous  ideas  and  plans  of  treatment  arise  from 
time  to  time,  and  efforts  sometimes  crowned  with  some 
success  have  been  made  to  supply  the  profession  with 
a  contrivance  which,  while  keeping  up  the  proper 
amount  of  extension,  would  not  confine  the  patient  to 
bed.     A  most  unique  device  of  this  kind  w-as  suggested 


498 


MEDICAL   RECORD. 


[September  29,  1900 


by  Dr.  Joseph  D.  Bryant;  its  description  being  a  little 
too  long  to  incorporate  in  this  article,  the  reader  is 
referred  to  the  Medical  Record  of  April  4,  1896. 
As  said  above,  various  kinds  of  treatment  occasionally 
present  themselves,  and  although  some  are  unique  in 
design,  possessing  perhaps  some  new  advantage,  tiie 
main  objectionable  features  still  e.\ist. 

We  come  now  to  the  operation  proper.  Our  text- 
books tell  us  that,  although  this  operation  seems  to  be 
a  brilliant  mode  of  treatment,  it  is  sometimes  asso- 
ciated with  loss  of  limb,  and  has  been  known  in  some 
instances  to  endanger  life;  therefore  they  have  drawn 
the  conclusion  that  the  nature  of  the  lesion  does  not 
warrant  such  heroic  measures.  This  opinion  was 
maintained  by  some  of  our  older  writers,  and  is  still 
held  by  a  number  of  the  surgeons  of  the  present  day, 
consequently  the  operation  has  been  slightly  over- 
shadowed, though  it  has  by  no  means  fallen  into  dis- 
repute. In  the  last  few  years,  this  method  has  been 
strongly  urged  by  Dr.  Charles  Phelps  of  this  city,  in 
whose  practice  I  have  had  occasion  to  see  many  happy 
results.  .\11  forms  of  treatment  admit  of  cavilling 
and  argument,  but  after  a  careful  review  of  the  whole 
subject  both  practically  and  theoretically,  the  radical 
operation  seems  to  have  the  fewest  objections.  They 
are  the  same  as  those  against  operation  on  any  part  of 
the  human  body,  viz.,  fear  of  shock,  anesthesia,  and 
suppuration.  The  physical  shock  accompanying  this 
procedure  is  no  greater  and  no  more  to  be  feared  than 
in  operations  on  other  parts  of  the  body,  and  the  only 
danger  to  life  and  limb  appears  to  lie  in  the  fact 
that  suppuration  may  take  place,  pyjemia  result,  etc. 
Happily  the  cases  resulting  in  this  manner  are  very 
rare,  and  strict  adherence  to  the  rules  of  aseptic  and 
antiseptic  surgery  will  prevent  any  sucli  unfortunate 
occurrence. 

Objections  to  the  non-operative  plan  are  exceedingly 
numerous,  some  of  which  cannot  be  remedied  unless 
the  treatment  be  changed  and  finally  result  in  opera- 
tion. 

When  the  patella  is  brokeji  by  muscular  action, 
which  is  usually  the  case,  its  aponeurotic  covering  and 
synovial  membrane  are  in  the  great  majority  of  cases 
torn  below  the  level  of  the  line  of  fracture;  hence  we 
have  folds  of  ligamentous  and  aponeurotic  tissue  in- 
terposed between  the  fragments,  which  will  in  all  cases 
prevent  osseous  union. 

In  order  to  control  the  quadriceps  extensor  muscle, 
great  pressure  must  necessarily  be  made  over  the  upper 
fragment;  this  pressure  often  threatens  to  stop  the 
circulation,  which  is  a  serious  obstacle  to  a  good  re- 
sult, and  in  one  instance,  which  comes  to  the  author's 
mind  at  this  time,  the  tissue  over  the  whole  front  as- 
pect of  the  patella  sloughed  away.  Again,  cases  have 
come  under  the  writer's  observation,  in  which  the  pain, 
oedema,  irritation  producing  traumatic  dermatitis,  and 
other  disagreeable  symptoms  caused  by  mechanical 
contrivances  were  so  unbearable  that  they  would  not 
be  tolerated  by  the  patient.  The  above  statements 
are  corroborated  by  Manning,  of  London,  who  has 
found,  after  numerous  dissections  of  the  arteries  which 
supply  the  patella,  tliat  the  arch  by  which  the  upper 
fragment  is  supplied  is  situated  in  the  exact  place 
where  the  greatest  amount  of  pressure  is  applied,  and 
in  a  great  majority  of  cases  the  superior  and  inferior 
articular  arteries  arise  from  a  common  trunk,  thereby 
cutting  off  the  blood  supply  from  both  fragments,  he 
has  also  found  that  in  a  limb  injected  after  being 
"put  up"  for  this  fracture,  all  the  arteries  are  filled 
except  those  supplying  the  patella. 

The  fibrous  or  ligamentous  union  gained  by  the 
various  non-operative  measures  is  claimed  by  some  to 
be  equally  as  good  to  restore  function  in  the  injured 
joint  as  bony  union,  and  although  it  is  very  firm  and 
close  in  some  cases,  it  will  invariably  stretch  to  some 


degree,  and  not  a  few  cases  have  been  known  to  allow 
of  separation  to  the  amount  of  two  or  three  inches; 
this  will  undoubtedly  weaken  the  joint  and  not  infre- 
quently deprive  the  patient  of  all  power  of  extension 
in  the  limb,  and  leave  him  a  cripple  for  life.  Stim 
son  has  justly  said  "that  the  test  is  found  in  time  and 
use,"  and  it  is  quite  common  to  see  a  gap,  which  is 
very  slight  at  the  time  treatment  ends,  increase  to  the 
width  of  half  an  inch  or  more  in  the  course  of  a  few 
months.  Ankylosis  is  one  most  formidable  enemy 
in  treating  these  cases,  and  although  it  sometimes 
occurs,  especially  following  the  refracture,  if  the  limb 
be  watched  and  carefully  attended,  viz.,  lateral  motion 
and  flexion  begun  very  early,  such  a  condition  of  afTairs 
will  be  averted,  and  we  can  in  most  cases  give  a  favor- 
able prognosis. 

The  time  of  operation  seems  also  to  be  a  question 
of  dispute,  and  it  has  been  stated  by  several  surgeons 
that  the  time  proper  is  within  twenty-four  hours  after 
the  accident.  This  is  good  advice  to  follow,  provided 
all  the  acute  inflammatory  symptoms  have  subsided:  if 
not,  it  certainly  seems  to  be  better  surgery  to  wait 
until  they  have,  as  experience  very  forcibly  teaches 
that  cutting  into  cedematous  and  contused  tissue  fre- 
quently causes  sloughing,  a  condition  which  we  most 
assuredly  wish  to  avert. 

A  good  course  to   pursue  is  to  treat  the  case  pallia 
tively  by  pressure    bandages  and    cold   applications, 
until  all  swelling  and  inflammatory  signs  have  ceased. 

The  operation  undertaken  by  the  writer  in  the  cases 
reported  is  as  follows; 

The  knee  is  put  in  a  soap  poultice  twenty-four  hours 
prior  to  operation;  on  the  morning  of  operation,  it  is 
thoroughly  scrubbed  with  water  and  tr.  viridi  saponis, 
then  washed  with  solution  of  bichloride  of  mercury 
I  :  2,000  ,  this  is  followed  successively  by  turpentine,  al 
cohol,  ether,  and  lastly  bichloride  again  The  incision 
is  made  transversely  between  the  fragments,  opening 
the  joint,  all  blood  clot  is  washed  away  by  continu- 
ous irrigation  (bichloride  of  mercury  i;  2,000),  and 
the  ragged  aponeurotic  fringe  is  lifted  from  between 
the  broken  pieces.  Each  fragment  in  turn  is  drilled, 
beginning  one-eighth  to  one-fourth  inch  behind  its 
fractured  edge,  going  directly  through.  Silver  wire  is 
used,  about  the  size  or  possibly  a  little  larger  than 
the  lead  in  an  ordinary  lead-pencil ,  it  is  filed  sharp 
on  each  end  to  facilitate  insertion.  The  pieces  are 
drawn  together  by  main  force,  and  the  wire  is  twisted 
tightly,  holding  them  in  apposition;  the  ends  are  then 
cut  and  the  wire  is  hammered  down  flat  on  the  bone. 
The  subcutaneous  tissues  are  then  sewed  down  over 
the  bone  with  heavy  catgut;  a  drainage  tube  is  inserted 
in  the  wound,  coming  out  of  the  most  dependent  part 
of  the  outside  of  the  joint,  a  small  incision  having 
been  made  on  the  end  of  a  Tait's  forceps  pushed  down 
through  the  original  wound ,  a  small  bunch  of  horse- 
hair drains  is  then  laid  across  the  patella  in  the  same 
line  as  tlie  original  incision,  each  end  protruding 
about  one  inch,  the  skin  is  then  stitched  with  silk. 
The  wound  is  dressed  on  the  third  day,  and  the  horse- 
hair drain  removed  and  possibly  the  drainage  tube; 
however,  the  tube  may  be  left  in  until  the  second  dress- 
ing if  desirable.  After  ten  days  the  wound  should  be 
entirely  healed,  and  at  the  end  of  the  second  week  pas- 
sive motion  should  be  begun,  the  patella  being  daily 
pushed  from  side  to  side,  each  day  more  Forcibly 
than  the  preceding.  At  the  end  of  the  third  week 
flexion  should  be  started  and  continued  daily  by  the 
surgeon,  until  six  weeks  have  elapsed  since  the  time  of 
operation;  the  patient  then  should  be  allowed  to  use 
his  limb,  keeping  up  the  active  motion,  but  carefully, 
until  ten  weeks  have  elapsed  since  time  of  opera- 
tion. 

Case  I. — March  2d.  William  R .  longshore- 
man, aged  forty-three  years,  single.     While  working 


September  29,  1900] 


MEDICAL    RECORD. 


499 


on  one  of  the  city  piers,  the  patient  slipped  and  fell, 
sustaining  a  violent  jerk  to  the  right  knee.  Kxamina- 
tion  showed  fracture  of  the  right  patella  in  transverse 
diameter,  attributed  to  muscular  action.  Considerable 
cedema  surrounded  the  joint.  The  case  was  treated 
for  five  days  with  the  ordinary  posterior  splint  and 
ice  bag.  The  patient  positively  refused  operation  of 
any  kind.  Adhesive  plaster  strips  and  traction  were 
tried,  but  the  patient  would  not  tolerate  it.  Plaster- 
of-Paris  dressing  could  not  be  endured,  and  finally 
treatment  was  continued  with  the  posterior  splint 
alone.  After  six  weeks  absolutely  no  union  had  oc- 
curred, and  the  patient  still  refusing  operation  was 
dismissed  on  account  of  obstinacy.  The  patient  re- 
turned on  April  29th  and  wished  to  be  operated  upon. 
Examination  showed  the  knee  in  good  condition  so 
far  as  swelling,  etc.,  was  concerned,  but  no  union.  The 
patella  was  wired  on  May  5th.  The  patient  was  ad- 
dicted slightly  to  alcohol  and  the  anesthetic  was 
poorly  taken;  post-operative  temperature  rose  to  101° 
F.  in  twenty-four  hours,  but  soon  fell  to  normal  and 
good  general  condition  ensued;  primary  union  ob- 
tained. The  wound  was  dressed  and  drainage  removed 
on  May  9th.  Dating  from  the  time  of  operation, 
passive  motion  was  begun,  from  side  to  side,  on  the 
patella  at  the  end  of  the  second  week;  at  the  end  of 
the  third  week,  flexion  was  begun  and  kept  up  daily; 
at  the  end  of  the  sixth  week,  the  patient  was  allowed 
to  use  his  leg  alone;  after  two  months  had  elapsed, 
he  was  dismissed  with  one-half  flexion,  and  afterward 
regained  full  use  of  his  limb. 

Case  II. — June  loth.  Michael  H ,  aged  twenty- 
one  ye.irs,  single,  laborer.  The  patient,  a  healthy  and 
muscular  man,  slipped  from  the  edge  of  the  sidewalk 
into  the  gutter,  and  in  trying  to  "catch  himself"  bent 
his  knee  strongly,  and  the  patella  parted  from  muscu- 
lar action.  Examination  showed  a  fracture  of  the 
patella  with  considerable  swelling  and  pain;  the  frag- 
ments could  be  nearly  apposed.  Quite  a  period  of 
time  elapsed  before  the  tissues  around  the  joint  were 
thought  to  be  in  good  enough  condition  to  be  operated 
upon.  The  operation  of  wiring  vvas  done  on  June  26th. 
The  anaesthetic  was  well  borne;  no  elevated  tempera- 
ture followed.  Primary  union  took  place;  passive 
motion  and  flexion  were  done  as  in  previous  case.  At 
the  end  of  the  fourth  week  the  patient  had  but  slight 
flexion,  but  it  gradually  increased  from  day  to  day 
until  one-fourth  flexion  was  produced,  when  the  patient 
disappeared. 

Case  III. — May  24th.  George  S ,  aged  twenty- 
six  years,  laborer.  The  patient,  an  active,  healthy 
man,  broke  the  left  patella  five  years  previous  to  date. 
It  was  treated  with  splints  and  plaster.  He  walked 
in  seven  weeks.  Only  ligamentous  union  occurred; 
the  fragments  were  four  inches  apart  on  account  of 
stretching;  there  was  fairly  good  motion.  The  present 
injury  took  place  from  muscular  action;  he  stumbled 
while  going  down-stairs.  The  knee  was  flexed  strongly 
and  the  right  patella  parted.  Examination  showed 
considerable  effusion  in  and  around  the  joint,  and  all 
the  signs  of  fracture.  Ice  bags  and  posterior  splint 
were  used  until  May  29th,  when  an  open  operation  and 
wiring  were  done.  Primary  union  took  place;  tliere 
was  no  elevated  temperature.  Passive  motion  was 
done,  the  same  as  in  previous  cases.  The  patient  was 
dis-nissed  on  July  15th  in  good  condition,  and  with 
one-fourth  flexion,  which  latter  was  inc  easing  daily. 

This  last  patient  sustained  a  refracture  of  the  patella 
on  August  17th,  about  one  month  after  being  dismissed. 
He  was  carefully  instructed  not  to  use  his  limb,  and, 
contrary  to  all  advice,  he  decided,  at  a  picnic,  to  out- 
do all  competitors  in  a  flat-foot  jumping  match.  The 
patella  was  wired  again  and  his  recovery  was  unevent- 
ful. However,  the  result  was  not  a  very  good  one,  he 
having,  when   last  seen,  considerable  ankylosis;    his 


obstinacy  in  disobeying  directions  was  the  chief  cause 
of  his  joint  stiffness. 

In  summing  up,  it  will  be  seen  that  the  aponeurotic 
fringe  can  be  removed  only  by  operation;  and  should 
such  good  fortune  befall  that  nothing  is  interposed  at 
the  time  of  injury,  the  pressure  exerted  to  control  the 
contraction  of  the  quadriceps  seriously  interferes  with 
the  circulation  and  causes  such  intense  distress  that  it 
is  unendurable.  We  are  forced  also  to  see  that  fibrous 
or  ligamentous  union  is  the  best  result  we  can  expect 
from  the  non-operative  means  of  treatment,  and,  as 
said  before,  this  will  in  time  stretch  to  such  a  degree 
that  a  condition  of  stumbling  is  produced,  thereby  fre- 
quently resulting  in  accident  and  fracture  of  the  op- 
posite patella. 

The  operation  should  not  be  attempted  after  the 
fiftieth  year;  other  contraindications  are  diabetes  and 
albuminuria.  Syphilis,  gout,  alcoholism,  and  tuber- 
culosis also  call  for  serious  deliberation.  However, 
taking  everything  into  consideration,  the  writer  be- 
lieves that  in  most  cases,  when  rigid  asepsis  can  be 
observed,  the  wire-suture  method  is  decidedly  the  best 
form  of  treatment. 

56  East  Twk.ntv-fii--th  Si  kf.et. 


Some  Points  in  the  Examination  and  Diagnosis 
of  Traumatic  Nerve  Affections.  —  D.  S.  Fairchild 
says  the  remote  effects  of  injuries  grow  in  complexity. 
A  factor  of  very  great  influence  is  that  of  the  mind. 
Psychic  complications  of  railway  accidents  can  scarcely 
be  estimated.  Medical  men  find  it  more  difficult  to 
agree  in  a  case  of  neurosis  than  in  most  other  affec- 
tions. Rules  of  conduct  to  be  followed  by  the  road's 
examiner  and  by  the  physician  in  attendance  or  ex- 
pert are  presented.  The  successful  simulation  of 
organic  nerve  disease  is  considered  practically  impos- 
sible. The  groups  of  symptoms  presented  by  trau- 
matic neurasthenia  are  very  complex.  Traumatic 
hysteria  is  closely  allied,  and  hysterical  symptoms  at 
times  suggest  degenerative  changes  in  brain  cells. 
Hysterical  paralysis  must  be  differentiated  from  that 
of  organic  disease.  In  the  former  there  will  be  no 
trophic  changes  in  the  muscles  and  no  impairment  in 
the  electrical  reactions,  the  patellar  tendon  reflexes 
are  probably  increased,  and  the  ankle  clonus  is  absent. 
—  The  Railway  Surgeon,  September  4,  1900. 

The  Modern  Treatment  of  Fractures  and  Bone 
Lesions. — Donald  Maclean  calls  attention  to  certain 
considerations  which  have  tended  to  modify  some  of 
the  classical  canons  affecting  the  treatment  of  frac- 
tures. Repair  of  bone  is  analogous  to  the  primeval 
function  of  fatal  development.  The  process  of  repair 
is  one  of  growth.  He  suggests  the  term  "guiding" 
or  "moulding"  the  products  of  repair  to  replace  that 
of  "setting  the  fracture."  There  is  only  a  limited 
field  of  usefulness  for  the  plaster  cast  in  surgery. 
All  methods  of  permanent  retentive  appliance  ■are  ob- 
jectionable. Owing  to  asepsis  compound  fractures  are 
to-day  so  little  dreaded  that  the  surgeon  may  even  con- 
vert a  simple  into  a  compound  wound  for  purposes  of 
diagnosis  or  treatment,  and  with  the  hope  of  better 
results  than  under  older  methods.  Subcutanous  sur- 
gery has  become  greatly  constricted.  The  .r-ray  makes 
it  now  possible  to  proceed  with  unfaltering  faith  in 
many  obscure  conditions,  especially  in  fractures  near 
the  articulations,  and  particularly  in  Colles'  fracture. 
Once  reduced,  only  the  simplest  retentive  measures 
are  required.  The  severe  injury  upon  surrounding 
structures  is  the  important  element.  The  only  rational 
treatment  for  sprains,  contusions,  etc.,  is  not  immobili- 
zation, but  movement.  What  is  true  of  Colles'  frac- 
ture is  also  true  of  fractures  in  general.  —  The  Clinical 
Rciezu,  September,  1900. 


500 


MEDICAL    RECORD. 


[September  29,  1900 


Medical  Record: 

A    Wcckiy  Journal  of  Medicine  and  Surgery. 


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

Publishers 

WM.   WOOD   &   CO  ,  51    Fifth   Avenue. 

New  York,  September  29,  1900. 

RATIONAL    THERAPEUTICS. 

During  the  recent  International  Medical  Congress 
one  of  the  many  speakers  who  treated  the  themes  in 
hand  referred  to  the  wonderful  progress  which  medi- 
cine and  surgery  had  made  in  recent  years  along  the 
lines  of  the  prevention  and  cure  of  disease.  \\'hat 
asepsis  had  done  for  surgery,  bacteriology  had  accom- 
plished for  medicine.  In  continuing,  however,  the 
orator  deplored  the  lag  in  general  therapeutics  which 
seemingly  made  the  many  increased  means  of  diagno- 
sis unavailable  by  the  uncertainty  of  the  action  of  the 
new  remedies  now  in  vogue.  But,  after  all,  when  we 
stare  the  latter  fact  in  the  face,  is  not  the  condition 
what  may  be  expected  with  our  increased  knowledge 
of  the  limitation  of  many  of  the  commoner  diseases 
and  the  impossibility  of  aborting  them  on  the  basis  of 
some  of  the  newer  theories  of  treatment? 

Pathology  has  certainly  done  much  for  us  in  teach- 
ing the  impracticability  of  many  of  the  cure-alls  that  are 
so  frequently  and  earnestly  advocated  by  optimistic 
enthusiasts.  If  we  are  less  hopeful  of  the  enactment 
of  miracles  we  are  certainly  the  better  practition- 
ers in  the  long  run.  With  an  increased  knowledge 
of  the  laws  which  govern  morbific  processes  we  are 
becoming  less  liable  to  go  to  extremes  in  expect- 
ing the  impossible  to  happen.  Pneumonia,  rheuma- 
tism, typhoid  fever,  scarlatina,  rubeola,  and  pertussis 
run  their  regular  course  in  spite  of  our  wishes  and 
efforts  to  the  contrary.  The  incurable  diseases  still 
hold  their  own,  and  the  degenerative  conditions  which 
follow  their  due  course  still  mock  our  futile  endeavors 
to  alter  nature's  laws. 

In  the  contemplation  of  this  state  of  affairs,  while 
there  is  reason  for  some  discouragement,  there  is  cer- 
tainly a  healthful  and  conservative  reaction  manifested 
in  our  increased  dependence  upon  the  now  well-recog- 
nized curative  powers  of  nature  and  a  becoming  recog- 
nition of  the  vital  resistance  of  the  individual.  In 
other  words,  rational  therapeutics  by  stern  common- 
sense  methods  are  replacing  senseless  polypharmacy. 
Meddlesome  interference  is  being  replaced  by  the  fur- 
therance of  nature's  effort  to  throw  off  the  disease. 
We  thus  mitigate  effects  rather  than  attempt  to  control 
causative  influences.  The  cold  bathing  -n  typhoid 
may  save  the  tissue  waste  resulting  from  high  temper- 
ature, but  does  not  abort  the  fever.  The  same  may  be 
said  of  pleuro-pneumonia.     The  curve  on  the  chart  is 


a  mere  incident  in  the  pathology  of  that  disease  as  in- 
dicating the  degree  and  gravity  of  the  danger.  The 
attempt  to  cure  the  malady  by  antipyretics  is  like 
tying  down  the  safety-valve  to  control  the  steam  pres- 
sure. In  other  self-limited  diseases  the  same  princi- 
ple is  involved.  We  are  learning  better  how  to  appre- 
ciate the  significance  of  the  indications  of  nature  in 
a  reasonably  helpful  way  rather  than  endeavoring  to 
divert  or  alter  them  by  senseless,  forcible,  and  radical 
methods. 

The  longer  one  is  in  practice  the  clearer  he  under- 
stands that  meddlesome  interference  is  bad.  The  old 
practitioner  who  said  when  he  came  to  his  wits'  ends 
that  he  studied  the  needs  of  his  patient  was  wise  in 
his  day  and  generation.  If  his  patient  was  hungry  he 
fed  him;  if  thirsty  he  gave  him  drink;  if  sleepy,  even 
at  odd  times,  he  allowed  his  own  theories  to  rest,  while 
he  gave  the  sufferer  an  opportunity  to  do  likewise.  In 
these  ways  he  followed  nature,  and  her  indications 
were  always  in  the  right  direction.  If  the  medicine 
did  not  act  according  to  his  theory  he  was  wise  enough 
to  change  his  methods;  in  this  way  he  wisely  con- 
cluded that  the  theory  did  not  fit  the  fact. 

The  real  progress  in  therapeutics  has  been  made 
precisely  in  this  direction,  and  accumulated  experi- 
ence is  always  on  the  side  of  common  sense  and  un- 
biassed judgment  in  the  interpretation  of  grand  princi- 
ples. The  remedies  are  mere  accessories  that  aid 
nature's  efforts.  It  is  always  a  good  plan  when  on  a 
dark  road  to  drive  with  a  slack  line  and  give  the  horse 
his  head.  The  theory  generally  engenders  over-confi- 
dence in  the  driver  and  jerks  the  animal  at  the  wrong 
place.  We  are  certainly  learning  this  much  on  the 
use  of  vaunted  specifics,  that  those  which  promise 
everything  accomplish  nothing.  Shot-gun  prescrip- 
tions never  show^  good  marksmanship.  The  trouble 
has  been  heretofore  to  discover  which  of  the  particular 
lot  hit  the  bull's-eye.  No  single  remedy  of  itself  can 
possibly  do  everything.  The  controlling  conditions 
are  the  complex  and  oft-times  antagonistic  receptivi- 
ties of  the  patient  himself.  We  note  this  in  the  vari- 
ous health  cures  so  plentiful  through  Europe.  The 
waters  get  the  credit  when  regular  living  and  proper 
feeding  really  deserve  it.  It  is  nature  speaking 
through  all  our  so-called  infallible  remedies.  When 
they  can  travel  together  we  are  always  safe  on  the 
darkest  roads.  It  is  in  this  direction  we  seem  to  be 
drifting.  We  may  be  prescribing  fewer  remedies,  but 
we  are  learning  to  use  tJiem  to  better  advantage.  We 
are  reconciling  the  absurdities  of  hobbyism  and  ultra- 
reasoning  to  the  common-sense  level  of  natural  laws 
and  more  rational  methods.  The  mark  is  plain 
enough — the  real  question  of  success  depends  on  the 
greater  accuracy  of  aim. 


TO  REGULATE  THE  OSTEOPATH. 

We  need  not  be  close  observers  to  know  that  the  eter- 
nal charlatan,  at  present  calling  himself  osteopath,  is 
with  us  in  increasing  numbers.  A  walk  through  the 
streets  in  certain  of  our  good  localities  will  convince 
any  one  of  the  fact,  for  this  particular  brand  of  pre- 


September  29,  1900] 


MEDICAL    RECORD. 


501 


tenders,  like  others  of  the  most  ambitious  kinds,  is  not 
given  to  hiding  his  light.  Occasionally  the  signs  in 
the  windows  will  have  after  the  name  the  letters  M.I)., 
indicating  that  the  inmate  either  has  or  claims  a  medi- 
cal degree.  We  do  not  wish  to  believe,  however,  that 
any  graduate  of  a  reputable  medical  school  has  al- 
lowed himself  to  assist  in  the  exploitation  of  such  an 
outrageous  fad  as  that  which  hides  behind  the  word 
osteopathy,  but  prefer  to  tiiink  that  the  assumption  of 
the  letters  indicating  the  possession  of  the  degree  is 
merely  a  part  of  the  game.  It  is  not  easy  to  under- 
stand the  apparent  apathy  of  the  medical  profession  in 
this  matter,  but  we  are  sure  that  the  majority  are,  in- 
dividually at  least,  convinced  that  it  is  important. 
The  various  county  medical  societies  ought  to  take  up 
the  subject,  and  try  to  get  an  authoritative  decision 
from  court  or  legislature,  after  proper  presentation  of 
the  case,  as  to  what  an  osteopath  is  and  what  consti- 
tutes practising  medicine.  The  cardinal  point,  in  our 
opinion,  as  we  have  previously  pointed  out  (Medical 
Record,  February  10,  1900),  depends  upon  whether 
one  who  professes  belief  in  any  system,  no  matter  how 
weird,  shall  be  allowed  to  decide  for  himself  whether 
he  is  to  be  considered  as  practising  medicine  in  the 
eyes  of  the  law  or  not,  with  his  amenability  to  law  in- 
versely proportional  to  the  inherent  absurdity  of  his 
professed  belief.  If  such  a  person  is  a  physician  ac- 
cording to  strict  definition,  it  is  certainly  clear  enough 
to  convince  anyone  that  he  should  be  subjected  to  ex- 
actly the  same  regulations  and  requirements  as  are 
enforced  in  the  case  of  graduates  of  schools  legally 
qualified  to  confer  the  medical  degree.  If  he  is  not 
a  physician  in  the  meaning  of  the  law,  he  has  emphat- 
ically no  right  to  examine  the  sick  and  injured,  to 
make  a  diagnosis,  to  suggest  and  carry  out  a  course  of 
treatment,  and  to  receive  remuneration  for  his  work. 

The  few  decisions  before  the  courts,  in  this  State  at 
least,  in  which  cases  of  this  sort  ha\e  been  considered, 
do  not  cover  this  point,  but*  seem  simply  to  have  de- 
cided that  so-called  osteopathy  is  a  form  of  massage, 
and  that  to  practise  it  is  not  to  practise  medicine. 
Such  decisions  could  have  been  given  only  after  im- 
proper and  imperfect  presentation  of  tiie  facts  to  the 
court.  Osteopathy  may  be,  and  no  doubt  is,  a  form  of 
massage;  but  if  it  were  proved  before  the  proper  tri- 
bunal that  osteopathy  is  also  the  name  given  to  what 
is  claimed  to  be  a  system  by  which  many  diverse  patii- 
ological  conditions  can  be  diagnosticated,  treated,  and 
cured,  we  fail  to  understand  how  the  decision  that  to 
practise  osteopatliy  is  not  to  practise  medicine  would 
hold,  or  could  indeed  ever  have  been  given.  If  it  is 
true  that  according  to  law  it  is  only  necessary  for  an 
individual  to  call  himself  an  osteopath  in  order  to  es- 
cape entirely  the  regulations  governing  medical  prac- 
tice, then  there  is  a  serious  defect  in  the  law,  and  a 
grave  injustice  is  inflicted  upon  the  graduates  of  medi- 
cal schools  who  are  compelled  to  pass  State  examina- 
tions before  they  can  do  what  the  osteopath  does  by 
putting  a  sign  in  a  window. 

It  is  astonishing  to  know  that  the  osteopaths  are 
starting  "schools"  in  various  parts  of  the  country 
with  the  avowed  intention  of  sending  forth  graduates 
to  practise  upon  the  sick,  but  that,  according  to  court 


decisions,  in  this  State  at  least,  they  are  not  going  to 
practise  medicine.  No  effort  should  be  spared  to  get 
the  various  State  legislatures  to  bring  the  products  of 
these  osteopathic  schools  down  to  the  same  level  of  re- 
striction which  is  required  of  the  mere  graduate  of  a 
licensed  medical  school,  so  that  the  former  can  no 
longer  soar  unfettered  in  the  lucrative  realms  of  a  spe- 
cially pernicious  form  of  quackery.  We  want  at  pres- 
ent nothing  but  a  provision  that  the  so-called  osteo- 
path shall  pass  the  regular  State  examination  in 
everything  but  materia  medica  and  therapeutics  before 
he  is  started  on  his  still-hunt  for  victims.  We  do  not 
care  what  his  ideas  on  materia  medica  and  therapeu- 
tics are,  not  because  we  do  not  know  that  they  are 
absurd  and  nonsensical,  but  because  we  recognize  the 
fact  that  restriction  by  law  on  such  subjects  is  neither 
desirable  nor  possible.  No  legislative  committee  with 
any  sense  of  fairness  could  deny  the  justice  of  what 
we  suggest,  and  we  hope  to  see  an  attempt  in  this 
State  to  have  the  matter  regulated. 

What  the  public  thinks  of  the  osteopath  is  shown  by 
the  prosperity  of  some  specimens,  but  the  public  rarely 
knows  what  is  best  for  it,  and  its  opinion  upon  techni- 
cal 'Objects  is  worse  than  valueless.  On  some  sub- 
jects public  opinion  may  be  very  important,  but  upon 
a  question  like  this  it  is  blind,  unreasoning,  and  often 
dangerous,  and  needs  the  guidance  of  the  expert  mind 
to  keep  it  from  serious  pitfalls.  We  may  be  sure  that 
as  soon  as  examining-boards  are  in  a  position  to  ask 
embryonic  osteopaths  questions  on  anatomy,  physiol- 
ogy, pathology,  and  obstetrics,  there  will  be  fewer  of 
them  where  they  are  dangerous.  We  do  not,  as  we 
have  said  already,  want  any  legislation  that  seems  to 
involve  persecution,  but  we  do  want  the  same  treat- 
ment for  all  who  wish  to  have  the  legal  right  to  direct 
and  supervise  the  care  of  the  sick,  and  we  will  trust 
to  time  to  eliminate  delusions  and  frauds  as  they  arise. 
Fiat  justitia,  mat  osteopathia. 


ANTI-TVPHOID    AND  ANTI-CHOLERA   INOC- 
ULATIONS   IN    INDIA. 

In  support  of  this  method  of  preventing  these  diseases, 
the  claim  is  made  by  its  adherents  that  the  results  of 
inoculation  in  India  have  been  eminently  satisfactorv, 
so  much  so,  indeed,  as  to  lead  to  the  hope  that  at 
length  a  means  of  successfully  fighting  two  of  the  most 
deadly  maladies  known  to  man  has  been  discovered. 
In  the  Medical  Record  of  August  i  ith  it  was  pointed 
out  that  the  statistics  with  regard  to  the  value  of  the 
use  of  anti-typhoid  serum,  both  in  India  and  South 
Africa,  were  not  sufficiently  convincing  to  confirm  such 
roseate  views.  This  expression  of  opinion  receives 
further  substantiation  from  the  perusal  of  a  parliamen- 
tary paper  containing  a  correspondence  relating  to  pre- 
ventive inoculation  against  cholera  and  typhoid  in 
India  and  published  in  the  London  Ncios.  The  corre- 
spondence on  the  anti-cholera  inoculation  consists  of 
extracts  from  the  sanitary  commissioner's  reports  for 
1896,  1897,  and  1898.  In  the  1896  report  tables  are 
given  which  show  a  greater  incidence  of  attack  and 
death  rate  among  persons  under  observation  who  have 


502 


MEDICAL    RECORD. 


[September  29,  1900 


been  inoculated  than  among  persons  who  have  not 
been  subjected  to  the  treatment;  but  at  the  same  time 
the  commissioner  remarks  that  its  further  test  is  nec- 
essar)'.  In  1897,  however,  the  results  from  inocula- 
tion are  decidedly  discouraging,  and  the  commissioner 
appears  more  than  ever  averse  to  delivering  any  defi- 
nite statement  on  tiie  matter.  He  says:  "It  does  not 
seem  that  anything  can  be  proved  regarding  the  pro- 
tective effect  of  the  proceeding."  The  1898  report  is 
the  most  inconclusive  of  the  three,  containing  but  the 
following  few  lines  relating  to  the  subject:  "Anti- 
cholera  inoculations  were  continued  at  the  coolie  de- 
pot at  Puralia  in  Bengal,  but  it  is  not  possible  to  say 
how  far  the  inoculation  was  protective,  as  there  are  no 
complete  statistics.  If  any  conclusion  is  permissible 
from  such  figures  as  are  available,  it  is  decidedly  in 
favor  of  the  operation." 

So  far  as  inoculation  against  typhoid  is  concerned, 
the  experiments  in  India  would  seem  to  have  been 
conducted  in  a  somewhat  slipshod  fashion,  as  the  vice- 
roy and  council  reported  last  year  that  they  regretted 
their  inability  to  furnish  the  actual  numbers  of  the  in- 
oculated together  with  the  results,  as  no  official  records 
were  kept,  but  that  over  two  thousand  men  had  been 
inoculated  and  that  in  no  case  had  any  bad  or  unfavor- 
able symptoms  followed  the  operation.  Further,  only 
a  very  few  of  those  inoculated  contracted  typhoid 
fever  subsequently,  and  with  the  exception  of  one  case 
the  disease  was  of  a  mild  character,  while  in  two  of 
the  cases  the  disease  was  in  the  stage  of  incubation 
when  the  operation  was  performed.  The  commander- 
in-chief  in  India  said  that  "  it  had  been  conclusively 
proved  to  the  satisfaction  of  those  who  were  best  com- 
petent to  judge  of  the  matter,  that  anti-typhoid  inocu- 
lation when  properly  carried  out  achieved  an  immunity 
equal  to  or  greater  than  that  which  accrues  to  a  per- 
son who  undergoes  and  recovers  from  an  attack  of  that 
disease." 

From  the  foregoing  reports  it  will  be  gathered  that 
in  India  at  least  neither  anti-cholera  nor  anti-typhoid 
inoculation  has  been  attended  with  a  marked  degree 
of  success.  Statistics  from  South  Africa  at  the  end  of 
the  campaign  should  tend  to  settle  the  question  as  to 
the  efficacy  of  anti-typhoid  serum. 


^cius  of  tlie  'SSlcck. 

Medical  Society  of  the  State  of  Pennsylvania. — 
The  fiftieth  annual  meeting  of  the  Medical  Society  of 
the  State  of  Pennsylvania  was  held  at  Wilkesbarre  on 
September  18th,  igth,  and  20th.  After  the  society  had 
been  called  to  order  by  the  president.  Dr.  George  VV. 
Guthrie,  prayer  was  offered  by  Rev.  E.  C.  Mogg,  D.D. 
Addresses  of  welcome  were  delivered  by  Hon.  F.  M. 
NichoUs,  mayor  of  VVilkesbarre,  and  by  Dr.  H.  M. 
Neale,  of  Upper  Lehigh,  president  of  the  Luzerne 
County  Medical  Society.  The  address  in  medicine, 
by  Dr.  Thomas  Turnbull,  Jr.,  of  Allegheny,  was  read 
by  Dr.  .Adolph  Koenig.  Dr.  Charles  Rea  read  a  paper 
on  "The  Diagnosis  and  Treatment  of  the  Karly  Stage 


of  Pulmonary  Tuberculosis'';  Dr.  \V.  H.  Hartzell,  of 
Allentown,  one  entitled  "  Old-'J'inie  Treatment  and 
Result  of  Typhoid  Fever";  Dr.  T.  D.  Davis,  of  Pitts- 
burg, one  entitled  "  Lecturing  not  Teaching '' ;  Dr.  J. 
C.  Bateson,  of  Scranton,  one  on  "The  Human  Tem- 
peraments and  their  Application  in  Medicine"; 
Dr.  J.  Emmet  O'Brien,  of  Scranton,  one  entitled 
"Analogies  between  Nervous  and  Klectric  Mechan- 
isms"; Dr.  Edwin  Rosenthal,  of  Philadelphia,  one  on 
"The  Treatment  of  Pneumonia  with  Antipneumonic 
Serum";  Dr.  Thomas  C.  Ely,  of  Philadelphia,  one 
entitled  "A  Case  of  Meningitis  Complicating  Pneu- 
monia'"; Dr.  Judson  Daland,  of  Philadelphia,  one  on 
"Raynaud's  Disease";  Dr.  J.  Montgomery  Baer,  of 
Philadelphia,  one  on  "The  Diagnosis  of  Ectopic 
Pregnancy."  On  the  second  day  Dr.  V\'alter  Lathrop, 
of  Hazleton,  delivered  the  address  in  surgery.  Dr. 
Charles  H.  Miner,  of  Wilkesbarre,  read  a  paper  on 
"The  Etiology  of  Typhoid  Fever'";  Dr.  H.  A.  Hare, 
of  Philadelphia,  a  paper  on  "The  Complications  and 
Sequela  of  Typhoid  Fever,"  and  Dr.  Alfred  Stengel 
one  on  "The  Treatment  of  Typhoid  Fever.'"  Dr. 
William  H.  Dudley,  of  Easton,  read  a  paper  entitled 
"  The  Question  of  the  Enforcement  of  the  Medical 
Laws  of  the  State  of  Pennsylvania."  Dr.  T.  M.  T. 
McKennan,of  Pittsburg,  read  a  report  of  some  medico- 
legal cases.  Dr.  Thomas  J.  Mays,  of  Philadelphia, 
presented  a  communication  entitled  "  P'our  Phthisical 
Remedies  which  Have  Proved  Most  Valuable  in  My 
Experience."  At  the  afternoon  session  Dr.  Mordecai 
Price,  of  Philadelphia,  read  a  paper  entitled  "Appen- 
dicitis and  its  Treatment.''  Dr.  Charles  P.  Noble,  of 
Philadelphia,  gave  the  address  in  obstetrics.  Dr. 
Gwillym  G.  Davis  read  a  paper  on  "Applied  Anatomy; 
its  Value  and  Place  in  the  Medical  Curriculum'"  ;  Dr. 
O.  C.  Gaub,  of  Pittsburg,  one  on  "The  Surgery  of  the 
Gall  Bladder,"  and  Dr.  Evan  O'Neill  Kane,  of  Kane, 
described  a  removable  buried  suture  for  abdominal 
incisions.  Dr.  F.  P.  Ball,  of  Lock  Haven,  pre- 
sented a  communication  on  "Tuberculosis  of  the 
Bladder."'  Dr.  J.  C.  Dunn  read  a  communication  en- 
titled "Silver  Nitrate  in  Dermatology."  Dr.  L.  J. 
Hammond,  of  Philadelphia,  read  a  paper  on  "  Primary 
Tuberculous  Adenitis  —  its  Surgical  Treatment ''  ; 
Dr.  W.  M.  Beach,  of  Pittsburg,  one  on  "Constipa- 
tion or  Obstipation  and  its  Practical  Treatment"; 
Dr.  Charles  L.  Leonard  one  on  "  Surgical  Diagnosis 
by  the  Roentgen  Method,"  and  Dr.  A.  A.  Eshner,  of 
Philadelphia,  a  paper  entitled  "  Paralysis  Agitans 
Without  I'remor."'  The  following  officers  were  elected 
for  the  ensuing  year:  President,  Dr.  Thomas  D.  Davis, 
of  Pittsburg;  First  Vice-President,  Dr.  W.  B.  Ulrich,  of 
Chester:  Second  Vice-President,  Dr.  L.  H.  Taylor, 
of  VVilkesbarre;  Third  Vice-President,  Dr.  A.  .\. 
Eshner,  of  Philadelphia;  Fourth  Vice- President.  YfY.'^i. 
L.  Herr,  of  Lancaster;  Secretary.  Dr.  C.  L.  Stevens, 
of  Athens;  Assistant  Secretary.  Dr.  W.  L.  Pyle,  of 
Philadelphia;  Treasurer,  Dr.  G.  J!.  Dunmire,  of  J'hil- 
adelphia  ;  Chairman  oj  the  Committee  oj  Arrangements, 
Dr.  John  H.  Musser.  of  Piiiladelphia.  The  next 
meeting  will  be  held  at  Philadelphia,  beginning  the 
third  Tuesday  in  September,  1901.  The  proceedings 
of  the  third   day  included  the   following  papers:  Ad- 


September  29,  1900] 


MEDICAL    RECORD. 


503 


dress  in  hygiene,  by  Dr.  Joseph  T.  Rothrock,  of  West 
Chester;  "  Recent  Advances  in  the  Bacterial  Purifica- 
tion of  Sewage,"  by  Dr.  D.  H.  Bergey.of  Philadelphia; 
"The  Role  of  Insects  in  the  Transmission  of  Disease," 
by  Dr.  Emma  O.  Cleaver,  of  Reading;  "  Humanology, 
or  Higher  Physiology,"  by  Dr.  E.  N.  Ritter,  of  Wil- 
liamsport ;  "  Sanitary  Milk  for  Children,"  by  Dr.  B.  H. 
Detwiler,  of  Williamsport;  "The  Use  and  Abuse  of 
the  P'orceps,"  by  Dr.  \V.  Knowles  Evans,  of  Chester; 
"  A  Further  Report  on  the  Cataphoric  Treatment  of 
Cancer,"  by  Dr.  G.  Betton  Massey,  of  Philadelphia; 
"The  Present  Status  of  Ovarian  Organo-Therapy," 
by  Dr.  VVilmer  Krusen,  of  Philadelphia;  "Nausea 
and  Vomiting  of  Pregnancy,"  by  Dr.  John  M.  Batten, 
of  Downington;  "Paroxysmal  Delirium  —  a  Short 
Study  in  Auto-intoxication,"  by  Dr.  W.  C.  Hollopeter, 
of  Philadelphia;  "Nephritis  as  a  Complication  in 
Gynecological  Disease,"  by  Dr.  George  Erety  Shoe- 
maker, of  Philadelphia;  "  Myocarditis,"  by  Dr.  John 
H.  Musser,  of  Philadelphia ;  "  Report  of  Two  Cases  of 
Ovarian  Hydrocele,"  by  Dr.  Reed  Burns,  of  Scranton; 
"  Do  We  Resort  too  Frequently  to  Surgical  Opera- 
tions.'" by  Dr.  Richard  H.  Gibbons,  of  Scranton. 
Address  in  ophthalmology,  by  Dr.  Charles  Mclntirc, 
of  Easton ;  "  The  Electro-Magnet  in  Eye  Surgery, 
with  Demonstrations;  and  Report  of  a  Number  of 
Cases,"  by  Dr.  Edward  B.  Heckel,  of  Pittsburg ;  "  A 
Plea  for  the  Earlier  Recognition  of  Squint  in  Children 
by  the  Family  Physician,  and  the  Earlier  Application 
of  the  Methods  of  Treatment,"  by  Dr.  C.  A.  Veasey, 
of  Philadelphia;  "The  Relation  of  the  Oculist  and 
Optician  to  the  Profession  and  the  Public,"  by  Dr.  P. 
J.  Kress-,  of  Allentown;  "Surgical  Intervention  in 
Purulent  Discharge  of  the  Ear,"  by  Dr.  Joseph  K. 
Willetts,  of  Pittsburg;  "The  Climatology  of  Neuras- 
thenia," by  Dr.  F.  Savary  Pearce,  of  Philadelphia; 
"Traumatic  Hysteria,  with  a  Report  of  Cases,"  by  Dr. 
Edward  E.  Mayer,  of  Pittsburg;  "The  Simplest  and 
Best  Method  of  Removing  the  Third  Tonsil  or  Post- 
Nasal  Adenoids,"  by  Dr.  Louis  J.  Lautenbach,  of 
Philadelphia ;  "  Living  Animal  Organisms  in  the  Ear," 
by  Dr.  Francis  R.  Packard,  of  Philadelphia;  "The 
Passing  of  the  Galvano-Cautery,"  by  Dr.  Charles  P. 
Grayson,  of  Philadelphia;  "Leukaemia  and  Pseudo- 
Leukoemia,  with  Presentation  of  Patients,"  by  Dr. 
Charles  H.  Miner,  of  Wilkesbarre;  "The  Operative 
Treatment  of  Ugly  Ears,"  by  Dr.  John  B.  Roberts,  of 
Philadelphia;  "Typhoid;  its  Etiology,  Course,  Treat- 
ment and  Pathology;  Concisely  Considered,"  by  Dr. 
James  Fulton,  of  New  London;  "The  Treatment  of 
OEsophageal  Stricture,  with  Particular  Reference  to  the 
Konig  Method,"  by  Dr.  Charles  H.  Frazier,  of  Phila- 
delphia; "What  I  Have  Learned  from  a  Personal  Ex- 
perience of  Thirty-two  Bottini's  Operations  in  the 
Radical  Treatment  of  Hypertrophy  of  the  Prostate 
Gland,"  by  Dr.  Orville  Horwitz,  of  Philadelphia. 

Suicides  in  the  French  Army. — A  despatch  to  the 
New  York  Times  states  that  suicides  are  becoming  of 
shocking  frequency  in  the  French  army,  and  it  is  no 
secret  that  it  is  the  result  of  the  insupportable  treat- 
ment which  the  soldiers  are  subjected  to  and  the  gen- 
eral brutalizing  condition  of  life  which  thev  are  com- 


pelled during  three  years  to  lead.  Three  suicides 
having  occurred  in  one  week  in  a  single  regiment,  the 
colonel  has  issued  an  order  of  the  day  declaring  that 
suicides  will  henceforth  be  treated  as  deserters,  and 
that  no  military  honors  will  be  rendered  them  at  their 
funeral.  .\o  man,  it  concludes,  who  is  a  real  patriot 
will  commit  suicide;  but  nothing  is  said  concerning 
the  non-commissioned  officers  whose  brutal  treatment 
has  caused  these  suicides. 

Pathological  Society  of  Philadelphia At  a  stated 

meeting  held  on  September  13th,  Dr.  J.  Dutton  Steele 
exhibited  a  specimen  of  hour-glass  stomach  and  sec- 
tions of  endothelium  of  the  lung  and  retroperitoneal 
glands.  Nominations  for  officers  for  the  ensuing  year 
were  made. 

The  Congress  of  Scandinavian  Ophthalmologists, 
which  has  been  organized  on  the  model  of  the  Ophthal- 
mological  Congress  annually  held  at  Heidelberg,  re- 
cently held  its  first  meeting  at  Stockholm.  The  meet- 
ings are  to  be  held  every  two  years;  the  next  will  be 
held  in  Copenhagen  in  1902. 

The  Medical  Association  of  Hawaii. — At  the  last 
annual  meeting  of  this  association  the  following  offi- 
cers were  elected:  President,  Dr.  W.  E.  Taylor;  Vice- 
President.  Dr.  H.  E.  Sloggett ;  Secretary  and  Treas- 
urer, Dr.  G.  A.  Hodgins.  The  executive  committee 
consists  of  the  officers  and  Drs.  R.  P.  Myers  and  C.  B. 
Cooper. 

Instruction  in  Tropical  Diseases,  stimulated  by 
the  good  work  of  the  two  British  schools  and  under 
the  growing  conviction  that  the  world's  work  in  the 
twentieth  century  is  to  be  the  enlightenment  and 
elevation  of  uncivilized  man,  is  becoming  general  in 
all  the  countries  of  Europe.  In  the  University  of 
Bordeaux  M.  Le  Dantec,  who  has  for  several  years 
lectured  privately  on  that  subject,  has  just  been  ap- 
pointed to  give  a  course  of  instruction  on  tropical  dis- 
eases. In  Holland  the  teaching  of  tropical  medicine 
has  recently  been  inaugurated  by  Dr.  J.  H.  Kohl- 
brugge,  Privat-docent  in  the  University  of  Utrecht. 

Inebriety  among  Women — At  the  recent  annual 

convention  of  the  Connecticut  Catholic  Total  Absti- 
nence Union,  the  president  stated  in  his  address  that 
while  habitual  intemperance  among  men  was  decreas- 
ing, alcoholism  among  women  was  becoming  more 
common.  This  statement  receives  startling  confirma- 
tion as  regards  England  by  the  fact  revealed  by  a 
parliamentary  report  on  the  working  of  the  Inebriates 
Act,  under  which  magistrates  are  able  to  commit 
habitual  drunkards  to  reformatories,  that  of  ninety-two 
such  commitments  ninety  were  of  women.  Of  six 
inebriate  reformatory  institutions  existing  in  Great 
Britain,  no  less  than  five  are  for  women. 

A  New  Diet  Sect.— The  daily  papers  report  the 
establishment  in  Chicago  of  a  new  association  of 
oddities  who  believe  that  eating  raw  food  is  the  secret 
of  longevity,  perfect  health,  superior  mental  vigor, 
amiability  of  disposition,  and  economical  living. 
They  contend  that  the  cooking  of  food  is  in  opposi- 
tion to  nature's  laws,  and  that  it  is  only  a  fad  which 


504 


MEDICAL   RECORD. 


[September  29,  1900 


originated  somewhere  in  the  early  ages  of  man,  and 
that  since  then  humanity,  mentally,  morally,  and 
physically,  has  been  steadily  on  the  decline.  All  the 
adherents  to  the  new  belief  have  discarded  from  their 
tables  every  edible  that  has  felt  the  influence  of  fire. 
They  say  fire  destroys  all  that  is  life-giving  and 
healthful  in  food.  Their  diet  list  includes  such 
toothsome  dainties  as  dried  beef,  raw  carrots  and  raw 
oats,  wheat,  and  rice  flour. 

Fire  at  Roosevelt  Hospital — An  explosion  of  ben- 
zin  used  by  painters  in  a  brick  building  adjoining 
Roosevelt  Hospital  caused  a  small  fire  there  last 
week.  The  building  was  used  as  the  stable  and 
morgue.     The  fire  caused  little  damage. 

A  Kentucky  Feud. — There  is  trouble  over  the  pro- 
posed celebration  of  the  semi-centennial  of  the  Ken- 
tucky School  of  Medicine  in  the  present  year,  a  for- 
mer member  of  the  faculty  asserting  that  the  college 
is  not  fifty  years  old,  and  also  that  it  is  not  the  lineal 
descendant  of  and  legitimate  successor  to  the  medical 
department  of  Transylvania  University. 

Physicians  Sued. — A  suit  for  $10,000  damages  has 
been  brought  against  two  physicians  in  New  Bruns- 
wick, N.  J.,  by  a  man  who  claims  that  he  was  wrongly 
incarcerated  in  an  insane  asylum  on  a  certificate 
signed  by  them.  He  was  released  in  three  days,  and 
asserts  that  his  seizure  and  detention  were  the  result 
of  a  conspiracy  to  which  the  accused  physicians  were 
party. 

The  American  Association  of  Obstetricians  and 
Gynaecologists. — At  the  annual  meeting  of  this  soci- 
ety, held  last  week  in  Louisville,  the  following  offi- 
cers were  elected :  President,  Dr.  W.  E.  B.  Davis,  of 
Birmingham,  Ala. ;  Vice-Presidents,  Dr.  Edwin  Walker, 
of  Evansville,  Ind.,  and  Dr.  A.  Goldspohn,  of  Chi- 
cago; Secretary,  Dr.  William  A.  Potter,  of  BufTalo, 
N.  Y. ;  Treasurer,  Dr.  Xavier  O.  VVerder,  of  Pittsburg, 
Pa.  Cleveland,  O.,  was  selected  as  the  place  of  the 
next  annual  meeting. 

The  Pan-American  Medical  Congress. — Dr.  To- 
mas  V.  Coronado,  secretary,  announces  that  the  third 
Pan-American  Medical  Congress  will  be  held  in  Ha- 
vana, Cuba,  on  Wednesday,  Thursday,  Friday,  and 
Saturday,  December  26,  27,  28,  and  29,  1900.  The 
official  languages  of  the  congress  will  be  French, 
Spanish,  Portuguese,  and  English,  though  naturally 
the  greater  number  of  the  papers  and  addresses  will 
be  in  Spanish.  Several  of  the  steamship  lines  run- 
ning to  Havana  announce  a  rate  of  one  fare  for  the 
round  trip,  and  the  Southern  Passenger  Association 
has  established  a  rate  of  one  fare  plus  $2  to  Havana 
and  return. 

A  Hospital  Interne  Suspended — The  commis- 
sioner of  charities  has  suspended  one  of  the  internes 
of  the  Metropolitan  Hospital  on  Blackwell's  Island 
for  thirty  days  on  the  charge  of  negligence.  A  con- 
sumptive had  been  turned  out  of  the  hospital  in  a 
dying  condition,  on  the  statement  of  the  physician 
that  he  was  not  a  proper  subject  for  hospital  treat- 
ment.    The  superintendent  accepted  the  physician's 


report  and  discharged  the  patient.  In  his  order  sus- 
pending the  physician  the  commissioner  also  repri- 
manded the  acting  superintendent,  who,  he  said, 
either  did  not  know  what  a  hospital  was  for,  or  had 
a  distorted  idea  of  the  purpose  for  which  the  tax-pay- 
ers support  the  Department  of  Charities.  Under  no 
circumstances,  the  commissioner  said,  was  there  any 
excuse  for  turning  any  one  away  as  this  dying  patient 
had  been.  Henceforth,  he  ordered,  the  physician  in 
charge  shall  personally  examine  every  patient  and  see 
for  himself  if  his  condition  is  such  as  to  warrant  dis- 
charge. 

Drowned  in  Two  Inches  of  Water An  epileptic 

in  Jersey  City  was  seized  with  a  convulsion  and  fell 
face  downward  in  a  puddle  of  water  only  two  inches 
deep,  and  when  found  was  dead  from  suffocation. 

Navy  Department,  Bureau  of  Medicine  and  Sur- 
gery, Washington,  D.  C. — Changes  in  the  medical 
corps  of  the  United  States  navy  for  the  week  ending 
September  22,  1900.  September  14th. — Surgeon  C. 
T.  Hibbett  detached  from  the  Cavite  naval  station 
and  ordered  to  the  Newark ;  Surgeon  O.  D.  Norton 
detached  from  duty  with  the  marine  regiment  in  China 
and  ordered  to  the  Alonadtwck ;  Assistant  Surgeon  F. 
L.  Benton  detached  from  the  naval  hospital,  Cavite, 
P.  I.,  and  ordered  to  the  Brooklyn.  September  i8th. 
— Medical  Director  J.  A.  Hawke  detached  from  the 
New  York  navy  yard  October  ist,  and  ordered  to  duty 
at  the  naval  hospital.  Mare  Island,  Cal.;  Medical  In- 
spector G.  P.  Bradley  detached  from  the  naval  hospital. 
Mare  Island,  Cal.,  on  reporting  of  relief,  and  ordered 
home  and  to  wait  orders.  September  2  ist..—- (Orders 
issued  by  commander-in-chief  of  Asiatic  station.) 
Passed  Assistant  Surgeon  G.  D.  Costigan  detached 
from  the  Newark  and  ordered  to  the  Yorktoum ;  As- 
sistant Surgeon  E.  Davis  detached  from  the  i'ork- 
town  and  ordered  to  the  Cavite  naval  station. 

The  Coal  Companies'  Doctors One  of  the  griev- 
ances of  the  striking  miners  in  the  anthracite  regions 
is  that  they  have  to  pay  for  the  services  of  a  "  com- 
pany doctor  "  whether  they  like  him  or  not.  Concern- 
ing this  a  correspondent  of  the  Commercial  Advertiser 
writes  that  "  the  '  company  doctor  '  is  in  many  sections 
of  the  Pennsylvania  coal  regions  a  worthy  and  ser- 
viceable man  who  stands  well  with  the  miners.  In 
other  sections,  however,  he  is  a  detested  bugaboo, 
whom  the  miners  have  to  pay  for,  but  seldom  see. 
Sometimes  the  miners  are  required  to  pay  a  certain 
amount  each  month  for  '  general  sanitary  supervision.' 
Such  payments  they  resent  bitterly,  for  few  of  them 
comprehend  the  meaning  of  the  service  charged  for. 
In  most  mining  settlements,  however,  the  doctor  makes 
his  own  charges  for  personal  service,  and  in  such 
cases  he  would  be  regarded  as  a  very  acceptable  man 
in  the  community  if  the  mine  owners  did  not  compel 
the  miners  to  pay  him.  A  coal  miner  is  very  much 
like  the  average  citizen  in  his  sentiments  toward  a 
doctor's  bill."  This  grievance,  however,  like  the 
companion  one  of  the  "company  store,"  is  a  purely 
local  one,  and  very  few  of  the  large  mining  compa- 
nies maintain  either  the  one  or  the  other  system. 


September  29,  1900] 


MEDICAL   RECORD. 


505 


©liitixarij. 

LEWIS   ALBERT    SAYRE,    M.D.,   LL.D., 


NEW    YORK. 


Dr.  Sayre  died  at  his  iiome  in  this  city  on  Septem- 
ber 2ist,  at  the  age  of  eighty  years.  He  had  been  in 
failing  health  for  some  time,  but  suffered  no  pain  and 
retained  his  faculties  to  the  last.  He  was  born  in 
Battle  Hill,  now  Madison,  N.  J.,  on  February  19, 
1820,  and  the  infrequency  of  his  birthdays  was  an  un- 
failing source  of  witticisms  by  himself  and  his  friends; 
he  always  said  that  he  hoped  to  live  to  see  his  twentieth 
birthday  which  would  not  be  until  1904.  His  father 
was  a  well-to-do  farmer  of  Morris  County,  N.  J.,  and 
his  grandfather  was  a  quartermaster  in  the  revolution- 
ary army.  During  Lafayette's  visit  to  this  country  in 
1825,  little  Sayre  was  chosen  on  one  occasion  to  recite 
some  verses  of  welcome  before  the  distinguished  vis- 
itor. His  early  education  was  received  in  a  local 
school  and  at  Wantage  Seminary  in  l)eckertown,  N. 
J.,  and  his  collegiate  course  was  passed  at  Transyl- 
vania University  in  Le.xington,  Ky.  In  opposition  to 
the  wishes  of  his  uncle  with  whom  he  lived  at  Lexing- 
ton, who  wanted  him  to  study  for  the  ministry,  he 
came  to  New  York  and  entered  the  College  of  Physi- 
cians and  Surgeons,  from  which  he  was  graduated  in 
1842.  For  ten  years  following  his  graduation  he  was 
prosector  of  anatomy  at  the  college  under  Dr.  VVillard 
Parker.  He  was  appointed  surgeon  to  Bellevue  Hos- 
pital in  1853,  and  to  the  Charity  Hospital  on  Black- 
well's  Island  in  1859,  and  had  remained  since  1873  a 
consulting  surgeon  to  both  these  institutions,  as  well 
as  to  St.  Elizabeth's  Hospital  and  the  Home  for  In- 
curables. 

He  was  one  of  the  founders  of  the  Bellevue  Hos- 
pital Medical  College  in  1861,  and  was  a  member  of 
its  first  f.iculty  as  professor  of  orthopedic  surgery, 
fractures,  and  lu.xations.  He  continued  to  fill  this 
chair,  later  designated  as  that  of  orthopedic  surgery, 
until  1898,  when  the  college  was  united  with  the  New 
York  University.  He  then  became  emeritus  professor 
of  orthopedic  surgery  in  the  consolidated  institution. 
He  was  also  one  of  the  founders  of  the  New  York 
Academy  of  Medicine,  the  New  York  Pathological 
Society,  and  the  American  Medical  Association.  He 
was  elected  vice-president  of  the  latter  in  1866,  and 
became  its  president  in  1880. 

In  i860  Dr.  Sayre  was  appointed  ''resident  physi- 
cian," or  health  officer,  of  New  York,  and  accom- 
plished much  in  the  way  of  the  sanitary  betterment  of 
a  city  which  sadly  needed  it  at  that  time.  He  held 
the  office  continuously  during  the  terms  of  three  suc- 
ceeding mayors,  and  his  annual  reports  pointed  out  a 
series  of  possible  reforms  that  are  still  being  acted 
upon.  They  included  the  first  suggestions  of  several 
sanitary  measures  which  are  now  regarded  as  matters 
of  course,  and  others  the  necessity  of  which  is  not  yet 
fully  appreciated.  These  reports  dealt  with  smallpo.x, 
sewerage,  lighting  and  ventilation  of  tenements,  and 
the  possibility  of  preventing  the  incursion  of  cholera 
by  quarantine  regulations,  which  was  an  original  idea 
with  him,  and  one  whose  truth  has  been  abundantly 
proved.  He  also  served  as  surgeon  in  the  militia 
from  1844  to  1866. 

But  the  fame  acquired  by  Dr.  Sayre  as  a  sanitarian 
was  outshone  by  his  brilliant  reputation  as  a  bold  and 
original  surgeon.  He  was  the  first  American  to  per- 
form successfully  an  exsection  of  the  hip  for  morbus 
coxarius,  his  first  operation  having  been  in  1854. 
During  the  medical  congress  in  Philadelphia  in  1876 
he  demonstrated  the  operation  before  a  number  of 
visiting  surgeons,  one  of  whom,  Lister,  said  that  the 
privilege  of  witnessing  that  operation  was  in  itself  a 


sufficient  reward  for  the  fatigues  of  the  voyage  across 
the  Atlantic.  Dr.  Sayre  had,  four  years  previously, 
visited  Europe  and  lectured  on  the  treatment  of  hip- 
joint  and  spinal  disease  before  a  number  of  medical 
societies.  In  1877  he  again  went  to  England  as  a 
delegate  for  the  .American  Medical  Association  to  the 
meeting  of  the  British  Medical  Association  in  Man- 
chester, and  demonstrated  there  and  elsewhere  in 
Great  Britain  the  use  of  suspension  and  the  applica- 
tion of  the  plaster  jacket  in  the  treatment  of  Pott's 
disease  of  the  spine.  His  contributions  to  medical 
literature  were  many,  and  as  a  lecturer  he  was  re- 
nowned. In  recognition  of  his  many  and  great  con- 
tributions to  surgery,  especially  orthopedic  surgery, 
Dr.  Sayre  was  made  an  honorary  member  of  the 
British  Medical  Association,  the  Medico-Chirurgical 
Society  of  Edinburgh,  the  Surgical  Society  of  St. 
Petersburg,  and  the  Medical  Society  of  Norway. 
Charles  IV.  of  Sweden  also  decorated  him  with 
knighthood  of  the  Order  of  Wasa  for  his  attendance 
on  a  member  of  the  royal  family. 

Of  three  sons,  all  graduates  in  medicine.  Dr.  Regi- 
nald H.  Sayre,  of  this  city,  is  the  sole  survivor. 

Dr.  Sayre  was  a  typical  American  in  every  sense. 
Ingenious,  original,  and  resourceful,  he  was  ever  ready 
to  do  and  dare  in  any  surgical  emergency.  Few  in 
his  time  commanded  wider  and  more  extensive  appre- 
ciation of  his  work,  and  no  American  surgeon  enjoyed 
a  better  reputation  than  did  he  whose  name  and  fame 
belonged  to  the  entire  civilized  world  of  progressive 
science. 

At  a  special  meeting  of  the  executive  committee  of 
the  New  York  County  Medical  Association,  held  Sep- 
tember 24,  190Q,  the  following  resolutions  were  unan- 
imously adopted : 

IV/it-reas,  It  is  our  sad  duty  to  announce  the  death 
on  September  21,  1900,  of  our  late  associate.  Dr. 
Lew  is  Albert  Sayre,  one  of  the  founders  of  the  Ameri- 
can Medical  Association,  and  its  president  in  1880; 
therefore  be  it 

I'icsolved,  That  we  place  on  record  our  high  appre- 
ciation of  the  valuable  services  which  he  has  rendered 
to  medicine  and  surgery  during  his  long  and  useful 
life; 

Resolved,  That  his  daring  originality,  his  freedom 
from  surgical  traditions,  along  with  his  unflagging  en- 
thusiasm and  interest  in  everything  pertaining  to  his 
beloved  profession,  constituted  him  a  teacher  of  rare 
excellence,  whose  pupils  will  cherish  his  memory 
long  after  the  voice  of  their  preceptor  is  hushed; 

Kesolved,  That  we  extend,  in  the  name  of  the  mem- 
bers of  the  New  York  County  Medical  Association, 
our  heartfelt  sympathy  to  the  afiflicted  relatives,  and 
direct  that  a  copy  of  these  resolutions  be  sent  to  the 
family  and  to  the  medical  journals. 


Obituary  Notes. — Dr.  James  Hart  Curry  died  on 
September  24th  at  his  home  in  Shrub  Oak,  N.  Y.  He 
was  born  in  this  city  in  1827,  but  had  lived  at  Shrub 
Oak  nearly  all  his  life.  He  studied  at  Peekskill  Mil- 
itary Academy,  and  was  graduated  from  the  Yale 
Medical  School  in  1852.  He  was  the  oldest  member 
of  the  Westchester  County  Medical  Society,  and  had 
held  every  office  in  that  society.  He  was  a  member 
of  the  State  Medical  Society,  and  the  Yale  Medical 
Alumni  Association,  of  which  he  was  the  third  presi- 
dent. He  served  as  surgeon  of  the  Eighteenth  Regi- 
ment, New  York  volunteers,  in  the  civil  war.  and  later 
was  surgeon  of  the  Fifth  Division,  N.  G.  S.  N.  Y.,  on 
the  staff  of  the  late  Gen.  James  W.  Husted. 

Dr.  Richard  H.  White,  of  this  city,  died  on  Sep- 
tember 22d  in  Sullivan  County,  where  he  had  gone 
for  his  health,  pulmonary  tuberculosis  being  the  cause 
of  his  death.      He  was  a  native  of  Canada,  and  was  a 


5o6 


MEDICAL    RECORD. 


[September  29,  1900 


graduate  in  arts  of  the  University  of  Toronto  and  in 
medicine  of  Trinity  Medical  College  in  1891.  In  his 
practice  he  had  devoted  himself  chietly  to  pulmonary 
diseases. 

Dr.  William  H.  Minn,  of  this  city,  died  on  Sep- 
tember 24th  of  congestion  of  the  brain.  He  was  fifty- 
one  years  of  age.  and  was  a  graduate  of  the  Univer- 
sity Medical  School  in  New  York  in  tlie  class  of 
1868. 

Dr.  Preston  B.  Scott  died  at  his  home  in  Louis- 
ville, Ky.,  on  September  24th,  aged  sixty -eight  years. 
Dr.  Scott  was  a  graduate  in  medicine  of  the  Univer- 
sity of  Louisville  in  the  class  of  1858,  and  served  as 
surgeon  in  the  Confederate  army  during  the  civil  war. 
He  was  a  member  of  the  American  Medical  Associa- 
tion and  of  the  Kentucky  State  Medical  Society,  and 
at  the  time  of  his  death  was  president  of  the  Associa- 
tion of  Surgeons  of  the  Confederate  Army  and  Navy, 
having  been  elected  to  that  office  at  the  third  annual 
meeting  of  that  society,  held  in  Louisville  early  in 
the  summer. 

Dr.  Henry  L.  Smyser,  the  oldest  physician  of 
York,  Pa.,  died  in  that  city  on  September  i6th,  at  the 
age  of  seventy-five  years.  He  was  graduated  from 
the  University  of  Pennsylvania  in  1S47,  but  in  1S49, 
seized  with  the  gold  fever,  he  went  to  California,  re- 
turning in  the  course  of  two  years.  In  1856  he  be- 
came attached  to  the  Russian  army  as  surgeon-major, 
and  served  through  the  Crimean  War.  On  return- 
ing to  the  United  States  he  enlisted  in  the  Union 
army  and  served  throughout  the  War  of  the  Rebellion 
as  contract  surgeon  at  York  barracks. 

Dr.  James  Willoughhy  Phillips,  superintendent 
of  I3urn  Brae  Sanitarium  at  Clifton  Heights,  Pa.,  died 
September  19th,  at  the  age  of  fifty-three  years.  He 
was  a  graduate  of  the  University  of  Toronto  and  a  fel- 
low of  the  Royal  College  of  Surgeons. 


progress  0f  Vertical  Science. 

AVti/  Yoj-k  Medical  Jou}-naI,  Scptt'niber  22,  /goo. 

The  Treatment  of  Chronic  Cystitis  in  the  Female  by  Cu- 
rettement  of  the  Bladder  and  Instillations  of  Corrosive  Sub- 
limate.— C  G.  Cumston  does  not  consider  it  necessary  or 
possible  to  curette  the  entire  surface  of  the  vesical  mucosa 
through  the  urethra,  as  the  lesions  show  a  marked  prefer- 
ence for  only  the  trigonum,  arouud  the  mouths  of  the  ure- 
ters, neck  of  the  bladder,  and  posterior  urethra.  In  a  gen- 
eral way  we  may  commence  in  the  adult  with  a  solution  of 
I  ;  4,000  and  in  the  child  r  ;  5.000.  Two  to  four  cubic  centi- 
metres make  a  sufficient  quantity  with  from  ten  to  fifteen 
drops  in  the  neck  of  the  bladder  and  posterior  urethra. 
He  describes  the  special  instruments  which  he  prefers  and 
the  progressive  steps  of  the  operation.  His  conclusions 
are  as  follows :  (i)  Sublimate  instillations  will  often  pro- 
duce a  very  great  improvement  in  the  distressing  symp- 
toms met  with  in  both  tuberculous  and  non-tuberculous 
cystitis,  such  as  a  diminution  in  the  frequency  of  micturi- 
tion, a  decrease  of  the  pain,  an  increase  in  the  capacity  of 
the  bladder,  and  an  improvement  in  the  condition  of  the 
urine.  In  some  cases  a  complete  cure  may  be  obtained. 
(21  When  the  instillations  fail  to  produce  the  desired  ef- 
fect, curettage  of  the  bladder  is  indicated  in  both  tuber- 
culous and  non-tuberculous  cystitis.  (3)  In  gonorrhceal 
cystitis  instillations  of  sublimate  are  particularly  effica- 
cious and  rapidly  subdue  the  pain.  (4)  Under  favorable 
circumstances  a  radical  cure  of  primary  tuberculous  cys- 
titis may  be  obtained  by  curettage  when  the  vesical 
lesions  are  localized  and  the  kidneys  free  from  the  disease. 
Curettage  per  urethram  will  not  allow  the  surgeon  to 
reach  the  entire  surface  of  the  bladder,  so  that  when  the 
lesions  arc  extensive  they  should  be  directly  treated  by 
suprapubic  cystotomy.  (5)  Much  relief  may  be  afforded 
by  curettage  to  a  large  number  of  patients  suffering 
from  tuberculosis  of  the  bladder,  but  who  on  account  of  the 
advanced  stage  of  generalized  infection  are  in  no  condition 
to  undergo  a  more  radical  o])eration.  (6)  When  cystitis  is 
due  to  a  prolapsus  of  the  genital  organs,  and  when  hystero- 
pexy, combined  with  anterior  and  posterior  colporrhaphy, 


does  not  relieve  the  bladder  symptoms,  curettage  of  the 

bladder,  followed  by  sublimate  instillations,  is  the  proper 
treatment. 

A  Report  of  Three  Cases  due  to  Ascending  Urinary  Infec- 
tion due  to  the  Bacillus  Pyocyaneus  and  the  Proteus  Vul- 
garis.^— By  'J.  Blunier  and  A.  J.  1-arligau.  Case  I.  showed 
symptoms  referable  in  the  main  to  the  nervous  system,  the 
most  important  of  these  being  partial  paraplegia  and  exag- 
gerated reflexes  succeeded  by  complete  paraplegia,  loss  of 
reflexes,  anaesthesia,  and  analgesia.  No  lesion  of  the  cord 
was  present.  On  autopsy,  evidences  of  an  old  affection  of 
the  bladder  were  found  itpon  which  was  superimposed  a 
fresh  inflammation,  and  it  is  probable  that  this  was  the 
route  of  infection.  A  bed-sore  developed,  and  this  became 
infected  witli  bacillus  pyocyaneus.  Case  II.  followed  a 
stone  in  the  bladder.  Case  III.  presented  the  clinical 
features  of  a  hemorrhagic  septictemia,  probably  incidental 
to  puerperal  streptococcus  infection. 

Membraneous  Enteritis.— H.  F.  Slifer  gives  the  clinical 
history  of  a  case  with  a  brief  outline  of  the  general  fea- 
tures of  the  malady. 

T/ie  Bos/on  Medical  a/id  Surgical  Journal.  Sept.  20.  igoo. 

Knee-joint  Surgery  for  Non-Tuberculous  Conditions. — Joel 
E.  Goldthwait  reports  thirty-eight  operations  for  synovial 
fringes,  injured  semilunar  cartilage,  loose  cartilage,  coag- 
ula,  exploratory  incision,  etc.,  and  judging  from  the  results 
obtained  holds  that  operations  upon  joints  need  not  be 
feared  more  than  operations  upon  other  parts  of  the  body. 
He  urges  the  importance  not  only  of  operating  to  relieve  a 
definitely  recognized  condition,  but  also  of  making  use  of 
exploratory  incisions  in  doubtful  cases  to  determine  the 
exact  nature  of  the  disease.  Without  this,  it  is  impos- 
sible in  many  cases  to  differentiate  in  the  incipient  stage 
between  several  difl^erent  conditions,  and  it  is  at  this  very 
time  that  the  most  can  be  accomplished  in  the  way  of  treat- 
ment if  the  exact  condition  is  known.  No  unpleasant  re- 
sults followed  the  operation  except  in  one.  a  case  of  osteo- 
arthritis, in  which  the  disease  was  apparently  made  more 
acute.  The  explorator\'  incision,  with  this  one  exception, 
did  not  alter  the  course  of  the  disease.  The  cases  from 
which  the  semilunar  cartilage  was  removed  have  function- 
ally normal  joints.  The  cases  in  which  the  synovial  fringes 
and  coagula  were  removed  are  improved  in  proportion  to 
the  nature  of  the  disease  which  caused  the  condition  to  be 
present. 

Fat-Free  Tincture  of  Digitalis. — Elbridge  G.  Cutter  calls 
attention  to  this  preparation,  devised  and  used  in  the 
Philadelphia  Hospital  to  meet  the  serious  drawback  of 
bulk  in  the  use  of  the  infusion  of  digitalis,  and  to  obtain 
a  preparation  which  would  net  nauseate.  A  still  more 
valuable  feature  of  the  remedy  is  the  rapidity  with  which 
the  preparation  is  absorbed  and  assimilated  in  comparison 
with  the  official  product.  The  time  element  of  direct  action 
is  a  very  important  matter  in  some  cases,  and  might  read- 
ily mean  the  difference  between  the  life  and  death  of  a 
patient.  No  especial  dift'erence  in  the  time  of  absorption 
between  hypodermic  injections  and  mouth  administrations 
is  observable,  but  when  the  tincture  is  given  hypodermi- 
cally  the  pulse  reduction  seems  to  be  greater  with  the  fat- 
free  tincture,  though  not  extending  over  any  greater 
length  of  time.  Directions  are  given  for  the  preparation 
of  this  tincture. 

Treatment  of  Pott's  Disease  after  the  Development  of  the 
Deformity. — By  Edward  H.  Bradford  and  F.  J.  Cotton. 

Journal  oj  tlie  American  Medical  Ass' n,  Sept.  22.  /goo. 

Trauma  as  a  Cause  of  Nervous  Diseases. — C.  W.  Burr 
speaks  solely  of  the  causative  influence  ot  trauma  and  of 
the  various  ways  in  which  it  acts,  and  considers  only  the 
organic  and  functional  diseases  unaccompanied  by  serious 
external  injury.  It  is  not  safe  to  say  always  that  because 
a  disease  follows  a  trauma  it  is  The  result.  It  is  generally 
accepted  that  trauma  without  injury  to  the  skull  or  spine 
may  produce  organic  disease  referable  to  the  brain  or  cord. 
Certain  functional  nervous  diseases  may  result  from  acci- 
dent. It  is  diflicult  to  prove  that  trauma  is  a  cause  of  lo- 
comotor ataxia.  Hysteria  and  neurasthenia  frequently 
follow  an  accident,  and  are  .sometimes  quickly  recovered 
from  after  legal  settlement.  In  hysteria  there  is  no  dis- 
coverable lesion.  Serious  physical  injury  is  rarely  fol- 
lowed by  hysteria.  It  is  doubtful  if  the  attemjjt  to  group 
together  certain  symptoms  under  the  term  traumatic  neu- 
rosis serves  any  good  purpose. 

Medico-Legal  Relations  of  Traumatic  Nervous  Affections.— 
J.  II.  Lloyd  gives  a  case  as  a  text  for  Ins  pa]ier.  After  a 
fall  downstairs  there  was  immediate  paralysis  of  body,  legs, 
and  arms,  presenting  the  picture  of  total  transverse  lesion 
in  tlie  middle  cervical  region.  Death  took  place  in  five  days. 
The  chief  lesion  was  a  small  hemorrhage  involving  prin- 
cipally the  anterior  halves  of  the  posterior  columns.  The 
microscope,  however,  showed  extensive  destruction  of  the 


September  29,  1900] 


MEDICAL    RECORD. 


507 


essential  elements  of  the  medullary  tissue,  involving  the 
whole  transverse  area  of  the  cord.  Abolition  of  function 
in  these  traumatic  cases  is  accounted  for  by  necrotic  or- 
ganic changes  in  the  neurons.  Most,  if  not  all,  obdurate 
symptoms  represent  changes  in  the  organic  bases.  They 
are  none  the  less  real  because  they  cannot  be  seen  without 
the  microscope.  Functional  diseases  causing  disablement 
are  entitled  to  the  same  consideration  as  the  more  impos- 
ing "organic  "  affections. 

Prognosis  and  Treatment  of  the  Traiunatic  Neuroses. — \V. 
Skinner  seeks  to  determine  what  is  meant  by  traumatic 
neurosis,  and  discusses  prognosis.  Some  make  a  distinc- 
tion between  the  neuroses  and  traumatic  neurasthenia  and 
hysteria.  Xeuroses  include  all.  Heredity  and  previous 
health  should  always  be  inquired  into.  Litigation  has  a 
great  intluence  tending  to  self-concentration  and  magnify- 
ing of  symptoms,  which  increase  in  severity.  Simulation 
is  held  to  be  rare  by  neurologists,  and  exaggeration  fre- 
quent, while  railway  surgeons  believe  the  former  common 
and  traumatic  neurosis  an  imaginary  disease.  The  truth 
lies  between.  Rest  treatment  is  the  best.  Prince  is  quoted 
to  the  contrary.  Rigid  isolation  should  be  insisted  upon. 
If  this  fails,  there  should  be  complete  change  of  climate 
and  .scene.  Hydrotherapy  is  of  great  utility.  Drugs  are 
of  comparatively  little  value. 

Traumatic  Neuroses  from  the  Standpoint  of  a  Surgeon. — 
A.  I).  Hcvan  says  the  medical  atlendaiit  is  chiclly  respon- 
sible for  the  condition  of  so-called  traumatic  neurosis.  It 
is  a  mental  state,  not  an  organic  disease,  and  he  illustrates 
his  point  with  cases.  Without  jrositive  and  immediate 
symptoms  of  gross  lesion,  malingering,  or  abnormal  cere- 
bral state,  traumatic  neuroses  or  a  mixture  of  the  two  are 
present.  In  traumatic  neuroses  there  are  two  factors :  a 
brain  readily  affected  by  suggestions  ;  suggestions  fur- 
nished I)y  an  accident.  Refined  means  of  diagnosis — dy- 
namometer, jestliesiometer,  and  electricity — are  seldom  of 
value.  Recovery  may  be  indefinitely  postponed  under  im- 
proper surroundings  and  advice.  N'o  secondary  degenera- 
tions of  the  nervous  system  follow  traumatic  neuroses. 

The  Identification  of  Dextrose  in  Human  Urine. — By  H. 
Stern. 

Physicians  as  Speakers. — By  William  Whitford. 

Specialism  in  Medicine. — By  F.  C.  Shattuck. 

Medical  Xe-ws,  September  »^,  tgoo. 

Toxicity  versus  Septicity  in  the  Infectious  Pathogenic  Bac- 
teria.—  Kiigene  Wasdiu  says  in  such  diseases  as  typhoid 
fever  and  gonorrhoea,  in  which  the  infection  may  take 
place  from  the  mucosa  of  some  organ  other  than  the  respi- 
ratory tract,  tlie  septic  quality  will  be  as  readily  followed 
by  sepsis  as  from  infections  along  this  tract.  The  law, 
then,  in  these  acute  types  of  cases  encountered  in  all  of 
them,  is  that  the  infection  having  taken  place,  the  type  of 
the  disease  must  depend  upon  tlie  development  in  the  in- 
fecting organisms  of  the  inherent  qualities  of  to.xicity  and 
septicity  ;  that  if  toxicity  preponderate  there  will  result  the 
toxajmia;,  and  if  septicity  be  the  more  pronounced  the  sep- 
tica;miie  will  be  produced,  since  tlie.se  qualities  coexist  in 
each  infective  germ,  the  one  or  the  other  being  exhibited 
in  greater  perfection  according  to  environment. 

Total  Extirpation  of  the  Ureter. — Willy  lleyer  speaks  of 
the  o])eralion  at  the  time  of  nephrectomy  or  subsequently. 
He  gives  two  i>crsi>iial  cases.  The  three  indications  for 
nephrectomy  and  their  influence  upon  a  probable  extirpa- 
tion of  the  ureter  are  discussed  ;  tumor,  tuberculosis,  and 
pyonephrosis.     The  ojieration  is  <lcscribe'l. 

Studies  in  Surgical  Technique,  with  a  Report  on  Operative 
Surgery  at  the  City  Hospital  for  1898  and  1899. — By  George 
Emerson  Brewer. 

Pltilailelphia  Medical  Journal.  September  22,  tgoo. 

Chronic  Ear-Vertigo  (Me'niere's  Disease) ;  its  Mechanism 
and  Surgical  Treatment. — H.  Burnett  says  that  inasmuch 
as  the  essential  cau.sc  of  chronic  ear  vertigo  is  the  impac- 
tion of  the  stapes  in  the  oval  window,  removal  of  this  re- 
tractive force  and  liberation  of  the  stapes  will  cure  the  dis- 
ease. He  therefore  advises  the  removal  of  the  incus,  which 
breaks  the  retractive  force  of  the  tensor  tympani  and  mal- 
leus exerted  through  the  incus  upon  the  stapes,  and  the 
latter  Ijonelet  is  liberated.  In  clironic  purulent  cases  it  is 
necessary  to  excise  the  remnants  of  the  diseased  niem- 
brana,  and  the  malleus  and  the  incus,  with  their  synechial 
bands,  in  order  to  liberate  the  stapes.  This  operation  in 
such  cases,  supplemented  by  local  treatment  of  the  puru- 
lent drum  cavity,  is  followed  by  cessation  of  the  vertigi- 
nous attacks,  and  cure  of  the  chronic  purulency.  Thus 
excision  of  the  diseased  ossicles  leads  to  curing  the  chronic 
purulency  and  acts  as  a  prophylaxis  of  antrum  and  mas- 
toid disease.     The  operation  is  described  in  full. 

Acute  Seminal  Vesiculitis. — By  H.  H.  Morton.  The  au- 
thor's treatment  is  as  follows  :  The  patient  is  piit  to  bed  and 
given  a  saline  cathartic,  which  is  always  in  order  in  every 


pelvic  inflammation.  Hot  sitz-baths  and  copious  irriga- 
tions of  the  rectum  with  hot  water  are  useful  in  allaying 
the  inflammation.  If  the  posterior  urethritis  is  severe, 
sandal-wood  oil  relieves  the  tenesmus  and  renders  the 
urine  less  irritating.  Injections  into  the  anterior  urethra 
of  course  are  contraindicated,  but  above  all  things  any  at- 
tempt at  massage  or  stri])ping  the  vesicles  should  be  abso- 
lutely interdicted.  Under  this  i)lan  of  treatment  most 
cases  of  acute  vesiculitis  will  recover  in  from  two  to  four 
weeks. 

A  New  Hjemoglobinometer  for  the  Examination  of  Undi- 
luted Blood.— By  Arthur  1  >are. 

The  Chemical  Examination  of  Faeces  for  Clinical  Purposes. 
— By  A.  1;.  Austin. 

The  Injured  Tramp  ;  Who  is  Responsible  for  Him  ? — By 
F.  Julian  Carroll. 

Gynaecology  ;  its  Present,  Past,  and  Future.— By  Howard 
A.  Kelly, 

Multiple  Metastatic  Sarcomata  of  the  Lungs. —  By  S.  S. 
Burt. 

T he  Lancet,  September  /j,  igoo. 

Thrombosis  in  the  Veins  of  the  Pelvis  and  Lower  Extrem- 
ities after  Operations. — By  K.  G.  Lennander.  The  autlior 
makes  a  strong  plea  for  the  elevation  of  the  foot  of  the  bed 
after  operations.  He  says  that  if  we  wish  to  prevent  tl.e 
formation  or  spreading  of  a  thrombus  it  is  necessary  to 
combat  all  causes  of  local  stasis.  For  the  pelvic  and  lower 
extremity  veins  the  raising  of  the  lower  end  of  a  patient's 
bed  should  be  of  considerable  mechanical  assistance  in 
promoting  the  flow  of  blood  toward  the  inferior  vena  cava 
and  right  auricle.  The  value  of  this  aid  may  l)e  increased 
and  the  patient  made  more  comfortable  by  frequently  al- 
tering his  position  in  the  bed.  and  lightly  ruljbiiig  the  feet 
and  legs,  provided  that  he  has  not  already  a  thrombus. 
If  any  varices  exist  on  the  distal  side  of  the  operation 
wound  in  a  lower  extremity  the  part  should  be  bandaged 
from  the  foot  to  such  a  point,  the  leg  should  be  elevated, 
or,  better,  the  bed  should  be  raised.  This  procedure  ex- 
erts a  very  much  more  noticeable  influence  upon  the  circu- 
lation. By  its  use  he  believes  we  may  largely  prevent 
thrombosis  following  surgical  operations,  parturition,  and 
those  di.seases  which  are  accimipanied  by  intense  anamia 
and  auto-intoxication,  in  which  a  tendency  toward  the 
complication  of  thrombosis  exists. 

Heat-Stroke  in  India ;  an  Examination  of  Some  Statistics 
Relating  Thereto. — \V.  J.  P.uehanan  presents  statistics  of 
the  British  army  in  India  showing  that  heat-stroke  is  most 
fatal  and  most  prevalent  where  the  heat  is  greatest  and 
most  oppressive  and  at  the  time  of  year  when  these  influ- 
ence's are  at  their  maximum.  It  will  require  much  more 
evidence  than  has  yet  been  produced  to  make  those  who 
have  had  experience  of  the  disease  in  India  accept  a  micro- 
bial or  any  otiier  cause  which  seeks  to  minimize  the  great 
and  predominating  influence  of  fierce  and  continuous  heat 
While  looking  upon  heat  as  the  most  important  factor  we 
must  also  bear  in  mind  the  great  influence  of  the  usually 
mentioned  predisposing  causes,  as  age,  length  of  residence 
in  the  tropics,  occupation,  exposure,  unsuitable  clothing 
(as  the  tight-buttoned  and  belted  uniform  of  soldiers),  in- 
temperance (perha]>s  especially  beer-drinking),  over-fa- 
tigue and  overcrowding,  want  of  ventilation,  and  previous 
illnesses. 

A  Case  of  Total  Gastrectomy. — By  Viera  de  Carvalho. 
The  patient  was  a  Brazilian  woman  aged  forty-six  years, 
who  suffered  acute  gastric  pains  after  eating  and  vomited 
freely.  At  times  blood  was  raised.  A  tumor  was  found  in 
the  right  epigastric  region  close  to  the  costal  margin.  A 
diagnosis  of  malignant  growth  of  the  pylorus  was  made 
and  an  operation  begun  for  gastro-enterostomy.  The  tu- 
mor was  found  as  expected,  but  there  were  adhesions  to 
neighboring  organs  afl^ecting  the  greater  part  of  the  gastric 
lymphatics.  It  was  therefore  decided  to  remove  the  entire 
stomach.  This  was  done  by  Carvalho,  who  describes  the 
operation  in  detail.  The  patient  was  doing  finely  on  the 
ninth  day,  the  superficial  wound  having  healed.  Her  ap- 
petite was  ravenous,  and  she  was  able  apparently  to  digest 
small  quantities  of  solid  food. 

Poisoning  by  Carbon  Monoxide. — Two  cases  are  described 
by  C.  B.  Elgood.  one  proving  fatal.  He  advocates  the  use 
of  artificial  respiration,  which  employed  alone  is  not  free 
from  danger,  but  which  should  he  accompanied  by  oxygen 
inhalations,  slapping  and  friction  over  the  cardiac  region, 
and  faradization  of  the  phrenic  nerves. 

General  Nervous  Shock,  Immediate  and  Remote,  after  Gun- 
shot and  Shell  Injuries  in  the  South  African  Campaign. — 
By  M.  I.  Finucane. 

Tuberctilous  Lesions  from  a  Clinical  Point  of  View.— By  E. 
Owen.     .Address  before  the  Canadian  Medical  .Association. 

Hysterical  Somnolence  and  States  of  Double  Consciousness. 
—By  Ethel  M.  X.  Williams. 


5o8 


MEDICAL   RECORD. 


[September  29,  190Q 


Prevention  and  Treatment  of  Post-Partum  Hemorrhage. — 
Address  liy  J.  W.  ISycrs. 

The  Chemical  Examination  of  the  Gastric  Contents.— By 
F.  Sliufflebotham. 

British  Medical  Journal.  Scpletnhcr  /j.  rgoo. 
An  Address  on  Tuberculous  Lesions  from  a  Clinical  Point 
of  View.— Edmund  Owen,  in  his  address  before  ihe  Cana- 
dian Medical  Association,  stated  that  there  are  three  itn- 
portaut  facts  of  which  the  public  must  be  made  con- 
scious; first,  that  the  disease  is  communicable;  second, 
that  it  is  preventable  ;  and  third,  that  it  is  curable.  Tu- 
berculosis is  not  of  the  intractable  nature  it  was  formerly 
considered  to  be.  At  the  end  of  the  nineteenth  century  it 
is  somewhat  unusual  for  a  patient  with  any  surgical  affec- 
tion to  be  allowed  the  opportunity  of  showing  wliat  he  can 
do  without  submitting  himself  to  operation.  The  follow- 
ing disconnected  statements  are  based  upon  clinical  ob.ser- 
vation  :  (i)  Chronic  inflammation  of  a  joint  in  a  child  or 
young  person  is  always  tuberculous — except  in  those  very 
rare  cases  in  which  it  is  due  to  liereditary  syjihilis  or  osteo- 
arthritis. (2)  Tuberculous  inflammation  may  completely 
destroy  a  joint,  and  then  leave  it  solidly  and  soundly  syu- 
ostosed,  without  the  surrounding  tissues  or  the  skin  having 
been  implicated.  (3)  If  tuberculous  granulation  tissue 
breaks  down  into  a  fluid,  that  fluid  is  not  pus,  and  the 
collection  is  not,  properly  speaking,  an  abscess — unless, 
by  bad  fortune,  or  by  worse  surgery,  it  has  become  in- 
fected by  septic  micro-organisms.  (4)  The  fluid  collection 
is  not  to  be  treated  as  an  abscess — by  incision  and  drain- 
age, that  is — but  is  to  be  opened  and  emptied,  and  scraped 
and  cleansed  of  its  unhealthy  lining  of  granulation  tissue. 
Then  the  wound  in  tlie  skin  is  to  be  completely  closed  by 
sutures ;  firm  pressure  is  to  be  evenly  applied,  and  the 
part  is  to  be  kept  absolutely  at  rest.  The  success  attend- 
ing this  line  of  treatment  leaves,  as  a  rule,  little  to  be  de- 
sired, and  for  this  important  advance  in  practical  surgery 
we  are  chiefly  indebted  to  the  patient  researches  of  our 
friends  with  the  smock-frocks  and  the  guinea-pigs.  (5) 
Iodoform  is  of  no  peculiar  value  in  the  treatment  of  tuber- 
culous lesions.  The  author  has  long  since  discarded  it,  and 
has  not  noticed  any  falling  off  in  the  results  of  his  practice 
in  consequence.  Iodoform  is  an  irritant  and  a  poison  ;  it 
is  apt  to  be  septic,  as  germs  can  grow  upon  it,  but  Mr.  Owen 
said  he  had  no  knowledge  of  the  truth  of  the  statement  that 
mushrooms  have  actually  been  cultivated  on  it.  Other 
questions  discussed  are  "the  forcible  straightening  of 
carious  spines  "  and  "the  treatment  of  vertebral  caries," 

Miinchcttcr  medicinische  Woche/ischrift,  Sept.  4.  igoo. 

Observations   on  the   Cocainizatlon  of  the   Spinal  Cord. — 

August  Bier  over  a  year  ago  published  a  paper  (Deutiche 
/.eitsclir.  f.  Cliir.,  April,  1S99)  in  which  the  production  of 
major  an;esthesia  by  the  injection  of  minute  quantities  of 
cocaine  into  the  spinal  canal  was  described  and  favorably 
commented  on.  At  the  same  time  the  author  drew  atten- 
tion to  the  very  serious  by-effects  sometimes  produced,  and 
advised  great  care  in  conducting  further  experiments. 
His  present  communication  is  a  protest  against  the  reck- 
lessness with  which  the  method  is  being  apjjlied,  regardless 
of  the  fact  that  no  noteworthy  improvement  in  the  tech- 
nique has  been  made,  and  especially  the  dangerously  large 
doses  that  are  being  employed.  Experiments  upon  ani- 
mals conducted  under  his  direction  have  shown  that  like 
most  drugs  cocaine  exerts, a  much  more  powerful  and  to.xic 
action  when  thrown  into  the  spinal  canal  than  when  ad- 
ministered by  other  avenues.  As  much  as  4  cgm.  have  been 
used  clinically  at  one  injection,  while  in  the  author's  opin- 
ion even  15  mgm.  is  a  high  dose  and  should  not,  and  need 
not,  be  exceeded.  In  conducting  further  observations  on 
the  subject  the  point  is  not  to  apply  the  drug  in  the  old 
way  as  originally  described,  which  method  is  not  very 
promising,  but  to  attempt  to  devise  means  to  reduce  its 
toxicity  when  absorbed  from  the  meninges,  and  to  prevent 
the  occurrence  of  unpleasant  by-effects.  Furtlicrmore,  the 
effort  should  be  made  to  apply  the  method  to  operations 
on  the  entire  trunk  and  the  arms,  and  to  find  other  harm- 
less drugs  which  shall  be  also  able  to  produce  auiEsthesia 
in  this  way. 

A  Peculiar  Case  of  Azoospermia. — F.  A.  Kehre.  taking  for 
his  text  the  history  of  a  case,  urges  the  necessity  for  a 
more  general  recognition  among  the  laity  of  the  far-reach- 
ing results  of  gonorrhceal  infection,  which  he  considers  al- 
most entitled  to  rank  with  tuberculosis  as  a  scourge  of 
mankind.  Before  matrimony  every  individual  who  has 
suffered  from  a  specific  genito-urinary  disea.se  should  sub- 
mit his  genitals  and  the  testicular  secretion  to  medical  ex- 
amination to  determine  their  condition  and  especially  the 
fecundating  power  of  the  semen.  In  the  instance  cited  no 
spermatozoa  were  present  in  the  semen  of  a  man  wlio  had 
been  married  seven  years  before.  Inasmuch  as  it  was  al- 
most certain  that  the  trouble  dated  back  to  a  severe  orchi- 
tis necessitating  a  unilateral  castration,  which  was  second- 


ary to  a  gonorrhceal  infection  contracted  thirteen  years 
previously,  the  patient  was  told  that  his  wife's  statement 
that  the  two  children  she  had  borne  were  the  offspring  of 
another  man  was  probably  true. 

A  Case  of  Indirect  Fracture  of  a  Metatarsal  Bone. — Ernst 
Maillefert  says  that  while  this  form  of  injury  is  not  infre- 
quent in  infantry  soldiers  it  is  rarelj'  observed  in  civilians. 
The  former  usually  acquire  it  on  the  march,  when  the  feet 
are  subjected  to  undue  fatigue  and  when  it  is  impossible 
to  pay  much  attention  to  inequalities  of  the  ground  walked 
on,  while  the.se  conditions  do  not  obtain  among  other 
classes.  The  characteristic  symptoms  of  fracture  are  usu- 
ally absent,  swelling  and  slight  pain  but  no  loss  of  function 
being  commonly  found,  so  that  the  true  nature  of  the  in- 
jury is  usually  overlooked,  and  inasmuch  as  displacement 
of  the  fragments  is  rare  even  .r-ray  examination  does  not 
reveal  it.  Cases  of  foot  injury  should  always  be  most 
carefully  tested  for  such  a  condition,  and  doubtless  it 
would  be  found  in  many  unsuspected  instances.  Rest 
in  bed  for  from  two  to  four  weeks  is  sufticient  in  the  way 
of  treatment,  as  the  broken  bone  is  so  well  splinted  by  its 
neighbors  that  no  dressing  is  necessary. 

A  Case  of  Intrauterine  Compound  Fracture  of  the  Femur. 
— Otto  Kraemer  reports  a  case  in  which  a  pregnant  woman 
in  her  fifth  month,  while  attempting  to  raise  a  weight,  expe- 
rienced a  severe  pain  in  the  abdomen.  This  gradually 
diminished,  but  did  not  completely  cease  until  three  weeks 
before  delivery.  At  birth  the  child  presented  a  sharp  cur- 
vature in  the  lower  third  of  the  right  thigh  together  with 
a  healed  cicatri.x.  undoubtedly  the  result  of  a  healed  in- 
trauterine compound  fracture. 

Optic  Neuritis  in  Chlorosis ;  Clinical  Course  and  Death 
with  Symptoms  of  Brain  Tumor. — By  A.  Engelhardt. 

The  Observation  of  the  Vital  Process  of  Living  Phagocytes 
Stained  with  Neutral  Red.— By  J.  Plato. 

A  Cured  Case  of  Multiple  Intestinal  Injury. — B3'  Deiters. 

Pregnancy  and  Ovarian  Tumors. — By  Ricliard  Mond. 

Lohnstein's  Saccharometer. — By  Jacob  Meyer. 

An  Electric  Sterilizer. — By  Heeht. 

The  Adrenals.— By  Otto  Aichel. 

Deutsche  juedicinische  Wochenschrift,  Septejnber  6,  igoo. 

The  Diagnosis  of  (Esophageal  Stenosis. — G.  Holzknecht 
gives  the  details  of  a  new  method  of  applying  the  Roent- 
gen rays  to  the  diagnosis  of  oesophageal  strictures.  The 
introduction  of  a  bougie  filled  with  shot  or  mercury,  and 
subsequent  exposure  of  the  patient  to  a  protracted  fluoro- 
scopic observation  under  these  conditions,  is  a  disagreeable 
and  sometimes  dangerous  procedure,  the  inconveniences  of 
which  the  author's  proposal  is  intended  to  obviate.  Three 
tests  are  to  be  made ;  the  first  consists  in  causing  the  pa- 
tient to  drink  several  ounces  of  water  holding  gr.  xv.  to 
XXX.  of  subnitrate  of  bismuth  in  suspension  as  a  shake 
mixture.  If  the  stricture  is  of  any  degree  of  tightness  a 
precipitation  of  the  bismuth  will  take  place  at  its  site  and 
be  vi.sible  when  properly  illuminated.  The  only  direction 
ill  which  the  oesophagus  is  accessible  to  observation  is 
from  the  left  behind,  forward,  and  to  the  right,  when  it  is 
visible  as  a  light  streak  between  the  spinal  column  and 
heart  shadows.  In  the  second  test  the  patient  swallows 
a  capsule  containing  the  bismuth  while  the  observer  has 
the  oesophagus  under  observation  on  the  screen,  the  place 
of  arrest  of  the  black  metallic  shadow  indicating  the  site 
of  the  stenosis.  In  corroboration  of  these  two  proced- 
ures, or  in  case  they  give  a  negative  result,  the  degluti- 
tion of  the  capsule  is  preceded  by  the  administration  of  a 
morsel  of  bread,  which  is  sure  to  lodge  in  the  stricture  if 
present  and  arrest  the  test  object  in  its  descent.  The  ad- 
vantage of  this  diagnostic  measure  is  that  it  is  applicable 
when  the  use  of  bougies  is  not  permissible  owing  to  sus- 
pected aortic  aneurism,  h^matemesis,  or  the  wishes  of  the 
patient,  and  that  in  a  simple,  safe,  and  painless  way  it 
gives  accurate  information  concerning  the  jjresence,  loca- 
tion, calibre,  and  length  of  a  stricture. 

The  Chemical  Resources  of  the  Body  Serving  as  Anti- 
dotes.— Alexander  EUinger  understands  under  the  term  an- 
tidote used  in  this  sense  not  alone  the  ability  to  render 
harmless  a  certain  quantity  of  any  poison  which  may  have 
penetrated  into  tlie  system,  but  the  stopping  of  its  toxic 
action  after  it  has  already  reached  the  circulation.  A  con- 
sideration of  the  etiological  investigations  of  recent  years 
brings  the  conviction  that  a  vastly  greater  proportion  of 
di.seases  than  is  supposed  is  due  to  the  action  of  poisons 
either  directly  introduced,  produced  by  adventitious  organ- 
isms which  have  gained  access  to  the  body,  or  originating 
within  it  as  tlie  result  of  anomalies  of  metabolism.  The 
whole  understanding  of  the  processes  by  which  the  system 
is  enabled  to  combat  these  subst:mces  is  still  shrouded  in 
mystery,  and  the  only  direction  in  which  it  is  possible  to 


September  29,  1900] 


MEDICAL    RECORD. 


509 


approach  the  subject  is  by  studying  first  the  chemical  proc- 
esses by  which  the  coarser  poisons,  whose  composition 
is  well  understood,  are  disposed  of.  These  are  neutraliza- 
tion, oxidation,  reduction,  synthesis,  and  decomposition, 
but  for  the  details  of  their  apjjlication  to  specific  reactions 
reference  must  be  made  to  the  original  paper. 

The  Examination  of  the  Thorax  by  the  Roentgen  Rays, 
with  Some  Results. — By  Levy  Dorn. 

Haematological  Inve?tigations. — By  Ernst  Becker. 

A  Sieve  for  Stools. — By  I.  Boas. 

Frciiih  Journals. 

Nodules  of  Rabies  and  Rapid  Diagnosis. — V.  Babes  refers 
to  a  previous  publication  in  which  he  stated  that  if,  after 
minute  examination  of  the  sjiiue  and  bulb,  no  perivascular 
or  pericellular  miliary  nodule  was  found,  it  was  to  be  re- 
garded as  highly  probable  that  the  animal  bitten  was  not 
mad.  Pericellular  nodules  speak  in  favor  of  rabies.  The 
nerve  centres  as  well  as  the  ganglia  should  be  examined. 
When  the  bulb,  marrow,  and  ganglia  present  no  leucocytic 
thromboses  or  perivascular  or  pericellular  undulations,  we 
may  suppose  with  great  probability  that  the  dog  was  not 
mad.  If  the  dog  died  a  natural  death  this  examination 
permits  us  to  exclude  rabies  with  certitude. — La  Prt-sse 
Mt'dicali',  September  S,  1900. 

Suppurative  Arthritis  Consecutive  to  a  Penetrating  Wound 
of  the  Knee  Joint.- — Xavier  l.)elore  gives  a  case  witli  ar- 
throtomy  followed  by  recovery  in  a  man  aged  si.xty-three 
years.  Sujipurative  arthritis  of  the  knee  after  penetrating 
wounds  presents  such  gravity,  especially  in  the  adult,  that 
treatment  should  most  often  consist  in  resection  of  the 
knee.  At  any  rate,  in  certain  cases  characterized  by  slow 
evolution  and  by  attenuation  of  the  virulence  as  shown  by 
cultures  and  inoculations,  arthrotomy  is  sufficient.  It  is 
justifiable  by  the  results  of  laboratory  research  when  the 
latter  is  possible.  Benign  arthritis  of  traumatic  origin 
is  an  exception. — Ga:ette  llehdomadaire  de  Aledecine  et 
dc  Cliirtiri^ic,  September  g,  1900. 

Abscess  of  Bones. — L.  Longuet  concludes  an  article  in 
which  he  advocates  trepanation  by  tunnelling  as  a  substi- 
tute for  trepanation  by  grooving  or  scooping  out.  There 
is  nearly  always  absence  of  fluctuation.  Distinction  must 
be  made  between  tuberculous  osteitis,  syphilitic  osteitis, 
chronic  primary  osteomyelitis,  bony  neoplasm,  etc.  Tre- 
phining is  indicated  in  all  bone  abscesses.  It  is  also  imper- 
ative in  neuralgic  osteitis  without  tumor.  The  technique 
is  indicated. — Le  Progres  JMedkal,  September  S,  1900. 

7 he  Practitioner,  September,  igoo. 

Notes  on  a  Case  of  Gastric  Tetany. — J.  Christian  Simpson 
describes  a  case  of  tetany  associated  with  dilatation  of  the 
stomach.  Kussmaul  was  the  first  to  associate  tetany  with 
gastrectasis  in  1S69,  and  latterly  it  has  been  observed  more 
particularly — ninety-two  per  cent,  according  to  Fenwick — 
in  those  who  have  pyloric  or  duodenal  disease  rather  than 
a  primary  affection  of  other  parts  of  the  stomach.  Its  mor- 
tality has  been  placed  as  high  as  seventy-five  per  cent.  As 
to  treatment,  if  the  active  cause  be  auto-intoxication,  this 
must  be  dealt  with  in  two  direct  ways  ;  first,  to  remove  the 
gastric  and,  if  possible,  the  intestinal  contents ;  and  sec- 
ondly, to  flush  the  toxins  out  of  the  blood  and  lymph  by 
saline  transfusion  in  one  way  or  another.  A  secondary 
point  in  favor  of  the  saline  treatment  is  the  relief  it  gives 
to  thirst.  After  the  acute  symptoms  have  been  alleviated 
comjs  the  questiou  of  operation  as  a  preventive  of  further 
attacks,  by  curing  or  relieving  the  local  gastric  condition 
which  allows  the  auto-intoxication  to  be  carried  on. 

The  Surgical  Treatment  of  Trigeminal  Neuralgia. — Victor 
Horsley  has  in  twenty-one  cases  removed  the  Gasserian 
ganglion  for  the  cure  of  trigeminal  neuralgia,  limiting  this 
term  strictly  to  what  was  originally  called  tic  douloureu.x. 
In  the  early  stages  the  disease  can  be  treated  by  drugs, 
but  neither  drugs  nor  electricity  bring  about  a  cure.  All 
clinical  evidence  seems  to  point  to  the  fact  that  it  begins 
in  the  peripheral  branches  of  tlie  fifth  nerve,  and  creeps 
as  an  inflammatory  process  up  the  peripheral  branches  of 
the  nerve  until  it  reaches  the  Gasserian  ganglion.  The 
writer  describes  the  technique  of  the  operation,  and  says 
that  out  of  the  twenty-one  cases  operated  on  there  were 
only  two  deaths.  He  has  operated  on  four  patients  over 
eighty  years  of  age,  so  that  age  itself  is  not  necessarily  a 
bar  to  the  operation.  In  no  one  of  his  cases  has  he  seen  a 
recurrence,  and  his  experience  extends  over  five  years. 

Some  Disorders  of  Memory  Associated  with  Epilepsy,  with 
Special  Reference  to  "  Reminiscences." — H.  Campbell  Thom- 
son describes  a  reminiscence  as  a  strange,  evanescent  feel- 
ing of  familiarity  with  some  place  or  event  which  occasion- 
ally crosses  the  mind,  although  the  place  is  being  visited 
or  the  event  happening  for  the  first  time.  They  occur  in 
otherwise  healthy  people,  but  their  occurrence  must  be 
looked  upon  as  abnormal,  and  probably  due  to  a  localized 
discharge  of  ner\-ous  energy.     Undue  or  sudden  increase 


in  the  frequency  or  intensity  of  sensations  should  be 
viewed  with  suspicion,  and  should  lead  to  careful  inquiry 
for  any  other  suspicious  symptoms.  Their  association 
with  any  other  slight  symptoms  of  epilepsy,  which  may  be 
so  trivial  as  almost  to  pass  unnoticed  by  the  patient,  is  of 
the  utmost  importance,  and  will  often  permit  an  accurate 
diagnosis  to  be  made  and  early  treatment  to  be  adopted. 

A  Clinical  Lecture  on  Pelvic  Pain. — By  G.  Drummond  Rob- 
inson. 

The  I'.dinhiirgh  Medical  Journal,  September,  /goo. 
Sarcoma  of  the  Suprarenal  Capsules  in  a  Child  Aged  Seven 
Weeks. — John  Orr  reports  a  case  which  presents  the  fol- 
lowing points  of  interest:  (i)  The  extreme  youth  of  the 
patient.  Abdominal  swelling  had  been  noticed  as  early 
as  five  weeks.  (2)  The  entire  absence  of  any  symptoms 
pointing  to  the  organ  ai^ected.  One  would  have  expected 
involvement  of  or  pressure  on  the  kidney,  but  evidence  of 
such  never  occurred.  (3)  The  absence  of  all  bronzing,  or 
cutaneous  or  mucous  pigmentation  of  any  sort,  which  seems 
to  be  a  point  of  distinction  between  malignant  disease  of 
the  suprarenal  capsules  and  tuberculous  affections  of  these 
organs  associated  with  Addison's  di.sease.  (4)  The  pecul- 
iarly smooth,  uniform  character  of  a  secondary  hepatic 
enlargement,  especially  the  deceptive  and  misleading  en- 
largement of  the  left  lobe,  which  was  erroneously  supposed 
during  life  to  be  the  spleen. 

L'  I' II ion  Mi'dieale  du  Canada,  August,  /goo. 

Voluminous  Chondroma  of  the  Leg  in  a  Patient  with  Cuta- 
neous Angioma. — A.  Murien  reports  the  case  of  a  young  girl 
aged  fourteen  years,  whose  leg  was  amputated  because  of 
a  large  tumor  which  from  its  macroscopic  and  clinical  char- 
acters was  supposed  to  be  an  osteo-sarcoma.  Jlicro.scopic 
examination  showed  it  to  be  a  chondroma.  It  first  ap- 
peared when  the  child  was  only  four  years  old,  and  fol- 
lowed a  severe  injury  caused  by  a  fall.  For  about  eight 
years  it  was  quiescent,  very  slightly  painful,  hard,  smooth, 
and  the  size  of  a  hen's  egg.  It  then  began  to  grow,  and 
invaded  the  whole  circumference  of  the  leg,  attaining  the 
size  of  a  child's  head.  For  a  year  and  a  half  previous  to 
the  operation  the  patient  was  unable  to  walk,  the  slightest 
motion  of  extension  causing  exquisite  agony.  Angiomata 
were  found  on  the  lower  left  eyelid  and  the  dorsal  surface 
of  the  left  foot.  This  would  seem  to  point  to  some  congen- 
ital affection. 

Attempt  at  Murder. — J.  O.  Villeneuve  reports  in  detail 
the  case  of  a  boy  aged  fifteen  years,  who  attempted  to  kill 
a  station-master  whom  he  saw  handling  a  large  sum  of 
money.  The  boy  acknowledged  the  crime  and  regretted 
it,  attributing  it  to  a  momentary  evil  impulse.  He  was 
intelligent,  but  had  been  early  deprived  of  home  influences 
and  obliged  to  work  for  masters  who  overtaxed  him  and, 
in  most  cases,  cheated  him  out  of  his  wages.  The  question 
arose  as  to  his  mental  condition,  and  responsibility  for  the 
act.  He  was  found  guilty,  but  recommended  to  mercy, 
and  sentenced  to  five  years  in  a  reformatory  scliool. 

Two  Cases  of  Cysts  with  Torsion  of  the  Pedicle. — L.  Har- 
wood  describes  two  cases  of  ovarian  cysts  which  were  re- 
moved by  opeiation,  the  patients  making  a  good  recovery. 

Chemical  Analysis  of  Potable  Water  from  a  Hygienic 
Standpoint. — By  J.  A.  Chopin. 

Finska   Ldkaresdllskapets   Handlingar,  July   and 
August,  /goo. 

Dietetic  Treatment  after  Gastrotomy. — Max  Buch  observes 
that  very  frequently  in  the  case  of  patients  who  have  had 
a  gastrotomy  for  atresia  of  the  oesophagus,  improvement 
does  not  follow  in  spite  of  nourishment  introduced  into  the 
stomach.  The  reason  for  this  appears  to  be  that  when 
food  is  introduced  directly  into  the  stomach,  the  secretion 
caused  by  stimulation  of  the  pneumogastric  nerve  by  appe- 
tite and  the  pleasure  of  the  palate  is  absent,  and  digestion 
incomplete.  Pancreatic  secretion,  which  is  usually  in  pro- 
portion to  the  gastric  juice,  is  also  deficient,  and  there  is 
of  course  no  salivary  digestion.  The  patients  should  be 
made  to  masticate  their  food,  and  be  given  palatable  food, 
and  anything  repugnant  to  their  taste  should  be  avoided. 
Bouillon,  w-ater,  and  milk  have  slight  influence  on  the 
psychically  induced  secretion,  but  they  have  on  the  reflexly 
induced  secretion,  and  can  therefore  be  introduced  directly 
into  the  stomach.  Solids,  especially  starchy  foods,  should 
be  masticated  because  the  psychically  induced  gastric 
juice  is  more  potent  upon  them  than  the  juice  produced  by 
reflex  action  on  the  sympathetic. 

The  Treatment  of  Rupture  of  the  Uterus. — Georg  von 
Zweygberg  gives  the  statistics  in  regard  to  twenty-six 
cases  treated  in  the  Helsingfors  Hospital  since  its  founda- 
tion in  1S33.  Only  two  of  the  mothers  and  none  of  the 
children  lived.  In  twenty-two  cases  treatment  was  con- 
ser\-ative ;  in  four  operation  was  performed.  The  death 
of  twenty-one  patients  who  were  treated  conservatively 
was  due  in  eight  cases  to  septicaemia  with  peritonitis,  one 


5IO 


MEDICAL    RECORD. 


[September  29,  1900 


and  one-half  to  eight  days  post  partuni  ;  six  times  one-half 
to  twenty-two  hours  jiosl  partum  with  signs  of  peritonitis  ; 
once  probably  from  septica,'mia\vith  pelvic  abscess,  twenty 
days  post  partuni  ;  three  times  from  profuse  hemorrhage 
one  and  one-half  to  three  or  six  hours  after  labor;  once 
immediately  after  delivery  (the  patient  was  dying  when 
admitted)  ;  twice  two  to  three  days  after  labor,  cause  not 
recorded.  In  the  cases  operated  upon,  death  was  due  to 
septica'miiL  The  high  death  rate  is  doubtless  owing  to 
infection  during  labor. 

Arteriosclerosis  :  its  Clinical  Aspect,  Symptoms,  Course,  and 
Treatment.  -J.  \V.  Runeburg  says  that  the  heart  is  the 
chief  organ  affected  by  this  di.sease.  He  divides  the  dis- 
orders caused  by  arteriosclerosis  into  three  chief  classes ; 
(I)  Syphilitic  sclerosis,  attacking  the  large  and  medium- 
sized  arteries,  characterized  by  intense  local  symptoms, 
without  general  circulatory  disorders  ;  (2)  sclerosis  of  the 
type  of  granular  atrophy  (arterio-capillary  fibrosis) ,  a  gen- 
eral affection  of  the  small  arteries  and  capillaries,  charac- 
terized by  slight  local  symptoms,  but  by  serious  general 
circulatory  disturbances;  (3)  the  sclerosis  of  old  age,  a 
general  affection  of  the  large  and  medium-sized  arteries, 
characterized  bj-  mixed  symptoms  of  the  various  organs 
and  disorders  of  the  general  circulation.  These  three  vari- 
eties may  be  found  combined. 

Retrosternal  Goitre  with  Grave  Dyspnoea. — E.  Sandelin  re- 
ports a  case  of  severe  dyspncea  due  to  a  retrosternal  goitre. 
Traclieotomy  gave  only  temporary  relief,  for  which  rea.son 
strumatomy  was  performed,  and  complete  recovery  ensued. 
The  tumor  was  a  benign  colloid  goitre,  which  had  developed 
in  the  left  lobe  of  the  thyroid  gland.  In  its  lower  posterior 
portion  was  an  extravasation,  to  which  the  author  attributes 
the  dyspnoea.  The  laryn.x  and  the  upper  part  of  the  tra- 
chea were  pushed  to  the  right  and  bent,  and  the  walls  of 
the  trachea  were  flattened ;  lower  down,  behind  the  ster- 
num, the  tumor  had  completely  flattened  the  trachea. 
From  the  fact  that  these  deformities  persisted  after  re- 
moval of  the  tumor,  it  may  be  supposed  that  they  had  ex- 
isted for  a  considerable  time. 

Myxoedema  in  Childhood. — Albert  de  la  Chapelle  reports 
a  case  in  a  girl  aged  fourteen  and  one-half  years,  who 
since  the  age  of  two  years  has  had  symptoms  of  the  disease, 
with  almost  complete  arrest  of  physical  and  mental  devel- 
opment. Under  thyroid  treatment,  continued  for  four 
years,  the  symptoms  of  myxoedema  have  disappeared,  the 
body  is  less  deformed,  and  the  movements  are  more  active. 
She  has  grown  twelve  inches,  the  large  fontanelle  has  ossi- 
fied, and  the  patient  has  twenty-eight  new  teeth.  The 
genital  organs  have  not  developed,  nor  has  puberty  ap- 
peared. The  patient  has  improved  mentally  to  the  extent 
that  she  can  attend  to  her  own  needs  and  no  longer  has  a 
mania  for  destroying  and  picking  up  objects. 

Speech  in  Memory  of  J.  M.  Charcot  at  the  Banquet  of  the 
Neurological  Society  at  Paris,  August  9,  1900. — By  E.  A. 
Homen. 


©orrespciiulence. 

OUR    LONDON    LETTER. 

(From  our  Special  Correspondent.) 

THE  PLAGl'E  IN  CLASlJOVV— -COMMISSION  ON  DYSENTERY  ANI> 
TYPHOID — WAR  HOSPITALS  COMMISSION— BRITISH  ASSOCIA- 
TION'S MEETING — PRIVATE  ASYLUMS — THE  LAMENT  OF  THE 
DEALERS    IN   POISONS. 

London,  September  7,  1900. 

The  outbreak  of  plague  at  Glasgow  is  a  source  of  some 
alarm  and  much  speculation  throu,ghout  the  country. 
After  I  sent  off  my  last  letter  some  other  cases  occurred, 
and  the  next  day  there  were  eleven  in  hospital  and  ninety- 
three  contacts  isolated.  You  will  have  learned  by  cable 
the  daily  numbers.  We  heard  on  Monday  that  your  sani- 
tary authorities  had  imposed  quarantine,  and  of  course 
other  places  are  doing  the  same.  Our  port  authorities  are 
pretty  confident  of  tlieir  al)ility  to  meet  tlie  danger,  and 
you  know  a  few  years  ago  they  kept  cholera  out  of  Lon- 
don. On  Tuesday  there  were  fourteen  patients  in  hospi- 
tal, three  doubtful,  and  one  hundred  and  three  per.sons 
isolated.  On  Wednesday  the  hospital  cases  stood  at  thir- 
teen, one  doubtful.  Yesterday  the  figures  were  the  same, 
and  one  luindred  and  nine  i)ersons  are  still  under  ol)serva- 
tion.  All  tlie  patients  are  progressing  satisfactorily,  and 
the  authorities  are  confident  of  their  ability  to  restrict  the 
outbreak.  The  health  committee  will  keep  all  contacts  iso- 
lated until  the  houses  from  which  they  have  been  removed 
have  been  thoroughly  cleansed  and  disinfected.  They  are 
also  ready  to  accept  any  "suspects"  from  any  suburb.  In 
some  districts  a  "scare  "  has  taken  jilace  for  a  day  or  two, 
but  generally  a  calm  confidence  prevails.     In  Govan  the 


same  precautions  are  taken,  and  the  single  case  has  not 
been  followed  by  anotlier. 

The  commission  to  "inquire  into  the  nature,  causation, 
pathology,  and  modes  of  prevention  (more  particularly  as 
affecting  armies  in  the  field)  of  dysentery,  and  its  connec- 
tion, if  any,  with  enteric  fever,"  consists  of  Prof.  W.  J.  K. 
Simpson,  J.  Lane  Notter,  and  Major  D.  Bruce,  R.A.M.C. 
On  accepting  this  office  Colonel  Notter  has  resigned  his 
professorship  at  Netley  and  is  succeeded  by  Major  Krith. 
It  is  hoped  that  this  commission  will  obtain  valuable  infor- 
mation. 

Items  of  evidence  before  the  War  Hospitals  Commission 
continue  to  attract  some  attention  even  on  the  part  of  those 
who  are  determined  to  await  the  conclusion  of  the  inquiry 
before  attempting  to  digest  them  or  to  form  an  ojiinion  cm 
the  questions  involved.  Thus  one  officer  admitted  that  a 
portion  of  some  stores  was  mislaid  for  three  days  and  an- 
other part  delayed  at  the  base.  Major  Watson  said  Indian 
ambulances  were  superior.  Colonel  Exham,  principal 
medical  officer,  declared  that  on  his  arrival  on  April  23d 
at  Bloemfontein  there  was  ample  accommodation,  and  to 
meet  the  rush  after  the  advance  he  added  to  it  largely. 
He  flatly  contradicted  several  statements  of  Mr.  Burdett- 
Coutts,  and  denied  that  there  were  ten  thousand  patients 
on  May  22d,  the  highest  number  on  any  day  being  four 
thousand  and  ninety-eight  men  and  one  hundred  and  sev- 
enty-eight officers,  and  there  was  no  insufficiency  of  staff. 
Nor  was  there  any  foundation  for  Mr.  Burdett-Coutts' 
statement  that  convalescents  were  sent  down  without 
proper  food.  He  put  in  a  statement  controverting  in  de- 
tail Mr.  Burdett-Coutts'  allegations,  and  said  he  believed 
the  sanitary  arrangements  at  Bloemfontein  were  satisfac- 
tory and  not  accountable  for  the  outbreak  of  fever.  Fur- 
ther, he  was  not  aware  of  any  friction  between  the  military 
and  civil  surgeons  at  No.  S  hospital.  On  this  last  point, 
however,  other  witnes.ses  spoke  of  the  existence  of  some 
friction.  Dr.  Kirkman  declared  every  necessary  was  defi- 
cient, and  specified  bed-pans,  feeding-cups,  and  utensils 
Dr.  Whittmgton  corroborated  him.  Dr.  Fitchell  said  some 
of  the  orderlies  had  been  drunk,  and  he  thou.ght  the  senior 
officers  were  indifferent  to  the  state  of  the  patients,  though 
he  had  seen  the  principal  medical  officer  inspecting  the 
tents.  Dr.  Leon,  in  charge  of  the  enteric  division,  said 
there  was  a  shortage  of  utensils,  and  requisitions  for  them 
and  for  more  orderlies  and  nurses  took  a  fortnight  to  be 
complied  with.  Colonel  Butcher  attributed  the  delay  to 
the  exigencies  of  railway  transport.  He  was  never  short 
of  blankets,  there  was  an  ample  supply  of  all  articles  ex- 
cept bed-pans,  bedding,  and  mattresses ;  the  shortage 
lasted  five  weeks  and  was  due  to  interruption  of  transport 
and  the  excessive  number  of  patients.  Dr.  Johnstone,  who 
practised  for  years  at  Bloemfontein,  said  there  was  typhoid 
among  the  Boers  at  several  places,  and  they  took  it  with 
them  to  Paardelierg.  where  the  British  of  course  contracted 
it.  He  thought  the  principal  medical  othcer  was  too  .spar- 
ing in  bedding. 

The  British  Association  for  the  Advancement  of  Science 
held  its  annual  meeting  on  Wednesday  at  Bradford,  where 
it  was  cordially  welcomed.  The  president  this  year  is  Sir 
William  Turner,  who  is  quite  at  home  in  such  a  position. 
His  opening  address  was  devoted  to  a  careful  review  of  tlie 
century's  prngress  in  the  department  of  science  he  so  well 
represents  and  adorns.  The  advance  of  knowledge  of  ani- 
mal structures,  especially  in  reference  to  the  cell  theory, 
was  an  attractive  subject  and  interested  the  large  audience. 
The  sections  were  opened  on  Thursday,  most  of  them  by 
addresses  of  their  presidents. 

Private  asylums  have  been  a  good  deal  to  the  front 
lately,  and  much  ink  has  been  shed  by  correspondents  who 
are  not  well  versed  in  the  differences  of  the  law  relating  to 
the  different  classes  of  lunatics.  Undoubtedly  there  are 
extra  precautions  in  the  law  for  the  protection  of  private 
patients,  but  that  is  because  in  their  cases  the  motive  for 
consigning  them  to  an  asylum  is  more  open  to  suspicion. 
No  one  is  likely  to  take  a  pauper  to  a  private  asylum  and 
pay  heavy  exi)euses  for  his  accommodation.  Then  the 
keepers  of  such  asylums  are  bound  to  forward  to  the  com- 
missioners every  letter  of  a  liatieiu.  and  that  uno])ened. 
The  i>ossibility  of  a  lawsuit  must  also  be  present  continu- 
ally to  the  minds  of  such  owners,  for  liti.gation  would  prob- 
ably spell  ruin,  and  border  cases  must  be  a  source  of  great 
anxiety. 

The  dealers  in  disinfectants  are  making  a  great  outcry 
against  the  order  adding  carbolic  acid  to  the  poison  sched- 
ule. They  now  say  nearly  all  disinfectants  contain  this 
poison — a  fact  they  grievously  tried  to  conceal.  They 
plead  for  the  poor,  who  could  hitherto  buy  two  ])eniiy- 
worth  at  the  grocer's,  but  will  now  have  to  go  to  the  chem- 
ist and  have  it  registered  and  labelled.  "  Pity  the  poor  " 
is  an  excellent  cry,  but  here  it  seems  to  mean  pity  the 
tradesman,  and  let  the  poor  supply  the  holocaust  of  acci- 
dental poisoning.  It  is  surprisin.g  that  the  manufacturers 
of  poisons  should  have  the  impudence  to  father  such  a  plea 
for  their  profits. 


September  29,  1900] 


MEDICAL    RECORD. 


511 


POSITION    IN    LABOR. 

To  THK  Kditok  of  the  Medical  Recokd. 

Sir  :  Some  twenty-five  years  since  the  New  York  Mkdhai. 
Record  published  a  letter  from  me  entitled  "Position  in 
Labor."  I  was  culled  to  attend  our  pastor's  wife  in  labor, 
over  tliirty-two  years  ago.  For  several  hours  she  made  no 
progress— what  was  the  trouble'  Easier  asked  than  an- 
swered. The  question  arose,  had  position  anything  to  do 
with  the  lack  of  progress?  I  questioned  the  lady  as  to  the 
position  she  occupied  when  lying  in  bed.  Her  reply  was 
that  she  "had  usually  lain  upon  the  right  side."  I  had  her 
at  once  assume  a  position  on  that  side,  and  to  my  gratifica- 
tion her  labor  took  on  a  favorable  and  satisfactory  turn. 
The  child  was  soon  delivered. 

Many  times  after  that  I  had  women  in  tardy  labor 
change  their  position  to  that  occupied  for  .some  weeks  ])rior 
to  confinement,  with  like  results  ;  and  I  became  convinced 
that  tliere  was  a  good  deal  in  this  question  of  jxisition. 
I  called  the  attention  of  several  medical  men  to  this  sul)- 
ject,  who  told  me  of  their  experience.  There  is  a  good 
deal  in  this  question  of  position. 

But  again,  some  thirty  years  since  I  was  called  to  attend 
a  young  lady  in  her  first  labor.  The  forceps  was  used  in 
her  mother's  labors,  she  warned  me,  and  I  would  have  to 
■use  the  forceps  in  her  case,  and  did  so  successfully.  I 
used  the  forceps  in  other  labors  of  this  woman.  When  I 
was  called  on  another  occasion,  this  lady  remarked  to  me, 
"You  will  have  to  use  the  instruments."  My  re])ly  was, 
"I  will  sec."  I  had  used  the  knee  position  a  good  deal  in 
difficult  labors  with  satisfactory  results,  and  resolved  to 
use  that  position  in  this  case.  She  was  placed  on  a  cush- 
ion on  the  floor,  with  a  person  in  front  for  sujjport.  The 
result  was  that  an  infant  was  delivered  in  a  short  time.  I 
attended  this  woman  once,  and  I  think  twice,  afterward 
with  like  results.  I  attended  her  sister-in-law  a  number 
of  times.  The  first  child  was  still-born — this  was  in  Sep- 
tember, iSSi.  In  most  of  her  confinements  I  had  to  use 
the  forceps.  In  one  case  her  husband,  a  strong  man,  took 
hold  of  the  forceps  with  me,  and  straightened  out  one 
blade  of  Bedford's  forceps.  Finally,  I  resolved  to  try  the 
knee  position  in  her  next  case,  and  did  so  iu  two  subse- 
quent labors  with  satisfactory  results. 

My  experience  has  been  such,  in  the  more  than  forty- 
seven  years  since  I  received  my  degree  of  M.D.  in  New 
York  City,  that  I  have  come  to  consider  the  knee  jiosition 
to  be  the  normal  position  in  the  very  many  difficult  labors, 
and  I  believe  that  the  assumption  of  this  position  will  ob- 
viate the  necessity  of  instrumental  labors  in  very  many 
cases. 

For  several  years  I  have  thought  to  write  this  experience 
out,  believing  the  matter  of  so  much  importance. 

A  word  further  upon  the  use  of  chloroform.  Some 
thirty-five  years  ago  I  had  a  case  of  labor  in  which  there 
were  convulsive  symptoms.  I  used  chloroform  at  once, 
which  relieved  those  symptoms,  and  since  that  time  I  have 
used  chloroform  when  the  pains  were  severe.  My  mode 
of  using  it  was  to  have  the  patient  inhale  the  chloroform 
while  the  pain  was  on,  and  only  then. 

S.  Havnes,  M.D. 

Sar.anac,  N.  Y. 


DEFENCE   OF    SUITS    FOR    ALLEGED    MAL- 
PRACTICE. 

To  THE  Editor  of  the  Medical  Record. 

Sir  :  I  was  very  much  interested  in  the  editorial  which  ap- 
peared in  your  journal  for  Septemi:>er  15th,  entitled  "Plea 
for  a  Medical  Defence  Union  in  the  United  States,  "and 
which  was  based  on  an  article  that  appeared  in  the  S/. 
/'till/  Medical  /dtirnn/  for  July,  written  by  Dr.  Donald  B. 
Prichard,  in  which  you  state  as  follows:  "His  idea  is  to 
organize  a  mutual  association,  the  membership  of  which 
should  be  confined  to  those  who  belong  to  the  State  or 
some  properly  organized  medical  society.  In  order  that 
the  organization  might  be  of  the  highest  standing,  it  would 
not  be  proper  to  defend  one  guilty  of  gross  malpractice. 
That  this  might  be  accomplished,  every  case  should  be 
submitted  to  a  standing  committee,  who  after  a  thorough 
examination  would  decide  whether  or  not  it  would  be 
proper  for  the  association  to  defend." 

The  New  York  State  Medical  Association,  last  winter, 
believing  that  the  time  had  come  when  State  organiza- 
tions of  physicians  must  do  something  more  for  their  mem- 
bers than  simply  to  furnish  a  scientific  meeting  once  a 
year,  if  they  would  keep  abreast  of  the  time  in  which  we 
live,  applied  for  a  charter  from  the  legislature  (which  was 
granted)  giving  it  increased  powers,  especially  in  regard 
to  its  legal  rights,  as  shown  in  Section  2  :  "  '  The  New  York 
State  Medical  Association  '  may  and  shall  have  perpetual 
succession,  shall  be  capable  of  suing  and  being  sued,  of 
pleading  and  being  impleaded,  answering  and  being  an- 


swered unto,  defending  and  being  defended,  in  all  courts 
and  in  all  causes  whatsoever.  " 

In  the  by-laws,  which  the  committee  on  reorganization 
has  drawn  up  in  conformity  with  this  charter,  the  follow- 
ing provision  is  made  for  the  protection  of  its  members 
from  suits  for  alleged  malpractice :  Section  6,  Article  2 : 
"It  shall  be  the  duty  of  the  council  to  receive  and  consider 
all  applications  of  members  of  "  The  -New  York  State  Med- 
ical Association  '  for  assistance  111  defence  of  suits  for  al- 
leged malpractice,  or  other  matters  affecting  their  profes- 
sional status,  and  all  complaints  of  violations  of  the  laws 
of  medical  iiractice  and  of  public  health  ;  and  the  council 
shall  without  delay,  and  with  the  advice  of  its  attorney,  ex- 
amine the  ease  and  determine  the  expediency  of  defending 
such  action  or  prosecuting  the  alleged  violators.  ...  If 
the  council's  decision  be  in  the  affirmative,  then  the  '  New 
York  State  Medical  Association  '  shall  furnish  the  funds 
and  legal  services  necessary  for  the  conduct  of  such  de- 
fence or  prosecution. " 

From  this  you  will  readily  see  that  it  is  our  intention  to 
defend  only  such  of  our  members  as  can  show  that  they 
have  been  reasonably  right  in  their  treatment  of  their  pa- 
tients. We  believe  that  much  benefit  will  accrue  to  the 
general  profession  as  well  as  to  the  individual  practitioner 
from  State  organizations  looking  out  for  the  welfare  of 
each  of  its  members  in  any  matter  relating  to  their  profes- 
sional honor  and  status.  Common  interests  are  necessary 
if  we  desire  to  bind  men  together  into  a  compact  and 
strong  organization,  and  we  believe  that  this  can  best  be 
done  by  the  concentration  of  all  work  which  can  be  done 
by  medical  men  in  these  county.  State,  and  national  asso- 
ciations in  addition  to  the  ordinary  scientific  work  which 
these  associations  are  in  the  habit  of  doing. 

The  multiplication  of  associations  having  diflferent  ob- 
jects in  view  weakens  the  profession  by  subdividing  the 
interests  of  its  members. 

Frederick  Holme  Wiggin,  M.D.. 
Chairman    Coiiiinittc-i:  on   Ri-organization^   Sew   York 
State  AMedical  Association. 


glcuiinus 


antl  3"loticjes. 


A   DicTioN.\Rv   OF   Medicine   and   the   Allied   Sciences. 
Comprising  the  Pronunciation,  Derivation,  and  Full  Ex- 
planation of  Medical,  Pharmaceutical,  Dental,  and  Vet- 
erinary Terms,  together  with  much  Collateral  Descriptive 
Matter.  Numerous  Tables,  etc.     By  Alexander  Diane, 
M.D.,  Assistant  Surgeon  to  the  New  York  Ophthalmic 
and   Aural    Institute ;    Reviser    of    Medical   Terms   for 
Webster's  International  Dictionary.     Third  edition,  en- 
larged and  thoroughly  revised.     Philadelphia  and  New 
York  ;  Lea  Brothers  &  Co.     1900. 
An  epidemic  of  dictionary  making  passed  over  the  medical 
profession  a  few  years  ago,  and  some  eight  or  ten  works, 
some  in  several  volumes,  others  in  a  single  volume  of  un- 
wieldy bulk,  others  again  of  pocket  size,  were  successively 
brought  out  for  the  convenience  and  instruction  of  students 
and  practitioners.     Some  of  these  have  already  disappeared 
from  view,  and  some  others  ought  to  follow  them.     Among 
those  which  have  survivc<l  the  test  of  actual  use  and  have 
appeared  in  successive  editions,  one  of  the  most  deserving 
is  that  of  Dr.  Duane.     The  book  is  of  convenient  size  to 
be  taken  from  the  slielf  by  others  than  Sandow,  yet  is  large 
enough  to  contain  all  the  words  that  any  reader  of  medical 
literature  is  likely  ever  to  come  across.     The  type  is  small 
but  clear,  the  definitions  are  correct  so  far  as  our  examina- 
tion has  gone,  and  the  tables  are  good ;  but  the  figured 
pronunciation  is  in  many  places  execrable.     In  most  cases 
this  attempt  to  represent  the  sounds  is  of  benefit  only  to  a 
foreigner,  and  he  often  pronounces  badly  enough  without 
being  misled  by  an  assumed  authority,  as   he  assuredly 
would  be  if  he  consulted  this  dictionary.     It  is  to  be  hoped, 
if  this  work  reaches  a  fourth  edition,  as  we  trust  it  will, 
that  the  author  will  cut  out  this  useless  feature.     It  is  a 
pity  to  mar  a  book  of  such  excellence  as  is  Duane's  dic- 
tionary. 

A  Manual  of  Personal  Hvgiene.     Edited  by  Walter  L. 
PvLE.    A.M.,    M.D.,    Assistant   Surgeon   to   Wills'    Eye 
Hospital,  Philadelphia;    Fellow  of  the  American  Acad- 
emy of  Medicine  ;    Former  Editor  of  the  International 
Medical    Magazine.     Philadelphia ;    W^.   B.   -Saunders  & 
Company,     igoo. 
This  is  apparently  primarily  intended  to  be  a  work  for  t'-iC 
guidance  of  the  laity,  but  we  fear  there  are  many  members 
of  the  medical  profession  whose  knowledge,   or  at   least 
practice,  of  the  elementary  rules  of  hygiene  is  so  slight 
that  they  are  in  as  great  need  of  direction  as  their  patients. 
There  are  seven  writers  of  this  work,  each  contributing  a 


512 


MEDICAL    RECORD. 


[September  29,  1900 


chapter,  as  follows :  Hygiene  of  the  digestive  apparatus, 
by  C.  G.  Stockton  ;  of  the  skin  and  its  appendages,  by  G. 
H.  Fox  ;  of  the  vocal  and  respiratory  apjiaratus,  by  E.  F. 
Ingals ;  of  the  ear,  by  B.  A.  Randall;  of  the  eye,  by  W. 
L.  Pyle  ;  of  the  brain  and  nervous  system,  by  J.  W.  Court- 
ney ;  and  physical  exercise,  by  G.  N.  Stewart.  There  is  a 
sufficiently  complete  index,  but  one  should  read  the  book 
through  first,  and  use  the  index  only  when  he  subsequently 
wishes  to  refresh  his  memory  regarding  some  special 
point.  We  can  commend  the  book  as  .sound  in  advice  and 
as  free  from  the  common  fault  of  books  for  the  laity,  of 
going  too  deeply  into  purely  medical  and  technical  mat- 
ters. 

Derm.ito-histoi.ogische  Technik.  Von  Dr.  Max  Joseph 
und  Dr.  George  Loewenbach.  Second  edition.  Ber- 
lin ;  Louis  Marcus.     1900. 

This  guide  to  histology  of  the  skin,  especially  prepared  to 
demonstrate  the  technique  to  students  and  physicians,  has 
reached  its  second  edition  within  a  brief  period,  and  has 
been  enlarged  and  improved,  meeting  the  requirements  in 
an  excellent  manner. 

Report  on  the  Mortality  Records  ok  the  Mutual 
Life  Insurance  Company  of  New  York,  for  Fifty-six 
Years,  from  1S43  to  1S9S.  By  Elias  J.  Marsh,  M.D.  ,  and 
Granville  M.  White,  JLD.,  Medical  Directors.  New 
York:  The  Mutual  Life  Insurance  Company.     1900. 

This  collection  of  tables  is  of  great  value  to  the  medical 
statistician  as  well  as  to  the  insurance  man.  The  very 
careful  analysis  of  the  tables  made  by  Drs.  Marsh  and 
White  is  exceedingly  interesting  to  the  plain  medical  man 
who  is  neither  a  statistician  nor  an  insurance  examiner,  but 
who  is  curious  as  to  the  relation  of  age  to  the  several  dis- 
eases of  greatest  fatality. 

The  Medical  Directory  of  New  York,  New  Jersey,  and 
Connecticut.  Published  by  the  New  York  State  Medi- 
cal Association.     Vol.  II.     1900. 

This  is  an  almost  indispensable  work  for  the  physician  in 
this  city  or  State,  who  cares  to  know  anything  of  his  col- 
leagues and  of  the  work  in  which  they  are  engaged.  We 
are  glad  to  note  several  improvements  in  this  volume,  es- 
pecially in  the  list  of  hospitals,  where  we  find  information 
as  to  the  class  of  patients  admitted,  the  names  of  the  con- 
sulting, attending,  and  house  stafEs,  and  such  other  mat- 
ters as  may  be  of  value.  Other  useful  features  of  the  vol- 
ume are  an  official  list  of  registered  pharmacists,  and  a 
list  of  the  health  board  stations  in  this  city  at  which 
antitoxin  and  culture  outfits  may  be  obtained. 

Manual  of  the  Diseases  of  the  Eye,  for  Students  and 
General  Practitioners.  By  Charles  H.  May,  M.D., 
Chief  of  Clinic  and  Instructor  in  Ophthalmology,  Eye 
Department  College  of  Physicians  and  Surgeons.  Medi- 
cal Department  Columbia  University,  New  York.  New 
York  :   William  Wood  &  Company.     1900. 

We  know  of  no  book  at  present  before  the  profession  which 
better  answers  its  purpose  than  this.  It  is  not  intended 
for  the  specialist,  but  for  the  student,  who  needs  an  ele- 
mentary knowledge  of  ophthalmology  as  of  the  other  spe- 
cialties to  fit  him  for  graduation,  and  for  the  general 
practitioner  practising  at  a  distance  from  cities  where 
specialists  congregate,  who  is  obliged  to  treat  many  cases 
of  eye  disease  whether  he  will  or  no.  Such  a  one  will  find 
here,  expressed  in  clear  and  not  too  ophthalmologically 
technical  language,  just  the  guide  he  needs  to  enable  him 
to  benefit  his  patient  and  save  his  own  reputation.  The 
book  will  also  teach  him  to  recognize  the  serious  eye  trou- 
bles which  he  had  better  not  attempt  to  treat. 

Beneath  Hawaiian  Palms  and  Stars.  By  E.  S.  Good- 
hue, M.D.,  Government  Physician;  Medical  Superin- 
tendent, Malulani  Government  Hospital,  etc.  Illus- 
trated by  photographs  and  pen  sketches.  Cincinnati: 
The  Editor  Publishing  Company.     1900. 

Tins  is  an  entertaining  description,  made  after  no  particu- 
lar system  or  order,  of  matters  in  the  Hawaiian  Islands. 
The  author  writes  in  a  colloquial  and  rambling  style  that 
is  a  little  provoking  at  times,  for  just  as  the  reader  becomes 
interested  in  .some  description  he  gets  a  jar  by  being 
shunted  off  on  some  other  subject;  then  probably  the 
writer  forgets  to  come  back  and  pick  up  the  thread  he 
dropped,  and  the  reader  is  left  with  his  curiosity  piqued 
but  unsatisfied.  However,  there  is  enough  information  in 
the  book  on  all  imaginable  topics,  from  coffee  to  leprosy 
and  from  missionaries  to  annexation,  to  satisfy  any  one, 
and  though  descri])tions  of  what  we  learned  at  school  to 
call  the  Sandwich  Islands  are  plentiful  we  have  read  none 
that  gives  more  practical  information  than  this.  Dr. 
Goodhue  has  lived  several  years  in  the  islands,  and  his 
book  is  filled  with  the  knowledge  he  has  him.self  acquired. 


and  not  that  gathered  at  hearsay  during  a  hurried  visit  to 
Honolulu.  It  is  well  worth  reading  despite  its  peculiarities 
of  style. 

Transactions  of  the  American  Association  of  Obstet- 
ricians AND  GvN.«coi.oGisTS.  Vol.  XII.  For  the  year 
1899.     Philadelphia ;  William  J.  Doran.     1900. 

This  volume  contains  the  usual  number  of  papers,  good, 
bad,  and  indifferent,  but  chiefly  good.  Some  are  illus- 
trated with  plates  and  wood-cuts  in  the  text. 

Transactions  of  the  Southern  Surgical  and  Gvn.i;co- 
LOGiCAi.  Association.  Vol.  XII.  Twelfth  Session,  held 
at  New  Orleans,  La.,  December  5,  6,  and  7,  1S99.  Pub- 
lished by  the  Association.     1900. 

This  is  one  of  the  most  active  and  progressive  of  the  spe- 
cial societies  in  the  country,  and  its  volume  of  transactions 
always  contains  many  papers  of  interest.  The  present 
volume  offers  no  exception  to  this  statement. 

Les  Tubercules  des  Pedoncules  CfiREBRAUX.  Par  le  Dr. 
Georges  Edouard  Raviart,  Ancien  Interne  des  H6pi- 
taux  de  Lille,  etc.  Paris :  Georges  Carre  et  C.  Naud. 
1900. 

This  interesting  monograph,  based  upon  the  study  by  the 
author  of  a  case  of  tubercles  of  the  cerebral  peduncles,  con- 
tains a  resume  of  all  the  cases  of  this  condition  of  which 
the  writer  has  been  able  to  find  reports  in  medical  litera- 
ture, forty-three  in  number.  The  morbid  anatomy,  symp- 
tomatology, and  diagnosis  of  this  rare  affection  are  quite 
fully  di.scussed,  and  we  may  say  that  Dr.  Raviart's  work 
contains  an  epitome  of  all  that  is  known  at  present  of  these 
neoplasms.  A  bibliography  of  one  hundred  and  seventy- 
one  titles  is  appended. 

A  Text-Book  of  Practical  Therapeutics.  With  Espe- 
cial Reference  to  the  Application  of  Remedial  Measures 
to  Disease  and  their  Employment  upon  a  Rational  Basis. 
By  HoBART  Amorv  Hark,  M.D..  Professor  of  Therapeu- 
tics and  Materia  Medica  in  the  Jefferson  Medical  College 
of  Philadelphia.  With  special  chapters  by  Drs.  G.  E. 
de  Schweinitz,  Edward  Martin,  and  Barton  C.  Hirst. 
New  (eighth)  edition.  Philadelphia  and  New  York : 
Lea  Brothers  &  Co.     1900. 

It  is  hardly  necessary  to  review  a  book  which  is  so  well 
known  as  this,  and  the  popularity  of  which  is  evidenced  by 
the  fact  of  eight  editions  in  ten  years.  It  differs  from 
many  works  of  the  kind,  and  herein  probably  lies  the 
.secret  of  its  popularity,  in  that  the  author  does  not  take  it 
for  granted  that  his  reader  already  knows  the  subject  per- 
fectly. He  addresses  himself  to  students  and  endeavors  to 
teach  them  what  they  ought  to  know  in  order  to  become  rea- 
soning physicians.  The  drugs — their  source,  preparations, 
physiological  actions,  and  therapeutic  uses,  are  treated  of 
in  alphabetical  order,  no  attempt  at  classification  having 
been  made.  Although  especially  adpated  to  the  neeils  of 
the  undergraduate  student,  the  book  will  be  found  to  be  a 
useful  work  of  reference  by  the  practitioner  who  may  be 
temporarily  in  doubt  or  difficulty. 


A  City  Hall  and  Basement  Schools. — Major  Farley 
is  right  when  he  says  that  no  money  should  be  spent 
upon  a  new  city  hall  for  Cleveland  so  long  as  one 
child  remains  in  a  basement  school.  The  educational, 
utilitarian,  and  sesthetic  value  of  fine  buildings  in  a 
city  is  not  to  be  questioned;  but  it  sinks  into  unim- 
portance when  compared  with  the  city's  crime  in  forc- 
ing a  large  number  of  its  children  to  attend  school  in 
poorly  lighted  and  worse  ventilated  basements.  We 
hope  the  committee  of  the  Cleveland  Medical  Society 
appointed  to  study  the  school  question  will  be  able 
to  suggest  practical  ways  and  means  for  permanently 
and  radically  improving  the  unhygienic  conditions 
under  which  our  school  children  are  condemned  to 
work.  It  has  been  said  that  the  basement  school-room 
is  even  at  its  worst  a  more  hygienic  place  than  the 
homes  from  which  many  of  the  children  come  who 
occupy  it,  but  this  is  really  an  additional  reason  for 
improving  the  school  conditions.  .  .  .  This  question  of 
basement  schools  has  much  to  do  with  the  sobriety, 
industry,  and  health  of  the  coining  generations,  and  in 
comparison  five  or  ten  years'  delay  in  securing  a  mag- 
nificent city  hall  is  a  mere  bagatelle. — Clci'dand  Med- 
ical Journal. 


September  29,  1900] 


MEDICAL    RECORD. 


513 


J»ocicti3  ^vcports. 

CANADIAN    MEDICAL   ASSOCIATION. 

Thirty-third  Annual  {Century)  Meeting,  Held  in  the 
Academic  Hall  oj  the  Otta^va  L'?iiversity,  Olta7i'a,  on 
September  12,  ij,  and  14.  igoo. 

Dr.  R.   \V.  Powell,  President,  in  the  Chair. 

The  minutes  of  the  last  meeting,  held  in  Toronto,  were 
read  by  the  secretary,  Dr.  F.  N.  C.  Starr,  of  Toronto, 
and  adopted. 

Dr.  Drewer,  of  Ottawa,  presented  the  report  of  the 
committee  of  arrangements. 

The  Present  Status  of  the  Eliminative  and  An- 
tiseptic Treatment  of  Typhoid  Fever. — Dr.  W.  B. 
Thistle,  of  Toronto  University,  read  this  paper.  Some 
seven  years  ago  he  had  introduced  this  plan  of  treat- 
ment of  typhoid  fever  to  the  profession.  He  claimed 
that  this  form  of  treatment  for  typhoid  fever  had  time 
and  again  been  misrepresented  by  Professor  Osier  and 
others,  as  he  had  never  held  to  the  opinion  that  the 
eliminative  and  antiseptic  plan  could  rid  such  organs 
as  the  liver  and  spleen  of  the  bacilli  lodged  in  them. 
When  once  the  typhoid  bacilli  gained  access  to  the 
intestinal  tract,  the  multiplication  of  them  occurred 
with  extreme  rapidity  and  the  intestinal  contents 
teemed  with  countless  numbers  of  them.  These  were 
not  confined  to  the  intestine,  but  were  to  be  found  in 
the  w'alls  and  in  fact  in  almost  every  organ  of  the 
body.  He  was  of  the  opinion  that  the  draining  of  the 
intestinal  walls  following  upon  tlie  action  of  a  purga- 
tive, either  calomel  or  magnesium  sulphate,  would 
tend  to  get  rid  of  some  of  these  bacilli  in  the  intestinal 
walls,  but  he  did  not  claim  that  it  would  effect  their 
exit  from  the  liver,  etc.  He  thought  the  treatment  had 
been  imperfectly  applied  in  many  instances  without  a 
clear  conception  of  the  underlying  principles.  Under 
this  plan  of  treatment  Dr.  Thistle  had  never  had  a  sin- 
gle case  of  hemorrhage,  what  hemorrhage  occurred 
having  been  always  very  slight.  He  had  also  had 
very  few  perforations,  and  twenty  per  cent,  of  the 
death  rate  was  from  perforation  and  hemorrhage.  In 
Toronto  this  plan  of  treatment  was  universally  adopt- 
ed. Statistics  at  the  Toronto  General  Hospital  showed 
that  from  1893  up  to  the  present  time  there  had  been 
eight  hundred  and  thirty-three  cases  in  that  institu- 
tion, with  fifty-six  deaths — a  mortality  of  6  '5  per  cent. 

Dr.  McPhedran  said  that  he  had  been  watching 
Dr.  Thistle's  work  in  this  direction  from  the  time  of 
the  appearance  of  his  first  paper  on  the  subject,  but 
could  not  agree  with  all  his  conclusions.  He  did  not 
think  that  this  plan  of  treatment  lessened  diarrhcea, 
tympanites,  fever,  or  delirium.  He  considered  that 
Dr.  Thistle  was  harboring  the  idea  that  purgatives  in 
typhoid  were  a  new  discovery  with  him;  this  was  not 
so.  Twenty-five  years  ago  the  speaker  gave  these  for 
the  first  ten  days  at  least.  In  addition  to  this  he  used 
to  give  carbolic  acid  and  iodine,  and  in  a  certain  class 
of  cases  he  thought  he  had  the  exact  treatment.  An- 
other class  would  then  come  along  in  which  that  treat- 
ment had  no  effect  whatever.  He  considered  that  the 
general  toxaemia  that  existed  could  not  be  eliminated 
through  the  bowel ;  it  had  to  be  done  through  the  kid- 
neys and  skin. 

Dr.  Thistle,  in  his  reply,  emphasized  the  fact  that 
he  was  not  trying  to  eliminate  bacilli  from  the  glands; 
in  clearing  out  the  bowels  he  was  trying  to  eliminate 
toxins  from  the  body  and  not  bacilli. 

A  Case  of  Sarcoma  of  the  Right  Nasal  Fossa 
with  Acute  Sinusitis  and  Orbital  Cellulitis.  —  Dr. 
Perry  G.  Goldsmith,  of  Belleville,  Ontario,  present- 
ed this  paper  and  patient.     The  patient  was  a   man 


aged  thirty-eight  years,  a  farmer,  with  an  unimportant 
family  and  personal  history.  He  consulted  the  doc- 
tor on  August  4th  last,  with  severe  frontal  headache 
and  double  vision.  Examination  of  the  nasal  fossai 
revealed  growths  which  along  with  some  of  the  bone 
in  the  right  fossa  were  removed.  After  this  swelling 
and  pain  in  the  eye  began,  so  that  it  was  seen  to  pro- 
ject far  forward,  downward,  and  outward.  The  right 
nasal  fossa  was  curetted,  the  tissues  being  sent  to  Pro- 
fessor Anderson,  of  the  Trinity  pathological  labora- 
tory at  Toronto,  who  pronounced  them  of  sarcomatous 
origin,  small  round-cell  variety,  with  the  walls  of  the 
blood-vessels  thin  and  poorly  developed.  The  dis- 
charge from  the  nostril  was  of  an  odor  similar  to  that 
emanating  from  cancer  of  the  rectum.  Up  to  ten  years 
ago  Bosworth  had  collected  forty  of  these  cases. 

Dr.  K.  a.  Reeve  stated  that  a  number  of  years  ago 
he  had  presented  a  paper  before  this  association  on 
the  same  subject.  He  directed  attention  to  the  impor- 
tance of  examining  the  naso-pharynx  in  diseases  of 
the  orbit.  He  instanced  a  similar  case  to  Dr.  Gold- 
smith's. In  his  case  there  was  little  pain,  but  an  ex 
amination  of  the  nose  revealed  the  tumor. 

Some  of  My  Experiences  in  the  South  African 
War. —  Dr.  George  S.  Ryerson  addressed  the  associ- 
ation on  this  subject.  He  dealt  first  with  the  experi- 
ence gained  of  modern  bullets.  The  very  latest 
returns  showed  that  986  officers  and  11,701  non-com- 
missioned officers  and  men  had  been  wounded,  of 
whom  only  732  died  of  wounds  received  in  battle,  w  liich 
was  to  be  ascribed  to  the  aseptic  character  of  the  bullet 
and  the  prompt  attention  and  antiseptic  treatment.  Dr. 
Ryerson  then  dealt  with  the  wounds  caused  b\  these 
bullets.  Referring  to  poisoned  bullets  being  used,  he 
said  this  was  not  the  truth,  as  the  tarnish  or  verdigris 
probably  accumulated  in  transit  through  the  barrel. 
He  also  doubted  the  fact  of  explosive  bullets  being 
used.  The  Boers  made  use  of  thousands  of  the  Mar- 
tini-Henry, a  heavy  bullet,  which  caused  great  destruc- 
tion of  soft  parts,  necessitating  amputation.  There 
were  few  amputations  in  this  war.  He  quoted  Kendal 
Franks,  who  had  performed  twenty  amputations  in  two 
thousand  cases.  While  abdominal  section  in  wounds 
of  the  abdomen  was  mainly  inadvisable,  he  saw  one 
case  in  which  the  results  were  excellent.  He  spoke 
highly  of  the  magnificent  work  of  the  Royal  Army 
Medical  Corps. 

Dr.  T.  G.  Roddick,  M.P.,  told  of  the  great  sacri- 
fices of  Dr.  Ryerson  in  proceeding  to  South  Africa  at 
his  own  expense  to  carry  out  the  work  of  the  Red  Cross 
Association.  While  in  England  recently,  he  stated 
he  had  made  it  his  special  business  to  inquire  of  re- 
turning Canadian  soldiers  as  to  the  hospital  manage- 
ment in  South  Africa,  and  although  he  had  spoken  to 
many  of  these,  he  had  completely  failed  to  find  a  sin- 
gle Canadian  who  had  anything  but  praise  for  the  hos- 
pital arrangements  in  that  country. 

Our  Race  and  Consumption.— This  was  the  title  of 
a  very  able  paper  contributed  by  Sir  James  Grant, 
of  Ottawa,  who  considered  it  an  important  fact  and 
one  worthy  of  consideration  that  races  had  been  born 
on  this  continent,  had  lived  and  entirely  disappeared, 
leaving  mounds  in  the  V\'est  and  other  traces  in  Flor- 
ida and  elsewhere  of  their  undoubted  existence;  and 
that  thus  far  there  was  no  information  as  to  the  exact 
cause  of  the  disappearance  of  these  races.  He 
thought  it  remained  for  the  Anglo-Saxons  to  see 
whether  they  would  prove  more  successful  than  their 
predecessors  in  establishing  themselves  on  this  conti- 
nent. He  referred  to  the  loss  of  three  thousand  lives 
in  the  fair  province  of  Ontario  in  1898  by  consump- 
tion alone,  and  deplored  the  fact  that  the  people  were 
not  as  yet  alive  to  their  danger.  Sir  James  indorsed 
the  legislation  passed  at  the  last  session  of  the  provin- 
cial Parliament  designed  for  the  purpose  of  assisting 


5'4 


MEDICAL    RECORD. 


[September  29,  1900 


municipalities  in  the  erection  and  maintenance  of  san- 
atoria for  consumptives. 

Recognition  and  Management  of  Tabes  Dorsalis. — 
Dr.  Allan  McLane  Hamilton  had  prepared  this  pa- 
per, but  on  account  of  illness  was  unable  to  be  present 
to  read  it.  The  president  undertook  this  tdsk.  It  ap- 
peared that,  as  an  etiological  factor,  syphilis  was  not 
referred  to  by  the  early  writers  on  this  disease.  While 
some  would  attempt  to  divide  the  symptoms  of  the  dis- 
ease into  the  leg  and  eye  types,  the  writer  would  con- 
sider that  to  be  unwarranted.  He  considered  there 
was  a  close  resemblance  or  rather  relationship  between 
the  different  forms  of  cerebro-spinal  sclerosis.  There 
was  no  disease  of  the  nervous  system  which  had  drawn 
forth  so  many  plans  of  treatment;  and  but  little  or  no 
good  had  resulted  from  any  one  thing.  Most  tabetics 
were  favorable  subjects  for  expectant  treatment,  and 
many  derived  temporary  benefit  from  some  new  drug. 
Looking  back  over  a  number  of  years,  he  found  that 
most  good  had  been  accomplished  when  little  or  no 
medicine  had  been  given.  He  had  found  rest  by  sus- 
pension and  persistent  cauterization  of  the  back  good 
treatment.  In  the  opinion  of  the  writer,  syphilis 
could  not  be  traced  in  more  than  fifty  per  cent,  of  the 
cases.  For  the  arthropathies  there  was  little  to  be 
done.  Perforating  ulcer  was  a  rare  feature  of  loco- 
motor ata.xia,  and  most  obstinately  resisted  treatment. 
He  had  seen  three  cases  of  this  unusual  condition  in 
ataxics,  and  the  ulcer  rarely  e.xceeded  2  or  3  cm.  in 
diameter.  One  authority  mentioned  five  cases  resulting 
in  cure  by  means  of  nerve  stretching.  Throughout  the 
course  of  the  paper  numerous  cases  were  cited  with 
their  symptoms  and  treatment. 

The  Physician's  "  Vaster  Empire." — In  this  pa- 
per Dr.  John  Hunter,  of  Toronto,  dealt  with  the 
questions  of  sanitary  science,  education,  social  purity, 
and  medical  missions.  Referring  to  sanitary  science, 
he  entered  a  plea  for  the  broader  and  freer  application 
of  the  principles  of  this  branch  of  medicine,  in  the 
building  and  construction  of  our  homes,  schools, 
churches,  theatres,  etc.  No  dwelling-house  should  be 
constructed  except  under  the  supervision  of  an  archi- 
tect and  a  physician  versed  in  sanitary  science.  In 
the  matter  of  sanitary  science  architects  had  improved 
wonderfully  during  the  past  ten  years.  Another  im- 
portant question  was  that  of  our  educational  system — 
the  mental  and  physical  health  and  development  of 
our  school  children.  The  best  way  to  secure  physical 
vigor  and  high  mentality  was  surely  within  the  prov- 
ince of  the  physician  to  grapple  with  and  study.  In 
all  forms  of  social  purity  and  impurity,  physicians 
should  speak  ^.v  (athedra  against  every  form  of  vice 
and  immorality.  The  boys  and  the  girls  of  the  family 
should  be  enlightened  as  to  their  sexual  proclivities 
at  proper  periods,  by  their  fathers  and  mothers  respec- 
tively. In  medical  missions  he  referred  to  the  vast 
field  for  medical  missionary  work  in  foreign  countries. 

Address  in  Surgery — Tuberculous  Lesions  from  a 
Clinical  Point  of  View.  —  The  president  introduced 
Mr.  Edmund  Owen  in  a  few  well-chosen  words. 
This  address  was  delivered  at  the  evening  session  of 
the  first  day,  and  the  distinguished  visitor  was  greeted 
by  a  crowded  house.  In  commencing  his  masterly  ad- 
dress, he  stated  that  he  would  deal  with  tuberculous 
lesions  as  the  surgeon  met  them  day  by  day  in  the 
hospital  wards,  in  private  practice,  or  in  the  operating- 
theatre.  Referring  to  the  pathologists,  he  considered 
his  (the  pathologist's)  thought  to  be  only  of  tiie  dead 
tissue,  while  the  surgeon  saw  the  human  tree  during 
its  life  and  rarely  followed  it  after  death.  The  stu- 
dent did  clinical  and  pathological  work  at  different 
times;  and  he  was  enabled  to  follow  the  case  straight 
from  the  ward  to  the  laboratory.  He  considered  that 
study  of  the  fresh  specimen  was  the  best;  for  the  speci- 
men taken  from  formalin  was  no  more  like  the  actual 


condition  than  canned  salmon  was  like  fresh-run  fish. 
He  would  not  hinder  experimental  research  work ;  it 
was  absolutely  necessary.  The  life  of  a  man  was  of 
more  value  than  a  sparrow  or  many  guinea-pigs.  It 
would  be  almost  impossible  to  overestimate  the  direct 
value  of  experimental  laboratory  work.  Strumous  and 
scrofulous  were  now  terms  devoid  of  meaning,  and 
tubercle  was  now  called  by  its  proper  name.  There 
were  three  great  factors  in  connection  with  tuberculo- 
sis which  the  public  must  be  made  acquainted  with: 
(i;  The  disease  was  communicable;  but  the  public 
must  be  allowed  a  little  time  before  accepting  this 
statement  and  fact.  (2)  The  disease  was  preventable; 
this  followed  almost  as  a  corollary  to  the  first  state- 
ment. (3)  The  disease  was  curable.  Years  ago  the 
subject  of  tuberculosis  was  regarded  as  wellnigh  hope- 
less; but  now  it  was  not  considered  of  the  untractable 
nature  that  it  was  formerly  thought  to  be.  Tubercu- 
lous lesions  were  exactly  what  they  used  to  be;  and 
Mr.  Owen  had  worked  at  tiie  largest  children's  hospi- 
tal in  London  for  over  a  quarter  of  a  century.  We 
now  took  a  much  more  hopeful  view  of  these  lesions. 
Many  of  his  hearers  had  studied  tuberculous  lesions 
under  these  skies  and  also  in  the  mother  country. 
Did  they  find  that  the  tuberculous  lesions  were  the 
same  in  both  hemispheres?  One  rarely  heard  now  of 
the  vis  medicatrix  naturae;  surgery  had  rendered  it 
superlluous.  :V11  had  noticed  cases  of  old  standing 
hip-joint  disease  in  which  in  time  the  sufferer  actually 
grew  out  of  his  trouble.  This  might  be  a  popular  su- 
perstition, but,  like  most  erratic  beliefs,  it  was  founded 
upon  a  stratum  of  truth.  In  children  these  chronic  dis- 
eases were  always  tuberculous.  When  chronic  ab- 
scesses occurred,  it  would  not  do  to  open  and  drain,  but 
they  must  be  scraped  out — their  unhealthy  lining  de- 
stroyed. In  the  treatment  of  these  diseases,  the  speaker 
stated  that  he  had  failed  to  find  any  virtue  whatever 
in  the  employment  of  iodoform.  It  was  an  irritant 
and  a  poison,  and  it  was  apt  to  be  septic,  as  germs  can 
grow  on  it.  Mr.  Owen  condemned  the  use  of  compli- 
cated apparatus,  and  also  forcible  correction  in  cases 
of  spinal  deformities.  He  considered  that  this  defor- 
mity did  not  lend  itself  to  operative  treatment.  There 
might  perhaps  be  a  small  class  of  cases  in  which  it  might 
eventually  be  found  applicable,  as  when  bone  or  or- 
ganized inflammatory  deposits  pressed  upon  the  cord 
so  that  the  patient  had  lost  movement  in  the  lower  ex- 
tremities. The  plaster-of-Paris  jacket  must  be  held 
responsible  for  much  of  the  deformity  of  Pott's  disease. 
The  proper  treatment  of  these  cases  was  rest  in  the 
horizontal  position,  with  plenty  of  good  fresh  air  and 
sunlight. 

At  the  conclusion  of  his  extremely  able  and  instruct- 
ive address  the  thanks  of  the  association  were  moved 
in  a  complimentary  speech  by  Professor  Shepherd,  of 
Montreal,  and  seconded  by  Professor  Cameron,  of 
Toronto,  put  by  the  president,  unanimously  carried 
amid  great  enthusiasm,  and  appropriately  presented 
to  Mr.  Owen  by  Dr.  Powell.  Mr.  Owen  made  a  happy 
reply. 

Excision  of  the  Knee  Joint  in  Tuberculous  Dis- 
ease.— Professor  Prlmrose,  of  Toronto  University, 
minutely  described  Kocher's  method  of  dealing  with 
tuberculous  disease  of  Llie  knee  joint.  He  recited  the 
histories  of  a  few  cases  in  which  he  had  obtained  ex- 
cellent results,  in  which  this  operation  had  been  em- 
ployed. The  steps  of  the  operation  were  made  clear 
by  a  blackboard  drawing.  At  the  conclusion  of  his 
demonstration.  Dr.  Primrose  was  highly  complimented 
by  Mr.  Owen  for  iiis  lucid  exposition  of  his  suiiject. 

Recent  Pathological  Studies  of  the  Blood.  —  'I'he 
last  paper  on  the  evening  of  the  lirst  day  was  a  most 
interesting  antl  instructing  one  by  Dr.  L.  H.  Warner, 
of  Brooklyn.  At  the  commencement  of  his  paper  he 
asserted  that  he  believed  there  was  a  necessity  for  ex- 


September  29,  1900J 


MEDICAL    RECORD. 


515 


periments  for  the  progress  of  pathology.  His  experi- 
mental researches  were  directed  along  three  lines  of 
inquiry,  viz. :  experiments,  observation,  and  individual 
observation  at  clinics  in  hospitals.  He  considered 
that  the  examination  of  the  blood  in  most  cases  was 
of  more  importance  than  an  examination  of  the  urine. 
Dr.  Warner  gave  the  formula  of  a  new  staining-solu- 
tion  which  he  had  found  very  practicable:  The  blood 
specimen  should  be  prepared  in  the  regular  manner. 
The  slides  were  heated  in  a  hot  oven  to  98'  F.,  and  im- 
mersed for  one  minute  in  a  one-per-cent.  aqueous  solu- 
tion of  methylene  blue,  washed  in  water,  then  put  in  a 
one-per-cent.  alcoholic  solution  of  eosin,  washed  again 
with  water,  and  then  placed  in  a  one-per-cent.  solution 
of  Bismarck  brown.  Dr.  Warner's  paper  was  illustrat- 
ed with  suitable  diagrams. 

President's  Address — On  the  afternoon  of  the  sec- 
ond day,  with  a  packed  hall  for  an  audience,  Dr. 
Powell  delivered  the  annual  presidential  address. 
He  first  recited  a  few  reminiscences,  when  on  former 
occasions  the  Canadian  Medical  Association  had  con- 
vened in  the  capital  city;  that  was  in  1S71,  1881, 
1889,  and  1893.  He  referred  to  the  South  African 
war  in  order  to  show  the  unsatisfactory  condition  of 
affairs  which  permitted  other  colonial  surgeons  from 
Australia  and  \ew  Zealand  to  practise  their  profession 
in  that  land  without  hindrance,  while  Canadians  were 
debarred  from  the  same  privileges.  An  earnest  and 
united  effort  on  the  part  of  the  profession  throughout 
the  whole  Dominion  of  Canada,  in  an  endeavor  to 
bring  about  inter-provincial  registration,  would  facili- 
tate matters  in  the  direction  of  securing  these  privi- 
leges for  the  Canadian  profession  in  other  parts  of  the 
British  empire.  The  hackneyed  subject  of  tuberculo- 
sis was  lightly  touched  upon;  while  a  very  important 
matter  relating  to  the  profession,  that  of  a  Medical 
Defence  Association,  was  dealt  with  at  considerable 
length.  Dr.  Powell  favored  the  formation  of  such  an 
association,  and  later  on  in  the  proceedings  nominated 
a  committee  to  look  into  the  question,  to  report  on  the 
advisability  and  practicability  of  forming  a  Dominion 
association  of  this  character. 

Some  Experiences  in  the  Treatment  of  Hernias. 
— Dr.  F.  J.  Shephkrd,  of  Montreal,  contributed  this 
paper.  He  said  that  some  twenty  years  ago  surgeons 
began  to  perform  these  operations  by  the  open  method. 
Older  methods  in  vogue  were  touched  upon  and  de- 
scribed; and  he  instanced  one  very  large  hernia  which 
had  come  under  his  observation  then,  when  the  man 
could  not  put  his  trousers  on.  The  methods  of  opera- 
tion were  almost  as  numerous  as  were  surgeons,  but 
there  were  certain  general  principles  underlying  all 
operations:  (i )  The  necessity  for  excision  or  oblitera- 
tion of  the  sac;  (2)  closure  of  the  canal;  (3)  union 
by  first  intention.  Some  also  held  that  alteration  in 
the  direction  of  the  canal  was  necessary.  The  opera- 
tion performed  by  Dr.  Shepherd  was  Bassini's,  but 
with  it  he  was  not  always  successful.  He  had  used 
all  kinds  of  sutures.  Absorbable  sutures  were  the 
best,  and  if  aseptic  they  were  to  be  preferred.  A 
suture  that  would  last  for  three  weeks  was  all  that  was 
wanted.  He  had  used  chromicized  catgut  now  for 
some  time.  He  never  washed  out  the  wound,  and 
thought  it  better  to  dissect  out  the  sac  with  the  knife 
than  to  tear  it  with  the  fingers.  He  never  used  a 
drain.  For  the  pa.st  two  years,  he  had  used  rubber 
gloves  in  all  his  surgical  work  abdominal  in  char- 
acter, and  he  considered  that  he  had  got  better  results 
since  he  began  their  use.  In  hernia  operations,  the 
mortality  was  practically  nil.  Operations  on  children 
were  now  the  most  successful  cases;  formerly  they 
were  not  advised  except  in  strangulated  cases. 

Dr.  Lapthorx  Smith  discussed  this  paper  and  the 
cases  described,  although  his  experience  lay  mostly  in 
ventral  and  umbilical  work.     In  some  of  this  he  had 


seen  hernias  so  large  as  to  require  twenty  stitches. 
During  the  past  two  years  he  had  abandoned  silk  and 
resorted  to  chromicized  catgut,  which  he  always  pre- 
pared himself. 

Replying  to  the  criticisms,  Dr.  Shepherd  stated  that 
if  there  was  any  oozing  in  the  wound,  he  would  pass 
a  probe  between  the  edges  of  the  wound  to  let  out  the 
accumulated  serum.  This  way  he  found  to  be  quite 
efficacious,  as  thus  the  chance  of  the  introduction  of 
any  germs  from  witiiout  was  minimized. 

A  Case  of  Sypilitic  Gummata  of  the  Spinal 
Cord  Successfully  Treated  by  Enormous  Doses  of 
Iodide  of  Potassium. — Dr.  F.  W.  C.ampuell,  of 
Montreal,  reported  the  history  of  this  very  interesting 
case.  It  occurred  in  a  man  of  highly  neurotic  tem- 
perament, who  a  short  time  before  the  onset  of  symp- 
toms of  a  definite  character  had  suffered  from  repeated 
attacks  of  insomnia  of  a  very  aggravated  character. 
When  his  sickness  began,  there  were  noticed  retention 
of  urine  and  loss  of  power  in  the  lower  limbs.  The  pa- 
tellar reflex  was  about  normal.  The  loss  of  power  in 
the  lower  limbs  was  absolute.  The  pulse  varied  from 
80  to  96;  the  temperature  was  never  above  99°  Y. 
The  stomach  remained  in  fairly  good  condition  all  the 
time.  .A  consultant  from  New  York  was  brought  on, 
and  a  diagnosis  was  established  of  tumor  of  the  spinal 
cord  situated  about  at  the  first  lumbar  vertebra;,  which 
might  be  sarcomatous  or  syphilitic.  The  advice  of 
the  consultant  was  to  give  gr.  d.  of  iodide  of  potassium 
per  day,  commencing  with  one  drachm  three  times  a 
day.  Dr.  Campbell  detailed  minutely  the  daily  his- 
tory of  the  patient  while  getting  him  under  the  large 
dose,  and  then  again  while  it  was  gradually  being  with- 
drawn. The  patient  was  alive  to-day  and  in  good 
health,  having  recovered  complete  control  of  his  lower 
extremities. 

Address  in  Gynaecology. — A  very  practical  ad- 
dress was  delivered  by  Dr.  Willia.m  Cardner,  of 
Montreal,  on  the  mistakes  in  diagnosing  gyna;cologi- 
cal  and  obstetric  cases.  He  said  that  we  often  learned 
more  from  our  mistakes  than  we  did  from  our  success- 
es. Correct  and  accurate  diagnosis  depended  mainly 
upon  the  sense  of  touch,  which  could  be  attained  only 
by  long  and  patient  practice.  He  referred  to  the 
advantages  of  examining  on  a  plain  table  instead  of 
on  a  couch  or  bed.  The  patient's  rectum  should  al- 
ways have  been  emptied  before  she  presented  herself 
for  examination.  As  for  the  bladder,  it  was  best  for 
one  to  empty  that  viscus  himself  per  catheter  when 
the  patient  was  on  the  table,  as  in  this  way  one  would 
be  able  to  notice  any  discharges,  etc.  That  the  phy- 
sician would  have  to  do  this  often  was  quite  clear  from 
the  fact  that  there  were  many  women  of  nervous  tem- 
perament who  would  not  be  able  to  empty  the  bladder 
voluntarily  in  the  physician's  office.  Another  advan- 
tage of  doing  this  for  one's  self  was  that  an  uncontami- 
nated  specimen  for  examination  was  obtained.  In 
cases  in  which  tension  was  present  in  the  muscles  of 
the  abdomen,  if  a  series  of  circular  movements  over  the 
lower  abdomen  were  made,  gradually  narrowing  the 
circle,  one  would  be  able  to  overcome  whatever  rigid- 
ity might  be  present.  Dr.  Gardner  urged  caution  in 
the  use  of  the  uterine  sound.  He  considered  it  a 
rather  dangerous  instrument,  so  that  its  use  ought  to 
be  extremely  limited,  and  held  the  opinion  that  many 
women  had  lost  their  lives  through  this  instrument. 
Then  there  were  the  danger  and  risk  of  infecting  and 
injuring  the  uterine  canal.  This  sound  was  a  great 
deal  too  much  employed  by  the  general  practitioner. 
Mistakes  in  diagnosing  displacements  of  the  uterine 
body  he  considered  to  be  the  most  common.  The  uterus 
was  a  very  movable  organ,  and  a  distended  rectum  or 
bladder  might  cause  it  to  be  diagnosed  as  an  ante-  or  a 
retroversion.  Then  it  was  important  to  remember  that 
it  might  be  displaced  through  acts  of  coughing,  vomit- 


5i6 


MEDICAL   RECORD. 


[September  29,  1900 


ing,  etc.  In  all  examinations  of  the  pelvic  organs, 
Dr.  Gardner  had  made  it  a  point  to  examine  the  posi- 
tion of  the  kidneys  as  well.  Referring  to  examina- 
tion by  the  Sims  method  he  said  it  was  necessary  to 
have  the  patient  in  the  proper  position ;  and  if  one 
had  not  a  Sims  speculum,  a  bent  table-fork  or  the 
finger  of  the  iipposite  hand  could  be  used  to  distend 
the  perineum.  Mistakes  were  often  made  in  the 
diagnosis  of  pregnancy;  but  still  the  patients  were 
few  in  whom  the  diagnosis  could  not  be  made  by  care- 
ful examination  of  history,  signs,  etc.  Many  women 
were  probably  inaccurate  as  to  date.  Dr.  Gardner 
illustrated  his  points  as  he  proceeded,  by  reciting 
cases.  One  in  particular  he  instanced,  when  he  once 
found  a  woman  in  his  office  on  her  hands  and  knees 
in  the  throes  of  a  twin  labor,  which  a  fellow-prac- 
titioner had  failed  to  recognize  and  had  tapped  the 
gravid  uterus  and  drawn  a  quantity  of  the  liquor 
amnii.  Dr.  Gardner  spoke  of  the  mistakes  made  by 
himself  as  well  as  by  his  brother  practitioners.  The 
close  of  the  paper  referred  to  an  interesting  account 
of  mistakes  which  had  occurred  in  diagnosing  extra- 
uterine pregnancy. 

The  association  tendered  him  unanimously  a  hearty 
vote  of  tiianks  for  his  exceedingly  practical  paper. 

An  Unnoticed  Factor  in  the  Production  of  Ab- 
dominal and  Pelvic  Disturbances  in  Women. — Dr. 
Clarence  Wemstek,  of  Chicago,  contributed  an  inter- 
esting paper  with  the  above  title.  Symptomatology 
in  women,  he  said,  was  often  overlooked  by  the  gen- 
eral practitioner.  The  question  of  the  normal  rela- 
tionship of  the  abdominal  and  pelvic  contents  was 
dwelt  upon,  and  then  he  proceeded  to  account  for 
intra-abdominal  pressure,  holding  the  view  that  the 
pelvic  as  well  as  the  abdominal  organs  were  to  a  large 
extent  held  in  their  respective  positions  by  reason  of 
the  pressure  of  the  abdominal  and  pelvic  walls.  He 
stated  the  average  specific  gravity  of  the  viscera  to  be 
a  little  more  than  that  of  water;  that  of  the  liver 
was  1.5.  He  maintained  that  there  was  no  proof  that 
the  mesenteries  acted  as  constant  supports  or  were 
ever  meant  to  be  such;  and  the  main  factor  in  sustain- 
ing the  viscera  was  the  strength  of  the  abdominal  wall 
and  pelvic  floor.  Local  weakness  of  the  abdominal 
wall  had  been  fairly  well  described  under  hernia, 
while  general  weakness  of  the  abdominal  wall  had 
been  described  as  pendulous  belly.  General  weakness 
in  his  experience  was  an  exceedingly  rare  condition. 
As  to  the  question  of  etiology,  this  condition  was 
found  in  women  who  had  borne  children;  and  so,  on 
examination  of  the  great  majority  of  women,  there  was 
found  some  degree  of  separation  of  the  recti  muscles 
in  the  region  of  the  navel.  All  evidence  later  on 
might  disappear,  but  permanent  widening  remained. 
The  results  of  all  this  was  unavoidable  enteroptosis; 
and  this  was  generally  found  in  women  who  had  been 
addicted  to  the  pernicious  habit  of  tight-lacinp.  A 
very  common  displacement  seen  was  that  of  the  right 
kidney.  Dr.  Webster  dwelt  upon  the  diagnostic  symp- 
toms of  these  conditions,  and  then  proceeded  to  de- 
scribe the  operation  he  performed  for  their  relief. 
This  consisted  in  bringing  the  edges  of  the  two  recti 
muscles  into  apposition.  He  first  performed  this 
operation  in  November,  1898.  Since  that  time  he  had 
operated  upon  forty-one  cases,  and  the  results  had  been 
most  satisfactory  in  all. 

Mr.  I.  H.  Cameron  took  exception  to  Dr.  Webster's 
using  the  word  "unnoticed"  in  the  title  of  his  paper, 
as  he  thought  this  was  not  an  unknown  factor  in  the 
production  of  the  conditions  mentioned. 

Dr.  W.  S.  Muir,  of  Truro,  N.  S.,  asked  what  leav- 
ing off  the  use  of  the  binder  after  confinements  had 
to  do  with  the  production  of  these  conditions. 

Dr.  Wehster  held  to  the  opinion  that  this  had  not 
been  noticed  except  by  himself,  and  cliallenged   Mr. 


Cameron  to  quote  authority  otherwise.  The  absence 
of  the  binder  in  his  opinion  had  not  made  any  special 
difference. 

Address  in  Medicine. — Prof.  S.  F.  Shattuck,  of 
Harvard  University,  said  in  opening  his  address  tliat 
there  was  noticed  a  subdivision  of  labor  in  every  branch 
of  industry.  As  a  consequence,  specialization  had  tak- 
en place  in  the  science  and  art  of  medicine.  In  special- 
ization lay  the  cleavage  between  medicine  and  surgery; 
and  nowhere  had  the  line  been  more  closely  drawn 
than  in  England.  Ana;sthesia  had  greatly  enlarged 
the  bounds  of  surgery.  Twenty-five  years  ago  there  was 
not  a  pure  surgeon  in  America.  Bellyache  was  now  a 
surgical  disease.  The  heart  was  practically  the  only 
viscus  which  remained  the  exclusive  property  of  the 
physician,  and  he  was  not  so  sure  but  that  even  this  or- 
gan would  soon  be  attacked  and  we  might  hear  of  sutur- 
ing of  the  mitral  valves.  In  this  country  the  general 
practitioner  was  clinging  to  obstetrics  for  family  prac- 
tice. In  some  of  the  larger  centres,  there  was  now 
even  a  tendency  to  specialism  in  obstetrics,  when  the 
specialist  would  preside  at  the  accouchement,  and  the 
family  practitioner  then  step  in  to  oversee  the  attend- 
ance throughout  the  puerperium.  Pure  gynaecology 
scarcely  existed  to-day,  and  pelvic  tinkering  was  suf- 
fering from  a  rapid  decline.  'i"he  great  bulk  of  major 
gynaecology  was  nothing  more  than  abdominal  sur- 
gery, which  properly  belonged  to  the  general  surgeon. 
Gynaecologists  should  study  general  surgery  and  be- 
come general  surgeons  first.  The  field  in  medicine 
was  so  large  that  no  one  man  could  grasp  it  all  in  a 
lifetime.  Other  specialties  were  referred  to.  The 
desire  on  the  part  of  some  to  escape  the  hurly-burly 
of  general  practice  might  be  a  cause  in  throwing  them 
into  special  lines;  and  then  there  was  the  f Act  that 
special  knowledge  drew  larger  fees.  Ophthalmol- 
ogists got  more  for  removing  a  speck  of  dust  from  the 
eye  than  did  the  general  practitioner.  Since  we  had 
specialists  for  diseases  of  the  young,  why  not  also 
have  a  specialty  for  the  diseases  of  the  old?  In  the 
belief  of  the  speaker  specialism  had  come  to  stay. 

The  gathering  was  exceedingly  delighted  with  the 
deliverance  of  Dr.  Shattuck,  and  at  the  close  tendered 
him  a  cordial  vote  of  thanks,  to  which  he  made  an 
appropriate  reply. 

Gastric  Hemorrhage.— This  paper  was  read  by  Dr. 
George  E.  Ar.m.strong,  of  Montreal,  who  said  he  be- 
lieved there  was  a  fairly  well-determined  field  in 
which  surgical  interference  might  be  of  use  in  hemor- 
rhage of  the  stomach.  Hemorrhage  occurred  in  fifty 
per  cent,  of  gastric  ulcers  and  was  fatal  in  eight  per 
cent.  Cases  were  arranged  in  two  groups,  the  acute 
and  the  chronic.  Rodman  had  reported  thirty-one 
operations  for  frequently  occurring  or  chronic  hemor- 
rhages, with  six  deaths.  The  speaker  had  operated 
five  times  for  gastric  hemorrhage,  one  being  a  chronic 
case.  In  one  of  these  the  patient  was  getting  along 
nicely  after  the  operation,  when  siie  expired  suddenly; 
and  on  a  post-mortem  examination  being  made,  thrombi 
were  found  in  the  branches  of  the  pulmonary  artery. 

Some  Cases  in  Stomach  Surgery — Gastrotomies, 
Two  Cases ;  Gastro-Enterostomies,  Two  Cases ; 
Pylorectomy. — Dr.  A.  E.  Garrow,  of  Montreal,  re- 
ported these  cases.  In  one  patient  operated  on,  the 
patient  was  fed  before  he  left  the  operating-table. 
Another,  a  woman  aged  fifty  years  who  had  a  persistent 
hacking  cough,  had  gastrostomy  performed,  and  was 
discharged  able  to  feed  herself  through  a  tube.  In 
another  case,  in  a  man  aged  thirty-three  years,  who 
had  vomiting  and  blood  in  the  stools,  the  patient  sud- 
denly felt  acute  pain  and  became  pale.  Duodenal 
perforation  was  present,  and  when  the  abdomen  was 
opened,  gas  escaped  from  the  incision.  V\'hen  dis- 
charged on  July  24th  last,  the  patient  was  feeling 
well.     Six  cases  were  reported. 


September  29,  1900] 


MEDICAL    RECORD 


517 


The  Modern  Treatment  of  Retroversion  and  Pro- 
lapse of  the  Uterus.  — Dr.  A.  Lapthorn  Smith  pre- 
sented an  able  paper  with  the  above  title.  It  referred 
to  the  proper  and  most  successful  management  of  pro- 
cidentia uteri  in  elderly  women  between  seventy  and 
seventy-five  years  of  age — a  most  pitiable  condition. 
E.xcept  for  this  trouble,  the  patient  might  be  otherwist- 
in  excellent  health;  the  perineum,  however,  was  so  re- 
laxed that  no  pessary  would  remain  in  place.  Then  in 
the  majority  of  these  cases  there  was  an  ulceratetl  rer- 
vix.  After  confinement  the  uterus  remained  largi,. 
and  the  pernicious  habit  of  keeping  women  too  long 
on  their  backs  had  a  tendency  to  produce  the  back- 
ward displacement.  Dr.  Smith  felt  certain  that  women 
who  had  been  relieved  of  this  distressing  condition 
would  have  little  difficulty  in  persuading  others  to 
avail  themselves  of  the  treatment.  He  removed  a 
woman's  uterus  a  few  months  ago,  which  had  been  out 
of  her  body  for  twenty  years;  and  the  patient  now  as- 
sured him  that  she  felt  like  a  young  woman.  In  cor- 
recting this  deformity,  Dr.  Smith  luade  a  small  incision 
in  the  abdomen  and  performed  ventrofixation.  After 
that  the  vaginal  canal  was  narrowed  by  a  large  anterior 
and  posterior  colporrhaphy.  In  selected  cases,  he  also 
amputated  the  lower  half  of  the  organ  and  then  stitched 
the  vagina  to  the  upper  half.  He  considered  ventro- 
fixation, if  properly  performed,  a  most  reliable  means 
of  fastening  up  the  uterus.  The  operation  had  given 
him  the  most  complete  satisfaction  of  any  operation 
he  had  ever  performed,  especially  when  combined  with 
amputation  of  the  cervix  and  posterior  colporrhaphy. 

Gasoline  as  a  Surgical  Detergent. — A  highly 
original  paper  was  contributed  by  Dr.  BrI'ce  I,. 
RioRDAN,  of  Toronto,  on  the  use  of  gasoline  as  a 
detergent.  With  this  the  dirty,  greasy  hands  of  ma- 
chinists, who  are  the  subjects  of  injuries  in  the^e 
parts,  could  be  effectually  and  rapidly  cleaned,  with- 
out the  ordinary  brush  and  soap  and  water.  It  was 
far  better  for  this  purpose  than  any  method  heretofore 
devised  for  cleansing.  He  now  constantly  carried  a 
small  bottle  of  this  in  his  surgical  bag.  A  report 
from  Dr.  VVilliam  Goldie,  of  Toronto,  showing  its 
effects  upon  germs  and  germ  life,  would  conduce  to  its 
employment  as  indicated.  One  word  of  caution  was 
thrown  out  by  Dr.  Riordan  as  to  its  use;  as  it  was  a 
highly  inflammable  substance,  it  should  not  be  used 
in  any  quantity  near  an  exposed  light;  and  then  it 
was  painful  in  the  eyes  or  ears.  It  was  also  useful 
in  cleansing  sutures  of  accumulated  serum,  blood, 
and  dressing-powder,  thus  freeing  these  particles  and 
enabling  one  to  locate  the  stitches  more  easily  and 
quickly. 

Dr.  J.  C.  Mitchell,  of  Inniskillen,  Ont.,  stated 
that  he  had  tried  gasoline  recently  as  a  detergent  in 
two  very  severe  threshing-machine  accidents,  in  which 
the  parts  were  all  smeared  over  with  oil  and  grease 
and  dirt;  and  it  was  very  satisfactpry,  as  he  was  able 
to  get  perfect  cleanliness  in  a  short  time,  both  wounds 
healing  by  first  intention. 

Dilatation  and  Prolapse  of  the  Stomach. — Prof. 
Alexander  McFhedra.n,  of  Toronto  University,  pre- 
sented this  paper,  which  dealt  principally  with  pro- 
lapse. This  condition  rarely  occurred  alone,  but  was 
associated  with  prolapse  of  other  abdominal  organs. 
There  was  generally  present  as  well  some  degree  of 
dilatation,  and  the  abdomen  might  be  prominent  or 
flat,  or  even  retracted.  The  case  of  a  man  aged  tifty- 
one  years  was  referred  to,  a  manufacturer,  who  had 
been  ailing  for  two  or  three  years.  The  stomach  was 
below  the  umbilicus.  He  was  directed  to  massage  the 
abdomen  very  thoroughly  and  to  practise  abdominal 
gymnastics.  Through  this  treatment,  combined  with 
dietetics  and  some  strychnine,  he  had  been  restored  to 
health  and  was  able  to  resume  business.  Another 
case  of  a  woman  aged  thirty-five  years  was  reported. 


This  woman  had  been  the  subject  of  recurrent  at- 
tacks of  vomiting  for  two  years.  The  symptoms  were 
detailed;  massage  and  abdominal  gymnastics  were 
ordered  with  satisfactory  results.  The  different  ways 
of  examining  the  stomach  were  described,  and  in  con- 
cluding Dr.  McPhedran  spoke  of  the  benefits  of  a 
change  of  scene  in  treating  these  cases. 

Physical  Training ;  its  Range  and  Usefulness 
in  Therapeutics. —  Dr.  J!.  K.  Mackenzie,  of  Toronto, 
gave  a  very  interesting  account  of  the  methods  em- 
ployed by  him  in  correcting  deformities  in  his  ortho- 
pedic hospital  in  that  city.  The  paper  was  illustrated 
by  lithographs  showing  improvements  in  spinal  de- 
formities after  physical  training  in  the  direction  in- 
dicated. The  paper  embraced  the  results  of  his  ob- 
servations for  thirteen  years  past,  and  was  ample 
justification  of  the  benefits  derived  from  gymnastics 
in  the  correction  of  lateral  curvature,  club-foot,  etc. 
He  had  also  found  physical  training  valuable  in  hy.s- 
teria  and  chorea,  especially  the  former. 

Inter-Provincial  Registration. — Dr.  T.  G.  Rod- 
DicV;,  M.l'.,  read  the  report  of  the  committee  having 
this  matter  in  hand.  A  new  feature  to  be  incorpor- 
ated in  the  measure  was  that  of  allowing  the  honiao- 
paths  representation  on  the  proposed  Dominion  coun- 
cil, as,  according  to  the  law  of  Ontario,  these  had  their 
vested  rights  in  that  province,  and  so  must  be  accorded 
similar  interests  in  any  proposed  Dominion  council. 
These  would  be  allowed  three  representatives,  which 
would  be  equivalent  to  the  representation  from  any  one 
province  of  the  Dominion.  Their  term  of  office  would 
be  four  years.  Homaopaths,  however,  as  such,  would 
not  be  mentioned  in  the  measure,  but  they  would  be 
classified  under  "any other  school  of  medicine  having 
legal  recognition  in  any  of  the  provinces  in  Canada," 
as  the  British  Medical  Council  would  not  recognize 
any  such  body.  Dr.  Roddick  stated  that  the  bill 
would  be  introduced  at  the  next  session,  and  advised 
the  members  of  the  committee  from  each  province  to 
bestir  themselves  before  their  respective  provincial 
parliaments,  as  these  bodies  must  sanction  the  meas- 
ure before  it  can  be  finally  acted  upon  by  the  Dominion 
Parliament. 

Cerebral  Abscess. — Dr.  James  Stewart,  of  Mon- 
treal, reported  two  interesting  cases  of  abscess  of  the 
brain  situated  in  the  temporo-sphenoidal  lobe,  and  re- 
ferred to  the  unusual  existing  aphasia  which  was  pres- 
ent in  both  cases,  viz.,  simple  inability  to  name  ob- 
jects. The  first  case  occurred  in  a  young  man  of 
twenty-two  years  who  had  otitis  media  following  an 
attack  of  influenza.  Some  six  weeks  afterward  an 
abscess  formed.  The  abscess  was  diagnosed  as  being 
confined  to  this  area  simply  on  account  of  the  peculiar 
aphasia — the  simple  inability  to  give  the  name  of  a 
pen  when  that  object  was  presented  to  him.  The  pa- 
tient was  operated  on  by  Professor  Bell,  who  secured 
two  ounces  of  pus.  Meningitis,  however,  set  in,  and 
the  patient  died.  The  second  case  was  that  of  a  gir! 
of  twenty-one  or  twenty-two  years  of  age.  She  had 
had  ear  trouble  for  a  great  many  years,  with  very 
severe  pain  at  times.  She  too  had  difficulty  in  nam- 
ing objects,  and  finally  she  could  not  name  any  object 
whatever.  She  died  suddenly  a  few  hours  before  the 
operation  was  to  be  performed  for  her  relief.  On  llie 
opening  of  the  skull  at  the  subsequent  post-mortem  ex- 
amination, two  abscesses  were  found,  one  skirting  the 
upper  margin  of  the  lobe  and  the  other  situated  about 
the  centre  thereof. 

In  reply  to  a  question  of  the  president,  whether  we 
were  to  take  this  kind  of  aphasia  as  a  distinct  diag- 
nostic symptom  of  abscess  in  that  region.  Professor 
Stewart  stated  that  there  was  what  they  called  a  "nam- 
ing centre,"  and  when  this  was  destroyed  that  particu- 
lar form  of  speech  defect  was  present.  The  cases  were 
aptly  illustrated  by  a  diagram. 


5i8 


MEDICAL    RECORD. 


[September  29,  1900 


Gangrene  of  the  Leg  following  Typhoid  Fever. 
—  Ur.  H.  H.  Chowx,  of  Winnipeg,  reported  two  cases 
of  gangrene  of  the  leg  following  typhoid  fever,  which 
had  recently  come  under  his  observation.  In  the  first 
case  the  [jatieiit  liad  the  classical  symptoms  of  typhoid 
lever,  the  spots  appearing  at  the  end  of  the  lirst  week 
and  being  very  numerous.  There  was  great  pain  in 
the  calf  of  tiie  leg,  with  collapse  symptoms,  while  tiie 
limb  was  cold  and  bloodless.  Cutaneous  sensibility 
was  lost  over  the  leg.  The  third  day  after  the  com- 
plication set  in  the  part  involved  included  tiie  lower 
third  of  the  leg  on  the  inner  side  and  tiie  lower  half 
of  the  outer.  Operation  was  done  at  tiie  junction  of 
the  upper  and  middle  third  of  tlie  femur.  The  pa- 
tient stood  the  operation  well.  The  temperature  before 
the  operation  was  102.6°  F. ;  the  pulse  was  120.  On 
the  following  day  the  temperature  was  normal  and  the 
pulse  no.  On  the  tenth  day  the  Haps  were  united. 
There  was  a  rise  of  temperature  a  few  days  later— a 
relapse,  with  hypostatic  congestion  of  the  lungs.  On 
the  fifth  day  after  there  was  hemorrhage  of  the  bowels. 
The  patient  was  now  a  picture  of  health,  weighing  two 
hundred  pounds.  The  second  was  a  somewhat  similar 
case,  in  whicli  the  blood  reacted  early  and  promptly 
to  the  W'idal  test.  The  gangrene  began  in  the  first 
case  on  the  eleventh  day  of  the  disease;  in  the  second 
on  the  nintli.  Keen  had  reported  gangrene  on  the 
fourteenth  day.  The  gangrene  in  the  second  case  ex- 
tended to  the  upper  and  middle  third  of  the  leg.  The 
leg  was  amputated,  and  prompt  union  took  place 
throughout. 

Dr.  R.  B.  Nevitt,  of  Toronto,  discussed  these  cases 
and  mentioned  a  similar  case  coining  under  his  obser- 
vation during  the  past  summer.  Gangrene  occurred 
in  his  case  about  the  third  week  of  the  fever,  and  the 
patient  was  seen  about  a  week  or  ten  days  thereafter. 
Amputation  was  performed  through  the  middle  third 
of  the  femur.  He  also  referred  to  a  case  of  gangrene 
of  the  arm  following  an  attack  of  pneumonia,  recently 
observed  by  him. 

Notes  on  Atropine. — An  interesting  paper  was  con- 
tributed by  Dr.  R.  D.  Rudolf,  of  Toronto  University, 
which  was  illustrated  by  means  of  a  chart  showing  the 
action  of  the  drug  on  animals  and  the  inferences 
drawn  therefrom  of  its  therapeutic  uses.  He  found 
that  the  drug  directly  stimulated  the  heart,  and  thus 
the  blood  pressure  was  markedly  raised.  He  consid- 
ered the  maximum  single  dose  as  laid  down  by  Wither- 
stine,  of  gr.  ^L,  as  too  large  unless  used  as  an  antidote; 
and  he  thought  that  one  ought  never  to  give  more  than 
gr.  ,-/j,y  of  atropine  sulphate  at  one  time  except  in 
emergencies.  He  also  referred  to  its  action  in  catar- 
rhal pneumonias  of  children,  and  its  employment  be- 
fore anesthesia  to  ward  ofi'  danger. 

The  paper  was  discussed  by  1)r.  A.  D.  Blackader, 
who  congratulated  Dr.  Rudolf  upon  it,  and  said  that 
he  hoped  he  would  pursue  his  studies  further  upon 
the  same  subject  to  find  out  the  efTecl  produced  by 
atropine  in  controlling  vomiting  after  anesthesia.  He 
considered,  however,  tliat  strychnine  and  not  atropine 
was  the  most  powerful  heart  tonic  in  our  pos.session. 
He  thought  that  late  experiments  would  throw  doubt 
upon  atropine  being  a  direct  stimulant  to  tlie  heart 
muscle,  and  thought  it  would  be  (|uestionable  practice 
to  administer  a  drug  that  would  paralyze  nerve  end- 
ings, when  it  was  desired  to  stimulate  the  heart's  action. 
Lantern-Slide  Demonstration  of  Skin  Diseases. 
— The  demonstration  of  these  cases  was  conducted  by 
Dr.  George  H.  Fox,  of  New  York  City,  and  proved 
to  be  one  which  the  members  of  the  association  thor- 
oughly appreciated.  The  great  majority  of  the  skin 
lesions  shown  were  of  syphilitic  origin:  and  as  ihey 
appeared  on  the  canvas  Dr.  Fox  described  the  his- 
tories of  the  cases.  One  in  particular  was  remarkable 
from  the  disfigurement  of  the  woman's  face.     It  was  a 


large  mass  of  excrescences  on  the  nose,  which  Dr.  Fox 
was  able  to  get  rid  of  in  the  course  of  two  or  three 
months,  leaving  only  a  slight  superficial  scar.  He  laid 
down  a  timely  word  of  caution  in  treating  syphilitic 
condition.s,  that  when  the  patient  was  run  down  and 
emaciated  through  large  doses  of  mercury  or  iodide 
of  potassium,  one  should  not  continue  pushing  these 
drugs,  but  should  desist  for  a  time,  and  in  the  interval 
endeavor  to  build  up  the  patient's  strength  and  general 
condition.  That  accomplished,  the  specific  treatment 
should  be  resumed,  and  the  results  would  be  found  to 
be  more  beneficial. 

At  the  conclusion  of  the  doctor's  demonstration, 
which  will  rank  as  one  of  the  features  of  liie  meeting, 
Dr.  Fox  was  tendered  a  cordial  vote  of  thanks  for  his 
instructive  work. 

Dr.  F.  J.  Shepherd  showed  a  very  interesting  case, 
that  of  a  boy  of  sixteen  years,  who  at  the  age  of  six 
sustained  a  severe  cutting  injury  of  the  nerves  and  ves- 
sels of  the  axilla,  all  the  nerves  of  the  brachial  plexus 
below  the  cords  of  the  brachial  plexus  being  severed 
completely.  At  that  time,  ten  years  ago.  Dr.  Shepherd 
dissected  out  each  nerve  separately  and  united  their 
respective  ends  by  suture.  All  did  well  with  the  ex- 
ception of  the  niusculo-spiral;  as  a  consequence,  the 
lad  exercised  very  little  control  over  the  extensors  of 
the  forearm. 

The  Successful  Treatment  of  Two  Important 
Cases  of  Disease  of  the  Eyes  by  the  Combined 
Methods  of  Mercury  and  Iodide  of  Potassium  In- 
ternally and  Pilocarpine  Hypodermically.— Dr.  C. 
H.  BuRNHAM,  of  Toronto,  reported  two  cases  success- 
fully treated  by  his  combined  method.  No  such  re- 
sult followed  other  plans  of  treatment,  and  with  this 
plan  a  permanent  result  was  got.  This  treatment  had 
a  wide  application.  Whenever  iodide  of  potassium 
and  mercury  or  the  iodide  alone  was  given  internally 
in  suitable  cases  without  satisfactory  results,  if  the 
pilocarpine  was  added  good  results  would  always 
follow. 

Mental  Sanitation — Dr.  R.  W.  Bruce  S.mith,  as- 
sistant superintendent  of  the  Brockville  Asylum  for 
the  Insane,  contributed  a  scientific  paper  with  the 
above  title.  It  was  a  plea  for  prophylaxis  in  insanity, 
and  he  thought  that  much  would  be  accomplished  in 
this  direction  during  the  twentieth  century.  Insanity 
was  on  the  increase  in  Canada,  and  it  could  be  ascribed 
to  the  fact  that  while  these  unfortunates  were  well  at- 
tended when  they  become  insane,  the  fact  that  there 
had  been  no  preventive  measures  employed  spoke  for 
itself.  In  order  to  accomplish  good  in  this  direction, 
we  must  seek  either  to  lessen  the  demands  on  the 
brain,  or  to  strengtiien  its  resisting-power.  He  con- 
demned intermarriages  in  families  and  also  among 
those  of  a  deranged  mentality.  Fifty  per  cent,  of  the 
cases  of  insanity  were  hereditary,  and  the  descendants 
of  these  persons  should  be  careful  in  contracting  mar- 
riage ties.  He  referred  to  a  portion  of  one  county  in 
Ontario  alone,  where  indiscriminate  marriage  and 
intermarriage  had  become  most  fruitful;  he  had  seen 
several  members  of  one  family  from  that  locality  in- 
mates of  the  same  institution  at  the  same  time.  '  He 
considered  that  the  day  would  yet  dawn  when  the 
same  attention  would  be  given  to  the  rearing  of  chil- 
dren as  was  now  given  to  the  breeding  of  horses. 
Speaking  of  farm  life  and  the  tendency  it  had  to  in- 
duce melancholy,  he  thought  this  class  of  the  com- 
munity should  receive  education  by  participating  more 
in  the  enjoyments  of  life  and  not  continue  to  rot  in 
domesticity.  An  upheaval  in  the  sentiment  and  sur- 
roundings of  the  rural  homes  would  work  wonders  in 
prophylactic  principles. 

Anti-Consumptive  League.— The  Canadian  Medi- 
cal Association  indorsed  the  scheme  for  the  forma- 
tion of  a  Dominion  Anti-Consumptive  League.     The 


September  29,  1900] 


MEDICAL    RECORD. 


519 


following  were  recommended  as  provisional  officers: 
/'resilient  (honorary)  the  governor-general;  President, 
Sir  James  Grant,  of  Ottawa;  vice-presidents  were  ap- 
pointed for  all  the  provinces;  the  secretaries  are  to 
be  the  secretaries  of  the  different  provincial  boards  of 
health.  Secretary-Organizer,  Rev.  Dr.  Eby,  of  i'oroiito  ; 
Treasurer,  J.  N.  Courtney,  Esq.,  deputy  finance  minis- 
ter of  Ottawa. 

The  Medical  Defence  Association, — The  associa- 
tion recommended  that  Dr.  V.  H.  Moore,  of  Brockville, 
be  the  permanent  chairman  of  the  committee.  One 
member  for  each  province  was  appointed.  This  com- 
mittee will  gather  information  on  the  subject  and 
bring  in  a  recommendation  at  thene.xt  annual  meeting. 

Election  of  Officers. — The  following  ofticers  were 
elected:  Frcsiilent,  H.  H.  Chown,  of  Winnipeg.  Vice- 
J'residenis — Prince  Edward  Island,  II.  D.  Johnson,  of 
Charlottetown;  Nova  Scotia,  A.J.  Maiter,  of  Halifax; 
New  Brunswick,  T.  D.  Walker,  of  St.  John;  Quebec, 
A.  Lapthorn  Smith,  of  Montreal;  Ontario,  A.  A.  Mac- 
donald,  of  Toronto;  Manitoba,  J.  A.  Macdonald,  of 
Brandon;  Northwest  Territory,  J.  D.  Lafferty,  of  Cal- 
gary; British  Columbia,  S.  J.  Trinstile,  of  V'ancouver. 
Treasurer,  H.  15.  Small,  of  Ottawa.  Genera!  Secretary, 
E.  N.  G.  Starr,  of  Toronto. 

Sir  William  Hingston  and  Dr.  F.  W.  Campbell,  of 
Montreal,  were  appointed  on  the  board  of  governors 
of  the  Victorian  Order  of  Nurses,  as  representatives 
of  the  Canadian  Medical  .Association. 

The  treasurer's  report  showed  that  one  hundred  and 
fifty-three  members  were  in  attendance,  and  that  tiiere 
was  a  balance  in  the  treasury  of  S240.65. 

The  next  place  of  meeting  will  be  Winnipeg. 


IpctUcat  Jtcms. 

Cholera  in  India.  -  Cholera  is  devastating  Western 
India  in  an  darming  manner.  The  death  returns  are 
truly  appalling.  The  epidemic  is  pursuing  its  course 
through  the  area  under  British  rule  as  well  as  in  tlie 
native  states.  To  comment  on  the  tragic  significance 
of  the  weekly  death  roll  would  be  superfluous.  The 
dreadful  facts  speak  for  themselves.  It  is  natural  to 
connect  the  appearance  of  the  complaint  among  the 
sufferers  from  famine  with  that  scourge,  but  it  is 
equally  severe  at  long  distances  from  the  zone  of 
dearth.  Apart  from  the  mortality  and  suffering  in 
volved,  the  officials  who  minister  to  the  wants  of  tiie 
stricken  people  are  almost  in  despair  as  to  what  to  do 
for  the  best.  Those  engaged  in  the  Indian  service 
have  brave  hearts  and  no  doubt  will  conquer  in  the 
end,  but  it  is  enough  to  make  angels  weep  at  this  last 
load  of  misery. — English  J'ublic  Opinion. 

Modern  Small-Bore  Rifle  Bullets. — Dr.  Clinton 
Dent,  who  has  recently  returned  from  service  as  a  sur- 
geon with  the  British  army  in  Soutii  .Africa,  read  a 
paper  at  the  meeting  of  the  British  Medical  Associa- 
tion on  the  effect  of  wounds  by  modern  rifle  bullets. 
The  London  Lancet  reports  his  remarks  as  follows; 
Broadly  speaking,  bullet  wounds  of  all  kinds  in  the 
South  African  campaign  had  done  well.  Recoveries 
from  very  severe  wounds  had  been  numerous,  and 
many  of  these  recoveries  had  been  most  remarkable. 
The  percentage  of  wounded  men  who  had  been  found 
fit  to  return  to  duty  had  been  unusually  high.  Wounds 
inflicted  causing  permanent  disability  had  been  Ifss 
frequent,  and  injuries  the  consequences  of  which  ne- 
cessitated amputation  had  been  proportionately  fewer 
than  in  previous  wars.  Conservative  surgery  had 
most  probably  been  carried  further  and  with  more  suc- 
cessful results  than  in  former  campaigns.     These  sat- 


isfactory results  had  been  ascribed  mainly  to  the 
"  humanity  '"  of  the  modern  small-bore  bullets.  He 
believed  that  the  surgical  healthiness  of  the  climate 
of  South  Africa  and  the  widespread  employment  of 
the  "open-air"  method  of  treatment  had  quite  as  much 
to  do  in  bringing  about  this  most  satisfactory  state  of 
affairs.  Septic  complications  attacking  either  bullet 
or  operation  wounds  had  been  very  rare.  The  idea 
that  the  heating  of  the  bullet  had  any  influence  was 
proijably  universally  discarded.  The  heating  effect  was 
never  seen  even  when  bone  was  struck ;  although  arrest 
of  motion  was  possibly  the  mode  of  transformation  of 
motor  energy  into  heat,  yet  its  effects  were  not  seen. 
Again,  the  bullet,  even  if  made  white-hot  by  aerial 
friction,  passed  far  too  rapidly  through  the  tissues  to 
have  any  cauterizing  effects.  The  "  hydrodynamic  " 
theory  as  explaining  the  destructive  effects  of  certain 
bullet  wounds  has  now  few  adherents.  As  instances 
of  cases  in  which  military  surgery  was  now  much  more 
conservative  than  formerly  might  be  cited  perforating 
abdominal  wounds,  compound  fractures,  wounds  of 
joints,  and  nerve  injuries.  All  wounds  did  well,  even 
shell  wounds;  the  only  joint  wound  which  did  not  do 
well  was  that  of  the  ankle.  Among  injuries  in  which 
surgery  was  now  much  more  active  were  those  of 
the  head,  which  nearly  all  had  to  be  and  were  oper- 
ated on,  and  with  success. 

Dangers  to  Public  Health  from  Railway  Car- 
riages  Mr.  Durant  Cecil,  a  civil   engineer,  read   a 

papi-r  upon  this  subject  at  the  Congress  of  the  British 
Institute  of  Health  lately  held  at  Aberdeen.  In  the 
course  of  his  remarks  he  said  that  the  difficulties  and 
costliness  of  properly  cleansing  carriages  were  illus- 
trated a  short  time  ago  by  a  report  made  to  the  cor- 
poration of  London  by  tiie  medical  officer  of  health, 
describing  the  means  employed  to  cleanse  and  disin- 
fect a  carriage  in  which  a  person  suffering  from  small 
pox  had  travelled.  The  whole  carriage  had  to  be 
completely  dismantled.  As  to  the  shutting  up  of 
carriages  as  soon  as  they  have  been  vacated  by  pas- 
sengers, strong  and  authoritative  and  reiterated  protests 
are  needed.  There  are  wonderful  remedial  forces  in 
nature  if  only  we  would  give  them  free  scope  and 
harmonize  our  artificial  arrangements  with  their  health- 
giving,  life-renewing  action.  This  shutting  up  of  car- 
riages belongs  to  the  same  category  of  benighted  prej- 
udices as  the  drawn-down  blinds  and  closed  windows 
of  houses. 

Heredity  and  Imitation. — The  social  sciences  have 
always  been  ardently  pursued  and  brilliantly  ex- 
pounded in  France,  and  nowhere  have  the  doctrines 
of  Darwin  and  Spencer  received  a  warmer  welcome. 
Indeed,  fifteen  years  ago,  when  Oxford  lecturers  were 
riddling  Spencer  with  criticism,  he  ruled  the  Latin 
Quarter  like  a  sultan.  But  of  late  there  has  been,  as 
elsewhere,  an  effort  made  to  delimit  with  greater  ac- 
curacy the  sphere  of  hereilitary  transmission.  In  the 
field  of  strict  biology  Weissmann  has  denied  the  trans- 
mission of  acquired  quality.  In  the  field  of  sociology 
a  young  French  thinker,  M.  Tarde,  whose  singular 
union  of  philosophic  insight  and  expository  pow-er 
reminds  one  of  De  Tocqueville,  has  called  attention 
to  the  importance  of  the  social  as  distinct  from  the 
biological  factors.  M.  Tarde  does  not,  of  course,  deny 
the  influence  of  hereditary  transmission  or  the  biolog- 
ical basis  of  social  life,  but  in  the  brilliant  volume 
entitled  "  Les  Lois  d'lniitation,"  he  points  out  that 
the  biological  force  is  continually  supplemented  and 
corrected  by  the  social  force  of  imitation.  The  racial 
factor  is  not  presocial,  insoluble,  persistent,  nor  is  the 
ultimate  term  of  human  progress  a  world  divided  into 
highly  differentiated  social  groups.  On  the  contrary, 
man   is  essentially  imitative   and  goes   through   life 


520 


MEDICAL    RECORD. 


[September  29,  1900 


like  a  somnambulist,  unconsciously  registering  and 
imitating  the  desires,  the  thoughts,  and  the  actions  of 
others.  Every  day  the  world  is  becoming  more  simi- 
lar, not,  as  De  Tocqueville  thought,  because  of  democ- 
racy, but  because  a  series  of  inventions  has  increased 
the  imitativeness  and  the  "  iniitativity  "  of  man.  So- 
ciety is,  in  fact,  "the  organization  of  imitativity," 
and  perfect  and  absolute  sociality  would  consist  in  an 
urban  life  so  intense  that  a  thought  once  conceived  by 
an  individual  would  be  immediately  communicated  to 
his  fellow-citizens.  The  prospect  is  appalling,  but 
that,  of  course,  is  not  to  the  point.  The  process  of 
biological  evolution  is  slow,  the  process  of  social  evo- 
lution is  very  often  surprisingly  rapid.  How  many 
centuries  did  it  take  to  develop  the  wing  of  the  eagle.' 
How  many  months  to  modernize  Japan?  Social  prog- 
ress, then,  as  distinct  from  biological  progress  depends 
upon  the  discovery  and  diffusion  of  inventions,  some 
of  which,  sucli  as  Christianity,  are  substituted  for  old 
inventions,  while  others,  as  telegraphy,  are  added  to 
them. — London  Speaker. 

Garbage  Disposal  in  China. — Consul  Fowler  says: 
"The  cleanest  cities  in  China  are  Hang-Chow  and 
Ning-Po.  In  the  centre  of  these  two  cities  I  have  my- 
self seen  dogs  eating  bodies  of  babies;  the  rotting 
corpses  of  cholera  cases;  snakes  winding  in  and  out — 
in  fact  the  most  horrible  filth  on  one  side,  while 
across  the  way  was  the  glitter  of  gold,  pomp,  and  lux- 
ury." 

First  Aid  for  the  Wounded — The  Vincennes  an- 
nex of  the  Exposition,  notwithstanding  its  distance, 
attracts  quite  a  crowd  of  people  every  Sunday  to  wit- 
ness the  sports  and  the  international  competition  of 
physical  exercises.  One  Sunday,  a  few  weeks  ago,  the 
spectacle  offered  to  those  who  wended  their  way  toward 
the  municipal  velodrome  was  both  novel  and  pictur- 
esque. Their  programme  announced  an  international 
competition  of  aid  to  the  wounded.  The  various  soci- 
eties proceeded  in  turn  to  the  installation  of  relief 
stations,  which  the  public  were  afterward  allowed  to 
inspect,  and  which  comprised  all  the  usual  material — 
carriages,  harness,  and  various  apparatus  designed  for 
the  carriage  of  the  wounded.  Then  the  competitions 
proceeded  with  exercises  in  lifting  the  patients  and 
dressing  their  wounds.  Several  obstacles  had  been 
set  up  upon  the  lawn  of  the  velodrome,  such  as  walls, 
liedges,  and  taluses.  Here  and  there  were  seen  young 
men  seated  or  lying  flat  upon  the  ground,  the  victims 
of. an  imaginary  battle,  and  bearing  placards  that  in- 
dicated the  nature  of  their  wounds.  Then  came  the 
relief  corps  with  their  litters,  antiseptics  in  bags,  and 
bottles  and  rolls  of  linen,  wadding,  and  lint,  and  lifted 
each  wounded  person  and  bandaged  his  leg,  arm,  or 
neck  with  dexterity,  rapidity,  and  delicacy.  Then  the 
patient  was  placed  on  a  litter  in  a  proper  posture  to 
spare  the  part  affected.  Then,  more  speedily  than 
they  had  arrived  upon  the  scene,  the  litter-bearers 
carried  away  the  patient  to  the  ambulance  or  hospital. 
In  coming  as  well  as  going,  it  was  necessary  to  sur- 
mount walls,  hedges,  taluses,  and  pass  their  burden 
over  them  gently  and  without  shock. — V Illnstration. 

Weight   of   Hydrogen    Gas Lord    Rayleigh    has 

determined  the  weight  of  hydrogen  gas  dried  by 
means  of  liquid  air  acting  as  a  cooling  agent.  In  re- 
cent experiments  by  himself  and  others  phosphoric 
anhydride  has  been  the  desiccating  agent,  but  a  doubt 
remained  as  to  whether  on  the  one  hand  the  removal 
of  aqueous  vapor  was  complete,  and  on  the  other 
whether  some  new  impurity  might  not  have  been 
introduced.  The  object  was  not  so  much  to  make  a 
new  determination  of  the  highest  possible  accuracy  as 
to  test  whether  any  serious  error  could  be  involved  in 
the  use  of  phosphoric  anhydride,  such  as  might  explain 


the  departure  of  the  ratio  of  the  densities  of  oxygen 
and  hydrogen  from  16:1.  The  experiment  proved 
that  no  serious  error  could  result  in  this  way. — Pro- 
ceedings of  the  Royal  Society. 

Destruction   of   Rats  by   Means   of    Bacteria. — 

Loefilcr  has  already  advised  the  destruction  of  field 
mice  by  means  of  cultures  of  bacteria  of  bacillus 
typhi  murium  mixed  with  food,  and  the  method  has 
been  carried  out  on  a  practical  scale  with  some  suc- 
cess. Danysz  has  used  cultures  of  another  species  of 
bacillus  in  a  similar  way  for  the  destruction  of  rats 
in  the  public  sewers  in  Paris.  The  bacillus  employed 
is  one  which  Danysz  isolated  in  investigating  a  spon- 
taneous epidemic  which  occurred  in  field  mice.  V\'hen 
freshly  isolated  the  organism  was  pathogenic  to  a  cer- 
tain extent  for  gray  rats,  killing  about  two  or  three  out 
of  every  ten  animals  inoculated.  It  was  found  possi- 
ble by  artificial  means  to  increase  the  virulence  for 
rats  to  a  much  higher  degree.  The  method  employed 
for  exalting  and  fixing  the  virulence  was  as  follows: 
"A  mouse  was  first  killed  by  an  ordinary  inoculation; 
broth  cultures  from  the  mouse  were  then  enclosed  in 
collodion  capsules,  which  were  kept  in  the  peritoneal 
cavity  of  a  living  rat  for  thirty-six  hours.  At  the  end 
of  that  time  a  subculture  was  made  in  broth  and  then 
passed  through  another  mouse.  This  process  having 
been  repeated  four  or  five  times,  the  culture  was 
passed  first  through  the  more  susceptible  young  rats 
and  then  through  adult  rats.  In  the  end  a  culture 
highly  pathogenic  for  both  the  gray  rat  and  the  black 
rat  was  obtained.  Pieces  of  bread  soaked  in  broth 
cultures  of  the  bacillus  were  then  laid  down  in  the 
sewers,  and  by  this  means  a  large  number  of  rats  were 
killed.— /'///V/V  Health. 

Health  Reports. — The  following  cases  of  smallpox, 
yellow  fever,  cholera,  and  plague  have  been  reported 
to  the  surgeon-general  of  the  United  States  Marine- 
Hospital  service  during  the  week  ended  September  22, 
1900 : 

Smallpox — ITnited  States. 

Kansas,  Cherokee  Co August  ist  to  31st Reported. 

Crawford  Co August  ist  to  31st 11 

Eureka August  ist  to  31st 1 

Olathe August  ist  to  31st i 

Parsons August  ist  to  31st i 

Sumner  <"o. August  ist  to  31st   11 

Louisiana,  New  Orleans    . . .  September  Sth  to  i5lh 3 

Mictiigan,  Houghton September  Sth  to  15th 5 

Torch  Lake September  Sth  to  15th 2 

Massachusetts,  I*"all  River  .  .September  Sth  to  15th i 

Ohio,  Cincinnati September  7th  to  14th i 

Cleveland September  8th  to  15th 8 

Portsmouth September  Sth  to  15th 3 

Utah,  .Salt  Lake  City September  8th  to  islh 6 


Cases.    Deaths. 


Brazil.  Pernambuco 

Canada,  Province  of  Quebec, 
St.  Alexandre 

St.  Sebastian 

England,    Liverpool 

London 

France,  Paris 

Rouen 

India,  Bombay 

Mexico,  City  of  Mexico 

Russia,  Moscow 

St   Petersburg 

Warsaw 

Scotland,  (jiasgow 


Smallpox — Foreign. 
August  Sth  to  15th  , . . 


September  4th 3 

September  4th a 

August  24lh  to  Septeml)cr  ist...     6 
.August  24th  to  September  jst....     2 

August  24th  to  September  ist 

July  ist  to  31st 

August  14th  to  21st 

August  31st  to  September  Sth 

August  iSth  to  25th 6 

Au.gust  24th  to  September  ist....  21 

August  i8th  to  25th 

August  31st  to  September  7th 30 

Yellow  Fevek. 

Colombia.  Panama September  3d  to  loth 3 

Cuba,  Havana September  ist  to  Sth 

Sagua September  17th 2 

Mexico,  Vera  Cruz September  1st  to  Sth 

Cholera. 

India,  Bombay .'\ugust  14th  to  aist 

Karachi .\ugust  13th  to  19th 23 

Madras August  4th  to  17th 

Japan,  Osaka  and  Hiogo  . .  August  nth  to  iSth 1 

Plague. 

China, -Amoy July  38th  to  August  4th 

Hong  Kong July  aSth  to  August  4th 51 

India,  Bomliay August  14th  to  jist 65 

Scotland,  Glasgow August  31st  to  September  4th....  33*  z 

Govan September  4th x 

*  Four  under  suspicion. 


764 


100 
50 


Medical  Record 

A    IVeekly  Journal  of  Medicine  and  Surgery 


Vol.  58,  No.  14. 
Whole  No.  1561. 


New  York,  October  6,    1900. 


$5.00  Per  Annum. 
Single  Copies,  loc. 


©rigiuat  Articles. 

MEDULLARY    NARCOSIS    DURING   LABOR. 


By    S.    MARX,    M.D., 


NEW    YORK. 


In  the  preliminary  report'  on  this  subject,  I  was  ex- 
tremely conservative    in    my    remarks.      Further    and 
ever-increasing  experience  makes  me  realize  that  in 
medullary  narcosis  we  have  a   means  of  the  greatest 
importance  and  of  supreme  scientific  value,  not  alone 
for  annulling  the  pains  of  labor  but  as  a  substitute  for 
general  narcosis,  covering  an  enormous  domain  in  sur- 
gery.    It  is  of  interest  to  note  that   this  form  of  nar- 
cosis is  not  a  new  metiiod. 
As  far  back  as   1885    Dr. 
J.    Leonard     Corning,   of 
this  city,  not  alone  sug- 
gested   but    carried    to   a 
practical  termination  the 
method    about  to  be    de- 
scribL,'d.     In  a  small  book 
entitled  "  Local  Anasthe 
sia."    our     distinguished 
countryman  exjierimenteci 
on    animals,   and    in    one 
case  in  one  of  his  patients, 
furthered    suggestions 
which    absolutely  compel 
us  to   admit   him   as   the 
originator    of    the    opera- 
tion for  special   anasthe- 
sia     vvitii     cocaine.       He 
described    his    technique 
almost  as  it  is  carried  on 
by  us,  except  that   he  did 
not  consider   it  essential 
to   successful   anasthesia 
to  enter  the  subarachnoid 
space.     He  simply  intro- 
duced the  needle  between 
the  spinous  processes,  and 
sent  the  solution  in,  "al- 
lowing it  to  become  absorbed  by  the  minute  plexuses 
of  veins  and  so  carried  to  the  cord.""     In  this  we  do 
notagree;   but  more  of  this  farther  on.      In  this  classic 
work,  the  author  finishes    by  saying:    "  Whether  the 
method  will  ever  find  an  application  as  a  substitute 
for  etherization  in  genito-urinary  or  other  branches  of 
surgery,  further  experience  alone  can  show.     Be  the 
destiny  of  the  observation  wiiat  it  may,  it  has  seemed 
to  me.  on  the  whole,   worth   recording."     The  prior 
claim  to  the  operation  must  in  all  justice  and  honor  be 
given  to  Corning,  not  alone  because  of  his  suggestions, 
but  because  of  his  original  practical  experiments  in 
1S85.     A  number  of  papers  by  the   same  author  ap- 
peared thereafter  in  rapid  succession.     These  will  form 
the  basis  of  a  historical  review  to  be  published  shortly. 
I   have    used   this  method   of  anEESthesia   in   fully 
thirty  cases,  and  there  has  never  appeared  any  symp- 
tom which  would  make  me  apprehensive  of  either  im- 
'  Medical  Xews,  August  25,  Kjoo. 


mediate  or  remote  danger.  In  fact  I  never  have  had 
such  smooth  convalescences  as  since  my  experiments 
commenced.  All  the  patients  made  ideal  convales- 
cences, and  all  the  children  alive  before  delivery  were 
born  alive  and  well,  in  spite  of  the  fact  that  many  dif- 
ficult and  trying  labors  were  encountered. 

Technique. —  From  an  increased  experience,  the 
position  of  the  patient  for  an  easy,  successful  puncture 
is  the  exaggerated  inclined  one,  i.e.,  the  scorciiing 
(bicycle)  position.  When  for  any  reason  the  patient 
cannot  sit  up,  a  rigiit-  or  left-sided  jiosture  with 
arched  back,  the  head  in  an  elevated  position,  is  the 
next  best  one.  When  so  placed  there  is  a  distinct 
curve  in  the  lumbar  region  with  the  convexity  down- 
ward. This  has  a  tendency  to  increase  the  space  be- 
tween  the   individual    vertebra;,  and   the   puncture   is 

made  from  the  convex 
side.  When  the  punc- 
ture fails.  /.(•.,  inability  to 
get  spinal  fluid,  the  other 
side  may  be  tried.  It 
is  always  absolutely 
necessary  for  successful 
anaesthesia  to  enter  the 
spinal  canal;  in  other 
words,  a  sine  qua  twit  to 
an  absolute  analgesia  is 
the  escape  of  subarach- 
noid Huid  before  the  co- 
caine solution  is  injected. 
By  the  escape  of  fluid  I 
am  in  positive  position  to 
state  that  the  needle  is  in 
the  space.  There  is  no 
other  absolute  guide. 
My  primary  trials  in 
the  first  three  cases  were 
al)solute  failures,  for  this 
important  landmark  was 
unknown  to  me  and  con- 
sc(|uently  omitted.  Since 
I  have  depended  on  get- 
ting a  fluid  tap  I  have 
never  failed  to  get  a  per- 
fect anaesthesia.  As  a 
rule  the  puncture  is  very  easily  done,  but  in  some  few 
cases  there  has  been  the  greatest  difficulty  in  its  per- 
formance. In  one  case  six  distinct  punctures  were 
made  before  the  tap  revealed  fluid.  In  one  case  with 
an  antecedent  lumbar  disease  I  failed  absolutely,  and 
was  compelled  to  make  the  injection  in  the  dorsal 
region,  and  then  with  good  success.  The  operation 
was  an  abdominal  hysterectomy,  and  when  the  abdo- 
men was  opened  the  lumbar  lesion  was  readily  noted. 
The  patient's  back,  from  the  coccyx  to  the  middle 
of  the  dorsal  vertebrae,  is  rendered  absolutely  sterile 
after  the  usual  methods,  even  as  the  abdomen  is  ster- 
ilized before  abdominal  section.  The  parts  are  sur- 
rounded by  sterile  towels.  A  finely  tempered  needle, 
10  cm.  long,  is  employed  with  a  solid  metal  hypodermic 
syringe,  both  of  which  are  boiled  for  ten  minutes. 
The  patient  having  been  placed  in  position,  the  thumb 
of  the  left  hand  is  placed  on  the  spinous  process  of  the 
fifth    lumbar    vertebra.     This    point    may  readily  be 


—  I  >ark  Spot  Marks  tin-  Spine  of  Fifth  Lumbar  Vertebra. 


522 


MEDICAL    RECORD. 


[October  6,  1900 


found  by  locating  the  deep  depression  between  the 
spine  of  the  fifth  lumbar  and  first  sacral,  the  posterior 
landmark  of  the  external  conjugate;  or,  in  very  fat 
women,  a  line  drawn  joining  the  highest  points  of  the 
crista  ilii  will  pass  over  the  centre  of  the  fourth  lum- 
bar vertebra  and  is  a  reliable  guide.  The  needle  is 
inserted  immediately  in  front  of  and  just  outside  the 
edge  of  tlie  thumb  at  an  angle  of  about  165  .  The 
direction  of  the  needle  is  slightly  from  below  upward 
and  without  inward.  If  the  point  strikes  the  lamina 
it  is  to  be  moved  gently  up  or  down  until  the  space 
between  the  vertebra;  is  felt.  The  point  is  pushed  in 
very  slowly  and  gently  in  a  downward  direction  until 
the  clear,  limpid  spinal  fluid  runs  out  drop  by  drop. 
If  the  tap  brings  pure  blood  it  is,  in  my  experience, 
beyond  the  canal,  and  gradual  withdrawal  will  usually 
bring  success.  Should  clogging  of  the  needle  be  sus- 
pected, then  it  can  be  cleared  by  the  stylet.  Immediate- 
ly tluid  runs  out,  the  barrel  of  the  syringe  is  screwed 
on  and  the  cocaine   injected.     From    TTl  x.  to  xv.  of  a 


-Posiiioi:  as  Needle  is  Being  Introduced.     Note   position  of  tliuiiib 
and  its  relation  to  needle. 

two-per-cent.  cocaine  solution  is  used,  representing  be- 
tween gr.  ^  to  gr.  i  of  the  salt. 

Within  from  two  to  fifteen  minutes  anae'sthesia  is 
ushered  in,  occurring  rather  suddenly,  occasionally 
preceded  by  a  marked  hyperrtsthesia.  Operating  can 
usually  be  commenced  as  soon  as  firm  pinching  or 
pulling  upon  the  labia  minora  elicits  no  pain.  If  at 
the  end  of  fifteen  minutes  the  desired  result  is  not 
obtained,  the  injection  maybe  repeated;  or  if,  after 
complete  anaesthesia,  the  sensation  of  pain  returns,  the 
same  dose  may  be  repeated.  Thus  I  have  injected 
three-fourths  of  a  grain  in  one  hour  in  a  rebellious 
case  without  bad  results.  The  cocaine  solution  to  be 
efticacious  must  be  freshly  prepared,  or  else  it  be- 
comes inert  from  frequent  sterilization.  Kucaine  1 
have  found  valueless;  Schleicli's  infiltration  tablets  I 
have  found  of  little  value.  The  area  of  ana'Sthesia 
varies  considerably  and  cannot  be  influenced  by  either 
the  dose  given  or  tiie  force  with  which  the  solution  is 
thrown  in.  In  son\e  cases  the  w^hole  body  from  the 
neck  down  is  absolutely  in  an  analgesic  condition. 
In  all  cases  the  patient  is  void  of  sensation  from  the 
umbilicus  down. 

The  anaesthesia  lasts  from  one  to  five  hours.  Com- 
plications of  a  severe  grade  have  never  occurred.  Dis- 
agreeable features  frequently  occur;  in  fact  it  is  a  rule 
to  have   them  present,  but  fortunately  their  effect  is 


very  transient,  lasting  from  eight  to  twenty-four  hours. 
There  are  frequent  nausea,  vomiting,  severe  headache, 
profuse  perspiration,  chilly  sensations,  temperatures 
up  to  102°  to  103°  F.,  probably  all  due  to  a  shock  to 
the  central  nervous  system  or  to  a  disturbed  intra- 
spinal pressure,  whether  diminished  or  increased  I 
am  not  prepared  to  state.  F'ortunately  when  severe 
these  symptoms  can  be  readily  controlled  by  nitro- 
glycerin gr.  3,',jr  alone  or  combined  with  small  doses 
of  morphine.  I  have  tried  to  anticipate  these  symp- 
toms by  combining  morphine  with  the  cocaine,  but  the 
results  were  not  satisfactory.  In  fact  in  one  case  in 
which  gr.  -J  morphine  was  injected  into  the  canal,  I 
got  dangerous  symptoms  of  morphine  poisoning,  show- 
ing how  strong  is  the  absorbing  power  of  the  spinal 
fluid.  Lately  I  have  had  good  results  by  injecting 
hydrobromate  of  hyoscine  gr.  Tt},-„  as  soon  as  the 
symptoms  arose.  In  a  limited  experience  with  this 
drug  I  would  suggest  its  use  by  the  ordinary  hypo- 
dermic method  as  soon  as  the  cocaine  is  administered, 
or  else  its  use  immediately  on  the  occurrence  of  the 
nausea  and  vomiting,  which  are  always  the  earliest 
symptoms  to  arise  after  the  puncture. 

The  physiology  of  the  anasthesia  is  not  quite  clear. 
Most  probably  the  cocaine  solution,  thrown  directiv  in 
contact  with  the  lumbar  plexus,  deadens  its  sensibility 
or  that  of  its  important  nerve  roots  (Fig.  3).  The  greater 
area  of  analgesia  is  probably  due  to  rapid  molecular  ab- 
sorption by  the  cord  or  its  membranes.  Motor  dis- 
turbances so  far  as  the  uterus  is  concerned  have  not 
been  noted.  Uterine  contractions  go  on  regularly  as  if 
no  narcotic  had  been  used,  the  patient  feeling  no  pain  ; 
and  one  is  cognizant  of  the  contractions  only  when  the 
hand  is  placed  on  the  abdomen.  Reflex  action  of  the 
.  abdominal  muscle  was  found  only  when  incomplete 
anaesthesia  existed,  and  was  then  accounted  for  by  the 
presence  of  pain.  When  analgesia  was  complete  there 
was  no  spontaneous  bearing  down,  and  the  muscles 
were  not  voluntarily  called  into  action.  Only  on  com- 
mand did  the  patient  bear  down  and  bring  her  abdom- 
inal muscles  into  play  as  powerfully  as  in  an  ordinary 
case.  Explorations,  versions,  extractions,  placental  re- 
movals were  readily  done,  not  with  quite  as  great  ease 
as  under  chloroform,  but  with  greater  facility  than  in 
a  non-narcotized  woman.  I  never  noted  a  disposi- 
tion to  bleed,  at  least  no  greater  than  in  an  ordinary 
case.  Is  the  operation  associated  with  danger  whether 
immediate  or  remote.'  There  are  two  possible  imme- 
diate dangers:  (i)  collapse  from  cocaine,  (2)  sepsis 
fro!n  the  puncture.  I  have  used  as  much  as  gr.  ^' 
of  the  drug  within  one  hour,  and  have  never  noted  any 
untoward  symptoms.  My  average  dose  is  about  gr. 
|,  the  smallest  gr.  -J,  the  maximum  individual  dose 
gr.  },.  The  symptoms  which  follow  all  the  injections 
are  not  due  to  cocaine,  since  they  occur  after  an  injec- 
tion of  a  saline  solution.  It  is  possible  that  danger- 
ous symptoms  might  arise  in  some  cases  from  a  spe- 
cial idiocyncrasy  to  the  drug,  since  severe  symptoms 
of  poisoning  have  been  noted  after  instillation  of 
cocaine  in  the  eye  or  nose.  But  I  have  never  met 
them  after  lumbar  injection. 

(2)  Sepsis.  There  is  no  denying  the  fact  that,  in 
unclean  hands  and  with  unclean  instruments,  this  other- 
wise safe  operation  can  and  will  produce  a  severe  if 
not  fatal  sepsis.  Any  serous  cavity  invaded  carries  a 
certain  i)rofound  risk.  In  the  operation  we  penetrate 
dura  and  oia  mater,  and  invade  a  canal  freely  com- 
municating with  a  similar  space  in  the  brain,  conse- 
quently a  dangerous  territory.  Therefore  we  must  sur- 
round our  manipulation  w-ith  every  possible  known 
safeguard.  A.sepsis  of  person,  of  instruments,  of  pa- 
tient, of  solution  is  the  only  safeguard,  and  this  must 
be  as  carefully  attended  to  as  if  the  belly  were  about 
to  be  opened.  The  o]ieration  should  be  done  only 
by  one  trained    in    surgical    r.sepsis,  or    else  surely 


October  6,  1900] 


MtUlCAL    Kt-L-UKU. 


bad  results  will  occur  in  the  form  of  septic  intra- 
spinal complications.  I  have  never,  at  least  so  far, 
noted  anv  remote  conplications;  but  this  may  be  due 
to  the  fact  that  my  cases  are  too  recent,  the  latest 
being  about  two  months  old.  One  useful  point  that  my 
experience  has  taught  me,  in  order  to  further  the  abso- 
lute success  of  operating  under  spinal  ana.-sthesia,  is 
to  have  perfect  quiet  while  operating.  Sight  and 
hearing  are  unusually  acute  in  these  women.  Appre- 
hension is  ever  present,  and  a  morbid  fear  that  they 
might  suffer  pain  causes  not  actual  but  psychical  pain. 
This  I  have  demonstrated  on  more  than  one  occasion. 
To  this  end  my  audiences  are  told  to  refrain  from 
talking,  especially  in  reference  to  pain.  The  eyes  of 
the  patient  are  snugly  bound,  and  the  ears  are  thor- 
oughly plugged  with  cotton.  No  unusual  bustle  is  al- 
lowed, and  instruments  are  handled  so  as  to  insure  abso- 
lute quiet.  The  patient  is  constantly  being  reasstjred, 
and  is  interrogated  by  one  person  as  to  her  sensations. 
Indications.  — I  have  carried  a  woman  by  repeated 


Dorsal  vertcbr;t:  i 


absolutely  allay  the  dreadful  pains  of  a  normal  labor, 
with  no  danger  to  the  mother  and  none  to  the  child, 
immediate  or  remote. 

In  the  preparation  of  the  report  of  these  cases,  I  am 
deeply  indebted  to  my  very  excellent  house  staff,  Drs. 
\V.  R.  Stone,  M.  M.  fiuillen,  and  \V.  P.  Healy.  for 
their  very  efficient  assistance  in  all  my  work  upon 
this  subject.  If  it  be  remembered  that  our  work  lias 
been  almost  entirely  original,  that  references  as  to 
operative  technique  practically  unknown  to  us,  espe- 
cially with  reference  to  the  absolute  necessity  for  enter- 
ing the  spinal  canal— all  these  various  little  details  for 
furthering  the  success  of  our  inquiries,  must  make  evi- 
dent the  difficult  work  entailed  upon  all  during  the 
trying  months  of  a  hot  summer.  Again  I  must  slate 
that  without  so  proficient  and  enthusiastic  a  house 
staff,  the  material  for  this  paper  would  have  been  well- 
nigh  impossible  to  obtain. 

As  an  addendum,  since  writing  this  article,  I  feel 
that  in  the  use  of  the  hydrobromale  of  hyoscine,  about 


Plexus  lumbalis- 


Luiiibar  vencbra;  i 


Poinl  of  insertion  of  needle. ?, 


Os  sacrum. 


lleo-hypoKastricus. 
Ileo-inguinalis. 

r.enlto-cruralis. 
Cutaneus  femoris. 

/Ramus  muscularis. 

'(iluteus  superior. 

Gluteus  inferior. 

'-  Nervus  ischiadicus. 


injections  for  eight  hours  through  her  labor  with  prac- 
ticallv  no  pain.  By  improved  methods  and  further 
observations  it  may  be  possible  to  carry  a  labor 
through  from  beginning  to  end  under  this  narcosis.  In 
multipara-  we  must  be  prepared  to  inject  when  the  os  is 
three-fourths  dilated,  in  the  primipara  when  fully  di- 
lated. For  purposes  of  exploration,  either  pelvic  or 
fcetal,  there  is  a  field.  In  very  prolonged  and  pain- 
ful first-stage  labors,  when  it  is  impossible  for  the 
doctor  to  sit  for  hours  giving  whiffs  of  chloroform,  it 
would  be  ideal  to  give  a  lumbar  puncture  and  relieve 
all  pain  and  suffering  for  from  one  to  five  hours,  and 
yet  have  the  labor  go  on  and-the  os  dilate  painlessly. 
Again  a  case  might  be  imagined,  in  which  both 
ether  and  chloroform  are  contraindicated,  or  a  case 
in  which  no  assistance  can  be  had,  and  operating  is 
absolutelv  necessary.  A  simple  puncture  is  made,  an- 
aesthesia '  is  complete,  and  the  operator  can  attend 
strictly  to  his  field  of  operating.  In  cases  of  threat- 
ened or  already  present  convulsions,  in  which  a  simple 
examination  would  produce  the  spasm,  a  lumbar  nar- 
cosis, lessening  as  it  does  peripheral  nervous  sensibil- 
ity, might  be  of  avail.  Again  in  cases  of  sepsis,  such 
as  is  noted  in  one  of  the  cases  cited  below,  one  of  pro- 
found nature  in  which  both  heart  and  kidney  are  af- 
fected, making  the  administration  of  a  general  anas- 
thetic  dangerous,  exploration  and.  if  necessary,  curet- 
tage could  be  undertaken.  But  at  last,  so  far  as  we  are 
concerned,  it  is  a  method  ideally  suited  to  mitigate  or 


gr.  ^L-  given  by  the  needle,  we  have  a  drug  of  the 
greatest  utility  in  combating  to  a  positive  degree  the 
post-operative  symptoms  arising  from  the  cocaine 
puncture.  If  future  results  bear  out  past  experiences, 
we  have  in  the  hyoscine  a  veritable  specific. 

Case  I.— H.  B ,  aged  thirty-three  years,  multi- 
para, ansemic,  double  femoral  hernia.  August  ylh, 
in  labor  at  1 1  p.m.,  presentation  L.  O.  A.  August 
8th,  membranes  ruptured  3:30  p.m.,  os  fully  dilated; 
3:48  P.M.,  cocaine  injected;  3:56  p.m.,  pain  sensation 
dulled  and  detayed;  3:59  p.m.,  muscle  and  motor 
sense  not  affected;  sensory  paralysis  complete  belo^v 
the  level  of  the  umbilicus;  uterine  contractions  every 
two  minutes;  patient  has  no  painful  sensations;  4 
P.M.  child  born  spontaneously  without  the  knowledge 
of  themother;  4:22  p.m.,  placenta  born  spontaneously, 
and  after  a  lapse  of  ten  minutes  the  mother  asked  if 
afterbirth  had  come.  The  following  afternoon  the 
temperature  rose  to  100.5°  F.,  but  fell  to  normal  in 
eight  hours.  Three  hours  after  the  injection  the  pa- 
tient experienced  a  tingling  sensation  in  her  legs  and 
thighs.  During  the  next  ten  hours  a  slight  throbbing 
headache  was  felt,  whicli  disappeared  in  twenty-four 
hours  without  medication. 

Case  II.— K.  S ,  aged  thirty-five  years,  multi- 
para; previous  labors  normal  with  a  great  deal  of  pain 
during  the  second  stage;  physical  condition  poor;  pa- 
tient has  hydramnios  to  extreme  degree.  August  nth, 
2:30  P.M.,  patient  went  into  labor;  6  p.m.,  waters  broke; 


524 


MEDICAL    RECORD. 


[October  6,  1900 


cervix  present,  os  admits  four  fingers;  head  presenting 
above  but  fixed  at  brim.  August  12th,  9  a.m.,  pains 
all  night,  no  effect  on  os,  contractions  have  now  ceased. 
August  i2tli,  I  :47  P.M.,  lumbar  injection  of  gr.  J  co- 
caine; 1:52  I'.M.,  sensation  to  pain  diminished  and 
delayed;  1:56  p.m.,  absolute  sensory  paralysis  below 
the  umbilicus.  Manual  dilatation  was  begun,  and  dur- 
ing its  performance  the  patient  gave  no  evidence  of 
knowing  what  was  taking  place.  The  operation  was 
as  easily  carried  out  as  under  chloroform  narcosis. 
The  head  was  then  above  the  brim.  It  was  then  de- 
cided to  leave  the  patient  luimolested  to  see  if  labor 
would  proceed  spontaneously  without  any  complica- 
tion. She_  was  therefore  put  to  bed,  version  or  high 
forceps  being  ab^dpned  for  the  sake  of  the  experi- 
ment. In  twelve  hours  the  woman  broke  out  in  a  pro- 
fuse sweat.  Temperature,  102°  F. ;  pulse,  90;  res- 
piration, 60;  slight  headache.  In  twelve  hours  the 
conditi.gi)  returned  to  normal.  The  following  day 
labor-pains  again  appeared,  and  in  five  hours  the 
child  was  born  spontaneously;  normal,  severe  second- 
stage  labor  pains. 

C.A.SE   III. — This  proved  to  be  a  control    test.     S. 

D ,  primipara,  aged  twenty  years.     August  12th  in 

labor  at  6  a.m.  ;  in  twelve  hours  os  fully  dilated ;  gr.  J 
cocaine  injected;  no  effect  whatsoever.  In  forty  min- 
utes another  ill  x.  of  the  same  solution  was  injected 
and  still  no  effect.  As  the  patient  became  very  ner- 
vous and  hysterical  it  was  decided  to  use  chloroform 
and  deliver  by  forceps.  Later  on,  having  the  cocaine 
solution  tested  by  various  methods,  it  was  found  totally 
inert.  This  case  proved  to  be  an  excellent  control  test, 
as  did  the  case  in  which  the  saline  solution  was  used 
by  mistake.  Here  also  in  three  hours  the  patient  com- 
plained of  headache,  tingling  in  the  legs,  slight  nausea, 
and  vomiting.  In  fourteen  hours  the  temperature  rose 
to  102°  F. ;  pulse,  100;  respiration,  28.  Her  condi- 
tion returned  to  normal  in  eight  hoTirs. 

Case  IV. — M.  T ,  aged  thirty-eight  years,  mul- 
tipara; condition  excellent,  previous  labor  normal. 
August  13th,,  3  P..M.,  in  labor;  V.  L.  O.  A.,  head  in 
cavity;  3:48  p.m.,  cocaine  gr.  -J-  injected;  3:53  p.m., 
sensation  below  umbilicus  delayed  for  pain;  3:55 
p.m.,  total  sensory  paralysis  below  uinbilicus.  Pa- 
tient had  no  knowledge  of  the  uterine  contraction, 
which  occurred  normally  every  two  minutes;  4:28 
P.M.,  head  at  outlet,  and  forceps  applied  without  the 
patient  being  aware  of  the  operation;  4:32  p.m.,  pa- 
tient delivered;  the  mother  was  conscious  of  the  trac- 
tion alone;  she  wished  to  know  why  she  was  being 
pulled  to  the  bottom  of  the  bed.  At  4:40  p.m.,  peri- 
neum repaired  without  pain;  4:55  p.m.,  placenta  ex- 
pressed ;  sensation  of  mother  was  as  if  something  warm 
were  passing  through  the  vagina;  5:15  p.m.,  sensory 
paralysis  still  present;  6:45  p.m.,  sensation  restored 
to  lower  part  of  body;  7  p.m.,  patient  complained  of 
intense  throbbing  headache  referred  to  frontal  lobes; 
7:45  P.M.,  gave  injection  of  morphine  gr.  '4,  nitro- 
glycerin gr.  -j\y;  patient  felt  cold  and  was  shivering; 
8  P.M.,  vomited;  head  symptoms  less,  rise  of  tempera- 
ture to  101.5°  ^-'i  pulse,  88;  respiration,  22  ;  twelve 
hours  later  patj^nt  was  in  normal  conditi'on. 

Case   V. — L.  M ,  aged  thirty-five  years,  m^ilti- 

para,  admitted  to  surgical  ward  with  ce.Uulitis  of  leg 
and  thigh.  August  18th,  10  a.m.,  ipembranes  ruptured 
spontaneously ;  no  labor  pains.  Transferred  to  sep- 
tic ward;  V.  R.  O.  A.;  os  nearly  dilated;  prolapse 
ol  cord;  pulsation  120  per  mjnute;  no  contractions; 
11:45  a.m.,  pulsation  had  fallen  to  100;  indication 
to  deliver  child;  12  :45  p.m.,  cocaine  injection,  gr.  ,'.  ; 
12  150  P.M.,  sensation  of  pain  delayed  and  one  minute 
later  complete  sensory  paralysis;  slight  nausea  and 
vomiting;  burning  sensation  along  spinal  cord  and 
feeling  of  cold  in  feet  and  legs;  podalic  version  was 
performed  without  any  pain  to  mother,  although  she 


expressed  a  feeling  of  suffocation  when  the  hand  was 
being  introduced  into  the  uterus;  i  p.m.,  child  born  by 
extraction.  Mother  had  no  knowledge  of  its  birth.  Dur- 
ing the  version  the  uterus  contracted  firmly  around  the 
operator's  hand  so  that  manipulation  was  very  trying. 

Case  VI. — R.  M ,  aged  twenty-six  years,  primi- 
para. August  19th.  9  P.M.,  labor  began  with  rupture 
of  the  membranes,  child  presenting  foot.  August 
20th,  6  130  a.m.,  OS  fully  dilated;  pains  not  severe  nor 
frequent;  7  :2i  a.m.,  cocaine  injection,  gr.  J.  During 
the  next  thirty  minutes  the  only  change  noted  in  the 
patient's  condition  was  slight  dulling  and  painful  sen- 
sation; 7:51  A.M.,  injection  repeated;  patient  com- 
plained of  burning  in  lower  extremities;  nausea  and 
vomiting;  profuse  sweat;  8:20  a.m.,  sensation  en- 
tirely gone;  hand  introduced  without  pain,  both  feet 
brought  down;  8:26  a.m.,  child  delivered  in  usijal 
fashion  unknown  to  mother.  A  second  child  is  fouijd 
in  utero;  8:50  a.m.,  hand  introduced  into  uterus, 
macerated  fcvtus  discovered;  8:55  a.m.,  child  de- 
livered, mother  still  oblivious  of  any  pain  or  discom- 
fort. The  uterus  continued  to  contract  regularly  and 
strongly  up  to  birth  of  first  child;  9:15  a.m.,  neither 
placenta  having  come  away,  the  Credc  method  was  un- 
successfully tried;  9:35  a.m.,  attempts  were  made  in 
succession  by  the  entire  house  staff  to  remove  the  pla- 
centae manually,  but  because  of  the  pathological  ad- 
herence and  the  spastic  contraction  of  the  uterus  it 
was  found  impossible  to  remove  them.  During  all 
this  manipulation  the  patient  did  not  copiplain  of 
pain  or  discomfort.  Chloroform  was  now*  adminis- 
tered to  the  surgical  degree.  Dr.  Stone  then  made  the 
attempt,  but  it  was  still  found  impossible  to  remove  the 
placentae,  as  the  same  conditions  obtained  as  during 
the  cocaine  analegesia,  i.e.,  placental  adhesion  and  a 
spastic  uterus.  The  uterus  was  accordingly  packed 
with  gauze,  and  the  patient  put  to  bed.  At  2  p.m.  I 
made  the  attempt  to  remove  the  placenta  under  local 
cocaine  narcosis,  gr.  -J^;  2:08  p..m.,  sensation  delayed 
and  dulled;  the  hand  was  introduced  and  the  placenta 
peeled  off.  The  uterine  contractions  were  not  so 
strong  as  normal,  nor  did  they  materially  interfere 
with  the  manipulation;  3:30  p.m.,  nausea  and  vomit- 
ing; sensation  to  pin-prick,  dull ;  anesthesia  continues; 
5  P.M.,  temperature,  100.8°  F. ;  pulse,  90;  same  head- 
ache, but  not  severe;  no  medication  was  employed, 
and  the  condition  became  in  every  respect  normal  in 
twenty-four  hours.  This  patient  received  half  a  grain 
of  cocaine  in  less  than  seven  hours. 

Case  VII. —  A.  M ,  aged  twenty  years;  primi- 
para; general  condition  excellent;  full  term,  went 
into  labor  August  29th,  10  a.m.;  pains  strong  and 
occuring  every  half-hour.  At  8:30  p.m.,  patient  was 
brought  to  the  delivery  room;  pains  strong  and  occur- 
ring every  three  minutes;  cervix  four  fingers  dilated; 
9  P.M.,  pulse  good  and  strong;  9:07  p.m.,  cocaine  gr. 
}  injected  into  the  spinal  canal  between  third  and 
fourth  lumbar  vertebra;;  6:09  p.m.,  complains  of  ter- 
rific cramps  in  legs  and  all  through  her;  9:11 
P.M.,  nausea  and  vomiting;  9:16  p.m..  sensation  to 
pin-prick  gone;  9:20  p.m.,  pain  during  uterine  con- 
traction is  absent;  9:40  p.m.,  foetal  heart  130  per 
minute,  clear  and  strong;  mother's  pulse,  80;  10:40 
P.M.,  pain  sensations  still  absent;  pulse,  100;  10:50 
P.M.,  patient  seems  to  feel  uterine  contractions  and 
bears  down  with  them;  11  p.m.,  sensibility  to  pin-prick 
returning  in  legs;  11  :io  p.m.,  patient  is  again  having 
labor  pains;  uterine  contractions  for  the  last  one  and 
one-half  hours  have  occurred  every  two  minutes  un- 
known to  the  patient;  11:24  P.M.,  cocaine  gr.  j  in- 
jected into  spinal  canal;  11:30  p.m.,  cumplains  of 
cramps  in  her  legs  and  coldness  of  the  lower  half  of 
her  body;  she  is  nauseated;  pain  from  pin-prick  gone 
below  the  umbilicus;  11  :32  p.m.,  patient  is  vomiting; 
II  :4o    I'.M.,  Magendie  solution  given  hypodermically 


October  6,  1900] 


MEDICAL    RECORD. 


525 


to  quiet  the  vomiting;  11  145  p.m.,  sensibility  to  labor 
pains  gone;  12:01  a.m.,  cramps  in  legs  severe,  have 
been  present  since  11  124  to  more  or  less  marked  de- 
gree; 12:12  A.M.,  complains  of  pain  over  thesympiiy- 
sis  pubis;  pulse,  114;  12  :25  a.m.,  complains  of  heatl- 
ache  and  great  thirst;  12:48  a.m.,  perception  of  pin- 
prick as  pain  still  absent;  :2  :si  a.m.,  labor  pains  are 
returning;  pin-pricks  not  noticed  ;  12  :56  a.m.,  chloro- 
form administered  and  forceps  applied;  i:ii  p.m., 
child  was  born.  The  third  puncture  was  not  per- 
formed in  this  case,  as  the  patient  refused  to  permit 
it,  saying  that  she  did  not  care  to  vomit  again;  2:50 
a.m.,  patient  has  headache;  postpartum  temperature. 
gg-S'-"  [•'. ;  pulse,  120;  respiration,  30;  5  p.m.,  temper- 
ature, 100.4°  F-  August  31st,  5:10  A.M.,  temperature. 
98.6°  F. 

Case  VIII. — M.  L ,  aged  seventeen;  primipara; 

piiysical  condition  excellent,  previous  history  nega- 
tive; somewhat  neurotic;  went  into  labor  September 
6th,  8  A..M.;  uterine  pains  slight,  occurring  every  half- 
hour.  Examination  at  12  noon  showed  cervix  conical 
and  hard,  admitting  one  finger.  Patient  had  pains 
all  the  afternoon  and  night.  At  10  a.m.,  September 
7th,  on  examination,  the  cervix  is  thinned  out  and  ad- 
mits three  and  a  half  fingers;  membranes  intact  and 
protruding.  Position  R.  O.  A. ;  presentation  vertex  ; 
11:47  A.M.,  cervix  four  fingers  dilated;  cocaine  gr.  \, 
morphine  gr.  ,1  injected  into  spinal  canal  at  the  third 
lumbar  interspace;  11:53  A..\i.,  uterine  contractions 
not  so  painful;  11  :57  A.M.,  patient  complains  of  burn- 
ing sensations  in  legs  and  feet;  sensation  of  pain 
abolished  as  high  as  the  umbilicus;  12  noon,  uterine 
contractions  strong,  but  patient  is  unaware  of  this  oc- 
currence; 12:15  P.M.,  feels  nauseated  and  vomits; 
12:20  P.M.,  vomiting  continues;  12:50  p.m.,  patient 
again  vomits;  i  p.m.,  complains  of  burning  in  feet 
and  legs;  is  unconscious  of  uterine  contractions;  1:20 
p.m.,  is  in  a  profuse  perspiration;  1:40  p.m.,  cervix 
thin,  dilated  five  fingers;  "bag  of  waters''  bulging; 
head  well  down  but  not  fixed;  2  p..m.,  patient  says  she 
cannot  see,  feels  as  if  she  had  been  in  a  sound  sleep 
and  is  just  awakening;  2:20  p.nf.,  pulse,  96;  2:36 
p.m.,  pulse,  120;  2:46  p.m.,  cocaine  gr.  ,V  injected; 
2:50  P.M.,  membranes  rupture;  2:53  p.m.,  pulse,  120; 
2:56  P.M.,  ordinary  forceps  applied  without  mother's 
knowledge;  2:58  p.m.,  axis-traction  applied;  3  p.m., 
forceps  removed  after  rotation  had  been  made,  the 
mother  feeling  only  the  traction;  3:05  p.m.,  low  for- 
ceps reapplied,  no  pains  with  the  tractions;  pulse, 
124;  3:10  P.M.,  child  born;  pulse,  120;  3:12  p.m., 
placenta  removed  manually,  without  pain  to  mother; 
3  :i5-3  :2o  p. Nr.,  perineum  repaired  without  pain;  4:10 
p.m.,  patient  carried  to  ward.  Temperature,  100.6'  F'. ; 
pulse,  106;  respiration,  14.  The  patient  was  drowsy 
and  showed  contracted  pupils;  atropine  gr.  y,',,,  given; 
7  P.M.,  complains  of  headache;  strychnine  sulphate 
gr.  3',,-  and  atropine  gr.  ^l_  given,  also  saline  enema. 
Temperature,  102.2°  F. ;  pulse,  100;  respiration,  lo; 
12  midnight,  atropine  gr.  ^J^  given;  respiration,  9. 
September  8th.  i  a.m.,  temperature,  101.6°  F. ;  pulse, 
112;  respiration,  14.  The  patient  is  still  drowsy;  5 
A.M.,  temperature,  99.8°  F.,  and  then  fell  to  normal, 
as  did  the  pulse  and  respiration,  where  they  remained 
after  the  iodoform  gauze  was  removed  at  the  end  of 
twenty-four  hours. 

Case  IX. — Y.  L ,  aged  twenty  years;  physical 

condition  excellent ;  in  her  seventh  month  of  gestation  ; 
foetus  has  been  dead  a  week.  At  11  p.m.,  August 
27th,  went  into  labor;  pains  irregular  and  infrequent. 
August  28th,  I  P.M.,  patient  was  brought  to  delivery 
room  ;  OS  three  and  a  half  fingers  dilated,  cervix  thinned 
out,  and  having  pains  every  two  minutes;  2:11  p.m., 
cocaine  gr.  ,'.  was  injected  into  spinal  canal;  2:16 
p.m.,  nausea  and  vomiting;  2:20  p.m.,  sensation  of 
pain     abolished     below    umbilicus;     cervix    dilating 


rhythmically  and  to  a  degree  of  four  and  a  half  fingers; 
diagnosis  of  macerated  foetus  made;  2  :25  p.m.,  cervix 
manually  dilated,  hand  introduced  into  uterus;  2:30 
P..M.,  macerated  fatus  delivered;  2:56  p.m.,  placenta 
expelled  with  difficulty  by  modified  Credc  method;  3 
P..M.,  the  patient  taken  10  ward  and  complains  of  slight 
dull  pain  in  right  leg.  Temperature,  99.6°  ¥.:  pulse, 
84;  respiration,  26;  5:50  p.m.,  complains  of  thirst; 
6:05  P.M.,  temperature,  102.6°  F". ;  pulse,  92  ;  respira- 
tion, 26;  9  P..M.,  temperature,  102^  F. ;  pulse,  84;  res- 
piration, 26.  Complains  of  severe  headache;  11:20 
P..M.,  still  complains  of  headache;  1  a.m.,  August 
29th,  headache  gone;  temperature,  101°  F. ;  pulse, 
So;  respiration,  24;  8  a.m.,  temperature,  99°  F. ; 
pulse,  74;  respiration,  24.  U'ith  the  exception  of  a 
rise  of  the  temperature  to  100.6'  F.  at  5  p.m.  the 
same  afternoon,  there  was  no  further  point  of  interest 
during  the  puerperium. 

Case  X.  — M.  L ,  aged  twenty-eight;    Russian; 

primipara;  physical  condition  excellent.  The  pa- 
tient went  into  labor  1 1 :30  a.m.  September  3d,  pains 
strong  every  fifteen  to  twenty  minutes.  Cervix  soft, 
thin.  Position,  vertex  R.  O.  P.;  6  p.m.,  cervix  fully 
dilated;  6:08  P..M.,  cocaine  gr.  /.  given  by  lumbar 
puncture  with  morphine  sulphate  gr.  J^ ;  6:11  p.m., 
has  lost  all  pain  sensibility  below  umbilicus.  Uter- 
ine contractions  continued  normally,  but  painlessly; 
6:23  p.m.,  child  born  spontaneously  without  pain  to 
mother;  6:35  p..m.,  perineal  tear  (first  degree)  sutured, 
and  6:40  P.M.,  placenta  expressed  by  modified  Crede; 
7  :30  P.M.,  the  patient  is  carried  to  ward,  complains 
of  heavy  feeling  in  the  head.  Post-partum  temper- 
ature, 100.2°  F. :  pulse,  116;  respiration,  30;  9:30 
P.M.,  complains  of  headache  and  vomited;  ice  cap  to 
head  for  headache.  September  4th,  i  a. .m.,  temperature, 
102  F. ;  pulse,  146;  respiration,  48 ;  4  a.m.,  headache 
ceased;  i  p..m.,  temperature,  100°  F. ;  pulse,  102;  res- 
piration, 24.  September  5th,  i  a.m.,  temperature, 98.4'"' 
F. ;  pulse,  102;  respiration,  24.  Temperature  has  re- 
mained normal  ever  since  this  time.  The  remainder 
of  convalescence  was  uneventful.  The  patient  was  dis- 
charged on  the  sixteenth  day  of  her  puerperium. 

Case  XI. —  A.  E ,  aged  thirty-eight;  primipara; 

physical  condition  excellent;  the  patient  at  full  term. 
■September  iith,  7  a.m.,  went  ipto  labor.;  pains  were 
hard,  but  had  little  .effect  upoh  the  cervix.  The 
patient  was  brought  to  the  delivery  room  at  11:15 
P.M.,  September  12th,  cervix  gone  and  four  and  a  half 
fingers  dilated.  Septembej  13th,  12:39  a.m.,  cocaine 
gr.  jr  injected;  12:43  a..m.,  sensation  delayed  and 
diminished';  12:48  a.m.,  nausea  and  vomiting;  sensa- 
tion abolished;  12  :53  A.. M.,  profuse  perspiration  ;  1:15 
P.M.,  sensation  returned  for  uterine  contraction ;  1:30 
P.M.,  membranes  were  ruptured  artificially,  the  patient 
unconscious  of  the  procedure;  2:37  p..m.,  cocaine  gr. 
,'.  injected;  2:45  p.m.,  nausea  and  vomiting;  2:50 
p.m.,  forceps  applied;  traction  at  regular  intervals 
painless;  3:05  p.m.,  first  child  born,  vertex,  three  and 
seven-sixteenths  pounds;  3:15  p.m.,  second  child  born, 
breech,  two  and  eleven-sixteenths  pounds;  3:25  p.m., 
placenta  born;  3:50  P. .m.,  sensation  seems  to  be  nor- 
mal; 4:25  P..M..  returned  to  ward.  Post-partum 
temperature,  98"  F. ;  pulse,  72;  respiration,  24.  The 
patient  complains  of  headache;  glonoin  gr.  -,'„  given; 
I  A..M.,  temperature,  100.6"^  F. ;  pulse,  84;  respiration, 
22.  For  twelve  hours  temperature  remained  about 
100°  F.,  and  then  fell  to  normal,  where  it  has  re- 
mained. In  this  case  the  headache  was  very  pro- 
nounced, so  that  in  all  the  patient  received  gr.  y|J,j^  of 
glonoin  to  stop  the  headache  within  twenty-four  hours. 

Case  XII. — M.  Y ,  aged  twenty;  colored;  cu- 
rettage; admitted  from  another  hospital  to  maternity 
five  days  after  delivery.  Temperature,  104^  F. ;  foul, 
stinking  uterine  discharge.  September  15th,  5  p.m., 
cocaine  gr.  J  injected;   5:10  p..m.,  sensation  partially 


526 


MEDICAL    RECORD. 


[October  6,  1900 


abolished;  5:15  p.m.,  feels  the  tenaculum  forceps  on 
the  cervix;  5:33  p.m.,  cocaine  gr.  jr  injected;  5:38 
P.M.,  sensation  abolished;  hand  introduced  and  pin- 
cental  particles  located;  ^.48  P.M.,  curettage  finished. 
Patient  says  she  felt  no  pain  or  discomfort,  nor  was 
there  any  evidence  that  she  did. 

C.\si;XIII. — M.  P ,  aged  twenty-eight;  Illpara; 

physical  condition  e.xcellent;  full  term;  went  into  la- 
bor at  II  A.M.,  September  i8th;  1 1  :45  .x.m.,  brought  to 
delivery  room;  cervix  thinned  out,  and  four  lingers 
dilated;  12:25  p.m.,  cocaine  gr.  [  injected;  12:30 
P.M.,  painful  sensation  abolished,  complains  of  cold- 
ness of  feet;  12:40  P.M.,  child  born;  mother  heard  it 
cry  and  exclaimed,  "  Thank  God,  and  no  pain  "  ;  12  -.^o 
P..M.,  placenta  born  spontaneously  without  mother's 
knowledge;  i  :3o  p.m.,  patient  carried  to  ward.  Post- 
partum temperature,  99.2°  F. ;  5  p.m.,  temperature, 
102.6°  F.;  pulse,  90;  respiration,  24;  9  a.m.  next  morn- 
ing, September  19th,  normal;  rest  of  convalescence 
normal — no  headache,  vomiting,  or  sweating. 

Case  XIV. — L.  R ,  aged  thirty-two;  multipara; 

physical  condition  fair;  five  previous  labors;  fourth 
child  delivered  with  instruments:  went  into  labor 
12:10  a.m.,  September  12th,  position  V.  R.  j\[.  P.; 
membranes  ruptured  3  a.m.,  September  12th;  patient 
brought  to  delivery  room  at  7:30  a.m.;  cervix  fully 
dilated;  8:30  A.M.,  cocaine  gr.  ^  injected;  8:36  a.m., 
patient  nauseated  and  vomiting;  8:38  a..m.,  sensation 
to  pain  abolished  below  nipples;  9:34  am.,  still  feels 
uterine  contractions,  but  does  not  notice  pin-prick; 
9:30  A.M.,  pains  have  returned;  10:35  profuse  perspi- 
ration for  about  one-half  hour;  10  :40  a.m.,  head  shoved 
back  above  brim  of  pelvis  and  rotated  into  L.  M.  A. ; 
1 1  A.M.,  child  spontaneously  born  without  pain  to  moth- 
er; 1 1  :20  A.M.,  placenta  expressed  by  modified  Crede 
metliod;  11:30  A.M.,  patient  carried  to  ward.  Post- 
partum temperature,  99.4°  F. ;  pulse,  74;  respiration, 
2S;  12:05  P--^i-i  patient  vomited;  i  p.m.,  temperature, 
100'  F. ;  pulse,  103;  respiration,  16;  complains  of 
pain  in  back  and  head;  9  p.m.,  temperature,  100.2" 
F. ;  pulse,  80;  respiration,  18;  severe  headache, 
(ilonoin  gr.  -J^f  given  and  headache  ceased  after  an 
hour.  September  13th,  9  a.m.,  temperature,  98.4"  F. ; 
pulse,  72;  respiration,  18.  Temperature  has  been 
normal  up  to  time  of  discharge  from  hospital. 

Case  XV.— M.  H ,  aged  twenty.  First  full- 
term  child;  had  a  miscarriage  at  four  months,  eigh- 
teen months  before;  physical  condition  good;  highly 
neurotic.  September  nth,  7  a.m.,  went  into  labor; 
pains  fair;  cervix  admits  tip  of  finger;  vertex  L.  O. 
A.  September  12th,  10:45  a.m.,  the  patient  was 
brought  to  delivery  room;  cervix  three  and  a  half  fin- 
gers dilated  and  thinning  out;  head  partly  engaged; 
11:30  a.m.,  September  12th,  cocaine  gr.  L,  morphine 
gr.  vj'ij-  were  injected  into  spinal  canal;  11:37  a.m., 
sensation  to  pin-prick  gone;  muscles  tonically  con- 
tracting. Uterine  pains  still  felt;  11:45  a.m.,  total 
abolition  of  pain  sensation  below  nipples;  uterine 
contraction  not  felt;  12:04  P•^'•l  marked  tonic  con- 
tractions of  leg  muscles;  12  :34  P.M.,  profuse  perspira- 
tion. Says  that  for  the  last  ten  minutes  things  have 
looked  red  before  her  eyes;  1:12  p.m.,  pain  to  pin- 
prick felt,  but  uterine  contractions  give  none;  1:40 
and  I  :50  p.m.,  patient  vomited;  2  p.m.,  feels  the  con- 
tractions of  uterus;  2:28  p.m.,  cocaine  gr.  J  injected 
with  no  further  result;  2:49  p.m.,  cocaine  gr.  ^,  re- 
peated; 3:02  P.M.,  forceps  applied  and  patient  com- 
plains severely  of  the  tractions  alone,  but  has  no  pain  ; 
3:13  P.M.,  child  born  ;  no  pain.  There  was  some  doubt 
in  the  minds  of  the  gentlemen  present  whether  the  nar- 
cosis was  successful,  as  the  patient  yelled  at  the  top  of 
her  voice  when  the  necessarily  powerful  tractions  were 
made.  To  my  mind,  the  patient,  seeing  all  the  mani- 
pulations as  they  were  done,  was  simply  fearful  of  our 
giving  her  pain,  and  aTiticipating    this    pain   simply 


gave  vent  to  her  feeling,  for  fear  of  realizing  what 
never  was  felt  by  her.  To  prove  that  she  really  did 
not  sulTer,  the  forceps  was  removed:  a  natural  pain 
occurred  of  which  she  was  absolutely  unconsious,  and 
on  command  she  began  to  bear  down,  so  that  tiie  head 
was  forced  well  down  into  view  of  those  around  her. 
Again,  when  thi  perineum  was  absolutely  distended, 
the  house  surgeon  held  the  head  fixed  at  this  point  for 
fully  two  minutes,  and  yet  when  under  other  normal 
condition  the  acme  of  suffering  is  reached,  this  pa- 
tient lay  perfectly  quiet,  absolutely  free  from  all  pain 
or  discomfort.  After  the  labor,  when  the  patient's 
mind  was  clear,  and  her  nervous  condition  quieted, 
she  admitted  total  absence  of  pain.  3  :i8  p.m.,  placen- 
ta removed  manually;  3:35  p.m.,  the  patient  returned 
toward.  Post-partum  temperature,  100.6^  F. ;  pulse, 
100;  respiration,  32;  7:30  p.m.,  profuse  perspiration 
and  severe  headache;  10  p.m.,  glonoin  gr.  yi,,  was 
given.  The  temperature  stayed  about  100°  F.  until 
5  P.M.,  next  day,  when  it  dropped  to  normal  and  re- 
mained there. 

Case  XVI. — L.  S ,  aged  thirty-one;  multipara; 

previous  labor  normal ;  has  mitral  regurgitant  mur- 
mur. Presentation  vertex,  position  R.  O.  A.  The 
patient  went  into  labor  August  25th,  at  4  a.m.:  pains 
poor;  cervix  admits  tip  of  one  finger.  At  i  p.m.,  pa- 
tient was  brought  to  delivery  room,  four  fingers  dilated 
and  cervix  tliinned  out  completely;  1  -.^^  p.m.,  cocaine 
gr.  1^  injected  into  spinal  canal;  i  :34  p.m.,  pulse,  go; 
1:35  p.m.,  sensation  to  pin-prick  and  pinching  below 
umbilicus  gone;  1:43  p.m.,  patient  vomited;  1:45 
P.M.,  pulse,  iiS;  1:46  P.M.,  version,  and  baby  delivered 
without  pain  to  mother ;  i  :46  p.m.,  pulse.  92.  Placen- 
ta removed  manually  without  pain  to  mother;  1:51 
P.M.,  slight  nausea  and  vomiting.  Pulse,  94;  1:54 
P.M.,  patient  is  beginning  to  perspire:  Pupils  moder- 
ately dilated  and  react  well  to  light  and  on  accommo- 
dation; 1:57  P.M.,  marked  perspiration;  pulse,  88; 
2:10  P.M.,  suture  of  cervix  gives  no  pain  to  patient; 
2:35  P.M.,  vomited;  2:40  p.m.,  patient  taken  to 
ward;  no  pain.  Post-partum  temperature,  98.6  F., 
pulse,  66;  respiration,  18.  August  25th,  1:30  a.m., 
temperature,  100.4' F. ;  pulse,  80;  respiration,  22  ;  she 
has  had  headache;  glonoin  gr.  -f\-  slopped  it;  9  a.m., 
temperature  99.2     F.,  and  remained  normal. 

Case  XVII. —  B.  E ,  aged  twenty-nine;  physical 

condition  poor  at  term.  August  22d,  at  7  p..m.,  patient 
went  into  labor ;  pains  strong  and  occurring  every  half- 
hour.  Presentation  vertex;  position,  L.  O.  A.  At  11 
A.M.,  August  23d,  patient  w'as  brought  to  delivery 
room:  cervix  gone,  and  four  fingers  dilated;  pains 
strong  every  two  minutes;  11:30  a.m.,  eucaine  gr. 
Jj  injected;  11:35  a.m.,  patient  vomited;  11:45  a.m., 
no  anaesthesia  obtained;  12:45  ''•^'•i  eucaine  gr. 
i^  injected;  12:50  p.m.,  the  patient  vomited  and 
complained  of  cramps  in  lower  extremities;  i  p  m., 
ana;sthesia  below  umbilicus;  uterine  contractions  not 
felt;  1:15  P.M.,  sensation  is  reluming  for  pin-prick, 
and  there  is  slight  knowledge  of  uterine  contractions; 
1:25  P. .M.,  pains  are  severe;  i  :35  p.m.,  child  born,  and 
during  the  last  uterine  contractions  the  pain  was  nor- 
mal; 2:15  P.M.,  the  patient  in  ward.  Post-partum 
temperature,  98°  F.  ;  pulse,  60;  respiration,  28;  3 
P.M.,  complains  of  headache  and  thirst;  5  p.  m  .  tem- 
perature, 101'  F.  ;  pulse,  80;  respiralio"n,  20.  The 
patient  is  in  profuse  sweat:  iieadache  severe,  heavy 
feeling  in  legs;  10:20  p.m.,  glonoin  gr.  ^^-(i-,  "lO'P'^'"^ 
sulphate  gr.  ]  given  hypodermically ;  i  :45  a..m.,  August 
24th,  glonoin  gr.  jjjj  given  by  mouth;  5  a.m.,  tem- 
perature, 99.4°  F.  ;  pulse,  78;  respiration,  24.  No 
headache  after  this;  temperature  remained  normal, 
and  rest  of  convalescence  was  normal. 

Case  XVIII.  — K.  G ,  aged  twenty-one:   primi- 

para;  physical  condition  excellent.  The  patient  went 
into  labor  September  13th,  at  11  p.m..  pains  good  and 


October  6,  1900] 


MEDICAL    RECORD. 


527 


strong,  and  occurring  every  twenty  minutes;  patient 
was  brought  to  delivery  room  at  9:30  a.m.,  Septem- 
ber 14th.  cervix  gone  and  four  fingers  dilated;  10:14 
A  >.r.,  cocaine^  gr.  \  injected;  10:18  a..m.,  sensation 
to  pin-prick  gone  in  perineum  and  lower  extremities: 
10:19  A.  M. ,  no  longer  perceived  uterine  contractions; 
1020  A.M.,  the  patient  is  quiet  and  no  longer  com- 
plains of  pain;  11  a.m.,  child  born,  no  painful 
sensations;  11  :o5  a.m.,  perineum  sutured,  no  discom- 
fort to  mother;  11:15  A.M.,  placenta  delivered  without 
pain  to  mother  by  modified  Crede ;  1 1  -.^o  a.m.,  the  pa- 
tient returned  to  the  ward.  Post-partum  temperature 
97  8'  F. ;  pulse,  60;  respiration.  22.  The  patient 
seems  slightly  e.xhausted;  2:15  P..M.,  complains  of 
headache,  which  became  severe  at  3:20  p.m.;  4:45 
p.  M. .  glonoin  gr.  |,',y,with  relief;  5  p.  .m.,  temperature, 
101.4  F.  ;  pulse, gh;  respiration,  26;  i  a  .M,  Se|)tem- 
ber  isth,  temperature.  99.4"  F.  ;  pulse,  84;  respira- 
tion, 22.  Since  then  there  have  been  no  rise  of 
temperature  and  no  further  headache. 

Case  XIX. — M,  B— — ,  aged  twenty;  primipara: 
physical  condition  poor.  Patient  went  into  labor  at 
midnight  of  September  15th;  the  uterine  contractions 
were  poor  and  irregular.  Presentation,  vertex ;  posi- 
tion, R.  O.  A.  September  16th,  8  a.m.,  the  patient 
is  having  labor  pains  every  three  minutes,  but  not  very 
severe;  pain  in  back  moderate;  position,  V.  R.  O.  A.  ; 
8:14  A.M.,  cocaine  gr.  {  per  spinal  canal  adminis- 
tered. .\t  this  time  pains  were  quite  severe;  8:20 
A.M  ,  pain  sensation  in  tiie  right  side  gone,  slightly 
dulled  in  left  leg  and  thigh;  8:23  a.m.,  analgesia 
complete  below  nipples;  8:32  a.m.,  patient  pale  and 
nauseated;  8:35  a.m.,  is  shivering  but  says  she  is  not 
cold.  Temperature,  98.2  F. ;  pulse,  124;  respira- 
tion, 20;  8:50  A.M.,  the  patient  is  still  shaking:  abil- 
ity to  distinguish  between  heat  and  cold  absent  in 
lower  extremities;  this  is  not  so  on  the  abdomen,  arms, 
or  face;  9  :io  a.m.,  uterine  contractions  not  felt;  9:11 
am.,  membranes  rupture  spontaneously;  the  patient 
thought  she  was  micturating;  0:30  a.m.,  has  con- 
sciousness of  uterine  contractions;  9:56  a.m.,  cocaine 
gr.  /.injected;  10.05  a.m.,  pain  abolished  ;  10:20  a. .\r., 
forceps  is  applied;  10:29  a.m.,  episiotomy;  10:30 
a  m.,  child  born,  no  pain;  10:37  a.m.,  placenta  born 
by  expression;  10:45  a.m.,  perineorrhaphy;  5  p. .m., 
Sei)tember  i6th,  temperature  was  10 1.2  F.  ;  pulse,  88; 
respiration,  20.  September  17th,  5  a.m.,  temperature 
normal:  pulse,  88;  respiration,  22.  Rest  of  conva- 
lescence was  uneventful. 

Case    XX — L.    S ,   negress,   aged    twenty-six; 

primipara;  physical  condition  excellent ;  at  full  term. 
.U  10:30  P.M.,  August  27th,  the  patient  went  into 
labor.  Presentation  vertex;  position,  L.  O.  A. 
Pains  infrequent  and  poor;  before  the  injection  of 
the  cocaine  the  patient  was  crawling  over  the  Hoor 
and  shrieking  with  pain.  August  28th,  at  6:54  a..m., 
cocaine  gr.  i  w-as  injected;  6:59  a.m,  sensation  to 
pain  diminished  in  feet,  legs,  and  thighs;  7:04  A.M., 
nausea  and  vomiting;  7  :i2  a.m.,  membranes  ruptured 
artiticially ;  7:18  a.  m.,  the  patient  in  profuse  perspira- 
tion ;  uterine  contractions  still  keeping  up  rhytiimi- 
cally ;  8:16  a.m.,  the  uterine  contractions  are  more  fre- 
quent, and  during  them  the  patient  is  told  to  l)t.ar 
down,  and  in  so  doing  experiences  no  discomfort ;  9 
a.m.,  low  forceps  was  attempted,  but  the  pains  have 
returned,  and  so  operations  were  suspended,  and  9:16 
A.M.  cocaine  gr.  ,1  injected;  9:24  a.m.,  pains  have 
•;one  and  forceps  is  now  applied;  9:30  a.m.,  child 
born  without  knowledge  of  the  mother;  9:33  a.m., 
placenta  born  spontaneously  and  no  pain;  10:20  a.m., 
patient  returned  to  ward.  Post-partuin  temperature, 
gS^  F.  ;  pulse.  90;  respiration,  20;  2:10  P.^t.,  patient 
complains  of  headache;  ice  bag  gives  relief;  5  p  m., 
temperature.  100.6°  F.  ;  pulse,  104;  respiration,  20  :  9 
p. .M.,  temperature,  100.2'  F. ;   pulse,  100;  respiration. 


24;  she  complains  of  headache.  August  2Sth,  9  a.m., 
temperature,  98.2°  F.  ;  pulse,  92;  respiration,  20;  no 
headache.     Rest  of  convalescence  was  normal. 

Case  XXI.  — M.  W ,  aged  twenty-ihree  ;  primi- 
para; physical  condition  good;  came  to  delivery  room 
at  2  A. -M.,  September  21st,  cervix  three  fingers  dilated 
and  thinned  out.  At  2:21  a..m.,  cocaine  gr.  J  in- 
jected; 2:24  A.M.,  the  patient  vomited;  2:25  a.m., 
does  not  feel  pin-prick  below  the  nipples,  nor  is  she 
aware  of  the  uterine  contractions;  2:40  a.m.,  the  pa- 
tient complains  of  great  heat  and  is  perspiring;  2:^0 
a.m.,  an  enema  was  given  with  no  discomfort  to  the 
patient;  3:20  a.  M..  uterine  contractions  begin  to  give 
pain;  4:07  A.M.,  cocaine  gr.  ,'.  injected;  4:16  a.m., 
absolute  analgesia:  the  patient  is  vomiting  at  4:36 
A..M.  ;  5:30  A.. M.,  child  is  born,  some  slight  pain:  5:10 
A.M.,  perineum  sutured;  5  :24  a..m.,  placenta  delivered 
with  slight  pain;  6:14  A.M.,  the  patient  is  carried  to 
ward.  Post-partum  temperature,  99'  F.  ;  pulse,  80; 
respiration,  36;  7  a.m.,  vomited;  9  a.m.,  tempera- 
ture, :oo.6°  F.  ;  pulse,  68;  respiration,  36;  9  p.Nr., 
temperature,  99.4  F.  ;  pulse,  80;  respiration,  26. 
September  22d,  temperature,  98.4^  F.  ;  pulse,  80; 
respiration,  20.  N.  B. :  This  patient  never  had  the 
slightest  headache,  and  has  been  perfectly  comfortable 
during  her  convalescence. 

Case  XXII.  —  R.  B ,  aged  twenty-two;  primi- 
para; is  in  secondary  stage  of  syphilis.  The  patient 
is  in  the  ninth  lunar  month  and  has  not  felt  child 
move  for  the  last  week;  fcetal  heart  not  heard.  The 
patient  went  into  labor  at  8  a..m.,  September  2 2d, 
pains  poor  and  infrequent;  at  11  :3o  p.m.,  patient  was 
brought  to  delivery  room  with  very  hard  pains;  cer- 
vix three-fourths  dilated  and  thinned  out  almost  com- 
pletely; i2;i8  A.M.,  September  23d,  cocaine  gr.  J 
injected;  12:22  A..M.,the  patient  still  feels  the  con- 
tractions but  to  a  lessened  degree;  12:24  a.m.,  uterine 
contractions  still  less  felt;  12  :45  a.m.,  slight  pain  above 
symphysis  pubis  during  contractions;  12  :47  a.m.,  sen- 
sation to  pain  below  nipjjles  absent;  i  :i5  p.m.,  the 
patient  is  beginning  to  have  severe  pain  during  uterine 
contraction;  2:18  p..m.,  cocaine  gr.  }  again  injected; 
2  :57  P.M.,  forceps  applied  without  the  patient's  knowl- 
edge; 4:04  P.M.,  macerated  fittus  born,  without  pain 
to  mother;  4:15  p.m.,  placenta  born  spontaneously; 
4:20  P.M.,  perineal  tear  sutured  without  pain  to 
mother.  Post-partum  temperature,  99.2°  F. ;  pulse, 
88;  respiration,  24;  6:10  p. .m.,  the  patient  has  head- 
ache; n  P. -M.,  hyoscine  iiydrobromate  gr.  ^J^^  given; 
headache  gone  in  twenty  minutes.  The  twenty  hours 
are  not  up  at  the  report  of  this  case,  so  that  the  tem- 
perature curve»cannot  be  noted. 

Case  XXIII. — H.  S ,  aged  twenty-two:  primi- 
para. September  23d,  at  9:29  p.  m.  ,  cocaine  (lumbar 
puncture)  gr.  J;  external  os  two  fingers  dilated;  cer- 
vix almost  gone.  Uterine  contractions  every  three 
minutes;  9:35  p.m.,  sensation  to  pin-prick  in  lower 
extremities  almost  gone.  Vaginal  examination,  which 
before  lumbar  puncture  gave  great  pain,  now  causes 
no  discomfort;  manual  dilatation  of  cervix,  no  pain; 
9:55  p.m.,  pains  in  back  have  returned;  10:15  P-^'- 
cocaine  gr.  {  injected:  10:18  p..\i.,  sensibility  to  pain 
again  totally  abolished;  10:30  p..m.,  the  patient  vom- 
ited; 10:32  P..M.,  complains  of  great  warmth  and  per- 
spires profusely;  10:34  P. .m.,  forceps  applied  without 
pain  or  knowledge  of  patient:  10:55  p.m..  child  born 
without  pain,  but  during  the  tractions  on  the  head 
there  was  some  slight  pain;  11  :io  p.m.,  placenta  born 
spontaneously  with  no  pain;  11:25  P.^^.,  perineum 
sutured  with  not  much  discomfort  to  the  patient;  pa- 
tient carried  to  ward  at  11:50  p.m.  Following  this 
delivery  hyoscine  hydrobromate  gr.  j/,„  was  given,  and 
none  of  the  usual  after-symptoms  came  save  a  rise  of 
one  degree  in  temperature. 

947  Madiso.s  .-Vvenue. 


MEDICAL    RECORD. 


[October  6,  1900 


OBSERVATIONS    ON    SUBCLAVIAN    DELIGA- 
TION.* 

Bv    SCHLVI.EK    COLFAX    tIKAVKS.    M.D.. 

GRAND    KAPIDS,    MICH. 

While  the  operation  of  placing  a  ligature  around  the 
subclavian  artery  is  not  a  common  one  and  hence  has 
no  everyday  bearing  upon  the  profession,  it  neverthe- 
less is  a  most  important  procedure,  and,  as  a  rule,  an- 
nounces in  the  demanti  for  its  performance  an  urgent 
necessity.  That  the  operation  is  anything  but  simple 
every  operator  of  experience  will  admit,  and  therefore 
any  contribution  to  the  anatomy  or  surgery  of  this  sub- 
ject which  will  tend  to  diminish  its  perplexities,  and 
thus  render  its  performance  easier,  will  add  materially 
to  our  common  stock  and  bear  fruit  in  the  curtailment 
of  its  present  dangers. 

The  original  guide  to  the  third  or  operative  portion 
of  the  subclavian  artery  was  the  scalenus  anticus  mus- 


FlG.  I. — Boundaries  of  the  New  Trianyle  :  Cord  of  the  brachial  plexus  externally  ;  scalenus  anticus  muscle 
internally  ;  first  rib  inferiorly.  i,  Sternnmastoid  muscle  ;  2,  3,  divided  portions  of  the  posterior  belly  of 
the  omohyoid  muscle  ;  4.  scalenus  anticus  muscle  ;  5,  cord  of  the  brachial  plexus  ;  6,  scalenus  medius 
muscle  ;  7,  subclavian  artery  ;  8,  tirst  rib  ;   9.  subclavian  vein. 

cle,  with  the  first-rib  tubercle  marking  the  site  of  its 
insertion,  and  these  factors  have  retained  their  promi- 
nence in  this  respect  to  the  present  day. 

That  the  exposure  of  these  landmarks  is  a  delicate 
feat  in  itself  no  one  will  gainsay.  The  scalenus  anticus 
lies  deeply  in  the  neck  and  bears  an  intimate  relation 
to  such  important  structures  as  the  subclavian  vein, 
the  phrenic  nerve,  the  thoracic  duct,  the  pleural  apex, 
etc.,  not  mentioning  the  artery  under  consideration  and 
its  branches.  In  fact,  the  thorough,  workmanlike  ex- 
posure of  this  anatomical  guide  constitutes  the  princi- 
pal and  most  dangerous  feature  of  subclavian  deliga- 
tion. 

In  my  own  experience,  limited  to  one  case  on  the 
living  subject,  but  including  many  dissections  and 
post-mortem  operations,  the  truth  of  the  foregoing  has 
been  brought  forcibly  to  my  mind;  but  I  early  saw 
what  I  then  believed  would  prove  to  be  an  easier  and 
as  constant  a  guide  to  the  artery  as  the  scalenus  anti- 
cus.    I  refer  to  the  cord  of  the  brachial  jilexus. 

The  plexus  in  its  relation  to  the  suliclavian  artery 
is  not  spread  out  and  loosely  arranged,  but  is  round, 
compact,  and  invested  with  a  special  fascia,  so  that  by 
the  novice  it  can  readily  be  mistaken  for  tiie  anterior 
scalene  muscle.  As  a  matter  of  fact,  the  tendinous 
expansion  of  this  muscle  above  its  point  of  attachment 

•A  paper  read  before  the  Surgical  Section  of  the  Michigan 
State  Sledical  Society  at  Mackinac  Island.  Mich.,  July  11,  ii)i><). 


to  the  first  rib  bears  a  striking  resemblance  to  the 
white,  corded  nerve-trunk  as  seen  througli  its  fibrous 
investment.  The  inexpert,  seeing  and  feeling  the 
cord,  can  thus  easily  imagine  that  he  has  exposed  the 
muscular  guide,  and  hence  be  thrown  completely  off 
the  track. 

Speaking  of  the  brachial  plexus,  Gray,'  in  this  con- 
nection, says;  "It  is  broad  and  presents  little  of  a 
plexiform  arrangement  at  its  commencement,  is  nar- 
row o/'posi/t-  the  liavick  [italics  mine],  and  becomes 
broad  and  forms  a  more  dense  interlacement  in  the 
axilla."  This  narrow  portion  is  the  new  guide,  and  is 
the  structure  previously  described  as  round  and  com- 
pact and  as  bearing  so  close  a  resemblance  to  the  old 
muscular  guide. 

I  desire  to  call  the  attention  of  the  profession  to 
two  facts  in  connection  with  this  subject: 

I.  The  brachial-plexus  cord  is  an  easier  guide  than 
the  anterior  scalene  muscle  to  the  subclavian  artery. 

2.  This  nerve  bundle  is  as 
reliable,  is  as  constant  a  fac- 
tor as  the  latter. 

Kocher"  says :  "  The  re- 
lation of  the  artery  to  the 
nerve  plexus  is  very  charac- 
teristic." 

The  mere  statement  of  the 
liability  of  error  in  mistaking 
the  cord  for  the  muscle  proves 
the  existence  of  the  first  of 
these  facts,  and  for  convinc- 
ing evidence  as  to  the  truth- 
fulness of  the  second  I  re- 
commend to  my  hearers  the 
scalpel  and  frequent  visits  to 
the  dead-room. 

If  this  recommendation  be 
adopted     not     only   will    the 
constancy  of    the    cord    as    a 
guide   factor  be    established, 
but  the  investigator  will  also 
notice  that  the  artery  lies  con- 
siderably higher   in   the  neck 
than      does     its      companion 
vein,  this  difference  in  altitude 
being    more    pronounced    on 
the  left  side  than  on  the  right. 
Some  authors  seem  to  think  that  the  brachial   cord 
is  more  difficult  to  expose,  because  of   its  imagined 
depth,  than  the  anterior  scalene  muscle.     This  is  not 
so.     Tiie  easily  and,  I  believe,  oft  made  error  of  mis- 
taking the  cord  for  the  muscle  demonstrates  the  rela- 
tive superficiality  of  the  former.     Moreover,  my  per- 
sonal dissections  as  well  as  my  operative  experience 
confirm  this  statement,  and  eminent  practical  surgeons 
bear    corroborative    testimony   as    follows:     Liston :° 
"You  get  at  tiie  nerves  and  expose  them  distinctly 
enough,  and  a  little  lower  down  on  the  same  plane  vou 
at  least  reach  the  vessel."     Agnew:'  "  If  tiie  cords  of 
the  brachial  plexus  or  the  omo-hyoid  muscle  are  seen 
the  exploration   must  be   carried  farther  downward  in 
the  direction   of  the  chest,  and  more   inward,  as  the 
artery  lies  between  the  scalenus  anticus  muscle  on  the 
inside    and    the    brachial    plexus    on    the    outside." 
Kocher:'    "After    removing    the    adipose    tissue    the 
thin,  deep  fascia  covers  the  brachial   plexus,  now  be- 
coming visible,  whose  thick  nerve  trunks  emerge  be- 
tween the  .scalene  muscles  and  descend  steeply  under 
the  clavicle." 

It  was  with  mucii  interest  and  considerable  pleasure 
that  I  noted,  in  my  dissections,  a  clear-cut  triangle 
which  l)ears  a  constant  relation  to  the  third  portion  of 
the  subclavian  artery;  in  which,  as  a  rule  without  ex- 
ception save  in  case  of  gross  irregularity,  this  portion 
of  the  artery  will   always  be  found.     This  triangle  is 


October  6,  1900] 


MEDICAL    RECORD. 


529 


located  almost  wholly  below  the  posterior  belly  of  the 
omo-hyoid,  and  hence  is  a  component  part  of  the  sub- 
clavian cervical  triangle.  Its  boundaries  are  as  fol- 
lows: externally,  the  cord  of  the  brachial  plexus; 
internally,  the  scalenus  anticus  muscle;  inferiorly,  the 
first  rib.  Within  these  boundaries  the  subclavian 
artery  can  always  be  found.  It  is  an  ultimate  triangle, 
incapable  of  further  subdivision,  because  its  bounda- 
ries come  into  actual  touch  with  the  vessel,  no  other 
tissue  intervening. 

Treves"  describes  a  triangle  in  connection  with  the 
subject  of  subclavian  ligation.  He  says:  "It  [the 
subclavian  artery]  runs  in  a  triangle,  the  base  of 
which  is  formed  by  the  outer  edge  of  the  anterior 
scalene  and  the  sides  by  the  clavicle  and  the  omo-hy- 
oid." This  triangle  varies  but  slightly  from  the  sub- 
clavian triangle  itself,  the  outer  edge  of  the  scalenus 
anticus  being  substituted  for  the  corresponding  edge 
of  the  sterno-niastoid,  and  it  has  no  working  value  in 
the  performance  of  the  operation  under  consideration. 
The  relative  merit  of  the  newly  mentioned  triangle  and 
the  one  described  by  Mr.  Treves  I  leave  to  the  judg- 
ment of  my  audience. 

The  subclavian  vein  crosses  this  new  triangle,  if  it 
cross  it  at  all,  low  down,  passing  in  front  of  the  sca- 
lenus at  its  costal  attachment,  wiiile  most  of  the  tri- 
angular interspace  is  occupied  by  the  artery,  particu- 
larly in  its  upper  portion  where  the  vessel  will  be 
found  solitary.  Reference  to  this  condition  of  affairs 
has  indirectly  been  made  in  the  foregoing  ljy  the  state- 
ment concerning  the  different  cervical  levels  of  the 
artery  and  vein.  This  solitary  point  in  the  course  of 
the  artery  being  the  most  superficial,  the  highest,  and 
the  least  associated  with  important  structures,  is  natu- 
rally the  site  of  election  in  any  operative  attack  upon 
the  same. 

In  contradistinction  to  the  exposure  of  the  vessel  at 
this  point  I  need  but  mention  the  usual  search  for  the 
first-rib  tubercle,  deeply  situated  in  the  neck  and 
in  relation  to  structures  the  accidental  wounding  of 
which  might  mean  dire  calamity  to  the  unfortunate 
patient. 

Moreover,  the  reliability  and  hence  the  real  value 
of  this  guide  is  sadly  shattered  by  no  less  distinguished 
an  authority  than  Agnew,'  who  says:  "This  tubercle 
to  which  so  much  importance  has  been  attached  is,  in 
my  experience,  not  a  very  reliable  guide  in  conse- 
quence of  its  development  being  very  imperfect." 
The  contrast  between  the  deeply  lying  tubercle  (which 
may  or  may  not  have  an  existence)  and  the  brachial 
cord  at  the  upper  confines  of  the  new  triangle  must 
make  self-evident  the  superiority  of  the  latter  over  the 
former,  as  a  guide  to  the  artery  under  discussion. 

Now  to  the  point  of  this  paper.  I  propose  substi- 
tuting for  a  difficult  guide  in  the  ligation  of  the  sub- 
clavian artery  an  easy  one,  viz.,  the  cord  of  the  brachial 
plexus  of  nerves  for  the  scalenus  anticus  muscle. 

In  the  performance  of  this  operation,  then,  if,  instead 
of  exposing  the  deep-lying  scalene  muscle  and  feeling 
in  front  of  it,  the  more  easily  located  brachial  cord  is 
exposed  and  the  finger  placed  behind  it.  less  time  will 
be  consumed  and  fewer  important  structures  endan- 
gered. The  resultant,  other  things  being  equal,  must 
be  a  shrinkage  in  the  mortality  rate. 

The  illustration  is  from  a  photograph  of  a  personal 
dissection  made  for  the  purpose  of  elucidating  the 
points  I  have  here  brought  out. 

BIBLIOGRAPHY. 

1.  Gray:  Anatomy,  eighth  edition,  p.  671. 

2.  Kocher  ;  Operative  Surgery,  first  edition,  p.  ill. 

3.  I.iston  :   Lectures  on  Surgerj',  first  edition,  p.  34S. 

4.  Agnew:  Surgery,  first  edition,  vol.  i.,  p.  644. 

5.  Kocher:  Operative  Surgery,  first  edition,  p.  in. 

6.  Treves:   Manual  of  Surgerj-,  first  edition,  vol.  i.,  p.  140. 

7.  Agnew:  Surgery,  first  edition,  vol.  i.,  p.  644. 


AUTHORS  CONSULTED. 

.\gnew,  American  Te.\t-Book  of  Surgery,  Brj-ant  (Joseph), 
Bryant  (Thomas),  Da  Costa,  Dennis,  iJruitt.  Ellis,  Erichson, 
(iibson,  Gray,  Gross.  Jacobson,  Kocher,  Leidy.  Liston,  Miller, 
.Morris.  MouUin,  Reference  Handbook,  Roberts,  Syme,  Treves, 
Wyeth. 


TUBERCULOSIS    AND    ITS    TREATMENT." 
By    .MARGARET   STANTON,    M.D., 

PRESIDENT   OF   THE    O.NONDAGA    COt'NTV    MEDICAL   SOCIETV, 

It  is  safe  to  say  that  the  burning  medical  question  of 
tiie  day  is  tuberculosis  and  its  treatment.  We  are  now 
in  the  closing  years  of  the  longest  reign  in  Uritish  his- 
tory; you  know  what  of  war  and  conquest  that  period 
embraces.  Could  the  dead  buried  in  those  battles  by 
land  and  sea,  with  those  who  afterward  died  of  their 
wounds  or  from  exposure  or  disease  contracted  in  the 
service,  rise  in  one  great  company,  it  would  be  far  out- 
numbered by  the  dead  from  tuberculosis.  The  loss  is 
not  the  less  striking  because  unaccompanied  by  the 
boom  of  cannon,  the  clash  of  steel,  tiie  whiz  of  bullets, 
the  click  of  telegraph  wires,  the  speed  of  railways,  or 
the  big  type  of  yellow  journals.  The  masked,  the  in- 
sidious progress  of  the  capture  of  the  citadel  of  life  by 
this  all-conquering  disease  is  marked  with  such  delu- 
sive fair-seeming,  that  the  tuberculous  with  his  dying 
lips  assures  you  he  feels  better,  and  is  confident  of 
recovery.  \\'ar  takes  away  our  strongest  and  those  in 
their  prime,  but  this  dread  scourge  makes  of  our 
strongest  the  weakest,  and  spares  neither  sex  nor  age. 

I  have  lived  the  greater  part  of  the  last  ten  years 
among  the  tuberculous,  and  the  study  of  the  treatment 
of  this  disease  has  forced  itself  upon  me.  We  have 
progressed  so  far  in  the  study  of  the  cause  of  the  dis- 
ease that  we  feel  sure  we  have  caught  the  culprit.  We 
have  declared  it  to  be  contagious,  and,  therefore,  a 
menace  to  the  public  health — yet  we  have  left  it  at 
large  to  prey  upon  the  people  because  there  is  not 
sufficient  public  enlightenment  to  quarantine  it  prop- 
erly. Fellow-practitioner,  that  is  your  fault  and 
mine.  We  have  not  been  doing  our  duty.  We  have 
been  taking  our  work  lightly.  Is  it  that  we  have  been 
careless  or  ignorant  or  commercial?  There  is  war  to 
be  waged;  there  is  to  be  brisk  fighting  all  along  the 
lines  to  the  extermination  of  the  germ  or  the  patient. 
Let  us  prepare  ourselves  well,  for  the  enemy's  pha- 
lanxes are  full  and  the  patients  must  put  up  a  great 
fight.  But  if  it  is  true,  whisper  it  not  in  Gath,  '"that 
the  struggle  must  begin  in  the  ranks  of  the  profession 
itself;  let  it  start  at  once  and  not  cease  until  every 
old  prejudice  and  ignorance  are  crushed  to  earth  to 
rise  no  more."  Our  only  chance  is  during  the  incip- 
iency  of  the  disease.  Early  diagnosis  is  all-impor- 
tant. It  wins  the  day  by  reducing  the  number  of  the 
slain  to  a  minimum.  Even  with  improved  methods  of 
diagnosis  we  must  often  revert  to  the  old,  which  ex- 
isted before  the  discovery  of  the  bacillus.  Though 
the  lungs  give  forth  no  sign  and  though  the  family  and 
personal  history  be  mute,  when  there  is  loss  of  flesh, 
appetite,  and  strength,  loathing  of  fat  and  distress  of 
digestion,  with  absence  of  symptoms  of  other  diseases, 
remembering  that  the  lungs  hide  away  their  secret  as 
their  depths  are  silently  being  undermined,  that  family 
history  is  often  unreliable,  and  that  tuberculosis  fre- 
quently begins  that  way,  let  us  treat  our  case  as  if  it 
stood  out  clearly  photographed.  Having  the  case  be- 
fore us,  tiie  next  move  is  taking  those  measures  which 
will  insure  that  which  we  call  cure.  To  cure,  what 
will  cure.'  When  death  gives  up  life's  secrets  we 
know  that  nature  cures  sometimes;  but  her  powers  are 
not  ours,  and  we  cannot  distil  her  elixirs. 

I  will  illustrate  by  a  case  under  my  observation  how 

'  Address  of  the  president  at  the  annual  meeting  of   the  Onon- 
daga County  (N.  V.;  Medical  Society. 


530 


MEDICAL    RECORD. 


[October  6,  1900 


physicians  proceed  to  bring  about  cure.  The  patient 
was  from  one  of  the  largest  cities  in  this  State,  a 
young  woman  teacher  twenty-four  years  old,  well  built, 
taking  much  exercise  in  the  open  air,  passing  her  va- 
cations with  her  brother  in  the  woods  fishing,  tramp- 
ing, bicycling,  and  taking  long  nights  of  sleep;  she  was 
out  of  sorts,  nothing  definite,  food  didn't  taste  good, 
bicyling  was  an  exertion,  walking  a  task,  schoolroom 
duties  were  irksome.  After  a  while  of  this  the  family 
physician  was  consulted,  and  recommended  change  of 
air,  a  visit  to  the  Adirondacks.  as  a  condition  existed 
that  might  give  rise  to  trouble  in  the  lungs.  This  was 
scouted  at  home,  no  lung  trouble  ever  having  been 
known  on  either  side.  The  family  physician  was  get- 
ting old,  they  said,  and  the  patient  was  advised  to  go  to 
Dr.  Blank,  who  was  young,  modern,  had  European  ad- 
vantages, etc.  He  declared  there  could  be  no  degen- 
eration in  such  finely  developed  lungs,  laughingly  re- 
marked of  the  suggestion  to  go  to  the  Adirondacks, 
''  That  will  do  no  harm,  but  you  need  not  go  now ;  you 
can  go  a  little  while  in  the  summer  if  you  like  "  (vet 
six  months);  "torpid  liver;  don't  mope  nor  worry,  do 
this  and  take  that."  More  valuable  time  passed  with- 
out improvement.  Once  more  to  the  doctor's,  still 
another.  This  one  had  neither  ifs  nor  ands.  "  Your 
lungs  are  in  danger.  Waste  no  more  time  with  drugs. 
Go  into  pure  air  at  once,  and  keep  in  it  a  year." 
When  doctors  disagree,  who  shall  decide?  I  am  not 
throwing  stones,  but  is  it  too  much  to  require  unanim- 
ity in  the  treatment  of  tuberculosis?  The  meeting  to 
discuss  this  entire  subject,  held  at  Berlin  a  year  ago, 
did  not  settle  this  vexed  question  of  treatment.  There 
were  differences  of  opinion,  although  the  great  major- 
ity favored  the  outdoor  treatment.  Pure  air  is  the 
remedy ;  believe  me,  it  is  the  whole  thing.  The  purest 
air  is  to  be  sought  for  out-of-doors,  and  in  the  incipi- 
ency  of  the  disease.  This  air  may  be  found  in  differ- 
ent parts  of  the  world,  but  I  will  confine  myself  to  that 
part  easiest  of  access  to  us,  the  Adirondacks  of  our 
own  State.  They  may  be  reached  from  within  the 
boundaries  of  this  State  in  twenty-four  hours.  That  is 
an  inestimable  advantage.  The  journey  does  not  ex- 
haust the  patient's  strength  nor  deplete  his  pocket- 
book.  He  can  communicate  with  his  friends  quickly, 
and  have  their  society  when  that  seems  a  good  meas- 
ure. He  may  also  have  the  hope  and  cheer  of  a  visit 
from  his  family  physician,  if  at  any  time  it  may  seem 
advisable.  He  may  even  be  permitted  a  few  days  at 
home  when  the  craving  for  familiar  scenes  appears  to 
stand  in  the  way  of  improvement.  Whether  he  goes 
to  a  sanatorium  or  not,  certain  rules  must  be  followed. 
One  of  the  most  difficult  things  to  be  eradicated  in 
the  lines  set  down  for  a  patient  to  follow  is  the  belief 
in  the  necessity  of  exercise — exercise  in  every  shape, 
from  complicated  gymnastics  to  record-breaking  walks. 
We  see  the  poor,  deluded  victims  of  a  pernicious 
relic  of  barbarism  every  day  on  the  streets  liter- 
ally walking  to  death.  They  exercise  even  in  the  sec- 
ond stage  when  they  have  "  temperatures."  Fancy  a 
patient  with  typhoid  fever  or  any  other  fever  walking. 
It  is  left  to  their  own  judgment  and  discretion,  too, 
when  actually  they  have  neither.  The  less  left  to 
their  own  determination  the  better.  They  are  ill,  and 
everything  should  be  prescribed  for  them.  The  nour- 
ishment that  should  be  used  in  building  up  the  degen- 
erate tissues  of  the  body  is  wasted  in  harmful  chan- 
nels. Insist  strongly  upon  this — no  exercise  whatever 
beyond  lounging  about  to  vary  the  position.  It  is 
pleasant  and  efficacious  to  be  driven  about  at  a  moder- 
ate pace,  kept  without  exertion  in  that  finest  of  tonics, 
moving  air,  exhilarated  and  refreshed  by  changing 
scenery.  This  may  be  indulged  in  to  the  fullest  ex- 
tent in  fine  weather.  Of  course,  when  hemorrhage  is 
to  be  feared,  even  the  gentlest  driving  is  not  to  be 
recommended.     Mountain-climbing  is  a  great  tempta- 


tion. It  alone  is  responsible  for  a  large  increase  in 
the  death  rate  every  year.  Imbue  your  patients  with 
such  a  wholesome  fear  of  it  at  the  start  that  they  would 
consider  it  the  wildest  folly  even  to  think  of  such  a 
thing.  The  tuberculous  patient  must  live  to  eat;  he 
must  be  a  feeder;  his  eating  must  be  the  object  of  con- 
stant care  to  himself  and  others.  It  is  astonishing 
how  much  he  can  assimilate  if  he  can  only  get  it  down. 

One  of  my  patients  worked  out  a  good  rule  for  her 
own  guidance  which  others  will  do  well  to  follow: 
"I  eat  all  I  can  of  the  dishes  supplied  for  each  meal; 
then  when  I  can  take  no  more  I  finish  with  several 
glasses  of  milk,  sometimes  with  a  raw  egg  in  each." 
I  have  given  the  rule  to  others  and  find  it  works  won- 
ders. It  never  spoils  the  appetite  for  the  next  meal, 
and  one  can  worry  down  fluids  when  it  would  be  im- 
possible to  swallow  solids.  For  those  who  can  take 
but  very  small  quantities  of  food  at  a  time,  lunches 
every  two  hours  are  desirable.  Many  patients  re- 
quire the  most  minute  attention  in  the  matter  of 
food;  the  exact  quantity  must  be  insisted  on  with 
them.  F'or  lack  of  this  insistence,  I  have  seen  them 
pass  days  with  food  scarcely  enough  to  support  an  in- 
fant, yet  thinking  themselves  indulging  almost  vora- 
ciously in  the  light  of  their  poor  appetites.  The  time 
when  the  patient's  demijohn  could  not  be  emptied  too 
quickly  has  gone  by,  I  hope  never  to  return.  Vet  the 
shadow  of  that  belief  still  lingers,  especially  among 
the  laity,  and  the  patient  must  be  fortified  to  refuse 
the  drop  of  good  whiskey  or  the  sip  of  old  brandy  that 
is  offered  him  for  his  good,  and  to  turn  a  deaf  ear  to 
the  histories  of  cures  that  stimulants  have  wrought. 
Patent  medicines  and  cough  mixtures  will  be  urged 
upon  him,  and  if  weak  or  unwarned  he  may  use  them, 
to  his  detriment.  Early  retiring  must  be  inculcated. 
There  cannot  be  too  much  of  nature's  sweet  restorer, 
balmy  sleep.  Exciting  amusements  between  the  last 
meal  and  bed-time,  and  also  irritating  arguments,  are 
to  be  forbidden.  Quiet  conversation,  light  reading, 
etc.,  are  the  best  pastimes.  A  dry  rub  or  an  alcohol 
or  sea-salt  bath  every  night  is  most  excellent,  the  pa- 
tient being  his  own  rubber.  Protected  from  draughts, 
he  must  sleep  with  windows  well  open,  even  in  30^ 
below  zero  weather.  When  possible,  in  summer  he 
should  sleep  in  a  tent,  well  floored.  If  he  is  confined 
to  the  house  or  bed  an  airy  room  must  be  selected,  and 
all  windows  must  be  thrown  open  night  and  day.  We 
should  discourage  requests  for  permission  to  go  home, 
even  for  a  few  days.  I  have  seen  the  work  of  months 
in  the  Adirondacks  negatived  by  a  week  at  home,  and 
cases  which  might  have  resulted  in  cure  go  on  to 
death  from  the  same  cause.  You  will  be  assailed  by 
piteous  appeals  for  a  home  visit,  but  you  must  firmly 
deny.  Occasionally  it  is  wise  to  grant  the  indulgence, 
but  generally  a  kind  letter  stating  the  danger  suflices. 
Patients,  especially  men,  in  the  second  stage  should 
never  be  sent  away  alone.  If  they  cannot  have  the 
company  of  a  friend,  a  woman  preferred,  then  a  trained 
nurse  should  go.  These  lonely,  unhappy  creatures 
present  the  saddest  sights.  As  in  the  end  some  one 
must  be  sent  for,  it  is  better  to  start  with  a  care-taker, 
when  care  will  not  come  too  late  for  cure.  For  these 
unfortunates  admonitions  and  precautions  must  be 
doubled,  as  this  stage  is  one  of  despair.  They  do  not 
yet  appreciate  their  slow  but  sure  gain.  Patients  in 
the  third  stage  should  never  be  encouraged  to  leave 
home.  Their  days  are  shortened  in  most  cases,  and 
disrepute  is  brought  upon  the  treatment.  Failures 
are  remembered,  while  no  account  is  kept  of  their 
causes. 

Explain  the  danger  that  lurks  in  dried  sputum.  The 
handkerchief  should  never  be  used  to  receive  it,  but 
instead  of  this  the  individual  cuspidor,  squares  of 
cheese-cloth,  Japanese  paper,  absorbent  cotton,  or 
clean  rags.     These  should  be  burned  within  twenty- 


October  6,  1900] 


MEDICAL   RECORD. 


531 


four  hours.  Tlie  enormity  of  promiscuous  expectora- 
tion should  be  lielcl  up  to  general  execration.  Among 
the  tuberculous  will  be  found  the  usual  percentage  of 
those  who  "cheat  the  doctor,"  especially  in  the  matter 
of  remaining  out-of-doors.  Eight  hours  in  winter,  and 
ten  in  summer  at  least,  should  be  spent  in  taking  the 
cure.  Dry  summer  evenings  may  be  passed  in  the 
open  air  until  nine  o'clock.  Time  spent  indoors  does 
not  count.  Indoor  air,  about  the  same  in  all  sections, 
is  not  fit  to  breathe.  A  temperature  of  20  below  zero 
in  the  open  air  in  the  .\dirondacks  does  not  seem  so 
cold  as  zero  weather  here;  it  is  wonderfully  bracing. 
In  it  the  hours  pass  quickly  and  pleasantly  while  one  is 
out-of-doors,  bundled  up  in  furs.  When  exercise  can 
be  taken,  walks  in  the  forest,  skating,  and  snowshoe- 
ing  are  delightful  amusements.  The  encouragement 
of  a  fad  is  to  be  strongly  urged — an  out-of-door  fad 
by  all  means.  I  have  met  tuberculous  patients  whose 
camera  work  was  fine;  and  some  added  largely  to  tiieir 
income  by  the  sale  of  their  pictures.  A  partnersiiip 
in  which  one  furnished  the  description  for  the  news- 
papers and  the  other  ilie  photographs  of  places  of  in- 
terest in  the  mountains,  interested  me  very  much. 
The  indulgence  in  a  fad  occupies  the  mind,  preventing 
too  much  brooding  and  introspection.  Time,  next  to 
air,  plays  the  principal  part  in  the  cures — time,  plenty 
of  time.  We  say  to  a  patient  in  the  incipient  stage: 
"In  a  year  you  will  be  cured."'  True,  but  not  cured 
in  his  sense — to  go  back,  pick  up  the  thread  of  his  life 
where  he  dropped,  it  and  carry  it  on  as  he  left  it. 
His  cure  does  not  enable  him  to  do  that.  In  nine 
cases  out  of  ten  he  pursues  that  course  only  to  experi- 
ence a  renewal  of  his  trouble.  It  requires  from  three 
to  five  years  spent  in  the  Adirondacks  to  make  it  safe 
for  a  man  to  marry  and  live  anywhere.  So  when  we 
say  a  year  to  these  patients,  it  is  with  a  reservation. 
Is  it  well  to  have  that  reservation  ?  One  might  despair 
at  the  beginning  if  told  that  the  treatment  must  be 
continued  so  long,  who  might  be  brought  on  to  accept 
the  limit  in  progressive  stages  from  one  year. 

Now  comes  a  consideration  of  those  who  from  their 
own  resources  cannot  hope  to  avail  themselves  of  this 
or  any  other  means  of  cure.  What  is  to  be  done  for 
them?  The  tuberculous  patient  without  money  or 
friends  is  the  most  pitiable  creature  on  earth.  Our 
heart's  profoundest  sympathy  is  his.  Let  us  give  him 
our  very  greatest  aid.  Let  us  hold  up  his  misery  and 
desolation,  until  the  whole  world  recognizes  them  and 
joins  in  ameliorating  his  condition.  In  this  age  of 
altruism,  we  see  philanthropy  shedding  its  bounty 
with  overflowing  hands  on  every  conceivable  cause. 
Bibles  for  the  Hottentots,  clothes  for  the  South  .Sea 
Islanders,  churches  for  the  millions,  colleges  for  the 
different  sects  and  sexes,  libraries  for  the  masses,  hos- 
pitals for  the  maimed,  the  cancerous,  and  the  epilep- 
tics, and  every  claim  is  answered,  while  the  hosts  of 
the  tuberculous  have  not  been  offered  a  place  where 
they  may  cough  out  their  allotted  three  years  in  decent 
peace  and  comfort.  And  now  that  the  government  is 
becoming  so  paternal,  what  has  the  State  done  for  the 
tuberculous?  Nothing.  I  may  say.  Certainly  nothing 
for  them  as  a  class.  Their  claims  upon  it  have  been 
met  with  scant  recognition.  To  those  having  abso- 
lutely no  other  resource  it  has  offered  its  poor-houses, 
which  means  death  without  reprieve  in  a  very  short 
time,  and  burial  by  the  State.  If  the  cost  even  of 
maintenance  in  the  poor-house  and  of  burial,  with  a 
trifle  more,  w-ere  used  in  a  more  judicious  way,  lives 
would  be  saved  and  good  citizens  spared  to  the  State. 
Zola,  in  his  last  great  work  "  Feconditc,"  makes  a 
powerful  appeal  for  larger  families  in  France.  At  the 
present  birth  rate,  he  says,  France  will  soon  lose  her 
rank  as  a  great  nation  from  sheer  lack  of  numbers. 
If  he  would  but  enlist  his  masterly  pen  in  the  effort  to 
keep  in  life  those  already  bom,  his  task  would  not  be 


so  formidable.  The  tuberculous  poor  are  best  cared 
for  in  sanatoria,  and  these  should  be  built  and  main- 
tained by  the  State.  They  should  be  absolutely  free 
for  those  having  no  means  whatever,  and  at  a  low 
fixed  rate  for  those  able  to  pay  something.  The  san- 
atorium is  an  educator;  in  it  a  patient  is  taught  how 
to  get  well,  keep  well,  and  preserve  himself  from  being 
a  source  of  danger  to  others.  When  he  goes  abroad 
he  is  capable  of  teaching  self-care  to  others.  The 
best  model  of  a  sanatorium  on  the  cottage  plan  is  to 
be  found  at  Saranac  Lake:  a  central  building  con- 
taining the  offices  of  administration,  common  dining- 
room,  reception  and  music  rooms,  with  baths  and  in- 
firmary; an  amusement  pavilion  that  may  be  opened 
on  all  sides  to  the  weather,  fitted  with  pool  and  bil- 
liard tables;  a  separate  building  for  the  library,  golf, 
croquet,  and  tennis  grounds.  The  cottages  contain 
from  six  to  eight  light  rooms  opening  upon  a  central 
common  sitting-room,  they  are  surrounded  by  verandas 
and  are  very  cozy.  A  Catholic  sisterhood  maintains 
a  similar  one  at  Cabriels,  N.  Y.  It  has  the  advantage 
of  being  close  to  the  railway  station.  The  Berlin  con- 
gress decided  that  sanatoria  need  not  necessarily  be  in 
the  mountains,  but  must  be  in  the  vicinity  of  forests. 
Each  county  can  find  an  excellent  site  within  its  own 
border.  Pompey  Hill  affords  just  the  spot  for  Onon- 
daga.    Let  this  society  make  a  foundation  there  its  aim. 


APPENDICITIS  LARVATA  AND  INFLAMMA- 
TION OF  THE  KIGHT  BROAD  LIGA- 
MENT,   TUBE,    AND    OVARY. 

By   otto   THIKXHAUS,    M.D., 

MILWAl'KEE,    WIS., 

FORMERLV      DIRECTING      IHVSICIAN    OF     THE      WO.MAN's    PRIVATE    HOSPITAL, 
STENDAL,    GERMANY. 

At  the  twenty-eighth  German  Surgical  Congress  held 
at  Berlin,  in  .April,  1899,  Ewald  introduced  the  term 
appendicitis  larvata.  By  this  expression  he  understood 
appendicitis  of  a  chronic,  insidious  character  which 
moves  softly  without  developing  into  a  real  attack  of 
acute  appendicitis.  Such  a  conception  would  corre- 
spond to  the  actual  situation  and  reveal  the  nature  of 
the  disturbance. 

Not  infrequently  we  meet  in  practice  patients  com- 
plaining of  intermittent  pain  in  the  abdomen  of  vary- 
ing degrees  of  severity,  which  disappears  after  a  longer 
or  shorter  time.  These  cases  are  very  often  treated 
as  intestinal  colic,  gastritis,  or  flatulent  enteritis  with- 
out or  in  connection  with  some  sort  of  enteroptosis. 
On  a  careful  examination  of  these  patients  pain  may 
be  elicited  by  palpation,  sometimes  at  McBurney's 
point,  sometimes  in  the  neighborhood  of  the  navel,  or  • 
even  in  the  left  iliac  region  or  beneath  the  liver;  in 
some  of  these  cases  there  are  occasionally  slight  ele- 
vations of  temperature. 

In  recent  years,  in  which  the  study  of  the  topo- 
graphical anatomy,  pathology,  and  symptomatology  of 
the  processus  vermiformis  has  aroused  the  deepest 
interest  and  has  resulted  in  the  most  exact  investiga- 
tions, it  has  also  been  shown  that  these  vague  pains 
may  have  their  real  origin  in  an  anatomical  lesion  of 
the  appendix.  In  some  cases,  in  which  it  was  be- 
lieved that  movable  kidney  or  retroflexio  uteri  was 
the  cause  of  the  symptom  complex,  and  in  which,  in 
order  to  overcome  these  disturbances,  the  kidney  or 
the  uterus  was  fixed,  it  has  been  found  that  these 
operations  had  no  influence  whatever  upon  the  pain, 
and  many  operators  have  had  to  confess  with  Wood :' 
"I  can  attribute  many  of  my  early  failures  in  abdomi- 
nal work  to  not  directing  my  attention  to  the  appen- 

'  American  Journal  of  Obstetrics,  iSgg,  p.  94. 


532 


MEDICAL    RECORD. 


[October  6,  igcio 


dix,  the  pain  in  the  right  side  persisting  as  well  as  the 
gastro-intestinal  disturbances." 

Kdebohls'  has  shown  that  movable  kidneys  are  very 
often  closely  connected  witii  appendicitis  larvata, 
which  he  thinks  is  due  to  the  pressure  of  the  movable 
kidneys  on  the  vena  mesenterica  superior  causing 
hyperreniia  in  the  processus.  He  even  says  that  mov- 
able kidney  which  is  not  followed  by  appendicitis 
does  not  furnish  an  indication  for  treatment.  This 
opinion  is  still  very  far  from  being  generally  accepted, 
as  other  authors  have  not  been  able  to  find  any  rela- 
tion between  these  two  disturbances.  So  far  as  my 
experience  goes  I  must  confess  that  in  some  cases 
this  coincidence  without  doubt  exists,  and  when  we  fix 
the  kidney  in  such  cases,  without  paying  attention  to 
the  appendix,  the  patients  will  be  in  the  same  condi- 
tion as  before  the  operation.  Upon  a  macroscopic 
and  microscopic  examination  of  the  underlying  ana- 
tomical causes  of  the  above-named  disturbances,  it  has 
been  found  that  there  is  no  proportionate  relation  be- 
tween the  anatomical  conditions  and  the  troubles  pre- 
sented by  the  patient.  Sometimes  it  has  been  seen 
in  the  sectio  in  vivo  that  the  serosa  of  the  appendix 
was  only  slightly  injected,  generally  at  the  tip;  some- 
times there  have  existed  only  delicate  adhesions  be- 
tween the  appendix  and  another  portion  of  the  bowel, 
or  one  of  the  pelvic  organs,  or  the  lateral  abdominal 
peritoneum;  and  upon  dissection  of  the  processus 
there  is  frequently  found  only  a  slight  catarrhal  in- 
flammation with  swelling  of  the  follicles  of  the  muco- 
sa, or  sometimes  a  follicular  abscess,  sometimes  ste- 
nosis at  one  or  more  points,  sometimes  slight  fecal 
concretions.  On  the  other  hand,  we  all  know  of  cases 
coming  to  post-mortem  section,  in  which  during  life 
there  were  no  or  very  few  symptoms  of  disturbances, 
but  in  which  were  found  surprising  destructive  lesions 
and  malformations  of  the  appendix.  At  this  point  I 
will  call  attention  to  cases  cited  by  Combemale,"  Gutt- 
man,°  and  Maryland,'  in  which  the  distal  portion  of 
the  appendix  was  dilated  into  an  egg-shaped,  tense, 
cyst-like  structure  without  giving  rise  to  any  subjec- 
tive symptoms. 

Wood  '"  says  that  in  nearly  every  recorded  case  of 
cystic  disturbance  of  the  vermiform  appendix  there 
were  no  subjective  phenomena  arising  from  the  condi- 
tions, and  that  in  the  majority  of  cases  the  affection 
was  discovered  accidentally. 

There  seems  to  be  some  analogy  between  the  condi- 
tion of  the  processus  vermiformis  and  gastric  ulcer. 
Many  pathological  anatomists  have  stated  that  large 
cicatrices  of  former  gastric  ulcers  are  found  in  cases 
in  which  during  life  an  examination  would  not  have 
revealed  any  lesion  of  the  stomach. 

As  the  diagnosis  of  an  appendicitis  larvata,  which 
at  any  moment  may  be  followed  by  an  acute  attack  of 
appendicitis,  menacing  life,  is  very  difficult,  I  think 
•every  point  which  might  suggest  the  possibility  of 
such  a  condition  should  receive  favorable  considera- 
tion. In  the  following  three  cases,  observed  in  my 
practice,  there  w-ere  symptoms  of  such  a  nature  that  it 
was  possible,  relying  upon  them,  to  make  the  diagno- 
sis of  appendicitis  larvata: 

Case  I. — Miss  O ,  twenty-two  years  of  age,  com- 
plained for  two  years  of  vague  pain  in  the  abdomen, 
mostly  in  the  right  side;  since  the  beginning  of  this 
pain  she  suffered  from  dysmenorrhtea,  sometimes  in 
combination  with  menorrhagia.  Very  often  the  pain 
extended  to  the  epigastrium,  the  attack  being  followed 
by  headache  and  slight  rise  of  temperature,  sometimes 

'  Centralblatt  ftir  Gynakologie,  1898,  p.  1084. 
'  Bulletin  medical  du  Nord. 

'  Deutsche  medicinisclie  Wochenschrift,  1899,  p.  186. 
•*  Transactions  of  the  Glasgow  Pathological  and  Clinical  Society, 
vol.  iv.,  p.   III. 
'  .\merican  lournal  of  Obstetrics. 


by  diarrhoea.  She  thought  the  trouble  was  due  to  a 
blow  on  the  abdomen.  Since  the  beginning  of  her 
illness  she  had  lost  nearly  fifteen  pounds.  At  her 
first  appearance  I  could  not  decide  whether  or  not 
there  was  an  hysterical  element,  though  the  family 
history  on  this  point  was  negative.  Examining  the 
patient,  1  found  by  abdominal  palpation  slight  ten- 
derness upon  pressure  in  the  region  of  McBurney's 
point;  no  sign  of  exudate;  hymen  intact,  but  so  dis- 
tensible that  it  permitted  the  careful  introduction  of 
the  index  finger.  There  were  no  indications  of  gon- 
orrhea. On  bimanual  palpation  I  found  the  right 
tube  and  ovary  very  tender  and  slightly  enlarged;  the 
right  broad  ligament  was  retracted;  the  uterus  was  in 
dextro-retroposition ;  from  the  right  ligament  extend- 
ing to  the  enseal  region  there  was  a  not  well-defined 
resistance,  which  gave  the  impression  of  a  structure 
of  about  the  size  of  a  lead  pencil.  My  diagnosis  was 
appendicitis  larvata;  the  appendix  extending  to  the 
small  pelvis  and  perhaps  adherent  with  the  tube,  re- 
traction of  the  right  broad  ligament,  inflammation  of 
the  right  tube  and  ovary,  dextro-retroposition  of  the 
uterus.  At  the  operation  ( Sonnburg's  oblique  inci- 
sion in  the  region  of  the  anterior  spine),  which  was 
kindly  performed  by  Professor  Rotter,  of  Eerlin,  who, 
seeing  the  case  for  the  first  time,  was  somewhat  loath  to 
believe  the  appendix  was  the  cause  of  the  trouble,  the 
diagnosis  was  confirmed.  The  appendix  removed  was 
about  10  cm.  long;  upon  opening  it  we  found  three 
constrictions  with  two  fecal  concretions,  one  at  the  tip 
of  the  appendix,  the  other  between  the  two  constric- 
tions; the  patient  made  an  uneventful  recovery,  her 
weight  increasing  twenty  pounds  in  two  and  one-half 
months.     The  dysmenorrhcea  disappeared. 

Case  II. — Miss  L ,  twenty-three  years  of  age, 

from  a  healthy  family,  complained  of  running  pain 
over  the  abdomen  mostly  in  the  umbilical  region. 
This  condition  in  a  more  or  less  pronounced  state  had 
existed  for  some  eight  weeks,  interrupted  sometimes 
by  constipation,  sometimes  by  diarrhcea.  The  last 
menstruation  had  been  very  painful.  The  patient  had 
been  treated  for  some  time  on  the  diagnosis  of  enter- 
itis catarrhalis.  The  examination  showed  tenderness 
on  palpation  near  the  navel  on  the  right  side;  no  sign 
of  exudate;  hymen  intact.  Rectal  bimanual  examina- 
tion revealed  the  uterus  lying  in  dextro-retroversion 
position,  the  right  broad  ligament  shortened,  and 
slight  tenderness  of  the  right  adnexa.  When  I  per- 
formed the  operation  I  found  the  uterus  lying  as  above 
mentioned;  the  tip  of  the  processus  vermiformis, 
whose  serosa  was  slightly  injected,  with  an  appendix 
epiploicus  originating  from  it.  was  attached  to  the 
right  ovary  by  adhesions.  I  removed  the  appendix 
and  fixed  the  uterus  to  the  abdominal  wall,  after  the 
method  of  Czerny-Leopold.  The  dissection  of  the  ap- 
pendix showed  only  swelling  of  the  mucous  membrane 
and  follicles,  the  distal  part  of  the  process  containing 
fluid  fecal  matter. 

Case  III.. — Martha  P ,  nurse  in  my  private  hos- 
pital, twenty-eight  years  of  age,  complained  for  two 
years  and  a  half  of  pain  in  the  right  inguinal  region 
sometimes  in  connection  with  very  painful  menstrua- 
tion. Since  the  beginning  of  her  illness  she  never 
felt  quite  well  and  could  scarcely  perform  her  usual 
work.  Six  months  ago  she  had  to  remain  in  bed  six 
weeks  suffering  from  intermittent  fever  and  great  dis- 
turbances in    the  abdomen,    and  was   treated  by    Dr. 

P ,  of  Frankfort-on-the-Oder,  Germany.    Examining 

her,  I  found  great  tenderness  on  palpation  at  McIJur- 
ney's  point;  no  exudate;  hymen  intact;  no  sign  of 
gonorrhcea;  on  bimanual  palpation  I  found  the  right 
broad  ligament  retracted;  the  right  tube  enlarged  at 
its  distal  end,  the  size  of  a  hen's  egg;  the  ovary  on 
the  same  side  the  size  of  a  small  apple  adherent  to 
the  tube,  and  very  painful  on  palpation;  the  uterus  in 


October  6,  1900] 


MEDICAL   RECORD. 


5'>  ^ 
00 


retroflexion  position ;  an  adhesion  from  the  ovary  to 
the  cacal  region  could  not  be  palpated;  the  adnexa  on 
the  left  side  showed  no  abnormal  condition.  Diagno- 
sis: Appendicitis  larvata,  hydrosalpinx  or  pyosalpinx 
dextra,  retroflexio  uteri,  oophoritis  dextra.  Performing 
appendectomy,  oophorectomy,  and  salpingectomy,  and 
dextraventrofixation  of  the  uterus,  I  found  the  proces- 
sus adherent  to  the  fimbriated  extremity  of  the  tube, 
and  the  other  complications  as  mentioned.  The  re- 
covery was  uncomplicated.  A  fortnight  after  the 
operation  the  patient  was  able  to  chloroform  another  of 
my  patients  for  operation,  and  in  a  letter  received  half 
a  year  afterward  she  assured  me  that  she  was  quite 
healthy  and  able  to  perform  any  required  work.  Tiie 
dysmenorrhcea  had  not  recurred. 

If  the  symptoms  found  in  these  three  cases  are  sum- 
marized, the  following  of  a  more  general  nature  are 
obtained:  Disturbances  in  the  intestinal  tract,  flatu- 
lent colic,  abdominal  pain  of  more  or  less  intermittent 
nature,  located  by  the  patient  sometimes  in  the  right, 
sometimes  in  the  left  iliac  region,  extending  in  some 
cases  to  the  navel,  epigastrium,  or  right  hypochon- 
drium.  These  disturbances  are  associated  sometimes 
with  headaches,  dysmenorrhcea  combined  with  men- 
orrhagia,  and  more  or  less  increasing  cachexia;  slight 
attacks  of  fever  occur  in  some  cases.  On  physical 
examination  slight  ill -defined  tenderness  is  found 
at  McBurney's  point,  about  the  navel,  even  some- 
times in  the  left  side  or  in  the  neighborhood  of  the 
liver.  On  bimanual  palpation,  through  either  the 
vagina  or  the  rectum,  the  uterus  is  found  to  be  in  dex- 
troposition, or  dextro-retroverted  or  flexed,  the  right 
broad  ligament  shortened  and  retracted;  the  right 
tube  and  ovary  more  or  less  in  a  state  of  inflamma- 
tion. In  one  case  I  was  able  to  distinguish  a  struc- 
ture of  the  configuration  of  the  processus  vermiformis 
with  adhesions. 

The  question  which  should  arise  in  a  diagnosis  of 
any  abdominal  intlammatory  process  in  a  woman  is 
tiie  possibility  of  the  existence  of  hysteria.  It  is  well 
known  how  diflicult  it  is  generally  to  exclude  hysteria 
in  cases  of  abdominal  disturbance,  mostly  in  those 
cases  in  which  there  is  paralysis  of  the  intestines,  and 
the  literature  contains  reports  of  cases  in  which  a  dis- 
regard of  possible  hysteria  has  led  surgeons  to  per- 
form laparotomy  not  only  once,  but  even  three  times 
on  one  patient  without  finding  ai:  anatomical  basis  of 
the  trouble.  Xothnagel  calls  this  condition  pseudo- 
peritonitis  or  pseudo-perityphlitis  hysterica.  I  shall 
never  forget  one  case  in  which  the  abdominal  symp- 
toms combined  with  the  general  condition  of  the  pa- 
tient misled  Dr.  Madgeburg  (first  assistant  to  von 
Bergmann's  clinic  in  Berlin)  and  myself  to  a  diagno- 
sis of  peritonitis,  possibly  of  appendicular  origin.  It 
was  shown  by  von  Bergmann  after  chloroforming  the 
patient,  during  which  the  bowels  collapsed,  that  the 
whole  symptomatology  was  due  to  hysteria,  excited 
by  a  very  slight  attack  of  gall-stone  colic.  Of  course 
an  operation  was  unnecessary. 

When  the  above-mentioned  conditions  of  the  pelvic 
organs  are  discovered  in  a  female  patient,  the  second 
most  important  and  difficult  question  that  arises,  after 
excluding  hysteria,  is  to  determine  whether  this  in- 
flammation of  the  right  side— tube,  ovary,  and  broad 
ligaments — has  its  origin  in  an  ascending  inflamma- 
tion, brought  there  by  way  of  the  vagina,  or  in  a  de- 
scending inflammation  originating  in  the  appendix,  it 
being  assumed  that  inflammations  having  their  origin 
in  other  abdominal  parts  can  be  excluded.  Prob- 
ably the  most  common  cause  of  inflammation  of  the 
tubes  and  ovary  is  the  gonococcus,  and  the  question 
of  the  existence  of  gonorrhoea  must  be  settled  before 
other  causes  can  be  considered.  When  it  is  found. 
as  in  the  cases  cited,  that  the  patient  shows  no  evi- 
dence of  an  earlier  urethritis,  no  redness  surrounding 


the  region  of  the  outlet  of  the  Bartholinian  glands,  no 
sign  of  catarrh  of  the  vagina  and  cervix,  and  when  the 
inflammation  is  limited  to  only  one  side  of  the  pelvis 
— as  it  is  well  known  that  gonorrhoea  is  prone  to  be 
bilateral — then  another  cause  may  be  taken  into  con- 
sideration. It  has  been  shown  in  recent  years  that 
contraction  of  the  right  broad  ligament  in  connection 
with  inflammation  of  the  right  tube  and  ovary,  some- 
times wilii  dcxtro-retroversion  or  flexion  of  the  uterus, 
points  to  an  appendicular  origin  of  the  trouble.  The 
diagnosis  may  be  rendered  still  more  probable  by  the 
already-mentioned  general  disturbances  of  the  abdo- 
men, and  confirmed  when  one  is  able  to  palpate  alter- 
ations of  the  processus,  and  to  recognize  adhesions 
between  it  and  the  pelvic  organs. 

It  has  been  shown  by  many  observers  that  appen- 
dicitis is  more  common  in  males  than  in  females 
(McBurney  states  in  the  "  International  Text-I!ook 
of  Surgery,"  p.  399,  that  the  ratio  is  about  four  to 
one),  and  one  thinks  the  reason  for  that  is  that  the 
appendix  in  the  female  receives  additional  blood 
supply  from  the  artery  appendiculo-ovarica  running 
through  the  ligamentum  apjjendiculo-ovaricum.  For 
the  same  reason  it  is  said  that  appendicitis  gangrae- 
nosa  occurs  less  often  in  females.  Through  the  lym- 
phatics of  this  ligament,  bacteria,  it  is  believed,  may 
wander  from  the  appendix  to  the  broad  ligament  and 
tube,  causing  inflammation  of  the  latter.  The  exist- 
ence of  this  ligament  has  been  demonstrated  by  Fow- 
ler and  Waldeyer.  Of  late  it  has  been  the  subject  of 
a  great  deal  of  discussion,  and  among  others  Parnsby' 
has  denied  its  presence  and  believes  that  the  bacteria 
are  transported  through  adhesions  between  the  organs. 
This  was,  I  believe,  the  fact  in  the  cases  above  re- 
ported, in  which  the  inflammation  of  the  appendix 
had  caused  adhesions  between  it  and  the  right  tube 
and  ovary. 

Of  course  adhesions  between  these  organs  can  be 
developed  only  in  those  cases  in  which  the  appendix 
is  rather  long,  gravitating  by  its  own  weight  into 
the  small  pelvis,  or  in  which  there  is  a  long  meso- 
CECum  or  even  no  mesoca.cum,  but  instead  of  it  a 
mesenterium  ileoca;cale  commune.  The  latter  condi- 
tion allows  for  the  greatest  mobility  and  dislocation 
of  the  CEecum,  together  with  the  appendix,  and  makes 
the  recognition  of  inflammation  of  sucii  a  dislocated 
organ  sometimes  not  only  difficult  but  impossible,  be- 
cause it  can,  when  lying  for  example  in  the  left  iliac 
region,  produce  inflammation  and  adhesions  with  only 
the  left  adnexa,  or  in  other  cases  with  the  gall  blad- 
der and  liver.  Von  Manteuft'el  has  shown'  that  this 
condition  can  be  a  cause  of  volvulus  of  the  cacum 
followed  by  peritonitis,  and  that  has  to  be  taken  into 
consideration  when  the  question  arises  whether  or  not 
there  is  a  peritonitis  following  volvulus  or  a  perito- 
nitis which  had  its  origin  in  the  appendix. 

Another  question  which  I  would  like  to  propose  at 
this  point  is:  Can  the  bacteria  which  are  usually 
found  in  inflammation  of  the  appendix  (streptococcus, 
staphylococcus,  and  bacterium  coli).  when  transported 
by  way  of  the  lymphatics  or  adhesions  to  the  tube,  give 
rise  to  suppuration  of  the  normal  mucous  membrane 
of  the  tube?  This  question  arises  in  connection  with 
my  last  case,  in  which  there  was  a  hydrosalpinx,  and 
it  is  believed  that  hydrosalpinx  may  result  from  an 
earlier  pyosalpinx.  Other  authors  deny  this  possibil- 
ity (Tiife  Veil's  "  Handbuch  der  Gynakologie,"  p. 
702).  But  it  has  been  shown  that  the  patient  had 
intermittent  septic  fever  lasting  six  weeks,  some  six 
months  before  the  operation,  and  I  think  this  was  due 
to  an  existing  pyosalpinx  originating  from  the  appen- 
dix. This  question  arose  also  in  a  discussion  of  a 
paper  by  Fueth,  "  Ueber  Erkrankung  des    Processus 

'  Revue  de  gj'necol.  et  de  chir.  abdora.,  1898. 
'  Sammlung  klinischer  Vortrage,  No.  260. 


534 


MEDICAL    RECORD. 


[October  6,  1900 


vermiformis  und  der  Adnexe,"  '  when  Zweifel  of  Leip- 
sic  objected  to  the  possibility  of  streptococcus,  staphy- 
lococcus, and  bacterium  coli  being  able  to  excite 
pyosalpinx  in  the  presence  of  an  uninjured  mucous 
membrane  of  the  tube.  Fueth  thought  it  possible,  but 
whether  or  not  this  can  be  accepted  remains  for  more 
exact  demonstration.  This  condition  has,  of  course, 
nothing  to  do  with  those  cases  in  which  an  abscess, 
originating  from  the  appendix,  breaks  through  into  a 
tube  and  causes  pyosalpinx. 

Concerning  the  treatment  of  appendicitis  larvata,  it 
must  be  recognized  that  only  operative  measures  can 
be  taken  into  consideration.  They  are  indicated  be- 
cause (i)  there  is  no  otiier  means  of  correcting  the 
existing  pathological  conditions,  and  (2 )  the  patient 
is  in  constant  danger  of  an  attack  of  appendicitis  fol- 
lowed by  peritonitis.  Barnsby,  already  mentioned, 
says  that  when  the  tip  of  the  appendix  is  adherent  to 
some  abdominal  organ  with  or  without  vascularization 
of  its  peritoneal  serosa,  there  is  absolute  indication 
for  operations.  Furthermore,  in  young  female  pa- 
tients one  has  to  deal  with  the  possibility  of  a  subse- 
quent pregnancy,  and,  as  we  all  know  that  appendicitis 
in  combination  with  pregnancy  gives  the  most  serious 
prognosis  both  for  the  foetus  (abortion  is  practically 
inevitable)  and  for  the  mother,"  it  is  the  physician's 
duty  to  explain  to  the  patient  the  above-mentioned 
complication  and  to  resort  to  radical  treatment,  that  is, 
to  operation. 

Eleventh  and  Wells  Streets. 


Lupus  Treated  by  Excision — E.  Lang  gives  the 
results  of  eighty-five  cases  of  this  disease,  in  which 
the  aiTected  portions  of  skin  were  excised  and  the  de- 
fect covered  by  a  plastic  operation.  Of  this  number 
thirty-nine  are  for  various  reasons  not  available  for 
statistics,  but  the  forty-six  remaining  have  been  free 
from  recurrence  for  periods  varying  from  one  to  seven 
years.  Most  of  these  had  already  for  years  been  sub- 
jected to  skilful  medical  treatment  without  permanent 
improvement,  and  in  view  of  the  absolutely  positive 
results  obtainable  by  surgical  intervention  the  author 
strongly  advises  the  measure  in  all  cases  in  which  a 
sufficiently  radical  operation  can  be  done. — Klinisch- 
therapeutische  JVocheiisckrifi,  August  19,  1900. 

The  Connection  between  Gastric  and  Uterine 
Disorders. — Odon  Tuszkai  has  made  a  careful  study 
of  the  anatomical  and  other  factors  subtending  the 
well-known  reciprocal  relationships  of  stomach  and 
uterus.  The  connection  between  the  two  is  intimate 
and  far-reaching,  but  care  is  necessary  to  exclude  dis- 
orders which  simply  chance  to  affect  coincidentally 
both  organs  without  being  in  any  way  interdependent. 
Three  main  channels  of  mutual  inlluence  lie  open, 
through  the  nervous  system,  the  circulation,  and  ab- 
normal static  relations.  Of  these  the  first  is  tiie  most 
important,  and  the  author  differs  from  the  usually  ac- 
cepted belief  in  placing  the  genital  centre  not  in  the 
brain  or  spinal  cord  but  in  the  sympathetic  system, 
its  abdominal  centre  being  not  in  the  lumbar  cord  but 
in  the  solar  ganglion.  This,  by  means  of  the  inferior 
hypogastric,  the  solar,  and  spermatic  plexuses,  estab- 
lisiies  the  retiex  track  between  the  uterus  and  the  gastric 
branches  of  the  vagus.  Another  more  indirect  route 
lies  through  the  communications  of  the  vagus  with  the 
sympathetic  system  through  the  utero-vaginal  plexus 
and  the  para-uterine  ganglia.  In  addition  to  the  liga- 
mentous and  structural  attachments  of  both  organs 
intra-abdominal  pressure  plays  a  large  part  in  main- 

•  Centralblatt  ft'ir  Gynakologie,  1S99,  p.  17. 

"  Illawacek  (Monatsschrift  fiir  Geburtshilfe  und  Gynakologie. 
1S97,  Bd.  vi.,  lift.  4)  reports  thirteen  cases  of  pregnancy  compli- 
cated wilh  .ippendicitis,  eleven  of  whicli  resulted  in  death. 


taining  their  normal  positions.  Thus,  under  ordinary 
conditions  this  force  strikes  the  uterus  posteriorly  near 
the  fundus,  keeping  it  normally  anteflexed,  but  when 
the  static  equilibrium  is  disturbed  or  destroyed  in 
consequence  of  gastric  dilatation,  gastroptosis,  etc., 
the  axis  of  pressure  may  run  directly  through  the  fun- 
dus and  induce  a  downward  displacement,  or  lie  still 
farther  forward  and  produce  a  retroversion.  While 
chemical  and  endozymotic  influences  may  travel 
through  the  blood  current  and  so  effect  reciprocal  gas- 
tric and  uterine  changes,  this  channel  is  of  less  im- 
portance than  the  other  two. — Monaisschrijt fiir  Ge- 
burtshiilfe  und  Gytidkologie,  August,  1900. 

Inflammation  of  the  Middle  Ear  in  Infants  and 
Children. — A.  O.  Pfingst  says  middle-ear  involvement 
is  particularly  noticeable  in  measles.  Jobeitz  believes 
it  is  affected  in  every  case.  The  Eustachian  tube  in 
children  is  wider  and  gives  a  better  passage  to  infec- 
tions from  the  naso-pharynx.  The  benign  course  is 
characteristic  of  otitis  in  early  life,  and  pain  is  not  so 
pronounced  a  symptom  as  in  the  adult.  Spontaneous 
rupture  of  the  drum  is  also  not  so  common.  The  ten- 
dency for  the  inflammation  to  spread  to  the  mastoid 
cells  is  not  so  great,  and  operative  intervention  is  less 
often  called  for.  The  suggestion  of  Earth  to  examine 
the  ears  of  all  sick  children  several  times  during  their 
illness  is  a  good  one.  At  the  first  sign  of  retained 
pus  or  of  extension  of  the  inflammation  to  the  mastoid 
cells  paracentesis  should  be  done.  The  incision 
should  be  kept  open  as  long  as  acute  symptoms  are 
present.  This  is  best  done  by  applying  a  crystal  of 
chromic  acid  to  the  cut  edges.  Whenever  the  symp- 
toms of  mastoid  involvement  are  pronounced  or  per- 
sistent the  mastoid  must  be  opened.  Fortunateh',  a 
small  opening  suffices  in  babies. —  The  American  Prac- 
titioner and  Ne7i<s,  August  i,  1900. 

Legal  and  Medical  Insanity ;  Reflections  upon 
the  Recent  Trial  and  Conviction  of  Bradford  P. 
Knight  at  Augusta,  Me.^ — C.  P.  Bancroft  states  that 
the  judge  in  his  charge  to  the  jury  acknowledged 
that  the  murderer  might  be  insane,  but  that  his  mental 
disease  might  not  have  progressed  to  this  particular 
point  of  destroying  a  knowledge  of  right,  and  wrong 
with  reference  to  the  particular  act.  The  author  says 
that,  in  point  of  fact,  insanity  and  irresponsibility,  or 
at  least  modified  responsibility,  are  nearly  if  not  quite 
synonymous.  The  real  test  of  responsibility  is  not  a 
knowledge  of  right  and  wrong  with  reference  to  the 
particular  act,  but  as  Dr.  C.  F.  Macdonald  has  ex- 
pressed it,  "  knowing  the  right  and  knowing  the  wrong, 
has  the  man  the  power  to  choose  the  right  and  avoid 
the  wrong?"  It  is  not  a  question  of  knowledge,  but 
of  power  to  choose  between  two  courses  of  action.  If 
he  has  not  such  power,  then  his  act  is  the  product 
of  his  disease,  and  he  is  not  responsible.  Chief  Jus- 
tice Doe's  ruling  in  a  famous  case  vi'as  that  there  is 
no  legal  test  of  insanity,  but  that  each  case  must  be 
decided  on  its  own  merits;  that  insanity  is  a  mental 
disease;  the  product  of  mental  disease  cannot  be  a 
crime;  tests  of  mental  disease  are  matters  of  fact,  and 
whether  the  defendant  has  a  mental  disease,  and 
whetiier  his  act  is  the  product  of  that  disease,  are 
questions  of  fact  for  the  jury  to  decide.  This  is  good 
law  and  sound  medicine. — American  Journal  oj  In- 
sanity, July,  1900. 

Further  Laboratory  Studies  on  Uric  Acid  in 
Neurasthenia,  and  on  Auto-intoxication  in  Nervous 
Disease.  —  F.  Savary  Pearce  concludes  from  experi- 
mentation and  observation  that  we  have  sutVicient  data 
to  say  positively  that  neurasthenic  conditions  are  as- 
sociated with  the  circulation  of  such  an  irritant  as  uric 
acid  in  the  blood.  The  physiological  absorption  of 
proteids  is   inhibited   in   an   irregular  fashion   in  the 


October  6,  1 900] 


MEDICAL   RECORD. 


535 


neurasthenic  subject,  or  else  the  condition  is  due  to 
want  of  proper  vasomotor  control  of  the  capillary 
blood-vessels,  thus  permitting  an  irregular  and  im- 
proper elimination  of  uric  acid,  etc.  It  must  needs  be 
that  in  such  central  disease  the  central  energizing  in- 
fluence (of  the  neuronic  vitality /c-/- j-e-)  is  greatly  en- 
feebled, and  is  unable  to  carry  this  weakened  vital 
action  through  the  nerves  to  the  organs  of  digestion 
and  absorption.  This  viciouscycle  of  disturbed  meta- 
bolism being  established,  we  have  secondary  irritations 
continuously  operating  on  the  already  devitalized  nerve 
centres.  The  sympathetic  also  becomes  over-excited, 
and  in  a  condition  of  irritable  weakness  as  manifested 
in  the  resultant  symptomatology  of  neurasthenia. — 
The  American  Journal  of  Insanity,  July,  1900. 

The  Effects  of  Migration  from  the  Northern  to 
the  Southern  Hemisphere. — R.  Humphrey  Martin, 
who  has  practised  medicine  in  Australia  for  twelve 
years  after  a  previous  experience  in  England,  gives  an 
entertaining  comparison  of  the  people  met  with  in  the 
two  latitudes.  Concerning  matters  purely  medical  he 
notes  in  the  southern  hemisphere,  Australia  especially, 
the  prevalence  of  hydatids,  the  absence  of  rickets,  the 
relative  infrequency  of  post-diphtheritic  paralysis,  the 
great  mortality  of  typhoid,  particularly  that  variety 
known  as  "gold-fields"  fever,  and  the  fact  that  pul- 
monary tuberculosis  is  only  about  one-half  as  frequent 
as  in  the  northern  hemisphere.  Measles  is  about  as 
severe,  while  scarlatina  is  much  milder. — Australasian 
Medical  Gazette,  July  20,  1900. 

The  Pathogenesis  of  Fiat-Foot  in  Cases  of  Vari- 
cose Veins. — Eriberto  Aievoli  holds  that  tlat-foot  is  a 
result  of  the  varicose  condition,  the  cause  being  found 
in  the  nutritive  disturbances  induced  by  the  perturbed 
circulation  in  the  power  and  resistance  of  the  plantar 
arch,  and  in  the  disturbed  mechanism  of  the  lower 
limb,  flat-foot  representing  functional  adaptation. 
The  author  gives  in  detail  his  reasons  for  this  view, 
and  also  goes  into  the  history  of  the  subject. —  Gl'In- 
ciirahili,  July  i  and  15,  1900. 

The  Diagnosis  of  Neurasthenia. — After  enumerat- 
ing the  more  common  symptoms  of  the  affection  and 
touching  upon  the  chief  points  of  distinction  between 
organic  and  functional  nervous  diseases,  Gustavus 
Eliot  discusses  the  differential  diagnosis  between  neu- 
rasthenia and  hysteria,  hypochondriasis,  various  men- 
tal aberrations,  and  litha;mia.  Concerning  the  differ- 
entiation from  hysteria  he  says  that  the  sudden  and 
violent  convulsive  attacks  of  hysteria  do  not  belong 
to  neurasthenia,  although  in  the  latter  disease  slight 
muscular  twitching  and  subjective  quivering  and 
throbbing  are  not  uncommon.  The  globus  hystericus 
is  common  in  and  characteristic  of  the  disease  whose 
name  the  symptom  bears,  but  is  rare  in  neurasthenia. 
The  symptoms  of  hysteria  are  characterized  by  vio- 
lence and  activity.  Those  of  neurasthenia  are  of  a 
less  obtrusive  character.  They  are  more  quiet  and 
subdued.  Hysteria  is  seen  in  individuals  of  emotional 
temperament,  whose  mental  organization  is  not  well 
balanced,  while  neurasthenia  very  commonly  affects 
the  intelligent  and  intellectual.  Finally  the  symp- 
toms of  hysteria  very  frequently  disappear  early  and 
completely,  leaving  the  patient  in  usual  health,  while 
neurasthenics  recover  slowly  and  gradually. —  Vale 
Medical  Journal,  September,  1900. 

Bronchial  Asthma ;  its  Relation  to  Nasal  Dis- 
ease.—  H.  L.  Swain  discusses  the  various  theories  of 
the  causation  of  asthma,  believing  it  to  be  due  to  a 
spasm  of  the  muscular  fibres  which  encircle  the  point 
where  the  terminal  bronchus  ends  and  opens  out  into 
the  atrium.  When  this  narrow  opening  into  the  larger 
sac  is  suddenly  contracted  by  a  spasm  the  respiratory 


space  beyond  the  terminal  bronchus  becomes  more 
and  more  stretched.  Hence  the  lobule  corresponding 
to  the  space  becomes  distended,  and  this  occurring  all 
over  the  pulmonary  structure,  we  have  the  familiar 
distention  of  the  chest.  The  exciting  cause  of  this 
spasm  may  come  from  the  intra-nasal  condition,  but 
even  here  we  must  have  an  explosive  nerve  tendency, 
lack  of  vasomotor  control,  and  thin-walled  veins,  which 
are  present  in  some  individuals  but  absent  in  others. 
Given  this  combination  of  factors,  a  cause  operating 
through  any  one  of  various  organs  may  excite  an  asth- 
matic attack.  The  nasal  condition  is  only  one  of  the 
factors  which  may  initiate  the  bronchial  spasm. —  Vale 
Medical  Journal,  August,  1900. 

The  Use  of  Diphtheria  Antitoxic  Globulins  of 
the  Blood  Serum  Instead  of  the  Entire  Serum  in 
Diphtheria. — \V.  H.  I'ark,  in  an  attempt  to  isolate  the 
globulins  which  are  closely  connected  with  the  anti- 
toxic substances  in  the  blood,  has  carried  out  a  series 
of  experiments.  The  antitoxic  globulin  secured  has 
been  tried  with  a  view  of  obviating  the  toxic  mani- 
festations, rashes,  etc.  The  results  are  disappointing, 
and  there  seems  no  probability  of  separating  the  anti- 
toxic properties  from  the  globulin.  This  the  author 
thinks  probably  true  of  other  protective  serums. — Pe- 
diatrics, August  15,  1900. 

Critical  Review  of  the  So-Called  Physiological 
Theory  of  Emotion, — Charles  A.  Franc^ois-Franck 
combats  the  notion  held  by  many  modern  psycholo- 
gists, that  the  circulatory  disorders  accompanying 
mental  emotions  and  disturbances  are  their  cause; 
that  the  brain  is  in  reality  a  mere  servant  or  passive 
agent  of  arterial  pressure  and  the  general  circulation. 
He  adduces  many  reasons  and  experiments  to  prove 
that,  on  the  contrary,  emotional  excitement,  whether 
directly  cerebral  or  generally  sensory,  produces  the 
active  congestion  of  the  brain,  which  always  precedes 
elevation  of  arterial  pressure,  and  can  therefore  not 
be  due  to  it. — Bulletin  de  VAcadhnie  de  Medecine, 
August  14,  1900. 

Enlargements  of  the  Spleen  in  Children.— Samuel 
West  draws  attention,  in  the  splenic  anaemia  of  infants, 
to  its  chronic  course,  to  its  very  varying  prognosis, 
and  to  the  fact  that  syphilis  is  occasionally,  and  rick- 
ets frequently,  associated  with  it.  The  association  is 
in  neither  case  constant,  nor  is  either  of  these  diseases 
the  sole  cause — probably  not  the  cause  at  all  except 
indirectly  by  means  of  the  ill  health  to  which  either 
leads.  As  to  relation  between  the  splenic  enlarge- 
ment and  the  anamia,  it  is  very  likely  that  both  are 
due  to  a  common  cause.  The  treatment  should  be  that 
of  anffimia.  In  regard  to  other  forms  of  splenic  en- 
largement in  children  the  author  calls  attention  to  the 
frequency  in  the  very  young  of  malaria,  leucocythemia, 
and  Hodgkin's  disease. — Medical  J'ress  and  Circular, 
August  22,  1900. 

On  Convulsive  States  in  General — A.  Pierret  says 
that  the  convulsive  movements  of  cortical  origin  may 
be  simply  motor  disturbances,  as  in  Jacksonian  epi- 
lepsy, or  exclusively  sensory,  as  in  sensory  epilepsy, 
but  they  may  also  involve  the  entire  brain,  in  which  • 
case  their  dynamic  state  is  such  that  consciousness  is 
temporarily  affected.  This  constitutes  the  epileptic 
coma  with  amnesia;  at  other  times  consciousness  is 
but  partially  inhibited.  The  particular  variety  of  the 
affection  depends  upon  the  state  of  impressionability 
of  the  cells,  and  on  the  conditions  which,  by  forming 
an  obstacle  to  the  establishment  of  equilibrium  of 
nervous  tension,  favor  local  hypertension.  These  two 
factors  may  be  modified  in  thousands  of  ways.  When 
the  cortex  is  involved  in  the  shock,  phenomena  make 
their  appearance  which  the  spinal  cord,  or  even  the 


536 


MEDICAL    RECORD. 


[October  6,  1 900 


medulla  oblongata,  is  incapable  of  determining. 
Cortical  epilepsy,  even  when  of  the  Jacksonian  type, 
is  invariably  associated  with  some  psychical  element, 
the  complete  epileptic  paro.\ysm  being  thus  merely 
the  result  of  blending  together  the  spinal,  medullary, 
subcortical,  and  cortical  convulsive  phenomena.  The 
latter  may  also  exist  alone,  and  in  this  case  various 
simple  or  complex  acts,  sensory  aura,  delirium,  hallu- 
cinations, vertigo,  perverted  impulses,  or  even  crimes 
become  the  morbid  equivalents  of  the  lacking  motor 
convulsion. —  The  Medical  Press  atui  Circular,  August 
22,  igoo. 

The  Functions  of  the  Cerebellum.— R.  Gatta  from 
the  results  of  physiological  experiments  concludes: 
(i)  That  clinically  the  cerebellar  complex  of  symp- 
toms is  often  rendered  multiform  by  phenomena  of 
compression  and  irritation  of  adjacent  or  peripheral 
organs  (pons,  bulb,  cranial  and  cerebral  nerves).  (2) 
The  cerebellar  alterations  or  phenomena,  whether 
clinical  or  experimental,  are  more  marked  on  the  side 
of  the  lesion.  (3)  Complete  destruction  of  the  cere- 
bellum in  animals  determines  phenomena  of  ataxia, 
asthenia,  and  atony,  just  as  do  lesions  of  the  cerebel- 
lum in  clinical  practice.  In  the  experimental  cases 
these  symptoms  persist,  although  in  attenuated  form. 

(4)  In  the  absence  of  rapid  infiltrating  action  and 
diffusible  toxemic  powers,  these  experimental  patho- 
logical processes  may  continue  for  months  and  years. 

(5)  The  results  of  the  author's  experimentation  are  in 
harmony  with  those  already  obtained  experimentally 
in  regard  to  the  functions  of  the  cerebellum  and  its 
relations  to  the  locomotor  apparatus. — La  Rijor/na 
Medica,  August  6  and  7,  igoo. 

Evil  Results  following  Abdominal  and  Pelvic 
Surgery,  and  the  Measures  Requisite  to  Prevent 
or  Counteract  Them.— E.  Stanmore  Bishop  directs 
attention  to  the  perfection  of  small  details  in  common 
surgical  work.  The  utility  of  early  operation  in 
fibromyomata  before  secondary  changes  have  occurred 
is  discussed.  Evil  results  are  avoided  by  attention 
paid  to  the  small  points  in  technique.  Bad  results 
follow  delay,  delay  is  produced  by  knowledge  of  former 
bad  results.  Among  bad  results  are  death,  ventral 
hernia,  sinus,  vaginal  prolapse,  intestinal  adhesions, 
persistent  pain,  and  prolonged  invalidism.  Operation 
should  be  done  if  pyosalpinx,  or  pressure  on  the 
ureters,  great  loss  of  blood,  development  into  the  broad 
ligament,  or  possibility  of  necrosis  is  threatened.  The 
mortality  will  be  low  if  operation  is  done  to  forestall 
these  conditions.  The  bowels  should  be  w^ell  cleared 
out  before  operation.  The  small  intestines  should  be 
incited  to  action  immediately  after,  not  in  order  to 
empty  itself  but  because  we  wish  to  produce  and  main- 
tain intra-peritoneal  currents  which  shall  carryall  stray 
micro-organisms  rapidly  away  from  points  where  they 
may  develop,  into  the  lymphatics  and  glands  where 
they  will  be  consumed  by  phagocytes.  Gravity  should 
be  made  to  aid  in  this  matter  by  elevation  of  the  foot 
of  the  bed.  Cases  so  treated  are  cited.  Many  of  the 
evil  results  are  avoidable.  The  causes  of  hernia  pro- 
duction are  discussed,  and  the  rational  suture  to  pre- 
vent its  occurrence  is  given.  A  variety  of  evil  results 
and  the  precautions  necessary  in  order  to  avoid  them 
are  given. —  The  Scalpel,  August,  1900. 

A  New  Theory  in  Regard  to  Concussion  of  the 
Brain — D.  B.  Roncali  sums  up  his  article  as  follows: 
(i)  In  grave  cases  of  concussion  speedily  becoming 
fatal,  the  shock  to  the  cells  of  the  cerebro-spinal  axis 
and  of  the  bulb  causes  so  great  a  molecular  disturb- 
ance that  the  individual  neurons  become  incapable  of 
regulating  the  nutritive  and  dynamic  exchanges,  which 
results  in  a  suspension  of  the  nutritive  and  secretory 
functions,  causing  violent  death   of  the  neurons  from 


lack  of  nourishment  and  from  intoxication,  and  for 
this  reason  there  is  complete  absence  of  any  lesion  in 
the  nerve  tissue.  (2)  In  cases  of  concussion  in  which 
recovery  occurs  in  a  few  hours  or  days,  and  in  which  the 
nerve  cells  show  the  lesions  described  by  observers, 
there  is  a  transitory  suspension  of  the  nutritive  and 
dynamic  exchanges  with  temporary  suspension  of  nour- 
ishment, and  a  transitory  intoxication.  The  neurons 
appear  to  be  in  lethargy;  their  cellular  body  is  shrunk- 
en, and  there  is  retraction  of  the  prolongations  and  fu- 
sion of  the  chromatic  substances.  According  to  the 
author's  theory,  with  retraction  of  the  protoplasmic 
prolongations  there  comes  absence  of  nerve-protoplas- 
mic contact  and  contact  between  the  individual  neu- 
rons; conduction  of  impulses  to  or  from  the  cells  is 
prevented,  and  nerve  waves  are  impossible,  the  result 
being  a  temporary  suspension  of  the  vital  functions. — 
11  Foliclinicfl,  July  15,  1900. 

Echinococcus  Cysts  of  the  Domed  Surface  of  the 
Diaphragm;  Removal;  Cure.— Edmondo  Berger  re- 
ports the  case  of  a  man  aged  forty  years,  in  whom  a 
tumor  as  large  as  a  foetal  head  was  found  between  the 
left  hypochondrium  and  the  epigastric  region,  non- 
continuous  with  any  abdominal  organ,  sinking  with 
inspiration,  rising  with  expiration,  and  subject  to 
rhythmic  pulsations.  Exploratory  puncture  brought 
out  a  fluid  containing  echinococci.  Operation  revealed 
a  multiple  cyst  on  the  under  surface  of  the  diaphragm. 
The  patient  made  a  good  recovery.  The  cause  of  the 
cyst  was  probably  a  heavy  fall  upon  the  nates,  the 
shock  being  carried  up  to  the  diaphragm.  The  pulsa- 
tion observed  in  the  cyst  was  undoubtedly  transmitted 
from  the  heart. —  Gl' Inciiralyili,  August  i  and  15,1900. 

The  Therapy  of  Chorea — VV.  v.  Bechterew  consid- 
ers that  the  action  of  arsenic  in  this  disease  depends 
on  its  power  of  reducing  reflex  excitability,  basing 
his  views  on  experimental  evidence  which  shows  that 
the  primary  increase  in  irritability  is  succeeded  by  a 
secondary  blunting  of  the  centres.  In  accordance  with 
this  theory  he  combines  sedatives  with  the  arsenic, 
giving  the  latter  in  the  form  of  Fowler's  solution  or  as 
a  solution  of  arsenious  acid  in  doses  which  are  rapidly 
raised  to  twice  or  even  three  times  what  is  usually  ac- 
cepted as  the  maximum.  At  the  same  time  sodium  or 
potassium  bromide  and  antipyrin  are  given  in  large 
doses,  while  the  relationship  between  rheumatism,  en- 
docarditis, and  chorea  is  a  sufificient  indication  for  the 
routine  use  of  the  salicylates  in  conjunction  with  the 
other  remedies.  When  the  heart  lesion  actually  ex- 
ists cardiacs  are  administered.  Warm  baths  and  rest 
in  bed  are  also  valuable  adjuvants. —  Centralhlatt  Jiir 
Nervcnlicilkuude  mid  Psychiatric,  August,  1900. 

The  Prophylactic  Douche — O.  S.  Chapman  says 
that  in  regard  to  this  measure  there  are  two  classes  of 
observers  whose  results  are  absolutely  contradictory, 
but  the  weight  of  testimony  since  the  report  of  Kronig 
in  ICS94  seems  to  be  in  favor  of  discarding  the  douche. 
Doubtless  the  vaginal  secretions  may  contain  a  great 
variety  of  bacteria,  but  they  are  non-pathogenic,  or 
produce  only  a  moderate  rise  of  temperature.  The 
secretions  are  more  or  less  bactericidal  in  character; 
they  provide  nature's  barrier  against  the  entrance  of 
deleterious  germs  into  the  circulation,  and  to  remove 
them  is  held  to  be  unwise.  Severe  puerperal  fever 
and  death  are  generally  held  to  be  due  to  infection  from 
without,  which  is  usually  because  of  neglect  of  aseptic 
precautions  on  the  part  of  the  attendant.  Free  cathar- 
sis aids  in  the  elimination  of  bacteria  from  the  system. 
The  author  is  of  the  opinion  that  the  bacteria  will  meet 
with  more  timely  neutralization  without  the  prelimi- 
nary douche  than  with  it. — Annals  of  Gymrcology  and 
Pediatry,  September,  1900. 


October  6,  1900] 


MEDICAL    RECORD. 


537 


Medical   Record: 

A    Weekly  Journal  of  Medicine  and  Surgery. 


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

Publishers 

WM.   WOOD  &.  CO  ,  51    Fifth  Avenue. 

New  York,  October  6,  1900. 

THE  NOMENCL.VTURE   OF  INFLAMMATION. 

Inixammai'ion  has  always  been  a  difficult  condition 
to  express  in  a  word  so  distinctive  as  to  convey  to  the 
mind  of  the  scientific  man  a  clear  and  accurate  defini- 
tion. Even  in  the  days  gone  by,  the  term  was  vague 
to  a  certain  degree.  But  since  the  marvellous  advance 
made  in  pathology  within  recent  years,  the  situation 
in  this  respect  is  so  infinitely  worse  that,  without  much 
exaggeration,  it  might  be  described  as  almost  a  state 
of  chaos.  \\\y  man  who  can  point  a  path  out  of  the 
difficulty  will  be  deserving  of  the  heartfelt  thanks  of 
the  entire  medical  profession.  However,  it  requires 
the  possession  of  a  large  amount  of  courage  and  a  firm 
conviction  in  one's  own  opinions,  to  take  upon  one's 
self  the  part  of  reformer,  be  the  projected  change 
medical  or  otherwise. 

Most  people,  including  the  members  of  the  medical 
profession,  who  after  all  are  but  human,  when  once 
settled  in  a  groove  and  accustomed  by  the  force  of 
habit  to  a  certain  routine,  are  by  no  means  thankful  to 
the  earnest  and  well-meaning  person  who  is  wishful  to 
lead  them  into  the  right  way,  and  are  apt  to  regard  him 
as  a  decidedly  officious  and  troublesome  individual. 
With  regard  to  the  term  inflammation,  there  has  been 
for  some  time  more  tiian  a  suspicion,  w^hich  is  gradually 
changing  to  a  certainty,  that  it  is  not  the  right  word  in 
the  right  place,  and  one  or  two  eminent  scientists  have 
thrown  out  strong  hints  to  this  effect  in  order,  prob- 
ably, to  feel  the  pulse  of  medical  opinion  on  the  mat- 
ter. 

A  wonderful  change  has  passed  and  is  passing  over 
the  science  of  medicine  as  regards  the  etiology  of  dis- 
ease. Maladies  of  all  kinds  are  year  by  year  being 
referred  to  specific  causes.  Those  which  were  former- 
ly regarded  as  simple  inflammations,  in  order  to  dis- 
tinguish them  from  general  diseases,  are  now  placed 
in  their  correct  category.  Pneumonia  but  a  short 
time  since  was  esteemed  one  of  the  most  typically 
local  diseases,  although  it  has  now  been  demonstrated 
to  be  due  to  streptococcic  origin.  P-rysipelas  again, 
though  still  looked  upon  by  some  as  a  simple  inflani 
niation,  is  held  by  the  larger  number  of  investigators 
to  be  owing  to  a  distinct  microbe.  The  term  menin- 
gitis includes  a  whole  class  of  varying  forms  of  the 
malady,  none  of  which  can  be  called  simple;  and  the 
list  can  be  lengthened  almost  indefinitely.  Dr. 
Payne,  in  his  address  on  pathology  before  the  British 


Medical  Association  in  1898,  touched  on  all  these 
points,  and  remarked  pertinently  that  it  was  becoming 
a  question  whether  every  organ  of  the  body  had  its  in- 
flammation denoted  by  a  name  ending  in  itis.  This 
being  the  case,  it  is  contended  by  many  that  the  time 
has  come  to  alter  the  appellation  of  inflammation,  and 
to  bestow  upon  conditions  of  disease  names  truly  ex- 
pressive of  their  real  nature.  But,  as  said  before,  it 
takes  a  man  of  courage  even  to  recommend  a  change 
in  the  established  order  of  things.  A  few  have  done 
so  with  regard  to  the  term  inflammation,  although  in 
most  instances  somewhat  timorously;  and  by  none  has 
the  present  position  of  affairs  and  the  need  for  revi- 
sion been  put  so  boldly  and  clearly  as  by  Dr.  Andrew 
H.  Smith,  of  this  city. 

Dr.  Smitii  contributed  a  paper,  published  in  the 
Transactions  of  the  Association  of  American  Physi- 
cians, on  this  subject,  which  is  full  of  good  points. 
After  giving  a  lucid  explanation  of  the  phenomena  of 
inflammation  as  now  conceived  and  indeed  established, 
he  urges  that  the  terminal  itis  be  dropped.  He  shows 
that,  speaking  of  what  is  known  as  the  inflammatory 
process  in  injuries  as  a  matter  of  fact,  the  most  recent 
American  authorities  are  by  no  means  agreed  as  to 
what  manifestations  are  to  be  included  in  the  inflam- 
matory process,  and  what  are  to  be  left  without  the 
pale.  Thus  in  Park's  "  Surgery,"  by  American  authors, 
the  term  inflammation  is  restricted  to  those  disturb- 
ances which  are  produced  by  bacteria  themselves  or 
by  their  toxins,  and  which  tend  to  pus  formation. 
Nancrede  holds  a  similar  view  and  entitles  one  of  his 
lectures  "Inflammation  a  True  Microbic  Process." 
Dr.  Smith  suggests  that  as  most  of  the  phenomena 
heretofore  included  under  the  term  "  inflammation  " 
are  manifestations  of  the  local  action  excited  by  a 
micro-organism  or  by  a  poison  circulating  in  the 
blood,  such  action  be  expressed  by  a  termination  to  be 
affixed  to  the  name  of  the  organism  or  poison  if  the 
same  can  be  determined,  or  to  the  organ  or  part  af- 
fected in  case  the  particular  infecting  organism  or 
poison  is  not  identified.  He  aptly  cites  as  a  prece- 
dent for  the  first-named  use  the  case  of  tuberculosis. 
Dr.  Smith  contends  that  no  word  ought  to  be  made  to 
include  all  the  heterogeneous  unrelated  precursors  and 
conditions  which  have  been  comprised  under  the  term 
'■  inflammation,"  and  that  the  phenomena  ascribed  to 
the  inflammatory  process  should  be  assigned  to  new 
relations  in  accord  with  recent  advances  in  pathology, 
and  especially  in  bacteriology. 

He  further  would  have  us  adopt  traumosis  in  place 
of  inflammations  from  wounds  and  injuries,  toxosis  in 
lieu  of  inflammations  from  poisons,  and  bacteriosis  to 
denote  inflammations  from  the  action  of  micro-organ- 
isms. We  are  thus  presented  not  only  with  bold  ety- 
mological innovations,  but  the  whole  trend  of  Dr. 
Smith's  argument  is  of  an  iconoclastic  strain,  which  a 
less  courageous  man  would  have  hesitated  to  advance. 
If  the  medical  profession  should  accept  these  views 
with  half  the  enthusiasm  and  earnestness  with  which 
its  author  is  imbued  in  putting  them  forth,  the  gain 
would  be  considerable.  For  so  long  as  inflammation 
is  treated  as  a  disease  with  the  ciiief  object  of  combat- 
ing  its   more   conspicuous   manifestations,  heat,  red- 


538 


MEDICAL    RECORD. 


[October  6,  1900 


ness,  and  pain,  which  are  now  not  even  regarded  as 
essential  to  its  conception,  the  physician  is  too  much 
given  to  lose  sight  of  the  true  etiological  factor.  Dr. 
Smith  points  to  the  greater  success  in  the  management 
of  appendicitis  since  the  bacterial  origin  has  been 
recognized  and  the  antiphlogistic  treatment  has  been 
abandoned,  as  an  apropos  illustration  of  this  proposi- 
tion. 

Although  physicians  are  ever  becoming  more  and 
more  pervaded  by  the  enlightened  spirit  of  the  times, 
yet  the  shadow  of  antiquated  pathology  still  obscures 
the  clearer  conception  of  inflammation  reached  by  mod- 
ern research.  Dr.  Smith's  courageous  arraignment  of 
the  inappositeness  of  the  term  inflammation  as  used 
now  is  a  valuable  contribution  to  latter-day  scientific 
literature,  which  should  embolden  those  less  fearless 
to  follow  his  sagacious  lead  into  this  interesting  field 
of  inquiry.  The  most  valuable  outcome  from  the  pro- 
pagation of  the  view  that  inflammation  is  in  no  proper 
sense  a  new  force  projected  into  the  arena,  a  disturbing 
influence,  an  enemy  to  be  dreaded,  a  disease  to  be 
"treated,"'  will  be  that  its  treatment  will  be  abandoned. 
The  cause  of  the  true  malady  will  be  sought  out,  and 
when  found  attacked.  The  direction  of  modern  thera- 
peutics, too,  tends  toward  the  method  of  not  treating 
the  disease  so  much  as  the  patient  in  acute  infectious 
diseases.  Attention  was  drawn  to  this  truth  in  a 
paper  recently  published  in  the  Medical  Record.  If 
Dr.  Smith's  conclusions,  and  the  conclusions  of  those 
who  have  written  to  the  same  end  but  have  not  stated 
the  case  so  strongly,  are  accepted,  their  papers  will 
serve  a  most  beneficial  purpose,  and  should  pave  the 
way  to  a  more  enlightened  therapy.  Since  the  latter 
is  the  very  essence  of  the  physician's  life  work,  the 
importance  of  the  theme  cannot  be  overestimated. 


A    VERIFICATION    OF    THE    MOSQUITO- 
MALARIA   THEORY. 

We  have  referred  several  times  to  the  interesting  ex- 
periments which  some  English  observers  had  under- 
taken during  this  summer  in  the  hope  of  definitely  veri- 
fying or  disproving  the  mosquito  theory  of  the  spread 
of  malaria.  These  experiments  were  to  be  conducted 
both  in  Italy  and  in  England.  That  in  Italy,  which  is 
still  going  on,  consists  in  the  residence  of  several  men 
in  one  of  the  most  malarious  parts  of  the  Roman  Cam- 
pagna,  near  Ostia,  drinking  the  water  and  exposed  to 
the  night  air,  taking  no  quinine,  and  protected  only 
from  the  biles  of  Anopheles,  the  malarial  mosquitos. 
VVe  learn  from  the  British  Medicaljourna!  of  Septem- 
ber 22d,  that  it  is  highly  probable  this  experiment  will 
be  successful.  A  telegram  to  Dr.  Manson  from  Pro- 
fessor Grassi,  dated  September  13th,  stated  that  the 
health  of  the  experimenters  had,  up  to  that  time,  re- 
mained perfect.  Certainly,  if  these  men  (Drs.  Sam- 
bon  and  Low,  and  Signor  Terzi,  with  their  servants) 
escape  malaria,  we  shall  have  negative  evidence  of 
much  value  to  the  efTect  that  malaria  is  not  conveyed 
by  the  water  or  the  air. 

The  other  experiment,  which  has  just  been  concluded 
in  England,  has  furnished  us  with  very  positive  and 


conclusive  evidence  of  the  part  played  by  mosquitos 
in  the  transmission  of  this  disease  from  the  sick  to 
the  well.  In  a  leaflet  inserted  in  \.\\&  Jiuinial  of  Tropi- 
cal Medicine  iox  September,  1900,  it  is  stated  that  the 
experiment  of  inoculating  malaria  in  England  by  mos- 
quitos fed  on  malaria  patients  in  Rome  has  succeeded. 
"  At  Dr.  Manson's  request,  three  batches  of  Anopheles 
were  fed  in  Rome  by  Dr.  Bastianelli  on  three  sep- 
arate malarials  (tertians)  and  forwarded  in  cages  to 
the  London  School  of  Tropical  Medicine.  Dr.  Man- 
son's  son,  P.  Thurburn  Manson,  was  bitten  every  sec- 
ond day  by  the  insects  until  they  died — usually  about 
ten  days  after  their  arrival  in  London.  The  first  batch 
was  fed  in  London  on  the  first  and  second  week  of  July, 
the  second  at  the  end  of  August,  and  the  last  during  the 
second  week  of  this  month.  The  subject  of  this  ex- 
periment remained  in  perfect  health  till  the  morning 
of  September  13th,  when  headache,  bone-ache,  lassi- 
tude, and  anorexia,  with  rise  of  temperature  to  102°, 
set  in.  On  the  15th  there  was  a  distinct  intermission 
during  the  forenoon.  High  fever,  104°,  set  in  about 
4  P.M.,  with  delirium,  relieved  during  the  night  by 
profuse  diaphoresis.  The  same  series  of  events  re- 
curred on  the  1 6th.  On  the  morning  of  the  17th,  ter- 
tian parasites  were  found  in  the  blood." 

The  editor  of  the  journal  from  which  we  have 
quoted  adds  to  this  account  that  he  has  himself  seen 
the  parasites,  and  that  Dr.  Manson  has  been  careful 
to  have  the  observation  verified  by  several  competent 
observers.  This  is  unquestionably  the  most  conclu- 
sive of  the  inoculative  experiments  yet  made,  for  the 
possibility  of  infection  by  other  channels,  which  was 
present  in  the  Roman  experiments,  and  to  a  less  de- 
gree in  a  similar  one  which  we  understand  was  carried 
out  in  New  York  this  summer,  was  here  eliminated. 
Dr.  Manson's  son  could  not  get  tertian  fever  in  Lon- 
don in  any  ordinary  way,  and  he  had  not  been  in  a 
malarious  country  since  his  childhood,  therefore  there 
can  be  little  room  for  doubt  as  to  the  agency  of  the 
imported  mosquitos  in  the  causation  of  his  illness. 


THE  CHICAGO  DRAINAGE  CANAL. 

In  the  Rcvieru  oj  Reviews  for  January  is  an  article 
by  Professor  Edwin  O.  Jordan,  bacteriologist  in  the 
University  of  Chicago,  upon  the  Chicago  drainage 
canal.  The  article  in  question  is  moderate  in  "tone 
and  conservative  in  views,  the  author  expressing  his 
belief  that  the  dilution  with  so  large  a  body  of  water 
and  the  great  distance  (above  three  hundred  miles)  in 
which  the  stream  will  have  time  to  clear  itself  will 
render  it  harmless  before  reaching  St.  Louis,  but  the 
admission  is  made  that  a  "thoroughgoing  chemical 
and  bacteriological  examination,  both  before  and  after, 
is  the  only  way  by  which  the  questions  relating  to  the 
public  health  can  be  satisfactorily  and  conclusively 
answered.  If  it  should  be  found  on  impartial  in- 
quiry, after  the  canal  has  been  put  into  operation,  that 
danger,  inconvenience,  and  loss  arc  resulting  to  other 
communities,  ways  must  be  found  to  remedy  these 
difficulties."  This  is  the  ordinary  attitude  nowadays 
with   regard  to  pollution  of  water  supplies — pollute 


October  6,  1900] 


MEDICAL    RECORD. 


539 


first  and  inquire  afterward,  probably  when  it  is  too 
late  to  alter  to  any  great  extent  the  existing  insalu- 
brious conditions.  The  wholesale  and  careless  con- 
tamination of  streams  and  water  supplies  generally  is 
an  ever-growing  evil,  and  the  time  has  come  when  the 
public  must  insist  in  self-defence  that  very  much  more 
stringent  laws  than  those  relating  to  the  matter  now 
in  force  must  be  introduced  and  strictly  carried  out. 
It  may  be  in  the  case  of  the  Chicago  canal  that  at 
such  a  distance  purification  by  natural  means  may  take 
place,  and  tiiat  when  St.  Louis  is  reached  the  canal 
may  at  least  not  be  a  menace  to  the  health  of  the  in- 
habitants of  that  city.  So  far,  however,  as  the  proper- 
ties of  streams  or  rivers  purifying  themselves  is  con- 
cerned, it  has  been  proved  on  many  occasions  that  at 
all  times  a  much  longer  distance  than  was  formerly 
held  to  be  needful  is  necessary.  Also  this  is  a  matter 
in  which  the  character  and  amount  of  contamination 
and  the  flow  of  water  must  be  taken  into  account. 

']"he  fact  is  incontrovertible  that  the  hurtful  and 
alarming  conditions  whicii  have  been  brought  about 
by  a  stupid  and  careless  disposition  of  sewage  and 
wastes  of  mines  and  mills  is  so  evident  that  examples 
of  the  baneful  results  abound  on  every  side.  Mr. 
Henry  Talbot,  in  a  pamphlet  recently  published  by 
him  on  the  pollution  of  water  supplies,  makes  use  of 
the  following  strong  but  justifiable  language:  "The 
streams  have  been  made  sewers  through  selfishness, 
and  it  is  through  selfishness  alone  they  can  be  re- 
deemed and  purified."  The  people  of  St.  Louis  are 
undoubtedly  well  within  their  rights  in  objecting  to 
the  health  of  their  city  being  menaced  by  the  Chicago 
canal.  The  suggestion  of  Professor  Jordan  should  be 
promptly  acted  upon,  and  steps  taken  to  test  its  re- 
puted unsavory  waters. 


Philadelphia  County  Medical  Society At  a  stated 

meeting  held  September  26th,  Dr.  M.  J.  Karpeles  pre- 
sented a  communication  entitled  "  Imperforate  Hymen 
with  an  Interesting  History,"  and  Dr.  Joseph  Price 
read  a  paper  on  "  Delayed  Operations  in  Appendici- 
tis." 

The  Pathological  Society  of  Philadelphia.— At  a 
stated  meeting  held  September  27th,  Dr.  Joseph  Mc- 
Farland  presented  a  communication  entitled  "  Experi- 
mental Tuberculosis  in  Cats,"  detailing  the  results  of 
injections  of  "  avian,"  "bovine,"  and  "human"  tuber- 
cle bacilli.  Dr.  W.  Wayne  Babcock  presented  a 
specimen  of  multiple  pregnancy  in  association  with 
fibromyoma  of  the  uterus,  and  also  sections  from  a 
case  of  retroperitoneal  ( ?)  endothelioma. 

The  Tri-State  Medical  Society  of  Alabama,  Geor- 
gia, and  Tennessee. — The  twelfth  annual  meeting  of 
this  society  will  be  held  in  Chattanooga  on  Thursday, 
Friday,  and  Saturday,  October  11,  12,  and  13,  1900, 
during  the  reunion  of  the  Army  of  the  Cumberland 
and  the  Spanish-American  war  veterans.  A  rate  of 
one  fare  for  the  round  trip  will  doubtless  be  given  the 


latter  from  all  parts  of  the  country.  The  Southeast- 
ern Passenger  Association  has  already  given  this  rate, 
and  the  other  associations  will  take  up  the  matter 
shortly.  A  large  attendance  is  expected  and  a  good 
programme  is  in  prospect.  All  desiring  to  present 
papers  should  send  the  title  to  the  secretary,  Dr.  Frank 
Trester  Smith,  of  Chattanooga. 

A  Death  from  Anthracene A  woman  died  in  this 

city  recently  in  violent  convulsions.  Investigation 
showed  that  she  had  committed  suicide  probably  by 
taking  a  mixture  of  morphine  and  anthracene,  a  pre- 
scription calling  for  which  was  found  in  her  room. 
Anthracene  is  a  coal-tar  product  occurring  under  the 
form  of  colorless  fluorescent  crystals.  It  is  the  base 
from  which  alizarin  dyes  are  made. 

Cremation  in  Spain A  new  sanitary  law  which  is 

now  under  consideration  in  the  Cortes,  having  already 
passed  the  upper  house,  removes  the  ban  of  •illegality 
which  has  hitherto,  through  the  influence  of  the 
church,  rested  upon  the  practice  of  cremation  in 
Spain.  In  anticipation  of  the  passage  of  this  law  a 
cremation  society  has  recently  been  established  in 
that  country. 

By  the  Will  of   the  Late   Dr.  J.  M.    Da  Costa, 

formerly  professor  of  the  practice  of  medicine  and  of 
clinical  medicine  in  Jefferson  Medical  College,  the 
sum  of  $5,000  IS  devised  to  the  Pennsylvania  Hospi- 
tal for  the  endowment  of  a  free  bed,  an  equal  sum  to 
the  Children's  Hospital,  likewise  for  the  endowment 
of  a  free  bed,  in  memory  of  his  son,  John  M.  Da 
Costa;  $5,000  to  the  College  of  Physicians  of  Phila- 
delphia, for  the  endowment  of  a  publication  fund; 
?5,ooo  to  the  University  of  Pennsylvania  for  the  pro- 
fessors' retiring  fund.  His  valuable  and  extensive 
medical  museum,  including  charts,  models,  medical 
pictures,  and  drawings,  is  bequeathed  to  Jefferson 
Medical  College.  His  medical  library,  containing 
many  good  books,  is  bequeathed  to  the  College  of 
Physicians  of  Philadelphia. 

Prognosis  of  Yellow  Fever  in  Havana. — A  tele- 
gram from  Havana  to  The  Sun  says  that  the  statement 
was  made  recently  in  a  local  paper  that  forty-five  per 
cent,  of  the  Americans  attacked  by  yellow  fever  died. 
In  reply  to  this  Dr.  Gorgas,  w-ho  came  here  under  direc- 
tion of  the  Marine-Hospital  service,  has  written  a 
letter  to  the  journal  referred  to,  in  which  he  says  that 
during  the  year  1900  up  to  and  including  the  12th  of 
September,  out  of  a  total  of  one  hundred  and  nine 
American  cases  there  were  nineteen  deaths.  Sixty-six 
of  these  American  cases  were  treated  at  the  Las  Animas 
Hospital,  and  there  were  only  six  deaths.  Dr.  Gorgas 
says  that  his  object  in  correcting  the  statement  is  to 
relieve  Americans  from  the  feeling  that  forty-five  per 
cent,  of  them  are  bound  to  die  if  attacked  by  this  dis- 
ease. Under  favorable  circumstances  ninety-one  out 
of  every  one  hundred  attacked  recover.  This  is  not 
guesswork,  but  is  shown  by  actual  statistics. 

Infectiousness  of  Tuberculosis. — The  supreme 
court  of  Michigan  has  recently  decided  that  physicians 
must  obey  the  injunction  of  the  State  board  of  health 
to  report  all  cases  of  tuberculosis  coming  under  their 


540 


MEDICAL    RECORD. 


[October  6,  1900 


cognizance.  A  medical  man  of  prominence  had  dis- 
regarded this  requirement,  insisting  upon  his  right  to 
do  so  because  tuberculosis  was  not  expressly  men- 
tioned in  tile  statute.  The  lower  court  excused  him 
on  this  ground,  but  the  supreme  court  has  reversed 
this  decision,  holding  that  the  State  board  has  the 
discretionary  power  to  classify  pulmonary  consumption 
among  contagious  or  communicable  maladies. 

Professor  Th.  Escherich  of  the  chair  of  pediatrics 
has  been  elected  dean  of  the  medical  faculty  of  thu 
University  of  Graz  for  the  academic  year  1900-igoi. 

Dr.  James  Musgrove  has  been  appointed  the  first 
professor  to  tiie  new  chair  of  anatomy  established  and 
endowed  by  the  Marquis  of  Bute  at  St.  Andrews  Uni- 
versity by  a  gift  of  ^"20,000  for  the  purpose. 

The  Famine  in  India. — Some  idea  of  the  great 
calamity  which  has  visited  India  in  the  failure  of  the 
crops  through  lack  of  rain  is  to  be  had  from  a  report 
of  the  viceroy  of  India,  according  to  which  the  num- 
ber of  persons  receiving  relief  at  the  beginning  of 
September  was  4, 89 r, 000. 

Satisfactory  Health  Conditions  in  Santiago — 
Although  yellow  fever  has  been  rather  more  than 
usually  troublesome  in  Havana  this  summer,  no  case 
of  the  disease  has  been  reported  in  Santiago  since  De- 
cember. This  good  showing  is  attributed  to  efficient 
sanitary  administration  inaugurated  by  General  (Dr.) 
Leonard  Wood  and  maintained  by  Col.  Samuel  M. 
Whiteside,  commander  of  the  department  of  Santiago 
and  Puerto  Principe.  One  hundred  miles  of  streets 
are  swept  daily  and  previously  infected  houses  have 
been  three  times  disinfcQted.  A  house-to-house  in- 
spection is  made  by  the  surgeons,  and  thousands  of 
gallons  of  carbolic  acid  and  tons  of  chloride  of  lime 
have  been  used. 

A  Vaccinator  Charged  with  Assault. — A  physi- 
cian in  New  Bedford,  in  the  course  of  his  duties  as 
vaccinator  of  the  board  of  health,  visited  a  house  in 
which  he  found  a  six-year-old  boy  who  had  not  been 
vaccinated.  He  thereupon  vaccinated  the  lad  without 
any  objection  on  the  part  of  the  mother,  who,  how- 
ever, remarked  to  him  at  the  time:  "You  won't  have 
to  vaccinate  my  baby,  will  you?"  The  doctor  an- 
swered that  he  thought  he  would,  and  in  response  to 
further  objections  by  the  mother  told  her  that  she 
would  have  to  settle  them  with  the  board  of  health. 
He  then  proceeded  to  vaccinate  the  baby,  a  child  five 
months  old.  Some  time  later  he  was  more  surprised 
than  pleased  to  be  dragged  into  court  on  a  charge  of 
assault  and  battery.  It  was  proved  w-ithout  contradic- 
tion that  the  mother,  notwithstanding  her  remon- 
strances, bared  the  infant's  arm  for  the  operation; 
and  the  court  acquitted  the  defendant  on  this  ground, 
holding  that  it  was  convincing  evidence  that  the  com- 
plainant, although  undoubtedly  reluctant,  had  finally 
consented  that  the  child  should  be  vaccinated. 

A  Course  of  Hospital  Economics  at  the  Teach- 
ers' College. — .\t  the  request  of  the  American  Society 
of  Superintendents  of  Training-Schools  for  Nurses, 
the  authorities  of  Columbia  University  will  establish 


this  fall  a  special  course  in  "Hospital  Economics,"  to 
be  given  at  Teachers'  College.  The  aim  of  the  course 
is  to  fit  persons  who  arc  already  trained  nurses  for  the 
responsible  duties  of  superintendents  of  hospitals  and 
principals  of  training-schools  for  nurses.  It  is  in- 
tended to  present  the  practical  problems  of  hospital 
administration  and  to  give  students  systematic  instruc- 
tion in  tlie  organization  and  management  of  training- 
schools.  The  prescribed  course  of  study  will  include 
general  psychology  and  its  application  in  teaching; 
methods,  practice,  organization,  and  supervision  of 
hospitals  and  training-schools,  biology,  physiology, 
hygiene,  tlie  production  and  manufacture  of  foods, 
home  sanitation  and  management,  bacteriology,  and 
household  chemistry.  Special  researches  will  also  be 
made  on  the  subjoined  topics:  Laboratory  preparation 
of  culture  media,  isolation  and  culture  of  bacteria, 
preparation  of  antitoxins;  milk  laboratories,  modified 
milk,  sterilized  milk,  pasteurized  milk,  dairies,  source 
of  bacteria  in  milk,  effects  of  bacteria  in  milk;  gen- 
eral hospitals,  private  hospitals,  special  hospitals, 
training  schools,  small  general  hospitals,  insane 
asylums,  dietary  on  a  scientific  basis  in  an  insane 
asylum,  operating-theatre,  sterilizing-plant,  preparation 
for  operation,  detail  work  of  clinic,  philanthropic 
organizations,  relations  of  the  nursing-professor. 

American  Public  Health  Association. — The  twenty- 
eighth  annual  meeting  of  this  society  will  be  held  at 
Indianapolis  on  October  22,  23,  24,  25,  and  26,  1900, 
under  the  presidency  of  Dr.  Peter  H.  Bryce,  of  Toronto. 
The  following  subjects  will  be  discussed:  The  Pollu- 
tion of  Public  Water  Supplies,  The  Disposal  of  Refuse 
Material,  Animal  Diseases  and  Animal  Food,  Car 
Sanitation,  Etiology  of  Yellow  Fever,  Steamship  and 
Steamboat  Sanitation,  Relation  of  Forestry  to  the 
Public  Health,  Demography  and  Statistics  in  their 
Sanitary  Relation,  Cause  and  Prevention  of  Infectious 
Diseases,  Public  Health  Legislation,  The  Duration  of 
Infectious  Diseases,  Cause  and  Prevention  of  Infant 
Mortality,  Disinfectants,  Municipal  Sanitary  Admin- 
istration, To  Define  What  Constitutes  an  Epidemic,  A 
National  Leper  Home,  Dangers  to  the  Public  Health 
from  Illuminating  and  Fuel  Gas,  Revision  of  Bertillon 
Classification  of  Causes  of  Death,  Transportation  of 
Diseased  Tissue  by  Mail,  The  Teaching  of  Hygiene 
and  Granting  of  Degrees  of  Doctor  of  Public  Health, 
and  Sewerage  and  Water  Supply.  Special  attention 
will  be  given  to  tlie  engineering  phase  of  the  last- 
named  subject. 

Examination  for  Acting  Assistant  Surgeon  in 
the  Marine-Hospital  Service. — The  United  States 
Civil  Service  Commission  announces  that  on  October 
23  and  24,  J 900,  an  examination  will  be  held  in  any  city 
in  the  United  States  where  it  has  a  local  board  of  ex- 
aminers, for  the  position  of  acting  assistant  surgeon  in 
the  Marine-Hospital  service.  The  examination  will 
consist  of  the  subjects  mentioned  below,  whicii  will 
be  weighted  as  follows:  Letter  writing,  5  ;  anatomy 
and  physiology,  15;  surgery  and  surgical  pathology, 
20;  chemistry,  materia  niedica,  and  therapeutics,  10; 
bacteriology  and  hygiene,  10;  theory  and  practice  of 
medicine  and  general   pathology,  25;  obstetrics  and 


October  6,  1900] 


MEDICAL    RECORD. 


541 


gynaecology,  15  ;  total,  100.  The  examination  will  be 
divided  into  two  days  of  seven  hours  each.  Applicants 
for  this  examination  must  be  competent  physicians  and 
surgeons,  graduates  of  reputable  medical  colleges,  and 
must  furnish  satisfactory  certificates  relative  to  their 
moral  character  and  ability.  From  the  eligibles  re- 
sulting from  this  e.xamination  it  is  expected  that  cer- 
tification will  be  made  to  the  position  of  acting  assist- 
ant surgeon,  United  States  Marine-Hospital  service, 
at  Juneau,  Alaska,  and  for  similar  vacancies  as  they 
shall  occur.  This  examination  is  open  to  all  citizens 
of  the  United  States  who  comply  with  the  requirements 
and  desire  to  enter  the  service.  All  such  persons  are 
invited  to  apply,  and  applicants  will  be  examined, 
graded,  and  certified  with  entire  impartiality  and 
wholly  without  regard  to  any  consideration  save  their 
ability  as  shown  by  the  grade  attained  in  the  examina 
tion.  It  is  the  practice  of  the  department,  however, 
whenever  practicable,  to  appoint  a  regularly  practis- 
ing physician  residing  at  the  place  where  the  vacancy 
exists.  Persons  who  desire  to  compete  should  at  once 
apply  to  the  United  States  Civil  Service  Commission, 
Washington,  I).  C,  for  application  forms  304  and 
375,  which  should  be  properly  executed  and  promptly 
forwarded  to  the  commission. 

Decreasing  Infant  Mortality  in  New  York  City. 
— Although  the  summer  just  passed  was  one  marked 
by  excessive  heat  and  humidity,  almost  without  a 
break  for  three  months,  the  infant  death  rate  was  less 
than  for  any  year  in  the  past  decade.  The  following 
table  is  made  up  from  the  statistics  of  the  board  of 
health : 

Deaths  and  Death  Rates  of  Children  Under  Five 
Years  ok  Ac.k,  for  the  Months  of  June,  July,  and 
August. 


1891  . 

1892  . 

1893  . 

1894  . 
1895. 
1896  . 
1897. 

1895  . 

1899  . 

1900  . 


Population. 


188,703 

194.214 
199,88c 
205,723 
212,983 
216,728 
220,641 
224,736 
229,029 
233.537 


Deaths. 


5.945 
6,612 

5,892 

5.789 
6,183 

5.671 
5.401 
5.047 
4,68g 
4.562 


Death  Rate. 


126.0 

1 36. 1 

I17.9 

112. 6 

1 16. 1 

104.7 

91.3 

89.8 

81. S 

78.1 


It  is  claimed  by  those  who  are  interested  in  ihe 
Nathan  Straus  booths  for  the  distribution  of  pasteur- 
ized milk  that  this  good  showing  is  largely  due  to  this 
establishment.  The  first  sterilized-milk  booths  were 
opened  in  1893,  and  the  infant  death  rate  has  almost 
steadily  declined  since  then.  No  doubt  this  is  one  of 
the  causes,  but  we  are  inclined  to  the  belief  that  to 
the  late  Colonel  Waring  belongs  much  of  the  credit 
for  this  saving  of  life,  for  the  progressive  decrease  in 
the  infant  mortality  reall)'  began  with  the  cleaning  of 
the  streets  effected  by  that  noble  citizen. 

A  Testator  Objects  to  Chaplains It  is  stated  in 

the  National  Hospital  Record  that  a  recent  bequest  of 
$50,000  to  the  Geneva,  N.  V.,  City  Hospital  contains 
a  peculiar  clause,  stipulating  that  the  hospital  "shall 
not  have  an  officer  known  as  a  chaplain  or  have  any 
person  in  its  service   at  any  time  any  part  of  whose 


duties  it  shall  be  to  perform  such  services  as  are 
usually  performed  by  a  chaplain."  The  will  provides 
that  in  case  the  request  is  not  complied  with  such  be- 
quest shall  revert  to  the  estate  of  the  testator  and 
then  be  given  to  the  Rochester  City  Hospital.  Not 
more  than  $10,000  of  the  sum  is  to  be  expended  for 
buildings. 

Medical  Fraternities  for  Women. — We  are  re- 
quested by  a  member  of  "Zeta  Phi"  to  state  that  this 
society  is  not  the  first  and  only  woman's  medical 
fraternity,  there  being  one  and  possibly  more  in  west- 
ern medical  colleges. 

Trinity  Infirmary,  which  has  been  closed  since 
last  spring,  will  be  reopened  about  the  middle  of  this 
month.  The  hospital  was  formerly  under  the  charge 
of  the  Episcopal  Sisters  of  St.  Mary,  but  will  in  future 
be  under  the  management  of  a  woman  superintendent 
and  a  staff  of  lay  nurses. 

The  Plague  still  lingers  in  Glasgow.  There  were 
two  deaths  on  September  29th,  one  of  them  being  of 
an  infant  born  of  a  woman  suffering  at  the  time  from 
the  disease.  Up  to  the  first  of  this  month  there  had 
been  seven  deaths,  and  twenty-one  cases  w-ere  still 
under  treatment. 

Insanity  of  a  Christian  Science  Convert.^A 
young  woman  physician,  formerly  practising  in  Con- 
cord, is  confined  at  the  New  Hampshire  Asylum  for 
the  Insane  under  treatment  for  melancholia,  which 
began  to  show  itself  shortly  after  she  embraced  the 
teachings  of  Christian  Science  and  relinquished  the 
practice  of  her  profession. 

Ptomain  Poisoning  at  a  Dental  Dinner Twenty- 
four  dentists,  members  of  the  Delta  Sigma  Delta 
fraternity  in  Chicago,  attended  a  banquet  of  the  so- 
ciety on  September  28th,  and  more  than  half  of  them 
presented  serious  symptoms  of  ptomain  poisoning 
during  the  night.  The  poison  is  believed  to  have 
been  contained  in  some  canned  salmon. 

A  Collective  Investigation  of  Cancer  in  Prussia. 
— The  Prussian  government  has  sent  a  circular  to  all 
practising  physicians  in  the  kingdom  calling  for  an- 
swers to  a  series  of  questions  bearing  upon  the  eti- 
ology of  cancer.  The  principal  points  are  whether 
cancer  is  hereditary  and  contagious,  whether  it  is  con- 
nected with  a  particular  habit  such  as  indulgence  in 
alcohol,  tobacco,  etc.,  and  w'hether  it  is  more  prevalent 
in  one  town  or  province  than  in  another. 

Scarlet  Fever  at  a  Health  Resort.^It  is  reported 
from  Quebec  that  many  members  of  the  large  Ameri- 
can colony  at  Murray  Bay,  the  watering-place  of  the 
lower  St.  Lawrence,  have  been  placed  in  quarantine 
on  account  of  the  outbreak  of  scarlatina  in  their 
families,  and  they  are  unable  to  leave  for  home.  The 
family  in  which  the  first  case  of  scarlatina  occurred  had 
made  purchases  of  homemade  Canadian  rugs,  home- 
spun cloths,  etc.,  manufactured  by  the  local  French- 
Canadian  housewives,  and  these  are  believed  to  have 
carried  the  infection.  The  rapid  spread  of  the  dis- 
ease is  attributed   in  part  to  the  promiscuous  use  by 


542 


MEDICAL    RECORD. 


[October  6,  1900 


visitors  of  the  calashes,  or  peculiar  two-wheeled 
public  conveyances.  All  these  are  now  being  disin- 
fected. 

Evidences  of  the  Coal-Miners'  Strike  have  dark- 
ened the  sky  of  this  city  during  the  past  two  weeks, 
for  many  establishments  have  begun  to  use  bituminous 
coal  and  their  chimneys  have  sent  forth  great  clouds 
of  black  smoke.  No  doubt  it  would  have  been  even 
worse  but  for  the  action  of  the  health  department  in 
causing  the  arrest  of  many  of  the  offenders.  There  is 
no  law,  we  believe,  against  the  burning  of  soft  coal, 
but  only  against  permitting  the  smoke  thus  formed  to 
escape. 

A  Valued  Diploma. — A  physician  in  Brooklyn 
nearly  lost  his  life  a  few  days  ago  while  attempting  to 
save  his  diploma  of  the  College  of  Physicians  and 
Surgeons  from  his  burning  residence.  A  few  minutes 
after  the  doctor  had  been  aroused  and  had  reached  the 
street  he  rushed  back  into  the  burning  building  for 
his  diploma,  which  was  in  a  room  on  the  second  floor. 
He  succeeded  in  finding  it,  but  while  groping  about 
the  lower  vestibule  was  overcome  by  smoke.  He  was 
found  unconscious  on  the  floor  and  dragged  to  the 
open  air,  where  he  was  revived.  The  diploma  was 
recovered,  after  the  fire  had  been  extinguished,  near 
the  spot  where  the  doctor  had  fallen  unconscious. 

Insanity  at  the  Elmira  Reformatory. — It  is  re- 
ported that  in  the  past  six  months  sixty-five  inmates 
of  the  State  Reformatory  at  Elmira  have  been  trans- 
ferred to  the  Matteawan  State  Hospital  for  the  Insane. 
Some  of  the  young  criminals  at  the  reformatory  de- 
velop symptoms  of  insanity  and  are  transferred  to  the 
asylum  every  month,  but  this  is  greatly  in  excess  of 
the  usual  number.  It  is  noteworthy  that  this  increase 
is  for  the  period  following  the  resignation  of  the 
former  superintendent,  concerning  the  alleged  brutal- 
ity of  whose  administration  there  was  such  an  outcry 
in  the  sensational  newspapers. 

Navy  Department,  Bureau  of  Medicine  and  Sur- 
gery, Washington,  D.  C. — Changes  in  the  medical  corps 
of  the  United  States  navy  for  the  week  ending  Sep- 
tember 29,  1900.  September  21st. — Assistant  Surgeon 
M.  K.  Elmer  detached  from  Boston  navy  yard,  ordered 
to  accompany  battalion  of  marines  to  Mare  Island,  then 
to  duty  on  Ranger.  Assistant  Surgeon  J.  C.  Thomp- 
son detached  from  Newark  on  reporting  of  relief, 
to  proceed  home  and  wait  orders.  Assistant  Surgeon 
W.  B.  Grove  ordered  to  duty  on  Vermorit.  Assistant 
Surgeon  H.  E.  Odell  detached  from  Ranger  on  report- 
ing of  relief,  and  ordered  to  Asiatic  station  with  bat- 
talion of  marines  for  duty  as  relief  of  Assistant  Surgeon 
J.  C.  Thompson.  September  24th. — Surgeon  B.  F. 
Stephenson  detached  from  the  Baltimore  when  out  of 
commission,  ordered  to  examination  for  promotion  at 
Washington  navy  yard,  October  ist,  thence  home  and 
wait  orders.  Assistant  Surgeon  W.  H.  Bell  relieved 
from  additional  duty  at  Norfolk  Hospital,  and  ordered 
to  continue  duty  on  the  Vixen.  September  2Sth. — As- 
sistant Surgeon  H.  A.  Dunn,  order  of  September  22d 
modified,  ordered  to  report  for  duty  on  Dorothea  Oc- 
tober 1st,  instead    of    proceeding   home.     September 


26th. — Assistant  Surgeon  K.  Ohnesorg  detached  from 
the  Naval  Academy  and  ordered  to  the  Viikslnirg. 
Assistant  Surgeon  A.  Stuart  detached  from  the  For- 
tune and  ordered  to  resume  duties  on  the  Yankton. 
Assistant  Surgeon  E.  V.  Armstrong  ordered  to  report 
to  commandant  of  New  York  navy  yard  for  duty  on 
Vermont.  September  27th. — Medical  Director  C.  U. 
Gravatt  commissioned  medical  director  from  August 
24th.  Surgeon  G.  B.  Wilson  commissioned  surgeon 
from  February  7th.  September  22d.- — Pharmacist  R. 
Waggener  ordered  to  duty  at  naval  proving-grounds, 
Indian  Head,  Md. 


©liitxxaxn;. 

SAMUEL    SMITH   PURPLE,    M.D., 

NEW    VORK. 

Dr.  S.  S.  Purple,  whose  death  occurred  on  Saturday 
night,  after  a  brief  illness,  was  one  of  the  last  of  the 
generation  of  New  York  physicians  which  included 
Sayre,  Willard  Parker,  Fordyce  Barker,  Post,  Clark, 
and  others.  He  was  born  in  Lebanon,  Madison 
County,  N.  Y.,  June  24,  1822,  and  was  graduated  at 
the  medical  department  of  the  University  of  the  City 
of  New  York  in  1844.  In  1846-48  he  was  physician 
at  the  New  York  City  Dispensary,  and  was  ward  phy- 
sician under  the  board  of  health  during  the  cholera 
epidemic  of  1849.  He  was  vice-president  of  the 
New  York  Academy  of  Medicine  from  1870  to  1875, 
and  its  president  from  1876  to  1880.  The  profession 
of  this  city  owes  to  Dr.  Purple's  generosity  the  library 
of  the  Academy  of  Medicine,  for  it  was  his  presenta- 
tion of  four  thousand  volumes  that  formed  the  nucleus 
of  the  library  which  has  now  grown  to  such  proportions. 
He  is  said,  notwithstanding  this  gift,  to  have  owned 
at  the  time  of  his  death  one  of  the  largest  private 
libraries  in  New  York.  Dr.  Purple  was  a  prominent 
member  of  the  New  York  Genealogical  and  Bio 
graphical  Society,  and  was  elected  a  vice-president  of 
the  society  in  18S8.  For  a  number  of  years  he  was 
senior  editor  of  the  Ncc  York  Journal  of  Medicine 
until  it  was  merged  into  the  Atnerican  Medical  Times 
in  i860.  He  followed  the  active  practice  of  his  pro- 
fession until  fifteen  years  ago,  when  he  retired  to  en- 
joy the  ease  to  which  he  was  entitled  after  his  long 
and  busy  career. 


ALFRED    STILLE,    M.D., 

I'HII.ADRLI'HrA. 

Dr.  Alfred  Stille  died  at  Philadelphia  on  Septem- 
ber 24th  in  the  eighty-seventh  year  of  his  age.  He 
was  gra-duatcd  from  the  University  of  Pennsylvania 
in  1832,  and  from  its  medical  department  in  1S36, 
wlien  he  became  a  resident  physician  in  the  Phila- 
delphia Hospital.  After  post-graduate  study  abroad 
for  two  years,  he  became,  in  1839.  a  resident  phy- 
sician in  the  Pennsylvania  Hospital.  From  1845 
to  1859  he  was  lecturer  on  general  pathology  and 
the  practice  of  medicine  in  the  Philadelphia  As- 
sociation for  Medical  Improvement,  and  from  1854 
until  1859  he  occupied  the  chair  of  the  theory  and 
practice  of  medicine  in  liie  Pennsylvania  Medical 
College.  In  1864  he  was  elected  professor  of  the 
theory  and  practice  of  medicine  in  the  University  of 
i'ennsylvania,  and  upon  his  resignation  many  years 
ago  he  was  elected  emeritus  professor.  He  became  a 
visiting  physician  to  St.  Joseph's  Hospital  in  1840, 
resigning  this  position   m    1877.     During  the  Civil 


October  6,  1900] 


MEDICAL    RECORD 


543 


War  he  was  one  of  the  visiting  physicians  to  tiie 
United  States  Satterlee  Hospital.  He  was  from  1865 
to  187 1  one  of  the  physicians  to  the  Philadelphia 
Hospital.  He  was  one  of  the  founders  of  tiie  Ameri- 
can Medical  Association  and  a  mtniber  of  many 
scientific  bodies,  in  several  of  which  he  at  times  held 
important  offices.  He  was  a  prolific  writer,  being 
among  other  things  co-editor  of  the  United  States 
Dispensatory,  co-translator  of  Andral's  "  J'athological 
Ha'matology,'"  and  author  of  "  Klenients  of  General 
Pathology  "  and  of  "  Materia  Medica  and  Therapeu- 
tics."   

Obituary  Notes.— Dr.  S.  Potts  Eagleto.n-,  for- 
merly of  Philadelphia,  died  at  Ocala,  Fla.,  on  Sep- 
tember i8lh,  at  the  age  of  thirty-three  years.  He 
was  graduated  from  the  University  of  Pennsylvania 
in  1890. 

Dr.  Jesse  \V.  Lazear,  acting  assistant  surgeon  in 
the  United  States  army,  died  of  yellow  fever  in  Cuba 
on  September  25th.  He  formerly  practised  in  Balti- 
more, and  was  a  graduate  of  the  College  of  Physicians 
and  Surgeons  in  New  York  City  in  the  class  of  1S92. 


progress  of  |]actUcal   Science. 

Journalojtiii:  American  Medical  Ass' it,  Scpl.  sg,  igoo. 

Etiology  of  Scarlatina.  —  William  J.  Class  considers  the 
eviduiice  in  favor  of  the  view  that  the  diplococcus  scarla- 
tina' is  the  cause  of  scarlet  fever.  This  organism  is  a  new 
germ.  Its  presence  in  cases  of  the  disease  has  been  well 
proved,  tiradwohl  found  it  in  seven  consecutive  cases  and 
Jaqucs  in  every  one  of  a  large  number  of  cases  examined. 
The  writer  in  1S99  had  found  it  in  three  hundred  succes- 
sive cases  of  scarlet  fever  and  scarlatinous  sore  throat.  It 
is  pathogenic  for  mice,  swine,  and  guinea-pigs.  Scarlet 
fever  can  be  reproduced  in  animals  by  the  diplococcus 
scarlatina',  and  the  pathological  changes  resemble  those  of 
scarlet  fever.  The  disease  produced  by  this  organism  is 
of  a  contagious  nature.  Scarlet-fever  blood  has  an  inhil)i- 
tory  action  on  the  growth  of  this  organism.  This  germ  is 
found  in  throat  secretions  of  patients  with  scarlatinous 
sore  throat.  The  growth  of  the  organism  in  milk  does  not 
affect  that  medium.  The  germ  is  found  in  cases  of  surgi- 
cal scarlet  fever. 

Gauze  Carrier. — Clinton  T.  Cooke  describes  this  new  in- 
strument designed  to  introduce  gauze  into  cavities  in.  or 
orifices  <if,  the  body  for  drainage  purjioses  or  for  control- 
ling hemorrhage.  It  will  rapidly  and  often  painlessly 
pack  gauze  into  cavities,  wounds,  fistula;,  or  sinuses.  Only 
one  introduction  is  necessary  at  one  dressing.  The  gauze 
is  transferred  directly  from  container  to  cavity,  and  is  not 
touched  by  hum.TU  hands. 

Technique  of  Vaginal  Extirpation  for  Cancer  of  the  CervLx 
by  Ligature  Only.— I5y  Rufus  B.  Hall. 

Abdominal  vs.  Vaginal  Hysterectomy  for  Uterine  Carci- 
noma.—  By  John  B.  Dcaver. 

Importance  of  Early  Recognition  of  Cancer  of  the  Uterus. 
— By  William  11.  Humiston. 

Operative  Treatment  of  Cancer  of  the  Uterus.— By  Wil- 
liam R.  Pryor. 

PhiiailclpJiia  Mcilical  Journal  Scplctnber  sg.  iqoo. 
Inhibition  of  the  Heart  as  an  Aid  in  Diagnosis. — Albert 
Abranis  sums  up  the  following  conclusions  :  i.  The  inhibi- 
tion manceuvre  will  cause  organic  cardiac  murmurs  to  be- 
come faint,  and  in  exceptional  cases  inaudible.  2.  Trans- 
mitted murmurs  are  more  amenable  to  the  manceuvre.  3. 
The  fainter  the  murmur,  the  more  easily  is  it  sujjpressed 
by  the  manoeuvre.  4.  When  a  transmitted  murmur  can  be 
inhibited,  the  tone  which  it  masks  can  be  auscultated.  5. 
Heart  tones  are  less  amenable  than  are  heart  murmurs  to 
inhibition.  6.  Ilsemic  murmurs  are  more  readily  inhibited 
than  arc  the  organic  murmurs.  7.  As  a  rule,  the  murmurs 
of  anjemia  may  be  suppressed  and  their  evanescence  is 
marked  by  the  reappearance  of  tones.  8.  Exocardial  mur- 
murs are  easily  influenced  by  the  inhibition  mauoeuvre.  9. 
When  the  inhibition  manoeuvre  is  incorrectly  executed,  the 
result  is  to  increase  the  intensity  of  the  murmurs  owing  to 
increased  exertion  which  intensifies  the  force  of  the  heart's 
action.  10.  The  manoeuvre  often  repeated  gives  no  results, 
owing  to  overstimulation  of  the  vagi.     1 1.  In  irregular  ac- 


tion of  the  heartor  in  delirium  cordis,  the  inhibition  manoeu- 
vre is  valuable  in  determining  the  time  of  a  murmur.  12. 
This  manoeuvre  enables  us  to  determine  the  condition  of  the 
vagi  as  inhibitors  of  the  heart  and  is  a  guide  in  the  admin- 
istration of  cardio-touics.  For  clinical  purposes,  inhibition 
of  the  heart,  according  to  the  writer's  experience,  is  best 
attained  by  voluntary  contraction  of  the  muscles  of  the 
neck,  wliicli.  however,  must  needs  be  forcible.  The  ma- 
nceuvre IS  readdy  learned. 

On  Some  Cases  of  Pleural  Exudate,  with  the  Physical 
Signs  of  Pneumonia. — Herman  B.  Allyn  recounts  a  case 
of  empyema  in  a  young  woman  who  had  been  perfectly 
well  till  nine  days  before  admission  to  the  hospital.  Four 
days  before  admission  she  had  been  taken  with  a  severe 
chill,  and  since  had  been  in  bed  with  fever,  cough,  pain  in 
the  side,  and  expectoration.  The  physical  signs  on  admis- 
sion consisted  of  flatness  on  percussion  over  the  left  luiig, 
increased  vocal  fremitus,  bronchophony  and  pectoriloquy, 
tubular  breathing,  and  some  subcre])itant  rales  at  the  left 
base.  At  the  autopsy  was  found  a  thickened  pleura,  with 
about  250  c.c.  of  pus,  a  fibroid  lung,  with  bronchiectasis 
and  old  tuberculous  foci  in  both  lungs.  There  was  prob- 
ably just  enough  air-space  above  the  small  layer  of  pus  to 
act  as  a  resonator  for  the  voice  and  breath-sounds  trans- 
mitted through  the  dilated  bronchus.  There  is  evidently 
no  pathognomonic  sign  of  a  jileunil  exudate.  The  most 
important  test  of  tlie  presence  of  fluid  in  the  jileural  cavity 
is  puncture  with  an  aspiratmg-iieedle.  The  .i-rays  are  of 
great  service  in  the  diagnosis  of  pleural  effusion  and  of 
the  amount  <if  fluid  jjresent. 

Pylorectomy  for  Adenocarcinoma,  with  Report  of  a  Case. 
—  By  Josejih  11.  Braiiham. 

Hemorrhoids  :    Etiology,   Pathology,   and    Treatment. — By 

J.  William  J.  Doyle. 

Somo  Clinical  Effects  of  Ammonio-Formaldehyde.— By  Ed- 
ward L.  Keyes. 

A  Digest  of  Two  Hundred  Cases  of  Pneumonia. — By  C.  Z. 

Weber. 

Appendicitis. — By  Samuel  Lloyd. 

Medical  A'ews.  Seplevtbcr  2q,  iqoo. 

Some  Studies  in  Metabolism  in  Chronic  Nutritional  Dis- 
ease.— (J.  W.  XlcCaskey  says  that  in  the  study  of  chronic 
nutritional  disease  of  various  sorts,  they  can  be  divided 
into  three  groups:  one  with  diminished,  another  with  ex- 
cessive, and  a  third  with  normal  urea  excretion.  Out  of 
forty  cases  of  neurasthenia  with  marked  hypoazoturia,  the 
lowest  quantity  found  was  2  gm.  in  one  case,  ten  cases 
had  5  to  6  gm.,  and  the  remainder  ranged  from  6  to  ig.  In 
cases  of  hyperazoturia  we  find  numerous  chronic  morbid 
states,  among  which  diabetes  mellitus  occupies  a  conspicu- 
ous position,  in  which  tissue  metabolism  is  excessive,  and 
the  output  of  urea  greatly  in  excess  of  what  it  ought  to 
be.  In  the  case  of  a  young  girl  weighing  ninetj--five 
pounds,  the  quantity  of  urea  was  48  gm.  In  cases  of  or- 
tho-azoturia  we  find  the  urea  excretion  strictly  within  the 
normal  range,  and  yet  have  to  deal  with  obvious.  cl;ronic, 
morbid  nutritional  states :  here  we  commonly  have  to  deal 
with  toxic  conditions  resulting  from  functional  disturb- 
ances of  some  one  or  more  of  the  principal  organs  of  the 
body.  In  studying  the  urea  excretion  a  series  of  analyses 
of  measured  twenty-four-hour  collections  is  advisable  in 
all  cases  in  which  unusual  conditions  are  met  with. 

The  Art  of  Keeping  Cool,  with  Special  Reference  to  the 
Proper  Use  of  Water. — Ralph  Wait  Parsons  says  that  by 
introducing  water  in  small  and  frequent  quantities  cither 
into  the  stomach  or  rectum,  we  can  obtain  a  reduction  in 
the  bodily  temperature,  due  to  the  direct  effects  of  the 
cooling  properties  of  the  water,  to  reflex  action,  and  to 
stimulation  of  the  function  of  the  sweat  glands.  In  hot 
weather,  he  advocates  a  dip  in  water  at  (xj  to  70'  F.  last- 
ing from  one-half  to  one  minute,  and  followed  by  a  vigor- 
ous rub  with  a  coarse  bath  towel.  A  shower  bath  is  even 
better.  This  cold  bath  stimulates  the  heart  and  nervous 
system,  gives  a  sense  of  well-being,  gives  a  healthy  glow 
to  the  .skin,  improves  the  appetite,  and  rejuvenates  the 
whole  organism,  giving  energy  to  resist  the  depressing 
effects  of  heat  and  sultriness.  At  the  close  of  a  hot  day, 
a  bath  at  103^  to  105'  F.,  lasting  from  three  to  seven  min- 
utes, is  cleansing  and  stimulating;  it  should  be  followed 
by  cold  water,  and  after  a  brisk  rub  the  bather  can  go  to 
rest,  and  in  the  majority  of  eases  enjoy  a  good  night's 
sleep,  although  the  temperature  be  very  high. 

The  Dose  of  Potassium  Iodide  with  Reference  to  its  Un- 
toward Effects  upon  the  Upper  Respiratory  Tract. — Lewis 
S.  Somers  calls  attention  to  the  frequent  production  of 
iodism  from  small  doses,  and,  in  contrast,  the  comparative 
immunity  which  attends  the  administration  of  large  quar.- 
tities.  In  some  instances,  should  congestion  of  the  upper 
respiratory  tract  be  developed  after  the  administration  of 
small  initial  doses,  the  symptoms  will  disappear  if  the 


544 


MEDICAL    RECORD. 


[October  6,  1900 


drug  be  vigorously  pushed.  To  avoid  unpleasant  phe- 
nomena, when  the  drug  is  gfiven  in  ascending  doses  for 
long  periods,  it  is  sometimes  useful  to  administer  also  other 
drugs,  such  as  arsenic  and  belladonna.  The  chances  of 
unpleasant  symptoms  are  decreased  by  dilution  with  water 
or  milk.  If  potassium  iodide  is  taken  in  large  amounts 
wit.'i  little  fluid,  it  is  retained  much  longer  in  the  body  than 
otherwise,  whereas  if  liquids  in  copious  amounts  are  freely 
exhibited  elimination  is  facilitated,  and  at  the  same  time 
favorable  results  are  obtained. 

A  Rare  Case  of  Injury  to  the  Membrana  Tympani.— 
Thoman  D.  Tuttle  reports  the  case  of  a  young  girl  who 
had  gone  to  bed  with  her  hair  done  up  with  hairpins.  She 
was  wakened  m  the  night  by  a  sudden,  severe  pain  in  the 
left  ear.  and  a  hairpin  was  found  protruding  from  the  ca- 
nal and  removed  with  some  difficulty.  The  pin  had  entered 
open  end  first,  and  had  punctured  the  tympanic  mem- 
brane. The  latter  appeared  almost  black,  and  bulged 
slightly.  The  case  was  treated  on  antiseptic  principles, 
and  at  the  end  of  eight  days  there  was  no  evidence  of  in- 
jury except  a  slight  congestion  of  the  membrane  about  the 
point  of  puncture,  which  had  healed. 

Medicine  and  Superstition. — By  G.  W.  Guthrie. 

.\t"L'  ]'i'/-i-  Mciiical  JoKrna!.  Sc-p/t-iiihcr  sg,  igoo. 

Hypertrophy  of  the  Turbinated  Bodies  and  their  Relations 
to  Inflammations  of  the  Middle  Ear ;  with  Report  of  Fifteen 
Hundred  Operations. — C.  R.  llcilnics  covers  in  this  article 
familiar  ground,  saying  that  his  experience  has  led  him  to 
prefer  the  saw  and  scis.sors  to  the  cautery  and  cold  wire 
snare.  He  aims  to  remove  as  little  of  the  edge  of  the  in- 
ferior turbinate  as  is  consistent  with  the  restoration  of 
sufficient  breathing-space,  and  save  as  much  ot  the  anterior 
end  of  the  bone  as  possible,  inclining  the  direction  of  the 
line  of  cut  upward  and  backward  from  the  lower  edge  of 
the  anterior,  and  so  as  to  include  as  much  as  possible  of  the 
posterior  hypertrophy,  the  saw  having  been  pushed  back- 
ward till  its  blunt  point  is  in  the  pharynx. 

A  Case  of  Ozaena,  Probably  of  Sphenoidal  Origin. — The 
patient  of  J.  \V.  Fallow  showed  oza;natous  changes  in  only 
one  nostril.  While  probing  he  happened  to  pass  the  in- 
strument into  what  was  evidently  the  sphenoidal  sinus. 
Special  attention  to  the  cleansing  of  this  cavity  was  fol- 
lowed by  great  improvement  of  all  symptoms. 

The  Treatment  of  Umbilical  Hernia  in  Children  and  Adults ; 
Some  Points  in  Technique ;  A  New  Method  of  Radical  Cure 
—  By  J.  C.  Stinson. 

Some  Observations  upon  Syphilitic  Manifestations  in  the 
Optic  Nerve  and  Retina  ;  Inflammatory  Manifestations. — By 
P.  T.  Vaughan. 

The  Use  of  Piperazin  in  Nephrolithiasis — By  C.  J.  Al- 
drich. 

A  Chinese  Physician. — By  W.  E.  S.  Fales. 

Bos/on  Mciiical  and  Siirsiical  Journal,  Si-pt.  s-j,  tgoo 

A  Critical  Review  of  Thirty  Cases  of  Pyosalpinx. — G.  S. 

Whiteside  and  W.  J.  Walton  report  these  cases,  some  of 
which  were  operated  on  in  the  JIassachusetts  General  Hos- 
pital, others  being  taken  from  the  records  of  private  cases 
of  Dr.  M.  H.  Richardson,  while  two  of  them  are  the  writer's 
cases.  They  believe  that  the  gonococcus  cannot  be  proved 
to  be  the  cause  either  directly  or  remotely  in  as  large  a 
number  of  instances  as  is  generally  supposed.  Among 
other  organism  which  they  have  demonstrated  to  be  the 
only  living  microbe  present  in  a  considerable  number  ot 
cases,  are  the  bacillus  mesentericus.  pneumococcus  lanceo- 
latus,  bacillus  tetragenus,  colon  bacillus,  and  streptococ- 
cus pyogenes.  From  this  series  of  cases  they  draw  the 
following  conclusions  The  mortality  of  the  operation 
taken  as  a  whole  is  sixteen  per  cent.  The  greatest  dan- 
gers to  be  apprehended  are  in  streptococcus  infections 
from  peritonitis,  in  all  drained  cases  from  fecal  fistula,  in 
tuberculous  cases  from  extension  of  the  disease  to  other  or- 
gans. The  authors  have  inserted  tables  which  help  in 
determining  the  cause  of  pyosalpinx  and  defining  the 
symptom  comple.t  of  the  condition. 

Traumatic  Joints. — Homer  Gage  concludes  his  paper  on 
this  subject  as  follows:  (i)  All  injuries  to  joints  accom- 
panied by  loss  of  function  are  always  attended  by  more  or 
less  laceration  of  the  tissues  in  or  about  the  joint.  (2) 
The  delays  in  the  restoration  of  function  are  due  in  most 
instances  not  to  any  complicating  diathesis,  but  to  the 
changes  incident  to  the  repair  of  these  lacerations  and 
their  effects.  (3)  Such  delays  are  best  avoided  by  an 
early  resort  to  massage  and  active  or  passive  motions,  and 
are  favored  by  too  long  a  continuance  of  rest  and  fixation. 
(4)  When  such  delays  have  occurred,  they  arc  best  over- 
come Ijy  more  vigorf)US  and  persistent  manipulation,  sup- 
plemented by  the  ajiplication  of  heat  or  such  other  agents 
as  may  best  stimulate  the  local  circulation  and  favor  the 
elasticity  of  the  tissues. 


Post-Operative  Haematemesis — Kenelm  Winslow  says  that 
this  condition  occurring  without  any  visible  lesion  and 
without  any  apparent  cause  is  very  rare.  He  believes  the 
etiology  to  be  yet  unsolved.  Others  have  suggested  liga- 
ture of  tlie  omentum,  also  twisting  of  the  same,  sepsis, 
and  the  use  of  cocaine  as  causative  factors.  He  then  re- 
counts the  history  of  a  case  of  this  nature. 

A  Study  of  the  X-Ray  Plates  of  One  Hundred  and  Forty 
Cases  of  Fracture  of  the  Lower  End  of  the  Radius. — By  E. 
A.  Codman. 

7 lie  Lancet.  Septetnber  22.  /goo 

Beri-Beri. — C.  BuUmore  does  not  believe  that  beri-beri  as 
it  appears  in  England  is  either  infectious  or  contagious  and 
regards  it  as  a  different  malady  from  that  seen  in  foreign 
countries.  He  puts  forward  the  theory  that  the  di.sease 
that  reaches  us  is  due  to  an  alkaloidal  poison  fanned  into 
flame  by  the  disarranged  digestion  of  sailors  who  are  kept 
on  improper  diet,  and  in  that  case  by  properly  dieting  the, 
vessels  and  sujjplying  the  captains  with  iron  and  digitalis 
tabloids  the  disease  in  all  probability  would  be  reduced  to 
a  considerable  extent  if  not  stamped  out. 

Some  Points  about  Post-Diphtheritic  Paralyses  — B.  E. 
Myers  presents  a  statistical  table  of  thirtL-en  hundred  and 
sixteen  cases  of  diphtheria  .seen  in  the  Park  Hospital, 
Hither  Green,  during  the  year  iSgg.  Of  this  number  two 
hundred  and  seventy-five  showed  various  paralyses. ,  Four 
tables  are  given  relating  to  occurrence  as  to  age,  months 
in  which  the  cases  occurred,  to  cardiac  paralysis,  etc. 
Nothing  new  is  presented  as  regards  etiology,  course  or 
treatment. 

Multiple  Warts  Cured  by  Re  vaccination. — J.  D.  Staple 
revaccinated  a  girl  whose  hands  were  covered  with  warts. 
there  being  ninety-four  on  one  hand.  The  operation  was 
successful,  but  no  effect  on  the  warts  followed  until  seven 
weeks  later,  when  they  began  to  disappear,  leaving  tempo- 
rary white  spots.  In  three  months  the  hands  were  entirely 
clean. 

Treatment  of  Some  Common  Diseases  of  the  Skin. — Ad- 
dress before  the  British  Jledical  Association  by  P.  S. 
Abraham. 

Some  Notes  on  the  Use  of  Mercurol ;  a  New  Remedy  in 
Urethritis. — By  R.  Guitcras. 

A  Fatal  Case  of  Poisoning  by  Paraldehyde. — By  L. 
Dragc. 

The  Etiology  of  Rheumatic  Fever. — By  F.  J    Poynton. 

A  Case  of  Phosphorus  Poisoning. — By  W.  E.  Newey. 

British  Medical  Journal .  September  22,  igoo. 

Insanity  in  Lead  Workers  ;  Acute  Delirious  Mania. — Robert 

Jones  concludes  ,  (i)  That  lead  poisoning  is  a  contribu- 
tory factor  in  the  causation  of  insanity,  and  that  in  lead 
workers  there  is  a  higher  average  number  of  general 
paralytics  than  in  others  of  the  populatum  ;  (2)  that  there 
is  a  tendency  in  these  cases  to  cardiac,  renal,  and  arterial 
degeneration  with  complications  due  to  syncopal  or  epilep- 
tiform fits  ;  (3)  that  most  cases  present  marked  signs  of 
anremia  and  ill-health,  with  unsteadiness  of  gait  and  gen- 
eral impairment  of  muscular  strength  and  very  frequently 
a  history  of  temporary  failing  vision  .  (4)  that  the  mental 
symptoms  may  be  grouped  among  one  or  other  of  the  fol- 
lowing varieties  :  (a)  those  in  the  nature  of  toxePmia  and 
with  sensory  disturbances,  and  which  tend  rapidly  to  get 
well  :  (/')  those  with  hallucinations  of  sight  and  hearing 
more  chronic  in  their  nature,  and  which  may  be  irrecover- 
able. The  delusions  in  this  class  are  almost  invariably 
those  of  being  poisoned  or  followed  about,  and  are  in  the 
main  persecutory  ;  (t)  those  resembling  general  paralysis 
with  tremors,  increased  knee  jerks,  inco-ordination,  and 
accompanied  with  listlossness  amounting  to  profound  de- 
mentia, but  which  tend  to  get  well  ■  (5)  and  that  in  most 
lead  cases  presenting  mental  symptoms  the  tendency  is  to 
recovery  unless  the  patient  dies  early. 

Some  Cardio-Psychical  Associations. — J.  R.  Whitwell  slates 
that  we  may.  pcrlia[is.  with  some  reserve  for  further  obser- 
vations accept  a  certain  series  of  cases  of  imbecility  as  due 
to  disproportion  between  the  development  of  brain  and  car- 
diovascular system  ;  here,  the  mental  symptoms,  as  a  re- 
sult of  this  imperfect  evolution,  are  entirely  on  the  lower 
plane  of  psychical  reactions.  Another  class  is  one  in 
which  congenital  or  early  infantile  heart  disease  of  serious 
type  is  jnesent.  the  proportionate  cardiac  development 
being  normal,  and  compensation  being  more  or  less  prop- 
erly carried  out.  Certain  cases  of  mitral  disease  present 
symptoms  of  gloom  and  depression,  as  well  as  self-absorp- 
tion. sus])icion,  and  irritaliility.  In  conclusion,  the  writer 
notes  the  condition  of  pathological  eupathy  in  which  the 
heart  at  last,  refusing  to  respond  to  ordinary  cardiac  stimu- 
lants, gradually  fails  beyond  recovery.  Vet  the  patient  is 
convinced  that  he  is  better  and  stronger  daily. 


October  6,  1900] 


MEDICAL    RECORD. 


545 


Acute  Delirious  Mania. — John  Turner  believes  that  all 
forms  of  acute  delirious  mania  are  of  toxic  origin,  some 
being  caused  by  the  introduction  of  a  poison  from  without, 
others  by  the  absorption  of  sejjtic  material,  while  a  third 
class  is  due  to  auto-intoxication.  As  regards  tlie  action 
of  a  possible  poison  ou  the  nerve  cell  and  its  functions  the 
subject  is  too  speculative  for  any  advantage  to  be  derived 
from  discussing  it.  In  cases  with  high  delirium  and  a  rap- 
idly fatal  termination  there  is  generally  a  condition  pres- 
ent in  which  all  the  giant  cells  are  profoundly  altered,  and 
probably  the  inspection  of  a  section  in  such  cases  would 
furnish  a  tolerably  accurate  diagnosis  of  the  mental  state 
preceding  death. 

The  Effects  of  Inhalation  of  Certain  Anasthetics  on  the 
Kidneys. — Dudley  Buxton  and  A.  G.  Levy  quote  cases 
whicli  show  that  the  quantity  of  urine,  after  the  administra- 
tion of  ether,  was  reduced  in  amount.  However,  the  rou- 
tine ])reparatory  treatment  may  have  had  considerable  in- 
fluence in  bringing  about  this  result.  This  reduction  is  in 
the  urinary  water  only.  There  is  little  evidence  to  show 
that  ether  exerts  directly  any  deleterious  influence  on  the 
kidney  parenchyma.  The  administration  of  this  ana;s- 
thetic,  however,  should  be  performed  with  care,  and  an 
undue  quantity  should  not  be  given. 

The  Condition  of  the  Cells  in  the  Spinal  Cord  after  Vari- 
ous Nervous  Lesions. — P>y  \V.  B,  Warrington. 

On  Some  Changes  in  Volume  of  the  Submaxillary  Gland 
Accompanying  Secretion. —  I'y  J.  L.  P.uiuh. 

Observations  on  the  Temperature  of  Man  after  So-Called 
"Heat-Stroke."  — By  M.  S.  Pembrey. 

The  Correlation  between  Sexual  Function,  Insanity,  and 
Crime.  —  I'y  H.  MacXaugliton-Jones. 

The  Relation  of  the  Lunacy  Laws  to  Neuro-Psychological 
Diseases.  —  I'yJ.  M.  MacCorniac. 

Muscular  Tonus  in  Relation  to  Diseases  of  the  Nervous 
System.  — By  P.  \V.  Mntt. 

The  Structure  of  the  Mucous  Membrane  of  the  (Esophagus. 
—  By  Denis  J,  Cntley. 

The  Metabolisms  of  the  Nucleins  in  Birds.  —By.  T.  PI. 
Milroy. 

Organo-Therapeutics  in  Mental  Diseases. — By  C.  C.  East- 
erbrook. 

The  Treatment  of  Epileptics  in  Colonies. — Bv  W.  Aldren 
Turner. 

Ansesthetics  and  Urinary  Secretion. — By  W.  II,  Thompson. 
The  Retinal  Response  to  Light. — By  Augustus  D.  Waller. 
On  Blood  Pressure  in  the  Insane. — By  Maurice  Craig. 
Peripheral  Neuritis  and  Insanity. — By  R.  P.  Smith. 
A  Digital  Sphygmograph. — By  A.  D.  Waller. 
A  Note  on  Respiration. — By  R.  J.  Anderson. 
Epileptic  Insanity. — By  E.  S.  Pasmore. 

Deutsche  nit-dicinisclie  Wochenschrift.  Sep/.  /?,  igoo. 

Death  following  Psychical  Trauma,  with  Observations  on 
the  Delirium  Nervosum  of  Dupuytren  and  Operative  Psy- 
choses.—  Pagenstecher  describes  an  interesting  case  of  liti- 
gation against  an  accident  insurance  company.  The  pa- 
tient, a  man  aged  tifty-oue  years,  who  was  somewhat 
neurasthenic  but  otherwi.se  in  good  health,  was  heavily  in- 
sured in  a  number  of  accident  companies.  While  sharpen- 
ing a  pencil  he  slightly  cut  the  ball  of  his  thumb,  his  pen 
at  the  same  time  falling  from  behind  his  ear  and  covering 
the  little  wound  with  ink.  The  patient  became  greatly 
alarmed  lest  blood  poisoning  set  iu,  and  consulted  several 
physicians  with  the  idea  of  having  the  arm  amputated. 
Simple  antiseptic  treatment  was  apjilied,  but  the  patient 
insisted  on  the  idea  of  infection,  complained  of  pains  as- 
cending the  arm  as  the  process  progressed,  and  went  into 
syncope,  followed  by  a  restless  night  and  severe  delirium, 
with  agitation  and  convulsive  symptoms  the  next  day. 
There  was  no  fever  or  rise  in  pulse  rate,  and  the  patient 
came  to  himself  when  addressed,  but  suddenU-,  without 
any  change  in  the  symptomshe  went  iiitocollapse,  and  died 
thirty-two  hours  after  rccei\ing  the  injury.  On  autopsy 
nothing  explaining  the  fatal  ending  could  be  found ; 
ptomain  or  other  poisoning  was  excluded  by  proper  inves- 
tigation of  the  internal  organs.  The  case  is  one  of  trau- 
matic delirium,  such  as  is  observed  after  accidents  and 
surgical  operations  which  are  often  comparatively  trifling 
and  out  of  all  proportion  to  the  resulting  mental  derange- 
ment, the  gravity  of  the  condition  depending  not  on  the 
extent  of  the  injury  but  on  the  state  of  psychical  shock. 
In  the  ca.se  m  question  death  was  probably  due  to  an 
acutely  supervening  attack  of  cardiac  insufficiency.  The 
decision  of  the  courts  has  not  yet  been  rendered. 

First  Aid  by  the  Laity  in  Lime  or  Mortar  Injuries  to  the 
Eye.  — H.  G.  Stutzer  considers  irrigation  with  water  as  the 
best  and  most  easily  applicable  remedy  to  he  entrusted  to 
lay  hands  m  injuries  of  this  sort.     Sugar  solution  has  been 


recommended,  but  though  lime  is  slightly  more  soluble  in 
this  medium  than  in  pure  water,  it  forms  a  pasty  mass  with 
it  which  is  hard  to  remove.  Oil  or  milk  lessens  the  pain 
but  does  not  check  the  destructive  action  of  the  foreign 
substance  ;  glycerin  gives  good  results  but  is  not  adapted 
for  a  first-aid  remedy,  as  it  is  not  always  quickly  obtain- 
al)le,  and  in  these  cases  speed  is  the  first  consideration. 
The  following  directions  with  suitable  illustrations  should 
be  printed  on  placards  and  posted  about  all  buildings  in 
course  of  construction.  The  patient  is  at  once  to  be  laid 
on  the  ground,  and  any  convenient  vessel  quickly  rinsed 
and  filled  with  clean  water.  A  fellow-workman  kneels  at 
his  side,  and  ojiens  the  injured  eye  by  ajjplying  the  thumbs 
to  the  two  eyelids  and  forcilily  seiKuating  them.  At  the 
same  time  some  one  else  pours  tlie  water  into  the  eye  in  as 
fine  a  stream  as  jiossible,  holding  the  vessel  at  the  height 
of  one  and  one-half  feet  and  continuing  as  long  as  any  i)ar- 
ticles  are  still  to  be  seen  in  the  eye.  Then  the  patient 
should  be  brought  under  medical  care  as  soon  as  possible. 

Cured  Peritoneal  Tuberculosis  in  Children.  — Cassel  says 
that  while  it  is  now  universally  recognized  that  operative 
treatment  is  the  proper  measure  in  this  disease  in  adults, 
the  same  conclusion  is  not  so  unreservedly  applied  when 
the  patients  are  children.  In  his  experience,  however,  no 
distinction  should  be  made  on  the  ground  of  age,  and  he 
presents  three  case  histories  in  which  a  cure  effected  in 
this  way  has  persisted  for  several  years.  Whenever  in 
])atients  of  this  class,  in  spite  of  a  suitable  general  and 
hygienic  regimen,  including  the  application  of  the  proper 
external  and  internal  remedies,  a  febrile  movement  con- 
tinues during  several  weeks,  the  abdominal  swelling  does 
not  diminish  but  increase,  and  the  emaciation  continues  to 
jirogress,  the  case  is  a  suitable  one  for  operation,  no  matter 
what  form  of  ])eritoneaI  tuljerculosis  it  may  be. 

The  Examination  of  the  Thorax  with  the  Roentgen  Rays 
and  Some  Results. — By  Levy  Dorii. 

The  Pathogenicity  of  the  Staphylococcus  Quadrigeminus 
Czaplewski.  —  By  G.  Kieseritzky. 

The  Prophylactic  and  Curative  Action  of  Urotropin. — By 
Zaudy. 

Berliner  k-liitische    W'oelienschrift,   Sefi/e»il>er  j,  /goo. 

Eye  Injuries  from  Lime. — H.  Schmidt-Rimpler  analyzes 
fifty-six  cases  seen  during  the  last  ten  years.  The  imme- 
diate procedure  in  these  cases  should  be  the  careful  re- 
moval of  all  particles  of  lime  from  the  cornea  and  ])upil. 
This  is  best  done  with  a  piece  of  clean  linen  dipped  in  oil, 
or,  if  no  oil  is  at  hand,  with  a  piece  of  linen  alone.  The 
accidental  abrasion  of  the  epithelium  is  of  less  danger  than 
the  continuance  in  the  eye  of  the  offending  body.  Next 
the  eye  should  be  thoroughly  syringed  with  some  bland 
oil,  care  Ijeing  taken  that  the  oil  penetrates  thoroughly 
under  the  upper  lid  and  in  the  conjunctival  sac  of  the 
lower.  The  writer  advocates  the  use  of  s])ectacles  by  those 
whose  occupations  render  them  liable  to  this  class  of  in- 
juries. 

Treatment  of  Lepra. — W.  Donitz  advises  the  subcutane- 
ous injection  of  the  familiar  chaulmoogra  oil.  The  injec- 
tions should  be  repeated  every  ten  to  fourteen  days,  using 
for  dosage  o. i  to  0.2  gm.  A  reaction  similar  to  that  of  in- 
jections of  cantharidin  has  been  observed.  Some  subsi- 
dence of  the  affected  areas  was  oljserved. 

The  Permeability  of  the  Intestinal  Wall  by  Bacteria. — A 
series  of  experiments  on  animals  by  C.  Fosner  and  J.  Cohn. 

Pathogenesis  of  Malignant  Tumors  of  the  Upper  Nasal 
Chambers.— By  J.  Herzfekl. 

Angina  Pectoris. — A  study  of  five  ca.ses  by  Max  Soloman. 
Mihuhener  tiiedicinische   W'oelienschrift,  Sept.  ir,  /goo. 

A  New  and  Simple  Method  for  the  Observation  of  Injury 
to  Living  Cells  and  Organisms  (Bioscopy) . — Xeis.ser  and 
Wechsberg,  in  conducting  an  investigation  on  staphylococ- 
cus toxin,  had  occasion  to  study  the  action  of  leukocidin  on 
leucocytes.  In  doing  this  advantage  was  taken  of  the  re- 
ducing power  of  the  cells  to  avoid  the  necessity  for  the 
time-consuming  direct  inspection  with  the  oil-immersion 
lens.  If  to  a  fluid  containing  numbers  of  living  leuco- 
cytes a  small  amount  of  methylene-blue  solution  be  added 
in  a  test  tube  sealed  with  paraffin,  and  the  mixture  be 
placed  in  the  thermostat,  in  a  short  time  decolorization  of 
the  fluid  will  take  place.  If,  however,  the  leucocytes  be 
killed  by  the  addition  of  leukocidin,  quinine,  or  overheat- 
ing, the  solution  retains  its  color,  showing  tlie  ab.sence  of 
vitality  in  the  cells.  The  reaction  succeeds  with  all  cells 
capable  of  surviving,  such  as  kidney  and  jiancreas  cells,  as 
well  as  the  motile  leucocytes,  spermatozoa,  and  ciliated 
epithelium.  Under  similar  conditions  many  forms  of  bac- 
teria give  the  same  reaction,  which  is  especially  strong  for 
tubercle  and  typhoid  bacilli,  cholera  vibrios,  and  staphylo- 
cocci. 

A  Method  for  the  Demonstration  of  a  Capsule  in  Bacteria 
Grown    in    Non-Liquid    Media. — Icilio  Boni  concluded   that 


546 


MEDICAL    RECORD. 


[October  6,  1 900 


the  reason  that  the  capsule  of  tlie  jjneumococcus  was  visi- 
ble in  stained  specimens  that  had  been  grown  on  bouillon, 
but  not  in  those  cultivated  on  agar,  was  that  the  capsule 
being  colorless  depended  for  its  differentiation  on  the  con- 
trast afforded  by  the  staining  of  the  slight  film  of  bouillon  , 
bacteria  taken  from  solid  cultures  are  spread  in  a  drop  of 
water  which  affords  no  background  oa  drying.  Hetter 
than  bouillon  for  mounting  bacteria  to  be  stained  with  the 
object  of  showing  the  capsule  is  a  solution  of  the  yolk  of 
one  egg  in  50  gm.  of  glycerin,  with  the  addition  of  two 
drops  of  formalin.  By  using  this  fluid  it  is  jiossible  regu- 
larly to  identify  the  capsule  of  bacteria  which  under  the 
older  methods  do  not  always  show  it,  and  it  is  probable 
that  by  its  means  capsules  will  be  detected  about  bacteria 
now  not  supposed  to  have  them. 

The  Prevenion  of  Puerperal  Fever. — Hofmeier  enters  a 
strong  plea  for  greater  thoroughness  in  the  sterilization 
of  the  operative  field  in  obstetrical  work.  While  the  ne- 
cessity for  asepsis  is  great  at  all  times,  whenever  any 
operative  interference  is  proposed,  such  as  manual  extrac- 
tion of  the  placenta,  it  is  ab.solutely  essential  that  a  thor- 
ough sterilization  of  the  vagina  itself  as  well  as  the  vulva 
be  carried  out. 

New  Regulations  for  Bavarian  Midwives  Concerning  the 
Prevention  of  Ophthalmia  Neonatorum. — By  S.  Xeuburger. 

A  Journey  through  Switzerland  Performed  in  the  Epileptic 
Subconscious  State.— By  George  Buigl. 

Clinical  Contributions  to  the  Diagnosis  of  Tjrphoid  Fever. 
• — By  Berliner  and  Cuhn. 

Cavernous  Angioma  of  the  Cerebrum. — By  Struppler. 

French  /ournaU. 

Thyroid  Cancer. — A.  Carrel  at  the  close  of  an  interesting 
paper  on  this  subject  states  that  death  is  the  fatal  termi- 
nation of  the  evolution  of  cancer  of  the  thyroid  bodj-.  It 
may  be  due  to  the  progressive  cachexia,  or  to  respiratory, 
vascular,  or  infectious  complications.  In  the  majority  of 
cases  the  local  conditions  assume  the  chief  importance, 
but  now  and  then,  especially  if  the  tumor  be  very  ma- 
lignant, cachexia  holds  the  first  place.  Most  frequently, 
however,  tracheal  compression  causes  death,  and  often 
suddenly,  by  asphyxia.  Death  from  vascular  complica- 
tions is  rare,  although  certain  examples  of  extreme  hemor- 
rhage from  ulceration  of  the  carotid  artery  are  quoted. 
The  various  infections  find  a  fertile  soil  111  the  respiratory 
apparatus  of  the  victim  of  this  malady. — Gazette  cies  Hopi- 
tti!i.\,  September  iS,  1900. 

Indications  and  Operative  Technique  of  Gastrostomy  for 
(Esophageal  Neoplasm. — M.  Mauclaire  states  that  the  prog- 
nosis of  (Esophageal  neoplasm  is  most  grave,  and  as  the  re- 
moval of  the  growth  is  not  practicable,  palliative  treatment 
only  is  left  to  the  surgeon.  The  writer  then  briefly  reviews 
the  history  and  chief  methods  of  gastrostomy.  The  re- 
sults of  this  operation  are  not  so  brilliant  as  one  could 
wish,  but  nevertheless  the  lesion  improves  so  much  that 
sometimes  food  can  again  be  taken  by  the  mouth.  Life  is 
prolonged  for  weeks  or  months,  pain  is  diminished,  and 
the  patient  is  greatly  relieved. — Le  Bulletin  Medical, 
September  12,  1900. 

Sternal  Adenitis. — Maurice  Patel.  after  discussing  this 
subject,  concludes  that  sternal  adenitis  falls  into  three 
groups  due  to  the  anatomical  position,  whose  principal 
symptoms  are  as  follows  :  (i)  Deep  adenitis,  phenomena  of 
constriction,  extension  to  the  mediastinum  and  the  axilla; 
(2)  medium  adenitis,  no  phenomena  of  constriction,  posi- 
tion substernal,  deep  cicatrix,  retrosternal ;  (3)  superficial 
adenitis,  position  presternal,  cicatri.x  presternal.  sujier- 
ficial. — Gazette  llehdoiiuxclairc,  September  16.   1900. 

Subconjunctival  Injections.— M.  Etievant  shows  that  by 
subconjunctival  injections  of  mercurial  solutions,  the  anti- 
septic substance  by  means  of  the  lymphatics  penetrates  to 
the  infected  parts  and  exercises  its  action  directly  there. 
The  writer  believes  that  the  results  of  this  method  are 
most  successful,  and  that  accidents  do  not  attend  it. — Ga- 
zette lies  J/ofiitau.x,  September  15,  1900. 

The  Journal  of  Tropical  Medicine,  September,  /goo. 

The   Use   of   Quinine   in   Malarious    Fevers. — Rai    Kailas 

Chunder  Bose  Bahadur,  of  Calcutta,  relies  absolutely  upon 
quinine  in  the  treatment  of  malarious  fevers,  always  ob- 
taining satisfactory  results.  He  considers  it  simply  a 
waste  of  time  to  wait  for  a  remission  or  perfect  intermis- 
sion, for  one  cannot  be  positive  about  the  prognosis,  how- 
ever mild  the  case  may  appear  at  the  onset,  apparently 
uncomplicated  cases  sometimes  assuming  a  iiernicious 
form  and  killing  the  patient.  The  use  of  quinine  during 
the  hot  stage  of  fever  lias  often  been  followed  by  hopeful 
results.  In  remittent  fever  it  should  be  given  in  small  re- 
peated doses,  as  big  doses  are  apt  to  cause  sickness,  in- 
somnia, and  depression  of  spirits.  Failure  of  the  heart's 
action  may  be  prevented  by  the  judicious  administration 


of  quinine  from  a  very  early  stage  of  the  disease.  Inter 
mittent  fevers  yield  rapidly  to  the  remedy ;  one  dose  of 
gr.  XV.  shortly  followed  by  another  similar  do.se  rarely  fails 
to  cut  short  the  fever  and  prevent  its  return.  The  author 
reports  several  cases. 

Malignant  Malaria,  with  Urticarial  and  Petechial  Erup- 
tions.— Cliarles  Todd  reports  the  only  one  of  seven  hun- 
dred cases  of  malaria  seen  by  him  in  Mashonaland  in 
which  urticaria  was  observed.  The  rash  appeared  first, 
and  the  case  was  regarded  as  one  of  ptomain  poisoning, 
probably  due  to  tinned  food  ;  but  other  persons  who  had 
partaken  of  the  same  dishes  did  not  suffer.  The  succes- 
sive crops  of  urticaria,  coupled  with  the  fact  that  the  pa- 
tient's condition  was  gradually  becoming  worse,  suggested 
that  the  poison  producing  these  symptoms  was  still  being 
formed  in  the  body,  and  the  appearance  of  coma  and  a 
petechial  eruption  pointed  to  malaria  as  the  cause  Mala- 
rial parasites  were  found  in  the  blood.  Hypodermic  injec- 
tions of  the  acid  hydrochloride  of  quinine  caused  an  im- 
provement in  the  patient's  condition,  but  on  the  next  day 
death  occurred  from  heart  failure,  the  temperature  reach- 
ing 104'  F.  immediately  before  death. 

On  the  Action  of  Light  upon  the  Human  Body  in  Relation 
to  Dress. — By  Joseph  Ritter  von  Schmaedel  Communicated 
and  translated  by  R.  \V.  Felkin. 

On  Plague  and  its  Dissemination. — By  Frank  Tidswell. 

Zeitschrift  J  iir  Id  in.  Medicin ,  7'ol.  xl..  JSos.  5  and  6  tqoo. 

The  Influence  of  Morphine  on  Gastric  Secretion  — F.   Rie- 

gel  in  view  of  extensive  experiments  on  men  and  animals 
believes  that  the  universally  accepted  belief  that  the  secre- 
tion of  gastric  juice  is  inhibited  by  the  administration  of 
morphine  rests  on  errors  of  observation,  and  that  the  thera- 
peutic use  of  this  agent  in  conditions  in  which  the  object  is 
to  diminish  the  secretory  activity  of  the  stomach  is  ill  ad- 
vised. On  the  contrary,  morphine  given  either  when  the 
patient  is  fasting  or  with  the  food  causes  an  increased 
pouring  out  of  gastric  juice,  though — and  this  perhaps  ex- 
plains the  former  idea — there  is  a  considerable  latent  pe- 
riod before  this  result  makes  itself  manifest.  This  con- 
clusion applies  only  to  cases  in  which  the  drug  has  been 
given  for  a  short  time  ;  whether  it  would  still  hold  true 
after  it^  habitual  use  for  a  considerable  length  of  time  is 
not  certain.  But  even  if  this  question  remains  an  open 
one.  still  the  advice  that,  owing  to  its  property  of  checking 
secretion,  morphine  be  administered  in  cases  in  which  even 
the  normal  hydrochloric  acid  is  injurious,  especially  in 
gastric  ulcer,  is  certainly  to  be  condemned.  On  the  con- 
trary, reflecting  on  the  results  of  these  experiments,  it 
would  seem  that  caution  should  be  exercised  in  selecting 
morphine  as  an  anodyne  in  gastric  affections,  and  it  should 
be  administered  only  in  cases  in  which  an  increased  secre- 
tion cannot  do  harm.  The  results  of  further  experimentation 
have  shown  the  author  that  atropine  and  belladonna  prep- 
arations do  have  to  a  high  degree  the  faculty  of  reducing 
the  amount  of  gastric  juice,  and  this  fact  explains  the  clin- 
ical observation  that  the  addition  of  a  small  amount  of 
atropine  often  gives  relief  when  the  injection  of  morphine 
alone  is  powerless  to  control  gastric  pain. 

The  Mechanics  of  Memory. — Adamkiewicz  regards  mem- 
ory as  a  purely  physical  function  underlying  and  in  some 
sense  forming  the  basis  of  the  jisychical  life  but  still  in 
its  nature  as  separate  and  distinct  from  it  as  any  other  of 
the  purely  vegetative  processes.  Judged  by  a  standard  of 
efficiency  memory  is  most  developed  in  childhood,  de- 
creases during  adult  life,  and  is  least  active  in  old  age, 
while  hand-in-hand  with  these  functional  alterations  go 
organic  changes  in  the  brain  substance.  In  infancy  and 
early  life  the  brain  tissue  is  extremely  tender  and  vascu- 
lar, but  with  increasing  years  its  blood  supply  diminishes 
and  it  grows  coarser  in  texture.  The  ability  of  young 
children  to  acquire  large  numbers  of  disconnected  and  ir- 
relevant facts  with  an  ease  and  accuracy  quite  out  of  the 
power  of  their  elders  is  well  known  but  no  one  would 
maintain  that  they  are  therefore  011  a  higher  psychical 
plane,  and  it  is  a  matter  of  every-day  experience  that  after 
a  few  years  the  same  individual,  though  undoubtedly  much 
farther  advanced  intellectually,  is  unable  to  perform  the 
same  feats  he  formerly  accomplished  without  effort. 

The  Study  of  the  Cerebrospinal  Fluid  —M.  Lewandow- 
sky  says  that  m  view  of  the  increasing  interest  attaching 
to  the  subdural  injection  of  drugs,  and  especially  the  co- 
caine anicsthesia  of  Bier,  and  the  direct  injection  of  tet- 
anus antitoxin,  it  is  of  imjiortance  to  recognize  fully  the 
nature  of  the  cerebrospinal  fluid.  In  general  it  may  be 
said  that  this  jiartakes  of  the  nature  of  tlie  lymph,  receiv- 
ing only  a  small  )iortion  of  transuded  matter  and  this 
after  modification  through  the  specific  action  of  the  cere- 
bral capillaries.  On  the  whole  it  is  to  be  regarded  as  a 
specific  product  of  the  brain,  and  represents  that  part  of 
the  lymph  originating  through  organic  action.  Experi- 
ments with  strychnine  and  ferrocyauate  of  sodium  showed 


October  6,  1900] 


MEDICAL    RECORD. 


547 


that  when  thrown  into  the  subdural  space  these  substances 
penetrated  directly  into  the  nerve  substance  through  its 
lymph  channels  and  without  the  intervention  of  the  circu- 
lation. 

The  Behavior  of  the  Bone  Marrow  in  Disease  and  its  Re- 
lation to  Blood  Formation. — By  Schiir  cuul  Liiwy. 

The  Excretion  of  the  Products  of  Intestinal  Decomposition 
in  the  Urine.  — By  .Strauss  and  Philippsohn, 

The  Nucleoproteid  of  the  Pancreas.— By  Amber. 


Covvcsponclcncc. 

OUR   LONDON    LETTER. 

(From  our  Special  Correspondent.) 

PLAOUE  AT  GLASGOW — WAR  HOSPITALS — SIR  R.  IllLLER  AND 
LORD  ROBF.RTS  DEFEND  THE  MEDICAL  SF.RVICE — ALLEGED 
CRUELTY  TO  A  LfNATIC — THE  NATIONAL  HOSPITAL  SCANDAL 
— PROFESSIONAL  PHILANTHROPISTS — SOME  BOOKS — COMING 
SESSION. 

London  September  14,  1900. 

Glasgow  has  had  a  trying  week  but  has  not  given  way  to 
panic.  Her  sanitary  authorities  are  wide  awake  and  ac- 
tive, but  the  name  of  plague  naturally  causes  fear,  and  in 
addition  to  the  direct  danger  from  disease  there  is  the 
serious  injury  to  commerce.  On  Monday  and  Tuesday  the 
cases  of  plague  numbered  sixteen  ;  there  were  two  doubt- 
ful and  one  hundred  and  thirteen  persons  under  observa- 
tion. These  numbers  have  not  increased.  It  was  an- 
nounced that  one  of  Mondays  admissions  was  a  case  that 
had  existed  undetected  for  many  days  in  the  infected  dis- 
trict. This  gives  rise  to  misgivings  lest  during  that  time 
the  infection  may  have  spread  from  it.  Further  accom- 
modation is  being  provided  for  doubtful  cases,  and  no 
precautions  will  be  omitted.  In  this  respect  I  may  remark 
that  for  months  past  the  medical  officers  of  health  have 
adopted  precautions  against  the  arrival  of  infection,  such, 
for  instance,  as  scheduling  the  arrival  nt  ships  from  in- 
fected places  at  any  of  our  own  ports.  Inquiry  has  been 
made  as  to  the  condition  of  such  ships,  the  water  supply 
on  the  voyage,  the  nature  of  their  cargo,  whether  any 
dead  rats  have  been  found,  and  the  health  of  the  crew  and 
passengers.  By  intercommunication  among  the  health 
officers  of  our  several  ports  the  most  important  informa- 
tion is  circulated. 

The  sensational  press  has  done  its  level  best  to  get  up 
"a  scare"  about  plague,  but  fortunately  with  little  suc- 
cess, although  a  statement  was  made  that  cases  had  ap- 
peared in  the  London  docks — a  statement  for  which  there 
was  no  foundation.  It  would  not  be  at  all  surprising 
should  cases  find  their  way  to  this  port,  but  the  port  sani- 
tary authorities  are  confident  that  they  will  be  able  to  deal 
with  such  a  case  and  prevent  it  spreading.  Should  a  case 
ever  pass  their  lines  it  would  almost  certainly  reach  the 
Seaman's  Hospital,  where  the  staff  are  well  prepared  for 
such  a  contingency,  and  the  Tropical  School  would  second 
them,  Mr.  Cantlie,  F.R.C.S.,  who  had  experience  of  the 
disease  at  Hong  Kong,  has  visited  Glasgow  and  published 
his  conclusion  as  to  the  outbreak  in  the  local  journals. 
Dr.  Colvin,  who  saw  the  first  cases,  has  recorded  their 
clinical  features  in  T/ie  Laiict-t.  Dr.  Chalmers,  the  medi- 
cal officer  of  health,  has  invited  the  local  profession  to  a 
series  of  clinical  demonstrations  on  plague  to  be  given  by 
the  physician-superintendent  of  the  Belvedere  Fever  Hospi- 
tal, which  IS  being  utilized  for  the  plague  cases.  This  is  a 
specially  commendable  step,  considering  that  early  dl.^g- 
nosis  IS  so  essential  to  prevent  the  spread  of  the  disease, 
and  scarcely  any  practitioner  has  had  an  opportunity  of 
studying  it.  All  those  who  have  experience  of  the  disease 
and  have  seen  the  cases  at  Glasgow  agree  that  they  are 
very  mild,  but  this,  of  course,  does  not  make  the  infec- 
tiveness  any  less.  A  large  supply  of  plague  serum  has 
been  sent  by  the  Pasteur  Institute,  and  any  amount  can  be 
obtained.  It  is  asserted  that  the  institute  has  stock 
enough  to  inoculate  the  population  of  the  continent ;  but  it 
seems  improbable  that  such  a  quantity  should  have  been 
accumulated,  for  its  keeping  qualities  are  not  to  be  trusted. 
Probably  the  report  is  due  to  a  statement  that  the  insti- 
tute could  obtain  a  supply  to  meet  an  epidemic  extending 
over  all  Europe. 

The  Royal  Army  Medical  Corps  must  await  the  verdict 
of  the  commission  as  to  the  way  in  which  it  met  the  de- 
mands made  upon  it.  The  corps  can  wait  patiently.  Not 
so  the  "plague  of  women  "  or  the  sensational  M.P.  Lady 
Sykes,  who  wrote  some  "sidelights  on  the  war,"  has  re- 
peated in  7/;t'  Daily  S^'eius  the  unsupported  charges  in 
which  she  indulged,  and  in  the  repetition  has  "gone  one 
better,"     Mr,    Murray  Guthrie,    M.P. ,    not   satisfied   with 


giving  evidence  before  the  commission,  has  added  to  it  an 
article  in  the  Sinetcenllt  dntury  magazine,  where,  of 
course,  he  cannot  be  cross-examined.  He  imputes  the 
blame  of  any  defects  to  the  Royal  Army  Medical  Corps, 
and  casts  out  his  charges  and  insinuations  as  confidently 
as  if  he  possessed  a  knowledge  of  what  he  is  writing  about 
— a  qualification  which  he  evidently  lacks. 

Mr.  Lees  Knowlcs,  M.P. ,  has  brought  upon  himself  a 
crushing  rebuke  from  Sir  Redvers  Buller.  who  in  refer- 
ence to  his  charges  asks.  "Was  ever  a  more  shameful 
accusation  more  shamelessly  published  ?  "  Mr.  Knowles  was 
challenged  by  Sir  Redvers  to  substantiate  his  slanders  or 
withdraw  them,  and  has  accordingly  climbed  down.  His 
bid  for  popularity  will  therefore  prove  of  little  avail,  and 
other  M.P. 's  may  well  take  warning.  But  it  .seems  a  sad 
indication  of  public  veracity  when  members  of  parliament 
and  spiteful  women  disseminate  slanders  for  the  sake  of 
getting  temporary  notoriety.  It  is  not  every  slander  that 
is  so  easily  scotched,  and  it  is  not  every  general  who  can 
be  expected  on  every  occasion  to  speak  out.  All  honor  to 
the  man  who  does  I 

Lord  Roberts  has  given  evidence  to  the  commission  and 
told  how  he  ordered  the  transport  to  be  cut  down  as  an 
imperative  necessity.  That  was  of  course  understood,  but 
it  is  more  to  the  point  to  have  his  lordship's  testimony  as 
to  the  medical  care  of  the  sick  and  wounded.  He  told  the 
commission  they  were  sent  down  from  the  front  with  the 
least  possible  delay  ;  that  he  frequently  visited  the  hospi- 
tals, and  was  satisfied  that  both  the  army  and  civil  doctors 
did  their  duty  well.  Perhaps  after  this  the  newspapers 
will  be  ashamed  to  circulate  one-sided  assertions  lihelling 
a  body  of  men  who  cannot  reply,  but  whose  defence  must 
await  the  report  of  the  commission. 

A  painful  case  of  alleged  cruelty  to  a  lunatic  has  excited 
much  attention.  The  patient  was  a  congenital  idiot  and 
resided  with  his  brother,  who  is  a  medical  man.  a  sum  of 
_^So  \.o  £(f>  being  allowed  for  his  maintenance.  When  his 
habits  became  unbearable  in  the  house,  a  harnes.s-room  at 
the  end  of  the  stable  yard  was  furnished  as  a  bedroom,  and 
an  enclosure  also  fenced  off  and  partly  roofed  over  for  a 
day-room.  The  only  attendant  seems  to  have  been  the 
defendant's  coachman,  who  was  fined  £%  for  cruelty.  The 
defendant  himself  c-caped,  as  the  magistrate  who  in- 
spected the  place  thought  that  reasonaljle  care  had  been 
taken  by  him,  and  that  the  allegations  of  cruelty  against 
him  were  without  foundation.  It  was  admitted  that  a  cane 
had  been  used  to  frighten  the  patient  and  to  chastise  him 
lightly.  The  defendant  may  be  thankful  that  he  has 
been  acquitted.  He  will  probably  suffer  much  in  costs  and 
regret.  Though  the  patient  was  taken  charge  of  at  the 
wish  of  the  family  for  a  nominal  sum,  he  was  surely  en- 
titled to  more  consideration.  Obviously  he  ought  to  have 
been  in  an  institution  where  he  would  have  been  properly 
attended  to.  It  was  not  a  fit  case  for  private  care.  It  is 
an  object  lesson,  too,  on  the  necessity  of  communicating 
to  the  lunacy  commissioners  all  cases  of  boarding  luna- 
tics. 

Sir  J.  Crichton-Browne  has  engaged  the  "  secretary-di- 
rector "of  the  National  Hospital  for  Paralysis  in  a  corre- 
spondence which  illustrates  the  sort  of  tactics  resorted  to 
by  the  board.  It  comes  out  that  the  sjiecial  meeting  was 
intended  to  be  at  an  inconvenient  time  to  the  staff  and 
others;  that  the  statement  of  facts  admitted  at  the  meet- 
ing to  be  incorrect  is  still  being  circulated  ;  that  the  meet- 
ing was  packed,  though  the  packing  secured  the  pres- 
ence of  only  sixteen  voters.  Even  proxies  were  sent  out — 
not  to  all  governors,  however,  for  the  secretary-director 
says,  "Naturally  the  board  did  not  send  proxy  papers  in 
support  of  their  policy  where  it  was  known  they  would  be 
unwelcome."  In  another  letter  he  even  says  it  would  have 
been  "an  impertinence  to  solicit  the  support  of  friends  of 
the  staff."  Sir  J.  Crichton-Browne  then  asked  how  these 
were  discriminated  in  the  distribution  of  proxy  papers? 
This  is  the  way  the  board  carry  on  their  campaign  against 
the  staff. 

You  will  not  be  surprised  to  hear  that  the  true  inward- 
ness of  the  situation  relates  to  the  question  of  paying  pa- 
tients at  hospitals,  as  well  as  to  the  rights  of  the  staff  to  a 
voice  in  the  government.  The  latter  is  the  better  position 
to  fight,  but  the  former  is  the  one  that  most  interests  the 
mass  of  the  profession.  The  professional  philanthropists 
are  sure  to  be  generous  at  the  expense  of  the  practitioners, 
and  generally  are  very  wroth  if  their  views  are  questioned. 
They  want  to  speak  with  authority,  and  when  they  have 
no  case  abuse  the  other  side.  Even  the  Hon.  Sidney  Hol- 
land, who  tries  to  pose  as  a  friend  of  the  profession  as  well 
as  a  philanthropist,  when  he  finds  a  letter  in  the  Medi- 
cal Press  from  an  indignant  practitioner  to  which  he  can 
give  no  adequate  reply  flies  off  at  a  tangent,  accuses  the 
writer  of  being  "exceedingly  discourteous,"  and  by  way 
of  teaching  him  by  example,  hopes  "he  is  not  as  ill-man- 
nered in  his  consulting-room  as  he  is  in  his  correspond- 
ence." Now,  why  should  this  hospital  question  excite  the 
anger  of  those  who  profess  so  much  charity  and  good-will? 


548 


MEDICAL    RECORD. 


[October  6,  1900 


Major  G.  M.  Giles,  I. M.S..  M.B.  London,  has  published 
a  work  which  at  the  present  time  must  attract  attention. 
It  IS  entitled  "A  Handbook  of  the  Gnats  or  Mosquitos, 
Giving  the  Anatomy  and  Life  History  of  the  Culicida;." 
It  IS  a  volume  of  nearly  four  hundred  pages,  and  the  de- 
scriptions are  clear,  though  as  much  can  hardly  be  said  of 
the  illustrations.  These  the  publishers  should  miprove  in 
a  second  edition,  which  will  probably  be  called  for.  An- 
other timely  publication  is  "Besieged  by  the  Boers;  a 
Diary  of  Life  and  Events  m  Kimberlev  during  the  Siege," 
by  E.  Oliver  Ashe,  M.D.  London,  F.'R.C.S.  Sir  Joseph 
Fayrer's  "  Recollections  of  My  Life  "  is  a  much  larger  pro- 
duction, and  one  which  every  medical  man  who  has  the 
opportunity  will  be  pleased  to  peruse.  Professor  Monte- 
negro's work  on  "  Bubonic  Plague  "  has  been  translated  by 
Dr.  Munro.  It  contains  notes  on  the  cases  m  Oporto,  and 
the  author  lias  written  an  appendix  expressly  for  the  Eng- 
lish translation. 

The  coming  season  is  casting  its  shadow  before  it,  and 
many  teachers  are  back  from  their  holidays  and  thinking 
about  the  dinners  or  introductory  lectures,  or  more  prob- 
ably the  entries  of  new  students. 

And  with  this  shadow  comes  a  foretaste  of  winter — after 
our  heat  and  sunshine.  There  is  a  nip  of  frost  in  the 
mornings  and  evenings — almost  an  October  weather. 


STERILIZATION    OF    RUBBER   GLOVES. 

To  THE  Editor  of  the  Medical  Record. 

Sir  :  In  the  Medical  Record  of  September  15th,  under  the 
head  of  "Surgical  Suggestions,"  Dr.  Richardson's  method 
of  sterilizing  gloves  is  described.  While  I  was  an  interne 
at  Bellevue  Hospital  rubber  gloves  were  used  extensively 
in  the  wards  of  Dr.  J.  R.  Hayden,  and  the  following  sim- 
ple and  thorough  method  of  sterilizing  them  was  adopted  : 
The  gloves  were  filled  with  gauze,  each  finger  being  care- 
fully packed  so  that  two  layers  of  rubber  were  nowliere  in 
contact.  They  were  wrapped  separately  m  several  laj-ers 
of  gauze  and  were  boiled  in  plain  water  for  twenty  min- 
utes. From  this  they  were  transferred  to  cold  bichloride 
solution  I  :  2,000,  where  they  were  left  until  ready  to  use. 
The  difficulty  experienced  in  putting  on  wet  gloves  was 
easily  overcome  by  filling  them  with  solution,  allowing 
the  hand  to  force  it  out  as  the  gloves  were  drawn  on. 

E.  L.  Kellogg,  M.D. 

New  York,  September  20,  1900. 


THE    WEARING    OF    EYEGLASSES. 

To  THE  Editor  of  the  Medical  Record. 

Sir  :  Observing  that  Dr.  Jenkins  seems  to  have  miscon- 
strued my  criticism,  in  w^hich  I  differ  with  him  as  to  the 
"continued  "  or  the  "interrupted  "  wearing  of  lenses  when 
ametropia  or  anomalies  exist.  I  beg  your  forbearance  in 
permitting  space  for  the  following  propositions,  which  I 
present  as  the  gist  of  my  opinion  upon  the  question  under 
controversy  : 

(i)  The  entire  solution  depends  upon  the  question 
whether  an  eye  has  been  corrected  right  or  wrong,  /.<•., 
making  the  eye  normal  or  abnormal.  That  an  improper 
correction  should  be  worn  "as  little  as  possible"  is  self- 
evident  ;  again,  if  you  can  make  an  abnormal  eye  normal, 
why  limit  the  time  as  to  the  keeping  of  that  eye  normal? 

(2)  Ametropia,  like  other  structural  defects  and  abnor- 
malities, is  followed  by  functional  disturbances  and  se- 
quences such  as  scowling,  frowning,  squinting,  nictita- 
tion, eye  strain,  asthenopia,  neurasthenia,  heterophoria, 
strabismus,  anisometropia,  amblyopia,  mental  disturb- 
ances, etc.  Why  the  cause  of  these  disturbances  should 
be  removed  only  "as  little  as  possible  "  is  a  matter  of  suffi- 
cient gravity  to  warrant  either  a  thorough  confirmation  or 
denunciation. 

(3)  A  myope  of  a  fair  degree  of  myopia  has,  beyond 
reading  distance,  defective  vision,  and  when  the  myopia 
exceeds  two  or  three  diopters  his  vision  is  exceedingly  bad. 
excluding  him  from  various  vocations.  He  can  do  consid- 
erable near  work  without  glasses,  but  he  cannot  completely 
avoid  muscular  unbalance  and  its  resulting  discomfort. 
This  jierson's  vision  can  be  made  practically  perfect  and 
his  annoyance  relieved  if  properly  corrected  for  both  near 
and  far  vision,  and  why  in  the  name  of  common  sense  this 
person's  comfort  should  be  interrupted  merely  to  foil  the 
"caricaturist"  is  a  strange  demand.  Why  should  he  not 
see  well  all  the  time? 

(4)  An  hyperope  of  about  three  or  four  diopters  defect 
in  youth  can  overcome  by  extra  exertion  this  defect  so  that 
he  can  see  practically  normally.  But  as  the  near  point  re- 
cedes his  power  and  scope  of  exertion  "diminish,"  so  that 


in  time  when  his  accommodation  =  o  he  will  need  a  plus 
lens  as  badly  as  the  myope  needs  the  minus  lens,  and 
without  this  lens  his  vision  for  distance  is  as  poor  as  the 
myope's  vision  with  an  equal  degree  of  myopia.  He  may 
develoj)  hypertrophy  of  the  accommodation  muscle  (as 
strabismus  and  what  not),  but  in  time  his  presbyojiia  will 
extend  to  inlinity,  and  he  will  need  lenses  as  badly  to  tell 
his  friend  across  the  street  as  he  does  to  read  the  type  be- 
fore his  nose,  only  less  in  degree.  All  ordinarily  informed 
ophthalmologists  know  that  such  degrees  of  hyperopia  left 
uncorrected  are  prolific  factors  in  the  causation  of  muscu- 
lar unbalance,  amblyopia,  etc.  But  why  should  not  this 
hyperope  see  well  all  the  time  as  well  as  part  of  the  time? 
The  answer  lies  in  the  proper  correction. 

(5)  The  individual  with  even  an  ordinary  amount  of  as- 
tigmatism has  bad  sight,  while  only  a  few  dio])ters  of  this 
defect  give  him  miserable  sight.  That  this  is  a  fertile 
etiological  factor  in  amblyopia  is  little  disputed.  Why 
such  individuals  should  go  about  guessing  at  objects  part 
of  the  time,  carrying  their  lenses  in  pocket  or  hand,  hold- 
ing them  before  the'eyes  "as  little  as  possible  "  (sn),  en- 
couraging the  bad,  inevitable  sequels  as  much  as  possible, 
is  not  in  harmony  with  either  modern  or  "antiquated 
tables "  of  refraction.  To  encourage  this,  to  me  seems 
analogous  to  encouraging  grape-seeds  to  remain  in  the 
appendix. 

(6)  Let  me  emphasize  that  when  we  deal  with  muscular 
and  refraction  anomalies  we  are  facing  a  structural  condi- 
tion per  si\  with  but  rare  exceptions,  A  "functional" 
refraction  error  I  do  not  consider  a  refraction  error  proper, 
but  look  ujwn  it  as  a  symptom  or  sequel  of  some  other 
trouble.  If  this  is  confusing  "function  with  structure,"  I 
prefer  confusion.  No  qualified  oculist  corrects  insignifi- 
cant and  harmless  errors. 

T.  T.  Blaise,  M.D. 

Mason  Git's-,  Iowa. 


THE   LATE    DR.    FRANK   C.    MERRIAM. 

To  the  Editor  of  the  Medical  Record. 

Sir:  Frank  C.  Merriam,  whose  death  is  recorded  m  this 
week's  Medical  Record,  deserves  particular  mention  be- 
cause of  certain  traits  which  characterized  him.  His  intel- 
lectual honesty  was  uncommon,  and  he  took  pains  to  think 
for  himself.  He  was  not  aggressive.  He  did  not  strain 
to  force  his  opinions  on  others.  He  sought  to  be  on  the 
right  side  with  facts  as  they  are.  He  took  no  pride  in  dif- 
fering from  others  for  the  mere  sake  of  appearing  to  be  an 
independent  thinker.  He  was  a  studious  as  well  as  an 
active  practitioner. 

In  many  of  the  jubilee  and  holiday  addresses  of  medical 
presidents  the  medical  practitioner  has  bec<mie  a  good  deal 
lost  behind  the  glorification  of  the  progress  of  scientific 
medicine.  Our  era  is  one  of  Sturm-und-Drang  therapie. 
Now  and  then,  however,  a  medical  orator  will  be  bold 
enough  fo  say  that  the  general  practitioner  has  become 
"too  reverent  for  authorities  and  scarcely  believes  the  evi- 
dence of  his  own  senses,  if  it  conflict  with  what  the  books 
say."  Dr.  Merriam  did  not  disregard  authoritj'.  Not  even 
the  cutest  and  wisest  practitioner  can  afford  to  do  that. 
But  Dr.  Merriam  held  his  authorities  accountable  to  proper 
logical  divisions,  and  definitions  controlled  by  facts  and 
historical  data.  He  was  a  large-hearted  and  sympathetic 
man,  but  he  did  not  fail  to  distinguish  between  the  results 
he  wished  and  hoped  for  and  tho.se  which  nature  grudg- 
ingly allowed.  He  looked  for  the  fact,  and  strove  to  avoid 
the  factitious.  And  in  this  way,  like  many  a  practitioner 
who  remains  known  only  to  his  friends  and  associates,  he 
did  his  share  in  the  advancement  of  medicine. 

At  the  meetings  of  the  Charity  Hospital  Alumni  he  par- 
ticipated in  the  discussions  and  always  told  us  what  he  saw 
and  heard  and  felt.  He  was  a  man  of  one  opinion  .  not 
having  one  opinion  for  public  statement  and  another  for 
private  uses.  He  was  never  in  a  hurry  to  speak,  and  when 
he  did  speak  he  spoke  to  the  point,  sensibly  and  mod- 
estly. He  was  a  true  discijile  of  Socrates,  for  he  admitted 
his  ignorance  when  he  did  not  know.  He  was  a  truly  self- 
respecting  man,  and,  taken  all  in  all,  a  good  fellow  in  the 
best  sense  of  the  word  ;  and  not  only  are  his  Charity  Hos- 
pital colleagues  losers  by  his  early  death,  but  the  public  is 
too,  in  as  far  as  he  was  m  touch  with  it  as  a  medical  prac- 
titioner and  a  man. 

A  Charity  Hospital  Alumnus. 

September  93,  1900. 

A  Too  Common  Neglect  in  antiseptic  operating-room 
procedure  is  the  use  of  instrument  trays,  irrigators, 
and  tubes  which  have  not  been  boiled.  Boiled  instru- 
ments in  unboiled  trays  is  doubtful  antisepsis. — R.  N. 
Joyce. 


October  6,  1 900] 


MEDICAL    RECORD. 


549 


Jiocietvj  ^cpoirts. 


AMERICAN    ASSOCIATION'    OF    OBSTETRI- 
CIANS AND  GVN.KCOLOGISTS. 

Froaedin^s  oj  the  Thirteenth  Annual  Meeting,  Held  in 
Louisville,  Ky.,  September  j8,  19,  and  20,  igoo. 

First  Day — Morning  Session. 

The  association  met  at  the  Gait  House  under  the  pres- 
idency of  Dr.  Rufus  ]i.  Hall,  of  Cincinnati,  Ohio. 

Dr.  Lewis  S.  McMurtry,  of  Louisville,  welcomed  the 
association  on  behalf  of  the  local  medical  profession. 

The  address  of  welcome  was  responded  to  by  Presi- 
dent Hall. 

After  the  election  of  Fellows,  reading  of  telegrams 
and  letters  from  absentees,  etc.,  the  reading  of  the 
papers  was  begun. 

Erroneous  Objections  to  Bilateral  Inguinal  Cosli- 
otomy  and  Shortening  of  the  Round  Ligaments 
via  the  Dilated  Internal  Inguinal  Rings,  and  its 
Superior  Ultimate  Results  in  Simple  and  Compli- 
cated Aseptic  Retroversions  of  the  Uterus. —  Dk.  \. 
Goi.DSPOHN,  of  Chicago,  read  a  paper  with  this  title. 
For  a  description  of  the  technique  of  his  operation, 
the  writer  referred  to  his  previous  articles  on  this  sub- 
ject. He  laid  stress  upon  cutting  only  through  the 
skin  and  fat,  and  making  the  required  opening  through 
the  aponeurosis,  the  canal,  and  the  internal  ring 
bluntly.  The  ring  was  very  readily  dilated,  suffi- 
ciently to  admit  one,  or,  if  needed,  two  fingers,  and  to 
admit  of  drawing  out  the  tube  and  ovary  for  the  exer- 
cise of  the  highest  degree  of  delicate  and  e.xact  con- 
servative surgery  upon  them  without  doing  violence  to 
their  supports.  The  wound  was  closed  in  four  layers 
c\  la  Bassini.  In  the  second  layer  the  round  ligament 
became  placed  as  in  a  sandwich  between  the  posterior 
surface  of  Poupart's  ligament  and  a  good  bundle  of 
elastic  muscle  at  each  stitch,  which  made  hernia  im- 
possible and  saved  the  ligament  from  strangulation, 
while  it  held  it  firmly  enough  against  Poupart's  liga- 
ment to  secure  a  broad  union.  Thus  hernia  had  not 
followed  the  writer's  operation  in  fully  one  hundred 
and  twenty-five  cases  that  he  had  examined  or  had 
reports  from.  An  impending  hernia  in  one  case  was 
due  to  a  severe  accident.  As  the  internal  inguinal 
ring  was  just  in  front  of  the  normal  lateral  location  of 
the  ovary  and  ampulla  of  the  tube,  these  organs  and 
the  posterior  surface  of  the  uterus  could  be  reached  by 
one  finger  in  a  one-inch  opening  here,  as  well  as  by 
two  fingers  in  a  two-inch  opening  in  the  linea  alba 
midway  between  the  symphysis  and  the  umbilicus,  and 
for  the  necessary  access  to  the  pelvic  wall  to  shorten 
the  proper  suspensory  ligament  of  the  ovary  and  tube 
this  small  opening  served  well;  while  a  large  median 
ventral  incision  and  much  traumatism  of  viscera  by 
that  route  would  be  needed,  and  by  the  vagina  it  could 
not  be  done  at  all.  The  round  ligaments  were  always 
present  if  the  uterus  w-as.  In  fully  one  hundred  and 
ninety  cases,  including  seventy-five  simple  Alexander 
operations,  he  had  found  both  ligaments  in  each  case, 
after  his  pupilage  on  about  one  dozen  dead  women. 
But  in  four  patients  he  traced  one  from  within  the  pel- 
vis outward.  He  had  never  had  a  death  from  the 
operation.  But  one  patient  died  from  a  serious  renal 
complication  that  w'as  not  previously  discovered,  ow- 
ing to  an  exchange  of  samples  of  urine  by  a  nurse. 
Thorough  shortening  of  the  round  ligaments  via  their 
natural  channels  and  anchoring  forward  (not  laterally) 
was  the  only  operation  that  had  been  proven,  or  was 
likely  to  be  proven,  to  stand  what  the  writer  demanded 
as  the  normal  standard  for  all  operations  of  this  kind, 
and  had  called   the  "double  test  of  pregnancy,'' /'.<:•., 


that  it  did  not  embarrass  gestation  and  complicate 
labor,  which  was  the  single  test,  but  also  did  not  permit 
a  recurrence  of  retroversion  of  the  uterus  after  one  or 
more  subsequent  labors.  The  difficulties  in  diagnosis 
as  to  the  presence  of  pus  were  no  more  than  proficient 
gynaecologists  would  meet  successfully,  and  doubtful 
cases  could  be  cleared  up  by  ten  to  fourteen  days  in 
bed  with  warm  douches  and  extensive  fomentations. 
The  scars  being  in  the  groins,  and  covered  mostly 
by  hair,  were  not  seen  like  regular  laparotomy  scars. 

The  writer  published  a  table  of  twenty-two  cases, 
fourteen  of  which  were  actually  adherent  cases,  and 
the  adnexa;  in  all  cases  required  exsection  of  diseased 
particles  from  one  or  both  sides.  The  present  position 
and  condition  of  the  patients'  organs  and  their  general 
health  was  stated  after  an  average  observation  of  fif- 
teen months.  He  had  eight  patients  that  had  borne 
children  normally  after  his  operation,  and  he  cited 
lifty-one  cases  from  other  Alexander  operators,  in  all 
of  which,  except  two,  the  same  was  true.  Aside  from 
llurrage,  the  advocates  of  the  more  harmless  abdom- 
inal and  vaginal  operations  for  retroversion  have  not 
officially  adduced  one  case  to  offset  this  collection. 
Tiiey  applied  only  the  single  test  of  pregnancy.  Their 
operations  did  not  hold  the  uterus  in  normal  position 
after  subsequent  labor,  as  a  rule,  and  therefore  they 
were  merely  temporary  or  auxiliary  relief  measures, 
but  not  curative  procedures. 

In  the  discussion.  Dr.  Charles  G.  Cumston,  of 
Boston,  said  that  from  his  experience  in  operating  both 
by  the  abdomen  and  vagina,  as  well  as  from  a  patho- 
logical standpoint,  it  had  always  seemed  to  him  that 
serious  lesions  of  the  adnexa,  such  as  the  essayist  had 
treated  through  a  bilateral  inguinal  incision,  were 
usually  out  of  reach,  and  that  these  lesions  could  be 
dealt  with  more  easily  and  satisfactorily  through  a  me- 
dian, a  posterior,  or  anterior  vaginal  incision.  Sim- 
[ile,  uncomplicated  cases  of  retroversion  were  rare. 
The  Alexander  operation  in  the  so-called  simple  cases 
of  retroversion  could  be  greatly  improved  by  an  addi- 
tional operation  through  the  posterior  cul-de-sac. 

Dr.  Edward  J.  Ill,  of  Newark,  N.  J.,  called 
attention  to  the  modified  operation  which  was  pro- 
posed by  Dr.  H.  \V.  Longyear,  of  Detroit,  at  the  meet- 
ing of  the  association  last  year. 

Dr.  J.  Henry  Carstens,  of  Detroit,  rarely  saw  cases 
of  plain,  uncomplicated,  non-adherent  retroverted  uteri 
that  required  the  .Alexander  operation.  The  compli- 
cated cases  of  retroversion  required  some  other  opera- 
tive procedure. 

Dr.  VV.  E.  B.  Davis,  of  Birmingham,  Ala.,  re- 
ferred to  the  indications  for  performing  the  Alexander 
operation,  and  called  attention  to  the  class  of  cases  in 
which  it  should  be  performed. 

Dk.  Frederick  Coc;geshall,  of  Boston  (by  invita- 
tion), had  performed  over  a  hundred  Alexander  opera- 
tions in  combination  with  some  other  operative  pro- 
cedure. In  simple,  uncomplicated  cases  of  retrover- 
sion of  the  uterus,  the  organ  could  be  easily  replaced. 

Dr.  Rufus  B.  Hall,  of  Cincinnati,  thought  that  the 
old  operation  of  anterior  fixation  or  ventro-suspension 
of  the  uterus  was  not  so  popular  as  it  was  a  few  years 
since.  Soon  it  would  be  done  only  in  rare  instances. 
He  believed,  however,  that  a  modified  operation,  such 
as  that  advocated  by  the  essayist,  was  based  on  rational 
surgical  principles,  and  tliought  that  the  author  was 
working  in  tlie  right  direction. 

Round  Ligament  Ventro-Suspension  of  the  Uterus. 
— Dr.  D.  Tod  Gii.lia.m,  of  Columbus,  Ohio,  read  a 
paper  with  this  title.  Various  devices  had  been  re- 
sorted to  for  restoring  and  holding  in  place  the  retro- 
displaced  uterus.  All  of  these  had  been  faulty  and 
many  absolutely  prejudicial.  The  need  of  the  hour 
was  an  operation  that  would  utilize  the  natural  sup- 
ports of  the  uterus,  that  would  insure  a  fair  amount  of 


550 


MEDICAL   RECORD. 


[October  6,  1900 


mobility,  that  would  adapt  itself  to  the  various  func- 
tions of  the  uterus — pregnancy  and  parturition— and 
that  would  be  lasting  in  its  results  and  withal  easy  of 
execution.  Profiting  by  the  work  of  Ferguson  along 
this  same  line,  he  had  devised  an  operation  which  he 
thought  fulfilled  all  these  indications,  and,  as  he  be- 
lieved, solved  the  problem  most  satisfactorily. 

The  steps  of  the  operation  were  as  follows:  i.  A 
median  abdominal  section  was  made  three  or  four  inches 
in  length  and  at  the  usual  site  between  the  umbilicus 
and  pubis.  2.  The  adhesions  were  broken  up  and  the 
fundus  was  brought  forward,  after  which  the  patient  was 
placed  in  the  Trendelenburg  position.  3.  The  round 
ligament  was  seized  on  one  side  and  brought  to  the 
opening.  This  might  be  done  either  by  the  fingers  or 
by  the  aid  of  forceps.  4.  A  thread  was  carried  under 
the  ligament  at  a  distance  of  about  one  and  a  half 
inches  from  the  uterus.  The  free  ends  of  the  thread 
were  brought  out  of  the  abdomen  and  secured  by  clamp 
forceps.  5.  The  other  round  ligament  was  secured 
in  the  same  way.  6.  The  rectus  muscle  was  exposed 
near  the  lower  end  of  the  incision  by  retracting  its 
sheath  and  by  rolling  it  out  of  its  sheath  on  the  tips 
of  two  fingers  applied  to  the  peritoneal  surface  under 
it.  7.  A  point  was  selected  one  inch  external  to  the 
margin  of  the  incision  and  something  over  an  inch 
above  the  pubis,  through  which  the  perforating  forceps 
specially  devised  for  this  purpose  was  thrust  into  the 
peritoneal  cavity.  The  two  fingers  already  in  the  cav- 
ity guarded  the  instrument  in  its  passage  and  placed 
the  thread  which  surrounded  the  ligament  within  its 
jaws.  8.  The  perforating  forceps  was  now  withdrawn, 
after  removal  of  the  clamp  forceps  from  the  thread, 
and  both  thread  and  ligament  were  brought  up  through 
the  perforated  wound  in  the  abdomen.  9.  While  the 
ligament  was  held  taut,  it  was  fastened  into  the  wound 
by  a  to-and-fro  catgut  suture  passed  deeply  through 
the  ligament  and  including  the  tissues  on  either  side. 
10.  The  opposite  side  was  treated  in  the  same  manner 
and  the  median  abdominal  incision  closed.  Rigid 
observance  of  all  the  rules  of  aseptic  surgery  was  es- 
sential to  prevent  suppuration,  and  only  a  small  loop 
of  the  ligament  should  be  drawn  up  through  the  wound. 


First  Day — Ajtenwon  Session. 

A  Case  of  Composite  Teratoma  of  the  Ovary — 
This  was  the  title  of  a  brief  paper  by  Dr.  W.  E.  B. 
Davis,  of  Birmingham,  Ala.  The  author  was  in  doubt 
as  to  the  nature  of  the  tumor  which  he  presented,  not- 
withstanding the  above  diagnosis  was  made  by  pathol- 
ogists of  high  standing 

Mrs.  N ,  aged  thirty-four,  married,  was  referred 

to  him  by  Dr.  E.  G.  Givhan,  of  Montevallo,  May  3d. 
She  was  the  mother  of  three  children,  and  had  always 
menstruated  regularly,  except  when  pregnant  or  nurs- 
ing. The  patient  noticed  a  growth  in  the  abdomen  two 
years  ago.  She  had  menstruated  in  January  before 
the  growth  was  noticed,  and  then  missed  her  periods 
until  March,  at  which  time  she  menstruated  or  bled 
very  freely  for  two  weeks.  She  then  missed  periods 
until  the  following  October,  with  no  untoward  symp- 
toms except  an  attack  of  colic  in  August.  The  move- 
ments were  noticed  before  August.  After  October 
she  menstruated  regularly  until  the  following  January, 
missing  her  periods  then  until  October  24,  1899,  when 
a  child  was  born.  She  had  not  menstruated  since. 
After  the  birth  of  the  child  at  term,  the  tumor  devel- 
oped quite  rapidly,  and  on  May  7,  1900,  she  was  oper- 
ated upon.  The  patient  was  discharged  as  cured  June 
9th.  The  tumor  was  quite  large  and  had  a  pedicle 
nearly  two  inches  in  breadth,  quite  thick,  which  was 
attached  to  the  uterus.  The  ffttus  was  so  large  and 
so  well  formed  that  the  essayist  was  of  the  opinion 
that  there  had  been  an  ectopic  gestation,  with  rupture 


of  the  gestation  sac  and  the  expulsion  of  its  contents 
into  the  cavity  of  a  pre-existing  ovarian  cystoma. 
From  the  history  of  the  case,  the  diagnosis  of  an  old 
ectopic  pregnancy  had  been  made.  He  was  still  in- 
clined to  that  opinion. 

Pathological  Description:  Examination  revealed 
a  large,  rounded,  ovoid  mass  about  the  size  of 
an  adult  head,  covered  by  a  moderately  thin  fibrous 
capsule.  The  capsule  was  continuous  on  one  side 
with  the  tumor  mass.  The  weigiit  of  the  whole  tumor 
was  2,850  gm.  Within  the  capsule  were  observed  nu- 
merous sacs  of  variable  size,  which  w^ere  rounded  in 
contour,  and  were  filled  with  a  semi-fluid,  gelatino- 
albuminoid  tissue.  Lying  in  one  side  of  the  tumor 
was  part  of  a  fcetus.  There  were  numerous  bones  of 
a  fcetus  lying  in  the  capsule.  The  upper  part  of  the 
fcetus  was  embedded  in  the  solid  portion  of  the  tumor. 
This  portion  of  the  foetus  was  so  intimately  combined 
with  the  tumor  that  no  sharp  line  of  demarcation  could 
be  determined,  one  tissue  gradually  passing  over  into 
the  other.  There  were  numerous  nodular  and  teat-like 
elevations,  in  some  places  covered  by  smooth  skin  (.'), 
in  others  by  skin  (?)  provided  with  fine,  brownish, 
silky  hair.  Incision  of  these  frequently  revealed  a 
whitish,  cheesy  substance  resembling  sebaceous  secre- 
tion. The  soft  parts  of  the  fcttus  were  macerated  and 
quite  soft.  Tlie  bones,  such  as  the  vertebra;,  ribs, 
tibis,  and  metatarsals,  were  exposed  in  many  places 
There  were  two  well-developed  scapula  (right  and 
left),  and  to  the  left  was  attached  some  slight  sem- 
blance of  an  extremity.  Lying  in  a  mass  of  muscular 
tissue  to  the  left  of  the  vertebral  column  was  a  long 
piece  of  bone  resembling  somewhat  a  humerus.  At- 
tached to  the  lower  end  and  left  side  of  the  vertebral 
column  by  means  of  a  flattened  piece  of  bone,  was  an 
almost  perfect  lower  extremity.  The  femur  was  en- 
tirely covered  by  muscle,  but  the  tibia  was  exposed  at 
its  lower  end.  Some  of  the  phalanges  were  missing, 
but  the  foot  was  fairly  well  formed.  Careful  dissec- 
tion of  the  upper  part  of  the  foetus  failed  to  reveal  any 
cranial  bones  attached  to  the  vertebral  column.  There 
were  two  pieces  of  jaw-bone  (inferior  maxillae)  lying 
in  the  mass  of  tissue  at  this  place.  They  were  well 
shaped,  and  a  dissection  of  the  right  one  showed  rudi- 
mentary tooth  sacs  and  a  piece  of  nerve.  The  lamina 
of  the  vertebra;  had  not  united,  so  that  the  spinal 
canal  was  not  complete,  and  the  spinal  cord  was  seen 
lying  in  this  position,  with  nerves  arising  regularly 
from  each  side.  The  bones  lying  free  within  the  cap- 
sule were  two  parietal,  an  occipital,  two  pieces  of 
frontal  abnormally  united,  several  well-formed  ribs, 
and  five  or  six  long  bones  of  extremities.  Parts  of 
the  lungs,  liver,  stomach,  and  about  60  cm.  of  intes- 
tine were  preserved. 

Microscopical  Examination  :  Microscopical  exami- 
nation of  sections  of  tissue  selected  from  all  portions 
of  the  tumor  showed  a  very  complex  histological  struc- 
ture. Some  portions  of  the  tissue  were  composed  of 
simple,  fully  developed  adipose  tissue,  enclosing  oc- 
casional bands  of  unstriped  muscular  tissue,  the  whole 
surrounded  by  fully  developed  and  practically  perfect 
skin.  The  skin  contained  sebaceous  and  sweat  glands 
in  considerable  quantities,  and  hair  follicles  with 
hairs  in  position.  The  sebaceous  glands  were  larger 
than  those  found  in  normal  skin.  Other  portions 
showed  true  myxomatous  tissue,  still  others  cartilage, 
and  the  early  stages  of  osseous  develojjment.  Sec- 
tions from  the  walls  of  cysts  showed  the  inner  surface 
of  them  to  be  lined  by  almost  true  skin;  the  epithelial 
layers  lay  internally,  lining  the  cyst,  the  papillary  por- 
tion lying  externally.  Sebaceous  and  sweat  glands  oc- 
curred in  these  sections,  and  frequently  they  might  be 
seen  opening  into  the  cysts  Other  cysts  were  lined 
by  a  simple  layer  of  low  cubical  epithelium,  either  in 
uniform  arrangement  or  thrown  into  folds  or  villi,  sim- 


October  6,  1900] 


MEDICAL    RECORD. 


551 


ilar  to  the  formations  found  in  uncomplicated  cystic 
papillomatous  adenoma  of  the  ovary.  The  lining  of 
other  cysts  was  made  up  in  some  parts  of  flat  or  squa- 
mous epithelium,  in  other  parts  of  columnar  or  cubical 
upithL-lium  of  the  glandular  type,  and  frequently  one 
kind  of  epithelium  passed  over  into  the  other.  Ana- 
tomical diagnosis:  Composite  teratoma,  combined 
with  cystic  adenoma  of  ovary. 

The  Treatment  of  Chronic  Cystitis  in  the  Female 
by  Curettage  of  the  Bladder  and  Instillations  of 
Corrosive  Sublimate. — Dr.  Charles  Greene  Cums- 
To.v,  of  Boston,  read  a  paper  with  this  title.  He  drew 
the  following  conclusions:  i.  Sublimate  instillations 
would  often  produce  a  very  great  improvement  in  the 
distressing  symptoms  met  with  in  both  tuberculous  and 
non-tuberculous  cystitis,  such  as  a  diminution  in  the 
frequency  of  micturition,  a  decrease  of  the  pain,  an 
increase  in  the  capacity  of  the  bladder,  and  an  im- 
provement in  the  condition  of  the  urine.  In  some 
cases  a  complete  cure  might  be  had.  2.  When  the 
instillations  failed  to  produce  the  desired  effect,  curet- 
tage of  the  bladder  was  indicated  in  both  tuberculous 
and  non-tuberculous  cystitis.  3.  In  gonorrhoeal  cys- 
titis instillations  of  sublimate  were  very  efficacious 
and  rapidly  subdued  pain.  4.  lender  favorable  cir- 
cumstances a  radical  cure  of  primary  tuberculous  cys- 
titis migiit  be  obtained  by  curettage  when  the  vesical 
lesions  were  localized  and  the  kidneys  free  from  the 
disease.  Curettage  per  urethram  would  not  allow  the 
surgeon  to  reach  the  entire  surface  of  the  bladder,  so 
that  when  the  lesions  were  e.xtensive  they  should  be 
directly  treated  by  suprapubic  cystotomy.  5.  Much 
relief  might  be  afforded  to  a  large  number  of  patients 
suffering  from  tuberculosis  of  the  bladder,  but  who  on 
account  of  the  advanced  stage  of  generalized  infection 
were  in  no  condition  to  undergo  a  more  radical  opera- 
tion. 6.  When  cystitis  was  due  to  a  prolapsus  of  the 
genital  organs,  and  when  hysteropexy,  combined  with 
anterior  and  posterior  colporrhaphy,  did  not  relieve  the 
bladder  symptoms,  curettage  of  the  bladder,  followed 
by  sublimate  instillations,  was  the  proper  treatment. 

Dr.  a.  Goldspohx  did  not  believe  that  infiltrations, 
etc.,  of  the  bladder  could  be  recognized  by  the  curette 
at  an  early  stage  of  the  disease  process.  \\'ith  this 
instrument  the  operator  could  not  detect  beginning  ul- 
cerations or  papillomatous  growths  in  this  organ.  The 
bladder  being  a  membranous  organ,  curettage  of  it  was 
entirely  different  from  that  of  the  uterus,  in  that  the 
operator  did  not  receive  the  tactile  information  or  in- 
telligence from  this  instrument  in  the  bladder  that  he 
obtained  from  it  in  curetting  the  uterus.  Scraping  the 
bladder,  therefore,  was  done  largely  at  random,  with- 
out any  touch  sensation  to  govern  the  operator  as  to 
how  little  or  how  much  surface  he  should  curette. 
Under  such  circumstances  it  was  not  rational  to  as- 
sume that  the  mucous  lining  of  the  bladder  would  be 
evenly  and  uniformly  curetted.  Uneven  surfaces  or 
small  areas  would  be  left  untouched.  In  the  trejtment 
of  infectious  cystitis,  not  tuberculous,  he  had  obtained 
good  results  from  a  solution  of  from  one-half  to  one 
per  cent,  of  oil  of  cloves  in  water. 

Dr.  J.  Henry  C.arstens  agreed  with  the  last  speaker 
that  there  were  certain  points  in  the  bladder  in  the  class 
of  cases  under  consideration  that  could  not  be  reached 
by  the  curette.  He  had  had  cases  of  tuberculous,  gon- 
prrhceal,  and  septic  infections  of  the  bladder  which  had 
yielded  to  the  judicious  application  of  permanganate 
of  potassium. 

Dr.  Edwin  Ricketts  had  never  tried  this  method 
of  treating  cystitis  in  the  female,  but  it  seemed  to  him 
plausible,  and  he  was  inclined  to  try  it. 

Dr.  Rufus  B.  Hall  directed  attention  to  the  danger 
of  over-distention  of  the  bladder  with  injections.  Dis- 
tention of  the  organ  up  to  the  point  of  causing  discom- 
fort to  the  patient  should  be  the  limit  of  safety. 


Dr.  James  T.  J  elks  concurred  in  the  statement  of 
Dr.  Carstens  that  permanganate  of  potassium  was  an 
invaluable  remedy  for  infective  disease  of  the  bladder, 
particularly  of  the  gonorrhoeal  variety.  A  solution  of 
1 : 6,000  was  strong  enough  to  begin  with,  the  strength 
being  increased  in  accordance  with  the  indications  of 
the  particular  case. 

Dr.  T.  J.  Crofford,  of  Memphis,  had  performed 
curettage  of  the  bladder  several  times.  If  the  inflam- 
matory process  was  confined  to  the  neck  or  there- 
abouts, there  was  very  little  difficulty  attending  the 
curettage  of  that  area  of  surface.  No  inflammatory 
zones  would  be  left  to  cause  further  trouble. 

Dr.  Goldspohn  did  not  wish  to  be  understood  as 
opposing  curettage  of  the  bladder  in  loto,  but  believed 
it  ought  to  be  done  under  the  guidance  of  the  eye  or 
tactile  sense.  He  called  attention  to  a  new  urethro- 
scope with  an  electric-lamp  attachment,  the  latter  illu- 
minating the  bladder  nicely  without  generating  heat. 

Dr.  CuMSTo.N',  in  closing,  referred  to  the  pathology 
of  bladder  lesions,  and  said  they  were  almost  always 
situated  in  thetrigonum:  consequently  this  was  the 
portion  of  the  viscus  which  the  operator  should  strive 
to  reach.  If  the  whole  bladder  surface  was  involved, 
suprapubic  cystotomy  was  the  operation  of  choice,  and 
curettage  in  such  a  case  would  do  very  little,  if  any 
good.  He  used  the  cystoscope  in  the  treatment  of  this 
class  of  cases. 

Four  Cases  of  Perforated  Gastric  Ulcer,  with 
Remarks. — Dr.  Henry  Howitt,  of  Guelph,  Ontario, 
read  this  paper.  The  first  two  cases  occurred  years 
ago  before  the  operative  procedures  were  commonly 
known,  and  had  the  usual  termination,  one  patient 
dying  within  twenty-four  hours  from  the  commence- 
ment of  the  illness  without  having  had  a  single  symp- 
tom indicating  the  existence  of  the  trouble.  The  other 
two  reported  by  him  were  of  recent  date,  and  the  pa- 
tients were  saved  by  timely  operations.  In  one  the 
operation  was  devoid  of  any  serious  difficulty,  but  in 
the  other  the  abdomen  contained  gas  and  a  large 
amount  of  pus;  the  colon  was  enormously  distended, 
requiring  to  be  opened  and  collapsed  before  the  stom- 
ach could  be  reached.  There  existed  also  the  remains 
of  a  ruptured  abscess  cavity  below  the  transverse  por- 
tion of  larger  bowel,  the  walls  of  which  were  formed 
by  it  together  with  the  coils  of  small  intestine  and 
omentum.  This  had  its  origin  probably  in  a  slight 
leakage  which  occurred  days  before  the  final  rupture. 
The  orifice  of  the  ulcer  was  of  sufficient  calibre  to  ad- 
mit his  little  finger,  and  was  situated  in  front  close  to 
the  pyloric  valve.  The  surrounding  parts  were  so 
thickened,  dense,  and  nodular  as  to  resemble  exactly 
carcinoma  of  the  pylorus  and  adjacent  part  of  the 
stomach.  A  section  nearly  two  inches  in  length  had 
to  be  removed  before  the  ulcer  could  be  closed.  The 
intestines  were  previously  eviscerated  to  gain  the  room 
necessary  to  reach  the  part  and  to  expose  the  pools  of 
pus  in  the  pelvic  flanks  and  other  places  difficult  to 
reach.  The  upper  portion  of  the  jejunum  was  anasto- 
mosed by  means  of  a  Murphy  button  to  the  anterior 
wall  of  the  stomach.  Before  this  was  done  care  was 
taken  to  allow  for  every  possible  movement  without 
causing  tension  of  the  proximal  arm  of  gut.  After  the 
anastomosis  was  completed,  the  arm  of  intestine  above 
was  stitched  to  the  wall  of  the  stomach  an  inch  or 
more  to  the  right  and  a  little  above  the  line  of  the 
button.  This  procedure  in  his  opinion  overcame  the 
acute  angle  and  its  ill-effects.  Drainage  tubes  were 
inserted  through  perforations  made  in  the  flanks  well 
to  the  back,  and  in  the  lower  abdomen  close  to  the 
pelvis  to  the  outer  side  of  the  right  rectus  muscle. 
The  sutures  were  all  removed,  except  two  in  the  mid- 
dle of  the  wound  opposite  the  umbilicus,  on  the  sev- 
enth day.  Three  hours  later  the  patient  had  a  sneez- 
ing-fit, and  the  wound  tore  open  from  the  upper  angle 


552 


MEDICAL   RECORD. 


[October  6,  1900 


to  the  umbilicus,  exposing  the  situation  of  the  anasto- 
mosis, and  coils  of  bowel  protruded.  It  was  restitched 
an  hour  later  without  anaesthesia,  and  no  ill-effects  fol- 
lowed. The  patient  made  an  uneventful  recovery,  and 
was  now  for  the  first  time  in  eighteen  years  free  from 
gastric  distress. 

In  the  remarks,  which  were  confined  chiefly  to  points 
which  had  appeared  to  him  as  important  when  certain 
conditions  were  present,  he  called  attention  to  the 
danger,  in  the  early  stage  after  the  occurrence  of  per- 
foration, of  the  medical  man  being  misled  by  the 
state  of  the  pulse  and  temperature  until  the  oppor- 
tune time  had  passed,  and  narrated  three  instances; 
two  after  perforation  of  the  stomach,  in  which  both 
were  to  all  indications  normal,  and  one  after  rupture  of 
the  spleen,  in  which  the  pulse  was  normal  and  the  tem- 
perature subnormal.  Attention  was  drawn  to  the  ad- 
missibility of  temporary  enterotomy  and  evisceration 
when  the  part  on  which  the  operation  was  required  lay 
deep,  or  when  the  abdomen  contained  much  septic  ma- 
terial. The  former  was  advised  by  him  in  all  cases 
in  which  the  intestines  were  distended  with  gas  or 
liquid  fecal  matter.  In  one  patient  four  separate  open- 
ings were  made  without  ill-effects.  The  puncture  be- 
came minute  when  the  bowel  contracted,  and  was 
readily  closed  by  a  suture  or  two.  He  pointed  out 
that  the  patients  were  frequently  reduced  by  starvation 
to  a  very  low  ebb  before  perforation  occurred,  owing 
to  the  irritable  condition  of  the  stomach  and  rectum, 
the  latter  from  the  effects  of  oft-repeated  nutritive 
enemata,  and  for  obvious  reasons  constipation  was  the 
rule.  In  order  to  nourish  the  patient  after  operation 
he  advised  the  introduction,  by  means  of  an  apparatus 
similar  to  that  used  for  decinormal  saline  injections, 
of  a  pint  of  peptonized  milk  into  the  jejunum  during 
the  operation,  and  also,  if  constipation  was  a  fac- 
tor, of  a  suitable  saline  cathartic  into  the  ascending 
colon. 

Dr.  Richard  Douglas,  of  Nashville,  Tenn.,  had 
had  two  cases  of  perforating  ulcer  of  the  stomach  in 
which  he  urged  operation,  and  while  preparations  were 
being  made  to  operate  on  one  of  them,  the  patient 
died.  In  the  other  operation  was  refused.  Death  en- 
sued some  time  later.  Post-mortem  examination  in 
this  case  revealed  a  perforating  ulcer  on  the  posterior 
wall  of  the  stomach;  while  in  the  other  case  the  ulcer 
was  confined  to  the  lesser  curvature. 

Dr.  James  F.  W.  Ross,  of  Toronto,  called  attention 
to  the  difficulty  attending  the  diagnosis  of  gastric 
ulcer  in  some  cases.  He  had  operated  successfully 
on  one  case  of  perforating  gastric  ulcer.  The  patient 
did  not  know  that  she  had  anything  seriously  the  mat- 
ter with  her. 

Dr.  Charles  Greene  Cumston  mentioned  a  case 
in  which  there  was  an  ulcer  of  the  stomach  and  one  in 
the  vagina,  of  embolic  origin,  associated  with  arterio- 
sclerosis. 

Dr.  W.  E.  B.  Davis  had  never  operated  for  ulcera- 
tion of  the  stomach  attended  by  perforation.  He  had 
encountered  two  cases  which  he  should  have  operated 
upon  had  the  symptoms  been  sufficiently  marked  to 
warrant  operative  procedure,  but  they  were  not,  and 
he  did  not  feel  therefore  emboldened  to  undertake  it. 

Dr.  Edwin  Ricketts  narrated  the  case  of  a  woman 
forty-eight  years  of  age,  who  had  had  a  gastric  ulcer 
for  three  years.  Under  rectal  alimentation  she  gained 
sixty  pounds  in  flesh.  Subsequently  she  committed 
some  indiscretion  in  diet,  was  again  taken  sick,  and 
consulted  another  physician,  who  made  a  diagnosis  of 
cancer  of  the  pylorus.  She  went  from  bad  to  worse, 
and  finally  died.  Post-mortem  examination  revealed 
a  perforating  gastric  ulcer  the  size  of  a  lead  pencil, 
situated  on  the  anterior  surface  near  the  pylorus. 

Dr.  F.  \V.  McRae,  of  Atlanta,  said  that  the  work  of 
Mayo,  of   Rochester,  Minn.,  and  other   surgeons  was 


sufficiently  encouraging  to  justify  surgeons  in  operating 
on  this  class  of  cases. 

Dr.  a.  X'ander  Veer,  of  Albany,  spoke  of  two  cases 
of  gastric  ulcer  which  ultimately  resulted  in  carcinoma 
of  the  pyloric  end  of  the  stomach.  From  the  number 
of  cases  in  which  he  had  done  gastro-intestinal  anasto- 
mosis, he  was  satisfied  that  he  had  had  to  deal  with 
the  cicatrices  resulting  from  gastric  ulcers  in  many 
instances. 

])r,  D,  Tod  Gilliam  believed  that  whenever  an  ac- 
curate diagnosis  of  ulcer  of  the  stomach  was  made,  an 
exploratory  operation  at  least  should  be  made. 


First  Day — Evening  Session. 

Some  Points  Regarding  the  Surgery  of  the  Gall 
Bladder. — Dr.  A.  Vander  Veer,  of  Albany,  read  a 
paper  with  this  title.  No  great  reliance  was  now 
placed  upon  jaundice  as  a  positive  symptom.  Four 
interesting  and  instructive  cases  were  reported,  and 
the  following  conclusions  drawn:  1.  An  early  diag- 
nosis of  cases  was  necessary.  2.  In  suppuration  of 
the  bladder  with  adhesions,  a  most  thorough  exam- 
ination should  be  made  from  within  by  digital  explo- 
ration and  use  of  the  probe  for  any  possible  deep- 
seated  calculi.  3.  In  prolonged  operations  upon  the 
common  duct  or  hepatic  ducts,  when  adhesions  were 
present  and  it  was  difficult  to  close  the  incision,  after 
removal  of  the  calculus,  drainage  through  the  perito- 
neal pouch  by  means  of  the  lumbar  stab  was  advisable. 
4.  When  the  patient  was  suft'ering  seriously  from  cho- 
Itemia,  with  marked  ecchymotic  spots  over  the  body, 
intense  itching,  and  the  blood  on  examination  was 
found  in  a  septic  condition,  an  operation  was  not  to 
be  encouraged.  It  w'as  too  late  in  the  vast  majority  of 
cases  for  the  patients  to  recover.  5,  General  practi- 
tioners as  well  as  the  surgeon  should  place  more  ear- 
nestly before  the  patient  and  friends  the  dangers  of 
repeated  attacks  of  gall-stone  irritation  resulting  in 
cancer  of  the  ducts,  stomach,  or  liver. 


Second  Day — Morning  Session. 

Diagnosis  of  Ectopic  Gestation  before  Rupture, 
Based  on  Eleven  Cases. — Dr.  James  F.  Baldwin,  of 
Columbus,  Ohio,  read  a  paper  on  this  subject,  which 
consisted  of  a  brief  report  of  six  cases  of  tubal  preg- 
nancy which,  added  to  five  similar  cases  previously 
reported  by  him,  made  eleven  cases  in  which  he  had 
made  a  diagnosis  of  tubal  pregnancy  and  had  operated 
before  the  occurrence  of  rupture,  his  experience  hav- 
ing been  in  direct  contradiction  to  the  dictum  of  Law- 
son  Tait  that  such  an  early  diagnosis  was  not  possible. 
His  argument  was  that  in  a  large  number  of  cases 
such  an  early  diagnosis  was  entirely  feasible  and 
would  be  made  as  a  routine  when  the  attention  of  in- 
telligent general  practitioners  was  sufficiently  directed 
to  the  subject.  He  said  that  while  there  were  no 
pathognomonic  symptoms  of  tubal  pregnancy,  the  fol- 
lowing points  would  usually  be  found  in  these  cases: 
The  patient  gave  a  history  of  several  years  of  sterility 
(many  exceptions) ;  she  had  missed  a  menstrual  pe- 
riod, perhaps  two  of  them  (numerous  exceptions);  she 
had  noticed  some  unusual  pains  in  the  pelvis,  which 
she  would  probably  describe  as  boring,  griping,  or 
colicky  in  character,  these  pains  being  situated  usu- 
ally in  the  region  of  an  ovary.  She  iiad  perhaps 
within  a  few  days  of  the  time  of  consulting  her  physi- 
cian had  a  more  or  less  irregular  hemorrhage;  perhaps 
had  discharged  pieces  of  membrane  whicli  she  sup- 
posed indicated  an  abortion,  and  consulted  her  physi- 
cian with  the  idea  that  such  was  the  case,  owing  to  the 
hemorrhage  and  the  pain  and  the  suspicion  of  an  ex- 
isting pregnancy.  Possibly,  however,  there  had  been 
no  suspicion  of  a  pregnancy,    as  the  woman  had  ac- 


October  6,  1900] 


MEDICAL    RECORD. 


553 


cepted  her  sterility  as  incurable  and  had  dismissed 
from  her  mind  such  a  possibility.  On  making  a  vag- 
inal examination,  if  the  conditions  were  at  all  favor- 
able, the  examiner  would  find  upon  one  side  or  tiie 
other  of  the  uterus,  or  back  of  it,  a  fusiform,  quite 
well-detined  cystic  tumor,  about  the  size  of  a  pullet's 
egg  or  a  little  larger.  This  tumor  would  probably  be 
quite  tender  on  pressure,  quite  .symmetrical  in  outline, 
and  usually  distinctly  pulsating.  When  such  a  tumor 
w-as  found  in  a  woman  in  whom  there  was  reasonable 
grounds  to  suspect  a  pregnancy ;  when  the  uterus  at 
the  same  lime  was  found  somewhat  enlarged,  and 
having  the  feel  of  pregnancy,  but  not  enlarged  so  much 
as  one  would  expect  in  a  pregnancy  of  so  long  contin- 
uance as  the  history  indicated,  a  presumptive  diagnosis 
of  tubal  pregnancy  was  warranted,  and  the  matter  of 
an  operation  should  be  carefully  and  without  delay 
considered.  To  render  the  early  diagnosis  of  ectopic 
pregnancy  possible,  it  was  necessary  for  physicians  to 
learn  to  suspect  it,  and  to  examine  patients  with  that 
suspicion  in  mind.  The  physician  who,  without  mak- 
ing any  examination,  told  all  middle-aged  women 
who  came  to  him  complaining  of  irregular  hemor- 
rhages that  they  W'ere  merely  having  the  change  of 
life,  would  not  be  likely  to  make  an  early  diagnosis  of 
cancer  of  the  uterus,  anci  he  would  probably  tell  patients 
who  came  to  him  with  symptoms  of  ectopic  pregnancy 
that  they  were  merely  threatened  with  a  miscarriage. 
He  would  make  no  further  investigations,  and  would 
hence  uniformly  fail  to  make  a  diagnosis.  The  phy- 
sician, however,  who,  having  in  mind  the  possibility 
of  an  ectopic  pregnancy,  throughly  examined  all  pa- 
tients wiiose  history  and  symptoms  pointed  to  this 
condition,  would  in  a  large  proportion  of  cases  make 
a  correct  diagnosis,  and  by  prompt  intervention  would 
achieve  a  signal  triumph  for  himself  and  his  profes- 
sion. 

Dr.  Edward  J.  Ill  asked  as  to  the  nature  of  the 
contents  of  the  tube,  to  which  Dr.  Jialdwin  replied 
that  in  nearly  all  of  the  cases  there  were  some  blood 
clots  pure  and  simple. 

Dr.  Charles  A.  L.  Reed  said  that  to  make  a  diag- 
nosis of  tubal  pregnancy  before  the  time  of  rupture,  it 
was  necessary  to  have  the  patient  under  observation 
constantly  for  a  considerable  length  of  time.  He  had 
encountered  such  a  case  about  seven  years  ago,  the  de- 
tails of  which  were  narrated. 

Dr.  L.  H.  Laidley  said  the  only  diagnosis  of  ectopic 
pregnancy  he  had  ever  made  was  in  a  case  of  cancer 
of  the  uterus  when  there  was  no  rupture.  He  did  not 
suspect  the  existence  of  it  until  he  had  removed  the 
tubes  and  had  found  indications  of  a  developing  foetus 
within  the  tubes. 

Dr.  Zinke,  of  Cincinnati,  thought  the  diagnosis  of 
ectopic  gestation  was  easy  in  some  cases  if  the  gyn.t- 
cologist  had  certain  symptoms  to  guide  him,  namely, 
loss  of  blood,  either  scanty  or  profuse,  attended  with 
pain,  and  a  tumor,  pulsating  in  ciiaracter,  found  on  one 
or  the  other  side  of  the  uterus.  In  other  instances, 
however,  the  diagnosis  was  very  obscure,  particularly 
in  those  cases  in  w^hich  the  ectopic  gestation  was  com- 
plicated with  a  normal  pregnancy.  Sucli  a  case  was 
narrated. 

Dk.  D.  Tod  Gilliam  said  that  if  the  gynecologist 
could  diagnosticate  most  cases  of  ectopic  gestation 
before  rupture  had  taken  place,  it  would  prove  a  great 
boon  to  womankind.  .V  distinction  between  tubal 
pregnancy  and  intianimatory  conditions  should  always 
be  borne  in  mind 

Dr.  a.  Goljjspohn  said  he  had  made  a  diagnosis  of 
extr.i-uterine  pregnancy  in  five  cases. 

Dr.  J.  Henry  Carstens  did  not  think  cases  of  ex- 
tra-uterine pregnancy  were  as  common  as  the  profes- 
sion generally  supposed.  The  average  general  prac- 
titioner with  a  yood  practice  observed  but  very  few 


such  cases  in  a  lifetime.  He  spoke  of  the  difficulty 
in  diagnosis,  and  said  that  when  this  condition  was 
expected  and  operated  for.  something  else  was  found. 
The  Surgical  Treatment  of  Uterine  Displacements 
was  the  title  of  a  paper  read  by  Du.  C"harles  A.  L. 
Reed,  of  Cincinnati,  Ohio.  Attention  was  called  to 
a  couple  of  modifications  of  technique  in  the  manage- 
ment of  a  class  of  cases  that  was  hajipily  becoming 
less  and  less  perplexing.  It  was  not  the  author's  pur- 
|)ose  to  discuss  the  relative  merits  of  Alexander's  and 
Mann's  operations,  or  to  consider  the  ingenious  tech- 
nique of  Ferguson.  In  a  majority  of  all  cases  of 
retrodisplacements  that  demanded  operation  at  all,  the 
author  believed  that  the  intraperitoneal  shortening  of 
the  round  ligaments  was  the  operation  of  choice.  It 
had  been  his  habit  during  a  number  of  years  to  effect 
this  by  making  a  letter-of-S  fold  in  the  ligaments  and 
stitching  tiiem  thus  folded  to  the  parietal  peritoneum 
along  the  line  of  I'oupart's  ligament.  This  method 
had  yielded  him  better  results  than  any  which  he  had 
previously  tried.  He  had,  however,  become  convinced 
that  the  parietal  fixation  of  the  folded  ligament  was 
not  necessary  for  the  purpose  of  holding  the  uterus  in 
its  normal  position,  and  that  the  technique  devised  by 
Mann  was  all  that  was  required  to  accomplish  this 
object.  His  application  of  this  technique  differed  a 
little  from  that  originally  adopted  by  Mann,  the  modi- 
fications being  those  of  convenience  rather  than  of 
necessity.  These  modifications  are  here  given  in  the 
language  of  the  author:  "In  seizing  the  round  liga- 
ment with  hamostatic  forceps  for  the  purpose  of  fold- 
ing it  upon  itself,  the  tissues  are  frequently  wounded. 
W'ihle  the  accident  is  not  a  serious  one,  it  is  certainly 
not  desirable.  The  use  of  two  ha;mostatic  forceps  for 
the  purpose  of  effecting  the  fold  makes  the  services  of 
two  hands  of  an  assistant  necessary.  To  obviate  these 
objections,  which  though  of  minor  importance  are  slill 
objections,  I  have  devised  a  forceps  with  four  Mat  ap- 
proximating prongs,  the  whole  being  an  inch  across. 
The  prongs  of  the  opposing  blades  approximate  with 
sufficient  force  to  hold  the  ligament,  but  not  enough  to 
induce  tissue  necrosis;  while,  when  approximated, 
they  are  far  enough  apart  to  permit  the  passage  of  a 
medium-sized  needle  between  them.  The  ligament, 
brought  up  into  the  field  of  operation  on  the  finger,  is 
seized  in  its  middle  third  by  this  instrument,  which  is 
then  turned  one-half  around,  thus  effecting  by  a  simple 
twist  of  the  wrist  the  desired  shortening  of  the  liga- 
ment. It  is  then  held  in  this  position  until  all  of  the 
sutures  are  applied.  These  are  inserted  as  follows: 
one  interrupted,  one  fixing  the  loop  of  ligament  to 
the  cornua  of  the  uterus;  a  similar  suture  is  utilized 
to  fix  the  outer  fold  of  the  ligament;  a  continuous  su- 
ture is  then  passed  between  the  prongs  of  the  fixation 
forceps,  its  ends  being  obliquely  tied  after  the  instru- 
ment is  withdrawn.  A  pathological  condition  that 
often  exists  in  cases  of  long-standing  Hexions  and  the 
persistence  of  which  militates  against  tiie  success  of 
any  fixation  operation,  consists  in  an  atrophy  of  the 
concave  wall  and  an  hypertrophy  of  the  convex  wall 
at  the  point  of  flexure.  In  many  cases,  particularly 
when  associated  with  diffuse  fibrosis,  the  elongated 
and  hypertrophied  wall  offers  a  persistent  resistance 
to  the  maintenance  of  the  normal  axis  of  the  organ. 
To  overcome  this  I  have,  for  some  time,  removed  a 
cuneiform  segment  from  the  hypertrophied  wall,  an 
operation  which  Thiriar  calls  cuneo-hysterectoniy, 
and  which  is  applicable  in  either  anterior  or  poste- 
rior flexions.  To  do  this  the  patient  is  placed  in  the 
Trendelenburg  position.  .Ml  adhesions  between  the 
uterus  and  bladder,  or  between  the  uterus  and  other 
organs,  are  carefully  broken  up,  the  rents  in  the 
serosa  that  may  be  induced  thereby  being  carefully 
stitched.  The  uterus  is  then  brought  toward  the 
incision  by  gentle    but  firm  traction,  and  an  ellipse 


554 


MEDICAL    RECORD. 


[October  6,  1900 


of  tissue  about  i  cm.  wide  and  having  a  length  cor- 
responding to  the  breadth  of  the  organ  is  removed  from 
the  convex  side  at  the  site  of  Hexure.  Care  must  be 
taken  not  to  carry  this  dissection  into  the  cavity  of 
the  uterus  nor  to  wound  either  the  circular  artery  or 
the  anastomosing  brandies  of  the  uterine  artery. 
Should  the  latter  accident  occur,  it  is  l)est  controlled 
by  ligatures  en  masse  passed  deeply  into  the  uterine 
tissue  at  either  end  of  the  yet  gaping  ellipse.  Retrac- 
tion of  the  vessels  generally  prevents  their  isolation 
and  closure  by  direct  ligature,  which,  when  practicable, 
is  always  the  preferable  method.  After  all  hemor- 
rhage, except  mere  capillary  oozing,  is  controlled,  the 
margins  of  tiie  ellipse  should  be  carefully  approxi- 
mated and  closed  by  a  continuous  animal  suture  passed 
deep  into  the  matrix.  It  may  be  well  to  fortify  the 
continuous  suture  with  two  or  three  interrupted  ones 
of  the  same  material.  The  uterus  is  then  dropped 
back,  and  after  pausing  a  moment  to  make  sure  of 
complete  haniostasis,  the  abdomen  is  closed  without 
drainage.  A  further  modification  of  this  operation, 
that  I  have  practised  with  satisfaction  in  anteflexion, 
consists  in  stitching  a  reef  of  the  posterior  folds  of  the 
broad  ligament  to  either  side  of  the  posterior  surface 
of  the  uterus.  I  have  been  able  by  these  combined 
methods  to  relieve  the  most  distressing  and  persistent 
symptoms,  vesical,  uterine,  ovarian,  and  neurotic,  due 
to  otherwise  intractable  anteflexion  of  the  womb  " 

Fibroma  of  the  Ovary,  and  Exhibited  Specimens. 
—  Dr.  L.  H.  Laidley,  of  St.  Louis,  Mo.,  read  this 
paper.  After  giving  the  pathology  of  fibromata  of  this 
organ,  the  author  reported  the  following  case; 

Mrs.  H ,  aged  twenty-nine  years,  married,  usual- 
ly enjoyed  good  health,  with  the  exception  of  almost 
complete  deafness  due  to  a  specific  disease,  for  which 
siie  was  treated  some  fifteen  years  ago.  She  became 
pregnant,  and  was  delivered  of  a  healthy  child  about 
two  months  before  the  removal  of  the  tumor.  She 
had  noticed  a  tumor  in  the  region  of  the  left  ovary  about 
two  years  ago;  it  was  hard  and  slightly  movable,  and 
continued  to  grow  to  the  size  of  two  fists.  In  the  de- 
velopment of  pregnancy  it  was  pressed  upward  on  a 
line  with  the  umbilicus  and  could  readily  be  felt  in 
her  left  side.  There  was  no  pain  or  discomfort  with 
its  presence  up  to  the  tenth  day  after  her  delivery. 
She  had  a  favorable  "  getting-up."  when  on  the  fifteenth 
day  she  had  fever  with  pains,  causing  her  again  to  take 
to  her  bed.  These  continued  until  he  saw  her  two 
months  later.  Upon  examination  he  found  the  lungs, 
heart,  and  abdominal  viscera  in  normal  condition. 
There  could  be  readily  felt  and  seen  a  hard,  immova- 
ble tumor  in  the  left  umbilical  region,  with  considera- 
ble ascitic  fluid  in  the  cavity.  On  January  2otii  an 
abdominal  section  was  made,  revealing  a  solid  tumor 
adlierent  to  the  anterior  wall  of  llie  abdomen,  which 
was  detached.  Posteriorly  the  folds  of  the  bowel  were 
adherent  to  that  ]5ortion,  which  were  also  dissected  off 
ant!  the  tumor  was  freed.  It  was  kidney-shaped,  hard, 
with  short  pedicle,  one  inch  in  diameter  by  two  inches 
in  length ;  this  was  ligated  and  the  tumor  removed. 
When  the  ligature  was  tied  it  readily  cut  through  its 
peritoneal  covering,  but  secured  the  stump  from  lieni- 
orrhage.  On  examination  of  the  remaining  organs, 
the  stump  of  the  pedicle  occupied  the  location  of  the 
ovary;  the  tube  remained  distinct  and  separate  from 
the  tumor;  the  opposite  side  showed  a  healthy  tube 
and  ovary;  there  was  considerable  loss  of  blood  from 
the  surface  hemorrhage  following  the  operation,  ijut 
with  that  exception  there  was  no  difficulty  encountered, 
■{'he  patient  made  an  uninterrupted  recovery.  The 
tumor  weighed  thirty-two  ounces,  and  measured  six  by 
five  by  three  inches.  A  histological  report  accom- 
panied the  recital  of  the  case. 

Dr.  Laidley  also  reported  an  interesting  case  of 
hernia  or  diverticulum  of  the  chorion. 


Diffuse  Non-Malignant  Papilloma  of  the  Vulva. 
—  Dk.  Luwahu  J.  Ill,  of  Newark,  X.  J.,  read  this 
paper  and  showed  a  specimen  whicii  he  had  removed 
from  a  patient  sixty-eight  years  of  age.  The  growth 
had  been  of  over  three  years'  standing.  The  inner 
surfaces  of  the  vulva  were  thickened,  at  some  places 
appearing  horn-like,  white,  and  smooth;  at  other  places 
there  were  heavy  papilla;  which  rose  considerably 
above  the  surroimding  tissue  and  were  from  3  mm.  to 
15  mm.  in  diameter  at  their  base.  The  disease  ex- 
tended from  the  beginning  of  the  vulva  above  down  to 
the  posterior  commissure.  It  covered  the  whole  vesti- 
bule except  the  tissue  immediately  surrounding  the 
external  meatus  of  the  urethra,  and  was  well  defined, 
but  stopped  at  the  vaginal  mucous  membrane.  The 
vulva  as  a  whole  stood  out  far  beyond  its  normal  eleva- 
tion. The  whole  vulva  was  excised.  The  structure 
of  the  tumor  corresponded  with  that  usually  found  in 
papillomata  of  the  skin.  A  second  case  was  spoken 
of  by  the  writer.  These  two  cases  comprised  all  the 
experience  he  had  had. 

President's  Address. — This  was  delivered  by  Dr. 
RuFus  B.  Hall,  of  Cincinnati,  who  selected  for  his 
subject  "The  Education  of  the  Laity  upon  Sexual 
Matters;  When  Shall  They  be  Taught  and  to  \\'hat 
Extent  ?  The  family  physician  should  be  the  educator 
of  the  people  in  sexual  matters,  and  when  he  got  the 
indorsement,  and  was  sustained  in  his  position  by  the 
specialist,  his  influence  would  be  greatly  strengthened 
and  widened.  The  author  advised  that  during  the  last 
year  in  High  School,  in  every  school  in  the  land,  a 
text-book  be  employed  embracing  embryology,  hygiene, 
anatomy,  and  physiology,  including  sexual  physiology, 
and  that  these  subjects  be  taught  to  every  student, 
both  male  and  female.  He  believed  that  this  could 
be  accomplished  without  shocking  the  morals  of  the 
most  fastidious  individual,  by  dividing  tlie  classes  so 
as  to  separate  the  sexes.  A  female  teacher  should  in- 
struct the  girls,  and  a  male  teacher  the  boys.  This 
was  the  very  time  in  life  when  individuals  should  be 
taught  to  know  the  functions  with  which  Providence 
had  endowed  them,  and  how  to  care  for  their  bodies  as 
well  as  their  minds.  It  would  be  a  revelation  to  tiiem 
to  know  that  the  sexual  organs  in  animals  as  well  as 
the  human  race  were  among  the  first  centres  to  be 
formed,  and  could  be  recognized  as  such  earlv  in  intra- 
uterine life.  When  the  laity  became  educated  upon 
this  subject  as  they  should  be,  and  understood  the 
meaning  of  pelvic  inflammation  in  young  wives  as 
gyna;cologists  understood  it,  the  parents  and  guardians 
of  young  girls  would  realize  that  they  owed  them  a 
duty  before  consenting  to  their  marriage. 

Second  Day — Afteniooii  Session. 

Private  Hospitals  and  their  Management. —  This 
was  the  title  of  a  jiaper  by  Dr.  Joseph  Price,  of  Phil- 
adelphia. The  well-organized  private  hospital,  man- 
aged by  such  distinguished  men  as  Marion  Sims,  T. 
G.  Thomas,  Thomas  Addis  Emmet,  William  Goodell, 
Stone,  of  New  Orleans,  and  a  few  institutions  of  the 
present  time  doing  the  best  work,  offered  advantages 
that  were  not  given  by  the  schools  or  the  political  hos- 
pitals, 'i'he  political  hospital  was  not  the  only  cor- 
rupt institution;  a  few  of  the  well-endowed  general 
hospitals,  managed  and  handed  down  in  families  to 
the  third,  fourth,  and  even  the  fifth  generations,  were 
the  most  dangerous  institutions  in  the  medical  profes- 
sion. It  was  always  a  misfortune  to  an  endowed  char- 
ity or  public  hospital  for  a  family  to  be  in  full  posses- 
sion of  tlie  funds  or  endowments,  in  that  this  resulted 
in  impairing  or  destroying  its  u.sefulness.  No  one 
had  ever  to  the  speaker's  personal  knowledge  made 
money  and  accumulated  wealth  out  of  a  private  sanato- 
rium.     He  might  do  so  out  of  the  fees,  but  never  out 


October  6.  1900] 


MEDICAL    RECORD. 


555 


of  the  board,  care,  and  nursing  of  patients.  Tlie  board 
of  patients  rarely  paid  five  per  cent,  on  the  money  in- 
vested. A  good  number  of  these  institutions  had  been 
financial  failures  and  had  closed.  Private  hospitals 
gave  the  operator  the  best  opportunity  for  doing  good 
work.  In  well-managed  private  institutions  the  pa- 
tient had  one  or  more  attendants  with  well-regulated 
relays.  In  public  institutions  the  speaker  rarely  found 
a  nurse  in  large  wards,  the  only  attendants  about  ihc 
patients  being  a  convalescent  patient  or  an  old  pelicati 
of  an  attendant.  Professional  care,  one  or  many  \  is- 
its  daily,  favored  a  speedy  convalescence.  The  early 
and  late  assurance  that  a  patient  was  doing  nicely  did 
a  world  of  good.  Fresh  beds,  and  the  numerous  little 
attentions  from  young,  intelligent  nurses,  favored  com- 
fort and  conlidence.  It  was  surprising  how  much 
more  cheerful  patients  were  in  private  hospitals  than 
in  general,  puiilic,  or  school  institutions.  The  sur- 
roundings of  general  hospitals  were  generally  depress- 
ing. Patients  were  eager  or  impatient  to  get  home 
])rematurely.  In  a  well-managed  private  institution 
they  were  easily  controlled  and  were  willing  to  remain 
until  they  were  fully  convalescent.  Hurrying  patients 
out  of  general  hospitals,  one,  two,  or  three  weeks  after 
serious  operations,  resulted  in  accidents  and  complica- 
tions, post-operative  sequeUt,  ditliculi  to  correct.  In 
private  institutions  there  was  added  a  well-directed 
rest-cure  treatment,  which  gave  pleasing  results. 

Post-Rectal  or  Pre-Sacral  Growths. — Uk.  J.amks 
F.  \V.  Ross,  of  Toronto,  presented  this  paper,  in  which 
he  reported  four  cases  of  post-rectal  tumors,  excepting 
the  osteomata.  He  discussed  benign  and  malignant 
growths  in  this  region ;  also  their  etiology,  symptoma- 
tology, diagnosis,  prognosis,  and  treatment.  No  nov- 
ice should  undertake  the  removal  of  a  post-rectal 
growth.  It  could  be  done  only  by  one  who  had  become 
familiar  with  pelvic  surgery,  and  who  was  fully  master 
of  the  situation.  The  operator  must  be  full  of  re- 
source and  should  be  rapid  in  his  movements.  In 
making  his  incision  into  the  abdominal  wall,  he  should 
always  remember  that  it  should  be  made  high  up  and 
enlarged  downward  after  the  position  of  the  bladder 
had  been  ascertained.  The  author  had  had  noe.xperi- 
ence  with  the  removal  of  such  post-rectal  growths  by 
enucleation  from  above.  He  was  well  aware  that 
many  thoughtful,  prudent,  and  daring  surgeons  did  not 
hesitate  to  close  the  abdomen  when  this  condition  was 
met  with.  What  should  the  technique  of  such  an  oper- 
ation be?  Should  the  meso-rectum  be  incised  close  to 
or  far  away  from  the  bowel.'  Should  not  the  incision 
always  be  parallel  to  the  vessels  and  not  across  them? 
How  was  the  surgeon  accurately  to  determine  the  situ- 
ation of  the  ureter,  and,  when  discovered,  how  could 
he  avoid  it?  How  could  he  best  guard  against  injury 
to  the  large  vessels?  In  dealing  with  branchial  c\sts 
in  the  neck  the  speaker  iiad  followed  them  almost  to 
the  spine,  but  had  then  left  the  deep  portion  of  the 
cyst  wall,  if  it  could  be  called  a  wall.  It  seemed  to 
him  that  he  would  have  been  forced  to  deal  with  the 
last  case  he  reported  of  pre-sacral  cyst  in  exactly  the 
same  manner,  because  the  periosteum  and  so-calleil 
cyst  wall  were  so  intimately  connected.  It  would  not 
be  wise  to  drain  such  a  cavity  into  the  peritoneal  cav- 
ity, but  would  be  more  prudent  to  attack  such  cysts 
through  the  post-anal  tissues,  perhaps  with  the  removal 
of  the  coccyx.  The  solid  tumors  should  always  be  at- 
tacked from  the  front. 


Third  Day — Morning  Session. 

The  Ligature  and  the  Value  of  Dry  Sterilized 
Catgut — By  Dr.  J.  Henry  C.\rstexs,  of  Detroit, 
Mich.  The  author  described  a  modification  of  the 
Poeckman  method  of  preparing  catgut.  The  ligatures 
were  prepared  in   the  following  manner :  Catgut  was 


put  in  ether  for  a  few  days  or  a  week  until  the  fat  was 
all  removed,  and  then  cut  in  strips  eighteen  or  twenty 
incfies  long.  Three  of  these  were  wrapped  in  fine  tis- 
sue paper,  then  placed  in  a  small  envelope.  The  lat- 
ter was  closed,  placed  in  a  lioeckman  sterilizer,  and 
subjected  to  dry  heal  for  three  hours.  A  thermometer 
was  kept  in  the  apparatus,  so  that  the  heat  was  at  least 
300^.  At  the  expiration  of  that  time  the  heat  was  shut 
off,  and  the  ligatures  remained  in  the  sterilizer  without 
disturbance  for  twelve  to  eighteen  hours.which  gave  any 
spores  that  might  be  present  an  opportunity  to  develop. 
Tiien  heat  was  again  used,  and  the  ligatures  were  sub- 
jected to  another  300".  They  were  now  sterile.  They 
were  put  in  an  envelope  and  could  be  carried  that  way 
in  a  satchel.  When  ready  for  use  the  end  of  the  en- 
velope could  be  torn  off  and  the  ligature,  with  the  tissue 
paper,  dropped  into  alcohol,  the  tissue  paper  removed, 
and  the  ligature  could  be  threaded  and  used.  These 
ligatures  were  not  slippery  or  greasy,  as  was  the  catgut 
prepared  with  different  oils.  The  following  points 
were  emphasized:  All  buried  sutures  ought  to  be  ab- 
sorbable, and  absolutely  sterile.  Chemicalized  sutures 
were  no  more  sterile  than  plain  sutures.  A  chemical- 
ized suture  was  harder  and  remained  longer  in  the  tis- 
sues. This  latter  was  a  disadvantage.  If  in  a  special 
case  it  was  desirable  that  a  suture  should  remain 
longer,  dry  sterilized  kangaroo  tendon  could  be  used. 

Some  Contraindications  to  the  Intraperitoneal 
Use  of  Decinormal  Salt  Solution  after  Abdominal 
Section. — Dr.  Fr.wk  F.  Snii'sn.N-,  of  Pittsburg,  Pa., 
read  a  paper  dealing  witli  this  suliject. 

Simple  Methods  in  Pelvic  Surgery  was  the  title 
of  a  paper  read  by  Dr.  John  B.  Deaver,  of  Philadel- 
phia. Simplicity  was  the  sine  tjtia  non  of  good  sur- 
gery. It  meant  safety,  surety,  confidence,  neatness, 
and  great  saving  of  time,  which  was  an  essential  factor 
in  the  success  of  many  operations.  The  abdominal 
route  was  by  far  the  more  rational,  and  therefore  the 
best  method  of  approaching  an  operation  on  the  pelvic 
organs  in  the  majority  of  cases,  and  offered  several 
advantages  that  rendered  it  preferable  to  the  vaginal. 
It  was  simpler  of  performance.  It  was  safer,  as  the 
surgeon  could  avoid  distributing  infection  when  in- 
fected areas  were  present.  It  reduced  the  danger  of 
general  peritonitis  by  the  use  of  gauze  packing.  It 
rendered  injuries  to  the  bowel,  ureters,  important 
blood-vessels,  etc.,  less  likely.  It  minimized  the  dan- 
ger of  hemorrhage.  It  aided  generally  by  the  facility 
offered  for  inspection.  Through  the  abdominal  inci- 
sion the  surgeon  was  able  to  open  the  belly  to  the 
proximal  side,  of  the  infected  area,  when,  by  the  prop- 
er disposition  of  sterile  gauze  sheets  practically  all 
risk  of  peritoneal  contamination  was  done  away  with. 
It  enabled  the  surgeon  to  operate  with  a  very  few  instru- 
ments. Radical  operations  per  vaginam  were,  with  few 
exceptions,  the  author  thought,  to  be  discountenanced, 
for  several  good  and  sound  reasons:  (i)  'Ihe  limited 
area  for  manipulation;  (2)  the  impossibility  of  in- 
spection without  destruction  and  removal  of  the  uterus, 
which  should  not  be  removed  except  for  good  and  suf- 
ficient disease  of  that  organ  itself;  (3)  the  marked 
increased  liability  to  hemorrhage,  both  primary  and 
secondary;  (4)  increased  danger  of  injuring  ureters, 
bowel,  bladder,  and  large  blood-vessels;  (5)  danger 
of  doing  incomplete  surgery;  (6)  inability  to  repair 
satisfactorily  injuries  to  bowel  or  bladder,  etc.;  (7) 
inability  to  deal  safely  with  an  inliammatory  mass 
which  involved  the  vermiform  appendix. 

The  Treatment  of  Fibroids  in  the  Non-Pregnant 
Uterus — ,A  paper  on  this  subject  was  read  by  IJr.  F. 
F.  Fish,  of  Milwaukee,  Wis.  The  author  discussed 
the  advisability  of  operating  in  all  cases  of  fibroids  of 
the  uterus  as  soon  as  discovered,  and  left  it  an  open 
question.  He  emphasized  the  necessity  of  radical 
interference  whenever  the  tumor  or  tumors  were  pro- 


556 


MEDICAL    RECORD. 


[October  6,    1900 


duclive  of  symptoms — pain,  hemorrhage,  pressure, 
constitutional  impairment,  unless  there  be  existing 
disease,  such  as  nephritis,  diabetes,  tuberculosis,  etc. 
Of  radical  treatment,  he  thought  that  myomectomy 
was  the  operation  of  choice,  whether  subserous,  inter- 
stitial, or  subcutaneous,  if  the  tumor  was  single  and 
could  be  enucleated  without  loss  of  tissue  and  tlie 
cavity  closed  and  covered  with  peritoneum.  When 
several  tumors  existed,  the  judgment  of  the  operator 
came  into  play.  Many  nodules  meant  many  foci,  and 
the  author  opposed  myomectomy  on  the  ground  that 
some  of  these  might  not  be  discovered,  and  later  might 
develop  and  demand  another  operation.  He  thought, 
too,  that  under  such  circumstances  the  condition  was 
a  general  one  extending  to  the  tubes  and  ovaries,  and 
this  condition  might,  and  likely  would,  call  for  future 
operation.  The  vaginal  route  was  favored  for  small 
tumors,  the  abdominal  for  large  ones.  Hysterectomy 
was  favored  when  the  tumor  involved  so  much  uterine 
tissue  that  a  proper  closing  of  the  tumor  cavity  was 
not  possible,  when  the  organ  was  studded  with  small 
tumors  or  nodes,  when  coexisting  pelvic  disease  was 
present,  when  the  growth  was  degenerating,  when  there 
were  adhesions,  when  the  tubes  and  ovaries  were  in- 
volved to  such  an  extent  that  they  must  be  sacrified, 
when  the  disease  was  no  longer  local,  or  when  the 
change  of  life  had  occurred.  He  favored  supravag- 
inal amputation,  leaving  the  cervix  when  sound,  and 
panhysterectomy  when  the  cervix  was  lacerated  or  dis- 
eased. He  left  the  ovaries  if  sound,  or  if  only  one 
was  sound  he  left  that,  or  if  only  part  of  one  he  left 
that.  He  believed  in  ignipuncture  for  small  pea-like 
cysts,  and  left  the  ovary.  He  was  convinced  that 
this  plan  modified  the  nervous  symptoms  which  usu- 
ally followed  complete  removal. 

Palliative  treatment  was  discussed,  the  author  pay- 
ing most  attention  to  curettage  and  electricity,  and  he 
briefly  touched  on  salpingo-oophorectomy,  ligation  of 
the  uterine  artery,  organotherapy,  medical  treatment, 
and  natural  cures.  He  concluded  that  myomectomy 
was  the  operation  of  choice  (i)  when  the  tumor  was 
pedunculated;  (2)  when  single,  whether  subserous, 
interstitial,  or  subcutaneous,  and  could  be  enucleated 
without  loss  of  uterine  tissue,  and  the  tumor  cavity 
closed  and  covered  with  peritoneum;  (3)  when  the 
desire  for  an  heir  outweighed  all  other  considerations. 
Hysterectomy  was  indicated  (i)  when  the  tumor  in- 
volved so  much  of  the  uterus  tb.at  a  cavity  too  large 
to  be  properly  closed  and  covered  with  peritoneum 
would  follow  its  removal;  (2)  when  several  tumors 
existed,  especially  little  nodules;  (3)  when  the  ad- 
nexa;  were  diseased  to  such  an  extent  that  they  must 
be  sacrificed ;  (4)  when  the  disease  had  ceased  to  be 
local;  (5)  when  hemprrljage,  pressure,  or  pain  was  a 
persistent  symptom ;  (6)  whenever  malignancy  was 
suspected,  or  the  tumor  was  of  rapid  growth;  (7) 
after  the  change  of  life.  I'aljiative  treatmeot  was 
indicated  when  the  patient  was  much  reduced  from 
loss  of  blood,  as  a  prelude  to  rational  cure;  when  the 
existence  of  chronic  nephritis,  diabetes,  tuberculosis, 
or  other  constitutional  disease  forbade  rational  cure; 
and  when  the  patient  was  past  forty  years  of  age,  the 
tumor  small,  the  main  annoyance  hemorrhage,  and  she 
was  desirous  of  awaiting  the  effect  of  the  menopause. 

Acute  Senile  Endometritis. — Dr.  L.  H.  Dunninc 
of  Indianapolis,  Ind.,  read  a  paper  with  this  title,  it 
being  the  second  written  by  him  upon  this  subject,  and 
in  which  he  reaffirmed  his  belief  that  it  was  a  distinct 
lesion  that  had  not  heretofore  been  adequately  de- 
scribed. Since  his  previous  paper  he  had  encountered 
three  more  cases,  two  of  which  were  attended  by  san- 
guino-purulent  discharges  from  the  uterus,  and  one  in 
which  there  was  a  large  pelvic  abscess.  The  inllam- 
mation  tended  to  spread  beyond  the  endometrium 
into   the  Fallopian   tubes,  ovaries,  and  pelvic  perito- 


neum, resulting  in  much  suffering  and  ill  health,  and 
not  infrequently  leading  to  so  serious  involvement  of 
these  structures  as  to  demand  operative  procedures, 
such  as  extirpation  of  the  uterus  and  appendages,  or 
vaginal  incision  and  drainage  of  a  pelvic  abscess. 
The  chief  cause  of  the  lesion  was  infection.  It  was 
not  definitely  self-limited,  but  tended  to  become 
chronic  and  to  lead  to  marked  degenerative  changes 
witliin  the  uterus.  The  treatment  recommended  was, 
in  cases  in  which  the  appendages  were  net  involved, 
dilatation,  curettage,  the  application  of  a  mild  caustic, 
and  prolonged  drainage.  When  the  uterine  appendages 
were  involved  in  the  inflammatory  process,  extirpation 
of  the  uterus  and  appendages  was  advocated. 

Tube-Ovarian  Abscess  and  How  to  Deal  with  It. 
—  A  paper  on  this  subject  was  read  by  I)u.  Edwin 
RicKETTs,  of  Cincinnati,  Ohio.  Tubo-ovarian  ab- 
scess was  frequently  caused  by  the  proximity  of  the 
ovary  to  an  infected  Fallopian  tube.  The  disease 
might  be  complicated  by  normal  or  ectopic  pregnancy, 
intestinal,  vaginal,  or  vesical  fistulse,  and  by  appendi- 
citis. In  the  dormant  stage  the  author  operated  by 
the  abdominal  route;  in  the  acute  stage  he  explored 
by  the  abdominal  route,  and  then  decided  between 
completing  the  operation  in  one  or  two  sittings.  Fol- 
lowing abortion  or  delivery  at  full  term,  vaginal 
drainage  in  his  opinion  often  put  the  patient  in  better 
shape  for  an  abdominal  section  later  on. 

Observations  Respecting  Malignant  Disease  of 
the  Pelvic  Organs. — By  Dr.  Augustus  P.  Clarke, 
of  Cambridge,  Mass.  Cancer  may  have  its  starting- 
point  in  a  lacerated  cervix  uteri;  but  its  seat  of  de- 
velopment was  usually  in  the  epithelium.  Its  occur- 
rence not  infrequently  took  place  after  the  patient  had 
become  a  multipara  and  before  she  had  become  of  ad- 
vanced age.  The  exposu'te  of  the  mucous  membrane 
to  continued  or  repeated  irritation  hastened  its  onset. 
Cancer  of  the  uterine  body  had  had  its  origin  from 
endometritis  and  from  its  allied  conditions.  The  dis- 
ease might  be  induced  or  intensified  by  intlamma.tion 
of  the  utricular  glands  qt  the  uterus  and  by  the  effects 
of  external  pressure.  A  sarcomatous  condition  might 
result  from  the  same  cause.  Cancer  of  the  broad 
ligament,  as  also  that  of  the  ureter,  had  been  observed 
as  the  result  of  extension  from  the  uterine  cervix. 
The  meatus  urinarius  had  been  noticed  as  an  original 
seat  of  cancer.  In  such  cases  vesical  and  urethral 
disturbances  had  been  known  to  antedate  the  appear- 
ance of  the  malignant  change.  Cancer  of  the  ovary, 
or  of  other  portions  of  the  adnexse,  might  occur  as 
secondary  to  a  primary  point  of  invasion.  The  route 
of  transmission  was  usually  along  the  course  of  neigh- 
boring lymphatics,  or  along  the  epithelial  cells  of  the 
ducts  (?f  such  open  channels  of  communication.  Tlio 
fact  that  cancer  cells  might  so  readily  invade  the  epi- 
thelium of  newly  formed  growths  containing  endothe- 
lium showed  the  importance  of  taking  measures  for 
their  early  removal  before  degenerative  changes  had 
extensively  occurred.  The  morbid  development  un- 
doubtedly arose  at  tjmes  by  abnormal  proliferation  of 
the  epithelium  from  its  basic  point  of  origin  to  the 
deeper  structures  within.  The  majority  of  cases  of 
cancer  occurring  in  the  bladder  were  secondary  to  in- 
volvenient  of  the  cervical  portion  of  the  uterus.  The 
cases  which  called  for  special  consideration  were  those 
of  the  villous  type.  Curettage  and  the  employment  of 
the  galvano-cautery  afforded  the  best  means  of  relief. 
In  those  cases  of  rectal  cancer  in  which  the  sphincter 
ani  was  not  invaded,  excision  of  a  portion  of  the  rec- 
tum and  the  removal  of  the  coccyx  and  the  lower  sec- 
tion of  the  sacrum  could  sometimes  be  advantageously 
done.  The  use  of  the  Murphy  button  in  such  cases 
was  of  service.  The  only  effectual  radical  method  of 
treatment  was  by  excision.  Partial  removal  of  the 
uterus  on  account  of  extensive  invasion  by  malignant 


October  6,  1900] 


MEDICAL    RECORD. 


557 


disease  would  not  suffice.  The  fact  that  uterine  or 
pelvic  fibroids  and  fibromyomata  might  take  on  malig- 
nant transformation  was  coming  more  and  more  to  be 
recognized.  The  necessity  of  watching  closely  for 
changes  that  might  be  assumed  became  obvious. 
Both  the  round  and  the  spindle-shaped  cell  sarcomata 
might  originate  in  benign  fibroids.  The  total  exci- 
sion of  such  neoplasms  in  their  earliest  stages  would 
afford  the  most  satisfactory  results. 

Difficult  and  Obscure  Pus  Cases  in  Pelvic  Sur- 
gery in  Women. — By  Dr.  Waltkk  B.  Chask,  of 
Brooklyn,  N.  Y.  The  author  first  considered  the  eti- 
ology of  these  cases,  classing  gonorrhcea  as  the  most 
frequent  cause,  closely  followed  by  miscarriage  and 
labor  at  full  term,  these  usually  following  some 
infection  from  without.  Among  the  causes  from 
within  were  considered  those  following  the  rupture 
of  an  ectopic  tube,  hematoma,  malignant  or  tubercu- 
lous disease,  and  others  less  frequent  in  occurrence 
The  question  of  time  should  be  considered  in  tiie 
diagnosis,  but  tlie  great  mainstay  was  thorough  and 
systematic  bimanual  and  rectal  examination.  The 
author  called  attention  to  the  fact  that  Huctuation 
might  be  due  to  cystic  growths,  recent  haematomas, 
amyloid  degeneration,  etc.,  as  well  as  to  pus.  Pain 
and  fever,  or  their  absence,  went  far  to  clear  up  diag- 
nosis in  many  a  case,  but  the  fever  due  to  malignancy 
must  not  be  confused  with  that  due  to  septic  causes. 
Appendicitis  and  pus  tubes  might  cause  difficulty  in 
differentiation.  The  rule  that  pus  in  the  jielvic  cav- 
ity must  be  evacuated  was  general,  though  not  uni- 
versal. The  manner  and  route  of  its  evacuation 
were  thoroughly  discussed.  Drainage  was  next  con- 
sidered, the  author  taking  up  the  direction  and  the 
material,  usually  preferring  plain  or  iodoform  gauze, 
and  at  the  same  time  considering  irrigation,  for 
which  he  generally  used  decinornial  salt  solution. 
Multiple  abscesses  were  considered  next  with  their 
management.  The  serious  cases  in  which  pus  existed 
free  in  the  pelvic  cavity  were  taken  up,  and  among 
other  things  he  stated  that  sentiment  should  be  al- 
lowed no  weight  in  their  treatment.  Another  embar- 
rassment to  the  operator  was  the  failure  of  the  public 
to  discriminate  as  to  the  cause  of  fatality,  in  many  of 
which  cases  the  operator  had  nothing  to  do  with  the 
mortality.  In  closing,  he  cited  several  pertinent 
cases,  in  one  of  which  two  abscess.es  were  caused  by 
the  escape  of  the  bacillus  cpli  communis,  evidently 
from  a  denuded  spot  on  the  serous  covering  of  the 
bowel. 

The  following  officers  were  elected  for  the  ensuing 
year:  President,  Dr.  W.  E.  B.  Davis,  of  Birmingham, 
Ala.  ;  First  Vice-President,  Dr.  Edwin  Walker,  of  Evans- 
ville,  Ind.  ;  Second  Vice-President,  Dr.  A.  Goldspohn, 
of  Chicago,  111.  ;  Secretary,  Dr.  William  Warren  Pot- 
ter, of  Buffalo,  N.  Y.,  re-elected;  Treasurer,  Dr.  X. 
O.  Werder,  of  Pittsburg,  Pa.,  re-elected. 

Cleveland,  Ohio,  was  selected  as  the  place  for  hold- 
ing the  next  annual  meeting;  time,  the  second  Tues- 
day in  September,  igoi. 


No  Danger  of  Overcrowding. — Mr.  M.  G.  Mulhali, 
the  well-known  British  statistician,  says  that  there  will 
be  plenty  of  room  on  the  earth  to  support  human  life 
comfortably  for  many  centuries  to  come.  The  area  of 
the  United  States,  excluding  Alaska,  is  just  three 
million  square  miles;  the  average  density  of  the  New 
England  States  is  seventy-one  inhabitants  to  the  square 
mile,  so  that  judging  from  these  figures  it  may  be  said 
that  this  country  could  easily  support  two  hundred 
and  ten  million,  or  three  times  its  present  population. 
In  the  mean  time  other  vast  fields  are  opening.  Can- 
ada, Brazil,  Spanish  .America,  .Africa,  and  Australia  can 
each  find  room  for  hordes  of  immigrants. 


l^lccUcal   Items. 

Chronic  Constipation — Cheadle  says  that  the  treat- 
ment of  clironic  constipation  is  a  subject  of  consider- 
able importance  and  deserves  more  attention  than  it 
usually  receives.  It  lies  for  the  most  part  outside 
hospital  practice.  It  is  a  frequent  source  of  trouble 
to  the  practitioner  and  sometimes  of  discredit  to  him. 
In  the  first  place,  if  treatment  is  to  be  successful  it 
must  comprise  something  more  scientific  and  compre- 
hensive than  the  mere  administration  of  occasional 
aperients.  It  is  not  enough  to  open  the  canal  when 
blocked  or  sweep  it  clear  of  accumulations  which  have 
lodged  there.  'J'he  essential  point  is  to  establish,  if 
possible,  such  a  habit  of  daily  evacuation  that  accu- 
mulation of  noxious  waste  and  its  evil  consequences 
may  not  recur,  to  modify  the  condition  permanently  if 
the  age  and  condition  of  the  patient  render  such  a 
consummation  possible.  In  order  to  do  this  the 
causes  which  give  rise  to  it  must  be  thoroughly  un- 
derstood, removed,  neutralized,  or  compensated. 

Some  of  the  Properties  of  Oysters.— Oysters  have 
for  centuries  been  much  esteemed  by  medical  men  as 
being  very  nutritious  and  easy  of  digestion,  but  both 
these  properties  are  much  diminished  when  not  taken 
in  their  raw  state.  It  may  not  be  generally  known 
that  the  fluid  which  surrounds  the  oyster  bears  a  closer 
analogy  to  the  gastric  secretion  than  anything  else  in 
nature.  In  addition  to  the  solvent  properties  of  this 
fluid  it  is  not  without  its  nutritive  properties.  We 
have  of  late  devoted  considerable  attention  both  to  the 
substance  and  secretion  therefrom,  and  find  that  in  a 
given  weiglit  of  the  latter  and  the  same  of  the  oyster 
the  fluid  yields  only  forty  per  cent,  less  of  animal 
gluten  or  jelly  than  the  fish.  Consequently  all  per- 
sons who  are  accustomed  to  eat  oysters  should  be  ever 
mindful  that  as  little  as  possible  of  the  juice  should 
be  lost.  When  oysters  are  eaten  stewed  or  scalloped, 
the  two  properties,  as  before  stated,  are  much  dimin- 
ished; consequently  they  ought  never  to  be  taljen  by 
invalids  except  in  their  raw  state. — Sanitary  Record. 

Mushrooms. — There  are  more  than  six  thousand 
varieties  of  mushrooms,  of  which  three  hundred  are 
edible.  Many  of  the  noxious  species  produce  intoxica- 
tion. The  convicts  of  Siberia  use  for  this  purpo.se  a 
mushroom  termed  the  fly-agaric,  which  is  rolled  into 
a  ball  and  swallowed  whole.  Its  effects  are  not  unlike 
those  produced  by  opium.  Taken  in  light  doses  the 
person  is  affected  as  by  the  inhalation  of  laughing  gas. 
There  are  six  families  of  fungi,  to  the  first  or  highest 
of  which  belong  mushrooms  and  toadstools.  The 
minutest  forms  of  fungus  have  been  found  in  places 
where  no  one  would  expect  to  find  them — for  example 
in  the  interior  of  apparently  perfectly  sound  hazelnuts, 
in  the  cavities  in  tomatoes  with  unbroken  skins,  in  the 
inside  of  polisiied  Bonduc  nuts,  which  are  almost  as 
hard  as  metal,  and  even  in  the  bubbles  within  pieces 
of  amber.  They  are  independent  of  light  even  for 
growth.  In  some  cases,  offering  a  decided  contrast 
to  the  usual  plant  requirements,  light  appears  posi- 
tively harmful  to  the  fungus. — Ans'ioers. 

Plague  in  Glasgow. — The  British  journals,  as  was 
perhaps  only  natural,  endeavored  first  to  throw  doubt 
on  the  truth  of  the  announcement  that  the  Oriental 
pest  had  broken  out  in  Glasgow,  and  then,  when  it  had 
been  clearly  proved  that  unfortunately  such  was  the 
case,  took  pains  to  show  that  there  was  little  or  no 
cause  for  alarm.  A  prominent  weekly  paper  discusses 
the  question  as  follows:  "There  are  two  great  allies 
of  the  fell  disease,  without  which  it  never  makes  and 
never  can  make  much   progress.     Those   are  dirt  and 


558 


MEDICAL    RECORD 


[October  6,  1900 


funk.  Modern  sanitary  science  is  quite  capable  of 
dealing  wiiii  the  plague,  and  secure  in  the  knowledge 
of  this  central  fact  we  may  cheerfully  def_v  the  enemy's 
other  chief  supporter — the  abject  terror  which  jjredis- 
poses  its  victims  to  catch  any  infectious  disease  which 
may  be  going  about,  and  which  is  really  responsible 
for  half  the  mortality  in  most  epidemics.  When  in- 
deed one  remembers  that  the  plague  must  be  sea- 
borne, and  that  the  greater  portion  of  the  world's 
carrying  trade  is  in  English  hands,  the  wonder  is  not 
that  the  infection  should  have  reached  us  at  last,  but 
that  it  did  not  effect  a  landing  at  one  or  more  of  our 
ports  many  months  ago.  The  fact  that  it  should  not 
have  done  so  should  suffice  to  convince  the  most 
nervous  among  us  that  we  are  in  no  danger  of  an  epi- 
demic of  the  '  Black  Death  '  of  the  Middle  Ages  or  the 
pestilence  whose  ravages  in  seventeenth-century  Lon- 
don were  so  graphically  described  by  Daniel  Defoe. 
Let  us  only  keep  clean  and  cool,  and  the  doctors  may 
call  the  new  malady  by  any  nanie  they  please."  This 
is  very  good  reasoning  so  far  as  it  goes,  and  especially 
witli  regard  to  the  evil  effects  of  panic,  but  at  the  same 
time  it  should  be  borne  in  mind  that  parts  of  Glasgow 
are  woefully  overcrowded  and  distressingly  dirty.  If 
the  health  authorities  of  Sydney  did  not  succeed  in 
stamping  out  the  plague  in  that  city  for  many  months 
and  until  many  lives  had  been  lost,  then  the  argument 
may  be  made  that  in  all  probability  the  health  au- 
thorities of  Glasgow,  which  is  no  cleaner  than  Sydney, 
will  have  quite  as  much  difficulty  in  abolishing  the 
disease  from  its  borders. 

Women  Longer-Lived  than  Men — An  English 
weekly  magazine  says  that  statistics  show  that  women 
live  longer  than  men.  For  instance,  in  Germany  only 
413  out  of  1,000  males  reach  the  age  of  fifty  years, 
while  more  than  500  out  of  1,000  females  reach  that 
age.  In  the  United  States  there  are  2,583  female  to 
i,3rj8  male  centenarians.  In  France,  of  10  centenarians 
7  are  women  and  only  3  men.  In  the  rest  of  Europe, 
of  2  1  centenarians  16  are  women. 

Yawning  is  Healthy. — A  German  scientist  has 
discovered  that  yawning  is  a  healthy  pastime.  It  is 
wholesome  like  oatmeal  and  brown  bread.  Yawning, 
it  is  said,  stretches  the  muscles,  maybe,  or  the  tendons 
of  the  head,  sends  the  blood  to  the  jaws,  and  sharpens 
appetite  and  intellect.  It  is  a  cheap  remedy,  acces- 
sible to  young  and  old,  rich  and  poor,  and  if  it  is  as 
efficacious  as  our  Teuton  says,  health  is  surely  within 
the  reach  of  every  one. —  The  Loudon  People. 

The  Origin  of  the  Glasgow  Plague — Surgeon- 
General  Wyman  has  received  a  report  from  Assistant 
Surgeon  Thomas  of  the  Marine-Hospital  service,  in 
charge  of  the  plague  inspection  work  at  Glasgow,  de- 
tailing the  history  of  the  outbreak  there.  The  report 
states  that  all  the  cases  now  under  surveillance  are  to 
be  traced  to  a  wake  held  over  a  woman  who  died 
?bout  August  2ist.  She  lived  in  a  crowded  tenement 
quarter,  some  distance  from  the  shipping,  and  no  con- 
nection can  be  traced  between  her  sickness  and  any 
infected  ship  except  that  her  luisband  was  at  work  on 
the  docks.  The  disease  in  the  early  cases  was  of  the 
pneumonic  form,  and  the  death  of  this  woman  was 
certified  as  pneumonia,  and  there  were  a  number  of 
other  cases  of  supposed  pneumonia  among  those  who 
had  attended  the  wake  or  had  been  thrown  into  con- 
tact with  the  woman.  On  August  25th  a  child  died, 
and  on  the  27th  his  mother  and  two  brothers  were 
taken  to  the  hospital.  One  of  the  brothers  died,  and 
his  death  was  certified  as  bubonic  ])lague.  Cultures 
of  the  plague  bacillus  were  made  from  his  organs,  but 
the  inoculation  experiments  are  not  yet  complete.  As 
soon  as  a  suspicion  of  plague  arose  all  persons  known 
to  have  been  in  contact  with  the  cases  mentioned  were 


removed  to  new  quarters,  were  bathed,  and  their 
clothing  was  disinfected.  A  few  cases  have  been  sent 
to  the  hcjspital  from  this  contingent,  which  at  present 
amounts  to  something  over  fifty.  All  the  cases  in  the 
hospital  at  the  time  of  Dr.  Thomas'  report  were  of  the 
bubonic  form.  Careful  inquiry  does  not  show  that 
there  has  been  any  unusual  mortality  among  the  rats 
in  Glasgow,  but  war  has  nevertheless  been  declared 
against  them,  and  rat-catchers  are  busy  capturing  and 
killing  them. 

The  Right  of  a  Hospital  to  Discriminate  in  the 
Reception  of  Patients. —  It  is  stated  in  I'lu-  Sun  that 
a  medical  controversy,  growing  out  of  the  custom  of 
club  practice,  is  about  to  be  carried  into  the  courts  of 
Massachusetts  at  Springfield.  The  Hampden  County 
Medical  Association  has  expressed  its  disapproval  of 
this  practice,  insisting  that  no  special  arrangements 
for  charging  less  than  the  ordinary  fees  should  be 
made  with  medical  clubs,  lodges,  and  other  benevolent 
organizations,  but  the  societies  have  found  no  diffi- 
culty in  securing  the  services  of  physicians  who  agreed 
to  treat  their  members  for  a  stipulated  sum  per  annum. 
A  patient  who  was  sent  by  one  of  these  contract  phy- 
sicians to  the  Mercy  Hospital  in  Springfield  was  re- 
fused admission  to  that  institution  unless  the  doctor 
in  attendance  withdrew  from  the  case,  which  he  finally 
consented  to  do  for  the  sake  of  the  patient,  who  re- 
quired treatment  which  could  be  afforded  only  at  a 
hospital.  A  suit  will  now  be  brought  to  ascertain 
whether  the  hospital  staff  could  lawfully  take  this  ac- 
tion under  its  charter,  which  provides  that  all  patients 
shall  be  treated  there  who  are  brought  to  the  institu- 
tion by  reputable  physicians. 

The  Fatal  Bloom  on  the  Fruit — Schnirer  reports 
the  results  of  an  examination  showing  the  danger  of 
eating  fruit  without  first  washing  it.  While  at  work 
one  dav  in  Weichselbaum's  laboratorj'  he  sent  for  some 
grapes  to  eat.  The  fruit  had  been  kept  for  some  time 
in  a  basket  outside  the  laboratory,  and  was  covered 
with  dust,  so  that  the  water  in  which  it  was  washed 
was  black.  On  examining  this,  Schnirer  reffected 
that,  inasmuch  as  the  neighboring  street  was  traversed 
by  consumptive  patients  going  to  the  clinic,  the  dust 
might  contain  tubercle  bacilli,  and  to  settle  this  he  in- 
jected into  three  guinea-pigs  lo  c.c.  of  the  water  in 
which  the  grapes  had  been  washed.  One  animal  died 
in  two  days,  the  two  others  died  on  the  forty-eighth 
and  fifty-eighth  days  respectively,  the  latter  presenting 
marked  tuberculous  lesions,  especially  at  the  place  of 
injection.  The  water  in  which  the  grapes  had  been 
washed  was  taken  from  the  faucet,  and  the  glass  con- 
taining it  had  been  sterilized;  neither  the  boy  who 
had  brought  the  grapes,  nor  the  merchant  who  had 
sold  them,  was  consumptive.  The  cause  of  infection 
was  beyond  doubt  the  dust  on  the  grapes  This 
danger  was  recognized  long  ago  by  Pasteur.  One 
day  at  a  large  family  dinner  he  called  the  attention 
of  those  present  to  the  danger  of  imbibing  germs  while 
eating  fruit,  and  to  impress  the  necessity  of  caution 
upon  his  hearers  washed  his  bunch  of  grapes  in  a 
glass  of  water.  After  he  had  finished  the  grapes  and 
had  forgotten  his  little  speech,  being  thirsty,  he  drank 
from  the  glass  in  which  the  grapes  had  been  washed, 
thereby  arousing  much  merriment  among  the  irrever- 
ent voungsters  present. 

MosquitOS The    department     of     Agriculture     is 

about  to  issue  a  bulletin  prepared  by  Entomologist  L. 
O.  Howard  on  the  mosquitos  of  the  Lniited  States. 
It  discusses  their  stiucture  and  biology  and  indicates 
the  difference  in  all  stages  of  existence  between  the 
kind  of  mosquitos  that  transmit  malaria  (  .Anopheles) 
and  those  that  do  not  (Culex),  and  also  discusses  the 
subject  of  remedies.      Among  other  things  the  bulletin 


I 


October  6,  1900] 


MEDICAL    RECORD. 


559 


says  that  since  the  opening  up  of  the  gold-fields  in 
Alaska  and  the  great  inhux  of  miners  and  traders, 
knowledge  of  the  abundance  and  ferocity  of  the 
Alaskan  mosquito  has  become  widespread,  and  gov- 
ernment surveying  parties  in  starting  for  Alaska  for 
their  summer's  work  are  in  the  habit  of  consulting  tlie 
department  for  mosquito-bite  remedies.  The  bulletin 
says  there  is  a  constant  carriage  inland  from  the 
marshy  coast  of  very  many  mosquitos,  the  railway 
trains  seeming  to  be  the  most  important  mode  of  con- 
\eyaiice.  Many  of  the  cars  contain  mosquitos  by  the 
liundreds.  In  this  way  even  mountain  resorts  will  get 
their  supply  of  mosquitos,  and  with  the  improvement 
of  railway  service  and  the  increase  in  the  numljer  of 
through  cars  the  danger  is  constantly  increasing 
Only  about  thirty  of  the  two  hundred  and  fifty  known 
\arieties  of  mosquitos  have  been  found  in  the  Uniteil 
States.  Of  the  remedies  in  use  in  houses  the  burning 
of  pyrethrum  powder  and  the  catching  of  mosquitos  on 
the  walls  in  kero.seiie  cups  are  probably  the  best,  next 
to  a  tiiorough  screening  of  doors  and  windows  and  the 
use  of  mosquito  bars  about  the  beds.  The  remedies 
mentioned  for  bites  are  glycerin,  a  lump  of  indigo, 
and  household  ammonia. 

Care  of  the  Feeble-Minded.— Dr.  .\.  W.  Wilmarth, 
in  a  |)aper  read  before  the  recent  meeting  of  the 
.American  Medical  Association,  made  a  difl'erence  in 
the  classification  of  the  lower  grades  of  mental  defi- 
ciency, idiocy  and  imbecility,  and  the  higher  t\  pes 
of  feeble-minded  and  backward  children.  He  said 
that  at  an  early  stage  of  mental  development  a  child 
begins  to  notice  objects,  lights,  persons,  sounds, 
etc.;  if  these  manifestations  of  intelligence  be  long 
delayed,  it  may  be  inferred  that  the  child  is  de- 
ficient in  sight  or  hearing.  As  delay  in  walking 
indicates  backwardness  in  physical  development  or 
the  jjresence  of  paralysis,  so  will  delay  in  the  de- 
velopment of  speech  be  a  sign  of  mental  de- 
ficiency. If  speech  be  wanting  at  four  years,  one 
may  suspect  permanent  mental  defect;  if  it  does 
not  develop  at  six  years  the  suspicion  becomes  a  cer- 
tainty. At  seven  years  the  child  emerges  from  the 
inquisitive  stage  when  it  asks  all  sorts  of  questions, 
answerable  and  unanswerable,  about  everything  im- 
aginable, and  begins  to  analyze  the  facts  gathered 
during  that  stage,  putting  them  together  into  ideas. 
It  is  then  that  systematic  teaching  should  begin. 
With  feeble-minded  children  it  is  not  a  question  of 
judgment  or  morals,  but  the  question  is  whether  a 
child  learns  as  much  as  a  normal  child  does  at  the 
same  age.  .-Vfter  fifteen  the  diagnosis  is  comparative- 
Iv  easy.  The  treatment  of  feeble-minded  children  of 
the  higher  types  should  consist,  in  addition  to  liie 
necessary  medication  for  whatever  physical  ills  be 
l^resent,  of  systematic  training  of  the  mind  in  properly 
conducted  institutions.  The  author  believes  that  the 
only  way  to  stimulate  the  minds  of  these  children  is 
to  arouse  their  imitative  tendency,  and  this  can  take 
place  only  in  the  presence  of  the  rivalry  and  compan- 
ionship of  an  institution.  In  the  family,  no  matter 
how  wealthy,  this  system  cannot  be  maintained,  and 
the  discipline  is  the  more  lax  because  the  backward 
child  is  regarded  with  special  indulgence. —  2'he  Nuis- 
'  ry. 

Ptomain  Poisoning.  —  Regarding  the  symptoms  of 
nicu  poisoning.  Dr.  Thompson,  Professor  Osier,  and 
other  well-known  authorities  appear  to  agree  that  the 
symptoms  are  substantially  the  same  in  each  case. 
These  symptoms  may  follow  almost  immediately  or 
after  an  interval  of  several  days.  The  former  is  much 
the  better  for  the  patient,  because  the  sooner  the  ali- 
mentary canal  is  relieved  from  the  poisonous  material 
bv  vomiting  and  diarrhoea,  the  greater  the  chance  of 


recovery.  In  the  majority  of  cases  there  is  a  latent 
period  of  from  twelve  to  thirty-six  hours  between  the 
taking  of  the  tainted  food  and  the  development  of  the 
symptoms,  liallard  found  that  in  observing  fifty-one 
cases  of  meat  poisoning,  a  period  of  twelve  hours 
elapsed  in  five  of  the  cases  before  the  symptoms  de- 
veloped. In  thirty-four  cases  between  twelve  and 
thirty-six  hours  elapsed,  and  in  eight  cases  between 
thirty-six  and  forty-eight  hours  elapsed.  There  were 
only  four  of  these  fifty-one  cases  in  which  it  took  a 
longer  period  than  forty-eight  hours  for  the  symptoms 
to  develop.  According  to  Dr.  Thompson,  the  symp- 
toms usually  develop  suddenly  and  with  violence,  but 
occasionally  the  development  is  preceded  by  an  in- 
definite uneasiness  on  the  part  of  the  patient,  nausea, 
lassitude,  and  abdominal  cramps.  When  the  symp- 
toms develop  suddenly,  they  are  preceded  by  rigor 
with  vertigo,  or  faintness.  or  a  violent  headache. 
Sometimes  there  is  great  difficulty  in  breathing,  and 
there  may  be  cold  perspiration  and  sudden  severe 
pains  in  the  upper  abdomen  or  in  the  thorax,  and  es- 
pecially between  the  shoulders.  Intense  thirst  has 
also  been  observed.  Soon  after  one  or  more  of  these 
symptoms  have  appeared  there  is  violent  colicky  pain 
in  the  bowels  accompanied  by  nausea,  retching,  and 
vomiting.  There  is  an  extreme  degree  of  muscular 
prostration,  which  comes  on  suddenly  and  prevents  the 
patient  from  standing.  This  may  i)e  due  to  the  ab- 
dominal pain,  but  it  also  occurs  independently.  The 
tongue  is  dry  and  coated  with  a  thick,  brownish-yellow 
fur  in  the  middle,  but  the  margins  are  of  a  bright  red 
with  distinct,  minute,  nipple-like  projections.  Fever 
is  usually  present,  and  the  temperature  may  rise  to 
103.5^  or  104°  F.,  although  the  skin  may  feel  cold 
and  moist.  The  pulse  is  somewhat  accelerated,  and 
the  rate  may  reach  130  or  140.  Occasional  symptoms 
which  have  been  noted  by  Ballard,  according  to  Dr. 
Thompson,  are  severe  cramps  in  the  legs  and  arms, 
convulsive  twitchings  of  the  muscles  of  the  face  and 
hands,  stiffness  in  the  joints,  and  various  abnormal 
sensations  such  as  numbness,  tingling,  and  flashes  of 
cold  and  heat  in  the  extremities.  There  may  also  be 
drowsiness,  intolerance  of  either  natural  or  artificial 
light,  and  in  the  worst  cases  unsound  nervous  excite- 
ment or  mild  delirium.  If  the  poison  results  fatally, 
the  prostration  increases,  tlie  pulse  grows  rapid  and 
feeble,  and  rapid  emaciation  follows.  The  patient 
becomes  extremely  blue  about  the  lips,  and  passes  into 
a  state  of  collapse  resembling  tliat  of  the  last  stages 
of  cholera.  In  the  more  severe  cases,  if  convalescence 
follows  the  attack  it  is  prolonged,  and  the  weakness 
of  the  patient  may  be  fully  as  great  as  after  some  in- 
fectious fevers,  such  as  cholera  or  yellow  fever.  Dr. 
Thompson  says  that  the  diagnosis  is  almost  always 
obtainable  from  the  history  of  the  case  in  connection 
with  the  symptoms  already  descrilied.  When  the 
cause  of  the  poisoning  is  ptomains  from  canned  food, 
the  only  difficulty  consists  in  determining  whether  the 
poisoning  is  the  result  of  eating  the  tainted  meat  or  of 
acute  metallic  poisoning  from  chloride  of  zinc,  tin, 
or  lead  used  in  the  process  of  soldering  the  can. —  The 
Sun. 

Fat  Food  as  a  Preventive  of  Consumption.  — Dr. 
Hell  says  that  fat  as  an  article  of  diet  furnishes  the 
potential  force  necessary  for  the  conversion  of  other 
food  material  into  organic  tissue  and  to  maintain  the 
bodily  functions.  Prof.  W.  O.  Atwater,  in  one  of  his 
most  recent  contributions  on  the  nutritive  value  of 
foods,  in  comparing  nutrients  in  respect  to  their  fuel 
values,  their  capacities  for  yielding  heat  and  mechanical 
power,  states  that  "one  pound  of  protein,  lean  meat  or 
albumen  of  egg  is  just  about  equivalent  to  a  pound  of 
sugar  or  starch,  and  a  little  over  two  pounds  of  either 
would  be  required  to  equal  one  pound  of  the  fat  of 


56o 


MEDICAL    RECORD. 


[October  6,  1900 


meat  or  butter."  The  mistake  commonly  made  with 
reference  to  the  use  of  fat  food  is  that  it  is  only  or 
especially  applicable  in  cold  climates,  an  erroneous 
inference,  the  same  as  that  cold  is  preventive  of  con- 
sumption. That  fat  is  the  almost  exclusive  food  in 
Arctic  regions  is  because  other  food  is  not  obtainable, 
not  because  of  the  frigid  climate.  It  is  necessary 
food,  though  not  in  such  excess  at  all  limes  and  every- 
where, to  supply  the  potential  energy  required  by  the 
organism  to  construct  the  tissues  and  maintain  the 
body,  the  temperature  of  the  body  being  about  the 
same  in  all  climates.  Fat  does  not  stand  alone  in  this 
regard  except  under  such  extraordinary  circumstances 
as  those  referred  to.  Carbohydrates  of  various  kinds 
contribute  to  the  same  functions  as  fat  under  ordinary 
conditions,  but  they  do  not  suffice  to  maintain  the 
stamina  of  the  organism  to  the  highest  degree  any- 
where without  the  assistance  of  or  being  supplemented 
by  some  kind  of  fat. —  The  Sniiitaiian. 

Sweat  Shops  as  a  Means  of  Spreading  Disease. 

. —  Dr.  Roche  recently  delivered  a  lecture  on  the  above 
subject  at  Dublin.  He  said  it  was  not  necessary  for 
him  to  show  that  clothes  as  clothes  carried  infection. 
In  the  case  of  whooping-cough  a  person  might  carry 
infection  in  his  clothes,  and  it  might  be  retained  in 
them  for  an  indefinite  period.  It  was  therefore  abso- 
lutely necessary  that  the  making  of  clothes  should  be 
carried  on  under  circumstances  that  should  put  them 
beyond  all  suspicion  of  infection.  Consumption  was 
an  infectious  communicable  disease,  and  some  time 
ago  he  had  suggested  that  infection  was  carried  in 
clothes.  The  Laiuet  had  remarked  that  suggestion. 
and  as  a  result  experiments  were  made  in  America 
and  elsewhere  which  proved  that  tlie  germs  of  con- 
sumption would  live  in  clothing  for  an  indefinite 
period  and  would  spread  infection.  It  was  no  exag- 
geration to  say  that  sweating  opened  the  door  for  the 
spread  of  consumption  in  the  families  of  those  who 
bought,  used,  or  wore  clothes  manufactured  under  the 
existing  sweating-system. — SaiiHary  Record. 

Infectious  Diseases  on  Board  Ship.  —  Staff  Sur- 
geon W.  J.  Colborne  of  the  Uritish  navy  read  a  paper 
on  the  above  subject  at  the  recent  meeting  of  the  Brit- 
ish Medical  Association.  In  brief,  he  said  that  the 
space  alloted  to  sick  on  board  ships  of  war  was  lim- 
ited. Though  limited  it  was  sufficient  for  all  ordinary 
purposes;  yet  provision  should  be  made  for  infec- 
tious diseases,  for  observation,  and  for  isolation.  On 
visiting  a  port  the  medical  officer  should  make  in- 
quiries as  to  the  prevalence  or  absence  of  infectious 
diseases,  the  extent  and  the  district  infected,  in  order 
to  warn  the  men  against  visiting  that  district.  The 
ship  should  remain  in  that  port  only  according  to  cir- 
cumstances, and  no  longer.  Persons  visiting  the  ship, 
as  washerwomen,  etc.,  should  be  carefully  supervised. 
All  minor  ailments  in  that  port  occurring  on  board 
ship  should  be  carefully  watched,  and  isolation  prac- 
tised when  a  case  was  doubtful;  messmates  as  well  as 
the  sick  man  should  be  watched.  A  proper  place  for 
isolation  must  be  found  either  below  or  above  decks. 
The  ventilation  was  important,  as  it  siiould  lead  di- 
rectly out  above  decks  and  not  lend  itself  to  the  dis- 
semination of  infection  iietween  decks.  All  such  ven- 
tilators should  be  stopped  up.  The  patient  and  the 
attendant  should  not  leave  the  apartment.  Wiien  no 
apartment  could  be  found  a  portion  of  the  deck  should 
be  totally  screened  off  from  deck  to  deck,  and  the 
screen  kept  moist  with  perchloride  of  mercury  solu- 
tion, I  :  1,000.  No  intercourse  of  any  sort  should  be 
allowed  with  the  outside,  not  even  for  food.  If  the 
patient  were  landed  to  hospital  the  attendants,  the 
boat,  and  the  crew  should  he  disinfected  by  approj^ri- 
ate  means.     In  smallpox  every  man  should  be  revac- 


cinated.  If  feasible  every  infectious  case  or  even 
cases  under  observation  should  be  landed.  By  the 
above  means  epidemics  on  board  ship  could  be  easily 
limited  and  stamped  out. 

Death  Rate  of  Chicagc — The  bureau  report  of 
the  department  of  health  of  the  city  of  Chicago  gives 
the  death  rate  for  the  year  ending  April  30,  1900,  at 
14.82;  for  1899  at  14.38;  for  1898  at  13.99;  for  1897 
at  13.98;  for  1896  at  14.82.  These  figures  are  based 
upon  a  population  of  1,750,000. 

Decreasing  Birth  Rate  in  Europe. — New  statistics 
demonstrate  the  fact  that  in  all  the  countries  of  Europe, 
with  the  exception  of  Russia,  the  percentage  of  in- 
crease by  births  has  been  diminishing  since  1891,  the 
average  decline  being  3  per  cent.  The  greatest  dif- 
ference is  shown  by  England,  where  births  have  re- 
ceded from  34  per  cent,  to  29.1  per  cent.,  and  the 
smallest  by  Norway,  namely,  o.i  per  cent.  From 
187 1  to  187s  the  increase  by  birth  in  Germany  was 
39.9  per  cent.,  but  in  1891-95  this  had  sunk  to  36.3 
per  cent.,  and  in  the  year  1897  it  went  down  to  36  per 
cent.  The  general  average  from  1881  to  1885  was 
36.8  per  cent.,  but  is  now  36  per  cent.  More  note- 
worthy is  the  decrease  in  Austria,  where  in  the  course 
of  twenty-five  years  it  has  dropped  from  39.5  per  cent, 
to  37.4.  In  lielgium  the  percentage  in  187  i  was  still 
32.1,  but  in  1897  only  29;  and  in  France  the  shrink- 
age in  the  same  period  was  from  25.5  to  22.4.  Next 
to  Norway  the  most  favorable  data  are  reported  from 
Switzerland. — Aledical  A-eics. 

Health  Reports. — The  following  cases  of  smallpox, 
yellow  fever,  cholera,  and  plague  have  been  reported 
to  the  surgeon-general  of  the  United  States  Marine- 
Hospital  service  during  the  week  ended  September  29, 
1900 : 


Smallpox — United  States. 


Cases,    Deaths. 


Alaska.  Port  Safety August  zsth Reported. 

Colorado,  Arapahoe  Co August  ^th  to  September  nth  . . .  3  * 

El  Haso  Co August  qth  to  September  iilli  . ..  2 

Fremont  Co August  gth  to  September  nth  . . .  3 

Garfield  Co August  9th  t<)  September  nth...  3 

Glenwood  Springs. -August  9th  to  September  nth  ...  2 

Huerfano  Co .\ugust  gth  to  September  nth  . . .  3 

Las  Animas  Co. .  .August  9th  to  September  nth  ...  4 

Pueblo  Co August  gth  to  September  nth  . ..  21 

Louisiana,  New  Orleans September  15th  to  azd 6 

Michigan,  Houghton September  8th  to  15th 2 

Torch  Lake September  8lh  to  15th 2 

Ohio,  Cleveland September  15th  to  :>2d 6 

Utah,  Salt  I^ke  City September  15th  to  22d 3 

Wisconsin,  Ashlield  Co September  18th  Pfesent. 

Uayfield  Co September  i8th " 

Dane  Co September  18th ** 

Eauclairc  Co September  iSth 

*  At  Denver. 

Smalli'OX— FoiiRlGN. 

Austria.  Prague .  ..September  1st  to  8tli i 

r.elgium.  ("ihent September  Slh  to  15th 

F.gypt,  Alexandria August  28th  to  September  3d i 

Cairo August  18th  to  2'ith 

England,  Liverpool September  ist  to  Blh 3 

France,  I.yons August  25th  to  September  ist 

Paris September  1st  to  8th 

India,  Bombay August  21st  to  aSth 

Calcutta August  iilh  to  26th 

Madras August  nth  to  24th 

Mexico.  Vera  Cruz September  8th  to  isth 

Russia,  Moscow August  25th  to  September  ist 

Odessa August  25th  to  September  8th  ...     7 

Warsaw August  25lh  to  September  ist 

Scotland,  IHmdee August  25th  to  September  isl 2 

Cilasgow September  7th  to  14th 31 

Spain,  Madrid August  nth  to  September  ist 

Yellow  Fevek, 

Cuba,  Cicnfuegos September  22d i 

Havana September  8th  to  15th 

Mexico,  Vera  Cruz September  8th  to  15th 

Plagi'e. 

India,  Bombay August  21st  to  28th 

Calcutta .August  nth  to  25th .. 

Scotland,  Cilasgow August  31st  to  September  14th  ..    16 


5 
2 
18 


Cholera. 

Indiil,  Bombay August  21st  to  j8th 

Calcutta August  nth  to  25th 

Karachi August  igth  to  29th 

M.qdr.is August  i8th  10  24th 

Japan,  Yokohama August  25th  to  September  ist  ... 


64 

136 


408 
29 


Medical  Record 

A    PVeckly  yournal  of  Medicine  and  Surgery 


Vol.  58,  No.  15. 
Whole  No.  1562. 


New  York,   October    13,    1900. 


$5.00  Per  Annum. 
Single  Copies,  loc. 


MEDULLARY  N.\RCOSIS  (CORXIXG'S  MKTH- 
OD):    ITS    HISTORY    AND    DEVELOR.MKNT. 

l!v   I..    MARCUS,    M.I).. 

NEW   VORK. 

This  method  of  anresthesia,  which  is  engrossing  the 
attention  of  the  entire  profession,  appears  to  me  to 
have  taken  a  permanent  place  as  a  valuable  therapeu- 
tic agent.  It  seems  but  proper  at  this  time  to  view  it 
from  its  historical  side.  While  not  wishing  to  bring 
about  a  controversy  similar  to  that  caused  by  the  in- 
troduction of  ether  as  an  ana,sthetic,  credit  should  be 
given  to  ilie  one  wlio  not  alone  was  the  first  to  use  this 
method,  but  took  the  pains  to  let  it  be  known  to  all  in 
Several  monographs  published  in  our  representative 
journals. 

J.  Leonard  Corning,'  of  New  York,  in  1885,  is  the? 
first  gentleman  to  record  spinal  anesthesia;  he  reports 
his  experiments  tried  on  a  dog  and  the  human  subject. 
In  this  his  first  report  he  claims  that  it  is  unnecessary 
to  inject  the  medication  into  the  spinal  canal,  stating 
"that  in  the  human  subject  numerous  small  veins  (ve- 
na: spinos.t)  run  down  between  the  spinous  processes 
of  tlie  vertebra;,  and,  entering  tlie  spinal  canal,  join 
the  more  considerable  vessels  of  the  plexus  spinalis  in- 
terna"; that  by  this  arrangement  of  the  circulation 
the  cocainization  of  the  cord  would  be  obtained. 

The  record  of  his  experiments  is  as  follows:  (I.)  He 
injected  twenty  minims  of  a  two-per-cent.  solution  of 
cocaine  into  the  space  situated  between  the  spinous 
processes  of  two  of  the  inferior  dorsal  vertebrce.  Five 
minutes  after  the  dog  had  been  injected  he  noticed  in- 
co-ordination  of  the  lower  extremities.  A  short  time 
after,  on  testing  with  the  faradic  current  he  noticed 
anaesthesia  of  the  region  supplied  by  the  cord  below 
his  point  of  injection.  Four  hours  later  the  animal 
had  entirely  recovered.  In  Experiment  11.  he  injected 
in  a  human  subject,  between  the  spinous  processes  of 
the  eleventh  and  twelfth  dorsal  vertebra;,  thirty  min- 
ims of  a  three-per-cent.  solution  of  cocaine.  After  the 
lapse  of  six  or  eight  minutes,  having  obtained  no  re- 
sults, he  injected  a  similar  quantity  into  the  same 
place.  Ten  minutes  later  the  subject  complained  that 
his  legs  "felt  sleepy."  Sensibility  was  impaired 
when  tested  by  the  electrical  current.  The  impairment 
"was  principally  limited  to  the  lower  extremities — the 
lumbar  regions,  the  penis,  and  the  scrotum."  When 
standing  the  subject  complained  of  dizziness:  the 
ability  of  distinguishing  differences  in  pressure  seemed 
to  be  well  preserved.  He  was  able  to  pass  a  sound 
almost  unnoticed,  though  this  was  usually  accomp.i- 
nied  by  considerable  pain.  The  pupils  were  slightly 
dilated.  The  constitutional  symptoms  noted  were 
headache,  slight  vertigo,  but  no  nausea.  The  subject 
experienced  tingling  sensations  and  numbness  of  his 
lower  extremities  until  night,  also  dryness  of  the 
throat  and  mouth  accompanied  with  mental  exhilara- 
tion, probably  due  to  the  amount  of  cocaine  injected, 

'  New  York  Medical  Journal.  iSS;.  vol.  42,  page  4S3.  Corn- 
ing ;  ■•  Local  Anaesthesia,"  .Vppleton,  1S86. 


over  gr.  iss.  The  motor  functioRs  were  not  disturbed, 
as  the  patient  was  able  to  walk  an  hour  after  the  injec- 
tion, though  sensibility  was  still  impaired  to  a  marked 
degree.  He  closes  this  report  of  his  first  experiments 
with  the  following  remark  :  "  Whether  the  method  will 
ever  find  an  application  in  genito-urinary  or  other 
branches  of  surgery,  further  experience  alone  can 
show.'' 

The  utility  of  this  method  so  impressed  Corning 
that  he  continued  his  experiments  and  widened  its  field 
of  application  in  neurology,  reporting  his  results  in 
1888.'  In  this  article  he  describes  his  technique  and 
gives  illustrations  of  a  trocar  and  needle  for  this  spe- 
cial method.  It  appears,  though  he  was  not  aware  of 
it,  that  all  of  his  injections  which  were  followed  by 
a  favorable  result  must  have  been  made  into  the 
spinal  canal;  as  Marx'  has  shown  that  when  the  co- 
caine solution  is  injected  around  the  cord,  the  phe- 
nomena of  anaesthesia  or  the  symptoms  of  post-opera- 
tive insults  are  not  obtained. 

It  is  in  his  work  on  "  I'ain."  '  that  he  records  the 
definite  results,  for  which  I  believe  he  should  receive 
the  credit  of  being  the  first  to  try  medullary  nar- 
cosis for  therapeutic  purposes;  and  by  his  results  of 
anjEsthesia  opened  up  the  field  for  the  possibilities  of 
operating  in  or  upon  the  analgesic  areas. 

In  the  chapter  headed  "  Local  Medication  of  the  Spi- 
nal Cord,"  he  carefully  weighs  the  possibility  of  danger 
following  lumbar  puncture,  stating:  "As  to  the  ques- 
tion of  possible  injury  arising  from  jiricking  the  fila- 
ments of  the  Cauda  with  the  needle,  it  must  be  borne 
in  mind,  in  the  first  place,  that  serious  disturbances  of 
sensation  and  motility,  having  their  origin  in  the  Cau- 
da, are  always  due  to  gross  lesions  and  not  to  insignifi- 
cant circumscribed  causes."  The  very  fact  that  the 
Cauda  is  composed  of  a  great  number  of  filaments,  that 
these  fill  out  the  entire  canal  and  are  widely  distrib- 
uted, would  a  priori  lead  us  inevitably  to  this  conclu- 
sion did  we  not  know  inductively  from  clinical  histo- 
ries and  subsequent  post-mortem  investigation  that 
such  is  the  case.'  Secondly,  we  must  remember  that 
the  wounding  of  a  nerve  stem  (and  the  Cauda  is  noth- 
ing more  than  an  aggregation  of  nerve  stems)  with  a 
fine,  sharp  needle  is  practically  without  significance. 
There  is  an  interesting  observation  bearing  on  this 
point  in  Weir  Mitchell's  well-known  book  on  nerve 
injuries,  which  we  may  here  apply  with  perfect  legiti- 
macy. "The  passage  of  a  needle  into  the  nerve  of  an 
animal  causes,"  he  says,  "usually  a  little  bleeding, 
which  passes  away  without  grave  results.'  Such  a 
statement  applies  to  simple  puncture  with  a  fine  nee- 
dle. Wounds  made  with  an  awl  or  other  coarse  in- 
strument may,  of  course,  set  up  the  symptoms  of  cir- 
cumscribed neuritis."  This  removes  all  possible 
immediate  or  remote  injuries  referable  to  a  puncture 
made  below  the  limits  of  the  true  spinal  cord. 

His  modus  operandi viii'A  as  follows :  "  A  small  trocar, 
half  an  inch  long  and  of  the  diameter  of  a  wax  match, 

'  Medicai.  Record,  1888,  vol.  xxxiii.,  p.  291. 

'  Medical  Record.  October  6,  igoo. 

'Corning:   "Pain,"  I.ippincott.   1S94. 

■•Vide  "Injuries  of  the  Cauda  Equina,"  by  William  Thor- 
burn.  M.D..  Brain,  vol.  x. 

'"Injuries  of  Xenes  and  their  Consequences. "  by  S.  Weir 
Mitchell,  Philadelphia,   1872. 


562 


MEDICAL    RECORD. 


[October  13,  1900 


was  first  thrust  through  the  skin  between  the  second 
and  third  lumbar  vertebra;.  A  long,  tine,  hollow  nee- 
dle, screwed  to  an  ordinary  hypodermic  syringe,  was 
then  passed  through  the  opening  in  the  trocar  and 
down  through  tiie  soft  tissues  adjoining  the  ligamen- 
tum  interspinosum  till  the  spinal  canal  was  entered. 
The  entire  contents  of  the  syringe  were  then  emptied 
upon  the  fibres  of  the  cauda  equina."  The  solution 
injected  consisted  of  tinct.  aconiti,  gtt.  v.;  cocaina:;, 
gr.  ss. ;  aquai,   ;  i. 

In  from  five  to  eight  minutes  the  patient  complained 
of  tingling  sensations  in  his  lower  extremities.  On 
examination,  there  proved  to  be  a  decided  impairment 
of  tactile  sensibility,  "amounting  in  certain  localities, 
particularly  in  the  lower  third  of  the  thigh  and  ankle, 
to  a  positive  anastiiesia."  His  error  of  technique 
was  due  to  tlie  fact  that  he  inserted  liis  needle  with  the 
syringe  attached;  the  cerebro-spinal  fluid  was  not  al- 
lowed to  escape,  and  onlv  in  the  presence  of  this  fluid 
is  it  possible  to  know  absolutely  and  definitely  wheth- 
er or  not  the  canal  has  been  entered. 

If  the  original  literature  referred  to  by  me  is  thor- 
oughly examined,  I  believe  that  there  will  not  be  a 
dissenting  voice  against  giving  J.  Leonard  Corning 
full  credit  for  having  introduced  medullary  narcosis. 

Five  years  elapsed  after  the  last  article  of  Corning, 
when  the  attention  of  the  world  was  again  called  to 
this  form  of  anaesthesia  by  A.  Bier,  in  1899,  in  his 
original  monograph.'  He  experimented  with  it,  and 
was  able  to  obtain  anesthesia  sufficient  to  do  any  oper- 
ation on  the  lower  extremities. 

The  honor  is  due  him  for  having  established  it  as  a 
new  anaesthesia  in  surgery.  He  used  Quincke's  meth- 
od of  lumbar  puncture,  but  kept  his  needle  plugged 
until  he  believed  he  was  in  the  spinal  canal.  He  was 
very  careful  not  to  lose  any  more  lluid  after  establish- 
ing the  fact  that  his  needle  was  in  the  canal;  he  then 
attached  his  syringe  (he  prefers  a  Pravaz)  and  injected 
his  solution  of  cocaine,  leaving  the  needle  attached  to 
the  syringe  in  situ  for  two  minutes  so  that  the  solution 
should  not  escape  through  the  artificial  canal  made  by 
his  puncture.  The  skin  puncture  he  sealed  with  col- 
lodion. He  made  his  puncture  painless  by  using 
Schleich's  infiltration  down  to  the  vertebra.  He  ob- 
tained signs  of  anesthesia  five  to  eight  minutes  after 
injecting,  the  patients  complaining  of  tingling  sensa- 
tions and  formication  in  the  legs.  His  longest  ana-s- 
thesia  lasted  forty-five  minutes. 

The  quantity  of  cocaine  he  used  varied  from  0.005 
gm.  to  0.01  gm.  The  area  of  anesthesia  varied  in  his 
different  cases;  in  some  it  extended  to  the  mamnie,  in 
others  as  high  as  the  neck.  He  believes  that  the  di- 
minution of  sensation  is  due  to  the  effect  of  the  cocaine 
upon  the  "  scheidenlosen  Nerven,"  and  perhaps  the 
ganglion  cells.  I-fe  reports  the  results  of  having  him- 
self injected  as  well  as  his  assistant.  The  report  of 
his  personal  case  is  interesting  because  it  shows  the 
result  when  too  much  spinal  fluid  is  lost,  and  the 
proper  treatment,  rest  is  not  obtained;  likewise  iiis 
assistant,  though  he  lost  very  little  spinal  fiuid,  suffered 
by  trying  to  pursue  an  active  life  following  his  injec- 
tion. He  believes  it  necessary  after  every  injection  to 
demand  absolute  rest  to  lead  to  a  rapid  recovery.  The 
sensibility  to  appreciate  touch  remained  intact  in  most 
cases,  and  was  absent  only  wlien  large  amounts  of  co- 
caine were  used. 

The  constitutional  symptoms  he  noted  were  head- 
ache, vomiting,  sweating,  slight  chills  usually  soon 
after  the  injection,  rise  in  temperature  (which  was  not 
of  a  surgical  nature)  usually  occurring  within  a  day. 
He  noted  nothing  of  a  dangerous  nature,  but  believes 
it  is  contraindicated  in  hysterical  or  excited  patients. 

A  short  time  after  Seldovitch"  confirmed  Uier's  re- 

'  Deutsche  Zeitschrift  fiir  Chirurgie,  vol.  li.,  p.  361. 
'  Ccntralblatt  fUr  Chirurgie.  iSSg,  vol.  xli.,  p.  mo. 


suits,  having  also  experimented  on  dogs.  The  disa- 
greeable symptom  of  rise  of  temperature  he  attributed 
to  the  cocaine,  which,  he  claims,  has  been  proven  to 
occur  frequently  when  this  drug  is  given  hypodermi- 
cally.  He  failed  to  get  any  rise  of  temperature  when 
a  saline  solution  was  injected  into  the  spinal  canal  of 
a  dog.  He  emphasizes  the  necessity  of  asepsis  in 
using  this  method. 

The  next  step  in  its  advancement  was  made  by  Tiif- 
fier,'  who  extended  the  field  of  operation  from  the 
lower  extremities,  established  by  Bier,  to  the  genito- 
urinary organs,  rectum,  and  intestines.  He  is  the  first 
to  report  a  large  number  of  cases;  they  were  comprised 
of  both  sexes.  He  recommends  a  platinum  needle,  9 
cm.  long,  with  an  external  diameter  of  1 .  i  mm.  and  inter- 
nal one  of  0.8  mm.,  the  oblique  bevel  much  shorter  than 
that  of  the  ordinary  aspirating  needle.  He  also  uses 
the  I'ravaz  syringe.  He  locates  his  point  of  puncture 
by  dr;iw  ing  an  imaginary  line  joining  the  crests  of  both 
ilia,  this  crosses  the  centre  of  the  fourth  lumbar  ver- 
tebra, and  from  this  point  it  is  easy  to  find  the  space  be- 
tween the  fourth  and  fifth,  where  he  prefers  to  inject. 
He  prefers  the  scorching  position,  as  all  others  he  has 
tried  are  subject  to  flexure  or  deviation  of  the  vertebrae, 
which  makes  the  puncture  more  difficult;  another  ob- 
stacle is  deformities  of  the  spine.  He  never  injects 
the  solution  of  cocaine  until  he  sees  the  escape  of 
cerebro-spinal  fluid.  He  lays  great  stress  on  the  ne- 
cessity of  using  a  fresh  sterilized  solution,  as  he  has 
found  it  becomes  rapidly  inert  from  frequent  steriliza- 
tion. The  maximum  quantity  of  cocaine  he  used  was 
15  mgm.  He  noted  the  same  constitutional  symptoms 
as  I^ier;  for  the  vomiting,  which,  he  says,  conies  on 
soon  after  injecting,  he  recommends  the  use  of  ice 
given  internally.  He  has  found  the  Jieadache  the  most 
constant  symptom.  It  varies  greatly  in  duration  and 
severity;  most  frequently  it  is  light  and  lasts  a  short 
time,  but  he  has  seen  it  severe  and  continue  for  two 
days.  His  anesthesia  lasted  from  one  to  one  ami  a 
half  hours. 

The  first  report  of  its  use  in  obstetrics  was  made  by 
O.  Kreis.'  He  noted  no  disturbance  of  the  muscular 
power  of  the  uterus;  the  contractions  occurred  just  as 
frequently,  also  with  apjiarently  the  same  intensity  as 
before  the  injection.  The  patient,  though  not  suffer- 
ing any  pain,  complained  that  her  abdomen  felt  as  if 
it  were  being  stretched.  'I'he  pressure  of  the  head,  the 
stretciiing  of  the  vulva,  the  entrance  of  the  forceps, 
and  the  extraction  of  the  head  were  appreciated  by  the 
patient,  but  absolutely  devoid  of  pain.  The  abdomi- 
nal muscles  remained  at  rest,  lacking  the  stimulation 
of  the  pain  due  to  pressure  of  the  head;  but  when  the 
patients  were  told  to  bear  dow-n  they  were  able  to  ex- 
ert as  much  power  as  before  receiviii;^  the  injection. 
No  disturbance  of  the  motor  function  of  the  uterus  was 
noticed  at  any  time.  His  anasthesia  averaged  about 
two  iiours  in  duration.  He  does  not  believe  it  is  ad- 
visable to  use  it  when  tlie  assistance  of  the  abdominal 
muscles  is  required,  or  in  frightened  or  excited  pa- 
tients who  would  scream  or  cry  out,  although  suffering 
no  pain.  He  believes  it  is  useful  in  cases  complicated 
by  heart  or  lung  disease,  or  when  the  operator  can- 
not obtain  proper  assistance. 

The  first  extensive  report  and  application  of  this 
method  in  this  country  was  made  by  Marx."  He  ex- 
perimented also  with  eucaine,  but  was  not  able  to  get 
any  aiKfsthesia.  He  injected  a  saline  solution  into 
the  spinal  canal  and  obtained  the  same  constitutional 
efiect  as  lie  obtained  by  injecting  cocaine,  minus  anes- 
thesia. He  used  nitroglycerin,  gr.  f,',j|,  to  counteract 
symptoms  which,  he  believes,  are  due  to  the  shock  of 

'  I. a  .Seniaine  nu-dicalc,  iSijg,  p.  Tli'},,  and  May  10,   lyoo. 
'  t'cntralbiatt  filr  (iyniikologie,  July  14,   igoo. 
^  Medical  News,  August  25,  igoo.     Medical  Record,  Octo- 
ber (),   Igoo. 


October  13,  1900] 


MEDICAL    RECORD. 


56: 


the  central  nervous  system,  and  met  with  varied  re- 
sults. He  has  tried  hydrobromate  of  hyoscine,  gr.  ;,', „ 
given  hypodermically,  immediately  after  finishing  his 
spinal  injection,  or  at  the  first  sign  of  any  of  the  dis- 
agreeable symptoms.  He  has  used  from  gr.  ^  to  gr.  ?, 
of  cocaine  for  one  injection,  and  has  given  as  much  as 
gr.  J-  within  an  hour.  He  objects  to  injecting  any 
other  drug  than  cocaine  into  the  spirtal  canal,  as  he 
has  seen  toxic  results  from  the  combination  of  mor- 
phine sulphate,  gr.  ,';,  in  his  solution.  His  anx-sthesia 
has  lasted  from  one  to  five  hours,  and  by  repeated  injec- 
tions he  has  kept  a  patient  under  its  influence  for  eiglil 
hours.  He  recommends  that  the  patients  be  blind- 
folded and  have  their  ears  plugged  with  cotton;  that 
it  is  necessary  for  the  operator  and  his  assistants  to 
refrain  from  any  unnecessary  noise  or  talking.  Tlie 
patient  sliould  be  reassured  constantly. 

He  has  not  met  witli  any  dangerous  results  to 
mother  or  child,  and  believes  it  has  opened  up  tlie 
field  for  normal  labor  without  any  pain.  He  termi- 
nates his  report  by  stating  that  he  thinks  it  is  indi- 
cated in  a  prolonged  painful  first  stage,  convulsions 
present  or  threatening,  in  septic  cases  for  explorations 
and  operations. 

In  a  personal  interview  with  Dr.  Mar.x,  I  am  in- 
formed tiiat  he  has  given  cocaine  puncture  for  abdom- 
inal and  vaginal  hysterectomy,  the  operator  being 
GofTe,  of  New  York,  the  results  in  both  cases  being 
ideal. 

Other  successful  cases  have  been  reported,  but  they 
give  us  nothing  new  in  technique  or  application. 

'I'he  question  now  is  to  ascertain  a  technique  by 
which  the  area  of  anaesthesia  will  be  constant  in  all 
cases. 

1  take  pleasure  in  thanking  Dr.  Ware  for  the  refer 
ences  he  has  given  me. 

In  closing,  it  is  needless  to  say  that  this  being  a 
surgical  procedure,  asepsis  is  an  absolute  requisite  to 
avoid  fatal  sequelae. 


1215    M.\DISO.S*    .-\\KM.li. 


PULMO- 


MH.MBER     CON- 


THE     MODKRN     TRF..\TMKXT     OF 
NARY    TUBERCULOSIS. 

liv    M.    J.    BROOKS,    .M.U., 

STAMFORD,   CONN., 

I-HVSICIAN-IN-CHARGK     STAMFORD     Fl'LMONARV    SANATORIL-M  ; 
.NECTICIT   STATE    MKDICAL   SOCIETY,    F.TC. 

Upon  the  threshold  of  the  twentieth  century  there 
dawns  a  new  era  in  practical  therapeutics — no  less  a 
boon  than  the  successful  treatment  of  the  greatest 
scourge  to  which  human  fiesh  is  heir. 

A  short  while,  a  bit  more  patience,  and  a  trifle  more 
effort  are  still  requisite  for  its  consummation  and  gen- 
eral acceptation.  A  short  time  is  still  required  before 
this  knowledge  will  be  appreciated  by  the  great  body 
of  general  practitioners. 

'I'he  present  is  formative.  It  is  a  transitional  pe- 
riod. The  profession  in  general  has  scarcely  as  yet 
emerged  from  the  gloom  of  empiricism  in  the  treat- 
ment of  this  disease,  through  which  it  has  been  grop- 
ing from  time  immemorial. 

No  single  period  in  the  world's  history  has  been  so 
fraught  with  practical  progress  in  phthisio-therapeutics 
as  the  closing  years  of  the  present  century.  Perhaps 
no  similar  period  has  possessed  so  many  ardent  work- 
ers in  this  field,  nor  has  greater  amount  of  effort  been 
expended. 

Ihe  studies  and  perquisitions  of  Cornet,  Strauss, 
Chauveau,  Cohnheim,  Villemin,  Klebs,  Aufrecht, 
Koch,  and  others  have  served  to  elucidate  and  exem- 
plify its  etiology  and  pathology.  We  are  indebted  to 
these  gentlemen  for  a  clear  and  accurate  conception  of 
the  causes  and  factors  involved,  without  which  there 
could  be  no  rational  treatment. 


A  brief  reiteration  of  certain  etiological  and  patho- 
logical principles  is  essential  to  a  proper  comprehen 
sion  and  lucid  understanding  of  the  modern  methods 
of  successful  treatment. 

Tuberculosis  is  a  disease  of  crowding,'  of  unsani- 
tary dwelling,"  of  deficient  ventilation,'  of  insufficient 
use  of  soap'  and  water,'  of  deficient  and  insufficient 
feeding,"  of  uncleanliness,'  of  defective  hygienic  envi- 
ronment;" in  short,  of  departure  from  the  conditions 
of  a  healthy  animal  life.' 

True  it  has  a  specific  infectious  organism,  but  the 
bacillus  is  only  the  "  histological  exponent,  not  the 
whole  of  the  tubercle,  much  less  of  the  disease."  '" 

Local  tuberculosis,  regardless  of  its  situation  in  the 
human  economy,  has  the  same  characteristics — the 
locus  luinoris  resislcnliie  and  the  proliferation  of  con- 
nective-tissue cells  resulting  in  a  sequestration  of  its 
offending  concomitant  infective  agent. 

Remove  the  primordial  etiological  factors  enumerated 
and  the  disease  abates;  if  neglected,  further  infection 
ensues.  That  is  the  so-called  mixed  infection.  The 
ubiquitous  pyogenic  organisms  find  a  suitable  soil,  and 
then  is  presented  the  typical  clinical  configuration  of 
consumption. 

Pure  local  tuberculosis,  whether  pulmonary  or  artic- 
ular, does  net  possess  the  time-honored  and  respected 
signs  of  inrtammation  —  riihor,  dolor,  tumor,  calor,  et 
Junclio  hesii.  Pulmonary  tuberculosis  is  quite  afebrile 
and  without  exudation,  but  add  mixed  infection  and 
pulmonary  phthisis  is  the  sequence.  In  other  words, 
phthisis  is  pulmonary  tuberculosis  plus  a  pya-mia  or 
septicsemia.  The  due  appreciation  of  this  complica- 
tion is  of  paramount  importance,  for  almost  all  the 
dreaded  symptoms  of  phthisis  are  the  result  of  this 
pyogenic  superinfection. 

The  subject  of  mixed  infection  has  recently  been 
studied  with  great  care  by  one  of  the  cleverest  of  bac- 
teriologists, Sata,  of  Tokio,  Japan.  He  has  shown 
that  the  broncho-pneumonia  of  consumptives  is  due 
invariably  to  these  mixed  bacteria.  The  predominant 
micro-organisms  are  the  streptococcus  pyogenes,  sta- 
phylococcus pyogenes,  diplococcus  of  Fraenkel,  and 
Pfeiffer's  influenza  bacillus. 

Sata,"  Pfeiffer,'"'  and  Brieger,"  in  harmony  with 
Petruschky,  attribute  the  hectic  fever  and  night  sweats 
to  the  work  of  the  streptococcus.  These  gentlemen 
have  been  able  to  recognize  the  so-called  streptococcus 
curve  in  the  fever  charts  of  many  consumptives.  F"ur- 
ther,  the  staphylococcus  pyogenes,  from  its  known 
liquefying  action  upon  connective  tissue,  is  in  the 
main  responsible  for  tlie  breaking  down  of  pulmonary 
tissue.  Pfeiffer's  bacillus  as  well  as  Eraenkel's  often 
causes  consolidation,  thus  hastening  the  progress  of 
the  disease.  The  bacillus  pyocyaneus  of  Gessard 
gives  the  characteristic  greenish  coloring  to  the  sputa. 
The  micrococcus  tetragenus  described  by  Koch  and 
Gaffky  is  frequently  found  in  phthisical  sputa  as  well 
as  many  other  micro-organisms  having  more  or  less 
pathogenic  qualities. 

Now  as  for  treatment.  It  is  obvious,  again  to  quote 
Hrieger,"  that  a  specific  serum  cannot  meet  the  indi- 
cations furnished  by  a  mixed  infection.  It  has  been 
repeatedly  noted  that  in  the  contest  between  the  sys- 
tem and  the  organisms  associated  with  phthisis,  the 
leucocytes  and  their  alexins  play  a  lesser  part  than  in 
any  other  infectious  disease.'" 

Yet  there  are  many  who  still  have  faith,  for  in 
stance,  in  Koch's  tuberculin  in  spite  of  Yirchow's  pro- 
testations, or  Hausemann's  and  Baumgarten's  assur- 
ance that  an  eruption  of  tubercles  occurred  regularly 
during  the  injections;  or  Bozzolo's"  observation  that 
it  converted  a  chronic  process  into  an  acute:  or  Papil- 
Ion's"  evidence  that  the  reaction  was  to  be  obtained  in 
any  ordinary  cachexia;  or  Landouzy's,"  in  general 
erethism. 


5^4 


MEDICAL    RECORD. 


[October  13,  1900 


There  are  yet  advocates  of  Maragliano's  serum  not- 
withstanding J)e  Renzi's'"  and  Fraenkel's'"  demonstra- 
tions as  to  its  futility;  of  Klebs'  and  Hulinel's,  in 
spite  of  Debove's,''  IJlache's,'"'  and  my  own^"  investi- 
gations. Portucalis'"  recent  advocacy  of  a  serum 
prepared  from  tertiary  syphilitics,  which  he  considers 
"  would  be  of  great  advantage  to  consumptives,"  should 
surely  require  no  contradiction.  It  is  manifestly  ab- 
surd. 

But  it  is  hardly  necessary  to  mention  each  and  every 
one.  Omeltchonko"'  has  experimented  with  a  vari- 
ety of  sera  and  found  them  wanting.  The  consensus 
of  opinion  it  seems  is  with  Beck,"°  Rabinowitsch,"' 
Osier,'*  Richardiere,-"  Sir  Herbert  Maxwell,-""  Pye- 
Smith,"  and  others,  that  all  sera,  diagnostic  or  spe- 
cific, have  proven  nugatory  in  their  application  to  this 
disease. 

As  for  drugs:  Centuries  of  experimentation  with 
every  ingredient  mentioned  in  the  pharmacoptcia  have 
given  us  not  a  single  one  that  has  the  slightest  favora- 
ble action  upon  tuberculous  processes.'"  Even  the 
much  vaunted  creosotes,  guaiacols,  and  the  like  have 
proven  in  some  instances  inert,"''  in  others  injurious." 
However,  be  they  inert  or  injurious  they  have  certainly, 
to  use  the  words  of  Osier,  "no  essential  influence  on 
the  progress  of  this  disease."  "" 

Again,  the  virtues  of  climate,  altitude,  and  atmos- 
pheric pressure,  upon  which  so  much  reliance  has  been 
placed,  have  dwindled  beneath  the  searchlight  of  close 
investigation.  The  old  theory  of  immune  zones  is  no 
longer  tenable.  The  bacillus  is  found  regardless  of 
temperature,  of  elevation,  of  moisture,  or  prevailing 
winds.'"  The  disease  prevails  regardless  of  demo- 
graphic conditions  or  geographical  positions.'*' 

Thus  we  find  Crowley'"  and  Duckman,"  of  Califor- 
nia, inveighing  against  the  practice  of  sending  the  tuber- 
culous to  their  State;  the  Honolulu  health  reports'" 
showing  progressive  increase  in  tuberculosis  among  the 
natives;  Girdner"  affirming  the  percentage  among 
the  citizens  of  Asheville,  N.  C,  to  be  the  same  as  that 
of  Manhattan  ;  Newton'"  assuring  us  of  its  prevalence 
among  the  natives  in  the  Adirondacks;  Davies'"  de- 
monstrating tuberculosis  rampant  even  upon  the  Isle 
of  Man,  "  where  the  temperature  is  equable,  abundant 
sunshine,  and  fogs  unknown."  Yet  the  climate  of 
these  places  has  frequently  been  lauded  as  a  specific 
in  consumption. 

Detweiler"  and  Blumenfeld,  it  is  affirmed,  were  the 
first  to  prove  these  factors  unessential  to  treatment. 
Lannelongue,  Archard,  and  Guillard"  have  recently 
carefully  studied  the  question  of  the  influence  of  cli- 
mate upon  the  evolution  of  tuberculosis.  Their  con- 
clusions are  as  follows:  "In  certain  regions  the  dis- 
ease is  rare,  and  its  relative  infrequency  is  attributable 
solely  to  the  mode  of  life  of  the  inhabitants.  The 
improvement  which  has  been  noted  in  patients  at 
health  resorts  which  have  a  reputation  for  the  cure  of 
phthisis  is  due  alone  to  the  effects  of  the  different 
methods  of  treatment  adopted,  and  cannot  be  attributed 
to  the  region  or  place."  F.  Hueppe's"'  deductions 
were  practically  the  same. 

That  climate  is  unessential  to  successful  treatment 
was  the  verdict  of  the  International  Medical  Congress, 
held  at  Moscow  in  1897. 

Dr.  Pannwitz's  rejjort  as  general  secretary  of  the 
Berlin  Congress  of  Tuberculosis  contains  the  follow- 
ing: "The  fact  has  been  proven  that  tuberculosis  can 
be  treated  successfully  anywhere  without  regard  to  cli- 
mate." 

"  Elevation,"  to  quote  Braine-Hartwell  Birming- 
ham," "  of  a  few  hundred  feet  may  be  desirable,  though 
not  necessary."  J.  E.  Birmingham"*  declares  from 
much  experience  that  "elevation  has  no  influence 
whatever  over  this  disease.  Patients  do  as  well  at  sea 
level  as  at  liigh  altitudes." 


Atmospheric  conditions  are  unimportant.  Baromet- 
ric pressure  does  not  hold  the  slightest  causative  rela- 
tionship to  any  disease.'*  Professor  Stewart  in  his 
address  before  the  International  Congress  showed  that 
the  results  obtained  in  Edinburgh  with  its  "rain  and 
mist  and  east  winds  "  were  equal  to  the  most  favorable 
obtained  in  Germany. 

If  further  evidence  along  this  line  be  desired,  I 
refer  to  VN'alker,"'  Burton-Fanning,"  von  Schrotter,'" 
Otis,  Knight,  "  Shaper,"  Girdner,'*'  Tew,*"  Roane 
IJrunnon,  '  Hillier,'"  Wolff,  and  others. 

If  drugs,  sera,  climate,  altitude,  and  atmospheric 
pressure  have  proven  inefficient,  in  what  does  the  cure 
consist.' 

The  sum  substance  of  successful  treatment  resolves 
itself  into  the  rational  application,  conversely,  of  its 
fundamental  causative  factors;  the  diametric  antith- 
esis of  its  so-called  predisposing  etiology;  plus,  to 
use  the  words  of  Moeller, '"  "  the  summation  of  many 
minor  curative  measures,  each  of  which,  perhaps,  if 
taken  by  itself  has  but  slight  eft'ect,  but  collectively 
productive  of  the  greatest  good.  ' 

It  is  apparent  that  these  measures,  with  their  multi- 
tudinous details  incident  thereto,  can  propeily  be  car- 
ried out  only  in  institutions  where  tlie  patients  are 
under  constant,  competent,  sincere,  painstaking  medi- 
cal supervision.*^" 

To  quote  a  recent  author,  "  the  value  of  sanatoria 
treatment  has  been  too  incontrovertibly  demonstrated 
to  permit  of  any  difference  of  opinion."  "'  To  men- 
tion the  advocates  of  sanatoria  treatment  for  this  dis- 
ease would  be  but  to  name  every  student  of  the  subject 
the  world  over,  iiemitie  cimtiadicente. 

Now  as  to  the  armamentaria  of  sanatoria.  Perfect 
sanitation  and  prophylaxis,  scrupulous  cleanliness, 
the  routine  of  occupation,  the  systematic  hygienic 
regimen,  aerotherapy,  Dauerluftkur,  the  time  air  cure 
of  the  Germans,  efficient  nursing  and  the  like,  it  goes 
without  saying,  are  of  prime  importance.  There  are 
other  measures,  however,  not  generally  appreciated, 
although  none  the  less  valuable,  which  are  deserving 
of  consideration.  Eoremost  among  them  is  inhalation, 
which  dates  from  the  period  of  Paracelsus.  "There 
can  be  no  questioning  the  fact,"  to  use  the  words  of 
Schroeder,""  "that  inhalation  therapeutics  play  a  great 
role  in  the  treatment  of  phthisis."  Dr.  Penrose"'  of 
Johns  Hopkins  assures  us  that  the  antiseptic  action  of 
inhalation  is  manifested  by  the  rapid  disappearance 
of  pus  organisms  from  the  sputiun,  and  Burghart "' 
and  Hrieger*''  are  practically  of  the  same  opinion. 

Antiseptics  and  the  aliphatic  hydrocarbons  of  the 
turpentine  group  are  the  ingredients  generally  used. 
They  are  administered  by  siphon  or  comminuter  ar- 
rangement with  compressed  air.  Of  course,  no  sana- 
torium is  complete  without  its  inhalation  chamber,  as 
von  Schrotter,  Meissen,  J.  Lazarus,  and  others  affirm, 
but  from  special  study  I  am  quite  satisfied  that  an 
equally  valuable  method  of  application  consists  in 
charging  the  atmosphere  of  the  entire  institution  with 
antisejitics  by  means  of  vacuum  pumps  and  engine. 

An  antiseptic  or  medicated  atmospiiere  constantly 
maintained,  particularly  during  the  night's  rest,  is  cer- 
tainly, to  say  the  least,  an  efficient  coadjutor  of  the 
inhalation  chamber.  It  destroys  much  of  the  mixed 
infection,  limits  toxin  necrosis,  loosens  and  facilitates 
the  removal  of  alveolar  and  tubular  exudations,  and 
allays  local  tissue  irritation.  P.  Lacroix*'*' claims  still 
further  from  his  experiments  with  medicated  air  that 
the  tubercle  bacilli  as  well  as  the  microbes  of  mixed 
infection  are  destroyed.  Properly  adniinisiered,  tiien, 
inhalation  is  without  doubt  the  most  potent  single 
remedy  at  our  command  in  the  treatment  of  this  dis- 
ease. 

Hvdrotherapy  is  manifestly  an  essential  to  success- 
ful treatment.     It  should,  however,  be  systematically 


October  13,  1900] 


MEDICAL    RECORD. 


565 


and  rationally  carried  out  as  part  and  parcel  of  daily 
routine.  So  important  is  this  measure  that  many  en- 
thusiasts, such  as  Kuthy"'  and  Winternitz,"  maintain 
that  cures  may  be  effected  by  this  means  alone. 

The  carbonated  or  Nauheim  bath  has  been  found 
valuable  in  its  application  to  this  disease;  of  course, 
minus  the  resistant  gymnastics.  It  is  a  certain  means 
of  steadying  an  intermittent  or  irregular  pulse,  or  of 
reducing  its  frequency,  liy  promoting  a  superficial 
capillary  congestion  it  likewise  tends  to  relieve  visce- 
ral engorgement.  It  is,  without  doubt,  a  sujierior  sub- 
stitute for  the  pneumatic  cabinet. 

The  importance  of  diet  in  a  synthetic  condition  is 
self-evident.  Wilcox""  and  more  recently  Harris'" 
have  carefully  studied  the  subject,  but  it  is  a  wide 
field  and  worthy  of  further  investigation.  Suffice  it  to 
say  that  feeding  should  be  slightly  in  excess,  but  the 
food  should  be  well  selected,  nutritious,  temptingly 
served,  and,  of  course,  properly  cooked. 

Symptomatic  treatment  is  strictly  a  subsidiary  meas- 
ure. Sciiroeder"  observes  that  despite  the  innumer- 
able substances  which  have  been  uselessly  employed  in 
connection  with  the  therapy  of  phthisis,  there  are  cer- 
tain indications  which  we  are  justified  in  meeting  with 
symptomatic  remedies,  as  drugs  and  nutrient  prepara- 
tions; as,  for  instance,  hyperpyrexia,  ha;moptysis,  in- 
somnia, profuse  night  swe;its,  the  pains  accompany- 
ing pleur;il,  larnygeal,  or  intestinal  infection,  severe 
rigors,  paroxysms  of  cougiiing.  diarrhtta,  collapse,  and 
the  like.  .\t  the  same  time  it  should  not  be  forgotten 
that  the  tuberculous  are  as  prone  to  the  minor  ailments 
as  the  non-tuberculous,  and  their  innumerable  com- 
plications or  personal  idiosyncrasies  must  necessarily 
be  intelligently  dealt  with. 

Exercise,  which  many  of  the  earlier  phthisiologists, 
notably  Detweiler,  deemed  appropriate  to  treatment 
and  encouraged,  has  of  late  been  very  much  restricted. 
Dr.  Edson,"'  a  short  time  since,  struck  the  keynote 
when  lie  said  tiiat  "there  were  indications  in  the  pa- 
thology of  this  disease  for  rest.  While  physicians  fol- 
lowed tiiem  as  they  applied  to  articular  and  laryngeal 
tuberculosis,  they  ignored  them  when  the  lungs  were  in 
question."  Prof.  William  H.  Thomson  at  a  recent 
New  York  medical  meeting  averred  that  even  at  rest 
"the  constant  movement  in  respiration  was  a  great 
hindrance  to  cure." 

The  advocation  of  golf  and  horseback  riding  in  the 
treatment  of  phthisis  a  f^riori  contravenes  both  patho- 
logical and  clinical  indications.  In  the  light  of  pres- 
ent knowledge  and  experience  Liegekur,  therefore, 
supersedes  Uebungskur.  As  Hillier''  states,  frequent 
and  complete  rest  is  imperative. 

Lastly,  it  is  hardly  necessary  to  add  tiiat  the  secret 
of  institutional  success  lies  in  the  competency  and 
sincerity  of  the  physician  in  charge;  "in  his  ability," 
as  Mutliu"'  puts  it,  "to  discriminate  and  shape  his 
treatment  according  to  the  physical  requirements  of 
the  individual  case." 

In  conclusion,  jiermit  me  to  add  that  the  success  of 
treatment  is  intimately  connected  with  its  early  rec- 
ognition; that  pulmonary  tuberculosis  is  positively 
curable.  That  it  may  be  diagnosticated  even  without 
bacteriological  examination,  Fraenkel,"'  Fluegge,'" 
Petrushky,"  Anders, '"  Senator,'"  Bozzolo,""  Giovanni,"' 
and  many  others  aver. 

.-Vs  to  phthisis,  however,  it  is  of  course  dependent 
upon  the  extent  of  lung  involvement  and  duration. 
The  corollary  is  patent,  that  treatment  must  be  ef- 
fected early. 

Sanatorium  treatment  for  pulmonary  tuberculosis  is 
the  achievement  of  the  closing  years  of  the  century, 
and  embraces  in  sum  and  substance  modern  and  suc- 
cessful methods. 

REFERENCES. 

I.   Evans:   I'le.xus,  June,  lyoo. 


2.  Flick  .   Distribution  of  Tuberculosis  in  Philadelphia. 

3.  IJenison  :  Jdurnal  of  Tuberculosis,  July.   1900. 

4.  Emperor  William  of  Germany  ;   Herlin  Congress  of  Tubercu- 
losis. 

5.  Winternitz  :    Gazetta  degli  Ospcdali  e  delle  Cliniche,  June, 
lyoo. 

6.  Sir  II.  K.  Heevor,  Hart.:   British  Medical  Journal,  Aug:ust, 
iS,  1900.     A.  \.  Hell  ■   Sanitarian.  June,  1900. 

7.  Arthur  Kansome  ;  Zeitschrift   fiir   Tuberkulose   und    Ileil- 
stattenwesen,  March,  1900. 

S.    Osier  :   I'ractice,  third  edition. 

9.  Ilillier:   Tuberculosis,  its  Nature  and  I'revention.     Cassell 
&  Co.,  1900. 

10.  Baccelli  :     Inaugural  Address,   Naples  Tuberculosis  Con- 
gress, April  25,  1900. 

11.  Sata  :   Naples  Congress,  British  Medical  Journal's  Report 

12.  Pfeiffer  :   I.oc  cil. 

13.  Brieger  :   Herlin.  klinische  Wochenschrift,  March  26,  1900. 

14.  Loc.  cil. 

15.  Evans:  Ple.xus,  June,  1900. 

16.  Naples  Congress. 

17.  (Quoted  by  I.andouzy,  Naples  Congress. 
iS.    Loi-.  ill. 

19.  Zeit.   f.    Hygiene  und    Infectionskrankheit.,    vol.   .\.\xiii., 
I  yoo. 

20.  Loc.  fit. 

21.  International   Congress,    Paris,   .August,    lyufj,   la   Presse 
-Medicale  Report. 

22.  International    Congress,   Paris,   .Xugusl,    Kpo,    I.a   Presse 
.Medicate  Report. 

23.  Saiiitariiini,  June,  1900. 

24.  Zeit.  f.    Tuberkulose  und  llcilstattenwesen,  July.  1900. 

25.  Vratch,  July  15.   1900. 

26.  Naples  Congress. 

27.  Loc.  cil. 

2S.   Practice,  third  edition. 

29.  Transactions    Thirteenth    International    Congress,    Paris, 
August  7,  1900. 

30.  British  Government    Report    of   the    Berlin    Tuberculosis 
Congress. 

31.  British  Government    Report   of    the    Herlin    Tuberculosis 
Congress. 

32.  Professor  Robert,  of  Rostock  :  International  Congress  of 
Tuberculosis. 

33.  J.  A.  Crook  :  Memphis  Medical  Monthly,  .Vugust  15,1900. 

34.  Syers  :   Treatment,  May,  1900. 

35.  Loc.  cil. 

36.  Professor  Evans  :  June  Plexus. 

37.  Loc.  cil. 

3S.   California  State  Board  of  Health  Reports. 

39.  Medical  -News,  August  4,  1900. 

40.  June  and  July,  1900. 

41.  J.  II.  Girdner  :   Mkiucai.  Rkcokd,  May  14,  1898. 

42.  Richard  Newton:  Mkdicai.  Record,  June  23,  1900. 

43.  Charles   I  )avies :   British   Medical   .\ss'n.    .Xugust  3,  1900. 

44.  Knopf:   Prophyla.Nis  and  Treatment  of  Tuberculosis.  1S99. 
4;.    Naples  Congress,  Hritish  Medical  Journal's  Report. 

4O.    Herlin.  ined.  W'och.,  May,  1S99. 

47.  Medical  Review,  July,  1899. 

48.  Philadelphia  .Medical  Journal,   March  iS,  1899. 

49.  Kuhemann  :   Zeitsch.  f.  diiitct.  u.  physik.  Therap. ,  vol.  iv., 
No.  4,  1900. 

50.  British  Medical  Ass'n,  August  7,  I90(j,  Journal's  Report. 

51.  Hritish  Medical  Ass'n,  August  7,  1900,  Journal's  Report. 

52.  Zeitsch.  f.  Tuber.,  vol.  i.,  1900. 

53.  Boston  Medical  and  Surg.  Journal,  February  8,  1900. 

54.  Berlin,  klin.  Woch.,  Aprils,  1899. 

55.  I.oc.  cil. 

56.  British  Medical  Journal,  August  18,  1900. 

57.  Revue  de  Medecine,  July,  1900. 
!;S.    Recent  work. 

59.  Zeitsch.  f.  Tuberkulose  u.  Heilstattenwesen,  July,  igoo. 

60.  Theo.  Williams:   British  Medical  Journal,  .\pril  S,  1900. 

61.  Moeller :    I.oc.  cil. 

()2.    Zeit.  f.    Tub.  u.   Heil  ,  March,  1900. 

63.  Johns  Hopkins  .Medical  Society,  February  5,  1900. 

64.  Berlin,  klin.  Woch.,  July  9,  1900. 

65.  Berlin,  klin.  Woch  ,  March  26,  1900. 

66.  British  Medical  Journal.  October  14,  1900. 

67.  Naples  Congress,   Hritish  Medical  Journal's  Report. 

68.  Berlin,  klin.  Woch.,  April  13,  I900. 

69.  Medical  News,  .May  7,  189S. 

70.  I'dinburgh  Medical  Journal,  August,  1900. 

71.  Zeit.  f.    Tub.  u.  Heil.,  March,  igtxi. 

72.  American  .Medical  Ass'n,  June  7,  Igoo. 

73.  Recent  work. 

74.  Treatment,  June,  1900. 

75.  Munch,  med.  Woch.,  January  20,  I900. 

76.  International  Congress. 

77.  Naples  Congress. 

78.  Ne«r  V'ork  Medical  Journal,  June  23,  1900. 

79.  Naples  Congress. 

80.  Naples  Congress. 

81.  Naples  Congress. 


566 


MEDICAL    RECORD. 


[October  13,  1900 


A  CONSIDERATION  OF  THE  ANATOMICAL 
COXSTRUCTIOX  PREDISPOSING  TO  IN- 
GUINAL AND  FEMORAL  HERNI/E,  AND 
THE  MEASURES  TO  BE  TAKEN  IN  SECUR- 
ING   THEIR   RADICAL    CURE.' 

By    IRVING   S.    HAYNES,    Ph.  13.,    M.I). 

PROFESSOR     OF     PRACTICAL     ANATOMY,     CORNELL     UNIVERSITY     MEDICAL     COI  - 
LEGE.    \'ISITING    Sl'RGRON    TO   THE    HARLBM    HOSPITAL,    ETC. 

In  inviting  your  attention  to  the  subject  of  inguinal 
and  femoral  hernia:  nothing  new  or  novel  is  promised. 
The  importance  of  tiie  subject  alone  justifies  its  fre- 
quent consideration.  The  careful  study  of  any  matter 
with  which  we  are  already  reasonably  conversant  often 


; 


dispose,  at  times,  to  the  development  of  such   an  oc- 
currence. 

The  more  closely  nature  is  imitated  by  the  surgeon 
in  the  re-formation  of  the  parts  during  an  operation  for 
hernia  the  more  permanent  will  the  result  remain.  It 
is  therefore  very  essential,  before  we  proceed  to  advo- 
cate any  operation  for  the  cure  of  this  condition,  that 
we  know  the  arrangement  of  the  parts  when  hernia 
does  not  exist,  and  the  changes  produced  in  the  parts 
when  it  develops. 

The  Inguinal  Region  and  Hernia. — Tiie  features 
of  construction  which  predispose  to  an  inguinal 
hernia  are  these : 

First,  the  position   of  this  region  at  the  bottom  of 

.   _, ,     the    abdominal    cavity 

where  effects  of  pressure 
are  more  pronounced. 
This  operates  also  in 
the  case  of  the  femoral 
variety. 

Second,  the  existence 
[(_  in  these  regions  of  areas 

of  unequal  curvature  of 
the  peritoneum. 

The    interior    of    the 
perineal  sac  reflects,  of 
course,  the  shape  of  the 
abdominal   wall   and   is 
not    uniformly     sphere- 
like, but    presents    cer 
tain  ridges  and  hollows. 
In  the    ingumal   region 
three   ridges    are    found 
formed    by   the    urachus 
passing  from  the  top,  and  the  obliterated   hypogastric 
artery  from   the   side  of  the  bladder   to  converge  at 
the  umbilicus  and  still  inore  externally  the   deep  or 
internal    epigastric    artery,   which    extends    from    the 
external    iliac    in    a   direction   upward   and    inward. 
Between  the  ridges  formed   by  these  three  cords  are 
depressions  called  the  inguinal    fossae — internal,  mid 
die,  and   external.      As  we   are   limited    in    this   paper 
to  the  oblique  inguinal  hernia  we  have  to  do  with  the 
last.     This  is  usually  quite  pronounced,     It  is  limited 
internally  by  the  ridge  formed  by  the  deep  epigastric 
artery,  below   by  the  line  of   Poupart's  ligament,  and 
above  and  outward  smooths  out  into  the  general  peri- 
toneal wall.     The  significance  of  this  pouch  is  this. 
Its  deepest  point  is  immediately  over  the  internal   in- 
guinal orifice.      It  predisposes  to  the  development  of  a 


Fig.  I.— Cast  of  the  Lower  Abduiuinal  and  Pelvic  Cavity  oi  an  Old  Man  (Si.\ty-five  to  Seventy  Vears).  a.  The  external 
inguinal  (ossa  (what  are  fossse  in  the  subject  appear  as  tuberosities  in  the  casts)  ;  6,  the  femoral  fossa  (the  middle  and 
internal  inguinal  fossae  have  their  negatives  in  the  cast,  but  are  not  lettered)  ;  c,  groove  (blackened)  produced  by  the 
deep  epigastric  artery. 

proves  valuable  in  bringing  to  our  attention  lesser 
facts  we  had  nearly  forgotten,  and  clearly  defining 
others  that  had  grown  indistinct. 

My  purpose  to-night  is  stated  in  the  title  of  the 
paper.  I  wish  to  ask  you  to  review  with  me  the  pecul- 
iar construction  of  the  body  that,  we  may  justly  say, 
predisposes  to  the  formation  of  an  inguinal  or  femoral 
hernia.  I  acknowledge  that  I  have  had  my  doubts 
about  the  popularity  of  any  subject  so  closely  allied 
to  anatomy,  for  many  shy  at  the  mention  of  this 
branch.  Anatomy  probably  represents  more  than  any 
other  study  the  nightmare  of  our  medical  course.  A 
report  of  cases  operated  on  and  cures  obtained  is 
more  inviting,  but  is  it  as  profitable  to  all  of  us  as  a 
study  of  the  conditions  which  make  a  hernia  possible 
and  the  steps  to  betaken  to  eliminate  these  conditions.'' 

A  hernia  is  the  tumor  and   its        _  _^ 

coverings  formed  by  the  pro- 
trusion of  aviscus  through  an 
opening  in  the  walls  of  the 
cavity  in  which  it  is  contained. 

This  paper  is  limited  to 
the  consideration  of  the  in- 
direct inguinal  hernia,  when 
the  viscus  passes  through  the 
inguinal  canal,  and  a  femoral 
hernia,  when  the  escape  takes 
place  through  the  femoral 
canal.  The  permanent  cure 
of  these  hernia;  depends  upon 
several  factors.  The  prin- 
ciple which  underlies  the 
rational  interpretation  and 
management  of  these  factors 
is  that  the  abnormal  condi- 
tions existing  which  allow  the  development  of  a  hernia 
shall  be  restored  to  the  normal. 

In  the  normal  individual  there  is  no  hernia,  al- 
though certain  facts  of  construction  exist  which  pre- 

'  Read  June  ii.  ifjoo.  before  the  Harlem  Medical  .\ssociation, 
and  demonstrated  by  plaster  casts  and  numerous  dissections. 


■w 


■Similar  Cast  from  an 


IIr-  references  arc  ihc  same  .is  in  Fig 


rupture  by  concentrating  at  the  orifice  the  force  of  intra- 
abdominal pressure.  Such  jiressure  may  be  no  greater 
here  than  at  any  other  point  on  the  same  level,  but  all 
other  points  do  not  have  a  potential  opening  leading 
through  the  abdominal  wall,  iience  the  elTects  of  press 
ure   are    localized    by    the    presence    of    this    pouch. 


October  13,  1900] 


MEDICAL    RECORD. 


567 


Should  there  be  a  state  of  weakness  at  the  ring,  as  dt- 
scrilied  later,  a  hernia  may  result. 

Third.  From  the  bottom  of  the  fossa  the  funicular 
process  of  peritoneum  extends  onward  through  the 
inguinal  canal   to   the   scrotum.      Usually  this  tubular 


T^ 


Fig. 


-Similar  Last  irum  a  \  oung  W  l 


Structure  is  obliterated  and  only  a  thin  fibrous  cord 
remains,  wiiich  may  be  hard  to  demonstrate.  This  is 
the  normal  condition  and  does  not  in  itself  influence 
the  occurrence  of  a  hernia.  Should  the  tube  remain 
open,  either  partially  or  completely,  a  hernia  is  not 
only  possible  but  is  extremely  probable. 

Fourth.  'I'he  next  predisposing  factor  is  found  in 
the  manner  in  which  the  elements  of  the  cord  itself 
converge  at  the  internal  ring.  The  vas  deferens  comes 
from  the  pelvic  cavity  at  the  inside  of  the  internal 
ring,  the  spermatic  vessels  descend  from  the  lumljar 
region  above  the  ring.  They  meet  and  unite  at  the 
internal  ring.  Their  junction  forms  a  V- 
shaped  figure,  the  apex  of  which  is  at 
the  ring.  This  arrangement  serves,  no 
doubt,  in  a  slight  degree  to  direct  a  loop 
of  intestine  toward  the  internal  orifice. 
Fifth.  There  is  a  more  potent  factor 
in  the  fact  that  the  cord  traverses  the 
abdominal  wall.  So  long  as  nature 
determines  that  the  testicle  shall  be 
worn  externally,  so  long  will  the  cord 
need  to  traverse  the  abdominal  wall  and 
a  state  of  weakness  will  remain.  I  am 
hardly  ready  to  advocate  the  placing  of 
a  testicle  within  the  abdominal  cavity 
merely  to  eliminate  this  feature  of 
architectural  weakness. 

The  larger  and  more  vascular  the  cord 
the  weaker  becomes  the  abdominal  wall 
about  it,  because  the  cord  may  be  com- 
pressed by  unusual  pressure,  its  attach- 
ments to  the  surrounding  parts  weak- 
ened, and  a  knuckle  of  intestine  may  be 
forced  between  it  and  the  margins  of 
the  inguinal  ring.  Repeated  stretch- 
ings of  this  sort  will  tend  to  enlarge 
the  orifice  and  allow  the  escape  of  in- 
testine or  omentum. 

Sixth.  The  inguinal  canal  and  rings. 
In  order  that  we  may  all  think  of  the 
same  thing  when  these  terms  are  used 
it  is  best  to  define  them.  By  the  in- 
ternal inguinal  ring  is  meant  the  open- 
ing, or  really  the  potential  opening,  in  the  transver- 
salis  fascia,  not  the  muscle,  through  which  passes  the 
spermatic  cord  in  the  male  or  the  round  ligament  in 
the  female.  The  external  inguinal  ring  is  the  simi- 
lar opening  in  the  aponeurosis  of  the  external  oblique 
muscle  through  which  the  same  structures  pass,  and 
the   inguinal   canal    is  the   tract  joining   these  rings 


and  situated  between  the  internal  and  external  oblique 
muscles,  which  is  occupied  by  the  cord  or  round 
ligament  f»  route  from  the  abdomen  to  the  scrotum 
or  labium. 

We  all  understand  that  these  terms  of  rings,  orifices, 
and  canals  are  used  be- 
cause there  are  no  better. 
There  are  no  open  holes  or 
rings  unless  a  hernia  has 
existed  or  the  dissector 
been  at  work.  Normally 
the  cord  is  snugly  enclosed 
by  the  tissues  at  all  points. 
A  word  about  just  how 
these  so-called  openings 
are  formed  may  not  come 
amiss  and  will  help  to 
make  clear  the  later  state- 
ments. 

In  early  foetal  life  the 
testicle  lies  within  the  ab- 
dominal cavity  below  the 
future  kidney.  Gradually 
it  works  down  until  it 
comes  against  the  internal  surface  of  the  abdominal 
wall.  Preceded  by  a  small  pouch  of  peritoneum  the 
testicle  now  passes  through  the  transversalis  fascia, 
the  transversalis  and  internal  oblique  muscles,  then 
between  the  latter  and  the  external  oblique  muscle, 
traverses  the  last,  and  finally  settles  in  the  scrotum. 

\ow  the  testicle  does  not  make  any  hole  or  rent  in 
these  layers  of  the  abdominal  wall,  but  .stretches  each 
layer  before  it.  Kacii  layer  then  contributes  a  long, 
funnel-shaped  pouch  covering  the  cord  and  testicle. 
Thus  the  transversalis  fascia  furnishes  the  layer  called 
the  infundibuliform  fascia,  which  can  be  demonstrated 


1  lit  rrlert-iKcs  arc  the  same  as  in  Fig. 


Fl<i.  4.  Posterior  Surface  of  the  Anterior  Abdominal  Wall  Peritoneum  in  position.  Inguinal 
and  Femoral  KwRions.  i ,  The  iliacus  muscle  ;  2,  anterior  crural  nerve  ;  3,  external  iliac  artery  ;  4, 
external  iliac  vein  ;  5,  vas  deferens ;  6,  bladder  covered  by  peritoneum  ;  7.  superior  vesical  artery 
(the  still  pervimis  portion  of  the  hypogastric  artery-  ;  S,  internal  inguinal  fossa  ;  g.  the  middle  in- 
guinal fossa  ;  lo,  femoral  fossa  ;  11,  external  inguinal  fossa  ;  12,  Poupart's  ligament  ;  13,  perito- 
neum ;  14.  fold  of  peritoneum  made  by  the  urachus;  15,  fold  of  peritor.eum  made  by  the  obliter- 
ated hypogastric  artery  ;  16,  fold  of  peritoneum  made  by  the  deep  epigastric  artery. 


for  a  short  distance  surrounding  the  cord  and  forming 
a  funnel-shaped  pit. 

The  transversalis  and  internal  oblique  contribute 
muscular  fibres  as  well  as  fibrous  tissue  to  help  in 
forming  the  cremasteric  fascia.  This  layer  is  readily 
demonstrated,  and  becomes  greatly  hypertrophied  in 
chronic  scrotal  hernia. 


568 


MEDICAL    RECORD. 


[October  13,  1900 


The  external  oblique  furnishes  a  thin  tissue  called 
the  external  spermatic  fascia,  which  also  covers  the 
cord  and  testicle. 

We  thus  see  that  while  the  testicle  may  be  said  to 


Fig.  5. — Posterior  Surface  of  the  -Anterior  Abdominal  Wall.  The  Peritoneum  removed.  In- 
guinal and  Femoral  Regions,  i,  Poupart's  ligament  ;  2,  the  iliacus  muscle  ;  3,  semilunar 
fold  of  the  transversalis  fascia  ;  4,  spermatic  vessels  ;  5.  vas  deferens  ;  6.  base  of  the  hnea 
alba ;  7,  the  urinary  bladder  ;  8,  seminal  vesicle  ;  q,  the  ureter  ;  10,  superior  vesical  artery 
(the  still  pervious  portions  of  the  hypogastric  artery)  ;  11,  obturator  nerve  ;  12,  obturator 
artery;  13,  external  iliac  vein-  14,  external  iliac  artery  ;  15,  anterior  crural  nerve;  16,  in- 
ternal inguinal  ring  ;  17.  deep  epii^astric  artery  and  veins;  18.  rectus  muscle;  19.  suspen- 
sory ligament  of  the  liver;  20,  the  urachus  ;  21,  obliterated  hypogastric  artery;  22,  semi- 
lunar fold  of  Douglas. 


pass  through  the  abdominal  wall,  yet  it  does  so  only 
after  protruding  the  thinned  layers  of  this  wall  before 
it;  these  layers  in  turn  furnishing  the  coverings  for 
the  testicle  and  cord  and  the  variety  of  hernia  we  are 
discussing. 

The  union  then  about  the  rings,  canal,  and  cord  is 
always  a  weak  one  and  easily  destroyed.  This  makes 
the  rings  weak  points  in  the  abdominal  wall.  Vet 
this  weakness  in  itself  is  not  sufficient  to  cause  the 
development  of  hernia  unless  some  of  the  other  factors 
are  present. 

The  inguinal  canal  is  about  one  and  three-fourths 
inches  long;  that  is,  the  two  rings  are  this  distance 
apart,  measured  along  Poupart's  ligament. 

A  weakness  about  the  canal  and  rings  will  be  found 
to  consist  in  an  enlargement  of  the  rings  and  a  short- 
ening of  the  canal.  These  constitute  most  effective 
predisposing  causes  for  a  hernia. 

Two  rings  there  must  be  normally,  and  yet  no  hernia 
need  result  so  long  as  these  openings  are  normal  in 
size,  far  apart,  and  each  guarded  by  a  strong  fascia, 
the  internal  opening  by  the  external  oblique  fascia, 
the  external  ring  by  the  conjoined  tendon. 

The  internal  ring  is  still  further  reinforced  by  an 
active  structure,  viz.,  the  common  fibres  of  the  trans- 
versalis and  internal  oblique  muscles,  which,  arising 
from  Poupart's  ligament,  arch  over  the  cord  and  pass 
on  as  the  conjoined  tendon  to  be  attached  to  the  linea 
ilio-pectinealis. 

Intra-abdominal  pressure,  then,  in  the  normal  sub- 
ject serves  to  press  the  component  parts  of  the  ab- 
dominal wall  together;  the  weak  places  are  sufficiently 
protected  by  the  stronger  reinforcements,  and  no  escape 
of  viscera  occurs. 

The  external  inguinal  ring  is  found  presenting  the 
appearance  of  a  slit,  caused  by  the  divergence  of  fiijres 


of  the  external  oblique  aponeurosis  near  the  spine  of 
the  pubis,  for  the  passage  of  the  cord.  'I'he  sides  of 
the  openings  are  called  tlie  pillars  or  columns  of  the 
ring.  The  further  separation  of  the  fibres  of  the  exter- 
nal oblique  is  prevented  and  the  weak  place 
strengthened  by  some  transverse  fibres 
called  the  intercoluninar  fascia.  From  this 
fascia  and  the  pillars  of  the  ring  the  ex- 
ternal spermatic  fascia  passes  on  to  the  cord. 
If  the  fibres  of  the  external  oblique,  or 
pillars  of  the  ring,  are  separated  for  an 
unusual  distance,  then  both  rings  are 
weakened,  the  external  directly,  the  inter- 
nal indirectly,  by  impairment  of  its  external 
support,  and  the  condition  becomes  favor- 
able for  the  development  of  a  hernia. 

In  infancy  and  early  childhood  before 
the  pelvis  has  developed  the  inguinal 
canal  is  a  short  affair,  the  rings  are  close 
together,  and  a  state  exists  favorable  for 
the  development  of  hernia.  If  added  to 
this  there  is  an  open  funicular  process,  a 
rupture  will  probably  appear. 

Seventh.  An  abnormally  long  mesentery 
or  omentum.  The  mesentery  and  omen- 
tum are  probably  unnecessarily  long  in 
case  a  hernia  actually  exists;  still,  it  does 
not  follow  that  an  increase  in  the  length  of 
these  parts  is  an  active  predisposing  factor 
to  hernia.  In  the  cure  of  a  hernia  no  ac- 
count is  taken  of  an  elongated  mesentery 
or  omentum  (unless  the  latter  is  hyper- 
trophied),  as  the  permanency  of  the  result 
of  the  operation  dejiends  solely  upon  the 
repair  of  the  abdominal  wall  and  treatment 
of  the  cord. 

The  changes  which  are  produced  by  a 
hernia  depend  to  some  extent  upon  the 
time  of  life  when  it  appears  and  its  dura- 
tion. In  early  life  an  open  funicular  process  will  be 
occupied,  and  this  pouch  will  form  the  sac  of  the  her- 
nia.    I-n   later  life  the  hernial  sac  is  acquired,  either 


Flc.  6.— The  Inguinal  and  Femoral  Sections.  Superficial  dissection,  i,  Pou- 
part's ligament  ;  2,  superficial  circumflex  iliac  artery  ;  3,  suiicrlicial  circuin- 
Ilex  iliac  vein  ;  4,  femoral  artery  (its  position  shown  beneath  the  fascia 
lata  by  heavier  sh.iding);  5.  internal  saphenous  vein  ;  6.  su[Jcrticial  epigas- 
tric arteiy  ;  7.  superficial  epigastric  vein  ;  8,  cribriform  fascia  ;  9,  spermatic 
cord  ;  10,  superficial  external  pudic  vein  ;  ti,  superficial  external  pudic  ar- 
tery. 


October  13,  1900] 


MEDICAL    RECORD. 


569 


gradually  or  suddenly,  by  the  invagination  of  tiie 
peritoneum  in  the  inguinal  fossa.  In  both  cases  the 
hernia  has  passed  through  the  rings  and  canal  into 
the  scrotum,  or  labium,  and  there  continues  its  devel- 
opment.    I  purposely  omit  reference  to  the  numerous 


3 

Fic.  7, 


The  Inguinal  and  Femoral  Ref^ions.  Deep  Dissections,  i,  Crcinaster  muscle  ;  2, 
ilio-pectineal  fascia— deep  layer  of  the  fascia  lata;  3.  superficial  layer  of  the  fascia  lata;  4, 
Roscnmittler's  lymphatic  gland  ;  5,  transversalis  fascia  ;  6,  CoUes'  ligament'  7,  fossa  ovalis; 
8,  internal  saphenous  vein  ;  q,  femoral  vein;  10,  femoral  artery;  ji,  falciform  process  of 
the  fascia  lata  ;  12,  anterior  crural  nerve  ;  13.  spermatic  cord  ;  i.^,  Poupart's  ligament  ;  15, 
fibres  of  the  intercolumnar  fascia  ;  16.  inferior  crus  of  the  external  inguinal  ring  ;  17,  superior 
crus  of  the  external  inguinal  ring  ;  18,  aponeurosis  of  the  external  oblique  muscle  ;  19,  deep 
epigastric  vessels — represented  as  showing  through  the  muscles  ;  20,  aponeurosis  of  the  ex- 
ternal oblique  muscle  ;  21,  internal  oblique  muscle. 


varieties  of  the  indirect  inguinal  hernia  and  content 
myself  with  the  complete  scrotal  (or  labial)  form. 

A  rupture  of  this  sort  profoundly  alters  the  normal 
construction  of  the  region.  The  inguinal  rings  will 
be  abnormally  enlarged  and  the  internal  displaced 
toward  the  middle  line,  until  it  is  found  in  a  majority 
of  cases  directly  behind  the  external,  and  the  inguinal 
canal  has  been  obliterated.  The  peritoneal  sac  pre- 
sents various  features  into  which  it  is  not  my  purpose 
to  enter,  except  to  say  that  it  is  thickened  and  will 
usually  communicate  with  the  abdominal  cavity  by  a 
narrow  orifice  that  flares  out  funnel-shaped  into  the 
general  peritoneal  layer. 

The  various  structures  given  as  furnishing  the  cov- 
erings to  the  testicle  and  cord  in  turn  become  the 
coverings  for  the  hernia.  As  they  play  no  part,  with 
the  exception  of  the  cremasteric  fascia,  in  the  develop- 
ment and  cure  of  hernia,  they  will  be  ignored. 

The  cord  itself  undergoes  changes.  It  becomes  more 
vascular  and  hence  larger.  This  increase  in  size  is 
due  chiefly  to  a  varicose  condition  of  the  veins,  ]5ro- 
duced  by  obstructed  circulation,  such  obstruction  be- 
ing usually  found  at  the  internal  ring.  The  omentum 
present  in  the  hernia  becomes  in  time  thickened,  and 
numerous  adhesions  may  be  formed  between  it  and  the 
sac  or  intestine.  In  the  intestinal  form  the  mesentery 
becomes  elongated  to  allow  the  gut  to  descend. 

The   Radical   Cure Given    an    oblique    inguinal 

hernia,  we  now  seek  to  find  what  measures  must  be 
taken  to  cure  it. 

My  text  at  the  beginning  serves  us  now.  It  is  this: 
Imitate  and  reproduce  nature's  plan  of  construction. 

Let  us  see  how  this  can  be  done  at  the  ordinary  op- 
eration. It  is  taken  for  granted  that  the  sac  has  been 
opened,  its  contents  have  been  dealt  with,  and  the  op- 
erator is  now  ready  to  proceed  to  close  up  the  wound. 
To  summarize  the  difficulties,  it  will  be  necessary  to  deal 
with  the  sac,  the  cord,  and  inguinal  canal  and  rings. 

The    Sac. — The    external    inguinal    fossa    (in    the 


peritoneumj  cannot  be  entirely  obliterated,  but  it  can 
be  made  less  prominent,  and  the  funnel,  which  leads 
into  the  sac,  can  be  eradicated  and  the  sac  itself  re- 
moved. To  do  this,  first  divide  the  transversalis  and 
internal  oblique  muscles,  outward  just  above  Poupart's 
ligament  as  far  as  its  outer  and  middle 
thirds.  This  will  give  plenty  of  room  in 
which  to  manipulate  the  sac  and  will  be 
utilized  in  re-forming  the  internal  ring. 
Free  tiie  neck  of  the  sac  and  the  perito- 
neum all  about  the  internal  ring.  Then, 
while  making  strong  traction  on  the  sac, 
ligate,  with  chromic  gut  No.  2  or  silk,  the 
pedicle  as  high  as  possible  and  cut  the 
sac  away.  This  procedure  fulfils  two  con- 
ditions. It  removes  the  sac  and  oblit- 
erates the  funnel  leading  into  it. 

Theoretically  it  would  appear  to  be  a 
good  plan  to  roll  up  or  plait  the  sac  and 
leave  it  as  a  pad  over  the  internal  ring, 
forming  a  distinct  projection  into  the  ab- 
dominal cavity.  Practically  this  pad 
serves  as  a  wedge  to  reopen  the  ring  until 
it  disappears  by  absorption.  Thus  nothing 
is  gained  by  retaining  the  sac  at  the  time 
of  the  operation,  but  a  fancied  security  is 
obtained  and  a  source  of  possible  future 
trouble  included. 

The  Cord  next  needs  most  careful  atten- 
tion. Numerous  large  veins,  much  loose 
areolar  tissue,  thickened  coverings,  must 
be  removed  and  a  thick,  vascular  cord 
converted  into  a  normal,  firm  one.  All 
the  veins  but  two  or  three,  with  the  excess 
of  tissue,  should  be  removed  between  the 
ligatures.  Care  must  be  taken,  however, 
not  to  injure  the  arteries  and  the  vas  itself,  and  to  leave 
two  or  three  veins  to  carry  on  the  return  circulation. 

Halsted  deserves  credit  for  suggesting  this  diminu- 
tion in  the  size  of  the  cord. 

The  next  thing  in  which  nature  is  to  be  imitated  is 
in  the  re-formation  of  the  inguinal  canal  and  rings. 
This  attempt  is  attended  with  difficulty  diminishing 
with  the  thoroughness  with  which  the  operator  has  ex- 
posed the  field  of  operation,  and  the  care  with  which 
the  preceding  steps  are  carried  out.     The  farther  apart 


Fig.  8. — Section  through  the  Left  Femoral  Canal  ;  tjpper  Segment.  The 
section  runs  just  below  and  parallel  with  I'oupart's  ligament,  i,  'I'he  ad- 
ductor longus  muscle  ;  2,  the  pectineus  muscle  ;  3,  the  gland  of  Roscn- 
muller  ;  4,  the  femoral  vein  ;  5.  the  femoral  artery  ;  6.  the  anterior  crural 
nerve  ;  7,  fascia  lata,  the  superficial  layer ;  8,  sartorius  muscle  ;  9,  fascia 
lata,  the  deep  layer  ;  10,  the  iliacus  muscle  ;  11,  the  psoas  major  muscle. 

the  inguinal  rings  are  the  less  liable  is  a  hernial  pro- 
trusion to  occur.  The  external  ring  is  fixed  by  differ- 
ent factors  at  the  spines  of  the  pubes;  the  internal,  on 
the  contrary,  is  a  movable  affair.  In  the  normal  state 
it  lies  opposite  the  middle  of  Poupart's  ligament — in 
the  abnormal,  much  to  the  inside  of  this.     In  our  at- 


570 


MEDICAL    RECORD. 


[October  13,  1900 


tempt  to  imitate  the  natural  construction  it  should  be 
moved  outward,  at  least  as  far  as  the  outer  and  middle 
thirds  of  Poupart's  ligament.  The  transversalis  and 
internal  oblique  have  already  been  divided  for  this 
purpose  to  this  point.     Now  transfer  the  cord  to  the 


Fig.  9. — Indirect    Ingui 

Hernial  Sac.  i ,  The  rectus  muscle  ;  2,  the  deep  epigastric  vessels  ;  3,  the  hernial 
sac;  4,  obliterated  hypogastric  artery;  5,  transversalis  fascia;  f^,  the  urinary 
bladder  ;  7,  lip  of  the  seminal  vessel  ;  S,  the  internal  inguinal  ring  ;  9,  semilunar 
fold  of  the  transversalis  fascia;  10,  Poupart's  ligament;  ti,  iliacus  muscle;  12, 
the  deep  circumflex  iliac  artery  and  vein  ;  13,  the  anterior  crural  nerve  ;  14,  the 
at  iliac  artery  and  vein  ;  15,  vas  deferens. 


external 


outer  angle  of  the  incision,  and  while  holding  it  there 
suture  the  transversalis  and  internal  oblique  muscles 
and  the  transversalis  fascia  to  Poupart's  ligament  as 
advised  by  Bassini.  Slack  muscular  tissue,  loose  con- 
joined tendon,  even  the  adjoining  edge  of  the  rectus 
sheath  can  be  gathered  up  and  all  sutured  firmly  to 
Poupart's  ligament.  Place  the  cord  along  the  sutured 
line,  and  in  similar  manner  close  the  aponeurosis  of 
the  external  oblique  over  it,  leaving  at  the  spine  of 
the  pubis  a  small  opening  for  the  transit  of  the  cord. 
The  inguinal  region  is  thus  reconstructed  on  sound 
natural  lines.  The  first  line  of  sutures  is  interrupted, 
the  second  interrupted  or  continuous.  The  matericil 
is  No.  I  or  2  chromic  gut.  The  placing  of  the  sutures 
at  the  cord  is  most  important,  as  by  them  the  inguinal 
rings  are  re-formed  and  will  fitthe  cord  snugly  or  loosely 
according  to  the  nearness  of  the  suture  to  the  cord. 
The  suture  should  be  so  placed  that  when  tied  the 
tissues  will  grasp  the  cord  snugly  but  not  constrict  it. 

In  the  Female,  the  conditions  which  allow  the  de- 
velopment of  an  inguinal  hernia  and  the  steps  neces- 
sary for  its  radical  cure  are  similar  to  those  in  the 
male,  and  the  subject  does  not  require  a  separate  con- 
sideration. The  herniae  are  less  frequent  and  are 
seldom  as  large  as  in  the  male.  The  operation  can 
be  done  wilii  greater  ease  and  is  more  often  attended 
with  a  permanent  result. 

Bearing  on  this  subject  is  the  frequency  with  which 
Alexander's  operation  for  shortening  the  round  liga- 
ment is  followed  by  hernia.  This  undesirable  result 
is  due  to  a  failure  to  reproduce  the  natural  construc- 
tion, and  can  be  prevented  by  carrying  out  the  opera- 
tion on  the  same  lines  as  given  for  a  herniotomy  minus 
the  sac  and  contents. 

Shorten  the  round  ligament,  and  re-form  the  internal 
ring  at  the  outer  and  middle  thirds  of  Poupart's 
ligament;  when  closing  up  the  inguinal  canal  include 
the  round  ligament  in  the  sutures.  After  the  external 
oblique  has  been  sutured  place  the  round  ligament  in 
the  line  of  the  skin  incision,  and  when  suturing  the 
latter  include  the  former.  The  entire  inguinal  region 
is  thus  re-formed ;  there  has  been  secured  ample  room 
satisfactorily  to  shorten  the  round  ligaments,  and  these 


have  been  firmly  anchored  by  a  double  line  of  suturing, 

so  that  they  cannot  slip  and  a  hernia  cannot  develop. 

The  Femoral  Region  and  Hernia.— While  herniae 

do  not   take   place   at  the  femoral  opening  with   the 

same  degree  of  frequency  that  they  do  at  the  inguinal, 

the  attempt  at  radical  cure  is  attended  with  greater 

difficulties  and  more  frequent  failures. 

The  reasons  why  femoral  are  less  frequent  than 
inguinal  hernia.-,  why  they  are  four  times  more  nu- 
merous in  women  than  in  men,  and  why  they  are 
more  difficult  to  cure,  are  due  to  structural  con- 
ditions. The  peritoneal  pouch,  or  femoral  fossa, 
over  the  site  of  the  femoral  ring  is  smaller  and 
shallower  than  the  external  inguinal,  and  is  ren- 
dered less  effective  in  predisposing  to  hernia  by  a 
packing  of  adipose  tissue  and  a  small  lymphatic 
gland.  When  the  peritoneum,  fat,  and  gland  are 
removed  we  find  a  well-marked  pit  at  the  inner  side 
of  the  femoral  vein.  This  is  the  so-called  inter- 
nal femoral  ring.  It  has  for  its  boundaries,  in 
front  and  above,  the  inner  part  of  Poupart's  liga- 
ment; at  the  inside,  Gimbernat's  ligament;  be- 
hind. Cooper's  pubic  ligament,  and,  at  the  outer 
side,  the  femoral  vein  in  its  sheath. 

The  usual  description  states  that  a  membrane 
is  found  closing  in  this  ring,  the  so-called  septum 
crurale  of  Cloquet.  Joessel,  on  the  other  hand, 
says  there  is  no  fascial  covering  between  the  fem- 
oral vein  and  Gimbernat's  ligament.  This  space 
is  occupied  by  the  gland  of  Rosenmiiller,  which 
lies  free  in  the  upper  part  of  the  femoral  canal,  and 
the  septum  crurale  does  not  exist.  At  this  spot 
the  intestine  can  pass  under  Poupart's  ligament  into 
the  femoral  canal  by  invaginating  the  parietal  perito- 
neum without  being  hindered  by  any  layer  of  fascia. 
Such  a  hernia  passes  out  directly  from  the  abdominal 
cavity  assisted  by  gravity,  and  appears  at  the  saphe- 
nous opening.  This  opening  is  a  gap  in  the  fascia 
lata   for  the  passage,  chiefly,  of  the   internal    saphe- 


FiG.  10. — Femoral  Hernia  Showing  the  Relations  about  the  Neck  of  the  Sac. 
1,  The  iliacus  muscle  ;  3,  the  anterior  crura!  nerve  ;  3,  the  psoas  inugnus 
muscle  ;  4,  the  external  iliac  artery  ;  5,  the  external  iliac  vein  ;  C,-the  ob- 
turator vein  ;  7,  the  obturator  artery;  8,  the  pubic  branch  of  the  obturator 
artery;  9,  the  rectus  muscle;  lo,  the  transversalis  fascia ;  11.  the  deep  cir- 
cumtlex  iliac  artery;  12,  the  deep  epigastric  artery;  ij,  the  spermatic 
artery;  14,  Poupart's  ligament,  15,  pnbic  branch  of  the  deep  epigastric 
artery;   16,  hernial  sac  ;  17,  Llinibcrnat  s  ligament  ;  tS,  the  tliac  fascia. 


nous  vein.  It  is  closed  hy  the  deejier  layer  of  the 
superficial  fascia,  which,  on  account  of  jjerforations 
for  numerous  structures,  is  called  the  cribriform  fascia. 
This  layer  is  protruded  before  the  advancing  hernia 
and  furnishes  one  of  its  coverings.     The  hernia  now 


October  13,  1900] 


MEDICAL    RECORD. 


571 


changes  its  direction  and  enlarges  forward  and  upward 
over  J'oupart's  ligament. 

The  explanation  of  this  change  of  direction  is  found 
in  two  factors.  One  is  that  the  cribriform  fascia  is 
more  firmly  attached  around  the  lower  margin  of  the 
saphenous  opening  than  above;  a  second  one,  and  one 
more  potent  to  deflect  the  hernia,  is  the  presence  of 
the  superficial  veins  (external  pudic,  epigastric,  and  cir- 
cumliex  iliac),  which  empty  separately  or  by  a  branch 
common  to  two  or  more  into  the  saphenous  vein  just 
before  it  joins  the  femoral.  A  downward  enlargement 
of  the  hernia  would  require  that  the  veins  be  stretched 
or  displaced.  The  hernia  is  still  further  assisted  in 
its  upward  course  by  Mexion  of  the  thigh.  The  re- 
maining coverings  to  the  hernia  do  not  interest  us  now. 

Besides  the  factors  indicated  above  which  allow 
and  even  favor  the  occurrence  of  femoral  hernia,  there 
is  another  reason  which  I  think  is  not 
sufficiently  emphasized.  It  is  the  un- 
avoidable presence  of  the  large,  easily 
compressed  femoral  vein  alongside  a 
distinctly  weak  spot  in  the  abdominal 
wall.  Under  excessive  pressure  the 
vein  can  be  compressed;  this  stretches 
and  weakens  the  adjacent  tissues.  This 
stretching  and  yielding  of  the  tissues 
will  take  place  mostly  at  the  inside  of 
the  vein.  Furthermore,  the  vein  does 
not,  like  the  cord,  traverse  the  different 
layers  of  the  wall  obliquely,  but  leaves 
at  a  point  beneath  these  fixed  layers  and 
in  a  direct  course  from  the  abdominal 
cavity. 

The  only  reason,  then,  why  femoral 
herniai  are  not  more  frequent  is  the 
small  extent  of  this  weak  area. 

When  Poupart's  ligament  stretches 
as  in  the  aged,  male  or  female,  or  in 
the  female  after  repeated  pregnancies, 
then,  one  of  the  main  supports  being 
lost,  the  weak  area  is  enlarged  and  a 
condition  for  the  development  of  a 
femoral  hernia  is  present.  As  regards 
the  inriuence  of  sex,  the  broader  female 
pelvis  plus  the  influences  of  pregnancy 
furnish  the  explanation  of  why  this 
form  of  hernia  is  four  times  more  preva- 
lent in  the  female  than  in  the  male. 

To  summarize  the  architectural   fea- 
tures which  predispose  to  a  hernia  in  the   femoral   re- 
gion, we  find  these  present: 

First.  The  peritoneal  depression,  especially  promi- 
nent if  the  usual  filling  of  fat  and  Ro.senmiiller's 
lymphatic  gland  are  absent,  or  I'oupart's  ligament  is 
unduly  lax. 

Second.  An  open,  according  to  Joessel,  femoral 
ring  and  canal. 

Third,  'ihe  course  of  the  femoral  canal  leading 
directly  outward  from  the  abdominal  cavity. 

Fourth.  The  large  saphenous  opening  covered  by 
the  weak  cribriform  fascia. 

Fifth,  and  most  effective  to  my  mind,  the  presence 
of  the  large  compressible  femoral  vein. 

How  can  such  inherent  and  acquired  weaknesses  be 
overcome  by  an  operation  ?  Tlie  plans  are  many,  some 
simple,  some  very  complicated.  I  shall  not  enter  at 
this  time  into  a  discussion  of  the  various  opera- 
tions. 

Theoretically,  the  indications  are  to  obliterate  the 
peritoneal  fossa  and  close  up  the  abnormally  large 
ring  and  canal,  and  shorten  the  elongated  Poupart's 
ligament.  Practically  this  is  much  more  easily  said 
than  done. 

First  of  all,  lay  open  the  hernial  tract,  but  do  not 
cut  through  Poupart's  ligament.      P'ree,  ligate,  and  re- 


move the  hernial  sac,  as  in  the  inguinal  operation. 
.Suture  Poupart's  ligament  to  the  fascia  and  even  peri- 
osteum in  front  of  the  ilio- pectineal  line,  beginning  as 
close  to  the  femoral  vein  as  is  safe  and  passing  inward 
to  the  spine  of  the  pubis;  then  by  deep  sutures  obliter- 
ate the  femoral  canal  and  close  up  the  saphenous 
opening.      Suture  the  skin. 

This  is  a  very  simple  plan,  yet  it  fulfils  all  the  re- 
quirements of  the  case  as  well  as  do  the  more  elaborate 
operations;  because  after  all  has  iieen  done  there 
remain  the  femoral  vein  and  the  elements  of  weak- 
ness its  presence  induces.  The  main  point  is  to  place 
the  deep  sutures  so  close  to  the  vein  that  when  they 
are  tied  Poupart's  ligament  will  closely  hug,  but  not 
compress,  the  vein,  and  the  slack  in  the  ligament  itself 
is  taken  up. 

In  conclusion,  then,  I  wish  to  emphasize: 


Fir,.  II. — Dissection  of  an  Inguinal  and  Femoral  Hernia,  i,  Deep  epif^astric  vessels  represfnted 
as  showing  through  the  overlying  parts  ;  2.  aponeurosis  of  tlie  external  oblique  muscle  ;  3.  tlie 
intercolumnar  fasiia  ;  .;,  femoral  artery  and  vein  ;  5,  fascia  propria  of  the  inguinal  hel^ia  ;  h.  the 
hernial  sac;  -.the  superficial  external  pudic  artery;  S,  knuckle  of  small  intestine;  9,  internal 
saphenous  vein  ;  10.  the  testicle;  1 1.  Poupart's  ligament  ;  12,  lymphatic  glands ;  13, fascia  pro- 
pria of  the  femoral  hernia;  14,  sac  of  the  hernia,  ij.  knuckle  of  small  intestine;  16,  superficial 
external  pudic  artery  ;  17,  fascia  lata,  superficial  layer;    18,  spermatic  cord. 


First.  That  we  should  know  the  construction  of  the 
normal  inguinal  and  femoral  regions. 

Second.  That  we  should  know  the  changes  which 
take  place  when  a  hernia  has  occurred  ateitherof  these 
regions. 

Third.  That  in  attempting  a  radical  cure  we  should 
seek  to  reproduce  the  natural  construction  of  the  parts. 

Fourth.  That  nothing  but  absorbable  suture  ma- 
terials should  be  used. 

Fifth.  Tiiat  every  precaution  for  obtaining  primary 
union  be  utilized  and  carefully  followed. 

Sixth.  Do  not  apply  a  truss  to  preserve  the  effects 
of  the  operation.  If  a  radical  cure  has  been  done  a 
truss  is  unnecessary;  if  it  has  not  been  done,  a  truss 
will  not  prevent  the  return  of  hernia. 

Note  in  reference  to  the  illustrations:  Figs,  i,  2, 
and  3  are  photographs  of  plaster-of- Paris  casts,  made 
by  the  writer,  of  the  lower  abdominal  and  pelvic  cavi- 
ties, in  the  following  manner:  The  sulajects  were 
suspended  vertically.  .A.  median  incision  was  made 
into  the  peritoneal  cavity  from  the  umbilicus  upward. 
The  intestines  were  held  upward  by  cords  while  liquid 
plaster  was  poured  into  the  abdomen  until  it  rose  to 
the  level  of  the  opening,  and  allowed  to  set.  The  re- 
:naining  figures  (4-T1)  are  from  Joessel's  "Anatomy." 

II2S  Madison   Avenue. 


57^ 


MEDICAL    RECORD. 


[October  13,  1900 


LIGHT    AS    A    REMEDIAL    AGENT. 
Cv   J.    W.    KIME,    .M.D., 

FOKT   DODGE,    IOWA. 

Light  has  great  power  of  penetration ;  it  is  exceeded 
in  this  respect  by  tlie  Roentgen  rays  only.  This  I 
have  been  able  to  demonstrate  by  the  following  ex- 
periments in  whicli  I  was  assisted  by  Mr.  G.  L.  Hos- 
tetler,  a  photographer  of  this  city.  The  subject  upon 
whom  the  experiments  were  to  be  made  was  taken  into 
the  dark  room,  and  the  plates  were  app.lied  with  great 
care  so  that  all  rays  of  light,  save  those  that  traversed 
the  body  from  front  to  back,  might  be  excluded. 

The  first  illustration  shows  the  method  of  photo- 
graphing through  the  body.  The  direct  rays  of  the 
sun,  falling  upon  the  refiector  through  the  skylight, 
are  focussed  upon  the  chest  of  the  person  upon  whose 
back  has  been  placed  the  photographic  plate  upon 
which  the  picture  is  to  be  taken. 

A  transparency  on  glass  of  a  valley  in  the  Klondike 
region  was  used  as  the  original  from  which  the  picture 


transmitted  through  the  body,  plates  were  arranged 
in  the  same  manner  and  for  like  periods  of  time  with- 
out attempting  to  pass  light  through  the  body,  and  no 
pictures  developed  upon  them. 

Fig.  2  represents  a  scene  in  the  valley  of  the  Klon- 
dike photographed  as  shown  in  Fig.  i. 

Fig.  3  represents  a  picture  of  the  Mason  City 
and  Fort  Dodge  depot,  and  in  the  background  the 
Fort  Dodge  High  School  building,  taken  through  the 
rigiit  hand  of  the  writer,  which  is  one  and  one-fourth 
inches  thick.  The  same  care  was  exercised  in  this 
instance  as  above  described,  and  all  possible  sources 
of  error  were  carefully  excluded.  Time  of  exposure, 
five  minutes. 

Fig.  4  was  produced  as  a  transparency  from  the 
same  negative  as  Fig.  2,  and  was  taken  inside  the  cheek 
of  the  w'riter  with  the  mouth  tightly  closed  and  covered 
with  the  hand.     Time  of  exposure,  five  seconds. 

These  photographs  were  taken  with  such  care  and 
exactness  that  they  establish  the  fact  that  the  actinic 
rays  of  the  sun  when  sufficiently  concentrated  may  be 


Fig.  I. 


was  to  be  taken.  This  was  fastened  to  a  photographic 
dry  plate  which  had  not  been  exposed  to  light,  and  the 
two  were  placed  upon  the  back  between  the  shoulder 
blades  of  the  subject,  a  well-developed  man  weighing 
one  hundred  and  fifty  pounds,  the  transparency  being 
placed  next  to  the  skin  with  the  sensitive  plate  im- 
mediately behind  it.  Over  these  were  placed  black 
paper,  black  cotton  wadding,  a  surgeon's  plaster,  and 
some  large  black  cloths,  and  all  were  bound  firmly 
down  by  means  of  long  black  bandages.  He  was  then 
taken  to  the  light  room  and  the  reflector  was  turned 
upon  the  chest  for  fifteen  minutes.  After  exposure  he 
was  again  taken  to  tiie  dark  room,  and  the  plates  were 
removed  and  the  picture  shown  in  Fig.  2  was  developed 
on  the  photographic  plate. 

All  sources  of  error  were  excluded  with  the  greatest 
care,  and  the  operation  was  repeated  many  times  on 
various  persons  with  like  results.  To  test  further  tlie 
reliability  of  the  procedure,  and  to  make  certain  that 
the  picture  was  not  produced  by  contact  of  tiie  trans- 
parency w-ith  the  plate,  aidecl  by  tlie  body-heat  or  by 
some    undetermined    intluence    other    than    the    light 


made  to  pass  entirely  through  the  body  of  a  well- 
developed  man. 

The  rays  of  light  pass  through  the  skin  with  con- 
siderable dititiculty;  more  readily  through  muscular 
tissue,  and  much  more  readily  through  bone.  In  pro- 
ducing a  picture  through  the  cheek  the  rays  of  light 
pass  through  but  a  single  thickness  of  skin,  and  the 
picture  is  reproduced  almost  instantly.  As  a  matter 
of  liierapeulic  interest  it  is  important  to  bear  in  mind 
the  structures  tiirough  which  light  must  pass  in  reach- 
ing the  deepest  portions  of  the  lungs.  There  are  a 
single  thickness  of  skin,  the  semi-transparent  sternum 
and  ribs,  a  few  thin  muscles,  and  the  transparent 
pleura  to  be  passed  through,  and  then  the  liglit  has 
reached  tlie  lungs,  themselves  almost  wholly  conipo.sed 
of  the  tiiin-walled  air  cells.  Light  of  considerable 
intensity  must  therefore  reach  to  the  posterior  thoracic 
walls. 

The  reflector  used  in  making  these  experiments  is  a 
compound  circular  mirror  thirty  inches  in  diameter 
and  overlaid  witii  blue  glass.  It  is  so  con.structed 
that  all  the  light  which  falls  upon  it  is  focussed  upon 


October  13,  1900] 


MEDICAL    RECORD. 


573 


a  spot  six  inches  in  diameter  at  a  distance  of  eight 
feet  in  front  of  it.  Thus  a  very  powerful  blue  light 
is  brought  to  bear  upon  the  parts. 

The  heat  rays  of  the  solar  spectrum  are  largely  con- 
tained in  the  red  band,  while  the  actinic  or  chemical 
rays  are  much  more  abundant  in  the  violet  and  ultra- 
violet bands;  thus  by  utilizing  the  blue  light  we  get 
a  much  greater  percentage  of  aclinic  light  in  propor- 
tion to  the  heat  rays  than  if  ordinary  white  light  be 
used. 

The  therapy  of  light  is  based  upon  the  following 
principles: 

1.  Light  is  a  powerful  germicide,  its  bactericidal 
action  being  due  to  the  violet  and  ultra-violet  rays,  or 
so-called  chemical  rays,  of  the  solar  spectrum. 

2.  The  chemical  rays  of  light  are  irritant  in  tlieir 
action,  not  only  upon  the  skin  but  to  all  the  tissues 
through  which  they  pass.  This  irritant  effect  is  noted 
in  erythema  solare,  and  is  often  seen  even  in  mid- 
winter. Very  strong  electric  light  produces  similar 
effects.  Widinark,  of  Stockholm,  has  been  able"  to 
demonstrate  that  this  dermatitis  is  due  to  chemical 
action  and  is  independent  of  the  heat  rays,  and  that  it 
is  not  a  burn.  In  the  treatment  of  disease  by  this 
agent  the   improvement  may,  at   least   in  part,  be  due 


Fig.  2. 

to  the  irritant  action  arousing  to  greater  activity  the 
vital  forces  in  the  parts  upon  and  through  which  the 
light  is  made  to  pass;  in  other  words,  increased  phago- 
cytosis may  play  an  important  role  in  the  therapy  of 
light. 

3.  The  power  of  light  to  penetrate  the  tissues  of  the 
body.     To  these  may  be  added : 

4.  The  chemical  action  of  the  light  upon  the  blood 
itself  while  circulating  through  the  parts  bathed  in  the 
jjowerful  light.  Sunlight  must  be  carefully  excluded 
from  our  bacteriological  laboratories,  otherwise  many 
of  our  choicest  cultures  will  be  killed  or  fail  to  develop. 
If,  then,  light  of  sufficient  intensity  may  be  made  to 
penetrate  the  tissues  of  the  body,  a  baneful  inlluence 
will  be  exercised  upon  the  growth  and  development  of 
bacteria  in  them. 

The  bacillus  of  tuberculosis  in  lupus  is  destroyed 
by  the  action  of  the  light.  Finsen,  .Abrams,  and  the 
writer  have  reported  over  four  hundred  cases  of  lupus 
thus  treated  and  cured.  If  light  may  be  applied  suffi- 
ciently strong  to  tuberculous  deposits  in  other  tissues 
of  the  body,  there  is  every  reason  to  hope  that  like 
results  may  follow. 

I  am  now  treating  a  number  of  cases  of  tuberculosis 
pulmonalis  in  the  manner  siiown  in  Fig.  i,  and  all 
the  patients  are  gaining  in  weight  and  are  otherwise 
improving.  The  cases  are  treated  twice  daily,  and 
each  se'ance  is  of  thirty  minutes'  duration. 

From  my  records  I  will  select  the  following: 


Case  \'.— Miss  M.  K.,  aged  twenty-one  years,  do- 
mestic; has  had  lupus  nasi  one  year.  The  patient  had 
previously  been  treated  with  ointments  of  various 
kinds.  Her  father  died 
of  lupus  two  years  before 
the  beginning  of  treat- 
ment of  her  case.  He 
had  lupus  of  the  face 
and  died  as  the  result  of 
an  operation  for  its  re- 
moval. On  August  9, 
1898,  light  treatment 
was  begun,  and  was  prac- 
tised daily  for  half  an 
hour  until  September 
I  St.  No  nodules  then 
appearing,  the  treatment 

was  discontinued.     On  September  20th,  the  ulcer  was 
completely  healed,  and  there  has  been  no  relapse. 

Case  IX. — Miss  G.,  aged  twenty-five  years,  has  had 
lupus  of  the  side  of  the  neck  for  six  months.     The  proc- 
ess had  ulcerated  deeply  into  the  subcutaneous  cellu- 
lar tissue.     The  lesion  was  one  and  one-half  inches  in 
length  by  one   incii   in   breadth.     Previous  treatment 
was  by  ointments  of  various  kinds,  but  the    ulceration 
had  steadily  progressed.     Light  treatment  was  begun 
.April  21,  1S99,  and  continued  on  each  alternate  day 
until  May  5,  1899.     The  seances  were  of  ten  minutes 
each.       The  scabs  were   removed   before  treatment 
began   and  the   ulcer  was   kept    clean  with    sterile 
water.     All  nodules  had  disappeared  by  May  1st  and 
the  wound  was  completely  healed  May  25th.     There 
has  been  no  relapse. 

Case  X. — .\nna  K.,  aged  thirty-six,  single,  domes- 
tic. The  mother  died  at  thirty  of  tuberculosis. 
Nothing  is  known  as  to  the  father,  'i'he  present 
trouble  began  two  weeks  prior  to  the  first  visit.  It 
began  as  a  bleb  the  size  of  a  ten-cent  piece  on  the 
left  cheek.  On  June  ylh,  the  ulcer  had  penetrated 
all  the  layers  of  the  skin;  there  were  also  other 
small  ulcers  which  are  not  so  deep.  There  was 
great  pain  in  the  distribution  of  the  facial  nerve 
owing  to  one  of  its  branches  being  laid  bare  by  the 
ulceration.  Treatment  was  begun  on  June  7,  1900. 
Three  treatments  of  ten  minutes  each,  with  blue  lens 
at  near  cautery  point,  effected  a  cure  in  two  weeks. 
There  has  been  no  relapse  to  date. 

Five  cases  of  lupus  now  under  treatment  are  all 
improving. 

Ordinary  cases  of  lupus  require  treatment  for  from 
four  to  twenty  weeks. 

It  has  long  been  known  that  countries  having  a 
maximum  of  sunshine  were  most  favorable  to  recovery 
from  the  ravages  of  tuberculosis.  Arizona,  New 
Mexico,  California,  and  Colorado  have  been  the 
Meccas  foi'  those  suffering  from  this  disease.  It  has 
likewise  been  recognized  that  cattle  on  our  western 
plains  are    practically  free    from  tuberculosis,  while 

those  confined  in 
barns  are  seriously 
affected  with  it. 

Sunshine  has  not, 
however,  been  used 
in  the  most  effective 
manner.  Patients 
have  been  sent 
across  the  continent 
to  enjoy  its  advan- 
Kir,  4.  tages,    but    upon 

reaching  the  land 
of  sunshine  they  have  still  enveloped  their  bodies 
in  clothing  impervious  to  light.  That  sunshine  may 
be  of  greatest  value  it  must  fall  upon  the  man 
himself  and  not  upon  his  clothing.  Ordinary  sun- 
shine falling  upon  the  surface  of  the  body  penetrates 


574 


MEDICAL    RECORD. 


[October  13,  1900 


the  tissues  to  a  considerable  depth.  The  condensed 
actinic  rays  of  the  sun  pass  entirely  through  the  human 
body. 

The  Influence  of  Sodium  Salicylate  on  General 
Metabolism. — Francis  W.  Goodbody,  as  the  result  of 
original  investigations,  concludes:  (i)  That  sodium 
salicylate  causes  an  increase  in  the  quantity  of  urine 
excreted,  and  in  the  specific  gravity;  the  latter  in- 
crease being  principally  due  to  the  increased  elimina- 
tion of  the  nitrogenous  substances,  especially  of  the 
urea;  (2)  that  sodium  salicylate  causes  an  increased 
breaking  up  of  proteids  in  the  body;  (3)  that  sodium 
salicylate  has  no  influence  on  general  metabolism,  so 
far  as  the  absorption  of  proteids  and  fats  is  concerned, 
in  spite  of  its  known  cholagogue  action. — The  Journal 
of  Physiology,  August  29,  1900. 

The  Lymph  Node  as  a  Factor  in  Diagnosis. — 
C.  A.  W'heaton  describes  the  physiological  functions 
of  these  structures,  dwelling  on  the  fact  that  they  are 
engaged  in  a  constant  warfare  against  systemic  con- 
tamination and  in  the  manufacture  of  cell  elements, 
the  duty  of  which  is  to  maintain  the  orderly  metabo- 
lism of  the  body.  He  deprecates  the  excessive  zeal  of 
some  modern  surgeons  in  e.xcising  enlarged  cervical 
glands,  contending  that  in  many  cases  the  enlargement 
can  be  removed  by  proper  attention  to  bodily  nutri- 
tion. He  says  that,  with  the  exception  of  the  indis- 
criminate castration  of  women,  none  of  the  operative 
procedures  have  been  more  fashionable  than  the  ex- 
cision of  enlarged  lymph  nodes  in  the  neck,  and  the 
indiscriminate  application  of  this  operation  merits 
just  as  severe  denunciation  as  the  other. — St.  Paul 
Medical  Journal,  September,  1900. 

Removal  of  the  Cervical  Sympathetic  Ganglia 
for  the  Relief  of  Exophthalmic  Goitre ;  with  the 
Report  of  a  Case.  —  M.  F.  Coomes,  after  some  remarks 
on  the  nature  of  Graves'  disease,  states  that  he  oper- 
ated on  April  7,  igoo,  upon  a  colored  woman,  twenty- 
nine  years  of  age,  removing  the  three  cervical  sympa- 
thetic ganglia  on  the  right  side.  This  was  a  most 
typical  case,  and  had  existed  two  years,  receiving  the 
ordinary  treatment  at  the  hands  of  different  physicians. 
Her  temperature  preceding  the  operation  was  101°  Y.\ 
the  average  pulse  rate,  140.  The  temperature  and 
pulse  records  show  that  after  the  operation  her  tem- 
perature went  down  below  100"  F.,  and  the  third  day 
after  tiie  operation  the  pulse  rate  fluctuated,  being  110 
on  .April  19th,  when  she  was  discharged  from  the  hos- 
pital, and  that  the  temperature  was  normal,  with  the 
exception  of  two  or  three  days,  when  it  was  up  a  de- 
gree or  two,  as  a  result  of  irritation  of  the  wound. 
There  was  no  suppuration  whatever  in  connection 
with  this  operation;  all  the  unpleasant  symptoms 
gradually  decreased;  there  was  a  decided  improve- 
ment in  the  exophthalmos,  the  eyes  receding  very 
perceptibly;  the  excessive  nervousness  disappeared 
almost  entirely,  her  sleep  becoming  peaceful,  and 
there  has  been  a  decided  increase  in  her  bodily  weight 
— a  very  great  contrast  to  her  restless  condition  pre- 
ceding the  operation. — American  Practitioner  and  News, 
August  15,  1900. 

Atriplicism. — Under  this  heading  A.  lioddaert  calls 
attention  to  an  article  by  Matignon,  who  saw  service 
in  China  at  the  time  of  the  late  war  with  Japan.  The 
cases  reported  by  the  latter  writer  occurred  during  the 
famine  subsequent  to  the  war.  They  consisted  of  a 
group  of  cases  due  apparently  to  the  ingestion  of  the 
sprouts  of  the  orach  or  chenopodium  (family  Atri- 
plex).  This  is  a  vegetable  growth  especially  pre- 
ferred by  the  Chinese,  who  prepare  it  in  several  differ- 
ent ways  and  under  usual  circumstances  do  not  seem 


to  suffer  any  ill  effects  from  eating  it.  Matignon 
saw,  however,  cases  in  which  its  ingestion  was  fol- 
lowed by  parasthesic  sensations  in  the  thumb,  gradu- 
ally followed  by  swelling  extending  up  the  arm.  and 
later  involving  the  face,  making  the  patient  look  like 
a  case  of  scarlatinal  nephritis.  This  stage  was  fol- 
lowed by  a  subsidence  of  the  infiltration  and  the  oc- 
currence of  large  phlyctenule  containing  a  sero-puru- 
lent  Huid  and  leaving  ulcerated  surfaces,  finally  these 
cicatrized  and  were  succeeded  by  large,  exuberant 
cheloid  masses.  It  does  not  appear  that  the  condition 
has  ever  resulted  fatally. — Bulletin  dc  la  Sociele  de 
Aledecine  de  Gaiul,  Jul)',  1900. 

The  Use  of  Gold  Wire  in  the  Radical  Operation 
for  Inguinal  Hernia.  —  Gaspare  Fiore  advocates  the 
use  of  gold  wire  which  is  extremely  fine,  strong,  and 
flexible.  So  far  it  has  been  used  on  seven  patients, 
with  the  best  possible  results.  For  ligature  of  the 
neck  of  the  sac,  a  wire  with  the  diameter  of  m.  0.0065 
was  used,  while  for  suture  of  the  triple  layers  m. 
o.ooii  was  found  to  be  better.  The  wires  were  ster- 
ilized by  being  boiled  in  water  for  several  minutes. — 
La  Rifortna  Medica,  August  28,  1900 

Severe  Case  of  Poisoning  from  Black  Varnish  on 
Boots  of  Yellow  Leather. — A.  Hallipre  and  laellicaud 
give  an  account  of  a  patient  who  during  the  funeral 
services  of  a  relative  was  seized  with  serious  symp- 
toms of  poisoning,  viz.,  asphyxia,  blueness  of  extremi- 
ties, lips,  nose,  and  tongue,  coldness  of  extremities, 
drowsiness,  accelerated  respiration  (321,  feeble  pulse 
(90).  Treatment  consisted  of  injections  of  caffeine 
and  ether,  sinapisms,  friction  with  alcohol,  bleeding, 
injection  of  serum,  inspiration  of  oxygen,  potions  of 
ether  and  ammonium  acetate.  Recovery  followed. 
The  cause  of  the  poisoning  was  traced  to  the  patient's 
boots,  which  had  been  newly  varnished  with  aniline 
black.  The  patient  had  found  the  odor  of  the  varnish 
very  unpleasant  and  oppressive.  An  analysis  of  the 
varnish  proved  the  presence  of  an  aniline  oil. — La 
Revue  Ml-dicale  de  Normandie,  August  25,  1900. 

Physiology  of  Voice  Production. — In  a  general 
article  on  this  subject  M.  A.  Goldstein  concludes  as 
follows:  (i)  All  elements  carefully  considered,  the 
best  form  of  breathing  applicable  to  voice  production 
and  singing  is  the  rational  combination  of  the  costal 
with  the  diaphragmatic  type.  Reserve  force  in 
breathing  is  best  attained  by  deep  inspiration,  fixa- 
tion of  the  distended  diaphragm  and  thorax,  and  con- 
trol of  these  muscles  while  tone  is  produced.  (2)  To 
facilitate  vocalization,  the  larynx  should  never  be 
tightly  contracted  by  the  muscles  of  the  throat,  espe- 
cially in  the  production  of  the  upper  registers.  (3) 
On  the  resonating  cavities,  their  proper  conformation 
and  position  in  relation  to  the  vibrating  cords  and 
larynx,  depend  the  quality  and  timbre  of  the  voice, 
and  the  careful  and  proper  placing  of  tones  is  per- 
haps the  most  essential  factor  in  voice  production. — 
Medical  Fortnightly,  September  15,  igoo. 

The  Pathogenesis  of  Icterus. — Browicz  comes  to 
the  following  conclusions:  (1)  The  occurrence  of 
jaundice  primarily  depends  on  the  increased  activity 
of  normal  liver  cells,  which  through  various  stimuli 
may  be  caused  to  take  up  unduly  large  amounts  of 
nutritive  material  and  h.ainoglobin.  and  so  produce 
an  increased  quantity  of  bile  and  bile  pigment.  (2) 
Only  a  healthy,  normally  functionating  liver  cell 
which  has  absorbed  and  converted  an  excess  of  nutri- 
tive material,  and  therefore  produced  an  increased 
amount  of  bile,  is  able  wht)lly  to  dispose  of  this  ex- 
cess through  the  intracellular  bile  passages,  there- 
fore bile  reaches  the  circulation  through  the  walls  of 
the  capillaries.     (3)   Mechanical  conditions  have  but 


October  13,  1900] 


MEDICAL    RECORD. 


575 


an  unimportant  part  in  the  causation  of  jaundice 
through  the  production  of  intra-acinous  circulatory 
disturbances  in^the  capillaries.  (4)  The  path  of  the 
bile  in  reaching  the  blood  lies  through  the  blood 
capillaries  of  the  iiepatic  acini,  and  only  to  a  moder- 
ate degree  involves  the  lymph-vessels  of  the  larger  bile 
passages.  (5)  All  forms  of  jaundice  are  explicable 
on  these  grounds,  viz.,  an  increased  activity  of  the 
liver  cells  and  a  concomitant  overproduction  of  bile 
and  bile  pigment. —  Wiener  klinische  Wochenschrijt, 
August  30,  1900. 

A  Case  of  Typhoid  Fever  Treated  by  the  So- 
Called  "Woodbridge  Treatment."— A.  Schmidt  re- 
cently treated  a  man  who  was  in  the  sixth  day  of  the 
fever  when  first  seen.  The  case  was  rather  a  severe 
one  when  treatment  was  begun,  the  nervous  symptoms 
with  headache  being  marked.  'J'he  usual  Woodbridge 
tablets  were  given  and  a  diet  allowed  of  milk,  eggs, 
and  rice  with  a  moderate  amount  of  alcohol.  The 
patient  was  convalescent  on  the  thirteenth  day  of  tre.it- 
.lent,  on  the  fourth  day  of  which  the  temperature  fell 
to  normal  and  did  not  rise  again. — Alontreal  Mcdiiid 
Jiniinal,  August,  1900. 

Perforation  of  the  Foetal  Skull  intra  Partum, 
with  Favorable  Outcome. — I..  I'emice  reports  tlie 
following  case:  Owing  to  almost  complete  absence  of 
labor  pains  and  an  apparently  contracted  pelvis  the 
presenting  vertex  was  perforated  with  the  instrument 
of  Naegele.  An  abundance  of  bloody  fluid  mixed 
with  what  appeared  to  be  brain  matter  came  away, 
the  forceps  was  applied,  and  the  child  was  delivered 
without  further  trouble.  As  it  still  breathed,  an  anti- 
septic dressing  was  applied  to  the  wound  as  a  matter 
of  form,  with  the  result  that  the  child  lived  and  a  com- 
plete hemiplegia  existing  at  birth  also  entirely  sub- 
sided. At  present  the  child  is  one  and  three-fourths 
years  of  age.  and  is  mentally  and  physi,cally  normal 
except  for  a  large  cerebral  hernia  over  the  occiput. — 
Ceiitialhlatt Jiir  Gyinihflloi^ie,  September  i,  1900. 

Apparent  Death  in  the  New-Born. — B.  S.  Schultze 
directs  that  the  cord  should  not  be  cut  if  the  apparently 
asphyxiated  infant  is  bluish-red  in  color  and  muscle 
tonus  is  still  present.  Aspiratod  matter  should  be  re- 
moved from  the  mouth  and  cutaneous  stimuli  applied. 
If  no  reaction  follows,  the  cord  should  be  cut  and  the 
child  dipped  momentarily  into  cold  and  then  warm 
water,  repeating  until  a  loud  cry  results.  If  the  child 
is  pale  and  limp  like  a  corpse,  useless  time  would  be 
lost  in  trying  to  produce  reflex  excitability.  The  cord 
must  be  cut,  the  mouth  cleansed,  the  root  of  the  tongue 
pressed  forward  to  raise  the  epiglottis,  and  artificial 
respiration  should  be  performed  by  the  Ewing  method. 
Eight  to  ten  inspiratory  and  expiratory  movements  are 
then  to  be  made  and  then  a  w-arm  bath  should  be  given. 
If  no  result  follows  the  swinging  should  be  repeateti. 
After  the  first  spontaneous  inspiration  which  usually 
follows  the  end  of  the  expiratory  swing,  the  child  is 
placed  in  the  warm  bath;  if  respiration  is  superficial 
it  should  be  plunged  into  cold  water. —  Wiener  jncdizi- 
nische  B/dtter,  August  30,  1900. 

Spurious  Meningocele — Joseph  Sailer  describes 
under  this  name  a  condition  in  which  there  is  defect 
in  the  skull  produced  by  some  injury;  through  this 
defect  cerebro-spinal  fluid  passes  to  and  accumulates 
on  the  outer  side  of  the  skull  beneath  the  pericranium 
that  has  been  elevated  by  its  force.  The  symptoms 
are:  first,  the  tumor,  which  fluctuates,  pulsates,  and 
occasionally  upon  auscultation  gives  a  harsh  mur- 
mur, and  the  signs  of  injury  to  the  brain — that  is, 
vomiting,  alterations  in  character,  convulsions,  and 
paresis.  A  curious  murmur  has  been  heard  in  some 
cases,  the  nature  of  which   it  is  hard  to  understand. 


It  is  synchronous  with  the  pulse,  loud  and  hard,  re- 
sembling that  of  an  aneurism.  The  nervous  symptoms 
vary  according  to  the  nature  of  the  brain  injury.  In  a 
surprisingly  large  number  of  cases  they  are  absent,  and 
epilepsy  seems  much  less  frequent  than  after  simple 
fractures.  The  treatment,  now  that  infection  can  be 
a\oided,  should  always  be  operative.  There  is  prac- 
tically no  danger,  and  in  recent  cases  the  likelihood 
of  perfect  cure  is  very  great. —  University  Medical 
Magazine,  September,  1900. 

Peri-Tonsillar  Abscess   in  Children L.  T.  Roy- 

ster  reports  a  case  of  this  affection,  which  is  rare  in 
childhood,  occurring  in  only  three  per  cent,  of  this  class 
of  patients.  It  occurs  as  a  local  infection,  consequent 
upon  acute  catarrhal  inflammation  of  the  pharynx, 
upon  the  acute  infectious  diseases,  and  also  rarely  as 
a  complication  of  retro-pharyngeal  abscess.  The  mi- 
cro-organism is  usually  the  staphylococcus.  The 
general  symptoms  resemble  those  of  acute  follicular 
tonsillitis,  but  the  temperature  is  lower  and  depression 
less  marked.  The  local  symptoms  differ:  there  is 
great  pain  on  swallowing,  torticollis  is  common,  and 
a  fixed  lower  jaw  is  almo.st  invariable.  The  pain 
complained  of  is  more  marked  than  the  examination 
can  account  for.  By  palliation  the  unilateral  indura- 
tion can  usually  be  detected.  The  danger  in  severe 
cases  comes  from  ctdema  (rarely  fatal),  spontaneous 
rupture  and  perforation  of  an  artery.  Vertical  inci- 
sion of  the  most  prominent 'joint,  with  drainage  of  the 
cavity,  is  the  only  treatment. — Pediatrics,  September 
15,  1900. 

Operation  without  Digital  Contact  with  the 
Wound. — Ktinig  believes  that  the  surest  way  to  se- 
cure asepsis  of  the  wound  lies,  not  in  the  sterilization 
of  the  hand  nor  in  the  use  of  gloves  or  varnishes, 
which  means,  necessary  as  they  are,  still  cannot  help 
being  inadecjuate,  but  in  a  persistent  effort  to  avoid 
touching  the  wound  with  the  fingers  at  all.  By  trial 
he  has  found  it  perfectly  feasible  to  do  such  opera- 
tions as  joint  resections,  osteoplastic  operations,  and 
in  fact  most  of  the  commoner  surgical  procedures  on 
the  extremities,  without  touching  the  tissues  otherwise 
than  with  instruments.  The  abdominal  cavity,  in- 
deed, is  a  field  where  digital  manipulation  will  always 
be  a  necessity,  but  even  here,  with  practice  and  suit- 
able modifications  of  the  armamentarium,  much  may 
be  accomplished  without  actual  contact.  The  assis- 
tants as  well  as  the  operator  should  be  trained  to 
avoid  manipulation  of  the  operative  field,  and  with  an 
abundance  of  especially  long  and  variously  shaped 
retractors,  forceps,  etc.,  may  perform  nearly  all  tlieir 
functions  from  a  distance. — Centralldatt Jiir  Chirurgic, 
September  8,  1900. 

The  Treatment  of  Sciatica. — A.  Heym  says  that 
in  acute  sciatica  bed  and  warmth  often  relieve  the 
pains  with  surprising  rapidity.  The  patient's  knees 
must  be  bent.  The  latest  and  best  remedy  is  freezing 
the  skin  by  means  of  methyl  chloride  or  ethyl  chloride. 
This  works  best  in  thin  persons,  but  often  fails  in  the 
corpulent.  In  chronic  sciatica,  rest  in  bed  is  not  to 
be  recommended,  but  a  certain  amount  of  exercise  is 
necessary,  the  affected  leg  being,  however,  protected 
from  all  exertion.  The  best  treatments  consist  of 
electro-therapeutics  with  the  constant  current ;  hydro- 
therapeutics,  principally  steam  or  hot-air  baths;  mas- 
sage, and  Swedish  movements.  If  all  these  remedies 
have  been  tried  without  success,  nerve  extension  may 
be  tried,  but  the  percentage  of  cases  resulting  in  cure  in 
this  way  is  very  small. —  The  Chicago  Clinic,  September, 
1900. 

The  Use  of  Morphine  in  Surgical  Practice Ed- 
ward Martin   says  the  general    indications  as  to  the 


5/6 


MEDICAL    RECORD. 


[October  13,  1900 


employment  of  morphine  in  surgery  may  be  summa- 
rized as  follows:  (i)  Morphine  should  be  given  hypo- 
dermically  and  in  doses  sufficient  to  accomplish  the 
purpose  for  which  it  is  given.  (2)  When  surgical 
shock  is  attended  by  such  severe  pain  as  to  cause  un- 
controllable restlessness,  morphine  siiould  be  given  in 
doses  adequate  to  relieve  it.  The  same  treatment  is 
indicated  for  shock-restlessness  without  pain  (usually 
due  to  hemorrhage),  the  appropriate  general  treatment 
for  shock  being  also  carried  out.  (3)  Morphine  is  the 
best  internal  h;T;mostatic  in  the  treatment  of  hemor- 
rhage. When  the  hemorrhage  is  complicated  by  rest- 
lessness, morphine  is  absolutely  indicated  because  of 
its  quieting  effect  upon  both  mind  and  body.  (4) 
When  drunkards,  or  exceptionally  neurotic  patients,  are 
to  be  anesthetized  a  preliminary  hypodermic  injec- 
tion of  morphine  renders  such  anesthetization  quicker, 
easier,  and  safer,  and  favorably  affects  the  stage  of 
recovery.  Obstinate  and  exhausting  vomiting  after 
ether  is  sometimes  relieved  by  morphine.  (5)  If  in 
the  first  twenty-four  hours  after  operation  pain  be- 
comes so  severe  as  to  cause  uncontrollable  restless- 
ness, this  pain  should  be  relieved  by  morphine.  To 
this  rule  there  are  practically  no  exceptions;  it  ap- 
plies to  all  operations  regardless  of  the  operative  area. 
(6)  \\hen  used  in  accordance  with  these  indications 
the  beneficial  effects  of  morphine  so  overshadow  its 
injurious  effects  that  the  latter  are  not  demonstrable. 
To  this  rule  there  may  be  a  very  few  exceptions. — 
Therapeiitii  Gazette.  September  15,  1900. 

Antagonism  between  Cocaine  and  Hypnotics. — 
Carlo  Gioffredi  concludes  from  a  long  series  of  ex- 
periments: (i)  That  chloral  hydrate  is  a  decided  an- 
tagonist of  cocaine,  being  able  to  counteract  the  action 
of  doubly  lethal  doses  given  to  a  dog;  (2)  other  hyp- 
notics, such  as  paraldehyde,  are  likewise  antagonistic 
to  cocaine;  (3)  the  antagonism  is  complete,  influenc- 
ing all  the  important  organic  functions;  (4)  it  is  a 
one-sided  antagonism,  for  cocaine  does  not  counteract 
poisoning  by  the  hypnotics;  (5)  the  antagonism  is  a 
mechanical  one,  similar  to  the  antagonism  between 
the  hypnotics  and  strychnine. —  Gioriiale  Inieniazionak 
delle  Scieuze  Mediche,  August  31,  1900. 

On  the   Physiological  Action  of  Senecio  Jacobce. 

— J.  L.  Bunch,  by  experimenting  on  dogs  with  prep- 
arations from  the  entire  plant,  found  that  intravenous 
injection  produced  a  slight  rise  in  general  blood  press- 
ure and  diminution  in  the  magnitude  of  both  auricular 
and  ventricular  contractions.  There  are  two  substances 
of  distinct  physiological  action  in  the  plant.  Intra- 
venous injection  of  a  watery  extract  of  the  residue  on 
evaporation  of  an  alcoholic  solution  caused  a  marked 
fall  of  blood  pressure  followed  by  a  slight  rise  due  to 
constriction  of  peripheral  vessels.  The  two  substances 
have  not  been  separated.  The  substance  which  causes 
a  rise  of  blood  pressure  is  not  contained  in  watery  ex- 
tracts.—  Therapeutic  Gazette.,  September  15,  1900. 

The  Crises  of  Development — Walter  R.  Jordan 
speaks  of  the  periods  of  birth,  dentition,  and  puberty 
as  difficult  passes  from  one  tract  of  mountainous 
country  to  another,  with  a  minor  crisis  during  the 
stage  of  childhood  at  seven  years.  The  author  urges 
the  young  physician  in  his  first  months  or  years  of 
comparative  leisure  to  lake  up  child  study — the  scien- 
tific observation  of  children.  Such  study  would  give 
a  more  thorough  grasp  of  the  meaning  of  the  develop- 
mental period  of  life,  with  its  peculiar  susceptibility 
to  damage,  not  only  throughout,  but  accentuated  at 
special  crises;  would  throw  light  on  the  after-effects 
of  the  specific  and  other  diseases  in  ciiildhood;  would 
give  greater  precision  and  force  to  the  physician's  di- 
rections as  to  the  general  hygiene  of  the  growing 
child,  hours  on  work,  play,  and  sleep.      It  would  be  a 


guiding  influence  on  all  therapeutic  measures  adopted 
in  cases  in  which  development  was  not  proceeding  nor- 
mally. It  would  introduce  system  iato  his  estimation 
of  the  defects  of  backward  children,  and  would  supply 
clews  to  the  meaning  of  the  behavior  of  precocious  and 
unsatisfactory  children.  It  would,  when  previous  per- 
sonal or  family  history  supplied  facts,  justify  him  in 
making  predictions  as  to  the  future  physical  and  men- 
tal development  of  particular  children;  it  would  thus 
give  him  opportunities  of  instituting  preventive  meas- 
ures against  developmental  failure  of  body  and  mind. 
—  The  Birmingham  Medical  Jievieii.',  September,  1900. 

An  Unusual  Symptom  of  Perforative  Appendi- 
citis.—David  Owen  Thomas  reports  a  case,  the  chief 
features  of  which  he  sums  up  as  follows:  (i)  The 
perforation,  which  took  place  very  early,  was  preceded 
by  the  history  of  pain.  Ulceration  probably  had  been 
going  on  without  any  rise  of  temperature,  (2)  The 
severity  of  the  pain,  tenderness,  and  rigidity  of  the 
abdominal  wall  were  better  guides  than  pulse  and 
temperature,  and  indicated  that  operation  was  neces- 
sary. (3)  Pain  in  the  penis  was  so  extreme  that  the 
boy  was  fairly  beside  himself — rolling  and  tossing 
around  in  a  desperate  manner,  this  special  symptom 
overshadowing  all  others  for  nearly  half  an  hour.  (4) 
If  perforation  had  not  been  promptly  recognized  the 
amelioration  of  the  symptoms  by  the  next  day  might 
have  caused  postponement  of  the  operation  and  per- 
haps loss  of  the  patient.  The  author  has  known 
this  same  chief  symptom  to  occur  in  the  perforation 
of  typhoid  ulcer.  It  is  probable  that  in  such  cases,  as 
well  as  in  this  case  of  appendicitis,  pain  is  transferred 
through  the  hypogastric  plexus  to  the  penis.— 77^^ 
Medical  Dial,  September,  1900, 

The  Relation  of  Diseases  of  the  Eye  to  those  of 
the  Teeth.— X.  Weill  states  that  this  phase  of  medi- 
cine and  dentistry  belongs  to  the  newer  time.  Patho- 
logical conditions  of  the  eye  or  orbit  can  cause  dental 
disturbances,  and  vice  versa,  either  reflexly  or  by  con- 
tinuity, those  of  the  latter  group  being  less  frequent 
but  graver,  \'ery  serious  may  be  the  results  of  ab- 
cesses  of  the  orbit,  which  may  be  primary  or  secondary 
in  origin.  When  of  dental  origin  they  may  arise  in 
one  of  two  ways:  either  via  the  periosteum  of  the  su- 
perior maxillary  bone  and  the  orbit,  or  via  the  antrum 
of  Highmore.  Timely  operation  is  demanded.  The 
writer  is  unable  to  find  any  case  recorded  in  which  an 
ocular  or  orbital  affection  involved  the  teeth  by  con- 
tinuity. The  reflex  currents  can  originate  in  the  eye 
and  manifest  themselves  by  pain  in  the  teeth,  but  the 
reverse  neuroses,  i.e.,  the  teeth  the  cause  of  the  eye 
disturbance,  are  probably  more  frequent.  The  writer 
cites  numerous  cases  in  illustration  of  this  subject, — 
Pennsylvania  Medical  Journal,  September,  1900. 

Purpura  Rheumatica.— M.  A.  Bliss  reports  the 
case  of  a  boy  aged  six  years.  Red  spots  appeared  on 
the  dorsum  of  the  hands  and  feet,  and  on  both  aspects 
of  the  arms  and  legs.  They  multiplied  rapidly  and 
extended  up  the  thighs  and  over  the  ujiper  arms,  this 
increase  being  accompanied  by  an  extensive  urticaria. 
The  right  knee  and  left  elbow  joints  were  the  seat  of 
stiffness,  swelling,  and  soreness,  but  no  redness.  This 
joint  involvement  would  recur  every  evening  about  five 
o'clock,  disappearing  over  night.  IJy  the  ninth  day  the 
skin  was  free  from  purpuric  spots,  but  a  slight  stiffness 
still  recurred  in  the  joints.  Two  months  previously 
the  child  had  suffered  from  malaria,  so  that  on  the  ap- 
pearance of  the  purpuric  spots  the  writer  administered 
quinine.  The  pigmented  form  of  the  malarial  jilas- 
modium  was  found  in  the  blood.  The  author  tliinks 
there  is  a  possibility  tiiat  the  purpura  was  due  to  the 
malarial  infection. — St.  Louis  Courier  of  Medicine, 
September,  1900. 


October  13,  1900] 


MEDICAL   RECORD. 


577 


Medical  Record: 

A    Weekly  Journal  of  Medicine  and  Surgery. 


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

Publishers 
WM.  WOOD  &.  CO.,  51    Fifth  Avenue. 


New  York,  October  13,  1900. 


CORNING'S    METHOD   OF    MEDULLARY 
NARCOSIS. 

The  value  of  recording  original  observations  as  soon 
as  made  and  prospecting  their  adaptability  to  given 
ends  is  well  shown  in  the  matter  of  spinal  cocainiza- 
tion  concerning  which  so  much  is  being  written  and 
said. 
I  Although  fully  fifteen  years  have  elapsed  since  Dr. 
J.  Leonard  Corning  of  this  city  published  his  experi- 
ments on  this  subject,  and  notwithstanding  it  is  only 
within  a  few  months  that  his  suggestions  have  been 
followed,  no  one  can  question  his  claims  to  priority 
in  first  calling  attention  to  a  method  of  anaesthesia 
which  is  now  challenging  a  trial  by  numerous  sur- 
geons here  and  abroad. 

As  tlie  real  one  who  first  established  the  principle 
of  the  action  of  cocaine  upon  the  cord  and  who  first 
demonstrated  its  practicability  not  only  by  actual 
trials  upon  the  lower  animals,  but  by  using  it  for 
anajsthetic  purposes  upon  the  human  subject,  his  name 
must  necessarily  be  associated  with  that  particular 
field  of  work,  however  it  may  be  extended  by  other 
investigators. 

While  it  is  well  proven  that  the  anaesthesia  is  per- 
fect so  far  as  it  goes,  the  question  of  the  hour  which 
would  naturally  suggest  itself  bears  upon  the  possibil- 
ity of  safely  e.xtending  the  area  of  absolute  insensi- 
bility to  the  upper  portions  of  the  body.  The  cauda 
equina,  which  is  the  particular  part  exposed  to  the  in- 
fluence of  the  drug,  although  within  the  spinal  canal, 
is  not,  physiologically  speaking,  the  spinal  cord.  What 
may  be  done  with  comparative  impunity  to  a  bundle 
of  nerves  may  be  exceedingly  dangerous  to  attempt 
with  a  distinct  motor  or  sensory  centre.  Particularly 
must  this  be  the  case  when  any  portion  of  the  cord  in 
the  neighborhood  of  the  centre  of  a  vital  organ  is 
cocainized.  Thus  it  is  very  reasonable  to  suppose 
that  injections  higher  up  in  the  canal  for  purposes  of 
anaesthetizing  the  chest  regions,  neck,  and  upper  ex- 
tremities are  presumably  very  dangerous. 

From  such  a  point  of  view  the  many  enthusiasts  who 
are  practising  the  method  with  a  desire  to  extend  its 
usefulness  are  in  great  danger  of  going  too  far.  Par- 
ticularly is  this  the  case  with  the  dosage  of  the  drug, 
as  many  surgeons  have  taken  great  risks  by  injecting 
very  strong  solutions — some  of  them  containing  as 
much  as  six  grains — while  the  standard  is  generally 
placed  as  two  per  cent  of  cocaine. 


It  must  also  be  recollected  in  such  a  connection 
that  cocaine  is  sometimes  very  treacherous  in  its  ac- 
tion and  that  a  large  dose  in  a  place  beyond  the  reach 
of  counteracting  influences  may  leave  the  ruthless  ex- 
perimenter entirely  at  the  mercy  of  a  serious  and  pre- 
ventable accident. 

The  extreme  aseptic  precautions  that  must  be  taken 
in  making  the  injection  cannot  be  too  strongly  urged. 
For  the  surgeon  of  to-day,  trained  to  the  high  att  of 
absolute  cleanliness  of  instruments,  hands,  and  opera- 
tion area,  no  lesson  or  suggestion  is  needed,  but  the 
novice  is  extremely  liable  to  do  great  mischief.  The 
apparent  simplicity  of  the  manoeuvre  constitutes  its 
greatest  danger  in  the  hands  of  the  tyro.  Fortunately 
so  far  no  serious  mishaps  have  occurred,  neither  have 
any  deaths  been  reported  from  ovei-dosage,  but  it  is 
quite  plain  at  this  stage  of  the  investigation  that  we 
must  proceed  slowly  and  carefully  if  we  would  prevent 
accidents. 

While  this  new  form  of  anaesthesia  in  certain  ways 
lessens  some  of  the  well-known  dangers  of  ether  and 
chloroform  administrations,  it  is  still  a  question  if  the 
preservation  of  the  mental  faculties  during  the  terrible 
ordeal  of  a  severe  and  prolonged  surgical  operation  is 
especially  desirable  in  itself.  With  most  persons 
unaccustomed  to  the  experience  the  mere  sight  of 
blood,  and  more  especially  mutilation  in  any  form, 
causes  faintness  and  other  forms  of  mental  shock. 
Certainly  such  an  element  is  not  a  requisite  addition 
to  the  physical  strain  of  the  operation  itself.  In  fact 
in  some  of  the  recorded  cases  the  mere  expectation  of 
pain,  even  without  its  ultimate  realization,  appears  to 
have  had  a  marked  depressing  effect  upon  the  vital  en- 
ergiesof  the  victim.  Psychologically  and  aesthetically 
this  claimed  advantage  of  spinal  anaesthesia  is  hardly 
to  be  advocated  on  the  score  of  its  demonstrated  utility. 

It  must  be  admitted,  however,  on  the  other  hand,  that 
the  well-founded  prejudice  against  loss  of  conscious- 
ness in  general  aneesthesia  is  thus  elTectually  overruled 
and  that  the  patient  not  only  escapes  the  dangers  of 
the  helplessly  stupefied  state,  but  is  saved  many  of 
the  disagreeable  and  ofttimes  distressing  phenomena 
attending  its  preliminary  induction.  There  may  also 
be  occasions  during  an  operation  in  which  con- 
ditions warranting  more  severe  procedures  than  were 
at  first  expected  may  require  the  consent  of  the  pa- 
tient before  going  further,  and  this  being  possible  may 
save  both  him  and  the  operator  much  subsequent 
trouble.  Even  under  such  circumstances  it  is  not 
necessary  that  the  patient  actually  sees  or  hears  what 
is  going  on,  it  being  sufficient  only  tliat  he  has  the 
privilege  of  expressing  an  opinion  and  being  a  party 
to  a  very  important  contract.  Hence  most  operators 
deem  it  best  to  blindfold  the  patient  and  plug  his  ears 
in  order  to  eliminate  all  the  objectionable  elements 
of  the  direct  mental  shock  in  question. 


DEGENERATES    IN    THE   ARMY. 

Dr.  Charles  E.  Woodruff,  U.S.A.,  in  the  American 
Journal  oj  Insanity,  July,  1900,  contributes  an  instruc- 
tive article  on  the  above  subject.  His  position,  of 
course,  qualifies  him  to  speak  with  authority,  that  is, 


578 


MEDICAL   RECORD. 


[October  13,   1900 


so  far  as  anny  degenerates  are  concerned.  As  miglit 
be  supposed,  however,  the  field  of  observation  of  this 
type  of  human  beings  is  considerably  restricted,  as 
slight  deviations  from  normal  development  are  suffi- 
cient cause  for  rejection  of  candidates  for  the  army. 
Nevertheless  it  seems  that  a  certain  number  of  men 
with  some  psychical  stigmata  contrive  to  pass  the  re- 
quired examination  and  become  soldiers.  Dr.  Wood- 
ruff would  appear  to  be  somewhat  in  agreement  with 
the  views  of  Nordau  that  a  markedly  high  type  of  in- 
telligence as  well  as  a  distinctly  low  type  is  abnormal 
and  evidence  of  an  unstable  development.  He  says: 
"  It  must  not  be  forgotten  that  the  man  who  represents 
a  strict  average  in  every  respect  is  an  absolutely 
characterless  individual  in  that  he  has  no  marked 
characteristics.  His  intelligence  is  quite  limited, 
for  the  mean  between  the  imbecile  and  the  genius  is 
a  man  of  very  ordinary  ability.  Soldiers  with  aver- 
age bodies  have  average  brains,  and,  though  strictly 
normal,  have  not  a  high  grade  of  intelligence."  And 
again:  "The  moral  sense,  also,  being  nothing  more 
than  the  resultant  of  all  the  higher  intellectual  faculties, 
is  of  average  development  among  soldiers.  Extremes 
are  very  rare,  whether  ideal  morality  on  the  one  side, 
or  crime  on  the  other."  Perhaps  the  argument  that 
an  average  man  physically  is  also  an  average  man 
mentally  is  a  sound  one,  but  if  this  is  so  will  it  be 
contended  further  that  a  magnificent  animal  specimen 
of  humanity  is  also  as  a  rule  endowed  with  a  super- 
abundance of  brains?  By  an  average  man,  however, 
probably  Dr.  Woodruff  means  one  with  no  anomalies 
or  stigmata.  Certain  it  is  that  men  of  what  is  called 
genius  differ  from  other  men,  and  it  may  be  that  they 
must  be  classed  among  the  large  and  increasing  army 
of  degenerates.  The  best  position  to  hold  in  the  order 
of  brain  power  would  appear  to  be  between  the  aver- 
age individual  and  the  man  of  genius.  Dr.  Woodruff 
gives  some  brief  studies  of  deserters  from  the  army 
who  came  under  his  notice,  and  who  were  one  and  all 
of  abnormal  development. 


ISOLATION    OF    TUBERCULOUS     PATIENTS 
IN    HOSPITALS    FOR   THE   INSANE. 

By  reason  of  his  lowered  resistance,  of  the  confine- 
ment and  inactivity  that  his  treatment  often  entails,  of 
his  association  with  numbers  of  other  individuals,  and 
of  his  indifference  to  and  neglect  of  ordinary  hygienic 
observances,  in  addition  to  the  usual  causative  influ- 
ences, the  insane  patient  is  especially  liable  to  infec- 
tion with  tuberculosis.  While  this  disease  is  respon- 
sible for  one-seventh  of  the  deaths  due  to  all  causes 
in  the  community,  the  proportion  is  much  larger  in 
many  hospitals  for  the  insane.  According  to  a  col- 
lective investigation  undertaken  by  Harrington  (Anicri- 
can  Journal  oj  Insanity,  vol.  Ivii.,  No.  i,  p.  257)  it  has 
been  found  that  the  total  number  of  deaths  for  the  five 
years  ending  1899,  in  sixty-seven  State  hospitals  for 
the  insane  in  the  United  States,  was  eighteen  thou- 
sand five  hundred  and  thirteen,  of  which  number  two 
thousand  seven  hundred  and  forty  (14.8  per  cent.) 
were  due  to  tuberculosis       Dividing  the  hospitals  into 


groups  in  accordance  with  their  geographical  situation, 
it  appeared  that  the  total  number  of  deaths  in  institu- 
tions in  the  New  England  States  was  three  thousand 
two  hundred  and  eight,  of  which  three  hundred  and 
eighty-three  (i  1.9  per  cent.)  were  due  to  tuberculosis; 
the  total  number  in  institutions  in  the  Middle  States 
was  four  thousand  four  hundred  and  ninety-four,  of 
which  six  hundred  and  eleven  (13.5  per  cent.)  were 
due  to  tuberculosis;  the  total  number  in  institutions 
in  the  Western  and  Southwestern  States  was  eight 
thousand  eight  hundred  and  fifty-three,  of  which  one 
thousand  three  iiundrcd  and  fifty-three  (15.2  percent.) 
were  due  to  tuberculosis;  and  the  total  number  in  in- 
stitutions in  the  Southern  States  was  one  thousand 
nine  hundred  and  fifty-eight,  of  which  three  hundred 
and  ninety-three  (20  per  cent.)  were  due  to  tubercu- 
losis. Inasmuch  as  the  figures  obtained  are  not  com- 
plete, conclusions  based  upon  them  as  to  the  geo- 
graphic prevalence  of  tuberculosis  in  hospitals  for  the 
insane  cannot  be  wholly  relied  upon.  A  much  more 
important  fact,  however,  is  developed  by  the  investi- 
gation, namely,  that  while  in  tliirty-three  hospitals  the 
percentage  of  deaths  from  tuberculosis  was  less  than 
fifteen  per  cent.,  it  varied  from  fifteen  to  sixty-five  per 
cent,  in  the  remaining  tliirty-four.  In  view  of  all  the 
facts,  there  seems  to  be  especially  good  reason  and 
urgent  need  to  isolate  cases  of  tuberculosis  in  hos- 
pitals for  tlie  insane.  Some  efforts  have  already 
been  made  in  this  direction,  and  these  can  be  most 
warmly  encouraged  and  advantageously  extended.  It 
is  the  duty  of  preventive  medicine,  in  restricting  the 
dissemination  of  communicable  diseases,  ever  to  insist 
on  the  principles  of  a  rational  prophylaxis,  namely, 
isolation  and  disinfection. 


THE   PATHOGENESIS    OF   GOUT. 

It  is  better  to  confess  ignorance  than  to  assume 
false  knowledge.  In  spite  of  the  careful  study  that 
has  been  given  to  the  subject  of  gout,  it  must  be  ad- 
mitted that  we  are  as  yet  uninformed  as  to  its  exact 
nature.  That  it  is  a  disorder  of  metabolism  is  ob- 
vious, but  in  what  manner  it  is  brought  about  has  not 
been  made  perfectly  clear.  The  tendency  or  the  pre- 
disposition to  the  affection  may  be  transmitted  by 
heredity,  so  that  one  must  think  of  some  inherent 
peculiarity  in  cellular  activity,  giving  rise  to  disturb- 
ances in  the  internal  chemistry,  with  the  accumulation 
in  the  system  of  the  immature  products,  especially  of 
proteid  metabolism.  In  an  interesting  communication 
presented  to  tlie  Section  of  Internal  Pathology  at  the 
recent  International  Medical  Congress  held  at  Paris, 
Sir  Dyce  Duckworth  {/.anccf,  August  25,  1900,  p.  571) 
expressed  the  opinion  tiiat  gout  is  a  morbid  condition 
dependent  upon  an  inherent  vice  of  nutrition,  which 
is  manifested  by  imperfect  metabolism  in  various  or- 
gans or  parts  of  the  body,  presumably  in  the  kidneys 
and  probably  in  the  liver.  This  trophic  disorder  or 
in.ideqiiacy  leads  to  the  formation  of  uric  acid,  prob- 
ably in  excess,  and  to  its  periodic  retention  in  the 
blood.  Histologic  study  throws  no  light  upon  the 
intimate  nature  of  this  defect,  which   thus  relates  to 


October  13,  1900] 


MEDICAL   RECORD. 


579 


cellular  potentiality,  possibly  under  neurotrophic  in- 
fluence and  not,  so  far  as  is  known,  to  structural  al- 
teration. This  textural  disability,  or  a  tendency  to  it, 
may  be  primarily  acquired,  and  also  transmitted  as  a 
fault,  thereby  inducing  from  time  to  time  urichamia, 
with  gouty  manifestations,  in  tlie  descendants.  In 
most  instances,  under  conditions  that  provoke  it,  and 
in  some  cases  independently  of  these,  attacks  of  gout 
may  grow  up  and  come  to  a  crisis.  Such  crises  are 
attended  with  an  alteration  in  the  solubility  of  the 
uratic  salt  in  the  blood,  whereby  irritating  crystals  of 
sodium  biurate  arc  produced,  and  precipitated  in  vari- 
ous parts  of  the  body.  The  paroxysm  of  gout,  the  sites 
of  its  occurrence,  and  its  metastases  are  thought  to  be 
determined  by  nervous  influences,  probably  dominated 
from  a  bulbar  centre,  and  the  local  attacks  involve 
either  the  joints  or  textures  that  have  been  weakened 
or  rendered  vulnerable  by  impaired  nutrition,  owing 
to  past  injury  or  overuse.  Tliis  central  neurosis  is 
considered  an  essential  and  transmissible  feature  in 
the  pathogenesis  of  gout,  and  pertains  to  the  arthritic 
diathesis  generally.  The  uricliamiaof  gout  is  peculiar 
and  unlike  that  which  is  induced  by  other  morbid  con- 
ditions, but  the  occurrence  of  urichKmia  in  the  gouty 
is  by  itself  inadequate  to  induce  attacks  of  gout. 
Uratic  deposits  in  any  parts  of  the  body  may  be  re- 
moved in  course  of  time,  but  are  likely  to  be  permanent 
in  the  least  vascular  tissues.  Uratic  deposits  may 
take  place  to  an  enormous  extent  in  gouty  persons 
without  the  occurrence  of  pain  or  paroxysms.  The 
clinical  features  of  gout  indicate  that  both  chemical 
changes  (due  to  inherent  morbid  tissue-metabolism) 
and  a  neurotrophic  disturbance  act  as  pathogenic 
factors,  and  that  consequently  gout  is  to  be  regarded 
as  a  neurohumeral  malady. 


Ileitis  0f  tlxe  'miccU. 

The  New  York  State  Hospital  for  Consumptives. 
— The  commission  appointed  to  select  a  site  for  tiie 
State  Hospital  for  Consumptives  has  examined  twenty- 
six  different  places,  and  has  finally  selected  one  on 
Lake  Clear,  about  two  miles  south  of  Upper  Saint 
Regis  Lake  in  the  .\dirondacks.  The  site,  which  in- 
cludes a  tract  of  about  five  hundred  acres,  is  readily 
accessible  by  rail  from  all  parts  of  the  State.  The 
site  has  been  objected  to  because  of  the  comparatively 
large  rainfall  in  this  region,  but  the  soil  is  sandy  and 
quickly  absorbs  moisture,  and  experience  has  shown 
that  the  climate  is  a  favorable  one  for  the  treatment  of 
tuberculosis,  for  it  is  practically  the  same  as  that  of 
the  entire  Adirondack  lake  region.  Saranac  Inn  is 
only  some  three  miles  southwest  of  Lake  Clear.  The 
purchase  price  of  the  tract  is  about  $8,000.  It  is  not 
yet  certain  that  the  land  will  be  acquired,  as  it  is  said 
the  law  forbids  the  securing  of  any  land  in  that  region 
by  the  State  except  for  forestry  preserves. 

Intelligence  in  Proportion  to  Size. — The  Society  for 
Child  Study  has  been  making  some  investigations  in 
Chicago  schools,  the  results  of  which  are  rather  interest- 


ing. Some  seven  thousand  pupils  of  various  ages  were 
examined,  and  taking  those  of  the  same  age  for  com- 
parison, the  results  showed  that  small  children  on  an 
average  are  not  so  bright  as  children  physically  larger. 
The  examinations  which  led  to  these  conclusions  were 
held  in  schools  where  there  was  the  largest  proportion 
of  pupils  descended  from  American-born  parents. 
The  average  height  of  pupils  twelve  years  old,  who 
were  in  the  second  grade,  was  four  feet  four  and  three- 
tenths  inches,  while  the  twelve-year-old  pupils  in  the 
eighth  grade  averaged  five  inches  taller.  The  same 
rule  was  found  to  hold  good  in  the  examination  of 
children  of  all  other  grades. 

Dr.  James  P.  Glynn  has  been  appointed  associate 
surgeon  to  St.  Mary's  Hospital,  Brooklyn. 

An  Unusual  Cause  of  Death.— It  is  reported  in 
the  papers  that  one  of  the  contestants  in  a  sword  duel 
fought  last  week  in  France  was  killed  by  a  sword- 
thrust  through  the  lungs.  Death  occurring  as  the  re- 
sult of  a  French  duel  is  rare  enough  to  be  worthy  of 
record. 

The  August  Mortality.— The  monthly  bulletin  of 
the  New  York  State  board  of  health,  recently  issued, 
shows  that  during  the  month  of  August  11,047  deaths 
occurred,  which  is  almost  the  average,  and  is  a  de- 
crease of  600  from  tlie  reported  mortality  of  July.  The 
death  rate  was  1^.5,  against  19  5  in  July.  No  cases 
of  smallpox  have  been  reported  in  the  State  since  July. 

Memorial  Hospital  at  Oneonta.— The  corner  stone 
of  tlie  Aurelia  Osborn  Fox  Memorial  Hospital  at 
Oneonta,  N.  Y.,  was  laid  with  Masonic  ceremonies  on 
October  5th.  The  hospital,  which  is  designed  to  be  a 
beautiful  structure  erected  according  to  the  most  ap)- 
proved  sanitary  and  scientific  plans,  is  the  gift  of  Mr. 
Reuben  L.  Fox,  in  memory  of  his  wife. 

The  Medical  Society  of  the  Missouri  Valley  held 
its  annual  meeting  at  Council  Bluffs,  la.,  September 
20th.  The  society  voted  to  contribute  $25  to  the 
Rush  monument  fund,  and  a  resolution  was  adopted 
providing  for  a  banquet  after  each  meeting.  The  fol- 
lowing officers  were  elected:  President,  Dr.  V.  L. 
Treynor,  of  Council  Bluffs,  la.;  First  Vice-President, 
Dr.  B.  B.  Davis,  of  Omaha,  Neb. ;  Second  Vice-Presi- 
dent, Dr.  E.  E.  Sampson,  of  Creston ;  Treasurer,  Dr. 
T.  B.  Lacey,  of  Council  Bluffs,  la.;  Secretary,  Dr. 
Charles  Wood  Fassett,  of  St.  Joseph,  Mo.  The  next 
meeting  will  be  in  March,  1901,  at  Omaha. 

Alvarenga  Prize  of  the  College  of  Physicians  of 
Philadelphia. — The  next  award  of  the  Alvarenga 
prize,  being  the  income  for  one  year  of  the  bequest  of 
the  late  Serior  Alvarenga,  and  amounting  to  about 
$180,  will  be  made  on  July  14,  1901,  provided  that  an 
essay  deemed  by  the  committee  of  award  to  be  worthy 
of  the  prize  shall  have  been  offered.  Essays  intended 
for  competition  may  be  upon  any  subject  in  medicine, 
but  cannot  have  been  published,  and  must  be  received 
by  the  secretary  of  the  college  on  or  before  May  i, 
1 90 1.  Each  essay  must  be  sent  without  signature,  but 
must  be  plainly  marked  with  a  motto  and  be  accom- 
panied by  a  sealed  envelope  having  on  its  outside  the 


58o 


MEDICAL    RECORD. 


[October  13,  1900 


motto  of  the  paper  and  within  the  name  and  address 
of  the  author.  It  is  a  condition  of  competition  that 
the  successful  essay  or  a  copy  of  it  shall  remain  in 
possession  of  the  college ;  other  essays  will  be  returned 
upon  application  within  three  months  after  the  award. 
The  Alvarenga  Prize  for  1900  has  been  awarded  to 
Dr.  David  De  Beck,  of  Cincinnati,  Ohio,  for  his  essay 
entitled:  "Malarial  Diseases  of  the  Eye." 

Navy  Department,  Bureau  of  Medicine  and  Sur- 
gery, Washington,  D.  C. — Changes  in  the  medical  corps 
of  the  United  States  navy  for  the  week  ending  October 
5,  1900.  September  28th.— Surgeon  J.  C.  Byrnes  de- 
tached from  the  Massachusetts  October  ist,  and  ordered 
to  the  New  York  navy  yard.  September  30th. — 
Medical  Inspector  J.  R.  Waggener  detached  from  duty 
at  naval  hospital,  Yokohama,  Japan,  and  ordered  to 
duty  in  charge  of  the  naval  hospital,  Cavite,  P.  I.; 
Assistant  Surgeon  B.  L.  Wright  detached  from  the 
Isla  de  Luzon  and  ordered  to  the  naval  hospital, 
Cavite,  P.  I.  October  2d. — Passed  Assistant  Surgeon 
L.  L.  von  Wedekind  detached  from  the  Riihmond  and 
ordered  to  the  Puget  Sound  naval  station ;  Passed  As- 
sistant Surgeon  R.  S.  Blakeraen  detached  from  the 
naval  training-station,  Newport,  R.  I.,  and  ordered  to 
temporary  duty  on  the  Pensacola;  Passed  Assistant 
Surgeon  J.  F.  Leys  ordered  to  the  naval  hospital, 
Newport,  R.  I.,  for  duty;  Passed  Assistant  Surgeon  J. 
M.  Moore  detached  from  the  naval  recruiting  rendez- 
vous, Chicago,  111.,  October  8th,  and  ordered  home  and 
to  wait  orders;  Passed  Assistant  Surgeon  W.  F. 
Arnold  ordered  to  the  naval  recruiting  rendezvous, 
Chicago,  111.,  October  8th;  Assistant  Surgeon  C.  R. 
Burr  detached  from  the  Puget  Sound  naval  station 
and  ordered  to  proceed  home  and  to  be  ready  for 
orders  to  sea  duty;  Surgeon  S.  H.  Dickson  detached 
from  the  Washington  navy  yard  and  ordered  to  duty 
at  the  headquarters  of  the  marine  corps,  Washington, 
D.  C;  Surgeon  C.  G.  Herndon  detached  from  the 
naval  museum  of  hygiene,  Washington,  D.  C,  October 
8th,  and  ordered  to  duty  at  the  Washington  navy  yard ; 
Surgeon  E.  H.  Green  detached  from  duty  at  the  head- 
quarters of  the  marine  corps,  Washington,  D.  C,  and 
ordered  to  wait  orders.  October  4th. — Surgeon  E.  H. 
Green  ordered  to  the  Alabama  October  i6th.  October 
5th. — Assistant  Surgeon  T.  M.  Lippitt  detached  from 
the  Monocacy  and  ordered  to  the  naval  hospital,  Yoko- 
hama, Japan,  for  treatment. 

Yellow  Fever  in  Havana.— Reports  from  Havana 
state  that  the  yellow-fever  situation  there  shows  no 
sign  of  improvement.  During  the  month  of  September 
two  hundred  and  fifty-seven  cases  were  officially  report- 
ed, with  a  mortality  of  twenty-five  per  cent.  Eighty- 
four  cases  were  under  treatment  on  September  3otli,  and 
twenty-eight  new  cases  were  reported  on  the  first  two 
days  of  October.  There  is  some  discussion  regarding 
the  diagnosis  of  the  disease,  and  many  cases  which  some 
competent  authorities  regard  as  yellow  fever  are  not 
reported  because  of  the  absence  of  albuminuria. 
There  are  not  many  cases  among  the  United  States 
troops,  but  there  has  been  some  alarm  occasioned  by 
an  unusual  prevalence  of  yellow  fever  among  civilian 
employees  of  the  government  of  occupation. 


The  Plague. — A  death  from  this  disease  has  oc- 
curred at  Cardiff,  Wales.  The  victim  was  a  sailor 
who  recently  arrived  on  the  Tyne  from  Rosario, 
Argentina.  Another  case  of  plague  came  to  light  in 
Glasgow  on  October  6th,  in  a  part  of  the  city  which  has 
hitherto  been  free  from  the  disease. 

The  Biennial  Congress  of  Scandinavian  Physi- 
cians met  recently  in  Copenhagen.  It  was  voted  to 
publish  a  report  of  the  proceedings  in  the  Nordisk 
Medicmisk  Archiv  in  the  German  language,  as  it  was 
said  that  papers  and  abstracts  piiblislied  in  French  or 
English  were  more  or  less  nei;lected  by  the  foreign 
press,  while  those  in  German-were  much  more  likely 
to  receive  notice.  The  next  congress  will  be  held  in 
1902  at  Helsingfors  under  the  presidency  of  Professor 
Runeberg. 

The   New   York  State  Medical   Association  will 

hold  its  seventeenth  annual  meeting  at  the  Academy 
of  Medicine  in  this  city  on  October  15th,  i6th,  17th, 
and  18th,  under  the  presidency  of  Dr.  E.  D.  Ferguson, 
of  Troy.  The  other  officers  are:  Vice-Presidents, 
Charles  H.  Glidden,  of  Little  Falls,  John  M.  Farring- 
ton,  of  Binghamton,  William  H.  Thornton,  of  Buffalo, 
and  Julius  C.  Bierwirth,  of  Brooklyn;  Secretary,  M. 
Christopher  O'Brien,  of  New  York;  Treasurer,  Edward 
H.  Squibb,  of  Brooklyn.  Dr.  T.  H.  Wiggin  is  chair- 
man of  the  committee  of  arrangements. 

Sanatoria  for  Tuberculosis  at  Fort  Stanton. — 
Several  mutual  benefit  societies,  including  the  Ancient 
Order  of  United  Workmen,  the  Woodmen,  and  Odd 
Fellows,  have  requested  of  the  government  permission 
to  erect  sanatoria  for  consumptives  in  the  Fort  Stanton 
Reservation,  one  hundred  and  fifty  miles  south  of 
Santa  Fe',  N.  M.  It  has  been  suggested  that  the  gen- 
eral government  allot  a  certain  tract  to  any  or  all  of 
the  States  which  may  make  application  for  ground 
upon  which  to  erect  sanatoria.  There  is  already  a 
government  hospital  there. 

Obituary  Notes. — Dr.  William  Webb  Browning 
died  at  iiis  home  in  Brooklyn  on  October  3d,  of  apo- 
plexy. He  was  born  in  Metuchen,  N.  J.,  in  1852. 
He  was  graduated  from  Yale  in  1873,  with  the  degree 
of  A.li.,and  in  1875  was  graduated  from  the  Columbia 
Law  School  with  the  degree  of  LL.B.  After  practis- 
ing law  in  this  city  for  seven  years,  he  entered  the 
Bellevue  Medical  College,  from  which  he  was  gradu- 
ated in  1884.  In  1895  Yale  College  conferred  upon 
him  tlie  honorary  degree  of  A.M.  He  was  professor 
of  anatomy  and  of  clinical  orthopedics  in  the  Long 
Island  College  Hospital,  and  was  a  member  of  the 
Kings  County  Medical  Society  and  of  the  American 
Academy  of  Medicine. 

Dr.  Maria  Upton  Hanford,  a  homoeopathic  phy- 
sician of  Brooklyn,  died  on  October  6th  at  the  age  of 
sixty-three  years.  She  was  a  graduate  of  tiie  New 
York  Medical  College  and  Hospital  for  Women  in 
1S90,  and  was  the  wife  of  a  practising  physician  of 
Williamsburg. 

Dr.  Stephen  E.  D.  Hoornbeck  died  suddenly  at 
his  home  in  Ellenville,  N.  Y.,  on  October  3d.  He 
was  bom  in  Wawarsing  Corners,  N.  Y.,  in  1844,  and 


October  13,  1900] 


MEDICAL   RECORD. 


5S1 


was  graduated  from  the  College  of  Physicians  and 
Surgeons  in  this  city  in  1865.  He  soon  retired  from 
the  medical  profession  and  entered  business.  He  was 
appointed  a  member  of  the  Eastern  New  York  Re- 
formatory Commission  in  1894. 


grogrcss  ot  g^cdical  Science. 

Medical  News,  Oitvber  6,  igoo. 

The  Treatment  of  Consumption  at  Home. — Joseph  Eichbeig 
states  that  all  tlicrapcutists  in  the  pursuit  of  the  specific 
idea  seem  to  have  lost  sight  of  the  idea  that  pulmonary  tu- 
berculosis in  the  only  forms  which  are  amenable  to  treat- 
ment, i.e.,  in  its  clironic  forms,  is  always  either  a  mixed 
infection  or  a  process  so  limited  iu  its  distribution  that 
natural  safeguards  will  surround  the  tuberculous  area  with 
an  investinj^  capsule  and  thus  make  it  harmless.  The 
treatment  of  consumption  may  be  properly  classified  as  the 
specific,  the  climatic,  the  dietetic,  and  the  hygienic.  It  is 
fair  to  presume  that  the  search  for  specifics  is  no'-  yet  done, 
nor  likely  to  be  given  up,  but  the  patient's  safety  proba- 
bly does  not  lie  in  that  direction.  The  most  noteworthy 
feature  in  the  reports  of  recent  studies  is  the  uniformity 
of  success  under  climatic  conditions  tlie  most  diverse.  We 
may  safely  feel  that  we  are  not  of  necessity  bound  to  any 
climate  or  altitude.  The  patient  must  live  out-of-doors. 
Next  to  good  air  we  place  good  food,  and  of  this  there  must 
be  an  abundance.  'I'he  patient  should  be  steadily  encour- 
aged to  eat  more  than  he  wants.  Cream  and  butter  should 
be  introduced  into  as  many  dishes  as  possible.  The  third 
feature  is  good  rest.  It  is  a  good  rule  for  the  patient  to 
take  no  e.^ercise  until  there  is  no  fever.  All  sources  of  ex- 
citement and  worry  should  be  eliminated.  The  patient 
should  sleep  as  much  as  he  chooses.  The  fourth  factor  is 
good  cheer.  The  moral  influences  surrounding  the  patient 
are  all-important.  Medicines  from  the  shop  really  do  not 
enter  as  a  necessary  jiart  into  this  plan  of  treatment.  The 
various  symptoms  may,  however,  be  treated  by  the  well- 
known  remedies.  The  ordinary  hygienic  rules  should  be 
carefully  observed.  All  cases,  even  the  most  desperate, 
are  suitable  for  this  home  treatment. 

Internal  Secretion  of  the  Ovary. — Arthur  W.  Johnstone 
writes  that  retained  excretions  are  the  causes  of  nearly  all 
nervous  conditions,  whether  at  the  menopause  or  during 
menstrual  life.  There  is  not  an  iota  of  proof  that  the  ova- 
ry has  any  other  function  than  the  manufacture  of  eggs. 
The  writer  believes  the  rule  to  be  that  if  a  woman's  men- 
struation is  for  any  reason  except  pregnancy  delayed,  she 
is  very  apt  to  have  symptoms  closely  approximating  those 
of  the  change  of  life.  This  being  so,  he  is  led  to  believe 
that  the  internal  secretion  of  the  ovary  is  a  myth.  The 
ovary,  then,  not  having  any  kind  of  interna!  secretion,  the 
troubles  which  accompany  the  menopause,  both  natural 
and  artificial,  arc  due  to  a  faulty  oxidation  and  excre- 
tion. One  other  cause  of  this  condition  is  the  intestinal 
infection  that  goes  with  nearly  all  these  cases,  and  this 
allows  the  colon  bacillus  and  its  associates  to  contaminate 
the  nitrogenous  bodies  with  their  ptomains  before  they 
are  absorbed  into  the  blciod.  Until  we  get  rid  of  the  old 
superstition  of  "ovarian  influence"  and  similar  terms 
which  we  have  heard  for  so  many  centuries,  the  reproduc- 
tive functions  will  never  be  thoroughly  understood.  As 
to  the  limits  of  conservative  surgery  :  When  an  ovary  and 
its  accompanying  tube  can  be  left  in  a  healthy  condition  so 
that  their  functions  can  iie  easily  carried  out,  they  should 
be  preserved,  but  those  dangerous  experiments  which  re- 
sult in  the  leaving  of  a  scrap  of  one  ovary  in  one  part  of 
the  abdomen  and  a  piece  of  a  tube  in  another,  or  the  trans- 
plantation of  an  ovary  from  one  patient  to  another,  should 
be  condemned. 

Iritis. — J.  H.  McCassy  defines  the  iris  as  the  colored 
membrane  which  separates  the  lens  and  its  capsule  from 
the  cornea.  The  iris  is  the  only  muscular  organ  that  is 
constanly  immersed  in  liquid.  Iritis  furnishes  from  three 
to  four  per  cent,  of  all  ophthalmic  cases.  It  is  not  very 
frequent  during  the  first  fifteen  years  of  life  and  during 
old  age.  It  atfects  men  more  frequently  than  women. 
Syphilis,  rheumatism  (articular) ,  injury,  gonorrhoea,  gout, 
diabetes,  malaria,  etc.,  are  the  most  frequent  causes. 
There  are  three  varieties:  (i)  Plastic;  (2)  serous;  (3) 
parenchymatous.  The  symptoms  are  pain,  photophobia, 
lacrymation,  pericorneal  redness,  impaired  mobility  of  the 
iris,  exudation  of  inflammatory  products,  and  disturbance 
of  sight.  Iritis  should  be  differentiated  from  conjunctivitis 
and  glaucoma.  The  course  of  this  trouble  may  be  acute, 
subacute,  or  chronic.     If  free  dilatation  of  the  pupil  can  be 


secured  and  the  injury  has  not  been  too  gfreat,  the  progno- 
sis is  favorable.  Atropine  is  the  sheet-anchor  in  iritis.  It 
is  the  great  anodyne.  Paracentesis  is  indicated  when  the 
tension  of  the  eyeball  is  persistently  and  notably  raised ; 
also  in  large  hypopyon  or  dotted  spots  upon  the  back  of 
the  cornea,  or  when  the  inflammation  refuses  to  yield  to 
milder  means.  In  seclusion  or  occlusion  of  the  pupil  an 
iridectomy  should  be  performed  as  soon  as  the  disease  be- 
comes quiescent. 

Internal  Antisepsis. — By  Reynold  Webb  Wilcox. 

Neuralgia  Paraesthetica. — By  James  J.  W^alsh. 
T/ie  Boston  Medical  and  Surgical  Journal,  Oct.  4,  tqoo. 

Remarks  upon  Obscure  Non-Traimiatic  Tumors  of  the 
Lower  Abdomen  Suddenly  Appearing  where  None  had  Pre- 
viously been  Detected.  — Maurice  H.  Richard.son,  in  summing 
up  the  matter  of  the  acute  abdominal  emeigencies  which 
constitute  the  greater  portion  of  obscure  and  suddenly 
appearing  tumors,  says  that  the  chief  aim  should  be  to 
view  the  whole  with  common  sense,  to  consider  carefully 
the  history,  weigh  carefully  the  symptoms,  to  apply  all 
reasonable  methods  of  examination,  and  finally,  if  it  is  de- 
termined that  intervention  is  necessary,  to  proceed  to 
operation  without  unnecessary  delay.  In  all  suddenly  ap- 
pearing tumors  of  tlie  lower  abdomen,  however  obscure 
they  may  be,  intervention  is  demanded  if  the  symptoms 
are  the  least  urgent.  A  tumor  that  has  attributes  of  sud- 
den formation,  of  tenderness,  of  hemorrhage,  of  profound 
constitutional  disturbance,  demands  immediate  interven- 
tion. Tumors,  however,  svhich  do  not  possess  the  attri- 
butes of  urgency  may  be  watched,  especially  if  the  local 
symptoms  are  subsiding  and  if  the  patient's  strength  is 
returning.  From  their  very  nature,  however,  they  all  re- 
quire surgical  intervention  sooner  or  later. 

Case  of  Patent  Foramen  Ovale  in  Advanced  life. — Wil- 
liam L.  Worcester  reports  the  case  of  a  negro  aged  fifty- 
seven  years,  admitted  to  the  hospital  suffering  from  gen- 
eral paralysis.  In  the  physical  examination  then  made, 
the  following  condition  of  the  heart  was  noted:  "Apex 
beat  in  sixth  interspace,  under  nipple  ;  no  heart  sounds 
heard  ;  a  long,  loud  murmur,  systolic  in  time,  can  be  dis- 
tinctly made  out  at  apex."  No  indications  of  embarrassed 
circulation  were  noticed.  The  patient  died  of  exhaustion 
from  a  series  of  convulsions.  At  the  autopsy  the  heart 
was  found  to  be  moderately  hypertrophied  ;  the  cavities,  es- 
pecially the  right  ventricle,  were  dilated.  The  valves  were 
healthy.  The  foramen  ovale  was  patent,  measuring  2)^ 
by  2  cm.  in  diameter.  It  was  divided  into  two  unequal 
parts  by  a  small  tendinous  cord.  Immediately  under  the 
right  aortic  semilunar  valve  was  an  opening  forming  a 
communication  between  the  ventricles.  On  the  side  of 
the  left  ventricle  it  was  about  i  cm.  in  its  longest  diam- 
eter ;  on  the  side  of  the  right  ventricle  not  more  than  2  mm. 
in  diameter.  So  far  as  could  be  judged  from  appearances, 
this  was  probably  a  congenital  defect. 

Serum  Therapy  in  Pneumonia. — William  H.  Smith  says 
that,  as  the  question  stands  to-day,  it  may  be  stated  that 
experimentally  animals  may  be  rendered  immune,  that 
their  serum  has  protective  property,  and  that  continued 
investigation  is  doing  away  with  some  of  the  difticulties 
which  previously  harassed  the  early  investigators.  But 
the  fact  still  remains  that  in  dealing  with  the  pneumococ- 
cus  we  are  dealing  with  an  organism  capable  of  many  va- 
riations and  degrees  of  virulence,  and  that  the  serurn  ob- 
tained under  such  conditions  mu.st  of  necessity  vary  both 
in  strength  and  character.  Experimentally,  antipneumo- 
coccus  serum  seems  to  be  of  value.  Practically,  that  it  is 
of  any  great  value  does  not  at  present  seem  to  have  been 
demonstrated,  as  the  reported  number  of  cases  are  too  few. 
and  the  series  of  any  one  observer  is  too  small. 

A  Case  of  Inflamed  Peritoneal  Cyst  Simulating  Ovarian 
Cyst  with  Twisted  Pedicle. — By  Agnes  C.  Victor. 

AVti'  York  Medical  Journal,  October  6,  rqoo. 
Prevalent  Errors  regarding  the  Diagnosis  and  Treatment 
of  "Eye  Strain"  from  Various  Causes. — A.  L.  Ranney 
gives  his  conclusions  as  follows  :  (i)  All  errors  of  refraction 
(manifest  and  latent)  should  be  first  very  accurately  de- 
termined, and  as  far  as  possible  corrected  for  both  distant 
and  near  points.  (2)  A  mydriatic  should  be  employed  be- 
fore suspected  latent  refractive  errors  are  finally  decided 
upon.  (3)  The  ophthalmometer  of  Javal  should  first  be 
employed  to  detect  and  measure  corneal  astigmatism. 
Subsequently  cylindrical  trial  lenses  should  be  employed 
to  verify  the  instrument  of  Javal  or  to  detect  astigmatism  of 
the  lens.  (4)  Neither  retinoscopy,  nor  trial  lenses,  nor  the 
opiithalmoscope  are  positive  and  trustworthy  in  estimat- 
ing "latent  "  refractive  errors.  The  former  is  probably  the 
best  of  the  three  in  skilful  hands;  but  serious  errors  may 
be  made  even  by  a  competent  retinoscopist.  (5)  A 
marked  difference  in  the  refraction  of  the  two  eyes  should 
be  corrected  by  proper  lenses  at  all  times  and  for  all 
points.     This  is  vital  to  good  work  on  eye-muscles  as  a 


582 


MEDICAL   RECORD. 


[October  13,  1900 


preliminary  step.  (6)  Cylindrical  glasses  should  prefer- 
ably, but  not  necessarily,  be  set  in  spectacle  frames,  in 
order  to  lessen  the  clanger  of  alteration  in  the  a.\is  of  the 
cylinder.  (7)  Xo  glas.ses  prescribed  should  ever  be  worn 
by  a  patient  until  they  have  been  inspected  and  verified 
by  the  oculist  who  prescribed  them.  (S)  The  frames 
selected  by  the  patient  or  optician  should  always  be  in- 
spected by  the  oculist  with  care  t )  guard  against  de- 
centred  lenses  Each  pupil  should  accurately  correspond 
to  the  centre  of  the  lens.  In  children,  the  frames  may  haev 
to  be  changed  from  time  to  time,  on  account  of  the  growth 
of  the  head  and  face,  (q)  Patients  should  be  personally 
instructed  by  the  oculist  to  observe  any  decentiing  of 
their  own  lenses,  that  often  occurs  from  bending  of  the 
frames  or  nose-clips  :  also  personally  to  test  the  vision  of 
each  eye  separatelj-  from  time  to  time  (by  means  of  a  test 
card)  to  see  if  the  refractive  correction  remains  perfect. 
(10)  Patients  should  also  be  cautioned  by  oculists  always 
to  iiave  their  lenses  verilied  whenever  they  fall  out  of 
the  frames  and  are  replaced,  or  whenever  a  lens  gets 
broken  and  a  new  one  is  made.  (11)  All  tests  made  to 
determine  either  the  power  of  individual  muscles  of  the 
orbit  or  the  presence  or  absence  of  equilibrium  of  the  ocu- 
lar muscles  are  of  no  positive  value  until  all  errors  of  re- 
fraction are  determined  and  properly  corrected  by  lenses. 
(12)  The  first  "  muscular  tests  "  made  upon  any  patient  by 
the  oculist  should  be  recorded  as  revealing  only  the  "'man- 
ifest "  muscular  errors  (in  contradistinction  to  "latent" 
muscular  errors)  ;  and  these  tests  should  invariably  be 
made  with  the  proper  lenses  placed  befoie  the  eyes  of  the 
patient  to  correct  refractive  errors,  if  any  exist.  (13) 
The  "manifest"  muscular  errors  (revealed  at  the  first  ex- 
amination) should  never  be  regarded  as  possessing  much 
clinical  importance,  except  as  possible  pointers  toward 
some  special  type  of  heterophoria  and  a  guide  to  the  ocu- 
list in  searching  for  "latent"  heterophoria.  (14)  The  most 
positive  and  uniform  standard  of  power  in  any  of  the  ocu- 
lar muscles  (when  studying  some  puzzling  case  of  sus- 
pected heterophoria)  is  the  normal  power  of  abduction. 
(151  A  marked  difference  in  the  power  of  sursumduction 
on  the  two  eyes  is  always  to  be  regarded  as  a  suspicious 
sign  of  hyperphoria.  (16)  It  is  usually  wise  to  follow  up 
suspected  latent  hyperphoria  with  vertical  prisms,  prior  to 
any  investigation  of  apparent  anomalies  of  the  internal  or 
external  muscles,  whenever  hypoesophoria  or  hypoexo- 
phoria  seem  to  exist.  (17)  Whenever  the  refraction  of  a 
patient  requires  the  constant  wearing  of  glasses  to  correct 
it,  the  investigation  of  heterophoria  by  the  wearing  of 
prisms  is  most  easily  made  through  the  aid  of  lorgnette 
frames  that  can  be  attached  to  spectacle  frames  by  means 
of  small  hooks.  (iS)  Operative  procedures  upon  the  eye 
muscles  should  never  be  too  hastily  performed.  It  is  vi- 
tally important,  to  insure  the  best  results  in  any  case,  that 
the  effects  of  accurate  refractive  correction  (and  possibly 
of  prisms  also)  be  noted  for  a  time  ;  and  that  repeated 
muscular  tests  be  made  in  any  case  of  heterophoria  before 
any  s 'rgical  steps  for  its  radical  correction  be  advised  or 
undertaken. 

The  Use  of  the  Suprarenal  Capsule  in  Diseases  of  the 
Heirt;  a  Preliminary  Report. — S.  Flnersheim  has  noticed 
no  effect  upon  the  normal  heait,  but  found  that  in  cases  of 
mitral  regurgitation  bj'  giving  dry  powdered  suprarenal 
gland,  gr.  v.  in  a  capsule,  to  be  chewed,  within  from  one 
minute  to  ten  minutes  the  action  of  the  drug  became  ap- 
jjarent.  In  one  case  he  noted  that  the  effects  became  ap- 
parent as  rapidly  as  in  fifteen  seconds.  The  pul.se  grew 
fuller,  stronger,  and  more  regular,  the  contractions  of  the 
heart  more  rhythmical  ;  the  murmur,  which  was  diffused 
and  blurred,  became  circumscribed,  and  in  two  cases  the 
murmur,  which  was  slight,  actually  disappeared  and  re- 
mained absent  for  more  than  fifteen  minutes,  while  in  a 
number  of  other  cases  the  murmur  became  reduced  in  vol- 
ume, the  heart  sounds  clearer,  the  murmurs  more  distinct, 
more  easily  recognized  and  differentiated.  In  a  genera! 
way  it  may  be  said  that  under  this  remedy  tlie  rapidity  of 
the  heart  is  not  noticeably  altered  while  the  tone  is  im- 
proved, especially  in  conditions  of  dilatation,  and  a  much 
better  force  is  induced.  Concerning  the  rapidity  of  effect 
he  found  that  manifest  effect  was  apparent  at  times  in  ten 
seconds,  while  at  other  times  ten  minutes  were  neces.sary 
to  show  any  evident  change.  He  uses  the  extract  as  an 
adjuvant  toother  remedies.  No  claim  is  made  that  it  takes 
the  place  of  nitroglycerin,  strychnine,  or  digitalis. 

Implantation  of  an  Artificial  Vitreous  ;  "  Mules'  Operation." 
— M  L.  Foster  refers  to  three  cases,  two  of  which  were 
operated  on  by  himself.  He  finds  that  the  great  advan- 
tage of  Mules'  operation  is  that  the  glass  ball  within  the 
sclera  maintains  the  muscular  apparatus  of  the  eye  in 
nearly  its  normal  position,  and  so  secures  its  better  action, 
which  results  in  better  motility  of  an  artificial  eye  when 
properly  fitted.  The  most  .serious  objection  he  finds  to  be 
the  prolonged  convalescence,  which  lasts  from  ten  to  fif- 
teen days,  about  double  the  length  of  that  following  enu- 


cleation. Failure  of  the  operation,  with  extrusion  of  the 
glass  ball,  occasionally  happens.  It  may  be  the  result  of 
the  insertion  of  too  large  a  glass  ball,  suppuration,  or  the 
absorption  of  catgut  sutures  in  the  sclera  before  the  cut 
edges  of  that  tissue  have  become  firmly  united.  It  seems 
better  to  use  the  smallest-sized  ball  in  every  case,  and  to 
use  silk  to  unite  the  edges  of  sclera.  Sujipuration  is  to  be 
guarded  against  by  the  observation  of  strictest  asepsis. 

Some  Observations  upon  Syphilitic  Manifestations  in  the 
Optic  Nerve  and  Retina;  Inflammatory  Manifeitations.— By 
P.  T.  Vaughan. 

A  Case  of  Pin  in  the  Larynx  for  Two  Years ;  Removal  by 
Endolaryngeal  Methods.— By  A.  \V.  Ue  Roaldes. 

Combined  Electrization,  or  Galvanofaradization. — By  A.  D. 
Rockwell. 

Fibroma  of  the  Larynx.  —  Case  reported  by  A.  B. 
Thraslier. 

Journal  of  Die  American  Medical  Ass' n,  Oct.  6,  /goo. 

The    Reefing    Operation    for    MovabL-    Kidney. —  Edward 

Wyllys  Andrews  describes  the  technique  of  this  opera- 
tion as  follows;  (i)  Incision  at  the  outer  borders  of 
the  quadratus  from  the  twelfth  rib  to  the  ilium.  This 
is  carried  through  the  lumbar  fa.scia  and  along  the  edge 
of  the  quadratus  to  the  loose  fat  about  the  kidney.  (2) 
The  mu.scles  are  retracted  and  the  fatty  capsule  is  split 
the  wliole  length  of  the  kidney.  The  two  flaps  thus 
formed  are  pulled  outside,  and  the  kidney  is  thus  held 
well  up  and  back.  Care  should  be  taken  that  the  lower 
pouch  of  this  capsule  is  pulled  high  up.  In  cases  of  great 
prolapse,  the  fatty  capsule  will  be  found  drawn  into  a 
long  tube,  like  a  stocking.  It  will  surprise  one  who  has 
not  tried  it  to  see  how  nicely  it  can  be  reefed  by  draw- 
ing it  out  of  the  skin  opening,  and  how  well  the  kidney 
obeys  every  pull  we  make  in  the  upward  and  backward 
direction.  It  is  expected  that  Gerota's  capsule  is  included. 
Five  or  six  inches  of  this  fatty  sac  can  sometimes  be  drawn 
up.  The  kidney  will  now  be  seen  to  lie  snugly  in  the  lum 
bar  wound,  and  yet  to  rise  and  fall  in  respiration.  Prob- 
ably it  will  be  an  inch  or  more  below  its  normal  place. 
This  is  an  advantage,  because  it  removes  from  it  the  pres- 
sure of  the  liver,  and  enables  us  to  hold  the  entire  organ 
and  not  merely  its  lower  pole.  He  has  had  cases  of  relapse 
by  older  methods  in  which  the  lower  pole  was  still  an- 
chored by  his  stitches,  while  the  upper  end  tilted  forward 
and  could  be  felt  below  the  costal  arch  in  front.  (3)  The 
broatl  segments  of  the  fatty  capsule,  and  its  enclosing,  or 
Gerota's,  fascia  already  drawn  outside  are  now  held  by 
the  hands  of  an  assistant  or  by  long  forceps,  while  the 
oijening  in  the  muscular  wall  is  closed  by  a  line  of  mat- 
tress stitches.  These  transfix  the  fatty  capsule.  The  real 
support  is  obtained,  how^ever,  not  by  the  stitches,  which 
would  cut  out,  but  by  compression  between  the  muscles. 
(4)  The  flaps  should  now  be  cut  off  an  inch  or  two  outside 
the  muscle,  everted  and  stitched  down,  after  which  the 
skin  can  be  closed  in  any  simple  manner. 

Yellow  Fever ;  its  Nature  and  Cause. — Eugene  Wasdin 
in  discussing  tliis  subject  says  that  yellow  fever  has 
presented  a  uniform  complex  of  symptoms  which  distin- 
guishes it  clinically  from  other  infections.  In  a  character- 
istic case,  the  temperature  rises  to  its  maximum  within  the 
first  twenty-four  to  thirty-six  hours,  the  pulse  rising  at 
first  in  proportion  to  the  temperature,  but  this  does  not 
continue.  Upon  the  second  or  third  day  the  temperature 
generally  declines,  the  patient  entering  a  period  of  com- 
parative calm.  Then  comes  the  third  stage  with  rising 
temperature.  This  phenomenon  presenting  the  two  acces- 
sions of  temperature  with  a  decline,  the  period  of  calm 
separating  them,  has  been  recognized  by  southern  clini- 
cians as  the  most  characteristic  of  all  the  symptcmis  of  yel- 
low fever.  Among  the  clinical  phenomena  is  the  "black 
vomit."  Cases  of  the  fever  have  been  divided  into  three 
classes — the  ephemeral,  the  grave,  and  the  siderante  or 
fulminantly  fatal  cases.  Tlie  writer  believes  that  the  ba- 
cillus icteroides  is  constantly  present  in  yellow  fever,  and 
that  it  is  the  cause  of  the  disease. 

Lessons  from  a  First  Series  of  One  Hundred  Cataract  Op- 
erations.— F.  T.  Rogers  from  a  study  of  these  cases  draws 
the  fnllowing  conclusions:  (i)  More  attention  should  be 
paid  to  the  general  condition  of  the  patient,  and  the  pres- 
ence of  any  systemic  disturbance  slumld  influence  the 
prognosis.  (2)  All  operative  procedures  on  the  crystal- 
line body  should  be  done  under  the  best  possible  illumina- 
tion. (3)  Providing  that  it  is  large  enough,  the  exact  site 
of  the  corneal  section  does  not  materially  influence  the  re- 
sult. (4)  The  combined  operation  is  the  safest  and  the 
easiest  for  the  operator  of  limited  experience.  (5)  The 
most  frequent  complications,  iritis  and  iridocyclitis,  should 
be  combated  by  the  early  instillation  of  atropine,  and  their 
existence  does  not  necessarily  prevent  an  ultimate  good 
result.     (6)   Discission  of  the  capsule  can  be  done  with 


October  13,  1900] 


MEDICAL   RECORD. 


583 


comparative  safety  and  materially  increases  the  acuity  of 
vision.  (7)  Infection  of  the  wound  does  not  in  all  cases 
destroy  the  sight.  (8)  The  patient  should  be  frankly  in- 
formed of  tile  possible  outcome. 

Resection  and  Anastomosis  of  the  Divided  Ureter. — By 
Howard  A.  Kelly. 

Aseptic  Minor  Gynaecology:  with  Demonstrations.— By  Au- 
gustin  H.  Goelet. 

Demonstration  of  Home  Milk  Modifier. — By  A.  L.  Sher- 
man. 

Acute  Graves'  Disease. — By  James  R.  Arneill. 

Philadelphia  Medical  Journal,  October  6.,  iqoo. 

The  Etiology  of  Gall  Stones.— Frederick  C.  Shattuck 
says  that  little  is  known  of  this  subject.  What  we  do 
know  is  that  (i)  gall  stones  are  composed  mainly  of  cho- 
lesterin,  often  partly  of  biliverdin  calcium  precipitated  by 
changed  reaction  of  the  bile.  A  nucleus  may  be  formed 
of  biliverdin  calcium,  bacteria,  a  foreign  body,  or  a  com- 
bination of  these.  (2)  Gall  stones,  while  not  unkiiowu  in 
childhood,  are  rare  under  the  age  of  thirty  years  ;  from 
thirty  to  sixty  they  are  more  common,  little  difference  ex- 
isting between  the  several  decades  of  this  period  in  point 
of  frequency  :  after  sixty  they  are  more  common  than  in 
earlier  life.  (3)  They  are  from  two  to  four  times  more 
common  in  women  than  in  men.  Stasis  of  the  bile  is  a 
very  important  etiological  factor,  and  the  chief  causes  of 
this  seem  to  be.  in  the  writer's  opinion,  tight  lacing  and 
want  of  exercise,  and  typhoid  fever.  He  thinks  we  can  get 
rid  of  the  latter  cause  more  easily  than  of  the  fornur. 

A  Case  of  Gall-Stone  Obstruction  of  the  Cystic  Duct,  Illus- 
trating the  Difference  in  Pathology,  Symptoms,  and  Treat- 
ment between  This  and  Gall-Stone  Obstruction  in  the  Com- 
mon Duct. — By  Krederiik  \.  McGrew. 

■  Hemorrhagic  Pancreatitis  and  Fat-Necrosis  following  an 
Operation  on  the  Gall  Bladder. — By  Charles  G.  Stockton  and 
Herbert  U.  Williams. 

Two  Interesting  Cases :  Gall  Stone  of  the  Cystic  Duct, 
with  Situs  Viscerum  Inversus ;  and  Gumma  of  the  Liver. — 
By  I'rank  Billings. 

Indications  for  Drainage  in  Diseases  of  the  Biliary  Passages 
and  the  Technique  of  Operation.-  By  J.  E.  Summers,  Jr. 

On  Lesions  of  the  Pancreas  Simulating  Gall-Stone  Impac- 
tions of  the  Common  Duct. — By  Maurice  H.  Richaidson. 

Diagnosis  of  Medical  and  Surgical  Diseases  of  the  Liver 
and  Biliary  Passages. — By  John  Herr  Musser. 

The  Relation  between  Gall  Stones  and  Appendicitis. — By 
A.  J.  Ochsner, 

Obstruction  of  the  Common  Bile  Duct. — By  John  B.  Deaver. 

The  Lancet,  Septcjiiber  2g,  igoo. 

A  Lymphatic  Anaemia  Met  with  in  Children. — .\.  Mac- 
gregor  has  seen  within  the  last  few  months  some  twenty- 
three  cases  of  an  anaemia  which  he  does  not  find  described 
in  any  of  the  books.  Boys  are  far  more  often  affected  than 
girls,  and  the  favorite  age  seems  to  be  between  three  and 
eleven  years.  The  cervical  triangles  become  packed  with 
small,  hard  glands,  and  there  is  a  chain  of  them  along  Pou- 
part's  ligament.  The  spleen  is  generally  enlarged.  It  is 
not  the  condition  in  which  the  glands  become  tuberculous, 
nor  is  it  gland  fever.  The  axillary  glands  are  never  af- 
fected, while  the  bronchial  glands  frequently  are.  Catar- 
rhal pneumonia  is  not  uncommon.  The  anamia  is  not 
always  very  marked.  Examination  of  the  blood  shows  a 
decrease  of  the  red  and  a  large  increase  of  the  white  cor- 
puscles, and  of  the  latter  tlie  increase  of  the  large  uninu- 
cleated  corpuscles  is  very  striking.  Normally,  it  is  said, 
lymphocytes  form  fifteen  to  twenty  percent,  of  the  white 
corpuscles,  the  large  uninucleated  from  six  to  eight  per 
cent.,  the  multinucleated  from  seventy  to  eighty  per  ceut.. 
and  the  eosinophilic  from  two  to  four  or  seven  per  cent. 
Macgregor  stained  a  large  number  of  films  of  the  blood  of 
children  suffering  from  this  lymphatic  ansemia,  and  on 
counting  the  leucocytes  found  that  the  lymphocytes 
formed  from  twelve  to  thirteen  per  cent.,  the  large  uninu- 
cleated from  twenty  to  thirty-nine  per  cent.,  the  multinu- 
cleated from  forty-one  to  sixty-three  per  cent.,  and  the 
eosinophilic  from  two  to  nearly  seven  percent.  The  in- 
crease of  the  large  uninucleated  corpuscles  from  six  tn 
thirty-nine  per  cent,  is  certainly  noteworthy. 

The  Etiology  of  Rheumatic  Fever.— F.  J.  Poynton  and  A. 
Paine  have  found  in  this  disease  a  diplococcus  concerning 
which  they  make  the  following  claims:  "  (i)  We  have 
demonstrated  these  diplococci  in  eight  successive  cases  ot 
acute  rheumatism.  (2)  They  have  been  present  in  five 
cases  in  pure  culture.  (3)  We  have  obtained  them  (at 
from  the  blood  of  living  patients  suffering  from  acute  rheu- 
matic pericarditis  :  {b)  from  the  pericardial  fluid  and  from 
the  fragments  of  granulations  removed  from  the  valves 
after  death ;  and  (C)  from  the  throat  of  the  living  patient 


suffering  from  rheumatic  tonsillitis.  (4)  We  have  isolated 
them  and  grown  them  in  an  acid  medium  and  also  upon 
blood  agar.  (5)  They  have  also  grown  in  the  pericardial 
fluid,  which  we  proved  on  those  occasions  to  be  acid.  (6) 
They  do  not  thrive  on  ordinary  media.  (7)  We  have  iso- 
lated them  in  pure  culture  from  the  joint  exudation,  heart 
blood,  urine  from  the  bladder,  and  cerebro-spiual  fluid  of 
rabbits  that  have  been  inoculated  with  a  sufficient  dosage." 
The  authors  believe  the  organism  to  be  identical  with 
those  described  by  Triboulet  and  Wassermanu  a  few  years 
ago.  The  rest  of  the  article  is  devoted  to  the  detailsof  the 
facts  laid  down  in  the  general  summary  given  above. 

A  Case  of  Rupture  of  the  Anterior  Annular  Ligament 
of  the  Ankle  Joint.— The  patient  of  G.  W.  Ord  was  a  strong 
boy.  aged  thirteen  years,  who  had  twisted  his  ankle  at 
cricket.  There  was  slight  puffiness  just  internal  to  the 
external  malleolus  and  no  ecchymosis,  but  there  was 
great  pain  on  flexing  the  foot  and  on  pressure  over  the 
swelling.  When  he  stood  up  with  feet  uncovered,  the  big 
toe  couhl  be  extended  fairly  well  but  not  so  well  as  its  fel- 
low on  the  sound  limb;  the  second,  third,  and  fourth  toes 
could  not  be  raised  from  the  ground,  though  he  was  just 
able  to  communicate  movement  to  them  :  while  the  little 
toe  was  immobile.  Ord  applied  the  battery  to  exclude  the 
possibility  of  ruptured  tendon,  and  obtained  muscular  con- 
traction of  the  extensor  longus  digitorum.  but  with  dimin- 
ished extension,  especially  of  the  little  toe.  Treatment 
consisted  in  firm  strapping  and  bandaging.  Complete  re- 
covery resulted. 

The  Treatment  of  Typhoid  Fever. — James  Barr  states  that 
in  tho.se  cases  often  protracted  by  recrudescences  and  re- 
lapses, in  which  we  get  evening  rises  of  temperature  lasting 
for  one  or  two  weeks  and  due  to  secondary  infection,  we 
may  cut  the  pyrexia  short  by  a  few  injections  of  antistrep- 
tococcus  serum.  The  article  in  general  follows  along  fa- 
miliar lines. 

The  Determination  of  Chloroform.  A  Method  of  Peter- 
mining  with  Precision  Minute  Quantities  of  Chloroform  in  the 
Blood,  Secretions,  or  Organs  of  Animals  Variously  Anaes- 
thetized with  Chloroform.— By  James  Edmunds. 

On  the  Caloric  Value  of  Certain  Artificial  Infant's  Foods. 
—By  W.  Overend. 

Experimental  Proof  of  the  Mosquito-Malarial  Theory.— By 
Patrick  Manson. 

A  Halfpenny  Impacted  in  the  CEsophagiu. — By  T.  C. 
Sqiiance. 

The  Etiology  of  Scarlet  Fever.— By  W.  J.  Class. 

Puerperal  Sepsis. — By  R.  P.  Ranken  Lyle. 

British  Medical  Journal,  Septcinhcr  sg,  iqoo. 

The  Significance  and  Pathology  of  the  Argyll-Robertson 
Pupil  (Illustrated). — Wilfred  Harris  declares  that  the  loss 
of  the  pupil  reaction  to  light  is  a  physical  sign  of  the  great- 
est value  in  the  examination  of  cases  of  nervous  disease. 
Of  these  it  is  by  far  the  most  commonly  met  with  in  two 
diseases,  locomotor  ataxy  and  general  paralysis,  inasmuch 
as  these  diseases  are  due  largely  if  not  entirely  to  previous 
syphilis,  acquired  or,  in  a  few  cases,  congenital.  The 
morbid  anatomy  of  the  Argyll-Robertson  pupil  has  never 
been  demonstrated,  though  it  has  been  variously  surmised 
to  depend  on  a  nuclear  lesion,  or  on  sclerosis  of  Meynert's 
fibres  between  the  anterior  corpora  quadrigemina  and  the 
third  nucleus,  or  even  on  a  lesion  of  the  ciliary  ganglion. 
It  is  highly  probable  that  in  man  and  other  animals  with 
binocular  vision,  in  whom  there  is  semidecussation  of 
the  optic  nerves  at  the  chiasma,  a  similar  arrangement 
holds  good  between  the  anterior  corpora  quadrigemina  and 
the  third  nuclei,  namely,  that  there  is  a  semidecus:;ation 
of  the  fibres  subserving  the  light  reflex  between  these  two 
parts.  Meynert's  fibres  have  been  shown  by  Boyce  and 
others  to  be  not  a  complete  decussation,  some  fibres  re- 
maining uncrossed  in  or  close  to  the  posterior  longitudinal 
bundle  of  the  same  side,  and  it  seems  not  improbable  that 
these  fibres  have  the  above  function.  This  being  the  case, 
it  is  no  longer  necessary  to  conceive  the  two  third  nuclei 
being  tied  together  in  order  to  explain  the  consensual  leac- 
tion  of  the  pupils  to  light,  as  light  thrown  on  either  pupil 
in  any  diiection  will  thus  cause  afferent  stimuli  to  reach 
both  third  nuclei  independently.  It  seems  much  more 
probable  then,  in  the  absence  of  direct  pathological  evi- 
dence, that  the  Argyll-Robert.son  pupil  is  due  to  sclerosis 
of  these  fibres  on  one  or  both  sides  according  as  the  loss  of 
light  reaction  is  unilateral  or  bilateral,  rather  than  due  to 
any  nuclear  degeneration  such  as  has  been  suggested. 

The  Etiology  of  Tropical  Dysentery. — Simon  Flexner  be- 
lieves that  the  present  knowledge  of  the  cause  of  dysentery 
maybe  summed  up  as  follows:  (il  No  bacterial  species 
yet  described  as  the  cause  of  dysentery  has  an  especial 
claim  to  be  regarded  as  the  chief  micro-organism  concerned 
with  the  disease,  (i)  It  is  improbable  that  any  bacterial 
species  that  is  constantly  and  uormaUy  present  in  the  in- 


584 


MEDICAL   RECORD. 


[October  13,  1900 


testine  or  in  the  environs  of  man,  except  where  the  dis- 
ease prevails  in  an  endemic  form,  can  be  regarded  as  a 
probable  cause  of  epidemic  dysentery.  (3)  The  relations 
of  sporadic  to  epidemic  dysentery  are  so  remote  that  it  is 
improbable  that  the  two  diseases  are  produced  by  the  same 
organic  cause.  (4)  The  patliogeuic  action  of  the  amoeba 
coli  in  many  cases  of  tropical  and  in  certain  examples  of 
sporadic  dysentery  has  not  been  disproved  by  the  discov- 
ery of  amoebae  in  the  norma!  intestine  and  in  diseases 
other  than  dysentery.  While  amccba  are  commonly  pres- 
ent and  are  concerned  in  the  production  of  the  lesions  of 
subacute  and  chronic  dysentery,  they  have  not  thus  far 
been  shown  to  be  equally  connected  with  the  acute  dysen- 
teries even  in  the  tropics.  In  the  former  varieties  bacte- 
rial association  probably  has  much  influence  upon  the 
pathogenic  powers  of  the  amccbae. 

Subcutaneous  Saline  Infusions  in  Pneumonia. — William 
Ewart  and  Beaumont  Percival  conclude  that:  (i)  In  the 
severe  cases  treated,  no  unfavorable  results  were  observed 
from  the  saline  infusions  ;  (2)  these  seemed  to  delay  rather 
than  to  accelerate  the  fatal  termination  :  (3)  they  were  not 
resented  by  the  patients,  and  by  some  of  them  they  were 
acknowledged  to  be  comforting ;  (4)  they  were  powerless 
to  check  the  fatal  course  of  the  pneumonia  in  the  worst 
type  of  cases  :  (5)  they  do  not  seem,  except  in  one  case  in 
which  no  pus  but  clear  serum  exuded  from  the  cut  surface 
of  the  gray  hepatization,  to  have  made  any  difference  in 
the  characteristic  appearances  of  the  pulmonary  changes. 
At  the  same  time,  while  results  have  been  disappointing, 
they  do  not  prove  the  infusions  to  be  useless.  A  different 
composition,  a  larger  bulk,  or  a  greater  frequency  of  ad- 
ministration miglit  lead  to  very  different  results.  The 
cases  reported  were  exceptionally  severe,  and  may  have 
been  incapable  of  recovery.  But  the  effects  were  such  as 
to  recommend  the  method  for  more  extensive  trial  in  cases 
with  anxious  prognosis,  for  there  may  be  among  them 
cases  not  of  the  worst  type  which  might  be  saved  by  this 
treatment. 

Headaches  and  Other  Nervous  Symptoms  in  Relation  to 
Post-Nasal  Adenoids.— David  McKeown  believes  that  the 
condition  of  the  tissues  in  the  nasopharynx  and  the  nasal 
fosscC,  with  the  consequent  obstruction  to  the  vascular  and 
lymphatic  circulation  and  pressure  upon  nerves,  to  be  an 
important  factor  in  the  production  of  headache  and  the  al- 
lied symptoms,  for  one  of  the  immediate  results  of  opera- 
tion is  the  cure  or  relief  of  headache  ;  after  many  opera- 
tions without  an  anaesthetic,  patients  who  had  headache  at 
the  beginning  were  free  from  it  a  few  minutes  after  com- 
pletion of  the  manipulation ;  even  when  cerebral  symp- 
tcmis  have  not  been  realized,  there  ii  experienced  a  great 
relief  after  operation  ;  the  anatomical  relations  of  the  path- 
ological area  with  the  intracranial  contents  are  very  inti- 
mate ;  headache  is  a  symptom  of  acute  nasal  catarrh  and 
also  of  evanescent  attacks  of  nasal  congestion  as  well  as  a 
feeling  of  weight  or  oppression  in  the  region  of  tne  fore- 
head, an  inability  or  disinclination  for  mental  or  physical 
work,  and  a  general  depression  of  the  vital  functions. 
These  concomitants  of  headache  are  found  in  cases  of  ade- 
noids. 

On  Intermittent  Pulse  (with  Diagrams)  .—Arthur  R. 
Cuslmy  believes  that  intermissions  of  the  pulse  may  be 
divided  into  several  classes:  (i)  True  ventricular  inter- 
missions in  which  the  pause  is  exactly  equal  to  two  pulse 
intervals,  and  during  which  there  is  no  cardiac  sound ; 
(2)  true  auricular  intermissions  in  wliich  the  pause  is 
shorter  than  two  pulse  intervals,  and  during  which  there 
is  no  cardiac  sound  ;  (3)  false  ventricular  intermissions, 
in  which  the  pause  is  equal  to  two  pulse  intervals,  but  is 
often  interrupted  by  a  slight  elevation  ;  (4)  false  auricu- 
lar intermissions,  in  which  the  pause  is  shorter  than  two 
pulse  intervals:  (5)  another  form  which  has  been  de- 
scribed by  Wenckebach.  Tlie  treatment  of  cardiac  dis- 
ease may  be  rendered  more  exact  by  tlie  careful  examina- 
tion of  the  pulse,  which  may  indicate  wliether  the  existing 
condition  is  that  of  excessive  irritability  or  of  deficient 
activity. 

Two  Cases  of  Lipoma  of  the  Kidney. — W.  S.  Lazarus- 
Barlow  says  that  lipoma  is  apparently  a  very  rare  condi- 
tion, judging  from  the  statements  concerning  it  in  books. 
In  both  tliese  cases  which  he  reports,  the  tumors  were  re- 
moved under  the  impression  that  tliey  were  small  second- 
ary deposits.  In  the  one  case,  the  prime  lesion  was  a 
glioma  of  the  brain;  in  tlie  other,  an  intense  suppurative 
meningitis  arising  from  disease  of  the  antrum.  Both  the 
patients  were  adults — a  man  aged  seventy  years,  and  a 
woman  aged  thirty  years.  The  growths  were  approxi- 
mately spheroidal,  about  the  size  of  a  Spanish  nut,  and 
found  in  the  cortex  just  beneath  the  capsule,  to  which  they 
were  not  adherent.  Lipomata  of  this  size  are  only  patho- 
logical curiosities,  but  occasionally  one  is  met  so  large  that 
it  is  the  object  of  operative  interference. 

The  Origiii  of  Gout.— William  Ringrose  Gore  presents  the 


following  conclusions:  (i)  Gout  is  not  due  to  the  presence 
of  uric  acid  in  the  blood.  (2)  The  symptoms  of  gout  are 
due  to  a  toxin.  (3)  The  concurrent  presence  of  uric  acid 
is  due  to  the  action  of  the  toxin  on  the  liver.  {4)  The 
toxin  is  formed  by  the  action  of  one  of  the  intestinal  ba- 
cilli on  an  intestinal  secretion  specifically  altered  by  diet, 
this  alteration  being  assisted  by  hereditary  disposition. 

A  Discussion  on  the  Pathological  Distribution  of  the  Diph- 
theria Bacillus  and  the  Bacteriological  Diagnosis  of  Diph- 
theria.—By  F.  W,  Andre wes  and  otliers. 

The  Diastolic  Expansion  Movement  of  the  Ventricles  as  a 
Factor  in  Compensation  for  Disease  of  the  Mitral  Valve. — 
By  T.  Stacey  Wilson.      (Illustrated.) 

A  Discussion  on  the  Pathology  of  Cirrhosis  of  the  Liver  in 
Adults  and  Young  Children. — By  Arthur  Voelcker  and  oth- 
ers.     (Illustrated.) 

A  Case  of  Purpura  and  Intense  Ansemia,  with  Marked  De- 
ficiency in  the  Red  Bone  Marrow. — By  Robert  Muir.  (Illus- 
trated.) 

A  Discussion  on  Influenza  as  it  Affects  the  Nervous  Sys- 
tem (Illustrated). —  By  Judson  S.  Bury  and  others. 

The  Progress  of  the  Sanitarium  Treatment  of  Consump- 
tion in  England. — By  Jaue  H.  Walker. 

A  Case  of  Fatal  Malignant  Endocarditis  and  Right  Em- 
bolic Hemiplegia.  — By  William  Ewart. 

Nutrient  Media  of  "  Standard  "  Reaction  for  Bacteriologi- 
cal Work.— By  J.  W.  H.  Eyre. 

A  Discussion  on  the  Problems  of  Gastric  Ulcer. — By  J. 
Frank  Payne  and  others. 

Consanguinity  as  a  Factor  in  the  Etiology  of  Tuberculosis. 
— By  Charles  A.  Davies. 

Uterine  Myomata  and  Developmental  Irregularity. — By  W. 
Roger  Williams. 

Deutsche  medicinische  Wochenschrift,  Sept.  so.  igoo. 

General  Actinomycosis  with  Localization  in  the  Brain. — 
Nikitin's  case  began  with  pharyngitis  and  an  obstinate 
dry  cough,  while  later  on  signs  pointing  to  a  slight  tuber- 
culous inhltration  developed  at  the  left  apex.  No  tubercle 
bacilli  were  found  m  the  sputum,  however,  and  some  time 
later  an  abscess  developed  below  the  left  clavicle.  This 
was  opened,  but  was  succeeded  by  another  in  which  the  ray 
fungus  was  found.  Potassium  iodide  was  given  in  large 
doses,  but  this  did  not  prevent  the  formation  of  further 
metastases  about  the  thorax,  fingers,  tibia,  and  femur. 
Finally  severe  cerebral  symptoms  (convulsions,  headache, 
paralysis,  aphasia)  set  in,  and  the  patient  passed  into  the 
comatose  state  and  died.  On  section  a  walnut-sized  acti- 
nomycotic abscess  was  found  just  posterior  to  the  left  fron- 
tal convolutions. 

Prolapse  of  the  Foetal  Intestines  during  Labor. — Jaerisch 
vras  called  to  deliver  wliat  apparently  was  a  lateral  pres- 
entation. On  digital  examination  tlie  fcetal  small  intes- 
tines were  found  filling  the  vagina,  and  the  hand  could  be 
passed  into  the  child's  abdominal  cavity  through  a  defect 
in  its  anterior  wall.  Version  was  impracticable,  and  em- 
bryotomy had  to  be  done  before  delivery  was  possible. 
The  foetus  was  then  found  to  be  a  monster  with  imperfect 
frontal  development,  a  large  left-sided  encephalocele.  hare 
lip,  deformed  thorax,  right  arm  atrophied,  syndactylism 
of  the  right  toes,  and  a  five-inch  cleft  in  the  abdominal 
paries  permitting  the  escape  of  intestine  and  liver. 

The  Theory  of  Infection. — Hugo  Marx  proposes  the  fol- 
lowing theory;  A  bacterium  effects  its  passage  from  the 
non-infectious  or  virulent  to  the  infectious  or  virulent  state 
llirough  the  intracellular  condensation  and  localization 
which  results  in  the  formation  of  the  Babes-Ernst  bodies. 
The  index  for  present  virulence  is  to  be  found  in  the  num- 
ber of  individuals  containing  these  bodies,  for  future  viru- 
lence in  the  ability  of  the  cells  to  produce  them. 

An  Improved  Instrument  for  Obtaining  the  Urine  from  the 
Kidneys  Separately  in  Women. — By  Neumann. 

Riedel's  Method  of  Reduction  in  Anterior  Dislocation  of 
the  Humerus.  —  By  Graef. 

The  Neuron  in  Anatomy  and  Physiology. — By  Max  Ver- 
worn. 

Miinchener  uicdiiinisclic  VVochenschriJt,  Sept.  iS.  igoo. 
Acute  Leukaemia.— A.  Dennig  believes  that  many  cases 
diagnosed  as  scurvy  or  Werlhof's  disease  would,  if  a 
blood  examination  were  made,  turn  out  to  be  acute  leukae- 
mias. In  illustration  he  details  an  instance  in  which  the 
history,  symptoms,  and  physical  signs  seemed  to  justify 
the  diagnosis  of  sporadic  scurvy  until  on  examination  the 
blood  was  found  to  be  that  of  leukaemia,  showing  the  im- 
portance in  all  ca.ses  of  stomatitis  of  unknown  origin,  espe- 
cially if  accompanied  by  the  hemorrhagic  diathesis,  of 
making  a  hematological  investigation.  Acute  leukaemia 
is  not  to  be  differentiated  from  the  chronic  form  by  any 
stated  time  measure,  but  whenever  the  disease  from  the 


October  13,  1900] 


MEDICAL    RECORD 


585 


outset  presents  symptoms  and  lesions  usually  not  obser\-ed 
until  late,  it  may  be  cimsidered  acute.  In  addition  to 
the  usual  symptoms  of  progressive  asthenia,  palpitation, 
syncope,  pallor,  liemorrhagic  petechia;  in  the  skin,  mucous 
membranes  and  internal  organs,  swelling  of  the  liver  and 
spleen,  etc.,  wliich  are  common  al.so  to  the  chronic  form, 
there  is  a  marked  difference  in  the  character  of  the  blood 
changes  wliich  serves  to  distinguish  the  two.  In  acute 
leukzemia  there  is  an  increase  of  the  uninuclear  elements 
exclusively  :  thi.se  belong  to  the  class  of  lymphocytes  and 
are  present  in  all  sizes.  They  possess  a  large  round  nu- 
cleus surrounded  by  a  narrow  rim  of  poorly  staining  non- 
granulated  ])rotoplasm.  JJuItinuclcar  leucocytes  and  nor- 
moblasts are  scanty,  while  the  uninuclear  cells  witli 
neutrophile  granules  and  the  eosinophile  myelocytes  typi- 
cal of  the  clironic  form  are  entirely  absent. 

The  Occurrence  and  Diagnosis  of  Gout. — Striimpell  com- 
ments on  the  increasing  fre(|Uoucy  with  which  the  diag- 
nosis of  gout  is  being  made,  and  thinks  it  is  due  to  a  bet- 
ter recognition  of  its  nature  rather  than  to  any  greater 
prevalence  of  the  disease.  Characteristics  which  distin- 
guish it  from  acute  articular  rheumatism  are  the  tendency 
to  attack  the  joints  of  the  lower  extremity,  especially  those 
most  distal,  like  the  metatarso-phalangeal  articulation  of 
the  great  toe,  tlie  fact  that  only  one  or  but  few  joints  are 
involved,  the  frequency  of  tlie  attacks,  and  their  short  du- 
ration. Masked  gout  is  often  confounded  with  arthritis 
deformans,  but  a  careful  study  of  the  history  usually  makes 
the  distinction  clear.  Various  i)ainful  affections  of  the 
foot,  tarsalgia,  achillodynia,  atypical  ischialgia  are  often 
of  gouty  origin.  Of  tlieinternal  changes  the  gouty  kidney 
takes  first  place;  the  organic  lesion  is  usually  recognized, 
but  the  causative  factor  is  overlooked.  Concerning  the 
degenerative  changes  in  the  heart  and  arteries  which  so 
often  accompany  gout,  it  is  hard  to  say  to  what  degree  they 
are  the  result  of  the  specific  poison  of  the  disease  and  how 
large  a  jiart  in  their  etiology  is  played  liy  the  usually  con- 
comitant alcoholism  and  luxurious  habits  of  living.  Of  the 
etiology  of  the  disease  in  general,  it  may  be  said  that  while 
such  poisons  as  alcohol  and  lead  .seem  to  be  directly  re- 
sponsible for  tlie  trouble  in  the  majority  of  cases,  still  the 
element  of  lieredity  is  the  governing  factor  and  is  present 
in  nearly  all  instances. 

Malignant  (Edema. — G.  Muscatello  and  C  Gangitano 
draw  the  following  conclusions  from  the  clinical  observa- 
tion of  five  cases  of  the  disease  and  a  bacteriological  study 
of  the  morbid  tissues.  Two  micro-organisms,  the  bacillus 
aerogenes  capsulatus  and  the  bacillus  coli  communis,  stand 
in  direct  causal  relationship  to  the  affection.  Of  these  the 
former  is  to  be  regarded  not  as  the  specific  producer  of  the 
disease,  but  as  a  gas-forming  organism  which  is  simply  a 
toxic  saprophyte  and  is  able  to  locate  itself  only  where  the 
vitality  of  the  tissue  has  become  depreciated  to  a  serious 
degree.  The  bacillus  coli  communis  is  usually  associated 
with  other  organisms  and  is  capable  of  jirodvicing  ma- 
lignant oedema.  Clinically  two  courses  of  the  disease  are 
to  be  noted.  The  first  of  these,  due  to  the  bacillus  aero- 
genes capsulatus  alone,  is  unaccompanied  by  inflammatory 
manifestations,  does  not  exhibit  a  very  marked  tendency 
to  spread,  and  assumes  a  rapidly  ]>rogressive  course  only 
in  the  later  stages  when  the  organism  has  become  incap- 
able of  further  resistance.  The  other  form,  resulting  from 
a  mi.xed  infection,  is  usually  inflammatory  in  nature  and 
rapidly  invades  surrounding  parts  from  the  very  begin- 
ning. Although  malignant  fedema  is  one  of  the  most  seri- 
ous of  infections,  the  prognosis  is  no  longer  as  grave  as  was 
formerly  supposed.  Through  free  exposure  of  the  focus, 
early  and  complete  extirpation  of  the  entire  necrotic  mass, 
and  energetic  disinfection,  a  favorable  result  may  be  looked 
for  in  a  large  number  of  cases. 

The  Treatment  of  Joint  Abscesses  by  Drainage  with  the 
Glass  Speculum,  and  Pure  Carbolic  Acid.  — By  A.  M.  Phelps. 

Cholecystitis  and  Secondary  Gastro-Intestinal  Disturbances. 
— By  Kleiner. 

The  Indications  for  and  Technique  of  Myomectomy. — By 
Slartin. 

Berliner  klinische  Woeliensclirift,  Sept.  lo,  igoo. 

Gonorrhoea!    Joint    Inflammation. — F.    Rubinstein    distin- 

guislies  four  forms  of  tliis  affection:  (i)  Gonorrhoeal  hy- 
drops ;  (2)  fibrino-serous  exudation ;  (3)  purulent  in- 
flammation, empyema  of  the  joint ;  {4)  phlegmonous 
inflammation.  To  relieve  the  first  he  advises  rest  of  the 
joint,  iodine  applications,  blisters  or  vasogens  (guaiacol  or 
creosote).  If  the  amount  of  fluid  is  great,  puncture.  Some 
writers  inject  a  five-per-cent.  carbolic  solution.  For  the 
fibrinous  form  Rubinstein  advises  rest,  immobilization, 
and  elevation  of  the  joint  with  splints  and  plaster  ban- 
dages, an  ice-bag  being  applied  if  pain  is  severe.  Puru- 
lent accumulations  call  for  incision  and  drainage.  Later, 
when  all  active  manifestations  have  come  to  an  end,  mas- 
sage and  warm  baths  are  to  be  recommended. 


Experimental  Researches  on  Sterilization  of  Catheters,  with 
Some  Remarks  on  Asepsis  in  Catheterization  of  the  Ureters. 
^By  M.  Katzenstcin. 

Injurious  Suggestions  in  Patients  Suffering  from  Accidents. 
—By  \V.  Seiffer. 

Polyneuritis  after  Malaria  and  Landry's  Paralysis. — By  B. 
Baumstark. 

French  Journals. 

Local  Trophic  Effect  of  Gentle  Abdominal  Massage. — Saquet 
speaks  of  the  effect  of  gentle  abd<miinal  massage,  citing  two 
cases.  The  first  was  that  of  a  young  man  aged  twenty 
vears,  who  for  six  months  had  been  suffering  with  his 
stomach.  In  spite  of  varied  treatment  he  was  gradually 
growing  worse  and  looked  like  one  in  the  last  stages  of 
phthisis.  He  suffered  from  constii)ation  and  insomnia  :  he 
was  very  nervous,  and  was  convinced  that  he  was  about 
to  die.  After  instituting  the  abdominal  massage,  his  con- 
dition rapidly  improved  :  his  abdomen,  which  had  resem- 
Ided  that  of  a  child  with  meningitis,  became  supple  and 
daily  enlarged.  The  treatment  was  not  severe  niir  very 
special.  His  pain  disap])eared,  and  he  was  al)le  to  digest 
all  that  was  given  to  him.  The  patient  gained  in  si.x 
months  about  sixty-five  pounds,  which  he  has  not  lost 
since  that  time,  now  five  years  ago.  The  second  case  was 
that  of  a  woman  aged  fifty  years,  who  had  been  sickly 
since  birtii.  She  presented  all  the  symptoms  of  enterop- 
tosis  of  the  last  degree.  .\t  the  end  of  a  few  weeks  the 
patient  returned  in  a  condition  of  healtli  which  she  had  not 
known  for  years.  The  author  believes  that  by  diet  alone 
it  will  often  take  years  to  obtain  improvement,  while  with 
massage  added  the  benefit  will  be  noted  in  a  few  weeks. 
— La  Medichtc  MiHliine.  Septemljcr  ig,  k/x). 

Treatment  of  Genital  Prolapse  in  the  Woman.— Co ville 
divides  prolapse  into  three  sections:  (i)  Partial  prolapse  ; 
(2)  complicated  prolapse  (tumors,  hypertrophies,  or  uterine 
deviations)  ;  (3)  complete  prolapse.  Prophylaxis  should 
consist  in  keeping  the  parturient  woman  in  bed  from  ten 
to  twelve  days  at  the  least.  Any  laceration  should  be  im- 
mediately repaired.  Curative  treatment  should  consist  in 
operating  for  prolapse,  whatever  the  degree,  unless  there 
exists  the  contraindication  of  an  inoperable  malignant  tu- 
mor. The  time  of  pessaries  has  passed  and  ought  now  to 
give  way  to  surgical  treatment,  rational  and  benign,  and 
which  promises  to  the  patient  not  only  relief  from  suffering 
but  the  integrity  of  her  iuncXXon'i.—La  Presse  Mhlicale, 
September  ig,  1900. 

The  Treatment  of  Biliary  Lithiasis. — A.  Gilbert  and  L. 
Fournier  slate  tliat  certain  hygienic  rules  by  themselves 
constitute  true  projihylactic  measures  against  lithiasis — 
regular  meals,  the  use  of  clothing  producing  neither  dis- 
placements nor  deformity  of  the  abdominal  organs,  exer- 
cises, care  about  the  digestive  functions — one  of  the  prin- 
cii>al  results  being  the  avoidance  in  a  certain  measure  of 
biliary  stasis  and  ascending  infection.  To  these  measures 
may  be  added  the  use  of  alkalies,  cholagogues,  abdominal 
massage,  and  cold  intestinal  injections.  This  same  treat- 
ment is  indicated  after  the  establishment  of  lithiasis. 
When  .serious  complications  are  threatened,  then  surgical 
intervention  is  indicated. ^/yw/v/a/  ties  Pralieien.^,  Sep- 
tember 22.  Ig'Kj. 

Epididymo-Testicular  Tuberculosis  Treated  by  Ligatures  of 
the  Spermatic  Cord. — P.  Jlauclaire,  in  describing  this  oper- 
ation states  that  he  generally  ties  and  cuts  en  nnrvse  all 
the  spermatic  cord.  The  cord  is  tied  very  high,  near  the 
external  orifice  of  the  inguinal  canal.  Two  ligatures  are 
used,  about  2  cm.  apart.  Sometimes  chloroform  is  used, 
sometimes  only  cocaine.  Sometimes  he  has  curetted  the 
focus,  sometimes  incised  it.  At  times  he  has  u.sed  the 
thermocauter\^  His  results  have  been  most  encouraging. 
Instead  of  castration,  there  is  a  chance  of  saving  the  tes- 
ticle even  if  it  atrophies  a  little,  while  the  method  is  not 
dangerous. — La  Presse  Medicale,  September  22,  igoo. 

The  Journal  i>J  K.\periiiiental  Medicine,  October  1.  /goo. 

An  Experimental  Study  of  Oxaluria,  with  Special  Refer- 
ence to  its  Fermentative  Origin. — Helen  Baldwin  concludes 
her  discussion  of  this  subject  as  follows:  (i)  As  varying 
amounts  of  calcium  o.xalate  may  be  held  in  solution  in  the 
urine,  conclusions  based  upon  the  presence  or  number  of 
calcium-oxalate  crystals  found  therein  are  of  no  real  value 
as  an   indication  of  the  quantity  of  oxalic   acid  present. 

(2)  Unless  the  utmost  care  is  exercised,  the  results  ob- 
tained by  quantitative  estimation  of  oxalic  acid  are  sub- 
ject to  large  percentages  of  error.  This  is  especially  true 
in  the  u.se  of  Xeubauer's  or  Schultzen's  methods,  in  which 
the  calcium  oxalate  is  precipitated  in  an  alkaline  solution. 

(3)  An  ordinary  mixed  diet  regularly  contains  traces  of  ox- 
alic acid  or  its  salts.  (4)  A  portion  of  the  oxalic  acid  in- 
gested with  the  food  may  be  absorbed  and  reappear  un- 
changed in  the  urine.  (5)  The  normal  daily  excretion  of 
oxalic  acid  in  the  urine  fluctuates  with  the  amount  taken 


586 


MEDICAL    RECORD. 


[October  13,  1900 


in  tlie  food,  and  varies  from  a  few  milligrams  to  2  or 
3  cgm.,  being  usually  below  10  nigm.  (6)  In  health, 
no  oxalic  acid,  or  only  a  trace,  is  formed  in  the  body, 
but  that  present  in  the  urine  has  been  ingested  with 
the  food.  (7)  In  certain  clinical  disturbances  which  in 
some  of  the  cases  studied  above  were  associated  with  ab- 
sence of  free  hydrochloric  acid  from  tlie  gastric  juice,  ox- 
alic acid  is  formed  in  the  organism.  (S)  This  formation 
in  the  organism  is  connected  with  fermentative  activity  in 
the  alimentary  canal.  (<?)  The  prolonged  feeding  of  dogs 
with  excessive  quantities  of  glucose,  together  with  meat, 
leads  eventually  to  a  state  of  oxaluria.  (/')  This  experi- 
mental oxaluria  is  associated  with  a  mucous  gastritis,  and 
with  absence  of  free  hydrochloric  acid  in  the  gastric  con- 
tents, (c')  The  oxaluria  and  the  accompanying  gastritis 
are  referable  to  fermentation  induced  by  the  excessive 
feeding  with  sugar.  (1/)  The  experimental  gastritis  from 
fermentation  is  associated  witli  tlie  formation  of  oxalic  acid 
in  the  gastric  contents,  (g)  The  symptoms  attributed  to 
an  oxalic-acid  diathesis,  with  the  exception  of  those  due  to 
local  irritation  in  the  genito-urinary  tract,  do  not  appear 
to  be  due  to  the  presence  in  the  system  of  soluble  oxalates, 
but  are  more  likely  to  depend  on  other  jjroducts  of  fermen- 
tation and  jiutrefactidn. 

Proliferation  and  Phagocytosis. — F.  B.  Mallory  declares 
that  the  effects  which  injurious  agents,  especially  the  to.x- 
ins  secreted  by  bacteria,  produce  on  tissues  are  manifested 
in  four  different  ways  ;  (i)  By  degeneration  or  necrosis  of 
cells;  (2)  by  exudation  from  the  blood-vessels  ;  (3)  by  pro- 
liferation of  cells;  (4)  by  phagocytosis,  this  term  being 
used  here  to  mean  the  inclusion  and  digestion  of  certain 
cells  by  other  cells.  These  four  processes  may  occur  sepa- 
rately, or  in  various  combinations  and  proportions.  The 
author's  object  in  this  paper  is  to  show  that  strong  toxins 
cause  degeneration  or  necrosis  of  cells  and  exudation, 
while  dilute  and  weak  toxins  produce  proliferation  and 
phagocj'tosis.  The  results  of  the  study  of  large  numbers 
of  cases  of  certain  diseases  and  of  typical  and  unusual 
lesions  support  this  hypothesis.  The  statement  of  the  pro- 
liferation and  phagocytosis  occurring  in  diphtheria  is 
based  on  the  histological  study  of  two  hundred  and  twenty 
cases.  Pratt  has  recently  shown  in  a  study  of  fifty  cases 
of  acute  lobar  pneumonia  that  micrococcus  lanceolatus 
causes  marked  proliferation  of  the  cells  lining  the  alveoli, 
the  pleural  cavities,  and  tlie  lymphatics ;  these  newly 
formed  cells  are  very  phagocytic.  The  acute  lesions  of  the 
glomeruli  of  the  kidney  throw  much  light  on  the  question 
of  proliferation  due  to  bacterial  to.xins.  The  t^-phoid  and 
tubercle  bacilli  produce  mild  toxins  which  act  slowly  and 
usually  produce  proliferation  only.  The  kind  of  cells 
which  a  phagocyte  incorporates  depends  on  its  situation 
in  the  tissue.  In  acute  proliferative  intracapillary  glom- 
erulo-nephritis  the  writer  has  never  found  any  evidence  of 
phagocytosis.  The  tendency  of  the  cells  which  proliferate 
under  the  action  of  toxins  is  to  degenerate  and  disappear 
as  soon  as  the  agent  to  which  tliey  owe  their  existence  is 
destroyed  or  neutralized.  The  processes  of  proliferation 
and  phagocytosis  which  have  been  described  as  due  di- 
rectly to  the  action  of  toxins  are  regarded  generally  as 
reparative  in  nature.  Similar  processes  occur  in  repair. 
The  phagocytic  cells  are  phagocytic  beyond  all  bounds  of 
necessity  and  destroy  great  numbers  of  active,  useful  cells. 
These  are  all  abnormal  and  to  a  certain  degree  malignant 
properties. 

Pathological  Report  on  a  Case  of  Dermatitis  Vesiculo-Bul- 
losa  et  Gangrsenosa  Mutilans  Manuum  (Duhringi,  with  a 
Consideration  of  the  Relations  of  Vascular  and  Nervous 
Changes  to  Spontaneous  Gangrene  and  Raynaud's  Disease. — 
William  G.  Spiller  draws  the  following  conclusions  from 
the  study  of  this  case:  (i)  Gangrene  may  be  caused  by 
endarteritis  obliterans.  (2)  Alteration  of  nerves  alone 
without  alteration  of  the  vessels  is  believed  by  some  to  be 
a  cause  of  gangrene.  We  need  probably  more  evidence 
before  tliis  conclusion  can  be  definitely  accepted.  (3) 
Gangrene  may  cause  degeneration  of  the  vessels,  espe- 
cially of  the  portions  near  the  gangrenous  area.  (4)  Gan- 
grene is  less  liable  to  cause  degeneration  of  nerves  except 
of  the  portions  within  or  near  the  gangrenous  areas.  (5) 
Sudden  closure  of  blood-vessels  causes  degeneration  of  the 
nerves  nourished  by  these  vessels,  unless  an  adetjuate  col- 
lateral circulation  is  promptly  established.  If  the  vascular 
disease  is  of  a  chronic  tyjie  the  nerves  may  esca])e,  at  least 
for  a  time,  but  do  not  always  do  so,  the  result  doubtless 
depending  upon  circulatory  conditions  which  vary  in  dif- 
ferent cases,  (fj)  Degeneration  of  nerves  is  a  possible, 
but  not  thoroughly  demonstrated,  cau.se  of  degeneration  of 
the  blood-vessels. 

Refractory  Subcutaneous  Abscesses  Caused  by  Sporothrix 
Schenckii.  A  New  Pathogenic  Fungus.  — Ludvig  Hektoen 
and  C.  F.  Perkins  describe  an  organism  which  is  undoubt- 
edly identical  with  that  described  by  Schenck  in  the  bul- 
letin of  the  Johns  Hopkins  Hospital  for  December,  1898. 
To  study  an  abscess  of  this  nature,  it  should  be  excised  in 


an  early  stage  of  formation.  It  is  very  interesting  to  note 
that  wc  have  here  a  pathogenic  fungus  that  in  the  lesions 
it  produces  in  animals  exists  in  the  spore-form,  or  in  a 
modified  spore-form,  and  that  it  undoubtedly  multiplies  as 
such  :  threads  do  not  seem  to  develo])  in  the  tissues  of  sus- 
ceptible animals.  This  fungus  produces  a  slow,  circum- 
scribed, and  nodular  inflammation  with  necrosis  and  pus 
formation  in  the  centre,  and  the  develo])ment  of  granulation 
and  fibrous  tissue  at  the  jieriphery — encapsulation.  A  char- 
acteristic clinical  feature  of  the  human  cases  is  the  refrac- 
tory nature  of  the  subcutaneous  abscesses.  In  the  three 
cases  on  record  there  appeared  a  succession  of  these  ab- 
scesses on  tlie  upper  extremity  con.sequent  upon  injury; 
the  scratch  of  the  skin  of  the  finger  by  a  nail;  the  blow 
upon  the  finger  by  a  hammer  ;  the  puncture  of  a  finger  by 
a  wire. 

Serum-Globulin  and  Diphtheric  Antitoxin.  A  Comparative 
Study  of  the  Amount  of  Globulin  in  Normal  and  Antitoxic 
Sera,  and  the  Relation  of  the  Globulins  to  the  Antitoxic  Bodies. 
—  By  Philip  Hanson  Hiss  and  James  P.  Atkinson. 

A  Contribution  to  Staining  Methods,  i.  A  Differential 
Stain  for  Connective-Tissue  Fibrillae  and  Reticulum.  2. 
Chloride  of  Iron  Hamatoxylin  for  Neuroglia  Fibres. — Bv  1". 
B.  Mallory. 

A  Study  of  the  Neurofibrils  in  the  Ganglion  Cells  of  the 
Cerebral  Cortex. — By  Stewart  Paton. 

.iiina/s  oj  Sufi^cry,  i1cfo/>cr.  rgoo. 

The  Surgical  Treatment  of  Primary  Renal  Tuberculosis, 
with  a  Consideration  of  the  Immediate  and  Remote  Results 
after  Operation. — The  conclusions  drawn  by  Otto  G.  Ram- 
say are  summarized  as  follows  :  (I)  That  renal  tuberculosis 
may  be  classed  as  a  semi-malignant  form  of  inflammation, 
and  that  for  this  reason  surgical  treatment  of  some  .sort  is 
always  indicated;  (2)  that  this  surgical  treatment  will 
have  a  palliative  or  a  curative  end  in  view  depending  on  the 
condition  of  the  patient  and  the  duration  and  extent  of  the 
disease  ;  (3)  that  nephrotomy  in  renal  tuberculosis  is  to  be 
classed  as  a  palliative  operation  ;  and  that  as  a  palliative 
operation  for  the  immediate  relief  of  dangerous  symptoms, 
and  as  not  precluding  a  later  nephrectomy,  nephrotomy 
with  drainage  of  the  ab.scess  cavity  is  most  valuable;  (41 
that  resection  of  the  diseased  part  of  the  kidney  is  contra- 
indicated  in  renal  tuberculosis  because  of  the  danger  of 
leaving  a  tuberculous  focus  in  the  portion  left  in  the  body  ; 
(5)  that  nephrectomy  or  nephro-ureterectomy  is  indicated 
in  every  suitable  case,  and  in  suitable  cases  should  be  fol- 
lowed by  a  lasting  cure  in  55.5  per  cent,  of  the  cases  ;  (6) 
that  the  indications  against  nephrectomy  are  tuberculous  or 
other  disease  of  the  second  kidney,  or  tuberculous  foci  in 
other  organs  ;  (7)  that  tuberculosis  of  tlie  bladder  is  not  to 
be  considered  a  contraindication  to  nephrectomy,  as  it  will 
probably  heal  later  ;  (8)  that  a  small  tuberculous  focus  in 
the  lung,  if  the  patient  otherwise  is  in  good  condition,  may 
.sometimes  not  be  considered  a  contraindication  ;  (g|  that 
in  doubtful  cases,  when  it  is  questionaljle  whether  the  pa- 
tient can  stand  an  immediate  nephrectomy,  it  is  better  to 
do  a  nephrotomy,  following  it  later  by  nephrectomy;  (10) 
that  the  clamp  method  of  controlling  the  pedicle  is  contra- 
indicated  from  the  danger  of  hemorrhage  after  the  removal 
of  the  clamp;  (11)  that  it  is  safest  to  remove  the  ureter 
with  the  kidney,  as  a  persistent  fistula  may  give  trouble  if 
it  be  allowed  to  remain  in  the  body;  (12)  that  a  certain 
proportion  of  these  fistulte  will  finally  disappear,  either 
after  the  removal  of  a  deep  suture,  or  because  of  the  slow 
disappearance  of  the  tuberculous  disease  in  the  ureter, 
which  in  these  cases  gradually  changes  into  a  fibrous  cord  ; 
(13)  that  we  may  expect  a  steadily  increasing  number  of 
final  cures  as  our  means  of  diagnosis  improve,  and  as  our 
surgical  technique  is  carried  out  more  carefully  and  scien- 
tifically. 

Mesenteric  Cysts. — By  C.  X.  Dowd.  The  patient  was  a 
woman  aged  forty-one  years.  The  cyst  was  remarkable 
in  the  following  particulars:  (i)  It  showed  the  exact 
structures  and  fluid  contents  of  an  ovarian  cyst-adenoma, 
and  hence  suggested  its  probable  origin  from  an  embry- 
onic ovarian  se<piestration.  (2)  It  showed  in  the  smaller 
loculi  the  epithelial  structure  which  explained  its  growth, 
and  in  the  main  cyst  wall  the  firm  fibrous  structure  which 
has  been  found  in  most  mesenteric  cysts.  (3)  It  contained 
clear  fluid  in  some  of  its  loculi  and  liloody  fluid  in  others, 
and  showed  large  blood-vessels  in  the  delicate  cyst  walls, 
thus  indicating  lliat  hemorrhages  from  the  cyst  walls  ex- 
plained the  sanguineous  fluid,  and  suggesting  a  similar 
cause  in  other  sanguineous  cysts.  A  general  ccmsidera- 
tion  of  mesenteric  cysts  is  summarized  as  follows  :  (i)  The 
occurrence  in  the  transverse  mesocolon  of  a  multilocular 
cyst-adenoma  which  contained  pseudomucin,  and  which 
was  exactly  like  a  cyst-adenoma  of  the  ovary,  suggests  its 
probable  origin  as  an  embryonic  ovarian  sequestration. 
(2)  The  occurrence  of  dermoid  cysts  in  a  similar  position 
suggests  a  similar  origin.  (3)  The  occurrence  of  chylous 
cysts  in  the  mesentery,  which  have  the  structure  and  ap- 


October  13,  1900] 


MEDICAL    RECORD. 


587 


pearance  of  ovarian  and  parovarian  cysts,  and  which  have 
in  tlieir  walls  lymph  vessels,  suggest  embryonic  cysts  into 
wliieh  there  has  been  an  etfusion  of  chyle.  (4)  The  san- 
guineous cysts  appear  to  be  preformed  cysts  into  wliieh 
iiemorrhage  has  taken  place  ;  hiematomata  in  the  mesen- 
tery should  not  be  described  as  cysts.  (5)  The  presence 
of  cysts  which  have  the  structure  of  the  intestinal  wall 
suggest  sequestration  from  the  intestine.  (6)  .Serous 
cysts  arc  apparently  similar  in  origin  an<l  structure  to  the 
cysts  already  considered.  They  are  usually  not  situated 
in  the  path  of  the  lacteal  vessels.  (7)  Hydatid  cysts  form 
a  class  by  themselves  and  are  due  to  the  t;enia  echinoeoe- 
cu.s.  (8)  Reports  indicate  that  mesenteric  cysts  are  being 
removed  at  least  as  often  as  once  a  month.  If  microscopi- 
cal examinations  of  the  cyst  walls  and  chemical  and  micro- 
scopical examinations  of  the  cyst  fluid  are  made,  the  entire 
subject  should  soon  be  understood.  (9)  It  is  probable  tliat 
all  mesenteric  cysts  may  be  included  in  the  classifications 
(<0  embryonic  cysts,  (/■)  liydatid  cysts,  (c)  cystic  nia!ign;ait 
disease. 

Tetanus :  a  Study  of  the  Nature,  E.xcitant,  Lesions, 
Symptomatology,  and  Treatment  of  the  Disease,  with  a  Crit- 
ical Summary  of  the  Results  of  Serum  Therapy.— A.  V.  -Mcisch- 
cowitz  concludes  a  very  lengthy  article  by  calling  atten- 
tion to  the  following  points  :  (I)  All  forms  of  tetanus  are 
caused  by  the  bacillus  of  Nicolaier;  hence  the  diagnosis 
of  rlieumatie  or  idiopathic  should  have  no  room  in  our  no- 
sology. (2)  The  tetanus  toxins  ajjpear  to  have  a  decided 
afhnity  for  the  anterior  horns  of  the  spinal  cord,  which  may 
be  distinctly  recognized  by  Xissl's  method  of  staining. 
(3)  The  cerebrospinal  fluid  of  tetanus  patients  is  more 
to.xic  than  the  blood.  (4)  The  antitoxin  therapy  appears 
to  have  a  distinct  beneficial  influence  tfpfm  the  cour.se  of 
tetanus.  (5)  With  the  antitoxin  treatment  the  mortality 
percentage  has  been  reduced  from  about  ninety  per  cent. 
to  forty  per  cent.  (6)  Although  the  use  of  the  serum  is  a 
most  important  factor  in  the  treatment  of  tetanus,  the  other 
recognized  therapeutic  measures  should  not  be  neglected. 

Suprapubic  Retrocystic  Extraperitoneal  Resection  of  the 
Seminal  Vesicles,  Vasa  Deferentia,  and  Half  of  the  Bladder. 
— P.y  11.  V<Hin,u. 

Excision  of  the  Right  Vas  Deferens  and  Vesicula  Semi- 
nalis  for  Secondary  Tubercular  Disease.—  By  J.  A.  Hutch- 
ison. 

A  Study  of  One  Thousand  Operations  for  Acute  Intestinal 
Obstruction  and  Gangrenous  Hernia.  —  IJy  C.  L.  inl^son. 

Dislocation  of  the  Humerus,  Complicated  by  Fracture  at  or 
Near  the  Surgical  Neck. — By  C.  B.  Lyman. 

Remarks  on  the  Technique  of  Prostatectomy,  with  Report 
of  a  Case. — By  Herman  Mynter. 

A  New  Method  of  Colpoplasty  in  a  Case  of  Entire  Absence 
of  the  Vagina. — By  Carl  Beck. 

/.t-ilSilnift f.    Tiihi-rk.  u.  Hi'ihtdtl.,  7h>!.  /. ,  Xo.  4.  iqoo. 

The  Treatment  of  Pulmonary  Tuberculosis  and  Diseases 
of  the  Respiratory  Passages  with  Organo-Toxin. — De  Lan- 
noise  ajiplies  this  name  to  an  attenuated  toxin  obtained  by 
keeping  bouillon  cultures  of  tubercle  bacilli  at  a  tempera- 
ture of  98  to  100  F.  for  a  period  of  from  two  to  four 
months.  Treated  in  this  way  the  product  is  harmless 
when  injected  into  men  or  animals,  and  exercises  a  very 
favorable  effect  on  the  course  of  tuberculous  disease.  After 
a  few  injections  respiration  becomes  more  free  and  deep. 
the  cough  and  expectoration  are  iucrea.sed,  the  expectora- 
tion losing  its  mucopurulent  character,  becoming  first  yel- 
lowish, then  white,  and  finally  disappearing  entirely. 
Cavities  already  present  apparently  cicatrize,  the  temper- 
ature drops  and  stays  down,  and  the  digestive  and  renal 
functions  are  greatly  improved.  The  rationale  of  this  ac- 
tion is  not  entirely  clear  ;  apparently  it  is  not  the  bacillus 
but  the  body  cell  which  is  acted  on  and  made  more  resist- 
ant to  the  pathogenic  agent. 

The  Significance  of  Heredity  in  Pulmonary  Tuberculosis. — 
F.  Keiche,  basing  his  conclusions  on  statistics  obtained  by 
examination  of  over  one  thousand  cases,  believes  that  the 
prevalent  idea  that  a  family  tendency  to  tuberculosis  may 
exist,  and  that  individuals  may  from  birth  be  predisposed 
to  this  infection,  is  erroneous.  While  it  is  undoubtedly 
true  that  oftentimes  the  offspring  of  markedly  phthisical 
parents  is  lacking  in  stamina  and  resisting-power,  just  as 
is  the  case  in  the  children  of  those  cachetic  from  other  rea- 
sons, e.g..  cancer,  nephritis,  orcirrhosis,  yet  in  the  majority 
of  instances  the  child  acquires  the  disease,  which  may  lie 
dormant  for  years,  by  direct  infection  from  the  diseased 
parent.  This  is  an  encouraging  view,  for  it  permits  the 
hope  that  with  increasing  care  in  the  prophylaxis  such  in- 
fections may  be  greatly  diminished  and  the  dread  of  a 
hereditary  taint  be  robbed  of  much  of  its  terror. 

The  Marriage  of  Phthisical  Patients.— C.  Gerhardt  says 
that  on  the  one  hand  it  has  been  proposed  to  make  the 
marriage  of  tuberculous  subjects  a  legal  offence,  and  on 


the  other  it  has  been  stated  that  the  better  care,  greater 
comfort,  more  regular  habits,  and  mental  quietude  attend- 
ing the  married  state  more  than  counterbalance  the  dan- 
gers. He  himself  is  of  the  opinion  that  the  risks  are  quite 
as  grave  as  usually  considered,  and  while  exceptionally 
favorable  cases  are  to  be  found  it  is  still  the  physician's 
duty  to  warn  the  public  most  emphatically  of  the  dangers 
acc<mipanying  such  unions.  In  general  it  should  be  de- 
manded of  a  tuberculous  individual  that  before  matrimony 
he  should  have  been  perfectly  healthy  for  at  least  a  year. 

The  Educational  and  Legislative  Control  of  Tuberculosis. 
— Charles  l^eiiisoii  ascribes  a  large  uart  of  the  nujrbidity 
from  tuberculosis  to  deficient  ventilation  in  dwellings. 
Owing  to  the  rebreathingof  devitalized  air  the  lungs  grow 
inactive,  and  there  is  gradual  clogging  of  the  out-of-the- 
way  air  cells  with  the  products  of  combustion,  and  a  dam- 
aging form  of  local  auto-intoxication  follows.  Legislation 
should  provide  for  each  individual  in  a  living-apartment 
fifteen  hundred  cubic  feet  of  air  space  and  a  minimum  ven- 
tilation of  two  thousand  feet  per  hour  per  person.  Courses 
in  ventilation  should  be  instituted  in  institutions  of  learn- 
ing, and  governmental  commissions  be  appointed  properly 
to  investigate  and  study  the  subject. 

E.xperimental  Contributions  to  the  Understanding  of  Tuber- 
culous Toxaemia. — M  .Maragliauo,  by  injecting  the  bhiod  of 
tuberculous  individuals  prepared  in  various  ways  and  pie- 
cipitates  obtained  from  their  urine  into  guinea-pigs  and 
rabbits,  was  able  to  determine  that  (i)  patients  givingclin- 
ical  evidence  of  toxiomia  had  in  their  blood  (injected  as 
such,  in  the  form  of  a  glycerin  extract  or  as  blood  serum), 
and  also  in  tlieir  urine,  substances  which  when  injected 
into  healthy  or  tuberculous  animals  produced  toxic  symp- 
toms :  (2)  that  this  intoxication  resembled  that  produced 
by  tuberculin  ;  (3)  that  this  toxic  pio])erty  could  be  neu- 
tralized by  a  simultaneous  injection  of  tubercle  antitoxin. 

The  Diagnostic  Value  of  Koch's  Tuberculin.— Albert  Fraen- 
kel  says  that  the  reaction  against  the  use  of  this  agent, 
which  was  the  natural  result  when  it  was  found  that  not 
only  was  it  useless  as  a  therapeutic  agent  but  also  that 
even  as  a  means  of  diagnosis  its  employment  was  not  free 
from  danger,  has  gone  too  far,  and  that  pro]ierly  and  care- 
fully administered  it  gives  valuable  information  with  very 
little  risk.  A  large  portion  of  the  undesirable  by-effects 
and  sequelae  attributed  to  the  reagent  are  due  solely  to  the 
unnecessarily  large  doses  which  it  has  been  customary  to 
give. 

Tuberculous  Gastric  Ulcer  in  Connection  with  a  Case  Ending 
Fatally. — Theodor  Struppler's  case  presented  the  rare  pic- 
ture of  a  tuberculous  ulcer  which  almost  entirely  surrounded 
the  pylorus  and  perforated,  inducing  a  fatal  secondary 
peritonitis.  The  patient  was  a  youth  aged  eighteen  years, 
who  was  also  suli'ering  from  jmlmonary  tuberculosis  and 
tuberculous  enteritis.  The  author  believes  that  in  this  case 
the  infection  was  due  to  the  swallowing  of  sputum  con- 
taining bacilli. 

How  Does  Infection  of  the  Intestine  Take  Place  ?  (To  be 
concluded) .  —  By  Buttersack. 

Respiratory  Exercises  in  the  Treatment  of  Pulmonary  Tu- 
berculosis.—  By  Schultzen. 

A>-iliivcs  Gencrali-s  dc  Mi'tfecine,  ^eplciiihcr,  /goo. 

The  Psychology  of  Phthisis. — Maurice  Letulle  believes 
that  certain  psychical  and  intellectual  changes  occur  dur- 
ing the  course  of  this  disease.  In  the  early  stages  there  is 
a  species  of  hyperexcitability  in  the  mental  state,  a  fever- 
ish desire  for  occupation,  change,  and  society,  followed 
later  by  mental  lassitude  and  indolence,  a  veritable  intel- 
lectual neurasthenia.  As  to  the  moral  state  of  the  patients, 
some  retain  their  strength  and  beauty  of  character  through 
their  long  illness  until  the  end.  others  undergo  a  species 
of  psychic  irritability.  Melancholy  is  the  rule,  with  an 
indifference  which  is  plainly  shown  in  the  facial  expres- 
sion. Egotism  is  apt  to  follow,  tuberculosis  being  of  all 
diseases  the  one  most  conducive  to  the  "contemplation  of 
self" — "Myself,  always  myself,  myself  alone,  whatever 
happen."  All  affection  and  every  service  are  accepted  as 
a  right.  Jealousy  is  apt  to  be  marked,  rendering  the  lives 
of  those  who  care  for  the  patient  hard  in  the  extreme.  The 
consumptive  is  impatient  of  every  little  discomfort,  and 
unforgiving  of  neglect.  For  the  treatment  of  these  sad 
changes  in  character  no  amount  of  reasoning  will  have 
one-hundredth  part  of  the  effect  that  is  produced  by  warm 
sunshine,  the  light  of  warm  countries,  flowers  with  their 
sweet  perfume,  a  view  of  the  sea,  and  beautiful  scenery  of 
all  kinds. 

The  Diabetograph. — Under  this  name  F.  Coulon  describes 
an  instrument  devised  for  the  purpose  of  rapidly  and  au- 
tomatically estimating  the  amount  of  sugar  contained  in 
the  urine  of  diabetic  patients.  In  consists  of  a  glass  cyl- 
inder 20  cm.  in  length,  bell-shaped  at  the  mouth,  tapering 
to  the  other  extremity  where  there  is  a  stop-cock.  Figures 
are  marked  along  the  tube.     The  cylinder  is  filled  with  the 


588 


MEDICAL    RECORD. 


[October  13,  1900 


urine  to  be  analyzed,  and  by  careful  management  of  the 
stop-cock  allowed  to  flow  drop  by  drop  into  a  small  glass 
receptacle  in  which  2  c.c.  of  Fehling's  solution  diluted 
with  six  times  its  volume  of  distilled  water  has  been  al- 
lowed to  come  to  the  boiling-point.  When  the  desired  reac- 
tion is  obtained,  the  number  opposite  tlic  level  of  the  urine 
in  the  tube  will  indicate  the  amount  of  glucose  to  the  litre 
of  the  urine.  The  diabetograph  is  based  upon  the  two  fol- 
lowing principles:  (i)  All  urine  which  is  capable  of  reduc- 
ing an  equal  volume  of  Feliling's  solution  contains  5  gm. 
of  sugar  to  the  litre.  (2)  Tlie  amount  of  m-ine  necessary 
for  the  reduction  of  Fehling's  solution  is  in  •inverse  pro- 
portion to  the  amount  of  sugar  contained. 

The  Development  of  Typhoid  Fever  during  the  Course  of 
Active  Syphilis. — G.  Etienne  from  a  study  of  several  cases 
concludes  that  syphilis  renders  more  grave  tlie  prognosis 
of  typhoid.  On  the  other  hand,  typhoid  may  aggravate 
the  condition  of  the  coexistent  syphilitic  lesions,  which  may 
under  its  influence  lead  to  dangerous  complications,  such 
as  gangrene  of  the  vulva,  which  occurred  in  one  of  the 
cases  reported.  Typhoid  fever  may  perhaps  cause  a  re- 
awakening of  syphilitic  lesions. 

Multiple  Sclerosis.  Paralysis  of  the  Sixth  and  Seventh 
Cranial  Nerves,  and  Both  Limbs  of  the  Right  Side. — liy  M. 
Bouchaud. 

A  Case  of  Recklinghausen's  Disease,  or  General  Neuro- 
fibromatosis.—  By  P.  Bourcy  and  Laiquel-Lavastine. 

E.xperimental  Researches  in  Regard  to  Reflex  Amyotrophia. 
—By  ilign..t  and  Mally. 

Anatomical  Study  of  Tuberculosis  of  the  Pancreas. — By 
E.  Lefas. 

Revue  lie  Medeciiie,  September  10,  igoo. 

A  Case  of  Compression   of  the   Superior  Vena  Cava. — Ch. 

Dopter  reports  the  case  of  a  man  apparently  in  good 
health,  in  whom  the  following  symptoms  appeared:  Grad- 
ual increase  in  size  of  the  neck,  with  swelling  and  conges- 
tion of  the  face ;  (.edema  of  the  anterior  thoracic  wall,  and 
varicosities  at  the  base  of  the  thorax,  soon  extending  up- 
ward ;  upper  limbs  oedematous  and  cyanosed.  The  sub- 
jective symptoms  were  retrocostal  and  scapular  pain,  ver- 
tigo, attacks  of  suffocation,  dysphagia,  dysphonia,  but  no 
palpitation.  Vesicular  murmur  was  lessened  in  the  right 
lung  ;  a  .soft  souffle  was  heard  with  both  inspiration  and  ex- 
piration in  the  right  bronchus  ;  to  the  right  of  the  sternum 
were  simple  beatings,  synchronous  with  those  of  the  heart. 
The  .r-rays  showed  an  aneurism  of  the  aorta,  and  the  fol- 
lowing diagnosis  was  made  ;  An  aneurismal  ectasis  of  the 
ascending  portion  of  the  arch  of  the  aorta  and  a  part  of  tlie 
transverse  portion,  which  by  its  development  had  com- 
pressed the  superior  vena  cava,  the  right  Ijronchu?,  the 
pneumogastric  and  left  recurrent  laryngeal  ner%'es.  Syph- 
ilis was  undoubtedly  the  cause  of  the  condition,  and  mixed 
treatment  resulted  in  a  partial  cure. 

Pneumothorax  with  a  Valve  due  to  Pleural  Adhesions.— F. 
Duplant  concludes  a  study  of  tliis  form  of  disease  by  say- 
ing (i)  that  pleural  adhesions  do  not  prevent  the  produc- 
tion of  pneumothora.x.  (2)  The  frequent  formation  of  ad- 
hesions in  tuberculous  patients  explains  the  fact  that  the 
pneumothora.x  occurring  in  the  phthisical  is  at  first  par- 
tial or  enclosed  within  septa.  (3)  Pneumothorax  in  tu- 
berculosis with  a  broncho-pleural  fistula  usually  acts  like 
pneumothorax  with  a  valve.  (4)  The  existence  of  a  mem- 
branous valve  closing  the  orifice  is  altogether  exceptional. 
(5)  Treatment  is  scarcely  ever  palliative.  To  be  curative 
it  sliould  be  directed  to  the  obliteration  of  the  broncho-pleu- 
ral fistula. 

Premature  Medullary  Syphilis  with  Brown-S^quard's  Com- 
plex of  Symptoms  (Hemiparaplegia  with  Crossed  Hemianaes- 
thesia.— By  M.  Brousse  and  .\rdin-lJelteil. 

Hypertrophic  Hepatico-Pancreatic  Sclerosis  with  Hyper- 
splenomegaly. — By  Georges  Gudlain. 


(Covvcsponclcncc. 


A  Chinaman's  First  Ambition. — The  first  ambi- 
tion of  every  Chinaman  is  to  have  a  splendid  coffin. 
A  poor  man  will  starve  himself  for  years  to  buy  one. 
It  is  always  received  with  great  ceremony  on  its  arrival 
at  the  house,  and  is  regarded  as  the  most  valuable  piece 
of  furniture  in  the  establishment.  It  is  kept  in  the 
place  of  honor.  There  arc  many  strange  customs  con- 
nected with  the  funeral  rites.  One  of  these  is  the 
burning  at  the  tomb  of  paper  horses,  idols,  umbrellas, 
and  clothes.  These  are  supposed  to  be  necessary  or 
useful  to  the  man  when  he  gets  to  heaven.  By  being 
burned  they  undergo  some  material  resurrection  and 
meet  him  there. 


OUR   LONDON    LKTTER. 

(From  our  Special  Correspondent.) 

PLAGUE — WAR    HOSPITAL    COMMISSION — MORE     CONTRADICTION' 

TO   MR.    lUKDKTT-COUTTS — CRUELTY   TO   HRITISH    PRISONERS 

—  REPORT  OK  ASYLUMS  CO.MMITTEE — niR.MINGHAM  UNIVERSITY 

^HUXLEY    LECTURE. 

London,  September  24,  igoo. 
The  progress  of  the  plague  in  Glasgow  has  not  been  so 
reassuring  to  the  jjublic  this  week  as  last,  but  then  the 
public  is  greatly  influenced  from  day  to  day  by  variations 
in  the  figures  which  do  not  alarm  those  in  charge  of  the 
hospitals.  On  Monday  five  fresh  casus  were  reported— the 
total  being  twenty-two,  with  one  doubtful.  One  patient  lias 
since  died,  making  the  fifth  death,  of  which  two  occurred  in 
the  Belvedere  Hospital  and  the  others  outside.  The  figures 
last  night  were  twenty-one  cases,  one  doubtful,  and  one 
hundred  and  five  persons  isolated  as  "contacts."  One  of 
the  new  cases  was  that  of  a  woman  who  had  been  employed 
as  a  ward-cleaner.  She  had  been  inoculated  with  serum 
soon  after  the  outbreak,  and  her  attack  was  extremely  mild  ; 
Dr.  Chalmers,  the  medical  officer  of  health,  thinks  that  if 
more  .serum  had  been  injected  she  vi'ould  have  been  quite 
immune,  but  the  remedy  was  available  only  in  small  quan- 
tity at  first.     Now  there  is  an  abundant  supply. 

It  is  quite  clear  that  the  di.sease  in  Glasgow  is  in  its 
mildest  form.  The  progress  of  the  cases  and  the  death 
rate  both  show  this.  In  India  a  rate  of  forty  per  cent,  is 
common.  Here,  on  the  highest  computation,  it  has  not 
exceeded  half  that.  This  is  better  than  even  Sidney — the 
lowest  rate  I  call  to  mind,  and  which  showed  one  hundred 
and  three  deaths  out  of  three  hundred  and  three  cases. 

The  circumstances  at  Glasgow  are  far  more  favorable 
than  they  were  at  Oporto  when  plague  broke  out  there  last 
year.  Every  effort  has  been  made  to  prevent  the  spread 
of  the  disease, "and  so  far  with  considerable  success,  for 
twenty-tw  o  cases  in  a  month  and  only  five  deaths  certainly 
encourage  the  belief  that  the  sanitary  authorities  are 
waging  a  successful  war.  Even  in  Glasgow,  however, 
there  may  be  found  weak  joints  in  her  armor,  but  her  au- 
thorities are  making  every  effort  to  find  them.  We  must 
not,  however,  forget  that  there  is  a  danger  of  other  places 
becoming  infected.  For  a  considerable  period  now  the 
West  has  been  threatened,  and  with  here  and  there  small 
outbreaks  occurring  we  have  frequent  warning.s  that  we 
are  not  immune  to  the  pestilence. 

Professor  JIuir's  report  on  the  cases  shows  that  the  ba- 
cillus pestis  was  found  and  cultures  produced  the  disease 
in  animals. 

Glasgow  has  parliamentary  powers  permitting  the  prohi- 
bition of  holding  "wakes  "  over  the  liodies  of  persons  dead 
of  infectious  di.seases.  The  magistrates  have  first  of  all 
urged  upon  the  Roman  Catholic  .prie;>ts  to  discountenance 
wakes,  as  at  one  of  these  the  outbreak  occurred.  The 
priests  say  watching  the  dead  is  a  solemn  act.  No  doubt 
it  is.  But  one  would  suppose  that  in  times  of  danger  they 
might  assist  the  authorities.  The  fact  is,  these  solemn  acts 
too  often  degenerate  into  drunken  orgies. 

Lord  Kitchener  has  given  evidence  before  the  hospitals 
commission  which  further  controverts  Mr.  Burdett-Coutts. 
His  lordship  admitted  some  delay  in  tlie  supply  of  stores, 
but  said  this  was  inevitable  owing  to  the  rapid  advance. 
The  field  hospitals  he  held  had  done  the'r  work  remark- 
ably well.  He  had  frequently  ridden  with  Mr.  Coutts, 
who  never  once  made  a  comjilaint  to  him.  Had  he  done 
so  it  would  have  been  immediately  investigated.  The 
medical  staff  worked  tremendously  hard,  and  the  civilian 
doctors  did  excellent  service. 

Lord  Stanley,  private  secretary  to  Lord  Roberts  and 
principal  cen.sor,  denied  that  criticisms  on  the  hospitals 
were  stifled.  Jlr.  Burdett-Coutts  was  given  every  facility 
until  Lord  Rolierts  thought  lie  had  had  time  enough  to 
acquaint  himself  with  the  facts  and  should  return  to  Cape 
Town.  When  an  order  was  given  to  that  effect,  ^Ir. 
Coutts  said  if  he  could  not  have  iliore  time  he  would  have 
to  make  a  bad  report.  .  This  .seems  very  like  a  threat,  and 
may  well  be  compared  to  the  spite  of  the  society  ladies 
when  they  were  excluded  from  the  hospitals.  Mr.  Coutts 
lias  now  been  so  much  contradicted  that  no  rea.sonable 
person  can  place  reliance  on  liis  statements.  I  have  men- 
tioned only  a  few  of  tlie  more  important  contradictiims. 
They  suHice  for  the  present,  and  we  can  await  calmly  the 
report  of  tlie  commission  for  other  evidence. 

Another  inquiry  arising  out  of  the  war  is  that  into  the 
treatment  of  British  |nisoiiers  by  the  Boers.  This  has 
now  been  ])ublished  and  shows  a  good  deal  of  cruelty. 
Lord  Rolierts  says  "the  inhuman  treatment  of  the  sick 
])risoncrs  throws  the  greatest  discredit  on  the  authorities 
at  Pretoria."     He  speaks  of  the  efforts  of  Urs.  P.  H.  Hay- 


I 


October  13,  1900] 


MEDICAL    RECORD. 


589 


lett  and  R.  von  Gernett  to  ameliorate  the  condition  of  their 
patients  as  the  gratifying  features  of  the  inquiry.  On  tlie 
other  hand,  he  says,  it  "would  be  difficult  to  condemn  tou 
strongly  the  conduct  of  Dr.  H,  P.  Veale. "  You  will  deeply 
regret  that  any  doctor  should  have  laid  himself  open  to 
such  a  verdict  from  so  mild  a  judge  as  Lord  Roberts. 

The  report  of  the  asylums  committee  of  the  County 
Council  for  the  year  ending  March  31st  shows  a  diminu- 
tion in  the  number  of  lunatics  from  21,393  in  the  previous 
year  to  21,069. 

The  first  .session  of  the  medical  faculty  of  the  new  Uni- 
versity of  Birmingham  will  be  opened  on  October  ist, 
when  Professor  Windle,  M.D.,  D.Sc,  will  deliver  an  inau- 
gural address.  Dr.  Windle  is  the  dean  of  the  medical 
faculty. 

Lord  Lister  will  give  the  Huxley  lecture  on  October  2d. 


WHY    GYX.-FXOLOGISTS    ARF.     RELUCTANT 
TO    USE    ELECTRICITY. 

To  THE  Editor  op  the  Medical  Record. 

Sir;  I  have  read  with  much  amusement  Dr.  Robert  New- 
man's ingenuous  article  entitled  "Electricity  in  Gyntccol- 
ogy,  and  the  Present  Reluctance  of  Gynjecologists  to  Use 
Electricity,"  published  in  the  Medical  Record  for  Septem- 
ber 29th.  I  say  "amusement"  and  "ingenuous,"  because 
the  doctor  surely  cannot  have  intended  his  question  seri- 
ously, when  he  asks  why  gynaecologists  have  discarded 
electricity  in  their  practice.  Where  has  my  venerable 
friend  spent  the  last  ten  years  tliat  he  needs  to  ask  this 
naive  question,  which — after  reciting  at  some  length  his 
own  experience  of  many  years,  and  stating  that  he  "has 
treated  successfully  with  electricity  most  of  the  diseases 
above  enumerated  "  (liis  list  includes  the  majority  of  pel- 
vic diseases  in  tlie  female,  from  abrasion  of  the  os  uteri  to 
e.xtrauterine  pregnancy)  and  "has  always  treated  his  cases 
of  fibroid  tumor  successfully  by  electricity "— he  finally 
fails  to  answer,  remaining  content  with  the  conclusion  that 
"the  reluctance  of  gynaecologists  to  apply  electricity,  or  at 
least  to  recommend  it,  has  not  been  explained." 

If  the  doctor  had  chosen  to  look  outside  of  the  circuit  of 
his  batteries,  and  had  followed  the  progress  of  gynecology 
in  the  last  ten  or  fifteen  years,  even  ever  so  slightly,  he 
would  have  found  the  explanation  for  the  abandonment  of 
electricity  by  gyniecologists  in  the  fact  that  the  recent  im- 
provements in  antisepsis  and  in  surgical  technique,  and 
their  consequent  better  acquaintance  with  many  jiathologi- 
cal  conditions  in  the  female  pelvis,  have  taught  them  that 
they  can  cure  the  majority  of  those  conditions  far  more  eas- 
ily, rapidly,  and  safely  by  the  use  of  the  knife  and  its 
allies  than  by  any  form  of  electricity,  how,  how  long,  or 
by  whom  applied. 

I  speak  as  a  former  believer  in  "  Electricity  as  a  Thera- 
peutic Agent  in  Gyna."cology,"  having  published  my  expe- 
rience in  a  paper  with  the. above  title  in  ihe  .-Imc-rniiti 
louinal  of  Ohslelrics  for  December,  1SS5  (an  article  of 
forty-one  pages,  which  seems  to  have  escajicd  Dr.  New- 
man's observation,  although  it  was  thought  worthy  of 
translation  into  French  by  P.  Meniere,  Spanish  and  Rus- 
sian) .  and  in  a  second,  "  Jly  Recent  E.xperience  with  Elec- 
tricity in  GywcecoXogy,"  Joiiriia/  0/ Olfsteirics.  June,  1S90: 
as  well  as  in  a  chapter  on  the  subject  in  Thomas  and 
Munde,  1891  ;  and  I  reported  one  case  of  cure  of  a  tubal 
pregnancy  by  the  constant  current  (see  M?;i)ic.-\i.  Rkcord 
and  foiirnal  of  Obstetrics.  October,  18S4)  when  the  patient 
almost  died  from  shock,  but  rallied  and  is  still  alive.  But 
who  would  to-day  dream  of  curing  a  tubal  pregnany,  rup- 
tured or  unruptured,  by  electricity  ?  Certainly  no  man  who 
is  able  to  use  the  knife  ! 

.■\nd  who  would  to-day  attempt  to  cure  chronic  salpingi- 
tis, or  salpingo-obphoritis,  or  old  intraperitoneal  adhe- 
sions, or  chronic  uterine  displacements,  by  electricity  ?  I 
will  not  deny  tlie  utility  of  the  mild  galvanic  current  in 
many  cases  of  salpingo-oophoritis  for  its  soothing  effect, 
as  also  in  neuralgic  dysmenorrhcea  ;  or  that  galvanism  lo- 
cally applied  may  hasten  the  absorption  of  pelvic  exudates 
unattended  by  suppuration.  But  a  cure  of  an  inflamed 
tube  or  ovary,  a  disappearance  of  its  adhesions,  or  of  any 
old  intraperitoneal  adhesions,  is  a  physical  impossibility 
by  electricity  or  any  other  than  a  surgical  procedure.  The 
author  is  to  be  congratulated  on  his  unfailing  success  in 
the  cases  treated  by  him  with  electricity.  Especially 
would  I  have  been  ])Ieased  to  see  the  cases  of  prolapsus 
uteri,  with  external  and  irreducible  uterus,  in  which  the 
"  liigh-tension  current  cured  every  case,  and  caused  the 
contraction  and  diminished  the  size  of  the  organ,  so  that 
it  was  reduced  and  pulled  back  to  its  normal  place  without 
the  use  even  of  the  hand,  and  solely  by  the  action  of  tlie 
electric  current."  I  devoutly  wish  I  could  have  that 
"high-tension  current"  at  my  disposal  for  the  cases  of 
complete  prolapsus  uteri   et  vaginae  which  I   laboriously 


and  often  not  tco  successfully  endeavor  to  cure  by  a  series 
of  plastic  operations.  It  is  strange  that  no  gynaecologist 
seems  to  have  confidence  in  the  miraculous  power  of  elec- 
tricity in  these  old  cases  of  complete  prolapse,  which  are 
still  the  opprobrium  of  gynaecological  surgery. 

But  Dr.  Newman's  chief  successes  have  been  with  fibroid 
tumors  of  the  uterus.  He  quotes  ancient  history  in  support 
of  his  position,  notably  my  friend  the  late  Dr.  Apostoli,  who 
certainly  deserved  credit  for  his  persistence  and  persever- 
ance in  pushing  the  claims  of  electricity  in  gyna.'cology, 
but  who  quite  as  certainly  was  an  enthusiast,  a  fanatic,  a 
"crank  "  on  the  subject.  He  went  so  far  as  to  propose  to 
cure  a  large  submucous  polypus,  presenting  through  the 
widely  dilated  external  os,  which  he  showed  me  at  his 
clinic  in  1SS6,  by  electro-puncture,  and  answered  my  in- 
quiry why  he. did  not  remove  it  by  the  knife  or  scissors, 
as  could  easily  be  done  in  ten  minutes,  by  saying,  "Why, 
that  would  not  be  curing  it  by  electricity."  I  used  gal- 
vanism, with  and  without  a  milliampere,  for  a  number  of 
years  in  uterine  fibroids  ;  I  employed  mostly  mild  currents, 
using  intravaginal  and  intra-uterine  blunt  platinum  sounds 
and  an  abdominal  wet  clay  or  sponge  electrode,  and  all  the 
results  I  achieved  were  a  temporary  arrest  in  growth  of 
the  tumor  and  an  amelioration  of  symptoms  (hemorrhage 
or  pressure)  wlule  the  treatment  was  continued.  That  I 
do  not  deny,  and  that  in  my  opinion  constitutes  the  ben- 
efit to  be  derived  in  fibroids  of  the  uterus  from  Apostoli's 
method.  A  cure,  a  complete  disappearance  of  the  tumor, 
I  never  saw.  Dr.  A.  Lapthorne  Smith,  whom  Dr.  New- 
m m  quotes  as  one  of  his  supporters,  was  obliged  to  admit 
that  of  sixty  patients  with  uterine  fibroids  whom  he  treated 
with  electricity,  to  his  own  certain  knowledge  only  two 
had  been  cured  of  the  fibroid,  for  the  tumor  was  expelled 
from  the  uterus  (Am.  Gyii.  Trans.,  vol.  23,  1S98).  In  the 
others,  the  symptoms  had  been  relieved  as  the  tumor  had 
diminished  in  size.  That  a  fibroid  of  the  uterus  can  be 
inflamed  and  made  to  slougli  by  galvano-puncture  is  well 
known.  I  reported  several  spch  cases  with  ultimate  cure 
in  my  paper  of  1S90  (loc.  (it.).  But  that  is  a  very  unsafe 
proceeding,  and  hardly  to  be  recommended. 

I  believe  I  am  known  to  be  rather  conservative  as  re- 
gards the  removal  of  the  finroid  uterus  by  abdominal  sec- 
tion, for  the  reason  that  I  do  not  think  that  the  symptoms 
in  a  very  large  proportion  of  fibroids  justify  the  risks  nec- 
essarily and  inevitably  attending  every  such  operation. 
Hence  electricity  would  be  to  me  a  veritable  boon  in  the 
treatment  of  such  tumors,  even  if  only  to  relieve  the  symp- 
toms and  arrest  tlie  growth.  But  I  have  of  late  years  al- 
most entirely  discarded  it,  because  it  is  too  troublesome, 
complicated,  and  principally  because  it  is  too  uncertain. 

I  have  a  galvanic  and  a  faradic  battery  in  my  office,  and 
occasionally  employ  them,  mostly  for  scanty  or  irregular 
menstruation  from  ovarian  inertia,  as  occurs  often  in  anae- 
mic or  in  obese,  flabby  women.  And  I  consider  intra- 
uterine faradization  as  the  mnihod.  per  se  in  stimulating  the 
uterus  and  ovaries  to  increased  growth  and  activity  in 
amenorrhoea  and  sterility.  But  much  as  I  esteem  elec- 
tricity as  a  therapeutic  agent  in  nervous  affections,  muscu- 
lar atrophy,  general  nervous  prostration,  neuroses,  neural- 
gias of  various  kinds,  etc.,  in  fact,  in  diseases  which  are 
outside  of  my  domain,  and  of  which  I  pretend  to  know  lit- 
tle, quite  as  much  do  I  regret  to  be  compelled  to  consider 
electricity  a  failure  in  gynaecology,  with  the  above-men- 
tioned exceptions,  as  compared  with  our  present  improved 
surgical  methods  for  treating  the  majority  of  the  affections 
which  come  under  the  obser\-ation  of  gyniecologists.  I  do 
not  think,  intelligently  and  moderately  used,  that  it  can 
do  much  liarm,  for  instance,  jiroduce  intraperitoneal  adhe- 
sions as  Dr.  Newman  quotes  to  have  been  asserted.  But  I 
do  not  think  it  does  as  much  good  as  the  length  of  treat- 
ment, its  expense,  and  the  trouble  incurred  should  lead  us 
to  expect. 

Evidently  the  electrotherapeutist  feels  differently  on  the 
subject;  and  that  is  but  natural,  since  electricity  is  his 
special  line  of  practice.  It  does  not  seem  quite  fair  to  inti- 
mate, as  Dr.  Newman  substantially  does,  that  only  the 
cases  which  are  surgically  or  otherwise  incurable  are  re- 
ferred to  the  electro-therapeutist,  as  he  claims  has  been 
done  in  hospitals  ;  and  the  mothod  is  then  blamed  for  the 
failure.  Surely  no  member  of  a  hospital  staff  can  be 
forced  to  treat  patients  referred  to  him  by  a  certain  method, 
when  he  knows  that  they  are  not  suitable  cases  for  that 
treatment. 

To  include  the  galvano-cautery  under  the  head  of  thera- 
peutic electricity,  as  Dr.  Newman  does,  is  incorrect,  since 
it  is  the  hot  knife  or  wire  which  produces  the  therapeutic 
effect,  not  the  electricity  which  does  the  heating.  No  one 
denies  the  utility  of  galvano-cautery,  any  more  than  of  the 
Paquelin  thermo-cautery,  when  indicated. 

An  explanation  for  the  decline  of  electricity  as  a  thera- 
peutic agent  in  gynjecology,  which  I  have  heard  hinted  by 
electro-therapeutists,  is  that  the  gyntecologist  does  not 
know  how  to  use  electricity  so  as  to  benefit  his  patients. 
That  may  be  true,  although  those  of  us  who  have  used 


59C 


MEDICAL    RECORD. 


[October  13,  1900 


electricity  have  tried  faithfully  and  perseveringly  to  fami- 
liarize ourselves  with  the  details  of  the  batteries,  currents, 
and  instruments  before  using  them.  But  that  insinuation 
might  be  answered  with  equal  justice  by  another,  namely, 
that  the  electro-tlierapeutist,  not  being  an  expert  gyn.ecol- 
ogist,  might  fail  to  make  a  correct  diagnosis  of  the  case, 
both  before  and  after  his  treatment,  and  that  therefore  his 
so-called  "cures"  were  open  to  doubt,  even  though  he 
might  be  perfectly  honest  in  his  statements. 

When  Dr.  Newman,  therefore,  says,  "Basing  my  con- 
clusion on  my  own  experience  and  on  reports  contained  in 
the  literature  on  the  subject,  I  may  say  that  we  obtain 
better  results  from  treatment  by  electricity  than  by  other 
means,"  I  am  compelled,  from  my  experience,  to  contra- 
dict him,  and  to  question  the  correctness  of  his  observa- 
tions. As  he  himself  says,  "An  investigation  for  facts 
and  truth  may  not  be  pleasant,  and  it  is  not  my  desire  to 
elicit  unpleasantness  :  hence  let  us  cover  with  professional 
love  all  differences." 

However  this  may  be,  I  wish  I  could  conscientiously  feel 
the  confidence  in  electricity  which  I  did  when  I  published 
my  papers  fifteen  and  ten  years  ago.  But  the  last  ten 
years  have  wrought  a  great  change  in  gynaecological  prac- 
tice, and  where  formerly  tampons,  applications,  pessaries, 
and  electricity  were  employed,  to  the  exhaustion  of  pa- 
tient and  physician,  now  otherwise  incurable  diseases  of 
the  uterus  and  appendages,  displacements,  ectopic  gesta- 
tions, ruptured  and  unruptured  (hsematoma  and  htcma- 
tocele) ,  pelvic  abscesses,  etc. .  are  rapidly  and  safely  treated 
by  surgical  methods.  That  is  why  electricity  is  no  longer 
used  by  gynjecologists.  Paul  F.  Munue. 

20  West  Forty-fifth  Street. 


LETTER    FROM    PERU. 

(From  our  Special. Correspondent.) 
VACCIN".\TION — PREVAILING   DISEASES — VITILIGO. 

Arequipa,  Peru,  August  20,  1900. 
We  are  at  present  passing  through  our  annual  influenza 
epidemic.  \Ve  have  also  smallpox,  but  that  comes  only 
every  three  or  four  years.  Vaccination  is  gratuitous,  mu- 
nicipal, but  not  compulsory.  If  all  do  not  take  advantage 
of  it,  it  is  not  owing  to  any  theoretical  ideas  or  conscien- 
tious scruples,  but  to  the  dilatory  "to-morrow"  way  of 
doing  things.  Sometimes,  however,  children,  among  the 
lower  class,  are  not  vaccinated  owing  to  certain  "astrologi- 
cal "  ideas — a  child  born  in  a  leap  year  or  year  in  which 
tliere  is  a  solar  eclipse  does  not  require  vaccination,  being 
already  protected.  How  such  ideas  originated  I  cannot 
make  out,  and  how  tliey  still  exist  in  spite  of  constant 
proofs  to  the  contrary  is  one  of  tho.se  mysteries  appertain- 
ing to  most  superstitions.  When  I  was  a  younger  man — 
at  the  age  when  one  knows  everything  with  certainty — I 
had  no  doubt  that  vaccination  should  be  compuLsorv.  Now 
I  am  not  so  sure  about  it ;  at  least,  it  is  not  the  profession 
who  should  insist  upon  compulsory  vaccination.  Let  the 
public  demand  it  if  they  like. 

When  a  man  comes  to  me  and  asks  "Should  I  have  my 
children  vaccinated?"  I  say.  "Yes,  and  you  also  shouli 
be  re  vaccinated."  I  have  then  more  than  fulfilled  my 
duty.  I  am  not  going  to  seize,  or  get  the  law  to  seize,  him 
and  his  children,  and  vaccinate  them  by  force.  I  might 
with  equal  (or  more)  justice  have  a  law  passed  that  any 
f)ne  with  a  strangulated  hernia,  if  irreducible,  should  be 
compelled  to  submit  to  operation.  Appendicitis,  glaucoma 
— where  shall  we  draw  the  line? 

I  think  there  are  two  reasons  (?)  at  the  root  of  the  resist- 
ance to  forcible  vaccination.  First,  human  (especially 
Anglo-Saxon)  nature,  when  ordered  to  do  a  thing,  feels 
inclined  to  resist;  secondly,  with  many  there  is  the  idea 
that  the  physicians  wish  compulsory  vaccination  so  that 
tliey  may  be  paid  for  it  ;  they  do  not  realize  that  if  there 
l)e  no  vaccination  the  jihysicians  will  be  largely  the  gain- 
ers. The  doctors  will  take  good  care  that  they  and  their 
households  will  not  get  smallpox.  In  this  respect  small- 
pox differs  from  other  infectious  diseases  or  diseases  bred 
or  promoted  by  filthy  soil,  air,  water,  or  overcrowding. 
These  may  be  contracted  from  no  fault  or  neglect  on  one's 
own  part,  but  from  one's  neighbors'  faults,  and  therefore 
it  is  that  in  these  cases  a  central  authority  is  required  who 
will  make  all  obey.  It  may  interest  some  of  your  readers 
to  know  what  diseases  we  have  here  and  what  do  not 
trouljle  us.  I  give  my  im])ressions  gathered  during  more 
than  thirty -five  years'  residence.  Statistics  I  do  not  give, 
as  there  are  none  that  can  be  relied  upon.  Measles,  whoop- 
ing-cough, and  typhus  come  every  three  or  four  years.  As 
there  is  free  traffic  in  contagion,  they  go  through  most  of 
the  available  material  in  llie  population.  Scarlet  fever 
lias  not  visited  us.  Typhoid  fever  is  rare.  Diphtheria 
(and  crou]))  did  not  exist  when  I  first  arrived,  but  during 
the  last  twenty  years  there  have  been  sporadic  cases,  at 


other  times  epidemics,  particularly  in  some  rural  districts. 
Scrofulous  necks  or  joints  are  not  common.  External 
aneurisms  are  very  rare  ;  the  contrary  is,  I  am  told,  the 
case  in  Valjiaraiso. 

Dysentery  and  hepatic  abscesses  are  rather  common,  as 
compared  with  Europe,  but  less  since  we  changed  our  wa- 
ter supply  frfmi  river  to  spring,  a  \vork  executed  by  our 
present  President.  Cholera  never  has  appeared.  Yellow- 
fever  cases  have  been  brought  here  from  the  coast,  but  in- 
fection has  never  taken  ])lace,  even  though  the  cases  were 
brought  in  the  summer  when  the  temperature  does  not  go 
to  o'  C.  Pneumonia  is  at  times  epidemic  and  seems  to  be 
more  fatal  (case  mortality)  than  at  or  near  coast  level.  In 
Cuylloma,  about  sixteen  thousand  feet  above  sea  level  and 
twice  the  height  of  Arequipa,  it  seems  to  be  even  more 
deadly.  I  should  like  to  hear  the  experience  of  some  of 
my  Californian  colleagues  who  practise  about  these  alti- 
tudes as  to  the  fatality  of  pneumonia. 

Phthisis  is  not  common,  l)ut  has,  I  think,  become  more 
frequent  during  the  last  twenty  years,  as  we  have  easier 
communication — rail — with  the  coast,  and  so  more  patients 
suffering  from  tliis  disease  are  sent  here  and  doubtless 
communicate  the  disease  to  some  who  otherwise  would 
have  escaped.  Of  tubercular  leprosy  I  have  .seen  one  case 
• — a  young  negro  from  a  coast  valley. 

As  to  hydrophobia.  I  have  known  of  four  cases,  each 
separated  from  the  others  by  intervals  of  years. 

Ot  malaria,  there  are  no  cases  here,  but  many  cases 
come  from  the  neighboring  valleys.  It  must  be  remem- 
bered that  Arequipa  is  the  medical  centre  of  a  district  ex- 
tending toward  the  coast  a  hundred  miles  and  more  later- 
ally, and  toward  the  interior  much  more. 

In  some  of  the  valleys  there  is  a  disease  comparatively 
common,  but  rare  here,  viz.,  vitiligo.  In  Europe,  Canada, 
and  the  Northern  States  I  fancy  it  is  a  rare  disease.  Is  it 
common  in  the  Southern  States?  When  I  was  a  clinical 
clerk  in  the  Edinburgh  Royal  Infirmary,  I  do  not  remem- 
ber having  ever  seen  a  case  in  the  skin  ward.  Most  of  the 
cases  here  come  from  the  valley  or  have  originated  there, 
but  I  have  seen  cases  here  in  youths  and  adults  who  had 
never  been  in  the  valleys.  It  is  a  general  belief  here  that 
the  disease  is  given  to  a  person,  by  an  enemy,  in  food  or 
drink;  some  asserting  that  the  su'ostance  which  cau.ses  it 
is  toad's  excrement.  I  need  hardly  remark  that  any  proof 
of  the  above  is  wanting.  The  patient  is  looked  upon 
askance,  people  even  avoiding  taking  his  hand  from  fear 
of  contagion,  and  often  he  is  called  "leprous,"  this  term 
being  looseU'  applied  to  many  skin  diseases.  The  surface 
attacked  varies  in  extent  from  a  few  small  patches  to  half 
or  more  of  the  body  surface.  I  have  seen  an  almost  pure 
negress,  aged  forty-five  years,  whose  abdomen  and  thorax 
were  more  white  than  those  of  a  Caucasian.  I  cannot  say 
how  much  more  of  her  surface  was  affected,  as  I  came 
upon  it  when  examining  her  abdomen  for  a  uterine  fibroid 
and  did  not  e.xtend  my  surface  examination  farther.  No 
connection  seems  to  exist  between  the  affection  and  the 
general  health  ;  often  the  patients  are  otherwise  jierfectly 
healthy  and  attain  to  a  fair  age.  I  cannot  say  that  I  have 
ever  cured  a  patient,  but  in  a  very  few  cases  I  have  seen 
a  limited  eruption  disappear  -.pontaneously  after  some 
months.  There  are  some  natives  who  pretend  to  be  able 
to  cure  it.  Some  of  the  so-called  cases  of  cure  I  have  seen  ; 
they  were  not  satisfactory,  in  the  best  of  their  cases  what 
was  left  was  superficial  matrix  from  a  destruction  of  the 
skin.  They  seem  to  use  sometimes  vegetable,  sometimes 
metallic  (mercurial)  irritants  roughly  rubbed  in.  I  have 
latterly  been  trying  on  small  patches  repeated  sinapisms 
with  some  apparent  effect — a  diminution  of  the  extreme 
whiteness  of  the  patch  and  of  the  darkness  of  the  sur- 
rounding border. 


LIGAMENTOPAXIS. 

To  THK  Editor  of  thr  Mrdical  Record. 

Sir  :  Your  issue  of  October  6th  publishes  a  description  of 
my  method  of  operation  of  "ligamentopaxis, "  or  "round 
ligament  ventrosuspension  of  tlie  uterus,"  by  Dr.  D.  Tod 
Gilliam,  of  Columbus,  Ohio,  which  gives  the  details  of  the 
operation  but  does  not  mention  my  name. 

My  method  was  first  jniblished  and  illustrated  in  the 
Cent  nil  III  lit  t  fa  )■  Chiiufi^ic.  Au.gust  21,  1897.  It  was  also 
reported  by  Dr.  C.  A.  von  Ramdohr  before  the  New  York 
Obstetrical  Society  in  the  same  year,  and  was -made  a  grad- 
uation thesis  at  tlic  University  of  Paris  under  the  auspices 
of  Poirier,  Berger,  (Juyon,  and  Albarran.  (Jarrigues' 
"Diseases  of  Women  "  also  contains  it,  and  the  Anicriian 
Jotirtial  of  Obstctriis  tiiiit  Piscascs  of  Women  aiut  Cliil- 
lircii,  vol.  xlii.,  No.  8,  1900,  gives  a  description  of  the  orig- 
inal operation  and  some  of  its  modifications. 

I  must  assume  that  these  facts  were  unknown  to  Dr. 
Gilliam,  and  that  he  will  correct  his  descri))tion  accord- 
ingly.    Very  rcsjicctfully  yours,  Carl  Bei  k,  M.D. 


October  13,  1900] 


MEDICAL    RECORD. 


591 


J'ocicti}  Jlqjorts. 

MEDICAL  SOCIETY  OF  THE  COUNTY  OF 
NEW  YORK. 

Stated  Meeting,  September  24,  jgoo. 
George  B.  Fowler,  M.D.,  President. 

In  Memoriam :  Dr.  Landon  Carter  Gray. — Dr. 
William  B.  Pritchard  delivered  this  address.  He 
said  that  Dr.  Gray  counted  on  both  sides  a  long  line 
of  distinguished  ancestors.  His  boyhood  had  been 
spent  at  liis  father's  home  on  Staten  Island.  He  had 
graduated  from  ]5ellevue  in  1873,  and  had  begun  prac- 
tice in  this  city.  In  a  year  or  two  he  had  moved  to 
Brooklyn,  and  had  there  developed  his  aptitude  for 
the  study  of  diseases  of  the  nervous  system.  In  1890 
he  had  been  in  the  full  vigor  of  health,  though  handi- 
capped by  an  overcultured  inentalit}'.  Following  a 
third  attack  of  la  grippe  in  1894  he  had  developed 
pneumonia  and  certain  marked  circulatory  changes. 
A  fourth  attack  of  lagrippe  led  to  an  endocarditis,  and 
from  that  time  on  his  health  had  steadily  failed.  He 
was  fully  cognizant  of  his  condition,  but  rather  than 
prolong  his  life  by  retirement  and  inactivity  he  de- 
liberately and  courageously  chose  to  die  in  the  harness. 
In  no  other  sphere  did  Dr.  Gray  attain  a  more  deserved 
distinction  than  in  medico-legal  work.  A  distin- 
guished jurist  characterized  him  as  the  model  of  what 
a  medical  expert  witness  should  be.  He  was  a  type 
of  the  loyal  friend  and  the  generous  foe.  To  him  a 
cardinal  crime  was  ingratitude.  He  was  an  intel- 
lectual gladiator,  and  the  atmosphere  of  the  intel- 
lectual arena  was  to  him  as  sweet  incense.  He  was 
bold  to  audacity;  his  sense  of  humor  was  keen;  his 
ability  as  a  teacher  was  .striking.  He  possessed  in  a 
remarkable  degree  the  faculty  of  organization.  Of 
those  who  stood  highest  here  in  his  special  field  to- 
day there  was  not  one  who  did  not  bear  tribute  to  his 
memory. 

Demonstration  of  New  Intravesical  Instruments 
and  Photographs. — Dk.  F.  Bierhoff  gave  this  demon- 
stration, all  of  the  instruments  being  modifications  of 
those  devised  by  others.  One  of  the  instruments  was 
an  improved  Civiale's  meatotome.  It  was  provided 
with  a  scale,  a  set-screw,  and  an  indicator,  so  that  the 
exact  size  of  the  meatus  could  be  accurately  gauged. 
A  second  instrument  was  a  forceps  for  removing  for- 
eign bodies  from  the  bladder.  The  next  instrument 
shown  was  a  modification  of  Xitze's  lithotrite  and 
foreign-body  forceps.  In  using  the  original  he  had 
found  that  because  the  posterior  jaw  moved  toward  the 
inside  of  the  bladder  and  covered  the  prism  it  was 
exceedingly  difficult  to  seize  and  hold  the  foreign 
body.  The  improvement  consisted  in  having  the  pos- 
terior jaw  fixed  and  the  posterior  shaft  fenestrated. 
The  operator,  while  looking  through  the  fenestra, 
could  then  readily  seize  the  foreign  body.  Still  an- 
other instrument  was  a  cystoscopic  intraprostatic  in- 
cisor. It  consisted  of  two  parts — one,  the  cystoscope; 
the  other,  the  incisor.  >  With  this  instrument  it  was 
entirely  feasible  to  select  accurately  the  part  of  the 
prostate  to  be  incised,  and  then,  by  rotating  the  in- 
strument, to  make  the  incision  at  this  point.  By  a 
graduated  milled  head  the  length  of  the  incision  could 
be  regulated  to  a  nicety.  The  instrument  was  the 
joint  invention  of  Dr.  A.  Freudenberg,  of  Berlin,  and 
Dr.  Bierhoff,  and  it  was  designed  to  do  away  with  the 
objection  that  the  Botlini  operation  had  hitherto  been 
done  entirely  in  the  dark. 

A  series  of  interesting  intravesical  photographs 
were  then  projected  on  the  screen  and  explained. 

Dr.  William  K.  Otis  said  that  he  had  been  inter- 


ested in  intravesical  photography  for  the  past  three  or 
four  years,  and  hoped  soon  to  present  an  instrument 
which  could  be  used  for  such  photography  with  ordi- 
nary plates  and  cystoscopes.  The  electric  light,  being 
always  a  yellow  light,  made  it  difficult  to  get  good  pic- 
tures on  ordinary  plates,  and  for  the  same  reason  yel- 
low screens  had  not  proved  advantageous.  According 
to  his  experience,  a  good  photograph  could  rarely  be 
secured  with  a  shorter  exposure  than  twenty  seconds. 
The  larger  the  cystoscope  used  the  better.  He  now 
employed  one  having  a  circumference  of  26  to  30  mm. 
Small  telescopes  ga\e  a  fairly  large  field,  but  one 
which  is  poorly  illuminated.  The  speaker  congratu- 
lated Dr.  Bierhoff  on  his  photographs,  but  remarked 
that  it  was  asking  almost  too  much  of  intravesical 
photography  to  require  that  these  small  photographs 
be  greatly  magnified  and  projected  upon  a  screen. 
Such  treatment  would  render  even  the  best  of  such 
photographs  almost  unintelligible. 

Dr.  H.  N.  Vineberg  spoke  in  favor  of  Kelly's 
method  of  cystoscopy  in  the  female  in  preference  to 
the  use  of  the  instruments  of  Nitze  and  Caspar.  The 
Kelly  instrument  possessed  all  of  the  advantages  and 
none  of  the  disadvantages  of  the  other  instruments. 
He  would  like  to  ask  what  method  was  employed  in 
removing  the  hair-pin  from  the  bladder  in  one  of  the 
cases  described.  In  a  case  of  this  kind  coming  under 
his  own  observation  he  had  succeeded  in  doing  this 
by  sharply  bending  the  foreign  body  before  extract- 
ing it. 

Dr.  Bierhoff,  in  closing,  said  that  he  had  had 
made  in  Berlin  a  special  photographic  plate,  which 
was  particularly  sensitive  to  yellow  light.  This  plate 
was  circular,  for  use  with  the  Nitze  cystoscope.  By 
using  improved  electric  lamps,  capable  of  giving  a 
fairly  white  light,  he  had  been  able  to  get  photographs 
of  the  interior  of  the  bladder  with  exposures  varying 
from  five  to  twelve  seconds.  Nitze  claimed  to  have 
succeeded  with  exposures  of  only  three  seconds,  but 
he  had  used  extremely  powerful  lamps,  the  use  of 
which  had  been  known  to  cause  serious  burns  and 
hemorrhage.  In  the  case  of  hair-pin  in  the  bladder, 
the  pin  had  been  removed  by  rapid  dilatation  of  the 
urethra  under  ancesthesia,  followed  by  withdrawal  of 
the  foreign  body  through  a  large  urethral  speculum. 


NEW    YORK    ACADEMY   OF   MEDICINE. 

Stated  Meeting.  October  j.  igoo. 

William  H.  Tho.mson,  M.D.,  President. 

Artificial  Infant  Feeding.  Complete  Report  Writ- 
ten for  the  Children's  Section  of  the  Thirteenth 
Medical  Congress — Dr.  A.  Jacob:  presented  this  re- 
port. He  said  there  were  certain  experiments  going 
to  show  that  the  casein  was  not  identical  in  the  milk  of 
different  animals.  Cow's  milk  contained  twice  as 
much  phosphorus  as  did  breast  milk,  but  in  the  form 
of  inorganic  compounds.  This  fact  might  perhaps 
explain  the  greater  tendency  to  rachitis  in  children 
fed  on  cow's  milk  than  among  those  artificially  fed. 
In  his  opinion,  the  chief  advance  in  infant  feeding 
had  been  in  the  more  general  adoption  of  the  custom 
of  heating  the  milk  and  the  various  substances  mixed 
with  it  before  giving  it  to  the  infant.  As  long  as 
there  was  danger  of  infection  of  the  milk  with  typhoid, 
scarlatina,  tuberculosis,  and  similar  diseases^  just  so 
long  must  milk  be  subjected  to  pasteurization  or 
sterilization.  For  the  purpose  of  infant  feeding  it 
was  of  the  greatest  importance  that  lactic-acid  fermen- 
tation should  be  interrupted  or  prevented.  By  pasteuri- 
zation all  of  the  lactic-acid  germs  were  not  destroyed, 
and  if  there  was  present  only  one-fifth  of  one  per  cent. 


592 


MEDICAL    RECORD. 


[October  13,  1900 


of  lactic  acid,  the  milk  could  not  be  pasteurized. 
Perhaps  it  was  because  Dr.  Koplik  did  not  usually 
obtain  milk  in  this  city  until  sufficient  time  had 
elapsed  to  permit  of  a  certain  amount  of  lactic-acid 
fermentation  that  he  was  led  to  speak  so  strongly 
against  pasteurization  and  in  favor  of  sterilized  milk 
for  infants.  One  should  not  depend  upon  milk  pas- 
teurized or  sterilized  on  a  large  scale  by  dairymen, 
for  it  was  impossible  to  guarantee  such  an  article  of 
commerce,  and  there  might  be  no  alteration  perceptible 
in  the  taste  and  smell  to  indicate  that  the  milk  was  a 
dangerous  article  of  food.  The  only  safe  way  was  for 
the  milk  to  be  sterilized  or  pasteurized  at  home  daily. 
Last  year,  in  the  Journal  oj  Expctiimtital  Alcdkine, 
Theobald  Smith  had  called  attention  to  the  fact  that 
by  heating  milk  to  only  140^  F.  tubercle  bacilli  were 
killed  on  an  average  in  from  five  to  ten  minutes.  In 
order  to  secure  this  result,  however,  it  was  necessary 
to  prevent  the  formation  of  tiie  membrane  or  "  skin  " 
on  the  milk  by  constant  stirring  during  the  heating- 
process.  Regarding  the  interesting  question  of  the 
modification  of  milk,  the  speaker  quoted  Professor 
Rotch  as  saying  that  the  chief  object  should  be  to 
learn  how  to  prescribe  milk  with  exactitude,  and  then 
he  went  on  to  show  how  inconsistent  it  was  to  insist 
upon  such  exactitude  in  prescribing  milk  for  infants 
when  mother's  milk,  which  should  be  our  model,  varied 
greatlv  in  composition,  not  only  in  different  individuals 
but  in  the  same  person  at  different  times.  The  great 
point  to  remember  was  that  in  artificial  feeding  no 
routine  mixture  would  suit  any  large  number  of  cases. 
A  certain  abuse  had  already  crept  into  this  practice  of 
depending  on  laboratory  milk,  for  it  was  not  uncom- 
mon for  nurses  to  go  to  the  laboratory  and  ask  for  a 
milk,  and  receive  in  response  to  this  request  a  milk 
modified  by  the  "bar  maid"  in  charge  in  accordance 
with  a  certain  printed  schedule  giving  what  a  child  of 
a  certain  age  or  size  should  take.  Dr.  Jacobi  said  he 
had  known  Hies  and  cockroaches  to  be  found  in  the 
milk  coming  from  the  laboratory,  and  the  fact  that  they 
had  been  pasteurized  or  sterilized  did  not  make  them 
any  the  less  objectionable  additions  to  an  infant's 
food.  Another  important  and  practical  objection  to 
laboratory  milk  was  its  great  expense;  it  would  often 
take  the  whole  of  a  workingman's  income  to  pay  for 
such  milk  for  one  infant.  A  goodly  part  of  the  milk 
sugar  in  mother's  milk  had  been  found  to  be  eliminated 
unchanged.  A  milk  mixture  containing  twenty-five 
per  cent,  of  milk  had  sufficient  milk  sugar  in  it  to  in- 
sure lactic-acid  fermentation.  It  was  well  known  that 
in  healthy  infants  a  large  quantity  of  fat  was  eliminated 
from  the  system  in  the  faces,  and  hence  he  did  not 
think  it  rational,  under  ordinary  circumstances,  to 
add  cream  to  milk  in  preparing  the  latter  for  infant 
feeding.  Moreover,  the  fat  in  cow's  milk  was  differ- 
ent from  that  of  breast  milk;  the  emulsion  was  not  so 
fine,  and  there  was  less  oleic  acid.  His  own  experi- 
ence in  the  feeding  of  infants  had  led  him  to  reduce 
rather  than  to  increase  the  proportion  of  fat  for  in- 
fants, and  under  this  practice  he  saw  no  acid  or  fat 
diarrhceas.  W'hile  some  infants  seemed  to  thrive  on 
almost  anything,  this  did  not  vitiate  the  general  rule, 
that  milk  should  be  diluted  for  infants.  This  was 
particularly  necessary  if  the  infant  was  sick.  In  in- 
fantile atrophy  the  milk  should  be  diluted  and  also 
reduced  in  C|uantity.  Nurses  and  mothers  often  forgot 
that  the  child  might  cry  because  of  thirst  as  well  as  of 
hunger,  and  that  they  should  frequently  offer  it  water. 
It  had  been  objected  that  this  practice  led  todilatation 
of  the  stomach ;  but  as  he  had  never  seen  a  case  of 
dilatation  from  this  cause  he  could  not  but  feel  that 
this  objection  was  purely  theoretical.  In  diluting 
milk  it  should  be  remembered  that  the  mere  addition 
of  water  would  cause  the  formation  of  rather  tough 
curds.     He  had  always  preferred  to  use  cereal  decoc- 


tions for  this  purpose,  chiefly  barley  and  oatmeal. 
He  recommended  that  one  tablespoonful  be  placed  in 
one  quart  of  water  and  boiled  down  to  half  a  quart, 
and  then  used  to  dilute  the  infant's  milk  to  the  desired 
degree.  Regarding  the  question  of  whether  young  in- 
fants could  digest  starch,  he  said  that  experiments  had 
been  made  which  showed  conclusively  that  the  saliva 
from  the  parotid  of  the  newly  born  infant  exerted  an 
active  diastasic  influence  on  starch. 

Dk.  Hii.VKV  Koplik  said  that  the  secret  of  infant 
feeding  was  to  study  each  case.  In  doing  so,  it  would 
be  found  that  all  of  the  recognized  methods  of  feeding 
would  prove  useful  at  times.  After  all,  the  great 
essential  was  a  fresh  and  clean  milk.  Sometimes 
everything  would  go  along  well  if  the  cow's  milk  were 
simply  diluted  with  a  cereal;  at  other  times  this 
would  not  be  sufficient,  and  it  might  be  necessary  to 
add  malt — a  diastase.  When  this  was  done  some  sick 
children  would  immediatL-ly  improve,  and  after  a  time 
could  then  be  put  back  upon  the  very  mixture  which 
had  originally  given  trouble.  The  explanation  of  this 
was  probably  to  be  found  in  the  fact  that  the  physician 
had  to  deal  with  a  sick  infant  and  an  unhealthy  bowel. 
Scurvy  was  not  so  much  the  result  of  a  particular  food 
as  of  processes  going  on  in  the  gut.  It  was  seen  in 
breast-fed  infants,  as  well  as  in  those  fed  artificially 
on  raw  milk  or  on  milk  that  had  been  pasteurized  or 
sterilized.  He  looked  upon  scurvy  as  a  true  toxaemia, 
and  sterilization  as  only  one  of  several  causes  of 
scurvy.  In  spite  of  the  fact  that  pasteurized  or  steril- 
ized milk  was  used  all  over  this  country,  the  American 
Pediatric  Society  had  been  able  to  find  only  four  hun- 
dred cases  of  scurvy.  Surely  it  was  far  better  to  have 
even  this  small  percentage  of  cases  of  curable  scurvy 
rather  than  hundreds  of  thousands  of  desperate  cases 
of  gaslro-enteritis. 

Dr.  Henry  D.  Chapix  said  that  in  New  York  City 
the  milk  supply  had  improved  very  much  in  the  past 
few  years,  and  he  believed  it  was  in  the  power  of  the 
medical  profession  to  secure  still  greater  advance 
along  this  line.  He  had  recently  made  an  extensive 
study  of  the  milk  supply,  and  had  been  surprised  to 
find  how  good  it  was  on  the  whole.  The  most  impor- 
tant defect  noted  was  a  lack  of  cleanliness.  The  butter 
fat  ranged  from  3.5  to  five  per  cent,  and  the  lactic 
acid  about  i.r5  per  cent.  It  was  perfectly  well  known 
at  the  present  day  how  milk  should  be  handled,  and 
this  being  the  case  it  was  only  a  question  of  education 
and  of  money.  He  believed  the  prescribing  of  milk 
in  percentages  had  been  carried  to  an  extreme.  The 
proteids  were  calculated  in  the  laboratory  on  an  as- 
sumed ratio  to  the  fats,  and  hence  it  was  absurd  to 
prescribe  small  fractions  of  percentages  of  proteids 
under  these  circumstances.  He  agreed  with  what  Dr. 
Jacobi  had  said  about  the  advantages  of  using  cereals 
as  diluents,  but  he  also  believed  that  there  was  a  de- 
cided gain  from  the  use  of  dextrinized  gruels. 

Dr.  Walter  Lester  Carr  took  the  same  position 
regarding  the  way  physicians  had  been  misled  by 
placing  too  much  dependence  on  the  printed  tables 
supposed  to  represent  the  conposition  of  milk.  The 
dis])osition  was  to  forget  that  at  the  bedside  one  was 
called  upon  to  face  condition;)  quite  different  from 
those  which  obtained  in  the  laboratory. 

Dr.  a.  Caii.lk  sent  a  communication  in  which  he 
expressed  the  belief  that  the  most  serious  and  com- 
mon mistake  in  connection  with  infant  feeding  was  to 
pin  one's  faith  on  certain  routine  mixtures — in  other 
words,  the  physician's  motto  should  be  "  individualize 
treatment." 

Anthrax.- — Excise  well  outside  the  areola  surround- 
ing the  eschar.  The  best  substitute  for  the  knife  is 
the  actual  cautery.— Warren,  Siiigical  Futhology  and 
Therapeutics. 


October  13,  19C0] 


MEDICAL    RECORD. 


593 


THE     AMERICAN      ELECTRO-THERAPEUTIC 
ASSOCIATION. 

Tenth  Annual  Mi-etiiig,  Ilelil  in  New    York,  September 
2j.  26.  and  2J,  igoo. 

Waltkr    H.  White,    M.l).,  ok    Boston,  President. 
J'irst  Day — Tuesday.   September  2§th. 

The  meeting  was  called  to  order  in  the  New  York 
Academy  of  Medicine  by  the  president,  Dr.  Walter  H. 
White,  of  Boston,  and  the  address  of  welcome  was  de- 
livered by  the  acting  mayor,  Hon.  Randolph  Giig- 
genheimer.  Dr.  Charles  K.  Dickson,  of  Toronto,  re- 
sponded to  Mr.  Guggenheimer.  Other  addresses  were 
delivered  by  Dr.  Louis  Faugeres  IJishop,  secretary  of 
the  Academy  of  Medicine,  and  by  tlie  Rev.  Newman 
Laurence. 

Report    of    the    Committee    on    Electrodes Dr. 

Charles  R.  Dickson',  of  Toronto,  chairman  of  this 
committee,  presented  the  report,  and  in  connection 
tlierewith  exiiibited  various  electrodes.  Several  of 
those  shown  were  made  of  aluminum,  at  the  recom- 
mendation of  Dr.  Walter  H.  White,  and  were  intended 
for  use  with  the  static  current.  One  of  these  was  a 
disc,  three  and  three-fourths  inches  in  diameter,  hav- 
ing on  its  circumference  twelve  large  rivet-heads,  and 
pro\ided  with  a  handle  thirteen  inches  long.  Another, 
a  multiple-point  electrode,  was  made  of  a  disc,  as  in 
the  first  instrument,  but  instead  of  the  rivets  were 
seven  long  steel  points.  Standard  connections  for 
electrical  apparatus  were  exhibited,  and  their  formal 
adoption  by  the  association  was  recommended. 

Mr.  R.  O.  Hrowx,  another  member  of  the  commit- 
tee, presented  his  perforated  llat  electrode,  made  both 
in  brass  and  aluminum.  His  plug  connection  was 
again  shown,  and  its  advantages  were  emphasized. 
He  said  that  it  had  been  found  that  aluminum  was 
acted  upon  by  the  salt  water  often  used  to  moisten 
electrodes.  Mention  was  made  of  the  use  of  amadou, 
or  punk.  Pads  were  made  of  this  material,  and  were 
then  covered  on  both  sides  with  linen  and  carefully 
quilted.  Made  in  tliis  way  they  constituted  excellent 
electrodes.  He  advised  the  use  of  the  ordinary  tinsel 
connecting-cords  covered  with  small  rubber  tubing. 
This  gave  perfect  insulation,  and  insured  greater 
cleanliness  and  durability.  In  connection  with  bipo- 
lar electrodes  it  was  recommended  that,  as  a  matter  of 
uniformity,  the  marked  terminal  at  the  rear  of  the  in- 
strument should  always  correspond  with  tile  distal  me- 
tallic portion  of  the  electrode.  The  connections  should 
be  made  by  means  of  a  plug  and  "split  tube,"  and  the 
electrode  was  preferably  constructed  so  that  it  could 
be  separated  and  disinfected. 

The  association  adopted  the  report,  including  its 
reconmiendations  concerning  electrodes  of  standard 
size  and  construction. 

Dr.  G.  Betton  Massev,  of  Philadelphia,  criticised 
the  seven-point  multiple  electrode,  contending  that 
this  number  of  points  was  altogether  insufficient  if  one 
desired  to  guard  completely  against  the  passage  of 
sparks.  For  some  time  he  had  obviated  this  danger 
by  making  a  rosette  of  the  metallic  thread  used  in 
making  tinsel  cloth.  A  whole  spoolful  of  this  thread 
was  wound  around  the  fingers  and  then  cut,  thus  giv- 
ing a  rosette  made  up  of  a  very  large  number  of  fine 
and  soft  metallic  points.  If  the  patient  should  acci- 
dentally come  in  contact  with  this  rosette,  he  would 
not  be  injured  as  he  would  if  the  electrode  were  made 
up  of  large,  stout,  steel  points. 

Dr.  R.  J.  Nu.NN,  of  Savannah,  said  that  while  un- 
doubtedly tin  was  a  valuable  material  for  electrodes, 
it  could  be  used  to  advantage  only  with  currents  of 
high  voltage  and  low  amperage,  because  otiier  currents 
o.xidized  it  very  rapidly.     He  preferred  thin  annealed 


copper,  which  possessed  the  advantages  without  the 
disadvantages  of  block  tin.  Aluminum  also  oxidized 
rapidly  and  became  brittle — a  fact  of  whicii  any  one 
could  readily  convince  himself  by  attempting  to  wear 
an  aluminum  corset  during  the  hot  months. 

Dr.  Wai.tkr  H.  White,  of  Boston,  in  defence  of  his 
electrodes,  said  that  they  had  been  modelled  after 
those  by  the  French,  and  were  intended  to  be  used 
only  with  the  French  method.  He  had  used  the  mul- 
tiple-point electrode  for  five  or  six  years,  and  had 
never  known  it  to  produce  sparking.  He  had  used 
with  a  great  deal  of  satisfaction  a  mitten  electrode 
made  out  of  a  tinsel  cloth  known  to  the  trade  as  "  ar- 
mor cloth." 

Dr.  Massev  explained  that  what  he  had  said  about 
the  multiple-point  electrode  used  by  Dr.  White  would 
not  apply  to  the  French  method. 

Dr.  Frederick  H.  Morse,  of  Melrose,  Mass.,  said 
that  he  had  found  that  electrodes  made  out  of  ordinary 
asbestos  cloth,  such  as  plumbers  used,  were  cleanly 
and  inexpensive.     They  could  be  boiled  or  baked. 

Electro-Therapeutic  Sins. —  Rev.  New.man  Law- 
KEN'CE,  of  Stapleton,  Staten  Island,  read  a  paper  with 
this  title.  He  said  that  one  of  the  most  common  of 
electro-therapeutic  sins  was  the  practice  of  this  form 
of  therapeutics  by  physicians  who  understood  ordinary 
medicinal  therapeutics,  but  were  almost  completely 
ignorant  of  electrical  laws.  This  sin  was  almost  on  a 
par  with  that  of  the  electrician  who  essayed  to  treat 
disease  without  having  had  any  instruction  in  thera- 
peutics. The  author  pointed  out,  by  reference  to  well- 
known  physical  laws,  the  utterly  fraudulent  nature  of 
those  so-called  electro-inagnetic  body  appliances, 
which  consisted  of  a  number  of  small  magnets  and 
conductors  which  did  not  change  their  position  with 
reference  to  one  another.  He  said  that  he  had  repeat- 
edly tested  certain  electric  belts  dependent  for  their 
action  upon  the  moisture  of  the  body,  and  he  pointed 
out  that  as  all  of  the  metal  plates  were  excited  by  the 
moisture  of  the  body,  and  they  could  not  be  divided  up 
into  cells,  the  increase  in  the  number  of  plates  used 
in  such  belts  simply  con\erted  the  arrangement  into 
one  large  plate.  The  concluding  portion  of  his  paper 
was  devoted  to  a  consideration  of  the  all  too  common 
practice,  especially  prevalent  among  clergymen,  to  give 
testimonials  about  things  which  were  not  at  all  un- 
derstood by  the  person  thus  so  extravagantly  singing 
their  praises. 

The  paper  was  enthusiastically  received,  not  only 
because  of  its  impartial  presentation  of  the  subject, 
but  because  of  the  manly  arraignment  of  the  testi- 
monial evil.  A  committee  was  appointed  to  endeavor 
to  secure  its  wide  publication,  especially  in  the  lay 
journals,  where  it  would  do  much  more  good  than  in 
those  intended  exclusively  for  the  eyes  of  physicians. 

Discussion  :  Electricity  in  Tuberculosis  and  Pres- 
ent Modes  of  Treatment.— The  following  topics 
were  considered  : 

Etiology  of  Tuberculosis ;  its  Course  and  Ter- 
mination.—Dr.  S.  .\.  Knopf,  of  New  York,  opened 
the  discussion  with  this  paper.  He  divided  the  etiol- 
ogy of  tuberculosis  into  two  parts — the  sources  of  in- 
fection, and  the  causes  which  permitted  the  disease 
process  to  gain  a  foothold  in  the  human  economy. 
Undoubtedly,  he  said,  the  chief  source  of  infection 
was  indiscriminate  expectoration.  "  Drop  infection  " 
or  the  transmission  of  the  disease  by  the  transporta- 
tion of  particles  occurred,  but  it  was  comparatively 
rare,  as  it  required  close  proximity  to  the  diseased  per- 
son. The  source  of  infection  next  in  importance  was 
bovine  tuberculosis.  Only  by  uniform  State  laws  or 
by  Federal  legislation  could  bovine  tuberculosis  be 
controlled.  Almost  all  other  countries  had  a  ministry 
of  public  health,  and  the  advantages  of  such  a  depart- 
ment in  our  national  government  were  obvious.     Tu- 


594 


MEDICAL    RECORD. 


[October  13,  1900 


berculosis  might  be  disseminated  by  kissing.  Tuber- 
cle bacilli  had  been  found  in  cigars  made  by  hand, 
owing  to  the  saliva  used  to  cause  the  final  coating  of 
the  cigars  to  adhere.  The  nurses  and  friends  of  tu- 
berculous patients  were  exposed  to  infection  with  the 
disease  by  inoculation.  This  was  particularly  apt  to 
occur  when  they  were  washing  out  vessels  soiled  with 
tuberculous  sputum.  .Auto-infection  might  arise  in  a 
tuberculous  patient  from  a  wound.  Ordinarily  the 
inhalation  of  air  laden  with  tubercle  bacilli  did  not 
give  rise  to  the  disease,  as  the  epithelial  cells  of  the 
upper  air  passages  opposed  the  entrance  of  the  germs, 
and  the  nasal  mucus  was  inimical  to  their  growth. 
.Anything  which  lowered  the  vital  resistance  favored 
infection.  The  speaker  declared  that  tuberculosis  was 
eminently  a  curable  disease,  its  natural  tendency  being 
to  fibrous  transformation.  His  belief  was  that  in  the 
majority  of  cases  a  fatal  termination  was  the  result  of 
mixed  infection  and  an  intense  tox.'Emia. 

The  Modern  Treatment  of  Pulmonary  Tubercu- 
losis.—  Dr.  M.  J.  Brooks,  of  Stamford,  Conn.,  read 
this  paper  (see  page  563). 

Electric  Light  as  a  Therapeutic  Agent. —  Dr. 
Charles  O.  Files,  of  Portland,  Me.,  in  presenting 
this  contribution,  stated  that  it  was  a  recognized  fact 
that  the  bacilli  were  destroyed  by  free  exposure  to 
light;  hence  the  effort  to  combat  the  disease  by  expos- 
ure not  only  to  the  electric  light,  but  to  the  ozone  that 
was  incidentallygenerated.  The  treatment  was  best 
carried  out  in  an  arc-light  cabinet.  In  every  case  of 
tuberculosis  that  he  had  treated  by  the  electric  light 
improvement  had  been  apparent,  but  it  should  be  noted 
that  none  of  these  cases  was  in  the  later  stages  of  the 
disease. 

Electric  Light ;  its  Physiological  Action  and 
Therapeutic  Value  in  Tuberculosis  of  the  Throat 
and  Lungs.  —  Dr.  Woi.ff  FREunExiHAL,  of  New  York, 
presented  this  communication  (will  appear  in  a  future 
issue). 

Report  of  the  Practical  Value  of  Grotte's  Method 
and  of  Others  who  Advertise  Cures. — Dr.  Egbert 
Le  Fevre,  of  New  York,  presented  this  paper.  He 
said  that  one  year  ago  this  method  of  treatment  had 
been  tried  experimentally  in  St.  Luke's  Hospital,  New 
York  City.  Both  in-patients  and  out-patients  were  se- 
lected, and  careful  records  were  kept,  including  notes 
of  the  local  and  general  physical  condition,  the  num- 
ber of  tubercle  bacilli,  and  the  toxicity  of  these  bacilli. 
The  treatment  was  kept  up  continuously  for  three 
months.  A  number  of  cases  in  the  first  stage  of  pul- 
monary tuberculosis  were  treated  by  this  method,  and 
in  none  was  a  cure  effected:  moreover,  the  local  proc- 
ess was  not  modified,  the  physical  signs  did  not  abate, 
and  in  two  of  the  cases  there  was  a  distinct  aggrava- 
tion of  the  local  signs  after  two  weeks,  so  that  the 
treatment  was  soon  discontinued  in  these  instances. 
In  another  case  there  was  no  effect  on  the  physical 
signs,  but  the  tubercle  bacilli  increased,  and  their  vi- 
tality was  unimpaired.  Three  of  the  cases  at  first 
showed  some  improvement,  but  no  more  than  had  been 
previously  observed  in  these  same  individuals  during 
their  stay  in  the  hospital  under  the  same  hygienic  and 
dietetic  treatment.  A  case  of  glandular  tuberculosis 
did  very  badly  under  tiiis  electrical  treatment;  the 
external  application  of  iodine,  together  with  the  elec- 
tricity, causing  violent  irritation,  and  finally  necessi- 
tating a  surgical  operation.  In  this  patient,  with  the 
breaking  down  of  the  glands  there  was  rapid  softening 
of  the  lung,  and  the  disease  then  ran  a  very  rapid 
course.  Cases  in  the  so-called  second  stage  —  /.<•., 
when  there  was  beginning  softening — were  not  im- 
proved by  the  electrical  treatment,  there  being  no  per- 
ceptible effect  on  the  bacilli  or  on  the  septic  infection. 
In  the  advanced  cases  the  treatment  apparently  did 
harm.     In  one  case  which  had   been  in   tiie  wards  for 


eighteen  months,  and  in  which  the  process  had  been 
apparently  arrested  for  a  considerable  time,  there  was 
a  rapid  breaking  down  of  the  lungs  after  six  weeks  of 
the  treatment,  and  the  patient  died  four  months  after 
the  treatment  had  been  discontinued.  Regarding  the 
Crotte  method.  Dr.  Le  P'evre  said  that  in  the  three 
months'  trial  just  described  astatic  machine  had  been 
used  in  connection  witii  tiie  apparatus  invented  by  .M. 
Grotte.  In  this  machine  there  was  supposed  to  be  for- 
malin, and  his  claim  was  that  it  was  acted  on  by  the 
electric  current  and  by  the  latter  carried  into  the  pa- 
tient. 'l"he  patient  was  put  on  an  insulated  stool,  and 
a  towel  wrung  out  of  a  mild  solution  of  formalin  was 
spread  upon  the  chest,  and  the  current  then  passed. 
A  solution  of  iodine  in  spirits  of  camphor  was  also 
painted  over  the  portions  of  the  chest  corresponding 
to  the  diseased  areas  of  the  lung.  It  was  worthy  of 
note  that  the  pathologist  of  the  hospital  could  not  de- 
tect any  iodine  in  the  patient's  secretions  in  spite  of 
the  claims  of  the  inventor  that  it  was  carried  into  the 
system  by  cataphoresis. 

The  Treatment  of  Tuberculosis  by  Means  of 
Transfusion  of  Antiseptics  by  Means  of  Static  Cur- 
rents of  High  and  Low  Tension. —  Dr.  J.  L.  HArcH, 
of  New  York,  said  that  since  last  winter  he  had  con- 
stantly seen  some  of  Grotte's  patients,  and  the  results 
of  the  treatment  in  them,  as  well  as  in  some  of  his 
own  cases,  had  surprised  and  pleased  him. 

Dr.  G.  Betton  Massev,  of  Philadelphia,  opened 
the  general  discussion  by  describing  his  method  of 
treating  tuberculous  glands  of  the  neck.  An  opening 
was  made  into  the  gland  large  enough  to  admit  a  gold 
electrode  not  much  larger  than  a  hypodermic  needle. 
This  electrode  was  amalgamated  at  its  tip,  and  through 
it  a  globule  was  injected.  An  electric  current  of  from 
three  to  ten  milliamperes  was  used,  and  by  electroly- 
sis the  tissues  were  asepticized  by  the  formation  of  the 
oxychloride  of  mercury.  Cases  were  cited  to  prove  the 
good  effect  of  this  treatment,  and  the  speaker  urged 
that  this  method  be  employed  for  the  purpose  of  de- 
stroying the  tubercle  bacilli  in  cases  of  local  tubercu- 
losis in  almost  any  part  of  the  body  except  possibly 
the  cranium,  thorax,  and  abdomen.  He  believed  it  to 
be  both  a  quick  and  an  efficient  method  of  improving 
the  local  and  general  condition. 

Dr.  Robert  Revburn,  of  Washington,  D.  C,  said 
it  was  not  at  all  essential  to  use  a  gold  needle,  as  he 
had  successfully  conducted  a  similar  metiiod  of  treat- 
ment, using  an  iron  needle.  He  was  of  the  opinion 
that  it  was  much  better  to  operate  without  making  an 
opening  into  the  skin,  as  the  latter  would  needlessly 
open  up  a  possible  channel  of  infection. 

Dr.  William  J.  Morton,  of  New  York,  said  that 
Dr.  Massey  deserved  credit  for  adding  mercury  to  the 
list  of  substances  that  were  serviceable  in  carrying  out 
that  useful  method  of  treatment  introduced  by  Gautier 
under  the  name  of  metallic  electrolysis.  At  one  time 
he  had  been  an  enthusiastic  advocate  of  metallic  elec- 
trolysis, but  had  sobered  down  somewhat  after  making 
some  experiments  to  determine  the  extent  to  which  the 
various  metals  used  as  electrodes  could  be  driven  into 
the  tissues  by  the  electric  current.  He  had  never  been 
able  to  make  this  diffusion  extend  farther  than  one- 
fourtii  of  an  inch,  and  even  to  do  this  it  had  been  nec- 
essary to  use  a  stronger  current  than  was  desirable. 
Regarding  the  Grotte  treatment  of  consunijition.  Dr. 
Morton  said  that  he  had  visited  St.  Luke's  HospiUi 
with  a  view  of  learning  by  personal  inspection  some- 
thing regarding  this  method.  He  had  seen  on  one 
side  of  the  room  an  excellent  static  machine  of  Ameri- 
can manufacture,  and  on  the  opposite  side  a  cumber- 
some French  machine  having  ebonite  plates.  He 
could  voucli  for  tiie  vigor  witii  which  the  electricity 
was  applied,  for  the  sparks  were  flying  freely,  but,  to 
his  surprise,  on  testing  the  French  machine,  which  he 


October  13,  1900] 


MEDICAL    RECORD. 


595 


was  informed  was  the  one  depended  upon  almost  en- 
tirely for  the  essential  part  of  the  treatment— the  cata- 
phoresis — he  could  secure  from  it  no  sparks  whatever. 
This  observation  had  very  naturally  aroused  his  sus- 
picions, and  he  hoped  the  association  would  appoint 
a  committee,  and  instruct  it  to  search  for  definite 
proof  that  formalin  vapor,  or  any  similar  substance, 
could  be  made  to  enter  the  human  system  by  the  aid 
of  electricity.  Its  effect  on  disease  could  then  be  de- 
termined by  physicians  at  the  bedside.  He  wishetl  to 
be  perfectly  fair  to  all  concerned,  and  for  that  reason 
the  committee  should  inquire  carefully  into  the  elec- 
tro-physics Of  the  Grotte  method.  M.  Grotte  should 
prove  that  iodine,  or  the  products  of  formaldehyde, 
could  be  really  introduced  into  the  healthy  human  sys- 
tem in  this  way. 

Dr.  Le  Ff.vke,  in  closing  the  discussion,  said  that 
when  the  pathologist  of  St.  Luke's  Hospital  had  re- 
ported that  he  had  been  unable  to  prove  that  either  the 
formalin  or  the  iodine  had  been  introduced  into  the 
patient's  system,  M.  Grotte  objected  to  the  person  car- 
rying out  the  investigation,  on  the  ground  that  he  was 
incompetent.  Grotte's  own  chemist  was  then  allowed 
to  conduct  an  investigation,  but  he  too  failed  to  prove 
that  any  medicinal  substance  had  been  introduced 
into  the  system  by  the  treatment.  The  treatment  had 
been  abandoned  because  apparently  useless  and  be- 
cause the  claims  of  its  inventor  had  not  been  substan- 
tiated. It  was  hardly  necessary  to  add  that  the  physi- 
cians of  the  hospital  had  conducted  this  investigation 
with  all  sincerity  and  in  an  impartial  and  scientific 
spirit. 

A  committee,  consisting  of  I)rs.  VV'illiam  J.  Morton, 
Robert  Newman,  and  f'mil  Heuel,  of  New  York  City, 
was  then  appointed  to  investigate  the  electro-physics 
of  the  Grotte  nifthod. 

A  Plea  for  the  Better  Application  of  Electricity 
in  Diseases.  —  Dr.  J.  GRiFrrrH  Davis,  of  New  York, 
in  this  paper  cited  various  cases  to  illustrate  the  im- 
portance of  studying  well  the  mode  of  application  of 
electricity  best  suited  to  the  individual  patient. 

Some  New  Appliances  for  X-Ray  Work Mr.  E. 

W.  Caldwell,  K.K. ,  of  New  York,  made  this  e.xhibit. 
The  first  appliance  shown  was  an  improved  stand  and 
holder  for  tiie  .v-ray  tube.  The  latter,  instead  of  be- 
ing held  with  a  screw-clamp  rigidly  -a  method  fraught 
with  danger  to  the  tube — was  securely  held  in  a  forked 
piece  of  wood  by  easily  graduated  pressure  made  by  a 
band  and  a  small  coil  spring.  A  most  interesting  and 
ingenious  device  was  a  wooden  shelf  or  adjustable 
table  for  supporting  the  arm  firmly,  no  matter  what  its 
position.  This  rest  was  supported  on  a  ball-and-socket 
joint,  and  by  means  of  two  or  three  simple  attachments 
the  arm,  forearm,  and  hand  could  be  prevented  from 
twitching  or  trembling,  and  the  photographic  plate 
could  be  readily  placed  parallel  to  the  condyles. 
Considerable  difficulty  was  often  experienced  in  ob- 
taining good  .r-ray  photographs  of  the  pelvic  and  hip 
joint.  To  facilitate  getting  the  two  limbs  parallel  to 
each  other  and  to  the  plate,  each  limb  was  strapped  to 
a  small  wooden  table,  and  the  latter  were  joined  by 
levers  in  such  a  way  that  when  the  injured  limb  was 
put  in  the  desired  position  and  clamped,  the  well  limb 
would  be  parallel  to  the  injured  one.  The  speaker 
said  that  in  taking  .v-ray  photographs  the  plate  was 
often  injured  by  the  moisture  of  the  person's  body. 
The  best  and  cleanest  way  of  preventing  this  was  by  in- 
terposing a  thin  sheet  of  celluloid,  such  as  could  be  pro- 
cured at  artists'  supply  stores.  This  material  was  clean 
and  waterproof,  and  was  very  transparent  to  the  .v-ray. 

Dr.  Charles  O.  Files,  of  Portland,  Me.,  asked  if 
it  were  possible  in  most  cases  to  secure  a  good  picture 
of  the  head  of  the  femur.  He  had  tried  this  a  good 
many  times,  and  with  indifferent  results  when  there 
was  much  adipose  tissue.     He  was  under  the  impres- 


sion that  one  could  not  get  a  good  picture  of  the  head 
of  the  femur  under  such  circumstances. 

Mr.  Caldwell  replied  that  it  was  always  difficult 
to  get  such  a  picture,  even  with  a  young  and  lean  sub- 
ject, but  in  the  majority  of  cases  it  was  possible  to  get 
one  sufficiently  good  to  show  whether  there  was  pres- 
ent a  fracture  or  any  extensive  necrosis  of  the  head  of 
the  femur  or  of  the  acetabulum.  With  a  fieshy  subject 
having  small  bones  it  was  decidedly  difficult.  'J'he 
best  picture  of  this  kind  that  he  had  made  had  been 
of  a  man  weighing  one  hundred  and  fifty  pounds,  and 
this  had  required  an  exposure  of  six  minutes.  The 
longest  exposure  which  he  used  in  such  cases  was  fif- 
teen minutes,  though  with  children  one  minute  would 
often  suffice.  In  most  of  his  work  tlie  .v-ray  tube  had 
been  excited  with  the  coil,  and  he  preferred  this  to  the 
static  machine,  as  he  found  that  he  could  obtain  cer- 
tain results  with  the  coil  that  he  could  not  with  the 
static  machine.  He  would  admit,  however,  that  some 
of  the  most  beautiful  radiographs  that  he  had  seen 
had  been  made  with  the  static  machine.  For  the  ex- 
tremities the  static  machine  was  excellent,  and  per- 
haps gave  rather  better  definition  than  the  coil,  but 
for  the  hip  joint  he  personally  preferred  the  coil. 

Combined  Electrization  or  Galvano-Faradization. 
■ — Dk.  a.  D.  RoiKWKLL,  of  .\ew  York,  read  a  paper 
with  this  title.  He  said  that  by  the  term  galvano- 
faradization  was  meant  the  simultaneous  application 
with  the  same  electrodes  of  the  galvanic  and  faradic 
currents.  He  believed  that  the  contractile  fibre  cells 
were  more  powerfully  excited  by  the  interrupted  or 
high-frequency  currents,  and  that  there  was  greater 
stimulation  of  waste  and  repair  than  when  the  gal- 
vanic current  alone  was  used.  It  had  always  seemed 
to  him  that  the  combination  of  these  currents  was  as 
rational  as  the  combination  of  our  medicines  in  pre- 
scriptions. His  experience  had  fully  confirmed  this 
view.  The  faradic  current  alone  had  very  little  effect 
on  osmosis;  the  galvanic  current,  on  the  other  hand, 
stimulated  osmotic  action  to  a  great  degree.  This 
was  still  more  marked  by  combining  the  two  currents. 
\Vhen  this  was  done,  heat  production  was  also  in- 
creased. The  physiological  action  of  electricity  was 
shown  chiefly  through  its  influence  on  secretion,  ex- 
cretion, and  absorption.  All  forms  of  electricity 
would  relieve  certain  painful  conditions,  one  succeed- 
ing when  the  others  failed,  and  via'  icrsa.  Parts  sen- 
sitive to  pressure,  barring  the  hyperesthesia  of  hyste- 
ria, were,  as  a  rule,  more  favorably  affected  by  the 
galvanic  than  by  the  faradic  current.  The  same  re- 
lief from  pain  was  often  not  observed  from  these  cur- 
rents when  combined.  The  use  of  the  combined 
currents  was  especially  valuable  in  the  treatment  of 
spasmodic  conditions,  particularly  local  ones.  The 
symptoms  of  exophthalmic  goitre  were  more  readily 
controlled  by  the  combined  than  by  the  simple  electri- 
zation. 

Dr.  G.  Betton  Massey  said  that  the  galvanic  and 
faradic  batteries  could  be  easily  combined  by  connect- 
ing the  negative  of  the  galvanic  with  the  positive  of 
the  faradic  battery,  and  setting  both  in  action,  prefera- 
bly controlled  by  a  controller.  There  was  a  distinct 
value  to  galvano-faradic  electrization,  which  was  ex- 
plicable on  a  consideration  of  the  subject  of  electro- 
tonus.  Years  ago  Waller  had  shown  that  at  the  nega- 
tive pole  the  galvanic  current  would  cause  the  faradic 
current  to  be  more  active,  and  at  the  positive  pole  less 
active. 

Mr.  R.  G.  Brown  said  that  he  was  unable  to  under- 
stand how  it  was  possible  to  use  this  so-called  com- 
bined electrization,  for  the  one  must  short-circuit 
through  the  other.  This  remark  gave  rise  to  a  lengthy 
discussion,  which  was  finally  cut  short  by  lack  of  time 
and  before  a  definite  agreement  of  opinion  had  been 
reached. 


596 


MEDICAL    RECORD. 


[October  13,  1900 


Gleanings  in  the  Field  of  Electro-Therapeutics. 
—  Dk.  Chakiks  O.  Files,  of  I'ortland,  Me.,  read  tliis 
suggestive  paper.  The  first  case  reported  was  one  of 
double  amputation  of  the  thigh,  done  about  one  hour 
after  the  crushing  of  the  limbs  in  a  railroad  accident. 
During  the  operation  the  patient  suddenly  succumbed 
to  the  combined  shock  of  the  injury  and  the  operation, 
and  appeared  to  be  dead  on  the  table.  The  prompt 
application  of  a  galvanic  current,  one  pole  being  put 
to  the  epigastrium  and  the  other  to  the  base  of  the 
brain,  revived  the  patient  almost  immediately.  It 
was,  however,  necessary  to  resort  to  electrization  at 
short  intervals  for  nearly  three  weeks,  as  the  heart  fre- 
quently flagged.  Kvery  surgeon  who  saw  the  case  dur- 
ing the  first  fortnight  expressed  the  opinion  that  the 
prognosis  was  practically  hopeless.  The  man  com- 
pletely recovered.  Another  case  mentioned  was  one 
in  which  most  gratifying  improvement  followed  elec- 
trical treatment  and  massage  in  a  case  of  incipient 
tuberculosis.  For  many  years  the  author  had  found 
electricity  a  most  valuable  ally  as  a  hypnotic,  and  in 
many  inveterate  cases  of  facial  neuralgia,  even  those 
which  had  persisted  after  repeated  surgical  operations 
on  the  nerves  and  ganglia. 


Second  Day —  Wednesday,  September  26//1. 

Electricity  in  Gynaecology,  and  the  Present  Re- 
luctance of  Gynaecologists  to  Use  Electricity. — This 
was  the  general  suliject  for  discussion. 

The  General  Office  Work   of   a   Gynaecologist 

Dr.  Fred.  H.  Mor.se,  of  Melrose,  Mass.,  read  a  paper 
with  this  title.  He  said  that  nowhere  had  electricity 
a  greater  range  of  usefulness  than  in  gynaecological 
work.  The  man  who  could  see  no  other  treatment 
than  surgical  for  pelvic  adhesions  and  sore  ovaries 
would  save  much  suffering  and  unnecessary  operating 
by  the  intelligent  and  proper  use  of  electricity.  Elec- 
tricity was  invaluable  in  making  the  diagnosis  when 
there  was  a  deep-seated  pus  formation.  In  metritis,  en- 
dometritis, subinvolution,  uterine  displacement,  ova- 
rian neuralgia,  painful  menstruation,  electrical  treat- 
ment was  most  satisfactory.  In  acute  inflammatory 
conditions  electrical  treatment  was  not  contraindi- 
cated,  but  special  care  was  requisite  in  its  application. 
The  intensity  of  the  current,  the  size  and  nature  of  the 
electrode,  and  the  lengtTi  of  the  treatment  must  all  be 
carefully  considered.  In  most  cases  such  treatment 
could  be  carried  out  properly  in  the  physician's  office. 
A  reliable  battery  and  amperemeter  and  a  good  high- 
tension  faradic  battery  were  absolutely  essential.  He 
preferred  asbestos  cloth  for  the  material  of  which  the 
distributing  electrode  was  constructed.  Ordinarily 
the  external  electrodes  employed  were  too  small. 

The  Morton  Wave  Current — A  Valuable  Addition 
in  Electro-Therapeutics. — Dr.  W.  B.  Snow,  of  At- 
lanta, Ga.,  sent  a  paper  with  this  title.  In  his  absence 
the  paper  was  read  by  Dr.  Dickson.  The  author  stated 
that  the  wave  current  was  unique  in  many  of  its  char- 
acteristics. In  the  first  place,  it  was  the  only  current 
administered  from  but  one  side  of  the  generator;  (2) 
it  was  the  only  current  in  which  the  alternations  were 
of  charge  and  discharge;  (3)  it  was  the  only  current 
administered  to  the  patient  while  insulated;  (4)  it 
was  the  only  current  with  high  potential  that  could 
be  passed  to  and  fro  through  the  body  with  little  dis- 
comfort; (s)  it  was  the  only  current  with  the  passage 
of  which  the  patient  received  general  electrization,  the 
surges  of  the  current  passing  through  the  tissues  of 
the  body.  These  properties  of  the  wave  current  made 
it  the  choice  of  all  electrical  currents  if  there  was  any 
virtue  in  electricity,  for  it  permitted  the  use  of  the 
highest  possible  electromotive  force  upon  the  patient. 
The  fact  that  it  penetrated  every  part  of  the  body 
made  it  unexcelled.     It  was  so  controllable  that  it 


might  be  applied  to  the  eye.  One  million  volts  of  this 
wave  current  might  be  applied  with  safety,  and  with 
but  little  discomfort  to  the  patient.  The  physiologi- 
cal actions  of  this  current  were  the  result  of:  (i)  The 
surges  of  the  current  to  and  fro,  and  (2)  the  intense 
vibratory  and  peculiar  local  electrical  effects.  The 
constitutional  effects  were:  (i)  Marked  lowering  of 
arterial  tension;  (2)  lessened  frequency  of  the  heart's 
action  and  increased  volume  of  pulse;  {3)  increased 
oxidation  and  metabolic  activity ;  (4)  marked  diminu- 
tion of  nervous  irritability  with  sense  of  drowsiness; 
and  (5)  a  sense  of  fatigue  if  the  sitting  was  too  pro- 
longed. The  current  was  said  to  be  absolutely  harm- 
less and  a  powerful  tonic.  .So  far  as  had  been  deter- 
mined, polarity  did  not  affect  the  result.  The  local 
effects  were:  (i)  A  sense  of  vibration,  marked  over 
the  muscles  when  there  was  little  underlying  fat,  and 
by  rhythmic  contractions;  (2)  physiological  tetanus: 
(3)  the  sedation  of  pain  and  nervous  irritability  by 
prolonged  and  gradually  increased  electromotive  force 
as  toleration  ijerniitted  ;  (4)  an  antispasmodic  action  : 
(5)  stimulation  of  the  glands  beneath  the  electrodes 
to  more  active  secretion;  (6)  local  congestion  and 
hyperremia  were  relieved  when  not  due  to  specific  poi- 
son or  to  necrosis.  Metabolism  was  most  active  be- 
neath the  electrode.  As  a  general  rule,  the  treatment 
gave  better- results  than  sparks  except  where  the  small 
muscles  contracted  too  painfully,  as,  for  instance,  in 
the  hands  in  cases  of  rheumatoid  arthritis.  All  atonic 
conditions  and  chronic  menstrual  disorders  were  re- 
lieved by  treatment  with  this  current.  To  obtain  the 
best  tonic  effect,  a  long  block-tin  electrode  should  be 
placed  under  the  clothing  and  over  the  vertebral  col- 
umn, and  a  one-inch  spark-gap  employed.  Most  cases 
of  neuralgia  not  due  to  pressure  or  to  specific  poison 
were  relieved  by  a  few  treatments.  Most  cases  of  sci- 
atica could  be  successfully  managed  by  daily  treat- 
ments. Few  conditions  required  treatment  at  shorter 
intervals  than  twelve  hours.  A  most  important  factor 
in  such  treatment  was  what  was  termed  by  the  author 
"  bridging,"  /.(•.,  a  repetition  of  the  treatment  before 
the  pain  had  had  time  to  become  severe  again.  It 
was  the  only  current  in  which  the  alternations  were  of 
charge  and  discharge.  For  sprains  and  bruises  the 
application  of  the  wave  current  was  the  treatment /(?/• 
exieZ/enee. 

The  Nervous  Disorders  Peculiar  to  Women.— Dr. 
G.  Betton  Massey,  of  Philadelphia,  in  this  paper  dis- 
cussed more  particularly  the  relation  of  neurasthenia 
to  these  disorders,  and  the  frequency  with  which  affec- 
tions within  the  abdomen  underlay  the  neurasthenia. 
He  pointed  out  the  frequent  need  for  well-regulated  and 
properly  directed  activity  as  opposed  to  the  notion  of 
absolute  rest. 

Use  of  the  Continuous  Current  and  Electrolysis. 
— Dr.  Robert  Newman,  of  New  V'ork,  presented  this 
paper  (see  page  486). 

Dr.  Massey  said  that  this  field  was  less  attractive 
and  less  remunerative  than  that  of  operative  surgery, 
and  hence  the  reluctance  of  gynecologists  to  use  elec- 
tricity. He  quoted  Dr.  Thaddeus  Reamy,  of  Cincin- 
nati, as  saying  that  in  the  State  of  Ohio  many  physi- 
cians by  the  use  of  electricity  were  now  keeping  their 
patients  in  their  own  hands,  and  protecting  them  from 
the  specialists  in  the  large  cities. 

Du.  Reyiuirn  remarked  that  one  reason  for  their 
reluctance  was  that  they  were  quite  often  ignorant  of 
the  laws  of  electricity  and  hence  could  not  use  elec- 
trical treatment  with  advantage. 

Dr.  VVirr.iAM  J.  Morton  thought  it  was  time  for 
electro-therapeutists  to  admit  that  they  sometimes  ad- 
hered too  fondly  to  their  favorite  method,  and  refrained 
from  the  use  of  the  knife  sometimes  when  perhaps  it 
might  be  better.      Fxtremes  should  be  avoided. 

Dr.   Lucy  Hall-Brown  said  that  another    reason 


October  13,  1900] 


MEDICAL    RECORD. 


597 


why  gynascologists  were  loath  to  employ  electricity  in 
their  practice  was  that  it  required  such  a  large  amouni 
of  apparatus  and  attendance,  and  consumed  so  much 
time ;  however,  she  could  not  see  how  any  gynecologist 
could  be  really  conscientious  in  his  work  and  wholly 
refrain  from  the  use  of  electricity.  She  had  had  three 
cases  of  fibroid  tumors  in  which  com])lete  hysterectoniv 
had  been  done.  One  of  these  patients  had  made  a 
good  recovery  and  had  remained  well ;  another  had  ap- 
parently recovered,  but  had  later  developed  melancholia 
and  had  committed  suicide  three  months  after  opera- 
tion ;  the  third  had  died  three  days  after  operation —  not 
a  very  excellent  showing  for  the  operative  treatment. 

Dr.  Revburn  said  lie  liad  treated  about  half  a  dozen 
cases  of  fibroids  by  the  use  of  electricity.  In  all  of 
them  there  had  been  improvement,  and  three  had  been 
practically  cured. 

Several  other  members  took  part  in  the  discussion, 
expressing  views  similar  to  the  foregoing  regarding 
the  operating  gynascologists  and  their  methods  of 
practice. 

Spark-Gap  Currents,  viz.:  Franklinic  Inter- 
rupted, Static  Induced,  and  Wave  Currents.— Dr. 
WiLl.i.AM  J.  MoKTox,  of  New  York,  discussed  this 
subject.  In  his  opinion,  the  wave  current,  or  as  he 
preferred  to  call  it,  the  "displacement  current,"  pre- 
sented more  advantages  than  either  the  franklinic  or 
static  induced  current.  I'rom  the  standpoint  of  the 
electro-therapeutist  he  believed  this  wave  current  em- 
bodied all  that  could  be  obtained  from  an  electro-static 
machine  in  current  form.  He  made  use  of  it  in  neu- 
rasthenia and  in  all  cases  when  the  object  was  to 
improve  the  general  nutrition.  One  of  its  most  re- 
markable elTects  was  the  production  of  analgesia  or 
an.a'sthesia.  It  was  more  pleasant  to  take  and  more 
diffusive  than  the  static  induced  current  and  was  quite 
as  easily  localized. 

Dr.  Hall-Brown  spoke  more  especially  concerning 
the  technique  that  she  had  made  use  of  in  treating 
patients  with  the  wave  current.  The  loud  noise  made 
by  the  static  machine  she  had  succeeded  in  reducing 
very  materially  by  inserting  the  terminals  of  the  ma- 
chine in  corks  at  either  end  of  a  very  large  glass  tube. 
In  order  to  insure  good  contact  between  the  electrode 
and  the  patient  she  made  use  of  block-tin  strips,  and 
carried  these  down  along  the  spine,  under  the  cloth- 
ing, very  easily  by  the  use  of  a  director  made  of  a 
piece  of  hard  rubber  not  unlike  a  thin  ruler  in  appear- 
ance. The  strips  of  tin  should  be  kept  very  smooth, 
and  this  was  accomplished  by  passing  over  them  the 
"squeegee"  roller  sold  in  photographic  shops.  She 
had  employed  this  current  (luite  extensively  in  the 
treatment  of  neurasthenia  and  neuralgia.  A  study  of 
the  urine  showed  quite  conclusively  the  profound 
effect  of  the  current  on  glandular  activity,  and  gave  a 
valuable  hint  as  to  why  it  proved  so  useful  in  the 
treatment  of  neurasthenia.  For  gynacological  work 
she  made  use  of  a  wooden  table  insulated  by  screwing 
glass  telegraph  insulators  on  to  the  legs.  The  current 
was  conveyed  into  the  room  by  a  wire  insulated  with 
rubber  and  enclosed  in  a  glass  tube. 

Dr.  C.  R.  Dickson,  of  Toronto,  said  that  the  wave 
current  had  proved  of  great  value  in  his  hands  in  the 
treatment  of  sciatica  and  peripheral  neuritis. 

Dr.  Margaret  A.  Cleaves,  of  New  Vork,  attributed 
the  great  value  of  this  wave  current  to  the  fact  that 
with  it  one  was  able  to  expend  a  greater  amount  of 
energy  within  the  tissues  of  the  body  without  causing 
discomfort.  In  this  way  profound  changes  of  nutrition 
were  set  up.  It  had  seemed  to  her  that  the  method 
was  indicated  more  especially  in  pathological  processes 
of  rather  long  standing.  She  had  used  it  in  neuritis, 
rheumatoid  arthritis,  neurasthenia,  and,  in  gynecology, 
especially  in  prolapsus,  and  had  found  it  an  agent  of 
exceeding  great  value. 


Dr.  Walter  H.  White,  of  Boston,  remarked  that 
he  had  been  using  this  current  for  about  a  year  past 
in  neurotic  conditions,  and  with  good  success. 

On    Methods    of    Generating    and    Transforming 

Electric     Currents     for     Therapeutic     Uses Mr. 

Charles  T.  Child,  V..I:.,  technical  editor  of  the  /iVi-c- 
/r/'oi/  A'c-7-/ac,  sent  a  communication  with  this  title. 
In  it  he  said  that  what  was  ordinarily  known  as  the 
direct  current  was  a  special  case  of  the  alternating 
current  in  which  the  frequency  was  reduced  to  zero. 
One  must  know  the  electromotive  force  or  tension 
(measured  in  volts)  and  the  volume  of  current  flowing, 
the  latter  being  measured  in  amperes  or  millianiperes. 
For  therapeutic  purposes  the  maximum  of  pressure  was 
sixty  or  seventy  volts.  There  were  two  ways  in  gen- 
eral use  for  producing  the  direct  current  for  therapeutic 
purposes,  one  the  familiar  battery,  and  the  other  by 
the  cutting  down  of  currents  of  high  voltage.  Although 
the  battery  had  recently  celebrated  its  centennial  it 
was  yet  far  from  a  state  of  perfection.  The  so-called 
dry  battery  was  useful  only  for  small  currents  and  for 
short  periods.  For  the  running  of  motors  and  cauteries 
storage  batteries  were  best.  The  reduction  of  high- 
pressure  currents  for  tiierapeutic  purposes  was  done 
most  simply  by  employing  a  shunt  around  a  resistance, 
such  as  coils  of  wire  or  incandescent  lamps.  In  order 
to  avoid  abrupt  stops,  the  resistance  coil  must  be  very 
finely  subdivided,  or  so  arranged  that  contact  could 
be  made  with  it  at  any  point  of  its  length.  The  ac- 
tion of  static  machines  depended  upon  the  principle 
of  the  familiar  electrophorus.  They  generated  poten- 
tials up  to  several  hundred  thousand  volts.  The  com- 
plexity of  action  of  the  static  spark  was  astonishing  in 
view  of  its  apparent  simplicity.  To  produce  the  static 
induced  current  two  condensers  or  Leyden  jars  were 
attached  to  the  terminals  of  the  machine.  A  brief  de- 
scription was  given  of  the  modern  methods  of  produc- 
ing induced  currents,  and  emphasis  was  laid  on  the 
part  played  by  interrupters,  particularly  the  (iuid  in- 
terrupter. 

Illustrations  of  the  Value  of  the  Cataphoric 
Method  in  Cancer — Dr.  G.  Betton  Massev,  of 
Philadelphia,  discussed  this  subject.  He  said  that  he 
had  recently  published  statistics  showing  that  there 
could  be  no  doubt  that  cancer  was  very  decidedly  on 
the  increase.  He  declared  that  cancer  was  now  known 
to  be  a  curable  disease.  His  method  of  treatment 
consisted  in  driving  the  salts  of  mercury  into  the 
cancer  under  the  action  of  a  heavy  electric  current. 
Of  course,  cataphoresis  was  well  known,  but  the  plan 
of  using  mercury  in  this  way  was  original  with  him. 
As  the  method  was  painful,  the  patient  should  be 
etherized  and  placed  on  a  large  negative  electrode 
consisting  of  a  leaden  plate  covered  with  heavy  pads. 
The  active  electrode  was  made  of  a  tube  of  gold  the 
tip  of  which  was  amalgamated.  A  current  of  three 
hundred  or  four  hundred  milliamperes  was  used,  and 
mercury  was  injected  through  the  hollow  electrode. 
Within  ten  minutes  the  tumor  began  to  blanch.  The 
operation  was  kept  up  sometimes  for  two  hours  or 
more,  and  resulted  in  extensive  necrosis  of  tissue 
which  had  been  asepticized  by  the  penetration  of  the 
mercury.  An  inodorous  slough  separated  in  from  one 
to  three  weeks.  This  was  a  bloodless  method  of  de- 
stroying an  accessible  growth,  and  at  the  same  time 
sterilizing  its  immediate  neighborhood.  Dr.  Massey 
said  he  had  used  the  method  in  37  cases,  and  of  these 
II  had  been  successes.  Of  this  number  of  cases,  22 
were  metastatic  at  the  time  of  beginning  the  treatment, 
showing  that  the  treatment  had  been  begun  too  late. 
Of  the  37  cases,  2  were  fatal  from  causes  traceable  to 
the  treatment,  and  avoidable  in  the  future.  One  was 
that  of  a  woman  dying  of  carcinoma  of  the  tonsil.  She 
took  ether  badly  and  died  before  the  full  current  could 
be  turned  on.     He  had  used  as  much  as  four  hundred 


598 


MEDICAL    RECORD. 


[October  13,  1900 


iiiillianiperes  about  the  neck,  and  as  much  as  six  hun- 
dred immediately  over  the  heart,  but  such  currents 
must  be  used  with  great  care.  It  was  not  intended,  of 
course,  that  it  should  take  the  place  of  the  knife  in 
all  cases,  but  in  many  instances  it  would  be  a  more 
convenient  means  than  the  knife.  It  afforded  an  ex- 
cellent opportunity  of  reaching  the  earliest  manifesta- 
tions of  cancer,  or  of  treating  very  promptly  the  first 
recurrences  after  a  cutting  operation. 

Dr.  Morton'  said  that  while  reasonable  success  had 
been  met  with  in  the  use  of  this  method,  he  was  frank 
to  say  that  he  had  never  felt  like  using  such  heavy 
currents.  If  by  any  inadvertence  the  patient  should 
move  there  would  be  variation  of  potential,  and  it 
must  be  remembered  that  a  variation  of  only  two 
miUiamperes  about  the  head  would  produce  severe 
\ertigo.  He  had  known  twenty-five  miUiamperes  to 
produce  a  momentary  syncope. 

Dr.  a.  D.  Rockwell,  of  New  York,  suggested  that 
it  might  be  well  in  a  case  of  large  cancerous  tumor  to 
introduce  the  mercury  into  the  base,  thus  diminishing 
the  amount  of  sloughing. 

Dr.  Morton  remarked  that  when  these  metals  were 
oxidized  at  the  positive  pole  it  was  at  the  expense  of 
the  electrolyte,  so  that  when  the  tissues  became  dry 
during  the  electrolysis — in  other  words  deficient  in 
water,  oxygen,  and  sodium — the  process  went  on 
slowly.  To  obviate  this  he  had  been  in  the  habit  of 
using  a  hollow  platinum  needle,  with  the  aid  of  which 
he  injected  a  solution  of  chloride  of  sodium,  thus  re- 
newing the  supply  of  electrolytic  material. 

Dr.  Massey,  in  closing,  urged  as  an  additional  ad- 
vantage of  the  method,  that  cancer  of  an  organ  could 
be  extirpated  without  necessitating  the  removal  of  all 
of  the  organ.  The  method  was  particularly  suited  to 
cases  of  carcinoma  of  the  cervix  uteri.  The  chief 
danger  from  using  these  heavy  currents  was  from  in- 
terference with  respiration  or  with  the  heart's  action. 
In  these  etherized  patients  syncope  amounted  to  noth- 
ing, and  the  operator  was  justified  in  taking  some  risk 
because  of  the  desperate  nature  of  cancer. 

The  Causes  of  Some  Cases  of  Neurasthenia,  and 
their  Treatment. — Dr.  Francis  B.  Bishop,  of  Wash- 
ington, D.  C,  read  this  paper.  He  said  he  had  been 
in  the  habit  of  having  a  quantitative  analysis  made  of 
the  daily  amount  of  urea  and  phosphates  in  cases  of 
neurasthenia,  and  lie  had  learned  in  this  way  that  in 
neurasthenics  there  was  quite  commonly  a  diminution 
of  the  daily  quantity  of  urea  and  an  excess  of  phos- 
phates. The  muscular  tissue  formed  about  forty-two 
per  cent,  of  the  body  weight,  and  seemed  to  be  the 
chief  seat  of  metabolism.  Muscular  exercise  in- 
creased the  output  of  urea,  but  not  until  the  day  after 
the  exercise  had  been  taken,  thus  showing  that  certain 
chemical  changes  must  take  place  before  the  urea  was 
formed  and  excreted.  The  object  of  t^reatment  should 
be  to  promote  these  chemical  changes  by  muscular 
exercise.  Ordinary  muscular  exercise  was  good  in  its 
way,  but  was  followed  by  fatigue,  and  these  persons 
were  already  fatigued.  P"or  this  reason  he  made  use 
of  electricity.  He  began  with  a  mild  galvanic  current 
to  stimulate  the  cells  of  the  brain  and  spinal  cord. 
This  was  followed  by  genera!  galvanization,  and  then 
by  general  faradization  according  to  the  method  of 
Dr.  Rockwell.  General  galvanization  was  applied  by 
having  the  patient  lie  upon  a  pad  twelve  inches  square 
[ilaced  under  the  back,  and  passing  a  hand  electrode 
over  the  different  muscles.  Lastly  the  patient  re- 
ceived treatment  for  about  fifteen  minutes  in  his  ozone 
cage,  receiving  a  mild  spray  during  this  time.  This 
cage  had  proved  particularly  beneficial  in  cases  re- 
quiring a  soothing  effect  and  gentle  stimulation.  Many 
functional  nervous  troubles  could  lie  successfully 
treated  with  his  ozone  cage. 

Dr.  Rockwell  spoke  of  the  two  principal  types  of 


neurasthenia,  the  hereditary  and  the  acquired,  and 
said  it  was  difiicult  to  treat  neurasthenics  without  at 
least  occasionally  using  drugs.  He  had  found  the 
bromides  and  cannabis  indica  especially  valuable. 

Dr.  D.  R.  Browkr,  of  Chicago,  remarked  that  in 
many  of  his  neurasthenics  he  had  found  dilatation  of 
the  stomach,  while  in  others  there  had  been  an  im- 
paction in  the  colon.  He  was  convinced  that  there 
was  an  intimate  relation  between  the  slate  of  the  ab- 
dominal cavity  and  neurasthenia. 

Dr.  S.  I'airweathkr  Wilson,  of  Montreal,  men- 
tioned two  or  three  cases  of  neurasthenia  that  had 
been  marked  by  renal  insufficiency.  In  addition  to 
hydropathic  measures,  he  had  treated  them  with  static 
electricity,  using  the  iiead  breeze  and  small  spaiks 
over  the  abdomen,  and  had  in  each  instance  been  re- 
warded by  seeing  the  patients  recover  promptly. 

Dr.  Cleaves  said  that  when  certain  neurasthenics 
seemed  to  require  something  more  than  the  convective 
discharge  she  was  in  the  habit  of  using  the  galvanic 
current  in  the  form  of  the  vaginal  hydro-electric  douche. 
Dr.  Bishop's  "ozone  cage"  acted  like  covering  the 
patient  with  a  large  crown  electrode,  so  that  the  dis- 
charge was  through  the  whole  body  instead  of  simply 
from  the  head.  Of  course,  a  large  quantity  of  ozone 
was  generated,  but  the  name  ozone  cage  was  perhaps 
a  little  misleading,  as  directing  the  attention  away  from 
the  main  point. 

X-Ray  Photography. — Dr.  E.  R.  Corson,  of  Savan- 
nah, read  a  paper  on  this  topic.  He  expressed  the 
opinion  that  the  most  important  thing  was  to  have  a 
generator  which  would  furnish  powerful  .r-rays.  A 
skiagraph  giving  mere  bone  outlines  was  certainly  not 
satisfactory,  and  unless  the  .r-rays  were  powerful 
enough  to  penetrate  the  bone,  details  could  not  be 
properly  brought  out,  no  matter  how  great  one's  photo- 
graphic skill.  The  mere  length  of  the  spark  did  not 
indicate  the  efficiency  of  an  .v-ray  apparatus.  By  in- 
creasing enormously  the  number  of  interruptions  the 
quantity  of  current  passing  through  the  tubes  was  also 
augmented,  and  the  efficiency  of  the  apparatus  pro- 
portionately increased.  The  author  recommended  the 
use  of  a  coil  giving  a  spark  of  only  eight  or  ten  inches, 
and  all  of  the  current  the  -v-ray  tube  would  stand.  It 
was  also  recommended  that  a  hydrochinone  developer 
be  employed,  and  that  all  negatives,  no  matter  how 
strong,  be  intensified  after  development.  His  nega- 
tives were  usually  so  black  that  they  were  difficult  to 
print,  but  when  printed  they  showed  no  flesh,  and  gave 
sharp  contrasts.  The  object  was  to  give  as  clearly  as 
possible  the  internal  bony  structure. 


Thiid  Day — Thursiiay.  Scptemlnr  2Jtli. 

Electricity  in  Brain  Failures. — Dr.  D.  R.  Hrower, 
of  Chicago,  read  a  paper  with  this  title.  He  attributed 
the  frequency  of  cerebral  neurasthenia  at  the  present 
time  to  the  almost  universal  condition  of  unrest,  the 
keenness  of  competition,  the  drifting  away  from  the 
authorities  of  the  past,  and  not  a  little  to  '"  Voung 
America"  and  "the  new  woman."  In  his  experience 
it  was  rare  not  to  find  this  disease  associated  with  dis- 
order of  the  intestinal  tract,  or  with  dilatation  of  the 
stomach.  He  recommended  most  earnestly  intragas- 
tric electrization,  claiming  that  the  treatment  could 
be  readily  carried  out  by  the  patient  himself.  The 
stances  should  be  daily,  and  of  about  five  minutes' 
duration.  Applications  through  the  abdominal  wall 
were  far  less  efficient  than  with  the  Kinhorn  gastric 
electrode.  The  applications  in  any  case  should  be 
made  three  or  four  hours  after  a  meal.  Of  course, 
proper  attention  should  be  paid  to  the  diet,  but  in  ad- 
dition the  physician  should  resort  to  intestinal  fara- 
dization. (Jalvanization  of  the  brain  was  also  neces- 
sary, and  was  entirely  feasible,  as  had  been  abundantly 


October  13,  1900] 


MEDICAL    RECORD. 


599 


proved  by  Erb  and  other  eminent  and  trustworthy  ob- 
servers. The  electrodes  which  lie  used  were  three  by 
seven  inches,  one  being  placed  on  the  forehead,  and 
the  other  at  the  nucha.  The  general  character  of  the 
mental  phenomena  determined  the  polarity.  If  the 
case  was  one  of  general  depression,  the  negative  pole 
was  placed  at  the  forehead,  but  if  the  case  was  char- 
acterized by  e.xcitement,  the  positive  pole  was  placed 
there.  He  rarely  exceeded  a  current  strength  of  two 
milliamperes,  and  often  not  more  than  one  milliam- 
pere.  It  should  be  continued  for  two  minutes,  and 
then  be  followed  by  transverse  galvanization,  using 
the  same  electrodes  and  a  current  of  one  to  one  and 
one-half  milliamperes  for  five  minutes.  This  should 
be  followed  by  bulbar  galvaniz.\tioii.  tiie  positive  elec- 
trode being  placed  at  the  nucha  while  the  negative 
was  moved  up  and  down  over  the  cervical  sympathetic 
on  both  sides  without  breaking  the  current.  The 
duration  of  this  treatment  should  be  five  minutes. 
This  application  should  be  followed  by  static  insula- 
tion from  a  machine  giving  a  ten-inch  spark.  'I'his 
latter  application  should  be  made  daily  for  the  first 
ten  days,  and  then  on  alternate  days.  Special  stress 
was  laid  on  the  great  advantage  of  using  currents  of 
low  amperage  and  protracted  applications  in  the  cere- 
bral galvanization  of  neurasthenics. 

Electro-Therapy  of  Insanity.  — Dr.  Alkred  T. 
LiviN(;sTON,  of  Jamestown,  \.  Y.,  read  this  paper. 
He  said  that  it  was  now  about  nineteen  years  since 
he  had  first  used  electricity  in  the  treatment  of  mental 
disorder.  He  had  at  first  proposed  tiiis  to  the  eminent 
consultant,  the  late  Dr.  John  1'.  Gray,  of  Utica,  but 
the  latter  had  opposed  the  treatment  very  vigorously. 
However,  he  had  ultimately  tried  it  on  a  patient,  a 
woman  of  tliirty  years  suffering  from  acute  melancholia. 
The  first  application  showed  plainly  the  calmative 
effect  of  the  galvanic  current  when  applied  to  the  cen- 
tres connected  with  the  brain.  In  the  course  of  a  few 
weeks  the  patient  was  thoroughly  restored  to  health. 
He  had  since  used  it  frequently,  and  had  been  greatly 
pleased  with  its  calming  action.  Inquiry  both  at 
home  and  abroad  had  shown  that  this  use  of  electricity 
was  almost  unknown.  The  author  closed  with  an 
earnest  plea  for  larger  medical  staffs  in  our  insane 
hospitals,  and  for  better  treatment  of  insanity  in  the 
earlier  stages,  thus  curing  many  patients  now  allowed 
to  become  chronic  or  incurable.  The  treatment  advo- 
cated was  founded  on  the  theory  that  insanity  was 
largely  dependent,  in  the  first  instance,  upon  circu- 
latory changes  in  the  brain.  As  a  rule,  the  current 
should  be  made  to  pass  through  the  nervous  centre 
related  to  the  part  affected.  The  method  of  applica- 
tion consisted  in  directing  the  galvanic  current  to  the 
tliree  pairs  of  the  sympathetic  cervical  ganglia,  begin- 
ning and  ending  witii  the  lower  pair,  and  using  small 
hand  electrodes.  A  current  of  ten  to  fifteen  milliam- 
peres was  used  on  the  lower,  eight  or  ten  on  the 
second,  and  from  five  to  eight  on  the  upper  pair.  The 
electrodes  were  slid  along  without  producing  any  break 
in  the  current.  He  was  of  the  opinion  that  in  any 
case  of  insanity  the  effort  should  be  made  to  correct 
all  disordered  bodily  functions,  with  the  object  of  aid- 
ing mental  recovery. 

Dr.  M.\ssev  said  that  static  electricity  seemed  to 
him  to  offer  much  hope  of  relief  in  this  class  of  cases. 

Dr.  E.  B.  Silvers,  of  Rahway,  said  that  in  alcoholic 
patients  the  use  of  cannabis  indica  internally,  and 
electricity  externally,  had  succeeded  very  well  in  his 
hands,  and  the  method  had  been  tried  with  good  re- 
sults in  the  Trenton  asylum. 

Dr.  W.  E.  Ford,  of  Utica,  said  that  the  ranks  of 
the  insane  were  recruited  from  neurasthenics  who  had 
gone  from  one  physician  to  another  for  months  or  even 
years,  without  the  gravity  of  their  condition  being  ap- 
preciated,  or  without    receiving  benefit   because    the 


physicians  did  not  care  to  give  them  sufficient  atten- 
tion. He  was  positive  that  electricity  always  did 
these  persons  some  good.  The  mild  stage  of  dementia 
which  followed  serious  neurasthenia  was  the  same 
mild  condition  of  dementia  which  came  after  a  mild 
attack  of  acute  melancholia.  'I'he  relaxed  condition 
of  the  capillaries  seen  in  these  patients  could  be  im- 
mensely improved  by  electrical  treatment—  often  much 
more  so  than  by  drugs. 

Dr.  Brower  remarked  that  he  had  found  that  many 
neurasthenics  among  the  poorer  classes  could  be  treated 
very  satisfactorily  in  general  hospitals. 

Dr.  V\'ili.iam  J.  Morton  was  of  the  opinion  that 
all  these  neurasthenics  should  be  cared  for  by  the 
general  pracitioner,  but  he  had  very  little  respect  for 
the  treatment  ordinarily  meted  out  to  these  poor  neu 
rasthenics.  The  wave  current  was  valuable  in  these 
cases  because  it  soothed  the  nervous  irritability  and 
promoted  sleep.  Much  of  his  success  in  the  treat- 
ment of  these  cases  he  veritably  believed  arose  from 
stopping  them  from  taking  the  various  tonics  pre- 
scribed for  them  by  general  practitioners  who  should 
know  better.  Strychnine,  iron,  and  the  hypophosphites 
were  the  favorite  remedies.  If  such  medication  were 
stopped,  and  the  patient  was  told  to  take  plenty  of 
rest,  abstain  from  starchy  foods,  and  live  chieHy  on 
meats  and  salads,  the  result  would  almost  always  be 
satisfactory. 

Dr.  Francis  B.  Bishop  said  that  it  had  been  his 
experience  that  neurasthenics  were  very  prone  to  com- 
mit suicide,  yielding  to  the  inlluence  of  suddenly  de- 
veloped delusions.  He  was  accustomed  to  apply  the 
galvanic  current  to  the  sympathetic,  as  outlined  in  the 
paper,  and,  in  addition,  to  make  use  of  the  static 
spray,  surrounding  the  patient  with  what  he  had  called 
the  "ozone  cage.''  This  application  was  usually  very 
soothing. 

Officers  Elected. — The  election  of  officers  of  the 
association  for  the  ensuing  year  resulted  as  follows. 
/'resident.  Dr.  Ernest  W'ende,  of  Buffalo;  First  Vice- 
President,  Dr.  Fred.  H.  Morse,  of  Melrose,  Mass. ; 
Sceotid  Vice-J'resideiit,  Dr.  1).  K.  Brower,  of  Chicago; 
Secretary,  Dr.  George  E.  Bill,  of  Harrisburg,  Treas- 
urer, Dr.  R.  J.  Nunn,  of  Savannah.  The  next  annual 
meeting  will  be  held  in  Buffalo  on  September  9,  10, 
and  1 1,  1901. 


I^XaUcal   Items. 

Contagious  Diseases — Weekly  Statement. — Report 
of  cases  and  deaths  from  contagious  diseases  reported 
to  the  Sanitary  Bureau,  Health  Department,  for  the 
week  ending  October  6,  igoo; 


Tuberculosis 

Typhoid  fever 

Scarlet  fever 

.Measles 

Diphtheria 

Laryngeal  diphtheria  (croup) 
Cerebrd-spinal  meningitis. .  . . 


Cases. 

Deaths. 

261 

152 

104 

15 

87 

2 

30 

4 

210 

19 

6 

2 

0 

6 

An  Alleged  Danger  in  Porcelain  Ware.— The 
United  States  consul  at  Mentz  quotes,  in  a  report  to 
the  State  Department  at  VVashington,  certain  remarks 
of  a  journal  published  at  Frankfort-on-the-Main  re- 
garding the  silver-mounted  porcelain  cups,  jars,  vases, 
etc.,  which  have  recently  been  placed  upon  the  market. 
The  silver  on  these  articles,  the  writer  states,  is  ap- 
plied by  an  electrical  process,  in  baths  which  contain 
very  large  quantities  of  potassium  cyanide.  As  glazed 
wares  have  innumerable  hairlike  cracks,  this  poison 
enters  these  cracks,  and  the  articles  become  a  menace 


6oo 


MEDICAL    RECORD. 


[October  13,  igoo 


to  the  health  of  anybody  using  them,  since  it  is  im- 
possiljle  in  the  course  of  manufacture  to  remove  this 
poisonous  residuum.  Only  a  short  time  ago,  it  is  as- 
serted, a  nearly  fatal  case  of  poisoning  resulted  from 
the  use  of  such  ware. 

A  Paris  Sewage  Farm. — On  August  12th  some 
three  hundred  niLinbers  (if  the  Congress  of  Hygiene 
and  Demography  were  conveyed  by  special  train  to  the 
plains  of  Achcres  situated  on  the  banks  of  the  Seine 
close  to  the  forest  of  St.  Germain.  'This  estate  meas- 
ures 10  km.  in  length  and  i  km.  in  width.  It  is  irri- 
gated throughout  with  the  crude  sewage  of  Paris.  A 
writer  in  llie  Lancet  says  that,  in  1895,  when  the  sew- 
age from  I^aris  was  just  beginning  to  arrive,  the 
greater  part  of  this  plain  seenitd  like  a  vast  desert. 
The  small  brushwood  had  bten  cleared  away  and 
nothing  had  ytt  grown  in  its  stead.  "The  contrast 
to-day  is  most  remarkable.  The  barren  plain  is  now 
verdant  with  luxurious  \'egetation.  Beetroot  is  grow- 
ing over  a  large  part  of  the  ground,  but  there  are  also 
many  fields  rich  with  golden  grain.  The  avenues  are 
planted  with  trees,  mostly  walnut.  Of  course  they  are 
still  young  and  small,  but  they  are  healthy  and  flour- 
ishing. The  greater  part  of  the  land  is  let  out  to  cul- 
tivators, iiut  the  municipality  has  kept  a  portion  in  its 
own  hands  for  e.xperimental  purposes  and  to  lay  out  a 
few  ornamental  parks,  and  to  plant  orchards.  It  was 
at  tliese  spots  that  the  members  of  the  congress  stopped 
so  as  to  stroll '  among  the  tlower-beds,  admire  the 
peaches  and  other  fruits  ripening  on  the  trees,  and 
above  all  to  visit  the  ornamental  waters;  these  were 
as  clear  as  crystal.  Fish  darted  rapidly  about,  and  as 
the  water  came  out  of  the  earth  in  little  jets  glasses 
were  filled  and  the  water  was  eagerly  drunk  by  nearly 
all  the  visitors.  Yet  this  was  neither  rain-water  nor 
spring-water:  it  was  the  water  of  the  Paris  sewers. 
What  this  meant  was  evident  to  all,  for  close  by  on 
the  surface  of  the  soil  in  countless  little  drains  the 
black,  foul  sewage  was  exposed  to  view.  But  having 
fed  the  plants  and  having  passed  through  more  than  si.\ 
feet  of  sandy  soil  the  water  collected  at  the  lower 
levels  is  found  to  be  quite  free  from  the  sewage.  The 
sewage,  which  contained  1 1,750,000  bacteria  per  cubic 
centimetre,  retained  but  2,350  bacteria  in  one  part  of 
the  estate  and  only  188  in  another  part  —  that  is,  of 
course,  after  it  had  filtered  through  the  soil.  The 
purified  sewage  water  at  Acheres  is  more  free  from 
bacteria  than  is  usually  the  case  with  good  spring 
water.  In  regard  to  organic  matter,  when  the  amount 
extracted  from  the  sewage  weighed  34.9  gm.,  after 
passing  through  the  soil  the  same  bulk  of  water  re- 
tained only  1.8  gm."  Tiie  sewage  farms  of  Paris  now 
cover  an  area  of  5,000  hectares  (approximately  12,355 
acres),  consisting  of  900  hectares  at  Gennevilliers, 
1. 000  hectares  at  Acheres,  2,150  hectares  at  Mery- 
Pierrelaye,  and  950  hectares  at  Carrieres-Triel. 

Surgical  Treatment  of  Hydatid  Cysts  of  the 
Liver. — I'rof.  Thomas  Jonnesco,  of  Buciiarest,  said 
in  a  paper  read  at  the  recent  International  Medical 
Congress  at  Paris,  that  at  the  present  time  four  kinds 
of  operations  are  performed  for  hydatid  cysts  of  the 
liver:  (i)  Puncture,  whether  followed  by  parasiticide 
injections  or  not ;  (2)  marsupialization;  (3)  incision 
followed  by  evacuation  and  suture  of  the  cyst;  (4) 
enucleation  and  extirpation  of  the  cyst.  The  last 
operation,  which  is  ideal,  is  so  rarely  applicable  that 
it  can  hardly  be  taken  into  account  unless  as  an  ex- 
ceptional intervention.  Puncture  should  be  given  up 
as  uncertain  and  even  dangerous.  Marsupialization, 
in  view  of  the  duration  of  the  treatment,  remains  an 
operation  of  necessity  applicable  to  suppurating  cysts 
and  to  those  in  which  the  calcified  adventitiano  longer 
allows  retraction  of  the  pouch  to  take  place.  The 
operation   of  choice  consists  in   incision  of  the  cyst 


which  is  emptied  of  its  liquid  contents,  daugiiter  cysts, 
and  germinal  membrane,  and  suture.  The  pouch  is 
left  without  drainage  or  fixation  of  the  cyst  to  the 
abdominal  wall.  Jonnesco  has  operated  in  six  cases 
of  cysts,  varying  in  size  from  that  of  a  man's  fist  to  a 
diameter  of  20  or  30  cm.,  and  always  with  success. 
The  effusion  of  bile  into  the  cyst  is  not  a  contraindica- 
tion. 

Cape  Town  Verdict  on  Food  Preservatives. — 
Cape  'I'own  seems  determined  to  have  undrugged  food, 
and  recently  a  dealer  has  been  fined  for  selling  milk 
containing  formaldehyde.  Mr.  C.  F.  Juritz,  public 
analyst  for  Cape  Town,  has  rightly  described  formal- 
deiiyde  as  a  strong  disinfectant  which  impaired  the 
nutritious  value  of  food,  making  it  less  digestible. 
Its  use  minimized  the  necessity  of  cleanliness  and 
made  it  possible  to  sell  old  milk  instead  of  new. — 
British  Food  Journnl. 

A  Death  from  Sulfonal  was  reported  recently  in 
the  daily  papers.  The  deceased  had  taken  440  grains 
of  the  drug. 

Medical  Fees  in  China. — .As  Chinese  affairs  are 
very  much  to  the  fore  just  now,  it  may  be  interesting 
to  mention  that  a  doctor's  fee  is  perhaps  the  smallest 
in  the  world,  ranging  from  2it.  to  5./.,  but  this  can  be 
accounted  for  by  the  fact  that  any  one  can  practise,  it 
being  necessary  only  to  hang  out  a  sign  intimating 
the  fact  that  the  owner  has  some  medical  knowledge; 
and,  although  these  are  very  numerous,  they  are,  as  a 
body,  the  most  respected  men  in  China. —  77ie  Medica) 
Press. 

The  Medicine  Habit  in  Great  Britain. — George  R. 
Sims,  better  known  by  his  iioin-dc-plumc  Dagonet,  has 
this  to  say  upon  the  above  subject  in  his  journal,  the 
London  Kejeree :  "  We  hear  a  good  deal  of  the  tobacco 
habit  and  the  alcohol  habit,  but  very  little  notice  has 
been  taken  of  a  habit  which  is  more  common  than 
either,  viz.,  the  medicine  habit — which  prevails  to 
quite  an  alarming  extent.  It  affects  all  classes,  and 
when  once  it  gets  a  victim  in  its  clutches  it  never  lets 
him  go.  There  are  hundredsof  thousandsof  Fnglish- 
men  who  take  medicine  of  some  sort  every  day  of  their 
lives.  They  do  not,  as  a  rule,  trouble  the  doctors — 
they  doctor  themselves.  They  take  pills  and  draughts, 
patent  medicines,  and  old-fashioned  remedies  with  as 
much  regularity  as  they  take  tiieir  meals.  The  habit 
is  not  confined  to  the  class  that  read  the  advertise- 
ments of  wonderful  cures,  and  take  the  various  reme- 
dies one  after  the  other,  even  when  they  ha\e  nothing 
the  matter  with  them.  Every  chemist  has  upon  his 
books  well-to-do  customers  who  have  mixtures  made 
up  almost  every  day.  A  doctor  is  called  in  and  gives 
a  prescription,  say  for  nervous  depression  or  for  dys- 
peptic trouble.  That  prescription  will  live  for  years. 
The  entire  family  will  try  it  one  after  the  other,  and 
get  at  last  to  take  it  about  once  a  week  as  a  mere  mat- 
ter of  habit.  The  system  having  been  saturated  with 
medicine  craves  for  medicine?  The  victims  of  the 
medicine  habit  would  feel  miserable  if  they  were  not 
dosing  themselves.  Some  habitual  medicine-takers, 
who  have  had  a  long  illness  and  many  jirescriptions, 
will,  when  they  get  well,  have  the  prescrijnions  made 
up  again  one  after  the  other,  and  go  through  the  whole 
series  three  or  four  times  a  year  for  the  rest  of  their 
lives.  There  are  families  to  whom  the  chemist  sends 
in  his  book  weekly  just  like  the  butcher  or  baker. 
Some  of  the  customers  are  not  content  with  one  kind 
of  medicine  at  a  time.  I  know  one  man  who  fre- 
quently takes  doses  from  four  or  five  different  bottles 
during  the  day,  and  who,  when  he  goes  out  of  town  for 
a  fortnight,  takes  his  favorite  mixture  with  him  in 
quart  l)ottles.  He  also  has  a  packet  of  about  fifty 
prescriptions  in  his  portmanteau  incase  of  accidents." 


Medical  Record 

A    IVeekly  yottnial  of  Medicine  and  Surgery 


Vol.  58,  No.  16. 
Whole  No.  1563. 


New  York,   October  20,    1900. 


$5.00  Per  Annum. 
Single  Copies,  loc. 


SOME  CONSERVATIVE   JOTTINGS    APROPOS 
OF    SPINAL   ANESTHESIA. 

Bv   J.    l.EON.-^Kl)   CORNING,    .\.M.,    M.D..    L1,.I)., 

NEW    VORK. 

Whenever  propositions  tending  to  modify  the  trend 
of  current  practice  are  brought  before  the  profession 
they  incur  a  twofold  danger:  (i)  either  they  are  re- 
ceived with  an  indifference  born  of  former  and  mani- 
fold disappointments;  or  (2)  they  excite  anticipations 
beyond  their  legitimate  potentiality.  In  the  first  in- 
stance, the  proponent  may  be  compelled  to  wait  a  long 
time  for  an  audience;  or,  if  his  proposals  be  not  vital 
with  truth  of  that  insistent  character  which  will  not 
down,  he  may  never  obtain  n  hearing. 

The  fate  of  spinal  anaesthesia,  however,  is  unique 
in  this,  that  while  at  first  and  for  long  its  advantages 
in  a  larger,  and  more  especially  in  a  surgical,  sense 
were  disregarded,  there  came  a  time  when  recognition 
leaped,  as  it  were,  into  the  arena  of  professional  life, 
driving  thence  such  small  adjuncts  of  scepticism  as 
remained.  And  from  this  long  waiting  and  this  be- 
lated acclamation  has  come  a  buoyant  expectancy,  a 
kind  of  vaulting  zeal  which  sets  one  a-trembling  at 
the  possible  consequences  of  disappointment,  misap- 
plication, or  bungling.  Spasmodic  hardihood,  defec- 
tive technics,  and  so  on  to  the  killing!  A  thousand 
pities  by  a  false  thrust  or  impossible  exactions  to 
relegate  once  more  to  the  limbo  of  the  forgotten  a 
procedure  which,  be  the  limits  of  its  usefulness  ever 
so  sharply  drawn,  must  still— in  view  of  what  has 
already  gone  before — possess  a  unique  and  e.\tensive 
field  of  usefulness! 

Though  a  neurologist,  and  strange  to  the  great  and 
useful  art  of  surgery,  I  venture  at  this  time  to  utter  an 
unostentatious  word  of  caution,  trusting  that  by  so  do- 
ing I  may  serve  a  useful  purpose,  yet  not  offend. 

In  the  issue  of  this  journal  for  October  13,  1900, 
Dr.  George  F.  Shrady  thus  expressed  himself  edito- 
rially: 

"The  value  of  recording  original  observations  as 
soon  as  made  and  prospecting  their  adaptability  to 
given  ends  is  well  shown  in  I'le  matter  of  spinal 
cocainization,  concerning  which  so  much  is  being 
written  and  said. 

"  Although  fully  fifteen  years  have  elapsed  since  Dr. 
J.  Leonard  Corning,  of  this  city,  published  his  experi- 
ments on  this  subject,  and  notwithstanding  it  is  only 
within  a  few  months  that  his  suggestions  have  been 
followed,  no  one  can  question  his  claims  to  priority 
in  first  calling  attention  to  a  method  of  anaesthesia 
which  is  now  challenging  a  trial  by  numerous  sur- 
geons here  and  abroad. 

"As  the  real  one  who  first  established  the  principle 
of  the  action  of  cocaine  upon  the  cord,  and  who  first 
demonstrated  its  practicability  not  only  by  actual 
trials  upon  the  lower  animals,  but  by  using  it  for  anes- 
thetic purposes  upon  the  human  subject,  his  name 
must  necessarily  be  associated  with  that  particular 
field  of  work,  however  it  may  be  extended  by  other 
investigators." 


Here  is  gallantry;  here  chivalric  treatment.  But, 
as  if  this  were  not  enough,  and  as  though  kindness,  in 
prodigal  mood,  were  determined  to  eclipse  herself,  he 
reveals  at  one  stroke,  in  the  last  paragraph,  thanks  to 
a  happy  mating  of  insight  with  expression,  the  basic 
principle  of  my  discovery  of  1885,'  as  it  has  never 
been  revealed  before.  Up  to  the  time  of  my  first  pub- 
lication in  the  Nai'  York  Medical  Journal,  \.\\^  fact 
that  the  cord  could  be  brought  under  the  dominion  of 
an  anaesthetic  was  utterly  unknown.  VVhat  I  then  ac- 
complished was  to  prove  tliat  this  could  be  done  by 
injecting  deeper  and  deeper  between  the  vertebrae  till 
I  had  produced  all  the  phenomena  of  what  I  then 
called  "spinal  anasthesia,"  or,  as  some  prefer  to  call 
it,  "medullary  narcosis,"  precisely  as  they  are  pro- 
duced by  others  to-day. 

Time  sped  on,  and  I  ccntinued  to  experiment;  till, 
perceiving  with  full  force  the  utility  of  penetrating  the 
meninges,  the  better  to  come  at  the  cord,  I  began  to 
produce  anjesthesia  of  the  cord  by  deliberately  punc- 
turing the  membranes  of  the  latter  in  the  lumbar 
region,  and  depositing  a  cocaine  solution  directly 
upon  the  cauda  equina. 

A  full  account  of  these  undertakings  may  be  found 
in  my  book  on"  Pain  "  •'  (1894),  and  in  the  first  volume 
of  "  A  Refe'ence-Book  of  Practical  Therapeutics," 
edited  by  Frank  P.  Foster  (1896).'  Very  recently 
Dr.  L.  Marcus  has  reviewed  the  historical  side  of 
spinal  anaesthesia;  and  his  paper,  published  in  the 
Mkdic.al  Record  for  October  13,  1900,  is  a  worthy 
contribution  to  the  subject. 

All  my  work  in  this  field,  be  it  remembered,  was 
done  and  published  years  before  any  one  else  entered 
the  field. 

So  much  for  recorded  history,  which  confers  beyond 
all  challenge  not  only  priority  in  principle,  but  prior- 
ity in  method  as  well.  But  to  appreciate  this  fully  it 
is,  of  course,  necessary  to  read  what  I  have  written. 

I  have  frequently  been  asked  of  late  by  numerous 
correspondents  for  an  expression  as  to  what,  in  my 
judgment,  are  the  essentials  of  technique.  To  com- 
ply as  succinctly  as  possible  with  these  requests,  the 
better  to  save  much  waste  of  ink,  I  would  set  down 
the  following: 

(i)  The  needle  may  be  from  three  and  a  half  to 
four  inches  in  length.  It  should  be  fine,  but  not  over- 
tempered.  The  bevel  of  the  point  should  be  short,  so 
that  the  needle  will  not  require  to  penetrate  the  mem- 
branes very  far,  in  order  to  insure  the  deposit  of  the 
solution  within  them. 

The  needle  may  be  made  of  gold  or  platina,  which 
niLtals  being  bendable  are  not  liable  to  break,  even 
when  the  calibre  is  small. 

There  should  be  a  small  steel  nut,  transfixed  by  the 
needle,  sliding  freely  upon  it,  and  fixable  at  any  point 
of  its  (the  needle's)  length  by  the  aid  of  a  small  set- 
screw.* 

'  The  New  York  Medical  Journal.  October  31,  1885.  See 
also  the  author's  book  on  "  Local  Ana;sthesia,"  D.  Appletoti  & 
Co..  18S6,  p.  85. 

"■  "  Pain,"  J.  B.  Lippincott  Company,  Philadelphia,  1894,  p. 
247  et  seq. 

•*  D.  Appleton  &  Co. ,  1896.    See  more  particularly  p.  281  et  stq. 

'  This  needle  was  described  by  the  author  in  the  Medical 
Record  of  March  17,  l388. 


6o2 


MEDICAL    RECORD. 


[October  20,  1900 


When  the  needle  is  thrust  in,  and  a  few  drops  of 
the  cerebro-spinal  Huid  (.merge,  this  nut  is  slid  down 
till  its  lower  aspect  rests  upon  the  skin.  The  nut  is 
then  fixed  in  place  by  tightening  the  screw,  and  a 
further  entrance  of  the  needle  into  the  spinal  canal 
eflfectually  prevented. 

(2)  A  syringe  of  glass,  graduated  up  to  thirty 
minims  or  more,  and  provided  with  an  asbestos  pack- 
ing, is  the  best  because  it  is  so  easily  and  thoroughly 
sterilized. 

("3)  I  prefer  to  employ  a  short,  delicate  trocar  (see 
Fig.  I  I,  half  an  inch  in  length,  to  penetrate  the  thick 
skin  of  the  back,  subsequently  passing  the  needle 
through  the  opening  of  the  trocar.  This  permits  of 
the  use  of  a  very  fine  needle.  Many  of  the  needles 
recently  employed  by  others  are  too  large.  The  com- 
paratively large  puncture  which  they  make  in  the 
membranes  allow-stoo  much  of  the  cerebro-spinal  fluid 
impregnated  with  the  anaesthetic  to  flow  out,  after  with- 
drawal of  the  needle.  Moreover,  the  bevel  at  the  point 
of  the  needle  is  often  far  to  long,  necessitating,  as  has 
been  said,  too  great  a  penetration  beyond  the  mem- 
brane. 

(4)  As  to  the  operator:  He  who  undertakes  to 
penetrate  the  membranes  of  the  cord  should  go  about 
it  with  clean  hands:  an  application  of  soap  and 
water,  followed  by  washing  with  alcohol,  and  a  dip  in 
a  solution  of  bichloride  solution  (i  :  2,000),  will  suffice 
to  insure  the  necessary  asepsis. 

(5)  As  to  the  patient:  The  back  should  be  scrubbed 
with  ((?)  green  soap  and  water;  (/')  bichloride  solu- 
tion I  :  2,000;  (f)  ether;    {(f)  alcohol. 

(6)  Sterilization  of  syringe:  Cylinder,  piston  (with- 
drawn from  cylinder),  and  needle  should  be  boiled  be- 


=fo ^ 


Fig.  I. 


fore    use;    and,  thereafter,  the  hot  water    should    be 
forced  through  the  needle  several  times. 

(7)  The  ancesthetic:  At  present  cocaine  (the  hydro- 
chlorate)  gives  the  most  satisfaction.  A  two-per-cent. 
solution  seems  to  be  the  favorite,  though  I  myself 
have  tried  many  other  strengths. 

For  the  purpose  of  sterilization  many  are  accustomed 
to  boil  the  solution,  which  may  be  conveniently  done 
in  a  test  tube  over  an  alcohol  lamp.  To  facilitate  the 
filling  of  the  syringe,  the  solution  may  be  poured  into 
a  watch-glass,  previously  well  sterilized  by  boiling. 
Care  should  be  taken  to  expel  all  air  from  the  syringe 
before  use.  The  solution  should  be  allowed  to  cool 
before  being  injected. 

(8)  To  make  the  injection:  If  possible  the  patient 
should  be  placed  in  a  sitting  posture,  inclining  in  a 
forward  direction,  so  as  to  bend  the  spine,  and  there- 
by cause  some  slight  separation  of  the  vertebra:. 

I  have  made  the  injection  at  various  points  along 
the  lumb.ir  and  even  the  lower  dorsal  spine.  At  pres- 
ent there  seems  to  be  in  some  quarters  a  predilection 
for  the  space  between  the  spinous  processes  of  the 
fourth  and  fifth  lumbar  vertebra.  It  is,  perhaps,  a 
little  easier  to  enter  the  canal  at  this  point;  but, 
whether  the  deposit  of  the  solution  higher  up  and 
nearer  the  cord  proper  is  not  better  practice  from  a 
physiological  point  of  view  is,  to  my  mind,  still  an 
open  question.  Certainly,  to  puncture,  as  I  did  years 
ago,'  between  the  second  and  third  lumbar  venebra;. 
would  cause  the  anesthetic  to  arrive  at  the  cord  more 
quickly  and  in  a  more  concentrated  condition  than 
when    introduced    lower   down.      As   a    consequence, 

'  Referred  to  in  my  book  on  "  Pain."  J.  B.  Lippincott  Com- 
pany, Philadelphia,  1804. 


anesthesia  is  more  rapidly  induced  than  when  the  in- 
jection is  made  lower  down.  If  it  be  decided  to  inject 
at  this  point,  the  relatively  profound  depression  be- 
tween the  first  sacral  and  fifth  lumbar  may  serve  as  a 
convenient  landmark.  Thence  the  spinous  processes 
may  be  counted  backward  till  the  spine  of  the  third 
lumbar  vertebra  is  reached.  This  should  be  marked 
\*ith  India  ink  or  a  blue  crayon.  Just  anterior  to  this 
point,  and  a  little  to  the  right  of  the  lig;iment,  the 
needle  is  introduced  at  something  of  an  angle.  I  ad- 
vise those  who  contemplate  practising  spinal  anesthe- 
sia to  take  a  look  at  the  skeleton,  especially  the  rela- 
tions of  the  lumbar  vertebre.  An  intelligent  glance 
of  that  sort  is  worth  many  words. 

The  needle  should  be  introduced  slowly,  the  direc- 
tion being  slightly  from  witlicut  inward  and  from  be- 
low upward.  Any  obstruction  of  its  lumen  may,  of 
course,  be  cleared  with  the  stylet.  The  outflow  of  a 
few  drops  of  cerebro-spinal  fluid  will  tell  of  the  pene- 
tration of  the  membranes.  The  syringe  may  now  be 
attached,  and  the  injection  made. 

Even  though  the  needle  be  small  it  should  not  be 
withdrawn  immediately  after  the  injection  has  been 
made;  but  on  the  contrary  it  should  be  maintained  in 
place  till  the  advent  of  anesthesia.  By  so  doing  the 
opening  made  by  the  needle  in  the  membranes  is 
eff'ectually  plugged,  and  hence  the  anesthetic  cannot 
possibly  flow  out  till  it  has  done  its  work. 

It  is  obvious  from  these  considerations  that  plung- 
ing hither  and  yon  and  sawing  with  the  needle  are  to 
be  avoided.  Better  withdraw  the  needle  and  begin 
i/e  noTo,  than  risk  the  tearing  of  the  membrane.  The 
most  recent  physiology  favors  the  close  reciprocal  re- 
lations between  the  cerebro-spinal  fluid  and  the  circu- 
lation of  brain  and  cord.  This  is  neither  tiie  time  ror 
place  to  discuss  the  evidence  bearing  on  the  point. 
We  shall  do  better  to  admit  the  contention,  and  accept 
the  corollary  that  the  spinal  membranes  should  be  in- 
jured as  little  as  may  be,  and  as  small  an  amount  of 
the  cerebro-spinal  fluid  allowed  to  flow  out  as  possible. 
Because  the  immediate  efifects  of  a  considerable  with- 
drawal of  fluid  are  not  necessarily  threatening  is  no 
reason  why  we  should  wantonly  modify  the  natural 
conditions. 

When  the  heart's  action  is  feeble  or  irregular,  a 
small  dose  of  strychnine,  nitroglycerin,  and  digitalin 
may  be  exhibited  hypodermically  a  short  time  before 
the  cord  is  anesthetized. 

At  present  from  ten  to  fifteen  minims  of  a  two-per- 
cent, solution  of  cocaine  at  a  dose  seem  to  give  satis- 
faction. In  the  old  days,  however,  when  I  first  began 
experimenting,  I  was  accustomed  to  inject  very  much 
larger  quantities.  But  "enough  is  as  good  as  a 
feast  ";  and  it  would  be  poor  practice  to  add  unneces- 
sarily to  the  vehemence  of  the  physiological  effects. 

Clreat  stress  has  been  laid  by  recent  writers  upon 
the  outflow  of  tlie  cerebro-sjjinal  fluid  as  a  criterion  by 
whicli  to  determine  with  certainty  that  the  membranes 
have  been  pierced.  To  admit  the  value  of  this  sign, 
however,  is  one  thing,  and  to  declare  that  it  .is  the 
only  means  of  knowing  that  the  membranes  are 
pierced  quite  another.  The  latter  assertion  is  incor- 
rect. It  is  feasible  by  thrusting  a  needle  down  to  the 
point  of  the  spinous  process  to  measure  the  distance 
between  the  latter  and  the  surface  of  the  skin.  To 
this  add  the  maximum  length  attained  by  the  lumbar 
spinous  process  (in  adults),  say  4  cm.,  taking  the 
measurement  from  the  posterior  wall  of  the  canal. 
Then  add  a  little  (say  },  cm.)  for  certainty's  sake, 
and  to  compensate  for  the  slight  inclination  of  the 
needle;  thrust  in  and  slowly  inject  a  little  of  the  an- 
esthestic  and  wait  a  few  minutes.  If  after  the  lapse 
of  ten  minutes  there  is  neither  tingling  nor  numbness, 
go  a  little  deeper  and  inject  a  little  more.  Often  it  is 
possible  to  obtain  complete  anaesthesia  in  this  way. 


October  20,  1900] 


MEDICAL    RECORD. 


603 


A  large  amount  of  solution  is,  however,  unnecessary 
to  success,  and  I  do  not  recommend  it  now,  but  cite  it 
merely  to  show  that  there  is  more  than  one  road  to 
Mecca. 

Again,  and  better,  a  needle  may  be  thrust  down  to 
the  transverse  process — the  upper  (dorsal)  surface  of 
which  corresponds  approximately  with  the  upper  (dor- 
sal) edge  of  tlie  vertebral  foramen — and  thus  the  dis- 
tance between  the  surface  of  the  skin  and  the  edge  of 
the  foramen  may  be  quite  accurately  determined. 
.\dd  half  a  centimetre  to  insure  penetration  of  the 
membranes;  set  the  nut  accordingly  on  the  hollow 
needle:  insert,  and  inject  gradually  as  before  de- 
scribed. 

t)f  course  there  is  no  objection,  but  on  the  contrary, 
good  reason  to  watch  for  the  appearance  cf  the  cere- 
bro-spinal  fluid  at  the  top  of  the  needle,  which,  if  it 
does  not  absolutely  guarantee  the  success  of  the  anjes- 
thesia,  is  certainly  of  the  best  omen. 

A  preliminary  measurement  of  this  kind  is  of  es- 
pecial service  for  purposes  of  orientation  when  tiie 
needle  becomes  filled  with  blood,  and  the  cerebro- 
spinal fluid  is  not  immediately  forthcoming. 

In  1888  I  described  this  method  of  ascertaining  the 
distance  between  tiie  surface  of  the  skin  and  the  upper 
rim  of  the  vertebral  foramen,  and  designed  a  long 
needle  with  a  handle  to  execute  the  manoe  ■"'■e.' 

All  the  world  is  now  familiar  with  the  ^.nenomena 
induced  by  such  injections:  the  paresthesia-  tin- 
gling, numbness,  "sleepiness";  the  subsequent  disap- 
pearance of  sensibility  to  pain  in  the  regions  below 
the  point  of  injection,  as  well  as  the  familiar  constitu- 
tional symptoms  of  the  drug. 

I  have  minutely  described  these  phenomena  in  my 
very  first  paper  (1885),'"  as  well  as  in  subsequent  writ- 
ings; and  what  has  been  published  recently  in  the 
course  of  what  migin  be  termed  the  late  renaissance 
of  my  ideas  serves  but  to  confirm  my  own  observations 
of  long  ago. 

And  now  a  further  vi'ord  or  two  as  to  the  danger  of 
expecting  too  much  from  this  discovery,  and  of  bring- 
ing it  once  more  into  the  neglect  certain  to  follow  in 
the  train  of  disappointed  hopes. 

First  and  foremost,  it  is  necessary  frankly  to  look  at 
facts  and  confess  that  there  is  nothing  in  those  till 
now  brought  forward  remotely  to  warrant  the  belief 
that  the  days  of  cerebral  or  general  ancesthesia  are 
numbered.  Some  curtailment  in  their  use  there  may, 
ay,  doubtless  will  be;  but  abdication  of  their  broad 
dominion — never. 

Again,  it  is  absolutely  necessary  to  remember  that, 
despite  all  apparent  conformity  with  the  exactions  of 
technique,  spinal  anaasthesia  sometimes  leaves  one  in 
the  lurch.  To  what  is  this  failure  to  appear  ascrib- 
able?  Is  it  due  to  the  outflow  of  the  anjesthetic 
through  the  puncture,  or  to  a  lack  of  proper  distribu- 
tion ?  I  do  not  know,  nor  have  I  yet  come  upon  a 
convincing  explanation.  In  such  cases,  after  all  has 
been  done  that  ingenuity  can  suggest,  resort  to  gen- 
eral anjEsthesia  is,  of  course,  imperative. 

Equally  disappointing,  or  nearly  so,  are  the  cases  in 
which  the  subject  quite  naturally  suflfers  the  imagina- 
tion of  pain  rather  than  its  reality.  Failure  to  appre- 
ciate this  fact  may  lead  not  only  to  disappointment, 
but  to  wholesale  and  unmerited  condemnation.  Cases 
are  of  record,  too,  in  which  the  anaesthesia  was  not  of 
sufficient  duration,  and  the  injections  had  to  be  re- 
peated, always  a  deplorable  circumstance.  Future  de- 
velopment of  the  technique  may,  however,  render  such 
supplementary  injections  either  less  inconvenient  than 
they  now  are,  or  even  altogether  unnecessary.  Just 
now  experiments  are  being  conducted  with  various 
anesthetics,  but  cocaine  still   holds,  and  is  likely  to 

'  The  Medical  Record,  March  17.  iSSS. 

'  The  New  York  Medical  Journal,  October  31,  1885. 


hold,  the  field.  I  know  of  no  facts  in  physiological 
chemistry  capable  of  explaining  the  discrepancy  in 
the  local  effects  of  different  anssthetics,  when  used 
about  the  cord. 

Often  the  anaesthesia,  both  in  quality  and  duration, 
leaves  absolutely  nothing  to  be  desired;  and  this 
without  notable  modification  of  technique  or  any  other 
apparent  departure.  Such  facts,  it  seems  to  me, 
should  urge  all  concerned  to  studious  attempts  to 
solve  the  physiological  riddle  of  this  perfection,  the 
better  ultimately  to  attain  constancy  of  result. 

Uncouth  needles,  with  a  long  bevel  at  the  point,  are 
of  all  things  to  be  avoided.  Only  imperfect  results 
are  to  be  anticipated  from  such  clumsy  implements,  as, 


Fig. 


on  the  one  hand,  an  overplus  of  penetration  is  requi- 
site to  insure  the  entry  of  the  fluid  below  the  mem- 
branes; and,  on  tiie  other,  an  immoderate  outflow  of 
cerebro-spinal  fluid — and  hence  of  the  anaesthetic — is 
inevitable  after  withdrawal  of  the  needle. 

The  comparative  value  of  injections  made  at  differ- 
ent points  along  the  dorsal  and  lumbar  spine  should 
also  be  carefully  tested.  1  know  very  well  that  some- 
thing has  already  been  done  in  tiiis  direction,  and  I 
myself  have  had,  in  times  past,  a  hand  in  such  under- 
takings; but  this  phase  of  the  question,  simple  though 
it  may  appear  at  first  view,  is,  in  my  opinion,  not  yet 
conclusively  decided. 

Every  one  at  all  conversant  with  the  serious  results 
inevitably  following  infection  of  a  serous  cavity  must 
be  profoundly  impressed  with  the  necessity  of  a  rigid 
asepsis.  This  point  has  been  insisted  upon  by  most 
if  not  all  recent  writers.  Yet  I  foresee  that  amid  the 
indiscriminate  slitting  by  irresponsible  persons,  sure 
to  follow  in  the  wake  of  the  conservative  achieve- 
ments of  the  judicious  and  the  competent,  there  is  likelv 
to  be  a  neglect  of  those  necessary  and  elaborate  rules 
of  antisepsis  so  necessary  to  the  safety  of  the  subject. 
I'hen  a  procession  of  gory  tales;  and  a  great  and 
useful  principle  cast  into  shadow  by  the  misadventures 
of  a  herd  of  venturesome  empirics. 

There  has.  it  is  true,  been  a  singular  immunity  from 
fatality  till  now — not  a  single  death,  I  believe;  but 
the  history  of  innovation  in  the  realm  of  anaesthesia 
does  not  countenance  the  hope  that  this  can  go  on  in- 
definitely.    No;  there  will  be  fatalities,  but  let  there 


6o4 


MEDICAL    RECORD. 


[October  20,  1900 


be  a  concerted  effort  by  the  invocation  of  every  known 
precaution  to  keep  the  percentage  of  mortality  as  low 
as  possible.  Let  there  be  less  riv.ilry  of  the  knife — 
less  endeavor  of  one  tooulslit  the  other  -and  more  at- 
tention to  improvement  of  method  by  the  invocation 
of  the  good  offices  of  experimentation  and  tlie  creative 
imagination. 

."Vgain,  I  repeat,  I  am  no  surgeon;  but,  as  a  neurolo- 
gist, I  tremble  for  the  cord.  In  view  of  such  solici- 
tude, may  1  be  forgiven  this  preachment — the  only  bit 
of  strenuous  didacticism,  so  fur  as  I  can  recollect,  of 
which  1  have  been  guilty  during  my  entire  profes- 
sional career. 

Finally,  the  author  desires  to  express  his  sincere 
acknowledgment  of  all  the  kind  things  which  have 
been  said  of  the  method,  both  by  his  confreres  and 
the  medical  press.  It  would,  however,  be  a  sorry  mis- 
interpretation of  its  significance  were  the  author  to  re 
gard  all  this  eulogy  as  a  personal  compliment.  On 
the  contrary,  he  is  fully  aware  that  the  applause  is  for 
the  idea  as  a  part  of  the  heritage  of  American  medi- 
cine, and  not  for  himself. 

53  West  Thirtv-ek.hth  Strhrt. 


THK  TREATMENT  OF  NECROSIS  OF  THE 
ENTIRE  SHAFT  OF  A  LONG  BONE;  WITH 
REPORT    OF    A    CASE. 

By    J.     SIIELTON'    IIORSLEY,     M.D., 

EL    PASO.  TEXAS. 

Actn'E  osteo-myelitis  is  responsible  for  the  largest  por- 
tion of  the  diseases  of  the  sliafts  of  long  bones,  so 
its  importance  to  the  surgeon  can  hardly  be  overrated. 
It  usually  follows  a  definite  and  typical   pathological 


KlG.  I. — Tile  Patient  afler  Operalion. 

course,  though  the  symptoms  are  not  so  well  defined, 
especially  in  the  early  stages,  wlien  the  diagnosis  is 
frequently  confounded  with  that  of  rheumatism  or 
typhoid  fever.     It  is  practically  only  for  necrosis  as 


a  sequela  of  this  disease  that  shafts  of  long  bones 
have  to  be  removed  subperiosteally,  for  after  severe 
injuries  the  periosteum  is  destroyed  with  the  bone, 
and  in  malignant  diseases  it  is  involved. 

The  time  required  for  separation  of  dead  bone  may 
be  from  four  weeks  to  a  number  of  months.  Living 
bone  immediately  adjacent  to  necrosed  bone  under- 
goes rarefying  osteitis,  softens,  and  becomes  gradually 
converted  into  granulation  tissue.  Suppuration  oc- 
curs where  the  dead  and  living  bone  are  in  contact. 
New  bone  is  being  constantly  formed  from  the  peri- 
osteum and  from  the  granulations  which  have  separated 
the  sequestrum  ;  and  this  new  formation,  constituting 
the  involucrum,  is  necessarily  thoroughly  infected  with 
pus  organisms,  as  it  is  constantly  bathed  in  pus  during 
ossification. 

But  however  definite  the  pathological  course  that 
leads  to  necrosis  of  shafts  of  bones  may  be,  the  proc- 
ess of  repair  after  operation  is  not  so  well  defined. 
Occasionally  bone  will  not  be  reproduced  either  from 
whatever  remaining  bone  there  may  be  left  or  from 
the  periosteum.  In  March,  1899,  I  saw  in  consulta- 
tion with  Dr.  J.  F.  McConnell,  of  Las  Cruces,  N.  M., 
a  middle-aged  man  of  excellent  physique  and  good 
general  health,  who  had  had  a  circumscribed  area  of 
necrosed  bone  in  the  upper  epiphysis  and  adjacent 
portion  of  the  shaft  of  the  tibia.  This  had  been 
thoroughly  removed,  and  a  few  weeks  later  the  walls  of 
the  resulting  cavity  were  curetted.  The  wound  followed 
an  aseptic  course  as  a  result  of  these  operations,  yet 
with  the  exception  of  a  few  isolated  patches  of  insig- 
nificant granulations  there  was,  during  the  course  of 
more  than  six  months,  no  attempt  at  reproduction  of 
bone;  and  tiiis  in  spite  of  the  fact  that  decalcified 
bone  chips  and  numerous  other  measures  had  been 
patiently  tried.  The  man  finally  committed  suicide, 
rather  than  lose  his  leg. 

Every  surgeon  of  much  experience  in  emergency 
surgery  has  had  at  least  one  case  of  ununited  fracture 
that  would  unite  by  no  known  method  of  treatment. 
This  frequently  occurs  in  young  or  middle-aged  pa- 
tients who  have  had  excellent  health  and  are  without 
a  trace  of  constitutional  or  hereditary  disease.  Age 
modifies  reproduction  of  bone.  It  is  a  well-recognized 
fact  that  in  the  young  bone  is  reproduced  much  more 
rapidly  than  in  the  old.  Swoboda,'  after  a  study  of 
osteomyelitis  in  infancy,  finds  it  more  acute  and 
necrosis  of  bone  more  rapid  than  in  adults.  Epi- 
physeal separation,  he  says,  is  also  more  likely  to 
occur.  Reproduction  of  bone  in  infancy  unquestion- 
ably requires  a  shorter  time. 

When  we  consider  that  bone  and  periosteum  are 
abundantly  supplied  with  blood,  and  that  they  belong 
to  the  connective-tissue  group,  a  comparatively  low 
grade  of  tissue  histologically,  we  cannot  help  wonder- 
ing why  reproduction  of  bone  is  so  uncertain  and 
irregular.  Wounds  in  much  more  highly  constructed 
tissues,  except  in  central  nerve  matter,  are  almost  in- 
variably repaired  more  or  less  perfectly.  Vet  with 
comparative  frequency  we  find  injuries  of  bones^ — a 
pure  connective  tissue — followed  by  no  attempt  at  re- 
pair, even  after  the  most  careful  and  skilful  treatment. 

So  in  a  small  jiroportion  of  cases  failure  will  result, 
but  in  the  vast  majority  of  instances  the  periosteum 
alone  is  fully  capable  of  reproducing  the  entire  shaft 
of  a  long  bone  when  reproduction  is  at  all  possible. 
Dr.  H.  W.  Cushing,  of  Boston,  reports  a  case'^  in 
which  the  entire  shaft  of  the  tibia  was  removed,  and 
another  regenerated  from  the  periosteum.  He  at- 
tributes the  successful  result  largely  to  the  time  at 
which  the  operation  was  performed,  when  the  peri- 
osteal osteoblasts  were  in  the  most  active  regenerative 
stage,  but  before  an   involucrum  had  formed.     An  in- 

'  Wien.  klin.  Woch.,  vol.  x..  1S97. 
'  Annals  of  Surgery,  October,  1 899. 


t 


October  20,  1900] 


MEDICAL    RECORD. 


60= 


volucrum  always  contains  pyogenic  germs  that  may 
live  in  its  small  foramina  and  crevices  almost  in- 
definitely. For  this  reason  and  on  account  of  the 
denseness  of  bony  structure,  it  is  wellnigh  impossible 
to  disinfect  it. 

In  necrosis  of  the  entire  shaft  of  long  bones,  not 
only  the  sequestrum  but  the  involucrum  should  be 
completely  removed,  the  periosteum  being  carefully 
preserved.  After  removal  of  a  sequestrum,  the  in- 
volucrum consists  of  a  mass  of  badly  formed  bone, 
impossible  of  being  rendered  aseptic,  and  containing 
a  cavity  which,  under  the  most  favorable  circum- 
stances, is  difficult  of  closure.  If  the  periosteum  is 
carefully  stripped  off,  the  wound  can  be  treated  as  in 


%^ 


Fig.  2. — The  Sequestrum  Removed. 

the  case  of  Cashing  by  sutures,  leaving  buried  in  the 
leg  "a  solid  cord  of  bone-producing  tissue,"  or  if  the 
periosteum  itself  is  infected,  may  be  lightly  packed 
with  gauze,  as  in  the  case  here  reported.  In  either 
event,  the  reproduced  shaft  will  more  nearly  corre- 
spond in  both  shape  and  quality  to  the  natural  diaphy- 
sis  than  is  possible  than  by  leaving  a  clumsy,  infected 
involucrum  surrounding  a  large  dead  space.  The 
following  case  of  necrosis  of  the  entire  shaft  of  the 
tibia  serves  to  support  this  view: 

B.   K ,  girl,  aged  one  year  and  eight   months; 

German-American  parentage;  has  three  brothers,  all 
healtliy.  Family  history  of  no  importance.  About 
September  i,  iSgcS,  she  commenced  suffering  from  pain 
and  some  swelling  in  both  legs.  The  right  leg  re- 
covered, but  the  left  grew  worse,  and  finally  an  abscess 
formed  near  the  upper  end  of  the  shaft  of  the  tibia. 
This  was  opened  by  Dr.  J.  F.  McConnell,  who  found 
a  movable  mass  of  dead  bone  at  the  bottom  of  the 
abscess.  On  October  30,  1S98,  he  referred  the  case 
to  me  for  operation,  with  a  diagnosis  of  necrosis  of 
the  shaft  of  the  tibia.  On  the  following  day  I  oper- 
ated, with  his  assistance.  A  long  incision,  the  length 
of  the  shaft  of  the  tibia,  was  made  over  its  interior 
surface  near  the  anterior  border.  Attempts  at  involu- 
crum formation  at  the  upper  third  of  tiie  shaft  were 
poor,  and  resulted  in  only  a  few  bony  spicules,  but  in 
the  lower  and  middle  thirds  a  thin  layer  of  soft, 
cheesy  bone  had  formed.  After  the  periosteum  was 
raised,  the  front  of  this  was  removed,  and  a  sequestrum 
exposed.  All  of  the  remaining  involucrum  seemed  in- 
fected, so  it  was  removed  with  a  sharp  spoon  and  peri- 
osteal elevator,  leaving  at  the  lower  part  of  the  leg  a 
small  strip  that  was  closely  united  to  the  lower  epi- 
physis and  apparently  healthy.  The  upper  epiphysis 
was  badly  infected,  but  a  V'olkmann  spoon  thoroughly 
removed  its  diseased  bone.  The  upper  part  of  the 
periosteum  was  gently  scraped,  and  the  wound  lightly 
packed  with  iodoform  gauze.  It  was  dressed  every 
third  day.  Recovery  progressed  slowly  but  satisfac- 
torily. Two  small  sinuses  existed  near  the  upper  end 
of  the  incision  for  ten  months,  but  finally  closed. 
The  leg  is  now  useful,  and  a  slight  bowing  of  the  tibia 
seems  not  to  interfere  with  its  function.  The  photo- 
graphs showing  the  leg  were  taken  in  June,  1900, 
twenty  months  after  the  operation. 


Supra-Orbital  Neuralgia. — Castor  oil  two  or  three 
times  a  week,  to  be  kept  yp  at  less  frequent  intervals 
after  pain  ceases. — N.  O'D.  Parks. 


TREATMENT  OF  THE  PATIENT  DURING 
THE  WEEKS  PREVIOUS  TO  EXPECTED 
CONFINEMENT. 

By    EDWARD   P.    DAVI.S,    A.M..    M.D., 

PROFESSOR  OF  OBSTETRICS  IN  THE  JKFFSRSO.S  MEDICAL  COLLEGE  ;  PROFESSOR 
OF  OBSTETRICS  AND  DISEASES  OF  INFANCY  IN  THE  PHILADELPHIA  POLY- 
CLINIC ;  VISITING  OBSTETRICIAN  TO  THE  JEFFERSON,  PHILADELPHIA  AND 
POLYCLINIC    HOSPITALS,   ETC. 

We  shall  best  understand  the  treatment  needed  by  the 
pregnant  woman  during  the  later  weeks  of  gestation 
by  reference  to  the  condition  of  the  patient  during  this 
time. 

If  she  be  healthy,  the  mother's  nutritive  processes 
are  well  performed.  The  anamia  of  early  pregnancy 
has  given  place  to  the  plethora  of  its 
later  stages.  The  patient's  excretion  is 
often  better  than  at  seven  or  eight  months. 
In  those  who  are  overta.xed,  ill-nourished, 
and  living  in  unfavorable  surroundings, 
the  later  weeks  of  pregnancy  find  them 
witii  a  threatened  toxaniia  which  may  lead 
to  eclampsia.  In  neurotic  women  and 
those  who  habitually  excrete  badly,  it  is 
also  true  that  the  later  weeks  of  pregnancy 
form  a  period  of  increasing  danger. 
In  women  of  normal  shape  and  tissues,  the  pelvis 
undergoes  changes  during  the  later  weeks  of  preg- 
nancy which  fit  it  to  give  passage  to  the  child.  Its 
joints  become  more  filled  with  synovial  liuid,  and  its 
articulations  more  elastic  and  capable  of  distention. 
This  is  an  important  factor  in  securing  that  accom- 
modation so  essential  to  the  normal  mechanism  of 
labor.  Uterine  contractions  become  more  pronounced 
at  this  time,  and,  aided  by  the  action  of  the  abdominal 
muscles,  cause  the  entrance  of  the  ftelus  into  the  brim 
of  the  pelvis  in  primipara;  and  its  presentation  at  the 
pelvic  brim  in  multipara;.  Observation  shows  that  a 
very  important  function  in  securing  accommodation  is 
that  of  the  voluntary  muscles,  as  seen  in  cases  in  which 
pregnant  women  in  the  later  months  of  pregnancy  take 
exercise  and  thus  assist  in  causing  the  child  to  de- 
scend. 

Mammary  changes  during  the  later  weeks  of  preg- 
nancy prepare  the  breasts  for  nursing  by  the  accumu- 
lation of  colostrum,  and  warn  us  to  see  to  it  that  the 
nipples  are  brought  into  condition  for  this  function. 

To  estimate  the  perfection  of  the  patient's  assimila- 
tion and  to  detect  failure  in  excretion,  we  must  study 
the  clinical  symptoms  of  toxa:niia,  and  by  examination 
ascertain  chemically,  so  far  as  possible,  the  condition 
of  the  excretory  processes.  Attention  has  long  been 
drawn  to  the  violent  frontal  headache,  lassitude,  dis- 
turbance of  vision,  and  high  pulse  tension  which  often 
precede  eclampsia.  There  are  other  symptoms,  how- 
ever, which  mark  the  pre-eclamptic  state  and  whose 
recognition  is  of  importance.  The  persistent  presence 
of  gas  in  the  intestines,  with  a  furred  and  coated 
tongue,  points  to  deficient  elimination.  Neuralgia, 
disturbance  in  the  rhythm  and  frequency  of  the  heart 
beat,  changes  in  temperament,  slowly  progressing  loss 
of  appetite,  deficient  action  of  the  skin  with,  in  many 
cases,  eruptions,  vague  headache  frontal  in  character 
but  not  extremely  severe,  failing  excretion  by  the 
kidneys,  liver,  and  bowels,  form  a  clinical  picture  not 
difficult  to  recognize  if  the  attention  be  directed  to  it. 
In  rare  cases  uterine  hemorrhage  is  a  most  important 
symptom  of  profound  toxsmia. 

In  examining  the  urine,  we  ascertain  its  quantity, 
its  amount  of  solid  material,  and  the  presence  or  ab- 
sence of  de'bris  from  the  kidney  as  of  primary  impor- 
tance. Of  secondary  value  is  the  presence  or  absence 
of  serum  albumin  and  of  lactose. 

To  ascertain  the  solid  waste,  the  specific  gravity  of 
the  urine  should  be  taken,  and  the  last  two  figures  of 
this  number  multiplied  by  2.33   give  approximately 


6o6 


MEDICAL   RECORD. 


[October  20,  1900 


the  number  of  grams  of  solid  matter  in  one  thousand 
cubic  centimetres  of  urine.  Haines'  modification  of 
Haeser's  method  consists  in  multiplying  the  hist  two 
figures  of  the  specific  gravity  by  the  number  of  ounces 
voided  in  twenty-four  hours  and  the  product  by  i.i. 

The  estimation  of  the  amount  of  urea  is  valuable 
not  only  to  assist  us  in  measuring  the  quantity  of  solid 
matter  excreted,  but  also  because  the  presence  of  urea 
in  considerable  amount  indicates  that  assimilation  is 
well  performed  and  that  nitrogenous  food  is  well  di- 
gested and  is  not  broken  up  into  irritating  and  poi- 
sonous compounds.  Hence  the  estimation  of  urea  dur- 
ing pregnancy  is  an  important  clinical  resource,  the 
value  of  which  e.xperience  has  fully  confirmed.  A 
number  of  convenient  forms  of  apparatus  are  readily 
available  for  this  purpose. 

It  is  sometimes  difficult  in  dealing  with  patients  to 
induce  them  to  measure  accurately  the  quantity  of 
urine  passed  and  to  send  specimens  regularly  for  ex- 
amination. In  most  cases,  however,  the  patient  co- 
operates willingly  in  the  physician's  attempt  to  give 
her  accurate  care.  Kidney  debris  may  be  obtained 
by  the  use  of  the  centrifuge  or  by  sedimentation.  The 
character  of  the  epithelia,  the  degree  of  degeneration 
present,  the  number  and  ciiaracter  of  casts  found,  and 
the  presence  or  absence  of  blood  give  reliable  infor- 
mation as  to  the  condition  of  the  kidney. 

Serum  albumin  when  present  in  excess  is  accom- 
panied by  kidney  debris  and  indicates  a  seriously 
impaired  condition  of  the  renal  epithelium.  Unless, 
however,  kidney  debris  is  present  and  the  solid  waste 
is  poorly  eliminated,  serum  albumin  alone  is  of  little 
significance  as  an  indication  of  danger.  Anaemic  mul- 
tiparae  are  sometimes  seen  with  much  swollen  legs, 
who  have  considerable  quantities  of  serum  albumin  in 
the  urine  but  who  excrete  well  in  other  ways  and  pass 
through  pregnancy  without  danger. 

The  presence  of  various  forms  of  sugar  in  the  urine 
suggests  interesting  problems.  Lactose  is  naturally 
referred  to  the  activity  of  the  mammary  glands.  Other 
forms  of  sugar  may  be  seen  in  highly  nervous  women 
who  have  ravenous  appetites  and  eat  very  largely. 
In  a  case  now  under  observation,  at  the  fourth  month 
of  pregnancy,  a  highly  nervous  multipara  had  for  some 
time  in  the  urine  an  average  of  one  per  cent,  of  sugar 
which  was  not  lactose.  This  was  accompanied  by 
polyuria  and  excessive  appetite.  Sugar  is  now  absent 
from  the  urine  without  especial  modification  of  the 
diet  or  medical  treatment. 

The  treatment  of  the  toxsmia  of  pregnancy  is  too 
large  a  subject  to  occupy  us  extensively  at  this  time. 
Experience  constantly  proves  that  physicians  must 
not  be  deceived  by  supposing  that  serum  albumin  is 
the  most  important  indication  of  failing  excretion. 
The  part  which  the  liver  plays  in  the  production  of 
poisonous  compounds  causing  eclampsia  is  recognized 
more  and  more.  The  physician  must  satisfy  himself 
that  the  liver,  intestines,  kidneys,  skin,  and  lungs  are 
doing  their  part  in  digestion  and  excretion. 

The  diet  of  the  patient  should  be  as  nearly  as  pos- 
sible milk,  fruit,  and  bread.  If  heartburn  be  annoy- 
ing, milk  may  be  diluted  with  any  carbonated  water 
with  advantage.  In  some  cases  it  should  be  partially 
peptonized.  Buttermilk  is  exceedingly  useful  with 
those  who  can  take  it.  In  my  experience  the  majority 
of  women  in  comfortable  circumstances  can  limit  the 
consumption  of  meat  during  the  latter  two-thirds  of 
pregnancy  to  once  daily  with  advantage.  P^ish,  oysters, 
whits  meat  of  poultry,  and  mutton  or  lamb  are  to  be 
preferred  when  meat  is  taken.  The  alkaloids  of  tea 
and  colTee  check  excretion  very  markedly  with  some 
women.  ColTee  is  especially  injurious  to  those  who 
suffer  from  chronic  intestinal  indigestion.  Alcohol  in 
tox.Temia  is  not  indicated  but  injurious.  The  mistake 
must  not  be  made  in  dealing  with  these  patients  so  to 


limit  the  diet  as  to  reduce  strength.  It  often  requires 
considerable  perseverance  and  attention  to  induce  the 
patient  to  take  sufficient  milk.  The  skilful  prepara- 
tion of  milk  foods  such  as  junket,  koumiss,  and  milk 
puddings  is  of  great  assistance.  When  thoroughly 
ripe  fruit  is  not  available,  fruit  should  be  stewed 
or  baked,  and  when  fresh  fruit  cannot  be  obtained, 
dried  fruits  and  those  put  up  with  little  sugar  should 
be  used. 

The  use  of  water  in  toxaemia  deserves  especial  men- 
tion. At  least  one  quart  should  be  taken  internally 
daily,  and  this  may  be  any  pure  w-ater  agreeable  to  the 
patient.  Externally,  water  should  be  used  in  a  cool 
sponge  bath  in  the  morning  and  a  warm  tub  bath  at 
night.  The  evening  bath  is  our  best  reliance  in  di- 
minishing the  irritability  and  insomnia  which  often 
annoy  these  patients.  Water  may  also  be  used  in 
flushing  the  colon  and  by  injection  into  the  bowel. 
In  cases  of  obstinate  constipation  when  the  bowel  has 
been  emptied,  a  daily  flushing  with  one  gallon  of  deci- 
normal  salt  solution  followed  by  the  injection  of  two 
quarts  of  sterile  water  is  of  great  advantage.  A  skilful 
nurse  can  usually  succeed  in  this  treatment  by  turning 
the  patient  on  her  left  side  with  her  hips  raised  and 
by  introducing  a  long  rectal  tube  with  patience  and 
gentleness. 

The  patient  must  spend  as  much  of  the  day  as  pos- 
sible in  the  open  air,  and  her  house  must  at  all  times 
be  well  aired. 

The  choice  of  drugs  in  the  treatment  of  toxemia  is 
in  my  experience  a  limited  one.  Salines  should  be 
selected  for  their  freedom  from  potassium.  Sulphate 
of  magnesium  in  some  form  is  especially  valuable. 
Carlsbad  salts  taken  in  hot  water  upon  rising  answer 
exceedingly  well  in  many  cases.  In  others,  a  mineral 
water,  rich  in  sulphate  of  magnesium,  may  be  selected. 
Those  patients  who  are  annoyed  by  the  presence  of 
gas  often  complain  that  salines  increase  the  gas  in  the 
intestine,  and  this  statement  is  borne  out  by  careful 
observation. 

I  know  of  no  drug  which  so  efficiently  influences 
tlie  throwing  out  of  solid  waste  in  the  body  as  calomel. 
In  doses  of  t,';,^  of  a  grain  night  and  morning  or  in 
much  smaller  doses,  -J,^  of  a  grain  three  times  daily, 
in  my  experience  it  is  most  successful.  I  have  con- 
tinued this  for  several  weeks  without  signs  of  mercu- 
rial irritation.  It  is  sometimes  necessary  to  supple- 
ment this  by  salines,  while  others  do  well  upon  this 
drug  only.  Under  its  use  the  percentage  of  solids  in 
the  urine  increases,  the  percentage  of  urea  is  distinctly 
increased,  the  pulse  tension  is  lessened,  the  patient's 
symptoms  are  much  improved,  and  her  condition  is 
very  greatly  benefited.  I  know  of  no  other  drug  which 
is  of  essential  value  in  this  condition.  If  the  patient 
complains  of  insomnia,  restlessness,  and  headache,  the 
practitioner  would  natually  be  tempted  to  give  seda- 
tives, notably  bromides.  This  in  my  experience  is 
a  mistake,  as  treatment  addressed  to  increasing  elimi- 
nation causes  the  disturbance  of  the  ner\'ous  system 
speedily  to  cease.  If  a  sedative  is  needed  in  toxaemia, 
chloral  or  some  derivative  of  it,  gives  the  best  promise 
of  success. 

Up  to  the  present  time,  I  have  been  uniformly 
successful  in  the  treatment  of  toxemia  during  preg- 
nancy by  the  methods  described.  An  illustrative  case 
is  the  following:  The  patient  was  in  her  sixth  preg- 
nancy. The  first  was  followed  by  a  miscarriage  upon 
violent  exertion.  During  the  second,  she  was  exposed 
while  yachting  to  severe  cold,  followed  by  a  sharp 
attack  of  nephritis,  from  which  she  was  rescued  with 
difficulty.  Her  next  pregnancy  was  followed  by  an 
abortion  at  six  months.  In  the  next  pregnancy  at 
eight  months,  albuminuria  developed  rapidly  and 
labor  was  induced  with  th,e  birth  of  a  living  child 
which    survives.     At    the    next    pregnancy,    she    had 


October  20,  1900] 


MEDICAL    RECORD. 


607 


eclampsia  and  labor  was  induced,  followed  by  the 
birth  of  a  child  which  soon  died.  She  came  under 
observation  when  one  month  pregnant  for  the  sixth 
time.  The  patient  was  in  other  respects  strong  and 
robust  and  had  in  previous  pregnancies  strictly  fol- 
lowed the  general  hygienic  precautions  which  her  phy- 
sicians had  ordered.  Her  case  had  been  very  carefully 
and  thoroughly  studied  during  previous  pregnancies. 
The  examination  of  her  urine  showed  it  to  be  nor- 
mal. Owing  to  the  bad  previous  history,  pregnancy 
was  considered  most  hazardous  by  the  physicians  con- 
sulted in  the  case.  When  seven  weeks  of  pregnancy 
had  elapsed,  hyaline  and  granular  casts  with  a  trace  of 
albumin  were  found  in  the  urine.  The  amount  of 
solids  excreted  continued  good.  The  interruption  of 
pregnancy  was  declined  by  the  patient,  who  preferred 
to  make  a  further  effort  to  secure  a  second  living 
child.  Accordingly  between  the  tenth  and  twelfth 
week  of  gestation  the  patient  was  put  upon  a  diet 
from  which  meat  was  omitted  and  nitrogenous  food 
reduced  very  largely.  Examinations  of  the  urine  were 
made  most  carefully  each  week,  and  tiie  patient  was 
seen  frequently  by  her  attending  physician.  The  only 
medication  employed  was  calomel  in  ^',pgrain  doses 
and  a  saline  taken  in  the  morning.  The  patient  gave 
up  her  entire  life  to  the  continuation  of  the  pregnancy, 
and  in  addition  to  restriction  of  diet  and  medication, 
followed  strictly  other  precautions  in  maintaining  her 
general  hygiene.  She  was  warned  that  in  the  later 
months  of  pregnancy  labor  might  come  on  rapidly, 
and  as  pregnancy  progressed  and  elimination  began 
to  decrease,  her  urine  was  examined  daily.  At  about 
eight  months,  she  suddenly  expelled  a  living  child 
weighing  five  pounds  fourteen  ounces.  This  child 
survives  in  excellent  condition  and  is  still  nursed  by 
its  mother.  IJoth  have  made  an  excellent  recovery. 
The  placenta  in  this  case  was  highly  degenerated,  a 
large  portion  being  filled  with  white  infarcts.  In  this 
case,  the  fact  that  the  husband  is  a  physician  and  that 
she  w-as  so  closely  watched  made  the  continuance  of 
pregnancy  possible.  Every  preparation  was  made  to 
empty  the  uterus  should  the  patient  fail  at  any  time 
during  the  pregnancy.  In  view  of  the  fact  that  she 
had  taken  most  careful  precautions  regarding  diet  and 
in  other  ways  during  previous  pregnancies  which  had 
resulted  disastrously,  the  success  of  the  last  pregnancy 
may  be  thought  to  be  owing  not  only  to  general  pre- 
cautions but  to  the  use  of  calomel  under  the  observa- 
tion of  her  husband,  at  intervals  during  the  later 
months. 

While  the  descent  of  the  foetus  into  the  pelvic  brim 
is  a  spontaneous  process,  it  may  be  aided  by  the  vol- 
untary acts  of  the  mother.  Such  exercise  as  causes 
the  muscles  of  the  lower  extremities  and  of  the  ab- 
dominal region  to  contract  while  the  patient  is  erect 
or  bending  forward  is  most  efficient  in  furthering  the 
descent  of  the  fatus.  To  utilize  the  muscles  of  the 
upper  portion  of  the  body,  the  patient  must  contract 
them  while  in  the  kneeling  or  squatting  posture. 
Scrubbing  a  floor  or  stairs  while  kneeling  is  most 
efficient.  Such  exercise,  however,  is  not  available 
among  those  well  to  do.  Walking  is  also  useful  and 
is  the  most  available  exercise  for  all  classes  of  pa- 
tients. 

The  arrangement  of  the  patient's  clothing  is  not 
without  influence  in  furthering  or  hindering  the  ac- 
commodation of  the  fcetus.  It  is  possible  by  extreme 
compression  of  the  abdomen  to  force  the  child  down 
upon  the  pelvic  floor,  as  seen  in  cases  of  illegitimate 
pregnancy,  in  which  the  mother  laces  tightly  to  hide  her 
condition.  Long-continued  compression,  however,  so 
weakens  the  abdominal  muscles  that  accommodation 
is  imperfectly  secured  in  spite  of  the  downward  press- 
ure exerted.  To  bring  about  the  desired  result,  the 
patient  should  be  advised  to  remove  all  constriction 


from  the  abdomen,  to  allow  the  uterus  to  assume  as 
nearly  as  possible  its  natural  situation.  The  bowels 
should  be  kept  open  and  the  patient  urged  to  take  ex- 
ercise. Should  the  abdomen  be  pendulous  and  the 
uterine  wall  stretched,  it  may  be  necessary  to  apply  a 
well-fitting  abdominal  supporter  or  bandage. 

The  presence  or  absence  of  accommodation  is  to  be 
ascertained  by  palpation  and  the  comparative  test  of 
fitting  the  child's  head  into  the  pelvic  brim,  if  the 
head  has  entered  the  brim,  this  will  be  detected  by 
grasping  the  head  between  the  thumb  and  fingers  of 
one  hand  placed  above  the  pubes  or  by  grasping  the 
head  with  the  two  hands  pressing  deeply  into  the  tis- 
sues parallel  to  Poupart's  ligaments  upon  each  side. 
A  vaginal  examination  will  confirm  the  diagnosis,  and 
inform  us  of  the  degree  of  descent  present.  Attention 
must  be  called  to  the  fact  that  the  child's  head  may 
lodge  at  the  brim  of  the  pelvis,  and  strong  lateral  flex- 
ion taking  place,  may  force  down  one  of  the  parietal 
bones,  giving  a  very  deceptive  impression  to  the  finger 
of  the  examiner.  Mistaking  the  parietal  eminence  for 
the  vertex,  he  may  imagine  that  descent  has  begun 
when  the  head  has  not  entered  the  pelvic  brim.  In 
cases  in  which  the  induction  of  labor  must  be  accepted 
or  rejected,  if  there  be  difiiculty  in  making  an  examin- 
ation, an  anaesthetic  should  be  employed.  In  patients 
who  take  ether  badly,  chloroform  may  be  used  with 
great  comfort  to  the  patient  and  convenience  to  the 
physician.  With  anesthesia,  the  physician  can  make 
a  bimanual  examination  of  the  position  of  the  head, 
fitting  it  into  the  pelvis  with  one  hand  while  the  fin- 
gers of  the  other  study  its  position  and  relation  to  the 
pelvic  brim.  It  must  not  be  forgotten  that  success  in 
such  an  examination  requires  that  the  bladder  be 
empty,  and  that  it  is  well  to  catheterize  a  patient  who 
is  under  an  anaesthetic,  because  the  nervous  apprehen- 
sion of  anesthesia  often  results  in  a  free,  sudden 
secretion  of  urine,  thus  distending  the  bladder  with 
but  little  warning.  Aseptic  precautions  should  be 
observed  in  this  as  in  all  other  manipulations  during 
pregnancy. 

For  disproportion  and  disease  threatening  life,  the 
induction  of  labor  is  clearly  indicated. 

I  can  allude  but  briefly  to  the  most  recent  papers 
upon  the  induction  of  labor  and  its  results.  Hey- 
mann'  reports  one  hundred  and  seven  cases  of  in- 
duced labor.  For  disproportion  he  chose  the  thirty- 
third  or  thirty-fifth  week  of  gestation;  64.3  per  cent, 
of  the  children  survived.  The  shortest  antero-poste- 
rior  diameter  of  the  pelvic  brim  in  his  cases  was  7 
cm.  He  could  trace  no  mortality  among  the  mothers 
which  he  could  fairly  assign  to  the  induction  of  labor. 
He  failed  in  some  cases  to  rescue  the  mother  from  a 
dangerous  condition  by  induced  labor.  Aside  from 
disproportion,  he  induced  labor  most  frequently  for 
threatened  eclampsia,  lesions  of  the  heart,  and  tuber- 
culosis. His  method  was  that  of  Krause :  the  intro- 
duction of  an  aseptic  bougie  to  excite  uterine  con- 
tractions. In  Schauta's  "Festschrift"'  Skorscheban 
reports  forty-four  cases  of  induced  labor,  eleven  of  them 
for  contracted  pelvis.  He  chose  the  thirty-fourth  to  the 
thirty-eighth  week  and  secured  91.7  per  cent,  of  living 
children.  There  was  a  large  mortality  among  these 
children  during  the  first  year  of  life.  The  mothers 
had  no  mortality  traceable  to  the  operation.  In  thirty- 
three  patients  he  induced  labor  three  times  for  osteo- 
malacia, in  fourteen  for  lesions  of  the  heart,  in  seven 
for  nephritis,  in  three  for  pernicious  nausea,  in  five  (or 
tuberculosis,  and  in  one  for  paratyphlitic  abscess. 
The  mortality  was  six  per  cent,  among  the  mothers; 
79.4  per  cent,  of  the  children  were  born  living.  The 
success  of  induced  labor  is  emphasized  by  Grusdew's 

'  .\rchiv  fUr  Gynakologie,  Band  59,   Heft  2,  1S99. 
^  Monatsschrift  fur  Gieburtshulfe  und  Gynakologie,   Band  11, 
Heft  I,  IQOO. 


6o8 


MEDICAL    RECORD. 


[October  20,  1900 


report.'  He  teiminated  pregnancy  in  this  way  nine 
times  in  one  patient.  A  new  method  of  inducing 
labor  is  advocated  by  Spinelli."  He  carries  a  strand 
of  gauze  soaked  in  ichthyol  and  glycerin  between  the 
membranes  and  tlie  wall  of  the  uterus.  .\  plea  for  the 
revival  of  Kiwisch's  method  of  inducing  labor  by 
vaginal  douches  is  made  by  Sanvey.^ 

Disorders  of  the  blood  during  pregnancy  become 
most  pronounced  in  the  later  months  and  demand  rec- 
ognition and  treatment.  An  examination  of  the  blood 
will  reveal  the  nature  of  the  disease  and  give  us  valu- 
able information  as  to  the  severity  of  the  process.  If 
leucocytosis  is  well  marked,  we  may  suspect  some 
chronic  inllaromatory  process  with  the  development  of 
a  focus  in  the  pelvis,  which  may  occasion  septic  infec- 
tion after  confinement.  If  the  patient  is  highly 
ancemic  and  the  corpuscles  are  much  disintegrated  the 
danger  of  hemorrhage  during  and  after  labor  will  be 
considerable.  In  the  treatment  of  these  conditions, 
the  action  of  the  intestine  must  be  stimulated  by  gen- 
tle but  thorough  purgation,  and  arsenic,  iron,  and 
bitter  tonics  employed  liberally.  The  abundant  use 
of  milk  is  especially  valuable  with  these  patients. 

One  of  the  causes  of  ansemia  in  pregnancy  is  syphilis, 
and  search  must  be  made  for  this  disorder  in  all 
highly  anamic  patients.  The  treatment  of  syphilis 
during  pregnancy  must  be  not  only  constitutional  but 
local,  and  thorough  disinfection  with  green  soap, 
mercurial  solutions,  and  lysol  or  carbolic  acid  is  de- 
manded. The  danger  of  septic  infection  following 
labor  in  syphilitic  women  having  an  active  lesion  in 
the  vagina  or  cervix  is  so  great  that  heroic  measures 
may  be  justified  during  pregnancy.  The  use  of  strong 
antiseptic  mixtures,  such  as  carbolic  acid  and  iodine 
upon  these  lesions,  or  even  the  application  of  the  cau- 
tery may  be  demanded. 

In  the  later  months  of  pregnancy,  infection  by  gon- 
orrhoea must  receive  attention.  The  free  use  of 
douches  of  tincture  of  green  soap  and  water,  followed 
by  bichloride  injections,  gives  good  results.  The 
region  of  the  urethra  and  meatus  must  be  thoroughly 
cleansed  and  disinfected  by  suitable  measures. 

Cancer  in  the  later  months  of  pregnancy  may  in- 
crease with  distressing  rapidity,  causing  hemorrhage 
and  threatening  the  life  of  the  patient.  If  the  cervix 
be  extensively  diseased,  it  is  better  to  extract  the 
child  by  Cassarean  operation,  removing  the  entire 
womb. 

The  possibility  of  autogenetic  infection  is  of  great 
interest  in  connection  with  the  responsibility  of  the 
physician  to  prevent  sepsis  by  the  disinfection  of  the 
{jatient  before  labor.  At  the  recent  Paris  Congress, 
Doleris,  Menge  and  Kronig,  and  Pestalozza  read 
papers  upon  this  subject,  distinctly  reiterating  the  be- 
lief whicli  has  been  held  by  many,  that  previous  infec- 
tions may  leave  a  patient  during  her  pregnancy  with 
infectious  germs  within  the  birth  canal.  \Miile  in 
perfectly  healthy  women  the  birth  canal  is  aseptic  and 
its  secretion  antiseptic,  if  this  canal  has  been  invaded 
by  gonorrhoea,  syphilis,  cancer,  or  other  mixed  infec- 
tion, in  pregnancy  subsequent  to  this  infection  the 
patient  must  be  considered  as  capable  of  autogenetic 
sepsis.  It  is  the  duty  of  the  physician  in  the  later 
months  of  pregnancy  to  know  whether  his  patient  has 
a  vaginal  discharge  indicative  of  infection.  If  possi- 
ble, a  bacteriological  examination  of  suspicious  dis- 
charges should  be  made,  ard  such  disinfection  prac- 
tised as  the  results  of  the  examination  indicate. 
Certainly  no  obstetrician  could  be  held  entirely  re- 
sponsible for  puerperal  septic  infection  in  the  case  of 
a  patient  who  at  the  time  of  labor  was  known  to  be 
suffering  from  a  pre-existing  infection.     So  difficult  is 

'  Ccntralblatt  fUr  Gynakologic.  No.  17,  1900. 

'Arch.  Ital.  diGin.,  1S9S,  December  31st. 

'  Archiv  fUr  Gynakologic,  Band  60,  Heft  3,  1900. 


it  to  thoroughly  disinfect  the  birth  canal  that  our 
efforts  to  do  so  are  not  always  attended  by  success. 
That  this  effort  must  be  made  is  evident,  but  we  must 
also  remember  in  such  cases  so  to  conduct  labor  as  to 
give  the  least  opportunity  for  infection,  and  we  must 
recognize  the  danger  of  infecting  others  from  such  a 
case. 

During  the  later  weeks  of  pregnancy  the  drawing 
out  of  the  nipples,  the  cleansing  of  their  surfaces,  and 
the  healing  of  cracks  and  fissures  in  the  epithelia 
should  receive  attention.  Sterile  cocoa  butter  or  olive 
oil,  subnitrate  of  bismuth  and  castor  oil,  and  a  borated 
lanolin  or  oxide-of-zinc  ointment  are  all  useful. 
Congenital  fissures  of  the  nipple  expose  the  patient  to 
added  danger,  because  the  epithelium  is  often  thinner 
than  usual  upon  these  surfaces. 

Abnormal  conditions  of  the  fcetus  may  often  be 
diagnosticated  during  the  later  weeks  of  pregnancy 
and  demand  attention.  The  coiling  of  the  cord  about 
the  child's  neck  may  be  recognized  by  the  murmur 
which  accompanies  it,  and  w^arns  the  obstetrician  not 
to  permit  the  labor  to  continue  indefinitely  lest  press- 
ure upon  the  cord  and  asphyxia  should  result.  Ab- 
normal presentations  may  often  be  corrected  in  the 
very  first  stage  of  labor  and  tlireatened  danger  avoided. 
Polyhydramnios  may  require  the  rupture  of  the  mem- 
branes at  the  later  portion  of  the  first  stage,  with  com- 
pression of  the  abdomen  and  uterus  in  the  interests  of 
mother  and  child.  Rapidly  increasing  polyhydram- 
nios calls  for  the  interruption  of  pregnancy,  and  the 
patient  must  be  warned  that  sudden  rupture  of  the 
membranes  may  occur  at  any  time. 

During  the  later  weeks  of  pregnancy  occur  those 
hemorrhages  from  partial  separation  of  the  placenta 
which  are  so  dangerous  to  mother  and  child.  In 
cases  in  which  direct  violence  is  present  as  a  ca.use, 
the  accident  is  sufficient  to  warn  the  obstetrician.  An 
abnormal  position  of  the  placenta  can  often  be  detected 
by  auscultation  and  palpation,  and  thus  the  ])hysician 
can  be  warned  of  the  danger  of  hemorrhage  at  the  very 
beginning  of  labor.  The  presence  of  a  serious  heart 
lesion  in  the  patient,  of  advanced  kidney  disease,  and 
of  any  condition  interfering  seriously  with  the  circu- 
lation of  the  blood  through  the  abdominal  viscera, 
predisposes  to  hemorrhage  in  the  later  nionthsof  preg- 
nancy. The  detection  of  this  condition  must  put  the 
obstetrician  upon  his  guard. 

By  placenta  previa  we  understand  such  an  attach- 
ment of  the  placenta  that  it  is  separated  from  the 
uterus  when  dilatation  of  the  womb  begins.  If  the 
placenta  be  as  low  in  the  womb  as  the  lower  uterine 
segment,  it  is,  properly  speaking,  a  placenta  pravia. 
It  is  not  infrequently  possible  to  diagnosticate  such 
an  attachment  if  the  placenta  be  upon  the  anterior 
wall  of  the  uterus.  The  recent  papers  of  Ponfick  '  and 
Fraenkel '  describe  recent  investigations  into  the  anat- 
omy of  placenta  previa  which  illustrate  the  point  in 
question.  In  the  treatment  of  this  condition  the  diag- 
nosis of  central  placenta  praevia  at  any  time  during 
pregnancy  must  be  followed  by  the  immediate  termi- 
nation of  the  pregnancy.  This  may  be  done  by  the 
gauze  tampon  or  the  elastic  bag  as  recommended  by 
Von  Hoist'  in  a  recent  paper.  If  the  patient  be  near 
term  and  the  child  viable,  if  the  conditions  for  opera- 
tion are  favorable,  some  urge  delivery  by  Ca-sarean 
section.  I'.xperience  in  this  application  of  the  Ca.'sar- 
ean  operation  is  not  yet  sufficient  to  warrant  a  positive 
recommendation.  Tlie  treatment  of  placenta  prsevia 
by  rapid  dilatation  and  version  is  not  without  danger 
as  illustrated  by  Schutze's  case,*  in  which  rupture  of 
the  uterus  followed  delivery  in   placenta  pravia  by 

'  Archiv  fUr  Gynakologic,  Band  60,  Heft  i.  1900. 
'//'/i/..  Band  59,  Ilcft  3,  1S99. 
'Ccntralblatt  flir  Gynakologic,  No.  46,  1899. 
*//>ui..  No.  19,  1898. 


October  20,  1900] 


MEDICAL    RECORD. 


609 


rapid  dilatation  and  version.  The  use  of  elastic  bags 
may  lead  to  accident  as  in  Jardine's  case.'  In  in- 
ducing labor  for  contracted  pelvis  and  placenta  praevia, 
a  I)e  Ribes  bag  was  introduced  as  a  dilator.  The 
bag  burst  and  the  fluid  which  it  contained  rapidly 
separated  the  placenta,  causing  sudden  and  severe 
hemorrhage. 

The  later  weeks  of  pregnancy  give  opportunity  for 
a  most  useful  study  of  the  pregnant  patient,  by  which 
the  possibilities  for  spontaneous  labor  may  be  ascer- 
tained, abnormalities  detected,  complications  foreseen, 
and  such  measures  taken  as  to  conduct  the  woman 
and  her  cliild  safely  through  the  perils  of  parturition. 
A  physician  loses  a  great  opportunity  not  only  to  en- 
hance the  welfare  of  his  patient,  but  to  increase  his 
own  knowledge  and  skill  if  he  neglects  this  period  of 
gestation. 


SOME     APPLICATIONS     OF     STATIC     ELEC- 
TRICrrV    IN    DERMATOLOGV.' 

By    henry    G.    PIFKARD,    M.D.  ,    LL.D.. 

NEW    YOKK, 
PROFESSOR    (E.MER1TL-S)    OF    DERilATOLOGV,    NEW    YORK    UNIVERSITY. 

Static  electricity  as  a  therapeutic  aid  was  first  em- 
ployed in  America  by  Benjamin  Franklin,  about  one 
hundred  and  fifty  years  ago.  He  placed  patients  on 
an  insulated  stool,  charged  them  from  a  simple  fric- 
tional  machine,  and  drew  sparks  from  various  parts  of 
the  body.  He  also  charged  large  Leyden  jars,  and 
discharged  them  through  the  patient.  With  this  tech- 
nic  he  benetited  temporarily  or  permanently  a  few 
cases  of  paralysis.  Others,  both  in  America  and 
abroad,  employed  static  electricity  to  a  limited  degree, 
extending  somewhat  its  range  of  application. 

The  voltaic  cell,  however,  came  into  notice  as  a 
therapeutic  agent  and  gained  many  adherents,  in  con- 
sequence of  the  simplicity  of  its  operation,  and  static 
electricity  was  relegated  to  the  background.  The 
earlier  types  of  cell — zinc-platinum  (Grove)  and  zinc- 
carbon  (Bunsen),  both  employing  porous  cups  and 
strong  acids — were  inconvenient,  insomuch  as  it  was 
necessary  to  dismantle  and  clean  them  immediately 
after  use.  The  Smee  (zinc-platinized  silver)  and  the 
Grenet  (zinc-carlron),  each  requiring  but  a  single 
fluid,  rapidly  displaced  the  Grove  and  Bunsen  types, 
and  shared  the  popularity  accorded  the  Daniel  cell  and 
its  modifications.  An  efficient  apparatus,  however, 
adapted  to  general  use,  required  a  battery  of  from 
twenty  to  forty  cells,  capable  of  generating  a  current 
of  from  twenty  to  eighty  volts,  according  to  the  type 
of  cell  employed.  The  current  from  such  a  battery 
flows  continuously  in  one  direction. 

The  studies  of  Faraday  later  led  to  the  introduction 
of  a  new  type  of  electrical  apparatus  which  is  fre- 
quently called  after  his  name.  This  consisted  essen- 
tially of  one  or  more  voltaic  cells,  a  soft  iron  core  and 
hammer,  and  two  concentric  coils  of  copper  wire,  in- 
sulated from  each  other;  the  outer  coil  having  a 
longer  and  finer  wire  than  the  inner.  The  circuit 
from  the  cells  traversed  the  inner  coil,  and  being 
broken  by  the  interrupter,  generated  or  induced  a  cur- 
rent of  higher  voltage  in  the  outer  coil.  Instead  of 
using  voltaic  cells  to  generate  the  primary  current, 
the  constant  direct  current  from  a  dynamo  may  be 
conveniently  emplo3ed  as  I  have  formerly  shown  (AVji' 
York  Mtilical Jiiunial,  July  11,  1S91).  Instead  of  the 
magnetic  interrupter,  the  initial  current  may  be  broken 
by  some  mechanical  device,  as  a  toothed  w  heel  revolved 
at  a  rapid  rate  by  an  electro-motor.  If  Leyden  jars  or 
preferably  flat  condensers  be  added  to  the  installation 

'  Glasgow  Medical  Journal,  January.  1S98. 
'  Read  at  a  meeting  of  the  New  York   Dermatological  Society, 
September  25,  igoo. 


and  properly  connected  up  as  in  the  Ruhmkorff,  a  cur- 
rent of  still  higher  tension  is  obtained.  If  again,  in- 
stead of  the  apparatus  being  actuated  as  above,  the 
initial  current  be  taken  from  a  dynamo  giving  an  alter- 
nating current,  the  magnet,  and  hammer,  and  the 
toothed  wheel  may  be  dispensed  with,  and  the  appara- 
tus be  both  simplified  and  rendered  more  energetic. 
Some  ten  years  ago  Tesla  developed  this  phase  to  a 
higher  degree  than  any  of  his  predecessors.  In  other 
words,  he  produced  an  apparatus  that  yielded  a  current 
characterized  by  an  exceedingly  high  frequency  of  alter- 
nation, and  of  a  voltage  or  tension  that  was  a  surprise 
to  the  world.  Concerning  the  current  he  wrote  as 
follows:  "We  operate  a  coil  either  from  a  specially 
constructed  alternator  capable  of  giving  many  thou- 
sands of  reversals  of  current  per  second;  or  by  dis- 
ruptively  discharging  a  condenser  through  the  primary, 
we  set  up  a  vibration  in  the  secondary  circuit  of  a 
frequency  of  many  hundred  thousand  or  millions  per 
second,  if  we  so  desire;  and  in  using  either  of  these 
means  we  enter  a  field  as  yet  unexplored."  ' 

This  field  has  now  been  quite  thoroughly  explored 
from  a  physiological  and  therapeutic  standpoint  by 
d'Arsonval,  Apostoli,  and  others.  Briefly  the  effects  of 
this  H.  F.  (high  frequency)  and  H.  P.  (high  poten- 
tial) current  on  the  human  system  are  an  increased 
utilization  of  oxygen,  an  increased  elimination  of  car- 
bonic acid,  and  an  increase  in  the  general  metabo- 
lism. In  other  words,  it  acts  as  a  tonic,  or,  as  I  would 
prefer  to  term  it,  an  energizer.  This  statement  has 
been  borne  out  by  both  clinical  experience  and  scien- 
tific experiment.  The  local  effects  of  this  current  I 
shall  not  allude  to  here,  as  those  who  are  sufficiently 
interested  can  delve  into  the  ample  literature  of  the 
subject. 

The  distinguishing  features  of  the  Tesla  current  are 
the  extreme  rapidity  of  the  reversals  or  oscillations  of 
the  current,  so  great  indeed  as  to  defy  measurement 
and  almost  to  defy  computation,  and  accompanying 
the  high  frequency  the  potential  is  raised  to  a  point 
and  that  seems  incredible.  This  type  of  current, 
however,  was  already  known  to  the  world  through  the 
labors  of  Dr.  William  J.  Morton,  who  first  drew  atten- 
tion to  the  "static  induced"  current  in  various  affec- 
tions, and  thus  established  a  new  era  in  electro-static 
therapeutics.^ 

Some  have  endeavored  to  detract  from  the  credit  due 
Morton  in  respect  to  the  use  of  this  current,  claiming 
that  generations  ago  its  existence  had  been  demon- 
strated. Be  that  as  it  may,  it  was  certainly  Morton 
who  first  used  it  systematically  in  the  treatment  of 
disease,  and  made  public  the  fruits  of  his  experience. 
Thousands  of  people  had  seen  steam  issuing  from  the 
spout  of  the  tea-kettle,  but  the  world  waited  for  a 
Watts  to  harness  this  powerful  agency  and  adapt  it  to 
so  many  useful  purposes. 

The  physiological  effects  of  the  ordinary  "  faradic 
machine"  consist  in  little  more  than  localized  muscu- 
lar contractions,  accompanied  with  more  or  less  pain, 
but  so  far  as  I  have  been  able  to  obsene,  the  current 
possesses  but  little  constitutional  influence.'  With 
the  static  induced  current,  on  the  other  hand,  one  may 
obtain  simultaneous  tetanization  of  a  large  number  of 
muscles  with  little  or  no  pain,  and  constitutional 
effects  similar  to  those  obtained  w  ith  the  H.  F.  and 
H.  P.  currents  derived  from  the  D'Arsonval  appar- 
atus. 

Static  electricity  and  high-frequency  currents  have 
for  some  time  been  successfully  employed  in  the  treat- 
ment of  certain  cutaneous  affections,  more  perhaps  in 

'"Experiments  with  Alternating  Currents  of  High  Potential 
and  High  Frequency."  New  York,  1892. 

'  Medical  Record,  .Vpril  2,  1S81. 

'  I  am  not  unmindful  of  the  claims  made  in. behalf  of  Beard's 
"  general  faradization." 


6io 


MEDICAL    RECORD. 


[October  20,  1900 


Europe  than  in  America;  and  I  am  enabled  by  per- 
sonal experience  to  corroborate  in  great  measure  the 
claims  that  have  been  made  in  their  behalf. 

Desiring  to  use  in  dermatologic  practice  high-fre- 
quency currents  of  even  higher  potential  than  those  of 
the  static  induced  current,  my  thoughts  turned  to  the 
use  of  the  Tesla  oscillator,  which  would  involve  the 
installation  of  an  alternating  dynamo,  condensers,  and 
an  up-step  transformer.  Tesla,  however,  states,  as  al- 
ready quoted,  that  his  H.  F.  and  H.  P.  currents  may 
be  obtained  by  "  disruptively  discharging  a  condenser 
through  the  primary  of  a  coil."  All  that  would  be 
necessary,  therefore,  would  be  to  connect  the  coarse 
inner  wire  of  a  suitable  coil  in  series  with  the  static 
induced  current. 

^lentioning  my  requirements  to  Dr.  Harry  F.  Waite, 
of  this  city,  he  constructed  an  up-step  transformer 
that  has  yielded  the  most  satisfactory  results.  The 
transformer  itself  consists  of  an  inner  coarse  wire, 
the  terminals  of  which  are  connected  to  the  outer 
coatings  of  the  Leyden  jars  of  a  large  static  machine. 
A  long  coil  of  fine  wire  surrounds  the  inner  coil, 
and  the  whole  is  very  thoroughly  insulated  by  a 
modification  of  the  Tesla  insulation.  The  outer 
case  measures  seven  by  seven  by  twelve  and  one-half 
inches.  From  one  side  project  the  terminals  of  the 
primary,  and  from  each  end  the  terminals  of  the  sec- 
ondary coil.  The  Leyden  jars  are  twelve  inches  in 
height  and  four  in  diameter,  and  the  inner  and  outer 
coatings  extend  to  within  two  inches  of  the  top.  If 
the  static  machine  be  now  brought  into  action,  with 
the  sliding  poles  separated  so  as  to  give  a  spark  gap 
of  two  or  three  inches,  electric  streams  issue  from  the 
terminals  of  the  secondary  coil.  If  the  hand  be 
brought  to  within  about  two  inches  of  either  terminal, 
a  spark  appears  to  leap  forth  and  pierce  the  skin. 
The  impact,  however,  is  absolutely  painless,  in  fact 
barely  perceptible  to  the  senses,  in  this  respect  quite 
unlike  other  static  sparks.  If  fifty  or  a  hundred  of 
these  sparks  be  directed  to  one  point,  the  skin  becomes 
slightly  reddened,  and  the  blush  remains  for  several 
hours  or  even  a  day  or  two.  The  same  phenomena 
appear  whichever  terminal  is  approached.  If  one 
terminal  is  grasped  firmly  with  the  hand  there  are  ab- 
solutely no  sensation  and  no  muscular  contraction,  and 
the  same  is  true  even  if  both  poles  be  grasped,  one  in 
either  hand.  It  would  seem  almost  beyond  belief  that 
an  alternating  current,  with  its  millions  of  oscillations 
per  second  and  its  immeasurable  voltage,  also  (by 
calculation)  in  the  millions,  should  thus  traverse  the 
body  without  affecting  it  to  a  degree  appreciable  to 
the  senses.  Yet  such  is  the  case.  Whether  this  cur- 
rent produces  any  physiological,  constitutional,  or 
metabolic  effects,  I  have  not  determined,  as  my  obser- 
vations thus  far  have  been  confined  to  a  study  of  its 
local  effects  on  cutaneous  lesions. 

The  most  convenient  way  of  applying  the  current  is 
by  means  of  special  electrodes.  One  of  these  is  a 
metallic  point  with  insulated  handle,  and  the  other  a 
closed  glass  tuiae  about  five  inches  long  and  three- 
fourths  of  an  inch  in  diameter,  with  an  inner  coating 
of  tin  foil.  This  also  has  a  long,  well-insulated 
handle.  The  electrodes  should  be  connected  to  the 
terminal  of  the  secondary  coil  by  means  of  a  well-in- 
sulated cord,  and  when  in  use  kept  free  from  any  pos- 
sible conductor,  as  otherwise  a  portion  of  the  current 
will  be  dissipated.  From  the  character  of  the  current 
it  may  be  conveniently  termed  a  high-tension  oscil- 
lating current,  or  briefly  H.  T.  O.  As  the  term  "sec- 
ondary,'' however,  has  been  applied  to  the  static  in- 
duced current,  the  one  here  described  may,  with  equal 
propriety,  be  termed  tertiary. 

My  use  of  this  tertiary  current  has  been  chiefly  in 
connection  with  chronic  infiltrated  eczema,  rosacea, 
acne,  localized  pruritus,  pityriasis  capitis,  the  localized 


so-called  "eczema  seborrhoicum "  and  seborrhcea 
oleosum,  in  all  of  which  resolution  of  the  lesions  has 
been  accomplished  more  rapidly  than  by  any  means 
previously  at  my  command. 

Addendum.  It  has  already  been  stated  that  if  the 
terminals  of  the  secondary  coil  of  the  transformer  be 
grasped,  one  in  either  hand,  there  is  absolutely  no 
sensation  or  apparent  muscular  action.  If,  however, 
one  hand  be  removed,  say  half  an  inch  from  one  of 
the  terminals,  muscular  contractions  immediately  en- 
sue. This  led  me  to  intercalate  Ranney's  device  for 
regulating  the  spark  gap,  and  by  means  of  it,  general- 
ized contractions  can  be  controlled  with  the  utmost 
nicety;  ranging  from  those  barely  perceptible  up  to 
those  that  are  hardly  bearable.  If  asked  concerning 
this  current,  "  Cui  bono  1 "  my  only  present  reply  must 
be  "  Qiiien  sal>c." 

As  a  further  experiment  I  placed  the  Ranney  regu- 
lator in  series  with  the  primary  coil  of  the  transformer, 
and  obtained  a  current  apparently  more  energetic  than 
when  it  was  in  series  with  the  secondary,  but  both 
sparks  and  muscular  contractions  were  more  painful, 
and  the  cutaneous  reaction  was  greater.  It  reminds 
me,  in  fact,  of  the  effects  obtained  with  a  high-fre- 
quency machine  in  which  an  alternating  dynamo  is 
the  source  of  energy;  in  other  words,  of  the  Tesla  cur- 
rent. I  have  not  as  yet  made  any  therapeutic  use  of 
this  modification  of  the  current,  but  would  not  be  sur- 
prised if  it  should  prove  useful  in  some  of  the  pro- 
founder  lesions  of  the  skin. 

256  West  Fifty-seventh  Street. 


OBSERVATIONS    ON    THE  SURGERY  OF 
THE   GALL   TRACTS.' 

By   WILLIAM   JONES,    M.D., 

PORTLAND,    OREGON, 

PROFESSOR    OF     CLINICAL    SURGERY,     MEDICAL     DEPARTMENT,    t'NIVERSITY     OF 
OREGON  ;  SURGEON   TO   ST.    VINCENT'S    HOSPITAL. 

The  surgery  of  the  gall  tracts  may  be  said  to  have 
begun  about  twenty  years  ago.  In  1879,  Lawson  Tait 
did  his  first  cholecystostomy  for  removal  of  gall 
stones.  This  marks  the  opening  of  this  field  to  the 
operations  of  the  surgeon.  Its  development  has  been 
slow  when  compared  with  other  departments  of  ab- 
dominal surgery.  The  complicated  apparatus  for  stor- 
ing and  discharging  the  bile,  together  with  much  that 
was  obscure  as  to  its  properties  and  uses,  gave  rise  to 
many  complicated  problems  in  diagnosis  and  opera- 
tive procedure,  for  solution  by  the  surgeon.  These 
difficulties  have  made  progress  slow  and  hesitating. 
These  questions  have  engaged  the  attention  of  a  multi- 
tude of  workers  all  over  the  world  and  not  only  among 
surgeons.  Their  solution  has  been  contributed  to 
largely  by  the  work  of  the  physician,  the  physiologist, 
and  the  bacteriologist.  Chemistry  and  pathology 
have  lent  their  aid.  The  complete  solution  of  any  of 
them  cannot  yet  be  said  to  be  an  accomplished  fact. 
A  very  great  deal  of  work  still  remains  to  be  done. 
The  subject  still  remains  a  live  one.  As  its  investi- 
gation has  been  pushed  along  by  a  multitude  of 
isolated  workers,  so  it  must  be  carried  to  something 
like  finality  in  the  same  way. 

Each  year  gives  an  added  importance  to  the  biliary 
apparatus  as  a  factor  in  disease,  as  we  understand  it. 
Next  to  the  appendix  and, the  uterine  appendages,  it  is 
the  avenue  by  which  serious  disease  most  often  enters 
tlie  abdominal  cavity. 

Disease  of  this  part  mimics  many  other  troubles. 
Many  dyspeptic  symptoms,  nausea,  vomiting,  gastric 
pain,  and  discomfort  are  often  traceable  to  this  cause. 

'  Read  before  the  Oregon  State  Medical  Society,  June  26,  lyoo. 


October  20,  1900] 


MEDICAL    RECORD. 


611 


Chills  and  fever  simulating  malaria  are  produced  by 
infection  here.  Visceral  cancer,  as  well  as  disease  of 
the  appendix  and  of  the  right  kidney,  is  imitated. 

In  arriving  at  a  diagnosis  in  cases  of  digestive  dis- 
orders, in  abdominal  cases  having  localizing  symp- 
toms in  the  upper  half  of  the  abdomen,  and  in  fevers 
of  obscure  origin  and  causation,  disease  of  the  biliary 
tract  needs  to  be  considered  and  excluded. 

The  clinical  picture  in  disease  of  the  gall  tracts  is 
very  variable.  The  symptoms  are  numerous  and  their 
combinations  almost  infinite.  The  most  constant 
symptom  is  tenderness  on  jiressure  over  the  location 
of  the  gall  bladder.  During  the  quiescent  period  no 
symptoms  are  present.  The  gall  bladder  might  be 
filled  with  calculi,  which  would  give  no  indication  of 
their  presence  till  one  of  them  became  engaged  in  the 
duct,  and  then  there  would  be  developed  the  symptoms 
of  biliary  colic. 

As  severe  symptoms  may  be  caused  liy  the  presence 
of  a  single  stone  as  by  that  of  a  hundred.  During  an 
attack  the  pain  may  be  widely  diffused  over  the  upper 
part  of  the  abdomen  or  referred  to  the  stomach,  but 
the  point  of  maximum  sensitiveness  on  pressure  will 
be  over  the  gall  bladder.  There,  too,  will  be  the 
location  of  greatest  muscular  rigidity. 

The  attack  may  be  so  moderate,  the  pain  of  such  a 
character  and  location  as  to  be  referred  to  the  stom- 
ach, while  the  attendant  nausea  and  vomiting  seem 
to  point  to  a  gastric  rather  than  a  biliary  cause.  The 
differential  symptom  will  be  that  the  point  of  greatest 
tenderness  on  pressure  will  be  over  the  gall  bladder. 
If,  during  the  attack,  the  common  duct  should  be  ob- 
structed, jaundice  will  appear  if  the  obstruction  con- 
tinues sufficiently  long.  If  the  obstruction  lasts  but  a 
short  time  this  symptom  will  be  absent  or  so  slight  as 
not  to  be  certainly  recognized.  Then  another  symp- 
tom is  available.  If  the  urine  secreted  during  the 
attack  or  immediately  after  it  be  examined  it  will  give 
the  reaction  for  bile.  This  is  an  exceedingly  valuable 
means.  It  can  be  used  to  advantage  in  certain  cases 
of  suspected  biliary  attacks,  which  from  any  reason 
cannot  be  personally  observed  by  the  surgeon.  It 
■will  occasionally  convert  a  well-grounded  suspicion 
into  a  diagnostic  certainty. 

Not  to  be  too  curious  as  to  first  causes,  I  would  say 
that  gall  stones  are  the  cause  almost  invariably  of  the 
troubles  we  are  now  considering.  Of  course  there 
must  be  a  cause  for  the  stones. 

In  operating  on  cases  that  have  a  history  extending 
over  a  long  period  of  time,  quite  often  calculi  are  not 
found.  Yet  it  is  almost  certain  that  they  have  been 
present,  and  by  their  presence  and  the  traumatisms 
they  have  inflicted  have  worked  changes  in  the  biliary 
tracts  attended  by  the  most  serious  consequences. 
Stricture  of  the  ducts  causing  permanent  jaundice;  or 
obstruction  to  the  proper  drainage  of  the  gall  bladder 
giving  rise  to  overdistention,  etc.;  ulceration  and 
erosion  of  the  lining  mucous  membrane,  changing  the 
character  of  its  secretion,  making  it  thick,  viscid,  and 
difficult  of  discharge,  and  affording  a  culture  medium 
for  pathogenic  bacteria,  with  the  complex  train  of  dis- 
turbances that  an  infection  of  these  complicated  pas- 
sages implies — these  are  some  of  the  consequences 
referred  to. 

In  our  operative  procedures,  it  is  not  difficult  gener- 
ally to  give  relief,  at  least  temporarily.  The  opera- 
tion of  Tait  (cholecystostomy)  will  do  this,  and  is  the 
operation  attended  by  the  least  risk.  It  will  give 
permanent  relief  in  many  cases.  In  some,  it  will  be 
followed  by  permanent  fistula,  in  which  case  the  relief 
will  be  permanent  also,  but  with  the  annoyance  of  an 
external  discharge.  The  closure  of  the  fistula  may  be 
followed  by  a  return  of  symptoms,  a  relapse,  notwith- 
standing at  the  time  of  operation  every  stone  was  re- 
moved  from   the   gall   bladder,   and    the    ducts    were 


cleared.  Other  stones  may  form,  or  permanent 
changes  in  the  bile  passages,  referred  to  before,  may 
be  present  which  will  again  cause  trouble.  I  have  at 
present  under  observation  three  patients  who  either 
have  permanent  fistulce,  or  they  suffer  relapse  when 
the  fistulae  close. 

We  are  extremely  anxious  to  give  permanent  relief, 
and  if  possible  by  a  single  operation.  This  will  be 
most  certainly  accomplished  by  permanent  drainage 
of  the  gall  bladder,  by  means  of  a  cholecystenteros- 
tomy,  after  removing  all  stones  from  the  bladder  and 
ducts.  This  is  most  easily  and  rapidly  done  by  means 
of  the  Murphy  button.  The  button  has  the  disadvan- 
tage that  not  infrequently  it  is  not  recovered.  It  is 
either  retained  or  escapes  observation  when  passed. 
In  about  half  the  cases  in  which  I  have  used  it,  it  has 
not  been  recovered.  In  none  of  these,  however,  have 
I  noticed  any  evil  consequences  from  it;  nevertheless 
its  recovery  is  always  a  source  of  satisfaction,  and  re- 
moves a  certain  anxiety  as  to  the  patient's  future. 
When  the  common  duct  is  free,  the  connection  is  best 
made,  in  my  opinion,  with  the  colon.  This  serves  the 
purpose  of  draining  the  gall  bladder,  which  is  all  that 
is  necessary,  and  with  the  least  disturbance  of  the 
natural  arrangement  of  parts  as  they  are  in  relation 
with  each  other.  When  the  common  duct  is  ob- 
structed, then  the  connection  should  be  made  with  the 
duodenum  if  the  difficulties  are  not  too  great,  other- 
wise with  the  small  intestine  high  up. 

Should  it  be  demonstrated,  as  some  assert  to  be  the 
case,  that  the  bile  is  excrementitious  material  and  has 
no  function  to  perform,  then  the  colon  will  be  the  best 
point  of  attachment  in  all  cases. 

The  ducts  can  be  palpated  throughout  their  whole 
course,  by  introducing  one  or  two  fingers  though  the 
foramen  of  Winslow.  They  can  thus  be  engaged  be- 
tween the  fingers  and  thumb,  and  any  stones  within 
them  can  be  felt. 

Judging  from  my  own  experience,  and  the  published 
reports  of  others,  patients  with  long-standing  disease 
of  the  gall  tracts  are  poor  subjects  for  surgical  opera- 
tion, and  surgical  interference  is  attended  by  consider- 
able risk.  In  such  cases  I  believe  it  to  be  wiser  to  do 
first  a  cholecystostomy,  the  simplest  operation,  and  the 
one  attended  by  the  least  risk,  leaving  more  radical 
treatment  for  another  time,  should  it  become  neces- 
sary. 

I  would  emphasize  the  following  points: 

1.  The  diagnostic  value  of  the  point  of  maximum 
tenderness  on  pressure,  which  is  over  the  gall  bladder 
at  or  near  the  costal  margin  of  the  ninth  rib.  'J'his 
point  in  disease  of  the  gall  tracts  corresponds  in  im- 
portance with  McBurney's  point  in  disease  of  the  ap- 
pendix. 

2.  The  diagnostic  value  of  the  presence  of  bile  in 
the  urine  excreted  during  or  immediately  after  a  very 
brief  obstruction  of  the  common  duct. 

3.  Disease  of  the  gall  tracts  is  of  very  common  oc- 
currence, and  is  liable  to  be  mistaken  for  other  troubles 
which  it  closely  imitates. 

I  would  urge  upon  the  physician  the  importance  of 
these  troubles  and  of  their  early  recognition.  He 
should  familiarize  himself  thoroughly  with  their  symp- 
tomatology, and  train  himself  to  recognize  them  prompt- 
ly. The  time  is  not  very  remote  when  it  will  be  as 
much  a  matter  for  censure  to  fail  to  recognize  the  pres- 
ence of  disease  of  the  gall  tracts  as  it  now  is  to  over- 
look that  of  the  appendix. 


Bites. — Dr.  K.  Shimizu  recommends  the  local  ap)- 
plication  of  an  infusion  of  cassia  occidentalis  in  insect 
and  snake  bites.  He  also  praises '"  good  ripe  kaki  " 
(persimmon)  in  obstinate  vomiting  of  pregnancy  and 
in  diarrhoea. — Medical  Brief. 


6l2 


MEDICAL    RECORD. 


[October  20,  1900 


THE  SOLDIER'S   RATION  IN    THE  TROPICS 
—ITS    USE  AND  ITS   ABUSE. 

Bv   LOUIS   L.    SEAMAN,     iM.D., 

NEW    YORK, 
LATE   SURGEON    FIRST   V.   S.    V.    ENGINEERS. 

In  the  great  race  for  the  survival  of  the  fittest,  wars 
are  inevitable.  Temporary  checlcs  may  at  times  be 
brought  about  by  the  inHuences  of  civilization,  and 
peace  conferences  may  for  the  moment  gratify  the  op- 
timistic fancies  of  a  visionary  age.  15ut  the  great  truth 
remains  that  the  natural  termination  of  animal  life  is 
tragedy.  In  pre-historic  and  savage  ages,  this  applied 
to  the  human  as  well  as  the  lower  animals.  Civiliza- 
tion, in  a  measure,  temporarily  modified  this  through 
the  inHuences  of  church  and  state  and  the  conquests  of 
medicine;  to  nothing,  however,  so  much  as  to  the  sci- 
ence of  medicine,  which,  since  before  the  time  of  Hip- 
pocrates, has  been  steadily  fighting  and  conquering  the 
inost  terrible  devastating  enemies  of  humanity.  Med- 
icine has  done  far  more  than  militarism.  It  has  con- 
quered or  mitigated  plagues  and  pestilences,  which  in 
single  epidemics  have  destroyed  more  lives  than  the 
total  of  the  combined  armies  of  the  world.  In  one 
outbreak  of  cholera  in  China  thirteen  million  victims 
succumbed  to  this  disease.  History  commits  no 
greater  injustice  than  the  mention  of  a  thousand  gen- 
erals to  one  physician.  But  what  great  purpose  have 
the  conquests  of  science  attained  for  our  armies? 

Europe,  to-day,  is  one  vast  military  camp,  the  re- 
sources of  each  country  taxed  to  the  utmost  limit  to 
support  the  great  living  plants  for  human  destruction, 
the  armies  and  the  navies;  and  America  is  not  far  be- 
hind. Thousands  of  millions  of  dollars  are  annually 
expended  by  the  civilized  nations  of  the  world  in  the 
maintenance  of  great  military  schools  and  arsenals, 
for  the  education  of  men  in  the  art  of  war,  and  in  the 
manufacture  of  machines  of  human  destruction,  while 
comparatively  little  is  being  done  in  the  study  of 
those  equally  important  subjects,  preventable  diseases 
in  armies  and  the  preservation  of  the  health  of  "the 
man  behind  the  gun."  We  go  blundering  on,  expend- 
ing over  a  million  of  dollars  a  day  in  our  effort  to  de- 
stroy our  human  foes,  while  the  more  formidable 
adversary  in  the  ranks,  which  history  has  shown  to  be 
five  times  more  deadly  than  the  bullets  of  an  enemy,  is 
left  comparatively  unheeded.  Even  the  demand  for 
the  expenditure  of  a  single  million,  or  the  cost  of  run- 
ning our  army  for  less  than  a  day,  for  experimentation 
in  the  study  of  preventable  diseases,  and  in  the  solu- 
tion of  dietary  problems,  so  necessary  for  the  preser- 
vation of  the  soldiers'  health  and  energy,  would  be 
howled  down  by  the  short-sighted  representatives  of 
the  people. 

And  what  is  the  logical  result  of  such  mental  my- 
opia.' 

In  the  late  Spanish-American  war,  fourteen  men 
died  of  disease  for  every  one  that  was  killed  by  bullets. 

Every  death  from  preventable  disea.se  is  an  insult 
to  the  intelligence  of  the  age.  When  it  occurs  in  an 
army,  it  becomes  a  crime.  The  first  responsibility  of 
a  government  in  times  of  war  or  peace,  should  be  the 
proper  care  of  its  guardians.  The  state  deprives  the 
soldier  of  his  liberty,  prescribes  his  exercises,  equip- 
ment, dress,  and  diet.  It  should,  therefore,  give  him 
the  best  sanitation  and  the  best  medical  supi'rvision 
that  the  science  of  the  age  can  devise.  The  morals  of 
most  wars  are  ais/i.  From  a  moral  then,  as  well  as 
from  an  economical  standpoint,  the  state  should  guard 
the  soldier's  health,  for  nothing  is  more  costly  in  war 
than  disease,  and,  after  war,  than  the  pension  claims. 

A  personal  experience  in  two  of  the  latest  tropical 
wars,  and  a  study  of  the  statistics  of  others,  led  the 
writer  to  the  conviction  that  the  cause  most  prominent 
in  bringing  about  the  conditions  most  favorable  for 


the  development  of  preventable  disease  in  both  these 
wars  resulted  from  the  misuse  of  food.  And  that  this 
object-lesson  may  not  be  without  its  advantage  to 
other  lands  is  the  raison  d'etre  of  this  paper. 

Attributing  to  climate  the  diseases  of  the  tropics  is 
an  error  due  to  ignorance  and  custom.  The  vast  ma- 
jority of  ailments  accredited  to  climate  have  their 
origin  in  the  use  of  improper  foods,  in  over-feeding, 
or  in  the  abuse  of  stimulants. 

During  the  past  two  years,  it  has  been  my  misfor- 
tune to  see  two  great  armies,  one  in  my  own  southern 
country  in  Cuba  and  Porto  Rico,  and  one  in  the  Phil- 
ippine Islands,  largely  invalided  through  errors  in 
improperly  subsisting  the  troops,  and  through  hyper- 
alimentation. When  whole  regiments  were  suffering 
from  stomach  and  intestinal  catarrhs,  diarrhceas,  and 
kindred  ailments  (and  I  have  seen  over  seventy-five 
per  cent,  of  an  entire  command  in  this  condition  at 
one  time),  they  were  subsisted  on  a  ration  of  rich 
meats,  pork,  beans,  tomatoes,  and  other  foods,  that  ag- 
gravated the  diseases,  crowded  the  hospital  tents,  and 
left  the  men  weak  and  emaciated,  so  that  their  return 
to  health  was  a  prolonged  struggle. 

By  this  method  a  vicious  circle  was  established,  the 
diseases  grew  by  what  they  fed  upon — the  utter  unsuit- 
ableness  of  the  ration  creating  the  trouble  and  inten- 
sifying conditions  which  often  resulted  fatally,  and 
which  were  always  to  the  detriment  of  the  soldier. 
Taps,  and  the  last  volley,  were  often  the  only  reward 
many  a  poor  soldier  received  for  his  patriotism. 

From  an  extended  observation  of  the  commissary 
service  of  nearly  every  army  of  Europe,  and  those  of 
China,  Russia,  and  Japan,  I  believe  that  the  ration 
served  to  the  American  soldier  in  the  tropics  was  the 
richest,  most  expensive,  and  by  reason  of  its  richness 
the  most  unsuitable.  The  potential  energy  of  this  ra- 
tion as  represented  in  caloric  units  was  4,448;  that 
issued  to  the  British  soldier  in  a  temperate  climate  is 
but  2,800,  while  the  caloric  units  in  the  ration  of  Eng- 
lish prize-fighters,  as  given  by  Gillespie  of  Edinburgh, 
is  but  2,200.  It  is  an  old  saying  that  "  The  ration 
wins  the  battle."  As  furnished  to  the  army,  it  was  an 
excellent  winter  food,  rich  in  nutritive  and  caloric 
power  under  a  low  temperature;  but  for  a  tropical 
land,  the  excess  of  carbon  furnished  by  it  to  the  lungs, 
over  and  above  that  which  they  could  dispose  of,  im- 
posed upon  the  liver  and  kidneys  additional  duties  of 
elimination,  producing  congestions,  fermentation  and 
catarrhs,  dyspepsia  and  lithajmia,  glycosuria  and  phos- 
phaturia,  interfering  with  metabolism,  and  creating 
conditions  favorable  to  bacterial  development,  to- 
gether with  almost  the  entire  train  of  disease  which 
crowded  the  army  hospitals.  In  phosphaturia,  espe- 
cially, the  nervous  system  is  deprived  of  the  salts  nec- 
essary for  its  proper  functions,  which  deprivation  to 
the  soldier  not  infrequently  resulted  in  mental  disturb- 
ances that  in  many  instances  ended  in  suicide  or  in- 
sanity. How  little  the  climate  was  responsible  for 
these  cases  may  be  inferred  from  the  extreme  rarity  of 
sunstroke  in  the  tropics.  The  writer,  aficr  years'  ex- 
perience, has  yet  to  see  his  first  case  of  this  nature 
tl.  re,  although  he  has  numerous  friends,  En^,iish, 
German,  French,  and  American,  residing  between 
Bombay  and  Shanghai,  who  have  lived  in  those  lands 
for  periods  varying  from  twenty  to  forty  years,  and 
who  have  maintained  excellent  health  throughout  the 
entire  time,  simply  by  regulating  their  foods  and  ex- 
ercise. They  could  have  lived  equally  well  in  the 
arctic  zone  by  following  similar  precautions. 

Dr.  Ordronaux,  a  prominent  surgeon  of  the  Amer- 
ican army  in  the  war  of  the  Rebellion  ( 1 86 1-64),  said  : 
"  liy  a  proper  disposition  of  his  diet,  man  lives  as 
healthfully  under  the  equator  as  under  the  pole.  The 
East  Indian  with  his  rice  and  yams,  and  the  Esqui- 
mau with   his   seal   blubber   and    putrid   fish,  are  both 


October  20,  1900] 


MEDICAL    RECORD. 


613 


healthy  enough  in  Iheir  respective  climates,  but  let 
them  once  change  residences  without  changing  their 
diet,  and  what  would  be  the  consequences?  The  Es- 
quimau would  be  attacked  with  putrid  fever,  and  the 
West  Indian  would  die  of  inanition. 

'■  We  perceive  from  this  the  absolute  necessity  of 
modifying  all  forms  of  diet  in  such  a  way  as  to  accom- 
modate tiiem  to  the  physiological  requirements  of  the 
varying  seasons.  J''or  habit  is  not  acquirable  as 
against  the  laws  of  chemical  combination,  and  no  man 
can  become  habituated  to  doing  that  with  impunity 
which,  being  a  violation  of  the  physiological  laws  of 
his  system,  is  by  its  frequent  admonitions  of  pain  no- 
tifying him  of  the  evil  about  to  overtake  him." 

"  Habit  is  not  acquirable  against  the  laws  of  chem- 
ical combination."  The  soldier  cannot  disregard 
these  laws,  even  under  orders.  An  army  regulation 
may  provide  a  ration  which  violates  nature's  law,  but 
no  human  power  will  permit  a  soldier  to  subsist  on  it 
and  maintain  his  health. 

The  experiences  of  the  British  in  Burmah  and  the 
West  Indies,  and  the  French  in  Algeria,  forcibly  illus- 
trate this.  In  tiie  first  Burmese  war,  for  six  and  a 
half  months  the  troops  were  subsisted  on  salt  ration 
almost  exclusively,  and  forty-eight  per  cent,  of  them 
perished  within  ten  months,  principally  of  scorbutic 
dysentery,  while  in  the  reginient  of  Cameronians 
seven  hundred  out  of  nine  hundred  v.ere  invalided 
from  the  same  cause  in  two  months.  In  both  instances 
these  diseases  were  induced  by  an  almost  exclusively 
salted  diet,  which  not  only  irritated  tiie  intestines,  but 
did  not  furnish  sufficient  nutriment  to  the  system.  It 
was  observed  in  the  West  Indies,  in  the  Leeward  and 
Windward  Co.iimand,  tiiat  after  an  issue  of  salt  ration 
five  days  in  the  week,  the  mortality  was  twenty  per 
cent.  When  the  issue  was  reduced  to  two  days  per 
week  the  mortality  fell  to  two  per  cent.  An  excess  of 
fresh  meat  also  produces  intestinal  derangement. 
This  was  strikingly  shown  by  Lamaran  in  the  French 
campaign  in  Algeria,  when  the  men  ate  excessively  of 
captured  mutton,  and  rapidly  succumbed  to  intestinal 
disease.  The  same  condition  prevailed  in  the  Amer- 
ican army  during  the  Civil  War.  It  was  noticed  that 
immediately  following  a  raid  in  the  enemy's  country 
and  the  capture  of  quantities  of  live  stock,  which  was 
given  to  the  men  in  excessive  amounts,  an  epidemic  of 
intestinal  catarrh  or  dysentery  invariably  followed. 

Simple  catarrhal  affections  of  the  stomach  and  upper 
intestinal  tract,  not  resolving  rapidly,  will  lead,  under 
an  unsuitable  dietary,  to  congestion  of  the  liver,  with 
all  the  dangers  attached  to  such  a  state  in  a  climate 
where  the  natural  antiseptic  of  the  intestine  is  of  such 
paramount  importance.  The  reduction  of  quantity  in 
bile  will  lead  to  auto-intoxication  and  extension  of 
the  processes  of  inflammation,  until  the  entire  intesti- 
nal tube  may  be  involved;  and  jaundice,  duodenitis, 
enteritis,  or  colitis  is  developed,  conditions  which 
offer  an  open  door  for  the  entrance  of  micro-organisms. 

The  pathological  features  of  the  cases  on  which  I 
was  fortunate  enough  to  hold  autopsies,  whether  the 
causes  of  death  had  been  pronounced  intestinal  catarrh, 
hepatitis,  duodenitis,  typhlitis,  enteritis,  enteric  or 
typhoid  fever,  colitis,  dysentery  or  diarrhoea  associated 
with  malaria,  presented  many  similar  characteristics. 
The  liver  was  almost  invariably  congested.  The  mu- 
cous membrane  of  the  intestine  was  pale,  and  covered 
with  a  thick,  tenacious,  adherent  mucus;  the  mucosa 
was  hypertrophied,  often  deeply  congested  and  ulcer- 
ated; in  two  instances  these  ulcerations  almost  encir- 
cled the  entire  intestine.  The  toughess  of  the  opaque 
secretions  obliterated  the  intestinal  glands,  causing 
atrophy  and  thus  interfering  with  absorption  and 
metabolism.  The  solitary  follicles  stood  out  with 
prominence,  and  the  patches  of  Peyer  were  distinct, 
often  with  minute  ulcerations  on  the  surfaces,  notwith- 


standing many  of  the  cases  in  which  they  were  found 
presented  no  characteristic  typhoidal  temperatures,, 
and  during  life  failed  to  respond  to  the  Widal  reaction. 

P"rom  earliest  history,  experience  has  shown  that,  in 
time  of  war,  disease  was  a  far  more  deadly  foe  to  an  army 
than  were  the  bullets  of  an  enemy.  In  the  war  of  the 
Crimea  the  French  lost  in  killed  twenty-one  thousand, 
and  from  disease  one  hundred  thousand,  or  about  one 
from  bullets  and  wounds  to  five  from  disease.  The 
proportion  of  losses  of  the  British  from  disease  in  that 
campaign  ran  a  little  higher — six  having  died  from 
disease  for  every  fatality  from  bullets  and  wounds. 

In  the  American  war  with  Mexico  nearly  the  same 
proportions  were  maintained — five  fatalities  being 
ascribed  to  disease  for  every  one  resulting  from  bul- 
lets or  wounds.  So  too,  in  the  war  of  the  American 
Rebellion,  lasting  four  years,  the  rate  of  five  to  one 
remained  unchanged.  In  round  numbers  five  hundred 
thousand  perished  in  hospital  wards  from  the  more 
fatal  enemy  disease,  and  one  hundred  and  one  thou- 
sand fell  on  the  field  or  died  as  the  result  of  wounds. 

But  it  has  been  reserved  for  the  Spanish-American 
war  in  the  tropics  to  cause  a  blush  of  indignation  at 
the  apathy  that  permitted  preventable  diseases  to  play 
such  havoc  with  its  army.  In  a  campaign,  the  actual 
hostilities  of  which  lasted  from  July  ist  to  August 
18th,  about  six  weeks,  the  mortality  from  bullets  and 
wounds  was  two  hundred  and  sixty-eight,  while  that 
from  disease  reached  the  appalling  number  of  thirty- 
eight  hundred  and  sixty-two,  or  about  fourteen  to 
one.  With  proper  subsistence  and  sanitation,  these 
proportions  for  such  a  short  service,  and  with  men 
recruited  after  rigid  examination  and  accepted  on  ac- 
count of  their  splendid  physical  development  and 
health,  should  have  been  reversed. 

In  the  limited  scope  of  this  paper  it  is  not  purposed 
to  discuss  the  various  ration  tables  of  the  armies  of 
the  world,  or  the  relative  merits  of  each  article  of 
diet.  This  may  be  found  in  the  elaborate  works  of 
Parkes,  Yeo,  Carpenter,  Ranke,  Atwater,  Rattray, 
P'ijkman,  Mourson,  Cohnheim,  Notter  and  Frith, 
Church,  Duncan,  and  others  who  are  authorities  on 
foods.  ]!ut  I  wish  to  call  attention  to  the  dangers  in 
tropical  environment  resulting  from  overtaxing  the 
digestive  system  of  healthy  men  from  temperate 
climes,  by  the  excessive  use  of  meats  and  fats,  which 
require  more  oxygen  in  their  metabolism,  and  thereby 
create  more  heat  through  the  activity  imposed  upon 
the  internal  organs  in  their  digestion  and  elimina- 
tion. 

In  addition  to  tissue  repair  the  ingestion  of  food  is 
to  accomplish  two  results— the  development  of  body 
heat,  and  bodily  motion  or  energy.  The  mutual  rela- 
tion of  income  and  expenditure  has  been  calculated  to 
a  fine  degree  of  exactitude.  Ranke's  well-known  tables 
show  that  one-sixth  of  the  total  income  of  food  is  ex- 
pended in  mechanical  force,  and  five-sixths  in  pro- 
ducing heat.  Carpenter  on  this  question  (the  lesser 
production  of  body  heat  where  the  external  temperature 
is  high,  as  in  the  tropics)  says :  "  Every  change  in  the 
organic  components  of  the  body  in  which  their  ele- 
ments enter  into  new  combinations  with  oxygen  must 
be  a  source  of  the  development  of  heat,  and  as  a  con- 
siderable portion  of  the  carbon  dioxide  and  water  ex- 
haled in  respiration  is  formed  within  the  body  by  the 
metamorphosis  of  its  own  tissues,  and  since  the  meta- 
morphosis is  promoted  by  the  active  exercise  of  the 
nerve-muscular  system,  it  follows  that  in  animals 
whose  habits  are  peculiarly  active,  living  in  climates 
in  which  the  surrounding  temperature  is  high  enough 
to  prevent  any  cooling  influence,  the  combustive  proc- 
ess thus  maintained  may  be  adequate  for  the  mainte- 
nance of  the  temperature  of  the  body  at  its  own  nor- 
mal standard.  Hence,  it  appears  that  we  do  not  want 
to  provide  for  the  heat  of  the  body  in  the  tropics,  but 


6i4 


MEDICAL    RECORD. 


[October  20,  1900 


only  for  the  work  done  when  there  is  a  peculiarly 
active  life." 

Carpenter  says:  "The  general  experience  of  in- 
habitants of  warm  climates  is  in  favor  of  a  diet  chieHy 
or  entirely  vegetable,  inasmuch  as  such  diet  affords  an 
adequate  supply  of  albuminates  in  combination  with 
the  other  classes  of  foods  without  affording  more  fuel 
than  the  system  requires." 

These  statements  have  an  especial  interest  when 
considered  in  conjunction  with  the  highly  nitrogenous 
and  heat-producing  elements  of  the  United  States  field 
ration,  which  contains  nitrogen  1S.12  gm.,  protein 
1 13.26  gm.,  f.its  2  1S.26  gm.,  and  carbohydrates  489.08 
gm.,  and  represent  in  caloric  units  4,448. 

The  average  of  four  dietaries  of  natives  in  the 
tropics  when  at  hard  labor  (of  the  West  Indies  by 
Maurel,  the  Abyssinian  soldier  by  Labicque,  the 
cooly  in  British  India  by  Church,  and  the  Malay  by 
Eijkmann,  brought  up  for  comparison  to  the  common 
standard  of  body  weight,  145  lbs.,  of  the  European  by 
Munson,  in  an  admirable  essay  on  this  subject)  was 
found  to  contain  of  nitrogen  12.18  gm.,  protein  76.18 
gm.,  fats  40  gm.,  carbohydrates  560.01  gm.  and  repre- 
sented in  caloric  units  2,900. 

Compared  with  the  above  average  the  United  States 
ration  represents  an  excess  of  nitrogen  5.94  gm.,  pro- 
tein 36.08  gm.,  fats  178.26  gm,  and  of  caloric  units  of 
1,548,  while  in  the  principal  and  easiest  energy-lib- 
erating element,  the  carbohydrates,  there  is  a  deficiency 
of  80.93  gm. 

Life  in  the  tropics  is  found  to  produce  the  following 
conditions : 

1.  Increased  body  temperature,  amounting  on  an 
average  to  over  0.5  "  F. 

2.  Loss  of  body  weight  due  to  imperfect  oxygenation 
and  the  destructive  effect  of  continued  heat,  amounting 
to  over  eight  per  cent,  in  the  first  year. 

3.  Diminished  cardiac  action  due  to  low  arterial 
tension  and  the  relaxed  state  of  the  capillaries,  result- 
ing from  the  loss  of  fluids  by  increased  perspiration. 

4.  Lower  pulse  rate  amounting  to  three  per  cent. 

5.  Reduced  pulmonary  endosmosis  on  account  of 
the  rarefaction  of  the  atmosphere  and  the  low  arterial 
pressure. 

6.  Diminished  urinar)'  secretion  owing  to  increased 
perspiration,  amounting  to  thirty-three  per  cent.;  and 
a  higher  specific  gravity  of  the  blood  in  consequence. 

7.  Diminished  excretion  of  urea  by  the  kidneys 
amounting  to  ten  per  cent. 

S.  Increased  secretory  activity  of  the  liver  caused 
by  the  irritation  resulting  from  the  loss  of  fluids  and 
relaxation  of  the  capillaries,  and  the  decreased  elimi- 
nation of  urea  by  the  kidneys.  This  increased  activity 
frequently  amounts  to  congestion,  which,  if  continued, 
soon  becomes  chronic  with  danger  of  impaired  function. 

9.  Diminished  secretion  of  saliva,  mucus,  gastric 
and  pancreatic  juice,  and  bile,  in  consequence  of  in- 
creased perspiration  and  the  higher  specific  gravity  of 
the  circulating  fluids. 

10.  Dependent  on  these  are  dryness  of  the  throat  and 
fauces,  exaggerated  thirst,  weakness  of  appetite,  and 
impaired  digestion. 

In  order  to  cope  successfully  with  these  conditions 
it  is  necessary  to  relieve  the  digestive  apparatus  of  all 
superfluous  labor.  The  food  should  be  well  cooked  to 
prevent  alimentary  fermentation,  and  should  contain 
as  little  of  the  albuminoid  principles  taken  from  meats 
and  fats  as  is  compatible  with  tiie  repair  of  the  system. 
Meat,  in  the  fresh  state,  being  the  most  perishable  of 
all  foods,  should,  for  campaign  requirements,  be  re- 
placed as  largely  as  possible  with  dried  and  smoked 
varieties.  The  creosote  in  smoked  beef  being  a  gas- 
tric stimulant  and  intestinal  disinfectant,  when  prone- 
ness  to  diarrha-a  exists,  is  a  decided  advantage.  Salt 
and  tinned  meat  is  objectionable.     The  nutritive  value 


of  salted  meat  is  reduced  over  one-third  owing  to  the 
solution  of  the  albuminates  by  the  chloride  of  sodium, 
and  is  rendered  less  digestible  through  the  hardening 
of  its  muscular  fibre;  and  tinned  meats  produce  after 
continued  use  impairment  of  digestion.  On  the  con- 
trary, smoked  meats  are  not  prone  to  decay,  they  retain 
their  nutritive  qualities,  are  easily  digested,  concen- 
trated, and  far  more  portable  for  field  use. 

The  energy  of  the  system  should  be  derived  as 
largely  as  possible  from  easily  digested  carbohydrates, 
instead  of  from  meats  and  fats.  The  metabolism  of 
both  nitrogen  and  fat  produces  much  unnecessary 
heat,  through  the  splitting  up  of  the  proteids  and  the 
emulsification  of  the  fats.  Carbon  necessary  for  nutri- 
tion can  be  provided  either  in  the  form  of  fats  or  car- 
bohydrates. 

Fats  are  more  suitable  for  tissue  growth  and  repair 
than  carbohydrates  alone.  A  large  proportion  of  fat, 
however,  is  as  a  rule  not  well  tolerated  by  the  diges- 
tive organs  for  continued  use,  except  under  conditions 
of  climate  like  that  of  the  Arctic  regions. 

Dujardin-Beaumetz  regards  the  average  daily  allow- 
ance of  fats  as  55  gm.  The  great  purpose  of  fat  in 
the  food  is  to  diminish  albuminous  metabolism,  and 
it  is,  therefore,  regarded  as  an  albumen-sparing  food. 

As  stated  by  Baumer,  "  If  flesh  alone  be  given,  large 
quantities  are  required  in  order  that  nutrition  and 
waste  may  balance  one  another,  but  if  fat  be  added 
the  demand  for  flesh  is  less." 

External  temperature  influences  the  metabolism  of 
the  hydrocarbon  and  therefore  the  amount  of  carbon 
excreted.  The  lower  the  temperature,  as  long  as  that 
of  the  body  itself  is  maintained,  the  greater  the  metab- 
olism of  non-nitrogenous  foods  and  the  greater  the 
amount  of  carbon  discharged  from  the  body.  In  higher 
temperatures  the  reverse  conditions  prevail — there  is 
less  metabolism  and  less  carbonic  acid  exhaled;  there- 
fore, excepting  for  the  actual  necessities  of  the  system, 
fats  should  be  avoided  in  hot  climates. 

Natural  appetite  or  instinct  prompted  the  avoidance 
of  fatty  food  by  the  troops  in  Porto  Rico,  Cuba,  and 
the  Philippines.  Their  aversion  to  bacon,  the  best 
form  in  which  fat  can  be  supplied  for  campaign  use, 
led  practically  to  a  waste  of  this  article,  except  as  it 
was  used  for  culinary  purposes. 

Carbohydrates,  while  having  much  in  common  with 
fats,  have  additional  advantages.  They  serve  the  same 
purpose  of  checking  albuminous  waste,  and,  like  the 
fats,  they  are  resolved  by  combustion  within  the  body 
into  carbonic  acid  and  water.  They  also  yield  heat 
and  energy,  but  do  not  enter  into  the  structure  of  the 
tissues.  All  carbohydrates  are  converted  into  glu- 
cose before  absorption,  and  in  this  form  are  more 
readily  metabolized  than  fats  or  albuminates.  Bauer 
showed  that  carbohydrates,  even  when  administered  in 
great  excess,  are  almost  completely  destroyed  within 
the  body.  He  maintains  that,  owing  to  the  facility  with 
which  they  are  metabolized,  they  protect  other  foods 
from  destruction.  Owing  to  the  ease  with  which  they 
are  oxidized  (as  they  contain  hydrogen  and  o.xygen  in 
the  proportions  to  form  water),  the  carbon  is  easily 
liberated  for  the  purposes  of  energy,  and  with  less 
production  of  internal  heat.  For  this  reason  they  are 
our  most  valuable  factor  for  the  production  of  energy 
in  the  tropics,  as  they  impose  less  labor  on  the  organs 
of  dige.stion. 

Of  the  cereals  which  must  supply  a  portion  of  the 
carbohydrates,  those  indigenous  to  the  tropics  are 
better  than  those  grown  in  temperate  zones,  as  they 
contain  less  nitrogen.  Of  these  maize,  rice,  and  the 
native  lentil,  when  well  cooked,  are  preferable.  In  a 
mixed  diet  in  which  fat  and  albumen  are  supplied  from 
other  sources,  rice,  on  account  of  the  easy  digestibil- 
ity of  its  starchy  components,  is  especially  valuable. 

Napoleon,  commenting  on  the  terrible  trials  of  the 


October  20,  1900] 


MEDICAL    RECORD. 


6'5 


Moscow  campaign,  mentions  that  of  all  his  army  the 
Italian  troops  withstood  the  hardships  best.  They 
were  subsisted  on  a  ration  made  up  almost  exclusively 
of  vegetables  and  cereals.  Leonidas  and  his  little 
Spartan  band  defended  the  passes  of  Thermopylae  on 
a  diet  of  lentils.  The  winner  of  the  late  interna- 
tional race  at  the  Olympian  games  at  Marathon  trained 
on  the  same  food,  the  lentil.  All  were  carbohydrate 
fed. 

The  advantages  of  sugar  are  only  now  beginning  to 
be  appreciated.  VVhen  energy  is  to  be  liberated  rap- 
idly with  the  least  tax  upon  the  digestive  system, 
sugar,  an  almost  pure  soluble  carbohydrate,  would 
seem  to  be  the  ideal  food  for  the  purpose. 

Nature's  prodigal  supply  of  sugar-cane,  and  low- 
heat-producing  but  nourishing  fruits  in  tropic  lands, 
would  seem  to  indicate  their  peculiar  adaptability  for 
the  particular  requirements  of  inhabitants  of  hot  zones. 

The  bee  and  the  colibri,  whose  marvellous  endurance 
is  the  wonder  of  the  physiologist  and  philosopher,  de- 
rive their  power  almost  exclusively  from  sugar. 
Every  one  who  has  seen  the  humming-bird  suspended 
in  space  for  hours,  with  wings  moving  with  lightning 
rapidity,  Hying  from  (lower  to  flower,  drawing  from  the 
chalice  the  sweetened  dew,  must  have  wondered  at  the 
marvellous  conservation  and  correlation  of  force  that 
enabled  it  to  perform  such  sustained  effort;  the  motive 
power  was  sugar. 

In  the  Philippines  the  cavalry  horses  imported  from 
America  became  emaciated  and  refused  to  eat,  until  it 
was  discovered  that  molasses  or  sweetened  water 
sprinkled  on  the  coarse  grass  or  hay  made  it  pala- 
table. When  fed  to  them  in  this  form  they  flourished 
and  grew  sleek  and  fat.  A  soluble  pure  carbohydrate, 
sugar,  had  supplied  the  deficiency.  Among  the  troops 
in  Porto  Rico  and  the  Philippines  whose  appetites  and 
digestions  had  become  impaired,  there  was  a  craving 
for  candies  and  sweets  which  was  astonishing,  all  due 
to  the  same  physiological  reason,  the  instinctive  desire 
for  an  easily  metabolized,  energy-producing  food  which 
these  articles  supplied.  Cyclists,  on  long  "  tours  de 
force,"  have  demonstrated  what  can  be  accomplished 
on  a  ration  containing  little  else  than  carbohydrates. 
In  these  record-breaking  trials,  extending  over  periods 
of  many  days,  the  expenditure  of  energy  is  nearly  con- 
tinuous. The  intervals  for  rest  or  sleep  are  very  short, 
and  exhaustion  can  be  counterbalanced  only  by  the 
most  easily  metabolized  diet.  Experiments  with  the 
ergostat  have  demonstrated,  by  the  use  of  sugar,  the 
rapid  liberation  of  energy  following  a  state  of  extreme 
exhaustion.  Sugar  relieved  fatigue  more  rapidly  than 
other  foods. 

The  excessive  use  of  sugar,  however,  with  a  mixed 
diet,  interferes  with  the  digestion  of  proteids,  in  dimin- 
ishing the  secretion  of  hydrochloric  acid;  but,  when 
the  supply  of  meat  and  fats  is  restricted,  hydrochloric 
acid  is  not  required  to  such  an  extent,  and  conse- 
quently sugar  can  be  used  more  liberally.  In  com- 
parison with  other  foods,  sugar  could  be  regarded  as  a 
refined  fuel  for  the  system,  just  as  alcohol  would  be 
if  used  for  fuel  for  an  engine.  In  their  easy  metabo- 
lism they  liberate  energy,  and  in  their  perfect  combus- 
tion they  leave  no  ash  or  waste  products. 

Tea  and  coffee  contain  the  identical  alkaloids,  theine 
and  caffeine;  but  for  campaign  purposes  tea  has  many 
advantages.  When  compressed  in  cakes  it  is  concen- 
trated and  easy  of  transportation.  Two  minutes  are 
sufficient  for  its  infusion,  and  if  taken  in  a  weak  solu- 
tion, as  it  always  should  be,  the  large  quantity  of  pal- 
atable sterilized  water  introduced  into  the  system 
forms  not  only  a  refreshing  beverage  but  stimulates 
the  processes  of  digestion,  and  increases  remarkably 
the  soldier's  power  of  enduring  great  fatigue  in  hot 
climates. 

Curry   is  a  valuable  addition  to  the  usual   condi- 


ments (pepper,  salt,  and  vinegar).  It  aids  digestion 
in  stimulating  intestinal  secretion,  and  acts  as  an 
anti-fermentative. 

A  liberal  ration  for  the  soldier  in  the  tropics  could 
be  supplied  in  the  following  articles: 

Fresh  meat  10  oz.  or  its  equivalent  in  dried  and 
smoked  beef,  bacon  2  oz.,  flour  12  oz.,  rice,  lentils,  or 
maize  4  oz.,  succulent  and  green  vegetables  14  oz., 
dried  fruits  2  oz.,  sugar  with  chocolate  4  oz.,  tea  and 
condiments  including  curry,  salt,  pepper,  and  vinegar 
3  oz. 

This  allowance  represents  about  40  grains  of  pro- 
tein, 15  of  nitrogen,  83  of  fat,  and  540  of  carbohy- 
drates, and  equals  3,300  caloric  units,  or  more  by  400 
tlian  the  average  given  in  the  dietary  ciuoted  by  Mun- 
son  for  men  at  hard  labor  in  the  tropics. 

From  this  list  an  extremely  light,  portable  travel 
ration  could  be  selected.  By  doubling  the  quantity  of 
sugar,  the  bulky  carbohydrates  (the  vegetables,  fruits, 
and  cereals)  could  be  omitted,  and  the  energy-supply- 
ing quality  of  the  ration  maintained  at  almost  its  full 
standard. 

If  supplemented  by  an  occasional  indulgence  in 
fruits  and  vegetables  to  be  found  en  route,  to  supply 
vegetable  salts  and  acids,  an  army  could  subsist  for 
months  under  severe  physical  strain,  and  maintain  its 
health  and  vigor.  The  pea  sausage,  as  used  by  Kitch- 
ener in  his  campaign  from  Khartoum  to  Omdurman, 
has  amply  demonstrated  this. 

A  consideration  of  this  topic  by  the  International 
Congress  may  not  seem  pertinent  to  its  members;  but 
just  now,  with  the  allied  armies  of  Christendom  gath- 
ered in  a  foreign  clime  for  a  common  purpose,  with 
the  Caucasian  arrayed  against  the  yellow  races — the 
Occident  against  the  Orient,  the  temperate  zone  against 
the  tropic,  and  the  prestige  or  preservation  of  modern 
civilization  the  tremendous  issue — the  study  of  these 
problems,  on  the  successful  solution  of  which  victory 
or  defeat  may  depend,  becomes  of  paramount  impor- 
tance. 

18  West  Thirty-first  Strbet, 


Subarachnoidean  Injections  of  Cocaine  as  a  Sub- 
stitute for  General  Anaesthesia  in  all  Operations 
Below  the  Diaphragm  ;  with  Report  of  Nine  Cases. 
— John  B.  Murphy  says  that  an  American,  Dr.  Leon- 
ard Corning,  demonstrated  in  1884-85  that  ansesthesia 
could  be  produced  in  this  way.  Oberst,  Bier,  and 
others  later  took  up  the  matter,  but  the  man  who  really 
advanced  it  as  a  practical  anaesthetic  is  Tuffier.  The 
advantages  of  the  procedure  are:  ease  of  application; 
thorough  analgesia  of  all  the  tissues  below  the  dia- 
phragm; the  retention  of  the  sense  of  touch;  absence 
of  the  reflexes;  consciousness  of  the  patient;  avoid- 
ance of  the  primary  intermediate  and  secondary  se- 
quences of  the  anaesthetic,  as  cardiac  phenomena,  pul- 
monary lesions,  and  renal  disturbance.  Whether  the 
cocaine  will  be  found  to  interfere  with  the  function  of 
other  organs  time  alone  must  determine.  Tuffier,  in 
his  extensive  experience  from  last  November  to  the 
loth  of  August,  has  had  no  untoward  results  of  any 
kind,  and  has  secured  complete  analgesia  in  every 
case.  Hysterectomies,  salpingectomies,  nephrecto- 
mies, pylorectomies,  cholecystostomies,  and  operations 
of  that  class  are  performed  by  him  regularly  in  accord- 
ance with  this  method.  The  author  gives  the  tech- 
nique of  the  method,  and  reports  nine  cases  of  his 
own. —  The  Chicago  Clinic,  September,  1900. 

Venomous  Snakes,  their  Bites,  and  How  to  Treat 
Them. — Joseph  McFarland  says  that,  briefly  outlined, 
the  treatment  of  snake  bite  is  (i)  immediate  interrup- 
tion of  the  circulation  of  the  bitten  member,  so  as  to 
prevent  absorption  of  the  poison;    (2)  free  incision 


6i6 


MEDICAL    RECORD. 


[October  20,    1900 


and  enlargement  of  the  fang  wounds  and  forcible  suc- 
tion to  extract  the  poison;  (3)  hypodermic  injection 
of  three  to  six  drops  of  a  fresh  ten-per-cent.  watery 
solution  of  chloride  of  calcium  into  about  a  dozen  dif- 
ferent areas  about  the  wound;  (4)  strychnine  given 
hypodermically  to  stimulate  the  respiratory  centre; 
(5)  immediate  and  frequently  repeated  hypodermic 
injections  of  10  to  20  c.c.  of  the  antivenomous 
serum,  or,  as  Calmette  calls  it,  "  antivenene."  The 
most  urgent  need  of  the  patient  is  for  the  immediate, 
unlimited  administration  of  antivenene.  It  would  be 
a  wise  precaution  for  jiersons  whose  travels  or  occupa- 
tions keep  them  in  continual  danger  of  snake  bites  to 
provide  tliemselves  with  the  remedy  and  carry  it  with 
them.  There  are  many  whose  occupations  of  berry- 
picking,  lumbering,  mining,  hunting,  engineering, 
etc.,  carry  them  into  wild  and  snake-infested  coun- 
tries, to  whom  the  possession  of  a  snake-venom 
antitoxin  with  even  a  limited  application  would  come 
as  a  boon. — Jiiternatioiial  Medical  Magazine,  Septem- 
ber, 1900. 

Permanganate  of  Potassium  as  an  Antidote  to 
Opium  Poisoning.  — W.  K.  Gatewood  saw  a  negro 
child,  aged  eighteen  months,  one  hour  after  taking  an 
overdose  of  laudanum,  exact  quantity  not  known. 
The  child  was  cold  and  clammy  with  slow  and  feeble 
respiration.  The  stomach  was  washed  out  and  one- 
quarter  grain  of  the  permanganate  was  injected  into 
the  thigh.  In  half  an  hour  tiiere  was  marked  im- 
provement in  respiration  and  circulation.  In  another 
hour  strong  coffee  could  be  taken,  while  in  the  course 
of  twelve  hours  the  child  was  out  of  all  danger  and 
able  to  walk.  Gatewood  does  not  believe  that  stomach 
v.-asliing  alone  would  have  saved  the  case. — Richmond 
Journal  (>J  Practice,  August,  1900. 

Hemorrhage  Occurring  after  the  Menopause. — E. 

C.  Davis  writes  that  at  the  time  of  the  menopause 
i.theromatous  changes  are  likely  to  take  place  in  the 
blood-vessels,  malignant  diseases  make  their  appear- 
ance, and  the  atrophic  changes  of  the  tissues  become 
observable.  After  menstruation  has  ceased,  any  hem- 
orrhage from  the  uterus  is  always  pathological,  the 
causes  of  hemorrhage  at  this  time  being  granular  en- 
dometritis, atheroma  of  uterine  blood-vessels,  vaso- 
motor relaxation,  uterine  polypus,  uterine  myofibro- 
mata,  and  carcinoma  of  the  uterus.  Of  this  last  new 
growth,  hemorrhage  is  the  danger-signal  whicii,  if  ap- 
preciated by  the  physician,  may  result  in  years  of 
comfort  and  health  to  the  victim.  If  neglected,  how- 
ever, a  horrible  death  awaits  the  patient.  During  the 
early  history  of  carcinoma,  the  tumor  is  local  and  cir- 
cumscribed, but  later  becomes  hopelessly  disseminated. 
The  cervix  is  the  inost  frequent  seat  and  epithelioma 
the  most  common  form  of  malignant  tumor.  The  his- 
tory of  hemorrhage  after  the  menopause  with  offensive 
discharge  is  almost  pathognomonic  of  malignancy. 
The  most  rational  treatment  is  complete  removal  of 
the  diseased  uterus,  with  appendages,  before  exten- 
sion has  taken  place  into  the  surrounding  tissues. — 
Obstetrics,  September,  1900. 

An  Anomalous  Case  of  Central  Hemorrhage,  Con- 
nected with  Increased  Pressure  in  the  Ear  due  to 
Violent  Coughing.  — Macleod  Yearsley  reports  the 
case  of  a  woman  aged  fifty-four  years,  who  two  weeks 
previous  had  a  violent  attack  of  coughing,  during 
which  she  experienced  vertigo,  deafness,  tinnitus,  and 
loss  of  memory.  Vertigo  continued  twelve  hours.  Tiie 
next  morning  there  was  some  weakness  of  the  right 
arm  and  leg,  and  slight  left  facial  paralysis.  Sym]5- 
toms  gradually  abated,  and  when  she  was  seen  by  the 
writer  the  deafness  had  almost  entirely  disappeared, 
while  the  vertigo  persisted  to  only  a  slight  degree.  Tin- 
nitus persisted  only  in  the  left  ear.     The  tuning-fork 


on  the  vertex  was  heard  better  by  tlie  left  ear;  Rinne's 
test  was  positive  on  both  sides.  Lone  conduction  was 
impaired  on  both  sides,  about  twenty-five  per  cent, 
being  lost.  Loth  membranes  were  dull,  opaque,  and 
indrawn,  but  there  were  no  signs  of  either  old  or  recent 
rupture.  Movement  to  the  pneumatic  speculum  was 
good  on  both  sides.  Treatment  consisted  in  counter- 
irritation  and  dilute  hydrobromic  acid  in  drachm 
doses  thrt-e  times  daily.  Gradually  all  evidences  of 
the  attack  disappeared  until  only  very  slight  deafness 
remained. — Journal  oj  Laryngology,  August,  1900. 

Chorea  and  Leukaemia  as  Indications  for  the  In- 
duction of  Labor. — According  to  JMerttens  severe 
chorea  occuring  during  pregnancy  is  a  sufficient  cause 
for  the  induction  of  premature  labor;  in  confirmation 
of  this  opinion  he  reports  a  case  of  the  utmost  gravity 
which  was  undoubtedly  saved  by  this  means.  Chorea 
intervening  in  the  course  of  gestation  is  undoubtedly 
of  reflex  origin  and  emanates  from  uterine  disturb- 
ances, hence  the  necessity  for  prompt  treatment.  Not 
every  case  requires  such  a  heroic  measure;  but  when 
the  convulsive  seizures  continue  during  the  night  and 
prevent  sleep,  which  is  unusual  in  the  ordinary  forms, 
abortion  is  indicated.  Another  condition  justifying 
the  premature  emptying  of  the  uterus  is  a  compli- 
cating leukaMiiia.  In  the  case  reported,  however,  the 
author  was  not  so  successful  as  in  the  preceding  one, 
and  deatli  occurred  soon  after  the  operation,  which 
might  have  saved  life  if  it  had  been  performed  earlier. 
— Alonatsschrijt  Jiir  Geburtshiilje  und  Gyiuikologie, 
September,  1900. 

On  the  Accentuation  of  the  Second  Sound  in  the 
Pulmonary  Area ;  Skoda's  Sign. — J.  T.  O'Carroll 
thus  states  the  views  of  Skoda  on  the  point  named  in 
the  title:  "In  many  cases  of  disease  involving  the 
left  side  of  the  heart,  the  second  sound  is  heard  with 
marked  clearness  and  even  accentuation  at  that  spot 
on  the  chest  wall  at  which  the  pulmonary  artery  comes 
nearest  to  the  surface.  The  sound  is  therefore  in  the 
pulmonary  artery.  Disease  of  the  valves  of  the  left 
iieart  induces  a  tendency  to  more  or  less  delay  in  the 
circulation  through  the  lungs:  the  pulmonary  system 
is  in  fact  over-full;  there  is,  therefore,  a  condition  of 
engorgement  of  the  pulmonary  artery,  and  consequent 
slamming,  so  to  speak,  of  the  pulmonary  valves,  indi- 
cated by  an  exaggerated  noise  or  accent."  O'Carroll 
objects  to  the  statement  that  a  vascular  murmur  heard 
at  the  surface  is  necessarily  produced  by  that  vessel 
which  happens  to  be  most  superficial  at  the  point  of 
observation.  With  regard  to  the  engorgement  of  the 
pulmonary  vessels  he  states  that,  other  things  being 
equal,  the  loudness  of  the  diastolic  note  will  be  in  pro- 
portion to  the  amplitude  of  the  recurrent  wave  from 
the  periphery  in  the  pulmonary  artery.  IJut  in  mitral 
incompetence  or  stenosis  tiie  pulmonary  artery  tends 
to  be  still  fuller  than  it  is  in  health,  and  in  liealth  it 
is,  as  the  physiologists  teach  us,  somewhat  distended 
or  over-full.  In  disease  of  tiie  mitral  valve,  therefore, 
tiie  artery  wall  is  stretched  in  the  jiresytolic  period 
nearer  to  its  liinit  of  elasticity,  and  therefore  its  range 
of  post-systolic  recoil  is  more  limited.  That  is  to 
say,  the  amplitude  of  the  recurrent  wave  will  be  less 
than  normal,  and  the  intensity  of  the  second  sound 
should  be  correspondingly  diminished.  Practically 
the  accentuation  is  absent  in  many  cases  in  which,  ac- 
cording to  the  theory,  it  ought  to  be  present.  It  is 
present,  on  the  contrary,  in  many  cases  in  which  tiiere 
is  not  the  sligiitest  reason  to  suspect  either  heart  dis- 
ease or  tendency  to  delayed  pulmonary  circulation. 
Finally  there  are  certain  cases  in  wliich  the  accentu- 
ated sound  is  produced  probably  in  the  aorta,  and  not 
in  tiie  pulmonary  valve  at  all. — Dublin  Journal  of 
Medical  Science,  September,  1900. 


October  20,   1900] 


MEDICAL    RECORD. 


617 


Medical   Rfxord: 

A    ]l't-cl'l}'  Journal  of  Medicine  and  Surgery. 


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

I'lBLISHERS 

VVM.   WOOD  &  CO.,  51    Fifth  Avenue. 
New  York,  October  20,  1900. 

THE  INCREASE    IN    SL'ICIDES. 

Self-destructiox  has  probably  been  practised  from 
the  very  earliest  times.  The  popular  belief  is  that  ihe 
Romans  and  Greeks  held  the  view  that  a  man  had  a 
right  to  end  his  life  if  he  so  wished,  and  that,  regarded 
from  a  moral  aspect,  he  was  not  only  absolved  from 
blame,  but  in  terminating  an  existence  tiresome  to 
himself  and  useless  to  the  community  at  large,  per- 
formed a  meritorious  and  courageous  action.  Cicero 
was  an  upholder  of  this  doctrine,  and  said  that  it  is 
living  according  to  nature  in  a  wise  man  to  take  his 
leave  of  life  when  he  is  in  the  midst  of  abundance, 
and  that  he  is  a  fool  to  prolong  it  if  he  is  miserable. 
Other  famous  Romans  and  Greeks  spoke  to  the  same 
effect.  Notwithstanding  these  e.xamples,  there  is  no 
complete  evidence  that  suicide  was  looked  upon  with 
favor  by  the  mass  of  the  inhabitants  of  ancient  Greece 
and  Rome,  or  indeed  even  by  the  greater  portion  of 
their  celebrated  men.  Horace,  Lucretius,  and  Plato 
all  declaimed  in  eloquent  language  against  suicide. 
There  is,  however,  little  doubt  that  in  latter  and  de- 
clining days  of  Rome,  when  her  richer  citizens,  sated 
with  luxury  and  enervated  by  every  kind  of  indulgence 
and  vice,  and  above  all  upheld  by  no  religious  senti- 
ments, tired  of  life,  sought  a  refuge  in  the  oblivion  of  the 
tomb.  Mr.  G.  Styles,  of  Union  City,  Mich.,  who  con- 
tributed to  the  American  Journal  oj  Insanity  ior  July 
last  an  article  on  suicide,  refers  to  the  fact  that  in  a 
former  age  the  city  of  Marseilles  kept  constantly  pre- 
pared a  hemlock  mixture,  so  that  any  one  tired  of  life 
might  obtain  it  at  the  public  expense,  the  only  condi- 
tion being  that  the  intending  self-murderer  should  ap- 
pear before  the  council  of  the  six  hundred,  and  give  an 
account  of  the  reasons  why  he  desired  to  die.  Chris- 
tianity has  always  set  its  face  against  suicide,  and  thus 
when  the  Christian  religion  supplanted  the  old  faiths 
of  European  countries,  and  when  those  who  killed  them- 
selves were  adjudged  guilty  of  a  heinous  crime,  self- 
destruction  decreased.  Unfortunately,  however,  within 
recent  years  the  number  of  suicides  has  enormously 
increased  and  is  still  increasing.  The  cause  of  this 
weariness  of  life  is  undoubtedly  to  be  found,  to  some 
extent,  in  our  advanced  civilization,  which  has  en- 
larged our  ideas  of  enjoyment  at  a  more  rapid  rate 
than  it  has  supplied  us  with  the  means  of  gratifying 
them.  Progress  in  education  is  another  powerful 
adjuvant  to  the  general  feeling  of  discontent,  inso- 
much as  the  poorer  classes  have  learned  sufficient  to 


be  dissatistied  with  their  lot.  But  the  decay  of  relig- 
ious sentiment — which  is  to  be  observed  in  all  those 
countries  which  are  in  the  foremost  rank  as  regards 
knowledge — and  especially  the  growth  of  scientific 
knowledge  have  perhaps  conduced  more  to  the  spread  of 
suicide  than  has  any  other  single  cause.  That  the  de- 
cadence of  orthodox  belief  is  an  important  factor  in  the 
increase  of  self-murder  is  demonstrated  in  great  cities 
like  Paris,  Uerlin,  and  Vienna,  where  agnosticism  is 
rampant,  and  where  the  greatest  number  of  suicides  oc- 
cur. Dr.  Ireland  traces  the  greater  portion  of  the  causes 
of  suicide  to  severe  strain  upon  the  nervous  system 
which  may  be  the  outcome  of  a  multiplicity  of  causes. 
Among  these  causes  may  be  mentioned  the  increased 
strain  of  modern  life  upon  the  nervous  system.  Again, 
the  contagious  effect  of  crime,  fostered  by  the  news- 
papers or,  as  Tlie  Lancet  puts  it,  operating  upon  those 
whose  "pithecoid  imitativeness"  is  part  of  their  "re- 
trocedent  organization,"  is  sufficiently  established  to 
enhance  the  regret  that  lay  journalism  within  its  un- 
doubted province  of  describing  current  events  inevit- 
ably panders  to  the  morbid  craving,  of  which  the  said 
imitativeness  is  an  expression,  and  neutralizes  most  of 
its  undoubted  benefit  by  helping  to  diffuse  the  criminal 
contagion.  The  psychological  factor  of  vanity  must 
surely  be  taken  into  account  in  discussing  suicide,  and 
this  human  weakness  is  greatly  influenced  by  the  mod- 
ern newspaper.  The  following  are  the  mean  annual 
rates  per  r, 000, 000  population  of  some  of  the  Euro- 
pean countries.  Saxony,  1861-70,  suicides  281; 
1871-80,  suicides  325  ;  1881-84,  suicides  370;  1885- 
88,  suicides  333.  In  Denmark  during  the  same  periods 
283,  266,  249,  259.  In  France,  129,  161,  189,  212. 
In  Prussia,  127,  153,  198,  204.  In  Belgium,  61, 
8r,  107,  116.  In  Sweden,  80,  86,  96,  no.  In 
England  and  Wales,  66,  70,  74,  78.  In  Norway,  82, 
70,  68,  66.  Italy,  27,  37,  37,  48,  48.  It  will  be  ob- 
served with  the  exception  of  Norway  the  suicide  mor- 
tality rate  has  increased,  and  in  most  countries  very 
considerably  within  recent  years.  The  diminution  in 
Norway  is  attributed,  says  the  Nineteenth  Century  Jie- 
?•;>«',  to  the  energetic  attack  which  the  Norwegian  gov- 
ernment has  made  on  alcoholism.  The  same  journal 
says  that,  in  the  case  of  Italy  particularly,  emigration 
accounts  to  some  extent  for  the  low  rate  prevailing  there. 
It  is  evident  that  emigration  provides  an  outlet  for  a 
great  deal  of  misery  and  constitutes  a  hopeful  alterna- 
tive to  suicide.  Most  persons  would  naturally  suppose 
that  the  season  of  winter  would  be  most  prolific  of  sui- 
cides. It  is  the  season  of  great  difficulty  for  the  poorer 
classes,  often  of  bitter  distress.  Contrary,  however,  to 
this  expectation,  the  months  of  May,  June,  and  July  are 
the  ones  in  which  the  largest  number  of  suicides  occur. 
The  connection  of  sex  and  suicide  is  an  interesting 
study,  and,  as  might  be  imagined,  many  more  men  take 
their  own  lives  than  women,  the  proportion  being  four 
to  one.  Marriage  exercises  a  most  beneficial  effect  in 
curbing  the  desire  of  self-destruction,  the  probability 
of  bachelors  committing  suicide  being  2.7  times  that  of 
married  men  of  same  age.  Soldiers  are  more  prone 
to  self-destruction  in  all  countries  of  Europe,  France 
alone  excepted,  than  those  engaged  in  civil  life. 
The  rate  of  suicide  mortality  in  the  United  States  is 


6i8 


MEDICAL    RECORD. 


[October  20,  1900 


I  in  35,000.  Dr.  D.  R.  Dewey  finds  that  in  the  New 
England  States  since  i860,  suicide  has  increased 
about  35  per  cent.  In  Massachusetts  it  lias  increased 
in  thirty  years,  1860-90,  from  70  to  90  to  the  million 
living,  and  in  Connecticut  from  61  to  103  per  million. 
A  steady  increase  of  self-destruction  is  common  to  the 
whole  civilized  world. 


THE    MALARIA    PROBLEM. 

Malaria  is  perhaps  the  most  deadly  disease  that  at- 
tacks man.  In  tropical  countries  it  certainly  claims 
more  victims  than  does  any  other  disease,  and  accord- 
ing to  some  authorities  it  kills  as  many  persons  as  do 
all  the  other  tropical  maladies  put  together.  For 
these  reasons  and  for  the  especial  reason  that  the 
white  man  is  invading  and  making  his  home  in  the 
tropics  to  a  greater  extent  every  year,  it  is  of  the  ut- 
most importance  that  means  of  successfully  combating 
malaria  should  be  devised  at  once.  The  solution  of 
the  malaria  problem  will  go  far  toward  paving  the 
way  to  render  residence  in  the  tropics  not  only 
harmless,  but  even  healthy  to  the  person  of  Cauca- 
sian race.  The  first  step  to  be  taken  in  fighting  any 
disease  is  to  discover  its  origin.  This  endeavor, 
owing  to  the  researches  of  a  long  line  of  investigators 
commencing  with  the  American  scientist  King  and 
ending  with  the  British  Manson  and  Ross,  has  cul- 
minated in  a  great  success.  There  can  now  be  but 
little  if  any  doubt  that  to  the  anopheles  species  of 
mosquito  is  mainly  if  not  entirely  due  malaria  in 
whatever  part  of  the  world  it  may  occur.  Attention 
was  drawn  in  the  Medical  Record,  October  6th,  to 
the  further  substantiation  of  this  theory  by  negative 
proofs  in  the  Roman  Campagna  and  by  positive  proofs 
by  inoculation  experiments  in  London.  The  next  step 
in  the  battle  against  this  disease,  seeing  that  its  eti- 
ology has  been  made  plainly  evident  to  the  satisfaction 
of  most  scientific  men,  is  to  initiate  methods  to  pro- 
tect against  the  attacks  of  the  malaria-bearing  mosqui- 
to, and  what  is  of  far  greater  import,  to  extirpate  these 
insects  if  possible.  The  means  of  protection  at  night, 
at  least,  is  easily  procurable,  and  consists  in  using  a 
mosquito  net,  so  made  and  arranged  that  no  insect  can 
bite  through  its  meshes  or  enter  through  casual  open- 
ings in  its  structure.  The  question  of  extirpating  the 
anopheles  mosquitos  is,  of  course,  one  of  infinite  diffi- 
culty, but  it  should  be  remembered  that  it  cannot  be 
insurmountable.  Situations  which  have  seemed  to  pre- 
sent as  many  and  as  great  problems  have  been  cleared 
by  the  genius  and  inventiveness  of  man.  This  coun- 
try in  her  newly  acquired  tropical  possessions,  and  in 
some  of  her  Southern  States,  has  territory  in  which 
malaria  (lourishes,  and  is  in  consequence  directly  in- 
terested in  the  successful  solution  of  the  malaria  prob- 
lem. Dr.  Manson,  referring  to  this  fact,  makes  the 
following  statement  published  in  the  Nnc  York 
Herald,  Sunday,  October  7th:  "When  I  suggested  six 
years  ago  that  malaria  could  be  carried  in  the  probos- 
cis of  a  mosquito,  American  scientists  wore  the  first  to 
grasp  the  reasonableness  of  the  idea  and  believe  in  it. 
The  gratification  I  have  consequently  always  felt  has 


been  brought  forcibly  home  to  me  in  the  light  of  our 
recent  demonstrations.  In  fact,  .\merica  herself  has 
now  to  grapple  with  an  evil  which  has  bafiled  the 
authorities  in  England's  tropical  possessions.  While 
this  is  a  matter  of  regret  and  deep  concern,  it  is  a 
promising  phase  of  tiie  situation  from  our  standpoint. 
We  believe  that  inventive  American  enterprise,  now 
that  that  country  has  an  incentive  of  its  own,  will 
manifest  itself  in  a  practical  scheme  of  mosquito  ex- 
termination. Thus  far  we  have  contented  ourselves 
with  prevention  and  defence,  but  the  results  have 
necessarily  been  doubtful.  The  evil  cannot  be  eradi- 
cated save  by  radical  measures.  There  must  be  a 
positive  campaign  against  malaria-breeding  condi- 
tions, and  fame  and  fortune  await  the  man  who  will 
devise  either  machinery  or  a  system  of  disinfection 
which  will  spell  death  for  the  mosquitos.''  Of  all 
civilized  countries,  Italy  is  the  only  one  that  suffers 
within  her  own  borders  to  any  extreme  degree  from 
the  ravages  of  malaria,  but  if  accounts  may  be  relied 
upon,  the  malady  is  an  absolute  scourge  to  a  large 
portion  of  that  peninsula,  and  one  of  the  most  potent 
causes  of  the  grinding  poverty  prevalent  among  its 
people.  M.  Eniile  Bertaux,  writing  in  the  Revue  des 
Deux  Moiides  on  the  subject,  goes  into  the  matter  at 
length,  and  after  giving  a  series  of  statistics  from  vari- 
ous sources  demonstrating  the  mortality  and  sickness 
in  Italy  due  to  malaria,  proceeds  to  remark:  "To-day 
London,  Paris,  and  Berlin  have  no  anxiety  on  the  sub- 
ject of  malaria,  except  for  colonists  and  soldiers  sent 
out  to  the  establishments  in  South  Africa  or  Asia. 
But  since  the  annexation  of  Naples  to  the  kingdom  of 
Italy,  and  the  placing  of  the  capital  in  the  midst  of 
the  Agro  Romano,  the  disease,  which  for  England, 
France,  and  Germany  remains  a  colonial  disease,  has 
become  for  the  kingdom  of  Italy  a  national  disease. 
Sad  destiny  for  an  energetic  and  ardent  people,  whose 
sobriety  up  to  the  present  time  has  preserved  it  from  the 
ill  effects  of  the  drunkenness  which  the  populations  of 
the  north  did  not  know  how  to  resist.  The  malaria 
alone  produces  the  same  ravages  in  Italy  that  the 
swamp  fevers  produce  in  Tonkin  and  Madagascar,  and 
which  alcoholism  produces  in  France."  Therefore  it 
is  Italy  who  will  benefit  in  the  first  instance  and  most 
greatly  if  the  outcome  of  the  experiments  amidst  the 
Pontine  marshes  can  be  put  to  a  practical  use.  The 
Roman  Campagna  was  once  a  fertile  tract  of  land  and 
able  to  support  a  large  population  ;  it  is  now  entirely, 
through  the  agency  of  malarial  fever,  a  region  of  bar- 
ren desolation,  whose  stricken  inhabitants  drag  out  a 
weary,  wretched  existence.  If  the  sanguine  expecta- 
tions of  those  who  are  firm  believers  in  the  malaria 
mosquito  theory  are  fulfilled,  the  Campagna  and  those 
other  parts  of  Italy  to  which  the  fever  has  brought 
ruin  may  once  again  be  restored  to  their  pristine  pros- 
perity. At  any  rate,  as  pointed  out  by  the  London 
Times,  the  experience  of  the  English  fen  districts 
shows  that  the  ague-carrying  anopheles  disappear  be- 
fore drainage  and  cultivation,  and  when  it  has  once 
been  shown  that  cultivation  can  be  securely  practised 
under  a  condition  no  more  onerous  than  that  of  sleep- 
ing in  a  niosquito-proof  hut,  there  can  be  no  doubt  that 
Italian  capital  and  enterprise  will  speedily  avail  them- 


October  20,  1900] 


MEDICAL    RECORD. 


619 


selves  of  the  great  opportunity  which  will  be  afforded 
them,  and  that  a  tract  of  land,  which  roughly  measures 
ninety  by  forty  miles  and  is  scarcely  used  except  for 
autumn  pasture,  will  be  reclaimed  for  all  the  purposes 
to  which  it  can  be  applied. 

There  can  be  no  doubt  that,  when  an  effectual  method 
has  been  found  to  destroy  the  pernicious  mosquitos 
wholly,  the  greatest  drawback  to  life  in  the  tropics 
■will  be  removed,  and  that  a  new  era  of  progress  in  all 
the  arts  of  civilization  will  be  inaugurated.  In  the 
Medical  Record  for  some  considerable  time  an  effort 
has  been  made  to  impress  the  American  men  of  science 
and  physicians  with  the  paramount  necessity  of  estab- 
lishing a  school  in  this  country  at  which  the  tropical 
diseases  will  be  taught.  Dr.  Manson  admits  that  the 
inventive  genius  of  the  American  is  more  likely  to 
evolve  a  practical  scheme  for  the  extirpation  of  ma- 
laria than  that  of  any  other  people.  It  is  urged  that 
scientific  investigators,  as  well  as  men  of  practical  ex- 
perience, should  discover  effectual  means  of  destroy- 
ing the  mosquito  pest,  both  for  the  honor  and  in  the 
material  interests  of  their  own  people  and  for  the  sake 
of  humanity  at  large. 


THE  PLACE  OF  MEETING  OF  THE  INTER- 
NATIONAL CONGRESS  OF  GYN.*:COLOGY 
AND    OBSTETRICS. 

It  has  been  generally  supposed  that  the  International 
Congress  of  Gynaecology  would  meet  in  London  in 
1902.  The  congress  had  received  a  unanimous  invi- 
tation of  the  British  Gynaecological  Society  to  do  so. 
Upon  the  suggestion  of  Dr.  Engelniann,  president  of 
the  American  Gynecological  Society,  and  of  Dr.  Men- 
des  de  Leon,  of  Amsterdam,  Prof.  A.  R.  Simpson, 
of  Edinburgh,  was  requested  to  preside,  and  had  ex- 
pressed his  willingness  to  act  in  that  capacity.  In 
the  mean  time,  however,  the  council  of  the  British 
Gynaecological  Society  had  communicated  with  the 
London  Obstetrical  Society,  asking  it  to  co-operate  in 
a  joint  invitation,  and  received  the  answer  that  the 
council  of  the  latter  society  deemed  it  inadvisable 
that  such  a  course  should  be  pursued.  Dr.  Engel- 
mann  then  wrote  to  Dr.  Macnaughton  Jones  as  fol- 
lows: "May  I  ask  you  again,  semi-officially,  as  to  tlie 
present  state  of  your  societies  in  relation  to  the  Inter- 
national Congress?  As  a  member  of  the  International 
Committee,  I  understand  that  an  invitation  has  again 
been  extended  on  the  part  of  the  British  Gynsecologi- 
cal  Society.  I  can  but  repeat  what  I  said  to  you  in 
London,  that  I  deem  it  most  desirable  that  the  coming 
meeting  be  held  in  an  English-speaking  country. 
London  would  be  to  the  best  interests  of  all  inter- 
ested, but  I  believe  that  I  voice  the  sentiments  of 
those  I  represent  when  I  say  that  the  feeling  is  gen- 
eral that  the  invitation  could  be  accepted  only  and  the 
congress  be  a  success  only,  if  the  two  great  societies 
of  Great  Britain  are  united  in  their  desire  to  see  the 
congress  intheir  midst,  and  I  sincerely  trust  that  some 
understanding  has  been  arrived  at.  May  I  ask  )ou 
unofficially  if  such  is  the  case,  and  what  is  the  present 
status?"     To  this   letter   an  answer  was  sent  to  the 


effect  that  the  invitation  of  the  British  Gynaecological 
Society  had  been  accepted ;  that  steps  had  been  taken 
to  secure  the  co-operation  of  the  London  Obstetrical 
Society,  but  with  negative  results.  A  committee  of 
organization  was  then  established  with  the  necessary 
officers,  at  a  meeting  of  which  committee  it  was  re- 
solved that  Dr.  Macnaughton  Jones  be  authorized  to 
approach  Professor  Simpson  with  a  view  to  the  nomi- 
nation of  a  London  president  of  the  obstetrical  sec- 
tion of  the  1902  congress,  and  that  Professor  Simpson 
be  requested  to  communicate  this  resolution  to  Dr.  VV. 
S.  Playfair.  Closely  following  on  this  meeting  the 
past  and  present  teachers  of  obstetrics  and  gynaecology 
at  the  metropolitan  medical  schools  met,  and  as  a  re- 
sult a  letter  to  the  International  Congress  of  Gynae- 
cology and  Obstetrics  appeared  in  the  medical  journals 
enclosing  a  copy  of  a  letter  to  Professor  Simpson, 
and  explaining  that  the  objection  of  the  signatories — 
who  include  the  past  and  present  teachers  of  gynae- 
cology and  obstetrics  in  the  metropolitan  medical 
schools  now  practising  in  London — was  not  to  the 
election  of  Professor  Simpson  as  president  personally, 
but  to  the  manner  in  which  he  was  elected.  In  the 
letter  to  Professor  Simpson  himself  the  position  taken 
by  the  London  obstetricians  and  gynaecologists  was 
phrased  thus:  "As  past  and  present  lecturers  and 
teachers  of  obstetrics  and  gynecology  in  the  London 
medical  schools,  we  wish  to  explain  to  you,  and  es- 
pecially to  such  of  our  foreign  colleagues  as  might 
contemplate  attending  such  congress,  that  those  who 
have  issued  this  invitation  have  assumed  a  representa- 
tive position  to  which  they  are,  in  our  opinion,  not  en- 
titled, and  which  we  find  ourselves  unable  to  recog- 
nize." On  the  receipt  of  this  communication  Professor 
Simpson  wrote  to  withdraw  his  nomination  as  presi- 
dent. The  British  Gynaecological  Society  then  wrote 
to  Dr.  Jacobs,  secretary  to  the  permanent  committee  of 
the  International  Congress  of  Gynecology  and  Ob- 
stetrics, explaining  how  matters  stood,  and  similar 
letters  were  sent  to  Dr.  Engelmann  and  Dr.  Mendes 
de  Leon.  A  letter  was  also  addressed  to  the  same 
medical  journals  which  published  that  of  the  teachers 
of  obstetrics  at  the  metropolitan  medical  schools,  de- 
fending the  action  of  the  British  Gynecological  Society. 
Dr.  Jacobs  in  his  reply  said  that,  "on  the  advice  of  a 
number  of  the  founders,  I  think  the  proper  course  is 
to  ask  you  to  postpone  any  decision  till  after  the  meet- 
ing of  the  congress  at  Paris  on  August  2d." 

The  fact  will  be  gathered  from  a  perusal  of  the  pre- 
ceding resume  of  the  affair  that  matters  are  at  a  stand- 
still, and  that  unless  the  two  British  societies  resolve  to 
sink  their  differences  and  come  to  an  understanding, 
the  International  Congress  is  not  likely  to  be  held  in 
London  in  1902.  It  would  be,  of  course,  absurd  to 
designate  a  body  as  representative  of  the  gynecolo- 
gists and  obstetricians  of  Great  Britain  which  did  not 
include  the  leading  London  specialists;  but  at  the 
same  time,  without  in  the  least  presuming  to  pass  an 
opinion  upon  the  merits  of  the  case,  we  cannot  but 
think  that  it  would  have  been  wiser  on  the  part  of 
both  societies  if,  rising  above  jealousy,  they  had  cor- 
dially co-operated  in  the  endeavor  to  make  the  pro- 
posed meeting  in  London  a  success,  and  in  presenting 


620 


MEDICAL    RECORD. 


[October  20,  1900 


a  united  front  to  the  world.  It  would  seem  that  the 
action  of  the  British  Gynecological  Society  in  send- 
ing an  invitation  to  the  International  Congress  of 
Gynaecology  to  meet  in  London,  without  having  been 
first  assured  of  the  co-operation  of  the  London  Ob- 
stetrical Society,  was  premature  and  perhaps  somewhat 
ill-advised. 


PROTECTIVE    INOCULATIONS    AGAINST 
TYPHOID    FEVER. 

Although  the  evidence  is  not  final  and  conclusive, 
such  as  is  accessible  rather  points  to  the  utility  of 
inoculation  with  sterile  cultures  of  typhoid  bacilli  in 
the  preventive  treatment  of  typhoid  fever.  Thus,  the 
official  statistics  with  regard  to  the  results  obtained  in 
the  beleaguered  military  garrison  at  Ladysmith,  as 
cited  by  Wright  (^Lancet,  July  14,  1900,  p.  95),  show 
that  among  10,539  non-inoculated  individuals  there 
occurred  1,489  cases  of  typhoid  fever — a  proportion 
of  I  :  707 ;  with  329  deaths — a  proportion  of  i  :  329  of 
the  whole  number,  and  of  1:4.52  of  the  number  of 
cases;  while  among  1,705  inoculated  individuals  there 
were  35  cases  of  typhoid  fever — i  :  48.7  ;  with  8  deaths 
—  I  :  213  of  the  whole  number,  and  i  :  4.4  of  the  num- 
ber of  cases.  Briefly  stated,  the  figures  demonstrate 
an  almost  sevenfold  reduction  in  the  morbidity  and  in 
the  total  mortality  among  the  inoculated,  with  little 
alteration  in  the  case  mortality,  but  this  latter  fact 
may  be  in  some  degree  dependent  upon  the  small 
number  of  cases  dealt  with.  It  has  further  been  re- 
ported that  the  disease  pursued  a  milder  course  in  the 
inoculated  than  in  those  not  inoculated.  There  was 
no  reason  to  believe  that  the  remaining  conditions  to 
which  inoculated  and  uninoculated  were  respectively 
e.xposed  exerted  any  noteworthy  influence  upon  the 
result. 


^mus  Df  tlte  "QcEcch. 

Saratoga  County  Medical  Association —  A  num- 
ber of  physicians  of  Saratoga  county  met  at  the 
Worden  Hotel  on  September  28th,  and  unanimously 
voted  to  form  the  Saratoga  County  Medical  Associa- 
tion. They  organized  by  electing  officers  as  follows: 
President,  Dr.  F.  J.  Sherman,  of  Ballston;  Vice-Presi- 
dent, Dr.  G.  F.  Comstock,  of  Saratoga;  Secretary,  J. 
Y.  Humphrey,  of  Saratoga;  Treasurer,  Dr.  VV.  E. 
Swan,  of  Saratoga.  The  association  then  formally 
adopted  the  code  of  ethics  of  the  American  Medical 
Association,  and  passed  a  resolution  requesting  the 
council  of  the  New  York  State  Medical  Association 
to  accept  the  new  organization  as  a  subordinate 
county  association. 

New  York  State  Medical  Association. — The  an- 
nual meeting  of  this  association  was  held  in  the 
New  York  Academy  of  Medicine  on  October  i6th, 
17th,  and  i8th.  A  very  full  and  interesting  scien- 
tific programme  was  provided,  the  chief  features  of 
which  were  three  formal  discussions,  participated 
in   by  eminent    physicians  from   this  city   and   else- 


where. On  tiie  afternoon  of  the  i6th  there  was  a 
discussion  on  obstetrics,  and  on  the  evening  of  that 
day  one  on  the  blood.  On  the  afternoon  of  the  17th, 
Prof.  Victor  Vaughn,  of  Ann  Arbor,  Mich.,  opened 
the  discussion  on  tuberculosis. 

J.  M.  Da  Costa  Memorial  Laboratory  of  Clinical 

Medicine The  faculty  of  Jefferson  Medical  College 

has  recommended  to  the  Board  of  Trustees  the  estab- 
lishment of  a  laboratory  of  clinical  medicine  in  honor 
of  and  to  be  named  after  the  late  distinguished  Dr.  J. 
M.  Da  Costa. 

College  of  Physicians  of  Philadelphia — Section 
on  General  Medicine At  a  stated  meeting  held  Oc- 
tober 8th,  Dr.  A.  O.  J.  Kelly  read  a  paper  on  ''  Splenic 
Anaemia,"  reporting  a  case.  Drs.  M.  H.  Fussell  and 
J.  D.  Steele  presented  a  report  of  two  cases  in  which 
the  signs  of  mitral  stenosis  disappeared  as  cardiac 
compensation  was  re-established. 

Large  Bequest  to  a  Hospital.  — By  the  will  of  the 
late  Charles  Edward  Orme.  of  Philadelphia,  an  estate 
of  $50,000  is  devised  to  the  Episcopal  Hospital,  to 
maintain  as  many  free  beds,  to  be  known  as  the 
'■  Charles  Edward  Orme  Free  Beds,"  as  the  income 
will  support,  after  the  death  or  remarriage  of  the 
widow. 

University  of  Pennsylvania. — It  has  been  an- 
nounced unofficially  that  the  wife  of  Dr.  S.  Weir 
Mitchell  will  present  to  the  University  of  Pennsylva- 
nia, in  memory  of  her  daughter,  either  an  addition  to 
the  present  hospital  building  or  a  separate  structure 
for  the  treatment  of  those  suffering  from  contagious 
disease. 

Medico-Chirurgical  College  of  Philadelphia. — 
Hon.  Edward  M.  Parson,  e.x-chief  justice  of  the  su- 
preme court  of  Pennsylvania,  has  been  elected  presi- 
dent of  the  Medico-Chirurgical  College  of  Philadel- 
phia. It  is  expected  that  the  nine  representatives  of 
the  faculty  and  the  one  representative  of  the  Alumni 
Association  on  the  board  of  trustees  will  withdraw,  so 
that  the  board  shall  be  constituted  of  fifteen  laymen. 

Pathological    Society    of    Philadelphia — At   the 

annual  meeting  held  October  iith,  the  president.  Dr. 
F.  A.  Packard,  read  the  annual  address;  the  treasurer. 
Dr.  T.  S.  Westcott,  made  his  report  for  the  year;  and 
the  following  officers  were  elected:  President,  Dr.  F. 
A.  Packard;  Vice-Presidents,  r')rs.  Joseph  McFarland, 
C.  W.  Burr,  Alfred  Stinzel,  Simon  Flexner;  Secretary, 
Dr.  J.  Dutton  Steele;  Treasurer,  Dr.  Thompson  S. 
Westcott ;   Curator,  Dr.  W.  Wayne  Babcock. 

Typhoid  Fever  at  Newport.— Quite  an  epidemic 
of  this  disease  exists  at  Newport,  R.  I.,  and  it  is  re- 
ported that  there  are  over  fifty  cases  in  the  city.  The 
hospital  accommodations  are  overtaxed,  and  the  board 
of  alderman  has  appointed  a  committee  to  arrange  for 
the  establishment  of  an  emergency  hospital.  Newport 
has  no  regular  board  of  health  composed  of  medical 
men  or  sanitarians,  the  aldermen  acting  in  that  capac- 
ity, and  on  this  account  it  is  much  harder  to  deal  with 
such  cases. 


I 


October  20,  1900J 


MEDICAL    RECORD. 


621 


The  Hospital  Ship  <' Maine." — The  American 
ladies'  committee  in  London  has  received  a  cable  de- 
spatch from  Wei-hai-W'ei,  China,  dated  Wednesday, 
October  joth,  reporting  tiie  return  there  of  the  Ameri- 
can hospital  ship  J/iii>ie  hom  Taku  with  many  invalids 
on  board,  of  whom  two  officers  and  sixty-nine  men  are 
Americans.  Eighteen  of  the  latter  belong  to  the 
Ninth  Infantry.  The  Maine  sailed  for  Nagasaki  on 
October  i  ith. 

The  Psychological  Laboratory  at  Columbia. — 
Many  improvements  in  this  laboratory,  made  pos- 
sible by  a  gift  of  $roo,ooo  from  Mr.  John  D.  Rocke- 
feller, have  now  been  completed,  and  the  space  and 
facilities  of  the  department  have  been  materially 
increased.  The  new  arrangement  gives  Columbia 
facilities  for  psychological  work  that  are  said  to  be 
unequalled  by  those  of  any  university,  with  the  pos- 
sible exception  of  that  of  Leipsic. 

Health  Conditions  in  Guam. — Surgeon-General 
Van  Reypen  of  the  navy  does  not  approve  of  Guam  as 
a  naval  station,  his  objection  being  based  upon  sani- 
tary grounds.  In  his  annual  report  to  the  secretary  of 
the  navy  he  says  that  typhoid  fever  is  practically  en- 
demic in  the  island,  owing  to  the  pollution  of  drink- 
ing-water in  shallow  wells  near  cesspools  and  to  the 
very  common  lack  of  any  provision  whatever  for  the 
receipt  of  refuse  matter.  The  disease  appeared  among 
the  United  States  sailors  soon  after  theii  arrival  on  the 
station,  as  access  to  contaminated  water  was  under 
the  circumstances  unavoidable.  During  less  than  five 
months  there  were  twenty-five  cases  and  four  deaths 
from  this  cause  in  a  force  of  one  hundred  and  forty- 
three  men.  The  climate,  he  says,  is  debilitating  after 
a  protracted  residence,  but  is  not  in  the  main  bad. 
The  mean  annual  temperature  is  above  77°  F.,  but  in 
the  winter  months,  though  the  days  are  hot  from  the 
larger  amount  of  sunshine,  the  nights  are  sufficiently 
cool  for  blankets.  At  this  season  the  humidity  is 
lessened.  From  June  to  November  or  December 
the  rainfall  is  heavy  and  almost  constant,  but  dur- 
ing the  rest  of  the  year  the  climate  is  very  agree- 
able. Leprosy  is  not  common  and  the  disease  is  not 
increasing.  There  are  only  fourteen  cases  known  to 
be  on  the  island  at  this  time.  The  surgeon-general 
thinks  it  would  be  better  to  establish  a  station  on 
Cabras  Island,  which  is  uninhabited  and  consequently 
uncontaminated,  in  place  of  the  present  one  at  Agana. 
As  Cabras  Island  is  not  inhabited,  its  soil  is  free 
from  infection.  Its  natural  drainage  is  excellent,  and 
it  is  reported  that  there  is  at  hand  an  ample  supply  of 
potable  water. 

Yellow  Fever. — One  hundred  and  thirteen  new 
cases  of  yellow  fever  were  reported  in  Havana  during 
the  first  twelve  days  of  October.  During  September 
there  were  fifty-two  deaths  from  yellow  fever  in  that 
city.  There  were  sixty-four  cases  among  Americans 
and  one  hundred  and  eighty-six  among  Spaniards.  Of 
the  former  five  died  and  of  the  latter  thirty-seven. 
The  Americans  there  say  that  now  is  the  time  to  have 
the  disease,  when  the  cases  are  working  out  a  low 
death  rate.     The  average  death  rate  is  25.68.     This  is 


considerably  better  than  for  any  September  in  the  last 
ten  years  with  the  exception  of  that  month  last  year. 
The  health  authorities  under  Major  Gorgas  are  mak- 
ing six  hundred  house  inspections  daily,  with  a  view 
of  enforcing  cleanliness.  In  a  recent  interview,  Gov- 
ernor-General Wood  is  reported  to  have  expressed  the 
belief  that  the  disease  is  propagated  by  means  of  bites 
of  insects,  either  fleas  or  mosquitos.  This  is  the 
theory  long  since  promulgated  by  Dr.  Carlos  Finlay, 
of  Havana,  but  which  found  little  support  until  the 
agency  of  mosquitos  in  the  spread  of  malaria  became 
an  established  fact.  Yellow  fever  is  epidemic  at  Vera 
Cruz  and  other  ports  on  the  lower  Gulf  coast  of  Mexi- 
co, but  Tampico  is  declared  free,  there  having  been 
but  two  cases  there  this  summer.  A  report  that  the 
disease  had  made  its  appearance  at  Monterey  has 
been  officially  denied. 

Health  Reports The  following  cases  of  smallpox, 

yellow  fever,  cholera,  and  plague  have  been  reported 
to  the  surgeon-general  of  the  United  States  Marine- 
Hospital  service  during  the  weekended  October  12, 
1900 : 


Smallpox — United  States. 


Cases.    Deaths. 


Alaska.  Nome October  7lh i* 

Kansas.  Wichita September  29th  to  October  6th.  . .     i 

Ohio,  Cleveland September  29th  to  October  6th. . .  10 

Pennsylvania,  Philadelphia. September  29th  to  October  6th. ..     4 
*  In  barracks. 

Smallpox — Foreign. 

Austria,  Prague September  8th  to  15th i 

Brazil,  Pcrnambuco August  24th  to  31st 4 

England,  Liverpool September  15th  to  22d i 

London September  1 5th  to  22d 3 

France,  Paris September  15th  to  aad 3 

St.   Etienne September  ist  to  15th i  i 

Germany,  K«jnjgsberg  ..    ..  September  8th  to  15th 2 

Mexico,  Vera  Cruz September  22d  to  29th i 

Russia,  Odessa September  15th  to  22d 11  2 

St.  Petersburg September  8th  to  15th    9  5 

Scotland.  Glasgow September  2ist  to  a&th 22  3 

Yukon  Territory,  Dawson. .  .September  8th Present. 

Yellow  Fever. 

Colombia,  Darranquilla September  16th  to  2  ,d i 

Cartagena September  ist  to  14th 3 

Cuba,  Havana September  23d  to  29th 

Mexico,  Vera  Cruz September  22d  to  39th 

Placl'e. 

Paraguay,  Asuncion ]u\y  21st  to  38th 

ScotUnd,  Glasgow September  15th  to  32d 3 

Wales,  I.landoff October  9th 

•  Imported  from  Rosario. 

Cholera. 
Straits    Settlements,    Singa- 
pore  August  nth  to  2Sth 


3 

'9 


Navy  Department,  Bureau  of  Medicine  and  Sur- 
gery, Washington,  D.  C. — Changes  in  the  medical 
corps  of  the  United  States  navy  for  the  week  ending 
October  13,  1900.  October  8th. — Passed  Assistant 
Surgeon  T.  W.  Richards  detached  from  the  Indiana 
and  ordered  to  the  Alabama,  October  i6th.  October 
9th. —  Passed  Assistant  Surgeon  L.  Morris  ordered  to 
the  naval  academy.  Assistant  Surgeon  D.  H.  Mor- 
gan detached  from  the  Vermont  and  ordered  to  the 
Pensacola  navy  yard.  Assistant  Surgeon  J.  A.  Mur- 
phy detached  from  the  Pensacola  navy  yard  and  or- 
dered to  the  Asiatic  station  for  duty  on  the  Don  Juan 
lie  Austria  ;  to  report  at  San  Francisco,  Cal.,  October 
30th,  for  passage  on  the  Solace.  October  loth. — As- 
sistant Surgeon  H.  II.  Haas  detached  from  the  Don 
Juan  lie  Austria  and  ordered  home  and  to  wait  orders. 
October  12th. — ("Orders  issued  by  commander-in-chief 
of  Asiatic  station.)  Passed  Assistant  Surgeon  G.  A. 
Lung  detached  from  the  Monocacy  and  ordered  to  the 


622 


MEDICAL    RECORD. 


[October  20,  1900 


Cavite  naval  station.  Assistant  Surgeon  J.  C.  Thomp- 
son, detached  from  the  Alonocacy  and  ordered  to  the 
Cavite  naval  station. 

The  Plague An  official  bulletin  has  been  issued 

in  Glasgow  announcing  that  the  outbreak  of  plague  in 
that  city  has  been  completely  checked.  All  the  sus- 
pects have  been  released,  and  the  reception  houses 
were  closed  on  October  nth.  On  that  date  twenty 
convalescents  were  still  in  hospital.  When  the  bu- 
bonic plague  appeared  in  Glasgow,  Dr.  A.  H.  Doty, 
health  officer  of  the  port  of  New  York,  ordered  a 
quantity  of  plague  serum  from  the  Pasteur  Institute, 
at  Paris,  as  a  precautionary  measure  for  use  at  quaran- 
tine in  the  event  of  the  plague  being  brought  to  this 
country  by  a  steamer  from  the  infected  port.  The 
serum  arrived  some  days  ago,  and  is  now  in  the  quar- 
antine laboratory. 

Obituary  Notes — Dr.  Crawford  Irwin  died  at 
Hollidaysburg,  Pa.,  on  October  7th,  at  the  age  of 
seventy-six  years.  He  was  president  of  the  Medical 
Society  of  the  State  of  Pennsylvania  in  1875  and 
1876. 

Dr.  Jacob  P.  Russel  died  at  Philadelphia  on  Octo- 
ber 7  th,  at  the  age  of  sixty-four  years.  He  was  gradu- 
ated from  the  Medico-Chirurgical  College  in  1887. 

Dr.  William  M.  Caterson  died  at  Philadelphia 
on  October  7th,  at  the  age  of  seventy  years.  He  was 
a  graduate  of  Jefierson  Medical  College. 

Dr.  Ross  Richardson  Bunting  died  at  Philadel- 
phia on  October  loth,  at  the  age  of  sixty-six  years. 
He  was  a  graduate  of  Jefferson  Medical  College  and 
of  the  Ecole  de  Me'decine  of  the  University  of  Paris. 

Dr.  Joseph  L.  Cutler  died  at  his  home  in  Bolivar, 
N.  Y.,  on  October  14th,  at  the  age  of  seventy-one 
years.  He  was  born  in  Moravia,  N.  Y.,  graduated 
from  the  University  of  New  York  in  1850,  and  the 
same  year  located  in  Bolivar.  He  served  ten  months 
as  assistant  surgeon  of  the  One  Hundred  and  Thirty- 
fourth  Regiment  New  York  Infantry  during  the  Civil 
War. 

Dr.  Franklin  Smith,  seventy-six  years  old,  died 
at  his  home  in  this  city  on  October  9th,  after  a  short 
illness.  He  was  born  in  this  State,  and  for  over  a 
quarter  of  a  century  had  been  a  resident  of  this  city. 
He  was  a  graduate  of  the  Medical  Department  of  the 
New  York  University  in  1865.  He  was  a  member  of 
the  Medical  Society  of  the  County  of  New  York. 
Three  daughters  and  one  son,  Dr.  Charles  Smith  of 
this  city,  survive  him. 

Dr.  Benjamin  Hussev  West,  one  of  the  old  gradu- 
ates of  Harvard  University,  died  at  Neponset,  Mass., 
on  October  i  ith.  He  was  born  in  Nantucket,  Novem- 
ber 10,  1814,  and  was  the  son  of  Paul  West,  a 
lieutenant  in  the  British  navy  and  commander  of  the 
ship  Cyrus.  He  graduated  from  Harvard  in  1835  in 
the  class  with  the  late  Bishop  VVilliams  of  Connecti- 
cut, Judge  E.  R.  Hoar,  Amos  A.  Lawrence,  John  A. 
King,  and  others  who  have  been  prominent  in  public 
life.  Only  five  survivors  of  the  class  remain.  He 
was  graduated  from  thi:  Haivard  Medical  School  in 
1838  and  commenced  professional   life  at  Pawtucket. 


In  the  early  forties  he  went  to  California,  where  he 
remained  for  several  years,  being  a  member  of  the 
committee  of  safety  during  1849.  Later  he  was  for 
many  years  head  surgeon  of  the  Pacific  Mail  Steam- 
ship Company. 


progress  of  ^ctlical  Science. 

AVTi'  York  Mtu/ical /oiirnal,  October  ij,  igoo. 

The  Future  of  Specialties. — In  a  general  consideration  of 
the  relationship  of  post-graduate  instruction  to  special  work 
in  medicine  and  surgery,  C.  B.  Kelsey  says:  "The  advice 
of  every  specialist  to  those  who  a.e  desirous  of  coming  into 
his  special  lield,  no  matter  what  his  own  course  may  be. 
is  invariably  now  :  fit  yourself  fcr  a  surgical  specialty  by 
first  learning  general  surgery.  The  result  will  be  that  a 
man  who  has  once  studied  general  surgery  will  never  be 
a  narrow  specialist.  Some  one  branch  of  work  he  may 
prefer,  and  that  branch  may  in  time  come  to  him  to  the 
exclusion  of  others  ;  but  arbitrary  lines  will  not  limit  him 
•SO  closely  as  they  have  done  in  the  past.  We  can  all  re- 
member when  gynaecology  consisted  practically  of  plastic 
work  upon  the  uterus  and  vagina.  It  will  never  go  back 
to  it.  The  specialty  to  which  I  have  devoted  my  own  life 
is  still  thought  by  many  to  consist  properly  of  piles  and 
fistulfe.  but  it  will  never  again  be  separated  from  gynjecol- 
ogy  and  genito-urinary  surgery.  Since,  for  success  in  any 
specialty,  a  broader  education  will  be  necessary,  this  will 
be  acquired  before  special  work  is  begun.  There  will  be 
fewer  men  who  have  begun  as  specialists  and  have  never 
done  general  practice,  or  men  will  commence  special  prac- 
tice after  more  years  of  preparation.  But  specialists  will 
not  disappear,  for  the  very  same  reason  that  they  ever 
came  into  existence,  which  is  that  the  whole  field  of  medi 
cine  is  too  large  to  be  covered  by  any  one  man,  no  matter 
how  hard  the  exigencies  of  life  may  induce  him  to  try  ;  and 
those  who  have  devoted  the  most  study  to  any  one  held 
and  acquired  the  greatest  experience  in  it  will  always  be 
sought  after  by  the  public  to  practise  in  that  field." 

Dilatation  of  the  Colon. — H.  G.  Marxmiller  gives  the  fol- 
lowing clinical  history  of  a  case  and  illustrates  his  paper 
with  some  excellent  photographs.  He  regards  the  condi- 
tion as  undoubtedly  secondary  to  a  tertiary  lesion  of  the 
spinal  cord,  which  at  last  accounts  was  responding  slowly 
to  specific  treatment.  His  patient  was  a  machinist  aged 
fifty-two  years,  a  man  of  medium  build.  He  had  con- 
tracted syphilis  twenty  years  before,  for  which  he  had  re- 
ceived treatment.  Ten  years  after  the  initial  lesion  had 
appeared,  several  specific  leg  ulcers  were  observed  He 
had  been  apparently  well  up  to  three  years  ago,  when, 
while  working  in  a  machine  shop  on  a  cold  November  day. 
he  was  seized  with  an  attack  of  chills  accompanied  by  fe- 
ver. There  was  also  severe  pain  in  the  dorsal  region, 
which  by  morning  had  become  inflamed.  Theie  was  no 
suppuration  or  necrosis.  Ten  days  after  the  acute  symp- 
toms had  subsided,  a  marked  angular  curvature  of  the 
spine  was  observed,  and  a  week  later  dilatation  of  the 
colon. 

On  the  Employment  of  the  Upright  Position  in  Ether  Op- 
erations upon  the  Nose,  Throat,  and  Ear. — By  means  of  some 
excellent  photographs  T.  R.  French  illustrates  his  method, 
which  consists  in  bringing  the  patient  partially  under  the 
ana;sthetic,  as  usual,  and  then  placing  him  in  the  specially 
devi.sed  chair  used,  and  gradually  bringing  the  lattjr  from 
a  position  of  being  tilted  far  back  to  an  upright  iiorition, 
the  patient  being  fastened  to  the  chair.  By  the  time  the 
upright  position  is  reached  the  patient  is  sufficiently  under 
the  aiia;sthetic  for  the  operation  to  begin.  No  bad  results 
have  been  exiierienccd.  and  French  claims  for  tli  ujiright 
position  the  threefold  advantage  of  reduction  in  amount  of 
t)loo(l  lost,  better  nasopharyngeal  drainage,  thereby  lessen 
ing  the  lialiility  to  car  complications,  and  finally  tlie  ease, 
thoroughness,  and  accuracy  with  which  operations  can  be 
done  in  the  shortest  time  by  the  retention  of  the  usual  re- 
lationship between  ojierator  and  patient. 

Hypertrophy  of  the  Turbinated  Bodies  and  their  Relations 
to  Inllammation  of  the  Middle  Ear,  with  a  Report  of  1,500 
Operations.  —  By  C.  K.  Holmes. 

The  Present  State  of  Our  Knowledge  Concerning  the  Cause, 
Nature,  and  Treatment  of  Asthma.— By  W.  A.  Wells 

The  Etiology  of  Pulmonary  Tuberculosis,  its  Course  and 
Termination.  — By  S.  A.  Kno])f. 

Boston  Miutical  aiui  Surgical  Journal,  October  11.  igoo. 

Breast    Feeding. — A.   Worcester   says   tliat   both    for  the 

mothers'  sakes   and   the   babies'    sakes  physicians   are   in 

duty  bound  to  urge  the  vital  importance  and  the  otherwise 


October  20,  1900] 


MEDICAL    RECORD. 


623 


Tjnattainable  ailvantaijes  of  breast  feeding.  Much  to  this 
■end  can  be  done  during  pregnancy  in  teaching  women 
wl)at  to  expect.  When  the  baby  is  first  put  to  the  breast, 
the  physician's  largest  chance  of  service  comes  in.  His 
unstinted  time  and  patience  are  then  needed.  Nature's 
indications  should  be  followed,  and  the  child  not  stuffed 
with  food  in  the  first  three  days  of  life.  It  will  then  be 
hungry  enough  to  ease  the  aching  breasts  when  there  is  a 
supply  of  milk.  No  washes  are  to  be  u^ed  on  the  nipples, 
but  olive  oil  or  lanolin,  with  tallow  and  beeswax,  or  the 
raw  white  of  egg  for  a  protective  dressing.  Cracks  and 
excoriations  will  then  be  infrequent.  If  they  occur,  disin- 
fection with  a  boracic-acid  lotion  (five  per  cent.)  should  be 
followed  by  ana;sthetizing  with  cocaine  and  treatment  with 
a  ten-per-cent.  solution  of  silver  nitrate.  The  part  is  then 
■dried  by  pressure  of  absorbent  cotton  and  painted  over 
with  egg  albumen.  For  the  next  few  nursings  a  glass-bell 
nipple  shield  should  be  used. 

Home  Modification  of  Milk. — Charles  W.  Townsend  thus 
concludes  his  article  :  The  modification  of  cow's  milk,  with 
A  knowledge  of  the  percentages,  is  preferable  to  guesswork 
feeding  of  infants.  Percentage  feeding  can  be  carried  out 
by  a  milk  laboratory  or  by  home  modifications.  Milk  lab- 
oratories are  unavailable  to  many,  and,  in  the  experience 
of  tlie  writer,  do  not  agree  with  infants  as  often  as  home 
•modifications.  Laboratory  modifications  are  necessarily 
subjected  to  more  handling  and  transportation  than  home 
modifications.  Milk  that  is  fresh,  clean,  and  from  cows 
free  from  tuberculosis  is  preferable  uncooked,  or,  in  other 
words,  pasteurization  and  sterilization,  although  some- 
times essential,  are  to  be  avoided  if  possible.  The  method 
•of  home  modification  and  of  calculating  percentages  should 
and  can  be  made  extremely  simple,  and  such  modifications 
are  sufficiently  accurate  and  uniform.  The  addition  of  ce- 
reals to  the  milk  in  the  form  of  barley  or  oatmeal  water  is 
generally  advisable  after  the  seventh  month,  and  is  desir- 
able before  that  age  in  some  cases  as  an  aid  to  the  diges- 
tibility of  the  milk. 

lesion  of  the  Chiasm. — S.  A.  Lord  reports  a  case  of  this 
■disease  occurring  in  a  laboring  man  aged  thirty-two  years, 
born  of  consanguineous  parents,  with  a  family  history  of 
gigantism  and  neuropsychopathic  tendencies,  this  individ- 
ual himself  presenting  evidences  of  gigantism  and  signs  of 
degeneracy,  and  of  defective  development.  There  is  no 
doubt  of  the  existence  of  a  chiasm  lesion,  the  trouble  hav- 
ing first  involved  the  fasciculi  of  the  left  optic  nerve,  and 
subsequently,  in  succession,  the  fasciculus  cruciatus  and 
fasciculus  lateralis  of  the  right.  The  presence  of  a  tumor 
is  rendered  probable  by  the  facts  that  other  conditions 
causing  these  visual  symptoms  can  be  eliminated,  that  the 
headache,  vertigo,  tinnitus,  and  momentary  loss  of  speech, 
and  the  irritative  optic-nerve  symptoms  can  be  better  ex- 
plained as  tumor  symptoms  than  otherwise.  There  is  at 
least  one  focal  sign,  slight  in  itself,  but  extremely  sugges- 
tive of  tumor^strabismus.  Various  arguments  point  to 
the  probability  of  a  tumor  of  the  hypophysis. 

The  Modification  of  Milk  in  Milk  Laboratories. — By  T.  M. 
Rotch. 

Philadelphia  Mciiiial  Journal,  October  /j,  ic)oo. 

General  Summary  of  the  Cases  of  Typhoid  Fevet  Treated 
in  the  Johns  Hopkins  Hospital  for  Ten  'years. — William  Os- 
ier makes  the  following  report  of  the  829  cases  of  typhoid 
fever  which  have  been  under  his  care  or  that  of  his  assist- 
ants to  May  .5,  1S99:  Sex — 631  were  males ;  19S,  females. 
Race — 729  were  white  ;  100,  colored.  As  to  nationality  the 
Americans  predominated,  numbering  348,  Germans,  200; 
the  remaining  number  being  Irish,  Bohemians,  English, 
Poles,  etc.  Age — 393  were  between  twenty  and  thirty 
years  of  age,  the  largest  number  in  any  one  decennary. 
Mortality — 7.5  per  cent.,  there  being  63  deaths  in  the  829 
cases.  'Treatment:  (i)  A  careful  and  thorough  system  of 
nursing;  (2)  diet,  milk  diluted  with  limewater  and  egg 
albumen  form  the  standard  diet  of  the  febrile  stage  :  abun- 
dance of  cold  water;  (3)  hydrotherapy,  either  the  full  tub 
at  70"  F.,  or,  if  occasion  requires,  ice-cold  sponges;  (4) 
drugs:  as  a  rule  no  medicines  are  given.  If  the  pulse 
becomes  rapid  and  feeble,  he  gives  alcohol  in  the  form  of 
good  whiskey,  and  strychnine,  if  necessary,  in  full  doses. 
No  antipyretics  and  no  intestinal  disinfectants  are  to  be 
given.  Special  complications  require  and  receive  appro- 
priate treatment.  The  rash — Rose-spots  were  present  in 
666  cases.  Diarrhoea — There  was  diarrhoea  at  the  onset  in 
322  cases  before  the  patient  entered  the  hospital.  In  163 
of  the  829  cases,  i.e.,  nineteen  per  cent.,  there  was  diar- 
rhoea at  some  time  or  other  in  the  course  of  the  disease,  and 
in  290  cases,  thirty-four  per  cent.,  there  was  constipation. 
Relapse — We  are  still  really  without  full  knowledge  of  the 
causes  of  relapse,  but  the  frequent  occurrence  is  a  positive 
indication  that  immunity  in  typhoid  fever  is  slowly  ac- 
quired, and  not  reached  at  the  period  of  apyrexia.  There 
were  86  relapses,  a  little  more  than  ten  per  cent.  Under 
complications  and  sequelte  are  mentioned  hemorrhage  from 


the  bowels,  perforation,  haematemesis,  phlebitis,  pneu- 
monia, albuminuria,  tube  casts,  acute  nephritis,  orchitis, 
and  herpes. 

Concerning  Calentura. — Frank  W.  Foxworthy  states  that 
in  tropical  countries  the  term  "calentura"  embraces  any- 
thing from  pernicious  malarial  fever  to  a  simple  pyrexia, 
and  the  natives  often  designate  any  febrile  condition  as 
calentura.  It  should,  however,  be  strictly  limited  to  that 
fever  occurrmg  usually  during  the  months  of  December, 
January,  and  February,  which  exhibits  the  symptoms  of  a 
simple  continued  fever  with  a  small  mortality.  There  is 
generally  a  sudden  rise  in  temperature  to  104',  105',  or 
even  to  106'  F.,  with  headache,  malaise,  furred  tongue, 
anorexia,  ])ains  in  the  back,  chest,  and  legs.  The  differ- 
ential diagnosis  from  dengue  is  difficult.  But  the  terminal 
fever  and  the  ever-present  eruption  and  desquamation  of 
dengue  are  entirely  absent.  Variola,  however,  with  its 
high  initial  fever  and  the  sharp  lumbar  pains,  also  is  much 
like  calentura.  Typhoid  fever  will  not  be  diagnosed  in  a 
case  of  calentura,  on  account  of  the  temperature  chart,  ab- 
sence of  epistaxis  in  calentura,  absence  of  abdominal  pain 
and  borborygmus  and  of  the  typhoid  eruption.  Phenace- 
tin  or  antipyrin  in  large  doses  seem  specific.  Cool  baths 
are  given.  The  fever  is  rarely  fatal  in  the  Philippines. 
Whether  ths  fever  will  be  designated  as  one  of  the  obscure 
varieties  of  malarial  fever,  or  will  be  known  as  a  distant 
relation  of  "influenza,"  which  it  simulates  often  in  epi- 
demic form,  or  whether  it  will  continue  to  be  one  of  the 
many  unclassed  fevers  of  the  tropics  with  only  a  local  ap- 
pellation, time  and  the  microscope  will  decide. 

A  Review  of  the  History  of  Cardiac  Pathology,  with  Espe- 
cial Reference  to  Modem  Conceptions  of  Myocardial  Disease. 
— By  Alfred  Stengel. 

Appendicitis  :  Pin  in  Appendix ;  Abscess  of  Liver ;  Puru- 
lent Peritonitis  ;  Death. — By  I-^.  H.  Trowbridge. 

Rupture  of  Symphysis  Pubis  during  Parturition,  with  Re- 
port of  a  Case. — By  (1.  A.  Ilimmelsljach. 

Some  Phases  of  the  Tuberculosis  Problem  in  Colorado. — 
By  S.  G.  Bonney. 

Fracture  of  the  Carpus. — By  G.  G.  Ross. 

Medical  News,  October  13,  /goo. 

A  Consideration  of  Finger  Infection  with  Special  Reference 
to  the  Joints  and  Tendons.  — Ellsworth  Eliot,  Jr..  at  the 
close  of  his  paper  on  this  subject  cites  several  cases,  one 
of  which  especially  is  of  unusual  interest.  It  is  that  of  a 
man  aged  thirty-two  years,  in  the  palmar  surface  of  whose 
right  middle  finger,  over  the  junction  of  the  first  and  sec- 
ond phalanges,  a  small  fragment  of  glass  became  embed- 
ded. This  the  patient  removed  with  an  old  razor,  and  sev- 
eral hours  later  there  were  unmistakable  signs  of  infection. 
Infection  was  introduced  a  short  distance  only  beneath  the 
skin,  and  from  this  point,  notwithstanding  early  and  exten- 
sive incisions,  the  infecting  material  was  carried  not  only 
into  the  tendon  sheath,  but  also  into  the  joint.  The  sepa- 
ration of  necrotic  tendon  required  several  weeks  longer 
than  usually  is  the  case  ;  in  fact,  at  one  time  it  was  hoped 
that  notwithstanding  the  suppurative  tenosynovitis  the 
viability  of  the  tendon  might  be  preserved.  The  arthritis 
behaved  in  a  very  peculiar  way.  The  second  phalanx  was 
double  its  normal  size  and  denuded  through  a  considerable 
part  of  its  extent.  Yet  exfoliation  did  not  take  place  en 
masse,  although  that  there  must  have  been  some  gradual 
loss  of  bone  is  demonstrated  by  the  permanent  shortening 
of  the  finger.  The  thickened  condition  of  the  phalanx  per- 
sisted months  after  healing  was  complete.  The  occurrence 
of  secondary  hemorrhage  was  an  indication  merely  of  in- 
sufficient drainage  of  the  abscess  cavity.  This  demanded 
the  joining  together  of  the  incisions  on  the  anterior  aspect 
of  the  finger  and  lower  palm  of  the  hand — a  procedure 
which  is  usualLy  necessary  before  the  abscess  cavity  will 
heal.  In  the  majority  of  cases  of  joint  infections  a  stiff 
finger  results  which  greatly  impairs  its  future  utility,  even 
if  the  finger  is  not  actually  in  the  patient's  way.  In  these 
cases  the  question  of  amputation  is  one  for  the  patient,  not 
the  surgeon,  to  decide. 

The  Prevention  and  Treatment  of  "  Colds."— W.  Schep- 
pegrell  declares  that  coryza  is  of  such  frequent  occurrence 
and  plays  so  important  a  role  in  the  development  of  other 
affections,  that  the  subject  merits  the  most  careful  atten- 
tion, especially  as  the  most  diverse  opinions  exist  as  to  its 
etiology  and  treatment.  Prophylaxis  is  of  the  first  impor- 
tance. Overheated  rooms  should  be  avoided.  The  cloth- 
ing should  not  be  too  heavy  or  warm.  The  cold  shower 
bath  is  an  e.xcellent  preventive.  The  nasal  passages 
should  be  kept  in  normal  condition.  The  writer  affirms 
that  his  personal  experience  and  observation  have  con- 
vinced him  that  there  are  but  few  constitutional  remedies 
of  any  value  in  this  condition.  When  coryza  is  due  to  a 
uric-acid  diathesis  lithia  is  sometimes  effective.  L'n-iced 
water  is  also  beneficial.  A  brisk  saline  purgative  within 
the  first  twenty-four  hours  is  most  useful.     Cocaine  should 


624 


MEDICAL    RECORD. 


[October  20,  1900 


rarely  be  used  and  never  be  prescribed.  It  has  enormous 
possibilities  for  evil.  The  nostrils  may  be  bathed  with 
a  warm  one-half-per-cent.  salt  solution.  It  should  be  ap- 
plied by  some  sort  of  douche,  gently,  and  the  nose  should 
not  be  blown  for  ten  or  twenty  minutes.  When  the  gen- 
eral condition  is  kept  in  good  trim,  coryza  will  be  very 
infrequent. 

Cocaine  Anaesthesia  by  Lumbar  Puncture :  Two  Cases  of 
Hysterectomy. — J.  Riddle  Gotfe  writes  that  the  success 
wliich  has  attended  the  intraspinal  injections  of  cocaine  for 
producing  anicstliesia  was  considered  one  of  the  prominent 
advances  in  surgery  at  tlie  recent  International  Medical 
Congress.  The  credit  of  demonstrating  the  advantages  of 
this  method  is  due  to  Professor  Bier,  of  Kiel,  but  Tufher, 
of  Paris,  and  Kreis,  of  Bucharest,  have  used  it  in  a  greater 
number  and  a  wider  variety  of  cases.  So  far,  no  detriment 
to  the  patient  has  attended  the  procedure  ;  complete  anal- 
gesia is  produced  during  operations  e.\tending  over  a  pe- 
riod of  two  liours,  the  benumbing  effect  gradually  wearing 
off  in  three  or  four  hours,  as  a  rule.  The  amount  of  the 
drug  used  varies  from  gr.  i],i  to  ',-2.  The  analgesic  effect 
e.xtends  usually  from  the  toes  to  the  umbilicus,  and  opera- 
tions may  be  performed  with  immunity  to  pain  on  any 
parts  below  the  latter  point.  The  writer  then  describes 
his  two  cases,  one  of  which  was  a  vaginal  hysterectomy, 
the  other  an  abdominal  hysterectomy.  The  results  were 
most  favorable. 

Treatment  of  Rheumatism  and  Some  Phases  of  Indiges- 
tion ;  Gouty  Diathesis. — By  Charles  E.  Page. 

Jo7irnal  of  the  American  Medical  Ass' 7!,  Oct.  ij,  /goo. 

A  Study  of  the  Inoculation  Theory  of  Malarial  Fever. — 
Albert  Woldert  states  that  one  may  devise  either  of  two 
methods  in  studying  the  relation  of  mosquitos  to  malarial 
fever  ;  first  to  search  for  the  anopheles  in  its  native  haunts, 
and  then  for  the  case  of  malarial  fever  ;  or  secondly,  to 
find  the  case  of  malarial  fever  and  afterward  look  for  the 
anopheles.  According  to  observations  made  by  different 
scientists  in  various  parts  of  the  world,  it  has  been  demon- 
strated that  not  all  genera  of  mosquitos  are  capable  of  in- 
oculating man  or  birds  with  malarial  fever.  This  power 
so  to  do  appears  to  rest  solely  with  the  different  species  of 
the  genus  anopheles.  Studies  of  the  human  blood  reveal 
the  presence  of  certain  small,  round,  actively  motile  intra- 
corpuscular  organisms.  These  grow  to  full  development 
at  the  e.Kpense  of  the  red  blood  disc,  and  subsequently  rup- 
ture, setting  free  a  number  of  hyaline  bodies  that  at  once 
re-enter  other  erythrocytes.  These  results  therefore  go  to 
show  that  the  sporozoa  or  plasmodia  of  Laveran  require  for 
their  complete  existence  two  biological  cycles,  one  being 
completed  in  the  body  of  man,  the  other  being  completed 
in  the  tissues  of  the  mosquito.  Should  the  mosquito  be  the 
only  agent  in  disseminating  malarial  fever,  the  destruction 
of  the  larva;  or  pupEe  of  that  insect  would  be  only  one  way 
of  getting  rid  of  the  disease.  Manson  suggests  the  follow- 
ing methods;  (i)  To  begin  by  administering  quinine  for 
long  intervals  in  all  cases  of  malarial  fever,  since  a  single 
man  is  a  source  of  infection  to  a  whole  locality;  (2)  to 
cause  all  persons  suffering  with  malarial  fever  to  sleep  un- 
der mosquito  netting  ;  (3)  to  compel  all  the  uninfected  to 
sleep  in  mosquito-proof  houses  or  beds  ;  (4)  to  kill  by  dif- 
ferent culicicides  all  mosquitos  entering  houses;  (5)  to 
destroy  all  the  mosquito  larvse  before  they  reach  maturity 
or  the  biting  stage — to  which  might  be  added  the  destruc- 
tion of  the  adidt  mosquitos  in  their  places  of  hiberna- 
tion ;    (6)  the  combination  of  all  these  methods." 

The  Atrophic  Pharynx. — Ralph  W.  Seiss  writes  that  all 
types  of  simple  chronic  inflammation  of  the  pharyn.x  tend 
to  progress  into  the  atro])hic  form.  What  might  be  called 
the  average  type  of  chronic  pharyngitis  is  characterized  by 
the  enlargement  of  the  lyni]>h  glands,  giving  the  so-called 
follicles,  by  dilatation  of  the  superficial  blood-vessels,  and 
especially  by  the  formation  of  small  masses  of  granulation 
tissue,  which  are  usually  situated  immediately  behind  the 
posterior  half  arches  of  the  palate.  Atrophic  areas,  show- 
ing as  sunken,  glistening,  light-colored  spots,  occur  in  the 
central  portions  of  the  pharyngeal  wall.  Such  a  throat 
may  remain  in  statu  quo  for  half  a  lifetmie,  but  in  certain 
cases  the  greater  portion  of  the  pharyngeal  surface  is  in- 
filtrated. The  pathological  process  is  identical  with  fibrosis 
elsewhere.  The  etiology  is  almost  unknown.  Gouty  sub- 
jects are  more  prone  to  it  tlian  others.  Treatment  so  far 
as  restoring  function  is  concerned  must  always  be  unsat- 
isfactory. Stimulant  and  alterative  sprays,  such  as  oil 
solutions  of  gaultheria,  cinnamon,  thymol,  and  the  like,  are 
certainly  of  benefit.  The  physician  should  apply  them,  and 
only  to  a  membrane  which  has  been  carefully  cleansed  by 
an  alkaline  spray.  The  massage  effect  of  properly  cliosen 
atomized  fluids  when  driven  witli  a  pressure  of  from  fif- 
teen to  eighteen  pounds  is  very  decided  and  most  beneficial. 
In  the  irritable  cases  much  less  can  be  done.  Pigments 
seem  to  give  more  definite  results  than  nebulje.  Tliymol 
solution  in  alcohol  and  glycerin,  tincture  of  sanguinaria 


and  glycerin  and  copper  sulphate,  are  favorites  with  the 
writer;  iodine  is  sometimes  useful.  Too  much  must  not 
be  hoped  for,  and  patients  must  be  frankly  told  that  the 
condition  is  not  definitely  curable. 
'  Systematic  Cleansing  of  the  Nasal  Cavities  before  Opera- 
tions which  Involve  Opening  of  Eyeball. — J.  A.  Lijjpincott 
descriljes  his  method  as  follows  :  A  few  hours  before  oper- 
ation in  every  case,  a  spray  of  potassium  permanganate, 
1:2,000,  is  thoroughly  applied  to  the  nostrils.  In  some 
cases  the  s])raying  is  repeated  immediately  before  the  op- 
eration, and  wlien  there  is  decided  evidence  of  nasal  dis- 
ease each  of  the  tliree  or  ff)ur  days  succeeding  it.  The 
permanganate  spray  has  potency  enough  to  destroy  a  large 
proportion  of  the  organisms  with  which  it  comes  in  contact. 
This  procedure  has  been  carried  out  in  one  hundred  and 
fifty-two  operations  in  which  the  globe  was  [jenetraled,  and 
there  was  not  only  a  complete  absence  of  any  sign  of  sup- 
purative inflammation,  but  there  was  an  unusual  degree 
of  freedom  from  inflammation  or  irritation  of  any  kind,  al- 
though a  number  of  the  cases  were  of  an  unfavorable  na- 
ture. The  wounds  healed  with  less  tlian  the  usual  degree 
of  redness,  and  convalescence  was  more  siieedy  than  in 
previous  experiences. 

Cellulitis  Succeeding  Contusion  of  Leg ;  Extensive  Slough- 
ing; Skin  Grafting;  Recovery. — Henry  W.  Sawtelle  reports 
this  case.  The  lesion  occurred  in  a  Danisli  seaman  aged 
twenty-four  years.  He  was  struck  on  the  inner  side  of  the 
left  leg  by  a  piece  of  lumber,  apparently  only  a  slight  con- 
tusion resulting.  Chill,  fever,  and  intense  headache  fol- 
lowed ill  a  few  hours.  The  injected  area  in  tlie  leg  was 
incised,  evacuating  much  pus.  Two  days  later  a  second 
incision  was  made.  Sloughing  followed,  despite  careful 
antiseptic  treatment.  As  soon  as  the  wound  allowed,  skin 
grafting  was  performed  with  happy  results.  The  lowered 
condition  of  the  constitution  probably  accounted  for  the 
history  of  the  infection. 

Epithelioma. — Charles  J.  Whalen  reports  two  cases,  the 
first  that  of  a  man  aged  eighty-five  years,  who  was  af- 
flicted by  this  growth  for  twenty-one  years  before  he  died. 
The  second  case  was  of  a  man  aged  forty  years.  The 
writer  removed  this  growth,  which  was  on  the  right  side 
of  the  nose  just  at  the  point  where  tlie  no.se-rest  of  the 
glasses  rests.  Nearly  four  years  later  the  patient  was  en- 
joying the  best  health.  These  seeming  warts  and  dry  fis- 
sures in  people  past  middle  life  are  always  suspicious. 

The  Present  Status  of  Our  Knowledge  Concerning  the  Bac- 
teriology and  Serum  Treatment  of  Diphtheria. — Bv  Samuel 
E.  Allen. 

Pathology  of  Malarial  Fevers,  Structure  of  the  Parasites, 
and  Change  in  Tissue. — By  Jesse  W.  I.azear. 

A  Case  of  Coloboma  of  Each  Lens  without  Coloboma  of  the 
Iris  or  Choroid. — By  James  Mooits  Ball. 

What  Amount  of  Visual  Defect  Should  Disqualify  in  Rail- 
road Service? — By  Frank  Allport. 

The  Health  and  Wealth  of  Benguet  Province,  P.  I.— By 
J.  C.  Minor. 

Facts  Regarding  Criminal  Abortion. — By  Denslow  Lewis. 

Operation  for  Secondary  Cataracts. — By  Peter  A.  Callan. 
T lie  Lancet,  October  6.  i()oo. 

Aneurism  of  the  Renal  Artery. — H.  Morris  regards  aneu- 
risms at  this  site  as  among  the  very  rare  lesions  seen  in 
the  human  subject.  Two  varieties  may  be  found  after  in- 
juries:  (I)  Small  sacciform  aneurism,  the  walls  of  which 
are  formed  by  some  or  all  the  coats  of  the  artery  ;  and  (2) 
large,  false  aneurism,  the  walls  of  which  are  composed  of 
the  condensed  fibrous  tissue  developed  around  theextrava- 
sated  and  coagulated  blood,  and  witli  which  the  surround- 
ing organs  and  tissues  become  more  or  less  firmly  matted. 
The  latter  may  develop  in  three  ways  :  (i)  By  the  giving 
way  of  a  small,  true  aneurism,  which  may  be  either  of 
spontaneous  or  traumatic  origin  ;  (2)  by  the  yielding  of  a 
thrombus  which  temjiorarily  closed  a  ruptured  artery  ;  and 
(3)  by  the  immediate  outpouring  of  blood  from  a  ruptured 
artery.  From  the  analysis  of  quite  a  large  number  of  cases 
he  summarizes  the  symptoms  as  tumor,  and  contrary  to  the 
usual  rule  in  this  aHection  without  pulsation,  a  possible 
bruit,  jiain.  and  ha'maturia,  with  such  constitutional  symp- 
toms as  might  be  expected  from  loss  of  blood  and  luessure. 
The  urine,  except  for  the  blood  and  a  little  albumin  be- 
tween the  attacks  of  bleeding,  is  normal.  The  only  treat- 
ment offering  any  satisfactory  result  is  ne|)hrectomy  and 
the  removal  of  all  or  a  part  of  the  aneurismal  swelling. 

The  Limits  of  the  Heart  Dulness  in  Cases  of  Anaemia  and 
Chlorosis.-  I\.  AVybauw  says  that  if  the  cardiac  muscle 
loses  its  strength  liccausc  its  nutrition  is  impaired,  con- 
traction will  l)ecome  impossible  and  dilatation  will  occur. 
This  condition  arises  when  the  relation  between  the  press- 
ure of  the  blood,  especially  in  the  ventricle,  and  the 
strength  of  the  muscle  is  no  longer  normal,  the  latter  being 
unequal  to  the  former.     It  may  be  that  in  chlorosis  there  is 


October  20,  1900] 


MEDICAL   RECORD. 


625 


a  gc-neral  infiltration  of  the  tissues  by  effused  blood  serum. 
Tlic  heart  muscle  would  be  affected  the  same  as  other  mus- 
cles and  cause  a  diminution  of  force  leading  to  dilatation. 
As  the  quality  of  the  blood  is  improved  i)y  appropriate 
treatment,  this  effusion  is  gradually  lessened  and  the  force 
of  tlie  cardiac  muscle  increased  with  a  consequent  return 
to  normal  ctmdiiions.     Illustrative  cases  are  given. 

A  Case  of  Acute  Albuminuria  (Acute  Renal  Congestion) 
with  Ursmia  ;  Recovery. —  The  case  is  reported  by  V.  C. 
Evill.  and  is  of  interest  in  view  of  tlie  extremely  short  pe- 
riod elapsing  (tliree  days)  between  the  patient's  being  in 
perfect  health  and  his  passing  through  the  usual  renal 
symptoms  into  a  distinctly  unemic  condition  with  restless- 
ness and  a  convulsion.  No  unusual  sym]>toms  in  kind 
were  noted.  (Jreat  relief  followed  free  venesection  at  the 
critical  period  of  the  attack,  and  oxygen  was  administered 
with  much  benefit.  The  patient  made  a  gootl  recovery.  S. 
West,  who  saw  the  ease  in  consultation,  adds  notes  of  two 
similar  cases  from  his  own  practice. 

A  Case  of  Anthrax.— Reported  by  E.  F.  U.  Neave.  The 
source  of  infection  was  bnne  dust  which  the  patient  had 
handled.  He  died  on  the  fourth  day  after  his  initial  symp- 
tom. The  temperature  did  not  rise  above  loo'  F.  The 
lesion  was  situated  on  the  breast  where  he  had  scratc'  .>d 
himself,  and  there  was  an  entire  absence  of  pain,  severe 
constitutional  disturbance,  and  feeling  of  distress. 

Early  Researches  Leading  up  to  the  Antiseptic  System  of 
Surgery. — The  Huxley  lecture,  by  Lord  Lister. 

The  Future  of   the  Medical  Student.— Address  by  IL  S. 

Collier. 

Case  of  Supra-Hepatic  Hydatid  Cyst.— By  G.  W.  Davis. 
Address  on  Science  and  Practice. — By  G.  V.  Poore. 

Briliih  Mrdkat  Journal,  October  6,  i<)oo. 

An  Address  on  Some  Problems  of  Tropical  Medicine. — Sir 
William  MacGregorin  his  address  touches  on  the  follow- 
ing diseases:  Sporadic  cases  of  typhoid  fever  have  been 
met  with  in  Polynesia  since  1S75,  but  there  is  a  form  of 
continued  fever  which  simulates  tyjihoid  up  to  the  ninth 
day,  when  it  culminates  suddenly  and  the  iiatient  recovers 
in  a  few  days.  The  disea.se  of  yaws  has  been  from  time 
immemoriai  endemic  in  Polynesia.  It  is,  like  most  other 
disea.ses  in  the  torrid  zone,  parasitic.  Venereal  di.sease 
was  not  known  to  the  Pacific  Islanders  nor  to  the  Papuans 
till  taken  to  them  by  Europeans.  In  the  islanders  the  soft 
cliancre  often  developed  into  a  great  spongy  mass,  easily 
bleedin.g.  Sometimes  the  ulcer  penetrated  the  abdominal 
wall.  Syphilis  was  slower  in  its  processes.  Gonorrhcea 
was  all  but  incurable  in  native  women.  Jleasles  was  in- 
troduced into  Fiji  by  one  of  Her  Majesty's  ships  of  war. 
The  epidemic  which  followed  destroyed  between  one-third 
and  one-fourth  of  the  whole  population.  The  itch  in  Brit- 
ish New  Guinea  also  spread  like  wildfire  at  first  in  its  most 
virulent  form.  Dysentery  in  its  epidemic  and  contagious 
forms  was  unknown  in  British  New  Guinea  ten  years  ago. 
In  recent  years  it  has  caused  many  deaths  there.  It  prob- 
ably causes  more  deaths  than  any  other  disease  in  tropical 
countries.  No  other  malady  is  so  universally  distributed 
and  of  such  constant  occurrence.  To  the  tropical  Euro- 
pean, the  most  important  study  is  probably  that  of  mala- 
rial fever.  The  parasitic  cycle  in  malarial  fever  is  un- 
doubtedly proved  by  deraotistratiou.  Now  we  require  to 
know  how  and  why  certain  conditions  bring  on  an  access 
of  fever  long  after  possible  infection  and  in  spite  of  long- 
continued  and  large  doses  of  quinine.  Koch  is  convinced 
that  a  practical  inoculation  against  Texas  fever  can  be  ar- 
rived at.  Elephantiasis  is  very  common  in  Fiji.  There 
seems  to|be  no  connection  between  this  disea.se  and  mal- 
aria as  some  have  supposed.  Phthisis  was  not  known  to 
the  Papuan.  The  natives  of  New  Guinea  are,  however, 
very  subject  to  a  form  of  pleuro-pneumonia.  The  first 
case  of  diphtheria  that  occurred  in  Fiji  was  about  twenty 
years  ago.  The  disease  was  lirought  from  Sydney.  Lu- 
pus exedens  is  very  common  in  New  Guinea,  but  it  is  al- 
ways clearly  distinct  from  cancer.  Tetanus  has  been 
known  in  British  New  Guinea.  Tinea  imbricata  has  made 
a  steady,  stealthy  pro.gress.  Ankylostomiasis  is  indige- 
nous in  the  Pacific.  In  New  Guinea  there  is  a  curious 
multiple  tumor  as  large  as  a  walnut  which  is  met  with.  It 
is  probably  parasitic,  but  has  not  been  investigated.  The 
Australian  and  New  Guinea  dingoes  are  free  from  rabies. 
The  "jigger"  should  be  carefully  studied.  The  whole  sub- 
ject of  leprosy  requires  to  be  studied  exhaustively  in  the 
light  of  the  new  pathologj-.  The  quarantine  is  necessary 
in  the  colonies.  The  author  then  emphasizes  the  impor- 
tance of  becoming  expert  in  the  examination  of  water. 

The  Causes  and  Treatment  of  Non-Malignant  Stricture  of 
the  Rectum. — Frederick  Charles  Wallis  believes  the  most 
common  cause  of  rectal  stricture  to  be  septic  ulceration, 
primarily  started  either  by  some  septic  discharge  from  the 
outside,  attacking  an  abraded  portion  of  the  mucous  mem- 
brane, or  post-operative  sepsis.    Protracted  labor  is  another 


cause.  Patients  suffering  from  rectal  ulceration  are  apt  to 
have  attacks  of  acute  synovitis.  The  author  describes  his 
operative  measures  in  two  cases,  the  latter  of  which  is  as 
follows:  A  primary  inguinal  colotomy  was  performed. 
Some  months  later  the  rectal  operation  was  performed.  The 
patient  being  placed  in  the  lithotomy  jiosition,  the  spliinc- 
ters  were  stretched  as  much  as  possible.  An  incision  was 
then  made  all  round  the  anus  at  the  muco-cutaneous  mar- 
gin, and  the  mucous  membrane  gradually  sepiiiated  from 
the  sphincter  by  scis,sors,  and  the  separation  continued 
right  up  to  the  stricture.  Great  care  had  to  be  exerci.sed 
at  this  point,  but  after  the  stricture  had  once  been  passed 
the  mucous  membrane  was  quite  healthy.  The  peritoneal 
cavity  was  ojiened  on  both  sides,  particularly  on  the  right ; 
these  openings  were  closed  agiin  by  sutures.  The  bowel 
was  divided  a'jove  the  stricture  through  healthy  mucous 
membrane,  and  the  lower  parts  with  the  stricture  were  re- 
moved :  the  cut  edges  of  the  healthy  bowel  were  brought 
down  to  the  skin  margin  by  gentle  traction  and  sewed  to  it 
by  a  large  number  of  internipled  sutures  of  chroinicizcd 
catgut.  No  vessels  were  ligatured.  The  sub.sequent 
course  of  this  operation  was  uneven iful.  A  few  weeks 
later  the  colotomy  wound  was  closed.  The  patient  is  now 
in  the  best  of  health. 

On  the  Best  Method  of  Removing  Large  Stones  from  the 
Bladder:  with  Notes  of  a  Case. — S.  II.  Burton  states  that 
tlie  advantages  of  suj^rapubic  lithotomy  are  that  the  blad- 
der can  be  opened  freely  and  examined  fully,  in  an  almost 
bloodless  manner,  and  a  stone  of  any  known  size  extracted 
with  least  disturbance  to  the  patient  of  any  operation,  and 
in  the  case  of  enlarged  prostate  these  advantages  are  ac- 
centuated. The  disadvantages  are  that  tlie  wound  mav  be 
long  in  healing,  and  sometimes  phosphates  may  crust  on  the 
scar,  reproducing  another  stone.  The  advantages  of  peri- 
neal lithotrity  are  that  the  bladder  wall  is  not  cut,  and  the 
neck  of  the  bladder  is  incised  only  enough  to  admit  the 
finger,  and  afterward  the  lithoclast.  and  the  opening  into 
the  bladder  is  dependent.  The  disadvantages  are  many  : 
frequent  instrumentation  during  the  operation  :  disturbance 
of  the  neck  of  the  bladder  by  removal  of  stone  fragments; 
the  bruising  of  the  vesical  mucous  membrane  by  the  litho- 
clast when  the  bladder  is  contracted  around  a  large  stone ; 
the  impossibility  of  examining  the  bladder  with  the  finger 
in  the  case  of  a  big  man  with  a  deep  pelvis,  and  the  di^ffi- 
chlty,  when  there  is  a  large  prostate,  of  manipulating  the 
instrument  easily,  and  of  removing  all  the  fragments,  and 
lastly  when  the  kidneys  and  ureters  are  diseased,  owing 
to  chronic  dilating  and  infective  changes,  the  danger  of 
setting  up  acute  pyelitis  and  nephritis  is  increased  in  pro- 
portion to  the  manipulation.  The  author  believes  the  su- 
prapubic operation  to  bo  the  best  one  for  large  stones. 

A  Case  of  Obstructive  Jaundice  due  to  Gummatous  Infil- 
tration, Involving  the  Head  of  the  Pancreas,  Duodenum,  and 
Gastro-Hepatic  Omentum,  in  which  Cholecystocolostomy  was 
Performed  with  Complete  Cure. — H.  Betham  Robin.son  re- 
ports this  case,  in  which  he  ])erformed  an  exploratory  lap- 
arotomy, draining  the  gall  bladder.  Potassium  iodide  was 
ordered,  and  the  further  history  was  most  satisfactory. 
The  progress  of  the  case  after  the  operation  leaves  little 
doubt  that  the  lesion  causing  the  jaundice  was  an  exten- 
sive gummatous  infiltration  radiating  from  the  head  of  the 
pancreas.  Such  a  manifestation  of  visceral  syphilis  must 
be  extremely  rare,  and  hence  unsuspected.  The  length  of 
time  during  which  the  improvement  continued,  with  the 
marked  increase  of  weight,  are  conditions  which  cannot  be 
accounted  for  by  the  laparotomy  alone,  or  from  the  relief 
of  the  bile  obstruction. 

The  Etiology  of  Phlyctenular  Affections  of  the  Eye.— Sydney 
Stephenson  rec^ards  jililyctenular  disease,  generally  speak- 
ing, as  due  remotely  to  the  tuberculous  diathesis,  and  im- 
mediately to  an  eruption  of  eczema  upon  the  surface  of  the 
eyeball.  Anything  tending  to  lower  general  resistance, 
as  measles  or  imperfect  hygienic  surroundings,  or  local  re- 
sistance, as  slight  injuries  to  the  eyeball,  may  induce  the 
disease  in  a  predisposed  subject.  It  is  important  to  bear 
in  mind  that  eczematous  inflammations  may  involve  mu- 
cous membranes  other  than  the  conjunctiva,  and  that  such 
changes  when  found  may  help  to  elucidate  the  etiology  of 
an  otherwise  obscure  corneal  ulcer. 

A  Discussion  on  the  Methods  at  Present  Available  for  the 
Treatment  of  Simple  (Subcutaneous)  Fractures.— 15y  William 
H.  Bennett  and  others. 

Pyloroplasty  for  Cicatricial  Contraction  of  the  Pylorus  and 
for  Gastric  Ulcer.— By  Leonard  A.  Bidv.ell. 
A  Discussion  on  the  Treatment  of  Chronic  Glaucoma.— By 

F.  Richardson  Ckiss  and  others. 

On  Fifty-Three  Operations  for  Stone  in  the  Bladder  ( Illus- 
trated 1.— By  P.  J.  Freycr. 

A  Discussion  on  Subdiaphragmatic  Abscess. — By  Rickman 

J.  GixWec. 

The  Huxley  Lecture. — By  Lord  Lister. 


626 


MEDICAL    RECORD. 


[October  20,  1900 


Berliner  klinische  Woclienschrijt ,  Scpliinbcr  /y,  jt^oo. 

A  Case  of  Chronic  Diffuse  (Edema  of  the  Skin. — H.  Rosin 
reports  the  case  of  a  woman  aged  forty-two  years,  present- 
ing swelling  of  the  face,  upper  portion  of  the  chest,  backs 
of  the  hands,  and  knuckles.  It  came  on  without  apparent 
cause  and  did  not  seem  to  be  associated  with  any  internal 
disturbance.  The  skin  was  not  so  stretched  that  it  could 
not  be  lifted  up  in  folds.  The  thyroid  was  not  enlarged. 
No  history  of  any  exanthem  could  be  obtained.  There 
were  no  glandular  enlargements,  no  fever  or  sensory  dis- 
turbances. The  pulse  was  normal.  Differentiation  was 
called  for  between  erysipelas,  my.xoedema.  Graves'  disease, 
scleroderma,  and  nephritis ;  but  all  these  could  be  ex- 
cluded. The  condition  was  regarded  as  due  to  some  dis- 
turbance of  the  circulatory  apparatus  taking  the  form  of 
an  abnormal  permeability  of  the  ves.sel  walls.  The  condi- 
tion of  the  patient  was  stationary  when  the  report  was 
made. 

An  Additional  Case  of  Polyneuritis  following  Malaria. — C. 
A.  Ewald's  patient  was  a  man  aged  thirty-one  years,  who 
suffered  from  what  was  regarded  as  a  malarial  attack, 
though  no  organisms  were  found  in  the  blood.  On  admis- 
sion to  hospital,  he  showed  a  paresis  of  the  lower  extremi- 
ties, while  the  patellar,  skin,  and  periosteal  reflexes  were 
completely  lost.  His  gait  was  weak,  and  he  had  to  be  sup- 
ported, but  showed  no  typical  ataxia.  The  speech  was  ra- 
ther stumbling,  and  he  found  it  difficult  to  continue  conver- 
sation, as  his  mind  seemed  blunted.  Electrical  reactions 
were  normal  for  both  currents.  The  spleen  was  large, 
urine  normal.  The  case  was  regarded  as  a  form  of  poly- 
neuritis due  to  malarial  infection. 

Polyneuritis  after  Malaria  and  Landry's  Paralysis. — In  this 
article  R.  Kaumstark  reviews  the  literature  of  the  condi- 
tions named  in  the  title  and  discusses  the  differential  diag- 
nosis of  the  two  diseases. 

Doubling  of  the  Left  Index  Finger  and  a  Threefold  Divi- 
sion of  the  Right  Thumb.— By  \)\\  Joachimsthal. 

A  Metrical  Visual  Disturbance  in  Hemianopsia. — By  H. 
Liepman  and  E.  Kalnius. 

Deiitsclie  iiicdicinische  Wochenschrift,  Sept.  2y.  iqoo. 

Observations  on  a  Case  of  Multiple  Typhoid  Periostitis.— 

Conradi  discusses  the  interesting  question  of  how  much 
significance  attaches  to  the  presence  or  absence  of  the 
Gruber-VVidal  reaction  in  determining  the  nature  of  post- 
typhoid suppurations,  especially  those  involving  the  bones. 
In  a  case  observed  by  the  author  five  months  after  a  ty- 
phoid infection,  which  ran  its  usual  course,  the  bacillus 
typhosus  was  isolated  and  cultivated  from  pus  obtained 
from  periosteal  lesions  in  several  pans  of  the  body,  and  its 
specificity  and  virulence  were  positively  determined.  A  pos- 
itive Widal  reaction,  however,  was  not  to  be  obtained  from 
the  blood  serum,  and  this  observation  leads  tlie  author  to 
several  noteworthy  conclusions.  The  first  of  these  is  that 
in  metastatic  typhoid  lesions  the  agglutination  reaction  is 
not  to  be  relied  on  as  an  index  of  the  origin  of  the  trouble. 
The  conditions  which  make  it  possible  for  th'j  bacillus  to 
maintain  its  vitality  in  remote  portions  of  the  organism, 
after  the  disease  has  run  its  course  and  the  body  15  sup- 
posably  thoroughly  charged  with  immunizing  bodies,  afford 
a  rife  topic  for  speculation.  It  is  well  established  that  the 
bone  marrow  participates  in  every  typhoid  infection  as 
constantly  as  do  the  spleen  and  intestine  ;  how  is  it,  then, 
that  it  is  only  the  latter  two  that  are  able  completely  to 
dispossess  the  invaders,  in  spite  of  the  fact  that  the  bone 
marrow  itself  is  one  of  the  most  prolific  sources  for  the 
manufacture  of  the  anti-typhoid  protective  substances? 
Furthermore,  why  are  not  other  tissues  also  attacked  ?  We 
must  take  it  for  granted  that  owing  to  its  reactive  changes 
the  body  has  become  at  least  an  unfavorable  dwelling-place 
for  the  bacillus,  and  that  in  order  to  keep  its  foothold  it 
must  greatly  adapt  itself  to  the  new  conditions,  and  so 
parts  with  a  large  measure  of  its  virulence,  becoming  lo- 
cally active  only  when  the  system  is  again  invalidated  by 
exterior  conditions,  other  infections,  trauma,  etc.  Most 
authorities  accept  the  belief  that  suppurative  processes 
due  to  tlie  typhoid  bacillus  do  not  differ  clinically  or  path- 
ologically from  those  produced  by  pyogenic  cocci,  and  in 
the  author's  opinion  local  manifestations  are  cau.sed  by  it 
only  when  it  has  been  deprived  of  its  specific  characteris- 
tics and  can  generate  only  the  irritative  poisons  common 
to  many  bacterial  forms. 

The  Diagnosis  of  Tuberculous  Peritonitis. — H.  Lohlein  com- 
ments on  the  many  ditliculties  in  the  way  of  diagnosticat- 
ing this  affection,  and  describes  three  signs  that  he  has 
found  of  use.  In  over  one-half  of  the  cases  operated  upon 
by  him  during  the  last  year  it  was  found  that  very  appreci- 
able differences  both  on  palpation  and  percussion  existed 
in  the  two  lateral  regions  of  the  abdomen.  It  is  especially 
the  change  in  tlie  percussion  note  tliat  is  significant,  and 
an  increase  in  duluess  on  the  left  side,  while  not  pathog- 


nomonic, yet  gives  strong  presumptive  evidence  in  favor  of 
the  existence  of  the  disease.  A  logical  explanation  of  the 
phenomenon  may  be  found  in  the  theory  that  the  diseased 
mesentery  naturally  contracts  in  the  line  of  its  oblique  at- 
tachment, and  therefore  draws  the  intestinal  coils  to  the 
right  side,  leaving  the  other  free  to  receive  the  major  por- 
tion of  the  exudate.  It  has  been  observed  and  well  sub- 
stantiated that  the  site  of  predilection  for  the  tuberculous 
deposits  is  found  in  the  most  dependent  portions  of  the 
peritoneal  cavity,  and  hence  the  lining  of  Douglas'  cul-de- 
sac  is  nearly  always  invaded.  By  rectal  palpation  it  is  al- 
most invariably  possible  to  note  the  presence  of  tuber- 
cles in  this  region,  which  give  to  the  examining  finger  the 
sensation  of  numerous  hard  nodules  of  varying  size.  The 
last  method  is  a  corollary  from  this  one,  and  consists  in 
making  a  slight  opening  in  the  posterior  fornix  sufficiently 
large  to  facilitate  the  digital  examination  or  even  to  re- 
move bits  of  suspected  tissue  for  microscopical  investiga- 
tion, while  in  cases  adapted  to  treatment  by  a  simple  coeli- 
otomy  the  therapeutic  indication  may  equally  well  be  met 
by  allowing  this  intravaginal  opening  to  take  the  place  ot 
an  abdominal  section. 

The  Treatment  of  Scabies. — Richard  Sachs,  in  view  of  the 
irritative  or  toxic  properties  often  manifested  by  many  of 
the  scabiosa  in  use,  such  as  balsam  of  Peru,  styrax,  sul- 
phur, and  beta-naphthol,  was  induced  to  make  experi- 
ments with  a  new  synthetic  product  to  which  the  name  of 
peruscabin  has  been  given.  This  is  a  compound  of  cinna- 
mein,  styracin,  and  cinnamic  acid,  and  represents  the  active 
constituents  of  balsam  of  Peru.  By  a  long  series  of  com- 
parative tests,  made  bj-  bringing  various  agents  into  direct 
contact  with  the  parasite  removed  from  the  body,  it  was 
determined  that  styrax,  beta-naphthol,  and  peruscabin 
possessed  the  greatest  parasiticide  power,  and  inasmuch 
as  the  last  of  these  has  the  advantages  of  being  odorless, 
of  not  staining  the  clothing,  and  of  being  free  from  all 
damaging  effect  on  the  skin  or  internal  organs,  it  ought, 
on  theoretical  grounds,  to  be  the  most  preferable.  The 
drug  was  tried  in  thirty-five  cases  with  a  positive  residt  in 
each,  while,  although  in  ten  mstances  there  were  compli- 
cating lesions  such  as  eczema  and  dermatitis,  no  secondary 
irritation  was  produced.  The  method  of  application  is  as 
follows  :  The  patient  takes  a  bath  and  is  then  anointed 
from  head  to  foot  with  a  mixture  (1:3)  of  peruscabin  and 
castor  oil.  The  inunctions  are  repeated  three  times  in 
thirty-six  hours,  at  the  end  of  which  time  the  underwear 
and  bed  linen  are  changed.  In  three  or  four  days  the  cure 
is  completed  by  another  bath,  which  it  is  well  not  to  give 
too  early  in  order  that  abundant  time  may  be  allowed  for 
the  remedy  to  reach  even  the  deeper-seated  parasites.  No- 
disagreeable  symptoms  whatever  were  caused,  even  though 
many  of  tlie  patients  were  children,  and  one  an  infant  four 
months  old. 

The  Pathology  and  Therapy  of  Abscess  of  Douglas'  Space 
in  Perityphlitis. — By  J.  Rotter. 
An  Unusual  Case  of  Purpura  Rheumatica.— By  Paul  Edel. 

Scottish  Medical  and  Surgical  Journal,    October,    igoo. 

On  the  Surgical  Treatment  of  Aneurisms  by  Excision. — 
Thomas  Annandale  urges  the  following  advantages  for 
this  operation.  If  successful,  the  result  is  a  complete  cure. 
The  ligatures  are  applied  to  the  ends  of  the  divided  ves- 
sels, and  not  to  them  in  their  continuity.  Even  if  the  cor- 
responding vein  be  divided  and  a  portion  of  it  removed, 
the  risk  of  gangrene  is  not  great.  All  the  advantages  of 
the  antiseptic  treatment  can  be  obtained  in  connection 
with  the  successful  healing  of  the  wound  and  closure  of  the 
vessels  when  divided.  Inflammation  and  suppuration  of 
the  sac  or  rupture  of  it  cannot  occur  in  connection  with 
this  method.  Although  as  yet  more  experience  is  required, 
it  seems  likely  that  certain  aneurisms,  such  as  the  subcla- 
vian, will  in  the  future  be  treated  more  successfully  by  this 
method.  The  author  believes  that  in  the  near  future  the 
treatment  of  all  aneurisms  of  the  limbs,  provided  they  be 
tolerably  circumscribed  and  free  from  complication,  will  be 
most  effectively  carried  out  by  excision  ;  and  that  aneu- 
risms of  a  diffuse  nature,  owing  to  rupture  of  the  sac  or 
from  other  causes,  will  be  best  treated  by  laying  ojien  the 
sac  and  ligating  the  vessel  at  its  point  of  communication, 
either  by  an  incision  through  the  walls  of  the  sac  or  by- 
exposing  and  ligating  the  vessels  immediately  outside  the 
sac. 

A  R^sum^  of  Our  Knowledge  of  Diseases  Transmissible 
from  the  Lower  Animals  to  Man. — Theodore  Shennan  says 
that  the  most  important  of  these  di.seases  are  tuberculosis, 
diphtheria,  scarlet  fever,  glanders  and  farcy,  anthrax, 
plague,  foot-and-mouth  disease,  and  rabies.  Ten  to 
twenty  per  cent,  of  all  cows  are  tuberculous.  Muscular 
tissue  is  rarely  affected  by  tuberculosis,  but  the  meat  is 
usually  infected  after  death,  the  butcher  having  to  cut 
through  diseased  lymphatic  glands.  Boiling  or  roasting" 
destroy  the  germs  on   the  surface.     Milk  tuberculosis  caa 


October  20,  1900J 


MEDICAL    RECORD. 


627 


be  prevented  by  boiling  the  milk.  Merely  raising  il  to 
lioiling  point,  loo'  C,  and  allowing  it  to  cool  is  usually 
sufficient  to  render  it  safe,  and  does  not  injure  the  flavor 
of  the  milk.  Uiphtheria  may  also  be  conveyed  in  milk, 
and  so  may  scarlet  fever.  The  author  takes  up  each  dis- 
ease in  detail,  showing  how  it  may  be  transmitted  to  hu- 
man beings  by  various  animals. 

A  Case  of  Perforated  Gastric  Ulcer  with  Recovery  after 
Suture. — John  Sliaw  McLaren  rciiorts  a  case,  and  urges 
immediate  operation  in  all  similar  ones.  Infiltration  ana's- 
tliesia  is  to  be  preferred  to  the  use  of  chloroform  or  ether  ; 
the  incision  should  be  made  in  the  middle  line  ;  the  ulcer 
should  not  be  e.xci.scd,  but  simply  tucked  in  wholesale, 
with  first  one  and  then  a  second  row  of  sutures.  If  the 
stiffness  or  friability  of  the  wall  makes  suturing  impos- 
sible, one  can  drain  with  gauze  or  tube,  or  make  artificial 
adhesions.  When  such  measures  are  impracticable  or 
would  consume  a  dangerous  amount  of  time,  the  stomach 
might  be  rapidly  stitched  to  the  wound  and  packed.  The 
detail  and  e.\t2nt  of  washing  out  the  peritoneum  with  sa- 
line solution  will  depend  on  the  amount  of  soiling  and  ])eri- 
tonitis.  The  solution  should  be  very  hot.  Rectal  feeding 
sliould  bo  the  rule  for  a  day  or  two. 

Jaw  Jerk  and  Jaw  Clonus. — Alexander  James  has  found 
by  investigation  of  the  reaction  time  of  the  jaw  jerk  as 
compared  witli  the  knee  and  ankle  jerks  in  the  same  indi- 
vidual, that  the  time  of  these  muscle  or  tendon  jerks  varies 
directly  with  the  distance  between  the  muscles  concerned 
and  their  nerve  centres  in  the  cord  or  medulla.  Although 
dillerences  due  to  individual  conditions  may  occur,  we 
find  that  the  ankle  clonus  is  slower  than  the  knee,  the  knee 
than  the  hi]),  etc.     The  jaw  clonus  is  the  most  ra[)idof  all. 

Clinical  Lecture  on  Undue  Adhesion  of  the  Membranes  as  a 
Complication  of  the  Third  Stage  of  Labor. — By  D.  Berry 
Hart. 

Clinical  Lecture  on  Cardiac  Failure  (Conclusion)  .^By  A. 
M.  .Stalk LT. 

Some  Simple  Surgical  Appliances. — By  Charles  W.  Cath- 
cart. 

The  Plague. — Hy  W.  Leslie  Mackenzie. 


CCorvespoutlcnce. 


OUR    LONDON    LETTER. 

(From  our  Special  Correspondent.) 

OENERAI,  ELECTION — WAR  HOSPITALS — TREATMENT  OF  PRIS- 
ONERS AT  PRETORIA — PLAGUE  AT  GLASGOW — PRECAUTIONS 
THROUr.IIOI'T  THE  COUNTRY — EXPERIMENT  WITH  MALARIA- 
INFECTED    MOSyUITOS — TYPHOID. 

London,  September  28,  1900. 
We  are  now  in  the  midst  of  a  general  election,  and  medi- 
cal questions  are  for  the  most  part  relegated  to  a  back 
seat.  The  one  which  most  frequently  intrudes  on  conver- 
sation is  the  war-hospitals  inquiry,  but  even  this  is  less 
exciting  than  it  was.  The  most  curious  point  in  regard  to 
this  is  the  tenderness  with  which  Mr.  Burdett-Coutts  has 
u])  to  now  been  treated  in  his  own  constituency,  where  one 
might  have  supposed  political  opponents  would  have  made 
the  most  of  the  accumulated  contradictions  with  which  his 
allegations  have  been  met.  He  has  said  that  he  told  only 
the  truth,  but  the  evidence  of  Lords  Roberts,  Kitchener, 
and  Stanley,  to  say  nothing  of  numerous  other  witnesses, 
is  irreconcilable  with  his  statements.  Still  there  seem 
to  be  some  persons  who  accejit  Mr.  Coutts  at  his  own  valu- 
ation, but  when  asked  for  proof  of  his  charges  they  have 
tocall  upa  very  different  classof  witnesses  and  very  singu- 
lar facts.  Thus  I  am  told  an  audit  officer  in  Natal  spoke 
of  a  deficiency  of  bedsteads,  but  my  informant  should  have 
remembered  that  this,  if  true,  had  nothing  to  do  with  the 
facts  at  Bloemfontein.  Again,  I  am  assured  two  persons 
had  stolen  patients'  comforts  and  are  in  prison  for  the 
crime,  but  tliis  is  no  proof  that  the  Royal  Army  Medical 
Corps  was  to  blame.  Once  more,  I  am  assured  that  Reu- 
ter's  agents  are  prejudiced  and  do  not  forward  the  evi- 
dence of  all  the  civil  surgeons  ;  to  which  I  reply  that  the 
agency  at  any  rate  does  not  suppress  the  evidence  of  Lords 
Roberts,  Kitchener,  and  Stanley,  and  their  statements  sat- 
isfy most  people — to  which  there  is  no  answer. 

Jlrs.  Dick  Chamberlain's  spite  against  the  doctors  for 
excluding  her  from  the  hospital  at  Wynberg  will  perhaps 
abate  now  that  she  finds  that  this  was  in  obedience  to  an 
order  of  Lord  Roberts  himself — rather  an  amusing  revela- 
tion even  for  her  own  .set. 

Another  woman  who  was  to  expose  a  scandalous  condi- 
tion on  the  hospital  ships  has  been  before  the  commission, 
but  her  evidence  seems  likely  to  recoil  on  herself.     She  de- 


clared that  three  hundred  sick  and  wounded  men  had  noth- 
ing- but  bread  and  tea.  On  this  Lord  Romer  said  it  was 
"impossible,"  they  would  have  all  died  ;  then  asked  "How 
many  did  die?"  Nurse  Roberts  replied  "none."  She  also 
said  the  wounds  were  cauterized  with  nitric  acid  ( I) ,  and 
made  other  equally  intelligent  statements.  The  civil  sur- 
geon on  board  fially  contradicted  her  evidence,  and  told  the 
commissio^i  she  had  been  "dismissed  as  incompetent."  He 
was  corroborated  by  other  witnesses. 

Dr.  A.  Morison  was  to  have  produced  a  sensation.  He 
had  written  letters  to  the  papers  alleging  various  things. 
Summoned  to  the  commission  to  give  evidence,  he  sent  a 
letter  pleading  that  ill-healtli  ]>revented — a  course  which 
only  produceil  the  remark  from  the  president  that  no  med- 
ical certificate  accompanied  the  letter. 

A  Mr.  Edmonds,  who  has  written  letters  to  The  Spectator, 
had  to  admit  that  he  had  only  hearsay  and  no  facts  for  his 
allegations,  whereupon  his  evidence  was  ruled  out.  Some 
other  contradictory  evidence  has  been  given — in  fact,  too 
much  to  epitomize.  I  have  selected  the  foregoing  as  illus- 
trating the  kind  of  campaign  against  the  hospitals  that 
was  starled,  and  as  showing  that  those  attacked  may  be 
content  to  await  the  report  of  the  commission. 

1  have  already  mentioned  the  severe  condemnation 
passed  on  Dr.  H.  P.  Veale  by  Lord  Roberts,  as  the  result 
of  the  inquiry  into  the  treatment  of  the  British  prisoners 
of  war  at  Pretoria.  Such  a  verdict  on  a  member  of  the 
profession  is  to  be  regretted.  But  a  careful  perusal  of  the 
report  seems  only  to  confirm  its  justice  ;  for  his  own  evi- 
dence seems  to  consist  chiefly  of  a  repudiation  of  his  re- 
sponsibility and  an  inability  to  remember  the  purjjort  of 
letters  addressed  to  him  by  the  resident  doctors — some  of 
which,  however,  he  declared  he  had  not  received. 

There  is  no  advance  of  the  plague  in  Glasgow.  Another 
case  developed  after  my  last  letter.  The  number  of  pa- 
tients in  hospital  is  now  twenty-two,  and  there  are  two 
doubtful  cases.  The  "contacts"  have  been  reduced  to 
forty,  showing  that  many  have  been  dismissed  after  pass- 
ing the  period  of  isolation.  The  outlook  is  therefore  en- 
couraging, and  the  confidence  of  the  sanitary  authorities 
has  been  justified.  But  they  are  not  relaxing  their  precau- 
tions, and  in  some  respects  are  improving  them. 

The  medical  officers  of  health  throughout  the  country 
seem  to  be  wide  awake  and  are  seizing  the  opportunity  to 
arouse  the  sanitary  authorities.  They  are  supported,  too, 
by  the  local  government  board,  which  has  issued  an  order 
making  plague  a  notifiable  disease,  and  requiring  any  case 
that  may  occur  to  be  immediately  reported  to  the  sanitary 
authority  of  the  place,  whether  urban,  rural,  port,  or  ripa- 
rian. They  are  also  to  send  circular  letters  to  all  legally 
qualified  practitioners  in  their  several  districts,  informing 
them  of  their  duties  under  the  regulation.  The  order  of 
the  board  is  being  carried  out  by  the  various  local  authori- 
ties. 

Stress  is  being  laid  on  the  mildness  of  the  disease  as 
seen  in  Glasgow,  but  however  satisfactory  this  may  be 
with  regard  to  individual  cases,  it  is  no  assistance  from  a 
preventive  point  of  view.  Rather  the  reverse,  for  in  the 
mildest  forms  the  idea  of  plague  would  scarcely  occur  un- 
less it  were  known  that  the  patient  had  been  exposed  to 
infection.  This  has  been  the  case  with  .some  of  those  oc- 
curring during  isolation,  and  it  is  easy  to  see  that  in  such 
cases  the  danger  of  spreading  the  disease  is  greatest. 

Above  sixty  persons  known  to  have  been  in  contact  with 
plague  patients  have  been  treated  with  Yersin's  serum. 
Two  of  these  had  verj-  mild  attacks  of  the  disease. 

You  know  that  the  experiment  of  residing  in  the  most 
malarial  locality  of  the  Roman  Campagna,  carried  out  by 
Drs.  Sambon,  Low,  and  Terzi,  has  been  so  far  successful. 
Their  mosquito-proof  huts  have  afforded  them  protection 
from  the  danger,  and  they  are  all  well.  A  similar  experi- 
ment under  Professor  (irassi  has  been  equally  successful. 
Now  comes  the  complement  to  this  method  of  experiment- 
ing. A  son  of  Dr.  Manson,  who  ha<l  never  had  malaria, 
allowed  himself  to  be  bitten  by  mosquitos  collected  by 
Bignami  and  Bastianelli.  under  whose  care  the  insects  had 
been  fed  on  malarial  patients,  and  forwarded  to  London. 
He  has  undergone  an  attack  of  tertian,  the  parasites  ap- 
peared in  his  blood,  and  the  spleen  enlarged.  This  con- 
firms the  experiments  of  Grassi  and  Bignami  which  were 
made  in  Rome.  As  that  is  a  malarial  district,  Mr.  Man- 
son  has  carried  the  prrxif  another  step. 

Typhoid  is  on  the  increase  in  London.  The  cases  ad- 
mitted to  the  fever  hospitals  during  the  last  five  weeks 
have  numbered  respectively  33,  40,  3S,  57,  89.  The  deaths 
from  this  disease  last  week  fell  to  14  from  23  in  the  previ- 
ous week. 

Typhoid  has  been  for  a  long  time,  in  fact  all  through 
this  year,  prevalent  in  Merthyr.  The  death  rate  has  been 
0.5  per  thousand — about  double  that  of  the  neighboring 
districts. 

In  London  scarlet  fever  is  on  the  increase,  as  .seen  in  the 
number  of  admissions  in  the  last  four  weeks  successively 
— 176,  213,  243,  26q. 


628 


MEDICAL    RECORD. 


[October  20,  1900 


SUMMER   VACATIONS    FOR   THE   POOR. 

To  THR  Editor  of  the  Medical  Recorh. 

Sik:  During  the  last  summer  fourteen  weekly  parties  of 
women  and  children  were  taken  to  "Sea  Breeze,"  the  home 
on  Coney  Island  of  the  New  York  Association  for  Improv- 
ing the  Condition  of  the  Poor.  I  examined  these  parties 
with  a  view  of  eliminating  possible  cases  of  Amtagious 
disease. 

Among  these  women  and  children,  some  fifteen  hundred 
in  all,  not  one  ca.se  of  diphtheria,  scarlet  fever,  measles, 
or  communicable  disease  of  like  nature  was  found.  At 
"Sea  Breeze  "  one  case — of  pertussi.s — was  developed  dur- 
ing the  summer.  A  great  many  children  (about  ten  per 
cent.)  had  conjunctival  inflammation  ;  of  these  more  than 
half  had  granular  lids. 

Many  of  the  children,  especially  the  infants,  needed 
greatly  the  change  from  the  air  of  the  tenements  to  tliat 
of  the  sea.  With  pale,  sallow  faces,  which  had  clammy 
sweat  upon  them,  and  with  eyelids  half  closed,  they  were 
listless  and  without  the  energy  characteristic  of  healthy 
children.  The  causes  of  disease  especially  manifested  at 
these  examinations  were  irregularity  in  feeding,  and  over- 
clothing.  As  regards  the  feeding  the  following  are  speci- 
fic instances;  One  child,  who  (so  the  mother  said)  was 
suffering  from  "stomach  trouble,"  held  in  its  fist  most  of 
a  cracker.  Its  mouth  was  full  of  half-masticated  food. 
It  was  given  food  "whenever  it  wanted  something  to  eat," 
so  that  its  digestive  apparatus  was  almost  never  at  rest. 
The  baby  was  thin,  weazened,  and  had  a  clammy  sweat 
on  its  face.  It  looked  senile.  It  was  bottle-fed;  and  the 
bottle  was  given  it  "  whenever  it  cried. "  One  child  during 
the  inspection  gorged  himself  upon  a  huge  cruller ;  the 
mother  explained,  "I  keep  him  quiet  that  way."  Several 
children  lunched  without  intermission  all  the  while  they 
were  seen. 

As  regards  the  clothing :  On  one  very  hot  day  the  suffer- 
ing from  over-much  clothing  was  especiall)-  conspicuous. 
They  (the  babies)  were  almost  never  without  heavy 
"belly-bauds."  Prickly  heat  was  very  rife  among  them. 
Almost  all  of  them  cried  piteousl)",  no  doubt  because  they 
were  over-clothed.  They  were  reeking  with  perspiration. 
Six  tliicknesses  of  clothing,  more  than  half  of  which  were 
woollen,  were  the  average.  One  mother  had  had  four  chil- 
dren die  of  "bronchitis  "  (probably  pneumonia).  There- 
fore she  had  the  baby's  thorax  heavily  covered  with 
woollen  garments.  The  baby  thus  clothed  had  its  chest 
contracted,  and  normal,  free  action  of  its  lungs  was  made 
impossible.  The  sweating  caused  by  the  superabundant 
clothing  put  it  in  a  condition  to  be  chilled  by  a  chance 
draught.  No  doubt  this  child  will  go  the  way  of  the  oth- 
ers, if  it  has  not  since  then  done  so.  Another  child  had  a 
reddened  face  and  it  puffed  laboriously.  The  mother 
wanted  to  know  why  it  had  prickly  heat.  Its  clothing  was 
removed.  There  was  a  heavy  flannel  binder,  next  two 
woollen  garments,  ne.xt  a  cotton  shirt,  and  lastly  a  thick 
woollen  cloak. 

Many  of  the  mothers  were  greatl^^  in  need  of  change  and 
rest.  There  were  a  number  of  large  families.  One  mother, 
thirty-seven  years  old,  had  had  nine  children,  of  whom 
three  had  died.  Anotiier  of  the  same  age  had  had  eleven, 
eight  of  whom  had  died.  Another,  thirty-one  years  old, 
had  had  ten,  etc.  One  woman  had  had  eight  children,  of 
whom  but  two  were  living.  She  wept  over  "a  beautiful 
baby  with  lovely  gold  hair,  "  that  died  when  but  a  few  days 
old.  The  other  five  had  died  almost  at  the  same  time  of 
diphtheria  and  scarlet  fever,  which  "had  been  brought  into 
the  house."  This  woman's  dissatisfaction  with  the  part 
allotted  to  her  in  the  universal  scheme  was  not  because  of 
the  number  of  children  she  had  borne,  but  because  they 
had  been  taken  from  her  care.  These  poor  women  seemed 
much  more  worthy  of  respect  than  many  in  other  social 
strata  who — as  medical  men  know  too  well — seek  to  forego 
the  dignity  and  honors  of  motherhood  and  to  avoid  its  per- 
ils and  responsibilities. 

There  were  a  number  of  old  women  who  went  to  "Sea 
Breeze."  Their  visits  no  doubt  benefited  them  greatly. 
Their  afflictions  were  those  of  advanced  life;  not  a  few 
hail  just  come  from  treatment  or  operation  in  hospital. 

Following  are  some  disjointed  data  :  A  very  much  ema- 
ciated woman  had  been  married  at  sixteen  ;  her  first  child 
was  born  before  she  was  seventeen.  A  child  a  few  months 
old  was  infected  with  syphilis.  The  eruption  was  distrib- 
uted over  its  body.  The  mother  explained  that  the  father 
"had  been  burned,  and  this  burn  turned  to  blood  ])oison- 
ing. "  One  child  had  her  face  disfigured  with  impetigo 
contagiosa.  She  considered  she  got  it"ljy  balliing  too 
long  at  Manhattan  Beach."  Perha))S  an  unclean  bathing- 
suit  was  resixjnsible.  A  girl  of  fifteen  limped  greatly. 
When  somewhat  over  two  years  old  she  "  became  suddenly 
paralyzed  in  her  sleep,"  .so  her  mother  stated.  It  may  be 
this  was  an  hysterical  jiaralysis — in  which  case  it  is  like  to 
disappear  as  quickly  as  it  came.  If  she  should  get  into  the 
clutches  of  a  Christian  Scientist,  another  "miracle  "  may 


be  performed.  A  young  woman  had  hysterical  hemiple- 
gia. This  came  on  shortly  after  her  marriage — to  a  Chi- 
naman. A  woman  not  forty  years  old,  who  exhibited  teu 
children,  was  an  optimist  of  the  first  water.  I  asked  her, 
"Are  you  well?  "  "To  be  sure  I  am."  said  she,  with  a  wink 
and  a  grin  ;  "only  for  that  I  coiUdn't  stand  the  racket." 
John  B.  Huber,  A.M.,  M.D. 
41  West  Kortv-fifth  Street. 


NEW  YORK  STATE  MEDICAL  ASSOCIATION. 

Seventeenth  Annual  Meeting,  Held  in   Netv  I'orf:    City, 
October  /j,  16,  ij,  and  18,  igoo. 

E.  I).  Ferguson,  M.D.,  of  Troy,  President. 

First  Day — Monday,  October  J§tli. 

The  meeting  of  the  Council  and  Fellows  was  a  large 
one,  and  convened  in  the  hall  of  the  New  York 
Academy  of  Medicine  at  10:30  a.m.  The  subject  for 
consideration  was  the  proposed  plan  of  reorganization. 
After  considerable  discussion  over  what  form  the  by- 
laws should  'take,  the  whole  matter  was  referred  to  a 
committee,  which  was  to  report  back  the  following  day. 

Second  Day — Tuesday,  October  i6th. 

The  first  order  of  business  was  the  report  of  the 
committee  on  by-laws.  Each  section  was  taken  up  in 
turn  and  discussed,  and  when  this  task  had  been  com- 
pleted the  association  adopted  practically  the  funda- 
mental plan  of  reorganization,  though  postponing  for 
the  present  the  adoption  of  certain  features  which  had 
been  embodied  in  the  first  draft  of  the  by-laws.  This 
preliminary  executive  work  having  been  disposed  of  to 
the  general  satisfaction  of  the  large  number  of  members 
present,  the  regular  scientific  programme  was  taken  up. 

The  Analogy  between  the  Nervous  Conductibility 
and  the  Electric  Conductibility,  and  their  Rela- 
tion to  Functional  Neuroses — Dr.  A.  D.  Rockwell, 
of  New  York  City,  read  this  paper.  He  said  that 
pathological  conditions  showed  that  the  conductibility 
of  the  neuron  may  be  complete  or  incomplete,  accord- 
ing to  the  permeability  of  the  nerve  tract.  To  under- 
stand the  analogy  between  nervous  conductibility  and 
electric  conductibility  one  should  note  the  behavior 
of  the  "  coherer,"'  an  apparatus  consisting  of  a  tube 
filled  witli  iron  filings.  Under  ordinary  conditions 
this  tube  was  a  non-conductor.  If,  however,  it  was 
placed  in  a  solenoid,  situated  in  the  course  of  a  cur- 
rent of  high  frequency,  this  tube  immediately  became 
an  electrical  conductor.  This  phenomenon  had  been 
explained  on  the  theory  that  each  grain  of  metal  was 
surrounded  by  condensed  ether,  and  that  the  expan- 
sion of  these  sheaths  of  ether  by  the  electric  current 
was  responsible  for  the  change  into  an  electrical  con- 
ductor. Neuromotor  energy  might  be  develojied  in 
the  nerve  cells  or  without  them,  and  this  overcame  the 
natural  resistance  of  the  neurons,  probably  in  the  same 
manner  as  tiie  particles  of  iron  in  the  coherer.  In  the 
normal  condition  of  the  mind  and  body  there  was  no 
severance  of  the  dendrites,  but  in  abnormal  psychical 
conditions  "the  points  of  contact"  were  broken.  The 
fundamental  idea  of  tlie  therapeutic  value  of  electricity, 
the  speaker  said,  was  its  influence  upon  the  nerve  cell 
and  on  general  and  local  nutrition. 

Cocainism.  —  Dr.  T.  D.  Crothers,  of  Hartford, 
Conn.,  read  this  paper.  He  said  that  although  the 
tonic  and  invigorating  effect  of  the  erythroxylon  coca 
had  long  been  known,  the  powerful  intoxicating  action 
of  its  alkaloid,  cocaine,  was  a  comparatively  recent 
addition  to  our  knowledge.  The  cheapening  of  cocaine 
had  greatly  increased  its  use,  and  its  administration 
hypodermically  being  free  from  obvious  after-effects, 


October  20,  1900] 


MEDICAL    RECORD. 


6^9 


the  person  taking  it  became  convinced  of  the  safety  of 
such  practice.  Cocaine  entered  very  largely  into  the 
composition  of  popular  prescriptions.  Only  a  small 
percentage  of  this  drug  was  consumed  legitimately  in 
large  cities.  In  New  York,  Boston,  Chicago,  and 
other  cities,  only  from  three  to  eight  per  cent,  of  the 
cocaine  sold  could  be  accounted  for  in  legitimate  ways. 
In  the  lowest  sections  of  large  cities  cocaine  was  in 
greater  demand  than  almost  any  other  drug.  U'hen 
the  pauper  classes  became  addicted  to  the  use  of  the 
drug,  they  became  thieves  in  order  to  procure  the  de- 
sired supply  of  it.  They  became  talkative  and  boister- 
ous criminals.  Large  quantities  of  cocaine  were  sold 
in  drug  stores,  both  with  and  without  prescriptions. 
Cocainism  seemed  to  be  limited  to  persons  in  early  or 
middle  life,  and  was  most  common  in  brain  workers 
and  neurotics.  The  cocaine  habit  was  really  a  new 
disease  of  civilization,  falling  most  heavily  on  the  ex- 
tremes of  society.  Probably  the  largest  number  of 
persons  who  became  addicted  to  the  use  of  cocaine  had 
been  previously  accustomed  to  take  alcohol  or  mor- 
phine. Cocaine  became  a  perfect  substitute  for  them. 
A  small  class  of  persons  began  the  use  of  cocaine  for 
the  relief  of  pain  or  discomfort,  such  as  that  attendant 
upon  catarrh  or  neuralgia.  Almost  every  condition 
of  pain,  irritation,  or  exhaustion  had  been  the  starting- 
point  of  the  cocaine  habit. 

Two  Forms   of   Cocainism Cocainism    appeared 

in  two  forms — the  periodic  and  the  continuous.  Many 
of  the  periodic  cases  suffered  from  neurotic  "  nerve 
storms"  which  preceded  the  use  of  cocaine.  The 
menstrual  period  in  women  and  congestive  headaches 
in  men  were  common  exciting  causes.  .Vfter  a  time 
these  persons  usually  became  continuous  users  of  the 
drug.  Cocaine  maniacs  became  literally  crazy  until 
they  could  procure  the  drug. 

Symptomatology. — The  action  of  cocaine  was  to 
raise  the  rapidity  of  the  heart's  action,  and,  in  large 
doses,  to  increase  tiie  respiration.  In  poisonous  doses 
it  caused  a  rise  of  temperature,  and  after  a  period  of 
excitement  collapse  occurred.  The  principal  action 
was  one  of  exhilaration,  the  brain  being  stimulated. 
When  given  hypodermically  the  local  sensation  was 
paralyzed.  A  peculiar  exaltation  of  brain  activity  was 
characteristic  of  cocainism.  Later  on,  hallucinations 
and  delusions  developed.  In  the  early  stages,  the 
cocainist  was  always  self-possessed,  happy,  and  con- 
tented, but  this  good  feeling  disappeared  as  the  effects 
of  the  drug  wore  off.  The  stage  of  intoxication  was 
marked  by  intense  talkativeness.  Many  political 
speeches  and  newspaper  articles,  the  speaker  declared, 
brought  out  this  peculiarity.  The  style  of  the  co- 
cainists  was  smooth  and  continuous,  but  their  words 
led  in  no  particular  direction  and  resulted  in  no  logical 
deductions.  This  talkativeness  was  in  marked  con- 
trast with  the  broken  sentences  of  the  alcoholist.  In 
some  cases  there  was  a  mania  for  letter-writing,  and, 
although  sometimes  slanderous,  they  were  usually  ex- 
ceptionally free  from  bitter  words  or  bad  language. 
It  was  very  common  for  the  cocainist  to  believe  that 
attempts  were  made  on  his  life,  and  hence  he  was  prone 
to  carry  a  revolver  with  him.  The  diagnosis  was  often 
very  difficult.  If  the  patient  was  a  physician,  there 
would  be  noted  slight  defects  in  judgment  or  an  in- 
creased indifference  in  ethical  matters.  Close  obser- 
vation would  usually  show  periods  at  which  the  gen- 
eral mental  exaltation  diminished  or  disappeared. 
The  cocainist  was  distinguished  from  the  alcoholist 
by  his  solitar)^  habits.  A  significant  symptom  in  the 
later  stages  was  the  feeling  of  bugs  crawling  over  the 
skin.  No  other  known  narcotic  made  such  a  pleas- 
ant impression  upon  the  brain.  The  prognosis  was 
always  grave,  cures  being  infrequent,  and  occurring 
only  as  a  result  of  persistent  and  intelligent  care. 

Treatment. — In  the  treatment,  the  removal  of  the 


drug  was  indicated  at  once.  As  temporary  substitutes, 
valerian,  hyoscyamus,  and  other  vegetable  drugs  of 
that  class  were  recommended.  The  patient  should  be 
sent  away  to  an  asylum  until  the  acute  symptoms  had 
subsided,  and  then  he  sliould  be  placed  for  a  long 
time  under  the  constant  care  of  the  family  physician. 
The  giving  up  of  the  drug  was  only  a  small  part  of 
the  treatment;  one  must  determine  and  remove  the 
causes  that  led  to  the  formation  of  the  habit.  One 
cause  for  the  undoubted  increase  in  the  use  of  cocaine 
was  the  absence  of  legal  restrictions  on  its  sale.  An- 
other cause  was  its  reckless  use  by  physicians.  As  a 
narcotic  or  as  a  sub.stitute  for  other  narcotics,  it  was 
a  very  dangerous  drug. 

Heart  Complications  in  Rheumatism Dr.  James 

J.  Walsh,  of  New  York  City,  presented  in  this  paper 
a  resume  of  some  of  the  views  expressed  in  the  recent 
International  Medical  Congress  at  Paris  concerning 
heart  disease.  He  said  that  while  it  was  generally 
agreed  that  heart  complications  were  common  in 
rheumatism,  it  was  not  so  well  settled  what  rheumatism 
really  was.  Recent  investigations  seemed  to  show- 
that  rheumatism  was  an  acute  infectious  disease,  and 
that,  whatever  might  be  the  specific  cause,  it  was  totally 
unlike  any  of  the  micro-organisms  at  present  known. 
It  was  probable  that  secondary  infections  played  an 
important  part  in  the  production  of  many  of  the  com- 
plications. It  was  essential,  therefore,  tliat  the  treat- 
ment should  be  directed  toward  securing  antisepsis  of 
the  alimentary  canal,  as  this  was  a  common  source  of 
infection.  At  the  congress  there  had  been  a  well- 
grounded  opinion  to  the  effect  that  heart  disease  was 
more  amenable  to  treatment  than  was  commonly  sup- 
posed. As  a  general  rule,  in  painful  affections  of  the 
heart  it  was  stated  that  strophanthus  was  the  drug  to 
be  selected. 

Symposium  on  Obstetrics. — Treatment  of  the  Pa- 
tient during  the  Weeks  Preceding  the  Expected 
Confinement. —  Dr.  Ehward  P.  Davis,  of  Philadel- 
phia, opened  the  discussion  with  this  paper  (see  page 
605  ). 

Management  of  Normal  Labor,  Including  the  Use 
of  Forceps. — Dr.  Austin  Flint,  Jr.,  of  New  York 
City,  read  this  paper.  He  urged  that  it  be  made  a 
routine  practice  carefully  to  examine  the  pregnant 
woman  at  the  end  of  the  eighth  month.  This  examina- 
tion should,  of  course,  include  pelvic  mensuration. 
The  patient  should  be  instructed  to  take  daily  walks 
up  to  the  very  lime  of  lalior,  as  this  exercise  would 
strengthen  the  muscles,  soften  the  cervix,  aid  dilata- 
tion of  the  latter,  and  make  abnormal  presentations 
less  frequent.  At  the  time  of  labor  the  genitals  should 
be  sterilized,  and  an  examination,  first  internal  and 
then  external,  made  in  order  to  confirm  the  results  of 
that  made  the  previous  month.  It  was  far  better  to 
make  this  one  examination  complete  and  thorough 
than  to  make  a  number  of  superficial  examinations  at 
short  intervals.  The.  practice  of  giving  a  little  ether 
with  each  pain  was  gaining  ground,  the  administration 
being  conducted  in  just  the  same  way  as  with  chloro- 
form. Emphasis  was  laid  upon  the  importance  of  ob- 
serving the  old  rule  to  prevent,  as  long  as  possible, 
the  rupture  of  the  membranes.  An  ansesthetic  was  of 
great  advantage  in  many  cases,  yet  those  who  used 
anasthetics  most  would  probably  see  the  largest  num- 
ber of  cases  requiring  forceps.  As  soon  as  the  head 
ceased  to  descend,  and  the  withdrawal  of  the  anaes- 
thetic or  stimulation  failed  to  restore  good  uterine 
contractions,  a  low  forceps  operation  should  be  done 
at  once.  This  practice  was  safer  than  the  waiting 
policy.  Traction  should  be  slow,  gradually  increas- 
ing in  force  until  the  soft  parts  in  front  of  the  head 
were  stretched.  Then  the  head  should  be  held  for 
about  one  minute  before  traction  was  slowly  relaxed. 
After  a  rest  of  three  or  four  minutes,  traction  should 


630 


MEDICAL   RECORD. 


[October  20,  1900 


be  resumed.  By  this  mode  of  procedure  delivery 
could  be  effected  with  an  intact  pelvic  floor  in  a  sur- 
prisingly large  percentage  of  cases.  Immediately  after 
the  delivery  of  the  head,  the  mouth  and  eyes  of  the 
child  should  be  wiped  out,  if  possible  before  the  first 
eflfort  at  inspiration.  The  interval  between  the  second 
and  the  third  stage  was  the  time  when  infection  was 
most  likely  to  occur.  It  was  rare  than  an  internal 
examination  was  required  in  normal  cases  after  the 
birth  of  the  child.  Before  attempting  to  deliver  the 
placenta  the  hands  should  be  sterilized  again,  and 
after  an  interval  of  twenty  or  thirty  minutes  the  pla- 
centa should  be  expressed.  The  length  of  this  third 
stage  depended  upon  the  firmness  of  the  uterine  con- 
tractions. It  was  his  custom  after  the  delivery  of  the 
placenta  to  give  a  hot  sterile  douche,  as  this  stimulated 
uterine  contraction,  removed  clots,  and  enabled  the 
obstetrician  to  inspect  the  parts  and  readily  detect 
even  slight  tears  of  the  birth  canal.  The  use  of 
gloves  had  not  proved  satisfactory.  The  speaker  said 
that  ether  possessed  many  advantages  over  chloroform, 
and  should  be  used,  as  a  rule,  when  the  pains  were  of 
moderate  severity.  He  had  not  yet  employed  the  new 
method  of  spinal  anesthesia  suiliciently  to  be  able  to 
express  an  opinion  regarding  its  value  or  possible 
dangers. 

After-Treatment  of  the  Mother  in  Normal  Cases. 
— Dr.  George  W.  Jar.man,  of  New  York  City,  pre- 
sented this  paper.  He  stated  that  it  was  with  no  small 
degree  of  reluctance  that  he  approached  a  subject 
about  which  so  little  could  be  said  that  had  not  been 
said  over  and  over  again.  If,  however,  the  very  few 
remarks  he  might  make  would  bring^ about  a  discus- 
sion from  which  something  new  on  this  subject  might 
be  heard  from  others  present,  he  would  be  amply 
satisfied.  The  clinical  history  of  the  puerperium 
from  the  completion  of  the  third  stage  of  labor,  he 
said,  presented  a  series  of  physiological  and  patho- 
logical conditions  which  were  necessary  to  the  full 
recovery  of  the  woman  from  the  incidents  of  pregnancy 
and  the  injuries  of  childbirth.  With  the  expulsion 
of  the  placenta,  even  though  it  might  have  come  away 
intact,  the  danger  of  hemorrhage  was  not  passed,  and 
it  should  be  the  duty  of  the  obstetrician  to  remain  or 
leave  some  competent  physician  with  his  patient  for  at 
least  one  hour  after  the  termination  of  the  labor. 
Women  of  lax  fibre  were  prone  to  have  their  uteri  re- 
lax, and  either  external  hemorrhage  or  else  the  forma- 
tion of  a  clot  in  utero  supervened.  This  accident 
could  often  be  obviated  if  the  adjustment  of  the  band- 
age was  delayed  for  half  an  hour  and  the  fundus  of 
the  uterus  frequently  examined  through  the  abdominal 
wall.  Should  this  tendency  of  relaxation  exist,  grasp- 
ing of  the  fundus  and  compressing  it  would  in  most 
instances  cause  it  to  contract  and  remain  firm.  The 
author  was  in  the  habit  of  giving  one  dose  of  ergot 
immediately  following  the  expulsion  of  the  placenta, 
and  this  medication  was  not  repeated  unless  there 
were  distinct  indications.  Should  the  relaxation  not 
yield  to  the  above  procedure  it  was  wise  to  resort  to 
more  heroic  methods:  the  irrigation  of  the  uterine 
cavity  with  a  solution  of  iodine  in  hot  water,  or  else 
the  tamponing  of  its  cavity  with  sterilized  iodoform 
(ten  percent.)  gauze,  would  bring  about  the  desired  re- 
sult. Only  casual  mention  of  the  hypodermic  injec- 
tion of  ergotin,  stypticin,  or  other  remedial  agents 
would  be  made,  as  they  would  naturally  occur  to  the 
minds  of  those  who  were  called  upon  to  treat  post- 
partum hemorrhage.  After  permanent  contraction 
had  been  insured,  either  the  nurse  or  the  physician 
should  apply  a  snug  and  well-fitting  bandage,  not  with 
the  reputed  idea  that  it  would  magically  restore  the 
waist  to  its  former  delicate  outlines,  but  because  it 
would  add  distinctly  to  the  comfort  of  the  patient  and 
removed  the  certainty  of  future  criticism,  if  the  pa- 


tient's abdomen  should  perchance  grow  to  undue  pro- 
portions. The  author  had  found  it  convenient  after 
the  expulsion  of  the  placenta,  and  while  waiting  for  the 
assurance  of  permanent  uterine  contractions,  to  keep 
the  vulval  region  covered  with  a  rather  thick  pad  of 
cotton  which  had  been  wrung  from  a  bichloride  of 
mercury  solution  i  :  2,000.  This  would  absorb  the 
rather  free  flow  which  immediately  followed  the  empty- 
ing of  the  uterus.  As  soon  as  the  bandage  had  been 
applied  this  cotton  was  replaced  by  a  pad  of  sterilized 
absorbent  gauze.  The  bed  linen  should  then  be  left 
in  a  perfectly  clean  condition.  The  patient  was  to  be 
allowed  to  turn  upon  her  side,  and  would  in  all  prob- 
ability obtain  a  few  hours  of  much-needed  rest.  In- 
structions should  be  left  that  the  aseptic  pad  be  fre- 
quently changed  during  the  first  twelve  hours  following 
the  labor,  and  that  the  genitalia  be  carefully  washed, 
at  least  twice  per  day,  with  a  weak  solution  of  the 
bichloride  of  mercury  (i  :  5,000).  It  was  wise  to  place 
the  infant  to  the  breast  three  or  four  times  per  day 
until  the  appearance  of  the  milk,  it  having  the  doubly 
good  effect  of  giving  the  infant  nature's  laxative  and 
through  the  reflex  nervous  influence  causing  the  uterus 
to  remain  in  more  firm  contraction.  The  first  visit  on 
the  part  of  the  physician  should  be  made  within  eight 
or  ten  hours  after  the  completion  of  the  labor.  At 
this  time  he  should  ascertain  the  condition  of  the 
pulse  and  temperature,  the  amount  and  character  of 
the  flow,  whether  the  patient  had  evacuated  the  blad- 
der, the  amount  of  sleep  the  patient  had  had,  and  the 
character  and  amount  of  nourishment  taken.  In  highly 
nervous  patients  there  was  frequently  a  rise  of  tem- 
perature of  one  or  occasionally  two  degrees,  even  in 
the  most  normal  cases  during  the  first  few  hours  fol- 
lowing labor.  If  the  uterus  seemed  to  be  abnormally 
high  in  the  abdomen  it  should  be  firmly  compressed, 
and  oftentimes  the  sudden  expulsion  of  a  blood  clot 
would  result.  The  amount  of  flow  would  govern  the 
future  administration  of  any  oxytocic.  The  bladder 
should  be  emptied  at  least  once  in  eight  hours.  A 
certain  number  of  patients  were  unable  to  pass  their 
urine  while  in  the  recumbent  posture.  Again,  a  few 
would  experience  a  more  or  less  marked  paralysis  of 
the  bladder  for  a  few  days  following  labor.  In  either 
instance,  if  the  application  of  cloths  wrung  from  hot 
water  and  placed  over  the  pubes  did  not  bring  about 
the  desired  result,  the  catheter  must  be  used.  The 
author  was  in  the  habit  of  using  the  sterilized  glass 
catheter  only,  and  requiring  the  nurse  to  use  it  under 
the  guidance  of  sight,  after  giving  her  most  rigid 
directions  as  regards  thorough  asepsis.  After  the 
third  day  there  did  not  appear  to  be  any  reason  why 
the  patient  should  not  assume  the  sitting  posture  to 
void  the  urine.  If  the  patient  had  been  unable  to 
obtain  the  desired  sleep  by  reason  of  nervousness  or 
after-pains,  some  sedative  should  be  allowed,  probably 
the  most  preferable  being  the  combination  of  the 
bromide  of  sodium  with  a  small  amount  of  chloral. 
Until  the  patient's  bowels  had  been  evacuated,  that 
is,  during  the  first  two  or  three  days,  the  diet  should 
be  restricted  to  one  of  a  fluid  character.  It  was  cer- 
tainly preferable  that  the  physician  should  make  two 
visits  per  day  for  the  first  three  days,  after  that  one 
per  day  for  a  week,  and  then  at  such  intervals  for  one 
month  as  the  conditions  seemed  to  require.  At  the 
termination  of  forty-eight  or  sixty  hours  some  gentle 
laxative  should  be  administered,  and  perhaps  no  better 
one  had  ever  been  suggested  than  the  time-honored 
castor  oil.  The  author  had  never  been  in  the  habit 
of  using  the  douche  in  the  after-treatment  of  puerperal 
cases  unless  there  was  a  distinct  indication,  such  as 
foul  lochia.  It  was  not  within  the  province  of  the 
paper  to  discuss  puerperal  sepsis  or  its  treatment. 
The  nipples  should  be  carefully  inspected  for  any 
abrasions  or  cracks ;  should  such  exist,  a  weak  solution 


October  20,  1900] 


MEDICAL    RECORD. 


631 


of  the  nitrate  of  silver  or  glyceride  of  tannin  might 
with  advantage  be  applied.  The  nipples  sliould  be 
carefully  bathed,  both  before  and  after  each  nursing, 
with  a  saturated  solution  of  boracic  acid,  and  kept  as 
dry  as  possible.  L'sually  on  the  third  day  the  breasts 
would  begin  to  fill  up  and  oftentimes  became  hard 
and  painful;  a  snug-titting  breast-binder  to  prevent 
the  dragging  of  the  breasts,  and  hot  stupes  would  be 
sufficient  to  give  the  desired  relief.  It  was  not  gener- 
ally known  that  coffee  would  distinctly  lessen  the  How 
of  milk.  Should  the  patient  have  a  superabundance 
of  milk,  a  restriction  of  the  Huids  drunk  and  the  ad- 
ministration of  a  cup  of  strong  coffee  with  the  morn- 
ing and  noonday  meal  would  control  the  excessive 
supply.  If  it  could  be  impressed  on  all  who  were 
called  upon  to  conduct  a  woman  through  the  puer- 
perium  that  all  abscesses  of  the  breasts  were  caused 
by  infection  through  the  nipple,  their  frequency  would 
be  greatly  diminished,  and  the  old  time-honored  ex- 
pressions of  "caking"  and  "catching  cold"  in  the 
breasts  would  lose  their  significance.  The  patient 
should  be  encouraged  to  lie  upon  iier  side  as  much  as 
possible,  as  this  posture  would  undoubtedly  lessen  the 
frequency  of  retroversion  of  the  uterus.  After  the 
fourth  or  fifth  day  the  author  had  been  in  the  habit  of 
having  the  patient  assume  the  sitting  posture  for  the 
evacuation  of  the  bowels  and  i)ladder,  as  it  had  seemed 
to  have  a  distinct  advantage  as  regards  drainage,  and 
no  untoward  results  had  been  observed.  After  the 
free  evacuation  of  the  bowels,  the  diet  siiould  consist 
of  easily  digestible  yet  at  the  same  time  nutritious 
food.  The  bowels  should  be  thoroughly  evacuated 
every  day  either  by  enema  or  some  simple  laxative. 
During  the  latter  few  weeks  of  pregnancy  there  was 
frequently  marked  torpor  of  the  large  intestine,  and 
an  unusual  amount  of  faeces  would  accumulate.  The 
comfort  of  the  patient  demanded  that  tlie  rectum  be 
thorougiily  unloaded.  Hemorrhoids  would  often  cause 
the  patient  as  much  discomfort  during  the  first  week 
or  two  following  labor  as  any  other  complication. 
Cold  applications  to  the  anus  and  the  use  of  one-grain 
ichthyol  suppositories  would  u-sually  give  relief. 
Should  the  continuance  of  the  red  flow  and  the  height 
of  the  uterus  indicate  tardy  involution,  it  was  wise  to 
hasten  this  process  by  the  administration  of  oxytocics. 
The  author  had  gotten  admirable  results  through  the 
use  of  a  tablet  containing  ergotin,  hydrastinine,  and 
strychnine.  He  had  never  been  in  the  habit  of  nam- 
ing any  certain  time  when  the  patient  was  allowed  to 
sit  up  in  a  chair;  it  had  always  seemed  to  be  a  ques- 
tion of  conditions  rather  than  days,  which  would  de- 
termine this  point.  However,  at  the  end  of  seven  or 
eight  days  the  patient  was  allowed  to  sit  up  in  bed  to 
eat  her  meals  and  nurse  the  child.  If  the  lochia  had 
practically  ceased,  that  is,  when  they  amounted  to  no 
more  than  a  scant  leucorrhoeal  discharge,  and  the 
uterus  had  involuted  sufficiently  to  be  well  within  the 
small  pelvis,  there  should  be  no  reason  why  the  pa- 
tient should  not  be  permitted  to  sit  up  for  a  short  time 
in  a  chair.  Siiould  this  posture  cause  a  recurrence  of 
the  red  flow,  the  patient  should  at  once  return  to  bed 
and  remain  until  the  flow  had  ceased.  Before  the  pa- 
tient had  been  discharged,  and  after  all  abrasions  had 
entirely  healed,  a  careful  vaginal  examination  should 
be  made;  any  abnormality  should  be  corrected  at  once 
if  such  existed  and  it  be  deemed  wise  to  do  so.  Should, 
however,  a  later  operation  be  necessary  for  this  pur- 
pose, tlie  attendant  should  be  certain  to  acquaint  some 
member  of  the  family  of  this  fact,  as  it  would  un- 
doubtedly save  future  criticism  on  the  part  of  either 
the  patient  or  the  gynecologist.  In  conclusion  he 
would  accentuate  these  points:  the  after-treatment 
should  be  made  as  simple  as  was  consistent  with  thor- 
oughness; the  attendant  should  see  to  it  that  all  who 
came  in  contact  with  the  patient  followed  the  laws  of 


surgical  cleanliness  not  only  in  letter  but  in  fact;  he 
should  bear  in  mind  that  it  was  the  duty  of  the  ob- 
stetrician to  see  to  it  not  only  that  his  patient  recovered 
from  the  dangers  of  childbirth,  but  that  she  should  be 
left  in  a  normal  condition,  with  healthy  pehic  organs. 

After-Treatment  of  the  Child  in  Normal  Cases. — 
Dr.  Bernard  Cohen,  of  Buffalo,  presented  this  part 
of  the  subject.  He  said  that  as  soon  as  born  the 
child  should  be  turned  on  its  right  side  to  favor  the 
establishment  of  the  proper  circulation,  and  as  soon 
as  possible  the  eyes,  nose,  and  mouth  should  be  wiped, 
and  washed  with  a  solution  of  boric  acid.  Ligation 
of  the  cord  should  be  delayed  for  several  minutes,  not 
so  much  with  the  idea  of  adding  two  or  three  ounces 
of  blood  to  that  circulating  in  the  infant's  body,  but 
because  this  course  seemed  to  lead  to  a  better  circula- 
tion. The  cord  should  be  stripped  of  its  jelly  for 
some  distance  from  the  umbilicus,  and  then  ligated  so 
as  to  give  a  short  stump.  A  narrow  tape,  or  half  a 
dozen  strands  of  cotton  thread,  formed  the  best  mate- 
rials for  the  ligature,  which  should,  of  course,  be  steri- 
lized. As  he  had  never  met  with  a  case  of  cord  infec- 
tion he  saw  no  reason  for  cauterization  of  the  stump,  as 
some  had  recommended.  Should  there  be  any  suspi- 
cion of  gonorrhoea  or  local  infection  in  the  mother,  the 
baby's  eyes  should  be  treated  by  the  Crede  method. 
After  an  inspection  of  the  child  to  determine  the  pos- 
sible presence  of  abnormalities  of  development,  its 
body  should  be  well  anointed  with  oil,  and  the  process 
of  cleansing  be  proceeded  with.  The  cord  should  be 
dressed  with  powdered  boric  acid.  A  tight  belly-band 
seemed  to  him  to  be  conducive  to  umbilical  hernia. 
For  the  first  few  days  of  life  the  physician  should 
keep  himself  informed  regarding  the  proper  secretion 
of  meconium  and  urine. 

Ophthalmia  Neonatorum ;  its  Pathology,  Pro- 
phylaxis, and  Treatment. ^Dr.  John  E.  Weeks,  of 
New  York  City,  discussed  this  subject.  He  said  that 
ophthalmia  neonatorum  usually  developed  about  the 
third  day,  being  announced  by  light  redness,  swelling 
of  the  lids,  and  the  presence  of  a  discharge.  When 
the  discharge  first  appeared  after  the  fourth  day  one 
could  be  almost  sure  that  the  ophthalmia  was  the  re- 
sult of  gonorrhoeal  infection,  and  this,  too,  whether  it 
was  of  a  mild  or  severe  type.  He  had  made  numerous 
observations  on  this  point  extending  over  many  years, 
and  they  all  justified  this  conclusion.  Many  gonor- 
rhceal  cases  were  so  mild  that  they  could  be  distin- 
guished only  by  an  examination  for  gonococci.  Out 
of  about  fifty  thousand  blind  persons  in  the  United 
States,  five  thousand  lost  their  sight  througii  ophthal- 
mia neonatorum.  The  prophylactic  treatment  con- 
sisted in  the  instillation  of  various  solutions  according 
to  the  Crede  method.  The  sublimate  solution  and  the 
two-per-cent.  solution  of  nitrate  of  silver  gave  the  best 
results.  Eighteen  times  as  many  children  sufifered 
from  ophthalmia  neonatorum  in  institutions  in  which 
this  prophylaxis  was  not  employed  as  in  those  where 
it  was  regularly  carried  out.  It  was,  therefore,  advis- 
able to  employ  prophylaxis  in  all  cases,  the  drops 
being  introduced  into  the  eyes  of  the  infant  just  after 
it  had  received  its  first  bath. 

Treatment. — By  cold  applications  to  the  lids,  the 
temperature  of  the  conjunctival  sac  could  be  reduced 
to  88°  or  94°  F.,  according  to  the  thickness  of  the 
lids.  At  this  temperature  the  gonococci  grew  much 
less  rapidly  than  at  the  normal  temperature  of  the  part. 
The  conjunctival  sac  should  be  cleansed  frequently  by 
the  use  of  a  non-irritating  aseptic  or  mildly  antiseptic 
solution.  Many  preferred  a  three-per-cent.  solution 
of  boric  acid,  though  a  solution  of  sublimate,  i  :  15,000 
or  20.000,  might  be  used.  The  tluid  should  be  tepid, 
and  should  be  used  freely  and  sufficiently  often  to 
keep  tlie  parts  free  from  secretion — usually  once  in 
twenty  or  thirty  minutes.     Care  should  be  observed 


6?2 


MEDICAL    RECORD. 


[October  20,  1900 


not  to  press  on  the  eyeball  or  cause  an  abrasion. 
This  treatment  should  be  kept  up  until  the  lids  as- 
sumed a  normal  condition.  Cold  applications  should 
also  be  used  continuously  for  from  one  to  four  hours 
at  a  time,  and  should  be  repeated  three  times  daily. 
Cotton  pads  were  preferable  for  this  purpose;  they 
should  be  changed  every  minute  or  two.  The  cold 
applications  should  be  discontinued  when  the  swelling 
of  the  lids  subsided.  A  one-per-cent.  solution  of  ni- 
trate of  silver  should  be  applied  to  the  entire  surface 
of  the  conjunctiva  once  daily  after  all  secretion  had 
been  removed.  It  should  be  made  daily  until  the 
secretion  ceased.  If  the  cornea  became  involved, 
atropine  should  be  used. 

The  Major  Obstetrical  Operations  from  the  Stand- 
point of  a  General  Practitioner Dr.  Edward  Rey- 
nolds, of  Boston,  in  considering  this  topic,  divided 
the  cases  into  two  classes,  viz. :  (i)  Those  in  which 
operation  was  elective  and  "was  done  early,  and  (2) 
those  unfavorable  cases  in  which  the  operation  was 
not  undertaken  until  after  infection  or  exhaustion  from 
a  tedious  labor.  He  had  been  surprised  to  find,  as  a 
result  of  a  careful  search  of  the  literature,  that  those 
operations  were  attended  by  a  large  fcetal  mortality — 
about  fifty  per  cent. 

Caesarean  Section. — It  had  been  assumed  that  the 
mortality  from  this  operation  was  only  between 
twenty-five  and  forty  per  cent.  If  considered  as  a 
whole,  without  reference  to  the  classes  of  cases,  this 
statement  was  correct,  but  it  was  nevertheless  mislead- 
ing. In  an  analysis  that  he  had  made  of  one  hundred 
and  fifty  cases, eighty-nine  favorable  cases  had  had  no 
mortality,  whereas  sixty-one  unfavorable  cases  gave  a 
mortality  of  thirty-three  and  one-third  jser  cent. 
When  extirpation  of  the  uterus  was  added  to  Cesarean 
section,  it  was  probable  that  the  maternal  mortality 
was  slightly  greater  in  the  favorable  cases,  and  in  the 
unfavorable  cases  a  little  less  than  that  of  the  classi- 
cal section.  There  was  practically  no  fcetal  mortality 
from  Cesarean  section  if  the  child  was  in  good  con- 
dition at  the  time  the  operation  was  undertaken. 

Symphyseotomy. — In  connection  with  the  oper- 
ation of  symphyseotomy  about  the  only  maternal  mor- 
tality was  that  due  to  the  performance  of  this  operation 
in  cases  in  which  the  degree  of  disproportion  was  too 
great  to  admit  of  easy  extraction  afterward.  In  these 
cases  there  was  also  a  considerable  maternal  mortality. 
It  was  worthy  of  note  that  the  mortality  from  symphy- 
seotomy in  the  unfavorable  class  was  only  very  slight- 
ly larger  for  both  mother  and  child  than  in  the 
favorable  cases. 

Selection    of    Operation When    the    mechanical 

relations  would  render  forceps  or  version  unusually 
difficult  or  prolonged,  and  the  mother's  condition  was 
favorable,  Cassarean  section  was  the  operation  of 
choice.  When  the  mechanical  conditions  made  the 
intrapelvic  delivery  of  an  intact  child  at  term  impos- 
sible or  very  diflicult,  the  great  superiority  of  Cesar- 
ean section  over  induction  of  premature  labor  was 
apparent.  In  the  unfavorable  class,  however,  symphy- 
seotomy was  the  operation  of  choice,  provided  always 
the  degree  of  mechanical  difficulty  permitted  of  its 
application.  When  in  the  unfavorable  cases  symphy- 
seotomy was  impracticable  because  of  the  dispropor- 
tion between  the  maternal  and  fcetal  parts,  craniotomy 
should  be  unhesitatingly  chosen. 

Prophylaxis. — -The  keynote  to  prophylaxis  was  pel- 
vimetry. It  was  most  easily  carried  out  by  determin- 
ing from  palpation  the  ease  with  which  the  fcetal  head 
could  be  made  to  descend  into  the  pelvis.  If  in  a 
primipara  with  rigid  uterus  and  abdominal  wall,  the 
head  was  well  wedged  in  the  brim  at  the  beginning  of 
labor,  the  case  was  probably  within  the  safe  use  of  the 
forceps.  If,  on  the  other  hand,  in  such  a  patit-nt  the 
head  was  above  and  had  not  entered  the  brim,  or  was 


not  pressed  against  it  firmly,  there  was  strong  possi- 
bility of  the  presence  of  a  disproportion  between  the 
foetal  and  maternal  parts.  When  the  woman  had  lost 
one  baby  from  mechanical  obstruction  in  a  previous 
labor,  he  thought  it  should  be  the  general  rule  to  offer 
her  the  advantages  of  a  cutting  operation. 

Puerperal  Sepsis  :  its  Pathology  and  Treatment. 
— Dr.  William  R.  Prvor,  of  New  York  City,  read 
this  paper  (to  appear  in  a  future  issue). 

Symposium  on  the  Blood. — Technique  of  Blood 
Examination.  —  Dr.  Edward  K.  Dunham,  of  New 
York  City,  opened  the  discussion  with  remarks  on  this 
subject.  He  said  that  the  blood  for  examination  was 
usually  obtained  from  the  lobe  of  the  ear  by  puncture 
with  one  nib  of  a  new  steel  pen.  The  first  drop  of 
blood  exuded  was  usually  discarded. 

Specific  Gravity The  specific  gravity  of  the  blood 

might  be  determined  in  two  ways:  (i)  By  the  use  of 
a  delicate  balance,  and  (2)  by  suspending  a  drop  of 
blood  in  a  mixture  of  chloroform  and  benzol.  If  the 
specific  gravity  of  the  mixture  coincided  with  that  of 
the  blood,  the  latter  would  neither  rise  nor  sink  in  the 
mixture.  If  the  drop  of  blood  rose,  it  showed  that  the 
mixture  was  heavier  than  the  blood.  It  was  made 
lighter  by  adding  benzol,  and  heavier  by  the  addition 
of  chloroform. 

Reaction. — The  reaction  of  the  blood  was  not  easily 
determined,  requiring  the  use  of  delicate  standardized 
solutions  and  sensitive  litmus  paper,  and  was  not  like- 
ly to  be  determined  by  the  clinician. 

Rapidity  of  Coagulation A  very  simple  method 

of  determining  the  rapidity  of  coagulation  consisted 
in  filling  a  graduated  capillary  tube  with  blood,  and 
alternately  introducing  and  withdrawing  a  horsehair. 
This  horsehair  did  not  become  stained  with  the  blood 
until  coagulation  began.  When  this  process  was  com- 
plete, the  clot  would  no  longer  stain  the  hair. 

Heemoglobin. — The  majority  of  methods  for  deter- 
mining the  h;t;moglabin  required  the  measuring  ot^f  in 
a  graduated  pipette  of  a  quantity  of  blood  freshly 
drawn  from  the  patient.  This  blood  was  usually  di- 
luted with  distilled  water,  and  then  the  tint  of  this 
solution  was  compared  with  some  standard  color.  By 
the  admixture  of  distilled  water  the  ha.'raoglobin  was 
extracted  from  the  blood  corpuscles,  and  its  color  was 
imparted  to  the  water.  There  were  several  important 
sources  of  error  in  connection  with  the  use  of  these 
instruments.  One  of  these  was  the  lack  of  uniformity 
in  the  distribution  of  the  heemoglobin  through  the 
water;  another  was  the  personal  equation.  The  lat- 
ter, the  speaker  thought,  amounted  to  about  five  per 
cent.  An  instrument  known  as  the  ferrometer  was  de- 
signed to  determine,  not  the  amount  of  hjenioglobin 
directly,  but  tlie  amount  of  iron  in  the  blood,  as  the 
latter  roughly  corresponded  with  the  amount  of  hrumo- 
globin.  A  measured  quantity  of  blood  was  evaporated 
to  dryness,  incinerated,  and  dissolved  in  an  aqueous 
solution  of  bisulphate  of  potassium.  Sulphocyanide 
of  potassium  and  dilute  hydrochloric  acid  were  then 
added,  thus  forming  the  blood-red  cyanide  of  iron. 
This  color  was  then  compared  with  a  standard  solu- 
tion of  this  salt  of  iron,  and  the  amount  of  iron,  and 
indirectly  of  ha'moglobin,  was  then  calculated. 

Blood  Count. — The  number  of  red  or  white  blood 
corpuscles  present  was  determined  with  the  aid  of  the 
haiinocytometer.  The  ha;matokrit  did  not  give  very 
accurate  results. 

Leucocytes  in  Relation  to  Surgical  Diagnosis. — 
Dr.  josF.i'H  C.  Bloodcood,  of  the  Johns  Hopkins 
University,  discussed  this  topic,  confining  his  re- 
marks to  the  diagnostic  aid  afforded  by  blood  counts 
in  abdominal  surgery,  particularly  in  cases  of  appen- 
dicitis, peritonitis,  and  obstruction.  The  speaker  said 
that  all  leucocyte  counts  above  7,000  might  be  looked 
upon  as  a  leucocytosis. 


October  20,  1900] 


MEDICAL    RECORD. 


033 


Appendicitis.  —  In  chronic  cases  of  appendicitis  ad- 
mitted to  the  hospital  after  an  attack  he  had  found, 
with  few  exceptions,  that  the  leucocyte  count  was 
below  normal.  In  cases  of  acute  appendicitis  ad- 
mitted at  tlie  end  of  the  attack,  the  leucocyte  count 
had  been  between  10,000  and  15,000.  In  cases  of 
acute  appendicitis  admitted  in  the  first  few  days,  and 
not  operated  on,  the  leucocyte  count  had  varied  be- 
tween 8,000  and  22.000.  In  these  cases  as  the  symp- 
toms abated  the  leucocyte  count  rapidly  fell.  In  cases 
of  acute  diffuse  appendicitis  in  which  operation  was 
done,  the  blood  counts  had  varied  between  7,000  and 
25.000,  and  in  gangrenous  appendicitis  between  13,000 
and  25,000.  In  cases  in  which  the  appendix  had  been 
distended  with  pus,  the  count  had  varied  between  15,- 
000  and  35,000.  In  the  acute  cases  of  appendicitis, 
if  operation  had  been  delayed,  there  would  be,  along 
with  the  increase  in  the  symptoms,  an  increase  in  the 
leucocyte  count.  If  the  local  symptoms  in  a  case  of 
appendicitis  had  subsided,  the  leucocytes  usually  dis- 
appeared. A  rising  leucocyte  count,  with  symptoms  of 
appendicitis,  was,  as  a  general  rule,  an  indication  of 
danger.  If,  in  a  case  giving  a  history  of  appendicitis, 
but  without  distinct  physical  signs  of  this  disease,  the 
leucocyte  count  was  large,  one  might  feel  reasonably 
sure  that  there  existed  an  abscess  so  deeply  situated 
that  it  was  not  palpable.  In  cases  of  appendicitis 
with  abscess,  and  presenting  acute  symptoms,  the  leu- 
cocyte count  had  varied  from  6,000  to  60,000.  The 
absence  of  a  leucocytosis  did  not  exclude  a  smal'i  ab- 
scess, but  the  presence  of  a  leucocytosis  was  almost 
pathognomonic  of  the  presence  of  an  abscess.  In  an 
acute  attack,  a  rising  leucocytosis  was  almost  invari- 
ably an  indication  that  the  patient  was  getting  worse 
— in  other  words,  there  was  abscess  formation,  gan- 
grene, or  beginning  peritonitis.  With  a  leucocyte 
count  over  :o,ooo,  in  a  case  of  appendicitis,  he  would 
lose  no  time  in  operating. 

Peritonitis. — Some  of  the  highest  leucocyte  counts 
occurred  with  peritonitis.  Most  of  the  blood  counts 
in  these  cases  had  varied  from  7,000  to  40,000.  As  a 
rule,  at  the  outset,  with  the  exception  of  typhoid  fever, 
the  leucocyte  count  was  very  high.  It  increased  for  a 
few  hours  and  then  fell  to  7,000,  and  to  below  the  nor- 
mal before  death.  In  cases  of  peritonitis  of  not  more 
than  twenty-four  hours'  duration  the  counts  had  varied 
from  14,000  to  22,000,  and  all  these  cases  had  ter- 
minated fatally.  A  high  leucocyte  count  was  not  of 
much  significance  in  the  first  twenty-four  hours  of  a 
peritonitis.  If  this  persisted  after  thirty-six  or  forty- 
eight  hours,  the  progtiosis  was  proportionately  good. 
In  cases  of  peritonitis  from  typhoid  perforation,  the 
blood  counts  had  varied  from  7,000  to  23,000.  He 
had  found,  almost  without  exception,  that  any  patho- 
logical condition  producing  obstruction  was  followed 
in  a  few  hours  by  a  rise  in  the  leucocyte  count. 

Obstruction. — In  the  first  forty-eight  hours,  obstruc- 
tion, without  gangrene  or  peritonitis,  gave  a  leucocyte 
count  of  only  6,000  to  16,000,  while  in  cases  of  ob- 
struction with  gangrene  the  leucocyte  count  was  higher. 
The  higher  the  count  and  the  shorter  the  duration  in 
these  cases  the  greater  the  probability  of  gangrene. 
If  there  was  a  count  above  20,000  in  the  first  twenty- 
four  hours,  the  chances  were  that  gangrene  was  pres- 
ent. After  the  third  day,  if  the  leucocytosis  remained 
high,  the  prognosis  was  good,  excluding  gangrene  and 
peritonitis.  During  the  past  summer.  Dr.  Thayer  had 
made  a  most  laborious  and  exhaustive  examination  of 
the  records  of  typhoid  cases  for  a  number  of  years,  and 
had,  as  a  result,  come  to  the  conclusion  that  there  was 
rarely  a  rise  in  the  leucocyte  count  in  typhoid  fever 
without  some  associated  complication  or  aggravation 
of  the  disease. 

Pernicious  Anaemia. — Dr.  Alfred  Stengel,  of 
Philadelphia,  read    this    paper.     It   was    certain,    he 


said,  that  this  disease  resulted  from  the  rapid  destruc- 
tion of  red  blood  corpuscles,  and  that  the  source  of 
these  haemolytic  agents  was  the  gastrointestinal  tract. 
It  followed,  therefore,  that  pernicious  anamia  was  not 
a  primary  disease.  But  it  should  be  noted  that  the 
disea.se  did  not  invariably  follow  upon  the  grave  gas- 
tro-intestinal  disorder  alluded  to.  In  certain  cases  a 
special  infection  might  be  added,  or  there  might  be  a 
disturbance  in  the  process  of  hasmatogenesis.  The 
number  of  red  blood  corpuscles  was  reduced  below 
that  seen  in  any  other  condition;  these  corpuscles  pre- 
sented marked  changes  in  size,  shape,  and  staining- 
relations;  the  total  number  of  leucocytes  was  usually 
reduced,  and  the  uninuclear  elements,  especially  the 
smaller  forms,  were  nearly  always  more  numerous  than 
the  polymorphous  cells.  Megalocytes  and  an  average 
excess  of  the  red  blood  corpuscles  were  more  common 
in  this  tlian  in  any  other  disease.  Irregular  staining 
was  more  striking  than  in  any  other  disease.  The 
large  nucleated  corpuscles  were  more  regularly  ]5res- 
ent  in  this  tiian  in  other  forms  of  anx-mia.  Dr.  Sten- 
gel said  he  would  regard  as  pernicious  anaimia  a  case 
presenting  the  usual  clinical  symptoms  of  tliis  disease, 
together  with  a  blood  count  of  the  red  blood  corpuscles 
of  1.500,000  and  a  proportionate  number  of  leucocytes. 
He  had  never  met  with  a  patient  who  had  been  ciired, 
but  he  had  had  them  under  observation  for  four  or  five 
years.  None  of  them  warrants  a  hopeless  opinion  re- 
garding its  treatment. 

Leukaemia. — Dr.  C.  Y.  White,  of  Philadelphia, 
took  up  this  topic,  dealing  with  it  chieliy  from  the 
laboratory  side.  He  recognized  two  varieties,  (i) 
spleno-myelogenous  leukjemia,  and  (2)  lymphatic  leu- 
kaemia. The  first  form  was  characterized  by  a  pro- 
gressive pernicious  anasmia  accompanied  by  all  the 
forms  of  red-cell  degeneration,  and  by  polymorphic 
leucocytosis.  Lymphatic  leukaemia,  on  the  other 
hand,  was  associated  with  less  marked  anamia,  less 
evidence  of  red-cell  degeneration,  and  a  less  pro- 
nounced leucocytosis,  which  was  chielly  formed  by  the 
lymphocytes.  Cases  of  leukaemia  had  been  reported 
in  which  the  red  cells  had  been  less  numerous  than  the 
white.  With  the  decrease  of  the  red  cells  there  was 
a  diminution  in  the  hjemoglobin.  In  addition  there 
were  two  pathological  cells  ])resent  in  large  numbers, 
viz.,  the  myelocyte  and  the  eosinophilic  myelocyte. 

Parasites  in  the  Blood. —  Dr.  Leo.>j  S.  Le  \\ald, 
of  New  York  City,  spoke  on  this  subject,  dwelling 
particularly  on  the  very  recent  interesting  experiments 
in  regard  to  the  relation  of  mosquitos  to  malaria.  He 
said  that  Drs.  Manson  and  Koss,  of  England,  had 
proved  within  the  last  month  most  conclusively  lliat 
malaria  was  transmitted  to  the  human  subject  by  mos- 
quitos. Mosquitos  raised  in  the  laboratory,  and 
known  to  be  free  from  malarial  infection,  were  allowed 
to  suck  the  blood  of  a  person  in  Italy  suffering  from 
malaria,  the  type  of  which  had  been  determined  by 
microscopical  examination  of  the  blood  and  identifica- 
tion of  its  contained  parasites.  These  mosquitos  were 
then  sent  to  London  and  allowed  to  bite  Dr.  Manson's 
son,  a  young  man  who  was  perfectly  healthy  at  the 
time,  and  free  from  malarial  infection.  He  promptly 
developed,  on  September  13,  1900,  the  characteristic 
signs  of  true  malaria,  and  examination  of  his  blood  on 
September  i6ih  showed  many  tertian  parasites— the 
same  form  present  in  the  blood  of  the  Italian.  After 
a  few  days,  quinine  was  administered  freely,  and  in 
two  days  more  these  parasites  had  disappeared.  A 
week  later  the  young  man  was  well  again.  .Another 
interesting  experiment  conducted  this  summer  was  that 
of  Drs.  Sambon  and  Low,  who  took  a  hut  with  them  to 
the  most  intensely  malarial  section  of  the  Roman 
Campagna.  Here  they  lived  for  several  weeks  with- 
out developing  malaria,  although  newcomers  to  that 
region   almost    invariably  became   promptly  infected. 


634 


MEDICAL    RECORD. 


[October  20,  1900 


All  that  they  did  was  to  remain  in  the  house  between 
sunset  and  sunrise,  and  took  unusual  precautions  to 
prevent  being  bitten  by  mosquitos  at  any  time  while 
there.  The  connecting  link  between  these  two  most 
important  experiments  was  to  be  found  in  the  discov- 
ery within  the  bodies  of  these  mosquitos,  known  to 
transmit  malaria,  the  flagella,  thus  demonstrating  be- 
yond all  doubt  that  the  mosquito  is  the  intermediary 
host  of  the  malarial  parasite.  It  should  be  noted  that 
this  statement  applied  only  to  certain  species  of  mos- 
quitos, and  this  explained  the  fact  that  malaria  was 
unknown  in  many  places  where  ordinary  mosquitos 
were  abundant. 

The  Value  of  Blood  Examinations  in  the  Diag- 
nosis of  Trichinosis,  with  a  Report  of  Two  Cases. 
- — Dr.  H.  C.  Gordineer,  of  Troy,  read  this  paper. 
He  said  that  mild  cases  of  sporadic  trichinosis  were 
doubtless  overlooked  by  all.  Such  a  confession  had 
been  made  by  no  less  an  authority  than  Osier.  The 
fact  that  there  was  an  enormous  increase  of  the  eosino- 
philes  of  the  blood  in  cases  of  trichinosis  had  directed 
new  attention  to  the  study  of  the  blood  in  this  disease. 
Dr.  Brown,  of  the  Johns  Hopkins  University,  had  pre- 
sented a  classical  study  on  this  subject.  This  author 
advised  that  systematic  blood  examinations  be  made 
in  doubtful  ceases.  The  observations  of  Brown  had 
been  abundantly  verified  by  Cabot,  Gwynn,  Atkinson, 
Stumpf,  Blumer,  and  Newman.  The  percentage  of 
eosinophiles  was  far  in  excess  of  that  observed  in  any 
other  disease.  The  first  case  reported  in  the  paper 
had  been  seen  in  the  Samaritan  Hospital,  in  the  per- 
son of  a  man  who  had  been  eating  freely  of  "  blood 
sausage."  There  was  a  peculiar  swelling  of  the  face, 
particularly  about  the  eyelids,  and  there  were  also 
swellings  over  the  tibia,  together  with  a  soreness  of 
the  muscles  and  marked  anaemia.  Examination  of  the 
blood  showed  seventy-seven  per  cent,  of  eosinophiles, 
and  examination  of  the  muscles  demonstrated  the  pres- 
ence of  the  trichinae.  The  second  case  was  that  of 
the  father  of  the  first  patient,  who  had  been  in  excel- 
lent health  up  to  three  months  previous  to  coming  un- 
der examination.  He  had  then  been  taken  ill  with 
fever,  diarrhoea,  and  cramps  all  over  the  body.  He, 
too,  had  eaten  freely  of  the  sausage.  The  man  had 
walked  unassisted  to  the  hospital.  He  was  pale,  but 
much  less  so  than  the  son,  and  there  was  only  slight 
swelling  of  the  eyelids.  His  temperature  was  99.5° 
F.  Examination  of  his  blood  showed  29.9  per  cent. 
of  eosinophiles.  Microscopical  examination  of  the 
biceps  muscle  showed  no  trichinae,  but  the  char- 
acteristic areas  of  degeneration  were  visible.  The 
speaker  said  that  he  had  also  seen  a  case  bearing  on 
the  negative  value  of  blood  examination.  A  man  had 
been  accustomed  to  eat  freely  of  raw  ham,  and  about 
this  time  had  developed  all  of  the  more  characteristic 
symptoms  of  trichinosis.  The  muscular  soreness  was 
such  that  slight  motion  caused  extreme  pain.  A  great 
many  microscopical  examinations  of  the  ham  were 
made,  but  without  showing  any  trichina;.  This  man's 
blood  showed  an  enormous  number  of  leucocytes,  but 
the  percentage  of  eosinsophiles  was  very  small.  'i"he 
patient  would  not  consent  to  the  removal  of  a  portion 
of  muscle  for  microscopical  examination.  So  severp 
was  the  disease  that  it  was  expected  the  man  would 
die,  but  he  eventually  recovered.  The  case  was  prob- 
ably one  of  polymyositis. 

Officers  Elected. — President,  Dr.  John  A.  Wyeth,  of 
New  York;  Vice- President,  Dr.  A.  A.  Hubbell,  of  Buf- 
falo; Secretary,  Dr.  Fredrick  Holme  VViggin,  of  New 
York;  Treasurer,  Dr.  E.  H.  Squibb,  of  JJrooklyn ; 
District  Presidents,  Charles  B.  Tefft,  of  Utica ;  First 
District,  John  T.  Wheeler,  of  Chatham ;  Second  Dis- 
trict, Theron  A,  Wales;  Third  District,  W.  H. 
Thornton,  of  Buffalo;  Fourth  District,  Dr.  J.  C.  Bier- 
wirth,  of  Brooklyn. 


THE    MEDICAL    ASSOCIATION    OF   THE 
GREATER    CITY    OF    NEW    YORK. 

Stated  Meeting,  October  8,  /goo. 

William  McCollom,  M.D.,  in  the  Chair. 

A  Case  of  Hypospadias. — Dr.  Carl  Beck  presented 
this  patient.  The  child  was  only  five  months  of  age 
when  operated  upon.  The  hypospadias  was  of  the 
balanic  type  and  of  small  extent.  There  was  no  re- 
action and  the  result  was  perfect.  This  was  the  young- 
est child  he  had  ever  operated  upon  for  this  condition. 

Forward  Dislocation  of  the  Urethra  after  Exten- 
sive Ulceration  of  the  Penis. —  Dr.  Beck  also  pre- 
sented this  patient.  A  colored  man,  twenty-four  years 
of  age,  arrived  from  his  home,  Nassau  (Bahama  Isl- 
ands), in  a  desolate  condition.  There  had  been  a 
destruction  of  the  urethra  by  a  phagedenic  chancre. 
The  glans  was  disfigured  by  ulceration  in  such  a 
manner  that  two  glandular  halves  had  formed.  The 
anterior  third  of  the  pendulous  portion  of  the  urethra 
was  also  totally  destroyed.  There  were  retention  of 
urine,  cystitis,  and  extensive  oedema  of  the  penis  as 
well  as  of  the  scrotum  which  required  many  weeks  of 
energetic  treatment  before  a  plastic  operation  could 
be  performed.  In  spite  of  all  precautions  the  first 
attempt  at  dislocating  the  urethra  (see  abstract  of 
paper  which  follows)  proved  a  failure,  probably  due 
to  the  immense  tension  caused  by  the  efforts  in  pro- 
tecting the  large  deficiency  left  by  the  ulceration. 
Lateral  flaps  had  been  taken  freely  from  the  integu- 
ment of  the  penis  for  the  purpose.  The  greater  por- 
tion of  the  deficiency  being  covered  by  this  attempt, 
the  second  effort  was  made  easy,  the  urethra  remaining 
attached  at  its  new  orifice.  Finally,  the  integumental 
gap  remaining  below  the  glans  was  covered  by  a  quad- 
rilateral flap  taken  from  the  scrotum.  So  the  final 
result  could  be  called  a  very  good  one,  the  patient 
passing  his  urine  in  a  normal  stream  and  not  showing 
any  abnormalities  during  erection. 

Hydrotherapy  for  Typhoid  Fever  in  Private  Prac- 
tice.— Dr.  S.  Baruch  read  a  paper  witii  this  title.  The 
Brand  bath,  he  stated,  consisted  in  the  use  of  water 
at  70°  F.  with  friction,  used  for  fifteen  minutes,  every 
three  hours  when  the  rectal  temperature  was  at  or  above 
103°.  Hospital  statistics  he  did  not  consider  at  all 
reliable.  In  statistics  referred  to,  soldiers  about  the 
same  age,  the  same  weight,  taking  the  same  food,  ex- 
ercise, rest,  sleep,  etc.,  with  typhoid  fever  gave  relia- 
ble data  showing  a  reduction  of  mortality  from  twenty 
per  cent,  to  2.7  per  cent,  when  the  strict  Brand  method 
of  treatment  was  applied;  these  results  were  obtained 
by  a  reduction  in  the  complications.  The  most  con- 
vincing proof  of  the  efficacy  of  this  treatment  was 
shown  in  the  fact  that  it  was  now  taught  in  our  schools 
and  hospitals.  Yet  it  was'  not  enough  employed  in 
private  practice.  Dr.  Baruch  first  made  a  plea  for 
the  application  of  this  method  in  1889,  since  which 
time  the  schools  and  hospitals  had  taken  it  up  and 
taught  the  method.  In  applying  the  Brand  method 
the  temperature  of  the  bath  was  at  first  85°  and  in 
each  bath  the  temperature  was  lowered  5°  until  65° 
was  reached.  He  emphasized  the  importance  of  ap- 
plying friction.  Patients  should  be  carefully  dried 
without  rubbing.  In  private  practice  an  ordinary  tin 
tub,  six  feet  long,  obtainable  at  almost  any  store,  may 
be  used.  This  tub  could  be  placed  alongside  the  cot. 
A  piece  of  gas  hose  was  attached  to  the  cold-water 
faucet.  The  tub  could  be  filled  with  water  at  the  re- 
quired temperature  in  this  way.  When  the  tub  was 
one-half  full  the  patient  was,  with  great  care,  placed 
in  a  hammock  and  gently  swung  into  the  tub.  After 
the  bath  the  patient  was  gently  raised  by  means  of  the 
hammock,  laid  on  the  sofa,  dried,  and  allowed  to  rest. 
In  most  cases  the  patients  then  fell   into  a  slumber. 


October  20,  1900] 


MEDICAL    RECORD. 


635 


The  patient  should  be  dried  without  friction.  The 
bath  should  be  repeated  in  four  hours  so  long  as  the 
temperature  was  at  or  above  103''.  'J'he  water  in  the 
tub  did  not  require  renewing,  unless  soiled,  for  forty- 
eight  hours.  Before  the  patient  xvas  placed  in  the 
bath  four  ounces  of  coffee,  or  whiskey,  might  be  given 
if  necessary.  Alcoholic  stimulants  were  rarely  re- 
quired. Six  ounces  of  milk  and  four  ounces  of  ice- 
water  should  be  given  alternately  every  two  hours. 
Patients  who  were  secreting  much  below  the  normal 
quantity  of  urine  he  had  seen  secrete,  after  this  treat- 
ment, from  eighty  to  one  hundred  and  thirty  ounces  in 
twenty-four  hours. 

Substitutes  for  the  Brand  Method. — When  the 
reaction  was  imperfect,  or  tiie  relatives  objected  to  the 
treatment,  some  other  procedure  than  the  ISrand  be- 
came necessary.  In  selecting  some  substitute  one 
should  bear  in  mind  that  the  nearer  we  approached 
the  JJrand  method  the  better  results  would  be  obtained. 
Cold  sponging,  as  usually  applied,  was  really  a  damp 
mopping  of  the  skin.  Ablution  he  considered  a  valu- 
able substitute.  The  water  should  have  a  temperature 
of  80'',  and  be  applied  first  to  the  back  with  friction, 
and  then  to  the  front.  It  might  be  repeated  every 
three  hours  when  the  temperature  was  at  or  above 
103.  Affusion  might  be  combined  with  ablutions. 
An  oil-cloth,  properly  covered  by  a  cotton  sheet,  was 
placed  beneath  the  patient.  The  head  of  the  bed  was 
raised.  A  large  pan  was  placed  below  to  receive  the 
water.  An  attendant  stood  at  the  head  of  the  bed  and 
formed  a  trough.  The  patient  was  then  turned  in 
order  to  make  the  back  accessible.  The  water  that 
was  poured  over  the  black  should  have  a  temperature 
of  85  \  The  parts  should  be  rubbed  with  the  fiat 
hand.  When  the  pjrts  ceased  to  be  warm  then  some 
other  part  should  be  treated.  In  the  late  war  these 
baths  were  called  the  "slush"  baths.  Towel-baths 
were  really  a  modification  of  the  sheet-baths.  The 
patient  was  laid  on  a  wet  sheet  and  water  at  a  temper- 
ature of  60^  was  poured  from  a  cup.  Each  treatment 
might  reduce  the  temperature  2°.  Friction  was  ap- 
plied after  each  pouring  of  the  water.  In  the  use  of 
towels,  they  were  spread  over  the  part  and  water  at 
60°  was  poured  from  a  cup  over  successive  parts,  fric- 
tion being  applied.  The  entire  body,  except  the  lower 
one-third,  should  be  so  treated.  The  ice-rub  was 
Dr.  Hare's  substitution.  After  proper  protection  of 
the  patient  ice  was  rubbed  over  the  patient's  body, 
active  friction  being  used  with  the  unemployed  hand. 
If  ice  be  rubbed  rapidly  tiiere  was  no  murmur  on  the 
part  of  the  patient;  rubbing  rapidly  was  the  key  to 
the  whole  thing.  The  doctor  had  never  seen  a  patient 
in  a  condition  of  blueness  or  cyanosis  when  properly 
rul)bed.  Cold  should  be  applied  to  the  head  while 
applications  were  being  made  to  the  body.  This  rub- 
bing and  application  of  cold  should  be  thoroughly 
made  to  the  muscles  of  the  body  and  thighs,  for  it  was 
in  these  situations  that  there  seemed  to  be  a  great 
reservoir  for  heat.  The  application  of  cold  and  fric- 
tion to  the  posterior  surface  of  the  body  seemed  to  be 
more  important  than  to  the  anterior.  Stress  was  laid 
upon  proper  techniciue.  Some  nurses  thought  it  was 
only  necessary  to  soak  their  patients.  It  was  a  good 
rule  to  follow  to  use  such  a  temperature  of  the  water 
as  would  produce  the  desired  effect,  whether  applied 
by  rubbing,  by  the  tub,  by  the  tepid  or  by  the  hot 
baths.  One  should  bear  in  mind  that  the  lethal 
element  in  typhoid  fever  was  a  toxamia  which  over- 
whelmed the  nervous  system,  according  to  its  inten- 
sity; to  this  toxaemia  might  be  ascribed  the  high  tem- 
perature, stupor,  delirium,  etc.  The  application  of 
cold  here  produced  a  shock,  which  was  followed,  when 
judiciously  applied,  by  a  reaction,  the  stimulating 
effect  of  which  was  conveyed  to  the  central  nervous 
system. 


Dr.  R.  E.  Van  Gieson,  of  Brooklyn,  said  the  good 
effect  of  the  Brand  treatment  was  not  so  much  in  the 
lowering  of  the  temperature  as  it  was  in  keeping  up 
the  action  of  the  heart  until  the  toxins  had  been  elim- 
inated. It  was  difficult  to  get  patients,  or  their  rela- 
tives, to  submit  to  the  original  Brand  method,  and  he 
hoped  that  some  gentler  method  might  be  found  which 
would  overcome  this  prejudice.  In  using  the  ice-rub 
he  had  had  made  an  ice-clip  which  enabled  one  to 
retain  hold  of  the  ice. 

Dr.  WiLi.iANt  McCoLLOM,  of  Brooklyn,  stated  that 
pyrexia  might  be  considered  normal  in  febrile  dis- 
ease. It  had  been  suggested  that  it  was  a  conservative 
process  of  protoplasm  and  nerve  energy  in  destroying 
toxins  of  the  invading  microbe.  If  this  was  true  the 
normal  temperature  of  febrile  disease  should  not  be 
lowered  to  a  marked  degree  by  antipyretics.  The  use 
of  hydrotherapy  in  continued  fevers  was  very  old;  it 
was  much  in  favor  at  the  commencement  of  this  cen- 
tury. Galen  clearly  defined  this  method  in  early 
times.  In  the  early  years  of  this  century  Dr.  Currie, 
of  Liverpool,  did  much  successful  work  in  advocating 
and  introducing  it,  or  reviving  an  old  practice.  Dr. 
Currie  seemed  to  have  carried  out  the  modern  princi- 
jjles  of  hydrotherapy  ably  and  systematically.  Dr. 
Jackson,  also,  did  much  in  the  same  line  at  the  same 
time.  In  fact  the  management  of  typhoid  fever,  then 
called  typhus  mitior,  nearly  a  hundred  years  ago,  was 
much  the  same  as  the  best  methods  of  to-day.  Heat 
reduction  by  heat  abstraction  was  transitory  and  of  lit- 
tle use  in  typhoid  fever.  He  had  long  been  of  the 
opinion  that  the  mere  extraction  of  heat  by  cold  ap- 
plied to  the  surface  was  not  directly  therapeutic,  but 
that  it  acted  as  a  neural  stimulant,  increasing  and 
toning  the  action  of  the  nerve  centres  of  respiration, 
circulation,  metabolism,  elimination,  etc.  Winlernitz, 
at  the  International  Congress  at  Rome,  demonstrated 
that  cold  applied  to  large  surfaces  of  the  body,  when 
good  reaction  followed,  led  to  remarkaijle  results:  it 
increased  the  leucocytes,  the  percentage  of  the  ha-mo- 
globin,  and  the  specific  gravity  of  blood.  Metabol- 
ism, constructive  and  destructive,  was  promoted,  and 
if,  according  to  Vaughn,  the  leucocytes  were  a  form 
of  destructive  metabolism  which  destroyed  the  mi- 
crobes and  toxins  of  fevers  we  had  a  plausible  theory 
of  the  reduction  of  pyrexia  by  the  increase  of  the 
leucocytes  in  the  blood  by  the  frequent  cold  bath.  It 
had  been  demonstrated  by  Jurgensen,  Roque,  and 
Well,  that  the  cold  bath  increased  the  specific  gravity 
and  the  percentage  of  urea  in  the  urine  to  a  great 
extent.  Leibminster  and  Voit  had  shown  that  the 
cold  bath  increased  the  elimination  of  carbon  dioxide 
by  the  lungs.  When  fever  resulted  from  toxamia  heat 
reduction  must  be  effected  by  the  elimination  of  the 
toxins.  Heat  reduction  did  not  destroy  microbes,  and 
artificial  antipyretics  were  worse  than  useless  if  they 
did  not  stimulate  the  nerves  of  organic  life,  and  in- 
creased elimination  and  metabolism.  To  invigorate 
and  increase  the  physiological  activities  so  as  to  effect 
the  elimination  of  poisonous  products  should  be  aimed 
at.  Cutaneous  transpiration  caused  by  the  coal-tar 
products  hel[)ed  elimination  in  one  direction,  but  they 
were  objectionable  because  of  their  depressing  effects. 

The  Operation  for  Hypospadias. —  Dr.  Cari.  Beck 
read  this  paper.  Hypospadias,  he  stated,  was  one  of 
the  most  frequent  malformations  affecting  the  human 
body.  Rennes  detected  one  in  eight  hundred  recruits 
of  the  French  army.  The  number  of  cases  had  been 
underestimated,  and  this  was  explained  by  the  natural 
aversion  of  the  unfortunate  patients  to  mention  their 
deformity.  The  common  balanic  form  was  considered. 
Fecundation  was  almost  impossible  on  account  of  the 
wrong  direction  of  the  urethra.  Among  more  than 
one  hundred  married  hypospadiacs  he  had  examined 
he  found  that  none  had  children. 


636 


MEDICAL    RECORD. 


[October  20,  1900 


Early  Operations  and  Reasons  for  their  Fail- 
ures  Early  operations  were  based  on  the  principle 

of  direct  union  of  tlie  margins  of  tiie  abnormal  groove. 
Disappointments  were  great,  and  this  fact  caused 
small  wonder  when  we  considered  the  small  space  of 
the  operative  field,  the  necessity  of  introducing  a 
catheter,  the  constant  contact  with  urine,  and  the  pre- 
antiseptic  modus  operandi.  Failures  were  readily  un- 
derstood when  we  considered  the  difficulties  encoun- 
tered in  the  after-treatment.  First,  a  foreign  body,  a 
tube,  must  be  introduced  into  the  newly  formed  wound 
channel,  kept  in  situ  with  great  difficulty.  Again,  the 
direct  contact  of  such  decomposing  elements  as  those 
of  the  urine,  as  well  as  the  mechanical  injury  caused 
by  the  stream  itself,  interfered  with  the  aseptic  course 
of  tile  operation. 

Extensibility  of  the  Organ. — The  theoretical  re- 
flection that  the  e.\tensibility  of  an  organ  which  was 
able  to  change  its  volume  to  such  a  marked  degree 
during  erection  could  be  utilized  for  surgical  pur- 
poses, gave  him  the  first  impetus  to  his  experiments. 
This  mobility  extended  over  the  whole  movable  por- 
tion of  the  penis;  it  was  absent  in  the  perineal  and 
pelvic  sphere.  In  adults,  the  length  of  the/(7/,f  mobilis 
amounted  to  8-9  cm.  in  the  relaxed,  and  to  15-16  cm. 
in  the  erected  condition.  In  children  of  five  years  5.5 
cm.  could  be  assumed  to  be  the  average.  The  calibre 
of  the  urethra  in  adults  could  be  estimated  at  6  mm. 
in  moderate  distention,  and  at  10.5  mm.  in  forced 
dilatation.  The  enormous  abundance  of  elastic  fibres 
which  characterized  the  mucous  membrane  of  the  ure- 
thra along  its  cavernous  portion  could  be  regarded  as 
an  expression  of  its  enormous  extensibility.  If  the 
difference  in  length  between  the  erected  and  the  re- 
laxed penis  could  be  regarded  as  fairly  proportional 
to  the  degree  of  the  extensibility  of  the  urethra,  it 
could  be  understood  at  once  what  a  surprisingly  long 
area  could  be  covered  with  the  mobilized  urethra.  In- 
stead of  forming  a  new  urethra  he  utilized  the  existing 
one,  dissecting  it  free  and  dislocating  it  forward  so 
that  a  new  canal  need  not  be  created,  the  existing 
urethra  doing  the  service  of  it. 

Technique  of  the  Operation. — The  most  minute 
aseptic  precautions  were  taken.  An  incision  was 
made  from  the  centre  of  the  abnormal  urethral  open- 
ing, through  the  skin,  to  the  posterior  third  of  the 
pendulous  portion.  At  the  upper  end  of  this  incision 
a  second  one  running  nearly  transverse  through  the 
integument  was  added,  while  the  glans  was  stretched 
upward.  This  incision  encircled  the  lower  third  of 
the  neck  of  the  penis  immediately  below  the  coronary 
sulcus.  Tire  skin  flaps  were  dissected  back  to  expose 
the  lower  third  of  the  penis.  While  the  wound  mar- 
gins were  firmly  retracted  downward,  the  urethra,  to- 
gether with  its  corpus  cavernosum,  was  dissected  from 
its  bed.  After  having  exposed  the  urethra  freely  so 
that  it  could  be  easily  drawn  to  the  top  of  the  glans, 
tlie  latter  was  tunnelled  by  creating  two  flaps  which 
were  formed  by  making  a  lateral  incision  along  each 
side  of  the  groove.  These  flaps  must  be  raised  so  far 
that  the  dislocated  urethra  could  be  placed  into  the 
wound  bed.  The  orifice  was  fastened  at  the  top  of 
the  glans  with  four  iodoform-silk  sutures  of  moderate 
strength.  The  flaps  formed  from  the  glans  were  next 
united  above.  The  cosmetic  effect  might  be  imjjroved 
by  uniting  the  small  cross  section  of  the  skin  above 
in  a  longitudinal  direction.  This  mode  of  attaching 
the  urethral  opening  to  the  new  meatus,  which  required 
considerable  thoroughness,  he  recommended  as  the 
general  way  of  procedure.  The  tunnelling  of  the 
glans  could  be  done  in  a  simpler  manner  by  perfo- 
rating it  with  a  narrow  bistoury.  The  cosmetic  result 
of  this  shorter  but  more  brutal  procedure  was  not  so 
perfect.  It  was  only  in  cases  in  which  but  a  shallow 
groove,  or  none  at  all,  was  present,  or  whenever  through 


preceding  operative  efforts  the  lowerglandular  portion  ■ 
was  infiltrated  by  much  cicatricial  tissue,  that  he  had 
selected  this  mode  of  tunnelling  the  glans  in  toio  by 
thrusting  a  narrow  straight  bistoury  through  it  from 
below  upward  and  well  behind  the  sulcus  which  would 
normally  be  the  fossa.  Thus,  a  new  meatus  was 
created  about  a  quarter  of  an  inch  behind  the  topmost 
angle  of  the  sulcus.  The  point  of  emergence  of  the 
bistoury  was  enlarged  by  turning  it  to  the  right  or  left, 
making  an  incision  at  each  side.  After  the  knife  was 
withdrawn,  a  long  narrow  forceps  was  passed  from 
above  through  the  channel  and  the  urethra  grasped. 
Now  the  free  end  of  the  urethra  was  drawn  through 
the  channel  perforating  the  glans,  and  its  opening  at- 
tached by  means  of  four  iodoform-silk  sutures  to  the 
new  meatus.  This  was  done  in  the  same  way  as  al- 
ready described.  The  flaps  below  the  glans  were  also 
united  in  the  same  manner.  When  choosing  this  mode 
of  attachment  it  was  advisable  to  support  the  urethra 
by  two  catgut  sutures,  uniting  its  wall  inwardly  to  the 
sulcus  of  the  new  canal.  The  after-treatment  was  very 
simple.  The  penis  was  surrounded  by  an  iodoform- 
gauze  dressing  so  far  that  a  free  space  for  the  new 
orifice  was  left.  This  region  was  then  covered  with 
compresses  saturated  with  Burow's  solution,  which 
were  changed  frequently. 

Dr.  John  H.  Branth  said  that  hypospadias  in  its 
broadest  sense  was  generally  mistaken  for  hermaph- 
rodism  (double  sex),  but  he  doubted  that  true  hermaph- 
rodism  existed  in  man.  There  might  be  a  condi- 
tion in  which  one  or  more  parts  of  an  organism  were 
wanting  or  deformed,  but  that  a  condition  of  double 
sex  ever  existed  he  disputed.  Like  cleft  palate,  hypo- 
spadias was  a  cleft  in  the  floor  of  the  urethra  extend- 
ing backward  toward,  and  sometimes  including,  the 
perineum  to  a  variable  extent  up  "to  the  membranous 
urethra.  The  fetus  in  the  first  two  months  was  nor- 
mally hypospadiac.  Incontinence  did  not  exist  as  the 
sphincter  of  the  bladder  was  not  involved.  The  testi- 
cles were  generally  in  tlie  abdomen  in  this  deformity. 
A  fancied  resemblance  to  the  female  vulva  was  made 
apparent  when  the  cleft  separated  the  scrotal  pouches 
which  may  look  like  the  labia  niajora.  In  this  cleft, 
somewhere  between  or  anterior  to  the  scrotal  pouches, 
was  the  stump  of  the  urethra  issuing  from  the  bladder. 
Anterior  to  this  opening  or  fissure  was  either  a  wholly 
or  partially  patulous  urethra,  or  it  might  be  a  solid 
cord-like  structure.  The  penis  was  short  and  thick 
and,  on  sexual  irritation,  would  be  arched  upward,  the 
corpus  cavernosum  and  corpus  spongiosum  expanding 
less  than  the  dorsum  of  the  penis.  The  urine  was 
very  often  delivered  backward.  The  disturbances 
were  functional.  If  the  urethral  opening  was  not  far 
from  the  glans,  no  disturbance  existed  and  such  a 
patient  would  soon  learn  to  hold  his  penis  upward  to 
prevent  wetting  his  clothes.  Sexual  indulgence  and 
impregnation  were  possible  in  the  milder  cases  of 
hypospadias.  Tlie  severer  cases,  complicated  with 
contraction  of  the  lower  section  of  tlie  penis,  had  been 
treated  by  Dr.  Physick  by  resection,  cutting  out  a 
wedge-shaped  piece  (base  upward)  from  the  corpus 
cavernosum.  Another  plan  was  to  make  cross  sections 
like  a  tenotomy  in  the  lower  portion  and  then  hold  the 
penis  straight  by  splints  until  healed.  After  this  the 
l)uilding  of  a  urethra  could  be  attempted.  The  skin 
in  all  the  cases  he  had  seen  was  so  redundant  and  so 
distensible  in  this  region,  that  one  was  not  at  a  loss 
to  find  material  to  build  a  canal  for  the  missing  ure- 
thra. He  had  succeeded  satisfactorily  by  cutting  the 
external  half  of  the  prepuce  as  a  llap,  and  inverting 
it  backward  over  the  defective  urethra.  This  flap  had 
its  raw  side  out.  Then  he  cut  along  the  two  sides  of 
the  urethra  and  dissected  up  the  skin.  The  edge  of 
the  everted,  turned-back  flap  was  then  sewed  over  the 
sides  of  the  urethra  and  the  lateral  flaps  over  this  were 


October  20,  tqoo] 


MEDICAL    RECORD. 


637 


brought  together  by  stitches.  This  brought  the  two 
raw  surfaces  together  all  along  the  urethra  to  the  pre- 
puce. The  .skin  of  the  prepuce  formed  now  the  inner 
wall  of  the  canal.  The  prepuce  had  no  hair,  and  in- 
crustations would  not  occur.  The  canal  was  formed 
over  a  rubber  drainage  tube  in  the  slit  prepuce,  which 
remained  in  position  for  a  few  days  if  possible,  until 
the  stitches  were  ready  to  come  out.  Sometimes  it 
might  be  well  to  permit  a  urinary  fistula  until  the 
anterior  canal  was  healed,  and  later  to  close  this  fis- 
tula, when  the  urinary  canal  would  be  continuous  to 
the  bladder.  A  forceful  ejection  of  semen  could 
hardly  be  expected  from  such  a  urethra,  and  impreg- 
nation was  more  or  less  accidental.  In  ju.xtaposition 
to  hypospadias  he  referred  to  epispadias,  a  fissure  in 
the  roof  of  the  organ.  A  little  more  tiian  a  year  ago  he 
had  presented  to  the  society  two  cases  of  exstrophy  of 
the  bladder,  in  which  epispadias  existed.  He  brought 
forward  a  theory  that  this  deformity  occurred  from  a 
horizontal  twist  in  the  f-cetal  os  pubis,  bringing  out 
above  the  os  pubis  the  penis,  which  condition  is  al- 
ways found  in  exstrophy.  Investigators  all  remarked 
that  it  was  unexplainable  why  in  epispadias  the  ure- 
thral structure  was  above  the  corpus  cavernosum. 
His  theory  of  twisting  the  parts  seemed  to  furnish  an 
explanation.  Complete  hypospadias  he  considered  of 
rare  occurrence,  while  cleft  glans  was  quite  frequent. 
Hypospadias  was  sometimes  hereditary.  Baran  was 
quoted  as  stating  that  epispadias  occurred  once  in  four 
hundred  and  fifty  cases  of  hypospadias.  Rennes  found 
ten  cases  of  hypospadias  in  three  thousand  conscripts. 
Marchal  did  not  find  a  single  case  of  epispadias  in 
sixty  thousand  conscripts. 


^ctUcal 


Items. 


Contagious  Diseases — Weekly  Statement. — Report 
of  cases  and  deaths  from  contagious  diseases  reported 
to  the  Sanitary  Bureau,  Health  Department,  for  the 
week  ending  October  13,  1900: 


Tuberculosis 

Typhoid  fever 

Scarlet  fever 

Measles 

Diphtheria 

Laryngeal  diphtheria  (croup) 
Cerebro-spinal  meningitis. . . . 
Varicella 


An  Alleged  Doctor's  Industry — A  warrant  was 
not  long  since  issued  for  the  arrest  of  a  man,  calling 
himself  a  physician,  whose  only  occupation  seems  to 
have  been  the  theft  of  typewriting  machines.  Mis 
way  was  to  hire  typewriters,  paying  the  first  instalment 
of  $3  in  advance,  and  thereafter  persuading  the  col- 
lectors not  to  enforce  payments  for  several  months. 
When  these  became  too  importunate  the  man  would 
disappear.  He  is  known  to  have  obtained  twelve  ma- 
chines in  this  way,  paying  for  each  the  $3  rental,  and 
selling  them  for  from  S20  to  S50,  according  to  make 
and  age. 

Large  Vesical  Calculi — We  have  been  able,  says 
the  Indian  Medical  Gazette,  to  collect  a  few  records  of 
gigantic  stones  which  have  formed  in  the  bladder. 
The  largest  whicii  we  have  got  accurate  details  about 
is  one  removed  by  Lieut. -Col.  G.  J.  Bamber,  I. M.S.. 
when  civil  surgeon  of  Guzrat  in  1893.  It  weighed  on 
removal  twenty-five  ounces,  and  is  now  twenty-three 
ounces,  and  is  still  in  the  possession  of  Lieutenant- 
Colonel  Bamber.  It  filled  the  bladder  almost  exactly 
and  had  to  be  removed  by  a  suprapubic  operation. 


The  Baccelli  Treatment  of  Tetanus Korty  cases 

of  tetanus  are  now  reported  as  having  been  treated 
with  carbolic  acid;  four  patients  died  and  thirty-six 
recovered. 

The  American  Red  Cross  in  India. — The  Ameri- 
can Red  Cross  Society  has  begun  its  work  in  behalf 
of  the  sufferers  from  the  famine  in  India.  'I'he  work 
for  the  present  is  merely  preliminary  and  is  in  the 
direction  of  accumulating  funds.  As  soon  as  a  sufii- 
cient  amount  of  money  has  been  received,  the  Red 
Cross  agents  will  be  sent  to  India.  The  plan  of  relief 
will  be  the  same  as  that  so  successfully  operated  in 
Cuba,  where  the  Red  Cross  Society  assumed  the  re- 
sponsibility of  ameliorating  the  wretched  conditions 
of  the  starving  reconcentrados  Men  and  women  will 
not  be  gratuitously  supplied  with  food  and  clothing. 
Work  will  be  demanded  of  them,  and  the  society  will 
make  an  effort  to  have  the  farms  again  worked  and 
return  persons  to  their  chosen  paths  of  trade  and  in- 
dustry. 

Sterility  in  Man — K.  Ries  has  made  a  study  of 
sterility  in  the  male,  paying  special  attention  to  azoo- 
spermia due  to  obstruction  in  the  system  of  sperm 
channels.  He  makes  two  classes  of  cases,  according 
to  the  presence  or  absence  of  changes  in  the  cellular 
tissue  surrounding  the  seminiferous  tubules.  The 
most  marked  of  these  changes  is  the  formation  of  a 
zone  of  hyaline  tissue  around  the  seminiferous  tubules 
in  the  place  of  the  normal  Hat  connective-tissue  cells 
whicii  form  the  physiological  sheath  of  the  tubules. 
This  zone  of  hyaline  tissue  cuts  oft'  the  epithelium 
from  its  supply  of  nourishment,  normally  derived  from 
the  blood-vessels  of  the  intertubular  connective  tissue. 
Degenerative  changes  of  the  epithelium  accompany 
the  formation  of  the  hyaline  rings.  Where  the  hyaline 
zone  is  thin  we  find  the  epithelium  of  tiie  tubule  either 
normal,  even  containing  spermatozoa,  or  the  sperma- 
tozoa are  absent  and  we  find  only  a  few  layers  of  epi- 
thelium, or  even  only  one  lajer,  the  border-lines  be- 
tween the  cells  frequently  becoming  indistinct.  There 
is,  however,  a  distinct  cavity  of  the  tubule,  which  is 
sometimes  filled  with  spermatozoa.  With  the  further 
encroachment  of  the  hyaline  zone,  the  epithelium  is 
reduced  to  a  very  thin,  flat  layer,  resembling  endothe- 
lium, and  these  tubules  contain  nothing  but  a  few 
fragments  of  cells.  In  the  most  pronounced  cases  the 
lumen  of  the  tubule  disappears  completely,  and  instead 
of  a  channel  lined  with  epithelium  nothing  is  seen 
but  a  more  or  less  wavy  and  hyaline  mass  of  tissue 
with  very  few  nuclei,  without  any  trace  of  the  normal 
testicular  epithelium.- — Medical  Times  and  Hospital 
Gazette,  September  i,  1900. 

Improved    Temperance    Conditions    in  Manila. — 

Some  time  ago  an  ex-chaplain  of  volunteers,  with  that 
thirst  for  intemperate  statements  which  many  of  his 
cloth  and  an  occasional  international  medical  orator 
seem  possessed  of,  upon  returning  from  the  Phili]> 
pines  made  the  startling  assertion  that  one  of  the  re- 
sults of  American  occupation  had  been  an  increase  of 
saloons  from  four  to  more  than  four  hundred.  Every 
one  who  knew  anytliing  of  the  iin|)roved  conditions  in 
Manila,  and  who  remembered  the  fate  of  the  many 
other  false  statements  regarding  American  rule  there, 
was  convinced  of  the  incorrectness  of  this  assertion, 
but  the  proof  of  its  falsity  was  lacking.  The  report 
of  the  chaplain's  rash  statement  got  back  to  Manila, 
and,  as  we  learn  from  the  Army  and  Naiy  Journal. 
was  commented  upon  by  the  Manila  Freedom  of  April 
21st,  as  follows:  "We  have  taken  some  pains  to  in- 
vestigate this  charge,  and  have  to  say  that  it  is  false 
in  every  sense.  When  the  Hag  was  first  planted  in 
Manila  there  were  between  4.000  and  5,000  grocery 
shacks,  kept  by  Chinos  and  Filipinos,  and  every  one 


638 


MEDICAL    RECORD. 


[October  20,  1900 


of  them  sold  liquors,  a  native  product,  whicli  did  more 
to  fill  graves  than  disease  and  bullets.  They  were 
not  saloons,  but  grog-shops,  insidious  hell-holes,  and 
many  soldiers  became  victims  of  tliem.  Vino  and 
other  native  drinks  could  be  purchased  for  one  cent  a 
drink,  American  money,  and  ten  cents  was  a  sufficient 
sum  for  a  common  drunk  and  a  penny  or  two  more  for 
a  bacchanalian  revel.  Governor-General  Otis  had  this 
problem  to  solve  during  the  early  days  of  occupation, 
and  he  was  happily  successful  in  closing  most  of  the 
Chino  and  native  shacks.  A  license  system  was 
established  and  the  American  saloon  took  the  place  of 
the  native  saloon.  With  their  establishment  the  death 
and  insane  rates  have  been  less,  and  the  greatest  good 
to  the  great  number  has  thus  been  subserved.  Instead 
of  over  four  thousand  places  where  liquors  were  sold 
we  now  have  less  tiian  four  hundred,  and  the  quality 
of  the  stuff  is  vastly  better  and  the  quantity  less.  The 
insidious  eft'ects  of  vino  and  native  gin  soon  alarmed 
physicians  and  surgeons,  and  an  order  was  issued  to 
seize  and  destroy  all  of  said  products  found.  This 
practically  eliminated  their  manufacture,  and  to  get 
them  is  as  difficult  as  it  is  to  get  liquors  in  the  veriest 
prohibition  town  of  Kansas.      Hail  the  reform  ! 

The  Age  of  the  Earth.— At  the  meeting  of  the 
British  Association,  which  opened  at  Bradford,  York- 
shire, on  Wednesday,  September  5th,  one  of  the  most 
engrossing  addresses  delivered  was  that  by  Professor 
W.  J.  Sollas  treating  of  the  age  of  this  sphere.  Leav- 
ing the  nebular  origin  of  the  world  to  astronomers. 
Professor  Sollas  accepted  "the  infant  earth  from  their 
hands  as  a  molten  globe  ready  made,  its  birth  from  a 
gaseous  nebula  duly  certified."  "In  its  early  days," 
he  said,  "our  planet  was  profoundly  disturbed  by 
tides,  produced  by  the  sun,  for  as  yet  there  was  no 
moon,  and  it  has  been  suggested  that  one  of  its  tidal 
waves  rose  to  a  height  so  great  as  to  sever  its  connec- 
tion with  the  earth  and  to  fly  off  as  the  infant  moon. 
This  event  may  be  regarded  as  marking  the  first  criti- 
cal period,  or  catastrophe  if  we  please,  in  the  history 
of  our  planet.  The  career  of  our  satellite  after  its  es- 
cape from  the  earth  is  not  known  till  it  attained  a  dis- 
tance of  nine  terrestrial  radii;  after  this  its  progress 
can  be  clearly  followed.  At  the  eventful  time  of  par- 
turition the  earth  was  rotating,  with  a  period  of  from 
two  to  four  iiours,  about  an  a.xis  inclined  at  some 
eleven  degrees  or  twelve  degrees  to  the  ecliptic.  The 
time  which  has  elapsed  since  the  moon  occupied  a 
position  nine  terrestrial  radii  distant  from  the  earth, 
is  at  least  fifty-six  to  fifty-seven  million  of  years,  but 
may  have  been  much  more.  The  solidification  of  the 
earth  probably  became  completed  soon  after  the  birth 
of  the  moon.  The  temperature  of  its  surface  at  the 
time  of  solidification  was  about  1,170°  C,  and  it  was, 
therefore,  still  surrounded  by  its  primitive  deep  at- 
mosphere of  steam  and  other  gases.  This  was  the 
second  critical  period  in  the  history  of  the  earth,  the 
stage  of  the  consistentive  status,  the  date  of  which  Lord 
Kelvin  would  rather  know  than  that  of  the  Norman 
conquest,  though  he  thinks  it  lies  between  twenty  and 
forty  millions  of  years  ago,  probably  nearer  twenty 
than  forty." 

Maternal  Impressions Maternal  impressions  is  a 

subject  to  which  every  pregnant  woman  should  give 
both  thought  and  consideration.  Impressions  of  an 
unpleasant  nature  made  upon  a  pregnant  woman  may 
cause  mental  and  bodily  elfects  in  her  child.  It  does 
not  follow  that  the  cause  or  object  producing  any 
shock  to  a  woman  will  be  photographed  upon  the  un- 
born child,  but  the  whole  system  suffers  from  the  un- 
pleasant impression  made  upon  tlie  mother.  The  con- 
sequence is  a  disastrous  effect  upon  her  offspring.  It 
is  only  in  the  very  early  months  of  pregnancy  that  a 


shock  can  produce  malformation  of  the  child,  but  at 
any  stage  an  unpleasant  mental  impression  may  pro- 
duce "  marks."  Because  so  many  defects  in  children 
are  traceable  to  maternal  impression,  a  wise  woman 
will  avoid  every  emotional  disturbance  during  the 
months  of  pregnancy.  A  shock  due  to  accident,  and 
consequently  unavoidable,  should  be  dismissed  ficm 
the  mind  immediately  and  never  spoken  of  afterward. 
During  the  last  siege  of  Paris,  a  very  large  percentage 
of  children  born  were  mentally  and  physically  weak, 
while  many  others  were  imbecile  or  idiotic. —  Dr. 
James  Kiernan. 

Controlling  Thirst. — There  has  been  recently  much 
discussion  in  the  London  Times  on  this  subject,  and 
some  of  the  correspondence  has  been  of  a  highly  in- 
teresting nature.  The  following  is  one  of  the  letters 
sent  to  the  British  Journal:  "The  habit  of  drinking 
even  cold  water  is  one  which  is  easily  kept  in  the 
limits  of  the  actual  necessity  of  the  body  for  renewing 
its  moisture.  But  the  habit  must  be  regulated  by  the 
exercise  of  a  certain  self-control  before  the  necessity 
arises.  When  I  was  a  boy  I  had  the  ambition  of  ex- 
ploration, and  prepared  myself  by  abstinence  for  pri- 
vation. I  used  to  abstain  from  drinking  any  liquid 
whatever  for  twenty-four  hours  at  a  time,  knowing  that 
thirst  was  the  hardship  most  to  be  dreaded.  I  found 
the  habit  so  acquired  of  great  utility  in  my  travels, 
and  especially  in  the  campaigns  in  Montenegro,  which 
is  a  country  of  few  wells  and  no  springs,  the  main 
supply  being  rain-water  collected  in  cisterns,  and  dur- 
ing the  Turkish  invasion  their  army  could  never  main- 
tain a  force  sufficient  to  hold  the  localities  occupied, 
for  the  want  of  water.  I  have  seen  the  Montenegrin 
army  on  a  forced  march  almost  uncontrollable  from 
thirst,  and  my  groom  lie  down  in  the  road  to  drink 
from  the  puddles  after  a  passing  shower,  though  the 
water  was  yellow  from  the  trampling  of  horse  and 
man,  while  I  felt  no  inconvenience  whatever.  I  have 
seen  the  soldiers  drink  the  entire  contents  of  a  cistern, 
such  as  is  provided  by  the  way  at  convenient  distances, 
down  to  the  mud  at  the  bottom,  as  long  as  there  was 
any  liquid,  huddling,  crawling,  almost  fighting  to  get 
to  the  cistern,  though  I  had  made  the  same  march 
(though  on  horseback)  without  the  sensation  of  thirst. 
In  the  hottest  weather  of  an  Athenian  or  Italian  sum- 
mer, I  have  rarely  drunk  anything  between  meals,  and 
avoid  iced  water  as  the  greatest  provocative  of  thirst." 

Venesection  and  Saline  Transfusion. — In  the  Ar- 
chi'i'cs prin'ituialcs  ilc  Ahdecinc  Raynaud  has  just  con- 
cluded a  serial  article.  The  following  is  the  author's 
own  resume' :  i .  Venesection  by  its  depletive  and  depur- 
ative  action  is  certainly  the  best  method  of  mechanical 
disintoxication  in  all  cases  which  represent  a  severe 
blood  intoxication.  It  is  not  to  be  used  as  a  routine 
procedure  but  only  in  emergencies,  and  its  beneficial 
effect  is  only  temporary.  2.  Saline  injections  should 
be  used  only  hypodermically.  Thus  employed  they 
present  none  of  the  drawbacks  of  intravenous  injec- 
tions, although  their    action  is  somewhat   less  rapid. 

3.  Massive  doses  of  saline  solution  may  be  employed 
in  the  treatment  of  medical  hemorrhages,  in  algid  col- 
lapse, in  the  ataxo-adynamia  of  typhoid  affections,  and 
in  dysentery;  but  this  remedy  must  always  be  used 
with  discretion  and  with  due  regard  to  the  state  of  the 
heart  and  kidneys.  There  are  cases  recorded  of  death 
due  to  the  intemperate  exhibition  of  saline  transfusion. 

4.  Small  fractional  doses,  as  well  as  enemata  of  cold 
saline  solution,  maybe  used  without  fear  in  infections 
and  intoxications,  especially  when  there  is  vascular 
hypotension  or  difficulty  in  the  action  of  the  emunc- 
tories.  It  should  be  exhibited  systematically  from  the 
on.set  of  the  disease  in  moderate  quantities  (150  to  500 
c.c.  daily).     The  general  course  and  duration  of  the 


October  20,  19CX)] 


MEDICAL    RECORD. 


639 


disease  are  often  very  favorably  modified.  5.  In  all 
severe  toxamias  or  infections,  when  the  patient's  cir 
cumstances  are  desperate,  venesection  followed  by  mas- 
sive injections  witliout  renouncing  other  methods  of 
treatment  is  often  capable  of  rendering  the  greatest 
services  and  even  of  saving  life.  One  should  not  wait 
until  the  last  moment  before  exhibiting  the  solution. 
6.  VVlien  the  patient  is  too  far  gone  for  phlebotomy, 
it  is  still  possible  to  withdraw  blood  and  inject  saline 
solution  at  the  same  time  and  in  equal  quantities,  this 
procedure  being  a  safe  one. 

A  Return  to  the  Aboriginal  Type. — Nearly  every 
summer,  after  interest  in  the  sea-serpent  begins  to  Hag, 
some  scientist  announces  that  Americans  are  approxi- 
mating in  facial  conformation  to  the  noble  red  man. 
Professor  Starr,  of  Chicago,  if  the  daily  papers  are  to 
be  believed,  has  tlie  floor  this  year,  saying  that  he  has 
carefully  measured  the  faces  of  more  than  five  thousand 
children  of  I'ennsylvania  Dutch  parentage,  and  has 
found  in  most  cases  "lengthening  of  the  face  and 
broadening  of  the  cheek-bones  in  accordance  with  the 
characteristic  features  of  Indian  races." 

The  Human  Eye  and  How  to  Care  for  It.  — Dr. 
Reik,  writing  in  tlie  Cosmopolitan  for  September,  says 
that  the  excessive  use  of  alcohol  and  tobacco  affects 
the  eyes  very  seriously  and  that  for  some  people  to- 
bacco is  a  poison  and  produces  a  lesion  in  the  nerve 
of  tiie  eye  leading  to  blindness.  The  most  important 
thing  of  all,  however,  in  order  to  take  care  of  the  sight 
is  to  get  su'Ticient  light  to  work  and  read  by.  The 
most  desirable  location  of  a  light  to  read  by  is  from 
above,  behind,  and  to  the  left  of  the  body.  Of  arti- 
ficial lights  the  incandescent  electric  is  the  best, 
though  the  use  of  incandescent  mantles  has  much  im- 
proved gaslight.  Where  coal  oil  is  the  only  illumi- 
nant  the  so-called  student  lamps  make  a  very  satisfac- 
tory light. 

An  Anti-Fat  Town. — "  The  little  town  of  .N'eodesha. 
Kan.,  claims  a  remarkable  distinction.  It  has  a  popu- 
lation of  fifteen  hundred,  and  it  is  claimed  that  there 
are  more  thin  people  living  there  than  in  any  place  of 
similar  size  in  the  United  States,  many  of  its  men  and 
women  weighing  less  than  one  hundred  pounds,  al- 
though in  perfect  health.  Thysicians  explain  that  the 
Neodesha  petroleum  and  natural  gas  wells  are  re- 
sponsible for  that  condition,  and  that  these  elements 
are  nature's  anti-fat  remedy.  It  is  said  that  if  the  thin 
people  of  tiie  town  were  dressed  in  the  garb  of  the 
East  Indian  and  stood  up  in  line  they  would  present  a 
picture  similar  to  that  of  'starving  India.'"  We 
hasten  to  remark  that  our  esteemed  contemporary  the 
New  York  Times  is  responsible  for  the  above  item. 
We  simply  quote  but  do  not  indorse. 

Burial  Weddings. — The  Karens  of  Upijer  Burma 
not  only  delay  their  weddings  till  they  can  celebrate 
tweiity  or  thirty  at  once,  but  make  the  same  occasion 
serve  for  their  funerals  a;  well.  When  a  man  dies  his 
body  is  cremated,  and  the  ashes  are  kept  until  the 
time  for  the  formal  funeral.  When  a  bad  harvest  or 
a  prolonged  rainy  season  occasions  the  need  of  a  little 
excitement,  and  some  enthusiast  arranges  a  burial  wed- 
ding, the  ashes  are  arranged  along  a  low,  narrow  plat- 
form, while  the  men  stand  on  one  side,  the  women  on 
the  other.  There  are  no  mourners,  for  the  dead  men 
have  been  forgotten  during  .he  convenient  interval, 
and  ihe  dresses  suggest  only  the  pleasanter  side  of  the 
double  function.  Proceedings  are  commenced  by  a 
sort  of  poetic  competition  between  the  men  and  the 
fairest  maid.  If  the  latter  is  not  satisfied  with  the 
compliments  paid  her,  she  avoids  the  embarrassment 
of  a  direct  refusal  by  bidding  her  suitor  come  for  her 
"before  he  is  awake."     In  this  case  he  consoles  him- 


self with  a  pipe,  and  after  a  short  interval  transfers  his 
addresses  to  some  less  exacting  lady.  As  soon  as  the 
young  people  are  equally  paired  olT  the  elders  compete 
for  the  more  valuable  portion  of  the  dead  man's  prop- 
erty. Jewels  or  weapons  are  set  swinging  by  a  string 
while  the  claimants  pass  in  single  file.  The  one  who 
is  nearest  when  the  pendulum  stops  swinging  secures 
whatever  is  attached  to  it.  When  each  has  thus  se- 
cured a  memento  of  the  day,  the  rest  is  handed  over 
to  the  children,  to  be  smashed  up  with  all  the  crockery 
of  tiie  deceased  and  buried  with  their  ashes  on  some 
neighboring  hill. — Answers. 

Plea  for  Consumptive  Poor. — Dr.  S.  A.  Knopf, 
writing  to  the  Sunday  'lri/>uru-,^a.ys:  "There  is  an 
urgent  need  for  a  large  city  iiospital  for  the  exclusive 
treatment  of  the  consumjjtive  poor.  Hospitals  sup- 
ported by  private  contributions  will  very  rarely  take  a 
tuberculous  case.  The  few  existing  institutions  which 
receive  consumptives  can  scarcely  acconmiodate  five 
hundred  of  these  invalids.  What  becomes  of  the  rest? 
Those  who  desire  to  know  I  would  advise  to  visit  a 
few  of  these  sufferers  in  their  tenement  homes.  The 
visitor  will  see  more  misery  caused  by  this  one  disease 
than  by  all  the  others  combined.  In  dingy,  dark  rooms 
the  poor  consumptive  lives,  often  without  medical  at- 
tendance, but  nearly  always  without  proper  food  and 
supply  of  fresh  air,  so  essential  in  combating  this  dis- 
ease. Some  faithful  member  of  the  family  remains  at 
home  to  nurse  the  sufferer,  and  in  the  majority  of 
cases  contracts  the  disease  as  a  result  of  this  devotion. 
We  will  see  the  faithful  wife  nursing  a  consumptive 
husband  in  the  last  stages  of  the  disease,  and  on  ex- 
amining her  we  will  discover  that  she  suffers  already 
from  incipient  tuberculosis.  If  there  are  children, 
they  too  may  fall  victims  to  the  malady,  owing  to  the 
ignorance  or  carelessness  of  the  sufferer,  and  to  tlie  re- 
ceptivity to  disease  of  badly  housed  and  underfed 
humanity.  Yet  could  we  take  this  invalid  hopelessly 
ill  away  from  the  dreary  tenement  home  to  a  special 
hospital,  where  he  could  be  made  comfortable,  we 
would  do  away  with  a  centre  of  infection  which  con- 
stantly endangers  tiie  lives  of  his  own  family,  neigh- 
bors, and  friends,  and  thus  indirectly  save,  perhaps, 
many  valuable  lives." 

Oysters  and  Disease In  their  small   volume  on 

"Oysters  and  Disease,"  Profs.  W.  A.  Herdman  and 
Robert  Boyce  record  the  results  of  an  investigation 
extending  over  a  period  of  three  years,  and  although 
they  have  not  actually  established  a  connection  be- 
tween oysters  and  disease,  they  have  produced  the 
most  important  contribution  which  has  yet  appeared 
on  the  subject,  which  is  one  of  considerable  scientific 
and  unusual  popular  interest.  The  disputed  question 
as  to  the  cause  of  green  oysters  has  been  re- examined 
with  the  result  that  several  forms  of  greenness  have 
been  recognized  and  studied.  But  little  is  added  to 
our  knowledge  of  the  well-known  oysters  of  Marennes, 
the  authors  being  in  practical  accord  with  most  pre- 
vious investigators,  but  concerning  green  oysters  of 
Falmouth  and  certain  green  American  oysters  laid 
down  in  the  vicinity  of  Liverpool,  they  reach  re.sults 
divergent  from  the  views  held  by  previous  workers, 
and  more  in  accord  with  popular  belief.  Copper  in 
minute  quantities  is  normally  present  in  all  oysters, 
but  in  the  green  Falmouths  and  Liverpool  Americans 
is  found  in  unusal  amount.  In  the  greenest  of  the 
American  oysters  as  compared  with  the  whitest,  the 
proportion  is  3.75  :  i  calculated  for  oysters,  and  3.63  :  i 
calculated  on  the  ash,  and  a  careful  study  of  the  dis- 
tribution of  tlie  copper  by  chemical  and  histo-chemi- 
cal  methods  demonstrates  that  it  is  the  cause  of  the 
greenness.  .  .  .  The  connection  of  oysters  with  the 
transmission  of  infectious  diseases,  especially  typhoid 


640 


MEDICAL    RECORD. 


[October  20,  1900 


and  enteric  fever,  is  carefully  considered.  Dacilli  of 
the  colon  group  are  frequently  found  in  oysters  sold 
in  towns,  but  there  is  no  evidence  thai  they  occur  in 
those  living  in  pure  sea  water.  The  experiments  show 
that  pure  sea  water  is  inimical  to  the  growtii  of  typiioid 
bacilli,  and  they  do  not  multiply  either  in  the  alimen- 
tary tract  or  in  the  tissues  of  the  living  oyster.  Ba- 
cillus typhosus  was  not  found  in  any  of  the  oysters 
obtained  directly  from  dealers  or  directly  from  the 
sea,  but  from  inoculated  specimens  the  bacilli  were  vh- 
tained  up  to  tlie  tenth  day,  although  the  results  indi- 
cate that  tliey  perish  during  passage  through  the  intes- 
tines. Oysters  and  other  niollusca  obtained  from 
dealers  frequently  contain  a  bacillus  presumptively 
resulting  from  sewage  contamination,  but  it  was  found 
that  the  infected  oysters  could  be  cleansed  by  washing 
in  clear  running  sea  water.  It  is  evident,  therefore, 
that  by  changing  oysters  from  an  infected  bed  to  one 
where  the  surroundings  are  pure,  they  may  be  purged 
of  their  dangerous  qualities. —  Satrne. 

Wounded   in  China The  London  Medical  Press 

announces  that  tlie  Grand  Ducal  government  of  Baden 
has  decided  to  grant  the  use  of  their  bathing  establish- 
ments with  all  their  therapeutic  appliances  to  officers 
and  soldiers  of  the  allied  forces  wounded  in  China, 
free  of  all  cost.  Baden-Baden  with  its  mild  climate 
and  efficacious  mineral  water  and  magnificent  bathing 
establishments  did  such  good  service  to  the  sick  and 
wounded  after  the  Franco-German  war  that  we  can 
only  hope  that  the  combatants  of  all  nations  will  now 
make  use  of  them  with  the  same  excellent  results. 

England's  Coming  Census When  the  results  of 

the  last  census  became  known,  the  fact  that  the  popu- 
lation of  England  and  Wales  fell  short  of  the  official 
estimates  by  nearly  three-fourths  of  a  million,  created 
quite  a  sensation,  but  the  random  charges  of  inaccu- 
racy were  not  substantiated.  England  and  Wales  were 
shown  to  contain  20,002,525  inhabitants;  Scotland 
4.025,647,  and  Ireland  4,704,750,  making  37,732,922. 
the  total  for  the  United  Kingdom.  What  increase  is 
the  forthcoming  census  likely  to  establish?  According 
to  the  registrar-general's  estimate,  the  population  of 
England  and  Wales  in  July  of  the  present  year 
amounted  to  32,091,907;  Scotland,  4,313.993;  and 
Ireland,  4,515,471,  representing  an  aggregate  of  40,- 
921,371  for  the  United  Kingdom.  Seeing  that  the 
natural  increase  of  the  population  amounts  to  112,712 
every  three  months,  the  census  of  1901  may  be  ex- 
pected to  demonstrate  that  Great  Britain  and  Ireland 
contain  no  fewer  than  41,259,507  people,  an  advance 
of  3,526,585  since  the  census  of  1891. —  Tribune. 

The  Hygiene  of  High  Altitudes 2'Jie  Lancet  says: 

"  It  is  well  known  that  the  chemical  composition  of 
the  atmosphere  differs  little,  if  at  all,  wherever  the 
sample  be  taken ;  whether  it  be  on  the  high  Alps  or  at 
the  surface  of  the  sea,  the  relation  of  oxygen  to  nitro- 
gen and  other  constituents  is  the  same.  The  favorable 
effects,  therefore,  of  a  change  of  air  are  not  to  be  ex- 
plained by  any  difference  in  tlie  proportion  of  its  gas- 
eous constituents.  One  important  difference,  however, 
is  the  bacteriological  one.  The  air  of  high  altitudes 
contains  no  microbes,  and  is,  in  fact,  sterile,  whilst 
near  the  ground  and  some  one  hundred  feet  above  it 
microbes  are  abundant.  In  the  air  of  towns  and 
crowded  places,  not  only  does  the  microbic  impurity 
increase,  but  other  impurities,  such  as  the  products  of 
combustion  of  coal,  accrue  also.  Several  investiga- 
tors have  found  traces  of  hydrogen  and  certain  hydro- 
carbons in  the  air,  and  especially  in  the  air  of 
pine,  oak,  and  birch  forests.  It  is  to  these  bodies, 
doubtless,  consisting  of  traces  of  essential  oils,  to 
which  the  curative  effects  of  certain  healtii  resorts  are 
ascribed.     Thus  the  locality  of  a  fir  forest  is  said  to 


give  relief  in  diseases  of  the  respiratory  tract.  But  all 
the  same  these  traces  of  essential  oil  and  aromatic  prod- 
ucts nui!;t  be  counted,  strictly  speaking,  as  impurities, 
since  they  are  not  apparently  necessary  constituents 
of  the  air.  As  recent  analyses  have  shown,  these 
bodies  tend  to  disappear  in  the  air  as  a  higher  altitude 
is  reached,  until  they  disappear  altogether.  It  would 
seem,  therefore,  that  microbes,  hydrocarbons,  and  en- 
tities other  than  oxygen  and  nitrogen,  and.  perhaps  we 
should  add,  argon,  are  only  incidental  to  the  neighbor- 
hood of  human  industry,  animal  life,  damp,  and  vege- 


tation. 


While  the  Medicai,  Record  is  pleased  to  receive  all  new  pub- 
lications which  may  be  sent  to  it,  ami  an  acknowledgment  will  be 
promptly  made  of  their  receipt  under  this  heading,  it  must  he  with 
the  distinct  understanding  that  its  necessities  are  such  that  it  can- 
not be  considered  under  obligation  to  notice  or  review  any  publica- 
tion received  by  it  which  in  the  judgment  of  its  editor  will  not  be 
of  interest  to  its  readers. 

Notes  on  Surgery  for  Nurses.  By  Joseph  Bell.  121110, 
194  pages.     Oliver  &  Boyd,  Edinburgh. 

Diet  Lists  and  S[ck-r<>om  Dietary.  By  Jerome  B. 
Thomas.      \V.  B.  Saunders.  Philadelphia. 

Tran'sactio.n's  of  the  Louisiana  State  Medical  Society. 
8vo,  427  pages.      W.  K.  Saunders  &  Co.,  Philadelphia. 

Transactions  of  the  Medical  Society  of  the  State 
OF  New'  York.  Svo,  522  pages.  Illustrated.  PubUshed  by 
the  Society. 


A  Treatise  on  Diseases  of  the  Nose  and  Throat.     By 
T     01 — 1..       gvQ_  744  pages.      Illustrated.      D.    Appleton 


Ernest  L.  Shurly. 
&  Co. ,  New  York. 


A  Treatise  on  Mental  Diseases.  By  Henr)-  J.  Berkley. 
Svo,  601  pages.     Illustrated.     D.  Appleton  &  Co.,  New  York. 

A  Manual  t>F  Otology.  By  Gorham  Bacon,  M.D.  i2rao, 
422  pages.      Illustrated.      Lea  Brothers  &  Co. ,  Philadelphia. 

Progressive  Medicine.  By  Hobart  Amory  Hare,  M.D. 
Svo,  408  pages.      Lea  Brothers  &  Co.,  New  York. 

Genito-Urinary  and  Venereal  Diseases  and  Syphilis. 
By  Robert  W.  Taylor.  Svo.  722  pages.  Illustrated.  Lea 
Brothers  &  Co. ,  New  York. 

A  Dictionary  of  Medical  Science.  By  Robert  Dunglison, 
M.D.     Svo.  1376  pages.      Lea  Brothers  &  Co..  Philadelphia. 

An  A.MF.RicAiN  Te.xt-Book  of  Physiology.  By  William  H. 
Howell,  M.D.  5gS  pages.  W.  B.  Saunders  &  Co.,  Philadel- 
phia. 

A  Maniai.  of  Sve'hii.is  and  the  Venereal  Diseases. 
By  James  Nevins  Hyde.  Svo,  594  pages.  Illustrated.  W.  B. 
Saunders  &  Co.,  Philadelphia. 

A  Text-Book  of  the  Diseases  of  \Vomen.  By  Henry  J. 
Garrigues.  M.D.  Svo.  756  pages.  Illustrated.  W.  B.  Saun- 
ders &  Co. ,  Philadelphia. 

Rhinologv,  Laryngology,  and  Otology,  and  their  Sig- 
nificance in  General  Medicine.  By  E.  P.  Friedrich,  M.D. 
Svo,  348  pages.  \V.  B.  Saunders  &  Co.,  Philadelphia  and  Lon- 
don. 

.\  Text-Book  upon  the  Pathogenic  Bacteria.  By  Jo- 
seph McEarland,  M.D.  Svo,  621  pages.  Illustrated.  W.  B. 
Saunders  &  Co.,  Philadelphia. 

The  .Vrt  of  Hreathing  as  the  Basis  of  Tone-Produc- 
tion. By  Leo  KoHer  Svo,  277  pages.  Edgar  S.  Werner  Pub- 
lishing and  Supply  Company,  New  York. 

pACIEKIciLOGY  AND  SURGICAL  TECHNIQUE  FOR  NURSES. 
By  Kniily  .M.  .V,  Stoney.  Svo  iqo  pages.  Illustrated.  W.  B. 
Saunders  ^  Co  ,  Philadelphia. 

Speech-Hesitation.  By  E.  J.  Ellery  Thorpe.  i2mo,  75 
pages.  Edgar  S.  Werner  Publishing  and  Supply  Company,  New 
\ork 

Flashes  of  Wit  and  lit  mor,  Hy  Robert  Waters,  izmo, 
iSfi  pages.  Edgar  S.  Werner  Publishing  and  Supply  Company, 
New  York. 


Medical  Record 

A    Weekly  yoiinial  of  Medicine  and  Surgery 


Vol.  58,  No.  17. 
Whole  No.  1564. 


New  York,   October  27,    1900. 


$5.00  Per  Annum. 
Single  Copies,  loc. 


©riginaX  Articles.  • 

PUERPERAL  SEPSIS:  ITS   PATHOLOGY  AND 
TREATMENT.' 

By   WILLIAM   R.    PRYOR.    M.D., 

NEW  YORK. 

It  is  hardly  possible  that  in  the  time  allotted  me  I 
can  give  a  description  of  the  many  and  minute  changes 
wrought  in  the  system  by  puerperal  sepsis  or  discuss 
all  the  various  methods  of  treatment.  Still,  I  can  call 
your  attention  to  certain  of  the  more  recent  investiga- 
tions into  the  pathogenesis  of  puerperal  sepsis  and 
perhaps  bring  out  a  discussion  regarding  treatment 
which  may  be  of  value  to  us  all. 

The  manner  in  which  women  become  infected  is  of 
great  interest.  It  is  a  comforting  belief  that  auto- 
infection  may  take  place,  but  the  observations  of 
Kronig  and  VVhitridge  Williams  pretty  thoroughly 
disprove  the  possibility  of  this  except  in  very,  very 
rare  instances. 

An  infecting  coitus  may  take  place  just  previous  lo 
delivery,  as  well  as  may  an  infecting  examination,  but 
such  is  not  auto-infection.  About  forty-nine  per  cent. 
of  prostitutes  have  thegonococcus  present  though  latent 
in  the  cervical  glands,  and  a  small  percentage  of  hon- 
est married  women  have  the  same.  In  such  of  course 
self-infection  by  the  gonococcus  after  delivery  is  pos- 
sible. Lastly,  a  few  women  with  a  pus  focus  in  one 
or  the  other  adnexa  will  conceive  and  go  to  full  term, 
and  become  infected  by  this  after  deliqery.  But  this 
must  be  exceedingly  rare,  because  such  a  lesion  sup- 
poses sterility  or  induces  early  abortion.  We  are 
therefore  forced  to  believe  that  puerperal  sepsis  is 
caused  by  germs  which  are  introduced  from  without. 

Causes:  Franz,  the  most  recent  writer  on  this  sub- 
ject, found  the  gonococcus  present  in  but  four  per  cent. 
of  his  fifty  cases  of  puerperal  fever:  once  in  a  mild 
case  accompanied  by  saprophytes,  and  once  in  a  severe 
case  with  streptococci.  The  degree  of  infection  pro- 
duced by  the  gonococcus  is  mild. 

In  three  hundred  cases  of  afebrile  puerperia  nine 
observers  found  some  sort  of  germ  in  twenty-seven  per 
cent.,  but  never  the  streptococcus  or  pyogenic  staphylo- 
coccus. In  a  very  few  cases  of  mild  form  streptococci 
are  found,  but  in  nearly  all  cases  of  infection  by  pyo- 
genic streptococci  and  staphylococci  the  symptoms  are 
grave.  We  are  therefore  warranted  in  as.serting  that 
puerperal  sepsis  is  caused  by  streptococci  and  staphy- 
lococci. But  in  most  cases  these  are  accompanied  by 
other  germs,  especially  saprophytes. 

Lesions  produced :  Upon  entering  the  uterus  these 
germs  soon  penetrate  deep  into  the  decidua  through 
the  endometrium  and  enter  the  lymph  channels  of  the 
uterus.  From  there  they  pass  into  the  venous  sinuses 
and  into  the  lymphatics  of  the  pelvis,  thus  entering 
the  general  venous  and  lymphatic  systems.  The  peri- 
toneum over  the  uterus  and  lymphatics  may  become 
inflamed,  pouring  out  serum,  lymph,  or  pus.  Septic 
emboli  may  break  from  the  thrombi  in  the  ovarian  or 

'  Read  before  the  New  York  State  Medical  Association, 
October  1 6,  igoo. 


iliac  veins  and  produce  septic  infarcts  elsewhere. 
Septic  pneumonia,  septic  endocarditis,  acute  nephritis, 
and  general  suppurative  peritonitis  are  some  of  the 
graver  lesions  induced,  while  ovarian  abscess  and  pyo- 
salpinx  are  local  results.  Viewed  in  the  light  of  the 
lesions  resulting  we  may  divide  puerperal  sepsis  into 
septic  thrombosis  and  pelvic  lymphangitis.  We  may 
also  describe  as  puerperal  any  septic  condition  occur- 
ring after  abortion  when  the  induced  lesions  are  such 
as  we  see  follow  full-term  labor.  The  most  rapidly 
fatal  cases  are  thrombotic. 

The  havoc  wrought  by  the  infection  is  governed  by 
a  great  many  factors.  Chief  among  these  is  the  viru- 
lence of  the  infecting  germs.  Then  the  traumatism 
to  which  the  uterus  has  been  subjected,  the  patient's 
general  condition,  and  the  area  of  endometrium  in- 
vaded, all  influence  the  result. 

Unlike  saprophytic  or  putrid  infection  which  tends 
to  spontaneous  recovery,  puerperal  sepsis  if  not  rapidly 
fatal  almost  always  produces  lesions  which  seriously 
damage  either  a  pelvic  organ  or  other  viscera.  I  wish 
this  fact  to  be  borne  in  mind  when  we  consider  the 
treatment.  Time  is  here  an  important  element. 
Therefore  we  are  to  consider  not  only  the  mortality 
figures  but  also  the  morbidity. 

Regarding  the  virulence  of  the  germs  in  different 
localities  we  notice  that  while  Kronig  and  Whitridge 
Williams  in  their  cases  had  a  mortality  of  about  five 
per  cent.,  Edgar  Macharg  in  fifty-seven  cases  had 
fifty-four  per  cent,  mortality.  .And  those  who  will  re- 
call the  epidemic  here  of  i88i  will  remember  the  great 
number  who  died. 

The  danger  from  saprophytic  infection  being  so 
slight  and  its  correction  so  easy,  while  the  danger 
from  streptococcus  infection  is  great  and  the  best 
method  of  dealing  with  it  in  dispute,  the  importance 
of  an  accurate  diagnosis  is  apparent. 

The  best  way  to  secure  uncontaminated  the  uterine 
lochia  is  by  means  of  a  Doderlein  tube  which  is  passed, 
after  sterilization,  into  the  uterus  and  without  touch- 
ing the  vulva  or  vagina.  Even  here  there  is  a  leak  in 
the  technique,  for  the  cervical  glands  may  soil  the 
tube,  but  will  hardly  get  into  the  lochia  which  issucked 
up  from  the  fundal  cavity. 

Having  found  pyogenic  cocci,  how  shall  we  proceed 
to  treat  the  case?  The  most  popular  method  of  treat- 
ment is  by  intermittent  washing.  This  is  what  Macharg 
did  ancj  lost  fifty-four  per  cent,  of  his  cases.  Besides, 
the  cocci  not  being  on  the  surface  but  deep  in  the 
uterine  walls,  washing  cannot  and  does  not  reach  them. 
All  it  succeeds  in  doing  is  to  increase  the  distress  by 
inflicting  additional  and  needless  trauma.  The  gen- 
tlemen who  laud  washing  have  not  made  bacterio- 
logical examinations  of  their  patients'  discharges,  and 
they  can  rest  assured  that  when  they  see  benefit  from 
the  treatment  it  is  not  in  streptococcus  cases  but  those 
of  saprophytic  nature.  And  even  in  these  they  have 
subjected  their  patients  to  needless  danger  by  improp- 
erly performed  manoeuvres,  for  it  is  too  easy  to  con- 
vert a  saprophytic  infection  into  a  septic. 

Curettage  of  the  septic  uterus  gives  a  prohibitive 
mortality;  and  again  we  must  condemn  a  measure  in 
sepsis  which  is  of  benefit  in  saprophytic  infection. 

Serum  therapy:    The  commission  appointed  by  the 


642 


MEDICAL    RECORD. 


[October  27,    1900 


American  Gynecological  Society,  of  whicli  I  have  the 
honor  to  be  a  member,  reported  in  1898  that  Mar- 
morek's  serum  when  used  in  one  hundred  and  one  caees 
of  streptococcus  puerperal  fever,  gave  a  mortality  of 
thirty-three  percent.  Of  course  if  used  in  cases  show- 
ing no  streptococci  the  mortality  is  less,  but  we  do  not 
believe  the  advocates  of  the  serum  claim  it  is  effica- 
cious against  any  germ  but  the  streptococcus,  and  in 
streptococcus  infection  the  mortality  is  thirty-three 
per  cent.  We  found  that  the  serum  was  used  in  two 
hundred  and  fifty-one  cases  in  which  no  bacteriological 
diagnosis  was  made  and  gave  a  mortality  of  sixteen 
per  cent.  Now,  as  Williams  found  the  streptococcus 
in  but  twenty-five  per  cent,  of  his  cases  of  puerperal 
fever,  Kronig  in  nineteen  per  cent,  of  his,  Franz  in 
twenty  six  per  cent,  of  his,  we  can  assume  that  of  these 
two  hundred  and  fifty-one  cases  about  one-quarter  were 
streptococcic;  and,  as  the  other  seventy-five  per  cent, 
would  have  lived  if  let  alone,  (he  serum  here  was  fol- 
lowed by  forty  deaths  in  sixty-three  cases,  or  sixty- 
three  per  cent,  morality.  If  we  could  only  know  the 
kind  of  streptococcus  a  given  serum  was  prepared  from 
and  could  secure  a  case  infected  by  just  that  identical 
streptococcus  we  might  secure  better  results  from  its 
use;  but  as  our  knowledge  of  streptococci  now  stands 
the  administration  of  antistreptococcus  serum  is  fol- 
lowed by  a  mortality  which  prohibits  its  use. 

Fortunately  in  taking  from  the  man  who  occasion- 
ally sees  a  case  of  puerperal  fever  this  much-lauded 
remedy,  we  have  other  methods  of  treatment  more 
efficacious  to  offer. 

These  septic  cases  are  to  be  considered  in  two 
classes.  The  cases  of  thrombosis  are  comparatively 
rare.  When  the  diagnosis  can  be  made  my  belief  is 
that  no  form  of  treatment  will  prove  effective  short  of 
an  abdominal  hysterectomy,  preceded  by  intravenous 
infusion,  and  rapidly  performed.  Inasmuch  as  here  as 
well  as  in  pure  pelvic  lymphangitis  the  peritoneum 
and  lymph  streams  are  invaded,  I  would  suggest  the 
use  of  a  large  abdominal  Mikulicz  iodoform-gauze 
dressing.  But  this  is  the  only  form  of  puerperal  sep- 
sis in  which  I  would  perform  hysterectomy. 

How  are  we  to  treat  the  more  common  cases  of  sep- 
tic pelvic  lymphangitis,  the  usual  perperal  sepsis? 

Kronig,  basing  his  practice  upon  fifty-six  cases  of 
sepsis,  lost  four  per  cent.,  employing  a  general  support- 
ing treatment  only. 

Whitridge  Williams,  in  twenty-three  cases  treated  in 
a  similar  manner,  lost  4.35  per  cent.  So  the  general 
practitioner  has  good  ground  for  refusing  to  listen  to 
the  gynaecologist  when  he  advises  operation.  ISut  I 
for  one  cannot  forget  the  mortality  which  attended  ex- 
actly the  same  treatment  in  olden  days,  emphasized  as 
it  is  by  Macharg's  recent  figures. 

I  must  believe  that  the  infecting  germs  in  Williams 
and  Kronig's  cases  were  weak  and  not  virulent.  But 
though  accepting  all  they  say  as  to  mortality,  the  un- 
checked sepsis  must  have  wrought  havoc  not  only  with 
the  pelvic  organs  but  also  with  the  general  health. 

I  cannot  see  the  logic  of  their  position  and  must 
believe  tiiat  these  gentlemen,  for  whose  scientific  at- 
tainments I  have  the  greatest  respect,  have  been  un- 
duly attracted  by  the  seductively  low  mortality.  At 
the  time  that  Williams  reported  his  cases  I  gave  a  list 
of  fourteen  cases  in  which  I  had  operated,  one  when 
the  patient  was  dying  with  endocarditis  and  nephritis, 
with  this  one  death.  To  show  how  completely  these 
women  recovered,  two  have  since  been  reported  as 
pregnant.  The  method  I  have  adopted  since  1894  has 
proceeded  along  these  lines:  I  have  attempted  to 
check  the  local  infection  and  to  combat  the  general 
septicaemia.  Incidentally  also  I  wished  to  prevent 
pelvic  sup]iuration. 

I  curette  the  uterus  as  thorouglily  as  (lossible.  being 
careful  to  wash  out  all  debris  with   this  tube,  using 


many  quarts  of  decinormal  salt  solution.  The  material 
removed  by  the  curette  is  placed  in  a  sterile  jar  for 
examination.  I  then  pack  the  uterus  full  of  five-per- 
cent, iodoform  gauze. 

The  next  step  is  to  make  a  broad  incision  into  the 
posterior  cul-de-sac.  Through  this  I  evacuate  all 
rtuids  in  the  pelvis,  saving  a  specimen  for  examina- 
tion. In  all  cases  there  is  much  serum  present,  some 
lymph,  and  often  pus  free  in  the  pelvis.  Any  false 
union  between  the  organs  is  broken,  and  the  pelvis  is 
wiped  dry.  I  now  make  what  I  call  the  pelvic  Miku- 
licz dressing  of  iodoform  gauze.  This  dressing  com- 
pletely fills  all  parts  of  the  pelvis  and  is  in  close  ap- 
position to  all  the  pelvic  peritoneum  to  the  pelvic 
bri;".i,  except  in  front  of  the  uterus.  The  iodoform  is 
soon  broken  up  by  the  serum,  and  so  rapid  is  its  ab- 
sorption tiiat  it  appears  in  the  urine  from  two  to  five 
hours  after  the  operation.  The  circulation  of  so  large 
an  amount  of  this  powerful  antiseptic  in  the  blood 
must  have  a  deterrent  efi^ect  upon  the  general  sepsis, 
as  these  charts  will  show. 

To  determine  whether  the  streptococci  which  I  found 
in  the  uterus  and  in  the  pelvic  cavity  were  destroyed, 
I  instituted,  with  Dr.  Jeffries,  bacteriologist  to  several 
of  our  institutions,  a  series  of  investigations.  We 
found  tiiat  invariably  all  cocci  were  destroyed,  strep- 
tococci remaining  to  the  third  dressing  in  only  one 
patient,  and  she  has  reported  pregnant. 

If  under  ether  I  find  the  pulse  120  or  over,  or  if 
there  are  grave  visceral  lesions  elsewhere,  particularly 
in  the  heart  and  kidneys,  I  always  do  an  intravenous 
saline  infusion  of  frolii  two  to  three  quarts.  This 
seems  a  severe  measure,  but  all  the  cases  brought  to 
me  are  in  bad  shape  and  most  of  them  have  nephritis. 

The  essence  of  the  treatment  is  local  and  general 
iodism,  together  with  promotion  of  the  function  of  the 
kidneys.  After  the  operation  I  use  colon  enemata  of 
salt  solution  every  three  hours,  for  the  purpose  of 
eliminating  the  toxins  and  the  iodine.  This  treat- 
ment has  been  employed  over  fifty  times  by  myself 
and  associates.  By  means  of  it  I  feel  sure  we  have 
saved  women  who  would  otherwise  have  died.  While 
the  procedure  is  novel  to  some  of  you,  and  while  it  is 
based  upon  a  new  principle,  namely,  the  introduction 
into  the  blood  of  so  powerful  an  antiseptic  as  iodine 
which  would  appear  dangerous,  I  cannot  but  be  gov- 
erned by  what  we  have  seen. 

Such  is  the  position  of  our  present  knowledge  re- 
garding puerperal  sepsis.  Repeated  irrigations  we 
find  do  harm.  Curettage  gives  twenty  per  cent,  mor- 
tality. Serum  therapy  gives  thirty-three  per  cent. 
mortality.  We  have  coming  from  great  men  the  con- 
clusion that  it  is  best  to  do  nothing  in  an  operative 
way.  You  may  elect  to  accept  that  advice.  But  what 
will  you  do  if  their  further  experience  prompts  them 
to  desert  you?  If  you  are  now  so  disposed  as  to  fol- 
low me  and  many  others,  perform  a  rapid  abdominal 
hysterectomy  in  your  cases  of  thrombosis,  and  in  the 
cases  of  true  puerperal  sepsis  the  curettage  and  cul- 
de-sac  operation  as  I  have  described  it. 


An   Enormous   Fibroma  of   the  Fundus  Uteri.— 

A.  I'inna  Pintor  removed  this  new  growth  through  an 
incision  extending  from  the  symphysis  to  two  inches 
above  the  umbilicus.  The  tumor  was  closely  adherent 
to  the  surrounding  parts,  but  was  successfully  removed 
and  the  attempt  made  to  save  the  uterus.  Owing  to 
the  hemorrhage  this  was  impossible  and  amputation 
had  to  be  done.  The  tumor  which  had  been  first 
noticed  by  the  patient  three  years  previously  was 
found  to  weigh  twenty-six  and  one-half  pounds  and 
to  measure  forty-eight  inches  in  circumference. — Ccn- 
tralblatt Jiir  Gyniikoiogie,  September  15,  1900. 


October  27,  1900] 


MEDICAL    RECORD. 


641 


FOREIGN    BODIES    IN    THE   (JiSOPHAGUo. 
Bv   GEORGE   W.    KING,    M.lJ., 

HELENA,    MOST. 

The  clinical  history  of  a  recent  case  of  impaction  of  a 
foreign  body  in  the  oesophagus  is  herewith  submitted 
for  the  purpose  of  illustrating  in  a  practical  way  the 
principal  points  to  be  considered  in  the  diagnosis  and 
treatment  of  this  accident.  A  girl  aged  six  years, 
while  amusing  herself  with  a  penny  whistle,  inadver- 
tently allowed  it  to  slip  backward  into  the  pharynx,  aiid 
becoming  alarmed  she  made  violent  efforts  at  sw-allow- 
ing,  which  forced  the  body  onward  into  the  oesophagus 
and  beyond  reach  of  the  finger.  Several  copious 
draughts  of  water  were  taken,  but  served  no  useful 
purpose  in  accelerating  the  progress  of  the  whistle 
downward.  She  then  informed  her  mother  of  the  acci- 
dent. Nothing  was  done,  however,  until  the  follow- 
ing day  when  she  was  presented  for  examination  with 
the  above  history.  During  the  night  several  attacks  of 
vomiting  had  occurred  without  effecting  dislodgmeiit 
or  expulsion  of  the  foreign  body.  Fluids  could  be 
swallowed  without  regurgitation.  Some  degree  of  dis- 
comfort existed,  pain  over  the  sternum  and  cervical 
region  being'the  most  prominent  symptom  complained 
of.  Respiration  appeared  to  be  normal.  No  informa- 
tion concerning  the  presence  or  position  of  the  whistle 
could  be  gathered  by  palpation  or  superficial  examina- 
tion. The  absence  of  urgent  symptoms  suggested  the 
probability  that  passage  downward  had  been  success- 
fully accomplished  during  the  interval.  The  trauma- 
tism produced  by  the  passage  of  a  body  of  that  size 
would  account  for  the  irritation  present.  Fortunately 
we  are  no  longer  compelled  to  remain  in  doubt  when 
dealing  with  this  class  of  cases.  The  fluoroscope  and 
skiagraph  demonstrate  clearly  what  we  desire  to  know 
without  subjecting  our  patients  to  the  annoyance  inci- 
dent to  the  use  of  sounds  or  other  instruments,  which 
after  all  are  liable  to  fail  in  the  object  for  which  they 
are  employed.  The  accompanying  illustration  made 
from  a  skiagraph  indicates  the  utility  of  this  method 
of  examination.  The  vertical  position  of  the  whistle 
is  well  shown,  but  its  exact  location  when  measured 
by  fractions  of  an  inch  is  largely  a  matter  of  conjec- 
ture. The  position  and  distance  of  the  Crookes  tube 
in  relation  to  the  object  and  the  diffusibility  of  the 
rays  must  be  carefully  noted  in  order  to  eliminate  er- 
rors in  the  interpretation  of  the  shadow.  Facility  in 
this  respect  is  acquired  by  experience  in  this  line  of 
work.  In  this  instance  the  picture  represents  the  ob- 
ject as  slightly  below  its  actual  position.  This  differ- 
ence was  immaterial,  inasmuch  as  there  was  positive 
assurance  that  the  impaction  was  in  the  cervical  por- 
tion of  the  oesophagus  and  therefore  accessible,  and 
this  furnished  sufficient  data  for  all  practical  purposes. 
The  patient  was  put  under  an  anajsthetic  and  extrac- 
tion by  the  mouth  was  undertaken.  It  was  found  to 
be  impossible  to  locate  and  grasp  the  foreign  body 
with  suitable  instruments;  sounds  or  bougies  failed  to 
give  evidence  of  contact,  apparently  passing  by  the 
seat  of  obstruction  without  impinging  upon  the  rim  of 
the  whistle.  It  soon  became  evident  that  nothing 
could  be  accomplished  by  this  route  and  the  operation 
was  for  the  time  abandoned.  Considerable  reaction 
followed,  the  temperature  went  up  to  102°  F.,  and  there 
were  marked  symptoms  of  acute  bronchitis,  induced  in 
all  probability  by  exposure  or  traumatism.  Appropri- 
ate remedies  were  prescribed  and  the  patient  was  left 
undisturbed  until  her  condition  would  justify  further 
operative  interference.  With  the  subsidence  of  the 
bronchitis  a  more  distressing  condition  developed, 
viz.,  spasm  of  the  glottis  accompanied  by  an  incessant 
cough,  reflex  in  character,  caused  by  the  presence  of 

'  Read  at  the  meeting  of  the  Rocky  Mountain  Interstate  .Medi- 
cal Association,  August  29,  igoo,  at  Butte,  Mont. 


the  foreign  body.  'Esophagotomy  being  the  only  oper- 
ation likely  to  afford  relief,  it  was  performed  without 
incident.  The  incision  was  made  in  the  usual  loca- 
tion, i.e.,  upon  the  left  side  along  the  anterior  border 
of  the  sterno-mastoid  muscle,  the  fascia  was  divided 
with  due  regard  to  the  position  of  the  vessels  and 
nerves  lying  within  the  field  of  operation,  the  tissues 
were  carefully  separated  by  blunt  dissection  until  the 
bodies  of  the  cervical  vertebra;  could  be  felt  with  the 
linger,  the  carotid  sheath  was  retracted  outward,  and 
the  trachea  and  thyroid  gland  were  rotated  in  the  op- 
posite direction.  A  sound  was  now  introduced  into 
the  oesophagus  and  two  silk  sutures  were  placed  in 
appropriate  position  in   its  walls,  and  the  ends  were 


left  long  to  facilitate  control  of  the  part  during  the 
subsequent  manipulations.  The  tube  was  opened  over 
the  point  of  the  sound  and  the  latter  was  withdrawn. 
.\  forceps  was  passed  downward  through  the  incision 
to  the  depth  of  six  inches  and  upward  to  nearly  the 
same  distance  without  encountering  the  foreign  body. 
A  metallic  bougie-a-boule  was  then  substituted,  and 
being  introduced  came  directly  in  contact  with  the 
whistle  which  was  embedded  just  below  the  cricoid 
cartilage.  A  small  instrument  was  passed  under  the 
rim,  and  by  a  prying  motion  the  whistle  was  loosened 
and  forced  upward  and  outward  where  it  could  be 
easily  grasped  with  the  forceps  and  extracted.  It  is 
worthy  of  remark  that  the  same  instrument  by  means 
of  which  the  whistle  was  located  through  the  incision 
had  been  passed  by  the  mouth  in  the  previous  attempt 
with  negative  result.  The  incision  in  the  oesophagus 
was  closed  by  absorbable  sutures  and  the  lower  angle 
of  the  wound  external  to  it  was  loosely  packed.  The 
head  was  fixed  by  a  pasteboard  splint  extending  uj> 
ward  from  the  dorsal  region.  No  vessel  of  sufficient 
size  to  require  a  ligature  was  divided  during  the  oper- 
ation; hemorrhage  therefore  was  limited  to  slight  ooz- 
ing. No  injury  to  the  nerves  resulted.  In  the  after- 
treatment  nothing  was  given  oy  the  mouth  until  the 
fifth  day,  nutrient  enemata  being  used  to  sustain  the 
patient.  The  wound  remained  free  from  infection  and 
the  healing  progressed  satisfactorily. 

A  small  fistulous  opening,  through  which  there  was 
an  occasional  escape  of  food,  remained  for  a  time,  but 


644 


MEDICAL   RECORD. 


[October  27,  igoo 


did  not  cause  any  special  inconvenience.  The  patient 
was  discharged  one  month  from  the  date  of  operation. 
The  whistle' measured  one  inch  in  diameter,  and  had 
been  impacted  for  ten  days. 

The  favorable  issue  in  this  case  was  due  to  the 
smooth  surface  and  accessible  location  of  the  foreign 
body,  permitting  its  removal  without  laceration  of  the 
tissues,  and  last  but  not  least,  the  absence  of  infection 
of  the  wounded  surfaces.  This  latter  complication 
cannot  be  effectually  guarded  against,  owing  to  the  im- 
possibility of  maintaining  accurate  apposition  of  the 
edges  of  the  incision  until  union  has  been  accom- 
plished. The  involuntary  act  of  deglutition  will 
sooner  or  later  cause  one  or  more  of  the  stitches  to 
cut  through,  with  subsequent  separation  of  the  line  of 
union.  For  this  reason  some  operators  omit  sutures 
altogether,  preferring  an  open  wound  to  a  partially 
closed  one.  Theoretically,  approximation  by  suture 
with  fi.xation  of  the  head,  nothing  being  taken  by  the 
mouth  for  the  first  week,  ought  to  give  the  best  re- 
sults. 

External  cesophagotomy  for  the  removal  of  foreign 
bodies  is  not  an  operation  of  recent  date.  Suggested 
by  Verdu  in  1643,  first  performed  byGoursald  in  1738, 
it  has  long  been  recognized  as  a  legitimate  operation 
when  indicated,  yet  up  to  1894  there  were  but  one 
hundred  and  thirty-five  recorded  cases,  mostly  the 
work  of  German  surgeons.  In  the  one  hundred  and 
thirty-five  cases  there  were  one  hundred  recoveries. 
The  mortality  rate  is  influenced  by  certain  conditions 
here  as  elsewhere;  thus,  late  operations  show  an  in- 
creased death  rate  over  the  early,  other  conditions 
being  equal,  and  again  the  situation  and  nature  of  the 
foreign  body  are  important  factors  in  determining  the 
result. 

If  we  study  the  anatomical  relations  of  the  oesopha- 
gus in  the  cervical  region  with  special  reference  to 
the  operation  of  cesophagotomy,  we  shall  find  that  the 
space  to  be  invaded  is  occupied  in  part  by  the  left 
lobe  of  the  thyroid  gland,  the  left  common  carotid 
artery,  the  inferior  thyroid  artery,  the  middle  and  su- 
perior thyroid  veins,  the  left  recurrent  laryngeal  nerve, 
and  the  omohyoid  muscle.  The  trachea,  from  its 
position  and  intimate  relation  to  the  tube,  may  be 
regarded  as  within  the  danger  limit.  Injury  to  the 
recurrent  laryngeal  nerve,  opening  the  trachea  by  mis- 
take or  otherwise,  wounding  the  carotid  artery,  are 
among  the  accidents  that  might  happen  to  experienced 
operators  as  well  as  to  the  novice.  Conditions  which 
add  to  the  difficulty  of  the  operation  are  chiefly  swell- 
ing or  enlargement  of  the  glands  in  the  cervical  region, 
unusual  depth  of  the  cesophagus,  and  failure  to  find 
the  foreign  body  or  when  located  to  loosen  it  from  the 
point  at  which  it  is  embedded.  The  causes  of  death 
following  the  operation  are  for  the  most  part  septicae- 
mia and  exhaustion. 

The  oesophagus  in  its  descent  through  the  thorax  is 
never  isolated  from  important  structures;  the  trans- 
verse portion  of  the  arch  of  the  aorta,  the  left  bronchus, 
the  pericardium,  a  part  of  the  descending  aorta,  the 
thoracic  duct,  and  the  pneumogastric  nerves,  are  in 
contact  with  or  in  close  relation  to  the  tube  at  certain 
points  in  its  course,  and  consequently  are  liable  to 
injury  by  retention  of  a  foreign  body  or  by  undue 
violence  in  the  passage  of  instruments. 

The  predisposition  of  the  oesophagus  to  the  lodg- 
ment of  foreign  bodies  is  due  to  normal  constrictions 
which  exist  in  three  places,  viz.,  at  the  cricoid  carti- 
lage, at  the  bifurcation  of  the  bronchi  (about  the  level 
of  the  first  rib),  and  at  the  diaphraginatic  opening. 
Large  or  rounded  bodies  are  usually  arrested  at  the 
cricoid  narrowing,  by  reason  of  the  unyielding  larynx 
in  front  and  the  bodies  of  the  cervical  vertebras  be- 
hind, which  serve  to  limit  dilatation  in  the  antero- 
fwsterior  direction.     Oblong  and  smaller  objects  may 


pass  on  to  the   second  or  third  constriction  and  be 
there  retained. 

In  view  of  the  manifold  dangers  and  difficulties  to 
be  encountered,  the  removal  of  foreign  bodies  lodged 
in  the  cesophagus  cannot  be  regarded  as  a  trivial  oper- 
ation. When  undertaken  with  no  conception  of  its 
gravity  and  without  an  accurate  knowledge  of  the  ana- 
tomical relations  above  detailed,  the  risk  to  the 
patient  exceeds  that  of  many  operations  of  greater 
magnitude.  Too  energetic  and  ill-directed  efforts  are 
most  likely  to  fail  and  in  addition  to  inflict  irrepar- 
able injury.  No  rules  can  be  laid  down  for  the  treat- 
ment of  those  cases  of  large  impaction  in  the  pharynx 
when  suffocation  is  imminent.  Here  the  choice  of 
adequate  instruments  and  the  presence  of  the  skilled 
hand  to  direct  them  must  yield  to  the  greater  urgency 
of  immediate  action.  The  finger  is  always  available 
and  should  be  unhesitatingly  employed,  as  should  also 
inversion  of  the  patient.  No  technical  skill  is  exer- 
cised in  these  acts,  yet  it  is  what  the  skilful  surgeon 
himself  would  do  under  similar  circumstances.  It  is 
true  the  latter  has  other  resources  at  command,  but 
this  does  not  imply  that  simple  and  common-sense 
methods  should  be  overlooked  in  any  case.  The  size, 
shape,  consistency,  and  location  of  the  object  must  be 
taken  into  consideration  in  forming  a  proper  estimate 
of  the  difficulties  to  be  overcome  in  the  process  of 
extraction.  The  diagnosis  can  be  made  with  certainty 
by  the  use  of  the  .^--ray,  the  exceptions  being  few  and 
unimportant  so  far  as  the  treatment  is  concerned. 
(Reference  is  here  made  to  impactions  which  consist 
entirely  of  alimentary  substances  that  cannot  be  skia- 
graphed.)  The  retention  of  bodies  which  are  uniform 
in  shape  with  smooth  rounded  exterior,  is  naturally 
attended  with  less  danger  than  that  of  bodies  present- 
ing irregular  outlines,  with  sharp  cutting  edges  or 
points  which  easily  pierce  the  tissues  and  in  some  sit- 
uations might  wound  important  organs  and  produce  a 
fatal  result.  It  is  obvious  that  in  the  latter  case  at- 
tempts at  withdrawal  or  propulsion  could  not  be  made 
without  more  or  less  laceration  of  the  tube,  even  in  the 
most  careful  hands.  This  fact  should  emphasize  the 
importance  of  a  careful  study  of  conditions  before 
resort  to  the  use  of  instruments,  and  also  the  avoid- 
ance of  brute  force  when  it  becomes  necessary  to  em- 
ploy them.  The  cervical  portion  of  the  cesophagus 
lies  within  reach  of  instruments  passed  by  the  mouth, 
and  removal  of  the  impacted  body  may  often  be 
effected  by  this  route.  This  is  the  method  almost 
universally  employed  and  is  the  operation  of  choice, 
and  if  conducted  with  a  reasonable  amount  of  skill  it 
ought  not  to  result  in  harm  to  the  patient.  Too  vio- 
lent or  long-continued  efforts  are  not  advisable,  since 
we  have  in  cesophagotomy  a  more  surgical  procedure 
which  may  be  relied  upon  to  succeed  within  proper 
limits.  The  incision  renders  the  part  more  accessible 
— a  decided  advantage  duly  appreciated  by  those  who 
have  had  occasion  to  resort  to  the  operation. 

'J'he  administration  of  an  anasthetic  as  a  prelimin- 
ary to  the  introduction  of  instruments  by  the  mouth  is 
seldom  required  in  the  case  of  adults,  but  when  we 
are  dealing  with  children   it  becomes  indispensable. 
The  patient  should  then  be  put  in  the  Roser  position  I 
to  lessen  the  danger  of  suffocation   and  at  the  same 
time  facilitate  the  passage  of  sounds  or  bougies  by] 
straightening  out  the  folds  in  the  oesophagus.     In  the 
search  after  and   removal  of  foreign  bodies  impacted 
in  the  cesophagus,  the  danger  and  difficulty  increase 
with  the  depth,  for  the  point  of  an  instrument  passed 
by  the  mouth   into  the  thoracic  portion  of  the  tube  is 
practically  beyond  the  control  of  the  operator  and  in  ' 
spite  of  the  utmost  care  rupture  and  injury  to  adjacent 
organs    are    among    the    possibilities.       The    flexible  | 
(esophageal   forceps  can  be   introduced   to  any  depth 
desired,  but  its  grasp  is  not  firm   enough   to  hold  an 


October  27,  1900] 


MEDICAL   RECORD. 


645 


object  which  requires  considerable  force  in  with- 
drawal. The  failure  to  extract  from  above  by  use  of 
the  finger  or  instruments  passed  by  the  mouth,  by  in- 
version of  the  patient,  or  by  emesis  wiien  applicable, 
limits  the  choice  of  further  interference  to  incision; 
by  that  I  mean  cesophagotomy  or  gastrotomy,  one  or 
both  combined,  or  to  propulsion,  i.e.,  forcing  the  im- 
pacted body  on  into  the  stomach.  The  latter  is  to  be 
preferred  when  feasible,  and  moreover  has  the  merit 
of  having  been  iinown  to  succeed  in  numerous  in- 
stances. In  suitable  cases,  then,  this  method  should 
be  employed,  but  we  must  keep  in  mind  the  chances 
of  error  arising  from  the  fact  that  a  sound  or  bougie 
may  glide  past  the  object  without  giving  evidence  of 
contact,  the  impression  being  conveyed  that  the  tube 
is  clear  and  requires  no  further  attention.  It  must  be 
admitted  that  propulsion  is  not  entitled  to  very  high 
rank  by  reason  of  its  uncertainty  in  results  and  its 
manifest  limitations.  It  is  permissible  only  when  the 
foreign  body  is  known  to  be  smooth  and  uniform  in 
shape  or  composed  of  an  alimentary  bolus  which  can 
be  safely  forced  through  the  passage.  K.xtraction  by 
incision  or  other  means  is  undoubtedly  the  correct 
treatment  for  foreign  bodies  in  the  cesophagus.  AX 
times  it  is  easy  of  accomplishment,  but  oftener  it  taxes 
the  ingenuity  and  resources  of  the  operator  even  though 
he  be  possessed  of  more  than  average  skill,  and  it  is 
not  surprising  therefore  that  the  expectant  plan  should 
be  adopted  by  many  and  that  the  foreign  body  should 
be  left  to  itself  when  situated  low  down  in  the  thoracic 
portion  of  the  cesophagus.  Such  practice  may  be  open 
to  criticism,  yet  it  is  not  without  precedent,  its  justi- 
fication resting  upon  the  absolute  failure  of  extraction 
or  propulsion. 


REPORT  OF  THREE  C.VSES  OF  IXTESTIXAL 
OBSTRUCTION  DUE  TO  MECKEL'S  DIVER- 
TICULA.' 

JOHN    F.    ERDMANN,    M.D., 

NEW    YORK, 

CLINICAL     PROFESSOR     OK     SURGERY     IN     THE     UNIVERSITY     ANI>     IIELLEVUE 
HOSI-ITAL  .MEDICAL  COLLEGE. 

In  presenting  this  report  no  attempt  at  any  scientific 
consideration  of  tiie  subject  will  be  made.  The  author 
was  struck  by  the  coincidence  of  three  of  these  rare 
cases  coming  under  his  observation  within  a  period  of 
five  and  a  half  months,  and  deemed  the  citation  of  the 
histories  of  the  cases  of  sufficient  importance,  from  a 
clinical  standpoint,  to  prove  of  interest  to  the  mem- 
bers of  this  association.  A  feature  of  these  cases  was 
the  pronounced  resemblance,  from  a  clinical  stand- 
point, to  appendicular  involvement;  another  feature 
was  that  in  each  of  two  of  the  cases  there  was  an  ex- 
isting appendicular  complication. 

I  confess  that  in  each  of  these  two  cases  the  diag- 
nosis of  appendicitis  was  made,  although  in  one  of 
them  doubt  as  to  the  diagnosis  was  expressed  and  ex- 
ploration was  suggested;  while  in  the  first  of  the 
cases  recorded  I  was  undecided  between  acute  ob- 
struction by  internal  strangulation  and  perforative  ap- 
pendicitis of  the  so-called  fulminating  variety.  Close 
study  of  the  symptomatology  of  these  cases  will  readily 
demonstrate  the  resemblance  to  three  varieties  of  symp- 
toms of  onset  in  appendicitis,  namely,  the  first  the 
so-called  acute  fulminating  or  profoundly  septic,  the 
second  a  subacute  attack  attended  by  abscess  forma- 
tion, and  the  third  an  acute  appendicitis  accompanied 
by  gangrene  with  toxic  absorption. 

In  the  first  case,  the  symptoms  were  due  entirely  to 
a  rapid  strangulation,  with  gangrene  of  seven  feet  of 
bowel  and  rapid  sepsis;  in  the  second  case,  the 
symptoms  were  produced  both  by  the  involvement  of 

'  Read  before  the  State  Medical  Association,  October  iS.  1900. 


the  appendix  and  a  oartial  strangulation  of  some  five 
feet  of  bowel,  with  gangrene  of  the  diverticulum; 
while  in  the  third  case  the  symptoms  were  due  to 
acute  appendicitis  and  a  gangrenous  adherent  diver- 
ticulum, with  no  gut  inclusion  except  through  the  me- 
dium of  bands  of  adhesions  of  some  former  trouble. 

Case  I. — M.  K— — ,  gentleman  rider  of  the  Horse 
Show  of  1899,  was  seen  by  the  writer  on  November 
15th  at  10:30  A.iM.,  exactly  twenty-four  hours  from  the 
date  of  onset  of  his  illness,  at  which  time  the  follow- 
ing history  was  obtained.  He  had  been  perfectly  well 
up  to  November  14th,  at  10:30  a.m.  He  said  he  had 
eaten  a  large  quantity  of  white  grapes  on  the  day  pre- 
ceding. On  the  morning  of  November  14th  he  was 
seized  with  an  attack  of  pain  in  the  abdomen  wiiich 
he  said  was  very  severe  and  was  accompanied  by  nausea 
and  vomiting.  At  this  time  the  hotel  physician  saw 
him  and  gave  him  several  injections  of  morphine. 
Owing  to  the  hotel  physician  being  called  out  of  town 
and  his  pain  still  persisting.  Dr.  John  Woodman  was 
called  in  the  evening  and  found  him  suffering  slightly 
from  pain,  the  abdomen  somewhat  rigid,  pulse,  tem- 
perature, respirations  practically  normal;  vomiting 
and  nausea  still  present.  Dr.  Woodman  saw  him  early 
the  next  morning,  at  which  time  the  symptom  com- 
plex presented  such  a  grave  aspect  that  a  consultation 
with  a  surgeon  was  advised.  I  saw  the  patient  at 
10:30  A.M.,  exactly  twenty-four  hours  after  the  onset 
of  pain;  at  this  time  there  were  all  the  manifestations 
of  an  .'\cute  abdominal  involvement;  his  face  was 
pinched  and  anxious,  somewhat  li\  id  or  cyanotic,  pulse 
144-150,  respirations  rapid  and  shallow;  the  tempera- 
ture was  not  taken ;  the  abdomen  was  distended  and 
exceptionally  sensitive — in  fact,  painful  to  the  touch; 
rigidity  of  the  abdominal  muscles  was  more  marked  on 
the  right  side,  and  pain  also  was  more  evident  on  this 
side.  He  had  just  vomited  some  greenish  material. 
There  had  been  no  evacuation  of  farces  by  the  bowel 
and  no  flatus  had  passed  in  twenty-four  hours.  An  ex- 
ploratory section  was  suggested,  and  the  patient  trans- 
ferred to  the  St.  Mark's  Hospital.  The  operation  was 
performed  at  12:15  p.m.,  twenty-six  and  one-quarter 
hours  after  the  onset.  Upon  opening  the  abdomen 
through  the  right  rectus  I  found  the  peritoneal  cavity 
filled  with  offensive  bloody  fluid  and  a  large  mass  of 
gangrenous  small  intestine;  at  the  points  between 
healthy  and  gangrenous  bowel  I  found  a  band  surround- 
ing the  bowel.  This  proved  to  be  a  Meckel's  divertic- 
ulum with  its  distal  end  attached  to  the  umbilicus  and 
its  proximal  end  within  three  feet  of  the  ileo-cacal  junc- 
tion. The  patient's  condition  was  such  that  nothing 
further  than  liberating  the  strangulation  and  excluding 
the  gangrenous  gut  from  the  abdomen  was  done.  Al- 
though the  patient  stood  the  operation  badly,  he  re- 
acted within  three  hours  in  a  most  gratifying  manner, 
with  absolute  freedom  from  pain,  nausea,  and  vomiting, 
and  a  well-marked  improvement  in  his  pulse.  This 
condition  of  improvement  continued  until  the  follow- 
ing morning  at  seven  o'clock,  when  he  became  rapidly 
toxic  and  died  within  an  hour.  There  were  exactly 
seven  feet  of  gangrenous  gut  removed  upon  autopsy. 

Case  II.— Previously  reported,  with  presentation  of 
the  patient  and  specimen   to  the  Surgical  Society  of 

New  York   City.     E.  D ,  twenty  years  old,  clerk, 

was  seen  by  me  with  Dr.  S.  Leo,  on  March  i,  1900,  at 
which  time  the  following  history  was  obtained.  On 
Wednesday,  the  la.st  of  February,  about  2  p.m.,  and  one 
and  one-half  hours  after  a  lunch  of  roast-beef  sand- 
wich, cake,  and  coffee,  he  was  seized  with  pain  in  the 
abdomen,  not  localized  in  any  one  region;  "he  broke 
out  in  a  perspiration,"  and  had  two  or  three  chills  last- 
ing in  all  about  two  hours.  He  vomited  about  four 
hours  after  the  onset  of  pain.  During  these  four  hours 
his  pain  was  constantly  increasing.  Pain  was  severe 
but    not    intensified    throughout   the  night.     He  was 


646 


MEDICAL    RECORD. 


[October  27,   1900 


given  some  codeine  by  Dr.  Leo.  No  movement  of  the 
bowel,  except  a  small  quantity  passed  as  a  result  of  an 
enema  on  Thursday,  March  ist.  I  saw  him  March  1st, 
8  P.M.,  at  which  time  his  pulse  was  86-90;  temperature, 
100.5°  F-  '"'^^  temperature  had  been  101.5°  '"  ^^^ 
forenoon.  Deep  pressure  elicited  some  pain  in  the 
abdomen,  localized  on  the  right  side  a  little  internal 
and  superior  to  the  usual  appendicular  situation.  'J'he 
right  rectus  was  somewhat  rigid.  The  urine  contained 
no  albumin;  its  quantity  had  not  been  measured,  but 
the  patient  said  he  had  been  passing  urine  as  frequent- 
ly and  in  as  large  quantities  as  usual.  He  was  taken 
ofT  the  codeine,  given  calomel  internally,  and  ice  used 
externally.  Friday,  March  2d.  I  saw  him  again  with 
Dr.  Leo.  Temperature,  995°  F. ;  pulse,  80-84;  pain 
localized  on  the  right  side,  not  excessive;  the  rectus 
was  tense,  but  not  markedly  so.  There  was  some 
tympanites,  not  general,  but  rather  outlining  coils 
of  intestines.  Dr.  Leo  telephoned  Saturday,  March 
3d,  that  the  patient's  condition  had  become  normal, 
and  that  my  services  were  not  necessary;  that  there 
was  a  very  slight  amount  of  pain  remaining  on  deep 
pressure.  Sunday  night,  March  4th,  I  was  telephoned 
that  his  condition  had  again  become  grave,  and  made 
an  appointment  for  the  following  morning,  at  which 
time  I  was  told  that  he  had  vomited  fecal  material 
Saturday  evening  twice  and  once  Sunday  morning,  and 
that  there  had  been  a  large  evacuation  per  rectum  fol- 
lowing the  introduction  of  an  enema.  When  I  saw  him 
Monday  morning,  at  10:30,  his  condition  was  one  of 
anxiety,  his  face  was  drawn  ;  pulse,  118;  temperature, 
ioT.5°  F. ;  abdomen  generally  tympanitic,  pain  in  the 
right  side  and  in  the  umbilical  and  hypogastric  regions. 
Operation  was  advised  and  accepted.  Dr.  C.  Leale  was 
present,  by  the  family's  request,  at  the  operation. 

An  incision  was  made  in  the  usual  manner  for  ap- 
pendicitis. When  the  peritoneum  was  incised,  a  large 
quantity  of  dark-brown  fluid  was  evacuated  and  a  coil 
of  deeply  congested  intestine  was  seen.  The  appen- 
dix was  found  bound  down  posterior  to  the  caecum  and 
ascending  colon,  and  several  coproliths  could  be  pal- 
pated. Many  recent  adhesions  were  also  present. 
The  examining  finger  palpated  a  dense  band  surround- 
ing a  mass  of  intestine.  The  incision  was  rapidly 
enlarged  through  the  right  rectus,  and  then  a  mass  of 
intestine  fully  five  feet  long,  dark  brown  and  ccdema- 
tous,  was  extruded,  with  a  Meckel's  diverticulum  about 
three  inches  long,  one-half  inch  in  diameter  at  its  base, 
and  a  long  fibrous  extension  leading  up  to  the  um- 
bilicus, literally  tied  about  the  involved  intestine. 
One  portion  of  the  diverticulum  was  gangrenous  and 
adherent  to  a  coil  of  ileum.  A  small  amount  of  pus 
\jas  present  at  this  situation.  The  intestinal  end  of 
the  diverticulum  was  cut  off,  and  the  intestinal  site 
of  the  diverticulum  was  inverted  as  in  an  appendix 
operation ;  a  row  of  Lembert  sutures  was  placed  to 
strengthen  the  area.  The  umbilical  end  was  cut  after 
the  application  of  a  catgut  ligature  near  the  umbilicus. 
The  appendix  was  next  removed  in  the  usual  manner, 
its  stump  being  inverted  after  the  method  of  Dawbarn. 
Feeling  that  it  would  be  rather  risky  to  close  the  ab- 
domen entirely,  I  placed  a  gauze  drain  at  the  site 
of  the  inverted  stump  of  tlie  appendix,  and  also  one  at 
the  site  of  the  removed  diverticulum.  The  greater 
portion  of  the  wound  was  then  closed  with  three  rows 
of  catgut  sutures  and  a  superficial  one  of  silk.  A 
great  amount  of  serous  discharge  was  present  the  first 
twenty-four  hours.  Temperature  and  jnilse  became 
practically  normal  after  the  second  day,  from  which 
time  convalesjence  was  rapid. 

Case   III.— Male,  J.  L ,  aged  thirty-four  years. 

Previous  history  negative.  He  was  seen  by  the  writer 
on.  May  ist,  in  consultation  with  l)rs.  Goldberger  and 
Kompert  at  about  midnight,  and  I  obtained  the  follow- 
ing history.     He  was  seized  with  a  severe  generalized 


pain  in  the  abdomen  on  Sunday,  .April  2gth ;  had  neith- 
er chill  nor  had  he  vomited;  on  the  day  following,  i.e.. 
April  30th,  the  pain  was  localized  in  the  right  iliac 
fossa,  with  evidences  of  a  tumor.  The  rectus  on  the 
right  was  rigid,  not  marked  on  the  left.  When  I  saw 
him  his  pulse  was  90;  temperature,  101°;  respiration, 
22;  abdomen  somewhat  distended,  pain  pronounced  in 
the  right  side,  and  a  tumor  distinctly  palpable.  The 
rectus  was  somewhat  rigid.  I  advised  operation  the 
following  day.  On  the  morning  of  May  2d,  the  day  of 
operation,  his  pulse  was  96;  temperature,  102.6";  and 
respiration,  26.  Under  anaesthesia  a  mass  could  be  out- 
lined, that  suggested  a  very  much  distended  appendix, 
or  one  accompanied  by  a  great  deal  of  exudate.  The 
abdomen  having  been  prepared,  an  incision  was 
made  after  the  manner  of  Kammerer,  etc.,  and  a  di- 
verticulum about  three  and  one-half  inches  by  one  and 
one-half  inches  wide,  with  a  pronounced  mesentery, 
was  found  adherent  to  the  parietal  peritoneum  in  the 
right  iliac  region;  the  apex  of  this  was  gangrenous 
and  covered  with  considerable  exudate;  in  addition, 
about  six  inches  of  bowel  was  partially  strangulated 
by  a  band  in  the  immediate  vicinity.  This  latter  was 
released,  the  diverticulum  cut  off,  and  the  opening  in 
the  intestine  closed  with  three  tiers  of  suture.  Search 
was  then  made  for  the  appendix,  which  was  found  in  a 
state  of  acute  inflammation  surrounded  by  a  dense 
mass  of  adhesions.  The  appendix  was  removed  by 
splitting  the  serosa  and  musculosa,  thereby  leaving 
only  the  mucosa;  in  other  words,  the  appendix  was 
stripped  (a  method  I  have  often  found  of  service  in 
cases  with  dense  adhesions,  and  one  by  which  an  im- 
mense amount  of  time  is  saved).  The  appendix  was 
then  removed,  and  the  stump  inverted  after  the  method 
of  Dawbarn.  Several  coproliths  were  found  in  the 
appendix.  The  abdomen  was  w'iped  out  with  gauze, 
a  small  wick  drain  was  placed  in  the  lower  angle  of 
the  wound,  and  tier  sutures  were  employed  to  close  the 
remainder  of  the  incision.  The  drainage  was  removed 
in  forty-eight  hours,  and  with  the  exception  of  a  stitch 
abscess  the  recovery  was  uncomplicated. 

Attention  has  been  called  in  this  paper  to  the  re- 
semblance of  the  onset  in  each  of  these  cases  to  an 
attack  of  appendicitis;  and  when  one  remembers  that 
the  usual  location  of  these  diverticula  is  within  three 
feet  of  the  caecum,  no  great  amount  of  suggestion  is 
necessary  to  show  the  etifect  syinptomatically  of  an  in- 
flammation or  involvement  of  a  viscus  in  such  proxim- 
ity to  the  appendix.  Naturally,  the  conditions  of 
obstruction  rapidly  supervene  upon  those  of  sympa- 
thetic involvement,  and  thus  the  diagnosis  of  obstruc- 
tion from  some  other  cause  than  appendicitis  is  more 
readily  made,  except  when  profound  sepsis  is  present, 
as  was  noted  in  the  history  of  Case  I. 


Black  Tongue A  new  case  of  this  rare  malady  is 

reported  by  J,  Maraval,  whose  patient  was  a  man  aged 
forty-two  years,  and  an  inveterate  smoker.  For  two 
months  he  had  complained  of  pharyngeal  dysesthesia, 
discomfort  in  movements  of  the  tongue,  sensation  in 
swallowing  as  of  a  foreign  body,  and  abundant  saliva- 
tion. Examination  showed  a  brownish-yellow  patch 
in  the  region  of  the  circumvallate  papilla;  which  could 
be  peeled  otT  in  threads,  and  which  under  the  micro- 
scope seemed  to  be  made  up  of  imbricated  epithelium 
surrounding  a  central  axis.  Tiie  area  of  implantation 
was  thoioughly  curetted  and  a  solution  of  zinc  chloride 
I  :  20  applied.  He  was  seen  six  months  later  with 
practically  the  same  condition.  He  had  abstained 
from  tobacco  for  four  months  after  the  curetting,  dur- 
ing which  time  he  remained  well,  but  on  resuming 
smoking  the  deposit  reappeared,  —  Revue  Hehdoma- 
daire  de  Laryiigologie,  No.  36,  iqoo. 


October  27,  1900] 


MEDICAL    RECORD. 


647 


ELECTRIC  LIGHT— ITS  PHYSIOLOGICAL 
ACTION  AND  THERAPEUTIC  VALUE  IN 
TUBERCULOSIS  OF  THE  THROAT  AND 
LUNGS.' 

I!y   W.     FKliUDENTHAL,    M.D., 

.NEW    YORK. 

While  in  modern  times  we  iiave  quite  a  number  of 
newly  discovered  drugs,  some  of  which  exert  a  remark- 
able effect  on  the  human  system,  we  have  come  to  be- 
lieve that  bottles  of  medicine  cannot  cure  every  dis- 
ease nor  afford  relief  to  many  sufferings  with  which 
the  physician  is  daily  brought  in  contact.  Thus  we 
have  come  to  rely  upon  resources  which  nature  has 
placed  at  our  command — the  scientific  ajjplication  of 
water,  hydrotherapy;  the  use  of  light  and  air,  which  is 
still  an  undeveloped  science;  and  fuially  the  use  of 
electricity  in  its  various  branches.  The  latest  of  these 
is  the  action  of  the  chemical  rays  of  light  upon  the 
diseased  human  system. 

\Vc  know  that  in  the  olden  times,  in  Greece  as  well 
as  in  Rome,  as  protection  against  disease  nothing  was 
esteomed  so  highly  as  the  sojourn  in  the  open  air. 
The  sun  and  the  air  were  considered  of  the  greatest 
importance  for  the  health  and  life  of  man  and  animal. 
The  whole  life  of  the  ancients,  as  Julian  Marcuse^ 
rightly  says,  was  built  upon  this  basis,  and  public 
affairs,  as  well  as  athletic  sports,  brought  the  Grecians 
and  Romans  on  the  street  and  into  the  open  air. 

Light  and  air,  the  imponderable  requisites  of  unim- 
paired bodily  and  mental  health,  were  then  the  foun- 
dation of  the  physical  and  psychical  well-being,  which 
will  always  remain  the  characteristic  sign  of  the  clas- 
sic ages.  Not  only  were  the  bedrooms  in  old  Greece 
open  to  the  rays  of  light,  but  the  houses  had,  as  is  well 
known,  on  their  roofs  what  was  called  r^/.'.unjrrj/^nr^,  a 
place  where  the  inmates  e.xposed  their  naked  and 
anointed  bodies  to  the  sun,  not  only  for  pleasure,  but 
for  the  pre.servation  of  their  health  as  well. 

In  Rome  this  place  on  the  roof,  which  was  perfectly 
flat,  was  called  solarium.  Afterward  this  solarium 
was  a  special  annex  to  the  house.  The  white  color  of 
the  skin  of  a  man  not  browned  by  the  sun  was  consid- 
ered effeminate,  and  its  possessor  was  ridiculed.  That 
later  on  these  prophylactic  sun-baths  were  taken  to 
cure  disease  is  not  remarkable;  and  in  Rome  there 
was  hardly  a  bath-house  without  a  solarium — that  is, 
a  place  to  take  sun-baths. 

In  the  Middle  Ages  these  baths  were  neglected  more 
and  more,  until  up  to  the  nineteenth  century  they  were 
entirely  forgotten. 

It  was  a  layman,  Arnold  Rikli,  of  Veldes,  in  Aus- 
tria, who  not  long  ago  started  the  first  institution  for 
what  he  termed  "  atmospheric  cure."  He  deserves 
great  credit  for  his  enthusiasm  and  energy.  After- 
ward Dr.  Lahmann,  of  "'W'eisser  Hirsch"  near  Dres- 
den, started  a  similar  institution.  It  would  seem  that 
the  success  of  this  "cure"  should  no  longer  be  disre- 
garded by  physicians,  and  it  has  become  our  duty  to 
investigate  its  merits  more  closely.  I  have  deemed  it 
important  to  refer  to  this,  as  I  consider  this  therapeutic 
agent  the  forerunner  of  our  modern  phototherapy,  or 
treatment  with  the  electric  rays.  Sunlight  and  electric 
ligiit  have  the  same  effect  on  our  system,  and  it  has 
been  proved  by  thousands  of  cases  already  treated  that 
the  beneficial  result  of  treatment  with  electric  light  is 
due  to  the  action  of  those  rays  which  approximate  most 
closely  to  the  sunlight — namely,  the  blue  and  ultra- 
violet rays  of  the  arc  light. 

Now,  before  entering  into  a  discussion  of  the  thera- 
peutic value  of  the  electric  light,  we  have  to  answer 
the  question.  What  are  the  physiological  effects  of  light 

'  Read  before  the  American  Electro-Therapeutic  Association, 
September  25,  1900. 

•' Zeitschr.  f.  diat.  und  phys.  Ther.,  1899,  p.  336. 


on  the  human  organism,  and  especially  upon  its  metab- 
olism.' 

Very  important  investigatiotis  have  been  made  in 
this  direction  as  early  as  1.S55  by  Moleschott.'  This 
author  reached  the  following  results:  Frogs  give  off' 
one-twelfth  to  one-quarter  more  CO.^  in  the  light  than 
in  the  dark,  /.(■.,  the  temperature  being  equal  or  nearly 
so,  and  the  units  of  body  weigiil  and  time  being  the 
same.  Further,  the  greater  the  intensity  of  the  light, 
the  greater  the  quantity  of  CO.^  given  off,  which  is  re- 
duced to  a  minimum  on  foggy  days. 

Von  Platen  made  experiments  on  rabbits,  covering 
their  eyes  alternately  with  black  and  with  transparent 
glasses.  He  proved  that  under  the  influence  of  the 
light  the  gaseous  and  watery  exchanges  were  consider- 
ably increased.  The  oxygen  consumption  in  liic  light 
and  darkness  was  as  116  to  too;  the  elimination  of 
CO,  as  114  to  100.  Later  on  Moleschott  and  Fubini 
demonstrated  the  fact  that  this  influence  upon  the 
metabolism  is  present  even  after  the  eyes  have  been 
enucleated;  that  is,  it  is  exerted  also  through  the 
skin. 

After  the  preliminary  experiment  of  Reid,  Scharliiig, 
and  Marchand,  it  was  proved  by  I'ettcnkofer  and  Voit 
that  man  gives  off  less  CO.,  at  night  during  ske|)  than 
in  the  daytime  in  absolute  repose.  They  proved,  there- 
fore, that  light  is  here  of  importance. 

I  omit  the  mass  of  all  other  researches  regarding 
this  particular  question.  Every  one  interested  in  it 
will  find  the  literature  in  a  work  by  VVillibald  Geb- 
hardt,'  entitled  "The  Flealing-Power  of  Light,"  which 
every  physician  ought  to  read.  I  also  refer  to  a  dis- 
sertation by  Franz  Schoenenberger,'  where  a  great 
deal  of  the  literature  can  be  found. 

Having  confined  my  investigation  to  diseases  of  the 
respiratory  tract,  it  became  necessary,  in  order  to  un- 
derstand the  finer  mechanism  of  the  rays  of  light,  to 
study  their  effect  upon  the  mucous  membrane  of  this 
tract,  and  especially  upon  that  of  the  bronchi,  etc.  In 
this  respect  the  investigation  of  Dr.  S.  Bergel,'  of 
Inowrazlaw,  are  of  very  great  importance  to  us.  Dr. 
Bergel,  whom  I  have  the  pleasure  of  having  known 
personally  for  a  good  many  years,  studied,  entirely  in- 
dependent of  the  subject  under  discussion,  some  eight 
years  ago  the  effect  of  light  and  darkness  upon  the 
movement  of  the  ciliated  corpuscles.  He  says  that  the 
peculiar  behavior  of  the  ciliated  corpuscles  towaid 
light  and  darkness  was  of  especial  interest.  He  pro- 
ceeded in  the  following  manner:  He  put  the  micro- 
scope into  a  dark  cabinet,  which  was  placed  upon  the 
observation  table.  The  cabinet  was  perfectly  closed, 
with  the  exception  of  two  openings.  The  one,  when 
illuminated,  was  for  the  observer,  but  could  be  dark- 
ened by  means  of  curtains  when  it  was  desired  to  shut 
the  light  off.  Just  opposite  the  microscope  was  an- 
other opening,  which  could  be  exposed  to  direct  sun- 
light or  closed,  as  desired. 

Now,  if  a  ciliated  corpuscle  in  motion  was  placed 
under  the  microscope,  and  the  latter  darkened,  it  could 
be  seen  on  inspection  after  a  while  that  the  motion  of 
the  corpuscle  grew  slower  and  slower,  and  finally 
ceased.  The  more  rapid  the  vibration  before  the  w  ith- 
drawal  of  light,  the  longer  the  period  of  activity  of  the 
corpuscle  in  the  darkness  until  it  became  motionless, 
and,  7/ie  Tcrsa,  the  slower  and  weaker  the  vibration  of 
the  cilia,  the  shorter  the  time  up  to  the  cessation  of 
all  motion. 

When  a  corpuscle  that  had  been  kept  in  the  dark, 
showing  no  motion   whatever,  was  exposed  to  bright 

'  Wiener  med.  Wochenschr.,  No.  43,  1S55,  and  PflUger's  Arch, 
f.  Physiol..  Hd.  xi..  p.  272. 

'  '•  Die  Heilkraft  des  Lichtes."  Leipsic,   1898. 

'  "  Der  Einfluss  des  Lichts  auf  den  tierischen  Organismus." 
Diss.,  Herlin.  1S98. 

■*  "  Beitrage  zur  Physiologie  der  Flimmerbewegung."  Sep. 
Abdruck  aus  d.  Arch.  f.  die  ges.  Phys.,  Bd.  78,  Bonn,  1900. 


648 


MEDICAL    RECORD. 


[October  27,  1900 


daylight  again,  the  oscillation  recommenced  after  a 
latent  period,  depending  upon  the  duration  of  the  ex- 
posure to  darkness.  'Flie  longer  the  corpuscle  re- 
mained in  the  dark  after  it  had  become  motionless,  the 
longer  it  continued  in  a  quiescent  stale  until  the  re- 
sumption of  oscillation.  This  could  be  repeated  sev- 
eral times,  but  soon  a  sort  of  fatigue  was  noticed  in 
the  corpuscle.  This  showed  itself  also  when  the  cor- 
puscle was  kept  too  long  in  the  dark. 

What  do  these  important  investigations  of  Bergel 
mean  ?  Are  they  not  in  contradiction  to  our  daily  ex- 
perience? The  cessation  of  the  movement  in  the  dark 
seems  to  be  opposed  to  the  real  conditions  of  life,  as 
in  the  animal,  or  at  least  in  the  higher  animal,  the 
ciliated  cpithelia  are  in  dark  regions  of  the  body, 
and,  nowitjistanding  this,  are  in  constant  motion.  I 
would  mention  here  that  in  a  series  of  experiments  on 
ciliated  corpuscles  no  cessation  occurred,  and  these 
were  the  ones  that  moved  quickest  before  they  were 
put  in  the  dark  chamber.  The  light  stimulus,  it  seems, 
shows  its  elTect  only  on  exhausted  ciliated  corpuscles, 


which  are  no  longer  in  full  possession  of  their  vitality. 
They  still  move  on  irritation,  that  is,  when  light  is 
thrown  on  them;  but  when  the  stimulus  ceases,  that 
is,  when  they  are  brought  into  the  dark,  then  they 
sooner  or  later  cease  to  oscillate.  Now,  inasmuch  as 
light  acts  as  a  stimulus  upon  the  movement  of  the  cil- 
iated corpuscle,  this  is,  according  to  Bergel,  nothing 
but  a  proof  that  the  ethereal  vibrations  of  light  have 
an  influence  upon  the  chemical  processes  within  the 
corpuscle;  they  cause  chemical  changes,  which  are 
transformed  into  motion,  or,  in  other  words,  into  la- 
bor. Now  we  can  understand  the  first  experiment  by 
Moleschott.  Every  action  of  the  organism  is  accom- 
panied by  the  chemical  process  known  as  oxidation. 
The  more  activity,  the  more  oxidation  ;  the  more  light 
was  thrown  upon  the  frogs,  the  more  oxygen  they  con- 
sumed and  the  more  CO,  they  gave  off,  and  all  this 
only  through  the  greater  activity  of  the  ciliated  bodies. 
In  pathological  conditions  there  is  an  accumulation  of 
metabolic  material  which  cannot  be  eliminated  nor 
replaced  by  new  nutritive  elements;  therefore  the  ac- 
tion stops,  as  the  ciliated  corpuscles  are,  so  to  speak, 
paralyzed. 

In  this  connection  I  have  to  mention  what  is  proba- 
bly well  known  to  all  of  you,  that  the  actual  labor 
done  by  these  cilia  in  the  human  S3'stem  is  enormous. 
If,  according  to  Justus  Gaule,  you  excise  in  a  frog 
just  killed  the  mucous  membrane  of  the  pharynx  and 
oesophagus,  splitting  open  the  latter  and  pinning  the 
whole  membrane  on  its  edges  on  a  piece  of  cork,  and 
if  you  put  small  particles  of  soot  or  of  cork  or  similar 
substances,  dipped  in  a  physiological  salt  solution, 
upon  it,  then  you  can  see  how  these  particles  are  car- 
ried away  until  they  finally  reach  the  stomach  end  of 
the  oesophagus.  Small  as  is  the  force  of  a  single  cil- 
ium,  so  enormous  is  the  total  effect  of  their  immense 
number  (Engelmann). 

In  the  example  just  mentioned  the  current  of  the 
cilia  is  in  the  direction  from  the  mouth  to  the  stomach, 
as  it  is  the  function  of  the  mucous  membrane  of  the  di- 
gestive tract  to  transport  substances  into  the  organism. 
The  current  is  just  the  reverse  on  the  mucous  mem- 
brane of  the  respiratory  tract,  that  is,  from  the  bron- 


chi to  the  nares.  This  is  natural,  as  here  there  is 
different  work  to  accomplish,  namely,  to  carry  the 
dust  jjarticles,  etc.,  out  of  the  organism.  This  work 
is  initiated  in  the  cells  by  the  cilia  nearest  to  the 
bronchi;  then  tlie  others  follow  suit.  Thus  with 
"great  intelligence''  they  sweep  out  during  tlie  night 
the  dust  that  is  inhaled  during  the  daytime;  and  in 
the  morning  it  is  found  deposited  at  the  entrance,  and 
with  a  little  hawking,  etc.,  it  is  easily  removed.' 

In  tuberculous  affections  of  the  respiratory  tract 
there  is  nearly  always  a  concomitant  catarrh  present, 
with  more  or  less  mucus.  Sometimes  this  is  present 
in  enormous  quantities.  That  such  a  superabundant 
secretion  should  prevent  entirely  the  oscillation  of  the 
cilia  is  very  plausible.  On  the  other  hand,  if  this  is 
present  in  a  smaller  degree,  it  will  paralyze — as  I  un- 
derstand it — temporarily  the  action  of  the  cilia,  and 
in  such  cases  a  stimulant  like  light  will  overcome  this 
paralysis  and  the  ciliary  corpuscles  will  be  able  to  re- 
sume their  work.  The  metabolism  of  the  cells  will 
return  to  the  normal,  and  coincidently  not  only  the 
mucus,  etc.,  will  be  removed  from  the  bronchi,  but,  in 
my  opinion,  also  the  end  product  of  the  tubercle  ba- 
cilli, and  undoubtedly  a  great  many  of  these  bacilli  as 
well.  This  would  be  the  ideal  cure  of  the  disease. 
Alas,  it  is  not  always  accomplished!  but  in  many 
cases  this  beneficial  effect  in  part  is  produced  without 
doubt. 

But  has  sunlight  not  a  direct  influence  on  the  ba- 
cilli? We  know  now  that  it  has,  and  I  agree  with 
Albert  Abrams,  of  San  Francisco,  when  he  says:' 
"The  value  of  sunshine  in  localities  adapted  to  the 
treatment  of  consumption  is  greater  than  is  generally 
believed.  That  this  value  is  dependent  in  part  upon 
the  germicidal  action  of  the  solar  rays  in  the  atmos- 
phere I  am  confident.  I  have  made  a  number  of  ex- 
periments to  test  the  influence  of  solar-heated  atmos- 
phere on  the  growth  of  tubercle  bacilli  in  culture 
tubes.  The  results  demonstrated  that  while  such  at- 
mosphere was  not  destructive  to  the  growth  of  tubercle 
bacilli,  it  nevertheless  retarded  their  development." 
I  have  not  hesitated  to  quote  even  such  a  conservative 
statement  before  you,  although  I  am  aware  that  the 
experiments  of  other  authors  have  shown  a  still  greater 
germicidal  power  of  the  rays  of  light.  It  naturally 
depends  upon  the  time  you  use  the  sunlight  for  such 
purposes. 

I  myself  was  led  to  study  the  effects  of  light,  and 
especially  electric  light,  on  the  diseased  tissues,  in  a 
very  curious  manner. 

In  18S9  I  had  the  honor  to  demonstrate  before  the 
New  York  Academy  of  Medicine  (section  on  laryngol- 
ogy) the  transillumination  of  the  larynx.  One  of  the 
patients  whose  larynx  I  had  frequently  examined 
asked  me  one  day  whether  I  no  longer  employed 
"electricity,"  which  always  benefited  her.  As  such 
patients  who  sufi'er  with  intense  pain  are  usually  not 
hysterical,  I  was  constrained  to  give  this  matter  my 
consideration.  I  applied  the  "  electricity '"  by  alter- 
nately placing  the  Voltolini  light,  modified  by  me, 
upon  one  or  the  other  side  of  the  larynx  or  upon  the 
pomuin  Adanii.  .As  this  lamp  has  in  the  mean  time 
probably  fallen  into  disuse.  I  will  rcpiat  here  my 
former  remarks:' 

"The  casing  contains  an  Kdi.son  incandescent  lamp 
and  in  front  of  it  a  ball  filled  with  water,  which  is 
similar  to  the  globe  commonly  used  by  shoemakers, 
and  subserves  the  double  purpose  of,  first,  concentrating 
the  light  by  acting  as  a  biconvex  lens,  and,  secondly, 
of  protecting  the  exterior  of  the  neck  from  too  intense 
heat.     I  have  taken  the  liberty  of  making  a  few  minor 

'  See  Gaule  :  "  Physiologic  dcr  Nase  "  in  Heymann's  "  Hand- 
biicli  der  I,.nrynj;olofjie,"  p.  i6i. 

•'  riiiladelpliia  Monthly  Med.  Journ..  March,  1899.  p.  175. 
•■  Medicinische  Monatsschrift,  November,  1889. 


October  27,  1900] 


MEDICAL   RECORD. 


649 


changes  in  this  apparatus.  In  the  first  place  I  have 
increased  the  amount  of  light  by  using  a  higher-power 
lamp.  It  also  appeared  to  me  that  in  some  patients 
with  a  large  pomum  Adami  many  of  the  rays  of  light 
were  lost.  For  this  reason  I  had  the  front  part  of  the 
apparatus  A'  (see  figure)  hollowed  out  and  covered 
with  rubber,  so  that  it  adapts  itself  better  to  the  exter- 
nal contour  of  the  neck.  A  handle  V,  which  can  be 
attached  to  a  posterior  or  lateral  surface  B,  seemed 
to  me  useful.  Finally  I  had  the  globe  more  firmly 
attached,  D  and  /:',  in  order  to  protect  it  from  br^^ak- 
age." 

I  then  applied  this  lamp  to  one  or  both  sides  of 
the  larynx  or  also  in  front,  and  usually  allowed  it  to 
remain  at  the  place  of  application  until  this  became 
heated,  ordinarily  about  five  minutes.  Several  times 
I  observed  a  formation  of  blebs  after  five  to  ten  min- 
utes. 

At  first  I  did  not  attribute  any  significance  to  this 
treatment,  as  I  was  at  a  loss  for  an  explanation.  Not 
until  1 89 1,  when  I  read  the  address  made  by  Robert 
Koch  before  the  International  Congress  in  Berlin,  was 
the  matter  clear  to  me.  Koch  referred  to  the  influence 
of  sunlight  upon  the  tubercle  bacilli — a  view  which 
was  soon  adopted  by  .\Iignano'  and  others.  Later 
Minck,  a  pupil  of  Buchner,  Santori,  Marshall  Ward, 
and  a  host  of  other  investigators  demonstrated  the 
same  inliuence  of  electric  light  upon  bacteria. 

If,  therefore,  sunlight  as  well  as  electric  light  ac- 
complishes all  that  which  has  been  demonstrated  by 
most  eminent  investigators,  there  remained  only  for 
decision  the  question  whether  light  actually  penetrates 
the  tissues  of  the  larynx.  This  could  not  appear 
doubtful  to  me,  since  I  had  examined  hundreds  of  pa- 
tients by  means  of  transillumination,  and  had  been 
able  to  see  distinctly  the  interior  of  the  larynx.  It 
seemed  to  me  that  if  any  portion  of  the  body  were 
adapted  for  testing  the  influence  of  electricity  it  must 
be  the  larynx. 

My  expectations  were  not  entirely  fulfilled,  and  I 
would  ascribe  this  to  the  incompleteness  of  my  appara- 
tus, which  permitted  me  to  apply  the  electric  light  for 
only  about  five  minutes  to  the  diseased  parts,  after 
which  it  became  too  hot.  Notwithstanding  this  I  had 
some  encouraging  results,  of  which  I  would  communi- 
cate the  following: 

Case  I. — Mrs.  R.  H — ■ — ,  thirty  years  old,  mother  of 
four  living  children,  pregnant.  She  has  suffered  four 
weeks  with  pain  in  the  throat,  especially  on  swallow- 
ing. On  retiring  she  has  a  feeling  as  if  "oil  were 
boiling  in  her  throat." 

Status  prajsens,  February  24,  1892:  Phthisis  inci- 
piens  of  both  lungs;  mucous  membrane  of  larynx  very 
ansemic;  slight  ulcerations  on  the  epiglottis  and  on 
the  right  ligamentuni  ary-epiglotticurr.  I  administered 
creosote  with  tincture  of  gentian  (equal  parts)  in  in- 
creasing doses  until  she  took  seventy  drops  three  times 
daily.  Besides  this  I  applied  the  electric  light  to 
both  sides  of  the  larynx. 

March  loth:  Up  to  this  time  the  patient  had  ap- 
peared only  once  every  week.  The  sensation  of  "  boil- 
ing "'  in  the  throat  was  better  after  each  application  of 
the  electric  light,  but  the  improvement  lasted  only  for 
a  short  time.  Later  it  was  still  troublesome  enough 
to  disturb  her  night's  rest.  From  now  on  she  calls 
every  second  day  for  treatment. 

April  15th:  The  peculiar  sensation  described  is  still 
present,  but  much  less  marked:  the  pain  is  less. 

April  27th:  The  sensation  is  still  present  at  night; 
the  pain  is  inconsiderable. 

June  5th:  The  ulcers  in  the  larynx  have  healed; 
she  feels  much  more  comfortable,  has  no  sensation  of 
"boiling"  in  the  throat  at  night,  no  dysphagia,  but 
some  cough. 

'  Archiv  fur  Hygiene,  Bd.  25. 


June  20th  :  She  was  ddelivered  of  a  child,  and  feels 
comparatively  well. 

June  26th:  She  had  a  violent  pulmonary  hemor- 
rhage, and  died  two  days  later  in  consequence. 

Case  II. — Mrs.  M.   S ,  twenty-three  years  old, 

had  one  living  child.  She  has  a  feeling  of  rawness  in 
the  chest,  and  complains  of  dysphagia. 

Status  prasens,  November  7,  1S93:  Phthisis  pul- 
monum  (cavity  of  the  size  of  the  palm  of  the  hand  be- 
low the  right  clavicle);  acute  pharyngo-laryngitis; 
infiltration  of  both  false  vocal  cords.  Curettage  re- 
fused. 

November  17th:  She  was  given  codeine,  creosote, 
and  application  of  the  electric  light,  the  latter  thrice 
weekly.  Swallowing  is  much  better,  and  she  requests 
further  application  of  the  electric  light. 

November  24th:  The  condition  of  the  larynx  is  the 
same,  although  the  patient  asserts  that  she  is  feeling 
better. 

December  12th:  The  patient  feels  quite  comfort- 
able, and  travels  to  Lakewood  and  then  to  Georgia, 
remaining  away  altogether  ten  weeks. 

March  22,  1S94:  The  patient  had  felt  quite  well 
up  to  a  week  ago,  when  she  was  seized  with  a  violent 
cough,  and  also  with  a  return  of  her  former  dysphagia. 
She  was  treated  in  the  same  manner  as  before. 

May  loth:  She  had  again  improved  so  much  that 
she  was  able  to  make  a  trip  to  the  Adirondacks. 

The  patient  had  been  under  treatment  of  various 
laryngologists,  and  stated  that  nothing  acted  as  well 
as  the  application  of  the  electric  light.  I  have  heard 
nothing  further  from  her,  but  she  is  said  to  have  died 
in  the  Adirondacks. 

Case  III. — Miss  L.  B^ — ,  nineteen  years  old, 
singer,  had  a  hemorrhage  about  one  and  a  half  years 
ago;  she  coughs  a  good  deal,  has  pain  on  swallowing, 
and  has  been  hoarse  for  four  months. 

Status  pra;sens,  November  25,  1895:  Phthisis  pul- 
monum,  both  apices  being  affected.  Larynx:  epiglot- 
tis somewhat  infiltrated;  deep  ulcer  on  the  left  cord. 
Treatment:  Creosote,  codeine,  antifebrin  occasionally 
for  the  fever,  and  every  second  day  application  of  the 
electric  light  to  the  left  side  of  the  larynx.  Under  this 
treatment  she  improved  considerably,  so  that  after 
three  months,  on  February  28,  1896,  the  ulcer  had 
healed  and  the  patient  was  absolutely  free  from  pain. 

September  3,  1896,  I  again  saw  the  patient,  and 
found  her  in  excellent  health  after  a  sojourn  of  six 
months  in  the  country.  The  pulmonary  affection  was 
cured  and  no  tubercle  bacilli  were  found. 

January  6,  1897  :  She  coughs  again  for  the  past  eight 
days  and  is  troubled  with  slight  dysphagia  on  the  left 
side;  superficial  ulceration  on  the  epiglottis  (left 
side);  acute  laryngitis  and  diffuse  bronchitis.  The 
ulceration  was  obstinate,  and  she  was  not  restored  to 
complete  health  till  after  the  lapse  of  fourteen  weeks' 
(irregular)  treatment. 

I  saw  her  again  in  December,  1897,  and  also  in 
March,  1898,  and  was  able  to  demonstrate  a  perma- 
nent cure. 

I  have  since  had  my  apparatus  changed.  In  order 
to  get  only  blue  rays  from  the  light  1  filled  the  little 
glass  bottle  with  a  very  dilute  solution  of  methylene 
blue  instead  of  pure  water.  This  gave  me  a  nice  blue 
color.  As  the  metallic  end  of  the  lamp  still  became 
very  hot  by  radiation.  I  attached  a  hard-rubber  piece 
at  the  end  of  it,  and  in  this  way  the  apparatus  remained 
cool,  and  the  patients  did  not  feel  any  annoyance  from 
the  heat.  Still  the  water  became  so  hot  that  once  it 
drove  out  the  cork,  spilling  the  hot  water  over  the  baie 
chest  of  the  frightened  patient.  .After  that  occurred 
I  modified  this  instrument  again,  and  you  see  here  the 
apparatus  which  I  use  now.  Instead  of  the  glass  bulb 
filled  with  colored  water  I  simply  inserted  a  disc  of 
colored  gelatin  or  glass.     In  this  way  I  have  overcome 


650 


MEDICAL    RECORD. 


[October  27,  1900 


all  difficulties.  I  can  apply  the  electric  light  as  long 
as  I  wish — as  a  rule  for  from  thirty  to  sixty  minutes — 
and  1  must  say  the  results  so  far  are  very  encouraging. 
These  results  demand  consideration  for  a  method  of 
treatment  which  is  so  agreeable  to  the  patient  and 
so  free  from  all  injurious  effects — phototherapy.  We 
do  not  hesitate  a  moment  to  subject  the  patient  to 
pain,  if  it  can  only  be  assumed  tiiat  some  relief 
is  thereby  afforded  him.  Have  we  not  all  of  us 
caused  severe  pain  by  applying  lactic  acid  and  in  us- 
ing the  curette,  as  well  as  other  methods,  all  without 
avail?  Therefore  since  the  majority  of  my  patients 
ask  for  the  continuation  of  the  treatment  with  the 
electric  liglit  because  of  the  benefit  which  they 
ascribed  to  it,  am  I  requesting  too  much  in  urging  you 
to  add  this  method  to  your  therapeutic  resources? 

After  having  for  years  used  the  electric  light  for 
tuberculosis  of  the  larynx,  it  was  natural  to  give  this  a 
trial  also  in  tuberculosis  of  the  lungs.  1  have  men- 
tioned above  that  the  electric  arc  light  is  the  one 
which  has  produced,  according  to  different  German 
authors,  the  best  results.  I  did  not  apply  this  in  tu- 
berculosis of  the  throat,  as  my  results  with  the  incan- 
descent lamp  were  quite  satisfactory.  Besides,  this 
lamp  could  be  applied  better  to  the  larynx.  It  is 
different  with  the  thorax;  here  we  would  have  to  place 
the  patient  in  a  box  provided  with  a  great  many  incan- 
descent lamps,  and  the  heat  produced  in  such  a  cabi- 
net would  not  be  beneficial  to  tuberculous  patients.  I 
therefore  resorted  to  the  arc  light,  which  I  have  ap- 
plied in  several  cases.  Encouraging  as  the  results 
appear  to  be,  I  am  not  prepared  to  give  you  the  histo- 
ries of  patients  thus  treated,  nor  can  I  present  a  defi- 
nite opinion  for  one  very  important  reason,  viz.,  the 
instruments  used  up  to  the  present  time  have  not  at- 
tained that  state  of  perfection  which  they  ought  to 
have,  and  which  I  think  can  be  reached  easily.  For 
the  last  twelve  months  I  have  been  trying  to  have  a 
more  perfect  apparatus  made,  but  regret  to  say  that 
I  have  not  succeeded  as  yet.  It  is  the  hardest  work 
to  get  a  new  electrical  instrument  made  here  in  this 
city  of  Greater  New  York,  although  it  is  overflowing 
■with  electricity.  Still  I  hope  I  shall  have  it  finished 
in  the  near  future,  when  I  shall  report  my  further  ex- 
periences. But  even  now  I  am  able  to  say  that  we 
have  in  the  chemical  rays  of  the  electric  light  a  heal- 
ing-power which  promises  to  be  of  the  greatest  value 
in  the  near  future.  The  results  so  far  achieved  can 
no  longer  be  ignored,  and  it  has  become  our  duty  to 
investigate  further  these  processes. 


THE  IMPORTANCE  OF  PRELIMINARY 
TREATMENT  FOR  INTRA-NASAL  OPERA- 
TION'S.' 

Bv   CARL   SEILER,    M.D., 

SCRANTON,    I'A. 

It  is  an  axiom  in  general  and  special  surgery  that  it  is 
of  great  importance,  whenever  possible,  to  jirepare  the 
general  condition  of  the  patient  as  well  as  tiie  parts  to 
be  operated  upon  before  any  surgical  procedure  is  un- 
dertaken ;  to  improve  the  general  health,  tone  up  the 
system,  quiet  the  excited  nerves  by  tonics  and  hygien- 
ic measures,  good  food  and  air  as  well  as  judicious 
rest  alternating  with  mild  exercise  in  the  fresh  air, 
aided  by  stimulants  when  indicated;  in  short,  to  bring 
about  a  condition  of  the  system  as  nearly  normal  as 
possible,  and  to  remove,  as  far  as  may  be,  any  acute 
or  subacute  inflammation  of  the  parts  to  he  operated 
upon  before  the  knife  is  resorted  to. 

In  a  large  number  of  cases  which  come  under  tiie 

'  Keail  before  the  Lackawanna  Medical  .Society.  Scranton,  I'a., 
September  ii,  igoo. 


care  of  the  general  surgeon  this  preliminary  treatment 
cannot  be  instituted  for  lack  of  time  and  opportunity, 
and  as  a  result  its  importance  with  regard  to  the  out- 
come of  the  operation  is  lost  sight  of;  and  it  is  but 
too  often  neglected  in  those  cases  in  which  both  time 
and  opportunity  are  present. 

The  surgeon  in  the  majority  of  cases  being  obliged 
to  rely  upon  the  resisting-power  of  the  system  as  it 
exists  at  the  time,  naturally  falls  into  the  error  of  ne- 
lecting  to  improve  this  "vis  natura  medicatrix"  in 
those  cases,  few  though  they  may  be,  which  come  un- 
der his  notice,  and  in  which  opportunity  and  time  are 
not  lacking  for  such  preliminary  treatment.  In  intra- 
nasal surgery  we  have  to  deal  with  cases,  on  the  con- 
trary, but  very  few  of  which  demand  immediate  opera- 
tive interference  (as  in  the  case  of  traumatic  injuries 
of  the  nasal  bones  or  the  impaction  of  foreign  bodies 
in  the  nasal  ciiambers),  while  the  great  majority  allow 
of  extended  and  often  lengthy  preliminary  treatment, 
which,  when  undertaken  intelligently,  will  amply  re- 
pay all  trouble  and  loss  of  time  by  the  often  apparent- 
ly miraculously  beneficial  results  of  the  operation. 

In  spite  of  the  axiom,  and  in  spite  of  the  more  or 
less  emphatic  warnings  by  almost  all  authors  on  the 
subject,  not  to  operate  before  the  preliminary  treat- 
ment has  been  carried  out,  and  not  to  operate  while  the 
nasal  mucous  membrane  is  in  a  state  of  acute  or  sub- 
acute inflammation  (as  during  an  attack  of  hay  fever, 
for  instance),  this  necessary  precaution  is  not  taken 
and  the  warning  is  not  heeded  by  the  majority  of  sur- 
geons; and  operations  are  performed  without  prelimi- 
nary treatment,  which  thus  prove  annoying,  painful, 
a.'^d  even  disastrous  to  the  patient  in  their  results. 

I  have  found  through  extensive  experience  that  in 
many  cases  this  general  and  local  treatment  in  itself 
is  sufficient  to  ameliorate  the  direct  as  well  as  the  re- 
Ilex  symptoms,  notably  insufficiency  of  accommoda- 
tion of  the  eyes,  to  such  an  extent  that  an  operation, 
which  at  first  seemed  inevitable,  becomes  unnecessary, 
and  the  patient  is  relieved  without  surgical  interfer- 
ence. 

Although  this  treatment  has  been  freely  discussed  in 
detail  in  text-books  and  in  current  literature,  yet  the 
apparent  neglect  of  it  on  the  part  of  surgeons  prompts 
me  to  refer  to  it  again,  and  to  give  in  outline  only  its 
salient  features. 

After  a  careful  examination  of  the  case  has  been 
made  and  we  feel  satisfied  that  many  if  not  all  the 
concomitant  symptoms  can  be  traced  directly  or  indi- 
rectly to  the  presence  of  abnormal  and  pathological 
conditions  within  the  nasal  cavities,  and  that  a  removal 
of  these  conditions  is  necessaiy  for  a  cure  of  the  ail- 
ment, the  preliminary  treatment  should  be  instituted. 

First  of  all,  the  patient  should  be  directed  as  re- 
gards diet  and  hygienic  measures.  Such  tonics  as 
may  be  indicated  for  the  purpose  of  toning  up  the  sys- 
tem and  counteracting  any  of  the  effects  of  general 
dyscrasias,  if  such  are  present,  should  be  given. 
Among  the  hygienic  measures  bathing  of  the  neck  and 
the  upper  portion  of  the  chest  and  back  with  cold  wa- 
ter or  salt  and  water  (one  teaspoonful  to  one  pint  of 
water),  morning  and  evening,  followed  by  gentle  dry- 
ing of  the  skin  with  a  soft  Turkish  towel,  without  fric- 
tion, will  be  found  very  grateful  and  beneficial  in 
those  cases  which  are  prone  to  acute  congestion  or  in- 
flammation of  the  mucous  membrane  of  the  upper  air 
passages.  It  regulates  the  capillary  circulation  and 
hardens  the  skin  of  the  neck  and  throat  so  as  to  with- 
stand the  frequent  shocks  of  changes  of  temperature 
about  the  region  of  the  neck,  such  as  are  caused  by 
draughts  of  cold  air  striking  the  skin. 

The  local  treatment  of  the  nasal  and  naso-pharyn- 
geal  mucous  membrane  should  begin  with  a  thorough 
cleansing  of  the  nasal  cavities  by  the  patient  twice 
daily  with   a  bland  antiseptic  solution  of  the  proper 


October  27,  1900] 


MEDICAL    RECORD. 


651 


density  and  temperature.  As  these  various  attributes 
are  of  the  greatest  importance  in  a  proper  nasal  wash, 
so  is  also  the  method  employed  in  washing  out  the  na- 
sal cavities  by  the  patient  himself,  lo  both  of  which  I 
have  frequently  called  attention  in  the  various  edi- 
tions of  my  book  on  diseases  of  the  throat,  and  in  va- 
rious papers  in  current  medical  literature;  but  a  more 
detailed  description  of  both  will  nevertheless,  I  trust, 
not  be  out  of  place  in  this  paper,  particularly  as  phy- 
sicians are  so  very  apt  to  neglect  thorough  instruction 
of  the  patient  as  to  how  to  use  a  nasal  wash.  It  is  not 
sulficient  to  tell  the  patient  to  sniff  up  "a  little  salt 
and  water"  for  a  nasal  wash,  witliout  giving  him  the 
e.xact  proportions  of  the  salt  to  the  water  and  the 
proper  temperature  (56  gr.  [or  more  simple  and  quite 
accurate  enough,  an  even  teaspoonful]  of  table  salt  to 
one  measured  pint  of  water  at  blood  heat). 

In  order  to  facilitate  the  making  of  the  proper  nasal 
wash,  and  to  insure  greater  accuracy  and  efficiency  of 
the  solution,  I  devised  several  years  ago  a  compressed 
tablet  composed  of  salts  and  antiseptics,  in  such  quan- 
tities and  incorporated  in  such  a  manner  that  one  pas- 
til dissolved  in  four  tablespoonfuls  of  warm  water 
would  give  a  solution  possessing  all  the  necessary 
properties  mentioned  for  a  proper  nasal  wash. 

Unfortunately  all  the  various  and  numerous  manu- 
facturers have  imitated  this  tablet,  which  goes  by  the 
name  of  "Seller's  antiseptic  pastil,"  without  paying 
attention  to  the  scientillc  principles  in  the  manufac- 
ture which  underly  the  efficiency  of  the  preparation,  so 
th.it  to-day  there  is  scarcely  to  be  found  in  the  market  a 
preparation  of  Sellers'  pastils  but  which  is  inefficient, 
and  in  many  instances  even  injurious;  hence  I  have 
been  coni])eIlcd  to  request  the  numerous  manufactur- 
ers to  withdraw  my  name  from  their  preparation  labels 
and  lists,  which  request  was  granted  by  most  of  them. 

Kqually  important,  as  already  mentioned,  is  the 
method  employed  in  cleansing  and  flushing,  so  to 
speak,  the  nasal  cavities  with  the  solution,  by  means 
of  which  a  thorough  cleansing  of  all  their  parts,  and 
without  undue  pressure  upon  the  column  of  liquid 
is  obtained.  It  is  therefore  apparent  that  atomizers, 
syringes,  nasal  douches  in  their  various  forms,  and 
even  the  sniffing  from  the  hollow  of  the  hand  are  all 
methods  inadequate  to  the  purpose  in  the  hands  of  the 
patient,  if  they  are  not  injurious,  as  is  frequently  the 
case  with  the  nasal  douches  by  forcing  the  mucus  and 
the  solution  into  the  pharyngeal  opening  of  the  Eusta- 
chian tube  when  obstruction  in  either  one  of  the  nasal 
chambers  exists. 

What  may  properly  be  called  the  natural  method, 
or,  as  some  patients  have  graphically  described  it, 
"drinking  through  the  nose,"  will  be  found  to  be 
at  once  easily  taught  and  easily  learned  by  the  patient, 
and  to  be  efficient  without  being  harmful.  It  consists 
in  placing  two  ounces  of  the  blood-warm  solution  in  a 
small  tumbler  or  cup,  placing  the  end  of  the  nose 
within  the  rim  of  the  tilted  vessel  until  the  liquid  en- 
ters the  nostrils,  then  closing  the  mouth,  and  by  a 
moderate  inspiratory  etTort  drawing  the  solution  into 
the  nose  and  naso-pharynx,  thus  bringing  it  in  contact 
with  all  parts  of  the  nasal  mucous  membrane.  The 
vessel  should  then  be  quickly  removed  from  the  nose 
and  the  liquid  within  the  nasal  cavities  be  blown  out 
through  both  nostrils  at  once,  and  the  process  repeated 
until  the  liquid  in  the  vessel  is  exhausted.  If  this 
cleansing  process  is  faithfully  carried  out  by  the  pa- 
tient morning  and  evening,  considerable  advance  to- 
ward the  removal  of  congestion  or  inflainmation  will 
be  observed.  In  the  paroxysm  of  hay  fever  or  acute 
coryza  the  greatest  possible  relief  is  experienced  by 
the  patient  in  a  very  short  time,  provided,  however, 
that  the  solution  is  of  the  proper  density  and  is  unirri- 
tating. 

This  cleansing  process  should  be  continued  by  the 


patient,  while  local  applications  of  mild  astringents 
and  alteratives  to  the  mucous  membrane  of  the  ante- 
rior and  posterior  nasal  cavities  are  made  by  the  sur- 
geon at  intervals  of  a  day  or  two.  All  the  numerous 
astringents  in  solution  with  the  atomizer  and  in  pow- 
der form  as  snulT  have  been  used  with  more  or  less 
success,  but  the  iodine  solution  in  glycerin  (iod.  met., 
gr.  viii.;  glycerin,  fl  ;  ss. ;  potass,  iodide,  gr.  xxiv.) 
has  proved  more  universally  useful  than  any  other  lo- 
cal remedy  in  my  experience.  It  is  best  applied  with 
a  pledget  of  cotton  on  the  end  of  a  delicate  armed  ap- 
plicator, which  should  be  carried  through  the  nostrils 
along  the  lower  meatus  into  the  naso-pharynx  on  botii 
sides  if  it  is  possible  to  do  so,  which  manipulation 
should  be  executed  as  gently  as  possible. 

The  hygroscopic  property  of  the  glycerin  causes  the 
iodine  solution  to  rise  and  quickly  to  come  in  contact 
with  the  upper  portions  of  the  mucous  membrane,  so 
that  it  is  not  necessary  to  touch  the  more  sensitive 
portions  of  the  anterior  nasal  ca\  ities  with  the  appli- 
cator. In  order  to  retain  the  iodine  solution  longer  in 
contact  with  the  nasal  mucous  membrane  and  prevent 
its  being  washed  away  by  the  often  copious  serous  dis- 
charge following  any  local  application,  a  triturate  of 
bismuth  subnitrate  and  gum  acacia,  equal  parts,  may 
be  blown  through  the  nostrils  into  the  anterior  nasal 
chambers.  If  necessary  a  direct  local  application  to 
the  nasopharynx  of  the  same  solution  may  be  made 
behind  the  soft  palate  with  a  curved  applicator.  Co- 
caine in  any  shape  or  strength  of  solution  should  never 
be  used  in  the  nasal  cavities  except  as  a  local  ana.-s- 
thetic  for  minor  intranasal  operations,  in  which  capac- 
ity it  is  invaluable.  As  its  primary  effect  is  a  contrac- 
tion of  the  capillaries  of  the  nasal  mucous  membrane, 
its  application,  it  is  true,  affords  immediate  but  eva- 
nescent relief  from  the  nasal  obstruction  due  to  turges- 
cence  of  the  blood-vessels  and  venous  sinuses  in  the 
turbinated  tissue;  but  after  the  cocaine  has  lost  its 
effect  a  reaction  takes  place  which  calls  for  a  fresh 
dose  of  the  drug,  and  the  patient  for  the  sake  of  tem- 
porary relief,  as  in  hay  fe\er  for  instance,  becomes  ad- 
dicted to  the  use  of  cocaine  and  cannot  exist  without 
a  pledget  of  cotton  saturated  with  cocaine  solution  in 
his  nose.  This  habitual  use  of  the  drug  has  a  relax- 
ing effect  upon  the  tissues,  which  become  flaccid  and 
pale;  and  any  operation,  no  matter  how  trivial  in  its 
nature,  undertaken  when  the  nasal  mucous  membrane 
is  in  this  condition  and  is  kept  cocainized  afterward, 
is  apt  to  be  followed  by  extremely  slow  repair.  This 
effect  of  the  drug  is,  however,  a  purely  local  one,  and 
the  effects  of  cocaine  upon  the  general  system  are  but 
rarely  observed  in  these  cases  of  "  nasal  cocaine  fiends," 
probably  because  absorption  of  the  drug  does  not  take 
place  through  the  anterior  portion  of  the  nasal  mucous 
membrane. 

This  preliminary  treatment,  as  outlined  here,  should 
be  kept  up  for  several  weeks,  the  local  applications 
being  made  as  stated,  at  frequent  intervals,  until  a 
comparatively  healthy  appearing  mucous  membrane 
shows  on  examination.  In  those  cases  in  which  a 
bony  or  cartilaginous  projection  occludes  one  of  the 
anterior  nasal  chambers  while  the  other  is  the  seat  of 
atrophic  changes  in  the  turbinate  tissue  and  in  the 
mucous  membrane,  the  atrophic  side  should  be  treated 
with  stimulant  astringents,  such  as  zinci  sulph.  tritu- 
rate diluted  with  sacch.  lact.  in  varying  proportions, 
or  with  nitrate  of  silver  diluted  with  starch  (gr.  i.  :  gr. 
x.xx.),  insufflation,  or  finally  with  the  cotton  tampons  in 
connection  with  the  wash  and  the  insufflations  until  a 
reaction  from  the  atrophic  condition  has  taken  place, 
as  indicated  by  the  increased  watery  secretion  found 
in  the  nasal  cavity. 

Very  little  and  only  that  which  is  self-evident  need 
be  said  of  the  treatment  after  an  operation,  except  that 
the  patient  should  be  kept  under  observation  for  a  con- 


652 


MEDICAL    RECORD. 


[October  27,  1900 


siderable  time  to  insure  a  return  to  the  normal  condi- 
tion of  his  nasal  cavities,  and  to  prevent  any  untoward 
little  accidents,  such  as  colds,  from  again  interfering 
with  normal  nasal  respiration. 


A   CONTRIBUTION    TO  THE  DIAGNOSIS    OF 
SUPPURATIVE   APPENDICITIS.' 

By   a.    robin,    M.D., 

PATHOLOGIST    AND     BACTERIOLOGIST  TO  THE   DELAWARE    STATE     BOARD     OF 
HEALTH,    NEWARK,    DEL. 

"To  operate  or  not  to  operate,"  that  is  the  question, 
as  perplexing  as  the  one  of  existence  was  to  Hamlet. 
There  are  just  as  many  arguments  for  as  against  op- 
eration in  cases  of  appendicitis.  The  surgeon  who 
sees  principally  suppurative  and  far-advanced  cases 
holds  that  only  by  a  timely  operation  can  a  fatal  issue 
be  averted,  while  the  general  practitioner,  on  the  other 
hand,  who  encounters  largely  cases  of  simple  catarrhal 
appendicitis,  contends  that  in  many  instances  an 
operation  is  a  useless  e.xposure  of  the  patient  to  a 
serious  risk,  and  that  such  patients  may  and  do  get 
well  without  any  surgical  intervention.  The  author 
has  examined  an  appendix  removed  from  a  physician 
who  had  had  repeated  attacks  of  appendicitis.  On 
section,  the  lumen  of  the  appendix  was  found  entirely 
occluded  by  strong  tibrous  bands.  Evidently  the 
operation  in  this  case  was  useless,  inasmuch  as  nature 
was  accomplishing  a  radical  cure.  On  the  other  hand, 
we  frequently  read  reports  of  cases  in  which  life  was 
saved  by  an  operation,  or  could  have  been  saved  by 
timely  surgical  intervention. 

Connected  with  the  above  contentions  there  is  a 
minor  one  among  the  surgeons  themselves.  When 
shall  we  operate.'  During  the  intervals,  immediately 
at  the  onset,  or  when  suppuration  is  evident.'  It  is 
clear  that  these  differences  of  opinion  will  exist  so 
long  as  we  have  no  means  of  differentiating,  at  a  suffi- 
ciently early  date  in  the  course  of  the  disease,  sup- 
purative from  catarrhal  appendicitis,  or  are  not  able 
to  foresee  whether  the  catarrhal  appendicitis  will 
terminate  in  recovery  or  become  suppurative. 

In  view  of  these  difficulties,  any  aid  we  can  get  in 
the  diagnosis  of  suppurative  appendicitis  should  be 
welcomed  by  both  the  physician  and  the  surgeon.  Such 
an  essential  aid  the  author  finds  in  a  blood  count,  as 
the  following  case  illustrates: 

On  October,  1899,  the  author  was  called  in  by  Dr. 
Kollock  of  this  town  to  see  a  colored  girl,  aged  seven- 
teen years,  who  was  suffering  from  appendicitis.  The  at- 
tack was  not  very  severe,  the  girl  having  been  confined  to 
bed  only  two  days  The  temperature  at  the  time  of  our 
visit  was  102°  F.  Constipation  existed.  On  ]5alpation 
a  large  oblong  mass  was  felt  in  the  right  iliac  region  ex- 
tending as  far  as  the  groin.  This  mass  proved  subse- 
quently to  be  the  distended  ascending  colon.  It  was 
tender  on  pressure.  The  abdomen  was  slightly  rigid. 
Her  general  condition  was  fair.  A  blood  count  re- 
vealed 23,500  white  blood  cells  per  cubic  millimetre. 
A  diagnosis  of  suppurative  appendicitis  was  made,  and 
the  girl  was  at  once  removed  to  the  VVilminglon  City 
Hospital,  and  there  operated  on  by  Dr.  VVilliamson,  of 
Wilmington,  Del.  The  appendix  could  not  be  found, 
but  while  searching  for  it  the  doctor  broke  some  adhe- 
sion, and  about  two  tablespoonfuls  of  pus  welled  out 
from  beneath  the  distended  colon.  The  attempts  to 
find  and  remove  the  appendix  were  abandoned;  the 
wound  was  flushed  with  sterile  water  and  packed  with 
gauze.     The  patient  made  a  good  recovery. 

This  case  shows  that  suppuration  was  detected  by 
means  of  a  blood  count  when  neitlier  clinical  symp- 
toms nor  external  signs  pointed  to  it.     Had  tiie  girl 

'  Read  before  the  Cecil  County  Medical  Society,  Md. 


been  allowed  to  go  on  for  another  day  or  two,  a  large 
abscess  would  have  formed,  and  even  admitting  that  it 
would  have  been  circumscribed  by  adhesions,  the  latter 
could  have  been  easily  broken,  and  if  operated  upon 
the  danger  of  infection  would  have  been  much  greater. 

In  order  that  tiie  importance  of  a  blood  count  may 
be  better  appreciated  by  the  non-specialist,  a  few  gen- 
eral remarks  w'ill  not  be  amiss. 

Our  medical  nomenclature  in  general  is  far  from 
perfect,  but  when  it  comes  to  the  nomenclature  of 
blood  it  is  below  criticism — a  veritable  Babylonian 
mixture  of  terms  indiscriminately  applied.  It  is  a 
very  unforKniate  thing  to  cover  our  ignorance  by  a 
high-sounding  and  alluring  terminology,  such  as 
"  idiopatliic  "  disease,  "alterative  "  action,  "aggluti- 
nin," "  vitality,"  etc.  It  were  much  better  to  follow  the 
modest  example  of  Roentgen  and  designate  the  un- 
known by  .V,  thus  calling  at  once  the  attention  of 
everybody  to  the  fact  that  the  unknown  quantity  is 
still  the  unsolved  part  of  the  problem.  How  many 
.t's  would  we  have  in  our  medical  science  if  this 
method  were  followed!  As  it  is,  we  have  "eosino- 
philes" — white  cells  possessing  granules  which  take 
up  the  eosin  stain,  "  lymphocytes."  "  polymorpho- 
nuclear neutrophiles,"  all  terms  applied  to  the  leuco- 
cytes, a  name  erroneously  employed  as  a  synonym  for 
white  blood  corpuscles.  It  is  true  that  the  word 
"leucocyte"  means  "white  cell,"  but  physiologists 
have  restricted  the  term  to  the  wandering  cells  which 
pass  from  the  lymphatic  spaces  into  the  lymph  chan- 
nels and  thence  to  the  general  circulation;  they  all 
possess  amoeboid  movement,  and  it  is  to  these  cells 
that  the  term  "  phagocytes  "  has  been  applied  by  Metch- 
nikoff  on  account  of  their  property  of  imbibing  and 
digesting  bacteria.  The  term  "  leucocytes  "  therefore, 
as  applied  by  the  physiologists,  would  mean  the  lym- 
phatic cells  outside  but  not  within  the  blood-vessels. 
These  lymph-corpuscles  or  leucocytes  entering  the  cir- 
culation from  the  thoracic  duct  become  white  blood 
corpuscles.  In  infectious  diseases  the  lymph-corpus- 
cles, and  not  the  white  blood  cells,  are  increased  (with 
few  exceptions).  This  may  a  priori  be  expected, 
knowing  that  the  lymphatic  system  is  stimulated  to 
activity  in  any  infectious  disease.  This  increase  in 
the  number  of  leucocytes  brings  about  indirectly  an 
increase  in  the  number  of  white  blood  corpuscles,  and 
indeed  it  is  by  the  increase  of  the  latter  that  we  judge 
of  the  increase  of  the  former.  The  term  "  leuco- 
cytosis,"  therefore,  may  be  used,  providing  its  physio- 
logical meaning  is  kept  in  view.  But  here  again  we 
confront  an  error  in  nomenclature.  "  Leucocytosis  " 
is  used  whenever  we  want  to  designate  an  increase  in 
the  number  of  leucocytes;  the  vvord  itself,  however, 
means  "morbid  state  of  while  cells"  (from  the  Greek, 
).i')/.ii<;,  "white,"  ■A''i-it<,  "cell,"  and  suffix — osis,  "mor- 
bid state."  This  "morbid  state"  exists  whether  the 
number  of  leucocytes  is  above  or  below  normal,  and 
the  terms  hyper,  "above,"  and  hypo,  "below,"  pre- 
fixed to  leucocytosis  is  the  more  proper  terminology. 

The  importance  of  leucocytosis  asserted  itself  since 
the  discovery  by  Metchnikoff  of  the  property  possessed 
by  the  leucocytes  of  imbibing  bacteria.  This  property, 
however,  is  not  specific  to  leucocytes  nor  to  bacteria;  it 
is  the  sole  means  by  which  manv  unicellular  organisms, 
such  as  the  anutba-,  nourish  themselves.  The  particles 
imbibed  are  granules,  bacteria,  etc.  The  imbibition 
of  bacteria  by  the  leucocytes,  therefore,  is  not  a  defen- 
sive act,  as  one  would  be  led  to  believe  from  the  fan- 
tastic picture  painted  by  the  adherents  of  the  "  phago- 
cytosis "'  theory.  While  swallowing  the  deadly  morsel, 
the  leucocyte  is  not  thrilled  by  any  altruistic  or  patriotic 
emotion.  The  bacterium  is  simply  within  its  reach, 
the  stimulus  is  suflficient  to  cause  expansion  and  con- 
traction of  the  protoplasm  of  the  leucocyte,  and  the 
morsel  is  devoured  regardless    of    consequences.     A 


October  27,  1900] 


MEDICAL    RECORD. 


653 


granule  of  carmine  would  suffer  the  same  fate.  To 
this  phenomenon  of  attraction  the  term  "  chemiotaxis" 
is  applied.  It  is  not  necessary  at  this  place  to  enter 
more  deeply  into  the  theory  of  "  phagocytosis  "  as  ex- 
plaining immunity.  Suffice  it  to  say  that  tlie  theory, 
universally  accepted  prior  to  1893,  is  no  longer  tenable. 
It  does  not  explain  the  immunity  acquired  against 
toxins,  such  as  toxins  of  diphtheria,  in  which  case  the 
bacilli  themselves  are  altogether  excluded.  Recently, 
Metchnikoff  tried  to  stretch  his  theory  by  ascribing  to 
the  phagocytes  the  property  of  secreting  the  immuniz- 
ing substances.  These,  however,  are  speculations 
which  do  not  interest  us  at  present.  Whatever  role 
the  leucocytes  play  in  establishing  immunity,  it  is  a 
well-established  fact  that  their  increase  or  decrease  is 
of  considerable  diagnostic  significance.  The  normal 
proportion  of  white  blood  cells  is  i  10300  or  i  to  700 
red  (5,000-10,000  per  cubic  millimetre),  somewhat 
higher  in  women  and  considerably  higher  in  infants 
(about  20,000  per  cubic  millimetre).  Physiologically 
it  is  increased  after  a  meal,  during  pregnancy  and 
parturition,  after  exercise,  and  as  shown  by  Winternitz' 
after  a  cold  bath  (this  explains  the  salutary  effects  of 
the  latter  in  typhoid  fever).  Pathological  hyperleuco- 
cytosis  takes  place  in  the  following  diseases:  Hemor- 
rhage, scarlet  fever,  diphtheria,  tonsillitis,  syphilis 
(secondary),  erysipelas,  pneumonia,  malignant  endo- 
carditis, puerperal  and  other  septicaimias  (in  the  case 
of  puerperal  septicaemia  not  of  aid  in  diagnosis), 
trichinosis,  glanders,  acute  multiple  neuritis,  acute 
articular  rheumatism,  septic  and  cerebrospinal  men- 
ingitis, infection  of  the  gall  bladder,  acute  pancre- 
atitis, some  acute  cases  of  cystitis,  gonorrhoea,  all 
kinds  of  abscess  formation,  gangrenous  inflamma- 
tions, and  various  forms  of  toxsmia.  Some  drugs 
such  as  pilocarpine,  antipyrin,  etc.,  produce  hyper- 
leucocytosis,  while  atropine  and  other  anidrotics  have 
the  opposite  effect.  Infection  with  cultures  of  the  colon 
bacillus,  as  has  been  demonstrated  experimentally  by 
I'ahland,^  produces  hyperleucocytosis,  and  some  cases 
of  cystitis  in  which  hyperleucocytosis  is  found  may  be 
thus  explained.  Hypoleucocytosis,  or  diminution  in 
the  number  of  leucocytes,  takes  place  in  fasting  and 
malnutrition,  and  in  some,  infectious  diseases,  such 
as  typhoid  fever,  malaria,  influenza,  measles,  mumps, 
and  tuberculosis,  except  in  advanced  stages. 

It  is  thus  seen  that  a  white  blood  count  will  often 
swing  the  pendulum  in  the  direction  of  the  diagnosis 
of  one  disease  or  another.  Especially  is  this  true  in 
cases  of  suppuration  complicating  an  infectious  or  in- 
flammatory disease.  Thus  a  sudden  hyperleucocytosis 
in  the  course  of  typhoid  fever  will  point  to  a  com- 
plication, and  if  accompanied  by  sudden  onset  of  pain 
in  the  abdomen  will  be  a  sufficient  justification  for  an 
exploratory  incision,  as  is  the  practice  in  the  Johns 
Hopkins  Hospital.  A  hyperleucocytosis  will  at  once 
differentiate  a  suppurative  appendicitis  from  simple 
colic,  typhoid  fever,  ovarian  neuralgia,  impaction  of 
faeces,  and  floating  kidney.  Developed  during  the 
course  of  a  catarrhal  appendicitis  it  will  point  to  sup- 
puration with  as  much  precision  as  any  of  the  diag- 
nostic signs  in  our  possession.  The  case  above  de- 
scribed certainly  lends  support  to  this  assertion.  The 
girl  was  not  very  sick,  only  two  to  three  days  in  bed 
and  comparatively  comfortable,  and  yet  the  presence 
of  pus  was  as  patent  to  our  minds  as  tliough  demon- 
strated by  an  exploratory  operation.  Cabot  tabulates 
seventy-two  cases  of  appendicitis  in  which  blood  counts 
were  made.  The  following  show  the  relation  of  sup- 
puration and  hyperleucocytosis : 
No.  I.  52,000  leucocytes — pus  found  on  operation. 
No.    2.   19,000  "  — pocket  of  pus  found. 

'  "  Ueber  Leucocytose  nach   Kalteeinwirkung,"     Centralbl.  f. 
klin.  Medicin,  iSq3,  Xo.  o. 

*  Centralbl.  f.  innere  Med.,  No.  17,  1899. 


No.  15.  22,300  leucocytes — abdomen  full  of  pus. 

No.  17.  21,900         "         — pus;  cacal  abscess. 

No.  18.  47,700  "         — second  operation  ;  pus. 

No.  18.  30,300  "         — third  operation  ;  pus. 

No.  23.  20,000  "         — operation,  pus. 

No.  28.   19,000         "         — purulent  peritonitis. 

No.  31.   17,500  "         — pint  of  pus. 

No.  34.   16,200  "         — abscess  cavity. 

No.  40.  32,800  "         — large  amount  of  pus. 

No.  50.   17,000  "         — pus. 

No.  54.  July  6.  iijSoo  leucocytes,    slight    tendernass, 

no  resistance  or  dulness. 
No.  54.  Ju-ly  7,  19,000  leucocytes  up  to,  resistance  and 

tenderness;  operation,  pus. 
The'last  case  shows  how  by  means  of  a  blood  count 
pus  can  be  detected  within  twenty-four  hours  and  a 
fatal  case  be  thus  converted  into  a  very  favorable  one. 
What  other  means  have  we  of  diagnosing  suppurative 
appendicitis.'  Unfortunately  none.  What  we  are 
able  to  diagnose  is  a  purulent  peritonitis,  but  then 
we  have  done  our  patient  very  little  good,  even  if  we 
are  able  to  fill  out  a  correct  death  certificate.  We 
may  also  occasionally  detect  a  walled-off  abscess,  if  it 
points  externally,  but  in  how  many  cases  does  the 
abscess  take  such  a  favorable  turn.'  It  appears 
rational,  therefore,  that  a  frequent  blood  count  in 
cases  of  appendicitis  is  almost  an  imperative  neces- 
sity. I  say  frequent,  because  in  some  fulminant  cases 
the  advent  of  fatal  toxaemia  may  be  so  rapid  that  no 
increase  of  leucocytes  is  present.  This  is  fully  in 
accord  with  the  experiments  on  animals  performed  by 
Havet,'  who  has  shown  that  whenever  the  dose  of 
staphylococci  injected  was  very  large,  the  ability  of 
the  organism  to  produce  leucocytes  was  proportionally 
abolished,  and  instead  of  the  usual  hyper-  a  hypo- 
leucocytosis took  place.  Similar  observations  were 
made  by  Everard,  Demoor,  Schultz,  and  others.  Ca- 
bot reports  four  cases  of  appendicitis  with  general 
purulent  peritonitis  in  which  no  hyperleucocytosis  was 
found.  When,  however,  examinations  are  made  fre- 
quently such  mistakes  would  in  the  majority  of  cases 
be  avoided,  for  we  could  always  detect  the  hyperleu- 
cocytosis before  the  organism  would  become  sufficiently 
depressed  to  fail  to  react.  With  all  tiiese  facts  before 
us,  we  can  hardly  fail  to  appreciate  the  important  role 
a  blood  count  plays  in  the  diagnosis  of  suppurative 
appendicitis. 


INTESTINAL  OBSTRUCTION  COMPLICATING 
APPENDICITIS,  WITH  THE  REPORT  OF  A 
CASE. 

By   THOMAS   M.    PAUL,    M.D., 

ASSISTANT  SURGEON   STATE   HOSPITAL,    HAZLETON,    PA. 

Asepsis  has  so  reduced  the  mortality  of  laparotomy 
that  conservative  surgeons  perform  this  operation  in 
grave  cases  for  purposes  of  diagnosis  as  well  as  treat- 
ment. Still  further,  asepsis  has  stimulated  the  pro- 
gressive operator  to  devise  means  for  mechanically 
treating  conditions  which  would  have  been  considered 
beyond  the  surgeon's  reach  in  days  when  bacteria  were 
unknown.  That  many  lives  have  been  saved  by  oper- 
ation in  obscure  abdominal  conditions,  and  that  what 
has  been  supposed,  even  by  eminent  surgeons,  to  be  an 
appendicitis  with  abscess  has  turned  out  to  be  a  pyo- 
salpinx,  is  evidence  in  contradiction  to  the  teaching  of 
a  few  years  ago.  An  interesting  case  is  recorded  by 
A.  F.  Jonas,  in  which  an  enterolith  was  mistaken  for 
appendicitis,  and  after  coeliotomy  for  malignant  dis- 
ease.' 

What  is  true  of  the  technique  of  laparotomy  in  gen- 
eral is  equally  true  of  progress  in  the  treatment  of  in- 

'  "  Pu  rapport  entre  le  pouvoir  bactericide  du  sang  de  chicn 
et  sa  richesse  en  leucocytes."     La  cellule,  t.  x. ,  1S94. 


654 


MEDICAL    RECORD. 


[October  27,  1900 


testinal  obstruction  in  particular.  Unless  the  occlu- 
sion of  the  bowel  is  due  to, fecal  impaction,  which  is 
generally  relieved  by  purgatives  and  enemas,  or  to  ad- 
vanced carcinoma,  it  is  not  only  justifiable  but  abso- 
lutely necessary  to  operate.  It  is  as  important  to 
relieve  an  invisible  obstruction  by  mechanic.d  means 
as  to  cut  the  constriction  in  a  case  of  strangulated  her- 
nia. The  earlier  the  operation  is  performed  in  these 
cases  the  better  the  general  and  local  condition  of  the 
patient  will  be,  and  in  consequence  tiie  better  the  pros- 
pect for  recovery.  Richardson  well  expresses  this 
when  he  says:  "  Six  cases  .  .  .  have  occurred  in  the 
writer's  experience;  three  died  and  three  recovered. 
In  the  three  fatal  cases  the  operation  was  performed  as 
a  last  resort,  the  patients'  condition  being  practically 
hopeless."  '  In  opposition  to  these  ideas  an  edition  of 
a  well-known  text-book  appeared  as  recently  as  1893, 
in  which  all  sorts  of  palliative  measures  were  advo- 
cated, its  author  stating  that  operative  interference  is 
to  be  resorted  to  only  as  a  final  procedure. 

In  an  extensive  research  into  the  literature  of  intes- 
tinal obstruction  I  have  been  able  to  collect  only  six 
cases"  in  which  it  was  due  to  the  appendix  itself,  al- 
though surgical  text-books  seem  to  consider  it  a  not 
unusual  cause.  As  for  ileus  due  to  inflammatory  ad- 
hesions, which  adhesions  in  turn  are  due  to  appendi- 
citis, I  have  read  of  only  two  instances.'  I  consider 
it  of  interest  therefore  to  report  the  following  case: 

B.  B ,  aged  sixteen  years.  Family  history  neg- 
ative. In  June,  1S99,  ^^  had  an  attack  of  acute  ap- 
pendicitis lasting  two  weeks.  A  second  attack  began 
July  31,  igoo.  This  attack  also  lasted  about  two 
weeks,  at  the  end  of  which  time  the  patient  got  out  of 
bed.  The  second  day  after  getting  up  he  ate  plenti- 
fully of  green  apples.  The  last  of  the  apples  was 
eaten  about  3  or  4  p.m.,  and  about  10:30  p.m.  he  was 
seized  with  violent  pain  in  the  abdomen  and  vomited 
a  considerable  quantity  of  the  apples.  During  the 
night  he  had  a  good  freejmovement  of  what  his  mother 
described  as  the  undigested  apples.  From  this  time 
until  the  time  of  admission  to  the- hospital,  a  period 
of  three  days,  the  patient  had  no  intestinal  evacuation, 
but  vomited  frequently. 

Examination  on  admission,  August  19,  1900:  The 
patient  was  generally  well  nourished;  he  was  very 
much  depressed  and  answered  questions  only  after 
they  had  been  repeated;  the  ]Julse  was  iio,  wiry,  and 
irregular;  the  respiration  slow  and  feeble;  the  tem- 
perature 97°  F.  The  abdomen  was  generally  distend- 
ed, but  more  so  above  than  below  the  umbilicus; 
there  was  no  visible  peristalsis.  Pain  and  tenderness 
were  general,  although  more  pronounced  in  the  neigh- 
borhood of  the  appendix.  The  liver  dulness  was  re- 
placed by  tympany,  which  extended  well  over  on  both 
flanks  and  down  to  the  pubis.  No  borborygmi  or 
gurgling  could  be  heard. 

As  high  enemas  and  purgatives  had  been  tried  by 
the  family  physician,  further  delay  was  considerd  dan- 
gerous and  the  patient  was  immediately  prepared  for 
cceliotomy. 

Operation,  August  19,  igoo,  3  p.m.,  performed  by 
Dr.  Lathrop,  assisted  by  Dr.  Dyson  and  myself. 
Ether  was  the  anaesthetic  used.  The  usual  incision 
was  made  for  the  removal  of  the  appendix,  which  was 
found  embedded  in  a  mass  of  adhesions.  These  were 
separated  with  dilTiculty  and  the  appendix  was  ligated 
and  amputated.  The  ca-cum  was  collapsed,  although 
several  coils  of  small  intestine,  which  had  been  drawn 
out  in  the  search  for  the  appendix,  were  distended 
almost  to  the  bursting-point.  A  systematic  search  was 
then  made,  beginning  at  the  CEECal  end  of  the  small 
intestine;  after  about  four  feet  had  been  drawn 
through  the  abdominal  wound,  an  adhesion  encircling 
and  completely  occluding  the  gut  was  discovered. 
The  intestine  above  this  constriction  was  so  distended 


that  it  was  drawn  well  out  of  the  abdomen  and  a  small 
incision  made  in  it,  letting  out  a  large  quantity  of 
fluid  fecal  matter.  The  offending  adhesion  was  read- 
ily broken  through  by  the  finger.  The  intestinal 
wound  was  sutured,  the  peritoneal  cavity  thorougiily 
flushed  with  decinormal  salt  solution,  and  the  abdom- 
inal wound  closed  with  gauze  drainage. 

Toward  the  end  of  the  operation  the  patient  suffered 
from  severe  shock,  despite  the  fact  that  the  coils  of 
intestine  withdrawn  from  the  abdomen  were  surround- 
ed with  hot  wet  gauze,  and  that  hypodermics  of  strych- 
nine were  administered  and  hot-water  bottles  were  kept 
applied  to  the  body  and  extremities.  After  being 
placed  in  bed,  the  boy  vomited  a  large  quantity  of 
fecal  liquid,  which  further  added  to  his  depressed  con- 
dition. He  sank  rapidly;  the  pulse  became  almost 
impalpable,  the  respiration  shallow  and  rapid,  and  the 
temperature  subnormal;  and  he  became  semi-con- 
scious. Two  quarts  of  hot  decinormal  salt  solution 
were  then  gradually  forced  into  the  median  basilic 
vein  by  means  of  a  Collins'  transfusion  apparatus. 
Under  this  treatment  the  patient  rapidly  improved; 
he  could  talk  coherently,  his  pulse  became  regular  and 
full,  his  respirations  were  normal,  and  his  temperature 
rose  to  99.5°  F.  The  following  morning  his  bowels 
moved  naturally.  The  gauze  drainage  was  removed 
on  the  second  day  after  the  operation,  and  the  wound 
healed  rapidly.  The  remainder  of  his  convalescence 
was  uneventful.  The  patient  was  able  to  be  up  Sep- 
tember nth,  and  left  the  hospital  September  16,  1900, 
perfectly  well. 

This  case  appeals  to  me  as  being  unusually  inter 
esting  for  the  following  reasons: 

1.  It  is  exceptional  to  bn  able  to  ascribe  ileus  to 
appendicitis  with  the  degree  of  certainty  that  could  be 
done  in  this  instance  before  the  abdomen  was  opened. 

2.  It  emphasizes  the  importance  of  early  operation. 

3.  It  demonstrates  the  value  of  the  intravenous  in- 
jection of  decinormal  salt  solution  in  cases  of  shock, 
particularly  when  the  solution  is  gradually  forced  in, 
the  transfusion  apparatus  under  these  circumstances 
acting  as  an  artificial  heart. 

REFERE^■CES. 

1.  Medical  Record,  March  3,  1S94,  vol.  xlv..  p.  267. 

2.  Dennis  :   System  of  -Surgerj-,  vol.  iv. ,  p.  302. 

3.  Fred.  C.  Pafford  :  Medical  Record,  July  2,  1S9S,  vol. 
liv.,  p.  2S.  Three  cases  are  quoted  by  Pafford  from  Dennis' 
System  of  Surgery.  The  fourth  case  is  reviewed  in  Philadelphia 
^ledical  Journal  (from  Journal  of  American  Medical  Association) 
April  2,  1S9S.  vol.  .\xx.,  No.  14.  .Simmonds  :  Medical  News, 
March  4,  1893,  vol.  l.sii.,  p.  245. 

4.  Richardson  :   Dennis'  System  of  Surger}',  vol.   iv. ,  p.   303. 


Vertigo  of  Meniere. — After  a  general  description 
of  the  disease  Urban  Pritchard  gives  the  history  of  a 
case  occurring  in  a  woman  aged  fifty-four  years  with  left 
otorrhcea  since  childhood.  In  Ker  fifty-second  year  she 
was  admitted  to  hospital  with  large  masto-squamous 
abscesses,  foul  otorrh(ta,  and  inability  to  walk  with- 
out assistance  in  consequence  of  vertigo.  Operation 
was  performed,  but  the  bridge  and  outer  wall  of  the 
attic  were  not  removed.  Two  years  later  she  again 
presented  herself  with  practically  the  same  symptoms. 
A  complete  mastoid  operation  was  then  done,  but  in 
the  removal  of  the  petrous  bone  the  semicircular  canals 
were  in  part  destroyed,  and  the  back  of  the  vestibule 
was  opened.  Clear  fluid  escaped.  Later  an  epithelial 
grafting  operation  was  done  with  complete  relief  to 
deafness  and  giddiness. — Journal  oj  Laryugolog}\  Sep- 
tember, 1900. 

Recurring  Parotitis  in  a  Healthy  Child,  Persist- 
ing for  Six  Years.  — F.  C.  Kwing  reports  the  case  of 
his  own  son,  eight  years  old,  whoever  since  his  second 


October  27,  1900] 


MEDICAL    RECORD. 


655 


year  has  been  subject  to  recurring  attacks  of  swelling 
and  inflammation  of  the  parotid  glands,  apparently 
idiopathic.  The  swelling  has  always  manifested  it- 
self suddenly,  as  a  rule  developing  to  its  fullest  extent 
during  the  night,  with  little  or  no  constitutional  symp- 
toms. VVith  one  exception  it  has  been  unilateral. 
These  attacks  have  occurred  at  irregular  intervals  of  a 
few  months  to  a  year,  becoming  notably  less  frequent 
as  the  child  has  grown  older.  They  are  attended 
with  pain  on  pressure  and  mastication,  but  it  is  never 
intensely  acute.  There  has  been  no  attendant  enlarge- 
ment of  the  lymphatics,  nor  the  slightest  hypertrophy 
after  subsidence  of  the  acute  symptoms.  These  swell- 
ings have  always  disappeared  without  treatment  within 
three  days,  generally  decreasing  somewhat  in  twenty- 
four  hours.  Fever  has  been  absent.  The  subject  is 
a  vigorous  boy,  and  considerable  of  an  athlete  for 
his  years.  He  has  never  been  specially  subject  to 
colds,  nor  shown  the  catarrhal  diathesis.  His  fam- 
ily history  was  good;  physical  history  was  confined  to 
great-aunts. —  S/.  Zouis  A/tw/ica/  /f^a'i'erc,  September  15, 
1900. 

Life  Insurance  and  Cardiac  Disease F.  G.  Fin- 
ley  says  that  the  cases  which  an  insurance  company  is 
safest  in  accepting  are  those  of  mitral  regurgitation 
and  aortic  direct  murmurs  in  which  secondary  ciianges 
in  the  heart  are  slight  or  absent,  ('ardiac  symptoms, 
particularly  dyspnoea  on  exertion,  should  be  excluded 
by  the  personal  observation  of  the  examiner,  and  as  far 
as  possible  all  cases  should  be  excluded  in  whicii  the 
lesion  is  likely  to  be  progressive.  Recurring  rheumatic 
attacks  exert  a  most  unfavorable  influence  owing  to 
further  attacks  of  endocarditis  or  pericarditis.  A  sta- 
tion in  life  not  involving  manual  labor,  and  early 
adult  life,  at  which  period  arterial  sclerosis  is  un- 
likely to  be  present,  are  further  elements  which  must 
be  weighed  in  the  acceptance  of  such  cases.  Careful 
habits  and  good  general  health  are  also  important  in 
estimating  these  risks. —  T/ie  Medical  Examiner  and 
Prae/itioner,  .September,  igoo. 

Safcoma  of  the  Naso-Pharynx  Cured  by  Injec- 
tions of  Formalin The  patient  of  J.  A.  Thompson 

was  a  man  aged  fifty  years,  who  had  had  several 
hemorrhages  from  the  nose  and  mouth  ascertained  to 
be  due  to  a  tumor  in  the  naso-pharynx.  His  general 
contlition  was  very  poor.  Examination  revealed  a 
mass  attached  to  the  posterior  wall  of  the  naso- 
pharynx, proven  by  the  microscope  to  be  a  round- 
celled  sarcoma.  The  patient's  general  condition  con- 
traindicated  operation,  and  it  was  decided  to  inject 
one-half-per-cent.  solutions  of  formalin  into  the 
growth.  Twenty-five  minims  were  used  at  each  injec- 
tion, the  latter  being  made  twice  a  week  at  the  physi- 
cian's office,  while  the  patient  used  at  home  a  cleans- 
ing spray.  The  injections  seemed  to  remove  the 
blood  supply  from  the  part  of  the  growth  injected, 
which  was  then  removed  by  forceps.  In  this  way  the 
entire  mass  was  completely  eradicated.  No  recurrence 
was  noted  fourteen  months  after  the  treatment  was 
begun.  Finally  the  case  was  dismissed.  No  recur- 
rence had  been  noted  three  months  later. —  The  Laryn- 
goscope, September,  1900. 

Is  Strychnine  Neutralized  by  the  Living  Animal 
Tissues? — S.J.  MeUzer  and  G.  Langmann  have  re- 
peated and  elaborated  the  experiments  of  Czyhlarz  and 
Donath  with  a  view  of  testing  the  accuracy  of  their 
statements  regarding  the  possibility  of  preventing  the 
toxic  action  of  strychnine  by  ligating  for  several  hours 
the  extremity  into  which  it  is  injected,  the  assumption 
being  that  the  poison  is  modified  and  made  harmless 
by  its  contact  with  the  tissues.  As  another  example  of 
such  action  Czyhlarz  and  Donath  referred  to  the  satis- 
factory results  in  treating  snake  bites  by  ligature,  but 


in  testing  this  in  rabbits  and  guinea-pigs  with  the 
venom  of  Crotalus  horridus  it  was  found  that  death 
was  delayed  but  not  prevented  by  tying  oil  the  affected 
limb.  In  a  similar  way  in  experimenting  with  strych 
nine  injections  in  rabliits,  guinea-pigs,  and  frogs  it 
was  founil  tiiat  the  toxic  action  was  delayed  and  di 
minished  somewhat,  but  that  it  was  much  more  prob- 
able that  tliis  effect  was  due  to  the  impaired  absor|)iive 
power  due  to  the  congestion,  cedema,  etc.,  secondary  to 
the  ligation,  rather  tiian  to  any  neutralizing  power  un- 
folded in  the  tissues. —  Ceutralblatt  Jiir  innere  Medicin, 
September  15,  1900. 

Disinfection  of  the  Hands  by  Means  of  Essences. 
^Eugenio  Calvello  draws  the  following  conclusions 
from  a  series  of  experiments:  i.  That  washing  with 
soap  and  water  and  alcohol  does  not  make  the  hands 
aseptic,  although  it  does  diminish  the  number  of 
germs  to  a  great  extent.  2.  That  the  methods  of 
Fiirbringer  and  Ahlfeld  do  not  result  in  complete  dis- 
infection. 3.  That  seven  to  eight  per  cent,  solutions 
of  essence  of  cinnamon,  eleven  per  cent,  of  essence  of 
thyme,  and  seventeen  per  cent,  of  essence  of  geranium 
act  precisely  as  do  solutions  of  bichloride  used  ac- 
cording to  Fiirbringer's  method,  and  should  be  given 
the  preference  in  modern  surgery,  because  they  do  not 
cause  the  alterations  that  bichloride  does.  4.  Nine- 
per-cent.  solutions  of  essence  of  cinnamon,  eleven  and 
twelve  per  cent,  of  essence  of  thyme,  and  eighteen  per 
cent,  of  essence  of  geranium  assure  complete  disinfec- 
tion of  the  hands.  5.  The  essence  of  patchouli  has 
no  antiseptic  powers. —  Giornale  Inhrnazionale  delle 
Scienze  Medic/ie,  September  15,  igoo. 

The  Continued  Use  of  the  Antiseptic  and  Elim- 
inative  Treatment  of  Typhoid  Fever  without  Any 
Deaths. — Virgil  Hubbard  defines  his  modified  Wood- 
bridge  treatment  of  typhoid  fever  as  follows:  Gener- 
ally the  patient  is  first  given  a  capsule  containing 
calomel,  gr.  ss;  guaiacol  carbonate,  grs.  ii. ;  podophyl- 
lin,  gr.  jjL  to  ^'„,  every  two  hours  for  twenty-four  to 
fort\-eight  hours,  depending  on  the  condition  of  the 
bowels.  This  is  continued  till  four  or  five  intestinal 
evacuations  for  two  successive  days  have  been  secured, 
when  the  calomel  is  stopped  and  gr.  ss.  of  menthol  is 
added  to  the  guaiacol  and  podophyllin.  If  after  stop- 
ping the  calomel  there  is  any  tendency  for  the  bowels 
to  become  inactive,  a  small  dose  of  salts  is  given  in 
the  morning.  There  should  be  two  or  three  evacua- 
tions daily.  If  after  four  or  five  days  of  treatment 
the  temperature  remains  high,  or  rises  after  having 
remained  stationary,  the  calomel  is  again  resorted  to 
for  a  few  hours.  The  guaiacol  and  menthol  are  con- 
tinued throughout  the  course  of  the  disease.  Besides, 
the  writer  often  administers  decinormal  salt  solution 
per  rectum.  The  collected  results  of  the  writer's 
cases,  together  with  those  of  other  men,  treated  in  this 
manner  give  a  mortality  of  less  than  two  per  cent.,  the 
writer  having  had  no  deaths. —  Georgia  Journal  of 
Medicine  and  Surgery,  September,  1900. 

Renal  Asthma.— S.  VV.  Macllwaine  says  that  while 
renal  asthma  is  familiar  enough  we  do  not  pay  suffi- 
cient attention  to  the  pre-albuminuric  stage  when  one 
might  hope  for  some  definite  results  from  treatment. 
All  cases  of  asthma  coming  on  after  middle  life  ought 
to  be  looked  on  with  suspicion.  Most  of  these  cases 
are  doubtless  due  to  toxamias  of  more  or  less  obscure 
origin.  Some  light  is  probably  thrown  on  their  true 
nature  by  comparing  them  with  the  very  rapidly  fatal 
cases  of  so-called  Bright's  disease  that  are  met  with 
in  elderly  people  as  a  result,  or  rather  a  part,  of  influ- 
enza. Here  the  consequences  of  a  toxaemia  of  easily 
recognized  origin  fall  directly  on  the  kidneys.  There 
is,  in  some  cases,  never  more  than  a  very  small 
amount  of  albumin,  the  history  is  terribly  short,  and 


656 


MEDICAL    RECORD. 


[October  27,  1900 


the  symptoms  are  almost  purely  uraemic:  there  is  no 
time  for  the  development  of  dropsy  and  other  more 
tardy  symptoms  of  kidney  breakdown. — Medical  Press 
and  Cirnilar,  September  29,  1900. 

The  Etiology  of  Acute  Lobar  Pneumonia. — In  a 
statistical  present.ition  of  certain  studies  in  the  bac- 
teriological field  W.  T.  Howard,  Jr.,  found  in  one 
hundred  and  seveniy-four  consecutive  autopsies  four* 
teen  cases  of  primary  and  fifty-three  of  secondary 
pneumonia.  The  pneumococcus  was  found  in  all 
cases  of  primary  croupous  pneumonia,  in  pure  culture 
in  eight,  with  the  streptococcus  pyogenes  in  one,  and 
with  the  bacillus  mucosus  capsulatus  in  one.  In  the 
thirteen  cases  of  secondary  croupous  pneumonia  the 
pneumococcus  occurred  alone  in  six  cases,  the  strepto- 
coccus pyogenes  alone  in  two  cases,  streptococcus  pyo- 
genes and  staphylococcus  aureus  in  two  cases,  strepto- 
coccus pyogenes  and  bacillus  mucosus  capsulatus  in 
one  case,  streptococcus  pyogenes  and  bacillus  coli  in 
one  case,  and  bacillus  mucosus  capsulatus  in  one  case 
in  pure  culture.  Thus  the  pneumococcus  occurred 
alone  in  nearly  fifty  per  cent,  of  the  secondary  croup- 
ous pneumonias,  while  the  streptococcus  was  concerned 
in  the  etiology  of  the  same  number,  but  occurred  alone 
in  only  two  cases.  In  all  thirteen  cases  the  pneu- 
monic process  was  clearly  secondary  and  often  acci- 
dental.—  Cki  eland  Journal  of  Medicine,  September, 
1900. 

Pneumatocele  of  the  Auditory  Canal. — A  case  of 
this  nature  is  reported  by  M.  Lannois.  His  patient 
was  a  man  of  twenty-four  who  played  in  the  orchestra 
of  a  theatre.  Six  days  before  while  playing  he  had 
been  attacked  with  a  sudden  deafness  of  the  left  ear. 
Examination  showed  in  the  corresponding  auditory 
canal,  one  centimetre  from  the  entrance,  a  large  pearly- 
'  looking  swelling  slightly  ulcerated  at  one  point.  A 
probe  was  passed  by  the  mass  which  was  easily  com- 
pressible. On  incision  with  a  paracentesis  needle, 
the  swelling  entirely  disappeared,  and  the  patient  heard 
with  about  the  usual  facility.  The  accident  hap- 
pened several  times,  and  finally  Lannois  curetted  the 
portion  of  the  bony  wall  over  which  the  swelling 
seemed  to  form.  This  led  to  a  complete  cessation  of 
the  annoying  repetitions  of  the  accident. — Revue 
Hebdomadaire  de  Laryngologie,  August  18,  1900. 

Rapidly  Progressive  Anaemia — H.  W.  Syers  re- 
ports a  rapidly  fatal  case  in  a  woman  of  thirty-four 
years.  The  etiology  is  altogether  obscure.  The 
whole  duration  of  the  illness  was  exactly  two  months, 
and  in  this  short  period  the  patient  passed  from  a  con- 
dition of  apparently  vigorous  health  through  rapid 
phases  of  increasing  weakness,  until  death  ended  the 
scene.  No  remission,  no  arrest  of  symptoms  occurred 
at  any  period  of  the  malady)  which  was  one  swift  de- 
scent to  the  fatal  end.  The  author  says  that  if  we 
are  ever  to  arrive  at  a  real  knowledge  of  the  pathology 
of  cases  such  as  the  one  here  recorded,  it  can  only  be 
by  the  methodical  investigation  of  the  blood  in  every 
case  of  disease.  When  this  knowledge  is  acquired, 
we  may  perhaps  be  able  to  explain  the  occurrence  of 
such  peculiarities  as  apparent  pericardial  friction 
sounds,  and  the  tendency  to  hemorrhages,  cutaneous 
and  other,  which  so  strongly  characterize  acute  blood 
changes. —  Treatment,  September,  1900. 

Hysterical  Ankle  Clonus. — Angel  Money  says  that 
the  great  characteristic  of  pure  hysterical  paraplegia 
is  the  remarkable  proneness  of  the  phenomenon  to 
vary  from  hour  to  hour  in  harmony  with  emotional 
and  nervous  excitement.  One  day  tlie  phenomenon 
may  be  elicited  with  the  greatest  ease  and  may  persist 
for   many   minutes;    the   next   day  only  a   few  feeble 


jerks  may  be  obtained.  All  degrees  of  intensity  and 
duration  between  these  two  extremes  maybe  observed. 
Some  clinical  investigators  regard  an  ankle  clonus 
lasting  for  five  seconds  as  a  sure  sign  of  organic  im- 
plication of  the  pyramidal  tracts.  The  author  thinks 
this  absolutely  inaccurate.  His  opinion  is,  that  if  an 
ankle  clonus  of  unvarying  intensity,  obtained  by  pas- 
sive dorsal  flexion,  lasts  thirty  seconds,  and  can  be 
got  at  any  hour  of  the  day  and  night  over  a  period  of 
seven  days,  the  presence  of  organic  disease  of  the 
pyramidal  tracts  may  be  diagnosed  with  certainty. 
To  prove  the  presence  of  organic  disease,  the  clonus 
must  be  easily  obtained,  must  be  strong,  and  must  last 
thirty  seconds.  Moreover,  it  must  be  obtained  at 
every  attempt  over  a  period  of  at  least  a  week.. —  TIte 
Australasian  Medical  Gazette,  August  20,  1900. 

Researches  into  the  Toxic  Properties  of  Maize 
Corn  Infected  by  the  "  Penicillium  Glaucum." — 
Enrico  Ferrati  in  his  experiments  on  dogs  and  rats 
finds  that  corn  infected  with  hyphomycetes  is  poison- 
ous, causing  general  weakness,  rigidity  of  the  trunk 
and  hind  legs,  dysphagia,  diarrhcea  with  bloody  stools, 
convulsions,  and  death.  Schizomycetes  undoubtedly 
may  produce  poisonous  substances  in  corn,  but  the 
author  believes  the  penicillium  glaucum  to  be  the 
chief  agent  as  a  rule.  The  hyphomycetes  develop 
under  conditions  in  which  the  schizomycetes  cannot  do 
so,  and  moreover,  the  latter  so  affect  the  corn  as  to 
cause  an  odor  which  prevents  its  use  as  food. — H 
Policlinico,  September  i,  1900. 

Prophylaxis  of  Surgical  Shock. — \\'.  M.  Perkins 
states  that  the  importance  of  perfecting  the  prophy- 
laxis of  shock  is  now  attracting  more  general  attention. 
Among  the  widely  difl^erent  causes  to  which  shock  has 
been  attributed  are  molecular  vibration,  cerebral  anae- 
mia, cardiac  failure,  passive  abdominal  hyperaemia, 
general  vasomotor  paresis,  and  reflex  inhibition. 
Briefly,  shock  seems  to  consist  essentially  of  a  central 
nerve  depression  due  to  the  exhaustion  induced  by 
long-continued  or  violent  stimulation,  and  manif«sting 
itself  in  symptoms  referable  to  three  main  causes, 
viz.:  (i)  a  vasomotor  paralysis;  (2)  a  respiratory 
paralysis;  (3)  a  cardiac  paralysis.  Crile  lias  espe- 
cially insisted  upon  the  dilTerence  between  collapse 
and  shock.  Inhibition  is  probably  the  most  potent 
factor  in  collapse,  while  in  shock  exhaustion  plays  the 
more  important  part.  Surgical  shock  may  be  greatly 
diminished  by  careful  pre-operative  prophylaxis.  All 
fatigue,  both  mental  and  physical,  should  be  avoided. 
When  practicable,  the  linal  purgative  should  be  given 
at  least  twenty-four  hours  prior  to  operation.  The 
patient  should  remain  in  bed  twelve  hours  previous  to 
operation.  Restful  and  abundant  sleep  should  be 
taken.  Nutrition  should  be  promoted  by  several  days 
of  well-planned  wholesome  feeding.  Gentle  flushing 
of  the  kidneys  is  another  factor,  as  are  baths  and 
friction  of  the  skin.  Loose  clothing  and  an  abundant 
supply  of  fresh  air  must  be  urged  during  the  last  few 
days.  The  question  of  ani'sthesia  will  demand  care- 
ful consideration.  Ether  is  preferable  to  chlorofoim 
as  a  general  an.X'sthetic  in  the  absence  of  any  contra- 
indication. A  liypodermic  of  morphine  sulphate  ^{ 
gr.,  with  atropine  sulphate  |-l,f  to  -^'i-i  gr.,  to  which  may 
be  added  strychnine  sulphate  -^'i,  gr.,  is  well  given 
about  twenty  minutes  before  starting  the  ana-sthetic. 
After  the  anaesthetic  has  been  given  there  may  occur 
conditions  demanding  the  administration  of  ammonia, 
amyl  nitrite,  or  saline  infusion;  inversion  of  the  pa- 
tient may  be  indicated  in  threatened  respiratory  fail- 
ure. Speed  is  an  essential  to  successful  operation. 
The  proper  temperature  of  tiie  room,  the  patient,  and 
the  solution  should  never  be  forgotten. — Nni'  Orleans 
Atedical  and  Surgical  Journal,  October,  1900. 


October  27,  1900] 


MEDICAL    RECORD. 


657 


Medical  Record: 

A    Weekly  Journal  of  Medicine  and  Surgery. 


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

I'lBLlSHERS 

WM.  WOOD  &  CO,,  51    Fifth  Avenue. 
New  York,  October  27,  1900. 

THE    DIAGNOSIS  AND   TRE.\TMENT    OF 

ANAEMIA. 

The  scientific  mind  must  be  ever  an  open  one,  with- 
out prejudice  or  prepossession,  alive  to  every  new  in- 
crement of  knowledge,  yet  not  too  ready  to  surrender 
the  old,  in  order  that  on  the  one  hand  secure  ground 
shall  not  be  given  up  and  that  on  the  other  theories 
and  hypotheses  that  have  outlived  their  usefulness  may 
be  replaced  by  new  and  better  ones,  and  their  appli- 
cation and  practice  yield  larger  and  more  successful 
results.  The  time  happily  is  passing  when  a  sharp 
demarcation  can  be  made  between  the  scientific  and 
the  practical,  as  it  has  been  amply  demonstrated  that 
no  scientific  observation  is  without  practical  potential- 
ity, although  this  relation  may  not  at  the  time  be  evi- 
dent. Inasmuch  as  language  is  employed  to  express 
ideas,  it  can  be  understood  how  erroneous  conceptions 
maybe  perpetuated  through  a  faulty  nomenclature  and 
progress  be  thus  intercepted.  In  this  way  some  con- 
iusion  has  arisen  from  the  use  of  such  qualifying  terms 
as  idiopathic,  essential,  primary,  etc.,  and  for  purposes 
of  clearness  it  were  perhaps  well  if  their  employment 
were  abandoned.  Disease  is  at  best  a  most  complicated 
process,  of  complex  etiology,  and  it  is  not  surprising 
that  at  times  all  of  the  causative  factors  and  their  mode 
of  operation  do  not  fall  within  the  range  of  observation ; 
but  for  this  reason  it  must  not  be  assumed  that  they 
do  not  exist  or  are  beyond  the  limits  of  recognition. 
The  force  of  some  of  the  foregoing  considerations  is 
illustrated  in  a  communication  by  Senator  (^Berliner 
klinische  Wochenschrijt,  1900,  No.  30,  p.  653)  dealing 
witli  the  recognition  and  the  treatment  of  the  several 
varieties  of  anaemia.  The  designation  ansemia,  he 
points  out,  is  employed  when  the  condition  of  blood- 
depravity  is,  if  not  the  only,  at  least  the  most  promi- 
nent symptom.  It  may  develop  without  obvious  or 
ascertainable  cause,  as  well  as  result  from  most  obtru- 
sive influences.  It  has,  however,  been  found  that  a 
sharp  discrimination  between  the  two  sets  of  cases 
cannot  be  made,  inasmuch  as,  once  established,  the 
disease  may  persist,  in  spite  of  removal  of  its  exciting 
agency;  and  it  seems  probable  that,  after  all,  the  in- 
fluences acting  injuriously  on  the  blood  are  of  extrinsic 
origin. 

As  tuberculosis  maybe  early  attended  with  anjemia, 
and  carcinoma  of  the  abdominal  organs  or  of  the  bones 
may  give  rise  to  the  same  condition  and  be  difficult  of 
detection,  these   should   always  be  thought  of  when 


other  causative  factors  are  not  evident.  In  any  event, 
macroscopic  and  microscopic  examination  of  the 
stools,  especially  for  ova  and  blood,  should  never  be 
omitted.  In  all  cases  of  profound  anxmia,  further, 
microscopic  examination  of  the  blood  should  be  un- 
dertaken for  the  detection  of  changes  in  the  corpus- 
cular elements  and  of  the  presence  of  parasites,  as  for 
instance,  the  plasmodium  of  malaria,  filaria  sanguinis 
hominis,  distoma  haematobium.  Finally,  a  study 
should  be  made  of  the  motor  and  chemical  functions 
of  the  stomach,  as  deficiency  in  these  may  give  rise  to 
anjemia.  A  proper  appreciation  of  the  relations  be- 
tween the  two  conditions  maybe  difficult  when  anxmia 
is  associated  with  the  presence  of  some  disease  that 
may  give  rise  to  it,  such  as  carcinoma  of  the  stomach 
or  carcinoma  or  other  malignant  disease  of  bone  or  the 
bone-marrow.  The  latter  are  sometimes  characterized 
by  pronounced  albumosuria. 

Chlorosis  has  been  attributed  to  auto-infection  from 
the  gastro-intestinal  tract,  and  also  from  the  ovaries. 
Upon  this  condition  iron  acts  almost  like  a  specific,  but 
when  gastric  derangement  exists  hydrochloric  acid 
should  be  administered.  Sometimes  the  waters  from 
alkaline-chlorine  springs  are  serviceable,  followed  by 
steel  waters  or  saline  iron  waters.  Of  pharmaceutical 
preparations  of  iron,  combinations  with  organic  acids 
(lactic,  citric,  acetic)  are  to  be  preferred,  although 
tincture  of  the  chloride  and  pills  containing  the  sul- 
phate are  useful.  In  cases  in  which  iron  fails  to  be 
of  service,  arsenic  may  be  given  alone  or  together  with 
iron  or  with  quinine.  In  recent  years  venesection  and 
sweating  have  been  in  some  instances  employed  in 
the  treatment  of  anaemia.  The  latter  should  be  in- 
duced by  means  of  baths  with  water,  sand,  or  air.  It 
is  possible  that  the  good  effects  attributed  to  bleeding 
are  due  in  part  to  the  associated  sweating. 

Among  the  distinctive  features  of  pernicious  anaemia 
is  the  presence  of  myeloblasts  and  of  large,  motile 
erythrocytes,  the  motility  of  the  latter  being  espe- 
cially characteristic.  In  addition,  there  occur  poikilo- 
cytosis,  the  presence  of  normoblasts,  of  basophile 
granules  in  the  erythrocytes,  glycogenic  degeneration 
(the  presence  of  iodophile  material)  in  the  leucocytes, 
and  a  disproportionately  high  percentage  of  haemoglo- 
bin. The  waxy  yellow  color  of  the  skin  is  peculiar, 
and  the  subcutaneous  fat  may  be  preserved.  Sternal 
tenderness  is  rarely  wanting,  while  retinal  hemorrhage 
is  common  and  symptoms  of  spinal  disease  may  be  pres- 
ent. Although  complete  recovery  cannot  be  looked 
for  in  cases  of  pernicious  anaemia,  marked  improve- 
ment often  follows  the  administration  of  arsenic,  to- 
gether with  quinine  in  large  doses,  in  conjunction  with 
appropriate  hygienic  and  dietetic  measures.  Prepara- 
tions of  bone-marrow  and  inhalations  of  oxygen  are 
also  worthy  of  trial. 

The  anaemia  that  develops  after  sudden  ascent  to  a 
high  elevation  is  to  be  attributed  to  the  attenuation  of 
the  oxygen  of  the  air,  and  consequently  of  the  blood, 
and  hence  is  really  an  anoxyheemia.  The  number  of 
red  blood  corpuscles  undergoes  increase,  in  which  the 
haemoglobin  fails  to  take  corresponding  part,  so  that 
a  disproportion  between  the  two  results.  This  may 
gradually  disappear  in  time,  but  its  results  are  best 


6=;  8 


MEDICAL    RECORD. 


[October  27,  1900 


averted  by  change  of  residence  to  a  lower  level,  with 
recumbency  in  the  horizontal  position,  and  the  admin- 
istration of  stimulants.  Inhalations  of  oxygen  or  of 
compressed  air  might  also  be  useful. 


AMPUTATION    AT   THE    KXEE   JOINT. 

There  are  several  methods  of  performing  amputa- 
tion at  or  near  the  knee  joint  which  are  well  thought 
of  and  usually  mentioned  in  te.xt-books.  but  their  sev- 
eral advantages  and  disadvantages  do  not  always  re- 
ceive the  attention  to  w-hich  they  are  perhaps  entitled. 
In  the  region  of  the  knee,  as  elsewhere  in  the  body, 
amputations  are  done  for  injury  or  disease.  In  the 
case  of  injury,  the  general  principle,  that  as  little 
tissue  should  be  sacrificed  as  is  consistent  with  the 
formation  of  a  serviceable  stump,  holds  as  elsewhere 
in  the  body,  so  that  under  such  circumstances  we  are 
often  not  able  to  carry  out  a  set  operation  when  we 
are  dealing  with  an  injury  which  requires  amputation. 
The  region  of  the  knee  presents  some  anatomical 
characteristics  which  from  the  operative  point  of  view 
make  it  different  in  many  respects  from  other  parts  of 
the  body.  The  ends  of  the  bones  forming  the  joint 
are  comparatively  very  large,  and  the  skin  and  sub- 
cutaneous tissue  are  both  comparatively  and  absolutely 
thin,  and  in  addition  the  largest  joint  in  the  body  is 
to  be  dealt  with.  There  are  in  general  two  ways  in 
which  amputations  in  the  immediate  region  of  the 
knee  joint  are  done — first,  directly  through  the  joint, 
and,  second,  through  the  lower  end  of  the  femur  with 
the  bone  section  at  or  somewhere  below  a  point  just 
above  the  condyles.  The  latter  method,  while  sacrific- 
ing a  little  more  tissue  than  the  method  of  cutting 
through  the  joint,  has  some  points  in  its  favor.  In 
operating  through  the  joint,  the  so-called  Stephen 
Smith  method  is  almost  always  chosen,  sometimes 
with  modifications,  but  always  involving  the  formation 
of  a  long,  sleeve-like  skin  flap  disposed  so  that  at  the 
end  of  favorable  healing  the  cicatrix  is  placed  pos- 
teriorly in  and  above  the  intercondyloid  notch.  The 
patella  may  or  may  not  be  left  in  place,  and  it  will 
often  be  found  advisable  to  leave  the  semilunar  carti- 
lages also,  though  there  is  some  danger  of  their  necrosis. 
This  operation  has  given  many  good  stumps,  but  there 
are  several  objections  to  it.  If  the  patient  has  athe- 
romatous arteries  there  is  serious  danger  of  more  or 
less  extensive  sloughing  of  the  long  flaps,  and  a  col- 
lection of  very  little  blood  between  the  articular  sur- 
faces of  the  femur  and  the  flaps,  even  in  those  with 
healthy  arteries,  causes  much  more  serious  interfer- 
ence with  healing  than  the  same  state  of  affairs  when 
two  surfaces  of  vascular  soft  parts  are  apposed.  Union 
between  the  articular  surfaces  and  the  subcutaneous 
tissue  of  the  flap  is  never  so  prompt  as  to  be  called 
ir\Ay  per  prima  III ;  in  fact,  it  is  probable  that  true  granu- 
lation must  begin  on  the  cartilaginous  surfaces  before 
union  can  occur.  When  the  patella  is  left  in  place 
and  healing  is  prompt  the  resulting  stump  is  very 
good.  The  chief  drawback  to  this  operation  is  the 
employment  of  the  very  long  skin  flaps,  which  on  slight 
provocation  show  evidences  of  more  or  less  serious 


interference  with  blood  supply,  which  may  result  in 
necrosis  and  the  necessity  of  reamputation.  The 
operation  named  after  Gritti,  and  its  modifications, 
eliminate  some  of  these  objections  by  the  removal  of 
the  lower  end  of  the  femur  and  the  posterior  surface 
of  the  patella,  so  tiiat,  when  the  resulting  surfaces  are 
placed  in  apposition,  we  are  able  to  use  a  shorter  skin 
flap  and  one  with  a  better  blood  supply,  without  any 
important  decrease  in  the  length  of  the  stump.  The 
flaps  are  both  actually  and  proportionately  shorter  than 
in  the  first  operation,  because  the  removal  of  part  of 
the  large  end  of  the  femur  enables  us  to  get  good 
covering  for  the  bone  with  much  less  tissue  than  we 
should  otherwise  need.  From  the  Gritti  operation  the 
resulting  stump  is  excellent,  and  the  dread  of  sacrific- 
ing a  little  more  tissue  should  not  deter  us  from  doing 
the  operation,  when  we  are  enabled  thus  to  secure 
greater  safety  from  the  dangers  of  tension  or  imper- 
fect blood  supply  in  the  skin. 


VENTILATION    AT   THE  ACADEMY. 

The  season's  work  is  about  to  open  in  all  its  activity 
at  the  Academy  of  Medicine,  with  every  prospect  of 
success  and  interest  we  hope,  but  there  is  one  point 
of  which  we  should  like  to  speak,  though  it  seems  al- 
most an  act  of  temerity  to  do  so  in  connection  with  a 
temple  partially  devoted  to  the  worship  of  Hygeia. 
The  ventilation  in  the  academy  building,  in  the  main 
hall,  in  the  library,  and  in  the  section  rooms  is  noth- 
ing less  than  abominable.  After  a  meeting  has  been 
in  session  an  hour,  especially  in  the  sections,  the  air 
becomes  so  foul  that  it  is  impossible  to  take  a  great 
amount  of  interest  in  the  proceedings,  and  many  be- 
come somnolent  or  seek  relief  in  flight.  Opening  of 
windows  gives  some  relief,  but  this  is  usually  objected 
to  by  those  who,  from  exigencies  of  space  or  for  other 
reasons,  sit  near  those  openings.  This  matter  is  one 
which  it  ought  not  to  be  difficult  to  correct,  and  it 
seems  almost  an  absurd  anomaly  that  it  should  exist, 
but  that  it  does  exist  will  be  made  evident  to  any  one 
who  will  sit  through  a  moderately  crowded  section 
meeting,  or  attend  one  of  the  meetings  in  the  main 
hall. 


fleius  of  the  ^leck. 

A  <' Bunco"  Game  on  Doctors. — A  correspondent 
writes:  "I  desire  your  assistance  in  the  apprehension 
of  the  persons  who  are  working  a  very  sharp  and 
dangerous  'bunco'  game,  and  in  protecting  other 
members  of  the  profession  from  the  misfortune  which 
I  have  suffered.  The  game  is  worked  through  the 
pretended  sale  of  goods  from  the  Onialia  Exposition, 
and  is  begun  by  a  circular  offering  most  attractive 
articles  at  absurdly  low  prices.  The  fraud  is  consum- 
mated by  the  sale  of  dress-goods  for  about  twice  their 
value,  with  an  agreement  to  make  them  into  suits  for  a 
nominal  price  as  an  advertisement  for  the  tailor,  who, 
however,  never  appears.  If  any  one  of  your  readers 
who  sees  this,  and  has  reached  the  circular  stage  of  the 


October  27,  1900] 


MEDICAL    RECORD. 


659 


game,  will  communicate  with  me  tiirough  you,  I  shall  matic  conditions  are  superior  to  those  of  Lake  Clear, 
be  happy  to  join  with  him  in  a  scheme  to  capture  The  prison  consumptives  are  all  sent  to  Dannemora, 
these  rascals  and    bring  them  to  a    merited    punish-      and  the  percentage  of  consumptive  deaths  there  is  less 


ment." 

The  Will  of  the  Late  Dr.  Alfred  Still6  bequeaths 
to  the  College  of  Physicians  of  I'hiladelphia  all  such 
of  his  medical  books  as  are  not  contained  in  the  library 
of  the  college;  a  full  set  of  his  own  works;  his  manu- 
script indexes  of  pathology  and  therapeutics  in  nine 
volumes;  his  copy  by  Leslie  of  Sir  Joshua  Reynolds' 
portrait  of  John  Hunter;  his  copy  text  and  plates  of 
Audubon's  "  Quadrupeds  '' ;  all  of  the  medical  works  of 
which  he  was  either  author  or  editor,  viz.,  "General 
Pathology,"  "Andral  on  the  Blood,"  "Therapeutics 
and  Materia  Medica,"  four  editions,  each  in  two  vol- 
umes; the  "National  Dispensatory,"  four  editions; 
"  Cerebro-Spinal  Meningitis,"  "  Cholera,"  the  (pirated) 
edition  or  report  of  his  University  lectures;  Wharton 
and  Stille's  "Medical  Jurisprudence,"  three  editions; 
and  whatever  other  medical  works  still  remain  in  his 
library,  first  and  second  editions,  and  all  the  current 
medical  journals  possessed  by  him  at  the  time  of  his 
death,  as  we.ll  as  a  number  of  dictionaries.  To  the 
.Stillc  Medical  Society  of  the  University  of  Pennsyl- 
vania are  bequeathed  all  of  the  photographs  of  the 
society  in  his  profession. 

The  State  Sanatorium  for  Consumptives — Consid- 
erable opposition  lias  developed  against  the  selection 
of  the  ]!ig  Lake  Clear  site  for  this  institution.  The 
site  was  selected  by  the  hospital  trustees,  comprising 
Howard  Townsend,  of  New  Vork  City,  Dr.  J.  H. 
Pryor,  of  Liuffalo,  Frank  E.  Kendall,  of  Saranac,  Dr. 
Willis  G.  MacDonald,  of  Albany,  and  Walter  E.  Jen- 
nings, of  New  Vork  City.  The  law  requires  the  estab- 
lishment of  the  site  in  tlie  Adirondacks,  and  that  the 
selection  of  such  a  site  by  the  trustees  must  be  ap- 
proved by  the  State  forest  preserve  board  and  tlie 
State  board  of  healtli.  These  two  boards  held  a  meet- 
ing a  few  days  ago  at  .\lbany  to  listen  to  arguments 
why  the  selection  of  the  Lake  Clear  site  should  not  be 
approved  by  them.  There  were  many  persons  at  the 
hearing  from  Clinton  county  who  want  the  sanatorium 
located  in  Dannemora.  As  the  two  boards  can  only 
approve  a  site  selected  by  the  trustees,  a  resolution 
was  adopted  requesting  the  trustees  to  make  a  further 
investigation  of  the  Dannemora  site  and  compare  its 
climatic  and  other  advantages  with  those  of  Big  Lake 
Clear.  Many  persons  who  own  camps  in  the  Adiron- 
dacks insisted  that  the  hospital  should  not  be  built  on 
Lake  Clear,  as  they  held  it  would  be  contrary  to  pub- 
lic policy  to  locate  such  a  charity  in  a  region  thronged 
with  pleasure  seekers,  where  the  inmates  of  the  hospi- 
tal must  either  be  subjected  to  unnecessary  and  unde- 
sirable restraint  or  permitted  to  range  over  the  coun- 
try, and  come  in  frequent  contact  on  the  roads  and 
lakes,  if  not  also  in  the  hotels  and  camps,  with  crowds 
of  summer  visitors.  Dr.  Ransom,  who  has  been  the 
prison  physician  at  Clinton  prison,  Dannemora,  for 
the  past  twelve  years,  made  the  principal  argument  in 
favor  of  the  Dannemora  site.  He  said  that  this  is  on 
the  dryest  slope  of  the  Adirondack  range,  and  its  cli- 


than  in  the  Lake  Clear  and  Saranac  regions. 

Koch  on  Malaria. — According  to  the  newspapers 
Dr.  Robert  Koch,  who  was  recently  in  Hong  Kong  on 
his  way  to  Euroije  from  Batavia,  announces  that  he  has 
conquered  malaria,  having  discovered  means  of  pre- 
venting the  spread  of  the  disease  in  malarious  dis- 
tricts and  even  of  stamping  it  out  completely.  He 
also  says  he  has  prepared  a  remedy  which  is  both 
curative  and  prophylactic.  The  latter  will  probably 
be  put  upon  the  market  as  soon  as  the  eminent  profes- 
sor can  make  satisfactory  arrangements  with  some 
German  chemical  house  of  good  financial  standing. 
He  also  declares  that  he  has  found  a  certain  method 
of  ridding  a  country  of  the  malarial  mosquito. 
Whether  or  not  this  is  merely  the  prelude  to  another 
fiasco  of  the  nature  of  Koch's  tuberculin  announce- 
ment time  will  show.  In  the  mean  while,  concerning 
his  scientific  honesty,  the  New  York  Tiiius  says:  "As 
might  have  been  expected  from  the  previous  course  ot 
Dr.  Robert  Koch,  there  is  not  award  in  the  announce- 
ment of  his  successful  investigation  of  the  cause  and 
cure  of  malaria  to  indicate  that  he  is  not  alone  in  this 
field  of  study,  or  to  hint  that  he  has  simply  been  fol- 
lowing a  line  carefully  marked  out  long  ago  by  other 
scientists  and  since  developed  by  them  with  an  indus- 
try and  ability  at  least  equal  to  his  own.  This  is  not 
to  say  that  the  Berlin  bacteriologist  is  either  indus- 
trious or  able;  he  is  both  to  a  high  degree;  but  his 
reputation — out  of  Germany,  at  any  rate — is  that  of  a 
man  not  less  businesslike  than  scientific,  and  he  has 
been  charged  before  now  with  a  somewhat  unprofes- 
sional tendency  to  monopolize  glory  and  profits  in  a 
way  not  quite  co.mpatible  with  delicacy  of  sentiment. 
His  recent  labors  in  China  have  apparently  brought 
nearer  to  the  point  of  actual  demonstration  the  theory 
that  malaria  and  mosquitos  are  closely  related,  but 
that  is  not  his  theory,  except  by  adoption,  and  he 
migiit  well  say  more  than  he  does  about  the  English 
surgeon  stationed  in  India  who  originated  it,  and 
about  the  men  of  the  same  and  other  nationalities  who 
have  done  so  much  to  lend  it  credibility." 

Philadelphia  Pediatric  Society. — At  a  stated  meet- 
ing hekl  October  9th,  Dr.  W.  ().  Xander  read  a  report 
of  two  cases  of  infectious  nephritis  in  children.  The 
patients  were  cousins  residing  in  the  same  house,  who 
became  ill  consecutively,  following  some  disorder  at- 
tended with  swelling  of  the  neck,  and  which  might 
have  been  glandular  fever,  mumps,  or  scarlet  fever. 
Other  cases  of  mumps  had  been  observed  in  the  neigh- 
borhood. Dr.  Thompson  S.  Westcott  described  a 
method  for  the  differential  modification  of  the  proteids 
of  milk  in  percentage  mixtures.  Drs.  Haniill  and 
MacLachlin  presented  a  case  of  congenital  syphilis 
with  rapidly  destructive  lesion.  In  addition  to  a 
vascular  nai^vus  on  the  right  side  of  the  face  and  also 
one  in  the  right  scapular  region,  the  patient,  an  in- 
fant three  weeks  old,  presented  ulceration  of  the 
right  half  of  tlie  upper  lig  and  at  the  inner  canthus  of 


66o 


MEDICAL    RECORD. 


[October  27,  1900 


the  right  eye,  together  with  lesions  of  the  palate  on 
the  right  side.  From  the  distribution  of  the  lesions, 
it  was  pointed  out,  the  case  was  suggestive  of  a  tro- 
phoneurosis rather  than  of  syphilis.  A  report  was 
presented  by  the  milk  commission  of  the  society,  giv- 
ing the  results  of  examinations  of  dairies  and  milk 
for  producers  who  have  signed  contracts  witli  the  com- 
mission, with  an  announcement  of  those  whose  milk 
has  come  up  to  the  required  standards.  Two  dealers 
have  complied  with  all  of  the  conditions,  and  others 
give  evidence  of  striving  to  attain  them.  The  re- 
quirements refer  to  the  proportion  of  cream  and  the 
chemical  constitution,  and  also  to  the  relative  bacterial 
purity  of  the  milk.  Dr.  Maurice  Ostheimer  reported 
a  case  of  fatal  intestinal  hemorrhage  of  unknown 
origin  in  an  infant  aged  five  months.  Careful  exami- 
nation after  death  failed  to  disclose  any  cause  for  the 
hemorrhage  which  occurred  in  the  marantic  child,  and 
in  whose  body  no  sign  of  tuberculosis  or  syphilis  was 
found.  It  was  suggested  that  the  case  might  be  an 
anomalous  one  of  hoeniophilia.  Dr.  John  H.  Jopson 
reported  a  case  of  stricture  of  the  pharynx  following 
intubation.  The  patient  was  a  boy  from  whom  the 
tube  could  not  be  removed  until  after  the  forty-first 
day.  Symptoms  of  laryngeal  obstruction  developed 
several  months  subsequently,  necessitating  trache- 
otomy, but  death  resulted  from  pneumonia  compli- 
cating an  intercurrent  attack  of  measles.  Post-mor- 
tem examination  disclosed  cicatricial  stricture  of  the 
larynx. 

The  Smoke  Nuisance. — ^The  following  remarks  of 
Sir  William  Richmond,  quoted  in  The  Lancet,  are  of 
interest  to  New  Yorkers,  who  are  now  threatened  with 
the  evil  of  bituminous  coal  smoke:  "It  is  cheaper  to 
consume  smoke  than  to  allow  it  to  pass  intathe  at- 
mosphere. Smoke  is  wasted  fuel.  At  a  comparative- 
ly small  cost  all  factories,  electric-lighting  stations, 
etc.,  can  be  provided  with  smoke-consuming  ap- 
paratus. This  being  the  case  the  public  has  only 
to  demand  a  clear  atmosphere — anyhow  as  far  as  the 
smoke  from  factories,  steamers,  and  railway  engines  is 
concerned — and  they  will  get  it.  The  vestries  and 
the  L.  C.  C.  do  not  enforce  the  law  against  smoke 
partly  on  account  of  apathy,  but  chiefly  because  in 
those  bodies  there  are  many  smoke-makers,  or  friends 
of  such."  We  trust  the  apparent  immunity  enjoyed 
by  certain  offenders  in  this  city — notably  several  large 
hotels — -is  not  due  to  apathy  or  the  other  thing  of  the 
health  authorities. 

Philadelphia  County  Medical  Society.  —  At  a 
stated  meeting  held  October  loth,  Dr.  William  Camp- 
bell Posey  read  a  paper  entitled  ''The  Successful  Re- 
moval of  Cataracts  in  Insane  Subjects,  with  Recovery 
of  Mind  Attending  the  Restoration  of  Sight."  Dr. 
Lambert  Ott  presented  a  paper  entitled  "Clinical 
Laws  of  Immunity  to  Disease,"  citing  numerous  in- 
stances illustrating  apparent  antagonisms  between,  and 
susceptibilities  induced  by,  various  infectious  dis- 
eases. Dr.  F.  Savary  Pearce  made  a  communication 
entitled  "Heart  Disease  or  Epilepsy,"  in  which  he 
pointed  out  the  difficulty  sometimes  encountered  in 
reaching  a  decision  as  to  the  nature  of  perversion  or 


loss  of  consciousness.  Dr.  Ernest  Laplace  exhibited 
a  new  aseptic  ether  and  chloroform  inhaler,  consisting 
of  a  hemiovoidal  receptacle  with  a  crucial  opening  and 
containing  sterile  gauze  held  in  place  by  a  strip  of 
wire  gauze  of  similar  form.  The  advantages  claimed 
for  the  apparatus  are  its  readiness  of  sterilization  and 
its  simplicity  of  manipulation  and  preparation. 

Petition    for    a    Municipal    Hospital The   City 

Council  of  Camden,  N.  J.,  having  failed  to  comply 
with  the  request  of  the  board  of  health  for  the  estab- 
lishment of  a  municipal  hospital,  the  medical  profes- 
sion of  that  city  has  presented  a  petition  renewing  the 
request  and  pointing  out  the  urgent  need  of  such  an 
institution. 

The  Health  of  the  Navy  in  the  Philippines. — In 
his  annual  report  to  the  secretary  of  the  navy,  Surgeon- 
General  Van  Reypen  says  that,  considering  the  climatic 
conditions  and  the  necessary  exposure,  the  health  of 
the  squadron  on  the  Philippine  station  has  been  remark- 
ably good.  It  has  been  and  still  is  the  practice  to 
send  officers  and  men  who  are  suffering  from  debilitat- 
ing climatic  conditions  to  the  naval  hospital  at  Yoko- 
hama, where,  as  a  rule,  they  soon  recover  and  return 
to  their  stations  for  duty. 

Philadelphia  Hospital. — In  accordance  with  reso- 
lutions adopted  by  the  bureau  of  charities,  the  clini- 
cal teaching  at  the  Philadelphia  Hospital  is  to  be  am- 
plified. In  addition  to  a  continuation  of  the  regular 
lectures  on  Wednesdays  and  Saturdays,  ward  classes 
not  exceeding  ten  are  to  be  encouraged ;  surgical  and 
gynaecological  operations  are  to  be  opened  to  students 
under  proper  restrictions;  clinical  instruction  in  in- 
sanity is  to  be  made  a  new  feature,  and  instruction  in 
the  specialties  and  in  pathology  is  to  be  permitted. 
Dr.  Joseph  McFarland  and  Dr.  Simon  Flexner  have 
been  elected  additional  pathologists. 

The  Medical  Society  of  Virginia. — The  thirty-first 
annual  meeting  of  this  society  was  held  at  Charlottes- 
ville on  Tuesday,  Wednesday,  and  Thursday,  October 
23d,  24th,  and  25th.  The  president  was  Dr.  Hugh 
T.  Nelson,  of  Charlottesville,  the  recording  secretary 
Dr.  Landon  B.  Edwards,  of  Richmond,  and  the  cor- 
responding secretary  Dr.  J.  F.  Winn,  of  Richmond. 
The  chairman  of  the  committee  of  arrangements  was 
Dr.  J.  Hamilton  Browning,  of  Charlottesville.  The 
subject  for  general  discussion  at  the  Wednesday  morn- 
ing session  was  malaria,  the  leader  of  the  discussion 
being  Dr.  H.  Stuart  MacLean,  of  Richmond. 

Typhoid  Fever  in  a  Brooklyn  School. — The  occur- 
rence of  many  cases  of  typhoid  fever  among  the  in- 
mates of  the  Boys'  Disciplinary  School  in  Brooklyn, 
has  brought  to  light  an  insanitary  condition  that  would 
have  been  thought  impossible  under  an  efficient  board 
of  health.  Ten  cases  of  the  disease  were  reported  on 
Monday,  and  the  inspector  of  contagious  diseases 
found  everything  most  favorable  for  an  epidemic  out- 
break. The  boys'  dormitory  was  found  to  be  without 
adequate  ventilation,  the  beds  were  crowded  so  closely 
together  that  there  was  barely  room  to  walk  between 
them,  and  in  place  of  a  ceiling,  which  was  recently 


October  27,  1900] 


MEDICAL    RECORD. 


661 


destroyed  by  fire,  there  was  only  a  rough  open  plank- 
ing. Directly  behind  the  school  was  an  open  ditch, 
said  to  communicate  with  the  sewer.  This  was  in  a 
frightful  condition  and  during  the  day  the  sun  would 
beat  down  upon  the  filth,  flies  feast  upon  it  and  from 
it  fly  into  the  kitchen  where  the  food  for  the  boys  is 
prepared.  The  back  yard  was  literally  honeycombed 
with  old  cesspools  that  were  not  properly  cleaned. 

Dr.  William  B.  Savage,  of  East  Islip,  N.  Y..  was 
appointed  consulting  surgeon  to  the  Manhattan  State 
Hospital  at  Central  Islip,  at  a  meeting  of  the  Board 
of  Managers  held  October  loth. 

Smallpox  ia  the  Klondike. — A  steamer  recently 
arrived  at  Vancouver  from  Skagway  brings  the  report 
that  smallpox  is  raging  along  the  Klondike  creeks, 
many  of  them  being  quarantined.  There  were  twenty- 
two  cases  in  Dawson  on  September  15  th. 

Cholera  in  Japan. — .-V  despatch  received  in  St. 
Petersburg,  on  October  23d,  from  Vladivostock  says 
cholera  is  increasing  to  such  an  extent  in  Japan  that 
steamships  from  there  have  been  quarantined.  .\ 
number  of  deaths  have  occurred  on  board  of  steam- 
ships from  Nagasaki. 

The  Shah  of  Persia  is  said,  in  a  recent  cable  de- 
spatch, to  have  consulted  over  a  dozen  physicians  in 
the  different  countries  he  has  visited  in  Europe.  He 
is  believed  to  be  suffering  from  kidney  trouble,  but 
declares  that  no  two  of  the  many  doctors  who  examined 
him  were  in  accord  as  to  his  actual  condition. 

Typhoid  Fever  is  very  prevalent  in  New  York  at 
the  present  time,  and  several  well-known  members  of 
the  medical  profession  are  ill  or  have  recently  recov- 
ered from  the  disease.  .-Vmong  the  former  we  regret 
to  say  is  Dr.  Reginald  H.  Sayre,  and  among  the  latter 
we  rejoice  to  say  is  Dr.  Emil  Mayer. 

Typhoid  Fever  at  Newport.— The  epidemic  of 
typhoid  fever  at  Newport,  R.  I.,  is  subsiding,  few  new 
cases  having  been  reported  since  the  middle  of  the 
month.  In  three  weeks  there  were  forty-five  known 
cases  with  six  deaths.  Examination  of  the  wells  and 
cisterns  in  the  city  has  shown  several  of  a  suspicious 
character,  one  in  particular  being  found  to  contain 
typhoid  bacilli  in  abundance.  One  result  of  the 
epidemic  is  the  getting  up  of  a  petition  addressed  to 
the  city  council,  praying  that  the  board  of  health  be 
restored  and  the  committee  on  sanitation,  which  con- 
sists of  city-council  members,  be  abolished. 

The  New  York  Obstetrical  Society. — .At  the  an- 
nual meeting  of  this  society,  held  October  9th,  the  fol- 
lowing officers  were  elected:  J'retitient,  Dr.  H.  J. 
Boldt;  Ftrsi  Vice-President,  Dr.  Ralph  Waldo;  Second 
Vice-President,  Dr.  H.  N.  Vineberg;  Pecording  Secre- 
tary, Dr.  G.  L.  Brodhead ;  Assistant  Recording  Secre- 
tary, Dr.  G.  G.  Ward,  Jr.;  Corresponding  Secretary,  Dr. 
E.  E.  TuU  ;  Treasurer,  Dr.  J.  Lee  Morrill ;  Pathologist, 
Dr.  W.  S.  Stone. 

The  University  of  Dallas  has  recently  received  its 
charter  from  the  State  of  Texas  and  the  first  board  of 
directors  has  been    elected.       The   incorporators  are 


empowered  to  teach  law,  medicine,  the  arts  and  sci- 
ences, and  to  confer  all  professional  and  academic 
degrees  usually  granted  by  universities.  At  present 
only  the  school  of  medicine  will  be  inaugurated. 
The  faculty  consists  of  the  following  physicians: 
Drs.  J.  E.  Gilcreest,  of  Gainesville;  V.  B.  Armstrong, 
of  Dallas;  B.  E.  Hadra  (president  Texas  Medical 
Association),  of  Waco;  S.  E.  Milliken,  of  Dallas; 
Joe  Becton,  of  Greenville;  L.  Ashton,  of  Dallas; 
C.  M.  Rosser,  of  Dallas;  A.  F.  Beddo.  of  Dallas; 
J.  B.  Titterington,  of  Dallas,  dean  of  the  faculty. 

The  Late  Prof.  Lewis  A.  Sayre.— At  a  recent 
meeting  of  the  Faculty  of  the  University  and  Bellevue 
Hospital  Medical  College,  the  following  minute  was 
entered  on  the  records : 

The  members  of  the  Faculty  realize  with  deep  re- 
gret their  great  loss  in  the  death  of  their  late  colleague. 
Prof.  Lewis  A.  Sayre,  M.D.  His  long  and  honorable 
professional  career  has  shed  lustre  on  the  calling  of 
his  choice  and  on  the  medical  school  to  which,  at  its 
birth,  he  plighted  his  earnest  support,  and  which  he 
sustained  with  loyal  vigor  until  his  death. 

While  bowing  in  humble  submission  to  the  will  of 
Him  "who  doeth  all  things  well,"  we  extend  to  the 
members  of  his  family  our  earnest  assurance  of  sym- 
pathy in  this  their  great  affliction. 

Hermann  M.  Biggs,  Secretary. 

Dress  Reform  in  Texas.— Dr.  C.  A.  Lindsley, 
secretary  of  the  Connecticut  State  Board  of  Health, 
in  his  monthly  report,  issued  October  i6th,  says:  "The 
authorities  of  El  Paso,  in  Texas,  are  a  judicious  and 
considerate  body.  They  object  to  the  practice,  so 
much  in  use  by  the  gentler  sex,  of  wiping  the  side- 
walks with  their  trailing  dresses  and  carrying  ac- 
cumulated microbes,  mud,  spittle,  and  other  filth  into 
habitations  and  occupied  places,  to  be  dried  and  shaken 
off  in  the  air  and  so  to  render  respiration  therein  dis- 
gusting and  dangerous.  They  have  proceeded  to  the 
extent  of  their  authority  by  prohibiting  the  admission 
of  teachers  within  the  public  schools  except  in  '  short 
skirts.'  Their  example  ought  to  be  imitated  through- 
out the  United  States."  Dr.  Lindsley's  commendation 
of  this  reform  is  needed  in  Connecticut,  for  in  two  or 
three  towns  in  that  State  the  school  commissioners 
have  forbidden  teachers  to  wear  short  skirts  and  even 
dismissed  two  who  persisted  in  dressing  hygienically. 

The   Roentgen   Society  of   the   United   States 

The  first  regular  meeting  of  this  society,  the  object  of 
which  is,  as  its  name  implies,  "the  advancement  of 
the  knowledge  of  practical  ;c-ray  work  and  allied  arts 
and  sciences,"  will  be  held  at  the  Academy  of  Medi- 
cine in  this  city  on  December  13  and  14,  1900.  The 
following  are  the  officers  of  the  society:  President, 
Dr.  Heber  Robarts,  St.  Louis,  Mo. ;  First  Vice-Presi- 
dent, Dr.  J.  P.  Girdwood,  Montreal,  Canada;  Second 
Vice-President,  Dr.  H.  P.  Bender,  Brooklyn,  N.  Y.; 
Secretary  and  Treasurer,  Dr.  J.  Rudis-Jicinsky,  Cedar 
Rapids,  Iowa;  Assistant  Secretary,  Dr.  Carl  Beck,  37 
E.  31st  Street,  New  York.  The  secretaries  of  all  sci- 
entific, medical,  surgical,  dental,  electro-therapeutical, 
and  all  auxiliary  societies,  wishing  to  be  represented, 


662 


MEDICAL    RECORD. 


[October  27,  1900 


are  requested  to  send  in  the  names  of  the  delegates 
on  or  before  the  meeting  in  December.  All  those 
wishing  to  become  members  or  to  read  a  paper  before 
the  society  may  communicate  with  the  secretary. 

The  Society  of  Russian  Surgeons  was  recently 
established  in  Moscow,  membersliip  being  open  to  all 
practitioners  in  Russia  upon  the  payment  of  8  rubles 
yearly  or  100  rubles  at  one  time.  The  organizing 
secretary  is  Professor  Diakanoff,  of  Moscow. 

Marriage  of   the  Unfit At   the    meeting   of   the 

Tri-State  Medical  Society  of  Tennessee,  Alabama,  and 
Georgia,  recently  held  in  Chattanooga,  Tenn.,  steps 
were  taken  to  obtain  medical  legislation  in  these  three 
States  for  the  purpose  of  regulating  or  prohibiting  the 
marriage  of  habitual  criminals,  persons  afllicted  with 
incurable  diseases,  drunkards,  and  victims  of  harmful 
drugs. 

Navy  Department,  Bureau  of  Medicine  and  Sur- 
gery, Washington,  D.  C. — Changes  in  the  medical 
corps  of  the  United  States  navy  for  the  week  ending 
October  20,  1900.  October  15th. — Medical  Inspector 
E.  C.  Derr  detached  from  the  navy  yard,  Portsmouth, 
N.  H.,  on  reporting  of  relief,  and  ordered  home  to  wait 
orders;  Surgeon  B.  F.  Stephenson  ordered  to  the  navy 
yard,  Portsmouth,  N.  H.,  October  2sth.  October  16th. 
■ — Assistant  Surgeon  H.  E.  Odell  ordered  to  the  Asiatic 
station  modified;  to  take  passage  on  the  Sohice.  Oc- 
tober 17th. — F.  B.  Stephenson  commissioned  medical 
inspector  from  May  31,  igoo;  Assistant  Surgeon  H. 
A.  Dunn  detached  from  the  Dorothea  and  ordered  to 
the  Frolic. 

The  New  Jersey  Board  of  Dental  Examiners. — 
Charges  have  been  brought  by  several  members  of  this 
board  against  one  of  their  fellow-members  of  incom- 
petency as  an  e.xaminer.  It  was  alleged  that  he  was 
slow  in  getting  up  papers  for  examination,  that  he 
sometimes  forgot  papers,  and  that  he  changed  the 
marks  made  by  another  examiner  on  a  certaiu  student's 
papers,  with  the  remark:  "I  generally  mark  higher 
than  you  do,  so  I  will  mark  20  instead  of  18."  The 
accused  member  stated,  at  the  hearing  of  the  charges 
before  Governor  Voorhees  a  few  days  ago,  that  with 
two  exceptions  he  had  always  turned  in  his  papers 
promptly.  He  said  that  he  had  never  confined  him- 
self closely  to  the  text  books,  but  gave  credit  if  a 
practical  knowledge  of  the  subject  was  shown  even  if 
it  did  not  have  the  exact  text-book  answer. 

The  Late  Dr.  John  M.  Brown. — At  a  meeting  of 
the  medical  board  of  the  Metropolitan  Dispensary  and 
Hospital,  the  following  resolution  was  passed: 

"  Inasmuch  as  by  the  death  of  Dr.  John  M.  Brown  the 
Metropolitan  Dispensary  and  Hospital  has  sustained 
a  loss  which  is  poignantly  felt  and  with  difficulty  re- 
trieved, and  since,  individually,  we  miss  the  rugged 
honesty,  the  incorruptible  friendship  which  was  con- 
stantly evidenced  to  us  wiio  knew  him  intimately, 
be  it 

"Resolved,  That  this  feeble  expression  of  our  esteem 
for  his  character  and  our  appreciation  of  our  loss  be 
spr.ead  on  the  minutes,  and  a  copy  of  this  resolution 
be  sent  to  his  family  and  to  the  medical  press." 


Obituary  Notes.— Dr.  William  R.  Lakkix,  of  this 
city,  died  on  (_>ctober  15th  after  a  brief  illness.  He 
was  born  in  this  city  forty-two  years  ago,  and  was 
graduated  from  Bellevue  Hospital  Medical  College  in 
1883.  He  spent  two  years  at  St.  Vincent's  Hospital, 
where  he  was  house  surgeon,  and  in  1885  began  practice 
in  Harlem.  At  one  time  he  was  on  the  stafT  of  the  J. 
Hood  Wright  Hospital,  and  at  the  time  of  his  death 
was  a  member  of  the  Harlem  Medical  Association. 

Dr.  Henkv  Morkton  died  at  his  home,  a  dingy 
little  drug  store  in  this  city,  on  October  20th  at  the 
age  of  ninety-three  years.  He  was  born  in  England, 
but  came  to  this  country  with  his  brother  in  1S28  and 
opened  a  drug  store.  His  brother  was  a  physician  and 
he  himself  studied  medicine  later,  being  graduated 
from  the  College  of  Physicians  and  Surgeons  in  1845. 
He  always  retained  his  shop  and  never  removed  from 
the  neighborhood  in  which  he  first  settled.  He  aban- 
doned practice  a  number  of  years  ago. 

Dr.  James  F.  Mahoney  died  at  his  home  in  this 
city,  after  a  lingering  illness,  on  October  15th,  at  the 
age  of  thirty-five  years.  He  was  a  graduate  of  Bellevue 
Hospital  Medical  College  in  1882.  He  practised  for 
about  four  years  only,  and  was  then  appointed  an  in- 
spector in  the  customs  service  at  this  port. 

Dr.  Harold  E.  Hobby,  a  dentist  of  Mount  Vernon, 
N.  Y.,  died  on  October  20th,  at  the  age  of  twenty-two 
years,  from  accidental  asphyxiation  by  illuminating- 
gas. 

Dr.  Philip  Roth  died  suddenly  at  his  home  in 
Newark,  N.  J.,  from  cardiac  trouble,  on  October  21st. 
He  was  born  in  Newark  in  1864  and  w'as  graduated 
from  the  College  of  Physicians  and  Surgeons  in 
1884. 

Sir  Henry  Wentworth  Dyke  Acland,  of  Oxford, 
England,  died  on  October  i6th  at  the  age  of  eighty- 
five  years.  He  was  honorary  physician  to  the  Prince 
of  Wales,  whom  he  accompanied  on  his  visit  to  this 
country.  He  was  born  in  1815,  and  was  educated  at 
Harrow  and  Oxford.  He  was  Regius  Professor  of 
Medicine,  Oxford,  1857-94,  and  member  of  the  Royal 
Sanitary  Commission,  1870-72.  .\mong  his  publica- 
tions is  a  "Memoir  on  the  Visitation  of  Cholera  in 
Oxford  in  1854."  He  had  been  Radcliffe  Librarian 
at  the  University  of  Oxford  since  1851.  In  1879  he 
revisited  New  York  as  the  guest  of  General  McClellan. 

Capt.  Ben-j.  Brooke,  late  a  surgeon  in  the  United 
States  army,  died  at  Radnor,  Pa.,  on  October  18th 
at  the  age  of  thirty-four  years.  He  was  graduated 
from  the  medical  department  of  the  University  of 
Pennsylvania  in  1889  and  served  subsequently  as  a 
resident  physician  in  the  Philadelphia  Hospital. 

Dr.  Willia.m  F.  Reillv  died  at  Carlisle,  Pa.,  on 
October  19th,  at  the  age  of  forty-two  years.  He  was 
graduated  from  the  medical  department  of  the  Uni- 
versity of  I'ennsylvania  in  1875,  and  was  for  ten  years 
assistant  surgeon  in  the  I'.ighth  Regiment.  N.  G.  P. 

Dr.  William  H.  Sitkceon,  the  oldest  physician  in 
Fayette  County,  Pa.,  died  at  Uniontown  on  October 
ijth,  at  the  age  of  seventy-two  years.  He  was  gradu- 
ated from  Jefferson  Medical  College  in  1849. 

Dr.  Daviii  Pki.i.man  Boyer  died  at  Philadelphia 
on  October  14th,  at  the  age  of  seventy-six  years. 


October  27,  1900] 


MEDICAL    RECORD. 


66 1 


progress  of 


|>XcxUcal 


s>cicnce. 


PhiUiiUlphia  Medical  Journal,  October  20,  igoo. 

The  Germ  of  Yellow  Fever. — Charles  Smart  speaks  of  the 
work  of  several  bacteriologists  with  reference  to  this  sub- 
ject and  quotes  a  communication  from  Dr.  Reed  under  date 
of  July  24,  1900,  in  which  he  states,  in  relation  to  the  pres- 
ent outbreak  of  yellow  fever  at  Pinar  del  Rio,  Cuba;  "Our 
laboratories  are  now  in  good  working  order.  We  have 
been  able  to  study  carefully  seven  cases  since  our  arrival. 
Of  these,  one  resulted  in  recovery  (a  severe  case)  and  six 
were  fatal.  Neither  during  life  nor  after  death  have  we 
been  able  to  isolate  bacillus  ictevoides  :  but  our  sixtli  au- 
topsy, which  occurred  day  before  yesterday,  cannot  be 
definitely  reported  upon  as  yet."  Agramonte  believes 
that  Sanarelli's  bacillus  icteroides  is  no  more  concerned 
in  the  production  of  yellow  fever  than  are  the  common  co- 
lon bacilli  which. are  frequently  found  in  the  blood  and  vis- 
cera of  individuals  suffering  or  dead  from  yellow  fever. 
Lutz  believes  that  those  observers  who  report  that  they 
have  found  the  bacillus  icteroides  in  all  cases  and  that 
they  can  make  the  diagnosis  by  the  agglutinating  action 
of  the  blood,  are  the  victims  of  gross  errors  of  observation. 
Lutz  believes  that  this  bacillus  cannot  be  found  in  more 
than  half  the  cases  of  yellow  fever  by  knov.-n  methods  of 
research.  Agramonte  reports  that  he  has  isolated  Sana- 
relli's bacillus  from  three  cadavers  in  which  death  was  not 
due  to  yellow  fever. 

Report  of  a  Case  of  Tetanus  with  Recovery.— Andrew  H. 
Whitridge  reports  this  case  of  a  young  colored  man  who 
entered  the  hospital  complaining  of  a  burned  foot.  The 
interesting  points  in  the  case  are  that  the  first  symptom  of 
tetanus  manifested  itself  on  the  thirteenth  day,  and  nine 
injections  of  tetanus  antito.\in  serum,  10  c.c.  each,  were 
made,  but  were  followed  apparently  by  no  improvement. 
Morphine,  gr.  ^,  was  then  given  hypodermically  every  four 
hours,  the  dose  being  increased  in  a  few  days  to  g^r.  ^, 
showing  most  happy  results  in  abating  the  spasms  and 
irritability  of  the  mu.scles.  The  patient  made  a  perfect 
recovery. 

Report  of  the  Milk  Commission  of  the  Philadelphia  Pedi- 
atric Society. —  By  Frederick  A.  Packard,  J.  P.  Cro/.er 
Grithlh,  Alfred  Stengel,  Thompson  S.  Westcott,  and  Al- 
fred Hand,  Jr. 

The  Surgical  Management  of  Umbilical  Hernia  with  Large 
Ring. — By  E.  1).  Ferguson  (illustrated). 

Petri  Dish  Forceps;  Exhibition  Test-Tube  Stand.— By 
Randle  C.  Rosenberger  (illustrated). 

Angioneurotic  (Edema  of  the  Salivary  Glands. — By  James 
Ely  Talley. 

Neiu  York  Medical  Journal,  October  zo,  /goo. 

The  Present  State  of  Our  Knowledge  Concerning  the 
Cause,  N.iture,  and  Treatment  of  Asthma. — The  conclusions 
of  \V.  A.  Wells  are  as  follows:  ii)  Asthma  has  so  many 
points  of  resemblance  with  migraine,  angina  pectoris,  and 
epilepsy  that  the  suspicion  may  reasonably  be  entertained 
that  they  all  have  a  similar  pathology.  (2)  Of  the  theo- 
ries which  have  been  advanced  to  explain  the  pathogene- 
sis of  the  asthmatic  paroxysm,  no  one  of  them  so  well  har- 
monizes all  the  facts  as  the  vasomotor  theory ;  and  this 
only  when  we  admit  that  the  disturbance  is  essentially 
that  of  arterial  contraction,  rather  than  dilatation.  (3) 
There  is  always  present  in  asthma  a  morbid  constitutional 
state,  affecting  especially  the  sympathetic  nervous  system 
and  giving  rise  to  a  certain  nutritional  aberration,  whose 
most  salient  feature  is  the  increase  of  uric  acid  and  the 
urates.  (4)  Asthma  occurs  as  a  reflex  neurosis  from  dis- 
eases of  different  organs,  but  especially  often  from  those 
directly  supplied  by  branches  of  the  vagus  nerve.  The 
nasal  trouble,  which  is  the  most  frequent  reflex  cause,  is 
not  necessarily  an  obstruction  and  may  be  very  incon- 
spicuous and  difficult  to  detect.  (5)  Nearly  all  cases  of 
asthma  show  evidences  of  a  pronounced  psychic  element, 
as  in  the  curious  variety  of  exciting  causes  of  the  attack, 
in  the  capriciousness  of  its  course  and  behavior,  and  its 
dependence  upon  emotional  states,  suggestion,  etc.  (6) 
In  the  treatment  of  the  paroxysm  of  asthma,  a  strict  indi- 
vidualization needs  to  be  observed.  The  best  remedies 
are  those  which  overcome  arterial  spasm,  such  as  mor- 
phine, nitroglycerin,  atropine,  and  chloral  hydrate.  (7) 
Treatment  in  the  intervals  of  the  attacks  must  be  directed, 
in  the  first  place,  to  the  removal  of  the  cause,  and  secondly, 
to  the  institution  of  sound  hygienic  and  prophylactic  meas- 
ures in  relation  to  the  mind,  diet,  air,  exercise,  etc.  (S) 
Medicinal  treatment  is  addressed  to  improving  the  consti- 
tutional state,  for  which  the  best  remedies  are  piperazin, 
iodide  of  potassium  and  the  other  iodides,  the  alkalies, 
and  general  tonic  treatment. 


Electrolysis  in  the  Treatment  of  Stricture  of  the  Lacrymal 
Passages. — L.  L.  Mial  gives  a  review  of  the  history  of  this 
si)ecial  application  of  electrolysis  and  speaks  enthusiasti- 
cally of  results  which  he  has  obtained  in  a  series  of  cases 
in  which  probing  extending  over  a  long  period  had  failed 
to  afford  relief.  Each  of  the  patients  exhibited  a  muco- 
purulent discharge  which  rapidly  ceased,  especially  as  to 
purulency,  after  two  or  three  applications  of  the  current 
through  a  Bowman  probe  at  intervals  of  a  week.  Advan- 
tages are :  rapid  result,  absence  of  pain,  no  bleeding,  and 
antiseptic  action.  Current  strength  should  not  exceed 
three  milliampcres.  The  ])Ositive  pole  is  a  flat  sponge  ap- 
plied to  the  nape  of  the  neck.  Sittings  should  not  exceed 
two  minutes.  Even  this  length  of  time  may  cause  consid- 
erable hypera;mia  with  itching  and  pain  lasting  a  day  or 
two.  Mial  recommends  in  addition  the  washing  out  ol  the 
canal,  after  withdrawal  of  the  probe,  with  a  four-per-ccnt. 
solution  of  protargol. 

Bullous  Enlargement  of  the  Middle  Turbinate  Bone  (Con- 
cha BuUosai. — Two  cases  are  reported  by  J.  I'ayson  Clark, 
who  mentions  two  additional  cases  which  have  come  under 
his  own  observation.  Twenty  other  cases  have  been  re- 
corded. Four-fifths  of  all  were  in  women.  Seventeen 
were  in  persons  under  twenty.  Clark  regards  the  condi- 
tion as  of  developmental  origin.  In  twelve  of  the  twenty- 
four  cases  the  cells  contained  air  only,  five  were  compli- 
cated by  the  presence  of  poly])i,  one  contained  a  yellow 
viscous  fluid,  and  in  seven  the  nature  of  the  contents  was 
not  mentioned.  Symptoms  are  headache,  nasal  obstruc- 
tion, sense  of  intranasal  pressure,  and  possibly  disturb- 
ances of  smell,  discharge  (from  complicating  sinus  dis- 
ease or  of  the  cell  cavity),  photophobia,  and  overflow  of 
tears.  Removal  with  the  wire  snare  or  forceps  is  the  only 
rational  treatment. 

The  Medical  and  Surgical  Treatment  of  Acute  and  Chronic 
Lymph  Nodes  of  the  Cervical  Region. — By  H.  Horace  (Iraut. 

A  Combined  Aspiration  and  Injection  Instnmnent  for  Sub- 
arachnoid Cocainization. — By  G.  K.  Fowler. 

Disturbances  of  Gastric  Motility  and  their  Significance. — 
By  .\.  MacFarlane. 

The  Subarachnoid  Injection  of  Cocaine. — By  J.  E.  Massey. 

Journal  of  the  Anurican  Medical  Ass'n,  Oct.  zo,  /goo. 

The  Diagnosis  of  Pulmonary  Tuberculosis. — Robert  H. 
Babcock  states  that  this  may  be  easy  or  difiicult,  depend- 
ing on  the  stage  of  the  disease  and  the  nature  of  the  path- 
ological conditions.  If  the  temperature  shows  a  constant 
elevation  ranging  between  99.5  and  100.5  F-,  it  is  in  a 
suspected  case  strongly  suggestive  of  tuberculous  infection. 
As  a  rule  the  pulse  is  accelerated  and  to  a  rate  out  of  pro- 
portion to  the  temperature.  Respiration  may  or  may  not 
be  increased.  In  incipient  cases  there  is  usually  no  dysp- 
noea. Loss  of  weight  is  suspicious  and  is  an  invariable  ac- 
companiment. Cough  is  frequently  symptomatic  of  this 
disease,  but  not  invariably  so.  Sputum,  when  present, 
exhibits  nothing  characteristic  unless  it  shows  bacilli.  As 
to  physical  signs,  one  of  the  earliest  is  lessened  expansion 
of  one  apex.  Another  is  atrophy  of  the  scapulo-thoracic 
muscles  on  the  affected  side,  also  drooping  of  the  shoul- 
ders. Palpation  does  not  furnish  very  reliable  or  positive 
information  except  as  corroborative  of  that  obtained  by 
other  means.  Percussion  is  greatly  relied  on.  but  is  not 
always  so  trustworthy  as  is  auscultation.  Auscultation  is 
valuable  for  the  early  recognition  of  pulmonary  tuberculo- 
sis, but  requires  considerable  skill.  Mensuration  of  the 
chest  is  an  accessory  method.  There  is  a  wide  diversity 
of  opinion  concerning  the  use  of  tuberculin  for  diagnostic 
purposes.  The  .i-ray  is  now  affording  valuable  informa- 
tion in  regard  to  the  condition  of  the  lungs.  Agglutination 
of  the  blood,  after  the  Widal  method,  is  too  recent  and  not 
sufficiently  proved  to  require  more  than  a  passing  mention. 
All  of  these  diagnostic  points  are  particularly  applicable  to 
the  disease  in  its  incipient  stages.  As  to  the  advai.ced 
stages,  the  symptom  complex  alone  is  sufficient,  but  exam- 
ination of  the  chest  should  always  be  made.  It  may  be 
accepted  as  a  general  rule  that  dulnessand  broncho-vesicu- 
lar or  bronchial  breathing  and  rales  at  the  apex  indicate 
pulmonary  tuberculosis.  Signs  of  excavation  corroborate 
the  diagnosis. 

State  Provision  for  the  Treatment  of  the  Consumptive  Poor. — 
Benjamin  Lee  declares  that  the  only  ground  on  which  state 
charities  can  be  justified  is  that  of  self-protection.  From 
the  standpoint  of  political  economy  and  true  statesman- 
ship, the  maintenance  of  hospitals  simply  for  the  relief  of 
suffering  and  healing  of  di.seases  is  a  gross  misuse  of  pub- 
lic funds.  In  the  case  of  infectious  disease,  the  dangers 
arising  from  its  extension  justify  the  expenditure  of  large 
amounts  of  money.  It  is  the  acceptance  of  the  view  that 
tuberculosis  is  communicable  that  makes  it  possible  to 
urge  the  state  to  contribute  to  the  care  of  the  consumptive 
poor  as  such.  The  knowledge  both  of  the  curability  and 
the  preventability  of  consumption  should  be  spread  abroad. 


664 


MEDICAL    RECORD. 


[October  27,  1900 


In  Germany,  France,  Great  Britain,  Sweden,  Belgium, 
Holland,  Spain,  and  Roumania  much  has  been  accom- 
plished. An  international  congress  of  tuberculosis  has 
been  held.  The  New  York  State  board  of  healtli  has 
adopted  resolutions  urging  the  early  construction  of  a 
State  sanatorium  for  consumptives  in  the  Adirondacks  at 
a  cost  of  not  less  than  $200,000.  The  legislature  of  that 
Stale  has  already  passed  a  bill  authorizing  large  cities  to 
establish  hospitals  for  sufferers  from  tuberculosis.  Massa- 
chusetts has  aleady  in  operation  an  institution  of  this  kind 
at  Rutland,  which  cost  $1^0,000.  Other  States  are  taking 
up  the  movement.  The  United  States  government  has 
established  a  sanatorium  at  Fort  Bayard,  N.  M.,  for  the 
care  of  its  soldiers  affected  with  this  disease.  The  day  is 
coming  when  this  disease,  which  kills  four  and  a  half  times 
as  many  as  smallpox,  scarlet  fever,  typhoid  fever,  and 
diphtheria  combined,  will  be  properly  taken  care  of. 

Climate  for  Tuberculosis. — Norman  Bridge  states  that  al- 
though climate  is  important,  it  is  only  one  element  in  the 
proper  management  of  this  disease.  To  increase  the  rc- 
sisting-power  of  the  body  is  the  great  requirement.  Prac- 
tically there  are  no  occupations  that  are  wholly  hygienic — 
especially  no  indoor  work.  The  needs  of  the  tuberculous 
patient  apart  from  special  me.lication  include:  ii)  Rest 
from  work;  (2)  change  of  work  and  cares;  (3)  attention 
to  the  digestion  and  the  feeding  and  nutrition  of  the  body  ; 
(4)  long  hours  of  sleep  ;  (5)  outdoor  life,  sunshine,  and 
fresh  air;  (6)  a  change  of  surroundings  for  novelty  and 
pleasure  ;  (7)  a  change  of  climate,  to  a  better  one  if  pos- 
sible, but  a  change  anyway.  Tlie  chief  value  of  any  cli- 
mate for  tuberculosis  depends  on  the  time  spent  out  of  doors 
and  the  amount  of  pure  air  breathed  all  night — at  the  same 
time  laying  aside  depression  and  hardship.  Sunlight  is 
valuable.  Altitude  helps  some  cases,  especially  the  in- 
cipient ones.  Dryness  of  air  is  an  important  element. 
Homesickness  wholly  counteracts  any  good  effect  of  cli- 
mate in  many  cases.  With  other  conditions  as  favorable 
as  possible,  a  good  climate  is  an  influence  that  will  often 
tip  the  balance  in  favor  of  recovery.  Nothing  more  than 
this  should  be  asked  of  any  climatic  resource. 

Municipal  Regulation  of  the  Spitting  Habit. — Elmer  B. 
Borland  has  been  during  the  j)ast  year  in  communication 
with  the  boards  or  bureaus  of  health  of  twenty-two  princi- 
pal cities  of  the  United  States.  An  analysis  of  the  infor- 
mation received  from  them  on  this  subject  may  be  for- 
mulated as  follows :  Special  laws  have  been  enacted  in 
one-half  of  these  cities,  and  about  one-fourth  are  regulat- 
ing partly  or  wholly  under  their  general  nuisance  acts. 
These  ordinances  empower  bureaus  of  health  to  abate  or 
prohibit  anything  of  an  unsanitary  character  ;  indiscrimi- 
nate spitting  is  included.  In  the  past  Jive  years.  New 
York  and  Brooklyn,  Newark,  Columbus,  Cleveland,  San 
Francisco,  Pittsburg,  Washingfton.  D.  C,  Rochester,  New 
Orleans,  Louisville,  and  Baltimore  have  enacted  special 
laws.  The  boards  of  health  of  Philadelphia  and  Boston 
are  doing  good  work  under  their  general  nuisance  acts. 
Public  opinion  is  being  rapidly  educated  and  the  work  is 
well  begun. 

Overcrowding  and  Tuberculosis. — S.  A.  Knopf  declares 
that  lack  of  air  and  light,  intemperance,  and  underfeeding 
help  to  create  in  the  body  the  best  soil  for  the  invasion, 
growth,  and  developmen:  of  tlie  tubercle  bacilli.  These 
conditions  predominate  in  many  of  the  city  tenements. 
He  then  speaks  of  the  great  danger  attending  the  careless 
disposal  of  tuberculous  sputum.  Damp  soil  fosters  tuber- 
culosis ;  model  tenements  built  on  good  soil  with  proper 
drainage  will  go  far  to  stamp  out  this  disease.  Overcrowd- 
ing of  all  institutions  as  well  as  dwellings  should  be 
avoided.  The  creation  of  schools  of  forestry  would  .give 
useful  and  healthful  employment  to  a  number  of  men  as 
well  as  rendering  the  regions  more  healthful. 

The  Advantages  of  the  Sanitarium  Treatment  of  Tuber- 
culosis When  Change  of  Climate  is  Not  Possible. — By  F.  S. 
Oliver  (Jolins  Hopkins). 

The  Sanitariiun  for  Consmnptive  Sailors  Established  by 
the  U.  S.  Marine  Hospital  Service  at  Fort  Stanton,  N.  M.— 
By  J.  O.  Col)b. 

Necessity  of  E.xamination  of  the  Sputum  in  the  Diagnosis 
of  Pulmonary  Tuberculosis. — By  C.  il.  Wood. 

Report  of  the  Committee  of  Tuberculosis. — By  Norman 
Bridge,  W.  A.  Evans,  and  Paul  I'aqnin. 

United  States  General  Hospital  for  Tuberculosis  at  Fort 
Bayard,  N.  M.— By  D.  M.  Ajip^l. 

Tuberculosis ;  its  Zoologic  and  Geographic  Distribution.— 
By  W.  A.  Evans. 

Notification  of  Tuberculosis.— ^By  Arthur  R.  Reynolds. 

Hereditary  Factors  in  Tuberculosis. — By  J.  M.  Anders. 

Tuberculosis  and  Insurance. — By  E.  Fletcher  Ingals. 

Tuberculosis  in  Pennsylvania. — By  Guy  Hinsdale. 


Boston  Mtiiical  aiul  Siirjriia/  Journal,  October  iS.  igoo. 

Hydrotherapy  in  Pneumonia. — Simon  Baruch  considers 
that  the  judicious  application  of  hydrotherapy  in  pneumo- 
nia fulfils  all  the  therapeutic  indications  by  meeting  all  the 
depreciating  conditions  which  lead  to  a  fatal  termination. 
Only  one  condition  is  unaffected  by  this  treatment,  namely, 
resolution.  He  has  observed  crisis  in  only  about  twenty- 
five  per  cent,  of  cases.  The  local  course  of  the  disea.se  ap- 
pears to  be  unchanged.  Resolution  ])roceeds  slowly  but 
surely.  The  patient  has  a  normal  temperature,  pulse,  and 
almost  normal  respiration  from  Hve  to  twenty  days  before 
all  signs  of  consolidation  have  disappeared.  The  special 
conditions  encountered  in  pneumonia,  which  Bainich  be- 
lieves are  successfully  met  by  appropriate  hydrotherapy, 
are:  (i)  To  fortify  the  nervous  system  ;  (2)  to  sustain  the 
heart ;  (3)  to  strive  for  elimination  of  noxious  products  aris- 
ing from  the  life  and  death  of  the  diplococcus;  (4)  to  ren- 
der the  patient  comfortable  by  reducing  high  temperature, 
deepening  inspiration,  and  producing  sleep.  Flexibility  is 
a  notable  quality  of  hydrotherapy.  By  various  procedures, 
changing  of  temperature  and  duration,  we  may  adaut  the 
application  of  water  to  the  most  opposite  conditions  for  the 
fulfilment  of  these  indications. 

Neuropathic  Joints. — Sidney  A.  Lord  takes  up  first  the 
classical  e.xamples  of  true  nervous  arthropathies,  those  of 
tabes  dorsalis  and  syringomyelia,  which  occur  in  from  five 
to  ten  per  cent,  of  all  cases  of  the  former,  and  ten  per  cent, 
of  the  latter  disease.  There  are  two  principal  types  of 
change,  atrophy  and  hypertrophy,  the  latter  being  the  more 
common.  The  author  holds  that  several  factors  undoubt- 
edly can  and  do  exist  in  the  etiology  of  both  high  and  low 
grades  of  the  arthropathies,  but  tlie  only  absolutely  con- 
stant element  is  the  nervous  system,  which  acts  directly 
by  influencing  nutrition,  and  indirectly  by  causing  ataxia. 
Other  joint  affections  which  may  be  spoken  of  as  neuro- 
pathic, are  hydrops  articulorum  intermittens,  the  location 
of  which  is  more  usually  in  the  knee  ;  and  the  acroarthritis 
of  Hutchinson,  in  which  the  terminal  finger  articulations 
become  typically  wobble-jointed. 

Suppurative  Pericarditis  and  its  Surgical  Treatment. — 
Charles  B.  Porter  concludes  that:  (ii  pericardotomy  is 
indicated  in  all  cases  of  suppurative  pericarditis.  (2)  Be- 
cause of  the  uncertain  and  varying  relations  of  the  pleura, 
and  because  of  the  anterior  position  of  the  heart,  whenever 
the  pericardial  sac  is  distended  by  fluid,  aspiration  of  the 
pericardium  is  a  more  dangerous  procedure  than  open  in- 
cision, when  done  by  skilled  hands.  {3)  Incisions  of  the 
pericardium  can  be  done  quickly  and  safely  by  resection 
of  the  fifth  costal  cartilage,  and  in  many  cases  under  local 
anesthesia.  (4)  In  many  cases  of  serous  effusion  open 
incision  without  puncture  will  offer  less  risk  and  speedier 
cure  than  aspiration.  (5)  The  method  and  detailed  tech- 
nique of  tlie  writer,  proposed  in  1897,  have  been  followed 
out  by  the  majority  of  recent  operators. 

Septic  and  Gonorrhoea!  Joints. — Charles  A.  Porter  says 
that  the  object  of  his  paper  is  to  show  :  (i)  That  the  gono- 
coccus  alone  can  cause  arthritis,  which,  without  the  pres- 
ence of  other  organisms,  may  be  purulent.  (2)  Gonor- 
rhneal  arthritis  occurs  not  only  in  acute  gonorrhcea.  but  in 
the  chronic  or  latent  stages,  which  persist  much  longer 
than  is  commonly  believed.  (3)  The  signs  of  such  chronic 
infection  in  the  male  and  female  are  often  slight,  and  dis- 
regarded or  overlooked  by  the  patient  and  physician.  (4) 
In  consequence,  not  a  small  proportion  of  cases  are  diag- 
nosed as  articular  rheumatism  which  are  really  of  gonor- 
rhceal  origin. 

To  What  Extent  Does  the  "  Rheumatic  and  Gouty  Diathe- 
sis" Enter  into  Traumatic  and  Other  Diseases  of  the  Joints? 
—By  William  11.  Porter. 

Medical  AVtcj,  October  20,  /goo. 

Treatment  of  Tjrphoid  Fever.— Ste]ihen  Smith  Burt  de- 
clares that  on  account  of  the  personal  equation  to  be  con- 
sidered in  typhoid  lever  there  can  be  no  stereotyped  method 
of  treatment.  The  individual  power  of  resistance  and  the 
probable  extent  of  the  infection  must  be  estimated.  The 
patient  should  always  be  put  to  bed  at  once  and  there  be 
kept  till  advanced  convalescence.  The  writer  is  inclined 
to  a  fluid  dietary  for  these  cases.  Water  should  be  freely 
administered.  There  must  be  plenty  of  fresh  air.  Themild 
cases  will  end  in  recovery  without  any  medication.  The 
malignant  infections  commonly  will  result  in  death  in  spite 
of  all  treatment.  The  nervous  symptoms  are  of  more  im- 
portance than  is  the  temperature.  Some  form  of  cold-water 
application  is  more  soothing  to  the  former  than  any  other 
treatment,  although  this  need  seldom  be  an  actual  tub 
bath.  A  sponge  bath  of  one-third  alcohol  and  two-thirds 
cold  water  thoroughly  carried  out,  in  the  majority  of  in- 
stances, will  accomplish  the  desired  results  with  consider- 
ably less  expenditure  of  strength  of  the  part  of  the  patient. 
The  safest  intestinal  antiseptic  remedies,  if  any  are  to  be 
tried,  are  mild  laxatives,  and  for  moving  the  bowels  ordi- 


October  27,  1900] 


MEDICAL   RECORD. 


665 


narily  a  rectal  injection  is  best.  In  hemorrhage  ice  to  the 
abdomen  and  jjr.  %  doses  of  powered  opium  every  fifteen 
minutes  are  efficacious.  When  the  bowels  move  more  than 
three  or  four  times  in  twenty-four  hours,  subnitrate  of  l)is- 
muth  in  large  doses,  alone  or  with  a  little  morphine,  will 
often  be  all  that  is  necessary.  Strychnine,  ammonia,  alco- 
hol, and  ether  are  reliable  supporting  remedies.  Caution 
should  be  observed  in  ret^uhitin).;  the  diet  in  convalescence. 

Increasing  the  Therapeutic  Value  of  Cod-Liver  Oil  by  the 
Addition  of  Free  Iodine  and  Free  Phosphorus. — Louis  J. 
Lautenbach  discusses  tlie  history  of  the  production  of  cod- 
liver  oil.  lie  gives  MiiUer's  classification  of  the  compo- 
nents of  cod-liver  oil :  Hydrocarbons  ;  oxygen  compounds  ; 
combinations  of  o.\ygen  compounds;  o.xygen  cyclo-coni- 
pounds  ;  halogen  compounds  ;  sulphur  compounds  ;  nitro- 
gen comijounds;  proteids ;  ptomains  and  leucomains ; 
toxins  and  antitoxins.;  ferments.  This  oil  has  alterative, 
tissue-building,  tissue-repairing,  and  nourishing  qualities 
which  are  wonderful.  But  the  modus  operandi  cannot  be 
clearly  exiilained.  Osmosis  and  endosmosis  are  more 
rapid  than  with  any  other  known  oil.  Its  emulsion  is  also 
very  rai)id.  It  has  wonderful  nerve  building  jiroperties — • 
perhaps  due  chiefly  to  the  phosphorus;  its  alterative  ef- 
fects are  probably  due  to  the  iodine  and  bromine.  Some 
years  ago,  the  author  began  to  contrast  the  etTects  of  the 
new  oils  as  compared  with  the  same  oil  fortified  by  the  ad- 
ditions of  iodine,  bromine,  and  phosphorus.  As  the  result 
of  experiments  the  author,  aided  by  his  druggist,  has  pro- 
duced a  prejiaration  called  "oleum  morrhuai  iodi-plios- 
phoratum."  In  each  tablespoonful  of  this  oil  are  gr.  y/.j,  of 
liure  free  phosphorus  and  gr.  ■^,  of  pure  free  iodine.  This 
oil  is  less  repulsive  to  taste  and  smell  tlian  are  others,  is 
more  easily  digested,  and  less  liable  to  be  followed  by 
eructations.  It  is  ordered  to  be  taken  on  retiring,  dose  one 
tablespoonful,  and  followed  by  a  taste  of  lemon.  Its  use 
has  been  followed  by  the  most  gratifying  results. 

Some  Remarks  on  the  Pathology  and  Surgical  Treatment 
of  Urinary  and  Uro-Genital  Tuberculosis. — By  Samuel  Alex- 
ander. 

Progressive  Pernicious  Anxmia. — By  Alfred  Stengel. 

T/ie  Lancet,  October  tj.  igoo. 

Dacrocystitis  Aggravans  Resembling  Tumor  of  the  Face. — 

Kenuetli  Scott  s.iw  in  Egy|it  a  woman  aged  seventy-five 
years,  who  presented  on  tlie  left  side  of  the  face  a  tumor 
which  on  examination  proved  to  be  a  double  dacrocystitis 
attaining  on  the  left  side  enormous  proportions.  Both  the 
upper  and  lower  left  eyelids  were  so  inflamed  and  cedema- 
tous  that  the  palpebral  fissure  could  not  be  opened,  but 
later  the  globe  of  the  eye  was  found  to  be  intact.  There 
was,  in  addition,  a  large  tumor,  vertically  oval  in  shape, 
which  extended  from  the  region  of  the  eye  to  the  angle  of 
the  mouth,  close  to  the  perpendicular  mesial  line  of  the 
face.  It  encroached  upon  the  eye  so  as  almost  to  conceal 
it.  filling  up  tlie  surface  depression  over  the  orbital  cavity 
and  extending  laterally  outward  to  be  in  line  with  the  ex- 
ternal canthus.  Its  lower  limit  was  marked  by  the  fold  of 
skin  running  between  the  side  of  the  nostril  and  the  corner 
of  the  mouth,  and  the  level  of  its  surface  lay  at  a  consider- 
able di.stance  forward  in  front  of  the  bridge  of  the  nose. 
The  tumor  had  a  well-defined  border  and  was  wholly  ses- 
sile ;  its  surface  was  smooth  and  even,  and  showed  no  signs 
of  redness.  Although  it  was  extremely  tense  there  was  a 
distinct  sen.se  of  fluctuation  present,  and  apparently  some 
degree  of  pointing  toward  its  lower  and  outer  aspect.  The 
surrounding  tissues  were  thickened  and  indurated,  but 
only  in  the  eyelids  was  there  any  outward  evidence  of 
acute  inflammation.  There  was  much  local  pain  but  no 
general  disturbance  of  the  system.  On  the  right  side  the 
condition  was  of  minor  degree  and  was  removed  by  cutting 
the  lower  canaliculus  and. following  the  ordinary  routine. 
On  the  left  the  tumor  was  incised  on  its  outer  edge  and 
pus  escaped,  allowing  com|)lete  collai)se  of  the  swelling. 
Twelve  days  later  the  lower  canaliculus  was  slit  and  a 
style  inserted  into  the  lacrymal  duct.  The  sac  forming 
the  swelling  was  found  to  be  a  multilocular  one.  A  counter 
opening  to  permit  free  drainage  was  made  and  cure  re- 
sulted in  five  weeks. 

Bilateral  Resection  of  the  Superior  Cervical  Ssnnpathetic 
Ganglion  of  the  Sympathetic  for  Glaucoma. — II.  \V,  iJodd 
repeated  the  operation  originally  described  by  Jonnesco, 
on  a  woman  aged  sixty-two  years,  and  thus  describes  it. 
An  incision  about  four  inches  in  length  was  made  along 
the  line  of  the  anterior  border  of  the  right  sterno-niastoid 
muscle,  beginning  above  at  the  level  of  the  angle  of  the 
lower  jaw,  through  the  skin  and  fasciae.  The  anterior  bor- 
der of  the  sterno-mastoid  muscle  was  then  exposed,  its  fas- 
cia divided.  The  common  facial  vein  was  ligatured  and 
divided.  The  fascia  below  the  sterno-mastoid  muscle  was 
then  torn  through  and  the  sheath  of  the  great  vessels  of  the 
neck  was  opened.  The  artery  and  vein  were  carefully  dis- 
sected apart  and  the  vagus  nerve  was  then  searched  for  and 


found.  It  was  then  drawn  forward  by  a  retractor,  together 
with  the  carotid  artery,  while  the  internal  jugular  vein  was 
held  backward  by  another  retractor.  The  cord  of  the  cervi- 
cal sympathetic  nerve  with  the  superior  cervical  ganglion 
was  then  found  in  the  fascia  at  the  bottom  of  the  wound, 
from  which  it  was  carefully  dissected  out.  The  gan- 
glion was  seized  in  a  strong  pair  of  forceps  and  pulled  forci- 
bly downward  with  a  twist  so  as  to  tear  out  the  nerve  from 
as  high  up  as  possible.  The  nerve  was  then  cut  off  at  the 
lower  angle  of  the  wound  and  about  one  and  a  half  inches 
of  its  length  were  removed,  including  the  ganglion.  The 
operation  was  then  repeated  in  exactly  the  same  manner 
on  the  other  side  of  the  neck.  The  wounds  were  closed 
with  .separate  silk  stitches  and  a  wet  gauze  dressing  was 
then  applied.  The  ana;.sthetic  employed  at  first  was  ether, 
but  it  was  found  necessary  to  change  this  to  chloroform  for 
the  second  operation  on  account  of  the  engorgement  of  the 
veins  of  the  neck  produced  by  the  ether.  The  eflfectof  the 
operation  on  the  glaucoma  could  not  be  told  until  after  the 
lapse  of  several  months'  time. 

Two  Illustrative  Cases  of  Sinus  Pyaemia  with  Unusual  Re- 
sults.— In  the  first  of  James  Kerr's  cases  which  were  treated 
by  operation  and  anti-streptococcus  serum  a  fatal  result 
occurred  and  autopsy  showed  the  following  condition  :  Ex- 
tension of  the  thrombus  back  from  the  obliterated  jiart  of 
the  sinus  and  up  the  petrosal  sinuses,  general  discoloration 
of  bone,  erosion  and  purulent  lymph  about  the  jugular 
foramen,  several  perforations  ]>unched  out  of  the  vein  wall, 
and  communication  from  the  floor  of  the  tynii)anum 
through  the  jugular  dome,  by  which  route  infection  seemed 
to  have  spread.  A  second  case  in  a  child  aged  five  years 
also  resulted  fatally.  The  mechanism  of  these  cases  is 
usually  a  chronic  suppurative  otitis  with  extension  to  the 
mastoid  antrum  and  cells,  which  discharge  freely  until 
suddenly,  either  from  increased  thickening  of  the  mucous 
membrane  or  from  slow  thickening  of  the  bone,  the  antral 
passage  becomes  blocked  and  discharge  ceases.  The  first 
signal  of  danger — pain — follows,  with  violent  inflamma- 
tion from  the  retained  pus,  which  often  in  children  breaks 
its  way  through  the  ununited  squamoso-mastoid  fissure, 
but  in  others  more  often  finds  its  way  into  cerebral,  sig- 
moid, or  cerebellar  foss;e. 

Eighteen  Consecutive  Cases  of  Abdominal  Hysterectomy ; 
Technique  and  Results. — By  A.  A.  Warden  (illustrated). 

Introductory  Address  before  the  University  College  of  South 
Wales  and  Monmouthshire. — By  Sir  John  Williams. 

Notes  on  Thirty-one  Cases  of  Diphtheria  Treated  with 
Antitoxin. — Piy  Julm  Jlaekenzic. 

Some  Problems  of  Tropical  Medicine. — Address  by  Sir 
William  -MacGrcgor. 

The  Romance  of  Surgery. — Address  by  J.  H.  Morgan. 
ISritish  Medical  Journal,  October  ij,  /goo. 

The  Medicinal  and  Dietetic  Treatment  of  Heart  Failure  in 
the  Aged. — F.  W.  Forbes  Ross  in  his  summary  of  this  sub- 
ject says  that  digitalis  stimulates  the  vagus,  and  depresses 
the  reflex  action  of  the  cord  and  motor  nerves.  It  acts  by 
prolonging  the  cardiac  diastole  and  increases  the  periph- 
eral resistance,  is  irregular  in  results,  is  cumulative,  is 
irritating  to  the  alimentary  canal,  and  induces  suppression 
of  urine  in  the  aged.  Strophanthus  does  not  stimulate  the 
vagus.  proFmgs  the  cardiac  systole,  renders  the  nervous 
system  hyperxsthetic  primarily,  and  does  not  have  any 
effect  on  the  peripheral  circulation  till  long  after  it  has  in- 
creased the  force  of  the  cardiac  systole,  is  non-cumulative, 
is  not  any  more,  if  as  much,  an  irritant  to  the  alimentary 
canal  than  digitalis,  acts  regularly,  and  can  be  given  with 
benefit  for  very  lengthened  periods,  even  up  to  four  years 
continuously,  with  only  good  effects.  The  nervous  system 
is  affected  adversely  only  when  strophanthus  is  combined 
with  a  mineral  acicf.  It  does  not  act  like  digitalis  on  the 
heart  as  it  can  be  given  at  once  even  after  digitalis  has 
produced  ill  effects  ;  yet  these  effects  pass  off  while  the  pa- 
tient is  actually  taking  strophanthus.  The  drug  next  in 
value  for  a  senile  heart  is  mercury.  Iodide  of  potassium  is 
prai.sed  as  a  diuretic  and  cardiac  tonic.  Nitrates  are  recom- 
mended. Phosphates  and  hypophosphites  of  lime,  sodium, 
potassium,  and  iron,  cod-liver  oil.  and  bone-marrow  for 
those  who  cannot  take  oil,  will  be  found  most  useful.  Nux 
vomica  serves  to  initiate  the  muscular  contraction  which 
strophanthus  makes  more  decided.  To  do  this  efficiently 
and  continuously  without  using  u])  the  cardiac  reserve  nec- 
essitates a  highly  nutritious  and  easily  assimilated  dietary. 
The  myosin  is  obtained  from  raw  minced  steak  extracted 
by  cold  o. 5-per-cent.  .sodium-chloride  solution  and  then 
curdled  out.  It  can  then  be  put  into  pudding,  milk,  or  be 
made  into  meat  panada.  Much  can  be  done  for  the  heart 
that  is  regarded  as  worn  out. 

The  Treatment  of  Gouty  Ecrema. — Gilbert  John  King 
Martyn  believes  that  in  the  vast  majority  of  cases  of 
eczema  gout  will  be  found  as  the  fundamental  dyscrasia. 
The  types  of  eczema  met  with  in  gout  are  roughly  the 


666 


MEDICAL    RECORD. 


[October  27,  1900 


acute  dry,  the  acute  moist,  the  chronic,  and  the  latent. 
By  the  last  is  meant  a  burning,  itching,  tormenting  sensa- 
tion beneath  the  skin  ;  nothing  is  visible  on  the  .surface. 
It  is  one  of  the  commonest  complaints  of  the  gouty,  and 
often  renders  their  life  intolerable.  It  is  usually  worse 
when  the  patient  is  in  bed,  and  nearly  always  associated 
with  gouty  acid  dyspepsia.  The  treatment  consists  in  en- 
forcing a  rigid  dietary.  Bismuth  and  alkalies  must  be 
freely  given.  For  the  burning  and  itching,  a  lotion  or 
ointment  containing  carbolic  acid  is  best.  One  of  the  most 
essential  points  in  the  treatment  of  gout  and  gouty  eczema 
is  the  production  of  a  healthy  action  of  the  skin  and  the 
avoidance  of  extreme  loss  of  heat  with  sudden  chilling  of 
the  surface  ;  while,  at  the  same  time,  irritation  is  kept  at 
a  minimum.  As  little  change  as  possible  should  be  made 
in  the  winter  and  summer  clothing.  Tlie  underclothing 
must  not  be  varied.  The  best  material  for  this  is  undoubt- 
edly cotton  in  the  cellular  woven  form  or  in  the  form  of 
Lahniann's  cotton-wool  clothing.  Climate  is  of  great  im- 
portance, the  best  being  one  which  is  equable  and  fairl)- 
bracing.  As  to  diet,  it  sliould  be  a  typical  gouty  diet,  with 
the  minimum  of  proteid  and  starchy  foods  and  all  those 
articles  which  produce  an  acid  fermentation.  The  writer 
believes  the  drugs  which  are  of  real  value  to  be  those  which 
benefit  dyspepsia  and  increase  the  alkalinity  of  the  blood, 
such  as  bismuth,  the  alkalies,  and  the  bromides.  Anti- 
mony wUl  at  times  relieve  the  itching,  though  sometimes 
morphine  is  necessary.  Lotions  and  dusting-powders  as 
well  as  the  use  of  water  are  then  discussed. 

The  Subcutaneous  Administration  of  Oxygen. — William 
Ewart  declares  that  no  conclusions  can  be  based  upon  so 
limited  an  experience  of  these  two  methods — subcutaneous 
infusion  of  solutions  of  peroxide  of  hydrogen  and  subcuta- 
neous injections  of  oxygen  gas — of  supplying  oxygen  lo- 
cally to  the  systemic  circulation,  nor  would  he  venture  at 
this  stage  to  recommend  their  employment  except  in  ur- 
gent conditions  when  oxj-gen  cannot  be  inhaled.  The 
two  series  of  observations  show  that  there  mav  be  set  up 
p.  local  o.xygen  emphysema  of  the  areolar  tissue  without 
any  evil  result,  and  that  the  gas  will  be  gradually  ab- 
sorbed, though  the  process  is  slow.  The  diluted  hydrogen 
peroxide  infusion  probably  presents  less  risk  than  the  other 
method,  though  the  oxygen-gas  injection  is  easier  to  carry 
out.  The  clinical  value  of  the  subcutaneous  method  as  a 
general  stimulant  has  yet  to  be  made  out. 

A  Discussion  on  Serum  Therapy. — T.  J.  Bokenham,  after 
discussing  tliis  subject  in  general,  takes  up  in  particular, 
first :  antidiphtheria  serum,  which  as  a  curative  agent  has 
quite  fulfilled  the  expectations  of  most  physicians.  As  an  im- 
munizing agent,  the  author's  ]iersonal  experience,  extend- 
ing to  nearly  five  hundred  inoculations,  is  altogether  in  its 
favor.  Antistreptococcus  serum  rapidly  deteriorates,  so 
the  results  are  not  likely  to  be  uniform.  Antipneumococ- 
cus  serum  is  not  bactericidal  as  pneumococci  grow  readily 
in  it.  The  chief  difficulty  in  its  clinical  use  arises  from  the 
great  number  of  bacteria  present  in  the  lung  exudation, 
and  from  the  fact  that  the  action  of  the  serum  seems  lim- 
ited to  preventing  the  entry  of  the  organisms  into  the  blood- 
vessels. 

Some  Work  Bearing  Upon  the  Preventive  Treatment  of 
Oxalate  of  Lime,  Gravel,  and  Calculus. —  Lindley  Scott  states 
that  it  is  certainly  known  that  oxalate  of  lime  contributes 
largely  toward  the  formation  of  calculus,  especially  renal 
calculus.  The  urine  which  deposits  calcium  o.xalate  is  gen- 
erally reported  as  acid,  of  an  increased  specific  gravity,  and 
frequently  with  a  high  proportion  of  urea  and  other  solid 
constituents.  The  prolonged  administration  of  small  doses 
of  magnesium,  say  gr.  xl.  of  the  sulphate,  given  in  the  af- 
ternoon and  at  bedtime,  in  a  well-diluted  solution  or  com- 
bined with  some  mild  diuretic,  would  seem  a  suitable  treat- 
ment. Attention  to  general  health,  regimen,  and  diet  must 
be  observed. 

Treatment  of  Asthma  and  Hay  Fever.— Ernest  Kingscote 
believes  there  are  three  pretty  con.^laiit  factors  in  cases  of 
asthma  of  long  standing — cardiac  dilalation,  acute  vesicu- 
lar emphysema,  and  chronic  congestion  of  the  liver.  The 
conditions  must  be  dispersed  in  addition  to  any  other 
causes  in  order  to  cure  the  patient.  Having  ascertained 
the  vagal  or  sympathetic  irritation,  it  should  be  removed. 
Cardiac  dilatation  is  nest  reduced  by  the  Schott  treatment 
and  emphysema  by  appropriate  breathing  exercises.  The 
patient  should  lie  in  the  open  air  as  mucli  as  possible. 

Contribution  to  Our  Knowledge  of  Proteid  Metabolism  in 
Children  (with  Charts). -By  F.  \V.  Tunnicliffe  and  Otto 
Rosenheim. 

An  Introductory  Address  on  the  Training  of  Body  and 
Mind  for  the  Profession  of  Medicine.  -By  Sir  Jolin  Williams. 

A  Contribution  to  the  Study  of  the  Vascular  Mechanism 
of  the  Testis    (Illustrated)  .  —  By  \V.  !•:,  DixDii. 

Some  Forms  of  Optic-Nerve  Disease,  Probably  of  Sympa- 
thetic Origin   (Illustialed). — By  K.  Fergus. 


A  Case  of  Leucosarcoma  of  the  Iris,  Showing  Fibro-Hyaline 
Changes   (Illustrated).— By  W.  W.  ("irifhn. 

Remarks  on  Extractum  Jaborandi  Liquidum  iB.  P.i. — I'v 
H.  A.  D.  Juwetl  and  C.  R.  Marshall. 

Remarks  on  the  Treatment  of  Town  Phthisicals  in  the 
Country. — By  II.  de  C.  Woodcock. 

A  Discussion  on  the  Therapeutics  of  Open  Air. — By  F,  W. 
Burton-Fanning. 

A  Discussion  on  the  Treatment  of  Lachrymal  Obstructions. 
—By  G.  A.  Berry. 

A  Discussion  on  the  Treatment  of  Internal  Hemorrhages. — 

By  W.  (;.  Smith. 

A  Discussion  on  Diet  in  the  Treatment  of  Disease. — By 
H.  Campbell. 

Dacryocystitis  Aggravans,  Resembling  Tumor  of  Face. — 
By  K.  Scott. 

The  Pharmacology  of  the  Jaborandi  Alkaloids. — By  C.  R. 
Maishall. 

The  Chemistry  of  the  Jaborandi  Alkaloids. — Bv  H.  A.  D. 
Jowett. 

The  Open-Air  Treatment  in  Ireland. — By  F.  H.  Sinclair. 

Cerebral  Tumor  with  Optic  Neuritis. — By  E.  Clarke. 

Miinchcncr  incd.  Woi/ieiisi/iriJ/,  Si-p/.  e;  and  Oct.  3,  tgoo. 

Eight  Cases  of  Sausage  Poisoning. — Lank  describes  an 
epidemic  of  a  disease  atiecting  three  adults  and  five  chil- 
dren, which  was  at  first  thought  diagnosed  as  diphtheria 
but  was  afterward  found  to  be  caused  by  the  eating  of  im- 
perfectly cured  sausages.  Poisoning  from  this  source 
(botulismus  or  allantiasis)  is  to  be  differentiated  from  that 
due  to  the  use  of  putrefying  meat,  and  a  specific  organism, 
the  bacillus  botulinus.  has  been  isolated  and  found  to  gen- 
erate a  toxin  resembling  the  poisons  of  tetanus  and  diph- 
theria in  its  chemical  composition.  The  course  of  the  dis- 
ease is  protracted  even  in  the  lighter  cases,  the  first 
symptoms  not  appearing  for  twelve  to  twenty-four  hours. 
They  are  then  ushered  in  by  general  malaise,  nausea, 
vomiting,  and  diarrhoea,  followed  by  dyspnoea  and  pros- 
tration. A  characteristic  effect  of  the  into.xication  is  the 
decrease  in  all  the  secretious  with  the  resulting  dryness  of 
the  skin  and  mucous  membranes.  As  a  consequence  the 
mouth  presents  aphthous  ulcers  and  the  throat  is  filled  with 
erosions,  red  patches,  and  a  grayish  membrane  frequently 
resembling  that  of  diphtheria,  while  the  condition  of  the 
intestinal  canal  and  air  passages  produces  obstinate  con- 
stipation and  hoarseness  often  accompanied  by  a  croupy 
cough.  Eye  symptoms  are  typical  and  comprise  cloudy 
vision,  chromatopsia,  evanescent  amaurosis,  and  diplopia ; 
ptosis  is  a  constant  and  pathognomonic  sign  of  the  intoxica- 
tion. There  are  no  central  manifestations,  but  dysphagia 
and  aphasia  of  peripheral  origin  are  observed  ;  there  is 
also  no  fever,  though  the  pulse  grows  rapid  and  weak. 
Death  may  not  occur  for  some  time,  and  then  be  due  to  the 
inanition  and  marasmus,  or  may  follow  in  from  eight  to  ten 
days  owing  to  paralysis  of  respiration,  no  typical  post- 
mortem appearances  being  produced. 

A  Case  of  Purpura  Haemorrhagica. — Nehrkorn  describes  the 
case  of  a  twenty-six-ycar-old  laborer  who  was  suddenly 
taken  witli  severe  epista.xis  followed  by  extensive  subcuta- 
neous Iiemorrhages,  hiematuria,  and  bleeding  from  the 
oral  mucus  membrane.  These  symptoms  were  accompa- 
nied Ijy  great  prostration  which  speedily  becan  e  extreme  in 
consequence  of  the  uncontrollable  loss  of  blood  from  mouth, 
kidneys,  and  gasti-o-intestinal  tract.  Finally,  delirium, 
restlessness,  and  coma  were  succeeded  by  death  four  days 
after  tlie  first  symptoms.  The  haemoglobin  was  found  re- 
duced to  twenty  per  cent.,  and  the  red  blood  cells  to  one 
and  a  half  millions.  At  the  autopsy  tliere  were  found  ex- 
tensive hemorrhages  into  all  the  viscera  with  moderate 
endocarditis  of  the  aortic  and  mitral  valves  and  a  narrow 
aorta.  The  ca.se  is  interesting  in  that  its  fulminating 
course  with  the  extensive  hemorrhages  and  pustule  for- 
mation very  greatly  simulated  hemorrhagic  variola,  and 
though  the  history  excluded  this,  the  jiicture  of  the  malady 
was  essentially  that  of  an  infectious  disease. 

The  Position  of  the  Stomach  in  Chlorosis. — Otto  Rostoski 
controverts  llie  view  of  Meinert  and  .some  other  authors 
who  maintain  that  chlorosis  is  always  accompanied  by 
gastroptosis,  or  even  go  .so  far  as  to  say  that  the  dislocation 
of  the  stomach  precedes,  and  through  the  resulting  nervous 
derangements  actually  produces  the  blood  dy.scrasia.  The 
writer's  observations  extend  over  a  series  of  fifty  ca.ses  of 
chlorosis,  in  thirteen  of  which  a  state  of  gastroptosis  was 
found  which  seemed,  however,  more  directly  referable  to 
a  too  early  use  of  the  corset,  a  circumstance  es])ecially  mer- 
iting attention  in  the  frequency  witli  which  distended  loops 
of  intestine  are  pushed  liefore  a  stomach  undergoing  artifi- 
cial inflation  for  purjioses  of  diagnosis  and  a  dilatation  is 
thus  simulated.  In  the  writer's  opinion  fauliy  conclusions 
are  often  reached  owing  to  this  source  of  error,  and  several 


October  27,  1900] 


MEDICAL    RECORD. 


667 


different  methods  for  determining  the  stomach  boundaries 
should  always  be  resorted  to  before  a  positive  diagnosis  is 
made. 

The  Question  of  Traumatic  Spinal  Disease. — M.  Oljerst 
attacks  the  iiosition  of  Kiininifll,  who  bi;lieves  in  trau- 
matic spondylitis,  i.e.,  a  rarefying  ostitis  beginning  weeks 
or  months  alter  slight  injuries,  and  leading  to  a  greater  or 
less  loss  of  substance,  and  maintains  that  all  such  cases 
are  really  compression  fractures.  Injuries  of  this  nature 
are  much  more  frequent  than  is  supposed,  and  inasmuch 
as  they  may  be  due  to  slight  trauma  and  give  but  few  sub- 
jective or  objective  symptoms  are  very  easily  overlooked. 
Still  a  certain  degree  of  violence  is  necessary  to  produce 
such  a  Ijsion,  and  in  accident  cases  when  kyphosis  follows 
in  spite  of  the  insignificant  nature  of  the  injury,  tuberculous 
disease  is  to  be  assumed.  The  term  traumatic  spondylitis 
is  misleading  and  may  advantageously  be  replaced  in 
doubtful  cases  by  tho  designation  "traumatic  kyphosis." 

The  Treatment  f  Spina  Bifida. — C.  Hennemann  reports 
an  instance  of  this  delect  in  wliich  the  result  of  treatment 
was  .so  happy  as  to  discount  the  usually  pessimistic  view 
taken  of  such  cases.  At  the  time  treatment  was  begun 
the  tumor  was  the  size  of  a  child's  head,  and  its  covering 
as  thin  as  paper,  threatening  to  burst  at  a  touch.  The 
lower  extremities  were  ana-sthetic  and  both  bladder  and 
bowel  completely  paralyzed.  The  fluid  was  aspirated  on 
three  occasions,  1,550  c.c.  being  obtained,  and  each  time 
30  c.c.  of  Lugol's  solution  were  injected  into  the  sac.  Af- 
ter the  third  operation  no  reaccumulation  occurred,  and  in 
the  course  of  time  all  the  secondary  sym]itoiiis  disappeared 
without  any  indications  of  a  possible  relapse. 

The  Occurrence  of  Carcinoma. — Reiclie  finds  that  the  car- 
cinoma statistics  of  Hamburg  show  what  has  been  found 
true  in  other  localities,  viz..  tliat  during  the  last  thirty 
years  tlie  mortality  from  cancer  has  been  slowly  but  stead- 
ily rising,  that  the  increase  afiects  the  male  po])ulation 
more  than  the  female,  and  that  the  average  age  of  the 
fatal  cases  is  growing  less.  By  contrasting  the  figures 
taken  before  and  after  certain  radical  sanitary  and  other 
reforms  were  instituted  in  the  city,  he  arrives  at  the  con- 
clusion that  the  local  occurrence  of  carcinoma  is  independ- 
ent of  the  nature  of  the  water  supply,  the  density  of  iiopu- 
lation.  the  comparative  altitudes  of  different  parts  of  the 
city,  and  conditions  f>f  poverty  or  affluence. 

The  Effect  of  Petroleum  on  the  Diphtheria  Bacillus.— J. 
Papasotiiin  made  numerous  experiments  with  a  view  to 
determine  whether  the  use  of  petroleum  in  diphtheria 
was  justified  by  the  facts.  The  agent  was  applied  to  grow- 
ing colonies  of  the  bacilli  in  various  ways  with  the  invari- 
able result  that  the  plates  so  treated  flourished  just  as  vig- 
orously as  the  control  growths.  Any  remedial  effect  of 
petroleum  in  dijihtheria  is  tlierefore  independent  of  a  germ- 
icidal action  on  the  organism. 

Our  Standpoint  in  Regard  to  Suppuration  of  the  Middle 
Ear  and  the  Question  Oi  Cholesteatoma. — By  Ernst  Leulci  t. 

The  Therapy  of  Chronic  Middle-Ear  Disease  and  the  Ques- 
tion of  Cholesteatoma.   -F>y  E.  Leiucrt. 

E.xamination  of  a  Case  of  Congenital  Sternal  Cleft  with 
the  Fluoroscope. — By  Criegern. 

A  Contribution  to  the  Study  of  the  Inflammatory  Anky- 
loses of  the  Spine.  —  By  Kiihn. 

The  Operative  Treatment  of  Habitual  Shoulder  Dislocation. 
—  By  Joseph  Miillcr. 

The  Duration  of  Fermentation  in  Urines  Containing  Sugar. 
— By  T.   I.ohnslein. 

Roborat  and  its  Comparison  with  Similar  Food  Products. — 
By  E.  Laves. 

The  Diagnosis  of  Death  by  Starvation. — By  11.  Diinsch- 
mann. 

A  Case  of  Hysterical  Fever. — By  E.  Wormser  and  Robert 
Bing. 

Deutsche  iiuuiuinische  ]]'ocluiischrifl,  October  4,  igoo. 

Black-Water  Fever. — In  a  preliminary  report  Hans  Zie- 
mann  athrms  his  inability  to  find  a  specific  organism  for 
this  disease  as  stated  by  Yersin.  In  certain  malarial  dis- 
tricts there  is  found  among  those  who  have  already  suffered 
from  a  malarial  infection  a  disposition  to  attacks  of  black- 
water  fever.  In  general  this  is  increased  proportionately 
to  the  number  of  previous  malarial  infections,  and  is  great- 
est among  those  having  the  hemorrhagic  diathesis  or  who 
have  been  weakened  by  hardships,  though  it  also  occurs 
in  healthy  individuals  of  good  antecedents.  The  small 
parasite  of  the  tropics,  or  the  a;stivo-autumnal  form,  seems 
mi>st  predisposing,  though  apparently  differences  in  viru- 
lence line  to  varying  conditions  in  different  localities  play 
an  im])ortant  role.  In  regard  to  the  positions  that  black- 
water  fever  is  purely  a  result  of  quinine  poisoning,  or,  on 
the  other  hand,  that  it  is  a  special  form  ot  malaria  charac- 
teristic of  certain  localities,  it  may  be  said  that  it  is  ob- 


served :  (I)  Following  a  new  malarial  infection  in  which 
no  quinine  has  been  given  ;  (2j  following  malaria  treated 
with  quinine;  (3)  following  the  administration  of  quinine 
to  those  who  have  formerly  had  malaria  but  are  at  the  time 
free  from  the  parasites;  (4)  in  those  who  have  suffered 
from  a  previous  attack  of  black-water  fever  but  have  not 
recently  taken  quinine  and  whose  blood  does  not  contain 
any  parasites. 

Dysentery  and  its  Specific  Cause. — \V.  Kruse  warns 
against  the  belief  that  dysentery  as  an  epidemic  disease 
has  died  out.  and  cites  several  localities  in  tJermany  which 
have  suffered  greatly  from  its  ravages  in  recent  times. 
The  disease  as  found  in  Eg\^)t  and  the  tropics  is  usually 
of  amoebic  origin,  but  study  of  an  epidemic  at  Laar  has 
brought  to  light  an  organism  which  the  author  thinks  is 
specific,  and  which  owing  to  its  cultural  and  other  affinities 
he  would  place  in  a  trinity  with  the  typhoid  and  colon  ba- 
cilli. In  api>earance  it  differs  markedly  from  the  typhoid 
bacillus,  being  shorter,  thicker,  and  devoid  of  flagella,  but 
its  biology  and  manner  of  growth  apparently  indicate  a 
close  relationship  between  the  two.  An  imi)ortanl  reaction 
serving  to  distinguish  the  new  organism  from  the  group 
usually  termed  collectively  colon  bacilli  is  its  inability  to 
produce  fermentation  in  grape-sugar  media.  It  is  not 
specific  for  animals,  but  is  agglutinated  by  the  blood  serum 
of  dysenteric  patients  and  remains  unaffected  by  that  of 
healthy  individuals. 

Pneumonia  through  the  Meningococcus. — J.  Bernheim  de- 
scriljes  in  detail  the  clinical  course  and  (lathological  find- 
ings in  a  case  of  pneumonia  running  so  rapidly  fatal  a 
course  as  to  make  a  general  systemic  infection  seem  prob- 
able. This  was  found  not  to  be  the  case,  however,  but  tlie 
fluid  from  the  lungs  contained  large  numbers  of  diplococci 
which  gave  all  the  microscopical  and  biological  evidence 
necessary  to  identify  them  with  Weichselbaum's  menin- 
gococcus intracellularis. 

The  Pathology  and  Therapy  of  Abscess  of  Douglas'  Space 
in  Perityphlitis.  —  By  1.  Rotter. 

The  Conversion  of  Proteids  and  the  Excretion  of  Sugar. — 
By  Th.  Kunipf. 

Ilcr/hu-r  i;iiiiisclie  W'ocltcnschrifl,  Sep/.  34,  /goo. 

Medical  Supervision  of  Cures  for  Obesity.— E.  H.  Kisch 
says  that  in  attempts  to  reduce  bodily  weight,  care  should 
be  taken  to  avoid  all  measures  which  tend  to  weaken  the 
patient's  strength  and  es])ecially  heart  action.  There 
should  be  a  regulation  not  only  of  the  amount  of  food  and 
drink,  but  also  of  the  general  mode  of  living  and  the  pa- 
tient's former  habits,  all  of  which  must  be  based  on  a  care- 
ful consideration  of  eacli  individual  case.  The  amount  of 
exercise  may  be  regulated  by  means  of  a  pedometer,  and 
the  number  of  daily  steps  carefully  increased  ;  in  due  time 
he  may  be  allowed  to  climb  hills,  but  the  heart  should  be 
carefully  watched. 

Treatment  of  Dropsy  by  Means  of  Cupping-Glasses. — K. 
Miura  lias  devised  a  cupping-glass  for  the  purjjose  named. 
To  the  glass  is  attached  a  rubber  tube,  the  whole  being 
filled  before  use  with  a  decinormal  salt  .solution.  Superficial 
incisions  are  made  in  the  dropsical  part  under  strict  anti- 
sepsis, care  being  taken  not  to  draw  blood,  and  the  apjia- 
ratus  is  then  applied.  Flow  of  the  salt  solution  from  the 
tube  is  then  induced,  and  the  author  has  found  that  it  is 
possible  to  draw  by  these  means  considerable  quantities 
of  fluid  from  tlic  tissues. 

The  R81e  of  Fixed  Cells  in  Inflammation.— By  P.  B:ium- 
garten. 

Physiology  and  Pathology  of  the  Biliary  Secretion. — By  Dr. 
Albu. 

Sjrmptomatology  of  Facial  Paralysis. — By  L.  Mohr. 
French  Journals. 

Simple  Primitive  Hyperchlorhydria  (Digestive  Chlorhydric 
Hypersesthesia)  and  Continuous  Gastric  Hypersecretion. — Luigi 
Sansoni  (juotcs  Linossiei  as  believing  tliat  under  the  syn- 
drome of  Reichmann  the  following  pathological  types 
should  be  accepted  :  (i)  Primitive  gastrosuccorrhoea  with- 
out pyloric  stenosis  ;  (2)  primitive  gastrosuccorrlKca  with 
consecutive  spasmodic  pyloric  stenosis  ;  (3)  i)rimitive  gas- 
trosuccorrhd'a  with  ulcers  and  consecutive  anatomical  py- 
loric stenosis  ;  (4)  gastiosuccorrhfjea  by  retention  following 
a  pyloric  stenosis.  The  surgeons  Carle  and  F'antino,  es- 
pecially, not  being  ab'e  to  deny  absolutely  the  existence 
of  a  primitive  gastrosuccorrhiea  not  accompanied  or  fol- 
lowei  by  pyloric  stenosis,  attribute  the  greatest  impor- 
tance to  alimentary  stasis,  consecutive  to  a  stenosis  of 
the  pylorus,  spasmodic  or  real.  The  prevalent  opinion  to- 
day relative  to  the  origin  of  continuous  gastrosuccorrhrea 
accords  almost  completely  with  that  expressed  by  the  au- 
thor in  iSSS.  He  believes  that  the  cause  of  the  symirome 
of  Reichmann  consists  in  alimentary  stasis  due  to  obstruc- 
tion, functional  or  otherwise,  of  the  pylorus.  Neverthe- 
less, the  primary  cause  for  a  certain  category  of  cases  is. 


668 


MEDICAL    RECORD. 


[October  27,  1900 


the  author  believes,  not  hyperchlorhydria  but  hypersesthe- 
sia  of  the  gastric  mucosa,  acimitting,  for  another  category, 
that  the  pyloric  spasm  depends  on  anatomical  lesions 
which  escape  clinical  diagnosis,  such  as  small  ulcerations, 
etc.  He  does  not  wish  to  deny  absolutely  the  existence  of 
a  secretory  trouble — primitive  and  fundamental  in  the  gen- 
esis of  continuousifastrosuccorrhoea.but  he  adds  that  among 
several  thousand  patients  with  gastric  trouble,  whose  stom- 
achs he  has  examined  from  a  functional  point  of  view,  in 
every  one  of  whom  the  symptoms  indicated  the  existence  of 
a  continuous  gastrosuccorrhoea,  he  has  always  found  in  the 
stomach  even  after  fasting  remnants  of  food  of  a  quantity 
greater  or  less. — Lii  Prcsse  Medicale,  September  29,  1900. 

Extra-Buccal  Alimentation. — According  to  M.  Ewald,  ex- 
tra-buccal  alimentation  cannot  completely  replace  buccal 
alimentation  ;  it  cannot  suffice  for  a  long  time  for  the  exi- 
gencies of  nutritive  changes  ;  in  the  majority  of  cases,  an 
alimentation  exclusively  extra-buccal  produces  from  the 
beginning  a  subnutrition  ;  this  form  of  feeding  may,  how- 
ever, for  a  short  time,  in  enfeebled  individuals  whose  nu- 
tritive metabolism  is  diminished,  increase  the  nitrogenous 
changes,  and  even  cause  an  increase  in  weight ;  its  best 
results  are  seen  when  used  transiently,  or  when  employed 
only  as  an  adjunct  to  buccal  feeding;  in  the  niaj(n-ity  of 
cases,  nutritive  enemata  ought  to  be  preferred  to  subcuta- 
neous injections.  Discussing  tiie  same  subject,  M.  Leube 
formulates  the  following:  (i)  Per  rectum:  albuminoids 
which  can  be  administered  are  preparations  of  peptone  (60 
gm.)  or  eggs  (3-I-3  gm.  of  salt).  The  vehicle  should  be 
300  gm.  of  milk.  Carbohydrates  can  be  given  in  doses  of 
15  to  20  gm.  for  300  gm.  of  liquid,  but  starches  are  to  be 
preferred — 15  to  20  gm.  to  too  gm.  of  water  or  milk.  Fat 
is  not  suitable  for  rectal  enemata.  The  value  of  each  of 
these  enemata  is  from  500  to  650  calories,  and  they  should 
be  given  twice  a  day.  (2)  Fat  can  be  employed  for  sub- 
cutaneous injections,  the  dose  being  from  50  to  100  gm. — 
Gazelle  J/e/xfoiiiai/aire  de  Meileeine  el  de  Chirur^ie,  Sep- 
tember 27,  looo. 

Disinfaction  by  Formacetone. — Eugene  Fournier  gives  the 
following  conclusions  on  this  subject:  Perfect  disinfection 
can  be  accomjilished  only  by  gas  or  vapor.  Of  all  the  sub- 
stances employed,  formacetone  can  be  considered  the  most 
energetic  disinfectant  and  a  very  active,  if  not  the  most  ac- 
tive, insect  destroyer.  The  proportion  of  the  vapor  nec- 
essary to  use  is  in  direct  ratio  to  the  size  of  the  object  to 
be  disinfected.  It  is  necessary  to  dampen  the  object  first 
by  a  projection  of  acetone  vapoi-.  The  vapors  of  formace- 
tone are  not  inflammable.  The  projections  ought  to  be 
made  under  a  pressure  of  4  kilos.,  which  ought  to  be  main- 
tained during  the  whole  process.  The  duration  of  con- 
tact of  the  disinfectant  vapor  is  to  be  in  inverse  proportion 
to  the  temperature.  In  places  where  there  is  no  apparatus 
for  disinfection,  clothing  is  sterilized  by  immersion,  and 
after  rinsing  and  drying,  an  iron  will  restore  the  former 
appearance.  Surgical  instruments  are  sterilized  by  form- 
acetone in  a  very  practical  manner  at  45'  C.  in  a  special 
sterilizer,  and  they  undergo  no  alteration.  —  Gazelle  des 
Hi'ipitaii.x,  September  29,  1900. 

A  Case  of  Sacro-Coxalgia. — E.  Leclerc  sums  up  the  char- 
acteristic symptoms  of  this  affection  after  describing  a 
ease;  Pain  distinctly  limited  to  the  level  of  the  sacro-iliac 
space ;  elevation  of  the  pelvis  on  the  alfected  site  (meas- 
ured by  the  elevation  of  the  anterior  superior  iliac  spine)  ; 
shortening,  both  apparent  and  real,  of  the  leg ;  increase  of 
the  distance  which  separates  the  mi<lcUe  of  the  sacrum — not 
the  sacral  crest — from  the  anterior  superior  iliac  spine ; 
slight  atrophy  of  the  mu.scles  of  tlie  buttock  and  of  the 
thigh. — l.e  Btillelin  Medical,  September  29,  1900. 

Archives  tyf  Pci/ialrics,  Oclober,  igoo. 

Report  of  a  Case  of  Pulmonary  Stenosis.— Samuel  McC. 
Haniill  reports  a  case  in  a  boy  aged  si.x  yeais.  Ausculta- 
tion of  the  heart  revealed  a  rather  rough,  blowing,  systolic 
murmur  heard  over  the  entire  precordia.  and  to  some  ex- 
tent over  the  entire  anterior  portion  of  the  left  chest,  with 
its  i)oint  of  maximum  intensity  in  the  second  left  inter- 
space. At  this  point  it  was  superficial,  very  loud,  low- 
pitched,  almost  grating  in  character.  This  very  marked 
loudness  was  limited  to  an  area  al)out  the  size  of  a  lialf-dol- 
lar,  corresponding  to  the  pulmonary  region.  Over  the  por- 
tion of  the  heart  extending  to  the  right  of  the  sternum  was 
heard  a  peculiar,  loud,  flap-like,  systolic  sound,  suggest- 
ing the  loud  first  sound  of  mitral  stenosis.  There  was  no 
accentuation  of  the  pulmonary  sound.  As  a  matter  of 
fact,  it  was  almost  inaudible.  The  heart's  action  was  rather 
rapid,  strong,  and  regular.  Hy  an  exclusion  of  other  le- 
sions, a  diagnosis  of  pulmonary  stenosis  was  reached.  The 
lesion  is  uncommon,  and  its  existence,  as  in  this  case,  with- 
out evidence  of  venous  stenosis  is  rare. 

Atrasia  of  the  Larynx  due  to  Traumatism,  the  Result  of 
Faulty  Intubation  — \V.  P.  Xorthrup  submits  a  si)ecimen, 
the  last  case  of  intubation  seen  by  the  late  Dr.  O'Dwyer. 
The  tubes  used  in  this  case  were  of  the  latest  approved 


pattern  ;  the  technique  was  that  of  a  beginner  and  proved 
faulty.  Imperfect  tubes  and  imperfect  technique  con- 
stantly worked  against  the  success  of  intubation  and  gave 
Dr.  O'Dwyer  great  uneasiness  of  mind.  Each  brought 
reproach  upon  the  operati<m  ;  each  meant  traumatism  to 
the  larynx  ;  each  worked  to  the  harm  of  the  patient ;  each 
diminished  the  chances  of  recovery.  The  inventor  wrote 
always  in  the  same  strain,  endeavoring  to  keep  it  before 
the  minds  of  the  medical  profession  that  the  operation 
should  be  done  by  skilled  hands  and  should  include  proper 
tubes. 

Acute  Nephritis  following  Influenza. — Rowland  Godfrey 
Freeman  concludes  that :  (i)  Although  albuminuria  is  fair- 
ly frequent  with  influenza,  nephritis  is  a  rare  complication. 
(2)  The  nephritis  complicatiug  influenza  is  clinically  of 
the  acute  hemorrhagic  type  and  morphologically  shows 
toxic  lesions.  (3)  It  apparently  attacks  children  more 
often  than  adults.  (4)  The  kidney  disturbance  may  ap- 
pear a  few  days  after  the  acute  symptoms  of  the  influenza, 
or  as  long  as  a  month  later.      (5)    The  prognosis  is  good. 

A  Case  of  Suppression  of  Urine  Apparently  due  to  Ascaris 
Lumbricoides. — By  Frank  Vander  Bogcrt. 

Congenital  Cardiac  Malformation  with  Endocarditis  and 
Anuria. — By  A.  C.  Cotton. 

Tlie  Edinburgh  Medical  Journal,  Oclober,  igoo. 

The  Clinical  Forms  and  Pathological  Anatomy  of  Spinal 
Syphilis. — R.  J.  Williamson  thus  classifies  the  clniical 
forms  of  the  disease :  (i)  Symptoms  of  compression  of  the 
spinal  cord  or  nerve  roots  may  be  produced  by  syphilitic 
disease  of  the  vertebra£,  syphilitic  caries,  necrosis,  gumma, 
exostosis,  periostitis,  or  osteitis.  (2)  In  another  very  rare 
form  there  are  symptoms  of  chronic  meningitis  without  in- 
dications of  involvement  of  the  spinal  cord.  (3)  Meningo- 
myelitis  is  the  most  common  form  of  spinal  syphilis.  (4) 
Acute  syphilitic  paraplegia  (acute  syphilitic  myelitis). 
(5)  Erb's  syphilitic  spinal  paralysis.  (6)  Paraplegia  with 
combined  degeneration  in  the  posterior  and  lateral  col- 
umns. (7)  Gumma  of  the  spinal  cord  or  meninges.  (8) 
Anomalous  forms.  The  author  gives  nine.  (9)  Locomo- 
tor ataxia.  Sir  William  Gowers  thinks  that  after  a  deduc- 
tion is  made  for  possible  accidental  coincidence,  there  is 
still  a  causal  relationship  between  this  disease  and  syphilis 
in  one-half  to  three-quarters  of  the  cases.  The  pathologi- 
cal changes  produced  by  syphilis  may  be  divided  into 
three  classes:  (i)  Those  which  indicate  syphilis  most 
clearly — gummata,  gummatous  infiltration  of  meninges  or 
cord,  etc.  ;  (2)  changes  suggestive  but  not  conclusive  of 
syphilis — disease  of  the  blood-vessels,  endarteritis  and  peri- 
arteritis, endo-  and  periphlebitis;  (3)  changes  secondary 
to  the  vascular  disease  ;  thrombosis  of  spinal  vessels,  or 
complete  or  partial  obstruction  of  the  vessels  from  thicken- 
ing and  disease  of  their  walls.  It  is  to  be  hoped  that  fu- 
ture bacteriological  research  will  lead  to  the  discovery  of 
a  characteristic  micro-organism  in  syphilitic  lesions. 

Points  of  Practical  Interest  in  Singical  Gyneecology  versus 
Affections  of  the  Female  Genitalia  as  Causal  Factors  in  the 
Etiology  of  Neuroses  and  Insanity. — By  H.  llacnaughton 
Jones. 

A  Contribution  to  the  Mechanism  of  Articulate  Speech 
(Contmuedj. — By  S.  W.  Caruthers. 


©orrcspoticleitce. 

OUR    LONDON   LETTER, 

(From  our  Special  Correspondent.) 

OPENING  OF  THF.  SESSION — NOTES  OF  INTKODfCTORV  LECTURES 
— LORD  lister's  HUXLEY  LECTURE — THE  GOVERNOR  OF 
LAGOS  ON  MALARIA — PROFESSOR  TOORE  ON  THE  LECTURE 
SYSTEM  —  DR.  PENROSE  ON  THE  LONDON  UNIVERSITY  — 
PROFESSOR  M'faDYEAN  ON  EXPERI.MENTAL  RESEARCH — THE 
PLAGUE — TYPHOID — THE   LATE   DR.    SAVAGE. 

London,  October  5,  iqcxj. 
The  opening  of  the  winter  session  is  important  enough  to 
demand  attention  even  amid  the  distractions  of  a  general 
election  and  the  excitement  of  war  news.  Dinners,  con- 
versazioni, and  [irize  distributions  have  in  some  cases  dis- 
placed the  old-time  introduetories ;  but  several  of  the 
schools  have  continued  their  lectures,  which  now  fulfil  an 
important  function,  though  one  somewhat  dillerent  from 
that  of  the  last  generation.  But  what  can  a  correspondent 
say  about  half  a  dozen  high-class  addresses  delivered  dur- 
ing the  week?  It  is  im[)ossible  to  summarize  them,  and 
space  interposes  barriers  against  criticism.  I  will  tliere- 
fore  give  you  only  samples  of  what  I  hear  about  them. 

Lord  Lister's  was  naturally  expected  to  be  something 
out  of  the  common.  He  gave  the  "Huxley  Lecture," 
which  was  founded  to  commemorate  the  fact  that  the  emi- 


October  27,  1900] 


MEDICAL    RECORD. 


669 


nent  physiologist  received  his  medical  education  at  Char- 
ing Cross  Hospital.  It  is  delivered  biennially  and  serves 
as  an  introductory  at  that  school  on  alternate  years.  Lord 
Lister's  is  the  third  of  this  series,  the  preceding  ones  hav- 
ing been  given  by  Sir  M.  Foster  (1896)  and  Professor 
Virchow  (189S). 

Lord  Lister's  subject  was  his  early  work  leading  up  to 
the  antiseptic  system,  and  he  was  induced  to  take  it  by  the 
desire  of  those  who  asked  him  to  give  the  Huxley  lecture 
that  he  should  deal  with  his  own  work.  He  objected  on 
the  ground  that  what  lie  had  done  had  for  the  most  part 
been  published,  l)ut  yielding  to  friendly  pressure  he  took 
up  his  early  efforts  as  those  least  known.  So  we  had  a 
charming  bit  of  semi-autobiography  from  the  time  when 
his  father,  who  had  done  so  much  to  improve  the  micro- 
scope, equipped  him  with  a  Ijrst-rate  instrument  and  sent 
him  to  study  at  University  College,  up  to  that  when  Pas- 
teur's demonstration  that  putrefaction  is  due  to  microbes 
was  made.  For  this  his  mind  was  quite  prepared  by  the 
researclies  he  had  made,  and  the  problem  became,  how  to 
exclude  microbes  from  wounds.  As  he  said  in  concluding, 
"It  has  been  since  shown  that  putrefaction  is  not  the  only 
cause  of  mischief  in  wounds — in  other  words,  it  has  been 
proved  that  there  are  microbes  which  produce  poisons  that 
do  not  occasion  unpleasant  smell.  But  the  principle  that 
first  guided  me  still  retains,  I  believe,  its  full  value,  and 
the  endeavor  to  apply  that  principle  so  as  to  insure  the 
greatest  safety  with  tlie  least  attendant  disadvantage  has 
been  my  chief  lifework." 

At  the  School  of  Tropical  Medicine,  Sir  William  Mac- 
Gregor,  M.U.,  governor  of  Lagors,  discoursed  among  other 
things  on  malaria  and  the  nio.squito  theory.  Judging  from 
personal  experience,  he  said,  it  seemed  to  him  that  dysen- 
tery caused  more  deaths  in  the  tropics  than  any  other  dis- 
ease ;  but  to  the  European  the  most  important  is  malarial 
fever.  He  proceeded  to  show  that  tlie  mosquito  on  the 
west  coast  of  Africa  must  be  reckoned  with  at  every  turn. 
To  meet  the  position  hospital  wards  must  be  painted  with 
colors  that  will  show  up  the  mosquito  ;  doors  and  windows 
should  be  of  fine  gauze  wire  netting,  and  all  beds  provided 
with  mosquito-proof  curtains  ;  all  water-tanks,  wells,  res- 
ervoirs, and  even  flower  pots  must  be  protected  with  wire- 
net  covers,  and  any  other  lireeding-place  near  a  hospital 
rendered  impracticable  for  the  insects.  In  hos])itaI  discip- 
line it  will  be  an  offence  to  allow  a  patient  to  be  bitten.  In 
the  tropics  Sir  William  MacGregor  would  have  the  subject 
of  malarial  genesis  i)ut  before  the  public  in  its  simjjlest 
form  and  taught  in  all  tlie  schools.  Prizes  should  be  given 
to  the  best  scholars  in  the  malarial  class.  Ladies  who  un- 
derstood the  theory  would  not  dine  in  low  dresses  ;  nor 
would  gentlemen  sup  with  their  ankles  covered  only  by 
thin  silk  socks.  The  governor  of  Lagos  gave  some  inter- 
esting details  of  personal  experience  with  anopheles.  One 
statement  he  made  was  that  this  mosquito  is  not  exclu- 
sively a  night  feeder,  but  will  at  times  bite  in  the  day, 
thougli  he  prefers  dusk  or  dark. 

At  University  College  Dr.  Poore,  as  professor  of  medi- 
cine, deliberately  addressed  himself  to  those  who  having 
gone  through  their  anatomical  and  other  scientific  work 
were  about  to  enter  the  wards  to  study  medicine  proper. 
There  bein,g  always  a  doubt  how  near  the  methods  of  the 
laboratory  apiiroachcd  to  those  of  nature,  he  argued  that 
the  discoveries  of  the  former  must  be  checked  by  observa- 
tion of  the  latter.  The  word  "science"  was  often  used  in 
too  narrow  a  sense,  especially  by  narrow-minded  people, 
but  practice  afforded  abundant  opportunities  for  the  best 
scientific  work.  Harvey  found  many  facts  among  his  pa- 
tients to  support  liis  doctrine  of  the  circulation,  and  other 
discoveries  made  by  comprehensive  observation  of  the  sick 
were  confirmed  by  bacteriology.  Practice  is  often  in  ad- 
vance of  theory  as  seen  in  inoculation  and  vaccination, 
to  which  our  eyes  are  only  beginning  to  be  opened.  The 
housewife  bottling  her  fruit  anticipated  Pasteur  ;  the  shep- 
herd with  his  bread,  cheese,  and  raw  onion,  guided  by  nat- 
ural appetite,  selected  a  food  which  the  physiological  chem- 
ist at  a  later  age  finds  to  be  a  judicious  blend  of  "proteids, 
carbohydrates,  fats,  antiscorbutics,  and  antiseptics"; 
Emiii  Pasha  used  mosquito  curtains  as  a  protection  from 
"miasmatic  exhalations."  We  must  not,  then,  lightly 
abandon  established  practices  at  the  bidding  of  half-edu- 
cated theorists,  but  theory  and  practice  must  go  hand-in- 
hand. 

Dr.  Poore  then  congratulated  his  hearers  on  the  nearly 
completed  hospital  which  will  soon  be  an  ornament  to  the 
district,  and  for  which  the  name  of  Blundell  will  in  future 
be  coupled  with  that  of  Guy.  About  two-fifths  of  the  hos- 
pital is  ready  for  occupation.  He  then  defended  the  sys- 
tem of  lectures,  though  many  people  had  thought  them 
useless  in  these  days  of  text-books.  He  had  himself  spent 
no  time  more  profitably  than  in  attending  the  lectures  of 
the  late  Sir  William  Jenner,  who  made  no  attempt  at  ora- 
tory and  no  display  of  learning,  but  whose  style  was  that 
of  an  honest  man,  brimful  of  knowledge  which  he  was 
eager  to  impart.     The  mere  reader  with  his  nose  in  his 


manuscript  might  be  replaced  by  the  phonograph,  but  the 
true  lecturer  is  in  sympathy  with  his  hearers,  knows  when 
they  are  interested  and  when  he  has  failed  to  make  him- 
self understood.  The  lecturer  could  treat  his  subject  with 
more  freedom  than  the  text-book  and  give  a  comjirehen- 
sive  view  of  the  whole  subject.  In  these  days  of  special- 
ism it  is  possible  for  a  student's  knowledge  to  be  "scrappy  " 
— such  as  might  be  that  of  the  aphis  to  the  rose-leaf  it 
feeds  on.  In  specialists'  books  rarities  naturally  assumed 
too  much  importance  to  serve  as  mental  pabulum  for  stu- 
dents. The  child  who  complained  that  in  its  Noah's  ark 
"the  beetle  was  as  broad  in  the  back  as  the  ele])hant " 
might  have  passed  a  similar  criticism  on  a  treatise  lately 
read  on  skin  diseases,  written  by  fifteen  different  derma- 
tologists, but  which  had  not  the  word  "itch  "  in  the  index. 

The  reconstitution  of  the  London  University  was  men- 
tioned in  several  of  the  addresses  and  hopes  were  ex- 
pressed for  its  future — hopes  which  are  doomed  to  disap- 
pointment unless  great  changes  are  made.  The  old 
university  was  a  mere  examining-board  and  its  require- 
ments led  to  cramming  to  such  an  extent  as  to  be  injurious 
to  the  best  students. 

At  St.  George's  Hospital  Dr.  Penrose,  though  he  ex- 
tolled the  high  standard  of  its  examinations — naturally 
enough,  perhaps,  for  one  who  had  passed  them — hoped  that 
one  good  effect  of  the  new  departure  would  be  to  lessen  the 
number  of  the  ordeals  a  man  has  to  pass  before  obtaining 
a  degree.  He  looks  forward  to  the  time,  not  far  distant, 
when  a  qualification  and  degree  may  00th  be  had  on 
passing  three  or  at  most  four  examinations  :  one  at  the  be- 
ginning, one  after  the  scientific  part  of  the  curriculum,  and 
one  final.  This,  he  said,  would  meet  all  necessary  require- 
ments and  would  bring  medical  examinations  into  more 
conformity  with  those  of  the  other  learned  professions. 
How  far  such  a  programme  differs  from  that  enforced  hith- 
erto will  be  seen  when  I  tell  you  that  the  old  university 
insisted  on  its  own  matriculation  being  above  the  standard 
of  others  ;  after  that  it  required  three  severe  examinations 
before  its  lowest  degree  was  obtained.  By  severe,  I  mean 
with  regard  to  book  work,  for  that  was  ever  kept  to  the 
front ;  and  however  much  information  might  be  crammed 
up  for  the  occasion,  you  know  that  such  knowledge  is  a 
very  poor  qualification  for  practice,  even  if  it  were  not  as 
evanescent  as  it  proverbially  is. 

Dr.  Penrose  has  evidently  felt  something  of  this,  for  he 
passed  on  to  remark  that  it  is  the  part  of  the  teachers  to 
direct  the  students  along  the  right  road,  and  assure  them 
that  it  is  better  to  train  them  to  read  the  sign-posts  and 
find  the  way  than  to  tell  them  what  is  written  on  the  posts 
and  expect  them  at  the  journey' send  to  be  able  to  repeat — 
not  what  they  have  actually  seen  and  heard,  but  what  they 
have  been  told  they  ought  to  see.  Dr.  Penrose  then  passed 
on  to  consider  some  problems  concerned  with  medical  edu- 
cation, and  strongly  urged  the  claims  of  laboratory  and 
ward  work  as  both  essential  and  best  conjoined. 

Professor  McFadyean  gave  an  introductory  at  the  Royal 
Veterinary  College  in  which  he  showed  the  valuable  re- 
sults of  the  experimental  methods  of  investigating  disease. 

Other  gleanings  from  the  addres.ses  would  give  plenty 
of  sound  corn,  but  for  the  present  the  foregoing  will  suffice. 

It  is  gratifying  to  see  that  Glasgow  has  succeeded  in  re- 
stricting the  jjlague.  Xo  new  cases  since  my  last.  Two 
deaths  occurred  during  the  week — one  the  baby  born  in  the 
hospital  of  the  mother  who  died  of  plague.  There  are 
only  twenty-one  patients  remaining  in  the  hospitals — two 
doubtful — and  the  "contacts"  in  the  reception  houses 
amount  to  only  nineteen. 

The  usual  increase  of  typhoid  in  autumn  has  begun. 
Last  week  ninety  new  cases  were  admitted  to  the  hospitals 
of  the  asylum  board,  bringing  the  total  up  to  three  hun- 
dred and  twenty-nine.  This  was  an  increase  of  fifty-five 
over  the  previous  week.  There  were  only  eighteen  deaths 
in  the  week,  which  indicates  a  mild  type  of  the  disease. 
Southwark  is  the  most  affected  district.  There  about  one 
hundred  cases  have  occurred  in  the  last  three  weeks.  But 
Dr.  Waldo  is  the  energetic  medical  officer  of  health  there, 
and  every  confidence  may  be  felt  that  nothing  he  can  do  is 
left  undone  to  restrict  the  outbreak. 

Dr.  Henry  Savage,  senior  consulting  ])hysician  to  the 
Samaritan  Hospital  for  Women,  died  on  Wednesday.  He 
took  his  London  M.D.  in  1849  and  the  F.R.C.S.  four  years 
previously.  You  will  remember  his  "Anatomical  Illustra- 
tions of  the  Sur,gery  of  the  Female  Pelvic  Organs."  He 
was  at  one  time  lecturer  on  anatomy  at  the  Westminster 
Hospital,  but  his  lifework  was  in  connection  with  the  Sa- 
maritan, which  he  served  on  the  staff,  and  on  the  commit- 
tee after  retiring  from  practice. 


The  Social  Science  Association The  next  meet- 
ing of  the  American  .Social  Science  Association  will 
be  held  at  Washington,  beginning  April  16,  1901. 


670 


MEDICAL    RECORD. 


[October  27,  1900 


J<ocietxj  ^vcports. 

NEW  YORK  STATE  MEDICAL  ASSOCIATION. 

Seventeenth  Annual  Meeting,  Helil  in  New    \  ork    City, 
October  75,  16.  //,  and  18,  igoo. 

E.  D.  Ferguson,  M.D.,  of  Troy,  President. 

(Concluded  from  page  634.) 

Third  Day —  Wednesday,  October  ijth. 

Dr.  C.  A.  L.  Reed,  of  Ohio,  President  of  tfie  Ameri- 
can Medical  Association,  made  a  forceful  speech  in 
favor  of  the  stand  taken  by  the  State  Association  look- 
ing toward  better  organization  of  the  profession.  He 
pointed  out  that  it  ought  to  take  but  little  time  and 
less  effort  to  accomplish  a  change  that  had  already 
been  effected  in  sentiment,  and  that  he  who  interposed 
prejudice,  preference,  or  prerogative  as  obstacles  to 
this  consummation  should  be  looked  upon  and  treated 
as  an  enemy  of  progress.  He  had  good  reason  for 
believing  that  the  medical  profession  of  to-day,  the 
country  over,  was  ready  to  take  any  necessary  step, 
through  its  organized  bodies,  that  it  might  present  a 
united  front  to  the  dawning  century. 

An  Epidemic  of  Diphtheria  Traced  to  a  Milk 
Supply.  —  Dr.  Chauncy  P.  Biggs,  of  Ithaca,  presented 
this  communication.  He  said  that  in  recent  years 
several  epidemics  of  diphtheria  had  been  reported  in 
which  it  had  been  clearly  shown  that  they  had  origi- 
nated in  the  milk  supply.  In  a  considerable  number 
of  these  reported  cases  the  strongest  evidence  of  milk 
infection  had  been  the  fact  that  a  large  percentage  of 
the  patients  had  been  supplied  by  a  certain  milkman, 
although  the  way  in  which  the  infection  had  actually 
taken  place  could  not  be  explained.  The  fact  re- 
mained, however,  that  the  epidemic  subsided  quickly 
on  stopping  the  sale  of  this  milk.  In  one  epidemic, 
the  liberal  users  of  boiled  milk  escaped.  In  the  epi- 
demic at  Ithaca,  one  student  in  a  family  of  eight  had 
diphtheria  wliile  the  others  escaped.  Inquiry  showed 
that  all  of  the  family  had  been  using  infected  milk, 
but  all  had  partaken  of  it  sparingly  except  this  stu- 
dent. From  January  3 1  to  March  7,  1900,  thirty  cases 
of  diphtheria  had  been  reported  to  the  board  of  health, 
and  the  diagnosis  in  each  instance  had  been  confirmed 
by  bacteriological  examination.  These  cases  had  oc- 
curred in  twenty-four  households  in  widely  separated 
parts  of  the  city.  Of  the  thirty  patients,  two  died, 
one  a  child  of  seven  years,  and  the  other  a  child  of  six 
years.  It  was  soon  discovered  that  nearly  half  of  the 
cases  had  received  milk  from  one  dealer,  and  then  it 
was  learned  that  some  of  the  milk  sold  by  this  man 
had  been  purchased  from  another.  The  milk  of  the 
wholesaler  proved  to  have  been  infected.  In  only 
three  families  had  it  been  impossible  to  trace  the  milk 
supply  to  the  source  of  infection.  Tiiere  had  been 
only  fourteen  secondary  cases. 

Management  of  Diphtheria  in  Small  Cities  from 
a  Bacteriological  Standpoint. —  Prof.  Vkranus  A. 
Mooke,  of  Cornell  University,  read  this  paper.  He 
said  that  all  persons  carrying  virulent  diphtheria 
bacilli  in  their  throat,  whetiier  suffering  from  the  dis- 
ease, convalescent  or  immune,  might  be  sources  of  in- 
fection to  those  with  whom  they  came  in  contact.  A 
bacteriological  examination  enabled  one  to  determine 
those  infected  among  a  number  who  have  been  exposed, 
and  also  when  one  recovering  from  the  disease  might 
safely  mingle  with  others.  Most  of  tht-  difficulty  met 
with  in  the  efforts  of  health  officers  to  conserve  the 
public  health  could  be  obviated  if  family  physicians 
would  explain  to  their  patients  the  reasons  for  the 
regulations  of  the  board  of  health,  and  the  need  for 
both  the  profession  and  the  laity  heartily  to  co-oper- 


ate. In  tile  recent  epidemic  at  Ithaca,  the  bacterio- 
logical examinations  instituted  by  the  board  of  health 
had  proved  useful  not  only  in  controlling  the  spread 
of  the  disease  but  in  tracing  the  source  of  infection. 

The  Tonsils  as  Portals  of  Infection Dr.  Julius 

Ullman,  of  Buffalo,  read  this  paper.  He  gave  a 
sketch  of  tiie  literature,  and  showed  the  probability 
that  the  tonsils  were  portals  of  infection  in  scarlet 
fever,  rheumatism,  and  endocarditis.  His  conclusions 
were:  (i)  'l"he  normal  tonsil  had  a  physiological  func- 
tion protective  to  the  organism  ;  ( 2  )  that  being  in  itself 
often  diseased,  its  physiological  function  was  often  im- 
paired, and  instead  of  being  protective,  it  became  a 
nidus  for  the  growth  and  distribution  of  jiathogenic 
germs;  (3)  that  many  grave  infections  had  their 
origin  in  the  tonsils;  (4)  that  acute  articular  rheu- 
matism and  the  diseases  often  associated  with  it,  such 
as  endocarditis  and  chorea,  were  in  the  great  majority 
of  cases  due  to  the  action  of  attenuated  bacteria  or 
their  toxins  entering  the  system  through  the  tonsils; 
(5)  that  scrofulosis  was  often  associated  with  disease 
of  the  tonsil. 

Report  of   Some   Interesting  Cases  of  Infectious 

Disease Dr.  De   Lahcey    Rochester,  of    Buffalo, 

made  this  report.  Among  the  cases  cited  were  three 
of  scarlatina  without  eruption.  Another  was  that  of  a 
child  of  five  years,  who  had  been  seen  by  several  com- 
petent physicians,  all  of  whom  had  made  a  positive 
diagnosis  of  scarlet  fever.  Three  days  after  the  com- 
pletion of  desquamation  the  disease  had  recurred. 
This  case  seemed  to  be  unique. 

Present  Status  of  Jonnesco's  Operation. — Dr. 
Marcel  Hartwig,  of  Buffalo,  was  the  author  of  this 
communication.  He  urged  the  use  of  the  name  "Jon- 
nesco's operation  "  for  that  procedure  more  commonly 
known  as  neurectomy  of  the  cervical  sympathetic,  be- 
cause of  the  classical  work  of  Jonnesco  in  this  field. 
In  speaking  of  the  physiological  effects  of  this  neu- 
rectomy, the  statement  was  made  that  these  were  quite 
variable,  but  the  most  constant  was  a  narrowing  of  the 
pupil.  Jonnesco  had  employed  this  operation  chiefly 
in  epilepsy  on  the  apparently  erroneous  theory  that  it 
should  prove  curative  by  the  production  of  an  ana^iiia 
of  the  brain.  The  final  results  in  ninety-seven  cases 
were  twelve  reported  cures.  This  surgeon  had  oper- 
ated upon  fifteen  cases  of  exophthalmic  goitre,  with 
eleven  recoveries,  and  four  patients  improved.  He 
had  also  operated  in  twelve  cases  of  glaucoma,  and 
these  cases  showed  more  or  less  improvement  in 
vision. 

The  Treatment  of  Pulmonary  Tuberculosis  with 
Special  Reference  to  the  Climate  of  Arizona.-  Dr. 
Clarence  G.  Campbell,  of  New  York,  read  this  pa- 
per (will  appear  in  a  future  issue.) 

President's  Address— The  Surgical  Management 
of  Umbilical  Hernia  with  Large  Ring. — Dr.  K.  D. 
Ferguson,  in  this  address,  said  that  the  method  of 
denudation  was  easy  and  satisfactory  when  the  ring 
was  small.  In  cases  of  large  ring,  a  successful  result 
had  been  the  exception  rather  than  the  rule.  The  es- 
sential feature  of  those  rings  which  should  be  classed 
as  surgically  "  large '"  was  the  inabilit}- of  the  operator 
to  approximate  the  borders  of  the  ring  by  vertical 
sutures  without  placing  these  parts  in  a  state  of  con- 
stant and  considerable  tension.  In  the  development 
of  an  umbilical  hernia,  the  yielding  began  just  at  the 
point  where  the  umbilical  vessels  entered  the  abdo- 
men, and  consequently  here  the  hernial  ring  would  be 
bounded  by  the  linea  alba  at  its  upper  and  lower  |)or- 
tions,  and  below  tliis  would  be  the  blended  borders  of 
the  lamella'  of  the  rectus.  His  own  method  of  oper- 
ating was  as  follows:  A  longitudinal  incision  was 
made  at  the  border  of  either  rectus.  The  anterior 
layer  of  the  sheath  was  then  separated  by  blunt  dis- 
section, and    lateral    flaps  were   cut    out,  care  being 


October  27,  1900] 


MEDICAL    RECORD. 


671 


taken  to  make  them  as  long  and  broad  as  possible. 
They  were  then  turned  over  to  the  median  line  and 
sutured  at  their  free  borders  by  the  cobbler's  stitch. 
It  was  important  thoroughly  to  coaptate  the  broad  sur- 
faces lielow  the  ring. 

Tuberculosis ;  its  General  Etiology,  General 
Pathology,  and  General  Prophylaxis. — Prof.  \ic- 
ToR  C.  Vaughn,  of  the  L'liivcrsiiy  of  Michigan, 
opened  this  symposium  on  tuberculosis  with  this 
paper,  the  other  papers  being  on  surgical  tuberculosis, 
lie  said  that  at  the  outset  he  wished  it  understood 
that  the  sole  cause  of  tuberculosis  was  the  tubercle 
bacillus  of  Koch.  The  morphology  of  this  germ  was 
not  so  simple  and  constant  as  had  been  at  first  as- 
sumed. Branched  forms  had  been  found  in  tuber- 
culous sputum,  and  many  investigators  had  noted  the 
striking  resemblance  at  limes  to  the  ray-siiaped  micro- 
organism of  actinomycosis.  Under  certain  conditions 
not  yet  well  understood,  it  seemed  to  be  pretty  well 
settled  that  the  tubercle  bacillus  assumed  some  forms 
of  growth  wiiich  pointed  to  the  probability  that  the 
specific  germ  of  tuberculosis  was  not  a  true  bacillus. 
At  least  one  pseudo-tubercle  bacillus  had  been  found 
not  infrequently  in  butter,  and  this  had  led  to  confu- 
sion in  the  examination  of  that  article  of  food  for  evi- 
dence of  tuberculosis.  An  organism  quite  commonly 
found  in  cow-dung  had  been  assumed  at  one  time  to 
be  the  tubercle  bacillus,  and  as  this  could  easily  find 
its  way  into  the  milk,  it  followed  that  microscopical 
examination  of  milk  was  not  an  adequate  means  of 
proving  or  disproving  the  existence  of  tuberculous  in- 
fection. The  most  striking  morphological  similarity 
between  the  tubercle  bacillus  and  the  "timothy  bacil- 
lus" lay  in  the  fact  that  both  organisms  assumed  a 
branched  form  at  times.  Culturally,  however,  they 
were  quite  distinct.  The  timothy  bacillus  had  been 
shown  to  be  practically  without  pathological  effect  on 
man,  but  Flexner  and  others  had  shown  that  some  at 
least  of  the  pseudo-tubercle  bacilli  were  pathogenic  in 
man.  Some  observers  had  assumed  that  the  tubercle 
bacilli  were  capable  of  living  quite  abundantly  and 
indefinitely  outside  of  the  body  as  saprophytes.  This 
was  a  mere  assumption,  however,  without  scientific 
basis.  There  was  nothing  to  show  that  any  one  of 
these  saprophytic  organisms  was  ever  converted  into 
the  pathogenic  organism  producing  tuberculosis  in 
man.  The  studies  of  the  pseudo-tubercle  organisms 
had  not  shown  the  evidence  of  the  true  parasitic  na- 
ture of  Koch's  tubercle  bacillus.  The  bacillus  tuber- 
culosis was  thrown  off  in  the  secretions  of  the 
tuberculous,  and  then  retained  its  vitality  for  a  com- 
paratively limited  period.  Even  the  tuberculous  in- 
dividual was  not  a  source  of  danger  to  others,  until  he 
began  to  cast  off  the  tubercle  bacillus  in  his  excre- 
tions, and  even  then  with  proper  precautions  he  might 
mingle  with  his  fellows  without  danger  to  them.  It 
had  been  shown  time  and  again  that  the  expired  air 
from  the  lungs,  even  in  the  advanced  stages  of  tuber- 
culosis, was  free  from  the  specific  infection  unless  it 
bore  particles  of  mucus  or  saliva,  as  happened  some- 
times in  coughing  or  sneezing,  and  sometimes  in 
speaking.  The  transmission  of  the  bacillus  was  rare- 
ly direct,  but  might  be  so,  as  for  instance  in  the  per- 
formance of  ritual  circumcision.  Inoculation  into  the 
skin  resulted  in  the  formation  of  tubercles,  and  a 
gradual  extension  into  the  lymphatic  glands.  When 
the  infectious  matter  was  introduced  under  the  skin, 
the  first  evidence  of  infection  might  be  in  the  neigh- 
boring lymph  glands.  It  was  probable  that  diseased 
tonsils  occasionally  served  as  portals  of  infection. 
Rabinovitch  had  shown  that  animals  with  initial 
tuberculosis,  and  without  detectable  disease  of  the 
udder,  might,  and  often  did,  furnish  milk  containing 
living  and  virulent  tubercle  bacilli.  This  observation 
confirmed   the  opinion   that  he  had   expressed   some 


years  ago,  that  every  dairy  cow  should  be  tested  with 
tuberculin.  Cattle  seemed  to  be  only  slightly  suscep- 
tible to  human  tubercle  bacilli;  on  the  other  hand,  the 
bovine  tubercle  bacillus  had  been  shown  to  be  more 
virulent  than  the  sputum  variety,  and  that  this  viru- 
lence increased  when  it  was  grown  in  milk.  Tuber- 
culosis always  began  as  a  local  disease,  confined  for  a 
greater  or  less  period  of  time  lo  a  minute  portion  of 
the  body.  The  destructive  changes,  as  a  rule,  pro- 
ceeded slowly  until  the  infection  became  a  mixed  one. 
Most  of  the  deaths  from  pulmonary  tuberculosis  were 
directly  the  result  of  mixed  infection.  That  the  tuber- 
cle bacillus  had  a  predilection  for  pulmonary  tissue 
was  shown  by  the  frequency  with  which  the  lungs  be- 
came involved  in  the  lower  animals  after  subcutaneous 
and  intraperitoneal  inoculations,  yet  it  was  known  that 
many  jDersons  lived  for  years  with  a  local  tuberculosis 
without  the  lungs  becoming  involved.  The  speaker 
said  that  our  ancestors  had  freed  the  race  from  leprosy, 
and  he  believed  the  same  would  be  accomplished  in 
time  in  regard  to  tuberculosis.  Very  little  could  be 
done,  however,  without  special  hospitals  for  tuber- 
culous patients.  In  Germany,  where  the  greatest  ad- 
vances had  been  made,  much  of  the  money  needed 
had  been  raised  by  insurance  companies.  In  our  own 
country  the  necessary  funds  would  probably  have  to 
be  raised  by  taxation.  It  was  well  to  remember  that 
there  were  wide  differences  in  the  degree  of  virulence 
shown  by  the  tubercle  bacilli  infecting  man.  L'n- 
doubtedl)'  individuals  differed  widely  in  their  suscep- 
tibility to  this  disease,  but  some  of  these  bacilli  were 
so  virulent  that  Dr.  ^'aughn  said  he  did  not  believe 
any  living  human  being  could  successfully  resist  their 
invasion  in  any  large  number.  Statistics  could  be 
readily  cited  to  show  the  absolute  necessity  of  improv- 
ing the  condition  of  the  poor  in  connection  with  our 
efforts  to  stamp  out  tuberculosis.  He  believed  that 
tuberculosis,  so  long  as  it  remained  an  unmixed  infec- 
tion, was  an  entirely  curable  disease. 

The  Diagnosis  and  Treatment  of  Laryngeal  Tu- 
berculosis.—  Dr.  Jonath.vn  Wright,  of  Brooklyn, 
read  this  first  paper  in  the  series  on  surgical  tuber- 
culosis. Regarding  the  diagnosis  of  laryngeal 
tuberculosis  he  said  that  he  did  not  feel  that  laryn- 
goscopy alone,  without  the  history  of  other  symptoms, 
was  sufficient  ground  for  a  diagnosis.  It  was  uasy  to 
confound  syphilis  of  the  larynx  with  laryngeal  tuljer- 
culosis,  and  the  worst  feature  about  such  an  error  was 
that,  whereas  laryngeal  syphilis  yielded  readily  to  ap- 
propriate treatment,  it  became  almost  as  fatal  as  laryn- 
geal tuberculosis  if  treated  as  the  latter  should  be. 
Tuberculous  laryngitis  was  not  usually  accompanied 
by  dangerous  dyspnoea,  whereas  syphilitic  laryngitis 
was  ordinarily  associated  with  shortness  of  breath. 
When  there  was  evidence  in  the  larynx  pointing  to 
laryngeal  tuberculosis,  the  tuberculous  process  in  the 
lungs  was  usually  sufficiently  far  advanced  to  permit 
of  its  ready  recognition.  If  the  examination  of  the 
sputum  in  a  doubtful  case  failed  to  show  the  presence 
of  tubercle  bacilli,  the  patient  should  be  at  once  put 
on  antisyphilitic  treatment.  In  laryngeal,  as  in  pul- 
monary, tuberculosis  he  was  of  the  opinion  that  the 
climatic  treatment  was  the  most  important  factor  in 
the  cure  of  the  disease,  yet  it  should  be  remembered 
that  in  a  large  proportion  of  these  cases  the  person 
was  so  inevitably  doomed  that  it  was  cruelty  to  send 
him  away  from  home.  After  an  exhaustive  study  of 
statistics  and  an  extensive  clinical  experience,  he  had 
come  to  the  conclusion  that  a  permanent  radical  cure 
of  the  local  lesion  in  laryngeal  phthisis  was  not 
effected  by  any  method  of  surgical  treatment.  Pallia- 
tive treatment  was  an  entirely  different  matter.  It 
was  the  height  of  folly  and  the  depth  of  cruelty  to  tell 
a  person  suffering  from  laryngeal  phthisis  that  he 
could  not  be  cured.     It  was  a  fact  that  lactic  acid  and 


672 


MEDICAL    RECORD. 


[October  27,  1900 


probably  some  other  drugs  would  stimulate  torpid 
granulations  to  a  more  healthy  appearance,  and  cause 
some  decrease  in  the  intiamniatory  swelling,  and  per- 
haps occasionally  produce  an  appearance  of  cicatriza- 
tion and  temporary  cure.  The  local  application  of 
iodoform  and  especially  of  orthoform  in  the  elegant 
prescription  employed  by  Dr.  Freudenthal  relieved  the 
pain,  but  probably  did  nothing  more.  The  interna! 
use  of  opiates  was  often  indicated  and  justifiable. 
Detergent  sprays  gave  temporary  relief,  but  produced 
a  favorable  psychical  impression.  The  submucous 
injection  of  creosote  and  lactic  acid  did  not  appeal  to 
his  knowledge  of  the  pathological  condition. 

Tuberculosis  of  the  Eye  ;  its  Differential  Diag- 
nosis, Pathology,  and  Treatment — Dr.  Charles 
Stedman  Bull,  of  New  Vork.  read  this  paper.  He 
said  that  our  knowledge  of  tuberculosis  of  the  eye 
dated  back  to  1868.  Tuberculosis  of  the  eye  was 
chieriy  met  with  between  the  ages  of  five  and  thirty 
years,  and  the  tendency  was  to  involve  the  deeper 
structures  primarily. 

Eyelids. — In  tuberculosis  of  the  eyelids  the  lesion 
usually  appeared  first  in  the  retrotarsal  fold.  The 
lids  were  often  much  swollen,  but  were  soft  to  the 
touch,  and  often  presented  distinct  folds  around  the 
tuberculous  mass.  It  was  exceptional  to  find  the  tu- 
bercle bacilli  in  sections  of  the  tuberculous  masG,  yet 
they  might  be  found  in  scrapings  from  the  floor  of  the 
ulcer.  The  neighboring  lymph  glands  were  not  always 
swollen.  Tubercles  of  the  conjunctiva  must  be  differ- 
entiated from  trachoma,  epithelioma,  and  syphilitic 
ulceration.  In  trachoma,  the  glands  were  not  in- 
volved. The  differentiation  from  epithelioma  could 
be  made  by  the  age  of  the  patient.  The  character  of 
the  ulceration,  the  lardaceous  aspect  of  the  mucous 
membrane,  and  the  engorgement  of  the  glands  would 
usually  suffice  to  make  the  diagnosis.  The  ulcerative 
surface  should  be  cauterized  unless  near  the  edge  of 
the  lid,  when  it  should  be  excised.  If  the  lesion  was 
primary,  the  prognosis  was  good;  if  secondary  it  was 
always  unfavorable. 

Cornea. — The  cornea  was  much  less  liable  to  tuber- 
culous disease  than  any  other  tissue  of  the  eye  with 
the  exception  of  the  lens. 

Iris, — Tuberculosis  of  the  iris  occurred  most  fre- 
quently between  the  ages  of  five  and  twenty-five  years, 
and  was  more  frequently  secondary  than  primary. 
The  diffuse  form  spread  rapidly,  and  occurred  in 
persons  predisposed  by  hereditary  tendency  to  the 
disease.  It  occurred  in  children  as  small  grayish 
nodules  at  the  ciliary  margins  of  the  iris.  It  might 
be  confounded  with  gumma,  sarcoma,  and  leprosy. 
They  might  be  distinguished  from  the  first  by  their 
color  and  bv  the  presence  of  glandular  enlargements, 
and  the  usual  signs  of  pulmonary  tuberculosis.  When 
the  growths  were  multiple,  non-vascular,  and  gray,  and 
were  accompanied  by  glandular  enlargement,  they  were 
usually  tuberculous.  With  our  present  knowledge, 
enucleation  of  the  eyeball  seemed  to  be  the  best  treat- 
ment. 

Choroid. — Tuberculosis  of  the  choroid  occurred 
either  as  solitary  tubercle  or  miliary  tubercles.  It 
was  most  commonly  seen  before  the  age  of  twenty,  par- 
ticularly in  little  children. 

Retina  and  Optic  Nerve Tuberculous  lesions  of 

the  retina  and  optic  nerve  were  almost  always  an  indi- 
cation of  a  tuberculous  meningitis.  The  changes  in 
the  optic  nerve  were  always  bilateral  and  consisted  in 
a  papillitis  .ind  a  typical  neuritis. 

The  Pathology,  Diagnosis,  Special  Prophylaxis, 
and  Treatment  of  Tuberculosis  of  the  Ear.  — Dr. 
Seymour  Oppenhei.mer,  of  New  Vork,  read  this  pa- 
per. He  said  that  tuberculosis  of  the  ear  was 
characterized  by  the  insidious  development  of  a  slight 
discharge  without   pain       With  this  there  was  slight 


impairment  of  the  hearing,  and  the  drum  was  of  a 
bluish-white  color  and  somewhat  cedematous.  To  es- 
tablish the  diagnosis  microscopical  examination  of  the 
pus  from  the  deepest  parts  or  even  inoculation  experi- 
ments might  be  required.  Extensive  alterations  of 
structure  had  usually  taken  place  before  attention  had 
been  called  to  the  possibility  of  a  tuberculous  infec- 
tion of  the  ear.  Prompt  and  effective  treatment  of  the 
nose  and  throat  in  persons  predisposed  to  tuberculosis 
was  an  important  prophylactic  measure.  In  such  in- 
dividuals the  physician  should  carefully  abstain  from 
the  use  of  the  Politzer  douche.  The  local  treatment 
comprised  the  use  of  such  non-irritating  applications 
as  would  insure  cleanliness.  The  usual  constitutional 
treatment  of  tuberculosis  should  not  be  neglected. 

Acute  Tuberculosis  of  the  Mesenteric  Lymph 
Glands.  —  Prof.  Mairice  H.  Richarhson',  of  Har- 
vard University,  made  this  contribution  to  the  discus- 
sion. He  said  that  in  general  disseminated  tuber- 
culosis of  the  peritoneum  it  appeared  as  miliary 
tubercles,  or  in  masses  of  greater  or  less  size.  In 
these  cases  the  mesenteric  glands  might  or  might  not 
be  involved.  Sometimes  a  single  group  of  glands  was 
involved,  and  this  was  associated  with  general  dis- 
seminated tuberculosis.  The  symptoms  of  acute  tu- 
berculosis of  the  mesenteric  glands  were  so  obscure 
that  their  interpretation  was  impossible.  In  chronic 
tuberculosis  of  these  glands  the  diagnosis  was  com- 
paratively clear.  In  the  acute  form  the  symptoms 
were  often  those  of  an  ill-defined  appendicitis  or  of  a 
local  peritonitis.  In  addition  to  the  pain  and  tender- 
ness of  the  glands  themselves  there  would  be  tender- 
ness of  the  surrounding  peritoneum.  Therefore  the 
diagnosis  in  the  early  stages  must  be  mere  guesswoik. 
Most  of  the  cases  operated  upon  had  advanced  to  the 
stage  of  caseation  and  of  breaking  down.  The  prog- 
nosis of  acute  tuberculosis  of  the  mesenteric  glands 
had  alwavs  been  looked  upon  as  extremely  unfavor- 
able, yet  he  had  often  seen  at  operations  many  exam- 
ples of  spontaneous  cure.  These  cures  could  not, 
however,  represent  the  proportion  of  good  results  that 
should  be  obtained  by  early  surgical  intervention. 
The  chief  danger  was  the  injury  of  large  veins,  there- 
by compromising  the  integrity  of  the  bowel.  When 
there  was  general  dissemination,  removal  of  the  dis- 
eased glands  was  out  of  the  question.  It  was  not  im- 
probable that  the  removal  of  some  of  the  larger  glands 
would  lead  to  the  disappearance  of  many  others. 
When  the  glands  were  caseous  and  suppurating,  drain- 
age was  demanded. 

The  Surgical  Treatment  of  Urinary  and  Uro- 
Genital  Tuberculosis. — Dr.  Samuel  Alexander,  of 
New  York,  read  tnis  paper.  He  said  that  while  it 
w-as  possible  for  the  genitourinary  tract  to  be  the  seat 
of  ascending  infection,  clinical  observation  did  not 
support  this  view.  Primary  tuberculous  infection  of 
the  genito-urinary  tract  he  believed  to  be  generally  of 
hcemic  origin.  It  was  probable  that  the  tubercle  ba- 
cilli entered  the  genito-urinary  tract  from  the  blood, 
most  often  through  the  kidney,  although  this  organ 
might  itself  escape  at  the  time.  Clinically  speaking, 
the  most  common  seat  of  primary  tuberculosis  in  this 
region  seemed  to  be  the  epididymis.  He  had  found 
that  it  was  usually  associated  with  more  or  less  in- 
volvement of  the  prostate  or  of  the  prostatic  urethra. 
While  tuberculosis  of  the  bladder  might  be  primary, 
clinical  data  in  proof  of  this  were  wanting.  The 
object  of  treatment  in  so-called  primary  tuberculosis 
of  the  genito-urinary  tract  should  be  curative.  The 
removal  of  isolated  tuberculous  foci  was  not  in  itself 
curative.  Unnecessary  and  frequent  instrumentation 
was  a  common  and  potent  exciting  cause  of  the  spread 
of  tuberculosis  throughout  the  genito-urinary  tract. 
By  a  routine  examination  of  the  urine  for  tubercle  ba- 
cilli many  more  cases  would  be  diagnosed  early.     To 


October  27,  1900] 


MEDICAL   RECORD. 


^7Z 


succeed  in  fitiding  the  tubercle  bacilli  in  the  urine,  it 
was  necessar)-  to  collect  the  sediment  by  the  use  of 
the  centrifuge.  If  the  urine  had  stood  for  some  lime 
after  having  been  voided  before  the  examin.ition  was 
made,  or  if  the  sediment  had  been  collected  by  gravity 
alone,  it  was  probable  that  the  bacilli  would  not  be 
found. 

Kidney. — In  all  cases  of  tuberculosis  of  the  kidney 
in  which  operation  was  not  absolutely  contraindicated 
by  the  condition  of  the  patient,  surgical  intervention 
was  imperatively  demanded.  As  a  general  rule,  the 
choice  should  be  given  to  nephrectomy  when  only  one 
kidney  was  affected.  This  operation,  he  believed,  was 
indicated  even  in  cases  in  which  there  was  a  beginning 
tuberculosis  of  the  other  kidney. 

Epididymis — He  was  strongly  of  the  opinion  that 
when  the  epididymis  was  diseased,  excision  of  the 
part  did  as  much  good  as  castration.  When  the  epi- 
didymis or  testicle  was  to  be  removed  for  tuberculosis, 
as  much  of  the  seminal  duct  should  be  removed  as 
could  be  reached. 

Prostate. — He  was  convinced  that  primary  tuber- 
culosis of  the  prostate  was  far  from  infrequent,  though 
difficult  to  diagnose.  It  was  often  possible  by  rectal 
pressure  to  express  a  few  drops  of  secretion,  and  in 
that  to  find  tubercle  bacilli  when  none  of  these  organ- 
isms could  be  found  in  the  urine.  As  much  as  possi- 
ble of  the  diseased  prostate  should  be  removed. 

Bladder. — The  surgical  treatment  of  tuberculosis  of 
the  bladder  was  necessarily  palliative.  In  the  s|3eak- 
er's  opinion,  local  treatment  was  absolutely  valueless. 

The  Pathology,  Diagnosis,  Special  Prophylaxis, 
and  Treatment  of  Tuberculosis  of  the  Bones  and 
Joints. — Dr.  E.  H.  Nichols,  of  Boston,  made  some 
remarks  on  this  subject,  illustrating  them  with  lantern 
slides.  He  said  that  in  the  great  majority  of  cases  of 
tuberculous  joint  disease  coming  to  autopsy,  tubercu- 
lous lesions  were  found  elsewhere  through  the  body. 
Very  rarely  was  the  joint  lesion  the  only  evidence  of 
infection.  Primary  tuberculosis  was  so  rare  that  he 
himself  had  never  seen  it.  In  spinal  caries  the  tuber- 
culous process  usually  began  in  the  anterior  part  of 
the  vertebra.  The  character  of  the  kyphosis  depended 
upon  the  extent  of  the  process  and  the  region  affected. 
In  cases  coming  to  autopsy  an  abscess  was  almost 
always  found.  Certain  extraordinary  deviations  of 
the  aorta  might  occur,  especially  if  the  disease  in  the 
vertebra  developed  after  the  person  had  attained  his 
growth.  Mere  angular  deformity  seldom  if  ever 
diminished  the  calibre  of  the  spinal  canai  sufficiently 
to  make  pressure  on  the  cord.  Occasionally  pressure 
on  the  cord  was  produced  by  bony  fragments.  In  rare 
instances  an  abscess  caused  a  pressure  paralysis.  In 
a  very  large  proportion  of  the  cases  of  hip-joint  dis- 
ease the  process  began  in  the  acetabulum  itself,  and 
hence,  in  such  cases,  excision  of  the  head  of  the  femur 
did  not  remove  the  primary  focus.  In  the  ankle  joint 
the  primary  focus  might  be  in  the  lower  end  of  the 
tibia  or  in  any  of  the  tarsal  bones. 

The  Pathology,  Diagnosis,  Special  Prophylaxis, 
and  Treatment  of  Tuberculosis  of  the  Skin  and 
Superficial  Fascia.  —  Dr.  John  A.  Fordvce,  of  New- 
York,  also  gave  a  lantern  exhibition  in  addition  to 
discussing  this  subject.  Speaking  of  lupus,  he  said 
that  it  might  remain  as  a  single  jiatch  for  many  years. 
The  recurrence  of  lupus  nodules  in  scar  tissue  sponta- 
neously formed  or  following  operation  was  common. 
Scarification  of  a  lupus  patch  was  sometimes  followed 
by  redness  and  phenomena  similar  to  those  observed 
after  the  injection  of  tuberculin.  Secondary  infec- 
tion with  pus  organisms  might  give  rise  to  consider- 
able crusting,  thus  obscuring  the  true  nature  of  the 
lesion.  Epithelioma  occurred  so  frequently  as  a  com- 
plication as  to  indicate  something  more  than  a  merely 
accidental  relation.     Age  was  a  predisposing  factor  in 


lupus.  'J'he  greatest  difference  of  opinion  prevailed 
concerning  the  probability  of  the  tuberculous  process 
spreading  from  the  lupus  patch  throughout  the  body, 
and  while  many  observers  maintained  that  it  was  a 
common  result,  others  declared  that  in  an  extensive 
experience  they  had  not  seen  the  two  associated. 
Late  syphilis  and  epithelioma  had  a  tendency  like  lu-' 
pus  to  clear  up  in  the  centre  and  spread  at  the  per- 
iphery. When  epithelioma  develojied  on  a  lupous 
surface  the  diagnosis  was  rather  complicated.  Blasto- 
mycetic  dermatitis  had  been  confounded  with  cutaneous 
tuberculosis.  Tuberculosis  around  the  orifices  was 
usually  preceded  by  marked  tuberculosis  of  the  lungs. 


Fourth  Day — Thursday,  October  i8lh. 

The  Treatment  of  Ichthyosis  Hystrix  by  Elec- 
tric Light. —  Dr.  George  W.  Goler,  of  Rochester, 
presented  a  brief  report  on  this  subject.  The  patient 
was  a  boy  of  nine  years  who  had  developed  ichthyosis 
at  the  age  of  four  years.  When  seen  in  July,  1900, 
the  affection  involved  both  the  upper  and  the  lower 
extremities.  The  first  treatment  was  made  upon  the 
arm,  the  area  selected  being  well  rubbed  with  lanolin 
and  then  a  light  from  a  twenty-millampere  lamp  was 
projected  through  two  eight-inch  plano-convex  lenses 
upon  the  arm.  This  was  kept  up  for  twenty  minutes, 
and  was  repeated  on  the  following  day.  On  the  third 
day  the  skin  had  lost  its  warty  character,  and  at  the 
end  of  six  or  seven  days  iiad  assumed  its  normal  ap- 
pearance. The  other  affected  portions  of  skin  were 
treated  in  a  similar  manner,  and  at  the  end  of  twenty 
days,  and  after  eighteen  exposures  of  half  an  hour  each 
to  the  electric  light,  the  disease  had  entirely  disap- 
peared. It  had  not  returned  since,  and  the  patient 
now  perspired  naturally  over  the  area  of  skin  formerly 
affected. 

The  Differential  Diagnosis  of  Ectopic  Gestation 
with  Special  Reference  to  Early  Abortion. —  Dr. 
HikAM  X.  Vi.vebkrg,  of  New  \'ork,  read  this  paper. 
He  said  that  he  was  not  one  of  those  who  thought  the 
differential  diagnosis  of  this  condition  always  easy, 
and  that  it  could  be  made  by  relying  solely  on  one  or 
two  prominent  symptoms.  He  had  followed  the  plan 
of  making  an  exploratory  incision  into  Douglas'  cul- 
de-sac  in  a  number  of  doubtful  cases,  and  looked  upon 
this  as  an  important  diagnostic  aid.  If  an  ectopic 
pregnancy  was  found,  unless  the  conditions  were 
specially  favorable  the  operation  was  completed 
through  a  suprapubic  incision.  Every  case  of  early 
uterine  abortion  should  be  looked  upon  with  suspicion, 
and  when  there  was  much  doubt  the  patient  should  be 
anaesthetized.  The  flow  attendant  upon  a  ruptured 
ectopic  pregnancy  was  apt  to  occur  as  a  mere  "show," 
appearing  and  disappearing  at  intervals.  The  pain 
usually  experienced  was  described  as  like  that  of 
labor.  Microscopical  examination  of  pieces  of  mem- 
brane discharged  may  show  decidual  cells,  but  even 
the  most  expert  microscopist  could  not  distinguish  be- 
tween the  decidual  cells  of  a  uterine  and  of  a  tubal 
pregnancy.  An  erroneous  diagnosis  was  apt  to  be 
made  in  cases  of  irregular  sacculation  of  a  pregnant 
uterus,  elongation  of  the  cervix,  and  retroflexion  of 
the  uterus. 

Dr.  Frederick  Holme  Wiggin  related  a  case 
in  which  he  would  have  been  misled  by  a  retroflexed 
uterus  if  the  woman's  appearance  had  not  denoted 
something  more  serious,  thus  leading  to  examination 
with  the  uterine  sound. 

Drs.  C.  C.  Frederick  and  E.  V.  Delphey  also  nar- 
rated interesting  cases  in  point. 

The  Resources  of  Modern  Minor  Gynaecology. — 
Dr.  a.  H.  Goelet,  of  New  York,  read  a  paper  with 
this  title.  In  it  he  called  attention  to  a  rubber  sheath 
which  he  had  had  made  for  laminaria  tents,  thus  per- 


674 


MEDICAL    RECORD. 


[October  27,  1900 


mitting  of  the  use  of  this  excellent  means  of  securing 
uterine  dilatation  without  fear  of  causing  infection. 
Concerning  the  topical  use  of  glycerin  in  gynaecology, 
he  said  that  strips  of  gauze  moistened  with  glycerin 
would  be  found  far  better  and  more  comfortable  than 
the  usual  cotton  tampons.  He  had  found  a  mixture  of 
one  part  iodine  and  thirty-two  parts  glycerin  more  use- 
ful than  boroglyceride.  He  considered  uterine  irriga- 
tion a  very  important  therapeutic  resource.  He  had 
devised  a  special  form  of  double  metallic  irrigating- 
tube,  which  could  usually  be  passed  in  without  pre- 
vious dilatation.  If,  however,  it  met  with  obstruction, 
it  could  be  withdrawn  and  a  rubber  tube  slipped  over 
it  to  give  the  necessary  insulation,  and  then  it  could 
be  connected  with  the  negative  pole  of  a  galvanic  bat- 
tery until  the  desired  patulousness  of  the  os  had  been 
secured.  Regarding  electricity,  he  said  that  despite 
the  fact  that  surgical  gynaecologists  had  repeatedly  en- 
deavored to  kill  electrical  treatment  in  gyna;cology,  it 
was  still  very  much  alive,  and  was  doing  much  good. 
It  was  a  most  valuable  gynecological  resource.  Gal- 
vanism would  relax  the  cervical  canal  and  promote 
drainage,  and  so  materially  aid  the  treatment  of  endo- 
metritis. It  would  dispel  pelvic  congestion  and  re- 
lieve pain  dependent  upon  pelvic  exudates  much  bet- 
ter than  any  other  agent  except  faradization.  He  had 
found  a  few  internal  remedies  useful  in  gynaecological 
cases.  The  combination  of  bromide  and  iodide  of 
potassium  was  particularly  valuable  in  cases  of  pelvic 
pain  from  the  presence  of  exudates.  Bromide  of  ar- 
senic would  often  lessen  the  menstrual  flow  even  in 
cases  in  which  curettage  was  indicated. 

Dr.  Eden  V.  Delphey,  of  New  York,  said  that  he 
had  used  the  rubber-coated  laminaria  tents  with  much 
satisfaction.  Faradization  had  proved  in  his  hands  a 
most  useful  means  of  relieving  pelvic  pain  and  also  in 
treating  functional  amenorrha-a. 

Strabismus  and  its  Management. — Dr.  Julius 
H.  \^'ooDWARD,  of  New  York,  presented  this  paper. 
In  it  he  described  both  the  paralytic  and  the  non-para- 
lytic forms  of  strabismus.  The  symptoms  of  the 
former,  he  said,  were  confusion  of  sight,  vertigo, 
double  vision,  impairment  of  the  sense  of  perspective, 
deviation  of  one  of  the  lines  of  sight  from  the  object 
observed,  and  a  confused  feeling  in  the  head.  The 
diplopia  was  the  most  characteristic  and  troublesome 
of  the  symptoms.  The  first  symptom  of  non-paralytic 
strabismus  was  deviation  of  the  line  of  sight  of  the 
squinting  eye  away  from  the  object  on  which  the  gaze 
was  fixed.  If  the  defect  was  promptly  corrected  a  con- 
siderable degree  of  vision  might  be  restored.  In  these 
cases  the  patient  did  not  complain  of  diplopia,  for 
even  when  it  was  present  the  person  was  not  conscious 
of  it.  'I'he  deformity  associated  with  squint  had  an 
important  influence  upon  the  temperament  of  the  in- 
dividual, and  this  sociological  aspect  should  be  kept 
steadily  in  mind.  In  the  majority  of  cases  more  than 
one  operation  would  be  required.  It  was  frequently 
advisable  to  begin  the  operative  work  at  an  early  age. 

Investigations  upon  Specific  Corporal  Gravity  and 
upon  the  Value  of  this  Factor  in  Physical  Diag- 
nosis.—  Dr.  Heinkich  Si'ERN,of  New  Vork,  read  this 
paper.  He  said  that  it  was  the  density  of  the  tissues 
and  not  the  absolute  weight  of  tiie  body  that  was  an 
important  factor  in  physical  diagnosis  and  in  life  in- 
surance. In  his  investigation  of  this  subject  he  had 
determined  the  specific  gravity  of  the  body  by  dividing 
the  amount  of  its  absolute  weight  by  the  loss  of  weight 
sustained  when  it  was  submerged  in  water.  He  had 
at  first  made  use  of  a  huge  hydrostatic  balance  for  de- 
termining the  specific  gravity,  but  further  study  had 
shown  this  to  be  unnecessary,  as  the  result  varied  but 
slightly  if  tiie  body  was  submerged  instead  of  sus- 
pended. Fat  had  an  average  specific  gravity  of  0.0932. 
The  larger  proportion  of  fat  in  the  female  naturally 


made  the  specific  gravity  of  the  average  female  less 
than  that  of  the  male.  The  specific  gravity  of  chil- 
dren was  less  than  that  of  adults,  but  did  not  differ 
materially  in  the  two  sexes.  The  body  weight  of  the 
aged  was  above  the  average  for  middle  life.  The 
specific  gravity  in  the  latter  in  the  male  was  between 
1.057  ^i^''  i-o63,  and  in  the  female  between  1.051  and 
1. 06 1.  His  studies  also  showed  the  relation  between 
the  body  density  and  the  density  of  the  blood  through- 
out the  different  periods  of  life  to  be  so  close  that  it 
was  perfectly  feasible  to  estimate  the  specific  gravity 
of  the  body  by  determining  the  specific  gravity  of  a 
drop  of  blood  from  the  person.  The  determination  of 
corporal  specific  gravity  would  show  :  (i)  Body  sound- 
ness, (2)  body  immunity,  (3)  endurance,  and  (4)  the 
probable  duration  of  life. 

Aseptic  Minor  Surgery.— Dr.  Douglas  Avres,  of 
Fort  Plain,  gave  in  this  paper  a  few  thoughts  on  the 
pre-aseptic  period,  the  thoughts  and  provings  that  had 
gradually  led  up  to  the  present  greatly  improved 
technique,  and  the  arrangement  of  an  office  or  house  by 
which  modern  surgical  methods  could  be  best  carried 
out. 

Amputation  at  the  Hip  Joint.  A  Report  of  Two 
Hundred  Cases  in  which  the  Author's  Method  of 
Hasmostasis  was  Employed.  — Dr.  Juhn  A,  W  veih, 
of  New  York,  read  a  paper  with  this  title  in  which  he 
gave  a  review  of  the  literature.  He  said  that  the  first 
hip-joint  amputation  by  his  method  had  been  done  in 
February,  1890.  The  operation  had  been  done  with- 
out the  two  pins  in  some  instances,  but  since  these 
pins,  if  properly  inserted,  were  not  in  the  way,  and 
the  control  of  hemorrhage  was  better,  they  should  be 
used  invariably.  A  wick  of  sterilized  gauze  was  in- 
serted into  the  cavity  of  the  acetabulum  because  of  the 
free  oozing  from  the  muscles.  Two  other  successful 
methods  had  been  used  by  surgeons  in  recent  years. 
One  of  these  was  the  performance  of  abdominal  sec- 
tion and  the  control  of  hemorrhage  by  digital  com- 
pression of  the  aorta.  The  other,  devised  by  Dr.  \V. 
L.  Estes,  consisted  in  making  a  gradual  dissection  of 
the  tissues,  exposing  the  femoral  vessels,  and  ligating 
them  before  their  division.  The  method  by  lapa- 
rotomy was  objectionable  because  of  the  unnecessary 
entrance  of  the  peritoneal  cavity.  Compression  of  the 
common  iliac  could  not  so  completely  control  the 
hemorrhage  as  the  pins  and  elastic  ligature,  because 
of  the  free  anastomosis  of  branches  of  the  opposite 
iliac  within  the  pelvis  and  on  the  abdominal  wall.  In 
the  two  hundred  and  forty-seven  cases  of  disarticula- 
tion of  the  hip  that  he  had  collected  in  this  report,  the 
total  mortality  had  been  fifty-two,  or  twenty-one  per 
cent.,  though  this  included  cases  of  death  from  inter- 
current disease. 

Drs.  J.  A.  BoDiNE,  H.  LiLiENTHAL,  and  \V.  B.  COLEY 
presented  reports  showing  clearly  that  in  their  experi- 
ence the  W'yeth  method  was  the  best  of  all. 

Report  of  Three  Cases  of  Intestinal  Obstruction 
due  to  Meckel's  Diverticula.— Dr.  John-  F.  Krd- 
MANN,  of  New  York,  made  this  report  (see  page  645). 

Intraspinal  Cocainization  for  the  Production  of 
Surgical  Anaesthesia. —  Dr.  S.  OuMoxn  Goldan,  of 
New  York,  read  this  paper.  He  said  that  while  he 
did  not  believe  this  new  method  of  anesthesia  would 
supersede  the  other  and  better  known  ones,  he  felt 
sure  that  it  would  be  held  as  a  reserve  in  special  cases. 
It  was  generally  admitted  that  the  credit  of  devising 
this  striking  method  of  anesthesia  should  be  given  to 
Dr.  J.  Leonard  Corning,  of  New  York  City,  who  had 
published  in  1885  a  series  of  interesting  jiapers  de- 
tailing his  experiments  in  this  field.  The  finest  needle 
through  which  the  cerebro-spinal  fluid  would  pass 
should  be  selected.  The  ordinary  long  aspirating 
needles  had  too  large  a  calibre.  He  had  had  con- 
structed special   needles  made  in  one  piece  of  four- 


October  27,  1900] 


MEDICAL    RECORD. 


675 


teen  karat  gold.  Tliese  could  be  kept  sharp  by  the 
physician.  A  sterilized  and  freshly  prepared  two-per- 
cent, solution  of  cocaine  should  be  used.  The  needle 
should  be  introduced  very  quickly  through  the  skin, 
and  then  very  slowly  until  cerebro-spinal  Huid  began 
to  drop  from  the  needle.  After  the  cocaine  was  in- 
jected, the  syringe  should  not  be  removed  from  the 
needle  for  at  least  two  minutes.  In  a  period  varying 
from  four  to  twelve  minutes  the  ana;sthesia  would  be 
sufficiently  complete  for  operation.  In  no  case  had 
he  failed  to  get  tiie  cerebro-spinal  fluid,  and  he  had 
invariably  followed  most  carefully  the  prescribed 
technique.  'I'he  first  two  cases  had  been  failures, 
probably  because  such  large  needles  had  been  used  as 
to  permit  the  solution  to  flow  out  into  the  tissues  ex- 
ternal to  the  canal  on  their  withdrawal.  In  these  cases 
the  cocaine  solution  had  been  tested  and  proved  ac- 
tive. The  usual  quantity  of  cocaine  injected  was  iTl 
XX.  of  a  two-per-cent.  solution,  and  this  dose  should 
not  be  exceeded  until  it  had  been  proved  to  have  ex- 
erted ncj  effect;  then  a  second  injection  might  be 
given.  IJeginning  anjesthesia  was  indicated  by  the 
patient  experiencing  a  feeling  of  numbness  in  the 
limbs.  It  was  his  present  practice  to  give  whiskey  in 
every  case  before  performing  spinal  puncture. 

Dr.  M.  L.  Maduro,  of  New  York,  said  that  he  had 
seen  complete  collapse,  and  had  heard  of  other  com- 
plications following  this  method.  He  felt  sure  that, 
at  the  present  time,  few  physicians  would  be  willing 
to  submit  to  this  method  themselves. 

Dr.  Hodine  thought  some  of  the  uncertainties  of 
the  method  might  arise  from  a  too  rapid  diffusion  of 
the  cocaine  solution,  and  suggested  that  this  might  be 
obviated  by  adding  salt  solution  to  the  fluid  injected, 
thus  increasing  its  density.  Skin  infection  could  be 
best  guarded  against  by  making  an  incision  through 
the  skin  before  introducing  the  needle. 

Dr.  R.  H.  M.  Dawharn  remarked  that  he  had 
known  of  this  method  of  anx-sthesia  having  been  al- 
ready tried  in  a  case  in  which  it  was  required  to  open 
a  large  boil  on  the  thigh.  It  was  not  improbable  that 
the  cord  might  be  so  injured  as  to  lead  ultimately  to 
secondary  neuroses. 

The  Technique  of  Bloodless  Work.— Dr.  Robert  H. 
M.  Dawbarn.of  New  York,  read  a  paper  with  this  title. 
He  said  that  the  older  the  surgeon,  the  greater  his  re- 
spect for  loss  of  blood.  Operations  on  the  extremities 
shoul  be  made  bloodless.  The  best  method  was  to 
raise  the  limb  and  for  several  minutes '"  milk "  the 
blood  out  of  the  part.  A  rubber  tube,  half  an  inch  in 
diameter,  should  be  passed  around  the  limb  two  or 
three  times  and  fastened  with  a  piece  of  wet  bandage. 
For  the  control  of  medical  hemorrhage,  especially 
from  the  lungs,  the  most  useful  procedure  was  tying  a 
cord  around  three  of  the  extremities  so  tightly  as  to 
cause  the  limb  to  swell.  This  was  kept  up  until  the 
patient  felt  faint  from  the  cerebral  anamia  produced, 
and  broke  out  in  a  cold  sweat.  After  the  first  limb 
had  been  bandaged  in  this  way  for  a  short  time,  it 
should  be  released  and  the  fourth  extremity  bandaged, 
and  this  process  should  be  repeated  with  each  limb  in 
turn.  After  two  or  three  hours  the  original  hemor- 
rhage should  have  been  sufficientlv  controlled. 

Operative  Treatment  of  Symblepharon  by  the 
Use  of  Thiersch  Grafts.— Dr.  Wii.r.iR  B.  Marpi.e, 
of  New  York,  presented  a  communication  on  this  sub- 
ject, in  which  he  advocated  his  original  method  of 
using  a  shell  of  glass  to  hold  the  graft  in  position 
until  union  had  taken  place.  The  graft  was  stretched 
over  the  glass  shell,  and  the  latter  was  left  in  from 
three  to  seven  days.  If  the  patient  experienced  pain 
after  the  operation  it  usually  meant  that  the  shell  was 
pressing  on  the  cornea.  The  graft  must  be  one-half 
to  one-third  larger  than  the  defect  to  be  covered,  as  it 
would  be  considerably  reduced  by  contraction  at  the 


time,  and,  to  a  lesser  extent,  subsequently.  The  ob- 
jection to  the  use  of  grafts  from  the  conjunctiva  and 
the  mucous  membrane  of  the  mouth  was  that  these  did 
not  sufficiently  resist  this  subsequent  contraction. 


NKVV    YORK    ACADEMY   OF    MEDICINE. 

Stateil  Meeting,  October  18,  igoo. 

William   H.  Thomson,  M.D.,  President. 

The  discussion  of  the  evening  was  a  continuation  of 
that  begun  at  the  last  stated  meeting. 

Advantages  and  Limitations  of  Sterilizing  and 
Pasteurizing  Milk.  — Dr.  A.  D.  Blackader,  of  Mon- 
treal, read  tiiis  paper.  He  said  that  milk  obtained 
under  unfavorable  conditions  and  kept  at  a  rather 
high  temperature  contained  many  bacteria,  and  in  ad- 
dition, their  spores  and  toxins.  According  to  our 
present  knowledge,  all  forms  of  bacteria  were  unde- 
sirable in  an  infant's  food.  It  had  been  shown  that 
99.8  per  cent,  of  the  bacteria  could  be  destroyed  by 
pasteurization.  The  older  the  milk  was  the  more 
difficult  it  was  to  pasteurize  it.  Pasteurization  at  70° 
C.  destroyed  the  vast  majority  of  the  forms  liable 
to  produce  extensive  and  rapid  change  in  the  quality 
of  the  milk.  It  was  necessary  in  most  instances  to 
maintain  the  pasteurized  milk  at  a  low  temperature  in 
order  to  preserve  it  from  further  change.  However, 
the  same  could  be  said  of  milk  heated  to  100°  C. 
Milk  exposed  to  60^  C.  or  140'  F.  had  ninety-six  to 
ninety-nine  per  cent,  of  its  bacteria  destroyed.  Kussell 
had  found  that  when  milk  was  heated  in  tubes  to  140° 
F.  tubercle  bacilli  were  not  entirely  killed  because  the 
little  pellicle  which  formed  on  the  surface  of  the  milk 
protected  the  bacilli  to  some  extent.  If  this  pellicle 
was  broken  up  complete  destruction  of  the  tubercle 
bacilli  was  assured.  Milk  raised  to  100°  C.  was 
markedly  altered  in  taste,  smell,  and  chemical  com- 
position. The  albumin  and  globulin  were  coagulated, 
the  lecithin  and  nuclein  were  destroyed,  and  the  or- 
ganic phosphates  converted  to  some  extent  into  the 
inorganic  phosphates.  F"or  the  coagulation  of  milk  in 
the  stomach  calcium  must  be  present  in  a  more  or  less 
free  form.  It  was  probable  that  the  preliminary  curd- 
ling of  milk  was  an  aid  to  digestion.  It  was  also 
probable  that  in  milk  heated  in  this  way  certain  use- 
ful ferments  were  destroyed.  As  long  as  milk  could 
be  rendered  practically  sterile  at  comparatively  low 
temperatures  it  seemed  useless  and  even  deleterious 
to  subject  the  milk  to  a  higher  temperature.  It  was 
generally  stated  that  milk  was  pasteurized  at  157'  F. 

Relation  of  Scurvy  to  Recent  Methods  of  Artificial 
Feeding.-  Dr.  J.  P.  Crozer  Griffith,  of  Philadel- 
phia, discussed  this  topic.  He  said  that  two  years 
ago  the  American  Pediatric  Society  had  published  the 
collective  investigation  on  scurvy  in  this  country. 
There  were  tliree  hundred  and  seventy-nine  cases  re- 
ported, and  in  three  hundred  and  fifty-six  the  nature 
of  the  diet  at  the  time  of  the  development  of  the  dis- 
ease was  stated.  Food  containing  or  derived  from 
starch  seemed  to  be  a  powerful  etiological  factor.  The 
use  of  cooked  or  partially  cooked  milk  seemed  to  be  a 
cause  of  scurvy  in  about  nineteen  per  cent,  of  the  in- 
fants. Several  children  developed  the  disease  on  a 
diet  of  raw  milk.  The  speaker  also  referred  to  sixteen 
of  his  own  cases  which  showed  very  plainly  the  very 
large  proportion  of  cases  in  which  some  proprietary 
food  appeared  to  be  the  cause.  It  was  evident  also 
that  scurvy  developed  even  when  the  milk  used  had 
been  taken  raw,  or  only  very  slightly  heated.  One 
fact  that  had  impressed  itself  specially  upon  his  mind 
was,  that  irrespective  of  the  food  much  depended  upon 
individual  peculiarities. 


676 


MEDICAL    RECORD. 


[October  27,  1900 


The  Use  of  Cereals,  Emulsions,  and  Proteids — 
Dr.  '1".  M.  RoTCH,  of  Boston,  rend  this  paper.  He 
said  that  cereals  were  added  either  to  increase  the 
nutritive  value,  or  to  aid  the  digestion  of  the  proteids 
by  acting  meclianically  on  the  coaguluni.  The  addi- 
tion of  an  element  such  as  starch,  that  never  existed 
in  milk  except  as  a  foreign  element,  seemed  to  him 
utterly  irrational.  Barley  water  was  the  favorite  cereal 
diluent  for  milk,  although  actual  experiment  showed 
that  there  was  no  difference  in  the  various  cereal  dilu- 
ents, provided  they  were  of  the  same  degree  of  dilu- 
tion. These  statements  had  received  abundant  con- 
firmation in  some  recent  experiments  conducted  by 
Urs.  White  and  Ladd,  of  Boston,  under  his  directions. 
They  had  been  unable  to  show  any  marked  ditiference 
between  the  laboratory  milk  and  that  in  which  the 
natural  emulsion  had  been  disturbed  by  the  use  of  the 
centrifuge.  It  was  true  that  at  times  globules  of  fat 
would  be  found  on  the  surface  of  the  milk,  but  in- 
vestigation seemed  to  show  that  this  occurred  only  in 
warm  weather,  and  not  then  unless  the  milk  had  been 
disturbed  by  transportation  for  a  considerable  distance. 
In  his  clinical  experience  he  had  been  unable  to  find 
any  special  difference  in  the  action  of  such  milk  and 
milk  that  did  not  exhibit  this  separation  of  the  fat. 
Recent  experiments  seemed  to  indicate  that  whey  was 
a  better  diluent  than  barley  water,  and  that  milk  so 
diluted  was  less  likely  to  show  disturbance  of  the 
emulsion. 

General  Principles  of  Artificial  Feeding,  and  the 
Home  Modification  of  Milk. — Dr.  L.  Em.mett  Holt 
read  a  paper  with  this  title.  He  said  that  good  breast 
milk  must  be  looked  upon  as  the  ideal  food;  the  near- 
est approach  to  it  was  fresh  cow's  milk.  Though  the 
latter  contained  all  of  the  elements  needed,  they  were 
present  in  improper  proportions,  and  the  elements 
themselves  were  not  identical  in  composition  with 
those  of  breast  milk.  It  was  for  this  reason  that  cow's 
milk  could  not  be  fed  to  most  infants  without  some 
modification.  Percentage  feeding  was  a  great  step  in 
advance,  but  while  the  formulas  succeeded  well  with 
some  children,  they  utterly  failed  with  others.  Ex- 
perience had  shown  that  no  single  formula  could  be 
made  to  do  duty  generally.  The  physician  must  know 
the  approximate  quality  of  the  milk  used  at  the  home. 
The  formulas  actually  needed  might  be  grouped  into 
three  series:  (i)  Those  in  which  the  fat  was  three 
times  the  proteids,  or  the  ratio  in  breast  milk;  (2) 
those  in  whicli  the  fats  were  twice  the  proteids,  and 
(3)  those  in  which  the  two  were  nearly  equal.  As  a 
rule,  the  first  formula  was  suited  for  normal  cases  up 
to  the  third  month;  the  second  was  suited  for  them 
from  the  third  to  the  tenth  month,  and  the  third  from 
the  tenth  to  the  thirteenth  month.  Ordinary  milk 
after  standing  four  hours  contained  in  its  upper  third 
about  all  of  the  cream.  A  simple  plan  was  to  strain 
into  a  jar  that  which  was  needed  for  each  day,  and 
then  to  place  the  jar  in  a  vessel  containing  ice.  The 
first  formula  called  for  the  proportion  of  3  to  i,  or  ten 
per  cent,  fat,  and  was  obtained  by  taking  one-third  of 
the  upper  milk.  The  .second  formula  was  represented 
by  half  of  the  milk,  or  seven  per  cent.  fat. 

Dr.  Josei'H  E.  Winters  said  that  the  physician 
could  not  help  to  be  impressed  with  the  fact  that  in- 
fants suckled  by  a  healthy  mother  were  rarely  sick, 
and  that  while  eight  per  cent,  died,  fifty-one  per  cent, 
of  artificially  fed  infants  died.  These  were  the  figures 
from  private  practice,  whereas  in  the  Charily  Hospital 
at  Bsrlin,  where  the  infante  were  for  the  most  part 
artificially  fed,  the  mortality  varied  between  fifty-nine 
and  ninety-three  per  cent.  As  a  result  of  experience 
with  laboratory  feeding  he  had  come  to  feed  new-born 
infants  from  the  very  first  day  of  life,  and  had  found 
that  this  practice  prevented  the  loss  of  weight  gener- 
ally seen  in  the  first  week  of  life.     The  formula  which 


he  found  most  generally  useful  in  the  newly  born  was, 
fat  2,  sugar  7,  and  proteids  0.25  per  cent.  If  the  in- 
fant was  premature  he  increased  the  sugar  to  even  ten 
per  cent.  Cow's  milk  for  infant  feeding  should  con- 
tain nothing  which  was  not  found  in  human  milk, 
and  it  must  be  pure  and  fresh.  He  believed  that  when 
one  reaches  0.50  per  cent,  proteids  all  infants  would 
do  better  on  three  per  cent,  than  one  one  per  cent.  fat. 
When  one  reaches  one  per  cent,  proteids  there  should 
be  the  percentage  of  fat  found  in  human  milk — four 
per  cent.  It  was  very  important  to  increase  the  pro- 
teids as  rapidly  as  possible,  but  it  was  necessary  to  do 
this  much  more  slowly  in  summer  than  in  winter.  In 
the  cool  months  an  infant  should  be  on  two  per  cent, 
proteids  when  about  four  months  old.  During  all  the 
years  that  he  had  been  using  laboratory  milk,  and  with 
unvarying  success,  a  cereal  had  not  entered  into  one 
of  his  prescriptions.  Hundreds  of  infants  had  been 
brought  up  to  full  milk  on  laboratory  milk  and  with- 
out any  disturbance  whatever.  For  the  past  three 
years  he  had  been  using  the  laboratory  milk  absolutely 
raw,  and  the  infants  had  done  better  than  before. 
There  had  been  less  complaints  of  sourness  and  signs 
of  fermentation  since  he  had  been  using rawmilk  than 
before  with  the  pasteurized  milk.  In  one  instance, 
some  raw  milk  and  some  heated  milk  had  been  sent 
on  board  a  steamer.  The  heated  milk  had  soured  first. 
He  had  made  a  trial  of  gravity  cream  at  one  time,  and 
had  not  found  it  superior  to  the  centrifugal  cream  for 
infant  feeding.  When  milk  was  immediately  cooled 
to  40°  F.  after  milking,  and  was  kept  at  that  tempera- 
ture, it  would  keep  sw-eet  a  long  time.  Proper  super- 
vision was  more  of  a  safeguard  than  pasteurization. 

Dr.  H.  D.  Chapin  said  that  the  great  defect  of  per- 
centage feeding  was  that  it  took  no  cognizance  of  the 
differences  in  composition  of  cow's  milk  and  breast 
milk.  This,  he  thought,  disposed  of  the  argument  that 
the  addition  of  cereals  was  the  addition  of  a  foreign 
body.  Any  trouble  from  the  starch  could  be  easily 
overcome  by  dextrinizing  the  gruel,  and  the  mechanical 
separation  of  the  particles  of  coaguluni  made  a  milk 
diluted  in  this  way  much  more  digestible  than  milk 
diluted  to  the  same  extent  with  water  alone. 

Dr.  R.  G.  Freeman  commented  upon  the  great  dif- 
ferences of  opinion  regarding  the  effect  of  heating 
milk.  Some  used  pasteurization  at  155",  others  at 
167°  F.,  and  one  physician  in  this  city  heated  the 
milk  to  190°  F.  We  had  been  told  that  breast-fed  in- 
fants were  rarely  ill,  yet  this  could  not  be  because  the 
milk  was  sterile,  as  the  fissured  and  dirty  nipples  usu- 
ally afforded  a  good  opportunity  for  the  introduction 
of  germs.  The  breast-fed  infant  got  a  fresh  raw  milk 
containing  a  few  bacteria.  Most  of  the  milk  received 
in  this  city  was  twenty-four  hours  old  when  it  was  re- 
ceived, and  was  twenty-four  hours  older  when  the  baby 
was  through  with  the  day's  supply.  The  long  trans- 
portation and  the  opportunities  for  contamination  with 
pathogenic  germs  added  to  the  risks  of  such  milk; 
hence  it  seemed  wise  to  heat  milk.  Pasteurization  at 
155°  F.  for  twenty  minutes  had  practically  no  effect 
on  the  composition  of  the  milk,  yet  the  milk  was 
rendered  almost  sterile — at  any  rate  the  common 
pathogenic  germs  were  killed. 

Dr.  Louis  Fischer  said  that  as  scurvy  was  known 
to  be  produced  by  feeding  heated  milk,  and  that  im- 
provement rapidly  followed  change  to  raw  milk,  it 
seemed  reasonable  to  begin  Teeding  with  raw  milk.  A 
healthy  child  should  gain  six  or  eight  ounces  a  week. 
His  experience  had  been  that  children  fed  on  labora- 
tory milk  exclusively  were  backward  in  development. 
Children  using  this  milk  were  anai-mic  and  their  skin 
was  flabby  even  though  they  were  the  children  of  the 
wealthy.  The  theory  of  percentage  feeding  had  always 
appealed  to  him,  yet  he  had  never  been  able  suc- 
cessfully to  put   it  in  practice.     Dr.  Jacobi  had  often 


October  27,  1900] 


MEDICAL   RECORD. 


677 


called  attention  to  the  frequent  fluctuations  observed 
in  the  composition  of  mother's  milk,  and  this  in  itself 
must  throw  considerable  doubt  on  the  practical  value 
of  percentage  feeding. 

Ur.  a.  M.  Spai.dinc  said  he  had  had  a  good  deal 
of  experience  with  infant  feeding  and  with  the  modifi- 
cation of  milk,  and  had  had  good  success  with  the  use 
of  raw  milk  modified  so  as  to  make  it  approach  the 
composition  of  mother's  milk.  Milk  could  be  modi- 
fied so  as  to  adopt  it  nicely  to  the  wants  of  the  indi- 
vidual.    He  saw  no  reason  for  the  addition  of  cereals. 

Dr.  Rotch  said,  in  closing,  that  he  had  seen  very 
large  tough  curds  vomited  by  breast-fed  infants,  but 
the  density  of  the  coagulum  was  dependent  upon  the 
proportion  of  caseinogen  present.  By  reducing  the 
proportion  of  caseinogen  the  coagulum  would  not  be 
so  tough. 

Dr.  Chapin  remarked  that  under  the  ordinary  con- 
ditions of  practice  it  was  necessary  to  split  up  the 
curd  by  some  diluent  such  as  the  cereals. 


^ccUcal  Jtcnis. 


Contagious   Diseases — Weekly   Statement Report 

of  cases  and  deaths  from  contagious  diseases  reported 
to  the  Sanitary  Bureau,  Health  Department,  for  the 
week  ending  October  20,  1900: 


Tuberculosis 

Typhoid  fever 

Scarlet  fever , 

Measles 

Diphtheria 

Laryngeal  diphtheria  (croup) 
Cerebro-spinal  meningitis. .  .  . 


Cases. 


254 
88 

55 

36 

192 

4 
o 


Deaths. 

166 

16 

I 

I 

35 
3 
6 


Leprosy    in    China Dr.    \Vittenberg.  writing   on 

the  above  subject,  states  that  the  pure  nerve  form  is 
the  least  common.  In  such  cases,  as  is  well  known,  the 
patients  may  go  on  for  years.  As  to  the  mixed  form, 
it  is  fairly  common,  but  it  is  a  difficult  matter  to  esti- 
mate the  number  of  lepers  in  any  given  district.  The 
sufferers  lead  the  common  life  so  long  as  they  remain 
free  from  destructive  lesions.  VV'hen  these  occur  to 
any  marked  degree,  the  leper  is  either  segregated  in  a 
hut  or  he  is  allowed  to  wander  about  the  country  sus- 
taining life  by  begging.  At  other  times  the  relatives 
get  rid  of  him  by  burying  him  alive,  a  proceeding  to 
which  the  patient  readily  consents.  He  is  given  a 
good  meal  as  a  farewell  banquet,  possibly  joins  in  the 
funeral  procession,  following  his  own  coffin,  and  after 
partaking  of  a  generous  dose  of  laudanum,  philosoph- 
ically settles  down  comfortably  in  his  grave.  This  is 
Dr.  Wittenberg's  account,  and  as  it  accords  with  the 
fatalism  of  the  Chinese  there  need  be  no  hesitation  in 
accepting  it  as  accurate.  The  German  observer  also 
records  cases  of  direct  contagion — for  instance,  from 
mother-in-law  to  daughter-in-law,  but  no  further  de- 
tails in  this  connection  are  given. — British  Medical 
Journal. 

Antivenene. — For  some  years  past  Professor  Frazer 
of  Edinburgh,  and  Dr.  A.  Calmette  of  the  Pasteur  In- 
stitute, Lille,  and  others  have  been  engaged  in  the 
very  laudable  endeavor  to  discover  a  remedy  for  snake- 
bite. This,  they  believe,  has  been  found  in  the  poison 
of  the  reptile  itself.  The  system  adopted  by  the  doc- 
tors is  that  of  Pasteur,  the  scope  of  which  since  its 
first  inception  has  become  so  widely  extended  as  to 
embrace  many  diseases  formerly  regarded  as  incurable, 
but  now  found  to  be  more  or  less  amenable  to  the  new 
treatment  which  consists  of  inoculation  with  attenu- 
ated virus  of  the  disease  itself,  or  with  the  blood  serum 


of  animals  which  have  been  immunized  by  the  proc- 
ess, the  treatment  being  employed  not  only  as  a  cure 
but  as  a  prophylactic.  In  the  case  of  snake-bite  the 
remedy  consists  in  the  subcutaneous  injection  of  grad- 
ually increasing  doses  of  the  venom  of  deadly  snakes 
until  the  animal  treated  becomes  proof  against  the 
poison.  The  blood  serum  of  an  animal  thus  immu- 
nized, known  as  antivenene,  or  of  the  snake  itself, 
is  used  to  cure  and  protect  others.  The  animals  thus 
treated  have  been  chietly  rabbits,  rats,  and  pigeons, 
and  it  is  asserted  that  instead  of  being  injured  or 
weakened  by  the  experiments,  they  gain  in  weight  and 
vigor.  The  do.ses  administered  have  been  propor- 
tioned to  the  weight  of  the  animal,  and  four  methods 
of  administration  have  been  tried  experimentally.  In 
the  first  the  venom  and  the  antivenene  were  mixed 
together  before  injection.  In  the  second  the  two  were 
administered  separately  but  simultaneously,  in  the 
third  and  fourth  the  antivenene  was  injected  before 
and  after  the  venom.  The  latter  is  of  course  the  only 
method  applicable  to  actual  cases  of  snake  bite,  and 
it  is  of  special  interest  to  know  how  long  after  the 
bite  antivenene  may  be  relied  on  as  a  remedy,  because 
the  poison  of  the  more  deadly  of  the  snakes  acts  so 
quickly  that  no  remedy  can  avail  unless  close  at  hand. 
In  some  of  Dr.  Calmette's  experiments  serum  injected 
an  hour  and  even  an  hour  and  a  half  after  a  large  dose 
of  venom  seems  to  have  effected  a  cure,  which  would 
at  all  events  allow  time  for  the  application  of  the  rem- 
edy should  anyone  competent  to  administer  it  be  near 
at  hand. 

Alcohol  in  Illness — Professor  Atwater,  writing  in 
Harpci's  Magazine  upon  the  much  vexed  subject  of 
the  use  or  uselessness  of  alcohol,  says:  "In  talking 
with  physicians  about  this  matter  I  have  been  much 
impressed  by  the  frequent  and  emphatic  statements  of 
their  experience  in  administering  alcohol  to  patients 
in  forms  of  disease  when  the  bodily  activities  are  at  a 
low  ebb.  They  tell  me  that  they  often  find  that  peo- 
ple in  such  a  condition  will  take  without  intoxicating 
effects  quantities  of  alcohol  which  would  under  ordi- 
nary circumstances  produce  drunkenness.  They  say, 
furthermore,  that  there  are  many  cases  in  which  the 
bodily  functions  are  maintained,  and  life  is  even  saved 
by  alcohol  when  ordinary  food  could  not  be  endured. 
From  the  standpoint  of  the  physiological  chemist  this 
effect  of  alcohol  would  seem  entirely  natural.  The 
bodily  functions  are  weakened  and  the  power  of 
digestion  is  impaired.  While  the  patient  is  lying  still 
the  labor  required  of  the  muscles  is  not  large  and  the 
chief  need  is  fuel  to  carry  the  body  through  the  time 
of  stress.  What  is  wanted  is  a  material  which  will 
not  have  to  be  digested,  can  be  easily  absorbed,  is 
readily  oxidized,  and  will  supply  the  requisite  energy. 
I  know  of  no  other  material  which  would  seem  to  meet 
these  requirements  so  naturally  and  so  fully  as  alcohol. 
It  does  not  require  digestion,  is  absorbed  by  the  stom- 
ach and  presumably  by  the  intestine  with  great  ease. 
Outside  of  the  body  it  is  oxidized  very  readily,  within 
the  body  it  appears  to  be  quickly  burned.  Why  it 
should  have  less  effect  upon  the  nervous  system  in 
some  forms  of  illness  than  in  health  is  perhaps  hard 
to  say,  but  that  it  should  under  these  circumstances  be 
an  invaluable  source  of  energy  is  easy  to  believe.'" 

Drug-Store  Physicians. — The  latest  development 
of  the  cheap  medical-treatment  scheme  is  a  combina 
tion  of  society  and  druggist.  The  prospectus  of  one 
of  these  relief  bureaus  states  that  for  "  Si  admission  fee 
and  50  cents  monthly  dues  a  family  may  secure  the 
reduced  rates  offered  by  the  bureau.  The  rates  are 
50  cents  a  call  and  25  cents  for  a  consultation  and 
special  rates  for  chronic  cases.'"  The  prescriptions 
are  all  turned  over  to  the  drug  stores  in  the  combina- 
tion, and  as  one  of  the  subscribers  said,  "  When  you 


678 


MEDICAL    RECORD. 


[October  27,  1900 


pav  for  the  medicine  you  begin  to  realize  that  you 
have  not  got  a  bargain."  A  physician  who  practises 
his  profession  in  the  crowded  Kast  Side  district,  where 
many  of  the  cheap  medical -treatment  schemes  have 
flourished,  said,  "The  laws  which  make  a  certificate 
from  the  Board  of  Regents'  examiners  necessary  to 
practise  medicine  have  done  much  to  drive  the  quacks 
out  and  to  make  the  drug-sellers  stick  to  their  busi- 
ness, but  these  clubs  and  bureaus  still  keep  at  it  with 
the  help  of  regular  physicians.  But  the  service  is  un- 
satisfactory because  the  physician  who  is  employed  by 
another  person  to  attend  to  your  family,  or  the  physi- 
cian who  gives  bargain-counter  service,  never  becomes 
the  friend  of  the  family  and  is  soon  dropped  for  a 
regular  practitioner.  The  family  gladly  pay  a  little 
more  for  the  satisfaction  of  speaking  about  '  our  doc- 
tor,' a  distinction  which  raises  them  a  degree  above 
their  neighbors  who  employ  a  club  physician  or  go  to 
the  drug  store  when  the  bureau  doctor  may  be  seen 
there." 

Sale  of  Patent  Medicines  in  Great  Britain. — The 
stamp  duty  paid  on  medicines  during  the  year  ended 
March  31.  1900,  amounted  to  the  sum  of  ^^88,827, 
being  an  increase  over  the  previous  year  of  ^^22,423. 
There  has  been  a  steady  increase  in  the  net  receipts 
since  1894.  when  the  amount  was  ^"213,210,  the  lowest 
during  the  past  ten  years. 

The  Census. — The  Riview  of  Reviews  for  October 
is  rather  sceptical  as  to  the  large  increase  of  popula- 
tion in  this  country  estimated  by  some  computators, 
and  says,  "  Is  it  true  then  that  there  has  been  any 
appreciable  increase  during  the  present  decade  in 
birth  rate  or,  on  the  other  hand,  any  marked  decrease 
ift  the  death  rate,  which  would  favorably  affect  the 
average  annual  increase  of  our  total  numbers? 
Doubtless  the  continued  improvement  of  sanitary  con- 
ditions in  large  towns  and  the  general  progress  in  the 
conditions  of  living  and  in  the  treatment  of  disease 
are  adding  steadily,  if  not  rapidly,  to  the  average 
longevity  of  our  people.  But  all  indications  would 
tend  to  confirm  the  impression  that  the  average  annual 
birth  rate  is  declining  rather  than  gaining  in  the 
United  States.  In  France,  for  example,  although  the 
modern  improvements  in  sanitation,  treatment  of  dis- 
ease, and  care  of  children  are  diminishing  the  death 
rate,  there  has  at  the  same  time  been  such  a  falling  off 
in  the  birth  rate  that  the  total  population  figures  are 
approximately  maintained  solely  by  reason  of  a  mod- 
erate stream  of  immigration  from  Italy  and  other 
neigh'ooring  countries.  It  is  perhaps  true  that  there 
are  now  some  localities  of  considerable  extent  in  the 
United  States,  where,  if  it  were  not  for  the  fact  that 
there  is  some  immigration,  and  "also  that  there  is  a 
comparatively  high  birth  rate  among  the  immigrants, 
the  total  population  would  by  no  means  hold  its  own 
on  account  of  the  lower  birth  rate  among  the  native 
American  element.  An  analytical  study  of  the  facts 
that  the  new  census  will  gather  must  throw  much  light 
upon  interesting  questions  touching  the  present  ten- 
dencies of  population  in  this  country.  If  the  statis- 
tics are  to  be  relied  upon  the  increase  in  population 
that  was  due  to  the  excess  of  births  over  deaths  was 
about  fourteen  per  cent,  for  the  ten  years  1880-90, 
but,  further,  assuming  the  correctness  of  the  immigra- 
tion statistics  for  the  past  decade,  if  we  accept  tiie 
estimates  which  call  for  a  population  of  80,000,000 
this  year  we  shall  have  to  look  to  the  excess  of  births 
over  deaths  for  a  gain  of  almost  twenty-two  per  cent. 
To  any  one  at  all  familiar  with  vital  statistics  it  is 
evident  without  further  discussion  that  such  a  radical 
change  in  the  conditions  of  population  increase  in  the 
United  States  could  not  possibly  have  taken  place. 
Even  if  one  were  to  be  content  with  estimating  that 
we  should  have  gained  population  at  the  same  average 


rate  in  the  current  decade  as  in  the  one  preceding  it 
would  still  be  necessary  on  account  of  the  falling  off 
in  immigration  to  rely  upon  a  considerably  higher  rate 
of  gain  in  the  excess  of  births  over  deaths  in  order  to 
bring  up  the  total.  And  there  is  not  sufficient  reason 
to  believe  that  the  actual  census  work  will  show  any 
such  gain." 

Medical  Commission  in  South  Africa. — It  is  as- 
serted, and  to  those  able  to  read  between  the  lines  it 
would  appear  with  some  degree  of  truth,  that  those 
gentlemen  who  have  reflected  most  severely  upon  the 
conduct  of  medical  and  surgical  departments  of  the 
British  army  in  South  Africa  are  not  so  much  swayed 
by  motives  of  humanity  or  even  by  the  sentiment  of 
patriotism  but  by  the  less  unselfish  aim  of  the  ad- 
vancement of  themselves  politically  and  for  the  desire 
of  notoriety.  Most  of  those  who  peregrinated  through 
South  Africa  in  search  of  information  were  members 
of  Parliament,  who,  aw^are  that  a  general  election  was 
at  hand,  judged  that  the  showing  up  of  abuses  of  the 
war  would  be  an  excellent  battle  cry  with  which  to 
rouse  the  passions  and  gain  the  votes  of  their  constit- 
uents. Among  this  band  is  numbered  Mr.  Murray 
Guthrie,  M.P.,  wiio,  not  content  with  airing  his  opin- 
ions as  a  witness  before  the  commission,  contributes  a 
poorly  constructed  article  to  the  Nineteenth  Century  of 
September,  in  which  he,  without  fear  of  contradiction, 
ventilates  his  views  at  length.  He  criticises  in  a 
severe  and  palpably  unfair  manner  the  whole  working 
of  the  British  army  medical  corps  and  ends  by  saying, 
"  It  can  scarcely  be  questioned  that  the  government 
and  Lord  Roberts  did  everything  in  their  power  to 
meet  and  even  foresee  the  difficulties  that  occurred, 
fulfilling  every  demand  that  was  made  upon  them  in 
the  most  generous  spirit  and  even  giving  more  than 
thev  were  asked  for.  I  am  therefore  compelled  to  urge 
that  the  deficiency  of  doctors  and  orderlies  and  nurs- 
ing sisters  was  due  to  a  lack  of  foresight,  and  that  the 
blame  rests  on  the  head  of  the  medical  department  in 
South  Africa.  This  being  so  one  is  reluctantly 
brought  to  the  conclusion  that  the  local  military  au- 
thorities were  unfitted  for  the  task  they  had  to  per- 
form, a  task  I  admit  of  the  greatest  difliculty  and  mag- 
nitude and  one  which  I  do  not  think  their  previous 
training  in  any  way  fitted  them  to  cope  with.  There 
was  apparent  at  headquarters,  where  most  of  the  sick- 
ness prevailed,  an  obvious  lack  of  energy;  initiative 
was  non-existent.  Had  the  Royal  Army  Medical 
Corps  had  at  headquarters  some  men  of  capacity  and 
determination  who  would  have  grasped  the  whole 
problem  and  worked  it  out  in  time  I  believe  there 
would  have  been  no  occasion  for  a  royal  commission." 

Consumption  of  Spirituous  Beverages. — H.  Bence- 
Jones,  in  a  paper  read  before  the  British  Statistical 
Society,  gave  the  following  figures  with  regard  to  the 
above-named  subject:  The  amount  of  wine  that  is 
drunk  per  head  in  wine-consuming  countries  is  amaz- 
ing. In  France  the  consumption  per  capita  is  twenty- 
four  gallons  a  year,  while  the  average  Italian  drinks 
twenty  gallons  annually,  and  the  average  Spaniard 
eighteen.  But  in  mere  quantity  the  beer-drinkers  far 
exceed  the  wine-drinkers.  Thus  the  annual  consump- 
tion of  the  United  Kingdom  is  nearly  thirty-two  gal- 
lons a  head;  that  of  Germany  is  twenty-seven  gallons; 
that  of  the  United  States  where  the  Saxon  element 
predominates,  is  thirteen  gallons.  The  general  im- 
pression is  that  Germany  heads  the  list,  but  this  is  true 
only  of  parts  of  the  Empire.  Bavaria  leads  the  world 
in  the  consumption  of  beer,  its  inhabitants  drinking  at 
the  rate  of  fifty-six  gallons  a  head  a  year.  VVurtem- 
berg  makes  a  good  second  with  forty-three  gallons  a 
year,  while  each  inhabitant  of  the  Grand  Duchy  of 
Baden  may  be  reckoned  as  drinking  thirty-six  gallons 
in  a  year.      But  this  indulgence  is  balanced  by  a  very 


October  27,  1900J 


MEDICAL    RECORD. 


679 


moderate  rate  of  indulgence  in  other  parts.  Taken  as 
a  wiiole,  IJelgium  leads  the  world  in  the  matter  of 
beer-drinking.  In  fact,  Beligum  seems  to  be  a  self- 
indulgent  little  country,  for  in  addition  to  this  large 
amount  of  beer  its  inhabitants  drink  per  capita  twice 
as  much  wine  and  spirits  as  the  Knglishdo.  Belgium 
drinks  more  of  alcohol  in  every  form  than  any  other 
nation  (of  which  statistics  are  to  be  had),  with  the 
possible  exception  of  Denmark.  Denmark  is  not  so 
much  of  a  beer-drinking  country,  though  its  twenty 
gallons  a  head  annually  is  a  pretty  large  average;  but 
it  has  the  pre-eminence,  affix  to  it  what  adjective  you 
like,  of  drinking  more  spirits  than  any  other  nation  — 
no  less  than  three  gallons  per  head.  No  other  nation 
consumes  more  than  two  gallons  per  head.  The  coun- 
tries which  take  even  so  much  are  France,  Germany, 
Austria,  Holland,  Belgium,  and  Sweden.  In  the 
United  Kingdom,  the  Russian  Empire,  the  United 
States,  and  Switzerland,  the  average  consumption  is 
about  a  gallon  per  inhabitant.  Of  all  Great  Britain's 
colonies  Canada  holds  the  proud  position  of  being  the 
most  sober,  indeed  it  is  probably  the  most  abstemious 
country  in  the  world.  The  consumption  of  spirits, 
too,  is  steadily  decreasing.  In  1898  the  consumption 
of  spirits  was  only  a  little  more  than  half  a  gallon  per 
head,  while  of  wine  there  is  not  consumed  more  than 
one-tenth  of  a  gallon  per  capita.  Three  and  a  half 
gallons  of  beer  are  drunk  per  ca])ita  annually.  (Joffee 
is  being  consumed  more  and  more  both  in  Canada  and 
in  this  country.  The  consumption  of  coffee,  indeed, 
in  the  United  States  exceeds  that  of  any  country  in 
the  world.  The  Americans  drink  anually  eleven 
pounds  of  coffee  a  head,  the  Germans  five,  and  the 
French  three  and  a  half  a  head. 

Tuberculosis    in   the  Russian  Army Dr.  H.  K.. 

Chlchepotiev  published  last  February  in  Vratch  the 
sick  rate  from  tuberculosis  in  the  Russian  army  dur- 
ing the  octennium  1890-97.  During  that  period  it  is 
said  to  have  amounted  to  4  per  1,000  annually,  and 
the  death  rate  to  1.07  per  1,000.  Contrasting  these 
high  rates  with  the  condition  of  things  prevailing  in 
other  countries,  the  author  finds  that  the  annual  admis- 
sion rates  of  tuberculosis  in  the  German  army  is  2.3 
per  1,000  of  strength,  in  the  Austrian  army  3.4  per 
1,000,  in  the  F'rench  army  5.0  per  1,000,  the  death  rate 
varying  from  one-sixth  to  one-third  of  the  total  mor- 
tality from  all  causes.  In  the  French  army,  according 
to  Makiewicz,  out  of  1,000  soldiers  invalided  for  tuber- 
culosis 1 16  had  acquired  the  disease  before  enlistment, 
while  197  developed  tuberculous  symptoms  during  the 
first  six  months  of  their  service  and  278  during  the 
second  six  months.  In  the  course  of  their  second  year 
254  were  found  to  be  afl'ected,  leaving  only  155  who 
remaineH  immune  until  they  had  served  two  years  and 
upward.  At  Kiev  Dr.  Chtchepotiev  found  that  during 
the  period  from  [anuary,  1895,  to  November,  1899,  the 
number  of  admissions  to  the  military  hospital  on  ac- 
count of  tuberculosis  was  527.  Of  these  1 1 1  men  had 
less  than  six  months'  service,  and  32  less  than  a  year's. 
The  second  year  furnished  127  tuberculous  cases,  the 
third  1 1 1,  the  fourth  95,  the  fifth  t,},,  sixth  and  upward 
18;  I  2  of  the  young  soldiers  in  the  first  series  died  in 
hospital,  the  remaining  99  being  sent  to  their  homes 
whilestill  able  to  travel.  Dr.  Chtchepotiev  is  strongly 
of  opinion  that  the  great  prevalence  of  tuberculosis  in 
the  Russian  army  is  due  to  entry  each  year  of  a  num- 
ber of  recruits  who  carry  in  their  systems  seeds  of  the 
disorder.  Although  a  great  many  of  the  affected  sol- 
diers have  tuberculous  antecedents,  hereditary  or 
otherwise,  it  is  also  true  that  of  the  men  attacked  after 
serving  a  year  or  more  fully  half  are  strong  and  robust 
with  nothing  about  them  to  suggest  predisposition  or 
inheritance  of  family  taint.  Unfortunately,  it  is  not 
always  an  easy  matter  to  recognize  incipient  phthisis 


pulmonalis.  A  recruit  who  presents  easily  diagnosed 
symptoms  of  tuberculosis  can,  to  a  certain  extent,  be 
guarded  against,  but  the  harborer  of  latent  germs  is  a 
veritable  anguis  in  herba.  Living  as  soldiers  do  more 
or  less  promiscuously,  sleeping  in  numerously  occu- 
pied dormitories  where  they  must  inevitably  respire 
air  that  has  already  passed  through  human  lungs,  it  is 
of  the  utmost  importance  that  every  one  of  these  should 
be  as  sound  as  possible.  In  order  completely  to  erad- 
icate tuberculosis  from  the  army  the  most  strict  inquiry 
into  the  previous  medical  history  of  every  recruit 
should  be  insisted  on  and  provided  for,  together  with 
a  far  more  searching  examination  of  his  physical  con- 
dition than  at  present  obtains.  The  small  additional 
cost  thus  entailed  would  be  recouped  over  and  over 
again,  even  though  but  one-quarter  of  the  present  loss 
of  efficiency  from  a  preventable  cause  were  to  be  at- 
tained. As  a  palliative  it  would  be  well  to  provide 
for  the  early  elimination  of  tuberculous  patients.  At 
present  the  custom  in  the  Russian  army  is  to  retain 
them  as  long  as  they  can  manage  to  carry  out  their 
duties.  Incidentally  Dr.  Chtchepotiev  confirms  the 
fact  already  noticed  by  several  writers  that  Jewish  sol- 
diers are  seldom  the  victims  of  tuberculosis. —  Lancet. 

Diagnosis   of    Tuberculosis    of   the   Kidney i. 

The  frequent  micturition.  2.  Limpid  polyuria.  3. 
Pyuria,  spontaneous  and  persistent.  4.  Hrematuria, 
slight,  and  repeated  capriciously.     5.  Renal  tumor. 

In  young,  pale,  somewhat  feeble  subjects  we  have 
practically  three  types:  1.  Patient  has  ha-maturia 
alone.  2.  Patient  has  hematuria  and  pyuria.  3.  Pa- 
tient has  tumor  alone. 

1.  Ha;maturia.  The  peculiarities  of  hematuria  due 
to  renal  tuberculosis  must  be  borne  in  mind.  In 
tumor,  much  more  abundant.  In  stone,  due  to  exer- 
cise and  controlled  by  rest  in  bed.  F'requent  mictu- 
rition, pyuria,  albuminuria,  and  tuberculosis  else- 
where, either  in  genito-urinary  tract  or  any  place  else 
in  body,  make  the  diagnosis  possible. 

2.  Patient  has  pyuria  and  hfematuria;  this  usually 
follows  the  hivmaturia  and  the  limpid  polyuria.  The 
characteristics  of  the  pyuria  are  those  of  pyelo-nephri- 
tis.  To  determine  that  it  is  tuberculosis:  (a)  I'res- 
ence  of  bacilli  tuberculosis;  (b)  presence  of  tubercu- 
lous foci  elsewhere,  especially  of  bladder  around  the 
opening  of  the  ureter;  (i)  general  condition;  (//)  ab- 
sence of  antecedent  infection. 

3.  When  tumor  alone  exists,  then  the  diagnosis  is 
alone  possible  when  other  foci  are  to  be  found,  or 
when  the  bacilli  tuberculosis  can  be  demonstrated  in 
urine  or  in  fluid  obtained  by  puncture. — C.  S.  Evans, 
C  'inciiiiiiiti  Lancet-  Clitiic. 

Food  Poisoning  by  Copper  a.  Fallacy. — The  poi- 
sonous nature  of  copper  salts  is  held  by  Dr.  T.  \V. 
Hime,  medical  officer  of  health  of  Bradford,  England, 
to  afford  insufficient  ground  for  the  prohibition  of  the 
sale  of  coppered  vegetables,  and  he  asserts  that  there 
is  no  more  reason  for  such  prohibition  than  for  inter- 
fering with  the  sale  of  the  innumerable  kinds  of  fruits, 
vegetables,  shell-fish,  cereals,  mineral  waters,  wines, 
and  animal  flesh  which  naturally  contain  the  metal  in 
some  form.  These  views  were  advanced  in  a  paper 
read  before  the  British  Association,  wherein  Dr.  Hime 
urged  that  if  any  general  prohibition  of  the  sale  of 
foodstuffs  containing  copper  were  attemi^led  absolute 
and  general  starvation  would  be  the  inevitable  result, 
so  widely  is  the  natural  presence  of  copper  in  articles 
of  food  extended.  But  The  Lancet  thinks  that  on 
such  grounds  Dr.  Hime  might  justify  arsenic  as  a 
useful  food  preservative,  since  it  is  now  known  to 
be  a  normal  constituent  of  the  body  though  in  infi- 
nitesimal amount.  Objection,  however,  is  taken,  not 
to  the  plan  of  preserving  the  color  of  peas  by  copper, 
but  to  the  consumer  not  being  made  plainly  aware 


68o 


MEDICAL    RECORD. 


[October  27,  1900 


that  such  is  the  case  with  the  provisions  he  consumes. 
Some  people  like  their  meats  roasted,  others  do  not 
care  a  tittle  whether  it  is  baked  or  gas-cooked;  but  it 
is  clearly  deception  when  a  person  is  told  that  a  piece 
of  beef  has  been  roasted  which  has  instead  been  cooked 
in  the  gas  oven.  Neither  does  Dr.  Hime  seem  to  pay 
special  regard  to  the  important  question  of  personal 
idiosyncrasy.  If  the  quality  of  our  food  supply  is  to 
be  state  protected,  with  any  degree  of  efficiency,  that 
is  a  point  which  must  not  be  lost  sight  of,  for  in  all 
attempts  to  keep  up  the  health  of  the  community  all 
sorts  and  conditions  of  men  must  be  reckoned  with. 
In  conclusion,  The  Lancet  hopes  that  a  statute  will 
very  soon  be  introduced  which  shall  definitely  control 
all  methods  of  coloring  and  preserving  food. — Phai- 
maceulieal  Journal. 

Futile  Plague   Precautions. — The   Medical  Press, 

writing  on  the  above  subject,  says:  "For  ridiculous 
inadequacy  it  would  be  difficult  to  surpass  the  meas- 
ures adopted  in  most  foreign  ports  to  prevent  the  im- 
portation of  plague  when  these  are  limited  to  fumiga- 
tion of  the  clothing  of  the  passengers  and  crew,  and 
the  so-called  disinfection  of  the  ship.  The  very  idea 
of  disinfecting  a  ship  strikes  one  as  preposterous  in 
view  of  the  myriad  of  corners  and  subdivisions  which 
no  process  of  purification  can  be  expected  to  reach. 
An  efficient  medical  examination  of  the  personnel  and 
the  isolation  of  suspicious  cases  for  a  suitable  period 
are  unquestionably  the  only  effectual  means  of  control. 
The  more  popular  measures  merely  induce  a  fallacious 
confidence  which  may  run  counter  to  the  very  object 
for  which  they  are  carried  out." 

Extemporaneous  Methods  of  Water  Purification. 
— Surgeon-Major  Schucking  of  the  Austrian  army  is 
of  the  opinion  that  of  the  various  methods  of  purifica- 
tion there  are  only  two  that  can  be  taken  into  account 
for  the  use  of  troops  in  the  field:  (i)  filtration;  (2) 
purification  by  the  addition  of  chemical  agents. 
Among  filters  aiming  at  the  sterilization  as  well  as 
the  clarification  of  water,  the  Berkefeld-Nordtrueyer 
alone  is  so  constructed  as  to  meet  the  exigences  of 
war.  But  although  well  adapted  for  use  in  field  sta- 
tions, it  can  only  be  carried  in  baggage  wagons.  Port- 
able filters  only  clarify  muddy  water.  The  use  of 
them  therefore  requires  to  be  supplemented  by  some 
means'of  destroying  micro-organisms.  After  extensive 
experiments  and  researches  (Traube,  Lode,  Kratsch- 
mer,  Vogel)  such  a  means  has  been  found  in  hypo- 
chloride  of  chlorine.  This  chemical  agency  certainly 
kills  all  bacilli  in  thirty  minutes. — British  Medical 
Jountal. 

Concurrence  of  Typhoid   and   Malarial  Fever. — 

In  view  of  the  statement  made  in  Osier's  "  Principles 
and  Practice  of  Medicine"  that  among  a  large  number 
of  cases  of  typhoid  in  which  blood  examinations  were 
made,  in  not  a  single  instance  were  the  plasmodia  of 
malaria  found,  although  many  patients  came  from 
malarious  districts,  it  is  well  to  note  that  Major  M.  T. 
Yare,  R.A.M.C,  records  a  case  of  apparently  mild 
but  well-marked  typhoid  in  which  the  malarial  para- 
site was  discovered.  From  about  the  twenty-first  day 
his  blood  was  examined  and  a  few  crescents  were  seen, 
but  very  few.  About  a  week  later,  however,  he  had 
rigors  followed  by  shivering  and  then  numerous  pig- 
mented parasites  of  the  kind  figured  by  Marchiafava 
and  Bignami  as  pigmented  malignant  quotidian  were 
f  oun  d .  —  Hospital. 

An  Analysis  of  Ice  Cream. — -Additional  informa- 
tion as  to  what  may  be  found  in  that  fearful  and  won- 
derful concolion  sold  as  ice  cream,  has  been  obtained 
from  a  recent  analysis  of  samples  taken  in  London, 
and  at  Ramsgate,  Margate,  Dover,  and  Heme  Bay. 
Some  of  the  samples  were  obtained  from  shops.     As 


is  well  known  there  is  neither  milk  nor  cream  in  this 
frozen  stuff;  boiled  starch  and  maize  being  the  prin- 
cipal ingredients.  Some  contained  gelatin  or  size, 
also  traces  of  lead,  zinc,  and  antimony,  and  others  were 
flavored  with  acetate  of  amyl  which  is  extracted  from 
fusel  oil,  and  will  produce  headache,  drowsiness,  sick- 
ness, and  stupor  in  children.  Microbes,  it  need  hard- 
ly be  said,  were  found  in  abundance. —  Tit-Bits. 

Health  Reports. — The  following  cases  of  smallpox, 
yellow  fever,  cholera,  and  plague  have  been  reported 
to  the  surgeon -general  of  the  United  States  Marine- 
Hospital  service  during  the  week  ended  October  19, 
1900: 

Cases.    Deaths. 
Smallpox — United  Staths. 

Kentucky,  Lexington October  6th  to  13th r 

Louisiana,  New  Orleans  ....September  30th  to  October  I3lh.  i  i 

Minnesota,  Minneapolis    ..  October  6th  to  13th    ,.- 2 

Nebraska,  Omaha September  30th  10  October  6th. .  i 

<3hio,  Cleveland October  6th  to  13th 9 

Huh,  Salt  Lake  City October  6th  to  nth     10 

West  Virginia,  Wheeling September  30th  to  October  6th. .  i 

Smallpox — Foreign  and  Insular 
Brazil,  Rio  de  Janeiro  ..    .    -August  ist  to  September  15th  . .     ..  57 

England,  London  September  22d  to  29th 2 

France.  Paris September  22d  to  29th 6 

India,  Bombay September  6th  to  18th 3 

Calcutta September  1st  to  15th 17 

Philippines January  ist  to  September  8th. . .     35  i 

Russia,  Moscow    September  8th  to  15th 4 

Odessa September  22d  to  2Qth g  4 

St.  Petersburg September  i5thto22d 9  4 

Scotland,  Dundee September  22d  to  2gth i 

Yellow  Fever — LTnited  States. 
New  York,  New  York  Quar- 
antine  October  9th \* 

*  On  steamer  HaTuna  from  Havana, 

Yellow  Fever— Foreign  and  Insular. 

Brazil,  Rio  de  Janeiro August  1st  to  September  15th 10 

Cuba.  Havana October  5th  to  12th 76 

Mexico,  Progreso September  15th  to  30th 3 

Vera  Cruz September  30th  to  October  6th. . 

Cholera. 

India,  Bombay September  6th  to  i8th 

Calcutta September  8th  to  15th 

Karachi September  ist  to  i6th 34 

Madras September  1st  to  14th 

Japan,  Yokohama September  ist  to  8th 1 

Plague — Foreign  and  Insular. 

China,  Amoy August  nth  to  September  8th..      . . 

India,  Bombay September  4th  to  i8th 

Calcutta September  1st  to  15th 

Japan,  Osaka September  17th  to  23d 12 

Philippines.  Manila  January  ist  to  September  8th. . .  215 

Scotland,  Glasgow .-Vugust  31st  to  October  6th 29 

*  Estimated. 


3 


26 
■33 


go- 
»55 
100 

146 


While  the  Medical  Record  is  pltaseJ  to  receive  all  new  pub- 
lications winch  may  be  sent  to  it,  and  an  acknowledgment  will  be 
promptly  made  0/ their  receipt  U7uter  this  heading,  it  must  be  with 
the  distinct  understanding  that  its  necessities  are  such  that  it  can- 
not  be  considered  under  obligation  to  notice  or  review  anv  publica- 
tion received  by  it  which  in  the  judgment  of  its  editor  will  not  be 
of  interest  to  its  readers. 

A  rR.\CTIC.4L  TrKATISE  on  FRACTURES  AND  DISLOCATIONS. 
By  Lewis  A.  Stimson,  M.I).  8vo,  842  pages.  Illustrated. 
Lea  lirotliers  &  Co.,  New  York. 

Pathology  ano  Morbid  Anatomy.  By  T.  llenrj-  (Ireen, 
M.D.  Svo,  5S5  pajjes.  Illustrated.  Lea  Brothers  &  Co. ,  New 
York  and  Philadelphia. 

Ei.ixtrh-Therai'EUTICS  and  X-Rays.  By  Dr.  Charles 
Sinclaire  lilliott.  8vo,  349  pages.  Illustrated.  Boericke  & 
Tafel,  Philadelphia,  Pa. 

Heart  Disease  in  Childhood  and  Youth.  By  Charles 
W.  Chapman,  M.I).  i2mo,  loi  pages.  The  Medical  Publish- 
ing Company,  London. 

Lahoraioky  Dikections  for  Bk.cinners  in  Bacieriology. 
By  Veraiius  A.  Moore,  M.D.  l2mo,  143  pages.  Ginn  &  Com- 
pany, Boston,  Mass. 

KuRZGEFASSTEs  Lehriiuch  der  Kinderheii.kunde.  Von 
Dr.  Carl  Seitz.  8vo,  499  pages.  Verlag  von  S.  Karger,  Berlin, 
Germany. 

Anleitunc  zur  Diagnose  und  Therapie  der  KEHiKorF- 
Nasen-  und  Ohrenkrankheiten.  By  Dr.  Richard  Kayser. 
8vo,  169  pages.     Illustrated.     S.  Karger,  Berlin,  Germany. 


Medical  Record 

A    IVeekly  Journal  of  Medicine  and  Surgery 


Vol.  58,  No.  18. 
Whole  No.  1565. 


New  York,  November  3,  1900. 


$5.00  Per  Annum. 
Single  Copies,  loc. 


©rioinaX  Articles. 


MODERN  OUARAXTIXK  IN 
TO    PASiJENGERy,  CREW, 


ITS  RELATIONS 
AND    CARGO.' 


By   ALV.\H    H.    doty.    M.D., 

HEALTH   OFFICE,    PORT   OP  NEW  YORK. 

For  some  years  past  the  conviction  has  been  forced 
upon  me  that  a  careful  review  of  the  subject  of  public 
health,  particularly  that  part  of  it  which  relates  to 
marine  sanitation,  will  show  that  many  of  the  methods 
now  employed  in  carrying  out  this  important  work  are 
not  in  harmony  with  the  facts  which  have  been  pre- 
sented by  scientific  investigation  and  practical  experi- 
ence, and  I  believe  the  time  has  come  when  this  matter 
should  receive  the  most  serious  consideration.  The 
term  "  commerce  destroyer,"  which  has  been  applied 
to  coast  quarantine,  has  not  been  used  without  some 
justification,  inasmuch  as  such  rigorous  and  unreason- 
able regulations  have  been  imposed  in  dilTerent  sec- 
tions of  the  world  that  commercial  intercourse  with 
those  sections  has  been  almost  abandoned.  In  the  past, 
excuse  may  have  existed  for  the  enforcement  of  these 
measures,  as  but  little  was  known  concerning  the  cause 
of  infectious  disease,  the  germicidal  value  of  agents 
known  as  disinfectants,  etc.  However,  the  brilliant 
researches  of  Pasteur  and  of  Koch  twenty  years  ago,  and 
the  subsequent  investigations  of  other  savants,  have 
given  to  the  world  indisputable  evidence  of  the  germ 
origin  of  many  of  the  infectious  diseases  and  have 
stimulated  bacteriological  inquiry  in  all  directions. 
As  a  result,  regarding  this  subject,  we  are  now  in  pos- 
session of  definite  scientific  knowledge  which  is  in  har- 
mony with  our  practical  experience.  Therefore  but 
little  reason  exists  for  the  continuation  of  some  of  the 
methods  at  present  employed  in  sanitation.  If  we  pro- 
fess a  sanitary  science  we  must  abide  by  its  teachings. 
In  other  words,  we  must  have  the  courage  of  our  con- 
victions, no  matter  to  what  extent  they  may  conflict 
with  theory.  Unfortunately  tiie  latter  plays  a  promi- 
nent part  in  many  of  the  quarantine  regulations  now 
in  force,  and  while  it  adds  nothing  toward  protecting 
the  public  health,  it  seriously  injures  commerce. 

Contrary  to  the  popular  belief,  the  most  careful  in- 
vestigation both  from  a  scientific  and  a  practical  stand- 
point has  demonstrated  that  the  clothing  actually  worn 
by  well  persons  is  not  a  medium  of  infection.  This 
is  also  true  of  ships'  cargoes.  In  making  this  state- 
ment, I  do  not  mean  to  imply  that  it  is  not  within  the 
bounds  of  possibility  for  exceptions  to  present  them- 
selves, but  such  instances  are  rare  and  should  not 
be.  given  undue  weight  in  the  consideration  of  this 
matter;  exceptions  confront  us  many  times  in  public 
health  work.  For  instance,  it  is  generally  accepted 
throughout  the  world  that  tlie  maximum  period  of  in- 
cubation of  smallpox  is  fourteen  days,  and  it  is  for 
this  period  that  persons  who  have  been  in  contact  with 
the  disease  are  kept  under  observation  by  the  health 
officials.  Reliable  evidence,  however,  has  occasion- 
ally been  presented  which  tends  to  show  that  the  ap- 
pearance of  smallpox  may  be  delayed  until  the  fifteenth 

'  Read  at  the  meeting  of  the  American  Public  Health  .Associa- 
tion, Indianapolis,  Ind. .  October  23,  Igoo. 


or  sixteenth  day  after  exposure.  Again,  we  accept  five 
days  as  the  maximum  period  of  incubation  of  yellow 
fever,  although  instances  are  cited  in  which  the  disease 
has  occurred  after  an  incubation  of  six  or  seven  days; 
still  we  are  not  justified  in  making  rules  and  regula- 
tions to  conform  to  these  exceptions.  In  discussing 
this  subject  some  time  ago  with  a  very  distinguished 
health  official,  he  emphatically  indorsed  the  state- 
ment which  I  have  just  made  regarding  the  clothing 
worn  by  well  persons,  and  said  that  in  his  official  ex- 
perience covering  a  period  of  thirty-five  years,  he  re- 
membered but  one  case  in  which  the  clothing  worn  by 
a  well  person  could  have  been  regarded  as  the  medium 
of  infection.  After  an  active  experience  of  twenty 
years,  I  can  bring  to  my  mind  but  one  instance  of  this 
kind.  This  occurred  during  the  epidemic  of  typhus 
fever  in  1893.  I  was  not  surprised,  however,  to  find 
out  subsequently  that  the  man  who  had  succumbed  to 
the  disease  had  been  in  direct  contact  with  persons 
who  at  the  time  were  suffering  from  typhus.  During 
the  different  epidemics  of  smallpox,  typhus  fever,  etc., 
which  have  occurred  in  New  York,  the  physicians, 
ambulance  drivers,  and  helpers  connected  with  the 
health  department  have  been  in  close  contact  with 
the  patients;  the  ambulance  drivers  being  frequently 
obliged  to  carry  the  sick  in  their  arms.  Nevertheless 
no  evidence  that  I  am  aware  of,  after  a  careful  investi- 
gation, has  ever  been  presented  to  show  that  infection 
was  carried  either  to  the  homes  of  these  officials  or  to 
their  associates.  Cases  of  smallpox,  typhus  fever, 
etc.,  are  frequently  found  which  have  passed  through 
the  various  stages  of  these  diseases  before  detection. 
In  many  instances,  the  relatives  of  these  patients,  liv- 
ing in  the  same  apartments  with  them,  who  by  success- 
ful vaccination  or  otherwise  have  become  immune, 
are  employed  in  factories  where  they  are  in  close 
contact  with  others,  yet  without  transmitting  the  dis- 
ease. The  busy  medical  practitioner  may  during  the 
day  visit  many  cases  of  infectious  disease  and  may 
go  from  them  to  others  without  previously  chang- 
ing his  clothing  or  performing  disinfection.  He  has 
reason  to  believe  that  he  does  not  act  as  a  medium  of 
infection;  he  sees  no  evidence  of  it  in  his  own  home, 
nor  is  evidence  presented  to  him  that  he  transmits 
disease  to  his  patients.  If  under  the  circumstances 
which  I  have  just  cited  the  clothing  worn  by  well  per- 
sons does  not  act  as  a  medium  of  infection,  it  is  hardly 
reasonable  to  believe  that  danger  exists  in  the  cloth- 
ing worn  by  those  who  are  in  good  health  and  have 
been  for  a  number  of  days  or  weeks  removed  from  an 
infected  port  or  other  exposure.  Bacteriological  re- 
search goes  far  to  confirm  the  results  of  practical  ex- 
perience to  which  I  have  just  referred,  inasmuch  as  it 
has  shown  that  pathogenic  organisms  can  continue 
their  existence  for  only  a  few  hours  when  exposed  in 
the  presence  of  sunlight  and  air.  As  a  matter  of  fact, 
many  careful  observers  believe  that  the  activity,  at 
least  of  some,  of  the  specific  organisms  is  inhibited 
by  an  exposure  of  only  a  few  minutes  to  air  and  sun- 
light and  that  their  activity  and  power  of  propagation 
are  not  renewed  unless  brought  in  contact  with  proper 
media.  It  is  upon  such  evidence  that  we  must  base 
our  conclusions  in  deciding  what  methods  shall  be 
employed  to  protect  the  public  health. 


682 


MEDICAL    RECORD. 


[November  3,  1900 


As  I  have  already  stated,  exceptions  may  exist,  and 
occasionally  evidence  is  presented  to  us  from  a  reliable 
source  which  tends  to  show  that  disease  is  contracted 
through  the  medium  of  the  clothing  of  well  persons. 
It  is  reasonable  to  believe  that  when  a  person  is  in 
close  and  prolonged  contact  with  a  case  of  scarlet  fever 
or  smallpox,  for  instance,  then  puts  on  an  outside  wrap 
and  removes  it  after  going  directly  to  another  apartment 
but  a  short  distance  away,  he  may  transmit  infection. 
However,  careful  investigation,  with  the  most  reliable 
evidence,  shows  that  tliis  occurs  only  in  rare  instances. 
In  connection  with  municipal  sanitation  the  possi- 
bility that  such  instances  may  occur  should  receive 
proper  consideration,  and  reasonable  efforts  be  made 
to  prevent  their  occurrence,  whereas  in  marine  sanita- 
tion this  possibility  need  receive  consideration  only 
when  infectious  diseases  actually  exist  on  the  arrival  of 
the  vessel  in  port.  It  is  not  proper  nor  does  it  aid  in 
the  advancement  of  sanitary  science  to  overlook  facts. 
The  importance  of  a  clear  understanding  of  this  matter, 
particularly  in  relation  to  marine  sanitation,  cannot  be 
overestimated ;  it  means,  as  a  rule,  that  we  can  safely 
dispense  with  the  disinfection  of  clothing  actually  worn 
by  well  persons  arriving  on  vessels  from  infected  ports; 
this  not  only  lessens  the  detention  of  ships,  but  dimin- 
ishes the  expense  to  commerce.  In  municipal  sanitary 
work  this  knowledge  is  valuable,  as  we  are  then  reason- 
ably assured  that  the  disease  will  not  spread — at  least 
to  any  serious  extent — through  the  medium  of  clothing 
worn  by  well  persons;  moreover,  it  teaches  us  to  make 
a  more  thorough  inspection  in  order  to  ascertain  the 
origin  of  an  outbreak  of  infectious  disease.  Such  an 
inspection  will  frequently  bring  to  light  mild,  ambu- 
lant, or  convalescent  cases  which  otherwise  would  not 
be  found. 

When  we  have  given  to  the  patient  his  clothing  and 
effects,  an  apartment,  and  the  required  attention,  and 
have  surrounded  the  case  with  every  possible  sanitary 
precaution,  and  when  at  its  termination  we  have  per- 
formed careful  and  thorough  disinfection,  we  have,  I 
believe,  given  to  the  public  the  full  protection  which 
is  dictated  by  practical  science. 

We  have  equally  satisfactory  evidence  that  a  ship's 
cargo  does  not  act  as  a  medium  of  infection ;  if  excep- 
tions exist  they  have  not  been  brought  to  my  atten- 
tion. 

The  outbreaks  of  bubonic  plague  in  European  and 
other  ports  with  which  the  United  States  is  in  frequent 
and  constant  communication  have  brought  prominently 
to  our  notice  the  question  of  the  transmission  of  this 
disease  by  rats  and  other  vermin,  (-)ur  information  on 
this  subject  is  at  present  by  no  means  complete;  al- 
though Kitasato  and  Yersin  demonstrated  the  presence 
of  the  disease  in  rats  during  the  epidemic  of  bubonic 
plague  in  Hong  Kong  in  1894,  we  have  beyond  this 
but  little  authentic  information  on  the  subject.  It  is, 
however,  reasonable  to  believe  that  in  such  communi- 
ties as  are  found  in  India  and  China,  where  tilth,  over- 
crowding, and  bad  sanitary  regulations  exist  to  an 
extent  which  is  almost  beyond  belief,  the  dissemi- 
nation of  infection  is  so  general  that  even  vermin  are 
involved.  However,  in  civilized  communities  where 
the  ordinary  sanitary  regulations  are  carried  out,  the 
danger  from  this  source  would  seem  to  be  very  limited. 
What  may  be  a  satisfactory  summing  up  of  this  detail 
of  the  subject  from  a  theoretical  standpoint,  although 
entitled  to  respectful  consideration,  should  not  over- 
shadow the  practical  experience  in  this  direction.  So 
far  as  I  am  able  to  ascertain,  no  authentic  report  exists 
whicli  shows  that  cargoes  of  vessels  have  transmitted 
bubonic  plague  through  the  medium  of  infected  rats 
or  other  sources.  Since  1870  tiiis  disease  has  been 
particularly  active  in  India  and  China  and  other  East- 
ern countries,  where  it  has  visited  many  important  sea- 
ports.     During    this    time    both    sailing-vessels    and 


steamers  have  been  plying  between  the  ports  referred 
to  and  the  United  States,  carrying  cargoes  which  come 
directly  from  the  plague-infected  districts,  and  which 
include  raisins,  rugs,  silks,  and  other  general  merchan- 
dise. No  quarantine  restrictions  whatever  have  been 
placed  upon  these  cargoes,  and  in  no  instance  has  the 
disease  been  conveyed  to  this  country.  It  would  seem 
that  a  test  of  thirty  years  ought  to  be  regarded  as 
satisfactory  evidence  that  bubonic  plague  is  not  likely 
to  be  transmitted  in  this  manner,  either  by  the  cargoes  or 
by  the  transportation  of  infected  vermin.  During  the 
recent  outbreak  of  the  plague  in  Rio  Janeiro  and  San- 
tos, many  vessels  carrying  coffee  from  these  ports  ar- 
rived at  the  New  York  Quarantine  Station,  probably  two 
during  each  week,  and  for  two  months  or  more  the  car- 
goes were  removed  in  open  stream  and  transferred  to 
the  city  on  lighters,  an  opportunity  thus  being  given 
to  collect  such  rats,  dead  or  alive,  as  could  be  found  on 
board.  These  were  removed  to  the  laboratory  and  ex- 
amined bacteriologically,  and  in  no  instance  was  there 
the  slightest  evidence  of  bubonic-plague  infection. 
During  the  past  six  years  about  thirty-five  thousand 
vessels  from  different  parts  of  the  world  have  entered 
the  port  of  New  York,  and  while,  save  in  seven  or  eight 
instances,  their  cargoes  have  in  no  way  been  disturbed, 
yet  not  the  slightest  evidence  has  been  presented  that 
this  material  has  in  any  way  transmitted  any  form  of 
infectious  disease.  I  may  add  to  this  the  fact  that  the 
most  careful  investigation  has  failed  to  present  satis- 
factory evidence  that  either  foreign  or  domestic  rags 
act  as  a  medium  of  infection,  although  they  include 
all  kinds  of  wearing-apparel  which  is  frequently  frlthy 
and  offensive.  From  what  source,  then,  do  we  receive 
information  which  is  supposed  to  give  proof  that  the 
clothing  worn  by  well  persons  or  the  cargoes  of  ves- 
sels act  as  a  medium  of  infection?  1  believe  it  to  be 
principally  from  vague  reports,  which  have  been 
handed  down  to  us  from  almost  ancient  times.  These 
reports,  so  far  as  my  investigations  are  concerned, 
carry  with  them  no  scientific  or  practical  proof,  and 
are  mainly  hearsay  evidence.  For  instance,  an  out- 
break of  infectious  disease,  the  origin  of  which  is  un- 
known, appears  at  a  small  seacoast  town.  It  is  learned 
that  a  ship  had  previously  arrived  from  an  infected  port, 
discharged  its  cargo,  and  departed;  this  appears  to  be 
a  satisfactory  explanation  and  it  is  decided  that  the  dis- 
ease was  probably  introduced  by  the  cargo;  but  little 
or  no  attention  is  paid  to  the  fact  that  on  the  arrival 
of  the  vessel  the  passengers  and  crew  were  not  sub- 
jected to  an  examination,  and  that  nothing  is  known  of 
the  possible  existence  of  a  mild  case  of  infectious  dis- 
ease which  may  have  remained  in  town  or  departed 
with  the  vessel.  The  license  which  theorists  assume 
in  dealing  with  this  matter  is  apparently  witliout  any 
limit.  Some  time  ago  a  foreign  health  official  very 
gravely  asserted  that  an  outbreak  of  bubonic  plague 
was  caused  by  the  transmission  of  infection  through 
the  medium  of  some  neckties.  Other  statements  arc 
made  regarding  the  origin  of  outbreaks  of  infectious 
disease  which  are  equally  ridiculous.  No  fair  evidence 
is  presented  to  substantiate  such  theories,  which  go  far 
toward  making  public  sanitation  a  farce.  I  believe 
that  the  future  will  show  that  if  a  vessel  arrives  in 
port  and  there  are  no  cases  of  sickness  present  on 
arrival  and  none  have  occurred  in  transit,  the  vessel 
and  its  cargo  will  in  no  w-ay  act  as  a  menace  to  the 
public  health.  l''roni  my  own  experience  I  am  satisfied 
that  this  is  true,  and  I  believe  that  an  outbreak  of  in- 
fectious disease  when  the  cause  is  unknown  is  almost 
always  due  to  the  presence  of  mild,  ambulant,  or  conva- 
lescent cases  which  have  passed  unrecognized.  These 
constitute  a  great  danger  to  a  community  inasmuch  as 
there  is  no  protection  against  them.  Cases  of  smallpox 
occur  in  which  the  patient  is  apparently  well  and  the 
eruption  is  with  difficulty  recognized.    The  frequent  ex- 


November  3,  1900] 


MEDICAL    RECORD. 


683 


istence  of  mild  cases  of  diphtheria  is  known  to  all  phy- 
sicians; mild  or  walking  cases  of  typhoid  fever  which 
are  mistaken  for  malaria,  colds,  etc. ,  are  well-known 
causes  of  serious  outbreaks  of  this  disease.  The  fre- 
quency with  which  mild  cases  of  yellow  fever  occur  is 
notorious;  a  vessel  which  arrived  at  this  station  some 
time  ago  from  a  port  infected  with  this  disease  brougin 
a  large  number  of  jiassengers,  many  of  whom  were  not 
immunes;  these  were  removed  to  Hoffman  Island  for 
observation  and  to  complete  the  period  of  incubation; 
at  the  final  examination  all  reported  well,  and  from  a 
visual  inspection  apparently  were  so.  However,  when 
the  thermometers  were  used,  four  of  the  passengers 
were  found  to  have  elevated  temperatures  and  were 
detained;  of  these,  three  were  subsequently  found  to 
have  yellow  fever,  one  case  being  so  mild  that  the  pa- 
tient could  with  little  exertion  have  attended  to  his 
duties  had  he  been  allowed  to  proceed  to  his  home. 
At  least  he  could  have  kept  up  and  around  without 
arousing  suspicion  as  to  his  condition.  Cases  of  bu- 
bonic plague  frequently  assume  a  very  mild  form  ;  of  the 
four  cases  of  this  disease  which  occurred  on  the  steam- 
ship/(zw«  IF.  Taylor  arriving  at  this  port  from  Santos, 
Brazil,  on  November  18,  1899,  one  was  fatal  and  the 
body  was  buried  at  sea.  On  the  arrival  of  the  vessel  at 
quarantine  the  facts  connected  with  the  death  of  the 
steward  were  reported.  The  remainder  of  the  crew 
were  assembled  on  deck,  reported  well,  and  from  ex- 
ternal appearance  were  so.  Inasmucii  as  the  vessel 
came  from  a  plague-infected  port  and  as  the  symptoms 
associated  with  the  steward's  death  were  suspicious, 
the  crew  were  made  to  remove  their  clothing  and  were 
subjected  to  a  careful  inspection,  including  a  glandular 
examination.  .\t  this  inspection  the  characteristic  local 
lesion  and  the  glandular  affection  were  found  in  three 
of  the  crew,  and  the  diagnosis  of  bubonic  plague  was 
then  made  and  afterward  confirmed  by  bacteriological 
examination.  The  captain  of  the  ship,  who  was  one 
of  the  three  members  of  the  crew  removed  to  Swin- 
burne Island  Hospital,  stated  that  he  felt  bad  only 
for  a  day  or  so  while  in  transit,  and  was  surprised 
when  informed  of  the  serious  nature  of  the  disease.  It 
is  possible  for  such  a  person  arriving  on  a  vessel  from 
a  port  issuing  a  clean  bill  of  health  or  believed  to  be 
free  from  quarantinable  diseases,  to  pass  an  ordinary 
inspection,  then  proceed  to  some  interior  town,  there 
to  act  as  a  medium  of  infection  without  being  recog- 
nized as  such. 

I  believe  the  lessons  which  we  are  to  learn  from  the 
facts  which  I  have  presented  are  that  mild  or  ambulant 
cases  of  infectious  disease  and  convalescents  from 
these  diseases  constitute  a  serious  menace  to  the 
public  health  and  are  chiefly  responsible  for  out- 
breaks which  from  time  to  time  occur,  and  which 
cannot  be  accounted  for;  and  that  neither  scientific 
investigation  nor  practical  experience  justifies  us  in  as- 
suming that  either  the  clothing  worn  by  well  persons 
or  a  ship's  cargo  acts  as  a  medium  of  infection  except 
in  such  rare  instances  as  I  have  referred  to.  The 
views  which  I  have  thus  expressed  as  the  result  of  my 
scientific  investigation  and  practical  experience  are  in 
harmony  with  the  policy  which  I  pursue  in  the  treat- 
ment of  vessels  arriving  at  the  port  of  Xew  York.  I 
believe  this  to  represent  scientific  sanitation  ;  and  while 
it  offers  the  full  protection  which  we  can  give  to  the 
public,  it  also  relieves  commerce  of  unnecessary  delay 
and  expense,  a  most  important  consideration. 

In  the  inspection  of  persons  coming  from  infected 
ports,  it  is  evident  that  the  ordinary  examination, 
which  includes  statements  from  the  persons  con- 
cerned, is  not  sufficient  at  all  times  to  detect  mild  or 
ambulant  cases.  It  appears  to  me  that  the  most  prac- 
tical and  important  addition  that  we  can  make  to  the 
ordinary  method  of  inspection  is  the  use  of  the  clini- 
cal thermometer.     This  has  been  in  operation  at  this 


station  for  the  past  two  years,  and  the  most  satisfac- 
tory results  have  been  obtained  in  detecting  mild  or 
ambulant  cases.  Although  I  am  firmly  convinced  that 
the  maximum  period  of  incubation  of  yellow  fever  is 
five  days,  there  is  no  doubt  that  during  the  first  day 
or  so  of  the  disease,  persons  affected  may  present 
themselves  and  pass  an  ordinary  inspection.  The  use 
of  the  thermometer  at  this  time,  however,  will  almost 
always  show  an  elevation  of  temperature  sufficiently 
high  to  justify  us  in  causing  a  longer  detention.  The 
statements  of  persons  detained  at  quarantine  cannot 
be  depended  upon,  and  at  this  station  we  accept  them 
only  as  corroborative  evidence.  Persons  from  yellow- 
fever-infected  ports,  who  are  detained  here  to  complete 
the  period  of  incubation  dating  from  the  time  of  depart- 
ure from  the  infected  port,  are  never  released  until  their 
temperatures  have  been  taken.  I  have  already  cited  one 
of  the  number  of  instances  in  which  the  disease  has  been 
detected  in  this  manner.  Passengers  or  crews  coming 
from  plague-infected  ports  are  not  released  until  their 
temperatures  have  been  taken,  no  matter  how  long  they 
may  have  been  in  transit.  These  are  instances  of  the 
value  of  the  use  of  the  thermometer  at  this  station.  It 
is  frequently  necessary  to  take  the  temperature  of  a 
thousand  or  more  persons  on  the  arrival  of  a  vessel  here. 
Therefore  I  have  constantly  on  hand  forty  or  fifty  first- 
class  [jroperly  registered  instruments.  If  these  are  un- 
reliable, or  the  exposure  is  insufficient,  this  procedure  is 
worthless.  What  are  known  as  half-minute  thermom- 
eters are  not  practical,  as  they  are  extremely  delicate 
and  break  easily.  It  is  very  important  that  those 
whose  temperatures  are  being  taken  should  be  watched 
carefully,  as  they  frequently  take  out  the  instrument, 
keep  their  mouths  open,  or  otherwise  interfere  with  the 
proper  registration.  A  very  interesting  fact  has  been 
observed  in  connection  with  this  portion  of  the  exami- 
nation. A  temperature  of  100  F.  does  not  necessarily 
signify  an  abnormal  condition,  as  our  records  show  that 
this  temperature  is  frequently  present  in  well  persons, 
and  is  probably  due  to  some  slight  or  transient  cause, 
as  it  commonly  disappears  within  a  few  hours.  A 
large  percentage  of  the  temperatures  range  from  99°  to 
99 '4  °  F.  in  persons  in  a  normal  condition.  However, 
the  rules  of  this  department  now  require  the  detention 
of  all  whose  temperatures  reach  100^  F.  or  over. 

I  cannot  conclude  this  article  without  a  reference  to 
modern  sanitary  regulations,  the  value  of  which  has 
been  so  forcibly  presented  to  us  during  liie  past  two 
years.  Since  1895  or  1898,  the  civilized  world  has 
been  made  uneasy  by  reports  from  India  relative  to 
the  terrible  ravages  of  the  bubonic  plague  in  that 
country,  and  the  possibility  of  its  appearance  at  Kuro- 
pean  and  other  seaports  has  caused  much  apprehen- 
sion. During  the  past  two  years,  the  disease  has  ap- 
peared at  Oporto,  Lisbon,  Alexandria,  Santos,  Kio 
Janeiro,  San  Francisco,  and  Glasgow,  but  in  no  in- 
stance has  it  proved  to  be  a  serious  menace  to  the 
public  health,  the  outbreaks  having  been  rapidly 
brought  under  control,  and  in  all  but  one  of  the  above 
places  the  disease  has  disappeared.  In  Glasgow,  a 
city  which  has  an  enviable  reputation  for  cleanliness 
and  good  sanitary  conditions,  the  duration  of  the  out- 
break was  exceedingly  short,  although  the  disease  ex- 
isted some  time  before  it  was  recognized.  Than  the 
above  no  more  conclusive  evidence  has  ever  been  pre- 
sented to  show  the  absolute  certainty  with  which  out- 
breaks of  infectious  disease  can  be  controlled  when 
good  sanitary  conditions,  thorough  inspection  and  ob- 
servation, and  cleanliness  are  maintained. 


Snake-Bite — The  patient  should  be  kept  quiet, 
encouraged  and  soothed,  and  his  strength  spared.  Hot 
bottles  should  be  applied  to  the  heart.  Estimate  the 
dose  of  venom  before  making  attempts  to  counteract  it 
by  any  of  the  serums  advised. — W.'vrre.v. 


684 


MEDICAL    RECORD. 


[November  3,  1900 


INCINERATION     FS.      EARTH     SINKS     AND 
CHEMICAL    DISINFECTION. 

Bv    WILLIAM   G.    BISSELL,    M.D,, 

BlfFFALO,    N.  V. 

During  the  late  Spanish-American  War  from  among  an 
enrolment  of  18;, 687  volunteers,  4,015  died  of  disease. 
It  has  been  conservatively  estimated  that  this  death 
rate  represents  about  one-twentieth  of  the  number  sick 
with  severe  illnesses.  If  this  be  true,  at  least  80,300 
men  were  totally  unfit  for  duty  for  a  greater  or  lesser 
period  of  time;  and  when  it  will  be  remembered  that 
the  prevailing  illness  was  typhoid  fever,  and  that  many 
of  the  New  York  State  regiments  suffered  as  a  conse- 
quence, it  is  not  surprising  that  Col.  Nelson  H.  Henry 
recommended  to  Major-General  Charles  F.  Roe,  com- 
manding the  National  Guard  of  New  York,  that  an  in- 
dependent investigation  be  carried  on  by  the  State  of 
New  York,  to  be  entirely  non-political,  pertaining  to 
the  improvement  of  sanitary  methods  in  camps  of  mo- 
bilization, so  that  if  the  National  Guard  of  this  State 
should  again  be  called  upon  to  serve  as  volunteers, 
tiiey  would  not  be  subjected  to  the  danger  recently  en- 
countered. It  has  long  been  taught  that  typhoid  fever 
is  a  preventable  disease,  and  that  its  mode  of  trans- 
mission is  by  the  ingestion  of  water  or  any  food  sub- 
stance containing  the  bacillus  of  Eberth.  During  the 
late  war  there  was  little  doubt  that  the  earth  interment 
of  excrement  was  directly  responsible  for  the  ravages 
of  this  fever,  in  that  it  made  it  possible  for  the  germ, 
if  present,  not  only  to  contaminate  the  water  supply, 
but  to  be  deposited  upon  food  substances  by  flies. 
The  e.\perience  of  the  navy  during  this  war  fully  cor- 
roborates this  view,  for  although  the  men  were  cramped 
in  quarters,  and  in  a  much  warmer  climate,  they  expe- 
rienced little  or  no  typhoid  fever. 

During  the  first  year  and  a  half  of  the  Civil  War  ty- 
phoid fever  was  epidemic  among  the  troops  camped 
near  Washington,  and  during  1861  and  r862  there  was 
a  morbility  rate  of  78.62  per  thousand,  and  ig.55  per 
thousand  succumbed  to  the  disease.  All  this  was 
known  and  thought  to  be  understood  when  the  troops 
entered  the  United  States  service  in  1S98. 

Much  has  since  been  written  and  more  stated  about 
'"inexperienced  volunteers"  being  the  cause  of  ty- 
phoid-fever infection  in  our  army  during  the  Spanish- 
American  War.  The  truth  of  these  statements  might 
perhaps  have  some  weight  were  it  not  a  fact  that  the 
regulars  likewise  suffered. 

Camp  Alger  in  Virginia,  a  strictly  volunteer  camp, 
with  a  population  of  over  twenty-five  thousand  National 
Guardsmen,  occupying  poorly  selected  ground,  had  but 
thirty-nine  cases  of  typhoid  fever  at  the  end  of  sixty 
days  occupancy  of  this  camp.  Had  the  troops  been 
moved  from  this  territory  after  six  weeks,  as  they 
should  have  been,  they  would  not  have  been  subjected 
to  the  positive  evils  of  the  earth  interment  of  excrement 
which  had  become,  even  at  this  time,  an  unpleasant 
feature. 

It  is  the  history  of  all  wars,  with  the  exception  of 
the  Franco-l'russian  of  1870,  which  might  be  termed 
a  "constant  fight,"  that  jjreventable  diseases  have 
caused  more  deaths  than  the  bullet.  The  early  Ro- 
mans, thousands  of  years  before  the  discovery  of  fire- 
arms, deposited  their  excrement  in  the  soil,  and  at  the 
time  of  the  excavation  of  Pompeii  a  system  of  sewering 
was  found  constructed  along  the  same  lines  as  that  in 
use  in  the  cities  of  to-day.  There  has  been  no  change 
in  principle  for  excrement  disposal  from  the  earlier 
days  up  to  the  present  lime.  Is  it  surprising  that  his- 
tory has  repeated  itself.' 

Military  camps  have  not  alone  suffered  from  the  evil 
effects  of  the  soil  interment  of  excrement,  and  nearly 
any  one  can  name  towns  which  dei)end  entirely  upon 
the  privy  for  its  sewage  disposal,  that  have  as  high  a 


death  rate  from  typhoid  fever  as  did  Camp  Alger  at 
the  end  of  its  occupancy. 

I  am  not  endeavoring  to  uphold  the  administration 
of  this  camp,  but  simply  desire  to  demonstrate  that  it 
was  not  the  "  inexperienced  volunteers"  who  were  re- 
sponsible for  the  transmission  of  typhoid  infection, 
but  rather  the  method,  or  better  perhaps  lack  of  meth- 
ods, furnished  tiiese  volunteers  for  the  disposal  of 
their  offal. 

The  cities  of  to-day  are  doing  away  with  the  use  of 
the  privy.  To  be  sure,  a  system  is  substituted  which 
ultimately  contaminates  the  water  ways,  and  for  this 
reason  is  far  from  the  ideal.  How  much  better  it 
would  be  if  every  household  had  its  individual  device 
by  which  the  offal  could  be  completely  consumed! 

During  the  latter  part  of  the  Spanish-American  War 
the  army  medical  board  began  to  appreciate  the  dan- 
gers of  the  earth  sink  and  recommended  as  a  substi- 
tute the  use  of  zinc-lined  wooden  troughs  containing 
milk  of  lime,  into  which  the  excrement  was  deposited, 
this  mixture  stirred,  and  after  a  time  drawn  off  into 
tanks  and  carted  to  receive  its  soil  interment.  At 
about  the  same  time  this  board  considered  the  possi- 
bilities of  the  use  of  heat  for  the  disposal  of  excrement. 
Several  different  devices  were  experimented  with,  and 
after  a  thorough  trial  of  one  month,  as  is  stated  in  their 
report,  they  ventured  the  opinion  that  none  of  the 
methods  tried  during  this  time  met  the  conditions  of 
troops  in  the  field  as  well  as  the  above  "  milk-of-lime 
soil-interment  process."  This,  no  doubt,  is  true  if  we 
are  to  understand  that  moving  bodies  are  meant  by 
■■  troops  in  the  field,"  for  as  a  matter  of  fact  moving 
troops  are  not  subjected  to  the  evil  influences  of  the 
earth  sink,  and  it  is  not  necessary  to  exercise  the  same 
precautions.  But  exception  can  be  taken  if  it  is  meant 
that  the  milk-of-lime  method  is  more  adaptable  than 
burning  in  camps  of  mobilization.  The  use  of  milk  of 
lime  for  the  chemical  reduction  of  sewage  is  not  new. 
It  coagulates  albumin  and  forms  an  insoluble  precipi- 
tate. This  was  the  first  process  tried  by  the  Commis- 
sion on  River  Pollutions  in  i858,  and  was  pronounced 
by  this  commission  to  be  a  failure.  The  lime  coats  the 
bacteria  and  their  spores,  forming  calcium  carbonate. 
And  many  investigators  have  proven  that  when  this 
outside  portion  of  excrement  is  removed,  the  interior 
of  a  typhoid  stool,  for  example,  is  capable  of  transmit- 
ting typhoidal  infection.  This  method  does  not  appeal 
to  one  from  a  labor-saving  or  pleasant  standpoint. 
The  use  of  milk  of  lime  was  the  fundamental  jirinci- 
ple  of  the  Suvern  mixture  formerly  used  in  Leipsic. 

Taking  into  consideration  these  facts,  the  New  York 
State  authorities  decided  to  direct  their  efforts  toward 
methods  of  incineration  rather  than  ciiemical  reduction 
for  tlie  disposal  of  excrement,  as  heat  is  recognized  to 
be  the  best-known  germicide.  The  object  to  be  at- 
tained is  the  adoption  of  some  method  which  will 
surely  and  completely  consume  human  excrement  in  a 
]5leasant  and  inexpensive  manner  if  possible,  but 
which  will  without  fail  prevent  the  transmission  of 
infection  from  this  source  at  any  cost. 

In  May,  i8gg,  the  following  circular  letter  was  sent 
to  many  of  the  more  experienced  sanitarians  of  this 
country  and  Europe: 

Dkar  Sir:  I  have  been  informed  by  the  New  York 
State  National  Guard  authorities  that  an  opportunity 
is  to  be  provided  in  the  near  future  for  a  series  of  ex- 
periments to  be  conducted  under  my  direction,  pertain- 
ing to  the  practical  application  of  methods  of  incinera- 
tion of  excrement  and  garbage,  to  be  used  by  military 
forces  in  field  service. 

Should  you  have  ideas  on  this  subject,  I  will  be 
greatly  honored  if  you  will  acquaint  me  with  same  and 
will  endeavor  to  put  in  practical  operation  any  benefi- 
cial suggestions  that  may  be  offered.  In  the  final  re- 
port on  this  subject,  special  credit  will  be  given  those 


November  3,  1900] 


MEDICAL   RECORD. 


68s 


Kui.  1. — Interior  Vii-w  of  Incin- 
erator Showing  Draught  C»)n- 
structioD. 


persons  offering  suggestions  that  prove,  in  this  con- 
nection, of  value.  Kcspectfully, 

(Signed)  William  G.  Hissell, 

Bacteriologist,  Dipnrtmciit  oj  Health,  Buffalo,  N.   Y. 

Of  the  replies  received,  many  emphasized  the  neces- 
sity for  a  radical  change  from  the  present  time-honored 
army  method  of  excrement  disposal,  but  few  offered 
any  practical  suggestions. 

A  communication  from  Dr.  Albert  H.  Gihon,  the 
retired  medical  director  of  the  United  Stales  navy, 
was  the  single  e.xception. 

He  made  reference  to  an  incinerating  apparatus, 
with  which,  after  a  comparison  of  the  various  types  on 
the  market,  the  New  V'ork  State  National  Guard  had 
previously  decided  to  conduct  tests. 

Dr.  Gihon  slated  that  "an  instrument  I  saw  in  Buf- 
falo a  couple  or  more  years  ago  seemed  to  me  to  pos- 
sess all  the  requisites,  and 
to  be  particularly  adapted 
for  military  field  service." 
The  .New  York  State  au- 
thorities decided  in    1899 
to  construct  fifteen  inciner- 
ators   after    the    principle 
in     question,    and    e.xperi- 
ment  with  them  during  the 
tours  of  field  duty  ordered 
for  the   Seventh  Regiment 
of   New  York  and  Twenty- 
third    Regiment   of  Brook- 
lyn.      T  h  e  s  e     regiments 
established    camps    in    the 
near  vicinity  of    the  State 
grounds  at  Peekskill,  and  disposed  of   all  their  offal 
by  the  use  of  the  experimental  device. 

The  accompanying  illustration  plainly  shows  the 
construction  of  the  incinerators,  of  which  A  is  the 
upper  space  between  the  pot  or  receptacle  B  and  the 
top  of  the  casing ;  C  is  the  fire-box,  and  D  is  the  draught 
passage;  E  is  a  passage  leading  down  from  an  upper 
spaced  into  the  draught  passage  /J*,  and  /'is  an  open- 
ing leading  from  the  fire-box  up  into  the  draught  pass- 
age D.  A  deflecting  wall  G  is  located  midway  between 
the  passage  E  and  opening  F.  The  odors  from  the  ma- 
terial in  the  pot  or  receptacle  are  drawn  down  through 
the  passage  E  by  the  draught,  as  indicated  by  the  ar- 
rows, and  pass  through  the  draught  passage  D  into  a 
chimney  or  smoke  pipe  //,  and  the  products  of  combus- 
tion from  the  fire-box  d' jjass  up  through  the  opening /'" 
into  the  same  draught  passage  D,  mingling  therein  with 
the  odors  and  gases  from  the  upper  space  A,  whicli  are 
destroyed  before  passing  into  pipe  H. 

For  use,  the  incinerators  were  placed  in  a  conveni- 
ent location,  and  pieces  of  pipe  three  feet  in  height 
were  attached  to  portions,  as  shown  in  diagram  at  //. 
At  the  time  of  incineration,  the  wooden  seat  supplied 
with  each  instrument  was  replaced  by  an  iron  cover. 
The  draught  near  the  smoke-pipe  was  opened  and  fire 
made  by  using  wood  as  fuel. 

These  devices  were  built  of  the  best  cast  iron,  hav- 
ing a  steel  jacket  with  asbestos  lining,  and  weighed 
approximately  three  hundred  pounds  each  As  to 
whether  they  were  a  success  or  not  will  be  shown  by 
the  attached  communications  which  were  received  from 
the  medical  officers  of  the  Seventh  and  Twent) -third 
Regiments. 

MEnic.\L  Department, 
Seve.n'th  Regiment,  N    G.,  N.Y., 
Park  Ave.  and  66th  Street, 
New  York,  June  30,  1899. 
Major    William     G.     Bissell,    Surgeon    Seventy-Joiirth 
Regiment,  N.  G.,  N.   I'.,  Buffalo,  N.   Y. 
Sir  :  I  have  the  honor  to  acknowledge  the  receipt  of 
your  letter  of  June  28th.     In  response  thereto  it  gives 


me  much  pleasure  to  state  that  from  my  observation  of 
the  incinerators  used  under  your  direction  in  the  re- 
cent camps  of  the  Seventh  Regiment  at  Crofts'  Farm 
and  Lake  Oscawana,  I  have  no  hesitation  in  pronounc- 
ing them  most  satisfactory.  Of  course,  I  understand 
that  these  particular  incinerators  were  not  built  for 
military  purposes,  nor  was  easy  and  rapid  transporta- 
tion greatly  considered  in  their  construction.  But 
they  certainly  do  completely  and  rapidly  reduce  excre- 
ment and  garbage  to  ashes  without  odor,  and  thus 
demonstrate  their  great  value  for  military  camps,  both 
from  a  labor-saving  and  sanitary  point  of  view. 

Could  they  be  considerably  reduced  in  size  and 
weight  and  be  mounted  on  some  sort  of  low  vehicle 
for  quick  transportation,  their  usefulness  would  be 
greatly  enhanced.  Respectfully, 

(Signed)  Chris.  J.  Colles, 

Assistant  Surgeon   Seventh  liegiment,  N.  G.,  N.   Y., 
Acting  Surgeon. 

Medical  Department, 
Seventh  Regiment,  N.  G.,  N.  Y., 
Park  Ave.  and  66th  Street, 
New  York,  June  30,  1899. 
Major  W.  G.  Bissell,  Surgeon  Scventy-Jourth  Regiment^ 
N.  G.,  N.   )'.,  Bufalo,  N.   Y. 
Sir:   I    have  the  honor  to  report  that   I   observed 
carefully  the  incinerators  in  use  at  Crofts'  Farm  and 
Lake  Oscawana  during  the  camp  of  the  Second  Battal- 
ion of  the  Seventh  Regiment,  X.  G.,  N.  Y.     I  found 
that  the  faces  deposited   in   these  had   been   entirely 
consumed,  that  the  fourteen    in    use  were   quite  suffi- 
cient, that  by  their  use  the  digging  of  sinks  was  made 
entirely  unnecessary,  that  a  possible  source  of  danger 
to  the  battalion  was  absolutely  removed,  and  that  the 
hygienic  condition  of  the  camps  was  therefore  notably 
improved.     If    the   incinerator  could    be  made   more 
portable  and  could   be  mounted   on   low  wheel-trucks 
suitably  covered  and  screened,  the  practical  use  of  the 
apparatus    would    be    furthered.      Respectfully    sub- 
mitted, (Signed)         John  H.  Huddleston, 
Assistant  Surgeon,  Seventh  Regiment,  N.  G.,  N.   Y. 

Castleton,  Vt.,  July  4,  1899. 
Ma/or  W.  G.  Bissell.  Buffalo,  N.   Y. 

Sir:  Your  letter  of  June  28th,  asking  for  my  per- 
sonal opinion  in  regard  to  the  incinerators  which  were 
tried  during  the  march  of  the  Second  Battalion,  has 
just  been  received,  having  been  forwarded  from 
Brooklyn. 

I  was  very  much  pleased  and  surprised  at  the  suc- 
cess of  the  trial  to  which  the  incinerators  were  put. 
Only  ten  were  used,  and  no  sinks  were  dug;  the  num- 
ber was  sufficient  for  the  battalion. 

During  their  use  there  was  no  perceptible  odor  or 
anything  that  could  be  considered  in  any  way  objec- 
tionable. 

The  incineration  of  excrement  was  all  done  after  the 
battalion  had  left  the  camp,  so  that  I  did  not  have  an 
opportunity  of  seeing  that  process. 

The  only  suggestion  that  I  have  to  make  is  that  the 
incinerators  are  too  bulky  and  heavy  as  now  made.  If 
made  one-half  the  size  and  weight,  they  would  be 
much  easier  of  transportation,  and  would  be  large 
enough  for  the  uses  intended.    '     Respectfully, 

(Signed)  Henry  L.  Cochran, 

Surgeon  Twenty-third  Regiment,  N.  G.,  N.  Y. 

In  accordance  with  the  suggestion  that  a  reduction 
in  size  was  desirable  and  the  necessity  for  some  class 
of  vehicle  for  the  easy  transportation  of  the  incinera- 
tors, in  the  early  part  of  1900  Gen.  Edward  M.  Hoff- 
man, .-Adjutant  General,  S.N.Y.,  authorized  the  con- 
struction of  sixteen  incinerators,  10  be  three-fourths 
the  size  of  those  previously  experimented  with,  which 
allowed  of    a    reduction    in  weight    of    one    hundred 


686 


MEDICAL    RECORD. 


[November  3,  1900 


pounds  for  each  machine,  but  still  maintained  a  capac- 
ity of  five  gallons  to  each  incinerator. 

A  contract  was  entered  into  with  the  International 
Garbage  and  Excrement  Incinerator  Company  of  Buf- 
falo, who  built  the  machines  after  the  suggestions 
offered.  Transportation  plans  and  specifications  were 
submitted  to  the  Harvey  Carriage  Company,  who  con- 
structed two  wagons  carrying  eight  incinerators  each. 
One  wagon  was  given  a  thorough  trial  on  the  tours  of 
field  service  from  the  State  camp  of  instruction  of  the 
Eighth,  .\inth,  Twelfth,  Fourteenth,  'J'wenty-second, 
Forty-seventh,  Sixty-ninth,  and  Seventy-first  Regi- 
ments. The  specification  of  these  wagons  was  as  fol- 
lows : 

New  York  State  Wagon,  for  Transportation  of 
Eight  (8)  Incinerators. 

Body:  Length  of  body,  15 'j  feet.  Width  at  ends 
of  body,  4 '2  feet.  Width  at  centre  of  body,  6  feet. 
Height  of  body,  6'j  feet.  Sills  and  frame  of  body  to 
be  constructed  of  iron.  Sills,  2j^^  inches  angle  iron; 
frame,  i  'j  inches  by  Sg  inch.  Floor  of  wagon  to 
be  ■'  skeleton  "  structure,  of  sheet  iron.  Floor  iron 
stringers,  2  inches  by  jj  inch.  Sides,  ends  and  top 
of  body  to  be  16  inches  gauge,  best  quality  sheet  steel. 


of  a  driver's  seat;  same  to  be  of  such  structure  to  per- 
mit of  transportation  of  small  tentage,  etc.  Top  of 
wagon  to  be  \entilated.  One  lamp  on  interior.  Two 
lamps  on  exterior.  Four  metallic  rolls  for  toilet  paper 
in  each  wagon. 

The  "march  outs"  from  the  camp  of  instruction 
consisted  in  the  establishment  of  a  camp  near  Lake 
Mohegan.  a  distance  of  about  nine  miles,  and  each 
regiment  remained  there  for  a  period  of  three  days. 
The  incinerators  constructed  by  the  State  in  1899 
were  placed  in  service  in  addition  to  the  new  wagon. 
This  afforded  seating  facilities  for  twenty-three  per- 
sons at  the  same  time,  and  permitted  the  collection  of 
one  hundred  and  forty-five  gallons  of  excrement  before 
the  destructive  process  began.  In  accordance  with 
army  custom  the  seating  capacity  of  any  sink  should 
represent  at  least  eight  per  cent,  of  the  strength  of 
commands,  and  it  can  be  understood  that  the  number 
of  incinerators  in  use  during  this  second  investigation 
were  taxed  to  their  utmost,  as  they  represented  a  little 
over  four'per  cent,  of  the  average  number  of  the  troops 
present. 

Incineration  was  accomplished  daily  during  a  period 
of  one  month.  During  the  greater  part  of  this  time 
little  or  no  odor  was  perceptible,  notwithstanding  the 


Ifc^lt^lt.     # 


Fig. 


Rear  end  of  body  to  have  a  neatly  finished  door,  6 
feet  by  2  feet  10  inches  wide.  The  forward  end  of 
body  to  have  a  neatly  finished  window. 

Gear:  Platform  gear,  with  platform  springs,  front 
and  back.  Springs,  2  inches  wide;  8  plates  40  inches 
long. 

Axles:  Concord  axles,  r?-^  inches  by  10  inches. 

Wheels:  Sarven  Wheels.  Front  wheels  to  be  3 
feet  high,  2  '3  inches  spoke,  10  inches  hub,  1 3+  inches 
rims,  3  inches  tread.  Hind  wheels  to  be  4  feet  high. 
Other  material  same  as  front  wheels.  Tire  3  inches 
wide  by  ^'i.  inch  thick. 

Painting  of  body  and  gear  to  be  of  light  gray  dress- 
ing, with  asbestos  fireproof  paint.  Workmanship  of 
wagon  to  be  of  the  best  quality.  Height  of  wagon, 
over  all,  above  ground,  not  to  exceed  8  '  j  feet.  Weight 
of  wagon,  with  load,  not  to  exceed  3,500  pounds. 
Track  of  wagon  to  be  5  feet.  Pole  of  wagon  to  be 
constructed  of  best  quality  of  ash,  as  also  the  whiffle 
trees  and  cross  tree.  Forward  end  of  pole  to  have 
hook  attachment  with  chains.  Wagon  to  be  construct- 
ed with  serve  of  brakes  for  rear  wheels,  to  be  operated 
from  driver's  seat.  Interior  of  wagon  to  contain  box 
on  either  side  of  entrance,  neatly  constructed,  for 
transportation  of  fuel.  Front  partition  of  body  of 
wagon  to  be  constructed  at  such  a  distance  as  to  allow 


fact  that  in  many  instances  the  climatic  conditions 
were  most  unfavorable.  The  fuel  used  was  unseasoned 
wood,  mostly  birch  with  some  oak,  and  was  not  such 
as  would  furnish  the  hottest  fires  with  a  large  tiame. 
Failure  to  incinerate  was  never  experienced,  but  in 
several  instances  some  odor  was  noticeable,  this  be- 
ing occasioned  when  the  flame  was  not  sufficient  to 
carbonize  the  gases,  i.e.,  indol,  skatol,  and  members 
of  the  marsh-gas  series,  as  they  repassed  tiirough  the 
fire  pit. 

In  order  to  incinerate  without  odor  it  is  necessary 
to  have  a  quick  live  flame,  and  it  was  found  that  the 
application  of  a  small  amount  of  tar  or  oil  would  ma- 
terially assist  in  this  connection.  Soft  pine  wood  was 
found  to  be  the  best  fuel.  When  odor  did  occur  dur- 
ing the  destructive  process  it  was  never  sufficient  to 
offer  a  serious  objection  to  the  use  of  the  incinerators, 
as  it  lasted  but  a  short  time  and  never  equalled  that 
which  is  experienced  during  the  use  of  an  old  earth 
sink.  It  was  decided  that  for  a  regiment  of  six  him- 
dred  men  about  four  wagons,  furnishing  thirty-two  in- 
cinerators, would  be  required  to  permit  of  the  daily 
incineration  of  all  ofTal. 

In  August  of  the  present  year  the  Sixty-fifth  Regi- 
ment, N.  G.,  N.  v.,  effectually  destroyed  the  excre- 
ment from  over  five  hundred  men  during  a  tour  of  field 


November  3,  1900] 


MEDICAL    RECORD. 


687 


service  of  seven  days  by  the  use  of  two  wagons,  each 
containing  eight  incinerators;  and  in  an  official  report 
Major  Albert  H.  15riggs,  surgeon,  who  during  the  Span- 
ish-American War  was  the  sanitary  inspector  of  the 
Second  Army  Corps,  states:  "  It  is  my  opinion  it  (in- 
cinerator) is  the  only  proper  way  to  dispose  of  excre- 
ment in  camps.  I  think  it  would  suppress  if  present 
and  prevent  the  outbreak  of  typhoid  fever,  cholera, 
etc."  That  the  views  of  the  surgeons  who  accompa- 
nied the  troops  during  the  "  march-outs"  from  State 
camp  might  be  received,  the  following  blank  form  for 
report  was  mailed  each  organization,  and  the  filled-in 
copy  from  Nelson  H.  Henry,  chitf  surgeon  of  the 
Guard,  is  submitted  as  example. 

Statement  from  Nelson  H.  Henry,  Surgeon  X.  G., 
N.  Y. 

1.  (a)  Do  you  consider  the  use  of  incinerators,  such 
as  operated  during  the  "  march-outs  "  at  State  Camp 
during  1900,  an  improvement  over  the  old  earth-sink 
method  for  the  disposal  of  excrement?  Most  decided 
progressive  step  and  great  improvement. 

{/>)  Please  state  reasons  for  your  opinion.  A  posi- 
tive and  infallible  destruction  from  infection  from 
such  source. 

2.  During  collection,  in  which  instance  is  there  the 
more  odor:  (i)  In  vicinity  of  incinerators,  or  (2)  in 
vicinity  of  earth-sinks.'     The  latter. 

3.  (c)  Do  you  consider  the  odors  that  arise  occa- 
sionally under  certain  conditions  during   burning   of 


N.  Y.,  my  unqualified  approval  of  the  incinerators 
used  by  you  to  dispose  of  the  fecal  matter  at  the  latter 
camp.  It  is  not  necessary  for  me  to  state  here,  in  de- 
tail, all  of  the  advantages  of  this  method  of  disposing 
of  fecal  matter;  it  is  enough  to  say  that  I  believe  your 
method  would  be  an  excellent  plan  to  adopt,  especially 
for  large  or  permanent  camps  or  camps  of  mobiliza- 
tion. 

I  want  also  to  state  that  I  observed  the  operation  of 
your  incinerators,  both  stationary  and  movable,  under 
nearly  every  imaginable  condition,  and  that  their  work 
was  satisfactory.     Very  respectfully, 

Henry  G.  Lyon, 
Cap  fa  in  Tiventy- Second  C.  S.  Jnfanlry. 

The  wagons  built  by  the  State,  although  not  ideal 
as  at  present  constructed,  many  points  requiring  alter- 
ation, received  the  highest  commendation  as  to  the 
principles  involved. 

There  seems  to  be  little  doubt,  according  to  the 
views  expressed  by  persons  familiar  with  the  progress 
of  the  investigation,  that  the  military  authorities  of 
the  State  of  New  York  have  discovered  a  method  by 
which  the  occurrence  of  ty])hoid  fever  among  its  troops 
will  be  materially  lessened,  and  too  great  credit  can- 
not be  given  Major-General  Roe  and  the  members  of 
his  staff  for  their  untiring  efforts  in  furthering  this 
investigation. 

The  military  authorities  of  the  world  are  becoming 


f^  „f^   fr  /t 


i  .M.  3.— i  ,^u,it  ..1  li.itn.ji  ^.1  U..K 


incinerators  a  decided  objection?  No;  as  such  odor 
is  harmless. 

(/')   Please  state  reasons  for  your  opinion. 

4.  In  your  judgment  would  the  complete  daily  incin- 
eration of  all  the  excrement  in  camps  of  mobilization 
have  a  marked  influence  in  preventing  typhoid  fever? 
I  certainly  consider  that  such  plan  would  minimize 
the  danger  of  infection  and  prevent  the  extension  of 
typhoid  fever. 

It  is  the  almost  universal  opinion  that  incineration 
is  far  more  efficient  for  the  final  disposal  of  excrement 
in  camps  of  mobilization,  and  less  objectionable  as 
regards  labor,  odor,  etc.,  than  the  use  of  the  "zinc 
trough  milk  of  lime"  or  any  other  device,  and  would 
to  a  greater  certainty  eliminate  the  opportunities  for 
camp  pollution  and  render  the  occurrence  of  typhoid 
fever  and  other  preventable  diseases  almost  impossi- 
ble. The  following  report  was  submitted  by  the 
United  States  army  detail  to  the  Camp  of  Instruction 
for  the  season  of  1900: 

Army  and  Navy  Ci.up.  of  New  York  City. 
July  3,  1900. 
Major    Williatn    G.    Bissell,    Sevent\-fourth   Regiment. 
iV.  G.,  N.   Y. 
Sir:   Before  completing  my  tour  of  duty  with  the 
National  Guard  of  New  York,  I  desire  to  express  to 
you,  as  sanitary  officer  of  the  Camp  of  Instruction,  at 
Peekskill,   and    the    sub-camp    near    Lake    Mohegan, 


interested  in  this  work,  and  the  following  letter  is  a 
sample  of  the  many  inquiries  received  during  the  past 
few  months: 

Military  Attachi^;  British  E.mbassy,  / 
Washington,  August  22,  1900.         f 
Major    William    G.    Bissell,    Surgeon,    Seventy-Jourth 
Regiment,  N.  G.,  JV.   Y. 
My  Dear  Sir:  The  attention  of  the   British   war 
office  has  been  called   to  the   portable  incinerator  in- 
vented by  you,  and  which,  I  think,  I  had  the  pleasure 
of  inspecting  at  Peekskill  camp  last  year.     The  direc- 
tor-general of  ordnance  in  London  is  anxious  to  obtain 
one  of  these  incinerators  for  trial,  and  has  directed  me 
to  find  out  where  one  could  be  purchased,  and  particu- 
lars of  the  price,  etc.     Yours  very  truly, 

A.  H.  Lee, 
Lieutenant-Colonel  Military  Attache,  British  Embassy. 

There  is  one  thing  certain,  just  so  long  as  the  anti- 
quated earth  method  for  the  disposal  of  excrement  is 
practised  in  military  camps  of  mobilization,  just  so 
often  will  history  repeat  itself  as  regards  the  ratio  be- 
tween deaths  from  preventable  diseases  and  bullets. 
Instead  of  continued  government  expenditures  in  in- 
vestigating armor  plate,  projectiles,  etc.,  a  much  more 
profitable  result  could  be  obtained  by  inaugurating 
improvements  for  camp  sanitation. 

Let  the  Spanish-American  War  at  least  be  the   Na- 


688 


MEDICAL    RECORD. 


[November  3,  1900 


tional  Guardsmen's  object  lesson,  and  if  no  other 
remedy  can  be  had,  let  the  National  Guards  of  the 
individual  States  inaugurate  methods  for  the  protec- 
tion of  the  "inexperienced  volunteer." 


SOME   CASES    OF    ACUTE   APPENDICITIS.' 
By    .\LE.\ANDER    13.    JOHNSON,    M.D., 

SURGEON   TO    THE   NEW    YORK    HOSi'lTAI.. 

Among  some  forty  cases  of  acute  appendicitis  operated 
upon  by  the  writer  during  a  period  of  rather  more  than 
one  year,  there  are  certain  ones  which  appear  to  him 
worthy  of  record  on  account  of  unusual  complications, 
and  certain  others  in  wliich  recovery  took  place  in 
spite  of  extensive  involvement  of  the  peritoneum  in 
the  inflammatory  process. 

These  latter  appear  to  the  writer  to  demonstrate  fair- 
ly well  the  value  of  abundant  saline  irrigation  of  the 
peritoneal  cavity  through  a  moderate  incision  and 
without  evisceration,  in  cases  of  widespread  purulent 
peritonitis. 

The  following  list  exhibits  the  various  types  of  the 
disease : 

Number  of  cases,  40.  Number  of  deaths,  5.  Mor 
talit)',  12  'j  per  cent. 

Causes  of  death:  i.  Acute  appendicitis,  perfora- 
tion, general  purulent  peritonitis,  shock. 

2.  Acute  appendicitis,  perforation,  general  purulent 
peritonitis,  peritoneal  sepsis. 

3.  Acute  appendicitis,  perforation,  general  purulent 
peritonitis,  nephritis,  septic  diarrhoea,  exhaustion. 

4.  Acute  appendicitis,  perforation,  localized  peri- 
tonitis with  abscess,  acute  mesenteric  lymphangitis, 
suppuration  of  the  retro-peritoneal  glands,  septic 
pneumonia,   pyemia. 

5.  Acute  appendicitis,  abscess,  intestinal  paresis, 
persistent  vomiting. 

Types  of  the  disease:  Acute  appendicitis,  perfora- 
tion, progressive  purulent  peritonitis — 3  cases,  3  re- 
coveries. 

Acute  appendicitis,  perforation,  progressive  fibrino- 
purulent  peritonitis — 3  cases,  i  death. 

Acute  appendicitis,  perforation,  general  purulent 
peritonitis— 8  cases,  3  deaths.  Mortality,  37'.'  per 
cent. 

Chronic  appendicitis,  abscess,  intestinal  obstruction 
by  bands — i  case. 

Acute  appendicitis,  localized  peritonitis,  abscess 
filling  the  pelvis — 9  cases. 

.\cute  appendicitis,  gangrene  of  the  appendix,  ab- 
scess, suppurative  mesenteric  lymphadenitis,  pyaemia 
—  I   case,  death. 

Acute  appendicitis,  gangrene  of  the  appendix,  cir- 
cumscribed abscess — 12  cases. 

Acute  gangrenous  appendicitis,  localized  peritonitis 
— 3  cases. 

Acute  appendicitis,  localized  peritonitis — i  case. 

Acute  appendicitis,  recurrent,  abscess — i  case. 

The  appendix  was  removed  in  34  cases. 

In  6  cases  the  appendix  could  not  be  identified,  and 
the  duration  and  character  of  the  inflammatory  proc- 
ess were  such  as  to  lead  to  tlie  belief  that  the  appen- 
dix was  destroyed. 

No  previous  attacks  in  30  cases.  Several  attacks  in 
4  cases.  Relapsing  appendicitis  in  2  cases.  Two 
attacks  in  2  cases.  One  previous  attack  in  i  case. 
Nine  previous  attacks  in  i  case. 

The  number  of  cases  which  may  be  fairly  described 
as  cases  of  general  purulent  peritonitis  were  eight. 
Three  of  these  were  fatal — a  mortality  of  thirty-seven 
and  a  half  per  cent.     The  number  of  cases  of  progres- 

'  Read  before  the  Surgical  Section  of  the  New  York  Academy 
of  Medicine,  October  8,  1900. 


sive  purulent  peritonitis  accompanied  by  only  a  small 
amount  of  fibrinous  exudate,  in  which  a  large  part  of 
the  peritoneum  was  the  seat  of  purulent  inflammation, 
but  in  which  a  considerable  area  remained  free  from 
infection,  numbered  three  with  three  recoveries.  The 
cases  in  which  an  extensive  tibrino-purulent  exudate 
existed,  but  in  which  a  considerable  part  of  the  abdo- 
men was  protected  more  or  less  perfectly  by  adhesions, 
numbered  three  with  two  recoveries  and  one  death. 
The  remaining  cases  included  several  in  which  un- 
usual complications  existed,  and  among  them  were 
also  several  in  which  an  extensive  but  strictly  limited 
fibrino-purulent  exudate  existed  among  the  intestines. 

To  avoid  misunderstanding  I  desire  to  define  the 
pathological  condition  which  I  have  characterized  by 
the  designation  "general  purulent  peritonitis."  By 
this  I  mean  cases  in  which  fluid,  purulent  in  charac- 
ter and  not  merely  cloudy  serum,  appears,  at  the  time 
of  operation,  to  occupy  the  pelvis,  both  flanks,  the  re- 
gion beneath  the  liver,  the  region  of  the  spleen,  the 
general  surface  of  the  small  intestines,  and  in  some 
cases  the  space  between  the  liver  and  the  diaphragm. 

In  none  of  the  cases  operated  upon  was  the  lesser 
cavity  of  the  peritoneum  explored,  and  I  suppose  that, 
at  least  in  those  cases  which  ended  in  recovery,  it  is 
safe  to  assume  that  the  peritoneum  lining  this  cavity 
was  healthy;  and  this  being  the  case,  I  cannot  quarrel 
with  those  who  upon  a  strict  anatomical  basis  assert 
that  the  cases  operated  upon  were  not  cases  of  general 
peritonitis. 

In  addition  to  the  purulent  exudate,  flakes  of  fibrin 
were  present  in  greater  or  less- amount,  partly  free  and 
partly  attached  here  and  there  to  the  peritoneal  surface 
which  appeared  in  the  wound. 

In  some  of  the  cases  the  coils  of  intestine  which 
presented  themselves  near  the  wound  were  distinctly 
inflamed  and  more  or  less  dull  in  appearance;  in 
some  the  peritoneal  surface  seen  was  injected,  but  not 
dull.  In  all,  the  intestines  were  distended  to  a  greater 
or  less  extent. 

The  method  of  operation  was  the  same  in  the  cases 
of  general  purulent  peritonitis  without  much  fibrin 
and  the  cases  of  fibrino-purulent  peritonitis  with  more 
or  less  distinct  limitation  of  the  infected  areas.  The 
incision  was  from  three  to  four  inches  in  length, 
made  parallel  with  the  fibres  of  the  external  oblique 
aponeurosis  between  the  outer  border  of  the  right  rec- 
tus muscle  and  the  iliac  spine,  with  this  bony  point 
opposite  its  centre.  In  two  cases  a  second  incision 
was  made  upon  the  opposite  side  of  the  abdomen,  and 
in  these  a  widespread  fibrinous  exudate  existed,  and 
the  barriers  between  the  separate  foci  of  pus  were  un- 
usually firm. 

When  the  abdomen  was  opened  and  it  was  noted  that 
the  belly  appeared  to  be  infected  in  all  directions,  the 
appendix  was  sought  for  and  removed  as  rapidly  as 
possible.  The  stump  was  usually  inverted  in  the  cen- 
tre of  a  catgut  purse-string  suture,  reinforced  in  cases 
in  which  the  wall  of  the  caecum  appeared  infiltrated  and 
friable  with  one  or  more  mattress  sutures  of  the  same 
material.  Tiie  cautery  and  catgut  ligature  were  em- 
ployed in  some  cases. 

The  appendix  being  disposed  of,  the  various  re- 
gions of  the  abdomen  were  carefully  explored  in 
turn  to  determine  the  extent  of  peritoneal  invasion. 
The  pelvis,  being  the  commonest  site,  was  explored  with 
a  gauze  pad  on  the  end  of  a  holder,  and  if  a  purulent 
collection  was  detected,  a  long  glass  tube  open  at  one 
end  and  five-eighths  of  an  inch  in  diameter  was  inserted 
to  tiie  bottom  of  the  pelvis,  and  through  it  a  quantity 
of  hot  sterile  salt  solution  at  a  temperature  of  116°  or 
118^  F.  was  allowed  to  flow  from  an  irrigator  held 
about  four  feet  above  the  patient's  body. 

The  wound  was  held  open  with  the  left  hand  (kuing 
the  irrigation,  and  the  tube  was  moved  about  with  the 


November  3,  1900] 


MEDICAL   RECORD. 


689 


right  hand,  gently  breaking  up  any  adhesions,  and  the 
washing  was  continued  not  only  until  the  water  re- 
turned perfectly  clear,  but  for  a  while  thereafter. 

The  ascending  colon  and  the  region  beneath  the 
liver  were  then  explored,  and  if  found  infected  they 
were  washed  out  in  a  similar  manner.  Ne.xt,  a  sponge 
holder  containing  a  pad  of  gauze  was  pushed  across  to 
the  opposite  iliac  region  and  Hank,  and  if  pus  ap- 
peared these  regions  were  treated  in  the  same  way. 

Next,  after  exploration  the  tube  was  pushed  in  the 
direction  of  the  spleen,  and  then  to  the  anterior  sur- 
face of  the  stomach  in  front  of  and  behind  the  omen- 
tum, and  then  into  the  space  between  the  liver  and  the 
diaijhragni. 

Lastly,  the  pelvis  was  again  thoroughly  irrigated 
and  then  gently  dried  with  large,  loose  masses  of  ster- 
ile gauze  pushed  down  witii  a  sponge  holder,  the  intes- 
tines being  meanwhile  protected  as  far  as  possible 
with  the  fingers  of  the  left  hand.  No  intestines  were 
removed  from  the  cavity  of  the  belly  at  any  time,  and 
during  the  manipulation  their  escape  was  prevented  by 
the  left  hand  held  over  the  wound.  The  fibrinous 
plaques  which  sometimes  covered  the  coils  of  gut  were 
not  disturbed. 

A  large  glass  drainage  tube  was  tiien  inserted  to  the 
bottom  of  the  pelvis  and  repeatedly  packed  with  sterile 
gauze  strips,  until  no  more  fluid  appeared  upon  the 
gauze.  In  some  cases  a  second  glass  tube  was  passed 
upward  along  the  ascending  colon.  A  small  strand  of 
iodoform  gauze  was  then  inserted  to  the  bottom  of  the 
tube  in  the  pelvis,  and  another  small  strand  was  some- 
times led  from  the  base  of  the  appendix  outward.  The 
superficial  wound  was  then  loosely  packed  with  sterile 
gauze  to  keep  it  open  and  to  permit  the  escape  of  any 
free  Huid  which  might  find  its  way  to  that  neighbor- 
hood. A  voluminous  dressing  was  then  applied. 
The  packing  in  the  glass  drainage  tube  was  replaced 
four  times  during  the  first  twenty-four  hours;  there 
was  usually  a  profuse  watery  discharge  into  the  exter- 
nal dressings,  which  were  changed  as  often  as  they  be- 
came soiled.  If  the  patient  did  well  the  glass  tube  was 
removed  on  the  third  day;  and  if  any  Huid  appeared 
still  to  accumulate  at  the  bottom  of  the  pelvis,  a  strand 
of  iodoform  gauze  was  placed  in  situ  through  the  tube 
and  held  in  position  by  a  probe  while  the  tube  was 
being  withdrawn.  In  general  it  was  noted  that  those 
patients  whose  entire  belly  was  washed  in  the  manner 
described  suffered  but  little  or  not  at  all  from  shock. 
The  pulse  was  even  diminished  in  frequency  and  im- 
proved in  quality  in  some  of  the  cases  when  the  irri- 
gation was  finished. 

In  several  cases  in  which  there  was  an  elevated  tem- 
perature at  the  time  of  operation,  the  thermoniLter 
showed  a  drop  nearly  to  normal  in  a  few  hours.  An 
example  of  this  is  offered  by  Case  XXV.,  one  of 
general  purulent  peritonitis  in  a  boy  eighteen  years 
old,  operated  on  during  the  third  day  of  the  attack. 
At  the  time  of  operation  his  temperature  was  103.6° 
F. ;  pulse,  120.  Within  six  hours  after  the  operation 
his  temperature  fell  to  99.6°,  his  pulse  to  go,  and  there 
were  only  trifling  elevations  of  temperature  thereafter. 

.\  similar  improvement  in  the  general  condition  soon 
after  operation  was  noted  in  all  the  patients  who  re- 
covered, except  one.  In  this  case  (No.  XX.XIII.  1,  in 
addition  to  a  general  purulent  peritonitis,  the  patient, 
a  boy  of  nine  years,  was  suffering  from  a-n  intense  de- 
gree of  septic  absorption  together  with  intestinal  pare- 
sis which  bade  fair  to  prove  fatal.  His  temperature 
remained  high,  the  amount  of  discharge  from  the  wound 
was  large,  he  was  unconscious  for  four  days;  then  im- 
provement became  manifest,  and  he  eventually  recov- 
ered. 

The  only  case  in  which  the  operation  seemed  to  add 
markedly  to  the  shock  already  existing  was  Case  \TII. 
A  man  aged  thirtj-nine  years,  suffering  from  typical 


peritoneal  sepsis,  was  operated  on  about  thirty  hours 
after  the  infection  of  the  belly  had  become  general. 
At  the  time  of  operation  his  temperature  was  subnor- 
mal;  pulse,  130.  The  general  condition  was  very 
unfavorable.      He  died  in  two  hours. 

The  ordinary  method  of  subcutaneous  and  rectal 
stimulation  was  used  in  such  of  the  cases  as  seemed 
to  require  it.  Irrigations  of  the  lower  bowel  with  salt 
solution  repeated  every  few  hours  appeared  to  do  good 
in  certain  instances.  The  injection  of  sulphate  of 
magnesia  into  the  gut  through  the  abdominal  wound  at 
the  time  of  operation  was  not  practised.  Calomel  in 
minute  doses  frequently  repeated,  or  sulphate  of  mag- 
nesium used  in  the  same  way,  together  with  enemala, 
was  depended  upon  to  produce  early  evacuations  of  the 
bowels.  Their  use  was  commenced  in  from  twenty- 
four  to  forty-eight  hours  from  the  time  of  operation. 

Several  of  the  patients  who  recovered  appeared  at 
the  time  of  operation  to  be  in  a  most  unfavorable  con- 
dition;  not  only  were  there  present  the  signs  of  severe 
sepsis  with  its  concomitant  symptoms  of  a  rapid  pulse 
of  poor  quality  and  a  septic  facies.  but  the  appearance 
of  the  interior  of  the  abdomen  was  in  several  instances 
exceedingly  unfavorable. 

I  am  inclined  to  think  that  had  the  intestines 
been  removed  from  the  belly  and  washed  and  wiped, 
the  patients  would  not  have  recovered.  It  seems  at 
the  present  time  hardly  necessary  to  mention  this 
method  of  treatment  in  cases  of  purulent  peritonitis 
except  to  condemn  it,  and  yet  I  am  informed  that 
several  prominent  surgeons  in  this  country  are  still  in 
the  habit  of  practising  it. 

Granting  that  a  certain  proportion  of  these  patients 
recover  after  evisceration,  yet  I  am  inclined  to  think 
that  the  same  good  result  might  have  been  accom- 
plished by  less  dangerous  means.  All  who  have  tried 
this  method  must  admit  not  only  that  the  inmiediate 
effect  of  sucii  procedures  is  a  severe  strain  upon  the 
already,  lowered  vitality  of  the  individual,  but  also 
that  subsequent  paresis  of  the  bowel  is  a  not  uncom- 
mon and  dangerous  sequence.  Of  course,  the  septic 
process  itself  is  a  frequent  cause  of  paralysis  of  the 
gut,  but  I  have  more  than  once  had  the  opportunity 
of  observing  the  condition  of  a  much-handled  coil  of 
intestine,  heahhy  at  the  time  of  operation  except  for  a 
perforating  wound  necessitating  suture;  while  five  days 
and  more  after  the  original  operation  1  have  seen  such 
a  coil  distended,  intensely  congested,  flabby,  its  mus- 
cular coat  evidently  .paralyzed,  although  the  interior 
of  the  belly  had  apparently  remained  quite  aseptic. 

In  the  twenty-six  cases  in  which  the  involvement  of 
the  abdomen  was  lessextensive  and  was  strictly  limited, 
there  were  presented,  as  already  noted,  sexeral  different 
types  of  the  disease. 

The  operative  technique  employed  was  a  moderate 
or  small  incision;  in  the  cases  which  appeared  before 
operation  to  be  milder  in  type,  the  intermuscular  in- 
cision was  used.  No  effort  was  made,  in  abscess  cases, 
to  avoid  opening  the  healthy  peritoneal  cavity.  When 
the  presence  of  pus  was  suspected  the  healthy  coils  of 
gut  were  protected  in  the  usual  manner  with  gauze  pads. 
The  abscesses  were  slowly  and  cautiously  evacuated, 
though  the  fear  of  opening  up  healthy  regions  did  not 
prevent  a  persistent  search  for  the  appendix. 

A  few  cases  presented  such  dense  adhesions  as  to 
rend^  extensive  dissection  dangerous  to  the  integrity 
of  the  gut.  They  were  all  old  cases  of  abscess  in 
which  it  appeared  probable  that  the  appendix  was  large- 
ly destroyed.  The  writer  is  not  aware  that  any  of 
these  patients  suffered  from  subsequent  attacks,  al- 
though he  has  made  no  especial  effort  to  acquaint  him- 
self with  their  later  histories. 

In  the  cases  presenting  large  abscesses  which  ex- 
tended to  the  bottom  of  the  pelvis,  irrigation  of  the 
abscess  cavity  as  before  described  was  practised,  and 


690 


MEDICAL    RECORD. 


[November  3,  1900 


a  glass  drainage  tube  was  inserted  during  the  first 
forty-eight  hours. 

Whenever  it  appeared  safe,  the  abdominal  wound  was 
sutured  in  part.  A  small  strand  of  iodoform  gauze 
was  led  out  from  the  stump  of  the  appendix,  and  if 
no  purulent  discharge  occurred  it  was  definitely  re- 
moved in  from  four  to  seven  days.  Among  these 
twenty-six  cases  there  was  one  death.  The  history  of 
this  case  will  be  given  later. 

Among  the  forty  cases  there  were  four  in  which  the 
appendix  having  been  removed,  a  small  fecal  fistula 
formed  in  the  wound,  to  close  spontaneously  after 
a  period  varying  from  one  week  to  a  month.  Among 
the  six  cases  in  which  no  appendix  was  found  there 
occurred  one  fecal  fistula,  which  closed  spontaneously 
in  a  short  time.  In  one  case  a  large  fecal  fistula  oc- 
curred apparently  from  the  sigmoid  flexure  or  rectum. 
It  closed  after  curettage  some  months  after  the  oper- 
ation. 

Two  cases  presented  complications  of  an  unusual 
character.  Their  histories  are  numbered  XI.  and 
XXXVII. 

Case  I. — Acute  appendicitis,  progressive  fibrino- 
purulent  peritonitis,  secondary  subdiaphragmatic  ab- 
scess;   recovery.     Joseph   N ,  male,  aged  sixteen 

years,  admitted  April  9,  1899.  First  attack.  Dura- 
tion three  days.  Onset  sudden.  General  abdominal 
pain,  localized  after  twelve  hours  in  the  right  iliac 
fossa.     Vomiting. 

Examination:  Abdomen  distended  and  tympanitic. 
Muscular  rigidity  marked  on  the  right  side.  Tem- 
perature on  admission,  103.8"  F. ,  pulse,  120. 

Operation:  Appendix  situated  behind  the  colon. 
Muoih  pus  filling  the  pelvis  and  extending  upward  as 
far  as  the  liver.  Limiting  adhesions  imperfect.  Sa- 
line irrigation  of  the  entire  belly. 

Pathology:  Appendix  strictured  one  inch  from  base, 
beyond  which  it  was  gangrenous  and  perforated,  con- 
taining two  concretions. 

Glass-tube  drainage  in  pelvis,  gauze  drainage  along 
the  colon  from  below.  Normal  course  until  the  tenth 
day,  when  a  marked  rise  of  temperature  occurred,  ac- 
companied by  abdominal  pain  and  tenderness  at  the 
free  border  of  the  ribs  on  the  right  side. 

Second  operation  on  the  fourteenth  day.  Vertical 
incision  from  ribs  three  inches  downward  through  the 
rectus.  Large  collection  of  stinking  pus  evacuated 
from  between  the  liver  and  the  diaphragm.  Slight 
fecal  fistula  followed  from  colon,  which  gradually 
closed.     Normal  recovery. 

Case    II. — Acute    gangrenous    appendicitis.     John 

D ,  male,  aged  nineteen  years,  admitted  August  8, 

1899.  No  previous  attack.  Duration  four  days.  On- 
set sudden.  General  abdominal  pain,  localized  after 
six  hours  in  the  right  iliac  fossa.  Vomiting.  On  ad- 
mission normal  pulse  and  temperature.  Abdomen  not 
distended.  Muscular  rigidity  not  marked.  Appendix 
felt  low  down  close  to  Poupart's  ligament.  Appendix 
as  large  as  an  index  finger.  Lntire  mucous  membrane 
gangrenous.  Gauze-wick  drainage.  Normal  wound- 
healing. 

Case  III. — Acute  appendicitis,  localized  peritonitis. 

Kate  VV ,  female,  aged  sixteen  years;  no  previous 

attacks.  Duration  of  present  attack  one  week.  Gen- 
eral abdominal  pain,  localized  after  twenty-four  hours 
in  the  right  iliac  fossa.  Vomiting  and  constipation. 
Intermuscular  operation.  Distal  end  of  appendix 
obliterated.  Proximal  end  acutely  infiamed.  Gauze- 
wick  drainage.     Normal  wound  healing. 

Case  IV. — Acute  gangrenous  appendicitis,  local- 
ized peritonitis.  Charles  J^— ,  male,  aged  eighteen 
years.  Nine  previous  attacks;  none  of  tiiem  severe. 
Duration  of  present  attack  three  days.  General  ab- 
dominal pain,  localized  after  twelve  hours  in  the  right 
iliacfossa.    Vomiting.     Intermuscular  operation.    Ap- 


pendix greatly  enlarged.  Gangrenous  near  its  tip.  No 
perforation.  Gauze-wick  drainage.  Normal  wound- 
healing. 

Case  V. — Acute  appendicitis,  abscess.  Thomas 
H ,  male,  aged  thirty-six  years.  No  previous  at- 
tack. Duration  of  present  attack  twenty  days.  Gen- 
eral abdominal  pain,  localized  after  forty-eight  hours 
in  the  right  iliac  fossa.  Occasional  vomiting.  Has 
continued  at  work  up  to  the  present  time. 

Examination:  temperature,  101.2";  pulse,  96.  A 
large  tender  mass  in  the  right  iliac  fossa  extending 
to  the  median  line.  Large  thick-walled  abscess  cavity 
opened.  Appendix  not  found.  Gauze  drainage.  In- 
testinal concretion  evacuated  upon  the  third,  and  two 
more  concretions  upon  the  eighteenth  day.  Slight  fecal 
fistula;  closed  spontaneously  at  the  end  of  the  month. 
Discharged  cured  at  the  end  of  two  months. 

Case      VI. — Acute     appendicitis,     abscess.      John 

M ,  aged  seventeen    years.     No  previous  attack. 

Four  days,  general  abdominal  pain,  localized  in  the 
right  iliac  fossa  after  five  hours.  Vomiting;  constipa- 
tion. Abdomen  distended,  not  rigid.  Small  tender 
mass  in  the  right  iliac  fossa.  Temperature,  100.4^; 
pulse,  100. 

Abscess  to  the  outer  side  and  behind  the  colon  con- 
taining a  large  concretion.  Appendix  one-half  gangre- 
nous; removed.  No  stricture  demonstrable.  Gauze 
drainage.     Normal  healing. 

Case  VII.^Acute  gangrenous  appendicitis.  Wil- 
liam VV ,  male,  admitted   February  3,   1899.     No 

previous  attack.  Duration  of  present  illness  two 
weeks.  Sudden  onset.  General  abdominal  pain,  lo- 
calized after  twelve  hours  in  the  right  iliac  fossa.  Con- 
stipation. Considerable  tumor  in  the  right  iliac  fossa. 
No  rigidity.    Temperature,  100.8°;  pulse,  100. 

Intermuscular  incision.  Gangrenous  appendix  re- 
moved with  curette  from  the  centre  of  a  mass  of  gran- 
ulation tissue  lying  rather  high  up  to  the  outer  side  of 
the  colon.  Hole  in  colon,  representing  base  of  appen- 
dix, sutured.      Normal  wound-healing. 

Case  VIII.— Acute  appendicitis,  general  septic  peri- 
tonitis; death.  Cornelius  F- ,  male,  aged  thirty- 
nine  years,  admitted  February  15,  1899.  No  previous 
attacks.  Duration  of  present  attack  eight  days.  Gen- 
eral abdominal  pain  and  vomiting.  Pain  localized  the 
second  day  in  the  right  iliac  fossa.  Day  before  ad- 
mission patient  suddenly  became  much  worse,  vomit- 
ing growing  severe,  with  intense  general  abdominal 
pain.  Examination  upon  admission:  temperature 
subnormal;  pulse  130  and  poor  quality.  General 
condition  bad,  abdomen  distended  and  generally  ten- 
der.    Frequent  vomiting. 

Operation,  February  15,  1899  :  Appendix  not  found; 
abdomen  everywhere  the  site  of  general  purulent 
peritonitis.  Flushing  of  abdomen  with  hot  saline 
solution  ;  death  in  two  hours. 

Case  IX. — Acute  appendicitis,  general  septic  peri- 
tonitis;   death.      Fred.    E.    M ,   aged    twenty-four 

years,  male.  No  previous  attacks.  Five  days  before 
admission  vomiting  and  general  pain,  localized  after 
forty-eight  hours  in  the  region  of  the  appendix;  con- 
tinued at  work  until  the  third  day,  wiien  he  went  to 
bed. 

On  admission,  large,  stout  man,  profoundly  septic  in 
appearance.  Temperature,  103  V2";  pulse,  108.  Ab- 
domen distended,  tender,  and  tympanitic. 

Operation:  Appendix  perforated  and  gangrenous, 
large  abscess  opened ;  the  abdomen  contained  every- 
where a  thin  sero-purulent  fluid.  Saline  irrigation. 
Died  septic  on  the  second  day  with  a  temperature  of 
.07°. 

Case  X. — Acute  appendicitis,  general  purulent  peri- 
tonitis; Cure.     Michel  F ,  aged  twenty-one  years, 

admitted  September  13,  1899.  No  previous  attacks. 
Five   days    ago,    general    abdominal    pain,    localized 


November  3,  1900] 


MEDICAL    RECORD. 


691 


after  twenty-four  hours  in  the  right  iliac  fossa,  ac- 
companied by  vomiting.  Since  then  and  up  to  the 
time  of  admission  the  pain  and  tenderness  had  advanced 
to  the  left  side  of  the  abdomen.  The  entire  abdomen 
tympanitic  and  tender.  Temperature,  100.6°;  pulse, 
80. 

Incision  into  either  iliac  region.  Appendi.x  swol- 
len, perforated  at  the  base.  Entire  lower  three-fourths 
of  the  abdomen  the  seat  of  purulent  peritonitis.  Sa- 
line irrigation;  glass-tube  drainage  into  both  iliac 
fosssE.  Normal  wound-healing.  Discharged  cured 
November  2  ist. 

Cask  XI. — Acute  gangrenous  appendicitis,  septic 
peritonitis,  suppurative  mesenteric  adenitis,  pyamia. 

Susie  W ,  aged  eighteen  years,  colored,  admitted 

November  17,  1899.  No  previous  attack.  Tliirty-si.x 
hours  before  admission,  general  abdominal  pains, 
localized  after  six  hours  in  the  right  iliac  fossa,  ac- 
companied by  tenderness  and  vomiting.  Chill  on  the 
day  of  admission,  tenderness  and  muscular  rigidity 
marked  on  the  right  side,  no  tumor.  Temperature, 
101.8^ ;   pulse,  92. 

Operation  on  the  day  of  admission:  Moderate-sized 
collection  of  pus  in  the  neighborhood  of  the  appendi.x 
without  limiting  adhesions.  Appendix  found  wrapped 
up  in  omentum,  lying  below  the  caput  coli  and  slight- 
ly to  the  inner  side.  Meso-appendix  and  adhesions 
ligated;  and  omentum  (one  and  one-half  inches),  after 
being  separated  from  appendix,  ligated  in  sections  and 
end  cut  away.  Appendix  freed  and  opened  one-fourth 
inch  from  caput  coli ;  probed,  and  found  pervious;  cau- 
terized, ligated  with  catgut,  and  cut  away.  Stump  again 
cauterized.  Saline  irrigation,  washing  and  sponging 
down  into  the  pelvis,  dry  sponging  into  small  intestine 
area  and  up  toward  the  liver;  in  these  directions  it 
appears  dry,  the  pus  being  only  about  the  appendix  and 
in  the  pelvis.  Iodoform  gauze  packed  to  stump  of  ap- 
pendix and  into  wound.  Glass  drainage  tube  with 
iodoform  wick  into  pelvis.  Sterile  dressing  and  ab- 
dominal binder  applied.  Mucous  membrane  gangren- 
ous throughout  its  whole  length;  three-fourths  inch 
from  base  is  a  stricture,  then  a  concretion  three-eightlis 
inch  long,  then  a  pin-liole  perforation  and  complete 
gangrene.  Chill  followed  by  temperature  of  105.2°. 
Signs  of  consolidation  in  right  upper  lobe,  November 
19th. 

November  20th  :  Tube  removed,  wound  quite  clean  ; 
two  chills,  one  in  the  morning,  one  in  the  afternoon. 
Upper  lobe  quite  clear  of  signs  of  consolidation,  lower 
right  lobe  has  some  bronchitis.  Blood  shows  no  ma- 
larial organisms.  Chill  in  the  morning  and  one  in 
the  afternoon  of  November  21st.  Vomited  four  times 
during  the  day.  Chill  in  the  morning  and  one  in  tlie 
afternoon  of  November  22d.  Vomited  once.  Chill 
in  the  morning,  slight  chill  in  the  evening  of  Novem- 
ber 23d.  Sputum  contains  no  tubercle  bacilli.  Chill 
in  the  morning,  no  pulmonary  consolidation  Novem- 
ber 24th.  Vomited  once;  general  condition  is  un- 
changed, looks  septic;  chilly  in  the  morning  of  No- 
vember 26th.  Urine  negative;  moderate  tenderness 
in  right  hypochondrium  and  in  right  limibar  region; 
some  resistance  and  muscular  rigidity  in  regions  of 
tenderness. 

Second  operation,  November  27,  1899:  Incision 
just  below  and  parallel  to  right  costal  border,  four 
inches  in  length.  A  mass  of  glands,  ovoid  in  shape, 
two  and  one-half  inches  in  long  diameter,  found  be- 
hind hepatic  angle  of  colon  in  front  of  the  right  kid- 
ney. Aspiration  of  foul  putrid  pus.  Incision  and 
removal  of  most  of  the  mass.  Packing.  No  other 
masses  felt.  Death  ten  days  later  with  continued 
symptoms  of  septico-pya;mia,  namely,  chills,  extreme- 
ly high  and  remittent  fever,  delirium,  stupor,  and  ex- 
haustion.    No  autopsy. 

Case  XII. — Acute  appendicitis,  progressive  fibrino- 


purulent     peritonitis,     persistent     vomiting;     death. 

Peter  G ,  aged  eighteen  years,  admitted  March  6, 

1899.  No  previous  attacks.  Ten  days  ago  he  was 
seized  with  general  abdominal  pain,  accompanied  by 
a  chill.  He  did  not  vomit.  He  continued  at  work 
during  the  two  following  days.  Six  days  ago  the  pain 
became  much  more  severe;  he  had  another  chill,  and 
the  pain  localized  in  the  right  iliac  fossa. 

Examination:  Poorly  developed  boy.  Marked 
tenderness  and  rigidity  over  the  lower  part  of  the 
abdomen  upon  the  right  side.  Temperature,  102.2°; 
pulse,  102. 

Operation,  March  7,  1899:  Large  abscess  lying  to 
the  outer  side  of  the  colon  together  with  a  large  collec- 
tion of  pus  in  the  pelvis.  The  appendix  was  long, 
extended  downward  into  the  pelvis,  and  was  perforated 
at  its  lip.  Saline  irrigation,  followed  by  glass-tube 
drainage.  The  patient  suffered  from  continued  vomit- 
ing, which  became  fecal  on  the  fifth  day  in  spite  of 
lavage.  The  bowels  continued  to  move.  There  was 
no  apparent  extension  of  the  peritonitis.  The  wound 
remained  fairly  clean  and  there  was  no  rise  of  tem- 
perature above  101°  until  just  before  death,  which  oc- 
curred on  the  eleventh  day  after  the  operation,  from 
exhaustion. 

Cask    XIII. — Acute    appendicitis,    abscess;    cure. 

Edward  E ,  aged  twelve  years,  admitted  February 

24,  1899.  No  history  of  previous  attacks.  Two  days 
ago  general  abdominal  pains,  accompanied  by  vomit- 
ing, located  after  six  hours  in  the  right  iliac  fossa. 
Next  day  a  chill  followed  by  an  increase  of  pain  and 
prostration.     Constipated. 

Examination:  General  abdominal  tenderness,  most 
marked  in  the  right  iliac  fossa;  together  with  muscular 
rigidity  in  the  lower  part  of  the  right  side  of  the  ab- 
domen.    T.,  100.8°;  P.,  116;   R.,  36. 

Operation,  February  24th:  The  appendix  was  found 
behind  the  colon  wrapped  in  omentum,  which  formed 
the  wall  of  an  abscess  of  moderate  size.  Appendix 
strictured  at  proximal  end  and  perforated  at  centre 
opposite  a  sharp  kink.  Pelvis  free.  Packing.  Nor- 
mal healing.     Eeft  hospital  well. 

Case    XIV. — Acute    appendicitis,    abscess;     cure. 

Thomas  McK ,  aged  ten  years,  admitted  March  3, 

1898.  No  previous  attacks.  Nine  days  ago  general 
abdominal  pain,  localized  after  twelve  hours  in  right 
iliac  fossa.  .  Continued  vomiting.     No  chill. 

Examination:  Well  nourished;  slight  abdominal 
distention,  everywhere  tympanitic.  Tenderness  most 
marked  over  base  of  appendix.     T.,  101.4°;  P.,  120. 

Operation,  March  4,  1898:  Colon  adherent;  large 
abscess  evacuated.  Appendix  three  inches  long, 
strictured  in  two  places,  perforation  at  middle,  gan- 
grene of  mucous  membrane.  Large  secondary  abscess 
filling  pelvis.  Salt  irrigation,  glass  drainage,  and 
yellow  packing.  On  the  tenth  day  a  large  lumbricoid 
worm  emerged  from  the  wound  together  with  fecal 
matter.     A  large  fecal  fistula  persisted. 

January  13,  1899:  Secondary  operation  revealed 
an  opening  into  both  large  and  small  intestine  rather 
deep  in  the  pelvis.  Curettage  of  cavity  and  packing. 
No  attem|5t  to  close  fistula?. 

April  30,  1899:  Fecal  fistula  have  closed  spon- 
taneously.    Left  hospital,  well.  May  17,  1899. 

Case  XV. — Acute  appendicitis,  abscess;  cure.     H. 

B ,  male,  aged  twenty-three  years,  admitted  April 

9,  1899.  One  year  ago  had  an  attack  of  appendicitis 
lasting  one  week.  Four  months  later  another  similar 
in  character.  On  the  day  of  admission  he  had  general 
abdominal  pain,  located  after  two  hours  in  the  right 
iliac  fossa,  accompanied  by  vomiting. 

Examination:  Well-nourished  man.  Rigidity,  pain, 
and  tenderness  over  right  iliac  fossa.  T.,  101.8°;  P., 
108. 

Operation  twenty-four  hours  later:  Abscess  behind 


692 


MEDICAL    RECORD. 


[November  3,  igoo 


colon.  Appendix  strictured  near  base  and  perforated 
at  centre.     Left  hospital,  well.  May  22,  1899. 

Case    XVI. — Acute    appendicitis,    abscess;     cure. 

James  K ,  aged  eleven  years,  male,  admitted  May 

I,  1899.  No  previous  attacks.  Seven  days  ago  vom- 
iting and  general  abdominal  pains,  localized  after  five 
hours  in  right  iliac  fossa.  Diarrhoea.  For  past  two 
days  a  mass  has  been  noted  in  region  of  appendi.x. 

Kxamination  shows  a  well-nourished  boy.  Tender 
mass  in  right  iliac  fossa.     T.,  101.8°;  P.,  112. 

Operation,  May  i,  1899:  Large  abscess  extending 
down  into  pelvis.  Appendix  bent  sharply  close  to  tip 
and  perforated  at  that  point.  Glass-tube  drainage 
into  pelvis.     Left  hospital  well. 

Case  XV^IL — Acute  appendicitis,  abscess;  cure. 
V.  F ,  male,  admitted  April  13,  1899.  No  previ- 
ous attacks.  Six  weeks  ago  had  pain  in  right  iliac 
fossa.  Kept  at  work  for  two  weeks,  after  which  he 
had  chills  at  irregular  intervals,  accompanied  by  fever 
and  sweating. 

K.xamination:  Well  developed;  large  tender  mass 
filling  rigiit  iliac  fossa.     T.,  102";  P.,  116. 

Operation  April  14,  1899:  Large  abscess  opened 
lying  to  outer  side  of  colon  and  upward.  Appendix 
not  identified.     Slow  convalescence. 

Case  XVIIL — Acute  appendicitis,  abscess;  cure. 
Patrick  T ,  aged  twenty-seven  years,  admitted  Oc- 
tober 3,  1899.  No  previous  attacks.  Four  days  ago 
vomiting  and  general  abdominal  pain,  located  in  right 
iliac  fossa  after  twenty-four  hours.  General  muscular 
rigidity. 

Operation.  October  4th:  Abscess,  gangrene  of  ap- 
pendix, perforation,  and  concretion.  Packing.  Left 
hospital  well. 

Case      XIX. — Recurrent      appendicitis,      abscess. 

George  E ,  aged  six  years,  admitted  May  17,  1899. 

Had  two  previous  operations  for  appendicitis,  at  neither 
of  which  was  appendix  removed.  A  week  ago  another 
abscess  appeared. 

Operation,  May  i8th:  Abscess  opened;  left  hos- 
pital well. 

Case     XX. — Recurrent    appendicitis,    progressive 

fibrino-purulent    peritonitis.      William    W ,    aged 

nine  years,  admitted  December  4,  1898. 

Previous  history:  An  attack  of  abdominal  pain  two 
months  ago,  lasting  a  few  days. 

Present  illness:  Five  days  ago  sudden  severe  ab- 
dominal pain  and  vomiting.  Pain  chiefly  in  the  left 
side  of  abdomen,  low  down. 

Examination:  T.,  101°;  P..  108.  General  condi- 
tion poor.  Abdomen  distended,  tense,  tympanitic, 
and  tender.  Tenderness  most  marked  in  the  left  iliac 
region. 

Operation,  December  4,  1898:  Incision  in  left  iliac 
region.  Peritoneum  opened  ;  small  intestines  aggluti- 
nated by  recent  adhesions,  which  being  separated  a 
moderate  amount  of  pus  escaped  from  among  the  coils 
of  the  small  gut.  Incision  on  right  side.  Similar 
adhesions  toward  median  line,  which  being  separated 
pus  in  moderate  quantity  escaped.  A  large  congested 
appendix  found  dipping  into  pelvis  and  crossing  to 
left  side  of  belly.  Appendix,  stricture  one-iialf  inch 
from  base,  beyond  that  inflamed  and  distended  with 
pus.  Salt  irrigation;  packing  of  both  wounds.  Nor- 
mal healing. 

Case  XXL— Recurrent  appendicitis,  abscess.  F. 
S ,  male,  aged  forty-two  years,  admitted  September 

25,  1899.  H;d  two  previous  attacks.  Eight  days 
ago  present  attack  began.  Pain  and  tenderness  in 
right  iliac  fossa.  Fever.  Examination  showed  con- 
siderable tumor.     Intermuscular  ojjeration,  September 

26,  1900.  Abscess  contained  six  ounces  of  pus.  Ap- 
pendix gangrenous;  concretion:  perforation  at  apex 
of  appendix.  Small  fecal  fistula  still  open  after  one 
month. 


Case  XXII. — Acute  appendicitis,  abscess;  cure. 
Lilian  D ,  aged  twenty-nine  years,  married,  ad- 
mitted November  26,  1899.  No  previous  attacks. 
Three  days  ago  vomiting  and  general  abdominal  pains, 
located  after  twenty-four  hours  in  right  iliac  fossa. 
Sharp  chill  accompanying  onset.  Bowels  open.  Ex- 
amination shows  a  strong  healthy  woman,  abdomen 
distended  and  tympanitic.  Rigidity,  pain,  and  tender- 
ness in  right  lower  abdomen.  T.,  104°;  P.,  128;  R., 
30.  Large  abscess  extending  into  pelvis.  Appendix 
gangrenous  and  perforated,  containing  a  large  con- 
cretion and  three  small  ones.  Glass-tube  drainage 
to  pelvis.  Temperature  fell  at  once  after  operation. 
Wound-healing.     Left  hospital  January  28,  1900. 

Case  XXIII. — Acute  appendicitis,  general  peri- 
tonitis, septic  diarrhoea.  James  R ,  aged  forty- 
two  years,  male,  admitted  January  22,  1900. 

Previous  history:  Diarrhcea  for  three  months,  with 
emaciation.  For  past  month  has  had  continuous  pain 
in  lower  abdomen,  worse  in  the  right  side.  Twenty- 
four  hours  ago  sudden,  very  severe  abdominal  pain  in 
lower  part  of  abdomen  and  vomiting.  Vomiting  has 
continued.  T.,  101.6°;  P.,  loo;  R.,  32.  Whole  ab- 
domen tender,  most  marked  below  ;  muscular  rigidity, 
free  fluid  in  belly  made  out  by  percussion.  Pulse 
weak.  Patient  much  prostrated.  Urine,  albumin 
present,  hyaline  and  granular  casts. 

Operation,  January  22,  1900:  Large  amount  of  free 
pus  in  peritoneal  cavity.  Appendix  perforated  at  tip. 
Free  irrigation  through  glass  tube.  After  operation 
wound  discharged  but  little  pus  and  continued  to  ap- 
pear clean.  Patient  suffered  from  severe  diarrhcea. 
No  gastric  disturbance  until  seventh  day,  when  vomit- 
ing occurred.  Patient  passed  but  very  little  urine, 
containing  albumin  and  casts.  The  temperature  was 
but  slightly  elevated  until  the  ninth  day,  when  it  rose 
to  1 01. 8'  just  before  death,  which  occurred  from  ex- 
haustion.    There  was  no  reaccumulation  in  the  belly. 

Case  XXIV. — Acute  appendicitis,  progressive  puru- 
lent peritonitis.     Marie  K ,  aged  twenty-one  years, 

admitted  January  i,  1900.  No  previous  attacks. 
Twenty-four  hours  ago,  sudden  severe  abdominal  pain, 
located  after  six  hours  in  right  iliac  fossa;  vomiting; 
marked  chill. 

Examination:  T.,  101.6°;  P.,  114.  Abdomen 
moderately  distended,  tympanitic,  and  rigid.  Tender- 
ness everywhere  marked,  but  most  so  over  the  base  of 
the  appendix. 

Operation,  January  i,  1900:  Appendix  gangrenous; 
no  adhesions.  Glass-tube  irrigation  of  entire  ab- 
dominal cavity.  Abundant  pus  extending  from  the 
bottom  of  pelvis  to  the  liver  on  the  right  side.  I'uru- 
lent  fluid  washed  from  left  side  of  abdomen  in  moder- 
ate amount.  Glass  drainage  tube  to  bottom  of  pelvis. 
Yellow  gauze  strip  upward  to  liver.  Wound-healing. 
Discharged  well,  February  6,  1900,  Temperature 
fell  at  once  after  operation  to  99.5°,  and  rose  but  twice 
to  100°  thereafter,  on  the  second  and  third  days. 

Case    XXV. — (General    purulent    peritonitis,   acute 

appendicitis.     George    R ,    aged    eighteen   years, 

admitted  December  24,  1899.  No  previous  attacks. 
Two  days  ago,  sudden  general  abdominal  pain,  located 
in  a  few  liours  in  right  iliac  fossa.  Vomited  several 
times;  constipated. 

Examination:  T.,  103°;  P.,  140;  R.,  24.  No  tumor, 
marked  rigidity  on  right  side;  both  sides  of  abdomen 
tender.  Abdomen  moderately  distended  and  tym- 
panitic. 

Operation,  December  24tli:  On  opening  of  perito- 
neum free  pus  escaped  from  all  directions.  Appendix 
strictured  at  the  base,  mucous  membrane  gangrenous 
throughout,  perforated  near  the  base.  A  portion  of 
gangrenous  onienluni  removed  with  appendix.  Pus 
appeared  to  be  present  in  every  portion  of  abdomen, 
with  but  little  fibrin  and  few  or  no  limiting  adhesions. 


November  3,  1900] 


MEDICAL    RECORD. 


693 


Entire  belly  washed  out  with  hot  salt  solution,  and 
glass  tube  inserted.  Glass  drainage  to  bottom  of 
pelvis,  another  upward  toward  liver.  Temperature 
dropped  at  once  from  103"  to  99-6°,  and  pulse  from 
120  to  90.  Temperature  remained  nearly  normal 
thereafter.  Bowels  moved  on  third  day  after  mag- 
nesium sulphate.     Left  hospital,  well,  February  9,  1900. 

Case  XXVI. — Acute  appendicitis,  progressi\e  puru- 
lent peritonitis;  cure.     James  G ,  aged  twenty-nine 

years,  male,  admitted  January  6,  1900.  No  previous 
attacks.  Chronic  alcoholic.  Abdominal  discomfort 
and  occasional  vomiting  for  past  two  months.  Last 
night  sudden  severe  pain  in  lower  abdomen,  localized 
after  a  few  hours  in  right  iliac  fossa,  with  vomiting. 

Examination:  I'ain  and  tenderness  in  right  lower 
half  of  abdomen,  most  marked  in  right  side.  No 
tumor.     T.,  104.9°;  ^^-  ''°- 

Operation,  January  6,  1900:  Free  pus.  Appendi.K 
gangrenous.  F'xlent  of  peritoneal  surface  already  in- 
fected large.  Irrigation.  Appendix  large  and  stric- 
tured  at  base;  distended  with  foul  pus,  gangrenous; 
no  perforation.     Left  hospital,  well,  F'ebruary  6,  igoo. 

Case  XXVII. — Acute  appendicitis,  abscess;  cure. 

Harold   13 ,   aged    sixteen    years,   male,    admitted 

December  I  7,  1899.  No  previous  attacks.  Four  days 
ago  sudden  severe  peri-umbilical  pain.  Vomiting  and 
fever.  Pain  located  in  right  iliac  fossa  after  twelve 
hours. 

Examination:  T.,  104.2°;  P.,  120.  Pain  and  rigid- 
ity and  tenderness  over  right  iliac  fossa.  Belly  tym- 
panitic. 

Operation,  December  17.  1899:  Normal  peritoneum 
opened ;  sacculated  small  abscess  on  outer  side  of  colon 
containing  two  drachms  of  pus.  Appendix  perforated 
near  base,  behind  a  tight  stricture.  Distal  extremity 
of  appendix  atrophied.  Remainder  inflamed  and 
greatly  thickened.  Normal  convalescence.  Left  hos- 
pital, well,  February  17,  1900. 

Ca.se  XXVIII. — Acute  appendicitis,  abscess;  cure. 

Mary  J ,  aged  twenty-three  years,  single,  admitted 

November  21,  1900.  No  previous  attack.  Three 
days  ago  general  abdominal  pain,  vomiting,  chill  next 
day.  Pain  and  tenderness  localized  after  forty-eight 
hours  in  right  iliac  fossa. 

Examination:  Large  tender  mass  occupying  whole 
of  iliac  fossa.     T.,  100.8°;  P.,  104. 

Operation,  November  21,  1900:  Large  localized 
abscess  extending  to  bottom  of  pelvis.  Appendix  half 
gangrenous  and  perforated.  Irrigation  and  yellow- 
gauze  drainage  to  bottom  of  pelvis.  Left  hospital 
well,  after  convalescence  delayed  by  a  persistent 
sinus,  which  closed  rapidly  after  administration  of 
iodide  of  potassium  and  mercury. 

Case  XXIX. — Acute  appendicitis,  abscess;  cure. 
William  \V ,  aged  seventeen  years,  admitted  No- 
vember 8,  i8gg. 

Previous  history:  Numerous  mild  attacks  during 
past  two  years. 

Present  illness:  Two  days  ago  general  abdominal 
pain,  located  after  twenty-four  hours  in  right  iliac 
fossa.     Chill  after  twenty-four  hours.     Diarrhoea. 

Examination:  T.,  102.6";  P.,  96.  .\bdomen  tym- 
panitic.    Rigidity  marked  on  right  side,  and  tenderness. 

Operation,  November  gth  :  Large  circumscribed  ab- 
scess extending  to  bottom  of  pelvis.  .Appendix  stric- 
tured,  containing  concretion,  partly  gangrenous  and 
perforated.  Irrigation  and  packing.  Wound-healing 
normal  e-xcept  for  a  temporary  fecal  fistula  which  closed 
spontaneously.     Dismissed,  well,  January  7.  1900. 

Case  XXX. — Acute  gangrenous  appendicitis,  ab- 
scess;   cure.     Julia    C ,   aged   twenty-nine  years, 

married,  admitted  March  22.  1900.  No  previous  at- 
tacks. Twelve  days  before  admission  general  ab- 
dominal pains,  nausea,  vomiting,  and  prostration. 
Pain   localized   after  twenty-four  hours   in   the   right 


iliac  fossa.  A  chill  on  the  fifth  day.  Bowels  moved 
daily.  Pain  in  the  region  of  the  appendix  continued 
to  grow  more  severe  until  admission.  Day  before  ad- 
mission another  chill. 

Examination :  There  is  a  tender  mass  in  the  right 
iliac  fossa  the  size  of  an  orange.  Firm  and  resistant, 
tympanitic.     T.,  102.2";  P.,  108. 

Operation,  March  23d;  Large  abscess  opened  to  the 
inner  side  of  and  below  the  cascum,  extending  well 
down  into  the  pelvis.  Appendix  not  found.  Probably 
destroyed.  Normal  wound-healing.  Temperature  fell 
to  normal  soon  after  the  operation.  Left  the  hospital, 
well,  May  8th. 

Case  XXXI. — Acute  gangrenous  appendicitis,  ab- 
scess; cure.     Maggie  M ,  aged  twenty-two  years, 

admitted  April  2,  igoo.  No  previous  attacks.  Five 
days  ago  severe  pain  in  the  right  lumbar  region,  local- 
ized after  twenty-four  hours  in  tlie  right  iliac  fossa. 
Bowels  constipated. 

Examination:  Pain  and  tenderness  and  rigidity  in 
the  right  iliac  fossa.     Temperature  and  pulse  normal. 

Operation,  April  3d:  Intermuscular  incision. 
Caecum  buried  in  adhesions.  Operation  largely  extra- 
peritoneal. Appendix  partly  gangrenous.  Small  cir- 
cumscribed abscess.  Gauze  drainage;  normal  wound- 
healing;   left  the  hospital,  well.  May  8th. 

Case  XXXI  I. — Acute  gangrenous  appendicitis;  cure. 

Mamie  R ,  aged  nineteen   years,  admitted   March 

27th.  One  mild  attack  of  appendicitis  three  years 
ago.  Four  days  ago  general  abdominal  pain,  localized 
after  twelve  hours  in  the  right  iliac  fossa. 

Examination:  On  the  third  day  had  a  chill  in  the 
morning.  Abdomen  not  distended.  T.,  100°;  P.,  go. 
Pain  and  tenderness  in  the  right  iliac  fossa  without 
rigidity.  There  is  a  tumor  the  size  of  a  small  orange 
to  the  inner  side  of  the  right  anterior  superior  spine, 
exceedingly  tender. 

Operation,  March  28,  igoo:  When  the  peritoneal 
cavity  was  opened  the  distal  extremity  of  the  greatly 
swollen  appendix  was  found  immediately  beneath  the 
abdominal  wall,  buried  in  recent  adhesions  and  firmly 
attached  to  the  inflamed  caecum.  The  appendix  was 
long  and  bent  upon  itself.  Its  base  was  situated  be- 
hind the  caecum.  Removed  in  the  ordinary  way. 
There  was  no  pus.  The  appendix  was  four  inches  in 
length  ;  there  was  an  impervious  stricture  at  its  middle, 
beyond  which  its  canal  was  greatly  dilated,  filled 
with  pus.  The  mucous  membrane  showed  several 
gangrenous  areas.  Gauze  drainage  and  partial  suture 
of  the  wound.  Normal  wound-healing.  Left  the  hos- 
pital well. 

Case  XXXIII. — Acute  appendicitis,  general  puru- 
lent peritonitis.  T.  McS ,  aged  nine  years,  ad- 
mitted December  2,  i8gg.  No  previous  attacks. 
Four  days  ago  he  was  suddenly  seized  with  general 
abdominal  pain,  accompanied  by  vomiting,  which  was 
localized  upon  the  following  day  in  the  right  iliac 
fossa,  although  tenderness  is  said  to  have  been  marked 
over  the  whole  abdomen.  The  vomiting  has  continued. 
The  bowels  have  been  constipated.  On  the  day  be- 
fore admission  his  abdomen  became  distended.  The 
distention  has  increased. 

Examination:  T.,  102°;  P.,  128.  He  appears  to 
be  very  ill.  He  is  rather  apathetic.  His  tongue  is 
dry  and  brown.  The  abdomen  is  markedly  distended, 
but  not  very  tender  except  over  the  appendix  region. 
There  is  slight  muscular  rigidity.  No  mass  palpable. 
Enemata  failed  to  move  the  bowels. 

Operation,  December  2,  i8gg:  Incision  over  base 
of  appendix.  When  the  peritoneum  was  opened,  pus 
in  abundance  gushed  out  under  considerable  tension. 
The  pelvis  was  found  full  of  pus  and  another  large 
collection  beneath  the  liver.  Irrigation  through  glass 
tube  showed  abundant  pus  everywhere  throughout  the 
greater  peritoneal  cavity.     There  were  slight  but  im- 


694 


MEDICAL    RECORD. 


[November  3,  1900 


perfect  fibrinous  adhesions  here  and  there  throughout 
the  abdomen,  which  were  broken  down  with  the  hand 
and  with  the  tube.  The  appendix  lay  behind  the 
caput  coli;  its  mucous  membrane  was  strictured  in 
two  places;  between  the  strictures  was  a  concretion, 
and  the  mucous  membrane  was  gangrenous.  Eeyond 
the  second  stricture  the  appendix  was  thickened,  per- 
forated, and  contained  much  pus.  Prolonged  irriga- 
tion of  the  entire  peritoneal  cavity  with  the  Chamber- 
lain tube  and  hot  saline  solution.  The  colon  at  the 
base  of  the  appendix  was  infiltrated  and  in  an  unfavor- 
able condition  for  suture.  A  purse-string  suture  was 
applied  and  mattress  stitches  were  inserted  over  it. 
Large  glass-tube  drainage  to  the  pelvis  with  iodoform- 
gauze  wick.  Packing  at  the  base  of  the  appendix. 
After  the  operation  the  patient  vomited  repeatedly. 
His  temperature  remained  higli,  he  was  unconscious 
for  several  days,  when  improvement  in  his  general 
condition  became  manifest.  Upon  the  ninth  day,  the 
wound  having  become  fairly  clean,  a  fecal  fistula  was 
noted,  which  in  spite  of  rest  in  bed  persisted  as  a 
superficial  sinus  leading  directly  into  the  calibre  of 
the  gut  until  it  was  closed  by  suture  four  and  one-half 
months  later. 

Case      XXXIV. — General      purulent      peritonitis. 

Henry  N ,  aged  seventeen  years,  admitted  April 

8,  1900.  No  previous  attacks.  Six  days  ago  severe 
general  abdominal  pain,  localized  after  three  days  in 
right  iliac  fossa,  and  accompanied  by  repeated  vomit- 
ing. He  has  steadily  grown  worse,  and  upon  admis- 
sion to  the  hospital  his  temperature  was  104.4°,  pulse, 
116.  The  abdomen  is  moderately  distended,  every- 
where rigid  and  tender;  the  tenderness  is,  however, 
slightly  more  marked  over  the  region  of  the  appendix. 
The  signs  of  free  fluid  in  the  abdominal  cavity  are 
fairly  well  marked.     There  is  no  circumscribed  tumor. 

Operation,  April  8,  1900:  Incision  over  base  of 
appendix.  Peritoneal  cavity  opened.  Thin  purulent 
fluid  flowed  out.  Csecum  with  the  appendix  pulled 
out  of  wound.  Mesentery  ligated;  portion  of  mesen- 
tery between  ligature  and  appendix  divided.  Purse- 
string  suture  around  base  of  appendix.  Appendix 
amputated  one-half  inch  distal  to  stump.  Stump 
cauterized.  Glass-tube  irrigation  of  every  part  of 
whole  abdomen;  large  quantity  of  pus,  with  scarcely 
any  limiting  adhesions  around  it,  was  washed  out  from 
pelvis.  More  pus  was  obtained  from  the  region  above 
the  appendix  area,  under  the  liver,  and  from  the  op- 
posite side  of  the  abdomen  to  the  spleen.  Glass  tube 
inserted  into  pelvis  and  iodoform  gauze  packed  to  its 
bottom. 

Pathology :  Appendix  three  inches  long,  large  per- 
foration in  distal  end.  Stricture  about  middle;  a 
large  concretion  dropped  out  of  it  as  soon  as  it  was 
manipulated  when  found  during  the  operation.  Sec- 
ondary abscess  opened  eleven  days  later  through  the 
left  rectus  muscle  at  the  level  of  the  umbilicus,  after 
which  the  patient  did  well. 

Case     XXXV. — Frank    D ,    aged    twenty-four 

years,  admitted  March  2d.  No  previous  attack. 
Four  days  ago  was  seized  with  nausea  and  vomiting 
and  general  abdominal  pains,  which  became  localized 
in  about  six  hours  in  the  right  iliac  fossa.  Symptoms 
have  steadily  grown  worse  up  to  admission,  vomiting 
has  continued. 

Examination:  T.,  106.6";  P.,  96.  There  is  marked 
muscular  rigidity  of  the  right  side  of  the  abdomen 
over  the  base  of  the  appendix.     No  definite  tumor  felt. 

Operation:  Incision  over  ba.se  of  appendix.  Small 
abscess  opened  behind  the  caecum.  Appendix  stric- 
tured near  the  base,  impermeable.  Beyond  this  dis- 
tended with  thin  pus,  small  perforation  near  the  apex. 
Gauze  drainage.  Partial  suture  of  the  wound.  Nor- 
mal convalescence. 

CilASE  XXXVI. — James  H ,  aged  twenty  years, 


admitted  April  9,  1900.  No  previous  attacks.  Be- 
came ill  March  31st  with  sore  throat,  fever,  chill,  and 
general  abdominal  pain,  followed  by  slight  pain  in 
right  iliac  fossa,  which  lasted  only  two  or  three 
hours.  On  April  3d  pain  in  iliac  fossa  recurred  and 
continued  constantly  until  April  5th,  when  it  sud- 
denly became  very  severe.  Bowels  regular,  no  nausea 
or  vomiting. 

Examination:  Well-nourished,  strongly  built  man. 
Abdomen,  upon  pressure  marked  tenderness  in  lower 
umbilical  and  lumbar  regions.  Greatest  tenderness 
in  the  right  iliac  region,  most  acute  a  little  below  site 
of  base  of  appendix.  Considerable  rigidity  over  right 
iliac  region.     T.,  103.6°;  P.,  100;  R.,  24. 

Operation,  April  loth:  Distinct  tumor  felt  in  lum- 
bar region,  just  above  iliac  crest.  Incision  in  the 
lumbar  region  parallel  to  the  border  of  the  ribs. 
Peritoneal  cavity  opened.  An  abscess  of  considerable 
size  was  found  situated  behind  and  to  the  outer  side 
of  the  colon.  At  the  lower  portion  of  the  abscess  the 
appendix  was  identified;  it  was  very  long  and  ex- 
tended upward  behind  the  colon,  and  was  perforated 
at  its  tip.  Length  of  appendix  was  six  inches.  The 
lesion  appeared  to  be  limited  to  its  distal  extremity. 
Suture  of  upper  portion  of  wound.  Normal  convales- 
cence. 

Case  XXXVll. —  Chronic  appendicitis,  abscess,  in- 
testinal   obstruction    by    bands,  operation ;    recovery. 

Charles  M ,  aged  twenty-nine  years,  admitted  to 

Roosevelt  Hospital  January  8,  1900,  with  following 
history.  During  the  past  ten  years  he  had  three  severe 
attacks  of  appendicitis.  In  the  opinion  of  his  attend- 
ing physician,  his  last  attack,  which  occurred  about 
four  months  ago,  was  accompanied  by  severe  pain, 
vomiting,  fever,  prostration,  swelling  of  the  abdomen, 
and  obstinate  constipation  lasting  five  days.  There 
was  evident  involvement  of  a  considerable  part  of  the 
peritoneum,  diagnosticated  as  general  peritonitis;  he 
recovered  from  this  attack  incompletely,  and  during 
the  past  three  months,  while  able  to  be  about,  has  had 
constant  discomfort  in  the  region  of  the  appendix, 
with  tenderness  upon  pressure.  His  stomach  has  also 
given  him  some  trouble,  he  has  had  numerous  attacks 
of  vomiting,  his  bowels  have  been  fairly  regular.  He 
remained  in  the  hospital  under  observation  for  a  fort- 
night or  twelve  days,  and  was  operated  upon  January 
20th.  During  this  time  he  had  a  slight  evening  rise 
of  temperature  on  several  occasions.  There  was  a 
sense  of  increased  resistance  to  be  felt  in  the  right 
iliac  fossa,  together  with  moderate  tenderness  on 
pressure. 

Operation:  Intermuscular  incision.  When  the 
peritoneal  cavity  was  opened  the  ca;cum  was  found 
bound  down  firmly  to  the  iliac  fossa  by  old  adhesions. 
When  these  were  separated  an  abscess  cavity  was 
opened  behind  the  ctecum  containing  only  half  a 
drachm  of  pus.  Upon  exploration  the  abscess  cavity 
was  found  to  communicate  on  the  one  hand  with  the  open 
end  of  the  partly  destroyed  appendix,  one  inch  in 
length,  and  upon  the  other,  distant  an  inch  and  a  half 
from  the  base  of  the  appendix,  with  the  lumen  of  the 
large  intestine,  through  an  opening  about  one-third  of 
an  inch  across.  The  appendix  was  amputated  and 
inverted  in  the  usual  way,  and  the  opening  in  the  gut 
was  sutured.  A  strand  of  gauze  drainage;  partial 
suture  of  the  wound.  The  wound  remained  quite 
clean,  but  the  patient  began  soon  after  the  operation 
to  vomit  occasionally;  his  bowels  w-ere  hard  to  move. 
His  temperature  was  slightly  elevated  from  lime  to 
time  and  he  continued  to  suffer  a  certain  amount  of 
abdominal  pain.  Upon  the  thirteenth  day  following 
the  operation  a  small  movement  of  the  bowels  occurred, 
but  the  continued  vomiting  had  greatly  weakened  the 
patient.  Upon  the  fourteenth  day  symptoms  of  in- 
testinal   obstruction   were   well   marked,   the  vomited 


November  3, 


1900] 


MEDICAL    RECORD 


695 


matters  began  to  have  a  fecal  character,  his  abdomen 
became  distended,  and  nothing  passed  per  rectum  in 
spite  of  repeated  enemata. 

Operation  on  morning  of  the  fifteenth  day:  Median 
incision.  Coils  of  distended  small  intestine  presented 
in  the  wound.  Upon  following  them  to  the  right  the 
following  conditions  were  noted.  A  coil  of  small  in- 
testine was  firmly  adherent  to  the  ascending  colon  for 
an  area  of  several  inches  in  length  along  its  inner  sur- 
face. A  second  coil  of  small  intestine  adhered  to  the 
first  coil  in  a  similar  manner.  Passing  transversely 
from  the  ascending  colon  toward  the  median  line  was 
a  broad  l)and  of  dense  organized  adhesions  crossing 
the  two  coils  of  small  intestine,  to  be  attached  to  the 
mesentery  near  the  middle  line.  The  division  and 
separation  of  these  bands  and  adhesions  was  followed 
by  severe  bleeding,  necessitating  ligatures  and  pad 
pressure  for  its  control.  Further  exploration  showed 
also  similar  broad  adhesions  among  the  coils  of 
small  intestine  situated  in  the  pelvis.  They  were  also 
spearated.  Upon  dividing  the  above-described  fibrous 
bands  tlie  patency  of  the  small  gut  was  restored. 
These  bands  and  adhesions  were  evidently  the  result 
of  an  ancient  inflammatory  process.  Suture  of  the 
wound,  with  gauze-wick  drainage.  The  patient  made 
a  slow  but  perfect  recovery  and  left  the  hospital,  well, 
early  in  March. 

Case  XXXVIII. — Acute  appendicitis,  progressive 
purulent  peritonitis;  recovery.  H.  M ,  aged  fifty- 
three  years,  male.  A  history  of  repeated  attacks  of 
abdominal  pain  accompanied  by  tenderness  in  the 
right  iliac  fossa,  e.xtending  over  a  period  of  several 
years.  None  of  them  was  severe  enough  to  confine 
him  to  his  bed.  During  the  afternoon  of  April  16, 
1899,  he  was  suddenly  seized  with  severe  abdominal 
pain,  localized  after  five  hours  in  the  right  iliac  fossa, 
at  which  time  he  had  a  chill  accompanied  by  a  rise  of 
temperature  to  103.5°.  Ihere  was  tenderness  over 
the  base  of  the  appendix,  involving  also  the  entire 
rigiit  lower  portion  of  the  abdomen. 

Operation  was  postponed  by  the  patient  for  twelve 
hours.  When  the  abdomen  was  opened  thin  pus 
escaped  in  considerable  quantities.  There  were  no 
limiting  adliesions.  The  pelvis  was  filled  with  thin 
purulent  fluid.  The  appendix  was  strictured  about 
midway  its  length  and  perforated  at  its  tip;  it  was 
amputated  and  the  stump  inverted.  Irrigation  of 
pelvis  and  neighborhood  of  appendix  with  hot  saline 
solution;  a  glass-tube  drainage  to  bottom  of  pelvis; 
packing  to  stump  of  appendix.  Convalescence  normal, 
except  for  the  escape  of  a  small  amount  of  fecal  matter 
from  the  stump  of  the  appendix.  The  fistula  closed 
after  cauterization  and  packing. 

Case  XXXIX. — Acute  appendicitis,  general  puru- 
lent  peritonitis.      Frank   C ,   aged   eleven   years, 

admitted  April  12,  1900.  No  previous  attacks.  On 
April  6th,  sick-headache  accompanied  by  vomiting; 
no  abdominal  pain.  April  9th,  suddenly  attacked  with 
severe  pain,  localized  from  first  in  right  iliac  fossa. 
Vomited  very  freely  for  two  days;  no  chill. 

Examination:  Tenderness  almost  entirely  localized 
in  right  iliac  fossa.  A  tumor,  the  size  of  a  lemon, 
distinctly  felt  under  anasthesia  close  up  under  an- 
terior superior  spine  of  ilium.  Considerable  ab- 
dominal rigidity,  most  marked  over  right  iliac  fossa: 
but  to  some  extent  over  whole  of  abdomen.  T.,  102.4'^  ; 
P.,  120;   R.,  24. 

Operation,  April  12th:  Four-inch  incision  over  the 
base  of  the  appendix.  Much  pus  filling  the  pelvis, 
found  among  the  small  intestines,  apparently  involving 
a  large  portion  of  the  peritoneal  cavity.  The  appen- 
dix lay  behind  the  caecum  and  was  perforated.  The 
entire  abdominal  cavity  was  irrigated  with  hot  saline 
solution  through  a  glass  tube.  Appendix  removed. 
Glass-tube  drainage    to  pelvis,   iodoform   packing  to 


stump  of  appendix;  partial  suture  of  the  wound.  Nor 
mal  convalescence. 

Case  XL. — Acute  appendicitis,  abscess;  recovery. 
J.  S ,  aged  twenty-three  years.  History  of  slow- 
convalescence  from  typhoid  fever  six  months  before 
present  illness,  leaving  him  in  a  weak  ansmic  condi- 
tion. Two  weeks  ago,  never  having  had  a  previous 
attack,  he  was  seized  with  vomiting  and  severe  ab- 
dominal pain,  localized  after  a  few  hours  in  the  right 
iliac  fossa.  His  condition  since  then  has  grown 
steadily  worse,  he  has  suffered  from  constant  pain  in 
the  region  of  the  appendix,  has  been  confined  to  his 
bed,  and  has  himself  observed  a  tender  mass  slowly 
increasing  in  size  in  the  region  of  the  appendix.  He 
has  had  a  continued  fever. 

Examination  shows  the  patient  to  be  a  rather  poorh 
nourished  individual;  his  face  is  distinctly  septic  in 
appearance.  T.,  103°;  P.,  100.  The  abdomen  is 
not  noticeably  distended,  but  everywhere  tympanitic. 
The  right  iliac  fossa  is  occupied  by  a  mass  as  large 
apparently  as  a  fcetal  head  at  term.  Percussion  note 
over  the  tumor  is  tympanitic.  There  is  moderate 
muscular  rigidity. 

Operation,  March  8,  1900:  Incision  four  inches  in 
length  over  tumor.  Caecum  adherent  to  abdominal 
wall  by  fibrin.  Large  abscess  extending  to  the  bottom 
of  pelvis  was  opened  behind  caput  coli.  It  was  walled 
off  by  dense  adhesions  from  the  general  cavity  of  the 
belly.  Appendix  not  found;  it  was  apparently  de- 
stroyed. Irrigation  of  hot  saline  solution  through 
Chamberlain's  tube,  lodoform-gauze  packing.  Nor- 
mal convalescence. 


The  Parasitic  Nature  of  Eczema. — ]'.  G.  Unna  in 
making  bacteriological  studies  of  seventy-four  cases 
of  this  disease  was  able  to  differentiate  twenty-three 
types  of  coccus.  These  he  arranges  in  five  classes, 
according  to  their  tendency  to  group  formation. 
Those  which  do  not  show  any  such  predilection,  i.e., 
the  monads,  form  the  first  class,  the  dyads  the  second, 
tetrads  the  third,  and  octads  and  hekkaidekads  the 
fourth  and  fifth.  Of  these  twenty-three  types  twelve 
were  found  to  give  no  results  on  inoculation  into  ani- 
mals, four  produced  lesions  somewhat  impetiginous  in 
nature  but  not  at  all  resembling  eczema,  five  types 
caused  appearances  strongly  suspicious  of  the  disease, 
and  finally  two  gave  all  the  characteristics  typical  of 
true  eczema  and  are  to  be  regarded  as  the  producers 
of  the  disorder.  One  of  these  was  found  in  over  one- 
half  of  the  cases  examined  and  the  other  in  only  two 
instances,  but  then  in  pure  culture.  Carrying  the  in- 
vestigation a  step  further  and  inoculating  human 
beings  it  was  found  that  absolutely  typical  eczematous 
lesions  were  produced  by  the  two  types  under  consid- 
eration. For  these  two  the  author  proposes  the  names 
of  Diclimactericus  eczematis  albus  tlavens  and  Mono- 
climactericus  eczematis  vivescens,  while  to  a  third 
strongly  suspicious  form  he  would  apply  the  appella- 
tion Triclimactericus  eczematis  tenuis. —  IVietur  ki'i- 
nische  Rundschau,  September  16,  1900. 

The  Restoration  of  Function  to  Ankylosed 
Joints.  —  V.  Chlumsky  refers  to  the  large  percentage 
of  failures  attending  efforts  at  cure  of  fixed  articula- 
tions either  by  manipulation  or  open  operation.  The 
usual  causes  of  this  condition  lie  either  in  contrac- 
tures of  the  soft  parts  or  in  bony  or  fibrous  outgrowths 
of  the  articular  surfaces.  By  massage  it  may  be  pos- 
sible to  restore  the  atrophied  muscular  tissues,  and 
function  may  temporarily  be  improved  by  the  non- 
bloody  brisement  force'  or  by  excision  of  the  new 
growths,  but  the  amelioration  is  apt  to  be  evanescent, 
for  the  re-formation  of  the  obstructing  masses  is  not 
prevented.     With  the  idea  of  imitating  the  false  joints 


696 


MEDICAL    RECORD. 


[November  3,  1900 


sometimes  occurring  at  tiie  site  of  fractures  owing  to 
the  interposition  of  muscle  fibres,  etc.,  between  tiie 
separated  ends,  the  author  introduced  foreign  bodies 
of  various  sorts  into  the  joints  of  dogs  and  rabbits 
after  having  resected  portions  of  tiie  articular  surfaces. 
Thin  plates  of  celluloid,  silver,  pewter,  and  rubber 
were  used  at  first,  but  later  it  seemed  preferable  to 
employ  substances  capable  of  absorption,  and  decalci- 
fied bone,  ivory,  and  magnesium  were  tried.  The  re- 
sults in  the  animals  experimented  on  were  very  en- 
couraging and  while  no  definite  technique  for  the 
human  subject  can  yet  be  formulated,  further  work 
will  doubtless  be  productive  of  valuable  tlierapeutic 
measures. ^ — Centralhlatt  Jiir  C/iirurgie,  September  15, 
1900. 

Leontiasis  Ossea. — VV.  H.  Stephenson  reports  a 
case  of  this  rare  disease,  which  is  characterized  by  an 
overgrowth  or  hyperostosis  of  all  or  some  of  the  facial 
or  cranial  bones,  without  any  concomitant  affection  of 
other  parts  of  the  body.  The  patient,  a  man  of  twenty- 
seven  years,  had  first  noticed  a  slight,  hard,  painless 
swelling  on  the  left  side  of  the  lower  jaw  when  thir- 
teen years  of  age.  About  eighteen  months  ago  a  sim- 
ilar swelling  had  commenced  on  the  right  side  of  the 
lower  jaw,  and  had  gradually  increased  in  size,  but 
was  not  accompanied  by  any  marked  pain.  During 
the  last  twelve  months  he  had  noticed  that  the  bones 
of  his  nose  had  been  growing  larger,  the  nose  had 
become  increased  in  tiiickness  and  breadth,  and  the 
left  nostril  had  become  almost  occluded.  With  the 
exception  of  neuralgic  pains  in  the  lower  jaw  of  the 
left  side,  extending  up  to  the  temple,  the  patient  had 
good  health.  The  etiology  of  this  disease  is  obscure. 
No  treatment  appears  to  be  of  any  avail.- — The  Medi- 
cal C/ironiek,  September,  1900. 

The  Leper  Colony  at  Robben  Island. — This  island, 
Jonathan  Hutchinson  writes,  is  on  the  West  coast  of 
Africa,  slightly  north  of  Cape  Town  in  Table  Bay. 
He  found  that  the  lepers  segregated  there  received  al- 
most no  medical  attention  owing  to  the  neglect  of  the 
medical  officers,  and  that  transportation  thither  was 
practically  equivalent  to  imprisonment  for  life.  He 
protests  against  such  methods  of  caring  for  these  un- 
fortunates. His  explanation  and  thoery  of  the  origin 
and  spread  of  leprosy  at  the  Cape  is  the  great  amount 
of  salted  fish  used.  Much  of  this  is  sent  to  the  inte- 
rior, for  it  is  light  and  easily  carried.  He  believes  that 
it  is  desirable  that  leper  houses,  comfortable  hospitals 
and  asylums,  should  be  built.  Lepers  nearly  always 
die,  and  that  very  soon,  of  tuberculosis  and  pneumonia. 
— Medical  Press  and  Circular,  September  26,  1900. 

Disturbances  of  the  Stomach  in  Relation  to  Dis- 
eases of  the  Chest. — J.  M.  Patton  says  that  of  dis- 
eases of  the  chest  pulmonary  tuberculosis  occupies  the 
most  prominent  place  in  connection  with  gastric  dis- 
orders. Tuberculous  ulceration  in  the  stomach  is  rare 
compared  with  that  of  the  intestines.  This  may  be 
due  to  the  germicidal  action  of  the  gastric  juice,  but 
more  likely  to  the  small  amount  of  lymphoid  tissue  in 
the  stomach  and  its  deep  situation.  Gastric  tubercu- 
losis presents  no  definite  symptoms.  It  occurs  some- 
what more  frequently  in  males  than  in  females. 
Clinically  it  is  not  of  great  importance,  because  dealii 
occurs  from  advanced  tuberculosis  of  other  organs,  and 
because  it  is  seldom  diagnosticated  though  frequently 
suspected. —  Clinical  Revieio,  October,  1900. 

Fliigge's  Theory  and  its  Application  to  Surgery. 
— Roberto  Einaghi  from  the  results  of  his  researches 
concludes  that  the  stapliylococcus  is  the  germ  most 
frequently  present  in  the  air  of  surgical  rooms.  The 
more  people  usually  found  in  these  rooms,  the  greater 
the  number  of   germs.     They   are   found   in   greatest 


abundance  in  the  lower  strata  of  air.  In  operating- 
rooms  the  author  has  never  found  them  before  or  dur- 
ing an  operation  but  always  after  it.  In  clinic  rooms 
they  are  present  during  and  after  the  hours  of  treat- 
ment. In  dispensaries  and  waiting-rooms  staphylococci 
are  constantly  present.  It  would  appear  that  they  are 
infrequent  when  the  temperature  and  pressure  are  low, 
as  in  February  and  March.  The  author  thoroughly 
believes  in  Fliigge's  opinion  that  even  when  personal 
asepsis  has  been  strictly  observed,  the  mere  motion  of 
persons  in  an  operating-room  may,  by  causing  light 
currents  of  air  in  which  germs  are  suspended,  cause 
infection  of  the  wound.  The  number  of  persons  in 
an  operating-room  should  be  reduced  to  the  minimum. 
— La  Rijonna  Medica,  September  22  and  24,  1900. 

Malarial  Haemoglobinuria. — James  M.  Parrott 
clinically  and  therapeutically  divides  the  disease  into 
two  varieties,  the  asthenic  and  the  sthenic.  The  latter 
is  engrafted  upon  the  more  or  less  robust,  thougii  its 
more  characteristic  manifestations  are  preceded,  as 
are  the  asthenic,  by  symptoms  which  are  generally 
supposed  to  be  those  of  ordinary  malaria.  The  as- 
thenic variety  is  engrafted  upon  one  with  a  previous 
malarial  cachexia.  It  occurs  in  those  who  are  debili- 
tated and  weakened  and  whose  excretory  organs  are 
functioning  below  normal  because  of  certain  organic 
pathological  changes  universally  recognized  as  these 
of  chronic  malaria.  The  author  gives  in  detail  the 
symptoms  of  the  two  varieties.  As  to  the  treatment, 
the  administration  of  quinine  is  a  subject  which  ad- 
mits of  much  discussion.  This  much  should  be  said, 
that  in  sthenic  cases  seen  before  the  beginning  of  the 
fourth  day,  quinine  should  be  given.  The  alkaloid  is 
not  to  be  used  in  the  asthenic  cases  except  in  very 
small  doses,  within  the  first  few  hours  after  the  initial 
symptoms.  Normal  saline  solutions  properly  used  are 
of  the  utmost  value.  In  sthenic  cases  the  author  some- 
times bleeds  from  one  arm  and  infuses  into  the  other. 
This  may  be  of  especial  service  when  suppression  of 
urine  threatens.  The  saline  solution  can  be  used  by 
hypodermoclysis  with  good  results.  High  rectal 
saline  injections  are  very  valuable.  Whatever  the 
form  of  treatment,  nature  must  always  be  assisted  to 
eliminate  the  poison,  and  the  system  supported  until 
it  can  do  so.  —  T/ie  Carolina  Medical  Journal ,  Septem- 
ber, 1900. 

Some  General  Considerations  in  the  Treatment 
of  Hysteria  and  Neurasthenia.— B.  C.  Loveland 
classifies  his  treatment  for  these  disorders  under  five 
heads,  i.  So  far  as  possible  correct  errors  of  phy- 
sique. Look  for  evidences  of  lithtemia,  malaria,  uter- 
ine disease,  syphilis,  cystitis,  catarrhal  disease  in  any 
part,  eye-strain,  dyspepsia,  and  constipation — any  dis- 
ease affecting  the  nutrition  or  any  irritation  which 
may  in  a  rellex  way  cause  nerve  waste.  2.  Institute 
healthful  surroundings  and  healthful  habits.  Charge 
of  scene,  abundance  of  fresh  air,  cheerfulness.  3. 
Hydrotherapeutics  and  calisthenics  as  equalizers  of 
the  circulation  and  natural  nerve  tonics.  Both  should 
be  under  supervision  of  the  physician.  4.  Correcting 
the  mental  attitude  by  properly  and  tactfully  applied 
suggestion.  By  tiiis  is  not  meant  hypnotism,  but 
rather  that  we  should  set  the  patient  to  expect  such 
and  such  results,  the  result  being  far  more  apt  to  fol- 
low than  if  such  a  state  of  expectancy  is  not  induced. 
5.  Medicines.  Strychnine  is  useful  in  these  cases  only 
in  very  small  doses.  \'alerian,  or  pil.  camphor, 
hyoscyamus,  and  valerian  makes  a  good  and  harmless 
sedative.  Bromides  have  their  place,  i'hosphate  of 
sodium  is  one  of  the  best  laxatives.  Medicines  alone 
never  cure  the  cases,  and  careful  attention  should  be 
given  to  physical  and  mental  hygiene  as  most  impor- 
tant factors  in  the  treatment.— ^/^'^few.  October, 
1900. 


November  3,  1900J 


MEDICAL    RECORD. 


697 


Medical   Record: 

A    Weekly  Journal  of  Medicine  and  Surgery. 


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

Publishers 

WM     WOOD   &   CO  ,  51    Fifth   Avenue. 


New  York,  November  3,  1900. 


MOSQUITOS    AND    YELLOW    FEVER. 

Dr.  Charles  J.  Finlay,  of  Havana,  was  the  first  to 
advance  the  proposition  that  the  mosquito  was  the 
agent  of  transmission  of  yellow  fever.  It  is  now 
nearly  twenty  years  since  he  denounced  the  insect  as 
such  in  a  Havana  medical  journal.  Dr.  L.  Gererd, 
tiien  surgeon-in-chief  to  the  Panama  Canal  Company, 
came  to  the  same  conclusion,  as  the  result  of  experi- 
ments performed  upon  himself,  and  made  his  opinions 
public  in  the  Canada  Medical  Record  in  1882.  Others 
h.ive  from  time  to  time  declared  their  belief  in  the 
tiieory,  but  until  Manson  and  Ross  succeeded  in  de- 
monstrating that  a  species  of  mosquito  played  a  most 
prominent  part  in  the  etiology  and  propagation  of  the 
malarial  infection,  interest  in  the  matter  had  become 
somewhat  faint.  However,  the  success  of  the  liritish 
investigators  in  probing  to  a  great  e.\tent  the  mystery 
of  the  dissemination  of  malaria,  coupled  with  the 
serious  outbreak  of  yellow  fever  in  Havana,  would 
seem  to  have  stirred  up  the  sanitary  authorities  of  this 
country,  and  to  have  suggested  to  their  minds  that 
there  might  be  something,  after  all,  in  Dr.  Finlay's 
ideas. 

But  before  going  into  the  question  of  the  work  ac- 
complished recently  by  the  commission  of  United 
.States  army  surgeons  in  Havana,  it  may  be  as  well 
to  epitomize  Dr.  Finlay's  theory  as  stated  in  the 
Medical  Record,  May  27,  1899.  In  the  first  instance 
he  does  not  regard  the  mosquito  as  the  intermediate 
host  of  yellow  fever,  but  considers  that  the  disease 
can  be  communicated  directly  by  the  mosquito  to  man. 
He  argues  by  the  process  of  exclusion  that  the  malady 
is  not  infectious  by  direct  contact,  by  the  inhalation 
of  the  emanations  of  a  sick  person,  or  by  the  use  of 
contaminated  food  or  drink.  Therefore  Dr.  Finlay 
contends  that  the  yellow-fever  germ  is  pathogenic  only 
when  introduced  in  a  less  trivial  manner,  probably  by 
inoculation  under  the  epidermis  or  even  directly  into 
a  blood-vessel. 

After  the  facts  brought  to  light  by  Dr.  T.  H.  Smith 
.IS  regards  the  transmission  of  Texas  fever  by  means 
of  the  cattle  tick,  this  theory  was  to  a  certain  extent 
modified  so  as  to  include  the  important  circumstance 
tliat  the  faculty  of  transmitting  the  yellow-fever  germ 
need  not  be  limited  to  the  parent  insect,  directly  con- 
taminated by  stinging  a  yellow-fever  patient,  but  may 
be  likewise  inherited  by  the  next  generation  of  mos- 
quitos  descended  from  the  contaminated  parent. 


This,  in  short,  was  the  situation  with  respect  to  the 
mosquito-yellow-fever  question  at  the  time  when  the 
United  States  commission  began  its  investigations  in 
Havana.  The  commission  consisted  of  Dr.  Reed,  sur- 
geon U.S.A.,  and  Drs.  James  Carrol,  A.  Agramonte, 
and  Jesse  W.  Lazear,  acting  assistant  surgeons  U.S.A. 

The  conclusions  which  they  reached  were  made  the 
subject  of  a  paper  read  recently  before  the  Public 
Health  Association  at  its  last  meeting  in  Indian 
apolis,  Ind.  The  studies  were  divided  into  two  parts, 
the  first  of  which  dealt  strictly  with  the  bacteriology 
of  the  disease  and  the  second  with  the  role  that  the 
mosquito  plays  in  its  propagation. 

Summarized  the  conclusions  were  as  follows:  From 
the  first  part  of  the  studies:  (i)  The  blood  taken  dur- 
ing life  from  the  general  venous  circulation,  on  vari- 
ous days  of  the  disease,  in  eighteen  cases  of  yellow 
fever  successfully  studied,  has  given  negative  results 
as  regards  the  presence  of  bacillus  icteroides  (San- 
arelli).  (2)  Cultures  taken  from  the  blood  and  organs 
of  eleven  yellow-fever  cadavers  have  also  proved 
negative  as  regards  the  presence  of  this  bacillus.  (3) 
Bacillus  icteroides  (Sanarelli)  stands  in  no  causative 
relation  to  yellow  fever,  but  when  present  should  be 
considered  as  a  secondary  invader  in  this  disease. 
The  deductions  drawn  from  the  second  part  of  the 
studies  read  thus:  "The  mosquito  serves  as  the  inter- 
mediate host  for  the  parasite  of  yellow  fever,  and  it  is 
highly  probable  that  the  disease  is  only  propagated 
through  the  bite  of  this  insect." 

While  the  conclusions  relating  to  the  Sanarelli 
bacillus  make  a  part  of  the  record  they  cannot  be  re- 
garded as  in  any  way  convincing  when  we  take  into 
account  the  mass  of  testimony  to  the  contrary.  At 
best  the  observations  were  very  limited  in  extent  and 
can  carry  only  a  proportionate  amount  of  weight  to  the 
conlrary  view  of  a  very  generally  accepted  opinion. 

The  conclusions  of  the  second  part  are  far  more 
suggestive  and  interesting,  and  were  arrived  at  as  the 
result  of  eleven  experiments  upon  non-immune  human 
subjects  who  allowed  themselves  to  be  bitten  by  mos- 
quitos  which  had  been  previously  fed  upon  yellow- 
fever  patients.  Of  these  experiments  nine  results 
were  negative  and  two  positive.  In  one  of  these  two 
positive  cases,  other  sources  of  infection  were,  it  is 
stated,  clearly  excluded:  The  offending  mosquito, 
Culex  fasciatus  Fabr.,  was  also  isolated. 

The  commission  is  to  be  warmly  congratulated  upon 
the  work  is  has  done  thus  far,  but  is  it  not  claiming 
rather  too  much  to  assert  that  "  it  is  highly  probable 
that  the  disease  is  only  propagated  through  the  bite 
of  the  mosquito,"  especially  when  the  fact  is  taken 
into  consideration  that  the  case  mentioned  above 
is  the  only  one  in  which  a  typical  attack  of  yellow 
fever  has  followed  the  bite  of  an  infected  mosquito, 
all  other  sources  of  infection  having  been  excluded? 
The  theory,  of  course,  is  identical  with  that  of  placing 
upon  mosquitos  the  onus  of  spreading  malaria,  and  the 
Culex  fasciatus  Fabr.  may  be  proved  as  much  of  a 
sinner  as  its  brother  the  Anopheles. 

In  the  mean  time,  however,  it  will  be  judicious  to 
"hasten  slowly,''  as  well  as  to  bear  in  mind  that  yel- 
low fever  differs  widely  in   its  mode  of  outbreak  and 


698 


MEDICAL    RECORD. 


[November  3,  1900 


in  other  important  characteristics  from  malarial  fever, 
more  resembling  in  many  respects  the  bubonic  plague. 
This  much  concerning  yellow  fever  is  agreed  upon  by 
the  majority  of  investigators:  That  the  disease  is  not 
contagious  in  the  strict  sense  of  the  word,  but  tiiat  its 
micro-organisms  will  infect  certain  circumscribed 
areas  or  zones,  conveyed  thither  perhaps  byfomites; 
that  maritime  commerce  has  hitherto  been  the  prin- 
cipal means  of  its  dissemination ;  that  it  is  conveyed 
neither  by  food  nor  by  water,  but  by  aerial  diffusion; 
that  soil  has  no  apparent  influence  on  its  origin  or 
spread,  but  that  climate  undoubtedly  has. 

Dr.  A.  H.  Doty,  health  officer  of  the  port  of  New 
York,  in  an  article  in  the  North  American  Revieti.', 
1898,  sagely  remarks:  "Although  there  may  be  some 
doubt  as  to  what  are  the  climatic  conditions  necessary 
to  propagate  yellow  fever,  there  is  no  difference  of 
opinion  as  to  what  are  the  local  requirements.  1  refer 
to  filth  and  defective  drainage.  There  is  no  city  in 
the  world  to-day  where  yellow  fever  is  epidemic,  which 
does  not  afford  substantial  proof  of  this  truth.'" 

Inspector-General  Turnbull,  R.N.,  read  a  paper  on 
the  subject  of  yellow  fever  at  the  recent  meeting  of  the 
British  Medical  Association,  in  which  he  contended 
that  environment  was  the  immediate  cause  of  yellow 
fever,  and  that  whenever  improved  sanitation  supplant- 
ed a  wholly  unsanitary  state,  yellow  fever  disappeared. 
It  is  true  that  there  are  no  facts  known  with  regard  to 
yellow  fever  which  render  the  proposition  that  the 
malady  is  spread  by  the  mosquito  quite  tenable;  on 
the  contrary,  many  appear  to  be  unfavorable  to  such  a 
theory.  In  this  connection  it  must  be  remembered 
that  yellow  fever  in  a  given  district  is  not  always  co- 
incident with  the  existence  of  mosquitos.  In  the  epi- 
demic of  Jacksonville  in  18S8,  the  mosquito,  while 
present,  was  by  no  means  in  such  number  as  to  con- 
stitute a  pest.  McHenry,  Miss.,  in  1897,  was  almost 
free  from  the  insect,  as  was  likewise  the  case  in 
some  of  the  stricken  districts  of  Florida  in  1888.  .Al- 
though this  does  not  absolutely  disprove  the  new 
theory,  the  spread  of  the  disease  in  every  instance 
was  duly  explained  by  fomites  in  the  nature  of  bed- 
ding or  wearing-apparel  packed  in  an  epidemic 
centre. 

In  the  absence  of  any  new  facts  bearing  on  either 
side  of  the  question  at  issue,  therefore,  it  is  quite 
evident  at  this  stage  of  the  argument  that  the  whole 
matter  requires  a  great  deal  more  sifting  before  a 
definite  opinion  can  be  expressed.  In  conclusion  we 
wish  to  express  our  unstinted  admiration  of  the  noble 
and  unselfish  conduct  of  Drs.  Lazear  and  Carrol  in 
offering  themselves  as  subjects  for  experiment  for  the 
furtherance  of  science.  The  first-named  fell  a  martyr 
to  his  devotion,  but  his  name  will  be  duly  inscribed 
on  the  roll  of  fame  and  reverently  remembered  as  an 
enthusiast  who  risked  and  lost  his  life  that  humanity 
at  large  might  profit  tliereby. 


Two  Sets  of  Triplets Two  sisters,  twins,  married 

two  brothers,  also  twins,  less  than  a  year  ago  in  Hunt- 
ington, W.  Va.  On  the  same  afternoon  last  week  each 
sister  gave  birth  to  triplets. 


THE      CORRELATION      BETWEEN      SEXUAL 
FUNCTION,    INSANITY,    AND    CRIME. 

It  is  probable  that  no  part  of  the  body  is  without  re- 
lation to  all  other  parts,  and  that  disease  of  any  organ 
will  not  be  without  influence  upon  the  remaining  or- 
gans. Such  a  conception  is  justifiable  from  a  knowl- 
edge of  the  interrelation  of  function  and  from  a  belief 
in  the  production  of  internal  secretions.  The  symp- 
toms that  arise  in  the  sequence  of  removal  of  glandu- 
lar structures  believed  to  possess  such  internal  secre- 
tions are  principally  referable  to  the  nervous 
system,  and  they  have  been  most  conspicuously  ob- 
served in  connection  with  disease  or  destruction  of,  or 
operation  upon,  the  thyroid  gland,  the  uterus  and  ova- 
ries, and  the  pancreas.  Great  importance — too  much, 
we  are  inclined  to  think — has  always  been  attached  to 
the  onset  and  the  cessation  of,  as  well  as  abnormalities 
in,  the  processes  of  ovulation  and  menstruation  in  the 
development  of  various  morbid  manifestations,  al- 
though it  does  not  seem  impossible  that,  in  one  predis- 
posed to  mental  derangement,  such  conditions  may  act 
as  the  exciting  cause.  At  the  conclusion  of  a  paper 
on  the  correlation  between  sexual  function,  insanity, 
and  crime,  read  before  the  section  of  psychology  at 
the  recent  meeting  of  the  British  Medical  Association, 
Macnaughton-Jones  {British  Medicaljournal,  Septem- 
ber 22,  1900,  p.  789)  expressed  the  belief  that  func- 
tional disorders  of  ovulation  are  frequently  attended 
with  mental  aberration,  and  in  a  proportion  of  cases 
originate  the  mental  disturbance.  The  same  state- 
ment is  applicable  to  disorders  of  ovulation  dependent 
upon  pathological  causes.  He  held  that,  in  the  great 
majority  of  such  cases,  the  disturbance  is  of  a  neuras- 
thenic character  and  is  associated  with  various  vis- 
ceral or  other  neuroses,  while  in  only  a  small  propor- 
tion does  the  alienation  assume  so  grave  a  type  as 
melancholia,  mania,  or  dementia.  In  his  opinion, 
when  in  an  insane  person  ovulation  and  its  external 
manifestation,  the  menstrual  discharge,  are  erratic  or 
absent,  the  erraticism  or  absence  may  be  a  conse- 
quence of  the  general  and  insane  condition  and  not  a 
causal  factor  in  its  production;  but  under  any  circum- 
stances such  abnormal  menstruation  appears  to  have 
an  aggravating  effect  on  the  insanity,  and  there  is 
sufficient  evidence  to  support  the  view  that  when  such 
irregularity — especially  if  it  be  due  to  a  pathological 
cause — exists,  it  should  be  treated  therapeutically  or 
by  operative  measures.  It  was  thought  that  the  ques- 
tion of  a  gynecological  examination  of  an  insane  woman 
must  be  a  matter  for  the  discretion  of  the  psychologist, 
influence<!  by  the  gynnecological  view  as  to  its  expedi- 
ency from  the  signs  and  symptoms  present  in  the  sex- 
ual organs.  For  many  reasons  tiiis  is  not  advisable 
as  a  universal  practice  with  our  present  knowledge. 
It  was  pointed  out  that  suliicient  evidence  is  now  ad- 
vanced to  justify  the  removal  of  the  adnexa  or  the 
uterus  in  insane  women  when  there  are  gross  lesions 
of  the  former  or  tumors  of  the  latter.  Here  again 
such  operation  must  be  advised  in  accordance  with  the 
psychological  condition  of  the  patient  and  the  type  of 
her  insanity.  The  conclusion  was  reached  from  a 
mass  of  e\idence,  including  some  of  the  largest  experi- 


November  3,  1900] 


MEDICAL    RECORD. 


699 


ences  in  Europe,  Canada,  and  America,  that  in  health- 
fully minded  women  who  suffer  from  diseases  of  the 
genitalia  there  is  no  special  risk  of  post-operative  in- 
sanity: on  the  other  hand,  if  there  be  a  psychopathic 
predisposition  that  has  existed  prior  to  and  independ- 
ently of  the  sexual  disease,  there  is  in  such  cases  a 
larger  percentage  of  post-operative  mental  disturbance 
than  follows  other  operations.  In  such  women  the 
prudence  of  a  radical  operation  may  have  to  be  care- 
fully discussed.  'I'he  post-operative  mental  efifecl 
does  not  appear  generally  to  be  of  a  serious  or  per- 
manent nature.  It  may  be  generally  affirmed  that 
when  mental  disease  of  a  graver  type  follows  upon  sex- 
ual disorder,  there  has  been  in  the  woman  affected  an 
underlying  and  often  unrecognized  psychopathic  pre- 
disposition; the  disorder  of  menstruation  or  the  dis- 
ease in  the  genitalia  completing  the  chain  of  the  vi- 
cious circle  needful  for  the  final  manifestation  of  the 
mental  condition.  Finally  the  contention  was  made 
that  the  relation  of  aberrant  sexual  function  or  disor- 
der of  menstruation  to  any  criminal  act  ought  to  be 
taken  into  consideration  in  determining  the  responsi- 
bility of  the  woman. 


^nus   of  the  "Smccli. 

More  Army  Surgeons  Wanted. — In  his  annual  re- 
port to  the  Secretary  of  War,  Surgeon-General  Stern- 
berg says  that  the  present  medical  staff,  consisting  of 
one  hundred  and  ninety-two  surgeons,  is  insufficient 
for  the  needs  of  the  service  in  view  of  the  large  num- 
ber of  coast-defence  stations  and  the  troops  operating 
in  Cuba,  Porto  Rico,  Hawaii,  and  the  Philippines. 
The  contract  surgeons.  Dr.  Sternberg  says,  have  ren- 
dered excellent  service,  but  the  situation  demands  a 
permanent  increase  in  the  number  of  regularly  com- 
missioned surgeons. 

New  Site  for  the  Harvard  Medical  School. —  The 
old  Francis  estate  in  Brookline,  Mass.,  has  been  pur- 
chased, and  is  now  held  in  trust  as  the  proposed  future 
site  of  the  Harvard  Medical  School,  and  the  allied 
departments  of  veterinary  medicine  and  dentistry  will 
also  be  located  on  the  recently  acquired  land.  The 
school,  during  the  comparatively  short  period  of  its 
residence  in  the  present  building,  has  outgrown  its  ac- 
commodation, and  the  land  furthermore  is  desirable 
for  the  future  use  of  the  Boston  Public  Library,  which 
is  already  feeling  the  need  for  more  space.  An  ap- 
propriation for  the  School  of  Comparative  Medicine  has 
already  been  made  from  the  H.  L.  Pierce  bequest  to 
Harvard  University.  Space  is  furthermore  provided 
for  a  possible  University  Hospital.- — Boston  Meiikal 
and  Surgical  Journal. 

The  Descent    of  Man A   despatch    to    The    Sun 

from  Berlin  states  that,  at  the  recent  congress  of  Ger- 
man anthropologists  at  Halle,  Professor  Klaatsch,  of 
Heidelberg,  read  a  paper  contending  that  the  direct 
descent  of  man  from  apes  was  no  longer  maintainable. 
His  conclusion  was  based  on  the  construction  of  the 
biceps  muscle  of  the  thigh.  He  contended  that  it 
was  a  mistake  to  regard  man  as  the  most  perfectly  de- 


veloped mammal  in  all  respects.  His  limbs  and  teeth 
do  not  show  any  high  degree  of  development,  and  he 
is  superior  to  other  animals  only  in  his  extraordinary 
brain  development. 

A  Falling  Birth  Rate  in  Berlin — It  is  not  in 
France  only  that  the  birth  rate  is  declining,  for  some 
recently  published  oflicial  statistics  show  a  continuous 
decrease  in  the  Berlin  birth  rate,  which  is  now  only  29 
in  1,000.  The  number  of  children  born  during  the 
period  covered  by  the  statistics  was  450,000,  which,  if 
the  birth  rate  had  been  the  same  as  in  the  whole  of 
Prussia,  would  be  700,000. 

Students  of  Medicine  in  Italy. — During  the  ses- 
sion of  1899-1900  there  were  6,648  students  in  attend- 
ance at  the  medical  schools  of  the  numerous  Italian 
universities,  being  distributed  as  follows:  Naples, 
2,009;  Turin,  783;  Rome,  530;  Bologna,  504;  Pavia, 
496;  Genoa,  358;  Padua,  309;  Palermo,  270;  Flor- 
ence, 260;  Pisa,  218;  Modena,  152;  Catania,  167; 
Parma,  175;  Messina.  128;  Siena,  81;  Cagliari,  75; 
Sassari,  54;  Camerino,  35;   Perugia,  29;   Ferrara,  15. 

Raw-Meat  Cure  of  Tuberculosis An   institution 

was  opened  a  few  months  ago  in  Belgium  for  the  pur- 
pose of  carrying  out  Richet's  alleged  "cure"  for 
tuberculosis  by  an  exclusive  raw-meat  diet.  After  a 
trial  of  not  more  than  three  months,  the  experiment 
lias  been  abandoned,  those  in  charge  of  the  hospital 
asserting  that  there  was  no  efficacy  whatever  in  the 
method. 

An    American    Nuisance    in    London "Zionist" 

Dowie  has  been  lecturing  in  London  and  several  hun- 
dred medical  students  have  been  silly  enough  to  ad- 
vertise him  by  attending  his  meetings  and  creating  a 
disturbance.  At  one  of  the  meetings  he  told  the  noisy 
students  that  they  had  been  incited  to  make  a  disturb- 
ance by  their  teachers  who  feared  that  faith  healing 
would  ruin  their  practice.  .\t  the  next  meeting  the 
students  assembled  in  greater  force,  and  shouted,  sang 
songs,  blew  trumpets  and  whistles,  sounded  rattles, 
and  caused  a  great  uproar.  Dowie  summoned  the 
police,  who  ejected  three  of  the  disturbers.  This  in- 
censed their  comrades,  who  stormed  the  platform. 
Dowie  bolted  through  a  side  door.  Fifty  of  his  sup- 
porters met  the  rush  and  a  fierce  fight  ensued,  in 
which  sticks  were  used.  The  police  eventually  cleared 
the  hall. 

A  Convalescent  Hospital  in  the  Philippines. — It 
is  stated  in  Washington  that  plans  are  under  consider- 
ation for  the  establishment  of  a  first-class  sanatorium 
within  convenient  distance  of  Manila,  in  order  to 
place  that  city  on  the  same  footing  in  that  respect  as 
other  large  cities  in  the  Orient.  A  sanatorium  is  re- 
garded as  necessary  for  dwellers  in  the  tropics.  The 
place  selected  is  Beago  de  la  Trinidad,  about  four 
thousand  seven  hundred  feet  above  sea  level,  with  a 
salubrious  climate,  the  thermometer  never  rising 
above  75°  in  the  daytime  and  the  nights  being  cool 
and  exhilarating. 

New  York  State  Association  of  Railway  Sur- 
geons.— The  annual  meeting  of  this  association  will 
be  held  at  the  Academy  of  Medicine,  New  York  City, 


700 


MEDICAL    RECORD. 


[November  3,  1900 


on  Thursday,  November  15,  1900,  under  the  presi- 
dency of  Dr.  J.  L.  Elddy,  of  Olean.  The  secretary  is 
Dr.  C.  B.  Herrick,  of  Troy. 

The  Philadelphia  Medical  Club  on  October  26th 
tendered  a  reception  to  Dr.  Maurice  H.  Richardson, 
of  Boston. 

Dr.  S.  Baruch,  of  this  city,  has  been  awarded  a  sil- 
ver medal  and  a  diploma  at  the  Paris  Exposition  for 
his  plates  and  statistics  showing  work  done  in  provid- 
ing free  cleansing  baths  for  the  poor.  In  this  exhibit 
the  aim  was  to  show  the  sanitarians  of  the  world  that 
we  have  solved  in  America  the  problem  of  free  cleans- 
ing baths,  which  have  been  in  full  operation  in  Buffalo 
and  Chicago  for  several  years.  There  are  no  other 
free  cleansing  baths  in  the  world. 

The  Mississippi  Valley  Medical  Association  will 
hold  its  next  annual  meeting  at  Put-in  Bay,  Ohio,  on 
September  10,  11,  and  12,  190J.  The  officers  for  this 
meeting  will  be :  President,  Dr.  A.  H.  Cordier,  of  Kan- 
sas City,  Mo. ;  Vice-Presidents,  Drs.  C.  F.  McGahan,  of 
Aiken,  S.  C,  Charles  L.  Minor,  of  Asheville,  N.  C; 
Secretary,  Dr.  Henry  E.  Tuley,  of  Louisville,  Ky; 
T-easurer,  Dr.  Dudley  S.  Reynolds,  of  Louisville,  Ky. ; 
C'airman  of  Committee  oj  Arrangements,  Dr.  J.  C  Cul- 
bertson,  of  Cincinnat. 

The  Southern  Surgical  and  Gynaecological  Asso- 
ciation.— The  thirteenth  annual  meeting  of  this  asso- 
ciation will  be  held  in  Atlanta,  Ga.,  on  November 
i3tli,  14th,  and  15th,  under  the  presidency  of  Dr.  A. 
M.  Cartledge,  of  Louisville,  Ky.  The  secretary  is 
Dr.  VV.  E.  B.  Davis,  of  Birmingham,  Ala.  The  pro- 
gramme contains  forty  titles  of  papers  to  be  read. 

Dr.  Bulkley's  Lectures  on  Diseases  of  the  Skin. 

— The  third  course  of  clinical  lectures  on  diseases  of 
the  skin  will  be  given  by  Dr.  L.  Duncan  Bulkley  in  the 
out-patient  hall  of  the  New  York  Skin  and  Cancer 
Hospital,  Second  Avenue  and  Nineteenth  Street,  on 
Wednesday  afternoons,  commencing  November  7th. 
These  lectures,  the  previous  courses  of  which  have 
been  largely  attended,  are  free  to  all  members  of  the 
medical  profession. 

Philadelphia  Hospital. — The  Council's  committee 
on  charities  and  correction  has  recommended  favorably 
the  appropriation  of  $130,000  for  the  erection  of  new- 
buildings  as  additions  to  the  Philadelphia  Hospital,  as 
follows:  $50,000  for  enlarging  the  buildings  of  the 
insane  department;  $35,000  for  erecting  a  children's 
hospital;  $10,000  for  erecting  a  maternity  house;  and 
$35,000  for  erecting  a  building  for  the  treatment  of 
infectious  diseases. 

Pan-American  Medical  Congress.— The  third  Pan- 
American  Medical  Congress  will  be  held,  as  already 
announced,  in  Havana  on  December  26th,  27th,  28th, 
and  29th.  There  will  be  three  general  sessions.  At 
the  opening  session  in  the  Marti  'I'heatre  there  will  be 
present,  besides  the  congressists,  members  of  various 
scientific  bodies  and  other  invited  guests.  The  report 
of  the  secretary-general  will  be  read,  and  there  will 
follow  an  address  of  welcome  by  the  president  of  the 
congress.  There  will  also  be  an  address  by  Governor 
Wood,  and  two  scientific  addresses.     At  the  second 


general  session  there  will  be  four  scientific  addresses, 
one  by  a  Cuban  physician.  At  the  closing  session 
the  report  of  the  treasurer  will  be  read,  one  scientific 
address  will  be  presented,  brief  remarks  will  be  made 
by  the  representatives  of  several  countries,  and  the 
secretary-general  will  announce  the  place  chosen  for 
holding  the  fourth  congress.  The  section  meetings 
will  be  held  daily  from  8  to  1 1  a.,m.  and  from  3  to  5 
P.M.  The  dues  for  members  of  the  congress  will  be 
$10  in  gold.  Each  member  who  purposes  reading  a 
paper  is  requested  to  send  to  the  secretary  an  abstract, 
not  exceeding  three  hundred  words,  not  later  than 
November  15th.  It  is  thought  that  about  one  thou- 
sand physicians  will  attend.  Three  hundred  of  the 
delegates  will  be  Cubans.  A  large  number  will  come 
from  Mexico,  travelling  on  a  Mexican  warship.  Many 
American  physicians  are  expected.  The  executive 
committee  consists  of  Dr.  Juan  Santos  Fernandez, 
president;  Gustavo  Lopez,  vice-president;  Tomks  V. 
Coronado,  secretary;  Enrique  Acosta,  treasurer;  and 
Vicente  K.  Vald^s,  Jose  I.  Torralbas,  and  Edwardo 
F.  Pla.  The  address  of  the  secretary  is  Prado,  105, 
Havana,  Cuba. 

Pathological  Society  of  Philadelphia. — At  a  stated 
meeting  held  October  2Sth,  Dr.  Simon  presented  for 
Dr.  Hidago  Nagouchi  a  communication  on  the  "  Influ- 
ence of  Cold  upon  the  Plague  Bacillus,"  based  upon 
observations  made  during  midwinter  in  northern 
China.  It  was  found  that  even  quite  low  temperatures 
had  little  injurious  influence  upon  the  micro-organ- 
isms, which  are  much  more  susceptible  to  elevations 
above  the  optimum.  Dr.  James  F.  Schamberg  read  a 
paper  entitled  "  Pathology  of  the  Skin  in  Scarlet 
Fever,"  accompanied  by  an  exhibition  of  sections  and 
photographs  illustrative  of  the  lesions.  Dr.  L.  N. 
Boston  demonstrated  a  forceps  for  holding  micro- 
scopic slides.  Dr.  A.  O.  J.  Kelly  exhibited  organs 
from  a  case  of  acute  phosphorus  poisoning,  occurring 
in  a  young  child  that  had  swallowed  about  a  dozen 
match-heads.  The  viscera,  the  skin,  and  the  mucous 
membranes  were  the  seat  of  small  hemorrhages,  and 
the  liver  was  enlarged  and  fatty.  Dr.  A.  A.  Eshner 
exhibited  a  specimen  of  cerebral  hemorrhage,  an  ex- 
tensive extravasation  of  blood  having  taken  place  into 
the  basal  ganglia  and  being  visible  from  the  lateral 
ventricle.  Dr.  F.  A.  Packard  exhibited  anthracotic 
lungs  from  a  miner  who  had  presented  symptoms  of 
pulmonary  gangrene,  and  relief  from  which  appeared 
urgently  indicated.  An  incision  into  the  lung  was 
made  and  drainage  provided  for,  but  although  the 
local  condition  improved,  except  for  the  development 
of  cutaneous  emphysema,  the  patient  failed  to  rally 
and  apparently  died  from  toxa^mia  and  exhaustion. 
Post-mortem  examination  disclosed  a  bronchiectatic 
cavity  at  the  apex  of  the  right  lung,  with  a  gangren- 
ous cavity  in  the  lower  lobe. 

Philadelphia  County  Medical  Society.— At  a 
stated  meeting  held  October  24th,  Dr.  Arthur  Dare 
demonstrated  a  new  ha;nioglobinometer,  in  which  a 
thin  layer  of  undiluted  blood  is  compared  with  corre- 
sponding standardized  color  discs.  Dr.  Henry  W. 
Stelwagon  gave   a    brief   account   of  a  visit    to  Pro- 


November  3,  1900] 


MEDICAL    RECORD. 


701 


fessor  Finsen's  light  institute  at  Copenhagen,  de- 
scribing the  treatment  of  lupus  by  means  of  natural 
and  artificial  light  concentrated  upon  the  disease  foci 
with  the  aid  of  lenses.  Daily  exposures  for  an  hour 
are  made,  but  the  treatment  must  be  continued  for  a 
long  time.  It  is  questionable  if  the  results  are  better 
than  they  would  be  if  the  same  attention  were  given  to 
details  in  tiie  application  of  other  remedial  measures. 
Dr.  Augustus  A.  Eshner  reported  some  anomalous 
cases  of  typhoid  fever,  one  unusually  severe,  one  ex- 
tremely mild,  two  with  hemorrhagic  tendencies,  one 
possibly  unatteiidetl  with  intestinal  ulceration,  one 
simulating  miliary  tuberculosis,  one  with  intercurrent 
malarial  fever  in  a  puerperal  woman,  one  associated 
with  pulmonary  tuberculosis  and  pneumonia,  and  one 
associated  with  syphilis  and  pulmonary  tuberculosis. 
Dr.  Norman  B.  Gwynn  read  a  paper  on  "The  Pres- 
ence of  Typhoid  Bacilli  in  the  Urine,  and  the  Disin- 
fection of  Such  Urine.''  After  reference  to  the 
relative  frequency  with  which  typhoid  bacilli  are 
found  in  the  urine  in  cases  of  typhoid  fever,  experi- 
ments were  detailed  showing  that  mercuric  chloride 
and  chlorinated  soda  are  the  best  disinfectants  for  the 
urine  after  it  is  voided.  Ammonium  formaldehyde 
may  be  employed  for  the  purposes  of  sterilizing  the 
urine  in  the  genito-urinary  tract. 

Insanity  among  the  Troops  in  the  Philippines. 
— In  his  annual  report  to  the  Secretary  of  War,  Sur- 
geon-General Sternberg  says  regarding  insanity  among 
the  troops :  "  In  the  army,  regulars  and  volunteers,  dur- 
ing the  calendar  years  1898  and  1899,  there  were  re- 
ported on  the  monthly  reports  of  sick  and  wounded  347 
cases  of  insanity,  and  202  of  these  cases,  or  58.2  per 
cent.,  were  committed  to  the  government  hospital  for 
the  insane.  One  hundred  and  thirty-five  cases,  or  66.7 
per  cent,  of  the  commitments,  recovered  in  an  average 
period  of  3.9  months,  13  were  improved,  6  died,  and 
48  remained  unimproved.  Ninety-six  of  the  347  cases 
were  reported  on  the  monthly  reports  of  troops  serving 
in  the  Pacific  islands,  and  32  of  these,  or  33.3  per 
cent.,  were  sent  to  the  government  hospital  for  the  in- 
sane. Seventeen  cases,  or  53.1  per  cent,  of  those 
committed,  recovered  in  an  average  of  3.6  month.s,  2 
were  improved,  2  died,  and  1 1  remained  not  improved." 

Suing  for  Expert  Fees.— Dr.  R.  A.  Witthaus, 
whose  bill  for  $18,550  for  examining  the  stomachs  of 
Mrs.  Katherine  J.  .\dams  and  Henry  C.  Barnett,  under 
direction  of  the  district  attorney,  in  the  Molineux 
case,  was  not  paid  on  account  of  the  small  amount  in 
the  sinking-fund,  will  sue  the  city  to  recover  the  full 
amount  of  his  bill. 

Dr.  Leopold  Javal,  tlie  eminent  French  ophthal- 
mologist, wlio  has  just  been  made  officer  of  the  Legion 
of  Honor,  recently  lost  his  sight  as  the  result  of  glau- 
coma. He  began  his  career  as  a  mining  engineer, 
but  having  undertaken  the  translation  of  Helmholtz's 
"Optical  Physiology,"  he  was  so  much  interested  that 
he  studied  medicine  and  took  up  ophthalmology  as  a 
specialty.  Some  years  ago  he  was  elected  member  of 
the  Chamber  of  Deputies,  and  was  instrumental  in 
passing  the  "Seven  Children  Law,"  which  exempts 
from  taxation  the  parents  of  families  of  not  less  than 


that  number.  Me  now  devotes  his  attention  to  the 
improvement  of  the  means  of  enabling  the  blind  to 
read  and  write.  — 7X/<?  Medical  Press  and  Circular. 

The  Flushing  HospitaL — The  trustees  of  this  hos- 
pital have  issued  a  statement  to  the  effect  that  the  in- 
stitution may  be  obliged  to  close  its  doois  because  of 
lack  of  funds.  Tlie  city  gives  the  hospital  f6,ooo 
and  it  has  an  income  of  $3,000  from  pay  patients,  but 
the  expenses  are  about  f  14,000. 

Obituary  Notes. — Dk.  Moses  C.  White,  of  New 
Haven,  Conn.,  died  at  his  home  in  that  city  on  Octo- 
ber 24th,  at  the  age  of  eighty-one  years.  He  was  born 
in  Paris,  Oneida  Co.,  N.  Y.  He  first  studied  for  the 
ministry  and  was  for  several  years  a  missionary  in 
China.  He  then  studied  medicine  and  was  graduated 
from  the  Yale  Medical  School  in  1854.  He  was  for 
many  years  pathologist  to  the  State  Hospital,  and  was 
a  member  of  the  faculty  of  the  Yale  Medical  School. 
Two  sons,  one  a  physician,  Dr.  Caryl  S.  White,  sur- 
vive him. 

Dk.  William  Arthur  Zabriskie  died  at  his  home 
in  this  city  on  October  27th  from  fracture  of  the  skull 
received  by  falling  and  striking  his  head  on  the  side- 
walk. He  was  forty-two  years  of  age,  and  was  gradu- 
ated from  the  College  of  Physicians  and  Surgeons  in 
1882. 

Dr.  William  J.  Nelson,  of  Middletown,  N.  Y., 
died  on  October  26th  at  the  age  of  forty  years.  His 
death  was  indirectly  due  to  an  injury  to  the  spine 
received  w^hile  a  student  at  college,  when  a  fellow- 
student  cut  a  rope  from  the  hammock  in  which  Dr. 
Nelson  was  swinging,  throwing  him  to  the  ground. 

Dr.  Edward  Addison  Hervey,  of  Rossville,  Bor- 
ough of  Richmond,  died  on  October  26th  in  his 
seventy-seventh  year.  He  was  born  in  South  Dur- 
ham, N.  Y.,  on  January  24,  1824,  and  was  graduated 
from  the  University  Medical  College  in  this  city  in 
the  class  of  1859,  receiving  the  Elliot  prize  for  pro- 
ficiency in  anatomy. 

Dr.  Edward  Robinson  Squibb,  of  Brooklyn,  died 
on  October  26th  of  cardiac  trouble  after  a  short  ill- 
ness, at  the  age  of  eighty-one  years.  He  was  born  in 
Wilmington,  Del.,  and  was  graduated  from  the  Jeffer- 
son Medical  College,  Philadelphia,  in  1844.  He  en- 
tered the  naval  medical  service,  and  was  surgeon  in 
charge  of  the  Brooklyn  navy  yard  when  the  Civil  War 
began.  About  this  time  he  resigned  from  the  navy 
and  because  a  manufacturing  chemist.  He  retired 
from  active  business  about  fifteen  years  ago.  He  was 
a  member  of  the  American  Medical  Association,  the 
New  York  State  Medical  Association,  the  Kings 
County  Medical  Society,  the  Metropolitan  Museum  of 
Art,  and  the  Philosophical  Society  of  Philadelphia. 
A  widow,  daughter,  and  two  sons,  one  of  whom  is 
Dr.  Edward  H.  Squibb,  of  Brooklyn,  survive  him. 

Dr.  Laurence  Turnbull  died  at  Philadelphia  on 
October  24th,  at  the  age  of  seventy-nine  years.  He 
was  a  native  of  Scotland,  coming  to  this  country  at  the 
age  of  twelve  years.  He  was  a  graduate  in  pharmacy, 
and  in  1845  was  graduated  from  Jefferson  Medical  Col- 
lege. He  served  as  resident  physician  in  the  Phila- 
delphia  Hospital,  and  was  for  thirty  years  prior  to 


702 


MEDICAL    RECORD. 


[November  3,  1900 


1887  one  of  the  physicians  to  the  Western  Clinical 
Infirmary  and  Howard  Hospital,  subsequently  becom- 
ing a  manager  of  this  institution.  He  was  in  1877 
made  aural  surgeon  to  Jefferson  Medical  College  Hos- 
pital. He  was  the  first  surgeon  in  the  United  States 
to  trephine  the  mastoid  for  ear  disease.  He  was  the 
author  of  a  "  Manual  of  Anaesthetic  Agents  and  their 
Employment  in  the  Treatment  of  Disease,"  and  of  a 
"Clinical  Manual  of  Diseases  of  the  Ear." 

Dr.  George  A.  Muehleck  died  at  Philadelphia  on 
October  25th  of  typhoid  fever,  at  the  age  of  forty  years. 
He  was  a  graduate  in  classics  of  the  University  of 
Tiibingen  and  in  medicine  of  the  University  of  Hei- 
delberg. He  was  a  member  of  numerous  medical 
societies,  and  pathologist  to  St.  Agnes  Hospital. 

Dr.  Alexander  H.  Johxson,  of  Newark,  N.  J., 
died  suddenly  at  Indianapolis  while  in  attendance 
upon  the  meeting  of  the  American  Public  Health  As- 
sociation. He  was  a  member  of  the  Newark  board  of 
health. 


progress  of  ^cjcXical  Science. 

Bos/on  Mi-iiua/  and  Surgidil  Journal.  October  3j,  /goo. 

Physiological  Dilatation  and  the  Mitral  Sphincter  as  Fac- 
tors in  Functional  and  Organic  Disturbances  of  the  Heart.— 

Morton  Prince  says  that  whenever  the  heart  is  obliged  to 
do  an  increased  amount  of  work,  whether  this  be  due  to 
increased  stimulation  of  the  heart  or  to  increase  of  the  re- 
sistance against  which  the  blood  is  thrown,  the  heart  phys- 
iologically dilates.  This  dilatation  within  normal  limits 
may  be  so  great  that  the  volume  of  the  blood  thrown  out  at 
each  contraction  may  be  trebled  or  quadrupled.  At  the 
end  of  systole  the  heart  may  be  larger  than  it  was  before  at 
the  end  of  diastole.  The  sphincters  may  be  so  dilated  that 
the  valves  cannot  close  the  auriculo-ventricular  orifices,  and 
thus  physiological  regurgitation  may  result.  Normally 
this  is  observed  under  nervous  e.xcitement  and  severe 
physical  exercise.  The  same  law  of  necessity  applies  to 
diseased  hearts  as  to  healthy  hearts,  and,  for  example,  the 
dilatation  observed  in  aortic  stenosis  may  be  physiological 
rather  than  pathological.  In  general  systemic  condi- 
tions, such  as  the  febrile  diseases,  ansemia,  Bright's  dis- 
ease, etc.,  the  dilatation  and  regurgitation  are  of  the  same 
sort,  due  either  to  an  absolute  increase  of  resistance  or  to  a 
relative  increase;  in  the  latter  case  because  of  a  weakened 
heart  working  against  normal  resistance.  Unless  this  is 
recognized  there  is  great  danger  of  confusing  this  purely 
physiological  condition,  which  probably  exists  in  a  great 
many  such  cases  with  serious  cardiac  disease,  and  in  con- 
sequence giving  an  unfavorable  prognosis. 

Congenital  Dislocation  of  the  Hip  Joint.— E.  H.  Bradford, 
discussing  the  various  procedures  for  the  cure  of  this  condi- 
tion, says  that  it  is  manifest  that  for  the  best  result  as  lit- 
tle injury  as  possilile  should  be  done  to  the  tissues.  Little  is 
inflicted  if  the  following  procedure  be  carried  out:  An 
incision  is  made  along  the  outer  and  anterior  edge  of  the 
femur,  reaching  from  above  the  greater  trochanter  to  two 
inches  below  the  lesser  trochanter.  The  upper  portion 
should  be  curved  slightly  ujjward  so  as  to  uncover  the  liead 
and  neck  of  the  dislocated  femur.  The  tensor  vaginae  and 
gluteus  medius  muscles  are  separated.  When  the  femur 
is  reached,  the  femoral  insertion  of  the  rectus  is  pushed 
aside,  and  the  attachments  of  the  psoas  and  iliacus  are 
pushed  away  by  a  ])eriosteum  elevator.  The  capsule  is 
then  opened  and  cut  across,  first  on  the  head,  in  the  line 
of  the  axis  of  the  neck,  and  then  from  the  neck  downward 
toward  the  acetabulum  in  front  and  behind.  The  finger  is 
inserted,  the  acetabulum  expo.sed.  and  the  size  of  the  cap- 
sular neck  estimated.  The  capsular  insertion  on  the  fe- 
mur is  then  enlirely  cut  away,  as  well  as  the  ligamentuni 
teres,  and  the  head  of  the  femur  pulled  aside.  Tliis  should 
be  placed  in  the  acetabulum  and  the  incised  capsule 
stretched  around  the  neck  and  secured  by  catgut  sutures 
to  the  cut  tissues  around  the  neck,  or  to  the  opposing  parts 
of  the  cut  capsules. 

A  Case  of  Contracting  Scar  of  the  Palm  of  the  Hand  Rem- 
ediad  by  a  Flap  from  the  Abdomen. — F.  M.  Briggs  reports 
a  case  in  which,  following  laceration  and  burning,  the 
entire  palmar  surface  of   a  woman's  left  hand  was  com- 


posed of  cicatrix.  The  author  describes  the  operation  by 
means  of  which  a  new  palm  was  created  by  a  flap  from  the 
abdomen.  The  result  is  wholly  satisfactory.  The  skin  of 
the  new  palm  is  .soft  and  pliable,  and  is  fully  doing  its 
work.  The  operation  not  only  has  substituted  good  skin 
for  weak  cicatrix,  but  has  restored  the  function  of  the  use- 
less hand.  Taking  such  a  flap  from  the  abdominal  wall 
insures  good  nutrition,  provided  a  long  base  line  is  left  for 
the  pedicle,  and  the  skin  giafted  in  the  manner  described 
makes  an  excellent  substitute  for  the  original  skin.  The 
author  believes  this  to  be  the  first  case  in  which  this  particu- 
lar method  of  plastic  work  has  ever  been  attemiitcd  in  the 
treatment  ot  such  a  defect. 

Removal  of  the  Greater  Part  of  Stomach  for  Carcinoma ; 
Closure  of  the  Pyloric  End  ;  Anastomosis  between  Jejunum 
and  Cardiac  End  ;  Recovery.— By  \V.  A.  Brooks.  Jr. 

Autopsies  and  Physical  Examinations. —  By  District-Attor- 
ney R.  O.  Ihirns,  East  Bridgewater,  Mass. 

The  Coroner  System  in  the  United  States  at  the  Close  o£ 
the  Nineteenth  Century.— By  S.  \V.  Abbott. 

MetiUa/  Acuis,  October  21,  /goo. 
Repairing  the  Abdominal  Wall  in  Ventral  Hernia. — Carl 
Beck  describes  his  operation  on  a  ventral  hernia  in  the 
scar  of  an  appendicular  incision.  The  scar  was  incised 
and  the  peritoneum  exposed.  After  the  few  adhesions 
were  disposed  of  and  the  difiierent  abdominal  layers  care- 
fully denuded,  an  appro.xiniation  of  the  muscular  tissues 
was  found  to  be  impossible.  Consequently,  the  rectus  was 
incised  alongside  its  internal  margin  to  the  extent  of  nearly 
half  its  thickness.  Two  transverse  incisions  connecting 
the  outer  and  inner  margins  of  the  muscle  and  extending 
down  the  substance  of  the  muscle  to  the  same  extent,  the 
lower  one  being  as  near  Poupart's  ligament  as  possible, 
and  the  other  one  below  the  umbilicus,  completed  the  out- 
lining of  the  flap,  which  was  carefully  lifted.  Beginning 
at  the  internal  marking  of  the  incision,  the  upper  layer  of 
fibres  of  the  rectus  was  also  divided,  until  the  flap  so 
formed  could  be  lifted  near  the  outer  margin,  with  which 
it  remained  connected  in  the  manner  of  a  hinge.  The  re- 
verted flap  was  now  fastened  to  the  muscular  remnant  with 
iodoform-silk  sutures.  The  ties  uniting  the  fascia  con- 
sisted of  formalin-catgut,  which  was  also  selected  for  the 
subcutaneous  suture.  Four  relaxation  sutures  were  ap- 
plied through  the  skin  three-quarters  of  an  inch  from  the 
wound-margin,  so  that  there  was  no  direct  contact  with  the 
wound-line.  Recovery  was  uninterrupted.  Two  months 
after  the  operation  no  protrusion  occurred  while  the  intra- 
abdominal pressure  was  increased  by  the  eff'orts  of  cough- 
ing. 

A  Plea  for  More  Frequent  Avoidance  of  Exsection  of  the 
Ovaries  in  Connection  with  Operations  upon  Diseased  Tubes. 
— Philander  A.  Harris  states  that  less  than  three  years 
ago  he  abandoned  the  routine  jjraclice  of  removing  the 
ovaries  with  their  diseased  tubes.  He  spares  as  nuich 
ovarian  tissue  as  possible.  He  remembers  but  two  in- 
stances in  which  a  surgical  menopause  followed  double- 
tube  amputation  or  excision  during  this  time.  To  the 
woman  of  respectability,  the  knowledge  that  she  is  not  as 
other  women  are  will  be  a  strong  factor  in  causing  her  uu- 
happiness.  The  writer  believes  that  sufficient  ovarian 
stroma  maybe  .saved  to  maintain  menstruation  and  ovula- 
tion in  at  least  ninety  per  cent,  of  all  the  bilateral  tubal 
amputations  and  exsections  for  the  so-called  purely  inflam- 
matory lesions  of  and  ])rimarily  in  the  tubes,  and  that  a 
cure  of  pelvic  pains  does  not  depend  on  the  removal  of  the 
ovaries,  but  on  a  removal  of  the  disease  from  the  Fallopian 
and  uterine  sinuses.  A  woman  with  sufficient  ovarian 
stroma  for  menstruation  and  ovulati<m,  but  with  one  tube 
exsected  and  the  other  amputated,  is  not  likely  to  con- 
ceive.    Still  pregnancy  is  possible  in  her  case. 

The  City  and  its  Consumptive  Poor :  A  Plea  for  a  Muni- 
cipal Sanatorium  Outside  of  the  Corporate  Limits. — By  Al- 
fred Meyer. 

Present  Status  of  Interstate  Reciprocity  Concerning  Li- 
censes to  Practise  Medicine. —  By  Eniil  Ambeig. 

The  Importance  of  Rest  in  Pulmonary  Tuberculosis.  — By 
Carroll  E.  Edson. 

New  York  Medical  Journal,  October  sy,  iqoo. 

"  Thimbles  "  for  Massage  and  Stripping  of  the  Seminal 
Vesicles.— J.  R.  Eastman  thus  describes  an  instruiiKiil  he 
has  devised  and  the  method  of  its  employment  ■  The  thim 
bles  imitate  m  shape  the  slightly  bent  fin.ger,  and  are  of 
nickel-plated  brass  three  inches  long,  thus  adding  about 
an  inch  and  three-quarters  to  the  length  of  the  massa.ging 
fingers.  The  distal  end  is  broadened  to  the  width  of  an 
inch  and  swells  rather  flatly  in  its  full  breadth  from  the 
jialmar  surface.  The  patient  stands  with  knees  straight 
and  bodyslightly  bent  forward  at  right  angles,  and  the  in- 
strument is  introduced  with  the  palmar  surface  of  the  enter- 
ing finger  iqiward.  the  concavity  of  the  thimble  toward  the 


November  3,  1900] 


MEDICAL    Ri:CORD. 


70^ 


sacrum.  When  the  inslrument  has  been  gently  introduced 
as  far  as  possible,  the  perineal  muscles  having  become  re- 
laxed, the  ringer  and  thimble  should  lie  so  turned  that  the 
palmar  surface  of  the  tinger  faces  the  bladder.  The  broad- 
ened and  projecting  anterior  face  of  the  distal  end  of  the 
thimble  will  now  rest  high  up  on  the  body  of  the  vesicle  or 
above  it.  While  gentle  pressure  is  maintained,  the  thim- 
ble should  be  drawn  slowly  forward  along  the  line  of  the 
vesicle  with  counter-pressure  over  the  abdomen.  By  pas.s- 
ing  the  instrument  successively  backward  and  forward,  the 
vesicle  may  be  thoroughly  emptied. 

Disturbances  of  Gastric  Motility  and  their  Significance. — 
Eleven  cases  of  gastric  disease  are  brielly  reported  by  A. 
Macfarlane,  in  order  to  emphasize  the  importance  of  motor 
disturbances;  three  are  cases  of  carcinoma,  one  involving 
tlie  pylorus,  two  affecting  the  lesser  curvature  ;  three  are 
cases  of  pyloric  stenosis  after  ulcer  ;  four  are  cases  of  gas- 
tro-neuroses  :  and  one  is  a  case  of  perigastritis  with  pyloric 
stenosis  due  to  carcinoma.  If  reliance  had  been  placed 
upon  the  chemical  e.xamination  alone,  it  would  have  been 
impossible  to  make  a  diagnosis,  because  the  same  varia- 
tions in  the  secretion  of  hydrochloric  acid  were  present 
equally  in  the  carciuomata  and  in  the  neuroses.  When  the 
motility  is  considered,  it  is  seen  that  all  the  organic  lesions 
were  markedly  affected,  while  the  neuroses  showed  no  dis- 
turbance. 

A  Case  of  Total  Eventration. — Report  of  a  case  by  C.  G. 
Schmidt.  The  cliild  was  born  by  the  aid  of  forceps.  The 
viscera  were  covered  only  by  peritoneum  as  a  protection, 
through  wliich  tliey  could  be  plainly  seen.  The  child  was 
seized  with  peritonitis  and  died  on  the  fourth  day. 

Effects  on  Digestion  of  Food  Prepared  by  the  Use  of  an 
Alum  Baking  Powder. — By  K.  E.  Smith. 

Supplementary  Report  on  a  Recurrent  Tonsillar  Tumor. — 
By  R.  1'.  Lincoln. 

The  Suture  and  the  Value  of  Dry  Sterilized  Catgut. — By 
J.  H.  Carstens. 

Labor,  lacluding  the  Use  of  the  Forceps.— By  Austin 
Flint,  Jr. 

Fractures  of  the  Nose. — By  Thomas  Amory  DeBlois. 

Journal  of  the  ^Imerican  Medical  Ass' n,  Oct.  ^7,  igoo. 

Laryngeal  Stenosis  due  to  Complication  of  the  Thyroid 
Cartilages. — Emil  Mayer  reports  at  length  the  case  of  a 
soidier  who  was  struck  on  the  right  frontal  bone  by  a  Mau- 
ser bullet,  which  went  through  the  superior  ma.xilia  down- 
ward and  backward,  cut  through  the  posterior  portion  of 
the  soft  palate,  and  entered  the  neck.  Here  it  was  de- 
flected, probably  by  the  hyoid  bone,  and  entered  the  thy- 
roid cartilage,  thoroughly  comminuting  it,  cutting  into  the 
oesophageal  wall,  when,  being  spent,  it  dropped  into  the 
stonjach.  The  eye  had  not  been  injured.  Under  cocaine 
ana;sthesia,  attempts  were  maJe  to  pass  the  hard-rubber 
fenestrated  SchriJtter  tube  of  small  calibre.  These  were 
used  till  dilatation  occurred,  followed  by  an  attack  of 
coughing  by  which  a  mass  of  lymph  was  ejected.  A  large 
chink  resulted,  and  some  air  could  be  inspired,  ami  the  man 
was  able  to  speak  in  a  hoarse  but  strong  voice.  Larger-sized 
tubes  were  used,  and  finally  a  large-sized  O'Dwyertube 
was  inserted.  He  was  fed  by  means  of  the  stomach  tube. 
After  a  considerable  course  of  treatment,  tlic  writer  had 
a  tube  made  whose  head  was  as  low  as  possible,  with  no 
retaining  swell,  and  with  a  threaded  opening  for  a  screw 
piece,  and  finally  a  hollow  introducer.  Intubation  was 
then  simple.  The  patient  was  then  sent  away  for  change 
of  air.  His  condition  is  materially  improved,  and  ho  will, 
with  an  intubation  tube  that  permits  deglutition,  probably 
attain  eventually  a  perfect  cure. 

Gastro-Intestinal  Hamorrhage  in  the  New-Bom. — Edward 
H.  Small  reports  a  case  of  this  nature.  A  long  list  of  etio- 
logical factors  has  been  given  for  this  condition.  Many 
more  cases  occur  in  institutions  than  in  private  practice — 
pointing  to  an  infectious  nature.  Various  organisms  have 
been  found.  The  course  of  the  disease  is  very  definite, 
soon  ending  in  death  or  complete  recovery  ;  it  is  self-lim- 
ited ;  the  temperature  is  elevated;  iu  most  cases  it  is  a 
general  and  not  a  1  jcal  disease,  not  limited  to  one  spot. 
These  facts,  together  with  its  greater  prevalence  in  institu- 
tions and  the  bacteriological  findings,  all  point  to  its  infec- 
tious nature  and  suggest  its  relationship  to  the  acute  infec- 
tious diseases.  It  is  a  very  serious  disease  ;  the  mortality, 
according  to  a  number  of  authorities,  varies  from  thirty- 
five  to  seventy-nine  per  cent.  Various  lines  of  treatment 
have  been  recommended,  the  most  recent  being  the  use  of 
a  solution  of  gelatin,  both  by  mouth  and  by  the  rectum, 
with  a  favorable  result  in  one  case.  The  writer  found  his 
hypodermic  use  of  morphine  more  beneficial  than  anything 
else. 

Chronic  Inflammation  of  the  Tear  Passages. — Willis  O. 
Nance  states  that  lacrymal  disease  constitutes  from  two 
to  three  per  cent,  of  all  eye  cases.     Females  are  more  lia- 


ble to  the  affection  than  males.  The  disease  occurs  at  all 
ages.  Chronic  inflammation  of  the  lacrymal  sac  some- 
times occurs  as  a  sequel  of  smallpo.x,  measles,  and  scarlet 
fever.  Syphilis,  by  necrotic  inroads  of  the  bony  canal, 
may  cause  an  attack  of  dacryocystitis  by  mechanical  ob- 
struction of  the  passages.  The  treatment  should  be  di- 
rected (I)  toward  the  removal  of  pathological  processes 
and  malformations  of  the  nasal  chamber ;  (2)  toward  the 
restoration  of  the  patency  of  the  i)as  ages  ;  (3)  toward  the 
alleviation  of  all  the  factors  conducive  to  the  production 
of  ocular  irritation  ;  (4)  towanl  the  proper  correction  of 
any  existent  dy.scrasia. 

Papillomata  of  the  Larynx  in  Children. — Edward  T.  Dick- 
erman  concludes  that :  (i)  Papilloma  of  the  larynx  is,  es- 
pecially in  this  country,  a  rare  disease.  (2)  In  a  number 
of  cases  they  undergo  spontaneous  cure.  (3)  Intralaryn- 
geal  methods  should  always  be  tried  first,  unless  dyspnoea 
is  pronounced,  when  traclieotomy  should  be  done  at  once. 
(4)  After  tracheotomy,  inlralaryngeal  methods  should  be 
tried.  (5)  The  patient  should  wear  a  tube  for  six  months 
after  the  growth  has  disappeared.  (6)  Thyrotoray  should 
be  considered  only  as  a  last  resort. 

The  Reciprocal  Relations  between  Consumptives  and  Soci- 
ety.—  By  S.  C  Bonney. 

Case  of  Fatal  Foetal  Ichthyosis.  —  By  Annie  Sturgis  Dan- 
iel an<l  Louise  Cordes. 

How  Shall  We  Induce  Immunity  in  Tuberculosis?— Bv  H. 
B.  Weaver. 

Unusual  Papillomatous  Growth  in  the  Larynx.— By  Joseph 
S.  Gibb. 

A  Few  Points  on  Appendicitis.— By  J.  Henry  Barbat. 

The  Serums  in  Tuberculosis. — By  Paul  Paquin. 

I'hiladetpliia  Medical  Journal,  October  3-j,  igoo. 

The  Etiology  of  Yellow  Fever :  A  Preliminary  Note. — 
Walter  Reed,  James  Carroll.  A.  Agramonlc,  and  Jesse  W. 
Lazear,  from  their  study  01  yellow  fever,  conclude  that :  (i) 
The  blood  taken  during  life  from  the  general  venous  circu- 
lation, on  various  days  of  the  disease,  in  eighteen  cases  of 
yellow  fever,  successively  studied,  has  given  negative  re- 
sults as  regards  the  jireseiice  of  bacillus  icteroides.  (2) 
Cultures  taken  from  the  blood  and  organs  of  eleven  yel- 
low-fever cadavers  have  also  proved  negative  as  regards 
the  presence  of  this  bacillus.  (3)  Bacillus  icteroides  (San- 
arelii)  stands  in  no  causative  relation  to  yellow  fever,  but 
when  present  should  be  considered  as  a  secondary  invader 
in  this  disease.  From  the  second  jiart  of  their  study  they 
conclude  that  (4)  The  mosquito  serves  as  the  intermediate 
host  for  the  parasite  of  yellow  fever,  and  it  is  highly  prob- 
able that  the  disease  is  only  propagated  through  the  bite 
of  tliis  insect. 

The  Inter-Relationship  between  Cardio-Vascular  Disease 
and  Renal  Disease  with  Particular  Reference  to  the  Diagno- 
sis and  Treatment. — By  Aloysius  ().  J.  Kelly. 

Restitution  of  the  Continuity  of  the  Tibia  by  Transplan- 
tation of  the  Patella  into  an  Extensive  Osteomyelitic  Defect. 
—  By  X.  Senn  (illustrated  1 . 

The  Significance  of  Diacetic  Acid  in  the  Urine. — By  C.  K, 
Johnson. 

A  Case  of  Progressive  Pernicious  Anaemia.— By  L.  M.  Van 
Meter. 

T he  Lancet,  October  20,  /qoo. 

The  Treatment  of  Severe  Cases  of  Diphtheria  with  Saline 
Infusions. — E.  E.  Laslett  slates  that  in  the  acute  stage  sa- 
line infusions  are  employed  to  dilute  the  toxin  by  the  in- 
troduction into  the  system  of  an  additional  amount  of  fluid 
which  helps  also  to  flush  out  the  kidneys.  In  the  late 
stage  they  are  used  when  along  with  the  persistent  vomit- 
ing, nutrient  enemata  are  also  rejected.  Inasmuch  as  the 
fluids  of  the  body  are  thus  constantly  diminished,  the  blood 
must  become  more  viscid  and  the  action  of  the  heart  be  im- 
peded. Saline  infusions  tend  to  prevent  this  state  of  af- 
fairs. Laslett  used  two  teaspoonfuls  of  common  salt  to  the 
pint  of  water,  utilizing  as  a  site  of  injection  the  loose  skin 
below  and  outside  of  the  right  breast.  Gravity  was  the 
force  employed,  the  bag  being  held  about  three  feet  up. 
He  found  that  from  ten  to  fifteen  ounces  can  be  injected  in 
half  an  hour.  The  child  does  not  seem  to  mind  the  opera- 
tion at  all.  Fifteen  cases  are  reported.  The  only  safe 
conclusion  drawn  (seven  died,  but  the  type  was  severe)  is 
that  the  treatment  seemed  to  have  some  influence  in  di- 
minishing both  the  frequency  of  onset  of  symptoms  of 
heart  failure  and  their  severity  when  they  did  occur. 

The  Prophylaxis  of  Malaria  and  the  Destruction  of  Mos- 
quitos  in  the  Island  of  Asinara.  — By  C.  Fermi  and  D>'. 
Tonsini.  This  island  lies  olf  the  Italian  coast  and  is  u.sed 
as  a  colony  for  convicts.  The  authors  instituted  measures 
for  the  destruction  of  the  mosquito  in  the  larval  stage  by 
pouring  petroleum  over  all  the  stagnant  water  pools,  by 
destroying  the  adult  insects  in  the  convicts'  rooms  by  va- 


704 


MEDICAL    RECORD. 


[November  3,  1900 


rious  powders,  gases,  etc.,  and  by  protecting  the  inhabi- 
tants against  the  insect,  thoroughly  screening  and  disin- 
fecting them.  The  following  is  a  summary  of  the  results 
obtained:  (i)  The  anopheles  was  almost  never  found  in 
anv  of  the  dormitories,  and  the  culex  pipieus  was  much 
diminished  in  comparison  with  former  years.  (2)  No  case 
of  primary  malaria  originating  in  the  island  was  observed, 
for  of  the  nine  cases  which  occurred,  two  came  from  Castia- 
das,  one  from  Isili,  and  six  were  relapses.  In  the  preced- 
ing vear  there  had  been  ninety-nine  cases,  of  which  forty 
had  been  contracted  in  the  island. 

The  Clinical  Study  of  Heart  Disease. — Norman  Moore,  in 
a  Huntcrian  lecture,  <iiscusscs  the  significance  of  murmurs 
in  general,  and  the  differential  features  of  those  commonly 
met  in  clinical  practice.  He  finds  that  one  of  the  most  diffi- 
cult points  to  determine  in  relation  lo  the  physical  examina- 
tion of  the  heart  is  whether  or  no  there  is  an  adherent  peri- 
cardium. In  his  opinion  this  diagnosis  can  be  made  with 
absolute  certainty  in  only  one  case,  and  that  is  when  mitral 
stenosis  without  other  valvular  lesion  is  pressnt.  This 
form  of  valvular  disease  is  never  on  its  own  account  asso- 
ciated with  hypertrophy  of  the  left  ventricle.  If,  therefore, 
with  mitral  stenosis  the  left  ventricle  is  hypertrophied  and 
if  there  are  no  signs  of  chronic  interstitial  nephritis,  then 
the  liypertrophy  is  certain  to  be  due  to  an  adherent  peri- 
cardium. This  is  a  rare  association  of  changes,  and  in 
every  other  condition  the  diagnosis  of  adherent  pericar- 
dium is  beset  with  dirticulties. 

The  Value  of  Anti-Streptococcic  Serum. — G.  S.  Walton  re- 
ports two  cases,  Ijoth  resulting  in  recovery  ;  one  was  of  a 
puerperal  woman  and  the  other  of  a  child  with  a  gangre- 
nous throat  in  which  diphtheria  bacilli  were  present. 

A  Rare  Case  of  Fracture  of  the  Os  Calcis  by  Muscular 
Force. — By  R.  Thompson. 

Operation  v.  Truss  in  the  Inguinal  Hernia  of  Childhood. — 
By  R.  Hamilton  Russell. 

Three  Cases  of  Gastrotomy  for  Hsematemesis. — By  C.  \V. 
Mausell-Moullin. 

A  Case  of  Anthrax  ;  Excision  of  Pustule ;  Recovery. — By 
E.  C.  Bousfield. 

A  Point  in  the  Diagnosis  of  Aneurism  of  the  Aorta.— By 
W.  Broadbent. 

John  Locke  as  a  Physician. — Address  by  William  Osier. 

Brilish  Mediial Joinnal,  October  20,  tgoo. 

A  Clinical  Lecture  on  the  Prevention  of  Valvular  Disease  of 
the  Heart  in  Cases  of  Acute  Rheumatism. — Richard  Caton 
outlines  his  treatment  of  acute  rheumatism  as  follows ;  In 
the  first  place  the  rheumatism  is  stopped  as  soon  as  pos- 
sible and  all  aggravation  of  it  by  chills  prevented.  The 
patient  is  kept  absolutely  at  rest  in  bed,  clothed  from  head 
to  foot  in  a  warm  flannel  garment.  Salicylates  are  given 
in  full  dose,  often  with  alkalies,  and  cholagogues  in  such 
measure  as  to  cau.se  free  evacuations  but  no  diarrlura. 
The  diet  is  confined  to  milk  and  light  farinaceous  food  ;  no 
red  meat  is  given  for  a  long  time.  The  patient  is  kept  in 
bed  long  after  all  paiu  and  fever  are  gone,  for  while  the 
salicylate  treatment  removes  pain  and  fever  in  twenty-four 
or  forty-eight  hours,  it  does  not  remove  the  rheumatic  en- 
tity itself  in  less  than  two  or  three  weeks  of  steady  admin- 
istration. Out  of  many  hundreds  of  cases  the  writer  has 
had  only  about  fifteen  per  cent,  of  cardiac  troubles,  which 
is  a  low  average.  Even  with  this  treatment  there  will  be 
some  cases  of  cardiac  trouble,  and  of  course  it  often  hap- 
pens that  mischief  in  the  heart  has  begun  before  the  pa- 
tient has  presented  himself  for  treatment.  In  such  cases 
the  patient  must  be  kept  strictly  in  bed.  the  head  should 
not  be  raised,  and  no  excitement  be  allowed.  He  must 
have  the  most  perfect  physiological  repose  possible.  This 
will  make  the  longest  intervals  between  the  systoles,  and 
keep  down  blood  pressure  as  far  as  practicable.  Local 
help  should  be  given  to  nature  This  is  accomplished  by 
applying  small  blisters,  each  in  size  rather  larger  than  a 
shilling,  over  the  upper  part  of  the  chest  between  the  clav- 
icle and  the  nipple  on  either  side.  Only  one  blister  is  ap- 
plied at  a  time,  and  after  each  a  small  poultice  is  placed 
on  the  blistered  surface.  This  involves  practically  no 
pain.  The  principle  of  this  treatment  is  the  action  of  the 
blisters  on  the  cutaneous  nerves  and  the  resulting  stimu- 
lation of  the  trophic  nerves  of  the  affected  part.  This 
stimulation  of  trophic  and  vasomotor  nerves  results  in  ex- 
tra nutritive  and  reparative  activity,  and  restoration  takes 
place  which  without  such  aid  might  not  have  been  accom- 
I)lishe(I.  The  heart  is  in  s[)ecial  relation  with  the  first  four 
dorsal  intercostal  nerves — this  explaining  the  position  indi- 
cated for  application  of  the  blisters.  It  is  important  that 
all  inflammatory  exudation  should  be  absorbed  and  re- 
moved from  the  endocardium  and  valve  cusps  as  early  as 
possible.  The  iodides  and  mercury  are  used  for  this  pur- 
pose. Rheumatism  should  be  most  carefully  treated  in 
children. 


On  Oophorectomy  in  Cancer  of  the  Breast. — In  reviewing 
the  history  of  this  surgical  procedure.  Stanley  Boyd  re- 
fers to  Beat.son's  suggestion  in  iSy6,  that  the  removal  of 
both  ovaries  might  be  useful  in  the  treatment  of  inoperable 
cancer  of  the  breast,  reasoning  in  the  following  way:  In 
lactaticm  there  is  rapid  multiplication  of  mammary  epithe- 
lium, the  cells  undergoing  fatty  degeneration  as  fast  as 
they  are  formed  ;  they  llien  break  down,  fall  into  the  lu- 
miua  of  the  gland  acini,  and  come  away  in  the  milk.  In 
cancer  the  mammary  epithelium  also  multiplies  rapidly, 
but  instead  of  undergoing  fatty  degeneration  and  being 
cast  off,  it  distends  the  acini,  penetrates  into  the  lymph 
spaces  of  the  breast,  and  there  floating  in  a  nutrient  fluid 
it  continues  multiplying  and  forcing  its  way  onward  tow- 
ard the  lymphatic  glands.  Oc])horeclomy  in  the  cow  main- 
tains fatty  degeneration  of  the  epithelium  of  the  lactating 
breast,  and  Beatson  thought  it  might  induce  fatty  degen- 
eration of  the  epithelium  of  the  cancerous  breast.  Accept- 
ing menstruation  as  the  evidence  of  ovarian  activity,  he 
was  inclined  to  believe  that  the  cessation  of  lactation  was 
due  lo  the  re-establishment  of  the  influence  of  the  ovaries, 
wliich  influence  had  been  suspended  by  the  gravid  uterus, 
and  thus  removal  of  the  ovaries  resulted  in  the  indefinite 
continuance  of  lactation.  He  thought  it  possible  also  that 
cancer  of  the  mamma  might  actually  be  due  to  some  "ova- 
rian irritation  "  or  to  "some  defective  steps  in  the  cycle  of 
ovarian  changes,  "  and  that  their  rem<ival  might  bring  can- 
cerous cell-proliferation  to  a  standstill  or  induce  fatty 
degeneration  of  the  cells  as  in  lactation.  The  writer  pre- 
sents a  table  of  forty-one  cases.  He  also  knows  the  results 
in  thirteen  other  cases,  making  a  total  of  fifty-four.  Of 
these  fifty-four  cases,  nineteen  (thirty-five  per  cent.)  were 
more  or  less  markedly  benefited,  thirty-four  were  not  bene- 
fited, or  only  doubtfully  so,  and  one  resulted  in  death  from 
exhaustion.  He  believes  that  oophorectomy  should  be 
offered  in  cases  other  than  the  very  acute,  in  women  over 
forty,  with  no  visceral  or  bony  lesions,  iu  fair  condition, 
and  before  the  menopause.  In  extensive  primary  cases 
and  recurrences  as  much  as  possible  of  the  disease  should 
be  removed  ;  healing  should  be  attained,  lest  the  operation 
fail  in  its  object  and  malignant  ulceration  be  started.  Work 
must  still  be  experimental.  The  writer  believes  it  desira- 
ble to  amputate  arms  which  are  so  heavy  from  ctdema  that 
by  their  weight  they  prevent  the  patient  from  getting 
about — this,  of  course,  at  the  patient's  request. 

A  Well-Marked  Family  Predisposition  to  Various  Manifes- 
tations of  the  Rheumatic  State. — 11.  T.  Nixon  reports  the 
following  family  history  :  The  father  and  mother  had  not 
suffered  from  acute  rheumatism :  the  paternal  grandmother 
had  had  seven  attacks  of  this  disease  and  finally  died  from 
heart  disease.  As  to  the  children:  (i)  Male,  aged  twenty- 
five  years  ;  suffered  from  first  attack  at  age  of  fifteen,  and 
six  weeks  after  convalescence  had  a  second  attack ;  now 
has  mitral  stenosis  and  regurgitation.  (2)  Female,  aged 
twenty-two  years,  has  not  had  rheumatism.  (3)  Male,  died 
at  fifteen  from  acute  rheumatism  and  heart  disea.se  ;  was 
an  epileptic.  (4)  Female,  aged  seventeen  years  ;  firstattack 
at  fifteen  during  which  she  developed  mit'  al  regurgitation  ; 
she  was  in  bed  a  month  and  developed  chorea  at  once  on 
leaving  bed.  At  seventeen  a  second  attack  was  ushered 
in  by  tonsillitis.  During  this  attack  she  developed  peri- 
carditis, pleurisy,  aortic  stenosis,  and  regurgitation,  and 
later  subcutaneous  nodules  appeared  over  both  external 
malleoli.  (5)  Female,  aged  fifteen  years  ;  had  chorea  every 
spring  for  three  years  ;  the  fourth  year  an  attack  of  rheu- 
matism during  which  mitral  regurgitation  developed.  16) 
Female,  aged  twelve  years,  no  rheumatism,  but  chorea  at 
eleven,  and  now  has  mitral  stenosis.  (7)  Female,  aged 
ten  years  ;  had  acute  rheumatism  and  now  has  mitral  ste- 
nosis and  regurgitation.  (8)  Female,  aged  eight  years, 
has  not  had  acute  rheumatism.  Four  of  this  family  were 
attacked  by  this  disease  one  after  the  other  and  were  in 
bed  at  the  same  time.  The  writer  has  obtained  a  rheu- 
matic family  history  in  sixty-two  per  cent,  of  his  one  hun- 
dred and  three  cases. 

On  the  Resting  Position  of  Anopheles. — 1j.  W.  Sanibon 
and  G.  C.  Low  criticise  the  report  of  Mr.  Austen  in  regard 
to  the  position  taken  by  mosquitos  when  resting.  The 
writers  in  their  observarions  have  noted  that  the  Anopheles 
belonging  to  the  species  claviger  (Fabr.)  never  stand  on 
their  heads  but  rest  on  their  feet  with  the  posterior  part  of 
the  body  slightly  inclined  away  from  the  supjjort  on  which 
they  rest.  The  inclination  of  the  body  was  less  when  the 
insect  rested  on  its  three  pairs  of  legs,  and  formed  a -maxi- 
mum angle  of  about  45  when  it  poi.sed  on  the  two  first 
pairs  and  stretched  out  the  last  pair  free.  Both  Culex  and 
Anopheles  frequently  sit  with  the  last  pair  of  legs  lifted 
away  from  the  support.  But  while  the  legs  of  Anopheles 
claviger  stretch  out  with  the  tarsi  pointing  downward, 
those  of  the  various  species  of  Cule.x  observed  by  the  writ- 
ers presented  the  tarsi  curled  upward  iu  a  very  ch;iracter- 
istic  manner.  He  adds  that  it  is  evident  that  the  observa- 
tions made  by  Ross  and  Austen  in  Sierra  Leone  were  quite 


November  3,  1900] 


MEDICAL    RECORD. 


705 


correct,  but  tliat  they  erred  in  extending  to  tlie  whole  genus 
a  character  which  is  peculiar  to  a  few  species  which  they 
had  observed  only  in  Anopheles  costalis.  Although  the 
resting  attitude  of  mosquitos  is  not  important  in  the  diag- 
nosis between  the  Culex  and  Anopheles  genera,  it  will  al- 
ways be  valuable  in  the  differentiation  of  species. 

Four  Cases  of  Recurrent  Mammary  Carcinoma  Treated  by 
Oophorectomy  and  Thyroid  Extract. — ("i.  Knust  Hcnnati  re- 
fers to  the  reports  of  two  cases,  and  gives  the  history  ol  the 
last  two  cases  of  this  nature,  lienetit  was  experienced  in 
each  instance.  After  referring  to  Boyd's  table,  in  which 
seventeen  cases  seemed  to  have  been  favorably  intluenced 
by  the  operation,  he  adds  that  twelve  of  these  patients  had 
been  given  thyroid  extract.  Twenty-one  cases  were  not 
benefited  and  only  Hve  of  these  had  had  thyroid.  This 
would  point  to  the  extrsict  as  being  concerned  in  the  result. 
He  believes  that  the  fact  that  benefit  does  follow  the  com- 
bination of  oophorectomy  and  thyroid  extract  should  first 
be  establislied  and  later  the  cases  be  <letined  in  whicli  ben- 
efit might  Ije  expected.  Then  it  can  bo  decided  what  share 
of  the  result  each  factor  in  the  treatment  is  entitled  to. 

Plastic  Operation  for  Inconti  icnti ;  Ani,  and  Some  Re- 
marks upon  the  Innervation  of  ti.e  Ivivsclts  which  are  Con- 
cerned in  the  Plastic  Operation  for  Sphincter  Ani. — I'y  K. 
G.  Lennander  and  Martin  Ramslroem  (illustrated). 

Three  Cases  in  which  the  Superior  Cervical  Ganglion  of 
the  Sympathetic  was  Removed,  with  Remarks  upon  the  Op- 
eration.— Hy  F.  F.  Hurgliard  (illustrated). 

Presidental  Address  on  and  Clinical  View  of  Some  of  the 
Mechanisms  of  the  Heart  and  its  Valves. — By  William  Ewart 
(illustratc'l). 

Observations  upon  Injuries  to  the  Internal  Semilunar  Car- 
tilage of  the  Knee-joint. — By  Joseph  Griffiths  (illustrated). 

On  the  Substitution  (when  Practicable)  of  Subastragalar 
for  Syme's  Amputation.  —  By  J.  Hutcliinson  (illustrated). 

Prostatectomy  in  Two  Stages,  with  an  Account  of  Seven 
Cases.  -By  W.  Bruce  Clarke  (illustrated). 

Antistreptoccus  Serum  in  Pulmonary  Tuberculosis.  — By 
Thompson  Campbell  (with  chart). 

Unusual  Case  of  Malignant  Disease  in  Early  Infant  Life. 
—By  H.  J.  Clark  (illustrated i. 

Note  on  the  Treatment  of  Abscess  of  the  Liver. — By  Eu- 
gene Laurent  (illustrated). 

Presidential  Address  on  the  Study  of  Clinical  Medicine. — 
By  R.  Uoiiglas  Powell. 

The  Surgical  Treatment  of  Exstrophy  of  the  Urinary  Blad- 
der.— By  John  Berg. 

The  Open  Operation  for  Talipes  lEquino- Varus). — By  A. 
M.  Phelp-;, 

Glaucoma  Fulminans. — By  A.  V.  Leche. 

French  Journals. 

Cyclic  Albuminuria  of  Adolescence. — The  author  of  this  pa- 
per, H.  Uauchez,  in  his  report  of  two  cases,  shows  that 
this  affection  can  sometimes  be  associated  particularly 
with  the  gouty  diathesis  and  sometimes  with  an  infection, 
e.g.,  typhoid  fever.  Dauchez  has  studied  especially  the 
fir.st  of  these  forms,  and  gives  the  following  notes  :  The  pa- 
tient, a  girl  aged  thirteen  years,  suffered  continuously  from 
evening  albuminuria  in  December,  iSyS,  and  during  the 
first  five  months  of  1899  excepting  April — in  the  beginning 
influenced  by  milk  diet.  The  patient,  of  undoubted  gouty 
ancestry,  arthritic  and  diabetic,  was  very  rajHdly  relieved 
by  the  milk  diet.  The  evening  albuminuria  reappeared 
periodically  during  si.x  or  eight  months  at  the  menstrual 
epochs,  independent  of  atmospheric  influences.  Intercur- 
rent febrile  affections  caused  a  distinct  but  transitory 
albuminuria.  This  trouble  seems  associated  with  a  pro- 
fusion of  leucocytes  in  the  urine,  as  well  as  epithelial  de- 
bris and  oxalate  crystals,  l)ut  no  casts.  The  kidneys 
always  remained  permeable  to  methylene  blue.  The  pa- 
tient was  cured  at  the  end  of  the  tenth  month,  but  she 
had  had  every  month  a  discharge  of  albumin  in  the  even- 
ing with  no  appreciable  cause,  varying  from  0.50  to  3  gm. 
She  has  now  passed  four  months  without  albuminuria. 
Arthritis,  gout,  menstruation,  and  adolescence  predispose 
to  this  renal  trouble  without  fever.  The  fevers  cause  a 
return  of  the  condition.  Pregnancy  can  also  have  the 
same  effect.  Without  a  course  of  treatment  very  severe 
and  very  prolonged,  which  is  absolutely  necessarv  for 
cure,  marriage  ought  not  to  be  ?LA\n%eA..— Journal  tie's  Sci- 
eincs  Mcdiialcs  de  Lille,  October  6,  igoo. 

Experimental  Repair  of  Tissues.— Paul  Carnot  speaks  of 
the  different  processes  of  repair  of  tissues,  whether  tliey  take 
place  in  the  course  of  normal  life,  or  follow  the  local  action 
of  a  traumatic  substance,  or  are  the  result  of  a  diffuse  infec- 
tious toxin.  In  the  first  case  the  method  of  repair  is  so 
diffuse  that  it  is  difficult  to  observe.     The  repair  following 


traumatism  is  most  favorable  for  experimental  analysis. 
The  repair  following  the  lesions  caused  by  infectious  toxins 
is  like  tliat  in  the  first  class,  generally  diffu.sc  and  hard  to 
study.  Most  tissues  are  capable  of  a  certain  plasmogenie 
powerandcan  proliferate  actively.  There  are  certain  biolog- 
ical conditions  which  greatly  influence  tissue  repair:  local 
infections,  for  example,  hinder  regeneration  of  tissues  and 
cau.se  fibrous  cicatrization,  or  even  the  complete  absence  of 
repair.  On  the  other  hanil,  several  mechanical  or  chemi- 
cal excitants  of  cellular  proliferation  are  known  :  mechani- 
cal contact  of  an  inert  foreigti  body,  massage  of  tissues, 
iodine,  cantharides,  certain  saline  solutions,  and  certain 
toxins  in  small  doses.  Organic  extracts  have  an  action  on 
the  homologous  organ.  If  we  are  still  in  almost  absolute 
ignorance  of  how  to  influence  morphogenic  function,  we 
may  influence  the  plasmogenie  function  of  tissues  in 
partly  regulating  and  directing  cellular  proliferation,  and 
so  causing  repair  of  tissue.  —  l.a  I'resse  Mi-tiiiaie.  October 

3,    I(/)0. 

Concerning  the  Gravity  of  Rheumatism  in  the  Child,  from 
the  Point  of  View  of  Caruiac  Complications.— M.  H.  barbier 
declares  that  articular  rheumatism  in  children  is  an  affec- 
tion of  grave  import  on  account  of  the  frequency  and  se- 
verity of  the  cardiac  lesions  incident  thereto.  Various 
authorities  state  the  percentage  of  cardiac  affections  to  be 
eig  ty-one  jier  cent.,  or  even  as  high  as  eighty-seven  ])er 
cent.  The  onset  of  rheumatism  is  often  marked  bv  gen- 
eral phenomena,  fever,  headache,  vomiting,  etc.,  which 
show  that  in  children  rheumatism  has  more  the  cour.se  of 
a  general  infectious  malady  than  that  of  a  multiple  arthrop- 
athy, and  that  the  vi.sceral  localizations  in  the  heart  in 
particular  are  not  in  relation  to  the  intensity  of  the  articu- 
lar manifestations.  The  majority  of  cases  of  rheumatism 
in  children  which  Barbier  has  observed,  accompanied  by 
more  or  less  grave  cardiac  coiiiplications,  have  yielded  in 
a  few  days  to  treatment  by  sodium  salicylate.  Death  may 
occur  in  from  three  to  si.x  months  after  the  beginning  of 
rheumatism  in  children  previously  in  good  health.  It  is 
probable  that  the  severity  of  the  cardiopathies  in  the  child 
are  mainly  due  to  pericarditis.  It  causes  in  a  great  num- 
ber of  cases  a  fatal  termination. — Journal  tie  Medeciite  de 
Paris.  October  7,  igoo. 

Alimentary  Glycosuria  in  the  Gastro-Enteritis  of  the  New- 
Born. — Kugene  Terrien  reports  the  results  oi'  fortv-tuo 
examinations  of  alimentary  glycosuria  in  nurslings  suffer- 
ing from  gastro-enteritis.  In  order  to  obtain  reliable  re- 
sults, it  is  neces.sary  to  conform  to  a  uniform  technique 
(nature  of  the  sugar  employed,  dilution,  mode  of  adminis- 
tration). Alimentary  glj-cosuria  occurs  physiologically  in 
the  infant  only  when  the  dose  is  rai.sed  to  5  gm.  of  sugar 
or  less  of  pure  glucose,  4.5  gm.  of  pure  lactose  to  a  kilo- 
gram of  body  weight.  In  gastro-enteritis  it  occurs  with 
doses  of  3.5  gm.  and  even  less.  Alimentary  glycosuria 
was  observed  in  nearly  half  the  cases.  It  is  in  direct  rela- 
tion with  two  factors:  diarrhita  and  emaciation.  Perhaps 
a  conclusion  as  to  the  functional  insufficiency  of  the  liver 
might  be  drawn  from  these  results,  but  the  author  does  not 
wish  to  encroach  on  this  f,uhject.^Journal  des  Prali- 
ciens.  October  6,  1900. 

Lipomata  of  the  Parotid.  — Baudet  speaks  of  the  larity  of 
the.se  tuiTiors,  and  classifies  them  under  three  heads :  (i) 
Superficial  subaponeurotic  lipomata  ;  (2)  deep  subaponeu- 
rotic lipomata;  (3)  intraglandular  lipomata.  The  size  is 
variable — half  a  hen's  egg,  a  lemon,  etc.  An  adeno-lipo- 
ma  the  size  of  an  infant's  head  has  been  recorded.  These 
tumors  occur  as  a  rule  between  the  ages  of  thirty  and  fifty 
years,  'i'he  parotid  lipomata  hitherto  recorded  have  been 
on  the  left  side.  Their  growth  is  slow  and  regular.  The 
diagnosis  is  difficult.  Cysts  and  enchondromata  must  be 
excluded.  Ablation  by  a  bistoury  is  the  only  treatment, 
when  they  are  large  enough  to  be  removed. — Gazette  des 
Hopilaiix,  October  6,  igofj. 

Treatment  of  Dysentery  by  Methylene  Blue. — M.  Berthier 
calls  attention  to  the  histological  origin  of  this  substance 
as  a  medicine.  It  has  been  widely  used  in  the  laboratory. 
As  used  in  dysentery  it  is  interesting  from  several  points 
of  view  :  Its  simplicity  is  recommended  in  comparison  with 
mercury,  which  is  managed  with  difficulty,  and  as  com- 
pared with  ipecac,  which  is  not  well  borne  by  the  organ- 
ism. Methylene  blue  is  efficacious  and  rapid  in  its  action. 
It  quickly  causes  the  pain  of  this  illness  to  subside.  It  is 
a  parasiticide,  cholagogue,  and  its  effects  are  soothing, 
while  it  exerts  no  harmful  or  irritating  action. — La  Mede- 
cine  .Moderne,  October  10,  1900. 

Boiling  Water  in  Local  Infections. — Moty  concludes  that : 
The  action  of  boiling  water  is  much  superior  to  that  of  hot 
water;  it  is  more  easy  to  localize  and  more  penetrating 
than  gas  at  a  high  temperature,  and  does  not  require  any 
special  preparation.  It  ought,  on  account  of  its  power,  to 
be  used  carefully.  Its  action  is  rather  tonic  than  antisep- 
tic. So  far  it  does  not  appear  that  the  cranial  and  thoracic 
cavities  can  be  subjected  without  danger  to  the  action  of 


7o6 


MEDICAL    RECORD. 


[November  3,  1900 


hot  water,  which  ought  elsewhere  to  be  carefully  accommo- 
dated to  the  important  organs  which  may  be  in  the  neigh- 
borhood of  the  part  to  be  treated. — Le  Bulletin  Medical. 
October  6,  1900. 

Contribution  to  the  Treatment  of  Psychoses  by  Repose  in 
Bed.  — Casteras  concludes  that  rejiose  in  bed  has  a  quieting 
effect  on  the  organism  ;  it  attenuates  the  symptoms,  but 
has  only  a  little  influence  on  the  course  and  duration  of 
psychoses;  it  facilitates  the  supervision  of  patients,  but  is 
accomplished  at  much  expense  ;  this  method  cannot  be  a 
general  one,  but  is  only  an  addition  to  other  thcra]ieutic 
means:  it  ought  10  be  based  on  perfect  knowledge  of  the 
personal  idiosyncrasies  ;  its  employment  has  not  always 
given  the  results  hoped  for.  —  I.e  Xonl  Medical,  October 
I,  1900. 

SIsnstrual  Troubles  in  Certain  Maladies  of  the  Stomach.  — 

XI.  Buimoiid  states  that  those  troubles  are  observed  chiefly 
in  neuro-arthritic  patients.  They  are  dysmenorrluEa  and 
amenorrlnea.  The  most  frequent  cause  is  dilatation  of  the 
stomach  with  hypoacidity  ;  hyperacidity  is  rarer.  Men- 
strual troubles  without  anatomical  lesion  area  nervous  syn- 
drome observed  in  predisposed  subjects. — Gazette  Heb- 
domadairc  de  Medecine  el  de  CInrurgie,  October  4.  1900. 

Muncliencr  iiudicinische  Wochenschrijt,  October  9,  igoo. 
A  Case  of  Hysterical  Fever. — Wormser  and  Bing  say  that 
the  prejudices  which  existed  formerly  against  a  belief  in 
the  possibility  of  fever  of  purely  hysterical  origin  are  now 
without  foundation,  since  the  existence  of  one  or  more  heat- 
regulating  centres  has  been  proven.  Just  as  any  of  the 
motor  or  sensor)'  centres  may  Ije  involved  in  a  hysterical 
seizure,  so  the  heat  centre  is  not  exempt  and  may  exhibit 

"disturbances  of  function  due  solely  to  nervous  impulses. 
Although  such  cases,  when  reported,  have  always  been  re- 
garded with  a  good  deal  of  professional  scepticism  and 
considered  as  explicable  either  on  the  ground  of  unrecog- 
nized organic  lesion  or  malingering  and  deceit  on  the  part 
of  the  patient,  there  are  some  instances  on  record  in  wliich 
such  fallacies  could  be  excluded,  and  this  number  the  au- 
thors increase  by  a  very  detailed  account  of  a  case  coming 
under  their  own  observation.  The  patient,  an  unmarried 
woman  aged  twenty-four  years,  with  a  very  neuropathic 
family  history,  at  the  age  of  puberty  manifested  the  first 
signs  of  a  rapidl)'  developing  hysteria  of  medium  inten- 
sity. In  addition  to  various  subjective  and  objective  stig- 
mata elicited  in  the  history  there  were  actually  present 
under  observation  an;ESthesia,  analgesia,  hyperecsthesia, 
dermatographia,  migraine,  ovarian  crises,   diplopia,   con- 

■  traded  visual  field,  achromatopsia,  astasia-abasia,  tremor, 
and  convulsive  seizures.  The  hysterical  temperament  was 
well  marked  in  the  emotional  crises,  the  instability  of  tem- 
per, precocious  and  excessive  sexual  irritability,  and  the 
tendency  to  exaggeration  and  simulation  of  symptoms. 
Under  these  conditions,  in  consequence  of  gonorrhoeal  in- 
fection pelvic  trouble  developed  which  necessitated  first 
the  partial  and  then  the  total  ablation  of  the  uterus  and 
adnexa.  The  abdominal  condition  was  greatly  improved 
by  the  operation,  but  the  inauguration  of  the  artificial  meno- 
pause  was  followed   by  unusually  stormy  molimina ;    in 

-addition  to  the  customary  vasomotor  disturbances — head- 
ache, obesity,  etc. — a  greatly  increased  tendencj'  to  hys- 
terical attacks  manifested  itself,  which  was  especially  well 
marked  at  the  time  of  the  periods.  After  several  such 
seizures,  eight  weeks  after  operation  the  patient  suddenly 
ran  up  a  temperature  of  104.7'  F-.  whicli  dropped  back  to 
normal  again  in  a  space  of  three  and  a  half  hours.  This 
disturbance  of  the  heat-regulating  function  was  followed  by 
an  attack  of  hysterical/^///  iiial  with  delirium  and  uncon- 
sciousness. The  fever  was  not  due  to  the  muscular  energy 
liberated  during  the  convulsion,  since  this  did  not  occur 
till  after  the  droph.ad  commenced  ;  and  the  minuteness  with 
which  other  possible  causes  were  searched  for  and  elimi- 
nated apparently  leaves  no  doubt  that  this  is  an  indubi- 
table case  of  high  fever  due  solely  to  nervous  disturbances- 

The  Occurrence  of  the  Bacillus  Xerosis  in  Progressive 
Phlegmon,  Secondary  Wound  Infection,  and  Otitis  Interna. - 
Warnecke  in  three  different  cases  was  able  to  j.solate  an 
organism  corresponding  to  the  bacillus  xerosis  in  its  bio- 
logical characteristics.  In  the  first  of  these,  operation  for  a 
chronic  fetid  suppuration  with  ostitis  of  the  mastoid  was 
followed  by  extensive  infiltration  of  the  ti.ssues  and  pro- 
gressive cellulitis  which  invaded  the  neighboring  areas  of 
the  scalp  and  in  the  neck  reached  down  to  the  clavicle. 
There  was  great  discoloration  of  the  parts  invaded,  with 
burrowing  in  all  directions,  and  even  the  most  energetic 
treatment  was  unavailing  to  check  the  spread  of  the  proc- 
ess. At  the  autopsy  there  were  found  purulent  arachnitis 
with  thrombosis  of  the  sigmoid,  transverse,  and  occipital 
sinuses,  with  metastatic  ab.scesses  in  the  lower  lobes  of 
both  lungs.  The  second  case  is  al.so  one  of  secondary 
wound  infection,  but  ended  in  recovery,  and  resembles  the 
first  only  in  the  presence  of  the  same  organism,  the  high 


temperature,  and  the  intense  discoloration  of  the  wound 
edges.  In  the  third  case  a  fatal  arachnitis  with  metastases 
in  the  lungs  was  produced  by  the  same  bacillus.  The  or- 
ganism resembles  the  diphtheria  bacillus  in  appearance, 
and  segmented  and  involution  forms  are  frequently  pres-  • 
eut.  l.)ifferent  cultures  showed  great  polymorjiliism,  and 
agar  culture  apparently  furnishes  the  most  favorable  me- 
dium ;  bouillon  growths  evincing  a  tendency  to  the  club 
shape  even  when  only  twenty-four  hours  old.  Gelatin  is 
not  liquefied,  bouillon  is  made  cloudy  and  shows  a  deposit 
in  twenty-four  hours,  and  glucose  is  not  fermented  by  the 
bacillus,  whicli  imparts  an  acid  reaction  to  litmus  whey. 

A  Case  of  Acute  Formalin  Poisoning. — J.  Kliiber  describes 
a  case  which  is  interesting  in  being  probably  the  first  re- 
ported instance  of  formalin  poisoning.  The  jiatient,  who 
had  accidentally  swallowed  an  unknown  amount  of  a  weak 
formalin  solution,  was  found  unconscious  and  covered  with 
cold  perspiration,  but  at  first  did  not  exhibit  any  other 
symptoms.  The  stupor,  which  resembled  that  accompany- 
ing alcoholic  intoxication,  persisted  for  a  number  of  hours  ; 
there  was  complete  anuria  for  nineteen  hours  and  redness 
of  the  conjunctiva  and  pharyngeal  mucosa.  The  diagno- 
sis was  made  by  the  chemical  examination  of  the  fluid 
drunk  and  the  demonstration  of  formic  acid  in  the  urine. 
The  treatment  was  apparently  symptomatic,  and  the  pa- 
tient made  a  good  recovery. 

The  First  Beginnings  of  Idiopathic  Enlargement  of  the 
Heart,  and  the  Significance  of  Dilatative  Cardiac  Muscular 
Weakness  in  Military  Service.  — Hy  Eugeii  Wolffhiigel. 

The  Therapy  of  Chronic  Middle-Ear  Disease  and  the  Ques- 
tion of  Cholesteatoma. — By  !•".  Leutert. 

Metapneumonic  Abscess,  with  Pure  Cultures  of  the  Diplo- 
coccus  Pneumoniae. — By  Roeger. 

Berliner  klinisclie  M'ochcnsclirijt,  October  /,  igoo. 
Physiology  and  Pathology  of  Bile  Secretion. — Albu  reports 
certain  oljservalions  made  in  the  case  of  a  woman  with  a 
biliary  listula.  The  latter  had  existed  for  nine  years. 
Various  diets  were  taken,  and  it  was  found  that  one  of 
milk,  eggs,  soup,  white  bread,  vegetables,  and  fruit  caused 
a  more  abundant  outflow  of  bile  than  a  diet  in  which 
meat  figured  largely.  The  author  thinks  that  it  is  not  pos- 
sible to  determine  from  experiments  on  animals  just  what 
remedies  will  in  man  produce  an  increased  bile  flow,  and 
thinks  that  many  investigators  have  mistaken  an  outflow 
of  bile  from  accumulations  in  the  various  biliary  reservoirs 
for  an  actual  increase  in  its  formation  in  the  liver  cell. 

Experimental  Bence-Jones  Albumosuria. — G.  Zuelzer's  ob- 
servations were  made  011  the  case  of  a  dog  which  had  been 
poisoned  with  pyrodin.  In  the  course  of  the  case  albu- 
mose  appeared  in  the  urine,  and  Zuelzer  believes  that  this 
is  a  constant  feature  of  this  form  of  poisoning  in  dogs. 
Other  observers  have  found  it  for  a  short  time,  but  it  has 
been  covered  up  by  the  albuminuria  which  quickly  ap- 
pears. In  the  animal  of  Zuelzer,  the  albumosuria  lasted 
for  five  days  before  albuminuria  appeared.  The  former 
substance  has  been  found  in  cases  of  mj'elogenous  sarcoma 
in  the  human  organism  and  regarded  as  pathognomonic 
therefor.  Doubtless  some  of  the  instances  in  which  the 
.so-called  peptonuria  has  been  found  in  pernicious  anfcmia 
were  really  cases  of  albumosuria. 

Neumann's  Modification  of  Fischer's  Phenylhydrazin  Test 
for  the  Detection  of  Sugar  in  the  Urine. — By  Marguliez. 

The  Role  of  Fixed  Cells  in  Inflammation. — By  P.    Baum- 
gartcn. 
The  Effect  of  Oil  Enemata  on  Metabolism. —By  E.  Koch- 
Hypnotics. — By  O.  Binz. 

American  Journal  of  tlie  Medical  Sciences,  October,  igoo. 

Internal  Hydrocephalus  following  Cerebro-Spinal  Meningitis. 
— Elliott  P.  Joslin  reports  a  case,  with  accounts  of  seven 
other  cases.  Internal  hydrocephalus  has  been  known  to 
be  a  result  of  epidemic  cerebrospinal  meningitis  since 
1S05.  The  symptoms  consist  of  paroxysms  of  severe  head- 
ache, and  also  of  pains  in  the  neck  and  extremities,  with 
vomiting,  unconsciousness,  convulsions,  and  involuntary 
evacuations  of  f.T?ces  and  urine.  The  attacks  either  occur 
in  a  fairly  regular  ty|ie,  or  make  pauses  which  not  rarely 
last  for  weeks,  during  which  the  activity  of  the  mind  and 
senses  may  be  unimpaired,  the  appetite  excellent,  the 
sleep  restful,  and  the  patient  in  good  sinrits  and  gaining 
strength.  If  we  fall  into  the  error  of  supposing  that  the 
disease  has  taken  a  favorable  turn,  a  new  attack  dispels 
the  illu.sion.  (lenerally  speaking,  the  cure  of  secondary 
hydrocephalus  is  impossible,  but  Ziemssen  states  that  he 
has  seen  some  cases  in  which  a  complete,  and  others  in 
.  which  an  incomjiletc,  recovery  took  ]ilacc. 

Primary  Splenomegaly ;  Endothelial  Hyperplasia  of  the 
Spleen. — David  Bovaird  reports  two  cases  in  children,  with 
autopsy  hnd  morphological  examination  in  one.  He  thus 
summarizes  their  clinical   relations:    Case   1. — Great  en- 


November  3,  1900J 


MEDICAL    RECORD. 


707 


largement  o£  both  liver  aud  spleen,  simple  auaniia,  slight 
enlargement  of  superficial  lymph  nodes.  Case  II. — Enor- 
mous splenic  enlargement  and  moderate  enlargement  of 
the  liver,  simple  antemia.  sliglit  enlargement  of  superficial 
lymph  nodes  ;  affection  of  thirteen  years'  duration.  Pa- 
tients  sister  had  enlargement  of  spleen  beginning  at  prac- 
tically the  same  age.  It  may  therefore  be  safely  assumed 
that  whatever  the  disease,  it  is  the  same  in  the  two  cases. 
From  both  the  history  of  the  patients  and  the  clinical  ob- 
servations, it  is  apparent  that  tlie  enlargement  of  the  liver 
is  secondary  to  that  of  the  spleen.  The  author  holds  that 
these  cases  represent  an  affection  hitherto  unrecognized. 

The  Value  of  Pedicled  Flaps  in  Injuries  of  the  Hand.  -W. 
E.  Schroeder  says  that  when  one  desires  simply  to  cover 
the  palm,  dorsum  of  liand,  or  tlie  palmar  surface  of  the 
thumb,  Haps  may  be  taken  with  freedom  from  the  chest  or 
abdomen.  When  the  palmar  surface  of  the  fingers  has 
been  destroyed,  it  is  nmch  better  to  have  double  pedicles, 
and  these  can  best  be  obtained  from  the  hip.  Further- 
more, this  position  is  reasonably  comfortable.  In  young 
and  old  patients,  however,  such  a  procedure  would  be  very 
trying  and  scarcely  justifiable.  The  advantages  of  the 
method  are :  (i)  Mobility;  (2)  elasticity  ;  (3)  certainty  of 
taking. 

Sarcoma  and  Cirrhosis  of  the  Liver. — W.  W.  Ford  reports 
a  case  in  which  the  jiresence  of  cirrhosis  of  the  liver  was 
explained  by  the  intemperate  habits  of  the  patient.  It  is 
more  difficult  to  explain  the  i)resence  of  a  huge  mass  of 
sarcomatous  tissue  in  the  right  lobe  of  the  liver.  It  was  a 
definite  sarcoma  of  a  combination  of  round  and  spindle 
cells,  and  its  presence  cannot  be  explained  unless  it  be 
considered  as  a  primary  tumor.  Its  association  with  cir- 
rhosis of  the  liver  must  be  considered  quite  unique. 

Report  of  a  Case  of  Melasna  Neonatorum  Due  Apparently 
to  an  Infection  by  the  Bacillus  Pyocyaneus. — By  Williani  R. 
Nicholson,  Jr. 

A  Critical  Summary  of  the  Literature  on  the  Diagnostic 
and  Therapeutic  Value  of  Lumbar  Puncture.  —  Hv  Alfred 
Hand. 

Primary  Echinococcus  Cysts  of  the  Pleura. — By  Charles 
Cary  and  Irving  I'.  Lyon. 

Distortion  of  the  Aorta  in  Pott's  Disease. — By  Thomas 
Dwight. 

/ouriuii  I'f  Lti>y>igo/i>_i^y,  Octohfr,  iqoo. 

Treatment  of  Otitic  Pyaemia. — Dundas  Grant  says  that 
expectant  treatment  is  useless.  Non-surgical  treatment 
consists  in  the  use  of  diuretics  and  purgatives,  and  in  the 
pure  septicicmic  cases  of  alcohol,  quinine,  ammonia,  and 
nourishiu'.;  diet.  Antistreptococcus  serum  may  be  injected. 
Surgical  treatment  should  commence  with  free  incision  of 
the  drum  membrane,  removal  of  broken-down  desquamated 
epithelium  in  the  tympanic  cavities,  and  in  the  presence  of 
pysemic  symptoms  the  petromastoid  cavity  must  be  opened 
without  delay.  In  acute  cases,  the  mastoid  cells  and  an- 
trum must  be  freely  exposed,  all  diseased  bone  and  granu- 
lation tissue  scraped  away,  and  the  peripheral  cells  be 
opened  up  to  the  very  tip  of  the  mastoid.  In  chronic  cases, 
if  there  is  evidence  of  thrombo-phlebitis  of  the  jugular  vein 
in  the  neck,  this  may  be  ligatured  previous  to  the  radical 
operation.  In  the  absence  of  such  evidence  we  proceed  at 
once  with  the  radical  operation,  and  then  expose  the  sig- 
moid sinus  by  a  continuation  backward  of  the  breach  in 
the  bone  and  explore  it.  If  it  is  thronibo.sed  and  there  is 
evidence  of  puriform  disintegration  high  up  in  the  sinus, 
it  may  be  freely  incised  and  the  purulent  debris  removed 
with  a  spoon.  If  firm  healthy  clot  occlusive  is  reached  the 
cavity  may  be  cleansed  with  sublimate  .solution,  dusted 
with  iodoform  and  boric  acid,  and  lightly  plugged  with 
iodoform  gauze. 

Pathology  and  Treatment  of  Toxic  Paralyses  of  the  I.ar- 
ynx.— Watson  Williams  sums  up  the  treatment  as  fol- 
lows: (I)  We  should  resort  to  appropriate  general  treat- 
ment of  the  infective  di-sease  when  that  is  the  cause  of  the 
paralysis.  Measures  should  be  directed  to  the  removal  of 
the  poison  in  the  circulation  and  tissues  in  the  case  of  or- 
ganic or  metallic  poisons.  (2)  The  faradic  or  galvanic 
currents  should  be  applied  to  the  interior  of  the  larynx. 
Strychnine  may  be  given  by  the  mouth  in  considerable 
doses.  When  feasible,  it  should  be  injected  directly  into 
the  muscles.  (3)  Intubation  or  tracheotomy  may  be  neces- 
sary to  relieve  dyspnoea  and  threatened  asphyxia  in  cases 
of  bilateral  abductor  paralysis. 

Naked-Eye  Diagnosis  in  Cancer  of  the  Larynx.— J  N. 
Mackenzie  says  that  it  is  impossible  to  exaggerate  the 
importance  of  naked-eye  diagnosis  in  the  detection  of  la- 
ryngeal cancer.  Taking  it  all  in  all,  it  is  by  far  more 
practical  than  either  thyrotomy  or  the  microscope.  Unfor- 
tunately in  most  quarters  it  is  relegated  to  a  subsidiary 
place.  Even  the  best  of  laryngeal  surgeons  lose  no  time 
in  procuring  portions  of  a  suspected  growth  for  microscopic 
examination  before  they  have  gone  thoroughly  into  the 


history  of  the  case  and  carefully  endeavored  to  make  the 
diagnosis  with  the  naked  eye  alone. 

.Irc/ih't's  oj  Otology.  Aiii^ml,  igoo. 

Diseases  of  the  Organ  of  Hearing  in  Pernicious  Anaemia. — 
Schwabach  reports  seven  cases,  in  five  of  which  subjective 
noises  were  present ;  by  three  of  these  patients  the  noises 
were  heard  in  both  ears  and  by  two  in  one  ear  only.  The 
two  remaining  patients  could  give  no  information  on  this 
point  on  account  of  their  condition  (delirium,  somnolence). 
Deafness  was  complained  of  by  three  of  the  five  patients 
by  whom  subjective  noises  were  heard,  but  in  one  of  them 
only  one  ear  was  affected,  and  in  another  the  deafness  of 
one  ear  was  due  to  an  old  traumatism,  so  that  this  ear 
must  be  left  out  of  account.  There  remain,  therefore,  four 
ears  in  three  of  which  the  hearing  was  markedly  impaired 
(voice  close  to  ear),  while  the  fourth  could  distinguish 
whispered  words  at  2-3  tii.  Accurate  tests  with  tuning- 
forks  could  be  made  in  only  two  of  the  patients,  compris- 
ing three  alYected  organs  of  hearing,  and  in  another  air 
and  bone  conduction  were  tested  with  fork  c  only.  The 
results  of  the  examination  of  the  first  three  ears  were  as 
follows:  Low  forks  (if),  32,  4S  vibr. )  were  not  perceived  in 
any  case;  c  (12S  vibr.)  and  c'"  (2048  vibr.)  also  were  not 
heard  by  one  of  the  ears,  while  the  period  of  perception  of 
the  two  remaining  cars  was  shortened  for  these  forks.  In 
two  of  the  ears  perception  of  c  through  mastoid  was  length- 
ened by  7  and  2  sec.  respectively,  m  the  other  shortened 
by  4  sec.  Kinne  was  negative  in  two  ears,  and  in  the 
third  was  of  no  value  as  a  test  since  c  cotild  not  be  heard 
at  all  through  air. 

Upon  the  Color  of  Living  Rhachitic  Bone  as  Found  during 
Mastoid  Operations  in  Rhachitic  Children. —  Muck  says  that 
in  major  opeialions  tlie  aurist  has  presumably  greater  op- 
portunity than  the  general  surgeon  to  see  the  interior  of  a 
rhachitic  bone,  for  he  frequently  meets  with  cases  of  puru- 
lent inflammation  of  the  i)neumatic  cavities  of  a  mastoid 
process  and  of  purulent  disintegration  of  the  surrounding 
bone  in  rhachitic  patients.  The  macroscopic  condition  of 
a  rhachitic  mastoid  during  life  differs  from  that  on  the 
post-mortem  table,  where  the  bone,  by  decreased  blood 
supply,  and  jjerhaps  also  by  other  post-mortem  changes, 
has  lost  the  bright  rose  color  which  it  has  during  life. 
Only  its  softness,  offering  no  resistance  to  the  knife,  is 
alike  both  in  living  and  dead  bones.  The  light  rose  color 
is  not  due  to  the  liypera'mia  of  underlying  structure  shin- 
ing through  the  chalkless  bone,  for  it  is  the  same  at  the 
thin  squamous  portion  of  the  temjioral  bone  as  it  is  at  the 
compact  (not  yet  pneumatized)  parts.  It  is  solely  brought 
about  by  the  increase  of  the  vascular  and  medullary  forma- 
tions. It  is  remarkable  that  this  hyperseniic  bone  does  not 
bleed  upon  chiselling,  as  we  are  accustomed  to  see  it  in 
infectious  inflammations  of  the  bone.  An  illustrative  case 
is  recorded. 

Two  Cases  of  Otitic  Lateral-Sinus  Disease ;  Operations, 
with  Ligation  of  the  Jugular. —  Concerning  the  latter  oper- 
ation U.  Joachim  says  that  other  avenues  of  infection  on 
one  hand,  and  the  presumptiota  of  an  occluding  clot  in  the 
jugular  on  the  other,  seem  to  argue  against  the  necessity 
of  always  tying  the  jugular,  aside  from  the  statistical  posi- 
tion of  the  question.  The  preponderance  of  recoveries 
being  in  favor  of  the  cases  in  which  ligation  was  made,  he 
personally  favors  it  when  a  high  degree  of  pyaemia  is  evi- 
dent, securing  the  patient  against  an  important  avenue  of 
infection.  When  ligation  is  performed  it  appears  to  him 
that  the  vein  should  be  resected  at  once  as  high  up  as  pos- 
sible. 

Dublin  fouriuil  of  Medical  Science,  October,  n/oo. 

The  Prevention  and  Treatment  of  Post-Partum  Hemor- 
rhage.—J.  W.  Byers  describes  the  various  causes  leading 
to  this  accident,  and  says  that  the  two  measures  which 
should  be  adopted  in  every  case  to  prevent  post-partum 
hemorrhage  are  :  (i)  The  proper  management  of  the  third 
stage  of  labor;  (2)  the  important  principle,  never  to  de- 
liver in  the  absence  of  pains.  Treatment  consists  of  the 
following  measures,  mentioned  according  to  the  author's 
ideas  of  their  relative  importance:  External  uterine  mas- 
sage and  hot  water  through  a  double-current  tube,  hand 
in  the  uterus,  biinanual  compression,  gauze  plugging  of 
the  uterus,  drawing  the  organ  downward  by  means  of  a 
vulsellum  forceps  passed  through  the  lips  of  the  cer\'ix 
("kinking"  and  comjiressing  the  uterine  arteries),  and  in- 
jection of  iron.  The  latter  is  a  remedy  not  without  dan- 
ger ;  it  causes  a  certain  amount  of  superficial  injury  of  the 
uterine  wall,  which  forms  a  suitable  nidus  for  the  growth 
of  germs,  and  if  it  fails,  plugging  cannot  be  done,  owing 
to  the  effect  the  iron  has  on  the  tissues. 

The  Delusive  Stage  of  Grave  Abdominal  Lesions. — J.  S. 
M'  Ardle  calls  attention  to  the  subsidence  of  symptoms  in 
grave  abdominal  conditions  which  is  often  hailed  as  an 
evidence  that  the  patient  is  on  the  road  to  recovery,  but 
which  is  often   followed  after  twenty-four  to  forty-eight 


7o8 


MEDICAL    RECORD. 


[November  3,  1900 


hours  by  intermittent  attacks  of  mental  aberration,  erratic 
temperature,  abdominal  distention,  delirium,  rapid  pulse, 
and  death.  He  details  a  series  of  appendectomies,  de- 
scribing his  personal  method  of  operating.  The  paper  is 
a  plea  for  timely  operation  in  the  class  of  cases  suggested 
by  the  title. 

Remarks  on  Senile  Dementia.— C.  Norman  recites  several 
clinical  histories  illustrative  of  the  various  phases  of  senile 
dementia.  He  finds  the  condition  more  common  among 
women  of  the  lower  classes  who  are  addicted  to  alcohol. 
Special  symptoms  discussed  are  restlessness,  hypochondri- 
acal delusion — suspicion,  amnesia,  aphasia  and  parapha- 
sia, disorientation,  and  sexual  excitement. 


Covfcspomlcuce. 


OUR    LONDON   LETTER. 

(From  our  Special  Correspondent.) 

PLAGUE,      ITS    PREVENTION,      ETC. — MEDICAL      SOCIETIES — THE 

ROMANCE   OF   St'RGERV — SIR   JOHN   WILLIAMS     ON     CLASSICAL 

EDUCATION — THE    PIBLIC    HEALTH. 

LoNDO.v,  October  12,  1900. 
No  fresh  cases  of  plague  have  occurred  at  Glasgow.  One 
man  died  on  the  7th  inst.  He  was  admitted  on  the  20th 
ult.  A  fatal  case  occurred  at  Cardiff  on  the  4th.  The  case 
in  Wales  proved  to  be  that  of  a  man  from  tlie  same  ship  as 
that  at  Cardiff.  Another  man  from  that  ship  was  landed 
at  Kiugs  Lynn  with  typhoid  fever.  He  Jias  been  carefully 
watched  and  is  now  convalescent.  These  events  illustrate 
the  need  of  our  local  authorities  being  on  the  alert,  and 
hitherto  they  have  been  so. 

The  local  government  board  has  issued  a  "plague  memo- 
randum." This  asserts  tliat  the  disease  "  will  not  readily 
fasten  upon  that  section  of  our  population  which  is  prop- 
erly housed,  cleanly,  and  generally  in  a  sanitary  sense 
well  to  do  ;  that  rather  it  will  especially  affect,  if  it  obtains 
foothold  in  one  or  another  district,  insanitary  areas  such 
as  are  peopled  by  the  poorest  class,  and  where  overcrowd- 
ing of  persons  in  houses  and  dirt  and  squalor  of  dwellings 
and  of  inhabitants  tend  to  prevail."  The  memorandum 
also  gives  a  brief  account  of  the  symptoms  of  plague 
and  points  out  the  importance  of  recognizing  those  cases 
in  which  buboes  are  not  found.  The  board  has  also  circu- 
lated directions  forabtainingand  forwarding  material  from 
suspected  cases  for  bacteriological  examination  without 
cost.  Moreover,  the  board  is  prepared  to  supply  Haffkine's 
serum  to  the  medical  officer  of  health  of  any  district  that 
m.iy  bs  invaded. 

The  London  County  Council  is  also  prepared  to  meet  an 
emergency  and  has  informed  the  government  board  of  the 
precautions  it  has  taken  and  the  preparations  it  has  made 
for  isolating  "contacts  "  should  an  invasion  occur.  Among 
these  measures  is  the  retaining  of  Mr.  James  Cantlie  to 
examine  and  report  upon  suspected  cases  and  to  make 
post-mortems  when  necessary.  Mr.  Cantlie  had  large  expe- 
rience in  one  of  the  plague  hospitals  at  Hong  Kong  where  he 
resided  for  many  years.  An  arrangement  has  also  been 
made  with  Dr.  Klein  for  bacteriological  examinations. 

Intiuiry  has  been  made  in  all  lodging-houses  and  shel- 
ters in  districts  likely  to  be  visited,  with  tlie  encouraging 
result  that  not  a  single  case  of  illness  suggestive  of  the 
infection  has  been  discovered  up  to  this  date. 

Professor  Zabolotny,  of  the  Russian  commission  on 
plague,  has  visited  (Jlasgow,  and  as  1  have  not  given  you 
any  account  of  the  peculiarities  of  the  cases  there  you  may 
like  to  have  his  conclusions.  He  says  (i)  the  Glasgow 
epidemic  compared  with  that  of  India,  China,  and  Africa, 
as  well  as  recent  outbreaks  in  Europe,  is  of  the  mildest 
description.  (2)  The  extension  of  the  epidemic  is  slight 
and  the  mortality  insignificant,  which  may  be  attributed 
to  the  excellent  sanitary  and  medical  arrangements  in 
Glasgow.  (3)  Bubonic  cases  are  less  dangerous  from  a 
point  of  view  of  epidemiology  than  the  pneumonic  forms. 
The  latter  are  excessively  contagious  because  the  sputum 
teems  with  the  bacilli.  (4)  Since  in  the  bubonic  form  it 
spreads  by  contact  with  the  skin,  isolation  and  cleansicg 
of  linen  and  clothing  play  the  chief  r61e  in  prevention. 
(5)  For  those  in  contact  with  the  sick  the  best  i)reventive 
is  injection  with  serum  as  practised  at  Glasgow.  (6)  So 
the  best  treatment  is  serum  by  intravenous  injections  of 
large  dose.s.  (7)  The  post-mortems  of  fatal  cases  at  Glas- 
gow have  shown  the  appearances  of  protracted  illness,  not 
those  of  acute  plague  lasting  two  or  three  days. 

The  session  of  the  societies  has  opened.  On  Monday 
evening  Mr.  J.  H.  Morgan  assumed  the  chair  at  the  one 
hundred  and  twenty-eighth  session  of  the  Medical  Society 
of  London  and  delivered  the  inaugural  address.  He  took 
for  his  subject  the  "Romance  of  Surgery."  His  discourse 
may  be  described  as  a  brief  survey  of  the  present  condi- 


tion of  surgical  art  contrasted  with  that  of  a  quarter  of  a 
century  ago,  and  then  an  endeavor  to  anticipate  its  further 
progress  in  the  more  or  less  near  future.  Listerism  natu- 
rally took  the  first  ])lace  in  his  review,  for  it  is  not  much 
more  than  twenty-five  years  since  that  had  been  accepted. 
Mr.  Morgan's  first  case  of  treatment  by  the  antisejjlic 
method  was  in  1873.  when  he  was  house  surgeon  to  Mr. 
Pick.  It  was  a  wound  by  a  circular  saw  which  had  di- 
vided the  patella  and  incised  the  outer  condyle  of  the 
femur.  Some  suppuration  occurred  and  the  patient  recov- 
ered with  an  ankylosed  knee.  At  the  time  it  was  looked 
upon  as  a  triumph,  since  such  cases  were  then  usually  am- 
putated and  pya;mia  often  followed.  This  case  was  con- 
trasted with  one  lately  treated  by  the  perfected  antiseptic 
method  which  is  now  universally  practiced.  A  man  had 
driven  a  chisel  through  his  knee  joint  into  the  condyle  and 
■was  well  in  a  few  weeks  with  complete  and  perfect  move- 
ment of  the  joint.  Abdominal  surgery,  malignant  disease, 
wounds  in  war,  prostatic  disease,  and  the  j-rays  were 
among  the  illustrations  given  of  the  "  Romance  of  Sur- 
gery." The  fancy,  too,  that  once  deluded  surgeons  that 
in  fractures  they  had  reached  finality  has  been  dismissed, 
and  it  is  said  that  our  methods  are  altogether  wrong. 
Startling  as  this  is,  we  may  pause  to  ask  wliether  the  dis- 
turbance of  tissues  involved  in  wiring  and  screwing  may 
not  do  more  harm  than  the  older  methods. 

In  conclusion  he  hoped  the  co-operation  of  physician  and 
surgeon  to  ease  the  sufferer  may  continue  to  grow  stronger, 
for  in  tlieir  union  is  strength  and  to  relieve  is  the  end  and 
object  of  our  art. 

The  introductory  addresses  stilloccupy  afairshareof  our 
conversation — not  so  much  as  to  complete  lectures  as  to  lit- 
tle points  that  have  dwelt  in  the  memory  of  hearers  and 
are  passed  on  to  others. 

Sir  John  Williams,  a  good  Welshman,  went  to  Wales 
and  discoursed  on  ffireek  and  Latin  at  the  University  Col- 
lege of  South  Wales.  He  is  evidently  at  one  with  the  mod- 
ern outcry  against  the  classics  and  in  favor  of  the  sciences 
with  modern  languages  as  the  best  outfit  for  medical 
study.  He  remarked  that  a  classical  education  is  pursued 
mostly,  not  for  the  culture  it  gives,  but  in  order  to  acquire 
instruments  for  sjjecial  pursuits — such  as  theology,  law, 
philology,  history,  teaching,  etc.  The  instruments  are 
necessary  to  them,  but  not  for  the  pursuit  of  science.  As 
to  medicine  Greek  is  no  longer  compulsory,  and  the  knowl- 
edge of  Latin  demanded  of  the  medical  student  is  so  small 
that  it  does  not  enable  hira  to  read  the  easiest  Latin  book 
except  with  difficulty  and  the  help  of  a  dictionary.  Thus 
the  long  time  often  spent  upon  it  is  wasted.  In  addition 
to  ordinary  school  subjects  Sir  John  would  give  a  thorough 
course  of  the  English  language  and  literature.  This  would 
give  him  a  vocabulary,  a  command  of  language,  a  taste  for 
good  literature,  and  a  larger,  better  cultuie  than  a  smat- 
tering of  Latin  too  scrappy  to  be  of  any  real  use.  He 
would  also  have  them  learn  French  and  German  as  neces- 
sary for  leaders  of  the  profession. 

Then  he  diverged  to  tell  his  hearers  some  distinct  ad- 
vantages of  a  knowledge  of  the  Welsh  language  and  liter- 
ature which  he  rejoiced  would  receive  due  recognition  now 
that  Wales  had  its  university. 

The  number  of  cases  of  typhoid  in  the  hospitals  of  the 
asylums  board  increased  last  week  by  forty,  and  fifteen 
fatal  cases  are  reported.  The  deaths  from  scarlet  fever 
rose  from  five  to  fourteen.  Over  two  thousand  cases  of 
this  disease  are  reported — an  increase  of  one  hundred  and 
thirty.  Still  the  general  death  rate  of  the  metropolis  is 
lower  than  it  has  been  for  about  twelve  weeks. 


LETTER    FROM    CONSTANTINOPLE. 

(From  our  Special  Correspondent.) 

THE  PLAGUE — A  PROPOSED  NATIONAL  UNIVERSITY  FOR  TURKEY 
— MEDICAL  STUDY — THE  MEDICAL  ASPECTS  OF  THE  SULTAN's 
F^TE — DEATH  OF  DR.  SAVELL— NEW  PHYSICIAN  TO  THE 
BRITISH    EMBASSY — ACCIDENT    TO    DR.    RIEDER. 

CONSTANTINUrLE,    OctobCf   1,    IQOO. 

The  presence  of  plague  in  the  Levant  has  not  excited  the 
degree  of  anxiety  that  might  have  been  expected,  whether 
it  be  that  there  is  more  confidence  in  the  sanitary  admin- 
istration, or  that — from  Constantinople  having  so  often 
escaped  epidemic  influences — the  population  have  shown 
much  indifference. 

A  false  alarm  of  plague  in  the  city  caused  Bulgaria  to 
impose  a  quarantine  of  eleven  days,  which,  however,  was 
removed  within  forty-eight  hours.  Since  then  the"Mes- 
.sagaries  Maritimes"  S.  S.  .\/|if(-r  arriving  from  Alexan- 
dretta  and  Beyrout  undoubtedly  brought  plague.  In  con- 
nection with  this  outljreak  of  plague  there  was  a  "fiasco," 
as  it  was  mildly  put.  The  passengers  were  landed  and 
scattered  before  the  existence  of  the  disease  was  discov- 
ered or  declared.     When  it  was  known,  much  excitement 


November  3,  1900] 


MEDICAL    RECORD. 


709 


and  alarm  were  created  in  sanitary  and  unsanitary  circles. 
The  jjassengers  were  placed  under  "surveillance."  The 
vessel  was  tiuarantined  to  the  station  of  Clazamine  and 
exposed  to  the  routine  of  disinfection.  Other  cases  oc- 
curred on  board,  among  them  the  doctor  of  the  ship. 
Nothing,  however,  transi)ircd  of  any  case  on  shore.  The 
mode  of  communication  is  not  very  evident.  The  Xi[f,'iT 
touched  at  Ale.xandretta  and  Beyrout.  At  the  former 
place  an  Armenian  boy,  said  to  have  escaped  from  the 
locality  of  the  alleged  massacres,  near  Sassam,  was  taken 
on  Ijoard  as  passenger.  The  boy  had  travelled  on  foot 
through  the  country  lying  between  Sassam  and  Alexan- 
dretta,  a  journey  of  from  sixteen  to  twenty  days.  There 
is  no  evidence  of  the  existence  or  prevalence  of  plague  in 
that  jjart  of  Asia  Minor,  so  it  is  impossible  to  trace  the 
.soui'ce  of  infection,  though  it  may  have  been  communi- 
cated at  Beyrout,  where  there  had  been  reported  isolated 
cases  of  plague.  The  Ottoman  Sanitary  Service  is  a  very 
"cock-sure  "  institution,  and  much  sarcasm  has  been  in- 
dulged in  with  reference  to  the  landing  and  scattering  of  the 
passengers  of  the  S..S.  -W^'^ev  before  the  presence  of  plague 
was  known  or  declared. 

This  tune  there  could  be  no  doubt  of  the  city  being  com- 
promised, and  naturally,  in  accordance  with  practice,  Rus- 
sia, (ireecc,  and  Balkan  States  imposed  ([uarantinc,  which 
is  still  continued  in  a  moditied  form.  Now,  contrary  to  the 
practice  of  former  years,  there  has  been  no  disposition  on 
the  part  of  these  countries  to  stretch  to  the  utmost  the 
limits  of  the  system.  The  laxity  of  observation  in  relation 
to  the  cases  on  board  the  .\Vi,'<v-  is  not  easily  exjilicable. 

The  great  event  of  the  year  so  far  is  the  celebration  of 
tlie  twenty-hfth  anniversary  of  the  accession  of  His  Impe- 
rial Majesty,  Sultan  Abd-ul-Hamid,  to  the  throne,  and 
certainly  the  form  of  commemoration  is  worthy  of  notice 
in  its  medical  asi)ects.  It  has  been  alread)'  noticed  that 
His  Majesty  has  always  shown  a  deep  interest  in  all  mat- 
ters relating  to  the  education  of  his  people,  and  that  dur- 
ing his  reign  more  has  been  accomplished  than  by  his  pre- 
decessors. It  would  apjjcar  as  if  the  crowning  stone  of 
this  educational  edifice  had  been  placed  by  the  creation  of 
a  university  for  Turkey.  This  intention  had  been  declared 
beforehand,  but  the  official  inauguration  has  taken  place, 
professors  have  been  appointed,  and  even  students  nomi- 
nated. 

Medicine  is  as  fully  represented  in  this  university 
scheme  as  other  sciences  are,  and  probably  will  be  more 
kindly  fostered  by  authorit)' ;  inasmuch  as  the  Turks — like 
Easterns  of  all  classes — take  kindly  to  the  healing-art. 
Mystery,  formerly  so  associated  with  the  practice  of  ])hysic 
and  religion,  has  not  yet  lost  hold  on  the  Turkish  mind. 

On  the  other  hand  it  must  be  borne  in  mind  that  this 
university  cannot  be  considered  a  product  of  the  evolu- 
tion of  very  advanced  education  and  science.  The  idea 
probably  originated  thus:  all  countries  in  Europe  possess 
universities.  The  time  has  come  for  Turkey  not  to  be  be- 
hind ;  therefore,  "let  there  be  a  university  in  Turkey," 
and  it  is  so.  No  idea  of  evolution.  But  as  there  has  been 
real  educational  jirogress  in  Turkey  for  some  years  past, 
and  especially  medical  education,  it  will  be  interesting  to 
watch  the  working  of  this  institution. 

The  medical  world  was  prominently  represented  on  this 
occasion  by  the"  Imperial  Society  of  Medicine,"  the".Soci- 
ety  of  Pharmacy  "  and  other  allied  bodies,  one  and  all  de- 
claring how  much  His  Imperial  Majesty  lias  contributed 
to  the  develoiHiieiit  of  medicine,  pharmacy,  and  their  allied 
branches  during  the  twenty-five  years  of  his  reign.  Hon- 
ors and  decorations  have  been  liberally  bestowed,  of  which 
the  medical  profession  has  had  a  full  share.  An  address 
to  the  throne  summarizes  thus;  "Ameliorations  which  en- 
able the  faculty  of  medicine  to  compare  favorably  with 
foreign  faculties;  the  native  teachers  are  increased  and 
replace  the  foreign  recruits.  The  new  faculty  of  medicine 
and  its  annexes  of  hospitals,  clinics,  laboratories  of  chem- 
istry and  bacteriology,  museum  of  natural  history  and 
large  botanical  gardens,  as  in  former  days,  all  of  which 
will  worthily  form  part  of  the  grand  university  just  or- 
dered to  be  made.  Council  of  civil  medical  affairs  to 
judge  all  medical  affairs  of  the  empire  ;  salutary  measures 
for  the  exercise  of  medicine  and  pharmacy  ;  a  superior 
council  of  hygiene ;  the  sanitary  administration  of  the 
empire  against  invasions  of  epidemic  diseases  by  an  inter- 
national council  of  health  " — which  boldly  proclaims  its 
functions  and  claims  to  have  barred  the  doors  of  the  em- 
pire against  invasions  of  epidemics  (7'ii/t-  S.S.  .\i\i:;ir). 
"The  creation  of  numberless  hospitals  in  the  provinces; 
a  maternity  hospital  at  Hasskien  ;  an  hospital  for  chil- 
dren (the  Hamidiah)  at  Chichli ;  an  asylum  for  the  ])oor ; 
hospitals  against  the  propagation  of  syphilis  in  the  prov- 
inces ;  an  antirabic  institute;  a  %'accinal  institute;  the 
restoration  of  the  baths  at  Yalova  (of  which  more  anon), 
and  the  institution  of  local  dispensaries." 

No  wonder,  then,  that  with  such  favoralile  opportuni- 
ties of  distinction  there  should  be  an  inundation  of  doctors 


of  every  nationality,  and  of  both  sexes,  seeking  permis- 
sion to  practise;  their  ages  varying  from  twenty-three  to 
sixty. 

Ur.  Richard  Savell,  a  surgeon  of  considerable  repute, 
well  known  to  his  colleagues  abroad,  died  suddenly  on 
September  3d.  Dr.  Savell  was  the  first  surgeon  in  Con- 
stantinople to  perform  ovariotomy  on  the  new  basis  of  an- 
tiseptic and  aseptic  surgery.  He  was  professor  of  clinical 
surgery  in  the  medical  school  and  a  bold  atid  successful 
operator. 

Dr.  Frank  Clemow  has  succeeded  the  late  Dr.  Dickson 
as  physician  to  the  British  embassy,  and  delegate  to  the 
Ottoman  health  council. 

A  sad  accident  has  just  occurred  (October  4th) .  Profes- 
sor Dr.  Rieder,  inspector  of  schools  of  medicine  and  chief 
of  the  hospital  at  Gulhand,  visited,  in  company  of  the  ar- 
chitect, the  new  School  of  medicine  at  Haidar  Pacha,  in 
course  of  construction.  In  consequence  of  a  false  step  he 
fell  a  distance  of  over  forty-five  feet.  His  tibia,  it  is  said, 
is  fractured,  and  he  has  sustained  other  grave  injuries  of 
the  head  and  spinal  column.  His  condition  is  stated  to  be 
dangerous. 


THE   NATURE   OF    HYSTERIA. 

To  THE    EdiTOK   of  THE   MEDICAL   RhcOKU. 

Sir  :  I  read  in  the  Medical  Record  of  August  25,  1900,  a 
paper  by  Alfred  Gordon,  M.D.,  in  which  the  following  pa.s- 
sage  occurs :  "In  1894  Lepine,  in  1895  Mathias  Duval  ap- 
plied the  theory  of  aniDcboism  to  the  intellectual  phenomena. 
Dercum  in  1S9O  adopted  the  same  theory  and  ingeniously 
explained  the  jihenomena  of  hysteria." 

I  take  iileasure  in  sending  you  a  copy  of  my  paper,  "Sur 
un  cas  d'hysterie  a  forme  particuliere  "  {Rc~c'Uf  de  iiu'de- 
cine,  July,  1S94),  from  wdiich  you  will  see  that  it  was  not 
Dercum  in  1S96,  but  I,  in  1894,  who  first  proposed  a  theory 
of  the  phenomena  of  hysteria  which  had  for  its  basis  the 
neuron  hypothesis.  I  hope  that  you  will  be  so  kind  as  to 
publish  the  present  letter  in  your  valuable  journal. 

R.  LliriNE. 

30  Place  Bbllevle,  Lyons,  Franxe. 


STATURE   Ax\D    INTELLIGENCE. 

To    THE    KUITOR  OF    THE    MeDICAL    ReCOKI). 

Sir  In  your  editorial  of  October  i3tli,  commenting  upon 
"Degenerates  in  the  Army,"  you  ask  whether  it  can  be 
claimed  that  magnificent  animal  specimens  of  humanity 
are  also  as  a  rule  endowed  with  a  superabundance  of 
brains.  This  brings  up  a  most  interesting  yet  puzzling 
anthropological  study,  full  of  contradictions. 

From  investigations  among  soldiers  and  from  the  litera- 
ture of  the  subject,  there  is  no  doubt  in  my  own  mind  that 
if  a  man's  development  is  so  unstable  that  he  has  psychi- 
cal stigmata,  he  is  invariably  of  bad  physical  develop- 
ment also  and  has  numerous  physical  stigmata.  As  far  as 
I  know,  there  are  few  if  any  cases  of  abnormal  minds  in 
average  bodies  devoid  of  stigmata.  It  is  a  fair  inference, 
then,  that  if  a  man's  body  is  nearly  an  average  in  all  re- 
spects, height,  weight,  ))roportioiis,  etc.,  there  must  also  be 
an  average  brain  and  therefore  a  normal  mind— excluding, 
of  course,  normal  men  who  have  acquired  insanity.  Be- 
yond this  we  dare  not  go,  for  there  is  ab.solutely  no  rela- 
tion between  intelligence  and  stature.  Men  of  genius  may 
be  big  like  Bismarck  or  little  like  Najioleon  or  Da  Costa, 
and  the  same  may  be  said  of  the  feeble-minded  as  well  as 
of  those  of  average  intelligence.  George  Washington's 
physical  measurements  are  said  to  have  been  identical 
with  those  of  Jeffries  the  giant  pugilist.  Other  illustra- 
tions might  be  given  indetinitelj'. 

It  is  true  that  the  human  brain  weight  depends  upon  the 
body  weight,  for  many  muscles  require  many  brain  cells. 
In  like  manner,  the  sparrow  needs  but  a  few  grains  of 
brain,  while  the  whale  and  elephant  must  have  more  than 
man.  Yet  that  indescribable  and  immeasurable  variable 
called  intelligence  depends  upon  other  things  in  addition 
to  weight  of  brain,  and  the  increase  of  brain  weight  due  to 
increased  stature  consists  of  tissue  which  may  not,  and 
probaldy  does  not,  have  any  bearing  upon  intelligence. 

A  big  physique  with  immense  reserve  power  and  endur- 
ance is  a  decided  element  in  forcing  men  to  the  front  in  the 
struggles  of  life.  This  is  in  accordance  with  recent  inves- 
tigations among  Chicago  school  children  which  are  said  to 
show  that  the  best  scholars  in  any  class  are  appreciably 
bigger  than  the  rest.  Hence  other  things  being  equal,  the 
big  men,  having  an  advantage,  should  have  a  larger  per- 
centage of  their  number  successful  than  the  little  men. 
Yet  statistics  show  the  very  opposite,  for  Lombro.so  men- 


7IO 


MEDICAL    RECORD. 


[November  3,  1900 


tions  ("Man  of  Genius,"  page  6)  but  twenty-six  great  men 
of  tall  stature,  while  he  names  fifty-nine  who  are  short, 
some  of  them  being  even  dwarfish  or  less  than  five  feet  in 
height.  As  tlie  anomalies  of  height  are  equally  ciistributcd 
on  each  side  of  the  mean,  there  must  be  some  tremen- 
dously active  cause  to  make  the  little  men  more  tlian  twice 
as  brilliant  as  the  big.  The  two  classes,  being  equally  re- 
moved from  the  average,  should  be  equally  abnormal  men- 
tally. 

Among  the  big  physiques  of  the  army  I  have  seen  men 
of  great  intelligence  and  immense  brain  power  or  capabil- 
ity for  work.  This  is  of  course  the  highest  type  of  mind. 
and  is  in  marked  contrast  to  the  si)onge-like  minds  capable 
of  great  absorption  but  too  fiabby  to  work  and  produce. 
Nevertheless  the  big  men  of  the  army  present  a  larger  per- 
centage of  cases  of  arrested  mental  development,  infantil- 
ism, feminism,  etc.,  than  does  any  other  stature.  This  is 
one  of  the  most  curious  facts  in  pathological  anthropology, 
if  I  may  so  term  this  new  science  of  the  study  of  abnormal 
cases  due  to  unstable  development — the  degenerates. 

Men  of  little  physique  cannot  enlist,  so  we  cannot  study 
them  among  soldiers,  but  moderate  sliortness  of  stature  is 
no  bar  to  a  commission,  and  such  are  fairly  numerous  as 
officers.  Taken  all  in  all,  the  officers  below  the  average  of 
height  are  on  an  intellectual  plane  decidedly  above  that  of 
the  "magnificent  animal  specimens. "  They  are  Ijoth  in  a 
small  minority,  for  the  work  of  the  army  is  almost  wholly 
accomplished  by  men  of  average  physique.  As  far  as  I 
have  been  able  to  determine,  the  decided  majority  of  the 
great  military  leaders  of  history  have  been  of  average  stat- 
ure or  decidedly  less — even  dimiimtive  like  Napoleon  or 
frail  like  Wolfe.  The  gigantic  Winfield  Scott  was  an  ex- 
ception, but  his  tremendous  egoism  and  innumerable  blun- 
ders almost  remove  him  from  the  list  of  great  men  in  spite 
of  his  record  from  1S12  until  1S4S.  So  many  of  the  "little 
fellows  "  of  my  acquaintance  are  excellent  officers  that  I 
almost  look  upon  diminutive  stature  as  a  military  advan- 
tage for  an  officer. 

.Such  a  discussion  need  not  be  complicated  by  reference 
to  specialized  types  of  brain,  capable  of  doing  but  one  kind 
of  work  well  and  either  accompanied  by  general  intelli- 
gence or  worthless  in  other  directions.  Such  types  are 
found  in  every  stature  and  in  every  kind  of  physique,  but 
the  matter  is  too  extensive  to  be  enlarged  upon  here. 

We  cannot  pretend  to  explain  the  alleged  increase  of  the 
feeble-minded  among  the  big  men,  but  we  can  guess  that 
it  has  some  relation  to  that  teeble-mindedness  so  charac- 
teristic of  giantism  and  acromegaly.  The  pituitary  is  un- 
doubtedly a  growth  centre,  and  is  just  as  apt  to  be  involved 
in  unstable  development  as  any  other  part  of  the  body.  If 
it  is  hypertrophied  early,  giantism  results  ;  if  later  in  life, 
acromegaly,  as  Woods  Hutchinson  has  shown.  Sometimes 
in  the  early  cases  there  is  muscular  increase  alone,  as  m 
the  "strong  men,"  all  of  whom  subsequently  become  as 
feeble  as  the  giants  and  sooner  or  later  show  acromegalic 
signs.  All  of  these  big  creatures  are  feeble-minded.  The 
class  of  "magnificent  animal  specimens  "  of  humanity  may 
then  contain  some  very  able  men  who  become  renowned 
partly  through  the  excess  of  animal  energy,  but  it  also  har- 
bors a  large  number  of  borderland  cases,  partially  degen- 
erate, overgrown  through  instability,  and  with  a  leaning 
toward  the  feeble  mindedness  of  giantism.  Can  we  not 
imagine  that  there  is  an  organic  basis  for  these  cases  in  an 
abnormal  pituitary? 

Is  it  not  a  fact  that  college  athletes  noted  for  strength 
and  size  do  not  furnish  as  large  a  percentage  of  successes 
in  life  as  the  less  robust,  and  simply  because  more  of  them 
are  mentally  below  par?  Joseph  Chamberlain,  in  a  speech 
at  the  o])ening  of  a  gymnasium,  is  said  to  have  confessed 
that  he  had  never  taken  regular  exercise  in  his  life  and 
rather  disliked  it.  Are  there  not  many  other  great  or  suc- 
cessful men  ready  to  confess  to  the  same  physical  laziness, 
no  matter  how  energetic  they  may  have  been  mentally? 
It  is  quite  likely  that  the  kind  of  intelligence  needed  for 
success  does  not  run  to  athletics,  nor  is  it  found  so  much  in 
the  big  men  as  in  the  little  ones  or  the  average  sizes. 
Strong  mental  power  must  check  bodily  growth  in  some 
unexplained  way  through  its  influence  on  the  ))ituitary — a 
theory  which  is  fascinating,  no  doubt,  but  which  of  course 
cannot  be  proved. 

CnARi.Ks  E.  Woodruff, 
Captain  and  Assistant  Surgeon,   U.  S.  Army. 

Fort  Rm.ey,  Ka.nsas,  October  i<i,  igoo. 


Gifts  to  a  Hospital. — Mr.  E.  P.  Wilbur,  formerly 
president  of  the  Lehigh  Valley  Railroad  Company, 
has  donated  $10,000  to  St.  Luke's  Hospital  at  Bethle- 
hem, the  income  from  which  is  to  be  used  in  maintain- 
ing the  children's  ward.  Mr.  Samuel  Thomas,  of 
Catasauqua,  will  build  an  operating-ward  for  the  hos- 
pital at  a  cost  of  $10,000. 


^ocxetxj  glqjorts. 

MISSISSIPPI     VALLEV     MEDICAL     ASSOCIA- 
TION. 

Proceedings  oj  the  Twenty-Sixth  Atinual  Meeting.  Held 
at  Asheville,  A'orth  Carolina,  October  9,  10,  and  11, 
igoo. 

The  association  met  at  the  Battery  Park  Hotel,  under 
the  presidency  of  Ur.  Harold  N.  Moyer,  of  Chicago. 

Addresses  of  welcome,  on  behalf  of  the  city  and 
State,  and  of  the  local  profession,  were  delivered  by 
Hon.  Theodore  F.  Davidson  and  Dr.  John  H.  Williams. 

After  the  reports  of  the  secretary,  treasurer,  com- 
mittee on  publication,  etc.,  were  read,  the  First  Vice- 
President,  Dr.  A.  H.  Cordier,  took  the  chair,  and  Dr. 
jMover  delivered  the 

Presidential  Address. — He  referred  to  matters  of 
general  interest  to  the  profession.  He  dwelt  at  length 
upon  an  address  which  was  delivered  before  the  In- 
ternational Medical  Congress  by  the  distinguished 
American  colleague,  Jacobi,  who  saw  fit  to  discuss 
the  old  code  question.  The  speaker  thought  it  un- 
fortunate that  this  subject,  long  since  dead  but  not 
buried,  should  be  embalmed  in  the  records  of  that 
congress.  The  medical  profession  of  America  did 
not  need  any  apologist,  but  it  did  need,  in  his  opinion, 
to  apologize  for  the  representative  appointed  to  speak 
for  it  on  that  occasion.  As  to  medical  societies, 
there  could  not  be  too  many  of  them.  In  no  other 
country  were  these  societies  so  numerous  as  in  America. 
They  were  usually  well  attended.  In  foreign  coun- 
tries these  societies  were  for  the  few  ;  in  this  country 
they  were  for  the  many,  and  it  was  to  their  collective 
voice,  speaking  in  no  uncertain  tones,  that  the  pro- 
fession owed  the  uplift  of  medical  education.  The 
speaker  then  discussed  the  relation  of  the  medical 
profession  to  the  law.  The  passage  of  medical  acts 
had  been  urged  by  the  medical  profession,  and  phy- 
sicians had  been  distinctly  misunderstood  in  their  at- 
titude toward  such  legislation.  Legislators  felt  that 
in  some  way  the  medical  profession  wished  to  put  a 
fence  around  the  practice  of  medicine,  so  that  physi- 
cians, being  on  the  inside,  may  fatten  upon  it.  This 
was  not  true.  Physicians  urged  the  passage  of  medi- 
cal-practice acts  not  for  their  personal  aggrandize- 
ment, but  simply  for  the  protection  of  the  people,  to 
prevent  the  illegal  practice  of  medicine  by  unqualified 
persons  and  by  quacks. 

Specialism — If  anything  could  be  said  in  criticism 
of  the  medical  profession  in  this  country,  it  was  the 
overweening  inclination  toward  specialism.  A  phy- 
sician should  spend  several  years  in  general  practice 
before  adopting  a  specialty.  Specialism  had  done 
many  good  things  for  medicine,  but  practitioners 
should  see  to  it  that  it  was  not  overdone.  If  a  phy- 
sician wished  to  acquire  a  broad  general  culture,  it 
could  come  only  from  general  practice.  The  selection 
of  a  specialty  should,  like  matrimony,  come  naturally 
and  without  being  forced. 

Abdominal  versus  Vaginal  Hysterectomy. — Dr. 
H.  C).  W.M.KER,  of  Detroit,  Mich.,  read  a  paper 
with  this  title.  The  question  of  the  best  approach 
surgically  to  the  uterus  and  adnexa.  he  maintained, 
had  evidently  not  been  settled,  judging  from  the 
amount  of  discussion  of  late  upon  this  imjjortant  sub- 
ject. Cancer  of  the  uterus  was  not  an  infrequent 
cause  of  death  in  women.  The  question  of  recurrence 
of  cancer  of  the  uterus  was  very  important  and  was 
immediately  connected  with  the  method  of  its  removal. 
The  manner  of  recurrence  of  cervical  carcinoma  was 
either  by  extension  into  the  broad  ligaments,  from  the 
vagina  downward  and   into  other  contiguous  parts,  as 


November  3,  1900] 


MEDICAL    RECORD. 


711 


the  bladder  and  rectum,  and  occasionally  to  the  body 
of  the  uterus,  or  by  metastases  through  the  lymph 
channels  and  by  distinct  direct  implantation.  The 
surgeon  should  be  governed  by  tlie  method  of  opera- 
tion which  would  offer  the  best  advantages  in  guard- 
ing against  recurrence  of  the  disease,  and  in  order  to 
illustrate  this  the  author  reported  two  interesting  cases, 
one  of  which  was  a  vaginal,  the  other  an  abdominal, 
hysterectomy.  The  report  of  one  case  showed  what 
he  could  not  have  done  by  the  vaginal  method:  the 
other  portrayed  what  he  could  have  done  better,  more 
safely,  and  more  surely  by  the  abdominal  method. 
All  tilings  being  equal,  the  abdominal  route  offered 
advantages  that  did  not  pertain  to  tiie  vaginal  route. 
First,  the  surgeon  was  better  able  to  see  what  he  was 
doing.  Second,  he  was  much  better  able  to  control 
hemorrhage  by  the  abdominal  than  by  the  vaginal 
route  when  he  was  working  in  a  dark  cavity.  There 
was  less  liability  of  slipping  of  the  ligatures,  and  if 
they  did  slip  they  were  got  at  more  easily  than  by 
vaginal  section.  Third,  the  danger  to  the  ureters  was 
minimized,  and  if  injured,  the  opportunity  for  repair- 
ing them  was  better,  while  if  injured  by  the  vaginal 
route  the  surgeon  would  have  to  do  an  abdominal  sec- 
tion in  order  to  effect  their  repair.  I'ourth,  the  pre- 
vention of  sepsis  was  more  certain  by  liie  abdominal 
than  by  the  vaginal  route,  aided  in  the  first  instance 
by  the  Trendelenburg  position,  which  gave  opportunity 
for  full  protection  of  the  intestines  and  peritoneum, 
while  in  the  latter  the  opportunity  for  protection  was 
limited,  as  it  was  an  utter  impossibility  to  secure  per- 
fect asepsis  in  the  vagina  when  there  had  been  long- 
standing infectious  disease. 

Cancer  of  the  Uterus  and  its  Treatment. — This 
paper  was  contributed  by  Dr.  R.  S.  Sutton,  of  Pitt.s- 
burg.  Pa.  Cancer  operations,  he  stated,  should  be 
recommended  not  as  curative,  but  as  palliative,  and 
therefore  useful.  Total  vaginal  e.xtirpation  of  the 
uterus,  at  or  after  the  time  of  the  climacteric,  should 
find  a  place  as  prophylactic  treatment  against  cancer- 
ous disease.  The  paper  consisted  of  a  compact  review 
of  the  anatomy,  pathology,  and  present  methods  of 
treatment.  The  author  expressed  the  opinion  that 
treatment  for  existing  cancer  of  the  uterus  had  prob- 
ably reached  its  complete  evolution.  In  view  of  the 
ultimate  results  of  this  treatment,  which  he  heartily 
indorsed,  because  there  was  none  other  known  to  take 
its  place,  he  asked  the  question,  ctii  bono  I  He  then 
discussed  the  question  of  prophylaxis,  and  showed  that 
the  average  age  of  the  patients  he  had  operated  upon 
was  forty-three  years  and  a  fraction,  and  he  claimed 
that  if  these  patients  had  all  been  subjected  to  total 
vaginal  extirpation  at  the  average  age  of  forty  years,  all 
of  them  would  have  escaped  cancer  of  the  uterus.  Ac- 
cording to  his  own  statistics,  but  four  per  cent,  of  the 
cases  would  have  been  fatal ;  whereas  nearly  one  hun- 
dred per  cent,  of  these  patients  did  die  within  a  period 
of  two  or  three  years  after  operations  for  cancer. 
He  urged  greater  attention  to  the  early  repair  of 
lacerations  of  the  cervix,  and  a  more  painstaking  ob- 
servation and  consideration  by  physicians  at  large  of 
that  train  of  symptoms  preceding  and  leading  up  to 
the  development  of  uterine  cancer.  He  unequivocally 
recommended  radical  surgical  treatment  in  all  such 
cases,  and  clearly  announced  that  if  we  were  to  dimm- 
ish the  number  of  cases  of  uterine  cancer,  and  con- 
sequent mortality  in  the  future,  it  must  be  done  in 
forestalling  the  disease. 

Dr.  Edward  \\".  Lee,  of  St.  Louis,  Mo.,  favored  the 
abdominal  operation  in  a  large  majority  of  cases. 
He  believed  it  was  easier  to  perform;  the  operator 
could  see  what  he  was  doing;  he  had  a  more  perfect 
control  of  the  tissues,  and  could  do  a  more  thorough 
operation.  The  only  cases  in  which  he  thought  the 
vaginal  operation  was  justifiable  were  those  of  small 


uncomplicated,  fibroid  tumors  of  the  uterus  that  could 
be  easily  shelled  out. 

Dr.  Chauncev  D.  1'almer,  of  Cincinnati,  Ohio, 
said  that  until  the  past  few  years  the  vaginal  method 
had  been  ])referred  to  the  abdominal.  In  cases  of 
cancer  of  the  uterus  it  was  important  to  remove  all  of 
the  diseased  structure,  consequently  this  could  be 
more  easily  and  thoroughly  done  by  the  abdominal 
than  by  the  vaginal  route.  The  causative  relation 
between  laceration  of  the  cervix  uteri  and  cancer  of 
the  uterus  was  so  clearly  defined  that  its  importance 
ought  to  be  recognized  by  all  physicians. 

Dr.  J.  Wesi.ev  PovtE,  of  \Vashington,  D.  C,  men- 
tioned three  classes  of  cases  in  which  vaginal  hyster- 
ectomy for  cancer  of  the  uterus,  with  the  removal  of 
such  other  structures  as  might  be  involved,  was  ad- 
visable. In  very  feeble  patients,  who  were  not  able 
to  stand  a  prolonged  operation,  he  favored  the  com- 
bined method  advocated  by  Kies,  Clark,  VVerder,  and 
others.  The  combined  operation  had  been  done  by 
him  upon  thirteen  patients,  all  of  whom  were  living, 
witii  two  recurrences. 

Dr.  a.  H.  Cordif.r,  of  Kansas  City,  Mo.,  said  that 
in  cases  in  which  there  was  extensive  involvement  of 
the  cervix  by  the  cancerous  process,  implicating  the 
bladder  and  rectum,  his  patients  had  been  much 
benefited  by  thorough  curettage  of  the  cancerous  mass, 
followed  by  the  use  of  the  I'aquelin  cautery  and  pack- 
ing of  the  parts  with  carbide  of  calcium.  Along  with 
this  treatment  he  used  the  old  Goodell  vaginal  injec- 
tion of  permanganate  of  potassium. 

Dr.  Hui;h  .•\.  Cowini;,  of  Muncie,  Ind..  urged  upon 
the  general  practitioner  the  importance  of  making  an 
early  diagnosis  of  uterine  cancer. 

Dr.  William  F.  Barclay,  of  Pittsburg,  Pa.,  said 
that  the  general  practitioner  was  to  be  censured  to  a 
certain  extent  for  not  referring  cases  of  cancer  of 
the  uterus  early  enough  to  specialists.  For  years  he 
had  made  it  a  rule,  when  in  doubt  as  to  the  diagnosis 
of  disease  of  the  uterus,  and  when  there  was  complaint 
on  part  of  the  patient,  to  refer  the  case  to  a  specialist, 
and  he  had  been  satisfied  with  the  result.  The  earlier 
operations  were  done  for  this  disease  the  greater  the 
prospect  of  prolonging  life. 

Post-Operative  Internal  Hemorrhage. — A  paper 
on  this  subject  was  read  by  Dr.  A.  H.  Cordier,  of 
Kansas  City,  in  which  he  drew  the  following  deduc- 
tions: r.  In  diagnosticating  post-operative  hemor- 
rhage, the  history  of  the  patient  would  aid  much.  2. 
Symptoms  of  shock  and  those  of  hemorrhage  were  very 
similar.  3.  In  suspected  cases  a  single  stitch  in  the  in- 
cision cut  would  tell.  4.  In  cases  in  which  bleeding 
was  anticipated,  a  tube  should  be  used.  5.  The  surgery 
must  be  quick  and  decisive  in  these  cases.  6.  Large 
quantities  of  decinormal  saline  solution  would  save 
many  cases.  This  should  be  used  both  per  rectum  and 
into  the  veins.  7.  Strychnine,  belladonna,  etc..  would 
not  control  bleeding  from  the  uterine  or  ovarian  artery 
any  better  than  from  the  radial  or  temporal.  8.  The 
surgeon  should  do  what  his  surgical  conscience  told 
him  was  right. 

Intermittent  Hydrops  of  the  Knee.— Dr.  George 
\V.  Cale,  of  Springfield,  Mo.,  reported  the  case  of  a 
woman  forty-five  years  of  age.  The  first  appearance 
of  her  trouble  began  five  years  ago.  There  was  no 
history  of  injury.  There  was  a  rapid  accumulation  of 
fluid  in  the  left  knee  joint,  which  was  not  painful,  how- 
ever. This  effusion  disappeared  in  from  one  to  four 
weeks,  with  or  without  treatment.  The  disease  re- 
curred at  periods  varying  from  one  to  six  months. 

Ventral  Hernia  Following  Laparotomy. — This 
paper  was  read  by  Dr.  F.  Brindley  Fads,  of  Chicago, 
111.  The  occurrence  of  ventral  hernia  as  a  sequence 
of  abdominal  section,  he  stated,  was  so  common  that 
it  should    command  thoughtful    consideration.      The 


712 


MEDICAL    RECORD. 


[November  3,  1900 


author  urged  the  adoption  of  those  methods  which 
personal  experience  had  demonstrated  to  be  of  the 
greatest  use,  both  immediate  and  remote.  He  quoted 
Greig  Smith  as  sajing  that  ventral  hernia  was  a  mere 
stretching  of  scar  tissue,  but  the  essayist  regarded  it 
as  a  stretching  not  onl)'  of  the  scar  tissue,  but  of  all 
of  the  tissues  of  the  abdominal  wall  at  the  site  of  its 
occurrence.  As  intact,  innervated  muscular  fibre  was 
the  only  safeguard  against  hernia  following  laparot- 
omy, the  first  rule  was  to  make  the  abdominal  incision 
parallel,  or  nearly  parallel,  with  the  direction  of  the 
motor  nerves  and  of  the  most  important  muscular  fibres 
supplied  by  these  nerves.  In  considering  the  incision 
the  following  points  must  be  taken  up: 

I.  The  length  was  largely  dependent  upon  the 
thickness  of  the  superficial  fascia;  it  must  be  sufficient 
to  allow  free  access  to  the  muscles  whose  functional 
integrity  was  essential  to  success.  2.  The  length 
must  be  relatively  greater  than  when  muscular  fibres 
were  to  be  separated  instead  of  divided.  3.  It  must 
vary  with  the  pathological  condition  for  which  the 
operation  was  performed.  4.  An  opening  of  sufficient 
size  must  be  made  for  thorough  exploration  and  for 
securing  the  requisite  degree  of  precision  and  rapidity 
in  manipulation.  5.  A  long  incision  through  the  skin 
and  superficial  fascia  did  not  predispose  to  hernia.  6. 
It  lessened  the  mortality  by  providing  ample  space  for 
the  protection  of  surrounding  viscera.  7.  It  lessened 
shock  by  diminishing  the  time  required  for  the  opera- 
tion, and  also  the  duration  of  the  ana;sthesia. 

Several  incisions  were  mentioned  by  the  essayist. 
The  difficulties  he  had  experienced  in  reaching  the 
appendix  through  the  McHurney  incision  in  acute 
suppurative  cases  of  appendicitis  had  caused  him  to 
devise  another  method  of  approach  in  a  more  depend- 
ent part.  This  incision  overlay  the  outer  border  of 
the  cacum,  and  led  directly  to  the  appendix.  It  was 
slightly  curved  outward  and  downward,  crossing  an 
imaginary  line  drawn  between  the  anterior  superior 
iliac  spines.  The  centre  of  this  curve  was  from  an 
inch  to  an  inch  and  a  half  to  the  inner  side  of  the 
right  superior  iliac  spine.  The  skin  and  superficial 
fascia  were  incised  for  about  two  inches.  This  freely 
exposed  the  aponeurosis  of  the  external  oblique,  which 
was  separated  by  means  of  the  dry  dissector,  or  the 
handle  of  a  scalpel,  in  the  direction  parallel  to  its 
fibres,  and  well  retracted.  This  brought  into  view  the 
transversely  arranged  fibres  of  the  internal  oblique 
and  transversalis  muscles,  and  the  twelfth  abdominal, 
ilio-hypogastric,  and  possibly  the  ilio-inguinal  nerves, 
which  were  in  turn  retracted  in  order  to  reach  the 
transversalis  fascia,  which,  together  with  the  peri- 
toneum, was  divided  transversely.  The  advantages 
gained  by  this  incision  were: 

I.  It  provided  easy  access  to  the  diseased  area.  2. 
It  enabled  the  operator  accurately  and  securely  to  pro- 
tect the  peritoneal  cavity  from  infection.  3.  It  less- 
ened the  liability  to  break  down  the  inner  limiting 
wall  of  adhesions.  4.  It  afforded  a  better  opportunity 
to  open  the  abscess  cavity  from  the  outer  side.  5.  It 
favored  drainage.  6.  It  had  not  been  followed  in  the 
author's  experience  either  by  appendicular  fistula  or 
post-operative  hernia. 

Gangrene  of  the  Scrotum  and  Penis. — Dr.  E.  H. 
Richardson,  of  Atlanta,  Ga.,  narrated  the  history  of 
a  case  which  showed  the  initial  lesion  to  have  been 
an  abrasion  of  the  skin  near  the  os  pubis,  with,  prob- 
ably, infection  by  the  erysipelatous  cocci  at  this  point, 
and  later  a  mixed  infection  by  the  streptococcus  of 
gangrene,  terminating  in  the  destruction  of  the  gan- 
grenous portion  of  the  entire  integument  of  the  penis 
and  of  three-quarters  of  the  scrotum.  A  plastic  opera- 
tion was  made,  with  the  result  that  the  integument  of 
the  penis  and  testes  was  restored.  The  patient  made 
a  perfect  recovery. 


Tracheloplasty. — Dr.  Henry  P.  Newman,  of 
Chicago,  read  a  paper  on  this  subject.  In  order  to 
maintain  a  condition  of  normal  health  in  the  body,  he 
stated,  it  was  necessary  that  all  of  the  organs  properly 
performed  their  functions.  He  called  attention  to  the 
great  importance  of  the  function  of  the  cervix  uteri  in 
relation  to  disease  in  women.  Informer  times  cervical 
lesions  were  recognized  as  a  fruitful  source  of  gynecic 
evils,  and  many  operations  and  instruments  were  de- 
vised for  their  correction.  Emmet's  trachelorrhaphy, 
once  so  popular,  had  ceased  to  be  adaptable  to  the 
needs  of  to-day  in  repairing  cervices.  Dr.  Emmet,  in 
conceding  this  himself  and  offering  amputation  as 
a  substitute,  stated  that  the  great  advance  in  the  ob- 
stetrical art  and  the  methods  of  caring  for  a  lacerated 
cervix  in  labor  had  altered  the  character  of  surgical 
pathology,  so  that  trachelorrhaphy,  as  formerly  prac- 
tised, was  rarely  called  for.  The  author  found  the  in- 
dications for  plastic  work  upon  the  cervix  still  wide- 
spread enough  to  justify  the  presentation  of  a  new 
method  of  operating.  This  he  called  tracheloplasty, 
it  being  plastic  work  designed  not  only  to  restore 
normal  contour  and  relation,  but  to  re-establish  jiroper 
function.  The  distinctive  features  of  the  method  were 
the  use  of  a  specially  designed  knife,  the  shape  of  the 
flaps  in  the  anterior  and  posterior  lips  of  the  cervix, 
clean,  smooth  cut  surfaces,  accurate  approximation  of 
flaps,  the  certainty  of  restoring  the  proper  lumen  of 
the  canal,  and  the  simplicity  of  the  after-treatment. 
Neither  tracheloplasty  nor  any  one  operation  of  the 
kind  should  be  relied  on  to  correct  all  the  ills  which 
accrued  from  lacerations  in  childbed.  It  was  fre- 
quently necessary  to  do  such  simple  work  as  shorten- 
ing the  round  ligaments,  or  suspensio  uteri,  when 
there  was  a  displacement  of  the  uterus;  divulsion  and 
curetting  when  disease  had  extended  to  the  endome- 
trium above;  reparation  of  the  pelvic  floor  when, 
through  relaxation  or  trauma,  there  was  a  hernial 
condition  of  the  rectum,  bladder,  vagina,  or  superim- 
posed viscera;  sometimes  even  the  opening  of  the 
abdomen  for  plastic  work,  or  resection  of  pathological 
conditions  of  the  ovaries,  tubes,  etc.  Any  one  or  two 
of  these  accessory  operations  might  be  necessary  to 
restore  the  patient,  although  the  disease  or  deformed 
cervix  might  have  been  the  essential,  perhaps  the 
sole,  etiological  factor  in  the  case. 

Middle-Ear  Disease  in  its  Relation  to  the  Cranial 
Cavity. — Dr.  O.  J.  Stein,  of  Chicago,  read  a  paper 
on  this  subject,  in  which  he  pointed  out  the  necessity 
of  recognizing  the  importance  of  possible  intracranial 
complications  in  every  case  of  middle-ear  disease. 
The  various  avenues  of  infection  were  dwelt  upon  at 
length,  these  being  illustrated  by  beautiful  drawings 
and  specimens.  The  symptomatology  of  intracranial 
phlebitis,  thrombosis,  and  abscess  was  discussed  and 
several  instructive  cases  were  reported.  In  connec- 
tion with  this  paper  Dr.  J.  Holinger,  of  Chicago,  gave 
an  interesting  slereopticon  demonstration. 

Nutrition  and  Stimulation. — This  was  the  subject 
of  the  address  in  medicine  delivered  by  Dr.  I.  N. 
Love,  of  New  York  City.  Continuance  of  life,  he 
said,  beginning  with  the  original  protoplasm,  the  cell, 
depended  upon  proper  nourishment.  The  recognition 
of  this  fact  was  essential  in  all  the  work  of  the  phy- 
sician. The  proper  nutrition  of  the  new  being,  from 
the  very  beginning,  prior  to  birth,  should  be  assidu- 
ously looked  after  by  the  careful  physician.  After 
birth  the  security  of  the  infant  depended  upon  the  due 
appreciation  of  its  proper  feeding.  From  infancy  to 
maturity  this  should  be  the  essential  thought  of  the 
parent  and  the  doctor,  who  should  ever  realize  his  im- 
portance as  the  helper  of  the  parent  in  the  building  up 
of  a  Complete  man  or  woman.  The  entire  scheme  of 
tissue  building,  of  repair,  of  maintenance  of  the  mech- 
anism of  the  human  body,  involved  not  only  nutrition 


November  3,  1900] 


MEDICAL    RECORD. 


7^Z 


but  perfect  elimination,  and  the  two  together  were  ex- 
pressed in  the  term  metabolism.  Interrupted  metabo- 
lism tended  toward  organic  disease,  and  finally  death. 
Perfect  metabolism  meant  perfect  health.  Stimulants 
were  of  value  if  used  in  the  right  way  and  at  the  right 
time.  In  the  healthful  condition  they  were  not  needed  ; 
they  were  essentially  a  luxury.  All  luxuries  should 
be  used  with  the  greatest  care,  and  only  the  thoroughly 
healthy  could  indulge  safely  in  luxuries.  Stimulants 
were  divided  into  two  classes,  namely,  those  that  were 
exclusively  remedial,  and  those  that  came  under  the 
head  of  luxuries  associated  with  every-day  life.  Of 
all  the  stimulants,  alcohol  stood  first.  It  was  probably 
the  most  prompt  diffusible  stimulant  we  had.  There 
were  arguments  for  and  against  the  thought  that  alcohol 
was  a  food.  Coffee  and  tea  were  essentially  domestic 
beverages,  and  while  seemingly  harmless  they  were 
potent  whippers-up  of  energy  and  should  be  used  with 
great  care.  Tobacco  had  never  been  thought  of  as  a 
food.  It  was  primarily  a  stimulant,  but  like  all  other 
stimulants  it  was  secondarily  a  depressant.  It  was  a 
luxury,  pure  and  simple.  Morphine,  cocaine,  and 
others  of  their  class  were  of  great  value  to  the  pro- 
fession, but  improperly  used  were  more  deadly  in  their 
effects  than  the  scalpel  in  the  hands  of  the  unskilful. 

The  Treatment  of  Perirectal  Abscesses.  — Uk. 
John  L.  Jelks,  of  Memphis.  Tenn.,  read  a  paper  on 
this  subject.  Rectal  abscesses,  he  stated,  when  prop- 
erly treated,  were  not  so  serious  as  when  it  was  the 
practice  to  use  poultices  and  await  pointing.  These 
abscesses  need  not  result  in  fistula,  unless  they  were 
the  result  of  malignant  diseases,  such  as  tuberculosis, 
cancer,  and  syphilis.  The  fault  to  be  found  with  a 
simple  incision  and  drainage  of  these  abscesses  was 
that  their  walls  were  not  gotten  rid  of,  hence  this 
barrier  to  general  infection  or  infection  of  other  and 
deeper  structures  remained  to  continue  an  irritation 
and  to  cause  suppuration.  In  many  cases  the  abscess 
wall  became  calloused,  and  all  efTorts  to  establish 
granulation  were  futile.  When  he  was  able  to  elicit 
fluctuation,  he  opened  freely  and  hastily  irrigated 
through  an  irrigating-curette  attached  to  a  fountain 
syringe,  until  the  irrigating-tluid  came  away  free  of 
debris;  then  with  a  sharp  irrigating-curette  he  re- 
moved all  of  the  abscess  wall,  thereby  converting  the 
cavity  into  a  surgical  wound.  He  used  formalin  solu- 
tion in  irrigating  these  cavities  and  packed  them  with 
iodoform  gauze.  After  thus  treating  these  cases  he 
expected  no  further  suppuration.  Since  using  formalin 
solution  in  irrigating  these  cavities  he  had  in  the  after- 
treatment  of  them  seldom  noticed  any  suppuration. 
Superficial  abscesses  should  be  dealt  with  in  the  same 
manner;  or  they  may  be  frozen  and  excised  as  the 
surgeon  would  a  tumor.  They  were,  when  otherwise 
treated,  liable  to  infect  deeper  structures.  Local  an- 
EEsthesia  would  suffice,  and  curettage  could  be  properly 
practised  with  it.  If  the  wound  was  painful,  or  the 
formalin  solution  irritating  even  when  very  dilute, 
some  other  and  milder  solution  would  be  indicated. 
In  rectal  surgery  he  had  not  found  the  objections  to 
the  use  of  formalin  which  had  been  referred  to  by 
rhinologists  and  laryngologists. 

Simple  Operation  for  Hemorrhoids :  Enucleation. 
—  I)k.  J.  Rawson  Pk.\.\in(;to.v,  of  Chicago,  con- 
tributed this  paper,  which  was  profusely  illustrated. 
He  stated  that  he  gave  a  cathartic  the  second  night 
before  the  operation,  a  saline  the  following  morning, 
and  a  bath  and  colonic  flushing  the  night  before.  The 
next  morning  he  gave  an  enema  of  from  one-half  to 
one  pint  of  cool  water,  and  operated  two  hours  later. 
He  emphasized  the  importance  of  carefully  examining 
the  entire  rectum.  He  grasped  each  anal  quadrant  at 
the  muco-cutaneous  junction  with  a  pair  of  forceps: 
the  anus  was  everted,  and  the  internal  tumors  were 
exposed.      Seizing  with  the  hand  the  forceps  attached 


to  the  posterior  quadrant,  he  fully  everted  it,  and  with 
a  pair  of  scissors  curved  on  the  flat  cut  off  the  re- 
dundant membrane  only,  which  was  usually  about 
one-third  or  one-half  of  the  uppermost  part  of  the 
hemorrhoidal  node.  This  permitted  the  blood  in  the 
tumor  to  escape.  All  of  the  angiomatous  tissue  was 
carefully  removed,  when  the  remaining  wall  collapsed. 
Each  quadrant  in  regular  order  was  treated  in  a  like 
manner.  A  stream  of  hot  sterilized  water  flowed  over 
the  field  continuously  during  the  operation.  Spurting 
vessels,  if  any,  were  caught  with  forceps  and  thor- 
oughly twisted.  Should  this  fail  to  control  hemor- 
rhage, he  threw  a  ligature  around  the  vessel  and 
ligated  it.  The  operation  having  been  completed, 
he  introduced  a  rubber-covered  tampon  which  had 
been  fully  described  in  previous  articles  by  the  author. 
The  ad\antages  of  this  method  were:  There  were  no 
stumps  to  slough,  no  nerves  were  caught  and  squeezed, 
which  would  cause  excruciating  pain,  as  when  the 
ligature  was  used;  nor  were  the  nerves  and  tissues 
burned  to  a  crisp,  as  when  the  clamp  and  cautery  were 
employed.  The  formation  of  a  stricture  was  obviated. 
The  patient  was  given  a  cathartic,  and  the  tampon  was 
painlessly  removed  at  the  end  of  forty-eight  hours. 
There  wtis  no  pain  or  bleeding  with  the  movement  of 
the  bowels.  .After  the  bowels  had  moved,  the  patient 
was  instructed  to  keep  them  soft  for  two  or  three  weeks 
by  taking  compound  licorice  powder  or  Apenta  water, 
the  latter  being  very  palatable  and  effective.  He  had 
performed  this  operation  in  fifty  cases,  with  more 
satisfactory  results  than  he  had  obtained  by  any  other 
method. 

Obstipation.— Dr.  Sterling  B.  Taylor,  of  Colum- 
bus, Ohio,  read  this  paper.  Obstipation  was  defined, 
and  a  comparison  of  obstipation,  constipation,  and 
costiveness  made.  The  causes  of  obstipation  were 
dwelt  upon  and  classified.  Hypertrophy  of  the  rectal 
valve  was  emphasized  as  the  usual  cause  of  obstipation. 
The  essayist  defended  the  views  of  Martin  and  his 
method.  The  symptomatology  of  the  affection,  and  the 
palliative  and  radical  treatment  were  discussed,  the 
author  closing  his  paper  with  the  citation  of  several 
cases. 

Tuberculosis  of  the  Spine. — Dr.  Ale.xander  C. 
VViENER,  of  Chicago,  contributed  a  paper  on  this  sub- 
ject. He  made  a  plea  for  early  diagnosis  before  de- 
formity was  noticeable.  Extension  and  hygienic  treat- 
ment were  essential  in  avoiding  complications,  such 
as  paresis  and  gravitation  abscess.  He  exhibited  a 
specimen  which  illustrated  the  possibilities  of  forcible 
correction  of  the  spine.  He  narrated  cases  of  psoas 
abscess  in  which  he  had  effected  a  cure  with  injections 
of  concentrated  carbolic  acid. 

Medical  and  Surgical  Treatment  of  Acute  and 
Chronic  Cervical  Lymph  Nodes.— Dk.  Horace  H. 
Grant,  of  Louisville,  read  this  paper,  in  which  the 
purpose  and  function  of  the  hmphatic  glands  were 
dwelt  upon.  The  author  showed  how  they  might  be 
rendered  useless  and  harmful  by  disease  and  disin- 
tegration. He  pointed  out  the  limitations  of  medical 
and  expectant  treatment,  and  outlined  the  indications 
for  the  various  surgical  procedures. 

Fulminating  Appendicitis.— This  was  the  subject 
of  the  address  in  surgery,  delivered  by  Dr.  Cilarles 
A.  Wheaton,  of  St.  Paul,  Minn.  He  said  that  every 
case  of  appendicitis  was  and  by  rights  ought  to  be 
considered  surgical,  because  the  surgeon's  training 
specially  qualified  him  best  to  interpret  the  meaning 
of  the  symptoms  encountered.  Every  case  of  so-called 
fulminating  appendicitis  should  be  operated  upon  as 
soon  as  its  distinctive  characteristics  were  known. 
High  temperature  and  accelerated  pulse,  associated 
with  local  pain  and  rigidity,  were  strong  presumptive 
evidences  of  malignancy  in  the  attack,  and  if  associated 
with  vasomotor    disturbances    were  practically    proof 


714 


MEDICAL    RECORD. 


[November  3,  1900 


positive  of  perforation.  The  surgeon  who  refused  the 
only  chance  that  drainage  might  give  even  the  most 
desperate  cases  was  false  to  himself,  and  failed  ma- 
terially in  discharging  his  obligations  to  his  patient 
— obligations  which  the  patient  had  a  right  to  expect 
at  his  hands.  A  puncture  in  the  median  line,  in  the 
loins,  or  in  a  woman  in  the  posterior  cul-de-sac,  under 
local  anasthesia,  did  not  add  to  the  danger  of  the 
condition,  and  it  materially  aided  nature  in  the  awful 
uphill  fight.  In  short,  in  every  fulminating  case,  the 
rule  was  to  operate  first,  and  philosopiiize  afterward. 

Subarachnoidean  Injections  of  Cocaine  for  Opera- 
tions Below  the  Diaphragm. — Dr.  Carl  H.  Ander- 
sen, of  Chicago,  spoke  on  this  topic.  He  referred  to 
the  work  of  Tuffier,  Bier,  and  others  in  this  compara- 
tively new  field,  saying  that  sufficient  credit  had  not 
been  given  to  Leonard  Corning  as  the  originator  and 
adviser  of  this  method  of  anasthesia.  He  described 
its  technique,  which  was  substantially  that  outlined  by 
Tuffier,  and  reported  six  cases  in  which  lie  had  resorted 
to  the  method. 

Case  I. — Hydrocele,  with  vague  history.  The  pa- 
tient, colored,  was  twenty-eight  years  of  age,  strong 
and  healthy.  A  subarachnoidean  injection  of  TTlxv. 
of  a  two-per-cent.  solution  of  cocaine  was  given. 
Anaesthesia  was  complete.  When  the  scrotum  was 
opened  sarcoma  of  the  testicle  was  found  and  removed. 
On  the  ninth  day  after  the  operation  the  patient  died 
of  pulmonary  embolism. 

Case  II. — Varicose  veins  of  the  leg.  An  injection 
of  TTlviii.  of  a  two-per-cent.  solution  of  cocaine  was 
given.  The  anesthesia  lasted  five  hours  and  ten 
minutes.  No  pain  was  felt  during  the  operation. 
Perfect  recovery  ensued. 

Case  III. — Trachelorrhaphy  under  cocaine  anes- 
thesia. As  soon  as  tlie  operation  was  finished  the  pa- 
tient fainted  and  remained  in  that  condition  for  two 
hours.  Under  strychnine  and  salt  water  per  rectum 
she  rallied  and  recovered. 

Case  IV. — Amputation  of  a  toe  in  a  man  sevent)- 
two  years  of  age.  TTlvii.  of  a  two-per-cent.  solution 
of  cocaine  was  injected.  Uninterrupted  recovery  fol- 
lowed. 

Case  V. — Operation  for  suppurative  appendicitis 
upon  a  woman.  The  operation  was  performed  at  10 
a.m.  ;  at  2  P.M.  the  patient  showed  symptoms  of  medul- 
lary irritation,  pain  in  the  back,  and  severe  headache. 
It  was  now  several  days  since  tlie  operation  was  done, 
and  the  patient  had  had  a  terrific  headache  ever  since. 

Case  VI. — Version  and  use  of  forceps.  At  the  sug- 
gestion of  Dr.  Harold  N.  Moyer,  Dr.  Andersen  injected 
TTlxvi.  of  a  four-per-cent.  solution  of  eucaine  B  in  this 
case,  with  very  satisfactory  results.  The  patient  suf- 
fered no  pain  whatever.  Eucaine  B  could  be  per- 
fectly sterilized  by  boiling. 

Dr.  Andersen  spoke  of  the  difficulties  attending  the 
sterilization  of  cocaine,  and  outlined  a  method  by 
which  this  could  be  accomplished.  He  regarded 
lumbar  puncture  as  a  serious  operation,  and  urged 
practitioners  to  be  exceedingly  cautious  in  employing 
it.  These  cases  were  reported  for  the  express  purpose 
of  warning  the  profession  that  the  method  was  far  from 
harmless,  and  if  it  was  employed  indiscriminately  it 
would  lead  to  disastrous  consequences. 

Dr.  Harold  N.  Mover,  in  the  discussion,  said 
that  if  advised  as  to  the  use  of  this  method  of  anaes- 
thesia, he  would  say,  Do  not  use  it.  No  surgeon 
should  undertake  it  unless  he  had  a  well-equipped 
laboratory.  The  method  was  at  best  in  its  experi- 
mental stage,  and  further  research  and  experiments 
should  be  carried  on  in  well-equipped  clinics  until 
the  possible  dangers  of  this  method  were  better  and 
more  clearly  understood.  Among  the  dangers  were 
the  toxic  properties  of  the  cocaine.  A  four-per-cent. 
solution  of  eucaine  B  could   be  used  with   absolute 


safety.  It  was  about  one-third  as  toxic  as  cocaine, 
and  one-half  as  anesthetic  as  cocaine,  but  it  could  be 
absolutely  stezilized.  The  danger  of  infection  from 
such  injections  was  considerable,  and  should  not  be 
overlooked.  As  to  the  remote  dangers  from  this  form 
of  anasthesia,  cases  had  not  been  observed  sufficiently 
long  to  enable  surgeons  to  say  whether  or  not  theie 
were  sucii  dangers. 

Treatment  of  Tuberculous  and  Purulent  Hip- 
Joint  Disease  with  Large  Speculum  Drainage  and 
Pure  Carbolic  Acid. — Dr.  A.  M.  Phelps,  of  New 
York  City,  read  a  paper  with  this  title.  All  abscesses, 
tuberculous  or  purulent,  he  maintained,  should  be 
opened  for  the  purpose  of  exploration  as  soon  as  the 
diagnosis  was  made;  secondarily,  for  drainage,  and 
for  any  surgical  procedure  which  might  be  deemed 
advisable.  Excisions  should  be  performed  when  the 
acetabulum  was  extensively  diseased,  the  diseased 
tissues  removed,  and  the  joint  thoroughly  washed  out 
with  pure  carbolic  acid,  then  with  pure  alcohol,  and 
finally  with  a  two-per-cent.  solution  of  carbolic  acid, 
and  as  large  a  drainage  tube  of  glass  as  the  wound 
would  take  should  be  inserted.  Through  this  large 
drainage  tube  the  packing  for  drainage  purposes  could 
be  made.  The  large  glass  speculum  enabled  the 
operator  to  watch  every  pathological  change  which 
took  place  tiiroughout  the  wound.  It  kept  the  soft 
parts  widely  separated,  and  prevented  their  union 
until  after  the  bone  had  granulated  up  and  healed.  It 
enabled  the  operator  to  dress  his  patient  without  do- 
ing violence  to  the  granulating  surfaces  of  the  wound 
and  inflicting  unnecessary  pain.  All  rubber  drainage 
tubes  should  be  entirely  discarded,  as  they  were  filthy, 
collapsible,  and  a  source  of  infection.  The  carbolic 
acid  was  absolutely  neutralized  by  the  action  of  the 
alcohol.  Local  carbolic  poisoning,  and  even  when 
the  drug  was  taken  internally,  was  neutralized  by  the 
action  of  the  alcohol.  Pure  carbolic  acid  applied 
locally  was  a  specific  for  erysipelas,  the  points  of 
which  were  brought  out  in  the  paper. 

Pulmonary  Tuberculosis  in  Infancy  and  Child- 
hood.— Dr.  Frank  p.  Norburv,  of  Jacksonville,  111., 
read  this  paper.  This  disease,  he  stated,  was  not  a 
rarity  among  children,  as  the  utilization  of  available 
post-mortem  material  showed.  Heredity  was  of  etio- 
logical importance,  but  it  had  lost  its  prestige  as  com- 
pared to  its  former  standing.  Modern  scientific  in- 
quiry has  shown  that  infection  was  the  etiological 
factor /(?/-  excellctice.  Direct  heredity  could  account  for 
a  limited  number  of  cases.  The  infection  theory  was 
proven  by  the  lateness  of  the  appearance  of  disease; 
few  cases  occurred  during  the  first  year  of  life,  and 
the  number  steadily  increased  thereafter.  The  mode 
and  route  of  infection  were  important  considerations. 
Northrup,  Carr,  and  others  had  shown  that  tuberculosis 
started  more  frequently  in  the  thorax  than  elsewhere. 
Pulmonary  affections,  such  as  whooping-cough,  in- 
fluenza, etc.,  created  favorable  conditions  for  infec- 
tion. Enterocolitis  and  gastro-enteritis  created  portals 
for  intestinal  infection.  Milk  was  a  source  of  infection, 
and  so  was  tuberculous  meat.  The  diagnosis  might 
be  confounded  with  that  of  malnutrition.  Bovaird 
stated  that  two  evidences  of  early  invasion  were  "pro- 
gressive emaciation,  not  explained  by  other  disease; 
continued  elevation  of  temperature  similarly  condi- 
tioned." The  differential  diagnosis  from  broncho- 
pneumonia could  i)e  made  only  by  laboratory  methods. 
Acute  miliary  tuberculosis  and  broncho-pneumonic 
tuberculosis  were  most  frequently  found  in  infants 
and  children.  The  complications  were  meningitis, 
empyema,  and  involvement  of  bones.  The  prognosis 
was  grave  in  almost  all  cases,  but  lesions  of  the  lungs 
might  heal  under  favorable  conditions.  With  refer- 
ence to  treatment,  prophylaxis  during  infancy  should 
include  attention  from   birth  if  the  mother  was   tuber- 


November  3,  1900] 


MEDICAL    RECORD. 


715 


culous;  also  good  hygiene,  open-air  treatment,  and 
climatic  change  when  possible.  The  symptomatic 
care  should  be  the  same  for  children  as  for  adults. 
Good  nutrition  should  be  maintained,  and  as  little 
medicine  given  as  possible.  Creosote  was  recom- 
mended i)y  the  author,  as  were  simple  tonics. 

The  Physician  as  a  Sanitarian. — Dr.  Hugh  A. 
Cowing,  of  Muncie,  Ind.,  read  a  paper  on  this  subject 
in  which  he  discussed  preventive  medicine;  hygiene 
of  infection ;  the  physician  as  a  factor  in  the  spread 
of  infection;  the  physician  and  the  health  officer; 
health  legislation;  and  the  physician  and  tiie  public 
schools. 

The  Philosophy  of  the  Science  and  Art  of  Medi- 
cine.—  l!y  I)k.  William  F.  Dakclay,  of  Pittsburg,  Pa. 
The  author  said  that  thoughtful  minds  siiould  be  en- 
gaged in  sifting  truth  from  falsehood.  True  and  false 
pliilosophy  should  be  appropriately  applied  to  results 
obtained  in  rational  conclusions.  Tiie  philosophy  of 
medicine  was  the  comprehension  of  the  truth  in  the 
investigation  of  the  science,  enabling  one  to  arrive  at 
rational  conclusions  in  the  study  of  physical  laws 
which  governed  organized  matter  under  normal  and 
pathological  condition. 

Asthma iiy  Dr.  J5.  Alkxander  Pate,  of  Louis- 
ville, Ky.  Tiie  author  stated  that  Loomis,  Trousseau, 
Salter,  and  others  had  considered  asthma  a  diathetic 
neurosis.  Haig  attributed  it  to  the  effect  of  uric  acid 
upon  the  'circulation  in  the  thorax.  Modern  opinion 
seemed  to  regard  asthma  as  a  neurosis  of  the  pul- 
monary plexus  due  to  arthritism.  In  bronchial  asthma 
uric  acid  in  the  iilood  so  altered  nutrition  as  to  cause 
a  neurosis  of  the  branches  of  the  pulmonary  plexus, 
thus  inducing  hyperjesthesia  and  engorgement  of  the 
bronchial  mucosa,  spasmodic  contraction  of  the  mus- 
cular fibres,  and  the  various  manifestations  of  metab- 
olism. .\sthma  frequently  alternated  with  such  dis- 
eases of  the  arthritic  diathesis  as  neuralgia,  migraine, 
angina,  and  gout.  Clearing  the  blood  of  uric  acid 
had  relieved  asthma,  only  to  be  followed  by  gout,  as 
the  uric  acid  was  precipitated  into  the  tissues.  Asthma 
might  be  said  to  belong  to  the  class  of  uric-acid  dis- 
eases due  to  the  effect  of  iiigh  arterial  tension,  in  con- 
tradistinction to  those  produced  by  precipitation  of 
urates  into  the  tissues.  The  attacks  came  on  most 
frecjuently  when  the  blood  was  loaded  with  uric  acid 
during  the  alkaline  tides.  The  causes  of  asthma  were 
divided  into  two  classes:  First,  the  systemic  or  essen- 
tial cause — the  arthritic  diathesis.  Second,  the  local 
or  exciting  cause  of  the  attack.  The  first  of  these  was 
perhaps  present  in  every  case.  Cases  were  recorded 
in  which  mediastinal  tumors,  pressing  upon  the  pneu- 
mogastric  nerve  continuously,  first  caused  asthmatic 
paro.xysms  during  tiie  alkaline  tide.  Pressure  ex- 
plained the  neurosis,  and  tiie  time  of  the  paroxysm 
manifested  the  uric-acid  factor.  The  second  class  of 
causes  could  act  only  when  the  first  desisted.  The 
exciting  causes  of  the  disease  were  mentioned,  also 
the  symptoms.  Modern  treatment  had  been  able  to 
cut  short  the  attacks  in  most  instances,  and  often  to 
prevent  their  return.  Propiiylactic  treatment  should 
embrace  proper  hygiene  and  diet.  Prophylaxis  should 
be  begun  in  the  children  of  lithaeniic  individuals.  'I'he 
therapeutic  measures  embraced  the  care  of  the  attack 
and  treatment  during  the  interval.  After  the  removal 
of  the  exciting  cause  the  treatment  consisted  in  the 
use  of  such  remedies  as  overcame  arterial  tension  by 
freeing  the  blood  of  uric  acid.  The  treatment  of  the 
interval  consisted  in  the  use  of  such  drugs  as  elimi- 
nated uric  acid  from  the  system,  and  the  adherence  to 
such  a  diet  as  permanently  kept  down  arterial  tension. 
Rational  treatment,  based  upon  the  theory  of  uric- 
acidsmia  as  the  chief  factor  in  the  production  of 
asthma,  had  been  most  satisfactory  in  the  hands  of 
the  essayist. 


The  Curability  of  Inebriety  by  Medical  Tieat- 
ment — Dr.  T.  D.  Crothers,  of  Hartford.  Conn., 
stated  that  inebriety  was  a  neurosis,  usually  self- 
limited,  and  very  largely  curable.  The  craze  for 
drink  was  symptomatic.  The  real  causes  were  central 
nerve  irritation,  exhaustion,  poisoning,  and  starvation. 
The  success  of  the  treatment  depended  upon  accurate 
knowledge  of  the  causes  and  conditions  present  in 
each  case,  and  the  accurate  application  of  general 
means  and  measures  for  their  removal.  Each  case 
required  special  means  and  measures  particularly 
adapted  to  meet  the  conditions  present.  The  family 
physician  as  well  as  the  specialist  should  treat  these 
cases  successfully. 

Further  Observations  on  the  Clinical  Application 
of  the  Suprarenal  Capsule. — Dr.  VV.  H.  Bates,  of 
New  York  City,  read  a  paper  with  this  title.  The 
author  regarded  the  aqueous  extract  of  the  suprarenal 
capsule  as  the  most  powerful  astringent,  ha;mostatic, 
and  heart  tonic  known  to  the  profession.  It  lessened 
congestion  of  the  eye  and  of  other  organs.  The  ex- 
tract was  not  irritating  or  poisonous,  and,  unlike  other 
powerful  drugs,  was  never  in  his  opinion  contraindi- 
cated.  In  short,  the  profession  had  no  remedy  which 
was  so  useful  in  all  forms  of  infianimation. 

Clinical  Value  of  Purgative  Mineral  Waters. — 
Dr.  Edwin  Rosenthal,  of  Philadelphia,  discussed 
this  subject.  He  spoke  of  natural  and  artificial  min- 
eral waters;  simple,  thermal,  common  salt,  or  muriated 
w'aters.  He  dwelt  upon  the  waters  mostly  met  with  in 
commerce,  spoke  of  their  chemistry,  names,  mode  of 
action,  uses,  method  of  selection  of  a  special  purgative 
water,  etc. 

What  the  Law  Requires  of  a  Surgeon.— Dr. 
Drni.EY  S.  Rkvnold.s,  of  Louisville,  K_\-.,  followed 
with  an  interesting  paper  on  this  subject.  A  surgeon, 
it  was  stated,  must  possess  a  reasonable  familiarity 
with  the  science  of  his  profession;  he  must  exercise 
reasonable  skill  for  the  locality  in  which  he  practises, 
and  must  devote  due  diligence  and  care  in  attending 
to  his  patient.  If  the  patient  declined  to  submit  to 
that  treatment  which  in  the  judgment  of  the  surgeon 
was  most  appropriate,  and  he  did  not  abandon  the  case 
at  once,  he  assumed  liability  for  the  result  of  failure 
to  do  that  wiiich  in  his  judgment  was  best  for  the  re- 
lief of  the  jjatient. 

Differential  Leucocytosis.— Dr.  L.  H.  Warner,  of 
Brooklyn,  N.  V.,  read  this  paper.  Experiments  in 
recent  times,  he  held,  had  given  us  a  better  insight 
into  leucocytosis.  It  had  been  demonstrated  to  be 
due  to  three  causes — digestion,  inllanmiation,  and  in- 
fection. Physiological  and  biological  experiments  had 
proven  that  by  means  of  medication  a  true  picture  of 
leucocytosis  might  be  jiroduced,  but  which  in  reality 
represented  leucocyto-diuresis  —  a  condition  very  de- 
sirable in  the  treatment  of  disease  and  a  recognition 
of  which  was  of  the  greatest  value  when  ha.matology 
was  called  upon  to  aid  in  arriving  at  a  correct  diag- 
nosis. 

The  following  officers  were  elected  for  the  ensuing 
year:  President,  Dr.  A.  H.  Cordier,  of  Kansas  City, 
Mo.;  First  Vice-President,  Dr.  Charles  F.  McGahan, 
of  Aiken,  S.  C. ;  Second  I'ice-President,  Dr.  Charles  L. 
Minor,  of  Asheville,  N.  C;  Secretary,  Dr.  Henry  E. 
Tuley,  of  Louisville,  Ky.,  re-elected ;  Treasurer.  Dr. 
Dudley  S.  Reynolds,  of  Louisville,  Ky.,  re-elected. 

Put-in-Bay,  Ohio,  was  selected  as  the  next  place  for 
holding  the  meeting;  time,  September  10,  11,  and  12, 
1901. 

Dr.  J.  C.  Culbertson,  of  Cincinnati,  Ohio,  was 
selected  as  the  chairman  of  the  committee  of  arrange- 
ments. 

The  meeting  ended  with  a  banquet  at  the  Battery 
Park  Hotel,  given  by  the  Buncombe  County  Medical 
Society. 


7i6 


MEDICAL    RECORD. 


[November  3,    1900 


NEW   YORK    ACADEMY    OF    MEDICINE. 

SECTION    ON   SURGERY. 

Stated  Meeting,  October  8,  igoo. 

Charles  N.  Dowd,  M.D.,  Ch.^irman. 

Recovery  from  Strangulation  of  Intestine  Due  to 
Meckel's  Diverticulum. — Dr.  John  ¥.  Erdmann  pre- 
sented a  man,  thirty-four  years  of  age,  first  seen  by 
him  in  consultation  on  May  1st.  On  April  29th  he 
had  been  seized  with  severe  abdominal  pain,  which 
had  become  localized  in  the  region  of  the  appendi.\ 
on  the  following  day,  and  had  been  associated  with 
the  presence  of  a  tumor.  On  incision,  a  large 
Meckel's  diverticulum  had  been  found  adherent  to  the 
appendix  and  strangulating  the  bowel.  The  appendi.\ 
was  removed,  and  inverted  before  suture.  With  the 
exception  of  a  stitch  abscess  recovery  had  been  un- 
eventful. 

Some  Cases  of  Acute  Appendicitis. — Dr.  Alex- 
ander B.  Johnson  read  a  paper  with  this  title  (see 
page  6S8). 

Glass  Drainage  Tube  Broken  off  in  the  Pelvis. — 
Dr.  Howard  Collins  spoke  of  the  usefulness  of  a 
sponge-holder  and  gauze  in  cleansing  out  the  pelvis. 
\Vhen  the  opening  is  deep,  the  cotton  should  be  placed 
in  the  holder  flat,  and  then  on  moving  the  holder  up 
and  down  the  suction  would  tend  to  open  up  small  ab- 
scess cavities  in  the  neighborhood.  Reference  was 
made  to  a  case  in  which  a  long  glass  drainage  tube 
had  been  inserted  into  the  pelvis  an-d  had  been  broken 
off  by  the  patient  while  delirious.  A  sharp  fragment 
of  the  glass  had  pierced  a  large  blood-vessel,  giving 
rise  to  all  the  symptoms  of  sfiock  from  loss  of  blood. 
The  patient  was  transfused,  and  then  the  tube  was  re- 
moved after  considerable  difficulty. 

Dr.  John  A.  VVyeth  heartily  concurred  in  the  state- 
ment made  in  the  paper  regarding  the  harinfulness  of 
evisceration  or  undue  handling  of  the  bowel.  In 
cases  of  purulent  peritonitis  associated  with  foul  pus, 
irrigation  with  hot  salt  solution  ofl^ered  the  best,  if  not 
the  only,  hope  of  recovery.  It  was  quite  important  in 
such  cases  to  use  the  irrigating-fluid  under  consider- 
able pressure,  and  to  do  this  he  placed  the  irrigator  at 
a  considerable  height.  He  also  laid  great  stress  upon 
the  wiping-out  process,  because  he  believed  it  to  be 
very  detrimental  to  leave  moisture  behind.  He  was 
particularly  careful  to  clean  out  the  space  behind  the 
ascending  colon.  He  had  always  feared  to  make  use 
of  the  glass  drainage  tube  in  the  pelvis,  although  he 
had  not  before  learned  of  any  such  accident  as  that 
mentioned  by  the  last  speaker.  When  drainage  was 
employed  he  made  use  of  the  wick  drain. 

Dr.  W.  K.  Otis  said  that  he  had  w  itnessed  a  number 
of  the  operations  described  in  the  paper,  and  could 
testify  to  the  fact  that  at  least  the  larger  cavity  of  the 
peritoneum  was  involved  in  the  cases  described  as  ex- 
amples of  general  purulent  peritonitis. 

Dr.  a.  Ernest  Gallant  asked  if  in  the  cases  of 
abscesses  in  the  pelvis  mentioned  in  the  paper  there 
had  been  free  pus  or  accumulations  behind  the  peri- 
toneum. He  had  himself  seen  these  cases  of  retro- 
peritoneal accumulations  end  in  recovery,  though 
slowly.  A  few  days  ago  he  had  operated  upon  a  case 
in  which  the  appendix  was  up  against  the  abdominal 
wall.  During  the  manipulations  incident  to  removal, 
he  had  broken  through  the  cacum  into  one  of  these 
retroperitoneal  abscesses.  He  had  been  surprised  in 
this  instance  that  the  pus  was  not  of  the  stinking  kind 
■  usually  found  in  pelvic  abscesses.  He  had  had  this 
•nan  under  observation  for  about  four  years  because  of 
syphilis,  and  this  had  suggested  to  him  the  iiossibility 
that  this  abscess  had  resulted  from  the  breaking  down 
of  a  gumma.  In  two  cases  he  had  secured  good  drain- 
age by  an  incision  through  the  vagina. 


Dr.  Joseph  Wiener,  Jr.,  remarked  that  at  the  very 
last  meeting  of  this  section,  a  few  months  ago,  the 
general  trend  of  discussion  had  been  against  the  use 
of  saline  irrigation,  and  yet  we  had  just  heard  of  ex- 
cellent results  from  such  irrigation.  It  was  certainly 
very  important  to  dry  out  the  peritoneal  ca\  ity  before 
the  wound  was  closed,  but  whether  it  was  better  to  be 
content  with  simply  drying  it  out  or  to  use  first  saline 
irrigation,  he  was  as  yet  undecided.  In  the  cases  in 
which  colon  bacilli  predominated  the  prognosis  was 
best:  the  next  best  were  those  in  which  staphylococci 
were  found,  whereas  the  worst  prognosis  was  in  those 
of  streptococcus  infection.  Subphrenic  abscesses  de- 
veloped almost  invariably  in  cases  of  peritonitis,  and 
were  probably  the  result  of  lymphatic  infection. 

Dr.  Wveth  asked  if  there  was  any  difference  in  the 
odor  of  tlie  pus  in  the  different  varieties  of  infection. 

Dr.  Wiener  replied  that  in  the  cases  characterized 
by  the  foulest  pus  the  colon  bacilli  predominated. 

Dr.  Robert  T.  Morris  was  of  the  opinion  that  the 
intravenous  infusion  of  large  quantities  of  physiologi- 
cal salt  solution  constituted  an  effective  metiiod  of 
eliminating  toxins  and  combating  sepsis.  According 
to  his  experience  the  foulest-smelling  cases  were  not 
the  gravest  ones,  but  they  were  associated  with  the 
colon  bacilli.  Concerning  drainage  he  would  say  that 
Clark's  classical  article  of  three  years  ago  on  the  sub- 
ject of  drainage  by  way  of  the  peritoneum  should  be 
carefully  read  by  all  surgeons.  He  was  very  glad 
that  at  the  present  day  there  was  a  greater  tendency 
toward  using  smaller  incisions  and  depending  more 
upon  the  well-known  capacity  of  the  peritoneum  to 
dispose  of  fluids.  In  some  cases  of  several  days' 
standing  and  having  symptoms  of  sepsis,  he  had  been 
surprised  to  find  the  pus  sterile;  hence  the  operator 
must  be  cautious  about  distinguishing  between  cases 
which  must  be  drained,  and  those  which  could  be 
safely  closed  without  drainage.  He  predicted  that 
surgeons  would  be  surprised  in  the  future  to  find  what 
could  be  accomplished  without  drainage. 

Dr.  Johnson,  in  closing,  said  that  in  his  cases  of 
abscesses  in  the  pelvis  the  pus  lay  among  the  viscera 
in  and  not  behind  the  peritoneum.  He  was  convinced 
that  the  less  mechanical  violence  was  done  to  the  peri- 
toneum, and  particularly  to  the  intestine,  the  better  for 
the  patient.  It  had  been  shown  that  the  reaction  to 
mechanical  irritation  was  greater  in  proportion  to  the 
degree  and  extent  of  inflammation  present.  For  this 
reason  he  preferred  the  method  of  placing  gauze  in 
the  cavity  to  the  plan  of  wiping  it  out  with  gauze. 
He  had  laid  great  stress  upon  the  harmfulness  of  evis- 
ceration because  in  conversation  with  an  eminent  sur- 
geon in  this  city  the  latter  had  told  him  that  he 
practised  that  method,  and  did  so  because  he  thought 
this  shortening  of  the  operation  was  in  itself  a  life- 
saving  measure.  The  prognosis  did  not  by  any  means 
depend  solely  upon  the  kind  of  bacteria  present;  many 
other  factors  must  be  taken  into  consideration. 

Some  Considerations  on  Abdominal  Section. — Dr. 
Howard  Collins  read  tliis  paper.  He  said  that  when 
a  choice  of  incision  was  practicable,  the  one  selected 
should  be  that  which  least  interfered  with  the  support- 
ing function  of  tiie  abdominal  wall.  Loss  of  conti- 
nuity of  the  nornual  structures  and  the  paralysis  of  the 
muscles  from  division  of  their  nerve  supply  were  im- 
portant contributing  causes  in  the  production  of  her- 
nia after  operation.  Tlie  most  important  nerves  were 
the  lower  dorsal.  They  emerged  from  under  cover  of 
the  ribs  and  passed  obliquely  downward,  forward,  and 
inward  until  they  reached  the  outer  margin  of  the  rec- 
tus. They  then  divided  into  two  brandies,  one  pass- 
ing inward  and  slightly  upward,  and  the  other  inward 
and  slightly  downward.  From  a  point  half  an  inch 
below  the  tip  of  the  last  rib  a  line  should  be  drawn  to 
the  spine  of  the  pubis  of  the  opposite  side.     'I'his  line 


November  3,  1900] 


MEDICAL    RECORD. 


717 


from  the  point  of  origin  to  the  outer  margin  of  the 
rectus  muscle  overlay  the  twelfth  dorsal  nerve.  A 
similar  line  drawn  from  a  point  half  an  inch  above 
the  tip  of  the  twelfth  rib  to  the  middle  of  Poupart's 
ligament  on  the  opposite  side  marked  the  eleventh 
nerve.  A  line  starting  half  an  inch  -in  front  of  and 
above  the  tip  of  the  eleventh  rib,  and  extending  to  the 
anterior  superior  spine  of  the  ilium  on  the  opposite 
side,  traced  tlie  course  of  the  tenth  nerve.  The  ninth 
nerve  lay  between  the  ninth  and  tenth  ribs.  It  split 
into  two  branches  at  the  edge  of  the  rectus,  midwa)- 
between  tlie  entrance  of  the  eighth  and  tenth  nerves. 
'J'he  speaker  said  that  for  this  method  of  mapping  out 
these  nerves  he  was  indebted  to  Dr.  Brewer.  The 
nerves  supplying  the  recti  muscles  lay  at  a  right  angle 
to  their  fibres,  and  hence  mere  splitting  of  the  recti 
did  not  do  away  with  the  chance  of  dividing  these 
nerves,  but  only  a  few  small  fibres  were  likely  to  be 
cut.  Instead  of  cutting  through  the  fibres  of  the  semi- 
lunaris he  suggested  making  the  incision  just  external 
to  this  point,  as  this  went  through  tissues  having 
sufficient  thickness  to  enable  one  to  secure  better 
union.  In  the  operation  for  extir|)alion  of  the  kidney, 
a  good  incision  was  one  starting  one  inch  below  the 
last  rib  and  extending  from  the  quadratus  lumborum 
to  the  rectus  muscle.  This  traversed  no  important 
nerves.  A  vertical  incision  through  the  substance  of 
the  right  rectus  muscle,  about  one  inch  from  its  outer 
border,  gave  a  most  favorable  entrance  in  gall-bladder 
cases.  McHurney's  intermuscular  incision  was  com- 
mended highly  except  for  cases  re(|uiring  drainage. 
Here  it  was  not  desirable  because  of  the  tendency  of 
such  an  incision  to  close.  He  had  heard  of  a  case  in 
which  the  intermuscular  incision  had  been  used  in 
making  an  artificial  anus.  In  that  case  it  was  re- 
ported that  the  muscular  opening  fulfilled  very  well 
the  function  of  a  sphincter. 

Dr.  Moschcowitz  said  that  with  the  so-called  Kam- 
merer  incision  the  nerves  usually  passed  across  the 
incision.  When  first  using  this  incision  he  had  di- 
vided one  or  more  of  these  nerves,  but  subsequently 
he  had  read  an  article  in  which  the  statement  had 
been  made  that  the  nerves  could  be  divided  and  su- 
tured again  very  satisfactorily,  even  though  the  sutur- 
ing were  done  very  rudely.  Further  experience  had 
taught  him  that  it  was  ordinarily  possible  simply  to 
dislocate  the  nerve,  and  that  when  this  precaution  was 
taken  hernia  rarely  followed  the  operation. 

New  Clavicular  Crutch. — Dr.  Carter  S.  Cole 
presented  this  splint,  which  was  founded  on  one  used 
by  the  late  Dr.  C.  Fayette  Taylor  in  connection  with 
his  spinal  brace.  It  consisted  of  a  connecting  steel 
bar,  adjustable  as  to  its  length,  and  having  at  either 
end  a  hard-rubber  pad  of  such  shape  as  to  take  the 
place  of  the  clavicle.  Round  leather  pads,  kept  apart 
by  a  band  of  steel,  were  adjusted  over  each  shoulder 
blade,  and  the  two  parts  of  the  apparatus  were  held 
together  by  webbing  straps.  The  original  Taylor  in 
strument  was  not  intended  for  the  treatment  of  frac- 
tured clavicle,  but  was  a  mere  adjunct  of  the  spinal 
brace.  In  the  instrument  presented,  adequate  provi- 
sion was  mads  for  the  accurate  adjustment  of  the  ante- 
rior pads  or  "false  clavicles."  Dr.  Cole  said  that  he 
had  made  use  of  many  other  varieties  of  splints  and 
dressings  for  fracture  of  the  clavicle,  and  they  had  all 
proved  quite  unsatisfactory  until  he  had  devised  this 
one. 

Intestinal  Anastomosis — Connell  Suture. — Dr. 
Thom.vs  H.  M.\nlev  reported  a  case  of  strangulated 
hernia  first  seen  by  him  at  the  Harlem  Hospital  on 
August  20th.  At  that  time  there  had  been  no  signs 
or  symptoms  to  indicate  that  the  hernia  was  a  compli- 
cated one.  Operation  had  been  done  immediately, 
and  the  sac  found  filled  with  foul-smelling  fluid,  and 
the  gut  gangrenous.     The  affected  portion  of  intestine 


extended  up  to  the  caecum.  About  40  cm.  of  intestine 
were  resected,  and  on  division  of  the  bowel  the  latter 
was  found  to  be  filled  with  blood.  Deep  interrupted 
Lembert  sutures  were  used.  The  ileum  was  implanted 
on  the  anterior  wall  of  the  cacum.  The  operation  for 
radical  cure  of  hernia  was  also  done,  but  the  wound 
was  left  open.  On  the  sixth  day  the  discharge  from 
the  wound  had  a  fa;cal  odor,  but  after  the  second  week 
this  ceased.  At  present  the  patient  was  in  excellent 
condition,  having  completely  recovered.  The  section 
of  the  bowel  was  made  with  a  long  slope,  with  the  ob- 
ject of  maintaining  the  circulation  up  to  the  tip.  The 
Connell  suture  was  employed — a  continuous  suture 
passing  through  all  the  layers.  It  was  the  most  rapid 
method  of  its  kind  that  he  had  ever  tried.  Emphasis 
was  laid  upon  the  technique  used  in  making  the  lat- 
eral anastomosis. 

Choledochotomy.  — Dr.  J.  A.  ]5lake  reported  a  case 
of  choledochotomy  and  presented  the  specimen.  Ac- 
cording to  the  history,  the  first  attack  of  colic  had 
been  only  four  months  previously,  and  had  resulted  in 
collapse  and  loss  of  consciousness.  The  patient  had 
several  attacks  associated  with  jaundice  while  in  the 
hospital.  For  the  last  two  months  before  operation 
there  had  been  chills  and  fever.  At  the  operation  the 
gall  bladder  was  found  very  much  contracted,  but  it 
contained  no  stone.  Palpation  of  the  common  duct 
revealed  the  presence  of  a  stone.  It  was  used  as  a 
splint  for  the  insertion  of  the  sutures  and  preventing 
the  escape  of  bile.  Eiglit  fine  silk  sutures  were  used, 
and  by  this  plan  were  quickly  inserted.  The  incision 
was  made  through  the  rectus  muscle.  The  drainage 
tube  had  been  removed  on  the  fifth  day.  At  no  time 
was  any  bile-stained  fluid  discharged,  and  the  healing- 
process  proceeded  most  satisfactorily. 


^hcvtipcutic  glints. 

Tonsillitis. — At  the  onset  of  acute  catarrhal  tonsil- 
litis give  a  saline  purgative,  and  spray  or  brush  the  ton- 
sils every  hour  with — 

B  Formalin ni  xv.-xx. 

Potass,  chlor 3  '• 

Liq.  ferri.  chlor 31. 

.•\quae  mentlnv  pip q.s.  ad  |  iv. 

And  give — 

li  Quininns  hydrobromat gr.  i. 

Sodii  benzoatis gr.  ij. 

Salol gr-  V. 

M.  ft  ft.  cap.  No.  i.     S.  One  every  three  hours. 

— J.  A.  Abraham. 
Tapeworm. — 

K  Pomegranate  b?rk  of  root 3  iv. 

Pumpkin  seed §  i. 

Ext.  male  fern 3  i. 

Pulv.  ergot 3  ss. 

Croton  oil "l  jj. 

Gum  arable 3  ■]■ 

Water ad  3  viij. 

M.  S.   At  one  dose. 

A  light  supper,  a  full  dose  of  Rochelle  salts. 

In  Bacteruria. — Lavage  and  instillations  of  nitrate 
of  silver,  sublimate,  or  protargol,  combined  with  the 
internal  administration  of  salol  in  increasing  doses  up 
to  3  iiss.  per  diem.  Large  quantities  of  water. 
— Jeanrrau. 

When  streptococci  predominate,  antistreptococcic  se- 
rum— Dewy. 

Urotropin  in  Typhoid  Fever. — During  the  first  two 
weeks  of  typhoid  fever  bacilli  can  be  obtained  from 
the  fieces,  but  they  gradually  disappear  during  the  third 


7i8 


MEDICAL    RECORD- 


[November  3,  1900 


and  fourth  weeks.  On  the  other  hand,  the  urine  is  free 
from  bacilli  in  the  early  stage  of  typhoid,  and  they 
appear  during  the  third  or  fourth  week  or  during  con- 
valescence. Both  excreta  are  a  source  of  reinfection. 
Dr.  P.  Horton  -Smith  recommends  urotropin  in  doses  of 
2  gm.  daily,  and  claims  that  under  its  use  the  bacilli 
disappear. — Briiish  Medical  Journal. 

Cholera  Morbus. — Very  hot  turpentine  stupes,  con- 
sisting of  one  tablespoonful  of  turpentine  to  the  quart 
of  water,  and  internally — 

I^  .Spir.  aether,  comp. , 

.Spir.  lavanduln;  comp., 

Tinct.  opii  c.imph aa  3  ij. 

Tinct.  capsici  ...    tlj,  xv. 

Tinct.  zingiberis 3  ij- 

M.     S.   One-half  to  one  teaspoonful  every  two  hours. 

— S.  A.  Buchanan. 
For  Earache. — 

'B,  Carbolic  acid gr.  vij. 

Fid.  extract  of  opium TI|^  vi. 

llydrochlorate  of  cocaine gr.  iij. 

Atropine  sulphate gr.  iij. 

Water 3  i. 

Gelatin gr.  xviij. 

Glycerin 3  iiss. 

M.  et  ft.  bougies  No.  .xlii.      S.   Insert  in  ear. 

N.B.  Keep  in  glass  bottle  and  dust  with  lycopodium. 
— G.  L.   Richards. 

Barber's  Itch. — 

"S,  Ichthyol gr.  xx. 

Sulphur  precipitat 3  i. 

Bismuth  formic  iodide 3  ss. 

Vaseline  (benzoinated) 5  i. 

M. 

— Buchanan. 
Scarlatinal  Angina. — 

IJ  Sozoiodol-sodium, 

Sulphuris  precip aa   15 

M.      S.    Insufflate  with  powder  blower  several  times  daily. 

When  insufflation  causes  nausea  the  sozoiodol-sodium 
maybe  given  internally  in  solution  in  half-teaspoonful 
•doses  three  times  a  day. — A.  Baginsky. 

In  Chronic  Prostatic  Hypertrophy,  suprarenal  ex- 
tract in  five  to  ten  grain  doses  three  times  a  day  after 
meals  is  recommended. 

In  Eclampsia,  if  the  spasms  are  apparently  under 
control  and  yet  the  pupil  is  contracted,  anticipate  a 
return  of  the  spasm. — Medical  Summary. 

Ptyalism. — 

H,  Sodii  boratis 3  ij. 

Pulv.  myrrha; 3  i. 

Aquae 3  vi. 

M.     S.   Mouth  wash. 

— Potter. 
In     Acute  Bronchitis.^ 

V,  Ammon.  muriat 3  i. 

Liq.  ammon.  anisatis 3  iiss. 

Tr.  opii  camph. , 

Tr.  hyoscyami aa  3  iij. 

Syr.  pruni  virgin q.s.  ad  §  ij. 

M .     S.    3  i.  every  three  hours. 

Purpura. — 

M,  Sodii  sulphatis 3  ij. 

Ferri  sulphatis gr.  iij. 

Ac.  sulphurici  dil '1  xv. 

Tr.  hyoscyami ni  xl. 

Infus.  calumba; 5  ij. 

M.     S.   To  be  taken  every  morning. 

— Tanner. 

Schoull's  Treatment  for  Pulmonary  Tuberculosis. 

— For  ten  successive  days,  mornings  (sometimes  even- 
ings also)  SchouU  gives  subcutaneous  injections  of 
0.05  gm.  of  sodium  cacodylate;  then  intervenes  a 
pause  of  ten  days;  meanwhile  and  for  fifteen  succes- 
sive days  he  gives  internally,  after  meals,  0.5  to   i.o 


gm.  of  thiocol  in  powder  form.  This  is  followed  by  a 
five  days'  pause,  and  the  cycle  is  then  repeated. — Jour- 
nal des  J'raticifns,  August  18,  igoo. 

In  Syphilitic  Lobar  Pneumonia. — 

If  .Amnion,  iodidi   gr.  xl. 

Spir.  amnion,  aromat 3  ij. 

Elixir  aromat |  i. 

Aqu;i; q.s.  ad  J  viij. 

M.     S.    ji.  t.i.d. 

In  Pelvic  Inflammation — Liquor  hydrargyri  per- 
chloridi  in  half-drachm  doses  three  times  a  day,  com- 
bined with  infusion  of  calumba,  often  exerts  a  marked 
influence  in  the  absorption  of  inflammatory  products, 
and  is,  in  my  experience,  the  simplest  and  most  suc- 
cessful drug  in  cases  of  prolapse  of  the  ovary,  with 
adhesions. — Bedford  Fen  wick. 

In  Pulmonary  Tuberculosis. — 

IJ  Calcii  phosphatis, 

Menthol aa  gr.  iv. 

Sodii  bicarb gr.  iij. 

Pulv.  nucis  vomicEE, 

Ferri  lactatis aa  gr.  ^ 

M.     S.  One  such  dose  to  be  taken  four  times  daily. 

In  Acute  Rhinitis.— 

IJ  Ichtliyoli 0.05 

■  Etheris 50 

Alcohol 50 

M.      S.   Use  as  a  spray. 

In  Acne  due  to  Digestive  Derangement.— Inter- 
nally: 

IJ  Creosoti HI  ss. 

Cerii  oxalatis gr.  ij. 

Pepsini  pur gr.  i. 

Strychnin*  sulphatis gr.  5'j 

Tinct.  belladonna?    ^U  ij. 

Podophyllotoxini gr    ^^ 

M.   et  ft.  cap.  No.  i.     S..  One  such  to  be  taken  after  each 
meal  and  at  bedtime  if  necessary. 

Locally: 

IJ  Acidi  salicylici gr.  .xx. 

Olei  eucalypti ni  x. 

Acidi  borici 3  ss. 

Ungt.  zinci  oxidi, 

Ungt.  aq.  rosa; aa  3  ss. 

M.  et  ft.  ungt. 

— Shoemaker. 
Furunculosis  of  the  Ear. — 

IJ  Zinci  oxidi 3  i. 

Acidi  carbolici gr.  x. 

Vaselini  albi |  i. 

M. 

A  cylindrical  tampon  of  cotton-wool  is  smeared 
with  a  layer  of  tliis  ointment,  and  inserted  into  the 
canal.  It  should  be  large  enough  to  produce  consid- 
erable pressure.  The  greater  the  swelling  the  greater 
should  be  the  pressure  exerted  by  the  tampon.  The 
pain  is  at  first  severe  but  disappears  after  a  few  mo- 
ments, if  not  insert  smaller  tampon.  Before  tampon- 
ing douche  canal  with  lysol  solution.  Repeat  tampon 
and  douche  daily. — Lamel,  O.xel  and  Mui.ler. 

Flatulence  and  Colic  in  Infants. — 

IJ   Magnesii  carb gr.   iiss. 

Khei  pulv gr.  X 

Syr.  zingiberis Til  v. 

Ung.  nienth.  pip q.s.  .ad  3  i. 

M.     S.   Given  every  two  to  four  hours  to  an  infant  three  or 
four  months  old. 

— Ashley  and  Wright. 

Cathartic  Lemonade. — 

IJ  .Sodii  phosphatis 3  viss. 

.Spir.  limonis ■. "1  xx. 

.Syr.  simplicis 3  ij. 

.\q    destill q.s.  ad  3  x. 

M.      S.    Take  at  a  dose. 

A  Study  of  the  Physiological  Action  of  Phenace- 
tin. —  I.  Moderate  doses  of  phenacetin  are  without  any 
distinct  action   on    any   vital   organ.     2.  Large  doses 


November  3,  1900] 


MEDICAL    RECORD. 


719 


lessen  reflexes  by  a  direct  action  on  tiie  spinal  cord. 
3.  Doses  of  0.5  gm.  per  kilo,  of  body  weight  (a  little 
less  tiian  one  ounce  for  a  one-hundred-and-fifty-pound 
man)  kill  by  arrest  of  respiration.  4.  Doses  even 
up  to  0.5  gm.  per  kilo,  have  no  distinct  effect  on  the 
circulation. —  H.  C.  and  H.  li.  Wood. 

Hyperidrosis  Pedis.— 

If  Balsam  of  Peru i 

Formic  acid 5 

Chloral  hydrate 5 

Alcohol,  absolute 89 

S.   Apply  by  means  of  a  pad  of  wool. 

If  .\lumnol 4 

Aristol 4 

Starch 15 

^  Boric  acid 2 

Horax 75 

Salicylic  acid 75 

Glycerin 100 

Alcohol 100 

M.  ft.  lotio. 

— Pharm.  Post. 


ITtXccUcul 


2  terns. 


Contagious  Diseases — Weekly  Statement. — Report 
of  cases  and  deaths  from  contagious  diseases  reported 
to  the  Sanitary  Bureau,  Health  Department,  for  the 
week  ending  October  27,  1900: 


Tuberculosis 

Typhoid  fever 

Scarlet  fever 

Measles 

Diphtheria 

Laryngeal  diphtheria  (croup) 
Cerebro-spinal  meningitis. . . . 
Varicella 


Cases. 


Deaths. 


Quinine  in  Malaria.— Dr.  Manson  in  the  discus- 
sion held  on  the  use  of  quinine  in  malaria  at  the  re- 
cent meeting  of  the  British  Medical  Association, 
spoke  as  follows:  "The  reputed  prophylactic  action 
of  quinine  is  but  a  phase  of  its  therapeutic  action,  it  is 
the  application  of  the  drug  to  the  parasite,  and  not  an 
immunizing  of  the  body  against  the  entrance  of  tiie 
parasite  we  have  to  deal  with,  therefore  we  may  confi- 
dently expect  that  if  it  will  cure  a  malarial  affection 
it  will  prevent  the  development — the  development 
though  not  the  introduction  of  the  germ.  Further, 
that  as  some  types  of  the  parasite  are  highly  amena- 
ble to  the  drug  given  therapeutically,  similarly  its 
prophylactic  power  will  be  greater  against  such,  thus 
we  may  confidently  expect  it  to  be  a  timely  prophylac- 
tic as  against  the  benign  tertian,  but  less  active 
against  the  malignant  tertian.  The  value  of  the  drug 
is  apt  to  be  underrated  in  consequence  of  its  being 
given  in  too  routine  a  fashion,  and  often  under  condi- 
tions in  which  it  cannot  be  absorbed  as  in  states  of 
severe  gastro-intestinal  catarrh.  Such  failures  should 
be  eliminated  in  assessing  its  prophylactic  value.  I 
should  recommend  that,  in  future,  experiments  in  pro- 
phylaxis be  made  with  the  aid  of  the  microscope,  and 
in  reference  to  the  particular  type  of  malarial  parasite 
it  is  used  against,  and  also  that  the  gastro-intestinal 
condition  of  the  individual  experimented  on  be  inves- 
tigated and  recorded." 

Origin  of  Syphilis. — It  has  always  been  a  moot 
question  to  know  whether  syphilis  was  of  American 
or  of  European  origin.  Dr.  Zambaco  Pacha,  who  has 
become  quite  an  authority  on  such  subjects  as  leprosy, 
Alorvan's  disease,  and  kindred  affections,  has  presented 
some  photographs  of  bones  that  had  been  found  in 
Upper  Egypt,  and  dating  from  eighty  centuries  back. 


These  bones  showed  indications  of  suppurative  ostei- 
tis, enlargement  of  the  femurs,  tibias,  and  fibula;. 
The  disjiosition  of  the  lesions  is  such  that  Professor 
Lannelongue  admitted  that  they  seemed  to  be  of  syphi- 
litic origin.  This  would  prove  that  syphilis  has  ex- 
isted in  Europe  from  the  first  ages.  Dr.  Fournier 
examined  the  photographs  and  declared  that  there  was 
no  sure  sign  that  the  lesions  were  of  syphilitic  origin. 
The  simple  examination  of  a  bone  is  not  sufficient  to 
demonstrate  the  existence  of  syphilis.  The  common 
varicose  ulcer  sometimes  causes  hyperosteosed  tibias, 
which  are  similar  to  those  caused  by  syphilis;  the 
same  can  be  said  of  typhoid  fever.  Dr.  Zambaco  in- 
sisted on  the  large  number  of  lesions  seen,  but  Dr. 
Fournier  said  that  tuberculosis  sometimes  produced 
similar  results. — Paris  correspondent  2'herapeutic  Ga- 
zette-. 

Health  Reports The  following  cases  of  smallpox, 

yellow  fever,  cholera,  and  plague  have  been  reported 
to  the  surgeon-general  of  the  United  States  Marine- 
Hospital  service  during  the  week  ended  October  27, 
1900 : 

Cases.    Deaths, 
Smalli-ox— Unitrd  States. 

Colorado,  Arapahoe  Co Scptcmljer  lylh  to  October  lolh..  9 

Rio  (irande  Co. .  .September  25th  to  October  slh. . .  4 

Custer  Co October  slh x 

Kansas,  Cherokee  Co September  ist  to  3ath 3 

Crawford Septcml>er  1st  to  30th 4 

DouKlas  Co September  ist  to  30th i 

Rawlins  Co September  ist  to  30th ....  4 

Shawnee  Co September  ist  to  30th 2 

Louisiana.  New  (Orleans October  13th  to  20th i 

Minnesota,  Minneapolis  ....October  13th  to  3oth i 

N.  Hampshire,  Manchester. October  13th  to  loth 1 

Oliio,  Cleveland October  I3lh  to  aoth  7 

Pennsylvania.  Philadelphia  .October  13th  to  20th 3 

Utah,  Salt  Lake  City October  13th  to  20lh 6 

SMALI.rOX— FOKKIGN. 

Argentina,  Buenos  Ayrcs. .  .AuRust  1st  to  31st 10  4 

Austria,  Prague September  23d  to  39th i 

iJel^ium,  Antwerp September  3zd  to  29th  i 

Canada,    Yukon     Territory, 

Dawson September  24th 4 

Epypt,  Cairo September  23d  to  sclh i 

England,  Liverpool September  30th  to  October  tth  ..     4 

London September  22d  to  October  6th  .. .     3 

Southampton September  30th  to  October  6lh  ...     4 

West  Hartlepool . .  September  30th  to  October  6th  ...     3 

France,  Paris September  23d  to  30lh 7 

Gibraltar October  1st  to  7th i 

Greece,  Athens September  30th  to  October  6th. . .     2 

India,  Bombay September  i8th  to  25lh z 

Calcutta September  15th  to  22d 6 

Madras September  islh  to  21st 3 

Italy,  Sorrento October  loth * 

iapan,  Formosa August  ist  to  31st i 
lexico.  Vera  Cruz October  6th  to  20th a 

Russia,  Moscow September  32d  to  20th 2  i 

Odessa September  30th  to  October  6th  . .    ro  I 

St.  Petersburg September  22d  to  2gth 7 

Warsaw September  15th  to  2^th 22 

Scotland,  Glasgow October  5th  to  12th 25  I 

*  Generally  prevalent. 

Yellow  Fever. 

Colombia,  Bocas  del  Toro  . .  October  22d i 

Cuba,  Havana October  6th  to  13th 18 

Mexico.  Tampico October  7th  to  i4lh 3  x 

Vera  Cruz October  6lh  to  20th 13 

Cholera. 
Indi.i,  F.ombay September  i8th  to  25th 

Calcutta September  i5lh  to  22d 

Madras September  1 5th  to  22d 

Japan,  Nagasaki September  nth  to  aoth 1 


64 

7 

5' 


Plague — United  States. 

California,  San  FrancLsco. .  .October  5th  to  loth a* 

*  Bactcriologically  confirmed. 

Plagl-e— Foreign  and  Insvlab. 

China,  Hong  Kong August  i8th  to  September  ist . ..  13  13 

Egypt,  Alexandria Septemt>er  17th  to  24lh 2  t 

India,  Bombay September  i8th  to  2£ith 89 

Calcutta September  15th  to  22d 24 

Japan,  P'ormosa .August  1st  to  31st 4  3 

Kobe October  23d Present. 

Sootland,  fiiasgow September  30th  to  Octot)er  6th x 

Wales,  Llandoff October  nth i* 

*  From  steamer  Southgarth  from  River  Platte. 

Water  Supply  in  Military  Camps.— Major  James, 
R.A.M.C.,  read  a  paper  before  the  British  Medical 
Association  at  their  recent  meeting  in  Ipswich  on 
sanitation  in  military  camps;  part  of  the  address  was 
as  follows:  "The  water  supply  is  one  of  the  most  im- 
portant things  to  supervise,  and  most  of  the  common- 
est camp  pests  in  the  shape  of  enteric  fever,  dysentery 
perhaps,  and  cholera,  are  water  borne.     Water  which 


720 


MEDICAL    RECORD. 


[November  3,  1900 


may  be  good  at  its  source  may  so  easily  become  poi- 
sonous between  that  and  tiie  consumer's  stomach,  that 
the  distribution  must  be  as  closely  watched  as  the  ori- 
gin, and  this  in  camp  is  a  great  difticulty.  When  men 
are  thirsty  they  will  drink  anything  and  anywhere;  I 
believe  something  could  be  done  by  education  to  re- 
strain a  man  at  ordinary  times,  but  when  the  weather 
is  hot  and  water  scarce,  reason  has  to  give  way  to  im- 
pulse. If,  however,  water  is  plentiful  and  good,  and 
obtained  from  a  stream,  a  spot  above  the  camp  should 
be  marked  for  drinking;  lower  down  for  horses,  and 
lower  for  washing  and  washing  clothes.  The  point 
of  obtaining  the  drinking-water  should  be  policed,  and 
the  stream  above  put  out  of  bounds,  and  the  area  drain- 
ing into  it  also.  The  water  should  be  delivered  from 
a  spout  or  pump,  and  no  dipping  of  vessels  into  it 
allowed.  It  may  be  dammed  up  so  as  to  accumulate 
and  allow  sediment  to  fall,  and  if  the  camp  be  stand- 
ing there  sheltered  or  roofed  over.  In  the  case  of 
water  being  obtained  from  a  large  river  it  should  be 
rough  filtered,  or  a  Norton's  tube  pump  sunk  in  the 
shore  to  stop  out  the  grosser  impurities,  then  boiled 
or  filtered  or  both.  The  use  of  alum  to  throw  down 
suspended  matter  is  universal  among  Chinese  on  the 
Peiho  and  might  take  the  place  of  rough  liltering  as  a 
prelude  to  boiling,  etc.  For  use  in  the  men's  water 
bottles,  tea  should  be  made  on  a  large  scale  where 
water  is  not  above  suspicion.  A  sterilizer  with  a 
coiled  tube  heated  at  one  point  was,  I  believe,  tried 
but  is  not  yet  very  portable.  The  use  of  aerated  water 
or  the  water  obtained  at  the  authorized  source  may  be 
encouraged.  Where  the  camp  is  a  standing  one  it 
may  be  possible  to  dig  wells.  This  should  be  done 
if  water  is  near  the  surface  and  the  alternative  source 
is  a  stream  liable  to  pollution." 

The  Smoke  Nuisance — At  the  International  Con- 
gress of  Hygiene  and  Demography  recently  held  in 
Paris,  Mr.  Adolphe  Smith,  in  the  discussion  which  fol- 
lowed a  consideration  of  the  smoke  question  in  towns, 
had  this  to  say:  "  He  protested  against  the  suggestion 
sometimes  lightly  made  that  smoke  was  not  injurious. 
Parisians  especially  would  have  to  be  careful  now 
that  wood  was  so  dear,  and  the  consumption  of  coal  in 
private  houses  was  increasing  rapidly.  There  was 
much  more  smoke  in  Paris,  and  even  if  this  smoke 
was  not  particularly  injurious  in  itself,  it  became  very 
mischievous  when  mixing  with  a  white  mist  it  pro- 
duced a  black  fog,  and  the  fogs  in  Paris  were  getting 
more  and  more  like  those  in  London.  Whatever 
chemists  might  say  about  smoke,  it  was  a  fact  that  in 
London  thick  '  pea  soup '  fogs  sent  up  the  death  rate 
by  leaps  and  bounds.  As  for  the  suggestion  made 
that  the  law  should  insist  on  perfect  combustion — what 
was  perfect  combustion?  Theoretically,  if  perfectly 
consumed,  a  kilogram  of  carbon  should  yield  8,080 
calorics  of  heat  and  produce  no  smoke  whatever  and  no 
carbon  mono.xide.  Practically  a  kilogram  of  carbon 
yielded  little  more  than  2,470  calorics  of  heat,  produced 
a  quantity  of  black  smoke,  and  some  carbon  monoxide. 
Could  any  one  say  where  and  how  perfect  combustion 
was  produced  for  industrial  or  commercial  purposes.'' 
The  speaker  had  been  privileged  in  making  experi- 
ments with  a  stove  that  did  realize  the  ideal  of  no 
smoke,  no  carbon  monoxide  of  perfect  combustion,  in- 
deed the  combustion  was  so  perfect  that  it  not  only 
melted  platinum  but  consumed  the  stove  as  well. 
Thus,  a  laboratory  success  proved  a  commercial  fail- 
ure, for  no  one  would  buy  a  stove  which  burnt  itself 
up  in  a  few  weeks.  The  fact  was  that  the  problem 
still  awaited  a  practical  solution.  They  might  reduce 
the  volume  of  smoke,  but  they  did  not  know  how  to 
abolish  it  altogether.  But  the  advantages  of  perfect 
combustion  were  so  enormous  from  the  sanitary,  eco- 
nomical, and  aesthetic  points  of  view,  that  every  effort 


should  be  made  to  encourage  research  and  inventions 
in  this  direction.  The  state  and  the  municipalities 
should  give  some  impulse  and  facilities  to  such  en- 
deavors."— Lanat. 

The  Rise  of  Surgery  in  Germany. — In  Germany, 

even  so  recently  as  one  hundred  years  ago,  surgery 
was  at  a  low  ebb.  George  Fischer  tells  us  that 
quacks  of  all  kinds,  "cutters"  for  stone  and  hernia, 
cataract  operators,  and  bone  setters  flourished  in  the 
land.  The  public  executioner,  whose  business  it  was 
to  fracture  bones  and  dislocate  joints  on  the  rack, 
was  supposed  thereby  to  have  acquired  a  knowledge 
of  disorders  of  these  parts,  and  was  consulted  freely 
about  them,  so  much  so  that  Frederick  the  Great  in 
1744  published  a  decree  limiting  the  power  of  these 
men,  and  while  permitting  them  to  treat  fractures, 
wounds  and  ulcers,  forbade  them  to  practise  medicine. 

New  Cure  for  Astigmatism. ^An  English  popular 
weekly  is  responsible  for  the  following  gem:  "In  the 
public  schools  of  some  cities  measures  are  taken,  by 
presumably  competent  otticials,  to  test  the  children's 
eyesight  upon  the  assumption — often  too  well  founded 
— that  the  parents  are  not  sufficiently  watchful  in  that 
important  particular.  A  little  boy  came  home  one 
day,  soon  after  the  term  had  commenced,  with  the  fol- 
lowing note  signed  by  the  principal:  'Mr.  Green: 
Dear  Sir,  It  becomes  my  duty  to  inform  you  that  your 
son  shows  decided  indications  of  astigmatism,  and  his 
case  is  one  that  should  be  attended  to  without  delay.' 
The  father  sent  this  answer  the  next  day:  'Mr.  Ker- 
shaw: Dear  Sir,  Whip  it  out  of  him.  Yours  truly, 
John  Green.'  " 


While  the  Medical  Record  is  pleased  to  receive  all  new  pub- 
lications which  may  be  sent  to  it,  and  an  acknowledgment  will  be 
promptly  made  of  their  receipt  under  this  heading,  it  must  he  with 
the  distinct  understanding  that  its  necessities  are  such  that  it  can- 
not lie  considered  under  obligation  to  notice  or  revie-ai  any  publica- 
tion received  by  it  which  in  the  judgment  of  its  editor  will  not  be 
of  interest  to  its  readers. 

Modern  Surgery.  By  John  Chalmers  DaCosta,  M.D. 
Svo,  II 17  pages.  Illustrated.  W.  B.  Saunders  &  Co.,  Phila- 
delphia, Pa. 

Text-Book  of  Physiology.  By  E.  A.  Schafer.  Svo,  1365 
pages.  Illustrated.  Young  J.  Pentland,  London.  The  Mac- 
millan  Co.,  New  York. 

A  Text-Book  of  the  Pr.\ctice  of  Medicine.  By  James 
M.  Anders,  .M.D.  Svo,  1292  pages.  Illustrated.  W.  B.  Saun- 
ders &  Co.,  Philadelphia,  Pa. 

A  Tf.xt-Book  of  Pathology.  By  .Mfred  Stengel,  M.D. 
Svo,  873  pages.  Illustrated.  W.  B.  Saunders  &  Co.,  Philadel- 
phia, Pa. 

Modern  Medicine.  By  Julius  L.  .Salinger,  M.  D.  Svo, 
Sol  pages.  Illustrated.  \V.  B.  Saunders  &  Co.,  Phil.-idelphia, 
Pa. 

The  American  Illustrated  Medical  Dictionary.  By 
W.  .\.  Newman  Dorland,  M.D.  Svo,  770  pages.  Illustrated. 
W.  B.  Saunders  &  Co. ,  Philadelphia,  Pa. 

Eye,  Ear,  Nose,  and  Throat.  By  William  Lincoln  Bal- 
lenger,  M.D.  Svo,  511  pages.  Illustrated.  Lea  Brothers  & 
Co.,  Philadelphia  and  New  York. 

The  Australian  Medical  Directory  and  Handbook. 
By  Ludwig  Bruck.  Svo,  224  pages.  Illustrated.  L.  Bruck, 
Sydney. 

Essentials  of  IIisiology.  By  Louis  Leroy.  M.D.  i2mo, 
231  pages.  Illustrated.  W.  B.  Saunders  &  Co.,  Philadelphia, 
Pa. 

The  Care  of  the  Consumttive.  i2nio,  1R2  pages.  G. 
P.  Putnam  &  Sons.  New  York  and  London. 

Les  Maladies  Qu'on  Soigne  a  Berck.  By  F.  Calot. 
l2mo,  443  pages.      Illustrated.     G.  Masson,  Paris. 

Saunders'  Pocket  Medical  Formulary.  By  William  M. 
Powell.      i6mo,  2y8  pages.     \V.  B.  Saunders,  Philadelphia,  Pa. 


Medical  Record 

A    IVeekly  jfournal  of  Medicine  and  Surgery 


Vol.  58,  No.  19. 
Whole  No.  1566. 


New  York,   November    id,  1900.    single  Copi 


$5.00  Per  Annum, 
es,  IOC. 


©riginaX  Articles. 

SOME   CLINICAL    ASPECTS    OF    GOUT.' 
By    BKVERLEY    ROBINSON,    M.D., 

.NEW    VOKK. 

To  the  practitioner  of  general  medicine  to-day,  the 
most  evident  tendency  is  unquestionably  the  all-per- 
vading disposition  to  localize  human  ills  and  to  as- 
sign, if  possible,  a  change  of  tissue  to  explain  symp- 
toms. 

From  the  laboratory  point  of  view  and  according  to 
those  who  limit  their  researches  in  this  direction, 
micro-organisms  are  brought  to  the  front  almost  in- 
variably, and  serve  to  explain  whatever  morbid 
sequences  may  arise.  When  neither  anatomical 
changes  can  be  detected,  nor  microbes  apparently 
causative  are  discovered,  chemical  research  is  ap- 
pealed to,  and  thus  theories,  usually  varied,  are  as- 
signed to  explain  facts  which  are  obscure. 

The  general  pathology  of  former  days  saw  undoubted 
facts  also  in  atmospheric  changes,  constitutional  pe- 
culiarities, habits  of  mind  or  body,  which,  because  ob- 
scure and  undetermined  ultimately,  are  now  relegated 
frequently  to  the  past,  and  when  appealed  to  merely 
seem  for  many  to  cloak  ignorance  or  incompetency. 
And  yet,  how  true  it  is  for  the  man  of  large  observa- 
tion and  philosophic  mind  to  trace  many  of  our  ills  to 
purely  functional  disturbances  that  probably  shall 
never  be  clearly  revealed,  unless  we  should  assume 
that  the  microscope,  the  chemical  balance,  and  all 
other  instruments  of  accurate  research  are  given  to 
solve  the  final  changes  of  man's  organism. 

Such  thoughts  as  these  are  forced  upon  one  who 
sees,  or  believes  he  sees,  many  of  the  protean  or  ob- 
scure forms  of  gout,  in  apparently  their  mere  func- 
tional expressions.  In  some  of  these  cases  there  is 
history  of  a  previous,  well-marked  gouty  attack,  typical 
perhaps  in  its  localization  and  symptoms.  After  such 
an  access  more  or  less  tissue  changes  remain;  in  rare 

\  instances,  however,  while  the  graphic  history  of  an  at- 
tack of  gout  is  given  by  the  patient,  locally  nothing 
perceptible  remains  to  show  where  it  had  been  present. 
Many  examples  there  are,  also,  when  we  have  practi- 
cally very  little  to  guide  us  accurately  except  our  gen- 
eral medical  acumen,  or  indeed  the  touchstone  of 
treatment.     Sometimes,  of  course,  we  feel  we  have  a 

I  right  to  be  suspicious  of  a  certain  pain  or  ache,  be- 
cause the  previous  history  of  ailments  among  ances- 
tors, or  with  the  father  or  mother  of  our  patients,  lends 
probability  to  our  diagnosis.  Particularly  is  this  true 
whenever  we  are  unable  to  find  after  careful  inquiry 
any  other  sufficient  causation  in  the  case  under  inves- 
tigation. We  must,  however,  be  willing  to  admit  that 
until  one  or  more  anti-gout  remedies  have  been  freely 
and  judiciously  tried,  certain  cases  appear  absolutely 
obscure;  and  even  with  the  use  of  lithia,  the  salicy- 
lates, and  above  all  of  colchicum,  no  satisfactory  re- 
sults may  be  obtained  unless  we  meet  squarely  certain 
indications  which  are  almost  individual  in  their  rarit)' 
or  specificity.     Thus  it  is,  for  example,  that  a  single 

'  Read  before  the  Practitioners'  Society,  October  I2,  igoo. 


article  of  diet,  or  a  particular  drink,  which  one  per- 
son may  indulge  in  with  relative  or  almost  absolute 
impunity,  to  another  seems  to  be  the  veriest  poison 
and  to  bring  out  the  gouty  dycrasia  in  the  most  strik- 
ing manner. 

I  confess  to  have  a  somewhat  sceptical  mind,  the 
longer  I  practise  medicine  and  the  wider  my  observa- 
tion has  become,  with  respect  of  any  absolute  theory 
to  govern  dietary  rules.  It  is  true  that  with  some  pa- 
tients a  liberal  meat  diet  will  accentuate  gouty  ten- 
dencies, and  to  such  a  one  vegetables  and  starchy 
foods  appear  singularly  acceptable.  If,  perchance,  one 
has  just  treated  a  patient  of  this  sort,  he  is  apt  to  be 
considerably  influenced  by  the  ideas  of  Haig,  and  to 
believe  one  very  clear  way  of  diminishing  uric  acid 
and  its  injurious  effects  is  to  limit  the  quantity  of 
nitrogenized  food  to  a  very  small  measure.  On  the 
other  hand,  if  we  have  just  had  the  fortune  to  care  for 
one  to  whom  the  starches  and  vegetarian  diet  are  in- 
imical and  bring  out  morbid  manifestations,  we  can 
then  appreciate  somewhat  how  a  diet  largely  of  meat, 
with  a  considerable  limitation  of  starches  and  sugars, 
is  above  all  essential.  Again  it  seems  evident,  in 
certain  cases,  that  it  is  mainly  a  question  of  what  one 
man's  stomach  or  liver  is  able  to  accomplish,  and 
what  another's  can  effect,  and  yet  the  explanation  of 
this  fact  does  not  reside  at  present  in  any  analysis  we 
can  possibly  make  of  either  urine  or  stomachal  con- 
tents. 

There  is  something  over  and  beyond  the  mere 
chemical  output,  so  to  speak.  To  prove  this,  I  would 
direct  attention  to  what  I  have  observed,  and  it  is  how 
the  power  of  digestion  for  the  same  food  will  vary  con- 
siderably under  apparently  similar  conditions;  how  it 
will  also  change  from  time  to  time,  without  any  ade- 
quate or  sufficient  cause,  so  far  as  we  can  judge. 
Again,  we  know,  and  I  have  seen  it  many  times,  that 
the  very  article  of  diet  which  theoretically  would  seem 
to  be  almost  the  worst  possible  for  the  patient  is  the 
very  one  that  is  easily  assimilated  and  affords  most 
satisfaction  to  the  palate.  Often,  when  a  patient  has 
expressed  a  longing  for  some  particular  food  or  drink, 
while  at  first  I  have  had  misgivings  as  to  the  wisdom 
of  gratifying  the  intense  desire,  I  have  found  by  so 
doing  that  the  patient  has  been  much  improved  by 
my  concession,  and  both  enjoyed  and  digested  the 
doubtful  food  thoroughly  well.  I  do  not  wish  to  be 
understood  as  saying  that  this  would  be  the  invariable 
result,  because  I  know  the  contrary  to  be  true,  and 
also  I  know  there  is  always  an  element  of  risk  in  lis- 
tening to  and  according  to  patients' vagaries  or  fancies. 

There  is  a  line  to  be  drawn,  a  limit  to  be  made,  by 
the  discretion  and  judgment  of  the  wise  physician,  and 
it  is  to  him  that  I  have  been  and  am  now  addressing 
my  remarks.  We  are  apt  to  forget,  I  believe,  that  in 
order  to  make  food  digestible  we  must  render  it  pala- 
table. We  know  very  well  that  this  rule  holds  good 
with  a  well  person ;  assuredly  it  is  even  truer  and 
more  important  about  an  ill  person.  Let  the  food  or 
drink  become  distasteful  in  any  degree,  and  I  am 
quite  sure,  in  many  instances,  it  becomes  equally 
difl[icult  to  assimilate  it. 

To  what  extent  the  central  nervous  system  has  power 
to  produce  this  effect,  I  am  not  prepared  to  affirm, 


722 


MEDICAL   RECORD. 


[November  lo,  1900 


although  I  am  convinced  it  is  an  important  influence 
and  has  a  decided  action.  I  am  also  sure  that,  from  a 
physiological  standpoint,  sapid  substances,  food  served 
in  an  attractive  form,  tend  to  promote  the  secretion  of 
the  digestive  fluids  in  larger  amount.  This  is  true 
invariably  when  there  are  mastication  and  deglutition. 
It  is  also  true  possibly  when  food  is  simply  carried 
to  the  stomach  by  means  of  the  stomach  tube.  It 
seems  to  me,  therefore,  that  Ewald's  test  meal,  consist- 
ing of  a  baker's  roll  and  six  to  twelve  ounces  of  weak 
tea  without  milk  or  sugar,  is  not  a  fair  judgment  of 
an  already  weakened  stomach  to  bring  out  its  real 
power,  or  to  gauge  the  amount  of  free  or  combined 
acids,  if  we  consider  that  most  of  us,  even  when  per- 
fectly well,  would  revolt  not  a  little  at  such  a  repast 
being  offered,  except  as  a  rigid  and  necessary  experi- 
ment. 

To  what  degree,  we  may  ask,  is  suitable  and  well- 
considered  preparation  of  food  essential  to  proper 
combustion  and  reduction  of  its  constituents  to  forms 
from  a  chemical  point  of  view  essential  to  our  well- 
being,  whether  sick  or  well?  The  addition  of  a  sub- 
stance, such  as  sugar,  in  moderate  amount,  to  many 
beverages  and  to  some  foods  will  not  only  render  tliem 
more  acceptable  to  taste,  but  will  likewise  help  diges- 
tion, and  in  both  these  ways  enable  the  digestive 
organs  to  transform  them  so  as  to  be  in  no  way  inju- 
rious. It  is  here  often  merely  a  question  of  quantity. 
If  the  limit  ordered  by  a  certain  personal  equation  be 
passed,  sooner  or  later  there  proceeds  either  distinct 
palatal  or  stomachal  revolt;  and  if  these  symptoms  be 
not  attended  to,  or  over-indulgence  be  practised,  and 
the  individual  be  advanced  in  life,  or  has  pronounced 
constitutional  tendencies,  inherited  or  acquired,  we 
shall  not  infrequently  be  called  to  consider  and  treat 
manifestations  which  we  must  call  gouty,  for  lack  of 
some  better  or  more  satisfactory  term.  It  is  true,  also, 
that  we  must  be  careful  not  to  eliminate  certain  foods 
from  our  dietary  regimen  of  people  thus  disposed, 
merely  because  generically  they  are  in  the  same  cate- 
gory as  others. 

There  are  assimilable  starches  easy  of  digestion  to 
stomachs  which  rebel  at  others,  and  yet  chemistry  or 
even  the  microscope  does  not  always  tell  us  why.  I 
have  known  many  instances  in  which  rice  cooked  in 
various  forms  was  perfectly  acceptable,  when  symp- 
toms of  dyspepsia  would  follow  after  a  small  portion 
of  potato  taken  in  any  form.  I  have  also  known  pa- 
tients who  could  not  digest  at  all  a  roasted  or  boiled 
potato,  but  could  readily  digest  a  potato  that  had  been 
stewed  or  properly  fried  in  thin  sections.  Of  course, 
some  changes  may  take  place  in  the  starchy  granules 
by  the  mode  of  cooking,  or  through  the  ingredients 
combined  with  the  potato,  which  render  it  perfectly 
suitable  food  even  for  an  invalid  stomach.  We  know 
this  is  true  of  bread :  when  fresh  or  not  thoroughly 
cooked  to  extreme  dryness,  or  cooked  more  than  once, 
until  we  have  either  toast  of  the  English  or  zwieback 
of  the  Germans,  it  occasionally  retains  the  starch 
granules  almost  intact,  or  a  large  portion  of  the  bread 
is  not  brought  to  that  intermediate  state  of  dextrin 
which  allows  the  saliva  to  take  hold  of  it  and  change 
it  so  as  to  become  a  most  readily  assimilable  food. 

In  the  matter  of  wine,  malt  liquors,  and  spirituous 
liquors,  such  as  brandy  or  whiskey,  habits  in  different 
countries  certainly  tend  to  put  the  mind  of  the  judi- 
cious, careful  practitioner  in  a  very  doubtful  state. 
An  Englishman,  followed  closely  by  the  American  of 
to-day,  permits  a  small  amount  of  good  Scotch  whiskey 
to  many  of  his  gouty  patients,  as  being  the  least  inju- 
rious form  of  alcoholic  stimulant.  The  German  con- 
siders that  the  light  beer  of  Munich  or  \'ienna  will  do 
no  harm  in  moderate  quantity,  and  yet  he  might  place 
his  veto  absolutely  on  the  stronger  alcoholic  stimulant, 
although  ever  so  much  diluted.     The  Frenchman  will 


permit  a  small  quantity  of  Bordeaux  at  dinner,  while 
looking  askance  at  brandy,  whiskey,  or  beer. 

Habits  and  climatic  conditions  no  doubt  are  very 
important  in  determining  the  injurious  or  innocuous 
effects  of  all  of  these  even  in  moderate  quantity.  I 
have  the  conviction  also  that  racial  peculiarity  is  no 
small  factor  in  determining  the  bad  or  good  effects  of 
them. 

I  have  known  a  German,  night  after  night,  and  for 
many  long  years,  drink  one  or  several  mugs  of  beer  or 
ale,  and  be  none  the  worse  for  it  in  any  perceptible 
way.  To  the  average  American,  such  a  habit  would 
not  be  long  in  bringing  about  absolute  functional  dis- 
order of  stomach  and  liver,  and  finally  be  expressed 
in  painful  joints  or  neuralgic  pains  of  no  uncertain 
significance. 

The  moral  of  much  that  precedes  is  to  show,  as  I 
believe  it  should,  that  no  absolute  theory  of  gouty 
troubles  based  on  mere  diet  will  answer  many  require- 
ments of  the  clinician,  and  again  that  functional  dis- 
turbances in  various  forms  may  arise  when  seemingly 
there  is  nothing  to  occasion  them. 

Many  gouty  expressions  are  simply  made  clear  to 
us  by  one  symptom,  and  that  is  pain.  The  pain  may 
be  localized  and  more  or  less  continuous.  It  may 
be  present  only  when  pressure  or  movement  is  brought 
to  bear  upon  the  aflected  spot.  I  have  noticed  this 
particularly  in  two  forms  of  gout,  in  which  the  pain  was 
in  the  region  of  the  sole  of  the  foot  or  behind  the  heel. 
It  has  seemed  to  me  that,  in  these  and  other  instances, 
gout  was  separated  from  rheumatism  by  the  fact  that 
the  heat  of  bed  at  night,  or  the  fixed,  more  or  less  con- 
strained position  during  sleep,  aggravated  rheumatic 
pains,  while  gouty  pains  were  relieved  or  did  not  ap- 
pear at  such  time  in  so  marked  a  degree.  This  state- 
ment is  not  true  of  certain  neuralgic  pains,  which  are 
spasmodic  in  nature,  come  and  disappear  rapidly,  and 
are  simple  twinges  or  severe  shocks  which  make  the 
most  courageous  cry  out  with  agony.  There  are  ex- 
ceptions also  to  be  found  in  those  severe  cramps  of 
the  muscles  of  the  lower  limbs  which  onlj-  a  strong 
effort,  or  pressure,  or  bandaging  of  the  affected  mem- 
ber is  sufficient  to  arrest. 

In  gouty  troubles  of  the  throat,  and  more  especially 
of  the  larynx,  all  astringent  or  powerful  applications 
are  out  of  place.  They  almost  invariably  aggravate 
the  local  determination,  and  add  to  the  patient's  dis- 
tress in  a  very  evident  manner.  What  is  needed  here 
must  be  soothing  and  anodyne.  Why  this  is,  is  not 
usually  appreciable  by  the  senses.  There  may  not  be 
the  slightest  evidence  of  local  inflammation,  and  yet 
the  pain  is  acute  and  sometimes  almost  unbearable. 
In  these  cases  I  have  known  a  spasm  of  the  glottis  of 
an  alarming  character  to  be  brought  on  suddenly  by 
the  intemperate  use  of  medicinal  agents  which  ordi- 
narily would  cause  little  or  no  distress. 

In  some  persons  the  gouty  disturbance  is  apparently 
ushered  in  with  functional  upset  of  the  liver.  Under 
these  circumstances,  I  have  known  the  urinary  excre- 
tion to  present  nothing  abnormal,  or,  at  all  events,  not 
enough  so  to  be  in  any  way  characteristic  of  an  im- 
pending gouty  seizure. 

Rapid  dyspncea  has  occasionally  followed,  of  a  dis- 
tressing type,  which  nothing  organic  would  explain, 
and  relief  was  obtained  only  when  colchicin  was  duly 
administered.  I  have  little  doubt,  it  is  true,  that  many 
gouty  manifestations  which  appear  to  be  functional,  or 
which  still  remain  somewhat  oJDscure,  are  of  the  nature 
of  congestive  or  inflammatory  disorders.  I  have  seen 
this  notably  in  the  prostate,  the  uterus,  and  ovary,  and 
rarely  the  intestine.  My  views  in  regard  to  the  prob- 
able rheumatic  or  gouty  origin  of  not  a  few  cases  of 
appendicitis  are  already  known  to  many.  In  these 
instances,  although  it  may  be  that  a  prior  distinctive 
attack  of  acute,  normal  gout  can  be  instanced,  it  is 


November  lo,  1900] 


MEDICAL    RECORD. 


723 


not  invariably  true.  Mainly  for  this  reason  doubtless, 
a  few  physicians  and  more  surgeons  are  sceptical  as 
to  the  existence  of  a  gouty  dyscrasia  as  efficiently 
causative  of  the  affections  to  which  I  have  referred. 

We  all  know  that  the  old-time  physician  believed 
in  a  peritonitis  independent  of  our  now  over-worked 
appendicitis.  These  cases  in  my  belief  existed;  they 
still  exist.  They  do  not  require  operation,  and  when 
operated  on  they  show  no  lesion  of  the  appendix  and 
certainly  none  which  justifies  an  abdominal  section, 
or  which  would  not  end  in  thorough  recovery  with 
time  and  well-managed  medical  treatment.  Of  course, 
I  do  not  wish  to  state  that  these  cases  are  not 
very  difficult  to  diagnose  satisfactorily  and  in  an  ac- 
curate manner.  Some  of  them  give  grave  anxieties 
for  a  time,  in  adults  and  children,  and  both  physi- 
cian and  surgeon  watch  for  hours,  or  even  days, 
thinking  at  any  moment  an  abdominal  section  may  be 
clearly  indicated  by  reason  of  symptoms  pointing  un- 
erringly to  appendical  inflammation,  abscess,  or  per- 
foration, which  should  admit  of  no  further  delay. 
Others  there  are  which  leave  us  in  reasonable  and  just 
doubt,  perhaps,  for  a  while,  and  yet  presently  the  pen- 
dulum swings  toward  operation  because  local  pain, 
temperature,  pulse,  general  condition,  local  resistance, 
all  point  to  its  need.  When  the  abdomen  is  opened 
and  the  appendix  explored,  a  slight  or  marked  redness 
may  be  evident;  there  may  be  also  some  localized 
peritonitis,  or  the  intestine  itself  in  a  limited  area 
may  be  inflamed  and  shagreened  on  its  outer  surface. 
Some  say  remove  the  appendix,  and  proceed  to  do  it, 
i)ecause  they  believe  this  organ  is  XhQ  fitiis  et  origo  oi 
the  trouble;  others  are  sceptical,  and,  after  searching 
vainly  in  the  abdomen  for  the  evident  cause  of  the 
trouble,  sew  up  the  abdominal  walls  and  remain  in 
doubt  as  to  what  the  matter  is. 

To  my  mind  the  surgeon  under  like  circumstances 
who  abstains  from  doing  more  than  this  acts  as  wisely 
as  may  be.  Nevertheless,  the  exploratory  incision 
followed  by  searching  for  the  obvious  cause  of  the 
symptoms  is  a  danger  to  the  patient,  although  a  less 
one  than  further  operative  interference,  especially 
when  what  to  do  is  not  clearly  indicated.  It  seems 
to  me  just  as  evident  that  the  localized  peritonitis  was 
primary  and  causative,  as  it  is  to  admit  that  the  ap- 
pendix began  the  sequence  of  morbid  events. 

The  important  question  is,  how  an  apparently  un- 
necessary operation  could  be  avoided,  and  this  ques- 
tion is  one  which  has  now  agitated  the  medical  and 
surgical  mind  for  many  years.  1  wish  fervently  1 
could  present  it  in  an  absolutely  irrefutable  manner. 
This  I  cannot  do  any  more  than  I  can  point  out  in- 
variably when  gout  or  rheumatism  has  attacked  another 
organ,  as  the  tonsil,  the  ovary,  or  the  uterus.  What  1 
can  say  still  in  all  doubtful  cases  is:  institute  besides 
other  rational  treatment,  local  and  general,  a  judi- 
cious anti-gout  or  anti-rheumatic  guidance  or  treatment 
before  operatory  procedure  is  undertaken.  I  admit 
frankly  that  in  some,  not  to  say  many,  acute  cases  this 
appears  almost  impossible,  or  at  all  events  it  is  ob- 
viously too  hazardous.  When  an  abscess  has  formed, 
when  a  sudden,  fulminating  case  of  appendicitis  occurs 
accompanied  with  perforation,  and  if  delay  is  permitted 
followed  by  grave  peritonitis,  more  or  less  general,  not 
to  operate,  and  operate  almost  immediately,  or  indeed 
very  soon,  means  death  most  probably,  according  to  our 
present  knowledge. 

The  other  cases  are  the  knotty  or  difficult  ones,  and 
here,  as  in  many  other  instances  of  medical  differen- 
tial diagnosis,  we  are  forced  to  make  one  by  way  of 
exclusion,  and  this  oftentimes  is  as  sure  as  the  one 
made  on  a  combination  of  signs  and  symptoms  which 
may  seem  at  first  thought  to  be  far  more  accurate. 

As  to  cases  of  recurring  appendicitis,  especially  in 
adults,  those  very  numerous  and  increasing  ones  which 


are  now  operated  upon  in  the  interval,  these  I  firmly 
believe,  and  I  am  more  thoroughly  convinced  than 
ever  of  the  wisdom  of  my  position,  should  never  be 
operated  upon  until  a  proper  and  preliminary  anti- 
gout  or  anti-rheumatic  treatment  has  been  followed 
up,  and  for  a  suflScient  length  of  time  thoroughly  to 
justify  the  operatory  intervention  if  subsequently  it 
must  be  resorted  to.'  Analogy  with  and  experience 
about  other  organs  convince  me  additionally  of  the 
proper  conservatism  of  such  a  position.  For  exam- 
ple: I  do  not  believe  because  a  tonsil  occasionally  be- 
comes inflamed  and  enlarged  under  rheumatic  or  gouty 
influences,  it  should  therefore  be  removed,  and  I  hold 
this  belief  for  several  reasons:  first,  there  is  a  slight 
risk  in  the  removal  of  a  tonsil,  particularly  the  adult 
one,  on  account  of  hemorrhage;  second,  even  though 
removed,  the  inflammatory  condition  may  and  does 
recur  at  times  in  the  stump;  third,  until  the  tonsil  is 
practically  proven  to  be  an  injurious  or  unnecessary 
organ  as  to  its  presence  or  physiological  function,  it 
should  remain  where  it  is;  fourth,  frequently  it  is  but 
an  index  in  its  inflamed  and  enlarged  state  of  the  gen- 
eral condition  of  the  organism;  and  if  we  are  wise 
advisers  we  shall  first  endeavor  rationally  to  change 
the  condition  of  fluids  and  solids  in  the  economy 
which  occasions  the  local  disease,  rather  than  simply 
to  remove  the  latter,  and  thereby  conclude  we  have 
been  of  real  service  to  the  patient.  What  is  true  of 
the  tonsil  is  true  of  the  ovary,  with  added  force  in  the 
latter  case,  because  here  the  operatory  procedure  is 
more  dangerous,  and  besides  we  are  of  the  opinion 
that  if  one  or  both  of  these  organs  be  removed,  we 
have  interfered  with  or  annulled  the  power  of  child- 
bearing,  and  likewise  effected  future  changes  of  quali- 
ties and  disposition  of  the  woman  which  occasion  irre- 
mediable sorrow  to  the  patient,  and  to  one  or  more  of 
those  she  loves  best. 

It  is  quite  unworthy,  in  my  judgment,  in  an  argu- 
ment of  this  kind  for  the  surgeon  to  quote  the  relative 
innocuousness  of  an  operation  done  to-day,  according 
to  the  best  technique,  as  justifying  his  action,  no  mat- 
ter how  little  danger  there  is  to  the  patient,  unless  it 
be  proven  that  it  is  essential  for  the  patient's  best 
good. 

We  are  apt,  I  believe,  also  to  regard  an  operation 
too  much  from  the  point  of  view  of  mere  danger  and 
not  enough  from  the  standpoint  of  what  shall  be  the 
ultimate  result.  How  many  times  have  I  seen  patients 
operated  on,  even  by  surgeons  of  widest  experience  and 
most  careful,  conscientious  judgment,  who  have  few 
or  no  thoughts  subsequently  except  to  wish  that  they 
had  never  had  recourse  to  the  knife.  Sometimes  the 
patients'  bodily  disability  or  suffering  has  been 
greater  than  if  they  had  really  borne  the  trouble  they 
already  had  and  had  become  accustomed  to.  Again, 
what  is  occasionally  clearly  defined  is  that,  the  local 
trouble  being  but  the  evidence  of  a  general  state, 
we  cannot  be  sure,  if  we  operate  on  one  important  organ 
or  system,  we  shall  not  ere  long  have  similar  cogent 
reasons  to  operate  on  another. 

A  former  patient  of  mine  suffered  torture  for  many 
years  owing  to  trigeminal  neuralgia,  for  which  she  sub- 
mitted to  much  operative  interference  at  the  hands  of 
dentist  and  general  surgeon;  subsequently,  and  al- 
though her  neuralgic  pains  were  by  no  means  cured, 
she  was  forced  to  have  a  cholecystotomy  performed  to 
be  rid  of  painful  and  threatening  gall  stones.  Behind 
and  beyond  all  this  was  unquestionably  the  obstinate 
old  gouty  condition  that  nothing,  even  the  most  ra- 
tional medical,  dietetic  and  climatic  treatment,  could 
neutralize. 

This  is  admittedly  an  extreme  and  disheartening 

'  In  children  I  would  not  insist  upon  an  anti-gout  treatment, 
other  than  proper  diet  and  healthful  surroundings,  except  in  cases 
in  which  heredity  was  pronounced. 


724 


MEDICAL    RECORD. 


[November  lo,  1900 


case.  There  are  others  and  many  of  them,  if  not 
wholly  similar,  at  least  very  analogous.  For  the 
sake  of  truth  we  must  get  beyond  the  individual  case 
or  the  affected  organ.  We  must  recognize  general 
laws  that  govern,  and,  for  conscience  as  well  as  for  the 
true  advancement  of  our  science  and  art,  we  should 
not  throw  aside  or  ignore  the  knowledge  which  has  re- 
quired centuries  on  the  part  of  observant,  accurate, 
skilful,  laborious  men  to  bring  to  light.  Merely  be- 
cause our  methods  of  research  are  fuller  and  more 
satisfactory  to-day  in  many  directions  than  ever  be- 
fore, is  no  reason  why  other  and  equally  valuable 
knowledge,  which  is  obtained  by  other  means  and 
from  other  sources,  should  not  be  duly  estimated. 

I  have  in  mind,  as  I  write,  a  patient  who  has  been 
under  my  care  for  many  years;  she  has  had  many 
functional  disturbances;  she  has  also  suffered  from 
many  local  determinations  of  constitutional  gouty  con- 
dition. A  long  while  ago  she  suffered  very  much  with 
an  affection  of  the  ears  which  the  aurists  claim  to  be 
a  dry,  proliferative  catarrh  often  leading  to  chronic 
deafness,  tinnitus,  and  other  symptoms,  and  due  main- 
ly to  impairment  of  movement  of  the  ossicles  and 
sinking  in  and  thickening  of  the  membrane.  Local 
treatment  by  sprays,  douches,  pigments,  politzerizing, 
introduction  of  Eustachian  catheter,  was  continuously 
tried,  but  never  resulted  in  more  than  temporary  good; 
finally,  the  outlook  appeared  to  be  very  considerable 
or  absolute  deafness,  unless  an  operation  might  prove 
remediable.  Knowing  how  unsatisfactory  such  oper- 
ations are  apt  to  be,  I  demurred.  '  In  the  belief  that 
anti-gout  or  anti-rheumatic  treatment  was  indicated 
from  the  point  of  view  of  her  general  manifestations, 
it  was  adopted  and  persisted  in,  and  finally  after  the 
lapse  of  several  years  her  hearing  is  now  about  as 
good  as  ever,  although  the  patient  is  no  longer  young, 
and  all  local  treatment  of  the  ear  has  been  abandoned. 
The  cases  of  psoriasis,  not  to  speak  of  other  forms 
of  cutaneous  disorders,  which  occasionally  fall  into  the 
hands  of  the  general  practitioner  can  be  satisfactorily 
treated  in  many  instances  only  when  the  underlying 
gouty  or  rheumatic  dyscrasia  is  attended  to.  Some- 
times this  constitutional  condition  may  affect  particu- 
larly the  intestinal  tract,  and  then  in  addition  to  suit- 
able dietary  certain  medicines  must  also  be  given  to 
neutralize  fermentative  changes  and  to  restore  nor- 
mal intestinal  functions.  Sometimes  the  constitu- 
tional tendency  is  toward  the  nervous  system.  This 
is  below  par,  in  an  easily  excited  state.  Hereditary 
influence  is  clearly  present,  and  bad  habits,  such  as  a 
life  in  a  poorly  governed  city  often  produces,  tend  to 
make  it  still  worse  in  a  rapid  manner. 

I  know  of  several  methods  to  correct  this,  but  the 
surest  and  quickest  is  to  get  pure  country  air,  if  pos- 
sible, live  out  of  doors,  go  to  bed  early,  have  plenty 
of  rest,  and  only  diversions  which  prey  least  on  the 
emotions.  Without  attention  to  these  major  indica- 
tions, it  seems  relatively  useless  to  pay  regular  visits 
to  the  dermatologist  and  cover  one's  self  in  part  with 
lotions  or  salves.  The  so-called  gouty  dyscrasia  is 
prone  to  affect  the  circulation,  as  is  familiarly  recog- 
nized. 

How  often  do  we  see  cardiac  or  vascular  changes 
clearly  of  this  provenieiice !  In  their  minor  forms,  and 
particularly  when  the  organic  changes  are  only  begin- 
ning, they  are  frequently  difficult  to  recognize  in  a 
positive  manner. 

It  is  true  that  a  slightly  increased  tension  of  the 
radial  arteries,  which  is  more  or  less  continuous  and 
accompanied  with  perhaps  perceptible  thickening  of 
the  vessels  themselves,  is  indicative  of  blood  changes 
already  present.  It  is  also  true  that  an  unusual  quan- 
tity of  light-colored  urine  of  low  specific  gravity,  with 
an  occasional  trace  of  albumin  and  a  few  granular 
casts  will  accentuate  premonitions  and  confirm  diag- 


nosis. Still  more  certain  are  we  when  cardiac  en- 
largement with  slight  hypertrophy  is  present  and  can 
be  accurately  made  out  by  careful  physical  methods  of 
research  ;  but  in  those  instances  in  which  none  of  these 
is  obvious,  what  shall  we  say  many  times?  The  heart 
action  is  often  irregular,  without  apparently  adequate 
cause;  its  beats  may  be  feeble  or  too  forcible,  tumul- 
tuous; they  may  vary  from  time  to  time,  rapidly  or 
suddenly,  and  with  these  functional  phenomena  most 
unpleasant  feelings  may  be  present.  Sometimes  these 
annoying  sensations  are  in  the  cardiac  region  and  di- 
rect our  attention  there  almost  immediately.  Again, 
the  disturbance  or  pain  may  be  far  removed,  and  diz- 
ziness or  persistent  or  recurring  headache  may  be  the 
sole  warning  note  which  may  act  as  our  guide  and 
teacher.  In  these  latter  cases  it  is  the  physician  who 
discovers  the  cardiac  disturbance  occasionally,  and 
without  the  patient  so  much  as  directing  his  attention 
to  it.  Even  then,  if  the  pulse  be  interrogated,  it  will 
not  invariably  respond  to  our  research  by  revealing 
to  us  any  additional  facts  of  value.  It  seems  to  be 
of  good  volume,  force,  and  properly  depressible. 
There  are  also  patients  who  suffer  cardiac  distress, 
and  who  speak  of  localized  pain,  fluttering,  gone  sen- 
sations, intermission  of  heart  beats,  and  when  we  put 
the  ear  to  the  chest  we  fail  to  recognize  any  symp- 
toms of  an  abnormal  character;  in  other  words,  the 
distress  is  purely  subjective. 

Every  practitioner  of  even  limited  experience  has 
seen  at  least  some  examples  of  the  foregoing  types. 
He  may  or  may  not  attribute  them  to  the  true  cause; 
he  may  regard  the  symptoms  as  purely  fanciful  or 
gross  exaggerations,  simply  the  outcome  of  a  fatigued 
brain  or  hysterical  disturbance;  he  may  think  that  too 
much  work,  mental  or  bodily,  malnutrition,  or  an  ex- 
cess of  food,  lies  at  the  source  of  it  all,  and  try  by 
neutralizing  errors  or  mistakes  thus  to  effect  curative 
results.  Be  that  as  it  may,  and  while  recognizing 
many  instances  in  which  success  will  reward  effort  in 
one  direction  or  another,  there  are  still  some  cases 
which  remain  very  obscure,  and  in  which  failure  to 
accomplish  much  that  is  real  and  beneficial  is  a  sad 
commentary  on  the  medicine  of  our  day  and  gener- 
ation. 

Mere  science  in  its  narrow  acceptation  will  not  al- 
ways accomplish  it.  We  may  weigh,  and  analyze, 
and  delve  with  every  scientific  instrument  and  method 
at  our  command  and  in  our  service,  and  still  we  are 
forced  back  to  the  old-time  method  of  theorizing  and 
explaining  as  best  we  can. 

It  is  the  senior  practitioner,  the  hospital  clinician, 
the  man  whose  opportunity  extends  also  outside  hospi- 
tal wards,  and  who,  wherever  and  whenever  his  meth- 
ods are  used  to  the  utmost,  also  utilizes  the  very  best 
men  and  talent  that  modern  ad\ances  and  enthusiastic, 
well-drilled  younger  spirits  afford,  who  reaches  near- 
est the  truth. 

In  this  thought  there  is  much  of  consolation  for  the 
man  who  has  grown  somewhat  old  and  tired  in  har- 
ness. He  is  no  longer  forced  to  submit  and  believe 
that  every  new  aspirant  for  fame  and  honors  has  elimi- 
nated his  worthy  labors  and  efforts  of  a  lifetime. 
His  work  and  his  doing  are  still  good  and  will  bear 
justly  all  comparisons  with  newer  and  other  methods, 
more  advanced  at  one  point  or  another,  but  always  to 
be  subjected  to,  and  under  the  control  and  supervision 
of,  the  more  experienced,  older,  wiser  head. 


In  Hip-Joint  Disease  the  pain  first  complained  of 
may  be  on  the  inner  side  of  the  thigh,  or  above  the 
patella,  or  in  the  popliteal  space,  or  about  the  knee, 
wherever  the  terminal  branches  of  the  obturator  nerve 
are  distributed. — Jnternationaljourna!  oj  Surgery. 


November  lo,  1900] 


MEDICAL    RECORD. 


725 


THE     RELIEF     OF     PROSTATIC     ENLARGE- 
MENT.' 

By   JOSEPH    B.    BISSELL,    M.D., 

VISITING  SURGEON   TO    OELLEVUE   HOSPITAL. 

Ix  the  past  few  years  so  much  improvement  has  been 
made  in  our  treatment  of  prostatic  enlargement  and 
its  results,  that  it  seemed  to  me  a  short  rtisumd  of  the 
subject,  from  a  surgical  standpoint,  might  be  of  inter- 
est to  the  members  of  the  Practitioners'  Club.  A 
more  intimate  knowledge  of  the  anatomy,  physiology, 
and  pathology  of  the  prostate  gland,  and  the  changes 
following  its  enlargement,  the  wider  use  of  the  local 
anesthetics,  and  the  application  of  the  cystoscope  for 
diagnostic  purposes,  have,  among  other  causes,  heljied 
us  to  a  more  exact  appreciation  of  tiie  value  of  the 
various  curative  procedures  for  the  relief  of  this  con- 
dition. No  surgeon  at  the  present  time  would  open 
the  bladder  without  first  attempting  to  confirm  his 
diagnosis  by  the  use  of  the  cystoscope. 

To  the  minds  of  most  of  us,  the  middle  lobe  is  the 
offender  in  about  all  of  the  cases  of  retention  and  cys- 
titis following  hypertro|jhied  ]5rostate,  As  a  matter 
of  fact,  it  has  been  shown  that  in  the  majority  of  cases 
it  is  not  the  middle  lobe,  or  not  the  middle  lobe  alone, 
which  causes  this  obstruction  and  its  sequelae.  Of 
these  causes  of  obstruction  and  changes  in  the  tissue 
of  the  prostate,  bladder,  etc.,  I  will  speak  later. 

The  interference  with  the  function  of  the  bladder 
by  this  obstruction  produces  cystitis,  trabecular  and 
sacculated  walls — possibly  calculi,  renal  disease,  di- 
lated ureters,  infection  of  the  whole  urinary  tract,  and 
thus  general  sepsis.  This  may  not  occur  in  every 
case.  The  bladder  muscle  may  be  able  to  overcome 
the  obstacle  and  empty  the  bladder  completely  or 
nearly  so.  For  a  time  this  compensation  will  con- 
tinue, and  in  mild  cases  it  may  keep  on  to  the  end  of 
life.  If,  however,  the  obstruction  is  too  great,  or  the 
bladder  muscle  too  weak  to  allow  of  emptying  the 
bladder,  a  cystitis,  with  all  its  concomitants  and  re- 
sults, soon  follows  and  compels  the  patient  to  seek 
relief.  For  this  purpose  there  are,  in  general,  two 
ways  for  our  consideration  :  Removal  of  the  residual 
urine  in  an  artificial  manner,  or  removal  of  the  ob- 
struction, so  that  the  bladder  may  again  be  able  to 
expel  its  contents. 

At  the  outset  it  is  well  to  have  it  understood,  by  the 
patient  as  well  as  by  the  physician,  that  certain 
changes  have  taken  place,  secondary  to  the  hypertro- 
phied  prostate,  to  such  an  extent  in  the  walls  of  the 
bladder  and  urethra  that  it  may  be  impossible  to  re- 
store these  to  their  normal  function,  even  after  the 
complete  removal  of  the  e.Nciting  cause. 

For  instance,  a  sacculated  bladder,  with  its  walls 
full  of  trabeculae,  such  as  I  show  you  here,  you  would 
hardly  expect  to  resume  its  duties,  no  matter  how 
thoroughly  the  prostate  had  been  removed. 

First,  as  to  the  different  ways  for  the  artificial  re- 
moval of  urine:  Systematic  catheterization,  or  "cathe- 
ter life,"  is  the  introduction  of  a  catheter,  withdrawal 
of  urine,  and  the  irrigation  of  the  bladder  by  a  proper 
solution  for  antiseptic  and  cleansing  jnirposes,  at  reg- 
ular intervals  during  each  twenty-four  hours. 

Aspiration  with  a  trocar  and  cannula  above  the 
pubes  is  a  temporary  means  of  relieving  a  distended 
bladder.  This  cannot  be  kept  up  long,  although  in 
one  case,  in  which  it  was  impossible  to  introduce  a 
catheter,  I  aspirated  three  times  daily,  for  over  three 
weeks,  without  infection  and  with  little  pain  or  diffi- 
culty, and  with  the  ultimate  recovery  of  the  patient. 

VVhen  for  some  reason  an  operation  on  the  prostate 
is   contraindicated  or   catheterization    is    impossible, 

'  Kead  before  the  Practitioners'  Club  of  Newark,  X.  J  .  Octo- 
ber I,  1 900. 


permanent  drainage  of  urine  through  a  fistula  can  be 
made. 

Catheterization,  if  available,  is  always  our  choice 
for  treatment  of  enlarged  prostate  and  retention.  It 
is  practicable  if,  in  a  fairly  normal  bladder  witli  a 
moderate  amount  of  residual  urine,  it  is  possible  to 
pass  a  catheter  of  fair  calibre,  at  regular  intervals,  in 
a  careful  manner,  with  perfect  asepsis,  without  pain 
or  hemorrhage  or  infective  reaction.  Catheterization 
may  answer  well  for  years,  the  residual  urine  dimin- 
ishing— or,  at  least,  not  increasing — until  slowly  or 
suddenly  the  symptoms  become  unbearably  worse,  or 
infection,  as  shown  by  a  suppurative  orchitis  or  cys- 
titis, takes  place;  then  some  other  means  of  relief 
must  be  found. 

Vesical  drainage  for  cystitis  and  enlarged  prostate 
is  a  course  we  may  have  to  resort  to  when  there  is 
inability  to  use  the  catheter,  and  when  the  local  or 
general  condition  does  not  warrant  a  prolonged  oper- 
ation like  a  prostatectomy,  or  when  the  patient  does 
not  wish  to  assume  the  risk.  This  drainage  can  be 
made,  by  means  of  local  anaesthesia,  through  the  peri- 
neal route,  or  suprapubically,  quickly  and  painlessly. 
By  the  use  of  a  silver,  rubber,  glass,  or  other  non- 
absorbable tube,  a  permanent  artificial  channel,  lead- 
ing to  the  bladder,  may  be  kept  open.  Witzel  makes 
a  permanent  fistula  above  the  pubes  by  stitching  the 
bladder  wall  over  a  tube  for  three-quarters  of  an  inch 
and  entering  the  viscus  obli(jucly,  like  the  operation 
for  a  gastric  fistula.  This,  he  claims,  will  not  leak 
at  any  time  and  will  be  permanent.  Through  the 
perineal  urethra  a  prostalomy  may  be  made  and  a  per- 
manent fistula  instituted  by  means  of  a  catheter  or 
glass  tube  sewed  in  or  otherwise  retained. 

None  of  these  methods  are  suitable  for  all  cases. 
Catheterization  may  fail  because  of  repeated  attacks 
of  infection.  The  patient  may  not  have  intelligence 
enough  to  use  a  catheter  properly.  He  may  not  be 
able  to  afford  the  necessary  accessories,  or  he  may  be 
too  careless  or  indifferent.  Certain  patients,  using 
every  precaution  that  can  be  taught  them,  are  con- 
stantly infecting  themselves;  just  as  others  seem  to 
have  an  almost  immune  genito-urinary  tract  and,  in 
spite  of  want  of  cleanliness,  never  meet  with  an  acci- 
dent in  the  way  of  infection. 

Sudden  and  complete  retention  of  urine  following 
enlarged  prostate  may  call  for  immediate  operative 
drainage,  which  may  or  may  not  have  to  be  made  per- 
manent. Continuous  drainage  by  means  of  a  fistula 
is  at  best  unsatisfactory  and  distressing.  It  is  almost 
impossible  to  prevent  leakage,  in  spite  of  the  many 
devices  that  have  been  tried  and  are  in  use  at  present. 
The  wearing  of  a  rubber  urinal  is  troublesome,  humil- 
iating, and  depressing;  and  the  constant  and  ready 
communication  with  air  renders  infection  continually 
liable. 

Various  radical  operations  have  been  proposed  and 
carried  out.  The  oldest  and  most  common  is  perineal 
prostatomy,  which  does  considerable  good  temporarily, 
probably  because  of  the  drainage;  but  within  a  few 
months  after  the  opening  is  closed  and  drainage, 
therefore,  ceases,  the  symptoms  frequently  return. 
The  other  operations  can  be  divided  into  two  classes: 

I.  Those  which  aim  to  remove  the  obstruction  by 
cutting  off  the  blood  and  nerve  supply,  and  thus  pro- 
duce atrophy  of  the  gland. 

II.  Those  which  affect  directly  the  obstruction  itself. 
First.  The  direct  cutting  off  of  the  blood    supply 

may  be  done  by  ligating  the  vessels  supplying  the 
gland. 

The  prostate  is  supplied  by  branches  of  the  internal 
pudic,  the  median  hemorrhoidal,  and  the  inferior  ves- 
ical. Anomalies  are  frequent,  and  the  anastomosis  is 
very  free,  so  that,  practically,  as  the  vessels  are  nu- 
merous and  deep-seated,  it  is  best  to  tie  off  the  main 


726 


MEDICAL    RECORD. 


[November  10,  1900 


trunk.  All  these  vessels  arise  from  the  internal  iliac. 
This  has  been  done  by  a  Dr.  Bier,  of  Kiel,  who  tied 
both  internal  iliacs.  Dr.  Willy  Meyer,  of  New  York, 
has  also  tied  these  arteries,  with  a  result  whicli  he 
calls  "encouraging  in  the  e.xtreme."  The  operation  is 
not  done  often,  in  this  country  at  least,  and  the  diffi- 
culties and  dangers  surrounding  it  are  too  grave  and 
the  result  obtained  is  too  uncertain  for  us  to  advise 
the  risk. 

The  blood  supply  to  the  prostate  may  be  reduced 
indirectly  by  a  double  castration,  theoretically. 

The  e.xplanation  is,  "  that  we  permanently  remove 
the  frequent  intermittent  active  hypera;niia  of  the 
genital  system,  which  is  produced  by  the  presence  and 
secretion  of  the  testicles  by  nervous  reflex."  I  quote 
from  Dr.  J.  William  White.  Owing  to  his  enthusias- 
tic advocacy,  the  operation  was  being  performed  quite 
frequently  a  few  years  ago.  An  analysis  of  the  cases 
reported  shows  that  in  nearly  every  instance  after  a 
time  all  the  symptoms  returned.  The  mortality  is 
much  higher  than  one  would  expect  to  find  it.  It  has 
been  given  as  from  seven  per  cent,  to  thirty  per  cent, 
by  various  reporters.  The  higher  percentage  must  be 
due  not  to  the  operation,  but  to  some  fault  in  the  sur- 
gical technique.  Melancholia  and  mania  are  reported 
as  not  infrequent  sequela;  of  single  and  double  orchi- 
dectomy.  It  seems  to  me  that  the  theory  on  which  the 
operation  is  based  is  as  fallacious  as  the  evidences  of 
cure  are  incorrect. 

Angioneurectomy  of  the  cord,  like  so  many  other 
surgical  procedures  for  this  trouble,  produces  just  as 
much  atrophy  of  the  prostate  as  rest  in  bed,  irrigation, 
and  other  local  treatment  would  produce,  and  no  more. 
That  these  methods  do  bring  about  a  distinct  reduc- 
tion in  the  congestion  and  cedema  in  and  around  the 
tissues  of  the  prostate,  there  is  no  doubt;  but  that  this 
is  a  functional  and  temporary  relief  for  the  most  part, 
there  is  also  no  doubt.  The  observer  v;ho  is  looking 
for  it  will  find  a  quite  diminished  tumor  in  this  region, 
easily  to  be  denominated  atrophy,  if  he  wishes  to  call 
it  so,  but  probably  due  to  the  reduction  of  the  engorged 
vesicular  tissues. 

Ligation,  division,  subcutaneous  incision  and  evul- 
sion of  one  or  both  vasa  deferentia  have  all  been  pro- 
posed and  tried  by  various  operators,  with  practically 
the  same  results  as  above  mentioned,  as  to  the  cure 
of  the  prostatic  enlargement.  The  mortality  in  these 
operations  on  the  vas  is  low,  but  the  functional  effect 
on  the  glandular  enlargement  is  not  of  sufficient  value 
to  justify  the  risk  of  these  operations.  Mikulicz  re- 
ported a  number  of  cases  of  evulsion  of  the  vas,  in 
every  one  of  which,  at  the  end  of  a  year,  on  the  aver- 
age, it  was  found  that  the  old  trouble  had  returned. 

Second.  The  procedures  which  attack  the  gland  di- 
rectly. Injections  of  various  irritating  substances  into 
the  parenchyma  have  been  tried  without  success  and 
may  indeed  be  dangerous.  Electrolysis  has  been  pro- 
posed, but  never  successfully  tried. 

Destruction  or  removal  of  the  obstacle  at  the  inter- 
nal orifice,  by  means  of  an  instrument  carried  into  the 
bladder  through  the  natural  channel,  the  urethra, 
seems  at  first  thought  to  be  an  ideal  way.  The  instru- 
ment of  Bottini  fulfils  the  indications  above  mentioned. 
The  operation  is  in  effect  a  multiple  galvano-caustic 
division  of  the  middle  lobe  of  the  prostate.  The  in- 
strument has  been  modified  in  several  details  since 
the  Italian  surgeon  first  presented  it  in  October,  1875. 
As  then  made,  it  looked  not  unlike  a  medium-sized 
rubber  catheter  with  a  short  beak.  On  this  a  porce- 
lain disc  carried  a  platinum  plate,  which  was  heated 
by  an  electric  current.  By  means  of  this  an  eschar 
was  made  on  the  prostatic  projection  in  the  bladder 
at  varying  points.  These  eschars  came  away,  leaving 
a  cicatrix,  which,  contracting,  produced  an  atrophy  of 
this  part  of  the  prostate. 


Bottini  reported  five  successful  cases  in  two  years 
with  this  instrument.  Later  he  modified  it,  so  that  at 
present  it  resembles  a  lithotrite,  in  having  a  male  and 
female  blade.  In  the  former  is  a  platinum  knife, 
which  leaves  and  returns  to  the  groove  of  the  female 
blade  by  the  turning  of  a  screw,  and  is  connected  to 
an  electric  current.  A  scale  at  the  outer  extremity 
shows  the  depth  of  groove  cut.  A  cooling  apparatus 
surrounds  the  instrument,  so  that  it  is  kept  free  from 
heat  while  the  knife  is  raised  to  a  white  heat.  Freu- 
denberg  modified  the  instrument  by  making  the  blade 
of  iridium  alloy,  rendering  it  firmer  and  less  difficult 
to  heat,  and  also  in  various  other  ways  changed  it 
greatly  to  its  advantage. 

Dr.  VVilly  Meyer,  to  whose  writings  on  this  pro- 
cedure I  am  indebted,  has  carried  out  almost  to  per- 
fection the  methods  and  manner  of  using  this  instru- 
ment. He  prefers  the  street  current  with  a  rheostat, 
but  a  fifty-ampere  storage  battery  can  be  taken  to  the 
patient's  house,  if  necessary.  Dr.  Meyer's  personal 
cases,  twenty-four  in  number,  show  eight  per  cent, 
mortality  directly  due  to  the  operation,  and  eight  per 
cent,  mortality  indirectly  due  to  the  operation,  with 
thirty-eight  per  cent,  of  cures. 

The  Bottini  operation  is  not  so  simple  or  so  easy 
as  at  first  sight  one  would  expect.  It  is  an  operation 
of  detail,  and  one  which  requires  care  and  skill  and 
an  intimate  and  clear  knowledge  of  the  exact  condition 
of  affairs  in  the  bladder  neck.  It  is  an  operation  by 
no  means  devoid  of  danger.  Death,  following  sup- 
pression of  urine  immediately  succeeding  this  pro- 
cedure, has  occurred  several  times,  to  my  personal 
knowledge.  Freudenberg  reports  a  case  in  which  he  cut 
through  a  fold  at  the  base  of  the  bladder;  sepsis  and 
death  resulted.  Perforation  of  the  urethra  and  sepsis 
are  reported.  Pulmonary  emboli  have  been  found  at 
autopsy.  Hemorrhage  is  a  constant  danger,  and  the 
greater  in  that  it  comes  on  at  the  time  the  sloughs  are 
thrown  off — about  ten  days  after  the  incision.  It  may 
take  place  earlier.  Cystotomy  and  tamponing  have 
been  necessary  in  a  number  of  cases,  in  order  to  save 
the  patient's  life.  Absolute  retention  is  not  an  infre- 
quent immediate  result  of  the  operation.  In  one  of 
Meyer's  cases  he  was  obliged  for  this  cause  to  tap  the 
bladder  over  the  pubes  for  three  days.  Pain  and 
severe  tenesmus,  almost  unbearable,  are  not  infrequent 
complications.  Dribbling  is  an  occasional  sequel 
which  may  be  permanent.  But  the  most  serious  of  all 
the  objections  to  Bottini's  method  is  the  risk  of  sepsis. 
In  every  case  of  enlarged  prostate  which  conies  to  us 
for  treatment  there  is  already  a  cystitis,  or  all  the  ele- 
ments preparatory  to  its  development.  There  are 
present  a  number  of  pathological  changes  in  the 
mucous  and  other  coats  of  the  bladder,  as  well  as  the 
tissues  of  the  prostate  gland  and  its  adnexa.  A 
trauma,  such  as  is  done  by  the  Bottini  instrument,  is 
all  that  is  needed  to  light  up  an  infiammation  in  these 
tissues.  The  destruction  of  a  considerable  amount  of 
tissue  in  a  closed  sac,  and  the  leaving  it  there  without 
drainage,  seems  to  me  to  be  a  surgical  negligence 
without  any  excuse.  To  say  that  it  is  done  with  every 
antiseptic  precaution  is  saying  what  is  impossible. 
The  cicatrization  produced  by  a  Bottini  is  said  to 
prevent  or  complicate  seriously  any  further  radical 
operation  upon  the  gland.  Moreover,  this  procedure 
does  not  take  into  account  the  real  causes  of  the  obstruc- 
tion and  its  sequences,  or  at  least  affects  only  a  small 
proportion  of  them.  If  the  retention,  cystitis,  and 
their  results  were  caused  by  a  bar  or  a  collar  or  other 
obstruction  at  the  lower  portion  of  the  vesical  opening 
only,  the  Jiottini  would,  apparently,  be  tlie  indicated 
operation,  always  provided  free  drainage  afterward 
could  be  instituted  to  prevent  septic  infection.  A  cathe- 
ter tied  into  the  urethra,  to  my  mind,  is  a  brutal  and 
painful  relic  of  the  dark  ages  of  genito-urinary  surgery. 


November  lo,  1900] 


MEDICAL   RECORD. 


727 


Bottini's  operation  does  not  adequately  appreciate 
the  causes  of  the  obstruction.  It  does  not  treat  the 
condition  complicating  the  hypertrophy.  It  does  not 
allow  for  drainage  of  a  dirty  wound.  In  a  word  it  is 
unscientific  and  unsurgical. 

Prostatectomy  is  the  removal  of  all  or  most  of  the 
prostate  gland.  In  order  to  consider  its  merits  prop- 
erly, it  is  necessary  to  understand  clearly  the  patho- 
logical anatomy  and  physiology  of  the  condition  we 
have  to  deal  with.  OlDStruction  to  the  complete  empty- 
ing of  the  bladder  and  the  results  of  this  obstruction 
— cystitis,  repeated  attacks  of  retention,  trabecule, 
and  sacculated  bladder,  calculi,  inflammation  of  the 
ureters,  pyelonephritis,  and  sequelae — are  due,  as  a 
rule,  to  more  than  one  factor.  Our  knowledge  of  the 
anatomy  and  relations  of  the  pathological  prostate  has 
been  greatly  advanced  by  the  recent  investigations  of 
the  subject  by  Dr.  Samuel  Ale.xander,  of  New  York. 
The  careful  and  elaborate  researches  and  dissections 
made  by  him  at  different  stages  of  the  condition 
known  as  hypertrophy  of  the  prostate,  show  a  consid- 
erably more  complicated  cause  of  these  results  than 
the  one  usually  given  of  enlargement  of  the  middle  lobe. 

The  prostate  gland  consists  of  two  lateral  lobes 
joined  by  a  middle  isthmus.  Backward  and  upward 
from  this  projects  the  middle  lobe  into  the  floor  of  the 
bladder  when  enlarged,  the  apex  being  at  the  opposite 
end  toward  the  membranous  urethra.  Dissections  of 
a  number  of  pathological  prostates  show  three  general 
varieties  of  enlarged  prostate  and  resultant  obstruction. 

First.  Enlargement  of  the  middle  isthmus,  forming 
a  bar  at  the  internal  meatus,  with  enlargement  of  the 
middle  lobes. 

The  second  form  consists  of  a  growth  of  the  middle 
isthmus,  with  enlargement  of  the  glands  which  lie  be- 
neath the  mucous  membrane  at  the  vesical  orifice. 

A  third  form  is  made  up  of  the  growth  and  devel- 
opment of  the  prostatic  glands  above  the  verumonta- 
num  and  an  intra-urethral  growth.  Of  course,  the 
variations  from  these  types  are  great  and  frequent. 
The  middle-lobe  variety  may  at  times  be  peduncu- 
lated, it  may  be  crescentic  in  form,  or  nipple-formed 
in  shape  and  size  both,  or  in  shape  of  a  collar  sur- 
rounding the  vesical  orifice.  The  distortion  of  the 
prostate  also  brings  about  a  wrant  of  proper  relation 
in  the  insertion  of  the  vesical  and  urethral  muscles 
arising  in  that  neighborhood.  As  a  result,  the  vesical 
outlet  closes  irregularly  and  before  the  bladder  is 
emptied. 

Another  cause  of  retention  is  venous  stasis,  the  re- 
sulting cedema  therefrom  further  increasing  the  ob- 
struction. The  constant  straining  of  the  muscular 
walls  of  the  bladder  to  overcome  its  disability  pro- 
duces finally  overstretching  of  the  vesical  muscles, 
changes  in  the  walls  from  prolonged  inflammation, 
and  connective-tissue  atrophy,  from  which  the  result- 
ing trabeculje  and  sacculce  increase  the  difficulty  of  a 
cure. 

The  hypertrophy  may  consist,  structurally,  of  gland- 
ular tissue  mostly,  or  with  the  fibrous  tissue  most 
prominent,  this  being  usually  simply  a  later  stage  in 
the  enlargement.  Often  an  acute  congestion  of  the 
gland  and  its  surrounding  structures  may  account  for 
complete  obstruction  and  retention. 

In  considering  the  best  radical  treatment,  all  these 
conditions  and  distortions  of  the  gland,  of  the  muscles, 
of  the  bladder,  of  the  deep  urethra,  and  the  mucous 
membrane,  together  with  the  causes  and  the  anatomical 
relations  of  the  pathological  state  called  hypertro- 
phied  prostate,  as  well  as  the  patient's  constitutional 
condition,  have  to  be  taken  into  account.  Not  at  all 
a  simple  problem,  and,  in  a  certain  number  of  cases, 
if  complete  cure  is  expected,  a  distinctly  unsolvable 
one. 

No   operation   or    ameliorating    procedure   will    do 


more  than  give  a  certain  amount  of  relief  to  a  patient 
with  an  old  pus  bag  of  a  bladder,  with  complete  atony 
of  the  muscular  coat,  and  with  deep  sacculations  in 
which  decomposing  urine  and  phosphatic  deposits  are 
continually  occurring.  Furthermore,  the  danger  to 
life  in  some  of  these  old  men  from  even  a  simple 
emptying  and  washing  out  of  such  a  bladder  is  known 
to  us  all,  by  that  most  convincing  of  teachers — expe- 
rience. 

Theoretically,  the  indications  for  treatment  are  two: 
removal  of  the  cause,  and  removal  of  the  results.  De- 
struction or  removal  of  the  offending  obstruction  does 
not  remove  the  diseased  bladder  or  restore  the  dislo- 
cated muscular  insertions,  or  renew  the  disorganized 
and  degenerated  bladder  wall;  but  complete  removal 
of  the  obstruction  if  possible,  and  then  drainage  and 
constant  irrigation  of  the  bladder  and  the  pockets  and 
sinuses  connected  with  it,  will  help  a  great  deal 
toward  bettering  the  conditions  which  it  has  taken 
years  to  produce.  Prostatectomy  and  drainage  with 
frequent  irrigation  is  the  nearest  approach  to  a  fulfil- 
ment of  these  indications.  Drainage  alone  can  be 
accomplished  by  means  of  a  prostatotomy,  but  this 
does  not  remove  or  make  any  attempt  to  remove  the 
cause  of  the  trouble. 

There  are  three  w-ays  by  which  prostatectomy  may 
be  performed :  by  the  suprapubic  route,  by  operation 
below  the  pubes,  and  by  a  combination  of  both  these 
methods.  The  suprapubic  route  is  open  to  serious 
objections.  First,  and  of  perhaps  most  importance, 
drainage  is  up  hill  and  against  the  force  of  gravity. 
Shock  is  much  greater  than  in  the  perineal  operation. 
The  floor  of  the  bladder  is  extensively  lacerated. 
The  prevesical  areolar  tissue  is  easily  infected,  and 
sepsis  is  not  an  infrequent  result  of  opening  a  puru- 
lent bladder  above  the  pubes. 

There  is  no  advantage  in  the  combined  operation 
that  is  not  present  in  the  infrapubic  one,  while  the 
time  of  operation  in  the  former  is  nearly  doubled. 
Shock  is  consequently  much  more  severe  and  hemor- 
rhage is  more  likely,  with  the  chances  of  infection 
increased  by  the  added  manipulation  required  by  a 
double  operation. 

Posterior  prostatectomy,  by  a  sacral  route,  is  a  long 
and  tedious  operation,  with  no  special  advantage. 

Perineal  prostatectomy  has  many  attractions.  By  it 
the  prostate  is  easily  reached.  Hemorrhage  is  light 
or  is  easily  controlled.  Drainage  is  in  the  shortest 
and  most  direct  route  by  force  of  gravity.  The  open- 
ing into  the  bladder  is  at  its  most  dependent  portion, 
and  the  best  possible  irrigation  is  obtained  for  both 
bladder  and  urethra.  Sepsis  following  this  formida- 
ble operation  is,  therefore,  less  apt  to  occur.  The 
urethra  need  not  be  injured  nor  the  floor  of  the  blad- 
der, except  at  the  point  where  drainage  is  to  be  made. 
With  the  perineal  prostatectomy  and  drainage,  restora- 
tion of  function,  with  minimum  danger  to  life,  can  be 
expected  in  suitable  cases  and  when  the  operation  is 
done  by  experienced  surgical  hands  with  exact  knowl- 
edge of  the  anatomy  of  the  region  and  the  structures 
involved. 

The  perineal  operation  is  quite  simple.  The  pa- 
tient has  been  prepared  by  several  days  or  more  of 
rest  in  bed,  irrigations  of  the  bladder,  and  gr.  viiss.  of 
urotropin  night  and  morning.  Cystoscopy  is  used  at 
least  once,  to  give  the  operator  a  good  idea  of  the 
inner  surface  of  the  bladder  and  the  amount  and  shape 
of  the  hypertrophy  of  the  middle  lobe.  The  patient 
is  given  calomel  the  night  before,  with  a  saline  purge 
in  the  morning  preceding  the  operation,  and  the  rec- 
tum cleared  out  with  thorough  irrigation.  The  blad- 
der is  also  irrigated  with  Thiersch's  solution  just  pre- 
vious to  beginning,  and  four  to  six  ounces  of  this 
solution  left  in.  A  full-sized  sound  is  passed  to  the 
bladder  and  held  in  by  an  assistant. 


728 


MEDICAL    RECORD. 


[November  lo,  1900 


I  prefer  the  lateral  to  the  median  incision,  as  it 
gives  more  room.  It  is  made  slightly  crescentic  with 
the  convexity  upvi-ard,  its  centre  being  a  little  less 
than  half-way  from  the  anus  to  the  perineo-scrotal 
junction.  The  patient  is  in  the  lithotomy  position. 
The  incision  is  two  and  one-half  to  three  inches  or 
more  in  length.  The  left  forefinger  in  the  rectum 
locates  the  prostate  and  also  warns  the  operator  when 
he  is  approaching  too  closely  to  the  rectum.  The  in- 
cision is  carried  by  careful  dissection  down  through  the 
tissues  to  the  membranous  urethra,  where  the  sound 
locates  that  canal  and  the  apex  of  the  prostate.  Strip- 
ping the  tissues  from  the  apex  backward  can  be  very 
easily  and  rapidly  done,  either  by  means  of  a  blunt 
dissector  or  with  the  right  forefinger  nail.  The  left 
forefinger  in  the  rectum  assists  in  forcing  down  the 
prostate  and  acts  as  a  guide.  Without  care  consider- 
able laceration  of  the  rectum  can  very  easily  happen. 

At  this  stage  of  the  operation  a  volsellum  hooked 
into  the  apex  draws  the  prostate  very  satisfactorily 
into  sight.  The  capsule,  stripped  pretty  clean  inte- 
riorly and  anteriorly,  can  then  be  incised  on  either 
side  of  the  urethra  and  each  lateral  lobe  pulled  out 
as  a  whole,  bringing  the  middle  lobe  with  them.  If 
the  enlargement  is  a  fibrous  one,  this  is  surprisingly 
easy  after  one  has  done  it  a  few  times;  if,  however, 
the  hypertrophy  is  mixed  or  the  glandular  element 
predominates,  the  enucleation  is  much  more  difficult. 
The  mucous  membrane  of  the  urethra  and  bladder  is 
quite  likely  to  be  lacerated,  unless  extreme  care  is 
taken. 

In  some  cases  these  manipulations  can  be  greatly 
aided  by  incising  the  urethra  in  the  posterior  mem- 
branous portion,  withdrawing  the  sound,  carrying  the 
right  forefinger  through  this  opening  into  the  bladder, 
and  pressing  downward  the  middle  lobe,  thus  assisting 
its  enucleation.  An  Edebohls  speculum  in  the  wound 
allows  of  better  access  to  the  inferior  and  posterior 
surface  of  the  capsule.  Great  care  is  needed  to  sepa- 
rate the  prostate  from  the  floor  of  the  bladder  without 
injuring  the  latter.  The  secret  of  success  is  to  keep 
within  the  capsule.  It  is  better  to  leave  behind  small 
portions  of  the  prostate  tissue  than  to  risk  lacerating 
the  bladder  wall  by  a  too  close  dissection.  If  the 
middle  lobe  is  a  pedunculated  or  teat-like  process 
this  accident  is  almost  impossible  to  avoid.  Even  if 
it  occurs  it  is  not  necessarily  dangerous.  It  is  better 
to  connect  this  opening,  if  made,  with  the  urethral 
■wound. 

Hemorrhage  usually  ceases  when  the  prostate  is  re- 
moved ;  if  not,  hot  irrigation  and  a  few  moments'  press- 
ure with  hot  gauze  or  sponges  will  control  it.  A  large, 
firm  drainage  tube  is  fastened  in  the  wound,  so  that  it 
opens  just  within  the  bladder,  and  the  lower  end  of  it 
attached  to  a  continuous  drainage  apparatus.  A  strip 
of  acetanilid  gauze  is  placed  loosely  in  the  wound 
to  drain  the  cut  surfaces. 

At  the  end  of  the  third  or  fourth  day,  and  every 
fourth  day  thereafter,  a  full-sized  sound  is  passed 
down  the  urethra  to  the  tube,  and  after  its  removal  to 
the  bladder.  This  tube  is  used  for  irrigations  twice 
daily.  As  the  irrigation  of  the  bladder  is  a  most  im- 
portant detail  if  we  wish  to  cure  the  chronic  cystitis, 
the  tube  is  left  longer  than  would  be  necessary  for 
simple  removal  of  the  prostate  gland,  the  time  varying 
accortiing  to  the  condition  of  the  bladder  wall.  After 
it  is  taken  away  tiie  viscus  is  washed  out  by  a  catheter 
passed  through  the  wound. 

The  average  time  before  the  wound  is  closed  is  six 
to  ten  weeks,  but  long  before  that  the  patients  are 
able  voluntarily  to  expel  their  urine,  the  bladder  re- 
taining it  in  the  interval  without  loss.  In  two  cases 
in  which  I  operated,  in  April  last,  in  the  above-de- 
scrii)ed  manner,  both  were  up  and  out  of  doors,  with 
the  wound  closed,  one  in  June,  the  other  early  in  July. 


One  of  these  patients  was  fifty-nine,  the  other  sixty- 
four  years  of  age.  Both  had  atony  of  the  bladder, 
both  had  several  ounces  of  residual  urine.  The 
amount  in  one  case  was  fifteen  ounces.  In  neither 
case  is  there  at  present  any  residual  urine.  The  ure- 
thra is  one-half  to  one  inch  shorter  in  each  case. 
There  is  no  dribbling.  The  intervals  are  six  hours 
at  night  and  four  to  five  hours  during  the  daytime. 

The  results  of  a  perineal  prostatectomy  become 
more  favorable  as  improvements  take  place  in  the  sur- 
gical technique,  in  the  methods,  and  in  the  time  em- 
ployed in  the  operation.  Statistics  prove  little,  noth- 
ing, or  everything,  as  a  rule,  to  suit  the  theory  of  the 
writer  of  any  special  subject.  Some  time  ago  Dr. 
Watson,  of  Hoston,  reported  a  series  of  nine  cases  with 
no  fatal  result.  Then  his  next  patient  died,  giving  a 
mortality  of  ten  per  cent.  At  a  certain  hospital  in 
New  Vork  I  found  a  mortality  of  sixty-six  and  two- 
thirds  per  cent.,  but  a  close  examination  of  the  hospital 
records  showed  that  three  patients  had  been  operated 
on,  of  which  two  died.  Of  two  books  published  about 
the  same  date,  one  gives  a  percentage  of  mortality  of 
twenty-five  to  twenty-eight  per  cent.,  the  other  of 
twelve  to  fifteen  per  cent.;  so  much  for  the  fallacy  of 
statistics. 

Of  the  dangers  of  the  operation,  hemorrhage  is  one 
of  the  least  and  can  be  almost  always  avoided  by  re- 
ducing, as  completely  as  possible,  the  congestion  and 
oedema  before  operating.  Injury  to  or  rupture  in  the 
rectum  is  likely  to  occur  only  if  the  operation  is  done 
too  hurriedly,  or  if  there  be  adhesions  present,  or  in 
very  large  prostates.  The  rent  should  be  at  once  re- 
paired from  the  perineal  side,  the  sutures  being  kept 
from  appearing  in  the  rectum. 

Sepsis  is,  of  course,  an  always  present  danger,  but 
never  more  so  than  in  any  other  operation  under  simi- 
lar conditions.  When  free  drainage  can  be  obtained, 
this  can  be  minimized  by  attention  to  surgical  tech- 
nique and  to  the  preliminary  preparations.  The  dan- 
ger of  the  anaisthetic  is  ever  present.  The  safest  is 
nitrous  oxide  gas  and  ether.  Hypostatic  pneumonia 
is  a  source  of  danger.  Uramia  has  been  responsible 
for  the  greatest  number  of  deaths  following  the  opera- 
tion, but  it  is  not  peculiar  to  this  special  procedure. 

Dribbling  and  incontinence,  due  to  rupture  and 
laceration  of  the  sphincter  vesic.t  at  the  time  of  opera- 
tion, may  occur;  but,  with  care  in  the  digital  dissec- 
tion, it  may  be  prevented. 

Shock  depends  upon  the  loss  of  blood  and  the  length 
of  time  of  the  operation,  and  it  is  to  be  treated  by 
avoidance  of  these  two  causes  as  much  as  possible,  and 
by  intravenous  saline  injections  toward  the  end  of  the 
operation  and  after  it,  or  earlier  if  necessary. 

To  recapitulate,  dissections  of  the  pathological  pros- 
tate show  that  liypertrophy  is  almost  never  confined  to 
the  middle  lobe  alone,  but  that  the  whole  of  the  pros- 
tate is  involved.  This  involvement  is  glandular  and 
fibroid  in  character.  The  older  the  case,  the  greater 
the  predominance  of  the  fibroid  element.  At  times 
there  is  a  venous  congestion  and  a  stasis  also  of  the 
capillaries,  which  adds  a  vascular  element  to  the  size 
of  the  prostate  and  its  adjacent  tissues.  Any  opera- 
tion which  does  not  attack  the  liypertrophy  of  the 
lateral  lobes  is  not  radical  and  cannot  effect  a  perma- 
nent cure.  The  removal  or  destruction  of  the  middle 
lobe,  in  the  great  majority  of  cases,  only  partially  if 
at  all  removes  the  cause  of  the  obstruction,  although 
the  multiple  cauterizations  may  so  relieve  the  capillary 
stasis  and  (edema  of  this  portion  as  to  give  a  very,  de- 
cided temporary  relief;  and  if  most  of  the  obstruction 
in  any  special  case  is  due  to  this  condition  the  relief 
may  be  marked  and  last  for  quite  some  time,  provided 
the  bladder  and  kidneys  have  little  or  no  secondary 
disease,  and  provided  sepsis  does  not  follow. 

From  the  above  we  may  assume  that  perineal  pros- 


November  lo,  1900] 


MEDICAL   RECORD. 


729 


tatectomy  with  drainage  is  an  operation — in  compe- 
tent hands — which  is  no  more  dangerous  to  life  than 
an  interval  operation  for  appendicitis,  provided  the 
cases  are  properly  selected  ones,  in  which  degeneration 
of  the  general  and  special  tissues  of  the  body  has  not 
gone  on  to  a  hopeless  extent,  in  which  the  bladder  and 
kidneys  are  not  too  seriously  damaged,  and  in  which 
septic  infection,  if  present,  is  not  too  profound.  But, 
even  under  part  or  all  of  these  adverse  conditions, 
complete  removal  of  the  prostate  with  free  drainage  is 
the  rational  and  scientific  method  of  radical  treatment, 
and  offers  the  best  hope  of  relief,  and  the  most  favor- 
able chance  for  a  permanent  cure,  with  the  least  dan- 
ger to  life. 

15    W'ESl    FiFTV-EIGHTH   STREET. 


THE  CONSTANT  QUANTITY  IN  THE  VARI- 
OUS CLIMATIC  TREATMENTS  OF  TUBER- 
CULOSIS. 

By   C.    G.    CAMPBELL,    M.D., 

PHOENIX,   ARIZ., 

LATE     PHYSICIAN     TO     NEW     VORK    CITV     HOSPITAL;     FELLOW    OF    THE    NEW 
YORK    STATE  MEDICAL  ASSOCIATION. 

Ir  should  not  be  necessary  to  defend  the  climatic  treat- 
ment of  tuberculosis.  Unfortunately  from  high  quarters 
in  Germany  the  declaration  has  of  late  gone  forth 
that  climatic  treatment  is  of  no  value,  and  with  some 
of  us  anything  emanating  from  Germany  is  considered 
ex  Ciit/iedni.  Let  it  be  remembered  that  a  few  years 
ago  practically  the  only  sufferers  from  phthisis  that 
received  any  benefit  were  those  viho  resorted  to  a  suit- 
able climate.  -Many  of  these  entirely  regained  their 
health.  If  better  methods  of  treatment  have  improved 
our  results  under  ordinary  conditions,  it  is  only  rational 
to  hold  that  these  better  methods  will  be  still  more 
elticacious  in  a  climate  which  is  highly  beneficial  of 
itself.  This  is  a  most  important  question.  If  climate 
is  of  benefit  the  physician  is  making  a  serious  error  in 
not  giving  his  patient  the  advantage  of  it. 

The  writer  is  of  the  opinion  that  the  principal  point 
possessed  in  common  by  climatic  conditions  beneficial 
to  phthisis  is  the  discouragement  of  germ-life  and 
thereby  the  prevention  of  reinfection.  The  following 
conditions  found  in  various  climates  may  be  enumer- 
ated as  discouraging  to  germ-life: 

{a)   High  percentage  and  volume  of  sunlight. 

(/')  Temperature  of  sun  sufficiently  high  to  promote 
sterilization. 

(c)  Dryness  of  atmosphere. 

(d)  Porousness  of  soil. 

(e)  Constant  freezing  temperature, 
(y)   Infrequency  of  habitation. 

{g)   Unfavorable  conditions  for  the  formation  of  dust. 

The  first  three  conditions  are  actually  germicidal 
and  positive  in  their  action.  The  last  four  simply 
offer  a  poor  soil  for  germ-life  and  therefore  are  not  so 
valuable.  Taking  the  discouragement  of  germ-life  as 
our  thesis,  we  will  find  that  climates  possessing  appar- 
ently opi)osing  qualities  have  this  common  point  though 
produced  by  different  conditions.  For  example,  the 
high  altitudes  of  Colorado  with  a  rarefied  dry  amos- 
phere,  small  rainfall,  and  high  percentage  of  sunlight 
present  exactly  opposite  conditions  to  those  obtained 
on  the  open  sea.  And  yet  a  long  sea  voyage  is  as 
beneficial  to  many  cases  of  tuberculosis  as  is  a  high 
altitude.  The  explanation  is  easily  found  in  that  the 
volume  of  sunlight  and  dryness  of  atmosphere  in  the 
high  altitude  discourage  germ-life,  whereas  the  entire 
absence  of  du.st  to  carry  germs  and  the  absence  of 
population  to  produce  them  free  the  patient  from  the 
danger  of  outside  infection  on  the  open  sea.  With- 
out a   detailed   analysis  it   will   be   found  that  every 


climate  beneficial  to  tuberculosis  discourages  germ- 
life  through  some  of  its  qualities.  The  high  percent- 
age and  volume  of  sunlight  and  the  dryness  of  the 
atmosphere  are  undoubtedly  the  qualities  of  great- 
est importance.  The  greater  extent  to  which  these 
are  possessed  by  a  climate  the  greater  is  its  curative 
value.  Ozone  was  formerly  dwelt  upon  as  the  element 
which  gave  climate  its  value.  There  is  no  question 
that  ozone  is  germicidal,  but  there  is  no  accurate 
method  of  measuring  the  percentage  of  ozone  in  the 
atmosphere  and  therefore  the  benefit  that  a  greater  or 
less  percentage  produces.  Whatever  its  e.xact  value 
its  action  is  common  with  that  of  the  before-mentioned 
conditions,  namely,  the  discouragement  of  germ-life. 

A  high  altitude  has  been  held  to  be  of  benefit. 
There  is  a  question  if  this  belief  is  not  founded  on  a 
false  theory,  and  it  is  possible  that  patients  improve 
in  a  high  altitude  because  of  the  sunlight  and  dry 
atmosphere  and  in  spite  of  the  altitude  rather  than 
because  of  it.  In  many  patients  the  heart  action  is 
greatly  overtaxed  by  a  high  altitude.  It  certainly  in- 
creases the  tendency  to  hemorrhage,  and  a  patient  who 
recovers  in  a  high  altitude  usually  finds  it  necessary 
to  remain  there  the  rest  of  his  life.  However,  whether 
a  high  altitude  possesses  positively  detrimental  quali- 
ties or  whether  the  criticisms  of  it  are  merely  academic, 
there  is  no  doubt  that  innumerable  cases  have  been 
greatly  benefited  under  the  conditions  there  prevailing. 

The  writer  having  had  considerable  experience  in 
the  treatment  of  tuberculosis  in  the  climate  of  the  low 
altitudes  of  Arizona,  feels  warranted  in  staling  his  ob- 
servations of  its  value  more  to  uphold  climatic  treat- 
ment in  general  than  to  advocate  this  climate  in  par- 
ticular. In  configuration  Arizona  slopes  from  an 
altitude  of  seven  thousand  feet  in  the  northeast  to 
practically  sea  level  in  the  southwest.  The  territory 
is  protected  on  all  sides  by  mountain  ranges  ten  thou- 
sand feet  high,  and  is  not  subject  to  the  continental 
waves  of  temperature  change.  The  low  altitudes  are 
exemplified  in  the  extensive  valleys  of  the  Gila  and 
Salt  rivers.  This  combination  of  low  altitude  and  ex- 
cessive aridity  is  not  found  elsewhere  on  this  continent. 
Here  the  altitude  is  under  fifteen  hundred  feet.  The 
low  altitude  not  only  serves  to  make  the  temperature 
mild,  but  the  configuration  of  the  country  and  the 
peculiar  infiuence  of  the  Gulf  of  California  make  it 
one  of  the  mildest  climates  in  winter,  as  well  as  one 
of  the  hottest  in  summer.  In  the  months  of  June,  July 
August,  and  September  the  heat  is  intense,  though 
comparatively  easy  to  bear  on  account  of  the  very  low 
humidity.  Many  sufferers  from  jihthisis  make  great 
improvement  in  these  months;  there  are  others  who 
do  not  stand  it  well,  and  these  can  best  spend  the 
summer  months  farther  north  or  in  higher  altitudes 
where  it  is  cooler,  l-rom  October  1st  to  June  i  st  no 
more  favorable  conditions  for  phthisical  patients  can 
be  found.  In  December  and  January  the  nights  are  a 
little  cool,  but  in  the  daytime  the  temperature  in  the 
shade  at  midday  is  seldom  under  60°,  and  in  the  sun 
it  is  40°  to  60'  higher.  There  is  practically  not  a  day 
in  the  winter  that  a  patient  cannot  sit  in  the  open  air 
for  six  hours  or  more  with  perfect  comfort  and  pleasure. 
Patients  who  have  gained  during  the  winter  months 
make  especially  rapid  impro\enient  during  the  spring 
months.  The  percentage  of  sunshine  is  not  only  very 
high,  but,  what  is  especially  beneficial,  its  volume  is 
very  great.  This  is  not  only  evident  to  the  eye,  but 
is  well  shown  in  photographic  work,  where  the  length 
of  exposure  to  light  required  is  less  than  half  of  that 
under  ordinary  conditions.  The  sun  furthermore 
throughout  the  greater  part  of  the  year  exerts  a  steri- 
lizing effect  by  its  heat.  In  the  winter  months  the 
heat  of  the  sun  is  over  120^  almost  daily,  and  in  the 
summer  a  thermometer  placed  in  dust  in  the  sunlight 
will  register  from  170'  to  200  . 


730 


MEDICAL    RECORD. 


[November  lo,  1900 


There  is  less  wind  than  in  any  other  part  of  the 
United  States.  This  is  a  most  desirable  condition  to 
a  patient  who  has  very  little  subcutanous  fat. 

The  most  distinctive  feature  of  this  country,  and  the 
one  in  which  it  exceeds  all  others,  is  its  aridity.  It 
is  a  desert  not  because  the  soil  is  unfertile,  but  be- 
cause very  little  rain  falls,  and  that  which  does  is  al- 
most immediately  evaporated  by  the  strong  sunlight. 
There  is  so  little  moisture  in  the  air  that  dew  is  un- 
known. The  annual  mean  relative  humidity  of  Phoe- 
nix is  36  per  cent.,  the  lowest  recorded  in  the  United 
States.  That  of  New  York  is  75  per  cent.  Relative 
humidity  as  low  as  3  per  cent,  has  been  observed,  and 
an  afternoon  record  of  5  or  6  per  cent,  is  common. 
The  lowest  relative  humidity  recorded  in  New  York 
in  1S99  was  40  per  cent.  It  will  thus  be  seen  that  the 
dryest  single  observation  in  New  York  is  not  so  dry 
as  the  annual  average  in  Arizona.  It  is  proper  to 
note  just  here  that  where  there  is  great  dryness  of  the 
atmosphere  the  change  of  temperature  between  day 
and  night  is  very  rapid.  This  is  necessarily  so  be- 
cause there  is  very  little  moisture  in  the  air  to  retain 
the  heat  of  the  sun.  This  is  of  no  consequence  to  the 
patient  in  the  morning  when  the  atmosphere  is  getting 
warmer,  but  in  the  winter  months  when,  in  the  after- 
noon, as  the  sun's  rays  become  less  vertical,  the  at- 
mosphere gets  rapidly  cooler,  it  is  very  easy  to  catch 
a  cold.  This  is  due  not  only  to  the  quickly  falling 
temperature  but  to  the  rapid  evaporation  from  the  skin 
occasioned  by  the  dryness  of  the  atmosphere.  Pa- 
tients are  especially  vulnerable  just  aft^r  taking  exer- 
cise. This  mishap  can  be  easily  guarded  against  if 
patients  are  properly  advised  and  follow  instructions. 

It  is  an  important  question  which  patients  to  send  to 
this  climate,  and  which  not  to  send.  Of  the  ordinary 
cases  of  subacute  or  fibro-caseous  phthisis,  practically 
all  improve  who  have  not  reached  the  cavernous  stage. 
In  patients  with  small  cavities  the  disease  is  often 
arrested,  but  their  complete  recovery  takes  a  very 
much  longer  time.  When  there  are  large  cavities, 
and  especially  when  there  is  bronchiectasis,  the  pa- 
tients do  not  seem  to  do  as  well  as  in  a  mild  maritime 
climate.  In  fact  the  very  dry  air  and  the  diurnal  tem- 
perature range  seem  to  aggravate  unduly  the  sensitive 
bronchial  mucous  membrane  of  these  patients.  Cases 
of  acute  or  galloping  phthisis  as  manifested  by  a  high 
remittent  temperature  do  not  do  well  anywhere  unless 
they  become  transformed  into  the  subacute  variety. 
It  is  reasonable  to  believe  that  a  favorable  climate 
will  increase  the  possibility  of  this  transformation  in 
such  cases.  The  physician  is  warranted  in  advising 
them  to  seek  climatic  benefit,  provided  they  or  their 
friends  clearly  understand  the  exact  situation.  Climate 
seems  to  be  altogether  hopeless  for  cases  of  acute  gen- 
eral tuberculosis.  The  wise  physician,  in  sending  a 
patient  to  a  beneficial  climate,  will  not  give  him  definite 
assurances  as  to  when  he  can  leave  it  with  safety.  To 
tell  a  patient  that  he  will  be  well  after  six  months 
there,  however  slight  and  incipient  his  disease,  is  a 
very  indiscreet  procedure.  While  patients  often  look 
and  apparently  feel  well  after  six  months  in  a  favor- 
able climate,  the  chest  seldom  shows  complete  arrest 
of  the  process,  and  relapses  on  returning  to  their  former 
homes  are  only  too  common.  A  prudent  rule  for  a 
patient  to  follow  is  to  live  in  a  favorable  climate  until 
a  year  after  his  cough  and  expectoration  have  entirely 
ceased.  In  sending  a  patient  away  it  is  best  to  advise 
him  that  he  will  probably  have  to  devote  several  years 
to  the  sole  object  of  regaining  his  health,  and  that  he 
will  have  to  sacrifice  every  other  consideration. 

It  is  well,  before  sending  a  patient  away,  to  make  an 
attempt  to  improve  his  general  nutrition  to  an  extent 
that  he  may  be  strong  enough  to  stand  the  journey. 
It  is  highly  desirable  that  he  should  have  a  companion 
competent  to  save  him  from  all  care  and  extra  exer- 


tion while  on  his  journey,  as  well  as  to  assist  him  to 
get  settled  when  he  reaches  his  destination.  In  many 
cases  favorable  under  ordinary  circumstances  the  pa- 
tients suffer  a  drain  on  their  strength  too  great  to  en- 
able them  to  react,  owing  to  their  having  to  provide  for 
their  own  necessities  during  a  long  journey. 

The  management  and  treatment  of  a  case  tf  tuber- 
culosis are  just  the  same  in  a  beneficial  climate  as  in 
one  that  is  not  so  beneficial.  The  natural  conditions 
being  more  favorable,  a  larger  percentage  improve, 
and  the  improvement  is  much  more  rapid.  Speaking 
generally,  the  two  main  objects  to  be  kept  in  view  in 
the  treatment  of  tuberculosis  are  the  prevention  of  re- 
infection and  the  increase  of  resistance.  The  pre- 
vention of  reinfection,  while  generally  recognized,  is 
not  given  the  supreme  position  of  importance  which 
it  should  hold  in  order  to  secure  the  best  results  in  the 
treatment  of  tuberculosis.  There  is  no  doubt  of  the 
fact  that  even  when  the  patient's  sputum  is  carefully 
sterilized  there  is  often  reinfection  from  dust  particles 
in  the  atmosphere,  which  in  a  populous  community  is 
always  more  or  less  infected.  It  is  in  this  respect 
that  the  favorable  climate  gives  the  patient  an  advan- 
tage and  the  physician  an  adjunct  in  treatment  that 
cannot  possibly  be  gained  in  any  other  way.  This 
tendency  to  the  prevention  of  reinfection  is  the  con- 
stant quantity  possessed  by  all  favorable  climates  to  a 
greater  or  less  degree,  and  until  it  is  possible  to  ex- 
terminate the  tubercle  bacillus  in  the  air  or  in  the 
human  organism,  climate  will  always  favorably  influ- 
ence treatment  and  afi^ord  the  patient  a  better  opportu- 
nity for  recovery. 

While  emphasizing  the  importance  of  the  preven- 
tion of  reinfection  gained  by  climate,  the  increase  of 
resistance  by  the  now  generally  accepted  measures 
of  open-air  living  and  superfeeding  is  regarded  by 
the  writer  as  of  equal  importance,  and  these  measures 
should  be  practised  as  faithfully  and  in  as  great  detail 
in  a  favorable  climate  as  in  one  not  specially  favor- 
able. It  is  not  within  the  scope  of  this  article  to  go 
into  the  details  of  these  methods,  but  their  efficiency 
is  very  great  if  practised  thoroughly  and  for  a  long 
period.  Otherwise  the  results  are  apt  to  be  disap- 
pointing. Furthermore  it  must  take  a  long  period  of 
time  and  the  combined  judgment  of  many  observers  to 
establish  the  exact  value  and  limitations  of  these 
methods.  It  is  usually  the  case  that  more  is  expected 
of  new  remedies  than  their  completed  test  realizes.  It 
seems  highly  probable  to  the  writer  that  it  will  be 
found,  in  addition,  that  these  methods  must  be  practised 
for  a  much  longer  period  after  the  disease  has  become 
arrested  than  is  now  deemed  necessary.  Six  months 
of  mercury  was  originally  regarded  as  sufficient  perma- 
nently to  arrest  syphilis,  but  three  or  four  years  is  now 
regarded  as  a  conservative  period.  While  the  analogy 
is  not  a  close  one,  it  is  sufficient  to  illustrate  the  point. 
Sir  James  Paget  said  that  no  disease  ever  gets  entirely 
well.  This  is  in  a  sense  true,  but  many  diseases  get 
well  enough  for  all  practical  purposes.  In  phtliisis 
which  has  been  arrested  there  is  a  permanent  impair- 
ment of  the  respiratory  function  and  an  established  sus- 
ceptibility to  the  tubercle  bacillus.  A  case  whicii  has 
been  arrested  or  which  has  been  pronounced  cured 
should  therefore  always  be  regarded  much  in  tlie  same 
light  as  a  case  of  renal  disease  which  is  quiescent  or  one 
of  valvular  disease  in  which  compensation  is  main- 
tained. It  is  much  better  for  the  patient's  welfare  for 
him  to  regard  his  disease  as  arrested  rather  than  cured. 
In  a  case  the  course  of  which  is  favorable  there  are, 
clinically  speaking,  three  stages  in  the  progress:  the 
first,  in  which  there  are  active  signs  of  disease  and  the 
nutrition  has  not  reached  par;  the  second,  in  which 
nutrition  is  good  and  weight  approximately  normal,  but 
in  which  there  are  still  cough  and  expectoration  and 
signs  in  the  chest  that  cicatrization  is  not  complete ;  the 


November  lo,  1900] 


MEDICAL    RECORD. 


731 


third,  in  which  nutrition  is  good,  cough  and  expectora- 
tion have  disappeared,  and  in  which  there  remains  only 
a  little  dulness  and  harsh  respiration  in  the  chest. 
The  patient  is  usually  amenable  to  discipline  in  the 
first  stage.  The  second  is  the  most  dangerous  stage, 
for,  exultant  in  his  improved  condition  and  renewed 
hope,  he  is  only  too  apt  to  abuse  himself.  He  cannot 
be  made  to  realize  that  each  successive  recrudescence 
of  the  disease  is  the  more  and  more  difficult  to  react 
from,  and  so  he  progressively  detracts  from  his  chances 
of  permanent  arrest.  Even  in  the  third  stage  he  should 
be  more  or  less  under  the  surveillance  of  the  physician, 
and  should  promptly  consult  him  upon  the  slightest 
deviation  from  complete  health.  Strict  obedience 
should  be  the  motto  of  the  patient,  and  infinite  care 
that  of  the  physician.  Therefore  while  it  seems  cer- 
tain that  a  favorable  climate  gives  an  advantage  not 
otherwise  obtainable,  in  order  to  afford  the  patient  his 
best  chance  he  should  have  not  only  such  a  climate, 
but  in  addition  the  most  careful  medical  supervision. 
Some  patients  will  get  well  by  modern  methods  of 
treatment  without  climate,  others  by  climate  without 
treatment,  but  modern  methods  of  treatment  and  climate 
together  will  save  many  patients  who  would  otherwise 
succumb. 


CHRONIC   COPPER    POISONING    AMONG 
ARTISANS. 

By    henry   a.    KUKTH.    A..M..    M.D., 

SCHENECTADY,    N.    V. 

Introduction If  an  artisan  at  his  regular  occupation 

takes  into  his  system  some  of  the  material  in  which  or 
with  which  he  works,  and  this  acts  injuriously  to  him, 
we  have  a  case  of  so-called  occupation  poisoning. 
The  varieties  of  occupation  poisonings  are  numerous, 
but  most,  because  of  their  rarity,  receive  little  atten- 
tion. Chief  of  these  poisonings  to-day  is  lead  poison- 
ing. This  from  its  frequency  is  nearly  always  recog- 
nized and  rationally  treated.  Copper  poisoning,  on 
the  other  hand,  is  at  present  only  too  rarely  diagnosed, 
and  its  treatment  is  anything  but  rational.  Until 
within  the  last  twenty  or  thirty  years  copper  poisoning 
was  not  at  all  common.  But  with  the  enormous  growth 
of  manufactures  in  the  United  States  these  cases  have 
become  so  numerous  that  any  physician  in  a  manu- 
facturing city  is  likely  to  meet  them.  The  object  of 
this  paper  is,  therefore,  to  impress  on  the  city  practi- 
tioner the  growing  importance  of  this  subject.  Cases 
of  this  kind  are  abundant  here  at  the  Edison  General 
Electric  Works,  and  it  is  from  among  these  that  the 
material  for  this  article  has  been  largely  drawn. 

Etiology. — Among  what  kind  of  workmen,  then,  are 
we  to  look  for  copper  poisoning?  In  a  general  way, 
any  man  working  in  copper,  or  more  commonly  its 
alloy  brass,  is  sure  to  get  some  of  it  into  his  system. 
In  fact,  some  persons  need  only  work  in  the  same  room 
where  the  metal  is  used  to  get  enough  of  the  poison  to 
cause  symptoms.  This  may  seem  exaggerated,  but  I 
have  repeatedly  found  it  true,  and  the  reason  for  this 
will  be  seen  later.  It  was  among  brass  founders  that 
the  disease  first  received  attention.  To-day  brass 
founders  form  but  a  small  percentage  of  brass  workers. 
Fully  as  numerous  are  the  solderers.  These  men  are 
very  quickly  affected.  Other  brass  workers,  such  as 
filers,  turners,  stampers,  grinders,  and  platers,  are  all 
more  or  less  slowly  affected.  The  most  dangerous 
employment,  however,  is  that  of  the  finishers  or  polish- 
ers. Many  of  these  use  the  buffing  wheel,  which  fills 
the  air  with  fine  particles  of  copper  dust,  directed 
toward  tiie  workman.  The  copper  enters  the  system 
by  both  the  alimentary  and  respiratory  tracts.  A 
small  quantity  is  taken  in  daily  with  the  food  and  oc- 


casionally with  water  that  ha  been  exposed  to  the 
dust  of  the  room.  Most  of  the  copper  that  enters  the 
system  first  passes  through  the  nose.  From  the  nose 
it  takes  two  courses.  Some  of  it  passes  straight 
through  the  nose  and  throat  into  the  lungs,  whence  by 
means  of  the  lymphatics  it  is  carried  into  the  general 
circulation.  The  larger  portion,  however,  is  caught 
up  by  the  mucus  of  tiie  nose  and  throat  and  then  swal- 
lowed. In  the  blood  and  the  tissues  the  copper  is 
probably  stored  up  in  the  form  of  an  albuminate.  The 
length  of  time  it  remains  in  the  system  is  still  a  matter 
of  speculation.  I  believe  it  to  be  a  question  of  months, 
with  elimination  constantly  going  on.  Copper  is 
eliminated  from  the  system  by  the  liver,  the  kidneys, 
salivary  and  intestinal  glands,  and  to  a  slight  extent 
by  the  skin. 

Pathology. — In  order  to  understand  the  pathology 
and  the  symptoms  it  is  necessaiy  to  recall  the  physio- 
logical action  of  copper.  Locally  copper  is  both  an 
astringent  and  an  irritant.  Constitutionally  it  is  an 
agent  promoting  waste.  Its  astringent  and  irriiant 
actions  come  into  play  at  its  entrance  into  as  well  as 
at  its  expulsion  from  the  body.  Its  action  promoting 
waste  comes  into  play  during  its  passage  through  the 
tissues  of  the  body. 

In  the  respiratory  tract  the  irritant  action  seems  to 
predominate.  The  nose,  pharynx,  larynx,  trachea,  and 
bronchi  are  intensely  congested.  The  parenchyma  of 
the  lungs  is  probably  at  first  also  congested.  Sooner 
or  later,  however,  there  is  destruction  of  theepithelium 
of  the  bronchioles  and  air  vesicles  with  the  formation 
of  new  connective  tissue.  The  lungs  being  thus  far 
crippled  offer  an  excellent  field  for  pathogenic  germs, 
notably  streptococci  and  tubercle  bacilli.  Conse- 
quently most  of  these  cases  end  in  purulent  bronchitis, 
or  phthisis,  or  both.  The  part  of  the  lungs  not  con- 
solidated then  takes  on  compensatory  emphysema. 
The  stomach  being  the  chief  port  of  entry  of  the  copper 
suffers  proportionately.  At  first  there  is  a  simple 
chronic  gastritis.  Sooner  or  later  this  invariably  ends 
in  chronic  atrophy  of  the  mucous  membrane.  Cases 
of  such  complete  loss  of  digestive  power  as  one  finds 
among  old  copper  workers  one  rarely  meets  elsewhere. 
In  the  intestines  we  find  no  constant  lesion.  This 
seems  to  be  due  to  the  fact  that  the  activity  of  the 
copper  is  largely  used  up  in  the  stomach.  The  liver 
is  the  principal  storage-place  for  the  copper.  Its 
normal  functions  are  generally  somewhat  interfered 
with.  Gross  lesions  (cirrhosis)  are  rare.  The  spleen 
is  enlarged  in  most  cases,  but  is  in  no  way  character- 
istic of  the  disease.  The  blood,  important  as  it  is, 
has  not  been  studied  sufficiently  to  warrant  any  state- 
ment, except  that  the  copper  combines  with  the  haemo- 
globin of  the  red  blood  corpuscles  and  so  diminishes 
their  usefulness.  The  arthritic  diathesis  one  fre- 
quently finds  among  lead  workers  is  not  found  among 
copper  workers.  For  this  reason  any  attempt  to  ex- 
plain copper  poisoning  as  analogous  to  lead  poisoning 
will  fail.  It  will  be  remembered  that  a  large  portion 
of  the  copper  is  eliminated  by  the  kidneys.  We  would 
naturally  expect  these  organs  sooner  or  later  to  be- 
come the  seat  of  a  chronic  inflammation,  especially 
interstitial  nephritis.  This,  however,  is  not  common, 
and  the  kidneys  give  but  little  trouble.  This  is  an- 
other instance  in  which  lead  and  copper  do  not  act 
alike.  On  the  nerves  copper  acts  as  an  irritant,  and 
this  action  is  responsible  for  a  great  many  symptoms. 
Some  authors  claim  that  copper  causes  various  forms  of 
neuritis,  paraplegia,  paralysis  agitans,  and  even  loco- 
motor ataxia,  but  they  have  failed  to  exclude  alcohol- 
ism and  irregular  living  as  causative  factors. 

Symptoms. — The  skin  is  sometimes  the  seat  of 
eczema.  This  is  found  on  the  face,  back,  or  wherever 
there  is  persistent  local  perspiration,  and  is  marked 
by  the  obstinacy  with  which  it  resists  treatment  while 


73- 


MEDICAL    RECORD. 


[November  lo,  1900 


the  patient  remains  at  his  wori<,  but  lieals  readily  with 
change  of  occupation.  The  hair  is  often  colored  green 
conspicuously  among  men  whose  hair  has  already 
turned  white  from  age  or  debility.  I'he  linen  is  regu- 
larly colored  green.  This  staining  is  due  lo  particles 
of  copper  dust  coming  in  contact  with  the  perspiration, 
and  is  in  no  sense  a  green  perspiration.  Sweating  is 
sometimes  profuse,  due  probably  to  debility,  the  same 
as  the  night  sweats  of  phthisis.  The  eyes  occasion- 
ally shosv  iiyperajmia  of  the  conjunctiva  with  consider- 
able irritability  and  photophobia,  but  only  when  they 
are  subject  to  the  direct  action  of  the  fumes  or  dust. 
In  the  nose,  pharynx,  and  larynx  we  find  the  action  of 
the  copper  pronounced.  F.xaniinntion  shows  intense 
hyper-Timia.  mostly  dry,  with  only  here  and  there  a 
streak  of  mucus.  The  best  way  of  describing  it  is  to 
say  that  the  entire  surface  looks  extremely  angry.  The 
ordinary  hypertrophic  rhinitis  appears  pale  in  com- 
parison and  has  more  mucus  on  its  surface.  The 
patients  complain  of  a  dry,  hacking  cough  or  a  feeling 
of  constriction  of  the  throat,  that  nothing  relieves. 
The  voice  is  often  husky.  The  nasal  irritation  may 
cause  fits  of  sneezing  which  are  accompanied  by  pro- 
fuse watery  discharge,  but  this  is  exceptional.  From 
the  lungs  proper  we  also  get  a  dry  irritating  cough. 
Sometimes  we  meet  a  patient  who  says  that  his  cough 
is  accompanied  by  expectoration.  This  means  that 
either  he  has  bronchitis  due  to  the  inhalation  of  large 
quantities  of  dust  other  than  copper,  or  that  he  has 
phthisis.  I  believe  that  in  uncomplicated  cases  of 
copper  irritation  we  have  little  or  no  expectoration. 
Haemoptysis  used  to  be  mentioned  as  frequent,  but  in 
these  days  of  exact  physical  examination  this  is  no 
longer  claimed  to  belong  to  copper  poisoning  purely. 
Copper  certainly  predisposes  to  phthisis;  so  anyone 
with  an  inherited  tendency  to  phthisis  should  avoid 
copper.  On  the  other  hand,  many  cases  look  and  act 
phthisical  that  are  not  so.  It  is  always  necessary  to 
have  the  positive  physical  signs,  and  above  all  elevated 
temperature,  to  call  a  case  phthisis.  I  have  sten  pa- 
tients apparently  in  the  last  stage  of  phthisis,  and  who 
had  been  told  by  their  family  physician  that  they  liad 
phthisis,  fail  to  show  the  least  trace,  and  have  had  this 
verified  by  subsequent  observation.  In  referring  to 
the  mouth  all  writers  dwell  on  the  green  line  on  the 
teeth.  This  is  merely  a  staining  green  of  the  tartar 
and  other  impurities  on  the  teeth,  and  is  not  to  be 
found  in  persons  who  use  the  brush  freely.  The  saliva 
is  regularly  diminished.  A  metallic  taste  is  frequently 
complained  of.  The  tongue  may  be  tremulous.  The 
stomach,  being  the  chief  port  of  entry  of  the  copper,  is 
very  early  affected.  Loss  of  ajspetite  is  the  first  and 
universal  symptom.  Later  comes  more  or  less  gastric 
pain.  Vomiting  is  not  common  in  the  early  stages, 
but  in  advanced  cases  may  be  so  severe  that  the  stomach 
retains  hardly  any  food.  The  gastric  secretion  being 
below  normal,  the  food  is  imperfectly  digested  and 
when  passed  on  into  the  intestines  cau.ses  colic.  Fer- 
mentation in  the  intestines  is  common,  due  partly  to 
the  undigested  state  of  the  food  that  reaches  them  and 
partly  to  the  insufficiency  of  the  bile.  The  action  of 
the  bowels  is  not  uniform.  Constipation,  diarrhoea, 
and  normal  stools  may  ail  be  found.  Jaundice  is 
mentioned,  but  seems  no  more  frecpient  than  in  other 
workmen.  'I'he  kidneys  again  give  no  characteristic 
symptoms.  Green  urine  is  mentioned  by  one  author, 
but  must  be  rare.  The  circulation  is  regularly  affected 
in  copper  workers.  The  common  symptom  is  over-ac- 
tion of  the  heart  with  more  or  less  palpitation.  The 
pulse  is  full  yet  easily  compressed.  Much  of  the 
dyspncea  those  patients  complain  of  is  accounted  for 
by  this  disturbed  heart  action.  Arteriosclerosis  I 
have  found  only  in  those  who  used  alcohol  freely. 
Such  symptoms  as  vertigo,  sinking-spells,  hot  and  cold 
flashes  are  all  purely  vasomotor  disturbances. 


We  now  come  to  certain  general  symptoms  which 
are  so  common  as  to  be  characteristic.  The  face,  in 
advanced  cases,  has  a  drawn,  anxious  expression  as  in 
marked  phthisis.  Anamia  is  found  in  all  cases. 
The  effect  of  this  upon  the  complexion  is  different 
from  that  of  other  anamias.  Tome  it  a|)pears  several 
shades  darker.  The  term  sallow  comes  close  to  de- 
scribing it.  1  know  of  no  class  of  men  who  can  be 
so  intensely  nervous  as  copper  workers.  Their  rest- 
lessness is  without  limit.  In  their  homes  they  are 
irritable  and  excitable.  Sleeplessness  is  of  course 
common.  Itching  and  neuralgic  pains  in  different 
parts  of  the  body  are  here  and  there  complained  of. 
Emaciation  is  typical  of  the  disease.  One  author  calls 
them  a  "  spare,  unhealthy  set  of  men."  The  emacia- 
tion is  not  confined  to  the  subcutaneous  fat  but  ex- 
tends even  to  the  muscular  tissue.  Loss  of  strength 
naturally  follows  such  emaciation. 

Diagnosis.- — The  symptoms  that  are  of  the  greatest 
value  in  the  recognition  of  cases  of  copper  poisoning 
are:  (i)  dyspepsia,  which  is  the  earliest  of  all  symp- 
toms; (2)  anaemia,  which  also  is  early  and  comes  be- 
fore emaciation,  loss  of  strength,  or  painful  facial  ex- 
pression;  (3)  nervousness  and  irritability.  Add  to 
these  the  fact  that  the  patient  works  in  copper  or  brass, 
and  you  cannot  be  mistaken. 

Prognosis. — This  is  uniformly  good  when  organic 
changes  have  not  taken  place  and  when  a  change  of 
occupation  can  be  effected.  If  the  patient  remains  at 
the  same  work  the  case  will  go  on  slowly  from  bad  to 
worse.  It  must  be  admitted,  however,  that  some  ac- 
quire a  toleration  for  copper  and  live  to  be  quite  old. 
A  few  seem  to  start  in  perfectly  immune,  but  these 
cases  are  so  rare  as  to  be  noted  exceptions.  I  have 
noticed  that  if  copper  workers  acquire  phthisis  it  is 
not  so  rapidly  fatal  as  one  would  expect,  and  patients 
who  receive  early  treatment  probably  show  a  larger 
percentage  of  cures  than  in  other  departments.  An- 
other fact  to  be  borne  in  mind  is  that  local  applica- 
tions to  or  operations  upon  the  nose  and  throat  for  the 
relief  of  distressing  symptoms  are  unsatisfactory  so 
long  as  the  patient  remains  exposed  to  the  source  of 
irritation. 

Treatment. — This  is  first  of  all  prophylactic. 
Some  factories  recognize  the  danger  from  copper  dust 
and  attempt  to  protect  the  men  by  systems  of  ventilat- 
ing fans.  Here  and  there  a  workman  will  protect 
himself  by  wearing  a  wet  sponge  or  cloth  over  the 
nose  and  mouth.  Both  of  these  methods  are  valuable 
and  should  be  encouraged.  But  even  men  who  clearly 
see  the  need  of  taking  precaution  will  after  a  time  tire 
of  it.  In  extreme  cases  of  poisoning  it  is  necessary 
to  advise  giving  up  the  occupation  altogether.  Yet  it 
must  be  remembered  that  workmen  subject  to  chronic 
copper  poisoning  are  generally  skilled  mechanics  re- 
ceiving high  wages,  who  will  not  readily  give  up  their 
work.  Next  to  this  I  have  found  a  vacation  of  from 
two  to  four  weeks  of  the  greatest  benefit. 

When  the  set  of  symptoms  before  enumerated  was 
first  discovered  to  be  due  to  the  presence  of  copper  in 
the  system,  physicians  instinctively  turned  to  iodide 
of  potassium.  They  reasoned  that  iodideof  potassium 
is  good  for  lead-poisoning,  and  therefore  from  analogy 
it  must  be  good  for  copper  poisoning.  Any  physician 
trying  this  remedy  will  soon  come  to  the  conclusion 
that  it  is  useless.  I  have  tried  it  faithfully,  and  know 
others  who  have  tried  it  and  given  it  up.  The  fact  is, 
there  is  to-day  no  specific  for  copper  poisoning. 
Strychnine  in  large  doses  is  of  value  against  several 
symptoms.  It  is  the  best  stomachic  and  nerve  tonic 
known,  and  is  certainly  indicated.  Phosphoric  acid 
is  strongly  advocated  by  some  writers  who  claim  ex- 
cellent results.  In  conclusion  we  see  that  to-day  our 
chief  reliance  must  be  jirophylaxis  and  change  of  oc- 
cupation.    In  some  of  the  manufacturing  districts  of 


November  lo,  1900] 


MEDICAL    RECORD. 


733 


Germany  a  law  is  in  force  that  a  man  cannot  work 
longer  tlian  three  months  at  a  time  at  glazing  (lead 
poisoning).  In  practice  this  works  admirably,  because 
the  men  are  taught  to  alternate  with  each  other  at 
their  work.  It  would  be  well  if  this  law  received  a 
wider  application. 


The  Physiology  of  the  Labyrinth  ;  a  New  Theory 
of  Hearing. — J.  W:  liarrett  gives  an  abstract  of  this 
new  theory  as  originally  propounded  by  J.  Rich  Ewald. 
He  calls  it  the  "Sound-Picture"  theory  and  gives  the 
following  as  its  ground  principle:  membranes  can 
vibrate  in  very  different  manners.  They  can  form  a 
vibration  type  of  their  own  when  they  give  out  their 
own  special  tone.  They  vibrate  then  in  a  manner 
similar  to  plates  which  show  Chladni's  figures.  In 
the  telephone  and  the  phonograph,  membranes  vibrate 
as  a  whole  when  influenced  by  sound  waves — that  is 
without  nodal  lines.  They  follow  the  sound  waves, 
and  for  this  purpose  must  not  be  too  thin  or  too  flex- 
ible, and  especially  if  they  are  very  extensible,  not  too 
weakly  stretched.  Finally,  they  can  be  stretched  on  a 
frame,  and  if  impulses  act  on  them,  they  can  create 
moving  waves.  If  these  are  reflected  from  the  frame, 
so  that  the  impulse  is  given  out  from  opposite  ends  at 
the  same  time,  then  the  stationary  waves  are  created 
which  produce  a  characteristic  picture  for  the  given 
impulse.  In  this  case,  the  membrane  must  be  as  thin 
as  possible,  as  Hexible  as  possible,  and  at  least  in  one 
direction  as  little  stretclied  as  possible.  In  the  ear, 
the  impulses  falling  on  the  ground  membrane  create 
a  sound-picture  whose  special  form  enables  the 
ground  membrane  to  create  a  link  in  the  chain  of  the 
transmission  apparatus,  which  intervenes  between 
sound  and  sound  sensations.  This  is  the  ground 
principle  of  the  sound-picture  theory,  no  more  and 
no  less. —  Intercolonial  Medical  Journal  oj  Australasia, 
August  20,  1900. 

Heart  Lesions  following  the  Acute  Specific  Fe- 
vers.— W.  A.  Dickey  says  that  success  in  the  treatment 
depends  more  on  recognizing  the  condition  of  the  car- 
diac fibre;  the  size  of  the  cavities,  whether  they  are 
increased  or  not;  if  so,  to  what  degree,  the  state  of  the 
vascular  system,  the  cause  or  causes  that  may  have  led 
to  the  changes  in  the  valves,  if  any  there  be,  and  the 
general  health  of  the  patient,  rather  than  to  the  exact 
diagnosis  of  whether  this  or  that  valve  is  involved. 
The  former  are  absolutely  essential  to  correct  thera- 
peutic application,  while  the  latter,  however  much  de- 
sirable from  a  diagnostic  point  of  view,  is  not  vitally 
necessary — so  long  as  we  have  compensation — which, 
however,  may  be  very  soon  and  easily  lost — an  effort 
should  be  made  to  keep  the  cardiac  fibre  in  a  good 
state  of  preservation  by  improving  the  patient's  nutri- 
tion and  regulating  his  habits  of  \\i^.— Chicago  Aletti- 
cal  Compemi,  October,  1900. 

A   Method  of  Hand   Disinfection J.    Hahn    has 

used  the  following  metiiod  with  success  and  believes 
it  possesses  advantages  over  those  in  general  use. 
The  hands  and  forearms  are  scrubbed  with  common 
yellow  soap  and  water  at  a  temperature  of  about  104" 
F.  with  a  boiled  brush,  the  water  being  changed  four 
times,  and  sufficient  soap  used  to  make  a  lather. 
.A.fter  the  second  scrubbing  the  nails  are  cleaned  and 
trimmed.  The  washing  is  then  continued  for  four  min- 
utes with  an  alcoholic  one-per-cent.  bichloride  solution 
which  is  rinsed  off  in  a  one  to  two  per  cent,  aqueous 
solution  of  the  same  agent  (for  one  to  two  minutes') 
and  they  are  finally  again  immersed  in  the  alcoholic 
solution  after  the  operating-gown  has  been  put  on. 
—  Centralblatt  Jiir  C/iirurgic,  October  6,  1900. 


Purulent  Frontal  Sinusitis  in  Ozaena. — G.  Ricard 
reports  the  case  of  a  woman  aged  fifty-two  years,  on 
whom  the  Ogston-Luc  operation  was  performed  with 
relief  of  the  sinus  trouble  while  the  ozaena  remained 
stationary.  The  case  brings  out  the  following  facts: 
Transillumination  may  give  no  shadow  in  the  region 
of  the  frontal  sinus  even  when  it  is  full  of  pus,  for 
clearness  depends  not  on  the  possible  contents  of  the 
sinus  but  on  the  thickness  of  its  lining  walls.  The 
destruction  of  the  orbital  wall  by  suppuration  does 
not  prevent  immediate  union  of  the  wound  and  drain- 
age by  the  nasal  passages.  Finally,  cure  of  the  sinus 
disease  does  not  necessarily  imply  that  of  an  accom- 
panying ozcena. — Rciiic  Hcbdomadaire  de  Laryngologie, 
September  22,  1900. 

Nasal  Polypus — L.  Rehti  reports  a  case  of  nasal 
polyp  remarkable  in  that  its  size  caused  considerable 
increase  of  the  width  of  the  nose  from  intra-nasal  press- 
ure. This  latter  feature,  while  common  enough  in 
various  intra-nasal  tumors,  is  yet  rare  in  ordinary 
polyps.  The  polyp  in  this  case  measured  four  inches 
in  length,  was  pear-shaped,  and  had  a  circumference  of 
somewhat  over  four  inches  at  its  greatest  diameter. 
In  general  appearance  it  suggested  a  fibroma  present- 
ing various  furrows  on  its  surface,  with  ulcerated  areas 
and  some  hemorrhagic  spots.  Microscopical  examina- 
tion showed  it  to  consist  of  areolar  connective  tissue 
in  an  oedematous  matrix,  with  here  and  there  some 
few  fibres  of  harder  tissue. — La  J'arole,  July,  1900. 

The  Surgical  Treatment  of  Anasarca. — After 
medical  measures  have  failed,  Menok  advises  surgical 
intervention  for  the  relief  of  the  oedema  of  the  ex- 
tremities accompanying  cardiac  or  renal  diseases. 
In  spite  of  tiie  apparent  simplicity  of  the  manoeuvre 
the  risk  of  maceration  of  the  skin  and  subsequent 
infection  have  always  been  considered  so  great  that  it 
has  never  found  favor  as  a  routine  treatment,  but  with 
care  and  the  adoption  of  aseptic  precautions  the  dan- 
ger from  these  causes  may  be  reduced  to  a  minimum. 
Of  the  various  procedures  that  have  been  suggested 
the  two  most  useful  are  incision  and  drainage.  The 
former  of  these  is  to  be  used  only  in  restless  or  deliri- 
ous patients,  or  in  those  whose  dyspnoea  prevents  the 
recumbent  posture,  for  it  favors  infection  to  a  much 
greater  degree  than  the  less  radical  operation.  The 
difficulty  lies  in  keeping  the  incisions  closed  and  so 
preventing  the  continual  oozing  of  fluid,  which  not 
only  renders  the  patient  uncomfortable  through  the 
saturation  of  his  bedding  but  prevents  the  healing  of 
the  wounds,  and  by  the  tendency  of  the  fluid  to  under- 
go ammoniacal  fermentation  irritates  and  macerates 
the  skin,  making  it  a  suitable  culture  ground  for  bac- 
teria. The  r  thod  of  drainage  is  not  open  to  these 
objections,  and  has  the  further  advantage  that  the  flow 
may  be  easily  checked  at  any  time  that  weakness  or 
collapse  on  the  part  of  the  patient  makes  it  desirable. 
The  author  employs  a  slightly  modified  Curschmann's 
cannula,  which  after  careful  sterilization  of  the  skin  is 
plunged  into  the  subcutaneous  tissue  and  may  then  be 
connected  to  a  rubber  tube  which  conveys  the  fluid  to 
a  vessel  at  the  bedside.  Anesthesia  may  be  dispensed 
with,  for  the  tension  renders  the  skin  insensitive,  and 
the  only  inconvenience  attending  the  operation  is  the 
necessity  it  enforces  upon  the  patient  of  remaining 
quiet  in  bed  for  from  eight  to  ten  hours,  longer  than 
which  time  it  is  not  advisable  to  leave  the  instrument 
in  place.  If  further  drainage  is  required,  a  fresh 
puncture  should  be  made  to  diminish  the  damage  to 
the  tissues  and  their  consequent  vulnerability  to  germs. 
To  seal  the  puncture  a  strip  of  iodoform  gauze  kept  in 
place  by  a  special  spring  compress  is  the  most  suita- 
ble dressing,  and  may  be  removed  at  the  end  of  three 
days,  at  the  expiration  of  which  time  closure  is  usually 
perfect. —  Wiener  klinischc  Rundschau,  October  7,  1900. 


734 


MEDICAL   RECORD. 


[November  lo,  1900 


Medical   Rfxord: 

A    W'lckly  Journal  of  JMcdicinc  and  Surgery. 


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

Publishers 

WM.   WOOD   &   CO.,  51    Fifth   Avenue, 

New  York,  November  10,  1900. 


PUBLIC    SPEAKING    IN    THE    MEDICAL 
PROFESSION. 

Public  speaking  is  of  various  kinds.  A  wide  gulf 
divides  the  high  flights  of  oratory  of  a  Bright  or  a 
Webster,  which  can  excite  the  passions  or  sway  the 
emotions  and  conlrol  the  moods  of  a  vast  audience, 
and  the  scintillations  of  wit  which  flash  from  a  Mark 
Twain  or  a  Depew,  and  which  are  so  admirably  calcu 
lated  to  promote  digestion  and  to  induce  that  com- 
fortable feeling  of  well-being  ever  the  desired  se- 
quence of  a  satisfactory  repast.  There  is  much  differ- 
ence between  the  lecture  on  some  abstruse  scientific 
subject,  delivered  by  a  learned  professor,  and  the 
plaintive  appeal  of  a  philanthropist  on  behalf  of  char- 
ity. But  it  matters  not  what  the  manner  or  matter  of 
the  speech  may  be,  the  object  to  be  attained  in  every 
description  of  public  speaking  should  be  to  express 
the  thoughts  in  words  as  clear  and  comprehensible  as 
possible.  Orators  are  few  and  far  between,  and  many 
think  that  to  possess  a  fervid,  burning  eloquence, 
which  by  its  mere  exercise  will  render  its  possessor  a 
power  in  the  land,  is  to  have  a  touch  of  the  divine 
spark,  and  that  such  a  man  is,  like  a  poet,  "born  and 
not  made."  Although  great  orators  at  the  present  time 
can  be  counted  upon  the  fingers  of  one  hand,  happily 
very  excellent  public  speakers  abound.  And  the  fact 
must  also  be  taken  into  account,  that  the  conception  of 
a  great  orator  now  prevailing  would  not  be  altogether 
in  accord  with  the  views  taken  on  the  same  subject 
years  ago.  It  is  more  than  likely  that  were  Demos- 
thenes or  Cicero  to  revisit  this  earth,  the  charm  of 
their  eloquence  would  fail  to  conquer  as  of  yore, 
and  that  even  Gladstone  would  not  be  appreciated  as 
he  was  thirty  years  ago.  So  far  as  physicians  are 
concerned,  it  goes  without  saying  that  for  them  to 
shine  conspicuously  as  speakers  they  must  be  endowed 
witli  similar  gifts  and  perfected  by  the  same  amount 
of  practice  as  are  men  in  other  lines  of  life.  It  is  as- 
serted, and  it  would  appear  with  a  substantial  basis  of 
truth,  that  physicians  taken  as  a  class  do  not  compare 
favorably  in  the  art  of  public  speaking  with  those  who 
follow  some  other  vocations.  This  may  be  put  down 
to  a  lack  of  training  and  of  practice. 

Dr.  William  Whitford,  official  stenographer  of  the 
American  Medical  Association,  published  in  'Cn.Q  Jour- 
nal ai  that  association  for  September  22d  an  article 


treating  of  the  physician  as  a  speaker.  The  article  in 
question  deals  with  the  subject  from  all  standpoints, 
but  especially  from  that  of  the  reporter.  It  is  shown 
that  the  pitch,  intensity,  and  amplitude  of  a  speaker's 
voice  have  much  to  do  with  the  work  of  the  reporter, 
in  that  they  will  greatly  expediate  his  work  or  render 
it  extremely  difficult.  It  is  an  irksome  task  for  any 
reporter,  no  matter  how  acute  his  hearing  may  be,  to 
follow  a  physician  who  has  a  low-pitched,  thick  voice, 
coupled  with  a  mumbling  mode  of  utterance.  On  the 
other  hand,  remarks  Dr.  Whitford,  the  physician  who 
takes  cognizance  of  acoustics  and  pitches  his  voice  in 
a  much  higher  key,  if  lie  articulates  well,  can  be  heard 
in  the  remotest  nook  or  corner  of  a  large  convention 
hall  without  apparently  unusual  effort.  A  low-pitched 
voice,  combined  with  rapidity  and  indistinctness  of 
utterance,  will  vi-orry  most  reporters.  A  physician 
with  a  tolerably  high-pitched  voice  may  be  clear  and 
distinct  in  utterance  yet  excessively  rapid  in  delivery. 
His  clear-cut  sentences  may  flow  uninterruptedly  at 
the  rate  of  between  one  hundred  and  sixty  and  one 
hundred  and  ninety  words  per  minute.  Such  a  man 
can  be  reported  with  comparative  ease  by  an  efficient 
hand.  Many  suggestions  and  hints  are  advanced  to 
would-be- speakers,  which,  of  course,  are  as  applicable 
to  men  of  any  other  calling  as  to  physicians,  but  as  it 
may  be  assumed  that  the  writer  has  gained  most  of  his 
experience  in  reporting  the  speeches  of  members  of 
the  medical  profession,  his  advice  may  be  taken  to 
themselves. 

Perhaps  the  most  personally  interesting  portion  of 
Dr.  Whitford's  article  is  that  in  which  physicians  and 
lawyers  are  compared  as  speakers.  After  pointing  out 
that  the  art  of  speaking  well  is  not  confined  to  states- 
men, jurists,  and  clergymen,  and  that  the  medical  pro- 
fession, like  the  ministerial  and  legal  professions,  has 
orators  within  its  ranks,  he  goes  on  to  say :  "  I  have 
had  the  pleasure  of  reporting  the  utterances  of  several 
eminent  lawyers  from  time  to  time,  and  to  speak  can- 
didly, I  must  confess  that  they  viere  not  the  superiors 
in  any  sense  of  many  of  the  physicians  whose  im- 
promptu speeches  I  have  reported."  As  striking  ex- 
amples of  the  extemporaneous  type  of  speakers  in  the 
medical  profession  the  follow-ing  three  are  cited.  Dr. 
Nicholas  Senn  is  referred  to  as  a  fluent,  forcible,  and 
impressive  speaker  with  an  excellent  command  of  lan- 
guage, who  possesses  a  richness  in  his  diction,  a  copi- 
ousness, ease,  and  variety  in  his  expression,  which 
are  rarely  surpassed  by  the  best  extemporaneous 
speakers.  In  debates  he  shows  to  best  advantage 
when  under  heavy  fire,  and  is  a  master  of  repartee. 
Dr.  Charles  A.  Reed,  of  Cincinnati,  is  presented  as  a 
splendid  specimen  of  the  scholarly,  well-read  speaker, 
who  is  chiefly  distinguished  for  his  elegant  diction  and 
the  ornateness  of  his  phraseology,  and  Dr.  Joseph  M. 
Matthews,  of  Louisville,  Ky.,  is  given  as  a  shining 
example  of  the  easy,  graceful,  polished  speaker,  whose 
forte  is  simplicity  of  language. 

No  one  can  deny  these  conclusions  or  refuse  the  due 
meed  of  praise  to  the  above-named  speakers,  but  it 
must  also  be  borne  in  mind  that  while  the  West  has 
every  reason  to  be  proud  of  her  elegant  medical  sons, 
yet  the  East  has  at  least  no  cause  to  be  ashamed  of 


November  lo,  1900] 


MEDICAL    RECORD. 


735 


the  physicians  within  her  borders  who  are  gifted  with 
considerable  rhetorical  powers. 

Ill  the  first  place,  however,  it  must  be  said  that  the 
character  of  the  speech-making  of  doctors  in  the  East 
and  West  differs  in  most  instances  in  many  important 
particulars.  The  speakers  of  the  West,  including  the 
medical  speakers,  would  appear  to  be  greatly  influ- 
enced by  the  size,  the  width,  and  breadth  of  their 
country;  the  air  of  the  illimitable  prairies  would  seem 
to  have  permeated  their  systems  and  to  have  perhaps 
unconsciously  imparted  to  their  speech  some  of  its 
breezy  vastiness.  On  the  other  hand,  the  manner  of 
public  speaking  in  the  East  is  founded  more  upon  the 
British  style,  less  copious  and  diffuse,  more  reserved 
than  the  oratory  of  the  West,  but  quite  as  much  to  the 
point.  Dr.  T.  Gaillard  Thomas,  Dr.  D.  B.  St.  John 
Koosa,  Dr.  William  H.  Draper,  of  New  York,  Dr.  Os- 
ier, of  Baltimore,  Dr.  Weir  Mitchell  and  Dr.  Keen, 
of  Philadelphia,  are  physicians  who  may  be  relied 
upon  to  uphold  the  honor  of  the  United  States  as 
speakers  in  any  company.  Some  may  think  that  to 
say  tiiat  public  speaking  in  the  East  is  founded  upon 
the  British  style  is  not  to  pay  public  speaking  in  the 
East  a  distinguished  compliment. 

VV'e  certainly  do  not  intend  to  convey  the  im- 
pression that  we  tiiink  public  speaking  anywhere  in 
the  United  States  is  slavishly  modelled  on  liritish 
lines,  for  the  .American  style  of  oratory  is  peculiarly 
its  own  and  in  many  respects  quite  superior  to  that  of 
any  other  country.  There  is  generally  in  the  speeches 
of  a  typical  American  speaker,  be  he  doctor  or  other- 
wise, a  fund  of  dry,  caustic,  but  withal  good-natured 
humor  whicii  is  unattainable  by  the  orator  of  Europe. 
However,  the  fact  must  be  confessed  with  some  degree 
of  shame,  that  neither  in  this  country  nor  in  Europe 
are  doctors  in  the  front  rank  of  public  speakers. 
Some  of  the  more  prominent  here  have  been  men- 
tioned. In  Great  Britain,  perhaps,  at  the  present  time, 
Sir  William  McCormac  is  the  best  medical  public 
speaker,  in  Germany  Virchow  and  von  Bergmann 
stand  at  the  head,  in  France  Lannelongue  leads,  and 
in  Italy  Durante.  The  United  States  can  lay  claim 
to  a  medical  man  who,  as  an  after-dinner  speaker, 
was  probably  never  surpassed,  the  inimitable  Oliver 
Wendell  Holmes,  and  Great  Britain  possessed  in  the 
late  Sir  James  Paget  an  orator  who  could  vie  with  the 
greatest  that  country  ever  produced. 

Before  leaving  the  subject  it  may  not  be  presump- 
tuous to  suggest  to  the  young  physician  that,  in  public 
speaking,  he  should  always  be  terse  and  to  the  point; 
needless  redundancy  of  language  should  be  avoided  as 
tlie  plague.  The  speaker  who  is  "  inebriated  with  the 
exuberance  of  his  own  verbosity"  will  surely  lose 
himself  and  his  audience  in  a  hopeless  maze  of  words. 
Physicians  should  cultivate  the  art  of  public  speak- 
ing. If  they  do  so  they  need  fear  no  comparison  with 
either  statesmen,  or  lawyers,  or  ministers. 


Displaced  Tendons The  tendons  most  liable  to 

displacement  from  violence  are  the  peroneus  longus 
at  the  outer  ankle  and  the  long  head  of  the  biceps, 
which  may  slip  out  of  the  bicipital  groove. 


THE  DIFFERENTIATION  FROM  RUBELLA 
AND  SCARLET  FEVER  OF  A  DISEASE  RE- 
SEMBLING   BOTH. 

The  disorder  variously  known  as  rubella,  Rotheln, 
German  measles,  French  measles,  roseola,  epidemic 
rose-rash,  has  ever  been  a  source  of  confusion  in 
diagnosis  with  reference  to  both  scarlet  fever  and 
measles,  with  each  of  which  it  possesses  certain  fea- 
tures in  common;  but  the  prevailing  opinion  is  that  it 
represents  a  distinct  entity  and  not  a  mixture  of  these 
two  other  diseases.  The  decisive  fact  in  this  connec- 
tion is  the  failure  of  any  one  of  the  diseases  to  confer 
immunity  to  any  of  the  others.  The  difficulties  of  the 
situation  will,  however,  not  be  lessened  by  the  an- 
nouncement recently  made  by  Dukes  {Lancet,  1900, 
No.  4,011,  p.  89)  that  what  has  hitherto  been  looked 
upon  as  rubella  consists  probably  of  two  distinct  dis- 
eases— a  fact  that  suggested  itself  several  years  ago, 
but  conclusive  evidence  in  favor  of  which  has  been 
obtained  only  recently.  For  the  new  disorder  the 
designation  of  fourth  disease  has,  by  reason  of  its  re- 
semblance to  rubella,  scarlet  fever,  and  measles  been 
tentatively  proposed,  and  this  may  be  wisest  until  its 
position  has  been  established  beyond  peradventure. 
The  differentiation  between  rubella  and  the  fourth 
disease  would,  however,  appear  by  no  means  easy,  as 
both  present  similar  symptoms;  both  frequently  occur 
in  the  same  locality  at  the  same  time,  and  the  period 
of  incubation  is  much  alike  in  both. 

The  fourth  disease,  it  has  been  found,  is  in  many 
cases  unattended  with  premonitory  symptoms,  al- 
though there  may  be  pronounced  malaise  for  some 
hours,  with  headache,  anorexia,  drowsiness,  chilliness, 
and  even  backache.  Like  rubella,  it  occurs  especially 
in  the  spring  and  summer.  The  period  of  incubation 
is  estimated  at  from  nine  to  twenty-one  days.  A  dif- 
fuse rash  appears  upon  the  surface  of  the  entire  body 
within  a  few  hours  after  the  inception  of  the  di.sease. 
The  exanthem  is  bright  rosy-red  in  hue,  and  somewhat 
raised  above  the  contiguous  surface.  The  sensation 
of  heat  conveyed  by  the  skin  to  the  finger  is,  however, 
less  than  in  scarlet  fever.  The  fauces  are  usually 
swollen  and  reddish,  assuming  a  velvety  appearance. 
The  conjunctivas  are  pink  and  suffused.  The  lym- 
phatic glands  universally  are  enlarged,  hard,  and  ten- 
der, feeling  like  peas,  though  less  manifest  than  in 
rubella;  those  mainly  affected  are  the  post-cervical, 
the  axillary,  and  the  inguinal.  Desquamation  may 
be  slight  or  marked,  but  it  bears  no  constant  relation 
to  the  intensity  of  the  rash.  The  kidneys  are  rarely 
involved.  There  is,  as  a  rule,  no  marked  sense  of 
illness.  The  tongue  is  clean  or  slightly  furred.  The 
pulse  may  be  normal,  but  it  is  proportionate  to  the 
temperature.  It  varies  between  98.4°  and  103°  or 
104°  F.,  and  it  bears  no  relation  to  the  extent  of  the 
rash.  The  symptoms,  even  if  severe,  subside  in  the 
course  of  a  few  days,  leaving  comparatively  little  feel- 
ing of  illness.  The  fourth  disease  has  been  found  to 
be  not  profoundly  infeclive  in  its  earliest  stage.  At 
a  later  one,  even  while  desquamation  is  taking  place, 
it  is  not  infective  beyond  two  or  three  weeks  after 
thorough    disinfection.     There     are    practically    no 


72,(> 


MEDICAL    RECORD. 


[November  lo,  1900 


sequelas,  although  the  submaxillary  glands  may  re- 
main enlarged.  The  disease  usually  terminates  in 
complete  recovery  within  three  weeks. 

It  will  be  seen  that  the  symptoms  described  do  not 
afford  a  ready  means  of  diagnosis  from  rubella.  The 
rash  of  the  latter,  however,  is  at  first  punctate,  subse- 
quently becoming  coalescent  and  forming  bats'  wings, 
in  contradistinction  from  the  dififuse  exanthem  of  the 
fourth  disease.  Further,  rubella  is  said  to  be  by  far 
the  more  infective  disease.  On  the  other  hand,  apart 
from  the  significant  fact  that  one  attack  of  either  dis- 
order does  not  confer  protection  from  attack  by  the 
other,  the  points  of  differentiation  are  not  so  clear  as 
to  justify  final  acceptance  of  the  individuality  of  the 
disease  without  further  confirmation.  As  compared 
with  scarlet  fever  the  period  of  incubation  of  the 
fourth  disease  is  longer;  premonitory  symptoms  are 
wanting;  the  pharyngeal  manifestations  are  slight;  the 
pulse  is  not  greatly  accelerated:  the  tongue  does  not 
peel;  the  period  of  infectivity  is  shorter;  the  kidneys 
are  not  involved,  and  one  attack  does  not  confer  im- 
munity from  scarlet  fever.  The  importance  of  accu- 
racy in  diagnosis  must  be  obvious,  as  failure  to  recog- 
nize scarlet  fever  may  be  attended  with  disastrous 
results,  and  the  mistaking  of  the  fourth  disease  for 
scarlet  fever  would  cause  the  patient  to  be  subjected 
to  unnecessarily  prolonged  isolation. 


sola  might  be  profitably  imitated;  that  is,  by  making 

membership  in  these  societies  a  prerequisite  of  mem- 
bership in  the  defence  associations.  At  any  rate  the 
scheme  of  a  medical  defence  association  established 
on  the  lines  of  that  of  London  is  worthy  of  trial,  and 
Dr.  Donald  Pritchard  and  his  coadjutors  in  Minnesota 
are  deserving  of  praise  for  setting  "the  ball  rolling" 
in  this  direction. 


A    MEDICAL    DEFENCE    ASSOCIATION    FOR 
MINNESOTA. 

In  an  editorial  published  in  the  Medical  Record 
September  15th,  the  eiTorts  being  made  by  Dr.  Donald 
B.  Pritchard  and  others  to  establish  a  medical  defence 
association  were  favorably  commented  upon.  It  was 
further  suggested  that  such  a  plan  intelligently  carried 
out  might  be  followed  with  advantage  in  all  parts  of 
this  country.  We  now  learn  that  Minnesota  has  in- 
corporated a  medical  defence  union.  Its  membership 
is  confined  to  residents  of  Minnesota  who  are  mem- 
bers of  the  State  Medical  Society  or  societies  auxil- 
iary to  it.  The  annual  dues  are  fixed  at  $5,  and  each 
one  pledges  himself  to  pay  $io  if  called  upon  to  do  so 
by  the  directors.  The  association  binds  itself  to  de- 
fend and  pay  all  the  costs  of  defence  in  the  event  of 
any  of  its  members  being  sued  for  malpractice,  when, 
after  proper  investigation,  the  directors  are  satisfied 
that  the  case  is  a  good  one.  It  does  not  purpose  to 
aid  those  guilty  of  malpractice,  but  simply  to  defend 
against  blackmail. 

Dr.  Wiggins  contributed  a  letter  to  the  Medic.'^l 
Record  of  September  29th,  in  which  he  advocated 
that  the  State  societies  should  make  the  defence  of 
suits  brought  against  their  members  for  malpractice  a 
part  of  their  work.  Where  w'orkable  this  would  seem 
to  be  the  most  rational  and  easiest  manner  of  settling 
the  question,  but  it  is  argued  that  the  State  societies 
do  not  care  to  take  up  the  matter,  and  that  defence 
associations  working  in  close  touch  with  their  respec- 
tive State  societies  can  accomplish  a  great  deal.  In 
those  cases  in  which  State  societies  are  disinclined  to 
act  of  their  own   initiative,  the  example  set  by  Minne- 


^cius  of  tlxe  iimccfe. 

Disease  in  the  Yukon.  —  A  despatch  from  Seattle 
says  that  the  Rev.  Father  John  B.  Rene,  in  charge  of 
the  Roman  Catholic  missions  on  the  Yukon,  has 
arrived  at  Dawson  with  a  terrible  story  of  the  suffer- 
ings of  the  natives  in  that  valley  from  an  epidemic  of 
a  mysterious  disease  resembling  a  combination  of 
pneumonia,  measles,  and  typhoid  fever.  At  Holy 
Cross  mission  sixty  out  of  one  hundred  and  fifty  In- 
dians died  in  less  than  two  months.  Famine  now 
threatens,  as  the  natives  have  not  been  able  to  lay  up 
supplies  of  fish  and  game  for  the  winter.  The  epi- 
demic, whether  it  is  of  plague  or  some  other  disease, 
has  been  general  all  along  the  river  and  along  the 
coast  of  Bering  Sea,  and  thousands  of  natives  have 
died,  and  it  is  feared  that  many  more  will  die  from 
the  disease  itself  or  the  starvation  following  in  its 
train. 

Philadelphia  Neurological  Society — At  a  stated 
meeting  held  October  22d,  Dr.  David  Riesman  ex- 
hibited a  case  of  probable  cerebellar  tumor,  in 
a  man  presenting  staggering  gait,  increased  knee 
jerks,  lateral  nystagmus,  pallor  of  the  optic  discs,  and 
vertigo  in  the  erect  posture.  Dr.  William  G.  Spiller  ex- 
hibited a  case  of  progressive  ascending  unilateral 
paralysis,  in  a  man  presenting  symptoms  of  unilateral 
spastic  paraplegia,  without  history  of  an  apoplectic 
seizure  or  of  any  loss  of  consciousness.  Dr.  Spiller 
exhibited  also  a  case  of  multiple  neuritis  of  the 
upper  limbs,  probably  the  result  of  hydrofluoric- 
acid  poisoning,  in  a  man  who  had  been  engaged  in 
one  of  the  processes  of  etching  on  glass,  and  had  de- 
veloped swelling  of  the  hands  and  arms,  followed  by 
wrist-drop  and  paresis  in  both  upper  extremities.  It 
was  thought  that  neuritis  might  have  developed  from 
absorption  of  some  poison,  such  as  hydrofluoric  acid, 
through  the  skin,  although  the  possibility  of  absorp- 
tion through  the  respiratory  tract  was  suggested.  Dr. 
James  Hendrie  Lloyd  exhibited  a  case  of  Bell's 
palsy  associated  with  complete  anaesthesia  in  the 
territory  of  the  fifth  nerve.  The  patient  was  a  young 
woman,  and  the  lesion  of  the  seventh  nerve  was 
attributed  to  exposure  to  cold,  while  the  disturbance 
in  the  distribution  of  the  fifth  nerve  was  thought  to  be 
hysterical.  Dr.  Charles  S.  Potts  exhibited  a  case  of 
left  hemiplegia  with  right  facial  palsy.  The  pa- 
tient was  a  young  man  presenting  central  paralysis  of 
the  left  side  of  the  face  and  peripjieral  paralysis  of 
the  right  side.  In  emotional  movement  the  action  of 
the  left  side  of  the  face  preponderated,  while  in  active 
movement  the  action   of   the  right  side  was  the  more 


November  lo,  1900] 


MEDICAL    RECORD, 


in 


pronounced.  Dr.  F.  Savary  Pearce  exhibited  a  case 
of  unusual  trauma  with  secondary  Bell's  palsy. 
The  patient  was  a  young  woman  who  had  been  struck 
upon  the  head  or  face,  with  the  result  that  the  tip  of 
a  pipe-stem  became  embedded  beneath  the  skin  on  the 
right  side  of  the  neck  behind  the  ascending  ramus  of 
the  lower  jaw,  probably  injuring  the  seventh  nerve  by 
contiguity.  Dr.  Clarence  Van  Epps  read  an  admirable 
paper  on  "The  Babinski  Reflex." 

A  Prison  Hospital  at  Dannemora. — A  new  hos- 
pital for  insane  convicts  has  been  erected  for  Clinton 
Prison,  most  of  the  work  on  it  having  been  done  by 
the  convicts.  The  building  is  three  hundred  feet  long 
by  forty  wide,  and  will  be  ready  for  occupancy  in 
November.  It  will  relieve  the  overcrowding  at  Mat- 
teawan  Hospital. 

Payment  for  Illegal  Practice  Refused.— A  phy- 
sician practising  in  the  Province  of  Quebec  made  a 
contract  some  time  ago  to  render  professional  services 
in  one  of  the  United  States  whose  laws  debarred  him 
from  engaging  in  the  practice  of  medicine  there.  The 
contract  was  broken  by  the  other  party  to  it,  and  the 
doctor  brought  a  suit  against  him,  in  the  Canadian 
courts,  to  recover  the  value  of  the  work  which  he  had 
done  under  the  agreement.  The  defendant  interposed 
a  defence  setting  up  the  illegality  of  the  contract,  as 
being  an  undertaking  on  the  part  of  the  plaintiff  to 
practise  medicine  and  surgery  in  a  foreign  State  where 
it  was  unlawful  for  him  to  practise.  This  defence  has 
finally  proved  successful,  the  court  holding  that  no 
compensation  is  recoverable  upon  a  contract  of  this 
character,  which  is  pronounced  illegal. 

Preliminary  Announcement. — The  ninety-fifth 
annual  session  of  the  Medical  Society  of  the  State  of 
New  York  will  be  held  in  Albany,  January  29.  30,  31, 
1900.  The  meetings  of  the  society  have  always  been 
replete  in  scientific  work  as  becomes  tiie  representative 
society  of  the  medical  profession  of  the  Empire  State, 
and  it  is  confidently  expected  that  this  meeting  will 
equal  those  which  have  preceded  it.  This  circular 
letter  is  sent  to  every  member  of  the  society  with  the 
request  that  those  who  desire  to  read  papers  will  com- 
municate at  once  with  the  chairman  of  the  business 
committee,  Dr.  Frank  Van  Fleet,  63  East  Seventy-ninth 
Street,  New  York  City,  or  with  the  jiresident,  Dr.  A. 
M.  Phelps,  62  East  Thirty-fourth  Street,  giving  the 
title  of  the  paper  and  such  other  information  as  the 
author  desires.  As  there  will  be  a  great  many  papers 
offered,  and  the  time  necessarily  limited,  it  is  sug- 
gested that  papers  be  condensed  as  much  as  possible 
in  reading,  as  they  can  be  published  more  fully  in  the 
Transactions.  Arrangements  for  reduced  fares  can 
be  made  when  purchasing  railroad  tickets.  A.  M. 
Phelps,  M.D.,  president. 

The  Craig  Colony  for  Epileptics. — The  board  of 
managers  of  the  Craig  Colony  at  Sonyea,  Livingston 
Co.,  N.  Y.,  held  their  seventh  annual  meeting  at  the 
Colony  on  October  gth.  Dr.  Frederick  Peterson,  of 
New  York,  was  re-elected  president,  and  Mr.  H.  E. 
Brown,  of  Mt.  Morris,  secretary.  The  report  of  the 
medical    superintendent.  Dr.    William    P.    Spratling, 


showed  that  there  were  six  hundred  and  twelve  pa- 
tients in  the  Colony  on  October  1st  last.  The  total 
capacity  of  the  Colony,  including  the  new  buildings 
nearly  ready  for  occupancy,  is  eight  hundred  and  forty, 
and  it  is  expected  that  the  Colony  will  have  that  num- 
ber by  July  I,  1901.  Ultimately  the  Colony  will  be 
inhabited  by  eighteen  hundred  or  more.  The  mana- 
gers decided  to  ask  the  coming  legislature  for  $169,- 
000  for  new  buildings  and  other  improvements,  and 
for  §125,000  for  maintenance.  Of  the  money  asked 
for  special  purposes,  ?9S,ooo  will  be  used  for  dormi- 
tories for  patients.  The  superintendent  called  atten- 
tion to  the  fact  that  thirty-six  out  of  six  hundred  and 
twelve  patients  at  the  Colony  are  suffering  from  tuber- 
culosis in  some  stage,  and  he  recommended  that  suit- 
able wooden  barracks  be  constructed  as  soon  as 
possible,  in  order  that  these  patients  might  be  iso- 
lated. It  is  possible  to  do  this  on  account  of  the  vast 
size  of  the  Colony  estate.  The  superintendent  called 
attention  to  the  great  necessity  for  providing  better 
means  of  transportation  on  the  Colony,  and  advocated 
the  construction  of  a  trolley  system,  the  power  for 
which  already  exists  at  the  Colony.  A  resident  path- 
ologist, at  a  salary  of  $2,500  a  year,  with  mainte- 
nance, will  soon  be  appointed. 

The  End  of  the  Glasgow  Plague.— The  last  of  the 
plague  patients  was  discharged  from  hospital  in  Glas- 
gow on  November  3d. 

Suit  against  Insane-Asylum  Oflicials. — A  Chicago 
man,  recently  released  by  order  of  the  court  from  an 
insane  asylum,  has  brought  suit  for  $250,000  damages 
against  the  superintendent  and  other  officers  of  the 
asylum.     He  alleges  that  he  was  illegally  detained. 

Dr.    Senn's    Gift  to    a    Medical    College Rush 

Medical  College  in  Chicago  is  to  have  a  new  §80,- 
000  building,  for  which  Dr.  Nicholas  Senn  has  just 
given  $50,000.  The  new  building  will  be  principally 
used  for  clerical  purposes,  and  will  be  named  Senn 
Hall. 

A  City  Plague  Laboratory. — The  New  York  City 
board  of  health,  at  a  recent  meeting,  awarded  a  con- 
tract for  the  building  of  the  laboratory  for  the  study 
of  the  bubonic  plague  on  the  Willard  Parker  Hospi- 
tal grounds  at  the  foot  of  East  Sixteenth  Street.  The 
cost  of  the  building  will  be  $19,893.  The  laboratory 
is  to  be  built  in  three  months. 

The  September  Mortality  in  this  State.— The 
New  York  State  board  of  health  bulletin,  issued  No- 
vember 2d,  shows  a  total  of  10,251  deaths  during  Sep- 
tember in  the  State,  representing  an  annual  death  rate 
per  thousand  of  population  of  16.5.  Of  this  number 
245  deaths  were  caused  by  typhoid  fever  and  930  by 
consumption. 

The    Medical    Inspection    of    Prostitutes.— It    is 

stated  in  the  Cleveland  Jnurnal  oj  Mcduine  that  the 
health  board  of  Columbus,  Ohio,  has  ordered  the  week- 
ly inspection  of  prostitutes  by  the  district  physicians. 
This,  of  course,  is  being  done  in  the  hope  of  control- 
ling the  spread  of  venereal  disease.  A  very  curious 
difficulty  has  arisen  in  consequence  of  this  order.     It 


738 


MEDICAL    RECORD. 


[November  lo,  1900 


seems  that  certain  physicians  have  been  conducting 
such  examinations  under  contract  with  the  proprietors 
of  the  houses  of  prostitution.  They,  therefore,  object 
to  the  curtailing  of  their  practice  by  the  city  putting 
the  matter  into  the  hands  of  the  district  physicians. 

A  City's  Right  to  Establish  Pest  Houses — A 
suit  was  recently  brought  against  the  city  of  Chicago 
by  the  owners  of  land  near  the  smallpox  hospital, 
opened  by  the  municipal  authorities  on  Lawndale 
Avenue  in  1896,  to  recover  damages  alleged  to  have 
been  sustained  by  their  property  in  consequence  of  the 
proximity  of  this  institution.  The  plaintiffs  have 
been  finally  defeated  in  the  supreme  court  of  Illinois. 
It  was  not  asserted  that  the  city  had  been  negligent  in 
the  care  and  conduct  of  the  hospital,  or  that  it  was  any 
more  of  a  nuisance  than  such  an  institution  must  be  of 
necessity.  The  supreme  court  held  that  there  is  no 
diflference  in  principle  between  the  right  of  a  muni- 
cipality to  establish  a  pest  house  and  its  right  to  build 
a  jail  or  fire-engine  house. 

The  Fight  over  the  Tuberculosis  Hospital  Site. — 
The  efforts  by  the  residents  of  Clinton  County  to  in- 
duce the  State  authorities  to  erect  the  proposed  hospi- 
tal for  the  treatment  of  incipient  tuberculosis  at  Dan- 
nemora,  and  their  opposition  to  the  selection  of  a  site 
at  Lake  Clear,  have  aroused  the  residents  of  the  Sara- 
nac  Lake  region  to  vigorous  protest.  At  a  recent 
meeting  resolutions  were  adopted  and  ordered  to  be 
forwarded  to  the  State  board  of  health  and  the  forest 
preserve  board,  by  whom  the  site  is  to  be  selected. 
These  resolutions  indorse  the  selection  of  the  Lake 
Clear  site  and  condemn  that  of  Dannemora.  They 
object  to  the  latter  on  the  ground  that  "  the  surround- 
ings in  a  penal  colony  are  incompatible  with  cheerful- 
ness "  and  "have  a  tendency  to  produce  melancholia, 
a  condition  most  to  be  avoided  in  tuberculous  pa- 
tients." They  also  object  to  the  employment  of  con- 
vict labor,  which  would  be  used  in  the  construction 
of  the  buildings  if  the  latter  were  erected  at  Danne- 
mora. 

A  New  Medical  Association A  committee  of  the 

El  Paso  County  (Texas)  Medical  Society  has  issued 
invitations  to  the  members  of  the  regular  medical 
profession  of  Texas,  New  Mexico,  Arizona,  and  Mex- 
ico to  meet  in  El  Paso  on  the  occasion  of  the  El  Paso 
midwinter  carnival  on  the  17th  daj^of  January,  190 1, 
for  the  purpose  of  organizing  a  tri-State  or  territorial 
medical  association.  Volunteer  papers  are  requested 
from  all  who  are  willing  to  contribute,  and  such  are 
especially  requested  to  send  in  their  names  and  the 
titles  of  their  papers  at  the  earliest  possible  date,  that 
the  programme  may  be  completed  and  sent  out  in  due 
time.  The  members  of  the  committee  are  Drs.  S.  T. 
Turner,  W.  N.  Vilas,  and  F.  W.  Galagher. 

Local  Health  Boards  in  Louisiana — We  learn 
from  the  Neia  Orleans  Medical  ami  Siirgieal  Journal 
that  twenty-five  new  health  boards  have  recently  been 
establisiied  in  Louisiana.  The  bill  which  was  passed 
at  the  last  session  of  the  legislature,  providing  for 
the  establishment  of  parish  boards  of  health  through- 
out the  State,  makes  it  obligatory  on   the   police    of 


every  parish  to  organize  a  parish  board  of  health. 
Formerly  the  law  required  the  physicians  lo  live  in  a 
parish  five  years  before  they  could  become  members 
of  the  board,  but  now  residence  of  one  year  as  a  regis- 
tered voter  in  a  parish  is  sufficient  for  membership  on 
such  board  of  health. 

A  Plague  Suspect  in  Bremen — A  despatch  from 
Bremen  slates  that  a  sailor  who  arrived  there  October 
27th  on  board  a  German  steamship  from  South  Amer- 
ica was  taken  ill  with  suspicious  symptoms,  and  the 
authorities  have  notified  the  bacteriological  experts  to 
determine  whether  it  is  a  case  of  the  plague. 

A  Famine  Threatening  in  Russia.  —  A  corre- 
spondent of  the  London  Daily  Mail,  writing  from  St. 
Petersburg,  says  that,  in  spite  of  official  denials,  there 
is  no  doubt  that  the  inadequate  harvest  will  produce  a 
famine  in  the  governments  of  Kherson  and  Bessarabia. 

Navy  Department,  Bureau  of  Medicine  and  Sur- 
gery, Washington,  D.  C. — Changes  in  the  medical 
corps  of  the  United  States  navy  for  the  week  ending 
October  27,  1900.  October  19th. — Passed  Assistant 
Surgeon  D.  H.  Morgan  commissioned  passed  assistant 
surgeon  from  November  27,  1899.  October  22d. — 
Assistant  Surgeon  R.  E.  Ledbetter  appointed  assistant 
surgeon  from  October  19,  1900. 

The  "  Decinormal "  Salt  Solution — We  receive 
from  time  to  time  letters  inquiring  why  the  saline  so- 
lution used  for  intravenous  injection  is  called  "  deci- 
normal." The  reason  is,  as  was  explained  by  Dr.  J. 
B.  Nicholas,  of  Washington,  in  the  Medical  Record 
of  August  14,  1897,  that  a  normal  solution  in  volume- 
tric chemistry  is  a  solution  containing  in  1,000  c.c.  an 
amount  of  the  active  constituent  just  sufficient  to  com- 
bine with  or  replace  i  gm.  of  hydrogen.  In  the  case 
of  sodium  chloride  this  amount  is  58.37  gm.,  hence  a 
normal  saline  solution  is  one  containing  58.37  gm.  to 
the  litre  of  water.  A  solution  one-tenth  of  this 
strength  (a  "decinormal"  solution)  contains  5.837 
gm.  lo  the  litre,  which  is  just  about  the  strength  of  the 
saline  solution  used  for  venous  infusion. 

The  Late  Dr.  S.  S.  Purple.— The  president  and 
fellows  of  the  New  York  Academy  of  Medicine  here- 
by express  their  high  estimate  of  the  character  of  the 
late  Dr.  Purple,  as  a  citizen  and  a  physician;  their 
earnest  appreciation  of  his  valuable  services  as  a  fel- 
low and  an  officer  of  the  Academy,  and  their  grateful 
acknowledgment  for  rare  books  and  pamphlets  pre- 
sented by  him  in  large  numbers  to  the  library  of  which 
he  was  the  founder.  They  earnestly  desire  to  extend 
to  the  members  of  his  bereaved  family  their  profound- 
est  sympathy  in  this,  the  hour  of  their  sad  affliction. 
William  H.  Thomson,  M.D.,  president;  Louis  F. 
Bishop,  M.D.,  secretary. 

\  committee  consisting  of  Drs.  Jacobi,  Stephen 
Smith,  Elsworth  Eliot,  and  J.  D.  Bryant,  appointed  by 
the  Academy  to  consider  a  suitable  recognition  of  the 
services  of  Dr.  Purple,  duly  reported  as  follows: 

That  on  account  of  his  beneficent  act  in  founding 
the  library,  and  because  of  other  significant  aid  to  the 
Academy,  it  is  recommended  that  a  tablet  suitably  in- 
scribed be  erected  in  the  Academy,  and  that  a  fellow 


November  lo,  1900] 


MEDICAL    RECORD. 


739 


be  appointed  by  the  president  to  deliver  a  eulogy  on 
the  late  Dr.  Purple  at  the  time  of  its  unveiling. 

Obituary  Notes. — Dr.  Matthew  J.  Grier  died  at 
his  home  in  Philadelphia  on  October  27th  at  tiie  age 
of  sixty-seven  years.  He  was  graduated  from  the 
Medical  Department  of  the  University  of  Pennsyl- 
vania in  1863,  and  at  once  entered  the  medical  service 
of  the  Union  army  and  served  until  the  close  of  the 
war.  • 

Dr.  Michael  Kelliher,  of  Pawtucket,  R.  I.,  died 
on  October  31st.  He  was  a  graduate  of  the  Xew  York 
University  Medical  School  in  the  class  of  1866. 

Dr.  Louis  W.  Read  died  at  his  home  in  Norris- 
town,  Pa.,  on  November  ist,  at  the  age  of  seventy-two 
years.  He  was  born  in  Montgomery  County,  Pa.,  in 
1828  and  graduated  from  the  medical  department  of 
the  University  of  Pennsylvania  in  1849.  When  the 
Crimean  War  began  he  offered  his  services  to  the 
Russian  government,  was  accepted,  and  served  through- 
out the  war,  etTecting  important  improvements  in  the 
treatment  of  gunshot  wounds,  which  were  afterward 
adopted  in  the  United  States  and  Europe.  In  1861 
he  was  appointed  surgeon  on  the  First  Pennsylvania 
Reserves  and  later  was  made  surgeon  of  the  United 
States  Volunteers.  In  1864  he  took  charge  of  the 
McKean  Hospital  in  Baltimore,  where  he  served  two 
years. 


progress  art  '^cAicixl   Science. 

Boston  Medical  and  Hiirgkal  Journal,  Xoi'.  /,  iqoo. 

Gunshot  Injuries  by  the  Rifles  of  Reduced  Calibre. — Louis 
A.  La  Garde  discusses  the  effects  of  the  seven-millimetre 
Mauser  ritle  as  observed  by  him  among  fourteen  hundred 
wounded  in  the  Spanish-American  war.  The  wounds  of 
entrance  and  e.\it  and  the  narrow  track  of  the  missile  fa- 
vored rapid  healing,  and  infection  was  seldom  noticed.  Of 
the  fourteen  hundred  wounded  none  died  of  external  hem- 
orrhage, nor  was  it  necessary  to  ligate  a  vessel  for  alarm- 
ing hemorrhage  on  the  field.  The  gunshot  injuries  of  the 
diaphyses  were  as  a  rule  attended  with  but  little  commi- 
nution. In  wounds  of  the  principal  joints,  including  epi- 
physes, clean-cut  perforations  without  fracture  were  the 
rule.  Of  thirty-one  cases  of  gunshot  injury  of  the  head, 
5S.  I  per  cent,  ended  fatally.  Fifty-three  penetrating 
wounds  of  the  thorax  were  observed,  with  a  mortality  of 
24.5  per  cent.  Penetrating  gunshot  wounds  of  the  abdo- 
men were  very  fatal.  Of  forty-one  recorded  cases  twenty- 
nine  ended  fatally.  The  value  of  skiagraphy  and  the  use 
of  the  fluoroscope  were  exhibited  in  locating  missiles,  in 
determining  the  extent  of  bone  lesion,  in  detecting  supposed 
cases  of  guttering  or  perforation  of  the  long  bones  without 
fracture,  and  in  probable  lesion  to  nerves  and  tendons  by 
loose  spicula  of  bone. 

Phthisis  .  Some  Causes  of  Failure  in  its  Climatic  Treat- 
ment.— Will  Howard  Swan  urges  three  points  to  be  remem- 
bered by  physicians  if  they  would  have  their  consumptive 
patients  benefited  by  the  climate  of  Colorado:  (i)  Do  not 
send  patients  with  far-advanced  phthisis  unless  they  are 
able  to  make  the  change  without  serious  fatigue,  and  un- 
less they  can  live  there  in  the  manner  they  should  and  for 
a  prolonged  period.  (2)  Do  not  send  early  cases  unless 
there  are  assured  means  for  proper  hygienic  living  for  a 
period  sufficiently  long  to  get  the  patient  well  enough  to 
earn,  in  part  at  least,  his  living,  and  to  find  employment. 
How  long  this  will  be  will  depend  upon  the  individual 
case  and  his  i>rogress,  but,  roughly  speaking,  three  or  four 
months  at  least.  There  are  many  openings  for  employ- 
ment, but  more  people  looking  for  the  desirable  ones.  (3) 
Most  important  of  all,  instruct  the  invalid  to  rest  and  to 
keep  quiet  after  his  aiTival  until  some  one  competent  to 
advise  him  considers  it  safe  to  begin  to  exercise  ;  and  then 
have  his  manner  of  life  and  hygiene  directed  from  time  to 
time,  according  to  his  progress  and  condition. 

Eye  Strain  as  a  Cause  of  Gastro-Intestinal  Neuroses. — >r. 
P.  Smithwick  calls  attention  to  eye  strain  as  one  factor 
to  be  considered  in  searching  for  the  cause  of  a  gastric  or 


intestinal  neurosis,  and  reports  a  number  of  cases  in  which 
indigestion,  nausea,  vomiting,  headache,  etc.,  were  relieved 
by  the  wearing  of  appropriate  glasses.  Of  20  cases  repre- 
senting various  types  of  digestive  neuroses,  eye  symptoms 
other  than  headache  were  present  in  7  ;  headache  was  a 
symptom  in  20  cases,  all  having  eye  defects.  Eye  defects 
were  found  in  i3  out  of  the  20  cases  and  glasses  given. 
Fifteen  patients  had  astigmatism,  13  hyperopia,  and  2  com- 
pound. Of  these  15  cases  5  patients  li.-id  also  hypermetro- 
pia.  3  muscular  trouble,  i  a.xis  "against  the  rule,"  i  opacity 
of  a  lens,  2  diminished  vision.  Two  cases  only  had  hyper- 
metropia  and  i  myopia. 

Purpura  Hemorrhagica,  or  Morbus  Maculosus  of  Werlhof. — 
By  Stephen  Smith  Burt. 

A  Note  on  Rectal  Feeding  in  Peptic  Ulcer. — By  George 
G.  Sears. 

Achlorhydria ;  its  Effects  and  their  Treatment. — By  H.  F. 
Hewes. 

Journal  oj  tlie  American  Medical  Ass' n,  Ko'o.  j.  igoo. 

Connell's  Operation  of  End-to-End  Anastomosis  of  Small 
Intestine  for  Repair  of  Enterotomy  Performed  to  Relieve 
Acute  Obstruction ;  First  Case  R(;ported  on  Human  Subject. 
— Franklin  H.  Martin  re]>orts  this  case.  After  describing 
the  preliminary  ste|)S  of  the  operation,  the  writer  states 
that  two  or  three  inches  of  the  small  intestine  were  excised 
on  each  side  of  the  opening  which  formed  the  artificial 
anus,  so  that  about  live  inches  of  the  gut  were  removed. 
The  intervening  mesentery  was  tied  in  three  sections. 
The  end  of  the  gut  representing  the  part  above  the  arti- 
ficial anus  was  larger  than  the  coil  below  that  point.  The 
smaller  end  was  incised  obliquely  in  order  to  increase  the 
diameter  of  the  free  end,  which  was  accomiilished  at  the 
expense  of  its  convex  border.  The  end-to-end  anastomosis 
after  the  method  described  by  Dr.  F.  G.  Connell  was  then 
performed.  The  method,  although  easy  to  e.xecute.  is  not 
easy  to  describe,  and  the  writer  points  to  his  illustrations 
in  order  to  assist  the  reader.  "This  method  consists  of  a 
modification  of  Maunsell's  procedure,  the  original  feature 
of  importance  being  the  ingenious  method  of  tying  the  last 
suture  in  a  way  which  effectually  places  all  knots  on  the 
mucous  surface  of  the  bowel  without  the  necessity  of  mak- 
ing the  ordinary  e-xtra  incision  employed  in  Maunsell's 
operation."  The  intestine  after  the  operation  looks  much 
like  the  end-to-end  anastomosis  with  the  Murphy  button. 
There  are  no  sutures  visible  between  the  approximated 
serous  surfaces,  although  all  coats  of  the  bowels  are  in- 
cluded. The  writer  believes  this  operation  to  have  all  the 
advantages  of  the  Murphy  button  with  none  of  its  serious 
faults.  The  time  consumed  in  the  anastomosis  was  be- 
tween fifteen  and  twenty  minutes.  Convalescence  was 
uninterrupted. 

Hypertrophy  of  the  Pharyngeal  Tonsil ;  its  Anatomy  and 
Physiology. — .\fter  speaking  of  the  anatomy  and  physiol- 
ogy of  the  jiharyngeal  tonsil,  Norval  H.  Pierce  states  that 
adenoids  are  hyperplasia  of  this  normal  tissue.  They  vary 
in  size,  consistency,  and  color.  The  infectious  diseases, 
especially  measles,  scarlet  fever,  etc.,  play  an  important 
r61e  in  the  causation  of  this  condition.  Acute  inflamma- 
tions of  the  gland  frequently  cause  acute  hyperplasia. 
The  question  of  the  dependence  on  tuberculosis  is  not  yet 
definitely  settled.  The  writer  does  not  believe  that  Dan- 
sac's  varieties,  the  scrofulous,  tuberculous,  and  syphilitic, 
comprise  all  the  varieties  of  adenoids.  Many  .scrofulous 
children  have  adenoids,  and  many  who  show  no  evidence 
of  scrofulosis  or  chlorosis  have  these  bodies  in  their  post- 
nasal spaces.  Abscesses  may  develop  in  this  tissue  which 
may  cause  septic  meningitis.  Cysts,  and  all  of  the  tumors, 
especially  sarcoma,  develop  from  the  membrana  preverte- 
bralis. 

Receptive  Quiescence  of  the  Stomach  during  Mastication ; 
Gastronomic  Phenomenon  Not  Previously  Described.— Evan 
O'Xeil  Kane  describes  this  case  on  which  he  had  operated, 
performing  a  gastrostomy.  The  patient  was  gradually 
starving  from  stricture  of  the  oesophagus  due  to  cancer  at 
the  cardiac  orifice  of  the  stomach.  Great  difficulty  was 
experienced  in  applying  the  retaining  pad  before  peristal- 
sis caused  the  rejection  of  the  fluid  food  which  was  intro- 
duced into  the  stomach.  It  was  observed  that  when  the 
patient  was  chewing  anything  while  he  was  fed.  his  stom- 
ach would  remain  quiet,  so  that  the  pad  could  be  placed 
before  muscular  activity  recjmmen^ed.  Chewing-gum 
was  used,  and  no  more  difficulty  was  experienced. 

Disease  of  the  Fallopian  Tubes,  with  Special  Reference 
to  Specific  Infection. — By  J.  R.  (Juthrie. 

Clinical  Observation  in  Malaria  as  Seen  in  the  Mississippi 
Delta.  — By  I-'rank  .\.  Jones. 

Portable  Compressed-Air  Atomizer. — By  George  F.  Cott. 

.aistivo-Autumnal  Malarial  Fever. — By  Charles  F.  Craig. 

Acute  Senile  Endometritis. — By  L.  H.  Dunning. 

Tuberculous  Peritonitis. — By  A.  H.  Cordier. 


740 


MEDICAL    RECORD. 


[November  lo,  1900 


i\V?4'  y'orA-  A/rtfh'ci/  /oiirnal,  Novciiiher ;;,  igoo. 

A  Case  of  Sudden  Death,  Probably  due  to  Pulmonary  Em- 
bolism.— -The  patient  of  J.  S.  Horsley  was  a  farmer  aged 
thirty-two  years,  who  suffered  from  stone  in  the  bladder. 
A  suprapubic  cystotomy  was  done,  and  the  patient  did  well 
for  three  days'  when  symptoms  of  suppression  ocoirred. 
Under  the  administration  of  large  quantities  of  distilled 
water  and  milk,  with  some  digitalis,  these  symptoms  en- 
tirely disappeared,  and  the  patient  advanced  in  convales- 
cence uninterruptedly  until  the  day  he  was  allowed  to  sit 
up.  He  felt  perfectly  well,  and  the  wound  was  in  excel- 
lent condition.  The  nurse  carefully  lifted  him  to  a  sitting 
posture  in  bed,  when  he  suddenly  gasped,  turned  purple 
in  the  face,  and  complained  of  pain  in  the  region  of  the 
heart.  The  doctor  was  summoned  by  telephone,  and 
reached  the  patient  in  five  minutes.  The  heart  was 
faintly  fluttering  and  liis  face  still  bluish.  His  heart 
stopped  entirely  within  seven  minutes  from  the  time  of 
the  attempt  to  sit  up.  Unfortunately,  it  was  impossible  to 
obtain  a  necropsy. 

Modem  Caesarean  Section ;  an  Ideal  Method  of  Treatment 
for  Placenta  Praevia. — A.  P.  Dudley  believes  tliat  this  plan 
of  caring  for  placenta  praevia  is  one  which  is  fully  justifi- 
able and  which  offers  greater  safeguards  than  those  hith- 
erto followed,  when  all  the  factors  in  the  case  are  taken  into 
account.  He  describes  his  method  of  operating  in  detail, 
one  important  feature  being  the  constant  irrigation  of  the 
field  with  a  warm  saline  solution.  He  does  not  believe 
that  the  patient  is  subjected  to  any  greater  danger  of  infec- 
tion than  those  which  follow  in  tlie  wake  of  forcible  intro- 
duction of  the  whole  hand  into  the  vagina,  rapid  manual 
dilatation  of  the  uterus,  turning  and  forcible  extraction  of 
the  child,  living  or  dead,  and  the  consequent  lacerations 
that  must  certainly  attend  such  a  procedure.  He  refers  to 
the  e.>cperience  of  others  with  placenta  praevia  in  general. 

A  Case  of  Paralysis  of  the  Recurrent  Laryngeal  Nerve; 
Recovery. — J.  F.  Gulp's  patient  was  a  man  aged  thirty- 
six  years,  in  whom  a  sudden  loss  of  voice  came  on  while 
smoking  and  talking.  When  seen  some  thre6  weeks  later 
acute  laryngitis  was  found  with  the  left  cord  in  the  cadav- 
eric position.  A  diagnosis  of  probable  neuritis  of  the  recur- 
rent nerve  was  made.  Abstinence  from  tobacco  and  rest  of 
the  larynx  were  ordered,  with  sprays  of  menthol  and  ben- 
zoinol.  Later  the  constant  current  was  applied  to  the 
neck.  Nux  vomica  was  given  as  a  tonic  and  checked  a 
diarrhoea  from  which  the  patient  had  sufi^ered  for  some 
years.  At  the  end  of  six  months  his  voice  was  normal  and 
examination  showed  a  perfect  larynx. 

A  Southern  Health  Resort :  Climatic  Advantages  of  Ashe- 
ville,  N.  C,  as  a  Temporary  Residence  for  Tuberculous  Pa- 
tients.—  By  B.  T.  Whitmore. 

An  Operation  for  Laceration  of  the  Perineum ;  Failure  of 
Medullary  Narcosis. — By  H,  J.  Boldt. 

Supposed  Glioma  of  the  Retina ;  Enucleation ;  No  Return 
in  Twelve  Years. — By  D.  Webster. 

Fulminating  Appendicitis. — By  C.  A.  Wheaton. 
Mi-dical  XciL's,  November  ^,  igoo. 

Obervations  upon  the  Quartan  Malarial  Parasite  and  upon 
the  Staining  Reactions  of  the  Tertian,  Quartan,  and  .Sistivo- 
Autumnal  Parasites. — According  to  the  statement  of  Charles 
F.  Craig,  of  nearly  two  thousand  cases  of  malaria,  the  rec- 
ords of  which  have  been  preserved,  and  in  which  the  mala- 
rial parasites  were  present  in  the  blood,  only  twelve  quar- 
tan infections  were  noted.  This  parasite  is  as  distinctive 
in  its  morphology  as  is  the  tertian  or  jestivo-autumnal  va- 
riety. In  twenty-four  hours  the  distinguishing  features 
are  fully  developed.  The  organism  is  sharply  cut  and 
looks  often  as  if  it  were  stamped  into  the  blood  corpuscle  ; 
it  is  refractive,  and  its  protojilasm  often  presents  a  pecul- 
iar, finely  granular  appearance ;  the  pigment  is  dark 
brown,  in  the  form  of  rather  coarse  granules,  and  is  gen- 
erally collected  around  the  edge  of  the  organism  ;  the  pig- 
ment is  motionless.  The  shape  of  the  organism  at  this 
stage  is  usually  triangular,  ovoid,  or  round,  and  it  is  not 
amoeboid.  The  invaded  corpuscle  is  smaller  than  the 
healthy  ones  and  is  of  a  darker  green  color.  The  writer 
then  (iescribes  Romauowsky's,  Chenzinsky's,  and  Fut- 
cher's  methods  of  staining. 

Treatment  of  Puerperal  Eclampsia. — J.  B.  Killebrevv  gives 
the  following  order  of  procedure  in  the  treatment  of  puer- 
peral eclampsia  :  (i)  Control  convulsions  v%'ith  chloroform  ; 
(2)  bleed  the  patient  and  give  intravenous  injection  of  deci- 
uormal  salt  solution  ;  (3)  empty  the  uterus.  If  the  numl)er 
of  competent  persons  present  is  sufficient, the  last  two  meth- 
ods can  be  practised  with  benefit  at  the  same  lime.  After 
these  measures  the  colon  should  be  thoroughly  irrigated. 
Many  physicians  have  had  good  results  with  veratrum 
viride.  Pilocarpine  is  dangerous.  Morphine  should  not  be 
used  on  account  of  its  effects  on  the  various  secretions. 
Since  the  mortality  so  far  in  this  affection  has  been  about 
twenty-five  per  cent.,  there  is  yet  room  for  improvement  in 
the  methods  of  treating  it. 


Is  Living  Animal  Tissue  Capable  of  Neutralizing  the  Ef- 
fects of  Strychnine  and  Venom?  An  Experimental  Study. — 
S.  J.  Mellzer  and  G.  Langmann  summarize  their  results 
as  follows  :  Constriction  of  an  extremity  of  an  animal,  even 
after  removal  of  tlie  constriction,  markedly  retards  the 
fatal  outcome  of  snake  poisoning  and  transforms  an  effec- 
tive minimum  dose  of  strychnine  into  an  ineffective  sub- 
minimum  dose.  This  effect  is  apparently  due  to  some  im- 
pairment of  the  power  of  absorption  within  the  constricted 
leg.  It  seems  quite  certain  that  no  part  of  either  poison 
becomes  fixed  or  neutralized  by  the  tissues  of  the  animal 
experimented  upon.  The  claim  of  v.  Czyhlarz  and  Uonath 
to  that  effect  could  not  be  sustained. 

Present  Status  of  Interstate  Reciprocity  Concerning  Li- 
censes to  Practise  Medicine. — By  ImiiiI  Amberg. 

Eye-Work  in  General  Practice. — By  S.  W.  S.  Toms. 
riiHade/pltia  Medical  Jottrnal,  November  3.  /goo. 

Subarachnoid  Injections  of  Cocaine  as  a  Substitute  for  Gen- 
eral Anaesthesia. — In  concluding  his  paper  on  this  subject, 
A.  M.  Phelps  declares  that  these  experiments  should  be 
done  by  men  of  mature  judgment,  of  long  experience,  of 
clear  heads.  He  thinks,  as  long  as  ether  and  nitrous-oxide 
gas  have  so  low  a  mortalit)",  the  profession  should  be  loath 
to  substitute  another  method  which  must  necessarily  have 
a  great  mortality.  Two  deaths  occurred  in  Paris  this  sum- 
mer from  this  method  of  administration  of  cocaine.  On 
this  side  the  water  there  are  occasional  reports  of  a  death 
or  of  alarming  symptoms  following  this  method. 

A  Note  on  the  Use  of  Nitrous  Oxide  and  Ether  as  an 
Anesthetic. — Thomas  R.  Brown  and  Howard  A.  Kelly  have 
for  the  past  eight  months  been  using  the  combined  nitrous 
oxide  and  ether  method  in  practically  all  the  cases  operated 
on  at  Dr.  Kelly's  private  hospital.  The  cases  number  be- 
tween two  hundred  and  three  hundred.  The  method  pos- 
sesses so  many  advantages  to  the  patient,  operator,  and 
anaesthetist,  and  so  few  disadvantages,  that  it  has  become 
an  indispensable  part  of  the  operative  technique  of  the 
writers. 

Large  Scrotal  Hernia ;  Operation  for  Radical  Cure  Under 
Spinal  Anaesthesia  with  Eucaine ;  Aluminum  Bronze  Wire 
Used  for  Buried  Sutures ;  Operative  Recovery ;  Death  from 
Exhaustion  and  Urinary  Sepsis. — By  W.  W.  Keen. 

Local  and  Regional  Anaesthesia  with  Cocaine  and  Other 
Analgesic  Drugs,  Including  the  Subarachnoid  Method,  as  Ap- 
plied in  General  Surgical  Practice. — By  Rudolph  !Matas. 
(Illustrated.) 

Anaesthesia  in  Children  with  Adenoids,  and  in  the  Adenoid 
Operation,  with  Special  Reference  to  the  Dangers  of  Chloro- 
form in  Children  of  the  Sympathetic  Diathesis. — By  T.  H. 
Halsted. 

Cocaine  Analgesia  from  Subarachnoid  Spinal  Injection,  with 
Report  of  Forty-four  Cases,  Together  with  a  Report  of  a 
Case  in  which  Antipyrin  was  Used. — By  George  Ryersou 
Fuwler. 

Subarachnoidean  Injections  of  Cocaine  as  a  Substitute  for 
General  Anaesthesia  in  Operations  Belov/  the  Diaphragm, 
with  Report  of  Seven  Cases. — By  Edward  Wallace  Lee. 

Intraspinal  Cocainization  for  Surgical  Anaesthesia. — By  S. 
Ormond  Goldan,      (Illustrated.) 

Analgesia  in  Obstetrics  Produced  by  Medullary  Injections 
of  Cocaine. — By  S.  Marx. 

Anaesthesia  by  Cocainization  of  the  Spinal  Cord. — By 
George  G.  Hopkins. 

Ethyl  Bromide  in  Obstetrics  and  Gynaecology. — By  Wilmer 
Krusen. 

Cocaine  Anesthesia  of  the  Spinal  Cord. — By  Ernest  La- 
place. 

Two  Cases  of  Medullary  Narcosis. — By  W.  L.  Rodman. 
'///(•  J.iiiicef,  October  :;-.  /goo. 

A  Case  of  Separation  of  the  Epiphyseal  Head  of  the  Fe- 
mur.— By  J.  J.  Clarke.  The  patient,  a  girl  aged  fifteen 
years,  had  fallen  and  was  unable  to  stand.  On  entrance 
to  hospital  no  fracture  or  injury  other  than  contusion  was 
made  out,  and  she  was  ordered  rest  and  liniment.  Five 
months  later  she  was  seen  by  the  writer,  who  found  her 
very  lame.  Stepping  on  the  right  foot  was  painful,  and 
the  right  limb  was  markedly  averted.  The  right  great 
trochanter  was  displaced  upwai'd  and  approximated  to  the 
anterior  superior  spine.  The  limb  was  an  inch  shorter 
than  its  fellow,  and  the  gluteal  fold  on  the  affected  side 
was  shortened  and  curved  up  at  its  outer  end.  On  the 
front  of  the  right  hip  joint  there  was  a  prominence  which 
suggested  an  anterior  dislocation  of  the  head  of  the  femur. 
Passive  adduction  of  the  affected  limb  was  easily  accom- 
plished, but  abduction  and  flexion  were  painful  to  the  pa- 
tient and  were  greatly  limited  in  their  range.  There  was 
no  crepitus  felt  in  carrying  out  these  movements.  A  good 
radiograph  was  obtained  which  clearly  showed  a  break  in 
the  neck  of  the  femur.     Excision  of  the  head  of  the  femur 


November  lo,  1900] 


MEDICAL    RECORD. 


741 


was  advised  and  done.  Tlie  parts  removed  consisted  of 
the  head  of  tlie  femur  (which  was  entire),  the  inner  end  of 
the  neck,  and  separate  fragments  of  granular  callus.  The 
head  had  remained  connected  with  the  neck  by  two  por- 
tions of  the  cervical  ligament,  one  at  its  postero-inferior 
aspect  and  another  at  its  antero-inferior  aspect.  The  liga- 
mentum  teres  also  was  intact.  By  these  connections  it  had 
escaped  necrosis,  but  there  was  no  attempt  at  bony  union, 
the  callus  having  l)een  formed  entirely  from  the  neck  of  the 
femur.  The  separation  had  taken  place  exactly  in  the 
plane  of  the  epiphyseal  cartilage,  no  trace  of  which  re- 
mained. The  fragment  of  the  neck  which  was  removed 
was  somewhat  sclerosed.  Although  the  patient  in  the 
pre.sent  case  had  no  definite  signs  of  rickets,  there  probably 
was  some  weakening  of  the  bone  from  slight  inflammatory 
(rachitic)  changes  in  the  juxta-epiphyseal  tissue,  predis- 
posing tlie  patient  to  the  accident.  The  operation  was  in 
every  way  successful. 

The  Differential  Diagnosis  in  General  Practice  of  Plague 
and  Typhoid  Fever. — T.  Colvin,  who  had  experience  with 
the  recent  cases  of  plague  in  (ilasgow,  notes  as  character- 
istics of  the  disease  its  sudden  onset  with  buboes,  rapid 
rise  of  temperature,  dyspnix-a  out  of  all  proportion  to  any 
physical  signs  revealed  on  examination,  general  pains  in 
the  chest,  cough  and  expectoration  which  is  .scanty  and 
streaked  with  bright  red  blood,  nervous  symptoms  of  the 
delirious  type  coming  on  early,  and  absence  of  skin  rashes. 
The  general  aspect  of  the  patients  after  a  very  brief  illness 
is  that  of  a  later  stage  ot  typhoid.  The  Widal  test  in  the 
plague  is  negative,  and  if  sputa  arc  present  the  character- 
istic bacilli  can  be  found  in  large  numbers.  As  to  the  site 
of  bubonic  enlargement  the  author  states  tliat  the  most 
common  glands  atifected  arc  those  in  tlie  groin.  In  almost 
half  of  the  cases  the  inguinal  or  femoral  glands,  or  both, 
are  alone  enlarged.  The  next  common  situation  is  the 
axilla  a;.d  in  order  of  frequency  the  cervical,  submaxillary, 
and  parotid  glands.  Enlargement  of  the  supratrochlear, 
iliac,  and  popliteal  glands  rarely  occurs. 

The  Anaemia  of  Dyspepsia  Consequent  on  Dirt-Eating. —  A. 

J.  P.  L)u|)rey  does  not  believe  that  the  aiuemia  observed  in 
ankylostomiasis  following  dirt-eating  is  due  to  the  abstrac- 
tion of  blood  from  the  intestinal  mucosa  by  the  parasite, 
but  ascribes  it  to  malnutrition,  due  to  insufficient  and  im- 
proper food.  This  causes  dyspepsia,  which  in  its  turn  leads 
to  anjEtiiia,  for  the  parasites  in  this  affection  feed  not  on 
the  blood  but  rather  on  the  soluble  products  of  digestion 
which  otherwise  would  have  been  absorbed  and  gone  to 
nourish  the  system.  He  believes  therefore  that  it  is  a  mis- 
take to  suppose  that  the  dirt-eating  habit  produces  its 
symptoms  from  the  parasites.  Anthelmintics  are  of  bene- 
fit, but  recovery  after  their  use  does  not  follow  as  quickly 
as  it  would  if  the  parasites  alone  were  the  causative  factor. 

On  the  Role  Played  by  the  Spleen  in  the  Pancreatic  Di- 
gestion of  Proteids. — By  H.  F.  Bellamy. 

Forces  Opposed  to  Harvey  and  His  Researches. — Harveian 
oration  by  T.  Clifford  Allbutt. 

A  Case  of  Complete  Coarctation  of  the  Arch  of  the  Aorta. 
— By  W.   Loe  iJickinsou. 

Notes  on  Cases  of  Injury  by  Lightning ;  One  Fatal. — By 
P.  E.  Hill. 

Some  Remarkable  Cases  of  Sarcoma. — By  A.  Marmaduke 
Shield. 

Appendicitis. — An  address  by  Harry  Littlewood. 
liritisli  MciUcat  Journal,  October  sy,  igoo. 

The  Signs  and  Symptoms  of  Bubonic,  Pneumonic,  and 
Septicaemic  Plague. — James  Cantlic  states  that  the  skin  is 
now  generally  considered  to  be  the  "port  of  entry  "  of  the 
plague  bacillus.  The  average  period  of  incubation  of  the 
bubonic  plague  is  from  three  to  five  days.  The  onset  is 
generally  sudden.  The  patient  complains  of  splitting 
headache,  of  great  weakness  and  prostration,  of  pains  in 
the  limbs  and  back,  and  sometimes  in  some  one  of  the 
larger  groups  of  lymphatic  glands.  In  severe  cases  there 
are  generally  rigors  or  chilly  feelings  and  often  vomiting 
and  nausea.  Diarrlura  is  not  uncommon.  The  pulse  is 
usually  fairly  full  at  first  and  of  increased  frequency. 
Respiration  is  rapid,  and  the  temperature  during  the  first 
three  days  may  gradually  reach  104'  or  105'  F..  or  even 
higher.  Mental  aberration  appears  early.  It  is  as  a  rule 
the  third  day  before  the  bubo  appears.  Abrasions  of  the 
skin  should  be  sought  for.  Adenitis  occurs  in  all  varieties 
of  plague  except  in  tlie  pneumonic  and  fulminant.  In  bu- 
bonic plague  unilateral  swelling  of  a  group  of  glands  is 
the  rule,  and  one  gland  of  the  group  ])roceeds  to  bubo. 
Various  parts  of  the  alimentar)^  canal  are  affected.  Con- 
stipation is  the  rule.  The  liver  may  be  tender  and  some- 
what enlarged:  the  spleen  is  invariably  swollen.  The 
urine  is  usually  slightly  albuminous.  Sleeplessness  is  one 
of  the  most  distressing  symptoms  in  ]>lague.  In  ])neu- 
monic  plague  the  sputum  is  profuse,  of  a  watery  character 
at  first.     Generally  blood  does  not  appear  till  after  twenty- 


four  hours'  duration  of  the  illness.  Pneumonic  patches 
occur  in  either  lung  and  at  any  portion.  The  .severity  of 
the  onset  of  septicaimic  plague  is  such  that  the  patient  re- 
sembles one  attacked  by  active  poi.son.  Prostration  from 
the  first  is  extreme.  Hemorrhages  from  the  no.se,  bowel, 
or  kidney  are  more  frequent  in  this  variety  than  in  any 
other  type  of  the  disease.  Apyrexia  is  not  uncommon. 
Busy  delirium  followed  by  coma  usually  ends  in  death  on 
the  second  or  third  day. 

A  Note  on  the  Method  of  Using  Haffkine's  Prophylactic. — 
Margaret  M.  T.  Christie  in  Calcutta  in  iSyS,  together  with 
Dr.  Niekl  Cook,  inoculated  some  2,400  patients  between 
April  and  July,  none  of  whom  died  of  plague  during  that 
year's  epidemic.  The  ordinary  dose  of  Hafikine's  prophy- 
lactic for  an  adult  male  was  5  c.c.  ;  for  a  woman,  40  c.c.  ; 
for  girls  between  the  ages  of  ten  and  fourteen  years,  3  c.c.  ; 
for  children  from  two  to  ten  years,  from  i>^  to  3  c.c.  The 
writers  selected  the  back  and  outer  side  of  the  arm  mid- 
way between  shoulder  and  elbow  as  the  site  of  inoculation. 
The  reaction  in  many  cases  began  at  once  with  pricking 
at  this  site,  and  the  gradual  formation  of  a  hard,  tender 
red  swelling  for  a  few  inches  round.  The  temjicrature 
rose  within  six  hours.  The  height  of  the  fever  v;iried 
-greatly,  rarely  lasting  more  than  two  days,  though  the 
arm  remained  more  or  less  painful  and  tender  for  a  week 
or  ten  days,  and  a  small,  hard  nodule  often  remained  for  a 
few  weeks.     There  were  no  untoward  results. 

The  Bacteriology  of  Plague  (with  Illustrations  on  Special 
Plate). — David  C.  Rees  declares  that  the  micro-organism 
which  he  describes  in  detail  in  his  paper  is  now  the  undis- 
puted causative  agent  of  plague.  This  organism  re- 
sembles .somewhat  closely  the  bacillus  of  chicken  cholera. 
It  is  generally^  from  i  /i  to  2  /t  in  length  and  from  0.3  /i  to 
0.5  /I  in  width.  It  has  rounded  ends  and  is  generally  non- 
motile,  although  at  a  temperature  of  37 '  C.  it  is  actively  mo- 
tile. It  does  not  form  spores  and  has  no  true  capsule.  It 
is  a  facultative  anaerobe.  This  bacillus  is  constantly 
present  in  the  body  of  an  individual  .suffering  from  the  dis- 
ease. If  a  susceptible  animal  be  inoculated  with  material 
from  this  individual,  the  animal  dies  and  the  organism  is 
found  in  its  organs.  These  bacilli  in  their  turn  will  prove 
fatal  to  other  susceptible  animals.  The  jilague  bacillus 
does  not  produce  pus,  but  it  can  cause  necrosis  of  tissue. 
If  buboes  containing  the  bacillus  suppurate,  it  is  gener- 
ally due  to  staphylococcic  and  streptococcic  infection. 

A  Case  of  Plague  from  a  Clinical  and  Pathological  Point 
of  View. — William  G.  Savage  and  D.  A.  Fitzgerald  sum 
up  the  chief  points  of  interest  in  this  case:  (i)  The  en- 
larged glands  ;  the  absence  of  pain,  tenderness,  or  inflam- 
matory signs  in  or  around  the  enlarged  glands;  (2)  the 
bacilli  in  the  blood  were  numerous  enough  to  be  readily 
detected  microscopically  ;  they  were  almost  certainly  bacil- 
lus pestis ;  (3)  there  were  many  whitish  areas  scattered 
through  the  liver  which  were  probably  necrotic;  (4)  the 
so-called  carbuncles,  red  and  subsequently  necrotic  patches 
on  the  shins,  appear  to  be  one  of  the  characteristic  features 
of  plague,  and  were  present  on  the  first  examination  of  this 
patient. 

On  the  Method  of  Making  Antitoxic  and  Preventive  Fluids, 
with  Special  Reference  to  Those  of  Plague. — By  C.  Balfour 
Stewart.      (Illustrated.) 

Some  Practical  Notes  on  the  Bacteriological  Diagnosis  of 
Human    Plague    (Pestis   Hominis)  .—By  Sheridan  Delepine. 

(Illustrated.) 

Notes  on  the  Introduction  of  a  Case  of  Plague  into  the 
Neighborhood  of  Cardiff.— By  K.  Walfoid. 

A  Note  on  the  Organization  and  Conduct  of  Plague  Labor- 
atories.— By  Walter  C.  C.  I'akes. 

Plague  and  Influenza :  Mixed  Infection  in  Houses. — By 
William  C.  Hossack. 

French  /oiirnals. 
Cancers  of  the  Heart. — Deguy  states  that  these  neoplasms 
comprise  two  distinct  groups:  primary  and  secondary. 
The  first  class  consists  of  myxomata.  sarcomata,  and  fibro- 
sarcomata.  Bauti  as  well  as  Albers  has  observed  a  case  of 
primary  lipoma.  The  class  of  secondary  neoplasms  is 
more  numerous.  This  group  presents  two  very  different 
types,  sarcomatous  and  epithelial,  the  former  jjossibly 
the  more  frequent.  Wagner  had  already  reported  one  of 
these  ca.ses  ;  then  Friedreich  made  the  observation  that 
melanosarcomata,  remarkable  for  their  malignity  and  their 
tendency  to  dissemination,  seem  to  give  rise  most  fre- 
quently to  multiple  metastases  in  the  cardiac  tissue.  Nod- 
ules, some  dark  brown  in  color  and  others  scarcely  tinted, 
could  be  seen  scattered  through  the  cardiac  tissue.  The 
writer  cites  two  cases  which  have  come  under  his  personal 
observation.  The  first  was  that  of  a  man  thirty-six  years 
old,  who  was  suffering  from  an  ulcerating  melanotic  sarcoma 
on  the  right  shoulder.  At  autopsy  two  nodules  were  dis- 
covered in  the  heart,  one  anterior,  the  other  posterior ; 
secondary  nodules  were  found  in  the  endocardium  as  well 


742 


MEDICAL    RECORD. 


[November  lo,  1900 


as  beneath  it.  The  myocardium  was  filled  with  them. 
The  second  case  was  that  of  a  woman  si.xty  years  of  age, 
afflicted  by  an  inoperable  melanotic  tumor  on  the  right 
leg.  Metastases  were  also  found  in  this  heart  at  autopsy. 
The  secondary  cancer  may  be  either  diffuse  or  nodular. 
It  is  a  very  important  fact  that  in  this  affection  the  valves 
are  usually  spared.  The  semeiology  will  naturally  be  ex- 
tremely varied  ;  there  are  generally  present,  however,  pal- 
pitations, pain,  dyspncea,  arrhythmia,  signs  of  pericardial 
effusion,  and  finally  .sudden  death.  It  can  be  seen  from 
this  enumeration  of  symptoms  that  they  do  not  form  a 
characteristic  group.  The  age  of  the  patient  and  the  exist- 
ence of  a  neoplasm  elsewhere  in  the  body  must  also  be 
taken  into  consideration.- — Gazette  des  Hopitau.x,  October 
13,  1900. 

Parasites  of  Cancer. — The  announcement  is  made  by  jNI. 
Bra  that  in  a  series  of  cases  of  cancer  he  has  found  and 
isolated  in  pure  culture  from  the  blood  and  pathological 
tissues  an  organism  belonging  to  the  class  of  the  lower 
fungi,  and  whose  isolation  is  practically  possible  in  the 
majority  of  cases.  He  has  determined  the  morphological 
and  biological  characteristics  of  the  organism.  The  inoc- 
ulation and  ingestion  of  cultures  of  this  fungus  reproduce 
in  animals  the  anatomical  lesions  that  are  considered  char- 
acteristic of  cancer  ;  these  experimental  tumors  have  the 
structure  of  sarcoma,  of  chondroma,  and  of  carcinoma. 
The  soluble  products  of  the  fungus  have  a  vaccinal  power 
which  it  would  be  possible  to  utilize  after  surgical  opera- 
tions to  prevent  recurrences.  They  exercise  an  attenuat- 
ing influence  on  the  pain,  the  hemorrhage,  and  the  suppu- 
ration of  cancer,  and  in  some  cases  a  curative  action. — La 
Me'dectne  Moderin\  October  17,  igoo. 

Two  Cases   of   Extreme   Brevity  of  Vaccinal   Immunity. — 

Charles  Viannay  cites  these  cases,  which  occurred  in  his 
own  family,  one  five  mouths  after  a  successful  vaccina- 
tion, the  other  seven  months.  The  disease  was  contracted 
by  both  individuals  as  they  were  nursing  the  writer,  who 
was  suffering  from  an  insignificant  attack  of  varioloid. 
The  writer  had  been  previously  vaccinated  six  times  with- 
out success,  and  then  contracted  the  disease  by  making  an 
autopsy  on  a  virulent  case.  One  of  the  first  symptoms  of 
invasion  in  the  cases  noted  was  aching  of  the  legs  which 
preceded  the  backache.  During  convalescence,  the  least 
fatigue  caused  a  sensation  of  extreme  lassitude  in  the  legs. 
The  history  of  these  three  cases  would  seem  to  indicate  a 
family  susceptibility  to  this  disease. — Lyon  Mi'dicat,  Oc- 
tober 14.  I  goo. 

Haematemesis  in  the  Course  of  Intestinal  Occlusion. — From 
the  study  which  Louis  Tixier  and  Charles  Viannay  have 
given  this  subject,  they  believe  that  hsematemesis  in  the 
course  of  intestinal  occlusion  offers  a  very  grave  prognosis 
just  as  gastric  hemorrhage  does  in  appendicitis.  This  com- 
plication is  an  indication  of  serious  trouble  dependent  on  the 
cause  of  the  occlusion  in  the  vasomotor  innervation  of  the 
digestive  tract  and  at  the  same  time  in  the  profound  into.x- 
ication  of  the  organism. — Gazette  Hcbdoviadaire  de  Mede- 
cine  et  de  C/nriirgte,  September  23,  igoo. 

The  Treatment  of  Metrorrhagia  by  Faradization. — Philip- 
pot  believes  faradization  to  be  the  best  method  of  treating 
metrorrhagia.  Its  field  of  action  is  more  extended  than 
that  of  galvanization.  It  arrests  positively  the  bloody  dis- 
charge after  a  few  applications  which  follow  each  other 
closely.  Its  employment  is  far  more  simple.  It  does  not 
e.\pose  the  patient  to  the  unpleasant  consequences  to  be 
feared  from  the  other  method.  It  is  painless  and  causes 
most  of  the  subjective  phenomena  to  disappear  rapidly.— 
Le  Xord  Medical,  October  15,  1900. 

Osteomalacia. — -Adenot  reviews  an  interesting  case  of  this 
disease,  and  concludes  that  the  infections  have  a  very  im- 
portant influence  on  the  development  and  evolution  of  os- 
teomal.tcia  ;  that  castration  probably  does  not  act  directly 
nor  reflexly  on  the  disease,  but  simply  by  preventing  preg- 
nancy, which  favors  the  develoimient  of  the  osseous  malady 
as  it  influences  all  other  pathological  states. — Gazette 
Hebdoiiiadaire,  October  14,  1900. 

Her  liner  ic/inise/ie   Woeheiiselirift.  Oetoher  S,  /goo. 

The  Anatomy  of  the  Accessory  Nasal  Sinuses. — G.  Briihl 
describes  a  new  method  of  demonstrating  the  exact  posi- 
tion of  the  sinuses  and  their  relation  to  surrounding  struc- 
tures. The  heads  are  immersed  in  an  acid  solution  of  for- 
malin, then  treated  with  alcohol  and  ether,  and  finally  with 
carbolized  xylol.  The  cavities  are  filled  with  a  molten 
mixture  of  lead,  tin,  bismuth,  and  cadmium  called  Wood's 
metal,  which  soon  hardens.  They  are  finally  submitted  to 
the  .r-ray  process,  whicli  brings  out  a  dark  spot  wlierever 
the  metal  has  penetrated.  The  positions  of  the  sinuses  are 
definitely  located  in  the  radiograph. 

The  Treatment  of  Bronchial  Affections  by  Position.— O. 
Jacoljson  advocates  the  use  of  the  prone  position  in  clearing 
the  bronchi  of  their  secretions.  The  patient  should  lie  flat 
on  the  stomach  while  the  foot  of  the  bed  is  raised.     The 


method  is  practically  of  benefit  only  in  chronic  cases  in 
which  the  muscles  of  the  air  tubes  have  lost  more  or  less  of 
tlicir  normal  tone. 

Certain  Problems  of  the  Cell,  and  their  Significance  for 
the  Scientific  Foundation  of  Organotherapy.— By  L).  Ilanse- 
mann. 

Methods  of  Preserving  Anatomical  Preparations  True  to 
Natuie.— By  L.  I'lck. 

The  Employment  of  Milk  Thermophors.— By  U.  Sommer- 
feld. 

Examinations  with  Eye  Magnets.— By  S.  Tiirck. 
Deiitsc/ie inediiiniselie  U'uiiieiise/iri/t,  Oct.  11  and iS.  igoo. 

Cure  of  a  Case  of  Epileptic  Idiocy. — Edmund  Rose  de- 
scribes the  operative  cure  of  eiiilejitiforni  convulsions  ac- 
companied by  aphasia  and  imbecility  in  an  otherwise 
healthy  boy  after  a  comparatively  slight  trauma  which 
produced  a  wound  of  the  forehead  above  the  left  eyebrow. 
Shortly  after  this  had  healed  the  convulsive  seizures  began 
and  continued  for  several  mouths,  while  the  patient  lapsed 
into  a  condition  of  complete  imbecility,  with  involuntary 
defecation  and  micturition,  etc.  In  spite  of  the  not  very 
great  hope  of  success  from  surgical  interference,  inasmuch 
as  the  uucontrollable  outbursts  of  fury  to  which  the  boy 
was  subject  made  permanent  confinement  in  an  asylum 
seem  the  only  alternative,  operation  was  decided  on.  Two 
trephine  openings  were  made,  one  at  either  end  of  the  scar, 
and  the  intervening  bridge  of  bone  was  removed.  No  evi- 
dences of  fracture  or  abnormalities  of  dura  or  brain  sub- 
stance were  found  even  on  exploring  with  the  needle,  and 
the  wound  was  closed.  Several  months  later  it  was  learned 
that  the  attacks  had  steadily  decreased  in  frequency  until 
two  and  a  half  months  after  the  operation  they  had  stopped 
entirely,  and  that  the  patient's  general  condition  mentally 
and  physically  was  perfectly  normal  for  a  child  of  his  age. 
Apparently  the  only  explanation  of  this  happy  result  lies 
in  the  supposition  that  the  disease  had  been  due  to  in- 
creased tension  within  the  skull,  and  that  the  fact  that  one 
of  the  trephine  openings  was  left  unclosed  and  was  occa- 
sionally bulged  out  by  the  pressure  within  furnished  a 
safety-valve  for  this  heightened  tension. 

The  Pathology  and  Therapy  of  Vesical  Tuberculosis. — 
Leopold  Casper  divides  the  treatment  of  this  condition 
into  the  general  hygienic,  the  local,  the  operative,  and 
combinations  of  these  three.  The  fact  that  the  bladder 
lesion  is  frequently  accompanied  by  involvement  of  other 
organs,  or  at  least  that  the  danger  of  extension  of  the 
disease  is  always  great,  makes  the  general  tonic  and 
strengthening  treatment  of  the  highest  importance,  and 
endeavors  to  increase  the  resisting-power  of  the  organism 
should  never  be  neglected.  Of  the  drugs  for  internal  use 
creosote  and  guaiacol  carbonate  appear  to  give  the  best  re- 
sults, though  positive  conclusions  are  hard  to  draw.  Uro- 
tropin  unfortunately  is  of  no  use  in  this  class  of  urinary 
disease.  In  the  opinion  of  many  writers  local  treatment  is 
contraindicated  in  tuberculosis  of  the  bladder,  and  reliance 
should  be  placed  solel)'  on  narcotics  to  control  the  pain. 
The  author  believes,  however,  that  by  careful  irrigations, 
which  should  always  be  small  in  amount  and  never  carried 
to  the  point  of  effecting  the  least  distention  of  the  bladder 
wall,  much  good  may  be  done  and  even  in  isolated  cases 
cures  effected.  Lactic  acid  (up  to  twenty  per  cent.)  and 
bichloride  solutions  (i  ;  10,000  to  i  :  1,000)  give  the  best  re- 
sults, though  the  former  is  so  unendurably  painful  in  its 
application  and  after-effects  that  it  can  but  rarely  be  used. 
Even  the  irrigation  with  bichloride  solutions  produces  a 
painful  reaction,  but  this  is  soon  succeeded  by  diminution 
or  cessation  of  the  pain  and  improvement  in  frequency  of 
micturition.  Operative  treatment  does  not  promise  very 
favorably,  and  should  be  resorted  to  only  when  there  is  a 
strong  probability  that  the  di.sease  is  strictly  localized  to 
small  areas. 

The  Etiological  Significance  of  Trauma. — Dirska  depre- 
cates the  tendency  lo  attach  undue  importance  to  acute 
trauma  as  a  cause  for  secondary  illness,  especially  in  cases 
in  which  suits  for  damages  are  involved.  Traumatic  neu- 
roses are  often  diagnosticated,  but  in  the  author's  opinion 
are  really  com|)arative  rarities.  The  possibility  of  the 
lighting-up  of  otherwise  latent  tuberculous  pneumonic  or 
cancerous  growths  through  somatic  concussions  is,  to  say 
the  least,  problematic.  There  are  three  fallacies  that  fre- 
(luenlly  stand  sponsors  for  an  erroneous  diagnosis  of  a 
traumatic  origin  of  a  disease.  First,  the  assumption  that 
it  is  ]>articularly  the  ligliter  forms  of  injury  that  are  fol- 
lowed by  such  consequences  :  second,  one  is  easily  car- 
ried away  by  the  i^lausibility  of  an  ingenious  theory  appar- 
ently correlating  the  supposed  cau.se  with  the  effect  ;  and 
third,  the  factor  oi  auto  suggestion  is  strong  in  the  pa- 
tient and  there  is  an  almost  universal  tendency  to  connect 
illness  witli  some  previous  injury. 

Viscin  and  its  Therapeutic  Application. — G.  Riehl  gives 
this  name  to  a  substance  obtained  from  viscum  album,  a 


November  lo,  1900] 


MEDICAL   RECORD. 


743 


European  member  of  the  tropical  family  of  t'.ie  Loran- 
thraceie.  which  has  long  been  used  in  the  preparation  of 
birdlime.  It  is  the  only  European  plant  adapted  to  fur- 
nish a  substitute  for  the  expensive  rubber  and  caoutchouc 
preparations  so  extensively  used  in  medicine,  and  the  au- 
thor's attempts  to  elaborate  a  useful  preparation  have  ap- 
parently been  successful.  The  new  agent  is  cheap,  is 
readily  prepared  from  the  crude  plant  by  simple  processes, 
and  is  soluble  in  unirritating  media.  The  combination 
most  I'kjiy  to  be  of  general  use  in  the  treatment  of  derma- 
tological  and  allied  affections  is  a  solution  in  benzin  with 
which  starch,  zinc  oxide,  and  salicylic  acid,  etc.,  may  eas- 
ily be  incorporated,  and  efficient  and  cleanly  substitutes  for 
plasters  and  ointments  secured. 

Atrophy  and  Development. — M.  Miihlmann  divides  cellu- 
lar atrophy  into  three  types,  plastic,  histogenetic,  and  ne- 
crotic. These  are  constantly  influencing  development  and 
go  hand-in-hand  with  growth.  The  earlier  periods  of  de- 
velopment are  dominated  by  the  plastic  and  histogenetic 
forms  of  atroph)',  although  these  are  also  to  some  extent 
present  all  through  life,  while  it  is  necrotic  atrophy  that  is 
most  active  in  later  periods  and  finally  cau.ses  the  death  of 
the  organism. 

An  Apparatus  for  Conducting  Investigations  on  the  Metab- 
olism of  Nurslings. — l;y  11  Bendix  and  H.  Finkelstein. 

Psychology  and  Cerebral  Anatomy  with  Especial  Reference 
to  Modern  Phrenology. — By  \V.  Weyj^andt. 

The  Present  Status  of  Hand  Disinfection  and  the  Problems 
of  the  Future. 


Hemianopsia  and  its  Diagnostic  Significance. - 
monsohn. 


-By  H.  Salo- 


MUnchener  niedicinische  Woc/iensc/irijt,  October  i6,  iqoo. 

The  First  Beginnings  of  Idiopathic  Enlargement  of  the 
Heart,  and  the  Significance  of  Dilatative  Cardiac  Muscular 
Weakness  in  Military  Service. — Eut;cn  Wolfhiigd's  obser- 
vations, while  conducted  entirely  on  military  material  and 
being  primarily  of  interest  to  army  examiners  and  sur- 
geons, have  yet  a  practical  bearing  on  the  understanding 
of  heart  lesions  in  general.  The  usual  belief  that  the  acute 
and  apparently  wholly  evanescent  dilatation  sometimes 
following  sudden  and  severe  exertion  is  a  purely  tempo- 
rary condition  without  significance,  and  likely  to  occur  to 
individuals  in  perfect  health,  is  somewhat  deprecated  by 
the  author,  who  is  of  the  opinion  that  such  an  event  is  pos- 
sible only  in  those  whose  muscle  has  previously  been  weak 
either  naturally  or  as  the  result  of  disease,  faulty  hygiene, 
etc.  Obesity,  influenza,  rheumatism,  and,  to  a  less  degree 
than  generally  supposed,  excessive  beer  consumption  are 
factors  predisposing  to  the  weakness,  while  of  the  mechan- 
ical moments  involved  impeded  respiration  and  increased 
blood  pressure  are  of  importance.  The  conditions  under 
which  the  soldier  does  his  severest  work,  viz.,  wearing  a 
tight  belt  supporting  heavy  cartridge  boxes,  carrying  a 
large  and  cumbersome  pack  on  his  shoulders,  and  encased 
in  a  snug  uniform  whicli  restricts  motion  and  does  not  per- 
mit active  skin  action,  are  such  as  greatly  to  diminish 
the  vital  capacity  of  the  lungs,  and  in  reducing  the  extent 
of  intrathoracic  changes  of  pressure  to  deprive  the  overbur- 
dened heart  of  a  great  aid  in  maintaining  both  the  pulmo- 
nary and  systemic  circulations.  Increased  tension  within 
the  ventricles  must  be  relieved  in  one  of  three  ways — eitlicr 
by  discharge  into  the  arteries,  dilatation  of  the  ventricular 
wall,  or  incompetence  of  the  auriculo-ventricular  valve. 
If  the  first  of  these  be  difficult  owing  to  high  arterial  press- 
ure, dilatation  may  result,  though  in  many  instances  the 
valves  yield  to  some  extent,  and  by  a  relative  incompe- 
tence save  the  heart  muscle.  The  author  recognizes  two 
forms  of  functional  incompetence — first,  this  regulatory  in- 
competence, which  he  likens  lo  a  safety-valve  action,  and 
second,  the  relative  insufficiency  following  and  due  to  dilata- 
tion. An  attack  of  temporary  dilatation  sufficiently.marked 
to  give  symptoms  severe  enough  to  call  the  patient's  atten- 
tion to  it  and  lead  to  its  recognition  by  a  physician  must 
have  been  preceded  by  other  slighter,  unnoticed  ones  ;  and 
while  such  attacks  in  a  raw  recruit  are  not  necessarily  seri- 
ous, since  by  proper  gymnastics  the  cardiac  tone  may  be 
sufficiently  improved  to  make  tlieir  recurrence  improbable, 
in  soldiers  of  several  years'  standing  they  indicate  dis- 
abling weakness  and  should  lead  to  the  man's  discharge. 

Cystitis  Typhosa.^Hans  Curschmann  collates  the  statis- 
tics of  numerous  observers  and  finds  that  in  at  least  fifteen 
to  thirty  par  cent,  of  all  typhoid  cases  the  specific  organism 
occurs  in  the  urine.  In  view  of  the  vulnerability  of  the 
parenchymatous  organs,  bones,  periosteum,  subcutaneous 
tissue,  etc.,  to  the  pus-producing  powers  of  the  typhoid  ba- 
cillus, it  is  rather  rerharkable  that  this  very  frequent  bacte- 
riuria  is  not  oftener  accompanied  by  cystitis.  Published 
reports  of  such  cases  are  rare,  however,  and  considerable 
interest  attaches  to  three  such  described  by  the  author.     In 


each  of  these  the  bladder  symptoms  were  preceded  by  an 
albuminuria  of  low  grade  apparently  purely  febrile  in  na- 
ture which  did  not  appear  until  convalescence  was  well  un- 
der way.  Typhoid  bacilli  were  obtained  in  pure  cultures 
from  the  purulent  sediment  in  the  urine,  whicli  was  acid  in 
reaction,  this  seeming  to  be  a  characteristic  of  the  disease. 
But  few  subjective  disturbances  were  noted  ;  only  one  of 
the  patients  suffered  from  vesical  pain  and  evinced  a 
slight  tendency  to  tenesmus.  A  temperature  rise  referable 
to  the  cornplication  was  not  observed.  The  etiology  of  the 
aflfection  is  still  obscure  ;  there  seems  to  be  no  satisfac- 
tory reason  why  the  vesical  mucosa  that  ordinarily  is  not 
attacked  by  the  bacillus  should  in  others  be  unable  to 
resist  it.  The  jirognosis  is  favorable,  for  though  the  con- 
dition is  prone  to  persist  for  some  time,  the  svmptoms  are 
never  severe  and  respond  well  to  the  usual  remedies, 
among  which  urotropin  is  said  to  hold  first  place  for  this 
class  of  cases. 

An  Addition   to   the   Technique  of   Leg  Amputations.— E. 

Meuscl,  in  order  to  prevent  pressure  gangrene  of  the  flao 
over  the  sharp  edge  of  the  sawn  tibia,  has  long  used  the 
following  plan  with  great  success  ;  After  the  flap  has  been 
sutured  it  hangs  down  perpendicularly  over  the  sharp  and 
easily  palpable  tibial  edge.  A  thread  is  passed  trans- 
versely one  and  a  half  inches  through  the  skin,  three-quar- 
ters of  an  inch  above  the  sawn  end  of  the  bone,  and  again 
similarly  through  the  skin  of  the  flap,  three-quarters  of  an 
inch  below  the  sharp  edge.  If  the  thread  be  now  tightened 
and  the  ends  tied  the  flap  will  be  drawn  straight  up  and  a 
crease  be  formed  over  the  dangerous  spot,  preventing  all 
pressure  gangrene.  At  the  end  of  eight  days  the  thread 
should  be  removed  lest  it  cut  in  too  deeply,  but  by  that 
time  the  tissues  will  have  gained  sufficient  vitality  to  ob- 
viate all  risk. 

Renal  Hemorrhage  in  Hsemophilia  Cured  with  Gelatin.— E. 

Hahn's  patient  was  an  hereditary  hicmopliiliac  who  for 
several  weeks  had  been  losing  large  quantities  of  blood 
daily  from  the  kidneys  with  the  usual  con.sequences  of  pro- 
tracted hemorrhage.  Other  forms  of  treatment  having 
proved  unavailing  he  was  given  large  amounts  of  gelatin 
incorjjorated  with  his  usual  food,  six  to  eight  ounces  daily 
being  used.  A  marked  improvement  was  noted  on  the 
next  day  and  a  permanent  cure  effected  in  a  week.  In 
view  of  the  simplicity  and  harmlessness  of  the  procedure, 
together  with  the  fact  that  it  does  not  interfere  with  other 
modes  of  treatment  that  may  be  carried  on  simultaneously, 
it  seems  well  worth  trying  in  such  cases. 

The  Occurrence  and  Significance  of  Crystals  in  the  Stools. 

— By  Schilling. 

Disinfection    with    Carboformal    Glow-Blocks.— By    Dieu- 
donne. 

Lithopsedia.— By  Kroemer. 


©orrcspotulcnce. 

OUR    LONDON    LETTER. 

(from  our  Special  Correspondent.) 

THE  ELECTION— ACTINOMYCOSIS— GASTROTOMY  FOR  H^MATEM- 
ES!S— EARLY  TREAT.MENT  OF  ABDOMINAL  SYMPTOMS- SUB- 
CUTANEOUS SYMPHYSEOTOMY — NATIONAL  HOSPITAL  SCANDAL 
— GUILD  OF  ST.  LUKE — LONDON  UNIVERSITY — TYPHOID — 
DEATH    OF   SIR    H.  ACLAND. 

London,  October  19,  1900. 
The  general  election  is  over  and  the  excitement  connected 
with  it  is  rapidly  subsiding.  There  are  eleven  members  of 
the  profession  in  the  new  House.  All  were  in  the  last  ex- 
cept one — Rutherford  Harris,  known  in  connection  with 
the  South  African  Company  rather  than  as  a  doctor.  Some 
of  the  others  have  forsaken  medicine  for  other  occupations. 
Three  doctors  lost  their  seats.  The  strength  of  the  profes- 
sion in  the  House  will  be  about  the  same  as  before. 

A  case  of  actinomycosis  related  by  Sir  IJ.  Duckworth 
gave  rise  to  a  little  discussion  at  the  meeting  of  the  Clini- 
cal Society.  It  was  a  case  in  which  subdiaphragmatic  ab- 
scess ensued.  Mr.  Marsh  remarked  on  the  difficulty  of 
diagnosis  and  thought  operative  interference  would  in  such 
cases  be  useless.  Mr.  Godlee  took  a  more  hopeful  view, 
as  many  patients  suffering  from  actinomycosis  of  the  cae- 
cum, abdominal  wall,  face,  and  neck  recovered  after  scrap- 
ing and  a  course  of  iodide  of  potassium.  This  view  was 
supported  by  other  speakers.  It  was  also  mentioned  that 
the  fungus  is  destroyed  by  carbolic  acid,  and  a  case  was 
mentioned  which  ended  in  recovery^  after  scraping  followed 
by  tlie  application  of  this  acid. 

Mr.  Mansell  Moullin  then  read  notes  of  three  cases  01 
gastrotomy  for  hsematemesis.  In  two  the  source  of  bleed- 
ing was  superficial  erosion  of  the  mucous  membrane,  which 
he  strangulated  with  silk  ligatures  at  the  base.     In  the 


744 


MEDICAL    RECORD. 


[November  lo,  1900 


other  the  ulcer  was  too  large  and  the  base  too  soft  for  this 
plan,  so  a  stout  ligature  was  tied  tightly  round  the  part  of 
the  stomach  wall  on  which  the  ulcer  was  situated,  and 
union  ot  the  serous  coat  secured  by  some  Lembert  sutures 
passed  from  the  peritoneal  surface.  There  was  some  fresh 
hemorrhage  a  fortnight  afterward,  possibly  from  separa- 
tion of  the  ligature,  but  tlie  patient  quite  recovered  and  is 
now  well.  Mr.  Moullin  said  tliat  although  luematemesis  is 
said  to  be  fatal  in  only  four  or  live  per  cent,  of  cases  in 
which  ulcer  of  the  stomach  is  diagnosed,  it  oflen  places 
life  in  danger  and  more  often  causes  so  much  apprehension 
that  if  this  operation  prove  to  be  unattended  by  great  risk 
many  sufferers  would  prefer  the  chance  of  pcrfeci  cure  to 
months  or  years  of  semi-starvation,  and  the  possibility  of 
sudden  death  always  before  them.  The  stomach,  owing 
to  the  thickness  of  its  coats,  bears  sutures  better  than  the 
rest  of  the  digestive  tract,  and  there  is  no  reason  why  the 
mortality  should  be  greater  than  in  appendix  cases,  pro- 
vided the  operation  is  performed  early  and  not  when  the 
patient  is  in  extremis.  The  difiiculty  of  finding  the  bleed- 
ing S|)Ot  is  great,  and  Mr.  Moullin  mentioned  a  case  in 
which  death  had  occurred  after  abdominal  e.xploration.  If 
such  a  case  occurred  to  him  again,  he  would  reopen  the 
abdomen  and  search,  and  would,  if  necessary,  incise  the 
stomach  wall  to  find  the  bleeding  spot.  In  one  of  his  cases 
the  erosion  would  in  all  probability  have  been  overlooked 
at  a  post-mortem,  but  the  bleeding  still  going  on  when  he 
operated  revealed  the  spot. 

The  early  treatment  of  abdominal  symptoms  was  the 
subject  of  Dr.  Schacht's  inaugural  address  at  the  West 
London  Society,  and  he  raised  a  voice  against  too  jjrecipi- 
tate  a  recourse  to  operations.  Recognizing  the  triumphs 
of  surgery  he  also  recalled  that  many  fashions  had  arisen 
and  passed  away  in  regard  to  abdominal  surgery.  The 
surgeons'  familiarity  with  the  peritoneum  taught  them  to 
differentiate  many  cases,  but  the  clinical  symptoms  were 
much  the  same  as  of  old.  Those  most  frequently  present 
— vomiting,  constipation,  diarrhoea,  increa.sed  temperature 
and  pulse,  pain,  tenderness — were  most  valuable  in  some 
cases,  but  individually  were  uncertain  and  very  often  were 
absent.  He  therefore  thought  that  all  cases  of  doubtful 
abdominal  symptoms  should  be  treated  at  the  earliest 
stage  in  one  manner,  viz.,  absolute  rest  in  bed,  restricted 
fluid  diet,  avoidance  of  all  aperients,  and  small  doses  of 
opiates,  preferably  as  hypodermic  injections  of  morphine. 

The  frequent  reiteration  of  "  wasted  early  opportunities  " 
in  reading  had  so  struck  him  that  he  felt  our  increased 
knowledge  had  perhaps  developed  a  new  danger,  viz.,  a 
liability  to  overlook  medical  prevention  on  account  of  our 
familiarity  with  surgical  cases.  Prompt  treatment  in  the 
earliest  stage  would  shorten  many  an  illness,  lessen  its 
gravity,  and  diminish  the  necessity  for  surgical  interfer- 
ence. 

Subcutaneous  symjihyseotomy  was  the  subject  of  a  paper 
read  at  the  Obstetrical  Society  by  Dr.  Herman.  He 
pointed  out  the  advantages  of  the  procedure  in  its  simplic- 
ity, quickness,  small  risk  of  sepsis,  and  insignificant  hem- 
orrhage, and  then  argued  that  to  obtain  the  most  favorable 
conditions  it  should  not  be  delayed  until  the  failure  of  the 
natural  powers  made  some  operation  immediately  neces- 
sary. The  accoucheur  should  ascertain  the  size  of  the  pel- 
vis before  labor  and  estimate  the  size  of  the  child.  If  he 
decided  on  symphyseotomy,  the  most  favorable  time  for  it 
was  immediately  after  full  dilatation  of  the  os.  The  chief 
risk  of  the  operation  was  injury  to  the  urethra,  and  this  was 
most  likely  to  occur  when  the  child  was  too  large.  Careful 
estimation  ot  the  size  beforeliand  was  tlierefore  the  only 
means  of  guarding  against  it.  Dr.  Griflith  described  an 
easy  mode  of  ascertaining  the  relative  size  of  the  head  and 
pelvis.  The  patient  sat  on  the  edge  of  the  bed  at  such  an 
angle  that  the  long  axis  of  the  fietus  was  vertical.  Its 
head,  then,  if  smaller  than  the  pelvis,  would  dip  into  the 
cavity  owing  to  gravity.  Dr.  Lewers  had  in  one  case 
found  a  dovetail  in  tlie  middle  of  the  joint,  and  had  to  use 
a  saw.  Dr.  Spencer  thought  the  subcutaneous  method 
had  advantages,  but  it  must  be  remembered  that  severe 
hemorrhage  from  division  of  large  vessels  had  been  re- 
corded. If  the  vagina  was  wounded,  there  was  also  some 
danger  of  sepsis.  Dr.  Herman  in  his  reply  said  laceration 
of  the  vagina  was  not  of  importance  unless  it  reached  the 
urethra.  He  would  try  Dr.Gritlith's  plan  of  estimating  the 
size  of  the  child's  head  and  ])elvis. 

The  board  of  the  National  Hospital  for  Epilepsy  and 
Paralysis  has  resolved  that  an  inquiry  is  desirable  into 
the  charges  that  have  been  made,  but  in  the  letter  to  'I he 
Times  stating  this  there  is  no  allusion  to  the  claims  of  the 
staff.  The  board  seem  unconscious  that  the  accused  is  not 
the  person  to  appoint  a  judge.  But  this  board,  or  its  "sec- 
retary-director," will  no  doubt  proceed  to  ask  some  one  to 
conduct  an  inquiry.  It  is  not  likely  the  staff  will  accept 
such  a  course. 
;  The  service  at  St.  Paul's  Cathedral  under  the  auspices 
«  of  the  Guild  of  St.  Luke  was  held  on  Wednesday  evening. 
About  one  hundred  and  fifty  doctors  attended,  and  a  goodly 


proportion  wore  their  robes,  to  the  delight  of  the  promoters 
of  the  Guild,  who  attach  great  importance  to  such  an  exhi- 
bition of  collegiate  clothes,  and  appeared  arrayed  in  all  the 
glory  of  their  various  gowns  and  hoods.  The  Bishop  of 
Rochester  preached  the  sermon. 

The  reorganized  London  University  will  soon  be  at 
work.  The  chancellor,  senate,  and  convocation  have  been 
elected.  The  standing  committees  and  other  boards  will 
no  doubt  soon  be  appointed,  and  this  complex  institution 
will  show  what  it  can  do. 

Typhoid  is  increasing,  as  I  intimated  it  was  likely  to  do. 
There  were  seventy-one  more  cases  admitted  in  the  week, 
bringing  the  number  in  the  hospitals  to  four  hundred  and 
five.  Tlie  deaths  were  proiwrtionately  increased  to  twenty- 
two  from  the  fifteen  of  the  jirevious  week.  Scarlet  fever 
showed  an  increase  of  above  one  hundred  cases,  but  the 
number  of  deaths  fell  from  fourteen  to  seven. 

Sir  Henry  Acland,  Bart.,  K.C.B.,  F.R.S.,  died  on  Tues- 
day evening.  He  was  born  in  1S15,  educated  at  Oxford,  in 
1841  became  a  fellow  of  All  Souls',  took  his  Jl.D.  Oxon.  in 
1848,  was  elected  F.R.C.P.  Lond.  in  1850.  Subsequently 
he  became  professor  of  medicine  at  the  University  of  Ox- 
ford (1S58  to  1S95) ,  and  a  recognized,  highly  esteemed 
leader  of  the  profession.  You  will  remember  that  he  ac- 
companied the  Prince  of  Wales  on  his  trip  to  America 
(i860),  and  since  then  has  been  one  of  His  Royal  Higli- 
ness's  physicians.  Cambridge,  Edinburgh,  an<l  Dublin 
conferred  on  him  honorary  degrees,  and  a  number  of  Amer- 
ican and  continental  medical  societies  enrolled  him  as 
member.  Among  the  numerous  offices  he  had  held  were 
the  presidency  of  the  General  Medical  Council,  the  cura- 
torship  of  the  Oxford  University  galleries,  and  of  the  Bod- 
leian Library.  He  also  served  on  several  commissions 
connected  with  education  and  sanitation.  He  wrote  me- 
moirs of  Sir  B.  Brodie  and  of  Dr.  Stokes,  and  numerous 
contributions  to  medical  and  sanitary  science.  The  fine 
work  on  the  "Oxford  Museum"  was  jointly  by  him  and 
Ruskin — his  intimate  friend. 


SUBARACHNOID   COCAINE   ANESTHESIA. 

To  THE  Editor  of  the  Medical  Recokd. 

Sir:  I  believe  in  giving  credit  to  whom  credit  is  due. 
When  we  give  a  historical  resume'  ot  the  origin  and  devel- 
opment of  subarachnoid  anaesthesia,  Dr.  J.  Leonard  Com- 
ing's name  should  occupy  a  conspicuous  place.  He  was 
certainly  one  of  the  first  to  perceive  the  "possibilities"  of 
the  method  of  spinal  cocainization.  But  it  seems  to  me 
going  a  little  too  far  when  an  attempt  is  made  to  parade 
Dr.  Corning  as  the  sole  originator,  discoverer,  and  intro- 
ducer of  the  method,  and  we  certainly  laj-  ourselves  open 
to  the  charge  of  ultrapatriotisra  when  we  designate  it  as 
"Coming's  method."  Dr.  Corning — and  I  say  this  not- 
withstanding the  high  esteem  in  which  I  hold  the  doctor 
and  his  contributions  to  neurology — had  only  a  dim  percep- 
tion of  the  possibilities  of  the  method.  He  stated  distinct- 
ly that  it  was  not  necessary  to  penetrate  the  subarachnoid 
space,  while,  as  we  know  now,  the  method  is  absolutely 
wortliless  unices  the  needle  has  penetrated  the  spinal 
column  and  cerebrospinal  fluid  has  been  seen  to  exude. 
Again,  he  had  not  used  his  method  in  a  single  operation 
(the  passage  of  a  .sound  cannot  be  considered  one) ,  and 
was  himself  uncertain  whether  the  method  would  ever 
find  an  application  in  genito-urinary  or  other  branches  of 
surgery.  It  is  the  method  of  .f/c/'araclinoid  ana'sthesi.t  that 
promises  to  work  a  revolution  in  general  surgery  and  ob- 
stetrics, and  the  credit  for  that  method  undoubtedly  be- 
longs to  two  men  — to  Prof.  August  Bier  and  to  Professor 
Tuffier :  to  the  first  as  the  discoverer  of  the  method,  to 
the  second  as  its  popularizcr.     Very  respectfully, 

William  J.  Roiunson,  M.D. 

iig  East  One  Hundred  and  Twenty-eighth  Street, 
New  V'ork  City. 


Rectal  Fistula. — The  various  methods  wlilch  have 
been  employed  from  the  earliest  time  may  be  classified 
as  follows:  1.  Methods  designed  to  promote  liealing 
without  laying  open  the  fistulous  tracts,  these  are:  (a) 
Cauterization;  (/<)  compression ;  (<■)  subcutaneous  di- 
vision of  the  sphincter  ani  externus;  (t/)  curettage 
with  packing  of  the  fistulous  tract.  2.  Division  of 
tiie  tissues  between  the  fistula  and  the  rectum  is  ac- 
complished; of  these  we  liave :  (17)  Simple  incision; 
(/')  ligature;  (c)  ecrasement;  (t/)  galvano-cautery. — 
Dr.  A.  E.  Halstead,  ///inois  Met/ica/your»a/,  October. 


November  lo,  1900] 


MEDICAL    RECORD. 


745 


<i«ocietij  Slcports. 

THE    PRACTITIONERS'    SOCIETY. 

One  Hundred  and  Fijty-seventh  Regular  Meeting,  Held 
on  Friday,  October  12,  igoo. 

A.    Alexander     Smith,    M.D.,   President,  in   the 

Chair. 

A  Case  of  Vertigo  of  Doubtful  Origin. — This  case  was 
presented  by  Dr.  H.  M.  Lii;c.s.  The  patient  was  a 
man,  forty-seven  years  old,  a  Canadian;  his  occupa- 
tion was  that  of  a  farmer,  and  in  former  years  he  fol- 
lowed the  sea.  His  family  history  was  negative.  He 
had  gonorrhoea  about  twenty  years  ago.  He  denied 
syphilis,  and  was  well  up  to  two  years  ago,  when  he 
had  an  attack  of  influenza,  and  to  this  he  ascribed  his 
present  illness.  Subsequent  to  this  attack  he  first 
noticed  a  tendency  to  sway  and  some  vertigo.  Tiiis 
symptom  had  gradually  increased  in  severity,  and 
when  Dr.  Biggs  first  saw  the  patient,  about  a  month 
ago,  the  vertigo  was  so  pronounced  that  he  could  with 
dirticulty  maintain  his  equilibrium  in  walking,  and  lie 
was  sometimes  unable  to  walk  without  assistance. 
When  he  lay  down  his  vertigo  disappeared,  but  it  re- 
appeared at  once  when  he  got  up  and  tried  to  walk. 
Aside  from  the  vertigo,  the  man's  only  symptom  was 
a  severe  headache,  partly  frontal  and  partly  occipital. 
He  iiad  not  suffered  from  nausea  or  vomiting  until 
about  two  months  ago,  and  then  he  attributed  his  gas- 
tric disturbance  to  some  strong  medicine  he  was  tak- 
ing at  the  time.  There  was  also  at  that  time  some  loss 
of  appetite,  but  these  symptoms  had  since  disappeared. 
The  motor  and  sen.sory  functions  appeared  to  be  nor- 
mal. There  was  no  marked  change  in  the  arteries. 
His  vertigo  was  slightly  better  in  cold  weather.  In 
staggering,  he  usually  fell  to  the  right  side,  but  some- 
times to  the  left.  The  patient's  eyes  were  examined 
by  Ur.  Peter  A.  Callan,  who  found  a  slight  degree  of 
astigmatism,  which  was  corrected  by  glasses.  Since 
then  the  patient  stated  that  he  had  been  free  from 
headaches.  There  were  no  symptoms,  ocular  or  other- 
wise, which  indicated  cerebellar  trouble.  There  were 
no  symptoms  pointing  to  labyrinthine  trouble.  The 
patient  had  never  ex|5erienced  sunstroke.  Dr.  Biggs 
said  he  put  the  patient  upon  small  doses  of  potassium 
iodide  and  inunctions  of  mercur)'.  The  former  soon 
gave  rise  to  severe  gastric  symptoms.  The  mercurial 
inunctions  were  continued  until  the  physiological  ef- 
fects of  the  drug  were  apparent.  Following  tiiis  there 
was  a  decided  improvement  in  the  man's  symptoms. 

Dr.  Chari.es  Sied.man  Bull  said  that  symptoms 
like  those  described  in  this  case  were  not  at  all  un- 
common after  the  occurrence  of  grippe,  and  they  often 
persisted  for  a  long  time,  even  without  a  discoverable 
lesion.  One  explanation  that  had  been  ofTered  was 
that  they  were  due  io  a  hemorrhage  in  the  labyrinth; 
another,  that  there  was  a  serous  inflammation  of  the 
lining  membrane  of  the  labyrinth.  In  such  cases 
there  were  absolutely  no  objective  symptoms.  In  the 
early  stages  they  were  difficult  to  dilTerentiate  from 
cerebellar  disease  of  a  malignant  type,  and  in  order 
to  distinguish  one  from  the  other  developments  must 
be  awaited.  In  the  case  shown  by  Dr.  Biggs  cerebel- 
lar disease  could  be  excluded,  as  the  symptoms  had 
lasted  for  nearly  two  years  and  there  was  no  hemian- 
opsia. As  regarded  treatment,  Dr.  Bull  suggested  the 
use  of  pilocarpine  hypodermically.  The  dangers  of 
this  drug  should  not  be  lost  sight  of. 

The  president.  Dr.  Smith,  said  he  had  seen  two 
similar  cases  in  which  the  symptoms  were  relieved, 
one  by  pilocarpine,  the  other  by  the  fluid  extract  of 
jaborandi. 


Dr.  Walter  B.  James  suggested  that  the  hot-air 
cabinet  might  answer  the  same  purpose  and  be  safer. 

Dr.  Robert  Abbe  said  the  labyrinthine  theory 
would  not  explain  the  frontal  and  occipital  headaches. 
He  had  been  struck  by  the  similarity  of  the  symptoms 
in  this  case  to  those  of  cerebellar  tumor.  In  the  lat- 
ter case,  however,  hemianopsia  would  be  present. 

Dr.  Smith  said  that  in  one  of  his  two  cases  head- 
ache was  quite  a  pronounced  symptom. 

Dr.  J.  \\.  Bran.van  called  attention  to  the  fact  that 
the  reriexes  were  quite  markedly  exaggerated  in  Dr. 
Biggs'  case. 

Dr.  Bull  said  the  reflexes  were  not  influenced  in 
labyrinthine  disease. 

Some  Clinical  Aspects  of  Gout This  paper  was 

read  by  Dr.  Beverlev  Robi.vson  (see  page  721). 

Dr.  George  F.  Shrady  said  that  Dr.  Robinson's 
paper  opened  a  wide  range  for  discussion.  The  re- 
marks on  appendicitis  seemed  to  be  a  challenge  for 
the  surgeons  to  discuss  that  particular  aspect  of  the 
subject  from  an  entirely  different  standpoint  than  that 
presented  by  Dr.  Robinson.  Personally,  Dr.  Shrady 
said,  he  had  never  seen  a  case  of  rheumatic  appen- 
dicitis. The  theory  of  a  possible  relationship  be- 
tween gout  and  appendicitis  was  a  very  taking  one, 
but  at  the  same  time  a  very  dangerous  one,  because  in 
obscure  cases  it  might  lead  one  to  temporize  and  lose 
valuable  time.  Of  course,  it  was  well  known  that 
there  were  cases  of  appendicitis  in  which  recovery 
took  place  without  the  knife,  but  the  very  large  ma- 
jority of  them  imperatively  required  operation.  It 
was  proper  for  the  physician  to  have  his  say  against 
the  surgeon,  but  statistics  proved  the  utility  of  opera- 
tive interference  as  the  almost  inflexible  rule,  and  the 
condition  could  hardly  be  discussed  on  a  purely  gouty 
basis. 

Dr.  Dana  said  that  he  considered  gout  a  form  of 
defective  metabolism  which  the  individual  inherited  or 
acquired,  and  that  the  nervous  system  controlled  in  a 
measure  its  acute  exacerbations;  otherwise  he  did  not 
think  gout  had  much  to  do  with  the  nervous  system  or 
with  nervous  diseases,  except  secondarily  through  the 
arterial  changes.  It  was  not  often  a  factor  in  causing 
the  organic  or  functional  diseases  seen  by  the  neu- 
rologists, and  he  rarely  had  occasion  to  prescribe  col- 
chicum  or  the  other  gout  specifics.  There  were,  he 
thought,  four  forms  of  defective  metabolism  which 
were  met  with  by  the  physician,  all  having  a  certain 
kinship;  these  were  rheumatism,  lithaemia,  gout,  and 
rheumatic  gout.  One  of  these  four  processes,  that 
known  generally  as  lithamia,  was  in  particularly  close 
relationship  with  the  neuroses.  It  was  a  disorder  of 
metabolism  which  stood  apparently  between  rheuma- 
tism on  the  one  hand  and  glycosuria  on  the  other;  it 
was  not  entirely  identical  with  rheumatism,  nor  was 
it  at  all  identical  with  gout,  and  it  had,  he  thought,  a 
certain  independence  in  its  pathology.  It  did  not  re- 
spond to  the  salicylates  or  to  colchicum  in  any  such 
way  as  acute  rheumatism  or  gout  itself,  and  it  was 
certainly  not  due  to  an  excess  of  uric  acid,  because 
very  often  there  was  no  such  excess  in  these  patients. 

Dr.  Roi!Ert  Arue  said  he  thought  it  important  that 
surgeons  should  combat  the  theory  that  peritonitis  of 
gouty  or  idiopathic  origin  was  a  factor  in  the  ordinary 
run  of  cases  which  they  were  called  upon  to  treat. 
The  speaker  said  he  had  never  seen  a  case  of  gouty 
peritonitis,  and  experience  showed  that  peritonitis  was 
invariably  bacterial  in  origin,  and  that  it  was  due  to 
the  transudation  of  the  bacteria  or  their  toxins  through 
the  walls  of  the  intestines.  If  many  cases  of  perito- 
nitis which  were  usually  attributed  to  appendicular 
trouble  were  really  of  gouty  origin,  how  would  Dr. 
Robinson  explain  the  fact  that  the  inflammation  was 
invariably  on  the  right  side?  Dr.  Abbe  said  that  in 
several   hundred  cases  of  recurrent  appendicitis  upon 


746 


MEDICAL   RECORD. 


[November  lo,  1900 


which  he  had  operated  between  the  attacks,  the  gross 
appearance  of  the  appendix  in  perhaps  thirty  or  forty 
per  cent,  was  apparently  normal,  but  after  distending 
and  hardening  them  in  alcohol,  and  slicing  them 
lengthwise  it  was  easy  to  make  out  the  sequels  of  a 
chronic  catarrhal  inflammation  with  strictures.  They 
all  showed  hypertrophic  changes  in  the  mucosa  and 
muscular  coats,  with  resulting  strictures.  With  each 
repeated  acute  attack  there  were  putrefactive  changes 
within,  and  when  the  stricture  finally  became  com- 
plete, rupture  and  septic  peritonitis  occurred.  These 
gradual  changes  in  the  appendix  might  extend  over  a 
period  of  from  five  to  twenty  years,  and  such  patients 
usually  gave  a  history  of  recurrent  attacks  of  appendi- 
citis, which  were  apparently  cured  by  all  sorts  of  med- 
icinal remedies,  but  finally  an  operation  became  nec- 
essary, or  grave  consequences  ensued.  Dr.  Abbe  said 
he  considered  the  term  "catarrhal  appendicitis"  a 
legitimate  one,  yet  to  speak  of  each  attack  as  catarrhal 
was  not  legitimate,  because  the  primary  catarrhal  con- 
dition dated  far  back,  being  perhaps  a  sequel  of  gen- 
eral influenza,  of  typhoid  fever,  or  of  some  intestinal 
trouble  which  left  a  lurking  focus  and  led  to  the  sub- 
sequent symptoms.  To  say  that  there  was  originally 
a  gouty  element  in  the  condition  was  open  to  grave 
doubt. 

Dr.  Joseph  D.  Bryant  said  that  in  several  cases  of 
gout  which  had  been  under  his  close  observation  for 
many  years,  a  nitrogenous  diet  had  proven  very  satis- 
factory. He  said  he  was  not  disposed  to  take  Dr. 
Robinson's  statements  regarding  a  possible  relation- 
ship between  gout  and  appendicitis  very  seriously.  If 
such  a  relationship  could  be  demonstrated  by  the  au- 
thor of  the  paper  in  any  given  case  of  chronic  appen- 
dicitis, the  speaker  said  he  would  be  willing  to  sub- 
mit the  patient  to  a  thorough  course  of  treatment  for 
the  relief  of  the  gout  before  advising  surgical  inter- 
ference, provided  Dr.  Robinson  would  assume  the  re- 
sponsibility of  the  delay.  It  had  been  found  at  au- 
topsy that  in  at  least  sixty  per  cent,  of  persons  who 
had  died  from  various  causes  the  appendix  had  un- 
dergone pathological  changes:  it  would  be  very  unfair 
to  assume  that  in  all  those  cases  the  changes  depended 
on  gout.  In  many  cases  the  appendix  had  been  found 
to  contain  fecal  concretions  and  purulent  products, 
which  certainly  could  not  be  wisely  ascribed  to  gout. 
Many  patients  recovered  without  operation  and  without 
any  treatment  directed  to  gout.  Moreover,  gout  and 
appendicitis  manifested  their  respective  characteristics 
at  periods  of  life  so  widely  dissimilar  as  not  to  en- 
courage belief  in  the  existence  of  a  specially  causative 
relationship  between  them. 

Dr.  Andrew  H.  Smith  said  the  problem  brought 
up  by  Dr.  Robinson  could  be  solved  by  the  collection 
of  sufficient  data  bearing  upon  the  subject.  We  could 
learn,  for  example,  the  proportion  of  cases  of  appendi- 
citis in  which  there  was  a  history  of  antecedent  gout, 
or  a  gouty  tendency.  We  might  thus  be  able  to  arrive 
at  some  definite  opinion  as  to  whether  the  gouty  infec- 
tion was  responsible  for  the  original  narrowing  of  the 
lumen  of  the  appendix,  and  that  this  was  followed,  in 
the  course  of  time,  by  the  usual  symptoms  of  appen- 
dicitis. There  must  be  some  beginning  for  these 
pathological  conditions  affecting  the  appendix,  and  it 
was  known  that  only  in  a  small  proportion  of  cases  had 
concretions  or  other  foreign  bodies  been  found  in  the 
appendix.  What  was  the  first  departure  from  the  nor- 
mal condition  of  the  appendix,  and  what  caused  it? 
After  the  pathological  condition  described  by  Dr. 
Abbe  existed,  all  were,  of  course,  willing  to  admit 
that  surgical  interference  was  necessary.  The  original 
cause  of  the  condition,  however,  if  it  could  be  learned, 
might  be  prevented  in  a  certain  proportion  of  cases. 

Dr.  Rorinson,  in  closing,  said  that  Dr.  .Smith  had 
struck  the  particular  point  which. the  speaker  deemed 


essential  in  his  remarks  about  appendicitis.  He 
would  be  extremely  loath  to  have  any  one  believe  that 
in  his  opinion  appendicitis  should  not  be  operated  on 
under  certain  conditions,  nor  did  he  mean  to  imply 
that  all  cases  of  appendicitis  were  of  gouty  origin.  A 
certain  number  of  cases,  however,  had  come  under  his 
observation  in  which  the  gouty  nature  of  the  affection 
was  very  probable.  Of  course,  in  speaking  of  gout 
we  should  not  confine  ourselves  to  those  cases  in 
which  there  was  a  history  of  swollen  joints  and  nod- 
ular deposits,  such  as  any  medical  student  would 
recognize  at  a  glance,  but  we  should  also  bear  in  mind 
the  more  obscure  manifestations  of  the  disease;  these 
the  speaker  had  in  mind  when  he  spoke  of  the  pos- 
sible relationship  between  gout  and  appendicitis. 
The  philosophy  of  medicine  taught  us  to  try  to  learn 
the  underlying  factors  of  a  disease.  The  mere  fact 
that  an  operation  was  safe  did  not  prove  its  utility. 


THE  NEW  YORK  ACADEMY  OF  MEDICINE. 

SECTION   ON    MEDICINE. 

Stated  Meeting,  October  23,  igoo. 

John  H.  Huddleston,  M.D.,  Chairm.vn. 

The  City  and  its  Consumptive  Poor :  A  Plea  for  a 
Municipal  Sanatorium  Outside  of  the  Corporate 
Limits. — Dr.  Alfred  Meyer  read  this  paper.  One 
year  ago,  he  stated,  he  had  addressed  the  section  upon 
the  subject  of  the  State  care  of  the  consumptive  poor, 
since  which  time  there  had  been  cause  for  rejoicing  in 
that  the  State  of  New  York  was  finally  induced  at  the 
last  session  of  the  legislature  to  commit  itself  to  the 
principle  of  State  aid  by  the  appropriation  of  $50,000 
for  a  State  sanatorium.  Twenty-six  sites  in  the  Adi- 
rondacks  had  been  inspected  by  the  commission  ap- 
pointed by  the  governor,  and  but  recently  a  decision 
had  been  made  in  favor  of  Clear  Lake.  In  spite  of  de- 
lay caused  by  opposition  he  thought  there  was  a  strong 
probability  that  within  the  next  eighteen  months  the 
State  of  New  York  would  have  reared  its  first  sana- 
torium for  the  cure  of  incipient  tuberculosis.  The  first 
organized  eft'ort  in  this  city  for  a  separate  institution 
for  the  consumptive  poor  dated  back  to  1855,  when  a 
society,  with  Peter  Cooper  as  president,  and  Dr.  Alonzo 
Clark  and  other  well-known  citizens  as  trustees,  was 
chartered  by  the  State  and  issued  "  An  Appeal  to  the  In- 
habitants of  the  City  and  State  of  New  York."  The 
arguments  used  were  almost  identical  with  the  ones 
used  to-day.  Last  year  the  object  of  his  paper  was  to 
enlarge  the  State's  responsibility  for  the  indigent  con- 
sumptive; in  his  present  paper  his  object  was  to  urge 
the  need  of  greater  responsibility  on  the  part  of  the 
city.  The  main  obstacle  to  action  under  the  law  for 
the  establishment  of  hospitals  for  the  regular  treatment 
of  pulmonary  tuberculosis  had  been  the  bugaboo  of 
expense.  Dr.  Meyer  quoted  from  a  recent  article  in 
the  Wiener  klinisihc  Riiniischau,  written  by  the  director 
of  the  sanatorium  at  AUand  near  Vienna:  "The  great 
expense  connected  therewith,  which  ajipears  to  be  the 
main  argument  against  the  establishment  of  municipal 
sanatoria,  must  appear  in  an  entirely  difterent  light  to 
every  one  who  studies  the  facts — that  is,  to  every  one 
who  studies  what  it  costs  society  to  supjiort  the  con- 
sumptive until  he  dies,  and  what  it  would  have  cost 
had  he  been  cured  or  at  least  sufficiently  improved  by 
treatment  according  to  modern  methods  to  permit  him 
to  return  to  the  ranks  of  bread-winners."  Enormous 
sums  of  money  were  being  spent  to-day  without  the 
saving  of  a  single  life,  merely  because  it  was  being 
spent  at  the  wrong  time.  Our  motto  should  be,  as  so 
forcibly  expressed  by  Dr.  Tryor,  of  Buffalo,  last  year: 


November  lo,  1900] 


MEDICAL    RECORD. 


747 


At  the  right  time,  in  the  right  place,  in  the  right  way, 
until  cured;  not  at  the  wrong  time,  in  the  wrong  place, 
and  in  the  wrong  way,  until  dead.  How  much  would 
it  cost  the  city,  approximately,  if  it  were  to  embark 
upon  a  project  of  this  kind?  According  to  the  board- 
of-health  reports  there  were  in  Greater  New  Vork  dur- 
ing the  current  year,  up  to  and  including  September 
22(1,  6,079  tleaths  from  pulmonary  tuberculosis,  from 
which  could  be  deduced  a  total  number  of  deaths  for 
the  year  1900  of  about  8,100.  If  we  remembered 
that  the  death  rate  and  the  average  duration  of  the 
disease  remained  about  the  same,  we  were  forced  to 
the  conclusion  that  there  were  about  8,100  new- 
incipient  cases  each  year  taking  the  place  of  those 
who  had  died.  If  each  one  of  the  8,: 00  had  si.\ 
months'  sanatorium  treatment,  the  expense  would  be 
equivalent  to  the  care  of  one-half  that  number  for 
one  year,  or  about  4,000  cases.  At  a  very  liberal 
estimate  nine-tenlhs  of  these  might  be  classified  as 
poor  and  liable  to  become  a  public  charge;  this 
reduced  the  total  to  3,645.  If  we  allowed  for  those 
taken  care  of  by  private  charitable  agencies  the  num- 
ber was  further  reduced  to  about  3,000,  for  whom 
buildings  and  equipments  would  cost  about  $3,000,000 
and  annual  maintenance  about  Si. 000, 000.  Hut  no 
one  had  asked  that  this  burden  be  assumed  by  the  city. 
An  appropriation  of  about  $300,000  is  all  that  the 
friends  of  this  measure  were  asking  for,  and  those  who 
persisted  in  claiming  that  this  sum  was  but  the  begin- 
ning of  an  endless  chain  of  annual  appropriation 
should  recall  the  fact  that  in  the  future  the  city  would 
be  the  judge  of  the  practical  value  of  its  first  invest- 
ment. Dr.  Meyer  then  tabulated  a  few  cogent  reasons 
why,  in  his  opinion,  the  proposed  hospital  should  be 
established:  First:  The  problem  was  an  enormous 
one  and  required  the  union  of  all  forces,  municipal. 
State,  and  private.  Second:  There  was  no  doubt  that 
the  expressed  sentiment  of  the  profession  in  this  city 
was  in  favor  of  the  plan.  Third:  The  increased 
hopefulness  of  the  medical  profession  of  the  curability 
of  the  disease.  The  results  in  Germany  had  been  so 
favorable  and  had  stimulated  the  erection  of  sanatoria 
to  such  a  degree  that  about  twenty  thousand  incipient 
cases  could  now  receive  treatment  for  three  months 
each,  and  seventy-two  per  cent,  of  these  were  returning 
to  the  ranks  of  wage-earners.  Fourth :  The  inade- 
quacy of  public  and  private  endeavor.  Two  conclu- 
sions drawn  from  figures  quoted  were,  that  the  city 
was  doing  insignificantly  little,  and  that  private  char- 
ity was  doing  twice  as  much.  Fifth:  The  disease  was 
a  menace  to  public  health.  Sixth:  An  object-lesson 
would  be  given  by  New  Vork  to  those  other  municipal- 
ities in  the  State  to  which  the  same  authority  had  been 
given,  as  yet,  however,  barren  of  results.  Seventh: 
There  would  be  great  value  in  the  hygienic  enduca- 
tion  of  the  patients,  and  their  training  in  the  proper 
disposition  of  their  sputa  would  diminish  the  spread 
of  the  disease.  Eighth:  The  money  value  to  the  city 
of  lives  saved  would  be  millions  of  dollars,  whether 
estimated  by  what  it  cost  to  rear  and  to  educate  an  in- 
dividual, by  what  it  cost  to  care  for  dependent  widows 
and  children,  or  by  the  law  once  upon  the  statute  books 
of  this  State  valuing  a  life  at  $5,000.  Ninth:  At  a 
general  meeting  of  the  Academy  of  Medicine  held 
December  21.  1899,  a  resolution  favoring  the  estab- 
lishment of  municipal  sanatoria  was  indorsed. 

Dr.  John  B.  Cosbv,  commissioner  of  charities, 
pledged  his  support  in  all  efforts  made  toward  procur- 
ing such  hospitals. 

JOHX  VV.  Keller,  commissioner  of  charities,  in 
referring  to  the  number  of  phthisis  patients,  the  num- 
ber of  beds  reserved  for  them,  the  number  who  died, 
etc.,  in  the  hospitals  of  the  department  of  public 
charities  for  the  borough  of  ISfanhattan  and  the  Bronx, 
stated  that  an  analysis  of  these  figures  would  show  that 


the  demand  for  room  for  the  treatment  of  phthisis  pa- 
tients was  in  excess  of  the  supply.  They  also  showed 
that  of  the  patients  admitted  from  January  1  to  Octo- 
ber I,  1900,  more  than  one-third  had  died.  The  bor- 
oughs of  Manhattan  and  the  Bronx  had  not  enough 
room  in  their  public  hospitals  to  care  for  phthisis  pa- 
tients properly.  Necessary  isolation  could  not  be 
had,  although  there  was  a  prospect  for  an  early  and 
effective  remedy  for  this  deficiency.  In  F'ebruary  of 
next  year  the  Manhattan  State  Hospital  would  have 
to  leave  Blackwell's  Island,  and  the  three  buildings 
now  occupied  by  the  insane  would  revert  to  the  de- 
partment of  public  charities.  Two  of  these  buildings 
were  isolated,  and  patients  there  need  not  come  in 
contact  with  any  other  class  of  patients  on  the  island. 
He,  therefore,  thought  that  the  borough  of  Manhattan 
and  the  Bronx  would  have  ample  accommodation  next 
year  for  all  destitute  persons  sulTering  from  phthisis. 
The  figures  demonstrated  the  fact  that  there  were  six 
hundred  and  thirty-five  deaths  among  eighteen  hun- 
dred and  thirty-nine  patients;  he  thought  this  was  too 
great  a  death  rate,  but  believed  that,  with  the  addi- 
tional accommodations  on  Blackwell's  Island,  it 
would  be  materially  reduced.  He  expressed  himself 
as  being  heartily  in  accord  with  any  movement  for 
the  relief  of  the  destitute  suffering  from  this  dreadful 
disease. 

Dr.  Herman  P.  Biggs  said  that  this  was  a  matter 
in  which  he  had  been  interested  for  years.  Six  or 
seven  years  ago  he  had  urged  upon  the  department  of 
charities  the  necessity  of  adequate  care  for  tubercu- 
lous patients,  and  had  asked  that  the  receiving-pavilion 
at  Bellevue  Hospital  be  set  aside  for  these  patients, 
and  also  that  sanatoria  be  established  for  the  care  of 
incipient  cases.  He  had  then  suggested  that  Central 
Islip  might  be  a  suitable  place,  since  the  city  then  had 
a  large  tract  of  land  there.  H.  H.  Porter  was  com- 
missioner of  charities,  and  had  acquiesced  in  the  plan 
proposed  by  Dr.  Biggs.  The  plan  fell  through  on  ac- 
count of  lack  of  money  enough  to  carry  it  out.  At  that 
time  the  question  of  the  transfer  of  the  insane  to  the 
State  hospital  had  come  up  for  consideration.  As  a 
result,  a  certain  number  of  wards  had  been  set  aside 
in  the  City  Hospital  and  in  the  Almshouse,  and  sub- 
sequently pavilions  were  erected  at  the  Almshouse  to 
be  devoted  to  the  care  of  these  unfortunates.  When 
the  insane  were  removed  from  the  Metropolitan  Hos- 
pital these  wards  were  assigned  for  the  care  of  such 
cases.  In  the  following  administration,  that  of  Mayor 
Strong,  there  was  a  scheme  for  the  establishment  of  a 
reception  pavilion  at  Bellevue:  appropriations  were 
made,  and  the  erection  was  begun.  That  building 
was  just  ready  for  occupancy.  He  was  strongly  in 
favor  of  establishing  sanatoria.  So  far  as  this  city 
was  concerned,  he  believed  that  the  total  number  of 
cases,  as  estimated  by  Dr.  Meyer,  was  far  below  the 
actual.  He  stated  that  the  department  of  health  was 
primarily  interested  in  the  prevention  of  the  disease; 
that  the  care  of  incipient  phthisis  also  came  properly 
under  the  department's  care,  yet  it  was  not  so  much 
the  prevention,  but  the  cure,  for  which  the  sanatoria 
were  required.  There  were  two  sides  to  be  consid- 
ered so  far  as  the  department  of  health  was  concerned: 
first,  what  could  be  done  in  the  way  of  saving  lives, 
and,  secondly,  what  could  be  done  in  the  way  of 
prevention.  In  1889  Dr.  J.  D.  Bryant  had  introduced 
a  resolution  asking  for  the  report  on  the  prevention  of 
tuberculosis.  Drs.  Loomis,  Prudden,  and  Biggs  were 
the  consulting  pathologists,  and  they  submitted  a  re- 
port. Many  prominent  physicians  were  consulted  as 
to  whether  they  considered  it  advisable  that  any  ac- 
tion should  be  taken  looking  toward  prevention;  a 
negative  reply  was  received  from  all  but  one— Dr. 
Janeway.  All  others  were  opposed  to  any  action  on 
the  part  of  the  department.     Then  it  was  decided  that 


748 


MEDICAL    RECORD. 


[November  lo,  1900 


it  was  not  advisable  to  take  any  action  except  in  a 
limited  way — that  is,  in  the  way  of  education  of  the 
people.  Many  circulars  had  been  given  out.  Noth- 
ing further  had  been  done  until  1893,  when  a  resolu- 
tion was  entered  calling  for  the  report  of  all  cases  of 
tuberculosis,  and  physicians  were  requested  to  aid. 
Following  this  in  1894  the  department  commenced  an 
inspection  of  all  cases  occurring  in  lodging-houses. 
In  1897  tuberculosis  was  declared  to  be  a  communica- 
ble disease.  Since  1888  there  had  been  a  reduction 
in  the  death  rate  from  tuberculosis  in  this  city.  In 
1S8I  the  death  rate  was  4.04;  last  year  it  was  2.87. 
He  emphasized  the  fact  that  the  function  of  the  de- 
partment of  health  was  the  prevention  of  the  dis- 
ease, by  education  of  the  people,  by  disinfection  and 
renovation,  etc.  He  was  strongly  in  favor  of  estab- 
li.'^hing  such  institutions.  The  appropriation  made 
in  1897  for  the  care  of  such  cases  in  Seton  Hospital 
was  made  at  his  suggestion. 

John  P.  Faure,  e-x-commissioner  of  charities,  was 
extremely  glad  to  notice  such  agitation  of  this  ques- 
tion. During  his  time  of  service  in  the  dejaartment 
hi  naturall)'  saw  a  great  many  cases,  and  it  was  a 
matter  of  much  regret  that  he  could  not  separate  them. 
He  was  particularly  glad  that  the  department  now  saw 
a  way  clear  to  do  so.  Again,  he  thought  it  was  a  mat- 
ter of  great  desirability  that  the  department  recognize 
the  value  of  specialists  or  those  with  some  special  idea. 
It  had  been  his  privilege  to  be  identified  with  work 
among  sick  children,  the  floating  hospital  of  St.  Johns 
Guild,  and  he  believed  that  the  large  diminution  in 
the  death  rate  among  children  was  due  to  the  fact  that 
somebody  was  doing  something  in  a  definite  direction. 
He  therefore  favored  this  movement.  He  had  recent- 
ly attended  a  meeting  of  the  Brotherhood  of  St.  Andrew 
in  Richmond,  Va.,  where  he  had  heard  a  voice  from 
Denver.  The  chapter  in  Denver  saw  that  many  of 
these  cases  were  relieved;  also,  that  many  of  those 
coming  there  were  poor  and  came  too  late,  and  the 
death  rate  was  large;  yet  many  recovered.  The  young 
men  of  this  organization  in  such  a  small  place  as 
Denver  got  together  and  purchased  land  for  a  ranch 
in  order  to  give  the  people  who  went  there  the  benefit 
of  climate  at  a  minimum  expense.  It  seemed  to 
him  that  if  the  poor3'oung  men  of  Denver  could  vol- 
untarily set  to  work  to  gain  such  an  object  and  set 
such  an  example  of  what  could  be  done,  it  should 
spur  on  those  present  to  accomplish  the  object  under 
discussion. 

Rev.  James  M.  Buckley,  LL.D.,  president  of  the 
board  of  managers  of  the  Methodist  Episcopal  Seney 
Hospital,  Brooklyn,  was  convinced  that  both  philan- 
thropy and  self-protection  required  the  institution  of 
measures  to  aid  those  of  the  poor  who  were  yet  in 
a  condition  to  be  helped,  and  to  give  to  the  families 
to  which  they  belonged  freedom  from  the  danger  of 
the  close  contact  which  was  inseparable  from  urban 
poverty.  He  fully  sympathized  with  the  movement. 
The  city  of  New  York  should  avail  itself  of  the  pro- 
visions of  the  law  and  try  one  experiment  thoroughly. 
Tiie  results  would  show  whether  it  remained  an  experi- 
ment or  furnished  a  demonstration. 

Jacoi!  H.  ScHii'i',  president  of  theMcntefiore  Home 
for  Chronic  Invalids,  believed  that  tuberculosis  could 
be  efficiently  dealt  with  only  in  sanatoria  located  in 
favorable  surroundings,  well  removed  from  centres  of 
population.  Some  few  years  ago  a  plot  of  one  hun- 
dred and  thirty-six  acres  was  selected  at  Bedford  Sta- 
tion. Westchester  County,  about  forty  miles  from  New 
York  (Jity,  and  provided  accommodations  for  a  limited 
number  of  phthisis  patients,  mostly  those  in  the  earlier 
stage  of  the  disease,  who  had  already  been  inmates, 
or,  upon  proper  application,  had  been  found  to  be 
proper  subjects  for  admission  to  the  benefits  of  the 
Montefiore    Home.     The    number    of    these    patients 


taken  care  of  there  was  thirty,  and  so  satisfactory 
were  the  results  that  the  directors  of  the  Montefiore 
Home,  about  eighteen  months  ago,  came  to  the  con- 
clusion that  they  would  erect  larger  buildings  at  Bed- 
ford Station  and  remove  thereto  all  of  the  phthisical 
patients  coming  under  the  care  of  the  Montefiore 
Home.  The  new  buildings  were  destined  to  accom- 
modate one  hundred  and  fifty  patients.  He  did  not 
think  private  philanthropy  could  ever  be  able  to  deal 
adequately  with  the  situation,  and  could,  at  best,  only 
experiment  for  the  benefits  of  the  State,  and,  with  the 
experience  gained,  point  out  the  means  whicli  the 
State  must  employ  if  it  was  to  do  justice  to  its  duty 
toward  its  people.  He  thought  the  time  had  arrived 
when  proper  steps  should  be  taken  by  the  common- 
wealth to  deal  in  an  efficient  way  with  this  problem, 
without  leaving  it  any  longer  lo  private  attempts 
alone. 

Charles  C.  Savage,  president  of  Roosevelt  Hospi- 
tal, said  that  forty  years  ago  he  had  been  a  member  of 
a  convention  of  physicians  which  took  up  the  question 
as  to  the  contagiousness  of  yellow  fever,  and  it  had 
been  decided  that  it  was  not  contagious;  there  was 
no  doubt  that  fomites,  such  as  clothing,  etc.,  could 
carry  yellow  fever  away  from  the  patient,  and  infect 
those  who  were  liable  to  such  infection.  Another 
question  brought  up  pertained  to  smallpox;  there  was 
but  one  opinion,  which  was  that  it  was  contagious. 
In  reference  to  this  last  disease  great  progress  had 
been  made,  especially  in  regard  to  vaccination.  Dur- 
ing the  past  fifty  years  he  had  had  much  experience  as 
a  layman  in  hospitals  and  dispensaries,  and  he  had 
been  greatly  interested  in  the  endeavors  made  to  stamp 
out  smallpox.  Now  he  was  confronted  with  tuber- 
culosis, and  he  asked  if  it  could  be  stamped  out,  and 
if  it  w^as  contagious.  He  believed  that  it  was  infec- 
tious, and  that  it  would  be  carried  to  those  who  were 
susceptible  to  it.  He  again  asked  what  could  be  done 
to  eradicate  it.  It  must  be  stamped  out  in  some  way. 
In  New  York  there  were  one  million  and  a  half  people 
living  in  residences  that  contained  two  or  more  fami- 
lies. The  hospitals  could  not  care  for  these  patients, 
because  they  had  not  the  means,  and  besides  he  did 
not  think  it  was  right  to  place  the  patients  there.  He 
did  not  believe  that  they  should  be  sent  to  the  Adiron- 
dacks,  because  it  would  require  too  great  an  expense, 
because  it  was  too  far  from  their  homes,  and  because 
of  the  difficulty  in  getting  them  there.  He  believed 
that  it  would  be  wiser  to  isolate  them  properly  on 
Blackwell's  Island  and  see  what  could  be  done 
there. 

AssEMELV.M.\N  Nelson  H.  Henrv  Said  it  was  im- 
possible to  obtain  a  reason  for  the  disapproval  of  the 
bill  on  the  part  of  the  mayor  after  the  bill  had  passed 
the  legislature  last  winter.  He  believed  that  the  peo- 
ple in  the  State  of  New  York  had,  to  a  certain  extent, 
been  educated  up  to  the  point  of  recognizing  that 
something  must  be  done  toward  treating  tuberculosis 
cases,  not  only  in  human  beings  but  also  in  animals, 
particularly  the  bovine  species.  The  people  must  be 
educated,  and  particularly  the  representatives  in  the 
State  must  be  educated  in  order  that  they  may  be  won 
over  and  make  the  i)roper  appropriation  for  the  carry- 
ing on  of  such  a  purpose.  It  was  not  well  to  be  dis- 
couraged at  the  failure  last  year  of  getting  an  appro- 
priation of  $250,000  or  $500,000;  nor  at  the  failure  of 
such  a  bill  to  pass  the  mayor  last  year.  He  thought 
that  probably  those  jiresent,  including  Dr.  Cosby,  had 
not  been  able  to  educate  the  mayor  up  to  learning  the 
importance  of  this  matter.  It  was  a  most  important 
point  in  dealing  with  these  things  not  to  use  too  dras- 
tic measures.  He  thought  we  were  quite  far  off  from 
the  compulsory  removal  of  tuberculosis  cases  from  our 
midst.  The  people  should  recognize  first  the  impor- 
tance of  such  a  law.     If  we  started  out  with  the  posi- 


November  lo,  1900] 


MEDICAL    RECORD 


749 


tion  that  the  cows  were  responsible  for  tuberculosis, 
and  that  they  should  be  removed  from  our  midst,  we 
would  immediately  rouse  the  anger  of  the  farmers 
tliroughout  tiie  Slate.  V\'e  must  be  patient  until  the 
hayseeds  died  off,  and  await  the  advent  of  the  modern 
farmer  who  might  ai^preciate  what  was  best  for  his  in- 
terest and  assist  in  stamping  out  tuberculosis.  It  was 
very  hard  to  train  the  old  hayseed  farmer.  The  re- 
moval of  the  incipient  cases  was  generally  recognized 
as  the  one  thing  certain  to  secure  the  most  beneficial 
results.  He  had  always  held  the  view  that  we  should 
establish  hospitals  for  the  advanced  cases  near  our 
dense  centres;  we  could  accomplish  much  in  giving 
them  a  place  of  comfort,  but  we  should  also  look  be- 
yond that  and  see  what  good  would  come  to  the  local- 
ity whence  they  had  been  removed.  He  believed  that 
the  secret  of  successful  treatment  lay  in  the  improve- 
ment of  the  general  sanitary  conditions  among  the 
people  as  well  as  among  animals.  The  old-st)  le 
barn  should  be  cleared  out,  and  hygienic  stables 
erected,  which  supplied  ])roper  air  and  exercise  for  the 
cows,  etc.;  this  would  probably  stamp  out  tuberculosis 
in  New  V'ork.  'I'he  same  principle  would  apply  to  the 
poor  of  .\ew  York:  the  tenements  must  be  improved. 
It  was  his  e.\perience  that  the  legislators  in  Albany 
had  given  this  subject  much  attention,  that  they  were 
convinced  that  something  should  be  done,  and  that  it 
only  rested  with  the  jx'ople  to  push  the  matter;  they 
should  state  just  what  was  the  best  course,  not  ask  loo 
much,  and  they  would  get  legislative  sup])ort.  He 
emphasized  the  fact  that  the  people  should  be  edu- 
cated in  this  most  important  subject. 

Dr.  CosiiV,  referring  to  what  Nlr.  Henry  had  stated 
about  the  mayor  not  signing  the  bill,  said  that  tlie 
mayor's  reason  for  not  signing  it  was  that  he  did  not 
know  w'here  the  expense  of  it  would  stop.  If  only 
$150,000  was  called  for  he  thought  that  amount  could 
be  obtained. 

Dr.  Hen'ry  W.  Beri;  said  it  was  the  duty  of  the 
community  to  care  for  tuberculosis  cases.  'I'here  were 
certain  cases  the  department  of  health  could  take  care 
of,  but  the  department  was  limited  in  this  effort  by  the 
amount  of  money  in  hand.  He  asked  if  it  was  the 
duty  of  the  department  to  take  care  of  the  incipient 
cases.  He  divided  tuberculosis  into  two  classes: 
first,  very  bad  cases,  or  cases  of  chronic  consumption 
which  had  reached  the  last  stage;  second,  those  cases 
which  modern  science  had  shown  to  be  in  the  curative 
stage  of  the  disease.  Fortunately,  incipient  phthisis 
was  curable,  and  as  a  civilized  community  it  was  our 
duty  to  treat  the  disease  by  tiie  most  successful  method. 
The  best  method  of  d  ling  this  was  the  segregation  of 
the  cases  in  sanatoria,  and  the  first  requisite  for  en- 
trance into  these  establishments  was  that  the  patient 
should  have  a  certain  amount  of  money.  That  re- 
quisite excluded  from  the  benefit  of  these  sanatoria  a 
large  number:  those  who  had  no  money.  He  thought 
it  was  more  logical  to  devote  money  to  the  cure  of  the 
disease  than  to  the  maintenance  of  these  patients; 
they  should  not  be  allowed  to  become  a  source  of  dan- 
ger to  the  community,  but  should  be  cared  for  in 
sanatoria.  'l"he  treatment  did  not  consist  in  the  ad- 
ministration of  drugs,  serums,  or  antitoxins;  the  best 
method  of  treatment  was  the  one  advocated  by  Dr. 
Meyer. 

J.  J.  McKelvey  said  it  was  a  fact  that  nearly  every 
public  agitation  was  opposed  on  the  ground  that  it  led 
to  the  injury  of  persons  or  property,  and  he  did  not 
think  this  present  agitation  was  an  exception  to  the 
rule.  Several  years  ago  the  State  legislators  began  to 
take  notice  of  these  cases  of  tuberculosis  among  the 
poor  of  the  city;  they  tried  to  find  means  for  bettering 
the  conditions  of  that  class  of  consumptives:  they 
naturally  looked  to  the  hospitals.  The  concentration 
of  these  patients  in  public  hospitals  could  be  effected 


by  various  charitable  organizations  or  by  the  appro- 
priation of  a  certain  amount  of  money  to  be  used  for 
their  care  in  these  institutions.  'I'hat  would  result  in 
concentrating  these  patients  in  particular  localities. 
Property  interests  might  interfere  with  the  scheme 
proposed  by  Dr.  Meyer.  As  soon  as  these  people 
were  collected  together  in  certain  localities,  the  peo- 
ple felt  that  something  had  happened;  the  landlord 
lost  because  of  the  proximity  of  a  consumptive  hospi- 
tal. All  this  might  be  combated  by  increased  knowl- 
edge, on  the  part  of  the  people  at  large,  as  to  the  dan- 
ger of  infection.  In  1900  a  bill  was  passed  which 
directed  the  city  to  take  action  in  apportioning  ?35o,- 
000  for  such  a  hospital  as  this.  He  believed  that 
there  was  no  department  that  had  to  do  with  such 
matters  in  the  city  or  the  State  that  was  not  in  favor 
of  the  indorsement  of  that  bill.  It  all  lay  in  the 
hands  of  one  man,  Mayor  Van  VV'yck.  Very  few  real- 
ized the  pressure  brought  to  bear  upon  the  mayor. 
I'hysicians  in  large  numbers  urged  its  passage;  repre- 
sentatives from  the  State  and  different  societies 
petitioned,  and  fifteen  hundred  physicians  signed  a 
petition  in  favor  of  approval  of  the  bill.  The  mayor, 
for  some  occult  reason,  failed  to  sign  the  bill.  It 
seemed  to  him  that  by  education  should  be  meant  the 
education  of  the  mayor,  of  the  board  of  estimate,  and 
of  the  board  of  apportionment. 

Dr.  Leonarf)  Weber  said  that  it  had  been  shown 
by  long  experience  that  the  care  and  treatment  which 
the  poor  tuberculosis  patients  in  the  incipient  stage 
needed,  in  order  to  be  cured  and  cease  to  be  a  menace 
to  those  around  him,  could  not  be  provided  in  tene- 
ments nor  in  the  city  hospitals.  Such  patients  should 
be  treated  in  a  properly  located  sanatorium,  which 
need  not  be  far  away  from  the  city,  and  they  would  be 
greatly  improved  in  a  short  time  and  have  a  chance  of 
getting  well.  Greater  New  York  ought  to  have  two 
sanatoria  for  this  class  of  the  sick  poor,  located  about 
thirty-five  miles  away  from  the  city,  to  the  east  and 
west  of  the  Hudson  River.  In  a  measure  these  sana- 
toria might  be  made  self-supporting  by  charging  each 
patient  $5  per  week,  to  be  paid  by  him,  or  by  the 
borough  to  which  ho  belonged  if  he  be  a  pauper.  In- 
asmuch as  the  tuberculous  poor  generally  applied  first 
to  one  of  the  dispensaries  for  treatment,  Dr.  V\'eber 
believed  that  it  would  be  good  and  proper  to  have  a 
special  department  for  pulmonary  tuberculosis  at 
every  dispensary,  so  conducted  that  the  jjatient  would 
be  thoroughly  examined,  his  sputa  at  once  submitted 
to  the  bacteriologist  of  such  department,  and  the 
necessary  treatment  conscientiously  and  liberally  or- 
dered for  him.  The  physicians  in  charge  should  be 
given  authority  by  the  commissioners  to  send  the  suf- 
ferer to  the  city  sanatorium  when  necessary. 

Dr.  S.  Adolf  Knopf  said  that  this  could  not  be 
solved  by  any  one  method.  He  thought  there  should 
be  institutions  for  incipient  as  well  as  for  advanced 
cases  of  tuberculosis.  He  thought  that  if  ^250, 000 
could  be  got  it  should  be  taken  at  once.  Part  of  it 
should  be  given  to  the  board  of  health  for  its  work  in 
purifying  the  tenements;  another  portion  should  be 
given  for  the  erection  of  a  hospital  for  the  advanced 
cases;  another  portion  sliould  be  given  for  the  erec- 
tion of  a  hospital  for  the  incipient  cases.  He  asked 
that  a  combined  effort  should  be  made. 

Dr.  John  A.  Wyeth  then  offered  the  following: 

Whereas,  A  law  permitting  the  city  of  New  York  to 
erect  a  sanatorium  outside  of  its  corporate  limits  for 
the  treatment  of  the  consumptive  poor  was  passed  by 
the  legislature  in  iSgg;  therefore,  be  it 

Resohed,  That  the  municipal  authorities  be  urged 
to  take  action  under  this  law,  and  that  in  the  further- 
ance of  this  object  a  committee  of  three  be  appointed 
by  the  chair  to  bring  the  matter  before  the  council  of 
the  Academy. 


750 


MEDICAL    RECORD. 


[November  lo,  1900 


SECTION    ON    OliSTETRICS   AND   GVN.IX'OLOGV. 

Stiittd  Meeting,  October  2J,  igoo. 

J.  Riddle  Goffe,  M.D.,  Chairman. 

Demonstration  -^f  Uterine  Myomata,  with  Remarks 
on  the  Attachment  of  the  Bladder  to  the  Anterior 
Surface  of  Uterine  Tumors. — Dr.  J.  A.  Schmmt 
presented  these  two  specimens  of  uterine  myoma  re- 
moved from  women  respectively  thirty-six  and  forty- 
two  years  of  age.  The  operations  had  been  difficult 
because  of  the  extensive  adhesions  present.  IJr. 
Schmitt  said  that  when  the  bladder  was  found  em- 
bedded in  front  of  the  peritoneum,  the  operator  was 
justified  in  making  a  diagnosis  of  infantile  bladder. 
In  those  rare  cases  in  which  the  bladder  was  adherent 
to  the  parietal  peritoneum,  or  in  which  a  uterine  tumor 
pressed  the  bladder  against  the  abdominal  wall,  one 
might  be  misled,  but  careful  examination  should  lead  to 
a  knowledge  of  the  true  condition  present.  The  vesico- 
uterine cul-de-sac  was  always  more  or  less  preserved. 

Dr.  H.  J.  Garrigues  said  that  these  cases  were 
rather  rare.  He  had  seen  one  operated  upon  many 
years  ago  by  Dr.  T.  G.  Thomas,  and  the  description 
had  been  published  subsequently.  In  that  case  the 
tumor  was  ovarian,  and  the  bladder  was  situated  about 
midway  between  the  umbilicus  and  the  ensiform  car- 
tilage. Dr.  Thomas  had  cut  into  the  bladder  and  in- 
serted his  fingers  in  order  to  determine  the  attachments. 
After  having  detached  the  circumference,  he  had  dis- 
covered that  the  posterior  border  of  the  bladder  was 
not  adherent.  After  the  removal  of  the  cyst  the  oper- 
ator had  included  the  edge  of  the  bladder  in  the  edges 
of  the  abdominal  wound.  Dr.  Garrigues  then  alluded 
to  the  case  that  he  had  reported,  one  in  which  he 
thought  the  term  "foetal  bladder"  was  warranted. 
The  bladder  in  this  case  had  extended  up  to  the 
umbilicus. 

Dr.  Schmitt  replied  that  he  considered  the  desig- 
nation infantile  bladder  more  appropriate.  In  some 
cases  the  infantile  bladder  persisted;  in  others,  it 
changed  from  the  conical  to  the  ovoid  shape.  The 
urachus  had  nothing  whatever  to  do  with  the  infantile 
bladder,  because  the  lower  part  of  the  allantois  was 
formed  into  the  bladder. 

Hyaline  Degeneration  of  a  Fibromyoma  of  the 
Uterus. — Dr.  Garrkjues  presented  a  specimen  show- 
ing hyaline  degeneration  of  a  fibroma  of  the  uterus. 
The  specimen  had  been  removed  from  a  woman  forty- 
five  years  of  age,  who  had  lost  flesh  and  had  suffered 
from  backache  for  some  years.  On  palpation  he  had 
felt  a  non-sensitive  tumor  of  considerable  size  in 
Douglas'  pouch,  and  in  front  of  this  he  thought  he 
had  felt  a  small  uterus.  He  had,  therefore,  diagnosed 
an  ovarian  cyst.  On  performing  abdominal  section 
he  had  found  that  what  he  had  taken  to  be  the  uterus 
was  the  hypertrophied  cervix.  The  interior  of  the 
mass  was  filled  with  gelatinous  and  degenerating 
myomatous  tissue.  These  cases  had  formerly  been  de- 
scribed as  fibro-cysts  of  the  uterus. 

Dr.  H.  N.  Vinebeug  said  that  the  case  was  of  in- 
terest because  the  |)atient  had  nearly  reached  the  meno- 
pause, and  still  had  a  fibroid  tumor  requiring  removal. 
Within  a  comparatively  short  time  he  had  been  called 
upon  to  operate  upon  twelve  women,  all  near  the  meno- 
pause, and  i^resenting  various  forms  of  fibroid  tumor. 

Analgesia  in  Obstetrics  Produced  by  Medullary 
Injections  of  Cocaine.— Dr.  S.  Marx  read  tliis  paper. 
He  presented  a  tabulated  record  of  the  conduct  of 
forty-two  cases  of  labor  in  which  medullary  analgesia 
had  been  employed  almost  from  beginning  to  end.  At 
first,  he  had  made  use  of  eucaine,  but  with  practically 
no  results,  although  it  had  been  given  in  heroic  doses. 
He  had  now  abandoned  it  altogether.  Some  of  his 
failures  had  been  due  to  the  inertness  of  the  cocaine 
from   its   having  been    repeatedly  sterilized  by  heat. 


After  various  experiments  he  had  come  to  the  conclu- 
sion that  the  best  way  was  to  carry  two  sealed  vials, 
one  containing  gr.  ss.  of  the  muriate  of  cocaine,  and 
the  other  il[  xxx.  of  sterile  water.  When  mixed  to- 
gether, v\  x.  of  the  resulting  solution  represented  ^x.\ 
of  cocaine.  In  obstetrics  he  had  yet  to  record  a  fail- 
ure with  this  method  of  ana-sthesia,  and  he  had  been 
so  deeply  impressed  with  its  efficacy,  as  well  as  with 
its  safety,  that  he  would  be  perfectly  willing  to  make 
use  of  it  in  his  own  family. 

Dangers. — He  recognized  only  two  dangers  from  it, 
viz.,  sepsis  and  cocaine  poisoning.  In  all  of  the  cases 
reported  there  had  been  no  symptoms  of  cocaine  toxic- 
ity. Some  of  the  symptoms  observed  might  have  been 
attributed  to  cocaine  toxicity  had  it  not  been  that  the 
same  symptoms  had  been  observed  in  control  tests  in 
which  cocaine  had  not  been  used  at  all.  They  were 
in  reality  due  to  spinal  shock,  or  to  a  disturbance  of 
the  equilibrium  inside  of  the  spinal  canal.  Cocaine, 
like  chloroform,  was  a  specially  safe  anaesthetic  in 
obstetrics.  He  believed  the  dangerous  symptoms  as- 
sociated with  cocaine  poisoning  were  owing  to  cerebral 
anaemia,  and  hence  grave  symptoms  of  this  kind  were 
not  likely  to  arise  during  labor,  in  which  cerebral  con- 
gestion was  commonly  present. 

Technique. — After  a  large  experience  he  had  seen 
no  occasion  to  change  the  technique  first  adopted  and 
already  described.  He  maintained.  Dr.  Coming's 
statement  to  the  contrary  notwithstanding,  that  it  was 
absolutely  necessary  to  inject  the  solution  into  the 
spinal  canal.  The  same  technique  had  for  some  reason 
failed  him  in  gynecological  work.  A  needle  three  or 
four  inches  long,  of  fine  temper,  and  with  a  short  bevel, 
should  be  selected.  Long  needle-points  might  pene- 
trate beyond  the  point  of  selection  and  do  injury.  The 
trocar  point  was  the  preferable  one.  To  insure  absence 
of  pain  from  the  puncture  in  the  skin,  a  freezing-spray 
might  be  used.  In  a  period  of  from  two  to  thirty 
minutes  the  anfesthesia  was  ushered  in,  often  rather 
suddenly.  The  operation  could  usually  be  begun  as 
soon  as  firm  pinching  of  the  labia  majora  caused  no 
pain.  Transient  vomiting  was  apt  to  be  associated 
with  the  ushering  in  of  the  anesthesia.  Some  annoy- 
ance had  resulted  from  severe  headache.  This  could 
be  avoided  by  giving  gr.  xxx.  or  xl.  of  bromide  about 
two  hours  previously.  If  this  were  not  sufficient,  gr. 
-^^-^  of  hyoscine  might  be  given  subcutaneously  in  the 
anesthetic  area.  He  reserved  nitroglycerin  for  cases 
exhibiting  more  disturbance  together  with  cyanosis. 
When  anesthesia  was  complete  spontaneous  bearing 
down  did  not  occur,  but  when  the  patient  was  told  to 
bear  down  she  did  so  as  vigorously  as  when  not  an- 
esthetized. Explorations,  versions,  extractions,  and 
forceps  operations  had  been  done,  not  with  as  great 
ease  as  under  chloroform,  but  much  more  easily  than 
when  no  anesthetic  had  been  given.  There  was  no 
greater  disposition  to  bleeding  than  in  ordinary  cases. 
His  rule  in  the  hospital  had  been  to  inject  when  the 
pains  became  severe.  The  method  was  specially  suited 
to  allaying  the  dreadful  pains  of  normal  labor.  The 
ease  w  ilh  which  the  cervix  could  be  dilated  in  a  cocain- 
ized wtmian  was  a  matter  wortiiy  of  note.  The  method 
was  effective  and  safe  for  both  mother  and  child.  It 
was  true  that  failures  would  sometimes  occur,  and 
probably  under  the  most  humiliating  circumstances, 
but  there  was  no  contraindication  to  the  use  of  chloro- 
form under  such  circumstances. 

Some  Observations  on  Medullary  Analgesia. — 
Dr.  S.  Ormoni)  Goi.dan  read  this  paper,  which  was 
based  on  the  use  of  the  new  method  in  twenty  cases 
of  various  kinds.  That  this  method  was  superior  to 
the  three  general  anesthetics  ordinarily  in  use  he  did 
not  believe.  To  prevent  rusting  of  steel  needles  from 
boiling  and  sterilization,  they  should  be  dried  in  the 
flame  of  an  alcohol  lamp,     h  platinum  needle  was  too 


November  lo,  1900] 


MEDICAL    RECORD. 


751 


soft.  He  now  recommended  the  use  of  an  "attenu- 
ated'' needle  of  fourteen  karat  gold  having  a  short 
bevel.  He  preferred,  as  did  Dr.  Marx,  the  use  of  a 
metal  syringe  witii  a  solid  metal  piston.  He  carried 
tlie  cocaine  divided  into  powders,  each  one  being 
wrapped  in  tinfoil  and  containing  gr.  '4.  A  line 
joining  the  crests  of  the  ilia  would  indicate  the  loca- 
tion of  the  lower  border  of  the  fourth  lumbar  vertebra, 
and  it  was  between  the  fourth  and  fifth  lumbar  vertebra: 
that  the  puncture  should  be  made,  and  not  more  than 
I  cm.  to  the  outside.  The  needle  should  be  thrust 
through  the  integument  quickly,  and  then,  after  a 
pause  to  allow  the  patient  time  to  recover  from  the 
first  slight  shock,  it  was  slowly  pushed  forward  into 
the  spinal  canal.  For  abdominal  cases  an  anaesthesia 
lasting  an  hour  and  a  half  would  probably  be  suffi- 
cient, but  it  should  be  remembered  that  sometimes  w  hen 
the  lower  extremities  were  still  anaesthetic  the  patient 
would  experience  painful  sensations  from  manipula- 
tions in  the  abdomen.  Vomiting  occurred  in  about 
half  of  the  patients.  Many  of  them  were  pale  and 
slightly  cyanosed  at  first,  but  later  the  face  became 
suffused.  More  or  less  profuse  perspiration  was  ob- 
served in  all  but  two  cases,  probably  as  a  result  of 
paralysis  of  the  sympathetic.  There  w'as  a  slight  rise 
of  temperature  in  most  of  the  cases.  Headache  was 
present  in  about  half  of  the  patients;  in  four  it  was 
quite  intense.  Two  of  the  patients  had  muscular 
rigidity  of  the  back  muscles  and  of  the  back  of  the 
head.  In  one  patient  this  had  persisted  for  one  week. 
Ana;sthesia  was  not  induced  in  three  cases.  Toxic 
symptoms  had  appeared  in  one  case — an  obstetrical 
case.  This  patient  had  a  very  intense  headache  for 
two  days  following  the  injection.  Cocaine  introduced 
into  the  subarachnoid  space  differed  in  its  action  in 
no  way  from  that  observed  when  it  was  injected  into 
the  general  circulation,  except  that  it  was  possibly  less 
toxic.  Some  patients  were  easily  influenced  by  small 
doses;  others  required  comparatively  large  doses. 
Large,  healthy  individuals  were  often  influenced  by 
small  doses,  while  feeble  and  sickly  persons  migiu 
not  be  susceptible  to  quite  large  doses.  It  was  curi- 
ous that  when  the  first  injection  failed  to  produce 
satisfactory  anresthesia  it  also  failed  to  give  rise  to 
the  characteristic  physiological  effects.  The  individ- 
ual susceptibility  of  the  patient  to  cocaine  must  be 
determined  in  the  same  way  as  in  giving  morphine  to  a 
stranger.  It  had  been  said  that  no  mortality  had  been 
reported  as  following  intraspinal  cocainization,  but 
he  was  under  the  impression  that  Tuffier  had  reported 
one  deaiii  attributable  to  the  cocaine.  The  majority 
of  patients  would  prefer  not  to  be  conscious  when 
operated  upon.  Ancesthesia  by  intraspinal  cocainiza- 
tion he  believed  would  have  a  place  in  surgery,  not 
generally,  but  when  for  various  reasons  general  anaes- 
thetics could  not  or  should  not  be  administered. 

Medullary  Injections  in  Gynaecology. — Dr.  J. 
Riddle  Goffe  made  some  remarks  on  this  subject. 
He  said  that  the  field  of  usefulness  of  this  new  method 
of  inducing- ancESthesia  had  been  greatly  extended 
until  it  was  now  possible  to  operate  on  every  part  of 
the  body  from  the  tips  of  the  toes  up  to  and  including 
tlie  breasts.  On  September  27th  he  had  seen  one  of 
Tuffier's  assistants  remove  a  small  fibroid  tumor  of  the 
breast  under  medullary  analgesia.  For  these  high 
operations  it  was  not  necessary  to  make  the  injections 
any  higher  than  the  fourth  space,  but  larger  doses  of 
cocaine  were  required.  It  had  also  been  observed 
that  the  line  of  anaesthesia  extended  higher  than  usual 
when  the  injection  was  made  quickly  or  forcibly. 
Tuffier  had  very  recently  declared  to  the  speaker  that 
the  dosage  in  the  future  would  be  higher  than  hitherto. 
Dr.  Goffe  said  he  believed  the  method  could  be  relied 
upon  in  all  obstetrical  and  gynecological  operations. 
Reasonable  explanations  had  been  offered  for  almost 


all  of  the  failures  so  far  encountered.  TuflSer  regarded 
the  method  as  absolutely  safe  if  rigid  asepsis  was 
maintained.  A  letter  was  read  from  Dr.  Keen,  in 
which  he  said  that  lie  had  just  used  eucaine  with  per- 
fect satisfaction.  In  gyna-cological  work  there  were, 
of  course,  psychological  and  aesthetic  reasons  for  not 
using  this  method  in  ordinary  cases.  Tuffier  insisted 
that  the  patient  should  sit  on  a  table,  not  near  the 
edge,  but  far  back,  as  in  the  latter  position  the  patient 
was  not  so  liable  suddenly  to  straighten  out  and  de- 
flect the  needle. 

Annoying  Features.— Dr.  A.  Palmer  Dudley  said 
that  he  had  tried  this  method  of  anaesthesia  in  only 
a  comparatively  small  number  of  cases  of  general  sur- 
gery, but  in  enough  to  make  him  far  from  enthusiastic 
regarding  it.  He  referred  to  six  cases,  viz.:  (i)  A 
large  abscess  of  the  liver;  (2)  a  hysterectomy ;  (3)  a 
double  ovariotomy  for  extra-uterine  pregnancy;  (4) 
for  laceration  of  the  perineum;  (5)  an  amputation  of 
a  portion  of  the  foot,  and  (6)  an  operation  for  the  re- 
opening of  an  old  hernial  abscess.  One  of  the  dis- 
agreeable features  of  this  form  of  anaesthesia  had  been 
the  associated  nausea.  In  his  judgment,  it  was  safer 
to  make  the  injection  gradually.  Symptoms  of  cocaine 
poisoning  had  been  marked  in  most  of  his  cases.  The 
method  advocated  a  short  time  ago  by  Tufher  had  been 
to  use  a  solution  of  cocaine  that  had  been  heated  to 
80°  C.  for  three  hours  each  day  for  three  days  in  suc- 
cession. It  was  evident  from  what  had  been  said  al- 
ready that  this  technique  had  since  been  materially 
changed.  In  four  of  his  cases  an  annoying  feature 
had  been  involuntary  stools.  The  retching  was  ex- 
ceedingly embarrassing  in  abdominal  work.  The  in- 
tense headache  seemed  to  him  much  worse  than  the 
after-effects  of  ether  or  chloroform.  General  surgical 
cases  certainly  must  be  as  carefully  prepared  as  for 
ether  or  chloroform.  If  it  became  necessary  to  lengthen 
the  operation  more  than  had  been  anticipated,  it  would 
often  be  not  at  all  easy  to  turn  the  patient  over  and 
give  another  intraspinal  injection. 

Duration  of  the  Anaesthesia.— In  his  first  case  he 
had  injected  i  c.c.  Anaesthesia  had  been  obtained  in 
eight  minutes,  and  had  lasted  one  hour  and  fifty-eight 
minutes.  There  was  no  vomiting,  but  the  patient  had 
an  involuntary  stool.  In  the  next  case  the  anaesthesia 
had  lasted  for  two  hours  and  thirty-nine  minutes. 
There  was  vomiting,  which  was  controlled  by  an  in- 
jection of  citrated  caffeine.  The  next  patient  received 
1.5  c.c,  and  the  ana-sthesia  lasted  two  hours  and  ten 
minutes.  There  were  vomiting  and  an  involuntary 
stool.  The  same  quantity  of  cocaine  solution  was 
used  in  the  next  case,  and  the  ana-sthesia  lasted  one 
hour  and  twenty-eight  minutes.  There  was  vomiting 
here  also,  but  no  stool.  In  the  next  case  the  same 
dose  had  been  used,  and  the  operation  had  lasted  one 
hour  and  sixteen  minutes.  In  all  but  one  case  the 
temperature  had  risen  to  101.5°  °''  ^°-^  ^-  within  an 
hour.  In  the  last  case  the  ansesthesia  had  been  in- 
duced in  six  minutes,  but  had  lasted  only  thirty-two 
minutes.  The  dose  in  this  case  was  1  c.c.  The 
method  seemed  to  him  more  useful  in  obstetrics  than 
in  general  surgery;  it  was  also  useful  in  cases  of  dis- 
ease of  the  heart  or  of  the  kidney,  bearing  in  mind, 
however,  the  deleterious  effects  of  the  cocaine  and  of 
nausea  and  vomiting  in  such  cases.  The  method 
might  be  considered  useful  in  certain  cases  of  minor 
surgery  in  which  the  patient  objected  to  taking  a  gen- 
eral anasthetic. 

A  Typically  Successful  Case. — Dr.  Henry  C. 
CoE  said  that  he  had  used  the  method  in  only  one 
case,  but  that  had  been  an  extremely  typical  one. 
The  patient  was  a  virgin  who  had  passed  the  meno- 
pause and  had  had  a  disease  of  long  standing,  for 
which  she  had  been  tapped  eight  times.  On  examina- 
tion, there  was  a  well-marked  dropsy  and  oedema  of 


752 


MEDICAL    RECORD. 


[November  lo,  1900 


the  lower  extremities  and  of  the  lower  portion  of  the 
back.  Examination  per  rectum  showed  a  dilluse  mass 
in  the  pelvis.  I'he  probable  diagnosis  was  a  papillo- 
matous cyst.  On  account  of  the  a-dema  the  injection 
had  been  made  with  great  difficulty.  \\'ithin  five  or 
six  minutes  anaesthesia  had  been  complete.  The  pa- 
tient was  a  woman  who  was  almost  free  from  nervous- 
ness, and  who  had  been  tapped  sufficiently  often  to 
have  lost  any  fright  she  might  have  had — indeed,  she 
said  that  the  tappings  had  always  been  '"  disagreeable." 
She  talked  during  the  whole  operation,  and  showed 
no  signs  of  discomfort.  The  adhesions  were  numer- 
ous, and  the  operation  was  rather  difficult.  She  was 
given  gr.  XX.  of  bromide  half  an  hour  before  the  induc- 
tion of  anasthesia.  When  seen  the  ne.xt  day  she  was 
extremely  comfortable  and  had  been  able  to  take  food 
from  the  first.  She  made  an  uninterrupted  recovery. 
This  was  a  case  in  which  he  felt  sure  it  would  have 
been  very  risky  to  etherize;  such  a  course  would  prob- 
ably have  led  to  a  fatal  termination.  The  pulse  had 
been  140  at  the  time  she  had  been  on  the  table,  but 
probably  this  was  largely  owing  to  the  action  of  the 
cocaine.  He  thought  he  would  have  to  wait  some 
time  before  he  found  another  patient  that  he  considered 
a  suitable  case,  particularly  as  the  patients  at  the  hos- 
pital were  largely  excitable  Italians  and  Hungarians. 

A  Humiliating  Experience. — Dr.  E.  H.  Grandin 
said  that  it  was  with  considerable  satisfaction  that  he 
found  the  general  opinion  prevailing  here  was  not 
quite  so  optimistic  as  he  had  expected  from  articles 
that  had  appeared  in  the  medical  and  lay  press.  The 
occasion  reminded  him  of  his  student  days  when  Dr. 
Bigelovv  used  to  come  into  the  operating-theatre  of  the 
Massachusetts  General  Hospital  and  tell  of  the  horrors 
of  the  pre-anaesthetic  days.  That  was  his  frame  of 
mind  at  present;  he  was  so  horrified  that  he  did  not 
care  to  try  the  method  of  intraspinal  cocainization  for 
a  long  time  to  come.  His  clinical  material  consisted 
largely  of  highly  nervous  Italians,  and  hence  the  diffi- 
culties, though  he  confessed  that  this  was  the  only 
class  of  people  upon  whom  he  would  care  to  try  the 
plan.  If  such  difficulties  were  experienced  among 
this  class  of  people,  how  could  one  expect  to  use  tiie 
method  in  private  practice.'  The  first  time  he  had 
tried  it  Dr.  Marx  had  given  the  injection,  and  after 
about  eighteen  minutes  anzesthesia  had  been  induced. 
He  had  then  made  one  sweeping  incision  down  to  the 
peritoneum,  but  on  endeavoring  to  proceed  further  the 
patient's  sensations  had  been  such  that  he  had  ad- 
ministered chloroform  and  completed  the  operation. 
In  another  case  he  had  proceeded  to  do  a  vaginal  sec- 
tion after  Dr.  Marx  had  very  skilfully  administered  gr. 
l  of  cocaine  by  spinal  puncture.  This  patient  had 
made  such  a  noise  that  the  next  patient  refused  to  be 
operated  upon.  The  lumbar  puncture  had  been  most 
skilfully  performed,  but  the  anesthesia,  at  least  while 
the  patients  were  in  the  operating-room,  had  not  been 
a  brilliant  success.  Continuing,  Dr.  Grandin  said 
that  he  had  probably  witnessed  upward  of  eight  thou- 
sand anaisthetizations,  and  had  made  use  of  chloroform, 
ether,  and  nitrous  oxide.  He  had  yet  to  see  a  death 
which  could  be  traced  to  these  aniesthetics  if  these 
had  been  administered  by  a  competent  person.  He 
had  seen  very  little  nausea  after  the  administration  of 
chloroform.  In  one  case  he  had  observed  suppression 
of  urine  and  death  after  etherization,  but  this  woman 
had  been  drenched  with  ether.  He  had  found  nitrous 
oxide  sufficient  for  plastic  work,  for  a  posterior  vaginal 
section,  and  for  simple  vaginal  hysterectomies.  He 
could  not  use  nitrous  oxide  for  abdominal  work  because 
there  was  not  sufficient  relaxation  of  the  muscles.  If 
both  cardiac  and  renal  disease  were  present  he  would 
be  perfectly  willing  to  test  lumbar  puncture  and  medul- 
lary analgesia. 

A   Rumor   of   High    Mortality  from    Intraspinal 


Cocainization — The  speaker  said  that  only  yesterday 
a  geiitlcuiai),  who  had  been  present  at  the  Interna- 
tional Medical  Congress,  had  given  and  \ouched  for 
the  following  astounding  figures,  and  from  another 
source  they  liad  been  confirmed — viz.,  one  hundred 
cases  of  lumbar  puncture  with  five  deaths;  in  only 
seventeen  per  cent,  of  the  cases  had  anaesthesia  been 
secured.  Dr.  Grandin's  comment  on  these  statistics 
was  that,  if  found  to  be  true,  it  would  take  one  hun- 
dred thousand  lumbar  punctures  to  warrant  any  one 
in  using  this  new  method  of  anaesthesia  in  his  own 
family  or  on  his  patients  without  having  first  obtained 
their  written  consent.  He  thought  the  less  this  method 
was  exploited,  the  better.  Women  were  to-day,  he 
declared,  talking  in  their  sewing-circles  about  how 
they  could  have  babies  easily.  It  could  not  be  denied 
that  every  case  of  lumbar  puncture  was  subject  to  the 
danger  of  sepsis,  no  matter  how  careful  the  operator. 
He  wished  it  to  be  understood  that  he  was  not  con- 
demning the  method  or  accepting  it;  he  would  be 
content  to  sit  by  and  wait  until  about  twenty  thousand 
cases  had  been  placed  on  record,  and  then  possibly  he 
might  be  willing  to  try  it  again. 

A  More  Favorable  Experience. — Dr.  J.  Bion 
BoGART,  of  Brooklyn,  said  that  his  own  experience 
with  this  method  covered  twenty-five  cases.  In  this 
series  there  had  been  four  operations  for  hernia,  two 
amputations  of  the  leg,  two  amputations  of  tlie  great 
toe,  one  excision  of  the  metatarsal  bone  of  the  great 
toe,  one  excision  of  the  hip,  one  double  osteotomy  for 
knock-knee,  and  five  rectal  cases,  so  that  the  field  of 
general  surgery  had  been  pretty  well  covered.  His 
experience  with  the  method  had  not  been  uniformly 
satisfactory,  ana;sthesia  not  having  been  secured  in 
the  third  and  fourth  cases.  In  these  the  cerebro-spinal 
fluid  had  not  been  obtained;  the  cocaine  had  been 
boiled  for  ten  minutes,  and  the  puncture  had  been 
made  between  the  fourth  and  fifth  lumbar  vertebra. 
Since  he  had  adopted  tiie  plan  of  making  the  puncture 
between  the  third  and  fourth  vertebr.-e,  securing  the 
escape  of  some  of  the  spinal  fluid,  and  boiling  the 
cocaine  for  only  two  minutes,  there  had  been  no  fail- 
ures. In  tliecase  of  amputation  of  the  leg  the  patient 
had  died  from  a  septic  peritonitis,  the  result  of  an  in- 
traperitoneal injury.  A  careful  autopsy  had  failed 
to  show  any  injury  from  the  puncture.  The  patient 
died  within  forty-eight  hours  after  the  puncture.  The 
speaker  objected  to  the  use  of  the  metal  syringe  with 
solid  piston  because  it  was  impossible  with  it  to  tell 
whether  the  instrument  was  in  proper  working  order. 
He  had  recently  called  for  three  such  syringes  in  suc- 
cession, and  each  one  had  failed  to  work.  In  only 
two  cases  had  there  been  vomiting  while  the  patient 
was  in  the  operating-room,  and  that  had  been  transient. 
In  one  case  there  had  been  an  involuntary  evacuation 
of  the  bowel.  Of  the  twenty-five  cases  there  were 
seven  failures.  One  of  these  was  a  case  in  which  an 
effort  had  been  made  to  utilize  this  method  of  anjES- 
thesia  for  the  amputation  of  the  arm,  but  it  had  not 
succeeded.  Ho  had  used  the  method  in  both  children 
and  adults.  In  one  of  the  cases  of  failure  a  very  large 
needle  had  been  used,  and  as  soon  as  the  syringe  had 
been  removed  the  injected  fluid  had  run  out.  As  the 
patient  was  a  young  child  he  had  not  cared  to  repeat  the 
puncture,  and  had  for  this  reason  given  chloroform. 
Most  of  his  work  had  been  done  at  the  Kings  County 
Hospital  among  a  class  of  poor  foreigners.  Of  the 
twenty-five  cases  six  were  in  Italians.  In  connection 
with  the  statement  that  the  bowel  often  showed  sensi- 
tiveness to  manipulation,  he  desired  to  say  that  one  of 
his  cases  was  an  operation  for  the  closure  of  a  fecal 
fistula.  Although  this  had  necessitated  much  manip- 
ulation of  the  bowel,  the  anaesthesia  had  been  perfect. 
The  greatest  difficulty  encountered  had  been  the  fear 
of  the  patient  of  the  primary  injection.     As  soon   as 


November  lo,  1900] 


MEDICAL    RECORD. 


753 


the  lumbar  puncture  had  been  made  and  the  cocaine 
injected,  tiic  field  of  operation  should  be  prepared, 
and  by  the  time  this  had  been  done  anaesthesia  would 
be  sufficient  for  going  on  with  the  operation.  One 
case  was  that  of  a  man  with  an  exceedingly  painful 
hip;  it  was  so  sensitive  that  he  dreaded  to  have  any 
one  approach  him.  The  speaker  said  that  he  dis- 
claimed any  wish  to  minimize  the  danger  of  infection, 
for  this  was  the  chief  danger,  but  the  chance  of  in- 
fecting the  spinal  cord  was  not  very  great,  if  only  be- 
cause the  needle  passed  through  so  much  tissue  before 
reaching  the  spinal  canal.  Tliis,  of  course,  did  not 
mean  tiiat  one  should  not  be  careful  about  sterilizing 
the  needle  and  observing  the  most  rigid  aseptic  pre- 
cautions. 

Dr.  Marx  said  that  he  had  warned  Dr.  Grandin 
that  the  anesthesia  was  not  complete,  yet  Dr.  Grandin 
had  insisted  upon  beginning  the  operation  at  once. 
He  would  admit  that  Dr.  Grandin's  cases  were  absolute 
failures,  but  others  wlio  had  had  many  successes  had 
also  met  with  some  failures.  It  was  just  as  wrong  to 
condemn  the  method  so  unreservedly  on  an  unfortu- 
nate experience  in  two  cases,  as  it  was  to  report  an 
experience  consisting  of  only  one  beautifully  typical 
and  successful  case.  He  was  of  the  opinion  that  Dr. 
Goldan  used  too  large  doses  of  cocaine,  and  that  it 
was  inadvisable  to  make  use  of  needles  with  stilettes, 
as,  if  these  were  used,  they  might  push  a  blood  clot 
back  into  the  subarachnoid  space.  It  was  unfortunate 
that  Dr.  (Jrandin  should  have  placed  on  record  those 
astounding  figures,  vouched  for  by  two  unknown  per- 
sons. We  should  not  condemn  or  praise  the  method 
on  mere  hearsay  and  rumor.  He  purposed  to  write  in 
the  near  future  a  paper  on  his  failures,  accidents,  and 
complications,  and  hoped  others  would  do  the  same. 

Dr.  Goldan,  in  closing,  said  that  his  first  two  cases 
had  been  failures,  yet  he  had  tested  the  cocaine  in 
those  cases  upon  himself  and  upon  another,  and  had 
in  this  way  proved  it  to  be  active.  'I'he  failure  was 
probably  attributable  to  the  use  of  too  large  a  needle. 
He  had  endeavored  to  make  his  observations  uniform 
by  employing  in  each  instance  ti^  xx.  of  a  two-per- 
cent, solution  of  cocaine.  In  another  case  the  anes- 
thesia had  been  partial  and  limited  to  one  side.  In 
three  cases  the  anesthesia  had  been  perfect  until  the 
intestine  had  been  handled,  and  then  the  patient  had 
given  evidence  of  pain.  As  these  manipulations  had 
been  made  toward  the  close  of  the  operation,  it  was 
quite  possible  that  the  effect  of  the  anesthetic  was 
beginning  to  wear  off.  In  one  case  he  had  made  the 
puncture  between  the  fourth  and  fifth,  and  also  be- 
tween the  third  and  fourth  lumbar  vertebre,  but  had 
failed  to  obtain  anesthesia.  Some  days  later  he  had 
resorted  to  the  method  again  for  a  secondary  operation 
on  this  person,  and  had  on  that  occasion  secured  com- 
plete anesthesia.  He  was  of  the  opinion  that  the 
sensation  of  traction  was  entirely  dilTerent  from  that 
of  ordinary  pain.  So  far,  he  had  not  had  occasion  to 
make  use  of  a  stilette  to  clear  the  needle  from  obstruc- 
tion at  the  time  of  puncture.  He  did  not  think  it 
made  any  difference  as  regards  the  anesthesia  whether 
the  puncture  was  made  between  the  fourth  and  fifth  or 
between  the  third  and  fourth  lumbar  vertebra.  If  the 
puncture  was  made  in  the  right  place  there  was  no  oc- 
casion to  depress  the  needle;  it  should  be  simply  in- 
troduced straight.  He  had  made  it  a  point  in  this  in- 
vestigation to  report  his  cases  just  as  they  had  been 
met  with,  both  the  failures  and  the  successes. 


In  Appendicitis,  even  though  the  temperature  be 
normal  or  only  slightly  elevated,  it  is  generally  con- 
ceded that  an  operation  is  indicated  when  the  com- 
bination of  a  rapid  pulse  and  respiration  exists. 


AMERICAN  PUBLIC  HEALTH   ASSOCIATION. 

Twenty-eighth  Annual  Meeting.  Held  at  Indianapolis, 
Jnd..  Oitolier  22,  2J.  24,  25,  and  26.  igoo. 

The  Section  on  Bacteriology  and  Chemistry  met  at 
the  pathological  laboratory  of  the  Central  Hospital 
for  the  Insane,  with  the  chairman  of  the  section.  Dr. 
Theobald  Smith,  of  Boston,  presiding.  Several  papers 
were  read  and  discussed.  Among  them  was  one  by 
Dr.  H.  L.  Russell,  of  Madison,  Wis.,  in  which  he 
showed  the  degree  of  heat  which  was  necessary  to  de- 
stroy the  tubercle  bacillus  in  milk  without  injuring 
commercially  the  value  of  the  milk.  He  also  read  the 
report  of  the  committee  on  the  bacteriology  of  milk 
in  its  sanitary  relations.  As  illustrating  the  peculiar 
way  by  which  such  germs  find  their  way  into  milk,  an 
incident  occurring  in  a  hospital  at  Leeds,  England, 
was  related.  The  nurses  in  that  institution  were  in 
the  habit  of  taking  glasses  of  milk  from  the  pantry  up 
into  the  sick  wards  several  hours  before  the  milk  was 
drunk.  An  outbreak  of  typhoid  fever  occurred  among 
the  nurses.  Investigation  disclosed  the  practice  to 
which  they  had  been  resorting,  and  when  it  was  ordered 
discontinued  the  epidemic  subsided. 

Dr.  V.  .-X.  Moore,  of  Ithaca,  N.  Y.,  related  an  ac- 
count of  a  diphtheria  epidemic  which  was  started  in 
that  city  from  milk  delivered  by  a  dairyman  whose 
family  had  suffered  from  acute  tonsillitis.  The  eldest 
son,  who  attended  to  the  milking  of  tlie  cows,  had  been 
pronounced  well  and  resumed  his  regular  work,  but 
scientific  investigation  demonstrated  that  he  still  had 
germs  of  the  disease  in  his  system. 

The  general  meeting  of  the  association  was  presided 
over  by  Dr.  Peter  H.  Bryce,  of  Toronto,  Canada.  The 
sessions  were  held  in  the  amphitheatre  of  the  German 
House.  Addresses  of  welcome  were  delivered  by  ex- 
President  Benjamin  Harrison,  Governor  James  A. 
Mount,  and  Hon.  Addison  C.  Harris,  Minister  to 
Austria.  The  response  to  these  addresses  was  made 
by  Dr.  Charles  A.  Lindsley,  of  New  Haven,  Conn. 

Car  Sanitation The  first  paper  presented  at  the 

general  meeting  was  by  Prok.  S.  H.  Woodbridge,  of 
Boston,  which  was  the  report  of  the  committee  on  car 
sanitation.  The  following  recommendations  were  re- 
ported in  the  paper:  (i)  When  a  passenger  was  known 
to  be  contagiously  ill,  he  should  be  isolated  in  a  com- 
partment appropriately  equipped  and  ventilated  in 
such  a  manner  as  to  separate  it  from  the  rest  of  the 
car.  Through  trains  should  be  provided  with  rooms 
for  the  sick,  as  well  as  state-rooms,  interchangeable 
in  use.  (2)  The  interior  of  passenger  cars  should  be 
plain,  finished  with  hard,  smooth,  and  polished  sur- 
faces. (3)  All  furnishings  should  be  as  non-absorb- 
ent as  possible.  (4)  Coaches  should  be  furnished 
with  effective  means  for  continuously  supplying  not 
less  than  one  thousand  cubic  feet  of  warm  air  an  hour 
for  each  single  seat,  and  for  distributing  and  removing 
the  air  without  troublesome  draught.  (5)  The  tem- 
perature should  be  regulated.  (6)  The  cleaning  of 
cars  should  be  frequent  and  thorough.  (7;  Floors 
and  sanitary  and  laboratory  fi.\tures  should  be  fre- 
quently treated  with  a  disinfecting  wash.  (8)  All 
fabrics  in  cars  should  receive  sterilizing  treatment. 
All  bed  and  lavatory  linen  should  be  thoroughly 
sterilized  in  the  process  of  laundering.  (9)  Sewage 
tanks  and  earth  closets  should  be  provided  under  the 
cars.  The  practice  of  disposing  of  excreta  by  scatter- 
ing it  over  road-beds  was  dangerous.  (10)  Water  and 
ice  should  be  obtained  from  the  purest  available 
sources.  The  use  of  tongs  in  handling  ice  should  be 
insisted  upon.  (11)  The  water  tank  should  be  fre- 
quently cleansed  and  periodically  sterilized  with  boil- 
ing water  or  otherwise.  (12)  The  public  should  be 
educated  to  use  individual  cups.  Paper  paraffined 
cups  might  be  provided  by  a  cent-in-the-slot  device. 


754 


MEDICAL    RECORD. 


[November  lo,  1900 


(13)  The  use  of  canned  goods  in  buffet-car  service 
makes  careful  inspection  of  such  goods  imperative. 
Fruits  and  all  eatables  before  and  after  purciiase 
should  be  stored  with  care  to  avoid  all  unnecessarj' 
exposure  to  street  and  car  dust.  (14)  The  filthy  habit 
of  spitting  on  car  floors  should  be  dealt  with  in  a 
manner  to  cause  its  prompt  discontinuance.  It  should 
be  punished  as  one  of  the  most  flagrant  of  the  thought- 
less olTences  against  the  public  right  to  health.  (15) 
Station  premises  should  receive  attention  directed  to 
general  cleanliness  of  floors,  furnishings,  air,  sani- 
taries,  lavatories,  platforms,  and  approaches,  and 
should  be  plentifully  supplied  with  approved  disin- 
fecting material.  The  recommendations  of  the  com- 
mittee were  concurred  in  by  the  association. 

Dr.  J.  N.  HuRTY,  of  Indianapolis,  said  that  if  the 
association  would  make  a  vigorous  demand  for  white 
blankets  for  sleeping  cars,  instead  of  colored  ones,  it 
would  be  a  great  reform.  The  white  blanket  would 
tell  its  own  story.  Colored  blankets  were  frequently 
saturated  with  filth. 

Dr.  H.  M.  Br.^cken,  of  Minneapolis,  said  that  inas- 
much as  the  travelling  public  paid  a  good  price  for 
Pullman  cars,  it  was  only  right  that  the  cars  should  be 
kept  clean  and  in  good  condition.  The  beds  were 
made  up;  people  slept  in  them;  the  next  morning  the 
linen  was  removed,  while  the  mattresses  and  blankets 
were  thrown  into  the  upper  berths  and  remained  there 
until  the  next  night,  and  then  were  used  again.  It 
was  not  uncommon  for  people,  on  entering  Pullman 
cars,  to  complain  of  the  odor  of  stale  bedding,  etc. 

Dr.  C.  H.  Jones,  of  Baltimore,  referred  to  tubercu- 
lous patients  who  travelled  long  distances.  When  the 
greatest  care  and  caution  were  observed,  the  blankets 
used  on  Pullman  cars  were  now  and  then  spat  upon 
by  them.  The  attendants  could  not  always  be  with 
such  patients  to  cover  their  mouths  with  handkerchiefs. 
Railway  managers  should  be  notified  of  the  great 
danger  to  the  public  from  this  source.  When  the 
public  had  been  educated  in  this  matter,  a  great  reform 
would  have  been  inaugurated. 

Dr.  C.  p.  Wilkinson,  of  New  Orleans,  stated  that 
the  chief  objection  to  the  equipment  and  furnishings 
of  railway  cars  was  that  they  were  upholstered  in  ab- 
sorbable material.  In  the  extreme  South  rattan  and 
steel  springs  were  now  used  instead  of  plush  and 
woollen  furnishings. 

Dr.  U.  O.  B.  Wingate,  of  Milwaukee,  referred  to 
the  work  that  was  being  done  in  this  direction  by  the 
International  Association  of  Railway  Surgeons,  and 
suggested  that  it  might  be  well  to  appoint  a  committee 
to  co-operate  with  a  similar  committee  of  that  associa- 
tion to  do  further  work  in  car  sanitation. 

Dr.  Hurty  spoke  of  one  railroad  which  was  now 
constructing  seven  cars  with  perfectly  plain  interiors. 
The  bottoms  and  backs  of  the  seats  could  be  taken  out 
and  thoroughly  sterilized  at  the  end  of  every  run. 

Dr.  Domingo  Orvananos,  of  the  City  of  Mexico, 
read  a  supplementary  report  on  car  sanitation.  P.oards 
of  health  in  the  territories  covered  by  the  association 
ought  to  try  to  obtain  support  from  the  different  legis- 
latures so  as  to  make  certain  provisions  obligatory  on 
railway  companies,  as,  for  instance,  (i)  the  isolation 
in  special  cars  of  any  persons  suffering  from  trans- 
missible diseases;  (2)  to  supply  guaranteed  filters  in 
the  tanks  of  drinking-water;  (3)  the  disinfection  of 
bed-clothes,  hangings,  curtains,  and  towels;  (4)  all 
sleeping-cars  should  be  provided  with  small  disinfect- 
ant stoves  for  small  toilet  articles;  (5)  the  absolute 
prohibition,  under  severe  penalty,  of  expectoration  on 
pavements;  (6)  all  railroad  cars  sliould  be  provided 
with  a  suflicient  number  of  cuspidors  containing  a 
strong  disinfecting  solution. 

New  Quarantine  Methods  and  Changes  which 
are   Called  for    in  Marine  Sanitation. — This  paper 


was  contributed  by  Dr.  Alvah  H.  Doty,  of  New  York 
City  (see  page  681). 

Prof.  F.  C.  Rohinson,  of  Maine,  said  that  formerly 
a  great  deal  of  pajier  was  made  from  rags,  and  he  was 
surprised  to  hear  that  there  w'as  no  danger  from  infec- 
tious diseases  from  cargoes  of  rags.  He  believed  out- 
breaks of  smallpox  and  other  contagious  diseases  had 
been  traced  to  rags. 

Dr.  H.  M.  Bracken  vigorously  controverted  the 
statement  of  the  essayist  that  healthy  persons  were  not 
liable  to  carry  disease  in  their  clothing.  Every  phy- 
sician of  experience  could  cite  instances  of  physicians 
who  had  carried  contagion  to  healthy  people. 

The  paper  was  further  discussed  by  Drs.  M'ilson, 
Montizambert,  the  president,  Lee,  Durgin,  and  Junes, 
nifst  of  whom  protested  against  the  idea  that  physi- 
cians could  not  carry  infection  in  their  clothing. 

Report  of  the  Committee  on  Cause  and  Preven- 
tion of  Infectious  Diseases.  — Dr.  A.  VA'ai.ter  Suiter, 
of  Herkimer,  New  York,  read  this  report.  Reference 
was  made  to  smallpox,  which  he  said  was  on  the  in- 
crease, and  he  cited  copious  statistics  to  prove  his  as- 
sertion. He  added  the  pleasing  assurance  that  the 
death  rate  from  this  malady  was  decreasing.  The 
latter  fact  must  not  be  viewed  too  optimistically,  be- 
cause smallpox  was  certain,  if  an  epidemic  of  it  con- 
tinued long  enough,  to  develop  its  greatest  degree  of 
virulence.  He  showed  the  value  of  sanitary  precau- 
tions and  of  vaccination  by  citing  the  fact  that  Porto 
Rico,  since  the  United  States  had  dominated  its  gov- 
ernment, had  rid  itself  of  the  disease,  which  before  the 
war  was  very  prevalent  in  that  island.  He  also  dis- 
cussed malaria,  scarlet  fever,  and  typhoid  fever,  and 
declared  himself  a  believer  in  the  theory  that  the 
germs  of  malaria  were  transmitted  by  mosquitos  in 
many  instances.  In  discussing  typhoid  fever  he  re- 
ferred to  the  declaration  of  Dr.  Vaughan,  that  more 
than  eighty  per  cent,  of  deaths  among  American  sol- 
diers in  the  Spanish  war  were  caused  by  typhoid  fever, 
and  emphasized  the  necessity  of  cleanliness  about 
military  camps.  He  touched  upon  bubonic  plague, 
and  said  that  he  did  not  anticipate  a  scourge  of  this 
disease  here,  but  urged  great  sanitary  precautions. 

Etiology  of  Yellow  Fever. — Dr.  Walter  Reed, 
of  Washington,  D.  C,  read  a  paper  on  this  subject,  it 
being  the  joint  production  of  himself,  Dr.  James  Car- 
roll, Dr.  A.  Agramonte,  and  Dr.  Jesse  W.  Lazear.  A 
series  of  clinical,  bacteriological,  and  pathological  ob- 
servations was  narrated,  comprising  eighteen  cases  of 
yellow  fever.  Of  this  number  eleven  were  designated 
as  severe  cases  of  the  disease,  with  four  deaths;  three 
as  well-marked  cases  with  no  deaths,  and  four  as  mild 
cases  with  no  deaths.  Blood  cultures  were  made  of 
eighteen  cases  during  life,  and  of  forty-eight  separate 
cultures  made  from  the  blood  on  various  days  of  the 
disease,  and  representing  one  hundred  and  fifteen 
bouillon  inoculations  and  eighteen  agar  plates,  they 
failed  to  find  the  bacillus  icteroides  in  any  of  the 
tubes  or  plates.  They  failed  to  isolate  the  bacillus 
icteroides  in  eleven  autopsies  of  yellow-fever  patients. 
Having  failed  to  isolate  this  bacillus  either  from  the 
blood  during  life  or  from  the  blood  and  organs  of 
cadavers,  two  courses  of  procedure  appeared  to  be 
worthy  of  attention — namely,  first,  a  careful  study  of 
the  intestinal  flora  in  yellow  fever  in  comparison  with 
the  bacteria  that  might  be  isolated  from  the  intestinal 
canal  of  healthy  individuals  in  this  vicinity,  or  of 
tho.se  sick  with  other  diseases;  or,  second,  to  give  at- 
tention to  the  theory  of  the  propagation  of  yellow  fever 
by  means  of  the  mosquito.  The  essayists  pursued  the 
second  line  of  investigation  by  reason  of  the  well- 
known  facts  connected  with  the  epidemiology  of  this 
disease,  and  by  the  brilliant  work  of  Ross  and  the 
Italian  observers  in  connection  with  the  theory  of  the 
propagation  of  malaria  by  the  mosquito.     Their  ob- 


November  lo,  1900] 


MEDICAL    RECORD. 


755 


servations  pointed  to  the  presence  of  an  intermediate 
host,  sucli  as  the  mosquito,  which,  having  taken  the 
parasite  into  its  stomach  soon  after  tiie  entrance  of 
the  ijatient  into  the  non-infected  house,  was  able,  after 
a  certain  interval,  to  reconvey  the  infecting  agent  to 
other  individuals,  thereby  converting  the  non-infected 
house  into  an  infected  house.  This  interval  would 
appear  to  be  from  nine  to  sixteen  days,  allowing  for  the 
period  of  incubation,  which  agreed  fairly  closely  with 
the  time  required  for  the  passage  of  the  malarial  para- 
site from  the  stomach  of  the  mosquito  to  its  salivary 
glands.  In  view  of  the  foregoing  observations  they 
tested  the  theory  of  Finlayon  human  beings.  Experi- 
ments were  made  on  eleven  non-immune  individuals. 
The  mosquito  used  in  all  cases  was  Culex  fasciatus 
Fabr.  The  results  were  nine  negatives,  two  positives. 
The  two  cases  reported  as  positive,  the  authors  de- 
tailed at  great  length.  Since  they  recorded  one  case 
in  which  a  typical  attack  of  yellow  fever  followed  the 
bite  of  an  infected  mosquito  within  the  usual  period 
of  incubation  of  the  disease,  and  in  which  other 
sources  of  infection  could  be  excluded,  they  felt  con- 
fident that  the  publication  of  their  detailed  observa- 
tions would  excite  renewed  interest  in  the  mosquito 
tlieory  of  the  propagation  of  yellow  fever,  as  first  pro- 
posed by  Finlay.  From  their  studies  thus  far  of  the 
disease,  they  concluded  that  the  bacillus  icteroides 
stood  in  no  causative  relation  to  yellow  fever,  but, 
when  present,  should  be  considered  as  a  secondary 
invader  in  this  malady.  The  mosquito  served  as  an 
intermediate  host  for  the  parasite  of  \ellow  fever. 

Report  of  the  Committee  on  the  Etiology  of  Yel- 
low Fever. — Dr.  Henry  13.  Hurliseck,  of  Charles- 
ton, S.  C,  read  this  report.  Reference  was  made  to 
previous  contributions  on  this  subject  by  the  commit- 
tee, and  a  digest  given  of  the  labors  of  bacteriologists 
who  had  during  the  past  twelve  months  devoted  them- 
selves to  the  study  of  the  bacillus  icteroides.  The 
report  closed  with  the  following  conclusions  from  an 
article  by  Proust  and  U'urtz,  published  September  7, 
1900:  (i)  The  bacillus  icteroides  of  Sanarelli  seemed 
to  be  the  specific  agent  of  yellow  fever.  That  micro- 
organism injected  into  certain  animals,  especially 
dogs,  reproduced  symptoms  and  lesions  strikingly  an- 
alogous to  those  observed  in  man.  The  toxin  of  this 
bacillus  produced  in  animals  the  same  effect  as  the 
microbe.  The  injection  of  this  toxin  into  five  indi- 
viduals reproduced  in  man  typical  yellow  fever  ac- 
companied by  its  symptoms  and  anatomical  lesions. 
The  serum  of  individuals  attacked  with  yellow  fever 
agglutinated  cultures  of  the  bacillus  icteroides.  (2) 
The  bacillus  had  a  prolonged  vitality  both  in  air  and 
water  (fresh  and  sea).  It  was  certain  that  it  was  the 
same  in  the  soil.  Moulds  favored  its  development. 
These  facts  confirmed  conditions  that  had  been  known 
a  long  time.  They  explained  the  reawakening  of  yel- 
low fever  a  long  time  after  the  extinction  of  an  epi- 
demic, and  the  longevity  of  the  disease  aboard  vessels 
in  bad  hygienic  conditions.  No  new  prophylactic 
measures  had  come  out  in  this  knowledge  of  the  etiol- 
ogy of  the  disease.  As  formerly,  the  prevention  of 
yellow  fever  consisted  in  applying  the  measures  of 
isolation  and  of  disinfection,  and  of  improving  the 
hygienic  conditions.  While  the  numerous  contribu- 
tions to  the  cause  of  yellow  fever  were  far  from  being 
conclusive,  the  researches  made  during  the  last  few 
years  furnished  matters  of  information  which  would  be 
guiding-stars  in  future  investigations. 

Dr.  J.  P.  Bernaldez,  of  Mexico,  spoke  of  human 
vaccine  as  a  prophylactic  of  smallpox,  and  discussed 
its  advantages  and  disadvantages. 

Dr.  M.  S.  Iglesias,  of  Vera  Cruz,  Mexico,  spoke  of 
the  elements  of  defence  against  infectio-contagious 
diseases  at  the  port  of  Vera  Cruz. 

Influence   of   Temperature   on   Vaccine   Virus. — 


Dr.  F.  VV.  Elgin,  of  Philadelphia,  read  this  paper. 
After  detailing  a  series  of  experiments,  he  drew  atten- 
tion briefiy  to  some  of  the  lessons  suggested  by  the 
experiments:  (1)  Vaccine  points  were  unreliable  when 
stored  for  any  length  of  time  at  any  temperature.  (2) 
Virus  on  points  might  be  inert,  yet  germs  charged 
along  with  the  virus  remained  active,  causing  a  form 
of  irritation  somewhat  resembling  vaccine  vesicles, 
and  known  as  spurious  vaccination.  (3)  Glycerin 
would  not  destroy  the  extraneous  bacteria  in  lymph 
when  stored  at  or  below  the  freezing-point.  (4)  Con- 
tinued exposure  of  germs  to  low  temperature,  when 
constant,  did  not  destroy  their  activity  and  but  slightly 
decreased  their  number.  (5)  Hot,  and  especially 
variable,  temperatures  speedily  injured  vaccine.  (6) 
Hot  temperatures  increased  enormously  the  number  of 
germs  in  fluid  lymph  other  than  that  stored  in  glycerin. 

Newark's  Diphtheria  Antitoxin  Plant.^ —  Dr.  H. 
C.  H.  Hekold,  of  Newark,  N.  J.,  read  this  paper. 
Early  in  1895,  a  laboratory  for  bacteriological  research, 
with  an  attendant  plant  for  the  application  of  antitoxin 
for  diphtheria,  was  established  under  the  jurisdiction 
of  the  board  of  health  in  Newark.  This  department 
had  been  in  practical  operation  for  more  than  five 
years.  The  author  presented  the  results  of  the  experi- 
ment of  establishing  such  a  plant,  and  showed,  by 
statistics  of  greatly  reduced  mortality  from  diphtheria 
by  the  use  of  antitoxin,  that  it  was  one  of  the  best 
things  the  city  officials  and  medical  profession  of  that 
city  had  ever  undertaken. 

Presidential  Address. — This  was  delivered  by  Dr. 
Peter  H.  Brvce,  of  Toronto,  who  sketched  at  great 
length  the  progress  of  sanitary  science  from  its  birth 
in  the  period  of  the  Renaissance  down  to  the  present 
time,  and  declared  that  scientific  workers  ought  to  take 
courage  from  what  they  had  seen  accomplished  in  this 
century.  The  address  was  scholarly,  and  an  admirably 
compact  sanitary  digest. 

Report  of  the  Committee  on  Pollution  of  Water 
Supply. — This  was  presented  by  the  chairman,  Mr. 
George  VV.  Fuller,  of  New  Vork  City.  The  report 
took  the  form  of  records  and  summaries  showing  recent 
progress  in  the  more  important  branches  of  the  sub- 
ject. With  regard  to  quality,  the  water  supply  of  the 
future  should  meet  the  following  requirements:  It 
should  be  free,  or  substantially  free,  from  disease- 
producing  germs.  It  should  be  clear  and  colorless, 
containing  no  noticeable  turbidity  or  vegetable  stain. 
It  should  be  free  from  objectionable  tastes  and  odors, 
as  supplied  to  the  consumer.  It  should  be  free  from 
noticeable  amounts  of  dissolved  iron,  such  as  make  it 
unfit  for  household  use.  It  should  be  free  from  ex- 
cessive amounts  of  lime  and  magnesia,  such  as  make 
water  too  hard  for  ordinary  use.  It  should  be  care- 
fully examined  with  regard  to  constituents  capable 
of  dissolving  metals  used  in  distributing  pipes.  Of 
the  various  branches  of  public  works  connected  with 
the  pollution  of  water  supply,  there  was  none  in  which 
such  substantial  progress  had  recently  been  made  as 
in  water  purification.  Ten  years  ago  information 
upon  this  subject  was  very  meagre,  and  comparatively 
few  plants  were  in  operation.  During  this  period 
English  sand-filter  plants  had  been  increased  from 
about  1.5  to  10  acres,  with  respective  normal  capacities 
of  about  4,000,000  and  57,000,000  gallons  daily;  and 
the  American  or  mechanical  filter  plants  had  been  in- 
creased from  about  12,000  to  90,000  square  feet,  with 
respective  nominal  capacities  of  about  36,000.000  and 
270,000,000  gallons  daily.  Projected  plants  for  some 
of  the  largest  cities  in  the  country  show^ed  that  in  the 
next  few  years  there  would  be  very  rapid  development 
in  the  application  of  both  of  the  leading  methods  of 
purification.  Of  the  various  processes  for  the  purifica- 
tion of  water  supplies,  there  were  two  general  methods 
which    had    shown    distinctly    their    practicability — 


756 


MEDICAL    RECORD. 


[November  lo,  1900 


namely,  the  English  method  of  slow  sand  filtration, 
and  the  American  method,  employing  rapid  mechan- 
ical filters.  For  those  waters  which  never  possessed 
more  than  a  slight  or  moderate  amount  of  turbidity  or 
dissolved  vegetable  color,  the  English  method  was 
somewhat  more  efficient,  and  as  a  rule  it  was  slightly 
the  cjjeaper  for  such  waters.  For  those  waters  which 
for  long  periods  at  a  time  contained  excessive  ciuanti- 
ties  of  either  finely  divided  clay  or  of  dissolved  vege- 
table matter,  there  was  now  no  practicable  method  of 
purification  without  the  use  of  coagulants  and  subsid- 
ing basins.  While  coagulants  could  be  successfully 
used  in  connection  with  the  English  method  of  sand 
filtration,  the  American  method,  in  which  coagulants 
were  imperative,  yielded  somewhat  more  efficient  and 
economical  results,  as  a  rule. 

Teaching  of  Hygiene  and  Granting  of  Degrees  of 
Doctor  of  Public  Health — Dr.  Wvatt  Johnston,  of 
Montreal,  compared  methods  of  hygienic  instruction  in 
vogue  in  the  United  States  and  in  foreign  countries, 
with  the  result  that  the  showing  was  decidedly  favora- 
ble to  the  foreign  countries.  He  inveighed  strongly 
against  the  looseness  of  methods  in  this  country,  by 
which  men  were  able  to  secure  positions  as  health 
officers  or  as  members  of  boards  of  health  without 
having  the  necessary  qualification.  Dr.  Johnston 
urged  the  association  to  consider  this  matter  and  en- 
deavor to  arrive  at  some  standard  for  a  purely  hygienic 
education. 

Dr.  L.  p.  Jones,  of  Greenwich,  Conn.,  followed  Dr. 
Johnston,  and  outlined  the  following  scheme  for  pre- 
ventive medicine:  (i)  The  endowment  of  a  chair  of 
preventive  medicine  in  each  of  the  leading  medical 
colleges  of  the  country;  (2)  the  establishment  of  an 
institute,  the  members  of  which  should  be  the  incum- 
bents of  these  chairs;  (3)  an  award  of  prizes  by  this 
institute  for  essays  and  discoveries  of  special  merit  in 
sanitary  science;  (4)  establishment  of  fellowships  for 
a  limited  number  of  advanced  students. 

Disposal  of  Refuse  Material —  This  subject  was 
dwelt  upon  by  Mr.  Rudolph  Hering,  of  New  York 
City,  who  presented  a  report  in  which  he  mentioned 
the  methods  for  disposing  of  garbage  in  the  great  cit- 
ies of  the  world.  He  referred  to  the  progress  made  by 
European  cities  in  this  direction,  and  said  that  the 
present  status  of  the  disposal  of  garbage  and  refuse  had 
resolved  itself  largely  into  a  question  of  engineering. 

Dr.  Juan  Brena,  of  Zacatecas,  Mexico,  dealt  with 
the  vice  of  smoking  among  youth,  and  offered  sugges- 
tions as  to  the  means  of  overcoming  it. 

Report  of  the  CommiUee  on  Disinfection. — This 
was  presented  by  fROF.  F.  C.  Robinson,  of  Bruns- 
wick, Me.  F'rom  what  had  been  accomplished  in  this 
work,  the  following  conclusions  seemed  warrantable: 
(i)  Household  disinfection  after  infectious  diseases 
should  combine  the  use  of  formaldehyde  with  other 
means.  It  could  be  safely  relied  upon  for  all  exposed 
surfaces,  and  these  only.  (2)  Formaldehyde  required 
moisture  enough  in  the  air  nearly  to  saturate  it  for  its 
most  efficient  working.  (3)  There  was  much  disagree- 
ment among  experimenters  as  to  the  disinfection  of 
tuberculous  matter.  One  said  a  two-per-cent.  solu- 
tion of  formaldehyde  disinfected  it;  another,  tliat  even 
a  ten-per-cent.  solution  did  not.  Several  said  that 
formaldehyde  gas  applied  as  above  destroyed  it;  oth- 
ers denied  this.  Further  experiments  were  needed. 
(4)  Soap  was  a  poor  disinfectant,  but  one-per-cent. 
caustic  alkali  or  twenty-per-cent.  carbonate  of  alkali 
was  efficient.  (5)  Carbolic  acid,  less  than  a  five-per- 
cent, solution,  had  little  scientific  value.  (6)  The 
creosotes,  as  used  in  creolin,  lysol,  and  solutol,  were 
safe  disinfectants.  (7)  Alcohol  at  from  fifty  to  sev- 
enty-five per  cent,  had  considerable  disinfecting  power, 
but  not  at  other  strengths.  (8)  Most  metallic  salts, 
except  those  of  mercury,  had  little  disinfecting  action. 


(9)  Bichloride  of  mercury,  or  corrosive  sublimate, 
should  be  used  in  strength  at  least  5  :  1,000  if  tubercu- 
lous matter  was  to  be  disinfected.  A  fresh  solution 
was  more  active  than  one  which  had  stood  for  some 
weeks.  The  addition  of  salts  did  not  increase  the 
strength  of  a  fresh  solution,  but  prevented  it  from  los- 
ing its  strength  as  rapidly.  (10)  Bright  sunlight 
killed  the  tubercle  bacillus  in  a  few  hours,  and,  as  a 
rule,  pathogenic  bacteria  retained  their  greatest  viru- 
lence only  when  kept  in  the  dark. 

Dr.  Jesus  Chico,  of  Guanajuato,  Mex.,  gave  some 
hints  about  malaria  from  jjersonal  observations.  He 
said  he  did  not  think  the  mosquito  was  as  important 
a  causative  factor  in  distributing  malaria  as  had  been 
attributed  to  it,  but  in  Mexico  he  thought  the  inju- 
dicious use  of  tropical  fruits  played  an  important  role. 

Mis.s  Hester  McCi.ung,  of  Indianapolis,  recounted 
the  sanitary  work  of  women  in  that  city. 

Report  of  the  Committee  to  Define  What  Consti- 
tutes an  Epidemic. — This  was  read  by  the  chairman, 
Dr.  Benja.min  Lee,  of  Philadelphia.  In  the  minds  of 
the  public  at  large,  and  of  many  of  the  profession,  the 
word  epidemic  still  conveyed  an  idea  of  universal  at- 
mospheric contamination.  This  was  to  be  deplored, 
because  while,  on  the  one  hand,  its  use  inspired  an 
indefinable  horror  and  created  panic,  on  the  other 
hand  it  led  to  the  disregard  of  the  very  precautions 
which  were  of  essential  use  in  restricting  the  spread 
of  the  contagion — namely,  those  which  should  be 
taken  in  regard  to  the  person  and  the  excreta  of  the 
patient,  his  effects,  and  his  immediate  environment. 
In  view  of  changed  views  as  to  the  propagation  of 
communicable  diseases,  the  word  epidemic  had  out- 
grown its  usefulness.  It  had  become  the  means  of 
perpetuating  false  conceptions,  and  its  official  use 
might  be  misleading  and  mischievous.  Without  at- 
tempting any  stricter,  more  comprehensive,  or  more 
lucid  definition  of  this  word,  the  committee  recom- 
mended that,  as  opportunity  occurred,  in  all  laws  and 
regulations  in  which  certain  executive  action  was 
made  contingent  on  the  declaration  by  health  authori- 
ties of  the  existence  of  an  epidemic,  the  phraseology 
should  be  altered  by  omitting  the  word  epidemic,  and 
in  place  thereof  inserting  a  brief  statement  of  the  con- 
dition calling  for  such  action,  as,  for  example,  "when- 
ever a  communicable  disease  prevailed  to  such  an 
extent,  or  was  spreading  with  such  rapidity,  as  in  the 
opinion  of  the  board  to  make  it  its  duty  to  notify 
either  the  general  public  or  the  authorities  of  neigh- 
boring towns  of  the  fact  that  such  and  such  action 
should  be  taken."  The  report  of  the  committee  was 
adopted,  and  the  committee  discharged. 

Report  of  the  Committee  on  National  Leper 
Home. — Dr.  H.  M.  Bracken,  of  Minneapolis,  chair- 
man, presented  this  report.  The  committee  dealt  with 
the  desirability  of  establishing  national  leprosaria  in 
the  United  States.  The  records  of  Dr.  Bracken  for 
certain  States,  compared  with  those  of  Dr.  Hyde,  were 
as  follows: 

.**'tatr.  Dr.  Hyde.  Dr.  Bracken 

North  Dakota 3  2 

South  Dakota I 

Iowa 20  3 

Minnesota 120  61 

New   [ersev I  I 

Ohio  ," '. I 

Pennsylvania 6  6 

Wisconsin 20  7 

He  presumed  that  Dr.  Hyde's  figures  for  Iowa  and 
Wisconsin  were  estimated.  Probably  they  were  not 
too  high.  He  had  taken  only  those  cases  of  which  a 
history  could  be  given.  It  is  probable  that  the  one 
hundred  and  twenty  cases  credited  to  Minnesota  were 
taken  from  Dr.  Hansen's  report.  It  seemed  to  him 
that  this,  loo,  must  be  an  estimate.  If  there  were  one 
hundred  and  twenty  cases   in   Minnesota,  the  speaker 


November  lo,  1900] 


MEDICAL    RECORD. 


757 


could  not  understand  why  they  were  not  on  his  rec- 
ords. If  there  were  that  many  cases  in  188S,  the 
number  for  Minnesota  was  much  higher  than  he  had 
given,  for  many  of  the  cases  in  the  official  list  could 
not  have  possibly  belonged  to  Dr.  Hansen's  one  hun- 
dred and  twenty.  It  migiit  appear  from  the  report  of 
cases  in  the  Northwest  that  leprosy  was  far  more 
common  in  Minnesota  than  in  the  neighboring  State. 
He  could  see  no  reason  for  this  belief,  for  the  lepers 
in  this  district  were  among  the  immigrants  from  Nor- 
way, Sweden,  Iceland,  and  China.  These  people  had 
quite  a  representation  in  all  this  group  of  States.  He 
could  attribute  the  more  complete  returns  for  Min- 
nesota only  to  the  fact  (i)  that  there  had  been  less 
agitation  against  leprosy  in  this  than  in  some  of  the 
neighboring  States;  (2)  that  with  this  lack  of  agita- 
tion against  leprosy  physicians  reported  their  cases 
more  willingly  to  the  State  board  of  health,  which  had 
endeavored  during  the  last  twenty  years  to  palliate  the 
sufferings  of  this  unfortunate  class;  (3)  that  Minne- 
sota was  fortunate  in  having  among  its  physicians 
men  who  were  familiar  with  leprosy,  and  who  were  in- 
terested in  philanthropic  work,  and  these  physicians 
had  given  material  aid  to  the  State  autliorities  engaged 
in  securing  a  list  of  all  lepers  in  Minnesota.  Several 
lepers  in  the  Minnesota  list  gave  the  history  of  a  pre- 
vious residence  in  Wisconsin,  but  tlieir  names  in  not 
a  single  instance  appeared  upon  the  Wisconsin  records. 
Of  the  thirty-seven  living  lepers  known  to  be  resident 
in  the  Northwest,  seventeen  only  were  in  Minnesota, 
and  there  was  a  strong  possibility  of  two  of  these  being 
dead,  but  he  had  no  positive  knowledge  of  the  fact. 
He  did  not  dwell  upon  these  facts  as  an  alarmist,  but 
simply  reminded  the  association  that  leprosy  had 
existed,  did  exist,  and  would  continue  to  exist  for  years 
to  come  in  all  three  countries  represented  in  the  asso- 
ciation. 

Establishment  of  Leprosaria. — A  leprosarium 
should  afford  a  comfortable  home  for  lepers.  This 
meant  not  only  good  buildings,  but  extensive  grounds 
comprising  many  acres,  where  the  lepers  might  have 
liberties  and  still  be  in  exclusion.  The  buildings 
connected  with  the  leprosarium  must  combine  the 
privileges  of  a  home  and  of  a  hospital.  Those  who 
had  the  disease  in  mild  form  might  need  little  if  any 
medical  care.  They  needed  comfortable  clothing  and 
good  food.  With  those  in  whom  the  disease  was  more 
advanced,  the  care  should  be  that  of  a  iiospital  patient, 
with  medicines  to  lessen  their  suffering  and  dressings 
that  would  commend  themselves  to  any  surgeon.  A 
leprosarium  should  resemble  modern  colonies  for  epi- 
leptics. It  should  furnish  employment  for  those  who 
were  able  to  work,  and  amusement  of  various  kinds 
for  all.  Two  of  the  strongest  medical  societies  in 
Minnesota  had  placed  themselves  on  record  as  favor- 
ing the  establishment  of  national  leprosaria;  and  the 
American  Dermatological  Association  had  also  ap- 
pointed a  committee  to  determine  the  best  methods  to 
be  used  in  the  care  of  lepers. 

By  resolution  the  association  placed  itself  on  record 
as  favorable  to  the  establishment  of  national  lepro- 
saria. 

Dr.  John  H.  S.  Fulton,  of  Baltimore,  described  a 
suitable  dress  for  defence  against  infectious  diseases. 

Mr.  F.  H.  Newell,  government  hydrographer,  con- 
tributed a  paper  showing  some  results  of  the  investiga- 
tion of  stream  pollution,  which  had  been  made  by  the 
United  States  geological  survey.  The  government, 
realizing  the  importance  of  public  water  supplies  and 
their  conservation  and  protection  against  pollution, 
had  established  a  special  division  under  the  title  of 
board  of  hydrography. 

Report  of  the  Committee  on  Animal  Diseases 
and  Animal  Food. — This  was  read  by  Dr.  D.  E.  S.\l- 
MON.  of  Washington,  D.  C,  chairman.     He  urged  the 


importance  of  careful  observations  being  made  of 
glanders,  in  view  of  the  fact  that  serum  for  use  in  the 
treatment  of  many  human  ailments  was  obtained  from 
horses.  Army  horses  were  peculiarly  liable  to  con- 
tract the  disease  in  time  of  war,  on  account  of  the  ex- 
tra exertion  and  frequent  lack  of  full  rations  during 
such  periods.  He  roundly  condemned  the  careless- 
ness of  the  United  States  government  in  the  matter  of 
providing  skilled  and  trained  veterinarians  in  the 
army.  He  discussed  the  subject  of  hydrophobia,  and 
emphasized  the  importance  of  active  measures  looking 
to  the  extermination  of  this  disease,  lie  cited  statis- 
tics of  many  outbreaks  of  rabies,  and  showed  the  dis- 
ease to  be  peculiarly  virulent  and  almost  invariably 
fatal  to  human  beings.  Misguided  people,  who  de- 
clared that  there  was  no  such  thing  as  hydrophobia 
communicated  to  man  from  animals,  were  sternly  re- 
buked. Dr.  Salmon  declared  that  their  obstructive 
tactics  had  wrought  incalculable  harm  in  the  way  of 
deceiving  people  into  a  careless  attitude  toward  this 
malevolent  disease.  The  Pasteur  treatment  was  high- 
ly commended  by  the  committee,  which  also  recom- 
mended that  the  association  take  steps  to  enlighten 
the  public  on  the  disease  and  its  treatment,  as  well  as 
means  for  its  prevention. 

Tuberculosis — The  committee  made  strong  recom- 
mendations on  the  subject  of  tuberculosis,  asserting 
its  belief  in  the  theory  that  the  disease  could  be  and 
was  communicated  from  infected  cows  through  their 
milk.  Here  also  the  committee  encountered  learned 
men  who  controverted  the  theory,  asserting  that  the  dif- 
ference in  appearance  of  the  bacillus  of  human  tuber- 
culosis and  that  of  bovine  indicated  that  the  latter 
could  not  communicate  the  disease  to  human  beings. 
Bovine  tuberculosis  was  undoubtedly  communicable. 
He  inveighed  against  loose  methods  prevailing  in 
many  creameries,  by  which  the  milk  received  from  an 
infected  herd  was  mixed  with  the  general  supply  of 
milk  on  hand;  and,  further,  the  practice  of  distribut- 
ing, without  previous  sterilization,  the  waste  milk 
and  cream  to  be  used  as  food  for  swine  was  con- 
demned. 

President  Bryce  added  a  few  terse,  vigorous  utter- 
ances on  the  subject  of  the  care  which  ought  to  be 
employed  in  dairies  to  guard  against  the  distribution 
of  milk  infected  with  tubercle  bacilli. 

Dr.  R.  M.  Woodward,  of  Washington,  D.  C,  gave 
a  re'sume  of  the  recent  foreign  work  of  the  Marine- 
Hospital  service. 

Dr.  F.  F.  Westbrook,  of  Minneapolis,  reported  on 
behalf  of  the  committe  on  transportation  of  diseased 
tissue  by  mail,  recommending  that  nose  and  throat 
specimens  be  included  in  one  package. 

Dr.  Cressv  L.  Wilhur,  of  Lansing,  Mich.,  presented 
the  report  of  the  committee  on  demography  and  statis- 
tics in  their  sanitary  relations.  He  mentioned  the 
progress  that  had  been  made  in  matters  relating  to 
vital  statistics  concerning  which  the  association  had 
acted  in  the  past.  He  urged  the  association  to  stand 
for  united  and  determined  action  in  elevating  the 
standard  of  registration  laws  in  this  country,  and  in 
insuring  the  practical  success  of  new  laws  when  en- 
acted. 

The  following  resolutions  were  introduced,  dis- 
cussed, and  adopted : 

1.  Kesohcd,  That  the  association,  recognizing  the 
benefits  of  medical  school  inspection,  heartily  ap- 
proves the  efforts  of  boards  of  health  and  of  education 
directed  toward  the  establishment  of  systems  of  inspec- 
tion.     (Offered  by  Dr.  Adolph  Gehrmann.) 

2.  Resolved,  That  the  association  approves  of  and 
encourages  all  efforts  made  by  governments,  whether 
national,  state,  or  municipal,  for  the  limitation  of 
pollution  of  streams.     (Offered  by  Mr.  C.  Monjeau.) 

3.  Resolved,   That    a   committee   of   three    be   ap- 


758 


MEDICAL    RECORD. 


[November  lo,  1900 


pointed,  to  be  known  as  the  committee  on  uniform 
municipal  statistics,  to  take  such  steps  as  may  seem 
practicable  toward  securing  greater  uniformity  in  all 
branches  of  municipal  accounts,  reports,  and  statis- 
tics, and  particularly  those  branches  relating  to  vital 
and  sanitary  statistics;  said  committee  to  have  power 
to  confer  with  similar  committees  from  other  societies 
already  or  hereafter  appointed  to  the  same  general 
end,  and  to  report  at  the  next  meeting  of  the  associ- 
ation.    (Offered  by  Dr.  Leal,  of  Paterson,  N.  J.) 

Election  of   Officers The  following  officers  were 

elected  for  the  ensuing  year:  President,  Dr.  Benjamin 
Lee,  of  Philadelphia;  First  Vice-President,  Mr.  Ru- 
dolph Hering,  of  New  York  City;  Second  Vice-Presi- 
dent, Dr.  J.  N.  Hurty,  of  Indianapolis,  Ind. ;  Secretary, 
Dr.  Charles  O.  Probst,  of  Columbus,  Ohio;  Treasurer, 
Dr.  Henry  D.  Holton,  of  Brattleboro,  Vt. 

Buffalo  was  selected  as  the  place  for  holding  the 
ne.xt  annual  meeting.  The  e.xecutive  committee  re- 
commended that  the  time  be  fixed  during  the  third  week 
in  September,  1901. 


THE   MEDICAL   SOCIETY   OF   THE   COUNTY 
OF    NEW    YORK. 

Annual  Meeting,  October  22,  igoo. 
George  B.  Fowler,  M.D.,  President. 

Officers  Elected. — President,  Dr.  George  B.  Fowler; 
first  Vice-President,  Dr.  Charles  N.  Dowd ;  Second 
Vice-President,  Dr.  Irving  S.  Haynes;  Secretary,  Dr. 
John  Van  Doren  Young;  Assistant  Secretary,  Dr.  Fred 
P.  Solley ;  Treasurer,  Dr.  John  S.  Warren ;  Censors, 
Drs.  Frank  Van  Fleet,  Henry  S.  Stearns,  Wendell  C. 
Phillips,  Robert  Lewis,  and  Louis  A.  Rodenstein. 

Report  of  Committee  on  Hygiene.  — Dr.  Henry 
DwiGHT  Chapin,  the  chairman  of  this  committee, 
presented  a  long  and  carefully  prepared  report.  After 
quoting  figures  to  show  that  there  had  been  a  tendency 
to  a  lower  death  rate  in  New  York  City  in  the  past 
few  years,  probably  as  a  result  of  the  subsidence  of 
epidemic  influenza,  and  of  a  more  careful  oversight  of 
the  water  and  milk  supplies,  he  took  up  at  some  length 
the  question  of  the  water  supply  as  having  a  most  im- 
portant bearing  on  the  health  of  the  city.  He  said 
that  it  was  a  matter  of  grave  concern  to  sanitarians 
that  the  water  supply  of  Greater  New  York  was  not 
keeping  pace  with  the  growth  in  population.  The 
Merchants'  Association  of  New  York  deserved  the 
thanks  of  all  good  citizens  for  its  exhaustive  and 
costly  study  of  this  matter.  The  boroughs  of  Man- 
hattan and  the  Bronx  were  at  present  supplied  from 
the  Croton,  Bronx,  and  Byram  watersheds.  All  of 
the  water  for  the  borough  of  Manhattan  and  nearly  all 
for  the  Bronx  was  furnished  by  the  city.  In  the 
borough  of  Brooklyn  all  but  about  seven  per  cent,  was 
furnished  by  the  city.  The  borough  of  Queens  was  sup- 
plied by  wells,  of  which  about  thirty  per  cent,  only 
were  owned  by  the  city.  The  borough  of  Riciimond 
was  supplied  by  wells  on  Staten  Island,  and  had  prac- 
tically no  municipal  supply.  Forty-five  per  cent,  of 
the  city's  supply  was  pumped,  and  the  rest  was 
delivered  by  gravity.  In  1899  the  average  daily  con- 
sumption in  all  the  boroughs  was  371,778,000  gallons, 
or  an  estimated  daily  consumption  per  capita  of  103 
gallons.  The  quantity  directly  available  for  the 
boroughs  of  Manhattan  and  the  Bronx  was  about 
290,000,000  gallons  per  day.  In  Brooklyn  and  Queens 
the  consumption  was  nearly  equal  to  the  average  avail- 
able supply,  or  1 1 C), 000,000  gallons  daily.  The  pres- 
ent daily  supply  of  about  5,000,000  gallons  in  the 
borough  of  Riciimond  could  not  be  greatly  augmented 
without  going  outside  the  limits  of  that  borough.  It 
had  been  estimated  that  the  consumption  of  water  in 


1903  would  nearly  equal  the  supply  to  the  boroughs 
of  Manhattan  and  Bronx  at  that  time  available  under 
present  methods.  The  engineers  employed  by  the 
Merchants'  Association  had  estimated  that  the  total 
daily  waste  was  nearly  150,000,000  gallons,  the  larger 
part  of  which  was  underground.  Most  of  this  waste 
could  be  avoided  by  putting  the  water  mains  in  sub- 
ways. If  this  amount  could  be  saved  the  present 
water  supply  would  be  adequate  until  1910.  It  would 
take  most  of  the  time  between  now  and  that  date  to 
secure  the  requisite  additional  water  supply;  hence 
the  necessity  for  its  immediate  consideration.  Of  the 
various  schemes  which  had  been  proposed,  the  best 
seemed  to  be  that  of  taking  the  water  from  the  Hudson 
River  above  Poughkeepsie.  All  the  water  that  New 
York  City  would  be  likely  to  need  until  its  popula- 
tion should  have  reached  18,000,000  could  be  secured 
in  this  way.  The  plan  comprised  the  building  of 
pumping-stations  and  filter-beds  on  the  east  side  of  the 
river,  and  an  aqueduct  from  Poughkeepsie  to  the 
northern  limits  of  the  city,  and  of  a  reservoir  near  the 
northern  limits.  The  experience  of  many  other  cities 
had  proved  beyond  all  question  that  artificial  filtra- 
tion, which  was  after  all  only  an  imitation  of  nature's 
process  of  converting  surface  water  into  spring  water, 
was  capable  of  freeing  even  highly  polluted  water 
from  all  dangerous  organisms.  The  report  closed  by 
strongly  advising  that  this  additional  water  supply  be 
placed  under  municipal  management  and  control,  as 
experience  had  shown  that  the  cost  to  the  consumer 
was  almost  always  much  less  under  public  than  under 
private  ownership. 

A  New  Gynaecological  Syringe Dr.  C.  A.  Buck- 

LiN  exhibited  a  new  gyncecological  syringe,  one  of  that 
class  which  had  for  its  object  the  closing  of  the  vaginal 
orifice,  thus  enabling  a  douche  to  be  taken  without 
the  use  of  a  bed-pan. 


NEW    YORK    COUNTY    MEDICAL    ASSOCIA- 
TION. 

Stated  Meeting,  October  j-j,  igoo. 
Parker  Syms,  M.D.,  President. 

An  Improved  Apparatus  for  the  Administration  of 
Gas  and  Ether. — Dr.  S.  Ormond  Goldan  exhibited 
this  apparatus.  A  simple  valve  device  allowed  the 
breathing  of  air  or  gas  as  desired.  The  patient 
breathed  back  and  forth  into  a  very  thin  rubber  bag 
holding  about  two  gallons  of  gas.  The  inhaler  was 
made  of  celluloid  preferably.  For  ether  inhalation, 
an  ether  chamber  was  slipped  on  between  the  valve 
and  the  face-piece.  After  breathing  a  few  times  into 
the  gas  bag,  the  ether  was  very  gradually  turned  on. 
By  this  method  all  struggling  was  avoided  and  anaes- 
thesia was  quickly  induced.  The  ether  chamber  could 
be  used  not  only  for  fluid  ether,  but  with  a  piece  of 
gauze.  P'or  ether  alone  the  etiier  chamber  was  simply 
attached  to  the  face-piece,  and  the  rubber  bag  added. 

New  Instruments. — Dr.  E.  D.  Ferguson,  of  Troy, 
exhibited  a  grooved  director  for  use  in  vaginal  hyster- 
ectomy, and  a  forceps  for  lifting  the  uterus  in  the 
operation  of  ventral  suspension.  The  director  was  in- 
tended to  be  passed  behind  the  broad  ligament  so  as 
to  bring  into  full  view  of  the  operator  the  lateral 
tissues  to  be  incised.  The  other  instrument  was  in- 
tended to  bring  the  uterus  into  the  field  of  operation 
in  ventral  suspension.  It  was  particularly  useful  in 
stout  women  who  took  ether  badly.  The  instrument 
had  acted  well  in  practice,  never  having  produced  a 
visible  abrasion  of  the  uterus. 

Address  of  the  Retiring  President:  "The  Need 
of  Better  Organization  in  the  Profession." — Dr.  F. 
H.  WiGGiN,  on  retiring  from  the  office  of  president, 


November  lo,  1900] 


MEDICAL   RECORD. 


759 


called  attention  to  the  fact  that  during  his  administra- 
tion many  important  changes  had  occurred — e.g.,  the 
change  of  the  place  of  meeting  to  the  Academy  of 
Medicine.  The  most  important  change,  aside  from 
the  advance  in  the  regular  scientific  work,  was  the 
merging  of  the  Association  into  the  New  York  State 
Medical  Association  as  a  subordinate  county  associa- 
tion. This  movement  was  significant,  and  indicated 
the  trend  of  the  age  and  the  reaching  out  of  the  pro- 
fession for  something  better  in  the  way  of  State  organ- 
ization. It  had  been  said  by  some  that  there  was  no 
demand  for  an  organization  that  would  prevent  its 
members  from  being  the  victims  of  unjust  suits  for 
malpractice,  but  he  knew  positively,  from  personal 
contact  with  many  physicians,  that  they  did  want  it. 
For  a  long  time  to  come  there  would  be  in  many 
parts  of  tiie  State  very  small  county  organizations, 
which  would  not  have  enough  money  to  defend  their 
members  against  unjust  suits.  A  large  and  well- 
organized  State  association  would  be  in  a  far  better 
position  to  take  up  such  a  fight.  An  organization 
which  was  managed  from  entirely  selfish  interests  he 
did  not  believe  could  succeed  any  more  than  an  in- 
dividual who  thought  of  himself  only  could  succeed. 
It  was  a  most  unfortunate  fact  that  the  general  public 
had  very  little  respect  for  the  medical  profession,  and 
unless  this  profession  was  willing  to  fight  for  its  own 
rights  and  look  beyond  selfish  ends  of  individuals,  the 
public  would  continue  to  esteem  them  lightly.  Our 
legislators  appreciated  thoroughly  the  value  and  in- 
fluence of  organization,  and  while  they  would  not 
listen  to  individuals  they  were  ready  to  give  serious 
consideration  to  petitions  and  propositions  coming 
from  an  organized  body  having  a  membership  of  sev- 
eral thousand.  We  had  been  very  blind,  the  speaker 
said,  all  these  years,  and  had  allowed  ourselves  to  be 
trodden  down  largely  through  our  own  selfish  indiffer- 
ence. An  excellent  example  of  this  was  found  in  the 
cry  that  had  been  raised  against  the  taxing  of  certain 
small  counties  in  order  better  to  protect  the  rights  of 
those  living  elsewhere. 

Inaugural  Address  of  the  President,  Dr.  Parker 
Syms.^DR.  Sv.ms,  on  assuming  the  chair,  declared 
emphatically  that  the  rapid  onward  strides  which  had 
placed  the  association  in  its  present  high  position 
had  been  initiated  and  carried  to  a  successful  conclu- 
sion chiefly  through  the  untiring  energy  of  his  prede- 
cessor in  office.  Dr.  Syms  then  spoke  of  the  possi- 
bilities of  the  future,  and  particularly  of  the  crying 
need  of  improving  the  status  of  the  medical  profession. 
He  sketched  what  he  considered  an  ideal  medical 
fraternity,  and  claimed  that  this  idea  could  be  realized 
by  advancing  along  the  line  proposed  by  the  com- 
mittee on  reorganization  of  the  New  \'ork  State 
Medical  Association.  Such  an  association  must  at 
tend  not  only  to  its  own  members,  but  must  look  after 
the  welfare  of  the  public  and  zealously  guard  the 
public  health.  His  address  was  fittingly  summed  up 
in  the  closing  words  of  advice:  "Honor  the  profes- 
sion, and  you  will  honor  yourselves."' 

In  Memoriam  Dr.  Lewis  Albert  Sayre. — Dr. 
John  Shr.'vdv  delivered  this  address,  which  was  sup- 
plemented by  remarks  by  Drs.  Gouleyand  J.  D.  Bryant. 

In  Memoriam  Dr.  Samuel  Smith  Purple. — Dr. 
J.  W.  S.  Gofi.KY  delivered  this  address. 

Testimonial  to  Dr.  Wiggin.  —  Immediately  after 
adjournment  of  the  association,  a  handsome  loving- 
cup  was  presented  to  Dr.  Wiggin  as  a  token  of  appre- 
ciation of  the  work  that  he  had  done  for  the  associa- 
tion while  acting  as  its  presiding  officer. 


^cdical  Jtetns. 

Contagious   Diseases — Weekly    Statement Report 

of  cases  and  deaths  from  contagious  diseases  reported 
to  the  Sanitary  Bureau,  Health  Department,  for  the 
week  ending  November  3,  1900: 


Tuberculosis 

Typhoid  fever 

Scarlet  fever 

Measles 

Diphtheria 

Laryngeal  diphtheria  (croup) 
Cerebro-spinal  meningitis. . . . 


Caies. 


Deaths. 


«i5 

131 

105 

23 

lOI 

0 

47 

I 

215 

25 

II 

4 

0 

2 

Cancer.  — Professor  Czerny  estimates  that  about 
seventy-five  per  cent,  of  known  cases  of  cancer  are  in- 
operable, and  that  in  Germany  forty  thousand  patients 
die  yearly  of  the  disease. 


Medical  Graduation  of  Women. — By  a  recent  de- 
cision of  the  (iernian  Federal  Council  female  medical 
students  are  entitled  lo  be  admitted  to  the  State  ex- 
aminations in  medicine,  even  if  they  have  passed  their 
preliminary  examinations  and  received  their  medical 
education  in  Switzerland.  As  the  State  examinations 
in  medicine  begin  in  November,  the  medical  men  of 
Germany  will  very  soon  have  the  opportunity  of  meet- 
ing female  practitioners,  the  number  of  German  female 
students  in  Switzerland  being  rather  considerable. 
Those  ladies  also  who  have  already  settled  in  Ger-« 
many  with  Swiss  diplomas  will  now  be  in  a  position 
to  take  German  qualifications  by  passing  State  exam- 
ination, without  being  forced  to  begin  their  curriculum 
again.  The  present  favorable  disposition  of  the  gov- 
ernment toward  medical  women  has  led  to  the  rather 
absurd  situation  that  female  medical  students  enjoy 
privileges  as  to  study  abroad  which  are  refused  to  the 
male  sex. — Lancet. 

The  Effect  of   Modern  Education   upon  Children. 

— The  stress  of  modern  education  has  enormously 
taxed  the  brains  of  children  by  the  multiplicity  of 
studies.  Children  cannot  assimilate  the  ideas  in 
widely  differing  department  of  knowledge  at  one  and 
the  same  time.  The  effort  to  do  so  deranges  in  many 
instances  the  entire  nervous  system  of  the  child.  The 
so-called  nervous  child  is  not  only  not  normal,  but 
may  be  the  victim  of  the  education  methods  of  the 
present  day.  The  examination  system  is  often  a  hor- 
ror to  such  a  child,  as  the  writer  knows  from  his  own 
experience.  The  studies  required  of  a  growing  child 
should  never  be  allowed  to  disturb  the  health  or  inter- 
fere with  proper  rest  and  exercise.  The  modern  city 
child  seems  to  be  unable  to  endure  the  burdens  of 
civilized  life  as  easily  as  did  the  children  of  the  past, 
who  were  brought  up  in  the  country  and  spent  the 
greater  part  of  the  time  in  the  fresh  open  air. 
Whether  our  fathers  were  more  hardy  and  robust  as 
children  than  the  progeny  of  the  present  generation 
may  be  an  open  question,  but  certainly  the  conditions 
of  civilized  life  have  so  completely  changed  that  at 
the  present  day  mental  and  physical  education  possess 
equal  importance  for  the  growing  child.  The  mind 
of  the  child  to-day  is  too  often  developed  at  the  ex- 
pense of  its  vitality  and  health. — W.  M.  D'Aubign£ 
Cahart,  M.D. 

Veterinary  Surgeons   in    the    Army — The   New 

York  Sunday  Trihuiie  contains  a  readable  article  on 
the  importance  of  the  animal  branch  of  the  medical 
profession.  After  referring  to  the  consideration  with 
which  the  veterinary  surgeon  is  treated  in  Great  Brit- 
ain, as  recently  evidenced  by  the  widespread  expres- 
sions of  regret  called  forth  from  all  sides  at  the  death 
of  Sir  Henry  Simpson,  veterinary-surgeon-in-chief  to 
the  Queen,  and  by  the  bestowal  of  commissions  on  the 
British  army  veterinary  surgeons,  the  article  calls  at- 


76o 


MEDICAL    RECORD. 


[November  lo,  1900 


tention  to  the  fact  that  no  commission  is  given  to  the 
veterinary  surgons  in  the  United  States  army.  In  fact, 
in  England  and  the  rest  of  Europe  military  veterinary 
surgeons  are  really  officers,  while  surgeons  are  not. 
The  latter  are  protected  in  the  field  by  the  Geneva 
Red  Cross  and  considered  as  non-belligerents,  the 
"vets"  being  regarded  as  full-fledged  combatants,  as 
much  so  as  any  other  regimental  or  staff  officers,  run- 
ning, therefore,  the  same  risk  of  capture,  imprison- 
ment, or  death  at  the  hands  of  the  enemy. 

Should  Consumptives  Marry  ? — Mr.  Edmund 
Owen,  M.B.,  London,  in  the  course  of  an  address  de- 
livered before  the  Canadian  Medical  Association  at 
Ottawa,  spoke  of  the  above  subject  as  follows  :  "  The 
extermination  treatment  of  tuberculosis  is  a  subject 
in  which  every  member  of  the  community  should  be 
encouraged  to  take  a  personal  and  intelligent  interest. 
It  is  a  great  mistake  to  allow  it  to  be  regarded  merely 
'  a  doctor's  question  '  and  to  wage  a  successful  war  of 
extermination  the  attack  should  be  begun  right  early. 
It  is  a  question  which  is  of  vital  importance  for  the 
nursery,  the  school-room,  the  dwelling-house,  the  store, 
the  office,  the  barrack,  in  fact  it  concerns  every  depart- 
ment and  every  period  of  life.  The  disease  is  every- 
where, and  its  eradication  is,  therefore,  a  matter  of 
concern  to  every  one.  It  has  not  yet  been  shown  that 
the  offspring  of  tuberculous  parents  are  born  actually 
tuberculous,  but  it  is  beyond  question  that  they  are 
very  prone  to  inherit  a  peculiar  physical  condition 
which  renders  their  tissues  an  easy  prey  to  the  germs 
of  the  disease.  The  family  history  of  many  patients 
who,  at  the  threshold  of  life,  become  the  subjects  of 
enlarged  glands  or  of  chronic  affections  of  the  bones 
or  joints,  gives  incontrovertible  evidence  of  there  be- 
ing a  marked  hereditary  disposition  in  the  matter  of 
tuberculosis.  So  comes  the  question,  Ought  there  to 
be  a  law  preventing  those  who  are  undoubtedly  tuber- 
culous taking  upon  themselves  the  responsibility  of 
parentage?  There  are  some  who  would  answer  this 
affirmatively  and  without  hesitation.  But  what  would 
the  church  in  general  say  to  it,  and  what  would  the 
tuberculous  minister  in  particular  say  to  it?  He 
would  tell  us  that  he  reads  in  the  very  beginning  of 
his  book  that  he  is  to  be  '  fruitful  and  multiply,'  and 
to  do  him  justice  it  must  be  admitted  that  in  England, 
at  any  rate,  he  does  his  best  to  carry  out  this  instruction 
to  the  very  letter.  But  let  him  finish  his  injunction, 
man  was  to  be  fruitful  that  he  might  replenish  the 
earth.  Now,  though  I  do  not  claim  to  be  in  posses- 
sion of  peculiar  knowledge  on  this  point,  I  cannot 
think  that  the  architect  of  the  universe  who  '  saw 
everything  that  he  had  made  and  behold  it  was  very 
good'  could  have  desired  that  this  beautiful  world  was 
eventually  to  be  stocked  with  so  large  a  proportion  of 
tuberculous  rubbish.  I  am  fully  conscious  of  the  fact 
that  I  am  advancing  a  somewhat  extreme  view,  but 
surely  the  subject  enters  very  largely  into  the  question 
of  prophylaxis.  It  is  one,  moreover,  that  will  have  to 
be  deliberately  approached  and  dealt  with  some  day 
and  that  perhaps  soon." 

Can  Life  be  Restored  in  Cases  of  Death  from 
Suffocation,  Chloroform  -  Poisoning,  or  Electric 
Shock  ?--In  a  paper  by  Dr.  Prus  (translation  of  which 
is  by  L.  Freyberger)  are  detailed  some  experimental 
results  of  Dr.  Prus  on  attempting  to  restore  dogs  par- 
tially killed  as  indicated  in  the  title.  In  cases  of 
suffocation  the  supply  of  air  to  the  animal  was  shut 
off  by  clamping  an  India-rubber  tube  connecting  the 
tracheotomy  cannula  with  an  apparatus  for  artificial 
respiration.  As  soon  as  possible  after  the  death  of  the 
animals  some  of  the  rib  cartilages  in  front  of  the  heart 
were  removed,  the  pericardial  sac  was  incised,  and 
the  heart  exposed.     After  it  had  been  ascertained  that 


there  was  no  trace  of  any  contraction  of  either  auricles 
or  ventricles,  Professor  Prus  waited  from  fifteen  to 
sixty  minutes  before  he  began  his  efforts  at  resuscita- 
tion. After  removal  of  the  clamp  artificial  respiration 
was  started.  The  heart  was  then  grasped  in  the  right 
hand  in  such  a  manner  that  the  thumb  rested  on  the 
right  ventricle,  and  the  four  fingers  surrounded  the 
left  ventricle.  Both  ventricles  were  now  compressed 
with  moderate  force,  the  compressions  being  made  to 
imitate,  as  much  as  possible,  the  systolic  and  diastolic 
phases  of  the  heart  action.  The  interval  between  the 
stoppage  of  the  action  of  the  heart  and  respiration- — 
in  other  words,  the  death  of  the  animal — and  the  be- 
ginning of  the  direct  massage  of  the  heart  varied  in 
different  cases  from  one  minute  to  one  hour.  In  thirty- 
one  cases,  or  seventy  per  cent.,  life  was  restored.  In 
chloroformed  dogs  under  the  same  general  conditions 
seventy-six  per  cent.,  and  in  dogs  shocked  by  the  elec- 
tric current  fourteen  per  cent.,  were  brought  to  life 
again.  An  attempt  to  try  the  massaging  of  the  heart 
was  made  on  the  body  of  an  alcoholic  who  had  com- 
mitted suicide  by  hanging,  but  resulted  fruitlessly. — 
Treatment,  October,  1900. 

Cases  Simulating  Glandular  Fever. — J.  P.  Crozer 

Griffith  says  that  in  the  minds  of  many  physicians  it 
is  far  from  settled  whether  or  no  glandular  fever  exists 
as  an  entity.  Epidemics  have  been  reported  which 
seem  to  prove  that  it  does;  but,  on  the  other  hand, 
cases  are  met  with  which  for  nearly  every  reason  might 
be  called  instances  of  this  disease,  but  in  which  a  more 
careful  consideration  points  to  the  glandular  enlarge- 
ment being  of  an  entirely  secondary  nature.  The 
author  reports  three  illustrative  cases,  in  which  he 
considers  the  disease  to  have  been  due  to  influenza. — 
University  Medieal  Magazine,  October,  1900. 

Health  Reports. — The  following  cases  of  smallpox, 
yellow  fever,  cholera,  and  plague  have  been  reported 
to  the  surgeon-general  of  the  United  States  Marine- 
Hospital  service  during  the  week  ended  November  2, 
T900 : 


Smallpox— United  States, 


Cases.    Deaths. 


Colorado,  Arapahoe  Co October  loth  to  13th 2 

Costilla  Co October  15th i 

Ouray  Co October  9th  to  t6th lo 

Wild  Co September  1st  to  30th 2 

Indiana,  Indianapolis (Jctobcr  20th i 

Kentucl<y,  Lexington October  27th 2 

Michigan,  Detroit October  20th  to  27th i 

Delta  Co October  14th  to  20th i 

Maple       River 

Township October  14th  to  20th 21 

N.  Hampshire,  Manchester.  .October  27th i 

Ohio,  Cleveland October  20th  to  27th 27 

Utah,  Salt  Lake  City October  20th  to  27th 9 

Smallpox — Foreign. 

Austria.  Trieste October  6lh  to  13th i 

Bohemia,  Prague October  6th  to  13th 5 

England,  Liverjjool October  6th  to  13th 3 

London October  6th  to  I3lh 1 

France,  Paris October  6lh  to  13th 

German^-,  Sniingcn October  1st  to  7tn 1 

India,  Karachi September  23d  to  30th 1 

Mexico,  Mexico October  7th  to  14th 3 

Russia,  Moscow September  agth  to  October  6th  . .  3 

Odessa October  6th  to  13th 17 

St.  Petersburg  September  2Qth  to  October  13th.  i8 

Warsaw September  2Qth  to  October  6th . . 

Yellow  Fever. 

Cuba.  Havana October  i.st  to  27th 273 

Mexico October  7th  to  2ist 4 

Cholera. 

India,  Bombay  .. .    September  a6th  to  October  2d 

Karachi September  17th  to  23d 4 

Plague — United  States. 
California,  San  Francisco. .  .October  14th 


67 


54 
3 


Pl-AGt'K— FOKEICN    AND    InSLj'LAR. 

China,  Hong  Kong September  ist  to  8th 4 

India.  Hombay Septtrnibcr  36th  ti»  (!)clober  ad 

fai>an,  ( >saka Sepicmber  nth  to  39th 26 

Slad.ijciiscar,  Tamatavi- October  16th • 

HIiilippinL'  Island-s  Manila  .  .September  Ttli  to  15th i 

Scotland,  (llasgow October  i.ith  to  iqtn 14 

West  Australia,  Perth April  7th  to  August  nth 6 

♦  Reported  present. 


Medical  Record 

A    J^Veekly  younial  of  Medicine  and  Surgery 


Vol.  58,  No.  20. 
Whole  No.  1567. 


New  York,  November   17,  1900. 


$5.00  Per  Annum. 
Single  Copies,  loc. 


©riginat  ^rtictcs. 

DIFFERENTIAL     DIAGNOSIS     IN     DISEASES 
OF   THE   GALL    BLADDER    AND    DUCTS.' 

By   GEORGE    EMERSOX    BREWER,    M.D., 


JUNIOR  SURGEON  TO  ROOSEVELT  HOSPITAL  ;  ATTBHDIHC  SURGEON  TO  THE 
CITV  HOSPITAL;  INSTRCCTOR  IN  SURGERY,  COLLBQE  OF  PHYSICIANS  AND 
SURGEONS. 

With  the  possible  exception  of  appendicitis,  no  sub- 
ject during  the  past  decade  has  received  more  atten- 
tion from  surgeons  than  diseases  of  the  gall  bladder 
and  ducts. 

If  one  refers  to  the  standard  surgical  text-books  of 
twenty  years  ago,  there  will  be  found  practically  no 
reference  to  tlie  subject;  the  combined  space  allotted 
to  these  conditions  in  the  works  of  Holmes,  Bryant, 
Erichsen,  and  Ashhurst  being  less  than  thirty  lines. 
In  the  treatises  upon  general  medicine  of  the  same 
period  the  subject  is  but  briefly  discussed,  the  classi- 
fication made  of  catarrhal  jaundice,  gall  stones,  and 
cancer,  and  the  treatment  limited  to  morphine,  calo- 
mel, and  olive  oil. 

Although  operations  upon  the  gall  bladder  have 
from  time  to  time  been  reported  since  the  seventeenth 
century,  when  Stalpart  van  der  VViel '  first  opened  the 
organ  for  the  removal  of  a  calculus,  it  was  not  until 
after  the  successful  cholecystostomies  of  Bobbs  of  In- 
dianapolis in  1867,  Marion  Sims  in  1878,  and  the 
cholecystectomy  reported  by  Langenbuch  in  1880, 
that  a  general  interest  was  awakened. 

In  his  e.xhaustive  work  upon  the  subject  published 
in  1890,  Courvoisier'  not  only  reports  his  own  sixteen 
cases,  and  the  twenty-seven  cases  of  Kocher,  Kap- 
peler,  Socin,  Kronlein,  Fritzche,  Kouffmann,  Kunz, 
and  Niehaus,  but  gives  in  addition  a  complete  review 
of  all  the  literature  of  the  subject,  and,  by  a  careful 
analysis  of  an  exceedingly  large  collection  of  clinical 
reports  and  autopsy  findings,  is  able  to  establish  certain 
facts  bearing  upon  the  pathology  and  symptomatology 
of  these  conditions,  which  have  formed  the  framework 
of  our  present  knowledge  of  the  subject.  Since  the 
publication  of  this  work,  many  new  and  ingenious 
operations  have  been  devised  and  successfully  carried 
out,  and  much  has  been  added  to  our  knowledge  of  the 
subject;  and  whereas  in  the  early  days  surgeons  were 
accustomed  to  be  content  before  operation  with  the 
diagnosis  of  cholelithiasis,  or  inflammation  of  the  bil- 
iary passages,  the  time  has  now  arrived  when,  by  a 
proper  classification  of  our  knowledge,  more  accurate 
special  diagnosis  may  be  hoped  for. 

The  object  of  this  communication  is,  therefore, 
briefly  to  review  the  facts  which  have  been  gathered 
relating  to  the  symptomatology  of  these  condition  and 
pre.sent  a  diagnosis  chart,  which  will,  I  think,  present 
in  condensed  form  most  of  the  facts  bearing  upon  the 
differential  diagnosis  in  diseases  of  these  organs. 

'  Read  by  invitation  before  the  surgical  section  of  the  Buffalo 
Academy  of  Medicine,  November  5,   igoo. 

•  Pantaloni  :   "  Chirurgie  du  foie  et  des  voies  biliaires,"  iSgg. 
^  "  Casuistisch-statistische  Beitrage  zur  Patholog^e  und  Chirur- 
gie der  Gallenwege,"'  iSgo. 


In  preparing  the  chart  the  writer  has  chiefly  con- 
sulted the  works  of  Courvoisier,  Waring,'  Mayo  Rob- 
son,"  Reidel,'  Osier,'  and  Hans  Kehr,"  as  well  as  the 
papers  of  Fenger,"  McCosh,'  August  Herrmann,' 
Naunyn,"  Richardson,  Mayo,"'  and  others. 

Perhaps  the  most  important  contribution  to  the  sub- 
ject is  the  recently  published  work  of  Hans  Kehr,  who 
has  presented  to  the  profession  a  valuable  report  of 
his  four  hundred  and  thirty-three  operations  on  the 
gall  bladder  and  ducts.  In  these  reports  the  sympto- 
matology of  each  case  is  carefully  recorded,  as  are 
the  actual  pathological  conditions  found  at  operation 
or  by  autopsy,  and  his  work  undoubtedly  furnishes  the 
most  important  collection  of  reliable  data  upon  the 
diagnosis  of  these  diseases  which  has  appeared. 

In  Part  I.,  Chapter  III.,  of  his  latest  work,  the 
writer  enters  a  plea  for  more  accurate  special  diagno- 
sis, which  he  assures  us  can  be  made  in  the  majority 
of  instances  if  sufficient  care  be  taken  in  obtaining 
the  history  and  accurately  noting  the  physical  signs. 
He  then  presents  in  a  masterly  manner  the  sympto- 
matology of  the  twelve  different  classes  into  which  he 
divides  these  diseases,  and  the  conditions  with  which 
they  are  likely  to  be  confounded,  closing  the  chapter 
with  a  table  in  which  he  briefly  outlines  the  chief 
diagnostic  points  of  each. 

His  classification,  which  is  largely  a  clinical  one,  is 
as  follows: 

I.  Stone  in  healthy  gall  bladder,  cystic  duct  free. 

II.  Stone  in  a  previously  inflamed  gall  bladder, 
ductj  free,  adhesions. 

III.  Subacute  cholecystitis  without  stone — adhe- 
sions. 

IV.  Acute  cholecystitis  with  stone. 

V.  Acute  cholecystitis  in  contracted  gall  bladder — 
duct  closed. 

VI.  Hydrops  of  gall  bladder. 

VII.  Empyema  of  gall  bladder,  stone  in  cystic 
duct. 

VIII.  Carcinoma  of  gall  bladder. 

IX.  Stone  in  common  duct — acute  obstruction. 

X.  Stone  in  upper  segment  of  common  duct,  chronic 
obstruction. 

XI.  Stone  in  common  duct  near  papilla. 

XII.  Obstruction  of  common  duct  from  pressure  of 
tumor  of  other  organs. 

With  a  view  of  rendering  this  table  more  useful,  the 
writer  prepared  a  miniature  card  catalogue  of  these 
classes,  jotting  down  at  first  the  symptoms  mentioned 
in  Kehr's  table,  then  adding  such  other  symptoms  and 
cigns  as  are  mentioned  by  the  writer  in  other  portions 

'  H.  J.  Waring:   "The  Diseases  of  the  Liver,  Gall   Bladder, 

and  Biliary  System,"  London. 

'  Mayo  Robson  :   "  Diseases  of  the  Gall  Bladder  and  Ducts." 
'  Reidel  :   "  Mittheilungen  aus  den  Grenzgebieten  der  Medizin 

und  Chirurgie."  iv.  Band,  iv.  Heft. 

*  Osier  :   "  Practice  of  Medicine." 

'Hans  Kehr:  "  .Vnleitung  zur  Eriernung  der  Diagnostik  der 
einzelnen  Formen  der  Gallenstein-Krankheit." 

'  Fenger  :  American  Journal  of  the  Medical  Sciences,  1896. 

'McCosh:  "Gall  .Stones;  Obser\-ations  on  their  Treatment," 
iSqg. 

*  August  Herrmann:  "Mittheilungen  aus  den  Grenzgebieten 
der  Medizin  und  Chirurgie,"  iv.  Band,  ii.  Heft. 

'  Naunyn  :   "  Mittheilungen  aus  den  Grenzgebieten  der  Medizin 
und  Chirurgie,"  iv.   Band,  iv.  Heft. 
'"  W.   I.  Mayo:  Annals  of  Surgery,  iSgq. 


762 


MEDICAL    RECORD. 


[November  17,  1900 


of  the  work,  and  occurring  in  the  individual  histories 
of  the  large  number  of  cases  reported. 

To  this  were  later  added  other  symptoms  and  signs 
mentioned  by  different  accurate  observers  and  writers 
on  the  subject,  either  in  treatises  or  in  reports  of 
cases,  and  finally  such  facts  as  he  has  been  able  to 
glean  from  his  own  personal  observation. 

During  the  progress  of  these  studies  it  occurred  to 
the  writer  that  this  classification,  valuable  as  it  is  in 
its  present  form,  might  be  somewhat  simplified,  and 
rendered  more  useful,  by  a  slight  re-arrangement 
which  would  separate  pathological  conditions  more  or 
less  associated  in  the  original  table,  and  making 
fewer  classes  of  purely  inflammatory  conditions. 

Excluding  such  exceedingly  rare  conditions  as  ac- 
tinomycosis, tuberculosis,  or  gumma  of  these  organs, 
the  natural  classification  would  be  into — 

1.  Calculous  disease. 

2.  Inflammatory  disease. 

3.  New  growths. 

Calculous  disease  of  the  biliary  passages  is  of  fre- 
quent occurrence,  according  to  Reidel  and  Kehr, 
being  found  in  ten  per  cent,  of  all  adult  autopsies. 
(The  writer  found  it  twelve  times  in  one  hundred 
subjects  examined  in  the  dissecting-room  of  the 
College  of  Physicians  and  Surgeons.)  In  perhaps 
ninety-five  per  cent,  of  all  cases  it  gives  rise  to  no 
symptoms  (Kehr).  In  the  remaining  five  per  cent,  it 
occasions  symptoms  which  vary  in  intensity  and  im- 
portance from  a  slight  discomfort  in  the  right  hypo- 
chondriac region  to  a  rapidly  fatal  septic  peritonitis. 

One  or  more  stones  in  a  healthy  gall  bladder  with 
patent  ducts,  produce,  as  a  rule,  no  symptoms,  and 
under  these  conditions  the  only  physical  signs  present 
are  those  of  a  tumor  of  the  gall  bladder,  caused  by  the 
number  or  size  of  the  calculi.  (The  writer  recently 
removed  seven  hundred  and  fifty-nine  stones  from  an 
enormously  enlarged  gall  bladder,  which  up  to  the 
time  of  the  operation  had  produced  absolutely  no 
symptoms,  the  reason  for  the  operative  interference 
being  the  presence  of  a  hard  and  irregular  tumor  sug- 
gesting carcinoma.) 

If,  however,  a  calculus  becomes  impacted  at  the 
neck  of  the  gall  bladder  or  in  the  cystic  duct,  or  if  the 
mucous  membrane  of  the  gall  bladder  becomes  in- 
flamed, symptoms  are  produced.  In  the  former  in- 
stance, pain  of  a  moderate,  paroxysmal  character  may 
be  present,  due  to  the  expulsive  efforts  of  the  organ 
to  rid  itself  of  the  obstruction,  or  to  a  gradual  dis- 
tention of  the  viscus  with  mucus;  in  the  latter,  to  dis- 
tention of  an  intlanied  and  sensitive  organ.  In  the 
first  instance  the  pain  may  occur  at  any  time;  in 
the  latter  it  generally  occurs  during  prolonged  fasting, 
as  at  night,  when  the  flow  of  bile  is  toward  the  gall 
bladder.  Kehr,  however,  believes  that  the  pain  in 
these  cases  is  practically  always  the  result  of  inflam- 
mation. It  is  certainly  a  well-recognized  fact  that  it 
usually  begins  at  night,  and  this  circumstance  seems 
to  distinguish  it  from  the  pains  of  gastric  ulcer  or 
other  digestive  disorders,  which  begin,  as  a  rule,  soon 
after  a  meal. 

The  pain  originating  in  the  gall  bladder  varies  con- 
siderably in  intensity,  but  presents  two  fairly  uniform 
characteristics  and  generally  extends  to  the  back  and 
upward  to  the  region  of  the  scapula  and  shoulder.  Ten- 
derness is  rarely  present  in  the  absence  of  inflamma- 
tion, but  when  present  it  is  immediately  over  the 
organ,  which  usually  is  found  behind  the  right  rectus 
muscle,  just  below  the  free  border  of  the  ninth  rib. 

Tumor  of  the  gall  bladder,  present  under  the  condi- 
tions enumerated  above,  from  the  large  size  or  number 
of  gall  stones,  or  from  an  accumulation  of  fluid,  is 
usually  more  easily  defined  than  in  inflammatory  con- 
ditions, on  account  of  the  absence  of  a  pericystic  exu- 
date and  of  rigidity  of  the  abdominal  wall. 


The  presence  of  a  number  of  stones  in  a  gall  blad- 
der has  occasionally  been  recognized  during  palpation 
by  a  bruit  which,  according  to  I'etit,  resembles  the 
rubbing  together  of  nuts  in  a  bag.  This  observation 
has  also  been  confirmed  by  Courvoisier  and  others. 

Occasionally  a  stone  can  be  distinctly  palpated,  as 
in  the  case  reported  by  Lessdorf,  in  which  he  was  able 
to  grasp  and  appreciate  the  stone  through  the  separated 
muscles  of  an  umbilical  hernia. 

If,  hov^ever,  the  stone  becomes  impacted  in  the  cys- 
tic duct,  or  if  the  duct  becomes  permanently  obstructed 
in  any  other  manner,  as  by  a  new  growth  or  cicatricial 
contraction,  there  occurs  a  gradual  increase  in  the  size 
of  the  gall  bladder  by  an  accumulation  of  fluid  within 
its  cavity.  In  the  absence  of  infection,  this  fluid  is 
sterile  and  consists  of  a  thin  mucus  secreted  by  the 
mucous  membrane,  which  gradually  distends  the  gall 
bladder,  often  to  an  enormous  size,  giving  rise  to  no 
discomfort  excepting  that  produced  by  pressure  from 
the  size  of  the  tumor.  In  this  condition  of  hydrops  of 
the  gall  bladder,  the  walls  of  the  viscus  become  ex- 
tremely thin,  the  fluid  is  at  first  bile  stained,  and  later 
becomes  cloudy  and  often  opalescent. 

A  tumor  of  this  character  develops  slowly,  is  situ- 
ated immediately  behind  the  abdominal  wall  below 
the  free  border  of  the  ribs  on  the  right  side,  and  ap-- 
pears  continuous  with  the  liver  at  a  point  opposite  the 
junction  of  the  ninth  rib  with  its  cartilage.  It  de- 
velops downward  and  somewhat  toward  the  median 
line;  it  moves  with  respiration  and  may  permit  a 
lateral  pendulum-like  motion  on  palpation.  It  is  gen- 
erally smooth,  of  even  oval  contour,  and  its  consist- 
ence may  be  soft,  hard,  fluctuating,  or  elastic.  'I'he 
shape  of  the  tumor  is  variable;  it  may  be  round,  elon- 
gated, pear-shaped,  or  reniform  (Reidel).  A  change 
in  the  size  and  shape  of  a  gall  bladder  tumor  is  occa- 
sionally observed,  and  is  probably  due  to  a  dislodg- 
ment  of  a  previously  impacted  stone,  or  to  a  valve-like 
obstruction  in  the  cystic  or  common  duct.  Petit  re- 
ported a  case  in  which  it  could  be  emptied  by  exter- 
nal pressure.  Goldwitz  and  von  Lucke  have  reported 
cases  in  which  the  tumor  was  apparently  due  to  a  paral- 
ysis from  over-distention,  similar  to  what  is  often  ob- 
served in  the  urinary  bladder.  It  may  be  of  interest 
in  this  connection  to  note  that  the  gall  bladder  has 
ocasionally  been  found  near  the  median  line  (Kehr) 
or  under  the  free  border  of  the  ribs  of  ihe  left  side,  as 
reported  by  Raymond  and  Carl  Peck.  Congenital  ab- 
sence of  the  gall  bladder  has  been  once  observed  by 
the  writer,  and  Courvoisier  has  referred  to  a  case  in 
which  it  was  apparently  absent,  but  in  reality  was 
deeply  embedded  in  the  substance  of  the  liver. 

The  passage  of  small  stones  through  the  cystic  duct 
may  give  rise  to  no  painful  symptoms.  Lawson  Tait, 
however,  expressed  the  belief  that  they  cause  far  more 
pain  than  when  passing  through  the  large  common 
duct,  and  Kehr  has  made  a  similar  statement.  Cour- 
voisier, however,  doubts  this,  and  reports  eight  autop- 
sies in  cases  in  which  death  occurred  during  an  acute 
attack  of  biliary  colic;  in  six  of  these  the  stone  was 
found  in  the  common  duct,  one  in  the  gall  bladder, 
and  in  one  instance  numerous  stones  were  generally 
distributed  throughout  the  bile  passages. 

The  diagnosis  of  stone  in  the  hejiatic  duct  is  often 
very  diflicult.  Courvoisier  reports  fifty-two  cases  with 
fairly  accurate  histories.  In  four  of  these  there  were 
no  symptoms,  in  twenty-two  pain  was  present,  without 
any  regular  type,  and  occasionally  accompanied  by 
digestive  disturbances  and  vomiting.  In  sixteen 
there  were  enlargement  of  the  liver  and  tenderness. 
Thirty-five  had  more  or  less  jaundice  (in  six  it  was 
distinctly  absent).  In  nineteen  there  was  fever  of  an 
intermittent  type.  In  fifteen  there  was  a  suppurative 
cholangitis. 

The  diagnosis  of  stone  in  the  common  duct  is  less 


November  17,  1900] 


MEDICAL    RECORD. 


76: 


00  Carcinoma  of  gall 
X       bladder. 

S  (/')  Tumor    of    cystic 
£      duct. 
III.  -K  (c)  Tumor  of  hepatic 
or  common  duct. 

Z  i^f)  Tumor   of  ncigh- 
SK      boring  viscera   pro- 
ducing  chronic  ob- 
struction of  common 
duct. 

InHaminalory  Dliwanc, 

3«=Q.3::u»                      r.                 T 

CalcnIoiiN  DliK'aKe. 

"3            "i"!            3'2=-,  S         ? 
-  3            0-3         3            .?      »     .T.;  0      0. 3 
"3             -3=3             ^      °-    ^^E     ?Z 

Pathological  ct>ndition. 

0 

3 
I 

No;  may  occur  late  in  dis- 
ease. 

No  ;  may  occur  late 

Present;  paroxysmal  durinc 
periods  of  cystic  duct  clos- 
ure from  stone  or  swollen 
mucous  membrane. 

Acute  paroxysmal  radiatin)^ 
pain  ;  extending  to  back 
and  shoulder  ;  may  be  very 
severe. 

Severe  radiating  pain  at 
first  ;  may  disappear  later; 
tendency  to  recur. 

Present ;  often  severe  ;  par- 
oxysmal. 

May   be    absent  ;    generally 
present    when    obstruction 
exists,  or  severe  infection  ; 
tenderness  and    pain   over 
liver  in  intrahepatic  chol- 
angitis. 

May    be   absent ;    generally 
present  during  obstruction; 
paroxysmal. 

No 

Frequently  present  ;  irregu- 
lar type. 

Present;  acute  paroxysmal 

Periodic    attacks  of    acute 
radiating  pain. 

May  be  absent  ;  frequently 
present  early;  may  be  in- 
termittent; variable. 

z 

0 

5- 

z 

0 

z    z 

0      0 

Z 

0 

Present   during 
attacks  of  colic 

Present,    with 
chills  and 
sweats. 

Present ;  severe 
at  first,  may 
diminish  later. 

Present ;  often 
with  chills  and 
sweats. 

Present :  chills; 
sweats;  severe 
prostr  at  ion  ; 
general  sepsis. 

No 

Occasio  nal  1  y 
present. 

Generally  pres- 
ent. 

Present    w  i  I  h 
chills    and 
sweats. 

May  be  present; 
variabfc. 

z 

z 

c 

7 

z 

0 

z   z 

0       0 

z 

0 

May     be 
present. 

Pre  se  n t ; 
often     se- 
vere. 

Present     at 

first. 

Present 

Present 

May  be 
present 
when  colic 
occurs. 

No 

May  b  e 
present 
during 
pain. 

Present 

Present 

Often  pres- 
ent. 

■z 

0 

f 

3_ 

1' 

Present    late 
<  portal 
glands). 

No 

Present;  pro- 
gressive. 

Present;   pro- 
gressive ; 

extreme. 

•      3 
P 

Z 

0 

Z 

0 

Z 

0 

Z 

Present  ;    in- 
termittent. 

Present;  pro- 
gressive ; 
may  vary  in 
intensity. 

No 

Frequent 

z 

c 

z 

0 

C 

s 
a. 

Hard,    irregular,    mov- 
able   tumor    at     first, 
later  diffuse  infiltration 

Present  when  obstruc- 
tion exists. 

May  be  present  from 
distention  with  bile. 

Pre^nt;  generally  from 
distention  with  bile. 

Present  during  attacks 
of  cystic  duct  obstruc- 
tion. 

Present ;    tender  n  e  s  s  ; 
often  muscular  rigidity 

Present ;  with  tender- 
ness ;  may  attain  large 
si/e. 

No  (occasionally  pres- 
ent, due  to  pericystic 
exudate). 

No 

5t3 

1 

<                   * 

3 

95 

0 

<* 

3 

Z 

3 

May  be  present  from 
large  number  or  size  of 
stones. 

May  be  present  from 
distention. 

Present ;     may     attain 
large  size. 
N<» 

e 
3 
0 

0 

i 

1 

Negative      ( a  t 
first). 

Negative 

Contains    bile 
pigment. 

Contains    bile 
pigment. 

May  con  tai  n 
albumin      and 
casts. 

Negative 

Negative 

May  contain 
bile  pigment, 
albumin,    and 
casts. 

Z 

Negative 

Contains    bile 
pigment  at 
times. 

Contains    bile 
pigment. 

Contains    bile 

pigment. 

Contains    bile 
pigment. 

z 

1 

1 

d 

May  be  clay 
colored,  late. 

Normal 

Clay  colored. 

Clay  colored. 

n 

is- 

z 

3 

i 

0^ 

z 

0 

3 

z 

0 

i 

May  be  clay 
c  0  1  ored  if 
obstruction 
occurs. 

Clay  colored. 

Clay  colored. 
Clay  colored. 

z 

% 

[ 

z 

s 

3 

E. 

1 

Knlargcd  late 
in  disease. 

Not  enlarged 

May     be    en- 
larged. 

Enlarged 

Not  enlarged. 
Not  enlarged. 

Not  enlarged. 
Not  enlarged. 

Enlarged 

Not  enlarged. 
Nut  enlarged. 

Not  enlarged. 

Frequ  e  n  1 1  y 
enlarged. 

Not  enlarged. 

May     be    en- 
larged   dur* 
ing  attack. 

May  he  en- 
larged late 
(pressure  on 
vein). 

Not  enlarged. 

Not  enlarged 

May    be    en- 
larged late. 

Not  enlarged. 

May    be    en- 
larged (sep- 
sis). 

Not  enlarged. 

May    be    en- 
larged (sep- 
sis). 

Enlarged 
(sepsis). 

Not  enlarged. 
Not  enlarged. 

Not  enlarged. 
Not  enlarged. 

Not  enlarged. 

May  be  en- 
larged from 
pressure  of 
stone  on 
vein. 

May  be  en- 
larged. 

tn 

•a 

s 

3 

P  resent 
late. 

No(?) 

May  be 
pre  sent 
late. 

Present 
late. 

z        z      z 

0            op 

z 

0 

? 

?        ?    f 

Z 

3 

? 

f 

? 

> 

3 

Eii 

1-3-C 

3^„?- 
m'p   5 

li 

n 

3 
p 

3 

3 

0 

3 

3 

3 

and  asthenia  ;  cachexia  ;  rapidly  fatal. 

Very  rare  ;  both  benign  and  malignant  giowtlis  have 

been  reported  ;  diagnosis  diflicult. 
ViTv  ran*  :  diairnosis  diflicult. 

5 

<* 

c 
A 

3 

§• 
S 
S 

c. 
f 

3. 

3S-5 

§-■: 

Tj,  2 

■3^3. 
|-Sa 

3  n 

ft   « 

iB- 

0 

sri 

3 

?•? 
§■1 

tumor;  local  peritonitis  ;  diagnosis  often  extremely 
dilTicult. 

III 

<     ! 

3          3. 

a.     n 

i  1 

i  1 

:  1 

0    3 
r    »5 

If 

"        — 

a         3 

_        3 

1       *< 

z     "r 

often  sudden  ;  rapid  develnpment  of  severe  symp- 
toms   resembling    appendicitis ;    may   be    necrosis 
of  walls  of  gall  bladder  with  perforation,  local   ()r 
general  peritonitis. 
Freoiientiv  follows  acute  cholprvslitis  •  nccasionallv 

rencc ;    generally   associated  with    stones  in  gall 
bladder. 

3 

s- 

3 

t 
1 

3 

a. 

s- 

s 

3 

a. 
f* 
3 
0 

< 

1 

jaundiie   with    digestive  di.>;turbances  and  loss  nf 
weight;  history  of  previous  attacks  (?).      Ascites 
may  be  present  from  pressure  of  large  stone  or  p()s- 
sibly  from  hydra,'mia. 

sembles  malaria;   all  symptoms  disappear  during 
interval. 

r. 

:" 

k 
1 

•? 

3 
? 
3- 

3' 

i 

5' 

a 

■1          -1 

J. 

1           a, 

'             0 
-1            " 

S         '-• 

!   ^ 
r   ? 
\    '= 

?       f. 

T 
1 
3 

\             t 

v    * 

0      . 

:. 

5 

2. 

=>  . 
i 

■5 

n.         5' 
3           =- 

5        "'- 
c,        3 

I        I. 
L 

Q 

3_ 

i 

> 

=       3 

i    ?■ 

\ 

i 

3 

r 

? 
1 

fi 

5 

2. 
s 

r 

X 
p 

■     1 

I 


764 


MEDICAL   RECORD. 


[November  17,  1900 


obscure;  the  three  most  important  symptoms  are  jaun- 
dice, pain,  and  fever.  Practically  all  observers  regard 
jaundice  as  the  most  constant  and  reliable  symptom 
•of  obstruction  of  the  common  duct.  When  this  symp- 
tom is  due  to  calculus  the  diagnosis  is  comparatively 
easy;  when  due  to  other  forms  of  obstruction  it  is 
often  extremely  obscure.  Acute  temporary  common- 
duct  obstruction  from  stone  produces  a  rapidly  de- 
veloping jaundice,  which  as  rapidly  subsides  when 
the  stone  passes  into  the  duodenum.  When  the  stone 
becomes  impacted  in  the  region  of  the  papilla  the 
jaundice  is  progressive  and  often  becomes  extreme. 
If,  however,  the  dilatation  of  the  duct  above  the  ob- 
struction, from  an  accumulation  of  bile,  causes  the 
stone  to  become  dislodged,  and  it  floats  upward  in  the 
dilated  common  cystic  or  hepatic  ducts,  the  obstruc- 
tion is  temporarily  removed,  the  bile  again  flows  into 
the  intestine,  and  the  jaundice  disappears,  only  to  re- 
cur when  the  ducts  cntract  around  the  stone  or  it  is 
again  impacted  at  the  papilla. 

Pain  in  common-duct  obstruction  strongly  points  to 
stone.  In  eighty  cases  of  calculus  in  the  common 
duct  reported  by  Courvoisier,  pain  was  a  prominent 
symptom  in  fifty-one ;  absent  in  ten ;  and  unrecorded 
in  nineteen. 

In  seventy-nine  obstructions  from  other  causes  it 
was  present  in  only  nine  instances. 

In  intermittent  obstruction  from  a  floating  stone,  it 
is  generally  more  acute  during  the  period  of  obstruc- 
tion. It  is  then  often  paroxysmal  in  character,  radi- 
ates to  the  back  and  shoulder,  rarely  is  it  constant 
and  fixed  in  one  locality.  Tenderness  is  generally 
more  marked  nearer  the  median  line,  and  slightly 
lower  than  when  the  gall  bladder  is  the  seat  of 
trouble. 

Fever  is  less  constantly  present,  but  when  present 
is  generally  of  a  characteristic  type.  It  was  noted  in 
nineteen  of  Courvoisier's  cases,  while  in  seventy-four 
obstructions  from  other  causes  it  was  present  but 
seven  times.  It  is  often  intermittent  in  character  and 
is  accompanied  by  chills  and  profuse  sweats.  This 
type  of  fever  was  described  by  Charcot  as  fievre  inter- 
mittente  hepatlque,  and  its  similarity  to  malaria  pointed 
out  by  many  other  observers.  When  present  with 
jaundice  and  colic,  it  is  almost  pathognomonic  of 
stone  in  the  common  duct.  Although  believed  by 
many  to  be  reflex  or  due  to  the  absorption  of  bile, 
most  modern  observers  agree  with  Schuppel  in  regard- 
ing it  as  of  septic  origin,  as  the  presence  in  these  cases 
of  a  certain  degree  of  cholangitis  is  practically  con- 
stant. 

When  the  flow  of  bile  into  the  intestine  is  hindered 
the  urine  will  be  dark  from  the  presence  of  pigment; 
when  completely  obstructed,  the  stools  will  be  clay 
colored. 

Tumor  of  the  gall  bladder  is  generally  absent.  It 
has,  however,  been  occasionally  observed.  Enlarge- 
ment of  the  liver  is  frequent  and  due  to  the  dilated 
intra-hepatic  ducts  or  to  an  extension  upward  of  the 
cholangitis,  in  which  case  there  will  be  tenderness 
over  the  liver,  and  enlargement  of  the  spleen.  As- 
cites is  present  only  when  the  obstructing  stone  is 
large  and  presses  on  the  portal  vein. 

Inflammation  of  the  gall  bladder  or  ducts  is  present 
in  the  vast  majority  of  patients  who  apply  to  the  sur- 
geon for  relief. 

Whereas  it  was  formerly  believed  that  biliary  colic 
was  due  simply  to  the  passage  of  a  calculus  from  the 
gall  bladder  through  the  narrow  ducts  to  the  intestine, 
most  surgeons  now  regard  this  symptom  as  the  expres- 
sion of  an  inflammatory  process  in  these  organs. 
Kehr  states  that  in  his  opinion  colic  is  practically 
always  due  to  an  inflammation  of  the  gall  bladder,  and 
this  view  is  also  expressed  by  many  other  observers. 

The  fact  that  ninety-five  per  cent,  of  all  cases  of 


calculus  present  no  symptoms,  and  the  fact  also  that 
the  majority  of  calculus  cases  that  come  to  operation 
present,  in  addition,  signs  of  inflammation,  would 
strengthen  tliis  view. 

Infection  of  these  organs  arises  generally  from  an 
upward  extension  from  the  intestine,  from  an  abnor- 
mal patency  of  the  duodenal  orifice;  occasionally  from 
some  general  septic  disease;  very  rarely  from  trauma- 
tism. Thus  Courvoisier  in  fifty-five  cases  of  empyema 
of  the  gall  bladder  found  cholelithiasis  in  forty-one; 
in  two  it  was  thought  to  be  due  to  trauma,  in  two  to 
general  sepsis,  in  one  to  typhoid  fever.  Inflammation 
of  these  organs  may  be  conveniently  divided  into  two 
general  classes — the  mild  and  the  severe  infections; 
the  former  due  to  the  colon  or  typhoid  bacillus,  the 
latter  to  the  streptococcus  or  some  other  equally  viru- 
lent organism.  In  the  great  majority  of  instances, 
cholelithiasis  has  preceded  the  inflammation  and  pre- 
pared the  way  for  it. 

The  symptoms  of  cholecystitis  are  pain,  tenderness, 
fever,  and  the  presence  of  a  tumor  of  the  gall  bladder. 

In  a  mild  infection  of  the  organ  with  the  ducts  open, 
insuring  free  drainage  into  the  bowel,  these  symptoms 
may  be  wanting.  If  the  cystic  duct  becomes  obstructed 
from  stone  or  swelling  of  the  mucous  membrane,  colick)' 
pains  occur,  which  may  radiate  to  the  back  and 
shoulder;  vomiting  is  generally  present  during  the 
period  of  obstruction;  there  are  usually  also  slight 
fever  and  general  malaise,  which  disappear  with  the 
pain  when  the  obstruction  is  relieved.  Unless  the 
gall  bladder  be  small  or  deeply  seated  under  the  right 
lobe  of  the  liver,  a  sensitive  tumor  may  be  felt  during 
the  continuance  of  the  obstruction.  These  symptoms 
frequently  subside  spontaneously,  but  the  tendency  to 
recurrence  is  marked. 

If  chronic  obstruction  of  the  cystic  duct  occurs,  em- 
pyema of  the  gall  bladder  results,  giving  rise  to  symp- 
toms of  varying  severity,  according  to  the  virulence 
of  the  infecting  agent  or  the  resistance  of  the  individ- 
ual. This  condition  may  also  exist  with  open  ducts, 
as  evidenced  by  Courvoisier's  statistics,  in  which  he 
reports  the  ducts  free  in  eleven  of  forty-one  recorded 
cases  of  empyema.  The  pain  and  fever  may  be  want- 
ing, the  only  symptoms  being  the  presence  of  a  tender 
tumor  in  the  gall-bladder  region,  or,  in  cases  of  a  small 
or  contracted  gall  bladder,  only  a  local  tenderness  or 
muscular  rigidity.  In  the  severer  cases  the  pain  is 
acute,  paroxysmal,  and  radiating,  the  fever  is  high  and 
accompanied  by  chills  and  vomiting.  A  local  peri- 
tonitis may  be  present  and  give  rise  to  intra-abdomi- 
nal abscess,  a  condition  often  resembling  appendicitis. 

In  the  mOre  virulent  infections  the  symptoms  often 
develop  with  great  rapidity,  and  are  accompanied  by 
marked  prostration  and  a  rapidly  developing  sepsis. 
Perforation  of  the  gall  bladder  with  a  fulminating, 
fatal,  septic,  general  peritonitis  has  been  reported  in  a 
number  of  instances. 

Jaundice  is  absent  in  cholecystitis  unless  the  tumor 
of  the  gall  bladder  or  cystic  duct  presses  upon  the 
common  duct. 

In  inllammation  of  the  common  or  hepatic  ducts, 
however,  jaundice  is  often  present  in  addition  to  the 
pain  and  fever,  but  unless  accompanied  by  stone  or 
complete  obstruction  from  other  causes  is  seldom  of  a 
severe  type.  In  the  more  virulent  infections  of  the 
common  and  hepatic  ducts,  the  process  extends  rapid- 
ly to  the  intra-hepatic  branches  and  gives  rise  to  gen- 
eral sepsis,  often  without  other  symptoms,  leading,  un- 
less speedily  relieved  by  surgical  means,  to  multiple 
hepatic  abscesses  and  death.  This  condition  is  prac- 
tically always  accompanied  by  the  presence  of  foreign 
bodies  in  the  ducts  or  gall  bladder.  In  seventy-four 
cases  analyzed  by  Courvoisier  fifty-seven  had  calculi, 
seven  ascarides,  and  three  echinococcus. 

While  new  growths  of  neighboring  organs  not  in- 


November  17,  1900] 


MEDICAL   RECORD. 


765 


frequently  produce  symptoms  referable  to  the  gall 
bladder  or  ducts  by  external  pressure  or  direct  exten- 
sion, primary  new  growths  in  these  organs  are  exceed- 
ingly rare. 

'i"he  gall  bladder  is  most  frequently  affected,  and  in 
the  great  majority  of  instances  the  growth  is  carcinoma. 

This  disease  was  observed,  according  to  Courvoi- 
sier,  in  seven  of  two  thousand  five  hundred  and  twenty 
autopsies.  In  one  hundred  cases  collected  by  the 
same  author,  seventeen  were  in  males  and  eighty-three 
in  females,  the  decade  furnishing  the  largest  number 
being  between  fifty  and  sixty  years  of  age.  Seven- 
eighths  of  all  the  cases  occurred  in  the  subjects  of  chole- 
lithiasis. In  sixty-six  of  these  cases  in  which  the 
history  was  fairly  complete,  the  early  symptoms  were 
generally  those  of  disturbed  digestion  and  malnutri- 
tion. Vomiting  was  noted  in  thirty-six  instances; 
colic  in  twenty-one;  jaundice  occurred  in  forty-eight 
instances,  generally  late  in  the  disease;  while  in  eigh- 
teen it  was  absent.  In  twelve  ascites  was  present. 
Kehr  states  tliat  the  last  two  symptoms  always  result 
from  an  involvement  of  the  portal  glands,  causing 
pressure  on  the  ducts  and  portal  vein. 

The  only  reliable  symptom  which  can  be  detected 
early  is  the  presence  of  a  hard,  irregular  tumor  of  the 
gall  bladder.  The  diagnosis  is  exceedingly  difficult; 
in  only  four  of  Courvoisier's  one  hundred  cases  was 
the  nature  of  the  disease  determined  during  life.  The 
disease  is  rapidly  fatal;  in  fifty-three  cases  followed 
to  the  end,  death  occurred  in  all  within  nine  months 
from  the  first  characteristic  symptoms. 

Tile  occurrence  of  both  benign  and  maligrvant 
tumors  within  the  lumen  of  the  bile  ducts  has  been  re- 
ported by  Mayo  Robson  and  others.  The  symptoms 
at  first  are  those  of  duct  obstruction  from  other  causes, 
and  the  malignant  varieties  are  later  accompanied  by 
malnutrition,  progressive  asthenia,  and  cachexia. 

Chronic  obstruction  of  the  common  duct  from  out- 
side pressure  of  tumors  of  the  pylorus,  duodenum,  or 
head  of  the  pancreas  is  of  fairly  frequent  occurrence. 
As  would  be  expected,  the  cardinal  symptom  is  a  pro- 
gressively increasing  jaundice  without  fever  and  wiih 
but  little  or  no  pain.  In  these  cases  there  is  a  gradual 
enlargement  of  the  liver  and  gall  bladder,  with  ascites. 

The  same  symptoms  may  be  occasioned  by  a  tumor 
within  the  duct.  Intermittent  jaundice  has  rarely 
been  observed  in  such  cases,  probably  due,  as  sug- 
gested by  Haarimann,  to  sloughing  of  a  part  of  the 
obstructing  mass,  allowing  a  temporary  flow  of  bile 
into  the  intestine;  or,  as  reported  by  Courvoisier,  a 
pedunculated  tumor  near  the  papilla  may  act  as  a  valve 
and  occasionally  permit  the  passage  of  bile. 

Let  us,  in  conclusion,  brielly  review  the  significance 
of  the  three  chief  symptoms  occurring  in  diseases  of 
the  gall  bladder  and  ducts. 

Pain :  The  occurrence  of  repeated  attacks  of  acute 
paroxysmal  pain,  in  the  upper  right  quadrant  of  the 
abdomen,  strongly  suggests  a  lesion  of  the  biliary 
passages.  This  suggestion  is  accentuated  if  the  at- 
tacks occur  at  night,  or  during  fasting,  and  are  accom- 
panied by  vomiting  and  fever.  If  the  pain  radiates 
upward  to  the  back  and  shoulder,  and  if  an  area  of 
tenderness  exists  under  the  free  border  of  the  ribs,  the 
diagnosis  is  still  more  probable. 

If  in  addition  to  the  pain  we  have  a  palpable  or 
tender  tumor  under  the  lower  border  of  the  ninth  rib, 
in  all  probability  the  case  is  one  of  cholecystitis.  If, 
on  the  other  hand,  there  is  jaundice  but  no  gall-blad- 
der tumor,  we  probably  have  to  do  with  a  lesion  of 
the  common  duct. 

Other  conditions  giving  rise  to  acute  pain  in  tlie  upper 
abdomen,  and  to  be  excluded,  are,  first,  gastric  ulcer, 
in  which  the  pain  and  tenderness  are  more  generally 
located  in  the  epigastric  or  left  hypochondriac  region, 
and  in  which  fever,  as  a  rule,  is  not  present;  appendi- 


citis, in  which  vomiting  and  fever  may  also  be  present, 
but  the  pain  and  tenderness  are  usually  located  in  the 
right  lower  quadrant  of  the  abdomen;  renal  colic,  in 
which  the  pain  originates  in  the  Hank  and  extends 
downward  along  the  ureter  to  the  testicle,  which  may 
be  retracted,  and  which  is  often  accompanied  by  vesi- 
cal irritation  and  ha;maturia;  the  gastric  crisis  of 
tabes,  in  which  fever  is  absent,  and  although  the 
vomiting  is  present,  there  is  no  characteristic  point  of 
tenderness.  These  cases  also  show  an  absence  of  the 
patella  reflex  and  the  presence  of  sensory  disturbance 
and  ataxia  in  the  extremities.  Occasionally,  pain  in 
this  region,  strongly  simulating  biliary  colic,  will  be 
caused  by  the  presence  of  inflammatory  adhesions  in 
the  region  of  the  pylorus  and  duodenum,  causing  a  nar- 
rowing of  the  canal  with  dilatation  of  the  stomach. 
Chronic  intestinal  obstruction,  or  the  early  pain  of  a 
local  peritonitis  from  other  causes,  has  given  rise  to 
difficulties  in  diagnosis;  and  lastly,  syphilitic  hepa- 
titis may  present  pain  and  other  symptoms  almost 
identical  with  those  generally  found  in  calculous  dis- 
ease of  the  biliary  passages. 

Tumor:  A  tumor  in  the  right  hypochondriac  region, 
which  develops  slowly  and  is  preceded  by  a  history 
of  cholelithiasis;  which  is  round,  oblong,  or  pear- 
shaped,  with  a  smooth  convex  surface,  elastic  or  fluc- 
tuating; which  lies  immediately  under  the  abdominal 
wall  below  the  ribs  and  near  the  outer  margin  of  the 
right  rectus  muscle;  whicli  moves  with  respiration; 
which  allows  a  certain  amount  of  lateral  pendulum- 
like motion  on  account  of  its  attachment  above;  which 
cannot  be  made  to  disappear  like  a  movable  kidney 
under  the  ribs;  and  which  is  not  accompanied  by  pain 
and  fever,  is  in  all  probability  a  gall  bladder  dis- 
tended with  mucus  (iiydrops).  If  with  such  a  tumor 
there  is  a  progressive  jaundice,  it  is  probably  a  gall 
bladder  distended  with  bile  from  common-duct  ob- 
struction. If  such  a  tumor  is  sensitive  to  the  touch 
and  is  accompanied  by  fever  it  is  doubtless  a  gall 
bladder  distended  with  pus  (empyema).  If  the  tumor 
is  ill  defined  on  account  of  muscular  rigidity,  if  tiiere 
are  acute  radiating  pain  and  marked  tenderness  in  the 
right  hypochondriac  region,  we  have  generally  to  do 
with  a  cholecystitis  with  local  peritonitis.  The  pres- 
ence of  a  tumor  corresponding  to  the  above  descrip- 
tion, W'ithout  pain,  fever,  or  jaundice  at  first,  but  pre- 
senting a  hard,  irregular  surface,  is  in  all  probability 
cancer. 

Jaundice:  The  occurrence  of  a  mild  transitory  jaun- 
dice unaccompanied  by  other  symptoms  suggests  a 
catarrhal  obstruction  of  the  common  duct  (a  mild 
duodenitis  from  indigestion).  The  occurrence  of  a 
temporary  jaundice  with  colic  suggests  the  passage  of 
a  stone  through  the  common  duct  into  the  intestine. 
The  occurrence  of  intermittent  jaudice,  intermittent 
colic,  and  intermittent  fever  suggests  a  floating  stone 
in  the  common  duct.  The  occurrence  of  continued 
jaundice,  with  chills,  fever,  hepatic  enlargement  and 
tenderness,  hypertrophy  of  the  spleen  and  general  sep- 
sis, suggests  an  infective  cholangitis.  The  occurrence 
of  a  progressively  increasing  jaundice,  and  enlargement 
of  the  liver,  with  a  previous  history  of  colic,  suggests 
an  impacted  stone  near  the  papilla.  The  occurrence 
of  a  progressively  increasing  jaundice,  without  pain  or 
fever  but  with  a  tumor  of  the  gall  bladder,  suggests 
common-duct  obstruction  from  new  growth. 


Tubo-Ovarian  Disease  and  How  Best  to  Deal 
with  it — (i)  In  the  dormant  stage  operate  by  the 
abdominal  route.  (2)  In  the  acute  stage  explore  by 
the  abdominal  route,  then  decide  between  completing 
the  operation  in  one  or  two  sittings.  (^)  Following 
abortion  or  delivery  at  full  term,  vaginal  drainage 
often  puts  the  patient  in  better  shape  for  an  abdomi- 
nal section  later  on. — Edwin  Ricketts. 


766 


MEDICAL    RECORD. 


[November  17,  1900 


THE  MORTALITY  FROM  DIABETES  MEL- 
LITUS  IN  THE  CITY  OF  NEW  YORK 
(MANHATTAN  AND  THE  BRONX)   IN  1899. 

CLASSIFIED  ACCORDING  TO  MONTH,  SEX,  AND 
AGE;  ALSO  AN  EXPOS^  AS  TO  NATIONALITY, 
DURATION  OF  RESIDENCE  IN  THE  UNITED 
STATES,  OCCUPATION,  DIRECT  CAUSES  OF 
DEATH,    AND   ACCOMPANYING   DISEASES. 

Bv    HEINRICH    STERN,    Ph.D.,    U.T).. 

NFW    YORK. 

A.  The  Mortality  from  Diabetes  Mellitus  ac- 
cording to  Month,  Sex,  and  Age.'  —  A  perusal  of 
Table  I.  evidences  that  202  deatlis  from  diabetes  melli- 
tus were  recorded.  Of  these,  102  took  place  in  males 
and   100   in  females.      As    in  the  preceding  decade, 


years,  and  it  exceeded  nearly  twice  the  mortality  of 
males  between  the  75th  and  85th  years. 

Below  the  25th  year  laut  10  deaths  ensued,  of  which 
7  occurred  in  males  and  3  in  females.  But  3  diabetics 
died  above  the  Ssth  year — 2  males  and  i  female. 

B.  The  Nationality  of  the  Deceased  Diabetics 

The  greatest  number  of  deaths  (Table  II.) — 57 — oc- 
curred among  those  born  in  Germany.  Of  natives  of 
tlie  United  States,  51  succumbed  to  the  affection. 
Thirty-seven  of  the  deceased  were  born  in  Ireland,  18 
in  Russia  and  Poland,  12  in  England  and  Scotland,  6 
in  Austria-Hungary-Rohemia,  6  in  Holland  and  Bel- 
gium, 4  in  Central  and  South  America  and  the  West 
Indies,  4  in  Italy,  3  in  France,  2  in  Canada,  i  in 
Switzerland,  and  i  in  China. 

These  figures  probably  stand   in  some  relationship 


Table   I. 


Months. 

Total 
Mortality. 

Total 

Mortality 

Under 
10. 

10-15. 

15-20. 

20-25. 

25-35- 

35--45- 

45-55- 

55-65- 

65-75. 

75-85- 

Above 
85- 

Colored. 

January 

22 

9 
16 
16 
21 

13 
16 

13 
13 
27 
17 
19 

M.        F. 

11  II 

I         .1 

8  8 
10       II 

9  4 

7  9 
4         9 

8  5 
13        14 

9  8 

12  7 

M.     F. 

M,     F. 

M.    F. 
I    . . 

M.     F. 
I 

M.     F, 
I     .  . 
I    .  . 

M.     F 
2       I 

4   •• 

1  .  . 

2  I 

3  ■• 

M.      F. 

2          2 
2          I 

4       2 
4        I 

I        .  . 

I        3 
4        I 

1  I 

2  1 
I         I 

M.      F. 
3       4 

3       7 
I       3 

I        3 

I          2 

I     4 
I     2 
I     7 
3     3 

6       2 

M.      F. 
2 
I 
2 

3       2 

2       3 

I        I 

4 

1  I 

2  1 
6       I 

M.     F. 

I     I 

. .     1 

--      3 
I 
I      1 

I 

M.     F 

I 
.  .      I 

I 

March    

I 

May 

2    .  . 

Tulv    . 

I       I 

I   .  . 

I 

1  2 

2  3 
I     I 

I      I 

2    .. 

I    .  . 

• 

I 

2       3 

I 

Total 

202 

102     100 

2      I 

2    .  . 

2       I 

I      I 

8     2 

17     5 

22       1  = 

24     40 

17     21 

5     9 

2       I 

3 

Total . 

3 

2 

3 

2 

10 

26 

37 

64 

38 

14 

3 

1889-1898,  the  greatest  mortality  from  this  affection, 
in  1899,  occurred  in  the  month  of  October.  The 
mortality  was  distributed  over  the  different  seasons,  as 
follows : 

Number  of  Deaths, 

Spring  :   March,  April,  May 53 

Summer  :   June,  July,  August 42 

Fall  ;  September,  October,  November 57 

Winter  ;   December,  January,  February 50 

Total 202 

The  mortality  among  males  was  greater  in  the 
months  of  February,  June,  September,  November,  and 
December;  it  was  greater  among  females  in  March, 
May,  July,  August,  and  October.  In  January  and 
April  the  deaths  were  equally  distributed  between  both 
sexes. 

The  greatest  mortality  took  place  between  the  55th 
and  65th  years  of  life;  the  smallest  between  the  loth 
and  isth  and  between  the  20th  and  2Sth  years.  The 
number  of  diabetics  who  succumbed  between  the  4Sth 
and  ssth  years  was  almost  the  same  as  of  those  who 
died  between  the  6sth  and  75th  years.  The  disease 
terminated  fatally  four  times  oftener  in  males  than  in 
females  between  the  2sth  and  35th  years  of  life.  Be- 
tween the  3Sth  and  4Sth  years  the  mortality  of  males 
was  about  twice  that  of  females.  Between  the  4Sth 
and  sS^'i  years  the  deaths  of  males  exceeded  those  of 
the  females  by  about  one-third.  Between  the  S5th  and 
6sth  years  the  mortality  of  females  surpassed  the  deaths 
of  males  by  just  40  per  cent.  The  mortality  of  the 
female  sex  was  also  higher  between  the  65th  and  7sth 

'  Some  of  the  following  data  differ  slightly  from  the  figures 
which  I  gave  in  a  recent  communication.  A  careful  search  of  the 
original  certificates  of  death  showed  that  the  enumerator  has 
classified  the  deaths  from  diabetes  insipidus  (certificates  Nos. 
23.2S2  and  36,004)  and  a  case  of  death  from  "  dilatatio  cordis  " 
(certificate  No.  13,272)  among  the  deaths  from  diabetes  mellitus. 


to  the  numerical  proportion  of  each  nationality  to  the 
total  populace  of  New  York  City.  However,  no 
Swedes,  Norwegians,  or  Danes  succumbed  to  the  affec- 
tion although  a  considerable  number  of  New  York's  in- 
habitants are  of  these  nationalities. 

Among  the  American-born,  27  were  males  and  24 
females.  The  mortality  of  males  exceeded  that  of 
females  also  in  those  born  in  England  and  Scotland, 
Austria-Hungary-Bohemia,  Holland-Belgium,  and  Cen- 
tral and  South  America  and  the  West  Indies.  No 
death  from  diabetes  was  reported  of  females  of  Cana- 
dian or  Italian  birth. 

The  mortality  was  larger  among  the  female  sex  than 
in  that  of  the  male  in  natives  of  Germany,  Ireland, 
Russia- Poland,  and  France. 

Among  the  51  deaths  in  the  American-born,  many 
were  of  individuals  of  Irish  parentage  or  of  unmistak- 
ably Irish  extraction.  The  high  mortality  of  natives 
of  Germany  is  not  only  due  to  their  numerical  strength 
but  to  the  great  number  of  German-born  Jews. 

The  Hebrews,  no  doubt,  are  more  commonly  affected 
with  chronic  glycosuria  than  natives  of  the  nation 
among  whom  they  dwell.  The  death  certificates  of 
Americans  furnisli  no  direct  evidence  whether  the  de- 
ceased belonged  to  the  Jewish  race  or  not,  nor  in  many 
instances  does  the  name  disclose  the  racial  identity. 
The  deceased  buried  in  Jewish  cemeteries  were  classed 
by  me  as  Jews.  A  few  others  of  undoubted  Jewish 
origin  (personal  name,  name  of  parents,  place  of  birth) 
who  were  not  interred  in  specific  Jew'ish  burial-grounds 
were  also  counted  among  the  Jews.  Out  of  the  total  of 
202  deaths,  54,  that  is,  almost  2S  per  cent.,  occurred 
in  Jews.     Of  these,  21  were  males  and  33  females. 

Thirty-seven  of  the  deceased  were  born  in  Ireland. 
Taking  the  Irish  as  a  race — as  I  have  done  with  the 
Jews  adding  those  who  were  born  outside  of  Ireland 
of  Irish  parentage  or  who  are  of  Irish  descent,  we  have 
a  total  mortality  of  at    least    51 — 22   males  and  29 


November  17,  1900] 


MEDICAL    RECORD. 


767 


females.  This  figure  also  forms  over  25  per  cent,  of 
the  total  mortality  from  diabetes  mellitus. 

The  diabetics  of  Russian  or  Polish  nativity,  with 
exception  of  one  female,  were  all  Jews. 

The  frequent  mortality  from  diabetes  in  certain 
races,  as  the  Jews  and  the  Irish,  may  be  ascribed  to 


Of  those  born  in  England  and  Scotland,  i  lived 
above  the  85th  year,  1  until  the  period  between  the 
75th  and  85th  years,  2  until  that  between  the  65th  and 
7Sth  years;  4  died  between  the  S5th  and  65th  years,  3 
between  the  45 th  and  5sth  years,  and  i  between  the 
3Sth  and  4Sth  years.     The  mean  age  attained  by  the 


TAI5LE  II. 


Nationality. 

Total 
Mortality. 

Total 
Mortality. 

Under 

10. 

10-15. 

1 5-^0. 

ao-35. 

"5-3S- 

35-«5- 

45-55- 

S5-<5- 

65-75. 

75-85. 

Above 

85. 

United  States 

51 
57 
37 
IS 
12 
6 
6 

3 
I 

4 

2 

M.        F, 

27        2J 
25        32 
16         21 
7       II 
7         5 
4         2 
4         2 
I          2 
I 

M.     F. 

2      I 

M.    K. 
2    .. 

M.     F. 
I      I 

M.    F. 
I      I 

M.     F. 
3      2 

M.       F. 

6       4 

2  .  . 

3  3 
2       I 
I 

2        I 

M.        F. 

2         3 

4  I 

5  6 
2       3 
I        2 

M.       F 
(>       7 
5     14 
5     10 
I       5 

3       I 

1  I 

2  . . 

M.       F. 
4        3 
8     12 
2 
I       I 
I       I 

I 
I       I 

I 

I 

M     F. 

2 

4     4 

I 

I 

I      I 

M.     F. 

Ireland 

England  and  Scotland 

Austria-llunjjary-liohemia  . 

Holland  and  Belgium 

France     

f 

Cent,   and    So.    Amer.    and 

3         I 
2 

I       I 

•  ■    •  ■ 

Italy      

4 

.       .. 

2 

I 

I 

Total 

202 

102   ion 

2      I 

2 

2       I 

I      I 

8     2 

17       9 

22     15 

24    40 

17     21 

5     9 

2      I 

Total     

3 

2 

3 

2 

10 

26 

37 

64 

38 

14 

•2 

manifold  causes.  Mental  exertion,  the  characteristic 
modes  of  living,  gluttony,  alcoholic  into.xication,  etc., 
might  be  considered  predisposing  factors  in  the  pro- 
duction of  the  diabetic  state,  but  the  cardinal  predis- 
posing cause,  in  my  opinion,  is  the  breeding  in  and 
in  tow-hich,  in  a  very  pronounced  measure,  the  Jewish 
as  well  as  the  Irish  race  still  adhere. 

C.  The  Age  of  the  Deceased  Diabetics  from  the 
Different  Nationalities  and  the  Duration  of  their 
Residence  in  the  United  States. — Out  of  the  57 
deceased  German-born  diabetics  2,  i  male  and  i 
female,  lived  above  the  age  of  85.  Eight  died  be- 
tween the  7sth  and  S5th  years,  20  between  the  65th  and 
75th  years,  19  between  the  ssth  and  65th  years,  5  be- 
tween the  45th  and  55th  years,  2  between  the  35th  and 
45th  years,  and  none  between  the  25th  and  35th  years. 
The  average  age  attained  by  the  diabetics  of  German 
nativity,  excluding  those  who  died  during  childhood 
and  adolescence,  was  therefore  almost  66  years. 

Two  diabetic  females  born  in  the  United  States 
died  between  the  75th  and  85th  years;  7  American- 
born  diabetics  succumbed  to  the  malady  between  the 
65th  and  75th  years;  13  between  the  5Sth  and  65th 
years,  5  between  the  45th  and  55th  years,  10  between 
the  3Sth  and  45th  years,  and  5  between  the  25th  and 
3Sth  years.  The  average  age  of  American-born  dia- 
betics, with  the  exclusion  of  those  who  died  before  the 
2Sth  year  was  reached,  amounted  therefore  to  53  years. 

Of  the  deceased  born  in  Ireland,  2  females  lived  to 
the  period  between  the  6sth  and  7slh  years;  15 — 5 
males  and  10  females — to  that  between  the  55th  and 
6sth  years;  11 — 5  males  and  6  females — died  between 
the  45th  and  55th  years;  6—3  males  and  3  females  — 
between  the  35ih  and  45th  years,  and  3,  all  males,  be- 
tween the  25th  and  35'^  years.  The  mean  age  attained 
by  the  Irish-born  diabetics  was  therefore  not  quite  52 
years. 

One  female  among  the  diabetics  of  Russian  birth 
attained  an  age  between  the  75th  and  85th  years;  2 
diabetics  of  Russian  nativity  lived  to  the  period  be- 
tween the  65th  and  75  th  years,  6  to  that  between  the 
ssth  and  65th  years;  5  died  between  the  4Sth  and  ssth 
years,  3  between  the  35th  and  45th  years,  and  i  between 
the  2sth  and  3Sth  years.  The  average  age  of  deceased 
diabetics,  natives  of  Russia,  amounted  therefore  to 
about  54^  years. 


diabetics  of  English  or  Scotch  birth  amounted  there- 
fore to  over  61  years. 

The  54  deceased  diabetics  of  Jewish  extraction   at- 
tained the  following  ages: 


Age. 

Male. 

Female. 

I— 10  years 

I 
I 

15-20      "      

25-35       "      

I 

TC-JC          '*        

4                           2 

45-55          "        

4  5 

5  II 
4                         9 
2                         4 

I 

e:E;-6^        "               

65-75        "       

TC-Ri;        "       

85  years  and  above 

Total 

21 

33 

In  the  average  those  who  had  died  after  the  25th 
year  of  life  attained  an  age  of  60  years. 

The  duration  of  residence'  in  the  United  States  of 
foreign-born  deceased  diabetics,  for  the  different  na- 
tions, was  as  follows: 


Nationality. 

Mean  Number  of  Years  of  Residence  in 
United  States. 

Male. 

Female. 

37 

31 

Between  15  and  16 

32    ■'     33 

17 
Between  36  and  37 

13 

40 

Irish 

Not  quite  36 
Between  15  and  16 
40    "     41 

20    "     21 

Russians  and  Poles 

English  and  Scotch 

Austrians,     Hungarians, 

Hollanders  and  Belgians. 

44 

D.  The    Occupation    of    the    Deceased    Diabetics 

(Table  III.). — The  occupation  of  the  deceased  dia- 
betic was  not  stated  on  every  certificate  of  death.  Out 
of  a  total  of  102  deaths  of  males,  the  occupation  of  82, 
and  of  a  total  of  100  deaths  of  females,  the  occupation 
of  44  was  recorded. 

'  The  question,  "  How  long  in  the  United  States  ?  "  I  found  not 
always  answered. 


768 


MEDICAL    RECORD. 


[November  17,  1900 


It  may  be  surmised  that  the  deceased  male  diabetics 
whose  former  occupation  is  not  mentioned  in  their  re- 
spective certificate  of  death  belonged,  in  the  majority, 
to  the  wealthier  class  of  the  population.  This,  how- 
ever, is  not  the  case.  Some  of  the  males  were  chil- 
dren; others,  w-ithout  an  apparent  occupation,  passed 
away  in  public  institutions  where  nothing  was  known 
about  the  deceased,  and  others  died  in  the  tenement- 
house  districts.  It  is  safe  to  assume  that  most  of  the 
56  females  whose  occupation  is  not  stated  were 
"  houseworkers,"  and  that  the  attesting  physician  did 
not  consider  these  duties  a  specific  or  definite  "oc- 
cupation." 

Table   III. 


Occupation. 


"  Houseworkers' 


Nurse 

Railroad  employees 

Restaurant,  hotel,   and  saloon- 
keepers  


Drivers. 


Porters,     janitors,    watchmen, 
etc 


Butcher 

Bakers  and  confectioners 

Peddlers 

Cattle  and  produce  dealers.  . . 
Clerks,  agents,  salesmen,  etc. 


Cooks 

Laundr}'men . 


Factory  worker. 
Merchants 


Shoemaker 

Tailors  and  dressmakers . 


Domestics  . 


Laborers. 


Cigarmakers  and  manufacturers 


Typesetter 

Police  officers 

Sculptor 

Gardeners 

Engraver 

Color-mixer 

Lawyer 

Physician 

Clergymen 

Teacher 

Nun 

Journalist 

Photographer 

Morgue  keeper 

Storage-warehouse  proprietor.  . 

Builder 

Student 

Stonemason 

Carpenter 

Waiter 


Sex  and  Age  of  De- 
ceased. 


F.  5S,  F.  60,  F.  57. 
F.  35,  F.  65,  F.  62 
F.  59,  F.  5S,  F.  75 
F.  58,  F.  55,  F.  67 
F.  47,  F.  6g,  F.  58, 
F.  60,  F.  68,  F.  66 
F.  59, F.  52,  F.  60 
F.47,  F.  69,  F.  55, 
F.  51,  F.  62,  F.  38, 
F.  58.  F.  55,  F.  70, 
F.  31,  F.  60,  F.  65, 
F.  75,  F.  54  

F.  4g 

M.  46,  M.  40 

M.  54.  M.  56,  M.  39, 
M.39,  M.  52,M.6o 

AL  53,  M.  65,  M.  32 
M.  56 


M.  35,  M.  71,  M.  49, 
M.20,  M.70,  M.67, 
M.  60 

M.  42 

M.  16,  M.  62 

M.  35,  M.  42 

M.  59,  M.  49 

M.  61,  M.  36,  M.  34, 
M.57,M.73,M.68, 
M.  46,  M.  61,  M.67. 

M.  36,  M.  50 

M.  44,  M.  Chinese 
30  years  in  U.  S.  ; 
50  years  sup 

F.  21 

M.  80,  retired ;  M. 
45,  M.  74,  M.  66, 
M.  55.   M.  55 

M.  43 

M.  25,  M.  86,  M.  60, 
M.  54,F.6o,  M.44, 
M.54 

F.  72,  F.  64.  F.  37, 
M.  50,  F.  19 

M.  50.  M.  55,  M.  61, 
M.  52 

M.  64,  M.  52,  M.  63 
M.  61 

M.  35 

M.  56,  M.  52...... 

F.  42 


M.  27,    M.  68. 

M.  63 

M.  34 


M.  65 

M.  32 

M.  48,  M.  57 
M.  67 

F.  45 

M.  42 

M.  68 

M.  35 

M.  55 

M.  63 

M.  15 

M.  46 

M.  ^2 

M.  69 


58 
49 
43 


50 


53 

42 

39 

3S|4 

54 


56 

43 


47 
21 


(,2yi 

43 


54^4: 

4S>^ 

54;^ 

60 
35 
54 
42 

ATA 

63 

34 

65 

32 

52K 

67 

45 

42 

68 

35 
55 
63 
15 
46 

52 
69 


Apart  from  the  35  "  houseworkers  ' — for  almost 
every  woman  of  more  advanced  age  dies  as  such — the 
greatest  mortality  (9)  occurred  among  the  great  class 
of  clerks,  agents,  salesmen,  etc.  'I'he  porters,  janitors, 
watchmen,  and  kindred  occupations  furnished  7  deaths 
from  diabetes.  The  same  mortality  from  this  affec- 
tion took  place  among  tailors  and  dressmakers.  Six 
restaurant,  hotel  and  barkeepers  and  the  same  number 
of  "merchants"  succumbed  to  diabetes.  The  mortal- 
ity from  diabetes  of  domestics  amounted  to  5,  of 
drivers  to  4,  of  laborers  to  4,  and  of  cigarmakers  and 
manufacturers  also  to  4. 

The  death  figures  for  1889  are  too  small  to  permit 
of  any  definite  conclusions  as  to  the  relationship  be- 
tween occupation  and  diabetes,  or  between  occupation 
and  fatal  termination  of  the  affection.  One  fact,  how- 
ever, is  clearly  evinced  by  a  perusal  of  Table  III., 
namely,  that  diabetes  mellitus  is  not  a  special  visita- 
tion upon  the  well-to-do,  as  is  commonly  supposed, 
but  that  it  occurs  in  great  frequency  among  the  work- 
ing people,  among  whom  gluttony  and  leisure  hours 
are  exceptions. 

Granted  that  of  the  20  deceased  male  diabetics 
whose  "  occupation  "  is  not  stated,  or  who  had  "  no 
occupation,"  10  were  persons  of  means,  we  still  have 
10  with  "no  occupation"  whom  we  are  compelled  to 
classify  among  the  poorer  strata  of  society. 

Adding  to  this lo 

Railroad  employees 2 

Restaurant,  hotel,  barkeepers,  total  mortality  6  ;  em- 
ployees, say 3 

Drivers 4 

Porters,  etc 7 

Bakers,  etc.,  total  mortality  2  ;  employees,  say I 

Peddlers 2 

Clerks,  etc g 

Laundrymen 2 

Cooks ^ 2 

Shoemaker •. i 

Tailors 6 

Domestic i 

Laborers 4 

Cigarmakers.  total  mortality  4  ;  employees,  say 2 

Typesetter I 

Police  officers 2 

Gardeners 2 

Engraver i 

Color  mi.xer i 

Stonemason i 

Carpenter i 

Waiter i 

We  have  at  least  66  of  the  102  deceased  males  who 
were  working  for  a  livelihood  or  who  were  dependents 
upon  others. 

Besides,  some  of  the  professionals,  whom  I  have 
entirely  omitted  from  this  last  calculation,  in  all  likeli- 
hood belonged  to  the  poorer  classes;  and  it  is  possi- 
ble that  some  of  the  "  merchants "  even  were  not 
wealthy  people.  In  looking  over  the  records  of  the 
last  places  of  residence  of  the  deceased,  the  fact  that 
the  working  classes  are  more  frequently  the  victims  of 
diabetes  than  are  the  so-called  upper  strata  of  the 
populace  is  once  more  confirmed. 

E.  The  Direct  Causes  of  Deaths. —  i.  Coma 
(Table  IV.). — Among  a  mortality  from  diabetes  of 
202,  death  supervened  60  times  by  coma. 

I  have  stated  elsewhere'  that  "  the  greater  number 
of  these  60  instances  which  were  designated  as  '  coma,' 
it  is  safe  to  assume,  were  not  those  of  typical  diabetic 
coma.  Coma,  associated  with  diabetes,  deserves  the 
appellation  '  diabetic  coma  'only  in  certain  well-defined 
instances." 

In  Table  IV.  I  have  collected  the  60  cases  of  coma. 
The  following  facts  are  elucidated  by  it: 

'"On  Coma  Diabeticum  and  its  Treatment,"  meeting  of 
American  Medical  Association,  .Section  Materia  Medica  and 
Therapeutics,  June  5,  1900.  to  be  published  in  Journal  of  the 
.\merican  .Medical  Association. 


November  17,  1900]                    MEDICAL 

Nationality :  Of  those  who  died  in  coma  were  born 
in 

RECORD.                                               769 

Of  these  60  who  have  died  in  coma,  23,8  males  and 
15  females  were  Jews. 

Willie  the  proportion  of  the  total  coma  cases  to  the 
total   mortality  from  diabetes  is  60  to  202,  or  29  per 
cent.,  coma  occurred  in  43  per  cent,  of  the  fatal  cases 
of  diabetes  in  the  Hebrews. 

Total, 

Male. 

Female. 

19 
16 

8 
7 
4 
2 
2 
I 
1 

6 

8 
4 
3 
3 

I 
I 

8              Sex:  Of  the  diabetics  who  have  died   in  coma   26 

Ireland 

4         were  males  and  34  females. 

*•             Age:  The  lowest  age  of  any  diabetic  who  has  died 

d 

England.  Sco 

land    

2         in  coma  in   1899   in  the  City  of  New  York  was  15 

Holland 

2         years,  the  highest  83  years  and  2  months.     The  mean 
age  of  all   who  have  died   in  coma  amounted  to  53 

Italy 

years  anu   auoui   3    iiiuiuiis.        i  iie    mean    age    01    iiie 
males  was  49  years  and  about  6  months,  that  of  the 
females  56  years  and  almost  2  months. 

i   IV. 

Total. .  . . 

60 

26 

34 

TABLl 

Number 

of  Certificate  of 

Death. 

Nationality. 

Sex. 

Age. 

Duration 

of 
Diabetes 

Mellitus. 

Duration 

of 
Coma. 

Occupation. 

Concurring  Diseases  and  Conditions— Remarks. 

Manbattaa  Bor. 
1,415 

Holland 

F. 
F. 

M. 
M. 
M. 
F. 
F. 
M. 
M. 
M. 
F. 
F, 
M. 

M. 
F. 
V. 
F. 
F. 
F. 
M. 
M. 

F. 
F. 
M. 
F. 
F. 
M. 
F. 
M. 
F. 
F. 
M. 
M. 
F. 
F. 
F. 
F. 
M. 
M. 
F. 
F. 
M. 

F. 
F. 
F. 
M. 
M. 
M. 
F. 
F. 
M. 
F. 
M. 
F. 
F. 
M. 
M. 

F. 
M. 
F. 

Vrs.    Mos 
71       6 
62     .. 

42  3 

49  9 
16      .. 

68  9 
22 

79     10 

43  ■• 
42      .. 
65      .. 

51  10 
35     .. 

64  .. 

58  .. 
55     ■• 

59  •• 
42       5 

67  .. 
40     .. 
35     •• 

65  .  . 

74  I 

59  •• 
83       2 

61  .. 

52  1 
76       6 

75  •• 

69  .. 

54  9 

35  •• 
65      .. 

55  •■ 

62  5 

37       9 

68  . 

53  •• 
65      .. 

31  II 
45      ■• 

62      .. 

60  .. 
60     .. 
67         2 

50  .. 

32  4 

76  8 

54  ■• 
15     .. 
42     .. 
6i     .. 
65     .. 

36  .. 
60     -. 

Vrs.    Mos. 
3     •■ 

2  3 

3  •• 
3      •• 

8     '..' 

5      •• 
4'A    '■'■ 

'.'.       8 
10     . . 

10  hrs. 

1  week. 
3  days. 

2  days. 

Few  hrs. 
24  hrs. 

2  days. 

.... 

2  hrs. 

1  day. 

Paralysis  ;  exhaustion. 

None. 
Butcher. 

Not  stated 

Confectioner. 
Not  stated. 
Factory  worker. . 
Retired  merchant 

Shoemaker 

Not  stated 

No  occupation.  .  . 

Not  stated 

Typesetter 

Not  stated. 
Housewife. 

Housewife 

Not  stated 

Sculptor 

Housewife. 

Not  stated 

Peddler 

1,901 

1,920 

2,272 

2,223 

2,336 

3.251 

3.925 

6,209 

7.306 

7.935 

7,962 

8.373 

8,771 

Germany 

Germany 

Germany 

United  States  . . . 
United  States  .  . . 

Germany 

Italy  

Asthenia. 

Convulsions. 

Died  in  .Mmshouse  Hospital. 
Died  in  Bellevue  Hospital. 
Heart  paralysis." 
( ".angrene. 

Chronic   diffuse  nephritis  ;  died  in  Roosevelt 
Hospital. 

United  States  .  .  . 
Germany 

Scotland 

England 

Austria 

9.549 

9.641 

9.932 

10,926 

11.367 

11,877 

Russia- Poland. . . 

Germany 

United  States  .  .  . 
United  States  . . . 

Lobular  pneumonia. 

Mastoiditis  (operated),  seven  weeks' duration. 

Hypostatic  pneumonia. 

Phthisis. 

Acute  pulmonary  tuberculosis  ;  died  in  Mount 
Sinai  Hospital. 

12,038 

12,836 

13,672 

14.146 

14.362 

15.078 

15,431 

Housewife. 
Housewife. 

Merchant 

Housewife. 
Not  stated. 
Postal  clerk. 

Housewife 

Not  stated 

No  occupation   .  . 
Housewife. 

Merchant 

Janitor .           ... 

United  States  .  . . 

CJermany 

Germany 

England 

Germany 

Ireland 

Thrombus. 

19.285 

19.485 

20,473 

20,525 

21,053 

21,380 

22,963 

23.S32 

24,682 

25,188 

25.675 

27.025 

27.674 

27.689 

28.018 

Germany 

Holland 

Germany 

West  Indies 

Ireland 

\Veak  heart ;  old  age. 

Arteriosclerosis  ;  decubitus  ;  exhaustion. 

Carbuncle  (three  weeks). 
Died  in  St.  Vincent's  Hospital. 
Died  in  St.  Marks  Hospital. 

Carbuncles. 

Died  in  St.  Mark's  Hospital. 

Died  in  City  Hospital. 

Paralysis  cordis. 

Cellulitis  hand   and   arm  ;  diabetic    gangrene  : 

chronic   nephritis ;    died    in    Mount    Sinai 

Hospital. 
Cardiac  paralysis. 
Died  in  St.  Vincent's  Hospital. 

Germany 

United  States  .  . . 

Germany 

Hungary 

United  States  . .  . 

Not  stated 

Housewife. 

Housewife 

Housewife 

Photographer. 

Germany 

United  States  . . . 

Not  stated. 

Not  stated 

Clergyman 

Not  stated 

Dressmaker 

Not  stated. 

Teacher. 

Butler 

Russia 

28,228 

28,536 

United  States  (col) 

28,865 

29,661 

29,896 

29.972 

30,147 

32.137 

32.506 

32.659 

32.675 

33.300 

34.079 

35.663 

Bron.^  Bor. 

1,087 

1,632 

2.059 

Germany 

United  States  (col) 

Ireland 

Russia-Poland   .  . 
United  States  .  . . 
United  States  .  . . 
United  States  . . . 

England 

Germany 

United  States  . . . 

Chronic  diffuse  nephritis  (four  years),  asthenia. 

Respirator)'  failure  ;  died  in  Flower  Hospital. 

Exhaustion. 

Chronic  nephritis ;  myocarditis. 

Cellulitis,  back  and  arm 

Paralysis  cordis  ;  died  in  German  Hospital. 

Diabetic  gangrene  of  foot  (two  weeks) . 

Gangrene. 

Died  in  Montefiore  Home. 
.\cute  gastro-enteritis. 

Not  stated 

Not  stated 

Student. 

Not  stated 

Cigar  m'n'f'cturer 

Housewife 

Not  stated. 
Porter 

United  States  . . . 

United  States  .  .  . 
United  States  . . . 
United  States  . . 

56 

19 

34 
31 

Driver. 

Domestic. 

Color  mixer 

Housewife 

770 


MEDICAL    RECORD. 


[November  17,  1900 


2.  Asthenia,  UiNCOmplicated. — Table  V. 


No.  of  Certificate 
of  Death. 

Manhattan  Bor. 

J.ogg 

1,880 

3,oi8 

4.840 

4,854 

7.841 

14,004 

14.863 

15.S79 

17.479 

20,969 

21,466 

26,878 

26,794 

29,023 

29,148 

34.083 

34.700 

35.885 

Bronx  Bor. 

1,145 

3.340 


Nationality, 


England 

Ireland 

United  States  . 

Poland 

Ireland 

Germany 

Germany 

West  Indies. . . 
West  Indies. . . 

Austria 

Germany 

Germany 

Ireland 

United  States  . 
United  States  . 
United  States  . 

Russia 

United  States  . 
United  States  . 


United  States . 
Ireland 


Sex. 


F.. 
F.. 
M. 
F.. 
M. 
F.. 
F.. 
F.. 
M. 
M. 
F.. 
F.. 
F.. 
F.. 
M. 
M. 
F.. 
M. 
M. 


M. 
F.. 


Age,  Years. 


49- 
51- 
57- 
35- 
39- 
87. 
69. 
62. 
65- 
53- 
70. 

74- 
63- 
64. 
71- 
4- 
56. 
40. 
63. 


65. 
61. 


Duration  of 
Diabetes  Mellitus. 


2  years.. 


5  years. 


Occupation. 


Nurse. 
Not  stated. 

H.  W. 

Not  stated. 


Merchant. 
Tailor. 
Not  stated. 


Not  stated. 
Railroad  employee. 
Not  stated. 


Lawyer. 
Not  stated. 


3.   Asthenia,  Together  with  Gangrenous  Processes. — Table  VI. 


No.  of  Certificate 
of  Death. 

Nationality. 

Sex. 

Age. 

Duration  of  Dia- 
betes Mellitus. 

Occupation. 

Location  of  Gangrene. 

Manhattan  Bor. 

Oerraanv .             ... 

F. 
M. 
M. 
M. 
F. 
F. 
F. 
M. 
M. 

F. 

58 
61 
64 
60 
67 
79 
47 
43 
55 

51 

Housewife 

Baker 

Cigarmaker 

Left  leg. 

Germany 

Foot. 

Foot,  amputation. 

United  States 

Not  stated 

Toes. 

2  years 

Housewife 

Not  stated. 

Not  stated 

Right  foot. 

Housewife 

Amputation  of  thumb. 

Germany 

Ireland            

Tailor 

(Carbuncles). 

•je  Aic 

Storage  warehouse  prop. 

* 

Not  stated 

Foot. 

Bronx  Bor. 

United  States 

(Mastoid  abscess.) 

Occupation:  '  In  the  great  majority  of  instances  the 
former  occupation  of  the  diabetic  whose  death  ensued 
in  coma  was  stated.  The  "occupations"  mostly 
omitted  were  those  of  females. 


Occupation,  Males.  No. 

No  occupation — 

Not  stated 5 

Butcher 

Confectioner 

Merchants 

Shoemaker 

Typesetter 

Peddler 

Postal  clerk 

Janitor,  porter 

Photographer 

Drivers 

Clergyman 

Teacher 

Domestic 

Cigar  manufacturer 

Student 

Color  mixer 

Total 26 


Occupation,  Females.  No. 

No  occupation 4 

Not  stated 13 

Houseworkers 13 

Factory  worker i 

Sculptor I 

Dressmaker, I 

Domestic I 


Total 34 


Duration  of  diabetes  mellitus  before  coma  ensued: 
In   but  few  instances — in  fact,  too  few  to  be  of  any 

'  It  may  be  of  interest  to  learn  that  13  out  of  these  f)0  patients 
died  in  public  hospitals.  While  a  few — probably  three — of  those 
who  died  in  hospitals  were  "pay  patients  "  ;  the  vast  majority,  on 
the  other  hand,  were  "charity  patients." 


definite  value — was  the  duration  of  the  affection,  prior 
to  the  establishment  of  coma,  recorded.  The  average 
duration  of  the  g  recorded  instances  amounted  to  4 
years  and  5  months. 

Duration  of  coma:  But  9  certificates  give  infor- 
mation as  to  the  duration  of  the  comatose  con- 
dition. This  varied  from  two  hours  in  one  instance 
to  one  week  in  another.  The  mean  duration  of  the 
comatose  state  in  these  9  instances  was  a  trifle  over 
44  hours. 

Diseases  and  conditions  concurring  with  the  cases 
of  diabetes  mellitus  which  terminated  in  coma: 

Occurred  in 

Carbuncle 2  instances. 

Cellulitis 2 

Diabetic  gangrene 4 

Mastoiditis i  instance. 

Nephritis 4  instances. 

Paralysis  cordis 4 

Exhaustion  ~| 

Asthenia         (without    specification) 7 

Old  age       J 

Paralysis  (without  specification) i  instance. 

Respiratory  failure i 

Pulmonary  phthisis 2  instances. 

Pneumonia 2 

Myocarditis 1  instance. 

Castro  enteritis I 

Convulsions  (no  specification) I 

Thrombus i 

Arteriosclerosis I         " 


^ 


November  17,  1900] 


MEDICAL    RECORD. 


771 


4.  Septic/Emia.' — Table  VII. 


No.  of  Certificate 
of  Death. 

Nationality. 

Sex. 

Age. 

Duration  of  Dia- 
betes Mcllitus 

Occupation, 

Extract  from  Certificate  of  Death. 

Manhattan  Bor. 
8  5S0 

-\ustria         

M. 

M. 

M. 
M. 
F. 
M. 
M. 
M. 
F. 

M. 
F. 
F. 
M. 

F. 

56 
70 

67 
63 
72 
39 
57 
61 
58 

65 
55 
37 
61 

57 

Police  officer 

Gangrene   of   foot,  septic   parotitis, 

Germany        

No  occupation 

general  sepsis. 
Chronic  nephritis  (6  mos  ),  gangrene 

Collector 

of  leg.  septic  fever  (i  week). 
Gangrene  of  foot,  septicemia. 

Holland 

3  years 

Gangrene  of  foot. 

Domestic 

Gangrene  of  leg. 

t8  02T 

Bohemia 

Saloonkeeper 

Septicaemia. 

Gangrene. 

Laborer 

Gangrene. 

Chronic  endocarditis,  gangrene  right 

Germany 

Ireland. .    

leg. 
Gangrene  of  foot. 

Housewife 

Gangrene  of  foot,  sepsis. 

20   TX1 

Domestic 

Gangrene. 

Gangrene  of  right  leg,  atheroma. 

Bronx  Bor. 

United  States 

Inmate  Colored  Home . . 

Gangrene,  amputation  of  thigh. 

Under  this  heading  I  have  classified  all  those  cases  of  "gangrene"  where  "asthenia"  is  not  given  as  direct  cause  of  deaths. 


5.  Cardiac  Paralysis,  Cardiac  Asthenia,  and  Fatal  Syncope.'— Table  VIII. 


No.  of  Certificate 
of  Death. 


Manhattan  13or. 

1,980 

7.404 


8,940. 
10,971. 
II. 251. 
11,380. 
11,403. 
12,362. 
M.774- 
15.039- 
15. "97- 
16,226. 

23.179- 
23,850. 

25, 103- 
28,619. 
29,623. 
30,197- 
31,796. 
32.850. 
35.388. 
33.170. 


Bronx  Bor. 


290. 

664. 

2.670. 


3,341 United  States. 

3,642 Germany 


Nationality. 


United  States. 
Germany 


Germany 

Ireland 

France 

Germany 

Switzerland. .  . 
United  States. 

Germany 

Belgium 

United  States. 

Germany 

Germany 

Germany 


Italy 

Ireland 

Germany 

United  States . 
United  States. 

Germany 

Italy 

United  States. 


United  States. 
United  States. 
Ireland 


S«. 


K. 

F. 

F. 
F. 
M. 
F. 
M. 
F. 
F. 
M. 
M. 
F. 
M. 
F. 

M. 
M. 
F. 
F. 
F. 
F. 
M. 
M. 


F. 
F. 
M. 

M. 
F. 


Age. 


60 
66 

58 
47 
70 
68 
52 
59 
62 
50 
49 
59 
67 
64 

52 
57 
62 
36 
75 
70 
68 
64 


77 
43 

51 

■  4 
6S 


Duration  of  Dia- 
betes Mellitus. 


3  years. 


4  years. 


12  years. 


Occupation. 


Housewife. 

No  occupation 

Housewife. 

Housewife. 

Timekeeper, 

Housewife. 

Cigar  manufacturer 

Housewife 

Not  stated. 

Cook 

Produce  dealer. 
Housewife. 
Not  stated. 
Domestic 

Carpenter. 

Clergyman 

Not  stated. 

Not  stated 

Not  stated 

Not  stated 

Clerk 

Not  stated 

Not  stated 

Not  stated. 
Bartender 

Not  stated. 

Not  stated 


Intercurrent  and  Concurrent  Diseases 
and  Conditions. 


Chronic  myocarditis,  chronic 
Bright' s  disease. 


Gangrene  of  right  foot. 
Gangrene,  nephritis. 


Gangrene,     amputation     of     thigh, 
shock. 

Acute  pulmonary  tuberculosis. 

Bright's  disease. 

Gangrene,  valvular  cardiac  disease. 

Chronic  endocarditis. 

Chronic  nephritis. 

Valvular  heart  disease. 


Endocarditis. 

Aortic   and   mitral   obstruction   and 
regurgitation. 

Dilated  heart. 


'  I  have  classified  under  this  title  all  the  cases  of  heart  paralysis,  with  exception  of  those  which  occurred  together  with  coma. 

6.  Congestion  and  CEdema  of  Lungs. — Table  IX. 


No.  of  Certificate 
of  Death. 

.Manhattan  Bor. 

12,207 

22,227 

25,093 

27.519 

29.374 

30,546 

33.049 

33.811 

Bronx  Bor. 

1,941 

2.683 


Nationality. 


Ireland. . 
Ireland. . 
Holland . 
Russia  . . 

Germany 
Scotland. 
Canada  . 
Germany 

Ireland. 
Germany 


Sex. 

Age. 

M. 

60 

M. 

55 

M. 

75 

F. 

49 

M. 

72 

F. 

47 

M. 

32 

M. 

60 

F. 

62 

M. 

63 

Duration  of  Dia- 
betes Mellitus. 


Several  vears 


9  years. 


Occupation. 


Tailor. 
Laborer. 
Not  stated. 
Not  stated .... 

Not  stated. . . . 
Not  stated. 
Physician. 
Wine  merchant 

Not  stated. 
Engraver 


Intercurrent  and  Concurrent  Affections. 


Chronic   nephritis,  myocarditis  (ap- 

noea  2  days) . 
Arteriosclerosis. 


Gangrene  (amputation  left  thigh). 


Dilatation   of    heart, 
neck. 


carbuncles   of 


772 


MEDICAL    RECORD. 


[November  17,  1900 


7.   Deaths  from  Diabetes  Mellitus.  Without  Specification  ok  Eithkr  Direct  or  Contributing  Causes.— Table  X. 


No.  of  Certificate 
of  Death. 

Manhattan  Bor. 

1.365 

1.765 

2,706 

4.455 

6,146 

7.9S6 

8,962 

12,990 

13.776 

14,182 

14.207 

14.899 

18,352 

21.557 

23.585 

24,878 

29.404 

30,187 

30,451 

30,991 

32,586 

32,851 

34.107 

34.S03 

35.432 

Bronx  Hor. 

1,672 

1,832 

2,913 

3,159 

3.714 


Nationality. 


United  States 
Germany  .... 

Ireland 

K  ussia 

Russia 

Ireland 

tlermany  .... 

Ireland 

Italy 

United  States 
Germany .... 
Germany .... 

China 

United  .States 
Russia  ...... 

Ireland 

Ireland 

Germany 

Ireland 

United  States 

(Germany 

West  Indies  .  , 

France 

Russia 

England 

Germany 

Germany 

United  States, 
United  States , 
Scotland 


Sex. 

Age. 

M. 

2 

M. 

54 

F. 

38 

M. 

25 

F. 

65 

F. 

61 

F. 

75 

M. 

39 

M. 

46 

M. 

44 

M. 

46 

F. 

75 

M. 

50 

M. 

20 

F. 

54 

M. 

63 

F. 

55 

F. 

76 

F. 

55 

M. 

42 

M. 

54 

M. 

55 

F. 

74 

F. 

53 

M. 

46 

F. 

55 

F. 

57 

M. 

27 

F. 

45 

M. 

63 

Duration  of  Dia- 
betes Mellitus. 


6  years. 


3  years. 


I  yr.  7  mo. 


Orcupation. 


Restaurant  keeper. 

Tailor  (operator)  . 

Housewife 

Not  stated. 

Not  stated 

Bartender. 
Stone  mason. 
Laundry. 

Railroad  employee 
Not  stated. 

Laundry 

Porter 

No  occupation. 
Builder. 
Not  stated. 
Not  stated. 

Not  stated 

Journalist. 
Tailos. 

Merchant 

Housewife. 
Housewife. 
Manager. 

Not  stated. 
Not  stated. 
Gardener. 
Not  stated. 
Gardener 


Notes. 


Died  in  Gouverneur  Hospital. 
Died  in  Hahnemann  Hospital. 

Died  in  St.  Francis  Hospital. 


Coroner's  case. 
Coroner's  case. 


Died  in  New  York  Hospital. 
Coroner's  case. 


Coroner's  case. 


I  made  no  attempt  to  classify  the  30  remaining  in- 
stances according  to  the  immediate  cause  of  death. 
In  the  majority  of  the  certificates  no  direct  cause  is 
stated.     Besides  this,  most  of  these  instances  occurred 


together  with  chronic  affections  such  as  phthisis  or 
nephritis,  from  which  death  may  have  resulted  just  as 
frequently  as  from  diabetes,  per  se. 


F.  Accompanying  Affections.- 


I.  Phthisis  Pulmonum. — Table  XI. 


Nationality. 

Sex. 

Age. 

Duration  of 
Diabetes  Mellitus 

Occupation. 

Remarks  (Extract  from  Certificate  of  Death). 

Germany 

M. 

M. 
M. 
M. 
M. 

M. 

58 
59 
56 
35 
34 
57 
14 
40 

^'ears.  Months. 
5 

"2            "t 

Cattle  dealer 

Phthisis  pulmonum,  duration  si.x  months. 
Pulmonar)-  tuberculosis. 
Consumption,  duration  one  year. 

Germany 

Russia 

Russia 

Peddler 

United  States 

Ireland 

Salesman 

Clergyman 

Not  stated. 

Tuberculosis  ;  nephritis. 
.•Xcute  pulmonary  tuberculosis. 
Pulmonary  tuberculosis. 
Phthisis  ;  coma. 

United  States 

Russia 

2.   Nephritis  and  Other  Affections  of  the  Kidney. — Tap.le   XII. 


Nationality. 


United  States  (col.) 
Germany 

Germany 

.Scotland 

Germany 

Russia 

Belgium 

Canada  

United  States 

Austria 

Russia 

Russia 

United  States  (col.) 

Ireland   

United  States 

United  States 

United  States 

Ireland 

Germany 

Italy 

Ireland 


Sex. 

Age. 

M. 

36 

F. 

57 

F. 

66 

M. 

35 

M. 

70 

M. 

45 

M. 

50 

M. 

48 

M. 

34 

M. 

42 

F. 

44 

M. 

45 

M. 

50 

M. 

35 

F. 

5 

F. 

36 

F. 

54 

F. 

60 

M. 

73 

M. 

68 

M. 

55 

Duration  of 
Diabetes  Mellitus 


Several  years. 


Occupation. 


Cook 

Housewife 

No  occupation 

Typesetter 

No  occupation 

Merchant 

Cook 

Bookkeeper 

Salesman 

Peddler 

Not  stated 

Clergyman 

Butler 

City  official 

Not  stated 

Not  stated 

Housewife 

Bookkeeper 

Clerk 

Storage  warehouse  prop 


Remarks  (Extract  from  Certificate  of  Death). 


Chronic  diffuse  nephritis. 

Interstitial  nephritis ;  aortic  stenosis ;  arterio- 
sclerosis. 

Chronic  Bright's  disease;  chronic  myocarditis. 

Chronic  diffuse  nephritis;  diabetic  coma. 

Chronic  nephritis;  gangrene;  septic  fever. 

Nepliritis. 

Nephritis  ;  gangrene. 

Unvmia  (not  stated  that  nephritis  existed). 

Nephritis  ;  tuberculosis. 

Pyonephritis  ;  cystitis. 

Chronic  nephritis;  pulmonary  oedema;  myocarditis. 

Chronic  nephritis ;   gangrene;  coma. 

Chronic  diffuse  nephritis  (four  years) ;  coma. 

Nephritis. 

Urxmic  convulsions  (not  stated  tliat  nephritis 
existed) . 

Bright's  disease. 

Chronic  nephritis  ;  myocarditis  ;  coma. 

Chronic  dilTuse  nephritis. 

Urxmia  (not  stated  that  nephritis  existed). 

Chronic  nephritis. 

Amyloid  degeneration  of  kidney  ;  gangrene. 


November  17,  1900] 


MEDICAL    RECORD. 


n: 


3.  Gangre.nol's  Processes. — Table  XIII. 


Nationality. 


Germany .... 
Germany  .... 
Belgium  .... 
United  .States 

Ireland 

Austria 

Germany  .... 
United  States 

Ireland 

Russia    

Germany  .... 

Belgium 

Holland 

Ireland 

Ireland 

England  .... 

Ireland 

Germany .... 

France 

Russia 

Germany  .... 
Germany  .... 

Ireland 

England 

Ireland 

United  States 
Germany  .... 
Germany  .... 
Germany  .... 

Ireland 

United  States 
Ireland 


Sex. 

Age. 

F. 

58 

M. 

61 

M. 

64 

M. 

60 

^. 

51 

M. 

56 

M. 

70 

F. 

59 

F. 

67 

M. 

67 

F. 

79 

M. 

50 

M. 

63 

F. 

46 

F. 

72 

M. 

57 

M. 

61 

F. 

64 

F. 

58 

M. 

45 

M. 

65 

M. 

69 

F. 

55 

F. 

70 

F. 

37 

F. 

75 

F. 

65 

M. 

60 

M. 

61 

M. 

55 

F. 

57 

M. 

60 

Duration  of 
Diabetes  Mellitus. 


2  years. 


3  years. 


Occupation. 


Housewife 

Baker 

Cigarmaker 

Not  stated 

Not  stated. 

Police  olilcer 

No  occupation 

Housewife 

Housewife. 

Collector 

Not  stated 

Cook. 

Cigarmaker 

Housewife. 

Domestic 

Agent. 
Laborer. 

Domestic 

Housewife 

Clergyman. 

Driver 

Waiter 

Housewife 

Housewife 

Domestic. 
Not  stated. 

Housewife 

Wine  merchant     

Agent 

Storage  warehouse  prop 

Not  stated 

Porter. 


Remarks  (Extract  from  Certificate  of  Death}. 


Gangrene  of  leg. 
Gangrene  of  foot. 
Gangrene  of  foot. 
Gangrene  of  toes. 

Gangrene  of  foot. 
Gangrene  of  leg. 
Gangrene  of  right  foot. 

Gangrene  of  foot. 
Gangrene  of  right  foot. 

Gangrene  of  foot. 

Gangrene  of  legs. 


Gangrene  of  leg. 
Gangrene  of  right  leg. 

Gangrene  of  foot. 
Gangrene  of  foot. 
Ganijrcne  of  foot. 
Gangrene  of  foot. 


Gangrene  of  foot. 
Gangrene  of  left  thigh. 
Gangrene  of  right  leg. 

Gangrene  of  thigh. 


4.  Arteriosclerosis. — Table   XIV. 


Nationality. 

Sex. 

Age. 

Duration  of 
Diabetes  Mellitus. 

Occupation. 

Remarks  (Extract  from  Certificate  of  Death). 

Clermanv  . . 

F. 
F. 

M. 

57 
75 
72 

Housewife 

Arteriosclerosis  ;  aortic  stenosis. 

Holland 

Not  stated 

Arteriosclerosis. 

5.  Cardiac   Dilatation. — Table   XV. 


Nationality. 

Sex. 

Age. 

Duration  of  Dia- 
betes Mellitus. 

Occupation. 

Bemarks  (Extract  from  Certificate  of  Death). 

Germany 

M. 
F. 

63 

63 

Not  stated 

Dilatation  of  heart. 

Dilatation  of  heart. 

6.  Paralysis  (Excluding  Cardiac  Paralysis). — Table  XVI. 


Nationality. 

Sex. 

Age. 

Duration  of   Dia- 
betes Mellitus. 

Occupation. 

Remarks  (Extract  from  Certificate  of  Death). 

Holland 

F. 

M. 

71 

85 

3  years. 

No  occupation Paralysis  ;  coma. 

Tailor General  naralvsis  :  bronchitis. 

Ciermany 

7.  Various  Other  Accompanying  Conditions  and  Disorders. — Table   XVII. 


Nationality. 

Sex. 

Age. 

Duration  of  Dia- 
betes Mellitus. 

Occupation. 

Remarks  (Concurring  or  Intercurring  Afiections). 

Scotland 

F. 
F. 
F. 
M. 
F. 
F. 
M. 
M. 
M. 
F. 
F. 
M. 
F. 

62 

55 
42 
74 
66 
54 
69 
52 
69 
70 
31 
52 
60 

Russia-Poland 

United  States 

Germany . 

Housewife 

Sculptor 

Mprrhnnt    _ 

Lobular  pneumonia. 
Hypostatic  pneumonia. 

ThrrtrnKlIC  Ipft  mpHian   vpin. 

Germany 

Not  stated Myelitis. 

1  Not  stated Acute  dysenter)-. 

i  Watchman Erysipelas  ;   fistula  in  ano. 

United  States 

Germany    

1  Waiter Pulmonary  embolism. 

United  States 

I  year . 

Housewife I  Acute  gastro-enteritis. 

United  States 

No  occupation 

Phlebitis  of  leg  :  cerebral  embolism. 

774 


MEDICAL    RECORD. 


[November  17,  1900 


It  is  a  deplorable  fact  that  many  practitioners  habitu- 
ally omit  to  furnish  the  exact  and  complete  data  con- 
nected with  a  case  of  deatli.  This  is  especially  true 
of  the  young  hospital  internes.  A  statistical  attempt, 
like  this  one,  can  serve  a  definite  purpose  only  if  all 
the  facts  pretaining  to  a  case  of  death  have  been  con- 
scientiously reported. 

Inasmuch  as  the  recognition  of  the  chief  and  con- 
tributing causes  of  death  depend  entirely  upon  the 
amount  of  attention  devoted  by  and  the  ability  of  the 
medical  attendant,  the  value  of  the  various  certificates, 
emanating  from  so  many  sources,  for  statistical  studies 
must  naturally  differ. 

Many  cases  treated  for  "diabetes"  or  glycosuria  are 
neither  "diabetes"  nor  glycosuria.  On  the  other 
hand,  diabetes  niellitus  is  not  infrequently  entirely 
overlooked  and  many  a  certificate  of  death  containing 
the  insignificant  words  "inanition,"  "asthenia,"  "ex- 
haustion," etc.,  affixed  to  the  name  for  some  acute  dis- 
order, should  instead  bear  the  designation  "diabetes 
mellitus." 

56  East  Seventy-Sixth  Street, 


THE  USE  OF  THE  SUPRARENAL  CAPSULE 
IN  DISEASES  OF  THE  LOWER  AIR  PAS- 
SAGES.    A   PRELIMINARY    REPORT. 

By   SAMUEL   FLOERSHEIM,    M.D., 

NEW    YORK. 

Reports  on  the  use  of  the  suprarenal  capsule  in  dis- 
eases of  the  upper  air  passages  have  been  published 
by  Joseph  A,  Mullen,  H,  L,  Swain,  Beaman  Douglass, 
H.  H.  Curtis,  VV.  H.  Bates,  S.  Solis-Cohen,  and  others. 

The  diseases  in  which  I  have  used  the  suprarenal 
powder  are:  acute  tracheo-bronchitis,  chronic  bron- 
ciiitis,  bronchiectasis,  congestion  and  oedema  of  the 
lungs,  hce:iioptysis,  and  pulmonary  tuberculosis. 

The  suprarenal  powder  was  always  administered  in 
the  form  of  three-grain  capsules,  placed  in  the  mouth, 
thoroughly  chewed  without  water,  and  swallowed  in  a 
few  moments.  The  action  of  the  suprarenal  powder 
ad  ninistered  in  this  way  became  apparent  in  three  to 
ten  minutes.  The  capsule  of  suprarenal  powder 
should  not  be  swallowed  whole  with  water,  because 
the  juices  of  the  stomach  may  destroy  it. 

Acute  tracheo-bronchitis:  In  thirty-two  cases  the 
suprarenal  powder  lessened  the  frequency  and  severity 
of  the  cough.  In  some  cases  the  cough  entirely  dis- 
appeared or  remained  absent  from  ten  minutes  to  nine 
hours,  according  to  the  severity  of  the  attack.  The 
expectoration  was  decreased  in  amount,  the  mucous 
rales  in  the  bronchi  were  diminished,  and  in  those 
cases  in  which  the  attack  was  of  a  mild  type,  the  rales 
entirely  disappeared.  The  sensations  of  tightness, 
rawness,  pulsation,  and  dryness  in  the  upper  portion 
of  the  chest  and  throat  were  more  or  less  temporarily 
relieved.  The  respirations  became  easier,  and  the 
putients  stated  that  they  could  expand  their  chests 
more  fully  than  before  the  administration  of  the  supra- 
renil  powder. 

When  the  suprarenal  powder  was  administered  at 
the  onset  of  a  bronchitis,  three  grains  every  one  or 
two  hours,  with  no  other  treatment,  a  cure  was  usually 
obtained  in  twenty-four  hours.  The  acute  rhinitis  was 
also  promptly  relieved  by  the  administration  of  the 
suprarenal  powder. 

(Jhronic  bronchitis:  Twelve  cases  of  chronic  bron- 
chitis were  temporarily  relieved  by  the  administration 
of  the  suprarenal  powder.  The  benefit  was  apparent 
within  fifteen  minutes  after  the  first  dose. 

Bronchiectasis:  The  expectoration  when  profuse 
was  markedly  diminished  by  the  suprarenal  powder. 


The  cough  was  lessened,  and  the  patients  felt  much 
relieved. 

Bronchial  asthma:  When  the  paroxysms  of  asthma 
are  due  solely  to  nervous  influences,  the  suprarenal 
powder  has  no  power  to  control  the  attack.  But  if  the 
attack  is  accompanied  with  hypcra;mia  of  the  bron- 
chial mucous  membrane,  the  suprarenal  powder  is 
usually  beneficial. 

Congestion  of  the  lungs:  When  the  suprarenal 
powder  was  administered  the  rales  disappeared  within 
fifteen  minutes.  The  slight  dulness  over  the  pos- 
terior and  lower  portion  of  the  lungs  also  disappeared. 
The  slight  cough  and  watery  expectoration  which  were 
present  in  many  of  the  cases  were  promptly  checked. 
In  a  few  the  rales  remained  absent. 

CJidema  of  the  lungs:  U'hen  the  suprarenal  powder 
was  administered  the  rales  markedly  decreased  in 
number,  and  the  dulness  became  diminished  with  the 
rapid  absorption  of  the  fluid.  It  should  be  adminis- 
tered frequently.  It  may  act  in  the  same  way  here  as 
it  does  in  cedema  of  the  nose,  by  relieving  congestion. 

Hasmoptysis:  In  sixteen  cases  of  ha-nioptysis  from 
various  causes,  the  suprarenal  powder,  chewed,  stopped 
the  bleeding  from  the  lungs  in  less  than  half  an  hour. 
In  six  cases,  the  hemorrhage  stopped  in  five  minutes. 
The  suprarenal  powder  was  more  efficient  than  other 
remedies  employed.  It  was  not  objectionable  in  any 
way. 

Pulmonary  tuberculosis:  In  eight  cases  of  pulmo- 
nary tuberculosis  the  expectoration  and  the  cough  were 
diminished  by  the  suprarenal  powder  within  fifteen 
minutes.  The  patients  breathed  more  easily  and  felt 
brighter.  Ha;moptysis,  when  present,  was  contiolled. 
Some  of  the  larger  rales  and  many  of  the  smaller  ones 
disappeared. 

The  following  are  a  few  of  the  cases  in  which  the 
suprarenal  powder  was  administered: 

Case  I. — Mrs.  L.  S ,  aged  fifty-nine  years,  had 

a  severe  attack  of  acute  bronchitis  with  profuse  ex- 
pectoration and  a  constant  harassing  cough.  The 
suprarenal  powder  was  administered  with  difficulty. 
In  four  minutes  the  cough  was  lessened  in  severity 
and  the  expectoration  diminished  in  amount.  Five 
minutes  later  gr.  vi.  more  was  administered,  and  in  six 
minutes  the  cough  had  almost  entirely  disappeared. 
The  hoarseness,  rawness,  and  sensation  of  tightness 
around  the  neck  and  chest  materially  lessened.  The 
action  of  the  two  doses  of  the  suprarenal  powder  con- 
tinued for  about  three  hours. 

Case  II. — Mr.  F- ,  aged  twenty-four  years,  had 

a  tracheo-bronchitis  with  acute  rhinitis,  with  a  short, 
frequent  cough  and  a  slight  expectoration.  Three 
grains  of  the  suprarenal  powder  was  administered, 
and  in  two  minutes  the  nose  opened,  the  cough  and 
expectoration  disappeared.  The  next  day  he  devel- 
oped a  severe  bronchitis  from  exposure,  when  gr. 
xviii.  of  suprarenal  powder,  in  divided  doses,  were 
necessary  to  control  the  cough  completely.  The  re- 
lief was  permanent. 

Case  III. — Mrs.  M.  A ,  aged  thirty-seven  years, 

developed  a  severe  attack  of  acute  bronchitis  Supra- 
renal powder  within  two  minutes  lessened  the  cough 
and  expectoration,  and  the  patient  felt  better.  The 
suprarenal  powder  was  administered  every  two  to  three 
hours  with  benefit. 

Case  IV. — Mr.  G.  H ,  aged   twenty-nine  years, 

had  a  severe  attack  of  acute  bronchitis  with  expectora- 
tion of  a  very  thick,  tenacious,  yellowisli  mucus  and 
a  severe  cough  with  marked  hoarseness.  Suprarenal 
powder,  gr.  vi.,  had  no  effect  in  ten  minutes.  At  the 
end  of  that  time  gr.  x.  more  was  administered  with 
apparently  no  benefit,  I'^ive-grain  capsules  of  ammo- 
nium carbonate  were  ordered  to  be  taken,  one  every 
two  to  three  hours,  and  the  patient  to  report  when  the 
expectoration   became  thin.     The  following  day  I  ad- 


November  17,  1900] 


MEDICAL    RECORD. 


775 


ministered  gr.  vi.  of  suprarenal  powder,  and  in  six 
minutes  the  cough  and  expectoration  became  percepti- 
bly lessened.  At  the  end  of  fifteen  minutes  gr.  ix. 
more  were  administered,  and  in  twenty  minutes  the 
cough  and  expectoration  had  almost  entirely  ceased. 
His  throat,  which  had  felt  hot  and  sore,  was  much 
relieved. 

Case  V. —  Mrs.   L.  H ,  aged   forty-seven  years, 

developed  a  severe  attack  of  bronchitis  following  an 
extensive  burn  of  the  face,  neck,  chest,  and  right  arm. 
Suprarenal  powder  was  administered  every  hour.  The 
cough  was  temporarily  controlled. 

Case  VI. — Miss  A ,  aged   fifteen  years,  had  an 

attack  of  acute  bronchitis.  She  was  suffering  from  ky- 
phosis, pulmonary  tuberculosis,  cardiac  disease,  ance- 
mia,  and  rachitis.  The  suprarenal  powder  stimulated 
her  diseased  heart;  tiie  cough  became  lessened,  the 
expectoration  diminished  in  amount;  the  pain  and 
rawness  in  the  chest,  which  she  experienced  on  inspi- 
ration, disappeared;  the  burning  sensation  in  the 
throat  lessened,  and  on  inspection  of  the  throat  it 
was  observed  that  it  gradually  became  paler.  Haemop- 
tysis, which  was  slight  but  constant  for  three  days, 
was  promptly  checked. 

Case  VII.  — Mr.  P.  K— — ,  aged  forty-eight  years, 
had  a  severe  attack  of  acute  bronchitis  on  a  chronic 
bronchitis  with  bronchial  asthma.  He  expectorated 
three  pints  of  mucus  daily  for  two  years.  He  was  in 
a  desperate  condition  :  he  was  cyanotic  ;  the  heart  was 
weak;  the  cough  was  extremely  harassing  with  no  in- 
termission for  two  hours  before  I  saw  him.  He  seemed 
to  be  suffocating,  and  showed  signs  of  impending  heart 
failure.  Six  grains  of  suprarenal  powder  was  admin- 
istered with  great  difficulty  on  account  of  the  constant 
coughing.  In  two  minutes  the  cough  became  |5er- 
ceptibly  lessened,  and  a  ch.mge  came  over  tlie  patient, 
which  indicated  that  marked  relief  was  afforded.  The 
respirations  became  fuller  and  easier,  and  the  heart 
was  siinuilated.  In  five  minutes  the  profuse  expecto- 
ration and  very  severe  cough  had  almost  entirely  dis- 
appeared, to  the  great  surprise  of  the  patient,  his  rela- 
tives, the  neighbors,  and  myself.  No  such  prompt  and 
marked  relief  was  afforded  by  any  other  treatment. 
The  patient  remarked  that  he  had  not  felt  so  well  in 
two  years.  The  action  of  the  suprarenal  powder  con- 
tinued twenty  minutes,  when  his  symptoms  began  to 
return.     A  second  dose  gave  prompt  relief. 

Conclusions. — i.  Indications  for  suprarenal  powder: 
The  suprarenal  powder  is  indicated  in  acute  and 
chronic  bronchitis,  bronchiectasis,  asthma,  congestion 
and  oedema  of  the  lungs,  hemoptysis,  and  in  some 
cases  of  pulmonary  tuberculosis,  especially  in  those 
associated  with  hajtioptysis. 

2.  Method  of  administration  :  The  suprarenal  pow- 
der was  administered  in  the  form  of  three-grain  cap- 
sules on  account  of  their  convenience.  The  powder 
is  to  be  ciiewed  without  water  and  then  to  be  swallowed 
in  a  few  moments. 

3.  Rapidity  of  the  action  of  suprarenal  powder: 
The  action  became  apparent  in  from  two  to  fifteen 
minutes. 

4.  Permanence  of  the  action  of  suprarenal  powder: 
In  some  cases  the  action  of  the  suprarenal  powder 
was  permanent,  while  in  the  majority  of  cases  the 
action  was  temporary,  continuing  from  ten  minutes  to 
six  hours. 

218  East  ToRTv-siXTH  Street. 


Rigidity  of  the  Spine.— J.  H.  McBride  reports  for 
the  first  time  the  histories  of  two  cases  seen  some  thir- 
teen years  ago.  Case  I.  was  that  of  a  soldier  who 
was  not  wounded  in  service,  but  whose  spine  some  ten 
years  later  began  to  get  stiff.  The  head  was  thrown 
forward  and  carried  in  that  position  apparently  with 


the  greatest  care.  The  knees  were  bent  in,  apparently 
from  contraction  of  the  adductor  muscles,  while  the 
hip  joints  were  almost  immovable.  Early  in  the  dis- 
ease he  had  some  pain  in  the  left  foot  but  that  disap- 
peared and  otherwise  he  had  no  pain,  spasms,  or 
tremors.  Later  a  curvature  of  the  dorsal  spine 
developed.  Case  II.  was  that  of  a  laborer  in  whom 
the  diagnosis  of  hypertrophic  cervical  pachymeningitis 
was  made,  the  condition  following  trauma.— /ow/vw/it/ 
Nervous  and  Mental  Disease,  October,  1900. 

The   Diagnostic    Value    of   Babinski's    Sign J. 

Kollarits  describes  this  phenomenon  as  being  best 
elicited  when  the  muscles  of  the  lower  extremities  are 
relaxed,  and  the  patient  with  closed  eyes  knows  noth- 
ing of  the  experiment  about  to  be  performed.  The 
thigh  with  the  leg  slightly  Hexed  is  to  be  supported  by 
the  observer's  hand,  and  the  sole  of  the  foot  gently  ir- 
ritated by  pricking,  tickling,  etc.  In  normal  adults 
the  foot  will  be  dorsi-flexed  and  the  toes  flexed  tow- 
ard the  plantar  surface,  but  if  the  sign  be  present, 
while  the  foot  is  flexed  as  before,  the  toes  are  extended. 
The  significance  of  the  phenomenon,  according  to  its 
discoverer,  is  that  it  is  present  only,  though  not  alw  ays, 
when  the  pyramidal  tracts  are  diseased.  A  review  of 
the  literature  leads  Kollarits  to  believe  that  this  is 
true,  and  that  the  symptom  is  of  value  in  distinguish- 
ing organic  from  functional  disorders.  Furthermore, 
in  apopletic  cases  it  gives  early  information  as  to 
which  side  will  be  the  paralyzed  one. — Kliiiisch-lhe- 
rapeutisclie  U'oclunschrijt,  September  23,  1900. 

Exclusive  Soup  Diet  and  Rectal  Irrigations  in 
Typhoid  Fever.  —  Basing  his  statements  upon  a  per- 
sonal experience  of  one  hundred  and  fifty-three  cases 
in  private  and  hospital  practice  during  the  last  ten 
years,  A.  Siebert  gives  the  following  as  the  results  of 
this  mode  of  treatment:  i.  Delirium,  headache,  in- 
somnia, nausea,  vomiting,  and  tympanites  usually  dis- 
appeared within  forty-eight  hours  of  treatment.  2. 
Tympanites,  nausea,  and  vomiting  never  developed  in 
any  patient,  even  when  complicating  pneumonia  was 
present.  3.  The  fur  on  the  tongue  disappeared  within 
a  few  days.  4.  Appetite  came  frequently  on  the 
fourth  day  of  treatment,  even  when  the  thermometer 
registered  102' to  103"  F.  5.  Even  excessive  diarrhcea 
(fifteen  to  twenty-five  daily  stools)  disappeared  inva- 
riably within  the  first  week  of  treatment.  6.  In  all 
uncomplicated  cases  the  temperature  began  to  decline 
within  twenty-four  to  forty-eight  hours  after  the  begin- 
ning of  treatment  and  invariably  would  reach  the  nor- 
mal figure  within  ten  to  twelve  days.  7.  In  cases 
complicated  by  pneumonia,  nephritis,  or  phlebitis 
when  treatment  began,  the  temperature  usually  re- 
mained in  accord  with  the  inflammatory  conditions 
found  until  these  also  disappeared  ;  while  the  cerebral, 
gastric,  and  intestinal  disturbances  usually  subsided 
as  rapidly  as  in  the  uncomplicated  cases,  excepting 
anorexia.  8.  Complications,  when  not  present  at  the 
start,  were  very  rare  and  then  usually  developed  with- 
in the  first  two  days.  9.  Intestinal  hemorrhage  was 
noticed  in  three  cases,  none  ending  fatally.  Perfo- 
ration did  not  occur.  Five  feedings  were  given  dur- 
ing the  day.  After  an  initial  purge  the  patients  seemed 
to  do  as  well  for  forty -eight  hours  on  cold  w^ater  alone 
as  on  any  kind  of  food.  Then  soups  were  given  made 
of  barley,  oatmeal,  rice,  and  peas,  strained  and  well 
salted  and  peppered.  Two  days  later  lentil  soup  and 
the  yolk  of  a  fresh  egg  were  added  to  the  oatmeal,  rice, 
and  barley  soups.  An  adult  was  allowed  half  a  pint 
of  two  kinds  of  soup  alternating,  every  three  hours. 
Five  to  fifteen  drops  of  dilute  hydrochloric  acid  were 
given  before  each  meal  unless  hyperacidity  prevailed, 
but  no  other  medicine.  Cold  water  was  allowed  ad 
libitum. — Northwestern  Lancet,  October  i,  1900. 


776 


MEDICAL    RECORD. 


[November  17,  1900 


Medical  Record: 

A    Weekly  Journal  of  Medicine  and  Surgery. 


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

Publishers 

WM.   WOOD   &.  CO.,  51    Fifth   Avenue. 

New  York,  November  17,  1900. 


THE  SYMPTOMATOLOGY  AND  TREATMENT 
OF    PANCREATITIS. 

The  difficulties  surrounding  the  diagnosis  of  intra- 
abdominal disease  are  so  well  known  as  not  to  require 
elaboration.  Nevertheless,  a  good  deal  of  light  has 
been  thrown  in  recent  years  upon  this  subject,  and 
among  the  affections  to  which  considerable  attention 
has  been  given  are  those  of  the  pancreas.  Like  other 
tissues,  this  organ  may  be  the  seat  of  hemorrhage,  of  in- 
flammation, of  new  growths,  and  its  ducts  of  cystic  dila- 
tation and  of  calculi.  A  special  feature  of  all  forms 
of  pancreatic  disease  may  be  the  development  of  the 
condition  known  as  fat  necrosis.  By  reason  of  its  re- 
lations with  the  intestine,  the  pancreas  is  peculiarly 
exposed  to  the  dangers  of  infection,  and  through  the 
junction  of  its  excretory  duct  with  that  of  the  liver, 
disease  of  the  one  may  give  rise  to  symptoms  also  of 
disease  of  the  other.  An  admirable  description  of 
pancreatitis  is  given  by  Mayo  Robson  {^Lancet,  July 
28,  1900,  p.  235)  in  a  clinical  lecture  recently  deliv- 
ered before  the  Medical  Graduates'  College  and  Poly- 
clinic of  London.  The  acute  disease,  it  was  pointed 
out,  may  be  hemorrhagic,  suppurative,  or  gangrenous. 
It  usually  sets  in  with  sudden  pain  in  the  superior 
abdominal  region,  attended  with  faintness  or  collapse 
and  followed  by  vomiting.  The  bowels  are  almost 
always  constipated,  although  flatus  may  escape  and  a 
large  enema  may  secure  an  evacuation.  Should  the 
patient  survive  for  a  few  days,  diarrhcea  may  super- 
vene. The  pain  undergoes  paroxysmal  exacerbations 
and  is  attended  with  tenderness  above  the  umbilicus. 
It  is  soon  followed  by  distention  in  the  superior  ab- 
dominal region,  which  may  become  general,  and  by 
vomiting,  first  of  food  and  then  of  bile.  Slight  icterus 
is  usually  present,  and  becomes  gradually  more  pro- 
nounced. The  aspect  is  anxious  and  the  face  pinched. 
The  pulse  is  rapid  and  small,  while  tlie  temperature 
may  be  normal,  subnormal,  irregular,  or  high.  Delir- 
ium may  develop  at  a  late  stage.  If  careful  examina- 
tion can  be  made  the  pancreas  may  be  found  enlarged. 
Death  usually  occurs  between  the  second  and  the  fifth 
day  from  collapse,  although  in  less  acute  cases  life 
may  be  more  prolonged. 

In  cases  of  subacute  pancreatitis  collapse  is  less 
marked  and  may  be  wanting;  tlie  upper  abdominal 
region  does  not  become  so  rapidly  swollen,  and  vomit- 
ing is  less  severe  and  less  prolonged.     In  other  cases 


the  onset  is  more  gradual,  though  the  symptoms  may 
be  similar.  Tenderness  over  the  pancreas  is  well 
marked,  and  it  may  be  possible  to  feel  the  swollen 
gland,  especially  under  an  anaesthetic.  Constipation 
gives  place  to  diarrhoea,  and  pus  or  blood  may  appear 
in  the  stools,  which  may  have  a  very  fetid  odor.  The 
pulse  is  less  rapid  and  less  thready,  and  the  temper- 
ature more  irregular.  Repeated  rigors  may  occur. 
Constant  dull  epigastric  pain  is  present,  with  paroxys- 
mal exacerbations.  The  more  urgent  symptoms  may 
subside  and  improvement  appear  to  be  taking  place, 
but  loss  of  flesh  continues  and  relapses  usually  occur, 
leaving  the  patient  each  time  more  feeble,  until  death 
supervenes  from  asthenia.  Albuminuria  is  pretty 
constant,  but  glycosuria  is  rarely  present,  and  lipuria 
is  an  uncommon  symptom.  Should  an  abscess  de- 
velop a  tumor  may  appear  in  the  superior  abdominal 
region,  or  the  pus  may  burrow  into  the  loin  and  form  a 
perirenal  abscess,  or  under  the  diaphragm  and  form  a 
subphrenic  abscess;  or  it  may  follow  the  psoas  muscle 
and  form  a  subperitoneal  abscess  in  the  iliac  region, 
or  pass  over  the  brim  of  the  pelvis  and  collect  in  the 
left  broad  ligament.  The  abscess  may  rupture  into 
the  stomach  and  the  pus  be  vomited,  or  into  the  bowel 
and  the  pus  be  voided  through  the  anus.  Witii  the 
evacuation  of  the  pus,  temporary  relief  follows,  but 
relapses  usually  occur  and  a  mild  form  of  septicaemia 
persists,  with  a  hectic  temperature.  Death  is  the 
usual  termination,  although  recovery  may  occur  after 
a  tedious  and  prolonged  illness. 

Chronic  pancreatitis  probably  arises  usually  by  ex- 
tension from  chronic  catarrh  of  the  pancreatic  duct, 
secondary  to  gastro-duodenal  catarrh,  though  it  is  fre- 
quently associated  with  biliary  or  pancreatic  lithiasis, 
or  with  gastric,  pyloric,  or  duodenal  ulcer.  Its  onset 
may  be  gradual  and  painless,  or  attended  with  severe 
epigastric  pain,  followed  by  jaundice  and  associated 
with  nausea  and  vomiting,  and  perhaps  followed  by  a 
feeling  of  chilliness  or  even  a  rigor.  A  tender  spot 
is  usually  present  an  inch  above  the  umbilicus  in  the 
middle  line.  The  jaundice  tends  to  deepen  with  each 
attack  until  it  becomes  continuous  and  chronic,  al- 
though it  is  not  necessarily  present  at  first.  The  pain 
may  undergo  paroxysmal  exacerbations  or  consist 
merely  in  a  dull  ache,  deeply  seated,  and  burning  and 
boring  in  character.  A  swelling  of  the  pancreas  can 
sometimes  be  made  out,  but  usually  only  under  anaes- 
thesia. Loss  of  flesh  and  of  strength  are  always  well- 
marked  symptoms.  Vomiting  may  sometimes  be  ab- 
sent, "but  the  appetite  is  usually  wanting,  and  flatulent 
dyspepsia  is  present,  together  always  with  a  sense  of 
fulness  and  weight  at  the  epigastrium  for  some  time 
after  eating.  The  stools  are  white  when  the  pancre- 
atic fluid  alone  is  absent  from  the  intestines.  Diar- 
rhoea is  often  present  and  tlie  intestinal  discharges  are 
offensive  and  fatty.  Albuminuria  is  common  and 
glycosuria  may  occur.  Fever  may  be  absent,  althougii 
in  some  cases  the  temperature  pursues  a  hectic  course, 
especially  when  ague-like  paroxysms  occur.  When 
jaundice  is  present  the  pulse  may  be  slow,  although  it 
is  not  much  accelerated  even  when  the  temperature  is 
elevated,  though  it  may  be  poor.  In  the  later  stages, 
especially  if  jaundice  is  present,  hemorrhages  from  the 


November  17,  1900] 


MEDICAL    RECORD 


m 


nose  and  the  bowel,  hasmatemesis,  and  petechia;  occur, 
and  death  results  from  progressive  asthenia.  In  the 
more  chronic  cases,  especially  when  there  is  contrac- 
tion of  the  head  of  the  pancreas,  a  tumor  will  be 
formed  by  the  distended  gall  bladder. 

Chronic  interstitial  pancreatitis  is  to  be  diflferentiated 
from  gall  stones  in  the  common  duct,  from  carcinoma 
of  the  head  of  the  pancreas  or  of  the  liver  and  the 
bile  ducts,  and  from  chronic  catarrh  of  tlie  bile  ducts. 
The  disease  may  last  for  months  or  even  years.  The 
presence  of  glycosuria  renders  the  outlook  more  grave. 
Increasing  weakness  and  the  supervention  of  hemor- 
rhagic tendencies  usually  indicate  the  near  approach 
of  a  fatal  termination.  Under  surgical  treatment  the 
prognosis  is  most  favorable. 

In  the  treatment  of  acute  infective  pancreatitis  the 
pain  at  the  outset  is  so  acute  as  to  necessitate  the 
administration  of  morphine,  and  the  collapse  will 
probably  demand  the  use  of  stimulants,  which,  on  ac- 
count of  the  associated  vomiting,  may  have  to  be  given 
by  enema.  In  the  early  stages  the  symptoms  are  so 
indefinite  that  the  indications  for  surgical  treatment 
are  not  sufficiently  clear  to  warrant  operation,  and  no 
surgical  procedure  would  be  justifiable  until  the  col- 
lapse has  passed  off.  As  prompt  evacuation  of  the 
septic  material  is  necessary  fy  recovery,  early  explo- 
ration in  the  left  costo-vertebral  angle  is  demanded. 

In  the  subacute  form  of  pancreatitis  morphine  may 
be  required  to  relieve  the  paroxysmal  pain,  and  stimu- 
lants and  food  by  the  rectum  to  relieve  the  collapse 
and  sustain  the  strength.  Distention  may  require  re- 
lief by  lavage  of  the  stomach  and  turpentine  enema- 
ta,  or  by  the  administration  of  calomel  by  the  mouth 
in  small,  repeated  doses,  or  in  doses  of  five  grains, 
followed  by  an  aperient.  Should  diarrhoea  super- 
vene, salol  and  bismuth,  with  small  doses  of  opium, 
may  be  given.  Should  surgical  treatment  be  decided 
upon,  a  median  incision  above  the  umbilicus  will  en- 
able the  operator  to  palpate  the  pancreas  and  locate 
any  incipient  collection  of  pus,  which  should  if  pos- 
sible be  evacuated  by  a  posterior  incision  in  the  left 
or  right  costo-vertebral  angle,  or,  failing  that  possi- 
bility, the  collection  of  pus  may  be  aspirated,  and  the 
cavity  opened  and  packed  with  gauze,  which  may  be 
brought  forward  through  a  large  rubber  drainage-tube 
that  will  in  the  course  of  from  twenty-four  to  forty- 
eight  hours  establish  a  track  isolated  from  the  general 
peritoneal  cavity.  Should  a  definite  abscess  form  and 
approach  the  surface  in  front  or  in  either  loin,  incision 
and  drainage  will  be  demanded.  The  strength  must 
be  maintained  by  careful  feeding  and  the  judicious 
administration  of  stimulants.  Further  collections  of 
pus  and  subphrenic  abscess  or  empyema  will  require 
special  treatment. 

In  cases  of  chronic  interstitial  pancreatitis,  manipu- 
lation of  the  indurated  tumor  may  detach  calculi 
impacted  in  the  duct,  while  in  others  the  relief  of  ten- 
sion, as  the  result  of  draining  the  bile  ducts  by  chole- 
cystotomy  or  cholecystenterostomy,  may  indirectly 
drain  the  pancreatic  duct  and  thus  lead  to  a  sub- 
sidence of  the  pancreatitis,  then  to  an  opening  of  the 
common  duct  by  the  relief  of  the  tension,  and  so  to 
cure.     The    simulation  of  malignant  disease   of   the 


head  of  the  pancreas  by  chronic  interstitial  pancrea- 
titis should  make  the  surgeon  hesitate  to  decline 
operation  in  any  case  of  distended  gall  bladder  when 
the  patient  is  in  a  condition  to  bear  it,  or  even  in  any 
case  of  chronic  jaundice  without  distention  of  the 
gall  bladder  when  the  general  health  is  deteriorating; 
for  although  if  the  disease  be  malignant  little  good 
can  be  done,  yet  if  the  disease  prove  to  be  chronic 
pancreatitis  real  and  permanent  cure  may  be  brought 
about.  If  a  calculus  be  felt  embedded  in  the  head  of 
the  pancreas  or  impacted  in  the  pancreatic  duct,  it 
may  be  reached  through  the  second  part  of  the  duode- 
num by  laying  open  the  papilla  and  exploring  the 
duct,  or  by  dividing  the  peritoneum  passing  between 
the  duodenum  and  the  hepatic  flexure  of  the  colon, 
and  then  cutting  through  the  overlying  pancreas  on  the 
concretion.  If  the  papilla  be  incised  it  does  not  re- 
quire suture,  and  exploration  of  the  ducts  by  the  duo- 
denal route  may  be  unattended  with  hemorrhage.  The 
anterior  duodenal  opening  requires  closing  by  a  mucous 
and  a  serous  suture.  Drainage  of  the  right  kidney 
pouch  for  from  twenty-four  to  forty-eight  hours  is  ad- 
visable, although  not  always  necessary,  and  this  is 
best  secured  by  means  of  a  stab  wound  at  the  most 
dependent  part.  For  attacking  the  head  of  the  pan- 
creas or  the  pancreatic  duct  a  vertical  incision  should 
be  made  through  the  right  rectus  and  not  in  the  mid- 
dle line.  In  cases  presenting  deep  jaundice,  it  is  well 
to  prescribe  calcium  chloride  in  twenty-grain  doses 
thrice  daily  for  twenty-four  or  forty-eight  hours  before 
operation,  and  to  give  it  in  an  enema  form  for  twenty- 
four  hours  afterward  in  sixty-grain  doses  thrice  daily. 
Of  seventeen  cases  operated  on  in  which  chronic  pan- 
creatitis was  found,  recovery  ensued  in  sixteen. 


CAUSES    OF    SUICIDE. 

Dr.  J.  VV.  C.  Cuddy,  professor  of  medicine  in  the 
University  School  of  Medicine,  Baltimore,  contributed 
to  The  Baltimore  Atneriain  an  able  article  on  the  sub- 
ject of  suicide.  He  is  of  the  opinion)  which  is  prob- 
ably shared  by  most  scientific  men,  that  no  absolutely 
sane  person  takes  his  own  life.  In  those  cases  in 
which  an  individual  commits  suicide  there  is  undoubt- 
edly an  unhinging  of  the  mental  balance.  This  may 
be  temporary,  but  nevertheless  self-destruction  must 
&e  attributed  to  an  insane  impulse.  There  are  many, 
however,  of  course,  who  do  not  hold  this  view,  but  be- 
lieve that  suicide  may  be  a  deliberate  sane  act.  Dr. 
Cuddy  writes  as  follows  on  the  matter:  "There  are 
very  few  direct  causes  of  suicide,  and  these  are  the 
very  ones  which  will  most  readily  disarrange  the  har- 
monious workings  of  a  healthy  mind.  The  most  fre- 
quent causes  of  self-destruction  to  which  I  allude  can 
best  be  told  by  a  quotation  from  c  le  of  my  own  lec- 
tures to  the  medical  class  during  the  last  session.  In 
that  lecture  I  said :  '  The  main  exciting  causes  of  sui- 
cide are  financial  depression,  religious  mania,  and 
unrequited  love.  The  first  mentioned  are  generally 
male  adults,  who,  as  a  rule,  complete  their  sad  taking 
ofif  by  the  help  of  the  leaden  ball  or  glistening  steel; 
the  unbalanced  religionist  generally  seeks  some  se- 
cluded spot,  where  with  hempen  cord  he  chokes  out 


778 


MEDICAL   RECORD. 


[November  17,  1900 


the  God-given  life  which  should  have  been  used  for  a 
better  purpose;  while  it  remains  for  lovesick  maidens 
and  half-crazed  men  to  terminate  their  useless  exist- 
ence by  the  aid  of  some  poisonous  drug,  nearly  always 
the  same,  for  the  intelligence  of  such  persons  rarely 
leads  them  beyond  the  laudanum  bottle  of  the  house- 
hold, in  whose  somnolent  depths  they  seek  their  vol- 
untary oblivion.'  Now  these  three  causes  which  cover 
the  majority  of  cases  of  suicide  are  all  producing 
agencies  of  deranged  nerve  action,  and  it  is  but  natu- 
ral to  conclude  that  in  these  instances  the  brain  cells 
are  sufficiently  disorganized  to  produce  a  condition 
whereby  normal  or  mental  control  is  lost  prior  to  the 
consummation  of  the  suicidal  act.  The  question 
might  be  asked.  Why  do  not  these  operative  causes  act 
alike  in  all  similar  cases?  All  brains  are  not  consti- 
tuted nor  developed  alike.  Some  are  able  to  resist 
the  most  distressing  and  depressing  agents,  just  as 
some  bodies  will  exist  in  a  bacteria-laden  atmosphere 
and  escape  unscathed,  while  others  similarly  placed 
will  readily  succumb,  even  to  fatal  results." 

Dr.  Cuddy  also  mentions  heredity  as  perhaps  a  pre- 
disposing cause,  but  fails  to  draw  attention  to  one  of 
the  most  potent  causes  of  suicide — alcoholism.  There 
can  be  no  doubt  whatever  that  strong  drink  drives  a 
vast  number  of  human  beings  to  death  by  their  own 
hands.  It  would,  of  course,  be  extremely  difficult, 
probably  impossible,  to  tabulate  definitely  in  their 
correct  order  the  various  causes  of  suicide.  The 
majority  of  observers  would  haply  declare  both  relig- 
ion and  the  lack  of  religion  to  be  responsible  for  more 
suicides  than  any  other  one  cause,  but  few  will  deny 
that  to  excessive  drinking  is  due  directly  and  indi- 
rectly a  holocaust  of  victims. 


SANATORIUM    FOR   CONSUMPTIVES   IN 
ENGLAND. 

Liverpool  is  one  of  the  most  progressive  towns  in 
Great  Britain. ,  The  good  work  she  has  done  in  further- 
ing and  extending  the  knowledge  of  tropical  diseases 
among  the  medical  profession  of  her  country  is  well 
known.  Through  the  efforts  of  Liverpool  philanthropists 
the  first  public  sanatorium  for  the  open-air  treatment 
of  consumption  has  been  commenced.  This  establish- 
ment will  be  in  connection  with  the  Liverpool  Hos- 
pital for  consumption,  and  is  to  be  erected  in  a  healthy 
locality  near  the  sea-coast  at  a  convenient  distance 
from  the  town.  The  building  is  to  be  essentially  for 
use  rather  than  for  ornament.  The  main  structure 
will  consist  of  three  blocks,  the  largest  of  which  will 
be  chiefly  devoted  to  dining-accommodation.  The 
peculiar  feature  of  the  dining-hall  will  be  that  it  has 
a  roof  only  and  no  sides.  Around  this  main  building 
a  number  of  small  bungalows  are  to  be  constructed, 
each  to  contain  six  bedrooms,  and  nothing  more.  No 
accommodation  will  be  provided  for  the  patients  other 
than  bedrooms  and  a  dining-room,  so  that  when  not 
eating  or  sleeping  they  will  be  living  in  the  fresh  air. 
The  erection  of  a  sanatorium  on  these  lines  is  decid- 
edly a  movement  in  the  right  direction.  The  organ- 
ized adoption  of  the  open-air  treatment  of  consump- 


tion has  in  Great  Britain,  and  in  a  lesser  degree  in 
this  country,  lagged  somewhat.  In  Great  Britain  es- 
pecially, old  views  die  hard  and  prejudice  is  difficult 
to  overcome.  In  Germany,  and  in  some  other  parts  of 
the  world,  the  new  method  has  had  gratifying  success. 
Probably  a  want  of  knowledge  among  the  general 
public  is  the  greatest  barrier  of  progress.  There 
are  undoubtedly  many  persons  who  would  regard  with 
distrust  the  suggestion  that  the  tuberculous  patient 
should  be  out  in  the  open  even  in  the  winter,  and 
there  are  assuredly  some  who  would  esteem  such  a 
mode  of  treatment  as  emanating  from  the  brain  of  a 
madman.  The  chief  requirements  of  a  person  suffer- 
ing from  phthisis  in  any  stage  are  air  and  light,  and 
further  than  this  it  is  undoubtedly  possible  in  the 
early  stages  by  these  means  to  effect  a  cure.  For  the 
popular  ignorance  on  the  question  of  the  treatment  of 
tuberculosis  the  medical  profession  itself  is  largely 
responsible,  having  up  to  a  comparatively  recent  period 
taught  and  practised  a  different  system.  If  its  mem- 
bers will  assist  strenuously  by  precept  and  practice  in 
illuminating  the  public  mind  on  the  subject,  they  will 
be  acting  for  the  good  of  everybody.  Dirt,  dust,  and 
darkness  are  the  greatest  propagators  of  tuberculosis, 
and  until  this  fact  receives  a  widespread  appreciation, 
then,  and  not  till  then,  will  there  be  a  fair  likelihood 
of  the  spread  of  the  disease  being  checked. 


^cius  of  the  IM.cch. 

Dr.  Pozzi's  Duel. — Dr.  Devillers,  who  some  time 
ago  wantonly  insulted  Dr.  Pozzi  in  his  club,  and 
forced  him  to  fight  a  duel,  has  had  to  pay  for  it  in  the 
courts.  The  government,  in  spite  of  Dr.  Pozzi's  pro- 
tests, instituted  proceedings  against  Devillers  for  as- 
saulting a  member  of  the  French  Senate,  and  the  court 
condemned  him  to  pay  a  fine  of  3,000  francs. 

The  Russian  Red  Cross  Society. — The  Russian 
government,  for  the  second  time  within  two  months, 
has  imposed  a  special  tax  for  the  benefit  of  the  Red 
Cross  Society.  The  first  was  a  tax  of  from  5  ■  to  10 
rubles  upon  licenses  to  travel  abroad,  according  to  the 
length  of  time  for  which  the  license  was  granted;  and 
now  railway  tickets  are  taxed  5  kopecks  when  the  fare 
is  2  rubles  or  upward.  It  is  estimated  that  the  ticket 
tax  will  yield  $125,000  yearly,  and  that  on  licenses 
$100,000.  It  is  understood  that  the  Czarina,  whose 
interest  in  the  Red  Cross  Society  is  keen,  originsted 
the  idea  of  imposing  the  taxes. 

Disinfection  of  Lepers'  Mail. — The  following  plan 
for  disinfecting  the  mails  from  the  leper  settlement  at 
Molokai  has  been  instituted  by  Dr.  Carmichael  of  the 
Marine-Hospital  service  at  Honolulu.  All  mail  from 
the  leper  settlement  will  be  disinfected  with  sulphur 
dioxide  at  the  settlement  and  then  transferred  directly 
to  the  steamship  and  received  aboard  in  clean  and 
disinfected  sacks  furnished  by  the  post-office  authori- 
ties. At  Honolulu  the  mail  will  betaken  in  the  sacks 
directly  to  a  room  in  the  post-office  used  for  disinfec- 
tion purposes  and  disinfected  with  formaldehyde  with- 


November  17,  1900] 


MEDICAL    RECORD. 


779 


out  removal  from  the  sacks.  All  letters  are  perfo- 
rated or  the  corners  clipped  at  the  settlement  before 
disinfection.  No  case  of  leprosy,  the  surgeon  reports, 
has  yet  been  discovered  among  the  post-office  em- 
ployees, although  non-disinfected  mail  from  the  leper 
settlement  has  been  handled  by  them  for  many  years. 

Crowd  Injuries. —  Si.xteen  hundred  persons  suffered 
injuries  requiring  medical  attendance  in  the  crowds 
that  assembled  in  London  on  Monday  of  last  week  to 
welcome  home  the  volunteers  from  South  Africa. 

The  Cost  of  the  Plague  in  Glasgow — According 
to  a  despatch  from  Glasgow  the  estimated  cost  to  that 
city  of  the  recent  visitation  of  the  bubonic  plague  was 
_;^i,ooo,ooo  ($5,000,000). 

Yellow  Fever  in  Mississippi  ? — A  case  of  sup- 
posed yellow  fever  has  been  reported  to  the  Missis- 
sippi State  board  of  health  from  Natchez,  the  patient 
having  died  last  week.  A  Marine-Hospital  surgeon 
has  been  sent  to  that  city  to  trace,  if  possible,  the 
source  of  infection. 

Smallpox  in  Paris. — It  is  reported  in  The  Sun 
tliat  an  epidemic  of  smallpox  has  broken  out  in  Paris, 
due  probably  to  the  massing  there  of  Arabs  and  other 
people  from  the  East  during  the  K.xhibition.  Notices 
have  been  posted  by  the  police  warning  persons  who 
have  not  been  vaccinated  within  six  years  to  be  vac- 
cinated now.  Every  precaution  to  stamp  out  the  dis- 
ease has  been  taken. 

Rabies  in  New  York. — A  fox  terrier  was  killed 
in  this  city  a  short  time  ago,  after  it  had  bitten  other 
dogs  and  a  boy,  and  examination  by  the  bacteriologi- 
cal department  of  the  board  of  healtli  confirmed  the 
diagnosis  of  rabies.  The  board  of  health  has  issued 
a  statement  calling  "  the  attention  of  physicians  and 
others  to  the  occurrence  of  a  number  of  cases  of  rabies 
among  dogs  throughout  the  city,  and  would  request 
that  wherever  persons  are  bitten  by  strange  dogs,  or 
stray  dogs,  they  immediately  consult  a  physician  and 
have  their  wounds  cauterized,  and  if  then  there  is  any 
question  as  to  the  existence  of  rabies  in  the  animal, 
communicate  at  once  with  the  department  of  health." 

The  Civil  Rights  of  Hospital  Internes.— The 
case  of  the  Bellevue  Hospital  interne  and  four  male 
nurses,  who  were  arrested  on  the  charge  of  having 
illegally  registered,  has  been  decided  in  their  favor 
by  Justice  Andrews.  The  cases  were  in  the  nature  of 
test  cases,  and  as  a  result  of  the  decision  five  hundred 
and  fifty-six  internes  and  helpers  in  Bellevue  and  other 
city  institutions,  whose  status  was  in  doubt,  were  al- 
lowed to  vote.  The  law  which  forbids  the  pauper 
inmates  of  city  institutions  to  vote  was  the  basis  of 
the  charge  against  them,  but  the  court  said  that  "  it 
cannot  be  truthfully  said  that  the  physicians,  hired 
helpers,  or  pupil  nurses  are  supported  by  the  public. 
The  physicians  render  most  valuable  services  to  the 
patients  in  the  hospital  and  are  allowed  to  lodge  and 
eat  there,  not  as  a  matter  of  charity,  but  as  a  matter 
of  convenience  and  almost  of  necessity,  owing  to  the 
nature  of  the  duties  which  they  are  at  all  times  called 
on  to  perform." 


A  Tax  on  Childless  Frenchmen A  bill  has  been 

introduced  into  the  French  Senate  providing  for  a 
tax  on  celibates  of  both  sexes  after  they  reach  the  age 
of  thirty,  and  upon  childless  couples  who  have  been 
married  for  five  years,  the  tax  to  be  maintained  until 
a  child  is  born  to  them.  The  aim  of  the  bill  is,  of 
course,  to  provide  a  remedy  for  the  threatening  de- 
population of  France,  by  increasing  the  birth  rate. 

A  Death  Under  Chloroform.— A  boy  nine  years 
old,  who  was  being  anaesthetized  preliminary  to  an 
operation  for  injury  to  the  thigh,  died  last  week  at  the 
New  York  Polyclinic  Hospital.  Chloroform  was  the 
anesthetic  employed,  and  the  boy  died  soon  after  the 
inhalation  was  begun. 

Excessive  Mortality  among  the  Alaska  Indians. 
— Officers  of  the  United  States  revenue  cutter  Jius/i 
report  that  the  Indians  of  the  Aleutian  Islands,  as 
well  as  those  of  the  Alaskan  peninsula  and  on  the 
mainland,  are  dying  at  an  alarming  rate.  The  Hus/i 
was  engaged  during  the  summer  in  Indian  census 
enumeration.  Attn  Island,  in  past  years  densely  pop- 
ulated with  Alaskan  natives,  contains  only  seventy- 
three,  and  Atka,  the  largest  island  of  the  group,  has 
an  Indian  population  of  but  one  hundred  and  seventy- 
five.  That  island  half  a  century  ago  supported  a  great 
tribe.  Last  season  measles  and  pneumonia  carried  off 
the  Indians  by  tiie  score,  and  should  these  diseases 
become  epidemic  again  next  year  the  archipelago  will 
become  almost  depopulated. 

Yellow  Fever  in  Havana  is  decreasing.  In  a  re- 
port recently  presented  to  the  Washington  authorities. 
Dr.  A.  H.  Glennan,  of  the  Marine-Hospital  service, 
now  chief  quarantine  officer  for  the  island  of  Cuba, 
says  that  the  number  of  cases  decreased  in  the  last 
week  of  October,  and  that  there  were  only  thirteen 
deaths  in  that  week.  He  quotes  with  approval  the 
assertion  of  Ur.  W.  C.  Gorgas,  of  the  United  States 
army,  now  chief  sanitary  officer  of  Havana,  that,  not- 
withstanding the  general  distribution  of  the  disease, 
infecting  localities  not  heretofore  infected,  and  the 
large  number  of  people  attacked,  an  epidemic  condi- 
tion does  not  exist,  and  that  such  a  situation  in  Havana 
is  impossible.  He  says  that  from  June  ist  to  October 
19th  there  were  seven  hundred  and  eighty-nine  cases 
officially  recorded;  that  the  official  maps  of  the  city 
show  that  there  are  eight  hundred  and  fifty-seven 
square  blocks  in  the  city,  and  that  of  this  number  five 
hundred  and  twenty-five  square  blocks  have  had  no 
cases  at  all.  In  any  ordinary  acceptation  of  the  word 
epidemic  as  applied  to  diseases  in  great  cities.  Major 
Gorgas  says,  this  certainly  does  not  show  that  there  is 
an  epidemic  there.  In  a  population  of  two  hundred 
and  thirty-two  thousand  the  average  during  October, 
which  has  been  the  largest  of  •the  year,  has  been  ten 
new  cases  a  day.  In  September  there  were  seventy- 
two  deaths  from  consumption,  fifty-two  from  yellow 
fever,  and  forty-three  from  enteritis.  Yellow  fever, 
therefore,  should  not  be  considered  epidemic  any  more 
than  consumption  or  enteritis.  It  has  been  decided 
that  hereafter  the  steamboat  companies  will  meet  tiie 
Spanish  transatlantic  liners  outside  of  Havana  harbor 


ySo 


MEDICAL    RECORD. 


[November  17,  1900 


and  will  transfer  immigrants  destined  for  other  points. 
Those  going  to  the  rural  districts  of  the  provinces  of 
Havana  and  Pinar  del  Rio  will  be  sent  to  the  Cabanas 
Barracks,  and  will  not  be  allowed  to  remain  in  Havana. 
It  is  thought  that  these  precautions  will  result  in  a 
rapid  decrease  of  the  yellow  fever,  as  ninety  per  cent, 
of  the  cases  now  under  treatment  are  among  the  immi- 
grants. 

Trial  of  an  Emergency  Ration — A  board  of  army 
officers  is  making  a  test  of  the  efficiency  of  three  dif- 
ferent emergency  rations.  Two  of  these  rations  are 
offered  by  manufacturers  and  the  third  is  one  proposed 
by  the  board  itself.  This  is  composed  of  two  cakes  of 
sweetened  chocolate  and  three  cakes  of  a  meat-and- 
cereal  compound.  The  chocolate  weighs  four  ounces 
and  the  meat  and  cereal  in  combination  respectively 
four  and  eight  ounces,  a  total  v/eight  of  sixteen  ounces, 
besides  three-fourths  of  an  ounce  of  salt  and  one  gram 
of  red  pepper.  The  ration  is  contained  in  a  hermet- 
ically sealed  can  with  rounded  edges  like  a  flask,  six 
and  one-fourth  inches  long  and  one  and  one-half  by 
two  inches.  The  can  is  opened  with  a  key.  The 
ration  is  to  be  part  of  the  permanent  equipment  of  the 
soldier  in  the  field.  It  can  be  eaten  dry;  as  a  soup 
or  a  porridge,  or  the  porridge  may  be  fried.  The 
question  to  be  decided  is  whether  the  ration  has  suffi- 
cient quantity  and  quality,  and  will  not  nauseate  when 
used  alone.  The  first  test  was  made  about  two  weeks 
ago  in  Oklahoma.  The  detachment  of  troops  started 
from  El  Reno,  and  marched  across  the  Indian  reserva- 
tions of  the  Kiowas,  Comanches,  and  Apaches  to  Fort 
Sill.  During  the  march  the  men  lived  wholly  upon 
the  emergency  ration.  The  food  went  hard  with  the 
men  for  the  first  few  days,  but  after  that  time  they 
seemed  to  enjoy  it. 

The  Distinction  between  Anopheles  and  Culex. — 
Major  Donald  Ross  and  Mr.  A.  E.  Austen  in  the  report 
of  their  expedition  to  Sierra  Leone  in  1899  laid  great 
stress  on  the  position  assumed  by  mosquitos  when  at 
rest,  as  a  means  of  discriminating  between  the  malaria- 
bearing  mosquitos  of  the  genus  Anopheles  and  those 
of  the  genus  Culex,  the  latter  of  which  so  far  seem  to 
take  no  part  in  the  dissemination  of  human  malaria. 
They  said  that  the  Anopheles  always,  when  at  rest, 
sat  in  a  characteristic  attitude,  their  bodies  being 
maintained  at  an  angle  of  at  least  45°  to  the  surface 
on  which  they  settled.  Frequently,  they  said,  the  tips 
of  the  palpi  were  in  contact  witii  the  wall  on  which 
the  insect  was  resting,  and  the  body  was  so  much  ele- 
vated that  it  was  practically  at  right  angles  to  the 
wall,  the  insect  appearing  as  if  it  were  standing 
upon  its  head;  and  it  was  held  that,  owing  to  this  ex- 
tremely characteristic  resting  attitude  of  Anopheles,  it 
would  be  impossible  for  any  one  who  had  once  seen  a 
specimen  at  rest  to  mistake  it  for  a  Culex,  for  the  lat- 
ter when  at  rest  allows  its  body  to  hang  down  verti- 
cally. Now  Dr.  Sambon  and  Dr.  Low  have  been  pass- 
ing the  summer  on  the  Campagna,  and  they  directly 
traverse  this  statement  as  to  the  attitude  of  these 
insects.  They  say  that  they  have  observed  thousands 
of   Anopheles,  but  none    of   them   ever   assumed  the 


position  described  by  the  members  of  the  Liverpool 
Malarial  Mission,  and  they  hold  that  although  the 
resting  position  may  be  a  means  of  distinguishing 
between  certain  species,  it  is  not  a  criterion  by  which 
Anopheles  can  be  distinguished  from  Culex  which 
was  the  point  insisted  on,  a  point  which  has  already 
been  copied  into  many  text-books. —  The  Hospital. 

The  Comparative  Cost  of  a  Medical  Education. 
— In  a  recent  article  in  the  London  Daily  Mail  a 
comparison  was  made  of  the  cost  of  education  in  the 
different  professions.  It  was  asserted  that,  on  the 
average,  it  cost  the  student  about  £^^0  to  qualify  as 
aphysician;  ^800  to  become  a  lawyer;  _;^775  to  enter 
the  church;  ;^6oo  to  become  an  officer  in  the  army; 
and  ^?4oo  for  an  officer  in  the  navy. 

College  of  Physicians  of  Philadelphia. — At  a 
stated  meeting  held  November  7,  1900,  Dr.  Charles 
W.  Burr  read  a  paper,  prepared  by  himself  and  Dr.  D. 
J.  McCarthy,  entitled  "Asthenic  Bulbar  Palsy,"  re- 
porting a  fatal  case  in  which  only  diminution  in  the 
size  of  tlie  pons  was  found  after  death,  without  his- 
tological alteration,  and  a  second  case  in  which  the 
symptoms  disappeared  and  recovery  ensued.  Dr. 
John  B.  Deaver  read  a  paper  entitled  "Appendicitis 
versus  Cystitis,"  reporting  several  illustrative  cases. 
He  emphasized  the  significance  of  pain  in  the  left 
iliac  fossa  as  indicative  of  appendicitis  with  pelvic 
involvement.  Dr.  W.  Joseph  Hearn  read  "A  Report 
of  a  Case  of  Resection  of  a  Large  Portion  of  the  Ilium 
for  Chondro-Sarcoma."  Dr.  W.  W.  Keen  described  a 
method  of  transplantation  of  the  tissues  in  one  mam- 
mary region  to  the  opposite  side  to  replace  structures 
removed  in  the  treatment  of  recurrent  malignant  dis- 
ease of  the  breast. 

Pathological  Society  of  Philadelphia.  —  At  a 
stated  meeting  held  November  8th,  Dr.  William  L. 
Coplin  exhibited  (i)  an  improved  mechanical  stage 
for  Dolken's  microscope;  (2)  an  i-mproved  drawing 
ocular;  (3)  a  revolver  for  securing  parfocal  adjust- 
ment. Dr.  M.  P.  Ravenel  presented  a  communication 
entitled  "A  Possible  Source  of  Infection  in  Tubercu- 
losis," in  which  he  detailed  observations  demonstrat- 
ing the  possibility  of  the  conveyance  of  tubercle  bacilli 
with  the  particles  of  mucus  exi;elled  by  cows  in  the  act 
of  coughing.  Dr.  Joseph  McFarland  reported  a  case 
of  deciduonia  malignum,  which  seven  years  ago  had 
been  clinically  considered  one  of  sarcoma  of  the 
uterus,  and  on  histological  examination  presented  ap- 
pearances suggestive  of  endothelioma.  Dr.  McFarland 
also  exhibited  the  Blake-Minot  microtome,  with  which 
small  sections  of  soft  tissue  embedded  in  paraffin  can 
be  cut  as  thin  as  i  <l.  Dr.  A.  E.  Woldert  exhibited 
specimens  of  the  middle  intestine  of  the  Anopheles 
quadrimaculata,  containing  the  xygates  of  the  Proteo- 
soma  Labbt^,  loaned  by  Surgeon-Major  Ronald  Ross, 
of  the  Liverpool  Tropical  School  of  Medicine.  Dr. 
Woldert  also  reported  a  case  of  malarial  liai-moglobin- 
uria,  and  exhibited  the  malarial  parasites  obtained 
from  this  source.  Dr.  M.  B.  Hartzell  presented  a 
communication  entitled  "Note  Relative  to  the  Parts 
of  the    Skin    Invaded  by  the  Microsporon   furfur  in 


November  17,  1900] 


MEDICAL    RECORD. 


781 


Tinea  Versicolor,  with  Illustrations."  He  showed 
that  the  invasion  of  the  parasite  was  not  confined  to 
the  horny  layer  of  the  skin,  but  at  times  invaded  also 
the  hair  follicles.  Dr.  A.  O.  J.  Kelly  e.xhibited  speci- 
mens of  abscess  of  an  hypertrophied  prostate,  greatly 
thickened,  contracted,  and  ulcerated  bladder,  diph- 
theroid inllammationof  the  large  and  small  intestines, 
and  inflammation  of  the  kidneys.  Dr.  \V.  M.  L.  Cop- 
lin  exhibited  a  specimen  of  ulceration  of  the  oesoph- 
agus into  the  trachea  and  the  posterior  mediastinum 
of  as  yet  undetermined  origin.  Dr.  VV.  G.  Spiller  ex- 
hibited specimens  illustrating  Mallory's  new  neuroglia 
stain. 

Modern  Bullet  Wounds.  — Surgeon-General  Stern- 
berg in  his  annual  report  has  much  to  say  regarding 
the  effect  of  gunshot  wounds  made  byrillesof  reduced 
calibre.  A  review  of  the  statistics  shows  that  the 
percentage  of  fatality  during  the  Spanish-American 
War,  in  which  small-calibre  projectiles  were  used, 
was  much  lower  than  in  the  Civil  War,  when  extremely 
large  bullets  were  used.  Rapid  healing  follows 
wounds  made  by  the  Mauser  bullet,  and  infection  was 
seldom  noted,  but  when  present  was  almost  invariably 
about  the  wound  of  exit  and  consisted  of  a  slight 
slough  and  a  drop  or  two  of  pus  under  a  scab.  Among 
the  fourteen  hundred  wounded  none  died  of  external 
hemorrhage,  and  it  was  not  necessary  to  ligate  a  ves- 
sel for  alarming  hemorrhage  on  the  field.  Clean-cut 
perforations  without  fracture  were  the  rule  in  wounds 
of  the  principal  joints.  A  majority  of  gunshot  wounds 
in  the  head  ended  fatally.  Penetrating  wounds  of  the 
abdomen  were  fatal  in  most  cases.  Owing  to  the 
smallness  of  the  secticHial  area  of  modern  bullets, 
pieces  of  clothing  and  other  infectious  material  are 
not  generally  carried  into  the  wound. 

Navy  Department,  Bureau  of  Medicine  and  Sur- 
gery, Washington,  D.  C. — Changes  in  the  medical 
corps  of  the  navy  for  the  two  weeks  ending  November  8, 
1900.  October  29th. — Surgeon  A.  M.  D.  McCormick 
commissioned  surgeon  from  November  11,  1899.  Oc- 
tober 30th. — Assistant  Surgeon  R.  E.  Ledbetter  ordered 
to  \.)\&  Constellation.  October  31st. —  Surgeon  C.  Bid- 
die  detached  from  the  Texas  when  put  out  of  com- 
mission, and  ordered  home  to  wait  orders.  November 
ist. — Medical  Director  C.  H.  White  detached  from  the 
naval  museum  of  hygiene,  Washington,  on  reporting 
of  relief,  and  ordered  home  to  wait  orders.  Medical 
Inspector  G.  P..  Bradley  ordered  to  duty  in  charge  of 
the  naval  museum  of  hygiene,  Washington,  November 
15th.  Surgeon  H.  E.  Ames  detached  from  the  Kcar- 
sarge  and  ordered  to  the  Massaclnisetts.  November 
3d. — Medical  Inspector  J.  C.  Boyd  detached  from  the 
New  York  when  out  of  commission,  and  ordered  to  the 
Kearsarge.  Passed  Assistant  Surgeon  E.  S.  Bogert, 
Jr.,  detached  from  the  New  York  when  out  of  commis- 
sion, and  ordered  to  the  Massachusetts.  Passed  As- 
sistant Surgeon  M.  S.  Elliott  detached  from  naval 
station,  Port  Royal,  and  to  duty  on  the  Annapolis  inhtn 
placed  in  commission.  Assistant  Surgeon  VV.  M. 
Garton  detached  from  the  Massachusetts  and  ordered 
to  the  Indiana.     November  sth. — Assistant  Surgeon 


J.  St.  J.  Butler  appointed  assistant  surgeon  from  Octo- 
ber 26,  1900.  Passed  Assistant  Surgeon  J.  M.  Moore 
ordered  to  naval  station,  Port  Royal.  November  Sth. 
— Passed  Assistant  Surgeon  E.  M.  Shipp  detached 
from  Norfolk  hospital  and  ordered  to  the  Michigan. 
Passed  Assistant  Surgeon  H.  D.  Wilson  detached  from 
the  Michigan  and  ordered  to  naval  hospital,  Norfolk, 
Va.  Passed  Assistant  Surgeon  L.  W.  Spratling  de- 
tached from  Yokohama  hospital,  and  ordered  to  naval 
station,  Cavite,  Philippine  Islands.  Pharmacist  S. 
Douglass  ordered  to  additional  duty  on  the  Massasoit. 


CDliituaviT. 

HENRY    DRURY    NOYES,    M.D., 

NEW    VOKK. 

Dr.  Henry  D.  Noves  died  at  his  sunmier  home  in 
Mount  Washington,  Mass.,  on  November  12th,  at  the 
age  of  sixty-eight  years.  The  cause  of  his  death  was 
pneumonia.  He  was  born  in  this  city  and  was  edu- 
cated at  the  New  York  University,  from  which  he  was 
graduated  with  the  degree  of  .A.B.  in  1851.  He  was 
graduated  in  medicine  from  the  College  of  Physicians 
and  Surgeons  in  the  class  of  1855,  and  after  serving  on 
the  house  staff  of  the  New  York  Hospital  went  abroad 
to  continue  his  studies.  Upon  returning  to  this  city 
he  entered  upon  a  special  practice  in  diseases  of  the 
eye  and  ear,  in  which  he  achieved  great  distinction. 
His  contributions  to  periodical  medical  literature  were 
numerous  and  valuable,  and  he  also  published  a  trea- 
tise on  the  diseases  of  the  eye.  He  was  among  the 
first  to  recognize  the  immense  importance  of  cocaine 
as  a  local  anaesthetic  in  operations  upon  the  eye,  and 
his  letters  on  this  subject  to  the  Medical  Record 
went  far  to  establish  the  value  of  Roller's  discovery 
and  to  popularize  it  in  this  country.  He  was  for 
many  years  professor  of  ophthalmology  and  otology 
in  the  Bellevue  Hospital  Medical  College,  and  was 
also  executive  surgeon  to  the  New  York  Eye  and  Ear 
Infirmary.  He  was  a  member  of  numerous  special 
and  general  medical  societies  and  social  organiza- 
tions.    A  widow  and  three  children  survive  him. 

Dr.  Noyes  was  the  type  of  the  progressive  special- 
ist, as  during  his  whole  professional  life  he  adhered 
strictly  and  solely  to  perfecting  himself  in  his  partic- 
ular branch  of  work.  Combining  the  rare  qualities 
of  skill,  sound  judgment,  and  broad  conservatism,  he 
was  ever  a  sound  counsellor  and  one  always  to  be 
trusted  in  the  management  of  the  gravest  and  most  re- 
sponsible cases.  Having  a  finished  and  terse  literary 
style,  and  being  an  eloquent  and  forcible  speaker,  he 
always  impressed  his  colleagues  as  a  born  leader  and 
a  clear  thinker.  To  the  very  last  he  was  active  in  his 
work  as  a  teacher,  writer,  and  lecturer,  proving  that  a 
sound  constitution,  a  clear  brain,  and  a  steady  hand 
are  the  legitimate  rewards  of  a  well-ordered  and  con- 
sistent life. 


Obituary  Notes.— Dr.  Salome  Merritt,  a  well- 
known  advocate  of  woman's  rights,  died  on  November 
7th  at  her  home  in  Somerville,  Mass.  She  was  born 
at  Templeton,  Mass.,  on  February  22,  1843.  In  1871 
she  took  up  the  study  of  medicine  in  the  New  Eng- 
land Female  Medical  College  (now  Boston  Univer- 
sity). Later  she  came  to  New  York  and  was  graduated 
in  1874  from  the  New  York  Free  Medical  College  for 
Women,  an  institution  which  flourished  for  six  years 
only.  She  began  to  practise  medicine  in  1876  and 
followed  it  as  a  profession  since.  She  was  a  charter 
member  of  the  Woman's  Suffrage  Association  of  Mas- 


78: 


MEDICAL    RECORD. 


[November  17,  igcxj 


sachusetts,  and  was  elected  its  president  in  1893  and 
tiie  four  years  following.  She  was  president  of  the 
Ladies'  Physiological  Institution,  and  also  served  on 
the  Committee  of  Coimsel  and  Co-operation,  a  union 
of  several  Boston  societies,  whose  aim  it  was  to  en- 
courage moral  reform,  improved  sanitation  and  dwell- 
ings for  the  poor,  and  other  branches  of  benevolent 
work. 

Dr.  Nathaniel  P.  Rice,  a  retired  physician  of  this 
city,  died  on  November  loth,  following  a  cerebral 
hemorrhage  which  occurred  last  summer.  He  was 
born  in  Cambridge,  Mass.,  seventy-two  years  ago. 
After  attending  the  public  schools  he  went  to  Har- 
vard, where  .he  was  graduated  in  the  class  of  '49. 
He  received  his  degree  in  medicine  at  the  Harvard 
Medical  School.  At  the  outbreak  of  the  Civil  War 
Dr.  Rice  joined  the  New  York  volunteers,  and  two 
years  later  became  a  surgeon  in  the  regular  army, 
serving  with  the  Army  of  the  Potomac.  He  was  medi- 
cal director  in  Virginia  and  North  Carolina  in  1864-65. 

Dr.  J.  S.  Walters  died  at  Pittsburg,  Pa.,  on  Novem- 
ber 8th,  at  the  age  of  fifty-four  years.  He  was  born  in 
Chede,  StalTordshire,  England,  and  was  a  graduate  of 
Guy's  Hospital,  London. 


gr00rcss  of  l^fXcdical  J'Cicnce. 

Medical  Xcius,  November  lo,  igoo. 

The  Examination  of  Stomach  Contents.  —  B.  A.  Bastedo 
states  that  the  simplest  and  best  test-meal  consists  of  a 
good-sized  hard  breakfast  roll  without  butter,  taken  on  an 
empty  stomach.  The  roll  should  be  thoroughly  chewed 
and  washed  down  with  twelve  ounces  of  water.  At  the 
end  of  an  hour  a  stomach  tube  is  passed.  If  fermentation 
is  present  there  is  a  layer  of  foam  on  the  surface  and  there 
is  an  odor  of  butyric  and  other  fatty  acids.  Mucus  may  be 
noted  by  lifting  it  up  on  a  loop  of  wire.  Of  the  filtered 
contents.  5  c.c.  is  placed  in  a  porcelain  dish  with  a  drop  or 
two  of  one-half  of  one  per  cent,  alcoholic  solution  of  di- 
methyl-amido-azo-benzol.  If  this  becomes  pink,  it  indi- 
cates the  presence  of  free  hydrochloric  acid.  The  Congo- 
red  test  may  then  be  tried.  If  blood  is  suspected,  it  may 
be  tested  for  by  adding  glacial  acetic  acid  and  then  ether 
to  a  bit  of  the  stomach  contents.  The  mi.Kture  should  be 
shaken,  set  aside,  and  the  ether  poured  off.  To  this  ether 
should  be  added  a  few  drops  of  tincture  of  guaiac  and  then 
a  like  amount  of  peroxide  of  hydrogen.  A  dark-blue  color 
indicates  blood.  The  writer  then  indicates  the  proper  diet 
for  various  conditions  of  abnormal  acidity.  A  suspected 
ulcer  contraindicates  the  use  of  the  stomach-tube,  in  which 
case  the  vomitus  may  give  valuable  information. 

Bronchial  Disease  Not  Invariably  a  Contraindication  for 
Ether  Anaesthesia  in  Abdominal  Surgery.— Tliaddcus  A. 
Reamy  declares  that  he  believes  tliat  in  properly  selected 
cases  ether  inhalation  is  positively  curative  of  bronchitis. 
Its  action  in  these  cases  is  probably  largely  local.  He 
enumerates  the  following  points  which  are  essential  to 
avoid  unpleasant  com])lications  and  to  secure  desired  re- 
sults; (1)  Proper  preparation  of  tlie  patient ;  (2)  prepara- 
tion of  the  operating-room  with  a  temperature  of  gS  to  100° 
F.  ;  (3)  pure  ether;  (4)  a  proper  inhaler;  (5)  the  proper 
methods  of  administration  ;  (6)  due  caution  against  expo- 
sure in  removing  the  patient  from  the  operating-room  to 
her  own  room,  which  should  not  be  below  80'  to  90  F.  for 
several  hours  after  the  operation  ;  (7)  proper  care  of  the 
patient  during  convalescence.  She  should  be  permitted 
to  drink  large  quantities  of  water  and  should  keep  the 
bowels  freely  open. 

Further  Experience  with  Subarachnoidean  Injections  of  Co- 
caine for  Analgesia  in  All  Operations  below  the  Diaphragm. 
—  liy  John  15.  Mur|)hy. 

Some  Observations  on  Anaesthesia  by  Intraspinal  Injections 
of  Cocaine. — By  S.  Ornvind  ('loldan. 

The  Hydriatric  Treatment  of  Tuberculosis.— By  J.  11.  Kel- 
logg. 

Ne'M  Yorl;  Medieal  Journal,  Xoveiiiher  to,  rgoo. 

Facial  Neuritis  Associated  with  Unilateral  Retro-Orbital 
Neuritis.  -Reportof  cascby  W.  M.  Leszynsky.  The  patient 
was  a  woman  aged  thirty-eiglu  years,  who  five  weeks  pre- 
viously, after  severe  pain  and  tinnitus  in  the  left  ear  (re- 
ferred to  exposure  to  cold)  noticed  that  the  left  side  of  her 


t. 


face  was  paralyzed.  Examination  showed  complete  left 
facial  jiaralysis  with  lagophthalmos.  and  loss  of  faradic 
irritability  in  nerves  and  muscles.  The  muscles  reacted  to 
galvanism  AnCC  <  CaCC.  Sense  of  taste  was  impaired 
on  the  left  anterior  two-thirds  of  tlie  tongue.  There  was 
loss  of  taste  for  sweet,  sour,  and  salt,  but  bitter  could  be 
distinguished.  The  palate,  tongue,  and  pupils  were  normal. 
Chronic  catarrhal  otitis  atTected  both  ears.  There  were  no 
physical  signs  of  pulmonary  disease,  and  no  evidence  of 
syphilis.  'I'he  usual  galvanic  treatment  of  the  facial  mus- 
cles was  instituted.  By  December  15th  (in  two  months)  she 
was  able  to  close  the  left  eye.  On  the  20th  she  began  to  com- 
plain of  severe  pain  in  the  left  temporal  region  and  also 
over  the  supraorbital-nerve  distribution,  with  tenderness 
on  pressure  and  inability  to  sleep  on  account  of  the  pain. 
There  was  no  fever,  but,  the  bowels  being  constipated,  she 
was  given  gr.  v.  of  calomel  and  gr.  xx.  of  conijioiind  jalap 
powder.  One  week  after  the  beginning  of  the  pain,  vision 
began  to  fail  in  the  left  eye,  and  two  days  later  the  eye 
was  totally  blind.  The  pain  disappeared  entirely  at  the 
end  of  the  second  week.  The  right  eye  was  not  involved. 
The  left  pupil  was  larger  than  the  right.  L.  f.  5;  R.  4. 
In  tlie  left  there  w-as  uo  reaction  to  light,  consensual,  -\-,  in 
convergence  normal.  Right  pupil :  no  consensual  reaction, 
but  otherwise  normal.  There  was  no  perception  of  light 
in  the  alTectcd  eye,  while  the  right  eye  showed  vision  of 

.     At   first  there  was  slight  oedema  of  the  paiiilla,  with 

urring  of  outline  on  the  nasal  side  of  the  disc.  This 
gradually  increased,  and  at  the  end  of  a  week  the  papil- 
litis was  quite  pronounced.  The  patient  improved  under 
the  iodide  and  mercurial  inunctions.  Ten  months  later, 
vision  was  ."„"(,  ;  the  ophthalmoscope  showed  optic  atrophy. 
One  year  from  the  last-named  date  the  following  note  was 
made:  Although  the  nerve  and  muscles  react  to  faradism 
28  mm.  (quantitative  decrease  in  irritability),  there  is  no 
improvement  in  the  motility  of  the  facial  muscles.  Optic- 
nerve  atrophy  is  well  advanced,  and  the  vision  of  the  af- 
fected eve  is  limited  to  perception  of  light,  while  the  pupil- 
lary condition  has  remained  unchanged. 

An  Unusual  Case  of  Meralgia  Paraesthetica,  with  Intermit- 
tent Lameness  (Claudication  Intermittente— Type  Charcot). — 
By  A.  Oordon.  Tlie  patient  was  a  man  aged  forty-five 
years.  The  symptoms  developed  during  typhoid  fever. 
The  di.sease  mentioned  in  the  title  is  due  to  some  jiatho- 
logical  or  functional  alteration  of  the  external  cutaneous 
nerve  or  a  branch  of  the  lumbar  plexus.  Whether  the  pa- 
tient was  sitting  or  walking  he  complained  of  a  burning 
sensation  over  the  antero-external  surface  of  the  upper 
two-thirds  of  the  thigh,  from  the  anterior  spinous  process 
down  and  over  the  posterior  surface  of  the  upper  third, 
from  the  crest  of  the  ilium  down,  covering  the  external 
surface  of  the  buttock.  Only  on  the  upper  third  of  the 
thigh  did  the  area  of  disturbed  sensation  pass  over  the 
middle  line.  There  it  reached  the  internal  surface  of  the 
limb  as  far  as  contact  with  the  scrotum.  The  area  bounded 
by  tlie  above  outlines  was  not  universally  affected.  Tac- 
tile sensation  was  much  diminished.  Pinching  and  rub- 
bing were  extremely  painful.  Thermic  sensations  were 
normal,  but  the  temperature  of  the  affected  side  was  lower 
than  that  of  its  opposite.  The  mechanical  and  (juantita- 
tive  electrical  reactions  were  exaggerated,  but  the  qualita- 
tive was  normal.  The  distribution  of  the  parjesthesia  was 
somewhat  irregular.  The  author  says  that  if  the  syndrome 
meralgia  para.'sthetica  is  the  result  of  some  functional  or 
pathological  change  in  the  external  cutaneous  nerve,  there 
are.  nevertheless,  cases  in  which  the  same  symptoms,  pain 
and  paresthesia,  go  beyond  the  zone  of  distribution  of 
that  nerve  ;  also  there  are  some,  if  not  the  majority,  in 
which  only  one  branch  of  it  is  affected,  some  in  which  other 
phenomena  are  associated  with  it,  and,  finally,  .some  so- 
called  ])seudo-nieralgias,  in  which  the  underlying  cause  is 
not  in  tliat  nerve. 

Ruptured  Urethra,  with  Report  of  Cases.— N.  Jacobson  re- 
ports four  instances  iiiuler  the  following  case  headings: 
Subcutaneous  rujiture,  external  urethrotomy,  faulty  dila- 
tation, subsequent  divulsion.  recovery;  complete  sever- 
ance of  the  urethra  subcutaneously,  perineal  section,  peri- 
neal drainage,  recovery  ;  urinary  fistula  following  urethral 
ru]iture,  perineal  section,  recovery ;  ])enetration  of  the 
liranch  of  a  tree  tlirough  the  anterior  wall  of  the  rectum, 
severing  the  urethra  comiiletely,  recovery.  In  general, 
diagnosis  is  made  from  urethral  hemorrhage  with  retention 
of  urine,  associated  with  bleeding  into  the  perineum,  scro- 
tum, and  buttocks.  Rejieated  introduction  of  a  catheter 
into  the  bladder  is  not  wi.se,  and  the  wearing  of  a  perma- 
nent catlieter  is  not  advisable.  Jacobson  believes  that 
careful  exploration  with  the  finger  will  often  enable  us  to 
locate  the  proximal  end  of  the  severed  urethra. 

A  Case  of  Congenital  Ocular  Defect.— By  E.  E.  Blaauw. 
The  patient  was  a  young  wi>man  aged  twenty  years,  who 
com])lainedof  headache.  On  examining  her  eyes  he  found 
vision  in  each  eve  f;  ;  vision  in  both  eyes  together  with  -}- 
0.5  D.  5.     With  the  Javal-Schiiitz  ophthalmometer  a  conical 


November  17,  1900] 


MEDICAL    RECORD. 


7^3 


astigmatism  of  ±  i  D.,  max.  o'  (D.  In  the  right  eye  line 
opacities  iu  the  vitreous.  When  asked  to  follow  an  object 
with  her  left  eye,  she  appeared  absolutely  incapable  of  so 
doing  in  the  temporal  pan  of  the  visual  Held  ,  all  abduc- 
tive  power  of  that  eye  seemed  absent.  She  did  not  squint, 
never  saw  double  images,  and  carried  the  head  in  a  nor- 
mal manner.  By  bringing  a  prism  with  its  base  horizon- 
tally before  one  eye  she  saw  two  homonymous  images, 
especially  after  coloring  the  one,  but  not  often  was  one 
image  perceived. 

A  Case  of  Mastoid  Abscess  ;  Recovery  without  Operation. 
—By  J.  IJ.  Harrigan. 

What  the  Law  Requires  of  the  Surgeon.  — By  Dudley  S. 
Reynolds. 

Endothelioma  of  Bone  with  Many  Metastases.—  By  F.  H. 
Brandt. 

/ouriial  of  tlie  American  Medical  Ass' n,  A'o?'.  lo.  igoo. 

Rotheln :  its  Differentiation  from  Measles  or  Scarlet  Fever. 
— Henry  Koplik  believes  that  rotheln  is  a  distinct  and 
definite  disease,  independent  of  measles  or  scarlet  fever. 
The  best  authorities  agree  that  the  exanthema  of  rotheln 
appears  first  on  the  tace.  After  remaining  in  full  efflores- 
cence on  the  face  and  trunk  only  from  a  few  hours  to  a 
day,  the  rash  begins  to  fade,  and  the  patient  may  in  the 
ne.Kt  twenty-four  hours  present  a  perfectly  normal  skin. 
The  writer  has  never  seen  the  pigmented  spots  seen  in 
true  measles.  The  buccal  mucous  membrane  is  the  crucial 
test  in  diagnosis.  In  no  case  of  true  rotheln  has  the 
writer  seen  the  rose-red  spots  with  the  bluish-white  speck 
in  the  centre  seen  in  measles.  The  buccal  mucous  mem- 
brane in  most  cases  of  rotheln  is  of  a  normal  pale-pink 
hue.  The  temperature  in  this  disease  is  highest  at  the 
outset  of  the  disease  when  the  eruption  has  appeared  on 
the  face.  The  writer  has  observe<l  enlargement  of  the 
lymph  nodes  behind  the  sterno-mastoid  muscle.  Gener- 
ally, the  tonsils  are  enlarged.  In  varicella  the  spleen  is 
sometimes  palpably  enlarged,  but  not  in  rotheln.  Scar- 
let fever  does  not  affect  the  face  so  distinctly,  and  on  the 
trunk  scarlet  fever  shows  the  acute  dermatitis  as  a  back- 
ground for  the  punctate  character  of  the  general  eruption. 
These  punctate  spots  in  scarlet  fever  have  no  particular 
arrangement;  in  riitheln,  if  the  papules  are  as  small  as 
those  of  scarlet  fever  the  skin  between  the  papules  has  a 
normal  color.  The  exanthema  of  measles  of  the  discrete 
type  closely  resembles  that  of  rotheln.  Then  tlie  buccal 
mucous  membrane  is  the  crucial  test.  The  highest  tem- 
perature never  goes  beyond  103'  F.  The  general  condi- 
tion of  a  patient  is  that  of  a  person  suffering  a  slight  mal- 
aise. It  requires  little  or  no  treatment.  Children  should 
be  kept  indoors  till  all  signs  of  the  exanthema  have  disap- 
peared. 

Measles  and  the  Exanthemata  :  Shall  Children  be  Kept 
Therefrom?  Likewise  from  Diphtheria  and  Pertussis. — C. 
F.  Wahrer  does  not  believe  that  it  is  always  best  to  kee]> 
children  from  acquiring  measles,  at  least  not  with  as 
good  a  reason  as  we  have  for  preventing  their  acquiring 
such  virulent  diseases  as  scarlatina,  variola,  or  diphtheria. 
As  to  rotheln  and  varicella,  neither  is  ever  fatal.  Scarla- 
tina not  only  kills  thousands  of  children,  but  is  followed 
frequently  by  serious  sequelae.  It  is  not  apt  to  be  acquired 
by  adults.  As  to  diphtheria,  what  has  been  said  of  scar- 
latina is  largely  true  of  it.  Variola  is  always  a  dangerous, 
loathsome  malady  with  a  large  mortality.  Pertussis  is  in 
early  life  very  fatal  and  frequently  attended  by  serious 
complications.  Although  adult  life  is  not  entirely  ex- 
empt from  it,  still  it  is  not  so  easily  affected.  The  mor- 
tality from  measles  is  great,  but  mostly  during  adult 
life.  Its  most  dreaded  complications  and  sequels;  are 
principally  met  with  in  adult  life.  Measles,  ever  so  mild, 
is  a  prophylactic  against  any  future  exposure.  There 
is  a  very  light  mortality  among  children  under  the  age  of 
fourteen  years.  The  writer  believes  the  disea.se  should  al- 
ways be  quarantined  against  in  children's  hospitals,  in 
private  schools,  in  severe  winters,  and  in  the  unsanitary 
districts  of  crowded  tenements.  But  when  children  in  or- 
dinary health  can  be  exposed  to  a  mild  epidemic  of  measles, 
there  would  probably  be  as  much  benefit  as  when  cowpox 
is  substituted  for  smallpox.  Adults  are  just  as  liable  to 
acquire  measles  as  children,  and  when  acquired  the  disease 
usually  becomes  more  dangerous.  Till  the  diagnosis  is 
established,  it  is  best  not  to  allow  patients  to  come  in  con- 
tact with  others. 

A  Clinical  and  Pathological  Study  of  the  Rash  of  Scarlet 
Fever. — The  following  inferences  are  drawn  by  Jaj-  F. 
Scliamberg  :  (i)  The  color  of  the  rash  in  scarlatina  varies 
in  different  individuals,  and  at  different  times  in  the  same 
individual.  Accurately  speaking,  it  is  never  scarlet  and 
only  occasionally  bright  red.  More  commonly  it  is  a  dull  red 
with  an  appreciable  element  of  brown.  (2)  There  are  other 
elements  of  the  eruption  of  scarlet  fever  besides  the  ery- 
thema, namely,  puncta,  vesicles,  and  goose-flesh  papules, 


and  these  lesions  occur  with  a  considerable  degree  of  con- 
stancy. (3)  Vesicles  are  far  more  common  in  the  rash  of 
scarlet  fever  than  is  ordinarily  believed.  They  are  more 
profuse  in  intense  eru|)ln>ns,  although  they  may  be  present 
in  mild  ones.  The  amount  of  desquamation  is  as  a  rule 
proportionate  to  the  degree  of  vesiculation.  Vesiculation 
may  be  .so  copious  as  to  deceive  the  physician  in  his  diag- 
nosis. (4)  Desquamation  011  the  body  begins  as  pin-point, 
powdery  scales  at  the  summits  of  the  desiccated  vesicles. 
Irregular  or  jagged  rings  of  desquamation  then  form, 
which  enlarge  until  the  horny  layer  is  completely  shed. 
(5)  Histologically,  the  rash  of  scarlet  fever  is  a  dermatitis 
exhibiting  deep  and  extensive  changes  in  the  corium.  The 
greatest  degree  of  inflammation  is  exhibited  about  the  hair 
follicles,  which  are  frequently  disintegrated  by  a  serous 
and  cellular  exudate.  Vesicles  have  their  seat  either  in 
the  epidermis  or  in  the  walls  of  the  hair  follicles.  The 
persistence  of  desquamation  and  of  the  infectivity  of  the 
scales  is  to  be  accounted  for  by  the  depth  of  the  pathologi- 
cal process  in  the  skin. 

Some  Experiments  of  the  Relation  between  Audition  and 
the  Circulation  of  the  Blood  in  the  Head. — Hamilton  Still- 
son  relates  some  of  his  personal  experiences  in  hearing. 
His  left  ear  had  for  a  time  a  slight  tinnitus  with  slight 
lowering  of  hearing-acuity.  The  tinnitus  was  caused  by 
tubal  (Edema.  The  writer  then  speaks  of  palpating  the 
tube  by  means  of  the  tongue  thrust  into  the  post-nasal 
space.  Fixing  the  attention  on  the  tinnitus  would  increase 
its  intensity,  and  brushing  the  hairs  at  the  external  orifice 
of  the  auditory  meatus  would  cause  a  different  tinnitus — 
caused  by  the  contraction  of  the  muscles  in  that  vicinity. 
Pressure  on  the  mastoid  bone  increased  the  tinnitus  and 
raised  its  pitch.  Pressing  against  the  mastoid  tip  of  the 
tinnitic  ear  caused  it  to  hear  objective  .sounds  louder  and 
in  a  slightly  higher  pitch.  Lying  down  increased  the  tin- 
nitus and  lessened  the  hearing-distance.  With  head  sus- 
pended, in  the  tinnitic  ear  the  hearing-power  seemed  at 
first  slightly  diminished  and  then  increased,  but  no  rhythm 
in  the  objective  sound  could  be  noticed.  Moving  the  head 
to  and  fro  in  its  vertical  axis  caused  a  peculiar  bell-like 
tinnitus  iu  both  ears,  more  noticealjle  in  the  tinnitic  one. 

Treatment  of  Lupus  Vulgaris  with  X-Rays. — J.  T.  Knox 
reports  this  case  of  a  girl  aged  twenty  years.  The  dis- 
ease involved  the  nose  and  upper  lip,  and  had  already 
caused  perforation  of  the  nasal  septum.  The  rays  were 
applied  for  from  six  to  ten  minutes  each  sitting,  every 
other  day.  placing  the  affected  jiarts  from  four  to  eight 
inches  from  the  lube,  according  to  the  density  of  the  rays. 
The  total  number  of  applications  was  seventy-four.  Im- 
provement was  noticed  soon  after  the  beginning.  The 
unaffected  parts  of  the  face  and  head  were  shielded  by 
means  of  a  mask.     A  cure  was  effected. 

Ossification  of  the  Choroid  Leads  to  the  Identification  of 
the  Body  in  an  Insurance  Case.  — By  Robert  L.  Ran(lol]i!i. 

Tuberculosis  of  the  Testicle,  with  Special  Consideration  of 
its  Conservative  Treatment. — By  John  B.  Murphy. 

Tubercular  Tumor  of  the  Orbit. — By  Howard  F.  Hansell. 

Etiology  and  Prognosis  of  Adenoids.— By  A.  M.  Corwin. 

Bos/on  MeJtLii/  iiiiti  Surgical  Journal.  .\o7'eniber  S.  /goo. 

A  New  Test-Meal. — A.  E.  Austin  says  that  the  Ewald 
test-meal  consists  of  two  rolls  and  two  glasses  of  water ; 
the  meal  of  Riegel  consists  of  soup,  beefsteak,  and  a  roll. 
That  used  in  the  experiments  described  by  the  author  con- 
sisted of  2  gm.  of  dried  egg  albumen,  compressed  into  half- 
gram  tablets.  These  are  taken  with  two  glasses  of  water 
and  the  stomach  contents  are  withdrawn  one  hour  after 
taking.  Among  the  interesting  points  brought  out  was 
the  unreliability  of  the  presence  of  lactic  acid  as  a  diagnos- 
tic symptom.  It  is  also  quite  evident  that  impaired  motil- 
ity is  the  most  important  condition  in  the  so-called  nervous 
dyspepsias,  arising  ])robabIy  from  the  lack  of  innervation 
deiiendent  ujion  sliock  or  worry.  It  may  be  present  with 
either  impaired  or  superabundant  secretion  of  hydrochlo- 
ric acid.  The  former  condition  is  probably  the  more  dis- 
tressing from  the  formation  of  organic  acids  and  gases.  It 
is  of  interest  also  that  the  increased  flow  of  gastric  juice  is 
always  accompanied  by  a  relative  increase  in  the  amount 
of  hydrochloric  acid,  or  it  may  be  that  lack  of  motility  and 
diminished  hydrochloric  acid  are  associated,  and  the  small 
quantity  withdrawn  is  due  to  inability  to  remove  the  total 
contents  of  the  stomach.  Egg  albumen  in  the  form  of  tab- 
lets seems  to  fulfil  all  the  conditions  that  attach  to  a  suc- 
cessful test-meal. 

Spinal  Caries  with  Abscess. — Ernest  B.  Young  gives  an 
analysis  of  seventy-eight  cases.  Incision  of  the  abscess 
was  done  in  the  majority  of  cases.  The  prognosis  of  spi- 
nal caries  with  ab.scess,  apart  from  the  cases  in  which  the 
abscess  opens  spontaneously,  seems  to  be  very  slightly  in- 
fluenced by  the  treatment  accorded  the  abscess,  although 
undoubtedly  affected  by  the  proper  fixation  of  the  spine. 
Considering  the  series  as  a  whole,  the  mortality  was  about 


784 


MEDICAL   RECORD. 


[November  17,  1900 


thirty- five  per  cent,  at  an  average  period  of  three  years  and 
nine  months  after  the  first  symptom,  the  mortality  being 
slightly  greater  among  those  in  whom  tlie  disease  com- 
menced before  the  tenth  year.  In  both  children  and  adults 
the  most  common  cause  of  death  seemed  to  be  a  gradual 
deterioration  of  the  whole  system.  The  causes  of  death  in 
a  few  cases  in  which  it  was  possible  to  get  a  reliable  report 
were:  general  tuberculosis,  4;  amyloid,  i;  tuberculous 
meningitis,  3  ;  shock  of  operation,  2  ;  sepsis  and  renal,  i  ; 
phthisis,  I. 

The  Agglutination  of  the  Patient's  Serum  of  the  Bacteria 
Found  ln°Cystitis  and  Pyelitis,  with  a  Consideration  of  the 
Pleomorphism  of  the  Bacteria  Found  in  These  Infections, 
Espscially  as  Regards  Chromogenic  Properties  of  the  Staphy- 
lococci.— Thomas  R.  Brown  reports  three  cases,  in  two  of 
which  there  was  an  absolutely  positive  reaction,  and  a 
suggestive  reaction  in  the  third.  A  careful  bacteriological 
study  of  over  eighty  cases  goes  to  show  that  the  colon 
bacillus  is  the  commonest  cause  of  cystitis  and  pyelitis  in 
women,  while  various  staphylococci,  the  tubercle  bacillus, 
and  the  bacillus  proteus  vulgaris  are  also  quite  frequently 
found.  The  pleomorphism  of  the  colon  bacillus  is  very 
marked.  Results  obtained  with  the  staphylococci  suggest 
that  many  of  what  we  now  consider  separate  species  may 
have  arisen  originally  from  a  common  staphylococcus,  and 
the  variations  in  cultural  peculiarities,  in  chromogenic  ten- 
dencies, etc.,  may  have  been  directly  dependent  upon  the 
various  factors,  favorable  or  otherwise,  which  surrounded 
the  special  micro-organisms  since  that  time. 

The  Management  of  Abdominal  Testicular  Ectopia  Associ- 
ated with  Inguinal  Hernia. — By  Cliarles  A.  Powers. 

Celluloid  as  Material  for  Fiat-Foot  Supports.— By  Alfred 
H.  Freiberg. 

Philadelphiii  Medical  Jou7-iial,  yoveinber  10,  igoo. 

Value  of  Potassium  Bicarbonate  in  Colds  and  Influenza. — 
Stephen  Harnsberger  states  that  potassium  bicarbor;^te, 
given  early,  will  in  nearly  every  instance  abort  a  cold  very 
effectually  and  almost  at  once.  The  remedy  is  well  borne 
by  both  elderly  and  weak  persons.  When  the  tonsils  are 
involved  or  when  the  catarrhal  inflammation  affects  the 
other  air  passages  or  the  alimentary  canal,  its  use  is  very 
effective.  Pneumonia  is  not  .so  frequent  in  such  cases,  and 
when  it  does  occur  its  course  is  milder  and  shorter.  The 
writer  wishes,  however,  particularly  to  call  attention  to  the 
influence  of  this  drug  in  influenza.  He  gives  gr.  xxx.  in 
a  cup  of  milk  every  four  hours  during  the  day,  and  no 
other  diet  for  forty-eight  hours.  If  milk  is  not  well  borne, 
then  cold  water  is  used.  He  also  believes  that  the  action 
of  this  drug  is  greatly  assisted  by  a  catliartic,  such  as  calo- 
mel, podophyllum,  etc.  When  heart  failure  is  imminent, 
then  rest  in  bed  should  be  enjoined.  The  writer  believes 
that  there  is  no  superior  treatment  for  influenza. 

The  Treatment  of  Syphilis  :  a  New  and  Tolerable  Form 
of  Administering  Mercury,  with  Report  of  Sixty-five  Cases 
Treated  at  Bellevue  Hospital. — Hy  Wmtield  Ayres. 

Localization  of  a  Bullet-Wound  of  the  Spinal  Cord ;  Re- 
moval of  the  Bullet  from  the  Spinal  Canal. — By  Howell  T. 
Pershing. 

Aneurism  of  the  Heart  with  Thrombosis  of  the  Left  Coro- 
nary Artery. — By  Jiidson  Daland. 

Analgesia  in  Obstetrics  Produced  by  Medullary  Injections 
of  Cocaine. — By  S.  Mar.x. 

Study  of  a  Mummy  Affected  with  Anterior  Poliomyelitis. 
—  By  John  K.   Mitchell. 

The  Journal  oj  E.xfit-yiiiu-ntat  Medicine,  October  ^j,  igoo. 
Acute  Internal  Hydrocephalus,  a  Clinical  and  Pathologi- 
cal Study.  —  Charles  W.  Burr  and  D.  J.  McCarthy  re- 
port the  case  of  a  man  aged  thirty-three  years,  who  was 
suddenly  seized  with  fever,  bradycardia,  constipation, 
rigidity  of  the  muscles  of  the  neck,  headache,  stupor,  and 
delirium.  For  three  weeks  the  intensity  of  the  symptoms 
varied  greatly,  after  which  the  patient  improved  very  much 
physically,  but  showed  many  of  the  mental  symjitoms 
of  paretic  dementia.  One  week  later  both  fever  and  me- 
ningeal symptoms  returned,  and  after  lasting  about  a  week 
again  intermitted  for  four  days,  only  to  return  again  and 
end  in  death.  On  post-mortem  examination  only  a  moder- 
ate internal  hydrocephalus  was  shown,  with  proliferation  of 
the  ependyma  and  cpendymal  glia,  perivascular  round-cell 
infiltration  in  the  subependymal  tissues,  and  sclerotic  and 
degenerative  changes  in  the  choroid  plexus.  To  determine 
the  cause  of  tlie  lesions,  if  possible,  the  writers  instituted 
a  series  of  experiments  on  kittens  by  injecting  into  the 
ventricles  of  these  animals  sterilized  urine,  glycerin  ex- 
tract of  tlie  adrenals,  tuberculin,  hydrochloric  and  car- 
bolic acids.  They  conclude  from  their  results  that  the 
non-purulent  inflammation  of  the  ependyma  produced  by 
acid  irritants  dilTers  only  in  degree  from  the  reactive 
changes  following  the  injection  of  toxins  into  the  ven- 
tricles.    Changes  in  the  ependyma  without  changes  in 


the  subjacent  tissue  probably  do  not  occur.  The  inflam- 
matory condition  experimentally  produced,  by  whatever 
agent,  did  not  cause  any  increase  in  the  ventricular  fluid, 
and  the  only  evidence  of  an  exudate  from  the  ependyma 
was  the  amorphous  material  which  probably  was  made  up 
of  degenerated  cells.  The  niicroscoi)ical  sections  in  the 
toxin  experiments  resembled  the  sections  from  the  case 
under  discussion.  The  mental  condition  of  the  patient 
corresponds  to  that  seen  in  other  auto-intoxications.  Both 
of  these  facts  point  to  the  hypothesis  that  the  changes 
found  were  secondary  to  a  toxic  condition  of  the  ventricu- 
lar fluid.  The  exacerbations  which  Quincke  compares  in 
their  sudden  development  and  variability  to  angioneurotic 
oedema  appear  to  them  to  be  rather  the  manifestations  of 
varying  intensity  of  auto-intoxication,  such  as  occurs  in 
uraemia  and  syphilis.  Finally,  the  hydrocephalus  alone  by 
its  mere  mechanical  action,  if  sufficient  fluid  is  present, 
can  cause  many  symptoms. 

A  Case  of  General  Gaseous  Emphysema  with  Gas  Cysts  in 
the  Brain  Found  after  Death  and  due  to  Bacillus  Mucosus 
Capsulatus,  with  a  Consideration  of  the  Gas  -  Producing 
Properties  of  Certain  Members  of  this  Group  in  the  Cadavers 
of  Animals. — This  case  is  reported  by  W.  T.  Howard,  Jr. 
The  patient  was  a  white  woman  aged  forty  ye;trs.  On 
admission  to  the  hospital  she  was  comatose  and  neverYe- 
gained  con.sciousness.  The  pulse  was  loS  to  the  minute, 
regular  and  rhythmical.  There  was  Cheyne-Stokes  respira- 
tion, the  apna?a  lasting  twenty  seconds.  The  extremities 
were  cold  and  cyanotic  ;  the  skin  was  cool  and  moist.  Ex- 
amination of  the  chest  and  abdomen  gave  negative  re- 
sults. There  was  incontinence  of  urine,  and  none  could  be 
obtained  on  catheterization.  The  patient  was  in  the  habit 
of  taking  large  quantities  of  morphine.  She  died  eight 
hours  after  admission.  The  clinical  diagnosis  was  mor- 
phine poisoning.  The  writer  presents  the  following  sum- 
mary :  In  the  case  reported  in  this  article  there  was  septi- 
caemia with  special  localization  of  the  micro-organisms  in 
the  brain,  with  gas  cysts  of  the  brain  and  general  ga.seous 
emphysema  due  to  bacillus  mucosus  capsulatus  (aerogenes 
group) .  The  bacillus  isolated  from  the  organs  of  this  case, 
as  well  as  other  members  of  the  aerogenic  group  of  bacillus 
mucosus  capsulatus,  can  cause  general  gaseous  emphysema 
in  the  cadavers  of  rabbits,  either  with  or  without  the  in- 
travenous injection  of  sugar  before  the  animal  is  killed; 
the  gas,  however,  being  most  abundant  and  rapidly  found 
in  the  former  case.  It  is  not  impossible  that  .some  of  the 
published  cases  of  gaseous  emphysema  in  wliich  a  bacteri- 
ological examination  was  not  made  may  have  been  due  to 
members  ot  the  bacillus  mucosus  capsulatus  group.  The 
writer  then  notes  that  Dr.  Welch  has  called  his  attention 
to  the  possibility  that  diabetes  may  have  existed  in  this 
case.  The  possibility  must  be  admitted,  since  no  examina- 
tion of  the  urine  was  possible.  There  is  evidence  that 
certain  bacteria  incapable  of  producing  gas  in  tissues  and 
organs  of  the  body  under  other  conditions  may  do  so  in  dia- 
betics on  account  of  the  presence  of  an  abundance  of  sugar. 

Two  Cases  of  Necrotic  Broncho-Pneumonia  with  Strepto- 
thrix. — Charles  Norris  and  John  H.  Larkin  call  attention 
to  the  rarity  and  importance  of  such  cases.  The  first  case 
was  that  of  a  man  aged  forty-five  years ;  the  second  was 
of  a  man  aged  twenty-three  years.  The  writers  give  the 
following  rt'snnitf  of  their  discussion :  The  two  cases  of 
broncho-pueumonia  in  men  forming  the  subject  of  this  arti- 
cle were  characterized  by  intense  catarrhal  and  necrotic 
inflammation  of  tlie  bronchi  and  by  the  presence  of  numer- 
ous streptothrix  colonies  in  the  bronchial  lumina.  Intro- 
duction of  the  bronchial  material  of  Case  I.  into  the  trachea 
of  three  rabbits  induced  pulmonary  abscesses  and  em- 
pyema of  the  pleura  and  pericardium  in  one  of  the  animals. 
Introduction  of  the  bronchial  material  of  Case  II.  into  the 
ear  vein  of  a  rabbit  and  into  the  trachea  of  a  second  rabbit 
induced  likewise  pulmonary  abscesses  and  empyema.  The 
empyemal  pus  of  these  rabbits  contained  filaments  and 
rods  morphologically  identical  with  those  composing  the 
streptothrix  colonies  of  the  human  cases.  From  Cases  I. 
and  II.  a  streptococcus  was  cultivated  on  the  ordinary 
media,  the  streptothrix  not  being  isolated  in  culture  di- 
rectly from  the  Iiuman  organs.  By  inoculating  the  fresh 
and  .sterile  kidneys  removed  from  a'normal  rabbit  with  the 
empyemal  ]nis  of  a  rabbit  injected  into  the  ear  veins  with 
the  bronchial  material  of  Case  II.,  the  streptothrix  from 
this  case  was  finally  isolated  in  pure  culture, and  its  mor- 
phological and  biiilngical  characters  were  studied  in  detail. 

Amyloid  Substance  and  Amylaceous  Bodies  in  Multiple 
Syphilitic  Tumors  of  the  Bones,  with  Remarks  on  the  Rela- 
tion of  Amylaceous  Bodies  to  Amyloid  Substance.— By  W. 
Ophiils. 

A  Preliminary  Report  on  Acid-Resisting  Bacilli,  with  Spe- 
cial Reference  to  their  Occurrence  In  the  Lower  Animals. — 
Hv  \).  .Murray  Cowie. 

On  the  Presence  of  New  Elastic  Fibres  in  Tumors.— By 
Alice  Hamilton. 


November  17,  1900] 


MEDICAL    RECORD. 


785 


The  Lancet,  .Xovember  3,  igoo. 

Puttee  Paralysis  (?)  after  Enteric  Fever. — J.  \V.  Springe- 
tliorpe  reports  the  case  of  a  soldier  who  suffered  from 
a  condition  frequently  seen  in  that  class  after  typhoid. 
Examination  disclosed  marked  wasting  of  the  tibial  mus- 
cles of  the  left  leg,  with  apparent  wasting  of  the  peroneal 
and  extensor  muscles  also.  The  muscles  reacted  to  the 
faradic  current,  but  with  a  noticeable  weakness.  Those 
on  tlie  right  leg  showed  no  present  difference  or  abnor- 
mality. There  liad  been  no  implication  of  the  calf  mus- 
cles and  there  was  no  present  tenderness  on  pressure 
over  the  nerve  trunks  in  that  region.  Under  faradisra 
and  massage  the  muscles  rapidly  regained  their  normal 
reactions,  and  their  action  at  the  time  of  writing  has 
become  practically  perfect.  The  trouble  was  thus  con- 
fined absolutely  to  the  muscles  and  surfaces  supplied  by 
the  peroneal  nerve,  the  musculo-cutaneous  branch  of  which 
supplies  the  peroneus  longus  and  peroneus  brevis,  together 
with  the  dorsal  surfaces  of  the  foot  and  toes,  while  the  an- 
terior tibial  branch  supplies  the  tibialis  anticus,  the  long 
and  short  extensors  of  the  toes,  and  the  long  extensor  of 
the  big  toe,  as  well  as  the  dorsal  surfaces  of  the  inner  toes. 
This  implication  of  the  peroneal  nerve  suggested  injury,  and 
when  symmetrical,  bilateral  pressure  as  the  probable  cause. 
Such  a  cause  is  at  once  suggested  in  the  puttees  used  so 
extensively  and  indiscriminately  by  the  soldiers  in  the 
South  African  campaign.  On  being  asked  the  patient 
stated  that  the  last  few  rounds  of  the  puttees  were  fast- 
ened rather  more  tightly  than  elsewhere  directly  over  the 
head  of  the  fibula,  and  thus  pressed  the  peroneal  nerve 
against  the  bone. 

Uncomplicated  .Slstivo-Autumnal  Fever  in  Europeans  in 
the  Gold  Coast  Colony,  West  Africa. — A.  J.  Clialraers  says 
that  this  is  the  most  common  fever  experienced  by  Euro- 
peans in  the  territory  named.  Predisposing  causes  are 
chills,  constipation,  mental  worry,  excesses  of  any  descrip- 
tion, disease  of  an  organ  lowering  the  vitality,  poor  food 
or  indigestion,  and  insolation.  Infection  occurs  through 
mosquitos,  the  especial  variety  being  called  by  the  author 
Anopheles  Kumasii.  The  causation  is  the  parasite  called 
"  Heamonenas  prjECOx."  At  first  small  and  unpigmented, 
it  grows  and  may  be  from  one-fifth  to  one-third  as  large  as 
the  corpuscle,  and  becomes  pigmented.  Clinically  the  type 
of  fever  is  quotidian  ;  rarely  it  is  tertian,  but  these  typical 
fevers  may  be  altered  and  become  almost  continuous  by 
slight  complications  without  malignant  symptoms.  The 
principal  symptoms  and  signs  are  headache,  pains  in  the 
back  and  legs,  sense  of  weariness,  thirst,  and  anorexia 
with  nausea.  There  is  tenderness  over  the  liver  and 
spleen,  which  are  enlarged.  Vomiting  is  frequent,  and  the 
bowels  incline  to  constipation.  The  pulse  rate  sinks  below 
normal  on  the  fall  of  temperature.  Without  malignant 
symptoms  the  mortality  rate  is  very  low.  Treatment  may 
be  summarized  as  follows;  During  the  rise,  antipyretics 
and,  if  necessary,  cold  applications  and  aperients  ;  during 
the  remission,  quinine  and  some  saline  diaphoretic  mix- 
ture. If  the  temperature  is  over  104'  F.,  phenacetin  with 
calomel  and  a  hot  lime  drink ;  after  the  attack,  tonics. 

Have  Maternal  Impressions  any  Effect  on  the  Foetus  in 
Utero? — By  William  Duncan.  A  woman,  in  the  seventh 
week  of  pregnancy,  was  photographed  with  her  husband. 
When  the  wife  saw  the  photograph  she  exclaimed  that  her 
husband's  "right  hand  looked  deformed  as  if  it  had  only 
a  thumb  and  little  finger."  On  frequent  subsequent  occa- 
sions she  showed  the  photograph  to  friends,  always  point- 
ing out  the  deformity  to  them.  When  the  child  was  born 
— after  a  normal  labor — the  right  hand  was  deformed,  and 
the  resemblance  to  the  father's  right  hand,  in  comiiaring 
the  two  photographs,  is  sufficiently  striking.  Now  comes 
a  very  remarkable  occurrence.  The  nurse  in  charge  of  the 
baby  while  out  walking  one  day  showed  the  deformed  limb 
to  a  neighbor  who  happened  to  be  a  few  weeks  pregnant. 
She  was  very  shocked,  but  remarked.  "  What  a  lucky  thing 
that  botli  arms  are  not  deformed."  This  woman  was  duly 
delivered  of  her  first  child  at  full  term,  and  "  both  its  hands 
and  feet  were  deformed."  The  mother  was  of  a  very  ner- 
vous temperament.  She  often  expressed  her  opinion  that 
it  was  the  shock  of  seeing  the  hand  of  the  first  patient's 
child  that  caused  her  child  to  be  born  deformed.  She 
would  allow  no  one  to  see  the  child.  She  has  since  been 
removed  to  an  asylum.  Both  of  the  children,  apart  from 
the  deformity,  are  well  developed  and  healthy.  No  pre- 
vious cases  of  deformity  can  be  ascertained  as  having  oc- 
curred in  either  family. 

Arrested  Mental  Development  following  Depressed  Fracture 
of  the  Slcull ;  Trephining;  Improvement. — Alfred  Clark  re- 
ports the  case  of  a  mulatto  child  aged  eleven  years,  whose 
development  was  normal  till  her  fourth  year,  when  she  fell 
backward  striking  her  head  against  the  leg  of  a  table.  On 
recovery  from  the  immediate  effects  of  the  injury  she 
seemed  all  right  except  that  she  had  a  fit  about  once  a 
week  preceded  by  a  spasm  of  the  right  arm  and  leg.    The 


mental  faculties  became  stationary  and  the  gait  sham- 
bling. She  developed  a  genius  for  mischievous  destruc- 
tion, so  that  she  had  to  be  closely  watched.  Examination 
showed  a  depression  in  the  left  occipital  bone  near  the 
parieto-occipital  suture  and  about  two  fingers'  breadth 
from  the  middle  line.  It  was  about  an  inch  and  a  half 
long  and  three-quarters  of  an  inch  wide.  Trephining 
showed  the  meninges  enormously  thickened  and  adherent. 
No  fluid  was  obtainable  by  trocar  and  cannula  passed  into 
the  brain.  The  adhesions  weie  separated  as  far  as  pos- 
sible, the  disc  of  bone  was  replaced,  and  the  wound  closed. 
Recovery  from  operation  was  uninterrupted.  The  fits  and 
spasms  never  returned  and  her  mental  condition  vastly 
improved,  so  that  three  months  later  she  seemed  develop- 
ing according  to  the  standard  of  a  child  of  four  or  five. 

Nature's  Alkaline  Treatment  of  Gout  and  Rheumatism  by 
the  Use  of  Natural  Alkaline  Thermal  Waters.— By  C.  N. 
Brandt. 

Diagnosis  of  Thoracic  Aneurism  by  the  Roentgen  Rays. — 
By  Hugh  Walsam. 

The  Wedge  Operation  for  Entropion  and  Trichiasis. — By 
H.  Herbert. 

Bacteriological  Diagnosis  of  Disease. — By  Sheridan  Del6- 
pine. 

Tonite  Explosion  as  a  Cause  of  Death. — By  A.  S.  Morton. 

Surgery  as  a  Science  and  an  Art.— By  C.  Y.  Pearson. 

Lengthening  the  Tendo  Achillis. — By  R.  A.  Hibbs. 

Impetigo  following  Vaccination. — By  J.  J.  Harding. 

Surgery  of  the  Stomach.— By  A.  Ernest  Maylard. 
Jlrilisli  Mcditul Juiirital,  .Wn'eiii&er  j,  igoo. 

Myelopathic  Albumosuria.— This  affection  is  defined  by 
T.  R.  Bradshaw  as  a  disease  characterized  by  an  invasion 
of  the  cancellous  tissue  of  the  bones  of  the  trunk  by  a  cel- 
lular growth,  by  a  disappearance  of  the  osseous  tissue,  and 
by  the  presence  in  the  urine  of  large  quantities  of  a  pecul- 
iar albuminous  substance  belonging  to  the  class  of  bodies 
known  as  albumoses.  The  bones  chiefly  affected  are  the 
ribs,  sternum,  and  the  bodies  of  the  vertebrae.  Microscop- 
ically the  structure  resembles  sarcoma.  The  condition  is 
called  "multiple  myeloma."  The  disease  occurs  in  the 
second  half  of  life  and  seems  more  frequent  in  men  than 
in  women.  The  first  symptom  noticed  is  generally  pain  in 
the  lumbar  region.  Later,  the  pains  become  more  general. 
The  urine  contains  a  proteid  which  superficially  resembles 
albumin  but  differs  from  it  in  several  reactions.  The 
writer  gives  the  following  characteristic  reactions,  (i)  It 
coagulates  at  a  comparatively  low  temperature  (6o'  C.  or 
140'  F. ).  (2)  The  coagulum  is  redissolved  on  boiling. 
(3)  It  is  readily  precipitated  by  hydrochloric  acid,  as  well 
as  by  nitric  acid,  and  the  precipitates  are  dissolved  on  boil- 
ing. The  diagnosis  is  easy,  as  the  condition  of  the  urine 
appears  to  be  pathognomonic  of  the  di.sease.  The  disease 
seems  always  fatal,  but  sometimes  its  course  is  remark- 
ably prolonged.  No  treatment  so  far  tried  seems  to  have 
the  slightest  effect  on  the  progress  of  the  disease. 

The  Treatment  of  the  Paroxysmal  Stage  of  Whooping- 
Cough. — John  Edward  Godson  describes  the  method  which 
seems  most  satisfactory  to  lym  as  follows:  Commence  at 
once  with  the  continuous  inhalation  of  creosote.  Before  the 
use  of  any  anti-spasmodic  remedies,  the  lungs  should  be 
cleared  of  bronchitis  as  much  as  possible.  Belladonna 
seems  effective  in  broncho-pneumonia.  Moderate  doses  of 
antipyrin  may  be  given  in  all  cases,  if  or  when  the  chest 
is  fairly  clear  and  the  circulation  good.  Expectorants 
should  be  used  at  the  same  time.  Wholesome  food,  fresh 
air,  light  and  warm  clothing  are  necessary.  The  writer 
gives  the  average  length  of  time  required  for  cure  in  a 
variety  of  cases  last  year  as  19. S  days.  These  figures  do 
not  represent  the  benefit  derived  from  the  creosote  treat- 
ment. The  number  of  paroxysms  is  immediately  much 
diminished  in  every  case  by  tlie  use  of  this  drug. 

The  Propagation  of  the  Filariae  of  the  Blood  Exclusively 
by  Means  of  the  Puncture  of  Peculiar  Mosquitos. — B.  Grassi 
and  G.  Noe  by  proper  experiments  have  demonstrated  that 
when  Anopheles  bite,  the  larvae  of  filaria  immitis,  which 
have  been  collected  in  the  inferior  labium,  come  out  of 
their  resting-place  and  are  thus  inoculated  in  the  bitten 
animal,  the  mechanism  of  exit  representing  a  most  singu- 
lar and  admirable  phenomenon  for  the  diffusion  of  para- 
sites. The  experiments  of  these  writers  have  been  far 
more  extended  than  their  present  report  of  them,  but  their 
entire  results  will  be  given  at  a  later  date.  However,  even 
now  it  can  be  stated  that  undoubtedly  the  blood  filariae,  as 
the  parasite  of  malaria,  are  inoculated  'uy  the  puncture  of 
special  mosquitos,  although  in  a  different  way.  The  exit 
of  the  larvffi  does  not,  as  Bancroft  thought,  take  place 
through  the  cesophagus  and  pharynx. 

Foreign  Body  Twenty-five  Years  in  the  External  Auditory 
Meatus. — Arthur  H.  Benson  reports  the  case  of  a  man  aged 
thirty-five  years,  who  twenty-five   years  ago   had  put  a 


786 


MEDICAL    RECORD. 


[November  17,  1900 


piece  of  slate  pencil  into  his  right  ear.  where  it  had  since 
remained.  He  was  very  deaf  and  both  ears  were  packed 
with  cerumen.  The  ear  was  syrin.ijed  and  the  cerumen 
softened  with  oil.  The  next  day,  when  the  ear  was  licinjr 
syringed,  a  piece  of  slate  pencil,  three-quarters  of  an  inch 
long,  came  out.  It  had  a  sharp  point  and  liad  lain  for 
twenty-five  years  jammed  sideways  in  the  meatus,  causing 
no  pain.  After  inllation  by  Politzer's  methol,  the  hearing 
in  the  right  ear  was  improved  to  whisper  at  two  metres  and 
C.  V.  at  seventy-live  metres. 

Ambidexterity.— James  Sawyer  is  an  enthusiastic  advo- 
cate of  ambidexterity.  He  states  that  an  excellent  way 
for  the  acquirement  of  this  accomplisliment  is  the  learning 
of  sinistral  handwriting  with  pen  and  ink.  When  one  can 
write  comfortably  with  the  left  h -nd  other  accomplishments 
will  become  easy.  Ambidexterity  would  prevent  many 
occupation  jjareses.  It  would  tend  to  a  more  equal  use  of 
the  two  sides  of  the  brain,  and  might  prevent  or  help  .some 
cases  of  hemicrania  or  perhaps  some  cases  of  hemiplegia. 

Contribution  to  the  Technique  of  Bacteriology. — By  Marc 
Armand  Ruffer  and   Milton  Crendiropoulo.      illlusfrated.) 

An  Address  on  Some  Aspects  of  Modern  Medical  Theory 
and  Practice. — By  Alfixil  H.  Carter. 

Mode  and  Rapidity  of  Reduction  of  Temperature  by  Qui- 
nine.—  By  William  Sykes. 

Abdominal  Wound  Inflicted  by  a  Rhinoceros.  — By  E.  Wyn- 
stone  Waters. 

Suprarenal  Gland  Extract  as  a  Hsemostatic. — By  O.  F.  F. 

Grunbaum. 

The  Bromide  Sleep  in  a  Case  of  Mania.— By  Philip  M. 
Ragg. 

A  Case  of  Perforating  Gastric  Ulcer. — By  G.  Michelraore. 

A  Case  of  Scarlatina  Pemphigoides. — By  Arthur  Somers. 

Poisoning  by  Strychnine  ;  Recovery. — By  William  Dick. 

Wasp  Sting  of  the  Tongue.— By  Herbert  W.  Nott. 

The  Diagnosis  of  Diphtheria. — By  H.  B.  Donkin. 
French  /ournals. 

Researches  Concerning  the  Natural  Immunity  of  the  Dog 
against  the  Anthrax  Bacillus.  —  In  the  discussion  of  this  sub- 
ject, M.  Phisalix  states  that  when  a  dog  is  inoculated  sub- 
cutaneously  in  the  thigh  with  a  young  culture  of  anthrax 
in  which  the  spores  have  not  yet  developed,  and  when  in 
the  course  of  from  five  to  eighteen  days  the  animal  is  killed 
and  the  glands  of  the  groin  are  examined,  new  cultures 
are  obtained  with  characteristics  completely  different  from 
those  of  the  anthrax  bacillus  which  has  been  inoculated. 
These  new  cultures  are  not  virulent ;  but  according  to  the 
length  of  time  between  the  inoculation  and  the  examina- 
tion of  the  gland,  and  according  to  the  intensity  of  the 
local  reaction,  the  morphological  characteristics  of  the  mi- 
crobe are  recognizable  or  they  are  so  changed  that  an  ob- 
server not  knowing  the  nature  of  the  original  inoculation 
would  fail  to  recognize  the  micro-organism  as  that  of  an- 
thrax. It  is  colored  by  the  Gram  method  and  does  not  form 
spores.  The  writer  in  his  experiments  has  introduced 
virulent  bouillon  cultures  contained  in  collodion  capsules 
into  tlie  peritoneum  of  a  dog.  The  transformation  of  the 
bacillus  is  due  to  the  influence  of  soluble  dialyzable  sub- 
stances. When  the  serum  of  a  dog  is  used  in  the  capsule  as 
the  culture  medium  the  modification  of  the  organism  is  far 
more  rapid.  It  is  probable  that  in  the  living  animal  the 
bactericidal  and  modifying  power  of  the  blood  is  due  to  sub- 
stances which  are  elaborated  principally  in  the  glands  and 
white  blood  corpuscles. — Le  lliilUtm  Mt'iiical.  September 
26,  lyoo. 

Fracture  of  the  Skull ;  Hemorrhage  from  the  Superior 
Longitudinal  Sinus  ;  Intervention  ;  Cure. — G.  Alexandre  re- 
ports this  case  of  a  sailor  aged  forty-four  years.  Hereceived 
a  violent  blow  on  the  head,  causing  a  severe  hemorrhage 
which  had  resisted  all  efforts  made  to  check  it,  till  he  was 
brought  to  the  hospital  six  hours  after  the  accident.  The 
pulse  was  very  weak  and  the  face  jjallid.  Blood  was  es- 
caping by  the  mouth,  nose,  and  from  the  wound.  The 
wound  was  located  in  tlie  left  frontal  region  about  an  inch 
and  a  lialf  above  the  eyebrow,  extending  laterally  to  the 
median  line.  Under  chloroform  an;esthesia  the  borders  of 
the  wound  were  excised,  and  a  large  resection  of  the  fron- 
tal bone  made  so  that  the  source  of  the  hemorrhage  could 
be  reached.  The  flow  of  blood  was  stopped  by  a  tampon. 
The  recovery  was  uneventful.  There  was  scarcely  any 
deformity,  only  a  small  depression  in  the  left  frontal  re- 
gion. Hearing  was  slightly  diminished  on  the  left.  There 
has  been  absolute  amaurosis  of  the  left  eye  since  the  acci- 
dent. The  results  led  to  the  conclusion  that  at  the  same 
time  with  fracture  of  the  vault  there  had  been  section  or 
compression  of  the  optic  nerve  or  of  the  chiasm  by  a  lesion 
at  the  base. — !.a  Mt'riciine  Modcrnc.  September  26,  1900. 

The  Intervention  of  the  Dentist  in  the  Treatment  of  Syph- 
ilis.— Bruneau  declares  that  in  the  course  of  syjihilis,  but 
principally  during  the  first  stage,  the  lesions  of  the  buccal 


mucous  membrane  alone  give  evidence  of  the  general  in- 
fection of  the  organism.  It  is  also  true  tliat  it  is  to  local 
causes  of  irritation,  situated  for  the  most  part  about  the 
teeth,  that  tlie  ])ersistence  of  sypliilitic  ulcerations  of  the 
mouth  can  be  attributed.  Also  the  phenomenon  of  intoler- 
ance, mercurial  salivation,  which  so  often  necessitates  in- 
terruption of  treatment,  has  no  other  origin  than  a  pre-ex- 
isting lesion  of  the  gums.  This  is  occasioned  either  by  a 
poor  state  of  dentition  or  by  the  presence  of  tartar  about 
the  neck  of  the  teeth.  Leaving  aside  external  causes  of  ir- 
ritation as  tobacco,  alcohol,  etc..  it  is  especially  the  teeth 
and  gums  that  must  be  carefully  examined  in  order  to 
combat  successfully  the  causes  of  syphilitic  buccal  lesions. 
The  effort  of  the  physician  in  treating  syphilis  should  be  : 
(I)  To  prevent  the  appearance  of  lesions  of  the  buccal 
mucous  membrane  ;  (2)  to  anticipate  and  prevent  the  harm- 
ful effects  of  mercurial  medication. — I.a  Presse  MddicaU, 
September  26,  1900. 

A  New  Method  of  Treating  Tuberculosis  by  the  Transfu- 
sion of  Medicines  by  Means  of  Static  Electricity,  or  the 
Method  of  F.  Crotte. — Ducamp  speaks  in  terms  of  the 
highest  praise  of  this  method  of  treatment  of  the  fearful 
scourge  tuberculosis;  Formic  aldehyde  is  transfused 
through  the  affected  organs  by  means  of  the  currents  of 
static  electricity.  The  vapors  of  formic  aldehyde  are  in- 
haled for  a  few  minutes  two  or  three  times  a  day.  The 
writer  concludes  from  his  own  experience  that  tuberculosis 
is  always  curable  in  the  first  stage  by  this  method,  almost 
always  in  the  second  stage,  and  a  third,  at  least,  of  the 
cases  in  the  last  stage.  He  thinks  great  credit  should  be 
given  to  H.  F.  Crotte  for  elaborating  this  method. — Ga- 
zftle  }Ii-bdoinadaire  des  Sciences  Medicules.  September 
23,  1900. 

Bucco-Pharyngeal  Tuberculosis. — Samuel  Bernheim  con- 
cludes that  the  etiology  of  bucco-pharyngeal  tuberculosis, 
like  that  of  every  localized  infection,  is  composed  of  three 
elements :  the  bacillus,  the  individual  predisposition,  ar.d 
the  port  of  entry.  It  may  be  primary  or  .secondary,  the 
latter  being  the  rule.  In  this  case  the  infection  is  carried 
by  the  lymphatics  or  the  blood.  When  primary,  it  follows 
a  direct  inoculation.  Among  the  causes  which  aid  this 
infection  are  tobacco,  poor  teeth,  and  defective  hygiene  of 
the  mouth.  Its  localization  on  tlie  different  organs  of  this 
region  is  very  variable. — La  1  ribune  Mcdicale,  Septem- 
ber 26,  igoo. 

Miinchener  inedtcinische  Wochenschrijt,  October  sj,  /goo. 

The  Treatment  of  Obstipation. — E.  Roos  has  endeavoicd 
to  enrich  our  therapeutic  resources  by  an  attempt  to  stimu- 
late a  sluggish  intestine  to  increased  peristaltic  activity  by 
modifying  its  bacterial  flora,  adopting  the  somewhat  unu- 
sual medicament  of  keratin-coated  capsules  containing 
pure  cultures  of  the  bacillus  coli  communis.  These  being 
obtained  from  the  fieces  of  an  individual  having  normal 
daily  movements,  it  was  supposed  that  on  introduction  into 
an  intestine  in  which  the  reverse  state  of  affairs  existed  a 
sufficient  stimulus  might  be  given  to  cause  a  more  adequate 
peristalis.  On  experiment  it  was  found  that  in  cases  of 
moderate  constipation  some  improvement  was  effected,  but 
that  the  cure  was  not  permanent,  which  latter  fact  seems 
explicable  to  the  author  on  the  ground  that  the  newcomers 
do  not  gain  a  permanent  foothold  in  the  alien  mucosa  and 
are  therefore  unable  to  continue  their  beneficial  actiin  in- 
definitely. Somewhat  similar  results  were  obtained  with 
lactic-acid  bacilli  and  yeast,  the  latter  being  equally  ef- 
fectual alive  or  dead. 

The  Atropine  Treatment  of  Intestinal  Obstruction. — Marci- 
nowski  contributes  two  cases  to  the  list  of  reported  in- 
stances in  whicfi  an  apparently  imperative  laparotomy  has 
been  avoided  by  the  u.se  of  large  doses  of  atropine.  The 
first  of  these  is  that  of  a  woman  presenting  the  typical 
picture  of  intestinal  obstruction,  who  six  hours  after  the 
subcutaneous  injection  of  gr.  -^^  of  atropine  sulphate  had  a 
soft  movement  accompanied  by  flatus,  and  went  on  to  make 
an  uncomplicated  recovery.  The  other  case  is  that  of  a 
m;in  who  gave  similar  symptoms  after  apjiarently  success- 
ful taxis  for  hernia.  After  fecal  vomiting  had  set  in,  the 
same  dose  of  the  drug  was  injected  with  a  like  hap])y  re- 
svilt.  Absolutely  no  untoward  effects  were  noted  from  the 
enormous  amount  of  alk;iloid  .given. 

The  Treatment  of  Gall  Stones  with  Olive  Oil.  — Kurt  Witt- 
hauer  assumes  a  conservative  jiosition  in  regard  to  opera- 
tive interference  for  cholelithiasis,  and  advi.ses  medical 
trealment  in  cases  in  which  there  is  no  daily  febrile  move- 
ment nor  palpable  gall  bladder.  The  most  successful 
agent  in  his  experience  is  olive  oil  in  lar.ge  quantities  (12- 
16  oz.),  daily  .given  by  mouth  as  long  as  the  jKitient  can 
stand  it,  and  then  by  rectum.  The  stools  sliould  always  be 
sifted,  that  no  stones  may  pass  unnoticed.  In  one  case  a 
patient  passed  one  hundred  and  thirty-seven  stones  while 
under  this  treatment. 

Bertillon's  Method  of  Body  Measurement  Practically  Ap- 
plied.— By  Wengler. 


November  17,  1900] 


MEDICAL    RECORD. 


787 


Short  Dermato-Therapeutic  Contributions. — By  K.  Siebert. 
The  Surgical  Treatment  of  Noma. — By  H.  Ranlie. 
A  Case  of  Thoracopagus.— By  E.  Toff. 
Lithopaedia. — By  Kroenier. 

Herliner  klinische  IVoclienscliriJt,  October  i^,  igoo. 
The  Effect  of  Johimbin. — A.  Loewy  says  that  this  is  the 
name  ji'ven  by  Siiicgcl  to  an  alkaloid  extracted  from  tlie 
bark  of  an  African  tree  called  "yunibelioa"  or  "johini- 
belie, "  and  appears  to  belong  to  the  rubiacea;.  To  another 
alkaloid  the  name  of  "  joliimbenin  "  has  been  given.  A 
decoction  of  the  bark  of  the  tree  is  used  by  the  African 
natives  as  an  aphrodisiac.  Loewy's  e.xperiments  on  mice, 
cats,  and  dogs  were  made  with  hydrochlorate  of  johimbin. 
The  effects  noted  were  a  dilatation  of  the  vessels  supplying 
tlic  genitalia,  with  swelling  of  the  testicles  and  finally  full 
erection  of  the  penis.  The  local  results  were  in  fact  very 
much  like  those  of  cantharides,  but  there  seemed  to  be  no 
irritant  effect  on  the  kidneys,  and  repeated  trials  on  the 
same  animal  did  not  seem  to  produce  any  inflammatory 
changes  in  the  parts  affected.  Overdosage  caused,  in 
warm-blooded  animals,  interrupted  respiration,  lessening 
of  the  pulse  rate,  and  fall  of  blood  pressure.  If  artificial 
respiration  was  continued,  the  pulse  rate  and  blood  press- 
ure gradually  diminished  in  a  proportionate  ratio  until 
death  occurred  from  cardiac  paralysis.  The  action  of  the 
remedy  appears  to  be  confined  to  the  genitalia  e.Kclusively 
in  safe  dosage.  The  author  has  given  the  remedy  to  one 
man.  who  took  by  mouth  5  mgm.  of  johimbin  three  times 
daily.  The  result  was  genital  hyperemia  with  powerful 
erections,  though  the  drug  did  not  seem  directly  to  stimu- 
late the  libido  se.\ualis. 

Certain  Cell-Problems  and  their  Significaace  for  the  Scien- 
tific Foundation  of  Organo-Therapy. — D.  Hausmann  lays 
down  the  general  proposition  that  there  exists  between 
the  various  kinds  of  cells  an  altruistic  relation  in  the  sense 
that  one  variety  of  cell  exercises  a  definite  influence  over 
all  other  varieties,  and  that  progressive  changes  in  one 
variety  cause  lu  the  others  an  altruistic  hypertrophy,  but 
retrogressive  changes  an  altruistic  atrophy,  Organo-ther 
apy  builds  itself  upon  this  theory  of  altruism  in  cell  rela- 
tion and  the  specificity  of  cell  function.  Hence  we  may 
attempt  to  introduce  into  the  body  the  particular  substance 
of  which  it  has  been,  by  cell  destruction,  deprived.  Natu- 
rally the  substance  introduced  can  replace  only  the  positive 
result  of  the  function  of  the  lost  cell,  that  is,  the  latter's 
internal  secretion.  In  ca.se  of  organs  with  a  double  func- 
tion but  little  or  no  result  can  be  expected.  Hence  organo- 
therapy is  necessarily  confined  to  organs  with  a  single 
definite  function.  It  is  folly  to  introduce  hepatic  substance 
for  liver  troubles  or  kidney  substance  for  kidney  diseases. 
Al.so  in  pancreiitic  diabetes  organo-therapy  can  have  but  a 
partial  result,  although  this  malady  results  from  a  failure 
of  internal  secretion. 

The  Theory  of  Rabies  at  the  Close  of  the  Nineteenth  Cen- 
tury.—By  V.  Babes. 

On  Methods  of  Preserving  Anatomical   Specimens  True  to 

Nature.— By  L.  Pick. 

The  Downes  Urine  Segregator. — By  A.  Freudenberg. 

Annals  of  Surgery,  No^iember,  igoo. 
Retrenchment  of  Lipomatous  Abdominal  Wall  Combined 
with  Operation  for  Radical  Cure  of  Umbilical  Hernia. — By 
J.  B.  Bullitt.  The  patient  was  a  woman  aged  thirty- 
ei.ght  years,  presenting  a  pendulous  abdomen  hanging 
down  like  an  apron  on  the  thighs,  being  on  a  level  with  the 
perineum  when  the  patient  was  in  a  dorsal  position  and 
two  inches  lower  when  in  an  upright  position.  Careful 
examination  led  to  the  diagnosis  of  omental  hernia.  The 
contents  of  the  sac  could  be  partially  reduced.  Operation 
was  done  as  follows  :  A  transverse  incision  about  six  inches 
long  was  made  two  inches  above  the  umbilicus,  which  had 
been  previously  stuffed  with  cotton  and  closed  by  means 
of  three  sutures.  The  hernial  sac  was  encountered  close 
to  the  skin,  being  covered  by  it  and  a  thin  layer  of  fat. 
The  sac  was  found  to  contain  a  part  of  the  transver.se  colon 
and  omentum.  The  omentum  alone  was  slightly  adher- 
ent, but  was  not  especially  large  and  fat-containing,  and, 
therefore,  was  not  tied  off.  The  intestine  and  omentum 
were  easily  returned  through  the  ring.  The  edges  of  the 
ring  could  be  readily  brought  in  apposition,  and  closure 
was  effected  by  mattress  sutures  taken  from  side  to  side 
through  the  base  of  the  ring,  closing  it  from  above  down- 
ward ;  a  half-dozen  heavy  chroraicized  catgut  sutures  were 
necessary  for  this  purpose.  The  sac  was  made  up  of  the 
peritoneum  on  the  inner  side  and  the  abdominal  fascia  on 
the  outer,  these  two  layers  being  amalgamated,  insepar- 
able, and  forming  one  structure.  The  sac  was  then  cut 
off  about  a  half-inch  from  the  margins  of  the  ring,  and  a 
second  running  suture  of  No.  2  plain  catgut  was  made, 
bringing  the  sac  stumps  together.  The  abdominal  wall 
contained  a  layer  of  fat  from  three  to  four  inches  thick. 


The  horizontal  incision  which  had  first  been  made  was  now 
prolonged  in  both  directions  to  the  two  flanks,  and  a  sec- 
ond transverse  incision  was  made  about  seven  inches  below 
the  first  and  joining  the  ends  of  the  first  incision  in  the  two 
flanks.  These  two  incisions  extended  through  the  fat  down 
to  the  fascia  :  the  enclosed  portion  of  the  abdominal  wall, 
amountin.g  to  several  pounds  of  skin  and  fat,  was  now  dis- 
sected up  and  removed  in  the  shape  of  a  wedge.  A  con- 
tinuous catgut  suture  was  now  applied  from  side  to  side, 
apposing  the  deeper  portions  of  the  exposed  area.  Above 
this,  interrupted  and  buried  catgut  sutures  were  applied 
in  tiers;  and.  finally,  the  skin  was  approximated  by  silk 
worm-gut  sutures  jjlacedat  intervals  of  several  inches,  and 
then  a  plain  catgut  suture  applied  in  buttonhole  fashion. 
Recovery  was  uneventful. 

Report  of  a  Case  of  Actinomycosis  Hominis. — The  patient 
of  J.  C  Oliver  was  a  man  aged  forty-nine  years.  The 
method  of  inoculation  could  not  be  determined.  The  dis- 
ease began  as  an  ulcer  on  the  inside  of  the  right  cheek  just 
opposite  to  a  clamp  used  for  holding  artificial  teeth  in 
place.  The  ulcer  was  curetted  under  cocaine  and  exami- 
nation made  for  tubercle  bacilli,  but  none  was  found. 
The  use  of  the  iodide  was  without  benefit.  The  ulcer  ex- 
tended and  became  very  painful,  and  the  submaxillary 
gland  of  the  same  side  enlarged,  later  softened,  and  was 
incised.  The  nature  of  the  discharge  led  to  a  suspicion  of 
actinomycosis,  but  microscopical  examination  at  this  time 
was  negative.  Other  swellings  appeared  about  the  neck 
and  under  the  ear.  Discharge  from  the  latter  site  pre- 
sented the  streptothrix  of  the  disease  and  later  the  ray 
fungi.  Previously,  with  a  view  of  removing  the  focus  of 
disease,  the  lower  lip  had  been  split  midway  between  its 
centre  and  the  right  angle  of  the  mouth,  and  the  incision 
was  carried  backward  in  a  curve  to  the  lower  j.art  of  the 
ear.  Everything  suspicious,  including  the  submaxillary 
gland,  was  removed.  Some  black,  sloughing  tissue  was 
found  in  the  vicinity  of  the  sinus  in  the  submaxillary  re- 
gion. This  was  removed  with  a  sharp  spoon.  The  ulcer 
in  the  mouth  was  removed  by  carrying  an  incision  com- 
pletely around  it.  In  the  dissection  of  the  neck,  the  lin- 
gual artery  was  divided.  The  patient  finally  died  of  a 
severe  arterial  hemorrhage  from  the  submaxillary  region, 
probably  from  the  lingual  artery,  which  had  been  divided 
at  the  time  of  operation.  Because  of  inability  to  ligate  this 
vessel,  a  hemostatic  forceps  was  left  on  fhe  divided  end  of 
the  artery  for  forty-eight  hours.  The  artery  was  divided 
January  4,  1900 ;  the  fatal  hemorrhage  occurred  March  3, 
igoo. 

A  Contribution  to  the  Study  of  Intra-Abdominal  Omental 
Torsion.— Weiner  gives  a  summary  of  the  histories  previ- 
ously reported  by  various  authors  and  adds  one  from  his 
own  practice.  From  his  summary  it  will  be  seen  that 
omental  torsion  occurs  more  often  in  males  than  in  females 
(presumably  on  account  of  the  more  frequent  occurrence 
of  inguinal  hernia  iu  men) ,  that  it  is  not  met  with  in  youth, 
and  that  it  is  found  only  in  persons  who  have  a  hernia  ; 
although  the  diseased  omentum  is  not  always  found  in  re- 
lation with  the  hernia.  The  portion  of  omentum  affected 
may  be  small,  or  may  be  composed  of  almost  the  entire 
omentum.  The  etiology  of  the  cases  in  which  the  omen- 
tum is  not  connected  with  a  hernia  is  very  obscure.  In 
the  other  cases  the  etiology  can  generally  be  traced  to  for- 
cible attempts  at  reduction  of  the  hernia.  In  not  a  single 
case  was  the  diagnosis  made  before  operation.  The  cause 
for  this  is  not  far  to  seek.  Not  only  are  omental  tumors 
extremely  rare,  but  they  have  no  characteristic  symptoms  ; 
the  symptoms  they  call  forth  are  those  produced  by  an 
abdominal  tumor  through  its  mechanical  action  When 
the  torsion  takes  place  in  connection  with  a  hernia,  the 
diagnosis  is  naturally  made  of  an  incarcerated  hernia.  In 
all  of  the  cases  the  urgency  of  the  symptoms  was  recog- 
nized, and  a  prompt  ojieration  was  performed.  There  is  a 
practical  jioint  of  some  value.  If  we  cut  down  on  a  hernia 
that  produced  the  symptoms  of  strangulation  and  find  only 
a  strand  of  omentum  in  the  inguinal  canal,  we  should  al- 
ways investigate  the  intra-abdominal  portion  of  the  omen- 
tum to  make  sure  that  there  is  no  torsion  present  there. 

Traumatic  Rupture  of  the  Small  Intestine ;  Abdominal 
Section;  Recovery. — By  J.  J.  Buchanan.  A  boy  aged  ei.gh- 
teen  years  was  hit  in  the  abdomen  with  the  handle  of  a 
pair  of  tongs  with  which  he  had  been  carrying  a  billet  of 
iron.  When  seen  five  hours  later  there  was  no  evidence 
of  contusion,  abdominal  distention,  or  excessive  rigidity 
of  the  abdominal  muscles.  Peristalsis  was  absent,  and  on 
this  symptom,  taken  with  the  slight  rigidity,  moderate 
pain  and  two  attacks  of  vomiting,  an  abdominal  section 
was  decided  on.  A  rupture  of  the  small  intestine  was 
found  at  the  free  border  with  eversion  of  the  mucosa  and 
escape  of  fecal  matter.  Peritonitis  with  exudation  of  sero- 
pus  involved  about  one-third  of  the  small  gut.  The  wound 
was  closed,  and  the  head  of  the  bed  elevated  ten  inches  as 
recommended  by  G.  R.  Fowler.  With  the  exception  of 
vomiting  on  the  second  day,  the  later  historj-  was  without 


788 


MEDICAL    RECORD. 


[November  17,  1900 


incident.  The  author  considers  the  points  of  interest  in 
the  case  to  be  (i)  the  extensive  peritonitis  and  free  exu- 
date present  six  hours  of  llie  iujuiy  ,  (2|  the  rupture  of  in- 
testine without  trace  of  exteinal  injury,  and  from  what 
would  appear  to  have  been  a  slight  blow;  (3)  the  almost 
entire  absence  of  symptoms  apart  from  cessation  of  per- 
istalsis and  slight  vomiting,  and  (4)  the  apparently  favor- 
able effect  of  Fowler's  posture  in  tlie  after-treatment. 

A  Study  of  One  Thousand  Operations  for  Acute  Intestinal 
Obstruction  and  Gangrenous  Hernia. — Concluding  article  by 
C.  L.  Gibson. 

A  Skiagraphic  Study  of  the  Normal  Membral  Epiphyses 
at  the  Thirteenth  Year.— Hy  E.  R.  Corson,  M.D. 

Zeitschrijtfiir  k/inisc/ie  Mfcikiii,  vol.  .v/i.,  Xos.  1-4,  /goo. 

(Festschrift  dedicated  to  Hermann  Senator  on  the  twenty- 
fifth  anniversary  of  his  professoriat.) 

The  Hydriatic  Treatment  of  Some  Common  Dispensary 
Diseases. — The  maladies  discussed  by  H.  Rosin  are  of  such 
mild  nature  that  they  are  never  brought  to  the  notice  of 
those  engaged  in  hospital  work,  and  have  received  but  lit- 
tle attention  at  the  hands  of  text-book  writers,  but  yet  come 
often  enough  under  the  observation  of  the  dispensary  or 
practising  physician,  and  frequently  tax  his  resources  to 
the  utmost  in  their  treatment.  The  first  of  these,  variously 
called  moysitis,  myitis,  or,  preferably,  as  corresponding  to 
neuralgia,  the  analogous  condition  in  the  nervous  system, 
myalgia,  may  be  etiologized  under  the  two  heads  of  cold 
and  trauma.  Of  these  the  later  is  by  far  the  most  frequent 
and  may  take  the  form  of  awkwaid  or  misdirected  move- 
ment overexertion  in  the  regular  performance  of  some 
normal  act,  such  as  the  lumbago  of  gardeners  and  brick- 
layers, or,  finally,  may  result  from  perfectly  natural  move- 
ments in  those  whose  muscles  have  become  weakened  and 
incapable  through  wasting  disease.  Almost  any  region  of 
the  body  may  be  affected,  but  the  musculature  of  the  trunk 
(neck,  thorax,  abdomen,  lumbarregion)  is  most  frequently 
the  seat  of  the  trouble.  The  diagnosis  is  often  difficult, 
for  the  subjective  symptoms  are  wholly  unreliable,  and  no 
dependence  is  to  be  placed  on  the  statements  of  the  patient, 
who  usually  locates  his  disease  in  heart,  lungs,  kidneys, 
etc.  Tenderness  limited  to  certain  muscles  with  increased 
sensibility  to  farad^sm  and  hypersesthesia  of  the  skin  help 
to  differentiate  the  affection  from  rheumatism,  neuralgia, 
bone  and  joint  diseases,  tabes,  trichinosis,  heart  disease, 
stomach  and  liver  disorders,  etc.,  which  must  all  be 
thought  of  and  excluded.  Internal  medication  is  nearly 
always  hopelessly  ineffectual,  while  massage  and  elec- 
tricity are  too  expensive  for  poor  practice.  Hydrother- 
apy affords  the  most  suitable  method  of  treatment,  and 
may  be  applied  as  a  Priessnitz  pack,  hot  fomentations,  or 
poultices  of  oatmeal  or  flaxseed,  brine  baths,  sweat  baths, 
or  the  half  bath  followed  by  cold  effusions.  An  afl'ection 
often  simulating  rheumatism  or  arthritis  deformans  is  a 
combination  of  parasthesiie,  most  often  involving  the  hands 
or  feet  of  women,  and  characterized  by  tingling,  numbness, 
pain,  stiffness,  etc.  In  these  cases  burying  the  affected 
member  in  a  pail  of  sand  which  has  been  heated  in  the 
oven,  together  with  daily  hot  full  baths  prolonged  for 
twenty  minutes,  is  of  great  service.  Various  forms  of 
disturbances  of  sensation  connected  with  the  stomach,  in- 
dependent of  organic  disease,  the  epigastric  pulsation  of 
neurotic  women,  and  chlorosis,  are  all  disorders  likely  to 
be  greatly  benefited  by  hydrotherapy  in  the  form  of  hot 
packs,  partial  or  full  baths,  cold  douches,  Turkish  baths, 
etc. 

Contributions  to  the  Study  of  Diverticula  and  Dilatations 
of  the  (Esophagus. — Th.  Rosenheim  believes  that  these 
conditions  are  mucli  more  frequent  than  is  usually  sup- 
posed, and  that  with  improved  methods  of  technique  the 
diagnosis  will  be  made  in  many  cases  that  would  formerly 
have  passed  unrecognized.  In  his  estimation  the  rcsopha- 
goscope  is  of  the  greatest  value,  though  its  use  and  the 
successful  interpretation  of  the  results  obtained  apjiarently 
require  a  degree  of  practice  and  experience  to  be  expected 
only  of  the  specialist.  A  manoeuvre  that  is  more  easily 
applicable  is  the  filling  of  a  suspected  diverticulum  with  a 
bismuth  subnitrate  mixture,  and  then  employing  the  Roent- 
gen rays,  when  the  sacculation  will  be  clearly  outlined  by 
the  shadow  of  its  metallic  contents.  Dilatations  not  sec- 
ondary to  new  growths  arc  usually  due  to  atony  of  the 
oesophageal  wall  accompanied  by  more  or  less  spasm  of 
the  cardia.  The  diagnosis  is  commonly  easy,  and  may  be 
made  by  the  presence  of  regurgitation  of  undigested  food 
which  has  not  been  acted  on  by  the  gastric  secretions,  dys- 
phagia, and  theocsophagoscope.  In  treating  this  condition 
systematic  lavage  is  of  the  greatest  value,  both  in  relieving 
the  subjective  discomforts  attendant  on  the  condition  and 
in  correcting  the  tendency  to  inflammation  nearly  always 
produced  by  the  presence  of  the  decomposing  food  mas.ses 
within  the  sack.     The  patient  may  safely  be  allowed  to 


perform  this  operation  himself,  though  the  systematic  over- 
distention  of  the  cardiac  orifice,  which  usually  has  also  to 
be  performed,  should  never  be  attempted  by  any  but  a 
physician.  Tlie  ai)])lication  of  astringent  and  antiseptic 
solutions  to  ;lie  atonic  mucosa  is  often  of  benefit,  as  is  also 
the  regular  use  of  electricity  by  means  of  the  oesophageal 
electrode.  Rest  and  general  hygiene,  which  may  have  to 
be  su]i])lemented  by  the  administration  of  sedatives,  and 
plentiful  nourishment  (by  the  rectum  if  necessary)  should 
be  insisted  on.  Fat  is  an  especially  important  article  of 
diet,  and  may  conveniently  be  given  in  the  form  of  melted 
butter  or  olive  oil  a  short  time  before  meals. 

Hanot's  Cirrhosis. — Hasenclever  ascribes  to  Senator  the 
credit  for  having  sj-stematized  the  formerly  conflicting 
views  on  the  various  types  of  cirrhosis,  and  by  establish- 
ing definite  pathological  classifications  having  reconciled 
to  each  other  the  contradictory  teachings  of  different  writ- 
ers. The  essentials  of  his  findings  are  as  follows  :  (i)  The 
size  of  the  diseased  liver  will  depend  on  the  amount  and 
the  character  of  the  adventitious  connective  tissue  it  con- 
tains. If  no  cicatrical  contraction  takes  place,  the  organ 
remains  enlarged  and  the  function  of  vessels  and  paren- 
chyma remains  unimpaired,  the  case  then  representing  a 
typical  Hanot's  cirrhosis.  On  the  other  hand,  contraction 
of  the  tissue  induces  a  diminution  of  size  with  concomitant 
destruction  of  liver  cells;  typical  Laennec's  cirrhosis. 
Portal  hypertrophic  cirrhosis  and  portal  cirrhosis  with 
jaundice  due  to  gastro-duodenal  catarrh  are  subclasses  of 
this  type.  (2)  If  the  formation  of  bile  is  diminished  while 
its  outflow  through  the  biliary  passages  is  unimpeded,  no 
jaundice  results.  This  is  the  case  in  Laennec's  type,  since 
the  parenchyma  cells  are  early  destroyed,  while  the  larger 
bile  passages  remain  patent.  In  Hanot's  form,  however, 
opposite  conditions  prevail,  since  the  bile  is  manufactured 
in  normal  amounts,  while  the  ducts  are  narrowed  through 
angiocholitis  or  periangiocholitis.  (3)  Ascites  and  venous 
dilatation  of  the  abdominal  wall  and  in  the  gastro-intesti- 
nal  tract  are  due  to  congestion  of  the  portal  vein.  (4)  The 
swelling  of  the  spleen  has  not  yet  been  satisfactorily  ex- 
plained. Congestion  alone  is  not  a  sufficient  cause,  and 
probably  the  same  poisons  (alcohol,  syphilis,  malaria) 
which  affect  the  liver  act  on  the  spleen  also. 

The  Relations  between  Diabetes  Mellitus  and  Tabes  Dor- 
salis. — W.  Croner  says  that  tabes  and  diabetes  may  occur 
simultaneously  or  consecutively  in  the  same  patient,  or  that 
either  disease  may  simulate  the  other.  In  looking  for  a 
common  cause  syphilis  is  the  most  plausible,  for  while  it  is 
now  universally  believed  that  locomotor  ataxia  is  not  a 
syphilitic  manifestation,  specific  infection  undoubtedly 
precedes  the  nerve  lesion  in  the  majority  of  cases,  and 
through  a  secondary  arteriosclerosis,  which  is  a  well- 
known  producer  of  diabetes,  may  also  be  assumed  to  stand 
in  at  least  an  indirect  causal  relationship  to  the  latter  dis- 
ease. Granting  the  possibility  of  a  common  cause,  the 
appearance  of  both  diseases  in  the  same  patient  is  not  so 
surprising,  but  it  is  also  of  interest  to  note  that  the  diabe- 
tic condition  may  be  only  a  secondary  complication,  possibly 
dependent  upon  the  invasion  by  the  tabetic  process  of  re 
gions  of  the  central  nervous  system  controlling  the  sugar 
metabolism  of  the  body.  Symptoms  common  to  both  dis- 
eases are  general  weakness  and  prostration,  various  forms 
of  paralysis,  ataxic  gait,  especially  in  the  dark,  jiarasthe- 
sias  of  the  legs,  patches  of  analgesia  and  ana?sthesia,  hy- 
persensitiveness  to  cold,  decreased  sexual  power,  trophic 
and  secretory  disturbances,  perforating  ulcer,  decubitus, 
hyperidrosis,  muscular  atrophy,  absence  of  the  patellar 
reflex,  the  occurrence  of  sugar  in  the  urine,  amblyopia  and 
amaurosis,  while  the  neuralgia  of  diabetes  often  closely 
simulates  the  lancinating  pains  of  tabes.  The  pupillary 
reaction  affords  the  most  constant  differential  diagnostic 
sign. 

A  Case  of  Hypertrichosis  Universalis  with  Precocious  Sex- 
ual Development. — E.  Lesser  says  that  cases  of  excessive 
hairy  growth  must  be  carefully  divided  into  two  classes. 
In  the  first  place  there  are  instances  of  true  hypertrichosis 
in  which  there  is  simply  an  abnormal  growth  of  hair  in 
those  parts  of  the  body  where  at  least  a  suggestion  of  hairy 
growth  is  norm:illy  present.  On  the  other  hand,  there  are 
also  cases  in  which  every  portion  of  the  body,  including 
the  forehead  and  cheeks,  is  covered  with  a  fine  silky 
growth  differing  in  nature  from  the  ordinary  hair.  These 
are  really  lanugo  growths  representing  instances  of  imper- 
fect development,  and  the  names  "hypotrichosis"  or  pseu- 
dohyperlrichosis  lanuginosa  have  been  projiosed  for  them. 
An  interesting  feature  is  that  defects  in  the  dentition 
nearly  always  accompany  anomalies  of  this  class.  The 
author  describes  .111  individual  of  the  former  type  who  at 
the  same  time  gave  evidence  of  premature  sexual  develop- 
ment. The  patient,  a  girl  aged  six  years,  ju'esentcd  noth- 
ing abnormal  at  the  time  of  birth,  but  in  her  second  year 
a  progressive  enlargement  of  the  breasts  took  ])lace.  which 
has  continued  until  now  they  are  of  the  size  of  a  fist.     In 


November  17,  1900] 


MEDICAL   RECORD. 


789 


the  third  year  a  menstrual  discharge  appeared  which  re- 
curred eight  or  nine  times  and  then  stopped,  while  eigh- 
teen months  ago  a  general  diffuse*  growth  of  hair  took 
place,  which  on  the  face  is  of  the  nature  of  a  masculine 
full  beard,  and  on  the  body  covers  the  whole  surface  more 
or  less  densely  except  the  hands  and  feet.  The  genitals 
resemble  those  of  an  adult  in  size  and  development. 

Critical  and  Experimental  Observations  on  the  Relation 
between  the  Kidneys  and  Glycosuria. — Friedrich  Richter's 
experiments  tend  to  furnish  a  theoretical  basis  for  the 
clinical  observation  frequently  made  that  an  intercurrent 
nephritis  often  lessens  the  mtensity  of  cases  of  diabetes. 
French  clinicians  have  made  the  observation  that  in  indi- 
viduals giving  symptoms  of  contracted  kidney  three  or 
tour  times  the  amount  of  sugar  usually  sufficing  to  produce 
an  alimentary  glycosuria  had  to  be  given  before  its  pres- 
ence could  be  detected  in  the  urine.  Acting  on  the  theory 
that  a  damaged  renal  epithelium  was  less  able  to  excrete 
sugar,  the  author  gave  animals  such  substances  as  aloin, 
cantharidm,  or  calcium  oxalate,  known  to  have  a  destruc- 
tive effect  on  the  kidney  parenchyma,  and  then  by  admin- 
istering phloridzin  or  diuretin  was  able  to  estimate  the 
degree  to  which  glucose  elimination  was  influenced.  In  all 
cases  the  appearance  of  the  sugar  reaction  was  greatly  de- 
layed, and  positive  evidence  afforded  that  the  permeability 
of  the  kidney  for  this  substance  had  been  notably  dimin- 
ished. To  what  degree  this,  so  to  speak  "mechanical," 
factor  is  concerned  in  the  pseudo-cures  of  diabetes  thnnigli 
nephritis,  and  whether  some  organic  condition  is  not  also 
to  be  considered,  remain  to  be  proven  by  further  investi- 
gation. 

The  Pathology  and  Treatment  of  Typhoid  Fever. —E. 
Barth  lengthens  somewhat  the  period  of  incubation  of 
typhoid,  winch  is  usually  given  as  two  to  three  weeks, 
but  which  he  thinks  may  extend  even  longer  than  four 
weeks,  the  conclusion  being  that  at  least  five  weeks'  time 
are  necessary  for  a  thorough  quarantine.  Cases  in  which 
the  disease  develops  in  less  than  two  weeks  are  likely  to 
be  severe,  often  ending  fatally.  In  the  matter  of  diagno- 
sis the  Widal  and  diazo  reactions  represent  the  greatest 
advances  of  recent  years.  Diarrhoea  is  not  the  typical 
symptom  that  the  older  cliniciarn;  made  it;  out  of  sixty 
cases  only  one-half  tlie  number  exhibited  it.  Of  the  vari- 
ous intestinal  antiseptics  in  use  calomel  is  perhaps  tlie 
most  reliable,  but  its  action  depends  rather  on  the  thor- 
ough cleaning  of  the  intestinal  canal  it  entails  than  on 
any  germicidal  action,  for  at  the  outbreak  of  symptoms 
large  numbers  of  bacilli  have  already  gained  access  to  the 
lymphatics  and  internal  organs,  where  they  are  safe  from 
antiseptic  drugs.  The  Brand  treatment  properly  applied 
is  the  most  important  factor  in  the  treatment,  but  it  requires 
careful  adaptation  to  each  individual  case,  and  even  then 
is  not  a  specific  but  simply  a  general  tonic  and  supporting 
measure. 

A  Contribution  to  the  Etiology  of  Progressive  Pernicious 
Anaemia. — -W.  Bussenius  endeavors  to  elucidate  somewhat 
the  complex  etiology  of  tins  disease  by  the  description  of 
a  case  in  which  the  cau.se  seemed  less  obscure  than  usual. 
The  patient  had  been  under  medical  observation  for  a  jie- 
riod  of  eleven  years,  at  the  end  of  which  time  he  was  suf- 
ering  from  chlorosis  and  obesity.  For  over  one  and  a  half 
years  his  condition  remained  practically  unchanged,  the 
symptoms  not  being  sufficiently  serious  to  prevent  the  jier- 
formance  of  his  military  duties.  He  was  then  given  a 
furlough  that  a  rest  in  the  country  might  completely  re- 
habilitate him,  but  instead  of  this  his  disease  rapidly  as- 
sumed a  malignant  form,  and  both  the  symptoms  and  blood 
examination  pointed  toward  pernicious  anaemia.  In  the 
absence  of  more  satisfactory  grounds  the  author  attributes 
the  destructive  action  on  the  red  blood  cells  to  the  toxins 
contained  in  supposalily  inferior  or  even  decomposed  thy- 
roid tablets  surreptitiously  taken  by  the  patient  to  reduce 
his  weight 

Investigations  on  Absorption  and  Metabolism  in  Gastric 
Apepsia  v/ith  Reference  to  Pernicious  Ansemia. —  By  Strauss. 

The  Simultaneous  Occurrence  of  Scoliosis  and  Apical  In- 
filtration in  Childhood. — I'.y  M.  Mosse. 

Congenital  Dextrocardia  without  Transposition  of  the  Vis- 
cera.—By  H.  Lowcnthal. 

Fibrinous   Pneumonia   in    Phenylhydrazin    Poisoning. — By 

S.  Kaminer. 

Faraday's    Law    in     Electro-Therapy.— By    F.    Franken- 

hauser. 

Corrosion  of  the  (Esophagus  with  Caustic  Lye.— By  Borni- 
koel. 

The  Gaseous  Contents  of  the  Stomach  in  Infancy.— By  H. 
Leo. 
Laryngoscopy  in  Childhood. — By  A.  Kirsten. 
Aneurism  of  the  Heart. — By  Strauch. 


C!>o  viTsp  omi  cncc. 

OUR  LONDON    LETTER. 

(From  our  Special  Correspondent.) 

THE  HARVEIAN  ORATION  —  GYN.5COLOGISTS  ON  MEDICAL 
TREATMENT — GUV's  HOSPITAL — NEWSPAPER  EDITORS  O.N 
HOSPITALS — STUDENTS  AND  A  '"DIVINE  HEALER"  gUACK — 
DRUNK    OK    DYING — PATHETIC    UE.\TIt    OK   A   SURGEON, 

London,  October  26,  1900. 

Prof.  Clifford  Allbutt  delivered  the  Harveian  oration 
at  the  Royal  College  of  Physicians  on  the  iSlh  inst.  He 
discoursed  on  the  forces  opposed  to  Harvey  and  his  re- 
searches, and  showed  the  physiological  darkness  which 
preceded  him.  To  put  his  great  discovery  in  right  jier- 
spective  he  thought  we  must  have  some  vision  of  the  his- 
tory of  philosophy,  science,  and  medicine.  Medicine,  he 
said,  had  its  sources  among  tlie  Greeks,  contrasting  therein 
with  theology  and  law  ;  in  the  schools  of  Hippocrates  and 
Alexandria  it  was  based  on  natural  history  and  anatomy. 
Galen,  the  first  of  physiologists  and.  last  of  the  great  Greek 
physicians,  practi.sed  the  method  of  verification  by  exjieri- 
raent,  introduced  perhaps  by  Archimedes,  sub.sequenlly 
lost  till  the  time  of  Gilbert,  Galileo,  and  Harvey.  The 
orator  then  referred  to  some  of  the  problems  which  en- 
gaged the  thoughts  and  energies  of  men  during  the  ages 
intervening,  with  special  reference  to  philosoi)hical  ques- 
tions which  bore  on  medicine.  He  pointed  out  the  weight 
of  the  social  systems,  opinions,  prejudices,  and  habits 
against  which  Harvey  had  to  contend.  As  an  example, 
almost  in  the  year  of  the  publication  of  the  "De  Motu 
Cordis,"  the  Paris  parliament  decreed  that  no  teacher 
should  promulgate  anything  contrary  to  the  accepted  doc- 
trines of  the  ancients.  Harvey's  discovery  burst  like  an 
earthquake  on  corrupt  Galenism,  venerable  .sophistries, 
current  abstractions  bequeathed  by  realism,  and  long- 
winded  dialectics  and  dogmas  based  on  uncritical  subser- 
vience to  texts.  His  work  stood  out  even  more  against 
a  background  of  superstition,  magic,  witch-burning,  al- 
chemy, etc.  In  terrestrial  and  celestial  physics  Galileo, 
persecuted  as  he  was,  had  some  strong  current  with  him  : 
Copernicus  was  before  him,  Kepler  beside  him  ;  but  in 
physiology  upon  the  path  of  Galen  the  waters  had  closed 
as  upon  the  track  of  a  ship.  Among  Harvey's  contempo- 
raries none  could  claim  a  share  with  him  in  the  discovery 
of  the  central  fact  of  piiysiology,  or  in  his  application  of 
the  method  which  opened  the  way  to  his  successors. 

At  the  GyniEcological  Society  a  paper  by  Dr.  Heywood 
Smith  gave  rise  to  a  discussion  on  treatment.  Dr.  Smith 
dwelt  rather  on  the  medical  aspect  of  gyna:?cological  cases, 
noticing  briefly  the  several  diseases  in  which  other  meth- 
ods than  operation  might  lie  considered.  Mr.  Skene  Keith 
thought  the  society  was  apt  to  ignore  the  medical  side  of 
the  specialty,  and  yet  he  thought  the  paper  showed  a 
hankering  after  operations,  though  in  some  cases  surgery 
was  put  in  the  background. 

Dr.  Routh  compared  gynaecologists  to  politicians  with 
their  divisions  of  conservatives,  moderates,  and  radicals. 
The  circumstances  and  wishes  of  each  patient  must,  he 
said,  be  considered.  He  related  three  remarkable  ca.ses 
illustrating  the  sympathy  between  the  uterus  and  the 
mamma. 

Mr.  Bowerman  Jessett  commended  the  caution  of  the 
paper,  and  said  that  was  the  line  of  the  prudent  surgeon. 
He  had  not  found  treatment  of  any  use  in  cysts  of  the 
breast,  and  if  no  improvement  took  place  after  a  few 
months  at  the  seaside  he  advised  excision,  as  these  cysts 
often  degenerated  into  malignant  disease.  In  inoperable 
cancer  he  had  tried  oiipliorectomy  and  thyroid  extract  in 
five  ca.ses,  but  without  benefit.  Several  years  ago  he  had 
removed  the  ovaries  of  a  jiatient  and  had  just  had  to  re- 
move her  breast  for  cancer,  so  the  principle  of  the  opera- 
tion seemed  at  fault.  If  it  were  correct,  a  patient  ought 
not  to  develop  mammary  cancer  long  after  the  ovaries  had 
been  removed. 

Dr.  Parsons  said  they  knew  little  of  the  causes  of  en- 
dometritis, but  one  of  them  was  prolapse,  and  this  he 
treated  by  pessaries.  For  local  applications  he  had  tried 
carbolic  acid,  iodized  phenol,  and  linimentum  iodi  for 
three  years  each,  and  found  the  last  the  most  effectual. 
He  observed  some  surgeons  practised  hysteropexy  for  dis- 
placements more  than  others.  In  his  experience  pessaries 
had  usually  sufficed. 

Dr.  Snow  protested  against  treating  tumors  of  the  breast 
in  patients  over  middle  age.  This  was  the  time  cysts  oc- 
curred, and  they  degenerated  into  cancer  sooner  or  later. 

Dr.  Jellett  mentioned  that  the  French  school  attribute 
one  out  of  four  cases  of  pyosalpinx  to  tubercle,  a  view  con- 
firmed by  experience  in  the  Rotunda  Hospital  of  Dublin. 


790 


MEDICAL    RECORD. 


[November  17,  1900 


Dr.  Macnaughtou-Jones  agreed  with  some  previous 
speakers  on  llie  value  of  a  discussion  on  these  lines.  He 
held  that  the  advance  of  gyntecology  was  through  patho- 
logical research,  and  on  that  alone  treatment  should  be 
based.  True  conservative  treatment  did  not  consist  in 
tampering  with  disease  by  uncertain  methods,  but  in 
adopting  radical  measures  when  nothing  could  be  expected 
from  palliative  ones. 

Dr.  F.  Edge  said  each  man  did  best  along  the  lines  he 
knew  best.  Some  men  might  operate  oftener  than  others, 
but  all  first  used  such  general  treatment  as  seemed  possi- 
ble and  suitable.  Personally  he  had  not  found  oophorec- 
tomy and  thyroid  administration  of  value. 

Guy's  Hospital  seems  to  have  been  particularly  unfortu- 
unate  in  referen.e  to  a  class  of  fatalities  in  which  charges 
of  neglect  or  mistake  have  been  made.  The  latest  is  a 
case  said  to  be  tuberculous  meningitis  sent  to  the  hospital 
late  at  night  by  a  local  practitioner,  and  which  was  refused 
admission  by  the  house  surgeon  on  duty.  It  is  not  said 
whether  any  beds  were  available,  but  some  of  the  news- 
papers have  endeavored  to  get  up  a  cry  against  the  hospi- 
tal by  depicting  a  fancy  scenfe  in  which  boys  were  dis- 
charging the  duties  of  the  physicians  and  surgeons.  It  is 
a  pity  tlie  writers  of  such  paragraphs  have  not  the  honesty 
to  inform  themselves  of  the  facts.  Superficial  inquiry 
would  te.icli  them  that  the  house  surgeons  are  by  no 
means  inexperienced  boys,  as  they  suppose,  but  the  pick 
of  the  young  men  coming  forward  in  the  profession,  inva- 
riably fully  qualified  and  serving  the  hospital  without  fee 
or  reward.  It  is  a  pity,  too,  that  editors  should  insert  sen- 
sational correspondence  containing  unsupjjorted  charges. 
One  of  these  letters  speaks  of  Guy's  as  "the  slaughter- 
house," and  declares  that  it  is  well  known  by  that  name. 
Another  thinks  mistakes  prove  the  want  of  "outside  control 
by  representatives  of  the  new  London  corporations,"  for- 
getting that  these  bodies  are  not  supporters  and  that  sub- 
scribers are.  But  that  letter  appears  to  be  the  production 
of  one  of  the  "anti  "  tribe. 

I  suppose  you  know  all  about  Dowie,  the  faith-healing 
quack,  as  he  hails  from  Chicago.  He  has  come  here  to 
raise  money  for  Zion  City,  which  he  will  build,  he  says. 
Some  medical  students  attended  one  of  his  lectures  and 
shouted  him  down.  On  a  second  occasion  others  boo'd 
him  as  he  approached  the  lecture  room  protected  by  a  band 
of  pugilists.  Result — arrest  and  tine  of  some  of  the  stu- 
dents. They  would  no  doubt  have  been  better  employed 
in  their  studies  than  in  disturbing  the  meeting  of  an  arch- 
impostor  who  calls  himself  the  "Divine  Healer,"  but  it 
seems  a  little  hard  to  be  severe  on  such  an  ebullition  of 
disapprobation  when  unbridled  violence  was  winked  at 
during  some  of  the  recent  elections. 

Now  and  then  cases  occur  showing  the  difficulty  of  diag- 
nosis between  "drunken  condition"  and  "disease."  A 
painful  case  came  before  the  coroner  on  the  iSth,  in  which 
a  gentleman  was  actually  seen  to  fall  three  times,  but  was 
taken  off  to  the  police  station  by  the  constable,  who  said  he 
knew  he  had  a  broken  skull.  But  a  medical  man  was  not 
sent  for  until  the  next  morning  ! 

Mr.  A.  S.  Brown,  F.R.C.S.  Edin.,  died  on  the  17th  after 
an  accident.  He  was  on  his  way  to  the  South  of  France, 
and  seeing  a  fellow-traveller  fall  off  the  quay  at  Boulogne 
waded  in  and  rescued  him,  carried  on  artificial  respiration 
for  two  hours,  and  then  went  on  in  his  wet  clothes  to  Paris, 
where  he  became  .so  ill  that  he  hurried  home  and  died  of 
pneumonia. 


THE     MODERN     TREATMENT     OF     PULMO- 
NARY   TUBERCULOSIS. 

(A  Criticism  ok  a  Papkr  on  the  Same  Subject  dv  M.  J. 
Brooks,  M.D.,  of  Stamford,  Conn.,  in  the  Medical 
Record,  October  13,   1900.) 

To  THK  Editor  of  the  Mhuical  Rkcord. 

Sir  :  Without  anticipating  the  annual  report  of  the  com- 
manding officer  of  this  institution,  I  desire  to  use  certain 
facts,  the  result  of  observation  both  here  and  in  previous 
experience,  to  controvert  some  of  the  very  positive  state- 
ments of  Dr.  Brooks.  Constant  association  with  consump- 
tives and  careful  studies  of  the  disease  have  not  furnished 
me  with  the  positive  views  on  the  subject  that  seem  to  be 
possessed  by  him.  In  view  of  the  fact  that  many  eminent 
students  of  phthisis  and  pulmonary  tuberculosis  are  still 
divided  on  many  points,  particularly  the  biocliemistry  of 
the  etiological  factor  and  the  histogenesis  of  tubercle,  I  do 
not  regret  my  own  somewhat  agnostic  attitude.  I  deem  it 
my  duty  to  use  the  facts  in  my  possession  to  combat,  if  not 
invalidate,  the  misleading  impression  gained  from  reading 
Dr.  Brooks'  article.  The  citation  of  a  large  number  of  au- 
thorities, all  on  one  side  of  a  question,  does  not  constitute 
argument,  and  that  seems  to  be  the  distinguishing  char- 


acteristic of  this  author's  method  of  treating  a  vast  sub- 
ject. 

in  an  easy,  off-hand  way  he  dispo.ses  of  all  the  per])lexing 
problems  of  this  di.sease,  and  with  an  iconoclastic  hand 
smashes  the  most  cherished  ideas  of  a  large  body  of  men. 
some  of  whom  for  a  quarter  of  a  century  have  studied  and 
labored  with  pulmonary  tuberculosis  in  all  its  phases,  and 
have  written  volumes  on  the  climatotherapy  of  the  dis- 
ease. The  evidence  accumulated  by  the  workers  in  this 
field  throughout  the  arid  regions  of  the  United  States  is  at 
least  worthy  of  citation,  and  must  be  taken  into  considera- 
tion, weighed,  and  studied  before  the  efficiency  of  high 
dry  climates  in  the  treatment  of  pulmonary  tuberculosis 
and  phthisis  is  voted  ;///. 

If  I  read  Dr.  Brooks'  article  understandingly,  he  be- 
lieves, unequivocally,  that  both  high  and  dry  climates  are 
unnecessary  in  considering  the  subject  of  phthisiotherapy. 
Notwithstanding  the  quotation  of  a  number  of  authorities 
bearing  him  out  in  this,  and  that  "the  verdict  of  the  Inter- 
national Congress  at  Moscow,  1S97,  was  to  the  same  effect," 
he  has  not  brought  any  cold  facts  to  bear  in  substantiation 
of  his  position. 

It  is  true  that  there  are  no  parts  of  the  world  suitable  to 
human  habitation  that  are  free  from  tuberculosis.  It  is 
equally  true  that  the  natives  of  certain  districts  enjoy  a 
partial  immunity.  According  to  Dr.  Brooks,  such  compar- 
ative freedom  from  the  disease  is  entirely  due  to  the  primi- 
tive and  healthful  mode  of  life  of  the  people  themselves. 
Now.  is  this  invariably  true?  To  my  mind,  for  New  Mex- 
ico at  least,  it  is  easy  to  prove  the  contrary. 

It  is  claimed  (and  has  been  proved)  that  the  inhabitants 
of  eastern  Colorado,  western  Texas,  New  Mexico,  and 
Arizona  enjoy  a  relative  immunity  to  pulmonary  tubercu- 
losis. Excepting  Colorado,  the  Mexican,  now  that  the  In- 
dian has  practically  vanished,  may  be  considered  to  con- 
stitute the  bulk  of  native  population  in  the  districts  named. 
It  is  a  fact  that  he  enjoys  practical  immunity  from  con- 
sumption. This  freedom  from  the  disease  cannot  be  due 
to  mode  of  life  alone;  for  the  Mexican  is  constitutionally 
filthy.  Witness  the  smallpox  which  they  have  always  with 
them.  The  Mexican  is  never  so  contented  as  when,  with 
his  family,  he  is  close  to  a  hot  fire  in  a  stuffy  one-room 
adobe  house,  having  but  one  window  and  one  door,  both  of 
which  are  tightly  closed  even  in  summer  time.  The  at- 
mosphere of  these  places  is  simply  intolerable  to  a  white 
man,  as  I  can  testify  from  many  personal  experiences. 

As  a  district  physician  among  the  poor  of  New  York,  I 
became  accustomed  to  the  dirty  and  unhealthful  environ- 
ment of  the  tenements,  but  have  never  seen  anything  ap- 
proximating the  unhygienic  surroundings  and  life  of  the 
Mexicans.  Their  food  is  very  objectionable  from  a  health 
point  of  view,  and  is  almost  invariably  fried  in  bacon-fat. 
Further  comment  on  the  habits  of  the  Mexicans  is  unnec- 
essary ;  and  yet  these  people  are  practically  immune  to 
tuberculosis,  and  undoubtedly  this  freedom  from  the  dis- 
ease can  be  explained  satisfactorily  only  by  taking  cli- 
matic conditions  into  consideration. 

The  vital  statistics  of  Denver,  Colorado,  have  an  impor- 
tant bearing  on  the  relation  of  pulmonary  tuberculosis  to 
climate.  This  is  a  modern  city  in  every  respect,  and  the 
habits  and  environment  of  the  people  in  no  way  differ  from 
those  of  other  cities  of  equal  size.  The  death  rate  of 
Denver,  including  the  large  number  of  consumptives  who 
yearly  make  this  city  a  Mecca,  is  no  greater  than  that  of 
New  York  (Manhattan),  and.  deducting  the  deaths  from 
this  alien  tuberculosis,  the  death  rate  from  tuberculosis  is 
the  lowest  of  any  city  of  equal  size  in  the  world. 

The  report  of  this  institution,  which  will  be  published 
early  in  the  new  year,  promises  to  be  instructive  in  this 
line  of  thought.  Uj)  to  date  the  results  obtained  here  con- 
firm the  therapeutic  usefulness  of  the  climate. 

I  do  not  believe  that  the  most  prejudiced  advocate  of  cli- 
matotherapy thinks  that  there  is  anything  actually  specific 
in  high  and  dry  climates.  It  is  simply  that  the  climate  of 
the  region  known  as  the  arid  plateau  of  the  United  States 
furnishes  a  particularly  favorable  environment  for  pulmo- 
nary invalids.  It  requires  no  argument  to  substantiate  the 
opinion  that  dry  climates  are  particularly  healthful,  and 
also  that  high  altitudes  arc  invigorating — even  to  people  in 
good  health.  As  a  necessary  corollary  to  dryness  there  is 
a  maximum  amount  of  sunshine  jiermitting  patients  to 
remain  comfortably  out-of-doors  three  hundred  and  forty 
days  out  of  the  year.  The  characteristics  of  the  climate  of 
the  arid  zone  of  this  country  have  been  exhaustively  de- 
scribed, and  it  is  not  necessary  to  take  space  to  go  farther 
into  the  subject  here.  The  literature  is  voluminous  and 
accessible. 

Dryness  and  sunshine  are  inimical  to  all  bacterial  life, 
the  bacillus  tuberculosis  having  been  proved  particularly 
vulnerable  to  their  action.  To  my  mind  this  goes  far  to 
exjilain  the  relative  freedom  of  the  people  of  the  arid  zone 
from  pulmonary  tuberculosis,  and  the  iufrequency  of  rein- 
fection among  our  ])atients. 

A  very  important  consideration  in  phthisiotherapy  is  the 


November  17,  1900] 


MEDICAL    RECORD. 


791 


protection  o£  pulmonary  invalids  from  intercurrent  dis- 
ease. Experience  at  this  hospital  bears  directly  and  for- 
cibly upon  this  point.  Up  to  date  two  hundred  and  twenty- 
four  patients  have  received  treatment  here,  and  their 
freedom  from  intercurrent  disease,  from  colds  to  iniluenza, 
is  proverbial  and  very  striking.  With  the  exception  of  an 
occasional  cold,  in  no  case  has  an  intercurrent  affection 
been  observed,  outside  of  those  complications  which  the 
patients  brought  with  them  from  the  tropics,  such  as  ma- 
laria, dysentery,  etc. 

The  course  of  both  pulmonary  tuberculosis  and  phthisis 
is  undoubtedly  much  moditied  by  a  residence  here,  and  to 
attribute  such  modification  to  the  climate  seems  the  only 
rational  thing  to  do.  For  instance,  a  gfKidly  proportion  of 
the  two  hundred  and  twenty-four  patients  mentioned 
above  give  a  history  of  haemoptysis  before  coming  to  New 
Mexico,  but  hemorrhages  are  strikingly  uncommon  here, 
and  except  in  one  or  two  instances  in  advanced  cases  a 
serious  one  has  never  occurred.  Fully  fifty  per  cent,  of 
our  cases  are  admitted  febrile,  but,  as  a  rule,  only  a  short 
rest  is  required  to  bring  the  temperature  down  to  approxi- 
mately normal.  But  fourteen  or  sixteen  per  cent,  of  the 
patients  are  permanently  febrile,  and  these,  with  but  few 
exceptions,  were  hopelessly  advanced  on  admittance. 
Even  in  this  class  of  cases  the  average  daily  maximum 
temjjerature  is,  I  am  sure,  lower  than  that  observed  in  the 
same  class  East,  viz.,  loi'  F.  Night  sweats  are  entirely 
confined  to  the  febrile  or  mixed  infection  type,  and  even 
among  them  are  rare  and  very  amenable  to  treatment. 
Except  in  patients  presenting  a  history  of  dysentery,  diar- 
rhiKas  are  infrequent,  and  the  so-called  diarrhoea  of 
phthisis  is  practically  unknown. 

It  strikes  me  that  no  further  argument  is  necessary  to 
prove  that  high,  dry  climates  present  ideal  conditions  for 
the  application  of  the  fresh-air-dict  treatment  which  here, 
of  course,  as  elsewhere,  forms  the  basis  of  therapeutic 
measures.  Dr.  Brooks,  or  any  man  who  fails  to  take  the 
"demonstrated  truths  "  of  this  subject  into  consideration, 
must  at  least  expect  to  have  his  motives  questioned.  For 
the  guidance  of  the  profession  of  the  United  States  the 
dictum  "send  your  consumptive  patients  west  as  soon  as 
the  diagnosis  is  made"  still  remains  unimpeachable.  A 
rutliless  application  of  this  rule,  regardless  of  the  patient's 
financial  condition,  is  necessarily  absurd,  and  for  the  many 
to  whom  a  sojourn  in  the  \Vest  or  like  region  is  impracti- 
cable, I,  for  one,  certainly  anticipate  great  results  from 
the  fresh-air-diet  treatment,  even  in  damp,  unstable  cli- 
mates such  as  that  of  Boston  or  Edinburgh  ;  in  fact,  such 
results  have  already  been  obtained.  Nevertheless,  the 
statistics  compiled  by  workers  "out  West  "  proved  beyond 
a  doubt  that  better  results  will  always  be  obtained  in  cli- 
mates which  present  the  features  emphasized  in  this  paper. 
The  question  of  the  applicability  and  usefulness  of  our 
Western  climate  in  phthisiotherapy  would  be  settled  for 
evermore  were  it  but  possible  to  get  the  testimony  of  tiie 
thousands  in  whom  the  disease  has  been  arrested  or  cured 
in  this  climate,  and  who  constitute  so  largely  the  white 
popul.ition  of  the  "arid  zone." 

With  a  characteristic  touch  Dr.  Brooks  negatives  the 
whole  of  serum  therapy  in  pulmonary  tuberculosis.  Some 
very  eminent  men  still  withhold  a  positive  opinion  on  this 
subject,  and  others  sincerely  believe  in  the  limited  useful- 
ness of  some  of  the  sera  already  on  the  market.  Most 
medical  men,  I  am  sure,  anticipate  a  "cure"  along  bio- 
chemical lines,  and  in  a  field  already  so  prolific  of  results 
it  does  not  pay  to  be  scornful.  Dr.  Brooks  is  undoubtedly 
right  in  discouraging  the  use  of  sera  in  advanced  or  mixed- 
infection  cases,  as  a  serum  derived  from  tubercle  bacilli  is 
manifestly  useless  in  such  cases.  The  point  is,  however, 
that  the  most  enthusiastic  advocate  of  sera  does  not  advise 
their  employment  in  cases  exemplifying  this  type  of  the 
disease.  Even  the  old  tuberculin  has  a  fixed,  if  somewhat 
uncertain,  value  in  the  treatment  of  lupus,  and  I  myself 
can  testify  that,  as  a  sequence  of  the  use  of  this  agent  for 
diagnostic  jnirposes,  I  have  witnessed,  in  a  number  of  in- 
stances, a  sudden  and  striking  impetus  to  recuperative 
power  that  is  difficult  to  understand  on  any  other  basis 
than  specific  action.  In  the  fact  of  the  evidence  against 
this  agent  in  phthisiotherapy  it  would  be  absurd  to  advo- 
cate its  use.  However,  the  fact  remains  that  the  seem- 
ingly antagonistic  action  of  tuberculin  must  be  explained 
before  serum  therapy  in  pulmonary  tuberculosis  is  filed 
with  the  "back  numbers." 

While  so  generally  nihilistic  toward  mo.st  special  thera- 
peutic measures.  Dr.  Brooks  exhibits  a  marked  bias  in 
favor  of  inhalation  of  antiseptic  vapors,  and  quotes  Pen- 
rose, of  Johns  Hopkins,  to  the  effect  "that  the  antiseptic 
action  of  inhalation  is  manifested  by  the  rapid  disappear 
ance  of  pus  organisms  from  the  sputum."  In  the  exami- 
nation of  thousands  of  specimens  of  sputum,  and  careful 
comparison  of  cases,  I  yet  fail  to  understand  the  signifi- 
cance of  adventitious  organisms  in  the  sputum.  One 
point  is  clear  to  me  :  in  the  majority  of  cases  in  which  ba- 
cilli tuberculosis  are  found  in  the  sputum  c*her  organisms 


are  absent,  or  few  in  number ;  per  contra,  as  soon  as  the 
bacillus  tuberculosis  disappears  from  the  sputum  the  ad- 
ventitious organisms,  including  pus  organisms  appear  in 
enormous  numbers.  In  fact,  in  our  work  here  the  appear- 
ance of  adventitious  organisms  is  heralded  as  rather  a 
favorable  prognostic  sign.  Now,  wherein  lies  the  signifi- 
cance of  the  occurrence  of  these  organisms  in  the  sputum, 
and  what  is  the  use  of  removing  them  if  present? 

A  number  of  years  ago  the  futility  of  medicating  the  at- 
mosphere of  institutions  was  proven,  and  I  believe  it  per- 
fectly safe  to  say  that  the  constant  inhalation  of  pure  air 
IS  the  only  inhalation  of  confirmed  value. 

I  do  not  say  that  medicated  inhalations  are  useless,  but 
simply  of  very  limited  applicability  in  certain  bronchial 
cases,  and.  if  I  have  understandingly  studied  the  litera- 
ture of  the  subject,  this  opinion  is  now  classic. 

Eakl  Spkagle  Bullock,  burgeon  U.  S.  Army. 


CORNING'S 


SUBARACHNOID 
ANyI':STHESIA. 


COCAINE 


To  THE  Editor  op  thb  Medical  Record. 

Sir  •  I  beg  to  call  attention  to  a  letter  by  Dr.  William  J. 
Robinson,  which  appeared  in  the  Medical  Record  of  No- 
vember 10,  1900.  After  an  introductory  panegyric  on  my 
work  in  neurology  the  author  of  this  interesting  epistle  has 
this  to  say  : 

"It  IS  the  method  of  subarachnoid  ana;sthesia  that  prom- 
ises to  work  a  revolution  in  general  surgery  and  obstetrics, 
and  the  credit  of  the  method  undoubtedly  belongs  to  two 
men — to  Prof.  August  Bier  and  to  Professor  Tuffier  .  to  the 
first  as  the  discoverer  of  the  method,  and  to  the  second  as 
its  popularizer." 

Had  the  author  looked  into  the  subject  more  carefully, 
he  would  have  found  that  in  my  book  on  "Pain"  (J.  B. 
Lippincott  Company,  Philadelphia,  1894)  I  have,  under 
the  head  of  "Irrigation  of  the  Cauda  Equina  with  Medici- 
nal Fluids  ■  (pp.  247-254),  devoted  six  pages  to  the  consid- 
eration of  suiiaracnnoid  anaesthesia,  which  I  devised  and 
executed  in  i8S3,  and  published  five  years  before  either 
Bier  or  Tuffier  entered  the  field.  Bier's  paper  \\%s  pub- 
lished in  1899'  and  Tuffier's  in  1899  and   1900.' 

Again,  your  correspondent  observes,  "He  [Corning]  was 
certainly  one  of  the  first  to  perceive  the  possibilities  of  the 
method  of  spinal  cocainization."  This  is  highly  diverting 
in  view  of  the  fact  that  not  only  was  I  the  first  to  perceive 
its  possibilities,  but  al.so  the  very  first  actually  to  anaesthe- 
tize the  cord — all  this  in  1885,  before  such  a  thing  was  even 
dreamt  of  '  Whatever  the  crudities  of  my  provisional  hy- 
potheses, they  led  me  to  the  establishment  of  the  action  of 
cocaine  on  the  cord  ;  and,  as  has  been  pointed  out  over  and 
over  again  by  others,  to  the  full  development  of  subarach- 
noid cocaine  anesthesia,  )-ears  before  Bier  or  Tuffier  or 
any  one  else  entered  the  field. 

Your  correspondent  intimates  that  I  was  "uncertain 
whether  the  method  would  ever  find  an  application  in 
genito-un nary  or  other  branches  of  surgery."  This  is  not 
true  ;  I  said  in  my  first  paper,  published  in  1883  :  "  Whether 
the  method  will  ever  find  an  application  as  a  substitute  for 
etherization  in  genito-urinary  or  other  branches  of  surgery, 
further  experience  alone  can  show  '  "  This  was  certainly 
a  correct  attitude  fifteen  years  ago ;  for  even  at  this  late 
day,  and  despite  the  many  trials  made  of  it,  the  method  as 
a  permanent  adjunct  to  surgery  is  still  sub  jiidice. 

As  a  neurologist  this  was  sufficient,  and  more ;  but,  I 
may  add,  as  a  matter  of  collateral  interest,  that  I  even 
tried  to  enlist  the  co-operation  of  a  prominent  surgeon  in 
the  matter,  but  without  success.  Nor  ought  we  to  judge 
him  harshly  for  this :  for  at  that  time  penetration  of  the 
meninges  of  the  cord  seemed  as  venturesome  an  undertak- 
ing as  did  mutilation  of  the  peritoneum  at  a  more  remote 
epoch. 

Your  corresjiondent  states  that  subarachnoid  anaesthesia 
"promises  to  work  a  revolution  in  general  surgery."  This, 
of  course,  is  absurd. 

It  is  not  scientific  to  make  a  fetish  of  the  cerebro-spinal 
fluid,  whose  appearance  is  by  no  means  an  infallible  her- 
ald of  the  success  of  the  injection.  Inversely,  this  fluid 
may.  for  some  reason  or  other,  fail  to  appear  in  the  needle; 
and  yet,  if  the  preliminary  measurements  which  I  recom- 
mend for  the  purpose  of  insuring  the  penetration  of  the 
membranes  be  taken,  the  injection  may  be  a  success. 

I  think  I  can  trust  the  profession  of  this  country  to  deal 
with  those  who  pervert,  ignore,  or  skate  blithely  over  much 
that  I  have  written  ;  and  neither  petty  casuistry  nor  minc- 
ing cavil  can  debase  the  import  of  recorded  and  conceded 
fact.  J.  Leonard  Corni.ng. 

53  West  Thirty-eighth  Street. 

'  Deutsche  Zeitschrift  fur  Chirurgie,  \'ol.  11  .  p.  361. 

'  La  Semaine  medicate,  1899,  p.  363,  and  May  16,  19OO. 


792 


MEDICAL    RECORD. 


[November  17,  1900 


Society  ^Icports. 

NEW    YORK   ACADEMY   OF    MEDICINE. 

Stated  Meeting,  November  I,  igoo. 

William  H.  Thomson,  M.D.,  President. 

The  Etiology  of  Cystitis.— Dr.  William  K.  Otis 
read  this  paper.  He  said  that  it  was  only  compara- 
tively recently  that  it  had  been  generally  recognized 
that  the  one  constant  and  determining  factor  in  cysti- 
tis was  some  microbic  infection.  For  our  knowledge 
on  this  subject  we  were  indebted  to  the  researches  of 
Pasteur  primarily.  At  first,  it  had  been  supposed  that 
this  infection  was  always  the  result  of  the  introduc- 
tion of  the  micrococcus  urea;,  but  further  research  had 
isolated  no  less  than  twenty  micro-organisms  in  the 
urine  of  cases  of  cystitis.  The  micro-organism  that 
occurred  most  frequently  and  of  late  attracted  the 
most  attention  was  the  bacterium  coli  commune.  Be- 
cause of  its  varied  morphology  it  had  been  known  by 
a  great  many  different  names.  The  most  important 
micro-organisms  in  connection  with  the  study  of  cysti- 
tis were  the  bacterium  coli  commune,  the  staphylococ- 
cus aureus,  albus,  and  citreus,  the  gonococcus,  and  the 
tubercle  bacillus.  Next  in  frequency  to  infection 
through  the  urethra  came  infection  through  the  blood 
as  a  cause  of  cystitis.  Inflammation  of  any  organ 
might  give  rise  to  a  metastasis  to  the  urinary  tract, 
but,  as  a  rule,  the  microbes  were  derived  from  the  ali- 
mentary tract.  This  might  be  the  case  even  without 
any  symptoms  pointing  to  disorder  of  the  bowel.  It 
was  not  improbable  that  at  times  microbes  from  the 
intestine  circulated  in  the  blood  of  every  one.  The 
kidney  was  one  of  the  organs  in  which  the  blood  most 
frequently  deposited  microbes.  Another  mode  of  in- 
fection was  by  the  breaking  through  of  an  adjacent 
abscess.  In  the  condition  known  as  bacteruria  the 
bacterium  coli  commune  was  present  in  enormous 
numbers  for  a  long  time  without  giving  rise  to  any 
inflammation.  Such  a  phenomenon  was  certainly  ex- 
tremely puzzling.  The  gonococcus  and  the  tubercle 
bacillus  could  not  be  regarded  ordinarily  as  a  direct 
cause  of  cystitis.  In  so-called  gonorrhceal  cystitis  the 
urine  taken  directly  from  the  bladder  without  any 
chance  of  contamination  from  the  urethra  contained 
very  few  gonococci.  It  was  generally  conceded  that 
tuberculosis  of  the  bladder  was  always  secondary  to 
tuberculosis  of  the  kidney  or  of  the  lower  urogenital 
tract.  Infection  took  place  most  frequently  from  the 
kidney.  The  resistance  of  the  mucous  membrane  of 
the  bladder  to  the  tubercle  bacillus  was  very  great,  the 
urine  sometimes  containing  tubercle  bacilli  for  years 
without  the  bladder  becoming  infected.  In  some 
cases  the  bladder  became  involved  by  rupture  into  it 
of  a  tuberculous  prostatic  abscess.  A  previous  simple 
cystitis  not  infrequently  prepared  the  soil  for  tuber- 
culous infection.  In  1888  Guyon  had  demonstrated 
that  pure  cultures  of  various  micro-organisms  might  be 
introduced  into  the  healthy  bladder  without  producing 
cystitis.  It  was  evident,  therefore,  that  there  must  be 
certain  predisposing  factors.  When  the  resisting- 
power  of  the  mucous  membrane  of  the  bladder  was 
reduced  by  the  presence  of  a  foreign  body  or  of  resid- 
ual urine,  micro-organisms  rapidly  produced  inflam- 
mation. The  presence  of  residual  urine  alone  without 
the  coexistence  of  micro-organisms  did  not  give  rise 
to  cystitis;  hence  the  great  importance  of  maintaining 
asspsis  when  there  was  residual  urine. 

Sterilization  of  Instruments Metal    instruments 

could  be  readily  sterilized  by  boiling  for  ten  minutes 
in  a  solution  of  carbonate  of  sodium.  Silk  or  gum 
catheters  could  not  be  boiled,  hence  they  must  be  so 


constructed  as  to  make  mechanical  cleansing  easy  and 
efficient.  It  was  most  important  to  have  no  blind 
end.  The  mechanical  cleaning  was  best  accomplished 
by  the  use  of  warm  soapsuds  immediately  after  the  use 
of  the  instrument,  the  soapsuds  being  driven  through 
with  a  syringe.  They  should  be  wiped  and  exposed 
to  a  dry  heat  of  100  F.  for  ten  minutes.  It  was  es- 
sential that  they  should  be  dry  on  the  outside,  and 
that  the  different  instruments  should  not  come  in  con- 
tact dtiring  this  drying  process.  Sterilization  by  for- 
maldehyde or  paraform  was  satisfactory,  but  the  in- 
strument should  be  washed  witii  sterile  water  before 
being  used  again,  otherwise  when  introduced  it  would 
cause  smarting.  Great  care  should  be  taken  in  in- 
structing those  who  were  about  to  begin  self-catheterism 
as  to  the  precautions  they  must  take  to  keep  the  bladder 
aseptic.  The  patient  should  ha\e  a  medium-sized 
coude  catheter,  and  twice  as  many  of  these  as  are 
needed  each  day.  The  urethra  should  be  irrigated 
before  catheterization.  A  good  lubricant  for  urethral 
instruments  should  be  aseptic,  and  easily  miscible 
with  water.  Vaseline  or  fat  should  never  be  used  as 
a  lubricant  for  catheters,  as  it  adhered  to  the  wall  of 
the  bladder  and  prevented  the  escape  of  such  micro- 
organisms as  chanced  to  be  in  the  urethra.  The  blad- 
der should  be  filled  after  instrumentation  with  foimalin 
solution  I  :  i,ooo,  nitrate  of  silver  in  two-per-cent. 
solution,  or  potassium-permanganate  solution  i  :  i,ooo. 
After  having  been  retained  in  the  bladder  for  three  or 
four  minutes  it  might  be  permitted  to  escape.  The 
best  internal  antiseptic  for  the  bladder  was  urotropin 
in  doses  of  gr.  viiss. 

The  Seed  and  the  Soil. — Dr.  E.  L.  Keves  said 
that  he  could  testify  to  the  fact  that  the  bacterium  coli 
commune  often  existed  in  the  urine  in  large  numbers, 
and  for  years,  without  giving  rise  to  cystitis.  A  case 
was  cited  in  which  for  upward  of  twenty-five  years 
bacteruria  had  been  present,  and  had  eventually  passed 
away,  although  during  all  this  time  the  man  had  been 
catheterizing  himself  and  very  carelessly  at  that.  In 
this  connection  one  should  not  lose  sight  of  the  rela- 
tion between  the  seed  and  the  soil.  When  the  bladder 
was  atonied,  when  the  circulation  was  poor,  as  it  usu- 
ally was  in  cases  of  enlarged  prostate,  when  the  person 
had  indulged  too  freely  in  sexual  inteicourse.  or  had 
refrained  therefrom  through  a  long  period  of  sexual 
excitement,  the  soil  was  likely  to  be  rendered  favor- 
able for  microbic  infection.  Perhaps  the  prettiest 
demonstration  of  the  importance  of  the  soil  was  the 
famous  experiment  of  injecting  into  the  ear  of  a  rab- 
bit a  micro-organism  known  to  be  capable  of  causing 
cystitis.  The  animal  being  healthy  and  well,  no 
harm  came  from  this  inoculation.  Another  rabbit 
was  then  given  a  similar  injection  after  one  kidney 
had  been  bruised  by  squeezing  the  loin.  The  animal 
developed  an  abscess  of  the  kidney  on  that  side,  but 
no  lesion  of  the  other  kidney.  Regarding  sterilization 
it  seemed  to  him  tlint  all  metallic  instruments  were 
best  sterilized  by  passing  them  through  the  flame  of  a 
Bunsen  burner,  and  rubber  instruments  were  best  ster- 
ilized by  boiling.  He  preferred  washing  out  the 
bladder  with  a  1:1.000  solution  of  nitrate  of  silver 
after  the  introduction  of  instruments.  He  never  used 
either  bichloride  or  formalin  because  he  had  found 
them  irritating,  and  he  would  be  afraid  to  use  a  two- 
per-cent.  solution  of  nitrate  of  silver  indiscriminately. 

Individual  Tolerance. — Dr.  L.  Boi.ion  JSanc.s  said 
that  the  vulnerability  of  the  individual  varied  at  dif- 
ferent times.  He  had  known  one  man  to  carry  his 
catheter  in  his  hat  and  lubricate  it  with  saliva,  and 
yet  he  had  succeeded  in  avoiding  any  serious  compli- 
cations. Another  man  by  careless  catheterization  had 
started  an  attack  of  cystitis  necessitating  the  use  of 
the  self-retaining  catheter.  While  on  the  commode, 
this  catheter  had  slipped  into  tiie  bowl,  but  the  man 


November  17,  1900] 


MEDICAL    RECORD. 


^93 


had  fished  it  out  from  the  mass  of  ffeces  and  without 
any  hesitation  had  slipped  it  back  into  the  bladder. 
There  had  been  no  alarming  consequences  of  this  ex- 
traordinary act.  The  directions  for  insuring  cleanli- 
ness should  be  as  simple  as  possible,  and  every  effort 
should  be  made  to  keep  the  general  health  at  the 
highest  point. 

Dr.  Eugene  Fuller  cited  a  recent  case  in  proof  of 
the  improvement  that  would  take  place  in  a  cystitis 
from  relieving  the  condition  of  atony  and  improving 
the  general  health.  He  said  that  the  gonococcus 
might  be  present  for  .some  time  and  do  no  harm  in  the 
bladder  unless  a  mixed  infection  should  occur. 

Bladder  Washing  a  Great  Safeguard — Dr.  A.  B. 
Johnson  recommended  for  self-catheterization  partic- 
ularly the  use  of  a  special  form  of  rubber  catheter,  of 
the  coude  pattern,  having  a  solid  end.  Because  of 
this  feature  it  was  easy  to  pass  the  instrument  in  cases 
of  marked  prostatic  enlargement.  J'he  patient  should 
be  directed  to  boil  the  instrument  for  a  few  minutes 
before  use,  and  to  wash  the  hands  and  glans  penis 
before  introducing  the  catheter.  It  did  not  seem  to 
him  of  great  importance  what  antiseptic  solution  was 
used  for  washing  out  the  bladder  after  instrumenta- 
tion, but  it  was  of  the  first  importance  that  this  wash- 
ing be  done. 

Dr.  Ferd.  C.  Vale.ntine  spoke  of  the  utter  innocu- 
ousness  of  the  gonococcus  when  thrown  into  the  healthy 
bladder  by  intra-vesical  irrigations.  He  had  adopted 
the  plan  of  filling  the  urethra  with  a  glycerin  emulsion 
of  iodoform  before  introducing  an  instrument,  for  the 
reason  that  slight  injuries  were  inliicted  upon  the 
urethra,  and  in  this  way  these  abrasions  were  at  once 
cleansed  and  made  aseptic.  Several  cases  had  been 
reported  recently  in  which  stones  had  formed  in  the 
bladder  around  hairs  which  had  been  carried  in  on 
catheters. 

Dr.  B.  Lapowski  said  that  Wassermann  had  dis- 
covered the  gonococcus  pure  in  the  tissues  of  the 
bladder.  Three  other  investigators  had  detected  the 
gonococcus  in  urine  drawn  from  the  bladder  asepti- 
cally.  The  fact  that  so  many  cases  of  gonorrhoea  did 
not  have  cystitis  was  no  argument  that  it  could  not 
occur. 

Dr.  a.  Jacobi  spoke  of  soil  and  vulnerability.  He 
said  that,  as  a  rule,  micro-organisms  would  not  gain 
entrance  through  sound  and  healthy  epithelium,  or 
when  the  circulation  was  sufficiently  active.  Tuber- 
culosis of  bone  was  almost  invariably  found  at  first  in 
the  ends  of  the  bones,  and  where  the  epiphysis  was 
growing — in  other  words,  where  there  were  congestion 
and  slow  circulation.  It  was  because  of  these  that 
the  tubercle  bacilli  g.iined  a  foothold.  As  long  as  the 
bladder  was  fairly  healthy  he  did  not  believe  cystitis 
would  arise  simply  from  the  presence  of  the  bacterium 
coli,  unless  these  bacteria  were  virulent  as  a  result  of 
certain  special  changes  going  on  in  the  intestine. 
The  bacteria  found  their  way  into  the  bladder  either 
directly  or  through  the  blood.  When  there  was  very 
little  uric  acid  and  much  urea,  decomposition  was 
readily  set  up. 

Dr.  Otis,  in  closing,  said  that  he  had  not  intended 
to  say  that  he  used  a  two-per-cent.  solution  of  nitrate 
of  silver,  although  this  was  employed  by  some.  He 
personally  favored  a  strength  of  1:1,000.  For  the 
first  few  days  of  catheter  life  it  was  well  to  give  uro- 
tropin  internally,  and  insist  upon  the  patient  remain- 
ing in  bed.  So-called  gonorrhceal  cystitis  was  almost 
always  the  result  of  other  organisms  than  the  gono- 
coccus. 


Inebriety. — No  single  remedy  is  capable  of  meeting 
a  wider  range  of  conditions  than  the  Turkish  hot-air 
baths,  with  free  massage. — Dr.  T.  D.  Crothers,  Vir- 
ginia Medical  Semi-Monthh,  October  12th. 


CUnical  gcpavtmcnt. 

PERFECT      RECOVERY      FOLLOWING      GAN- 
GRENE  OF    THE    SCROTUM    AND    PENIS.' 

By    EVER.\RD    II.VMILTON    RICHARDSON,  M.D.. 

ATLANTA,    GA. 

Because  of  its  being  unique — certainly  cases  of  this 
character  do  not  very  frequently  come  under  the  obser- 
vation of  the  physician  and  surgeon  of  the  widest  ex- 
perience and  having  the  largest  clientele — this  case  of 
exceeding  interest  to  myself  (and  I  indulge  the  hope 
that  it  may  prove  not  less  so  to  this  august  body  of 
practitionersj  is  reported. 

E.  H.  T ,    occupation  bank  cashier,  native  of 

Georgia,  now  a  resident  of  Sanford,  Fla.,  personal  and 
family  history  excellent,  was  treated  there  by  several 
physicians.  He  came  to  me  direct  from  the  Plant 
System  Railroad  Hospital  located  at  Sanford,  Fla. 
Summoned  by  wire  on  June  8,  igoo,  I  met  this  patient 
at  the  Union  Depot  at  Atlanta,  Ga.,  and  found  him  in 
a  Pullman  sleeper  almost  in  a  state  of  collapse,  with 
a  pulse  of  120  beats  per  minute,  temperature  103°  F., 
and  bathed  in  a  profuse  persjjiration  from  exhaustion, 

I  immediately  administered  gr.  ^',y  of  strychnine 
hypodermically,  gave  him  a  drink  of  brandy,  and 
placed  him  in  the  Grady  Hospital  Ambulance,  send- 
ing him  to  St.  Joseph  Infirmary.  There  from  the 
patient  himself  and  his  friends  the  following  clinical 
history  of  the  case  from  its  inception  was  obtained. 
Upon  May  16,  1900,  the  patient  observed  a  small 
pimple  upon  the  integument  a  short  distance  above 
the  OS  pubis  which  was  slightly  red;  shortly  afterward 
the  surrounding  tissues  became  swollen  and  somewhat 
tender  to  the  touch.  In  twelve  hours  from  the  date  of 
the  appearance  of  this  apparently  insignificant  pimple, 
the  inflammation  extended  to  the  penis,  where  in  addi- 
tion to  the  general  swelling  and  redness  then  obtaining, 
there  was  intense  itching  with  burning  in  the  affected 
parts.  The  pain  at  no  time  was  severe,  but  the  burning 
and  itching  were  great.  At  this  juncture,  forty-eight 
hours  from  the  appearance  of  the  initial  lesion,  the 
penis  turned  black  and  simultaneously  the  scrotum 
became  involved,  and  a  few  hours  later  also  turned 
dark.  The  physicians  in  attendance  denominated  the 
malady  gangrene.  The  patient  was  now  placed  under 
an  anjesthetic,  and  the  necrotic  structures  were  removed 
by  the  surgeons  in  charge  of  the  hospital. 

An  examination  of  this  patient,  after  coming  into 
my  charge,  revealed  the  fact  that  the  integument  of 
the  penis  had  been  entirely  destro\ed,  the  destructive 
process  extending  down  to  the  corpora  cavernosa  and 
the  corpus  spongiosum.  The  crura  and  suspensory 
ligaments  of  the  root  of  the  penis  were  intact,  and  the 
glans  penis  had  escaped,  as  the  line  of  invasion  did 
not  extend  beyond  the  corona  glandis.  Three-fourths 
of  the  scrotum  had  been  entirely  destroyed  by  the 
gangrenous  process  down  to  the  tunica  vaginalis. 
The  spermatic  cords,  the  testes  with  the  epididymis 
were  in  good  condition,  but  the  testes  were  entirely 
bare  of  covering  and  were  supported  only  by  the  sper- 
matic cords. 

The  penis  and  testes  were  thoroughly  cleansed  with 
a  solution  of  mercuric  chloride  i  :  3,000,  enveloped  in 
ten-per-cent.  iodoform  gauze;  rubber  tissue,  absorbent 
cotton,  and  a  double  spica  bandage  were  applied. 
Constitutionally  he  was  supported  by  the  regular  ad- 
ministration of  sweet  milk,  beef  juice,  raw  eggs,  and 
peptonoids.  He  was  also  placed  upon  tincture  of 
chloride  of  iron,  and  strychnine  with  tonic  doses  of 
quinine   were  continued.     Antiseptic  dressings   with 

'  Read  before  the  Mississippi  Valley  Medical  .Association  at 
Ashe^ille.  N.  C,  October  g,  igoo. 


794 


MEDICAL    RECORD. 


[November  17,  1900 


the  addition  of  solution  of  hydrogen  peroxide  in  full 
strength  and  a  twenty-five-per-cent.  solution  of  balsam 
of  Peru  in  olive  oil  were  continued  daily.  There  was 
very  grave  impairment  of  the  patient's  nutrition,  ema- 
ciation was  extreme,  and  the  patient  was  but  little  more 
than  skin  and  bones.  His  gei>eral  condition  was  such 
at  this  time  as  to  preclude  the  propriety  of  considering 
any  operative  procedure.  From  day  to  day  it  was  dif- 
ficult to  discern  any  improvement,  but  under  the  regime 
instituted  the  patient's  appetite  and  strength  slowly 
improved.  The  gangrenous  process  ceased  its  havoc, 
and  the  line  of  demarcation  was  clearly  established. 
But  not  until  the  lapse  of  twenty-six  days  from  the 
time  he  came  under  my  observation,  did  I  believe  it 
safe  to  risk  the  shock  of  operative  interference.  For 
good  reasons  he  was  removed  from  St.  Joseph  Infirm- 
ary to  a  private  house. 

At  my  instance,  on  July  2,  1900,  Dr.  W.  F.  West- 
moreland was  called  in  to  see  this  case  with  me.  It 
did  not  seem  possible  that  there  was  left  a  sufficient 
amount  of  the  scrotum  for  an  adequate  covering  for 
the  left  testicle.  VVe  decided,  however,  to  make  the 
attempt  to  save  both  testicles.  I  regret  that  owing  to 
a  hurried  call  from  the  city  Dr.  Westmoreland  did  not 
again  see  the  case  after  his  first  visit  until  the  com- 
pletion of  the  operation,  when  the  patient  presented 
himself  at  his  office  only  to  show  a  perfect  specimen 
of  restored  manhood. 

On  July  4th,  assisted  by  my  son,  medical  student 
Everard  Dugas  Richardson,  and  by  Dr.  Pierce  M.  But- 
ler who  administered  the  anaesthetic,  I  dissected  off 
the  scrotum  as  high  up  as  possible,  using  strict  anti- 
septic precautions,  and  succeeded  by  pushing  up  the 
testes  and  introducing  silkworm-gut  sutures  and  pull- 
ing down  the  scrotum  in  entirely  covering  both  testes 
with  integument.  A  small  piece  of  gauze  for  drainage 
was  left  in  the  centre  of  the  wound,  and  with  the  ex- 
ception of  this  point  perfect  union  by  first  intention 
was  secured. 

The  patient  was  slow  in  regaining  his  wonted 
strength,  but  by  September  ist  his  recovery  was  com- 
plete, and  on  October  ist  he  was  a  splendid  specimen 
of  physical  manhood,  strong  and  robust. 

Before  giving  my  conclusions  concerning  this  case, 
I  wish  to  state  that  from  my  own  long  and  intimate 
knowledge  of  the  family  history,  morals,  and  habits 
of  this  patient,  I  am  able  absolutely  to  exclude  the 
suspicion  of  any  venereal  taint  as  a  causative  factor  in 
the  production  of  the  lesion.  The  patient's  perfect  re- 
covery and  his  present  superb  health  warrant  the 
elimination  of  arteriosclerosis,  atheroma,  chronic 
nephritis,  and  diabetes  mellitus  as  etiological  factors 
in  the  production  of  the  case  of  gangrene  under  con- 
sideration. The  history  of  the  case  does  not  justify 
the  assumption  that  the  gangrene  was  due  to  any  ob- 
struction of  the  circulation  or  to  the  intensity  of  the 
inflammation,  because  at  no  time  did  the  inflammatory 
process  run  high.  We  are  also  able  to  exclude  embol- 
ism and  thrombosis. 

It  is  well  known  that  there  are  various  causes  of 
gangrene,  and  that  there  are  various  micro-organisms 
that  may  be  concerned  in  its  production,  and  it  is  true 
that  no  specific  germ  producing  gangrene  has  yet  been 
discovered,  though  I  believe  its  discovery  will  be  made 
by  bacteriologists  in  the  future. 

Reviewing  the  history  of  this  case  from  its  incep- 
tion, and  instituting  a  careful  analysis  of  the  symp- 
toms seriatim  as  they  occurred,  I  conclude  that:  The 
initial  cause  in  this  case  was  an  abrasion  of  the  skin 
at  the  spot  where  the  small  pimple  first  appeared. 
This  was  the  portal  of  entrance  of  the  pathogenic  ba- 
cillus, the  streptococcus  erysipelatis,  from  which  in- 
fection occurred.  Later  there  occurred  a  second  in- 
fection by  the  cocci  of  gangrene,  rather  than  that  this 
was  a  terminal  phenomenon  of  erysipelas. 


Fehleisen  teaches  us  that  the  streptococcus  erysipe- 
latis presents  distinct  differences  from  the  streptococ- 
cus pyogenes,  and  that  we  never  have  suppuration  in 
erysipelas  except  from  a  mixed  infection. 

Dr.  William  H.  \\'elch  has  recently  contributed  a 
most  admirable  article  to  the  transactions  of  the 
Massachu-setts  Medical  Society,  showing  a  collection 
of  forty-six  cases  of  emphysematous  gangrene,  in  all 
of  which  Bacillus  aerogenes  capsulatus  was  demon- 
strated to  have  been  present.  To  me  it  is  a  matter  of 
profound  regret  that  no  bacteriological  examinations 
were  made  in  the  case  under  consideration.  I  also 
lament  that  I  did  not  have  photographs  taken  in  order 
to  demonstrate  the  local  destruction  of  this  patient's 
genito-urinary  apparatus,  as  well  as  to  portray  the 
perfect  recovery  after  the  performance  of  the  simple 
operation  whicli  I  have  narrated. 


A  CASE  OF  CARBOLIC-ACID  POISONING, 
WITH  A  QUESTION  CONCERNING  AS- 
PHYXIA. 

By   H.    E.    KENDALL,    M.D., 

SIDNEY,    NOVA    SCOTIA. 

The  patient  was  a  child  under  two  years  of  age.  Pure 
carbolic  acid  of  unknown  quantity  had  been  taken  about 
twenty  minutes  prior  to  my  arrival.  The  mouth  and 
throat  were  white,  the  face  was  livid,  the  pupils  were 
dilated  and  fixed,  and  the  breathing  was  stertorous. 
The  child  was  completely  unconscious.  This  uncon- 
sciousness, the  mother  told  me,  had  come  on  a  very 
few  minutes  after  the  acid  was  swallowed. 

I  put  a  rubber  catheter  into  the  stomach  and  forced 
in  a  pint  and  a  half  of  a  solution  of  magnesium  sul- 
phate and  brandy.  This  I  attempted  to  siphon  out, 
but  unsuccessfully  as  the  child  had  just  previously 
eaten  a  substantial  meal.  All  attempts  to  produce 
emesis  failed.  The  child  was  rapidly  getting  worse. 
The  pulse  was  scarcely  perceptible,  and  the  respira- 
tions were  beginning  to  slow  down,  when  it  occurred 
to  me  to  draw  forward  the  tongue,  as  I  observed  con- 
siderable sinking  of  the  supraclavicular  regions  with 
inspiration.  On  doing  so  air  entered  the  chest  more 
freely,  the  face  assumed  a  better  color,  and  in  ten  or 
fifteen  minutes  the  pulse  had  become  decidedly  better. 
Then  the  child  began  to  cry,  and  from  that  on  recovery 
seemed  to  take  place.  P'or  a  time  the  breathing  would 
again  become  bad  whenever  the  tongue  was  let  go;  in 
short,  it  was  exactly  like  a  case  of  poisoning  with 
chloroform  in  anesthesia.  The  child  knew  its  mother 
in  about  two  hours.  After  this  the  breathing  became 
somewhat  croupy,  and  I  prepared  to  intubate  with  an 
O'Dwyer  tube,  but  this  did  not  prove  to  be  necessary. 
Vomiting  occurred  when  consciousness  was  returning, 
and  I  then  saw  tiiat  but  little  carbolic  acid  had  got  as 
far  as  the  stomach — at  least  so  I  judged  from  the  ab- 
sence of  its  odor  in  the  material  vomited.  The  next 
day  I  found  the  child  with  a  burnt  mouth,  but  other- 
wise pretty  well. 

From  this  ca.se  I  will  not  generalize,  but  there  are 
some  pretty  important  facts  which  I  will  note: 

(i)  The  child  after  swallowing  carbolic  acid  was 
apparently  dying  very  rapidly  with  symptoms  that 
might  reasonably  be  thought  to  be  produced  by  the 
systemic  effects  of  the  poison. 

(2)  These  symptoms  were  not  the  result  of  systemic 
influences;  otherwise  they  would  not  have  disap- 
peared so  quickly. 

(3)  The  unconsciousness,  dilated  pupils,  lividity, 
and  heart  failure  were  the  result  of  asphyxia,  and 
asphyxia  was  the  result  of  the  local  action  of  the 
poison  upon  the  structures  about  the  tongue  and  epi- 
glottis. 


November  17,  1900] 


MEDICAL    RECORD. 


r95 


CHYLOUS    ASCITES. 
Bv  J.    W.    KALES,    M.D., 

FHANKLINVII.LE,    N.    V. 

A  MAN,  thirty-four  years  of  age,  died  in  this  village 
August  19,  1900.  During  the  latter  part  of  December, 
1899,  he  noticed  some  swelling  of  the  left  scrotum  and 
adjoining  parts.  This  swelling  invaded  the  left  lower 
extremity,  and  gradually  extended  into  the  abdominal 
cavity,  and  then  extended  to  the  right  lower  extremity. 
Many  able  physicians  were  consulted.  The  disease 
continued  uninfluenced  by  treatment  until  relief  came 
by  death.  Several  diagnoses  were  made.  About  a 
month  before  death,  the  enlarging  abdomen  interfered 
with  respiration,  and  tapping  was  employed  to  secure 
temporary  relief.  On  the  first  occasion  about  one  gal- 
lon of  fluid  was  removed.  This  fluid  appeared  like 
rich  Jersey  milk.  When  allowed  to  stand,  a  thin  layer 
resembling  cream  collected  at  the  surface.  The  fluid 
accumulated  quite  rapidly,  and  was  removed  every 
four  or  five  days.  The  writer  removed  about  three 
quarts  the  day  before  death.  This  was  a  case  of 
chylous  ascites.  The  most  curious  part  of  the  case  is 
that  no  one  even  suggested  chylous  ascites  until  the 
fluid  flowed  through  the  trocar.  No  autopsy  was 
held,  because  the  writer  was  suffering  from  a  fractured 
elbow. 

No  adequate  cause  has  been  assigned.  The  patient 
was  born  and  reared  near  this  place.  He  has  lived 
near  here  all  his  life,  except  a  year  in  Tennessee  and 
a  year  (1897  and  1898)  in  the  Klondyke.  He  was 
somewhat  intemperate  in  the  use  of  alcoholic  liquors. 
It  is  regretted  that  an  autopsy  could  not  be  held,  as  it 
would  probably  have  revealed  the  connection  between 
the  lymphatics  and  the  abdominal  cavity. 


UNIVERSAL    ANKYLOSIS. 
By    H.    a.    ELLIOTT,    M.D., 

BARNET,    \T. 

During  my  summer  vacation  my  attention  was  called 
to  a  peculiar  case  in  an  adjoining  town,  and  for  the 
purpose  of  investigating  it  I  drove  over  to  see  it, 
tiiinking  its  report  might  be  of  some  interest.  It  is 
an  extreme  case  of  rheumatoid  arthritis,  and  as  I  have' 
never  seen  or  heard  of  such  a  case  before,  I  should 
like  to  have  it  published. 

B.   A -,   aged   forty-four  years;    white,   married, 

residing  in  New  Hampshire.  Parents  are  both  living. 
The  mother  is  sixt\'-eight  years  old,  and  has  slight 
rheumatic  tendencies,  but  no  disablement.  The  fatiier 
is  seventy  years  old,  and  has  no  rheumatism. 

Previous  to  1887  the  patient  had  attacks  of  rheu- 
matism which  disabled  him  partially  from  the  time  he 
was  twenty-one  years  old,  and  thirteen  years  ago  he 
was  obliged  to  take  to  his  bed,  and  ankylosis  set  in  very 
soon  in  almost  every  joint  in  the  body,  the  process 
being  accompanied  by  great  pain. 

I  saw  the  patient  in  August,  1900,  after  the  thirteen 
years  of  helplessness.  The  right  arm  and  hand  were 
across  the  chest,  the  left  was  on  the  abdomen,  the  legs 
w-ere  semiflexed  at  knees,  the  hips  were  partially 
flexed  at  the  pelvis;  the  cervical  vertebras  were  all  in 
their  anatomical  position,  and  the  jaw  was  set.  All 
of  the  above  joints  were  immovable  except  for  a  very 
slight  motion  of  the  right  hip  and  of  some  of  the 
phalanges.  There  was  not  enough  motion  to  enable 
the  patient  to  help  himself  in  the  least. 

Some  of  his  teeth  were  removed  to  permit  of  the 
introduction  of  food  for  which  he  has  a  good  appetite. 
He  is  now  without  pain  as  a  rule.  The  heart's  action 
is  nearly  normal,  the  bowels  act  with  some  regularit)', 


as  does  the  bladder,  and  his  skin  is  of  good  color,  act- 
ing well.     There  is  no  muscular  atrophy. 

P.S.  1  might  add  the  strangest  symptom  of  all, 
namely,  that  although  the  patient  had  been  utterly 
helpless  for  so  many  years,  about  one  and  one-half 
years  ago  his  wife  gave  birth  to  a  good,  big,  healthy 
boy.  Perhaps  some  of  the  brethren  may  atten)pt  to 
explain  it. 


PTOMAIX    POISOXINO    FROM    EATING 
CHEESE. 

Bv    G.     LEO    HAGEN    BURGER.   M.Sc,    M.D..    I'li.D., 

HELENA,    MONT. 

Being  called  by  a  father  about  1 1  .^o  p.m.  to  see  his 
family,  especially  two  boys,  three  and  six  years  old 
respectively,  I  found  them  prostrated,  vomiting  about 
thirty  times  during  the  interval  of  two  hours,  with  a 
flushed  head  and  face,  cold  extremities,  rapid  pulse, 
anxious  countenance,  cramped  muscles  of  the  legs, 
rigid  and  hard  abdominal  walls.  The  temperature 
was  normal  in  one,  104°  F.  in  the  other.  The  vomit 
presented  the  appearance  of  finely  divided  particles  of 
food,  cheese,  and  portions  of  an  apple  eaten  in  the 
afternoon,  several  hours  before  supper-time,  when  the 
cheese  was  eaten  by  the  whole  family,  including  the 
two  boys  mentioned.  The  vomiti-ng  set  in  several 
hours  after  ingestion  and  rapidly  increased,  being  ac- 
companied by  the  above-related  symptoms.  A  stimu- 
lant hypodermic  of  strychnine,  morphine,  and  cam- 
phor was  given,  and  the  stomach  washed  out  with  a 
warm  antiseptic  solution,  repeated  several  times  in  two 
hours.  Hot  sheets  were  wrapped  about  them,  and 
over  the  epigastric  region  mustard  pads  were  ap- 
plied. Hot  broths  only  were  given  for  several  days. 
During  this  time  the  little  fellows  had  sufficitnlly 
recovered  to  be  up  and  about  the  room.  Now  having 
learned  of  the  eating  of  the  cheese  previous  to  the 
vomiting,  and  reasoning  from  the  symptoms  presented, 
I  made  a  diagnosis  of  ptomain  poisoning  due  to  toxal- 
bumins.  Therefore  specimens  of  the  vomit,  cheese,  and 
diarrhoeal  discharge  were  collected,  and  an  examina- 
tion was  made  of  each.  Remembering  the  experiments 
of  Husemann  and  Fleishmann  I  proceeded  to  examine 
the  vomit  for  copper  and  zinc  sulphate  which  is  some- 
times added  in  the  centrifugal  machines,  to  prevent 
heaving,  as  the  dairymen  call  it.  The  result  proved 
negative.  No  poison  could  be  found  except  an  amount 
of  fatty  acid  which  gave  the  cheese  a  strongly  acid 
reaction,  identical  with  the  so-called  German  sausage 
poison,  of  which  I  had  examined  a  number  of  speci- 
mens while  in  the  health  department  in  New  York. 

I  have  previously  examined  cheese,  both  with  the 
microscope  and  chemically,  without  finding  any  cause 
whatever  for  the  physiological  effects  and  disturbances 
produced  when  eaten.  The  sample  was  rich  in  fats 
and  proteids ;  its  taste  had  nothing  unusual  about  it,  yet 
when  eaten  it  caused  vomiting  and  purging  and  made 
the  consumer  ill.  Some  was  given  to  several  kittens 
and  to  several  dogs,  with  the  result  that  two  of  the 
kittens  were  very  ill,  one  in  spasms  the  first  time, 
from  which  she  recovered;  the  second  time,  about  a 
week  afterward,  the  cheese  had  absolutely  no  effect  on 
the  same  animal,  but  made  the  other  one  vomit  and 
seem  quite  ill  and  depressed  for  four  or  five  hours;  it 
refused  all  food  for  several  days.  To  one  dog  large 
draughts  of  water  were  given  to  see  whether  the  water 
and  the  excessive  amount  of  gastric  juice  and  the 
acidity  characteristic  in  the  canine  would  have  a 
modifying  effect  upon  the  poisonous  substance  or  bac- 
teria. The  dog  seemed  to  enjoy  being  fed  with  cheese 
until  our  supply  was  exhausted,  and  remained  well. 
The  second  dog,  which  had  no  water,  presented  vomit- 
ing and  retching  for  hours,  abdominal  pain,  purging  for 


7g6 


MEDICAL    RECORD. 


[November  17,  1900 


several  days,  and  paralysis  of  the  posterior  extremities, 
leading  nie  to  think  that  perhaps  lead  or  tinfoil  used 
in  packing  the  cheese  had  permeated  the  crust  and 
that  lead  poisoning  was  present;  but  my  mistake  was 
soon  apparent  after  testing  the  specimen.  A  small 
quantity  of  substance  given  off  was  precipitated  by 
an  alkali,  soluble  in  a  few  drops  of  ether,  and  on  add- 
ing platinum  chloride  a  yellowish  fiocculent  precipi- 
tate resulted,  indicating  an  alkaloid  similar  to  that 
which  is  found  in  ripened  cheese  undergoing  putrefy- 
ing process.  Of  the  chemical  nature  of  this  pyrotoxin 
we  know  very  little  as  yet,  although  intense  symptoms 
of  toxajmia  ensue  if  it  is  ingested.  It  is  frequently 
found  in  oysters,  milk,  and  cheese.  The  urine  was 
dark  and  high-colored;  the  feeces  contained  nothing 
abnormal  save  undigested  fat,  the  diet  of  the  boys 
being  largely  milk,  and  the  bacterium  coli  commune 
and  bacterium  lactis  aerogenes. 


J>iivfjicat  ^UDocstions. 

Contraindications  to  the  Use  of  the  Decinormal 
Salt  Solution  may  be  summed  up  as  follows:  Athe- 
roma, arteriosclerosis,  cardiac  degeneration,  bad  val- 
vular disease,  and  recent  cerebral  apoplexy. — Dr.  Ed. 
S.MITH,  American  Practitioner  ami  News,  October. 

Conservative  Operations  on  Ovaries  and  Tubes. 
— It  is  advisable  to  do  conservative  operations  in  all 
cases  in  which  the  ovaries  and  the  tubes  are  not  hope- 
lessly diseased  in  all  parts  of  their  structure,  except 
on  patients  who  are  near  the  menopause,  on  patients 
who  have  pronounced  gonorrhoea  of  long  standing,  and 
on  the  rare  cases  of  malignant  disase. — Eurroge. 

Ingrowing  Toe-Nail. — Remove  all  pressure  from 
the  nail  by  cutting  away  a  piece  of  the  shoe.  Disin- 
fect with  hydrogen  dioxide  until  no  more  "foam"  ap- 
pears. Apply  a  drop  of  strong  solution  of  cocaine  to 
the  base  of  the  ulcer.  Apply  a  drop  of  Monsell's 
solution  to  the  ulcer,  then  cover  loosely  with  gauze. 
Repeat  this  process  every  second  day  until  the  edge 
of  the  nail  is  released  by  the  retraction  of  the  hyper- 
trophicd  tissue. — Kinsman. 

Prognosis    of    Dislocations    at    the    Shoulder. — 

Don't  be  too  quick  to  promise  a  perfect  result  after 
dislocation  at  the  shoulder.  The  eircumliex  nerve 
passes  closely  around  the  surgical  neck  of  the  humerus, 
and  often  takes  serious  and  lasting  offence  at  the  trau- 
matism. Paralysis  of  the  deltoid  prevents  abduction 
of  the  arm,  permits  gradual  elongation  of  tiie  capsular 
ligament,  and  recovery  from  it  is  usually  slow  and  in- 
complete; hence  the  wisdom  of  a  lagging  prognosis. 
• — William  V.  Morgan. 

Cancer  of  the  Uterus. — Total  extirpation  of  the 
uterus  should  be  practised  in  all  cases  of  cancerous 
lesions  of  the  uterus  of  whatsoever  part,  for  this  pro- 
cedure gives  the  maximum  guarantee  against  the  re- 
turn. Total  extirpation  of  the  uterus  through  the 
vagina  deserves  the  preference  over  the  other  methods. 
— Demitri  De  Ott,  of  St.  Petersburg. 

Wounds  of  Veins  are  of  importance  both  on  ac- 
count of  the  immediate  and  the  remote  effects  they 
proiluce.  The  immediate  troubles  which  have  to  be 
dealt  with  are  {a)  dangerous  hemorrhage  and  (/')  entry 
of  air  into  the  vein.  The  remote  troubles  are  chiefly 
tlironibosis,  embolism,  pya'mia,  and  oedema  of  the  part 
corresponding  to  the  distribution  of  the  vein.  The 
immediate  troubles  are  more  common  in  connection 
with  operation  wounds,  the  remote  troubles  in  ac- 
cidental wounds. — Chevne  and  Bcrghard. 


Cervical  Metritis. ^It  is  necessary  neither  to  con- 
sider nor  to  treat  cervical  metritis  as  an  isolated  affec- 
tion, since  the  greater  number  of  cases  are  complicated 
by  a  similar  affection  of  the  fundus.  The  term  "  cer- 
vical metritis  "  should  in  the  majority  of  cases  be  re- 
placed by  that  of  cervical  endometritis,  since  tiie 
inflammation  of  the  mucosa  is  only  rarely  accompanied 
by  a  lesion  of  the  deeper  tissues. — Mendes  de  Leon, 
of  Amsterdam. 

Mouth  and  Pharynx   Wash. — 

If  Acid,  benzoic 3. 

Tinct.  eucalypt 15. 

Alcoholis 100. 

01.  menth.  pip 0.75 

M.      S.    Add  enough  to  half  a  wineglassful  of  water  to  pro- 
duce distinct  clouding.      Hold  in  moutli  Tor  one  minute. 

— Warren. 

Tuberculosis  of  the  Testis — -Early  castration  has 
returned  to  favor  and  is  justified  on  the  following 
grounds:  i.  It  is  the  most  speedy  form  of  treatment 
for  this  local  tuberculosis.  2.  It  is  a  rapid  treatment, 
which  avoids  pulmonary  and  meningeal  complications. 
3.  It  prevents  the  spread  of  tuberculosis  to  the  genital 
tract  of  the  opposite  side.  4.  It  causes  a  recession  of 
the  concomitant  vesiculo-prostatic  lesions. — R.  Bau- 

DET. 

A  New  Injection  Treatment  for  Bone  Tubercu- 
losis.— 

IJ  Sodii  sulphuret 1.46 

Sodii  chloratis 16.40 

Sodii  phosphat o.  50 

Sodii  carbonat o.  70 

Potass,  sulphuret o  94 

Aq.  destill  .    So.o 

M. 

This  fluid  is  injected  into  the  sinuses  by  means  of  a 
cannula  attached  to  a  Pravaz  syringe.  The  sinuses 
are  distended  with  the  fluid,  which  is  injected  until 
a  reflow  occurs.  After  all  the  sinuses  are  thus  cauter- 
ized a  ten-per-cent.  iodoform-ether  injection  is  made, 
and  a  moist  Priessnitz  applied. — C.  Trunecek. 

Vasectomy  for  Enlarged  Prostate. — Reginald  Har- 
rison, F.R.C.S.,  in  the  Alcdical  Fortnightly,  May,  de- 
duces the  following  conclusions:  (1)  That  vasectomy 
has  been  shown  to  be  specially  effectual  in  Ihe  earlier 
stages  of  prostatic  enlargement  in  effecting  shrinkage 
of  the  gland  and  the  restoration  of  the  natural  process 
of  micturition.  (2)  That  in  cases  in  which  there  is 
evidence  to  show  that  the  gland  has  in  the  course  of 
degeneration  assumed  the  form  and  structure  of  a 
fibrous  growth  the  conditions  are  such,  provided  the 
symptoms  of  obstruction  warrant  the  adoption  of  other 
measures  than  catheterism,  as  to  render  some  form  of 
prostatectomy  preferable  to  either  vasectomy  or  cas- 
tration. (3)  That  when,  as  a  consequence  of  sudden 
or  protracted  prostatic  obstruction,  secondary  changes 
have  taken  place  in  the  bladder  itself,  in  the  form  of 
sacs,  pouches,  or  trabeculation,  the  possibility  of  re- 
storing its  natural  function  by  any  means  is  extremely 
unlikely.  Under  such  circumstances  the  induction  of 
shrinkage  of  the  enlarged  gland  will  do  good  in  afford- 
ing a  readier  access  for  the  catheter  and  in  removing 
spasm,  pain,  or  hemorrhage  connected  with  this  or 
other  similar  process. 

Indications  for  Operation  in  Hernia.— Not  every 
case  of  hernia  requires  operation.  In  reducible 
hernia,  when  the  patient  can  wear  a  fruss  with  com- 
fort and  without  inconvenience  to  him,  in  the  perform- 
ance of  his  necessary  duties,  operation  for  hernia  is 
superfluous.  In  irreducible  hernia,  an  operation  is 
usually  indicated.  The  fact  that  the  hernia  is  almost 
sure  to  increase  in  size,  tlie  pain  and  dragging,  and 
weakness,  associated  with  the  presence  of  the  hernia, 


November  17,  1900] 


MEDICAL    RECORD. 


797 


diminish  the  patient's  abilit)'  for  work, -and  become 
indications  for  operation.  In  obstructed  and  strangu- 
lated hernia  operation  is  indicated  and  should  be  per 
formed  as  soon  as  the  diagnosis  has  been  made.  In 
children  under  four  years  of  age,  unless  the  hernia  is 
strangulated,  incarcerated,  or  irreducible,  operation  is 
to  be  avoided,  for  it  has  been  found  that  a  large  pro- 
portion of  these  patients  recover  within  the  first  three 
or  four  years  by  the  application  of  a  suitable  truss. — 
Charles  B.  Parker. 

Stitch  Abscesses. — Don't  always  blame  your  suture 
material  whenever  you  get  a  so-called  stitch  abscess. 
The  great  majority  of  these  are  not  at  all  due  to  the 
sutures,  but  to  the  fact  that  there  has  been  an  infection 
due  to  the  existence  of  no-xious  organisms  in  the  deeper 
cutaneous  layers,  which  cannot  always  be  removed  by 
the  most  thorough  and  most  conscientious  scrubbing. 
Careful  washing  with  green  soap  and  alcohol,  followed 
by  a  large  wet  dressing  of  bichloride  applied  the  day 
before  an  operation,  will  greatly  diminish  the  num- 
ber of  these  generally  miscalled  stitch  abscesses. — 
Howard  Liliexthal. 


Flatulent  Dyspepsia. — 

li  Magnesia, 

Phosphate  of  lime, 

Powd.  charcoal. 

Sulphur  sublini aa  lO 

M.     S.    Teaspoonful  in  water  as  required. 

Or— 

If  Olei  creosoti H  xij. 

Spir.  tenuioris 3  ss. 

Ammonii  benzoatis 3  ij- 

Glycerin! 3  vi. 

Infusi  caryophylli q.s.  ad  ;  vi. 

M.     S.   Teaspoonful  in  water. 

— Richardson. 
Hemorrhoids. — 

If  Vaseline 5  i- 

Muriate  of  cocaine gr.  xij. 

Morphine gr.  vi. 

Calomel S"";  "'■. 

M.     S.   -Vpply    locally    night    and    morning.      If   itching  is 
severe  apply  menthol,  one  drachm  to  an  ounce  of  vaseline. 

— Joseph  M.  Matthews. 
Prostatic  Disease. — 

^  Tr.  aconite 3  i- 

Tr.  gelsemium 1  ij. 

Antipyrin 3  ij- 

Ergotol 3  i- 

Water q  s.  ad  I'lv. 

M.     S.  Give  a  dessertspoonful  in  a  wineglass  of  water  every 
one,  two.  or  three  hours. 

— Eugene  R.  Corson. 

Spray  for  a  Room  Occupied  by  a  Consumptive. 
— Free  ventilation  should  be  used  in  addition. 

If  Guaiacol 3  ij- 

Eucalyptol 3  ij- 

Menthol 3  i. 

Thymol 3  ss. 

Ol.  gaulther 3  vij. 

Ol.  menth.-e  pip q.  s.  ad  f1.  §  i. 

— Dr.    O.   F.    Baerens,    Regular   Medical    Visitor, 
October  15th. 

Cerebro-Spinal  Fever.  — In  the  treatment  of  cere- 
bro-spinal  fever,  as  in  so  many  other  diseases,  various 
remedial  agents  are  lauded,  but  until  the  value  of 
something  new  has  been  more  clearly  demonstrated, 
good  nursing,  easily  assimilable  nutriment  in  plenty, 
a  quiet  and  darkened  room  for  the  patient,  intelligent 
hydrotherapy,  and  the  bromide  of  potassium  will  be, 
it  seems  to  me,  our  mainstays. — Dr.  F.  B.  Mavnard, 
Albany  Medical  Annals,  November. 


Dysentery. — 

V,  I'otass.  et  sod.  tart. ,  sat.  sol 3  ij. 

Tinct.  opii.  camph 3  ss. 

Syr.  rhei  aromat q.s.  ad  3  iv. 

M.     S.   Two  teaspoonfuls  every  hour. 

This  should  be  given  until  two  or  three  evacuations 
are  produced.  In  later  stages,  when  there  is  much 
blood  and  tenesmus,  a  suppository  is  recommended  of 

If  Kxt.  opii gr-  ' 

Ext.  hyoscyami gr.  ij- 

Ext.  belladonna: gr.  \% 

to  be  repeated  if  necessary. — R.  B.  Hopkins. 
Nutritive  Enemata  after  Abdominal  Section. — 

If  Peptonized  milk 30  c.c. 

\Yhiskey 30   '" 

The  whites  of  two  eggs. 

Common  table  salt gr.  xxiv. 

The  rectum  should  be  thoroughly  irrigated  every 
morning  with  warm  physiological  salt  solution,  which 
will  keep  it  clean  so  that  the  nutritive  enemata  will 
be  better  absorbed. —  Hcnter  Ror-n. 

Indications  for  the  Use  of  Lavage. —  (i;  To  re- 
move undigested  food  and  foreign  matters;  (2)  to 
cleanse  the  mucous  membrane  for  the  action  of  medi- 
cines; (3)  to  check  hemorrhage;  (4)  to  give  antiseptic 
douchings;  (5)  for  sedative  purposes;  ( 6)  for  general 
tonic  effects  upon  the  gastric  mucous  membrane  and 
parietes. —  Dr.  J.  M.  G.  Carter,  Medical  Fortnightly, 
October  loth. 

Reflex  Vomiting  in  Children. — 

If  Olei  absinthii gtt.  -^j 

.Sodii  bicarb gr.  ij- 

Aq.  nientha;  piperitse 3  i. 

S.   Every  half-hour  until  relieved. 

— Dillon  Brown. 
Dysentery. — 

If  Olei  ricini 5  i. 

Tincturse  ipecacuanhuDe  comp 3  ij- 

Sacchar.  alb;e 3  ij- 

Pulveris  acacia? 3  iij- 

Aqua;  menth q.s.  ad   3  iv. 

M.     S.  A  teaspoonful  every  two  to   three  hours  when  the 
case  is  first  seen. 

This  tends  to  relieve  the  irritability  of  the  inflamed 
bowel  and  carries  away  the  concretions  of  fseces. — E. 
H.  Bavley,  Medical  Dial,  October  loth. 

Condylomata. — 

If  Calomel 30  parts. 

Boric  acid iS     " 

Salicylic  acid 5     " 

S.   Apply  three  times  a  day. 

—  Gazette  Hebdomadaire  de  Mcdeciiie  et  de  Chirurgie, 
July  22d. 

Lobar  Pneumonia. — Pain  is  the  most  prominent 
symptom,  and  the  relief  of  it  is  important.  The  most 
rational  thing  to  do  is  to  immobilize  that  side  of  the 
chest  and  apply  warm,  soothing  poultices.  If  neces- 
sary, a  small  amount  of  morphine  may  be  allowed. 
The  treatment  is  practically  expectant,  but  the  follow- 
ing may  be  allowed  in  some  cases: 

"B,  Tincturre  aconiti "l  i. 

Tincture  digitalis "l  iij. 

Spiritus  frumenti 3  iij. 

S.   This  is  to  be  taken  ever)-  three  hours. 

— Louis  F.  Bishop,  The  Medical  Times,  October. 

Hiccup. — Even  in  cases  of  the  gravest  organic 
lesion,  it  is  sometimes  possible  to  relieve  the  symp- 
tom by  some  of  the  following  methods:  (i)  Holding 
the  breath  for  fifteen  or  more  seconds;  (2)  adminis- 
tration of  quick-acting  emetics  (though  too  great  de- 
pression from  these  must  be  thought  of),  or  peristaltic 
stimulants;     (3;    hot   applications   over    the   cervical 


798 


MEDICAL    RECORD. 


[November  17,  1900 


spine  and  diapnTagmatic  area;  (4)  firm  pressure  upon 
the  phrenic  nerve  over  the  scalenus  amicus  muscle; 
(5;  rapid  swallowing  of  small  pieces  of  ice;  (6Mhe 
use  of  such  antispasmodic  drugs  as  morphine,  or 
chloroform,  in  full  dosage  (the  bromides,  camphor, 
belladonna,  valerianates,  antacids,  and  musk  have 
been  advocated,  but  are  commonly  too  slow  in  action 
for  severe  cases)  ;  (7)  traction  on  the  tongue,  inter- 
mittently applied,  as  in  chloroform  poisoning;  (8) 
galvanization  of  the  phrenic  nerve;  (9)  faradization 
of  the  epigastric  region  (Krb);  (10)  forcible  elevation 
of  the  liyoid  bone  by  the  attendant's  fingers  iNoth- 
nagel);  (11 )  the  method  described  by  Kingscote,  in  his 
work  on  asthma,  1899. —  The  Medical  World,  Novem- 
ber. 

Carbonic  Acid — In  an  article  on  the  "'  Carbonic 
Acid  Aerostat "  {/oiirnal  0/  Surgical  Technology,  Au- 
gust) Dr.  A.  Rose  sums  up  as  follows:  Carbonic-acid 
gas  e.xerts  a  feeble  antiseptic  action  and  also  an  anes- 
thetic action,  especially  upon  mucous  membranes. 
It  exercises  a  stimulant  action  on  the  enfeebled  heart. 
By  the  operation  of  the  law  of  the  diffusion  of  gases 
it  increases  the  amount  of  o.\ygen  in  the  pulmonary 
alveoli.  It  relieves  dyspncta  and  cough,  and  disem- 
barrasses the  respiration.  It  stimulates  ulcerated  sur- 
faces to  healthy  processes  of  repair;  while  for  diag- 
nostic purposes  it  forms  an  easily  available  method  of 
inflating  the  cavities  of  the  body. 

Variola — The  treatment  of  variola  is  based  upon 
the  same  scientific  principles  that  dictate  the  rational 
treatment  of  all  other  pathological  processes  going  on 
in  the  human  system.  It  consists  in  sterilizing,  so 
far  as  possible,  the  invading  microbe,  sustaining  the 
vital  force  with  all  the  necessary  food,  and  in  keep- 
ing all  of  the  secretions  and  excretions  as  near  normal 
as  possible.  —  E.  E.  Gilmore,  Kansas  City  Medical 
Record,  September. 


^cdicat  Items. 

Contagious    Diseases — Weekly   Statement Report 

of  cases  and  deaths  from  contagious  diseases  reported 
to  the  Sanitary  Bureau,  Health  Department,  for  the 
week  ending  November  10,  1900: 


Tuberculosis 

Typhoid  fever 

Scarlet  fever 

Measles 

Diphtheria 

Laryngeal  diphtheria  (croup) 
Cerebro-spinal  meningitis. .  . . 

Varicella 

Smallpox   


Cases. 

Deaths. 

250 

■59 

90 

27 

93 

4 

45 

0 

212 

27 

II 

7 

<) 

6 

15 

0 

I 

0 

Meningitis  Complicating  Pneumonia,  with  Re- 
covery.—  Dr.  T.  C.  Ely  {Pennsylvania  Medical  Jour- 
nal, October)  reports  a  case  of  meningitis  complicat- 
ing pneumonia,  with  recovery:  the  points  of  more 
than  usual  interest  he  summarized  as  follows:  (1) 
The  recovery  from  pneumonia  complicated  by  menin- 
gitis, a  rare  issue.  (2)  The  striking  clinical  resem- 
blance to  cerebro-spinal  fever  in  its  late  phenomena, 
which  calls  forth  the  query  whether  lumbar  puncture 
is  aijsolutely  essential  to  difTerentiate  such  cases  or 
whether  the  clinical  history  is  not  sufficient.  13)  The 
mixed  form  of  pneumonia,  of  croupous  type,  becom- 
ing lobular;  a  pneumonia  which  might  have  termi- 
nated by  crisis  as  a  croupous  form  had  not  pyogenic 
organisms  co-operated   in  a    soil    likely  tuberculous. 


(4)  The  family  history,  personal  history,  and  some 
aspects  of  the  clinical  course  point  to  tuberculous 
meningitis,  which,  contrary  to  the  general  belief, 
ended  in  recovery.  This  leads  to  the  question.  May 
not  some  local  cases  of  tuberculous  meningitis  ter- 
minate favorably,  just  as  local  tuberculosis  in  other 
parts  of  the  body  may  heal?  (5)  In  any  case  on  ac- 
count of  the  uncertainty  of  diagnosis  of  tuberculous 
meningitis,  the  scientific  inaccuracy  of  calling  a  case 
tuberculous  meningitis  because  it  terminates  fatally, 
or  some  other  form  of  meningitis  because  there  is  re- 
covery, is  open  to  criticism.  (6)  No  case  of  menin- 
gitis should  be  despaired  of  simply  because  there  is  a 
suspicion  of  tuberculous  infection. 

Fracture  of  the  Spine. — Dr.  Walter  Lathrop,  in 
the  Pennsylvania  Medical  Journal,  October,  summa- 
rizes an  article  on  this  subject  as  follows:  (1)  In  par- 
tial lesions  we  should  operate.  (2)  When  the  lumbar 
region  is  involved,  with  lesions  of  the  cauda  equina, 
operation  ofifers  the  best  chance  for  recovery,  (3)  In 
fracture  of  the  spinous  process,  lamina,  or  entire 
neural  arch,  operation  is  demanded.  (4)  Should  im- 
mediate operation  not  be  done,  and  we  wait  six  to 
eight  weeks,  with  the  result  that  paralysis  of  the  blad- 
der and  bowels  continues,  with  cystitis  and  severe  bed 
sores  present,  we  may  be  sure  that  nature  cannot  re- 
lieve the  case,  and  an  operation  is  not  only  indicated, 
but  demanded. 

Gingivo  -  Stomatitis      with     Albuminuria.  —  Dr. 

Charles  Lee,  in  the  British  Dental  Journal.  September, 
concludes  an  interesting  article  on  this  subject  as 
follows:  (I)  L'lcerative  membranous  stomatitis  in 
patients  suffering  from  Bright's  disease  is  a  polymi- 
crobic septic  stomatitis  which  may  be  classed  with  the 
variety  of  septic  stomatitis  described  by  Dr.  Lebedin- 
sky;  (2)  such  a  stomatitis  may  pass  through  various 
conditions;  it  may  be  erythematous,  then  ulcero-mem- 
branous,  or  even  gangrenous;  (3)  the  stomatitis  of 
albuminuria  commences  almost  always  on  a  level 
with  carious  teeth  or  infected  stumps;  (4)  those  who 
are  suffering  from  albuminuria  may  safely  avoid 
stomatitis  if  their  mouths  are  kept  in  a  hygienic  con- 
dition. 

Physical  Training — its   Range  of   Usefulness  in 

Therapeutics — Dr.  B.  E.  McKenzie,  in  the  Canadian 
Journal  of  Medicine  and  Surgery,  November,  simima- 
rizes briefly  as  follows:  (i)  Special  physical  training  is 
rendered  necessary  for  the  young  by  the  conditions  of 
modern  life.  (2)  The  work  is  made  special  and 
scientific,  having  for  its  object  the  development  and 
strengthening  of  every  organ  and  faculty  of  the  patient, 
(3)  .\s  we  conduct  this  work  it  is  mainly  educative. 
Force  from  without  the  patient,  however,  is  largely 
employed  with  such  as  cannot  of  their  own  volition 
correct  the  deformity.  To  name  the  aftections  benefited 
in  the  order  in  which  good  results  have  been  observed 
I  would  place  them  thus:  Hysteria,  roto-lateral  curva- 
ture. Hat  foot,  round  shoulders,  pigeon-breast.  Hat 
chest,  anaemia,  paretic  weakness,  chorea,  imbecility. 
In  this  list  I  have  placed  hysteria  first,  because  I  have 
not  known  any  method  by  which  this  condition,  gener- 
ally so  unsatisfactory  to  deal  with,  has  been  brought 
so  successfully  under  control. 

The  Operative  Treatment  of  Complete  Prolapse 
of  the  Uterus  in  Elderly  Women. —  Dr.  A.  Lapthom 
Smith,  in  the  Maritime  Medical  Nc'ius,  October,  comes 
to  the  following  conclusions:  (i)  That  a  woman  suf- 
fering from  procidentia  or  prolapse  of  the  uterus  out 
of  the  body,  though  not  in  much  pain,  is  yet  very  mis- 
erable, (2)  She  is  in  some  danger,  owing  to  the  cer- 
vix becoming  ulcerated  and  the  ulceration  frequently 
becoming   cancerous,     (3)    It    is  a   mistake  to  think 


November  17,  1900] 


MEDICAL    RECORD. 


799 


that  she  is  too  old  to  undergo  an  operation  because 
she  is  forty-five,  or  fifty,  or  even  seventy-five  years  of 
age.  (4)  Elderly  women  support  the  operations  re- 
markably well ;  the  operations  require  only  from  twenty 
to  thirty  minutes  for  performance ;  and  even  if  we  knew 
that  the  patients  were  going  to  live  only  a  year  after- 
ward, it  would  be  well  worth  while  operating  for  the 
sake  of  the  comfort  it  affords  them.  (5)  The  opera- 
tion of  vaginal  hysterectomy  is  especially  easy  and 
safe  in  these  cases,  having  not  more  than  one  per  cent, 
of  mortality  and  probably  not  even  that.  (6)  Ventro- 
'  fixation  gives  good  results  when  the  uterus  is  short, 
but  fails  when  it  is  long.  In  some  cases  the  vagina 
and  bladder  pull  down  and  elongate  the  cervix  after 
the  fundus  has  been  firmly  attached  to  the  abdominal 
wall.  (7)  In  either  case,  whether  hysterectomy  or 
ventrofixation  be  employed,  it  should  always  be  fol- 
lowed by  an  anterior  and  posterior  colporrhaphy. 
(8)  These  patients  should  remain  in  bed  for  six  weeks 
after  their  operation,  in  order  to  give  time  for  the  new 
tissue  to  become  strong. 

Tertian  iEstivo-Autumnal  Parasite  and  the  Quo- 
tidian Parasite The  tertian  a^stivo-autumnal  para- 
site differs  from  the  quotidian  parasite  in  the  follow- 
ing particulars:  (i)  During  the  hyaline  stage — the 
rings  are  larger,  being  from  one-eighth  to  one-fourth 
the  size  of  the  infected  corpuscle;  the  signet-ring 
shape;  the  sluggish  amoeboid  motion;  the  clear-cut 
and  refractive  outline;  the  less  wrinkled  and  lighter 
green  infected  corpuscle;  the  occurrence  of  only  one 
parasite  in  the  infected  corpuscle.  (2)  During  the 
pigmented  stage — the  larger  size,  one-half  of  the  cor- 
puscle; the  pigment  ring  forms;  the  continuance  of 
amttboid  motion  ;  more  sharply  defined  and  refractive, 
and  the  granular  protoplasm;  the  finely  granular  pig- 
ment, which  is  motile;  the  occurrence  of  only  one 
parasite  in  a  corpuscle,  and  the'lighter-colored,  seldom 
crenated  infected  corpuscle.  (3)  During  the  seg- 
menting stage — the  occurrence  of  segmentation  outside 
the  corpuscle;  the  number  of  segments,  ten  to  fifteen. 
(4)  The  larger,  more  narrow,  more  deeply  pigmented 
crescents  seldom  showing  a  double  outline.  (5)  The 
cycle  of  development,  forty-eight  hours. — Dr.  Charles 
F.  Craig,  m  Journal  oJ  the  Attur.  Aled.  Ass'n,  Novem- 
ber 3,  1900. 

Spinal  Anaesthesia.  —  I  would  limit  the  indications 
for  its  applications  at  the  present  moment:  (i)  To 
adults,  and  to  reasonable  persons  who  have  good  self- 
control,  thereby  excluding  children,  hysterical  pa- 
tients, and  the  insane;  (2)  to  patients  in  whom  the 
methods  of  local  or  regional  ana'sthesia  are  inap- 
plicable; (3)  to  patients  suffering  from  emphysema, 
advanced  asthma,  chronic  bronchitis,  and  other  re- 
spiratory affections  in  whom  a  general  inhalation  an- 
aesthetic is  absolutely  contraindicated;  in  advanced 
cardiac  cases  with  degenerative  lesions,  I  would  fear 
the  possible  depressing  effects  of  the  injection  and 
excitement  on  the  circulation.  (4)  In  the  majority 
of  cases  in  which  the  painful  part  of  the  operation 
is  not  likely  to  be  prolonged  beyond  one  hour  and  a 
half,  as  I  would  be  averse,  in  the  present  state  of  our 
knowledge,  to  repeat  a  second  cocainization  or  to  in- 
crease the  total  dose  of  the  cocaine  to  more  than  2  c.c, 
especially  in  exhausted  subjects.  —  Dr.  Rudolph 
Matas.  in  the  Pliila.  Med.  Journal,  November  3,  1900. 

Interstitial    Keratitis The    points   that    require 

emphasizing  are:  (O  That  treatment  supports  the  be- 
lief, now  almost  universal,  that  interstitial  keratitis 
in  childhood  is  a  manifestation  of  hereditary  syphilis; 
(2)  that  it  maybe  the  only  recognizable  manifestation 
of  the  hereditary  taint,  though  other  well-known  mani- 
festations are  often  present  as  well ;   (3)  that  prolonged 


constitutional  treatment  is  necessary  to  obtain  a  satis- 
factory result — the  result  being  nearly,  if  not  always, 
satisfactory  if  constitutional  treatment  is  thorough  and 
prolonged;  (4)  that  constitutional  treatment  by  mer- 
cury is  not  only  very  well  borne  but  the  general  health 
is  improved  under  it;  (5)  that  the  second  eye  may  be- 
gin to  have  an  attack,  and  even  proceed  to  have  a 
severe  one  in  spite  of  the  fact  that  the  system  has  been 
for  months  under  the  influence  of  mercury,  which  has, 
indeed,  been  the  cause  of  the  recovery  of  the  eye  first 
attacked  as  well  as  of  increased  bodily  health,  and 
which  will,  if  persevered  in,  cause  the  recovery  of  the 
second  eye  also. — Dr.  J.  Lockhart  Gibson,  in  The 
Australasian  Med.  Gazette,  September  20,  1900. 

Papilloma  of  the  Larynx  in  Children. — Dr.  Ed- 
ward T.  Dickerman,  in  the  Journal  oj  tlie  American 
Medical  Association,  October  27,  1900,  offers  the  follow- 
ing conclusions  in  an  article  on  this  subject:  (i)  That 
papilloma  of  the  larynx  is,  especially  in  this  country, 
a  rare  disease;  (2)  in  a  number  of  cases  papillomata 
undergo  spontaneous  cure;  (3)  intralaryngeal  methods 
should  always  be  tried  first,  unless  dyspnci-a  is  pro- 
nounced, when  tracheotomy  should  be  done  at  once; 
(4)  after  tracheotomy,  intralaryngeal  methods  should 
be  tried;  (5)  patients  should  wear  a  tube  six  months 
after  the  growth  has  disappeared;  (6)  thyrotomy 
should  be  considered  only  as  a  last  resort. 

A   Few  Points  on    Appendicitis Dr.   J.    Henry 

Barbat,  in  the  Journal  oJ  the  American  Medical  Asso- 
ciation, October  27,  1900,  concludes  as  follows:  (i) 
That  over  ninety  per  cent,  of  cases  of  true  appendicitis 
which  are  not  operated  on  have  recurrences;  (2)  that 
we  should  operate  on  all  cases  of  chronic  recurrent 
appendicitis,  if  possible  between  attacks;  (3)  that  in 
practically  all  cases  which  end  fatally  after  operation 
we  find  at  least  forty-eight  hours  between  the  onset  of 
the  attack  and  the  time  of  operation,  therefore  it  is 
reasonable  to  assume  that  if  these  cases  had  been  oper- 
ated upon  inside  of  the  forty-eight  hours  the  patients 
would  have  been  cured;  (4)  that  as  soon  as  a  diag- 
nosis of  acute  appendicitis  is  made,  we  should  operate 
immediately;  (5)  pulse  and  temperature  are  not  to  be 
taken  into  consideration  in  making  a  diagnosis  of  ap- 
pendicitis; (6)  in  acute  cases  the  diagnosis  must  be 
based  on  the  symptoms  which  were  manifested  during 
the  first  three  or  four  hours. 

Cancer  of  the  Uterus  and  its  Treatment.— Dr. 
Stansbury  Sutton,  in  the  Jnternational  Journal  oJ  Sur- 
gery, November,  states  his  views  from  the  standpoint 
of  a  mathematical  problem  as  follows:  Given  one 
hundred  cases  of  uterine  cancer  treated  by  vaginal 
hysterectomy;  result,  four  deaths,  ninety-six  recover- 
ies. Credit  the  latter  with  an  average  of  two  years  of 
life  after  the  operation;  thus  we  have  the  result:  gain 
in  human  life,  one  hundred  and  ninety-two  years. 
Given  the  same  one  hundred  cases  subjected  to  vagi- 
nal hysterectomy  from  two  to  three  years  earlier,  prior 
to  the  advent  of  cancer;  result,  deaths,  four:  recov- 
eries, ninety-six.  Credit  the  latter  with  an  average 
of  ten  years  of  life  after  the  operation;  thus  we  have 
the  result:  a  gain  of  nine  hundred  and  sixty  years  of 
human  life.  Take  the  difference  in  these  results,  viz., 
seven  hundred  and  sixty-eight  years  of  human  life,  in 
favor  of  prophylactic  operating,  viz.,  operating  before 
cancer  has  become  installed. 

Gall-Bladder  Surgery. — Dr.  A.  Vander  Veer  in  the 
International  Journal  oJ  Surgery,  November,  makes  the 
following  final  conclusions:  (1)  An  early  diagnosis 
of  cases.  (2)  In  suppuration  of  the  bladder,  with 
adhesions,  a  most  thorough  examination  should  be 
made  from  within  by  digital  exploration,  and  the  use 
of  the  probe  for  any  possible  deep-seated  calculi.     (3") 


8oo 


MEDICAL    RECORD. 


[November  17,  1900 


In  prolonged  operations  upon  the  common  duct  or 
hepatic  ducts,  when  adhesions  are  present  and  it  is 
difficult  to  close  the  incision  after  removal  of  the 
calculus,  drainage  through  the  peritoneal  pouch,  by 
means  of  the  lumbar  stab,  is  advisable.  (4)  When 
the  patient  is  suffering  seriously  from  chola;mia,  with 
marked  ecchymotic  spots  over  the  body,  intense  itch- 
ing, and  an  examination  of  the  blood  discloses  a  sep- 
tic condition,  an  operation  is  not  to  be  encouraged. 
It  is  too  late,  in  the  vast  majority  of  cases,  for  the 
patient  to  recover.  (5)  General  practitioners,  as  well 
as  the  surgeon,  should  place  more  earnestly  before  the 
patient  and  friends  the  dangers  of  repeated  attacks  of 
gall-stone  irritation  resulting  in  cancer  of  the  ducts, 
stomach,  or  liver. 

Tuberculous  Lesions  from  a  Clinical  Point  of 
View. — Edmund  Owen,  M.B.,  F.R.C.S.,  in  the  Canada 
Ahdical  Record,  September,  makes  the  following  state- 
ments: "  (i)  Chronic  inflammation  of  a  joint  in  a  child 
or  young  person  is  always  tuberculous — except  in 
those  very  rare  cases  in  which  it  is  due  to  hereditary 
syphilis  or  osteo-arthritis.  (2)  Tuberculous  inflam- 
mation may  completely  destroy  a  joint,  and  then  leave 
it  solidly  and  soundly  synostosed,  without  the  sur- 
rounding tissues  or  the  skin  having  been  implicated. 
(3)  If  tuberculous  granulation  tissue  breaks  down 
into  a  fluid,  that  fluid  is  not  pus,  and  the  collection  is 
not,  properly  speaking,  an  abscess — unless,  by  bad 
fortune  or  by  worse  surgery,  it  has  become  infected 
by  septic  micro-organisms.  (4)  The  fluid  collection 
is  not  to  be  treated  as  an  abscess — by  incision  and 
drainage,  that  is — but  is  to  be  opened  and  emptied 
and  scraped  and  cleansed  of  its  unhealthy  lining  of 
granulation  tissue.  Then  the  wound  in  the  skin  is  to 
be  completely  closed  by  sutures;  firm  pressure  is  to 
be  evenly  applied  and  the  part  is  to  be  kept  absolutely 
at  rest.  It  is  no  news  to  most  of  you  to  be  told  that 
the  success  attending  this  line  of  treatment  leaves,  as 
a  rule,  little  to  be  desired,  or  that  for  this  important 
advance  in  practical  surgery  we  are  chiefly  indebted  to 
the  patient  researches  of  our  friends  with  the  smock- 
frocks  and  the  guinea-pigs.  (5)  I  have  failed  to  dis- 
cover that  iodoform  is  of  any  peculiar  value  in  the 
treatment  of  tuberculous  lesions.  At  any  rate  I  have 
long  since  discarded  it,  and  I  have  not  noticed  any 
falling  off  in  the  results  of  my  practice  in  consequence. 
Iodoform  is  an  irritant  and  a  poison;  it  is  apt  to  be 
septic,  as  germs  can  grow  upon  it,  but  I  have  no 
knowledge  of  the  truth  of  the  statement  that  mush- 
rooms have  actually  been  cultivated  on  it." 

Field  Hospitals  in  War. — Mr.  Frederick  Treves, 
who  we  understand  will  shortly  publish  a  book  upon 
ambulances,  the  subject-matter  of  which  will  have 
been  gathered  from  his  experiences  in  South  Africa, 
read  a  paper  at  the  late  meeting  of  the  British  Medi- 
cal ."Association  treating  of  army  medical  matters  in 
general.  He  said  that  the  South  .African  campaign 
had  shown  the  value  of  a  large  mobile  field  hospital 
(taking  three  hundred  to  six  hundred  patients),  which 
should  immediately  follow  the  colors;  such  a  hospital 
to  have  its  own  transport.  The  campaign  had  also 
demonstrated  the  fact  that  the  field  hospital  was  no 
place  for  the  female  nurse,  but  that  in  the  base  hospi- 
tals they  might  be  increased  with  advantage.  When 
nurses  were  lacking,  the  orderly  had  to  take  their 
places,  and  he  is  an  almost  impossible  person.  He 
had  to  do  manual  labor  as  pitching  tents,  digging 
trenches,  and  then  nurse  complicated  cases.  Mr. 
Treves  also  urged  the  formation  of  an  army  medical 
reserve,  by  inducing  recently  qualified  medical  men 
to  agree  to  serve  for  three  years,  one  with  the  colors 
and  two  with  the  reserve.  This  reserve  would  be 
called  upon  only  in  time  of  war,  and  would  enable  the 


army  medical  department  to  avail  itself  of  a  body  of 
specially  trained  medical  men,  who,  from  its  point  of 
view,  would  have  the  advantage  of  an  army  training. 
He  was  of  the  opinion  that  the  services  of  men  thus 
trained  would  be  more  valuable  than  those  of  a  num- 
ber of  civilian  surgeons  chosen  more  or  less  irrespec- 
tive of  their  qualifications.  Mr.  Treves'  plan  might 
commend  itself  to  the  adoption  of  our  military  author- 
ities. 

Health  Reports. — The  following  cases  of  smallpox, 
yellow  fever,  cholera,  and  plague  have  been  reported 
to  the  surgeon-general  of  the  United  States  Marine- 
Hospital  service  during  the  week  ended  November  9, 
1900 : 

Cases.    Deaths. 

Smallpox— United  States, 

Colorado.  Arapahoe  Co October  13th  to  2slh s 

Elbcr  Co October  1 9th i 

Saguache  Co. . . .  October  14th i 

District  of  Columbia,  Wash- 
ington   November  3d 1 

Kansas,  Wichita October  27th  to  November  3d. .. .  3 

Kentucky,  Lexington October  27th  to  November  3d 2 

Louisiana,  New  Orleans    ..  .October  27th  to  November  3d 2 

Massachusetts,  Taunton October  27th  to  November  3d ... .  i 

Michigan,  Detroit October  27th  to  November  3d.. ..  i 

<-)hio,  Cleveland October  28th  to  November  3d i 

Oregon.  Portland October  31st  i 

South  Dakota,  Sioux  Falls.. Six  months  ended  October  31st  ..  1 

Utah,  Salt  Laice  City October  27th  to  November  3d  ...  5 

I'ennessee,  Memphis October  27th  to  November  3d 1 

Smallpox — Foreign. 

Bohemia.  Prague October  1 5th  to  20th  2 

England,  Liverpool October  13th  to  20th 2 

West  Hartlepool.  .October  13th  to  20th i 

France,  Paris October  13th  to  20th ix 

Oreece,  Athens October  6th  to  13th i 

1  taly.  Resina October  24th • 

Mexico,  Mexico October  14th  to  21st i 

Vera  Cruz October  2olh  to  27th 3  i 

Russia,  Moscow October  6th  to  13th 1  2 

Odessa October  J3th  to  20th 4 

Warsaw October  6th  to  13th 

Scotland,  Glasgow October  xoth  to  76th 29 

Spain October  13th  to  20th 

♦  Black  smallpox  reported  present. 

Yellow  Fever— United  States. 
Mississippi,  Natchez November  6th 1 

Yellow  Fever — Foreign  and  Insular. 

Colombia,  Barranquilla October  13th  to  21st 2 

Bocas  del  Toro. .  .October  24th I 

Cuba,  Gibara October  i6th 

Havana November  2d i6 

Sagua November  2d i 

Mexico,  Mexico    October  14th  to  21st 

Tampico Oetober  21st  to  28th 3 

Vera  Cruz October  20th  to  27th 12 

Cholera. 

India,  Bombay October  9th 

Karachi October  7th 3 

Plague — United  States. 
California,  San  Francisco. .  .October  13th  to  November  6th 

Plague— Foreign  and  Insular. 

Germany.  Bremen November  6th * 

India,  Bombay October  2d  to  glh 

Japan,  Kobe November  2d   t 

Osaka September  nth  to  October  7th. . .  25 

Mauritius,  Port  Louis September  7th 7 

Scotland,  Glasgow October  19th  to  26th 10 

♦  One  death  from  plague,  a  seaman  on  a  vessel  from  Buenos  Ayres. 
+  Reported  present. 


4 
iS 


87 


^oofes  ^ecctuccl. 

Whilt  the  Medical  Record  is  f  leased  lo  receive  all  new  pub- 
lications which  may  be  sent  to  it^  and  an  acknowledgment  will  be 
promptly  made  of  their  receipt  under  this  heading,  it  iiiust  be  with 
the  distinct  understatiding  that  its  necessities  are  such  that  it  can- 
not be  considered  under  obligation  to  notice  or  review  any  publica- 
tion received  by  it  which  in  the  judgment  of  its  editor  will  not  be 
of  interest  to  its  readers. 

.\  Practical  Treatise  on  Medical  Diagnosis  for  Sri- 
iiENT  AND  Physicians.  By  John  II.  Musser.  M.D.  Svo.  1,105 
p.igcs.  Illustrated.  Lea  Hrothers  &  Co. ,  Philadelphia  and  New 
York. 

Malaria.  By  Prof.  Angclo  Celli.  Svo.  275  pages.  Illus- 
trated.     Longmans,  Green  cS:  Co.,  London,  England. 

Terai'IA  dei.le  Malattie  dell'  Infanzia.  By  Prof.  Cesare 
Cattaneo.     i6mo,  507  pages.     Ulrico  Moepli,  Milano,  Italy. 

I".  Bkrgek's  French  Method.  i6nio,  igo  pages.  P.iris, 
Trance. 


Medical  Record 

A    Weekly  yoiirnal  of  Medicine  and  Surgery 


Vol.  58,  No.  21. 
Whole  No.  1568. 


New  York,   November   24,  1900. 


$5.00  Per  Annum. 
Single  Copies,  loc. 


©riQiiiaX  Articles. 

ON    APPARENT    TUMORS    OF    THE    ABDO- 
MEN.* 

By    max    EINIIORN,    M.D., 

FKOPESSOR  OF  MEDICINE  AT  THE  NEW  VORK  POST-GRADUATB  MEDICALSCHOOL, 
NEW   VOttK. 

About  two  years  ago  I  had  the  opportunity  to  present 
to  the  Society  of  Physicians  of  the  German  Hospital 
and  Dispi:nsary  of  New  York  a  patient  with  a  tumor 
in  the  epigastric  region,  that  could  be  distinctly  and 
plainly  palpated.  I  remarked  at  the  time  that,  in 
spite  of  the  resistance  which  could  be  easily  felt,  w^e 
did  not  have  to  deal  with  a  possible  neoplasm,  but  that 
a  somewhat  abnormal  position  of  the  abdominal  vis- 
cera was  the  cause  of  tliis  deceptive  tumor. 

Now,  gentlemen,  these  cases  of  apparent  tumors  as 
they  may  be  called — i.e.,  tumors  easily  palpated,  not 
caused  by  real  neoplasms,  however,  but  by  an  abnor- 
mal position  of  the  abdominal  viscera  or  an  abnormal 
condition  of  parts  of  the  abdominal  muscles^ — are  not 
so  very  rare,  and  it  would  perhaps  be  of  interest  to  in- 
vestigate them  a  little  more  closely.  We  do  not  find 
much  in  medical  literature  upon  this  subject. 

Da  Costa'  says  in  his  book  on  "  Medical  Diagnosis," 
p.  653:  "The  muscular  contractions  are  not  always 
confined  to  one  muscle,  or  to  the  whole  of  one  muscle, 
and  when  irregular,  and  particularly  when  associated 
with  tympanitic  distention  of  the  intestine,  give  rise  to 
most  of  tlie  so-called  '  phantom  tumors '  of  the  abdo- 
men. These  swellings  are  perplexing  and  are  con- 
stantly mistaken  for  serious  abdominal  tumors.  The 
history  of  the  case,  the  absence  of  grave  constitutional 
symptoms,  the  most  frequent  occurrence  of  the  tume- 
faction in  females,  especially  in  hysterical  females, 
and  the  usually  coexisting  constipation,  furnish  us 
with  valuable  signs  of  distinction." 

Potain-  has  accurately  described  a  case  of  phantom 
tumor  caused  by  an  anomaly  of  the  abdominal  mus- 
cles. In  connection  with  this  subject  he  has  called 
attention  to  the  faulty  conclusions  that  may  be  ar- 
rived at  as  t'he  result  of  palpation  of  the  abdomen. 
He  expresses  himself  as  follows:  "The  abdominal 
wall  seems  to  be  specially  adapted  for  examination  by 
palpation,  but  auscultation,  which  in  the  study  of 
thoracic  affections  renders  us  such  great  services,  fails 
us  altogether  in  the  recognition  of  diseases  of  the  ab- 
dominal organs,  whose  functions  are  performed  silent- 
ly. Moreover,  palpation,  which  usually  teaches  us  so 
much,  may  at  times  give  rise  to  singular  illusions;  and 
among  all  the  errors,  liable  to  be  thus  made,  none  are 
perhaps  more  frequent  than  those  caused  by  phantom 
tumors  (fausses  tumeurs)  of  the  abdomen." 

Santovecchi '  describes  the  case  of  a  young,  nervous 
girl,  who  was  suffering  from  a  swelling  in  the  right 
hypochondrium  that  was  looked  upon  as  a  tumor  of 
the  liver,  or  the  gall   bladder,  or  the   pylorus,  or   the 

*  Read  before  the  German  Medical  Society  of  New  York. 
October  i.  1900. 


omentum.  Since  the  tumefaction  caused  a  good  deal 
of  pain  to  the  patient,  and  as  she  readily  consented  to 
an  operation,  an  exploratory  incision  under  anaesthesia 
was  made.  No  tumor  was,  however,  found,  all  the 
organs  being  in  normal  condition.  As  far  as  the  sub- 
jective symptoms  were  concerned,  the  result  of  the  op- 
eration was  a  very  good  one.  Santovecchi  explains 
this  apparent  tumor  by  a  spasmodic  contraction  of  the 
abdominal  muscles. 

Whereas  in  the  cases  just  cited  the  apparent  tumors 
were  caused  by  the  abdoniinal  muscles,  the  tumefac- 
tion in  a  case  described  by  lirault  and  Rouger'  was 
caused  by  a  prolapsed  liver.  The  diagnosis  was,  how- 
ever, made  only  after  a  laparotomy. 

Bertrand,'  cited  by  Brault  and  Rouger,  in  the  year 
1896  collected  from  literature  twenty  cases  of  phantom 
tumors. 

Glenard"  frequently  mentions  in  his  well-known 
work,  "  Ptoses  Visce'rales,"  that  the  impression  of  the 
presence  of  a  tumor,  caused  either  by  an  anomaly  of 
the  abdominal  muscles  or  by  the  "  corde  colique  trans- 
verse," may  be  gained  in  some  cases  of  enteroptosis. 
He  says:  "There  are  patients  in  whom  the  exagger- 
ated sensitiveness  of  an  underlying  organ  provokes,  at 
the  approach  of  the  hand,  a  contracture  of  the  abdomi- 
nal muscles;  this  is  especially  observed  in  the  right 
rectus  muscle  near  its  costal  attachment.  One  would 
suspect  with  such  patients  that  the  left  lobe  of  the 
liver  is  the  seat  of  some  inllammation  or  congestion; 
the  muscle  contracts  to  protect  the  organ  from  the 
pain  which  pressure  would  produce.  This  is  another 
variety  of  what  have  been  called  '  phantom  tumors  '  of 
the  abdomen."  He  does  not,  however,  enter  further 
upon  a  differential  diagnosis. 

The  apparent  tumors  which  form  the  subject  of  this 
paper  do  not  include  cases  of  swellings  caused  by  a 
prolapse  of  the  whole  liver,  kidneys,  or  spleen.  Kid- 
neys and  spleen,  owing  to  their  characteristic  shape, 
are  nowadays  hardly  ever  confounded  with  tumors. 
A  prolapsed  liver  might  more  easily  give  rise  to  an 
erroneous  diagnosis.  This,' nevertheless,  may  also  be 
avoided  if  the  occurrence  of  movable  liver  is  kept  in 
mind.  The  apparent  tumors  which  I  will  speak  of 
here  relate  to  swellings  found  either  directly  in  the 
epigastrium  or  the  left  or  right  hypociiondrium,  and 
have  nothing  to  do  with  a  neoplasm  of  whatever  kind. 
(I  have  purposely  avoided  the  expression  "  phantom 
tumor,"  as  the  latter  is  usually  applied  to  tumefac- 
tions occurring  principally  in  the  lower  part  of  the 
abdomen  in  hysterical  subjects,  and  caused  by  a  high 
degree  of  meteorism.  With  these  our  cases  have 
nothing  in  common.) 

In  most  cases  of  this  kind  a  resistance  may  be  de- 
tected by  palpation,  sometimes  even  by  inspection, 
lying  between  the  ensiform  process  and  the  umbilicus, 
presenting  a  rather  smooth  surface  and  frequently 
pulsating.  The  size  of  these  tumefactions  varies  be- 
tween that  of  a  hen's  egg  and  a  man's  fist.  Light 
percussion  always  elicits  a  dull  sound  over  the  area  of 
resistance. 

These  apparent  tumors  are  not  exactly  of  fre- 
quent occurrence.      I   have  collected  the   cases  ob- 


802 


MEDICAL    RECORD. 


[November  24,  igoo 


served  by  me  since  1897,  and  have  tabulated  them  as 
follows : 

Table    of    the    Total    Ni'mukr    of  Cases   of   Apparent 
Tumor,  Oisservei)  by  Me  from  1S97  to  September,  iqoo. 


Year. 

Total 

Xuinber  of 

Patients. 

Males 

Females 

Total 

Number  of 

Apparent 

Tumors. 

Apparent 
Tumors, 

Males. 

Kc  males 

1897 

189S 

1899 

1900    (till 
Sept.  nth) 

1.439 
1,447 
1,741 
1.41S 

835 

872 

1.006 

809 

604 

575 
735 
609 

8 
12 
II 
II 

3 
3 

2 

5 

9 

9 

II 

Totals. .  . 

6,045 

3,522  1  2,523 

42 

8 

34 

Out  of  6,045  patients,  therefore,  there  were  42  cases 
of  apparent  tumor,  8  occurring  in  men  and  34  in  wom- 
en. Expressed  in  percentages  the  total  number  of 
cases  of  apparent  tumors  was  0.69  per  cent,  of  persons 
suffering  from  digestive  disturbances.  Of  these  the 
men  constitute  0.23  per  cent,  and  the  women  1.35  per 
cent,  of  all  cases.  As  an  example  I  will  now  relate 
the  histories  of  a  few  characteristic  cases  of  this  kind, 
tabulating  the  rest  of  the  cases. 

Case  I.— July  14,  1899.     Mrs.  R.  W ,  thirty-five 

years  of  age,  has  for  the  last  thiee  years  been  a  great 
sufferer  from  digestive  disturbances.  She  complained 
principally  of  slight  pains  in  the  epigastrium,  occur- 
ring about  one-half  hour  after  eating  and  lasting  two 
to  three  hours.  In  the  beginning  the  appetite  was 
good.  The  patient  was  much  troubled  with  eructa- 
tions. The  bowels  were  generally  sluggish.  About 
two  years  ago  she  became  worse.  The  pains  increased 
in  severity  and  used  to  occur  immediately  after  eating. 
She  now  began  to  vomit,  but  never  threw  up  blood. 
Her  physician  at  that  time  made  the  diagnosis  of  ul- 
cer of  the  stomach,  and  the  patient  was  put  on  a  strict 
diet,  extending  over  six  weeks.  She  recuperated  very 
slowly,  but  never  was  altogether  free  from  pain  in  the 
region  of  the  stomach.  About  two  months  after  her 
treatment  for  ulcer  she  was  able  to  take  light  food  and 
to  attend  to  her  domestic  duties.  Her  appetite  at  this 
time  was  capricious,  her  bowels  were  constipated,  her 
sleep  was  restless,  and  her  digestion  was  accompanied 
by  disagreeable  sensations  in  the  abdomen.  The 
patient  remained  in  this  condition  until  about  May, 
1899,  when  a  turn  for  the  worse  took  place.  Again 
vomiting  occurred  immediately  after  meals,  associated 
with  rather  intense  pains  in  the  region  of  the  stomach. 
She  could  not  take  sufficient  food  and  began  to  lose 
in  weight.  A  chemical  examination  of  the  stomach, 
undertaken  by  her  physician,  showed  a  high  degree  of 
hyperchlorhydria.  The  usual  method  of  treatment 
for  this  condition  (.alkalies)  remained,  however,  with- 
out appreciable  results,  and  the  patient  had  to  take 
considerable  doses  of  morphine  daily.  In  this  condi- 
tion she  remained  until  she  consulted  me  in  July, 
1899.  She  then  told  me  that  during  her  last  illness 
she  lost  twenty  pounds.  Her  physician,  who  was 
kind  enough  to  direct  the  patient  to  me,  sent  her  to 
me  with  the  diagnosis  of  a  probable  carcinoma  of  the 
stomach  on  the  basis  of  an  ulcer. 

Status  prffisens:  The  patient  is  of  slender  stature, 
looks  somewhat  emaciated  and  anamic.  Her  tongue 
is  sliglitly  coated.  The  thoracic  organs  are  intact. 
Inspection  of  the  abdomen  reveals  a  slight  protrusion 
of  the  size  of  a  hen's  egg  lying  in  the  linea  alba  at 
the  beginning  of  the  second  third,  between  the  ensi- 
forni  process  and  umbilicus  (Fig.  i).  On  palpation 
the  epigastrium  is  rather  sensitive  to  pressure.  .\i 
the  place  described  a  resistance  may  be  felt  which  has 
quite  a  smooth  surface  and  is  slightly  dull  on  percus- 
sion. The  position  of  the  stomach  can  easily  be  made 
out  by  the  splashing  sound.      The  stomach  reaches 


about  a  hand's  width  below  the  umbilicus.  Transil- 
lumination also  shows  a  high  degree  of  gastroptosis. 
The  area  of  transillumination  of  the  stomach  extends 
from  about  two  fingers  above  the  navel  to  about  a 
hand's  width  below  it.  The  protrusion  (resistance) 
described  above,  lies  about  4-5  cm.  above  the  small 
curvature  of  the  stomach.  The  patellar  reflexes  are 
present.  The  urine  is  free  from  albumin  or  sugar. 
The  examination  of  the  stomach  one  hour  after  Ewald's 
test  breakfast  shows  HCl  +  =  48 ;  T.  Ac.  =  68.  In 
the  fasting  condition  tlie  stomach  is  empty. 

A  diagnosis  of  gastioptosis,  hyperchlorhydria,  and 
probably  old  ulcer  of  the  stomach  was  made.  A  car- 
cinoma was  excluded  with  great  probability,  as  the 
protrusion  lay  above  the  stomach  and  presented  quite 
a  smooth  surface. 

As  I  was  unable  to  confirm  the  probable  diagnosis 
of  carcinoma  made  by  the  physician  in  charge,  the  lat- 
ter was  very  much  dissatisfied  with  my  opinion,  and 
wrote  me  a  letter  to  that  effect.  A  year  later,  how- 
ever, the  patient  was  in  a  much  better  condition  than 
when  she  first  came  to  me.  It  is  therefore  safe  to  as- 
sume that  carcinoma  was  not  present. 

Case  II.— April  8,  1898.  Dr.  F.  D.  A—,  phy- 
sician, forty  years  of  age,  has  been  suffering  for  a  year 
from  rather  severe  digestive  disturbances.  At  first  he 
used  to  complain  of  slight  pains  in  the  stomach  one 
and  a  half  hours  after  eating,  together  with  frequent 
eructations  of  gas  and  at  times  regurgitation  of  a 
strongly  acid  fluid.  Constipation  was  present  in  a 
high  degree.  Later  a  material  loss  of  appetite  devel- 
oped and  the  pains  in  his  stomach  began  to  appear 
earlier  (about  one-half  hour  after  eating).  He  began 
to  lose  steadily  in  weight,  became  weaker,  and  was 
unable  to  attend  to  his  professional  duties.  The  pa- 
tient consulted  several  physicians,  who  all  declared 
iiis  trouble  to  be  a  very  serious  one.  Carcinoma  was 
universally  suspected.  A  noted  surgeon  discovered  a 
tumor  in  the  gastric  region  and  advised  immediate 
operation.  Before  the  patient  followed  this  advice  he 
concluded  to  get  also  my  opinion.  I  found  the  fol- 
lowing condition  :  A  very  much  emaciated  and  cachec- 
tic-looking man  w'ith  pale  lips.  Examination  of  the 
thoracic  organs  revealed  nothing  abnormal.  On  pal- 
pating the  abdomen  an  oval  resistance,  of  the  size  of 
a  small  hen's  egg,  was  felt  above  the  umbilicus,  lying 
more  to  tlie  right  side  (Fig.  2).  It  had  a  smooth  sur- 
face, moved  a  little  with  respiration,  and  gave  on 
sligiit  percussion  a  dull  sound.  The  stomach  was 
quite  large,  the  lower  curvature  reaching  three  fingers 
below  the  navel ;  a  splashing  sound  could  easily  be 
elicited.  The  epigastrium  was  somewhat  tender  on 
pressure.  The  patellar  reflexes  were  present.  The 
urine  contained  neither  albumin  nor  sugar. 

The  examination  of  the  stomach  one  hour  after 
Ewald's  test  breakfast  gave  the  following  results:  The 
stomach  contents  consisted  of  a  watery  liquid  contain- 
ing only  fine  particles  of  roll.  Other  food  remnants 
were  not  resent.     Ht"l  -)-  Ac  =  72. 

Although  the  small  tumor  described  above  could  be 
plainly  felt  I  still  remained  in  doubt  about  its  nature, 
whether  I  had  to  deal  with  a  real  neoplasm,  or  an 
apparent  tumor  caused  in  this  case  principally  by  the 
abdominal  muscles.  I  advised  treatment  suitable  for 
a  case  of  atony  of  the  stomach  with  hyperchlorhydria. 
The  patient  received  alkalies  and  was  put  upon  a  lib- 
eral diet.  He  improved  visibly.  Seven  months  later, 
on  November  16th,  he  came  to  me  again.  He  then 
looked  strong  and  healthy,  and  told  me  that  he  had 
gained  thirty-five  pounds  and  had  not  been  suffering 
lately  from  any  digestive  disturbances  whatsoever. 
On  examination  of  the  abdomen,  1  found  that  the  re- 
sistance which  formerly  could  be  easily  felt  had  dis- 
appeared. 

Case  III. — January  4,   1898.     Mrs.  J.   P.   B , 


November  24,  1900] 


MEDICAL    RECORD. 


803 


about  fifty-four  years  old,  has  suffered  lor  about  ten 
years  from  dyspeptic  symptoms.  Her  appetite  was 
at  times  capricious,  her  sleep  was  restless  and  dis- 
turl)ed  by  dreams,  the  bowels  were  inclined  to  be 
constipated,  a  sli}<ht  feeling  of  oppression  in  the  re- 
gion of  the  stomach  was  felt  at  times  shortly  after  eat- 
ing, but  none  of  these  difficulties  was  of  a  serious  na- 
ture. In  1897,  however,  the  patient  began  to  suffer 
from  more  pronounced  symptoms.  There  was  nearly 
total  anorexia,  and  soon  after  every  meal  intense 
pains  in  the  epigastrium  developed.  Associated  with 
this  was  vomiting;  the  latter,  however,  occurred  only 
occasionally  (once  in  eight  to  fourteen  days).  The 
patient  was  treated  by  several  able  colleagues,  and 
was  put  on  a  strict  diet.  At  first  she  lived  on  an  ex- 
clusive meat  diet  for  several  weeks.  As  this  mode  of 
treatment  was  not  crowned  with  success,  she  was  put 
upon  a  strict  milk  diet.  IJut  even  this  does  not  seem 
to  have  exerted  any  favorable  influence.  The  patient 
lost  constantly  in  weight.  During  the  last  five  to  six 
monlhsshehad  been  on  the  following  diet :  Breakfast: 
Two  pieces  (30  gm.)  of  toast  and  a  cup  of  clear,  weak 


of  free  llCl  and  the  absence  of  food  particles  from  the 
day  previous.  A  diagnosis  of  enteropiosis  and  appar- 
ent tumor,  caused  in  this  case  probably  by  the  left 
lobe  of  the  liver,  was  made.  The  patient  was  put 
upon  an  ample  diet  and  received  bromide  of  strontium. 
She  was  told  to  wear  an  abdominal  bandage  and  to  eat 
punctually,  whether  she  had  appetite  or  not.  and  with- 
out regard  to  pains.  The  patient  recuperated  quickly 
and  began  steadily  to  gain  in  weight.  She  has  been 
well  since. 

Case  IV. — September  14,  1900.  Mrs.  F .fifty- 
two  years  old,  complains  since  Christmas.  1899,  of  a 
feeling  of  distress  in  the  stomach,  occurring  about 
one-half  hour  after  meals  and  lasting  just  as  long. 
Her  appetite  has  always  been  good  except  during  the 
last  three  to  four  weeks.  She  never  vomited  and  ne^er 
complained  of  eructations.  The  bowels  were  always 
more  or  less  constipated.  She  says  that  some  time 
ago  she  partly  lost  her  sense  of  taste,  so  that  she  could 
not  taste  salt  or  vinegar.  She  also  complains  about  a 
good  deal  of  salivation,  which  troubles  her  very  much. 
Since  November,   1899,  she  has    lost    thirty  pounds. 


Ftc.  3. -Mrs.  J.  1^  1; 


tea.  Lunch :  Extract  of  one  pound  of  meat,  three 
pieces  (45  gm.)  of  toast,  clear  tea;  only  one  of  the 
pieces  of  toast  buttered  (5  gm.).  Dinner:  Same  as 
lunch.  I  purposely  give  the  amount  and  kind  of  food 
according  to  the  patient's  statement.  'I'he  amount  of 
food  taken  in  twenty-four  hours  contained  six  hundred 
and  nineteen  calories.  No  wonder  that  considerable 
subnutrition  resulted.  When  tiie  patient  came  to  me 
she  stated  that  she  had  lost  fifty  pounds  during  the 
last  year.  She  complained  of  a  feeling  of  extreme 
weakness,  dryness  of  the  mouth,  vertigo,  intense  pains 
after  the  slightest  amount  of  food  taken,  and  obstinate 
constipation. 

Status  praisens :  A  tall,  stately  woman  ;  is  emaciated 
in  the  highest  degree.  The  skin  over  the  arms  can 
be  lifted  in  large  folds.  The  color  of  the  lips  and 
cheeks  is  pale.  The  tongue  is  much  coated.  Except 
for  a  slight  presystolic  murmur  at  the  apex  of  the  heart 
the  thoracic  organs  are  normal.  Examination  of  the 
abdomen  reveals  considerable  pain  on  pressure  over 
the  epigastrium.  The  large  curvature  of  the  stomach 
reaches  nearly  to  the  os  pubis,  whereas  the  smaller 
curvature  lies  somewhat  above  the  umbilicus.  A 
splashing  sound  can  easily  be  produced  in  the  stom- 
ach. The  right  kidney  can  be  palpated  in  its  entirety 
and  is  movable  in  the  fourth  degree.  Two  fingers 
below  the  ensiform  process,  in  the  epigastric  region, 
a  prominence  of  the  size  of  an  apple  can  be  demon- 
strated (Fig.  3).  It  has  a  smooth  surface.  The  gen- 
erative organs  show  nothing  abnormal.  The  patellar 
reflexes  are  present,  and  the  urine  contains  neither 
albumin  nor  sugar.  Examination  of  the  stomach  one 
hour  after  Ewald's  test  breakfast  shows  the  presence 


The  patient  looks  pale  and  anjemic.  The  skin  of  the 
arm  can  be  lifted  in  large  folds.  The  thoracic  organs 
are  intact.  The  tongue  is  only  slightly  coated.  Pal- 
pation of  the  abdomen  shows  a  resistance  beginning 
about  one  finger  to  the  left  of  the  linea  alba  and  ex- 
tending three  inches  to  the  right,  reaching  from  a  little 
above  the  lower  third  between  the  processus  ensiformis 
and  navel  to  one  finger  below  the  umbilicus  ( I-'ig.  4). 
The  stomach  extends  to  more  than  a  hand's  width 
below  the  navel.  Tiie  right  kidney  is  movable  in  the 
third  degree,  the  left  in  the  second.  The  liver  appears 
to  be  in  a  normal  position.  The  glands  are  not 
swollen.  The  jwtellar  reflexes  are  present.  The 
urine  contains  neither  albumin  nor  sugar. 

Examination  of  the  stomach  one  hour  after  Ewald's 
test  breakfast  shows  the  ])resence  of  HCI  and  the  ab- 
sence of  lactic  acid  and  of  food  particles  from  the 
previous  day. 

The  high  degree  of  enteroptosis  and  the  fact  that 
the  resistance  showed  a  smooth  surface  caused  me  to 
make  a  diagnosis  of  apparent  tumor.  The  jiatient  was 
told  to  take  light  food  in  sufficient  quantity,  and  re- 
ceived condurango  with  cascara  sagrada.  -About  a 
week  later  she  reported  that  she  had  followed  the  pre- 
scribed diet,  that  she  had  suffered  less  pain  during  this 
time,  and  that  she  had  not  lost  in  weight. 

The  time  of  observation  is  too  short  to  exclude  abso- 
lutely carcinoma,  but  it  seems  to  me  as  if  we  had  to 
deal  only  with  an  apparent  tumor. 

Case  V. — September  8,   1900.     Mrs.  P ,  about 

thirty-three  years  old,  began  to  suffer  from  digestive 
disturbances  about  eight  years  ago,  soon  after  mar- 
riage.    She  then   lost  her  appetite,  became  pale,  and 


8o4 


MEDICAL    RECORD. 


[November  24,  1900 


complained  of  pains  in  the  stomach.  She  has  suffered 
from  constipation  since  childhood.  About  five  years 
ago  she  was  operated  on  for  cysts  of  the  ovaries,  and 
both  ovaries  were  removed.  She  now  has  a  fair  appe- 
tite, but  complains  of  a  good  deal  of  gas  and  a  heavy 
feeling  after  eating.  Her  bowels  are  slightly  con- 
stipated. She  sleeps  fairly  well,  but  has  to  urinate 
rather  frequently. 

Status  praesens:  The  patient  looks  somewhat  pale. 
The  examination  of  the  thoracic  organs  reveals  noth- 
ing abnormal.  On  palpating  the  abdomen  a  resistance 
is  felt  beginning  half-way  between  the  ensiform  proc- 
ess and  the  umbilicus  and  reaching  down  to  two  fin- 
gers above  the  navel  (Fig.  5).  It  extends  across  the 
linea  alba  on  both  sides  for  a  width  of  three  and  a  half 
inches.  The  stomach  extends  to  a  liand's  breadth  be- 
low the  umbilicus;  the  transverse  colon  can  be  pal- 
pated as  a  horizontal  cord  beneath  tlie  navel.  The 
right  kidney  is  movable  in  the  fourth  degree,  the  left 
in  the  third.  The  liver  dulness  does  not  reach  beyond 
the  right  lower  margin  of  the  ribs.  The  patellar  reflexes 
are  present.    The  urine  is  free  from  albumin  and  sugar. 

The  examination  of  the  stomach  one  hour  after 
Kwald's  test  breakfast  reveals  the  presence  of  HCl  and 
a  total  acidity  of 
20.  A  diagnosis  of 
enteroptosis  and  ap- 
parent tumor  is 
made,  and  the  pa- 
tient is  treated  ac- 
cording to  the  usual 
methods  tor  enterop- 
tosis (bandage,  am- 
ple food,  iron). 

Epicrisis.  —  In 
considering  the 
cases  described  we 
see  that  in  all  there 
was  apparently  a 
tumor  in  the  upper 
half  of  the  abdo- 
men, which  could 
easily  have  been 
mistaken  for  a  neo- 
plasm. We  now  naturally  ask  ourselves  how  this  ap- 
parent tumor  is  produced.  Tlie  apparent  tumor  may 
be  produced:  (i)  By  a  prolapse  of  the  left  lobe  of 
the  liver;  (2)  by  exposure  and  thickening  of  the  ab- 
dominal aorta;  (3)  by  a  hypertrophic  condition  of 
parts  of  the  abdominal  muscles;  (4)  by  adhesions  ( ?) 
around  the  small  curvature  of  the  stomach. 

As  I  have  not  had  occasion  to  make  an  autopsy  in 
any  of  these  cases  (since  as  a  rule  most  of  Iheni  do  well 
under  rational  treatment)  it  is  natural  that  the  points 
enumerated  are  of  a  purely  theoretical  nature,  founded, 
however,  upon  the  results  of  clinical  examinations. 

The  left  lobe  of  the  liver  may  be  the  cause  of  the 
apparent  tumor  when  it  is  situated  in  the  median  line 
directly  under  the  ensiform  process.  Frequently  we 
will  get  above  the  resistance,  especially  at  tlie  ensi- 
form process,  instead  of  liver  dulness,  a  more  tympan- 
itic sound  on  percussion.  The  swelling  in  these  cases 
is  of  considerable  dimensions  (size  of  a  fist). 

If  the  apparent  tumor  is  caused  by  the  aorta,  it 
usually  lies  deep  in  the  abdominal  cavity,  close  to  the 
spinal  column,  has  an  elongated  shape,  and  pulsates 
strongly.  The  resistance  is  usually  one  to  two  thumbs 
in  diameter  and  about  two  inches  in  length.  Such  a 
tumor  is  often  mistaken  for  an  aneurism. 

The  abdominal  muscles  are  probably  the  cause  of 
the  tumor  if  it  lies  superficially  and  can  be  palpated 
to  one  side,  either  right  or  left,  of  the  linea  alba. 
The  resistance  usually  runs  horizontally  and  measures 
about  one  to  one  and  a  half  inches  in  breadth  by  two 
to  three  inches  in   length;  its  surface  is  not  globular 


Fic. 


-Mrs.  A.  F- 


like  in  tumors  caused   by  the  liver,  but  more  flat,  al- 
though it  may  be  slightly  rounded  at  the  sides. 

Adhesion  of  the  stomach  is  hard  to  determine  with 
certainty.  The  resistance  felt  is  rather  insignificant, 
small,  lying  generally  in  the  smaller  curvature  of  the 
stomach  toward  the  pylorus,  and  does  not  show  the 
characteristic  distinctions  of  the  three  other  groups. 
VVhether  the  tumor  belongs  to  one  or  other  of  the 
four  groups  is  of  less  importance  than  the  decision 
of  the  question,  whether  in  a  given  case  we  have  to 
deal  with  a  real  tumor  (neoplasm)  or  only  with  an  ap- 
parent tumor. 

In  apparent  tumors  the  swelling  presents  a  more  or 
less  smooth  surface;  at  all  events  there  are  no  distinct 
nodules.  The  tumor  is  not  always  felt  with  the  same 
degree  of  distinctness  and  sometimes  may  escape  pal- 
pation altogether.  The  tumor  occupies  the  position 
described  above,  and  a  high  degree  of  enteroptosis  is 
usually  associated  w^ith  it.  As  further  aids  to  diagno- 
sis we  have  the  course  of  the  disease,  which  usually 
extends  over  years;  the  age  (it  may  occur  from  the 
time  of  adolescence  to  old  age),  and  the  malnutrition, 
which  generally  is  not  of  recent  date  but  has  lasted 
tor  a  long  time.  If  all  these  points  are  present  to- 
gether, the  distinc- 
tion from  a  real, 
malignant  neoplasm 
is  easy.  Cases, 
however,  occur  in 
which  the  differen- 
tial diagnosis  is  not" 
so  easy.  In  the 
first  place,  real  neo- 
plasms may  at  limes 
present  some  of  the 
characteristics  o  f 
apparent  tumors 
{i.e.,  a  smooth  sur- 
face or  an  elongated 
shape,  etc) ;  on  the 
other  hand,  appar- 
ent tumors  may  sim- 
ulate the  character- 
istic appearance  of 
Thus  there  may  be  a  rapidly  progressing 

as  in   the  case  of  J.  P.  B and  other 

facts  pointing  more  to  carcinoma  may  be  present,  and 
yet  we  have  to  deal  with  only  an  apparent  tumor. 

The  cases  detailed  above  are  therefore  of  greater 
value  because  many  of  them  have  been  observed  for 
several  years,  and  consequently  the  diagnosis  of  appar- 
ent tumor  has  been  confirmed.  If  I  be  permitted  to 
draw  conclusions  from  my  experience  on  this  subject, 
I  should  say  that  in  general  the  diagnosis  of  apparent 
tumor  is  easy,  but  that  there  are  exceptional  cases  in 
which  the  decision,  whether  we  have  a  real  neoplasm 
before  us  or  not,  is  exceedingly  difficult.  In  these 
latter  cases  there  is  nothing  left  for  us  to  do  but  to 
wait  some  time.  Observation  extending  over  a  few 
weeks  or  months  will  then  decide  this  question.  In  a 
neoplasm  changes  will  occur  (the  swelling  grows,  the 
symptoms  become  worse),  whereas  an  apparent  tumor 
remains  unchanged,  or  its  symptoms  rapidly  diminish 
under  suitable  treatment. 

Concerning  the  etiology  of  apparent  tumors,  it  is 
evident  from  an  examination  of  the  above  cases  that 
they  occur  principally  with  pronounced  enteroptosis. 
(Jreat  emaciation  and  the  removal  of  certain  abdominal 
organs  (uterus,  ovaries,  etc.),  which  are  of  such  great 
importance  in  the  development  and  increase  of  enter- 
optosis, are  also  important  factors  in  the  development 
of  the  picture  of  apparent  tumor. 

As  to  treatment  it  is  hardly  necessary  to  remark  that 
the  apparent  tumor  itself  does  not  need  any  curative 
measures.     The  original  disease  must  be  determined 


-Mrs.  P- 


carcinoma, 
emaciation 


November  24,  1900] 


MEDICAL    RECORD. 


805 


and  treated  according  to  rational  methods.  Two 
points,  however,  are  to  be  observed  in  the  treatment  of 
all  these  cases  :  First,  the  attention  of  the  patient  must 
be  diverted  from  the  existence  of  the  tumor,  or  the  pa- 


tient's mind  must  be  assured;  secondly,  sufficient 
nourishment  must  be  prescribed  and  must  be  persisted 
in.  In  a  great  number  of  these  patients  sitophobia  is 
present,  and  this  must  be  overcome  according  to  the 


Taulk  ok  the  Rest  of  the  Cases  of  Aitarent  Tumor.  Ohservkd  by  Me  During  iSgy-igoo. 


No, 


Name. 


Mrs.  Rosa 

D. 
Mr.  F.  W. 

A. 
Miss  Mary 

S. 

Miss  Anna 

H. 
Mr.  Otto  S. 


Mrs.  C.  A. 
Mr.  S.  A.  G. 


Miss  Mary 
W. 

Mrs.  H.  F. 

Mre.  J.  S. 

Miss  Lillie 
C. 


23- 

24. 

25- 

26. 

27. 
28. 
29. 


Mr.  W.  J. 

W. 
Mrs.  D.  D. 

Mrs.  A. 

McG. 

Mrs.  Mary 

S. 

Mrs.  W.  E. 

M. 

Mr.  John 

O. 
Mrs.  McC. 

Rev.  A .  B . 

Mrs.  W.  S. 
L. 

Mr.  Marvin 
W. 

Miss  L.  P. 


Miss  L.... 

Mrs. 
Gertrud  S. 

Miss  Ida  U. 

Mrs.  J.  R. 
B. 

Mrs. 
Josefine  L. 
Mrs.  Lizzie 

H. 

Mrs.  Nora 

H. 


30.   Miss  Hattie 
C. 


34- 

35- 

36- 
37- 


Miss  .Mice 
M.  H. 

Miss  Olga 


Mrs.  E.  W 


MissS.. 


Miss  Mary 
G. 

Miss  (Dr.) 

Florence  W. 

Mrs.  Rosie 

B. 


Achylia    gast.,     insulT. 

mitr.,  gastroptosis. 
Hyperchlorhydria. 

Gastroptosis 


Entcroptosis,    gastrop- 
tosis, ren  mob.  dcxt. 

Gastroptosis,  gastralgia. 


Gastroptosis,  hepatop- 
tosis. 

Gastroptosis,  h  y  p  3  r- 
chlorhydria,  neuras- 
thenia. 

ICntcroptosis,  ren  mob. 
dext.  (3d  degree), 
gastralg.  nervosa. 

Gastroptosis,  hcpatop- 
tosis,  ana;inia. 

Entcroptosis,  achylia 
gastrica. 

Entcroptosis,  hyper- 
chlorliydria, 


Enteroptosis,      neuras- 

xhenia. 
Entcroptosis,    hyper- 

chlorhydria, 
Dilataiio  ventriculi 


Gastroptosis  . 


Enteroptosis,  ren  mob. 

dext. 
Atonia  ventric,  tuberc. 

puhn. 
Enteroptosis,    gastritis 

chron. 
Achylia  gastrica. 

Enteroptosis,  anxniia. 


Enteroptosis,  ren  mob. 
dext,,  hyperchlorhy- 
dria. 

Enteroptosis,  ren  mob. 
dext.,  gastralgia. 

Enteroptosis,  ren  mob. 

dcxt. 
Ren    mob.  ut.  (r.  3d,  1. 

2d  degree). 

Enteroptosis,  atonia 
vcntr. 

Enteroptosis,  ren  mob. 
wt.  (r.  4th,  1.  3d  de- 
gree). 

Neurasthenia 


Enteroptosis,  ren  mob. 

dext. 
Enteroptosis,  ren  mob. 

dext.  (^d  degree). 

Enteroptosis,  hepatop- 
tosis,  ren  mob.  dcxt. 
(4th  degree). 

Enteroptosis 


Aug.  26, 

1897. 
Sept.  16, 

1897. 

Nov.  3, 
1897. 

Jan.  15, 

1898. 
Feb.  17, 

1898. 
Nov.  22, 


Enteroptosis,  hepatop- 
tosis  (slight).  ren 
mob.  dcxt.  (3d  de- 
gree). 

Enteroptosis,  ren  mob. 
ut.  (r.  4th,  1.  3d  de- 
gree). 

Enteroptosis,  hepatop- 
tosis,  ren  mob.  dext. 
(3d  degree). 

Enteroptosis,  ren  mob. 
ut.  (r.  3d,  1.  1st  de- 
gree). 

Enteroptosis,  ren  mob. 
dext.  (3d  degree). 

Enteroptosis.  ren  mob. 
dext.  (4th  degree), 
gastralgia. 


June  9, 

1898. 
Aug.  9, 

1898. 
Dec.  3, 

1898. 
Dec.  7, 

1898. 
Dec.  16, 

1898. 
Dec.  19, 

1898. 
Dec.  20, 

1898. 
Mar.  17. 

i8qo. 
April  25, 

1899. 

April  29, 
1899. 

May  8, 
1899. 

July  2, 
1899 

Nov.    21, 

[899. 

Nov.  27, 
1899. 

Nov.  29, 
1899. 

Nov.  2g, 

1899. 
Dec.  20, 

Mar.  21, 

1900. 

April  1, 
1900. 

April  17, 
1900. 

May  2, 

1900. 


May  12, 
1900. 

May  23. 

1900. 

June  I, 
1900. 

Aug.  18. 

1000. 
Sept.  ti, 

1900, 


Situation  of  tumor. 


Tumor  lies  2  fingers  below  right  margin  of  ribs,  extends  some- 
what horizontally,  and  is  of  size  of  hen's  egg. 

Tumor  lies  horizontally  in  second  third  of  line  drawn  fromensiforni 
process  to  umbilicus,  is  size  of  small  egg.  and  pulsates  strongly. 

Tumor  lies  in  middle  between  ensiform  prrtccss  and  navel,  ex- 
rends  horizontally,  is  about  as  large  as  a  hen's  egg. 

Tumor  lies  under  ensiform  process,  is  of  a  smooth  surface,  and 

the  size  of  a  list. 
Tumor  lies  3  fingers  below  ensiform  process,  extends  more  to 

the  right,  and  is  about  the  size  of  a  small  apple. 


Tumor  lies  directly  under  ensiform  process,  has  a  smooth  sur- 
face, and  is  of  the  size  of  a  fist. 
Tumor  lies  somewhat  to  the  right  of  the  linea  alba,  3  fingers 

under  the  right  margin  of  ribs,  is  about  the  size  of  a  hen's 

egg. 
Tumor  lies  in   median   line,  halfway  between  ensiform  process 

and  navel,  is  of  elongated  shape,  pulsates  strongly,  and  is  of 

size  of  small  egg. 
Tumor  lies  directly  under  the  ensiform  process,  has  a  smooth 

surface,  and  is  of  the  size  of  a  fist. 
Tumor  lies  3  fingers  above  umbilicus,  runs  horizontally,  and  is 

the  size  of  a  hen's  egg. 
Tumor    begins   2    fingers    below    ensiform    process,    lies  in   the 

median  line,  has  a  smooth  surface,  and  is  the  size  of  a  fist. 


Tumor  lies  in  the  middle  between  navel  and  symphysis,  runs 

somewhat  horizontally,  and  is  of  the  size  of  a  small  egg. 
The  tumor  lies  2  fingers  below  ensiform  process,  has  a  smooth 

surface,  and  is  of  the  size  of  a  fist. 
Tumor  lies  under  t-nsiform  process,  has  a  smooth  surface,  and 

is  uf  the  size  of  a  fist. 
Tumor  lies  more  to  the  left  of  linea  alba,  somewhat  above  um- 
bilicus, pulsates  strongly,  and  is  of  the  hi/e  of  a  hen's  egg. 
Tumor  begins  about  i  to  2  fingers  under   the  ensiform   process, 

extends  to  just  abovt-  the  umbilicus,  and  has  a  smotjth  surface. 
Tumor  lies  almost  directly  under  ensiform  process,  has  a  smooth 

surface,  and  is  about  the  size  of  a  fist. 
Tumor  lies  close   under  ensiform  process,  has  a  smooth  round 

surface,  and  is  the  size  of  an  apple- 
Tumor  lies  under  right  margin  of  ribs,  has  a  smooth  surface, 

and  is  of  the  size  of  a  small  hen's  egg. 
Tumor  lies  3  fingers  above  the  navel,  extends  more  to  the  left. 

is  somewhat  elongated,  of  about  the  size  of  a  goose  egg,  and 

pulsates  strongly. 
Tumor  lies  to  the   right  of  the  linea  alba,  under  the  margin  of 

the  ribs,  is  uval,  and  of  the  size  of  a  hen's  egg. 

The  tumor  starts  in  the  beginning  of  the  second  third  of  a  Hoe 

drawn  from  the  cn?iform  process  to  the  umbilicus,  extends  on 

both  sides  of  lincu  alba,  and  is  about  the  si/f  of  an  apple. 
Tumor  lies  in   left  epigastrium  close  below  margin  of  ribs,  and 

is  of  the  size  of  a  yoose  egg. 
Tumor  lies  beneath   umbilicus  in  the  region  of  the  abdominal 

aorta,   has  an  chm^^ated  shape,  is  of  the  size  of  a  large  hen's 

egg,  and  pulsates  strongly. 
Tumor  lies  between  ensiform  process  and  navel,  is  of  the  size  of 

an  egg. 
Tumor  lies  about  in  the  middle  between  ensiform  process  and 

navel,  and  has  the  size  of  an  egg. 

Tumor  lies  2  to  1,  fingers  above  navel,  extends  more  to  the  right 
of  the  linea  alba,  and  is  of  the  size  of  a  large  fist. 

Tumor  extends  to  the  right  of  the  linea  alba,  lies  2  fingers 
above  navel,  and  is  nearly  the  size  of  a  fist. 

Tumor  lies  in  the  second  third  of  a  line  drawn  from  the  ensi- 
form process  to  the  navel,  extends  more  to  the  left,  and  is 
about  the  size  of  an  apple. 

Tumor  lies  in  median  line,  occupying  second  third  of  line  drawn 
from  ensiform  process  to  navel,  and  is  about  the  size  of  an 
apple. 

Tumor  lies  somewhat  to  the  right  of  the  linea  alba  in  the  mid- 
dle between  ensiform  process  and  navel,  and  is  of  the  size  of 
a  large  hen's  egg. 

Tumor  lies  i  to  3  fingers  above  navel,  extends  more  to  the  left 
than  the  right  of  the  linea  alba,  and  is  of  the  size  of  a  goose 
egg. 

The  tumor  lies  2  to  3  fingers  below  left  mirgin  of  ribs,  and  is 
about  the  size  of  a  goo'se  egg. 

Tumor  lies  to  the  left  of  linea  alba  in  the  middle  between  en- 
siform process  and  navel,  and  reaches  to  within  i  to  3  fingers 
above  the  latter. 

The  apparent  tumor  lies  in  the  median  line,  2  fingers  above  the 
navel,  and  is  about  the  size  of  a  goose  egg. 

Tumor  lies  on  right  side  of  linea  alba,  a  little  above  umbilicus, 

and  is  about  the  size  of  a  hen's  egg. 
Tumor  lies  in  lower  third,  between  ensiform  process  and  navel, 

and  extends  to  both  sides  of  linea  alba. 


Remarks. 


Patient  was  operated  on  about  one 
year  before  she  saw  me.  A 
double  nephrorrhaphy  was  done. 


Patient  had  lost  considerably  in 
weight,  and  I  myself  made  a  prob- 
able diagnosis  of  carcinoma  of 
stomach.  A  year  later  I  had  the 
opportunity  of  seeing  him  again, 
and  was  astonished  at  his  healthy 
appearance.  Palpation  of  al>- 
doinen  revealed  at  that  time  no 
tumor. 


The  patient  was  demonstrated  in 
the  winter  of  1898,  in  <)ne  of  the 
meetings  of  the  Physicians  of  the 
Cierman  Husp.  and  Disp.  She 
had  lost  then  over  30  lbs.  She 
was  suffering  from  vomiting  and 
violent  gastralgia.  Patient  was 
put  on  a  nourishing  diet  and  re- 
ceived alkalies  and  bromides.  She 
rapidly  gained  over  30  lbs.  in  1  to 
4  months,  and  has  remained  tree 
from  distress  ever  since. 


Patient  had  lost  considerably  in 
weight.  Carcinoma  of  stomach 
had  been  diagnosed  by  several 
colleagues.  One  year  later  pa- 
tient had  gained  33  lbs.  and  felt 
well. 


Double     nephrorrhaphy,     extirpa- 
tion of  uterus  and  both  ovaries. 


i 


8o6 


MEDICAL    RECORD. 


[November  24,  1900 


principles  laid  down  in  my'  anicle  on  the  diet  of  dys- 
peptics. 

If  both  these   indications  are  thoroughly  met   the 
main  object  has  been  accomplished,  and  a  favorable 

result  will  soon  follow. 

LITER.VTURE. 

1.  Da  Costa,  J.  M-:   Medical  Diagnosis,  rhiladelphia,  l8qo. 

2.  I'otain,   C:   Des  fausses  tumeurs  de  Tabdonien.      Semaine 
mcd.,  I'aris,   iSg6.  xvi.p.  209. 

3.  Santovecchi.   K.:  (."ontributo  alia  casuistica  dei  falsi  tumori 
deir  addome.     II  Morgagni,  Milano,  1696,  .\.>;.sviii. ,  pp.  704-70S. 

4.  lirault,  J.,  and  Rouger,  J. ;  Fausses  tuineurs  de  labdomen. 
I.a  Presse  med.,  I'aris,  I»q7,  ii.,  p.  37i- 

5.  Hertrand  ;  Cited  by  Brault  and  Rouger. 

6.  Gltnard,  K. ;   Les  Ptoses  V'isccrales,  Paris,  iSgg. 

7.  Einhorn,  Ma.\  :  The  Diet  of  Dyspeptics.     Medical  Rec- 
ord, January  i,  iSgS. 


MYASTHENIA    GR.WIS    WITH    CLINICAL 
REPORT   OF    CASE. 

By   S.VKGER   liROWX,    .\I  D., 

CHICAGO, 

PROFESSOR  OP  NECROLOGY,  POST-GRADUATE  MEDICAL  SCHOOL  ;  ASSOCIATE 
PROFESSOR,  PRACTICE  OF  MEDICINE  AND  CLINICAL  MEDICINE,  MEDICAL 
DEPARIMENT,  fSIVERSITV  OF  ILLINOIS;  ATTENDING  NEUROLOGIST  TO  ST. 
ELIZABETH'S  HOSPITAL  AND  ST.  LUKE'S  HOSPITAL;  CONSULTING  NEUROL- 
OGIST TO  THE  MARV  THOMPSON  HOSPITAL  FOR  WOIMEN  AND  CHILDREN, 
AND   TO   THE    HOME    FOR    DESTITUTE   AND    CRIPPLED    CHILDREN. 

Clinical  Report  of  Case :  The  patient  whose  history 
follows  came  to  me  September  27th  of  this  year 
through  the  courtesy  of  Dr.  VV.  T.  Montgomery,  whom 
she  had  consulted  for  ocular  disorder. 

Miss   .A.   B ,  aged   twenty-nine   years,  teacher, 

family  history  good,  regular  habits,  happy  in  family 
and  social  relations,  work  congenial;  always  enjoyed 
good  general  health  prior  to  present  illness.  She  is 
of  nervous  temperament,  but  not  an  extreme  e.vample 
of  that  constitutional  state,  and  has  average  endurance 
in  both  bodily  and  mental  e.xercise.  The  skin  is  natu- 
rally clear,  the  body  plump,  and  the  tissues  are  firm. 

About  sixteen  months  ago,  after  having  attended 
social  functions  rather  freely  during  several  months 
preceding,  involving  considerable  loss  of  sleep,  the 
patient  was  quite  rapidly  overtaken  with  a  feeling  of 
profound  muscular  exhaustion  upon  comparatively 
slight  exertion;  she  could  only  with  the  greatest  diffi- 
culty use  her  arms  and  legs,  and  could  scarcely  walk 
across  the  room  or  keep  her  arms  raised  in  combing 
or  doing  up  her  hair.  Diplopia  and  ptosis  speedily 
became  quite  troublesome,  tiie  former  being  aggra- 
vated when  the  patient  was  in  strong  sunlight.  Her 
voice  soon  became  very  distinctly  nasal  and  her  articu- 
lation thick  and  imperfect.  She  felt  that  the  voice 
and  speech  changes  resulted  mainly  from  excessive 
weakness  and  fatigue  in  the  tongue.  VVhen  commenc- 
ing to  talk,  if  not  tired,  her  voice  and  articulation 
would  sound  natural  and  no  sense  of  exliaustion  or 
effort  would  be  felt;  but  soon  the  distressing  symp- 
toms would  make  their  appearance  and  develop  quite 
rapidly,  till  she  could  go  on  no  longer.  The  muscles 
of  mastication  became  so  weak  and  tired  while  eating 
that  she  was  often  unable  to  finish  a  meal,  though  still 
quite  hungry.  There  was  occasional  and  not  very  se- 
vere palpitation,  never  globus  or  dyspnoea.  There 
was  sometimes  slight  humming  in  the  ears.  Occa- 
sionally there  were  slight  frontal  headache  and  pains 
shooting  through  the  whole  left  side  of  the  body;  but 
all  these  latter  symptoms  were  very  infrequent  and 
comparatively  trivial.  The  mucous  membranes  of  the 
moutii  and  nose  became  very  uncomfortably  dry  at 
times.  The  hair  and  scalp  have  also  been  very  dry 
and  the  hair  has  fallen  out  quite  badly,  but  the  skin 
generally  has  remained  in  good  condition.  Appetite, 
digestion,  sleep,  and  menses  are  satisfactory.  She 
suffers  from  habitual  constipation,  which  is  now  some- 
what aggravated. 


There  had  been  no  mental  depression  further  than 
what  might  naturally  be  expected  as  a  result  of  dis- 
couragement incident  to  such  an  illness;  no  unnatural 
irritability,  disturbance  of  the  intellectual  faculties  or 
feelings  at  any  time;  no  difficulty  in  holding  the  at- 
tention upon  a  given  subject,  nor  amnesia,  confusion 
of  ideas,  etc.,  as  are  so  often  seen  in  neurasthenics. 
The  patient  denied  the  possession  of  any  irregular  and 
unnatural  appetites,  propensities,  or  impulses. 

Within  a  week  or  two  after  the  symptoms  appeared 
she  became  unable  longer  to  continue  her  work,  and 
then  spent  several  months  resting,  much  of  the  time  in 
the  open  air  and  surrounded  by  favorable  hygienic 
influences.  A  marked  improvement  took  place,  so 
that  after  a  rest  of  four  months  she  resumed  her  scliool 
work;  but  in  a  few  weeks  her  former  symptoms  re- 
turned and  have  persisted  with  some  variations,  or 
perhaps  more  proi)erly,  partial  remissions,  down  to  the 
present  time.  She  has  not  been  able  to  do  her  hair 
for  six  months  and  usually  after  a  short  walk  has  not 
strength  enough  to  cross  her  legs  when  sitting.  The 
symptoms  referable  to  the  tongue  and  muscles  of  mas- 
tication— the  difficulty  of  speech,  nasa!  voice,  and  in- 
distinct utterance — remain  as  above  described;  and 
so,  indeed,  do  all  of  the  other  symptoms,  except  the  di- 
plopia and  ptosis,  which  are  less  frequently  observed 
and  less  severe  than  at  first.  She  has  lost  about  fif- 
teen pounds  in  weight  since  her  illness  began. 

Examination:  The  patient  is  highly  intelligent, 
cheerful,  well  developed,  well  formed,  well  nourished, 
and  of  medium  size;  the  skin  is  soft,  elastic,  and  of 
good  color;  the  hair  is  rather  thin  and  dry,  but  I  could 
discover  no  obvious  defect  in  the  condition  of  the 
scalp;  the  reflexes  are  all  normal  but  lively;  volun- 
tary motion  is  possible  in  every  direction  and  there  is 
no  inco-ordination ;  the  strength  is  greatly  reduced, 
the  patient  scarcely  being  able  to  raise  the  indicator 
of  a  dynamometer  to  5%  when  50  to  60°  would  be 
about  the  average  for  a  healthy  woman  of  her  age  and 
development.  I  did  not  make  an  electric  test  nor  did 
I  try  to  exhaust  the  knee  jerks  by  repetition,  for  rea- 
sons personal  to  the  patient.  There  was  no  suspicion 
of  muscular  atrophy  or  deformity  anywhere;  neither 
was  there  any  disorder  of  sensation  of  any  kind;  no 
pain  or  tenderness  upon  pressure  was  discoverable, 
and  indeed  I  sought  in  vain  for  any  evidences  of  hys- 
teria. 

The  eyes  were  tested  by  Dr.  W.  T.  Montgomery,  of 
this  city,  the  same  day  that  I  made  my  examination, 
and  according  to  his  notes  which  he  kindly  gave  me, 
after  some  slight  astigmatism  was  corrected  vision  was 
normal.  The  pupils,  which  were  quite  large,  reacted 
well  to  both  light  and  accommodation,  though  rather 
slowly.  The  fundus  was  normal.  There  was  diplopia 
when  the  eyes  were  strongly  turned  either  to  the  right 
or  to  the  left,  due  evidently  to  weakness  of  the  abdu- 
cens.  There  was  slight  but  distinct  ptosis,  equal  on 
both  sides,  and  the  movements  of  the  lids  were  nota- 
bly slow.  The  visual  fields  were  not  tested.  I  regret 
that  this  was  not  done  and  also  that  an  attempt  was 
not  made  to  exhaust  the  faradic  excitability  of  the 
muscles.  To  my  mind,  however,  the  diagnosis  is  en- 
tirely clear  in  the  absence  of  these  tests. 

Historically  I  will  only  say  that  tlie  names  of  Wilks 
and  Erb  are  connected  with  the  earliest  reported  caseo 
of  this  disease,  which  were  recorded  in  the  late  seven- 
ties. Since  then  the  subject  has  attracted  considera- 
ble attention  on  the  part  of  European  neurologists;  at 
least  I  judge  so  from  the  numerous  references  to  it  in 
the  "German  Year-Hook  of  Nervous  Diseases." 

In  this  country.  Dr.  .Archibald  Church  has  for  several 
years  past  given  abstracts  of  cases  in  the  "American 
Year-Hook."  He  has  also  given  a  concise  description 
of  the  disease  in  his  text-book.  Dana  likewise  de- 
scribes it  in  his  work,  as   also  does   Joseph    CoUinr- 


November  24,  1900] 


MEDICAL    RECORD. 


807 


quite  elaborately  in  the  "Twentieth  Century  Practice." 
These  authors,  in  cotninon  with  many  others,  desig- 
nate it  by  the  term  "asthenic  bulbar  paralysis." 
Cases  have  likewise  been  reported  as  "  bulbar  paraly- 
sis without  any  discoverable  anatomical  change."  In 
the  light  of  extended  experience  and  observation  these 
names  appear  misleading  and  possibly  they  have  not 
yet  taken  so  firm  a  position  in  literature  that  they  may 
not  be  replaced.  So  far  no  anatomical  changes  have 
been  discovered;  hence  the  propriety  of  adopting  a 
name  which  shall  embrace  the  most  salient  clinical 
features,  while  it  does  not  convey  any  unwarranted  in- 
timations as  to  tile  seat  of  the  disease  and  its  patholo- 
gy.    For  these  reasons  I  prefer  the  term  I  have  used. 

The  name  myasthenia  gravis  has  been  employed  by 
Campbell  and  Bramwell  in  a  recent  article  in 
Brain  (summer  nimiber,  1900  i,  in  which  they  pre- 
sent a  critical  digest  of  the  disorder,  with  an  appendi.x 
containing  notes  of  sixty  cases,  many  completed  by 
autopsy.  I  have  drawn  freely  upon  their  article  in 
the  preparation  of  this  paper.  So  far  as  I  am  aware, 
it  is  the  most  complete  presentation  of  the  subject  at 
present  available.  They  say  that  hitlierlo  only  four 
cases  have  been  published  in  America;  so  that  either 
the  disease  must  be  comparatively  rare  or  its  salient 
features  have  not  been  widely  and  clearly  understood. 

Etiology  :  Thirty-five  and  twenty-four  are  the  custom- 
ary ages  for  men  and  women  respectively,  while  their 
liability  is  about  equal.  Some  prostrating  disease,  as 
influenza,  typhoid  fever,  etc.,  quite  frequently  precedes 
the  affection,  and  ancemia  is  often  met  with  in  women. 
Alcohol  and  syphilis  are  not  of  especial  significance; 
neither  are  hereditary  influences. 

Onset:  This  is  usually  gradual,  but  occasionally 
the  disease  develops  very  rapidly,  almost  suddenly. 
Most  frequently  the  first  symptom  is  the  characteristic 
weakness  of  some  of  the  muscles  supplied  by  the  cra- 
nial nerves,  the  external  ocular  muscles,  the  muscles 
of  mastication  and  the  tongue:  but  it  may  begin  in 
the  extremities,  the  muscles  that  support  the  head,  or, 
indeed,  any  of  the  functionally  grouped  voluntary  mus- 
cles. 

Symptoms:  One  of  the  most  prominent  characteris- 
tics of  the  disease  is  the  profound  exhaustion, 
amounting  in  many  cases  to  temporary  but  almost 
complete  paralysis  of  the  functionally  grouped  volun- 
tary muscles  upon  comparatively  slight  exercise.  The 
muscular  symptoms  are  essentially  bilateral,  though 
there  may  be  considerable  variation  between  the  two 
sides.  Ptosis  and  diplopia  are  very  common  in  the 
earlier  stages.  Irregular  nystagmoid  movements  may 
be  induced  by  lateral  conjugate  deviation  of  the  eyes, 
and  as  might  be  expected,  the  eyes  tire  easily.  The 
pupils  are  usually  unaffected.  The  muscles  of  masti- 
cation are  very  constantly  implicated  and  often  among 
the  first  to  be  complained  of.  The  patient  often  fails 
to  finish  his  meal,  especially  the  evening  meal,  on 
account  of  fatigue  in  these  muscles,  and  the  jaw  is  not 
infrequently  supported  by  the  hand  during  mastication 
and  while  the  patient  is  at  rest.  The  muscles  of  the 
upper  face  are  likely  to  be  as  much  affected  as  those 
of  the  lower,  while  these  latter  suffer  much  less  than 
in  developed  cases  of  true  bulbar  paralysis,  so  that  the 
facial  expression  differs  very  much  from  that  observed 
in  the  latter  disease.  The  muscles  of  deglutition  are 
often  weak,  and  liquids  regurgitate  through  the  nose  on 
account  of  weakness  of  the  palate.  The  pharyngeal 
reflex  is  often  diminished  or  absent,  hence  the  liabil- 
ity to  choke  while  eating.  I  did  not  examine  the  lar- 
ynx nor  the  pharynx  in  the  case  above  reported,  but 
the  patient  did  not  complain  of  choking  or  difficulty 
in  swallowing.  Paralysis  of  the  laryngeal  muscles  is 
rare,  but  a  feeling  of  aching  and  stiffness  in  the 
tongue,  especially  after  eating  and  speaking,  is  com- 
mon.     Characteristic  alterations  in  speech  are  almost 


invariable.  It  becomes  nasal  shortly  after  the  patient 
begins  to  speak,  and  the  words  grow  more  and  more 
indistinct  until  he  is  finally  forced  to  desist  from 
sheer  exhaustion.  Inability  to  support  the  head  is 
common,  because  the  muscles  concerned  are  in  con- 
stant action  when  the  patient  assumes  an  erect  posture, 
and  are  therefore  constantly  the  seat  of  the  peculiar 
exhaustion.  When  the  respiratory  muscles  become 
involved,  they  cannot  recuperate  by  rest,  and  tlius  a 
fatal  result  may  ensue.  In  like  manner  any  of  the 
voluntary  muscles  may  suffer,  giving  rise  to  symjitoms 
as  various  as  their  normal  functions.  The  symptoms 
may  almost  wholly  and  unexpectedly  remit  for  several 
days  togetiier. 

Emotional  excitement,  cold  weather,  and  menstrua- 
tion have  each  been  known  to  aggravate  the  complaint. 

The  muscles  react  normally  to  electricity,  but  are 
speedily  exhausted  by  the  faradic  current  in  many 
cases.  After  rest  they  respond  again.  This  is  known 
as  the  myasthenic  reaction.  Atrophy  is  never  present 
in  pure  cases  and  the  various  skin  reflexes  and  muscle 
jerks  are  not  materially  disordered.  The  sphincters 
are  never  disturbed  and  there  are  no  trophic  or  sen- 
sory changes.  Muscular  inco-ordination  has  never 
been  observed. 

Morbid  Anatomj'  and  Pathology:  Though  in  the 
sixty  cases  above  referred  to  seventeen  came  to  autop- 
sy, some  of  which  were  examined  by  highly  skilled 
investigators,  who  employed  the  most  modern  micro- 
scopical technique,  in  only  six  cases  was  anything 
found  which  could  possibly  account  for  the  symptoms. 

Many  plausible  and  ingenious  hypotheses  have  been 
advanced  in  explanation  of  the  symptoms,  but  they 
cannot  profitably  be  discussed  within  the  limits  of  this 
paper.  I  will  say  in  this  place  only  that  the  fact  that 
in  severe  cases  the  symptoms  sometimes  vanish  quite 
rapidly  and  for  an  indefinite  period,  and  that  even  in 
fatal  cases  no  anatomical  lesion  can  be  demonstrated, 
suggests  a  toxic  influence  powerful  enough  to  inhibit 
function,  but  of  such  a  nature  as  to  produce  no  demon- 
strable changes  in  the  organic  elements  concerned. 
Also  the  nature  and  distribution  of  the  symptoms 
point  to  the  bodies  of  the  peripheral  motor  neurons  as 
the  main  seat  of  the  attack  of  this  toxin.  The  test 
recently  made  by  Dr.  Farquhar  Buzzard,'  of  London, 
upon  a  typical  case  appears  to  demonstrate  conclu- 
sively that  the  paralysis  is  wholly  due  to  a  failure  of 
nervous  energy.  In  this  test  he  simply  exhausted  the 
muscles  to  faradism  and  found  that  they  still  reacted 
perfectly  well  to  galvanism;  that  is  to  say,  temporary 
degeneration  reaction  was  present,  which  of  course 
always  implies  functional  integrity  of  the  muscles  and 
at  the  same  time  suspension  of  the  functional  activity 
of  their  peripheral  motor  neurons. 

Diagnosis:  This  is  very  important,  because,  unless 
the  physician  happen  to  have  the  salient  features  of 
the  disease  in  mind,  the  frequently  satisfactory  condi- 
tion of  the  general  health  of  the  patient,  together  with 
the  nature  of  the  symptoms,  is  not  likely  to  suggest 
any  immediate  or  even  remote  danger  to  life. 

The  diagnosis  is  easy  when  the  peculiar  exhaustion 
appears  in  the  external  ocular  muscles,  the  tongue,  and 
the  muscles  of  mastication,  and  when  the  peculiarities 
in  speech  are  manifest. 

But,  especially  in  the  early  stages  of  slowly  devel- 
oping cases  of  myasthenia  gravis,  the  frequent  and 
almost  infinite  variety  of  combinations  between  gen- 
eral neurasthenia  and  hysteria  have  to  be  reckoned 
with,  because  in  some  of  these  affiliations  profound 
muscular  exhaustion  after  comparatively  slight  exer- 
cise is  not  uncommon.  Neither  is  a  peculiar  loss  of 
power  (stiffness)  in  the  tongue  and  even  other  muscles 
supplied  by  the  cranial  nerves  uncommon,  while  ptosis 

'  Foot  note  in  Carapbei!  and  Bramwell's  article  previously  re- 
ferred to. 


8o8 


MEDICAL   RECORD. 


[November  24,  1900 


and  diplopia  are  frequently  met  with.  In  these  con- 
ditions, however,  the  underlying  state  is  usually  ap- 
parent, and  besides,  while  there  is  some  slight  simi- 
larity in  the  symptoms  themselves,  the  differences  are 
quite  conspicuous.  There  is  more  of  a  general  and 
lasting  prostration  and  less  of  a  temporary  paralysis. 
The  ptosis,  diplopia,  and  stiffness  of  the  tongue  and 
indeed  of  various  other  muscles  supplied  by  the  cranial 
nerves  are,  for  the  most  part,  independent  of  exercise. 

An  association  between  myasthenia  gravis  and 
hysteria  may  present  very  great  difficulties  of  diagno- 
sis in  which,  if  the  former  disease  were  not  delected, 
an  apparent  simple  hysteria  might  prove  fatal. 

When  the  disease  is  far  enough  advanced  to  suggest 
bulbar  palsy  or  polioencephalitis,  the  course,  the  dis- 
tribution of  the  weakness,  and  the  presence  of  muscu- 
lar atrophy  in  these  latter  instances  are  significant. 

Prognosis:  Of  the  sixty  cases  above  referred  to, 
twenty-three  ended  fatally,  the  average  duration  of  the 
disease  being  one  and  a  half  years.  Paralysis  of  the 
respiratory  muscles  resulting  in  asphyxia  is  usually 
the  essential  cause  of  death — a  fact  which  greatly 
increases  the  gravity  of  any  sort  of  pulmonary  disor- 
der in  these  patients.  Some  patients  improve  and  all 
symptoms  disappear  for  months  or  even  years,  while 
others  recover  permanently.  The  proportion  of  these 
latter  will,  I  believe,  be  much  increased  when  the  dis- 
ease comes  to  receive  general  recognition. 

Dr.  Hall  reports  a  typical  case  in  Brain  (sum- 
mer number,  1900)  in  which  a  woman  of  forty-four 
died  quite  suddenly  of  this  disease  from  failure  of  the 
respiratory  muscles  four  montlis  from  the  rather  rapid 
'^nset.  The  ■  post-mortem  findings  were  negative, 
though  a  thorough  microscopical  examination  was 
made.  This  case  improved  very  much  for  a  few 
weeks,  after  the  disease  had  lasted  two  months,  under 
isolation,  overfeeding,  electricity,  and  massage,  but 
grew  worse  again  while  these  measures  were  still  being 
employed. 

Treatment:  I  cannot  speak  of  the  treatment  from 
personal  experience.  Many  drugs  have  been  tried, 
but  so  far  none  has  been  found  with  any  specific  influ- 
ence over  the  disease.  Buzzard  tried  in  two  cases 
strychnine  hypodermically  in  gr.  \  doses  daily  with- 
out benefit;  but  I  should  like  to  see  nitrate  of  strycii- 
nine  tried  hypodermically  in  gr.  Jj  doses  daily,  as 
has  been  done  with  considerable  success  in  certain 
cases  of  progressive  degeneration  of  the  peripheral 
neurons  (progressive  muscular  atrophy  of  the  spinal 
form).  Of  course  all  general  measures  calculated  to 
maintain  a  high  standard  of  the  general  health,  con- 
sistent with  the  symptoms,  should  be  employed.  If, 
finally,  the  stomach  tube  has  to  be  used,  the  paralysis 
of  the  muscles  used  in  swallowing  demands  the  exer- 
cise of  special  caution. 

103  State  Street. 


The   Relationship  between  Cancer  and  Tubercu- 
losis  I.  D.  Nagle  gives  a  list  of   investigators  who 

have  studied  the  relationship  of  these  two  diseases. 
Burdel  declares  that  tiie  appearance  of  cancer  and  tu- 
berculosis in  the  same  family  cannot  be  due  solely 
to  accident,  but  must  be  the  result  of  an  intimate 
relation  between  the  two  diseases.  Croizet  reports 
twenty-four  cases  and  A.  Gouin  forty-two  cases  of 
coincidence  of  cancer  and  tuberculosis.  The  author 
has  in  the  past  ten  years  studied  the  family  his- 
tory of  more  than  seven  hundred  tuberculous  patients, 
and  found  that  in  eighty  cases  the  pre-existence  of 
cancer  in  one  or  more  parents  was  discovered.  He 
firmly  adheres  to  the  belief  expressed  by  Carmichael 
in  1809,  that  '"carcinoma  and  tuberculosis  belong  to 
the  same  family  of  diseases." — The  Medical  Examiner 
and  Practitioner,  October,  1900. 


NOTES    ON   TYPHOID    FEVER,  WITH    A    RE- 
PORT   OP    FIFTEEN    CASES. 

By    U.    li.    KEEKE,    M.D.. 

SPRINGFIELD,    MASS., 
VISITING    PHYSICIAN    TO  THE    MERCV    HOSPITAL. 

The  necessary  limitations  of  a  paper  for  the  Medical 
Record,  as  well  as  the  great  extent  and  interest  of 
the  subject,  to  say  nothing  of  its  familiarity,  preclude 
my  attempting  an  exhaustive  discussion  of  typhoid 
fever  or  of  giving  a  complete  re'sume  of  its  literature. 
I  shall  content  myself,  therefore,  with  a  very  cursory 
report  of  fifteen  cases  that  came  under  my  care  during 
my  present  term  of  service  at  the  Mercy  Hospital, 
making  observations  upon  them  and  upon  the  subject 
in  general. 

Etiology. — The  causative  factors  in  this  fever  are 
undoubtedly  the  Eberth  bacillus,  a  susceptibility  or 
predisposition,  or  a  want  of  resistance  on  the  part  of 
the  patient,  or  a  combination  of  all  these  circum- 
stances. True,  this  bacillus  conforms  to  but  two  of 
the  three  conditions  laid  down  in  Koch's  law,  namely, 
it  is  always  present  in  the  disease,  it  grows  outside  of 
the  body,  but  inoculations  of  its  cultures  have,  so  far, 
failed  to  produce  the  disease.  Nevertheless,  the  ex- 
periments of  Dr.  L.  Remey  seem  to  have  disposed  of 
the  claims  of  the  colon  bacillus  as  a  causative  factor 
and  established  Eberth's  as  the  only  true  cause. 

Incubation. — Until  very  recently  the  incubation 
period  of  typhoid  fever  was  not  definitely  known,  but 
the  experiments  of  Vaughn  and  others  have  estab- 
lished it  as  from  two  to  eight  days,  and  the  infection 
may  be  carried  on  the  person  or  clothing  for  eight 
weeks. 

Diagnosis. — The  prime  difficulties  in  the  prompt 
diagnosis  of  typhoid  fever  in  private  practice  are  its 
insidious  onset,  and  the  time  permitted  to  elapse  be- 
fore a  physician  is  summoned.  We  thus  lose  the  great 
advantage  of  observing  the  typical  range  of  tempera- 
ture in  its  development.  These  circumstances  are 
aggravated  by  the  atypical  form  and  the  remittent 
character  in  which  it  sometimes  presents  itself.  This 
atypical  form  is  due  either  to  a  difference  in  the 
dosage  of  the  infecting  germs,  to  mixed  infection,  a 
difference  in  the  resisting-power  of  the  patient,  or  to 
all  these  combined.  Finally,  the  extent  of  the  bron- 
chitis or  other  initial  complication  may  be  a  factor  in 
its  causation.  Be  this  as  it  may,  in  hospital  practice 
we  are  nearly  always  deprived  of  the  benefit  of  the 
observation  of  its  early  symptoms,  and  frequently  have 
but  a  very  incomplete  history,  and  that  often  entirely 
untrustworthy.  There  is  scarcely  one  of  the  acute  in- 
fectious diseases  so  protean  in  form  or  so  difficult  of 
diagnosis  in  the  early  stage  as  typhoid  fever.  If  it  is 
distinguished  for  one  thing  more  than  another,  it  is  for 
its  atypical  rather  than  regular  classical  form.  In  the 
words  of  a  great  author,  "Clinically  the  disease  is 
marked  by  fever,  a  rose-colored  eruption,  diarrhcea, 
abdominal  tenderness,  tympanites,  and  enlargement  of 
the  spleen ;  but  these  are  extremely  inconstant,  and 
even  the  fever  varies  in  its  character."'  In  pneumonia 
we  have  always  the  dulness  on  percussion,  and  the  in- 
creased fremitus;  in  scarlet  fever,  the  angina,  rasli,  and 
fever.  But  in  typhoid  fever  there  is  not  a  single 
symptom  invariably  present,  not  one  of  the  classical 
or  pathognomonic  symptoms  but  may  be  absent  in  a 
given  case,  even  the  fever  itself,  and  we  may  have  an 
afebrile  typhoid.  In  addition  to  the  symptoms  before 
referred  to,  we  have  those  of  lesser  importance,  as 
epislaxis.  cephalalgia,  prominent  and  sensitive  abdo- 
men, typhoid  tongue,  gurgling,  and  others  that  will 
readily  occur  to  tiie  reader.  Since  I  refer  to  most  of 
them  in  another  place,  I  need  not  waste  space  here 
with  their  further  enumeration. 

Widal  Reaction. — Thanks  to  the  labors  of  Pfeiffer, 


November  24,  1900] 


MEDICAL    RECORD. 


809 


Eisner,  VVidal,  and  their  co-workers,  the  last  few  years 
have  witnessed  a  great  advance  in  our  ability  to  diag- 
nose typhoid  fever.  This  is  due  to  what  is  known  as 
Widal's  test,  or  ren.ction,  and  depends  upon  the  known 
behavior  of  the  Kberth  bacilli  in  tiie  presence  of  an 
immunized  or  specific  blood  or  blood  serum;  namely, 
they  lose  their  motility,  clump  together,  and  sink  to  the 
bottom  of  tiie  liquid,  the  supernatant  fluid  becoming 
comparatively  clear.  PfeilTer  was  the  first  to  notice 
these  phenomena  taking  place  in  the  human  body.  It 
remained  for  Widal  to  apply  it  to  typhoid  fever  outside 
of  the  body,  to  simplify  it  and  make  its  application 
practicable.  I  am  aware  that  there  are  those  who  ques- 
tion both  the  utility  and  the  constancy  of  this  reaction, 
who  assert  that  it  is  neither  confined  to  typhoid  fever, 
nor  conclusive  of  it,  nor  is  it  invariably  present;  and 
finally,  that  it  is  present  in  many  other  diseased  con- 
ditions. It  is  true  that  many  circumstances  may  exist 
in  an  organism  affected  with  typhoid,  such  as  mixed 
infection  and  other  conditions  not  yet  well  under- 
stood. These  conditions  may  affect  the  reaction  two 
or  three  times  in  a  hundred,  but,  making  all  due  allow- 
ance for  such  cases,  its  importance  cannot  be  over- 
estimated. The  fact  that  VVidal,  by  its  use  alone, 
diagnosed  five  hundred  cases  without  an  error,  should 
be  a  sufficient  answer  to  such  objections.  Let  me  here 
quote  the  words  of  VVidal  in  his  last  paper  on  this 
subject:  "A  positive  reaction  should  be  considered 
a  sign  of  certitude  of  typhoid  fever.  A  negative  one 
furnishes  a  probability  against  it,  but  only  a  probabil- 
ity." Furthermore,  Pick  found  the  reaction  only  in 
typhoid  fever.  In  the  "  American  Year  Book  for  1898," 
pages  31  and  32,  is  presented  one  table  of  174  cases 
of  typhoid  fever  with  all  positive,  and  164  cases  of 
non-typhoid  with  151  negative,  reactions;  another 
table  contains  2,283  cases  of  typhoid  with  ninety-five 
per  cent,  of  positive,  and  1,350  non-typhoid  with  98.4 
per  cent,  of  negative,  reactions.  Such  statistics,  sup- 
plemented as  they  are  by  the  firfti  support  of  Frankel, 
W.  H.  VVelch,  Stewart,  VVilson,  Liebermeister,  Pfuhl, 
and  Johnson  and  McTaggart,  should  be  enough  to 
establish  the  VVidal  test  as  the  great,  I  might  say  the 
almost  certain,  test  for  typhoid  infection.  This  list 
could  be  multiplied  indefinitely  with  names  of  the 
most  eminent  men  in  the  medical  profession,  espe- 
cially in  the  department  of  bacteriology. 

Let  me  now  advert  briefly  to  another  tes,.  that  has 
been  used  somewhat  at  the  Mercy  Hospital.  I  refer 
to  Ehrlich's  diazo  reaction.  This  is  a  urinary  test, 
and  consists  in  a  reaction  taking  place  between  a 
solution  of  fifty  parts  sulphanilic  acid  and  one  thou- 
sand parts  hydrochloric  on  the  one  hand,  and  a  two- 
per-cent.  solution  of  sodium  nitrate  and  ammonia,  with 
which  the  suspected  urine  is  allowed  to  come  slowly 
in  contact  in  a  test  tube,  just  as  it  is  in  the  nitric-acid 
test  for  albumin.  (.A.  deep  brownish-red  ring  is  a 
proof  of  infection.)  This  reaction  may  be  present  be- 
fore the  appearance  of  the  rash  and  persist  until  the 
twenty-second  day.  Its  value  is  lessened,  however, 
by  its  occurrence  in  miliary  tuberculosis,  and  occa- 
sionally in  cases  associated  with  high  fever.  Osier 
found  it  in  twenty-two  out  of  twenty-six  cases  of 
typhoid  fever. 

Mixed  Infection. — There  are  still  those  who  ques- 
tion the  coexistence  of  the  typhoid  bacillus  and  the 
Plasmodium  of  malaria.  They  insist  that  typho- 
malarial  fever  is  nothing  more  nor  less  than  a  remit- 
tent or  continued  malarial  fever  with  typhoidal  symp- 
toms. True,  the  blood  of  our  typhoid  cases  at  the 
hospital  was  frequently  tested  for  plasmodia  with 
negative  results  in  all  but  one  case,  and  this  was  un- 
doubtedly one  of  mixed  infection  ;  still  there  are  symp- 
toms in  many  cases  of  typhoid  fever  that  cannot  be  ac- 
counted for  on  any  other  hypothesis  than  that  of  mixed 
infection.     There  are  the  recurring  chills,  the  atypical 


form,  and  the  remittent  character,  to  say  nothing  of  the 
double  quotidian  curve.  There  is  also  tiie  great  swing 
of  the  fever  wave,  its  height  and  depth.  As  bacteri- 
ology increases  both  in  the  number  and  enthusiasm  of 
its  workers,  I  firmly  believe  that  mixed  infection  will, 
in  the  near  future,  be  established  as  a  certainly.  In- 
deed, we  may  say  the  light  is  already  beginning  to 
shine,  when  a  man  of  such  attainments  as  V.  C. 
Vaughn  declares  in  its  favor  and  furnishes  proof  of  its 
existence.  A.  J.  Lartigau  reports  the  diplococcus  lan- 
ceolatus  and  the  streptococcus  pyogenes  present  in 
company  with  the  bacillus  typhosus.  Osier  acknowl- 
edges aqualified  belief  in  the  idea  of  mixed  infection, 
and  cases  are  reported  by  J.  M.  DaCosta,  C.  F.  Craig, 
A.  Stengal,  M.  Gollman,  and  T.  F.  Raven;  while  Dr. 
VVoodard  is  a  most  ardent  advocate  of  the  doctrine. 

Prognosis. — The  heart  in  typhoid  is  normally  rela- 
tively slow,  not  maintaining  its  relation  with  the  fever. 
So  a  weak  heart,  inaudible  first  sound,  a  change  in 
the  heart's  rhythm  are  most  unfavorable,  as  are  obesity, 
alcoholism,  profuse  hemorrhage,  nervous  tremors,  and 
serious  involvement  of  the  nervous  system,  active  de- 
lirium, too  profuse  diarrhoea. 

Mortality  Rate.— I'he  mortality  rate  varies  with 
different  epidemics,  and  with  the  different  treatments. 
Osier  gives  it  as  ten  to  thirty  per  cent.;  J.  C.  VVilson 
reports  one  series  of  selected  cases  at  the  German 
Hospital  with  3.4  per  cent.,  and  another  series  of  two 
hundred  and  seventeen  cases  with  7.8  per  cent.;  A. 
V.  Meigs  reports  two  hundred  and  fourteen  cases  in 
the  Pennsylvania  Hospital  with  a  mortality  rate  of 
8.88  per  cent.;  three  hundred  and  eighty-nine  cases 
were  treated  at  the  Johns  Hopkins  Hospital  in  six 
years,  with  a  rate  of  twenty-four  per  cent.  The  mor- 
tality rate  at  the  Montreal  General  Hospital  for  twenty 
years  was  11.2  per  cent.;  and  Murchison,  in  summing 
up  an  immense  number  of  cases,  made  the  death  rate 
nineteen  percent.  There  were  one  hundred  and  twenty- 
six  cases  treated  at  the  Mercy  Hospital  with  twelve 
deaths,  making  a  rate  of  g.oS  per  cent.  The  fifteen 
cases  here  reported  all  resulted  in  recovery.  There 
can  be  no  question  that  the  Brand  treatment  has  reduced 
the  mortality  rate  to  between  four  and  se\en  per  cent. 
Although  the  mortality  of  children  is  generally  thought 
to  be  small  in  typhoid  fever,  Dr.  Abraham  Jacobi  re- 
ports a  series  of  cases  in  the  children's  pavilion  of 
Bellevue  Hospital,  having  a  death  rate  of  twenty  per 
cent.,  and  he  refers  to  the  series  of  Oesterlin  with 
twenty-two  per  cent,  and  F'riederich  with  twenty-three 
per  cent. 

Symptoms  and  Treatment — Of  my  cases  the  ages 
ranged  from  seven  to  forty-five  years.  The  attacks 
were  quite  severe  in  one-third,  the  remaining  two- 
thirds  being  mild.  Two  of  the  mild  ones  proved 
abortive.  Widal's  test  gave  a  positive  reaction  in 
all  but  one,  and  in  this  one  the  plasmodiuni  of 
malaria  was  found.  The  disease,  however,  failed  to 
respond  to  cinchonization  and  continued  on  its  course, 
and  a  long  course  it  proved.  This  was  apparently 
a  case  of  mixed  infection.  'I'he  diazo  reaction  was 
used  in  one-third  of  the  cases,  with  all  positive  re- 
actions. Many  were  tested  for  the  presence  of  Plas- 
modium, especially  when  any  deviation  from  the 
normal  was  observed.  Limited  though  this  number 
of  cases  is,  it  embraced  some  without  diarrhoea,  some 
without  rose  spots,  and  as  for  the  typical  range  of 
temperature,  that  was  more  noticed  in  the  breach 
than  in  the  observance.  Epistaxis  was  present  in 
but  one  case,  and  as  to  the  prominent  sensitive  ab- 
domen, it  was  no  more  in  evidence  than  the  scaphoid 
or  boat-shaped  one.  Tympanites  was  frequently  pres- 
ent, but  not  invariably.  The  pale  olive,  leaden  look 
was  no  more  constant  than  the  suffused,  flushed  coun- 
tenance, especially  until  the  latter  part  of  a  long  run 
of  the  fever.     The  enlargement  of  the  spleen  was  not 


i 


8io 


MEDICAL    RECORD. 


[November  24.  1900 


a  very  constant  symptom.  1  may  say  parenthetically 
that  making  out  the  spleen,  especially  in  the  presence 
of  a  tympanitic  abdomen,  and  unless  the  enlargement 
is  very  considerable,  is  a  task  not  always  satisfactorily 
accom|)lished.  Nervous  sym])toms,  as  delirium,  car- 
phology,  and  subsultus  tendinum,  were  not  present  to 
any  unpleasant  degree  except  in  one  case:  constipa- 
tion was  present  more  frequently  than  diarrhcea;  in- 
deed, the  latter  was  not  prevalent  to  any  such  extent 
as  to  call  for  interference  except  in  one  case.  Ab- 
dominal pain  was  never  a  subject  of  complaint.  The 
tongue  generally  conformed  to  what  one  would  expect 
a  well-developed  typhoid  tongue  to  do,  namely,  to  be 
hrst  covered  with  a  while  coat,  which  gradually  cleaned 
from  the  edges  toward  the  centre;  to  be  replaced  by  a 
brown  coat,  or  to  remain  clean,  red,  beefy,  and  become 
fissured.  There  were,  however,  many  cases  in  which 
the  tongue  retained  its  first  white  coat  throughout  the 
disease.  True,  the  coat  grew  a  little  yellow  with  time, 
but  was  not  exfoliated  and  remained  moist.  After  all, 
the  cephalalgia  was  the  most  constant  symptom,  though 
the  pain  was  not  of  an  excruciating  character.  Bron- 
chitis was  an  almost  universally  present  initial  symp- 
tom. Albuminuria  was  present  in  a  majority  of  the 
cases,  as  were  hyaline  and  frequently  fine  granular 
casts,  and  they  persisted  in  some  of  the  cases  long 
after  defervescence.  One  of  the  cases  was  compli- 
cated by  true  nephritis  with  three  to  six  per  cent,  of 
albumin  and  fine  and  coarse  granular,  epithelial,  and 
hyaline  casts,  notwithstanding  which  the  patient  is 
convalescing.  I  may  add  that  this  patient  had  re- 
peated hemorrhages.  An  interesting  complication 
was  a  suppurative  appendicitis,  and  an  appendectomy 
was  done  by  Dr.  W'eiser;  the  patient  made  a  good  re- 
covery, except  that  he  had  an  unusually  long  run  of  the 
fever.  I  have  seen  two  such  cases  elsewhere  reported. 
One  little  girl  was  sent  in  for  operation  for  a  supposed 
appendicitis;  she  had  the  most  sensitive  abdomen  of 
the  series,  but  made  a  good  recovery  without  opera- 
tion. 

The  treatment  that  in  my  judgment  offers  the  great- 
est promise,  both  as  prophylactic  and  curative,  is  orrho- 
therapy.  I  could  report  many  favorable  cases  treated 
in  this  manner,  but  shall  content  myself  with  report- 
ing one  instance  of  its  use  for  prophylaxis  or  immuni- 
zation. Professor  Wright,  of  Netley,  inoculated  about 
three  thousand  soldiers  for  service  in  India,  where 
typhoid  is  very  prevalent.  He  subsequently  observed 
the  disease  rate  and  the  death  rate  in  the  inoculated 
as  compared  with  those  not  inoculated.  The  result 
was  that  the  disease  rate  in  the  uninoculated  was 
treble  and  the  death  rate  nearly  double  that  of  the  in- 
oculated. 

There  have  been  many  kinds  of  treatment  proposed, 
as  the  abortive,  the  antiseptic,  the  normal  salt,  and 
the  cathartic.  A  careful  study  of  the  literature  con- 
vinces me  that,  with  our  present  knowledge,  we  have 
no  medicinal  agents  able  to  abort  or  cure  typhoid 
fever,  or,  indeed,  any  of  the  acute  infectious  diseases. 
I  do  not  say  that  there  may  never  be  a  combination  of 
circumstances  when  tlie  proper  dose  given  at  just  the 
proper  moment  would  not  exert  an  influence  for  good, 
and  perchance  prove  curative.  Still,  I  believe  this 
is  an  exceptional  combination.  Such  treatment  may, 
however,  promote  tiie  comfort  of  the  patient  and  so  en- 
al)le  him  more  easily  and  successfully  to  bear  the  bur- 
den of  his  sickness.  In  consequence  of  this  belief  it 
will  be  readily  appreciated  that  my  treatment  was  sub- 
stantially ;;//,  and  so  indeed  it  was.  Some  medicines 
were  employed,  but  only  tentatively,  one  medicine  in 
this  case  and  another  in  that,  because  each  bore  some 
relation  to  the  prevailing  symptom,  but  principally  as 
placebos.  The  medicines  employed  consisted  of  gr.  v. 
salol  in  one,  and  tiie  same  with  gr.  xv.  subnitrate  of 
bismuth  in  another;  gti.  x.  tincture  of  nux  vomica,  or 


gr.  ,i„  strychnine  in  another;  gtt.  vi.  dilute  hydro- 
chloric acid,  or  a  teaspoonful  of  compound  tincture  of 
cinchona,  in  the  next — all  given  usually  three  times 
daily.  I'or  the  intestinal  hemorrhages,  lead  and  opium 
pills,  one  every  four  hours,  and  a  mixture  containing 
to  each  dose  gtt.  xv.  Huid  extract  of  ergot  and  gtt.  x. 
each  of  tincture  digitalis  and  colorless  fluid  extract 
hydrasiis  canadensis.  For  my  severest  cases  I  gave  a 
few  doses  of  gr.  x.  phenacetin  in  the  afternoon,  accom- 
panied by  gtt.  XX.  tincture  of  digitalis,  and  on  one 
occasion  gr.  xxx.  of  quinine,  cautioning  the  nurse  to 
administer  whiskey  and  digitalis  should  too  much  de- 
pression follow.  The  constipation  was  controlled  by 
calomel,  citrate  of  magnesia,  cascara,  or  salts,  the  latter 
generally  having  the  preference.  t)n  one  or  two  occa- 
sions an  hypnotic  was  required,  when  gr.  xv.  of  trional 
was  given.  As  before  stated,  I  consider  the  medi- 
cinal treatment  of  secondary  importance.  That  of 
paramount  importance  is  the  non-medicinal.  The  treat- 
ment by  cold  was  first  proposed  by  Currie,  of  Liver- 
pool, at  the  end  of  the  last  century,  but  there  being  at 
that  time  no  clinical  thermometers  to  measure  either 
its  immediate  or  ultimate  effects,  it  became  neglected 
and  finally  disused.  It  remained  for  Brand,  of  Stet- 
tin, to  bring  it  again  to  the  notice  of  the  profession 
and  to  formulate  rules  for  its  employment.  Although 
it  was  condemned  by  so  close  an  observer  as  the  late 
Prof.  Alfred  Loomis,  and  adopted  only  in  a  modified 
manner  by  Professor  Osier,  I  consider  it  rational, 
safe,  and  the  most  effective  treatment  for  hyperpyrexia. 

I  did  not  attempt  to  carry  out  the  Brand  treatment 
in  my  cases  by  reason  of  lack  of  facilities  on  the  one 
hand,  and  on  the  other  of  an  indisposition  to  resort  to 
such  radical  treatment,  especially  since  my  cases,  with 
one  exception,  were  not  sutificiently  grave.  Moreover, 
the  measures  resorted  to  seemed  to  accomplish  all 
that  was  desired.  The  application  of  cold  was  effected 
by  ice  in  rubber  ba^s,  applied  around  the  head  and 
on  the  abdomen.  These  bags  were  wrapped  in  towels 
to  prevent  wetting  the  patient  and  bedding  by  precipi- 
tation of  watery  vapor  from  the  atmosphere,  caused  by 
its  contact  with  the  cold  rubber.  In  addition  to  this 
in  my  most  severe  case  a  cold  coil  was  constantly  ap- 
plied to  the  abdomen,  sponging  was  done  every  two 
hours,  and  late  in  the  afternoon  a  sheet  wet  in  cold 
water  was  wrapped  round  the  patient.  This,  and  a  1  ittle 
attention  to  the  mouth  and  the  changing  of  bed  and  body 
linen,  composed  the  most  important  part  of  the  treat- 
ment. It  goes  without  saying  that  the  linen  was  re- 
moved and  disinfected  as  often  as  soiled,  that  the  excre- 
ments were  received  into  a  i  :  20  carbolic-acid  solu- 
tion, covered  with  a  like  solution  stirred  up  to  mix 
thoroughly,  and  immediately  disposed  of.  The  only 
tangible  effect  of  the  digitalis  was  to  produce  a  great 
increase  in  the  excretion  of  urine,  and  of  strychnine 
that  it  accentuated  the  etTect  of  the  digitalis.  I  was  not 
able  to  realize  any  useful  etTect  from  whiskey,  a  few 
one-ounce  doses  of  which  were  given  experimentally. 

Diet. — The  diet  consisted  for  the  most  part  of  milk, 
a  glass  of  which  was  usually  given  every  two  hours. 
This  was  varied  or  supplemented  by  beef  tea,  thin 
broths,  thin  gruels,  and  egg-water,  as  demanded  by  dif- 
ferent indications. 


The  Diet  in  the  Acute  Stage  of  Pneumonia. — 
Andrew  H.  Smith  prefers  egg-water  and  peptonized 
milk.  The  former  is  prepared  by  squeezing  the  albu- 
men of  one  or  two  eggs  through  a  cloth  and  adding 
half  a  pint  of  water  and  a  pinch  of  salt.  This,  or 
beef  tea,  may  be  given  alternately  with  milk  at  the 
rate  of  three  ounces  of  either  every  three  hours.  If 
llatulency  occurs  koumyss  or  matzoon  may  be  substi- 
tuted for  the  milk. —  liihnuUional  Aledual  Magazine, 
October,  1900. 


November  24,  1900] 


MEDICAL    RECORD. 


811 


THE     VALUE   OF    THERMAL    CARBONATED 
SALLNE   BATHS    IN    GYX.ECOLOGY. 

By   S.    \V.    BANULEK,    M.D., 

NEW    YORK. 

We  find  in  gynaecological  practice  a  very  large  number 
of  cases  which,  though  the  symptoms  may  be  Severe, 
deserve  conservative  treatment  for  the  following  rea- 
sons: (i)  Because  after  a  long  treatment  they  may  be 
considerably  improved ;  (2)  because  their  symptoms, 
as  local  affections,  do  not  justify  tiie  risk  of  operative 
interference;  (3;  because  tiie  desire  for  future  preg- 
nancy is  a  justification  for  conservatism;  {4)  because 
the  cases  after  acute  inliamniations  are  suited  to  con- 
servative methods  only  ;  (5)  because  such  methods  are 
a  valuable  preliminary  to  subsequent  operation;  and 
finally  (6),  because  the  local  affection  is  only  a  part  of 
a  generally  weakened  physical  state. 

Among  these  conditions  are  included  certain  forms 
of  metritis,  parametritis,  pelveo-peritonitis,  salpingitis, 
hydrosalpinx,  pyosalpinx,  etc.  A  large  proportion  of 
cases  iiave  these  affections  to  a  slight  degree,  but 
combined  with  them  are  displacements  of  the  uterus 
and  adnexa  witii  chronic  congestion  or  venous  stasis 
in  the  pelvis,  with  reflex  and  constitutional  symptoms. 
Not  infrequently  ren  mobilis,  gastroptosis,  and  enter- 
optosis  are  found  coexisting.  These  patients  often 
possess  a  tlabbiness  and  lack  of  elasticity,  which  is  by 
no  means  the  result  of  the  gynai-cological  condition,  so 
that  we  are  compelled  to  consider  the  latter  as  part  of 
a  general  state. 

From  the  gynecological  standpoint  we  name  this 
condition  hysteroptosis.  These  various  conditions 
are  through  local  treatment,  and  especially  through 
rest,  open  to  improvement.  Especially  is  rest  an  im- 
portant and  often  astonishingly  valuable  means  in 
aiding  resorption  and  relie\ing  congestion.  If,  com- 
bined with  local  treatment,  attention  is  given  to  exist- 
ing weakness,  anaemia,  and  circulatory  disturbances, 
then  we  obtain  decidedly  better  results.  Conditions 
such  as  rheumatism,  gout,  and  auto-intoxication  must 
be  taken  into  consideration.  The  important  element 
in  the  treatment  of  exudates  and  congestions  consists 
in  restoring  a  normal  pelvic  and  general  circulation, 
and  in  toning  up  the  muscular  structures  of  the  pelvis 
and  the  body  generally. 

It  was  the  frequency  with  which  the  cases  of  hyster- 
optosis came  under  my  observation  that  influenced  me 
to  look  to  constitutional  treatment  for  their  relief  in 
place  of  continued  local  applications  for  these  symp- 
toms, among  which  leucorrhcea,  pelvic  looseness,  and 
especially  backache  may  be  mentioned.  The  method 
which  has  the  greatest  and  most  rapid  effect,  and 
which  in  certain  cases  seems  almost  specific,  is  hydro- 
therapy, under  which  we  understand  both  thermal  and 
che'nical  stimuli.  A  study  of  the  general  action  of 
thermal  carbonated  saline  baths  confirms  me  in  the 
belief  that  we  have  in  them  an  excellent  method  of 
treatment  for  such  cases,  especially  to  promote  the  re- 
sorption of  exudates  and  inHamniations,  and  for  the 
relief  of  congestions.  The  results  obtained  in  the 
treatment  under  my  own  direction  in  the  clinic  Abel, 
Berlin,  of  twenty-one  selected  cases  with  various 
gyn;T;cological  ailments  amply  justify  the  acceptance 
of  this  method,  and  future  experience  will  suffice  to 
fix  the  limitations  and  indications.  Among  the  most 
gratifying  results  were  those  obtained  in  the  treatment 
of  pyosalpinx.  This  paper  deals,  therefore,  with  the 
treatment  of  (i)  exudates,  infiltrates,  and  inflamma- 
tions;   (2)  pelvic  congestions;    (3)  hysteroptoses. 

Winternitz  and  his  school  have  taught  us  the  effect 
of  baths  of  different  temperatures,  and  we  have  in 
hydrotherapy  a  powerful  oxidation  therapy,  whereby 
through  thermal  and  mechanical  influences,  activity 
and  function,  hunger  and  revulsion   can   be   produced 


in  the  cell.  Hydrotherapy  is  a  powerful  curative 
method,  since  thermal  and  mechanical  processes  are 
the  normal  stimuli  which  arouse,  strengthen,  and  reg- 
ulate our  organic  functions  in  a  physiological  way. 
An  important  efTect  of  hydrotherapy  results  through 
its  influence  in  changing  and  altering  the  blood  dis- 
tribution through  the  withdrawal  of  blood  from  con- 
gested and  overloaded  organs,  whereby  circulatory 
disturbances  may  be  corrected.  The  value  of  such  a 
change,  and  its  influence  upon  congestions  in  the  pel 
vis,  may  be  recognized  when  we  consider  that,  next  to 
the  peripheral,  the  region  of  the  pelvic  vessels  with 
their  large  venous  plexuses  is  one  of  the  most  impor 
tant  elements  in  regulating  blood  division  and  blood 
pressure.  Since  the  blood  and  lymph  channels  fur- 
nish the  material  for  the  organic  functions  and  for  the 
nutrition  of  the  organs,  the  circulation  of  anv  part  is 
one  of  the  most  important  factors  in  preserving  its 
tone. 

'J'he  use  of  cold  water  influences  also  a  change  in 
the  morphological  character  of  the  blood.  Jt  causes 
not  alone  an  increase  in  the  number  of  leucocytes,  but 
likewise  a  decided  increase  in  the  number  of  red 
blood  corpuscles.  A  necessary  factor  in  obtaining 
this  result  is  the  production  of  a  decided  hyperamia 
of  the  skin.  If  the  skin  remains  cool  for  a  considerable 
time,  and  if  a  complete  reaction  is  not  excited,  this 
change  does  not  result;  for  then  these  cells,  probably 
preformed  blood  cells,  do  not  enter  the  general  circu- 
lation. Since  after  warm  baths  the  increase  in  the 
number  of  erythrocytes  is  much  less,  this  increase 
rests  clearly  upon  changes  in  the  circulation,  in  the 
heart's  action,  and  in  vessel  tonus  and  tissue  tonus. 
The  blood  richer  in  cells,  richer  in  oxygen,  makes  the 
entire  tissue  change  more  complete,  and  causes  an 
increased  consumption  of  oxygen,  and  an  increased 
giving  off  of  CO,.  The  resulting  increased  produc- 
tion of  heat  is  reflexly  regulated,  and  not  by  the  de- 
gree or  amount  of  heat  withdrawn,  but  by  the  degree 
of  the  thermal  nerve  stimulus.  The  increased  tissue 
metamorphosis  brought  about  reflexly  through  the  in- 
fluence of  cold  causes  no  increased  consumption  of 
albumin,  but  concerns  chiefly  the  elements. 

The  combination  of  cold  with  a  mechanical  stimu- 
lus increases  the  reaction.  Cold  baths  cause  a  con- 
traction of  the  peripheral  vessels  and  bring  about, 
through  thermal  stimulation  of  the  vagus,  a  slowing  of 
the  pulse,  increase  tile  oxidation  processes  in  the  body, 
and  exert  a  stimulating  effect  on  the  central  nervous 
system.  An  important  result  of  the  contracting  influ- 
ence of  cold  is  the  increase  in  the  venous  tonus.  Since 
cold  temperatures  oppose  the  dilatation  of  the  periph- 
eral vessels,  mechanical  stimuli  are  necessary  to 
bring  about  a  dilatation,  so  that  in  hydrotherapy  the 
mechanical  stimulation,  frottement,  must  be  combined 
with  a  thermal  procedure  to  bring  about  peripheral 
relaxation;  for  only  with  the  resulting  sinking  of  the 
tension  and  of  the  blood  pressure  (reaction)  comes  a 
feeling  of  well-being,  and  only  those  thermal  processes 
which  influence  the  heat  balance  of  the  body  can  be 
considered  trophic,  and  only  those  which  lead  to  re- 
action tonic. 

A  warm  full  bath  causes  an  increase  in  the  rapidity 
of  the  pulse,  which  persists  after  the  bath.  This  occurs 
through  its  influence  on  the  peripheral  nerve  supply, 
which  reflexly  acts  upon  the  vagus  centre,  and  which 
stimulates  the  accelerantes  of  the  vagus.  Such  a  bath 
can  through  weakening  of  the  venous  tonus  cause  an 
increased  resistance  in  the  minor  circulation,  whereby, 
in  spite  of  increased  work  on  the  part  of  the  heart,  no 
bettering  of  the  circulation  results.  This  is  a  weaken- 
ing influence,  since  the  heart  is  sufficient  only  when  it 
is  able  to  force  the  blood  to  the  most  distant  organs, 
in  whose  capillaries  alone  tissue  metabolism  takes 
place.     A  warm  full  bath  causes  usually  no  increased 


8l: 


MEDICAL    RECORD. 


[November  24,  1900 


demand  for  nutrition  and  exerts  no  stimulating  effect 
on  the  central  nervous  system.  The  following  objec- 
tions may  be  raised  also  against  cold  fresh-water 
baths : 

1.  A  mechanical  frottement  of  the  skin  during  and 
after  the  bath  is  necessary  to  bring  about  a  complete 
reaction. 

2.  Many  patients  cannot  stand  the  first  shock  of  the 
cold  water. 

3.  The  effect  of  the  bath  lasts  but  a  short  time. 

4.  The  increased  tissue  metabolism  is  not  so  great 
as  in  other  baths. 

We  can  substitute  for  the  thermal  and  mechanical 
stimuli  chemical  stimuli,  and  can  likewise  overcome 
the  shock  of  the  cold  water,  if  the  bath  contain  chemi- 
cal ingredients  which  exert  a  frottement  of  the  entire 
periphery.  Through  varying  proportions  of  the  chemi- 
cal ingredients  we  can  regulate  the  strength  of  the 
stimulus.  We  can  in  a  bath  of  indifferent  temperature 
without  shock  in  this  way  obtain  the  same  and  more 
lasting  stimuli  than  by  thermal  means,  and  can  cause 
by  chemical  combinations  a  more  decided  increase  in 
the  processes  of  oxidation.  We  are  able  by  such 
baths  to  bring  about  a  lasting  protection  and  rest  to 
the  heart,  and  an  improved  state  of  the  circulation. 
An  important  element  is  the  ability  to  bring  about  a 
decided  and  increased  resorption  of  broken-down  tis- 
sue products. 

Salt  added  to  baths  increases  the  effect  of  cold. 
Zunts  found  that  in  a  three-per-cent.  saline  bath 
there  was  an  increase  of  oxidation,  as  compared  with 
a  fresh-water  bath,  so  that  fifteen  per  cent,  more  oxy- 
gen was  used  and  twenty-five  per  cent,  more  CO.,  was 
given  off.  This  effect  could  not  be  obtained  if  the 
nerve  ends  were  paralyzed  with  curare.  Agents 
which,  like  the  saline  bath,  bring  about  increased 
metabolism  are: 

r.  Sea  air,  which,  however,  diminishes  the  amount 
of  phosphoric  acid  excreted  and  stimulates  the  nervous 
system  constantly  vi'ithout  a  decided  or  permanent 
effect  upon  the  circulation.  2.  The  drinking  of  cold 
water,  which  increases  tissue  change  by  depriving  the 
body  of  heat,  but  is  not  well  borne  by  the  digestive 
tract.  3.  Physical  exercise,  which,  however,  demands 
the  increased  use  of  energy,  increases  the  amount  of 
phosphoric  acid  excreted,  and  is  decidedly  contraindi- 
cated  in  inflammatory  pelvic  conditions. 

Simple  rest  causes  no  increased  tissue  change,  has 
constitutionally  no  effect  on  the  general  tone,  rests  the 
nervous  system,  but  is  accompanied  by  no  stimulating 
action  on  the  same.  A  bath  containing,  in  addition 
to  salt,  calcium  chloride,  wliich  exerts  reflexly  a  de- 
cided action  on  the  breaking  down  of  old  tissue,  and 
CO,,  brings  about  most  valuable  results.  Its  action 
follows  the  law  of  normal  body  stimuli  and  causes  a 
relief  and  rest  for  the  heart,  since  the  chemical  ele- 
ments and  the  CO,  dilate  the  peripheral  vessels,  carry 
the  blood  into  the  vessels  of  the  muscles,  relieve  the 
interior  of  the  body  of  congestions,  and  cool  it  on 
the  return  of  the  blood.  The  effect  upon  metabolism 
and  tissue  change  is  here  not  brought  about  through 
exertion  or  through  the  giving  off  of  reserve  energy, 
but  through  the  channels  of  protection  and  tissue  sub- 
stitution. This  regulated  and  altered  tissue  change 
goes  on  within  a  certain  physiological  limit,  which 
does  not  endanger  or  overtax  the  functional  energies 
of  the  body.  However  low  the  temperature  of  the 
bath  may  gradually  be  reduced,  a  frottement  is  always 
brought  about  through  the  action  of  the  chlorides  and 
the  free  CO.. 

Beneke,  in  1859,  minutely  studied  -the  action  of 
such  baths  and  gave  them  a  decided  scientific  basis. 
The  advances  in  later  years  have  proven  that  the 
neurotherapeutic  value  of  such  baths  is  an  important 
factor,  since  reflexly  the  entire  nervous    system  and 


the  trophic  centres  are  greatly  stimulated,  especially 
by  the  CO., 

A  fifty-gallon  bath  containing  among  other  ingre- 
dients five  pounds  of  sodium  chloride  and  ten  ounces 
of  calcium  chloride  with  some  CO.^,  that  is,  a  Nau- 
heim  bath  of  a  temperature  of  27"  K.,  was  found  to  cause 
a  slight  daily  increase  of  tissue  metabolism.  The 
degree  or  intensity  of  this  change  varies,  however, 
considerably  at  certain  periods  of  the  day.  The  in- 
crease of  tissue  change  causes  an  increased  demand  for 
nutrition  and  is  accompanied  by  an  increase  in  the 
amount  of  kidney  secretion.  The  excretion  of  urea  is 
slightly  increased,  the  excretion  of  phosplioric  acid  is 
diminished.  The  inunediate  effect  of  such  a  bath  is  a 
diminution  in  the  frequency  of  the  pulse  and  in  the 
number  of  respirations.  Tissue  metabolism  is  imme- 
diately stimulated,  for  during  the  hours  directly  fol- 
lowing a  bath  most  of  the  solid  constituents  are  ex- 
creted in  the  urine.  In  the  later  hours  metabolism 
possesses  a  slighter  intensity  than  during  the  same 
hours  and  days  when  no  baths  are  taken.  The  dimi- 
nution in  the  amount  of  phosphoric  acid  excreted  is 
one  of  the  important  effects,  and  stands  in  relation  to 
the  benefits  which  later  result  to  the  body  nutrition. 
The  increased  amount  of  this  substance  in  the  body 
stimulates  the  further  production  of  new  tissue  and  is 
of  the  greatest  importance  in  determining  the  quality 
of  the  structures  which  replace  the  broken-down  tis- 
sues. If  the  broken-down  tissues  are  substances  of  an 
abnormal  character,  and  if  the  substituted  nutrition 
is  of  a  character  suited  to  the  building  up  of  nor- 
mal structures,  then  this  element  in  combination  with 
the  phosphoric  acid  offers  valuable  restoration  to  the 
body.  The  amount  of  carbonic-acid  gas  excreted 
through  the  skin,  and  especially  through  the  lungs,  is 
shown  through  the  frequent  occurrence  of  fetid  ex- 
piration after  a  bath,  a  process  which  can  be  attributed 
to  an  oxidation,  among  other  things,  of  organic  acids. 
A  retarded  metamorphosis  of  the  organic  acids  is  often 
found  in  persons  with  a  weak  nervous  system,  in  large 
eaters,  and  in  many  cases  of  ana:mia.  If  the  amount 
of  the  saline  ingredients  of  the  bath  is  increased,  there 
results  a  slight  increase  of  the  various  effects.  There 
may  be  a  still  further  demand  for  nutrition,  the  secre- 
tion of  the  kidney  is  increased,  but  the  amount  of 
phosphoric  acid  excreted  may  be  greater  than  nor- 
mally; therefore  the  subjective  feeling  varies,  and 
there  occurs  easily  a  feeling  of  weariness  and  lassi- 
tude. The  effect  depends  greatly  upon  individual 
qualities.  If  there  is,  with  stronger  baths,  no  over- 
stimulation, then  the  good  results  persist.  If  there  is, 
on  the  contrary,  an  over-stimulation,  then  comes  a 
weakening  effect  with  evidences  of  nervousness,  sleep- 
lessness, loss  of  appetite,  etc. 

There  is,  therefore,  for  every  individual  a  certain 
limit  beyond  which  an  increase  of  tissue  change  and 
nerve  stimulation  must  not  be  carried,  and  the  above- 
mentioned  symptoms,  together  with  the  increased  ex- 
cretion of  phosphoric  acid,  are  evidences  of  too  strong 
baths. 

The  power  of  these  baths  in  aiding  resorption  is 
evidenced  by  the  results  obtained  by  lieneke  in  the 
treatment  of  rheumatism  and  gout.  Almost  without 
exception  the  rheumatic  symptoms  in  the  joints  disap- 
peared after  a  course  of  baths.  Kecurrences  rarely  de- 
veloped. The  heart  action  was  always  quieted,  and  anse- 
mic  and  run-down  patients  improved  rapidly.  If  the 
inflammation  centre  was  changed  to  real  connective  tis- 
sue, or  was  retracted  and  sclerosed,  it  was  then  difficult 
to  obtain  improvement.  If  this  centre,  on  the  con- 
trary, was  fresh,  then  it  was,  as  a  rule,  capable  of  re- 
sorption. The  baths  were  well  borne  after  the  acute 
symptoms  were  overcome.  These  two-  to  four-per- 
cent, saline  baths,  slightly  carbonated,  of  a  temperature 
between  27 '-25°  K.,  were  well   borne  by  the  severest 


November  24,  1900] 


MEDICAL    RhCORD. 


813 


heart  cases.  The  resorption  of  serous  transudates 
and  joint  exudates  was  truly  astonishing.  A  partial  or 
complete  resorption  of  the  endocardial  growth  was 
found  to  be  more  certain,  the  nearer  to  the  acute  at- 
tack the  baths  were  begun,  and  the  improvement  in 
the  condition  of  delicate  persons  was  so  rapid  that 
Beneke  deemed  it  dependent  upon  other  influences 
than  increased  tissue  metamorphosis.  It  is  this  ele- 
ment, namely,  the  stimulation  of  the  trophic  centres 
through  the  salts,  and  most  especially  through  the  CO., 
upon  which  Graupner  lays  stress,  using  as  an  exam- 
ple the  vast  and  decided  improvement  in  cases  of 
locomotor  ataxia. 

The  action  of  CO,  is  to  produce  a  feeling  of 
warmth,  and  a  dilatation  of  the  capillaries  of  the  skin 
and  of  the  peripheral  vessels.  After  a  bath  the  CO, 
causes  a  feeling  of  exhilaration,  provided  the  amount 
of  CO,,  and  the  duration  of  the  bath  be  not  too  great. 

The  action  of  these  thermal  carbonated  saline  baths 
brings  about  the  following  results:  (i)  Slowing  of  the 
pulse  and  respiration,  (2)  increased  oxidation;  (3) 
increased  diuresis,  (4)  a  saving  of  phosphoric  acid; 
(s)  rest  and  protection  for  the  heart;  (6)  regulation 
of  the  circulation  and  a  subsequent  strengthening  of 
the  heart  through  increased  tonus  of  the  entire  circu- 
latory system,  and  through  the  removal  of  congestions; 
(7)  an  increase  in  the  number  of  red  blood  cells;  (8) 
a  building  up  of  healthy  tissue;  (9)  an  increased  de- 
mand for  nutrition;  (10)  a  stimulation  of  the  entire 
nervous  system,  especially  the  trophic  centres;  (11) 
the  removal  of  congestion;  {12)  the  resorption  of 
exudates. 

The  value  of  these  baths  has  been  proven  in  amenor- 
rhcea,  in  insufficient  development  of  the  genitalia,  and 
in  insufficient  muscular  condition  of  the  uterus,  with  or 
without  chlorotic  symptoms.  Uterine  catarrh,  depend- 
ing upon  a  lack  of  elasticity  of  the  pelvic  organs,  dis- 
turbances in  the  blood  supply,  and  atony  of  the  vessels. 
is  greatly  benefited  by  this  treatment.  The  immedi- 
ate effect  can  be  recognized  by  the  fact  that  often  after 
a  bath  large  amounts  of  mucus  are  discharged,  caused 
by  increased  secretion  and  a  stimulation  of  the  con 
traction  of  the  uterus.  This  latter  action  explains 
their  value  in  cases  of  subinvolution.  In  chronic 
metritis  the  bath  causes  a  diminution  of  hypercemia, 
removes  the  collateral  circulatory  disturbances,  and 
improves  the  general  condition.  This  effect  may  be 
obtained  so  long  as  no  interstitial  hypertrophy  exists. 
The  older  the  affection,  the  more  energetic  must  be 
the  treatment.  Cases  of  chronic  metritis  after  re- 
peated abortions,  or  during  the  climacterium,  should 
not  be  treated  with  strong  saline  baths,  since  througli 
a  continued  blood  supply  they  are  liable  to  exacerba- 
tions. Nervous  individuals  must  be  given  graded 
treatment,  and  in  these,  as  in  anamic  cases,  progress 
must  be  made  slowly,  for,  as  Graupner  says,  these  are 
cases  in  which  the  entire  energy  of  the  body  is  consumed 
in  preserving  a  balance  between  nutrition  and  the 
force  used  in  the  performance  of  the  most  necessary 
body  functions,  so  that  the  slightest  degree  of  over- 
stimulation is  of  decided  injury. 

The  first  severe  test  to  which  I  put  the  baths  was  in 
a  case  of  pelvic  cellulitis  of  gonorrhoeal  origin,  with 
the  most  complete  infiltration  of  the  pelvic  and  para- 
metric and  perimetric  tissue  I  have  ever  seen.  Local 
treatment  and  rest  in  bed  for  two  weeks  having  no 
effect,  I  sent  her  as  a  test  case  to  Nauheim.  On 
leaving,  the  uterus  was  so  embedded  that  it  could 
scarcely  be  made  out  from  the  surrounding  perimetrium. 
It  was  as  if  the  whole  bottom  of  the  pelvis  were  filled 
with  plaster  of  Paris.  The  patient  was  pale,  anaemic, 
without  appetite,  and  completely  despondent.  After 
four  weeks,  during  which  she  received  twenty-two 
baths,  beginning  with  the  simple  and  finishing  with 
the  "  Sprudel "  bath,  a  mar\-ellous  improvement  was 


found.  The  uterus  was  movable,  and  normally  situ- 
ated. The  ligamenta  lata  were  still  somewhat  infil- 
trated. Although  a  double-sided  pyosalpinx  existed, 
the  tubes  and  ovaries  could  be  distinctly  made  out,  and 
the  local  condition  was  relatively  painless.  The  gen- 
eral condition  of  the  patient  was  astonishing,  her  color 
pink,  her  appetite  good,  and  her  subjective  condition 
splendid.  Six  weeks  later  her  condition  remained 
absolutely  unchanged.  I  then  began  the  treatment 
of  twenty  patients,  all  selected  cases.  No  patient  was 
treated  without  rest  in  bed  for  a  week  previous  to  the 
baths,  to  determine  what  influence  rest  alone  exerted. 
The  baths  were  begun  at  a  temperature  of  27°  R.,  lasting 
eight  minutes,  and  contained  half  the  strength  of  CO, 
contained  in  a  Sprudel  bath.  The  temperature  of  the 
water  was  lowered  on  succeeding  da}s,  no  bath  being 
given  lower  than  22^  R.,  the  amount  of  CO,  being 
increased  with  the  lower  temperatures.  Baths  were 
given  on  three  successive  days,  with  a  rest  of  one  day 
before  the  next  three  baths.  During  menstruation  no 
treatment  was  given,  so  that  in  four  weeks  the  patients 
had  on  an  average  eighteen  baths  each.  All  remained 
in  the  clinic,  and  no  change  was  made  in  the  way  of 
diet.  In  all  cases  an  effect  was  noted  in  the  first 
few  days,  first  in  the  condition  of  exhilaration  after 
the  bath,  in  the  increase  in  diuresis  and  the  increase  in 
appetite,  and  then  decidedly  in  a  feeling  of  well-being 
and  confidence  in  the  method.  Locally  examination 
showed  a  fulness  of  the  parts,  and  a  distention  of  the 
ligaments  and  cellular  structures  with  a  decided  ele- 
ment of  elasticity.  The  cases  examined  every  other  day 
disclosed  a  most  rapid  resorption  of  exudates  and  in- 
filtrations, and  a  decided  diminution  in  the  size  of  the 
adnex  tumors.  As  it  is  my  purpose  later  on  to  dis- 
cuss these  and  future  cases  more  in  detail,  I  will  say 
that  the  majority  were  cases  of  pyosalpinx  with  severe 
symptoms.  \\'ith  the  exception  of  one  case  diagnosed 
as  hydrosalpinx,  the  remainder  belonged  to  the  class 
I  have  termed  hysteroptosis.  In  the  first-mentioned 
class  it  was  difficult  to  define  distinctly  at  first  the 
tubes  and  the  ovaries  on  account  of  the  accompanying 
inflammation  and  congestion  of  the  parametrium.  It 
was  astonishing  how  gradually  this  element  disap- 
peared, so  that  at  the  completion  of  a  treatment  the 
tubes  in  nearly  every  case  were  made  out  to  be  scarce- 
ly of  the  thickness  of  the  thumb,  and  the  ovary  could 
usually  be  well  defined.  One  case  of  a  very  chronic 
character  was  decidedly  bettered  so  far  as  resorption 
was  concerned,  but  on  account  of  the  pain  the  patient 
insisted  on  operation,  although  only  nine  baths  had 
been  given.  Double  salpingectomy  was  performed, 
and  I  found  the  adhesions  so  congested,  ordematous, 
so  soft  and  so  easily  loosened,  and  the  infiltration  of  the 
parametrium  so  slight,  that  I  consider  this  improve- 
ment, a  result  of  the  baths,  to  have  been  a  valuable 
preliminary  to  operation.  The  amount  of  pus  was 
not  large,  and  I  gained  the  impression  that  bath  treat- 
ment longer  continued  would  have  freed  the  patient 
from  her  annoyances.  I  feel  certain  that,  within  an 
interval  of  three  or  four  weeks  between  a  course  of 
baths,  in  a  series  of  three  treatments  she  would  have 
been  practically  cured.  We  know  that  salpingitis 
and  pj'osalpinx  are  not  incurable  affections.  It  is 
necessary  to  distinguish  those  cases  due  to  gono- 
cocci,  in  which  the  inflammation  follows  usually  the 
course  of  the  mucous  membrane  of  the  uterus  and 
tube,  and  those  cases  due  to  streptococci  and  staphy- 
lococci, in  which  the  inflammation  follows  the  course  of 
the  blood  and  lymph  channels.  In  the  first  class,  the 
peritoneal  affection  is  a  result  of  the  pus  accumulation 
in  the  tubes.  In  the  second,  the  pyogenic  affection  of 
the  tubes  is  usually  the  result  of  ths  peritoneal  exuda- 
tion. Since  these  so-called  septic  cases  rarely  give 
the  large  pus  tubes  found  as  a  result  of  gonorrhoeal 
infections,  we  may  say  that  in  the  septic  cases  the  peri- 


8i4 


MEDICAL   RECORD. 


[November  24,  1900 


toneal  affection  is  the  primary,  while  in  gonorrhoeal 
cases  we  are  dealing  with  an  affection  of  the  adnexa. 
And  yet  in  ail  probability  the  important  factor  in  the 
causation  of  the  severe  symptoms  associated  with  both 
tliese  classes  of  intlammations  of  the  adnexa  is  to  be 
found  in  the  resulting  peritoneal  adhesions,  and  the 
involvement  in  the  adhesions  of  the  omentum  and  the 
intestine.  That  already  formed  adhesions  can  be  re- 
sorbed,  and  further  adhesions  prevented  and  the  or- 
ganization of  the  adhesions  avoided  by  these  baths.  I 
believe  to  be  well  grounded  theoretically,  and  to  be 
proven  practically. 

Since  in  the  early  stages  of  pelvic  inllammations 
and  pus  formations  in  women  the  involvement  of  the 
parametrium  is  an  important  factor,  and  since  these 
baths  exert  such  a  decided  influence  on  parametric 
and  perimetric  intlammations,  I  consider  the  use  of 
these  baths  after  acute  intlammations  decidedly  indi- 
cated. Two  cases  of  febrile  purulent  parametritis 
were  relieved  by  vaginal  incision,  and  subsequent  treat- 
ment by  the  baths  proved  their  resorptive  powers  be- 
yond question.  One  case  of  double-sided  pyosalpinx 
was  treated  with  a  bath  two  days  after  a  return  to  nor- 
mal temperature.  After  tlie  first  bath  the  patient  suf- 
fered an  acute  exacerbation,  with  posterior  purulent 
parametritis,  subsequently  treated  by  vaginal  incision. 
I  doubt  that  the  bath  was  a  factor  in  the  causation  of 
this  attack,  yet  I  believe  it  to  be  unwise  to  begin  this 
treatment  until  the  temperature  has  remained  normal 
several  days.  The  case  of  hydrosalpinx  showed  a 
return  to  normal  size  after  ten  baths,  and  seen  four 
weeks  later  showed  no  sign  of  distention. 

In  the  later  stages  of  these  pelvic  intlammations,  the 
seat  of  the  trouble  is  localized  mainly  in  the  adnexa, 
and  I  believe  that  these  conditions,  even  though 
chronic,  may  be  cured  by  this  method  of  hydrotherapy. 
Though  the  prospects  in  gonorrhceal  cases  are  not  so 
good  as  in  the  septic,  Kiistner  favoring  conservative 
treatment  says :  "  Gonorrhoeal  processes,  even  when 
they  have  caused  decided  distention  of  the  tubes  or  large 
palpable  exudations,  are  often  open  to  cure.  Such  a 
cure  is  often  followed  by  sterility  as  a  result  of  per- 
manent changes  of  the  mucous  lining  of  the  tubes.  At 
times,  however,  their  function  is  restored."  Schauta 
finds  in  the  presence  of  pus.  even  without  severe  symp- 
toms, an  indication  for  radical  operation.  His  view 
is  shared  by  many,  although  evidence  is  furnished  of 
many  cases  in  which  under  sucli  conditions  after  con- 
servative treatment  pregnancy  occurred.  Kiistner's 
opinion  is  expressed  by  Herrmann,  who  says:  "  (  i  )  A 
certain  per  cent,  of  adnex  tumors  can  be  cured  without 
operation  to  such  an  extent  that  the  function  of  the 
tubes  is  not  impaired;  (2)  even  when  accumulations 
of  pus  in  the  tubes  is  proved  by  puncture  recovery 
with  possession  of  function  is  possible;  (3)  in  adnex 
affections  which  demand  operative  interference  the 
retained  healthy  or  only  slightly  diseased  adnexa  of 
the  one  side  can  later  functionate  normally."  Since 
Kiefer,  VVerlheim,  and  others  have  shown  that  within 
a  year  after  infection  the  pus  is  sterile,  Herrmann 
pleads  for  the  conservative  treatment  of  these  cases 
on  these  grounds:  "(ij  These  cases  not  infrequently 
are  restored  to  a  normal  condition;  (2)  in  this  limit 
of  one  year,  within  which  conservative  treatment 
should  be  tried,  the  pus  becomes  sterile;  (3)  if  opera- 
tion must  later  be  performed,  it  can  then  be  done 
abdominally  without  danger  of  infection,  a  method 
which  permits  of  the  retention  of  the  uterus  and  proba- 
bly of  an  ovary  or  ovarian  rests;  {4)  such  retention  of 
these  parts  spares  the  patient  the  annoying  symptoms 
following  radical  operation."  Without  at  this  time 
dilating  upon  the  indications  for  and  against  radical 
operation,  or  for  or  against  the  abdominal  method,  it 
is  sufficient  to  say  that  such  reasons  are  decidedly 
lesiitimate  and  demand  at  least  a  trial  of  conservative 


methods.  Since  at  least  one-half  of  the  cases  of  pyo- 
saljnnx  operated  upon  are  found  to  contain  sterile 
pus,  these  cases  as  well  as  the  others,  if  not  operated 
at  once  after  infection,  furnish  us  practically  with 
smaller  or  larger  encapsulated  sterile  abscesses,  and 
the  problem  which  confronts  us  is  the  possibility  of 
their  resorption,  and  the  resorption  of  the  infiltrated 
inrtammation  of  the  tube  walls.  Since  in  none  of  my 
cases  was  there  a  failure  of  resorption  of  the  exuda- 
tions about  the  tubes,  and  since  in  no  case  did  exami- 
nations show  the  tube  finally  to  be  more  than  finger 
thick,  and  since  in  most  of  these  cases  the  ovary  could, 
on  examination,  be  distinctly  felt  and  separated  from 
the  tube,  I  consider  that  a  resorption  of  the  tube  con- 
tents and  a  decided  intiuence  upon  its  mucous  lining 
are  possible.  It  is  certain  that  the  diminution  in  the 
pain,  both  subjective  and  that  experienced  on  exami- 
nation, was  diminished  to  such  an  extent  that  a  re- 
sorption and  a  loosening  of  adhesions  must  likewise 
be  taken  for  granted. 

Those  cases  called  hysteroptosis  were  decidedly  ben- 
efited. All  the  patient  gained  in  weight  and  strength, 
and  the  number  of  red  blood  cells  was  constantly  in- 
creased. Appetite  improved,  and  a  feeling  of  strength 
and  exhilaration  resulted,  such  as  no  other  treatment 
in  my  opinion  could  have  accomplished  in  the  same 
time.  At  the  same  time  the  local  symptoms,  and, 
what  is  more  important,  the  idea  that  a  diseased  local 
state  existed,  disappeared.  One  case  of  oophoritis 
was  in  no  wise  locally  or  generally  improved.  It  be- 
longed to  the  class  of  ovarian  affections  presenting 
anatomical  changes,  probably  cystic,  with  a  tense  tunica 
fibrosa,  in  which  no  beneficial  local  improvement  was 
expected  by  me. 

I  believe  that  the  results  obtained  justify  me  in 
claiming  for  the  carbonated  saline  baths  a  power 
of  resorption  too  valuable  to  be  underestimated,  a 
method  which  at  the  same  time  benefits  the  general 
state  to  a  decided  degree,  and  which  acts  by  increas- 
ing the  natural  and  effective  functions  of  the  body, 
and  in  toning  up  those  pelvic  structures-which  depend 
so  decidedly  for  their  elasticity  and  blood  supply  on 
the  condition  of  the  body  generally. 


A    SIMPLE    METHOD    FOR    WRITING    PRE- 
SCRIPTIONS   FOR    CHILDREN. 

liv    .M.\X    nUHNER,    M.D., 

ATTENDING   SfRGEON    bELl.EVlE    HOSMTAL,    OUT-rAIIENT    DEPARTMENT. 

As  is  well  known,  the  method  of  calculating  the  dose 
for  a  child  is,  according  to  Cowling's  Rule:  age  at 
next  birthday,  divided  by  twenty-four.  A  simple 
method  for  writing  the  prescription,  in  order  to  avoid 
much  calculation,  is  to  make  it  contain  exactly  twenty- 
four  doses,  whence  it  necessarily  follows  that  the  en- 
tire amount  of  any  drug  in  the  prescription  will  be  the 
adult  dose  multiplied  by  the  age  at  next  birthday. 
Let  us  for  example  take  three  drugs  .r,  j;  and  s,  of 
which  the  adult  dose  of  x  is  ill  v.,  of  j'  V[  viii.,  and  of  s 
iilx.     We  write  our  prescription  as  follows: 

U  ..■ 

.1' 

Aq (j.s    ad  ilc. 

Now  if  we  make  the  entire  quantity  3  iii.  and  the 
amount  taken  at  each  dose  ;  i.,  our  prescription  will 
contain  twenty-four  doses,  thus: 

K  .■ 

V 

z 

Aq q.s.  ad   ;  iij. 

M.     S.     Z\.  t.i.d. 

If  the  child  at  its  next  birthday  is  one  year  old,  our 


November  24,  1900]  MEDICAL 

prescription  is  completed  by  simply  putting  the  adult 
dose  after  each  item,  thus: 

For  baby  F ,  aged  one  year. 

^  X "I  V. 

y "l  viij. 

: "I  X. 

A() q.s.  ad  3  iij. 

M.     S.    ;  i.  t.i.d. 

If  three  years  old,  simply  put  down  three  times  the 
adult  dose,  thus: 

For  Baby  F ,  aged  three  years. 

I^ n  XV. 

y ni  x.xiv. 

; m  XXN. 

Aq q  s.  ad  l  iij. 

M.     S.    3i.  t.i.d. 

If  ten  years  old,  put  down  ten  times  the  adult  close. 
thus: 

For  Baby  F ,  aged  ten  years. 

R  ..• "11. 

y TH  Ixxx. 

3 "l  c 

.\q q  s.  ad  ?  iij. 

M.     -S.    3  i.  t.i.d. 

To  exemplify  with  an  ordinary  cough  mixture: 

5  Syr.  ipecac 

Ammon    mur 

Ex.  scillje  fl 

.-Vq q.s.  ad  ;  iij. 

M.      S.    3  i.  every  three  hours. 

If  the  child  is  one  year  old  (at  next  birthday)  we 
put  down  the  adult  dose  after  each  item,  as  follows: 

If  Syr.  ipecac HI  x. 

.■\mmon.  mur    gr.  v. 

Ex.  scilla;  11 "l  ii. 

.•\q q.s.  ad    r  iij. 

M.     S.    3  '■  every  three  hours. 

If  six  years  old,  put  down  six  times  the  adult  dose, 
thus: 

For  Baby  F— — ,  aged  six  years. 

B  Syr.  ipecac "l  Ix. 

.Amnion,  mur gr.  xxx 

Ex.  scill.v  n m  xij. 

Aq q.s.  ad  3  iij. 

M.     S.    3  i.  every  three  hours. 

And  so  forth.  The  advantage  of  this  method  will 
perhaps  be  more  fully  appreciated  by  giving  drugs 
with  fractional  doses.  Let  us  for  sake  of  example 
give  a  child  some  pills  containing  strychnine  sulphate 
and  digitalin.     We  write  our  prescription  as  follows: 

B  Strychninx  sulph. . 

Digitalin 

M.  et  liant  pil.  .No.  xxiv.     S.    One  pili  t.i  d. 

If  the  child  is  four  years  old  we  put  down  four  times 
the  adult  dose  after  each  item,  thus: 
For  Baby  F ,  aged  four  years. 

IJ  Strychninx  sulph gr.  jV  =  STr-  ^r. 

I'isitalin gr.  n1o  =  gr-   ;': 

M    et  fiant  pil.  No.  xxiv.      S.   One  pill  t.i.d. 

There  is  absolutely  no  calculation  necessary^  as  long 
as  we  make  our  prescription  contain  twenty-four  doses. 
All  w-e  need  to  know  is  the  adult  dose  of  each  item,  and 
multiply  it  by  the  age  of  the  child,  and  that  will  gi\e 
us  the  entire  amount  to  be  placed  after  each  item.  If 
we  do  not  wish  to  give  as  many  as  twenty-four  pills, 
we  may  give  twelve,  and  divide  each  amount  by  two. 

The  method  may,  of  course,  be  used  in  the  metric 
system,  as  follows: 

For  Baby  F . 

For  one  year.  For  four  years. 

3  Strychnin.^  sulph o.ooi  0.004 

Digitalin 0.0006  0.0024 

M.  et  fiant  pil.  No.  xxiv.     S.   One  pill  t.i.d. 


RECORD. 


815 


Another  slight  advantage  is,  that  we  may  give  the 
same  drugs  to  several  children  of  a  family  without 
writing  different  prescriptions.  Thus  in  the  first  exam- 
ple (the  cough  mixture)  we  may  give  the  same  pre- 
scription for  three  children,  aged  respectively  one, 
three,  and  five  years  (at  next  birthday),  by  telling  the 
mother  to  give  one  child  3  i.,  another  3  iii-.  and  the 
oldest   3  v.  at  each  dose. 

As  this  method  depends  upon  Cowling's  Rule,  it  is 
applicable  only  where  Cowling's  Rule  is  applicable. 
In  giving  opiates,  etc.,  where  less  than  j',  of  adult  dose 
is  given,  we  cannot,  of  course,  make  u.se  of  this  method. 

'i'he  fact  that  the  dose  for  a  child  should  be  reg- 
ulated not  by  its  age,  but  by  its  physical  development 
does  not  militate  against  the  use  of  this  method;  for 
if  a  child  of  three  years  has  the  development  of  a  child 
of  five  years,  it  may,  for  purposes  of  dosage,  be  con- 
sidered a  five-year-old  child,  and  the  prescription  cal- 
culated accordingly. 

3S8  East  Onk  Hi-ndkeu  anu  TwE.^■TV-FlR.'^T   Street. 


A  MKTHOI)  FOR  THE  DHTERMIXATION 
OF  KVK  DEFECTS  IN  SCHOOL  CHILDREN, 
WITH  A  REl'ORT  OF  SEVENTEEN  HUN- 
DRED AND  FORI  Y-SEVEN  EXAMINATIONS. 

Bv    LOLIS   C.    DEANE,    M.D., 

SAN    FRANCISCO, 
SL'ROEON    TO   THE   CA1.IE0RNI.\    EVE    ANI»    EAR    HOSPITAL,    ETC. 

The  object  of  this  class  of  work  is  to  determine  the 
ocular  defects  existing  among  school  children.  The 
public  can  be  divided  practically  into  two  classes, 
those  who  have  good  and  useful  eyesight  and  those 
whose  sight  or  condition  of  the  eyes  is  so  poor  as  to 
incapacitate  them  for  their  daily  pursuits.  The  large 
number  of  examinations  that  have  to  be  made,  and  the 
rapidity  with  which  the  oculist  is  compelled  to  com- 
plete them,  so  as  not  materially  to  interfere  with  the 
school  work,  compel  him  to  overlook  a  considerable 
number  of  minor  eye  defects,  which  he  can  only  sus- 
pect but  not  investigate;  for  instance,  to  discriminate 
between  a  low  grade  of  myopia  and  astigmatism, 
whether  there  exists  a  small  amount  of  plus  or  minus 
astigmatism,  or  even  higher  grades  of  astigmatism  at 
irregular  angles. 

Time  does  not  admit  of  an  ophthalmoscopic  exami- 
nation, hence  many  pathological  changes  in  the  fun- 
dus of  the  eye  must  be  overlooked.  If  the  sight  is 
poor  and  the  patient  refuses  to  show  symptoms  of  any 
of  the  refractive  defects,  a  more  thorough  examination 
is  necessary  at  a  later  period. 

The  method  used  I  believe  to  be  the  most  complete 
and  thorough  within  the  bounds  of  practice,  and  by  it 
one  is  enabled  to  examine  between  twenty  and  thirty 
pupils  hourly,  or  between  fifty  and  si.xty  eyes. 

Another  point  to  be  considered  is  the  age  and  ad- 
vancement of  the  pupil.  As  children  progress  in  their 
studies  and  are  compelled  to  concentrate  their  eyes 
more  closely,  they  develop  defects  which  do  not 
troui)le  younger  ones. 

As  age  increases,  the  range  and  tiexibility  of  accom- 
modation decreases,  and  refractive  ocular  defects,  which 
tax  the  accommodative  powers,  are  more  difficult  to 
overcome.  This  incapacity  is  manifested  by  head- 
aches, blurring  of  print,  inflamed  lids,  watery  eyes, 
etc.  The  statistics  with  regard  to  the  younger  ones 
of  between  six  and  ten  years  cannot  be  accurate,  since 
the  judgment  of  the  scholar  in  regard  to  what  he  sees 
and  how  he  sees  it  has  to  be  relied  on.  The  careful 
observer  will  always  detect  any  marked  error  of  re- 
fraction, with  defective  eyesight,  heterophoria,  strabis- 
mus, or  diseases  of  the  lids.  Any  objective  method, 
as  retinoscopy,  is  impracticable. 


8i6 


MEDICAL    RECORD. 


[November  24,  1900 


The  teacher  of  each  class  is  directed  to  arrange  in  a 
column  alphabetically  the  names  of  her  pupils,  their 
age  and  sex,  leaving  a  space  after  each  one  for  the 
result  of  the  examination.  A  copy  of  this  is  returned 
to  the  teacher  with  an  explanation,  so  that  she  is  cog- 
nizant of  the  visual  acuity  and  condition  of  the  eyes 
of  each  of  her  pupils.  This  is  of  twofold  importance: 
first,  it  allows  the  teacher  to  seat  the  pupils  with  rela- 
tion to  distance  from  the  blackboard  for  those  with 
poor  vision,  and  the  intensity  of  light  for  those  with 
weak  eyes,  also  to  favor  those  who  are  suffering  with 
an  unconquerable  eye-strain.  Secondly,  these  reports 
should  be  kept  on  file  so  as  to  be  of  future  value  to  the 
oculist  in  his  examination,  and  allow  him  to  elucidate 
many  important  facts  which  can  be  accomplished  only 
by  reference  to  numerous  personal  records  extending 
over  some  years.  The  bulk  of  such  a  work  would  fall 
on  the  first  year,  as  in  the  succeeding  years,  by  refer- 
ence to  previous  records,  most  pupils  could  be  excused 
from  a  repetition  of  the  examination,  and  the  suspected 
ones  re-examined  as  to  the  progressiveness  of  their 
condition.  It  is  unnecessary  to  repeat  here  the  value 
of  such  records,  not  only  to  regulate  and  correct  eye 
defects  during  the  school  term,  but  to  advise  the  par- 
ents as  to  the  care  and  future  pursuits  of  their  chil- 
dren. 

During  the  school  hours  the  children  are  allowed  to 
leave  the  class  five  at  a  time  and  adjourn  to  a  separate 
room,  twenty  feet  long,  with  good  light,  provided  for 
the  purpose. 

It  would  be  well  to  stop  here  and  note  the  appli- 
ances necessary  to  continue  this  examination:  Five 
ordinary  test  charts  with  radiating  lines  for  astig- 
matism. Spectacle  fronts  containing  pairs  of  the  fol- 
lowing spheres:  -|-  .75  D.,  -|-  i.  D.,  -|-  1.50  U.,  —  .50 
D.,  —  1.50  D.,  —  2.50,  and  cylinders  -|-  .75  D.  ax.  90% 
-|-  .75  n.  ax.  180",  —  .75  D.  ax.  90°  and  —  .75  D.  ax. 
180°;  also  prisms  6"  base  in  each  eye,  2''  prism  base 
down  on  one  eye  and  3°  base  up  on  the  other  eye.  A 
red  glass. 

The  children  are  directed  to  stand  in  line  and  cover 
their  left  eyes  with  their  left  hands,  using  the  palm  not 
the  fingers,  and  keeping  both  eyes  open.  The  first  is 
directed  to  read  the  r'||  line  on  chart  i  ;  if  he  reads 
the  line,  the  next  is  directed  to  read  a  similar  line  on 
chart  2,  and  so  on  through  the  five.  If  the  vision  is 
f  ^  no  record  is  made;  if  not  it  is  recorded  thus:  R.  V. 
fll,  or  whatever  the  sight  may  be,  following  the  name. 
Those  who  have  V.  |;i  both  are  tested  with  +  .75  D. 
sph.,  and  so  on  to  -|-  1.50  D.  sph.,  noting  which  one 
blurs  the  ||j  line.  If  +  .75  D.  sph.  reduces  the  visual 
acuity,  I  make  no  note  of  it,  but  consider  the  case  em- 
metropic. If  -f-  1-50  D.  sph.  is  the  first  glass  which 
blurs  the  print  I  consider  the  case  as  hypermetropic 
+  I.  D.,  etc.  It  is  well  to  note  that  the  maximum 
amount  of  relaxation  of  the  ciliary  muscles  is  not  ob- 
tained thus,  so  that  the  manif^'st  amount  only  is 
shown,  which  simply  serves  as  a  clew  to  almost  any 
amount  of  the  absolute  condition.  One  thing  is  cer- 
tain (providing  the  judgment  of  the  scholar  can  be 
depended  on) — that  there  is  a  hypermetropia  present, 
and  more  than  is  manifested  at  the  time.  Minus 
lenses  can  be  used  for  those  who  show  a  defective  vi- 
sion, and  the  strength  of  the  weakest  noted,  as  also  the 
cylinders. 

The  screen  test  is  used  to  determine  the  muscular 
balance  of  the  eyes,  and  is  most  practical.  ]iy  it  as 
little  as  2°  of  an  esophoria  is  easily  noted.  If  a 
further  investigation  is  desired  the  prisms  in  the  spec- 
tacle fronts  are  provided  for  that  purpose,  producing 
a  horizontal  or  vertical  diplopia,  which  are  used  here 
to  show  more  the  kind  than  the  amount  of  hetero- 
phoria;  though  the  latter  can  be  easily  estimated,  if 
desired,  by  a  chart  at  a  distance  of  twenty  feet,  divided 
off  to  show  the  deviation  produced  by  certain  prisms 


and  consequently  the  approximate  amount  of  a  heter- 
ophoria.  If  a  state  of  orthophoria  exists  no  note  is 
made,  and  the  examination  is  continued,  taking  note 
of  corneal  opacities,  blepharitis,  conjunctivitis,  etc. 

The  majority  of  those  examined  are  immediately  re- 
turned to  the  class  room,  those  who  manifest  some 
marked  defect  being  detained  for  a  further  exami- 
nation, possibly  of  each  eye  separately  with  the  test 
glasses  for  an  anisometropia,  etc.  It  is  well  to  ex- 
amine the  less  fortunate  ones  alone,  as  children  in 
schools  are  very  sensitive  as  to  imperfect  eyesight, 
and,  with  others  present,  their  answers  are  often  mis- 
leading. 

In  the  foregoing  one  is  impressed  with  the  fact  that 
the  examination  is  merely  qualitative  and  not  quanti- 
tative. Records  are  made  only  of  conditions  with  but 
approximate  measurements. 

What  are  we  to  find  in  this  examination,  and  what 
are  the  value  of  such  findings.' 

1.  Elimination  of  those  with  normal  eyesight  with- 
out apparent  ciliary  strain  or  muscular  imbalance  of 
the  two  eyes. 

2.  Hypermetropia  with  or  without  asthenopic  symp- 
toms. 

3.  Myopia,  percentage  in  the  different  grades  of 
school,  its  progressiveness  with  and  without  the  use  of 
glasses. 

4.  Astigmatism :  this  is  difficult  to  determine  by 
these  tests,  but  if  the  vision  remains  poor,  and  the  er- 
ror cannot  be  accredited  to  a  myopia,  a  further  exami- 
nation is  necessary  also. 

5.  Poor  vision  which  cannot  be  accounted  for  by  a 
refractive  error. 

6.  The  relation  of  ametropia  to  heterophoria  or 
heterotropia,  showing  the  relation  of  hypermetropia  to 
esophoria,  and  esotropia  and  myopia  to  exophoria  and 
exotropia. 

7.  Relation  of  marginal  blepharitis,  chronic  con- 
junctivitis with  styes,  phlyctenular  conjunctivitis,  etc., 
to  ametropic  conditions,  especially  to  hypermetropia. 

Following  is  a  report  of  the  examination  of  1,747 
school  children,  of  which  421  were  boys  and  girls  in 
the  high  school,  where  I  was  able  to  carry  out  the 
examination  with  considerable  accuracy.  The  re- 
maining 1,326  were  taken  from  the  higher  grammar 
grades,  where  the  results  were  also  fairly  satisfactory. 
The  appended  table  was  made  up  at  a  later  period 
from  the  reports  given  the  teachers.  On  account  of 
inadequate  space,  I  have  somewhat  condensed  it,  hav- 
ing omitted  acuity  of  vision,  which  was  arranged  in 
four  columns  as  follows:  V.  jlj  to  |||,  |{}  to  -:||,  |J|  to 
y-,i"i,,  and  worse  than  ,-;,",,  for  the  fourth  column.  If 
the  vision  was  normal  on  record  was  made,  if  both 
eyes  were  defective  the  vision  of  the  best  was  re- 
corded, which  shows  the  practical  vision  of  the  child 
with  both  eyes  open.  Two  columns  for  anisometropia 
were  also  omitted,  the  vision  of  the  worst  eye  being 
recorded  thus,  fi  to  ^J,  and  the  other  column  for  vi- 
sion worse  than  ^J.  The  vision  of  the  best  eye  had 
already  been  recorded  under  acuity  of  vision. 


II 

< 

s 
> 
< 

-1 

Hetero- 
phoria. 

Hetero- 
tropia. 

C 

•i 
> 

III 

.6.5 
7.6 

£| 

=6.3 
20.3 

"7 
•3-7 

.3 
0. 
0 
>, 

11.06 

■a. 
■4. 

.11 

s 

a. 
»-S 

0.4 

i 
4.6 

4-1 

.1. 

5-7 

k 

H 

.85 
1. 18 

1-3 
I.S 

0.6 
'5 

0. 
0.36 

Is 

^5 

Grammar  school 
CJrh 

620 

S06 

M5 

376 

16^ 

3-3 
3-3 

1.1 
1.8 

1.7 

Hoys 

HikIi  school. 
Girls 

"■3 
2. 

Hoys 

Tivlal  number  of 
examinations.. 

1.747 

It  will   be  noted  that  marginal   blepharitis   is  less 


November  24,  1900] 


MEDICAL    RECORD. 


817 


frequent  in  the  older  pupils;  this  may  be  due  to  two 
causes:  first,  the  percentage  wearing  correcting  lenses 
for  hypermetropia  is  much  greater;  second,  they  are 
more  likely  to  have  been  treated.  Certainly  many 
mild  cases  were  overlooked,  only  the  marked  and 
noticable  ones  being  recorded. 

The  increase  of  heterophoria  as  the  scholar  pro- 
gresses is  due,  I  believe,  to  the  fact  that  more  is  mani- 
fest, i.e.,  he  is  less  able  to  overcome  such  defects. 

Hypermetropia  remained  about  the  same,  but  many 
more  were  wearing  correcting  lenses  in  the  high  school 
than  in  the  grammar,  especially  among  the  boys. 

The  table  shows  a  large  percentage  of  myopia  in 
the  high  school,  especially  among  the  girls;  many  of 
the  latter  were  without  glasses  on  account  of  prejudice 
against  them,  while  most  of  the  boys  were  wearing 
their  proper  corrections.  This  may  account  in  a  way 
for  a  greater  frequency  of  myopia  among  the  girls.  I 
noted  that  in  the  classical  courses,  especially  in  the 
Greek  senior  classes,  the  percentage  of  myopia  was 
alarming.  In  one  class  of  38  pupils,  16  had  over  1.50 
D.  of  myopia,  or  42  per  cent. 

In  the  column  of  poor  vision  undetermined  were 
cases  in  which  an  ophthalmoscopic  examination  would 
be  likely  to  have  revealed  the  cause  in  a  possible  very 
high  myopia,  astigmatism,  fundus  disease,  or  opacity 
of  some  of  the  transparent  refractive  media. 

Of  the  6  cases  of  strabismus  observed  in  the  high 
school,  5  were  divergent  and  i  convergent.  Of  the 
divergent,  4  were  myopic  and  i  hypermetropic;  2 
were  anisometropic  and  3  isometropic.  The  one  case 
of  convergent  strabismus  was  hypermetropic  and  ani- 
sometropic. 

Of  the  7  cases  of  marginal  blepharitis  observed  in 
the  high  school,  4  were  hypermetropic,  two  myopic, 
and  1  emmetropic. 

The  relations  between  heterophoria  and  ametropia 
were  particularly  interesting.  Of  the  37  cases  of  hete- 
rophoria over  3"  found  in  421  pupils  examined  in  the 
higii  school,  5  had  esophoria  and  32  exophoria.  Of 
the  5  cases  of  esophoria  all  were  hypermetropic.  Of 
the  TyZ  cases  of  exophoria,  15  were  myopic,  2  hyper- 
metropic, and  15  emmetropic. 

606    SUTTEK    StREF.T. 


The  Operative  Treatment  of  Procidentia  Uteri 
in  Elderly  Women. — A.  Lapthorn  Smith  says  that  in 
the  majority  of  these  cases  we  find  a  lacerated  cervix, 
and  that  this  together  with  a  lacerated  perineum  forms 
the  initial  lesions,  which  brings  about  the  prolapse. 
The  laceration  prevents  involution  of  the  uterus,  and 
the  latter  organ,  instead  of  becoming  small  and  light, 
remains  large  and  heavy.  Owing  to  the  too  general 
practice  of  keeping  women  lying  on  their  backs  after 
confinement,  the  subinvoluted  uterus  becomes  a  retro- 
verted  one  by  gravity,  and  when  the  woman  gets  ujj 
the  bowels  fall  in  front  of  the  womb,  and  the  round 
ligaments  are  unable  to  pull  the  fundus  forward  again, 
so  that  the  uterus  is  forced  on  to  a  lower  plane  in  tiie 
pelvis.  There  being  no  perineal  support  to  oppose 
both  gravity  and  intra-abdominal  pressure,  the  cervix 
appears  at  the  vulva,  bringing  the  bladder  and  rectum 
with  it,  causing  a  chronic  cystitis  and  a  dragging  pain 
in  the  back.  In  regard  to  operative  measures  we  may 
follow  one  of  two  plans,  according  to  the  degree  of  the 
prolapse  and  the  size  of  the  uterus.  If  the  latter  is 
small  and  not  far  enough  out  of  the  body  to  become 
ulcerated,  the  safest  operation  is  to  make  a  small  in- 
cision in  the  abdomen,  and  catching  the  fundus  with 
the  bullet  forceps,  draw  it  up  to  the  incision  and  scar- 
ify the  whole  anterior  surface  of  the  fundus,  and  then 
to  sew  it  to  the  abdominal  wall  with  buried  chromi- 
cized  catgut;  after  which  the  vaginal  outlet  is  nar- 
rowed by  a  large  anterior  and  posterior  colporrhaphy. 


If,  however,  the  uterus  is  very  long,  sometimes  the 
sound  measures  seven  or  eight  inches  deep,  and 
especially  if  it  is  badly  ulcerated,  it  is  better  to  ampu- 
tate all  but  the  upper  two  inches  of  it,  and  then  to 
narrow  the  outlet. —  Canadian  J'raclitioner  and  Kt-vien', 
October,  1900. 

The  Psychical  Influences  Acting  on  Patients  in 
Sanatoria. — These  have  been  found  by  P.  Wiedeburg 
to  be  both  favorable  and  unfavorable,  and  to  be  of 
great  importance  in  facilitating  or  impeding  the  work 
of  successful  treatment.  Most  of  them  depend  direct- 
ly or  indirectly  on  the  tact  and  general  attitude  of  the 
physician  in  charge,  who,  by  attention  to  apparently 
minor  details,  can  to  a  remarkable  degree  enhance  the 
value  of  the  primary  therapeutic  measures  employed. 
The  work  of  psychical  inliuence  or  suggestion  begins 
even  before  admission,  for  the  idea  of  treatment  in  an 
institution  is  usually  of  itself  enough  in  some  cases  to 
put  the  patient  in  a  more  hopeful  frame  of  mind,  while 
in  others  it  has  precisely  the  opposite  effect.  It  is 
highly  important  that  the  patients  should  be  inmates 
of  the  establishment  itself,  and  not  board  outside  and 
come  there  merely  for  treatment;  for  the  disciplined 
life  under  the  personal  supervision  of  the  physician, 
who  should  make  it  a  point  to  meet  his  charges  fre- 
quently outside  the  consulting-room  as  well  as  in  it, 
removes  the  risk  of  many  indiscretions  in  the  way  of 
diet,  exertion,  etc.,  to  which  they  would  otherwise  be 
exposed.  The  social  life  among  the  patients  must  be 
subjected  to  careful  supervision;  while  the  encourage- 
ment of  association  with  a  cheerful  and  hopeful  fellow- 
invalid  can  be  of  inestimable  service,  depressing  com- 
panionship may  do  untold  mischief.  The  providing 
of  interesting  amusements,  attention  to  the  table, 
strict  management  of  the  employees  attending  to  the 
service  and  performing  the  functions  of  masseurs, 
orderlies,  etc.,  and  the  control  of  visits,  correspond- 
ence, and  reading-matter  are  all  of  great  import  in 
determining  the  psychical  state  of  the  patient,  and  his 
consequent  susceptibility  to  the  remedial  measures 
employed. — Zeitsclirijt  J.  didtetische  iind  physikalische 
'I'lierapic.  vol.  iv..  No.  5,  1900. 

Syphilitic  Sciatica. — In  a  general  article  on  this 
subject,  J.  K.  Baudy  enumerates  the  following  rules 
concerning  diagnosis,  i.  In  making  the  diagnosis  of 
syphilitic  sciatica,  it  is  necessary  in  the  first  place  to 
establish  the  fact  that,  in  addition  to  having  neuralgic 
pain  of  the  sciatic  nerve,  the  patient  has  previously 
had  syphilis.  It  should  not  be  forgotten  that  the  fact 
of  sciatica  occurring  in  a  syphilitic  patient  does  not 
warrant  the  assumption  that  the  nervous  complaint  is 
necessarily  due  to  constitutional  syphilis.  2.  If  the 
patient  has  been  free  from  sciatica  previous  to  syphi- 
litic affection,  this  fact  will  weigh  in  favor  of  the  sup- 
position that  the  neuralgia  is  of  syphilitic  origin.  3. 
While  syphilitic  sciatica  may  occur  at  an  early  period 
of  infection,  it  is  more  likely  to  occur  later.  4.  The 
occurrence  coincidently  with  the  sciatica  of  other  neu- 
rotic troubles,  clearly  traceable  to  syphilis  as  a  cause, 
constitutes  a  presumption  in  favor  of  the  syphilitic 
origin  of  the  sciatica,  and  this  presumption  will  be 
strengthened  if  the  patient  had  previous  to  constitu- 
tional infection  been  free  from  both  sciatica  and  the 
other  neurotic  infections.  5.  The  pains  of  sciatic 
neuritis  are  dull,  continuous  or  nearly  so,  and  persist- 
ent; also  are  felt  equally  throughout  the  whole  course 
of  the  sciatic  nerve,  thus  offering  a  marked  contrast  to 
the  lancinating  pains  of  a  pure  sciatica,  which  are 
chiefly  felt  at  the  extremities  of  the  nerve.  6.  In 
sciatic  neuritis,  again,  the  nerve  is  tender  to  togch, 
and  can  often  be  felt  as  a  thickened  cord  beneath 
the  skin. — St.  Louis  Medical  Review,  September  29, 
1900. 


8i8 


MEDICAL    RECORD. 


[November  24,  1900 


Medical  Record: 

A    Weckij  Journal  of  Medicine  and  Surgery. 


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

WM,   WOOD  &  CO,  51    Fifth  Avenue. 


New  York,  November  24,  1900. 


PROGNOSIS    IN    TYPHOID. 

The  importance  of  making  an  accurate  prognosis  in 
any  given  case  of  typhoid  fever  is  very  effectually  off- 
set by  the  absolute  uncertainty  of  foretelling  the  time 
and  nature  of  always  threatening  complications.  The 
question  from  this  point  of  view  has  an  added  interest 
in  connection  with  the  sickness  of  the  Czar  of  Russia, 
on  the  ultimate  issue  of  which  so  much  political  sig- 
nificance depends.  From  all  accounts  the  fever  is  in 
its  second  week,  with  a  comparatively  easy  temperature 
grade,  a  reasonably  quiet  pulse,  and  no  marked  feel- 
ing of  prostration.  Apparently  then  the  patient  is 
making  a  good  start,  with  mild  symptoms.  Every  one 
knows,  however,  that  such  signs  are  not  always  trust- 
worthy as  guaranteeing  against  future  dangers.  While 
very  high  temperatures  in  the  beginning  of  the  attack 
generally  indicate  the  degree  and  gravity  of  the  poison, 
it  by  no  means  follows  that  a  contrary  condition  can 
insure  the  patient  against  complications  which  have 
nothing  directly  to  do  with  the  degree  of  infection. 
The  "  walking  cases,"'  for  instance,  are  particularly 
prolific  with  accidents  of  intestinal  hemorrhage  and 
perforation,  are  peculiarly  liable  to  auto-infection  and 
relapse,  and  in  a  general  way  balance  the  chances  of 
a  good  beginning  with  a  bad  ending  on  the  usual 
compensatory  level. 

We  must  admit  of  course  that  tlie  vital  resistance  of 
individuals  is  a  very  powerful  determining  element  as 
to  the  impression  of  the  poison,  and  also  its  early 
elimination.  It  is  a  matter,  so  to  speak,  of  dead  reck- 
oning how  much  poison  is  absorbed  in  a  given  case 
and  how  quickly  and  effectually  it  can  be  thrown  off 
with  a  minimum  amount  of  harm  to  the  patient.  Ap- 
parent robustness  has  seemingly  nothing  special  to  do 
with  this  phase  of  the  calculation,  inasmuch  as  thin 
and  apparently  weakly  subjects  astonisii  us  by  their 
endurance,  prompt  responsiveness  to  remedies,  and  by 
their  staying-powers  during  convalescence. 

A  favorable  indication  of  satisfactory  progress  is 
the  steady  and  regular  course  of  the  temperature  curve: 
the  morning  and  evening  alternations,  the  gradual  rise 
to  the  top  wave,  and  then  the  decline  to  the  level  of 
convalescence.  In  the  same  way  the  pulse  must  match 
its  quickened  throb  with  the  increased  heat  of  the  tis- 
sue fire  and  mark  its  own  rise  and  fall  on  parallel 
lines.  Thus  the  consistency  of  satisfactory  progress 
is  made  possible,  and  tlie  fever  takes  its  course  through 


all  the  usual  presentments  of  accident.  We  trust 
everything  in  prognostication  to  the  integrity  of  the 
machinery  and  its  ability  to  bear  the  necessary  strain. 
The  careful  physician  is  content  to  say  that  under 
the  circumstances  the  patient  is  doing  well  for  the 
time  being.  If  he  attempts  to  look  too  far  ahead  he 
must  needs  only  guess  and  qualify. 

What  holds  good  as  to  positiveness  in  regard  to  the 
exact  duration  of  fever,  and  its  possible  complications, 
applies  with  equal  force  to  the  behavior  of  the  conva- 
lescence stage.  Often  the  latter  is  more  trying  to 
patient  and  physician  than  the  original  ailment.  Here 
also  there  is  no  law  that  can  govern  opinion  as  to  the 
precise  day  when  the  temperature  shall  become  nornip' 
and  remain  so.  Often  during  a  calm  of  symptoms 
there  is  an  ominous  and  threatening  afterclap  of  high 
temperature  and  increased  pulse  rate.  Indeed,  after 
such  profound  systemic  disturbances  as  have  existed 
for  weeks  it  takes  time  and  adjustment  to  get  to  the 
even  and  quiet  level  of  established  health.  But  how 
to  mark  the  exact  time  limits  along  the  line  must 
always  be  the  puzzle  so  long  as  one  patient  ditfers 
from  another  in  receptivity,  reaction,  and  vital  power. 


THE   PREVENTION    OF    INSANITY. 

One  who  follows  current  medical  literature  cannot  but 
be  struck  by  tlic  frequency — the  increasing  frequency 
— with  which  questions  of  prophylaxis  are  discussed. 
This  is  rather  in  striking  contrast  witli  the  criticism 
that  has  been  made,  more  especially  in  connection 
with  diseases  of  the  nervous  system,  tliat  only  a  small 
minority  of  papers  written  deal  with  questions  of 
treatment — and  it  is  worthy  of  note  that  not  a  few  of 
the  discussions  in  preventive  medicine  relate  more 
particularly  to  diseases  of  tlie  nervous  system.  The 
circumstance  in  question  is  obviously  referable  to  in- 
creased knowledge  of  the  etiology  of  disease,  and  it  is 
to  be  anticipated  that  further  advances  in  prophylactic 
measures  must  follow  upon  the  same  lines.  The  truth, 
with  regard  to  matters  of  healtli  and  disease,  is  viewed 
with  much  less  sentimentality  now^  than  it  was  formerly, 
and  the  importance  of  hereditary  influences  in  the  trans- 
mission of  morbid  tendencies  is  receiving  increasing 
recognition.  More  especially  is  it  being  appreciated 
that  mental  and  nervous  diseases  are  not  in  themselves 
to  be  considered  causes  for  shame  that  call  for  con- 
cealment; but  rather  that  they  sliould  be  early  and 
unreservedly  brought  to  the  attention  of  the  physician, 
in  order  that  such  steps  as  are  available  may  be  taken 
in  the  cure,  as  well  as  in  the  prevention  of  hereditary 
transmission,  while,  as  already  indicated,  a  full  knowl- 
edge of  the  etiological  factors  will  permit  of  the  recom- 
mendation of  measures  of  primary  prophylaxis.  This 
is  the  spirit  that  pervades  the  introductory  address  of 
the  president  of  the  section  of  psyciiology  at  the  recent 
meeting  of  the  British  Medical  Association.' 

It  is  pointed  out  in  this  communication  that  there 
has  been  not  only  an  absolute,  but  also  a  relative,  in- 
crease  in  insanity  in   England  and  Wales  in  recent 

'"The  Prevention  of  Insanity."  by  R.  Percy  Smith,  M.D., 
F.R.C.P.   I.ond.      L.nncet,  August  ii,   lyoo,  p.  3S8. 


November  24,  1900] 


MEDICAL    RECORD. 


819 


years,  so  that  there  is  ample  justification  for  efforts 
"to  diminish,  if  possible,  at  the  source  the  numbers  of 
those  who  thus  become  incapacitated  either  tempo- 
rarily or  permanently,  who,  if  not  possessing  private 
means,  become  either  a  burden  to  their  relatives  or  to 
the  tax-payer,  and  who  in  some  cases  become  crimi- 
nals as  the  result  of  their  mental  disorder."  Atten- 
tion is  devoted  to  three  subjects:  (i)  The  propagation 
of  the  race  by  those  of  insane  inheritance  or  those 
who  have  suffered  from  insanity;  (2)  the  influence  of 
alcohol  in  the  production  of  insanity,  and  the  need  for 
preventive  legislation;  and  (3)  the  causation  of  gen- 
eral paralysis  by  syphilis. 

Heredity  is  found  to  be  an  etiological  factor  of  insan- 
ity in  not  less  than  from  twenty  to  twenty-five  percent, 
of  cases — a  larger  proportion  than  is  associated  with 
any  other  single  cause.  For  the  future  welfare  of  the 
race  and  the  maintenance  of  its  stock  in  as  healthy  a 
condition  as  possible,  reproduction  from  defective  in- 
dividuals should  not  be  permitted.  It  is  true  that 
great  and  practical  advances  have  been  made  in  the 
care  and  treatment  of  the  insane,  but  there  is  urgent 
need  for  the  imposition  of  restraint  in  the  marriage  of 
members  of  families  in  which  insanity  exists  or  has 
existed.  The  danger  is,  of  course,  greater  when  the 
taint  affects  both  contracting  parties  and  also  when 
consanguinity  exists.  Remedial  or  restrictive  legis- 
lation can  scarcely  be  expected,  and,  even  if  enacted, 
it  would  be  more  commonly  honored  in  the  breach  than 
in  the  observance,  so  that  upon  the  medical  man  will 
devolve  the  responsibility  of  effectuating  so  much  of 
the  reform  in  this  direction  as  can  be  brought  about. 
His,  also,  will  be  the  duty  of  educating  the  commu- 
nity as  to  the  dangers  that  reside  in  marriages  among 
the  progeny  of  insane  parents  or  those  that  themselves 
are  or  have  been  insane.  Such  unions  must  be  looked 
upon  as  nothing  less  than  social  crime.  -So  common 
has  become  the  proposition  that  defectives  should  be 
deprived  of  the  power  of  propagating  their  kind,  tliat 
there  is  increasing  reason  to  hope  that  the  day  is  not 
distant  when  the  suggestion  shall  be  put  into  practical 
effect. 

Next  to  heredity,  alcohol  is  the  most  potent  single 
cause  of  insanity,  from  nine  to  twenty-two  per  cent,  of 
cases  being  attributed  to  its  influence  directly,  apart 
from  any  etfect  it  may  have  on  the  progeny,  and  not 
including  cases  of  acute  alcoholism.  In  addition,  it 
has  been  found  that  there  is  an  intimate  relationship 
between  alcoholism  and  suicide.  The  remedy  con- 
sists in  arrest  for  simple  drunkenness,  punishment  for 
serving  habitual  drunkards  with  alcohol,  and  afford- 
ing protection  to  the  family  of  the  victim. 

It  is  almost  universally  admitted  that  syphilis  is  the 
most  prolific,  if  not  the  sole,  etiological  factor  of  paretic 
dementia,  which  in  hospitals  for  the  insane  is  one  of 
the  most  common  causes  of  death,  especially  among 
men  in  the  prime  of  life.  Paretic  dementia  is  most 
common  where  syphilis,  alcoholic  influences,  and  dis- 
sipated methods  of  living  are  most  prevalent,  and 
in  addition  to  training  individuals  in  habits  of  self- 
control,  and  teaching  them  to  observe  physiological 
laws,  legislation  might  be  enacted  to  check  the  spread 
of  such  a  potent    poison    to  the    nervous    system    as 


syphilis.  It  is  suggested  that  the  disease  should  be 
made  notifiable.  In  Finland,  where  physicians  are 
required  to  notify  the  medical  officer  of  health  of  the 
existence  of  any  case  of  venereal  disease,  without  giv- 
ing the  name  of  the  patient,  where  opportunities  for 
hospital  treatment  are  afforded,  and  the  authorities 
have  the  power  to  compel  the  examination  of  any  sus- 
pected individual,  the  prevalence  of  syphilis  has  been 
greatly  diminished  in  the  past  twenty  years,  congeni- 
tal syphilis  has  become  less  frequent,  and  the  type  of 
both  the  hereditary  and  acquired  forms  has  become 
much  milder.  Punishment  has  been  proposed  for 
those  who,  knowing  themselves  to  be  infected,  put 
themselves  in  the  way  of  infecting  others. 


THE    HEALTH    OF    NEW    YORK. 

Dr.  Hexrv  DwiijiiT  Chapin,  chairman  of  the  commit- 
tee on  hygiene  of  the  Medical  Society  of  the  County 
of  New  York,  has  lately  published  his  annual  report 
regarding  the  health  of  New  York  City.  It  is  grati- 
fying to  gather  from  Dr.  Chapin's  investigations — the 
data  of  which  v.ere  gleaned  from  the  exhaustive  study 
of  the  question  made  by  the  Merchants'  .Association  of 
New  York — that  the  health  of  New  York  compares 
favorably  with  that  of  the  six  largest  capital  cities  of 
the  world.  Berlin  has  the  lowest  death  rate  and  St. 
Petersburg  the  highest,  while  the  mortality  per  one 
thousand  of  New  York  and  London  are  the  same. 
However,  the  fact  must  be  taken  into  account  that  the 
death  rates  for  New  York  are  estimated  for  the  bor- 
oughs of  Manhattan  and  the  Bronx  only.  Neverthe- 
less it  is  a  matter  for  congratulation  that  there  has 
been  a  steady  decrease  in  the  death  rate  of  New  York 
as  a  whole  during  the  past  few  years.  Dr.  Chapin 
attributes  tiiis  to  a  lessening  of  the  virulency  of  influ- 
enza brought  about  by  the  better  paving  of  streets  and 
a  more  careful  oversight  of  water  and  milk  supply. 
Further  improvement  in  the  quality  of  the  milk  sup- 
ply is  anticipated,  and  with  this  end  in  view  a  com- 
mittee of  the  Medical  Society  of  the  County  of  New 
York  has  been  making  a  careful  study  of  the  question 
and  suggesting  practical  measures.  The  greater  portion 
of  the  report  is  wisely  devoted  to  a  consideration  of 
the  water  supply,  which  has  of  late  been  attracting  the 
attention  of  sanitarians  and  citizens  of  all  classes.  It 
is  notorious  that  the  water  supply  of  New  York  is  in- 
sufficient for  the  growing  needs  of  the  population,  and 
it  is  also  manifest  that  steps  must  be  quickly  taken  to 
remedy  the  present  state  of  affairs.  Dr.  Chapin  points 
out  that  all  of  the  supply  of  Manhattan,  as  well  as  all 
of  the  Bronx,  is  furnished  by  the  city  with  the  excep- 
tion of  about  one  million  gallons  daily,  which  is  fur- 
nished by  a  private  company.  Brooklyn  depends 
mainly  upon  ponds  and  driven  wells  on  Long  Island, 
of  which  the  city  owns  all  but  about  seven  per  cent. 
Queens  is  supplied  by  wells,  about  thirty  per  cent, 
owned  by  the  city  and  the  remainder  by  private  cor- 
porations. Richmond  is  supplied  by  wells  on  Staten 
Island,  constructed  and  managed  by  private  enter- 
prise. The  average  daily  consumption  of  all  the  bor- 
oughs in  the  city  of  New  York  was  in  1899,  371,778,- 


820 


MEDICAL    RECORD. 


[November  24,  1900 


000  gallons,  an  estimated  average  daily  consumption 
per  capita  of  103  gallons.  The  Croton  watershed 
when  completed  is  expected  to  yield  from  278,000,000 
to  280,000,000  gallons  per  day.  From  other  sources 
available  for  the  boroughs  of  the  Manhattan  and  the 
Bron.\  from  1,5000,000  to  17,000,000  gallons  are  ob- 
tainable, making  in  all  for  these  boroughs  about  290.- 
000,000  gallons  per  day.  The  investigation  by  the 
engineering  committee  of  the  Merchants'  Association 
shows  that  in  Brooklyn,  Queens,  and  Richmond  the 
present  consumption  nearly  equals  the  present  supply; 
that  in  Manhattan  and  the  Bron.x  the  consumption  in 
1903  will  nearly  equal  the  supply  at  that  time  availa- 
ble under  present  methods.  Therefore  it  is  perfectly 
evident  that  vigorous  measures  should  be  initiated  at 
once  to  enlarge  the  present  water  supply,  and  to  intro- 
duce reforms  into  the  existing  mode  of  managing  the 
same.  As  Dr.  Chapin  ably  presents  the  situation, 
"From  six  to  seven  and  one-half  years  will  be  neces- 
sary from  the  inception  of  the  work  to  the  delivery  of 
additional  water,  and  immediate  steps  should  be  taken 
to  furnish  an  adequate  supply  of  water,  to  be  availa- 
ble at  the  latest  in  1910."  The  space  at  our  disposal 
is  too  limited  to  discuss  at  length  the  result  of  the  in- 
vestigations carried  out  by  the  engineers  of  the  Mer- 
chants' Association.  They  believe  that  the  Hudson 
River  above  Poughkeepsie  should  be  utilized  as  the 
main  source  of  water  supply  for  New  York,  and  con- 
tend that  by  an  efficient  system  of  filtration  such 
water  can  be  rendered  excellent  for  all  domestic  pur- 
poses. This  is  undoubtedly  the  case,  and  has  been 
conclusively  proved  in  London  and  in  many  large 
American  and  European  cities,  where  since  the  adop- 
tion of  like  methods  the  death  rate  from  zymotic  dis- 
eases, notably  diarrhoea  and  typhoid,  has  been  im- 
mensely decreased.  Dr.  Chapin  concludes  his  report 
by  entering  a  strong  plea  for  public  ownership  of  wa- 
ter supplies  in  New  York,  in  which  we  heartily  concur. 
The  plan  has  been  found  to  answer  admirably  in 
Glasgow,  Scotland,  and  in  other  centres  of  population 
in  which  it  has  been  given  a  trial.  The  cost  is  much 
less,  and  there  is  not  the  opportunity — or,  at  least, 
there  should  not  be — of  making  large  profits  at  the 
expense  of  the  general  public  as  in  private  owner- 
ship. The  sanitarians  and  medical  men  of  New  York 
should  use  their  best  efforts  to  procure  a  plentiful, 
pure,  and  cheap  water  supply. 


THE    ETIOLOGY    OF   YELLOW    FEVER. 

An  amusing  illustration  of  the  odium  medicum  is  fur- 
nished by  the  controversy  on  the  subject  of  the  yellow- 
fever  germ  now  occupying  the  thoughts  and  governing 
the  words  of  certain  surgeons  of  the  Marine-Hospital 
service  on  one  side  and  of  the  Army  Medical  Corps 
on  the  other.  The  former  have  warmly  espoused  the 
hypothesis  of  the  Sanarelli  bacillus  because  they  think 
they  have  found  that  germ  in  the  bodies  of  yellow- 
fever  patients.  The  latter  with  some  emphasis  reject 
that  theory  because  they  have  not  found  the  bacillus 
icteroides  in  cases  of  yellow  fever,  and  think  they 
have  found  it  in  the  cadavers  of  persons  dead  of  some 


other  disease.  We  have  read  with  more  or  less  inter- 
est the  now  somewhat  voluminous  literature  put  forth 
by  both  parties  to  the  dispute,  as  well  as  some  of  that 
produced  by  volunteer  partisans  of  one  side  or  the 
other,  and  we  are  obliged  to  say  that  we  have  as  yet 
come  across  no  very  convincing  testimony  advanced 
by  Sanarelli's  disciples  in  support  of  their  leader's 
assumption. 

The  dispute  has  now  entered  upon  a  new  and  to  the 
onlooker  a  more  interesting  phase  with  the  adoption 
by  the  army  and  the  rejection  by  the  Marine-Hospital 
service  of  Finlay's  mosquito  theory  of  the  spread  of 
yellow  fever.  The  army  board,  whose  inconclusive 
findings  we  noted  a  couple  of  weeks  ago,  suggests  that 
the  mosquito  is  the  intermediate  host  of  the  yellow- 
fever  germ,  but  Dr.  Wasdin,  of  the  Marine-Hospital 
service,  scouts  this  suggestion,  holding  that  any  in- 
oculation of  the  disease  in  that  way  is  purely  acci- 
dental, and  he  denies  that  Culex  fasciatus  or  any  other 
mosquito  is  essential  to  the  spread  of  yellow  fever. 
Of  course  the  facts  adduced  by  the  members  of  the 
army  board  in  support  of  their  adopted  theory  are 
utterly  inadequate,  and  it  is  strange  that  scientific 
men,  such  as  they  undoubtedly  are,  could  bring  them- 
selves to  put  forth  seriously  any  such  flimsy  evidence. 
They  could  have  made  out  a  much  stronger  case  by 
simply  republishing  Finlay's  papers  on  the  same  sub- 
ject. In  spite  of  the  lack  of  proof,  however,  this  fas- 
cinating theory  may  be  the  correct  one,  and  if  it  should 
prove  so  to  be  it  is  not  improbable  that  it  will  direct 
us,  following  out  the  analogy  of  the  malaria  germ,  to 
the  discovery  of  the  true  cause  of  yellow  fever. 

Some  time  ago  Klebs  published  a  paper  in  which 
he  described  certain  oval  or  egg-shaped  bodies  which 
he  had  found  in  the  liver  and  the  mucous  membrane 
of  the  stomach  and  duodenum  of  a  man  dead  of  yellow 
fever.  These  bodies,  which  were  somewhat  larger 
than  a  human  red  blood  corpuscle  and  were  found  in 
the  tissues  surrounded  by  leucocytes,  Klebs  believed 
to  be  amcfiba,  and  he  suggested  that  they  might  prove 
to  be  the  true  parasite  of  yellow  fever.  The  paper 
attracted  little  attention  beyond  a  letter  of  disapproval 
from  Surgeon-General  Sternberg,  who  said  that  Coun- 
cilman had  long  before  observed  similar  bodies  in 
advanced  cases  of  cirrhosis,  in  phosphorus  poisoning 
and  other  cases  of  rapid  fatty  degeneration,  and  espe- 
cially in  acute  yellow  atrophy.  Klebs  replied  that 
these  appearances  were  quite  different  from  those  seen 
by  him  in  the  organs  from  a  case  of  yellow  fever,  but 
he  admitted  that  llie  question  was  one  calling  for  more 
extensive  investigations  both  in  the  cadaver  and  in 
the  living  yellow-fever  patient.  There  the  matter 
rested,  and  the  alleged  discovery  of  the  Chicago  pathol- 
ogist seemed  to  have  gone  to  tiie  limbo  of  unsupported 
and  unpopular  medical  hypotheses.  If  Finlay's  theory 
becomes  established,  however,  we  may  find  that  the 
germ  which  the  insect  harbors  is  an  amoeba,  and  that 
it  has  a  separate  life  cycle  in  the  body  of  Culex  just 
as  the  Plasmodium  of  malaria  has  in  that  of  Anoph- 
eles. And  then,  may  be,  the  warring  surgeons  will 
bury  the  hatchet  at  the  feet  of  Klebs. 


Grippe  is  reported  to  be  quite  prevalent  in  London. 


November  24,  1900] 


MEDICAL    RECORD. 


821 


^cius  of  tTxe  "Sfilcck. 

A  Reception  to  Dr.  William  Osier,  of  the  Johns 
Hopkins  University  and  Hospital,  was  tendered  on 
November  15th  by  the  Faculty  Club  of  the  University 
of  Pennsylvania. 

The  Plague  is  raging  on  the  island  of  Mauritius, 
where  fifty  new  cases  occurred  during  the  first  week  in 
November.  The  deaths  were  thirty-five.  In  Alexan- 
dria, Egypt,  two  new  cases  were  reported  on  November 
13th.  The  disease  has  also  broken  out  among  the  na- 
tives near  King  William's  Town,  twenty-eight  miles 
northwest  of  East  London,  Cape  Colony.  Three 
deaths  have  already  occurred. 

Dr.  Angelo  Bellinzaghi,  who  is  reported  in  the 
papers  to  have  received  from  the  Mexican  government 
an  award  of  $50,000  for  the  production  of  a  really 
curative  serum  for  yellow  fever,  is  said  to  be  on  his 
way  to  New  York  and  Washington.  He  announces 
that  he  is  about  to  organize  a  company,  with  a  farm 
near  San  Antonio,  Texas,  for  the  production  of  his 
serum  on  a  large  scale.  Dr.  Bellinzaghi  seems  not  to 
have  published  his  method  of  preparing  the  serum, 
nor  have  we  seen  in  any  medical  journal  any  account 
of  his  bacteriological  studies  of  yellow  fever,  if  he  has 
made  any  such. 

A  Typhoid-Stricken  Town — It  is  stated  in  The 
Sun  that  typhoid ^ever  has  become  epidemic  in  Cemen- 
ton,  a  town  on  the  Lehigh  River,  not  far  from  Allen- 
town.  Pa.  Out  of  two  hundred  families  composing 
the  population,  there  are  one  or  more  cases  in  one 
hundred  and  eighteen  families.  Of  twenty-two  f.im- 
ilies,  all  members  from  the  father  down  to  the  young- 
est child  are  prostrated  by  the  disease,  which  has  now 
been  raging  two  weeks.  There  have  been  several 
deaths.  The  water  used  by  the  inhabitants  of  the 
town  is  drawn  from  tiie  Lehigh  River,  which  is  very 
low,  owing  to  the  prolonged  drought,  and  is  contam- 
inated with  the  sewage  and  cess-pool  leakage  of  the 
towns  above  Cementon. 

Philadelphia  Pediatric  Society.— At  a  stated  meet- 
ing held  November  13th  Dr.  David  Riesman  presented 
"  A  Case  of  Complete  Motor  Aphasia  in  a  Child  of 
Eleven  Years,  the  Result  of  Infantile  Cerebral  Palsy.'" 
There  had  been  difficulty  in  the  birth  of  the  ciiild, 
probably  with  the  occurrence  of  meningeal  hemor- 
rhage, which  had  destroyed  the  speech  mechanism  in 
both  cerebral  hemispheres.  Dr.  Alfred  Stengel  re- 
ported "  A  Case  of  Meningitis  ";  also  "  A  Case  of  Os- 
teoarthritis, with  .Skiagraphs'";  and  also  "A  C"ase  of 
Gisophageal  Stricture,  with  Skiagraphs."  Dr.  J.  P. 
Crozer  Griffith  presented  "A  Case  of  Possible  Cere- 
bellar Tumor."  Dr.  A.  Van  Harlingen  presented  a 
communication  entitled  "A  Case  of  Pemphigus,  with 
Some  Remarks  on  the  Treatment  of  this  Condition." 

College  of  Physicians  of  Philadelphia,  Section 
on  General  Medicine. — \\.  a  stated  meeting  held 
November  12th  Dr.  Thomas  C.  Ely  read  a  paper  en- 
titled "  Diabetes   Mellitus  as  a  Cellular  Fault."'     Dr. 


David  Riesman  read  a  paper  entitled  "Abscess  of 
the  Liver;  Hepatotomy;  Recovery."  Exploratory 
puncture  had  evacuated  considerable  sterile  pus,  and 
the  operation  yielded  a  like  result.  Dr.  James  Tyson 
read  a  paper  entitled  "  A  Physician's  Holiday  at 
Carlsbad."  Dr.  F.  A.  Packard  presented  a  specimen 
of  carcinoma  of  the  rectum  associated  with  the  lesions 
of  chronic  colitis. 

Philadelphia  Hospital. — The  Bureau  of  Charities 
has  elected  a  dental  staff  constituted  as  follows:  Dr. 
R.  H.  Nones,  Dr.  M.  H.  Cryer,  Dr.  J.  Norman  Brow- 
nell,  and  Dr.  Thomas  C.  Stelhvagen,  Jr.  It  is  pro- 
posed to  form  also  a  pediatric  staff. 

Philadelphia  County  Medical  Society. — At  a  stated 
meeting  held  November  14th  Dr,  Herman  M.  Biggs, 
pathologist  and  director  of  the  bacteriological  labora- 
tory of  the  New  York  department  of  health,  read  by 
invitation  a  paper  entitled  "The  Registration  of 
Tuberculosis,"  in  which,  after  considering  the  objec- 
tions that  have  been  made  against  this  practice,  he 
presented  a  logical  and  dispassionate  argument  in  its 
favor,  and  he  related  the  results  of  its  operation  in 
New  York  City.  For  properly  dealing  with  cases  of 
tuberculosis  it  was  contended  that  the  sanitary  super- 
vision in  every  municipality  should  comprise:  i,  com- 
pulsory notification;  2,  suitable  plans  for  the  educa- 
tion of  the  people;  3,  a  complete  and  efficient  scheme 
for  the  disinfection  or  renovation  of  premises  vacated 
by  death  or  removal;  4,  a  hospital  equipment;  5,  the 
power  of  compulsory  removal  and  detention  of  pa- 
tients in  a  hospital  when  necessary,  in  the  same  man- 
ner as  is  practised  in  the  contagious  diseases.  He 
showed  that  since  1886  there  had  been  a  reduction  in 
the  mortality  from  tuberculous  diseases  in  New  York 
City  of  more  than  thirty-five  per  cent.,  and  he  expressed 
the  opinion,  that,  with  a  complete  and  efficient  scheme 
for  dealing  with  pulmonary  tuberculosis,  including 
suitable  hospital  accommodations  and  the  proper  en- 
forcement of  precautionary  measures,  the  death  rate 
from  tuberculous  disea.ses  in  New  York  City  might  be 
further  reduced  at  least  one-third  within  a  period  of 
five  years.  This  would  mean  the  saving  of  three  thou- 
sand lives  annually.  After  extended  discussion,  par- 
ticipated in  by  Drs.  J.  C.  Wilson,  A.  C.  Abbott,  A.  V. 
Meigs,  J.  M.  Anders,  L.  Ott,  L.  F.  Flick,  W.  M. 
Angney,  M.  \\'oods,  S.  Flexner,  J.  Solis-Cohen,  A. 
Stengel,  W.  M.  L.  Coplin,  and  G.  Hinsdale,  a  resolu- 
tion was  adopted  recommending  to  the  bureau  of 
health  the  compulsory  registration  of  cases  of  tuber- 
culosis, with  the  adoption  of  measures  looking  to  the 
restriction  of  the  disease. 

Return  of  a  Disgraced  "  Ambulance  "  Corps.— 
Thirty-three  members  of  the  Chicago  Irish-.American 
Ambulance  Corps,  which  left  this  city  to  help  the 
Boers  in  the  Transvaal  last  February,  got  back  Satur- 
day on  the  steamship  7>v77r.  There  were  fifty-eight 
men  in  the  corps,  among  them  six  physicians.  They 
were  Drs.  J.  R.  McNamara,  Herbert  Mc.Auley.  James 
J.  Slattery,  R.  L.  Long,  A.  F.  Corney,  and  J.  B.  Ader- 
holt,  all  of  Chicago.  George  Cassidy  went  as  a  nurse. 
The  other  fifty-one  were  supposed   to  be  litter  men. 


822 


MEDICAL   RECORD. 


[November  24,  1900 


Before  leaving  this  country  each  of  the  fifty-eight  men 
went  before  a  justice  of  the  peace  and  niado  affidavit 
that  he  was  going  to  South  Africa,  not  as  an  ally  of 
the  Boers  but  as  an  ambulance  man,  and  each  man 
pledged  himself  not  to  fight.  Miss  Clara  Barton  gave 
the  Irish-American  Corps  a  Red  Cross  flag  and  recog- 
nized the  organization  as  a  Red  Cross  auxiliary.  The 
six  physicians  and  the  nurse  adhered  to  their  pledges, 
but  all  the  others  entered  the  fighting  ranks  of  the 
Boers  the  minute  they  reached  the  Transvaal.  Some 
of  the  men  were  killed,  some  were  captured  or  ran 
away,  and  some  are  still  fighting.  We  are  pleased  to 
note  that  the  reception  the  returning  band  of  pledge 
breakers  got  from  the  committee  which  had  been  ap- 
pointed to  meet  them  was  far  from  cordial,  and  instead 
of  congratulations  they  received  reproaches  for  having 
perjured  themselves. 

Fire  at  Cornell  University. — The  main  building 
of  the  Veterinary  College  at  Cornell  University  was 
damaged  by  fire  on  November  13th,  about  $10,000 
worth  of  laboratory  apparatus  being  destroyed.  The 
total  loss  was  about  $30,000. 

Yellow  Fever  in  Havana  is  diminishing  since  the 
appearance  of  cooler  weather.  At  the  middle  of  this 
month  there  were  sixty-five  cases  under  treatment  in 
the  city,  seven  of  them  being  in  Americans.  There 
have  been  two  cases  at  Natchez  and  one  at  Brook- 
haven,  Miss. 

Fire  in  the  Hudson  Street  House  of  Relief.— A 
fire  did  slight  damage  to  the  Hudson  Street  Hospital 
on  Friday  morning  of  last  week.  It  started  in  the 
laundry  on  the  top  floor,  but  was  extinguished  quickly 
without  disturbing  any  of  the  thirty-five  patients  at 
the  time  in  the  wards.  The  hospital  is  the  accident 
branch  of  the  New  York  Hospital. 

University  of  Michigan's  Homoeopathic  Hospital. 
— The  new  Homoeopathic  Hospital  of  tlie  University 
of  Michigan  was  opened  on  November  15th  and  filled 
with  patients  formerly  cared  for  in  part  of  the  Uni- 
versity Hospital.  The  formal  opening  will  take  place 
in  the  first  week  of  December.  Dr.  Charles  E.  Wal- 
ton, of  Cincinnati,  president  of  the  American  Institute 
of  Homoeopathy,  will  make  the  principal  address. 

A  Disgraceful  Riot  occurred  at  the  Omaha  Medi- 
cal College,  Thursday  of  last  week,  in  which  nearly 
one  hundred  students  participated,  and  two  of  them 
were  severely,  perhaps  mortally,  injured.  The  fight 
took  place  between  the  dental  and  the  medical  stu- 
dents over  the  question  of  seats.  At  the  beginning 
fists  were  the  only  weapons,  but  soon  a  railing  was 
demolished  and  its  severed  parts  were  used  as  clubs, 
with  serious  results. 

More  Free  Treatment  by  the  New  York  Board  of 
Health. — A  few  days  ago  notice  was  sent  to  physicians 
here  by  the  health  department  that  treatment  for  the 
prevention  of  rabies,  according  to  the  method  of  I'as- 
teur,  would  be  administered  free  to  any  person  resid- 
ing in  Greater  New  York;  that  it  would  be  adminis- 
tered on  request  to  persons  outside  the  city  upon  the 


payment  of  $50  for  the  virus  used,  and  that  to  persons 
unable  to  pay  that  fee  treatment  might  be  administered 
without  cliarge  by  direction  of  the  board  of  health. 
The  treatment  will  be  carried  out  at  the  Wi41ard 
Parker  Hospital. 

X-Ray  Treatment  of  Alopecia. — A  Viennese  phy- 
sician, Dr.  Kienbock,  claims  to  have  caused  hair  to 
regrow  on  a  bald  head  by  treatment  with  Roentgen 
rays.  The  case  reported  was  one  of  alopecia  in  a 
young  man,  cause  not  stated,  but  the  doctor  has  not 
succeeded  in  remedying  calvities  senilis. 

Presentation  to  Dr.  Wheelock. — On    the   evening 

of  November  14,  1900,  the  committee  appointed  for 
this  purpose  by  the  Alumni  Association  of  the  College 
of  Physicians  and  Surgeons,  medical  department  of 
Columbia  University,  presented  to  Dr.  George  G. 
Wheelock,  of  New  York  City,  a  testimonial  in  silver 
to  commemorate  the  faithful  and  wise  manner  in  which 
he  had  performed  the  duties  of  treasurer  for  the  Asso- 
ciation during  the  long  period  of  twenty-four  years. 
The  testimonial  bore  the  inscription:  "  Fidelitatis 
Causa." 

Testimonial  Banquet  to  Dr.  Christian  Fenger 

A  testimonial  banquet  was  tendered  to  Dr.  Christian 
Fenger  at  the  Auditorium  Hotel,  Chicago,  November 
3,  1900.  Over  five  hundred  physicians  from  all  parts 
of  the  United  States  were  present.  The  meeting  was 
called  to  order  by  Dr.  J.  B.  Murphy,  who  introduced 
as  toastmaster  Dr.  Charles  A.  L.  Reqd,  of  Cincinnati. 
Letters  and  messages  of  regret  from  the  officers  of 
various  State,  county,  and  local  medical  societies  in 
the  East,  West,  North,  and  South  were  read.  Dr.  U'. 
W.  Keen,  of  Philadelphia,  presented  the  loving-cup 
to  Dr.  Fenger.  One  side  of  the  cup  bore  the  inscrip>- 
tion : 

"  This  great  good  man  for  noblest  cause  displays 
What  many  labors  taught,  and  many  days." 

On  the  other  side  it  read:  "To  Dr.  Christian 
Fenger,  on  the  sixtieth  anniversary  of  his  birth,  from 
those  who  know  and  love  him  best — The  Medical 
Profession."  Dr.  Fenger  accepted  the  loving-cup  in 
a  brief  but  felicitous  speech. 

The  First  New  York  State  Conference  of  Char- 
ities and  Correction  was  held  in  tlie  Senate  Chamber 
at  the  Capitol  in  Albany,  on  November  20,  21,  and 
22,  1900.  This  Conference,  designed  to  meet  annu- 
ally in  this  State,  has  been  inaugurated  for  the  consid- 
eration of  cjuestions  of  practical  importance  with  rela- 
tion to  the  public  and  the  private  charitable  and 
correctional  work  of  the  State,  with  the  hope  that  the 
Conference  will  be  able  to  exert  a  powerful  force  for 
good  in  securing  intelligent  action  upon  such  que.-;- 
tions.  Conferences  similar  in  purpose  have  for  some 
time  been  organized  and  carried  on  in  many  of  the 
States,  principally  in  the  West,  and  those  who  are 
well  informed  on  the  subject  regard  them  as  .sources 
of  beneficent  influence.  All  who  are  officially  con- 
nected with  public  or  private  cliaritable  or  correctional 
work  in  New  York  State,  or  who  take  an  active  inter- 
est therein,  are  invited  to  enroll   themselves  as  mem- 


November  24,  1900] 


MEDICAL    RECORD. 


823 


bers  of  the  Conference  and  to  attend  its  sessions. 
There  are  no  other  tests  of  membership,  and  no  mem- 
bership fee  is  charged,  the  expenses  of  the  Conference 
being  met  by  voluntary  contributions.  The  officers  of 
the  Conference  were:  J'residcnt,  Hon.  William  Pryor 
Letchworth,  LL.D. ,  of  Portage ;  Vice-Presidents,  Robert 
VV.  de  Forest,  of  New  York;  Rev.  Thomas  A.  Hend- 
rick,  LL.D.,  of  Rochester;  Secretary,  Homer  Folks, 
of  New  York;  Assistant  Secretaries,  Frederic  Almy,  of 
Buffalo;  Dr.  John  ¥.  FitzGerald,  of  Rome;  Clarence 
V.  Lodge,  of  Rochester;  Treasurer,  Frank  Tucker,  of 
New  York. 

An  Impostor. — Dr.  VV.  Peyre  Porcher,  of  Charles- 
ton, S.  C,  writes  that  a  man  impersonating  himself, 
and  claiming  to  have  attended  the  meeting  of  the 
Congress  of  American  Physicians  and  Surgeons  in 
Washington  in  May  last,  has  been  victimizing  many 
of  the  profession  of  that  city  by  pretending  to  be  in 
distress  and  borrowing  money  from  them.  The  man 
is  described  as  being  between  sixty  and  seventy  years 
old,  with  a  heavy  gray  mustache,  about  five  feet  eight 
or  ten  inches  tall,  and  of  rather  spare  build.  There 
should  be  some  way  in  which  physicians  could  protect 
themselves  from  this  class  of  scoundrels,  and  Dr. 
Porcher  hopes  that  any  one  approached  by  this  man 
will  be  on  his  guard  and  will  be  able  to  cause  the 
swindler's  apprehension. 

Navy  Department,  Bureau  of  Medicine  and  Sur- 
gery, Washington,  D.  C. — Changes  in  the  medical 
corps  of  the  United  States  navy  for  the  week  ending 
November  17,  1900.  Medical  Director  C.  H.  White 
placed  on  the  retired  list  of  the  navy  from  November 
19th,  having  reached  the  age  of  sixty-two  years. 
Passed  Assistant  Surgeon  R.  S.  HIakeman  detached 
from  the  Pensacola  and  ordered  to  Naval  Hospital, 
Mare  Island,  for  treatment.  Assistant  Surgeon  C.  S. 
Butler  ordered  to  the  Independence.  Surgeon  W.  A. 
McClurg  ordered  to  additional  duty  on  the  Yankee. 
November  14th. — Assistant  Surgeon  VV.  M.  Carton 
detached  from  the  Indiana  and  ordered  home  to  wait 
orders.  November  15th. — Passed  Assistant  Surgeon 
A.  R.  Alfred  detached  from  the  Castinc  and  ordered 
to  the  Culgoa.  Passed  Assistant  Surgeon  M.  K.  John- 
son detached  from  the  Celtic  and  ordered  to  the  Brutus. 
Assistant  Surgeon  H.  C.  Curl  detached  from  the 
Culgoa  and  ordered  to  the  Castine.  Assistant  Surgeon 
E.  Davis  detached  from  the  Cavite  naval  station  and 
ordered  to  the  Brutus.  Assistant  Surgeon  VV.  L.  Bell 
detached  from  duty  at  Guam  and  ordered  to  the  Celtic. 
Assistant  Surgeon  B.  L.  Wright  detached  from  the 
naval  hospital,  Cavite,  and  ordered  to  the  naval  hospi- 
tal, Yokohama,  for  treatment. 

The  Late  Dr.  Lewis  A.  Sayre In  the  death  of 

Dr.  Lewis  Albert  Sayre  the  New  York  Pathological 
Society  loses  the  last  of  the  members  w^ho  brought  it 
into  existence.  The  first  meeting  of  the  society  was 
held  in  Dr.  Sayre's  office  on  June  14,  1844,  Drs. 
George  A.  Peters  and  Middleton  Goldsmith  participat- 
ing in  the  formation  of  the  new  society.  Dr.  Sayre 
kept  his  interest  in  the  society  alive,  occasionally 
attending  its  meetings,  until  the  end  of  his  profes- 


sional activity.  It  is  with  a  special  sense  of  loss  that 
the  society  sees  fade  from  its  list  of  active  members 
this  illustrious  name,  enrolled  at  its  first  meeting  when 
"the  oldest  pathological  society  in  the  world,"  as  he 
was  fond  of  saying,  was  created. 

The  New  York  Pathological  Society  now  records 
upon  its  minutes  the  death  of  Dr.  Lewis  Albert  Sayre, 
and  adopts  the  following  resolution: 

'''Resolved,  That  the  sympathy  of  the  New  York 
Pathological  Society  be  extended  to  the  family  of  Dr. 
Sayre  in  their  bereavement,  and  that  the  above  testi- 
monial be  published  in  the  current  medical  periodi- 
cals. (Signed)  W.  P.  Northrup,  iVLD.,  Ja.mes 
Ewi.N'G,  M.l).,  E.  K.  Du.vHAM,  M.D.,  Cun.initlee." 


(Obituary. 

HORACE   TRACY    HANKS,  M.D.,  LL.D., 


NEW    VuKK. 


Dr.  H.anks,  whose  death  from  Bright's  disease  oc- 
curred on  Sunday  last  at  his  home  in  this  city,  was 
born  June  27,  1837,  in  East  Randolph,  Vt.  After 
completing  his  college  studies  he  taught  school  in  his 
native  place  for  some  years,  and  then  began  the  study 
of  medicine  under  a  preceptor.  His  degree  was  ob- 
tained from  the  Albany  Medical  College  in  1861.  For 
two  years  after  graduation  he  served  in  the  Union 
army  as  acting  assistant  surgeon,  and  in  1863  entered 
upon  the  practice  of  his  profession  in  Royalston, 
Mass.  Here  he  remained  but  a  short  time  and  then 
removed  to  this  city.  Circumstances  turned  his  atten- 
tion almost  from  the  first  to  gyniecological  subjects, 
and  he  soon  became  recognized  as  an  authority  in  that 
specialty.  He  was  gynaecologist  to  the  Deniilt  Dis- 
pensary from  1872  to  1882.  and  in  1885  was  appointed 
professor  of  the  diseases  of  women  at  the  Post-Gradu- 
ate  Medical  School.  In  1875  lie  became  assistant 
surgeon  to  the  VVoinan's  Hospital  and  was  elected 
attending  surgeon  to  the  same  institution  in  1889. 
He  was  also  consulting  gynecologist  to  the  Tarry- 
town,  Mt.  Vernon,  and  St.  Joseph's  Hospitals,  and  to 
the  Newark  Hospital  for  Women  and  Children.  He 
was  a  member  of  the  New  York  Academy  of  Medicine, 
the  New  York  Obstetrical  Society,  the  New  York  State 
Medical  Society,  New  York  County  Medical  Society, 
the  Medico-Historical  Society,  and  the  American 
Medical  Association,  and  was  a  Fellow  of  the  Ameri- 
can and  of  the  British  Gynaicological  societies.  He 
was  an  honorary  member  of  the  Boston  Gynecological 
Society  and  the  Dubuque  Medical  Society.  He  uas 
a  prolific  writer  for  medical  publications  and  invented 
a  large  number  of  surgical  instruments  for  use  in  his 
sf)ecialty.       A  widow  and  two  daughters  survive  him. 


Obituary  Notes. — Dr.  Robert  B.  Brown  died  on 
November  15th  at  his  home  in  Phillipsburg,  N.  J.,  at 
the  age  of  seventy-six  years.  He  was  graduated  from 
the  medical  department  of  the  University  of  Pennsyl- 
vania in  1846.  He  served  as  surgeon  in  the  Union 
army  during  the  Civil  War. 

Dr.  a.  Miles  died  last  week  at  his  home  near 
Dallas,  Texas,  at  the  age  of  ninety-four  years.  He 
was  a  native  of  Kentucky,  but  practised  medicine  in 
Texas  for  nearly  sixty  years.  He  served  as  surgeon 
in  the  Confederate  army  during  the  C!ivil  War. 

Dr.  George  W.  Sparks  died  at  Philadelphia  on 
November  17th  at  the  age  of  fifty-six  years.  He  was 
graduated  from  Jefferson  Medical  College  in  i86s. 

Dr.  William  T.  Collins  died  at  Camden,  N.  J., 
in  November,  at  the  age  of  seventy-one  years.  He  was 
a  graduate  of  Jefferson  Medical  College. 


824 


MEDICAL    RECORD. 


[November  24,  1900 


grogrcss  of  g^cdicitl  J<cicnce. 

Xi-u'  York  Medical  Jouriuil,  Xoi'CinOcr  i-,  li/oo. 

Aa  Operation  Devised  for  the  Treatment  of  Marked  Pro- 
lapse of  the  Rectum  in  Women. — By  J.  Wesley  Bovee. 
The  jialicnt  was  a  woman  aged  thir'ty-tive,  who  suifered 
from  large  external  and  internal  hemorrhoids  and  a  protrud- 
ing roll  of  fully  three  inches  of  rectum  that  was  thickened 
and  much  discolored.  The  uterus  was  of  about  normal 
size,  with  its  cervi.x  just  l)ehind  the  pubes  and  the  fundus 
very  low  posteriorly.  The  hemorrhoids  were  first  removed, 
then  the  abdomen  was  opened  by  the  usual  subumbilical 
median-line  incision.  The  left  ovary  was  of  about  three 
times  its  natural  size  and  largely  consisted  of  numerous 
cysts.  The  appendages  were  removed  and  the  uterus  was 
firmly  fi-xed  to  the  abdominal  wall  by  four  strong  inter- 
rupted catgut  sutures,  which  passed  through  a  consider- 
able portion  of  the  uterine  fundus  at  the  top  and  the  prin- 
cipal fascia  of  the  abdominal  wall  on  either  side  ot  the 
incision.  The  rectum  was  now  drawn  upward  until  it  was 
fairly  tense,  and  was  so  held  by  an  assistant  until  it  was 
sutured  to  the  cul-de-sac  and  posterior  wall  of  the  uterus, 
up  to  the  abdominal  wall.  This  was  done  by  a  running 
catgut  suture.  It  completely  divided  the  retro-uterine  pel- 
vic cavity  into  two  equilateral  ones.  The  patient  was 
doing  well  eight  months  after  operation,  with  no  relapse. 

Delirium  Tremens. — C.  J.  Douglass  thus  states  his  views 
as  to  tlie  correct  method  of  treating  this  condition.  First, 
patients  should  be  put  to  sleep  with  apomorphine,  which 
can  be  done  in  a  few  minutes  without  danger  and  without 
emesis.  Secondly,  they  should  not  be  restrained  by  physi- 
cal force,  as  this  adds  to  their  suffering  and  prolongs  and 
increases  delirium.  Thirdly,  they  should  be  allowed  alco- 
hol in  .some  form.  Fourthly,  the  patients  should  be  nour- 
ished with  milk,  egg-nog,  or  some  other  liquid  food.  De- 
lirium tremens  seldom  affects  those  who  have  not  been 
deprived  of  proper  nourishment  for  some  time.  Hence 
easily  assimilable  food  is  indicated. 

The  Etiology  of  Eczema  with  Reference  to  Recent  Views 
as  to  its  Parasitic  Origin.  —  By  L.  Duncan  Bulkleyicon- 
linued  article). 

Phoenix,  Arizona,  as  a  Health  Resort  for  Tuberculous  Pa- 
tients.—  By  E.  Payne  Palmer. 

Endothelioma  of  Bone  with  Man;.'  Metastases. — Concluding 
article  by  F.  H.  Brandt. 

A  Review  of  Our  Knowledge  of  Malaria.— By  Joseph  JIc- 
Farland. 

Rational  Physical  Training  for  Women. — By  G.  A.  Saxe. 

Mcdiial  .AVti'.v,  yoi'fiiibfr  ij,  igoo. 

Pernicious  Anaemia ;  Report  of  a  Case. — G.  R.  Trowbridge 
states  tliat  tlie  etiology  of  this  affection  is  very  obscure, 
there  being  no  known  or  appreciable  cau,se.  As  yet  it  is 
impossible  to  say  whether  tlie  disease  is  produced  by  a 
defective  ha-mogenesis  or  htemolytic  process.  The  points 
on  which  to  base  a  diagnosis  are  as  follows,  and  in  every 
suspected  case  include  an  examination  of  the  blood:  (i) 
Greenish-yellow  tint  of  the  skin.  (2)  Dyspniea  and  rapid 
pulse  without  pulmonary  symptom.s  and  a  proportionate 
rise  of  temperature.  (3)  The  intense  oligocythemia.  (4) 
The  presence  of  macrocytes  and  microcj-tes.  (5)  The 
steady  and  uninterrupted  progress  of  tlie  disease  toward 
a  fatal  termination,  and  the  inefficiency  of  treatment.  The 
prognosis  is  always  unfavorable.  Arsenic  is  the  only  drug 
which  seems  to  have  a  beneficial  effect  in  these  ca.ses,  and 
then  it  is  only  slight  and  not  permanent  and  only  tempo- 
rarily checks  the  progress  of  the  disease.  The  writer  con- 
cludes by  saying:  In  cases  of  apparent  chlorosis  and  pri- 
mary aucemia  in  whicli  there  is  present  the  greenish  tint 
of  the  skin,  together  with  dys]moea,  palpitation,  and  gen- 
eral malaise,  one  should  not  depend  on  symptoms  for  the 
diagnosis,  but  should  let  the  blood  examination  (leci<le 
whether  one  is  dealing  with  either  of  tliese  diseases  or 
with  a  case  of  pernicious  anccmia. 

The  Surgical  Importance  of  Jaundice. — Archibald  Mac- 
laren  concludes:  (i)  Tliat  slight  attacks  of  jaundice  are 
of  comparatively  little  surgical  importance,  and  that  the 
majority  of  cases  of  surgical  disease  of  the  biliary  i)assages 
have  no  jaundice  at  all.  (2)  That  persistent  jaundice,  es- 
pecially if  progressive,  is  usually  a  contraindication  ;  {3) 
while  on  the  other  hand  intermittent,  deep  jaundice,  espe- 
cially if  associated  with  chills  and  a  rise  in  temperature. 
denotes  a  stone  in  the  common  duct  which  urgently  de- 
mands removal.  'i"he  writer  also  states  that  about  half 
the  patients  who  during  life  present  symptoms  of  carci- 
noma of  the  liver  are  jaundiced.  The  surgery  of  cancer  of 
the  liver  is  very  unsatisfactory.  The  disease  is,  in  his  ex- 
perience, very  aggravatc<l,  and  the  end  is  even  hastened  by 
an  exploratory  operation.     Cholccystotomy  and  drainage 


give  relief  except  in  cancer  of  the  common  duct.  Cancer 
of  the  gall  bladder,  which  is  almost  always  found  in  cases 
when  gall  stones  have  existed  for  years,  should  be  removed 
if  the  liver  be  not  too  extensively  infiltrated. 

Some  Observations  on  Affections  of  the  Gall  Bladder. — By 
Frank  Le.Moyne  llujip. 

The  Hydriatic  Treatment  of  Tuberculosis. — By  J.  II.  Kel- 
logg- 

JSostoii  M,-i/nci/  mil/  Sur^'ica/  foKrnal,  .Wt'..  ,-,  iqoo. 

Feeding  in  Typhoid  Fever,  with  a  Report  of  Cases. — 
George  W.  Moorehouse  urges  the  use  of  a  more  generous 
diet  in  the  treatment  of  typhoid  fever  than  is  the  usual 
practice,  and  describes  milk  diet,  liquid,  soft  typhoid,  ty- 
phoid convalescent,  and  full  typhoid  diets.  Out  of  one 
hundred  and  fifty  cases  ])ut  on  soft  diet  there  were  thirteen 
deaths,  or  a  mortality  of  S.fjy  per  cent.  Dr.  Bushuyev,  a 
Russian  surgeon,  rejiorts  the  result  of  experiments  upon 
one  hundred  and  fifty-four  patients  in  a  liospital.  Sev- 
enty-four, treated  by  a  colleague,  received  two  litres  of 
milk  and  one  or  two  soft-boiled  eggs  in  the  day.  Bushu- 
yev's  eighty  patients  were  put  upon  a  liberal  diet.  The 
general  mortality  was  ten  per  cent,  on  the  liberal  and  12.  i 
per  cent,  on  the  milk  diet.  The  average  duration  of  the 
fever  after  entrance  was  i.S.g  days  for  those  liberally  fed, 
and  22.3  days  for  those  on  milk.  The  average  stay  m  the 
hospital  was  forty-two  days  for  those  liberally  fed,  and 
49.2  days  for  the  others.  Of  the  patients  liberally  fed  only 
S.3  per  cent,  were  discharged  incapable  of  duty,  but  of 
those  who  were  kept  on  a  milk  diet  15.4  per  cent  were  so 
discharged. 

Three  Cases  of  Gunshot  Wounds. — A.  Farenholt  reports 
three  cases.  In  the  first  a  youth  was  shot  in  the  head  by 
a  Spanish  Mauser  ball,  calibre  S  mm.  The  wound  showed 
that  a  modern  high-power  bullet,  passing  through  a  bony 
cavity  at  a  very  short  range  (two  feet),  may  not  cause  a 
"ragged  and  enlarged  opening"  at  the  wound  of  exit,  as 
we  are  so  often  reminded  it  does  at  greater  ranges.  In 
the  second  case  a  45-calibre  Remington  ball  gave  a  round 
andclear-cut  wound  of  entrance  and  agouged-out,  large  and 
ragged  wound  of  exit.  In  the  third  case,  a  Mauser  ball, 
at  a  distance  of  seventy  yards,  gave  a  rather  ragged  wound 
of  exit. 

The  Co-operation  of  the  Medical  and  Legal  Professions.^ 
By  George  A.  Sanderson. 

Criminal  Neglect ;  Report  of  a  Case. — By  A.  W.  Buck. 

Public  Health  Laboratories. — By  Theobald  Smith. 

Journal  of  I  he  Aiiu-rUan  Medical  Ass'n,  K01'.  /-,  igoo. 

Iodine  Used  Hypodermically  in  the  Treatment  of  Pulmo- 
nary Tuberculosis. — Alfred  Careno  Croftan  declares  that 
iodine  is  peculiarly  a  drug  against  which  different  subjects 
show  marked  idiosyncrasies.  The  chief  symptoms  ob- 
served are  emaciation,  usually  accompanied  by  profuse 
sweats,  some  pyrexia,  and  an  accelerated  pulse ;  a  pecul- 
iar psychical  depression  develops  a  form  of  hypochondria- 
sis ("anxietas").  In  the  light  of  our  theoretical  beliefs  the 
administration  of  iodine  should  act  curatively  in  pulmo- 
nary tuberculosis.  Accurate  dosage  is  essential  to  the 
success  of  the  plan  of  treatment  that  is  being  advocated  ; 
too  large  doses  will  certainly  aggravate,  too  small  doses 
will  be  inefficient.  lodipin  injections  were  tried  only  on 
carefully  selected  cases.  Twenty-seven  cases  have  so  far 
been  treated  with  good  results  ;  nineteen  were  cases  of  in- 
cipient tuberculosis  with  only  circumscribed  areas  of  infec- 
tion in  one  or  the  other  of  both  apices.  The  results  ob- 
tained .so  far  are  not  conclusive,  they  are  only  suggestive, 
although  they  now  ajipear  to  be  sufficiently  striking  lo 
warrant  an  optimistic  view.  The  sooner  the  disease  is 
recognized  and  treatment  begun,  the  better  the  prognosis, 
lodipin  was  employed  m  the  form  of  the  ten-i)er-cent.  prep- 
aration, an<l  the  injections  were  made  into  the  subcutane- 
ous tissues  between  the  skin  and  the  muscle,  preferably  in 
the  gluteal  and  interscapular  regions.  Beginning  with 
one  drop  of  iodipin,  which,  to  give  the  necessary  bulk  for 
hypodermic  administration,  v  as  dissolved  in  half  a  drachm 
or  so  of  sterilized  oil,  the  injections  were  gradually  in- 
creased, one  drop  being  added  to  the  dose  each  day.  The 
dosage  was  regulated  by  the  symptoms :  as  soon  as  an  im- 
provement became  apparent,  the  dose  exhibited  at  the  time 
was  continued  for  a  jieriod  of  thirty  to  sixty  days.  If  the 
quantity  at  first  acting  beneficially  seemed  to  grow  insutli- 
cient,  the  dose  was  again  increased  dro])  by  drop;  more 
than  sixty  minims  a  day  h;ive  so  far  never  been  given. 
The  writer  believes  pulmonary  tuberculosis  in  its  inci]!- 
iency,  before  it  has  become  a  mixed  infection,  to  be  one 
of  the  most  easily  curable  of  bacterial  diseases. 

Symptoms  and  Diagnosis  of  Hypertrophy  of  the  Pharyn- 
geal Tonsil, — Georgr  Morgcnthau  states  that  the  most  com- 
mon of  these  sympKmis  is  the  excessive  discharge  which 
flows  either  into  tlie  nasojiharynx  or  into  the  nose.  Fi- 
nally, chronic  rhinitis  results.    'J'he  children  become  mouth 


November  24,  1900] 


MEDICAL    RECORD. 


825 


I 


breathers.  Infants  are  sometimes  unable  to  nurse  at  the 
breast.  Nosebleed  sets  in  often.  The  nasal  discharge  is 
apt  to  excite  eczema  at  the  introitus.  thickening  and  rough- 
ness of  the  upper  Ii[),  etc.  Impairment  of  smell  and  taste 
often  succeed  chronic  inflammation  of  the  nose.  Laryn- 
geal and  bronchial  symptoms  intervene :  cough,  hoarse- 
ness and  false  croup,  and  bronchitis  and  bronchopneumo- 
nia. Adenoid  growths  are  often  accompanied  by  nervous 
disorders.  Major  ascribes  enuresis  nocturna  to  carbonic- 
acid-gas  poisoning  from  insufficient  ventilation  of  the 
blood,  the  breathing  being  too  superficial  because  of  the 
stenosis  ;  of  this,  interrupted  sleep  and  snoring  are  a  fur- 
ther result.  Various  authors  explain  differently  the  chest 
deformities.  In  extreme  cases  the  anatomical  deformities 
of  the  buccal  cavity  are  marked.  The  patient  may  appear 
stupid  but  is  not  necessarily  so.  Adenoid  growths  are  the 
most  prolific  cause  of  certain  diseases  of  the  ear  in  child- 
hood, excepting,  perhaps,  the  infectious  diseases.  As  to 
the  diagnosis,  the  characteristic  appearance,  the  manifold 
signs  of  nasal  stenosis,  and  the  sound  of  the  voice  (which, 
to  be  sure,  is  very  similar  in  paralysis  of  the  soft  palate), 
combined  with  the  aural  symptoms,  make  the  diagnosis 
possible  almost  at  a  glance.  Rhinoscopy  offers  an  efficient 
aid. 

Massage  of  the  Eyeball. — Casey  A.  Wood  believes  that 
in  the  mam  indirect  massage  with  the  pulp  of  the  finger 
placed  on  the  skin  of  the  lids  is  to  be  preferred.  Direct 
massage,  especially  of  the  conjunctiva,  is  valuable  and 
sometimes  preferable  to  the  indirect  method,  but  the  lat- 
ter is  usually  sufficiently  efficacious,  is  less  difficult,  and 
is  more  readily  borne  by  most  American  patients.  Indi- 
rect massage  should  never  produce  actual  pain.  If  the 
lids  are  to  be  treated  the  patient  should  look  down  when 
the  upper  lid  is  being  massaged,  and  up  in  the  case  of  the 
lower  lid.  If  the  cornea  is  to  receive  attention  the  patient 
should  look  straight  forward.  Once  daily  to  twice  a  week 
constitutes  the  range  of  frequency  of  these  applications. 
The  writer  then  speaks  of  several  remedies  used.  In  mas- 
sage for  its  own  sake  cod-liver  or  pure  castor  oil  is  u.sed. 
He  believes  in  mercurials  of  various  strengths,  combined 
with  all  sorts  of  oleaginous  e.xcipients.  He  greatly  favors 
the  old  citrine  ointment.  The  patient,  half  an  hour  after 
lid  friction,  should  not  experience  any  added  discomfort. 
The  writer  believes  that  massage  in  young  subjects  espe- 
cially les.sens  the  opacity  following  ulcer  of  the  cornea. 
If  applied  early,  it  promotes  the  removal  of  the  surround- 
ing infiltrate  that  would  otherwise  remain.  In  the  same 
way  it  is  valuable  in  the  treatment  of  interstitial  keratitis. 

Use  and  Abuse  of  Potassium  Iodide  in  Ophthalmic  Practice. 

— The  following  conclusions  are  presented  by  All)ert  Rufus 
Baker  ;  (i)  Iodide  of  potassium  should  generally  be  admin- 
istered in  rapidly  increasing  doses  until  from  gr.  i.-d.  is 
given  daily.  (2)  The  drug  should  always  be  given  after 
eating,  and  well  diluted  with  water.  (3)  Frequent  hot 
baths  are  essential  to  the  best  results  in  the  use  of  the 
remedy.  (4)  Not  infretiuently  large  doses  will  be  toler- 
ated when  smaller  ones  cannot  be  well  taken.  (5)  The 
use  of  the  large  dose  is  not  limited  to  syphilitic  cases.  (6) 
Large  doses  are  indicated  in  optic  neuritis,  ocular  paraly- 
sis, choroiditis,  serous  iritis,  and  in  relapsing  iritis,  cyclitis, 
and  interstitial  keratitis.  (7)  It  is  contraindicated  in  gray 
atrophy  of  the  optic  nerve  and  in  most  cases  of  postneuritic 
atrophy.  (S)  Albumin  in  the  urine,  generally  speaking. 
is  a  contraindication  for  large  doses  of  iodide,  (g)  Young 
children  do  not  take  the  iodide  kindly,  and  it  should  be 
administered  cautiously.  (10)  The  remedy  is  of  doubtful 
value  in  early  syphilitic  iritis.  (11)  Large  doses  are  of 
doubtful  utility  in  the  removal  of  post-operative  exudates, 
but  should  l)e  given  farther  trial. 

Diabetes  Mellitus  in  Children. — Leopold  F.  \V.  Haas  con- 
cludes that:  (I)  Diabetes  occurs  more  frequently  in  chil- 
dren than  is  generally  supposed.  (2)  Uranalysis  is  just 
as  important  an  element  in  the  scientific  diagnosis  of  dis- 
ease in  children  as  it  is  in  adults.  It  is  to  be  regretted 
that  the  general  practitioner  rarely  realizes  this  fact.  (3) 
There  is  a  possible  etiological  connection  between  peliosis 
rheuniatica  and  diabetes.  The  pathogenesis  of  both  con- 
ditions is  so  obscure,  however,  that  speculation  on  this 
question  can  only  point  out  a  direction  for  further  research. 

Tuberculosis  of  the  Testicle,  with  Special  Consideration  of 
its  Conservative  Treatment. — By  John  B.  Murphy. 

Purpura  Hemorrhagica  or  Scorbutus  ?  A  Clinical  Sketch. — 
By  Henry  E.  Tr.ley. 

A  Double  Hook  for  Use  in  Advancement  Operations. — By 
C.  F.  Clark. 

Medullary  Ansesthesia  in  Gynsecology. — Bv  J.  Riddle 
Goffe. 

Hernia  or  Diverticulum  of  the  Chorion. — By  L.  H.  Laidley. 

Electric  Recording  Perimeter. — By  William  M.  Sweet. 

Malarial  Hsemoglobinuria.— By  William  Britt  Burns. 

Glioma  of  the  Retina.— Bv  G.  A.  Sulzer. 


Philadelphia  Medical  Journal,  November  ij,  /goo. 

The  Etiology  of  Yellow  Fever. — Eugene  Wasdin  quotes 
Sternberg  in  a  recent  note  ;  "  From  Wasdin's  point  of  view 
the  question  of  yellow-fever  etiology  is  settled."  The  au- 
thor adds  that  nothing  is  more  certain  than  that  fact,  and 
then  appends  his  reasons  for  the  statement.  Laborious 
clinical  observation  has  culminated  in  the  formulation  of  a 
group  of  infectious  diseases,  called  the  "acute  infectious 
diseases."  They  have  characteristics  in  common  ;  primar- 
ily, they  are  infectious;  they  are  characterized  by  clinical 
symptoms  due  to  the  influence  of  intoxicants  ;  they  are  all 
specific  infections  ;  many  of  them  are  caused  by  vegetable 
micro-organisms  of  low  type.  Clinically,  these  diseases 
closely  resemble  each  other  until  the  development  of  their 
specific  symptoms,  after  which  they  are  readily  diagnosti- 
cated. Pathologically  the  chief  di.saslers  arise  from  the 
influence  exercised  by  the  toxins  formed  by  the  organisms. 
In  some  of  these  diseases  the  infecting  organisms  also  pass 
into  the  circulation  and  add  their  effect  to  that  of  the  tox- 
ins. Co-instantaneously  there  are  developed  two  inherent 
forces,  or  qualities,  in  the  infecting  germ — toxicity  and 
septicity.  The  germs,  intensely  toxic,  iiroduce  a  reaction 
resulting  in  the  fatty  degenerations  and  at  times  the  ne- 
croses in  the  parenchyma  of  the  organs.  Those  intensely 
septic  are  characterized  by  more  prolonged  clinical  symp- 
toms, less  marked  fatty  changes,  and  more  marked  ne- 
croses in  the  tissues.  Each  infecting  organism  is  specific, 
and  it  is  only  .so  when  it  has  entered  into  contact  with  the 
living  tissues;  when,  if  the  environment  is  propitious, 
this  potential  becomes  a  developed  force.  When  these 
developments  are  mixed  the  pathological  changes  are 
found  to  be  combined.  When  the  toxic  potential  is  strong- 
ly developed  there  will  arise  the  acutely  toxic  cases ; 
if  it  is  only  slightly  developed,  such  cases  will  be  ephem- 
eral ;  if  the  septic  potential  is  developed,  either  alone  or  in 
conjunction  with  the  toxic,  there  must  arise  the  septic  cases 
of  these  diseases.  The  three  types  of  cases  named  are  and 
have  been  recognized  thus  far  only  in  yellow  fever  (Stern- 
berg), although  they  may  all  now  be  recognized  in  the 
other  acute  infections.  The  writer  continues  that  it  is  in  the 
application  of  this  law  to  the  acute  infection  of  yellow 
fever,  explaining  its  symptomatology  and  its  pathology 
upon  these  firm  facts,  that  he  now  contends  that  yellow 
fever  cannot  be  rudely  torn  from  its  place  in  the  list  of 
acute  infections  and  placed,  as  Reed  and  Carroll  would  have 
it,  among  the  accidental,  artificial  inoculations,  which  ap- 
pears to  be  the  fate  of  the  malarial  fevers  at  this  time. 
Each  one  of  the  specific  infectious  organisms  may  be  able, 
under  artificial  inoculation,  to  produce  its  specific  disease, 
but  this  docs  not  remove  these  diseases  from  the  list  of  the 
natural  infections. 

Carcinoma,  of  the  Rectum. — John  B.  Deaver  regrets  that 
more  radical  surgery  than  that  advised  is  not  permissible; 
by  which  he  means  the  removal  of  the  lymphatic  glands  of 
the  mesosigmoid,  in  this  wise  absolutely  cutting  off  the 
lymphatic  circulation  between  the  site  of  the  disease  and 
the  general  lymphatic  circulation.  If  this  was  possible, 
the  outcome  of  these  operations  would  be  more  promising. 
But  as  this  is  not  possible,  early  and  radical  operation  is  all 
the  more  urgently  called  for.  When  the  growth  occupies 
the  rectum  high  up,  the  writer  opens  the  abdomen  in  the 
left  iliac  region.  If  it  is  then  determined  that  the  growth 
with  the  rectum  can  be  taken  out  through  a  posterior  inci- 
sion, the  sigmoid  is  divided  transversely  and  removed  with 
its  mesentery  as  far  down  as  the  growth,  when  the  lower 
opening  is  clo.sed  and  the  margins  of  upper  opening  are 
stitched  to  the  margins  of  the  upper  part  of  the  incision, 
closing  the  lower  part  of  the  incision  entirely. 

Note  on  Specimen  Showing  a  Small  Saccular  Aneurism  on 
an  Accessory  Branch  of  the  Right  Renal  Artery. — Bv  Maude 
E.  Abbott. 

Aneurism  of  the  Spermatic  Artery  Simulating  Oblique 
Inguinal  Hernia.— By  S.  W.  Miller. 

Acute  Hemorrhagic  Encephalitis. — By  Charles  Dewey 
Center. 

Idiopathic  Phlegmonous  Gastritis. — By  Francis  P.  Kin- 
nicut. 

Venous  Thrombosis  in  Heart  Disease.— By  William  \X. 
Ford. 

The  Lancet,  Sovember  10,  tgoo. 

On  the  Influence  of  Fatigue  on  the  Minute  Structure  of  the 
Kidney  and  Liver. — By  Guido  Guerrini.  In  the  kidney  the 
grosser  modifications  of  structure  are  in  the  cells  of  the 
convoluted  tubules  and  of  the  ascending  part  of  the  loop 
of  Henle.  The  corpuscles  of  Malpighi  and  the  collecting 
tubes  are  nearly  always  normal.  In  the  affected  cells  the 
modifications  of  structure  are,  naturally,  in  relation  with 
the  degree  of  fatigue  undergone  by  the  animal.  The  more 
fatigued  a  dog  is  the  more  profoundly  altered  are  the 
cells.  In  animals  already  much  fatigued  the  following  ap- 
pearances may  be  ob.served  :   The   protoplasma   loses  its 


826 


MEDICAL    RECORD. 


[November  24,  1900 


usual  aspect  and  becomes  homogeneous  and  granular.  It 
appears  that  the  cellular  body  enlarges,  sometimes  little, 
sometimes  so  much  that  in  a  transverse  section  all  the 
openings  of  the  canals  seem  to  be  closed  by  the  swollen 
cells.  The  edge  between  the  cells  becomes  uncertain  and 
sometimes  disappears  altogether.  In  animals  still  more 
fatigued  the  minute  moditications  of  the  cells  of  the  con- 
voluted tubules  are  much  greater.  It  is  seen,  in  fact,  that 
tlie  borders  of  the  cells  which  surround  the  opening  of  the 
canals  fray  out  and  break,  and  that  the  cellular  protoplasm 
shows  liere  and  there  rarefied  points,  vacuoles  an<l  cracks, 
and  finally  crumbles  away  into  a  fine  detritus  which  col- 
lects in  the  opening  of  the  tubules.  In  the  midst  of  this 
detritus  normal  nuclei  are  sometimes  found,  sometimes 
lumps  or  granular  masses  which  stain  like  the  nuclei. 
This  degenerative  process  almost  always  attacks  a  certain 
number  of  cells,  but  sometimes  it  is  seen  only  in  a  group 
of  a  few  diseased  cells  which  are  in  the  midst  of  several 
normal  ones. 

The  minute  modifications  of  structure  of  the  liver  cells  are 
much  less  than  are  those  of  the  kidney  cells,  and  they  ap- 
pear conspicuously  only  in  the  liver  of  those  dogs  in  which 
the  modifications  of  structure  are  the  greatest.  They  are 
as  follows  :  From  the  beginning  all  the  cellular  protoplasm 
appears  homogeneous,  cloudy,  and  granular.  The  cellu- 
lar body  enlarges  and  the  edge  between  the  cells  becomes 
uncertain  and  sometimes  disappeais  altogether.  Some- 
times the  little  biliary  canals  are  evidently  compressed, 
whereupon  the  protoplasma  of  the  liver  cells  appears  rare- 
fied, full  of  knots,  spongy,  and  very  dark  from  biliary 
pigment. 

The  Physiology  and  Pathology  of  Inheritance,  or  What  do 
We  Inherit  from  Our  Parents? — Thomas  Oliver  says  that 
from  a  physiological  point  of  view  there  is  considerable 
evidence  to  show  that  mental,  not  less  than  physical,  qual- 
ities are  transmitted  ;  that  pathologically  such  a  disease  as 
hiemophilia  is  inherited,  and  that  when  there  is  a  family 
history  of  phthisis  and  cancer  there  is.  especially  as  re- 
gards phthisis,  a  greater  liability  to  the  disease  than 
when  a  family  shows  no  such  record.  He  believes  that 
the  influence  of  inheritance,  however,  has  been  exagger- 
ated. Tuberculous  disease  is  inherited,  but  only  in  the 
same  .sense  as  are  other  diseases  that  are  due  to  microbes  :  it 
is  in  the  form  of  an  enfeebled  resistance  on  the  part  of  the 
tissues.  Pulmonary  phthisis  seems  to  exhibit  a  kind  of 
inheritance  that  is  particularly  its  own,  but  on  scrutiny 
this  is  found  to  be  largely  due  to  the  domestic  character  of 
the  malady  which  is  encouraged  by  our  home  life,  insani- 
tary dwellings,  overcrowding  of  the  poorer  working-classes, 
infection,  Britain's  changeable  climate,  dusty  occupations, 
and  ill-assorted  marriages. 

Two  Cases  of  Hemorrhagic  Pancreatitis.  —  J.  H.  Bryant 
reports  the  cases  of  two  men,  aged  tliiny-six  and  twenty- 
two  respectively.  The  first  case  was  diagnosed  as  one  of 
perforating  gastric  ulcer,  and  the  abdomen  was  opened, 
with  the  finding  of  the  condition  named  in  the  title.  Death 
ensued  on  the  fourth  day.  The  autopsy  showed  (and  this 
is  the  reniarkalile  feature  of  the  case)  fat  necrosis  outside 
the  peritoneal  cavity.  There  was  fat  necrosis  of  both  the 
mediastinal  and  pericardial  fat,  and  the  cavity  of  the  ab- 
domen was  at  the  time  of  operation  distended  with  bile- 
stained,  serous,  sterile  fluid.  This  latter  condition  was  es- 
pecially noticeable  in  the  second  case  in  which  the  same 
diagnosis  was  made  before  operation  as  in  Case  I.  No 
fat  necrosis  was  found.  The  tissues  in  the  neighborhood 
of  the  bile  passages  and  the  pancreas  had  a  swollen  and 
sodden  appearance  and  were  all  very  deeply  stained  with 
bile.  It  was  thought  that  bile  might  have  escaped  into  the 
abdominal  cavity  by  either  the  blood-vessels  or  lymph- 
atics, or  both. 

An  Interesting  Case  of  Amenorrhoea. — \V.  J.  H.  Hcpworih 
reports  the  case  of  a  young  married  woman  aged  twenty- 
three  years,  who  had  had  two  children  and  suspected  a 
third  pregnancy,  as  she  had  menstruated  only  once  since 
her  infant  was  born,  and  that  was  six  weeks  after  birth. 
The  patient  found  as  soon  as  she  left  London  and  went  to 
the  country  that  her  sickness  would  return  at  the  regular 
times,  but  would  not  if  she  remained  in  town.  By  leaving 
town  for  two  days  each  month  it  was  possible  for  her  to  reg- 
ulate the  monthly  function  without  diHiculty. 

A  Series  of  Eleven  Operations  for  Perforated  Gastric  Ulcer. 
—  By  (1.  II.  Hume. 

The  Urinary  Pigments  in  their  Pathological  Aspects. — By 
A.  IJ.  Carrod. 

Surgical  Emphysema  of  the  Eyelids. — By  C.  L.  Birming- 
ham. 

Empyema  following  Lobar  Pneumonia. —By  W.  Hale  White. 
A  Case  of  Anthrax.  — By  E.  A.  Clarke. 

liritish  Atedical  /oiirnal,  yovemhcr  to.  /goo. 
Clinical   Lecture  on   Progressive   Pernicious  Anaemia  with 
Spinal  Symptoms. — Sir  Dyce   Duckworili  cites  the  case  of 


a  man  aged  thirty-six  years,  afflicted  with  this  disease. 
As  the  result  of  treatment  by  rest,  good  diet,  with  wine, 
red  bone  marrow,  and  the  action  ot  ar.senic,  the  patient 
improved,  although  he  never  recovered  his  original  health, 
having  been  a  vigorous  and  robust-looking  man.  Later  he 
had  a  relapse,  and  in  addition  he  gave  evidence  of  the  on- 
set of  some  grave  disorder  of  the  spinal  cord.  At  this  time 
the  red  cells  numbered  1.600.000;  white  cells,  5,000;  haemo- 
globin, twenty-seven  i)er  cent.  ;  the  patient  sweated  pro- 
fuselv.  and  was  very  exhausted  and  languid.  About  two 
weeks  later  tliere  was  weakness  in  all  muscles  of  both  legs, 
no  definite  jiaresis.  'I'here  were  complete  loss  of  sense  of 
position,  and  nearly  complete  anaesthesia  below  the  level 
of  the  i>atelia,  but  dipj)ing  down  the  popliteal  space  in  a  loop 
over  the  calf ,  in  the  "  small  sciatic  area. "  Four  days  later  loss 
of  rectal  control  occurred.  About  five  weeks  from  the  time 
the  above  blood  count  was  taken,  the  red  cells  had  dropped 
to  I,  500,000;  hjemoglobin,  thirty-two  per  cent.  Five  days 
later  he  died  ;  at  6  a.m.  the  temjierature  rose  suddenly  to 
104^  F.  The  respirations  were  34  and  the  pulse  120,  at 
times  very  small.  About  an  hour  before  death  the  tem- 
perature rose  to  105  .  The  pulse  was  136,  and  of  very- 
small  volume.  One  hour  after  death  the  temperature  was 
106, 2 \  The  present  conception  of  this  distressing  malady 
regards  it  as  the  result  of  a  special  form  of  bjood  destruc- 
tion, so-called  haemolysis,  occurring  in  the  course  of  the 
portal  circulation,  induced  by  the  action  of  some  toxic  mat- 
ter produced  in  and  absorbed  from  the  alimentary  tract. 
The  disease  is  therefore  a  chronic  infective  form  of  toxse- 
mia,  which  induces  profound  ana?mia,  and  it  is  surmised 
that  this  toxin  is  of  bacterial  ori.gin. 

The  Treatment  of  Dysentery. — Wilfred  Watkins-Pitchford 
gives  his  experience  in  the  treatment  of  this  disease  in 
Natal  during  the  first  part  of  this  year.  As  the  patients 
brought  to  the  hospital  were  nearly  all  beyond  the  first 
stages  the  saline  aperients  met  with  little  success :  ipe- 
cacuanha also  was  disappointing,  probably  for  the  same 
reason.  The  tincture  of  "monsonia  ovata"  appeared  to 
produce  no  effects  whatever  except  nausea  and  depression. 
Greater  success  attended  the  use  of  mercury  ])erchloride 
in  mi.xture  with  bismuth  and  opium,  and  several  of  the  pa- 
tients who  recovered  undoubtedly  owed  much  to  this  com- 
bination. "Izal"  in  5-minim  doses  certainly  produced 
amelioration  of  symptoms.  Izal  combined  with  bismuth 
and  chlorodyue  gives  a  most  satisfactory  result.  The  for- 
mula used  by  the  writer  is;  'B,"\za.\."  v\  iii.  ;  bismuthi  sub- 
nitratis,  gr.  .x.  ;  tinctura?  chloroformi  et  morphin;e.  m  viii.  ; 
mucilaginis  acacise  ad  3  i.  To  be  taken  every  two,  four, 
or  eight  hours,  according  to  the  severity  of  the  symptoms. 
Milk  is  not  a  suitable  diet  for  this  disease.  Beef-tea  and 
bread  with  butter  satisfy,  and  leave  a  residue  which  ap- 
pears to  cause  but  little  colic  or  rectal  irritation.  Great 
risk  must  frequently  accompany  the  giving  of  rectal  injec- 
tions, especiall)-  when  combined  with  abdominal  massage. 
The  coexistence  of  enteric  fever  and  dysentery  or  their 
occurrence  within  a  short  interval  of  one  another  is  not 
uncommon. 

Enteric  Fever  in  South  Africa  ;  Effective  Sterilization  of 
Excreta.  —  H.  A.  Cuiumiiis,  in  the  epidemic  of  enteric  fever 
at  Blocmfontein,  obtained  from  the  sanitary  contractor  a 
large  thirty-gallon  iron  "jackpot"  into  which  were  poured 
about  two  gallons  of  i  :  20  carbolic  solution  and  subse- 
quently the  excreta.  The  pot  was  kept  boiling  day  and 
night.  According  to  requirements  the  contents  of  the  pot 
were  emptied,  but  always  a  sufficient,  heated  residue  was 
left  to  affect  the  next  stool  emptied.  Carbolic  soluti<m  was 
poured  in  if  necessary  to  make  up  for  loss  by  evaporation. 
The  contents  were  thus  kept  fluid,  and  no  charring  could 
occur.  In  this  manner  the  practically  instantaneous  ster- 
ilization of  each  stool  the  moment  it  left  the  bedpan  was 
secured  day  or  night.  There  was  practically  no  smell  from 
the  fumes.  As  a  result  of  bacteriological  cxjieriment,  five 
nutrient  agar  tubes  which  were  inoculated  from  the  pot 
develojied  no  sign  of  bacterial  growth,  while  one  tube  in- 
oculated from  the  contents  of  a  bedpan  about  to  be  emptied 
into  the  c;uililnin  showed  al>out  one  Imiidrcd  wi-II-marked 
colonies. 

Notes  of  a  Series  of  Cases  of  Glandular  Fever  Occurring 
in  Epidemic  Form. — Leslie  Durno  makes  this  rejiort.  With 
the  exception  of  one  adult,  the  ages  of  the  patients  ranged 
from  two  and  a  half  to  thirteen  years.  In  every  household 
in  which  the  malady  appeared  very  few  of  the  youngn 
members  escaped.  The  illness  lommenced  with  headache, 
nausea  and  sickness,  pain  in  one  side  of  the  neck,  and,  in  by 
far  the  greater  ]iroportion.  of  the  left  side.  The  temperature 
ranged  ironi  Kx)  10105  F.  The  inilse  rate  was  high.  Con- 
stipation was  the  rule.  The  lymph  glands  on  the  afl'ectcd 
side  of  the  neck  became  swollen  and  tender.  Acute  ana?nija 
developed  ia])idly  and  in  some  cases  was  extreme.  There 
were  no  deaths.  The  disease  is  highly  infectious.  Sodium 
salicylate  with  one  or  two  calomel  purges  in  the  feverish 
stage,  arsenic  ancl  iron  during  convalescence,  appeared  to 
give  good  results.     An  important  element  in  treatment  i^ 


November  24,  1900] 


MEDICAL    RECORD. 


827 


to  maintain  as  thorough  an  antiseptic  state  of  the  mucous 
membrane  of  the  throat  and  pharynx  as  possible. 

The  "Hepatic  Odor"  in  Abscess  of  the  Liver. — W.  K. 
Hatcli  calls  attention  to  the  peculiar  odor  i)rescnt  in  pa- 
tients sulTering  from  abscess  of  the  liver.  In  one  patient 
who  had  been  treated  for  chronic  diarrhita  of  two  months' 
standing,  the  presence  of  this  smell  guided  the  writer  to 
suspect  the  liver,  although  as  the  temperature  was  subnor- 
mal and  the  liver  only  slightly  enlarged  the  medical  at- 
tendant had  not  considered  the  liver  at  all  affected. 

Apomorphine  as  a  Hypnotic. — E.  W.  Adams  administered 
a  hyiiixlcrmic  injection  containing  gr.  ^,  of  this  drug  to  an 
alcoholic  jjatient.  The  e.-cpected  did  not  occur.  In  about 
twenty  minutes  she  was  quietly  sleeping.  Instead  of  aid- 
ing the  ineffectual  retching  that  was  present,  this  latter 
was  quelled  by  the  e.xhibition  of  the  drug. 

Presidential  Address  on  the  Present  Position  and  Future 
Work  of  the  British  Medical  Association. — Bv  John  \V. 
Byers. 

The  Vulgar  Errors  and  Superstitions  of  West  Somerset  in 
their  Relation  to  Medicine.— By  ("/.  F.  Sydenham. 

Enteric  Fever  in  the  Army  in  South  Africa,  with  Remarks 
on  Inoculation. — By  Howard  H.  To^ith. 

Laparotomy  for  Intestinal  Obstruction,  Repeated  within 
Seven  Months. — By  J.  Lewtas. 

An  Account  of  Seven  Cases  of  Acute  Irritant  Poisoning. — 
By  \V.  II.  Packer. 

Notes  on  a  Case  of  Acute  Yellow  Atrophy  of  the  Liver..— 
By  ().  U.  Pearcc. 

A  Case  of  Compound  Dislocation  of  the  Wrist.  —By  Wil- 
liam Tiplady. 

A  Case  of  Acute  Yellow  Atrophy  of  the  Liver.— By  C.  T. 
Anderson. 

The  Treatment  of  Diphtheria  by  Iodine. — By  Hugh  Taylor. 

A  Case  of  Lead  Poisoning  by  Beer. — By  E.  R.  Morgan. 

Liquor  Thyroidei  in  Hemophilia. — By  C.  Royds  Jone.s. 

Case  of  Bullous  Urticaria. — By  Sidney  H.  Carr. 

French  Journals. 
Treatment  of  Inflammations  of  the  Uterine  Adnexa  by 
V/ater  at  60  C— A.  Suarez  dc  Meiuloza  reports  his  success 
with  this  treatment.  In  the  last  two  years  he  has  treated 
two  hundred  and  forty-two  women  by  vagina!  injections 
of  water  at  to  .  Some  of  these  patients,  one  hundred  and 
Hve  in  number,  were  afflicted  by  more  or  less  serious  le- 
sions of  gonorrhieal  origin.  In  tifty-two cases  the  infection 
was  traced  to  the  puerperium.  In  the  great  majority  of 
cases,  and  whatever  the  origin  of  the  infection,  at  the  fif- 
teenth or  twentieth  injection,  sometimes  even  before,  im- 
provement begins  and  makes  rapid  progress.  In  those 
cases  which  are  not  extremely  severe,  cure  appears  per- 
fectly established.  The  technique  is  very  simple.  There 
is  a  special  cannula  in  order  to  avoid  the  transmission  of 
heat  to  the  skin,  which  is  never  toucheil  by  the  water  :  and 
as  the  vaginal  mucosa  is  not  very  sensitive  to  heat,  the 
temperature  aljove  indicated  is  comfortably  borne.  The 
time  taken  for  the  injection  is  ten  minutes.  Tlie  patient  as- 
I  sumes  the  obstetrical  position,  and  the  reservoir  of  hot  water 
'  is  placed  at  a  height  of  60  cm.  above  her  ;  the  cannula  lubri- 
cated with  vaseline  is  introduced  into  the  posterior  cul-de- 
sac,  and  the  stop-cock  opened.  Generally  at  the  end  of 
live  or  six  seconds  the  water  flows  out  in  a  regular  stream, 
l)ut  sometimes  the  opening  of  the  cannula  is  obstructed  by 
a  fold  of  mucous  membrane,  which  necessitates  a  few 
movements  of  the  instrument  in  order  to  start  the  flow. 
The  cannula  must  be  carefully  supported  in  order  that  none 
•  >f  the  water  escape  over  the  patient's  exterior,  for  the  sen- 
sation of  burning  would  prevent  the  proper  application  of 
the  injection.  Consequently,  in  case  the  fourchette  is  torn, 
us  borders  must  be  gently  pressed  together  to  prevent  the 
water  from  escaping  between  the  cannula  and  the  inferior 
vaginal  wall. — Aitnales  tie  Gynicologii-  et  d'Ohstelriciuc, 
Septembre  et  Octobre,   ifjfjo. 

Hygiene  and  Therapeutics  of  Puberty  and  of  its  Diseases 
in  Woman. — Paul  Ualche  believes  that  as  far  as  possible 
the  young  girl  at  the  period  of  puberty  should  live  at  home, 
in  order  to  avoid  privation  and  fatigue.  The  child  cannot 
have  the  freedom  of  air  and  sun  in  even  the  best  regulated 
school  that  she  is  free  to  enjoy  at  home.  The  diet  should 
lie  generous  ;  the  meals  should  be  frequent  and  be  com- 
posed to  a  great  extent  of  roasted  or  broiled  meats  and 
wine.  Constipation  should  be  avoided.  Cold  should  be 
avoided  at  the  menstrual  epoch,  especially  in  the  young. 
Clothing  should  be  carefully  chosen  :  it  should  not  com- 
press the  organs  :  it  should  protect  efficiently  against  vari- 
ations of  air  and  climate.  Exercises,  gymnastic  and  other 
forms,  as  well  as  hydrotherapeutic  measures  should  be  in- 
telligently prescribed.  Faulty  attitudes,  so  often  assumed, 
sliould  be  condemned;  if  indulged  in.  they  should  be  cor- 
rected.    The  eyes  should  be  carefully  watched.     The  au- 


thor quotes  from  Lawson  Tait.  who  believes  in  the  associ- 
ation of  the  two  sexes.  He  states  that  although  it  may  be 
a  pure  coincidence,  yet  he  has  noticed  ovarian  hyperajmia 
especially  in  young  girls  who  have  no  brothers  or  whose 
brothers  are  younger  than  they.  Leucorrhoea  is  the  most 
frequent  and  the  earliest  affection  of  puberty.  It  results 
from  the  hypera;mic  state  which  accompanies  evolution  of 
the  uterus,  and  which  provokes  a  hypersecretion  of  the 
mucosa,  but  it  is  al.so  often  an  expression  of  a  debilitated 
condition.  This  discharge  may  cause  a  vulvar  eruption. 
For  such  a  case  boiled  hot  water  should  be  used,  the  sur- 
faces isolated,  and  talcum  powder  applied.  The  writer 
lastly  considers  vulvar  pruritus  and  eruptions  with  their 
treatment. — HulUlin  dncral  ifc  I'liirapciitique,  October 
23,  1900. 

Researches  in  the  Etiology  of  Cancer  and  the  Pathogenic 
Blastomycetes. —  Leopold  s])eaks  of  the  results  of  his  inves- 
tigations of  this  subject  as  follows:  There  can  be  seen  in 
the  fresh  tissue  of  almost  every  malignant  neoplasm  bril- 
liant bodies,  partly  round.  ])artly  biscuit-shaped,  in  which 
can  be  shown  reproduction  and  segmentation.  These  bod- 
ies, which  were  not  confu.sed  with  cocci  or  degenerated 
cells,  could  be  considered  only  as  blastomycetes  by  the 
fact  that  they  were  not  changed  in  a  solution  of  caustic 
soda  or  potassa,  or  in  hydrochloric  or  nitric  acid  After 
many  trials  pure  cultures  of  blastomycetes  were  ob- 
tained from  four  malignant  human  neoplasms.  These 
were  obtained  from  a  cancer  of  the  ovary,  from  a  cancer 
of  the  breast  and  the  axillary  glands,  and  from  can- 
cer of  the  uterus.  The  blastomycetes  were  therefore  ob- 
tained from  a  fresh  cancer  of  the  ovary.  The  pure  cul- 
ture can  be  obtained  from  fresh  carcinomatous  tissue. 
The  injection  of  this  pure  culture  in  the  testicles  of  a  rat 
was  followed  by  the  development  of  a  large  number  of  nod- 
ules in  the  peritoneum  to  which  the  animal  succumbed. 
Blastomycetes  taken  from  these  nodules  give  pure  cul- 
tures. Consequently,  there  is  no  doubt  that  blastomycetes 
can  be  the  cause  of  malignant  neoplasms  in  man.  and  that 
inoculated  into  an  animal  they  cause  a  neoplasm  in  it,  which 
destroys  life. — Annates  de  liyncco/ojfit-  el  li'Obs/elrigiie, 
September  and  October,  lyoo. 

Cervical  Metritis. — Pozzi  ])resents  tlie  following  conclu- 
sions on  this  subject:  (i)  Acute  or  chronic  inflammation 
of  the  cervix  can  exist  for  a  long  time  without  invading  the 
body  of  the  uterus.  (2)  Nevertheless,  the  acute  lesions  of 
the  cervical  mucosa  easily  extend  to  the  mucosa  of  the  body, 
and  the  chronic  lesions  of  the  cervical  parenchyma  of  in- 
flammatory origin  (sclerous  and  sclerotic  degeneration, 
partial  or  total)  promptly  react  on  the  nutrition  and  an- 
atomical condition  of  the  entire  uterine  body.  (3)  The 
operation  of  tracheIorrha])hy  is  inferior  to  the  biconical 
resection  of  the  cervix,  more  or  less  modified  according  to 
circumstances.  It  ought  to  be  abandoned.  (4)  There  are 
a  large  number  of  acute,  subacute,  or  chronic  inflamma- 
tions of  the  cervical  mucosa  in  nullipar;e,  which  are  de- 
pendent on  the  narrowness  of  the  external  orifice  and  on 
the  insufficient  drainage  resulting  therefrom.  The  most 
important  part  of  the  treatment  is  then  to  reconstruct  by 
operation  in  a  durable  manner  an  orifice  large  enough  for 
the  cervix. — Annates  tie  Oyneeotogie  el  tf  Obstt'triyue, 
Septembre  et  Octobre,  lyoo. 

Semeiology  and  Treatment  of  Refusal  of  Food. — After 
reviewing  the  causes  of  this  disorder,  which  may  be  either 
physical  or  psychological  (gastro-intestinal  disorders  being 
among  the  first  ;  melancholia,  a  maniacal  state,  general 
paralysis,  degeneracy,  acute  and  chronic  alcoholism,  neu- 
roses, epilepsy,  and  hysteria  being  psychological  causes), 
Paul  Gamier  and  Paul  Cololian  discuss  the  treatment  of 
the  condition.  Before  resorting  to  artificial  alimentation, 
the  reason  for.the  refusal  of  food  must  be  ascertained  and 
the  cause  removed  if  possible.  Moral  suasion  is  fiften  very 
efficacious.  Sometimes  if  victuals  are  placed  within  reach 
and  the  patient  believes  himself  unobserved,  he  will  eat. 
The  various  methods  of  artificial  feeding  are  described, 
after  which  the  kinds  of  food  suitable  are  enumerated. 
This  should  be  liquid :  milk,  chocolate,  eggs,  scraped 
meat,  puree  of  vegetables,  and  a  little  peptone.  Salt 
must  not  be  omitted.  Food  should  be  given  once  or  twice 
a  day.  Cod-liver  oil  is  excellent  for  this  condition. — Ga- 
zette ites  Hof>itau.\\  October  23.  19'xj. 

The  Accidents  of  Internal  Arsenical  Medication. — After 
taking  up  in  detail  the  troubles  not  infrequently  attending 
the  administration  of  arsenic,  according  to  Dupoux,  the 
writer  speaks  of  the  treatment  both  preventive  and  cura- 
tive :  The  physician  should  be  assured  of  the  good  con- 
dition of  the  eliminative  organs  and  of  the  digestive  ap- 
paratus before  prescribing  arsenic.  The  drug  should  be 
given  in  the  best  form  and  under  the  best  conditions .  it 
should  not  be  given  to  the  young.  The  dose  should  be  in- 
creased little  by  little,  stopped  at  the  end  of  fifteen  days, 
then  begun  again.  At  the  least  sign  of  intoxication  the 
doses  must  be  diminished,  and  wholly  stopped  in  case  of 


828 


MEDICAL    RECORD. 


[November  24,  1900 


severe  symptoms.  All  the  means  tending  to  favor  elimi- 
nation of  the  poison  should  be  used- — milk,  baths,  friction, 
purgatives,  diuretics,  etc.  Alkaline  remedies  might  be 
prescribed  together  with  arsenic,  such  as  bicarbonate  of 
sodium,  which  would  assist  in  eliminating  the  poison  and 
favor  digestion. — Gazette  ties  Hopitaii.x,  October  25,  lyoo. 
Nasal  Cough  in  Tuberculosis. — L.  Revillet  sums  up  the 
diagnostic  points  as  follows:  An  irregular  cough  occurring 
especially  at  night  in  the  dorsal  decubitus;  disproportion 
between  the  cough  and  expectoration ;  diseased  nose — 
polyps,  vegetations,  hypertrophy  or  atrophy  of  the  iiiu- 
cosa,  oza;na ;  the  posterior  pharyngeal  walls  bathed  in 
mucopurulent  discharge.  The  treatment  consists  in  wash- 
ing the  nose  with  boiled  salt  water,  or  with  the  addition  of 
a  little  boric  acid  or  lemon  juice.  Or  a  mixture  may  be 
used,  made  of  boric  acid,  menthol,  and  chlorhydrate  of  co- 
caine. A  nasal  douche  of  sulphur  water  gives  excellent 
results.  If  the  secretions  persist,  cauterizations  of  the 
mucosa  with  the  galvano-cautery  may  be  employed. — 
Lyon  Mdiiical.  October  2S,  lyoo. 

Deutsche  medicinisclie   ll'oi/i..  Oct.  2j  and  Xov.   /,  rgoo. 

Functional  Diseases  of  the  Heart. — H.  Hochhaus  believes 
that  at  least  one-third  to  one-lialf  of  all  neurasthenics  suf- 
fer from  cardiac  neuroses,  and  that  a  somewhat  smaller 
percentage  of  hysterical  patients  are  similarly  afflicted. 
Any  of  the  conditions  predisposing  to  these  two  affections 
may  also  cause  functional  disease  of  the  heart,  though  ad- 
ditional factors,  such  as  intoxication  with  tea.  coii'ee,  nico- 
tine, or  even  alcohol,  bodily  or  mental  overexertion,  or 
sexual  excesses  are  nearly  always  present.  Usually  the 
lesion  is  due  to  the  summation  of  several  minor  causes  of 
this  nature,  while  refle.x  disturbances  of  the  gastro-intesti- 
nal  tract  or  the  genital  apparatus  may  also  play  an  impor- 
tant role  in  the  etiology.  The  symptoms  may  be  grouped 
under  (i)  the  subjective  sensations  of  the  patient,  which 
may  run  the  gamut  from  slight  feelings  of  pressure  in  the 
cardiac  region  to  the  severest  spasms  of  angina-like  pain, 
and  (2)  the  objective  alterations  in  the  heart's  action.  In 
most  cases  this  is  rapid  and  forcible,  more  rarely  it  is  de- 
pressed, while  arrhythmia  is  not  as  uncommon  as  usually 
supposed.  In  many  instances  the  diagnosis  is  apparent  at 
once,  but  often  even  after  long  observation  and  considera- 
tion of  the  history  the  differentiation  between  organic  dis- 
ease, especially  a  beginning  muscular  insufficiency  and 
pure  neurosis,  is  of  tlie  greatest  difficulty.  The  author  has 
found  careful  determination  of  the  blood  pressure  by  the 
instruments  of  Gartner  or  Riva-Rocci  and  Roentgen-ray  il- 
lumination to  be  the  most  helpful  aids.  Whenever  the  arte- 
rial pressure  is  found  markedly  to  exceed  a  value  of  from 
130  to  140  mm.  of  mercury,  the  assumption  is  warranted 
that  the  disease  is  purely  functional,  while  the  fluoro.scopic 
observation  of  the  neurotic  heart  shows  that  its  contraction 
is  not  only  unusually  jerky  and  sharp,  but  that  the  differ- 
ence in  size  between  the  systolic  and  diastolic  phases  is 
abnormally  great. 

Observations  on  Copper  Workers. — L.  Lewin  has  attempted 
to  settle  the  mooted  point  as  to  the  toxic  action  of  copper 
taken  into  the  body  in  small  amounts  for  long  periods  of 
time  and  answers  the  question  by  denying  the  possibility 
of  any  chronic  copper  poisoning  analogous  to  that  pro- 
duced by  lead.  Previous  animal  experimentation  has  fur- 
nished evidence  giving  color  to  such  a  view,  but  decisive 
evidence  can  be  obtained  only  by  observations  on  those 
engaged  in  handling  the  material  industrially,  and  there- 
fore exposed  to  receive  small  amounts  daily  for  years  at  a 
time.  The  result  of  such  observations  conducted  by  the 
author  leads  him  to  conclude  that  while  as  an  immediate 
consequence  the  inhalation  or  swallowing  of  considerable 
quantities  (jf  metal  may  lead  to  local  disturbances  "of  the 
mucous  membranes  primarily  concerned,  tliese  effects  are 
but  slight  and  readily  i)ass  off  without  sequela',  and  fur- 
thermore tliat  in  man  there  is  no  such  thing  as  chronic 
copper  poisoning.  When  symptoms  exist  among  those 
exposed  to  daily  contact  with  the  metal  they  are  to  be  as- 
cribed to  other  grounds  than  this,  and  the  fear  that  minute 
amounts  of  organic  or  inorganic  sails  of  copper,  such  as 
might  exist  as  intentional  or  accidental  contaminations  of 
food  products,  are  dangerous  to  liealtli  is  wholly  ground- 
less. 

The  Gonorrhoea!  Nervous  Diseases. — .\.  Eulenlnng  calls  at- 
tention to  tlie  fact  tliat  wliile  nearly  every  other  part  of  the 
body  has  its  distinct  series  of  maladies  to  which  a  gonor- 
rhceal  etiology  is  attached,  the  ner\;ous  system  appears  to 
have  been  somewhat  neglected  in  this  regard.  This  omis- 
sion he  then  proceeds  to  rectify  by  describing  fourteen 
cases  of  nervous  disease  apparently  directly  traceable  to  a 
speciHc  urethral  infection.  In  considering  the  secondary 
nerve  lesions  due  to  the  gonococcus  three  classes  are  to  be 
made:  (i)  Xeural.gic  affections,  especially  gonorrlueal  sci- 
atica. (2)  Various  forms  of  muscular  atroi)hy  or  dystrophy, 
and  atrophic  palsies.  (3)  Gonorrhceal  neuritis  in  its  more 
restricted  sense,  as  mononeuritis  or  polyneuritis,  and  gon- 


orrhoeal  myelitis.  In  order  to  establish  a  connection  be- 
tween the  infection  and  the  disease  a  single  coincidence  of 
sym|)toms  is  not  sufficient,  but  a  general  consideration  of 
the  points  involved  in  each  particular  case  is  necessary. 
Important  factors  are  the  simultaneous  occurrence  of  ure- 
thritis with  or  without  the  presence  of  gonococci  in  the 
secretion,  the  existence  of  other  metastatic  specific  lesions, 
epididymitis,  endometritis,  endocarditis,  or  arthritis ;  Qr 
symptomatic  peculiarities  of  the  nerve  affectiim  itself. 

Do  Any  Genetic  Relationships  Exist  between  Appendicitis 
and  General  Neuroses? — Ossian  Schauman  answers  this 
question  in  the  affirmative,  and  as  evidence  cites  the  oc- 
currence of  appendicular  inflammations  in  several  mem- 
bers of  each  of  fourteen  different  families,  in  twelve  of 
which  there  was  a  hereditary  neurotic  taint.  Furthermore, 
in  investigatiug  seventy-five  cases  in  which  the  disease 
had  befallen  but  a  single  member  of  the  household,  it  was 
found  that  in  the  majority  of  instances  either  the  patient 
or  a  near  relative  gave  evidence  of  nervous  degeneracy. 
In  order  to  establish  a  connecting  link  between  the  neurot- 
ic condition  and  the  intestinal  lesion  the  author  adverts  to 
the  well-known  fact  that  neurasthenia  and  various  forms 
of  enteroptosis  are  frequently  found  in  the  same  individual, 
and  suggests  that  the  abnormalities  of  position  may  either 
provide  more  favorable  conditions  for  the  development  of 
the  bacterial  virus  which  represents  the  immediate  cause 
of  the  disease  or  may  lessen  the  resisting-powev  of  the 
appendix. 

Salkowski's  Method  for  Determining  the  Alkalinity  of  the 
Blood.—  By  Wakivogel. 

A  Contribution  to  the  Knowledge  of  Subphrenic  Abscess  — 
By  O.  Krohne. 

Hemianopsia  and  its  Diagnostic  Significance. — By  H.  Salo- 
mousohn. 

The  Choice  of  the  Suture  Material. — By  Kronig. 

Phloridzin  Diabetes. — By  Albert  Seelig. 

Miiucheiicr  incdiciiiische  W'ockenschrijt,  October ^o,  igoo. 

The  Determination  of  the  Functional  Integrity  of  the  Kid- 
neys before  Operation  by  Means  of  the  Freezing-Points  of 
the  Blood  and  Urine. — Hermann  Kiimmell  gives  these  four 
points  as  being  the  most  useful  in  indicating  whether  tlie 
state  of  "  the  other  kidney"  is  such  as  to  permit  extirpa- 
tion of  the  diseased  organ,  (i)  Estimation  of  the  urea. 
(2)  Determination  of  the  freezing-point  of  the  blood.  (3) 
Determination  of  the  freezing-point  of  the  urine,  if  pos- 
sible obtained  from  the  two  kidneys  separately  by  ureteral 
catheterization.  (4)  Examination  of  the  separated  urine 
from  the  two  kidneys,  with  and  without  the  previous  ad- 
ministration of  pliloridzin  or  methylene  blue.  The  value  of 
the  blood  investigation,  which  gives  far  more  reliable  re- 
sults than  the  urea  determination,  rests  on  these  facts.  The 
degree  of  concentration  of  any  solution  is  directly  propor- 
tional to  the  distance  its  freezing-point  lies  below  that  of  dis- 
tilled water,  and  the  normal  fieezing-point  of  human  blood 
has  been  found  to  lie  between  —  0.55'  and  —  0.57  C.  If 
the  kidney  function  is  impaired  an  increase  in  the  amount 
of  solids  takes  place,  with  a  corresponding  lowering  of  the 
freezing-point.  If  one  kidney  has  been  thrown  out  of 
function,  but  the  other  is  capable  of  carrying  on  the  work 
unaided,  i.e.,  when  a  nephrectomy  would  be  permissible, 
the  freezing-point  will  invariably  be  found  to  be  normal, 
and  per  contra  if  this  is  lower  than  the  limit  given,  op- 
eration is  contraindicated.  The  urine  examination  is  con- 
ducted on  similar  principles  but  is  less  reliable  in  ])ractice, 
owing  to  the  physiological  variations  being  much  greater. 

Processes  of  Compensation. — Adolf  Bickel  says  that  a  loss 
of  function  of  one  jiart  of  the  nervous  system  may  be  vica- 
riously compensated  for  through  the  adaptability  of  other 
portions  of  the  mechanism.  This  mutual  interchange  of 
function  is  more  jirominent  the  hi,glier  we  go  in  tlie  scale 
of  animal  development.  Thus  in  the  lower  animals  (frogs) 
the  disturbances  primarily  attending  injury  to  the  central 
nervous  system  persist  unchanged  indefinitely,  while  in 
more  highly  developed  organisms  (dog)  such  evidences  of 
impaired  function  may  in  the  course  of  time  be  entirely 
obliterated  tlirough  the  re-education  of  other  centres. 
This  physiological  fact  is  of  imjiortance.  since  it  affords 
a  scientific  b;isis  for  the  systems  of  compensatory  training 
advocated  in  various  nervous  diseases,  especially  locomo- 
tor ataxia,  by  v.  Leyden,  Krankel,  Goldschei<ler,  Jacob, 
and  otiiers. 

The  Substitution  of  Eucaine  B  for  Cocaine  in  Bier's  Method 
of  Medullary  Narcosis. — F.  Engolmaiin  adds  another  note 
lo  the  iinivt-rsal  cry  of  warning  which  is  beginning  to 
make  itself  heard  from  all  iiuarters  against  the  premature 
enthusiasm  of  the  advocates  of  this  method.  In  an  at- 
tempt to  find  a  less  dangerous  substitute  for  cocaine  he 
emi)Ioyed  eucaine,  whicli  lias  the  same  auiesthetie  power 
coupled  with  only  one-third  of  its  toxicity.  One-sixth  of 
a  grain  of  the  drug  was  injected  into  the  author's  medul- 


I 


November  24,  1900] 


MEDICAL    RECORD. 


829 


lary  canal,  but  no  anaesthesia  resulted,  and  exceedingly 
distressing  headache,  backache,  vomiting,  dyspnuja,  pal- 
pitation, etc.,  supervened,  the  effects  not  passing  off  en- 
tirely until  nine  to  ten  days  had  elapsed.  The  much-de- 
sired, harmless  but  effective  spinal  ana;sthetic  is  therefore 
apparently  not  to  be  looked  for  in  eucaine  B. 

A  Little-Known  Pupillary  Reaction  and  its  Therapeutic 
Application.— By  H.  Kirchner. 

Infection  with  Influenza  Bacilli  and  the  B.  Proteus.— By 
H.  iJoering. 

Albumen  and  its  Artificial  Oxidation. — By  F.   N.  Schulz. 

Clinical  Experiments  with  "  Fersan."— By  J.  E.  Folkel. 

lU-rliner  klinische   VVochensc/iriJt,  October  2^,  igoo. 

Hemorrhagic  Erosions  of  the  Gastric  Mucosa. — Carl  Parises 
gives  a  general  summary  of  the  views  on  this  condition  of 
the  gastric  mucosa.  The  principal  symptoms  are  a  burn- 
ing pain  over  the  entire  gastric  region,  a  lessened  inges- 
tion of  food,  and  a  marked  emaciation.  Nausea  is  often 
present,  but  actual  vomiting  is  rare.  Pain  comes  on  from 
fifteen  to  forty-five  minutes  after  taking  food,  and  is  dis- 
tinctly burning  in  character  and  not,  as  in  ulcer,  crampy 
and  nagging.  Moreover,  it  is  not  localized,  as  in  the  latter 
condition,  but  is  diffused.  Examination  by  means  of  the 
test-meal,  etc.,  shows  scarcely  any  departure  from  the 
normal  as  regards  motor  functions,  bits  of  mucosa  in  the 
washings,  and  in  the  majority  of  cases  a  subaciility.  The 
affection  is  due  to  circulatory  disturbances  in  the  mucosa, 
leailing  to  its  acute  inflammation,  and  spasm  of  the  muscu- 
losa.  Authorities  ditTer  as  to  the  specificity  of  the  lesion, 
some  claiming  it  to  be  a  distinct  affection,  while  others 
maintain  that  it  is  merely  a  feature  of  chronic  gastritis. 
Treatment  should  consist  of  irrigation  with  a  i  ;  1,000  to 
I  ;  2,000  solution  of  silver  nitrate,  which  is  allowed  to  re- 
main in  the  stomach  for  a  few  minutes  and  is  then  with- 
drawn, being  followed  by  irrigation  with  decinormal  salt 
solution.  Diet  is  in  a  general  way  as  for  ulcer.  Many 
patients  are  able,  however,  to  take  a  more  liberal  diet  tlian 
are  ulcer  patients. 

The  Fracture  of  the  Greater  Tuberosity  of  the  Humerus.— 
By  II.  Wohlgemuth.  This  condition  is  of  rare  occurrence, 
but  is  observed  in  certain  cases  of  dislocation  and  frac- 
ture of  the  neck  of  the  bone.  Two  cases  are  reported  by 
the  author,  who  finds  in  this  by-accident  the  explanation 
of  loss  of  power  in  certain  movements  at  the  shoulder 
joint,  after  all  evidences  of  either  dislocation  or  fracture 
have  disappeared.  An  .v-ray  picture  will  show  that  the 
tubercle  of  the  afTcctcd  bone  stands  above  and  to  the  out- 
side of  its  normal  position,  as  determined  by  comparison 
with  the  healthy  side,  so  that  it  must  approximate  to  the 
acromion  process  before  the  abducted  arm  reaches  the 
shoulder  level.  This  removal  of  the  normal  position  of  the 
site  of  attachment  of  the  supraspinatus,  and  the  associated 
atrophy  thereof,  render  it  impossible  for  this  muscle  to 
overcome  the  obstacle  interposed  by  the  conditions  stated  ; 
hence  tlie  imi)airment  of  movement  at  the  joint. 

Trigger  Finger. — Five  cases  are  reported  by  Dr.  Tilman. 
All  complained  of  difficulty  in  using  the  hand  and  of  pain 
running  up  the  arm.  It  is  noteworthy  that  in  all  the  con- 
dition seemed  to  result  from  over-use  of  the  hand  in  doing 
work  to  which  the  patients  were  not  accustomed.  Exami- 
nation showed  in  all  circumscribed  thickening  of  the  flexor 
tendon  of  the  finger  affected.  For  treatment  of  a  recent 
case  the  author  advises  fixation  in  extension  upon  a  splint, 
daily  clianging  of  the  bandage,  applications  of  tincture  of 
iodine,  and  massage.  In  older  cases,  if  the  finger  is  not 
too  painful,  passive  manipulation  is  advised.  In  other 
more  obstinate  cases  operative  intervention  is  necessary. 
Gout  and  rheumatism  may  cause  this  peculiar  tendon  af- 
fection. 

Molecular  Concentration  of  the  Blood  in  Eclampsia  of 
Pregnancy.  — By  A.  Szili. 

Weather,  Duration  of  Sunshine,  and  Infectious  Disease. — 
By  Professor  Hessler. 

The  Theory  of  Rabies  at  the  Close  of  the  Nineteenth  Cen- 
tury.—By  V.  Babes. 

Salsomaggiore  and  its  Springs. — By  G.  E.  Curatulo. 

Archives  of  Pediatrics,  November,  igoo. 

The  Quantity  of  Diphtheria  Antitoxin  Required  in  the 
Treatment  of  Diphtheria. — William  H.  Park  says  that  in 
diphtheria  we  should  give  enough  antitoxin  to  neutralize  all 
the  toxin  present  and  that  likely  to  be  produced  at  the  seat 
of  inflammation,  and  also  whatever  may  have  been  absorbed. 
The  tissue  changes  already  produced  we  cannot  hope  to 
remove,  neither  can  we  hope  to  neutralize  the  poisons  of 
the  other  bacteria  which  are  so  often  associated  with  the 
diphtheria  bacilli  in  the  disease.  From  the  results  of  ex- 
periments and  from  his  observation  of  cases  in  hospital  and 
private  practice,  the  author  has  been  led  to  adopt  the  fol- 


lowing dosage ;  Very  mild  cases.  1,000  to  1,500  units  for  the 
first  dose;  moderately  severe  cases,  2,000  to  3.000  units; 
very  severe  cases.  4,000  to  5,000  units  ;  laryngeal  cases,  ac- 
cording to  their  severity,  2,000  to  5,000  units.  Forchildren 
under  one  year  he  gives  about  one-third  less  than  for  older 
children  and  adults.  He  believes  that  the  condition  of  the 
throat  as  to  swelling,  e.xtent  and  nature  of  the  membrane, 
etc.,  is  a  better  guide  to  antitoxin  dosage  than  the  general 
condition  of  the  patient.  The  duration  of  the  disease  in- 
fluences the  curative  power  of  the  antitoxin,  rather  than 
the  dosage.  If  after  twelve  hours  inflammation  advances, 
or  after  eighteen  hours  it  has  not  begun  to  subside,  a  second 
dose  of  antitoxin  should  be  injected.  In  a  very  few  cases 
a  third  dose  is  required  at  the  end  of  thirty-four  to  thirty- 
six  hours.  For  tlie  bronchopneumonia  and  sepsis  compli- 
cating some  of  the  worst  cases  antitoxin  is  usually  of  no 
avail. 

Cough  in  Influenza  Simulating  Whooping-Cough. — F.  Forch- 
heimer  describes  a  cough  following  influenza,  which  pos- 
sessed the  following  peculiarities.  It  always  moved  in 
epidemics  and  was  decidedly  contagious  ;  previous  attacks 
of  whooping-cough  Were  no  protection.  The  onset  was 
that  of  ordinary  influenza,  and  the  cough,  which  followed 
in  a  few  days,  was  like  that  of  pertussis,  except  that  the 
whoop,  while  distinct,  was  not  usually  quite  so  marked. 
It  was  accompanied  by  congestive  symi)toms  and  followed 
by  vomiting  and  expectoration.  The  blue  color  of  the  mu- 
cous membrane  and  tongue  was  absent,  Imt  ulcers  of  the 
frenulum  were  marked.  If  left  to  itself  the  trouble  lasted 
from  six  to  eight  weeks,  but  in  the  majority  of  cases  it 
could  be  aborted — so  as  to  last  a  week  or  ten  days  only. 
Full  doses  of  quinine  form  Ihe  best  treatment,  but  must  be 
large — not  less  than  one  decigram  less  than  the  age  in 
years,  and  one  centigram  less  than  the  age  in  months. 
When  the  cough  has  thoroughly  developed,  phenacetin  or 
antipyrin  give  great  relief,  and  in  bad  cases  codeine  and 
chloral  may  have  to  be  administered. 

Malarial  Coma  in  Children. — George  N.  Acker  reports  two 
cases  of  coma  connected  with  malarial  fever,  which  he  be- 
lieves to  have  been  due  to  the  malarial  parasite.  Both  pa- 
tients recovered.  The  author  says  that  it  is  remarkable  that 
malaria  in  children  does  not  cause  more  disturbance  of  the 
nervous  system  than  is  usually  the  case,  for  with  the  un- 
stable condition  that  is  found  in  poorly  nourished  children 
one  would  expect  the  cerebro-spinal  system  to  be  chiefly 
affected,  resulting  in  paroxysms  characterized  by  delirium, 
convulsions,  coma,  and  tetanic  spasms,  producing  serious 
disturbance  of  the  functions  of  animal  life. 

The  Possibility  of  Eliminating  the  Deleterious  while  Re- 
taining the  Antitoxic  Effects  of  Antitoxic  Serum. — By  Wil- 
liam H.  Park. 

A  Case  of  Rachitis  with  Enlarged  Spleen. — By  William 
II.  Jessup. 

Epidemic  Paralysis  in  Children. — By  Henry  Dwight 
Chapin. 


©orresponrtcnce. 

OUR   LONDON    LK'ITER. 

(From  our  Special  Correspondent.) 

THE  NEW  BOROUGHS  AND  PUBLIC  HEALTH — WAR  NOTES — 
LISTER  AT  king's — EFFECT  OF  WINDY  LOCALITIES  ON 
PHTHISIS — SARCOMA — APPENDICITIS,  RELATION  TO  RHEUMA- 
TIS.M,  PREVENTIVE  OPERATIONS — MANGLES  AND  TYPHOID — 
PLAGUE,  DIPHTHERIA — THE  LATE  MR.  ANDERSON  AND  DR. 
ECCLES. 

London,  November  2,  1900. 

The  London  vestries  are  no  more.  AU  were  duly  exe- 
cuted yesterday,  and  Londoners  elected  the  members  of 
the  new  metropolitan  boroughs.  It  is  devoutly  to  be  hoped 
that  the  new  corporations  will  avoid  the  errors  of  their 
predecessors  and  will  give  their  attention  to  the  problems 
of  municipal  government  which  affect  the  public  health. 
What  with  a  new  Parliament  and  new  boroughs  we  have 
had  a  full  diet  of  electioneering  lately,  but  in  London  there 
is  an  amazing  amount  of  apath)'.  We  cannot  tell  yet  the 
effect  of  yesterday's  elections,  but  there  seems  a  distinct 
apprehension  in  many  quarters  that  the  voters  have  neg- 
lected to  poll.  If  so,  we  may  find  that  we  have  not  en- 
tered on  an  era  of  sanitary  improvement.  Yet  every  one 
is  hoping  for  something  better  than  the  old '  vestrydom. 
Even  men  who  would  not  take  the  trouble  to  vote  are  won- 
dering whether  the  water  supply  will  be  better  or  the  rates 
raised. 

The  commissioners  on  the  war  hospitals  have  returned 
from  South  Africa  and  will  take  evidence  here  next  week. 
Dr.  Conan  Doyle's  book  entitled  "The  Great  Boer  War" 


830 


MEDICAL    RECORD. 


[November  24,  1900 


is  exciting  some  comment  and  contains  much  of  his  expe- 
rience in  the  Langman  Hospital. 

Mr.  Treves  has  also  entered  the  list  of  writers  on  the 
war  with  "The  Tale  of  a  Field  Hospital."  giving  an  ac- 
count of  the  one  which  accomjianied  the  Ladysniith  relief 
column.  These  two  works  thus  give  the  e.\iierience  of  sur- 
geons at  .several  points  of  the   South  African  campaign. 

Lord  Lister  opened  the  new  laljoratories  at  King's  Col- 
lege on  Tuesday  evening  and  said  the  occasion  marked  an 
important  event  in  the  Liigner  education  of  the  metropolis. 
Lectures  alone,  he  declared,  were  not  suthcient— practical 
instruction  was  necessary  in  the  various  sciences.  He 
thought  it  a  hapjiy  coincidence  that  this  great  addition  to 
the  college  occurred  as  it  entered  on  an  enlarged  career  as 
a  part  of  the  new  London  University.  He  would  himself 
have  preferred  a  second  or  teaching  university,  but  other 
counsels  having  prevailed  he  hoped  all  would  co-operate  for 
the  common  good. 

The  influence  of  wind,  or  rather  windy  localities,  on 
phthisis  was  the  subject  of  an  elab(;rate  communication  to 
the  Medical  and  Chivurgical  Society  by  Dv.  Gordon  of 
Exeter.  The  paper  was  illustrated"  by  tinted  maps  and 
the  facts  brought  forward  pointed  to  results  which  were 
not  destitute  of  the  element  of  surprise.  Dr.  Gordon's 
investigations  were  confined  to  Devonshire.  Comparing 
the  mortality  of  phthisis  with  the  general  death  rate  of 
rural  districts  of  Devon,  he  found  that  the  variations  of 
soil  could  not  account  for  the  facts.  Rainfall  seemed  more 
closely  connected  with  prevalence  of  phthisis  but  he  was 
driven  to  the  conclusion  that  this  relation  was  that  of  a 
common  cause.  That  cause  seemed  to  be  ex])Osure  to  the 
west  and  southwest  winds.  Places  where  the  dwellings 
were  well  sheltered  from  these  winds  had  an  annual  death 
rate  from  phthisis  of  0.24  per  1,000.  With  imperfect  shelter 
the  rate  rose  to  0.57.  Where  the  dwellings  were  fully 
exposed  to  west  or  southwest  winds,  or  both,  the  rate  was 
1.34.  Dr.  Gordon  did  not  think  differences  in  sunshine, 
temperature,  or  purity  of  the  air  could  account  for  the 
figures,  but  we  have  no  means  of  accurately  estimating 
their  variations.  He  recalled  that  the  late  Dr.  Haviland 
had  directed  attention  to  exposure  to  wind  as  a  cause  of 
increase  of  phthisis. 

In  the  discussion  on  the  paper  several  suggestions  were 
made  to  account  for  the  facts.  Thus,  Dr.  Caj-ley  remarked 
that  in  the  .Scilly  Islands  the  climate  was  mild  but  the  winds 
were  very  violent.  He  had  noticed  that  the  windows  were 
small,  and  thought  the  excess  of  phthisis  there  might  arise 
from  the  people  shutting  themselves  up  too  closely  at 
night.  This  view  was  supported  by  Sir  D.  Powell  and  to 
some  degree  by  Sir  W.  Kroadbent,  who  thought  it  was  the 
force  of  the  wind  rather  than  its  direction  which  proved  in- 
jurious. This,  of  course,  points  in  the  same  direction. 
Other  speakers  mentioned  other  factors,  and  mostly  agreed 
that  windiness  is  a  contraindication  for  the  situation  of  a 
sanatorium.  Dr.  Longstaff  remarked  that  not  merely  the 
country  around,  but  the  state  of  the  dwellings,  the  occupa- 
tions of  the  inhabitants,  and  their  other  circumstances 
must  be  considered.  There  were  copper  and  tin  mines  in 
some  of  the  places  included  in  tlie  paper,  the  farmya'-ds  in 
others  were  notoriously  ill-kept,  and  other  indications  of 
dirtiness  were  obvious.  Violent  winds  might  induce 
"chills,"  as  well  as  lead  peojile  to  shut  themselves  up  too 
closely. 

.Sir  H.  Weber  thought  it  very  difficult  to  examine  one 
alone  of  the  numerous  factors. 

iJr.  Gordon,  in  his  reply,  said  he  thought  the  west  and 
southwest  winds  were  injurious  because  they  werethemost 
violent,  the  wettest  and  the  most  prevalent  in  Devonshire — 
to  which  all  his  statements  were  confined. 

Two  interesting  subjects  occupied  the  attention  of  the 
Medical  Society  on  the  22d  ult.  The  first  was  unusual 
cases  of  sarcoma.  Mr.  Shield  read  notes  of  four  such,  and 
others  were  mentioned  by  Messrs.  Turner,  Black,  Pope, 
Waterhouse,  and  Morgan  (president).  The  last  named 
referred  to  tlie  rarity  of  suppuration  in  association  with 
sarcoma,  though  some  had  been  mentioned  by  previous 
speakers.  He  had  seen  a  case  in  the  region  of  the  os  calcis 
which  at  first  simulated  tuberculosis,  and  one  of  ulceration 
of  the  toe  in  which  the  inguinal  glands  subsequently  be- 
came melanotic.  He  did  not  a])])rove  the  routine  adminis- 
tration of  potassium  iodide  to  patients  with  tumors.  Mr. 
Shield  also  held  that  this  medicatitm  should  not  be  allowed 
to  impair  the  chance  of  recovery  by  operation.  The  ques- 
tion of  ri.se  of  temperature  might  well  have  been  discussed. 
It  does  not  seem  to  be  regularly  recorded,  but  there  is  a 
rise  and  it  is  likely  to  cause  errors,  for  it  closely  resembles 
that  of  suppuration. 

The  other  subject  was  the  association  of  arthritis  and  ap- 
pendicitis. Cases  have  been  recorded  by  Dr.  Sutherland 
and  others  in  whicli  one  preceded  the  other,  or  the  two 
were  coincident,  and  some  in  which  perityphlitis  was  re- 
lieved by  salicylates.  The  similarity  in  structure  of  the 
tonsil  and  apjiendix  vermiformis  has  also  been  supposed 
to  point  to  similar  pathological  tendencies.     Dr.  Beverley 


Robinson  has  not  been  able  to  convince  himself  that  the 
two  are  causally  related,  and,  I  think,  many  other  observ- 
ers are  equally  doubtful.  Dr.  Pointon,  who'introduced  the 
subject,  seemed  in  this  position,  and  mentioned  the  re- 
searclies  of  Piard  upon  metastatic  suppurations  in  connec- 
tion with  apiiendicitis.  and  Akerman's  experimental  pro- 
duction of  osteomyelitis  in  young  rabbits  by  injecting  pure 
cultures  of  the  bacillus  coli.  The  polyarthritis  is  therefore 
probably  of  a  py;emic  rather  than  a  rheumatic  nature. 
This  view  c(mimended  itself  to  the  president  and  several 
of  the  speakers. 

Dr.  kolleston  thought  the  structural  analogy  between 
the  tonsil  and  appendix  supported  the  idea  that  appendi- 
citis might  lie  of  rheumatic  origin.  He  thought  the  preju- 
dice against  this  view  was  due  to  a  fear  lest  operation 
sliould  l)e  delaj-ed  in  consetjuence,  and  suggested  that  sep- 
tic infection  might  be  added  to  a  case  started  by  rheuma- 
tism. Some  patients  certainly  recovered  under  salicylates 
—a  treatment  long  employed  by  Dr.  Cavafy— but  he  admit- 
ted he  had  not  seen  a  case  arise  during  rheumatic  fever, 
nor  definite  joint  mischief  in  the  course  of  aiijicndicitis. 

Mr.  Wallis  questioned  the  rlieumatic  nature  of  a])])endi- 
citis,  but  thought  arthritis  might  be  due  to  it.  or,  indeed, 
to  septic  matter  absorbed  from  any  ulceration  in  the  lower 
bowel.  Dr.  Savill  had  seen  a  case  of  prohmged  polyarthri- 
tis in  which  death  occurred  from  perforated  appendix,  and 
the  joint  mischief  seemed  due  to  septic  absorption  from  the 
appendix. 

Dr.  Cayley  pointed  out  that  the  cases  in  which  there 
seemed  any  association  between  the  two  diseases  were  but 
very  few,  though  there  seemed  scmie  relation  between  ca- 
tarrhal colitis  and  rheumatic  symptoms.  Surgeon-Major 
Black  thought  an  abscess  round  the  appendix  might  lead 
to  absorption  of  jnis  into  the  femoral  sheath. 

The  appendix  vermiformis  has  also  been  the  subject  of 
discussion  at  another  society — the  Harveian — where  Mr. 
Mansell  Moullin  maintained  the  advisability  of  early  oper- 
ation in  all  cases  of  acute  inflammation.  By  early  opera- 
tion he  means  what  may  be  called  preventive.  In  all  se- 
vere cases  he  holds  tlie  question  should  be  determined 
within  thirty-six  hours  of  the  onset,  and  even  this  limit  may 
have  to  be  shortened  in  some  cases.  As  it  is  impossible  to 
determine  at  the  beginning  of  severe  cases  which  may 
wait,  he  adopts  the  general  principle  that  when  there  is 
danger  ahead  it  is  wise  to  ascertain  the  e.xact  condition  of 
things  by  a  simple  exploratory  (jperation.  He  thinks  an 
incision  one  and  a  half  inches  long  and  the  introduction  of  a 
finger  sufficient  for  this.  The  pulse  he  considers  the  best 
guide  when  to  operate.  It  is  better,  he  said,  to  optJrate  on 
all  severe  cases  at  first,  for  it  is  not  possible  to  distinguish 
those  which  might  wait  awhile.  This  course  is  wiser  than 
to  allow  those  to  die  who  will  otherwise  have  septic  peri- 
tonitis, in  order  to  save  others  from  an  operation  which  will 
become  necessary  later  on.  Mr.  Raymond  Johnson  rather 
supported  this  view,  though  he  admitted  that  such  prac- 
tice would  result  in  operations  being  done  on  patients  who 
might  recover  without.  Still  the  danger  of  the  operation 
was  very  slight.  He  thought  the  incision  proposed  very 
small,  and  that  there  was  some  danger  of  disturbing  adhe- 
sions round  small  collections  of  ])us. 

A  vigilant  medical  officer  of  health  has  traced  an  out- 
break of  typhoid  to  an  infected  mangle — an  additional  ter- 
ror of  the  laundry. 

Diphtheria  is  rather  on  the  increase,  but  typhoid  is  abat- 
ing. A  case  of  plague  arrived  in  a  steamship  from  the 
Philippines.  The  vessel  was  disinfected  and  every  pre- 
ca  jtion  taken.  Glasgow  is  to  be  congratulated.  No  sus- 
pected cases  occurred  in  the  last  month.  Only  eight  con- 
valescents remain  in  hospital  and  no  contacts  in  the 
reception  houses. 

Mr.  William  Anderson,  F.R.C.S.,  died  on  the  27th  ult., 
aged  fifty-seven  years.  He  was  surgeon  to  St.  Thomas' 
Hospital  and  professor  of  anatomy  in  the  Royal  Academy. 
From  1S73  to  iSSo  he  was  principal  of  the  Naval  Medical 
College  of  Jajian.  There  he  made  a  valuable  collection 
of  art  treasures,  which  is  now  in  the  British  Museum.  On 
returning  to  London  he  settled  down  to  steady  work  at  his 
old  school,  where  he  was  highly  esteemed  as  a  surgeon,  a 
colleague,  teacher,  and  friend. 

Dr.  Symons  ICccles  died  suddenly  on  the  22d  ult.  in  his 
forty-sixtli  year.  He  served  in  the  Russo-Turkish  war  and 
was  decorated  with  the  medjidieh.  On  returning  he  set- 
tled in  London  and  devoted  great  attention  to  massage,  his 
writings  on  that  subject  being  of  the  best  quality.  He  had 
been  president  of  the  West  London  Medical  Society,  and 
was  one  of  tlie  founders  of  the  journal  of  the  same  name. 


Dr.  Ramon  y  Cajal. — Tlic  Spanish  government 
has  appropriated  80,000  pesetas  (Si6,ooo)  to  establish 
and  maintain  a  laboratory  of  biological  research  in 
Madrid  under  tlie  direction  of  Dr.  Ramon  y  Cajal. 


November  24,  1900J 


MEDICAL    RECORD. 


831 


J^ocictij  ii'vcpovts. 

NEW  YORK  ACADEMV  OK  MEDICINE. 

S/iihii  Mttliiig,  N(>v,mhi-r  ij.  igoo. 
William  H.  Thomson,  M.!)..  I'mesidem. 

Conjugation  in  the  Asexual  Cycle  of  the  Mala- 
rial Parasite.  —  1)k.  [amls  Kwing  delivered  the  Wes- 
ley M.  Carpenter  Lecture,  taking  this  for  his  topic. 
He  said  that  in  1897  liis  attention  had  been  attracted 
by  a  specimen  of  blood  from  a  recent  tertian  infection, 
in  which  there  were  numerous  twin  parasites  of  a  few 
hours'  growth.  The  evidence  favoring  conjugation  of 
parasites  rested  principally  upon  morphological  ap- 
pearances. In  many  instances  the  young  organisms 
were  entirely  separate.  Many  red  cell.s  contained  two 
young  parasites  which  were  clearly  (used  together  along 
the  segments  of  tiieir  bodies,  and  two  chromatin  gran- 
ules were  found  at  different  points.  Tiie  bodies  of 
these  twin  parasites  apparently  became  fused  together 
while  their  nuclei  remained  separate.  Occasionally 
the  two  chromatin  granules  were  closer  together,  but 
no  fusion  was  observed  at  this  early  stage.  Later  on.  a 
number  of  long  budding  pseudopodia  might  be  seen. 
The  chromatin  masses  were  then  subdivided  into  ten 
or  twelve  masses,  but  still  remained  far  apart.  Fi- 
nally, the  chromatin  granules  came  to  lie  side  by  side 
surrounded  by  a  milky  or  achromatic  substance.  Very 
numerous  young  twin  parasites  were  succeeded  by  sin- 
gle forms,  and  a  full-grown  brood,  all  single,  was  found 
associated  with  a  young  brood  consisting  all  of  twins. 
The  suggestion  naturally  arose,  that  the  presence  of 
two  masses  of  chromatin  did  not  necessarily  mean  the 
presence  of  two  parasites  in  one  red  cell.  It  must 
be  admitted  that  this  objection  was  partially  valid. 
However,  he  had  never  seen  in  the  delicate  tertian 
ring  two  equal  chromatin  granules.  The  significance 
of  these  double  granules  was  not  quite  clear.  The 
accessory  granule  might  arise  from  incomplete  fusion, 
or  from  precocious  subdivision  of  the  chromatin,  or 
more  likely  by  incomplete  separation  of  the  bodies  of 
two  spores.  This  he  believed  to  be  the  mode  of  ori- 
gin of  some  of  the  small  "compact  bodies  "  with  more 
than  one  chromatin  granule.  In  some  of  the  conju- 
gated forms  three  masses  of  chromatin  granules  were 
found,  while  only  two  bodies  were  found  in  the  red  cell. 
It  might  be  objected  that  it  was  impossible  to  deter- 
mine when  the  bodies  of  two  parasites  were  united,  as 
one  might  overlap  the  other  and  so  give  an  appearance 
which  would  mislead  the  observer.  Examples  of  twin 
parasites  of  advanced  development  were  sometimes 
seen  in  severe  tertian  infection  without  subsequent 
conjugation.  This  was  a  rather  common  obser\ation. 
He  had  seen  hundreds  of  conjugating  forms  in  a  few 
months  but  only  three  or  four  twin  parasites  in  as 
many  years.  Conjugation  seemed  to  require  the  pres- 
ence of  a  compact  body  and  of  a  ring-shaped  parasite. 
In  some  instances  of  multiple  infection  by  full-grown 
malarial  parasites  there  was  evidence  of  death  of  one 
of  the  parasites.  In  his  own  cases  showing  conjuga- 
tion no  cases  of  dwarfed  parasites  could  be  found,  and 
while  young  twins  were  quite  common  all  the  other 
older  parasites  were  single.  The  usual  result  of  twin- 
ning of  tertian  parasites  was  conjugation.  Twins 
sometimes  went  to  maturity  without  twinning,  appar- 
ently when  both  parasites  showed  the  usual  ring  form. 
As  to  the  frequency  with  which  conjugation  occurred, 
the  speaker  said  that  the  majority  of  specimens  failed 
to  show  distinct  traces  of  the  process,  although  he  had 
found  little  difficulty  in  obtaining  specimens  showing 
a  few  conjugating  forms.  These  specimens  were  all 
taken  from    very    rich    infections.     The    conjugating 


forms  were  usually  few  or  wanting  when  the  number  of 
parasites  was  small,  or  when  quinine  had  been  given. 
Single  parasites  of  both  types — the  compact  bodies 
and  the  thin  rings — could  be  traced  through  the  later 
stages  of  their  development.  In  the  full-grown  stage 
of  the  compact  bodies  they  still  contained  numerous 
chromatin  granules.  As  the  thin  ring  forms  increased 
in  size  they  were  characterized  by  their  hyaline  ap- 
pearance and  tendency  to  stain  with  methylene  blue. 
In  the  full-grown  stage  it  was  e.xceedingly  difficult  to 
demonstrate  the  chromatin.  The  crescents  of  the 
astivo-autumnal  forms  had  been  long  divided  into  two 
kinds,  viz.,  the  small  flagellating  or  male  body,  and  a 
larger  and  more  densely  staining  or  female  body.  He 
had  been  unable  to  trace  the  development  of  the  two 
forms  of  .a-stivo-autumnal  rings  that  he  had  described. 
If  conjugation  occurred  in  this  parasite,  it  probably 
lasted  for  only  a  brief  period,  and  could  be  demon- 
strated only  in  peripheral  blood  in  which  these  bodies 
were  closely  massed.  It  was  a  well-recognized  biologi- 
cal principle  that  conjugation  among  protozoa  might 
be  the  only  sexual  feature  of  reproduction  during  a 
limited  number  of  generations,  after  which  the  sexual 
capacity  ceased,  and  must  be  redeveloped  by  the 
formation  of  new  bisexual  forms.  Tlie  spontaneous 
disappearance  of  the  malarial  infection  might  be  ex- 
plained by  a  gradual  failure  to  reproduce  by  conjuga- 
tion, and  the  development  of  single  parasites  into  in- 
dividuals sterile  for  the  human  host,  but  adapted  for 
development  in  the  mosquito.  The  malarial  parasite 
might  be  said  to  begin  its  existence  in  the  human  host 
by  a  series  of  development  of  amu-boid  bodies.  Later 
on  the  sexes  became  fully  differentiated,  as  shown  by 
the  formation  of  the  flagellated  and  non-flagellated 
bodies.  These  forms  were  sterile  to  the  human  host, 
but  fertilization  might  take  place  in  the  mosquito. 
Here  the  parasites  became  encysted,  but  subsequently 
in  some  way  germinal  rods  were  formed,  and  were 
eventually  introduced  into  the  human  body  as  amceboid 
forms. 

SECTION    ON    SURGERY. 

Stated  Meeting.  A'ovember  /2,  /goo. 

Charles  N.   Down,  M.D.,  Chairman. 

Intra-Abdominal  Omental  Torsion. — Dr.  Joseph 
U'lhNEK  presented  a  man  seventy-nine  years  of  age, 
upon  whom  he  had  successfully  operated  for  the  re- 
moval of  an  intra-abdominal  omental  tumor.  Owing 
to  the  patient's  bad  condition  at  the  time  of  operation, 
nitrous  oxide  gas  had  been  used  for  the  ana-sthetic. 
The  history  had  pointed  to  an  appendicitis,  but  the 
latter  had  been  excluded  at  the  operation.  Xt  the  site 
of  the  tumor  that  had  been  detected  on  palpation  was 
a  piece  of  omentum  which  had  been  subjected  to  tor- 
sion. It  was  of  a  dark  blue  color.  The  adhesions 
were  tied  off,  the  pedicle  was  untwisted,  and  the  ab- 
dominal wound  was  closed.  The  patient  had  made  a 
good  recovery. 

Gibson's  Method  of  Suprapubic  Drainage  of  the 
Bladder. — Dr.  P.  R.  BtjLToN  presented  a  man  who 
had  been  referred  to  him  last  summer  by  Dr.  Mc- 
Intyre.  He  had  a  calculus  in  the  bladder.  The 
bladder  had  been  exposed  by  an  incision  through  the 
recti,  then  opened,  and  the  calculus  extracted.  The 
bladder  had  then  been  sutured  in  the  angles  of  the 
incision,  taking  only  the  muscular  layer.  The  blad- 
der was  anchored  securely  to  the  posterior  surface  of 
the  recti  muscle.  X  drainage  tube  was  securely  fast- 
ened in  by  sutures.  On  the  fifth  day  the  sutures  had 
been  removed,  and  the  man  had  been  discharged  on 
the  following  day.  The  method  had  worked  admir- 
ably, having  completely  prevented  any  leakage  from 
the  bladder. 


832 


MEDICAL    RECORD. 


[November  24,  1900 


Perineal  Prostatectomy. — Dr.  Parker  Syms  pre- 
sented a  man  sixty-eight  years  of  age,  who  had  been 
admitted  to  the  Lebanon  Hospital  on  November  20, 
1899.  For  several  months  previously  there  had  been 
frequent  micturition,  and  at  the  time  of  his  admission 
complete  retention  of  urine.  Examination  had  shown 
a  large  prostate  but  no  cystitis.  A  median  incision 
had  been  made  in  the  perineum,  and  llie  prostate  enu- 
cleated. The  bladder  had  been  drained  through  the 
perineum  for  a  few  days.  The  man  was  now  able  to 
hold  his  urine  for  four  or  five  hours.  The  speaker 
said  that  he  was  desirous  of  doing  prostatectomy  with- 
out making  a  suprapubic  opening,  and  to  facilitate 
this  had  devised  a  special  drainage  instrument,  a 
sketch  of  which  was  shown. 

Dr.  Wiener  said  that  he  had  carefully  studied  the 
reported  cases  of  omental  torsion,  and  had  come  to 
the  conclusion  that  the  formation  of  a  pedicle  might 
be  explained  by  the  fact  that  at  one  time  a  portion  of 
the  omentum  had  been  in  a  hernial  sac,  thus  allowing 
the  distal  portion  to  become  thick,  and  by  pulling  on 
the  rest  of  the  omentum  tended  to  the  formation  of  a 
pedicle. 

Dr.  L.  Bolton  Bangs  commented  favorably  upon 
the  method  of  suprapubic  drainage  devised  by  Dr. 
Gibson.  He  had  had  an  opportunity  of  trying  it  in 
only  one  case,  that  of  an  old  man  in  bad  condition.  He 
had  opened  the  bladder  and  removed  twenty-six  faceted 
stones.  He  had  inserted  two  rows  of  sutures,  and  this 
had  prevented  all  leakage. 

Dr.  Willy  Meyer  said  that  the  case  presented 
showed  what  could  be  done  by  this  method,  but  there 
was  a  possibility  that  this  unfolding  of  the  bladder 
might  unduly  reduce  its  capacity. 

Dr.  Bolton  replied  that  in  his  case  there  had  been 
no  evidence  of  reduction  in  the  capacity  of  the  blad- 
der, for  the  patient  had  been  able  to  sleep  all  night 
and  urinated  only  three  or  four  times  a  day. 

Hernia  and  Obscure  Abdominal  Pain. — Dr.  Wil- 
liam H.  Thomson  said  that  some  years  ago  Mr.  Ben- 
nett, of  London,  had  delivered  a  lecture  on  certain 
obscure  abdominal  pains.  He  had  pointed  out  that 
such  pains  were  sometimes  due  to  small  omental  her- 
nia; in  the  walls  of  the  abdomen,  and  having  no  con- 
nection whatever  with  the  inguinal  canals.  Soon 
after,  the  speaker  said,  he  had  met  with  just  such 
a  case.  The  pain  had  developed  in  a  man  after  a 
sudden  misstep  on  the  sidewalk.  The  inguinal  canals 
were  perfectly  free,  but  aboiit  half-way  between  the 
symphysis  and  the  umbilicus  tiiere  was  a  tender  spot, 
and  operation  had  proved  this  to  be  a  hernia.  The 
operation  had  given  relief.  Another  case  had  been 
seen  shortly  afterward.  Last  May  he  had  seen  a  third 
case.  The  patient,  a  woman,  had  fallen  across  a  pipe 
railing,  and  had  broken  two  ribs.  After  the  ribs  had 
healed  there  was  a  continuous,  dragging,  severe  pain. 
Examination  had  shown  simply  a  small  tender  spot 
two  inches  to  the  left  of  the  umbilicus  and  nearly 
three  inches  above  this  level.  Palpation  had  failed 
to  detect  any  tumor,  and  a  surgeon  had  made  an  ex- 
ploratory incision  under  local  aniesthesia.  A  small 
knuckle  of  omentum  had  been  found  caught  in  the 
rent  in  the  abdominal  wall. 

Heat  Stroke  as  a  Post-Operative  Complication. — 
Dr.  Charles  L.  Gibson  said  that  in  this  city  during 
the  heated  term  a  combination  of  heat  and  humidity 
with  absence  of  breeze  was  very  liable  to  lead  to  heat 
stroke.  He  had  become  deeply  impressed  with  heat 
prostration  as  a  factor  in  causing  fever  and  other  con- 
stitutional disturbance  after  operation.  Of  course, 
one  must  be  cautious  about  attributing  to  heat  stroke 
many  disturbances  which  might  perhaps  be  the  result 
of  sepsis,  iodoform  poisoning,  or  other  causes.  The 
first  case  reported  was  that  of  a  boy  admitted  with 
gangrenous    appendicitis.     The    operation    had    not 


been  complicated  and  the  boy  had  reacted  well,  but 
on  the  following  day  had  developed  a  temperature  of 
104°  F.  and  a  pulse  of  148.  This  had  been  asso- 
ciated with  delirium  and  with  other  symptoms  which 
seemed  to  point  to  a  speedily  fatal  termination.  By 
cold  sponging  the  temperature  had  been  quickly  low- 
ered to  100.6°  F.,  and  with  this  change  in  tempera- 
ture the  pulse  had  dropped  to  98  and  had  become  of 
good  quality,  and  the  delirium  had  subsided.  After 
this  recovery  had  been  uninterrupted.  The  weather  at 
the  time  was  very  hot  and  sultry.  A  second  case  oc- 
curred on  August  loth,  one  of  the  most  trying  days  in 
the  hospital  operating-room  during  the  past  summer. 
By  bearing  in  mind  the  possibility  01  the  occurrence 
of  such  a  complication,  the  appropriate  treatment  was 
more  apt  to  be  instituted  and  preventive  measures 
were  likely  to  be  employed,  such  as  securing  good 
ventilation  by  electric  fans  or  other  means. 

Dr.  a.  B.  Johnson  spoke  of  a  case  on  which  he 
had  operated  last  summer  when  the  temperature  in  the 
operating-room  had  been  about  102"  F.  The  patient 
was  a  child  having  1  small  scar  on  the  lower  lip. 
The  child  was  apparently  in  perfect  health.  A  very 
small  quantity  of  chloroform  had  been  administered, 
the  scar  cut  out,  and  a  single  skin  graft  applied.  So 
trivial  was  the  operation  that  one  might  have  been 
justified  in  doing  it  in  a  physician's  office.  Within  a 
few  hours  after  the  child  had  been  returned  to  the 
ward  the  temperature  had  reached  108'  F.  He  had 
not  recognized  the  possibility  of  this  condition  being 
due  to  heat  stroke,  and  consequently  refrigeration  had 
not  been  resorted  to.  The  child  had  died  that  night. 
Within  a  few  days  after  this  he  had  encountered  two 
similar  cases,  and  all  the  other  probable  causes  of 
such  fever  had  been  carefully  excluded.  These  cases 
had  both  yielded  promptly  to  cold  sponging.  Look- 
ing back  over  the  years  past  he  could  not  but  feel  that 
he  had  seen  several  other  cases  explicable  on  the 
theory  of  heat  stroke.  He  remembered  particularly  a 
group  of  three  cases,  all  operated  upon  in  extremely 
hot  and  sultry  weather,  and  all  terminating  fatally. 

Dr.  George  E.  Brewer  said  that  on  July  4th  he 
had  had  occasion  to  operate  upon  a  youth  of  nineteen 
for  sarcoma  of  the  tonsil  and  soft  palate.  'The  opera- 
tion had  been  a  severe  one,  but  the  patient  had  left 
the  table  in  excellent  condition.  The  thermometer  in 
the  operating-room  on  that  day  had  registered  99°  F. 
Within  two  hours  after  being  returned  to  the  ward  the 
house  surgeon  had  reported  that  tlie  man  appeared  to 
be  dying.  Tiie  pulse  was  150  and  the  temperature 
105°  F.,  and  he  was  extremely  restless  and  delirious. 
Some  hours  later,  on  mentioning  this  case  to  Dr.  Gib- 
son, the  suggestion  had  been  made  by  the  latter  that 
this  was  a  case  of  heat  prostration.  The  treatment 
outlined  in  the  paper  had  at  once  been  undertaken, 
with  the  result  that  there  had  been  immediate  im- 
provement. It  had  been  several  days  before  the  tem- 
perature and  pulse  had  returned  to  the  normal,  but  the 
effect  of  the  refrigerating  treatment  had  been  immedi- 
ate and  most  marked.  This  was  the  only  case  that  he 
had  seen  in  which  the  symptoms  had  been  character- 
istic, and  he  had  felt  that  other  causes  could  be  ex- 
cluded. Since  that  time  he  had  seen  heat  stroke  in 
one  of  Dr.  Weir's  cases.  He  was  very  glad  that  this 
topic  had  been  presented  for  discussion,  for  he  felt 
confident  that  this  complication  of  heat  stroke  was  a 
reality. 

Dr.  Robert  T.  Morris  said  that  it  would  be  most 
interesting  to  study  in  this  connection  the  ana'sthetics 
employed  in  these  cases.  He  believed  a  large  pro- 
portion of  the  cases  of  sunstroke  occurred  in  alcoholic 
persons,  and  after  they  had  indulged  quite  freely  in 
alcoholic  drinks.  It  was  possible  that  the  anaesthetic 
agents  acted  somewhat  like  alcohol,  rendering  the  sys- 
tem less  resistant  to  heat.     He  recalled  an  experience 


November  24,  1900] 


MEDICAL    RECORD. 


83: 


of  two  years  ago,  in  which  there  had  been  several  high 
temperatures  immediately  following  operation,  occur- 
ring during  a  period  of  hot,  moist  weather.  He  had 
made  a  mental  note  of  it  at  the  time,  but  was  exceed- 
ingly glad  that  the  attention  of  the  profession  had 
been  directed  to  this  subject  by  this  paper. 

Dr.  Jamks  p.  'I'uiTi.E  said  tiiat  he  had  seen  several 
very  high  post-operative  temperatures  during  the  sum- 
mer, and  had  been  unable  to  explain  them  before 
hearing  this  paper.  One  of  these  cases  had  occurred 
last  summer,  and  had  terminated  fatally.  In  this  case 
the  temperature  had  risen  to  107'  F.  and  had  reached 
109'  at  the  time  of  death.  Owing  to  suppression  of 
the  urine  it  had  been  supposed  that  the  kidneys  had 
been  responsible  for  this  death,  but  the  autopsy  had 
failed  to  substantiate  this  view.  Chloroform  had 
been  the  anaesthetic  employed. 

Dr.  a.  V.  MoscHCowirz  said  that  during  the  past 
summer  he  had  performed  an  amputation  of  the  lower 
extremity  in  a  case  of  Raynaud's  disease  with  gan- 
grene. In  three  hours  after  operation  the  temperature 
had  been  107'^  F. ;  in  another  hour  it  had  reached 
109°,  and  in  five  hours  death  had  occurred.  Before 
this  a  diagnosis  of  heat  stroke  had  been  made.  Al- 
though a  most  exhaustive  and  painstaking  autopsy 
had  been  made  it  had  shown  only  hyperiemia  of  the 
meninges,  and  a  turgidity  of  all  the  blood-vessels  of 
the  brain.  In  another  case  a  prompt  re.sort  to  refrig- 
eration had  brought  down  the  temperature  and  the 
patient  had  made  a  good  recovery. 

Dr.  William  H.  Thomso.n'  said  he  would  like  to 
know  whether  any  of  those  present  could  recall  having 
seen  similar  cases  in  cool  weather. 

Dr.  Ale.xan'der  Lambert  said  that  the  cases  cited 
this  evening  reminded  him  very  strongly  of  some  of 
those  cases  of  heat  stroke  seen  by  him  at  Bellevue 
Hospital  during  the  very  hot  weather  of  1896.  The 
rapidity  with  which  the  temperature  had  risen  after 
these  operations  would  seem  to  be  sufficient  to  exclude 
septiccemia  or  even  kidney  complication.  He  had 
often  wondered  why  there  were  not  some  cases  of  heat 
stroke  w^hen  he  had  seen  the  way  in  which  many  oper- 
ative cases  were  swathed  in  cloths,  and  towels,  and 
thick  dressings.  The  most  important  meteorological 
factor  in  the  production  of  heat  stroke  was  lack  of  mo- 
tion of  the  air,  and  the  consequent  interference  with 
radiation  of  heat  from  the  body.  In  that  dreadful  hot 
season  in  the  summer  of  1896,  the  wind  did  not  for 
ten  days  move  faster  than  six  or  eight  miles  an  hour. 
This  memorable  period  was  marked  by  less  than  the 
average  humidity,  and  yet  the  number  of  cases  of  heat 
stroke  was  appalling.  He  could  not  agree  with  I)r. 
Moschcowitz  that  turgidity  of  the  cerebral  vessels  in- 
dicated heat  stroke;  there  was  nothing  indicative  of 
heat  stroke  except  the  changes  in  the  nerve  cells. 
One  of  the  best  methods  of  controlling  the  high  tem- 
perature in  heat  stroke  was  by  the  administration  of 
ice-water  enemata. 

Dr.  Studdifori)  reported  a  case  operated  upon  in 
July  about  9:30  a..m.  The  case  was  one  of  fibroid  and 
pus  tubes  with  total  hysterectomy.  At  i  p.m.  the  tem- 
perature had  been  102°  F. ;  at  8  p.m.  103.6",  and  the 
following  morning  102'.  In  the  evening  it  had 
reached  106  ,  and  a  little  later  107.6'  F.  The  case 
had  not  been  looked  upon  as  one  of  sepsis,  and  had 
been  given  an  ice-pack.  By  nine  o'clock  the  temper- 
ature had  fallen  to  101.6",  and  by  9  a.m.  to  98.6. 
There  had  been  nothing  about  the  wound  or  the  va- 
ginal drainage  to  indicate  sepsis.  The  patient  made  a 
good  recovery. 

Remarks  upon  the  Construction  of  Amputation 
Stumps,  with  a  Report  of  Two  Cases  of  Amputa- 
tion by  the  Osteoplastic  Method  of  Bier.— Dr.  A. 
V.  Moschcowitz  read  this  paper.  He  said  that  most 
of  the  really  satisfactory  amputation  stumps  had  fol- 


lowed disarticulations  or  amputations  near  a  lai-ge 
joint.  At  one  time  the  volume  and  thickness  of 
stumps  were  considered  to  determine  their  usefulness, 
but  every  one  had  seen  stumps  made  of  broad  bony 
surfaces  which  were  not  at  all  serviceable.  There 
could  be  no  question,  he  thought,  about  the  superior- 
ity of  Bier's  osteoplastic  method,  although  it  necessar- 
ily lengthened  the  operation  somewhat,  and  hence 
might  not  be  appropriate  in  certain  cases.  The 
technique  differed  from  ordinary  methods  in  the  for- 
mation of  an  osteoplastic  Hap.  As  it  was  difficult  to 
make  this  Hap  with  an  ordinary  saw,  he  had  devised  a 
special  saw  for  this  purpose.  Taking  the  leg  as  an 
illustration,  the  periosteum  of  the  anterior  surface  of 
the  tibia  was  circumcised  on  three  sides  of  the  quadri- 
lateral space,  the  edges  of  the  periosteum  were  raised 
for  a  short  distance  from  the  bone,  and  a  thin  plate  of 
bone  was  sawn  out.  This  was  used  as  a  cover  to  the 
sawn  edges  of  bone,  to  which  it  united,  giving  a  useful 
bearing  surface  for  the  stump,  and  one  free  from  ten- 
derness. A  skiagraph  taken  eighteen  days  after  one 
of  these  amputations  of  the  leg  showed  perfect  union 
between  the  osteoplastic  flap  and  the  tibia,  but  not 
between  this  flap  and  the  fibula.  The  speaker  said 
that  since  he  had  become  interested  in  this  subject 
he  had  embraced  every  opportunity  to  examine  ampu- 
tation stumps  of  all  kinds,  and  had  been  able  to  satisfy 
himself  of  the  fact  that  every  stump  made  by  other 
methods,  unless  the  result  of  a  disarticulation,  was  more 
or  less  painful.  Bier  claimed  that  his  method  was  an 
absolute  prevention  of  conical  stump. 


THE  NEW  YORK  PATHOLOGICAL  SOCIETY. 

Stated  3/eeting,  October  /o,  igoo. 

Eugene  Hodenpvl,  M.D.,  President. 

Sarcomatosis  of  the  Peritoneum Dr.  F.  C.  Wood 

presented  several  specimens.  'I'he  first  of  these  was 
one  of  sarcomatosis  of  the  peritoneum,  removed  from 
a  small  Chinese  woman  who  was  very  much  ema 
ciated.  An  exploratory  operation  had  been  done,  and 
she  had  died  soon  afterward.  The  autopsy  revealed 
the  mass  presented.  The  determination  of  the  pri- 
mary growth  was  especially  ditficult  in  this  case  be- 
cause nearly  all  of  the  abdominal  organs  were  in- 
volved. The  spleen  had  escaped.  There  were  no 
metastases  anywhere  in  the  body.  Presumably  the 
growth  had  originated  from  the  retroperitoneal  lymph 
nodes,  but  microscopical  examination  of  the  tumor 
was  rather  against  this,  for  the  appearance  presented 
was  that  of  a  sarcoma  consisting  of  round  and  spindle 
cells.  The  specimen  under  the  microscope  showed 
an  extreme  degree  of  fatty  degeneration.  The  right 
ovary  could  not  be  found,  so  that  possibly  the  growth 
might  have  started  from  that  ovary.  The  uterus  was 
not  invaded.  The  bladder  wall  had  been  invaded, 
and  was  about  one  inch  in  thickness.  The  woman 
claimed  to  have  been  in  perfect  health  up  to  five 
months  before  admission  to  the  hospital,  and  stated 
that  there  had  been  no  evidence  of  the  tumor  previ- 
ously. 

Diffuse  Lympho-Sarcoma  of  Both  Kidneys The 

pancreas,  liver,  uterus,  and  ovaries  were  involved  in 
this  case.  The  specimens  had  been  removed  from  a 
woman  twenty-six  years  of  age,  who  had  always  been 
an  invalid.  About  one  year  and  a  half  before  admis- 
sion to  the  hospital  she  had  begun  to  have  consider- 
able pain  in  the  abdomen,  and  about  the  same  time 
had  noticed  some  enlargement  of  the  abdomen.  The 
urine  had  been  examined  repeatedly  for  a  long  time 
by  a  competent  physician,  but  with   negative  result, 


834 


MEDICAL    RECORD. 


[November  24,  1900 


although  it  was  assumed  that  the  kidney  was  the  seat 
of  a  new  growth.  On  admission,  there  was  an  oval 
tumor  in  each  llank.  The  urinary  examinations  in 
the  hospital  had  also  been  negative.  The  blood  ex- 
amination showed  moderate  leucocytosis.  The  woman 
had  died  from  shock  the  day  after  an  exploratory  lapa- 
ratoniy.  The  kidneys  pre.sented  suggested  foetal  lob- 
ulation. When  fresh,  tiie  tubular  markings  had  shown 
pretty  well,  and  portions  of  the  kidney  tissue  seemed 
good  on  gross  examination.  Microscopical  examina- 
tion, however,  showed  that  the  kidney  tubules  were 
separated  from  one  anotiier  by  a  layer  of  small  round 
cells.  One  of  the  kidneys  presented  weighed  one 
pound  and  nine  ounces,  and  the  other,  one  pound  and 
four  ounces.  In  this  case  the  pancreas  was  large  and 
quite  firm,  and  microscopical  sections  showed  infil- 
tration of  lymphoid  cells  into  the  trabecule.  I'he 
ovaries  were  completely  infiltrated,  as  was  also  the 
uterus.  A  large  ragged  ulcer,  about  three  inciies  long, 
was  situated  in  the  ileum  just  above  the  caput  coli, 
and  extended  around  the  entire  circumference  of  the 
gut.  There  was  nothing  in  the  history  pointing  to 
such  a  condition.  Sections  of  the  ulcer  showed  noth- 
ing but  necrotic  tissue  extending  down  in  portions  to 
the  peritoneum.  No  tubercle  bacilli  were  found,  so 
that  the  cause  of  the  ulcer  was  still  in  doubt.  The 
spleen  was  perfectly  normal,  both  in  size  and  struc- 
ture. The  question  naturally  arose,  Did  not  this  pa- 
tient have  a  simple  pseudo-leuka;mia?  He  believed 
one  case  of  lymphatic  leukaemia  without  enlargement 
of  the  spleen  had  been  reported,  yet  the  general  find- 
ings had  not  been  those  usually  present  in  lymphatic 
leukamia.  He  would,  therefore,  classify  the  infiltra- 
tion in  the  case  just  presented  as  one  of  diffuse 
lympho-sarcoma.  Sections  of  the  kidney  were  exhib- 
ited under  the  microscope. 

Accessory  Lobe  of  the  Liver. — A  specimen  was 
shown  by  Dr.  Wood.  There  had  been  a  congenital 
atrophy  of  a  portion  of  liver  tissue,  thereby  cutting  off 
a  segment.  The  patient  had  entered  the  hospital  with 
pain  in  the  abdomen  and  a  high  temperature.  Phys- 
ical examination  of  the  chest  had  revealed  a  pneu- 
monia. As  there  were  jaundice  and  abdominal  pain, 
cholelithiasis  had  been  diagnosed.  Palpation  showed 
a  mass  thought  to  be  the  gall  bladder,  but  this  proved 
at  autopsy  to  be  an  accessory  lobe  of  the  liver.  Death 
had  resulted  from  pneumonia. 

Cirrhosis  of  the  Liver.  — In  this  case  there  were 
several  adhesions  between  the  anterior  abdominal  wall 
and  the  omentum,  containing  several  large  veins. 
The  diaphragm  was  likewise  adherent  to  the  liver. 
The  veins  running  from  the  liver  to  the  umbilicus 
were  also  enlarged.  The  man  was  about  fifty-five 
years  of  age,  and  up  to  three  weeks  before  admission 
had  been  able  to  work.  Nevertheless,  the  autopsy  had 
shown  advanced  cirrhosis  and  advanced  change  in  the 
portal  circulation.  The  explanation  probably  was  to 
be  found  in  the  existence  of  a  complete  collateral 
circulation.  The  operative  cases  in  which  a  collateral 
circulation  had  been  established  had  usually  been  re- 
lieved for  a  number  of  years.  This  operation  con- 
sisted in  stitching  the  omentum  to  the  abdominal  wall, 
and  thereby  short-circuiting  the  portal  circulation  into 
the  general  circulation  and  reducing  the  pressure  in 
the  portal  system. 

Metastatic  Epithelioma  in  the  Heart. — Regard- 
ing this  case  the  speaker  said  that  the  peculiar  feature 
was  that  there  were  no  other  metastases  in  any  part  of 
the  body.  The  patient  was  a  man  who  had  previously 
had  the  tongue  removed  for  epithelioma.  The  tumor 
had  recurred  in  the  supraclavicular  lymphatic  nodes, 
and  death  had  finally  resulted  from  pressure  on  the 
trachea.  'I'he  autopsy  had  revealed  infiltration  of  the 
tissues  of  the  neck  and  involvement  of  the  lymph 
nodes  in   the  anterior  mediastinum.     Examination  of 


the  heart  showed  metastases  deep  in  the  muscle,  and 
also  superficially  in  the  fat  on  the  line  of  the  vessels. 
'I'hey  were  probably  embolic  in  origin.  This  condi- 
tion of  the  heart  had  given  rise  to  no  .symptoms. 

Dr.  L.  A.  Conner  said  that  he  had  been  deeply  in- 
terested in  the  diffuse  sarcoma  of  both  kidneys.  He 
had  not  realized  before  that  it  was  possible  for  such  a 
growth  of  sarcoma  to  involve  the  kidney  and  still  the 
markings  to  be  preserved  so  well.  This  fact  led  him 
to  suspect  that  there  might  be  some  other  explanation. 

Dr.  VN'ood  replied  that  the  picture  under  the  micro- 
scope showed  plainly  that  the  cells  had  infiltrated  the 
spaces  between  the  tubules,  and  left  a  fairly  good  tis- 
sue between.  The  same  thing  was  seen  sometimes 
in  cases  of  nephritis  and  also  in  the  involvement  of 
other  organs.  He  did  not  assume  that  the  tumor  was 
primary  in  the  kidneys. 

Dr.  E.  Libman  said  that  last  spring  he  had  pre- 
sented some  cases  of  sarcoma  cf  the  intestine.  In 
one  of  these  the  kidneys  had  been  infiltrated  in  ex- 
actly the  same  manner,  as  shown  by  both  gross  and 
microscopical  examination. 

A  Case  of  Pulmonary  Stenosis  due  to  Ulcerative 
Endocarditis  of  Aortic  Valve. — Dr.  E.  Libman  pre- 
sented this  case.  The  patient  was  a  man  twenty-one 
years  of  age,  who  had  been  well  up  to  May,  1897, 
when  he  had  suddenly  lost  the  sight  of  the  right  eye. 
He  had  recovered,  some  weeks  later,  sufficiently  to  be 
able  to  read  large  letters.  Three  months  afterward  he 
had  lost  the  power  of  speech  for  twelve  hours.  On 
October  26,  1897,  while  sitting  in  a  chair  he  had  be- 
come paralyzed  on  the  left  side  and  totally  uncon- 
scious. On  admission  to  the  Mount  Sinai  Hospital 
the  following  day  he  was  found  to  be  hemiplegic  and 
unconscious.  The  left  ventricle  was  distinctly  hyper- 
trophied.  There  was  a  rough,  blowing  systolic  mur- 
mur at  the  apex,  transmitted  slightly  to  the  left. 
There  was  a  very  loud  systolic  murmur  over  the  aortic 
valve,  which  was  transmitted  upward  and  downward, 
and  accompanied  by  a  very  marked  thrill  in  both 
the  carotids  and  subclavian  veins.  There  was  no  ele- 
vation of  temperature  at  this  time,  but  about  two  weeks 
later  he  developed  a  fever,  and  this  continued  up  to 
the  time  of  his  death.  Six  days  before  death  a  blood 
culture  (blood  from  vein)  showed  the  presence  of  the 
staphylococcus  albus.  Two  days  before  death  a  sys- 
tolic murmur  and  thrill  developed  in  the  pulmonary 
region,  and  were  entirely  distinct  from  those  in  the 
aortic  region.  The  second  pulmonic  sound  did  not 
diminish  in  intensity.  The  clinical  diagnosis  was 
ulcerative  endocarditis  of  the  aortic  and  pulmonary 
valves  successively.  Petechia;  developed  over  the 
body.  A  culture  from  the  heart's  blood  made  directly 
post  mortem  after  burning  the  skin  also  showed  the 
staphylococcus  albus.  The  post-mortem  showed  the 
right  ventricle  very  markedly  hypertrophied.  The 
aortic  valve  was  ulcerated,  and  in  the  free  edge  of  two 
of  the  flaps  and  part  of  the  third  there  were  large 
vegetations.  The  sinuses  of  Valsalva  were  filled  with 
vegetations.  In  the  interventricular  septum  back  of 
the  aortic  valve  there  was  an  enormous  hemorrhagic 
swelling,  which  almost  entirely  occluded  the  pulmo- 
nary artery.  Cultures  from  the  vegetations  and  the 
centre  of  the  swelling  showed  the  staphylococcus 
albus.  Spreads  from  the  soft,  purulent  centre  of  the 
swelling  showed  numerous  staphylococci. 

Dr.  G.  Lancmann  said  that  all  these  or  similar 
cases  were  mostly  classified  under  the  name  of  aneu- 
rism of  the  heart  wall  or  septum,  although  they  surely 
did  not  form  a  true  aneurism.  Their  origin  was  justly 
attributed  to  an  infection  of  the  heart  wall  continu- 
ously hit  by  the  infected  valve. 

Dr.  Libman  replied  that  the  stenosis  had  been 
due  to  the  aortic  endocarditis,  as  the  latter  had  caused 
an  enormous  inflammatory  swelling  in  the  septum. 


November  24,  1900] 


MEDICAL    RECORD. 


855 


I 


Dr.  James  Ewing  asked  what  significance  was 
attached  to  the  presence  in  these  cultures  of  the 
staphylococcus  albus.  It  seemed  to  him  this  might 
have  been  an  accidental  germ  in  the  circulation,  or 
the  specific  cause  of  the  endocardial  lesion,  or  possi- 
bly a  contamination  of  the  culture.  It  was  also  pos- 
sibly the  result  of  an  ante-mortem  invasion  of  the 
blood  by  these  germs. 

Dr.  Libman  said  that  there  was  an  old  endocarditis. 
Out  of  one  hundred  and  fifty  blood  cultures  he  had 
never  met  with  the  staphylococcus  albus  as  a  contam- 
ination. From  the  technique  employed,  both  during 
life  and  at  the  autopsy,  he  felt  positive  that  the 
staphylococcus  albus  was  the  specific  cause.  Fur- 
'  thermore,  he  had  found  bacteria  in  the  blood  (intra 
vitam)  in  fatal  cases  of  ulcerative  endocarditis,  when- 
ever cultures  had  been  made. 

Dr.  Conner  said  that  two  or  three  years  ago  he 
had  presented  an  aneurism  involving  one  of  the  si- 
nuses of  Valsalva,  and  producing  a  bulging  forward  of 
the  conus  of  the  pulmonary  artery,  and  causing  a  very 
marked  pulmonary  stenosis,  in  which  the  appearances 
were  strikingly  similar  to  those  of  the  present  case; 
There  appeared  in  the  specimen  just  presented  also  to 
be  a  laminated  clot. 

Dr.  Lib-Man  said  that  the  examination  seemed  to 
show  that  this  was  a  developing  abscess  of  the  heart 
muscle. 

Effects  of  Repeated  Intubation — Dr.  David 
BovAiRD  made  some  remarks  on  this  subject,  and  pre- 
sented illustrative  specimens.  He  said  that  in  some 
instances  it  was  necessary  to  practise  intubation  re- 
peatedly on  the  same  person.  In  one  case  occurring 
under  his  observation,  a  child  had  been  intubated 
forty  times,  yet  had  recovered.  The  first  specimen 
presented  had  been  taken  from  a  child  about  three 
years  of  age,  who  had  been  suddenly  seized  with 
croupy  cough  and  severe  dyspntea.  .\ntitoxin  liad 
been  given  promptly,  and  intubation  done  almost  im- 
mediately afterward.  A  few  days  after  the  tube  had 
been  removed,  but  recurring  stenosis  had  required 
intubation  again.  While  the  tube  was  still  in  place, 
the  child  had  developed  measles  and  then  pneumonia, 
and  had  died  as  a  result  of  these  complications.  At 
tlie  autopsy  there  had  been  found  at  the  base  of  the 
epiglottis  an  ulcer  of  considerable  size.  In  the  body 
of  the  larynx,  just  within  the  cricoid  ring  was  a  large 
and  deep  ulcer.  This  ulcer  involved  the  cricoid  car- 
tilage, severing  it  completely  in  front.  Farther  down 
in  the  larynx  and  near  the  trachea  were  two  small 
ulcers  corresponding  to  the  lower  end  of  the  intuba- 
tion tube.  The  ulcer  at  the  base  of  the  epiglottis 
represented  the  pressure  made  by  the  head  of  thistuije. 
The  ulcer  at  the  cricoid  cartilage  was  the  result  of  the 
pressure  of  the  body  of  the  tube.  The  second  speci- 
men had  been  taken  from  a  child  aged  six  montlis. 
This  child  while  recovering  from  measles  had  devel- 
oped stenosis.  A  tube  for  a  one-year-old  child  had 
been  inserted,  and  the  child  had  done  well  until  the 
removal  of  the  tube  at  the  end  of  five  days.  Intuba- 
tion had  been  required  at  the  end  of  twenty-four  hours, 
and  this  had  to  be  repeated  ever}'  two  days  for  sev- 
eral days,  and  then  almost  constant  re-intubation  had 
been  demanded  because  the  child  kept  coughing  out 
the  tube.  For  this  reason  a  tube  for  a  two-year-old 
had  been  inserted,  with  like  result.  A  tube  for  a 
three-year-old  had  then  been  introduced.  This  speci- 
men showed  large  and  d*p  ulcers  at  the  base  of  the 
epiglottis.  Nothing  could  be  found  representing  the 
cricoid  cartilage,  it  having  apparently  been  absorbed 
by  reason  of  pressure.  There  were  three  ulcers  corre- 
sponding to  the  points  of  pressure  of  the  lower  end  of 
tlie  tube.  In  both  specimens  it  was  interesting  to  note 
the  amount  of  injury  done  to  the  cricoid  cartilage. 
As  this  cartilage  was  not  only  a  support  for  the  larynx 


but  the  attachment  of  important  muscles,  it  was  evi- 
dent that  the  destruction  of  this  cartilage  would  be  in 
itself  sutlicient  to  explain  the  recurrent  stenosis  cf  the 
larynx,  the  muscles  by  which  the  glottis  might  be 
opened  no  longer  having  2,  point  d'appui. 

Cystic  Kidney. — Dr.  liovaird  also  presented  a  spec- 
imen of  congenital  cystic  kidney  removed  from  a  child 
aged  one  year,  dead  of  some  enteric  affection.  The  right 
kidney  was  the  one  involved.  On  the  other  side  the 
pelvis  of  the  kidney  was  found  dilated  and  filled  with 
gravel.  There  was  also  a  stone  of  some  size.  These 
conditions  on  the  left  side  suggested  a  possible  ex- 
planation of  the  cystic  degeneration  on  the  right,  that 
the  ureter  or  pelvis  of  the  kidney  had  been  blocked 
by  a  stone  and  the  cystic  degeneration  had  resulted 
from  the  obstruction.  \o  stone  or  gravel  could,  how- 
ever, be  found  on  the  right  side. 

Dr.  \V.  p.  .VoRTHRLi'  said  that  these  two  cases,  fol- 
lowing closely  after  measles,  suggested  the  explana- 
tion of  the  tissues  bre.iking  down  so  easily.  These 
cases  of  so-called  "  retained  intubation  tube '"  were 
both  of  comparatively  short  duration.  One  should 
bear  in  mind  the  behavior  of  measles  in  a  children's 
institution.  Such  children  got  up  pressure  necrosis 
on  the  back  of  the  head,  cancrum  oris,  necrotic  proc- 
esses on  the  fingers,  and  pressure  sores  on  various 
parts  of  the  body.  Their  tissues  had  diminished  re- 
sisting-power.  As  regarded  the  prolonged  retention 
of  intubation  tubes,  a  case  had  just  been  reported  in 
the  Aniiives  of  J'fiiui/rics,  October,  1900,  p.  737.  In 
this  case  there  had  been  subglottic  stenosis,  and  after 
repeated  intubations  and  extubations  in  the  hands  of 
a  novice,  the  tissues  had  been  denuded  and  had  then 
grown  together.  Ultimately  a  tracheotomy  had  been 
required,  and  the  child  had  died  from  pneumonia 
after  this  last  operation.  In  this  case  the  larynx  iiad 
presented  distinct  hour-glass  constriction,  and  com- 
plete atresia. 

Photomicrographs  of  Filaria  Sanguinis  Made 
with  a  Special  Lens. — Dr.  Buxto.n  exhibited  a 
series  of  photographs  taken  with  a  one-tenth  Spencer 
lens  from  specimens  mounted  in  balsam  and  examined 
through  '-t-brom-naphthalene  instead  of  oil  of  cedar,  as 
recommended  by  Dr.  Piffard.  Certain  new  striations 
appeared  in  some  of  the  photographs  taken  with  this 
lens. 

Dr.  E\vin(;  said  that  the  method  employed  had  de- 
veloped in  the  body  of  the  filaria  a  peculiar  cross  stri- 
ation,  which  was  evidently  part  of  the  structure  of  the 
capsule  of  the  filaria.  So  far  as  he  knew  it  had  not 
been  described  before,  and  certainly  had  not  been 
observed  in  any  previous  drawing  or  photomicrograph. 

Effects  of  Milk  Preserved  by  Formalin  upon 
Mice  and  Kittens. — Dr.  William  H.  Park  read  a 
paper  with  this  title.  He  said  that  the  addition  of 
formaldehyde  to  milk  made  the  proteid  material  some- 
what less  digestible.  The  jjroportion  required  to  pre- 
serve milk  was  about  i  :  50,000,  and  in  this  quantity 
digestion  might  be  retarded  about  ten  per  cent.  It 
was  not  contended  that  the  end  products  were  different, 
only  that  the  digestive  process  was  retarded.  Certain 
reported  investigations  seemed  to  leave  in  doubt  the 
question  of  the  effect  of  formaldehyde  on  small  ani- 
mals. In  one  series  small  gains  in  weight  were  noted 
in  kittens  and  rabbits,  and  a  slight  loss  in  a  guinea- 
pig  only.  .Another  investigator  had  used  three  or  four 
kittens  for  each  control,  and  had  experimented  with 
different  proportions  of  formaldehyde.  When  1:50,- 
000  formaldehyde  was  used,  one  of  the  kittens  died  in 
the  third,  and  two  in  the  fourth  week,  while  the  other 
two  gained  in  weight.  Of  four  kittens  getting  i  :  25,- 
000  formaldehyde,  all  gained.  Of  five  getting  1:12,- 
500,  two  died  in  the  fourth  week,  two  gained,  and  one 
lost.  All  the  control  kittens  were  reported  to  have 
gained — certainly  a  very  remarkable  showing.     It  had 


836 


MEDICAL    RECORD. 


[November  24,  igoo 


been  stated  that  1:50,000  retarded  the  increase  in 
weight  twenty-nine  per  cent.,  and  i  :  12,500  sixty-nine 
per  cent.  These  statistics  had  been  manipulated  in 
such  a  way  as  to  leave  grave  doubts  as  to  their  relia- 
bility. Dr.  Park  said  that  he  had  accordingly  experi- 
mented with  young  white  rats,  using  1  :  50,000,  1:10,- 
000,  and  I  :  i,ooo  solutions  of  formalin.  All  of  the  rats 
had  gained  in  weight  and  at  very  nearly  the  same  rate. 
A  series  of  experiments  had  then  been  undertaken  with 
cats,  using  pure  milk,  milk  containing  i  :  10,000,  and 
milk  containing  i  :  i,ooo  formalin.  At  first  they  were 
fed  on  pure,  selected  milk.  They  all  gained  on  this, 
but  the  I  :  1,000  much  less  than  the  :  :  10,000,  i  :  50,- 
000,  or  pure  milk  series.  Later  on  changing  to  ordi- 
nary milk  the  cats  lost  weight,  except  those  fed  on 
milk  containing  1  :  10,000  formalin.  The  explanation 
probably  was  that  the  ordinary  milk  in  the  hot  weather 
(August)  fermented  through  the  night  in  the  feeding- 
dishes,  except  the  milk  containing  i  :  10,000  or  more 
formalin.  Ordinary  store  milk  in  summer  contained 
not  only  great  numbers  of  bacteria,  but  also  the 
products  of  their  growth.  He  was  inclined  to  think 
that  among  the  poor,  who  could  not  keep  the  milk 
properly  cold  and  sweet,  it  might  be  well  during  the 
hot  months  to  introduce  into  the  milk  a  small  quan- 
tity of  formalin,  or  if  possible  a  better  preservative, 
and  label  such  milk  "  preserved  milk,"  because  it 
would  do  less  harm  in  the  milk  than  the  products  of 
fermentation. 

Dr.  Northrup  thought  the  question  propounded 
by  Dr.  Park  could  have  but  one  answer.  If  the  for- 
malin only  retarded  digestion,  then  it  would  certainly 
be  better  to  feed  this  to  children  than  to  give  them 
milk  containing  a  large  quantity  of  bacteria  and  all 
sorts  of  by-products.  If  it  were  simply  formalin  de- 
laying slightly  digestion,  against  milk  containing  bac- 
teria plus  the  never-to-be-forgotten  toxins  incidental 
to  such  growth,  the  answer  was  in  favor  of  the  lesser 
poison,  namely,  formalin.  The  great  trouble  was  to 
accomplish  this  without  opening  the  way  for  many 
abuses. 


NEW    YORK    NEUROLOGICAL    SOCIETY. 

Stated  Meeting,  Octohei-  2.  igoo. 

J.  Arthur  Booth,  M.D.,  Chairman  pro  tem. 

Periodical  Psychoses. — Dr.  A.  B.  Defendorf  read 
this  paper.  He  said  that  years  ago  all  forms  of  in- 
sanity were  looked  upon  as  more  or  less  periodical, 
but  gradually  this  list  had  been  reduced  to  periodical 
mania  and  periodical  melancholia.  The  English  and 
American  observers  had  been  slow  to  recognize  period- 
ical insanity.  The  records  of  hospitals  for  the  insane 
showed  it  to  constitute  a  not  inconsiderable  percen- 
tage of  cases  admitted,  coming  second  to  dementia 
precox.  These  cases  were  characterized  by  intense 
psychomotor  restlessness,  yet  they  exhibited  no  signs 
of  fatigue  after  weeks  or  months  of  excessive  motion. 
One  of  the  striking  features  of  this  form  was  that  con- 
sciousness continued  unclouded.  In  the  extreme 
maniacal  condition  called  delirious  mania  the  pa- 
tient's consciousness  of  surroundings  did  become 
clouded.  These  patients  were  rich  in  words  if  not  in 
ideas.  Delusions  when  present  were  transitory,  and 
were  usually  of  the  expansive  type.  They  were  happy 
and  contented,  yet  they  changed  very  suddenly  from 
happiness  to  melancholia  or  vice  versa.  In  the  de- 
pressive form  the  associations  of  ideas  showed  re- 
tardation, and  the  emotional  attitude  was  uniformly 
one  of  depression  or  despair.  More  or  less  .stable  de- 
lusions were  present.  Cases  would  be  found  showing 
both  the  maniacal  and  depressive  elements,  but  usu- 


ally one  or  the  other  predominated.  The  most  promi 
nent  etiological  factor  was  defective  heredity,  it  being 
found  in  from  seventy  to  eighty  per  cent.  Other 
causes  were  shock,  acute  diseases,  and  mental  strain. 
When  the  first  attack  occurred  after  childbirth  it  was 
apt  to  recur  with  each  succeeding  confinement,  and 
continue  after  the  climacteric.  The  first  attack  was 
apt  to  be  of  the  depressive  form.  More  than  half  of 
the  cases  occurred  before  the  age  of  twenty-five.  As 
the  attacks  were  repeated,  the  lucid  intervals  tended 
to  shorten.  During  these  intervals  the  mental  facul- 
ties were  fully  retained.  The  prognosis  of  the  psy- 
choses was  bad.  During  the  height  of  the  disease  or 
in  the  extremely  maniacal  or  depressive  forms,  death 
might  occur  from  exhaustion,  or  might  be  self-inflicted. 
The  author's  conclusions  were:  (i)  Periodical  in- 
sanity was  characterized  by  a  definite  symptomatology, 
which  permitted  of  differentiation  in  the  first 
attack;  (2)   it  was  a  prominent  psychosis. 

Dr.  B.  Sachs  said  that  while  all  recognized  that 
there  was  such  a  thing  as  periodical  insanity,  there 
was  danger  lurking  in  the  term,  because  almost  all 
forms  of  mental  phenomena  were  apt  to  exhibit  a  ten- 
dency to  recurrence.  For  this  reason  it  should  be  in- 
sisted that  there  must  be  a  regular  recurrence;  for 
instance,  of  mania  and  depression  with  perhaps  a 
lucid  interval.  It  was  rather  curious  that  those  de- 
scribing periodical  insanity  insisted  that  there  must 
be  marked  depression.  He  could  recall  a  case  of 
distinct  hypochondriasis  followed  by  a  lucid  interval 
of  seven  years  and  then  an  attack  of  pronounced 
melancholia.  There  was  again  a  lucid  interval  fol- 
lowed by  an  attack  of  mania.  Attention  was  called  to 
the  remarkable  suddenness  with  which  the  patient 
passed  from  one  state  to  another.  He  had  had  under 
observation  a  girl  who  had  been  in  a  state  of  depres- 
sion for  over  eight  months,  and  then  very  suddenly 
had  had  a  lucid  interval  lasting  one  year.  This  had 
in  turn  been  followed  by  acute  mania. 

Dr.  W.  D.  Granger  said  that  a  few  cases  of  un- 
doubted circular  insanity  were  so  decided  in  their 
symptoms  that  they  could  not  be  mistaken  for  any- 
thing else.  This  was  particularly  true  if  the  person 
was  seen  late  in  life,  and  had  a  history  of  recurrent 
attacks  extending  over  many  years.  There  were,  how- 
ever, many  cases  less  pronounced  in  type,  rendering 
it  difficult  to  classify  them.  He  had  personally  seen 
only  a  few  cases  of  circular  insanity.  He  had  never 
seen  the  sudden  changes  referred  to  by  the  last 
speaker,  nor  had  he  ever  seen  a  case  of  true  incoher- 
ence in  connection  with  circular  insanity.  He  had 
seen  several  cases  of  recurrent  insanity  in  which  there 
would  be  from  two  to  five  attacks  of  rather  mild 
melancholia.  He  had  had  a  young  lady  suffering 
from  this  form  of  insanity,  and  also  her  mother, 
brother,  and  sister.  The  sister  had  had  a  most  vio- 
lent mania,  proved  at  autopsy  to  have  been  a  compli- 
cation of  typhoid  fever.  She  had  had  periodical 
attacks  of  active  though  not  violent  mania.  Another 
form  of  the  circular  type  that  he  had  noticed  and  had 
never  seen  described  in  the  text-books  was  the  form  of 
chronic  mania  developing  in  the  last  few  years  of  life 
recurrent  attacks  of  mania  and  melancholia. 

Dr.  William  H.  Thomson  said  that  he  had  had 
under  his  continuous  observation  for  ten  years  a  case 
of  periodical  insanity,  and  probably  the  only  one  to 
which  he  would  be  willing  to  apply  the  term  period- 
ical insanity.  The  attacks  had  recurred  regularly 
every  other  day  all  these  years.  The  patient  was  a 
man  forty-eight  years  of  age  when  the  disease  had  first 
set  in.  There  was  no  hereditary  psychosis.  At  the 
beginning  he  had  been  attacked  with  melancholia, 
ancl  had  attempted  suicide.  Attention  had  been  early 
directed  to  the  fact  that  his  condition  was  worse  every 
other  day,  and  for  this  reason  he  had  had  most  thor- 


November  24,  1900] 


MEDICAL    RECORD. 


83; 


ough  and  persistent  antimalarial  treatment.  When 
first  seen  by  the  speaker,  liis  memory  had  been  good, 
and  he  had  been  in  no  way  irrational.  The  temper- 
ature liad  been  normal.  Tlie  next  day  his  temperature 
had  risen  to  101°  F.,  and  lie  had  become  delirious. 
On  the  following  day  his  condition  was  that  noted  at 
the  first  visit,  'i'he  febrile  symptoms  had  ceased  after 
about  three  months,  but  in  otiier  respects  the  patient  had 
kept  up  this  alternation  ever  since  that  time.  Exami- 
nation of  his  secretions  had  thrown  no  light  whatever 
on  the  etiology  of  his  singular  mental  disturbance. 
The  type  was  that  of  melancholia  with  excitement. 
He  had  never  been  truly  maniacal.  Regarding  peri- 
odical psychoses  in  general,  Dr.  Thomson  said  be 
could  not  agree  with  the  reader  of  the  paper  that  they 
constituted  such  a  definite  class,  for,  if  so,  they  should 
be  delinitely  periodical.  Another  case  was  then  cited, 
in  which  the  attacks  had  begun  with  talkativeness  and 
an  appearance  of  well  being,  which  would  last  for 
about  six  weeks,  and  would  be  followed  by  extreme 
mental  depression.  At  no  time  was  there  any  con 
fusion  of  personality  or  any  delusion.  The  attack  of 
mental  paresis  would  last  two  or  three  months,  and 
would  usually  come  on  every  winter.  Such  a  case 
seemed  to  him  a  true  example  of  periodical  psycho- 
sis, but  many  of  those  described  in  the  paper  seemed 
to  him  to  come  rather  under  the  head  of  relapsing  than 
periodical  insanity. 

Dr.  \\'ir,i.i.\M  iM.  Leszvnsky  said  that  no  one  could 
tell  at  the  first  attack  whether  there  would  be  recur- 
rence or  not.  With  a  good  previous  history  it  was  an 
entirely  different  matter. 

Dr.  L  Pierce  Clark  said  that,  while  in  a  hospital 
for  insane,  he  had  seen  a  case  of  intermittent  mental 
stupor  which  recurred  at  short  and  fairly  regular  inter- 
vals, thus  resembling  in  some  respects  the  case  re- 
ported by  Dr.  Thomson.  Such  cases  were  very  rare, 
only  six  being  on  record.  Sudden  transitions  were 
quite  characteristic  in  the  mental  disorder  first  de 
scribed  by  Charcot  in  connection  with  mental  epilepsy. 
Dr.  Defendorf  said  that  the  periodicity  was  the 
characteristic  of  tlie  whole  course  of  the  disease 
throughout  the  life  of  the  individual,  and  it  was  cer- 
tainly an  irregular  periodicity.  But  there  were  certain 
fundamental  symptoms,  such  as  the  condition  of  the 
memory,  the  tendency  toward  deterioration,  and  the 
character  of  the  delusions  and  hallucinations,  upon 
which  the  diagnosis  should  be  founded.  Relative  to 
the  sudden  transitions  from  one  state  to  another,  he 
said  that  this  occasionally  happened,  sometimes  over 
niglit. 

Status  Epilepticus  ;  its  Nature  and  Pathology. 
—  Drs.  L.  1'.  Cl.^rk  and  T.  P.  Prolt  presented  this 
paper,  Dr.  Clark  reading  the  clinical  portion.  About 
forty-five  cases  formed  the  basis  of  the  paper.  Un- 
fortunately only  five  cases  could  be  studied  histo- 
pathologically.  The  modern  notion  of  status,  it  was 
stated,  was  that  it  was  the  acme  or  true  climax  of  the 
disease,  and  not,  as  formerly  supposed,  a  chance  termi- 
nation of  epilepsy  that  by  proper  treatment  could  have 
been  avoided.  It  was  a  state  of  epilepsy  in  which  one 
seizure  followed  another  so  closely  tliat  the  previous 
psychical  exhaustion  was  not  recovered  from.  One 
patient  at  the  Craig  colony  for  epileptics  had  three  hun- 
dred and  eighty-four  typical  psychic  seizures  in  one 
day.  It  occurred  with  about  equal  frequency  in  all 
the  different  forms  of  epilepsy  except  that  dependent 
upon  organic  brain  disease.  The  latter  constituted 
one- half  of  all  the  cases  of  status.  Exhaustion  paral- 
ysis was  very  characteristic  of  status.  No  foundation 
had  been  discovered  for  the  statements  of  some  writ- 
ers that  either  age  or  sex  exerted  any  influence.  Ac- 
cording to  the  authors'  experience,  the  shortest  interval 
had  been  in  those  developing  their  epilepsy  between  the 
ages  of  ten  and  sixteen  years.     On  an  average,  eleven 


years  elapsed  between  the  beginning  of  the  epilepsy 
and  the  occurrence  of  status.     Menstruation  in  women 
did  not  seem  to  be  productive  of  status.     In  the  great 
majority  of  cases  the  approach  of  status  was  denoted 
by  a  steady  increase  in  the  frequency  of  the  epileptic 
seizures.     They  had  seen  three  hundred  attacks  a  day 
in  several  cases,  and  still  recovery  had  occurred.     One 
patient  had  had  status  epilepticus  for  twelve  days,  and 
had  recovered,  having  had  during  this  time  eighteen 
hundred  seizures.     The  temperature  elevation   in  sta- 
tus usually  began  after  the  first  severe  convulsion,  and 
there  was  usually  a  direct  ratio  between  the  number 
and  severity  of  the  convulsions  and  the  elevation  of 
temperature.     'Ihe  record  of  the  pulse,  temperature, 
and  respiration  frequency  gave  the  best   indication  of 
the  severity  of  the  status.     Generally  the  maximum  of 
the  fever  marked  the  maximum  of  the  seizures,  and  if 
the  fever  persisted  after  this,  one  should  be  led  to  sus- 
pect some  complication.     Occasionally  the  (ever  sub- 
sided by  crisis.    Occasionally  also  the  temperature  rose 
to  107''  or  108    F.      As  to  the  cause  of  the  fever  curve, 
the  paper  stated  that  some  looked  upon  the  elevation  of 
temperature  as  purely  psychical,  while  others  believed 
it  was  the  result  of  a  direct  action  on  the  heat  centre. 
The  pulse  rale   increased  in  frequency  with  each   at 
tack,  but  the  pulse  curve  usually  ran  nearly  parallel  to 
the  temperature  curve,  though  responding  more  slowly 
on   recovery  from   status.     Almost    always  there  was 
Cheyne-Stokes  respiration,  but  it  was  not  so  unfavor 
able   a  symptom   as  in  some  other   disorders.      Hoth 
pneumonia  and  pleurisy  were  fairly  frequent  compli 
cations.     The    prognosis   of    status    was    necessarily 
grave.     A  low  temperature  was  supposed  to  be  a  fair 
sign,  though  there  might  be  recovery  after  a  tempera- 
ture of  107.5°  F.     Paralysis  of  the  muscles  of  deglu 
tition   was    a  very   unfavorable    sign.     The   gradual, 
steady    increase    in    the    symptoms    was    the     most 
unfavorable  sign  of  all.     Many  patients  had  a  record 
of  two  to  five  status  periods,  and  it  was  probable  that 
the  mortality  did  not  exceed  twenty-five   per  cent.     It 
was  possible  to  abort  a  case  of  status,  if  taken  in  time, 
and  certainly  the  present  mortality  should  be  reduced. 
The  plan  of  treatment  pursued  in  the  cases  mentioned 
in  the  paper  was  as  follows.     At  the  outset  the  patient 
was  given  a  dose  composed  of  gr.  xxv.  of  bromide,  gr. 
XX.  of  chloral,  and  a  large   dose  of  opium    and   mor- 
phine.    If  the  convulsions   were   not   controlled,   gr. 
XXX.  or  xl.  of  chloral  were  given  by  the  rectum,  and  if 
this  was  not  sufficient,  bioniide  was  given   h}poder- 
mically  in  a  part  of  the  body  that  would  be  the  least 
painful   if  abscesses  formed,  as  they  often  did   after 
such   injections.     The   latter  were   very   painful,  and 
should  be  given  only  in  the  stuporous  stage.     They 
usually  controlled  the  condition.     Dr.  Prout  ihen  took 
up  the  pathological  side  of  the  subject.      He  said  that 
the  modern  belief  was  that  the  epileptic  storm  had  its 
seat    inr  the   cortex.     Recent    experimental    research 
seemed    to    warrant    the    following    conclusions;  (i) 
That    the    transmission    of    the  impulse    in    epiltpsy 
was  through   the  extra-pyramidal  tracts  which   trans- 
mitted  motor  reflex   impulses;    (2)  that  the   sensory 
portions  must  be  irritated  in  order  to  produce  the  fit, 
and  (3)  the  fit  appeared  to  be  a  complex  reflex  phe- 
nomenon.    The    paper   was    founded    on    a    study  of 
thirteen  cases.      In  all  but  two  the  post-mortem  exami- 
nation was  made  within  seven  hours  after  death.     T  he 
changes  found   in  the   brain  were  by  far  the  most  pro- 
nounced  in  the  status  cases.     The  degree  of  thtoma- 
tolysis  seemed  to  depend  upon  the  number  and  sever- 
ity of   the  convulsions.      In  the   cells  of  the  second 
layer  the  nucleus  was  swollen  markedly;  the  nuclear 
membrane  was  hazy  and  indistinct,  and  the  nucleolus 
was  frequently  replaced  by  a  granular  mass.     These 
changes  were  especially  numerous  in  the  status  cases. 
Many  nucleoli  were  found  far  removed  from  the  cells 


838 


MEDICAL    RECORD. 


[November  24,  1900 


to  which  they  belonged.  He  had  examined  the  nor- 
mal human  brain  with  regard  to  tliis  nucleolar  extru- 
sion, and  had  found  it  comparatively  infrequent. 
Leucocytes  clinging  to  degenerated  nerve  cells  were 
also  very  frequently  observed.  The  neuroglia  was 
studied  in  seven  cases,  and  the  conditions  were  found 
to  vary  a  good  deal.  A  broadening  of  the  outer  cor- 
tical layer  was  fairly  constant,  and  occurred  apparent- 
ly at  the  expense  of  the  cortical  layer.  The  condition 
of  the  neuroglia  seemed  to  depend  largely  upon  the 
condition  of  the  epilepsy.  It  was  more  pronounced 
in  the  insane  epileptic  than  in  cases  of  simple  epi- 
lepsy. When  morbid  processes  attacked  the  nucleus 
the  vitality  of  the  cell  itself  was  endangered.  The 
increase  in  the  neuroglia  was  the  result  of  nerve-cell 
destruction.  The  authors'  conclusions  were:  (i)  it 
would  seem  that  epilepsy  was  essentially  a  sensory 
phenomenon;  (2)  the  essential  lesion  pertained  to  the 
nucleus  of  the  cortical  ceM  and  jeopardized  the  cell; 
(3)  the  chromatolysis  was  probably  a  nutritional 
change  brought  about  by  the  jeopardization  of  the 
nucleus;  (4)  the  role  of  the  leucocyte  in  the  cortex 
after  severe  convulsions  was  most  probably  that  of  the 
phagocyte;  (5)  the  neuroglia  proliferation  in  epilepsy 
was  one  of  the  more  remote  sequences,  and  (6)  epi- 
lepsy was  a  progress've  disease  of  which  status  was 
the  climax. 

Dr.  Schlapp  said  that  he  had  had  occasion  to  treat 
two  cases  of  status  the  past  summer,  and  both  patients 
had  recovered.  One  patient  had  had  thirty  attacks  in 
eight  hours.  She  had  then  become  stupid  and  had 
finally  developed  hallucinations,  the  whole  condition 
lasiing  two  weeks.  In  both  of  the  cases  there  was 
such  a  large  quantity  of  albumin  in  the  urine  that  the 
latter  became  solid  on  boiling.  He  thought  this  con- 
dition was  commonly  present  in  status.  He  did  not 
think  it  was  riglit  to  assume  that  the  second  or  third 
layer  of  cells  could  be  taken  as  sensory  cells,  so 
much  depended  upon  the  particular  region  of  the 
brain.  Most  of  these  cells  were  now  looked  upon  as 
associated  cells,  thus  opposing  the  theory  of  Bruce. 

Dr.  Defendorf  asked  regarding  the  temperature  of 
the  patient  dying  of  status.  He  had  had  an  oppor- 
tunity of  studying  two  cases,  and  in  both  there  had 
been  what  had  been  called  "acute  alteration."  This 
was  often  found  in  other  conditions,  particularly  when 
there  had  been  high  temperature. 

Dr.  Sachs  asked  whether  in  these  cases  of  status 
epilepticus  gross  changes  had  been  found  that  might, 
in  some  way,  have  been  accountable  for  these  cell 
changes.  A  number  of  years  ago  he  had  examined 
the  brain  of  a  child  dying  in  status,  and  the  one  con- 
dition found  at  that  time  had  been  a  very  large  sub- 
pial  hemorrliage  covering  almost  the  entire  brain. 
He  would  like  to  know  whether  in  the  brains  examined 
by  Dr.  Prout  similar  conditions  had  been  found.  If 
they  had,  it  did  not  seem  to  him  fair  to  determine  the 
true  pathology  of  epilepsy  from  patients  who  had  died 
in  status.  A  truer  knowledge  of  this  pathology  should 
be  obtained  from  a  study  of  the  iirains  that  had  not 
undergone  such  secondary  changes.  The  plates  ex- 
hibited showed  cellular  changes  such  as  had  been  re- 
ported in  a  number  of  very  widely  different  diseases 
of  the  brain. 

Dr.  Schlapp  said  that  he  had  recently  seen  a  case 
presenting  hemorrhages  throughout  all  the  membranes. 

Dr.  Leszynskv  said  that  fifteen  ye.irs  or  more  ago 
he  had  published  a  paper  entitled,  "  Epilepsy  as  a 
Cause  of  Diath."  In  every  one  of  the  cases  coming 
to  autopsy  there  had  been  intense  venous  stasis,  and 
in  some  a  few  small  hemorrhages.  One  or  two  of 
these  patients  died  within  two  hours,  and  one  after  a 
single  convulsion.  A  very  competent  pathologist  had 
made  the  autopsies.  At  that  time  the  most  successful 
method  of  treatment  of  these  cases   had  been   early 


venesection,  and  he  had  seen  no  reason  to  change  his 
view  regarding  the  efticacy  of  this  treatment.  The 
injection  of  chloral  into  the  rectum  was  certainly  very 
satisfactory.  He  had  practised  venesection  because 
of  the  intense  venous  stasis,  not  only  found  at  autopsy 
but  seen  in  the  face  of  the  patient. 

Dr.  L.  p.  Clark  said  that  albuminuria  had  been 
frequently  observed  in  the  cases  that  they  had  studied, 
yet  the  quantity  of  albumin  had  varied  greatly,  and 
had  not  been  at  all  in  proportion  to  the  severity  of  the 
seizures.  In  most  of  their  cases  there  had  been  no 
systematized  delusions  present,  and  the  delirium  had 
resembled  that  of  typhoid.  A  very  large  number  of 
gross  lesions  had  been  found  as  the  result  of  the  sever- 
ity of  the  convulsions.  He  had  seen  intense  venous 
engorgement  and  hemorrhages,  though  sometimes  these 
had  been  absent  in  very  severe  cases  of  status. 

Dr.  Prout,  in  closing,  said  he  did  not  wish  to  be 
understood  as  saying  that  the  invasion  of  the  cortex 
with  leucocytes  was  characteristic  of  epilepsy.  It  was 
well  known  that  such  an  invasion  was  marked  in  gen- 
eral paresis.  He  had  only  ment'ioned  the  fact  as  show- 
ing that  the  leucocyte  was  carrying  off  effete  material. 
In  speaking  of  the  cells  of  the  second  layer  he  had 
referred  to  them  as  sensory,  in  contradistinction  to 
those  which  we  were  accustomed  to  associate  with 
motor  phenomena.  He  did  not  think  it  had  been 
conclusively  shown  that  these  cells  were  associational 
in  character.  Many  of  the  sections  figured  in  the 
plates  showed  the  presence  of  punctate  hemorrhages. 


^eitj  Instrumcwts. 

A    NEW   VAGINAL    DOUCHE. 
By   GEORGE    H.    TUTTLE,    M.D., 

EAST    CAMDRIDCE,    MASS. 

The  use  of  hot  water  in  the  vaginal  canal  for  the  re- 
lief of  congestion,  inflammation,  and  hemorrhage, 
dates  back  far  into  the  past.  It  has  been  proved  con- 
clusively by  Dr.  Murray,  of  Edinburgh,  that  the  pro- 
longed use  of  hot  water  (100°  F.  or  more)  produces  a 
tonic  contraction  of  the  blood-vessels  followed  by  a 
very  slow  relaxation  of  the  same.  Davenport,  of  Bos- 
ton, states  that  three  conditions  are  necessary  to  pro- 
duce this  result:  the  water  must  be  fairly  hot;  it 
must  be  brought  thoroughly  in  contact  with  the  mucous 
membrane  of  tiie  whole  vagina;  and  the  application 
must  be  a  prolonged  one. 

To  meet  tiiese  requirements  Professor  Baker,  of 
Boston,  devised  the  method  now  in  use,  in  which  a 
six-quart  pail  and  a  douche  pan  are  employed.  The 
patient  lies  in  bed  with  the  hips  elevated,  for  a  period 
of  fifteen  to  twenty  minutes,  wiiile  six  quarts  of  water 
pass  in  aiid  out  of  the  vaginal  canal.  It  is  evident 
tliat  in  using  this  method  the  patient  must  lie  in  bed, 
a  special  apparatus  must  be  used,  a  nurse  is  almost  a 
necessity.  Furthermore,  if  the  hips  are  raised  the 
gravity  of  the  uterus  carries  it  backward  toward  the 
peritoneal  cavity,  and,  to  some  extent,  removes  its  body 
from  the  effects  of  the  hot  water. 

It  is  intended  by  this  new  device  to  produce  the 
desired  effects  with  an  ordinary  two-quart  syringe- 
having  a  special  attachment — while  the  patient  sits  at 
her  ease  on  a  closet  seat  or  chamber  vessel. 

Tlie  mechanism  and  action  of  the  new  device  are  as 
follows:  Tlie  douche  bag  is  simply  one  of  a  set  of 
syringe  attachments.  Ii  is  funnel-shaped,  made  of  the 
finest  rubber,  about  two  and  ont-half  inches  long,  and 
very  flexible.  At  its  fundus  are  a  series  of  pin-holes, 
hardly  distinguishable  by  the  eye.  The  smaller  end 
of  the  bag  is  stretched  over  the  vaginal  tube  and  held 


November  24,  igoo] 


MEDICAL   RECORD. 


839 


there  by  winding  soft  string  about  it.  The  bag,  being 
very  (iexible,  is  doubled  about  the  hard-rubber  tube 
for  insertion.  After  insertion  the  douche  bag  slowly 
fills  with  water  and  minu*e  streams  issue  from  the  pin- 
holes much  as  water  does  from  a  Hower-pot  sprinkler. 
The  weight  of  the  water  in  the  bag  causes  it  to  settle 
until  it  acts  as  a  perfect  stopper  of  the  vaginal  outlet. 
The  walls  of  the  vagina  are  pressed  apart  by  the  ex- 
panding b.ig,  and  the  folds  and  wrinkles  of  the  mucous 
membrane  are  spread  open  still  more  by  the  inflowing 
water.  This  influx  continues  until  the  force  of  the 
water  from  the  fountain  bag  is  equalized  by  the  vari- 
ous forces  at  work  within  tlie  vagina,  i.e.,  elasticity  of 
the  rubber,  contraction  of  the  vaginal  muscles,  and  the 
gravity  of  the  water  both  within  and  without  the 
douche  bag.  Thus  for  a  time  things  remain  nearly 
stationary,  and  the  uterus,  falling  to  the  lowest  possi- 
ble point,  is  bathed  in  the  supernatant  hot  water. 
After  four  or  five  minutes  the  patient  pushes  the  hard- 
rubber  nozzle  inward— loosening  the  stopper — so  as 
to  let  out  the  water  which  has  cooled  somewhat;  then, 
by  replacing  the  bag  as  before,  a  new  accumulation 
takes  place,  and  so  on  until  two  quarts  of  water  have 
,    ,  been     used.       It 

takes  fifteen  to 
twenty  minutes  to 
use  up  the  full 
amount  of  water. 
In  this  way  both 
a  cleansing  and 
a  poulticing  or 
parboiling  effect 
is  produced.  At 
the  end  of  the 
douche,  the  foun- 
tain bag,  which 
has  been  sus- 
pended from  a 
nail  about  one 
and  one-half  feet 
above  the  pa- 
tient's head,  is 
lowered  to  a 
point  below  the  level  of  the  vagina,  whereupon  the 
douche  bag  is  emptied  and  falls  out  of  itself. 

This  douclie  may  also  be  used  with  the  patient  in  a 
recumbent  position,  i.e.,  in  bed-ridden  cases,  'ihen  a 
douche  pan  is  necessary,  but  while  taking  the  douche 
the  shoulders  of  the  patient  should  be  raised  by  pil- 
lows, and  not  the  hips  as  in  Baker's  metiiod.  In  this 
way  the  weight  of  tiie  uterus  carries  it  downward  as 
far  as  possible  into  the  warm  water. 

I  have  used  these  bags  in  sixteen  cases  with  much 
satisfaction  to  the  patients  and  myself.  These  cases 
included  leucorrhcea,  abortions  with  hemorrhage  and 
retained  membranes,  intermenstrual  hemorriiages,  dys- 
menorrhoea,  and  subinvolution.  I  have  also  obtained 
good  results  in  cystitis  and  inflamed  or  bleeding  hem- 
orrhoids, and  should  expect  good  results  in  pelvic 
peritonitis,  etc.  I  should  think  that  this  bag  with 
slightly  larger  pin-holes  might  be  used  in  the  rectum 
when  it  is  desired  to  give  extra  large  rectal  injections 
and  have  them  retained. 


I 


Deaths  from  Consumption.— Last  year  in  the  Do- 
minion there  were  three  thousand  more  deaths  from 
consumption  than  from  all  other  infectious  diseases. 
In  Ontario  one  person  in  every  one  thousand  of  the  pop- 
ulation dies  annually  from  consumption.  Last  year 
the  province  lost  twenty-five  hundred  wage-earners 
from  this  disease,  which  means  a  direct  loss  of 
$2,500,000  and  an  indirect  loss  of  an  almost  incalcu- 
lable sum  besides.  —  Dr.  T.  V.  Hutchinson,  Dominion 
Medical  Monthly,  October. 


The  Ligature  and  the  Value  of  Dry,  Sterilized 
Catgut.— Dr.  J.  II.  Carstens  (The  Stylus,  October) 
makes  the  following  points  about  the  dry,  sterilized 
catgut  ligatures:  (i)  AH  buried  ligatures  ought  to  be 
absorbable.  (2)  All  absorbable  sutures  must  be  abso- 
lutely sterile.  (3)  Chemicalized  sutures  art  no  more 
sterile  than  plain  sutures.  (4)  A  suture  that  is  chem- 
icalized is  harder  and  remains  longer  in  the  tissues. 
(5)  This  latter  is  no  advantage,  but  a  disadvantage. 
If  in  a  special  case  it  is  desirable  that  a  suture  should 
remain  longer,  dry  sterilized  kangaroo  tendon  can  be 
used. 

Intussusception. —  Dr.  A.  Primrose,  in  the  Canadian 
Journal  oj  Medieine  and  Surgery,  November,  says  that 
one  must  remember  the  rare  possibility  of  spontaneous 
cure  in  intussusception.  The  intussusceptum  may  be 
cast  off  in  a  gangrenous  condition  and  passed  per 
rectum.  Recently  a  Russian  surgeon,  Segal,  reported 
a  case  of  this  character  occurring  in  a  man  fifty-six 
years  old,  in  whom  an  intussusception  occurred  and 
was  cured  spontaneously,  the  patient  having  passed 
per  rectum  large  portions  of  the  intussusceptum. 

Hernias  coexisting  with  adherent  omentum  are 
never  safe,  and  especially  so  in  men  of  active  life  and 
habits.  In  these  cases  it  is  always  best  to  advise 
operation. — In  Cancer  of  the  Breast  the  presence  of 
a  large  amount  of  fat  renders  less  easy  a  thorough 
removal  of  the  glands.  Hence  the  prognosis  of  cure 
or  prolonged  survival  must  be  more  guarded  in  fat 
than  in  lean  women.-  In  All  Plastic  Operations  it  is 
important  to  remove  the  stitches  as  soon  as  possible. 
If  left  too  long  in  the  skin  they  will  cause  tlie  forma- 
tion of  small  scars,  while  if  the  operation  has  been 
through  mucous  membranes  the  cutting  through  of 
stitches  causes  the  formation  of  little  tags. — Clubbed 
Fingers.  Sickly,  pale  children  with  clubbed  fingers 
may  have  chronic  bone  disease,  or  bronchiectasis,  or 
congenital  heart  trouble,  but  in  the  great  majority  of  in- 
stances there  is  an  empyema,  and  hence  the  necessity 
of  always  carefully  examining  tlie  lungs  in  this  class 
of  children.— Rectal  Exploration.  When  investigat- 
ing the  rectum  with  a  long  bougie  it  is  always  well 
to  remember  tiiat  there  are  two  possible  sources  of 
error.  In  the  first  place  tlie  instrument  may  so  double 
over  that  a  mistaken  idea  of  the  length  of  tlie  channel 
will  arise.  On  the  other  hand,  the  bougie  may  be 
arrested  by  one  of  Houston's  folds,  thus  simulating  a 
stricture. — Cancer.  It  is  permissible  to  do  an  incom- 
plete operation  for  cancer  only  when  it  is  know  ingly 
performed  with  the  object  of  relieving  pain,  soothing 
the  imagination  by  giving  the  patient  a  faint  hope,  and 
getting  rid  of  a  loathsome  sore,  and  because  we  know 
that  recurrence  in  a  scar  is  usually  much  less  painful 
than  the  original  ulcerative  process. — Pain.  In  the 
diagnosis  of  malignant  tumors  it  is  well  to  recollect 
that  the  element  of  pain  is  quite  an  uncertain  one. 
Sarcomata,  for  instance,  are  usually  less  painful  than 
carcinomata,  and  yet  we  occasionally  encounter  cases 
of  painless  carcinomata  of  various  regions.  In  some 
instances  of  adenoma  the  pain  may  he  just  as  severe 
as  in  either  of  the  other  two.-  Aneurism,  In  the 
presence  of  large  aneurisms  of  important  vessels  it 
is  well  to  remember  that  operation  is  most  likely  to 
succeed  when  the  occurrence  is  recent,  when  there  is 
no  evidence  of  aortic  or  mitral  disease,  when  there  is 
an  absence  of  the  rasp  sound  along  the  aorta,  which 
would  indicate  extensive  atheroma,  and  when  there  is 
no  important  visceral  disease. — International  Journal 
oJ  Surgery,  2io\emhei.  . 


840 


MEDICAL    RECORD. 


[November  24,  igoo 


^edical  |tcms. 

Contagious  Diseases — Weekly  Statement. — Report 
of  cases  and  deaths  from  contagious  diseases  reported 
to  the  Sanitary  Burea.u,  Health  Department,  for  the 
week  ending  November  17,  1900: 


Tuberculosis 

Typhoid  fever 

Scarlet  fever 

Measles 

Diphtheria 

Laryngeal  diphtheria  (croup) 
Cerebro-spinal  meningitis. . . . 

Varicella 

Smallpox    


292 
S6 

147 
17 

91 

I 

53 
226 

3 
25 

16 

14 

0 

5 

12 

0 

I 

0 

Deaths. 


Malaria  has  not  received  its  share  of  attention  in 
the  etiology  of  acute  nephritis. — J.  W.  Kelly. 

Preservative  Injection  for  the  Embalming  of 
Human  Bodies. — 

IJ  Sodium  arsenate 2  kgm. 

Aq.  bul 7.S50  c.c. 

Boil  until  complete  solution,  then  add 

Glycerin 2,000     " 

Formaldehyde   10G-150     " 

— Dr.  a.  Hewson,  Philadelphia  Medical  Journal, 
October  27  th. 

Diabetic  Coma Dr.  John  S.   Ely   (  Yale   Medical 

Journal,  October)  says:  "I  would  warn  against  too 
precipitate  withdrawal  of  carbohydrates  from  patients 
suffering  from  diabetes.  In  a  number  of  cases  this 
has  been  speedily  followed  by  the  development  of 
coma,  probably  because  of  the  readiness  with  which 
proteid  food  yields  acids  in  the  course  of  its  decom- 
position. To  avoid  this  the  alkaline  treatment  should 
be  instituted  prior  to  the  reduction  of  carbohydrates, 
and  these  should  then  be  gradually  withdrawn." 

Measles. — In  a  study  of  one  hundred  and  forty 
cases  of  measles,  with  reference  to  the  appearance  and 
value  of  Ko|5lik's  spots  as  a  diagnostic  signs.  Dr. 
William  J.  Maroney  (  y<th'  Medical  Journal,  October) 
gives  tlie  following  table  which  sums  up  the  results  of 
his  examinations: 


Time  of  Recognition. 

Cases 

Remarks. 

At  the   beginning  of 

the 

53 

In  the  large  majority  of  these  the 

eruption. 

children  did  not  come  under 
the  observation  of  the  physi- 
cian until  after  the  appearance 
of  the  eruption. 

Twenty-four  hours  before 

51 

Slight  fever,  ranging  from  go"  to 

the    appearance   of 

the 

101'  F.,  was  present  in  all  the 

eruption. 

fifty-one  cases.     Slight  coryza 
and   conjunctivitis    in    thirty- 
five. 
Slight    fever    as  above,    but    no 

Forty  eight  hours    before 

20 

the   appearance   of 

the 

coryza. 

eruption. 

Three  days  before  the 

ap- 

4 

.Slight    fever   as    above,   but    no 

pearance   of   the  erup- 

coryza. 

tion. 

Four  days  before  the 

ap- 

2 

Slight  fever  as   above,    but   no 

pearance   of   the   erup- 

coryza 

tion. 

Spots    observed,   but 

no 

2 

Both    children    were   very   deli- 

eruptions. 

cate.  Hyperpyrexia,  etc.. 
intervened  and  death  occurred 
in  a  few  davs. 

No  spots  observed  .  . 

8 

In  four  of  these  the  children  were 

marantic,      with       very      dry 

mouths.       Two  had  aphthous 

stomatitis  covering  the  mucous 

membrane. 

Health  Reports. — The  following  cases  of  smallpox, 
yellow  fever,  cholera,  and  plague  have  been  reported 
to  the  surgeon-general  of  the  United  States  Marine- 
Hospital  service  during  the  week  ended  November 
17,  1900 : 

Cases.    Deaths. 
Smallpox— United  States. 


Colorado,  total  for  the  State. 
District  of  Columbia,  Wash- 

inj,;ton 

Iowa,  Dcs  Moines 

Kansas,  Wichita 

Total  for  the  State. 

Kentucky,  Lt^xinyton 

Louisiana,  New  Orleans  . . . . 
Massachusetts,  Taunton  . . . . 

Michigan,  Detroit 

Minnesota.  Minneapolis 

New  York,  New  York 

Ohio.  Cincinnati 

Utah.  Salt  Lake  City, 

Washington,  St-attic 

West  Virginia,  Wheeling 


October  ist  to  31st 75 

October  28th  to  November  3d.... 
October  1st  to  31st..  .    . . 

November  3d  to  loth  ...        ....   x 

October  1st  to  51st 37 

October  28th  to  November  loth  ,. 
OctobtT  2&lh  to  Novcnibcr  ;;d.... 
October  28th  to  November  sd.... 

November  3d  to  loth 

October  2tth  to  November  10th  .. 

November  :d  to  icth 

November  3d  to  loth i, 

October  31st  to  November  loth  ..  4; 

October  ist  to  31st 9 

November  3d  to  10th i 


Smallpox — Foreign. 

Brazil,  Rio  de  Janeiro September  8th  to  16th 

Ecypt.  Cairo October  7th  to  uih 

England,  London October  20th  to  27th i 

India,  Calcutta September  22d  to  October  13th 

Madras   October  6th  to  12th 

Russia,  Moscow. October  15th  to  30th 3 

Odessa October  22d  to  27th i 

Scotland,  Edinburgh October  20th  to  27th .  i 

Glasgow October  26th  to  November  2d. . . .  a6 


33 

I 

24 


Yellow  Fever— United  States. 


Mississippi,  Natchez, 


About  October  15th la 

Yellow  Fever— Foreign. 


Brazil.  Rio  de  Janeiro September  8th  to  iCth  . 

Cuba,  Havana October  26th  to  November  5d. . . 

Dominican  Rtpiiblic,  Puerto 

I'lata October  6th  to  November  :d  . ... 

Tampico October  281  h  to  November  4th  . . 

Mexico,  Vera  Cruz October  26th  to  Kovcrabcr  3d. . . 

Cholera. 

India,  Bombay October  8th  to  i6th 

Calcutta September  22d  to  October  X3th  . 

Kar.^chi October  7lh  to  14th 

Madras October  Cih  to  i2th 


Plague. 

F.trypt,  Alexandria October  1st  to  14th i 

En„'land,  London Oc'.ober  30th     1  • 

Germany,  Jiremen November  f  th 

India,  Bombay .October  Slh  to  16th  

Calcutta September  20th  to  October  13th  . .    .. 

*  On  vessel  arriving  from  the  Philippines, 
t  Sailor  from  South  America. 


»3 

4 


17 
461 


it 
197 


While  the  Medical  Record  is  pUased  to  receive  all  new  pub- 
lications which  may  be  sent  to  it.  and  an  acknowledgment  will  be 
promptly  made  of  their  receipt  u?ider  this  heading,  it  must  be  with 
the  distinct  understanding  that  its  necessities  are  such  that  it  can- 
not be  considered  under  obligation  to  notice  or  review  any  publica- 
tion received  by  it  -which  in  the  judgment  of  its  editor  will  not  be 
of  interest  to  its  readers. 

Uric  Acid  as  a  F.\ctor  in  the  Causation  of  Disease. 
Hy  Alexander  Haig,  M.D.  8vo,  846  pages.  Illuslrated.  P. 
Blakiston's  Son  &  Co..  Philadelphia. 

Obstetric  Clinic,  By  Denslow  Lewis,  M  D.  Svo.  862 
pages.     Illustrated.     E.  H.  Colegrove,  Chicago,  lU. 

A  Text-Book  of  Histology.  By  A.  A.  I>6hni.  M.D.  Svo, 
501  pages.      Illustrated.     W.  B.  Saunders.  Philadelphia. 

Cancer  of  the  Stomach.  By  William  O^Ier,  M.D.  Svo. 
157  pages.  Illustrated.  P.  Blakiston's  Son  ii:  Co.,  Philadel- 
phia. 

A  Manual  of  Hyoif.ne  and  Sanitation.  By  Seneca  Eg- 
bert, M.D.  Svo,  S35  pages.  Lea  Brothers  &  Co.,  Philadel- 
phia. 

Oustktrica;  A  Manual  for  Students  and  Practition- 
ers. By  David  James  Evans,  M.D.  Svo,  430  pages.  Illus- 
trated.     Lea  IJrotiiers  &  Co. ,  Philadelphia. 

International  Clinics.  By  Henry  W.  Cattcll.  M.D.  Svo, 
29S  pages.      Illustrated.     J.  B.  Lippincott  Co.,  Philadelphia. 

A  Manual  of  Materia  Mfdica  and  PHARMAroi.oGY.  By 
David  M.  R.  Culbrcth.  M.D.  Svo,  8S5  pages.  Illustrated.  Lea 
Brothers  &  Co..  Philadelphia. 

The  Practice  of  Medicine.  By  James  Tyson.  M.D.  Svo. 
1222  pages.  Illustrated.  P.  Blakiston's  Son  &  Co.,  Philadel- 
phia. 


Medical  Record 

A    Weekly  yournal  of  Medicine  and  Surgery 


Vol.  58,  No.  22. 
Whole  No.  1569. 


New  York,  December   i,  1900. 


$5.00  Per  Annum. 
Single  Copies,  loc. 


©rioiuaX  Articles. 

PERNICIOUS  ANAEMIA  AN'D   ITS    RELATION 
TO    INHERITANCE.' 

By   CHARLES   L.    DANA,    M.D., 

NEW   YORK. 

Mv  apology  for  reporting  a  case  of  pernicious  anaemia 
is  this:  The  history  of  the  case  shows  interesting 
facts  in  the  family  and  personal  history  bearing  upon 
the  question  of  hereditary  or  congenital  influence  in 
producing  the  disease.  I  have  not  found  that  this 
phase  of  the  etiology  or  pathology  has  been  studied; 
at  least  no  reference  is  made  to  the  question  in  the 
systematic  treatises  upon  it,  or  in  any  of  the  recent 
monographs  to  which  I  have  had  access.  The  history 
of  the  case  is  as  follows: 

Joseph  K ,  married,  aged  forty-seven  years,  na- 
tionality German,  wood-carver  by  occupation,  was  ad- 
mitted to  the  wards  of  Bellevue  Hospital  April  6, 
1900.  He  presented  at  that  time  the  characteristic 
symptoms  of  pernicious  anaemia. 

Family  history:  The  patient  was  the  thirteenth  of 
fourteen  children,  all  of  whom  were  born  dead  except 
one  brother  next  in  age  to  himself,  and  who  afterward 
died  from  pneumonia.  The  father  was  a  tailor  by 
occupation,  a  Prussian,  and  was  about  forty  years  of 
age  when  his  child  was  born.  He  was  said  to  have 
been  always  a  healthy  man ;  never  suffered  from  rheu- 
matism or  ana;mia,  and  died  at  the  age  of  seventy- 
seven.  The  patient's  mother  was  about  the  same  age 
as  her  husband,  and  died  of  some  pulmonary  disease 
at  the  age  of  fifty-nine.  She  was  not  a  sufferer  from 
anaaniiaor  rheumatism,  nor  were  there  any  neuroses  in 
the  family.  It  is  evident  that  the  mother  was  some- 
what advanced  in  years  when  the  child  was  born,  being 
nearly  the  age  of  forty.  Despite  this  history  of  twelve 
successive  miscarriages  there  was  no  history  of  syphilis 
obtainable. 

Personal  history:  At  the  age  of  ten  the  patient  had 
scarlet  fever  and  suffered  at  this  time  from  inflamma- 
tion of  the  right  ear.  In  consequence  of  this  illness 
he  stated  that  he  had  to  learn  to  talk  again,  and  he 
had  stuttered  ever  since.  He  gave  a  history  of  having 
always  been  healthy  and  able  to  work,  never  having 
had  any  acute  illness,  except  as  stated,  until  July, 
1897.  At  this  time  he  was  taken  with  an  attack  which 
he  says  resembled  the  one  for  which  he  was  admitted. 
This  came  on  suddenly  after  a  meal  of  hard-boiled 
eggs  and  tea.  He  was  taken  with  violent  pains  in  the 
stomach  and  was  brought  to  the  hospital.  He  subse- 
quently became  jaundiced,  and  afterward  had  an  at- 
tack of  gastro-duodenitis.  He  did  not  at  this  time 
have  any  shortness  of  breath  or  swelling  of  the  feet, 
and  he  was  discharged  "cured.'"  He  denies  ever  hav- 
ing had  syphilis. 

Habits:  In  the  past  the  patient  had  been  in  the 
habit  of  taking  whiskey  and  beer  in  moderation.  He 
was  a  hard  smoker  from  the  time  he  was  twelve  years 
of  age  until  he  was  thirty-five,  when  he  stopped.     He 

'  Read  at  the  meeting  of  the  Practitioners  Society,  November 
2.  1900. 


began  to  chew  at  the  age  of  sixteen,  and  has  chewed 
tobacco  ever  since,  using  about  three  ounces  a  week. 

He  first  noticed  his  present  illness  in  January, 
1900.  At  that  time  he  found  that  his  hands  were  be- 
ginning to  shake  at  his  work;  they  were  numb;  he 
could  not  pick  up  anything  small  like  a  ten-cent 
piece.  Then  he  began  to  grow  generally  weak,  but 
his  numbness  disappeared.  He  noticed  that  he  would 
get  tired  during  his  work  much  sooner  than  formerly. 
He  soon  experienced  a  slight,  gradually  increasing 
shortness  of  breath  on  exertion,  but  paid  little  atten- 
tion to  it,  and  kept  at  his  work  as  best  he  could. 
About  the  middle  of  February,  1900,  he  noticed  a  diz- 
ziness on  getting  up  in  the  morning,  which|poon  became 
so  great  that  he  would  have  to  catch  hold  of  something, 
and  remain  quiet  with  eyes  shut  until  he  could  get  his 
bearings.  At  this  time  he  was  unalile  to  hold  a  cup 
of  water  in  his  hand  on  accoimt  of  its  shaking  so  vio- 
lently. He  went  to  the  Ifcllevue  dispensary,  and  was 
treated  by  .'.everal  doctors  there,  none  of  whom  exam- 
ined his  blood.  He  continued  to  get  gradually  worse, 
although  his  appetite  was  good  and  bowels  were  regular. 
When  he  lay  down  he  had  a  sensation  of  formication 
in  his  hands  and  sometimes  in  his  feet.  This  sensa- 
tion in  his  hands  was  present  only  during  the  day. 
He  slept  well  at  night,  and  did  not  feel  sleepy  during 
the  day.  The  symptoms  grew  worse,  and  so  he  went 
to  the  hospital  April  6,  1900. 

Status  praesens:  The  patient  is  a  short  man,  fairly 
well  nourished,  weighing  one  hundred  and  nineteen 
pounds.  His  complexion  is  the  peculiar  yellowish- 
white  characteristic  of  severe  ansemia.  There  is  some 
oedema  of  the  face  and  legs;  the  rfnucous  membranes 
are  pale  and  the  sclerotics  somewhat  jaundiced;  the 
tongue  is  smooth,  pale,  not  coated,  and  moist.  The 
heart  is  normal;  the  apex  beat  is  in  normal  position; 
there  is  a  soft  blowing  systolic  murmur  at  the  apex,  not 
transmitted;  also  a  booming  sound  in  the  vessels  of 
the  neck,  increasing  as  one  listens  higher  up.  The 
pulse  is  regular,  quick,  full,  and  compressible.  The 
arteries  are  thickened  and  tortuous.  The  chest  is 
barrel-shaped;  on  the  right  side  is  a  supernumerary 
nipple  about  three  inches  below  the  normal  nipple. 
The  lungs  are  hyperresonant ;  few  bronchial  rales  can 
be  heard.  The  liver  is  large,  the  spleen  normal. 
There  is  an  inguinal  hernia  on  the  left  side  and  some 
u;dema  of  the  scrotum.  There  is  no  eruption  on  the 
skin.  Some  few  enlarged  lymphatic  glands  can  be 
felt  on  the  right  side  of  the  neck.  The  conformation  of 
head  and  ears  is  normal.  The  veins  of  arms  are  promi- 
nent and  nodular;  not  so  those  of  the  trunk  or  legs. 

Nervous  system:  The  epigastric,  cremasteric,  and 
plantar  skin  reflexes  are  all  normal.  There  is  no  ex- 
tensor toe  reflex.  Vasomotor  reflex  very  sluggish, 
slow,  and  imperfect.  Elbow  jerk  not  present.  Knee 
jerk  very  feeble  on  left;  not  present  on  right  side. 
The  legs  are  not  hypotonic.  There  are  a  slight  amount 
of  ataxia  in  both  hands,  and  a  slight  static  ataxia. 
There  is  a  little  fine  tremor,  especially  in  the  left 
hand.  Muscular  strength  fair.  Eye  examination  by 
Dr.  Weeks,  June  isth,  showed  motility  of  muscles  and 
pupil  normal;  both  discs  pale.  There  was  slight 
catarrhal  condition  of  the  left  ear  drum,  the  left  drum 
head  being  drawn  in.     "Otitis  media  purulenta  chron- 


842 


MEDICAL    RECORD. 


[December  i,  igcxj 


ica  "  in  right  ear;  hearing  diminished — cannot  hear 
watch  tick  in  right  ear,  watch  heard  at  two  inches  in 
left  ear;  ordinary  voice  heard  in  left  ear. 

A  later  e.xamination  on  April  loth  shows  slight 
ataxia  of  hands  and  slight  tactile  anasthesia;  dyna- 
mometer record  is,  right  hand,  seventy;  left  hand, 
si.xty-five.  The  patient  sways  when  standing.  The 
knee  jerks  are  normal.  The  pupils  are  small,  the 
right  a  little  larger  than  the  left;  they  respond  well  to 
accommodation,  and  but  poorly  to  light. 

A  further  examination  on  April  igth  showed  slight 
numbness  in  tips  of  fingers  and  toes;  dynamometer, 
right  hand,  seventy;  left  hand,  forty;  slight  ataxia  of 
left  hand.  Patient  swayed  a  good  deal  on  walking. 
Knee  jerk  diminished  on  right  side. 

The  stools  were  well  formed,  of  normal  color,  odor, 
and  amount;  without  mucus  or  fat. 

May  22d.  Dynamometer  record,  right  hand,  fifty; 
left  hand,  forty;  some  paresthesia  and  slight  tactile 
anaesthesia  of  the  fingers  of  the  left  hand. 

The  blood  examinations  were  as  follows,  made  by 
Dr.  Camac,  and  later  by  Dr.  Scott: 


Coagulation 

M  icrocytes 

Macrocytes 

Poikilocytes 

Degeneration  areas    

Red  blood  cells    

White  blood  cells 

Hieiiioglobin  

Stained    specimen  —  Red 
blood  cells, 

Polychroniatiphilia 

Normoblasts 

G  igantoblasts 

White  blood  cells. 

Small  mononuclear 

Large  and  transitional 

Polynuclear 

Eosinophiles 


April  gth.      April  23d.      May  14th.     June  19th, 


Slow. 

Numerous. 
Numerous. 
Numerous. 
Numerous. 
1,400,000 
6,000 
25  per  cent. 

Marked. . . . 


35  per  cent. 
25  per  cent. 
40  per  cent. 


Numerous. 
Numerous. 
Numerous. 

1,800,000 
7,000 


Marked. . 
6.'.'.'.".'.'. 


Numerous. 
Numerous. 
Numerous. 

1,008,000 
7.000 
25  per  cent. 

Marked. 


958,000 
4,400 
23  percent. 


The  patient's  mind  was  clear,  but  he  was  somewhat 
apathetic.  He  complained  of  no  headache  or  pain  of 
any  kind.  He  was  quite  weak  and  easily  got  out  of 
breath.  He  slept  well  at  night;  his  appetite  was 
good;  his  kidneys  acted  freely,  and  he  had  an  average 
of  about  two  stools  a  day,  which  were  normal  in  ap- 
pearance. The  general  course  of  the  disease  during 
the  next  three  months  corresponded  very  perfectly  with 
Addison's  classical  description  and  hardly  needs  a 
recital  here.  There  was  a  slow  but  steady  progress 
downward.  Puffiness  of  the  face,  weakness,  breath- 
lessness  on  slight  e.xertion,  characteristic  pale-yellow- 
ish look,  swelling,  all  became  very  marked.  The 
patient  was  quiet  but  not  despondent  or  complaining. 
He  continued  to  suffer  from  the  paresthesia  and  clum- 
siness of  the  fingers.  The  blood  examination,  as 
shown  in  the  table,  revealed  the  characteristics  of 
pernicious  anasmia.  It  was  not  affected  by  any  form 
of  treatment.  High  rectal  injections,  arsenic,  iron, 
bone  marrow,  purgatives,  and  tonic  measures  of  all 
kinds  were  used  without  avail.  During  the  progress 
of  the  disease  the  urine  was  measured  daily.  It 
ranged  in  amount  from  forty-five  to  sixty  ounces,  and 
became  a  little  less  as  the  weather  grew  warmer. 

Urinary  examination  :  .\pril  7th.  Specific  gravity, 
1.032;  acid;  no  albumin  or  sugar  microscopically; 
phosphates  and  urates;  total  amount  for  the  day  sixty- 
two  ounces. 

May  19th.  Color,  light  straw;  specific  gravity, 
1. 013;  alkaline;  urea  sixty-five  per  cent. ;  no  albu- 
min or  sugar;  microscopically  negative;  total  amount, 
fifty-eight  ounces. 

June  iSih.  Color,  amber;  specific  gravity,  1.013; 
no  albumin  or  sugar  microscopically ;  urea,  .769;  few 
hyaline  and  granular  casts;  epithelial  cells,  phosphate, 
and  urates;   total  amount,  forty  ounces. 

These  records  show  a  gradual  diminution  in  amount. 


a  deficiency  in  urea,  and  low  specific  gravity,  and  de- 
ficient total  solids.  They  contrast  with  the  rather 
free  elimination  from  the  intestines. 

The  stools  showed  nothing  abnormal ;  no  parasites 
were  seen  after  purging.  There  were  two  to  three 
stools  daily  up  to  the  time  of  his  death.  The  diges- 
tion was  good.  There  were  no  symptoms  pointing  to 
the  disturbance  of  the  gastro-intestinal  tract,  beyond 
the  free  action  of  the  bowels.  The  temperature  during 
the  first  month  averaged  about  100"  F.,  ranging  from 
99.5^  to  100.5°  °''  '°'°  F-;  there  was  a  daily  rise  in 
the  afternoon  of  about  a  degree.  In  the  next  two 
months  it  ranged  about  one-half  a  degree  lower,  keep- 
ing slightly  above  normal  until  the  terminal  rise  at 
the  time  of  his  death.  This  slight  febrile  rise  is  char- 
acteristic of  typical  cases  of  pernicious  anjemia. 

The  pulse  beat  was  about  100,  ranging  from  95  to 

105. 

Respiration  slightly  accelerated,  averaging  24  in 
the  last  month  of  life,  running  often  to  28. 

There  was  no  further  development  of  the  nervous 
symptoms,  which  indicated  a  slight  involvement  of 
the  posterior  columns  in  the  cervical  region  of  the 
spinal  cord,  that  being  the  part  of  the  spinal  cord 
most  often  affected  in  this  disorder. 

The  patient  steadily  grew  weaker,  more  cedematous, 
and  more  anaemic.  He  died  of  exhaustion  on  June 
15th. 

I  do  not  intend  to  discuss  the  question  whether  per- 
nicious anjemia  is  a  specific  type  of  disease.  It  seems 
to  be  very  well  settled  that  there  is  such  a  disease 
which  has  clinical  characters  that  make  it  separate 
and  recognizable,  when  the  clinical  history  and  blood 
examinations  are  studied  together.  I  believe  the  ex- 
citing causes  of  the  disease  are  many  and  various.  It 
is  my  purpose  to-night  to  show  that  the  victims  of 
it  all  possess  one  common  thing,  viz.,  a  teratological 
defect  or  weakness  in  the  blood-making  organs. 

In  the  study  of  nervous  diseases  one  becomes  im- 
pressed with  a  fact  which  does  not  seem  to  have  been 
appreciated  by  pathologists  in  their  studies  of  perni- 
cious anjEinia — this  is  the  occasional  unequal  vital- 
ity of  the  different  tissues  of  the  body.  For  example, 
in  the  muscular  dystrophies  we  know  that  the  muscu- 
lar system  is  congenitally  short-lived  and  wastes  away 
before  the  individual's  other  organs  are  even  matured. 
In  hereditary  chorea  the  gray  matter  of  the  brain  cor- 
tex, especially  in  the  central  convolutions,  dies  before 
the  man  is  forty.  In  certain  forms  of  primary  demen- 
tia the  same  fact  is  true.  In  locomotor  ataxia  and  the 
spinal  atrophies  and  other  degenerative  diseases,  cer- 
tain systems  are  born  with  a  weak  vitality  and  suc- 
cumb to  infections,  toxins,  or  accidental  injuries,  which 
do  not  affect  the  other  parts.  Of  the  millions  who  get 
syphilis  only  some  thousands  have  tabes,  and  of  the 
thousands  who  are  poisoned  with  lead  only  a  few  have 
an  atrophy  of  the  cornual  cells.  The  same  law,  I  be- 
lieve, applies  to  other  structures.  The  kidneys  and 
the  liver  atrophy  and  die  early  in  some,  while  others 
subjected  to  the  same  influence  continue  healthy. 
These  tissues  have  inherited  a  feeble  resistance  to 
deleterious  agents. 

The  factor  of  teratology  or  unequal  vital  endowment 
of  the  tissues  is  one  of  the  most  important  and  com- 
pelling in  the  explanation  of  progressive  degenerative 
diseases  of  the  human  body. 

There  are  certain  microbic  poisons  and  toxins  so 
potent  that  they  can  sap  the  vitality  of  even  the  sound- 
est tissue;  but  such  potently  malignant  agents  cannot 
be  always  invoked  by  the  pathologist.  Are  they  suf- 
ficient to  explain  pernicious  anemia.' 

The  theory  of  atrophy  of  the  gastric  tubules  is  ad- 
mitted inadequate,  and  has  been  abandoned.  Only  a 
small  proportion  of  the  victims  of  intestinal  parasites 
have  pernicious  anemia,     .-^mong  twenty-three  African 


December  i, 


igooj 


MEDICAL   RECORD. 


84- 


negroes  all  were  found  to  have  intestinal  parasites 
and  twenty-six  had  ankylostoma,  but  none  showed  any 
signs  of  ana-mia.' 

The  theory  of  a  specific  infection  is  still  only  a 
guess.  The  theory  of  an  auto-intoxication  from  the 
gastro-intestinal  tract  is  the  one  which  now  holds  the 
most  support.  It  is  based  upon  the  evidence  of  gas- 
tric disease,  of  intestinal  parasites,  and  of  the  discov- 
ery of  certain  ptomains  in  the  urine.  Dr.  W.  Hunter 
has  found  putrescin  and  cadaverin,  substances  caused 
only  by  micro-organisms,  in  one  case;  but  these  sub- 
stances are  also  found  in  cysts.  Micro-organisms  and 
parasites  have  often  been  discovered  in  the  bowels, 
but  I  cannot  find  any  very  positive  or  convincing  evi- 
dence of  an  adequate  auto-toxaemia,  and  no  therapeutic 
attempts  addressed  to  this  condition  avail  at  all.  It 
is  difficult  to  understand  how  so  powerful  a  hremolytic 
agent  could  be  present  there  and  not  cause  more 
marked  general  symptoms.  It  is  a  characteristic  of 
all  progressive  degenerations  that  remedies  never  per- 
manently avail.  We  may,  however,  suppose,  if  you 
wish,  that  there  is  some  auto-poisoning.  It  would 
not  be  sufficient,  according  to  my  point  of  view,  if 
there  were  not  an  inherent  lack  of  vitality  in  the  blood 
cells  also.  In  the  same  way  the  posterior  spinal  roots, 
or  anterior  horn  cells,  would  not  atrophy  and  die  if, 
superimposed  upon  their  natural  weakness,  there  were 
not  some  luetic  or  lead  poison  to  affect  them.  The 
muscular  dystrophies  often  start  in  after  an  acute  in- 
fectious disease. 

All  the  degenerative  diseases  are  apparently  dis- 
eases of  lysis,  not  of  genesis.  The  full-grown  cell 
is  attacked,  not  the  embryonal  cells.  So  in  perni- 
cious ana;mia  it  is  now  generally  agreed  that  it  is 
not  the  blood-making  organs  but  the  finished  blood 
which  is  attacked.  It  may  be  objected  that  the  blood 
is  not  a  tissue  like  muscle  or  nerve  or  liver,  but  a 
tissue  feeder.  Still  the  analogies  are  sufficiently  per- 
fect. The  red  blood  cell  is  a  fully  developed  anatom- 
ical unit  with  a  definite  life  history  which  must  run  a 
certain  course,  in  order  that  it  may  perform  its  func- 
tions. If  it  dies  too  soon  through  lack  of  original 
endowment  of  vitality,  the  process  is  the  same  as  that 
of  the  degenerating  muscle  or  nerve  or  kidney  cell, 
which  lives  but  forty  years  instead  of  seventy.  The 
argument,  to  be  sure,  would  make  the  original  defect 
He  in  the  blood-making  organ.  This  is  not  able  to 
turn  out  a  cell  that  can  live  its  proper  life,  though  it 
may  mature  and  become  for  a  time  a  healthy  cell.  I 
should  accept  this  point  of  view  and  make  pernicious 
anaemia  a  disease  in  which,  owing  to  bad  endowment, 
those  organs  begin  to  fail  in  their  work  after  a  certain 
number  of  years.  This  does  not  affect  the  practical, 
accepted  fact  that  the  anamia  is  due  to  the  killing  or 
dying  off  of  cells  which  start  out  apparently  in  proper 
number  and  appearance. 

It  might  be  asked,  "Why  should  we  not  have  perni- 
cious anaemia  in  old  age  if  this  doctrine  is  true,  since 
in  advanced  life  other  tissues  grow  old?  "  As  a  mat- 
ter of  fact,  there  is  the  same  general  atrophy  of  the 
blood  at  that  period,  but  nature  has  arranged  it  that 
fatal  degenerative  diseases  occur  mostly  before  or  at 
middle  life.  It  seems  that  after  that  point  is  safely 
passed  it  means  that  the  individual  has  received  usu- 
ally a  well-balanced  endowment  and  that  the  machine 
will  run  on  with  a  fair  degree  of  certainty,  so  far  as 
degeneration  is  concerned.  After  this  period  it  is 
mainly  secondary  to  the  arterial  sclerosis  and  defec- 
tive vascular  supply. 

In  my  own  case  the  history  of  the  family  is  most 
striking,  and  shows  an  extraordinary  lack  of  vitality 
on  the  part  of  the  generation  to  which  the  patient  be- 
longed. Out  of  fourteen  children  twelve  died  in  in- 
fancy, and  the  other  two  before  the  age  of  forty.     There 

'  Zuin  and  Jacoby  ;  Berlin,  klin.  Wochensch.,  No.  36,  1896. 


was  no  evidence  of  lues,  and  though  this  may  have 
been  present,  it  is  rare  for  this  trouble  to  cause  more 
than  three  or  four  miscarriages  or  early  deaths. 

I  have  not  been  able  to  look  up  the  personal  his- 
tories of  the  many  cases  of  ix:rnicious  ana;mia  reported, 
but  in  the  systematic  articles  on  this  subject  by  Sten- 
gel, Cabot,  Henry,  Howard,  Shattuck,  C'oupland,  Pep- 
per, Ehrlicii,  and  Lazarus,  and  in  the  recent  numerous 
discussions  on  this  topic,  I  find  no  notice  of  any  care- 
ful study  of  the  family  history.  Such  studies  are 
always  difficult  and  usually  negative,  but  a  few  very 
positive  cases  like  my  own  ought  to  carry  weight. 

In  cases  in  which  a  njother  gives  birth  to  a  long 
series  of  still-born  children  it  has  been  found  that 
some  of  those  who  finally  survive  have  teratological 
defects.  Thus  Ballantyne'  reports  the  case  of  healthy 
parents  who  had  eight  children,  the  first  two  were 
normal,  then  came  an  abortion,  then  four  pregnancies 
resulting  in  still  births,  or  nearly  such  with  hydroceph- 
aly, anencephaly,  spina  bifida,  malformed  feet,  mal- 
formed hands,  absence  of  radius,  tlien  a  normal  child. 

I  hope  that  this  attempt  at  an  oblique  illumination 
may  at  least  start  some  inquiry  in  a  new  direction, 
even  if  it  only  leads  to  the  conclusion  that  my  case 
was  an  accident  or  a  coincidence.  I  shall  not  easily 
believe  this  so,  because  the  view  which  makes  perni- 
cious anaemia  a  teratological  defect  has  so  much  in  an- 
alogy to  support  it. 


i 


GASTROPTOSIS.' 
By   GEORGE    ROE   LOCKWOOD.    M.D., 

NEW    YORK. 

The  descriptions  in  the  books  of  the  symptoms  of 
gastroptosis  are  hopelessly  obscure  and  chaotic,  but 
not  more  so,  unfortunately,  than  is  the  complexity  of 
symptoms  actually  presented  by  the  patient.  V\  hen 
one  goes  over  the  series  of  his  cases  in  analytical 
study,  it  becomes  painfully  evident  that  no  two  are 
alike,  and  that  characteristic  and  diagnostic  points  are 
few  and  misleading.  It  seems  to  me  that  the  present 
jumble  arises  from  the  fact  that  we  are  apt  to  consider 
gastroptosis  a  morbid  entity,  and  that  we  do  not  go 
closely  enough  into  the  other  conditions  which  may 
be  found  in  the  displaced  stomach — atony,  gastritis, 
and  disorders  of  secretion  and  sensation,  for  example 
— any  of  which  or  all  of  which  may  be  potent  factors 
in  the  symptom  complex. 

Let  us  take  the  heart  by  analogy — a  hollow  muscu- 
lar viscus  to  which  the  stomach  may  well  be  compared. 
A  diagnosis  alone  of  mitral  insufficiency  or  of  enlarge- 
ment is  hardly  up  to  date.  The  cardiac  musculature, 
the  probabilities  of  present  or  future  degenerations, 
the  general  recuperative  power  of  the  patient,  the  con- 
dition of  the  arteries — all  these  and  more  have  to  be 
taken  into  consideration.  In  like  manner,  with  the 
stomach,  factors  other  than  the  mechanical  displace- 
ment should  enter  into  the  study  of  the  case. 

The  cases  upon  which  the  facts  of  the  paper  are 
based  are  taken  ffom  private  practice,  and  have  all 
been  under  observation  a  long  enough  period  of  time 
to  allow  of  their  bt  ing  carefully  studied.  The  cases 
of  hospital  patients  who  return  to  unhygienic  living 
and  erratic  diet  have  been  totally  excluded  as  have 
been  all  of  those  cases  which  have  been  seen,  diag- 
nosed, and  have  passed  from  under  observation.  Such 
a  selection  seems  to  me  the  fairest,  and  the  one  that 
promises  to  give  the  most  accurate  data. 

It  may  here  be  said  that  the  facts  obtained  coincide 
with  the  writer's  experience  of  other  cases,  greater  in 

'  .\merican  Journal  of  Obstetrics,  1900,  p.  577. 
■  Read  before  the  Clinical  Society.  May  25,  1900. 


844 


MEDICAL    RECORD. 


[December  i,  1900 


number,  seen   in  public  practice,  of  which  records  are 
incomplete. 

The  cases  thus  selected,  the  majority  of  which  have 
been  under  constant  observation  for  a  number  of 
months,  number  45,  8  males  and  37  females.  Of  the 
45  cases 

3  patients  were  between  20  and  25  years  old. 
9       25    "    30     "      " 

5        30    "    35      "      " 

6       35    "    40     "      " 

10       "  "  "         40    "    45     "      " 

6       45  "  50  •■  •' 

3       50  "  55  "  " 

1  patient  was         "  55  "  60  "  " 
o        "          "           ■'  60  "  65  "  " 

2  patients  were        "         65     "    70      "       " 

The  marked  preponderance  in  adults  during  the 
most  active  portion  of  life,  the  storm  and  stress  pe- 
riod, is  here  well  illustrated — 36  cases  occurring  be- 
tween twenty-five  and  fifty  years  of  age,  9  cases  at 
other  times.  Cases  in  persons  under  twenty,  giving 
symptoms,  have  not  been  seen,  quite  contrary  to 
Meinert's  experience.  A  cause  adequate  to  explain 
the  gastroptosis  was  found  in  but  a  single  case. 
This  patient  was  a  man  forty-five  years  of  age,  who 
three  months  after  marriage  developed  the  symptoms 
of  incomplete  intestinal  obstruction.  Exploratory 
laparotomy  by  Dr.  B.  F.  Curtis  showed  the  intestines 
in  a  contracted  condition,  resembling  the  appearance 
of  spastic  ileus.  The  gastro-hepatic  omentum  was  so 
lax  that  the  stomach  could  easily  be  pulled  about  the 
abdominal  cavity.  The  organ  was  of  normal  size 
and  muscular  tone.  The  mesocolon  was  also  long  and 
lax,  allowing  of  an  extreme  degree  of  coloptosis. 

There  have  never  been  gastric  symptoms  either  be- 
fore or  after  the  operation.  Tight  lacing  did  not  ap- 
pear to  be  a  cause  in  any  of  the  cases.  Rapid  emacia- 
tion was  not  found  in  any  of  the  cases.  Laxity  of  the 
abdominal  wall  was  not  a  marked  feature.  Of  the  37 
women  25  were  nullipara;,  3  had  one  child,  5  had  two 
children  (in  one,  diastasis),  i  had  three  children,  i 
had  four  children  (diastasis),  2  had  children,  number 
was  not  stated  (in  both,  diastasis;  one  was  sixty-seven 
years  old,  one  seventy-two  years  old). 

Only  four  cases  of  diastasis  recti  were  encountered: 
one  in  a  Ilpara,  one  in  a  IVpara,  two  in  old  people, 
multiparai. 

An  appreciable  displacement  of  the  right  kidney 
was  preseiit  in  about  one-half  the  cases. 

It  did  not  seem  to  me  that  any  woman  of  the  series 
laced  more  than  normally,  and  that  the  corset  was 
responsible  for  a  single  case.  This  is  contrary  to  the 
experience  of  Fleiner  and  Meinert. 

Only  one  case  showed  chlorosis.  I  have  examined 
a  large  number  of  chlorotic  girls,  and  can  dispute  the 
statement  of  Meinert,  that  gastroptosis  exists  in  every 
chlorotic  girl.  Meinert  bases  his  experience  on  one 
hundred  cases  of  chlorosis.  It  probably  depends  on 
what  dividing  line  you  draw  between  a  normal  and  a 
displaced  stomach,  for  Meinert  says  fifty  per  cent,  of 
girls  twelve  years  old  have  gastroptosis,  eighty  per 
cent,  of  girls  fourteen  years  old  have  gastroptosis, 
ninety  per  cent,  of  adult  females»have  gastroptosis. 
These  statistics  are  entirely  at  variance  with  our  ex- 
perience in  this  city. 

Stiller's  sign  or  stigma  of  neurasthenia —the  mobil- 
ity of  the  tenth  rib — was  not  always  looked  for,  but 
when  search  was  made  the  rib  did  not  seem  unat- 
tached. 

My  general  impression  is  that  gastroptosis  is  far 
more  common  among  the  upper  classes — a  more  fre- 
quent disease  of  private  practice  than  of  hospitals. 
Whether  this  is  due  to  the  more  highly  sensitive  ner- 
vous systems  of  the  upper  classes,  or  to  more  system- 
atic use  of  the  corset,  or  is  due  to  the  fact  that  iio.spital 
and  dispensary  patients  are  not  carefully  examined,  I 


do  not  know.  The  last-mentioned  reason  seems  to  me 
the  most  explanatory. 

An  exciting  cause  for  the  manifestation  of  symptoms 
occurred  very  strikingly  in  twenty-four  of  the  forty-five 
cases,  and  is  stated  as  follows: 

I.  Well  till  six  years  ago.  Then  the  only  sister 
died  after  a  long  illness. 

3.  Well  till  six  years  ago.  Then  nervous  prostra- 
tion developed  from  "  adequate  cause  "  (love  affair). 
Since  then  the  patient  never  was  well. 

5.  Never  well  since  domestic  complications,  six 
years  ago. 

6.  Well  until  she  lost  her  money,  and  had  to  keep 
a  boarding-house;  at  about  the  same  time  she  devel- 
oped exophthalmic  goitre. 

8.  Well  till  two  years  ago.  Then  she  had  a  still- 
born child;   nephritis  and  fever  followed. 

10.  Constantly  ill  for  four  years,  directly  following 
a  fall  through  the  ice. 

16.  Well  till  husband  had  pneumonia  four  years 
ago. 

17.  Lost  money  two  years  ago,  and  has  had  to  teach 
music. 

19.  Well  till  six  years  ago.  Then,  under  domestic 
strain,  she  developed  hystero-epilepsy. 

20.  Lost  money  six  years  ago.  Since  then  con- 
stantly stomach  sick. 

2  1.  Constantly  ill  since  death  of  only  sister,  eight 
years  ago. 

22.  Severe  attack  of  gall  stones  eight  years  ago. 
Never  well  since. 

23.  Six  months'  growth  of  ovarian  tumor. 

24.  Well  till  runaway  accident  six  years  ago,  in 
which  she  was  thrown  from  carriage.  Constant  indi- 
gestion since. 

26.  Husband  died  eight  years  ago. 

27.  Husband  died  three  years  ago. 

28.  Two  and  one-half  years  ago  operation  for  cer- 
vix and  curetting. 

29.  Well  till  one  year  ago.  Then  severe  overwork 
and  poor  treatment  (insufficient  diet). 

30.  Three  to  four  years  following  prolonged  nurs- 
ing of  a  sick  patient. 

31.  Woman,  aged  seventy -two  years,  with  lax  ab- 
dominal walls;  was  well  till  her  husband  died  two 
years  ago.     Since  then  constantly  ill. 

34.  Well  till  one  year  ago,  when  she  had  exhaust- 
ing hemorrhage,  said  by  Trudeau  to  be  "vicarious 
menstruation."  This  came  at  the  same  time  as  severe 
domestic  unhappiness.     Never  well  since. 

36.  Well  till  two  years  ago.  Patient  had  had  ex- 
udative nephritis  for  six  years,  but  the  stomach  was 
perfectly  satisfactory.  Then  the  father  became  ill, 
the  home  was  given  up  for  residence  south.  Since 
then,  nervous  worry  and  stomach  symptoms. 

40.  Well  till  one  year  ago.  Then  she  developed 
chlorosis,  and  her  stomach  began  to  trouble  her. 

Of  these  24  patients  23  were  women,  i  was  a  man. 
Probably  the  man  would  have  done  differently  if  at 
the  time  he  had  received  rational  treatment. 

Of  all  the  complications  of  gastroptosis  atony  is  the 
most  important,  and  is  usually  the  exciting  cause  of 
symptoms.  In  the  pre-atonic  period  the  symptoms 
seem  to  be  intermittent,  induced  by  fatigue  or  by  emo- 
tional or  nervous  strain,  and  are  interrupted  by  more 
or  less  lengtiiy  periods  of  well-being.  These  inter- 
mittent symptoms  seem  almost  entirely  due  to  gastric 
neuroses,  either  sensory  or  secretory.  When,  however, 
atony  develops,  the  clinical  picture  changes.  The 
patients  no  longer  feel  well  after  the  summer's  outing, 
but  there  is  more  or  less  continual  gastric  distress. 
Flatulence,  loss  of  appetite,  or  an  appetite  that  is  too 
easily  appeased,  and  an  increasing  malnutrition,  to- 
gether with  any  or  all  of  the  multiple  forms  of  neuras- 
thenia, are  the  most  prominent  symptoms. 


December  i,  1900] 


MEDICAL    RECORD. 


84: 


Of  the  45  cases,  atony  was  absent  in  19,  slight  in 
6,  moderate  in  16,  marked  in  13.  In  one  of  the  cases 
there  was  hypermotility. 

I.  Cases  without  atony.  In  the  ten  cases  (four 
males,  six  females)  there  were  practically  no  symp- 
toms. It  will  be  noticed  that  as  atony  increases 
there  is  an  increased  number  of  neurasthenic  females. 
In  thirteen  cases  no  gastric  analysis  was  made  be- 
cause no  stomach  symptoms  were  present.  One  case 
showed  hypermotility,  so  that  the  stomach  w^is  con- 
tinually empty  one-half  hour  after  the  test  break- 
fast. Aside  from  a  feeling  of  "goneness"  coming 
on  two  hours  after  eating  and  lasting  until  the  next 
meal,  no  gastric  symptoms  were  present.  In  two 
cases  gastric  analysis  showed  normal  acidity  and  di- 
gestive power.  In  one  of  these  there  was  coloptosis 
and  obstinate  constipation,  with  loss  of  appetite.  The 
other  case  was  a  nervous  society  woman,  who  com- 
plained of  a  peculiar  feeling  in  the  pit  of  her  stomach 
after  eating  whenever  she  was  overtired.  One  patient 
showed  in  tlie  fasting  condition  considerable  amount 
of  mucus — the  test  breakfast  showed  low  acidity  ( iC) 
without  HCl.  The  symptoms  were  weakness,  insom- 
nia, and  flatulence,  and  entirely  disappeared  after  one 
month's  treatment  by  lavage  and  Kissingen  water. 
Here  the  symptoms  were  due,  not  to  atony  or  gastrop- 
tosis,  but  to  an  intercurrent  gastritis. 

In  one  case  moderate  gastritis  was  present  (total 
acidity  40,  mucus  in  fasting  stomach;  in  test  break- 
fast tiiirty  small  pieces  of  gastric  mucosa  were  found), 
but  the  symptoms  were  entirely  neurotic,  and  con- 
sisted in  peculiar  feelings  during  the  height  of  gastric 
digestion.  .\  full  diet,  with  small  doses  of  bromide, 
chloral,  and  chlorofom  water,  brought  about  entire 
cessation  of  symptoms  in  two  days.  The  superficial 
erosions  gave  no  symptoms. 

One  case  (an  epileptic)  presented  the  complication 
of  periodic  vomiting  of  gastric  juice  (;' gastroxynsis 
of  Rossbach ")  together  with  gastric  and  cutaneous 
hyperresthesia,  resembling  the  gastric  crises  of  loco- 
motor ataxia.  Between  attacks  there  was  steady  hy- 
peracidity (nearly  4  per  cent.).  No  result  was  ob- 
tained by  treatment. 

One  case  showed  hyperacidity  (.025  per  cent.)  with 
superficial  erosions.  Sections  of  the  mucous  mem- 
brane in  the  wash  water  presented  the  lesions  of  mu- 
cous gastritis,  and  a  small  amount  of  interstitial  infil- 
tration. 

There  is  nothing  very  definite  about  the  symptoma- 
tology of  this  class  without  atony:  i  case  of  hyper- 
motility; I  of  moderate  gastritis  and  gastric  neurosis 
and  superficial  erosions;  1  of  marked  mucous  gastri- 
tis; 5  giving  no  symptoms;  i  of  superficial  erosions 
and  hyperacidity;  1  of  gastroxynsis,  hyperacidity, 
epilepsy. 

Of  the  ten  cases  six  might  well  be  described  as 
neurasthenic. 

II.  Ceases  with  slight  atony,  six  cases.  Of  the  six 
cases ■ 

1.  Complicated  by  hyperacidity:  principal  symp- 
toms, gas  on  empty  stomach  and  heartburn.  The  pa- 
tient showed  gastric  hypersesthesia  from  acids  de- 
scribed by  Talma.  Symptoms  steady  for  ten  years. 
The  patient  was  treated  by  atony  diet  and  alkalies  and 
small  doses  of  ciiloral;  he  recovered.  He  lias  been 
well  for  two  j-ears  past. 

2.  Girl,  aged  twenty  years,  was  well  till  she  devel- 
oped chlorosis  two  years  ago.  Then  she  had  attacks 
of  gastroxynsis.  HcEmoglobin  twenty-seven  per  cent. 
Treated  by  iron  and  recovered  entirely. 

3.  Male,  neurasthenic.  Gas  at  6  a.m.  always,  for 
past  three  or  four  years.  He  was  much  improved  by 
atony  diet,  and  for  past  year  has  had  no  complaint. 

4.  Female,  aged  twenty-eight  years.  Nausea,  con- 
stipation,  weakness,  and  anaemia.      Examination    of 


gastric  contents  showed  mucus  in  fasting  stomach  and 
subacidity.  i!y  lavage  and  Kissingen  and  intragastric 
faradism  she  made  good  recovery.  This  case  was  inter- 
esting because  of  quick  response  of  motor  functions 
to  intragastric  faradism,  and  because  after  any  fatigue 
or  mental  excitement  atony  returned  as  a  temporary 
condition. 

5.  Female,  aged  thirty  years.  She  was  well  until 
some  nervous  strain  occurred,  then  lost  appetite  and 
had  gas  constantly.  Chemical  analysis  showed  slight 
mucous  gastritis,  normal  acidity.  Treatment  by  Wies- 
baden, with  marked  improvement.  Still  under  obser- 
vation. 

6.  Female,  aged  twenty-eight  years.  She  had  at- 
tacks of  pyloric  spasm  for  two  years  at  intervals,  with 
nausea,  flatulence,  and  loss  of  fiesh  and  strength; 
slight  atony,  pulsating  and  tender  aorta,  cutaneous 
hyperesthesia.  Mucus  in  fasting  stomach.  The  test 
breakfast  showed  anacidity.  Treatment  by  lavage, 
Kissingen,  hot  wet  flannels.     Still  under  observation. 

Synopsis:  i.  Hyperacidity;  recovered.  2.  Gas- 
troxynsis, chlorosis;  recovered.  3.  Hypera-sthesia 
and  neurosis;  recovered.  4.  Chronic  gastritis;  re- 
covered. 5.  Gastritis;  improving.  6.  Gastritis  an- 
acida;  improving.  Three  of  the  six  might  be  consid- 
ered neurasthenic. 

III.  Cases  with  moderate  atony ;  fourteen  cases,  all 
females. 

In  all  of  these  cases  there  were  slight,  constant 
symptoms — loss  of  appetite,  vague  feeling  of  distress 
after  eating,  and  eructations  of  gas.  In  all  there 
were  periods  of  exacerbation  of  symptoms  regularly 
induced  by  fatigue  or  nervous  strains. 

In  six  cases  no  gastric  analysis  was  made,  as  there 
did  not  seem  to  be  sufiicient  severity  of  symptoms,  and 
the  six  cases  were  all  in  nervous  women  of  marked 
neurasthenic  habit.  In  one  of  the  cases  there  was 
"peristaltic  unrest." 

Of  the  eight  cases  with  gastric  analysis,  one  showed 
normal  acidity  after  test  breakfast.  The  fasting  stom- 
ach contained  regularly  20-40  c.c.  of  glairy  mucus 
reacting  to  free  HCl.,  but  no  food  remains  even  after 
the  Riegel  dinner  taken  seven  hours  previous  to  the  ex- 
amination. The  symptoms  were  loss  of  appetite,  gas, 
pyloric  spasm,  gastralgia,  oliguria,  neurasthenia,  and 
insomnia. 

Two  cases  showed  normal  acidity  and  absence  of 
mucus.  The  symptoms  of  one  were  weakness  and 
anaemia  which  disappeared  under  treatment.  The 
other  case  showed  anaemia  and  oliguria  which  were 
relieved  by  iron,  diet,  and  diuretics.  The  fourth  and 
fifth  cases  showed  gastritis  subacida.  The  .si.\th  and 
seventh  cases  showed  hyperacidity  and  gave  the  symp- 
toms of  hyperacidity  only.  The  eigiith  case  showed 
mucous  gastritis  with  normal  relation  of  acidity — neu- 
rotic vomiting  and  gastralgia — rapidly  relieved  by 
lavage  and  internal  administration  of  bromides.  There 
were  only  two  patients  in  forty-five  who  vomited,  and 
in  these  cases  the  vomiting  was  distinctly  a  neurosis. 

To  recapitulate  this  group.  Six  cases  gave  scarcely 
any  symptoms  of  any  severity — all  were  neurasthenic, 
and  did  well  without  local  gastric  treatment.  Eight 
cases  were  analyzed :  Four  cases  had  normal  acidity, 
two  cases  had  subacidity,  two  cases  had  hyperacidity. 
Thirteen  of  the  fourteen  were  neurasthenic — all  fe- 
males. 

IV.  Cases  with  marked  atony.  This  group  com- 
prises fifteen  patients,  including  two  males,  and  con- 
stituted the  worst  set  of  cases.  They  all  presented 
constant  gastric  symptoms,  were  never  free  from  indi- 
gestion, and  were  all  more  or  less  incapacitated,  thir- 
teen being  practically  semi-invalids.  Gastric  analy- 
sis was  made  in  all  but  one  case.  In  all  of  the  fourteen 
cases  examined  mucus  was  found  in  the  test  breakfast, 
and  in  eleven  cases  was  found  in  the  fasting  stomach. 


846 


MEDICAL    RFXORD. 


[December  i,  igcx? 


Eight  cases  showed  hyperacidity,  three  cases  showed 
normal  acidity,  three  cases  showed  subacidity.  One  of 
the  last  three  gave  practically  no  HCl,  either  free  or 
combined. 

All  the  fifteen  cases  were  neurasthenic,  and  all  to 
a  fairly  intense  degree. 

1.  Female,  aged  twenty-nine  years;  flatulence, 
heartburn,  pyloric  spasms,  hysteria,  insomnia,  oliguria, 
indicanuria  with  constipation,  weakness;  semi-invalid 
six  years.  Gastroptosis,  atony,  periodic  slight  dilata- 
tion, coloptosis,  mucous  colitis.  Slight  mucous  gas- 
tritis with  hyperacidity. 

2.  Female,  aged  forty-eight  years;  flatulence,  neu- 
rasthenia, semi-invalid.  Hyperacidity,  moderate  gas- 
tritis. 

3.  Female,  aged  thirty-five  years;  gas,  fluctuating 
acidity  (from  6  to  144),  bulimia,  profound  neurasthenia, 
peculiar  head  symptoms  with  visual  aura  resembling 
petit  mal,  gastroptosis,  atony,  enteroptosis,  intestinal 
auto-intoxications;   invalidism. 

4.  Female,  aged  thirty-five  years;  gas,  distress  in 
epigastrium,  feeling  of  load.  Alternating  diarrhoea 
and  constipation.  No  colitis.  In  wretched  health 
continually.     Hyperacidity.     No  mucus. 

5.  Female,  aged  si.xty-seven  years;  constipation, 
gas  and  flatus,  acidity,  semi-invalid.  Gastroptosis, 
atony,  hyperacidity,  slight  colitis,  diastasis  recti. 

6.  Female,  aged  forty-two  years;  pain,  neurasthe- 
nia, emaciation,  slight  mucous  gastritis  and  subacid- 
ity. Has  phthisis,  exophthalmic  goitre,  and  hay 
fever. 

7.  Male,  aged  forty-six  years;- gas,  anorexia,  attacks 
of  pyloric  spasm,  retention  followed  by  congestive  head- 
ache.    Never  has  a  well  day. 

8.  Female,  aged  fifty  years;  for  ten  years  ;iausea 
and  vomiting,  pain,  gas,  alternating  diarrhoea  and  con- 
stipation. Analysis:  normal  acidity.  No  mucus. 
Patient  more  or  less  of  a  wreck,  weighing  less  llian 
one  hundred  pounds. 

9.  Female,  aged  twenty-nine  years;  for  fifteen  years 
an  invalid.  Gas,  neurasthenia,  oliguria,  weakness. 
Mucous  gastritis  with  subacidity,  marked  atony. 

10.  Female,  aged  twenty-six  years;  for  four  years 
pains,  gas,  nausea,  vomiting,  insufficient  diet,  consti- 
pation. Weight  seventy-one  pounds  in  travelling- 
dress;  five  feet  six  inches  tall.  Gastroptosis,  atony, 
hyperacidity,  neurosis.     Invalid. 

11.  Male,  aged  forty-eight  years;  for  ten  to  twelve 
years  never  well.  Gas,  insomnia,  loss  of  flash  and 
strength.     Normal  acidity,  no  mucus. 

12.  Female,  aged  forty-two  years;  for  ten  years  gas, 
sore  feeling,  pyloric  spasm,  neurasthenia.  Slight 
mucous  gastritis.     Normal  acidity.     Invalid. 

13.  Female,  aged  forty-eight  years;  for  six  months 
pain,  gas,  acidity.  Lost  twenty-five  pounds  in  six 
months.  Analysis  shows  hyperacidity.  Stomach  dis- 
placed and  apparently  adiierent  to  ovarian  cyst. 

14.  Female,  aged  twenty-six  years;  for  one  year 
constant  peristaltic  unrest,  flatulence.  Analysis 
shows  slight  gastritis;  fasting  stomach  empty.  Test 
breakfast  shows  high  acidity.     Superficial  erosions. 

15.  Female,  aged  thirty-six  years;  for  two  years 
severe  and  constant  flatulence,  loss  of  appetite,  emaci- 
ation, and  loss  of  strength.  H.  forty-two  per  cent. 
Fasting:  small  amount  of  mucus  of  alkaline  reaction. 
Test  breakfast  f.  a.  16.      No  free  acid,  no  lactic. 

It  becomes  very  evident  on  reviewing  these  groups 
of  patients  that  the  severity  of  symptoms  and  the  ob- 
stinacy of  their  course  depend  to  a  great  extent  upon  the 
degree  of  the  associated  atony,  and,  moreover,  it  would 
seem  as  if  atony  progressed  with  advancing  neurasthe- 
nia and  malnutrition  in  equal  strides.  Of  the  cases 
showing  moderate  or  marked  atony,  not  one  well-nour- 
ished non-neurasthenic  victim  can  be  found.  Paul 
Cohnheim,  Boas'  able  assistant,  in  reviewing  a  series 


of  cases  seen  in  Boas'  clinic,  says  in  a  recent  number 
of  the  Archil'  J  iir  Vcrdauiiiigskrankheiten :  "Gastric 
atony  is  a  constitutional  malady — a  part  only  of  a 
general  muscle  and  nerve  we^-kness.  It  is  never  cured 
by  bland  diet,  but  only  by  raising  the  general  nutri- 
tion, and  by  increasing  the  strength  of  nerve  and  mus- 
cle. The  symptom  complex  wliich  we  call  atony,  is 
never  found  in  well-nourished  patients.'' 

These  expressions  of  Cohnheim's  coincide  com- 
pletely with  my  own  experience  in  these  cases,  and  I 
place  especial  emphasis  upon  this  point  when  we  con- 
sider the  treatment  of  the  condition.  Left  to  them- 
selves, these  patients  assume  a  starvation  diet  by 
which  the  real  difficulty  is  increased,  fatten  them, 
nourish  them,  test  the  motor  and  chemical  functions 
of  the  stomacii  by  test  meals,  and  so  prescribe  a  suita- 
ble diet,  and  then  and  then  only  is  no  class  of  cases  so 
encouraging  or  gives  better  results. 

Continual  secretion  of  gastric  juice  (Reichmann's 
symptom).  Continual  secretion  of  gastric  juice  was 
not  found  in  any  of  the  cases.  Six  patients  showed 
mucus  in  fasting  stomach  without  traces  of  HCl.  All 
these  six  had  gastritis.  In  four  patients  mucus  and 
free  HCl  could  be  demonstrated  in  the  fasting  condi- 
tion. 

To  constitute  a  true  continual  secretion,  it  is  gener- 
ally agreed  that  tiie  presence  of  HCl  must  (i)  be  con- 
stantly found  in  the  fasting  stomach  mornings  after  a 
lavage  the  previous  night;  (2)  that  the  quantity 
should  be  fairly  considerable.  Of  course,  an  arbitrary 
line  must  be  draw-n  for  the  exact  quantity  required  to 
justify  a  diagnosis.  This  quantity  Boas  places  at 
100  c.c,  Riegel  at  50  c.c.  Smaller  quantities  may  be 
present  from  time  to  time,  as  an  artefact,  and  are  to 
be  disregarded.  In  no  one  of  the  four  cases  men- 
tioned did  the  quantity  exceed  25  c.c.  It  is,  more- 
over, interesting  that  all  of  these  cases  were  cases 
complicated  by  atony;  two  of  the  four  cases  were  fur- 
ther complicated  by  superficial  erosions. 

Acidity.  The  relations  of  acidity  to  gastroptosis  are 
very  interesting,  especially  when  considered  in  con- 
nection with  complicating  atony  and  gastritis. 

It  was  found  impossible  to  draw  fine  distinctions  be- 
tween various  grades  of  acidity,  because  the  acidities 
varied  so  much  on  various  days.  It  may  be  stated  (i) 
that  a  displaced  stomach  is  a  neurotic  stomach;  and 
(2)  that  the  majority  of  gastroptosis  patients  requir- 
ing treatment  are  neurasthenics.  These  two  condi-  ■ 
tions,  tlie  local  and  the  general,  evidently  furnish  rea-  " 
son  enough  for  marked  fluctuations  in  the  secretory 
functions  of  the  stomach.  Just  here  I  would  add  that 
to  determine  the  actual  fluctuating  power  of  any  stom- 
ach one  single  examination  will  not  suffice,  but  that 
examinations  should  be  made  at  stated  intervals  and 
under  varied  conditions.  A  stomach,  for  example, 
that  will  digest  perfectly  the  Boas  meal  of  bread  and 
water,  may  fail  utterly  to  do  its  work  when  confronted 
by  the  Riegel  dinner  of  a  plate  of  beef  soup,  150-200 
gm.  of  beefsteak,  50  gm.  of  potato  puree,  and  one  roll. 

In  the  thirty-three  cases  examined,  however,  acid- 
ities, while  fluctuating,  kept  within  certain  broad  limi- 
tations, with  the  exception  of  one  case  (gastroptosis, 
atony,  post-operative  hysteria)  in  which  acidities  va- 
ried between  6  (.07  per  cent.)  and  144  (.5256  per 
cent.)  without  api^arent  reason. 

Tiie  easiest  and  most  practical  classification  seems 
to  be-  ((/)  normal  acidity,  40-60  (.146  per  cent,  to 
.219  per  cent.);  (/')  hyperacidity,  60  and  over;  (i) 
subacidity,  40  and  under. 

Of  33  cases  examined  there  were,  {a)  of  normal  acid- 
ity, 10  cases;  (/')  of  hyperacidity,  15  cases;  (r)  of  sub- 
acidity, 8  cases.  Cases  with  lower  acidity  than  22 
(.08  per  cent.)  were  not  encountered. 

Thus  it  will  be  seen  that  tlie  great  majority  of  gas- 
troptosis cases  show  ample  acidity  to  digest   ordinary 


December  i,  1900] 


MEDICAL    RECORD. 


847 


food,  and  that  if  symptoms  are  present  they  must  be 
referred,  for  the  greater  part  at  least,  to  derangements 
of  motor  or  secretory  functions.  Reference  will  be 
again  made  to  this  point  in  discussing  the  treatment 
of  these  cases. 

Again,  the  mildest  cases  are  generally  to  be  found 
in  the  subnormal  group;  the  severest  cases,  i.e.,  those 
presenting  the  greatest  severity  of  symptoms,  are  about 
equally  distributed  among  the  normal  and  hyperacid 
cases. 

Let  us  glance  for  a  moment  at  tiie  relation  between 
acidity  and  atony  for  an  explanation : 

Relation  of  acidity  to  atony,  (i)  Of  cases  with 
normal  acidity  (10),  i  case  showed  no  atony,  o  case 
showed  slight  atony,  3  cases  showed  moderate  atony, 
6  cases  showed  marked  atony. 

Summary:   One  case  showed  atony  absent  or  slight; 

9  cases,  atony  moderate  or  marked. 

(2)  Of  cases  witii  hyperacidity  (15),  3  cases  showed 
no  atony  (one,  epilepsy  and  gastroptosis;  two,  ero- 
sions); 2  cases  showed  slight  atony ;  5  cases  showed 
moderate  atony;   5  cases  showed  marked  atony. 

Summary:   15  cases;  5  cases  atony  absent  or  slight, 

10  cases  atony  moderate  or  marked. 

(3)  Of  cases  with  subacidity  (8),  2  showed  no 
atony,  2  showed  slight  atony,  i  showed  moderate  atony, 

3  showed  marked  atony. 

Summary:  4   cases  showed  atony   slight  or  absent, 

4  cases  showed  atony  moderate  or  marked.  The  large 
proportion  of  atony  present  in  cases  with  normal  or 
hyperacid  conditions  seems,  therefore,  to  afford  the 
connecting  link  between  the  acidity  and  severity  of 
symptoms. 

Acidity  and  gastritis.  By  going  over  this  list  of 
acidities  and  by  marking  off  those  patients  with  gas- 
tritis, the  following  data  are  furnished: 

(i)  Cases  with  normal  acidity  (10),  i  case  had 
gastritis,  9  cases  had  no  gastritis;  gastritis,  10  percent. 

(2)  Cases  with  hyperacidity  (15),  5  had  gastritis, 
10  had  no  gastritis;   gastritis  in  33  per  cent. 

(3)  Cases  with  subacidity  (8),  5  had  gastritis,  3  had 
no  gastritis.  (The  latter  three  were  very  profound  neu- 
rasthenics. In  one  case  after  a  four-weeks'  rest  cure 
the  acidity  had  passed  into  the  hyperacidity  class.) 
Gastritis,  62  per  cent. 

Tli-jse  figures  show  the  effect  of  a  mucous  gastritis 
in  re  iucing  acidity.     Such  facts  would  seem  to  show: 

t.  That  cases  of  gastroptosis  uncomplicated  by  gas- 
tritis give,  as  a  rule,  normal  or  excessive  acidity. 

2.  That  gastritis,  when  it  does  occur,  brings  down 
the  acidity  somewhat  to  normal  or  subnormal ;  but  it 
is  rare,  in  gastroptosis  and  gastritis  combined,  to  meet 
with  the  low  acidities  encountered  in  gastritis  alone. 

3.  Owing  to  the  fairly  high  acidities  seen  in  these 
complicating  gastritides,  the  ordinary  symptoms  of 
gastritis  are  not  marked. 

In  no  case  of  the  series  did  the  gastritis  seem  a  fac- 
tor in  the  severity  of  the  case.  A  few  of  the  cases 
were  treated  by  lavage  and  by  mineral  waters,  and  in 
every  case  mucus  practically  disappeared,  subacidities 
became  higher,  and  the  patients  did  well. 

An  analysis  of  pain  is  somewhat  interesting.  Pain 
was  complained  of  by  15  of  45  patients.  In  6  the 
pain  was  evidently  due  to  pyloric  spasm.  All  had 
mirked  atony,  with  normal  or  increased  acidity  in 
equal  proportions  (3  of  eachj.  In  no  case  was  dilata- 
tion present,  except  in  two  cases  as  a  transitory  phe- 
nomenon after  extreme  degree  of  spasm.  In  4  patients 
pain  was  due  to  superficial  ulcerations.  All  of  these 
were  hyperacid  cases;  three  had  gastritis. 

Two  patients  presenting  superficial  erosions  gave 
no  pain;  one  was  subacid,  one  hyperacid.  It  is  some- 
wh.it  striking  that  6  of  the  45  cases  should  be  compli- 
cated by  superficial  erosions,  especially  as  the  6  cases 
are  all    of  different  types  and  present  very  little  in 


common,  except  the  large  proportion  of  hyperacidity 
(S  of  the  6). 

In  2  patients  the  pain  was  evidently  due  to  drag- 
ging on  the  gastric  ligaments,  and  disappeared  after 
the  use  of  an  abdominal  belt.  In  2  patients  the  pains 
were  evidently  of  a  neurotic  nature,  in  2  cases  they 
were  due  to  hyperacidity. 

The  relations  between  atony,  gastroptosis,  and  dila- 
tation of  the  stomach  are  of  paramount  interest,  espe- 
cially as  the  whole  subject  stands  at  present  on  debat- 
able grounds. 

A  great  deal  of  trouble  may,  however,  be  averted,  if 
we  clearly  understand  what  is  meant  by  the  term  "  dil- 
atation." It  cannot  be  affirmed  with  too  much  empha- 
sis that  the  actual  size  of  the  stomach  has  nothing  to 
do  with  the  condition  tliat  we  call  dilatation;  hence 
the  term  is  a  misnomer,  and  should  pass  from  our 
medical  nomenclature  and  be  replaced  by  the  term 
"muscular  insufficiency.'" 

It  is  entirely  in  this  significance  that  I  use  the  term 
dilatation  in  this  paper,  meaning  not  the  size  of  the 
stomach,  but  its  power  to  expel  its  contents  through 
the  pylorus  into  the  intestine.  If  a  patient  is  given 
at  night  two  roll  sandwiches  and  water,  and  if  on  the 
following  morning  food-remains  are  found,  there  is 
present  muscular  insufficiency,  ectasia,  or  dilatation 
(whichever  term  we  prefer).  This  muscular  incapa- 
city is  the  main  fact — the  exact  size  of  the  insufficient 
stomach  is  entirely  a  secondary  and  insignificant 
affair.  Understanding,  then,  exactly  what  is  meant 
by  the  term,  it  is  evident  that  dilatation  theoretically 
can  arise  only  (i)  when  the  muscle  is  too  weak  to  ex- 
pel stomach  contents  through  a  normal  pylorus  or  (2) 
when  obstruction  exists  at  the  orifice.  While  acute 
muscle  weakness  has  been  known  frequently  enough 
to  lead  to  acute  dilatation,  there  is  no  evidence  that 
chronic  primary  muscle  weakness  alone  has  ever  led 
to  the  chronic  dilatation.  Cohnheim.  in  Boas'  clinic, 
after  an  experience  of  many  hundred  cases  of  pure 
atony,  has  never  seen  ectasia  follow,  and  while  he  and 
Boas  are  not  prepared  to  deny  that  such  may  result, 
they  would  regard  dilatation  from  such  a  cause  as  ex- 
tremely rare.  In  this  view  Boas  is  supported  by  a 
brilliant  minority,  Schreiber,  Ullmann,  and  Kausch. 
Kausch,  writing  from  Mikulicz's  clinic,  has  never  ob- 
served a  case  of  pure  atony  ectasia.  On  the  other 
hand  stand  in  array  Riegel,  Ewald,  and  Rosenheim. 
The  high  position  of  the  belligerent  parties  adds  an 
additional  zest  to  the  combat.  There  can  be,  however, 
no  doubt  that  gastroptosis  may  be  followed  by  dilata- 
tion, and  that  the  dilatation  may  come  about  in  one  of 
threeways:  (i)  kinking  of  the  duodenum  ;  (2)  pyloric 
spasm;   (3)  arterio-mesenteric  constriction. 

1.  Kinking  of  the  duodenum  usually  occurs  at  the 
junction  of  the  superior  horizontal  and  descending 
portion  of  the  duodenum.  If  tiie  stomach  wall  is  of 
fairly  good  strength,  compensatory  over-activity  may 
occur  just  as  the  left  ventricle  undergoes  compensatory 
hypertrophy  in  aortic  stenosis.  It  may  be  only  when 
the  stenosis  increases,  or  when  the  vital  powers  fail, 
that  muscular  insufficiency  of  the  stomach  results. 

2.  Pyloric  spasm  may  result  in  one  or  more  of  three 
ways:  (a)  hyperesthesia  of  the  pars  pylorica  or  py- 
loric antrum;  (/m  hyperacidity;  (f)  reflexly  from  gase- 
ous accumulations. 

Pyloric  spasm  is  extremely  apt  to  occur  in  gastrop- 
tosis with  atony,  as  in  these  cases  all  three  predispos- 
ing causes  are  apt  to  be  combined.  Transitory 
spasms  may  be  followed  by  transitory  muscular  insuffi- 
ciency, as  in  the  following  case: 

Male,  aged  forty-five  years,  markedly  neurasthenic; 
gastroptosis,  atony,  hyperacidity;  generally  increased 
reflexes:  occasional  attacks  of  spasm,  nausea,  vomiting 
of  rancid  acid  material,  congestive  headache  followed 
by  diarrhoea.     During  one  of  these  attacks  the  fasting 


848 


MEDICAL    RECORD. 


[December  i,  1900 


stomach  contained  200  c.c.  fluid  of  rancid  odor,  with 
food  remains.  Total  acidity,  56  ;  freeHCl,  36;  com- 
bined HL"1,4;  total  HCl,  40;  salts,  6;  organic  acids, 
10  (no  lactic,  chieHy  butyric). 

Subsequent  examinations  have  shown  the  stomach 
perfectly  empty  in  the  fasting  condition.  Under 
treatment  no  further  attacks  have  been  noted  for  three 
years. 

It  is  more  than  probable  that  many  cases  of  contin- 
ual or  periodic  secretion  of  g.^.stric  juice  are  to  be  ex- 
plained on  this  theory.  It  is  important  to  recognize 
and  prevent  pyloric  spasms  in  order  to  conserve  the 
motor  function  of  the  stomach. 

A  rarer  cause  for  dilatation  has  been  described  by 
Arnold  Albrecht  in  a  recent  number  of  Virchow's 
Archil'.  The  course  of  the  superior  mesenteric  artery 
is  such  that  whenever  downward  traction  is  made  on 
the  intestinal  mass,  the  root  of  the  mesentery  with  the 
superior  mesenteric  artery  and  veins  exerts  direct  press- 
ure on  the  junction  of  the  duodenum  and  jejunum. 
A  passage  obstruction  may  be  thus  caused  that  may 
run  even  an  acutely  fatal  course,  as  penalty,  from  some 
unknown  cause,  after  surgical  operations.  It  has 
seemed  to  me,  in  experiments  on  the  cadaver,  that  the 
downward  traction  of  enteroptosis  may  be  sufficient 
to  cause  considerable  insufficiency  in  an  atonic  stom- 
ach. 

My  own  conviction  is  that  atony  alone  does  not 
cause  dilatation,  but  that  one  of  these  three  mentioned 
causes  will  be  found  present  if  food  remains  are  de- 
tected in  a  fasting  stomach.  Although  the  atonic 
stomachs  are  often  larger  than  normal,  they  are,  with 
rare  exceptions,  empty  of  food  remains  in  the  fasting 
condition,  and  I  would  be  inclined  to  regard  any  mus- 
cular insufficiency  as  due  to  a  passage  obstruction, 
kinking,  pyloric  spasm,  arterio-mesenteric  constric- 
tion, or  the  contraction  of  cicatrix  or  neoplasm. 

Treatment;  Enough  has  been  said  to  emphasize  the 
point  that  gastroptosis  is  not  a  morbid  entity,  but  that 
it  merely  predisposes  toward  other  conditions  that  re- 
quire treatment.  In  general  words,  these  propositions 
of  treatment  may  be  made: 

1.  The  displaced  stomach  is  a  neurotic  stomach,  and 
subject  to  a  variety  of  sensory,  motor,  and  secretory 
neuroses  (pains,  spasms,  hyperacidity). 

2.  In  the  great  majority  of  cases,  the  gastric  juice 
shows  normal  or  increased  digestive  power. 

3.  That  atony  and  neurasthenia  progress  hand-in- 
hand,  and  either  one  cannot  be  treated  alone. 

Treatment  of  Neuroses:  Irritative  neuroses  are  eas- 
ily enough  controlled,  but  if  neglected  almost  invaria- 
bly suggest  to  the  patients  the  idea  of  over-dieting — the 
very  worst  thing  tiiey  could  do.  Indeed,  there  are  two 
chief  factors  in  producing  atony  in  these  cases:  (a) 
pyloric  spasm,  (/')  over-dieting  and  malnutrition. 
One  thing  after  another  is  cutoff  because  of  digestion 
distress  until  a  diet  is  reached  that  is  practically  one 
of  starvation.  In  these  patients  the  amount  of  gastric 
distress  does  not  seem  to  be  dependent  on  either  quan- 
tity or  quality  of  food,  and  if  the  irritation  of  the 
stomach  can  be  allayed  by  sedative  treatment,  the  more 
they  eat  the  better  they  seem  to  be.  Early  cases  show 
the  signs  of  nervous  indigestion  only,  and  unless  care- 
ful physical  examination  is  made,  may  be  regarded 
entirely  as  such.  This  is  unfortunate,  because  much 
valuable  time  is  lost.  If  possible,  diagnosis  should 
be  made,  and  treatment  started  before  atony  develops. 

A  combination  of  bromide  gr.  vi.-viii.,  chloral  gr. 
iii.,  resorcin  gr.  iii.,  and  chloroform  water  ;  i.  with 
gtt.  vi.  of  spirits  of  anise  ad  ;  iv.  to  disguise  the  taste, 
has  seemed  to  be  the  most  serviceable.  Next  in  effi- 
cacy has  appeared  to  me  to  be  hyoscyamus  extract. 

The  "  Priessnitz  umschlag,"  or  Neptune  girdle,  is 
one  of  our  most  efficient  means  of  soothing  gastric  irri- 
tability.    Two  layers  of  Hannel,  large  enough  to  cover 


the  entire  abdomen,  are  wrung  out  of  hot  water  as  dry 
as  possible,  and  covered  with  oiled  silk,  'i  his  is  to 
be  changed  twice  a  day  and  can  be  worn  constantly. 

The  internal  application  of  galvanism,  the  anode 
being  placed  wiihin  the  stomach,  has  been  of  great 
service.  With  the  electrode  which  I  have  devised  for 
this  purpose,  it  is  a  simple  procedure,  and  uniformly 
well  borne  by  the  patient. 

Lastly,  a  certain  amount  of  physical  or  mental  rest 
is  needed  in  nearly  every  case,  amounting  at  times  to 
the  necessity  of  a  thorough  rest  cure.  It  is  especially 
important  that  the  patient  should  not  eat  when  over- 
tired, but  should  rest  one-half  hour  before  meals. 

To  control  motor  spasm,  (i)  we  reduce  gastric  hy- 
pergesthesia  in  the  lines  just  indicated;  (2)  we  reduce 
the  hyperacidity. 

To  reduce  the  hyperacidity,  we  may  employ,  in  ad- 
dition to  the  previous  treatment:  {a)  Frequent  feed- 
ings. It  is  still  a  mooted  point  whether  an  overabun- 
dance of  nitrogenous  food  does  not  ultimately 
perpetuate  the  condition.  My  own  preference  is  for 
mixed  diet,  without  too  large  a  proportion  of  meats. 
(A)  Alkaline  powders  two  hours  after  meals — bismuth 
subcarbonate,  magnesia  usta.  magnesium  carbonate, 
sodium  bicarbonate,  prepared  chalk  in  varying  propor- 
tions. ((■)  Nitrate  of  silver,  either  in  gr.  ss.  doses  before 
meals;   or  as  spray  i  :  500  daily  or  i  :  3,000  by  lavage. 

As  cases  illustrative  of  this  treatment  may  be  cited: 

Case  I. — Male,  aged  thirty-one  years;  neurasthenic, 
gastroptosis,  mild  atony,  mild  gastritis,  subacidity, 
pyloric  spasms,  sensory  derangements,  spastic  consti- 
pation. Diet  consisted  of  two  eggs,  two  pieces  of 
toast,  one  cup  of  malted  milk  the  day  previous  to  ex- 
amination. 

On  March  15th  given  bromide-chloral -resorcin- 
chloroform  mixture.  General  diet  except  red  meats, 
six  meals  daily,  and  the  Priessnitz  umschlag. 

On  April  loth,  gained  eight  pounds,  eating  every- 
thing without  symptoms.  Bowels  have  been  regular 
since  the  second  day  of  treatment. 

On  May  loth,  gained  fifteen  pounds  more,  making 
twenty-three  pounds  in  eight  weeks.  E'eels  well,  is 
able  to  do  hard  work,  and  has  no  symptoms;  has  not 
taken  any  medicine  for  three  weeks. 

Case  II. — Female,  aged  forty-eight  years;  for  ten 
years  nausea,  vomiting,  pains,  and  general  gastric  dis- 
tress. Gastroptosis,  moderate  atony,  hyperacidity. 
Rest  in  bed;  forced  feeding,  bromide-resorcin-chloral-  ■ 
and-chloroform  mixture,  Priessnitz  umschlag,  and  in-  1 
tragastric  faradism.  Gained  nineteen  pounds  in  four 
weeks,  and  went  home  strong  and  free  from  symptoms. 

When  atony  develops  the  abdominal  belt  should  be 
constantly  worn  during  the  working  hours,  and  great 
attention  should  be  given  to  diet.  There  should  be 
frequent  small  meals  of  concentrated  nutritive  power, 
given  as  dry  as  possible. 

Asuffi.cient  amount  of  liquid  should  be  given  to  pre- 
vent thirst,  but  no  more.  The  proportions  between 
the  nitrogenous  and  non-nitrogenous  ingredients  should 
be  determined,  (i)  by  the  amount  of  gastric  acidity, 
(2)  by  the  presence  or  absence  of  indicanuria.  Exer- 
cise should  be  absolutely  prohibited  after  meals. 
Spasm  and  secretory  neuroses  should  be  energetically 
treated.  In  atony,  intragastric  faradism  has  been  of 
indis))ensable  service;  fifteen-minute  seances  three 
times  a  week  for  about  a  month  are  usually  sufficient. 
Such  treatment  should  be  given  about  twice  a  year 
in  advanced  cases  to  obtain  lasting  results.  Above 
all,  the  patient  must  be  considered  a  poorly  nourished 
neurasthenic,  and  treated  accordingly. 

Surgical  treatment,  from  a  medical  point  of  view,  is 
applicable  only  in  cases  of  muscular  insufficiency, 
witii  retention  of  food.  Here  a  gastro-enterostomy  is 
of  service,  as  in  cases  of  pyloric  stenosis.  Gastropli- 
cation   and  the  operation   for  shortening  the   gastro- 


December  i,  igoo] 


MEDICAL    RECORD. 


849 


hepatic  ligaments  may  sound  theoretically  correct,  but 
I  doubt  if  on  the  whole  they  will  prove  satisfactory. 
Neither  operation  would  be  of  the  least  benefit  in 
pyloric  spasm  or  arterio-mesenteric  constriction,  while 
gastroplication  would  hardly  control  even  duodenal 
kinking. 

Conclusions. —  i.  That  in  the  great  majority  of 
cases  an  adequate  cause  for  the  gastroptosis  is  not 
discoverable. 

2.  That  gastroptosis  does  not  of  itself,  in  an  un- 
complicated form,  produce  symptoms. 

3.  That  the  displacement  of  the  stomach,  however, 
is  a  predisposing  cause  of  a  variety  of  gastric  neuro- 
ses, of  sensation,  motion,  and  secretion. 

4.  That  these  neuroses  are  usually  induced  by  some 
definite  mental  or  physical  strain. 

5.  That  the  displacement  of  the  stomach  is  a  strong 
exciting  cause  for  muscular  atony;  that  atony  is  the 
most  common  cause  for  the  symptoms  presented. 

6.  That  a  complicating  atony  is  associated  with  a 
more  or  less  profound  neurasthenia,  and  that  a  direct 
relation  exists  between  these  two  conditions. 

7.  That  gastric  acidity  is  increased  in  direct  pro- 
portion to  the  atony,  unless  counteracted  by  gastritis. 

8.  That  mild  degrees  of  gastritis  are  apt  to  occur  in 
stomachs  that  are   displaced,    but   the  symptoms  are' 
neither  severe  nor  persistent. 

9.  That  gastritis  occurring  in  atonic  and  displaced 
stomachs  reduces  the  excessive  acidity  of  these  cases 
and  seems  to  modify  the  severity  of  symptoms. 

10.  That  atonic  dilatation  without  mechanical 
hindrance  is  exceedingly  rare. 

I  J.  That  dilatation,  or  better,  muscular  insuffi- 
ciency, may  occur  in  gastroptosis  from  duodenal  kink- 
ing, from  arterio-mesenteric  constriction,  or  from 
pyloric  spasm. 

12.  That  pyloric  spasm  is  common  in  displaced 
atonic  stomachs  with  hyperacidity,  and  may  lead  to  a 
temporary  dilatation. 

13.  That  in  a  large  number  of  cases,  inattention  to 
the  conditions  of  atony,  of  neuroses,  and  of  gastric 
secretions  has  led  to  an  unsuitable,  insufficient  diet 
which  reacts  both  on  general  nutrition  and  on  local 
conditions  within  the  stomach. 

14.  That  surgical  intervention  is  applicable  only  to 
the  cases  in  which  dilatation  exists. 


ON  THE  ANALOGY  BETWEEN  THE  NER- 
VOUS CONDLICTIBILITV  AND  THE  ELEC- 
TRIC CONDUCTIBILITY,  AND  THEIR 
RELATION  TO  THE  FUNCTIONAL  NEU- 
ROSES.' 

By   a.    D.    ROCKWELL,    A.M.,    M.D., 

NEW    VOkK. 

The  reproach  of  Mr.  Lecky,  that  the  medical  powers 
of  electricity,  which  of  all  known  agencies  bears  the 
most  resemblance  to  life,  are  unexplored,  is  no  longer 
deserved. 

It  is  true  that  as  a  remedial  agent  it  has  by  no 
means  kept  pace  with  its  unexampled  development  as 
a  commercial  power,  and  yet  from  the  immeasurable 
amount  of  chaff  that  has  flooded  and  still  floods  medi- 
cal periodical  literature  both  here  and  abroad  can  be 
winnowed  many  scientific  facts  of  value,  especially  in 
the  domain  of  body  nutritive  exchanges  and  the  rela- 
tion of  electric  to  nerve  conductibilit}-.  While  the 
electric  current  and  the  nen-e  current  are  quite  difTer- 
ent  in  their  essential  characteristics,  late  researches 
have  shown  some  very  interesting  and  suggestive 
points  of  resemblance.     The  nerve  tracts,  which  were 

'  Read  at  the  annual  meeting  of  the  New  York  Medical  .Asso- 
ciation, held  in  New  Vork,  October  16.  igoo. 


formerly  thought  to  be  continuous,  are  now  known  to 
be  made  up  of  independent  neurons,  along  which  in 
their  normal  condition  the  nerve  waves  are  propagated, 
or  are  arrested  if  there  is  a  defect  of  continuity. 

When  the  healthy  nerve  cell  receives  the  stimulus 
of  the  nerve  wave,  energy  is  liberated,  animating  and 
reinforcing  the  nerve  current.  In  the  sick  nerve  cell, 
on  the  contrary,  energy  is  not  excited,  much  less  in- 
creased. Without  this  reinforcement  as  developed  in 
the  healthy  cell,  the  nerve  wave  can  make  no  further 
progress.  In  other  words,  the  neuron  becomes  im- 
pervious to  it.  Pathological  conditions  show  that  the 
conductibility  of  the  neuron  may  be  complete  or  in- 
complete according  to  the  degree  of  permeability  of 
the  nervous  tract.  If  the  nerve  current  can  pass  it  is 
translated  into  sensation,  movement,  intelligence.  If 
it  cannot  pass  and  there  are  no  gross  structural 
changes,  we  get  a  variety  of  the  functional  neuroses, 
as  hysteria  and  hysterical  anaesthesia  and  paraplegia, 
forms  of  neurasthenia,  and  mental  defects  as  shown 
more  especially  in  confusion  of  ideas  and  impaired 
memory.  In  order  to  make  clear  the  striking  analogy 
between  the  nerve  current  and  the  electric  current,  it 
will  be  necessary  to  refer  briefly  to  a  novel  and  very 
interesting  contrivance  called  the  "  coherer,'' an  es- 
sential part  of  the  outfit  for  wireless  telegraphy.  This 
coherer  is  simply  a  tube  of  metallic  filings. 

Now,  although  metal  is  the  best  of  conductors,  yet 
when  it  is  divided  into  separate  and  distinct  particles 
like  the  filings  of  iron,  the  coherer  which  is  made  up 
of  these  filings  becomes  non-conducting  to  a  weak  cur- 
rent. If,  however,  the  tube  containing  the  filings  is 
placed  in  a  solenoid  through  which  course  currents  of 
high  frequency,  or  in  the  range  of  influence  of  the 
cathodic  ray,  the  tube  immediately  becomes  a  conduc- 
tor and  the  current  passes;  or  if  it  is  placed  in  prox- 
imity to  a  static  machine  in  operation,  the  electric 
waves  set  in  motion  by  the  electric  sparks  strike  the 
coherer  and  render  it  immediately  a  conductor. 

It  immediately  becomes  non-conducting  again,  if 
subjected  to  any  shock  however  slight.  Removed  from 
these  influences,  it  gradually  loses  its  conductibility, 
retaining  it  longer  under  the  influence  of  cold  than  of 
heat.  These  invisible  and  silent  waves  of  influence 
nothing  can  obstructor  deflect,  and  in  the  far  distance 
— the  limit  of  which  no  one  can  yet  say — striking  the 
tube  of  iron  filings,  are  translated  into  signs  of  intelli- 
gence. 

In  order  to  study  a  phenomenon  with  advantage  it 
is  well  to  have  a  theory,  and  although  the  theory  be 
defective,  it  yet  gives  us  a  point  of  departure,  leading, 
it  may  be,  to  a  clearer  conception  of  the  principles 
involved.  This  theory,  as  suggested  by  M.  llranly,  to 
whom  we  are  indebted  for  this  interesting  discovery, 
supposes  that  each  grain  is  surrounded  by  a  sheath  of 
condensed  ether,  but  not  in  contact  the  one  with  the 
other.  The  waves  of  an  electric  discharge  expand 
these  sheaths  of  ether,  and  it  is  their  mutual  penetra- 
tion that  changes  the  tube  of  filings  from  a  non-con- 
ductor to  a  conductor.  A  shock  retracts  these  sheaths 
and  destroys  their  conductibility. 

On  the  other  hand,  when  we  study  the  nervous  sys- 
tem on  the  basis  of  the  neuron  theory  we  find  analogies 
of  the  most  striking  character. 

Neuro-motor  energy  may  be  developed  primarily  in 
the  nerve  centres,  or  it  may  come  from  without,  exter- 
nal physical  energy  being  transformed  into  reflex 
nervous  energy;  in  either  case  it  overcomes  the  nat- 
ural resistance  of  the  independent  neurons,  making 
them  conductors  of  energy  in  the  same  way  that  the 
electric  wave  generated  at  a  distance,  and  striking  the 
disconnected  filings  of  the  coherer,  overcomes  its  nat- 
ural resistance  and  makes  it  a  conductor. 

The  neuron  with  its  dendrites  makes  up  the  central 
and  active   part  of  the  nerve  cell,  the  cylinder  axis 


S50 


MEDICAL    RECORD. 


[December  i,  igod 


prolongations  acting  as  conductors  of  the  nervous  cur- 
rent. Under  tlie  intluence  of  external  irritation  the 
dendrites  are  increased  and  developed,  and  the  greater 
the  activity  of  the  neuron  tlie  greater  the  tendency  to 
produce  new  protoplasmic  growths.  Does  not  this  har- 
monize very  closely  with  the  working-theor)'  in  explana- 
tion of  the  action  of  electricity  on  the  disconnected 
conductors  of  the  coherer — the  expansion  and  con- 
traction of  the  ether  surrounding  each  metal  particle 
corresponding  to  the  increase  and  development  or  the 
decrease  and  obliteration  of  the  protoplasmic  pro- 
longations of  the  cell?  The  points  of  contact  are 
broken  between  the  individual  neurons,  and  the  ner- 
vous wave  is  arrested  in  its  course. 

This  theory  of  the  alternating  conductibility  and 
non-conductibility  of  the  disconnected  conductor 
termed  the  coherer,  and  the  theory  of  the  neuron 
open  up  to  us  not  only  the  possibility  of  understand- 
ing more  clearly  the  gross  changes  of  organic  lesions 
of  the  brain  and  the  invisible  anomalies  of  structure 
that  we  term  nutritional,  but  throw  a  new  and  brighter 
light  on  the  rationale  of  the  well-established  value  of 
electricity  in  the  cure  of  so  many  functional  diseases 
of  the  nervous  system,  and  the  relief  often  afforded 
even  in  diseases  that  are  organic  and  structural. 

Reasoning  from  analogy  and  the  results  of  physical 
and  physiological  experiment,  it  is  natural  to  conclude 
that  conditions  such  as  hysteria  and  hysterical  anes- 
thesia and  paraplegia,  forms  of  neurasthenia,  and  vari- 
ous mental  conditions,  are  the  derangements  in  which 
electricity  in  some  one  of  its  manifestations  is  spe- 
cially indicated.  But  long  before  we  possessed  any 
knowledge  of  these  interesting  facts  relative  to  nerve 
and  electric  conduction,  the  clinic  had  assured  us 
positively  and  repeatedly  of  the  efficiency  of  this 
method  of  treatment  in  the  functional  diseases  of  the 
nervous  system.  One  case  bearing  on  this  point  I 
beg  leave  to  offer  as  illustrating  not  only  the  analogy 
between  the  nervous  conductibility  and  the  electric 
conductibility,  but  as  practical  evidence  of  the  power 
of  electricity  to  restore  the  conductibility  of  the  neu- 
ron that  had  become  resistant  to  the  nerve  current. 

Such  a  result  as  the  one  about  to  be  related  is 
sometimes  spoken  of  as  one  of  the  brilliant  results  of 
electrical  treatment.  It  was  a  brilliant  result  only  in 
so  far  as  it  was  a  quick  result.  Nature  was  simply 
reinforced  and  was  enabled  to  accomplish  at  once  what 
slie  was  slowly  trying  to  do,  and  what  she  would  in  all 
probability  have  succeeded  in  doing  if  left  to  herself. 

Miss ■,  aged    twenty-four    years,    whom    I    had 

treated  many  times  some  two  years  previously  for  a 
nervous  derangement,  and  who  had  in  great  measure 
recovered,  came  under  my  care  again  in  the  autumn 
of  T8g9  in  a  deplorable  state  of  mind  and  body,  the 
result  of  a  nervous  shock  in  escaping  from  a  burning 
building.  Up  to  this  date  she  had  been  for  some  time 
in  better  health  than  ever  before,  but  evidences  of  her 
hereditary  and.acquired  nervousness,  or  nervelessness, 
were  never  altogether  wanting.  She  suffered  more 
or  less  at  all  times  from  morbid  fears,  and  had  for- 
merly been  able  to  take  an  unusually  large  quantity  of 
stimulants  without  appreciable  effect. 

During  the  worst  periods  of  her  combined  hysteri- 
cal and  neurasthenic  attacks,  an  ordinary  claret  glass 
of  brandy  would  affect  her  seemingly  no  more  than  so 
much  water. 

As  her  condition  improved  this  insusceptibility  be- 
came less  and  less  marked,  until  finally  she  was  influ- 
enced by  stimulants  almost  if  not  quite  as  readily  as 
others.  After  the  great  shock  of  tht:  fire  this  craving 
and  remarkable  capacity  for  intoxicants  again  returned, 
and  was  associated  with  confusion  of  ideas,  impaired 
memory,  partial  paraplegia  with  anaesthesia,  and  pro- 
found mental  depression  relieved  by  violent  paroxysms 
of   weeping.     Her   amnesia   was   peculiar   in   that    it 


related  to  a  few  things  only.  Passing  events,  and 
the  ordinary  occurrences  of  the  day  were  well  remem- 
bered: but,  for  example,  she  claimed  to  be  unable  to 
remember  ever  having  been  to  my  office.  I  might  have 
ascribed  this  to  caprice,  excepting  that  her  mental 
failure  was  distinctly  pronounced  in  other  ways, 
Under  nerve  sedatives  she  was  temporarily  quieted, 
and  during  the  next  ten  days  improved  a  little,  but 
only  a  little,  in  her  general  and  special  symptoms,  suf- 
ficient to  be  brought  to  the  office  in  a  carriage. 

She  was  immediately  placed  in  what  may  be  termed 
an  electro-static,  vibratory  field.  More  specifically 
she  was  placed  on  an  insulated  stool,  and  connected 
with  the  positive  pole  of  the  apparatus.  The  negative 
pole  was  grounded  and  the  spark  gap  regulated  at  two 
inches,  giving  to  the  patient  vibratory  waves  very  dis- 
tinct, but  altogether  agreeable.  I  lay  especial  stress 
on  this  point.  If  she  had  been  simply  placed  on  the 
usual  insulating  platform  and  given  the  ordinary  treat- 
ment of  static  electrification,  the  nerve  tracts  would 
not  have  been  influenced  by  those  currents  of  vibra- 
tor)', alternating  potential  that  are  so  essential  in  re- 
storing conductibility  to  the  "coherer"  in  the  opera- 
tion of  wireless  telegraphy  to  which  allusion  has  been 
made. 

I  must  not  forget  to  say  that  the  tactile  sensibility 
of  the  patient  was  carefully  interrogated,  but  the  as- 
thesiometer  proved  of  little  value,  since  the  anaesthesia 
of  the  tips  of  the  fingers  and  of  the  body  generally  was 
so  profound  that  the  prick  of  a  pin  was  not  felt.  Only 
at  the  tip  of  the  tongue  was  there  any  sensation.  Here 
a  prick  was  felt,  but  the  two  points  of  the  aesthesiometer 
were  separately  felt  only  when  apart  some  3  mm. 

A  single  se'ance  of  fifteen  minutes  resulted  in  a 
very  remarkable  amelioration  of  several  symptoms, 
notably  of  the  anaesthesia,  and  within  a  week,  after 
three  additional  treatments,  she  was  able  to  walk  alone 
with  considerable  ease.  She  had  quiet,  restful  nights 
for  the  first  time  since  the  accident,  and  arose  refreshed 
and  cheerful.  Her  amnesia  quite  passed  away,  the 
fingers  were  ordinarily  sensitive  to  touch,  and  at  the  tip 
of  the  tongue  she  was  able  to  discriminate  the  points 
of  the  aesthesiometer  when  but  little  more  than  i  mm. 
apart. 

A  most  interesting  evidence  of  improvement  was 
the  disappearance  of  desire  for  and  the  insuscepti- 
bility to  stimulants. 

As  a  clinical  fact  the  foregoing  case  by  no  means 
stands  alone,  and  doubtless  could  be  duplicated  in  its 
essential  features  by  any  neurologist  who  makes  much 
use  of  electricity  in  medicine.  Not  only  have  there 
been  many  quick  recoveries  in  cases  of  profound  func- 
tional nervous  disorders  by  placing  patients  within  the 
field  of  the  influence  of  currents  of  high  potential  and 
high  frequency,  but  it  is  even  true  that  some  violent 
neuro-motor  excitation,  such,  for  example,  as  a  sudden 
fright,  anger,  and  even  joy,  has  restored  power  to  the 
paralyzed  limbs  of  hysterical  patients  by  overcoming 
the  non-conductibility  of  the  resistant  neuron. 

In  order  to  explain  the  sudden  change  of  the  coherer, 
as  the  tube  of  iron  filings  is  called,  from  a  non-con- 
ductor to  a  conductor,  recourse  was  had  to  the  theory 
of  a  sheath  of  ether  surrounding  each  particle,  whose 
alternate  expansion  and  contraction  under  electric  in- 
tluence and  shock  changed  entirely  its  power  of  con- 
duction. In  dealing,  however,  with  the  relation  of 
electric  energy  and  shock  to  the  nervous  system,  we 
find  in  the  physiology  and  minute  anatomy  of  its 
structure  a  basis  of  knowledge  rather  than  theory. 
We  are  told  that  the  nervous  system  is  composed  of 
independent  neurons,  and  that  the  connection  between 
them  is  made  by  simple  contact  of  the  cylinder  axis 
of  one  neuron  with  the  protoplasmic  prolongation  of 
another. 

The  readiness  with  which  the  nervous  current  flows, 


December  i,  1900] 


MEDICAL    RECORD. 


851 


translating  itself  into  sensation,  movement,  and  intel- 
ligence, depends  upon  the  functional  integrity  of  the 
neuron  and  the  perfection  of  its  collateral  connections. 
The  contact  Ijetween  the  dendrites  of  one  neuron  with 
the  protoplasmic  prolongations  of  another  must  not 
only  be  constant,  but  must  be  constantly  changing  in 
order  to  make  a  way  for  new  ideas  and  new  impres- 
sions. In  the  normal  condition  of  mind  and  body 
there  is  no  severance  between  the  dendrites  and  cylin- 
der-a.xis  fibres,  but  in  impairment  of  the  psychic  func- 
tion, whether  it  registers  itself  in  the  domain  of  sensa- 
tion, movement,  or  intelligence,  or  in  all  these  as  in 
the  case  just  related,  these  ties  or  points  of  contact 
become  impaired  or  altogether  broken. 

Klectricity  and  all  energy  are  amenable  to  the  law 
of  the  correlation  and  conservation  of  forces.  As  iron 
becomes  magnetized  or  heated  by  the  application  of 
force  or  heat,  so  the  electric  energy  applied  to  the 
human  body  is  not  lost,  but  in  its  transformation 
tends  in  a  single  direction,  the  stimulation  of  the  liv- 
ing molecule  and  the  nourishment  of  the  nerve  centres, 
the  depository  and  dispensers  of  all  vital  energy.  It 
calms  the  irritable  cell  and  increases  its  activity  when 
sluggish. 

The  modification  that  an  organic  compound  under- 
goes when  subjected  to  the  action  of  a  physical  force 
varies,  of  course,  with  its  intensity,  and  especially  with 
the  nature  of  tiie  body  on  which  it  acts.  When  the 
compound  is  a  metal,  the  passage  of  a  current  of  suf- 
ficient power  generates  heat  and  dilates  its  constituent 
molecules.  When  the  electrolyte  is  a  living  body,  the 
heat  generated  is  not  primary  but  secondary. 

Caloric  is  not  directly  absorbed  as  in  the  former 
case,  but  the  elevation  of  temperature  results  from  bio- 
logical changes  of  a  secondary  nature,  and  this  con- 
servatism is  indicated  by  a  quickened  circulation  and 
an  increased  activity  of  all  the  excretory  and  secretory 
processes  of  the  body.  The  increase  in  the  elimina- 
tion of  urea  and  all  toxic  products,  now  so  well  estab- 
lished, through  the  influence  of  currents  of  high  ten- 
sion and  high  fre(|uency,  acts  in  two  ways:  First,  "as 
a  rellex  of  defence  against  the  action  upon  the  system 
of  these  toxic  products  suddenly  set  free";  second, 
by  hastening  and  increasing  the  nutritive  exchanges 
throughout  the  body. 

Admitting,  as  has  been  claimed,  that  inherently 
electricity  has  neither  curative  nor  destructive  quali- 
ties, yet  it  is  the  bearer  of  energy  both  mechanical 
and  chemical.  It  has  to  do  with  molecules  and  atoms, 
shaking  them  apart  or  permitting  new  arrangements, 
and  the  benefit  or  injury  that  comes  to  the  organism 
through  this  disturbing  process  depends  upon  the  r<Me 
played  in  the  economy  by  these  new  atomic  arrange- 
ments. As  to  the  underlying  causative  factor  in  the 
field  of  the  functional  neuroses,  we  can  arrive  at  but 
one  conclusion,  namely,  that  it  is  an  impairment  or 
interruption  of  the  potential  energy  of  the  cell  life. 

We  have  seen  how  physical  shock,  or  the  stress  and 
strain  put  upon  the  nervous  system  by  the  dissipations 
and  even  the  legitimate  demands  of  our  modern  civili- 
zation, interferes  with  the  vital  function  of  the  neuron 
and  renders  it  impervious  to  the  nerve  wave. 

Wa  have  seen  also,  on  the  other  hand,  how  the  sub- 
tle electric  waves  generated  by  currents  of  high  ten- 
sion and  high  frequency-,  so  analogous  in  some  respects, 
and  yet  so  entirely  different  in  nature  from  the  ner- 
vous current,  have  power  to  restore  the  interrupted  con- 
ductibility  of  the  nerve  tracts.  The  inherent  energy 
of  the  nerve  cells  is  liberated,  new  paths  of  conduction 
form,  resulting  in  modification  of  motor,  sensory,  secre- 
tory, excretory,  and  vasomotor  processes. 

It  cannot,  therefore,  be  too  often  repeated  that  the 
fundamental  idea  of  the  therapeutic  value  of  electric- 
itv  is  its  influence  on  the  nerve  cell  and  on  general 
and  local  nutrition. 


BIBLIOGRAPHY. 

Branly  :  Assimilation  de  la  conductibilite  nerveuse  a  la  con- 
ductibilitie  clectrique  discontinue.  kevue  internationale 
d'clectrotherapie,   .Mars,  Avril  et  Mai,  iSyi. 

Guimbail  .  Kecherches  nouvelles  sur  les  conducteurs  ciectriques 
discontinus.     JhuL 

Soukhanoff :  l.a  thcorie  des  neurons  en  rapport  avec  I'explica- 
tion  de  quelques  i-tats  psycliiques  norniau.\  et  pathologiques. 
.Vrchives  de  neurologic,  Mai,  iSg". 

liallet  Lesions  corticales  et  medullaires  dans  le  psychose 
polyncuritique.      l.a  presse  nicdicale,  1S98,  No.  20. 

Regis  :  1-es  psychoses  d'auta-into.\ication,  etc.  Archives  de 
neurologie,  2  series,   iSgg. 

Van  tiehuchten  ;  I,a  doctrine  des  neurones  et  les  theories 
nouvelles  sur  les  connexions  des  elements  nerveux. 


THE  TREATMENT  OF   TYPHOID    FEVER  AT 
THE   NEW    YORK    HOSPITAL. 

Bv    FREDERICK    L.    KEAYS,    M.I)., 

HOUSE   PHVSICIA.S,    SEW   YORK    HOSPITAL, 

In  this  article  no  attempt  will  be  made  to  deal  ex- 
haustively with  the  subject  of  the  treatment  of  typhoid 
fever.  It  is  intended  to  outline  as  briefly  as  possible 
the  treatment  employed  at  the  New  York  Hospital. 
It  seems  convenient  lo  consider,  1st,  the  treatment  of 
an  uncomplicated  case;  2d,  the  treatment  of  the 
various  complications;  3d,  the  subject  of  feeding; 
4th,  the  management  of  the  patient  during  convales- 
cence, and  5tii,  the  prophylactic  treatment. 

I.  The  Treatment  of  an  Uncomplicated  Case. — 
As  the  treatment  is  altogether  symptomatic  we  will 
take  up  the  different  systems  of  the  body,  and  give  the 
treatment  of  symptoms  arising  under  these  heads. 

I.  The  Nervous  System.  ((/)  Fever:  This  symp- 
tom is  treated  almost  entirely  by  tub  baths.  The  baths, 
as  employed  here,  differ  somewhat  under  the  different 
attending  physicians.  One  gives  them  every  three 
hours  for  a  temperature  of  102.6'  F.  or  over,  the  bath 
being  at  a  temperature  of  65°  and  lasting  for  ten 
minutes.  The  others  make  the  bathing  temperature 
103°  or  over,  starting  the  bath  at  a  temperature  of  80°, 
and  diminishing  it  in  the  two  or  three  following  baths 
to  70°.  In  all  cases,  unless  the  temperature  of  the 
patient  runs  a  high  course  or  the  nervous  symptoms 
are  pronounced,  the  baths  are  omitted  at  11  o'clock 
P.M.  and  at  2  o'clock  a.m.  Of  course  these  are  not 
hard-and-fast  rules,  the  temperature,  as  well  as  the 
duration  of  the  baths,  being  modified  to  suit  various 
cases.  A  child  may  react  well  to  a  bath  at  80°  last- 
ing for  five  minutes,  while  a  strong,  alcoholic  patient 
may  require  fifteen  minutes  of  a  bath  at  65'  or  even 
60 ^  Throughout  the  bath  all  parts  of  the  patient's 
body  are  rubbed  by  two  assistants  and  cold  water  is 
applied  to  the  head  from  time  to  time.  The  condition 
of  the  patient  is  noted  during  the  bath,  and  if  any 
symptom  of  heart  failure  should  appear  he  is  taken 
out;  moderate  degrees  of  cyanosis  or  shivering,  which 
so  often  follow  the  bath,  are  not  considered  contrain- 
dications to  bathing  for  the  full  time.  It  is  custom- 
ary, after  the  bath,  to  give  the  patient  a  glass  of  warm 
milk,  and  even  to  place  hot-water  bottles  at  the  feet 
if  the  blueness  and  shivering  continue.  Compound 
capsicum  mixture  (tr.  capsici,  THiiss. ;  tr.  zingiberis, 
niviiss.;  chloroformi,  miiss. ;  spir.  frumenti,  q.s.  ad 
3  ii. )  is  often  used  after  the  baths  to  "  warm  up  "  the 
patient.  In  cases  in  which  complications  ccntraindi- 
cate  tub  bathing,  and  often  when  the  patient  is  heavy 
enough  to  be  unwieldy,  alcohol  sponges  are  substi- 
tuted for  the  baths,  the  alcohol  being  cooled  by  ice. 
A  modification  of  the  alcohol  sponge,  which  has  been 
used  here  with  good  effect,  is  to  have  one  person 
sprinkle  the  patient's  body  with  alcohol  by  means  of 
a  whisk  broom,  while  another  hastens  evaporation  by 
waving  a  fan.     The  alcohol  sponges  have  been  found 


852 


MEDICAL    RECORD. 


[December  i,  1900 


nearly  as  efficient  as  the  baths,  although  their  general 
stimulating  effect  seems  less  marked.  In  some  cases, 
when  the  temperature  does  not  react  well,  especially 
when  sponges  are  being  used,  small  doses  of  phenace- 
tin  or  acetanilid  are  given  every  three  hours  for  bath 
temperatures,  and  no  bad  effect  upon  the  pulse  has 
been  noticed.  One  patient,  who  had  a  large  granulat- 
ing wound  of  the  thigli,  ran  a  course  of  typhoid  very 
comfortably  with  gr.  iii.  doses  of  acetanilid  every 
three  hours  when  the  temperature  was  103''  or  over, 
an  ice  coil  being  kept  all  the  time  ujion  the  abdomen. 
It  is  needless  to  say  that  the  reduction  of  temperature 
is  only  one  indication  for  the  baths.  They  are  used 
just  as  much  to  control  the  other  nervous  symp- 
toms, as  for  their  general  tonic  effect.  The  value  of 
baths  in  typhoid  fever  is  now  so  generally  accepted 
that  it  is  unnecessary  to  argue  in  their  favor.  After 
seeing  them  used,  we  can  say  with  certainty  that  they 
rob  typhoid  of  most  of  its  unpleasant  symptoms.  Pa- 
tients running  bath  temperatures  are  covered  by  a 
sheet  only,  unless  they  complain  especially  of  cold, 
when  blankets  are  added.  In  cases  in  which  there  is 
an  afternoon  rise  of  temperature  during  the  period  of 
convalescence,  quinine  sulphate  is  given,  about  fifteen 
grains  a  day,  provided  no  obvious  cause  for  the  tem- 
perature can  be  found.  If  this  does  not  reduce  the 
temperature,  and  if  it  seems  certain  from  the  absence 
of  all  symptoms  that  the  active  process  of  the  disease 
has  ceased,  the  patient's  food  is  increased,  and  he  is 
gotten  out  of  bed.  Under  this  treatment  the  temper- 
ature soon  subsides. 

{b)  Headache:  When  this  symptom,  which  is  seen 
usually  in  the  first  weeks  of  the  disease,  is  not  relieved 
by  the  baths,  sodium  bromide  in  gr.  xv.-xxx.  doses 
is  given.  Phenacetin  and  acetanilid,  the  latter  usually 
in  the  form  of  the  compound  acetanilid  tablet,  are  also 
used.  Continual  application  of  cold  to  the  head,  by 
means  of  the  ice  cap,  is  employed  with  relief  in  some 
cases. 

(c)  Sleeplessness:  This  symptom,  like  headache,  is 
most  common  in  the  early  days  of  typhoid  and  is  often 
stopped  by  the  baths.  When  this  is  not  the  case  any 
of  the  mild  hypnotics  are  used,  perhaps  most  often 
trional  in  gr.  x.-xx.  doses,  given  in  hot  milk.  Sodium 
bromide  is  used  with  the  double  purpose  of  producing 
sleep  and  relieving  headache.  Sometimes  a  half-grain 
of  codeine  is  given  with  trional,  a  combination  whicii 
has  usually  proved  very  efficient.  Morphine  is  never 
used. 

(d)  Delirium:  With  tiie  use  of  baths,  except  in 
alcoholic  cases  or  in  neglected  patients  who  are  well 
along  in  the  disease,  this  symptom  is  seldom  seen  in 
other  than  its  mild  forms.  In  the  mild  cases  of  delir- 
ium, sodium  bromide  or  other  weak  hypnotics  are  often 
sufTicient.  The  whiskey  used  for  stimulation  has  a 
quieting  effect  in  many  cases.  In  severe  forms  of  de- 
lirium, seen  chiefly  in  alcoholic  patients,  more  fre- 
quent bathing  is  used,  that  is,  the  baths  are  continued 
through  the  night.  In  alcoholic  delirium  larger  doses 
of  whiskey  are  given,  one  ounce  or  even  more,  e\ery 
three  hours.  Continuous  doses  of  sodium  bromide 
are  also  given,  and  if  the  pulse  permits,  small  doses 
of  chloral  hydrate  are  added.  Paraldehyde  and  amy- 
lene  hydrate  often  work  well,  and  their  unpleasant 
taste  and  the  danger  of  upsetting  the  stomach  are 
overcome  by  giving  them  by  rectum  in  warm  milk, 
double  the  ordinary  mouth  dose  being  used.  An  al- 
coholic case  can  sometimes  be  quieted  by  substituting 
for  an  evening  bath  a  cold  pack  of  from  fifteen  to 
forty-five  minutes'  duration.  Delirious  patients  are 
secured  in  bed  by  draw  sheets,  and  when  tiie  delirium 
is  violent  their  hands  and  feet  are  tied  to  the  bed,  un- 
less they  can  be  constantly  watched. 

2.  The  Digestive  Sy.stem.  (a)  The  Mouth:  Each 
patient  is  ordered  a  mouth  wash,  made  by  adding  tr. 


of  myrrh  ;  i.  and  sodium  bicarbonate  gr.  xxx.  to 
water  ;  '\-  The  mouth  is  thoroughly  swabbed  out 
with  this  at  frequent  intervals,  usually  after  each  feed- 
ing. This  precaution  prevents  such  unpleasant  com- 
plications as  parotitis  and  otitis  media.  The  tongue, 
when  dry,  is  moistened  frequently  with  benzoinated 
oil  or  with  compound  syrup  of  hypophosphites. 

(/')  Nausea  and  vomiting:  When  nausea  is  com- 
plained of,  the  food  is  modified.  Prepared  milk, 
made  by  adding  cerium  oxalate  gr.  v.  and  sodium 
bicarbonate  gr.  x.  to  3  viii.  of  milk,  or  peptonized 
milk  is  given.  If  the  nausea  still  persists  or  if  vomit- 
ing ensues,  the  various  gastric  sedatives  are  employed, 
such  as  minim  doses  of  dilute  hydrocyanic  acid,  nitric 
acid  Til  /i  to  water  3  i.,  frequently  repeated,  or  small 
quantities  of  wine  of  ipecac  or  of  tartar  emetic.  Fre- 
quent feedings  of  small  quantities  of  peptonized  milk, 
say  3  i.  or  even  less,  every  hour  will  sometimes  settle 
the  stomach.  Counter-irritation  over  the  epigastrium 
by  means  of  a  mustard  paste  proves  beneficial  in  some 
cases.  When  all  these  means  fail,  and  they  often  do, 
gastric  lavage  is  done,  food  is  withheld  for  several 
hours,  and  then  the  feeding  is  begun  in  small  quanti- 
ties, gradually  increased. 

((*)  Constipation:  In  the  early  days  of  the  disease 
the  bowels  are  kept  well  open  by  means  of  calomel  in 
small  doses,  followed  by  saline  purgatives.  In  the 
second  and  third  weeks,  when  there  is  danger  of  in- 
testinal complications,  no  cathartics  are  given,  the 
bowels  being  moved,  when  necessary,  by  means  of 
glycerin  suppositories  or  soap-suds  enemata. 

{d)  Diarrhcea:  When  there  are  frequent  small  move- 
ments, the  condition  may  be  the  result  of  constipation 
and  is  relieved  by  means  of  a  large  enema  which 
washes  out  the  lower  bowel.  If  we  are  sure  that  the 
diarrhooea  is  not  due  to  fecal  impaction,  mild  astrin- 
gents, such  as  bismuth  subnitrate  or  tannalbin,  are 
used.  In  severe  or  protracted  cases,  small  doses  of 
powdered  opium  are  given. 

(1?)  Distention:  This  symptom  is  generally  treated 
by  means  of  enemata  containing  turpentine  in  snwil 
quantities  (  3  ss.-  3  i.)  The  rectal  tube  is  also  used, 
especially  after  the  enemata.  Sometimes  several  small 
doses  of  turpentine  (  TTl  v.-x.)  in  capsules  are  given 
with  benefit.  Turpentine  stupes  are  also  used,  tx- 
cept  in  neglected  cases,  this  symptom  is  seldom 
troublesome.  There  seems  to  be  no  doubt  that  the  pre- 
vention of  marked  abdominal  distention  dees  much 
toward  lessening  the  danger  of  such  serious  complica- 
tions as  intestinal  htinorrhage  and  perforation. 

3.  Circulatory  System.  With  the  baths  some  cases 
pass  through  their  whole  course  without  indications 
for  further  stimulation.  When  the  pulse  becomes 
rapid,  soft,  dicrotic,  or  intermittent,  whiskey  is  given 
in  three  or  four  half-ounce  doses  a  day  at  first,  in- 
creased to  six  or  eight  doses,  as  the  pulse  requires. 
Except  in  alcoholic  cases,  more  whiskey  than  this  is 
seldom  used.  In  some  persons,  whose  stomachs  do 
not  tolerate  whiskey,  brandy  is  substitued  to  advan- 
tage. Brandy  might  also  be  used  for  stimulation 
when  there  is  diarrhcea.  When  whiskey  or  brandy 
alone  fail  to  hold  the  pulse,  strychnine  sulphate  is 
added,  and  if  still  more  stimulation  is  needed  digitalis 
is  given  either  as  the  tincture  or  as  the  fiuid  extract. 

4.  Respiratory  System.  The  mild  forms  of  bron- 
chitis, which  usually  accompany  typhoid,  are  disre- 
garded in  treatments.  Bronchitis  is  not  made  a  con- 
traindication for  tub  bathing,  in  fact  the  bathing  often 
appears  to  improve  this  condition.  If  the  bronchitis 
becomes  extensive  or  troublesome  the  ordinary  reme- 
dies are  employed,  such  as  brown  mixture,  Stokes'  ex- 
pectorant, or  Delafield's  bronchitis  tablets. 

5.  Urinary  System.  During  the  active  stage  of  the 
disease  the  urine  is  measured  and  a  record  kept.  A 
specimen  of  urine  is  examined  every  three  days,  un- 


December  i,  1900] 


MEDICAL    RECORD. 


853 


less  more  frequent  examination  is  required.  Wlien 
the  quantity  of  urine  passed  is  small,  or  if  the  specific 
gravity  is  high,  patients  are  encouraged  to  drink  more 
tiuids,  either  water  or  Vichy.  The  ordinary  mild 
forms  of  acute  degenerative  nephritis  are  disregarded 
in  treatment.  Retention  of  urine,  if  not  yielding  to 
the  ordinary  remedies,  such  as  heat  over  the  bladder, 
hot  enemata,  and  sweet  spirits  of  nitre,  is  relieved 
by  cutheterization,  repeated  if  necessary. 

II.  The  Treatment  of  Complications. 

1.  Intestinal  hemorrhage:  When  blood  appears  in 
the  stools,  if  it  is  found  not  to  come  from  the  rectum, 
the  tubs  are  discontinued;  the  patient  is  kept  as  quiet 
as  possible,  Magendie's  solution  of  morphine  being 
used  if  necessary;  and  continual  application  of  cold 
is  made  to  the  abdomen  by  means  of  the  ice  coil. 
The  temperature,  if  high,  is  kept  down  by  alcoiiol 
sponges,  given  without  turning  the  patient,  and  by  an- 
tipyretics. If  the  hemorrhage  is  severe  enough  to 
produce  symptoms,  the  foot  of  the  bed  is  raised,  hot 
saline  enemata  of  about  eight  ounces  each  are  given 
at  intervals  of  from  three  to  four  hours  and  stimula- 
tion is  increased.  If  these  means  are  insufficient,  tiie 
patient  is  infused  with  hot  saline  solution.  Hot 
water  bottles  are  used  to  keep  up  body  temperature 
if  it  falls  below  normal. 

2.  Pneumonia:  Should  a  pneumonia  intervene  in 
the  course  of  typhoid,  the  treatment  is  modified  only 
in  so  far  as  new  symptoms  referable  to  the  pneumonia 
arise.  The  tubs  are  kept  up,  unless  the  condition  of 
the  patient  is  such  as  to  make  them  immediately  dan- 
gerous. If  tubs  seem  inadvisable  and  the  nervous 
symptoms  still  need  treatment,  sponges  are  substi- 
tuted. In  the  advent  of  heart  failure,  more  active 
stimulation  is  employed.  (Edema  of  the  lungs  is  met 
as  in  pneumonia  by  nitroglycerin,  dry  cupping,  and 
o.xygen  inhalations. 

3.  Nephritis:  If  a  severe  nephritis  arises,  appro- 
priate treatment  is  added.  Tension  in  the  pulse  is 
combated  by  nitroglycerin  or  chloral  hydrate.  Di- 
minished e.\cretion  of  urine  is  treated  by  diuretics, 
ihot  saline  enemata,  or  hot  rectal  irrigations  with  the 
Kemp  tube.  The  baths  are  stopped  and  the  tempera- 
ture is  reduced,  if  necessary,  by  means  of  antipyretics. 

4.  Phlebitis:  The  limb  affected  is  kept  as  quiet  as 
possible.  The  most  efficient  treatment  perhaps  has 
been  the  application  of  twenty-five-per-cent.  ichthyol 
ointment  to  the  course  of  the  vein  involved.  VVet 
carbolic  dressings  are  also  used.  Tincture  of  iodine 
is  sometimes  painted  over  the  affected  vein,  and  dress- 
ings of  lead-and-opium  wash  give  relief  to  the  pain  in 
some  cases. 

5.  Bedsores:  The  treatment  of  these  is  chiefly  pre- 
ventive. Each  patient's  back,  shoulders,  and  hips  are 
rubbed  daily  wirii  a  paste  made  from  zinc  oxide  with 
fifty-per-cent.  alcohol.  Reddened  areas  are  protected 
by  dressings  and  by  rubber  rings.  If  these  measures 
are  inadequate  the  patient  is  placed  upon  a  water  or 
air  mattress.  If  bed  sores  do  form,  dead  tissue  is  cut 
away,  and  various  antiseptic  and  stimulating  dressings 
are  applied.  Twenty-five-per-cent.  ichthyol  ointment 
has  been  found  efficient  for  cleaning  up  these  sores 
and  starting  granulations. 

It  is  hardly  necessary  in  this  article  to  give  the 
treatment  of  such  rare  complications  as  intestinal  per- 
foration, neuritis,  periostitis,  and-osteo-myelitis. 

III.  Feeding. — The  routine  diet  throughout  the 
active  stage  of  typhoid  is  milk,  fifty  to  seventy  ounces 
being  given  in  twenty-four  hours.  It  is  customary  to 
keep  a  daily  record  of  the  amount  of  milk  taken,  so 
that  it  will  not  fall  below  what  is  necessary.  When 
plain  milk  is  not  acceptable  to  the  patient  it  is  varied 
in  different  ways;  a  little  brandy  or  a  few  spoonfuls 
of  coffee  or  some  malted  milk  is  added;  koumyss  or 
matzoon  is  substituted  for  milk  from  time  to  time  for 


variety.  Patients  who  complain  of  hunger  are  given 
broths  and  beef  juice.  As  soon  as  the  temperature 
reaches  normal,  more  active  feeding  is  begun.  'I  he 
patient  is  given  a  lamb  chop,  or  an  egg  boiled  for 
twenty  minutes,  and  finely  cliopped,  or  scrapedbeef 
sandwiches.  Proper  mastication  of  the  food  is  urged. 
Each  day,  as  the  food  agrees,  new  articles  of  diet  are 
added  to  the  list,  or  those  already  given  are  increased 
in  amount.  Haked  custard,  bread,  milk  toast,  and 
finally  chicken,  raw  oysters,  baked  apple,  baked  pota- 
to, rice,  hominy,  and  green  vegetables  are  allowed,  the 
milk  all  the  time  being  cut  down.  The  patient  is 
kept  upon  this  food  while  in  the  hospital  and  is  told 
to  continue  it  for  several  weeks  after  leaving. 

IV.  Management  of  Patient  in  Convalescence. — 
(a)  Medication  :  Stimulants,  wliich  have  been  used, 
are  cut  down  as  fast  as  the  pulse  warrants.  Two  or 
three  half-ounce  doses  of  whiskey  are  usually  given 
for  some  days,  and  llien  one  or  two  egg-nogs  a  day,  if 
the  patient  likes  them.  If  tonics  are  indicated,  small 
doses  of  strychnine  sulphate,  tincture  of  nux  vomica, 
or  iron,  the  latter  often  in  the  form  of  citrate  of  iron, 
and  quinine,  are  administered;  but  good  feeding  and 
plenty  of  sleep  are  chiefly  relied  upon  to  build  up  the 
patient.  The  bowels  are  kept  well  open  by  means  of 
mild  cathartics  such  as  calomel  in  small  doses,  cas- 
cara  sagrada,  aloin-belladonna-and-strychnine  tablets, 
and  the  various  saline  purgatives.  Calomel  is  used 
especially  in  the  early  days  of  convalescence  to  clean 
up  the  tongue.  In  general  just  as  little  medicine  as 
possible  is  given. 

(If)  Getting  the  patient  up:  After  several  days  of 
normal  temperature,  the  head  of  the  bed  is  raised,  the 
height  and  time  of  raising  being  gradually  increased. 
At  the  end  of  about  ten  days  of  normal  temperature, 
the  patient  is  allowed  to  sit  up  for  from  a  half  to  one 
hour.  If  there  are  any  signs  of  weakness  the  time  is 
cut  short.  The  time  of  sitting  up  is  increased  about 
an  hour  a  day,  until  the  patient  can  stand  eight  or  ten 
hours,  when  he  is  given  his  clothes.  Meanwhile 
walking  has  been  tried  and  increased  as  strength 
allows.  After  about  three  weeks  of  normal  temper- 
ature the  patient  is  discharged. 

V.  Prophylactic  Treatment. — All  utensils  used  in 
the  care  of  typhoid  patients  are  marked  and  are  em- 
ployed only  for  such  patients.  Their  bedding  is  car- 
bolized  before  going  to  the  laundry,  where  it  is  washed 
separately.  The  dejecta  are  treated  with  a  strong 
solution  of  formaldehyde  before  being  thrown  into  the 
sinks.  Patients  who  are  suspected  of  having  typiioid 
are  put  upon  individual  enteric  precautions  until  the 
diagnosis  is  cleared  up.  The  utensils  for  these  pa- 
tients are  marked  with  their  names  and  are  used  only 
for  them.  Nurses  and  orderlies  having  the  care  of 
typhoid  patients  are  told  the  danger  of  infecting  them- 
selves as  well  as  others.  They  are  instructed  to  dis- 
infect their  hands  carefully  after  caring  for  enteric 
cases,  especially  after  carrying  bed  pans,  changing 
bedding,  or  giving  tubs. 


Kernig's  Sign  and  Meningism.  —  Paolo  Galli 
reaches  the  following  conclusions:  (r)  Kernig's  sign 
exists  only  in  meningitis,  whether  this  be  of  epidemic, 
secondary,  or  tuberculous  origin.  (2)  It  is  a  symptom 
of  great  importance,  being  found  in  83.5  to  80  per 
cent,  of  cases.  (3)  As  it  gives  us  information  in  re- 
gard to  the  pressure  of  the  cephalo-rachidian  fluid,  it 
may  in  regard  to  meningism  be  of  value  in  differen- 
tiating simple  dynamic  disturbances  from  a  true  menin- 
geal inflammation.  Its  presence,  if  positively  ascer- 
tained, may  take  the  place  of  lumbar  puncture  in  the 
generic  diagnosis  of  meningitis. — Rnista  Critica  di 
Clinica  Alcdka,  October  13  and  20,  1900. 


854 


MEDICAL    RECORD, 


[December  i,  1900 


A   FEW  REMARKS    RELATIVE   TO   TYPHOID 
FEEDING/ 

By   WILLIAN    M.    BROWN,    M.D., 

ROCHESTER,    N.    V. 

While  the  subject  of  this  paper  is  one  on  which  much 
has  been  said  in  the  past,  and  of  which  it  may  seem 
that  the  ground  has  been  well  covered,  yet  I  believe 
that  the  last  word  has  not  been  said,  and  that  the  rule 
now  so  commonly  observed,  that  a  patient  suffering 
from  typhoid  infection  should  have  exclusively  liquid 
diet  until  the  temperature  has  been  normal  for  a  week, 
will  soon  become  the  exception. 

Before  entering  on  the  subject  proper  I  wish  to 
emphasize  that  my  position  is  not  one  dogmatic  or 
that  I  would  expect  the  ideas  advanced  in  this  article 
to  apply  to  all  cases  alike.  I  feel  that  no  physician 
has  the  right  to  subject  each  patient  to  an  empirical 
rule;  rather  is  it  his  highest  duty  to  give  the  most 
careful  consideration  to  the  personal  element  in  each 
case.  Pre-eminently  should  this  be  so  in  typhoid  and 
notoriously  have  we  in  the  past  failed  to  observe  this 
obligation. 

It  has  been  stated  to  us  by  one  of  the  prominent 
members  of  the  profession  that  the  "mortality  rate 
and  the  prominent  symptoms  of  hemorrhage  and  dis- 
tension in  typhoid  fever  are  not  essentially  influenced 
by  the  diet." 

While  we  realize  that  the  large  increase  in  body 
temperature,  which  is  usually  observed  in  typhoid,  is 
the  result  of  the  toxamia — this  hyperpyrexia  being 
caused  in  part  by  the  irritation  of  the  thermic  centres 
by  the  toxins  which  result  from  the  growth  of  the 
bacillus  typhosus — yet  we  believe  that  the  toxins  from 
the  specific  bacillus  are  only  a  part  of  the  cause.  We 
remember  that  many  other  forms  of  bacterial  life  find 
a  fertile  field  of  culture  in  a  large  residue  of  partially 
digested  food,  and  that  the  typhoid  lesions  with  a  tur- 
gid intestinal  mucus  membrane  offer  ideal  opportuni- 
ties for  the  absorption  of  their  toxins,  and  further, 
that  the  mai-decomposition  cf  the  food  residue  is  very 
largely  responsible  for  the  distention  so  often  seen  in 
typhoid-fever  patients. 

I  repeat  that  typhoid  fever  is  a  toxeemia  from  the 
growth  of  a  specific  bacillus  plus  other  forms  of  bac- 
terial life,  the  secondary  toxaemia  developing  after 
the  specific. 

Another  consideration  in  arranging  the  diet  for  a 
typhoid  patient  is  the  influence  of  food  and  its  diges- 
tion on  heat  production,  which  though  slight  may  be 
decisive. 

The  ordinary  source  of  animal  heat  is  in  the  poten- 
tial energy  of  the  organic  foodstuffs.  This  energy 
may  be  converted  into  heat  directly,  as  the  immediate 
results  of  chemical  decomposition,  which  is  about 
ninety  per  cent.,  and  indirectly  as  by  the  mechanical 
movements,  such  as  muscular  contraction,  blood  flow, 
etc.,  which  is  about  ten  per  cent.  In  a  direct  way  one 
gram  of  proteids  yields  4,937  calories,  and  one  gram 
of  carbohydrates  yields  4,1 16  calories,  while  one  gram 
of  fat  yields  9,312  calories.  All  structures  produce 
more  heat  during  activity  than  during  rest,  and  the 
glands  are  the  greatest  heat-producing  structures  in  the 
body;  when  muscles  are  contracting  eighty  per  cent. 
of  the  energy  expended  results  in  heat,  while  only 
twenty  per  cent,  results  in  work. 

Now  if  you  will  keep  in  your  minds  the  foregoing 
facts,  we  will  consider  for  a  few  moments  some  of  the 
physiology  of  the  digestive  functions. 

The  method  of  production  of  a  digestive  secretion 
is  essentially  the  same,  whether  it  be  saliva,  the  gas- 
tric, the  pancreatic,  or  the  intestinal  fluid,  and  con- 
sists of  a  nerve  stimulation  which  is  followed  by  a 
production  of  the  special  fluid  of  the  gland  supplied 
'  Read  before  the  Monroe  County  Medical  Society,  1900. 


by  the  nerves  so  stimulated.  These  glands  are  com- 
posed of  cells  wliich  during  rest  have  a  granular  ap- 
pearance througliout  their  structure.  When  stimulation 
is  applied  to  the  nerves  supplying  a  gland  of  this 
kind,  whether  the  stimulus  is  direct  or  reflex,  the  cells 
begin  to  lo.se  their  granular  appearance  from  the  outer 
border,  and  if  the  stimulation  is  continued  the  gran- 
ules almost  entirely  disappear,  having  been  used  up  in 
the  formation  of  the  secretion.  Now  while  this  stimu- 
lation ])roduces  a  secretion  in  which  the  water  and 
salts  maintain  a  more  or  less  constant  relation,  the 
organic  constituents,  those  parts  of  the  secretion  on 
which  depends  its  effectiveness,  e.g..  ptyalin  in  the  sa- 
liva, pepsin  in  the  gastric  juice,  etc.,  are  dependent  very 
largely  on  the  condition  of  the  gland;  i.e.,  if  the  gland 
has  been  inactive,  is  unfatigued,  the  stimulation  is 
followed  by  a  secretion  in  which  the  percentage  of  the 
organic  parts  rises  way  out  of  all  poportion  to  the 
water  and  salts,  while,  on  the  other  hand,  if  the  gland 
is  fatigued  the  stimulus  will  have  very  slight  or  no 
effect  on  the  organic  pans,  and  the  result  is  a  secre- 
tion deficient  in  the  constituent  enzymes.  Khigine 
has  published  tables  which  show  that  a  diet  rich  in 
proteids  promotes  the  greatest  flow  of  the  digestive 
secretions,  but  that  a  rich  carbohydrate  diet  promotes 
a  secretion  witii  the  highest  digestive  power. 

Time  will  not  permit  me  to  go  into  details  of  the 
chemistry  of  digestion.  The  process  is  both  mechani- 
cal and  chemical,  and  both  processes  are  decided  heat 
producers,  and  also  during  functional  activity  of  the 
digestive  glands  the  constituent  enzymes,  which  are 
derived  from  the  cell  contents  of  these  glands,  are  used 
up,  and  it  takes  considerable  rest  for  those  cells  to 
regain  a  condition  in  which  they  are  able  to  furnish 
an  effective  digestive  fluid. 

It  has  been  stated  that  in  typhoid  fever  the  various 
digestive  fluids  are  deficient  in  both  quantity  and 
quality.  The  reason  for  this  seems  plain.  The 
toxins  resulting  from  bacterial  life  are  very  powerful 
chemical  irritants,  and  any  irritant  introduced  into  the 
alimentary  canal  stimulates  the  digestive  glands  and 
results  in  their  exhaustion.  The  restoration  of  the 
digestive  efficiency  should  be  one  of  the  principal 
objects  of  our  therapy.  Give  the  digestive  function 
enough  rest  so  that  when  needed  it  will  respond. 
Eliminate,  so  far  as  possible,  the  bacterial  life  in  the 
intestine  which  will  reduce  the  toxa-mia.  Give  food 
which  has  been  shown  to  increase  the  quantity  and 
power  of  the  secretions;  viz.,  proteid  and  carbohy- 
drate. Such  food  will  leave  but  little  residue  as  a 
bacterial  culture  medium. 

Overfeeding  or  too  frequent  feeding  fatigues  the 
digestive  glands.  The  secretions  are  inetTicient  and 
the  food  is  but  partially  digested.  That  portion  which 
is  not  prepared  for  absorption  undergoes  maldecom- 
position,  ferments,  distention  occurs,  bacteria  of  all 
kinds  find  a  mellow  soil,  and  the  toxaemia  is  increased, 
and  too  often  only  death  steps  in  to  disturb  the  de- 
plorable cycle  of  cause  and  effect. 

"  It  is  not  so  much  solid  food  as  the  indigestible 
which  should  be  eschewed,  and  it  should  never  be  for- 
gotten that  all  foods,  except  such  as  have  been  predi- 
gested,  are  solid  in  the  first  stage  of  digestion."  A 
pint  of  milk  contains  as  much  solid  material  as  a 
mutton  chop  and  will  take  as  long  to  digest.  If  all 
food  is  thoroughly  disintegrated  before  entering  the 
intestine  we  need  have  no  fear  of  mechanical  irrita- 
tion to  ulcerating  surfaces. 

The  preparation  of  a  diet  list  for  each  typhoid  pa- 
tient is  a  problem  which  must  be  solved  at  the  bed- 
side; but,  in  consideration  of  the  physiological  facts 
before  stated,  is  it  not  logical  to  give  these  patients  a 
more  liberal  diet,  rich  in  proteids  and  carbohydrates 
and  at  longer  intervals  than  have  prevailed  in  the 
past?     If  the  food  is  not  efficiently  digested,  supple- 


December  i,  1900] 


MEDICAL   RECORD. 


855 


ment  with  artificial  digestion.  Give  acidulated  bev- 
erages, which  relieve  thirst  and  aid  digestion.  Water 
favors  nutrition  and  the  elimination  of  wastes  and 
toxins,  and  also  aids  in  the  dissipation  of  heat. 

A  clean  tongue,  a  soft  abdomen,  natural  stools  not 
too  hard  and  without  coagula  of  casein  or  Hakes  of 
fat,  show  that  milk  if  taken  is  being  well  digested  and 
is  proper  food;  but,  on  the  other  hand,  milk  witii  its 
large  proportion  of  fat  is  not  easily  digested  by  many 
people,  and  should  be  given  with  caution  and  close 
observation  in  typhoid.  I  think  that  a  "  typhoid 
stool,"  so  called,  is  a  partially  digested  milk  stool. 
We  do  not  observe  the  typhoid  stool  from  patients  not 
fed  on  milk. 

During  the  past  two  years  medical  literature  has 
recorded  many  experiments  of  the  more  liberal  feeding 
of  typhoid-fever  patients,  and  in  each  instance  there 
has  been  conclusive  evidence  of  its  value. 

In  conclusion  the  facts  are:  ist.  That  the  bacillus 
typhosus  while  the  initial  is  not  the  prepondering  factor 
in  the  toxcemia. 

-  2d.  That  in  ordinary  cases  the  functions  of  diges- 
tion are  attended  by  heat  production,  which  is  varied 
in  amount  by  the  kind  of  food  ingested,  proteids  and 
carbohydrates  giving  the  least  number  of  heat  units 
while  promoting  the  most  effective  digestive  Huids. 

3d.  That  the  process  of  digestive  secretion  is  ac- 
companied by  a  transudation  of  certain  portions  of  the 
cell  substance  in  the  various  glands,  which  require 
considerable  time  for  restoration  before  they  are  capa- 
ble of  efficient  work.  Hence  we  should  not  feed  too 
often. 

4th.  That  an  inefficient  digestion  leaves  a  large 
residue  of  food  which  undergoes  fermentation,  causes 
distention,  increases  the  danger  of  hemorrhage  and 
perforation;  also  forms  a  favorable  culture  medium 
for  the  various  bacteria,  so  increasing  the  toxaemia, 
which  in  turn  hastens  the  disintegration. 

Sth.  That  milk  unprepared  is  not  a  liquid  food  and 
will  take  as  long  to  digest  as  many  solid  foods. 


A  Note  on  the  Causation  of  Breathlessness  in 
Anaemic  Debility. — J.  Henton  White  says  that  so  far 
the  established  facts  of  anaemia  show  that  a  consider- 
able strain  is  thrown  on  the  right  ventricle  and  pul- 
monary artery,  and  that  there  is  a  systemic  vasomotor 
paresis.  Granted  that  there  is  a  supply  of  vaso-con- 
strictor  fibres  to  the  lungs,  it  seems  obvious  that  under 
normal  conditions,  when  venous  blood  stimulates  the 
medulla,  the  impulses  to  the  respiratory  centre  and  the 
heart  would  be  assisted  by  a  dilatation  of  the  pulmonary 
vessels,  which  would  be  iDrought  about  by  an  inhibition 
of  the  vaso-constrictor  impulses  which  are  constantly 
travelling  along  all  vaso-constrictor  nerves.  In  anae- 
mic debility,  however,  the  dilatation  of  arterioles  ii  de- 
layed ;  this  being  the  case  in  the  pulmonary  system,  all 
the  extra  blood  which  has  to  be  forced  through  the 
lungs  on  exertion  must  depend  on  right-ventricle 
force,  unassisted,  as  in  health,  by  a  dilated  periphery. 
As  supporting  the  explanation  of  ansemic  dyspna-a  by 
vasomotor  failure,  it  is  to  be  noted  that  the  disease  is 
prevalent  in  the  female  sex,  whose  vasomotor  system  is 
more  unstable  than  that  of  the  male,  and  also  that  it 
usually  occurs  at  puberty,  when  this  system  is  un- 
usually active. —  T/ie  Birmingham  Medical  Review, 
October,  1900. 

Antitoxin  in  Cerebro-Spinal  Meningitis. — Francis 
M.  O'Gorman  was  called  to  see  a  child  which  was  evi- 
dently suffering  from  broncho-pneumonia  and  laryngeal 
diphtheria.  He  injected  1,000  units  of  anti-diphther- 
itic serum.  In  two  hours  the  temperature  had  fallen 
to  103°  F.,  the  respirations  to  86,  and  the  convulsions 


had  almost  ceased,  but  the  pulse  remained  at  igo. 
Five  hundred  units  additional  were  injected,  and  the 
breathing  became  easier.  The  next  day  breathing  was 
again  difficult,  and  1,000  units  were  injected  in  the 
morning,  500  in  the  afternoon,  with  beneficial  results. 
For  weeks  the  illness  continued,  but  the  child  con- 
stantly improved.  The  pulse,  howe\er,  remained  be- 
tween 150  and  182  for  a  fortnight  and  then  fell  to 
140,  where  it  stayed.  For  two  months  the  child  was 
in  excellent  health,  and  then  suddenly  had  violent 
convulsions.  C'erebro-spinal  meningitis  was  diag- 
nosed. The  child  died  within  two  days.  The  author 
believes  that  the  extraordinary  pulse  and  respiration 
of  the  previous  illness  were  due  to  a  latent  inherited 
meningeal  infiammation.  Antitoxin  had  a  decidedly 
beneficial  action  upon  the  convulsions  in  the  previous 
attack,  and  the  author  queries  whether  its  administra- 
tion might  have  saved  the  child's  life  in  the  second 
attack. — Biiffaht  Medical  Jounial,  October,  1900. 

Contagious  Insanity  ("  Folic  a  trois  "  and  "  Folia 
a  deux")  —  K.  F.  Chagnon  says  that  the  popular 
idea  that  insanity  is  contagious  is  true  only  under 
certain  circumstances.  The  persons  must  live  the 
same  family  life,  possess  the  same  ideas  and  senti- 
ments, live  out  of  the  pale  of  external  influences.  More- 
over, one  of  the  two,  the  one  playing  the  active  role, 
must  by  means  of  superior  intelligence,  energy,  and 
dominating  will  power,  be  able  to  impress  upon  the 
passive  nature  the  probability  of  the  delusions  which 
have  emanated  from  his  or  her  diseased  brain.  The 
author  reports  a  case  of  delirium  shared  by  three 
seamstresses  who  had  lived  together  for  years,  and 
another  of  delusions  held  by  a  brother  and  sister  who 
had  lived  together  for  fifty  years. — V  Union  medieale 
dit  Canada,  September,  1900. 

Acute  Fibrinous  Bronchitis  due  to  Influenza. — 
Luigi  Masciangioli  reports  a  case  of  this  affection, 
which  he  says  is  rare  enough  as  a  primary  disease,  and 
altogether  exceptional  as  a  complication  of  any  other 
disease.  In  the  case  under  discussion  the  usual  s)  nip- 
toms,  cough  and  dyspnaa,  were  absent.  There  were 
sopor  almost  from  the  onset  of  the  influenza,  and  a 
bronchial  souffle  at  the  apex  of  the  right  lung,  with 
other  indications  of  grave  functional  disturbance. 
The  diagnosis  was  difficult,  but  was  cleared  by  the 
appearance  of  fibrinous  sputum.  It  was  evident  that 
a  considerable  number  of  the  bronchial  branches  had 
become  rapidly  occluded,  causing  collapse  of  a  large 
amount  of  pulmonary  jiarenchyma,  with  consequent 
accumulation  of  carbonic  acid  in  the  system;  hence 
the  symptoms  of  depression.  Treatment  consisted  of 
the  usual  remedies,  followed  by  pulmonary  gymnastics 
with  the  inhalation  of  disinfectant  and  balsamic  prep- 
arations.—  La  Rijorma  Atcdica,  September  27,  1900. 

Delirium  in  the  Course  of  Infective  Diseases. — 
Luigi  Silvagni  thus  concludes  his  study  of  this  sub- 
ject: The  appearance  of  delirium  during  the  course  of 
infective  diseases  is  a  frequent  symptom  to  which  cer- 
tain individuals  are  predisposed  through  hereditary 
nervous  taint,  concomitant  functional  neuroses,  alco- 
holism, or  extreme  physical  or  mental  fatigue.  The 
differential  diagnosis  between  infective  or  temporary 
toxic  delirium  and  a  true  psychosis  is  extremely  diffi- 
cult, but  we  must  bear  in  mind  that  real  insanity  is 
most  rare  in  the  course  of  febrile  diseases;  that  the 
origin  of  the  delirium  in  these  cases  is  very  complex 
(hyperpyrexia,  intoxication,  inanition,  etc.),  and  that 
infective  delirium  being  under  no  special  rule,  but 
able  to  assume  any  form  of  the  disorder,  may  be  more 
under  the  influence  of  special  mental  tendencies  on 
the  part  of  the  patient  than  that  of  the  infective  proc- 
ess.— Rirista  Critica  di  Clinica  Medica,  September  22 
and  29,  and  October  6,  1900. 


856 


MEDICAL    RECORD. 


[December  i,  1900 


Medical   Record: 

A    IVcikly  Journal  of  Medicine  and  Surgery. 


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

I'lKLlSllERS 

WM^  WOOD  &.  CO,  51    Fifth  Avenue. 
New  York,  December  i,  1900. 


THE  NEED    OF  A  FILTRATION   PL.\NT  FOR 
OUR    WATER    SYSTEM. 

Now  that  the  grand  jury  has  taken  up  the  question  of 
a  purer  and  more  abundant  water  supply  for  Greater 
New  York,  there  is  a  reasonably  good  prospect  that 
some  very  necessary  reforms  along  desirable  lines  will 
be  instituted.  Up  to  the  time  of  the  recent  rainfall, 
the  higher  portions  of  the  beds  of  the  water-sheds  have 
been  e.xposed  and  the  lighter  showers  have  washed  de- 
caying vegetation  and  other  forms  of  organic  debris 
into  the  general  currents  of  the  entire  water  system. 
As  a  natural  result  there  has  been  a  public  clamor  for 
some  guarantee  against  what  is  of  almost  constant  oc- 
currence under  the  usual  conditions  of  prolonged 
drought.  It  is  useless  for  the  authorities,  in  view  of 
their  present  helplessness  in  fighting  against  natural 
causes,  to  urge  that  there  is  no  marked  increase  of 
sickness  as  the  result  of  the  state  of  affairs  in  ques- 
tion, inasmuch  as  it  is  extremely  difficult  to  persuade 
the  people  that  filthy  water  as  such,  because  it  may 
not  carry  with  it  typhoid  germs,  is  a  tolerable  inflic- 
tion which  must  be  complacently  borne.  The  cry  is 
not  only  for  safe  water,  but  for  pure  water. 

Much  of  the  trouble  in  the  districts  supplied  direct- 
ly from  the  larger  mains  is  due  to  the  stagnation  de- 
posits in  what  are  styled  the  "dead  ends"  of  the  fire 
plugs.  These  cul-de-sacs  not  only  afford  favorable 
conditions  for  the  accumulation  of  sediment,  but  indi- 
rectly contaminate  the  wdXe-x  circulation  in  all  the 
neighboring  pipes.  Obviously  a  ready  remedy  for  this 
part  of  the  difficulty  is  the  periodical  and'  systematic 
cleansing  of  the  dead  ends  by  what  is  called  the 
"  blowing-off "  process,  whereby  all  the  offensive  sedi- 
ment is  effectually  washed  out  through  the  various 
hydrant  vents. 

Although  such  measures  produced  good  results  in  a 
way,  the  supply  from  the  house  faucets  was  still  more 
or  less  turbid,  bad  smelling,  and  of  foul  taste,  forcing 
the  consumers  either  to  use  filters,  or  to  boil  the  water, 
or  to  drink  bottled  waters  altogether. 

The  necessity  for  this  form  of  filtration  has  natur- 
ally turned  public  attention  to  the  advisability  of 
adopting  it  on  the  larger  scale  as  applied  to  the  entire 
supply.  From  every  sanitary  point  of  view  it  goes 
without  saying  that  a  large  and  comprehensive  fil- 
tration system  is  now  a  public  necessity.  It  is  esti- 
mated that  the  cost  for  the  work  will  approximate  fif- 


teen million  of  dollars.  Large  as  this  sum  appears,  it 
will  certainly  be  a  cheap  investment  for  the  present 
and  future  generations. 

When  such  a  plant  is  in  effective  operation,  the 
question  can  be  practically  answered  once  and  for  all 
as  to  its  necessity,  utility,  and  far-reaching  influences 
upon  the  general  health  of  the  public.  There  is 
abundant  testimony  to  the  effect  that  it  is  the  only 
remedy  for  the  constantly  recurring  befoulment  of  our 
water  after  every  season  of  drought.  It  is  comforting 
to  know  that  the  municipality  has  absolute  control  of 
our  extensive  water-sheds,  and  can  guarantee  so  far  as 
such  is  possible  against  all  apparent  dangers  of  typhoid 
infection  of  the  river  beds  or  reservoirs.  Already  the 
health  board  with  commendable  zeal  is  inspecting  the 
entire  area  with  the  laudable  intention  of  quieting 
public  concern  on  that  point,  and  of  still  further  elim 
inating  the  future  possibility  of  disease  contamina- 
tion. 

Thus  it  would  appear  that  with  a  proper  filtration 
plant,  every  opportunity  can  be  seized  for  making  the 
water  supply  of  New  York  what  it  ought  to  be,  the 
best  and  purest  of  its  kind  the  world  over.  It  only 
remains  now  for  the  grand  jury  to  add  its  powerful  in- 
fluence in  the  right  direction. 


THE   ETIOLOGY   OF   ACUTE   ARTICULAR 
RHEUMATISM. 

Although  much  study  has  been  devoted  to  the  etiology 
of  acute  rheumatism,  there  is  as  yet  a  want  of  una- 
nimity of  opinion  with  regard  to  the  ultimate  causative 
factor.  The  disorder  was  formerly  believed  to  be  due 
to  metabolic  disturbances  resulting  in  the  presence  of 
an  excess  of  lactic  acid  in  the  blood,  but  with  the  ad- 
vances in  our  knowledge  of  disease  causation,  coinci- 
dent with  the  development  of  bacteriology,  acute  rheu 
matism  has  come  to  be  looked  upon  as  a  specific 
infectious  disease.  A  number  of  observers  have  iso- 
lated micro-organisms  from  the  lesions  and  the  tissues, 
but,  as  indicated,  there  are  wide  differences  between 
their  results.  Thus,  staphylococci,  streptococci,  dip- 
lococci,  and  bacilli  have  been  severally  found,  and, 
with  some  of  these,  lesions  have  been  excited  in  lower 
animals  comparable  to  those  of  acute  rheumatism. 
Now  it  is  to  be  borne  in  mind  that  inflammation  of 
one  or  of  many  joints  may  occur  as  a  complication  of 
numerous  infectious  processes,  as,  for  instance,  scarlet 
fever,  smallpox,  influenza,  pyaemia,  septiccemia,  but 
such  a  condition  represents  merely  a  secondary  or  com- 
plicating or  symptomatic  manifestation  of  the  primary 
disturbance,  due  to  different  etiological  factors,  and 
not,  as  acute  articular  rheumatism  probably  is,  to 
a  definite  specific  micro-organism  yet  unidentified. 
An  analogy  may  here  be  made  between  the  several 
varieties  of  angina  due  to  any  one  of  a  number  of 
micro-organisms,  and  that  specific  variety  that  we 
know  as  diphtheria  and  due  to  the  diphtheria  bacillus 
alone.  With  the  object  of  reaching  an  independent 
conclusion  in  the  matter,  I'oynton  and  Paine  {Lancet, 
September  22  and  29,  1900)  undertook  an  elaborate 
investigation,  with  the  result  of  finding  in  eight  sue- 


December  i,  1900] 


MEDICAL    RECORD. 


857 


cessive  cases  of  acute  rheumatism  a  diplococcus  grow- 
ing in  liquid  media  in  streptococcal  chains.  The 
organism  did  no:  thrive  upon  ordinary  agar  or  upon 
serum-agar,  and  though  it  could  be  grown  upon  blood- 
agar,  it  appeared  to  grow  best  in  a  liquid  medium 
of  milk  and  bouillon  rendered  slightly  acid  with 
lactic  acid.  On  three  occasions  the  organism  was 
isolated  in  pure  culture,  during  life,  from  the  blood  of 
patients  suffering  from  acute  rheumatic  pericarditis. 
It  was  obtained  also  after  death  from  the  pericardial 
fluid,  from  the  heart-blood,  from  the  valves,  and  from 
the  throat  of  a  rheumatic  patient,  as  well  as  from  a 
rheumatic  nodule.  In  five  of  the  eight  cases  the  diplo- 
coccus was  present  in  pure  culture.  Intravenous  in- 
oculation of  rabbits  with  pericardial  fluid  and  with 
pure  cultures  was  followed  by  polyarthritis  and  endo- 
cardial and  pericardial  complications;  and  from  the 
lesions,  as  well  as  from  tiie  kidneys  and  from  the 
liver,  diplococci  were  isolated.  The  micro-organisms 
were  found  also  in  the  heart  valves  or  pericardium  in 
eight  other  cases  of  undoubted  rheumatic  fever,  and  in 
the  pia  mater  and  brain  in  a  fatal  case  of  chorea. 
The  organisms  are  believed  to  be  identical  with  those 
previously  described  by  Triboulet  and  by  VVasser- 
raann,  but  the  opinion  is  expressed  that  while  they 
are  probably  the  cause  of  all  cases  of  rheumatism  that 
conform  to  the  usual  type  of  the  disease,  they  cannot 
be  claimed  to  be  the  only  cause. 


SEPARATE    PRISON    FOR    CONSUMPTIVE 
CONVICTS. 

Dr.  W.  H.  Blake  has  been  indefatigable  in  pleading 
the  cause  and  untiring  in  his  efforts  to  better  the  con- 
ditions of  those  unfortunate  prisoners  who  are  suffering 
from  pulmonary  tuberculosis  and  of  those  who  are 
compelled  to  live  in  close  association  with  them.  Dr. 
Blake,  who  is  physician  on  the  board  of  inspectors  of 
convicts  for  Alabama,  is  able  to  speak  with  authority 
on  the  subject,  and,  moreover,  his  views  are  in  accord 
with  those  of  all  persons  who  have  studied  the  hygiene 
of  prisons.  The  statistics  of  deaths  among  convicts 
in  the  Alabama  State  prisons  for  the  past  twenty 
years  show  that  for  the  first  half  of  this  period  con- 
sumption caused  20.3  per  cent,  of  the  total  mortality; 
for  the  last  half  it  caused  42  per  cent.  In  the  peni- 
tentiaries of  the  different  States,  of  the  total  deaths, 
the  percentage  caused  by  consumption  reads  thus: 
Mississippi,  20  per  cent.;  Arkansas,  20  per  cent.; 
Florida,  30  per  cent.;  Ohio,  31  percent.;  Michigan, 
33  per  cent.;  Alleghany  County  workhouse.  Pa., 
33 '3  f>ercent. ;  Virginia,  41  per  cent. ;  Kentucky,  42 
percent.;  Joliet,  111.,  70  per  cent.;  Huntsville  peni- 
tentiary, Texas,  66  per  cent.;  Rusk  penitentiary, 
Te.xas,  33  per  cent.;  Washington,  16  per  cent.;  Con- 
necticut (1898),  60  per  cent.,  and  in  1897  every  death 
that  occurred  in  the  penitentiary  of  Connecticut  was 
caused  by  consumption.  These  are  appalling  figures 
and  speak  for  themselves.  It  is  now  universally  ad- 
mitted that  under  certain  conditions  tuberculosis  is  a 
contagious  disease.  Living  with  and  breathing  the 
same  air  as  a  consumptive  person  is  a  method  emi- 


nently calculated  to  spread  the  disease.  Prison  man- 
agement in  Alabama  and  in  most  if  not  all  the  other 
prisons  mentioned  is  especially  favorable  to  the  prop- 
agation of  consumption.  In  the  Alabama  convict  in- 
stitutions, for  example,  the  inmates  are  not  kept  in 
separate  cells,  but  from  fifty  to  one  hundred  are  con- 
fined together  in  a  single  large  cell.  Consumptive 
convicts,  unless  in  an  advanced  stage  of  the  disease, 
are  shut  in  with  the  healthy  convicts.  The  conse- 
quence is  that  the  prison  is,  to  a  large  extent,  a  death 
trap,  and  the  mortality  from  consumption  is  increas- 
ing. Dr.  Blake  urges  the  cause  of  the  convict  in  the 
following  words:  "There  is  only  one  remedy  for  this 
condition,  and  that  is,  to  separate  the  consumptive 
convicts  from  the  non-consumptive.  We  need  some- 
thing more  than  separate  wards  in  the  same  building, 
or  separate  buildings  on  tiie  same  grounds.  We  need 
a  separate  camp  for  consumptive  convicts,  the  further 
from  the  other  prisons  the  better,  in  order  to  give  the 
non-tuberculous  prisoners  the  greatest  possible  immu- 
nity from  this  disease.  With  the  organi2ation  of  such 
a  camp,  and  the  exercise  of  painstaking  care  in  de- 
tecting consumption  in  its  early  stages,  and  the  prompt 
removal  of  such  convicts  to  said  camps;  in  doing  this, 
we  shall  have  accomplished  all  that  our  present  knowl- 
edge of  this  disease  points  out  as  our  duty  in  the  prem- 
ises. This  would  give  the  consumptive  better  treat- 
ment, and  the  well  man  a  chance  to  remain  well.  In 
this  matter,  the  duty  of  the  State  is  plain.  It  has  the 
right  to  deprive  the  offender  of  his  liberty,  but  it  has 
not  the  right  to  deprive  him  of  his  health."  The  fore- 
going is  the  weighty  opinion  of  an  expert  as  to  the 
best  means  of  improving  the  condition  of  the  con- 
sumptive convict  and  of  removing  him  when  a  prob- 
able source  of  infection  to  others.  There  is  no  need 
unduly  to  coddle  prisoners,  but  at  any  rate  they  should 
be  treated  with  ordinary  humanity. 


DOCTORS    IN    POLITICS. 

The  London  Practitioner,  referring  to  the  paucity  of 
medical  men  in  the  British  parliament,  makes  some 
very  apt  remarks  on  the  matter.  The  journal  in  ques- 
tion then  quotes  the  following  paragraphs  from  St. 
Paul's  Medical  Journal :  "The  Legislature  committee 
of  the  Minnesota  State  Medical  Society  has  under- 
taken the  task  of  organizing  the  profession  of  the 
State  into  a  body  which  will  exert  its  influence  politi- 
cally upon  the  legislature.  It  is  intended  to  exert 
this  influence  in  such  a  manner  that  candidates  for 
legislative  honors  shall  fully  understand  the  desires  of 
the  medical  profession  in  the  matter  of  legislation. 
.  .  .  Perhaps  no  individual  in  a  community  can  exert 
more  political  influence  than  the  physician;  the  hum- 
blest among  us  daily  meets  and  talks  with  many  whom 
he  can  influence  in  a  political  way.  The  doctor  who 
favors  a  certain  candidate  can  sway  scores  of  votes 
for  his  benefit,  and  equally  he  can  sway  those  votes 
against  an  undesirable  candidate.  Kis  power  is  prac- 
tically unlimited  in  that  direction."  Commenting  on 
the  foregoing  pronouncement  of  opinion,  the  writer  in 
the  Practitioner  says:  "Whatever  may  be  the  case  in 


858 


MEDICAL    RECORD. 


[December  i,  1900 


the  United  States,  the  power  of  the  doctor  in  political 
elections  is  very  far  from  being  unlimited  in  this  coun- 
try. Unquestionabl}'  he  can  often  '  sway  scores  of 
votes,'  but  the  majority  of  medical  men  would  prob- 
ably think  it  not  politic  and  perhaps  not  strictly  pro- 
fessional to  be  known  as  active  canvassers.  English 
statesmen  have  sometimes  used  physicians  as  inter- 
mediaries, and  Lord  Palmerston,  in  particular,  found 
them  very  useful  as  collectors  of  political  gossip. 
But  it  is  not  many  members  of  the  profession  that 
have  such  opportunities  of  directly  helping  in  the  con- 
duct of  public  affairs."  There  can  be  no  doubt  that 
both  in  Great  Britain  and  this  country  the  medical 
man  is  not  the  force  in  politics  he  is  entitled  to  be  by 
his  numbers  and  education.  However,  it  is  the  opin- 
ion of  the  Practitioner  that  the  medical  man  in  Great 
Britain  is  not  likely  to  be  anything  but  a  negligible 
quantity,  so  far  as  ordering  the  affairs  of  the  nation 
is  concerned,  in  the  near  future,  if  ever.  Here  the 
position  of  the  physician  is  somewhat  different — ^he 
is  not  so  bound  down  by  the  traditional  precedents 
of  his  profession  as  in  England,  his  numbers  are  pro- 
portionately greater,  and  the  system  of  government  is 
more  in  his  favor.  Undoubtedly  the  medical  practi- 
tioner should  have  more  to  say  in  the  ordering  of  pub- 
lic affairs  than  is  at  present  the  case,  but  at  the  same 
time  whatever  power  he  may  gain  should  be  strictly 
devoted  to  furthering  the  best  interests  of  his  profes- 
sion and  not  as  a  means  of  feathering  his  own  nest. 


^eius  of  tTie  'SSJeeli. 

Yellow    Fever    and    Mosquitos According   to    a 

press  despatch  from  Havana,  Dr.  Finlay  is  reported 
to  have  declared  his  belief  that  mosquitos  are  the  only 
propagators  of  yellow  fever,  and  that  if  Havana  could 
be  kept  absolutely  free  from  yellow  fever  for  two  or 
three  months  all  the  infected  mosquitos  would  die,  and 
then  the  only  way  the  city  could  again  become  in- 
fected would  be  through  the  importation  of  a  fresh 
case  from  another  place.  This  is  what  appears  to 
have  occurred  in  Santiago,  which  has  enjoyed  a  long 
period  of  immunity  from  its  former  scourge. 

Plague  Precautions  in  New  Orleans — The  New 
York  Times  states  tiiat  the  Louisiana  board  of  health 
has  adopted  some  important  changes  in  the  rules  gov- 
erning coffee  ships  from  plague-infested  ports,  and 
now  uninfected  vessels  will  be  detained  only  five 
days,  so  far  as  the  cargo  is  concerned,  instead  of  fifteen 
as  in  the  past.  The  vessels  are  to  be  disinfected  in 
midstream,  will  anchor  one  hundred  feet  from  shore 
at  night,  and  forty-five  feet  from  shore  in  the  day- 
time. Metal  funnels  will  be  used  on  the  hawsers  at- 
tached to  the  shore,  to  prevent  rats  from  leaving  the 
ships,  and  a  corps  of  men  armed  with  shotguns  will 
be  stationed  on  shore  and  in  skiffs  to  shoot  any  rodent 
that  may  attempt  to  get  away.  All  dead  rats  are  to  be 
handled  with  rubber  gloves  and  cremated.  Long  stage 
planks  closely  guarded  will  be  used  to  get  the  cargo 
ashore. 


The  St.  Louis  Academy  of  Medical  and  Surgical 
Sciences.  —  At  a  recent  meeting  ot  this  society  the 
following  otTicers  were  elected  for  the  year  1901  : 
Presiiknt,  Dr.  Ijiiory  Lanphear;  Vice-fircsidctits.  Drs. 
Carl  Pesold  and  H.  S.  P.  Lare;  Secretary,  Dr.  O.  L. 
Suggelt;  Treasurer,  Dr.  G.  M.  Phillips;  Orator,  Dr. 
\Mlliam  Porter;  Librarian,  Dr.  H.  G.  Wicks. 

A  Reception  to  Dr.  S.  Weir  Mitchell  was  tendered 
at  l^hiladelphia  by  the  Penn  Club  on  November  17th 
and  was  attended  by  many  men  distinguished  in  the 
professions  and  in  commerce. 

Sanitation  Needed  in  Peking. ^According  to  re- 
ports from  i^eking  the  sanitary  condition  there  is  be- 
coming serious.  Since  the  foreign  occupation  many 
Chinese  have  died  of  smallpox  and  other  infectious 
diseases.  Fearing  that  their  funerals  would  be  inter- 
fered with,  they  have  kept  most  of  the  coffins  contain- 
ing their  dead  in  their  houses  and  courtyards.  The 
question  of  removing  garbage  has  become  one  of  grave 
importance.  As  the  natives  are  forbidden  to  deposit 
refuse  in  the  streets  there  is  now  an  enormous  accu- 
mulation in  their  dwellings  and  yards.  Smallpo.\, 
which  is  always  prevalent,  is  much  more  malignant 
during  the  winter  season,  and  the  conditions  are  favor- 
able for  the  rapid  spread  of  epidemic  disease  among 
the  foreign  troops  and  the  natives. 

A  Hospital  for  the  Insane   in   Palestine — A  few 

years  ago  Mr.  Tlieophilus  Waldmeier,  the  founder  and 
superintendent  of  the  Friends'  Mission  on  Mount 
Lebanon,  directed  his  attention  to  the  needs  of  the 
insane  in  the  Holy  Land,  and,  though  advanced  in 
years  and  identified  with  his  particular  mission  field, 
consecrated  the  remainder  of  his  life  to  an  eiTort  to 
establish  a  modern  institution  for  their  relief.  He 
visited  Europe  and  America,  appealed  to  the  charity 
of  all  nations,  set  forth  plainly  the  facts  which  im- 
pelled him  to  take  the  step,  and  described  the  methods 
of  treatment  prevailing  in  the  Fast,  which  were  based 
upon  the  theory  of  demoniacal  possession  and  were 
crude  and  cruel  in  tiie  extreme.  He  wished  to  construct 
a  modern  cottage  hospital,  the  blocks  of  which  were 
to  be  provided  by  the  different  nations,  and  he  asked 
of  Great  Britain  an  appropriation  for  the  land  and  ad- 
ministration house,  and  of  America,  Germany,  Switzer- 
land, and  Syria  that  they  construct  cottages  for  patients. 
The  American  Journal  of  Insanity  now  announces  the 
success  of  Mr.  VValdmeier's  scheme,  and  the  formal 
opening  of  the  Lelnmon  Hospital  for  the  Insane  on 
August  6,  1900.  The  director.  Dr.  Wolff,  is  an  ac- 
complished specialist  in  nervous  diseases,  with  a 
European  education.  The  nursing  staff  consists  of 
deacons  and  deaconesses  from  Europe  and  some  young 
men  and  women  from  Brumana  who  will  learn  to 
nurse  the  insane.  On  the  i6th  of  .August  there  were 
nine  men  and  five  women  under  treatment. 

Medical  Inspection  of  Schools. —  The  physicians 
in  Philadelphia  engaged  in  the  medical  inspection  of 
schools  have  decided  to  form  a  permanent  organiza- 
tion and  to  petition  the  hoard  of  education  and  coun- 
cils for  compensation  commensurate  with  the  service 


December  i,  1900] 


MEDICAL    RECORD. 


859 


rendered.  The  inspections  have  thus  far  been  tenta- 
tive and  experimental,  and  the  services  of  the  physi- 
cians have  been  rendered  gratuitously.  It  is  claimed 
that  a  large  amount  of  the  decrease  of  contagious  dis- 
eases among  children  since  the  establishment  of  the 
system  of  daily  medical  examinations  is  due  to  this 
cause. 

The  Pan-American  Medical  Congress. — The  fol- 
lowing is  a  list  of  the  American  secretaries  of  section 
at  the  approaching  Havana  Congress:  Medicine,  Dr. 
Judson  Daland,  Philadelphia;  therapeutics,  Dr. 
Hobart  A.  Hare,  Philadelphia;  pa.-diatrics,  Dr.  I.  N. 
Love,  New  York  City;  mental  and  nervous  diseases. 
Dr.  C.  H.  Hughes,  St.  Louis;  medical  pedagogy,  Dr. 
Otis  K.  Newell,  New  V'ork  City;  medical  jurispru- 
dence, Dr.  H.  A.  West,  Galveston,  Tex. ;  dermatology 
and  syphilography,  Dr.  A.  Ravogli,  Cincinnati;  sur- 
gery, Dr.  VV.  P.  Xicolson,  Atlanta,  Ga. ;  gyna;cology 
and  abdominal  surgery.  Dr.  H.  P.  Newman,  Chicago; 
orthopcedic  surgery,  Dr.  John  Kidlon,  Chicago;  rail- 
way surgery.  Dr.  Duncan  Eve,  Nashville,  Tenn.;  den- 
tal and  buccal  surgery,  Dr.  Eugene  S.  Talbot,  Chicago; 
anatomy.  Dr.  Arthur  D.  ISevan,  Chicago;  physiology, 
Dr.  A.  P.  Brubaker,  Philadelphia;  pathology.  Dr. 
Hunter  McAlpine,  New  York  City;  ophthalmology, 
Dr.  John  E.  Weeks,  New  York  City;  laryngology  and 
rhinology.  Dr.  G.  H.  Makuen,  Piiiladelphia;  otology, 
Dr.  James  T.  McKernon,  Philadelphia;  obstetrics, 
Dr.  Gustav  E.  Zinke,  Cincinnati ;  general  hygiene  and 
demography.  Dr.  Alvah  H.  Doty,  New  York  City;  mili- 
tary medicine  and  hygiene.  Major  Jefferson  Kean,  U. 
S.  A.,  Quesnados,  Cuba;  marine  hygiene  and  quaran- 
tine, Dr.  R.  M.  Woodward,  U.  S.  .M.  H.  S.,  Washing- 
ton, D.  C. 

Yellow  Fever  in  Havana. — On  November  24th 
there  were  fifty-seven  cases  of  yellow  fever  in  Havana. 
During  October  there  were  seventy-four  deaths  from 
the  disease.  Of  the  entire  number  of  reported  cases 
sixty-two  patients  were  Americans  and  two  hundred 
and  twenty-five  Spanish  immigrants.  During  ten 
months  of  the  current  year  there  have  been  twenty 
cases  with  six  deaths  among  the  troops,  officers  and 
men,  stationed  in  Havana,  as  compared  with  twenty- 
six  cases  and  seven  deaths  during  the  twelve  months 
of  i8gg.  Dr.  W.  C.  Gorgas,  U.  S.  A.,  chief  sanitary 
officer  of  Havana,  in  a  recent  report  to  the  adjutant- 
general  says  that  during  the  past  month  many  exag- 
gerated reports  of  the  yellow-fever  situation  have  been 
published  in  the  United  States.  .  Out  of  a  population 
of  two  hundred  and  forty-two  thousand  there  have  been 
since  the  first  of  January  nine  hundred  and  sixty-eight 
cases.  The  correspondent  of  the  Associated  Press 
published  very  widely  the  statement  that  every  block 
in  Havana  had  from  one  to  seventeen  cases.  Major 
Gorgas  says,  however,  that  there  are  eight  hundred 
and  fifty-seven  occupied  blocks  in  the  city,  and  of 
those  three  hundred  and  ninety-seven  have  had  cases 
of  yellow  fever.  Of  the  blocks  which  have  had  cases, 
two  hundred  and  twenty-four  had  only  one  case,  and 
only  one  or  two  blocks  in  the  city  approximated  the 
numbers  given   by  the  correspondent  referred  to.     In 


Havana  there  are  sixteen  thousand  and  four  hundred 
and  eighty  houses,  of  which  seven  hundred  and  nine 
have  had  cases  of  yellow  fever.  Dr.  Gorgas  also  calls 
attention  to  the  good  results  of  the  present  system  of 
disinfection  and  isolation.  In  the  five  hundred  and 
fifty-three  houses  in  which  one  case  occurred  the  sani- 
tary methods  employed  were  apparently  successful  and 
prevented  a  further  spread  of  the  disease. 

A  Woman  Medical  Graduate  at  Budapest The 

degree  of  doctor  of  medicine  has  recently  been  con- 
ferred on  Fraulein  Charlotte  Steinberger  by  the  Uni- 
versity of  Pudapest.  She  is  said  to  be  the  first  woman 
to  have  been  graduated  with  the  degree  of  doctor  of 
medicine  in  Hungary. 

The  Plague  in  South  Africa. — A  despatch  from 
Cape  'J'own,  dated  November  2 2d,  announces  that  Sir 
Alfred  Milner,  the  British  high  commissioner,  has 
proclaimed  that  all  the  east  coast  ports  of  South 
Africa  between  the  tenth  and  fortieth  parallels  are  in- 
fected with  the  bubonic  plague. 

Nurses'   Home  for   the  Woman's   Hospital .\t 

the  forty-fifth  annual  meeting  of  the  Woman's  Hospi- 
tal in  the  State  of  New  York,  held  last  week,  it  was 
announced  that  Mrs.  Frederick  F.  Thompson,  who  re- 
cently resigned  the  office  of  treasurer,  had  offered  to 
build  a  nurses'  home  in  connection  with  the  hospital, 
the  hometocost  between  $100,000  and  $150,000.  The 
home  will  be  built  on  the  hospital  grounds.  This 
gift  of  Mrs.  Thompson  is  in  addition  to  another  of 
$55,000  which  she  made  in  the  early  part  of  the  year. 

The  Sanitary  Condition  of  Chicago  has  very 
markedly  improved  since  the  opening  of  the  drainage 
canal.  For  the  first  ten  days  of  November  the  montlily 
death  rate  was  .85  a  thousand,  which,  turned  into  an- 
nual death-rate  figures,  is  10.56  a  thousand.  This  is 
about  the  normal  death  rate  for  small  towns  and  vil- 
lages, and  far  below  most  city  death  rates.  The  low 
death  rate  is  especially  marked  as  regards  typhoid 
fever.  There  were  only  eight  deaths  from  that  dis- 
ease during  the  first  tw-o  weeks  of  this  month,  which 
is  at  the  rate  of  twenty-three  a  month,  as  against  a 
November  average  of  seventy  a  month  during  the 
years  1865  to  1899. 

The  Craig  Colony  Prize  for  Original  Research 
in  Epilepsy. — Dr.  Frederick  Peterson,  president  of 
the  board  of  managers  of  the  Craig  Colony  for  Epi- 
leptics, at  Sonyea,  N.  Y.,  offers  a  prize  of  $200  for 
the  best  original  unpublished  contribution  to  the 
pathology  and  treatment  of  epilepsy.  Originality  is 
the  main  condition.  All  manuscripts  should  be  sub- 
mitted in  English.  The  prize  is  open  to  universal 
competition.  Each  essay  must  be  accompanied  by  a 
sealed  envelope  containing  the  name  and  address  of 
the  author,  and  bearing  upon  the  outside  a  motto  or 
device  which  is  to  be  inscribed  also  upon  the  essay. 
All  papers  received  will  be  submitted  to  a  committee, 
consisting  of  three  members  of  the  New  York  Neuro- 
logical Society,  and  the  award  will  be  made  upon  its 
recommendation  at  the  annual  meeting  of  the  board 
of   managers  of  the  Craig  Colony,   October  8,  igoi. 


86o 


MEDICAL    RECORD. 


[December  i,  1900 


Manuscripts  should  be  sent  to  Dr.  Frederick  Peterson, 
4  West  5olh  Street,  New  York  City,  on  or  before  Sep- 
tember 30,  1901.  The  successful  essay  becomes  the 
property  of  the  Craig  Colony  and  will  be  published 
in  its  annual  report.  The  committee  has  made  no 
award  for  the  years  1899  and  1900,  for  the  reason  that 
the  essays  submitted  have  failed  to  come  up  to  the 
necessary  standard  of  originality.  The  prize  calls 
for  original  research  as  to  the  pathological  anatomy, 
chemistry,  symptomatology,  etiology,  nature,  or  treat- 
ment of  epilepsy — in  short,  anything  that  will  add  to 
the  sum  of  knowledge  regarding  this  disease. 

New    Operating-Theatre    at    Bellevue. — A     new 

operating-annex  in  connection  with  the  surgical  divis- 
ion, recently  erected  at  Bellevue  Hospital,  was  formally 
opened  and  dedicated  last  Saturday  afternoon.  The 
dedication  exercises  were  conducted  by  the  Rev.  Dr. 
Huntington  of  Grace  Church. 

Navy  Department,  liureau  of  Medicine  and  Sur- 
gery, Washington,  D.  C. — Changes  in  the  medical 
corps  of  the  navy  for  the  vi'eek  ending  November  24, 
1900.  November  17th. — Passed  Assistant  Surgeon 
A.  W.  Dunbar  detached  from  the  Monongahela  and 
ordered  to  the  Vermont  for  temporary  duty  with  the 
crew  of  the  Wisconsin  and  then  to  naval  hospital. 
Mare  Island,  Cal.  November  22d. — Assistant  Sur- 
geon R.  B.  Williams  appointed  assistant  surgeon 
from  November  17,  1900.  November  23d. — Assistant 
Surgeon  J.  T.  Kennedy  detached  from  the  Monocacy 
and  ordered  to  the  Cavite  naval  station. 

The  Harvard  Veterinary  School  is  to  be  discon- 
tinued, it  is  said,  because  there  are  not  enough  stu- 
dents to  pay  the  running  expenses.  For  several  years 
there  have  been  successive  annual  deficits  in  the  ac- 
counts of  the  veterinary  department  of  the  university; 
the  corporation  of  Harvard  has  decided  to  receive  no 
more  students  for  that  department,  but  the  students 
already  in  the  school  will  be  given  sufficient  instruc- 
tion to  obtain  their  degrees. 

No  Free  Treatment  for  Inebriates  in  Minnesota. 
— The  legislature  of  Minnesota  last  year  passed  what 
was  called  the  "jag-cure  law,"  which  provided  that  in- 
digent inebriates,  upon  proper  petition,  might  be 
treated  at  a  private  institution,  and  the  expense  would 
be  borne  by  the  county.  The  consent  of  the  inebriate 
must  have  previously  been  obtained.  The  supreme 
court  of  the  State  has,  however,  decided  that  the  law 
is  unconstitutional,  because  it  applies  only  to  counties 
of  over  fifty  thousand  population,  and  is  limited  in  its 
benefits  to  a  certain  number  in  each  county — one  per 
year  to  each  ten  thousand  of  population. 

Against   the   Spitting   Nuisance   in   St.  Paul. — 

An  ordinance  was  recently  passed  by  both  branches 
of  the  St.  Paul  city  council  and  signed  by  the  mayor, 
forbidding  expectoration  on  the  sidewalk  under  pen- 
alty of  a  fine  of  from  %\  to  $50,  or  imprisonment  from 
one  to  sixty  days.  The  duty  of  enforcing  the  law  and 
arresting  offenders  against  it  devolves  upon  the  police. 
The  throwing  of  fruit  skins  and  cigar  stubs  on  the 
sidewalk  is  also  forbidden.     The  ordinance  was  passed 


at  the  suggestion  of  the  health  commissioner.  We 
trust  it  will  be  less  contemptuously  treated  than  is  the 
health  board's  prohibition  against  spitting  in  street 
cars  in  New  York. 

Declining  Birth  Rate  in  France. — According  to  the 
official  statistics  recently  published,  there  were  847,- 
627  children  born  in  France  in  1899,  which  is  nearly 
ten  thousand  below  the  already  low  average  for  the 
past  decade.  The  number  of  marriages  increased 
during  the  year,  which  perhaps  presages  an  improve- 
ment in  the  birth  rate  for  this  year.  There  were  816,- 
233  deaths  reported  in  1S99. 

Salutary  Inconsistency.  —  A  Denver  Christian 
Science  "  healer '"  has  published  a  statement  to  the 
effect  that  he  always  reports  to  the  health  department 
all  cases  of  contagious  disease  that  he  meets  in  his 
practice.  This  must  indeed  be  a  wonderful  science  if 
its  votaries  can  so  read  the  thoughts  of  their  clients 
that  they  can  declare  which  are  contagious  and  which 
not.  The  inconsistency  is  absurd,  but  nevertheless 
most  salutary. 

A  Sanatorium  at  Mentone,  Cal. — The  Pacific  Hos- 
pital at  Los  Angeles,  Cal.,  will  erect  a  large  sana- 
torium at  Mentone,  San  Bernandino  County,  Cal.  It 
will  consist  of  a  two-story  and  attic  building  with 
forty  bedrooms,  a  parlor,  and  dining,  smoking,  and 
reception  rooms.  There  will  also  be  a  central  pavil- 
ion, 100  by  150  feet  in  size.  In  addition  to  the  main 
building  there  will  be  ten  cottages  for  the  use  of 
patients,  and  a  stone  power  house  for  electrical  and 
steam  plants.  The  buildings  will  be  in  the  centre  of 
a  tract  eleven  hundred  acres  in  extent. 

New  Medical  School  Buildings  at  Yale. — A  block 

of  ground  on  Cedar  Street  and  Congress  Avenue,  New 
Haven,  has  been  purchased  by  Yale  University,  and 
on  it  will  be  erected  new  and  commodious  buildings 
for  the  use  of  the  medical  department.  The  plans  for 
the  buildings  are  nearly  completed  and  work  will  be 
begun  in  a  few  weeks.  The  entire  Medical  School 
will  be  removed  to  the  new  site  in  a  year  or  two,  and 
laboratory  buildings,  clinical  buildings,  and  recitation 
rooms  will  all  be  clustered  about  it  as  a  centre.  The 
new  school  will  be  opposite  the  New  Haven  General 
Hospital. 

Red  Cross  Celebrations. — It  is  announced  that  on 
the  night  of  December  31st,  the  last  of  the  year  and 
the  century,  the  American  Red  Cross  Society  will 
hold  a  number  of  watch  meetings  in  tliis  city  to  see 
the  old  century  out  and  the  new  one  in.  There  will 
be,  according  to  the  plans  of  Miss  Clara  Barton,  thou- 
sands of  other  such  meetings  all  over  the  country,  ar- 
rangements for  which  are  being  made  with  various 
State  and  city  authorities  all  over  the  land.  The  Red 
Cross  plans  to  have  its  big  meeting  in  this  city  in 
Madison  Square  Garden,  where  music  will  be  furnished 
by  a  band  of  one  hundred  pieces  and  a  chorus  of  one 
thousand  voices. 

Obituary  Notes Dr.  Samuel  J.  Pearsai.l   died 

suddenly  at  his  home  in  Saratoga  on  November  19th. 
He  was  seventy  years  of  age,  and  was  graduated  in 


December  i,  1900] 


MEDICAL    RECORD. 


861 


medicine  from  the  Hahnemann  Medical  College  of 
Philadelphia  in  1858. 

Dr.  Romaine  J.  Curtis  died  at  JoHet,  111.,  on  No- 
vember 20th,  aged  fifty-eight  years.  He  was  born  in 
Huron  County,  Ohio,  and  studied  at  Hillsdale,  Mich., 
and  Buffalo.  During  the  Civil  War  he  became  a  cadet 
on  a  hospital  boat.  He  was  graduated  from  the  Ohio 
Medical  College  in  1864.  Later  he  was  assistant  sur- 
geon on  the  United  States  flagship  Bttmside.  He  was 
said  to  have  been  one  of  the  first  railroad  surgeons 
ever  appointed  in  the  United  States.  He  was  an  at- 
tending surgeon  to  St.  Joseph's  Hospital  in  Joliet  for 
ten  years,  and  previously  had  been  professor  of  patiiol- 
ogy,  bacteriology,  and  hygiene  in  the  College  of  Phy- 
sicians and  Surgeons  of  Chicago. 

Dk.  Robert  Acton  died  at  the  Presbyterian  Hospi- 
tal in  this  city  on  November  27th,  at  the  age  of  thirty- 
two  years.  He  was  born  at  Kinsale,  Ireland,  and 
came  to  this  country  in  1891.  He  was  a  graduate  of 
the  Harvard  Medical  School,  and  was  licensed  at  the 
Regents'  examination  in  this  State  in  1899.  He  was 
visiting  physician  to  the  House  of  Correction  on 
Blackwell's  Island. 

Dr.  Frederick  Cornell  De  Mund  died  at  his 
home,  in  Brooklyn,  on  November  2otii.  He  was  sev- 
enty years  old,  and  was  born  at  Millstown,  N.  J.  He 
was  a  graduate  of  Rutgers  College  and  of  the  College 
of  Physicians  and  Surgeons  in  this  city  in  the  class  of 
1855,  and  practised  in  New  Utrecht  from  that  time 
until  his  retirement  in  1895.  He  was  at  one  time 
health  officer  of  the  old  town  of  New  Utrecht. 

Dr.  Rufus  p.  Lincoln,  of  this  city,  died  on  No- 
vember 27th  from  appendicitis,  at  the  age  of  fifty-nine 
years.  He  was  a  graduate  of  the  Harvard  Medical 
School  in  the  class  of  1868.  Early  in  his  professional 
career  he  turned  his  attention  particularly  to  the  treat- 
ment of  diseases  of  the  throat,  and  speedily  attained 
eminence  in  his  chosen  specialty. 


grogi-css  of  ptalical  J'Cience. 


Journal  oj  Ihe   American  Medical  Ass'n,  Xov.  24,  igoo. 

Syphilis  of  the  Upper  Air  Tract ;  Some  Remarks  on  its 
Diagnosis  and  Treatment. — George  L.  Richards  states  that 
no  case  of  primary  syphilis  of  the  upper  air  tract  has  been 
met  in  his  private  practice  during  the  last  four  years.  Sec- 
ondary and  tertiary  manifestations  are  common,  the  areas 
most  frequently  involved  being  the  pharynx  and  tonsillar 
region,  the  nose  and  larynx.  The  primary  chancre  is  usu- 
ally found  on  the  tonsil  and  soft  palate.  The  secondary 
manifestations  occur  in  the  upper  air  tract  from  three  to 
nine  months  after  the  ])rimary  lesion,  and  are  at  first  those 
of  a  simple  catarrh  with  no  particular  diagnostic  character- 
istics apart  from  the  history,  except  that  recovery  is  much 
slower  than  in  ordinary  simple  inflammation  of  the  region. 
The  manifestations  of  the  tertiary  stage  appear  from  three 
to  fifty  years  after  the  primary  lesion.  All  histories  are  in 
the  main  apt  to  be  unreliable,  and  a  diagnosis  should 
never  hang  on  the  presence  or  absence  of  a  satisfactory 
history,  but  should  be  made  on  the  symptoms  as  positively 
as  though  a  clear  history  were  obtainable.  It  may  be 
stated  as  practically  an  absolute  rule  that  necrosis  of  the 
bony  framework  of  the  septum,  in  the  absence  of  history 
pointing  to  phosphorus  or  some  irritant  poison  as  a  cause, 
is  of  syphilitic  origin.  In  the  writer's  experience  the  pha- 
ryngeal lesions  have  been  the  most  troublesome,  especially 
when  occurring  high  enough  up  on  the  pharyngeal  wall  to 
result  in  adhesions  between  the  pharynx  and  the  pillars. 
An  important  diagnostic  point  is  the  almost  total  absence 
of  pain  in  syphilis,  whereas  in  carcinoma  and  tuberculosis, 


the  diseases  most  likely  to  be  confounded  with  syphilis  at 
the  tertiary  stage,  there  is  considerable  pain,  while  the  dis- 
turbance of  nutrition  and  general  constitutional  dy.scrasia 
are  very  marked.  The  writer  believes  in  the  combined  treat- 
ment of  mercury  and  ix>tassiuni  iodide  for  the  third  stage. 
The  hereditary  type  is  briefly  considered  at  the  close  of  this 
paper.  The  writer  concludes  by  saying  that  in  general 
syphilis  is  a  disease  to  be  treated  with  coustltutioual  meas- 
ures and  not  with  the  knife  or  curette. 

Differential  Diagnosis  between  Abdominal  Typhoid  and 
Appendicitis  by  Means  of  Iodine  Reaction ;  Report  of  a  Case. 
— Siegfried  Weiss  declares  that  the  clinical  value  of  the 
iodine  reaction  of  the  blood  has  an  established  place  among 
the  clinical  methods  of  examination.  In  the  ca.se  reported 
the  following  staining  solution  was  used ; 

IB,  lodi  sublim 5 

Totass.   iodid 1.5 

Aquae  destil 50. o 

Muc.  acacix ad  consist,  syruposam 

M. 

The  patient  was  a  girl  nine  and  three-fourths  years  old. 
There  seemed  to  be  at  first  a  type  of  influenza  with  a  form 
of  bronchitis,  and  intestinal  symptoms — constip;ition,  diar- 
rhoea, and  colicky  pains.  But  when  typhoid  symptoms — 
splenic  tumor,  roseola,  typhoid  tongue  and  lips,  the  Widal 
reaction  1:40,  and  also  the  diazo  reaction  in  the  urine- 
appeared,  then  the  diagnosis  of  abdominal  typhoid  was 
made.  The  fever  was  remitting  and  subfebrile  in  charac- 
ter, but  typhoid  symptoms  in  children  are  either  atypical 
or  irregular.  The  diagnosis  was  uncertain  when  the  blood 
gave  the  iodine  reaction  and  the  i>resence  of  pus  was  shown. 
The  tumor  argued  against  the  presence  of  typhoid,  and  the 
disappearance  of  the  same  was  noticeable.  The  case 
proved  to  be  one  of  sup])urative  local  perityphlitic  inflam- 
mation with  adjacent  peritonitis  which  subsided  in  the 
cour.se  of  a  few  days.  The  iodine  reaction  disappeared  with 
the  disappearance  of  the  tumor.  The  rapid  convalescence 
which  followed  the  tumor's  disappearance,  and  the  ab- 
sence of  the  Widal  reaction  were  against  the  diagnosis  of 
typhoid,  so  that  the  iodine  reaction  was  the  important  fac- 
tor in  establishing  the  diagnosis  of  suppurative  perityph- 
litis as  against  abdominal  typhoid. 

The  Value  of  Blood  Examination  for  Diagnostic  Purposes. 
— Julian  Walter  Brandeis  tiist  c(jnsidcrs  tlie  diseases  in 
whicii  blood  tjxaminalion  is  essential  to  diagnosis.  These 
he  enumerates  as  :  chlorosis,  secondary  anasmia,  pernicious 
anaemia,  leukaemia  (both  myelogenous  and  lymphatic), 
Hodgkin's  disease,  aua;mia  infantum,  pseudo-leu ka.'mia, 
malaria,  relapsing-fever,  and  filaria  sanguinis  hominis. 
As  characteristic  of  the  blood  of  children  the  writer  men- 
tions the  following  points :  A  leucocytosis,  polycythsemia, 
and  increased  ])ercentage  of  ha.moglobin  are  characteristic 
of  the  blood  of  the  new-i>orn,  but  gradually  disappear.  Any 
influence  retarding  the  child's  develojiment  causes  a  leuco- 
cytosis. a  large  percentage  of  the  corpuscles  being  lympho- 
cytes, and  the  appearance  of  nucleated  erythrocytes  with- 
out necessarily  the  coexistence  of  an  anaemia.  Also,  in  the 
anaemias  of  infants  and  children  the  red  cells  are  destroyed 
to  a  greater  extent,  and  degenerative  changes  are  more 
marked  than  in  like  cases  in  adults.  Nucleated  erythro- 
cytes and  myelocytes  are  more  common  than  in  ana.-mias 
of  corresponding  .severity  in  adults.  In  certain  cases  the 
discovery  of  the  etiological  germ  in  the  blood  has  ren- 
dered the  diagnosis  of  the  following  diseases  positive: 
Typhoid,  tuberculosis,  tetanus,  ulcerative  endocarditis, 
antlirax,  grippe,  glanders,  septicaemia,  pyamia.  and  pneu- 
monia. The  writer  then  speaks  of  disea.ses  in  which  blood 
examinations  are  an  important  aid  to  differential  diagnosis 
and  prognosis.  For  example,  both  in  pneumonia  and 
diphtheria  the  absence  of  leucocytosis  in  any  but  the  mild- 
est cases  is  a  bad  sign.  Neusser  is  quoted  as  stating  that 
in  deciding  whether  a  case  of  hysteria,  neurosis,  or  psy- 
chosis would  be  benelited  bj-  castration,  the  presence  of  a 
eosinophilia  suggests  the  afiirmative. 

The  Treatment  of  Adenoid  Vegetations  of  the  Naso- 
pharynx,— Otto  T.  Freer  declares  that  it  seems  logical  to 
conclude  that,  though  a  proportion  of  cases  with  adenoid 
vegetations  of  limited  extent  can  be  successfully  operated 
on  without  general  anaesthesia,  nevertheless  the  operation 
is  apt  to  be  incomplete,  haphazard,  and  imperfect,  with  a 
large  element  of  lucky  chance  in  its  successful  perform- 
ance, and  that  consequently  general  anaesthesia  is  neces- 
sary to  insure  the  thorough  removal  of  the  entire  hyper- 
trophy of  the  pharyngeal  tonsil.  It  is  important  for  the 
operation  to  be  complete  and  thorough,  for  if  any  lymphoid 
tissue  is  left  in  the  child  it  will  not  only  not  atrophy,  but 
will  often  prove  the  nucleus  of  a  new  set  of  vegetations. 
Another  reason  for  thoroughness  is  deafness,  which  is 
often  caused  by  adenoids  that  produce  no.  or  but  little, 
obstruction  to  breathing.  Some  authorities  believe  that 
entrance  of  tuberculous  infection  through  the  lymphatic 
structures  of  the  fauces  and  pharynx  is  the  most  frequent 


862 


MEDICAL    RECORD. 


[December  i,  1900 


source  of  pulmonary  tuberculosis  in  later  life.  Freer  be- 
lieves that  ether  narcosis  is  to  be  preferred  to  any  other. 
The  most  advantageous  position  for  the  patient  is  the  one 
where  he  lies  on  his  side  and  chest,  close  to  the  edge  of  the 
table,  with  the  left  arm  placed  behind  the  back.  As  to  in- 
struments used,  the  writer  declares  that  a  thorough  opera- 
tion with  the  Lbwenberg  and  Ingals  nasal-bone  forceps 
removes  the  hypcrtrophied  adenoid  tissue  for  all  time. 

The  Danger  of  Spinal  Anaesthesia. — John  V.  Shoemaker, 
in  reviewing  this  subject,  states  that  he  has  seen  a  single 
injection  give  rise  to  alarming  symptoms  of  respiratory 
failure.  The  procedure  is  likewise  productive  of  marked 
pain.  In  order  to  avoid  this  effect.  Bier  and  others  have 
employed  Schleich's  intiltration  antcsthesia  as  a  prelimi- 
nary measure.  In  some  cases  chill  and  fever  have  fol- 
lowed the  injection.  Severe  and  long-continued  headache 
is  not  uncommon.  Distressing  nausea  and  vomiting  have 
also  been  excited.  Exceptionally  staggering  gait  and  sharp 
spinal  pains  were  experienced  on  the  day  following  the  in- 
jection. In  some  patients  profuse  sweating,  and  in  others 
marked  debility  have  been  noted.  Numbness  and  tingling 
have  occurred.  In  certain  cases  ana;sthesia  was  not  pro- 
duced by  the  operation.  It  need  not  be  mentioned  that  the 
operation  should  be  undertaken  with  the  most  rigid  asep- 
tic precautions.  Great  caution  in  the  use  of  this  method 
should  certainly  be  exercised. 

Tuberculosis  of  the  Testicle  with  Special  Consideration  of 
its  Conservative  Treatment. — By  John  B.  Murphy  (contin- 
ued). 

Post-Operative  Treatment  of  Abdominal  Section  in  Women. 
—By  Walter  B.  Chase. 

A  Plea  for  Greater  Simplicity  in  Therapeutics.— By  Louis 
Faugeres  Bishop. 

Modes  of  Infection  of  the  Maxillary  Sinus. — By  M.  H. 
Cryer. 

The  Physician  as  a  Scientist. — By  N.  Senn. 

Therapeutic  Progress. — By  J.  Tracy  Melvin. 

Appendicitis. — By  Joseph  Price. 

.\'r'a'  York  Mi'dtLiil  Journal,  Aovember  24,  igoo. 

Post -Operative  Hemorrhage. — A.  H.  Cordier  advises  again.st 
the  use  of  catgut  for  ligatures  in  abdominal  work,  prefer- 
ring silk  instead.  Secondary  hemorrhage,  under  the  cir- 
cumstances indicated,  calls  for  the  most  rapid  intervention 
possible,  and  is  one  of  the  most  appalling  accidents  in  the 
whole  realm  of  surgery.  He  advocates  the  use  of  a  drain- 
age tube  when  bleeding  is  feared,  for  if  the  wound  is 
closed  up  tight  blood  in  an  air-tight  abdomen  will  not  coag- 
ulate, and  thus  nature's  great  haemostatic — a  firm  clot — is 
removed.  He  lays  down  the  following  propositions:  (i) 
In  diagnosticating  post-operative  hemorrhage,  the  opera- 
tive history  will  aid  much.  (2)  The  symptoms  of  shock 
and  those  of  hemorrhage  are  very  similar.  {3)  In  sus- 
pected cases  the  cutting  of  a  single  stitch  in  the  incision 
will  tell.  (4)  The  surgery  must  be  quick  and  decisive  in 
these  cases.  (5)  In  cases  in  which  bleeding  is  expected  the 
tube  should  be  used.  (6)  Large  quantities  of  decinormal 
saline  solution  will  save  many  patients.  This  should  be 
u.sed  both /eT  rectum  and  by  injection  into  the  veins.  (7) 
Strychnine,  belladonna,  etc.,  will  not  control  bleeding  from 
a  uterine  or  ovarian  artery  any  better  than  from  any  other 
artery.  (S)  The  surgeon  should  do  what  his  surgical  con- 
science tells  him  is  right.  Late  researches  in  Iia^matology 
make  it  appear  that  an  internal  concealed  hemorrhage  may 
be  demonstrated  by  a  careful  blood  count.  This,  it  is 
stated,  will  show  a  decrease  in  the  red  cells  and  an  increase 
in  the  white.  Very  similar  symptoms  .accompany  shock 
from  various  causes,  such  as  internal  hernia,  etc.,  none  of 
which  produces  a  change  in  the  red  cells.  If  an  operation 
was  performed  for  the  relief  of  an  inflammatory  ]irocess, 
this  test  would  lose  its  value  in  part,  as  there  would  exist 
at  the  time  of  operating  a  leucocytosis.  Saline  infusions 
apparently  increase  the  white  cells  at  first. 

Spasmodic  Wry-Neck  and  its  Treatment ;  Report  of  Two 
Cases  with  Recovery. — W.  M.  Lcszynsky's  patients  were 
women,  aged  thirty-six  and  twenty-four  years  respec- 
tively. His  plan  of  treatment  was  to  inject  atropine  into 
the  substance  of  the  affected  muscles,  in  combination  with 
massage,  and  the  methodical  education  of  the  muscles  and 
their  co-ordinating  centres.  He  adds,  that  while  the  atro- 
pine treatment  may  prove  exceedingly  beneficial,  nay, 
even  curative  in  some  cases,  it  is  evidently  unsatisfactory 
in  many  others,  and  should  be  considered  cmly  as  an  adju- 
vant to  absolute  rest  and  general  management,  lie  fur- 
ther states  that  it  is  universally  recognized  that  the  prog- 
nosis in  these  cases  is  always  unfavorable,  unless  suitaljle 
treatment  is  adopted  early  in  the  course  of  the  disease. 
Recovery  essentially  depends  on  the  duration  of  the  trou- 
ble and  the  i)ersistency  in  the  treatment.  In  old-standing 
cases  tliath.ave  existed  for  several  ye.ars  and  have  received 
only  desultory  treatment,  or  in   those  patients  who  have 


been  unsuccessfully  subjected  to  the  customary  routine 
methods  ol  management,  the  prospect  as  to  ultimate  recov- 
ery is  always  very  discouraging.  Surgery  should  not  be 
resorted  to  until  the  foregoing  measures  have  been  given 
a  thorough  trial. 

The  Etiology  of  Eczema  with  Reference  to  Recent  Views 
as  to  its  Parasitic  Origin. — L.  iJuncan  Bulkley  enumerates 
the  various  causes  which  have  been  assigned  for  this  com- 
mon skin  malady,  and  calls  special  attention  to  the  views 
of  Unna.  Concerning  seborrhoea  he  says  that  the  .sci- 
entitic  world  has  i>ractically  accepted  it  as  an  entity 
with  a  micro-organism  as  a  probable  etiological  factor, 
though  there  is  really  no  unanimity  in  regard  to  the  char- 
acter of  the  parasite.  All  that  Bulkley  admits  as  to  the 
question  of  ])arasitic  origin  is  that  some  of  the  organisms 
which  exist  abundantly  on  the  skin  do,  when  it  has  taken 
on  disease,  cease  to  be  saprophytic  and  exercise  more  or 
less  of  a  baneful  influence  in  heightening  the  eruption. 

The  Pathology,  Diagnosis,  Special  Prophylaxis,  and  Treat- 
ment of  Tuberculosis  of  the  Middle  Ear. — By  .Seymour  Op- 
penlieimer. 

Rational  Physical  Training  for  Women.— By  G.  A.  Saxe. 
.Medical  Xcvs,  .\o'<'c>iil>cr  34,  igoo. 

The  Operative  Treatment  of  Ugly  Ears. — John  B.  Roberts 
believes  this  subject  particularly  worthy  of  attention  since 
the  operative  treatment  for  the  correction  of  these  condi- 
tions is  free  from  risk  and  generally  unaccompanied  by 
confinement  to  bed  or  eveu  absence  from  business  pursuits. 
A  lacerated  or  incised  ear  may  be  so  carefully  sutured  that 
the  shape  of  the  organ  may  be  well  preserved  even  after 
considei-able  loss  of  structure.  After  the  removal  of  tu- 
mors, or  the  occurrence  of  sloughing  from  burns  or  trauma- 
tism, it  may  sometimes  be  necessary  to  alter  the  shape  or 
size  of  the  uninjured  ear  to  make  it  correspond  with  the 
injured  member.  If  new  tissue  is  demanded  to  replace 
that  which  has  been  lost,  it  may  be  transferred  from  the 
neck  or  cheek  or  transplanted  from  the  hand,  abdominal 
wall,  or  thigh.  Orthopaedic  measures  are  applicable  in 
some  cases — pads,  springs,  or  repeated  use  of  collodion. 
Artificial  ears  of  celluloid,  papier  mache,  or  platinum, 
properly  tinted,  may  replace  an  absent  member ;  or  re- 
peated plastic  operations  may  suffice  to  restore  some  sem- 
blance of  the  original  ear.  Congenital  nodules  are  to  be 
excised  as  a  rule.  Very  large  ears  may  be  reduced  by  ex- 
cising a  wedge-shaped  piece  or  by  taking  a  crescentic  piece 
from  the  central  part  of  the  auricle  and  a  horizontal  strip 
outward  from  the  centre  of  the  convex  margin  of  the  cres- 
cent. Flaring  ears  are  corrected  by  excising  a  vertical 
ellipse  of  skin  and  fascia  from  the  posterior  surface  of  the 
auricle  and  the  adjacent  part  of  the  skull,  and  then  cutting 
a  vertical  wedge-like  strip  from  the  exposed  cartilaginous 
structure  of  the  ear.  The  auricle  is  then  sewed  close  to  the 
skull.  In  lap  ears  the  suggestion  is  made  of  stiflening  the 
auricle  by  inserting  a  thm  sheet  of  metal  in  the  tissues, 
after  which  it  might  be  bent  to  the  normal  shape  of  the 
organ. 

The  Nature  Treatment  of  Tuberculosis. — R.  O.  Beard  says 
that  the  study  of  the  warfare  waged  between  the  human 
tissue  cells  and  the  bacillus  tuberculosis  teaches  us  the 
lesson  that  the  task  of  the  public  sanitarian  and  the  physi- 
cian is  largely  one  of  prevention,  and  that  cure — a  second- 
ary and  short-lived  possibility  in  the  course  of  the  disease 
—  is  best  accomplished  by  extending  the  principles  and 
metliods  of  prevention  to  the  assistance  of  the  tissue  cells. 
Only  now  are  we  learning  that  but  two  prime  factors  are 
essential  to  make  localities  favorable  to  the  tuberculous 
patient — purity  and  dryness  of  atmosphere,  in  whatever 
latitude,  at  whatever  altitude,  on  plain  or  mountain,  in 
forest  or  on  ranch.  Consumptives  should  be  isolated. 
Tuberculosis  should  be  quarantined  in  our  towns  as  effec- 
tively as  yellow  jack.  As  to  the  creation  of  the  Minne- 
sota jjark,  the  nature  treatment  of  tuberculosis  in  this 
available  region  will  repay  the  nation  in  men  more  than 
it  can  gain  in  timber  by  Hs  destruction  or  in  navigation  by 
Its  saving.  As  nearly  complete  physiological  rest  as  pos- 
sible should  be  attained  by  the  consumptive.  Forced 
feeding  is  also  an  important  element  in  treatment.  The 
gradual  increase  of  food  is  well  endured  even  in  advanced 
cases.  The  combination  of  all  these  measures  should 
brighten  the  hope  of  control  of  this  most  destructive  of 
the  diseases  of  civilization. 

Absorption,  Motility,  and  Digestive  Power  of  the  Stomach. 
— By  \.  v..  Austin. 

The  Hydriatic  Treatment  of  Tuberculosis.— By  J.   II.   Kcl- 

CEdema  Bullosum  Vesicae. — By  Frederic  liierhoff. 
7  lie  Bos/on  Medical  and  Surgical  Jour..  Xov.  22.  igoc. 

Diphtheria  Bacilli  in  Healthy  Throats  and  Noses,  with 
Report  of  Cases.  — Francis  I'.  Denny  thus  sums  uji  the 
points  which  he  .specially  wishes  to  emphasize .    ^n   Diph- 


December  i,  1900] 


MEDICAL    RECORD. 


863 


theria  bacilli  are  seldom  found  in  the  throats  of  those  who 
have  not  been  exposed  to  diphtheria.  (2)  The  bacilli  are 
more  frequently  found  in  those  who  have  been  exposed, 
especially  in  those  living  under  poor  hygienic  conditions 
or  in  institutions.  (3)  The  conditions  of  institution  life 
which  favor  the  growth  of  the  bacilli  in  healthy  throats  are 
the  living  together  of  a  large  number  of  persons  in  a  lim- 
ited air  space.  (4)  Healthy  individuals  with  virulent  ba- 
cilli in  their  throats  can  spread  the  disease.  They  are  just 
as  dangerous  as  mild  or  convalescent  cases  of  diphtheria, 
and  ought,  therefore,  to  be  detected  and  isolated.  (5) 
Cultures  ought  to  be  made  among  those  who  have  been 
exposed  to  diphtheria — (a)  by  physicians  among  the  mem- 
bers of  a  family  who  have  been  exposed,  {//)  by  inspec- 
tors in  the  schools,  (c)  by  health  officers  under  any  cir- 
cumstances when  they  think  the  disease  is  being  or  may 
be  spread  by  sucli  individuals. 

Some  Observations  on  Renal  Casts. — Walter  E.  Tobic  says 
that  since  the  centrifuge  has  come  into  more  general  use 
hyaline  casts  are  found  in  many  instances  in  which  neither 
clinical  history  nor  chemical  examination  would  seem  to 
point  to  then-  presence.  Certainly  there  is  no  good  reason 
for  believing  kidney  disease  to  be  increasing  to  the  alarm- 
ing extent  that  microscopical  examination  of  urine  might 
imply.  Inasmuch  as  hyaline  casts  may  be  present  for 
many  years  without  symptoms  pointing  to  their  existence, 
these  questions  naturally  suggest  themselves:  Is  the  mere 
presence  of  hyaline  casts  necessarily  a  grave  omen  ?  Jlay 
not  the  disease  be  checked  or  even  of  itself  cease  to  ad- 
vance? May  not  hyaline  casts  be  present  in  urine  from 
kidneys  whose  excreting  functions  are  practically  normal? 

Chronic  Diffuse  Interstitial  Nephritis. — Ky  Charles  J.  Ene- 
buske. 

A  New  Spinal  Jacket.— By  Edward  A.  Tracy. 

Philadelphia  Medical  Journal,  Xovember  24,  igoo. 

Conveyance  of  Yellow-Fever  Infection. — J.  O.  Cobb  con' 
eludes  his  discussion  of  this  subject  by  saying  that,  al- 
though he  has  the  highest  respect  for  Drs.  Sternberg, 
Reed,  and  their  assistants,  still  he  cannot  accept  their 
mere  negative  positions  as  disproving  the  validity  of  the 
Sanarelli  germ  as  the  cause  of  yellow  fever  or  as  establish- 
ing the  identity  of  tliis  germ  with  Sternberg's  bacillus  X. 
These  workers  have  not  disproved  the  work  of  Wasdin  and 
Geddings  and  others.  The  writer  states  that  he  is  pre- 
pared to  believe  that  mosquitos,  and  even  bed-bugs  and 
fleas,  may  convey  this  disease.  He  adds  that  it  is  discour- 
aging to  think  that  the  mosquito  may  be  the  sole  conveyor 
of  the  disease,  for  if  it  is  we  cannot  expect  to  confine  the 
disease  to  each  infected  house  as  has  heretofore  been  at- 
tempted. Undoubtedly  some  infected  mosquitos  will  cer- 
tainly elude  us  and  escape  to  other  nearby  houses.  Yet 
this  is  not  the  practical  experience  of  Marine-Hospital  offi- 
cers, for  they  have  shut  up  the  disease  and  prevented  its 
spread  under  the  most  discouraging  circumstances,  even 
in  the  presence  of  mosquitos.  In  the  midst  of  speculation 
the  practical  should  be  kept  in  mind,  for  it  is  well  known 
that  the  disease  can  be  confined  to  narrow  limits  by  the 
cordon  sanitaire  when  under  the  watchful  care  of  trained 
quarantine  officials. 

The  Occurrence  of  Malta  Fever  in  Manila. — This  report  is 
made  by  Ricluud  P.  Strong  and  \V.  E.  Musgrave.  Four 
laboratory  infections  with  the  micrococcus  melitensis  are 
noted.  One  case  in  the  Army  medical  laboratory.  Jla- 
nila,  was  inoculated  through  the  conjunctiva,  which  is  a 
comparatively  rare  portal  of  entry.  The  micro-organism 
of  Malta  fever  was  discovered  by  Bruce  in  1887,  since 
whicli  time,  cases  have  been  reported  in  various  localities. 
It  is  not  confined  to  the  Mediterranean  basin.  India,  Ilong 
Kong,  Secunderabadin,  the  Deccan,  Porto  Rico,  Corsica, 
England,  and  the  Philippines  are  all  reported  as  localities 
where  this  fever  has  been  contracted.  The  attention  of  the 
physicians  was  first  called  to  the  existence  of  Malta  fever 
in  Jlanila  in  the  post-mortem  work.  After  being  impressed 
from  discoveries  made  in  necropsies  that  Malta  fever  is  not 
a  very  uncommon  disease  in  Manila,  a  clinical  search  for 
the  cases  was  begun,  which  has  been  rewarded  by  the  dis- 
covery of  several  cases  which  give  marked  reaction  with 
micrococcus  melitensis  in  high  dilutions.  One  of  these 
cases  had  been  diagnosed  malarial  fever,  while  two  others 
were  thought  to  be  typhoid  fever  with  relapse.  The  Wi- 
dal  reaction  was  absent,  as  were  also  the  malarial  para- 
sites. 

History  of  a  Case  of  Removal  of  a  Retro-Bulbar  Lympho- 
sarcoma with  Preservation  of  Normal  Vision. — Bv  Cliarles 
A.  Oliver. 

Traumatic  Aneurism  of  the  Left  Internal  Carotid  Artery; 
Death  ;  Autopsy. — By  Burton  S.  Booth. 

A  New  Aseptic  Ether  and  Chloroform  Inhaler. — By  Ernest 
Laplace  (illustrated). 
A  New  Phimosis  Forceps. — By  \V.  T.  Baird  (illustrated). 


l  he  Lancet,  Xoveinher  //,  iqoo. 

The  Treatment  of  Sprains  and  of  Some  Fractures.— A.  H. 
Tubby  says  that  in  a  sprain  numerous  small  vessels  are 
ruptured  at  the  moment  of  injury,  and  that  there  is  an  in- 
stantaneous out-pouring  of  a  certain  amount  of  blood  and 
lymph,  and  that  this  effusion  goes  on  for  three  or  four 
hours.  It  is  quite  rational  to  apply  cold  during  this  period, 
and  it  is  the  best  resource  at  our  command.  It  constringes 
the  vessels,  lessens  the  amount  of  exudation,  etc.,  so  that 
the  duration  of  symptoms  is  shortened  and  there  is  little 
liability  of  stiffness  afterward.  Furthermore,  the  amount 
of  effusion  may  also  be  les.sened  by  application  of  pressure 
and  the  placing  of  the  joint  in  such  a  position  that  its  po- 
tential cavity  is  lessened.  During  the  period  of  quiescence 
the  same  line  of  treatment  should  be  adopted,  for  there  is 
some  quiet  effusion  still  going  on.  But  when  the  second 
attack  of  pain  ensues  and  it  is  becoming  more  .severe,  the 
application  of  cold  is  not  of  much  value,  since  by  this  time 
the  tissues  are  distended  with  blood  and  with  lymph  and 
effusion  has  now  ceased  to  be  poured  out.  The  right  tiling 
to  do  is  to  apply  heat,  as  hot  applications  not  only  dimin- 
ish the  ])ain  but  exercise  a  permanent  effect  upon  the  dura- 
tion and  the  amount  of  swelling  in  this  way.  When  the 
vessels  which  have  been  injured  have  recovered  their  tone, 
the  application  of  hot  water  or  of  heat  in  other  forms  pro- 
motes absorption,  so  that  the  effused  blood  and  lymph  are 
as  rapidly  as  possible  taken  up  into  the  blood-vessels  and 
lymph  channels.  During  this  time  the  joint  should  be 
kept  at  rest  and  pressure  should  be  maintained  on  it  by 
cotton- wool  and  a  bandage,  since  well-directed  pressure 
also  assists  absorption.  When  the  amount  of  swelling  is 
very  considerable,  hot  applications  and  rest  are  not  suffi- 
cient. The  best  thing  is  properly  applied  friction.  In 
regard  to  fractures  the  writer  lays  down  the  following  rule 
as  to  cases  occurring  about  the  elbow:  "In  all  injuries 
about  the  elbow  joint,  except  fracture  of  the  olecranon,  the 
forearm  should  be  forcibly  extended,  then  supinated,  then 
acutely  flexed — that  is  to  say,  the  limb  should  be  placed 
with  the  ball  of  the  thumb  of  the  affected  limb  resting 
against  the  neck  on  the  opposite  side.  No  splint  is  needed, 
and,  iiKleed,  is  harmful,  for  tlie  position  can  easily  be  se- 
cured by  means  of  a  sling  jjassiiig  round  the  neck  and 
round  the  wrist."  In  separation  of  the  lower  epiphysis  of 
the  femur,  the  separated  portion  is  usually  dislocated  for- 
ward and  not  backward,  unlike  the  displacement  which 
occurs  in  a  transverse  fracture  of  the  lower  end  of  the  fe- 
mur; the  displacement  is  backward  almost  always  in  the 
latter  case.  Forward  displacement  of  the  lower  epiphysis 
is  accounted  for  by  this  circumstance — the  epiphyseal  line 
is  directed  from  the  front  downward  and  backward  so  that 
the  epiphysis  more  readily  glides  forward  on  to  the  shaft. 
In  transverse  fracture  the  line  of  fracture  usually  passes 
above  the  attachment  of  the  gastrocnemius:  hence  the 
fragment  is  tilted  backward.  Reduction  and  retention  in 
proper  position  can  be  accomplished  by  division  of  the 
tendo  Achillis  and  forcible  e.xtension,  or  the  limb  may  be 
put  up  with  the  heel  touching  the  buttock,  or  the  joint  may 
be  opened  and  the  epiphysis  fi.xed  with  a  steel  nickel- 
plated  screw. 

The  Micro-Organisms  of  Vaccine  Materials. — J.  B.  Buist 
records  his  experiments  made  in  the  course  of  the  last 
fifteen  years  to  determine  the  cause  of  ojiacity  of  vaccine 
lymph.  All  he  is  prepared  to  say  is  that  this  opacity  was 
due  to  spores  from  unknown  sources,  of  a  yellow,  brown, 
white,  or  orange  color,  even  in  specimens  which  had  been 
kept  fifteen  years.  These  he  regards  as  the  active  ingre- 
dient of  the  lymph.  Some  authorities  have  isolated  these 
spores  and  inoculated  them  into  calves,  the  virus  from 
which  would  "take"  in  children,  but  direct  inoculation  of 
the  spore  products  into  the  human  being  were  failures. 

Complete  Inversion  of  the  Uterus.^ — A  case  is  reported  by 
David  Durran  in  a  woman  aged  twenty-five  years,  in  her' 
third  confinement.  Improper  methods  of  pressure  on  the 
abdomen  were  suspected  as  the  e.xcitin'g  cause,  but  the 
midwife  in  attendance  denied  that  such  methods  had  been 
used.  Symptoms  and  treatment  were  along  the  usual 
lines.  The  patient  did  well  until  the  eleventh  day,  when 
delusions  began  to  appear  and  ran  on  to  puerperal  mania, 
requiring  institution  treatment.  Cure  resulted  after  sev- 
eral months'  stay  in  the  asylum. 

Unusual  Conditions  at  Birth. — By  A.  J-  Rice  Oxley.  Case 
I.  was  one  of  fracture  of  the  clavicle  with  normal  presenta- 
tion. It  occurred  in  a  very  rapid  labor.  Case  II.  was  one 
of  'congenital  thickening  of  the  sterno-mastoid."  The 
case  was  one  of  forceps  delivery,  but  the  tumor  was  not  a 
haimatoma.     Such  swellings  clear  up  of  themselves. 

Remarks  of  Ten  Cases  of  Enteric  Fever  in  which  the  Blood 
was  Examined  Periodically  for  Agglutinative  Purposes.— By 
W.  (!.  Savage. 

Acute  Emphysematous  Gangrene ;  a  Clinical  and  Bacterio- 
logical Digest  with  Details  of  a  New  Case. — By  E.  M- 
Corner. 


864 


MEDICAL    RECORD 


December  i, 


1900 


A  Case  of  Acute  Rheumatism  with  Previous  Mitral  Regur- 
gitation followed  by  Pericarditis. — By  A.  R.  Hcnchlcy. 

Fibroid  Tumor  as  a  Complication  of  Pregnancy  and  Labor. 
— By  J.  E.  Genimell. 

Remarks  on  Two  Cases  of  Landry's  Paralysis. — By  T.  W. 
Griffith. 

French  Journals. 

Treatment  of  Acute  Mucous  Colitis  and  Dysenteric  Colitis 
by  Sulphate  of  Sodium. — Avira^uet  divides  aLute  eolnis 
into  two  varielics  mucous  and  dy.sentenc.  He  outlines 
his  treatment  of  these  cases  as  follows  .  (i)  Rest  in  bed; 
diet  of  water  and  milk.  (2)  The  application  of  cataplasms 
or  \varm  wet  compre.sses  for  the  abdominal  pain.  (3) 
Avoidance  of  large  intestinal  injections,  which  by  produc- 
ing distention  cause  great  pain  (sometimes  intolerable), 
besides  often  increasing  the  inflammatory  process.  (4) 
Small  laudanum  injections  to  diminish  the  extreme  fre- 
quency of  the  stools  and  the  rectal  tenesmus.  This  treat- 
ment is  to  be  preferred  to  suppositories.  (5)  In  order  to 
combat  the  iuflaramation  of  the  mucosa  of  the  large  intes- 
tine several  measures  have  been  suggested  :  .(a)  Introduc- 
tion into  the  large  intestine  of  medicinal  substances;  (/>) 
administration  of  ipecac  by  the  mouth  ;  (c)  purgatives. 
The  writer  much  prefers  to  use  sulphate  of  sodium  or  mag- 
nesium. With  the  employment  of  sulphate  of  sodium  his 
results  have  been  most  remarkable.  The  drug  has  a  mar- 
vellous action  on  the  secretions  of  the  large  intestine  ;  in  a 
large  dose  it  exaggerates  them  like  all  purgatives,  but  in 
a  small  dose  it  diminishes  them  and  causes  the  disappear- 
ance of  glairy  and  bloody  hypersecretion.  (The  hiErao- 
static  properties  of  sulphate  of  sodium  have  been  well  shown 
by  the  experiments  of  Reverdin,  of  Geneva.)  The  doses 
used  are  as  follows  :  10  to  15  gm.  the  tirst  day,  small  doses 
for  the  following  days  ;  5  gm.  for  example,  in  a  child  of 
twelve  to  fourteen  years ;  2  gm.  in  a  child  of  two  years. 
The  writer  believes  that  sodium  sulphate  given  in  small 
doses  is  a  remedy  of  the  first  order  in  acute  mucous  or  dys- 
enteric colitis. — Journal  des  Praticiens,  November  10, 
1900. 

Acute  Intoxications. — Among  other  acute  intoxications, 
Lemoine  speaks  of  cocaine.  The  only  cases  known  of 
acute  intoxication  by  this  drug  are  due  to  its  surgical  em- 
ployment for  producing  local  anaesthesia.  The  physician 
will  surely  be  held  responsible  for  these  accidents,  and  so 
must  know  how  to  prevent  and  combat  them.  The  first 
two  signs  of  the  intoxication  are  the  vascular  contraction 
which  is  shown  by  pallor  of  the  face  and  peripheral  tissues, 
and  the  nervous  symptoms,  such  as  delirium  and  incoher- 
ent speech.  Arterial  tension  is  raised,  and  convulsions 
both  tonic  and  clonic  soon  appear.  If  death  occurs  it  is 
caused  by  adynamia.  In  giving  cocaine  the  patient  should 
always  assume  the  dorsal  decubitus  to  prevent  cerebral 
anaimia,  and.  the  dose  should  never  pass  the  maximum  of 
10  cgm.  At  the  first  danger  signal  the  patient  should  be 
immediately  reversed.  Amyl-nitrite  inhalations  are  effica- 
cious. Chloral  hydrate,  morphine,  and  bromide  of  potas- 
sium are  good  to  combat  the  phenomena  of  cerebral  excita- 
tion. If  there  is  collapse,  ether  and  caffeine  hypodermically 
are  indicated.  The  patient  should  be  wanned  by  friction, 
hot  applications,  etc.,  to  prevent  the  cooling  of  the  body. — ■ 
Le  N ird  Medical,  November  1,  1900. 

Therapeutic  Value  of  Peroxide  of  Hydrogen. — ^Marcel  Ri- 
faux  states  that  peroxide  of  hydrogen  was  discovered  by 
Therard  in  iSiS.  This  substance  is  a  colorless,  odor- 
less, liquid,  having  a  piquant  taste.  It  can  be  mixed 
with  water  in  all  proportions.  Its  oxygenizing  power  is 
considerable,  for  it  gives  up  its  oxygen  with  the  greatest 
ease,  which  is  the  basis  of  its  real  antiseptic  character.  It 
is  also  a  hemostatic.  Clinically  it  is  of  tlie  greatest  ser- 
vice in  all  fetid,  suppurating  wounds.  Old  chronic  otor- 
rhoea,  for  example,  with  fetid  suppuration  is  rapidh'  deo- 
dorized by  its  use.  It  has  been  employed  with  some 
success  for  disinfecting  the  uterine  and  vaginal  cavities. 
In  epistaxis  it  is  u.sed  as  a  ha;niostatic.  The  writer  con- 
cludes from  the  study  of  peroxide  of  hydrogen  that  it  mer- 
its an  important  ]>lace  in  therapeutics,  as  it  is  non-toxic, 
inodorous,  a  powerful  deodorizer,  an  antiseptic  of  value, 
and  a  hemostatic  of  the  first  order. — Lyons  Medical,  No- 
vember 4,  1900. 

Prophylaxis  of  Tuberculosis. — E.  Malvoz  believes  that  va- 
rious social  mea-~ures  ought  to  be  taken  to  ameliorate  the 
condition  of  consumptives.  There  should  be  opportunity 
afforded  for  education  in  hygiene  ;  the  |)hysician  should 
g'ive  public  lectures  011  proper  dwellings,  food,  and  condi- 
tions suitable  for  workmen ;  an  examination  should  be 
made  of  suspects.  The  earliest  possible  diagnosis  of  tu- 
berculosis should  be  made,  facilitated  by  bacteriological 
laboratories  which  should  give  gratuitous  service.  There 
should  be  associations  to  support  the  invalids,  giving  all 
the  comforts  which  they  ought  to  have.  Physicians  should 
receive  both  a  clinical  and  bacteriological  education  which 


would  enable  them  to  make  a  very  early  diagnosis  of  this 
disease,  and  to  understand  its  prophylaxis  and  treatment, 
^La  Pressc  Medicate,  November  7,  1900. 

Miinchenir  medicinische  Wochenschrijt,  Nov.  6,  igoo. 

The  Significance  of  Oliver's  Sign  in  Aortic  Aneurism  and 
Thoracic  Ji  umors. — V .  Jessen  reports  two  cases  in  which 
the  tracheal  tug,  which  is  usually  said  to  be  absent  in  tu- 
mor and  present  in  aneurism,  gave  positively  misleading 
evidence.  The  first  of  these  is  that  of  a  young  girl,  who, 
witli  no  physical  signs  other  than  a  left  recurrtnt-nerve 
palsy  and  absence  of  the  Oliver-Cardarelli  symptom,  suc- 
cumbed to  wliat  appeared  to  be  a  deep-seated  tracheal  ste- 
nosis. Ulceration  with  subsequent  cicatrization,  due  to 
syphilis  or  tuberculosis,  was  excluded  from  the  history, 
the  freedom  from  congestive  conditions  was  against  medi- 
astinal tumor,  and  the  absence  of  circulatory  disturbances 
and  of  the  tracheal  tug  was  thought  to  rule  out  aneurism. 
The  autopsy  revealed  a  high  degree  of  aortic  endarteritis, 
together  with  an  aneurism  of  the  arch  as  large  as  a  walnut 
and  closely  adherent  to  the  trachea.  The  second  case  is 
that  of  a  middle-aged  woman,  who  presented  a  rather  com- 
plex syndrome  of  pulmonary  and  other  symptoms,  among 
which  the  Oliver-Cardarelli  sign  was  easily  obtainable. 
Under  urgent  dyspnoea  the  patient  died,  and  contrary  to 
expectation  was  found  to  have  had  a  mediastinal  sarcoma 
and  not  an  aneurism.  In  this  instance  the  simulation  of 
the  aneurismal  signs  was  due  to  the  intimate  relation  of  the 
new  growth  to  trachea  and  aorta,  both  of  which  it  partially 
surrounded.  In  the  author's  opinion,  therefore,  tracheal 
tug  is  not  a  diagnostic  sign  between  aneurism  and  neo- 
plasm, and  simply  indicates  the  presence  in  the  thorax  of 
an  abnormal  mass  in  close  relationship  to  the  aorta  and 
trachea. 

A  Little  Known  Pupillary  Reaction  and  its  Therapeutic 
Value. — Hans  Kirclmer  describes  an  ajipareutly  hitherto 
unnoticed  ocular  phenomenon  which,  although  as  yet  too 
little  studied  to  be  of  much  practical  value,  may  perhaps 
be  developed  into  a  useful  diagnostic  or  therapeutic  meas- 
ure. The  reaction  which  with  few  exceptions  is  found  in 
all  healthy  individuals  consists  in  a  contraction  of  the  pu- 
pil following  voluntary  closure  of  the  lids,  and  is  more 
marked  tlie  more  energetically  the  muscular  act  is  per- 
formed. The  same  effect  may  be  even  more  strikingly 
produced  by  holding  the  eye  open  with  the  fingers  while 
the  effort  is  made  to  close  it  against  resistance.  Consider- 
able difficulty  may  be  experienced  in  eliciting  the  reaction 
owing  to  various  interfering  factors,  such  as  the  light 
reflex  and  Bell's  phenomenon.  It  is  interesting  to  note 
that  a  pupil  which  fails  to  react  to  light  or  accommodation 
may  be  brought  to  contract  by  this  manoeuvre,  and.  fur- 
thermore, that  the  reaction  may  be  increased  by  practice. 

The  Occurrence  of  the  Demodex  Folliculorum  in  the  Eye- 
lid and  its  Relation  to  Conjunctivitis. — Karl  liunsche  tound 
this  organism  present  in  the  eyelids  of  seventy-nine  per 
cent,  of  the  heterogeneous  dead-house  material  investi- 
gated, and  believes  that  in  individuals  over  forty  it  is  al- 
ways to  be  found.  Its  occurrence  with  such  frequency  in 
the  lids  of  those  unaffected  by  any  ocular  disorder  leads  to 
the  conclusion  tliat  it  is  unable  to  jiroduce  any  lesion  of-the 
parts  in  question,  and  tliat  especially  the  conjunctivitis 
acarica  of  Joers  does  not  exist.  The  author's  observations 
were  conducted  by  epilation,  with  microscopical  examina- 
tion of  the  roots  of  the  cilia,  and  by  the  pre)  aration  of 
sections  of  the  lids,  by  which  he  was  able  to  demon.strate 
the  jjarasites  in  situ  after  hardening  in  formalin-alcohol 
and  double  staining  with  eosin-ha;matoxylon. 

The   Effect  of   Nutrient  Enemata   on  Gastric  Secretion. — 
Ludo  Metzger,  in  order  to  settle  the  question  as  to  whether 
the  stomach  is  really  at  rest  when  feeding  is  done  only  by         , 
rectum,  or  whether  gastric  secretion  goes  on  even  under        ■ 
these  conditions,  has  made  a  series  of  observations  on  men        1 
and  animals.     Briefly  summed  up  his  conclusions  are  that 
an  enema  of  milk  and  eggs  prodi  ces  in  the  stomach  only  a  . 
small  quantity  of  a  faintly  acid  .secretion  which  does  not 
appear  till  one  and  a  half  hours  after  the  injection.     The 
bouillon-claret  enema,  however,  is  sjjcedily  followed  by  a        j 
highly  acid   secretion,   which  disappears  within  an   hour        I 
after  the  feeding.     Control  exiierimenls  showed  that  this        ■ 
increased  secretory  activity  was  due  to  the  presence  of  the 
claret. 

Further  Contributions  to  the  Disinfection  of  the  Hands. — 
By  Sclunk  and  Zaufall. 

The  Use  of  Reindeer  Sinew  as  Suture  and  Ligature  Mate- 
rial.—By  A.  Schiller. 

Per  liner  ktinisclic  W'ochensclirijt,  October  zq,  igoo. 

Four  Cases  of  Disturbance  of  Equilibrium.— Rieken  reports 

four  cases  which  came  on  suddenly  during  a  period  of  damp 
weather  during  which  influenza  .-md  rheumatism  had  been 
specially  jirevalent.  The  symptoms  simulated  in  certain 
respects  those  of  M6niere's  disease,  and  are  analyzed  in 


December  i,  1900] 


MEDICAL   RECORD. 


865 


detail  in  the  original  article.  The  author  admits  that 
similar  symptom  groupings  are  seen  under  various  cir- 
cumstances, such  as  seasickness,  vertigo  from  various 
stomach  and  uterine  disorders,  galvanization  of  the  head, 
loud  noises,  alcoholic  poisoning,  etc.  He  thinks  it  very 
possible  that  toxic  poisoning  from  a  disordered  gastro- 
enteric state  is  the  underlying  factor  in  some  of  these 
cases. 

The  Treatment  of  Callous,  Resilient  Stricture. — H.  Lohn- 
stein  lias  devised  an  ajjparatus  (figured  in  tlie  original)  for 
the  i)urpose  suggested  by  t'ne  title.  The  stricture  is  en 
larged  as  nincli  as  possible  by  dilatatiim  and  then  the  spe- 
cial apparatus  employed.  The  principle  utilized  is  that  of 
the  Bottini  electric  knife,  modified  so  as  to  form  a  urethro- 
tome running  in  a  proper  cannula. 

The   Clinical  Value   of  A.  Schmidt's   Methods  of  Testing 
Intestinal  Functions. — Liy  II.  Philli])psiihn. 
Rose's  Diabetic  Milk.^By  Dr.  Saudmeyer. 
Drinary  Calculi. — By  C.  Posner. 

American  Journal  of  the  Med.  Sciences,  A'oi'ember.  iqoo. 
Biological  Studies  with  Reference  to  Pathology. — Theo. 
Klingmann  c.^perinicnled  witli  spirugyra  llueads  by  plac- 
ing .several  in  water  iii  which  was  immersed  a  piece  of  cop- 
per foil.  A  control  of  plain  water  was  used.  In  the  copper 
water  the  tir.st  change  noted  in  the  spirogyra  was  the  ces- 
sation of  the  protoplasmic  streaming,  the  protoplasm  be- 
coming granular,  while  the  division  of  the  protopla.smic 
cylinder  and  the  granular  evolutiim  in  the  protoplasm  fol- 
lowed, together  with  retraction  of  tlie  outer  part  of  the 
tube  and  destruction  of  the  chlorophyl  bands.  The  same 
pathological  conditions  can  be  brought  about  by  the  action 
of  various  bacterial  toxins  and  to.\ic  blood-serum.  Of  one 
hundred  and  fifty  cases  about  one-third  of  the  patients 
were  in  perfect  health,  the  other  two-thirds  being  patients 
suffering  from  various  disorders,  such  as  epilepsy,  neuras- 
thenia, hysteria,  mania,  pyaemia,  pneumonia,  syphilis, 
tuberculosis,  erysipelas,  typhoid  fever,  diphtheria,  measles 
and  other  infectious  diseases,  alcoholism,  gout,  and  rheu- 
matism. After  the  blood  has  been  obtained  it  is  dilated 
with  20  c.c.  of  water  and  thoroughly  mixed  ;  a  few  drops 
of  the  liquid  are  placed  on  a  clean  glass  slide  ;  a  thread  of 
spirogyra  is  put  into  this,  and  is  observed  under  the  micro- 
scope with  about  a  No.  3  Leitz  objective.  The  water 
which  is  u.sed  for  diluting  the  blood  is  tested  by  placing  a 
few  threads  of  spirogyra  in  a  glass  dish  containing  .some 
of  the  water,  and  is  allowed  to  stand  a  short  time.  If  the 
water  is  non-toxic,  the  specimen  is  not  altered.  The  time 
in  which  the  alteration  takes  place  varies  directly  with  the 
amount  of  toxin  and  the  species  of  spirogyra.  While 
changes  in  the  spirogyra  take  place  in  the  toxic  blood  solu- 
tion, the  blood  of  healthy  individuals  yields  negative 
results. 

The  R61e  of  the  AUoxuric  Bases  in  the  Production  of  the 
Cardio- Vascular  Changes  of  Nephritis. — Alfred  Careno  Crof- 
tan  states  that  the  alloxuric  bases  are,  unlike  uric  acid  and 
urea,  very  readily  soluble  in  the  tissue  fluids,  and  are 
highly  toxic.  Their  chief  representatives  are  xanthin, 
hypoxanthin,  adenin,  and  giiauin.  Xanthin  and  hypoxan- 
thin  are  capable  of  producing  the  cardio-vascular  changes 
in  those  forms  of  nephritis  in  which  retention  of  excremen- 
titious  substances  precedes  the  lesions  of  the  heart  and  ar- 
teries. The  author  believes  that  the  alloxuric  bases  are 
the  primary  factor  in  the  causation  of  "gouty"  kidney. 
In  the  "lead  "  form  of  interstitial  nephritis,  the  toxic  action 
of  this  metal  is  either  the  same  as  that  of  the  alloxuric 
bases,  or  it  can  cause  changes  in  the  organism  which  lead 
to  the  formation  of  these  bases.  The  same  toxins  may 
simultaneously  produce  both  nephritis  and  arteriosclero- 
sis (lead,  gout,  etc.).  From  his  investigations  the  author 
concludes  that  the  alloxuric  bases  have  an  important  role 
in  the  pro<luction  of  the  cardio-va.scular  clianges  observed 
in  all  forms  of  nephritis  excepting  the  chronic  indurative 
form  sometimes  seen  as  the  result  of  senile  arterioscle- 
rosis. 

A  Report  of  Cases  of  Pernicious  Anaemia,  with  Special 
Reference  to  the  Blood-Findings.— By  Frank  Billings. 

Aneurism  of  the  Arch  of  the  Aorta,  with  Rupture  into  the 
Superior  Vena  Cava. — By  Alfred  Stengel. 

A  Report  of  Two  Cases  of  Filariasis. — By  Howard  A. 
Lothrop  and  Joseph  H.  Pratt. 

Recurrent  Vomiting  in  Children  (Cyclic  Vomiting).— By  J. 

P.  Crozer  Griffith. 

Subpectoral  Abscess. — By  John  Herr  Musser. 
Medicine,  November,  igoo. 

The  Blood  in  Neurasthenia.- Theodore  H.  Romeiser  and 
Joseph  Collins  give  a  study  of  thirty-three  cases,  based  on 
a  differential  leucocyte  count,  and  give  a  detailed  report  of 
the  conditions  found.  As  regards  the  general  features 
they    record    the    following    ooservations .    JIany    cases 


showed  a  leucopenia— that  is,  a  decreased  ratio  of  leuco- 
cytes to  erythrocytes,  often  quite  marked.  In  connection 
with  this  they  note  that  one  of  the  therapeutic  measures 
considered  most  efficient  in  the  treatment  of  neurasthenia, 
namely,  hydrotherapy,  has  the  effect  of  removing  this  con- 
dition of  the  blood,  for  cold  baths  cause  a  physiological 
leucocytosis.  Some  patients,  chiefly  those  well'nourished 
and  physically  in  perfect  health  so  far  as  appearances  went, 
showed  a  normal  count ;  a  few  showed  a  slight  leucocyto- 
sis, associated  jierhaps  with  a  slight  local  inflammatory 
process  otherwise  unobserved,  as  would  be  the  case  had 
the  patient  an  infection.  Nearly  all  had  a  more  or  less 
marked  oligochromia,  often  with  many  microcytes  and  a 
few  poikilocytes.  In  one  case  a  normoblast  was  observed. 
It  is  to  be  observed  that  in  neurasthenia  there  is  often  a 
striking  lack  of  correspondence  between  the  intensity  of 
the  subjective  symptomatology  and  that  of  the  objective, 
and  in  general  it  may  be  stated  that  the  h;ematological  ab- 
normalities both  in  kind  and  in  degree  correspond  more 
with  the  objective  than  with  the  subjective  clinical  pic- 
ture. 

Multiplied  Ossified  Ecchondrosis  and  Exostosis  of  the  Tra- 
chea and  Larger  Bronchi. — I.  B.  Diamond  describes  the 
gross  and  tht;  microscopical  findings  in  a  case  which  in- 
volved the  entire  trachea  and  larger  bronchi  of  a  man  aged 
forty-eight  years.  There  were,  on  the  one  hand,  seem- 
ingly true  exostoses  arising  from  the  perichondrium,  and 
on  the  other  ecchondroses.  lie  believes  the  bony  rings  to 
be  ossified  ecchondro.scs,  and  describes  the  process  of  their 
development.  Very  little  can  be  said  as  to  the  clinical 
significance  of  tlie.se  growths.  They  are  rarely,  if  ever, 
recognized  during  life,  except  when  situated  at  the  ujiper 
portion  of  the  trachea  and  when  they  grow  to  such  size  as  to 
interfere  with  respiration.  When  situated  in  the  larynx 
they  are  readily  recognized  and  even  successfully  removed. 
It  is  remarkable  that  nearly  all  the  patients  have  died  from 
some  pulmonary  affection,  as  tuberculosis,  ab.scess,  or  gan- 
grene of  the  lungs.  It  would  seem  that  as  a  result  of  the 
condition  the  respiratory  tract  is  weakened  against  the  in- 
vasion of  microbes,  especially  since  the  epithelial  cells  are 
changed,  even  destroyed. 

Examination  of  the  Stomach  Contents  with  Respect  to  Di- 
gestive Ferments  and  Digestive  Products. — By  Frederick  A. 
McGrew. 

7 he  Journal  of  Tropical  Medicine,  October  /j-,  7900. 

A  Holiday  in  the  Mosquito-Proof  House  in  the  Roman 
Campagna. — D.  C.  Rees  visited  Drs.  Sanibon  and  Low  and 
gives  an  interesting  account  of  his  stay  with  them.  The 
hut  is  situated  in  probably  the  most  malarious  spot  in 
the  whole  Campagna,  practically  on  the  banks  of  one  of  the 
main  canals  whicli  in  September  is  literally  swarming  with 
Anopheles  claviger.  The  days  were  spent  in  scientific 
work  and  in  entertaining  eminent  scientists  and  other  visi- 
tors. The  resident  party  turned  indoors  before  six  o'clock, 
at  wdiich  time  the  door  was  locked  and  no  one  allowed  to 
enter.  The  Anopheles  would  appear  outside  as  regularly 
as  clockwork.  They  do  not  bite  in  the  daytime.  The  win- 
dows were  wide  open  all  night,  so  that  marsh  air  came  in 
freely,  but  in  spite  of  that,  in  spite  of  their  being  out  con- 
stantly in  the  daytime,  and  getting  soaked  to  the  skin  in 
the  rainy  season,  no  one  of  the  party  contracted  malaria. 
The  peasants  of  the  Campagna  and  the  inhabitants  of 
Ostia  were  practically  all  down  with  it,  and  the  picture  of 
woe  and  misery. 

A  Case  of  Blackwater  Fever  in  Trinidad.- R.  C.  Bennett 
reports  a  case  of  ordinary  chronic  intermittent  malarial 
fever  in  whicli  there  was  a  sudden  onset  of  urgent,  danger- 
ous hajmoglobinuric  symptoms,  in  a  region  where  black- 
water  fever  had  never  been  heard  of  before.  No  parasites 
were  found  in  the  blood.  JIany  of  the  red  cells  were  cre- 
nated  and  buckled.  The  patient  had  been  taking  much 
quinine.  The  author,  however,  does  not  believe  that  the 
condition  was  due  to  quinine,  for  he  says  that  practical 
experience  renders  Koch's  theory  untenable.  It  would  be 
more  in  keeping  with  the  maximum  amount  of  reasonable 
possibility  to  consider  blackwater  fever  a  "post-malarial 
condition  " — occurring  in  cases  that  have  been  saturated 
with  malaria — whose  resisting-powers  have  been  gradually 
lowered,  and  in  whom  dn  abnormal  amount  of  malarial 
toxin  has  been  accumulated  and  suddenly  explodes,  as  it 
were,  into  acute  haemoglobinuric  sj-mptoms  (rapid  destruc- 
tion of  red  blood  corpuscles  and  loss  of  albumin). 

Circumscribed  Cutaneous  (Edema. — A.  B.  Dalgettj'  de- 
scribes an  affection  which  is  occasionally  seen  among  tea- 
garden  coolies  in  India.  The  patient  comes  to  the  dispen- 
sary complaining  of  stiffness  and  swelling  in  one  hand, 
which  has  come  on  during  the  night.  The  dorsum  of  hand 
and  wrist  are  found  to  be  considerably  swollen  and  to  pit 
slightly  on  pressure,  but  there  are  no  other  symptoms.  The 
patient  cannot  account  for  the  condition.  The  author's 
patients  were  not  noticeably  ansemic.  nor  had  they  been 
suffering  from  malarial  fever,  nor  from  any  constitutional 


866 


MEDICAL    RECORD. 


[December  i,  1900 


affection.  The  cedema  disappears  in  from  two  to  twenty 
days.  Iodine  ointment  seems  to  aid  absorption.  The  eti- 
ology of  this  affection  is  a  complete  puzzle. 

The  Etiology,  Symptoms,  Diagnosis,  and  Treatment  of 
Round-Worm  Infection.— Hy  j.  Preston  Maxwell. 

An  Address  on  Some  Problems  of  Tropical  Medicine. — By 
Sir  WiUuim  Macsregor. 

Anchylostomiasis  in  the  Leeward  Islands. — By  H.  A.  Al- 
ford  Nicholls. 

Observations  of  Mosquitos. — By  P.  \V.  Bassett-Smith. 
Riisski  Arkhiv  J'ato/ogii,  eh.,  .\o.  .?,    Ky/.  .i..  iqoo. 

Koumyss  as  a  Therapeutic  Agent — C.  F"leuroff  has  during 
the  past  si.x  years  noted  the  following  action  of  koumyss, 
or  fermented  mare's  milk;  (i)  In  aufemia,  neurasthenia, 
and  hysteria,  amelioration  of  general  condition  and  all 
symptoms;  (2)  in  some  cases  of  hepatic  and  renal  colic,  in- 
crease of  the  pain  ;  (3)  in  diseases  of  heart  and  blood-ves- 
sels, negative  results ;  (4)  generalized  tuberculosis,  nega- 
tive results :  (5)  in  incipient  and  early  plithisis,  im- 
provement of  appetite,  of  digestive  functions  and  of  the 
general  condition,  increase  of  weight,  diminution  of 
cough,  amount  of  sputum,  fever,  etc.  ;  (6)  treatment  by 
koumyss  should  be  long  continued;  (7)  diseases  in  which 
it  is  contraindicated  are  :  Atheroma  of  blood-vessels,  heart 
diseases,  abdominal  plethora,  rheumatism  and  gout,  cere- 
bral hyperemia,  the  later  stages  of  pulmonary  phthisis, 
hicmoptysis,  hepatic  and  renal  colic. 

Acquired  Lesions  of  the  Valves  of  the  Pulmonary  Artery. 
— M.  Fisch  reports  a  case  of  lUcerative  endocarditis,  lo- 
calized on  the  valves  of  the  pulmonary  artery.  The  heart 
was  increased  in  size,  especially  on  the  right.  In  the  sec- 
ond left  intercostal  space,  auscultation  revealed  systolic 
and  diastolic  murmurs  of  a  rasping  quality  ;  at  the  apex 
there  was  merely  a  soft  systolic  murnmr.  The  second  aor- 
tic .sound  was  slightly  accentuated.  The  urine  contained 
albumin.  The  temperature  was  high  ;  a  diagnosis  was 
made  of  initral  insufficiency,  and  insufhciency  and  prob- 
ably stenosis  of  the  valves  of  the  pulmonar\'  artery.  The 
author  cites  twelve  cases  of  acquired  lesions  of  the  pulmo- 
nary artery  found  in  literature,  in  addition  to  those  men- 
tioned by  Barie  in  his  work  on  insufficiency  of  the  pulmo- 
nary artery. 

The  Pathogenesis  of  Acute  Yellow  Atrophy  of  the  Liver. — • 
N.  T.  Baimakoff  found  in  the  liver  of  a  patient  who  died 
from  this  disease  diplococci  which  were  situated  among  the 
red  blood  cells.  They  were  stained  blue  by  methylene  blue, 
and  were  in  groups  of  from  five  to  ten,  or  twenty,  or  thirty. 
An  aureole  resembling  a  capsule  was  around  them.  They 
were  found  in  every  part  of  the  organ.  No  success  fol- 
lowed the  attempt  to  cultivate  diplococci  taken  from  the 
blood  during  life,  nor  from  blood  taken  after  death  from 
heart,  liver,  gall  bladder,  spleen,  and  kidneys.  Diplo- 
cocci may  possibly  be  the  cause  of  acute  3'ellow  atrophy, 
which  is  an  infectious  disease  in  wdiich  the  liver  shows 
more  degeneration  than  do  the  other  organs. 

Spinal  Affections  in  the  Wew-Born  and  Nurslings  with 
Hereditary  Syphilis. — By  R.  Peters. 

Chemical  Examination  of  the  Fluid  in  Milky  Non-chyli- 
form  Ascites.— By  D.  Sherbatcheff, 


OPorvcspomU-nce. 

OUR   LONDON    LETTER. 

(From  our  Special  Correspondent.) 

THE  WAR  HOSPITALS  COMMISSION — TYPHOID  AT  m.OF.MFONTEIN 
— SIR  WALTER  FOSTER — NATIONAL  HOSPITAL  DISPUTE — THE 
BRADSHAW  LECTURE  ON  URINARY  PIGMENTS— SIR  MICHAEL 
FOSTER  ON  EXPERIMENT — PLAGUE — DEATH  OF  PROFESSOR 
HUGHES. 

London,  November  g,  igoo. 

The  South  African  hospital  commission  concluded  the 
taking  of  evidence  on  Monday.  The  last  witness  exam- 
ined was  Mrs.  Richard  Chamberlain,  as  the  reporters  oth- 
cially  style  her,  or  Mrs.  Dick  Chamberlain,  as  she  prefers 
to  be  called.  She  is  generally  known  as  a  woman  who 
seeks  a  certain  sort  of  notoriety,  and  on  this  occasion  has 
succeeded  in  advertising  herself  beyond  her  usual  circle. 
Some  of  the  reporters  say  .she  threw  about  twenty  thousand 
words  at  the  commission  in  less  than  two  hours.  One  of 
the  more  spriglitly,  as  if  despairing  of  finding  the  gist  of 
her  talk,  gives  himself  up  to  describe  her  dress,  her  face, 
her  eyes,  her  lips,  and  so  on.  This  may,  jierhaps,  grat- 
ify her  vanity  but  cannot  conduce  to  confidence  in  her 
statements.  "  Not  so  fast,  please,  my  dear  madam  ;  not 
so  fast,"  cried  the  president  from  time  to  time,  but  he  was 
unheeded.  When  direct  questions  were  put  to  her  she 
exclaimed  pettishly,  "You  are  doing  what  everyone  did 


in  South  Africa,  trying  to  make  things  as  awkward  as  you 
can.  You  are  behaving  not  as  if  you  were  judges,  but  as 
if  you  were  counsel  for  defence  of  the  army  doctors."  To 
this  reckless  imperti:.ence  the  learned  judge  contented 
himself  with  saying;  "You  are  quite  mistaken,  but  we 
want  you  to  understand  that  this  is  the  end  of  the  inquiry. 
W'c  have  taken  an  enormous  quantity  of  evidence,  and 
wliat  we  want  is  not  opinions,  but  facts,  madam  ;  facts, 
facts,  facts  !  "  But  what  were  facts  to  a  woman  with  a 
grievance  and  determined  to  vent  her  spite  on  the  whole 
department  which  failed  to  appreciate  her  proll'ered  help — 
from  the  heartless  director-general  down  to  the  dressers 
and  orderlies?  She  repeated  her  former  statements  that 
the  hospitals  were  filthy  and  had  nothing  for  use,  tliat 
plenty  of  fresh  milk  could  be  had  if  the  doctors  were  not 
too  lazy  to  get  it,  that  many  of  the  doctors  were  drunken, 
and  the  drunkards  sent  home  with  the  care  of  the  invalids 
on  the  vo)-age.  Asked  for  names,  she  seemed  non-plusscd. 
"Write  them  down,"  said  the  judge,  "we  will  treat  them 
in  confidence."  At  length  she  wrote  down  one  and  said 
she  had  forgotten  another,  but  they  could  ask  Lord  Lans- 
downe ;  "He'll  tell  you,  you  know ;  and  as  to  another,  he 
IS  such  a  very,  very  nice  little  man,  I  don't  like  to  tell  his 
name — you  must  take  my  word  for  it."  Many  more  un- 
supported assertions  were  made,  but  the  president's  appeal 
for  facts,  not  opinions,  remained  disregarded. 

At  length  the  president  asked;  "Do  you  really  mean  to 
tell  us  that  you  consider  your  opinion  better  than  that  of 
the  trained  army  medical  men?  "  To  thi=,  with  all  the  as- 
surance of  ignorance,  if  not  impertinence,  she  replied: 
"Why,  of  course  ;  if  not,  what  is  the  use  of  my  being  here?  " 
Could  feminine  logic  go  further? 

What  may  be  the  report  of  the  commission  it  is  not  worth 
while  to  conjecture,  as  it  will  probably  not  be  delayed 
longer  than  is  necessary  to  collate  and  digest  the  volumi- 
nous evidence.  Meantime,  some  jmirnals  are  drawing  at- 
tention to  the  folly  of  the  War  Office  in  keeping  the  medi- 
cal corps  below  the  necessities  of  the  army.  The  corps 
was  estimated  to  supply  fifty  thousand  men  with  medical 
aid,  and  by  March  it  had  to  attend  to  five  times  as  manv. 
As  late  as  June.  Surgeon-General  Hamilton  wrote;  "For 
years  the  condition  of  short-handedness  of  the  R.A.M.C. 
both  in  officers  and  men  has  been  urged  upon  the  War 
Office  with  but  little  effect,  the  view  of  the  authorities 
being  limited  to  '  drugs  and  doctors, '  the  former  to  be  pur- 
chased, the  latter  hired,  when  necessity  arose." 

With  regard  to  the  epidemic  of  tyjjhoid  at  the  front  there 
is  in  a  certain  quarter  a  disposition  to  blame  the  govern- 
ment for  declining  Sir  Walter  Foster's  offer  to  take  charge 
of  the  sanitary  arrangements.  It  is  even  asserted  by  some 
that  the  education  of  the  army  surgeon  is  imperfect  as  to 
sanitary  matters.  This  is  disingenuous.  Netley  has  been 
in  the  van  on  these  matters  ever  since  the  late  Profes.sor 
Parkes  taught  there.  Tlie  Royal  Army  Medical  Corps 
knows  more  about  military  hygiene  and  the  requirements 
of  camps  than  do  civilian  doctors.  Sir  W.  Foster's  work  at 
the  British  Medical  Association  and  in  Parliament  affords 
no  guarantee  that  he  knows  much  about  sanitation,  and  if 
he  had  gone  to  Africa  he  would  probably  have  had  to  read 
up  the  subject  in  Parkes  and  other  Netley  teachers. 
Events  have  happened  which  the  most  distinguished  army 
surgeons  foresaw  as  likely,  and  Sir  W.  Foster  should  be 
glad  he  had  not  the  responsibility  of  meeting  them. 

The  dispute  at  the  National  Hospital  for  the  Paralyzed 
and  Epileptic  has  advanced  another  stage,  and  a  most  im- 
portant one.  On  Saturday  7 /le  Times  published  a  letter 
signed  by  fifty-eight  prominent  members  of  the  profession, 
headed  by  Lord  Lister.  The  signatures  are  those  obtained 
by  submitting  the  letter  to  the  two  seniors  on  the  acting 
staff  of  every  London  hospital  having  over  one  hundred 
beds,  and  also  to  those  gentlemen  who  have  been  presi- 
dents of  royal  colleges.  In  order  to  add  weight  with  the 
general  public  the  signatures  were  also  obtained  of  those 
who  hold  court  appointments  or  who  are  knights  or  baro- 
nets. The  letter  expresses  a  firm  conviction  that  the  de- 
mand of  the  staff  for  representation  on  the  board  is  jier- 
fectly  rea.sonable,  and  one  which  in  other  hosjutals  has 
conduced  to  harmonious  working  and  efficient  administra- 
tion. 

Will  the  board  give  way?  If  not,  will  the  governors 
meet  and  dismiss  them,  or  let  the  hospital  fall  from  the 
position  described  by  this  document  as  "more  than  na- 
tional ?  " 

Dr.  Archibald  E.  Garrod  delivered  the  Bradshaw  lec- 
ture at  the  Royal  College  of  Physicians  on  Tuesday.  He 
took  for  his  subject  "Tlie  Urinary  Pigments  in  their  Path- 
ological Aspects. "  It  would  not  fje  ])ossible  to  consider  in 
a  lecture  all  the  colored  substances  met  with  in  the  urine, 
or  even  all  those  which  may  have  more  claim  to  the  name 
"urinary  pigments."  The  lecturer  accordingly  attempted 
to  deal  only  with  a  small  grou])  which  may  be  met 
with,  if  only  in  traces,  in  the  urine  of  persons  in  normal 
health  ;  urochrome,  urobilin,  hamiatoporphyrin.  and  uro- 
erythrin  constitute  such  a  group,  and  Dr.  Garrod  confined 


December  i,  1900] 


MEDICAL    RECORD. 


867 


his  attention  to  them  and  gave  as  full  an  account  of  them 
as  he  could  in  the  lime  at  his  disposal.  The  most  abundant 
is  urochrome,  to  which  probably  the  yellow  color  of  nor- 
mal urine  is  due.  Urobilin  occurs  only  in  small  quantity 
in  normal  urine,  and  tliat  in  the  form  of  cliromogen.  It 
does  not  influence  the  color,  but  in  some  morbid  states  it 
appears  in  much  larger  amounts,  and  to  a  great  extent  as 
formed  pigment,  when  it  has  a  distinct  effect  on  the  color 
and  can  be  shown  by  the  spectroscope  without  the  addition 
of  any  reagent.  Ha;matoporphyrin  is  found  only  in  traces 
in  normal  urine,  but  is  often  increa.scd  in  disease,  though 
very  rarely  enough  to  affect  the  color.  Uroerythrin  is  per- 
haps not  a  strictly  normal  constituent,  but  it  may  appear 
in  merely  trivial  deviations  from  perfect  health.  It  is 
often  abundant  in  morbid  urines,  and  is  the  coloring-mat- 
ter of  i)ink  urate  sediments. 

Dr.  (larrod  put  forward  no  extravagant  estimate  of  the 
importance  of  his  subject.  Such  as  it  possesses,  he  said, 
is  derived  from  the  light  it  throws  upon  processes  which 
are  at  work  in  the  body  both  in  health  and  in  disease,  espe- 
cially upon  those  which  are  concerned  with  the  disposal  of 
effete  blood  pigment.  Yet  there  are  cases  in  which  exam- 
ination of  the  urinary  pigments  may  afford  information  of 
diagnostic  value  and  which  may  not  be  easily  obtained  in 
other  ways.  He  therefore  claimed  that  their  study  is  not 
merely  of  academic  interest.  With  this  claim  he  concluded 
a  verj-  able  review  of  this  branch  of  chemical  pathology. 

Sir  Michael  Foster  distributed  the  prizes  at  St.  George's 
Hospital  on  Tuesday,  on  which  occasion  he  gave  an  ad- 
dress defending  experiment,  and  urged  that  every  touch  of 
the  surgeon,  every  counsel  of  the  physician,  was  in  its  very 
nature  an  experiment.  An  element  of  uncertainty  was  al- 
ways present,  although  sometimes  it  might  be  almost  in- 
significant. The  hospitals  ought  all  to  be  provided  with 
thoroughly  equipped  clinical  laboratories. 

The  last  plague  i)atient  in  Glasgow  has  been  discharged 
from  the  hospitals.  Xo  fresh  cases  have  occurred  for  six 
weeks,  and  unless  a  recurrence  takes  place  the  city  and 
port  will  be  declared  free  of  the  disease  on  the  13th.  The 
epidemic  has  extended  over  three  numths,  the  cases  num- 
bering twenty-eight,  the  deaths  only  eight.  Altogether 
Glasgow  is  greatly  to  be  congratulated.  A  fatal  case  is 
reported  from  Bremen,  and  elsewhere  suspicious  cases  are 
under  observation. 

Another  victim  to  South  Africa  from  our  ranks — Profes- 
sor A.  \V.  Hughes,  who  went  out  with  the  Welsh  hospital, 
died  on  Saturday,  aged  thirty-eight  years.  He  carried 
through  his  work  at  the  hospital  and  returned,  but  devel- 
oped typhoid  on  the  voyage,  and  a  fortnight  after  reaching 
home  the  end  came.  He  had  the  chair  of  anatomy  in  Car- 
diff University  College  for  about  four  years,  and  then  took 
tliat  at  King's  College  on  the  resignation  of  Professor  Cur- 
now.  Here  he  won  golden  opinions  and  became  dean  of 
the  school.  He  seems  to  have  inspired  esteem  and  affec- 
tion in  all  his  positions,  and  most  remarkably  in  South 
Africa,  where  all  ranks  who  met  him  lament  his  loss. 


MOSQUITOS  AND  YELLOW  FEVER. 

To  THE  Editor  of  the  Medical  Record. 

Sir:  It  is  with  mixed  feelings — of  deepest  regret  at  the 
untimely  and  almost  heroic  death  of  Dr.  Lazear.  of  admi- 
ration for  Dr.  Carroll's  self-devotion  to  the  cause  of  sci- 
ence, and  of  satisfaction,  seeing  that  my  own  experiments 
are  being  repeated  and  confirmed — that  I  have  just  read 
the  preliminary  notes  of  the  United  States  Yellow-Fever 
Commission. 

I  am  not  in  a  position  to  express  an  opinion  as  to  the 
importance  of  the  experiments  therein  described,  but  I  do 
feel  bound  to  rectify  .some  erroneous  statements  in  which 
I  am  personally  concerned,  specially  with  regard  to  an  ex- 
periment which  I  had  commenced  several  weeks  before  I 
was  honored  by  the  visit  of  Drs.  Lazear  and  Carroll.  I 
had  in  my  possession  a  small  bowl  in  which  several  gener- 
ations of  mosquitos  had  been  bred,  and  upon  the  sides,  a 
little  above  the  level  of  the  water,  there  were  numerous 
ova  laid  in  the  peculiar  manner  which  the  Culex  mosquito 
soofleu  adopts,  namely,  forming  a  ring  all  around  the  bowl, 
above  the  water.  It  occurred  to  me  that,  if  mosquitos  de- 
veloped from  the  eggs  of  a  contaminated  mother  are  cap- 
able themselves  of  transmitting  yellow  fever,  it  would  be 
important  to  determine  how  long  the  dry  ova  might  retain 
the  faculty  of  hatching.  I,  therefore,  emptied  the  bowl  of 
all  the  water  and  live  wrigglers  which  it  contained,  leaving 
only  the  ova  which  adhered  to  the  sides  of  the  bowl.  After 
having  allowed  the  ova  and  the  sediment  to  dry  in  the 
open  air,  I  placed  the  bowl  inside  of  a  small,  shallow  ket- 
tle, into  which  it  fitted  nicely,  and  by  fastening  the  lid  on 
the  kettle  made  sure  that  no  other  ova  would  be  depos- 
ited. This  was  done  on  the  29th  of  June,  so  that  when  the 
United  States  commission  called  on  me  the  dry  ova  had 
been  kept  isolated  over  one  month.     Dr.  Lazear  having 


expressed  a  wish  to  obtain  some  of  my  mosquitos  I  spoke 
to  him  about  the  expeiiment  which  I  had  in  progress,  and 
proposed  that  he  should  undertake  to  bring  it  to  a  close. 
As  the  means  of  procuring  a  good  supply  of  those  insects, 
I  would  hand  over  to  him  the  bowl  enclosed  in  its  kettle, 
he  might  pour  into  it  some  water  (preferably  rain-water) 
on  reaching  his  laboratory,  and  would  kindly  let  me  know 
whetlier  my  experiment  had  succeeded.  Dr.  Lazear  eager- 
ly accepted  my  proposal  and  carried  off  with  him  the 
whole  contrivance.  That  the  experiment  had  given  a  pos- 
itive result  I  subsequently  heard  from  Dr.  Agranumte.  and 
the  fact  is  confirmed  in  Dr.  Reads  preliminary  notes,  but 
(in  consequence,  no  doubt,  of  Dr.  Lazear's  death)  the  con- 
ditions of  the  experiment  are  entirely  distorted  and  Us  ob- 
ject is  completely  ignored. 

There  is  another  statement  which  I  beg  emphatically  to 
contradict,  viz..  "that  I  have  not,  as  yet,  succeeded  in  re- 
producing a  well-marked  attack  of  yellow  fever,  attended 
with  albumin  and  jaundice."  I  assert  most  distinctly  that 
I  obtained  every  one  of  those  symptoms  in  my  very  first 
experiment  with  a  contaminated  mosquito  in  July,  18S1, 
that  the  patient  had  also  bleeding  from  the  gums,  and  that 
during  the  four  years  which  the  patient  subsequently  spent 
in  Havana  he  never  h.id  another  attack  of  yellow  fever. 
In  my  subsequent  experiments  the  conditions  were  such 
that  I  was  in  honor  bound  not  to  run  the  risk  of  developing 
an  attack  which  might  endanger  life. 

Finally,  I  should  like  to  know  whether  the  entomologist 
who  identified  my  mosquito  as  the  "  Culex  fasciatus  "  had 
taken  into  consideration  the  very  remarkable  manner  in 
which  the  "Culex  mosquito"  lays  its  ova;  for  unless  both 
present  that  important  peculiarity  their  identity  must  be 
considered  very  doubtful.  Charles  Fi.nlav,  M.D. 

110  AcUACATE  Street,  Havana,  November  7,  1900. 


A   RACE-TRACK    HOSPITAL. 

To  THE  Editor  op  the  Medical  Record. 

Sir:  Having  to-day  witnessed  what  to  me,  and  as  far  as  I 
can  learn  to  others,  is  an  entirely  new  departure,  I  think  it 
wise  that  I  should  make  it  known  ;  hence  the  present  let- 
ter. 

While  in  no  way  a  "racing  man,"  I  received  a  courteous 
invitation  from  Jlr.  Thomas  Williams,  the  president  of  the 
Pacific  Jockey  Ciub,  to  visit  the  course.  While  there  we 
were  invited  to  visit  the  hospital.  I  must  confess  that  I 
was  somewhat  surprised,  and  that  I  expected  to  find  a 
dirty  room,  po<:>rly  equipped,  and  redolent  with  odors 
which  one  is  accustomed  to  find  about  stables  ;  in  fact,  the 
very  existence  of  an  hospital  in  connection  with  a  race 
course  was  novel. 

What  I  really  did  find  astounded  me — a  clean  modern 
operating-room  with  sterilizers,  instruments,  operating- 
table,  and  such  apparatus  as  one  would  expect  to  have  in 
a  well-conducted  cottage  hospital ;  a  ward  with  beds 
completely  equipped;  a  dispensary  well  stocked  with 
drugs,  and  a  storeroom  containing  splints,  crutches,  and 
surgical  dressings. 

On  inquiry  I  was  informed  that  a  regular  surgeon  is  em- 
ployed, whose  duty  is  to  be  present  during  the  racing  and 
give  his  undivided  attention  to  any  one  who  might  be  in- 
jured or  ill. 

This  goes  to  show  that  there  are  thoughtful  and  kindly 
men  in  all  walks  of  life,  and  that  a  too  ready  tendency  to 
condemn  the  owners  of  large  corporations,  on  account  of 
their  lack  of  interest  in  the  physical  welfare  of  their  em- 
ployees, is  liable  to  lead  us  into  error. 

During  the  past  decade  it  has  been  my  experience  to 
have  treated  quite  a  considerable  number  of  jockeys  who 
had  been  seriously  injured,  and  whose  condition  was 
made  infinitely  worse  by  crude  and  imperfect  primary 
treatment,  followed  by  poor  and  unskilful  transportation 
over  long  distances.  Had  hospitals  existed  such  as  that 
described  above,  there  would  have  been  a  great  saving  to 
life  and  limb,  for  primary  treatment  has  all  to  do  with  the 
subsequent  course  of  the  case,  as  any  one  who  has  had  an 
army  experience,  or  a  large  surgical  practice  in  civil  life 
must  know. 

I  trust  that  this  letter  may  be  read  by  your  subscribers, 
who  may  in  turn  be  able  to  suggest  a  similar  innovation  to 
the  owners  of  like  institutions  throughout  the  country. 
Jockeys  are  mostly  lads  of  tender  years,  and  it  is  indeed  a 
kindly  act  to  provide  for  their  care  when  injured  in  the 
fulfilment  of  their  work. 

I  might  add  that  this  corporation  not  only  looks  after  the 
physical  welfare  of  its  employees,  but  goes  a  step  further 
and  interests  itself  in  their  mental  advancement,  which  is 
evidenced  by  a  night  school  with  a  staff  of  instructors. 

George  Franklin  Shiels,  M.D.,  CM..  F.R.C.S.E.,  etc.. 
Professor  of  Surgery,  Medical  Department,  University 
of  California  ;  Surgeon,  San  Francisco  Polyclinic. 

Sa.s'  Francisco,  November  9,  1900. 


868 


MEDICAL    RECORD. 


[December  i,  1900 


SOUTHERN    SURGICAL   AND    GYNECOLOG- 
ICAL  ASSOCIATION. 

JVocceiiings  of  the  Thirteenth  Annual  Meeting,  Held  in 
Atlanta,  Georgia,  JVovember  ij.  14,  and  /J,  igoo. 

The  association  met  in  the  ballroom  of  the  Kimball 
Hotel,  under  the  presidency  of  Dr.  A.  M.  Cartledge, 
of  Louisville,  Ky. 

Governor  Candler,  of  Georgia,  delivered  an  elo- 
quent address  of  welcome,  which  was  responded  to 
by  President  Cartledge. 

Medullary  Narcosis. — Dr.  W.  L.  Rodman,  of  Phil- 
adelphia, read  a  paper  in  which  he  discussed  the 
points  of  most  practical  value  in  connection  with  this 
method  of  anaisthesia.  Would  it  displace  ether  and 
chloroform  in  operations  below  the  diaphragm?  In 
answering  this  question  the  author  said  that  no  one, 
however  optimistic  he  might  be  concerning  this  new 
method  of  producing  analgesia,  would  think  of  aban- 
doning ether  and  chloroform.  These  trusted  agents 
would  continue  to  enjoy  the  confidence  of  the  pro- 
fession, and  the  Corning  method  would  be  held  in 
reserve  for  certain  cases  in  which  there  was  seem- 
ingly a  clear  contraindication  to  chloroform  or  ether. 
Medullary  narcosis  should  be  induced  in  subjects  suf- 
fering from  bronchial,  pulmonary,  and  renal  diseases; 
in  patients  affected  with  fatty  or  dilated  heart  and  car- 
diac diseases  in  general.  It  might  also  be  induced  in 
old  people  in  whom  the  shock  of  general  anaesthesia 
was  oftentimes  great,  and  from  its  action  in  one  case 
the  author  believed  it  to  be  safer  than  chloroform  or 
ether  in  drunkards. 

The  place  where  the  spinal  canal  was  entered  was 
of  some  importance.  Tuffier,  Murphy,  Matas,  and 
others,  who  had  had  the  largest  experience  with  the 
method,  preferred  the  fourth  lumbar  space.  In  the 
opinion  of  the  author  any  of  the  lumbar  spaces  could 
be  punctured  with  safety.  The  fifth  interspace  be- 
tween the  last  lumbar  and  the  first  sacral  vertebra 
was  in  some  respects  the  easiest  route. 

The  author  considered  the  primary  dangers  of  sim- 
ple puncture  without  injection.  It  had  not  been 
shown  that  secondary  changes,  either  inflammatory  or 
degenerative,  had  taken  place  in  either  membranes  or 
cord,  leading  to  chronic  disease.  Theoretically,  one 
might  fear  some  form  of  sclerosis.  Simple  puncture 
of  the  spinal  cord,  if  aseptically  done,  was  unlikely  to 
be  followed  by  serious  changes  in  the  cord  or  its  mem- 
branes. If  to  simple  puncture  was  added  the  injec- 
tion of  some  chemical  substance  by  which  ana;sthesia 
was  produced,  a  new  element  of  danger  was  undoubt- 
edly incurred.  Therefore  the  choice  of  a  local  anaes- 
thetic became  of  paramount  importance.  Cocaine 
was  difficult  to  sterilize,  as  it  could  not  be  boiled 
without  impairing  its  anaesthetic  properties.  Raised 
to  a  temperature  above  180°  F.,  it  was  decomposed 
into  ecgonin,  and  became  comparatively  inert.  Some 
had  found  it  practical  to  boil  cocaine  and  then  to  in- 
troduce it  into  the  spinal  canal,  without  impairing  its 
ana'sthetic  properties.  By  raising  it  to  a  temperature 
of  180°  F.,  and  repeating  this  twice,  thrice,  even  six 
times,  as  recommended  by  Tuffier,  it  should  be  sterile, 
and  therefore  safe,  and  yet  a  dose  of  il^xxx.  of  a  two- 
per-cent.  solution  of  cocaine  was  too  large,  in  the 
judgment  of  the  essayist.  He  recommended  half  of 
this  amount.  A  small  dose  of  a  two-per-cent.  solution 
was  better  than  a  larger  one  in  greater  dilution.  He 
had  reduced  the  number  of  minims  of  a  two-per-cent. 
solution  each  time  he  had  practised  the  nicthod,  and 
thus  far  he  had  not  failed  to  obtain  complete  anal- 


gesia. In  his  first  case  he  had  injected  TTlxviii.,  in 
the  second  Tllxv.,  and  in  a  third  Tllxiii.,  and  hoped 
still  further  to  reduce  the  amount  to  TTlx.  We  should 
aim  to  get  complete  anaslhesia  with  the  smallest 
amount  of  the  drug.  The  primary  and  secondary 
efTects  of  the  injection  of  cocaine  into  the  spinal 
canal  were  those  of  a  simple  puncture  exaggerated. 
Shock  was  increased  ;  headache,  restlessness,  delirium, 
and  other  symptoms  were  necessarily  more  pronounced. 
The  speaker  referred  to  the  method  of  injection,  and 
to  the  length,  size,  shape,  and  composition  of  the 
needle.  He  recommended  an  irido-platinum  needle. 
He  described  the  technique  of  the  method,  which  was 
similar  in  many  respects  to  that  outlined  by  Tuffier 
and  others.  He  blindfolded  the  patient  and  filled 
the  ears  with  cotton  to  avoid  psychical  pain. 

Dr.  Lewis  S.  McMl'rtry,  of  Louisville,  predicted 
that  medullary  narcosis  would  not  take  the  place  of 
the  established  methods  of  anaesthesia,  and  said  that 
its  field  of  usefulness  would  be  restricted  to  the  class 
of  cases  outlined  by  the  essayist. 

Dr.  Willis  G.  Macdonald,  of  Albany,  mentioned 
the  case  of  a  man  forty-two  years  of  age,  who  had  suf- 
fered from  hemorrhoids  and  fissure  of  the  rectum. 
The  patient  had  always  been  a  hard  drinker.  Granu- 
lar and  hyaline  casts  were  found  in  the  urine,  as  was 
a  small  amount  of  albumin.  The  patient  likewise 
had  a  fatty,  dilated  heart.  The  speaker  had  injected 
Tllxviii.  of  a  two-per-cent.  solution  of  cocaine  in  the 
subdural  space,  and  when  he  was  about  to  begin  the 
operation  the  patient  had  become  cyanotic;  a  profuse, 
cold  perspiration  had  begun,  so  that  it  had  become 
necessary  to  give  the  patient  gr.  ^'„  of  strychnine,  and 
gr.  ^ij  of  nitroglycerin,  when  the  respirations  had  run 
up  to  sixty  or  eighty.  No_pulse  had  been  discernible 
at  the  wrist.  The  pupils  had  been  dilated;  the  pa- 
tient had  become  unconscious.  More  than  two  hours 
had  elapsed  before  the  speaker  felt  safe  as  to  the  con- 
dition of  his  patient.  The  man  had  suffeied  severely 
from  headache  and  projectile  vomiting  during  the 
entire  afternoon,  and  had  had  two  or  three  involun- 
tary bowel  movements.  Two  days  later  Dr.  Macdon- 
ald had  administered  nitrous  oxide  and  ether,  and 
operated  on  the  hemorrhoids.  The  patient  recovered. 
During  tiie  summer,  while  on  a  visit  to  Europe,  he 
had  seen  a  similar  experience  in  the  practice  of  Pro- 
fessor Kocher. 

Dr.  a.  M.  Cartledge,  of  Louisville,  said  his  expe- 
rience was  limited  to  eight  cases  in  which  he  had  used 
this  method  of  anaesthesia,  the  results  having  been 
satisfactory.  In  two  patients  severe  headache,  which 
soon  disappeared,  had  followed  its  use.  Analgesia 
was  complete  in  all  cases.  In  one  case  he  had  oper- 
ated for  tiie  removal  of  pus  tubes;  in  a  second  he  had 
removed  an  enormous  fibroid  tumor  of  the  uterus, 
and  in  a  third  a  large  intraligamentous  cyst.  Some 
of  tlie  patients  had  come  oflf  the  table  in  much  better 
condition  than  if  chloroform  or  ether  had  been  em- 
ployed. 

Dr.  E.  p.  Mallett,  of  New  York  City,  detailed  a 
case  of  retroverted  adherent  uterus  in  the  practice  of 
Dr.  Grandin,  for  wliich  an  abdominal  section  had  been 
made.  At  first,  much  difficulty  had  been  experienced 
in  finding  the  subdural  space  or  medullary  canal,  so 
that  the  patient  complained  of  intense  pain.  It  had 
been  finally  found,  cerebrospinal  lluid  had  escaped, 
and  cocaine  iiad  been  injected,  the  analgesia  having 
been  apparently  complete  in  eighteen  minutes.  So 
much  pain  had  .been  experienced  while  the  operator 
was  making  the  incision,  that  it  had  become  necessary 
to  administer  a  few  whiffs  of  chloroform  to  complete 
the  operation.  He  also  detailed  another  case  of  pos- 
terior vaginal  section  for  pelvic  abscess.  In  this  case 
the  needle  had  been  introduced  more  quickly  and  with 
better  success;    but  slight  vomiting  as  well  as  other 


December  i,  1900] 


MEDICAL    RECORD. 


869 


symptoms  had  occurred.  The  subsequent  course  of 
bo:h  patients  had  been  uneventful. 

IJR.  Ukveri.y  Macmonagle,  of  San  Francisco,  spoke 
of  two  cases  wiiich  he  had  seen  in  the  practice  of  Dr. 
li.irbat,  of  San  Francisco,  in  which  medullary  narcosis 
hid  been  used  successfully.  However,  he  had  been 
told  by  both  patients  afterward,  and  by  Dr.  Uarbat, 
that  they  had  suffered  a  good  deal  from  vomiting  after 
they  had  been  taken  to  their  rooms,  but  had  subse- 
quently recovered  without  any  marked  incidents. 

Dr.  Seneca  D.  Powell,  of  New  York  City,  did  not 
think  the  time  was  ripe  for  this  method  to  be  presented 
to  the  profession  at  large.  The  results  should  be 
worked  out  by  experienced  hands.  He  pointed  out 
the  dangers  of  cocaine,  referred  to  tiie  susceptibility 
of  some  patients  to'the  drug,  and  cited  two  cases  that 
had  occurred  in  iiisown  practice  in  which  he  had  used 
cocaine,  saying  that  both  patients  had  come  very  near 
dying  from  its  effects. 

Dr.  J.  W.  Long,  of  Salisbury,  N.  C,  referred  to  a 
discussion  that  took  place  before  the  Asheville  meet- 
ing of  the  Mississipjji  Valley  Medical  Association, 
the  consensus  of  opinion  having  been  that  the  method 
was  attended  with  danger  except  in  the  hands  of  ex- 
perts. 

Dr.  Rodman,  in  closing  tiie  discussion,  said  he 
had  used  medullary  narcosis  on  a  man  forty-five  years 
of  age,  who  had  a  bursa  in  the  popliteal  space,  with 
marked  kidney  trouble.  The  result  was  satisfactory 
in  every  respect.  The  next  case  was  one  of  advanced 
kidney  trouble  in  which  he  had  done  a  suprapubic 
cystotomy,  with  satisfactory  result.  He  would  use 
medullary  narcosis  in  cases  in  which  there  were  posi- 
tive contraindications  to  ether  or  chloroform.  The 
surgeon  should  always  obtain  the  consent  of  the  pa- 
tient before  using  the  method,  on  account  of  any 
medico-legal  complications  that  might  subsequently 
arise. 

The  Removal  of  Pelvic  Inflammatory  Masses  by 
the  Abdomen  after  Bisection  of  the  Uterus — A 
p.iper  on  this  subject  was  read  by  Dr.  Howard  A. 
Kelly,  of  Baltimore.  Recently  the  author  had  pointed 
out  the  great  advantages  which  accrued  from  bisection 
of  the  myomatous  uterus  in  an  abdominal  enucleation 
in  certain  complicated  cases.  In  (previous  contribu- 
tions he  had  described  his  method  of  enucleation  by  a 
continuous  transverse  incision  from  left  to  right,  or 
from  right  to  left.  He  now  called  attention  to  the 
great  value  of  a  somewhat  similar  procedure  in  certain 
cases  of  pelvic  intlammatory  diseases.  The  steps  of 
the  operation  were  these:  If  the  uterus  was  buried  out 
of  view,  the  bladder  was  first  separated  from  the  rec- 
tum and  the  fundus  found.  Then,  if  there  were  any 
large  abscesses,  adherent  cysts,  or  haematomata,  they 
were  evacuated  by  aspiration  or  by  puncture.  The 
rest  of  the  abdominal  cavity  was  then  well  packed  off 
from  the  pelvis.  The  right  and  left  cornua  uteri  were 
each  seized  by  a  pair  of  stout  Museaux  forceps  and 
lifted  up,  the  uterus  was  incised  in  the  median  line  in 
an  antero-posterior  direction,  and  as  the  uterus  was 
bisected  its  cornua  were  pulled  up  and  drawn  apart. 
With  a  tliird  pair  of  forceps  the  uterus  was  grasped 
on  one  side  of  its  cut  surface,  as  far  down  in  the  angle 
as  possible,  including  both  anterior  and  posterior 
walls.  The  Museaux  forceps  of  the  same  side  was 
then  released  and  used  for  grasping  the  corresponding 
point  on  the  opposite  cut  surface,  when  the  remaining 
Museaux  forceps  was  removed.  In  this  way  two  for- 
ceps were  in  constant  use  at  the  lowest  point.  He 
commonly  applied  them  three  or  four  times  in  all. 
As  the  uterus  was  pulled  up  and  the  halves  became 
everted,  it  was  bisected  farther  down  into  the  cervix. 
If  the  operator  preferred  to  do  a  panhysterectomy,  the 
bisection  was  carried  all  the  way  down  into  the  vagina. 
The  uterine  canal  must  be  followed  in  the  bisection. 


if  necessary  using  a  grooved  director  to  keep  it  in 
view.  The  Museaux  forceps  were  then  made  to  grasp 
the  uterus  well  down  in  the  cervical  portion.  If  it 
was  to  be  a  supravaginal  amputation  the  cervix  was 
bisected  on  one  side.  As  soon  as  it  was  divided  and 
the  uterine  and  vaginal  ends  began  to  pull  apait,  the 
under  surface  of  the  uterine  end  was  caught  with  a 
pair  of  forceps  and  ])ulled  up,  and  the  uterine  vessels, 
which  could  then  be  plainly  seen,  were  clamped  or 
tied.  As  the  uterus  was  pulled  still  farther  up,  the 
round  ligament  was  exposed  and  clamped,  then  finally 
a  clamp  was  applied  between  thecornuof  the  bisected 
uterus  and  the  tubo-ovarian  mass,  and  one-half  of  the 
uterus  was  removed.  The  opposite  half  of  the  uterus 
was  also  taken  away  in  the  same  manner.  The  peh  is 
then  contained  nothing  but  rectum  and  bladder,  with 
right  and  left  tubo-ovarian  masses  plastered  to  the 
sides  of  the  pelvis  and  the  broad  ligaments,  affording 
abundant  room  for  investigation  of  their  attachments, 
as  well  as  for  deliberate  and  skilful  dissection.  'Ihe 
wide  exposure  of  the  cellular  area  over  the  inferior 
median  and  anterior  surfaces  of  the  masses  offered 
the  best  possible  avenue  for  beginning  their  detach- 
ment and  enucleation.  The  operator  would  sometimes 
find,  on  com])leting  the  bisection  of  the  uterus,  that  he 
could  just  as  well  take  out  each  tube  and  ovary  to- 
gether with  its  corresponding  half  of  the  uterus,  re- 
serving for  the  still  more  diflicult  cases,  or  for  a  most 
difficult  side,  the  separate  enucleation  of  the  tube  and 
ovary  after  removal  of  the  uterus.  The  operation  just 
described  was  not  recommended  to  a  beginner  in  sur- 
gery. The  surgeon  who  undertook  it  must  be  calm, 
deliberate,  and  must  bear  in  mind  at  each  step  the 
anatomical  relations  of  the  structures.  He  had  had 
abundant  opportunity  to  demonstrate  the  practical 
value  of  this  method  of  treatment  in  his  clinic  this 
year.  The  advantages  of  a  bisection  and  enucleation 
of  the  uterus  as  a  preliminary  to  a  complete  enuclea- 
tion of  uterine  tubes  and  ovaries  for  pelvic  inflamma- 
tory and  other  diseases  by  the  abdominal  route  were 
briefly  recapitulated:  1.  Additional  space  for  hand- 
ling adherent  adnexa  was  afforded  by  the  removal  of 
the  uterus.  2.  Great  increase  in  facility  for  dealing 
with  intestinal  complications  was  secured.  3.  There 
was  better  access  by  new  avenues  from  below  and  in 
front  to  adherent  lateral  structures.  4.  Elevation  of 
structures  to  or  above  the  pelvic  brim,  or  even  out  into 
the  abdomen,  brought  them  within  easy  reach  of  man- 
ipulation and  dissection.  5.  Some  advantage  was 
gained  in  approaching  both  uterine  vessels  by  cutting 
from  the  cervix  out  toward  the  broad  ligament  over 
approaching  one  of  them  in  the  continuous  transverse 
incision.  In  general,  the  lime  of  the  operation  was 
shortened;  its  steps  were  conducted  with  greater  pre- 
cision;  surrounding  structures  were  far  less  liable  to 
be  injured.  In  this  way  there  were  fewer  troubles 
and  sequelae,  and  the  mortality  was  les.sened. 

Dr.  Willis  G.  Macdonald  said  his  experience  in 
bisection  of  the  uterus,  as  an  operative  procedure,  had 
been  very  largely  associated  with  tumors  of  the  uterus 
deeply  situated  in  the  pelvis,  attended  with  great  ten- 
sion upon  both  broad  ligaments.  In  dealing  with 
fibroids  of  the  uterus  it  had  been  his  custom  to  follow 
the  method  improved  by  Dr.  Kelly,  and  the  only  ob- 
jection to  the  operation  lay  in  a  certain  class  of  cases 
in  which  the  tumor  was  deeply  situated  in  the  lower 
segment  of  the  uterus,  or  extended  to  one  side  or  the 
other  in  the  broad  ligament,  or  was  associated  with 
microcystic  and  adherent  ovaries,  so  that  when  the 
operator  lifted  the  tumor  out  of  the  abdomen  to  begin 
preliminary  ligation  on  one  side  or  the  other,  he 
caused  considerable  tension  upon  the  broad  ligament, 
and  when  the  ligature  was  placed  upon  one  or  the 
other  ovarian  artery  there  was  more  or  less  danger  of 
its  giving  way  when  the  tension  was  released.     He 


S/O 


MEDICAL    RECORD. 


[December  i,  1900 


had  seen  many  cases  in  his  own  practice,  and  that  of 
other  surgeons,  in  which  this  accident  had  occurred. 

])r.  J.  VVesley  Bov6e,  of  Washington,  D.  C,  said 
he  had  occasionally  removed  the  body  of  the  uterus 
previous  to  the  removal  of  the  appendages  in  pus 
cases,  also  in  fibroid  tumors  of  the  uterus,  but  in  some 
instances  he  had  followed  the  methoil  of  Kelly,  after 
he  had  read  his  paper  before  the  Washington  meeting 
of  the  association  on  the  removal  of  fibroids  of  the 
uterus  by  going  down  on  one  side,  as  he  had  described 
it,  and  going  up  on  the  other.  He  had  recently  mod- 
ified this  plan  in  dealing  with  pus  cases;  namely,  he 
cut  ofi  the  tube  and  ovarian  ligaments  from  the  uterus 
on  one  side,  clamped  the  round  ligament,  went  down 
to  the  cervix,  clamped  the  uterine  artery,  cut  through 
the  cervix  and  uterine  artery  on  the  other  side,  went 
up  and  removed  the  appendage  on  the  other  side  with 
the  uterus. 

Dr.  W.  E.  B.  Davis,  of  Birmingham,  Ala.,  expressed 
the  opinion  that  the  method  outlined  by  Kelly  would 
be  of  great  assistance  in  the  severe  cases  of  inflam- 
matory pelvic  disease.  The  removal  of  the  uterus  for 
inflammatory  disease  had  its  origin  in  the  difficulties 
which  beset  French  surgeons  in  removing  the  appen- 
dages by  the  vaginal  method,  so  that  it  became  neces- 
sary for  them  to  remove  the  uterus  in  order  to  have  a 
route  by  which  they  could  reach  the  adnexa.  Dr. 
Kelly,  therefore,  had  accomplished  by  operating  from 
above  what  French  surgeons  had  so  frequently  done 
tlirough  the  vagina. 

Dr.  Beverly  Macmonagle  said  he  had  seen  Dr. 
Kelly  operate  on  two  cases  by  the  method  he  had  de- 
scribed, with  very  satisfactory  results. 

Dr.  George  J.  Engelmann,  of  Boston,  considered 
the  method  a  step  in  advance,  and  said  it  was  really 
amazing  that  no  one  had  tliought  of  doing  this  work 
by  the  abdomen  before  it  had  been  done  by  the  vaginal 
route. 

Report  of  a  Case  of  Osteofibroma  of  the  Uterus. 
—  Dr.  George  Ben  John'stox,  of  Riclimond,  Va.,  nar- 
rated this  case.  The  patient,  Mrs.  S — ■ — ,  aged  thirty 
years,  was  the  mother  of  three  children,  the  youngest 
being  three  years  old.  About  two  years  after  the  birth 
of  the  youngest  child  she  had  noticed  an  enlargement 
of  the  abdomen,  and  at  times  experienced  difficulty  in 
voiding  her  urine.  She  believed  herself  pregnant,  but 
on  account  of  the  continuance  of  her  menses  and  in- 
creasing difficulty  of  micturition,  she  consulted  her 
physician,  and  an  examination  of  the  genital  organs 
was  made.  This  examination  disclosed  a  tumor  which 
filled  the  pelvic  cavity,  growing  from  the  posterior 
■wall  of  the  uterus,  and  so  displacing  the  uterus  for- 
ward that  it  pressed  upon  the  bladder.  Six  months 
later  she  missed  her  menstrual  period,  and  by  this 
time  her  size  had  greatly  increased  and  her  ability  to 
void  urine  normally  was  almost  lost.  About  the  mid- 
dle of  March,  1900,  after  being  all  day  upon  her  feet, 
a  severe  hemorrhage  occurred,  and  the  next  day  she 
passed  a  foetus  of  six  or  eight  weeks'  development. 
Hemorrhage  was  promptly  checked,  but  her  size  did 
not  reduce  and  the  pressure  symptoms  continued.  He 
operated  upon  her  April  10,  1900.  Bimanual  exam- 
ination, made  before  the  operation,  revealed  two 
tumors,  one  a  large  fibromyoma,  situated  posteriorly 
and  to  the  right  of  the  uterus;  the  other  a  small 
tumor,  anterior  and  to  the  left.  Complete  hysterec- 
tomy was  performed.  The  smaller  tumor  was  found 
to  be  intramural  and  situated  at  the  j miction  of  the 
body  and  the  neck.  On  liberation  the  macroscopical 
examination  showed  a  tumor  about  the  size  of  a  small 
orange,  and  of  firm  consistence.  Held  between  the 
thumb  and  fingers,  it  gave  tiie  sensation  that  was  pro- 
duced by  pressing  a  hard-boiled  egg,  the  shell  of 
which  had  been  broken.  Plates,  apparently  of  bone, 
surrounded  the  surface,  and  on  opening  it  a  substance 


resembling  medullary  tissue  was  found.  This  was  un- 
fortunately lost,  so  that  no  subsequent  histological 
study  of  it  could  be  made.  Attached  to  the  lower 
part  of  the  osseous  tumor  was  a  small  fleshy  mass, 
which  contained  a  body  about  an  inch  in  length  re- 
sembling a  heart  in  shape.  On  opening  the  uterus  a 
recent  placental  site  was  found  near  the  uterine  open- 
ing of  the  right  Fallopian  tube.  Microscopical  exam- 
ination of  the  tumor  developed  the  following  character- 
istics: It  was  covered  by  a  fibrous  capsule,  scattered 
through  which  were  plates,  rounded  nodules,  and 
irregular  jagged  masses,  which,  when  decalcified, 
proved  to  be  dense  laminfe  of  bone,  with  tiieir  in- 
cluded bone  cells.  These  bone  cells  were  not  so 
numerous  as  in  normal  bone,  while  the  lamella;  were 
irregular  in  their  arrangement,  although  showing  a  gen- 
eral tendency  to  lie  parallel  to  frequent  openings  in 
the  bony  tissue.  These  openings  were  larger  and 
more  irregular  in  shape  than  the  Haversian  canals  of 
normal  compact  bone,  and  were  filled  with  a  connec- 
tive-tissue stroma  supporting  blood-vessels.  Tiie 
softer  parts  of  the  tumor  were  found  to  be  composed 
of  involuntary  muscle  fibres,  arranged  in  groups  and 
bundles,  which  were  supported  by  loose  connective 
tissue.  Dense  masses  of  fibrous  tissue  occurred 
throughout  the  tumor,  independently  of  the  muscular 
tissue.  Microscopical  examination  of  the  tumor  veri- 
fied the  diagnosis  made  niacroscopically  ■ — osteo- 
fibroma.    The  patient  recovered. 

Dr.  Howard  A.  Ivellv  said  he  would  be  loath  to 
accept  diagnoses  that  had  been  made  twenty-five  years 
ago  in  regard  to  tumors  of  this  kind,  when  the  differ- 
ence between  calcified  tumors  and  teratomata  was  not 
clearly  understood,  and  even  pathology  itself  was  in  a 
vague  condition.  Of  five  hundred  and  sixty-one  myo- 
mectomies, he  had  met  with  twenty-seven  calcified 
myomata. 

I^R.  J.  Wesley  Bov£e  mentioned  three  cases  that 
had  come  under  his  observation.  In  one  the  tumor 
was  removed  through  the  vagina,  it  being  a  submu- 
cous fibroid.  The  tumor  pressed  down  the  cervix,  so 
that  it  required  only  slight  slitting  of  the  latter  to  re- 
move it.  Around  the  base  of  it  he  had  found  consid- 
erable bony  structure  in  the  body  of  the  uterus  near 
the  fundus.  Two  other  interesting  cases  were  de- 
tailed. 

Appendicitis  in  the  Female. — A  paper  on  this 
subject  was  presented  by  Dr.  ¥.  VV.  AIcRae,  of  At- 
lanta, Ga.  At  the  outset,  the  author  referred  to  an 
exhaustive  article  by  Edebohls  as  to  the  relative  fre- 
quency of  appendicitis  in  the  two  sexes;  also  to  the 
work  of  Einhorn,  who  had  found  in  eighteen  thousand 
successive  autopsies  perforating  appendicitis  in  fifty- 
five  per  cent,  of  males,  and  fifty-seven  per  cent,  of 
females.  Robinson,  in  one  hundred  and  twenty-eight 
autopsies,  found  evidences  of  past  peritonitis  in  or 
about  the  appendix  in  sixty-eight  per  cent,  of  females, 
and  fifty-six  per  cent,  of  male  bodies.  Clinically, 
F!debohls  found  that  four  per  cent,  of  all  women  had 
appendicitis.  On  the  contrary,  Deaver  believed  that 
eighty  per  cent,  of  all  cases  occurred  in  males.  Of 
fifteen  hundred  and  seventy -seven  cases  of  appendicitis 
collected  from  the  annual  reports  of  the  city  hospitals 
of  Berlin,  nine  hundred  and  forty-nine  were  males, 
and  six  hundred  and  twenty-eight  females.  The 
speaker  quoted  eminent  authorities  to  show  the  diver- 
gence of  opinion  as  to  the  relative  frequency  of  the 
disease  in  the  male  and  in  the  female.  In  practically 
all  of  the  cases  that  had  come  under  his  observation 
in  females,  mistakes  in  diagnosis  had  been  made 
either  by  himself  or  by  the  attending  physician.  Al- 
most all  of  the  attacks  had  occurred  at  or  about  the 
menstrual  term,  and  most  of  them  had  been  diagnos- 
ticated "  inflammation  of  the  tube  or  ovary."  In  two 
cases  of  his  own  series  the  appendix  and  the  right 


December  i,  1900] 


MEDICAL    RECORD. 


871 


tube  and  ovary  were  involved;  in  two  otiiers  the  ap- 
pendicular trouble  was  complicated  with  dieased  kid- 
neys. Two  patients  suffered  with  recurrent  appendi- 
citis, and  attacks  of  renal  colic  before  or  after  operation 
for  the  removal  of  their  appendices.  He  had  records 
of  forty-nine  cases  of  appendicitis  seen  within  the 
last  si.xteen  months,  twenty-nine  of  them  being  in  males, 
and  twenty  in  females.  During  this  period  he  had  oper- 
ated on  seventeen  males  and  fourteen  females.  The 
author  then  detailed  thirteen  cases.  Of  this  number 
Cases  VIII.  and  XIII.  were  the  most  interesting,  which 
we  give  herewith. 

Ca.sk  VIII. — Mrs.  W.  C.  T .     First   operation, 

October,  1899,  for  ruptured  tubal  pregnancy.  Recov- 
ery with  persistent  fistula  where  drainage  had  been 
left.  Second  operation.  May  loth.  The  fistulous 
tract  was  dissected  out;  a  cyst  of  the  broad  ligament 
removed,  together  with  a  chronically  intlanied  and 
very  much  enlarged  appendi-x,  surrounded  by  dense 
adhesions  and  adherent  to  the  broad-ligament  cyst. 
The  diagnosis  at  the  time  of  the  first  operation  was 
"acute  appendicitis,  with  abscess,"  and  the  recovery 
from  the  first  operation  was  tedious.  The  patient, 
who  was  profoundly  septic  at  the  time  of  the  opera- 
tion, recovered  slowly,  with  characteristic  septic  tem- 
perature and  pulse  for  several  weeks.  W'iiether  appen- 
dicitisexisted  at  this  time  or  not,  he  was  unable  to  say. 
Recovery  from  the  second  operation  was  tedious,  but 
uneventful  and  complete. 

Case  XIII. — Miss  B.  C ,  aged  twenty-one  years ; 

seen  in  consultation  with  Dr.  Summerfield.  There 
was  a  history,  extending  over  a  period  of  about  two 
years,  of  indefinite  abdominal  pain  involving  tiie  whole 
right  side  from  the  liver  to  the  pelvis.  No  definite 
diagnosis  was  made,  and  an  exploratory  operation  was 
advised.  Operation,  September  7,  1S99.  Tlie  appen- 
dix was  chronically  inflamed,  adhesions  extending 
from  the  cacum  to  the  liver  upward  and  down  into  the 
pelvis,  involving  the  right  tube  and  ovary.  The  right 
ovary  was  as  large  as  a  lemon,  and  the  tube  thickened 
and  distended.  The  appendix,  tube,  and  ovary  were 
removed.  The  patient  made  a  tedious  recovery,  de- 
veloping a  left  saphenous  phlebitis  about  ten  days 
after  the  operation. 

The  cases  were  reported  to  emphasize  the  difficul- 
ties attending  diagnosis.  In  several  of  them  syste- 
matic treatment  directed  to  the  genitalia  had  been 
carried  on  without  giving  any  benefit  whatever,  while 
the  removal  of  the  appendix  effected  a  cure.  In 
others,  the  ovaries  and  tubes  had  been  removed,  and 
still  the  symptoms  persisted  until  relieved  by  appen- 
dectomy. The  author  was  convinced  that  tiie  great 
disparity  in  the  statistics  as  to  the  relative  frequency 
of  appendicitis  in  the  male  and  female  was  due,  in  a 
great  measure,  to  mistakes  in  diagnosis.  It  was  much 
more  difficult  to  make  a  diagnosis  of  appendicitis  in 
the  female  than  it  was  in  the  male.  Sufficient  stress 
had  not  been  laid  upon  the  fact  that  appendicitis  in 
women  usually  occurred  at  or  about  the  menstrual 
period. 

Dr.  J.  B.  S.  Holmes,  of  Atlanta,  detailed  three  in- 
teresting cases  of  appendicitis  in  females,  which  illus- 
trated forcibly  the  necessity  of  always  examining  the 
appendix  wiien  the  abdomen  of  a  woman  was  opened 
for  any  cause. 

Dr.  Hal  C.  Wvman,  of  Detroit,  cited  a  case  of 
e.xtra-uterine  pregna;icy  in  which  he  removed  a  fcetus 
that  had  apparently  died  at  about  the  end  of  the  sev- 
entii  month  of  pregnancy.  The  operation  was  done 
thirteen  months  after  the  appearance  of  the  first  symp- 
toms of  pregnancy.  The  appendix  was  found  inti- 
mately blended  with  the  fimbriae  of  the  right  tube. 
The  left  tube  had  also  suffered  some  disease,  so  that 
he  doubted  its  perviousness.  It  was  not  removed 
because   there  was  no  particular  indication  for  its  re- 


moval. The  right  Fallopian  tube,  however,  was  in- 
volved with  the  appendix  by  dense  inflammatory  ad- 
hesions, and  it  occurred  to  him  that  in  consequence 
of  that  blending  the  impregnated  ovum  had  escaped. 
With  this  experience  we  might  justly  charge  some  of 
the  cases  of  extra-uterine  pregnancy  possibly  to  adhe- 
sions between  the  fimbria  and  the  appendi.x.  The 
appendix  was  three  and  a  half  inches  long;  it  had  a 
number  of  scars:  it  was  niuch  hardened  at  its  end,  and 
at  the  point  where  union  with  tiie  fimbriae  had  oc- 
curred. 

Dr.  Howard  A.  Kelly  stated  that  for  four  years 
past  he  had  made  it  a  rule  at  the  Johns  Hopkins  Hos- 
pital to  have  the  exact  condition  of  the  appendix 
stated  on  a  slip.  During  this  period  he  had  removed 
one  hundred  and  fifty  appendices.  Of  this  number 
sixty  were  involved  in  pelvic  inflammatory  disease. 
He  had  found  the  appendix  adherent  to  myomata  in 
twelve;  adherent  to  ovarian  tumors  in  nine.  He  had 
found  carcinoma  of  the  appendix  secondary  to  ovarian 
carcinoma  without  any  traceable  macroscopical  rela- 
tion in  one  case,  and  primary  carcinoma  in  one  other 
case.  He  had  found  tuberculosis  of  the  appendix  sec- 
ondary to  tuberculosis  in  the  tubes  and  ovaries  in 
three  cases;  in  the  remainder  of  the  cases  calculi, 
csytic  disease,  and  uncomplicated  appendicitis.  If, 
in  an  abdomen,  opened  for  any  pathological  condition, 
the  incision  was  sufficiently  large,  he  would  examine 
the  appendix. 

Dr.  Lewis  S.  McMurtry  mentioned  a  case  in 
which  he  had  enucleated  an  ovarian  cyst  in  a  woman 
of  thirty  years.  She  iiad  had  a  typical  acute  perfora- 
tive appendicitis,  followed  by  septic  symptoms,  which 
was  quite  limited  in  the  area  of  peritoneal  involve- 
ment. When  the  abdomen  was  opened,  it  was  found 
that  the  appendix,  instead  of  perforating  the  general 
peritoneal  cavity,  pierced  the  ovarian  cyst,  in  that 
manner  limiting  the  infection  to  the  ovarian  cyst  and 
saving  the  life  of  the  patient. 

Dr.  Willis  V.  VVest.moreland,  of  Atlanta,  spoke 
of  the  practicability  of  stitching  the  kidney  back 
tlirough  the  same  incision  after  the  manner  described 
by  Dr.  McRae  in  one  of  his  cases. 

Dr.  William.  P.  Nicolson,  of  Atlanta,  called  at- 
tention to  the  coincidence  of  disease  of  the  appendix 
and  uterine  adnexa.  and  cited  cases  in  which  symp- 
toms for  years  had  been  ascribed  to  uterine  or  ovarian 
trouble,  but  operation  had  disclosed  the  fact  that  the 
appendix  was  solely  at  fault. 

Dr.  George  Ben  Johnston  expressed  the  convic- 
tion that  chronic  appendicitis  was  quite  as  frequent 
in  the  female  as  in  the  male.  He  believed,  however, 
that  fewer  cases  of  the  fulminating  form  of  the  dis- 
ease were  seen  in  the  female  than  in  the  male.  He 
had  observed  numerous  cases  of  chronic  appendicitis 
associated  with  movable  kidney  in  females,  and  it 
was  sometimes  difficult  to  determine  which  was  the 
cause  of  distress  for  which  the  patient  consulted  a 
surgeon — the  diseased  appendix  or  movable  kidney, 
or  both.  The  coexistence  of  the  two  conditions  was 
so  frequent  in  his  practice  that  oftentimes  he  kept 
patients  under  observation  for  days,  perhaps  weeks,  to 
determine  which  was  the  more  distressing  condition. 

Drainage  in  Abdominal  Surgery.— The  author  of 
this  paper.  Dr.  J.  W.  Loxg,  of  Salisbury,  N.  C,  said 
that  the  chief  purposes  for  which  drainage  was  em- 
ployed were  to  drain  away  existing  septic  material; 
to  afford  an  exit  for  the  sepsis  when  the  operator 
feared  he  had  possibly  infected  his  patient;  to  pro- 
voke adhesions  and  thereby  wall  off  weak  spots  from 
the  remainder  of  the  abdominal  contents:  to  keep  the 
peritoneal  cavity  free  of  blood  and  other  fluids;  to 
allow  of  a  more  certain  knowledge  of  the  conditions 
present  in  the  abdomen.  Gauze  drains  were  some- 
times employed  as  tampons  to  control   hemorrhage. 


8-2 


MEDICAL    RECORD. 


[December  i,  1900 


These  features  of  drainage  were  discussed  in  the  order 
given.  After  referring  to  the  work  of  VVegner,  in 
1S77,  and  that  of  Muscatello,  in  1895,  and  others,  re- 
garding tiie  histology  and  physiology  of  the  perito- 
neum, the  author  passed  on  to  the  consideration  of 
objections  to  drainage,  and  these  were  enumerated  as 
follows:  1.  Dainage  was  deceptive.  2.  Cases  not 
drained  did  better.  3.  Drainage  was  neither  scien- 
tific nor  workmanlike.  The  last  statement  was  made 
with  an  apology  and  due  deference  to  those  distin- 
guished gentlemen  who  drained  most  of  their  cases. 

Dr.  Manning  Simons,  of  Charleston,  S.  C,  agreed 
in  the  main  with  the  observations  of  the  essayist,  but 
said  there  were  some  surgeons  who  would  not  admit 
that  draining  in  suppurative  cases  was  an  evidence 
that  something  had  been  left  which  ought  to  have  been 
removed,  or  that  the  surgeon  had  done  something  that 
he  ought  not  to  have  done.  He  apprehended  that 
there  were  many  cases  in  which  suppuration  was  not 
confined  to  the  tubes,  but  had  dift'used  itself  more  or 
less  over  the  pelvic  and  abdominal  cavities.  The  sur- 
geon's conscience  would  scarcely,  in  such  a  case, 
prompt  him  to  close  up  all  avenues  for  the  escape  of 
reaccumulated  fluid  from  the  cavity.  Drainage  was 
applicable  to  such  cases. 

Dr.  Howard  A.  Kelly  believed  that  there  was  a 
tendency  on  part  of  the  profession  to  drain  entirely 
too  many  cases.  Of  his  first  one  hundred  cases,  eleven 
j^ears  ago,  he  had  drained  in  over  eighty  per  cent.  Of 
his  last  one  hundred  cases,  he  had  drained  in  about 
one  or  two  per  cent.  He  would  drain  cases  of  local- 
ized sepsis,  when  he  could  not  remove  the  entire  septic 
area. 

Dr.  W.  E.  B.  Davis  referred  to  drainage  in  general 
septic  peritonitis,  and  said  it  was  impossible  to  lay 
down  any  fixed  or  definite  plan  of  treatment  because 
results  were  uniformly  fatal.  Reports  in  the  past 
showed  the  percentage  of  recoveries  to  have  been 
small.  Much  good  could  be  accomplished  by  first 
using  peroxide  of  hydrogen  in  the  abdomen  in  this 
class  of  cases,  and  following  it  with  infusion  of  deci- 
normal  salt  solution,  injecting,  say,  a  quart  under  the 
skin  every  three  hours.  This  accomplished  even  more 
than  multiple  drainage  in  cases  of  general  septic  peri- 
tonitis. 

Dr.  Beverly  Macmonagle  called  attention  to 
drainage  in  connection  with  surgery  of  the  gall  blad- 
der and  gall  ducts.  When  the  gall  bladder  was 
opened,  it  was  absolutely  essential  to  drain  it.  In  all 
cases  in  which  he  had  operated  on  the  gall  bladder, 
he  had  found  it  in  such  a  condition  that  it  was  neces- 
sary to  drain  the  gall  bladder  itself.  In  so  doing  it 
was  almost  impossible  to  drain  it  in  such  a  way  that 
a  certain  amount  of  fluid  would  not  escape  into  the 
peritoneal  cavity,  hence  the  necessity  of  using  a  small 
drain  of  gauze  in  the  peritoneal  cavity  itself. 

Atresia  of  the  Vagina. — Dr.  Geori;e  H.  Noble, 
of  .'\tlanta,  described  a  flap  operation  for  the  relief  of 
this  condition,  saying  that  he  had  operated  success- 
fully in  several  cases  by  the  plan  he  had  outlined. 

Recent  Technical  Improvements  in  the  Surgery 
of  the  Stomach  for  Carcinoma. — A  jiaper  on  this 
subject  was  read  by  Dr.  Willis  G.  Macdonald,  of 
Albany,  N.  Y.  Reference  was  made  to  the  early  his- 
tory of  operations  for  the  relief  of  this  disease.  The 
technique  employed  by  Billroth  in  his  first  pylorec- 
tomy  was  the  technique  of  operations  done  by  most 
surgeons  for  a  number  of  yeais,  with  very  slight  modi- 
fications. This  earlier  operation  presented  many  tech- 
nical difficulties  in  its  performance.  The  matter  of 
the  adjustment  of  the  resected  stomach  and  the  duo- 
denum at  the  completion  of  the  operation  was  fre- 
quently defective.  Secondary  perforation  at  the  line 
of  suture  with  subsequent  peritonitis  had  been  a  fre- 
quent cause  of  death  associated  with  this  earlier  form 


of  operation.  Before  giving  a  more  accurate  descrip- 
tion of  the  preferable  forms  of  surgical  intervention  in 
carcinoma  of  the  stomach,  the  author  considered  the 
limitations  of  early  and  late  exploratory  abdominal 
section  in  the  treatment  of  this  condition. 

Any  one  or  a  combination  of  the  following  symp- 
toms was  a  sufficient  indication  for  operation:  i.  A 
chronic  gastritis  which  was  progressive  in  character 
under  proper  dietetic,  medicinal,  and  physical  treat- 
ment. 2.  A  loss  of  gastric  motility.  3.  Progressive 
diminution  of  gastric  peristalsis.  4.  A  diminution  of 
free  hydrochloric  acid,  progressive  in  character.  5. 
Emaciation  of  the  patient  under  forced  diet.  6.  Re- 
duction of  the  hemoglobin  in  the  blood,  progressive 
to  sixty-five  per  cent,  or  under,  and  a  moderate  leuco- 
cytosis.  The  widest  e-xtirpaticn  was  demanded  in  car- 
cinoma of  the  stomach. 

The  author  called  attention  to  the  careful  investiga- 
tions of  Cunec  and  Most  with  relation  to  the  distribu- 
tions of  the  lynipliatics  and  lymph  nodes  as  associated 
with  carcinoma  of  the  stomach.  All  surgery  for  car- 
cinoma involved  the  removal,  as  far  as  was  compatible 
with  adjacent  anatomical  structures,  of  lymph  nodes. 
In  a  complete  pylorectomy,  it  was  desirable  to  remove 
the  lymphatics  along  both  curvatures  of  the  stomach, 
as  well  as  those  lying  behind  the  pylorus.  As  a  rule, 
the  duodenum  w-as  not  extensively  involved  in  pyloric 
carcinoma,  although  a  few  observers  had  found  infil- 
tration of  Brunner's  glands  in  the  upper  portion  of  the 
duodenum.  There  was  little  justification  for  the  total 
extirpation  of  the  stomach  in  the  majority  of  cases, 
and  the  probability  of  cure  would  not  be  greater  than 
surgical  resection.  The  old  rule  of  cutting  one  centi- 
metre beyond  all  evidences  of  carcinomatous  infiltra- 
tion was  not  wide  enough.  Personally,  the  author  felt 
that  the  line  of  excision  in  the  stomach  should  be  at 
least  three  centimetres  from  the  border  of  the  last 
palpable  infiltration,  and  in  the  duodenum  at  least  two 
centimetres  from  the  most  dependent  portion  of  the 
growth.  The  recently  devised  clamps  of  Kocher  were 
presented  for  inspection,  also  diagrams  showing  their 
mode  of  application.  By  the  application  of  these 
clamps  to  the  stomach  and  duodenum,  with  a  little 
care,  all  dangers  of  sepsis  from  the  stomach  and  duo- 
denum were  avoided,  and  the  rapidity  with  which  a 
pylorus  might  be  resected  was  greatly  increased.  Very 
little  time  was  required  to  close  the  ends  of  the  stom- 
ach and  duodenum  with  a  running  catgut  suture  in- 
volving all  the  coats.  This  again  was  invaginated 
within  the  stomach  and  the  calibre  of  the  duodenum, 
and  the  stump  buried  by  rows  of  Lembert  sutures. 
The  manner  of  performing  the  subsequent  gastro- 
enterotomy  lay  largely  w  ith  the  preferences  of  the  sur- 
geon doing  the  operation.  The  speaker's  earlier 
gastro-enterotomies  had  been  done  by  the  Woeltler 
method  of  attaching  tlie  jejunum  to  the  anterior  wall 
of  the  stomach.  It  ajipeared  to  him  that  the  two  fatal 
cases  in  which  lie  applied  that  method  were  due  to 
regurgitation  of  bile  into  the  stomach  and  persistent 
vomiting  following  operation.  Some  two  years  ago 
he  began  employing  von  Hacker's  method  of  attaching 
the  jejunum  to  the  posterior  gastric  wall  witii  a  re- 
anastomosis  between  the  duodenum  and  the  jejunum. 
The  results  of  this  method  of  operation  had  been  most 
satisfactory.  During  the  jiast  year  he  liad  employed 
it  eight  limes,  with  seven  recoveries.  I'or  the  most 
part,  the  anastomosis  between  tiie  jejunum  and  stom- 
acii  iiad  been  made  by  the  suture  method,  although  a 
number  of  surgeons  had  been  quite  as  successful  in 
the  employment  of  the  Murphy  button.  For  the  sec- 
ondary anastomosis  the  author  had  uniformly  used  a 
Murphy  button  of  moderate  size.  The  anastomosis  by 
this  method  requires  very  little  time  for  its  perform- 
ance and  could  be  readily  completed  in  five  minutes. 
When  an  operation  had  been  carried  out  by  this  method 


December  i,  1900] 


MEDICAL    RECORD. 


873 


to  its  completion,  the  following  advantages  were 
chiimed  for  it:  i.  Freedom  from  contamination  of 
the  wound  by  stomach  contents.  2.  Accessibility  of 
the  neighboring  lymphatic  nodes  for  extirpation.  3. 
No  subsequent  danger  from  suture  perforation.  4. 
Freedom  from  loss  of  blood.  5.  The  great  saving  of 
time  required  for  the  operation. 

Lateral  anastomosis  could  be  readily  accomplished 
by  a  variety  of  methods,  including  the  button.  Prac- 
tical experience  had  shown  through  the  more  recent 
statistics  of  Mikulicz,  Maydl,  Kocher,  and  others  that 
an  operation  of  this  form  presented  far  less  immediate 
dangers  to  the  patient  than  did  the  older  method  of 
Billroth.  The  immediate  mortality  for  the  operation 
of  pylorectomy  was  an  interesting  study.  F.wakl  con- 
demned the  operation  because  of  its  great  mortality, 
seventy-three  per  cent.,  and  until  1888  the  mortality 
had  been  somewhere  in  the  neighborhood  of  sixty  per 
cent.  The  mortality  of  Billroth  was  forty-five  per 
cent.,  of  Mikulicz  thirty  per  cent.,  of  Kronlein  twenty- 
five  per  cent.,  of  Maydl  si.xteen  per  cent.,  and  of 
Kocher  8.7  per  cent.  Mayo  Robson  in  a  study  of  five 
hundred  and  seventy-two  cases,  collected  from  various 
sources,  found  an  average  mortality  of  30.4  per  cent. 
Guinard  found  that  in  one  hundred  and  forty-eight 
cases  of  pylorectomy  with  end-to-end  anastomosis,  the 
deaths  numbered  fifty-six,  or  37.8  per  cent.,  and  in 
sixty-four  cases  of  pylorectomy  with  subsequent  lat- 
eral anastomosis  there  were  ten  deaths,  or  15.6  per 
cent.  This  showing  had  been  equally  favorable  in 
the  experience  of  otiiers. 

Menstrual  Condition  of  the  Average  Girl  in 
Average  Health.  —  Dk.  George  J.  Engelmann.  of 
Boston,  presented  an  interesting  statistical  paper  on 
this  subject,  antl  the  facts  presented  by  him  were  culled 
from  the  records  of  forty-eight  hundred  and  seventy- 
three  cases  from  high  and  normal  schools,  colleges, 
and  department  stores.  The  girls  were  between  fifteen 
and  twenty-six  years  old,  the  majority  between  eigh- 
teen and  twenty-two,  in  rather  better  than  average 
health — -in  good  health — and  in  numbers  sufiicient  to 
admit  of  positive  deductions  as  to  what  maybe  termed 
normal  or  average  menstruation.  In  brief,  the  men- 
strual period  proper  was  intensified  by  the  increase  of 
all  vital  energies,  followed  by  a  depression  which  ap- 
peared with  the  coming  of  the  flow.  Under  ideal  con- 
ditions, and  in  perfect  health,  the  physiological  status 
was  such  that  this  epoch,  preceded  by  a  day  or  two  of 
heightened  activity,  was  marked  by  a  moderate  lassi- 
tude, mental  and  physical,  the  flow  persisting  for  from 
four  to  five  days,  and  recurring  at  regular  intervals  of 
about  twenty-eight  days.  It  was  a  period  of  height- 
ened susceptibility  that  quickly  recorded  any  variation 
from  the  normal;  excitement  or  exertion,  or  fatigue, 
mental  or  physical,  were  promptly  reflected  by  varia- 
tion in  the  function,  and  in  our  every-day  life  such 
disturbing  elements  constantly  occurred,  so  that  con- 
ditions actually  existing  varied  greatly  from  this 
ideal.  The  average  period  of  the  average  girl  in  aver- 
age health  presented  very  different  features:  Regular- 
ity in  fifty  per  cent,  of  the  cases  only;  recurrence 
every  twenty-eight  days  in  thirty  per  cent.,  varying 
most  frequently  from  twenty-six  to  forty-two  days, 
forty-five  per  cent,  being  over  twenty-eight.  The  dura- 
tion varied  from  two  to  seven  days,  average  4.6.  F'rom 
sixty-six  to  seventy  per  cent,  suffered  more  or  less,  the 
number  of  sufferers  varying,  according  to  age  and 
nature  of  occupation,  between  thirty  and  ninety  per 
cent.  Lessened  ability  for  e.xertion,  mental  or  physi- 
cal, was  admitted  by  sixty  per  cent.  Some  few  were 
habitually  incapacitated  from  work,  and  thirty  per 
cent,  occasionally.  The  function  of  the  girl  in  good 
health,  under  modern  conditions  of  life,  was  by  no 
means  an  ideal  one  in  the  judgment  of  the  essayist, 
and  in  fact  the  functional  health  of  the  American  girl, 


the  coming  mother  of  American  men,  was  far  from 
what  it  should  be  by  right  of  inheritance  and  sur- 
roundings. This  fact  physicians  must  recognize,  and 
upon  them  and  educators  devolved  the  duty  of  study 
and  correction  of  the  evil. 

Operation  for  the  Treatment  of  Marked  Prolapse 
of  the  Rectum  in  Women.  — i)u.  J.  Wl.^i.lv  JJovice, 
of  Washington.  D.  C,  described  an  operation  for  the 
relief  of  this  condition.  In  his  case  marked  prolapse 
of  the  uterus  was  associated  with  hemorrhoids  and 
great  procidentia  of  the  rectum  in  a  woman  to  whom 
the  uterine  appendages  were  of  little  value.  No  sim- 
ple operation  would  have  relieved  the  rectal  condition 
while  the  uterus  was  in  such  a  state  of  prolapse,  and 
vice  versa.  'I'hese  conditions  caused  him  to  resort  to 
the  unique  radical  procedure  which  could  be  best  de- 
scribed by  narrating  the  following  case: 

Sister  V — ^,  thirty-five  years  of  age.  had  been 
treated  unsuccessfully  a  number  of  years  for  prolapse 
of  the  rectum,  uterus,  and  hemorrhoids.  When  she 
came  under  the  speaker's  care  she  was  suffering  from 
large  internal  and  external  hemorrhoids,  and  a  pro- 
truding roll  of  fully  three  inches  of  the  rectum  that 
was  thickened  and  much  discolored.  The  uterus  was 
of  normal  size,  with  its  cervix  just  behind  the  pubes, 
and  the  fundus  very  low  posteriorly.  A  few  days 
later,  March  6,  1900,  operation  was  done.  The  hem- 
orrhoids were  first  removed,  then  the  abdomen  was 
opened  by  the  usual  subumbilical  median-line  inci- 
sion. The  left  ovary  was  about  three  times  its  natural 
size,  and  largely  consisted  of  numerous  cysts.  '1  he 
appendages  were  removed  and  the  uterus  was  firmly 
fixed  to  the  abdominal  wall  by  four  interrupted,  strong 
catgut  sutures  that  passed  through  a  considerable  por- 
tion of  the  uterine  fundus  at  the  top,  and  the  principal 
fascia  of  the  abdominal  wall  on  either  side  of  the  in- 
cision. The  rectum  was  now  drawn  upward  until  it 
was  fairly  tense,  and  so  held  by  an  assistant  until  it 
was  sutured  to  the  cul-de-sac  and  posterior  wall  of  the 
uterus  up  to  the  abominal  wall.  This  was  done  by  a 
running  catgut  suture.  It  completely  divided  the 
retro-uterine  pelvic  cavity  into  two  equilateral  ones. 

Carbolic  Acid  in  Surgery. ~Dk.  Seneca  D.  Pow- 
ell, of  New  York  City,  read  this  paper.  In  1894  he 
first  became  convinced  that  he  could  control  the  action 
of  carbolic  acid  under  all  circumstances.  At  that 
time  he  used  it  in  its  full  strength  of  ninety-five  per 
cent,  in  an  abscess  cavity  upon  a  patient  suffering 
from  suppurative  appendicitis.  Since  then  he  had 
extended  its  use  to  all  cases  in  which  he  had  to  fight 
disease  due  to  microbic  infection,  and  he  was  now 
prepared  to  assert  its  safety  and  reliability  when 
properly  brought  in  contact  with  an  infected  surface. 
He  based  his  statements  on  the  results  of  treatment 
of  hundreds  of  cases  which  had  come  to  his  clinic  at 
the  Post-Graduate  Hospital,  New  York.  The  essayist 
quoted  Phelps,  of  New  York,  as  saying  that  to  him 
(Dr.  Powell)  the  profession  was  indebted  for  one  of 
the  most  useful  discoveries  ever  made  in  surgery, 
namely,  the  antidotal  effect  of  alcohol  to  carbolic 
acid.  The  speaker  had  used  carbolic  acid  for  years 
in  the  treatment  of  infections  and  Lone  diseases  in 
various  parts  of  the  body.  He  recommended  its  use 
likewise  for  erysipelas  and  abscesses.  During  the 
past  six  years  he  had  treated  every  phase  of  microbic 
disease  with  this  agent,  and  as  early  as  1894  hip-joint 
cases  were  treated  by  him  with  pure  carbolic  acid  and 
with  a  large  glass  drainage  tube.  Abscesses,  where- 
ever  located,  could  be  speedily  treated  by  the  injection 
of,  or  swabbing  with,  pure  carbolic  acid.  The  size  of 
the  abscess,  or  the  amount  of  surface  covered,  was  not 
a  factor.  Only  thorough  drainage  and  complete  re- 
moval of  the  pyogenic  membrane  need  be  considered. 
The  essayist  dwelt  upon  its  use  in  diseases  in  other 
parts  of  the  body. 


8/4 


MEDICAL    RECORD. 


[December  i,  1900 


Early  Excision  for  Dislocations  not  Reducible 
by  Manipulation.— ibis  subject  was  discussLci  by 
Dr.  Willis  F.  Westmoreland,  of  Atlanta,  who  re- 
ported two  cases.  The  first  one  was  an  arthrolomy, 
with  excision  of  the  head  of  the  humerus,  for  old  dis- 
location   of    the    shoulder    joint.     Miss    A.    VV , 

white,  aged  twenty-four  years.  The  patient  was 
thrown  from  a  buggy,  liie  right  shoulder  and  Uie  el- 
bow joint  being  injured.  A  physician  saw  the  patient 
but  made  no  diagnosis.  On  account  of  continued 
pain  and  lack  of  motion,  she  consulted  a  second  phys- 
ician, who  recognized  dislocation  of  the  shoulder.  An 
effort  was  made  to  reduce  it,  but  he  failed.  Upon  ex- 
amination, the  essayist  found  a  subcoracoid  disloca- 
tion of  shoulder  joint,  and  a  badly  treated  fracture  of 
the  external  condyle  of  the  humerus.  Tlie  patient 
was  anaesthetized,  and  an  unsuccessful  attempt  to  re- 
duce by  Kocher's  method  was  made.  Any  legitimate 
force  completely  failed  even  to  move  the  head  of  the 
humerus.  The  patient  was  held  for  operation,  which 
comprised  a  vertical  incision,  begun  just  below  the 
acromion  process,  and  carried  along  the  inner  aspect 
of  the  deltoid  for  about  five  inches.  When  the  cap- 
sule was  reached,  it  was  split  transversely;  the  head 
of  tiie  humerus  was  released  from  its  attachments  by 
dry  dissection.  The  head  of  the  bone  was  then  turned 
out  and  excised  close  to  the  attachment  of  the  capsule. 
The  upper  portion  of  the  humerus  was  pusiied  up 
against  the  glenoid  fossa,  and  the  capsule  shortened 
sufficiently  to  hold  it  there.  In  shortening  the  cap- 
sule all  excess  was  inverted  and  helped  to  fill  the  cav- 
ity, leaving  a  very  much  smaller  space  to  be  filled  in 
by  adventitious  tissue.  In  this  case  the  slack  of  the 
long  tendon  of  the  biceps  was  excised,  and  the  tendon 
united  by  mattress  and  coaptation  sutures.  The  in- 
cision was  closed  except  a  small  central  opening  for 
drainage.  There  was  primary  union,  and  the  patient 
made  an  uneventful  recovery.  She  was  discharged 
wit!)  full  movements. 

Case  II.  —  E.  D ,  male,  white,  aged  twenty  years. 

The  shoulder  had  been  dislocated  two  months  before 
while  boxing.  Immediately  after  the  injury  a  local 
physician  had  attempted  reduction,  but  failed.  Four 
days  later  the  patient  was  aneesthetized,  and  Dr.  West- 
moreland made  an  unsuccessful  attempt  to  reduce  by 
Kocher's  method.  On  the  same  day  the  same  oper- 
ation as  previously  described  in  Case  I.  was  made, 
and  the  patient  made  an  uneventful  recovery. 

A  Plea  for  the  Better  Appreciation  of  the  Limi- 
tations of  Operative  Work. — This  was  the  title  of 
the  president's  address,  delivered  by  Dr.  A.  M.  Cart- 
ledge,  of  Louisville.  Every  surgeon,  he  maintained, 
must  be  his  own  arbiter  in  deciding  questions,  and  the 
judgment  he  displayed  would  depend  upon  his  profes- 
sional learning  and  wisdom.  Methods  of  surgical  di- 
agnosis had  undergone  striking  modifications  within 
the  past  decade,  and  had  influenced  operative  work. 
The  older  surgeon  made  his  diagnosis  of  abdominal 
and  pelvic  lesions  slowly;  his  skill  at  that  time  con- 
sisting largely  of  a  delicate  sense  of  touch,  a  trained 
eye  to  detect  asymmetry,  keen  ears  to  difterentiate 
sounds  elicited  by  percussion,  and  methodical  inves- 
tigation of  all  symptoms  botii  subjective  and  objective. 
The  result  was,  his  diagnosis  having  been  made,  he 
next  carefully,  and  with  abundant  time  before  him, 
considered  the  advisability  of  operative  intervention. 
It  was  as  much  a  part  of  tiie  knowledge  of  surgery  to 
know  its  limitations,  or  what  it  could  not  do.  as  to  be 
justly  proud  and  ready  to  perform  that  which  one  had 
very  good  reasons  to  believe  would  be  productive  of 
relief  and  cure  to  the  thousands  of  unfortunates  who 
sought  its  aid.  From  every  standpoint  there  was  much 
to  be  gained  by  abetter  appreciation  of  operative  limi- 
tations. A  plea  was  entered  for  more  careful  diagno- 
ses with  an  especial  view  to  the  detection  of  attending 


visceral  disease,  in  short,  for  surgeons  to  try  to  be- 
come more  expert  prognosticians.  There  were  two 
phases  of  surgical  practice  alone,  the  careful  observ- 
ance of  which  would  reduce  the  mortality  of  surgical 
operations  so  low  as  to  cause  us  to  believe  that  exact- 
ness had  almost  been  reached.  He  referred  to  greater 
care  in  the  detection  of  kidney  lesions  and  the  institu- 
tion of  measures  to  correct  this  frecjuent  cause  of  un- 
fortunate operative  terminations,  and  the  still  preva- 
lent practice  of  operating  upon  hopeless  cases  of 
cancer.  In  reviewing  the  field  of  abdominal  and  pel- 
vic surgery  it-would  seem  that  surgical  limitation  was 
most  often  exceeded  and  mortality  unnecessarily  in- 
creased in  operations  for  the  following  diseases:  gen- 
eral septic  peritonitis,  extensive  carcinoma  of  the 
ovaries,  uterus,  and  intestine,  and  in  operations  upon 
the  gall  passages  in  long-continued  and  profoundly 
cholajmic  patients  without  adequate  preparation.  He 
protested  against  the  too  frequent  practice  of  operating 
in  these  affections.  As  to  laparotomy  in  cases  of  gen- 
eral diffuse  septic  peritonitis,  with  irrigation  and 
drainage,  reports  of  such  cases  had  appeared  in  litera- 
ture from  time  to  time,  but  the  mortality  up  to  the 
present  time  of  such  operations  iri  exaggerated  types 
of  the  disease  was  so  great,  in  his  opinion,  as  to 
make  it  an  unwarranted  procedure.  He  was  strongly 
impressed  with  the  belief  that  the  successful  cases  re- 
ported had  been  cases  of  beginning  general  peritoni- 
tis, or  of  wide-extending,  yet  circumscribed,  peritoni- 
tis. In  closing,  the  author  emphasized  the  importance 
of  carefullfy  preparing  chola;mia  patients  before  sub- 
jecting them  to  operation,  with  a  view  of  lessening 
mortality.  Another  class  of  cases  amenable  to  the 
same  course  of  preliminary  treatment  were  those  of 
inefficient  renal  action. 

Excision  of  the  External  Carotid  Artery  in  Cases 
of  Inoperable  Malignant  Diseases  of  the  Face.— Dr. 
William  P.  Xicolson,  of  Atlanta,  Ga.,  reported  two 
cases  upon  which  this  operation  had  been  recently 
done.  The  first  case  was  one  of  sarcoma  of  the  nose 
which  had  begun  apparently  as  a  polypus  about  eight 
months  before.  This  was  removed  several  times,  but 
recurred  promptly  after  each  removal.  When  seen  a 
few  weeks  before  the  operation,  this  had  extended 
sufficiently  to  obstruct  the  nose  completely  and  cause 
great  pain  by  constant  pressure.  At  the  time  of  oper- 
ation this  had  progressed  in  only  a  few  weeks  so  that 
the  growth  pressing  under  the  orbit  had  forced  the 
right  eye  out  of  position,  and  there  had  been  also  an 
extension  upon  the  forehead  upon  the  left  side.  The 
patient  suffered  intense  pain  which  required  the  con- 
stant use  of  morphine  for  its  relief.  The  right  conr- 
mon  carotid  was  excised  on  October  3d,  and  the 
wound  healed  promptly.  The  enlargement  upon  the 
left  side  ot  the  forehead  broke  down,  and  the  large 
abscess  was  opened  a  few  days  after  the  operation. 
The  pus  from  this,  or  the  discharge  from  the  nose,  set 
up  a  violent  ophthalmia,  from  which  the  patient  suf- 
fered for  a  week  or  ten  days.  Two  weeks  from  the 
day  of  the  first  operation  the  carotid  upon  the  left  side 
was  removed,  and  very  soon  the  symptoms  improved 
in  every  respect,  the  patient  was  relieved  of  suffering, 
and  the  growth  was  not  only  checked,  but  it  apparent- 
ly began  to  recede,  with  the  prospects  of  a  material 
improvement  in  his  condition.  The  second  case  was 
one  of  inoperable  sarcoma  of  the  upper  jaw  of  three 
months'  duration,  and  of  very  rapid  giinvth.  In  this 
case  the  interval  between  the  operations  was  longer 
than  in  the  first,  on  account  of  the  occurrence  of  a 
severe  secondary  hemorrhage  on  the  seventh  day, 
which  was  due  to  tying  of  the  vessel  too  close  to  the 
bifurcation.  The  first  operation  in  this  case  relieved 
the  patient  of  all  symptoms  caused  by  the  rapidly  in- 
creasing pressure,  and  the  growth  apparently  subsided 
materially.     The  second  operation  had  not  been  per- 


December  i,  1900] 


MEDICAL    RECORD. 


875 


formed  long  enough  to  give  much  idea  as  to  how  much 
permanent  decrease  there  would  be  in  the  tumor.  In 
commenting  upon  'he  operation,  it  was  claimed  that 
in  these  cases  the  patient  was  simply  doomed  if  noth- 
ing were  done,  and  the  operation  performed  appeared 
to  be  the  only  recourse  that  offered  any  hope  of  bene- 
fit. He  had  performed  various  operations  upon  the 
external  carotid  artery  in  cases  of  malignant  diseases, 
having  tied  the  vessel  twenty-six  times,  four  of  these 
being  cases  of  double  ligation.  The  operation  had 
not  been  accompanied  by  any  mortality.  Little  could 
be  accomplished  by  simply  ligating  even  both  carotids, 
because  the  circulation  was  re-established  so  rapidly 
that  the  nutrition  could  not  be  cut  off  with  any  degree 
of  permanence.  The  operation  of  e.xcision,  as  recom- 
mended by  Dawbarn,  seemed  to  be  the  only  procedure 
that  offered  any  hope,  and  while  this  would  not  per- 
haps produce  much  permanent  effect,  yet  it  seemed 
undoubtedly  true  that  the  lives  of  patients  could  be 
much  prolonged  and  their  sufferings  greatly  lessened. 
The  operation  was  one  of  considerable  magnitude,  and 
dealt  with  structures  of  great  importance  anatomically, 
yet  the  results  demonstrated  tliat  there  was  compara- 
tively little  danger  in  the  performance  of  it. 

Auto-Intoxication  from  Renal  InsufSciency  with 
or  without  Disease  of  the  Kidneys.  — By  Ur.  James 
T.  Jiii.KS,  of  Hot  Springs,  .Vrk.  The  author's  atten- 
tion was  called  to  this  subject  several  years  ago  by 
reading  Bouchard  on  "Auto-intoxication,"  and  later 
by  papers  from  Etheridge,  of  Chicago,  and  L.  Duncan 
Bulkley,  of  New  York.  For  years  he  had  made  it  a 
point  to  examine  the  urinary  output  for  twenty-four 
hours  of  every  patient  who  consulted  him.  This  had 
been  a  revelation  to  him,  and  therapeutics  based 
thereon  had  enabled  him  to  accomplish  what  he  de- 
scribed as  marvellous  results.  Abundant  evidence  was 
adduced  to  show  that  as  the  result  of  faulty  elimina- 
tion by  the  kidneys,  without  the  presence  of  disease  in 
these  organs,  patients  might  have  vertigo,  contracted 
capillaries,  cold  skin,  especially  of  the  extremities, 
so-called  sick  headache,  which  was  now  recognized  as 
uric-acid  headache,  melancholia,  palpitation  of  the 
heart,  interrupted  heart  beat,  various  forms  of  skin  dis- 
eases, rheumatism,  gout,  hysteria,  epilepsy,  and  even 
genuine  insanity.  Among  the  remedies  used  to  cor- 
rect this  faulty  elimination  were  squills,  milk,  rectal 
or  hypodermic  injections  of  decinormal  saline  solu- 
tion, digitalis  or  its  derivatives,  sodium  phosphate, 
sodium  salicylate,  Vichy  water,  etc.  All  of  these  were 
used  in  connection  with  baths,  when  it  was  possible  to 
give  them,  and  the  patients  were  ordered  to  drink  from 
one-half  to  one  gallon  of  hot  water  daily.  Twenty-five 
cases  were  detailed  as  having  been  treated  along  the 
lines  mentioned,  with  the  most  gratifying  results. 

Dr.  George  S.  Brow.v,  of  Birmingham,  made  ((7) 
a  supplementary  report  regarding  a  case  of  litholopa.\y 
previously  presented  to  the  association,  and  (/<)  a  sup- 
plementary report  with  reference  to  a  case  of  vesico- 
rectal fistula. 

Dr.  James  A.  Gor.fiAXS,  of  Alexander  City,  .Ala., 
reported  one  case  of  strangulated  femor.il  hernia  in  a 
woman  forty  years  of  age;  three  cases  of  extra-uterine 
pregnancy;  one  case  of  thoracotomy  for  empyema,  and 
one  case  of  ovarian  cyst. 

Some  Life-Saving  Measures  in  Obstetric  Work. 
— By  Dr.  R.  R.  Kime,  of  Atlanta.  Leaving  out  of 
discussion  instrumental  deliveries.  Cesarean  section, 
symphyseotomy,  etc.,  the  author  considered  the  most 
important  life-saving  measures  to  be  saline  infusions, 
medicinal  remedies,  orrhotherapy,  hydrotherapy,  and 
drainage.  All  of  these  topics  were  taken  up  and  dis- 
cussed in  consecutive  order.  In  cases  of  placenta 
previa  and  post-partum  hemorrhage  saline  infusions 
or  intravenous  injections  were  of  prime  importance, 
not  only  to  save  life,  but  to  lessen  susceptibility  of 


infection  and  hasten  recovery.  The  report  of  one  01 
two  cases  would  illustrate  some  of  the  points  brought 
out  in  the  paper. 

Case  1. —  Mrs.  L ,  primipara;  her  husband  had 

had  gonorrhoea  before  marriage.  The  patient  had 
vaginitis  and  cervicitis,  which  were  relieved  by  local 
treatment.  At  the  fourth  month  of  pregnancy  the  es- 
sayist removed  by  a  continuous  strip  a  lot  of  warty 
growths  surrounding  the  posterior  three-fourths  of  the 
vaginal  outlet.  The  labor  was  normal.  No  lacera- 
tions occurred.  Twelve  days  after  labor  there  were  a 
slight  elevation  of  pulse,  some  headache,  and  a  tem- 
perature of  99"^  F.  The  next  day  the  symptoms 
slightly  increased.  The  third  day  the  patient  had 
two  chills,  and  the  temperature  was  nearly  105°  F. 
The  uterus  was  found  large  and  containing  half  a  pint 
or  more  of  pus;  he  irrigated,  inserted  double  uterine 
drainage,  and  administered  the  usual  remedies.  The 
drainage  tube  collapsed  and  bent  at  the  cervix,  ob- 
structing drainage,  hence  there  was  but  little  improve- 
ment the  first  twenty-four  hours.  After  this  rapid  im- 
provement took  place,  the  temperature  reaching  normal 
in  a  few  days.  The  patient  recovered  with  normal 
pelvic  organs. 

Case    II. — Mrs.     L ,    aged    twenty-one    years; 

primipara.  Miscarriage  occurred  at  about  the  fourth 
or  fifth  month.  Two  physicians  in  charge  tried  to 
empty  the  uterus  with  instruments,  causing  great  pain. 
Some  four  or  five  days  afterward  a  third  physician 
took  charge  and  called  the  essayist  in  consultation.  He 
found  the  patient  in  a  markedly  septic  condition,  with 
a  temperature  of  i03°-i04°  F. :  pulse,  120  to  140; 
abdomen  distended,  tender,  tympanitic,  with  abund;mt 
pelvic  exudate.  The  uterine  wall  and  cervix  were 
sloughing.  He  removed  some  debris  from  the  uterine 
cavity  with  forceps  (not  the  curette),  irrigated,  and  in- 
stituted double  drainage,  giving  the  usual  remedies. 
The  patient's  general  condition  improved.  The 
uterus  rapidly  assumed  a  healthy  condition,  it  being 
practically  normal  in  a  week.  At  this  time  a  vaginal 
incision  was  made,  and  the  abscess  cavity  drained. 
The  patient  made  a  good  recovery,  was  stout  and 
healthy  at  the  present  time,  and  complained  only  of 
some  pain  during  menstruation. 

Pseudo-Membranous   Enteritis    and    its   Relation 

to  Abdominal    Surgery Dr.   Frank    A.  Glasgow, 

of  St.  Louis,  Mo.,  was  the  author  of  this  paper.  He 
called  attention  to  this  very  common  disease,  and 
urged  physicians  to  study  its  relations  to  appendicitis. 

Solid  Ovarian  Tumor. — Dr.  John  G.  Earnest,  of 
Atlanta,  Ga.,  reported   a  case  of  solid  tumor  of  the 

ovary.      The   patient.    Miss    M ,   aged    thirty-two 

years,  unmarried,  w^as  seen  June  24,  1900.  She  was 
a  very  small  woman  with  a  narrow  pelvis,  and  had 
been  gradually  losing  flesh  for  several  months,  until 
she  had  become  greatly  emaciated.  For  months  the 
patient  had  had  fever  every  day.  There  was  constant 
pain  in  the  pelvis;  she  was  very  despondent,  worn-out, 
and  exhausted.  She  had  a  constant  watery  diarrhcea, 
which  was  occasionally  interrupted  by  a  few  days' 
constipation,  and  accompanied  by  great  abdominal 
distention.  This  condition,  when  occurring,  was  re- 
lieved with  difficulty,  requiring  active  purgatives  and 
the  free  use  of  enemas.  Nausea  was  a  distressing  fac- 
tor. When  the  abdomen  was  inspected,  a  mass  reach- 
ing above  the  umbilicus  was  observed.  It  stood  out 
prominently  in  the  median  line,  was  symmetrical, 
smooth  and  hard.  It  was  so  firmly  fixed  that  it  could 
not  be  moved.  The  dark  line  down  the  centre  of  the 
abdomen  was  unusually  pronounced.  Examination  by 
the  vagina  was  somewhat  hampered  by  an  unruptured 
hymen,  and  tenderness  due  to  the  local  peritonitis;  but 
he  found  the  cervix  pointing  forward,  low  down,  and 
twice  its  normal  size;  the  uterus  was  retroverted,  firm- 
ly fixed,  and  apparently  continuous  with  the  superim- 


876 


MEDICAL    RECORD. 


[December  i,  1900 


posed  tumor.  Rectal  examination  disclosed  that  the 
uterus  and  tumor  were  parts  of  the  same  body.  The 
fundus  uteri  could  not  be  reached  through  the  rectum. 
He  believed  it  to  be  a  uterine  libroid.  The  patient 
declined  operation  until  she  could  go  to  her  home  and 
build  up  under  the  care  of  her  family  physician.  This 
she  did,  returning  August  ist.  On  August  3d,  he 
opened  the  ahodmen  and  evacuated  a  small  amount 
of  light  yellow  ascitic  lluid.  The  abdominal  peri- 
toneum was  mottled  with  dirty  brown.  The  tumor 
showed  the  pearly  lustre  of  an  ovarian  tumor.  It  had 
so  grown  that  it  seemed  to  be  caught  under  the  prom- 
ontory of  the  sacrum,  and  was  adherent  to  the  pelvic 
wall.  It  was  enucleated  with  some  difficulty.  The 
pedicle  was  from  the  right  side,  and  comparatively 
small.  The  tumor,  when  removed,  was  found  to  be 
ovoid  in  its  general  outline,  with  an  indentation  corre- 
sponding to  the  promontory  of  the  sacrum.  It  meas- 
ured 20  cm.  in  length,  and  about  14  in  breadth  at  the 
widest  point.  When  cut  open  its  appearance  was 
very  much  like  that  of  an  ordinary  uterine  fibroid,  and 
the  tissue  was  quite  dense.  The  cortex  was  united  to 
the  tumor  by  a  thin  layer  of  cellular  tissue  infiltrated 
with  serum.  No  microscopical  examination  was 
made.  At  first  it  was  supposed  to  be  a  sarcoma,  but 
careful  examination  showed  the  fibres  to  be  distinct 
and  arranged  in  irregular  whirls,  as  in  uterine  fibroids, 
and  the  tissues  were  quite  as  hard  as  those  of  any 
fibroid,  and  absolutely  solid  without  a  break.  The  re- 
covery was  uninterrupted. 

Histogenesis  of  Ovarian  Dermoids — Dr.  W.  D. 
Haggard,  Jr.,  of  Nashville,  Tenn.,  gave  a  verbal  ab- 
stract of  a  paper  on  this  subject.  He  stated  that 
dermoid  cystomata  of  the  ovary  dififered  essentially 
from  dermoids  in  the  orbit,  pharynx,  mediastinum, 
scrotum,  coccyx,  and  elsewhere.  The  latter  were  un- 
questionably from  inclusions  or  nipping  off  of  the 
ectoderm  in  the  development  of  the  embryo,  which  was 
similar  to  the  "  healing  in  "  of  skin  in  wounds  and  the 
subsequent  development  of  a  dermoid  growth.  These 
structures  all  contained  sebaceous  material,  hair,  plates 
of  bone,  teeth,  etc.,  and  purely  dermal  derivates.  Ova- 
rian dermoids  contained  derivatives  of  all  the  meso- 
derm and  entoderm  as  well,  and  hence  some  adequate 
explanation  other  than  the  inclusion  of  the  skin-form- 
ing layer  must  be  forthcoming.  All  sorts  of  curious 
theories  had  been  successively  advanced.  The  vir- 
ginal pregnancy  idea  was  succeeded  by  one  which 
ascribed  the  origin  of  these  growths  to  prolonged  un- 
gratified  sexual  desire  on  the  part  of  the  woman.  A 
man  w-ho  jested  at  his  wife  during  travail  was  afflicted 
with  a  pregnancy  (dermoid)  of  the  thigh.  Dermoids 
of  the  ovary,  however,  were  akin  to  the  teratomata, 
and  it  was  to  the  ovum  itself  that  we  must  look  for  a 
solution  of  the  vexed  problem  of  their  etiology. 
Wilms  was  the  first  to  claim  the  ovulogenous  origin 
of  these  growths.  Some  pathological  activity  on  the 
part  of  the  ovum  in  the  Graafian  follicle,  was  respons- 
ible. Bland  Sutton  found  a  dermoid  of  the  ovary  in 
a  mare  when  the  growth  was  undoubtedly  in  the  ovum 
suspended  in  a  large  cystic  Graafian  follicle.  Similar 
cases  have  been  reported  in  women.  Kraemer  liad 
recently  gone  ovei  the  entire  field  and  amassed  an 
amazing  amount  of  material  that  went  far  to  settle  the 
question,  and  prove  that  ovarian  dermoids  contained 
products  of  all  the  blastodermic  tissues;  that  they 
could  not  spring  from  an  evolutional  inclusion  sim- 
ply, as  dermoids  elsewhere  undoubtedly  did;  that  they 
were  of  ovulogenous  origin,  a  sort  of  parthenogenesis. 
In  evidence  an  attempt  at  formation  of  nearly  all  the 
organs  of  the  body  had  been  found  in  the  lawless  de- 
velopment of  these  benign  growths — retinal  pigment, 
more  or  less  complete  optical  vesicles,  a  rudimentary 
pharynx,  with  an  attempt  at  the  formation  of  an  oeso- 
phageal tube;  the  sympathetic  nerves  in  the  alimen- 


tary canal,  and  curiously  enough  a  rudimentary  uterus, 
with  branching  cells  of  the  cervix  and  the  glands  of 
the  fundus;  mammae  (one  case  of  which  underwent 
carcinomatous  development).  An  easily  recognized 
heart  provided  with  valves  was  found  by  Johnston; 
and  many  other  more  or  less  perfectly  formed  organs 
and  tissues  other  than  dermal  had  been  reported  by 
investigators  too  numerous  to  individualize.  These 
data  had,  as  remarked  by  Clark,  dealt  a  telling,  if  not 
fatal  blow  to  the  inclusion  theory  of  ovarian  dermoid 
evolution.  The  researches  of  Kraemer  and  others 
seemed  to  establish  convincingly  the  ovulogenous 
theory  of  their  development. 

The  following  papers  were  likewise  read  and  dis- 
cussed:  "Removal  of  Cystic  Gall  Stones,"  by  Dr. 
Howard  A.  Kelly,  of  Baltimore;  "■  Osteo-Arthritis  of 
the  Spine,"  by  Dr.  Michael  Hoke,  of  Atlanta;  "  Epi- 
and  Hypospadias,  with  Special  Reference  to  the  Oper- 
ative Treatment,"  by  Dr.  W.  F.  Farhara,  of  New  Or- 
leans, and  "  Retrotlexed  Incarcerated  Gravid  Uterus," 
by  William  A.  Quinn,  of  Henderson,  Ky. 

Much  to  the  regret  of  the  members,  Dr.  W.  E.  B. 
Davis  resigned  the  secretaryship,  owing  to  the  pressure 
of  other  duties,  after  having  served  the  association  ably 
and  efficiently  from  its  organization  to  the  present  time. 
A  resolution  was  offered  and  unanimously  adopted, 
thanking  Dr.  Davis  for  his  efficient  services,  tireless 
efforts,  and  faithful  devotion  to  the  interests  of  the  as- 
sociation during  a  period  of  thirteen  consecutive  years. 

Officers  Elected  for  1901.  —  President,  Dr.  Manning 
Simons,  of  Charleston,  S.  C;  Vice-rresidents,  Drs. 
George  H.  Noble,  of  Atlanta,  Ga.,  and  L.  C.  Bosher, 
of  Richmond,  Va. ;  Secretary,  Dr.  W.  D.  Haggard,  Jr., 
of  Nashville,  Tenn.;  Treasurer,  Dr.  F.  W.  McRae,  of 
Atlanta,  Ga. 

Richmond,  Va.,  was  selected  as  the  place  for  holding 
the  next  annual  meeting;  time,  third  Tuesday  in  No- 
vember, 1901. 

Twenty-nine  new  members  were  elected  at  this  meet- 
ing. After  the  installation  of  officers,  and  the  adop- 
tion of  resolutions  of  thanks,  the  association  ad- 
journed. 


NEW   YORK    NEUROLOGICAL    SOCIETY. 

Stated  Meeting,  November  6,  igoo. 
Frederick  Peterson,  M.D..  President. 

A  Case  of  Paralysis   Agitans  without  Tremor 

Dr.  M.  G.  Schlapp  presented  this  case.  The  chief 
features  were  the  rigidity  of  the  muscles,  the  expres- 
sionless face,  and  the  position  of  the  arms,  body,  and 
hands.  The  tiexor  muscles  were  more  contracted 
than  the  extensors.  There  was  no  tendency  to  fall  in 
any  particular  direction. 

A  Case  of  Paralysis  of  the  Duchenne-Erb  Type. 
, —  Dr.  Schlapp  also  presented  a  man  \\\\q,  six  weeks 
ago,  had  fallen  from  a  bicycle,  striking  his  shoulder. 
He  iiad  been  unconscious  for  five  hours.  The  case 
was  interesting  because  the  anterior  pectoral  muscles 
were  affected.  There  was  complete  degeneration  re- 
action of  the  pectorals,  biceps,  and  the  coraco-bra- 
chialis,  and  it  was  incomplete  in  the  triceps  and 
supinators.  There  was  a  peculiarly  distributed  area 
of  anaesthesia  showing  involvement  of  the  musculo- 
spiral  and  musculo-cutaneous  nerves  chielly.  The 
lower  part  of  the  pectoral  muscle  showed  some  slight 
response  to  the  faradic  current.  The  lesion  evidently 
took  in  the  fifth  and  sixth  roots  of  the  cervical  plexus. 
As  the  anterior  thoracic  nerves  were  involved  it  was 
not  a  perfectly  typical  case. 

Drs.  C.  L.  Dana  and  M.  Allen  Starr  said  that 
they  had  each  seen  a  similar  case. 


December  i ,  1 900] 


MEDICAL    RECORD. 


877 


A  Case  for  Diagnosis. — Dr.  J.  Fraenkel  pre- 
sented a  man  forty  years  of  age,  a  tailor  by  occupa- 
tion, who  claimed  to  have  been  well  up  to  one  year 
and  a  half  ago.  There  was  no  family  history  bearing 
on  his  condition,  nor  was  there  any  history  of  any 
previous  acute  trouble.  About  eighteen  months  ago 
the  man  had  been  pushed  roughly  off  a  street  car. 
On  awakening  the  next  morning  at  home  he  had  been 
absolutely  helpless,  having  been  unable  to  move  his 
upper  or  lower  extremities.  .After  six  months  he  had 
been  admitted  to  the  Lebanon  Hospital,  but  had  left 
there,  according  to  the  history,  unimproved.  On  com- 
ing under  the  speaker's  observation,  there  had  been 
noted  at  once  the  presence  of  an  extensive  eczema. 
On  a  second  examination  the  shoulder  joints  had  been 
found  partially  ankylosed,  and  the  muscles  surround- 
ing them  had  appeared  atrophic.  There  was  also 
atrophy  of  the  supraspinatus  and  infraspinatus,  and 
slight  atrophy  of  the  serratus  muscle.  The  electrical 
reactions  were  not  changed.  A  thorough  examination 
of  his  nervous  system  had  proved  absolutely  negative. 
There  were  a  peculiar  atrophic  condition  of  the  skin 
and  a  condition  of  cyanosis  on  the  peripheral  parts. 
There  was  slight  valvular  disease  of  the  heart.  The 
diagnosis  seemed  to  rest  between  rheumatism,  a  gen- 
eral trophoneurosis,  and  general  syphilis. 

Dr.  H  -Sachs  said  that  he  had  examined  this  man 
previously  and  had  been  led  to  think  of  symmetrical 
muscular  atrophies  such  as  occurred  after  arthritic  proc- 
esses. It  was  not  usual,  however,  to  have  them  quite 
so  symmetrical.  The  case  did  not  seem  to  him  to  cor- 
respond to  any  of  the  dystrophies  or  any  of  the  spinal 
forms  of  progressive  muscular  dystrophy.  He  had  had 
a  suspicion  that  the  case  might  be  one  of  leprosy. 

Dr.  M.  -Alle.nt  Starr  said  that,  when  travelling  in 
Norway  some  years  ago,  he  had  seen  a  number  of 
lepers,  and  had  had  his  attention  called  to  the  exist- 
ence of  muscular  atrophies  in  them.  The  peculiar 
appearance  of  the  man's  face  had  led  him  to  think  of 
leprosy  without  knowing  Dr.  Sachs'  view  on  the  case. 

Dr.  Frae.xkel  said  that  very  careful  inquiry  had 
failed  to  elicit  anything  but  the  most  positive  state- 
ments that  the  man  had  been  in  perfect  health  up  to 
the  time  of  being  thrown  from  the  car.  The  man  had 
come  from  the  southern  part  of  Russia.  A  dermatolo- 
gist had  seen  the  case  and  had  been  told  that  leprosy 
was  suspected,  but  he  had  replied  that  the  thickening 
of  the  face  was  due  to  the  previous  eczema. 

Dr.  Schlafp  said  that  Hechteroff  had  described 
somewhat  similar  cases  of  "stiff  back."  There  was  a 
possibility  of  some  of  the  roots  being  affected. 

Dr.  C.  L.  Daxa  thought  this  case  was  one  of  rheuma- 
toid arthritis  and  the  condition  of  tiie  skin  the  result 
of  an  eczema. 

Dr.  F.  Peterson  thought  it  was  an  anomalous  type 
of  chronic  rheumatoid  arthritis.  The  fact  that  the 
muscles  reacted  normally  would  tend  to  confirm  this 
belief.  It  was  certainly  not  a  spondylose  rhizomyd- 
lique.  This  might,  of  course,  be  a  case  in  which  the 
spinal-cord  symptoms  were  developed  later. 

Dr.  B.  Sachs  presented  the  spinal  column  and  the 
shoulders  from  a  case  of  spondylose  rhizomye'lique. 
The  heart  also  showed  previous  rheumatic  disease. 

Spasmodic  Torticollis  and  its  Treatment ;  Report 

of  Two  Cases  with  Recovery Dr.  M.  W.  Leszv.n- 

SKY  read  a  paper  with  this  title.  He  said  that  wry- 
neck must  be  classified  among  the  musculo-nervous 
disorders.     The  first  case  reported  was  that  of  Mrs. 

X ,  thirty-six  years  of  age,  seen  by  him  in   1895. 

About  seven  years  ago  she  had  suffered  from  pain  and 
stiffness  in  the  muscles  of  the  back  of  the  neck  for 
several  days.  She  had  been  greatly  worried  for  a 
number  of  years  by  a  protracted  lawsuit.  There  was 
no  family  history  of  nervous  disease.  In  February, 
1895,  after   a  fall  on  the  ice,  she  had  begun  to  suffer 


from  ner\'ous  attacks,  and  in  June  she  had  first  noticed 
a  tendency  of  the  head  to  turn  toward  the  left.  On 
examination,  she  appeared  fairly  nourished  but  anse- 
mic.  There  was  frequent  and  well-marked  tonic 
spasm  of  the  right  sterno-mastoid  muscle.  Her  eyes 
had  been  examined  and  found  normal.  Her  general 
condition  was  that  of  neurasthenia  of  the  litha;mic  type. 
She  was  advised  to  rest  in  bed  for  three  months,  and 
was  given  the  usual  tonics.  After  two  weeks  atropine 
had  been  injected  into  the  affected  muscles,  the  daily 
dose  being  increased  slowly  up  to  gr.  ^'i^.  .At  this 
time  the  symptoms  of  atropine  poisoning  had  been  so 
severe  that  it  was  discontinued.  For  a  few  days  after 
this  the  spasm  of  the  muscles  was  decidedly  worse. 
The  convulsive  attacks  lasted  about  twenty  minutes, 
were  very  violent,  and  were  associated  with  marked 
impairment  of  respiration.  Under  the  use  of  morphine 
and  potassium  bromide  the  paroxysms  had  gradually 
subsided  in  the  course  of  two  weeks.  Subsequently 
various  remedies  had  been  employed,  but  without 
benefit.  The  urine  was  always  acid  and  of  high  spe- 
cific gravity.  After  four  months  there  had  been  con- 
siderable improvement  in  her  general  coiidition  but 
not  in  the  spasm  of  the  muscles.  The  rest  treatment 
had  been  continued  for  some  time  longer  under  the 
advice  of  the  late  Dr.  E.  C.  Seguin,  but  she  had  finally 
rebelled  and  had  gone  home.  Some  months  later  a 
brace  had  been  applied,  and  this  had  gradually  con- 
trolled the  convulsive  movements.  The  brace  had 
then  been  discarded,  but  some  tonic  spasm  in  the 
muscles  had  still  continued.  Although  there  had 
been  no  return  of  the  clonic  spasm,  there  was  still 
slight  occasional  tonic  spasm  of  the  upper  segment  of 
the  trapezius  muscle.  This  case  pointed  to  a  strong 
hysterical  element,  although  the  patient  did  not  pre- 
sent the  usual  stigmata  of  this  affection.  There  was 
undoubtedly  also  a  lithiBmic  condition.  The  second 
case  was  that  of  a  woman  aged  twenty-four  years 
whom  he  had  seen  on  October  24,  1897.  At  that 
time  there  had  been  a  marked  spasm  which  had 
existed  for  nearly  eight  months.  She  had  suffered 
from  migraine  for  a  number  of  years,  and  there  was  no 
history  of  trauma.  She  was  kept  in  bed  and  the  usual 
rest-cure  methods  were  employed  for  two  months. 
The  atropine  injections  had  been  used  for  about  two 
weeks,  and  they  had  temporarily  controlled  the  spasm. 
They  had  been  discontinued  after  two  weeks.  She 
had  made  a  complete  recovery  at  the  end  of  six 
months,  and  had  remained  well  since  that  time.  The 
speaker  said  that  in  1884  he  had  recommended  the 
use  of  atropine  in  this  class  of  cases.  Since  then  he 
had  employed  it  in  twelve  cases,  and  had  found  that 
in  many  cases  it  was  unsatisfactory,  and  he  now  be- 
lieved it  should  be  looked  upon  as  simply  an  adjuvant 
to  other  measures.  The  prognosis  depended  upon  the 
duration  of  the  disease  and  the  persistence  of  treat- 
ment. The  principal  therapeutic  feature  in  every  case 
should  be  the  use  of  massage  and  the  methodical  edu- 
cation of  the  muscles  and  their  co-ordinating  centres. 
His  attention  had  first  been  directed  to  this  valuable 
method  by  Dr.  Coggeshall,  of  Boston.  It  was  a  mis- 
take to  resort  to  surgical  measures  in  the  early  stages 
of  this  disorder. 

Dr.  C.  L.  Dana  said  that  in  his  experience  if  the 
w-ry-neck  were  pretty  closely  limited  to  the  spinal  ac- 
cessory and  sterno-mastoid  an  early  resection  would 
often  check  the  disease  and  prove  most  useful.  He 
quite  agreed  with  the  reader  of  the  paper  concerning 
the  treatment  of  the  older  cases. 

Acute  Ataxia. — Dr.  C.  L.  Dana  read  this  paper, 
classifying  acute  ataxia  as:  (i)  The  acute  bulbar  and 
cerebellar  ataxia;  (2)  acute  spinal  ataxia,  and  (3) 
acute  peripheral  ataxia  due  to  multiple  neuritis  of  the 
sensory  type.  He  said  that  Ebstein  had  reported  a 
case  of  acute  ataxia  with  autopsy,  and  as  patches  of 


8  78 


MEDICAL    RECORD. 


[December  i,  1900 


sclerosis  had  been  found  the  case  had  been  looked 
upon  as  one  of  multiple  sclerosis  in  an  early  stage. 
The  peripheral  type  included  the  cases  due  to  the 
sensory  form  of  multiple  neuritis.  Up  to  recent  times 
there  had  been  no  definite  description  of  acute  ataxia 
of  spinal  origin  not  due  to  tabes.  In  1897  Dr.  Strauss 
had,  however,  reported  two  cases  occurring  in  men 
about  thirty-four  years  of  age  without  history  of 
sypliilis  or  other  infection.  The  description  seemed 
to  the  reader  suggestive  only  of  locomotor  ataxia. 
The  cases  of  acute  ataxia  first  described  by  Leyden, 
and  still  referred  to  by  him  as  acute  bulbar  ataxia, 
certainly  had  a  strikingly  characteristic  clinical 
course,  so  that  the  name  might  have  some  clinical 
value.  Special  attention  was  called  to  five  cases  of 
non-tabetic  spinal  ataxia  which  were  reported  in  the 
paper.  The  following  is  illustrative:  A  man  aged 
sixty  years  on  January  9,  1S90,  had  begun  to  feel 
numbness  in  the  feet,  and  in  a  few  hours  this  had  ex- 
tended to  the  mid-dorsal  region.  He  soon  developed 
a  tight  sensation  around  the  waist.  Ten  days  later, 
on  coming  under  observation,  he  had  a  staggering 
ataxic  gait,  and  soon  became  tired.  He  could  not 
stand  with  the  eyes  closed.  He  showed  distinct  loss 
of  muscular  sense,  but  no  impairment  of  the  functions 
of  the  rectum  or  bladder.  The  patient  had  gradually 
recovered,  and  was  now  well.  In  anotlicr  case,  that  of 
a  man  seventy-six  years  of  age,  syphilitic  infection 
had  occurred  one  year  previously.  Just  after  recover- 
ing from  an  attack  of  iritis  he  had  developed  a  type 
of  ataxia  like  that  described  in  the  preceding  case. 
In  two  other  cases  the  disease  had  been  in  old  people, 
but  in  neither  of  them  had  there  been  a  history  of 
syphilis.  They  both  were  victims  of  overwork,  and 
both  had  presented  symptoms  of  marked  senility.  It 
would  seem  that  these  cases  were  due  to  senile  arterial 
changes,  or  due  to  syphilitic  changes  in  the  blood- 
vessels of  the  spinal  cord,  causing  hemorrhages  or 
blocking  of  the  vessels,  or  both.  It  was  possible  that 
in  old  age  the  syphilitic  virus  might  lead  to  attacks  on 
the  posterior  rather  than  on  the  lateral  columns,  so 
that  the  type  would  be  ataxic  rather  than  of  the  spastic 
paraplegic  type.  All  of  his  patients  had  recovered 
from  the  ataxia.  The  differential  diagnosis  must  be 
made  from  an  acute  onset  of  a  locomotor  ataxia. 

Dr.  Joskph  Collins  said  that  his  clinical  experi- 
ence had  been  somewhat  different  from  that  of  Dr. 
Dana,  so  that  he  had  been  led  to  a  very  different  con- 
clusion regarding  the  etiology.  Some  of  his  cases 
had  been  in  persons  of  about  forty-four  years  of  age 
without  evidence  of  syphilitic  infection.  Sometimes 
there  had  been  inability  to  walk  in  the  course  of  a 
week.  This  had  been  associated  with  slight  incon- 
tinence of  urine  at  times,  and  with  sexual  impotence. 
In  these  cases  there  had  been  none  of  the  cardinal 
sym|3toms  of  multiple  sclerosis,  and  no  evidence  of 
cardiac  or  vascular  degeneration.  This  was  a  tvpe  of 
case  which  he  had  been  accustomed  to  call  '"  acute 
ataxia."  A  second  class  of  acute  ataxia  was  acute 
bulbar  ataxia.  One  of  these  was  in  a  woman  thirty- 
five  years  of  age,  who,  about  .August  14th,  had  begun 
to  complain  of  dizziness  and  blurred  vision.  Shortly 
afterward,  while  dancing,  she  had  become  ataxic,  and 
then  had  lain  in  bed  for  a  long  lime  with  marked 
ataxia  and  with  slight  anaesthesia  of  the  face.  The 
sense  of  position  had  been  lost.  Later,  tiie  symptoms 
of  bulbar  involvement — regurgitation  through  the  nose 
and  bulbar  sjieech — had  ajipeared.  The  cases  of 
acute  ataxia  with  which  he  was  familiar  clinically 
were  those  presenting  similar  features  to  the  ones  re- 
ported by  Dr.  Sanger  Brown,  of  Chicago,  recently,  in 
The  American  Journal  of  the  Medical  Sciences.  Dinkier 
had  come  to  the  conclusion  that  the  lesion  must  be 
somewhere  in  the  corona  radiata  or  in  the  large  basal 
ganglion. 


Dr.  S.  Ely  Jelliffe  said  that  he  had  had  under 
his  observation  for  three  years  a  gentleman  thirty-six 
years  of  age,  who  had  been  infected  with  syphilis. 
He  was  a  politician,  and  at  the  crisis  of  a  campaign 
he  had  suddenly  found  himself  unable  to  walk.  On 
either  side  there  had  been  ataxia  confined  to  the  lower 
limbs,  and  associated  with  some  trouble  of  the  blad- 
der. He  had  been  put  on  anti.syphilitic  treatment, 
and  had  been  practically  well  in  three  weeks.  He 
had  remained  well  for  a  year,  and  then  had  had  a  sud- 
den attack  which  had  resulted  in  a  typical  spastic 
paraplegia.  He  had  eventually  died  from  this,  and 
his  spinal  cord  had  exhibited  the  usual  lesions  of  that 
affection.  In  the  first  attack  there  had  seemed  to  be 
an  acute  ataxia  due  to  involvement  of  the  minor  blood- 
vessels. 

Dr.  Schl.4pp  reported  the  case  of  a  man  aged  fifty 
years,  an  intemperate  longshoreman.  'I'hree  years 
ago  he  had  developed  ataxia  and  now  had  a  disturb- 
ance of  tactile  and  pain  sense  in  the  feet.  Klectrical 
reaction  was  diminished.  The  case  looked  to  him 
like  a  neuro-tabes  peripherica.  The  Romberg  symp- 
tom was  present.  The  knee  jerks  were  slightly  exag- 
gerated. The  case  might  perhaps  be  classed  as  an 
acute  ataxia  of  the  peripheral  type 

Dr.  Fraexkel  said  that  from  the  pathological 
standpoint  the  condition  probably  occurred  quite  fre- 
quently, and  was  often  overlooked.  He  would  like 
some  points  on  the  differential  diagnosis  between  or- 
ganic and  functional  conditions.  The  symptoms 
given  by  Dr.  Dana  were  not  sufficiently  objective. 

Dr.  J.  F.  Terriberry  commented  upon  the  fact 
how  these  old  people  reported  by  Dr.  Dana  could  have 
recovered  so  readily  if  the  vascular  system  had  been 
so  damaged.  For  this  reason  he  doubted  if  the  vascu- 
lar system  had  been  especially  at  fault.  Ataxia  was 
a  symptom  rather  than  a  disease,  and  the  attempt  to 
regard  it  as  anything  but  a  symptom  was  likely  to  lead 
one  astray.  He  was  in  favor  of  considering  the  cases 
that  ended  in  recovery  late  in  life  as  of  neuritic  origin. 

Dr.  Dax,\  said  he  had  not  met  with  the  class  of 
cases  described  by  Dr.  Collins.  Dr.  Brown's  cases 
did  not  seem  to  be  exactly  cases  of  pure  ataxia,  and 
hence  he  had  not  referred  to  them.  One  must  distin- 
guish between  an  ordinary  unilateral  ataxia  such  as 
occurred  from  acute  softening  of  the  pons  or  medulla 
and  the  acute  bulbar  ataxia  of  Leydtn,  which  is  bilat- 
eral. It  was  a  common  experience  to  see  old  people 
with  hemiplegia  and  hemorrhage  recover  in  spite  of 
the  degenerated  condition  of  the  blood-vessels. 


ijtXctlicat  Jtcms. 

Death    Rebuking    the    Doctor.  —  Dr.   X.   B.  Haynie 

writes  that  a  Callaiin.  Tenn.,  physician  attended  a 
funeral  the  other  day,  and  after  the  burial  services 
were  over  he  with  a  number  of  people  strolled  among 
the  graves  of  the  colored  population  in  a  portion  of 
the  cemetery  laid  off  for  them.  He  noticed  that  the 
children's  graves  were  decorated  with  almost  any- 
thing and  everything — a  little  chair,  a  broken  top, 
and  numberless  toys  that  the  departed  pickaninny  had 
possessed  while  living.  Over  one  little  grave  the  peo- 
ple lingered,  and  a  variety  of  vials  and  boxes  freshly 
labelled,  "Take  one  teaspoonful  every  two  hours  till 
relieved.  Take  one  powder  every  three  hours  till 
quiet,"  attracted  their  attention.  What  was  the  doc- 
tor's consternation  to  see  his  own  name  on  every  label! 

Leprosy  in  Germany. —Some  particulars  are  given 
in  a  recent  number  of  the  German  Imperial  Health 
Office  Reports  as  to  the  prevalence  of  leprosy  in  the 
empire.     On  December  15,  1899,  there  were  in  Prus- 


December  i,  1900] 


MEDICAL    RECORD. 


879 


sia  22  undoubted  cases  of  leprosy  known  to  the  author- 
ities. Of  these  16  belonged  to  the  Memel  district  and 
I  to  the  Rossel  district;  1  was  infected  in  Livonia,  2 
ill  Brazil,  i  in  Burmah,  and  i  in  the  island  of  Penang. 
Of  the  22  cases  10  were  under  treatment  in  their  own 
homes  and  11  in  the  leper  house  at  Memel.  In  addi- 
tion to  the  16  recognized  cases  there  were  4  doubtful 
cases  in  the  Memel  district.  In  Hamburg  there  were 
at  the  end  of  last  year  10  cases  known  to  the  author- 
ities. In  5  of  these  the  patients,  who  were  of  German 
origin,  were  under  treatment  in  private  houses.  The 
rest,  who  were  foreigners,  were  in  hospitals.  In  all 
of  them  the  infection  had  been  contracted  abroad. 
In  the  middle  of  January,  1900,  there  was  a  case  in 
the  state  of  Mecklenburg-Schwerin.  From  the  other 
federated  states  of  the  .German  empire  no  report  has 
been  received.  The  Memel  district  is  the  only  native 
focus  of  leprosy  in  the  German  empire.  Whenever 
leprosy  has  occurred  elsewhere  the  infection  has  been 
contracted  abroad.  There  appears  to  be  some  ground 
for  suspicion  that  as  regards  Memel  the  total  number 
of  cases  is  not  set  forth  in  the  official  statistics. — 
Brilish  Mciiical  Jounial. 

Typhoid  from  Shell-Fish. — The  medical  officer  of 
health  for  Newington — one  of  the  poorest  and  most 
crowded  districts  of  London — has  had  several  cases 
of  typhoid  or  enteric  fever  reported  to  him,  and  hav- 
ing carefully  inquired  into  them,  believes  the  out- 
break to  be  due  to  the  eating  of  mussels  and  other 
shell-fish.  He  has  accordingly  issued  notices  cau- 
tioning the  public  against  eating  shell-fish,  especially 
mussels,  during  the  month  of  October. 

Mosquitos  and  Malaria. — Laveran's  discovery  of 
the  Plasmodium  of  malaria  was  long  ignored;  then  the 
credit  was  given  to  some  one  else.  In  the  same  way 
the  mosquito  theory  has  been  claimed  for  Americans, 
Italians,  and  others;  and,  of  course,  for  the  noble  sav- 
age, whose  untutored  mind  seems  not  infrequently  to 
see  things  hidden  from  the  bespectacled  eyes  of 
science.  In  Koch's  extraordinary  reports  from  Ger- 
man New  Guinea  no  mention  is  made  of  any  other  in- 
vestigator; the  subject  is  treated  as  if  he  were  the 
Columbus  of  an  unknown  continent  of  knowledge. 
Koch  has  been  a  great  scientific  conqueror,  and  is 
fully  entitled  to  his  triumph.  But  the  way  in  which 
he  drags  at  his  chariot  wheels  the  discoveries  of  other 
men  is  ultra-Germanic  in  its  insolence  of  self-asser- 
tion. In  this  particular  field  of  research  our  German 
friends  have  done  nothing  at  all.  Laveran  proved 
that  malaria  is  a  parasitic  disease;  Manson  and  Ross 
have  siiown  how  the  parasite  is  conveyed  to  man. 
The  Italians  have  worked  out  certain  details  of  the 
problem  by  following  the  course  indicated  by  the 
British  workers.  But  the  credit  of  tlie  solution  be- 
longs to  our  countrymen. — I'lie  Practitioner. 

Therapeutics    and  Hygiene   of   Obesity.— At  the 

recent  International  Congress  at  Paris,  Deschamps 
read  a  paper  witli  the  above  title  (^Le  Bulletin  Medical, 
August  8,  igoo).  We  should  not  content  ourselves 
witli  a  mere  momentary  reduction  of  weight,  but 
should  aim  at  securing  physiological  equilibrium  be- 
tween the  ingesta  and  egesta.  Diet,  calorification, 
and  muscular  exercise  are  the  most  important  ele- 
ments to  consider  in  the  hygiene  of  obesity.  The 
dietetic  regimen  should  guarantee  the  patient  sufficient 
food  for  all  his  needs,  which  includes  the  maintenance 
of  all  the  gastro-intestinal  functions.  The  regimen  of 
ciioice  is  one  in  which  vegetables  predominate,  and 
from  which  farinaceous  and  feculent  articles  need 
not  be  excluded.  Water,  pure  or  slightly  alkaline,  is 
the  only  drink  to  employ,  and  enough  should  be  taken 
to  quench  the  thirst.  In  certain  cases  it  may  be 
necessary  to  recommend  an  excess  of  water.     Physio- 


logical calorification  plays  the  chief  role  in  reducing 
the  weight  of  the  corpulent.  This  is  effected  by  pro- 
longed bathing,  the  temperature  of  the  water  ranging 
from  33'  to  36°  C,  and  the  duration  one  to  two  hours. 
The  static-electric  bath  is  an  adjuvant  of  incontestable 
utility,  as  it  also  favors  organic  combustion.  Muscu- 
lar exercise  cannot  be  imposed  on  the  obese  beyond  a 
certain  point.  It  is  useful  when  regulated,  but  dan- 
gerous when  it  goes  beyond  the  endurance  of  the  in- 
dividual. The  temporary  loss  of  weight  obtained  by 
its  agency  is  more  than  offset  by  disorders  of  function 
which  are  set  up. — American  Medical  Review  of  Re- 
views. 

A  Cure  for  Insomnia. — Dean  R:i;;isey,  the  witty 
Scottish  divine  of  the  last  century,  used  to  relate  an 
amusing  tale  about  one  of  the  earls  of  Lauderdale. 
His  lordship  was  taken  very  ill,  the  worst  symptom 
being  insomnia  in  an  aggravated  form.  His  little 
son,  hearing  that  recovery  would  be  impossible  with- 
out sleep,  said:  "Send  for  the  preaching  mon  frae 
Livingston,  for  fayther  aye  sleeps  when  that  minister 
is  in  the  pulpit."  The  doctors  considered  that  to  act 
on  the  suggestion  w-ould  be  judicious;  so  the  minister 
was  immediately  brought.  He  preached  a  sermon; 
sleep  came  on^and  the  earl  recovered. 

Athletics  and  Practical  Physiology  in  Medical 
Schools.  — Dr.  Bayard  Holmes  {'Ihc  J'le.xus,  Octo- 
ber) says:  "Medical  schools  are  now  provided  with 
lecture  rooms,  laboratories,  libraries,  and  clinical  con- 
veniences, but  with  hardly  an  exception  they  are  des- 
titute of  gymnasia,  athletic  fields,  and  lavatories.  Be- 
fore our  education  reach-i"-  that  efficiency  which  the 
subject  demands,  these  equipments  must  be  added,  and 
probably  at  the  same  time  the  feeding  and  .social 
necessaries  of  the  student  will  be  improved  and  pro- 
vided for,  either  from  the  student  initiative  or  by  the 
co-operation  of  the  college  and  student." 

Physicians'  Beards. — According  to  an  exchange, 
the  Emperor  of  Germany  says  that  all  German  physi- 
cians must  cut  off  their  beards.  There  are  some 
physicians  in  the  United  States  who  would  be  glad  to 
have  beards  to  cut  off;  and  there  are  others  who  would 
be  seized  with  consternation  should  such  an  order  go 
forth  in  this  country,  since  their  whiskers  are  their 
principal  stock  in  trade,  and  the  proper  care  of  them 
seems  to  be  their  chief  concern  in  life. —  Tlie  S/rlus, 
October. 

Lord  Lister  and  Vivisection. — The  London  /'all 
Mall  Gazette,  referring  to  the  Huxley  lecture  recently 
delivered  by  Lord  Lister,  says  that  he  can  hardly  be 
considered  as  a  supporter  by  the  anti-vivisectionists. 
In  the  course  of  the  said  lecture,  the  eminent  founder 
of  the  system  of  antiseptic  surgery  gave  details  of  cer- 
tain experiments  he  had  made  on  frogs,  bats,  and  other 
animals.  We  have  no  doubt  that,  as  Lord  Lister  him- 
self put  -t,  some  people  would  consider  tliat  by  iliese 
experiments,  which  he  said  caused  no  pain  to  the 
victims,  he  had  "  deserved  a  horsewhipping.''  Other 
people  will  probably  agree  with  him  that  anythiig 
which  contributes  to  the  alleviation  of  human  suffer- 
ing is  worth  "  the  lives  of  a  few  frogs,  or  even  of  a 
rabbit."  Considering  the  inestimable  value  of  that 
antiseptic  system,  which,  as  Lord  Lister  said,  "has 
been  the  labor  of  his  life,  and  his  contribution  to  the 
profession  he  loves,"  the  price  certainly  does  not  seem 
excessive. 

Diphtheria. — Is  local  treatnient  necessary?  So  far 
as  danger  of  death  from  diphtheria  infection  is  con- 
cerned it  is  not.  But  there  is  danger  of  other  infec- 
tions being  implanted  on  the  inflamed  soil  left  by  the 
diphtheritic  process.     It    must  be  remembered,  also. 


88o 


MEDICAL    RECORD. 


[December  i,  1900 


that  antitoxin  does  not  destroy  the  diphtheria  bacilli, 
and  that  they  remain  in  the  throat,  nose,  etc.,  for  a 
variable  period  of  time.  That  this  period  can  be 
lessened  by  local  treatment  has  been  shown  by  the 
experience  of  Drs.  McDaniel  and  Adaire  at  the  State 
school  at  Ovvatonna.  They  sprayed  or  irrigated  the 
throat  and  nose  with  a  solution  containing  one-half  of 
one  percent,  of  formalin,  and  succeeded  in  freeing  the 
patients  from  bacilli  in  from  one  day  to  four  weeks. 
Some  of  these  patients  had  been  showing  the  presence 
of  bacilli  continuously  for  several  months. — Dr.  J. 
P.  Barber,  The  Medical  Dial,  October. 

Masturbation  and  Albuminuria.^ As  regards  the 
view  that  masturbation  was  the  cause  of  albuminuria, 
which  receives  support  from  Moxon,  Dickinson,  and 
Clement  Lucas,  I  have  found  that  this  form  of  sexual 
neurosis  was  present  in  a  considerable  number  of  my 
cases.  While  confirming  their  observations  as  to  the 
existence  of  this  neurosis,  I  cannot  accept  their  con- 
clusion that  it  is  the  cause  of  the  albuminuria. — Dr. 
Sutherland,  The  Clinical  Journal,  October. 

Chronic  Gastritis. — The  gastric  mucous  membrane 
has  so  much  resisting-power  that  it  practically  ignores 
insult  after  insult  offered  it  by  dietetic  errors,  alcohol, 
and  other  irritants.  A  few  years  ago  almost  every 
symptom  complex  of  the  stomach  was  at  once  set  down 
as  due  to  subacute  or  chronic  catarrhal  gastritis,  and 
even  to-day  the  profession  has  not  cut  loose  from  this 
short-sighted,  erroneous,  and  superficial  habit.  In 
point  of  fact,  chronic  inflammatory  affections  of  the 
stomach  are  not  very  severe  except  as  a  result  of  grave 
organic  disease  located  in  the  stomach  or  elsewhere. 
In  many  chronic  diseases,  as  for  instance  the  antemias, 
the  stomach  is  the  organ  that  bears  the  brunt  of  the 
complaint  of  all  the  cells  of  the  body,  and  it  is  not 
surprising  that  it  should  be  chosen  to  cry  out  and 
rebel  in  the  cause  of  the  complaining  cells  depending 
upon  it;  but  the  point  we  wish  to  make  is  that  gastri- 
tis exists  in  but  a  small  proportion  of  these  cases,  and 
if  the  stomach  and  its  contents  are  carefully  studied 
there  will  be  less  often  a  hasty  diagnosis  of  one  or 
another  form  of  gastritis. — Charlesont  Stock. 

Vaccine  Infection  of  the  Lips. — Alfred  Jungmann 
says  that  accidental  inoculations  of  vaccine  virus  are 
not  so  rare  as  is  supposed.  It  is  principally  the  nurses 
and  mothers  of  vaccinated  infants  who  are  susceptible 
to  this  form  of  infection,  owing  to  the  many  opportuni- 
ties for  direct  contagion  that  their  close  association 
with  their  charges  involves.  Physicians  are  also  lia- 
ble to  the  accident,  and  a  case  is  on  record  in  which  a 
splinter  of  glass  flew  from  a  vial  of  vaccine  lymph 
w'hile  being  uncorked,  and  struck  tiie  nose  of  the  doc- 
tor holding  it.  He  brushed  it  off  unthinkingly,  but 
the  skin  was  slightly  scratched  and  the  customary  le- 
sion with  its  resultant  scar  developed.  The  case 
reported  by  the  author  is  that  of  a  wetnurse  who  in- 
fected a  herpetic  lesion  on  her  lip  from  the  vesicle  on 
the  arm  of  her  newly  vaccinated  nursling.  The  lesion 
ran  its  usual  course,  thougii  owing  to  the  anatomical 
configuration  of  the  jsarts  a  very  extensive  and  tempo- 
rarily disfiguring  oedema  developed.  In  addition  to 
the  unusual  nature  of  the  accident  the  case  is  interest- 
ing owing  to  the  fact  that  the  patient  had  already  had 
variola,  as  was  attested  by  the  scars  on  her  face,  but 
the  immunity  acquired  had  apparently  died  out  in  the' 
thirty  years  that  had  elapsed  since  the  illness. —  Wiener 
klinische  Rundschau,  September  23,  1900. 

Women   as   Insurance    Risks M.    M.    Danforth 

says  that  the  investigation  of  statistics  made  by  R. 
Kingston  Fox  showed  that  as  a  rule  the  female  risks, 
if  as  carefully  selected,  would  be  even  preferaljle  to 
male  applicants.     As  to  the  dangers  incident  to  the 


child-bearing  period,  they  are  far  less  important  as 
affecting  the  insurance  risk  than  are  those  conditions 
of  mental  strain  and  worry  incident  to  business,  or  the 
exactions  of  alcoholic  excesses  and  dissipations  so 
much  more  common  in  the  male  applicant.  It  has 
been  stated  that  women  are  more  apt  than  men  to  con- 
ceal important  facts,  but  this  the  author  denies,  saying 
that  not  a  few  of  the  latest  writers  on  the  subject  as- 
sert that  women  are  more  likely  than  men  to  give  a 
truthful  answer  to  vital  questions.  The  so-called 
"  moral  hazard  "  of  female  insurance  is  a  much  over- 
rated, if  indeed  not  a  purely  imaginary,  objection,  un- 
warranted by  the  experience  of  insurance  companies 
in  general. —  The  Aledical  Examiner  and  Practitioner, 
October,  1900. 

The  Significance  of  Pain  in  Appendicitis. — E.  H. 

Lee  holds  that  in  appendicitis,  as  well  as  in  other  ab- 
dominal lesions,  the  pain  in  the  early  stage  of  the  dis- 
ease is  of  a  colicky  nature,  and  due  to  an  acute  disten- 
tion of  the  organ  affected;  the  greater  the  distention, 
the  greater  the  pain.  Second,  as  soon  as  the  acute 
constriction  or  distention  has  subsided  or  the  obstruc- 
tion has  been  relieved,  these  reflex  colicky  pains  and 
nausea  and  vomiting  cease,  and  the  pains  that  are 
present  after  this  time  are  of  a  steady  character. 
They  should  be  described  more  as  a  tenderness  in  the 
right  iliac  fossa,  and  are  due  to  the  circumscribed  peri- 
tonitis. Third,  tiiis  last-mentioned  pain  gradually 
subsides  as  the  disease  progresses  toward  its  favorable 
termination,  either  by  a  perforation  of  the  abscess  into 
the  bowel,  or  possibly  by  the  absorption  of  the  circum- 
scribed inflammatory  process. —  The  Chicago  Clinic,  Oc- 
tober, 1900. 

Health  Reports. — The  following  cases  of  smallpox, 
yellow  fever,  cholera,  and  plague  have  been  reported 
to  the  surgeon-general  of  the  United  States  Marine- 
Hospital  service  during  the  week  ended  November 
23,  1900: 

Cases.    Deaths. 
Smallpox— United  States. 

Maryland,  Prince  George  Co. November  gth  to  14th 9 

Michigan,   Detroit   November  loth  to  17th i 

Grand  Rapids. .  .November  loth  to  17th    1 

Minnesota,  Minneapolis November  loth  to  17th 3 

New       Hampshire,        Man- 
chester  November  loth  to  17th 10 

New  York,  New  York November  loth  to  i7ih i 

Ohio,  Cleveland November  10th  to  17th    ig  1 

Tennessee,  Memphis November  loth  to  17th 1 

Texas.  Houston October  31st  to  November  7th  ...  6 

I' tab.  Salt  Lake  City November  joth  to  17th 20 

Virginia,  Alexandria. November  i8th i 

Smallpox — Foreign. 

A  ustria.  Prattle October  20th  to  27th 8 

Brazil,  Pernambuco September  33d  to  30th 15 

England,  London October  27th  to  ^k)vembc^  3d . . .        i 

France,  Pans    ,    .  .October  27ih  to  November  3d 14 

India,  Calcutta October  i^ih  to  20th 6 

Japan,  Nav^asakl   (Ictober  11th  to  20th. .  ..* i 

Mexico,  Vera  Ouz November  3d  to  lotK i 

Russia,  St.  Petersburg October  2t  th  lo  27th 3  3 

Scotland,  Glasgow November  2d  to  gth 31 

Yellow  Fever— United  States. 

Mississippi,  Brookhaven  ...  .November  16th * 

Natchez November  a2d .    . .       3 

*  Many  cases. 

Yellow  Fevew— Foreign. 

Colombia,  Rocas  del  Toro  .  .October  31st  to  November  7th. ...     3 

Cartagena Ociuber  28th  tn  November  4ih. . .     i  i 

Cuba,  Havana November  3d  to  loth 15 

Matan/as November  15th 1* 

Mexico,  Vera  Cruz November  3d  to  loth 6 

*  In  Hamilton  I'arracks. 

Cholera. 

India,  P.ombay October  i6ih  to  23d ..  10 

Calcutta October  13th  to  20th 17 

Madras October  13th  to  igth 37 

Russia.  Siberia,  NovoHevsk. November Reported. 

Straits    Settlements,    Singa- 
pore   September  isth  to  22d i 

Plagi'e. 


China,  Hong  Kong  October  Clh  to  13th 

India,  Hombay October  i6th  to  23d 

Calcutta ( )ctober  i  ;:th  to  20th 

Madras October  i;,lh  to  igth 

Japan,  Kobe October  8th  to  23d 2 

Osaka October  8lh  to  33d 3 


74 
15 


Medical  Record 

A    IVeekly  yoiimal  of  Medicine  and  Surgery 


Vol.  58,  No.  23. 
Whole  No.  1570. 


New  York,  Dpxember  8,   1900. 


$5.00  Per  Annum. 
Single  Copies,  loc. 


©rxcjinaX  |irticlcs. 

TUBERCULOSIS  OF  THE  EYE:  ITS  DIF- 
FERENTIAL OI.VGNOSIS,  PATHOLOGY, 
AND   TREATMENT.' 

Uv   CII.XRLES   STEDMAN    BULL,    A.M.,    M.D., 

NEW    VOKK. 

It  may  safely  be  said  that  all  our  actual  knowledge 
of  ocular  tuberculosis  dates  from  1868,  when  Grade- 
nigo  published  the  first  case,  with  confirmation  of  his 
diagnosis  by  microscopical  examination.  Tubercu- 
lous disease  of  any  of  the  tissues  of  the  eye  is  a  rare 
disorder.  The  exact  proportion  of  such  cases  to  all 
lesions  of  the  organ  has  never  been  accurately  deter- 
mined, but  the  proportion  of  cases  of  conjunctival 
tuberculosis,  given  by  Eyre  as  i  in  2,700,  is  probably 
much  too  large. 

Tuberculosis  of  the  eye  is  met  with  between  the 
ages  of  five  and  thirty,  though  a  few  cases  have  been 
observed  at  a  later  period.  It  may  invade  any  part  of 
the  organ,  though  tlie  tendency  of  the  disease  is  to 
attack  in  its  progress  the  deeper  structures  primarily. 
Hence  tuberculosis  of  the  iris  and  chorioid  is  more 
frequently  met  with  than  the  same  disease  in  the  con- 
junctiva and  cornea.  According  to  Baumgarten 
(1878),  the  only  pathognomonic  feature  of  tubercle, 
aside  from  the  presence  of  the  bacilli,  is  the  tendency 
to  caseation. 

Tuberculosis  of  the  Conjunctiva  and  Lids. — The 
eye  may  serve  as  tlie  point  of  entrance  of  the  primary 
infection,  and  generally  from  the  conjunctiva,  but  this 
is  rare.  The  intact,  healthy  conjunctiva  is  never  in- 
fected by  bacilli;  there  must  always  first  be  a  loss  of 
substance.  In  many  cases,  relatively,  the  conjunctival 
tuberculosis  long  remains  the  sole  localization,  and 
the  early  destruction  of  the  neoplasm  may  lead  to  re- 
covery. When  an  abrasion  of  the  conjunctiva  exists, 
it  may  become  inoculated  with  bacilli  from  the  lids, 
the  nose,  or  the  lungs,  and  an  ulcer  develops  at  the 
point  of  inoculation.  The  lesion  usually  begins  in 
the  tarsal  conjunctiva  of  the  upper  lid,  or  in  the  re- 
trotarsal  fold.  The  lid  is  more  or  less  swollen,  and 
on  eversion  shows  a  punched-out  ulcer  with  gray  base, 
or  a  base  covered  with  small,  gray,  miliary  tubercles. 
These  ulcers  have  ragged  edges,  and  the  bottom  has 
a  worm-eaten  appearance  and  is  covered  by  detritus. 
The  small  nodules  may  be  in  the  edge  of  the  ulcer  in- 
stead of  on  the  door,  and  vary  much  in  size.  These 
ulcers  sometimes  bleed  on  handling.  The  pre-auricu- 
lar  gland  is  almost  always  involved,  and  sometimes 
the  submaxillary  also.  The  ulcers  may  be  unilateral 
or  bilateral,  and  may  spread  to  the  ocular  conjunctiva 
and  sclera,  and  thus  serve  as  a  focus  for  dissemination 
of  a  general  infection,  though  absolute  proof  of  this 
is  still  wanting.  The  eyelids  are  sometimes  much 
swollen,  but  are  soft  to  the  touch,  and  the  conjunctiva 
shows  distinct  folds  around  the  ulcerated  tuberculous 
mass.  There  is  usually  a  slight  purulent  discharge 
in  which  the  bacilli  are  sometimes  found,  but  even  in 

'  Read  before  the  New  York  State  Medical  Association,  Octo- 
ber 17,  1900. 


the  tuberculous  nodules  they  are  often  searched  for  in 
vain.  According  to  the  latest  accounts  about  sixty 
cases  have  been  reported,  of  which  eight  were  pub- 
lished in  1900.  All  were  between  the  ages  of  ten 
and  thirty  years,  and  there  were  more  females  than 
males  affected.  In  a  number  of  the  cases  the  lesion 
was  bilateral.  It  is  exceptional  to  detect  tubercle 
bacilli  in  microscopical  sections  of  the  ulcerated  tissues 
(though  they  may  be  found  in  the  scrapings  from  the 
floor  of  the  ulcers),  and  well-defined  giant  cells  are 
not  always  met  with.  The  ulcers  also  vary  clinically 
in  appearance.  .Some  of  them  are  sharply  cut,  with 
irregular  margins  and  yellow  base,  and  surrounded  by 
a  zone  of  infiltration.  Others  present  a  more  diffuse 
form,  with  small  elevations  of  the  mucous  membrane 
which  are  frequently  ulcerated.  Whether  the  conjunc- 
tival disease  be  primary  or  secondary,  it  is  quite  con- 
ceivable that  the  tubercle  bacillus  may  be  conveyed 
into  the  nose  from  disintegrating  pieces  of  conjunc- 
tiva, and  cause  infection  of  the  mucous  membrane  of 
the  nasal  duct  and  nose.  The  neighboring  lymph 
glands  have  not  always  been  found  swollen,  though  it 
.  is  very  possible  that  the  swelling  may  have  existed 
and  been  overlooked,  and  then  have  subsided  as  the 
local  disease  has  receded. 

The  differential  diagnosis  is  not  always  easy.  Yel- 
lowish nodules  sometimes  develop  in  the  vicinity, 
giving  a  granular  appearance  to  the  conjunctiva,  re- 
sembling a  case  of  trachoma.  Tuberculosis  of  the 
conjunctiva  must  be  differentiated  from  trachoma,  epi- 
thelioma, and  syphilitic  ulceration.  In  trachoma  the 
glands  are  not  involved,  and  in  acute  cases  the  granu- 
lations will  yield  to  treatment  by  caustics  and  astrin- 
gents, while  these  are  useless  in  tuberculosis.  If  we 
accept  the  dictum  of  Rhein  that  the  follicles  of  tra- 
choma and  those  of  tubercle  are  analogous,  the  latter 
must  then  be  differentiated  by  the  presence  of  bacilli. 
Tubercle  may  be  distinguisiied  from  epithelioma  by 
the  age  of  the  patient.  In  true  granuloma  the  granu- 
lation is  a  firm,  reddish,  vascular  mass  of  uniform 
character,  and  the  lymph  glands  are  not  involved.  In 
brief,  the  character  of  the  ulceration,  the  lardaceous 
aspect  of  the  mucous  membrane,  the  presence  of  per- 
ipheral tuberculous  nodules,  and  the  engorgement  of 
the  glands  will  usually  suffice  to  differentiate  the  case; 
and  if  bacilli  are  found  in  the  scrapings  of  the  ulcer 
the  diagnosis  is  confirmed. 

Some  very  interesting  experiments  in  inoculation 
were  made  by  Langhans  in  1873.  He  made  sixteen 
inoculations  of  tubercle  in  the  conjunctiva  of  the  rab- 
bit with  varying  results.  Some  were  entirely  negative. 
In  others  there  appeared  at  the  point  of  inoculation  a 
translucent  swelling  formed  of  grayish-red  nodules, 
ending  in  an  ulcer  with  flat  edges  and  pultaceous  base. 
In  a  third  series  of  cases,  after  a  period  of  incubation 
ranging  from  twenty-one  to  thirty-four  days,  there  ap- 
peared yellowish  granulations  which  became  red  but 
did  not  ulcerate,  and  some  of  these  animals  became 
tuberculous. 

Prognosis:  If  the  case  is  one  of  primary  infection 
and  is  seen  early  in  its  course  the  prognosis  is  fairly 
favorable,  provided  the  local  lesion  can  be  thoroughly 
cauterized  or  excised.  If  the  ulceration  is  secondary 
the  prognosis  is  always  unfavorable. 


882 


MEDICAL    RECORD. 


[December  8,  1900 


Treatment:  If  the  ulceration  is  single  and  removed 
from  the  lid  margin,  the  whole  ulcerated  surface 
should  be  cauterized  with  the  actual  or  galvano-cau- 
tery,  and  then  the  case  carefully  watched  and  the  cau- 
terization repeated  if  necessary.  If  the  ulcer  is  close 
to  the  edge  of  the  lid,  the  parts,  including  the  entire 
thickness  of  the  lid,  should  be  thoroughly  excised,  and 
a  plastic  operation  subsequently  made  to  correct  the 
resulting  deformity. 

Tuberculosis  of  the  Eyelid  appears  in  the  form  of 
lupus,  usually  along  the  ciliary  margin  of  the  lid,  and 
soon  involves  the  conjunctiva.  The  doctrine  that 
lupus  and  tuberculosis  are  one  and  the  same  disease 
is  now  generally  accepted,  giant  cells  and  bacilli  being 
found  in  both.  It  may  be  primary  or  secondary.  If 
primary  it  is  due  to  direct  infection  from  a  foreign 
body  or  to  operation.  The  disease  is  found  mostly  in 
children,  but  may  occur  at  any  age.  On  its  first  ap- 
pearance it  simulates  an  inflamed  chalazion. 

Prognosis:  If  the  lesion  is  primary  the  prognosis  is 
good.     If  secondary  it  is  unfavorable. 

Treatment:  Thorough  excision  of  the  infected  part 
is  the  only  thing  that  promises  any  real  cure. 

Tuberculosis  of  the  Sclera  is  occasionally  met  with 
in  the  form  of  nodules,  coincident  with  nodules  in  tlie 
iris  and  ciliary  body.  As  an  independent  lesion  it  is 
very  rare,  one  case  having  been  reported  by  Miiller  in 
1890.  The  sclera  may  also  become  involved  in  the 
ulceration  of  tuberculous  nodules  of  the  ocular  con- 
junctiva. The  prognosis  is  unfavorable.  The  only 
treatment  which  would  seem  to  promise  a  cure  is 
enucleation  of  the  eyeball.  Instances  of  treatment  by 
antitoxin  have  been  too  few,  and  the  results  not  suffi- 
ciently favorable,  to  enable  us  to  draw  any  satisfactory 
conclusion. 

Tuberculosis  of  the  Cornea. — The  cornea  is  much 
less  liable  to  tuberculous  disease  than  any  other  tissue 
of  the  eye  except  the  lens.  Tuberculous  nodules  may 
develop  primarily  in  the  marginal  zone  of  the  cornea, 
and  extend  toward  its  centre.  These  small  growths 
have  been  observed  as  theresult  of  inoculation,  and 
in  the  course  of  spontaneous  tubercle  of  the  iris. 
Panas  has  reported  a  single  case  occurring  in  a  woman 
aged  thirty  years,  of  delicate  health,  with  disease  in 
the  apices  of  both  lungs.  After  sharp  pain  in  the 
right  eye,  there  appeared  a  diffuse  interstitial  opacity 
in  the  superior  segment  of  the  cornea,  with  episcleral 
injection.  On  the  thirteenth  day  the  disease  had 
reached  the  centre  of  the  cornea,  and  around  the 
opacity  were  a  series  of  yellowish  nodules  resembling 
miliary  tubercles.  These  gradually  coalesced,  and  in 
the  fourth  week  the  whole  infiltration  was  ulcerated, 
with  a  yellow  base  and  irregular  edges.  Each  advance 
of  the  ulcer  was  preceded  by  new  marginal  tubercles. 
At  the  end  it  cicatrized  densely  opaque.  Panas  made 
some  experiments  in  corneal  inoculation  in  animals, 
and  the  course  followed  resembled  very  closely  that 
noted  in  his  patient.  A  tuberculous  tendency  may  be 
suspected  in  cases  of  non- inflammatory  abscess  of  the 
cornea,  in  scrofulous  children,  which  shows  no  ten- 
dency to  healing,  even  when  there  are  no  positive  signs 
of  tuberculosis  present. 

Tuberculosis    of    the    Uveal  Tract Tuberculous 

disease  here  may  be  either  primary  or  secondary,  the 
latter  being  much  the  more  frequent  of  the  two;  and 
the  patients  are  more  usually  found  among  those  suffer- 
ing from  the  chronic  pulmonary,  osseous,  or  cutaneous 
forms  of  the  disease  than  among  those  affected  with 
rapid  general  tuberculosis.  In  the  uveal  tract  the 
nodules  may  be  either  miliary  and  disseminated, 
or  in  circumscribed  small  masses,  or  in  solitary 
nodules.  Small  gray  nodules  appear  and  disappear, 
and  either  terminate  in  healing,  or  gradually  extend 
to  suppuration,  perforation,  and  destruction  of  the 
eyeball. 


Tuberculosis  of  the  Iris  and  Ciliary  Body. — 
Tuberculous  disease  of  the  iris  occurs  most  frequently 
between  the  ages  of  five  and  twenty-five  years.  It  may 
be  either  primary  or  secondary,  the  latter  being  the 
more  frequent.  Primary  tuberculosis  of  the  iris  may 
be  unilateral  or  bilateral.  Haab  recognizes  two 
forms:  one  of  rare  occurrence  and  ending  generally 
in  a  spontaneous  cure;  a  second,  much  more  common, 
ending  in  perforation  and  phthisis  bulbi.  The  symp- 
toms of  either  serous  or  plastic  iritis  are  generally 
present.  The  diffuse  form  spreads  rapidly,  and  gener- 
ally invades  the  entire  eye,  and  the  cornea  necroses 
and  becomes  perforated.  This  form  usually  occurs 
in  patients  predisposed  by  hereditary  tendencies  to 
the  disease.  The  first  or  attenuated  variety  of  the 
disease  may  recede  and  disappear  without  causing 
general  infection.  These  cases  of  attenuated  tuber- 
culosis, in  which  the  growths  become  absorbed  and 
the  eye  partially  regains  its  functions,  are  rare.  The 
nodules  are  very  small  and  scattered,  are  yellowish- 
gray  in  color,  with  a  slight  reddish  tint  due  to  the 
blood-vessels,  and  may  involve  the  peripheral  border 
or  occupy  the  angle  of  the  anterior  chamber.  Their 
course  is  very  slow,  with  periods  of  amelioration  and 
aggravation,  and  the  case  ends  in  a  total  disappear- 
ance of  the  nodules.  Tuberculosis  of  the  iris  occurs 
usuallv  in  children  as  small  grayish-red  nodules  at 
the  ciliary  margin  of  the  iris,  which  look  like  miliary 
growths.  The  successive  development  of  new  nodules 
leads  to  plastic  iritis  and  cyclitis,  and  then  to  a  gen- 
eral shrinking. 

The  solitary  tubercle  of  the  iris,  or  so-called  granu- 
loma, begins  as  a  small  gray  nodule,  which  slowly 
increases  in  size,  fills  the  anterior  chamber,  perforates 
the  cornea,  and  presents  as  a  large  granulation  mass, 
and  the  eye  is  lost  by  general  phtiiisis  bulbi.  The 
granulation  mass  always  contains  giant  cells,  and 
almost  always  bacilli.  At  first  tubercles  of  the  iris 
are  composed  of  masses  of  small  epithelioid  cells,  dis- 
posed concentrically  round  an  obliterated  vessel,  and 
of  a  varying  number  of  giant  cells.  After  softening 
has  begun,  histology  does  not  help  much  toward  a 
diagnosis.  If  a  case  of  tuberculosis  of  the  iris  is  ac- 
companied by  blood  in  the  anterior  chamber,  the  dis- 
ease has  probably  invaded  the  ciliary  body,  as  hemor- 
rhage from  this  quarter  has  been  known  to  be  the  first 
symptom  of  tuberculous  infection  here. 

Tuberculosis  of  the  iris  has  been  produced  by  inoc- 
ulation of  the  anterior  chamber  in  animals.  Within 
three  weeks  of  the  inoculation  the  iris  becomes  in- 
flamed, with  the  eruption  of  small  grayish  nodules 
which  grow  larger,  coalesce,  fill  the  anterior  chamber, 
infiltrate  the  cornea,  and  cause  perforation.  The  ani- 
mals succumb  later  to  a  general  tuberculosis.  The 
intra-ocular  tension  is  first  increased,  but  later,  as 
cyclitis  develops,  the  tension  falls  below  the  normal 
standard. 

Tuberculous  growths  in  the  iris  may  be  confounded 
with  gumma,  sarcoma,  and  lepra.  They  may  be  dis- 
tinguished from  gummata  by  their  color,  their  predi- 
lection for  involving  the  inferior  half  of  the  iris,  and 
by  the  presence  of  glandular  enlargements  and  the 
usual  signs  of  pulmonary  tuberculosis.  A  tuberculous 
nodule  may  in  its  early  stages  be  confounded  with 
sarcoma,  but  the  latter  is  almost  certain  to  be  soli- 
tary, is  rarely  accompanied  by  any  iritis,  seldom  occurs 
before  middle  life,  and  is  usually  more  vascular  than 
a  tuberculous  nodule.  In  general,  it  may  be  stated 
that  the  lesion  is  probably  tuberculous  when  the 
growths  are  multiple,  non-vascular,  and  gray,  and  are 
accompanied  by  glandular  enlargements.  Iritis  in  a 
child  is  generally  tuberculous  and  always  serious. 

The  prognosis  in  cases  of  tuberculosis  of  tlie  iris  is 
always  unfavorable,  for  none  of  the  symptoms  enable 
us  to  predicate  the  attenuated  form  of  the  disease. 


December  8,  1900] 


MEDICAL    RECORD. 


883 


Until  we  have  had  a  larger  experience,  and  have 
become  more  familiar  with  the  nature  and  etTects  of 
tuberculin  T.R.  as  an  antitoxic  agent,  our  only  ad- 
vice is  to  recommend  enucleation.  It  is  possible  that 
iridectomy  may  be  useful  in  the  case  of  solitary  tuber- 
cle before  softening  h;is  begun,  and  will  leave  the 
patient  with  a  varying  amount  of  useful  vision,  but  in 
all  cases  of  multiple  growths  the  eye  should  be  re- 
moved. 

Schieck  has  recently  reported  some  interesting  ex- 
periments with  tuberculin.'  He  considers  that  tuber- 
culin T.R.  has  shown  much  weaker  symptoms  of 
reaction  than  the  first  tuberculin,  and  thus  the  danger 
of  general  dissemination  is  lessened.  Tuberculosis 
of  the  iris  and  cornea  furnish  the  best  conditions  for 
the  employment  of  the  remedy,  viz.,  local,  unmixed 
forms  of  disease,  and  the  absence  of  increased  tem- 
perature. He  reports  live  cases  of  his  own  so  treated, 
varying  in  age  from  thirteen  to  twenty-eight  years. 
All  had  the  characteristic  nodules  at  the  periphery  of 
the  iris,  and  in  three  the  lesion  was  bilateral.  All 
were  treated  with  tuberculin  T.R.,  beginning  with  a 
dose  of  0.002  mgm.  and  increasing  each  dose  gradually 
from  0.002  to  0.5  mgm.,  and  going  as  high  in  one  case 
as  6  mgm.  at  a  dose.  In  three  of  the  cases  the  nodules 
rapidly  disappeared,  and  all  signs  of  inllammation 
subsided.  In  two  cases  all  the  symptoms  of  irritation 
were  increased,  while  the  nodules  continued  un- 
changed, but  when  the  injections  were  discontinued 
they  both  healed  promptly. 

Schieck  then  gives  the  statistics  of  the  results  of 
treatment  in  116  cases  of  tuberculosis  of  the  iris.  In 
the  13  cases  treated  by  tuberculin  injections  all  were 
improved  and  no  eye  was  entirely  lost.  In  the  103 
cases  which  were  not  treated  by  tuberculin  39  were 
healed  and  64  were  lost.  From  this  it  would  seem 
that  the  fear  of  the  spread  of  the  bacilli  from  a  tubercu- 
lous nodule  of  the  iris  by  the  employment  of  Koch's 
tuberculin  is  not  justified.  It  should  be  remembered 
that  Koch's  agent  is  not  a  bactericide,  but  merely 
supports  the  tissues  and  excites  them  to  resistance  in 
their  conflict  with  the  virus,  while  the  bacilli  are  at 
the  most  but  weakened.  Hence  the  occurrence  of  a 
relapse  should  not  be  laid  to  the  charge  of  the  tuber- 
culin. In  nineteen  reported  cases  in  which  an  attempt 
was  made  to  remove  the  local  disease  by  iridectomy 
only  eight  were  successful,  four  were  total  failures, 
and  in  the  remaining  seven  cases  the  disease  spread 
still  more  rapidly,  due,  doubtless,  to  fragments  of 
tuberculous  tissue  left  within  the  eye. 

The  second  part  of  Schieck's  work  consisted  in  an 
endeavor  to  determine  the  effect  of  tuberculin  T.R. 
upon  cases  of  artificially  produced  tuberculosis  of  the 
iris  and  cornea,  in  order  to  see  whether  these  disease 
processes  induced  in  animals  followed  the  same  course 
as  did  the  nodules  in  patients  treated  by  tuberculin. 
The  inoculation  materials  employed  were  fresh,  pure 
cultures  of  human  tuberculosis  on  glycerin-agar.  He 
made  a  number  of  elaborate  experiments  on  rabbits, 
divided  into  six  different  series.  The  results  varied 
greatly  in  the  different  series,  and  even  when  appar- 
ently positive  results  were  obtained,  they  were  not 
entirely  free  from  doubt.  The  most  important  fact 
established  seemed  to  be  the  possiliility  of  a  sponta- 
neous disappearance  of  tuberculous  nodules  of  the  iris 
in  rabbits,  a  fact  previously  mentioned  by  Sattler. 

Schieck  formulates  the  results  of  his  experiments 
as  follows:  (i)  An  immunizing  effect  of  tuberculin 
T.R.  does  not  exist.  (2)  Tuberculin  T.R.  cannot  cure 
every  case  of  experimental  tuberculosis  of  the  cornea 
or  iris  in  the  rabbit.  (3)  The  cases  treated  by  T.R. 
are  no  more  malignant  in  their  course  than  those  in 
which  T.R.  is  not  used.  (4)  The  study  of  the  action 
of  tuberculin  in  the  rabbit  cannot  be  an  exact  one,  for 
'  Archiv  fur  Ophthalmologic,  i. ,  2. 


undoubted  cases  of  cure  occur  without  the  use  of 
tuberculin. 

If  we  compare  our  knowledge  of  the  great  value  of 
tuberculin  in  cases  of  tuberculosis  of  the  human  iris 
with  the  very  uncertain  results  of  the  experiments  on 
animals,  we  find  ourselves  face  to  face  with  an  inex- 
plicable contradiction.  Schick  endeavors  to  explain 
it  as  follows;  In  the  disease  process  known  as  tuber- 
culosis of  the  iris  in  man  we  have  to  deal  with  an 
insidious  infiammation  of  endogenous  origin,  with  the 
formation  of  nodules  within  the  iris  tissue  itself,  with 
few  bacilli.  On  the  other  hand,  the  experimental  tu- 
berculosis of  the  iris  starts  from  masses  of  bacilli 
which  lie  either  free  on  the  surface  of  the  iris  or  in 
artificial  wounds  in  the  iris.  The  action  of  the  tuber- 
culin does  not  consist  in  killing  the  bacilli,  but  in 
e.xciting  the  surrounding  tissue  to  resist  the  tubercu- 
lous masses  and  the  formation  of  scar  tissue.  In  the 
experimentally  produced  tuberculosis  the  bacilli  are 
numerous  and  in  the  beginning  lie  outside  the  tissue, 
surrounded  by  a  structure  rich  in  cells  but  poor  in 
connective  tissue,  and  here  the  tuberculin  has  but 
slight  effect.  In  tuberculosis  of  the  human  iris,  how- 
ever, the  bacilli  are  few  in  number  and  the  iris  is 
abundantly  rich  in  connective  tissue,  and  here  the 
tuberculin  finds  the  most  favorable  conditions  for  its 
curative  action. 

Tuberculosis  of  the  Chorioid. — Tubercles  in  the 
chorioid  were  first  recognized  by  von  Jaeger  in  1855, 
shortly  after  the  invention  of  the  ophthalmoscope, 
'i'hey  were  supposed  to  be  always  secondary  growths 
till  1873.  They  are  met  with  under  two  forms:  the 
miliary  or  disseminate  tubercle,  and  the  solitary  or 
circumscribed.  The  former  are  usually  found  in  the 
posterior  part  of  the  fundus,  and  the  latter  in  the  an- 
terior part.  They  are  most  frequent  before  the  age  of 
twenty,  and  much  more  common  in  children  than  in 
young  adults.  The  miliary  form  is  met  with  in  gen- 
eral acute  tuberculosis  and  in  tuberculous  meningitis, 
while  the  circumscribed  large  masses  of  infiltration 
occur  in  chronic  tuberculosis. 

Miliary  tubercles  nearly  always  occur  in  both  eyes. 
They  vary  in  size  from  0.5  mm.  to  2.5  mm.  in  diame- 
ter, and  are  usually  found  in  the  vicinity  of  the  optic 
nerve  and  macula  lutea.  They  appear  as  round  spots, 
pale  yellow  in  color,  with  a  pinkish  zone  shading 
gradually  at  the  margin,  and  later  become  gray  in  color 
and  somewhat  prominent.  They  resemble  recent 
patches  of  chorioiditis  disseminata.  They  start  in 
the  deep  layers  of  the  chorioid,  growing  from  the  ad- 
ventitia  of  the  larger  vessels,  and,  as  a  rule,  cause  no 
defect  of  vision.  The  older,  large  tubercles  show 
under  the  microscope  giant  cells  surrounded  by  a  cir- 
cle of  nuclei,  and  these  in  turn  are  surrounded  by  a 
reticulum  of  fibres  with  small-cell  infiltration,  casea- 
tion, and  extravasation  of  blood.  The  newer  and 
small  tubercles  appear  to  be  collections  of  lymphoid 
cells  between  the  vessels.  Bacilli  are  by  no  means 
always  found.  Their  presence  in  the  chorioid  has  no 
connection  with  the  presence  of  tuberculous  meningitis. 
They  are  said  to  be  common  occurrences  in  miliary 
tuberculosis,  but  the  writer  believes  this  to  be  an  ex- 
aggeration. It  is  probable  that  tubercles  of  the  cho- 
rioid which  are  visible  with  the  ophthalmoscope  be- 
long to  the  terminal  stage  of  general  tuberculosis,  as 
they  often  develop  shortly  before  death.  Owing  to  the 
small  size  of  miliary  tubercles,  their  tendency  to  de- 
velop in  young  children,  and  the  consequent  difficulty 
of  examination,  they  are  much  oftener  found  after 
death  than  before  it.  Those  which  are  readily  visible 
with  the  ophthalmoscope  are  usually  from  six  to  ten  in 
number,  though  they  may  reach  as  high  as  thirty  or 
forty. 

When  the  tuberculous  deposit  is  in  the  anterior  seg- 
ment of  the  chorioid  and  takes  on  an  acute  process,  it 


884 


MEDICAL    RECORD. 


[December  8,  1900 


resembles  an  irido-cyclitis,  and  is  accompanied  by 
extensive  destructive  changes.  It  consists  of  a  mass 
of  tuberculous  matter,  which  generally  undergoes  case- 
ation, suppurates,  and  perforates  the  eyeball.  The 
bacilli,  when  found,  are  relatively  very  few.  Chronic 
tuberculous  tumors  of  the  brain  are  sometimes  accom- 
panied by  tubercles  of  large  size  and  slow  growth  in 
the  chorioid,  which  gradually  fill  the  eye  and  simulate 
malignant  tumors.  They  tend  to  perforate  the  eye- 
ball, usually  anteriorly  in  the  ciliary  region,  but  some- 
times extend  backward  along  the  sheath  of  the  optic 
nerve.  Extension  downward  along  the  same  course 
from  a  tuberculous  mass  in  tiie  brain  has  been  known 
to  occur,  but  is  not  common.  General  tuberculous  in- 
fection from  these  cases  has  been  observed  only  when 
the  eyeball  has  ruptured,  and  the  orbital  tissue  has 
become  infected.  Hence  the  advisability  of  an  early 
enucleation.  The  chronic  miliary  form  progresses 
slowly  and  insidiously,  the  capillaries  become  obliter- 
ated, there  is  no  pain,  and  very  rarely  any  external 
evidence  of  disease,  such  as  episcleral  injection,  is 
observed.  It  should  not  be  forgotten  that  while  mil- 
iary tubercles  of  the  chorioid  are  sometimes  found  in 
connection  with  tuberculous  meningitis,  they  are  more 
frequently  met  with  in  general  tuberculosis  without 
meningitis.  In  any  case  they  are  comparatively  rare, 
and  while  their  absence  is  of  no  significance,  their 
presence  is  valuable  evidence  of  general  tuberculosis. 
Owing  to  their  rapid  development,  ophthalmoscopic 
examinations  in  suspected  cases  should  be  frequently 
and  repeatedly  made. 

Tuberculosis  of   the    Retina   and  Optic  Nerve 

Tuberculous  lesions  in  the  retina  and  optic  nerve  are 
almost  always  associated  with  tuberculous  meningitis, 
and  in  about  fifteen  per  cent,  of  the  cases  of  menin- 
gitis, miliary  tubercles  are  found  in  the  chorioid. 
When  these  are  found  in  doubtful  cases  of  meningi- 
tis, the  differential  diagnosis  between  typhoid  fever 
and  tuberculous  meningitis  may  be  considered  as  made. 
Moreover,  myosis  is  frequently  a  symptom  in  the  early 
stages  of  tuberculous  meningitis,  just  as  its  opposite, 
mydriasis,  is  in  the  later  stages,  and  a  rapid  oscilla- 
tion between  myosis  and  mydriasis  is  rather  character- 
istic of  the  disease.  In  these  cases  there  is  a  peculiar 
marbled  reflection  in  the  retina  near  the  veins  in 
conjunction  with  the  tubercles  in  the  chorioid,  asso- 
ciated with  oedema  of  the  retina  and  optic  nerve. 
There  are  also  occasionally  seen  near  the  optic  nerve 
some  small  white  spots,  the  so-called  retinal  tubercles, 
but  these  are  rare.  Unequivocal  tubercles  in  the 
retina  are  usually  associated  with  tuberculous  growths 
in  all  the  structures  of  the  eye. 

The  subjective  symptoms  in  complications  of  the 
retina  and  optic  nerve  are  periodical  obscurations  of 
vision  and  photopsia,  and  to  these  is  sometimes  added 
the  objective  symptom  of  papillitis.  The  optic  nerve 
often  remains  normal  throughout  the  entire  course  of 
the  disease,  but  there  are  some  changes  in  about  half 
of  the  cases.  The  disc  becomes  red  and  the  outline 
hazy,  with  more  or  less  marked  striation  on  the  papilla 
and  in  the  retina.  It  is  more  a  neuritis  than  a  jiapil- 
litis,  and  hemorrhages  are  rare.  There  is  a  gauze-like 
opacity  over  the  disc  and  retina,  resembling  that  seen 
in  syphilitic  retinitis.  The  changes  are  always  bilat- 
eral, and  in  most  cases  the  patients  soon  die.  In  those 
who  recover  the  intra-ocular  signs  are  slight.  The 
neuritis  is  a  typical  descending  neuritis,  the  sheath  of 
the  nerve  being  not  only  distendi'd  but  inflamed.  In 
many  cases  the  symptoms  of  meningitis  are  distinctly 
marked  before  the  ocular  changes  occur.  In  some 
cases  tiie  cerebral  symptoms  are  latent  or  doubtful, 
and  here  the  ophthalmoscope  affords  assistance.  A 
diminution  in  the  severity  of  the  cerebral  symptoms 
may  be  accompanied  by  a  diminution  in  the  ocular 
changes.     It  should  be  remembered  that  optic  neuritis 


is  more  commonly  present  in  this  form  of  meningitis 
than  in  any  other,  and,  in  consequence  of  its  tendency 
to  attack  the  base  of  the  brain,  paralyses  of  the  ocular 
muscles  are  frequently  met  witii. 

Tuberculosis   of   the  Orbit   and  Orbital  Walls 

No  case  has  ever  been  reported  of  primary  tuberculosis 
starting  in  the  orbital  tissue.  In  the  cases  in  which 
this  tissue  has  been  involved,  the  disease  has  started 
either  in  the  iris  or  ciliary  body,  and  the  orbital  tissue 
has  become  infected  by  perforation  of  the  eyeball. 
As  regards  the  bony  walls  of  the  orbit,  the  presence 
of  periostitis  or  caries,  when  non-traumatic  in  origin, 
should  excite  suspicion  of  either  syphilis  or  tuber- 
culosis, especially  in  children. 


THE   TREATMENT    OF    TUMORS    BY    ELEC- 
TROLYSIS. 

By   WILLIAM    B.    NEFTEL,    M.D., 

NEW    YORK. 

It  may  not  be  generally  known  that  the  real  originator 
of  the  electrolytic  and  galvano-caustic  methods  of 
treatment  was  Gustav  Crussel,  a  medical  practitioner 
in  St.  Petersburg.  He  made  his  researches  in  the 
forties  under  the  guidance  of  my  celebrated  teachers, 
the  anatomist  and  surgeon  Pirogoff  and  the  physicist 
Lenz,  but  his  admirable  work  passed  unnoticed  at  the 
time.  Ten  years  later  Middeldorpf  reintroduced  the 
galvano-caustic  method,  which,  with  the  improved  ap- 
paratus and  technique,  was  adopted  by  surgeons,  while 
the  electrolytic  method  of  Crussel  remained  unknown, 
although  he  completely  and  with  remarkable  correct- 
ness laid  down  the  rational  indications  for  its  employ- 
ment. The  interest  of  the  profession  was  awakened 
only  much  later,  when  several  physicians  independ- 
ently and  almost  simultaneously  reintroduced  the 
method  in  special  morbid  conditions. 

I  too  must  confess  to  an  entire  ignorance  of  Crus- 
sel's  investigations  during  the  first  years  of  my  experi- 
mental work,  and  shall  always  regret  it;  as  a  previous 
acquaintance  with  his  writings  would  have  spared  me 
much  time  and  troublesome  experimenting.  While 
recommending  the  historical  study  of  electricity,  I  do 
not  ascribe  to  it  the  same  importance  as  to  personal 
observation  and  experiment.  My  first  electrolytic  ex- 
periments on  animal  fluids  and  tissues  gave  me  most 
valuable  suggestions,  which  I  was  later  able  to  verify 
during  my  long  practice.  The  hardening,  coagulat- 
ing, shrinking  effect  of  the  anode  offered  itself  at 
once  for  the  treatment  of  aneurisms,  varicose  veins, 
cavernous  tumors;  while  the  softening,  solvent  action 
of  the  cathode  seemed  indicated  in  strictures  and 
tumors.' 

In  this  country,  my  lamented  friends  the  late  Drs. 
J.  Marion  Sims,  .\.  Post,  Nott,  Mussey,  also  Dr.  Bailey 
of  Albany,  Dr.  Whitehead  of  Colorado,  Drs.  Jones  and 
Graham  cf  North  Carolina,  and  others,  sent  me  a 
number  of  interesting  cases  of  tumor.  I  was  thus 
enabled  to  study  the  electrolytic  process  from  the  clin- 
ical, biological,  and  physico-chemical  standpoints, 
these  latter  in  my  private  laboratory. 

The  first  thing  that  surprised  every  surgeon  who 
attended  the  electrolytic  treatment  was  the  slight  gen- 
eral and  local  reaction  following  the  operations.  The 
patients,  as  a  rule,  continued  their  mode  of  living  and 
their  daily  occupation.  Even  after  severe  electrolytic 
operations,  as,  for  instance,  the  necrotic  destruction  of 
large  malignant  tuinors  in  one  sitting,  by  my  method, 
under  the  influence  of  an  anaesthetic,  the  general  effect 

'  I  made  these  observations  while  studying  pathological  histol- 
ogy in  V'irchow's  Institute  in  the  years  iSOo,  iSOi.  and  1S62, 
anil  examining  the  action  of  ilifTerent  electric  currents  on  living 
unicellular  organisms  (am(vbx')  and  other  protoplasmatic  struc- 
tures (leucocytes,  sarcoma  and  cancer  cells). 


I 


December  8,  1900] 


MEDICAL    RECORD. 


8S5 


is  comparatively  insignificant — a  very  slight  elevation 
of  temperature,  if  any  at  all,  one  or  two  clays  in  bed, 
moderate  pain  not  requiring  narcotics;  sleep,  appetite, 
and  digestion  remaining  normal.  After  the  removal 
of  the  necrosed  tumor  the  wound  rapidly  healed  by 
granulation,  leaving  a  small,  soft  cicatrix. 

The  impression  produced  upon  me  by  the  electro- 
lytic operations  can  be  readily  understood,  consider- 
ing the  many  years  I  spent  in  the  clinics  of  PirogolT 
and  Langenbeck,  in  visiting  the  wards  of  celebrated 
English  and  French  surgeons,  and  in  performing  surgi- 
cal operations  in  the  hospitals  of  St.  Petersburg  and 
during  the  Crimean  war;  all  this  before  the  antiseptic 
era  of  Lister.  As  no  pya-mia,  septicemia,  hospital 
gangrene,  acute  purulent  cedema,  etc. ,  ever  followed 
my  electrolytic  operations,  I  concluded  that  they  are 
generally  void  of  danger.  I  expected  great  results 
from  the  adoption  of  electrolysis  in  general  surgery, 
but  the  brilliant  results  of  the  antiseptic  method  made 
such  an  innovation  apparently  unnecessary;  I  say  ap- 
parently, because  the  electrolytic  method  not  only  re- 
mains applicable  in  many  instances,  but  sometimes 
proves  preferable  to  the  usual  surgical  operations. 

For  convenience'  sake  I  may  here  explain  the  im- 
munity from  complications  which  so  often  accompanied 
former  surgical  operations,  although  this  should  per- 
haps be  said  in  connection  with  the  physico-ciiemical 
phenomena  of  electrolysis. 

I  always  ascribed  an  important  role  to  the  gases 
developed  in  electrolysis  of  living  animal  tissues. 
As  long  ago  as  1840  Schoenbein  discovered  that  a 
certain  amount  of  the  oxygen  evolved  at  the  anode 
passes  in  its  active  condition,  which  he  called  ozone, 
while  a  much  larger  amount  of  the  oxygen  combines 
with  the  hydrogen  of  the  electrolyte  and  produces 
peroxide  of  hydrogen.  Both  the  ozone  and  the  hy- 
drogen peroxide  are  easily  recognizable  by  their  re- 
actions. The  amount  of  these  gases  of  course  increases 
with  the  current  intensity. 

In  order  to  examine  the  properties  of  the  hydrogen 
developed  at  the  cathode  it  is  best  to  use  a  cathode  of 
palladium,  because,  according  to  Graham,  this  metal 
absorbs  a  very  large  amount  of  hydrogen.  The  hydro- 
gen thus  obtained  reduces  in  the  dark  the  iron  oxide 
salts  and  organic  substances,  and  readily  combines  in 
the  dark  with  chlorine  and  iodine;  therefore,  it  is  more 
active  than  the  ordinary  hydrogen  gas.  Such  active 
hydrogen,  according  to  Hoppe-Seyler,  is  able  to  cause 
strong  oxidations  by  rendering  active  (ozonizing)  the 
oxygen  of  the  air  and  of  the  electrolyzed  (iuid.  The 
effect  of  the  active  hydrogen  evolved  by  electrolysis 
is  thus  more  potent  than  that  of  the  active  oxygen 
(ozone),  as  the  former  calls  forth  oxidations  as  well 
as  reductions.  It  is  evident  that  the  ozone,  the  active 
hydrogen,  the  peroxide  of  hydrogen,  the  chlorine, 
being  powerful  antiseptics  and  bactericides,  render 
the  electrolytic  process  a  most  el'iicient  antiseptic. 
The  accumulated  acids  also  contribute  their  share  to 
the  antiseptic  result. 

The  above  facts  explain  the  absence  of  septic  phe- 
nomena, both  local  and  general,  after  electrolytic 
operations. 

I  became  acquainted  with  these  properties  of  elec- 
trolysis very  early  in  my  practice,  but  only  after  many 
years  of  laboratory  work  I  published  them  in  detail  in 
Virchow's  Archiv  in  1881.' 

Not  long  ago  my  views  were  confirmed  by  the  ex- 
cellent researches  conducted  by  Smirnow  in  the  St. 
Petersburg  institute  of  experimental  pathology.  He 
demonstrated,  besides,  that  electrolysis  is  not  only  a 
bactericide,  but  destroys  the  toxins  and  transforms 
them  into  antitoxins. 

'  More  recently  Apostoli,  with  the  aid  of  a  bacteriologist,  pub- 
lished as  a  new  discover)'  the  antiseptic  and  bactericidal  action  of 
the  anode  only. 


The  electrolytic  process  is  the  ideal  antiseptic, 
since  it  can  reach  the  most  hidden  places  and  ca\  i- 
ties  inaccessible  to  other  antiseptics.  The  electric 
current  being  able  to  permeate  the  surrounding  tis- 
sues, electrolysis  is  therefore  especially  indicated  in 
the  treatment  of  malignant  tumors. 

Owing  to  the  work  and  discoveries  of  Arrhenius, 
Van  t'Hoff,  Ostwald,  Raoult,  and  others,  a  new  scien- 
tific branch — physical  chemistry —  has  been  developed 
within  these  twenty  years,  especially  in  the  last  dec- 
ade, on  the  border  lines  of  chemistry,  physics,  and 
physiology.  This  new  science,  of.  great  theoretical 
interest,  offers  an  inexhaustible  source  for  new  re- 
searches and  discoveries,  and  is  intimately  connected 
with  physiology  and  medicine  (the  modern  theories  of 
solutions,  osmosis,  cryoscopy,  tonometry,  the  theory 
of  ions,  etc.). 

The  limits  of  this  article  permit  me  to  give  but  a 
few  elementary  facts  indispensable  for  the  rational 
employment  of  electrolysis  in  medicine  and  surgery. 
Electrolysis,  far  more  than  the  electrical  phenomena 
in  metallic  conductors,  affords  an  insight  into  the 
nature  of  electricity  in  general,  and  reveals  the  physico- 
chemical  changes  which  take  place  in  the  living  body 
under  the  influence  of  electric  currents. 

Substances  which  conduct  the  current  are  divided, 
as  is  generally  known,  into  conductors  of  the  first  and 
second  class.  The  conductors  of  the  first  class  form 
a  well-defined  group  characterized  by  the  following 
properties:  They  are  the  only  chemically  simple 
bodies  which  in  the  solid  state  conduct  the  current. 
They  conduct  it  with  an  incomparably  greater  velocity 
than  do  the  conductors  of  the  second  class,  and  they 
conduct  better  at  a  lower  than  at  a  higher  temperature, 
and  without  undergoing  any  change  in  their  substance, 
except  the  elevation  of  temperature.  To  this  group 
belong  the  metals  and  their  alloys  and  amalgams, 
hence  the  name  metallic  conductors.  All  other  chem- 
ically simijle  bodies  in  a  solid  state  do  not  conduct 
the  current,  and  are  designated  as  non-conductors  of 
electricity^insulators.  The  conductors  of  the  second 
class,  or  moist  conductors,  are  always  compound 
chemical  substances.  They  conduct  the  current  only 
in  a  dissolved  or  fused  condition,  invariably  under 
decomposition  of  their  constituent  parts  (electrolysis), 
and  are  therefore  called  electrolytes.  They  conduct 
the  current  better  at  a  higher  than  at  a  lower  temper- 
ature. The  conductors  of  the  second  class,  moist 
conductors,  electrolytes,  carry  tiie  electric  current  be- 
cause of  their  chemical  decomposition.  Substances 
which  do  not  undergo  electrolytic  decomposition,  like 
absolute  alcohol,  chemically  pure  water,  etc.,  do  not 
conduct  the  current.  If  these'substances  be  connected 
with  the  poles  of  a  battery  of  any  strength  no  elec- 
trolytic decomposition  will  take  place,  nor  will  the 
needle  of  the  intercalated  galvanometer  be  deflected. 
On  the  other  hand,  even  electrolytes  will  not  be  de- 
composed by  the  current  as  long  as  their  molecules 
remain  immovable,  solid  substances;  but  as  soon  as 
they  are  dissolved  they  immediately  undergo  electroly- 
tic decomposition.  Thus  acidulated  or  saline  water 
conducts  the  current  and  is  decomposed  by  it  so  long 
as  the  water  retains  its  liquid  condition,  but  when  in 
the  state  of  ice  it  can  r.aither  conduct  the  current  nor 
be  decomposed  by  it.  Hjnce  it  follows  that  both  the 
animal  fluids,  which  are  saline  aqueous  solutions,  and 
the  animal  tissues  impregnated  by  them,  are  electro- 
lytes and  readily  undergo  the  electrolytic  action  of  the 
current.  Even  the  compact  bones  and  cartilages  yield 
to  it;  for,  besides  medullary  tissue  and  soft  cellular 
elements,  the  living  bones  contain  blood-vessels  and 
canals  filled  with  electrolyzable  saline  solutions. 
This  is  especially  the  case  with  the  proliferating 
tumors  in  softened  bones  and  cartilages. 

The  decomposition  of  an  electrolyte  is  not  merely  a 


886 


MEDICAL    RECORD. 


[December  8,  1900 


phenomenon  accompanying  the  electric  current,  but  is 
the  essence  of  electric  conduction;  for  electric  con- 
duction is  inseparable  from  chemical  decomposition, 
I  and,  according  to  F'araday's  law,  the  amount  of  the 
/  decomposed  electrolyte  is  directly  proportional  to  the 
I    quantity  of  electricity  which  traversed  it. 

The  fundamental  condition  of  all  electrical  phenom- 
ena in  moist  conductors  is  the  presence  of  free  ions. 
The  ions  are  specific  atoms  and  molecules  temporarily 
charged  with  electric  energy.  But  as  energy  is  con- 
stantly undergoing  transformation  (the  transformations 
of  energy  really  constituting  all  the  phenomena  in 
nature)  the  ions  may  lose  their  specific  properties  and 
again  become  ordinary  atoms  and  molecules.  The 
electrolytic  decomposition  is  of  a  peculiar  nature  and 
differs  from  other  decompositions  by  producing  spe- 
cial electrical  elements,  ions  entirely  unlike,  for  the 
time  being,  any  ordinary  chemical  bodies.  A  large 
category  of  substances  cannot  undergo  electrolytic  de- 
composition and  are  impassable  for  the  electric  cur- 
rent; as,  for  instance,  alcohol,  ether,  petroleum,  glycer- 
in, oils,  and  other  organic  fluids,  etc.  It  is  therefore 
evident  that  not  every  material  atom  and  molecule  can 
become  an  electric  element,  an  ion.  However  re- 
stricted, the  class  of  electrolytes  is  still  very  numerous, 
as  it  comprises  the  solutions  of  salts,  acids,  and  bases. 
The  ions  are  the  only  carriers  of  electricity  in  its 
passage  through  solutions.  When  a  solution  contains 
no  ions  the  electric  current  cannot  pass  it.  If  the 
solvent  fluid  is  an  insulator  the  electric  charge  of  the 
ions  is  retained  by  them  and  cannot  leave  them  so 
long  as  they  are  surrounded  by  the  insulating  solvent. 
The  chemical  constitution  of  the  ions,  after  they  have 
lost  their  electric  charge  and  have  become  ordinary 
chemical  bodies,  is  that  of  salts  in  the  modern  sense 
of  the  term.  The  ions  developed  by  electrolysis  and 
temporarily  charged  with  electricity  have  for  material 
basis  on  one  side  a  metal  or  hydrogen,  on  the  other  a 
simple  radical  or  a  radical  group  or  hydroxyl.  For 
instance,  in  subjecting  to  electrolysis  solutions  of  salts, 
acids,  or  bases,  the  metals  Cu,  K,  Na,  etc.,  or  H  are 
cathions  and  are  attracted  by  the  negative  electrode, 
the  radicals  SO^,  OH,  CI,  etc.,  are  anions  and  are  at- 
tracted by  the  positive  electrode.  At  the  respective 
electrodes  the  ions  discharge  their  electricity  and  be- 
come again  free,  electrically  neutral,  chemical  bodies, 
with  their  former  properties  and  affinities,  and  imme- 
diately undergo  secondary  chemical  combinations 
with  the  surrounding  media,  which  they  were  incap- 
able of  while  charged  with  electricity  as  ions.  Thus, 
for  instance,  a  sodium  ion  does  not  decompose  water 
as  does  the  sodium  metal,  a  chlorine  ion  has  neither 
the  odor,  nor  the  color,  nor  the  affinity  of  chlorine  gas. 

Until  recently  a  prominent  feature  of  the  electroly- 
tic process  was  inexplicable,  namely,  the  presence  of 
products  of  electrolytic  decomposition  only  at  the 
electrodes,  while  the  intermediate  part  of  the  electro- 
lyte remained  unaltered.  Many  theories  were  off^ered 
j  in  its  explanation,  but  it  was  left  toArrhenius  to  eluci- 
'  date  the  facts  fully  and  explain  this  and  other  phenom- 
ena in  electro-chemistry. 

His  theory  presupposes  the  existence  of  dissociated 
molecules  in  every  solution  of  a  chemical  compound, 
even  before  it  is  traversed  by  a  current,  the  dissocia- 
tion being  produced  by  the  heat  absorbed  during  the 
process  of  solution.  Thus,  when  salts,  acids,  or  bases 
are  dissolved,  they  will  not  be  present  any  more  in  the 
solution  as  compound  chemical  bodies,  but  their  con- 
stituent atoms  alone  will  be  found  in  the  solution. 
For  instance,  if  we  dissolve  hydrochloric  acid  or 
sodium  iodide,  etc.,  the  solution,  if  sufficiently  diluted, 
will  not  contain  these  substances  in  their  compound 
state,  but  their  dissociated  atoms  of  hydrogen  or  so- 
dium, of  chlorine  or  iodine,  etc.,  in  the  form  of  free 
ions,  the  first  charged  with  positive,  the  latter  with 


negative  electricity.  If  such  solutions  be  subjected 
to  tiie  action  of  a  constant  current  the  cathions  will 
be  immediately  attracted  to  the  cathode,  the  anions  to 
the  anode,  and  both  will  discharge  their  electricity  at 
their  respective  electrodes:  after  which  they  return  to 
the  state  of  ordinary  bodies  with  all  their  natural 
chemical  properties  and  affinities,  as  hydrogen,  chlor- 
ine, sodium,  etc.,  in  statu  nascendi,  and  enter  into 
secondary  chemical  combinations. 

Tiie  theory  of  ions,  advanced  by  Arrhenius  in  1887, 
generalizes  the  laws  of  osmosis  discovered  by  Dutro- 
chet,  Pfeffer,  and  De  Vries  for  substances  which  are 
not  electrolytes,  and  makes  them  applicable  to  all 
other  bodies.  In  like  manner,  it  generalizes  the  laws 
concerning  the  freezing-point  of  solutions  and  the 
tension  of  their  vapors,  and  explains  a  great  many 
phenomena  of  paramount  importance  to  physics,  phy- 
siology, and  medicine,  which  until  then  remained  ob- 
scure and  witliout  connection. 

The  human  body,  taken  as  a  whole,  is  a  moist  con- 
ductor, an  electrolyte,  consisting  of  about  seventy  per 
cent,  of  water  which  constitutes  the  general  solvent 
fluid  of  the  substances  circulating  in  the  system,  viz., 
the  inorganic  salts — sodium  chloride,  potassium  chlor- 
ide, phosphates,  sulphates,  and  carbonates  of  sodium, 
potassium,  calcium,  and  magnesium,  with  salts  of  iron. 
There  are,  besides  a  fraction  of  sugar  in  the  blood,  the 
products  of  the  albuminous  tissue  change — urea,  uric 
acid,  creatin,  etc.  The  albuminous  substances  occupy 
a  distinct  place  on  account  of  their  extremely  complex 
chemical  composition,  the  great  number  of  atoms  con- 
tained in  their  molecules,  and  their  physical  peculiar- 
ity as  regards  solubility.  They  belong  to  the  so-called 
colloid  substances  and  do  not,  like  the  salts,  form  a 
genuine  aqueous  solution,  but  gradually  absorb  water 
until  they  form  a  fluid  from  which  they  cannot  be 
obtained  either  by  crystallization  or  difTusion. 

Of  special  importance  in  electrolysis  of  animal  tis- 
sues is  water,  the  combination  of  hydrogen  (H)  with 
hydroxyl  (OH),  which  is  not  only  the  general  solvent 
but  is  itself  an  electrolyzable  fluid.  The  tendency  to 
dissociation,  and  hence  the  conductibility,  varies  in 
different  electrolytes.  While  hydrogen  and  hydroxyl 
possess  but  a  slight  tendency  to  dissociate  into  free 
ions,  sodium  chloride  and  potassium  chloride  dissociate 
quite  readily.  Thus  the  salts  contained  in  the  tissues 
undergo  electrolytic  decomposition  while  their  solvent 
vehicle  still  remains  intact. 

The  velocity  of  the  current  increases  with  the  electro- 
motor force  and  diminishes  with  the  increasing  resist- 
ance. The  greater  the  mobility  of  the  solution  the 
less  the  resistance.  This  is  why  moist  conductors, 
contrary  to  metals,  conduct  better  at  a  higher  tempera- 
ture. The  resistance  depends  also  on  the  nature  of 
the  ions;  the  larger  they  are  the  greater  will  be  the 
resistance.  The  size  of  the  ions  depends  on  their 
chemical  composition  and  the  number  of  their  atoms. 
With  the  increase  of  the  number  of  atoms  tlie  surface 
of  the  ions  grows  and  presents  a  greater  resistance  to 
friction. 

Since  the  molecules  of  albuminous  substances  con- 
tain hundreds  of  atoms  and  thus  hardly  conduct  the 
current,  it  is  evident  that,  contrary  to  the  prevailing 
fallacy,  they  can  play  no  part  in  the  electrolytic  de- 
composition of  animal  tissues. 

The  constituent  parts  of  animal  tissues  in  regard  to 
electrolysis  may  be  divided  into  two  groups:  the  elec- 
trically inactive,  to  whicli  belong  the  colloid  substances 
and  the  non-dissociated  ions  offering  only  resistance 
to  the  current,  and  the  electrically  active,  the  disso- 
ciated ions  which  alone  conduct  the  current.  Among 
these  chlorine  and  sodium  are  prominent  for  their 
tendency  to  dissociate,  and,  assisted  by  the  water  of 
the  tissues,  they  principally  accomplish  the  electro- 
lytic decomposition    in    living  tissues.     The  sodium 


December  8,  1900] 


MEDICAL    RECORD. 


887 


metal  at  the  cathode,  unlike  the  sodium  ion,  abstracts 
hydroxyl  from  the  water  of  the  solution  and  forms 
caustic  soda,  setting  free  the  hydrogen;  at  the  anode 
the  chlorine  gas,  unlike  the  chlorine  ion,  takes  the 
hydrogen  from  the  water,  forms  hydrochloric  acid,  and 
lets  the  oxygen  escape.  Twice  as  much  hydrogen  is 
liberated  at  the  cathode,  as  oxygen  at  the  anode.  The 
products  of  electrolytic  decomposition  of  all  the  other 
salts,  acids,  bases,  and  water  of  the  tissues  react  in  an 
analogous  manner.  It  is  obvious  that  the  accumulated 
alkalies  at  the  cathode  and  the  acids  at  the  anode  must 
produce  a  powerful  destructive  chemical  effect,  espe- 
cially on  the  albuminous  substances,  where  it  mani- 
fests itself  by  discoloration,  coagulation,  disintegra- 
tion, and  necrosis.  But  these  phenomena  at  the 
electrodes  are  the  secondary  effects  called  forth  by  the 
chemical  products  of  electrolytic  decomposition  of  the 
living  tissues.  The  same  process  takes  place  every- 
where between  the  electrodes,  although  invisibly  in  a 
molecular  form.  For  it  must  be  borne  in  mind  that 
the  living  body  which  the  electrolyzing  current  has  to 
pass  is  not  a  homogeneous  moist  conductor,  but  con- 
sists of  a  great  variety  of  organs,  membranes,  even 
single  cells,  and  different  concentrations  of  the  aque- 
ous solutions,  all  of  wliich  act  as  so  many  entratices 
and  exits  for  the  current — as  anodes  and  cathodes. 
At  each  of  these  innumerable  electrodes  the  water,  the 
hyaloid  salts,  etc.,  undergo  the  same  chemical  decom- 
position as  at  the  principal  electrodes,  the  secondary 
chemical  combinations  excepted.  This  can  be  illus- 
trated by  a  simple  experiment.  If  a  constant  current 
is  sent  through  a  series  of  different  solutions,  decom- 
position takes  place  in  the  solutions,  not  only  at  the 
entrance  and  exit  of  the  electrodes,  but  in  each  of  the 
intermediate  solutions  as  well. 

The  secondary  chemical  effects  of  electrolysis, 
wiiich  manifest  themselves  at  the  electrodes,  are  ac- 
countable for  the  local  effects  in  the  treatment  of 
tumors;  but  equally  important  are  the  general  mo- 
lecular constitutional  effects  of  electrolysis  which 
take  place  between  the  electrodes  in  the  whole 
body,  in  proportion  to  the  density  of  the  current. 
The  local  caustic  effects  at  the  electrodes  can  be 
intentionally  eliminated  by  intercalating  another 
moist  conductor  between  the  body  and  the  electrodes, 
thus  making  available  only  the  general  constitutional 
effect. 

The  electric  current  in  passing  through  living  tis- 
sues is  not  entirely  expended  in  the  dissociation  and 
transmission  of  the  ions,  but  a  portion  of  the  current 
is  transformed  into  other  energies;  an  insignificant 
part  into  heat,  owing  to  the  small  intensities  employed, 
and  a  much  greater  part  for  the  transformation  of  the 
electrical  into  mechanical  energy — cataphoresis.  This 
consists  in  an  uninterrupted  flow  in  the  direction  of 
the  positive  current  of  the  whole  mass  of  the  electro- 
lyte, including  the  electrically  inactive  molecules. 
Cataphoric  action  has  quite  a  different  character  from 
the  motion  of  the  ions,  it  is  not  accompanied  by  de- 
composition, and  it  increases  with  the  resistance.  It 
has,  however,  one  point  in  common  with  the  electro- 
lytic action — it  is  directly  proportional  to  the  intensity 
of  the  current.  If  a  tluid  through  which  a  constant 
current  passes  be  intercepted  at  some  place  by  a  porous 
diaphragm  or  a  membrane,  the  fluid  will  How  through 
in  the  direction  of  the  positive  current  and  carry  with 
it  any  particles  that  may  be  suspended,  as  if  the  dia- 
phragm did  not  exist.  The  fluid  sinks  at  the  anode 
and  rises  at  the  cathode.  Such  a  diaphragm  offers  a 
new  resistance  to  the  passing  of  the  electric  current, 
and  therefore  increases  the  cataphoric  action.  In  the 
living  body,  where  the  current  has  to  encounter  innu- 
merable membranes  (diaphragms),  the  conditions  are 
very  favorable  for  cataphoresis.  I  often  avail  myself 
of  the  cataphoric  action  of  the  current,  for  instance,  in 


the  treatment  of  chronic  swellings,  especially  of  lym- 
phatic glands.  I  apply  to  the  swollen  part  percutane- 
ously  a  small  anode,  and  at  a  certain  distance  a  large 
cathode,  and  allow  the  current  to  flow  uninterruptedly 
for  several  minutes,  and  occasionally  move  slowly  the 
cathode  from  one  place  to  another.  After  each  appli- 
cation the  swelling  diminishes  at  the  anode,  and  the 
accumulated  fluid  with  the  suspended  particles,  carried 
by  the  cataphoric  action  of  the  current  to  the  cathode, 
gradually  disappears  by  diffusion  and  absorption.  In 
my  first  attempts  to  treat  malignant  tumors  more  than 
thirty  years  ago,  I  tried  to  enhance  the  electrolytic 
action  by  introducing  cataphorically  into  the  substance  / 
of  the  tumor  metallic  salts  (of  zinc),  but  soon  found 
it  useless,  the  electrolytic  action  alone  being  entirely, 
sufficient  when  properly  employed.  Whenever  elec- 
trolysis is  unable  to  cure  the  tumor  owing  to  the  gen- 
eralization of  tlie  disease,  cataphoresis  of  metallic 
salts  is  powerless  to  improve  the  result. 

It  may  be  proper  to  say  here  a  few  words  regarding 
the  relation  of  induction  currents  to  electrolysis,  or 
better,  give  the  following  simple  experiment:  If  in- 
duction currents  (currents  in  opposite  directions  in 
rapid  succession)  are  made  to  pass  through  a  volta- 
meter the  developed  gases  at  the  electrodes — oxygen, 
hydrogen,  etc.,  constantly  reunite  and  make  the  final 
electrolytic  result  very  insignificant. 

In  the  faradic  current  the  opening  currents  prevail, 
and  there  is  always  a  small  excess  of  ions  in  this  di- 
rection. Moreover,  it  displays  the  phenomena  of  cata- 
phoresis, and  in  living  tissues  stimulates  the  nerves, 
produces  muscular  contractions,  enhances  the  circula- 
tion and  the  absorption,  and  may  thus  contribute  to 
the  reduction  of  non-malignant  tumors.  On  the  whole, 
however,  the  electrolytic  action  of  induction  currents 
is  insignificant  and  unfit  for  the  reduction  of  large 
tumors,  or  for  the  destruction  of  malignant  growths. 
The  electrolytic  action  of  the  sinusoidal  current  and 
of  static  electricity  is  still  less  than  that  of  the  faradic 
current.  For  electrolysis  of  tumors,  therefore,  the  con- 
stant current  alone  ought  to  be  employed. 

In  living  animal  tissues  (tumors)  subjected  to  elec- 
trolysis by  means  of  inserted  needle  electrodes  the 
escape  of  fine,  frothy  gas  (hydrogen)  is  observed  at 
the  cathode  needle,  the  tissue  immediately  surround- 
ing it  becoming  discolored,  yellowish-gray,  soft,  and 
necrosed.  The  necrosed  tissue  is  gradually  dissolved 
in  the  accumulated  free  alkalies  around  the  needle 
and  forms  a  pale  yellowish,  odorless  fluid  of  an  alka- 
line reaction.  Finally,  the  fluid  is  absorbed,  and  thus 
directly  contributes  toward  the  diminution  of  the 
tumor.  Ey  a  considerable  increase  of  the  intensity 
and  duration  of  the  current  a  small,  thin  eschar  is 
formed  which  dries  and  comes  off.  Within  the  sphere 
of  the  cathode  the  tumor  at  first  becomes  swollen, 
crepitating,  and  fluctuating,  owing  partly  to  the  accu- 
mulation of  gas  and  partly  in  consequence  of  the  cata- 
phoresis, but  this  swelling  soon  entirely  disappears  by 
absorption.  Even  very  resistant  tissues,  in  which  the 
needle  can  be  introduced  only  with  considerable  diffi- 
culty, become  quite  soft  under  the  influence  of  the 
cathode  after  the  current  has  flowed  for  a  while,  and 
allow  the  needle  to  penetrate  easily  in  every  direction. 
Therefore,  the  extraordinary  hardness  of  a  tumor  does 
not  contraindicate  electrolysis. 

Around  the  anode  needle  a  dark,  almost  black,  dry 
layer  is  formed,  and  consists  of  hard  coagulated,  shriv- 
elled, mortified,  or  mummified  tissue.  This  necrosed 
tissue  likewise  disappears  gradually  by  molecular  dis- 
integration, by  a  kind  of  necrobiosis.  But  when  the 
intensity  of  the  current  is  great  and  its  duration  pro- 
longed, a  portion  of  the  tumor  surrounding  the  anode, 
or  the  entire  tumor,  may  undergo  necrotic  destruction. 
Later  on  appears  a  slight  inflammatory  demarcation 
line,  and  after  the  necrotic  mass  has  become  detached 


888 


MEDICAL    RECORD. 


/the  defect  rapidly  fills  up  with  healthy  granulations 
I  and  closes  with  a  small,  soft  cicatrix. 

As  the  action  of  the  two  electrodes  is  so  widely  dif- 
ferent, it  is  imperative  to  warn  against  their  indis- 
criminate use.  Many  times  have  I  introduced  the 
cathode  needle  into  the  substance  of  a  myomatous 
uterus,  the  parenchyma  of  the  spleen,  the  liver  (ecchi- 
nococcus),  the  articular  cavities,  and  for  several  sec- 
onds or  even  minutes  kept  increasing  the  current  to  a 
considerable  extent,  and  without  any  unpleasant  con- 
sequences. But  quite  different  would  be  the  result  of 
a  prolonged  insertion  of  an  anode  needle ;  the  necrosed 
mass  would  be  eliminated  in  toto,  which  is  not  with- 
out danger.  The  anode  needle  of  a  strong  current 
may  remain  inserted  for  a  considerable  time  in  such 
cases  only  when  it  is  intended  to  effect  a  necrotic 
destruction  en  masse  in  connection  with  the  surface 
of  the  body.  When  the  anode  needle  is  inserted  for 
the  purpose  of  coagulating  the  blood  in  aneurisms  or 
varicose  veins,  it  must  not  remain  too  long  in  the 
same  place;  or  several  branched  anode  needles  may 
be  used,  which  must  be  insulated  at  the  contact  with 
the  tissues. 

In  electrolysis  of  tumors  the  contents  of  the  blood- 
and  lymph-vessels,  being  better  conducting  fluids,  are 
especially  affected  by  the  current;  the  necrosis  of  the 
nutritive  vessels  greatly  contributes  to  the  regressive 
metamorphosis  of  the  electrolyzed  tumor. 

For  practical  purposes  tumors  can  be  classified  into 
malignant  and  non-malignant.  The  non-malignant 
tumors  originate  locally,  and  are  caused  by  a  local 
traumatic,  mechanical,  or  chemical  irritation.  This 
calls  forth  hyperaemia  and  hyperplastic  development 
of  the  irritated  normal  tissues.  Such  tumors  produce 
per  se  no  constitutional  disturbance,  but  may  become 
injurious  only  bj'  their  excessive  growth  interfering 
with  the  functions  of  the  affected  or  the  neighboring 
organs  and  with  the  circulation;  but  they  do  not  in- 
vade the  other  organs  and  have  no  tendency  to  become 
generalized.  Moreover,  after  complete  extirpation 
they  are  not  followed  by  relapses. 

The  origin  of  malignant  tumors  is  due  likewise  to 
some  local  irritation,  to  which,  however,  is  added  the 
action  of  some  parasitic  micro-organism  (protozoa, 
amotbae,  coccidia,  etc.).  Although  the  parasitic  origin 
of  malignant  tumors  is  not  yet  generally  accepted,  the 
infectious  nature  of  the  disease  points  to  this  theory. 
Malignant  tumors  always  invade  the  neighboring  and 
distant  tissues  and  organs;  they  become  generalized, 
produce  poisoning  of  the  whole  system  (cachexia),  and 
terminate  fatally.  Even  the  extirpation  in  the  fully 
developed  disease  is  of  no  avail,  as  it  is  followed  by  a 
relapse  and  generalization.  This  corroborates  the 
theory  of  the  parasitic  origin  of  malignant  tumors; 
for,  however  thorough  the  operation,  the  knife,  caus- 
tics, or  galvano-cautery  cannot  completely  remove  the 
infectious  germs  which  remain  infiltrated  in  the  sur- 
rounding tissues  and  continue  their  work  of  destruc- 
tion. Not  so  with  benign  tumors;  for  instance,  a 
large  fibromyoma  of  the  uterus  may  remain  during  life 
without  affecting  the  general  health,  but  a  small  can- 
cer of  the  cervix,  or  a  little  scirrhus  nodule  in  the 
breast,  in  no  way  even  interfering  with  the  functions 
of  the  organ,  are  nevertheless  disastrous  to  the  general 
nutrition,  produce  cachexia,  and  invariably  lead  to 
death.  With  our  present  knowledge  of  the  etiology 
of  infectious  diseases  it  seems  plausible  to  attribute 
the  essence  of  malignant  tumors,  their  spreading,  the 
general  poisoning  of  the  system,  and  other  symptoms, 
to  the  vital  activity  of  pathogenic  micro-organisms. 
Moreover,  the  parasitismus  of  malignant  tumors  has 
been  demonstrated  by  Jurgens,  Sawchenko,  Roncali. 
Doria  found  amcebjE  in  endometritis,  which  preceded 
the  development  of  adenoma  and  carcinoma  uteri, 
and  quite  recently  Dr.  Eisen,  of  San  Francisco,  de- 


[December  8,  1900 


monstrated  the  constant  presence  of  a  certain  amaba 
in  epithelioma. 

The  electrolytic  treatment  of  benign  and  malignant 
tumors,  like  their  etiology,  is  based  on  radically  differ- 
ent principles. 

In  treating  malignant  tumors  by  electrolysis  my 
aim  is  to  produce  in  one  operation,  by  the  action  of 
the  anode,  the  necrotic  destruction  of  the  tumor  and 
of  all  the  infectious  germs  of  the  surrounding  tissues. 
This  must  be  accomplished  in  the  first  stage  of  the 
disease,  so  long  as  the  tumor  is  loc^l,  the  lymphatic 
glands  are  not  yet  affected,  and  the  distant  organs  are 
free  from  deposits.  The  effect  of  such  an  electrolytic 
operation  is  the  disappearance  of  all  morbid  symp- 
toms, and  a  complete  recovery  without  relapses. 
A  number  of  patients  treated  by  me  some  twenty  or 
more  years  ago  are  still  in  good  health,  although  at 
the  time  the  microscopical  examination  of  the  necrosed 
mass  presented  the  characteristic  structures  of  carci- 
noma. The  operations  were  witnessed  by  physicians 
who  kindly  assisted  me  and  observed  the  results. 

I  published  the  details  of  my  method  in  Virchow's 
Arc/iiv,  vols.  57,  70,  86. 

The  treatment  of  benign  tumors  is  based  on  a  dif- 
ferent principle.  Here  the  indication  is  not  to  de- 
stroy the  tumor  by  electrolysis,  but  to  induce,  by 
the  action  of  the  cathode,  a  regressive  metamor- 
phosis, molecular  disintegration,  absorption,  and  atro- 
phy. 

The  following  cases  may  serve  as  illustrations: 

Mrs.  C ,    aged    thirty-eight    years,    a   childless 

widow  of  a  good  constitution  but  with  an  inherited 
tendency  to  obesity.  Of  late  years  she  noticed  a  steady 
increase  in  the  size  of  the  aljdomen  and  complained 
of  dyspeptic  symptoms,  constipation,  cedema  of  the 
lower  extremities,  and  great  discomfort  in  walking  or 
driving.  Both  her  father,  a  distinguished  physician, 
and  her  brother-in-law.  a  well-known  professor  of  sur- 
ger\-,  diagnosed  a  very  large  fibroid  tumor  of  the 
uterus,  which  filled  the  pelvic  and  a  part  of  the  ab- 
dominal cavities.  They  gave  their  opinion  that  an 
operation  (extirpation  of  the  uterus)  was  out  of  the 
question,  as  it  would  endanger  life,  and  recommended 
rest  and  a  careful  mode  of  living  as  the  best  pallia- 
tives. I  was  consulted  in  1878  in  regard  to  electro- 
lytic treatment,  and  made  a  favorable  prognosis,  based 
on  experience  with  similar  cases.  I  found  the  whole 
uterus,  except  the  cervix,  involved  in  the  hyperplastic 
development,  especially  the  posterior  wall  and  fundus 
of  the  uterus;  the  posterior  wall  was  quite  hard  and 
unyielding.  At  the  first  electrolytic  operation,  which 
I  performed,  without  an  anfesthetic,  a  large  flexible 
anode — a  metallic  plate  well  padded  with  compressed 
moss  and  flannel  and  soaked  in  warm  water — was  ap- 
plied to  the  hypogastric  region  and  a  rather  long  and 
strong  cathode  needle  of  platinum  introduced  through 
the  vagina.  This  needle  was  conveniently  curved, 
and  so  insulated  with  soft-rubber  tubing  (not  vulcan- 
ized) as  to  allow  the  metallic  needle  to  penetrate  at 
any  desired  depth  into  the  substance  of  the  tumor,  or 
to  be  partially  withdrawn  and  still  remain  insulated 
outside  the  uterus.  I  inserted  tlie  needle  into  the 
posterior  wall  of  the  tumor  with  considerable  effort, 
because  of  the  hardness  of  the  fibromyoma  at  this 
place.  The  current  was  turned  on  with  a  minimum 
intensity,  and  was  slowly  and  gradually  increased 
by  means  of  an  excellent  Hirschmann  rheostat,  when  it 
was  allowed  to  flow  for  about  five  minutes,  then  was 
gradually  diminished  and  finally  discontinued  by  the 
extraction  of  the  needle  at  a  very  low  current  intensity. 
The  whole  current  duration  was  about  ten  or  twelve 
minutes,  the  operation  was  almost  painless,  and  not  a 
drop  of  blood  was  lost.  The  lady  drove  home  from 
mv  office.  She  was  advised  to  remain  a  few  days  in 
bed,  without,  however,  changing  her  diet  and  without 


December  8,  1900] 


MEDICAL    RECORD. 


889 


any  treatment,  no  fever  or  any  other  unpleasant  symp- 
toms having  followed  the  operation. 

Three  electrolytic  operations  in  all  were  performed 
at  intervals  of  two  or  three  weeks,  with  the  only  dif- 
ference that  the  cathode  needle  was  introduced  at 
a  different  place  each  time  with  the  highest  current 
intensity  of  about  one  hundred  and  fifty  milliamperes. 

For  after-treatment,  I  used  galvanization  of  the 
splanchnic  nerves — a  method  I  described  in  West- 
phal's  Anhiv  (vol.  10),  and  whicii  infiuences  favora- 
bly the  circulation  in  the  pelvic  and  abdominal 
organs,  and  is  therefore  employed  by  me  in  all  chronic 
affections  of  the  female  pelvic  organs.  Besides  I  used 
faradization  of  the  relaxed  abdominal  and  perineal 
muscles,  and  of  the  ligaments  of  the  uterus.  The  tumor 
soon  began  to  diminish,  digestion  and  other  functions 
became  normal.  (Edema  having  entirely  disappeared 
the  patient  regained  her  excellent  health,  which  she 
continues  to  enjoy.  I  saw  the  patient  occasionally 
during  the  next  year  after  the  operation  and  every 
time  found  a  considerable  reduction  in  the  size  of  the 
uterus,  until  there  remained  only  a  circumscribed  en- 
largement in  the  posteriorwall  of  the  uterus,  which  did 
not  in  the  least  trouble  the  patient.  She  has  become 
again  a  good  pedestrian,  and  passed  through  the  change 
of  life  without  any  discomfort. 

The  method  employed  in  the  above  case  is  generally 
adopted  by  me  in  the  treatment  of  fibroid  tumors  of 
the  uterus.  My  experiments  taught  me  long  ago  that 
the  tissue  of  myoma  easily  yields  to  electrolysis.  I 
usually  postpone  each  subsequent  operation  as  long 
as  the  tumor  continues  to  diminish,  and  until  every 
trace  of  the  inserted  needle  has  disappeared.  The  in- 
tervals last  from  ten  days  to  three  weeks.  The  needles 
for  electrolysis  are  always  of  platinum,  which,  besides 
being  pliable,  does  not  oxidize  under  ordinary  circum- 
stances, and,  when  used  as  an  anode,  they  do  not  corrode 
or  break  and  can  be  easily  extracted. 

My  principal  work  in  electrolysis,  both  experimental 
and  practical,  was  published  between  1868  and  1881, 
i.e.,  before  the  introduction  of  the  absolute  galva- 
nometer. I  always  worked,  however,  with  the  excellent 
apparatus  of  Kriiger  and  Hirschmann,  which  contained 
a  good  current-selector,  a  commutator,  rheotome,  rheo- 
stat, Sieman's  constant  elements,  and  a  good  galvano- 
scope,  indicating  not  only  the  presence  and  direction 
of  the  current  but  also  its  approximate  intensity.  In 
using  this  apparatus  the  number  of  resistances  and 
the  angle  of  deflection  of  the  needle  gave  a  tolerably 
accurate  notion  of  the  amount  of  the  electric  cur- 
rent.' 

In  this  way  Du  Bois-Reymond,  PHuger,  and  others 
discovered  the  laws  of  electro-physiology;  Brenner 
the  normal  and  pathological  reactions  of  the  motor 
and  auditory  nerves;  Erb  the  degeneration  reaction;  I 
described  the  galvanic  reaction  of  the  optic  nerve,  and 
the  whole  doctrine  of  electro-diagnostics  was  estab- 
lished before  the  introduction  of  the  absolute  galva- 
nometer. 

For  scientific  electro-therapeutics  it  is  of  the  utmost 
importance  to  have  an  exact  standard  of  measurement, 
although  for  daily  practical  purposes  we  may  speak  of 
weak,  moderate,  or  strong  currents,  as  we  do  of  small, 
moderate,  or  large  doses  of  a  remedy;  still  more  so  in 
electro-therapeutics,  since  during  a  sitting  we  have 
constantly  to  change  the  intensity  of  the  current.  Be- 
sides in  medical  cases  it  is  not  so  much  the  current 
intensity  per  se,  as  the  insidious  or  abrupt  way  in 
which  it  is  increased  or  diminished  that  is  of  con- 
sequence. 

Generally  speaking,  I  use  from  20  to  200  railliam- 

'  Tlie  great  resistance  of  the  epidermis  need  not  be  considered 
when  needle  electrodes  are  used.  In  percutaneous  applications  of 
the  current  the  resistance  of  the  epidermis  is  reduced  to  a  mini- 
mum by  saturating  it  with  a  tepid  saline  solution. 


peres  in  treating  benign  tumors,  and  30  to  1,000  mil- 
liamperes for  malignant  tumors,  according  to  the 
nature  and  size  of  the  tumor  and  the  duration  of  the 
current. 

As  I  purposely  select  illustrations  from  my  old  cases 
which  have  stood  the  test  of  time,  I  give  the  amount 
of  electricity  only  approximately  in  milliamperes. 

I  discontinue  the  electrolytic  operations  when  the 
tumor  is  still  of  considerable  size,  because  the  regres- 
sive metamorphosis,  once  fairly  begim,  as  a  rule  pro- 
gresses spontaneously,  as  in  the  following  case: 

In  1869  I  was  consulted  by  a  married  childless  lady, 
about  forty  years  old,  who  suffered  from  dysmenor- 
rhcea  ascribed  to  a  retro-uterine  fibroid  tumor.  I  in- 
serted into  the  tumor  a  cathode  needle  of  a  moderate 
current,  and  repeated  the  operation  three  times  in  two 
months.  The  dysmenorrhcea  and  all  other  morbid 
symptoms  disappeared,  and  her  general  health  im- 
proved. She  had  to  go  home  (Chicago),  expecting  soon 
to  return  and  resume  the  treatment,  but  had  to  stay 
away  for  more  than  a  year,  still  feeling  well.  When 
she  returned  to  New  York  I  found  only  a  small  resid- 
uum of  the  tumor,  and  therefore  informed  her  that  all 
further  treatment  was  unnecessary. 

Since  this  experience  I  leave  the  further  reduction 
of  a  tumor  to  nature  and  to  the  spontaneous  regressive 
metamorphosis  which  has  been  induced  by  the  elec- 
trolytic operations.  The  electrolytic  effect  is  gener- 
ally better  when  the  operation  is  performed  before  the 
menstrual  period. 

When  I  first  began  to  treat  fibromyomata  accom- 
panied by  profuse  menstruation,  I  introduced  on  sev- 
eral occasions  into  the  cervix  a  sound-like  anode  of  a 
rather  weak  current;  but  the  effect  was  more  irritating 
locally  and  constitutionally  than  with  my  ordinary 
method;  and  as  soon  as  I  found  that  the  insertion  of 
the  cathode  needle,  as  practised  by  me,  removed  the 
hemorrhages  together  with  all  the  morbid  symptoms, 
I  never  afterward  treated  fibroid  tumors  through  the 
canal  of  the  cervix. 

As  mentioned  above,  my  researches,  conducted  dur- 
ing many  years,  were  published  in  Virchow's  Arcliiv, 
the  last  exhaustive  article  appearing  in  1881.  They 
were  all  extensively  quoted  in  the  leading  German, 
English,  and  French  periodicals.  In  1882,  a  year 
after  the  last  publication  of  my  work,  Apostoli  pub- 
lished his  first  article  on  the  electrolytic  treatment  of 
fibroids  of  the  uterus,  followed  by  numerous  articles 
on  the  subject  in  the  principal  cities  of  Europe  and 
America. 

His  method  of  introducing  a  sound  electrode  into 
the  cervix  requires  more  frequent  operations  with 
strong  currents,  and  is  in  so  far  injurious  as  it  more 
or  less  destroys  the  mucous  membrane,  together  with 
the  glandular  structures  of  the  cervix,  with  all  the 
harmful  consequences,  especially  in  case  of  a  subse- 
quent pregnancy.  Still  more  serious  is  the  insertion 
of  the  anode  into  the  substance  of  the  intramural 
fibroids,  which  may  cause  sloughing  and  even  a  fatal 
result.  These  disadvantages  are  absent  in  my  method. 
The  insertion  of  the  cathode  needle  into  the  tumor  is 
preferable  to  the  introduction  of  the  anode  sound  into 
the  cervix;  it  is  far  more  efficient  and  harmless;  it  is 
simple,  more  convenient,  less  painful,  and  free  from 
injurious  or  dangerous  effects. 

I  said  previously  that  the  electrolytic  treatment  is 
indicated  not  only  in  malignant  neoplasms  but  in 
such  cases  in  which  the  usual  surgical  operations  are 
employed  under  great  disadvantages;  for  instance,  as 
in  the  following  case: 

Mrs.  D ,  of  Boston,  aged  thirty-three  years,  an 

emaciated,  cachectic-looking  lady,  consulted  me  in  the 
spring  of  1873  about  an  e.xtremely  painful  affection  of 
the  left  thumb,  of  fifteen  years'  standing.  The  in- 
tensest  pain  was  concentrated  at  the  base  of  the  nail 


890 


MEDICAL    RECORD. 


[December  8,  1900 


on  the  ulnar  side.  The  patient  compared  the  pain  to 
toothache,  but  a  great  deal  worse;  she  said  it  was  as 
when  the  exposed  nerve  of  a  tooth  came  in  contact 
with  a  metallic  instrument.  The  pain  was  continuous, 
and  increased  at  the  slightest  touch,  so  that  she  kept 
the  thumb  protected  by  the  fingers  even  in  sleep.  The 
objective  examination  was  possible  only  in  deep  nar- 
cosis, but  nothing  abnormal  could  be  detected.  The 
patient  consulted  the  most  distinguished  neurologists 
and  surgeons,  and  used  all  sorts  of  narcotics  and  con- 
stitutional treatments,  without  relief.  She  tried 
three  different  kinds  of  electrical  treatment,  and  the  gal- 
vano-cautery  under  an  anesthetic,  and  maintained 
that  electricity  aggravated  her  suffering  every  time. 
Finally,  at  the  advice  of  eminent  surgeons,  among 
whom  was  Dr.  Mussey,  of  Cincinnati,  she  decided  to 
have  the  thumb  amputated.  Brown-Se'quard  objected 
on  the  ground  that  the  pain  might  be  of  a  central  ori- 
gin, and  the  amputation  would  not  abolish  the  pain. 
Dr.  Mussey  then  advised  the  patient  to  consult  me 
before  submitting  to  the  operation. 

With  the  assistance  of  Dr.  Rogers,  I  made  a  thor- 
ough examination  of  the  patient  on  May  15,  1873. 
The  excruciating  pain  was  concentrated  at  the  base  of 
the  nail,  and  the  spot  could  not  be  touched  even  under 
a  superficial  narcosis.  There  was  no  atrophy  or  other 
trophic  symptom,  no  pain  along  any  nerve  either  spon- 
taneously or  under  pressure.  The  most  careful  exam- 
ination under  a  complete  anaesthesia  gave  the  same 
result;  nothing  abnormal  could  be  detected,  no  nodule 
or  intumescence  of  any  kind.  It  was  obvious  that  the 
painful  affection  was  not  an  ordinary  neuralgia; 
again,  it  could  not  be  a  neuritis  on  account  of  the 
absence  of  any  trophic  or  other  neuritic  symptoms; 
neither  could  it  depend  on  a  central  cause,  all  central 
symptoms  being  absent.  I  thus  came  to  the  conclu- 
sion that  there  must  be  some  miliary  neuroma  inacces- 
sible to  palpation  owing  to  its  small  size,  but  which 
acted  as  an  irritant  on  some  sensitive  nerve-filament, 
and  I  decided  to  use  electrolysis,  from  which  I  had 
had  excellent  results  in  several  cases  of  neuroma  and 
tuberculum  dolorosum. 

Accordingly  on  June  4,  1873,  after  the  patient  had 
marked  the  painful  spot  with  silver  nitrate,  I  resorted 
to  the  electrolytic  operation  under  profound  anses- 
thesia.  A  flexible  anode  was  placed  around  the  fore- 
arm, and  the  cathode  needle  inserted  into  the  painful 
spot  as  far  as  the  bone;  the  current  was  rapidly  in- 
creased to  about  two  hundred  milliamperes,  and  after 
about  half  a  minute  or  so  gradually  decreased  to  zero 
and  the  needle  extracted.  No  blood  escaped,  only  a 
small  grayish  discoloration  appeared  around  the 
needle.  On  awakening,  the  patient  was  delighted  to 
find  no  pain  even  under  pressure,  felt  very  well  and 
slept  comfortably  all  night,  enjoying  the  complete 
disappearance  of  suffering.  The  scab  on  coming  off 
left  no  mark.  The  pain  that  had  lasted  day  and  night 
for  more  than  fifteen  years  never  returned  (since  1873 
— now,  1900)  after  the  apparently  insignificant  elec- 
trolytic operation  of  less  than  two  minutes'  duration. 
The  patient  belongs  to  an  old  Boston  family,  her  case 
was  known  at  the  time  to  the  profession  of  that  city,  and 
Dr.  Mussey  wrote  me  that  lie  had  been  so  impressed  by 
the  unexpected  result  that  he  concluded  to  try  himself 
an  electrolytic  operation.  He  sent  me  the  cast  of  a 
woman's  wrist  affected  by  cancer  involving  the  bones, 
which  he  cured  by  electrolysis,  aft^r  the  general  opin- 
ion of  surgeons  was  to  amputate  the  forearm. 

I  would  add  that  neuromatous  affections  of  this 
kind  are  of  more  frequent  occurrence  than  is  generally 
accepted.  The  "  points  douloureux  "  of  Valleix,  which 
are  considered  pathognomonic  for  genuine  neural- 
gias, are,  in  some  cases  at  least,  not  only  a  symptom, 
but  the  real  cause  of  the  neuralgia.  I  came  to  this 
conclusion  from  the  favorable  result  of  electrolysis  in 


several  obstinate  neuralgias  which  had  resisted  previ- 
ous treatments. 

In  the  treatment  of  benign  tumors  of  considerable 
size  I  often  use  the  following  method;  After  local  an- 
resthesia  I  introduce  the  cathode  needle  into  the  tumor 
and  apply  a  large  anode  at  some  distance  from  it, 
when  the  current  is  increased  very  slov.ly  to  a  moder- 
ate intensity  and  after  a  few  minutes  gradually  reduced 
to  the  minimum  and  the  needle  extracted.  This  pro- 
cedure is  repeated  as  often  as  advisable,  with  some 
modifications.  No  local  anesthesia  is  required  after 
the  first  operation,  the  needle  being  inserted  into  the 
same  place,  but  each  time  in  a  dift'erent  direction  in 
the  tumor.  The  current  intensity  may  be  somewhat 
increased  or  diminished.  These  operations  are  per- 
fectly painless,  and  do  not  inconvenience  patients  in 
their  daily  occupations.  The  insertion  of  the  needle 
leaves  no  mark  on  the  skin,  and  the  tumor  gradually 
diminishes  and  disappears.  After  a  certain  number 
of  such  needle  operations  the  current  may  be  applied 
percutaneously  by  means  of  a  small  flat  cathode  over 
the  place  where  the  needle  was  inserted  in  the  previ- 
ous operations.  The  current  in  its  greatest  intensity  is 
thus  conducted  into  the  substance  of  the  tumor  along 
the  lines  made  by  the  former  insertions  of  the  needle. 
In  this  painless  manner  I  treated  many  benign  tumors, 
including  goitres,  naso-pharyngeal  and  other  tumors. 

Mrs.  B ,  forty-five  years  old,  and  mother  of  five 

healthy  children,  was  referred  to  me  by  Dr.  Dunham, 
March  5,  1873.  Both  her  parents  died  early  (at  thirty- 
three  and  forty-six  years  respectively)  of  pulmonary 
tuberculosis.  The  patient  was  formerly  healthy,  but 
had  a  goitre,  the  origin  of  which  could  be  traced  back 
to  her  early  youth.  It  gradually  increased  until  it 
attained  considerable  dimensions,  and  while  it  for- 
merly had  no  unpleasant  features,  during  the  last  few 
years  morbid  symptoms  manifested  themselves  with 
increasing  severity  within  the  spheres  of  respiration 
and  circulation.  The  struma  occupied  the  anterior 
surface  of  the  neck,  especially  the  right  side,  the  mid- 
dle portion  filled  the  jugulum  sterni  and,  bulging  out 
in  an  oval  prominence,  extended  downward  into  the 
mediastinum.  Its  lower  end  could  not  be  ascer- 
tained. The  right  sterno-mastoid  muscle  was  pushed 
outward,  and  strong  pulsations  of  the  right  carotid 
could  be  felt  behind  it.  The  right  cervical  veins  were 
much  dilated,  the  deeper  cervical  glands  enlarged 
and  indurated.  Phenomena  of  paralysis  of  the  right 
cervical  sympathetic  were  very  marked;  the  right  eye, 
sunken,  appeared  smaller  than  the  left,  its  pupil  was 
contracted  to  the  size  of  a  pin's  head  (myosis),  and 
ptosis  of  the  right  lid  was  present,  the  vision  remain- 
ing normal.  The  patient  complained  of  difficult 
breathing,  especially  when  going  upstairs  or  lying  on 
the  left  side,  and  of  pains  in  the  left  shoulder  and  arm. 
The  area  of  cardiac  dulness  was  enlarged,  but  there 
was  no  valvular  atTection.  Evidently  it  was  a  case 
of  mediastinal  struma,  and  the  paralytic  phenomena 
of  the  right  cervical  sympathetic  were  caused  by  the 
pressure  of  the  indurated  glands.  The  patient  was 
treated  both  here  and  in  Europe  with  various  remedies, 
the  tumor  being  considered  inoperable  as  it  was  im- 
possible to  remove  its  mediastinal  portion. 

In  her  case  I  resorted  to  the  above-described  method, 
and  on  April  16,  1873,  after  local  anxsthesia,  a 
cathode  needle  was  introduced  through  the  central 
portion  of  the  struma — the  part  extending  into  the 
mediastinum — the  flat  anode  applied  at  a  distance,  the 
current  gradually  increased  to  about  fifty  milliamperes 
and  then  diminished  in  a  like  manner,  and  the  needle 
extracted.  The  operation  was  painless  and  lasted 
but  ten  minutes.  It  was  repeated  once  or  twice  a  week 
without  an;vsthetics,  the  needle  being  inserted  into  the 
same  place,  but  each  time  in  a  different  direction. 
On  discontinuing  the  needle  operations  she  was  treated 


December  8,  1900] 


MEDICAL    RECORD. 


891 


percutaneously  with  a  small  cathode  plate  over  the 
place  of  the  needle  insertion,  and  the  anode  as  before. 
The  treatment  was  discontinued  after  the  struma  was 
considerably  reduced  and  the  subjective  symptoms 
had  disappeared.  Ten  years  later  I  had  the  oppor- 
tunity to  examine  the  patient,  and  found  the  same  sat- 
isfactory conditions. 

Miss   B ,  eighteen  years  old,  a  well-developed, 

regularly  menstruated  young  lady,  with  an  unhealthy 
complexion  and  anasmic.  Four  years  ago  a  slight 
swelling  was  noticed  in  the  right  parotid  region,  and 
grew  to  the  size  of  a  hen's  egg,  extending  into  the 
space  between  the  maxilla  and  sterno-mastoid.  Al- 
though the  tumor  caused  no  pain,  its  steady  growth 
was  a  source  of  great  anxiety  to  her  parents.  There 
was  every  indication  for  surgical  interference,  but  all 
agreed  that  the  extirpation  of  the  tumor  would  be 
fraught  with  danger  on  account  of  its  intimate  connec- 
tion with  important  nerves  and  blood-vessels. 

The  case  was  referred  to  me  by  Dr.  Thompson,  of 
Indianapolis,  and  on  October  17,  1878,  I  began  the 
electrolytic  treatment.  The  tumor  in  the  right  parotid 
was  of  a  rather  hard  consistence,  somewhat  movable, 
and  covered  with  normal  skin  (lymphoma).  Besides 
this  large  lymphoma,  all  the  cervical  lymphatic  glands 
of  the  same  side  were  swollen,  .\fter  local  anes- 
thesia the  cathode  needle  was  introduced  into  the 
centre  of  the  tumor,  the  flat  anode  placed  over  the 
swollen  cervical  glands,  and  from  a  minimum  inten- 
sity the  current  was  gradually  increased  to  about  thirty 
milliamperes,  and  in  a  couple  of  minutes  diminished 
again  and  the  needle  extracted.  There  was  no  loss  of 
blood,  and  the  operation  was  painless;  the  patient  with 
her  parents  left  my  office  for  their  daily  drive  and 
walk  in  the  park.  These  operations,  but  without  an- 
aesthesia, were  repeated  several  times,  and  the  needle 
curved  to  enter  a  diflerent  direction  through  the  same 
puncture  each  time.  Later,  a  mild  current  was  daily 
applied  with  a  small  cathode  plate  over  the  spot  of 
the  needle  insertions,  and  the  anode  on  the  different 
swollen  cervical  glands.  Whenever  the  regressive 
metamorphosis  seemed  to  come  to  a  standstill,  the 
needle  operations  were  immediately  resumed.  This 
treatment  was  continued  until  the  tumor  entirely  dis- 
appeared. The  young  lady,  who  attended  school  in 
New  York,  continued  her  studies  without  interruption, 
and,  when  she  left  for  home  in  June,  1879,  she  was 
in  perfect  health.  A  few-  years  ago  I  had  the  oppor- 
tunity of  seeing  her  as  a  married  woman  and  mother 
of  healthy  children,  without  any  trace  of  the  former 
tumor. 

The  object  of  this  paper  is  to  elucidate  the  princi- 
ples on  which  the  electrolytic  method  is  based.  The 
space  being  limited,  I  have  to  omit  its  different  modi- 
fications in  various  forms  of  benign  tumors,  leaving 
the  details  to  be  acquired  by  practice.  I  omit,  too, 
the  histories  of  many  cases  in  which  the  electrolytic 
treatment  was  a  mild,  harmless,  seemingly  trifling 
procedure,  which  did  not  even  disturb  the  patients  in 
their  daily  occupations,  and  in  which  ordinary  surgical 
operations  could  have  been  applied  with  equal  success, 
but  would  have  been  of  a  far  more  difficult,  trouble- 
some, and  serious  nature. 

I  cannot  conclude  without  calling  attention  to  a 
very  distressing  surgical  affection — hypertrophy  and 
tumors  of  the  prostate — in  which  I  found  electrolysis 
of  great  benefit.  Soon  after  the  success  of  electroly- 
sis in  fibromyomata  of  the  uterus  it  occurred  to  me 
to  employ  the  same  in  prostatic  affections,  since  the 
prostata,  from  an  embryological  and  histological 
standpoint,  is  the  homologue  of  the  uterus;  three- 
fourths  of  its  substance  being  muscular  and  one-fourth 
glandular  tissue.  Moreover,  my  earliest  experiments 
on  li\ing  animal  tissues  taught  me  that  the  unstriped 
muscular  tissue  most    readily  undergoes   electrolytic 


action;  a  priori,  therefore,  it  was  a  rational  indication 
to  employ  electrolysis  in  prostatic  affections. 

Mr.  T ,  a    robust,   healthy-looking    gentleman, 

fifty  years  old,  gave  me  the  history  of  his  case.  When 
a  young  man,  in  a  course  of  athletic  games,  he  re- 
ceived an  injury  in  the  perinaium  which  laid  him  up 
for  six  weeks.  There  was  a  painful  inflammatory 
swelling,  with  fever  and  diflicult  micturition.  An 
eminent  surgeon  considered  serious  the  injury  to  the 
prostate,  and  treated  him  with  leeches,  poultices, 
cathartics,  and  prolonged  rest.  The  patient  recovered 
under  this  rational  treatment,  but  for  a  long  time  there 
remained  considerable  tenderness  in  the  perina-um, 
with  a  feeling  as  of  some  swelling,  and  an  occasional 
slight  impediment  in  passing  water.  These  symp- 
toms gradually  wore  off;  he  married  and  had  several 
healthy  children.  About  ten  years  ago  the  old  symp- 
toms began  occasionally  to  return,  especially  after 
physical  over-exertion  or  any  other  excess;  unpleasant 
sensation  in  the  perina-um,  slow  and  difficult  micturi- 
tion gradually  increased  and  became  permanent.  He 
was  treated  for  enlargement  of  the  prostate  here,  and 
later  in  London  and  Scotland,  and  received  temporary 
relief  from  the  introduction  of  metallic  sounds;  but  on 
the  whole  the  morbid  symptoms  kept  on  the  increase. 
When  he  consulted  me,  he  complained  of  discomfort 
in  the  perinaum  and  bladder,  which  he  could  never 
entirely  empty;  the  micturition  was  slow  and  painful, 
the  urine  was  turbid  and  contained  a  great  deal  of  mu- 
cus, pus-corpuscles,  and  epithelia  of  the  bladder.  The 
patient  said  his  urine  was  clear  before  the  treatment 
with  sounds.  He  evidently  had  cystitis  and  chronic 
hypertrophy  of  the  prostate.  I  advised  tepid  irriga- 
tions of  the  bladder  with  antiseptic  solutions,  which 
relieved  the  acute  inflammatory  symptoms,  while  the 
enlargement  of  the  prostate  remained  the  same.  I 
then  began  the  electrolytic  treatment.  After  the  evac- 
uation of  the  bowels  with  a  saline  aperient  and  an 
enema,  I  inserted  into  the  substance  of  the  prostate 
through  the  rectum  a  carefully  insulated  cathode 
needle,  allowing  but  a  small  part  of  it — the  very  end 
— to  be  active.  The  anode  plate  was  applied  to  the 
hypogastrium,  and  a  very  weak  constant  current  was 
gradually  increased  to  about  fifty  milliamperes,  then 
decreased  to  zero  in  a  few  minutes  when  the  needle  was 
extracted.  This  treatment  was  repeated  in  a  fortn ight ; 
in  the  interval  and  afterward  galvano-faradization  was 
used.  A  specially  prepared  cathode  electrode  was  in- 
troduced into  the  rectum  so  that  only  a  part  of  its  cylin- 
drical surface  came  in  contact  with  the  rectal  portions 
contiguous  to  the  prostate.  The  anode  plate  was  ap- 
plied to  the  hypogastrium  as  before.  By  means  of  a 
Hirschmann  apparatus  both  the  constant  and  faradic 
currents  were  used  simultaneously  with  the  same  elec- 
trodes, allowing  the  currents  to  be  increased,  decreased, 
or  reversed.  Under  this  treatment  the  patient  rapidly 
improved,  the  prostatic  enlargement  gradually  dimin- 
ished, the  cystitis  and  all  morbid  symptoms  disap- 
peared and  have  not  returned. 

I  often  employ  galvano-faradization  in  affections  of 
the  nervous  and  muscular  system  for  the  purpose  of 
stimulating  them  while  the  nerves  are  in  a  state  of 
electrotonus.  In  many  chronic  affections  it  greatly 
stimulates  the  circulation,  absorption,  osmotic  press- 
ure^in  fact,  all  the  physico-chemical  phenomena  and 
physiological  functions.  VVhen  used  after  electrolytic 
needle  operations,  it  enhances  the  electrolytic  and 
cataphoric  action  of  the  current.  In  affections  of  the 
abdominal  and  pelvic  organs,  too,  galvano-faradization 
of  the  splanchnic  nerves,  which  control  and  regulate 
the  circulation  and  nutrition  of  these  organs,  is  ex- 
ceedingly beneficial.  Altogether,  the  physiological 
and  therapeutic  effects  of  galvano-faradization  are 
most  remarkable. 

Mr.  L ,  sixty-five  years  old,  consulted   me    in 


892 


MEDICAL    RECORD. 


[December  8,  igoo 


March,  i8g6,  for  prostatic  enlargement  with  chronic 
cystitis  which  for  many  years  resisted  local  and  gen- 
eral treatment.  The  patient  was  of  a  sallow  com- 
plexion, anajmic,  emaciated,  worn  out  by  sleepless 
nights,  owing  to  the  bladder  trouble.  The  enlarged 
prostate  was  tumor-like  and  hard,  the  urine  very  turbid 
and  formed  a  massive,  thick  nuico-piirulent  and  gelat- 
inous deposit.  Tepid  antiseptic  irrigations,  contin- 
ued for  a  fortnigiit,  gave  relief,  and  I  could  proceed 
to  the  first  electrolytic  operation,  performed  as  in  the 
preceding  case  and  twice  repeated.  Later,  the  insu- 
lated rectal  cathode  was  applied  to  the  prostate  and 
the  large  anode  to  the  hypogastric  region  and,  as  in 
the  above  case,  strong  galvanic  and  faradic  currents 
were  used  simultaneously  with  frequent  reversions. 
This  was  repeated  three  times,  twice  and  once  a  week, 
and  afterward  only  occasionally.  The  subjective 
symptoms  disappeared  toward  the  end  of  two  months. 
Water  could  be  retained  for  hours,  and  the  patient 
could  sleep  comfortably.  The  prostatic  enlargement 
was  considerably  reduced  and  the  general  health  much 
improved.  As  an  after-treatment  I  employed  as  usual 
the  galvano-faradization  of  the  splanchnic  nerves. 

In  recent,  less  advanced  cases  of  prostatic  enlarge- 
ment, and  in  the  absence  of  cystitis,  I  entirely  dis- 
pense with  the  needle  operations  and  irrigations  of 
the  bladder,  and  use  instead  the  rectal  electrode  with 
the  anode  at  the  hypogastric  and  inguinal  regions  and 
combined  constant  and  faradic  currents,  as  described 
bove,  and  subsequently  galvano-faradization  of  the 
splanchnic  nerves.  In  mild  cases  even  the  rectal  elec- 
trode gives  way  to  a  properly  shaped  cathode  applied 
to  the  perinaeum  and  the  anode  to  the  lumbar,  hypo- 
gastric, and  inguinal  regions  with  strong  galvano- 
faradization,  as  in  the  following  case: 

Mr.  C ,  aged  fifty-eight  years,  noticed  in  the  last 

few  years  a  peculiar  change  in  the  voiding  of  the 
bladder;  the  flow  became  very  slow,  prolonged,  with 
interruptions  and  a  feeling  of  discomfort.  His  phy- 
sicians found  a  considerable  hypertrophy  of  the  pros- 
tate; the  urine  was  very  concentrated,  of  a  dark  color, 
of  high  specific  gravity,  containing  a  large  amount  of 
indican  and  urates.  In  November,  1897,  I  began  the 
electrolytic  treatment  of  the  prostatic  enlargement, 
with  a  cathode  of  convenient  shape  applied  to  the  per- 
inaum  and  a  large  anode  to  the  lumbar,  iiypogastric, 
and  inguinal  regions,  and  used  strong  galvanic  and 
surging  faradic  currents  simultaneously  with  frequent 
alternations,  as  previously  described,  until  the  com- 
plete disappearance  of  all  morbid  symptoms,  and  fol- 
lowed this  by  galvano-faradization  of  the  splanchnic 
nerves.     The  gentleman  continues  in  excellent  health. 

During  these  many  years  I  did  not  publish  my 
observations  of  prostatic  enlargements.  The  cases 
treated  by  me  with  electrolysis — seventeen  in  all — • 
may  be  considered  too  few  to  establish  the  value  of  a 
therapeutic  method,  but  I  give  some  of  them  because 
I  believe  that  even  one  positive  result  is  worth  more 
than  hundreds  of  negative  ones,  especially  in  prostatic 
affections,  in  which  the  available  palliative  is  only 
castration  or  Bottini's  operation. 

As  everywhere  in  practical  medicine,  the  electro- 
lytic treatment  has  to  be  adapted  to  the  exigencies  of 
each  special  case,  and  the  physician  often  has  to  de- 
viate from  a  general  rule.  Thus,  I  laid  down  the 
general  indications  for  the  treatment  of  malignant  and 
non-malignant  tumors  as  follows:  Malignant  neo- 
plasms ought  to  be  entirely  destroyed  in  one  sitting 
by  the  action  of  the  anode,  whereas  in  the  non-malig- 
nant tumors  a  regressive  metamorphosis,  a  gradual 
reduction,  and  atrophy  should  be  induced  isy  the 
action  of  the  cathode.  But  I  had  to  modify  this  pro- 
cedure in  some  cases,  as  in  the  following: 

Mr.  E ,  over  sixty  years  old,  of  a  good  constitu- 
tion, consulted  me  in  October,   1899,  about  a  small 


nodule,  the  size  of  a  pea,  at  the  right  angle  of  ;he 
mouth,  at  the  junction  of  the  skin  and  mucous  mem- 
brane, from  which  filiform  elongations  could  be  felt  in 
different  directions.  More  than  a  year  ago  he  noticed 
a  scarcely  perceptible  induration,  which  gradually 
reached  its  present  size,  and,  to  prevent  its  further 
growth,  his  family  piiysician  advised  the  removal  of 
the  nodule  by  the  knife,  as  all  external  treatment  was 
of  no  avail.  Bearing  in  mind  that  the  location  of  the 
nodule  is  frequently  the  seat  of  an  epithelioma  and 
that  under  the  former  treatment  it  showed  no  tendency 
to  resolution  or  absorption,  I  was  inclined  to  consider 
it  of  a  malignant  nature,  although  the  neighboring 
lymphatics  were  not  yet  involved,  and  there  were  no 
other  symptoms  of  malignancy.  I  introduced  the 
cathode  needle  of  a  very  weak  current  into  the  centre 
of  the  nodule  to  its  basis,  the  anode  plate  under  the 
chin,  gradually  increased  the  current  to  thirty  milli- 
amperes,  and  in  a  few  seconds  diminished  it  and  ex- 
tracted the  needle.  But  I  immediately  reinserted  the 
needle  into  the  same  puncture,  giving  it  a  different 
direction — into  one  of  the  elongations — and  in  a  little 
while  extracted  it  again  to  reintroduce  it  several  times, 
once  into  each  of  the  elongations,  but  always  through 
the  same  opening.  From  my  office  the  patient  went 
directly  down-town  to  attend  to  his  business,  as  usual, 
and  came  every  morning  during  that  week,  and  three 
ti.mes  the  next  week,  when  I  applied  for  a  few  minutes 
a  small  cathode  plate  of  a  weak  current  over  the  place 
where  the  needle  was  inserted,  the  anode  as  before. 
A  small  scab  came  off  leaving  no  mark  on  the  skin, 
and  the  induration  which  had  been  gradually  decreasing 
disappeared  entirely.  The  operation  left  not  the 
slightest  trace.     The  gentleman  is  in  excellent  health. 

Mr.  M ,  sixty  years  old,  of  good   constitution, 

had  a  molluscum  fibrosum,  the  size  of  a  small  plum, 
over  the  right  shoulder.  During  the  last  year  it  be- 
came more  -or  less  troublesome  and  irritating;  it 
changed  color  and  occasionally  bled.  I  found  it  red, 
with  partial,  dark  pigmentation;  the  excrescence  was 
connected  with  the  common  integument  by  a  thin  but 
rather  hard  pedicle  in  which  could  be  felt  the  pulsa- 
tion of  a  blood-vessel.  Such  a  fibroma  molluscum 
may  remain  in  statu  quo  for  life,  or  may  sometimes 
assume  a  malignant  course,  especially  in  the  pigmented 
variety  as  in  this  case.  I  operated  in  November, 
1899,  with  the  two  needles  of  a  bifurcated  cathode  in- 
serted at  the  base  of  the  fibroma,  and  the  anode  needle 
into  the  thick,  soft,  and  pendulous  end  of  the  mollus- 
cum. A  weak  current  was  turned  on,  gradually  in- 
creased to  one  hundred  milliamperes  and  continued 
until  the  whole  mass  became  livid  and  black,  when 
the  current  was  brought  back  to  zero  and  the  needle 
extracted.  No  blood  escaped,  and  the  pulsation 
ceased.  The  whole  fibroid  eventually  shrivelled  and 
mummified,  and  finally  came  off  without  leaving  a 
trace  of  its  former  existence,  or  even  a  mark  on  the 
skin. 

Thus  the  first  of  these  cases,  probably  of  a  malig- 
nant nature,  was  treated  like  a  non-malignant  tumor 
by  gradual  absorption  induced  by  the  cathode  needle. 
On  the  other  hand,  the  fibroma  molluscum,  generally 
a  benign  tumor,  was  here  treated  as  malignant  by 
necrotic  destruction  of  the  whole,  induced  by  the  1 
action  of  the  anode. 

I  made  this  modification  in  the  above  cases  on  ac- 
count of  the  location  occupied  by  the  tumors,  their 
size,  and  the  mode  and  degree  of  their  development. 


Cholera  in  India. — Cholera  has  been  so  bad  in  the 
Ram|7ore  state,  India,  that  the  Nawab  has  just  sacri- 
ficed one  of  his  elepiiants  in  the  hope  that  the  offering 
will  appease  the  goddess  of  the  disease. 


I 


December  8,  1900] 


MEDICAL    RECORD. 


893 


INFANT    FEEDING.' 

By    LOUIS    FISCHER,    M.IJ., 

ATTENDING       HHVSICIAN      TO      THE     CHILDREN'S     SERVICE     OF     THE     CERMA.S' 
POLIKLINIK.    ETC. 

Hand  Feeding  or  Bottle  Feeding. — The  most  impor- 
tant point  to  be  considered  in  the  proper  management 
of  bottle  feeding  is  to  have  pure  cow's  milk.  Such 
milk  can  be  secured  only  from  a  reliable  dairy,  in 
which  we  are  positive  that  all  modern  sanitary  laws 
are  so  applied  that  the  hygienic  condition  of  the  cow's 
stable  is  perfect.  The  principle  of  sterilization 
should  be  applied  to  everything  in  the  stable — to  the 
cow,  to  the  milker's  hands,  and  to  all  utensils  used  in 
milking  and  transportation  exactly  as  was  outlined  by 
Professor  Baginsky  in  his  paper  on  "Milk  Supply," 
which  I  had  the  honor  to  read  at  the  last  meeting  of 
the  section  on  diseases  of  children  at  Atlantic  City  in 
June,  1900.  The  principle  of  asepsis,  so  important 
in  surgery,  and  which  is  really  nothing  more  than 
absolute  cleanliness,  should  be  rigidly  enforced. 

Imitate  nature  in  feeding.  Nature  has  ordained  for 
woman  to  feed  her  infant  with  raw  milk,  for  it  must 
be  admitted  tiiat  the  breast  milk  of  a  woman  is  raw;  it 
is  neither  boiled,  nor  sterilized,  nor  pasteurized.  Thus 
we  should  simply  imitate  nature  in  feeding  the  milk 
of  the  cow  in  the  same  manner  as  the  infant  at  the 
breast  receives  it  from  its  mother  or  wetnurse. 

Objections  to  Raw-Milk  Feeding — There  is  a  de- 
cided objection  to  raw-milk  feeding  owing  to  the  con- 
tamination of  milk  with  various  pathogenic  bacteria. 
Such  risk,  however,  is  reduced  to  a  minimum  when  all 
the  principles  of  modern  hygienic  measures  are  rigidly 
enforced.  It  is  a  well-known  fact  that  the  prolonged 
use  of  sterilized  or  boiled  milk  will  produce  scurvy, 
and  when  scurvy  exists  both  sterilized  and  boiled  milk 
must  be  discontinued  to  give  place  to  fresh  raw  milk. 
Does  it  not  seem  more  plausible  in  the  face  of  such 
clinical  experience  to  commence  feeding  at  once  with 
raw  milk  rather  than  risk  the  development  of  scurvy 
and  be  compelled  to  discontinue  all  other  forms  of 
feeding  excepting  raw  foods?  There  is  a  certain  dead- 
ness,  or,  to  put  it  differently,  absence  of  freshness  in 
milk  that  is  boiled  or  sterilized.  It  seems  to  be  the 
lack  of  this  same  element  of  freshness  which  in  the  ab- 
sence of  fresh  meat  and  green  vegetables  w'ill  produce 
scurvy  in  the  adult.  Speaking  of  the  development  of 
scurvy  in  children  fed  on  sterilized  or  boiled  milk 
Rundlett  says  that  changes  take  place  not  in  the  albu- 
men, fat,  or  sugar;  but  in  the  albuminate  of  iron,  phos- 
phorus, and  possibly  in  the  fluorin,  vital  changes  take 
place.  These  albuminoids  are  certainly  in  milk,  de- 
rived as  it  is  from  tissues  that  contain  them  and  are 
present  in  a  vitalized  form  as  proteids. 

On  boiling  the  change  that  takes  place  is  due  simply 
to  the  coagulation  of  the  globulin  or  proteid  molecule, 
which  splits  away  from  the  inorganic  molecule,  and 
thus  renders  it  as  to  the  iron  and  fluorin  unabsorb- 
able,  and  as  to  the  phosphatic  molecule  unassimilable. 
This  is  the  change  that  is  so  vital,  and  it  is  this  only 
which  takes  place  when  milk  is  boiled.  It  is  evident 
that  children  require  phosphatic  and  ferric  proteids 
in  a  living  form,  which  are  contained  onlv  in  raw 
milk. 

Cheadle  says  that  phosphate  of  lime  is  necessary  to 
every  tissue.  No  cell  growth  can  go  on  without  earthy 
phosphates;  even  the  lowest  form  of  life,  such  as 
fungi  and  bacteria,  cannot  grow  if  deprived  of  them. 
These  salts  of  lime  and  magnesia  are  especially  called 
for  in  the  development  of  the  bony  structures. 

General  Rules  for  Infant  Feeding. — Each  child 
is  a  law  unto  itself,  and  its  individual  wants  must  be 
studied.     One  child  will  gain  in  weight  on  the  same 

'  Read  before  the  stated  meeting  of  the  .\cademy  of  Medicine, 
at  its  Sj-niposium  on  Infant  Feeding,  October  l3,  igoo. 


mixture  on  which  another  will  lose  in  weight,  thus  prov- 
ing the  difference  in  the  assimilation  of  the  same  food 
in  various  infants.  Having  chosen  a  given  food  for 
one  infant,  we  must  note  the  foUowiug  factors,  to  be 
satisfied  tliat  it  is  thriving:  I'irst,  the  infant  must  zp- 
pear  satisfied  after  taking  its  bottle;  second,  there 
should  be  no  vomiting;  third,  there  should  be  no 
colic;  fourth,  the  bowels  must  move  unaided  at  least 
once  or  twice  in  twenty-four  hours,  depending  upon 
the  age  of  the  infant;  the  stool  should  be  yellowish- 
white  and  of  a  medium  soft  consistency;  fifth,  the  in- 
fant should  sleep  from  four  to  eight  hours  at  one  time 
during  the  night;  sixth,  the  weight  must  be  taken  reg- 
ularly once  a  week,  and  if  an  infant  thrives  it  should 
gain  at  least  six  to  eight  ounces  every  week;  seventh, 
when  a  child's  weight  shows  no  increase  the  reason 
should  be  studied,  and  by  all  means  the  food  changed, 
for  the  infant  requires  more  substantial  nourishment. 
The  following  table  will  give  an  approximate  idea  of 
the  quantity  of  food  suitable  for  the  age  of  the  infant: 


Age. 

Quantity. 

Proportion. 

Frequency  of  Feeding. 

3  ounces. 
6-8 

i  milk,  }  water. 

i  ::  *  :: 

2             no     ' 

Feed  every  a          hours. 

3 

3  or  4      " 

6  8       "        

Laboratory  Milk.— The  sentiments  expressed  at  the 

last  meeting  of  the  Academy  by  Professor  Jacobi, 
regarding  the  use  of  modified  laboratory  milk,  coin- 
cide with  my  views.  My  experience  has  been  that 
children  fed  on  laboratory  milk  have  been  backvvard 
in  their  development,  after  its  use  for  a  long  time. 
When  first  used,  children  suftered  with  severe  consti- 
pation. Later,  a  distinct  atony  of  the  stomach  and 
intestines  was  seen;  poor  appetites,  requiring  nux 
vomica,  were  seen  still  later,  accompanied  by  delajed 
dentition  and  rickets.  Children  using  the  milk  always 
looked  pale  and  ana;mic;  their  Hesii  was  flabby.  Such 
cases  were  among  the  wealthy,  in  which  the  best  possi- 
ble hygienic  conditions  ])revailed.  1  have  never  had 
an  opportunity  to  study  its  effect  on  infants  reared  in 
tenement  houses,  with  the  poorest  hygienic  surround- 
ings. The  percentage  method  of  feeding  has  always 
appeared  plausible  to  me,  but  the  theory  cannot  be  put 
into  practice.  U'e  know,  as  Jacobi  so  well  says,  that 
mother's  milk  changes  at  almost  each  nursing,  and  we 
know  by  chemical  analysis  that  mother's  milk  is  dif- 
ferent in  composition  several  times  during  the  day.  It 
will  be  necessary  then,  if  we  do  intend  to  imitate  na- 
ture, to  change  the  formula  of  an  infant  several  times 
a  day. 

It  is  a  fact  well  known  to  chemists  that  once  an 
emulsion  of  milk  is  broken  up  by  centrifuging  or 
other  mechanical  process,  as  in  separating  the  top 
milk  from  the  skim  milk,  we  cannot  have  again  as 
homogeneous  an  emulsion  as  prior  to  this  breaking  up; 
and,  moreover,  that  we  increase  our  trouble  when  we  in 
addition  seek  to  improve  the  quality  of  the  milk  by 
subjecting  it  to  the  process  of  sterilization. 

Substitute  for  Milk  in  Diseases  of  Stomach  and 
Intestines. — V\'hen  milk  disagrees  and  the  infant's 
stomach  will  not  tolerate  it,  and  vomiting  is  provoked, 
or  when  gastro-intestinal  trouble  arises,  then  milk 
must  be  stopped.  At  such  limes  I  have  seen  good  re- 
sults in  many  children  follow  the  use  of  almond  milk. 
This  is  made  by  scalding  or  blanching  the  almonds, 
then  beating  them  up,  using  an  ounce  of  water  for 
each  ounce  of  blanched  almonds,  and  rubbing  up 
this  mixture  and  then  expressing  it  through  cheese- 
cloth. This  should  yield  an  ounce  of  almond  milk 
for  each  ounce  of  almonds  used.  It  is  well  known 
that  quite  a  large  quantity  of  vegetable  proteids  are 
contained  therein,  and  it  is  therefore  a  nourishing 
substitute.     This  almond  milk  can  be  made  at  home, 


894 


MEDICAL    RECORD. 


[December  8,  1900 


and  is  quite  serviceable  in  the  treatment  of  summer 
complaint. 

Dextrinization  of  Foods,  Chiefly  the  Cereals — 
Dextrinization  is  successful  in  children  having  sub- 
normal gastric  digestion.  It  sliould  be  used  during 
illness  only,  and  it  is  not  advisable  to  feed  healthy 
children  with  de.xtrinized  foods.  Nature  supplies  its 
own  dextrinizing  agents,  which  must  be  used  or  the 
glands  secreting  them  will  become  atrophied. 

Frequently  the  infant's  stomach  requires  assistance 
in  the  assimilation  of  food,  particularly  cow's  milk. 
The  examination  of  the  gastric  contents  in  weak- 
ened gastric  conditions  has  always  shown  a  deficiency 
in  hydrochloric  acid.  Hence  it  seems  more  plausible 
to  give  the  infant  several  drops  of  dilute  hydrochloric 
acid  after  feeding. 

In  conclusion  permit  me  to  say  that  two  drugs  must 
'  always  be  considered  in  the  management  of  infant 
feeding,  especially  the  difficult  cases:  (i)  nuxvomica; 
(2)  malt. 

65  East  Ninetieth  Street. 


A    MISTAKE   IN    THERAPEUTICS.' 

Bv    EDWARD    1'.    BUFFET,    M.D., 

JERSEY    CITY,    N.    J. 

This  mistake  is  the  over-estimate  of  the  efficiency  of 
drugs  in  the  cure  of  disease.  It  is  a  mistake  made  by 
both  physician  and  patient,  but  more  frequently  and 
decidedly  by  the  patient  than  by  the  physician. 

It  is  a  popular  belief  that  disease  is  inevitable. 
There  is  a  superstitious  or  a  fatalistic  sentiment  wide- 
spread that  through  some  unfortunate  event  the  human 
race  became  heir  to  ills  innumerable  imposed  by  some 
malignant  power,  which  should  be  expected  and  waited 
for  with  as  good  grace  as  possible.  As  a  remedy  for 
these  unavoidable  ailments  it  is  thought,  on  the  other 
hand,  that  some  benevolent  being  has  hidden  away,  in 
various  obscure  localities,  the  specific  drug  which  has 
been  specially  devised  for  each  particular  ill  that  fiesh 
is  heir  to.  If  only  this  remedy  can  be  found,  the 
demon  of  disease  can  be  exorcised;  if  it  cannot,  bad 
luck  to  the  patient.  The  idea  that  the  mischievous 
germ  can  be  met  and  destroyed  before  it  has  entered 
the  human  organism  has  not  yet  become  a  popular 
one.  Neither  is  it  a  general  belief  that  the  human 
animal  was  ever  intended,  like  the  wonderful  one-hoss 
shay,  to  run  his  allotted  course  without  medical  repair 
until  he  is  actually  worn  out  and  the  time  arrives  for 
him,  as  the  hospital  interne  says,  to  "go  to  pieces" 
all  at  once. 

It  is  in  consequence  of  the  mistaken  impression  as 
to  the  value  and  necessity  of  drugs  that  they  have  been 
and  are  now  accumulating  in  marvellous  proportions. 
Eighteen  thousand  preparations  of  medicines  are  reg- 
istered in  the  National  Dispensatory,  with  the  nature 
and  uses  of  which  the  patient  kindly  assumes  that  the 
doctor  is  familiar,  and  the  number  is  increasing  daily 
with  distressing  rapidity. 

With  drugs  so  numerous,  the  habit  is  easily  acquired 
of  using  them  to  excess,  and  ascribing  to  them  undue 
importance.  The  patient  divides  his  ailments  into 
two  classes,  those  which  are  fatal  and  those  which  are 
not.  In  the  treatment  of  each  class  he  thinks  only  of 
the  drugs  used.  They  are  the  visible  and  tangible 
weapons  upon  which  he  relies.  If  he  recovers,  the 
drugs  and  the  skill  of  the  doctor  in  their  use  are  sup- 
posed to  be  the  efficient  cause.  If  he  dies,  the  drugs 
and  the  doctor  are  held  responsible.  Undeserved 
praise  is  given  to  both  drugs  and  the  doctor  when  the 
issue  is  favorable,  undue  blame  when  it  is  unfavor- 

'  Read  before  the  District  Medical  Society  for  the  County  of 
Hudson,  N.  J.,  October  16,  igoo. 


able.  The  doctor  often  allows  one  to  counterbalance 
the  other,  and  makes  no  comment.  But  there  is  a  fact 
which  experience  teaches  him  and  which  he  does  not  al- 
ways disclose  to  the  patient.  This  fact  is  that  some 
other  cause  than  the  drugs  used  has  effected  the  re- 
covery, when  recovery  has  taken  place.  This  cause 
he  may  not  himself  fairly  understand.  He  knows  only 
that  some  inherent  tendency  to  recovery  helps  him 
along  very  unexpectedly  at  times,  and  very  satisfac- 
torily. He  finds  it  convenient,  as  well  as  proper,  to 
cover  his  ignorance  as  to  the  precise  nature  of  that 
which  gives  him  aid,  by  the  Latin  phrase,  "vis  medi- 
catrix  naturs." 

It  seems  hardly  necessary  to  bring  arguments  to 
prove  to  an  audience  of  intelligent  and  experienced 
physicians  that  an  overestimate  of  the  value  of  drugs 
in  the  cure  of  disease  and,  as  a  consequence,  of  the 
skill  of  the  physician  in  using  them  is  made  by  the 
patient.  It  is  the  experience  and  observation  of  the 
doctor  which  will  convince  him  of  the  fact,  and  if  he 
is  not  already  so  convinced,  words  will  be  useless. 
It  is  the  evil  effect  of  the  popular  mistake  and  its 
remedy  which  is  the  important  subject  for  considera- 
tion. 

Noah  Webster  defines  a  quack  as  a  boastful  pre- 
tender to  medical  skill,  one  who  boastfully  pretends 
to  knowledge  not  possessed.  Not  many  regular  practi- 
tioners are  quacks  as  thus  defined.  Most  are  inclined 
to  lament  their  want  of  medical  knowledge,  rather  than 
to  boast  of  their  proficiency.  But  it  does  sometimes 
happen  that  the  patient  who  believes  that  his  recovery 
has  taken  place  in  consequence  of  the  dose  selected  by 
his  doctor,  when  recovery  was  inevitable  under  any 
condition,  will  boast  on  his  doctor's  behalf  of  a  knowl- 
edge not  actually  possessed  by  him.  Should  the 
doctor  wink  at  such  undue  praise  by  the  patient  he 
becomes  a  quack  by  proxy  or  substitution,  and  here 
results  one  of  the  first  evils  of  the  mistake  made  by 
the  patient.  But  in  addition  to  the  unfortunate  posi- 
tion of  the  practitioner  who  receives  undue  credit  the 
mistake  opens  the  door  to  outside  quackery,  and  gives 
a  start  and  an  imaginary  success  to  every  new  so- 
called  system  of  practice  which  can  be  concocted  in 
the  brains  of  any  medical  enthusiast,  and  to  every 
patent-pill-maker  who  can  combine  two  or  more  drugs 
so  as  to  act  as  a  cathartic  without  immediate  death  to 
the  patient.  If  in  nine  cases  out  of  ten  the  patient 
would  recover  without  the  use  of  a  drug  in  which  now 
the  drug  gets  the  credit,  of  course  any  quack  or  nurse 
when  he  attempts  the  cure  will  get  the  same  credit  in 
the  popular  estimation  as  does  the  educated  physician. 
Also,  if  the  physician  allows  the  mistaken  belief  as 
to  the  importance  of  the  remedy  to  go  uncorrected,  he 
simply  places  himself  in  the  nine  cases  out  of  ten  on 
the  level  of  the  quack  and  the  nurse  who  can  and  do 
practise  as  successfully  as  himself  when  the  patient 
is  sure  of  recovery.  It  is  true  that  in  the  tenth  case, 
in  which  knowledge  and  skill  in  the  careful  selection  of 
the  drug  may  save  the  patient,  he  outshines  his  rival 
the  quack,  but  this  is  only  one  case  in  which  he  ap- 
pears to  advantage,  whereas  in  all  he  should  be  shown 
to  be  a  superior  in  knowledge  by  his  superior  success 
in  practice. 

The  next  important  question  is,  What  is  the  remedy 
for  the  evil?  What  shall  the  physician  do  to  outrival 
his  neighbor  the  quack,  who  practises  so  successfully 
when  nature  effects  the  cure?  The  answer  is  plain- — 
correct  the  popular  mistake.  Let  the  doctor  make 
known  to  his  patient  how  often  recovery  would  take 
place  under  the  same  careful  hygienic  treatment,  even 
if  drugs  were  not  used  at  all.  Let  liim  acknowledge 
the  fact,  if  he  believes  it  to  be  a  fact,  that  drugs — and 
doctors,  in  so  far  as  they  rely  upon  drugs^are  getting 
credit  for  cures,  whicli  does  not  belong  to  them.  Teach 
the  patient  to  rely  less  upon  medicine  and  more  upon 


December  8,  1900] 


MEDICAL    RECORD. 


895 


an  adherence  to  the  rules  of  hygiene.  Inform  him 
that  an  ounce  of  prevention  is  worth  several  pounds  of 
cure,  especially  when  the  ounce  is  the  bactericide 
which  destroys  the  germ  before  it  has  invaded  the 
body,  and  the  pounds  are  the  useless  drugs  deposited 
in  the  stomacii  after  the  disease  has  made  its  onset. 
Let  the  doctor  ennoble  his  calling  by  acting  as  a 
teacher  rather  than  a  nurse,  a  professor  of  medicine 
rather  than  a  druggist.  Let  tlie  doctor  of  the  future 
give  more  attention  to  the  rules  of  sanitation,  to  the 
dietetic  and  hygienic  treatment  of  his  patient  rather 
than  so  e.xclusively  to  the  medicinal,  to  the  diagnosis 
and  prognosis  of  disease.  If  he  can  do  no  more  than 
inform  his  patient  of  the  nature  of  his  ailment,  and  its 
probable  duration  and  issue,  his  services  will  be  in 
great  demand.  In  the  performance  of  these  duties  he 
need  not  fear  the  competition  of  the  charlatan.  If 
truth  is  better  than  error,  and  it  certainly  is  in  the 
lonij  run,  the  doctor  will  finally  be  reimbursed  for  any 
temporary  loss  he  may  sustain  of  either  property  or 
prestige. 

Forms  of  Tremor  and  their  Clinical  Characters. 
— R.  T.  Williamson  states  that  the  relation  of  tremor 
to  voluntary  movement  enables  us  to  arrange  the  cases 
into  three  groups;  but  there  are  other  sub-varieties, 
(i)  Tremor  occurring  during  repose  of  the  limb,  but 
ceasing  or  diminishing  on  voluntary  movement,  with 
attention  tremor  which  ceases  when  an  object  is 
grasped  or  when  the  hands  are  held  out.  The  tremor 
in  paralysis  agitans  is  usually  of  this  form.  (2) 
Tremor  occurring  only  on  voluntary  movement  and 
ceasing  during  repose  (intention  tremor).  This  is 
the  form  of  tremor  in  disseminated  sclerosis,  even  at 
an  advanced  stage;  but  several  other  forms  of  tremor, 
at  a  very  early  stage,  occur  only  on  voluntary  move- 
ment. (3)  Tremor  which  occurs  during  repose,  but 
which  is  much  greater  during  voluntary  movement; 
as  in  most  cases  of  marked  alcoholic,  senile,  asthenic, 
simple,  and  hysterical  tremor,  and  in  several  other 
varieties.  —  The  Medical  Chronicle,  October,  1900. 

Spontaneous  Gangrene  of  the  Legs  in  Childbed. 
— E.  Wormser  has  made  a  collection  of  the  cases  of 
this  complication  to  the  puerperium  found  in  the  lit- 
erature and  added  one  of  his  own  to  the  number.  The 
etiology  of  the  affection  appears  to  be  somewhat  com- 
plex. In  some  instances  it  may  be  due  to  direct 
thrombosis  caused  by  a  diseased  heart  valve  with  or 
without  a  patent  foramen  ovale,  or  there  may  be  a  pri- 
mary arterial  thrombosis  starting  at  the  placental  site 
and  extending  upward  through  the  common  iliacs  to  the 
general  arterial  tree,  or  there  may  be  widespread  ob- 
literation of  the  venous  channels.  The  possibility  of 
this  is  harder  to  understand,  since  in  order  to  produce 
complete  blocking  of  the  whole  collateral  circulation 
in  a  part  so  richly  vascular  as  the  foot  an  almost  uni- 
versal venous  thrombosis  would  seem  to  be  required. 
Possibly  the  increased  coagulability  of  the  blood  dur- 
ing the  puerperium  may  deserve  consideration,  and  in 
some  instances  resembling  Raynaud's  disease  a  ner- 
vous element  undoubtedly  is  also  concerned.  The 
trouble  may  start  suddenly  or  require  several  days  to 
develop,  and  presents  the  typical  appearance  of  dry 
gangrene,  though  when  there  is  general  sepsis  and 
suppuration  of  the  thrombi  wet  gangrene  may  result. 
Pain  is  acute,  but  ceases  as  soon  as  death  of  the  tissue 
has  taken  place;  the  only  treatment  is  amputation  as 
soon  as  the  line  of  demarcation  is  evident. — Central- 
Halt  Jiir  Gyniikahi^ie,  November  3,  igoo. 

The  Pyogenic  Origin  of  Rheumatism  and  the 
Rdle  of  Trauma  in  its  Causation. — Philip  Kis- 
singer's views  still  further  complicate  the  already  un- 
settled condition  of  the  rheumatism  question.  It  is 
now  almost  universally  admitted  that  the  disease  must 


be  infectious  in  its  nature,  but  as  yet  apparently  no 
organism  for  which  the  claim  of  specificity  can.be 
upheld  has  been  isolated.  On  the  other  hand,  in- 
stances are  numerous  in  which  pure  cultures  of  various 
pus-producing  cocci  have  been  obtained  from  the 
blood  or  other  fluids  of  rheumatic  patients,  and  the 
author  seeks  to  justify  his  belief  that  acute  articular 
rheumatism  is  closely  allied  to  pyasmia  by  the  cita- 
tion of  a  large  number  of  such  cases.  With  this  idea 
as  a  basis  the  frequent  occurrence  of  rheumatic  joint 
afTectious  after  injury  is  easily  comprehensible,  for 
the  local  damage  produces  the  place  of  lessened  resist- 
ance, which  is  all  that  is  needed  to  permit  the  germs 
to  invade  the  tissues.  These  may  have  already  gained 
access  to  the  system  through  some  separate  site  of  sup- 
puration, an  angina,  etc.,  or  may  directly  penetrate 
the  injured  skin  in  the  neighborhood  of  the  articula- 
tion.—  I'olbinaiin's  hlinisehe  I'ortrii^^e.  September,  igoo. 

Why  are  Typhoid  and  Other  Fevers  Self-Lim- 
ited ?— J.  O.  Malsbury  believes  that  the  law  which 
governs  higher  animal  life,  namely,  that  constant 
interbreeding  results  in  less  vigorous  progeny  until 
finally  there  ceases  to  be  fertility,  holds  good  in  the 
case  of  lower  animal  organisms.  In  typhoid  fever  it 
is  fair  to  assume  that  there  is  a  new  production  every 
twenty-four  hours,  since  there  is  a  reasonably  regular 
variation  of  temperature  of  about  one  degree  during 
that  time.  This  specific  element  or  spore  reproduces 
within  and  of  itself,  and  with  each  successive  repro- 
duction the  spores  become  less  vigorous,  until  finally 
fertility  ends,  reproduction  ceases,  and  the  active 
phenomenon — disease  in  this  particular  case — is  at  an 
end.  If  a  patient  be  infected  with  vigorous  spores  the 
attack  will  be  malignant,  severe,  and  abrupt,  while  if 
the  spores  of  infection  be  such  as  would  be  found 
after  several  successive  reproductions,  the  attack  would 
be  mild.  Cases  that  increase  in  malignancy  may 
have  been  infected  with  mixed  spores,  the  cross  result- 
ing in  increased  vigor.  Repeated  interbreeding  would 
of  course  end  in  failure  to  reproduce,  but  owing  to  the 
severity  and  prolongation  of  the  attack  the  patient's 
vitality  may  end  first. — Indiana  Medical  Journal,  No- 
vember, 1900. 

The  Malignity  of  Vesicular  Mole — Y.  La  Torre 
believes  that  after  the  expulsion  of  a  mole,  if  cells 
possessing  the  power  of  proliferation  remain  in  the 
uterine  muscle  walls,  they  may  continue  to  increase, 
and  by  their  degeneration  produce  a  malignant  tumor, 
a  deciduoma.  There  appears,  however,  to  be  a  be- 
nignant as  well  as  a  malignant  form  of  mole,  hence, 
although  every  patient  who  has  expelled  a  vesicular 
mole  should  be  carefully  watched,  it  is  well  not  to  re- 
move the  uterus  until  the  symptoms  characteristic  of 
deciduoma  appear. — La  Clinica  Osietrica,  October, 
1900. 

Prolonged  Applications  of  Ether  Compresses  in 
Strangulated  Hernia.  —  M.  Fiessenger  says  that  the 
majority  of  cases  of  strangulated  hernia,  which  it  used 
to  be  supposed  absolutely  necessitated  operation,  yield 
to  this  simple  method  of  treatment.  Not  only  the 
author  but  several  other  surgeons  have  obtained  a 
cure  by  the  applications  of  ether  compresses  continued 
from  a  quarter  of  an  hour  to  two  hours.  The  gauze 
or  cotton  is  kept  wet  with  the  ether,  and  at  a  given 
moment  there  will  be  a  sudden  reduction,  the  patient 
perhaps  giving  a  cry  of  pain,  and  then  immediately 
acknowledging  great  relief.  This  treatment  may  be 
used  during  the  first  thirty-six  hours,  but  after  that 
time  there  is  danger  of  a  gangrenous  loop  of  intestine 
re-entering  the  abdominal  cavity.  The  ether  doubt- 
less acts  in  a  reflex  manner  by  causing  vaso-constric- 
tion,  with  consequent  subsidence  of  the  congestion  of 
the  intestinal  loop. —  Bulletin  de  I'Academie  de  Mede- 
cine,  October  30,  1900. 


896 


MEDICAL    RECORD. 


[December  8,  1900 


•  Medical  Record: 

A    Weekly  Journal  of  Alcdicinc  and  Surgery. 


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

Publishers 
WM.  WOOD  &  CO.,  51    Fifth  Avenue. 

New  York,  December  8,  1900. 


PROPOSED  CHANGE  IN  THE  MANAGEMENT 
OF  NEW  YORK  CITY  HOSPITALS. 

The  charter  revision  commission  has  just  published 
the  results  of  its  deliberations.  Among  the  many 
radical  changes  suggested  in  the  mode  of  governing 
this  city  is  one  that  intimately  concerns  the  medical 
profession.  The  charter  revisers  have  proposed  an 
amendment  which,  if  carried  into  effect,  will  entirely 
alter  the  present  methods  of  managing  the  New  York 
City  hospitals. 

The  amendment  provides  that  on  February  i,  1902, 
the  control  and  management  of  Bellevue  Hospital,  in- 
cluding its  subsidiary  hospitals — Gouverneur,  Harlem, 
and  Fordham  hospitals,  and  the  Emergency  Hospital 
for  VVomen — shall  be  taken  from  the  Department  of 
Public  Charities  and  be  vested  in  a  board  of  trustees 
appointed  by  the  Mayor.  Should  this  amendment  be- 
come law,  the  city  hospitals  will  be  brought  under  the 
same  system  of  control  as  prevails  in  private  hospitals 
in  the  majority  of  the  cities  of  this  country  and  in  the 
city  hospitals  of  Boston  and  Cincinnati.  It  may  be 
also  remarked  that  somewhat  similar  methods  of  man- 
agement are  in  force  in  the  hospitals  of  London 
and  throughout  the  large  cities  of  Great  Britain  gen- 
erally, and  the  system — as  is  the  case  in  the  hospitals 
of  Boston  and  Cincinnati — has  on  the  whole  been 
found  to  work  smoothly  and  well.  There  are  many 
.solid  and  substantial  reasons  to  be  urged  in  favor  of 
the  charter  revisers'  recommendation,  and  it  is  to  be 
sincerely  hoped  that  so  sterling  a  scheme  will  not  be 
killed  or  mutilated  at  Albany. 

For  long  the  administration  of  Bellevue  Hospital 
and  its  subsidiary  hospitals  has  not  given  general 
satisfaction.  The  buildings  which  constitute  Belle- 
vue Hospital  are  sufficient  standing  evidence  of  the 
truth  of  this  statement,  to  say  nothing  of  the  condition 
of  the  old  frame  erection  known  as  Harlem  Hospital. 
The  extraordinary  and  incomprehensible  dilatoriness 
exhibited  by  the  authorities  in  neglecting  to  order  the 
removal  of  patients  to  the  new  Gouverneur  Hospital 
— a  building  which  now  has  been  completed  for  more 
than  a  year — is  yet  another  proof  that  the  powers  who 
rule  are,  to  speak  mildly,  lax  in  the  discharge  of  their 
duties.  The  greatest  gain,  however,  that  the  proposed 
change  would  bring  to  those  who  are  compelled  to 
liave  recourse  to  the  city  hospitals  for  medical  treat- 
ment would  be  the  removal  of  these  institutions  from 


the  domain  of  politics.  Indeed  it  is  mainly  owing 
to  the  part  that  politics  has  played  in  the  manage- 
ment of  the  city  hospitals  that  their  services  have  not 
been  so  efficient  as  the  citizens  of  New  York  had  a 
right  to  expect  they  would  be. 

No  person  of  ordinary  reasoning  powers  can  disa- 
gree with  the  plain  proposition  that  politics  should 
have  no  place  in  the  management  of  an  institution  set 
apart  for  the  care  of  the  sick.  The  trail  of  the  ser- 
pent of  politics  may  be  traced  in  the  administration 
of  all  the  public  affairs  of  New  York,  but  it  should  be 
surely  worth  while  to  make  a  strenuous  effort  to  re- 
move charitable  institutions  at  least  from  such  con- 
taminating influences.  Another  reason  (given  in  an 
article  on  the  matter  which  appeared  in  the  Sunday 
Siin^  December  2d,  demonstrating  that  Bellevue  would 
be  a  gainer  by  the  proposed  amendment)  is  that  it 
would  be  thereby  made  a  specific  city  interest,  inde- 
pendent of  the  other  institutions  in  the  Department  of 
Public  Charities.     As  The  Sun  says: 

"The  patients  in  Bellevue  are  by  no  means  all 
paupers;  they  are  for  the  most  part  workingmen  and 
workingwomen  who,  by  reason  of  illness  or  injury,  are 
temporarily  prevented  from  earning  a  living.  They 
cannot  afford  medical  care  and  nursing  at  their 
homes,  and  go  to  their  only  place  of  refuge — the  pub- 
lic hospital.  And  it  is  only  the  part  of  a  wise  policy 
on  the  part  of  the  city  to  make  them  well  and  again 
self-supporting  as  soon  as  possible.  It  is  not  just,  it 
is  not  humane  to  class  them  with  paupers  and  thus  rob 
them  of  their  self-respect.  Bellevue  has  too  long  been 
considered  in  the  public  mind  as  a  pauper's  hospital. 
Let  us  hope  that  this  stigma  will  be  removed  under 
the  new  form  of  administration." 

There  can  be  no  doubt  that  a  stable,  steady  form  of 
government,  entirely  divorced  from  politics,  would  ac- 
complish great  things  for  the  New  York  City  hospitals. 
That  amendment  proposed  by  the  charter  revision, 
tlierefore,  deserves  the  good  wishes  and  support  of  the 
medical  profession  and  the  general  public.  J 


SMALLPOX  AND  VACCINATION. 

The  outbreak  of  smallpox  on  the  West  Side  of  this 
city,  although  so  far  not  especially  alarming,  will 
doubtless  tend  to  impress  upon  tiie  minds  of  its  inhab- 
itants the  need  of  vaccination  and  revaccination.  In- 
deed, if  it  has  this  effect,  the  activity  of  the  disease — 
restricted  though  it  be — will  prove  a  "blessing  in  dis- 
guise." It  speaks  volumes  for  the  intelligence  of  the 
American  people  as  a  whole,  and  of  this  State  in  par- 
ticular, that  there  has  never  been  evidence  of  an  or- 
ganized opposition  to  vaccination.  Among  a  minor- 
ity of  the  inhabitants  of  the  United  States  a  certain 
prejudice  against  vaccination  exists,  but  with  the  bulk 
of  the  population  the  sentiment  with  regard  to  the  op- 
eration is  one  of  apathy,  or  rather  of  indifference.  It 
is  so  long  since  an  epidemic  of  smallpox  on  a  large 
scale  and  in  a  virulent  form  appeared  in  this  part  of 
the  country  that  many  persons  are  sceptical  as  to  the 
dangers  to  be  feared  from  such  an  occurrence,  ^^'ith- 
oul  wishing  in  any  way  to  act  the  part  of  alarmists,  we 


December  8,  1900] 


MEDICAL    RECORD. 


897 


would  nevertheless  sound  a  note  of  warning,  and  ad- 
vise parents  not  to  be  lulled  into  a  state  of  false  se- 
curity. The  fact  that  as  a  community  we  are  well 
protected  cannot  be  denied,  but  if  the  practice  of  vac- 
cination be  allowed  to  fall  into  disuse  it  is  impossible 
to  say  for  how  long  this  happy  condition  of  affairs  will 
last.  A  few  apropos  truths  concern iig  the  benefits 
conferred  by  vaccination  may  at  the  present  time  be 
of  interest.  The  following  statistics  are  culled  from 
an  able  article  on  the  subject  written  by  Dr.  C.  D. 
Smith,  president  of  the  board  of  health  of  the  State 
of  Maine:  The  German  law  of  1874  makes  vaccina- 
tion obligatory  in  the  first  year  of  life,  and  also  revac- 
cination  obligatory  at  the  tenth  year.  This  law  in 
Germany  resulted  from  the  epidemic  of  1871,  with  its 
one  hundred  and  forty-three  thousand  deaths,  among  a 
population  in  which  vaccination  had  been  allowed  to 
die  out.  Prior  to  1874  the  yearly  loss  was  fifteen  thou- 
sand to  twenty  thousand.  The  present  rate  is  less  than 
one  hundred  and  sixteen  per  year,  and  these  cases  occur 
on  her  borders,  where  there  is  constant  mingling  with 
the  poorly  vaccinated  of  other  countries.  The  disease 
does  not  spread  or  become  epidemic  among  well-vac- 
cinated people.  It  does  so  develop  among  the  unvac- 
cinated.  During  the  Franco-German  war  the  inevit- 
able mingling  of  the  two  peoples  spread  smallpo.x, 
which  was  epidemic.  The  Germans  had  made  vaccina- 
tion optional  for  its  civil  population,  but  compulsory 
for  its  army;  the  French  having  made  it  optional  alike 
for  army  and  population.  The  French  lost  from  small- 
pox twenty-three  thousand  men;  the  Germans  two  hun- 
dred and  seventy-eight.  Occupying  the  same  hos- 
pital tents,  with  the  same  surroundings,  the  French 
wounded  lost  many  from  smallpox;  the  Germans, 
not  any.  The  French  prisoners  of  war  died  by 
the  hundreds;  their  German  guards,  who  had  been 
vaccinated  and  revaccinated,  suffered  not  at  all.  In 
Denmark,  Sweden,  and  Norway,  where,  as  well  as  in 
Germany,  vaccination  is  compulsory,  the  annual  death 
rate  is  from  one  to  three  per  million.  In  England 
and  Wales,  before  the  introduction  of  vaccination,  the 
mortality  was  three  thousand  per  million  ;  since  the  in- 
troduction of  vaccination  it  has  been  reduced  seventy- 
five  per  cent.  F'rom  the  time  that  statistics  were  first 
collected,  facts  confirming  the  ravages  of  the  disease  in 
unvaccinated  communities  have  been  unvarying,  and 
the  reduction  of  its  prevalence  and  of  the  death  rate 
after  vaccination  has  received  equal  confirmation. 
Among  savage  races  and  in  other  unprotected  commu- 
nities smallpox  invariably  attacks  almost  all  who  are 
exposed  to  its  infection.  When  a  partially  protected 
community  is  attacked  the  victims  selected  are  the 
unvaccinated.  This  has  been  demonstrated  over  and 
over  again  on  this  continent  among  the  North  Ameri- 
can Indians  and  in  Mexico,  where  in  both  instances 
the  populations  of  entire  villages  were  completely 
wiped  out.  Observation  has  also  shown  that  when 
the  vaccinated  are  attacked  by  smallpox  the  disease 
is  in  them  in  a  modified  form.  The  contention  is 
not  made  that  vaccination  is  an  absolute  preventive, 
but  it  is  asserted  that  it  modifies  and  controls  the 
disease  to  a  very  considerable  extent.  The  great  ma- 
jority  are  protected  by  vaccination,  and  with  those 


affected  the  danger  to  life  and  disfiguring  marks  are 
avoided.  In  short,  vaccination  changes  the  whole 
course  of  the  malady.  Much  of  the  prejudice  that 
undoubtedly  exists  against  vaccination  is  due  to  the 
fear  that  by  the  use  of  unclean  lymph,  or  by  the  per- 
formance of  the  ojjeration  in  a  careless  manner,  cer- 
tain diseases  may  be  transmitted  to  the  person  operated 
upon.  In  times  gone  by  this  dread  was  sometimes 
warranted,  but  at  the  present  time,  by  special  prepa- 
ration and  storage,  the  lymph  is  rendered  practically 
harmless,  and  provided  that  the  operator  is  careful 
and  practises  aseptic  methods  no  ill  effects  are  like- 
ly to  result.  Revaccination  should  be  undergone  at 
the  age  of  puberty,  and  as  a  measure  of  precaution 
in  those  places  where  smallpox  is  prevalent.  The 
health  authorities  in  this  city  are  taking  energetic 
steps  to  check  the  spread  of  the  disease  and  may  be 
depended  upon  to  succeed  in  their  object,  but  at  the 
same  time  we  would  advise  e\'ery  one  who  is  in  a  fit 
state  of  health  to  be  revaccinated.  Especially  is  it 
incumbent  upon  parents  in  the  interest  of  public 
health  to  order  their  young  children  to  be  vaccinated. 


THE    PURIFICATION    OF   THE    NEW    YORK 
WATER    SUPPLY. 

On  Friday  last  the  grand  jury  finished  the  taking  of 
evidence  with  regard  to  the  New  York  water  supply, 
and  handed  the  conclusions  at  which  it  had  arrived 
in  written  form  to  tlie  recorder.  Respecting  the  qual- 
ity of  the  water  the  grand  jury  took  the  following  com- 
mon-sense view:  "While  in  no  way  detracting  from 
the  importance  of  a  pure  water  supply,  as  a  condition 
necessary  to  the  public  health,  the  grand  jury  was 
relieved  by  the  preponderance  of  testimony  to  the 
effect  that  no  immediate  danger  of  typhoid  existed  or 
was.  imminent,  although  it  was  conceded  that  along 
continuance  of  an  impregnated  water  supply  would 
be  liable  to  produce  disease.  The  conclusions,  after 
careful  consideration  of  the  subject,  are  that  the  only 
effective  and  permanent  means  by  which  a  remedy 
can  be  applied  to  existing  evils,  and  the  only  means 
to  secure  pure  water,  consist  in  the  adoption  of  a  sys- 
tem of  filtration  commensurate  in  all  respects  to  the 
needs  and  wants  of  this  great  municipality."  As  w^as 
pointed  out  in  the  Medical«Record  of  December  ist, 
the  primary  outlay  will  be  great,  but  the  establish- 
ment of  a  thoroughly  efficient  filtration  system  on  a 
scale  sufficiently  large  to  comprehend  the  entire  water 
supply  of  Greater  New  York  is  a  public  necessity,  and 
the  cost  in  the  end  will  be  money  well  spent.  The 
reduction  of  the  mortality  rate  from  typhoid  fever 
alone  is  adequate  cause  for  advocating  its  adoption. 
In  London,  in  Hamburg,  and  in  other  European 
cities  too  numerous  to  mention,  this  fact  has  been  so 
strongly  emphasized  as  to  admit  of  no  dispute.  In 
this  country  also  there  already  have  been  some  con- 
spicuous examples  of  the  benefits  conferred  upon  a 
community  by  ridding  the  drinking-water  of  noxious 
germs.  For  instance  Lawrence,  Mass.,  was  up  to  the 
time  of  the  establishment  of  a  filtration  plant  a  hot- 
bed of  typhoid  fever.     From   1887  to  1S92  inclusive, 


898 


MEDICAL    RECORD. 


[December  8,  1900 


the  number  of  deaths  from  typhoid  in  tliat  city  ranged 
from  forty-seven  to  sixty  per  annum,  a  rate  per  ten 
thousand  population  of  11.44  to  '3-44-  '^^e  filter 
plant  was  put  in  operation  in  the  latter  part  of  1893, 
and  the  typhoid  deaths  for  that  year  fell  to  a  total  of 
thirty-nine  and  a  rate  of  7.96  per  ten  thousand.  In 
1894,  the  first  full  year  the  filter  was  in  service,  the 
deaths  were  twenty-four  and  the  rate  4.75  per  ten  thou- 
sand. There  has  been  a  steady  diminution  ever  since, 
until  in  1898  there  were  but  eight  deaths  from  typhoid 
fever  in  the  city,  giving  a  rate  of  1.39  per  ten  thousand 
population.  Albany  is  another  case  in  point.  The 
evidence  in  favor  of  a  filtration  system  is  so  over- 
whelming as  to  be  conclusive.  The  city  of  New  York 
in  almost  every  respect  has  good  reason  to  be  proud  of 
her  water  supply.  Compared  with  London  and  Paris 
it  is  bountiful  in  the  extreme.  The  deficiency  of 
London's  supply  will  be  clearly  apparent  when  it  is 
contrasted  with  that  of  some  European  cities  and  with 
nearly  all  American  cities  of  any  size.  London  doles 
out  on  the  average  about  thirty  gallons  per  head  daily. 
Rome  and  Naples  are  generous  with  water  by  compar- 
ison, Vienna  is  lavish,  while  Washington  gives  each 
inhabitant  one  hundred  and  fifty-five  gallons  per  day, 
Chicago  one  hundred  and  nineteen  gallons,  and  New 
York  one  hundred  gallons.  Paris,  of  all  the  civilized 
cities  of  the  world,  is  the  only  one  which  is  content 
with  London's  low  level.  Although  we  must  confess 
with  shame  that  no  city  of  the  modern  world  can  equal 
ancient  Rome,  which  gave  to  each  citizen  on  the  average 
two  hundred  and  thirty  gallons  of  water  a  day,  car- 
ried at  an  enormous  cost  from  the  mountains  through 
aqueducts  which  are  at  once  the  admiration  and  de- 
spair of  present-day  engineers,  yet  the  cities  of  the 
United  States  are,  so  far  as  the  quantity  of  water  sup- 
plied is  concerned,  the  nearest  rival  to  the  erstwhile 
mistress  of  the  world.  Where  our  cities  fail  is  in  the 
quality  of  the  water  supplied,  and  hence  the  great 
prevalence  of  typhoid  fever  throughout  the  country. 
The  redeeming  feature  of  London  and  other  British 
centres  of  population  is  that  the  water  supply  is  ren- 
dered by  artificial  means  as  pure  as  possible,  and  in 
consequence  of  these  precautions  typhoid  fever  has 
been  almost  stamped  out.  Many  American  cities  are 
recognizing,  though  somewhat  tardily,  that  efficient  fil- 
tration of  water  is  one  if  not  the  most  important  safe- 
guard to  the  health  of  their  dwellers.  Philadelphia, 
Washington,  Cincinnati,  Pittsburg,  Louisville,  and 
Atlanta  are  busily  engaged  in  constructing  filtration 
plants,  and  New  York  in  her  care  for  the  welfare  of 
her  citizens  will  undoubtedly  follow  suit.  An  abun- 
dance of  water  is  an  absolute  need  for  every  city  in 
order  to  be  clean,  healthy,  and  pleasing  to  the  eye. 
There  should  be  not  only  an  ample  supply  of  water 
on  tap  in  our  houses,  but  enough  to  water  the  streets, 
flush  the  drains,  and  indeed  for  all  sanitary  purposes; 
and,  in  addition,  in  the  hot  weather  plenty  of  foun- 
tains should  be  continually  running,  lioth  for  drinking 
and  for  imparting  that  sense  of  coolness  and  rest  so 
necessary  to  those  who  are  compelled  to  pass  their 
lives  within  the  confines  of  a  town.  The  quality  of 
the  water  should  be  beyond  reproach,  and  the  quantity 
should  be  adequate  for  domestic  supplies  as  well  as 


sufficient  to  give  an  unstinted  amount  for  municipal 
purposes.  There  is  no  reason  that  New  York  should 
not  be  in  this  ideal  position  as  regards  water.  It  is 
certain  that  by  adopting  a  filtration  system,  founded 
upon  the  best  models  now  in  use,  she  will  be  making 
a  long  stride  in  this  direction. 


ARSENIC    POISONING     BY    BEER     IN     ENG- 
LAND. 

In  Great  Britain  of  late  arsenic  has  come  to  the  front 
in  a  very  unpleasant  manner.  It  is  not  very  long  since 
that  a  prominent  firm  of  wholesale  druggists  sent  out 
a  large  quantity  of  effervescing  salts,  into  which, 
through  some  grave  error,  arsenic  had  been  intro- 
duced. Before  the  mistake  could  be  rectified  by 
calling  in  the  pernicious  salts  several  persons  had 
suffered  severely  from  imbibing  the  so-called  cooling 
beverage.  A  short  time  ago  it  was  found  by  individ- 
uals who  drank  beer  brewed  by  some  Manchester 
firms,  that  extremely  deleterious  results  followed. 
Upon  investigation  the  discovery  was  made  that  ar- 
senic had  obtained  an  entrance  into  the  beer,  although 
it  must  be  said  that  it  was  present  only  in  a  beer  of 
special  brew.  The  brewers  themselves  assert  that  the 
products  of  only  one  firm  have  been  harmful,  and  that 
arsenic  was  introduced  through  improper  treatment  of 
sulphuric  acid  in  brands  of  sugar  coming  from  Spain.  , 
Others  aver  that  the  mischief  has  been  due  to  a  par- 
ticularly bad  lot  of  glucose  supplied  to  Manchester 
and  Liverpool  brewers,  which  caused  peripheral  neu- 
ritis very  similar  to  beriberi.  Be  this  as  it  may,  one 
fact  at  least  stands  out  with  sinister  prominence. 
There  have  already  been  over  a  thousand  patients  and 
nearly  seventy  deaths  owing  to  the  consumption  of 
this  ill-omened  beverage.  The  news  is  also  reported 
that  this  beer-poisoning  epidemic  has  spread  to  Lon- 
don, and  that  the  county  council  intends  to  take  up 
active  measures  to  protect  the  community.  The  AWi' 
York  Tribune  (Sunday,  December  2d)  states  that  the 
British  workman  now  empties  his  pewter  pint  with 
more  or  less  fear  and  trembling,  and  analysts  are 
busy  by  day  and  by  night  on  samples  of  the  glucose 
and  saccharin  used  extensively  by  brewers.  A  curi- 
ous suggestion  is  made  by  an  English  public  analyst, 
in  connection  with  this  matter,  that  the  Maybrick  case 
might  have  been  solved  had  the  facts  now  made  pub- 
lic in  regard  to  arsenic  in  beer  been  known  at  the 
time  of  the  trial. 


Widal  Examinations  at  Quarantine. — Dr.  Alvah 
H.  Doty,  health  officer  of  the  port  of  New  York,  an- 
nounces that  the  Widal  test  for  typhoid  fever  will 
be  made  free  of  charge  in  the  laboratory  of  the  quar- 
antine station  at  the  request  of  any  physician  in  New 
York  Slate.  The  material  and  full  directions  for 
securing  and  forwarding  the  blood  or  serum  to  the 
department  for  examination  will  be  sent  on  applica- 
tion, and  the  result  of  the  examination  will  be 
promptly  communicated  to  the  sender.  These  exami- 
nations are  intended  to  put  this  important  diagnostic 
aid  within  the  reach  of  physicians  in  the  country  and  in 
small  towns  where  no  bacteriological  laboratories  exist. 


December  8,  1900] 


MEDICAL    RECORD. 


899 


|lleu)s  of  the  "Gcacck. 

The  Late  Prof.  Henry  D.  Noyes,  M.D.  — At  a 
meeting  of  the  medical  start  of  the  New  York  Eye 
and  Ear  Infirmary  the  following  recognition  of  the 
services  of  the  late  Dr.  Noyes  was  duly  entered  upon 
the  minutes: 

Dr.  Henry  D.  Noyes  was  a  graduate  of  the  College 
of  Physicians  and  Surgeons  in  the  year  1S55.  After 
serving  on  the  house  staff  of  the  New  York  Hospital, 
he  went  to  Europe  to  continue  his  studies.  Having 
devoted  himself  to  special  work  in  the  ophthalmic 
clinics  there,  and  latterly  having  been  a  student  of  von 
Graefe  in  Berlin,  he  returned  to  America,  and  in  Sep- 
tember, 1859,  was  appointed  an  assistant  surgeon  to 
this  infirmary.  In  November,  1864,  he  was  made 
surgeon.  From  1873  until  1898  he  served  as  execu- 
tive surgeon,  and  on  October  23,  1900,  his  resignation 
as  a  member  of  the  surgical  staff  was  received  by  the 
board  of  directors — by  the  board  at  whose  councils  he 
had  sat  for  a  period  of  thirty-six  years. 

This  long  service  of  one  who  during  nearly  the 
entire  time  held  foremost  position  in  conducting  the 
affairs  of  the  institution  covers  more  than  half  the 
period  that  has  elapsed  since  the  foundation  of  the 
infirmary.  These  years  have  seen  marked  changes  in 
the  growth  of  the  institution,  and  a  brief  reference  to 
the  statistics  furnished  by  our  annual  reports  may 
not  be  out  of  place. 

In  the  year  1859  there  were  4,178  new  dispensary 
patients  and  144  in  the  wards.  In  1899  there  were 
47,684  new  dispensary  and  2,257  house  patients.  In 
1859  the  surgical  staff  consisted  of  nine  men.  Now> 
eighty-three  medical  men  are  engaged  in  the  work. 
In  1859  it  was  an  eye  infirmary.  Now,  there  are  the 
three  departments  of  the  eye,«ear,  and  throat. 

The  well-ordered  hospital  of  to-day,  with  its  super- 
intendent and  clerks,  its  isolated  cataract  wards  and 
pavilion  for  contagious  ophthalmia,  its  training-school 
for  nurses,  school  of  instruction  for  graduates  of  med- 
icine, its  annual  volume  of  scientific  transactions,  its 
valuable  medical  library,  owes  in  no  small  way  its 
pre-eminence  to  the  wise  forethought  and  ceaseless 
activity  of  Dr.  Noyes. 

The  rules  and  regulations  of  the  infirmary  were 
largely  the  result  of  his  careful  study,  and  it  was  per- 
haps characteristic  of  his  unselfish  devotion  to  the 
institution  that,  shortly  before  his  resignation  of  the 
position  of  executive  surgeon,  he  prepared  rules  that 
gave  this  office  largely  increased  powers  and  left  the 
enjoyment  of  them  to  his  successor. 

Bringing  as  he  did  to  the  discharge  of  his  profes- 
sional duties  a  vast  knowledge  of  medicine,  a  facility 
and  originality  in  operative  procedure,  he  was  un- 
sparing of  self  in  his  devotion  to  those  who  came 
under  his  care.  He  was  prompt  in  recognizing  the 
value  of  suggestions  made  by  others  in  his  field  of 
work,  and  his  distinguished  position  as  an  author  and 
teacher  added  to  the  fame  of  the  institution  both  at 
home  and  abroad. 

Throughout  the  years  of  his  connection  with  the 
infirmary  Dr.  Noyes  contended  for  an   increase  in  our 


scientific  and  laboratory  work.  He  urged  that  there 
could  be  no  effective  and  perfectly  developed  charity 
that  was  not  associated  with  scientific  investigation. 

Dr.  Noyes  died  on  the  12th  of  November,  1900. 
It  is  fitting  that  the  medical  staff  of  this  institution, 
to  the  service  of  which  he  had  devoted  all  the  years 
of  his  active  professional  life,  should  record  their  ap- 
preciation of  the  work  of  a  man  who  has  contributed 
so  largely  to  make  the  infirmary  what  it  is.  It  is 
proper  that  at  this  time,  feeling  the  irreparable  loss 
they  have  sustained  in  his  death,  they  should,  in  the 
spirit  in  which  he  lived,  dedicate  themselves  anew  to 
its  service,  not  alone  as  ministers  to  humanity,  but 
also  as  ministers  to  knowledge  in  medicine. 

A  Meeting  of  the  New  York  State  Medical  Al- 
liance will  be  held  at  the  New  York  Academy  of 
Medicine,  17  West  Forty-third  Street,  Thursday,  De- 
cember 13th,  at  8  P.M.  Dr.  Winfield  S.  Hall,  A.M., 
M.D.,  Ph.D.  (Leipzig),  professor  of  physiology, 
Northwestern  University  Medical  School,  Chicago, 
will  read  a  paper  on  "Ethyl  Alcohol:  its  Biology 
and  its  Relation  to  Physiology,  to  Pharmacology,  and 
to  Therapeutics."  Discussion  of  the  paper  is  ex- 
pected by  Professor  Conn,  of  Wesleyan  University; 
Prof.  C.  A.  Herter,  of  the  University  and  Bellevue 
Medical  School;  Professor  \\'oodbury,  of  the  Phila- 
delphia Polyclinic  and  College  for  Graduates,  for- 
merly professor  of  materia  medica  and  therapeutics 
in  the  Medico-Chirurgical  College  of  Philadelphia, 
and  by  others.  Dr.  Andrew  H.  Smith,  president  of 
the  alliance,  will  preside.  The  medical  profession  is 
invited. 

A  Suit  against  Physicians.— A  malpractice  suit 
for  $60,000  damages,  brought  against  Drs.  Manges 
and  Rosenberg  of  this  city,  has  resulted  in  a  disagree- 
ment of  the  jury,  the  division  being  nine  to  three  in 
favor  of  the  physicians.  The  suit  arose  from  a  curet- 
tage, in  1897,  to  check  severe  hemorrhage  in  a  woman 
with  large  fibroid  tumors  of  the  uterus.  It  was 
claimed  that  the  operation  was  performed  without 
consent,  that  it  was  unskilfully  done,  that  too  much 
chloroform  was  administered,  that  there  was  neglect 
in  the  after-treatment,  and  that  the  woman  had  no 
fibroids.  The  basis  for  the  claim  that  there  were  no 
fibroids  was  the  naive  statement  that  there  was  no 
external  protuberance  of  any  kind. 

The  Class  of  '9a  of  the  College  of  Physicians 
and  Surgeons. — On  November  15th  a  dinner  was 
given  at  the  New  York  Athletic  Club  to  commemorate 
the  first  decennial  anniversary  of  the  class  of  '90  of 
the  College  of  Physicians  and  Surgeons  of  New  York. 
Porty-nine  members  of  the  class  were  present,  and 
speeches  were  made  on  the  following  topics,  Dr.  H. 
Beattie  Brown  acting  as  toast-master:  "The  Class," 
by  Dr.  James  Pedersen ;  "Our  College,"  by  Dr. 
Charles  \V.  Townsend;  "A  Retrospect  and  Historical 
Report  of  the  Class,"  by  Dr.  A.  Ernest  Gallant :  "  The 
Decennial  Dinner,"  by  Dr.  VV.  Whitehead  Gilfillan; 
"Clinical  Medicine,"  by  Dr.  A.  W.  HoUis;  "Modern 
Surgery,"  by  Dr.  Percival  Bolton;  "Medical  Testi- 
mony," by  Dr.  Charles  I.  Proben;  "Commercialism 


90O 


MEDICAL    RECORD. 


[December  8,  1900 


in  jMedicine,"  by  Dr.  Henry  P.  De  Forest;  "What 
Measure  of  Success  Should  a  Physician  Achieve  in 
Ten  Years'  Practice?"  by  Dr.  Henry  L.  Palmer; 
"The  Physician  in  the  Country,"  by  Dr.  Charles  F. 
Chapman;  "Town  vs.  Country  Practice,"  by  Dr. 
Sidney  A.  Twinch;  "Philanthropic  Work  of  the 
Physician,"  by  Dr.  Edward  W.  Peet;  "Requirements 
necessary  for  Success  in  Our  Profession,"  by  Dr. 
Henry  H.  Forbes.  Impromptu  toasts  were  responded 
to  by  Drs.  Arthur  B.  Coleburn  and  Henry  F.  Adams. 
The  next  reunion  will  be  five  years  hence.  The  fol- 
lowing officers  were  elected :  President,  Dr.  James  F. 
McKernon;  Secretary,  Dr.  A.  Ernest  Gallant;  Treas- 
urer, Dr.  William  Whitehead  GilfiUan. 

Smallpox  ia  New  York. — A  nest  of  smallpox  pa- 
tients was  discovered  last  week  by  the  board  of  health 
in  West  Sixty-ninth  Street.  Between  thirty  and  forty 
patients  were  found  and  removed  to  hospital.  The 
result  of  the  discovery  and  its  publication  in  the  pa- 
pers has  been  a  vaccination  boom  of  no  mean  propor- 
tions. 

Dr.  Ramiro  Diaz,  a  graduate  of  Vanderbilt  Uni- 
versity, Nashville,  in  1894,  has  been  appointed  to  the 
medical  corps  of  the  Mexican  army  and  navy,  with  the 
rank  of  captain  (capitan  1°).  There  is  in  Mexico  a 
special  military  medical  school,  from  which  Dr.  Diaz 
was  graduated  after  completing  his  studies  in  this 
country. 

Typhoid  Fever  has  been  unusually  prevalent  in 
New  York  this  autumn,  but  the  number  of  cases  is 
now  diminishing  rapidly,  as  it  always  does  in  the  late 
autumn.  The  number  of  cases  reported  in  each  week 
for  the  period  beginning  with  the  week  which  began 
on  September  2d  and  extending  to  the  week  which 
ended  November  24th,  is  as  follows:  88,  116,  83,  129, 
104,  139,  88,  140  (week  ending  October  27th),  105, 
90,  86,  79.  The  deaths  from  the  fever  in  the  corre- 
sponding weeks  last  year  were  as  follows:  27,  28,  22, 
20,  15,  27,  16,  32  (week  of  October  27th),  28,  27,  17, 
22. 

The  State  Hospital  for  the  Treatment  of  Tubercu- 
losis.— The  trustees  of  the  State  tuberculosis  hospital 
have  presented  their  report  concerning  the  site  to  the 
State  board  of  health.  The  report  relates  that  after  the 
consideration  of  the  sites  offered,  the  one  at  the  west 
end  of  Lake  Clear  in  Franklin  county  was  selected. 
Protests  against  the  site  were  made  at  a  public  hear- 
ing, and  no  decision  has  yet  been  made  by  the  boards 
of  approval.  It  is  believed  that  the  necessary  ground 
can  be  purchased  for  $10,000  to  $12,000,  and  the  es- 
timated cost  of  construction  and  equipment  of  the 
hospital  is  $200,000.  The  plans  for  the  buildings 
are  now  being  prepared  by  the  State  architect. 

Gifts  to  the  Chicago  College  of  Physicians  and 
Surgeons. — Fifty  thousand  dollars  has  been  given  to 
the  College  of  Physicians  and  Surgeons,  of  Chicago, 
for  endowment  purposes  by  two  members  of  the  faculty. 
Dr.  William  E.  Quine,  dean  of  the  school,  gives 
$25,000  to  endow  the  college  library,  and  Dr.  D.  A. 
K.  Steele  gives  $25,000   to   endow  the  pathological 


laboratory.  The  gifts  are  conditional  upon  the  pur- 
chase by  the  trustees  of  the  University  of  Illinois,  of 
which  the  College  of  Physicians  and  Surgeons  is  a 
part,  of  a  building  suitable  for  the  library  and  the 
laboratory.  The  income  from  Dr.  Quine's  gift  will  be 
devoted  to  the  purchase  of  books. 

Arrest  of  a  Swindler. — A  man  who  gave  his  name 
as  Dr.  F"erguson,  of  Galveston,  was  arrested  in  this 
city  a  few  days  ago  on  a  complaint  by  Dr.  Jarman  that 
Ferguson  had  swindled  him  out  of  a  small  sum  of 
money.  When  the  man  was  brought  into  court  the 
detective  showed  to  the  magistrate  a  copy  of  the  Med- 
ical Record  containing  a  warning  sent  out  to  all 
physicians  by  a  Dr.  W.  Peyre  Porcher,  of  Charleston, 
S.  C,  against  a  swindler  impersonating  himself  and 
pretending  to  have  attended  the  Congress  of  American 
Physicians  and  Surgeons  in  Washington  and  to  have 
lost  all  his  money.  The  description  of  the  man  tal- 
lied exactly  with  that  of  Ferguson.  Later  he  was 
positively  identified  by  Dr.  Shands,  of  Washington,  as 
the  man  who  had  represented  himself  to  be  Dr. 
Porcher. 

Philadelphia  Neurological  Society. — At  a  stated 
meeting  held  November  26th  Dr.  F.  Savary  Pearce 
exhibited  "A  Case  of  Brachial  Monoplegia  of  Trau- 
matic Origin."  On  account  of  the  total  helplessness 
of  the  affected  member  the  wisdom  of  amputation  was 
considered,  but  the  consensus  of  opinion  was  against 
such  a  radical  operation,  although  a  year  had  elapsed 
since  the  causative  accident,  and  no  improvement  had 
resulted  from  treatment.  It  was  thought  better  rather 
to  expose  the  brachial  plexus  and  determine  its  condi- 
tion, at  the  same  time  remedying  any  gross  deficiencies 
that  might  be  found  and  persisting  subsequently  in 
massage  and  electricity.  Dr.  Charles  K.  Mills  exhib- 
ited "A  Case  of  Associated  Tabes  and  Disseminated 
Sclerosis."  The  patient  was  an  old  man  who  pre- 
sented abolition  of  the  knee  jerks,  Argyll-Robertson 
pupil,  tremor  of  the  head  and  of  the  hands  on  intended 
movement,  with  good  station  and  steady  gait.  Dr. 
Mills  exhibited  also  "A  Case  of  Pseudo-bulbar  Paral- 
ysis," apparently  due  to  lesions  of  both  cerebral  hemi- 
spheres and  attended  with  profound  emotional  mo- 
bility, bilateral  paresis  more  marked  upon  one  side, 
and  increased  knee  jerks,  without  trophic  changes. 
Dr.  F.  X.  Dercum  exhibited  "A  Case  of  Myopathy," 
in  which  there  was  wasting  of  the  muscles  of  the  face 
and  of  the  upper  extremities,  with  increased  bulk  of 
the  calves.  Dr.  Dercum  exhibited  also  "A  Case  of 
Obscure  Diagnosis,"  occurring  in  an  adult  male  in 
whom  there  had  been  pain  and  tenderness  in  the 
course  of  nerves,  followed  by  paraplegia  and  increased 
knee  jerks,  with  wasting  of  the  scajnilar  muscles. 
Dr.  A.  R.  Allen  exhibited  "  A  Case  of  Partial  Oph- 
thalmoplegia," with  exophthalmos,  in  a  man  in  whom 
onlj'  the  fourth  nerve  seemed  to  be  intact.  The  opin- 
ion was  expressed  that  the  condition  was  dependent 
upon  an  orbital  new  growth.  Dr.  D.  I.  McCarthy  ex- 
hibited "A  Case  of  Polyneuritis  of  all  Four  Extremi- 
ties, Passing  into  the  Duchenne-Erb  Type  of  Brachial- 
plexus  Palsy,"  occurring  in  a  young  typesetter,  who 


December  8,  1900] 


MEDICAL    RECORD. 


901 


had  exhibited  a  blue  line  on  the  gums  and  other  symp- 
toms of  lead  poisoning  and  had  been  addicted  to  alco- 
holic excess.  The  wasting  in  the  muscles  of  the 
shoulder  girdle  and  of  the  upper  extremities  was  ex- 
treme, and  suggested  possible  invasion  also  of  the 
ganglion  cells  of  the  anterior  horns  of  the  spinal 
cord.  Dr.  W.  G.  Spiller  reported  "  A  Case  Presenting 
Symptoms  of  Cerebro-spinal  Meningitis  with  Intense 
and  General  Alterations  in  the  Nerve  Cells,  and  Little 
Evidence  of  Inllammation,"  occurring  in  a  feeble- 
minded child  in  whom  death  had  occurred  suddenly 
in  the  course  of  an  acute  illness. 

The  Charles  K.  Mills  Neurological  Society  lis- 
tened on  November  igth  to  an  address  on  medicine 
delivered  by  Dr.  S.  Weir  Mitchell. 

Navy  Department,  Bureau  of  Medicine  and  Sur- 
gery, Washington,  D.  C— Changes  in  the  medical 
corps  of  the  navy  for  the  week  ending  December  i, 
1900.  November  23d. — Assistant  Surgeon  C.  R.  Burr 
ordered  to  the  Mononga/teh,  December  ist.  Assistant 
Surgeon  R.  K.  McClanahan  detached  from  the  navy 
yard,  Washington,  and  ordered  to  the  Indiana,  De- 
cember I  St.  November  27th. — Passed  Assistant  Sur- 
geon R.  Spear  detached  from  the  naval  hospital,  New 
York,  and  ordered  to  the  Buffalo,  December  5th.  As- 
sistant Surgeon  R.  B.  VVilliams  ordered  to  duty  at  the 
naval  hospital.  New  York,  December  5th. 

Philadelphia    County    Medical    Society.  —  At  a 

stated  meeting  held  November  2Sth  Dr.  Jay  F.  Scham- 
berg  read  a  paper  entitled  "  Refractory  Cutaneous 
Syphilis,  with  Report  of  a  Case  and  Exhibition  of  the 
Patient."  He  cited  instances  of  undoubted  syphilis 
in  which  the  symptoms  declined  to  yield  to  the  em- 
ployment of  mercurials  and  iodides  in  varied  form, 
mode  of  administration,  and  dosage.  Dr.  Edward 
Martin  presented  a  communication  on  "The  Treat- 
ment of  Gonorrhoea."  For  acute  anterior  urethritis 
he  recommended  injections  of  protargol  and  potas- 
sium permanganate  in  solution,  for  posterior  urethritis 
the  employmentof  irrigation,  and  for  chronic  urethritis 
local  applications.  Dr.  John  G.  Clark  made  a  com- 
munication on  "Cystoscopy  in  Women,"  with  a  dem- 
onstration of  instruments.  He  expressed  a  preference 
for  the  Nitze-Leitercystoscope  for  diagnostic  purposes, 
and  for  the  Kelly  cystoscope  for  therapeutic  purposes. 
The  latter  has  the  disadvantage  of  requiring  the  knee- 
chest  position,  while  the  former  requires  only  the  lith- 
otomy posture.  A  resolution  was  adopted  petitioning 
the  board  of  education  to  make  an  appropriation  of 
$500  for  each  of  a  sufficient  number  (one  or  two  hun- 
dred) of  medical  inspectors  to  carry  out  successfully 
and  continuously  the  work  of  daily  inspecting  children 
in  the  public  schools  presenting  symptoms  of  illness, 
and  sending  home  those  found  to  be  sick.  The  work 
has  been  done  gratuitously  for  nearly  a  year  by  a  vol- 
unteer staff  of  physicians,  with  the  result  of  preventing 
a  good  deal  of  contagious  disease  among  the  children 
and  their  families,  and  ameliorating  the  severity  of 
attacks  of  disease  through  early  diagnosis  and  confine- 
ment at  home. 


©liitxxan;. 

RUFUS    P.    LINCOLN,  M.D., 


NEW    VOKK. 


Dr.  Rufus  p.  LiN'coLN,  aged  fifty-nine  years,  died 
November  27th  at  his  home  in  this  city,  after  an  oper- 
ation for  appendicitis,  performed  ten  days  ago.  The 
immediate  cause  of  death  is  said  to  have  been  septic 
peritonitis.  I^r.  Lincoln  was  born  in  Belchertown, 
Mass.,  in  April,  1841.  He  received  his  early  educa- 
tion at  Wiliston  Seminary  and  was  graduated  from 
Amherst  College  in  1S62.  He  then  entered  the  army, 
as  a  second  lieutenant  in  the  Thirty-seventh  Massa- 
chusetts, and  served  until  the  close  of  the  war,  com- 
ing out  colonel  of  the  Thirty-seventh.  He  was 
wounded  at  the  Wilderness  and  again  at  Spottsyl- 
vania.  He  began  the  study  of  medicine  in  New  York 
at  the  College  of  Physicians  and  Surgeons,  but  after 
a  year  went  to  Harvard  and  obtained  his  medical  de- 
gree tliere  in  1868.  After  serving  as  interne  in  the 
Massachusetts  General  Hospital  in  Boston  he  returned 
to  New  York  and  entered  upon  the  practice  of  his  spe- 
cialty, namely,  that  of  lar)ngology,  in  which  he  soon 
won  deserved  distinction.  He  was  one  of  the  earliest 
physicians  to  apply  electric  cautery  to  throat  opera- 
tions, and  his  removal  of  a  tumor  from  the  throat  of 
Gen.  Judson  Kilpatrick  by  this  means  was  considered 
at  the  time  quite  remarkable.  Dr.  Lincoln  was  mar- 
ried in  1869.  His  wife,  who  was  a  Miss  Tyler,  of 
Pittsfield,  Mass.,  and  one  daughter  survive  him.  Dr. 
Lincoln  was  a  member  of  the  Loyal  Legion,  the  Uni- 
versity Club,  Amherst  College  Club,  and  the  American 
Laryngological  Society. 


Obituary  Notes Dr.  A.  L.  A.  Toroldt  died  at 

Philadelphia  on  November  23d  inura;mic  convulsions 
at  the  age  of  forty  years.  He  was  born  in  Germany, 
came  to  this  country  as  a  child,  and  was  graduated 
from  the  medical  department  of  the  University  of 
Pennsylvania  in  1880.  He  had  been  demonstrator  of 
materia  medica  in  the  university. 

Dr.  W.alker  R.  Stephen  died  at  Reading,  Pa.,  on 
November  27th,  at  the  age  of  forty-nine  years.  He 
was  a  graduate  of  the  medical  department  of  the  Uni- 
versity of  Pennsylvania. 

Dr.  Cl.'^rence  E.  Foster  died  on  November  26th 
at  Honesdale,  Pa.,  at  the  age  of  forty-three  years. 
He  was  coroner  of  Wayne  county. 


gtocjvcss  of  pXcxUcal   s,cicnce. 

Medical  yciL's,  December  /,  igoo. 

A  New  Operation  for  Hemorrhoids. — Ellsworth  Eliot  states 
that  the  following  procedure,  which  has  been  tried  during 
the  past  six  months  in  the  Presbyterian  Hospital  of  New 
York,  has  given  excellent  results  in  a  numlJer  of  cases: 
After  the  customary  preparation  and  with  the  usual  pre- 
caution of  as  perfect  cleanliness  as  is  possible  under  the 
circumstances,  an  anesthetic  is  administered,  and  the 
sphincter  having  been  stretched  the  hemorrhoids  are  al- 
lowed to  protrude.  Each  advanced  hemorrhoidal  area  is 
treated  similarly  as  follows;  Opposite  the  base  of  the 
hemorrhoid,  parallel  with  and  corresponding  to  the  muco- 
cutaneous junction,  a  curved  incision  is  made  and  car- 
ried upward  in  the  same  plane  as  in  a  Whitehead  operation 
beneath  the  |)ile-bearing  area  until  the  base  of  the  hemor- 
rhoid is  reached.  A  second  curved  incision  is  then  made 
in  and  through  the  mucous  membrane,  forming  an  ellipse 
with  the  first-mentioned  incision  and  including  within  this 
ellipse  any  area  of  ulceration  at  the  base  of  the  hemorrhoid 
that  may  have  developed  as  a  result  of  the  irritation  to 
which  the  exposed  surface  of  the  mucous  membrane  over- 
lying the  hemorrhoid  is  subjected.  From  the  junction  of 
the  two  curved  incisions  an  incision  is  carried  vertically 
upward  through  the  mucous  membrane  only,  and  the  re- 


902 


MEDICAL    RECORD. 


[December  8,  1900 


sultiug  quadrangular  flap  of  mucous  membrane  is  reflected 
from  the  surface  of  the  underlying  hemorrhoidal  area, 
having  its  base  of  blood-supply  superiorly.  After  the  dis- 
section of  this  flap,  the  same  vertical  incision  is  deepened 
through  the  hemorrhoidal  tissue  proper,  forming  a  rect- 
angular mass  of  hemorrhoidal  tissue  which  is  trausflxed 
at  its  base  with  stout  catgut :  the  ligatures  are  then  tied 
tightly  and  the  mass  is  removed.  The  rectangular  flap  is 
stitched  to  the  skin  and  the  retention  of  any  di.scharge 
prevented  by  cutting  the  catgut  ligature  long  and  allowing 
the  ends  to  protrude  below,  thus  acting  as  a  drain.  This 
same  procedure  is  repeated  in  not  more  than  two  other 
places  where  the  hemorrhoids  are  most  pronounced.  A 
dressing  of  sterile  gauze  is  placed  over  the  suture  line,  a 
large  tube,  surrounded  by  iodoform  gauze,  having  been 
previously  introduced  into  the  lumen  of  the  gut.  Prompt 
union  is  generally  secured  and  the  complete  excision  of  all 
areas  of  ulceration  at  the  base  of  the  hemorrhoid  is  attained. 

The  Treatment  of  Pneumonia  with  Anti-Pneximococcic  Serum. 
• — Edwin  Rosenthal  writes  that,  clinically,  pneumonia  is 
met  with  as  croupous  pneumonia,  a  self-limited  disease 
which  should  end  favorably,  and  catarrhal  pneumonia 
which  has  no  limitation.  A  very  great  and  essential  factor 
in  all  histories  of  catarrhal  pneumonia  is  told  in  the  word 
— complication.  When  pueumonia  comes  as  a  complica- 
tion or  sequel  to  other  diseases,  the  antipneumococcic  serum 
can  be  used  at  once,  and  the  addition  of  the  antistrepto- 
coccic serum  is  as  needful.  The  method  of  administering 
the  serum  is  by  hypodermic  injection  into  the  tissues  of  the 
body.  The  indications  for  its  use  are  as  follows:  The 
temperature,  pulse,  and  respiration  should  be  taken  as  a 
guide,  and  the  severity  of  these  symptoms  governs  the 
method  and  size  of  dose  and  its  repetition.  If,  for  instance, 
the  temperature  be  103'  F.  or  over,  the  pulse  140  or  over, 
and  the  respiration  48  or  over,  the  writer  begins  with  20 
c.c.  ;  when  the  type  is  more  severe,  with  40  c.c.  of  the 
serum,  followed  every  four  hours  by  double  the  initial  in- 
jection, until  the  disease  is  under  control,  as  manifested 
by  a  decline  of  temperature,  a  slower  respiration,  disap- 
pearance of  pain,  improvement  in  the  pulse,  and  a  change 
for  the  better  in  the  general  condition.  If  the  case  be 
croupous,  the  first  twenty-four  or  forty-eight  hours  show 
the  effect  of  the  remedy.  When  the  pneumonia  is  second- 
ary to  another  disease,  the  antipneumococcic  serum  should 
be  followed  in  four  hours  by  an  injection  of  antistrepto- 
coccic serum.  The  use  of  serum  does  not  interfere  with 
other  treatment,  nor  is  it  harmful  in  any  quantity,  at  any 
stage  of  the  disease.  At  the  same  time  the  familiar  suit- 
able remedies  should  be  employed.  None  of  the  foreign 
serums  is  reliable.  It  is  not  the  one  dose  or  the  one  bottle 
that  will  cure,  but  sufficient  quantities  must  be  used  till  re- 
sults are  obtained,  whatever  that  amount  may  be. 

The  Influence  of  Measles  and  Erysipelas  upon  Epilepsy, 
with  Report  of  Cases. — L.  Pierce  Clark  and  E.  A.  Sharp 
draw  the  following  deductions  from  the  study  of  their 
cases :  In  not  one  instance  was  the  pre-existing  epilepsy 
favorably  modified  for  any  great  length  of  time.  In  a  few 
cases  the  progress  of  the  disease  was  accelerated  by  the 
infectious  complication,  and  in  one  the  measles  caused 
status  epilepticus.  In  those  cases  in  which  the  epilepsy 
was  favorably  modified,  the  temporary  improvement  was 
slight  and  of  very  short  duration.  They  therefore  conclude 
that  instead  of  the  jihysician  urging  his  patient  to  run  the 
risk  of  an  infectious  disease,  with  the  small  chances  of  such 
an  accident  resulting  favorably  to  the  existing  neurosis, 
he  should  urge  them  to  avoid  any  and  all  such  complica- 
tions as  far  as  possible. 

A  Plea  for  the  Earlier  Recognition  of  Squint  in  Children 
by  the  Family  Physician  and  the  Earlier  Application  of  the 
Methods  of  Treatment.  — By  C.  A.  Veasey. 

Septic  Synovitis  of  Knee  Joint ;  Extensive  Drainage  fol- 
lowed by  E.xcision  of  Entire  Synovial  Membrane ;  Recovery. 
— By  Charles  A.  Powers. 

A  Medical  View  of  the  Treatment  of  the  Caecum  and  Appen- 
dix.—By  A.  L.  Benedict. 

Therapeutic  Studies  of  Heroin  Hydrochloride. — By  Benno 
Ilyams. 

When  Shall  We  Operate  in  Appendicitis  ?  -By  Frank  E. 
Bunts. 

.W'^i'  ]'(irA'  Mi-i/icii/  Journal,  December  /,  igoo. 

A  Case  of  Multiple  Aneurisms. — By  W.  J.  Pettus.  The  pa- 
tient was  a  man  of  forty-one  who  died  a  month  after  admis- 
sion to  hospital.  The  autopsy  showed  the  following  con- 
dition. The  whole  extent  of  the  innominate  artery  was 
involved  in  a  fusiform  aneurism  extending  u]>  to  and  includ- 
ing the  first  and  second  parts  of  the  subclavian.  Tliis  aneu- 
rismal  sac  was  about  two  inches  in  diameter,  and  also  in- 
volved the  right  common  carotid.  A  great  eff'ort  at  a  cure 
had  been  made,  especially  in  the  innominate  portion  of  the 
aneurism.  There  a  firmly  organized  clot  filled  the  sac, 
except  where  a  small  channel  for  the  blood  was  left.     The 


sac  of  the  subclavian,  too,  was  filled  with  partly  organized 
clot,  leaving  a  very  narrow  channel  for  the  blood  current. 
There  was  also  found  a  fusiform  aneurism  of  almost  the 
entire  abdominal  aorta,  beginning  at  and  including  the 
cccliac  axis  and  extending  down  to  the  third  lumbar  ver- 
tebra, just  below  the  origin  of  the  inferior  mesenteric 
artery.  The  bodies  of  the  last  dorsal  and  the  first,  second, 
and  third  lumbar  vertebrje  were  eroded  by  the  aneurism, 
to  the  depth  of  half  an  inch,  the  intervertebral  substances 
being  intact.  At  the  origin  of  the  coeliac  axis  the  sac  had 
ruptured  on  the  right  side,  and  the  blood  had  burrowed 
behind  the  peritoneum,  forming  an  immense  clot,  amount- 
ing to  half  a  gallon  of  blood,  extending  from  the  diaphragm 
to  the  crest  of  the  ilium  on  the  right  side.  The  liver  was 
pushed  upward  and  forward  by  the  large  clot.  From  the 
history  given  the  abdominal  aneurism  must  have  ruptured 
a  week  before  the  patient  came  under  observation. 

Report  of  a  Case  of  Empyema  of  the  Antrum  of  Highmore 
of  Fifteen  Years'  Duration,  Due  to  a  Foreign  Body,  Opera- 
tion ;  Recovery. — The  patient  in  the  case  reported  by  A.  B. 
Duel  was  a  woman  of  thirty.  The  symptoms  had  been  of 
the  type  usual  in  empyema  of  the  antrum.  Several  open- 
ings had  been  made  into  the  cavity  and  syringings  carried 
out  but  with  no  permanent  relief.  Duel  opened  through 
the  canine  fossa  and  on  exploring  with  the  finger  found  a 
calculus  made  up  largely  of  inspissated  mucus  around  a 
nucleus,  consisting  of  the  fang  of  a  molar  tooth  which  had 
been  forced  into  the  antrum  by  a  dental  operation  fifteen 
years  before.  Curetting,  packing,  etc.,  were  done,  the 
latter  being  repeated  daily  for  four  days  when  a  large  rub- 
ber tube  was  substituted.  The  discharge  stopped  in  a  week. 
The  tube  was  removed  in  three  weeks.  The  patient  has  re- 
mained well  for  eighteen  months. 

Practical  Medicine  and  Laboratory  Research. — Beverley 
Robinson  utters  a  protest  against  the  unreserved  accept- 
ance of  the  germ  theory  of  disease  causation.  We  are  to 
take  into  account  all  the  information  the  laboratory  can 
furnish  but  should  not  attach  undue  weight  to  evidence 
from  this  quarter.  Concerning  laboratory  reports  Robin- 
son says  that  he  has  had  more  than  once  been  sceptical  as 
to  the  time,  care,  skill,  and  knowledge  employed  in  making 
them.  He  feels  that  in  any  important  case  the  knowledge 
and  technique  of  the  observer  must  be  above  cavil.  Be- 
hind the  disease  is  the  patient  and  this  fact  should  always 
be  borne  in  mind.  The  clinician  must  rank  foremost  and 
to  him  the  chemist  and  bacteriologist  should  always  report 
their  findings.  It  is  he  who  should  settle  the  importance 
they  have  and  the  treatment,  prophylactic  and  curative, 
which  should  be  adopted. 

A  Contribution  to  the  Therapeutics  of  Phlegmasia  Alba 
Dolens. — A.  Ilerzfeld  has  used  in  one  case  the  unguentum 
Crede.  The  interesting  features  of  this  case  are  the  com- 
paratively late  appearance  of  the  phlegmasia  alba  dolens 
(on  the  twentieth  day  after  delivery)  and  the  rapid  effect 
of  unguentum  Crede  on  pain,  fever,  and  swelling,  after  all 
other  means  had  signally  failed,  leading  to  the  impression 
that  its  action  was  very  similar  to  that  of  antitoxin.  Herz- 
feld  calls  special  attention  to  the  large  dosage  used  (15 
gm.),  which  he  considers  necessary-  for  an  effective  use  of 
the  remedy. 

Cessation  of  Respiration  during  Chloroform  Ansesthesia  Due 
to  Chewing-Gum  in  the  Larynx. — By  E.  P.  Palmer. 

The  Treatment  of  Various  and  Long-Standing  Sexual  and 
Urinary  Symptoms  in  the  Male. — By  Follen  Cabot. 

Revelations  of  the  Proctoscope  in  Health  and  Disease. — By 
A.  B.  Cooke. 

A  Dissection  of  Some  Antitoxin  Statistics. — By  J.  E. 
Herman. 

Heroin  as  an  Analgetic. — By  N.  P.  Geis. 

Join  )tal  oj  the  Aiiu-riiiin  Medical  .iss'ii.  Dec.  /.  /goo. 

Bacteriological  E.xaminations  of  Otitis  Media  Purulenta  and 
Suppurative  Mastoiditis. — This  report  is  made  by  Talbot 
R.  Chambers.  At  the  beginning  of  the  autumn,  iSgg,  the 
rule  was  adopted  that  whenever  an  otitis  purulenta,  acute 
or  chronic,  came  under  treatment,  the  canal  was  to  be  thor- 
oughly cleansed  with  hydrogen  peroxide,  and  granulations 
and  polyps  were  to  receive  approjjriate  treatment  tending  to 
their  speedy  removal  if  [lossible.  The  same  order  was  then 
given  in  every  case,  viz.,  hot-water  syringing  to  be  followed 
by  instillation  of  enzymol  in  the  canal.  If  after  one  week 
no  improvement  was  noted,  the  enzymol  was  discontinued, 
and  the  hot-water  syringing  was  changed  to  hot  bichloride 
(I  :  4, (XX)).  or  hot  carbolic  acid  (10  to  20  drops  to  the  pint), 
or  hot  .Seller's  solution.  '1  he  water  was  at  120°  F.  NVhen 
the  auditory  canal  was  swollen  and  the  mastoid  painful, 
leeches  were  applied  in  the  early  stage  and  then  six  hours 
later,  after  the  bleeding  had  stopped,  the  following  treat- 
ment was  employed  every  hour  for  twenty-four  or  forty- 
eight  hours:  Ten  minutes'  syringing  with  hot  water  at 
120  F.,  ice  poultice  bound  firmly  on  for  fifteen  minutes, 
and  a  continuous  application  of  a  hot-water  bag  for  the 


December  8,  1900] 


MEDICAL    RECORD 


903 


remainder  of  the  hour.  The  writer  believes  that  tlie  abor- 
tion of  twenty-eight  out  of  thirty-nine  cases  of  acute  mas- 
toid inflammation,  presenting  swollen  auditory  canal  and 
mastoid  pain,  is  due  to  this  treatment.  In  no  acute  mas- 
toid case  when  this  treatment  was  properly  carried  out  was 
operation  done.  In  a  number  of  cases  paracentesis  of  the 
drum  membrane  was  performed  one  or  more  times.  Tonic 
constitutional  and  hygienic  measures  suitable  to  the  indi- 
vidual were  in  all  cases  taken.  The  writer  emphasizes  the 
fact  that  the  great  value  of  a  microscopical  examination 
of  the  catarrhal  or  purulent  discharge  is  seen  in  the  case  of 
diplococcus  pneumoni;e  (Fraenkel),  in  which  a  speedy  cure 
may  be  prophesied,  and  one  may  with  equal  confidence 
sew  up  the  mastoid  wound  comjiletely  and  discharge  the 
patient  in  about  one  week,  or  at  most  not  over  two  weeks  ; 
with  streptococcus  alone,  fifty  per  cent,  are  cured.  One 
case  of  acute  suppurative  mastoiditis  (streptococcus  alone) 
had  hot-water  syringing  and  zinc  chloride  instillation  of 
two  per  cent,  strength,  and  after  paracentesis  came  to  rest 
in  two  weeks.  Witlt  streptococcus  and  jjyocyaneus  the 
chances  are  even  of  an  eventual  if  tardy  cure.  With 
streptococcus  and  staphylococcus  the  chances  are  two  to 
one  against  cure.  If  stapliylococcus  alone  be  present,  four 
out  of  nine  may  come  to  a  cure.  If  pyocyaneus  exist  alone, 
one-half  may  be  cured  and  the  others  i)rove  stubborn.  If 
coh  bacillus  communis  be  the  germ  the  case  is  practically 
incurable.  All  these  ca.ses  may  prove  stubborn  except  the 
diplococcus  pneumoniae  (Fraenkel),  which  yields  forthwith 
to  pepsin. 

Cholecystectomy  ;  with  Special  Reference  to  the  Removal 
of  the  Mucous  Membrane  of  the  Gall  Bladder  as  a  Substi- 
tute ;  Report  of  a  Case  in  which  the  Gall  Bladder  was  Re- 
moved for  Malignant  Disease. — Hy  \V.  J.  Mayo. 

Tuberculosis  of  the  Testicle,  with  Special  Reference  to  its 
Conservative  Treatment. — By  John  B.  JIurphy. 

The  Importance  of  Early  Operations  on  Gail-Stones. — By 
Maurice  H.  Richardson. 

Gastric  Ulcer :  Non-Perforating  Hemorrhage. — By  William 
L.  Rodman. 

The  Diagnosis  and  Treatment  of  Cholelithiasis. — By  W. 
J.  Means. 

American  Medical  Journalism. — By  Charles  Wood  Fassett. 

Modern  Empirical  Inventions. — By  N.  C.  Morse. 

Boston  Medical  ami  Surgical  Journal,  Nov.  2g,  jqoo. 

Subperiosteal  Fractures. — Frederick  J.  Cotton  reports  a 
number  of  cases  of  tliis  class  of  fractures,  which  is  very 
common  among  children,  and  a  large  projiortion  of  which 
seem  on  close  examination  to  have  little  in  common  with 
the  type  known  as  green-stick  fracture,  with  which  they 
are  usually  classed.  Here  there  is  no  deformity,  because 
there  are  no  torn  surfaces,  but  a  clean-cut  crack  or  cross 
fracture,  and  no  bent  or  half-broken  layer  of  bone  to  pre- 
vent the  motion  necessary  to  readjustment  of  the  surfaces. 
The  lack  of  crepitus  and  mobility  seems  to  be  largely  or 
entirely  dependent  on  the  strength  of  the  thick  intact  peri- 
osteal layer.  From  cases  observed  and  experiments  tried, 
it  would  seem  that  blows  are  less  likely  than  a  more  slowly 
acting  strain  to  produce  typical  green-stick  fractures.  It 
seems  that  fractures  in  children  showing  no  deformity 
and  no  appreciable  mobility  are  not  uncommon  ;  that  they 
might  readily  be  overlooked  ;  that  they  often  need  no  re- 
duction, having  no  deformity  ;  that  they  often  repair  with 
callus,  and  quickly. 

Irritable  Breasts,  or  Chronic  Lobular  Mastitis.— R.  C. 
Cabot  reports  two  cases  of  lump  in  the  breast  in  two  young 
unmarried  women.  The  lumps  were  painful  to  the  touch. 
They  are  improving  under  treatment  addressed  to  general 
debility  and  anjemia.  The  author  queries  whether  these 
tumors  may  possibly  be  galactocele  (of  which  several  cases 
are  on  record  in  unmarried  women),  or  whether  it  may  not 
be  that  the  lumps  are  physiological,  and  that  a  consider- 
able number  of  women  have  them  and  do  not  find  them 
out.  He  also  seeks  information  as  to  the  prognosis,  and 
the  treatment. 

Observations  upon  the  Symptoms  and  Treatment  of  Hjrper- 
acidity  of  the  Stomach. — By  Henry  F.  Hewes. 

Acute  Hemorrhagic  Pancreatitis ;  its  Surgical  Treatment, 
with  Report  of  Six  Cases.— By  F.  B.  Lund. 

Cysts  of  the  Vocal  Cord.— By  J.  Payson  Clark. 

The  Philadelphia  Medical  Journal,  December  /,  igoo. 

On   the  Treatment  of   Tuberculosis  by  Sodium  Cinnamate. 

— Alfred  Mann  states  that  there  are  two  ini])ortant  charac- 
teristics in  which  tuberculosis  differs  from  the  acute  infec- 
tious diseases,  such  as  diphtheria  and  pneumonia:  i.  It 
tends  to  the  production  of  marked  and  permanent  anatomi- 
cal changes  in  the  organs  and  tissues  involved.  2.  Itcau.ses 
little  or  no  immunizing  reaction  in  the  organism.  The 
most  successful  modes  of  treatment  in  the  past,  excluding 


surgical  measures,  have  been  those  that  aimed  to  improve 
the  general  health  of  the  system,  those  that  relied  upon 
the  natural  tendency  of  the  body  to  resist  and  expel  infec- 
tion and  that  in  any  way,  directly  or  indirectly,  increased 
its  defensive  powers.  Among  the  chief  of  these  are  the 
outdoor  and  climatic  treatment,  the  dietetic  and  hygienic 
methods,  and  the  treatment  in  sanatoria.  The  writer  then 
gives  his  experience  in  the  use  of  sodium  cinnamate  or 
hetol.  He  has  employed  the  method  of  intravenous  injec- 
tion of  solutions  of  this  drug,  following  very  closely  the 
directions  given  by  Professor  Landerer.  Beginning  with 
yJn  to  5'j  of  ^  grain,  the  dose  is  gradually  increased  to  } 
or  5  gr.  which  should  rarely  be  exceeded.  The  injections 
are  repeated  every  other  day.  Only  pure  preparations 
should  be  used  such  as  are  made  synthetically  by  certain 
German  chemical  houses.  The  technique  is  very  simple,  the 
main  point  being  to  .secure  perfect  asepsis.  After  the  vein 
is  made  prominent,  the  needle  is  plunged  slantingly  into 
it.  The  duration  of  treatment  varies  considerably,  depend- 
ing upon  the  severity  of  the  infection.  Cinnamic  acid  is 
the  efficient  constituent  of  the  balsam  of  Peru.  The  com- 
pound used  for  injection  is  the  sodium  salt  of  this  acid, 
called  hetol.  It  possesses  all  the  efficacy  of  the  original 
balsam  and  is  free  from  its  defects.  The  injections  are 
entirely  harmless.  There  are  no  bad  effects  on  the  kidneys. 
There  is  no  diminution  of  the  red  corpuscles.  The  first 
effect  is  the  increase  in  number  of  white  corpuscles  for  from 
three  to  eight  hours,  after  which  they  gradually  decrease 
to  normal.  In  a  few  weeks  new  blood-vessels  spring  up 
and  granulations  extend  into  the  tuberculous  area,  absorb- 
ing and  replacing  the  necrotic  material.  Many  of  the  pa- 
tients become  drowsy  after  the  injections.  The  writer  has 
been  favorably  impressed  by  the  use  of  this  drug,  believing 
that  it  will  markedly  quicken  healing-processes  in  some 
though  not  in  all  of  the  cases. 

Where  the  Danger  Lies  in  Tuberculosis. — Adelaide  Dutcher 
gives  the  following  summary  of  tabulation  : 

Total  number  of  patients 190 

Number  of  houses  occupied 234 

Whites i;^o 

Blacks 40 

Russians 30 


Bad  sanitary  location 

Insufficient  light  and  ventilation 

Overcrowding 

Personal  and  household  cleanliness 


Russians, 
Per  Cent. 


69 

83 
76 
75 


Blacks. 
Per  Cent. 


40 
7" 
50 
£6 


Whites, 
Per  Cent. 


30 
46 
46 

43 


The  writer  has  made  her  observations  in  Baltimore.  The 
Russians  are  separated  from  the  rest  of  the  whites  on  ac- 
count of  their  extreme  unsanitary  condition.  The  occupa- 
tion of  many  of  these  patients  confines  them  within  doors, 
and  the  writer  emphasizes  their  disgusting  habits  in  regard 
tothedisposal  of  sputum.  Her  statistics,  although  limited, 
show  the  rapidity  with  vi'hich  Baltimore  houses  are  becom- 
ing centres  of  infection.  In  the  short  lime  of  these  obser- 
vations these  one  hundred  and  ninety  patients  occujiied 
two  hundred  and  thirty-four  houses.  There  was  never  any 
attempt  at  disinfection.  In  fifty-eight  ])er  cent,  of  the 
cases  the  family  history  was  absolutely  negative.  When 
the  tuberculous  patient  is  taught  to  destroy  his  sputum, 
to  rid  his  room  of  carpets  and  other  germ  catchers,  and  to 
throw  open  his  windows  to  admit  the  sunshine  and  fresh 
air,  a  visible  decrease  in  this  disease  may  be  looked  for  in 
our  dispensaries. 

Some  Observations  on  the  Occurrence,  Early  Diagnosis, 
and  Treatment  of  Incipient  Pulmonary  Tuberculosis  in  Dis- 
pensary Practice. — By  Henry  L.  Shively. 

Lupus  Vulgaris  of  Fifteen  Years'  Standing  Successfully 
Treated  and  Cured  by  Exposure  to  the  X-Ray. — By  A. 
Everett  .Smitli. 

A  Case  of  Acute  Tuberculosis  of  the  Mesenteric  Glands  of 
the  Ileo-caecal  Coil;  Removal,  Permanent  Recovery.  — By 
Maurice  H.  Richardson. 

Personal  Views  Regarding  the  Climate  of  the  Rocky 
Mountains  in  the  Treatment  of  luberculosis. — By  S.  D.  \'an 

Meter. 

The  Early  Diagnosis  of  Pulmonary  Tuberculosis. — By  De 
Lancey  Rochester. 

The  Fallacy  of  Climate  in  the  Treatment  of  Tuberculosis. 
—By  J.  W.  Kime. 

Sanatorium  Treatment  and  its  Relation  to  Climate. — By 
S.  F.dwin  Solly. 

Operation  in  Two  Cases  of  Tuberculous  Peritonitis. — Bv 
W.  L.  Grant. 

Public  Education  and  the   Prevention   of  Disease. — By  H. 
L.  Johnson. 
The  Registration  of  Tuberculosis. — By  Hermann  M.  Biggs. 


904 


MEDICAL    RECORD. 


[December  8,  1900 


Colorado  Climate  :  a  Comparative  Study.— By  Edwin  G. 
Dexter. 

Stomach  Conditions  in  Early  Tuberculosis.— By  Boaidm<in 
Reed. 

The  Diseases  of  the  Bronchial  Glands.— By  J.  N.  Hall. 

On  the  Study  of  Tuberculosis.— By  William  Osier. 

British  Medical  Journai^  November  ly  and  24,  igoo. 

A  Clinical  Lecture  on  Varix. — The  following  clinical 
classiticalion  of  varix  is  made  by  William  Thorburu :  A. 
Developmental  varix,  in  which  a  large  trunk  stands  out 
from  a  limb  whose  tissues  are  otherwise  healthy.  This  con- 
dition is  often  unilateral.  The  patient  is  often  young.  It 
is  more  common  in  males.  There  is  often  a  history  of 
hereditary  tendency  to  varicose  veins  or  to  hemorrhoids. 
These  cases  have  probably  a  congenital  origin.  B.  Ob- 
stinictive  varix,  in  which  the  varix  is  far  less  sharply  limited. 
It  is  bilateral  after  the  earliest  appearance  ;  rare  in  the 
young,  more  common  in  the  female.  Obstruction  of  the 
venous  return  is  the  prominent  cause.  C.  Hyperasmic  or 
inflammatory  varix,  in  which  there  is  no  varix  of  the  larger 
trunks  but  only  patches  in  which  the  venules  are  enlarged. 
These  small  varices  are  probably  a  direct  result  of  inflam- 
mation, and  of  prolonged  hypersemia  connected  therewith, 
due  to  long-continued  increase  in  the  arterial  blood  supplj'. 
In  the  lower  limb  this  condition  is  not  common.  As  to 
treatment  the  excision  of  varicose  veins,  however  per- 
foi-med,  is  capable  of  relieving  the  patient  of  dilated  areas 
and  of  developmentally  imperfect  vessels  ;  it  is  not  capable 
of  relieving  obstruction  except  by  the  indirect  method  of 
substituting  healtliy  for  valveless  channels.  When  the 
defect  is  limited  in  extent  the  best  results  will  be  obtained. 
When  it  is  more  widely  distributed  operation  is  far  less 
successful.  In  the  obstructive  type,  the  success  will  largelj- 
depend  upon  the  relative  etiological  importance  in  each 
case  of  developmental  error  or  of  obstruction. 

A  Case  of  Acute  (Traumatic)  Tetanus  Successfully  Treated 
■with  Antitetanus  Serum.— Sydney  H.  Long  reports  the  case 
of  a  boy  aged  thirteen,  whose  foot  had  been  ]iunci:ured  by 
nails  in  his  boot.  Five  days  later  he  was  admitted  into  the 
hospital  with  symptoms  of  tetanus.  The  maximum  daily 
number  of  spasms  occurred  on  the  fourth  day  after  the 
serum  treatment  was  commenced,  after  which  they  gradu- 
ally declined.  This  was  to  be  expected,  as  the  toxin  had 
had  seven  clear  days  to  produce  its  effects  before  the  serum 
treatment  was  begun  ;  and  the  operation  required  for  the 
hypodirmic  injections  in  part  explains  the  treqtiency  of 
the  spasms.  In  less  than  two  months  he  was  feeling  per- 
fectly well.  The  study  of  this  case  confirms  the  belief  that 
cases  of  acute  tetanus  can  be  successfully  treated  with  the 
antitetanic  serum  if  this  is  given  in  sufficiently  large  doses 
and  frequently  repeated.  It  is  probably  not  necessary  to 
resort  to  the  intracerebral  method  of  administering  the 
serum,  provided  that  this  be  given  in  sufficient  amount.  In 
serum-therapeutics  the  chance  of  ill-effects  from  over- 
dosage is  remote.  At  first  the  injections  were  given  sub- 
cutaneously,  but  later  per  rectum.  The  latter  were  given 
through  a  flexible  rubber  tube  of  small  calibre  under  hy- 
drostatic pressure,  about  an  ounce  of  pancreatized  milk 
being  used  to  drive  the  serum  into  the  bowel  ;  a  plain 
warm-water  injection  of  a  pint  was  given  daily  to  wash 
out  the  rectum  while  the  enemata  were  being  continued. 

Erythematous  Rash  due  to  Boric  Acid. — Henry  Handford 
reports  this  case.  The  patient,  a  man  of  forty-seven,  had 
suffered  from  dyspeptic  symptoms  for  three  years.  Vomit- 
ing had  been  noted  for  fourteen  months,  and  strength  and 
flesh  were  diminishing.  A  non-malignant  stricture  of  the 
pylorus  was  diagnosed.  The  stomach  had  been  washed 
out  for  three  and  one-half  months,  but  it  was  decided  to 
continue  this  treatment  for  a  short  time  longer,  and  boric- 
acid  lotion  1 :  60  was  selected.  About  two  and  one-half 
pints  of  the  warm  solution  were  used  and  allowed  to 
remain  two  or  three  minutes,  and  returned  by  the  siphon 
action  of  the  tube.  This  was  repeated  two  or  three  times 
till  the  fluid  was  nearly  clear.  Within  less  than  a  week  an 
erythematous  rash  appeared  on  the  face  and  back.  Plain 
water  was  substituted  for  the  boric  solution  and  the  rash 
disappeared  in  two  days.  Again  boric  solution  of  a 
strength  of  i :  200  was  used  for  three  days  and  the  ery- 
thema again  appeared.  The  solution  was  stopped  and  the 
rash  disappeared.  Later  the  trouble  was  found  to  be  a 
much  thickened  pylorus.  Pyloroplasty  was  performed 
and  the  patient  made  a  good  recovery. 

A  Case  of  Aortic  Aneurism  Treated  by  Hypodermic  Injec- 
tions of  Gelatin. — This  ])atieiit  was  a  man  of  fifty.  Arthur 
Cutficld  began  the  treatment  by  injecting  a  two-per-cent. 
solution  of  gelatin  into  the  subcutaneous  tissues  of  the 
abdominal  wall  on  July  22d,  using  at  first  three  fluid- 
ounces  and  after  the  fourth  injection  four  ounces.  The 
injections  were  given  every  second  day  for  about  three 
weeks,  and  then  every  third  or  fourth  day,  twenty  injec- 
tions having  been  given  altogether.  Improvement  began 
in  about  a  fortnight,  and  from  that  time  the  pain  steadily 


diminished  and  the  pulsatitm  became  less  marked,  till  at 
the  close  of  the  treatment  pain  was  practically  absent  and 
pulsation  felt  only  on  deep  pressure.  He  was  then  quite 
comfortable  exc-ept  for  an  occasional  spasm  once  or  twice 
in  the  twenty-four  hours.  The  improvement  was  very 
marked.  He  was  not  confined  to  bed  during  the  treat- 
ment, though  he  moved  about  very  little  and  with  great 
care.  He  took  five-grain  doses  of  potassium  iodide  three 
times  a  day,  and  his  food  and  drink  were  somewhat  re- 
stricted in  quantity. 

Successful  Removal  of  an  Enlarged  and  Displaced  Spleen. 

—  U'Arcy  Power  reports  this  case.  The  patient,  a  woman 
of  forty-three,  mother  of  two  children  three  }-ears  before 
operation,  struck  her  left  side  just  over  tlie  lower  ribs. 
Two  years  later  she  noticed  her  abdomen  increasing  in 
size.  She  had  suffered  much  pain  and  discomfort.  At 
operation  the  abdomen  was  opened  and  the  spleen  dis- 
covered to  be  attached  by  a  long  pedicle.  The  organ  was 
removed.  The  operation  lasted  an  hour  and  a  half  from 
the  beginning  of  the  anaesthetic.  On  the  forty-second  day 
after  operation  the  patient  went  home  and  hasphj-siologic- 
ally  sustained  no  inconvenience  from  the  loss  of  her  spleen. 
Just  after  removal,  the  organ  weighed  two  and  one-half 
pounds.  The  enlargement  was  due  to  hypertrophy,  the 
weight  being  seventeen  or  eighteen  ounces  after  it  had  been 
kept  in  spirit  for  six  months.  Splei  ectomy  seems  to  be  a 
successful  operation  in  cases  of  enlarged  and  displaced 
spleens  when  the  enlargement  is  not  leucocythsemic. 

The  Management  of  the  Soft  Parts  in  the  Mastoid  Opera- 
tion.— .\lter  reviewing  Sehwartze's  and  Ballance's  opera- 
tions, James  Kerr  Love  describes  the  single  channel  opera- 
tion. The  bone  is  dealt  with  as  in  the  ordinary  radical 
mastoid  operation.  The  posterior  superior  wall  of  the 
cartilaginous  canal  is  slit  through  its  entire  length.  The 
mastoid  skin  wound  is  closely  stitched  and  a  careful  pack- 
ing via  the  external  auditory  canal  causes  the  slit  posterior 
cartilaginous  wall  to  apply  itself  to  the  posterior  wall  of 
the  widened  bony  canal.  The  canal  is  much  widened, 
through  which  it  is  easy  to  conduct  future  treatment,  which 
consists  almost  entirely  of  packing  with  special  absorbent 
gauzes.  All  dressings  are  removed  from  the  side  of  the 
head  within  a  fortnight  and  the  patient  may  then  resume 
work.  Every  part  of  the  healing  surface  can  be  seen 
through  the  speculum.  Complete  healing  takes  place 
witliin  three  months,  and  two  ciressings  per  week  are  gen- 
erally sufficient. 

A  Case  of  Severe  Subcranial  Hemorrhage ;  Operation ;  Re- 
covery.—F.  G.  Proudioot  and  Gabriel  W.  Farmer  report  the 
case  of  a  woman  aged  fifty-six,  who  was  found  lying  uncon- 
scious. After  being  put  to  bed  she  regained  consciousness 
for  a  short  period,  after  which  she  again  lapsed  into  uncon- 
sciousness. Operation  was  advised  as  the  case  was  diag- 
nosed as  being  one  of  subcranial  hemorrhage.  A  trephine 
was  applied  and  on  the  removal  of  the  crown  of  bone  a 
large  clot  bulged  into  the  wound,  and  almost  instantane- 
ously the  stertorous  character  of  the  breathing  ceased. 
The' clot  was  scooped  away  and  a  large  depression  in  the 
convexity  of  the  brain  presented  itself.  Hemorrhage  was 
free.  The  depression  was  packed  with  sterilized  gauze 
and  a  dressing  .applied.  Within  a  week  the  sutures  were 
removed.  The  wound  healed  complete!)',  and  the  patient 
made  a  perfect  recovery. 

Note  on  a  Case  of  Protracted  Stupor. — This  case  is  re- 
ported by  David  Drummond.  The  patient  was  a  man 
aged  twenty-six,  with  a  neurotic  family  history.  When 
admitted  to  the  hospital,  he  lay  motionless  and  took  no 
notice  of  his  surroundings.  His  eyes  were  open,  his  limbs 
cold  and  flaccid.  Reflexes  were  just  perceptible,  but  the 
corneal  reflex  was  active.  Liquid  nourishment  was  given. 
The  treatment  consisted  in  attending  to  the  skin,  and 
massage  witli  passive  movements.  At  the  end  of  seven 
months  he  began  to  improve,  and  as  he  became  able  to 
speak  it  was  discovered  that  his  consciousness  and  memory 
had  not  been  entirely  in  abeyance  and  in  this  respect  the 
case  differed  from  anergic  stupor.  It  differed  from  melan- 
cholic stupor  in  that  the  muscles  were  flaccid  and  abso- 
lutely unresistive. 

Notes  of  Two  Cases  of  Excision  of  the  Gasserian  Ganglion 
for  Epileptiform  Neuralgia.-  J.  Crawford  Renton  believes 
that  this  most  .severe  complaint  can  now  with  safety  be  re- 
lieved. In  these  two  cases  he  removed  the  ganglion, 
adopting  the  method  of  Hartley  and  Krau.se,  which  he  calls 
the  high  road.  By  this  method,  a  flap  of  skin,  fascia,  and 
muscle  is  turned  down,  with  its  base  either  below  or  in 
front  of  the  ear,  and  a  large  portion  of  bone  removed  by  the 
trephine  or  burr.  The  dura  was  punctured  and  separated 
to  the  foramen  spinosum.  After  exposing  the  foramina 
rotuiidum  and  ovale  the  superior  and  inferior  divisions  of 
the  fifth  were  drawn  out  and  divided.  The  ganglion  was 
then  raised  uj)  and  pulled  away.  This  method  is  laborious 
and  requires  great  patience,  but  seems  to  meet  with  excel- 
lent success. 


December  8,  1900] 


MEDICAL   RECORD. 


905 


Abdominal  Tumor  (Included  Foetus)  Occurring  in  a  Child 
aged  Three  Months  ;  Laparotomy;  Death. — Bv<r.  A.  Wright 
and  I).  S.  VVylie. 

An  Outbreak  of  Tjrphoid  Fever  Attributed  to  the  Infection 
of  a  Well  by  a  Convalescent  Soldier  from  South  Africa. — 
I'.y  Thomas  J.  Walker. 

Two  Unusual  Cases  of  Stricture  of  the  (Esophagus  in 
which  Gastrostomy  was  Performed.  —  By  Walker  iJDWiiie. 

An  Epidemic  of  Peripheral  Neuritis  amongst  Beer  Drink- 
ers in  Manchester  and  District. — By  Enicsl  S.  Reynolds. 

A  Plastic  Operation  for  the  Closure  of  Ketio-Auricular 
Pjst-operative  Fistula. — By  Richard  Lake. 

A  Case  of  Neuritis  of  the  Posterior  Roots  :  Preataxic  Stage 
of  Tabes  Dorsalis?--By  W.  B.  Ransom. 

A  Case  of  Appendicitis  with  Abscess  Perforating  into  the 
Bladder  ;  Recovery. — By  A.  Percy  Allan. 
Presidential   Address   on  Physiology  and   the  Healing  Art. 

—  By  W.  H.  Thonii)son. 

Clinical  Lecture  on  Some  Exceptional  Cases  of  Gastric 
Surgery. — By  Walter  Spencer. 

A  Case  of  Tolerance  of  Abdominal  Section  in  Two  Differ- 
ent Pregnancies. — By  F.  Edge. 

An  Address  on  Some  of  the  SequelcE  of  Cranial  Injuries. 

—  By  Ernest  Tredinnick. 

Operation  for  Severe  Hypospadias. — Bv  R.  Hamilton 
Russell. 

Puerperal  Eclampsia  and  its  Treatment  by  Morphine. — By 
G.  E.  Fitzj^erald. 

Four  Cases  of  Laparotomy  for  Intussusception. — By  Keith 
Monsarrat. 

Shock  Caused  by  High  Explosives.— By  A.  W.  Forrester. 

Syphilis  in  the  Royal  Navy. — By  J.  P.  H.  Greeuhalgh. 

D2ath  from  an  Insect  Bite. — By  Chas.  J.  Moore. 

Poisoning  by  Lysol. — By  William  Hanijjan. 

7 he  Lancet,  Sovcmber  24,  igoo. 

Diphtheritic  Paralysis.  —  E.  F.  Trevelyan  presents  an 
analysis  of  si.K  cases  which  furnish  a  starting-point  for 
some  remarks  on  the  occurrence  of  albuminuria  and  ataxia 
in  connection  with  diphtheritic  paralysis.  He  concludes 
tliat  diphtlieritic  albuminuria  has  no  other  relation  to  diph- 
theritic paralysis  than  that  both  complications  are  more 
prone  to  occur  where  the  diphtlieritic  intoxication  is  most 
intense.  The  question  is  not  considered  here  as  to  whether 
kidneys  damaged  by  a  toxic  nephritis  are  not  more  likely 
to  lead  to  the  retention  within  the  body  of  tlie  paralysis- 
producing  poisons  than  would  liappen  with  healthy  kidneys. 
Ataxia  is  nearly  always  combined  with  more  or  less  paresis. 
Some  authors  state  that  the  ataxia  appears  first  and  then 
later  the  weakness.  0£  course,  the  weakness  would  tend 
to  mask  the  ataxia.  It  is  quite  true  that  it  is  very  unusual 
to  find  in  diphtheritic  paralysis  the  degree  of  disorderly 
movements  with  the  flinging,  stamping  gait  so  commonly 
seen  in  tabes,  but  this  is  no  reason  why  slighter  degrees  of 
inco-ordination  should  not  be  admitted.  Nothing  new  is 
stated  as  to  treatment. 

The  Diagnosis  of  Plague. — W.  C.  Hossack  makes  the  fol- 
lowing types  of  disease  :  the  bubonic,  pneumonic,  septic,  in- 
testinal, cerebral,  and  carbuucular.  Under  each  heading  are 
described  the  features  peculiar  to  the  type.  Diseases  liable 
to  be  confounded  with  plague  are  pueqieral  fever,  scpti- 
csemia,  pysemia,  smallpox,  influenza,  cerebro-spinal  men- 
ingitis, diphtheria  and  angina,  erysipelas,  measles,  gonor- 
rhoea, syphilis,  mumps,  malaria,  cerebral  embolism,  and 
scrofulous  glands.  Of  course  in  some  of  these  maladies 
there  is  rarely  any  difficulty  in  making  a  differential  diag- 
nosis, but  in  the  course  of  the  writer's  personal  experience 
cases  have  occurred  under  all  these  headings  in  which  the 
diagnosis  was  at  tirst  hard  to  make. 

Fourteen  and  a  Half  Hours'  Artificial  Respiration  in  a 
Child  One  Week  Old  ;  Recovery. — The  case  is  reported  by 
G.  E.  Keith.  Chloroform  was  given  for  circumcision.  The 
child  did  not  take  it  well  and  lost  more  blood  than  is  usual. 
He  afterward  slept  for  some  hours  and  was  apparently  do- 
ing well.  Some  hours  later  cyanosis  was  obser\-edand  the 
child  appeared  lifeless.  Artificial  respiration  was  begun 
and  in  a  few  minutes  all  seemed  well.  Again  cyanotic  at- 
tacks and  stoppage  of  breathing  came  on,  to  be  again  re- 
lieved by  artificial  respiration.  This  series  of  events  was 
repeated  several  times,  but  finally  normal  breathing  was 
permanently  re-established. 

Clinical  Remarks  on  the  Results  of  a  Pure  Proteid  Food  in 
Fifty-five  Cases   (Various  Diseases)  .—By  R.  E.  William.son. 

Mouth-Breathing  and  its  Relation  to  Diseases  of  the  Throat, 
Ear,  Nose,  and  Accessory  Cavities. — By  Mayo  Collier. 

Ichthyol  and  its  Uses  in  Some  Skin  Diseases. — By  A. 
Brownlie. 


Estimation  of  Iron  in  Animal  Organs.— By  Percy  A.  E. 
Richards. 

Mental  Disorders  Dependent  on  Toxaemia. — By  Dyce  Duck- 
worth. 

Landry's  Paralysis. — By  P.  R.  Griffiths. 

French  [cuinals. 

Intoxications  and  Infections  in  Mental  Troubles  and  in 
Neuropathies. — G.  iJ'Abundo  concludes  that  infections  and 
intoxications  represent  in  the  pathogeny  of  general  ner- 
vous troubles  the  most  frequent  and  active  elemeuts,  and 
this  in  all  conditions  of  life  both  intra-  and  extra-uterine. 
Toxic-infectious  heredity  (syphilis,  alcoholism)  gives  a 
tendency  in  the  descendants  to  the  evolution  of  neuro- 
pathies. Infections  and  intoxications  in  the  ancestors  or 
in  the  mother  during  gestation  cause  in  the  foetus  very 
frequently  a  striking  retardation  of  development  in  the 
nervous  system.  The  action  of  infectious  and  toxic  agents 
may  produce  nervous  troubles,  peripheral  or  central,  and 
may  lead  to  neuro  psycho.ses  either  acute  or  chronic. 
Mental  confusion  represents  simply  the  most  frequent 
clinical  type  of  the  toxic-infectious  action.  Acute  delirium 
may  be  considered  aclinical  symptom, caused  by  various  in- 
fectious and  toxic  agents.  Researches  into  the  etiology  of 
progressive  paralysis  only  fortify  tlie  conception  of  its  in- 
fectious and  toxic  origin.  Clinical  manifestations  of  in- 
fections and  into.xications  of  the  nervous  system  are  the  re- 
sult of  more  or  less  pronounced  nutritive  disturbances.  As 
to  the  treatment  on  this  basis,  it  will  consist  in  the  elimina- 
tion of  toxic  products,  and  will  seek  to  neutralize  or  dimin- 
ish the  effects  of  secondary  intoxications. — La  J'resse 
Alt'dicale,  November  3,  1900. 

Latent  Appendicitis.— Grandmaison  reports  this  interest- 
ing case.  Tlie  patient  was  a  man  fifty-one  years  old.  He 
was  a  chronic  alcoholic,  and  for  fifteen  days  before  enter- 
ing the  hospital  his  skin  had  been  growing  more  and  more 
yellow.  He  suffered  a  little  from  vague  abdominal  jiains 
and  from  severe  diarrhcea  and  slight  headache.  The  diag- 
nosis was  that  of  infectious  icterus  occurring  in  an  alcoholic 
and  accompanied  by  atrophic  cirrhosis  of  the  liver.  The 
patient  was  put  on  a  milk  diet.  The  three  signs  that  would 
be  at  once  looked  for  in  appendicitis  were  absent :  excessive 
abdominal  pain,  intestinal  obstruction,  and  symptoms  of 
peritonitis.  At  the  autopsy — the  patie-nt  died  on  the  fourth 
day  after  entering  the  hospital — the  appendix  was  found 
to  be  distended  and  perforated,  and  a  sero-purulent  collec- 
tion was  found  behind  the  csccnni,  as  well  ;is  a  generalized 
peritonitis. — La  Medecine  Miuferne,  November  7,  1900. 

Dysentery  in  Brittany;  Colon  Bacillus  in  the  Waters  of 
Landerneau. — E.  Lenoble  speaks  of  his  work  and  that  of  his 
associates  in  regard  to  the  analysis  of  the  waters  of  Lan- 
derneau in  the  midst  of  the  affected  region.  They  used 
various  methods.  The  nutritive  gelatin  plates  of  Ellsner 
showed  colonics  of  tlie  colon  bacillus,  the  method  of  Pere 
gave  analogous  results.  To  sum  np  the  results  of  the 
whole  work,  there  was  found  an  undeniable  varietyof  colon 
bacillus,  which  resembled  to  a  certain  extent  Eberth's 
bacillus  but  was  clearly  distinguished  by  certain  character- 
istics, e.g-..  the  lactose  te.st  which  differed  from  the  reaction 
with  Eberth's  bacillus  and  the  absence  of  Widal's  test. — 
La  Presse  Mcdicalc,  October  27,  irjoo. 

The  Relations  between  Alopecia  and  Dental  Lesions. — L. 
Jacquet  calls  attention  to  tlie  resemblances  between  the 
skin  and  the  teeth,  from  the  points  of  view  cmbrj'ological, 
histological,  and  evolutionary.  He  believes  that  deficiency 
of  various  salts  has  much  to  do  with  these  conditions. 
There  is  probably  a  vitiation  of  the  general  trophic  sytem. 
Dental  troubles  and  baldness  are  becoming  very  common 
and  can  but  call  attention  to  the  theory  of  the  evolution  of 
a  human  type  whicli  will  be  toothless  and  hairless. — La 
Presse  Medicate,  November  10,  igoo. 

Berliner  klinisclie   Woclienschrijt.  Nov.  j  and  12,  igoo. 

Nephrectomy  for  Calculous  Pyelitis. — L.  Thumim  reports 
the  case  of  a  woman  of  thirty-one  years,  whose  urine  con- 
tained pus  and  who  suffered  from  the  symptoms  of  renal 
colic.  Cystoscopic  examination  showed  cystitis,  but  cathe- 
terization of  the  ureters  failed  to  reveal  any  changes  in 
either  kidney  nor  was  there  sensitiveness  in  their  neigh- 
borhood. Later  attacks  of  pain  led  to  a  repetition  of  the 
catheterization  and  evidences  of  a  pyelitis  of  the  right 
kidney  were  manifest.  By  means  of  the  Casper-Richter 
phloridzintest  it  was  also  determined  that  the  parenchyma 
of  the  right  kidney  was  involved  and  its  removal  was  ad- 
vised. This  was  done  and  the  patient  made  a  good  re- 
covery. Several  calcareous  masses  were  found  in  the  ex- 
tirpated organ. 

Purpura  Rheumatica  and  Angina. — A.  Bruck  refers  to  the 
abundant  literature  of  recent  years  on  the  general  subject 
of  the  relation  between  sore  throat  and  rheumatism,  and 
then  relates  the  histories  of  four  casesoccurring  in  his  own 


9o6 


MEDICAL    RECORD. 


[December  8,  1900 


practice  in  which  manifestations  of  ordinary  tonsillitis 
were  followed  by  a  typical  petecliial  rash  of  a  purpuric  type. 
He  believes  that  iu  such  cases  the  poison  gains  entrance 
througli  the  tonsillar  structures  and  then  affects  the  system 
at  large.  It  is  not  necessary  that  the  throat  symptoms 
should  be  of  a  severe  type.  Often  they  are  very  mild  and 
vet  the  constitutional  rheumatic  symptoms  very  severe. 

Post-Mortem  Appearances  in  a  Case  of  Acromegaly. — E. 
Mendel  gives  the  tindings  in  a  case  which  had  been  under 
observation  for  some  time.  The  article  is  illustrated  by 
two  drawings  and  should  be  consulted  in  the  original  by 
those  interested  in  these  cases.  At  the  base  of  the  brain 
in  the  region  of  the  chiasma  a  walnut-sized  sarcoma  was 
found,  made  up  of  large  round  cells.  The  pineal  gland 
was  normal  throughout.  The  thyroid  gland  was  consider- 
ably enlarged.  The  spleen  was  large  and  soft.  The  thy- 
mus gland  was  present. 

The  Treatment  of  Catarrhal  Adhesive  Processes  in  the 
Middle  Ear  by  Means  of  Intra-Tubular  Pilocarpine  Injections. 
— I'ischenich  advises  the  use  of  muriate  of  pilocarpine  in 
two-per-cent.  watery  solution.  The  dosage  should  com- 
mence with  six  to  eight  drops  for  each  ear  and  gradually 
increase  to  twelve  or  even  sixteen.  These  are  injected 
through  a  catheter  in  the  usual  manner.  From  thirty  to 
fifty  injections  may  be  necessary  in  some  cases.  Some- 
times a  little  dizziness  and  even  pain  is  felt  at  first,  but 
only  for  a  short  time. 

The  Clinical  Value  of  Schmidt's  Method  of  Functional 
Examination  of  the  Colon. — By  H.  Phillippsohn. 

Contribution  to  the  Symptomatology  of  Facial  Paralysis. 
—By  M.  Bernhardt. 

The  Mechanism  of  Certain  Cortical  Visual  Disturbances  in 
Dogs. — By  E.  Hitzig. 

Urinary  Calculi. — By  C.  Posner. 

Miinchener  medicinische  VVochenschrift,  No%'.  ij,  igoo. 

The  Subjective  Symptoms  of  Neurasthenia. — L.  Hoefl- 
mayer  considers  that  the  more  or  less  generic  term  "neu- 
rasthenia "  should  be  replaced  by  more  specific  appella- 
tions indicating  the  system  diseased,  e.g.,  there  are  well 
recognized  cerebral,  spinal,  visceral,  intestinal,  and  cardiac 
forms  of  the  malady.  If  all  the  subjective  disturbances  of 
neurasthenics  be  collected  and  studied  it  will  be  found  that 
they  may  be  grouped  under  two  headings,  viz.,  (i)  dis- 
turbances of  intestinal  activity  and  (2)  vagus-sympathetic 
neuroses.  The  intimate  relationship  between  these  two 
sets  of  causes  is  clearly  shown  by  the  great  relief  afforded 
in  nearly  every  case  of  such  disease  by  a  thorough  and 
systematic  cleansing  of  the  intestinal  tract.  One  of  the 
commonest  and  at  the  same  time  most  alarming  symptom 
complexes  to  which  the  neurasthenic  is  subject  is  a  form  of 
angina-like  attack,  attended  by  great  cardiac  distress, 
dyspnoea,  rapid  feeble  pulse,  cold  clammy  extremities,  and 
which  on  inquiry  is  found  to  have  been  preceded  by  sev- 
eral days'  constipation.  It  is  impossible  to  be  certain 
whether  the  irritation  of  the  intestinal  connections  of  the 
vagus  is  the  result  of  the  mechanical  or  the  chemical  stimuli 
resulting  from  the  presence  of  the  inspissated  and  decom- 
posing fecal  masses,  but  that  they  are  the  causa  morhi  is 
shown  by  the  almost  instantaneous  relief  to  all  the  symp- 
toms after  satisfactory  clearing  of  the  intestine  has  been 
secured  by  copious  liigh  injections. 

The  Typical  Form  of  Laryngeal  Neuralgia. — Georg  Avellis 
has  found  that  otherwise  perfectly  healthy  individuals,  who 
are  above  the  suspicion  of  hysteria,  may  be  found  to  suffer 
from  a  painful  affection  of  the  larynx,  which  is  increa.sed 
by  motion  of  the  part,  and  may  become  so  severe  as  to 
cause  the  patient  to  refrain  from  eatingor  speaking  through 
fear  of  the  pain  attendant  on  these  acts.  The  one  sign 
which  differentiates  this  from  all  othei  similar  affections 
and  at  once  stamps  it  as  neuralgic  in  nature  is  the  exist- 
ence of  true  points  of  tenderness  where  the  nerve  involved 
pierces  a  layer  of  fascia;  namely,  pressure  over  the  spot 
where  the  superior  laryngeal  nerve  pierces  the  thyro-hyoid 
membrane  and  also  where  it  lies  superficially  in  the  pyri- 
form  sinus  elicits  the  characteristic  ])ain.  Local  treatment 
by  means  of  sprays,  etc.,  is  unavailing,  but  the  internal 
use  of  antineuralgics  and  external  application  of  dry  heat 
are  speedily  successful.  The  differential  diagnosis  lies  be- 
tween this  affection  and  rheumatism  of  the  cervical  mus- 
cles, bursitis  lateralis,  and  hysteria. 

A  Case  of  Formalin  Poisoning. — Ludwig  Zorn's  patient 
accidentally  took  about  four  drachms  of  the  commercial 
forty-per-cent.  solution  of  formalin.  Immediately  after 
swallowing  the  liquid,  realizing  his  error,  he  took  some  milk 
whicli  was  instantly  vomited.  When  he  came  under  ob- 
servation he  was  suffering  from  dys])n<L-a,  vertigo,  great 
anxiety,  burning  in  the  mouth  and  stomach,  and  nausea. 
The  pul.se  was  rapid  and  small,  and  after  twenty-four  hours 
of  absolute  anuria  a  small  quantity  of  albuminous  urine 
was   passed.      For   several   days   there   was   diarrlKva   of 


moderate  intensity  and  the  patient  was  discharged  cured 
a  day  or  two  later.  It  is  interesting  to  note  that  in  this 
case  the  gastro-intestinal  and  renal  symptoms  occupied  the 
foreground,  while  in  that  recently  reported  by  Kliiber  in 
the  same  journal  it  seems  to  have  been  the  sensorium  that 
was  most  affected. 

A  Case  of  Tetanus  following  Poisoning. — F.  Dammer  de- 
scribes a  case  of  what  appears  to  have  been  true  tetanus 
following  the  use  of  an  anthelmintic  containing  extract  of 
male  fern  and  calomel.  The  patient  was  a  woman  of 
thirty-five,  who  years  previously  had  taken  a  similar  dose 
with  no  unplea.sant  results.  At  the  present  time  the  ex- 
pulsion of  the  parasite  took  place  one  and  one-half  hours 
after  the  medication,  but  was  promptly  followed  by  tempo- 
rary loss  of  consciousness,  and  convulsive  seizures  in  every 
respect  resembling  those  of  true  tetanus.  These  were  re- 
peated at  short  intervals,  but  under  treatment  by  hydro- 
therapy recurred  less  often,  and  finally  the  patient  was  dis- 
charged cured  three  weeks  later. 

A  Case  of  Fatal  Spontaneous  Umbilical  Hemorrhage  in  a 
Hasmophilic  Infant. — By  Jens  Paulsen. 

The  Occurrence  of  Rhodan  in  the  Nasal  Secretion. — By  A. 
Keller. 

The  Obstetrician  and  Infant  Feeding.— By  Heinrich  Cramer. 

The  Plaster  Treatment  of  Scoliosis. — By  A.  Schanz. 

Intubation  in  Private  Practice. — By  Marx. 

Surgical  Contributions.— By  G.  Jochner. 


OUR    LONDON    LETTER. 

(From  our  Special  Correspondent.) 

WEATHER  AND  HEALTH — CLI.NICAL  SOCIETY — SEQUEL  TO 
HYDATID  CASE  ;  ABDOMINAL  SECTION  AND  ASCITES — SOCIETY 
FOR  THE  STUDY  OF  DISEASE  IN  CHILDREN — SIR  W.  THOM- 
SON— MR.  MAKINS — PROFESSOR  YOUNG — DEATHS  OF  DRS. 
EMBLETON,    QUINLAN,    TAUNTON,    I'ALMER,    ANDERSON. 

London,  November  16,    iqoo. 

Up  to  the  present  we  have  had  no  cold  weather  to  speak 
of.  In  London,  indeed,  it  seems  a  particularh'  mild  No- 
vember, and  the  impression  is  confirmed  by  the  meteoro- 
logical statistics,  which  show  a  temperature  of  13°  above 
the  average  for  this  month.  This  is  said  to  be  due  to  a 
series  of  depressions  from  the  Atlantic,  bringing  mild 
southerly  breezes  and  warm  rains  all  over  the  country, 
though  the  total  rainfall  is  not  heavy.  The  indications 
seem  to  be  that  warm,  moist,  showery  weather  will  last 
longer. 

The  effect  on  the  public  health  will  not  be  evidenced  for 
some  time  yet,  though  many  people  are  assuming  that  it 
will  be  bad,  and  assuring  us  that  frosty  air  is  more  whole- 
some. 

At  the  Clinical  Society  on  the  9th  Dr.  Norman  Dalton 
read  the  sequel  to  a  case  of  hydatids  of  the  liver,  showing 
also  the  results  of  abdominal  section  ou  ascites.  The  pa- 
tient was  a  girl,  who  at  eleven  years  of  age  passed  hyda- 
tids per  rectum  and  expectorated  bile  from  the  right  lung. 
She  recovered,  but  at  si.xteen  ascites  set  in.  After  some 
tappings,  at  fortnightly  intervals,  abdominal  section  was 
performed,  but  nothing  found  which  could  be  removed. 
There  were  then  no  adhesions  except  at  the  top  of  the 
liver,  round  the  fistula  into  the  lung.  Two  subsequent 
tappings  were  called  for  in  the  next  fortnight.  The  girl 
then  got  well  and  continued  so  for  five  years.  Examina- 
tion then  showed  a  small  quantity  of  fluid  in  the  hypogas- 
trium,  but  the  rest  of  the  peritoneal  cavity  seemed  to  be 
obliterated  by  adhesions.  In  May,  iSgg,  the  i>atient  died 
of  septic  peritonitis  at  the  age  of  twenty-three.  At  the 
post-mortem  the  old  cyst  was  found  communicating  below 
with  a  dilated  bile  duct,  and  above,  through  the  dia- 
phragm, with  a  dilated  bronchial  tube.  There  was  a  col- 
lection of  fluid  in  the  hypogastrium,  and  adhesions  obliter- 
ated the  rest  of  the  cavity,  just  as  had  been  surmised. 
Thus  the  ascites  had  been  practically  cured,  and  Dr. 
Dalton  thought  this  was  due  not  only  to  the  occlusion  of 
the  cavity,  but  to  the  portal  congestion  being  relieved  by 
the  opening  of  communications  between  the  portal  capil- 
laries and  tliose  which  joined  veins  in  the  abdominal  wall, 
diaphragm,  etc.  The  case  seems  to  encourage  abdominal 
section  for  ascites,  as  for  ten  years  the  patient  was  pretty 
well,  the  condition  being  that  of  cirrhosis. 

Sir  R.  D.  Powell  said  hepatic  cirrhosis  associated  with 
ascites  was  favorable  when  adhesions  formed,  and  their 
presence  might  be  inferred  from  uneven  distribution  of  the 
fluid.     He  mentioned  such  a  case,   and  agreed  that  the 


December  8,  1900] 


MEDICAL    RECORD. 


907 


adhesions    set    up   another   circulation,    and    so    relieved 
the  portal  congestion. 

Mr.  Marsh  pointed  out  that  Mr.  Morison,  of  Newcastle, 
had  operated  in  these  cases  for  the  express  i)urpose  of 
obtaining  this  collateral  circulation  by  setting  up  adhe- 
sions. 

Ur.  Rolleston  referred  to  the  paper  which  he  and  Mr. 
Turner  brouglit  before  the  Medical  Society  a  year  ago  on 
this  subject.  Their  statistics,  as  I  mentioned  at  that  time, 
showed  that  out  of  fifteen  cases  operated  on,  five  were 
cured.  They  agreed  that  the  collateral  circulation  had 
some  influence,  but  it  was  not  a  sufficient  e.xplanation 
alone,  as  other  symptoms  were  also  relieved.  Probably 
more  blood  being  brought  to  the  surface  of  the  liver,  its 
nutrition  was  increased  and  its  cells  became  hyjiertrophied. 

Mr.  Morison  thought  the  adhesions  acted  by  diminisliing 
the  size  of  the  cavity,  which  increased  the  aspirating-power 
of  the  thorax.  It  was  an  old  and  successful  plan  to  com- 
press the  abdomen  after  paracentesis  by  encircling  it  with 
strapping  to  be  worn  for  a  long  time. 

Dr.  Toogood  supported  the  view  that  adhesions  acted  by 
increasing  the  aspirating-power.  He  related  a  case  in 
which  ascites  had  disappeared  after  laparotomy.  iJr.  Nor- 
man Dalton  in  his  reply  said  a  serious  consideration  was 
the  likelihood  of  hernia,  and  he  believed  that  his  patient 
eventually  died  of  that. 

The  Society  for  the  Study  of  Disease  in  Children  has 
gone  vigorously  to  work,  and  a  number  of  interesting 
cases  have  been  exhibited  at  its  meeting.  Among  these  may 
be  named  that  of  an  infant  aged  eight  months,  weighing 
twenty-nine  and  one-half  pounds.  The  child  had  been  fed 
exclusively  by  the  breast.  The  maternal  milk  had  a  great 
excess  of  lactose.  The  child  seemed  otherwise  healthy. 
A  case  of  myxfjedema  with  ectropion  in  a  girl  aged  twelve 
years,  brought  by  Mr.  Sidney  Stephenson.  In  connection 
with  this  case  Dr.  Percy  Lewis  showed  photographs  of 
other  cases  of  myxcedema  in  young  subject.s.  A  lad  aged 
five  years,  with  Mongolian  imbecility,  on  which  some 
members  offered  remarks.  There  was  also  shown  a  si)eci- 
men  of  a  heart  weighing  nineteen  and  one-half  ounces.  It 
was  dilated  and  hypertrophied.  The  child  died  a  year 
after  an  attack  of  acute  rheumatism. 

The  court  of  appeal  has  reversed  the  decision  in  Dow- 
ling  7'.  Dods.  The  action  was  one  for  libel,  and  Dr.  Dods 
was  cast  in  damages  for  a  letter  in  which  he  stated  that 
Miss  Dowling  was  not  sane.  The  letter  was  sent  on  ac- 
count of  plaintiff  being  a  candidate  for  a  dispensary  ap- 
pointment. The  learned  judge  said  it  was  perfectly  plain 
the  lady's  mind  was  unhinged  and  there  was  not  a  scin- 
tilla of  evidence  of  malice.  It  seems  Dr.  Dods  merely 
gave  a  warning  of  the  danger  of  any  one  subject  to  hallu- 
cinations acting  as  a  dispenser. 

Sir  William  Thom.son  has  been  appointed  surgeon  to  the 
Queen  in  Ireland.  This  is  no  more  than  was  to  be  ex- 
pected, since  to  his  great  position  as  a  surgical  leader  in 
Dublin  he  added  that  of  chief  of  the  Irish  Hospital  at  the 
seat  of  war. 

Mr.  G.  H.  Makins,  of  St.  Thomas'  Hospital,  who  went  to 
South  Africa  as  one  of  the  consulting  surgeons,  is  engaged 
on  a  book  giving  an  account  of  his  experience  there. 

Professor  Young  is  to  succeed  the  late  Dr.  Leech  as  rep- 
resentative of  Victoria  University  in  the  General  Medical 
Council. 

Dr.  Dennis  Embleton,  consulting  physician  to  tlie  Royal 
Infirmary  of  Newcastle-on-Tyne.  died  on  the  I2th  inst.  at 
tlie  advanced  age  of  ninety.  He  was  for  a  long  time  a 
member  of  the  General  Medical  Council.  In  earlier  days 
he  taught  anatomy,  physiolog\-,  and  medicine,  and  there 
are  men  still  living  who  delight  to  recall  the  assistance  he 
gave  them.  But  his  interest  in  literature  and  natural  his- 
tory was  intense,  and  these  subjects  occupied  much  of  his 
time  and  attention.  This  venerable  member  of  the  pro- 
fession had  declined  in  health  for  the  last  few  months. 

Dr.  F.  B.  Quinlan,  of  Dublin,  died  on  the  9th  inst.  He 
was  for  a  long  time  physician  to  St.  Vincent's  Hospital 
and  professor  of  therapeutics  in  the  Catholic  University. 
He  graduated  in  1S57  at  Dublin  University,  and  in  due 
time  became  a  member  of  the  senate.  He  contributed 
many  papers  to  the  societies  and  journals,  and  was  es- 
teemed as  a  scholar  outside  professional  subjects.  He  was 
the  son  of  a  journalist  and  had  much  interest  in  literary 
subjects,  though  not  to  the  detriment  of  his  medical  senti- 
ments. He  retired  some  ten  or  twelve  years  ago.  His 
death  was  not  unexpected,  as  he  had  been  ill  for  some  time 
and  in  bed  for  several  weeks.  He  had  reached  his  si.xty- 
fifth  year. 

Another  venerable  member  of  the  profession,  Thomas 
Taunton,  died  on  the  5th  inst.  in  his  eighty-ninth  year. 
He  was  a  skilful  surgeon  and  very  successful  accoucheur. 
It  was  stated  that  he  had  never  lost  a  midwifery  case. 

Yet  another  octogenarian  :  Father  R.  F.  Palmer  took  his 
M.R.C.S.  diploma  in  1S46  and  practised  until  1S53,  when 
he  entered  the  Roman  Catholic  Church,  became  a  priest, 
and  devoted  himself  to  historical,  ecclesiastical,  and  anti- 


quarian studies.     He  was  given  the  degree  of  master  of 
theology. 

The  death  is  also  announced  of  Mr.  R.  B.  Anderson. 
F.R.C.S.  Eng.,  formerly  t)f  Tobago,  and  whose  name  you 
will  no  doubt  remember  in  connection  with  the  subject  of 
medical  reform. 


UNIVERSAL   ANKYLOSIS. 

To   THE    F.UITOK    OK   THE    .MbIMCAL    RrCORD. 

Sir  :  Dr.  H.  A.  Elliott's  account  of  a  case  of  universal 
ankylosis,  in  the  Mkiuc.m.  Rklokh  for  November  17th,  re- 
calls a  similar  case  which  I  saw  in  Buffalo  in  1SS7  or  18S8. 
This  case  was  on  exhibition  as  the  "ossified  man."  He 
was  also  exhibited  in  Boston  and  other  eastern  cities  a 
year  or  two  later.  I  made  no  notes  of  the  case,  but  my 
recollection  is  about  as  follows: 

He  was  a  native  of  Western  New  York,  about  fifty  years 
of  age,  and  had  been  in  his  then  present  condition  for  a 
number  of  years.  Every  joint  in  his  Ijody  was  absolutely 
solid,  tlie  only  motion  being  at  the  shoulders,  by  the  slid- 
ing of  the  scapul:c  in  the  muscles  at  the  back  of  'the  chest. 
He  lay  witb  legs  fully  extended  and  one  arm  semi-flexed, 
and  the  attendant,  by  placing  a  hand  under  the  occiput, 
would  raise  him  from  the  couch  like  a  log  of  wood,  resting 
only  on  heels  and  liead.  Some  of  the  bones  of  the  fingers 
had  disappeared  from  absorption,  and  as  his  nails  had  been 
allowed  to  grow  for  years  they  hung  in  spiral  ribbons  three 
or  four  inches  long,  giving  the  hands  a  most  uncanny  ap- 
pearance. Several  teeth  had  been  removed  to  allow  nour- 
ishment to  be  taken,  as  the  jaw  was  firmly  set. 

His  mental  faculties  were  perfectly  clear,  as  shown  by 
his  conversation  with  those  about  him,  but  he  was  totally 
blind.  Taken  all  in  all,  his  case  seemed  about  the  most 
pitiable  I  have  ever  witnessed. 

F.  B.  Storer,  M.D. 

HoLLEV,  N.   v.,  November  21,  1900. 


LETTER  FROM  NEW  ZEALAND. 

(From  our  Spccuil  Correspondent.) 

Ai'CKLASD,  October  a?,  1900. 
TiiF.  .session  of  our  legislature  has  just  closed,  to  the  great 
relief  of  every  one.  We  never  know  what  mischief  may 
be  done,  and  when  the  houses  are  prorogued  we  feel  like 
the  parents  of  disobedient  and  disorderlv  children  when 
the  latter  are  in  bed  and  asleep  for  the  night.  During  the 
.session  a  new  public-health  act  has  been  passed  under  the 
influence  of  the  plague  scare,  giving  despotic  powers  to 
the  central  board  of  health,  and  entirely  superseding  the 
local  boards,  whicli  are  now  reduced  to  the  function  of 
carrying  out  the  orders  of  tlie  central  authority. 

Among  other  changes  effected  by  the  new  sanitary  act, 
vaccination  has  been  made  so  far  voluntary  that  on  a 
parent  satisfying  the  magistrate  that  he  has  a  "conscien- 
tious "  objection  to  vaccination  the  magistrate  must  give 
hirn  a  certificate  exempting  the  child  from  vaccination. 
This  is  not  quite  so  complete  a  release  as  the  English  law 
affords,  but  it  will  have  to  be  brought  into  line  with  the 
latter  before  long.  The  rea.son  why  there  has  been  hardly 
any  public  outcry  against  vaccination  here  is  because  the 
compulsory  clauses  have  never,  or  hardly  ever,  been  en- 
forced. Smallpox  has  been  introduced  into  the  colony 
several  times  to  my  own  knowledge,  but  with  only  an  im- 
perfect system  of  quarantine  it  has  been  kept  from  spread- 
ing. Of  late  years  calf  lymph  has  been  used.  But  a  large 
majority  of  the  children  are  unvaccinated. 

We  hear  no  more  of  the  plague.  Some  weeks  ago  I  saw 
a  case  which  was  very  suspicious,  and  was  isolated  for  a 
few  days,  but  it  was  declared  not  to  be  the  plague.  The 
patient,  a  man  of  about  sixty,  had  been  ill  four  or  five 
days,  with  not  very  high  fever,  some  delirium,  and  a  very 
curious  mass  of  buboes,  extending  to  the  size  of  one's  hand 
equally  above  and  below  Poupart's  ligament  on  the  right 
side.  There  were  no  local  lesions  to  account  for  these  bu- 
boes. The  surgeon  in  attendance  and  the  local  medical 
officer  of  health  agreed  with  me  in  thinking  the  case  so 
suspicious  that  it  ought  to  be  isolated.  It  was  a  very  mild 
case,  the  temperature  being  only  about  100'  F.  The  medical 
officer  of  the  Plague  Hospital  (a  very  pretty  young  lady 
with  a  fluffy  fringe,  whose  experience  as  a  qualified  practi- 
tioner was  of  about  four  months'  duration,  and  acquired 
only  in  the  colony)  scouted  the  idea  of  its  being  plague,  and 
dismissed  the  case  in  a  week.  Noother  case  has  occurred. 
The  fact  is,  that  beyond  influenza,  and  every  few  years 
scarlatina,  we  cannot  get  up  a  good  lively  epidemic.  Even 
diphtheria  seems  to  be  dying  out.  Fortunately  for  some 
of  the  profession  there  are  plenty  of  chronic  diseases,  and 
by  performing  a  laparotomy  on  everj-body  who  complains 
of  belly-ache,  they  manage  to  exist.  The  colony  is  too 
healthy  ;  if  the  women  would  throw  away  their  corsets  and 
dress  rationally,  four-fifths  of  the  doctors  would  starve. 


9o8 


MEDICAL    RECORD. 


[December  8,  1900 


J>ocietij  ^vcports. 

THE   PRACTITIONERS'    SOCIETY. 

One  Hundred  and  Fijty-cighth   Regular  Meeting,  Held 
on  Friday.  Novetnber  2.  igoo. 

A.  Alexander  Smith,  M.D.,  in  the  Chair. 

A  Case  of  Large  Renal  Calculus  Detected  by  Radi- 
ograph ;  Pyuria  without  Hemorrhage  ;  Operation  ; 
Recovery. — Dr.  Roisert  Abue  presented  a  man  thirty- 
two  years  old,  who  had  had  an  attack  of  right  renal 
colic  nine  years  ago.  His  symptoms  at  that  time 
were  relieved  by  a  liy  blister,  and  there  was  no  recur- 
rence until  two  years  ago,  when  lie  suffered  from  inter- 
mittent pain  in  the  region  of  the  right  kidney,  which 
lasted  for  three  weeks.  There  was  no  blood  in  the 
urine.  Again,  during  the  past  si.x  months  he  had  had 
a  recurrence  at  times,  and  more  recently  the  pain  had 
been  quite  constant.  His  urine  had  appeared  muddy 
for  a  year.  He  had  been  losing  Hesh,  but  he  had  had  no 
fever  so  far  as  he  knew.  E.xamination  showed  a  large 
movable  tumor  in  the  right  hypochondriuni,  which  felt 
like  a  renal  sarcoma.  The  pyuria  suggested  a  tuber- 
culous kidney,  but  repeated  examinations  of  the  uri- 
nary deposit  failed  to  reveal  tubercle  bacilli.  A  radio- 
graph showed  a  large  branching  calculus,  with  two 
separate  pieces.  On  June  15,  igoo,  Dr.  Abbe  per- 
formed lumbar  nephrotomy  and  removed  the  large 
calculus,  but  a  careful  search  with  the  finger,  metal 
instruments,  and  needles  failed  to  detect  the  two  out- 
lying pieces  which  were  shown  in  the  radiograjih.  A 
bistoury  was  freely  used  inside  the  kidney  to  cut 
through  all  partitions  of  the  numerous  pockets.  Three 
weeks  later,  when  the  kidney  had  contracted,  digital 
and  instrumental  search — without  ether — revealed  the 
remaining  calculi  protruding  from  separate  pockets, 
and  by  cutting  around  tiiem  they  were  easily  dug  out. 
Since  the  operation  the  patient  had  gained  twenty 
pounds  in  weight.  He  still  had  a  pus-discharging 
sinus  which  would  doubtless  close  in  the  near  future. 
In  connection  with  this  case,  Dr.  Abbe  exhibited  the 
radiograph  which  had  revealed  the  presence  of  the 
renal  calculus. 

Dr.  Abbe  also  showed  a  radiograph  of  a  phosphatic 
stone  in  the  kidney  of  a  woman  who  had  suffered  from 
pyuria  for  two  years.  During  this  period  she  suffered 
from  fever  and  had  become  much  emaciated.  A 
small  tumor  could  be  made  out  in  the  region  of  the 
kidney.  There  was  no  history  of  ha;maturia,  and  the 
symptoms  were  suggestive  of  tuberculous  kidney.  A 
radiograph  showed  a  faint  shadow,  indicating  the 
presence  of  a  renal  calculus.  An  incision  revealed  a 
pyonephrosis,  and  a  soft  phosphatic  stone  an  inch  and 
a  half  long,  but  weighing  not  more  than  tliirty  grains. 
The  patient  made  an  uneventful  recovery.  Dr.  Abbe 
said  that  as  a  rule  a  phosphatic  calculus,  on  account 
of  its  lightness,  was  very  difficult  to  make  out  with 
the  .v-rays.  On  the  other  hand,  the  oxalate  of  lime  or 
mixed  calculi  usually  showed  very  well.  He  exhibited 
two  other  calculi  detected  and  removed  after  radiog- 
raphy, the  smaller  one  weighing  only  eight  grains. 

Dr.  \L  G.  Janewav  asked  Dr.  Abbe  whether,  in  any 
of  his  cases  in  which  an  operation  was  done  for  the 
removal  of  renal  calculi  upon  the  evidence  furnished 
by  the  radiographic  picture,  no  stone  was  found.  Dr. 
Janeway  said  he  had  heard  of  such  cases. 

Dr.  Abbe  replied  that  no  such  instance  had  come 
under  his  observation.  The  greatest  care  should  be 
exercised  in  taking  these  radiographs;  unless  the 
plate  was  well  protected  by  gutta  perclia,  it  might  be- 
come dampened  by  the  moisture  of  the  skin  and  give 
rise  to  a  false  shadow  simulating  a  stone  in  the  kidney. 


Dr.  Francis  P.  Kinnicutt  said  that  during  the 
past  summer  he  had  seen  a  case  in  which  the  radio- 
graph showed  multiple  stones  in  both  kidneys.  Sur- 
gical interference  had  seemed  contraindicated  on  ac- 
count of  the  number  of  the  calculi. 

Dr.  Abbe  said  the  conditions  mentioned  by  Dr. 
Kinnicutt  did  not  appeal  to  him  as  legitimate  grounds 
for  refusing  to  operate.  Usually  after  the  removal  of 
stone  the  urine  was  voided  into  the  bladder  and  the 
sinus  closed.  When  both  kidneys  were  involved,  one 
kidney  at  a  time  could  be  taken. 

Dr.  Janeway  said  that  in  such  a  case  suppression 
from  the  other  kidney  was  liable  to  occur. 

Dr.  George  L.  Peabody  said  that  in  certain  cases 
the  kidney  might  be  so  seriously  disorganized  by 
stone  that  restoration  of  function  could  hardly  be 
looked  for. 

Dr.  Abbe  said  he  did  not  refer  to  cases  of  suppurat- 
ing kidney  with  stone.  He  understood  that  the  case 
mentioned  by  Dr.  Kinnicutt  was  one  of  multiple  stone 
with  hematuria. 

A  Case  of  Multiple  Gall  Stones  in  the  Gall 
Bladder,  Simulating  Cancer. — Dr.  Apbe  showed  a 
collection  of  tiiree  hundred  and  forty-three  gall  stones, 
varying  in  size  from  a  bean  to  a  small  hen's  egg. 
The  history  of  the  case  was  as  follows:  The  patient 
was  a  woman  sixty  years  old,  who  had  never  had  gall- 
stone colic,  but  who  for  three  months  past  had  suflered 
from  abdominal  pain  and  loss  of  weight,  about  two 
and  one-half  pounds  weekly.  She  had  no  fever;  her 
urine  contained  bile,  and  the  stools  were  clay-cclored. 
Jaundice  came  on  slowly  during  the  last  ten  days. 
There  was  a  tumor  on  the  right  side  of  the  abdomen 
which  had  slowly  grown  to  the  size  of  a  cocoanut,  and 
on  account  of  its  mobility  her  physicians  regaided  it 
as  a  movable  kidney.  She  had  the  exhaustion  of  pro- 
found cholamia,  and  just  before  she  came  under  Dr. 
Abbe's  observation  this  nearly  proved  fatal.  Exam- 
ination by  Dr.  Abbe  showed  a  cocoanut-shaped  tumor 
which  was  so  movable  in  the  abdomen  that  it  bobbed 
about  and  could  be  moved  down  to  the  groin  and 
nearly  across  the  median  line.  VVhen  at  rest  it  was 
below  the  right  ribs.  The  mass  was  brought  over  to 
the  median  line,  and  under  cocaine  anaesthesia,  aided 
by  a  few  whiffs  of  chloroform,  it  was  evacuated 
through  a  median  incision,  a  pint  of  white  glairy  Huid 
and  three  hundred  and  forty-three  gall  stones  being 
removed.  The  bile  immediately  began  to  flow  freely 
through  a  tube  in  the  distended  gall  bladder,  and  the 
patient  made  a  perfect  and  very  rapid  recovery. 

Dr.  Peabody  said  that  gall  stones  were  not  infre- 
quently found  post  mortem  in  people  who  had  never 
given  a  history  of  biliary  colic. 

Dr.  Janeway  said  that  gall  stones  in  the  common 
duct  might  produce  obstructive  jaundice  without  any 
Ijiliary  colic.  Of  five  cases  of  this  kind  which  had 
come  under  his  observation,  three  viere  operated  on 
and  two  of  the  latter  were  fatal.  One  was  of  a  physi- 
cian who  had  never  complained  of  biliary  colic;  he 
died  after  an  operation  for  the  relief  of  jaundice  which 
was  due  to  the  presence  of  a  large  stone  in  the  com- 
mon duct.  A  second  case  was  that  of  a  young  mar- 
ried woman  who  had  suffered  from  obstructive  jaun- 
dice for  a  number  of  years.  'I'here  was  no  history  of 
biliary  colic.  It  was  thought  advisable  not  to  opeiate 
in  this  ca.se,  on  account  of  the  danger  of  hemorihage 
incident  to  the  long  duration  of  the  jaundice.  This 
patient  also  suffered  from  profuse  menorrhcea,  and  died 
about  a  year  after  she  first  came  under  Dr.  Janeway's 
observation.  The  jjost-mortem  showed  a  stone  in  the 
common  duct,  and  the  duct  itself  was  very  adherent. 

Dr.  Beverley  Robinson  said  he  had  seen  cases  in 
which  an  operation  failed  to  reveal  the  presence  of 
gall  stones,  in  spite  of  the  fact  that  the  history  and 
symptoms  of  the  patient  pointed  that  way.     He  recalled 


December  8,  igoo] 


MEDICAL    RECORD. 


909 


one  such  case  which  had  been  operated  on  for  him  by 
Dr.  Bull.  The  patient  finally  recovered  under  stom- 
ach lavage.  In  a  case  of  supposed  impacted  gall 
stone  which  was  operated  on  at  St.  Luke's  Hospital 
the  patient  died  of  subsequent  hemorrhage. 

Dr.  Jankwav,  in  reply  to  a  question  as  to  how  long 
after  the  onset  of  the  jaundice  lie  would  advise  against 
operation,  said  that  this  would  depend  upon  the  cause 
of  the  obstruction.  In  obstruction  due  to  cancer  of 
the  common  duct  an  operation  might  produce  fatal 
hemorrhage  within  four  or  five  months  after  the  onset 
of  the  jaundice.  The  speaker  said  he  had  seen  six 
fatal  cases  of  this  kind,  each  one  operated  on  by  a 
different  surgeon.  In  ob.struction  due  to  stone  it  was 
safe  to  operate  after  a  much  longer  period — perhaps 
within  two  years. 

Dr.  Kinnicutt  said  that  he  usually  advised  against 
operation  in  these  cases  in  the  presence  of  cholaemia 
on  account  of  the  danger  of  fatal  hemorrhage.  He 
had  seen  several  cases  in  the  past  few  years  in  which, 
with  a  moderate  degree  of  choljemia,  a  fatal  issue 
from  secondary  hemorrhage  had  followed  operation. 

Dr.  Rohix.son  referred  to  a  case  of  obstructive 
jaundice  supposed  to  be  due  to  gall  stones,  in  which 
death  occurred  in  a  convulsive  seizure.*  There  was 
no  autopsy. 

Dr.  Joseph  D.  Bryant  said  he  had  had  one  case  of 
fatal  secondary  hemorrhage  after  an  operation  for  gall 
stones. 

Dr.  Abbe,  in  closing  the  discussion,  said  that  in 
his  case  the  jaundice  had  lasted  only  ten  days.  The 
symptoms  closely  simulated  those  of  cancer,  and  the 
patient  nearly  succumbed  to  exhaustion  from  the  pro- 
found cholaemia.  There  was  nothing  found  but  this 
collection  of  stones,  and  the  patient  made  a  rapid  re- 
covery. 

A  Case  of  Peritonitis  from  Perforation  of  the 
Stomach  Wall  by  a  Toothpick — Dr.  Anr.i;  reported 
this  case.  The  patient  was  a  man  aged  fifty  years 
who  had  suffered  for  two  months  from  symptoms 
closely  resembling  those  of  gastric  ulcer,  to  wit,  pain 
and  tenderness  in  the  epigastrium,  more  severe  after 
ealing,  always  coming  on  between  meals  and  passing 
away  entirely  before  the  following  meal.  Two  weeks 
before  operation  the  pain  became  much  worse,  and 
was  accompanied  by  nausea  and  vomiting. 

On  examination  the  abdomen  was  found  to  be  dis- 
tended, the  epigastrium  hard  and  full,  and  there  was 
muscular  rigidity  of  the  upper  recti  and  on  the  right 
side  of  the  lower  half.  The  diagnosis  of  appendicitis 
had  been  made  before  Dr.  Abbe  saw  the  patient,  be- 
cause of  tenderness  in  the  lower  abdomen,  which  was 
more  marked  on  the  right  side.  The  epigastric  condi- 
tion, however,  clearly  indicated  perforating  ulcer. 
The  patient  had  a  temperature  of  104"  F.,  and  his 
general  condition  was  such  that  an  immediate  opera- 
tion was  indicated.  An  incision  was  made  above  the 
navel  and  a  matted  mass  of  intestine  uncovered,  from 
which  protruded  the  blackened  end  of  an  ordinary 
wooden  toothpick;  the  other  end  of  the  toothpick  was 
still  embedded  in  the  ulcer  of  the  stomach  wall.  No 
gas  was  noticed  in  the  foul  abscess,  which  was  still 
confined  by  the  matted  omentum,  but  spreading  down- 
ward to  the  navel.  The  wound  was  packed  and  left 
open.  The  temperature  was  normal  on  the  sixth  day, 
and  prompt  recovery  followed. 

In  connection  with  this  case,  Dr.  Abbe  exhibited  the 
toothpick.  The  patient  had  no  recollection  of  ever 
having  swallowed  it,  and  had  never  been  intoxicated, 
so  as  to  have  the  swallowing  occur  without  his  knowl- 
edge. 

Pernicious  Ana2mia  and  its  Relation  to  Inherit- 
ance.— This  paper  was  read  by  Dr.  C.  L.  Dana  (see 
page  841). 

Dr.   Robinson  said  that  in  the  November  number 


ol  \\\&  Amerkaii  Journal  oj  the  Medical  Sciences  Dr.  Bill- 
ings reported  twenty  cases  of  pernicious  anxmia,  in 
two  cases  of  which  the  patients  were  over  sixty  years 
of  age,  and  in  two,  sixty  years  old. 

Dr.  Peabody  said  that  Dr.  Dana's  paper  was  most 
suggestive  and  deserved  careful  reflection.  While  it 
was  not  always  safe  in  pathology  to  reason  by  analogy, 
the  array  of  analogies  presented  by  Dr.  Dana  was  very 
striking.  The  fact  that  several  cases  of  pernicious 
anaemia  had  occurred  in  the  same  family  had  been 
noted  before,  and  was  strictly  in  line  with  the  author's 
suggestion. 

Dr.  Ki.vNicurr  said  that  while  a  family  history  of 
pernicious  anaemia  was  occasionally  gotten,  he  doubted 
whether  this  fact  could  be  looked  upon  from  the  point 
of  view  suggested  by  Dr.  Dana.  The  speaker  said 
that  a  family  had  been  under  his  observation  in  which 
three  of  the  children  had  suffered  from  pernicious 
anxniia.  One  of  them  died;  the  other  two  were  still 
living.  Of  the  latter,  one  had  had  two  relapses.  All 
three  of  these  cases  were  instances  of  pernicious  an- 
aemia, based  upon  our  present  knowledge  of  blood  ex- 
aminations. None  of  these  patients  displayed  any 
other  congenital  peculiarities  or  weaknesses  than  a  con- 
genitally  large  spleen,  and  this  same  condition  had 
existed  in  the  father  and  paternal  grandfather. 

Dr.  Robinson  referred  to  one  instance  that  had  come 
under  his  observation  in  which  a  simple  ana;mia  had 
apparently  developed  into  pernicious  anamia.  This 
seemed  to  be  the  opinion  of  those  who  made  the  blood 
examinations.  The  latter,  however,  would  not  always 
decide  the  question,  and  the  clinical  evidence  must 
also  be  depended  upon. 

Dr.  Kinnicutt  said  that  on  Dr.  Dana's  theory  it 
would  be  difficult  to  explain  the  spontaneous  and  very 
rapid  and  marked  improvement  wiiich  was  often  seen 
in  cases  of  pernicious  anamia,  wilii  or  without  treat- 
ment. A  case  of  pernicious  anaemia  which  had  been 
regarded  as  hopeless  might  begin  to  improve  and  ap)- 
parently  result  in  recovery.  Clinical  experience 
pointed  to  the  certainty  of  a  relapse,  liowever,  even  if 
the  period  of  freedom  lasted  two  or  three  years,  or  even 
longer.  In  these  cases  the  blood  occasionally  recovered 
its  normal  condition,  so  far  as  our  present  methods  of 
examination  permitted  us  to  judge.  Such  an  improve- 
ment was  difficult  to  explain  on  any  supposition.  Prob- 
ably the  most  plausible  was  that  which  attributed  the 
an.-Emia  to  the  presence  of  a  toxin. 

Dr.  Dana  said  that  interims  of  improvement  were 
seen  in  other  degenerative  diseases,  such  as  paresis 
and  the  various  muscular  dystrophies. 

Dr.  Kinnicutt  said  that  while  in  certain  degenera- 
tive diseases  the  symptoms  might  remain  stationary,  in 
pernicious  ana:inia  the  constituents  of  the  blood  often 
became  both  quantitatively  and  qualitatively  normal 
during  the  period  of  improvement. 

Dr.  Janeway  said  that  while  Dr.  Dana's  theory  re- 
garding pernicious  anajmia  was  very  suggestive,  he 
did  not  feel  inclined  to  accept  it.  Before  doing  so,  it 
would  be  necessary  to  analyze  a  great  many  of  these 
cases  and  enter  very  fully  into  the  family  history. 
There  were  no  doubt  cases  of  pernicious  anaemia  in 
which  an  hereditary  history  of  the  disease  could  be 
obtained. 

Dr.  W.  Gilman  Thompson  said  it  was  interesting  to 
have  heredity  advanced  as  a  factor  in  disease,  for  in 
recent  years  it  had  been  relegated  more  and  more  to 
a  minor  role,  as  in  phthisis  and  rheumatism.  Before 
Dr.  Dana's  theory  was  accepted,  however,  the  potency 
of  heredity  in  these  cases  should  be  well  established. 
Dr.  Dana's  patient  evidently  belonged  to  an  interest- 
ing family  and  inherited  certain  weaknesses,  but  this 
did  not  prove  that  the  pernicious  ana;mia  was  neces- 
sarily due  to  an  inherited  blood  dyscrasia.  The 
speaker  said  he  had  looked  over  the  records  of  a  num- 


9IO 


MEDICAL    RECORD. 


[December  8,  1900 


ber  of  his  cases  of  pernicious  anremia  in  which  the 
patients'  antecedents  and  family  history  were  very  care- 
fully investigated,  and  liad  failed  to  tind  a  single  in- 
stance in  which  heredity  could  be  claimed  as  a  factor. 
On  the  other  hand,  Dr.  Thompson  said,  there  were 
one  or  two  blood  diseases  that  seemed  to  be  distinctly 
hereditary.  The  most  extraordinary  hereditary  con- 
dition was  hemophilia,  which  was  transmitted  by 
females  but  rarely  shared  by  them.  This  condition 
had  been  traced  back  for  several  generations.  Cer- 
tain cases  of  chlorosis  also  seemed  to  be  hereditary. 
While  the  possibility  of  an  hereditary  dyscrasia  in 
pernicious  anaemia  could  not  be  denied,  evidence  was 
still  lacking  to  prove  it.  There  might  be  an  heredi- 
tary weakness  of  the  general  constitution,  which  might 
lead  in  one  case  to  a  blood  disease  like  this,  in  an- 
other to  muscular  dystrophies,  neuroses,  and  so  on. 
It  should  be  borne  in  mind  that  the  accurate  diagno- 
sis of  all  blood  disease  was  of  recent  date,  and  com- 
parison of  early  records  was  unreliable.  The  possi- 
bility of  chlorosis  merging  into  pernicious  anaemia 
was  denied  by  many,  but  there  were  cases  in  which  the 
severe  form  of  chlorosis  and  the  mild  form  of  per- 
nicious anaemia  caused  blood  changes  which  were  very 
difficult  to  distinguish  from  each  other.  There  were 
cases  which  were  apparently  on  the  border  line,  just  as 
in  leukaemia  and  pseudo-leukamia,  and  the  etiology  of 
all  these  blood  diseases  was  not  at  all  established. 
In  conclusion  Dr.  Thompson  said  that  while  he  was 
much  interested  in  the  theory  of  Dr.  Dana,  the  argu- 
ments in  its  favor  did  not  appeal  to  him  as  convinc- 
ing. Other  theories,  particularly  that  of  auto-intoxi- 
cation, appeared  more  plausible. 

Dr.  C.  N.  B.  Camac  said  that  Dr.  Dana's  etiological 
explanation  of  pernicious  anemia  upon  teratological 
grounds  opened  up  an  entirely  new  line  of  thought.  In 
reviewing  the  history  of  the  cases  of  pernicious  anaemia 
reported  in  literature,  on:  was  struck  by  the  omission 
of  any  reference  to  family  history.  The  most  exten- 
sive report  in  connection  with  the  subject  was  prob- 
ably that  of  Hunter  in  The  Lamct  of  last  year.  In 
the  description  of  the  cases  that  appeared  in  this  re- 
port family  history  was  not  given  in  a  single  instance. 
Except  only  in  text-books  on  medicine  in  which  such 
history  was  a  matter  of  systematic  arrangement,  no- 
where did  family  history  appear,  and  even  in  these  no 
reference  w'as  to  be  found  to  miscarriage,  etc.,  which 
was  the  striking  feature  in  Dr.  Dana's  case.  It  was 
therefore  important,  in  order  to  verify  this  theory  of 
Dr.  Dana's,  that  this  portion  of  the  history  be  more 
thoroughly  inquired  into,  in  the  future.  It  was  perhaps 
natural  that  Hunter  should  have  omitted  this  inquiry 
as  to  family  history,  as  he  attributed  the  disease  to  the 
absorption  of  toxins  resulting  from  pathogenic  micro- 
organisms taken  into  the  digestive  tract,  and  reported 
two  cases  in  which  sewer  gas  apjieared  to  be  a  source 
of  infection.  Adami,  of  Montreal,  had  reported  four 
cases  in  which  he  suggested  that  a  chronic  gastro-enter- 
itis  was  the  seat  of  the  trouble.  He  believed  that,  as 
the  gastro-intestinal  tract  gradually  became  impaired, 
the  resistance  to  the  ordinary  micro-organisms,  which 
were  harmless  in  the  healthy  gut,  was  overcome,  and  ul- 
timately the  blood  suffered  and  toxic  effects  were  noted. 
If  the  theory  of  irregular  longevity  of  different  organs 
in  the  same  individual  was  correct,  as  Dr.  Dana  sug- 
gested in  connection  with  the  blood-making  apparatus, 
the  digestive  apparatus  might  also  be  considered  to 
fail  earlier  in  some  individuals,  and  thus  this  theory 
and  that  of  Hunter  and  .Vdami  would  be  in  accord. 
Continued  haemolysis  we  knew  might  in  time  lead  to 
a  faulty  ha;mogenesis.  Evidence  of  this  was  given  in 
the  blood  characteristics  of  secondary  anemia  of  long 
standing  giving  place  to  those  of  primary  anaemia,  with 
normoblasts,  gigantoblasts,  etc.  Thus  the  hemolysis 
of  the  theory  of  Hunter  and  Adami  would  hasten  the 


hemogenetic  failure  in  the  theory  suggested  by  Dr. 
Dana.  Dr.  Camac  said  that  if  Dr.  Dana's  idea  were 
correct  we  might  find  an  interesting  field  for  investiga- 
tion in  the  blood  of  the  aged.  We  might  find  in  the 
peripheral  circulation  of  old  persons  some  of  those 
bodies,  normoblasts,  gigantoblasts,  etc.,  associated 
with  failure  of  the  blood-making  organs. 

Dr.  Dana,  in  closing,  said  that  in  spite  of  the  re- 
searches made  in  connection  with  toxins  and  gastro- 
intestinal disturbances,  they  failed  to  explain  in  a 
satisfactory  manner  the  cause  of  pernicious  anemia. 
A  disease  which  came  on  without  apparent  cause, 
which  progressed  steadily,  and  proved  fatal  in  the 
course  of  a  few  months,  in  spite  of  the  fact  that  all  the 
other  organs  in  the  body  were  in  a  fairly  healthy  con- 
dition, suggested  to  him  a  striking  analogy  to  the  de- 
generative diseases  which  he  met  with  in  the  nervous 
system  and  in  other  parts  of  the  body.  In  such  de- 
generative diseases  neuropathologists  generally  ad- 
mitted that  there  was  an  inherent  weakness  in  certain 
groups  of  neurons.  In  connection  with  pernicious 
anemia  it  would  require  long  and  careful  research  to 
establish  this  view.  The  speaker  said  he  did  not 
mean  to  imply  that  the  disease  was  hereditary  in  the 
sense  that  it  was  directly  transmitted;  he  meant  that 
the  individual  was  born  with  some  defect  in  his  blood- 
making  organs  which  we  did  not  recognize  for  years. 
An  analogous  condition  was  seen  in  progressive  mus- 
cular dystrophy,  in  which  the  symptoms  did  not  appear 
until  after  the  lapse  of  a  certain  number  of  years.  In 
going  into  the  history  of  these  cases  of  pernicious 
anemia,  we  should  not  be  content  to  learn  that  there 
had  been  no  similar  cases  in  the  family,  but  we  should 
try  to  find  out  about  the  health  of  the  generation  to 
which  the  patient  belonged.  Congenital  defects 
should  also  be  inquired  after. 

A  Case  of  Tetany  Dependent  on  Auto-Infection. 
— This  case  was  reported  by  Dr.  Andrew  H.  Smith. 
He  said  that  in  April  of  this  year  he  was  called  by 
Dr.  Bradley,  of  Ottawa,  Canada,  to  see  a  patient  of  his 
in  that  city.  The  patient,  a  married  lady  about  thirty- 
two  years  of  age,  with  three  children,  had  had  fairly 
good  health  until  about  a  year  before  her  present  ill- 
ness. At  that  time  she  began  to  suffer  from  dyspep- 
sia, which  became  more  and  more  troublesome,  and 
was  marked  by  great  acidity  of  the  stomach  and  the 
formation  of  large  quantities  of  gas.  Her  health  and 
strength  failed  rapidly,  and  she  developed  marked  in- 
somnia. Two  months  before  his  first  visit  the  first  at- 
tack of  tetany  occurred.  The  contractures  as  described 
were  confined  to  the  hands  and  feet.  The  fingers  were 
forcibly  flexed  into  the  palms,  and  the  wrists  extended 
and  rotated  outward  to  an  extreme  degree,  causing  in- 
tense pain.  The  duration  of  this  attack  was  about  an 
hour.  Three  other  attacks  occurred  during  the  follow- 
ing two  months.  In  some  of  these  trismus  was  asso- 
ciated with  the  contractures  of  the  hands  and  feet.  In 
every  case  there  were  prodromal  symptoms  such  as 
tingling,  ])rickling,  etc.  There  was  also  a  sense  of 
painful  pressure  in  the  epigastrium.  On  two  occa- 
sions the  pain  attending  the  contractures  was  so  great 
as  to  demand  the  use  of  chloroform.  The  paroxysms 
lasted  from  one  to  two  hours,  and  were  succeeded  by 
great  soreness  of  the  muscles.  For  two  or  three  weeks 
before  Dr.  Smith's  visit  the  patient  had  been  suffering 
from  delusions  and  spectral  illusions  of  a  most  dis- 
tressing character.  She  thought  she  was  away  from 
home  and  was  being  very  cruelly  treated  by  her  nurse, 
and  that  frogs,  mice,  etc.,  were  running  over  the  bed. 
She  would  cry  out  with  horror,  and  these  cries  met 
the  doctor  at  the  door  on  his  first  arrival.  Food  of 
any  kind  excited  nausea  and  attempts  to  vomit,  which 
latter  were  ineffectual  owing  to  the  dilatation  and 
malposition  of  the  stomach.  The  resulting  distress 
was  extreme,  and  the  misery  of  the  patient  was  almost 


December  8,  1900J 


MEDICAL    RECORD. 


911 


indescribable.  She  was  greatly  emaciated,  and  too 
weak  to  bear  her  weight  upon  her  feet.  Sleep  was 
almost  out  of  the  question,  and  the  little  that  was  ob- 
tained was  at  the  expense  of  a  free  use  of  hypnotics. 
There  was  severe  and  persistent  headache,  with  a 
burning  sensation  at  the  base  of  the  skull.  M'hile 
there  was  little  sleep,  there  was  often  a  vacuous  con- 
dition of  the  mind,  rendering  the  jiatient  unconscious 
of  her  surroundings.  At  times  she  would  pass  into  a 
sort  of  revery  in  which  food  would  remain  in  her  mouth 
without  her  making  an  effort  to  swallow  it.  Her  ex- 
haustion was  such  that  a  fatal  termination  seemed  to 
be  near  at  hand.  The  cause  of  this  condition  had  been 
recognized  as  auto-infection  resulting  from  retention 
and  putrefaction  of  food  in  a  greatly  enlarged  and  de- 
pendent stomach.  The  lesser  curvature  of  the  stomach 
was  at  the  level  of  the  umbilicus,  and  the  lower  border 
reached  to  a  point  midway  between  the  umbilicus  and 
the  pubes.  There  was  no  history  pointing  to  ulcera- 
tive action  about  the  pylorus.  Apparently  the  enter- 
optosis  was  the  starting-point,  the  dilatation  being 
consecutive.  The  gastric  disturbance  followed  upon 
the  birth  of  her  last  child  about  five  years  ago,  and  it 
was  noteworthy  that  the  abdomen  never  regained  its 
shape  after  that  event,  but  remained  lax  and  somewhat 
pendulous.  A  plan  of  treatment  was  agreed  upon, 
based  upon  the  theory  that  the  toxin  was  probably 
albuminous  in  its  character  and  derived  from  the  pro- 
teids  in  the  food.  The  stomach  was  washed  out  twice 
a  day,  and  the  diet  was  so  selected  as  to  exclude  as  far 
as  possible  all  nitrogenous  substances.  After  each  irri- 
gation a  pint  of  whey  was  left  in  the  stomach,  together 
with  a  tablespoonful  of  powdered  willow  charcoal 
and  a  scruple  of  salicin.  In  the  inter\-als  farinaceous 
food  was  given  in  small  quantities,  and  later  the  yolk 
of  an  egg  was  added.  Additional  doses  of  salicin  or 
other  antiseptic  were  employed.  High  enemas  of  hot 
saline  solution  were  given  twice  daily.  A  calomel 
purge  was  ordered,  and  this  was  repeated  from  time  to 
time  as  required.  Hyoscine  hydrobromate,  with  mod- 
erate doses  of  sodium  bromide,  quieted  the  nervous 
excitement  and  procured  sleep.  Some  degree  of  im- 
provement was  apparent  very  soon  after  this  treatment 
was  begun,  and  each  day  marked  a  decided  advance. 
The  improvement  was  first  noticeable  in  the  mental 
condition,  which  became  quite  normal  at  the  end  of  a 
week.  Strength  was  regained  rapidly ;  in  a  fortnight 
the  patient  was  about  the  room,  and  by  another  fort- 
night she  was  able  to  drive  out.  Only  one  setback 
occurred,  which  was  about  ten  days  after  Dr.  Smith's 
visit,  when  there  were  two  attacks  only  a  few  minutes 
apart  and  quite  severe.  No  tetany  had  been  mani- 
fested since,  though  the  premonitory  prickling,  etc., 
returned  several  times  during  the  summer  when  the 
lavage  had  been  neglected  for  some  time.  The  use  of 
hyoscine  was  continued  for  some  two  weeks  with  excel- 
lent effect,  when  it  was  found  that  the  eyes  were  weak 
and  watery.  This  condition  was  traced  to  the  mydri- 
atic effect  of  the  hyoscine,  and  yielded  readily  to  in- 
stillations of  a  one-per-cent.  solution  of  pilocarpine. 
Great  benefit  resulted  from  the  use  of  a  tightly  fitting 
belt,  by  which  the  stomach  was  held  in  a  less  unnatural 
position. 

Since  the  above  was  written  the  patient  had  come 
on  to  New  York,  and  at  the  present  writing  was  under 
Dr.  Smith's  care.  For  some  time  she  neglected  the 
lavage,  and  ate  pretty  freely  of  animal  food.  The 
premonitory  symptoms  of  tetany  appeared  again,  and 
this  led  her  to  come  to  this  city.  In  the  few  days 
since  her  arrival  her  condition  had  not  improved,  not- 
withstanding a  resumption  of  the  measures  employed 
so  successfully  before.  In  view  of  the  very  serious 
nature  of  the  tetany  arising  from  gastric  dilatation  (the 
mortality  being  about  seventy  per  cent.)  the  present 
situation  was  not  reassuring. 


THE   MEDICAL    SOCIETY  OF   THE   COUNTY 
OF    NEW    YORK. 

Stated  Meeting,  November  26.  igoo. 

George  B.  Fowler,  M.D..  President. 

The  History,  Aim,  and  Purpose  of  the  Medical 
Society  of  the  County  of  Nev/  York. — Di<.  Fra.nk 
\'an  Fi.KKT  read  a  paper  with  this  title.  He  said  that 
the  system  of  medical  societies,  of  which  this  county 
society  was  a  part,  had  been  established  since  1806, 
and  was  no  new  experiment.  This  organization  had 
lived  through  many  trials  and  vicissitudes,  yet  had 
continued  to  fulfil  its  proper  functions.  This  society 
was  part  and  parcel  of  the  Medical  Society  of  the 
State  of  New  York,  and  what  was  said  of  one  applied 
to  the  other,  and  to  the  society  of  every  other  county 
in  the  State.  One  of  the  functions  of  this  organiza- 
tion was  the  dissemination  and  propagation  of  the 
knowledge  of  the  science  of  the  practice  of  medicine, 
but  a  more  important  function  was  the  regulation  of 
the  practice  of  physic  and  surgery  in  this  State,  and 
the  legislature  had  delegated  to  this  society  the  bur- 
den of  the  enforcement  of  the  medical  laws  of  the 
State.  The  law  of  1806,  creating  medical  societies, 
had  marked  an  epoch  in  the  history  of  medicine  in 
this  State.  It  gave  the  societies  so  incorporated  the 
right  to  examine  students  in  medicine  and  grant 
licenses  to  practise.  The  State,  by  tliis  act,  created  a 
special  department  which  became  an  integral  part  of 
the  machinery  of  the  State.  This  relation  between  the 
State  and  the  various  county  societies  continued  to 
exist  for  thirty-eight  years  with  slight  changes.  In 
i8i8a  law  had  been  passed  authorizing  colleges  to 
send  delegates  to  the  society,  and  ordering  all  practis- 
ing physicians  to  connect  themselves  with  the  county 
societies  in  the  counties  in  which  they  resided.  In 
1837  to  1839  the  Iniversity  of  the  City  of  New  York 
and  the  Albany  Medical  College  were  authorized  to 
send  delegates  to  the  State  society.  In  1844  a  law 
had  been  enacted  removing  all  the  restrictions  hitherto 
existing,  and  allowing  all  persons,  without  special 
qualifications,  to  practise  medicine.  It  was  strange, 
indeed,  that  at  so  late  a  date  in  liberty-loving  America 
there  should  have  been  such  intolerance  and  bigotry, 
that  physicians  differing  from  the  majority  of  the  pro- 
fession in  their  therapeutic  beliefs  should  have  been 
not  only  ostracized  but  prevented  from  practising  their 
calling.  This  was  bad  enough,  yet  there  existed  in 
the  State  and  in  the  county  of  New  York  at  the  pres- 
ent time  an  organization  founded  and  maintained  for 
the  special  object  of  keeping  alive  such  prejudices 
and  such  monstrous  bigotry.  In  the  early  part  of  the 
century  homojopathy  had  come  as  a  welcome  variation, 
and  it  would  have  been  tried  and  discarded  long  ago 
had  it  not  been  for  the  intolerance  of  the  advocates  of 
the  older  methods  of  practice.  Those  who  wished  to 
practise  homoeopathy  were  expelled  from  their  county 
societies,  which  was  equivalent  to  excluding  them 
from  the  practice  of  medicine.  In  1846  the  American 
Medical  Association  had  been  created  with  a  view  of 
securing  better  mutual  protection  among  medical  prac- 
titioners. It  was  preceded  by  the  American  Institute 
of  Homoeopathy  in  1844.  Both  of  these  bodies  had 
been  established  with  the  same  general  objects  in 
view,  and  a  bitter  war  had  been  waged  between  them. 
In  1883  the  Medical  Society  of  the  State  of  New  York, 
by  a  substantial  majority,  had  abolished  the  code  of 
ethics,  thereby  allowing  its  members  the  privilege  of 
meeting  any  legal  practitioner  of  medicine  in  consulta- 
tion. The  far-reaching  eftects  of  this  action  of  the 
State  society  had  probably  been  greater  than  many  had 
at  the  time  realized.  The  first  effect  had  been  to  bring 
the  warring  elements  together,  and  to  lead  them  to  see 
that   their   interests  were   more  nearly  identical  than 


912 


MEDICAL    RECORD. 


[December  8,  1900 


they  had  supposed.  This  had  led  to  certain  medi- 
cal legislation,  and  these  laws  now  stood  as  a 
monument  to  the  broad-minded  policy  initiated  and 
carried  out  by  the  Medical  Society  of  the  State  of 
New  York.  To  gain  the  right  to  practise  medicine  in 
the  State  of  New  York  to-day  meant  something  —  it 
meant  that  he  who  had  gained  this  right  had  shown 
to  an  impartial  board  his  ability  to  practise  medicine 
properly.  It  made  no  difference  who  the  candidate 
was,  or  from  how  many  colleges  iie  had  graduated. 
he  came  before  the  State  examining-board  on  an  equal 
footing  with  all  other  candidates,  of  whatever  school 
in  medicine,  to  obtain  his  license  to  practise.  The 
number  admitted  in  1899  was  six  hundred  and  seventy- 
one,  while  that  in  1895  was  four  hundred  and  eighty- 
two.  The  result  of  the  law  had  been  a  raising  of  the 
standard  if  requirements  in  this  State,  and  an  improve- 
ment in  the  teaching  in  the  undergraduate  schools.  It 
was  true  there  were  imperfections  in  the  present  law, 
but  they  would  be  remedied  very  soon  were  it  not  for 
the  enemies  of  the  society,  and  particularly  the  enemies 
within  its  own  ranks.  There  was  an  organization 
which  had  done,  and  was  doing,  its  utmost  to  over- 
throw the  Medical  Society  of  the  State  of  New  York 
and  its  county  branches — he  referred  to  the  New  York 
State  Medical  Association  and  its  county  branches. 
This  association,  he  stated,  represented  a  principle 
which  was  antagonistic  to  the  medical  laws  of  tlie  State 
of  New  York  as  well  as  to  the  spirit  of  the  institutions 
of  this  State  and  of  the  United  States.  This  principle 
was  formerly  upheld  by  the  Medical  Society  of  the 
State,  and  it  resulted  in  the  overthrow  of  the  medical 
laws  of  the  State  in  1844.  When  the  State  society 
had  refused  to  be  governed  by  the  code  of  ethics  of 
the  American  Medical  Association  it  had  abolished 
this  principle  and  had  made  possible  the  enactment  of 
the  present  medical  laws  of  the  State. 

The  State  society  had  no  representation  in  the 
American  Medical  Association  because  it  refused  to 
be  governed  by  the  code  of  ethics  of  the  latter  associa- 
tion. VVhy  was  this?  Because  this  code  of  ethics  up- 
held a  principle  which  was  un-American,  which  was 
contrary  to  the  teachings  of  the  Constitution  of  the 
United  States,  and  which  was  contrary  to  the  dictates 
of  humanity.  The  code  of  ethics  has  much  to  say 
about  the  dictates  of  humanity,  but  it  ostracized  from 
the  pale  of  professional  intercourse  and  consultation 
any  person  who  believed  contrary  to  what  the  associa- 
tion thought  he  ought  to  believe.  This  was  contrary 
to  the  Constitution  of  the  United  States,  which  gave 
to  every  man  the  right  to  believe  as  his  conscience 
dictated.  When  this  code  said  that  no  one  could  be 
considered  a  fit  associate  in  consultation  whose  prac- 
tice was  based  on  an  exclusive  dogma  it  denied  to 
humanity  intelligent  treatment.  Medicine  was  not  a 
commercial  calling,  nor  was  it  so  narrow  that  its  fol- 
lowers should  allow  themselves  to  be  swayed  by  whims 
and  individual  prejudices.  Surely  no  regular  physi- 
cian should  hesitate  to  give  the  benefit  of  his  knowl- 
edge to  a  patient  who  was  being  treated  by  one  whose 
practice  was  founded  on  an  exclusive  dogma. 

Continuing,  the  speaker  said  that  in  1897  the  legis- 
lature had  been  petitioned  to  grant  the  New  York 
State  Medical  Association  equal  representation  with 
the  State  society  in  the  State  board  of  medical  exam- 
iners, but  this  had  been  refused  by  the  legislature. 
The  request  had  been  renewed  last  year,  when  an 
effort  had  been  made  to  secure  a  charter.  The  legis- 
lature had  granted  a  charter,  but  had  refused  to  allow 
the  association  to  interfere  with  the  medical  laws. 
New  York  City  now  had  on  its  hands  a  lawsuit,  which, 
had  not  the  legal  authorities  considered  it  unjust,  the 
cify  would  have  settled  before  this.  The  suit  had 
been  brought  nominally  against  the  city,  but  it  was 
really  a  final  effort  of  the  New  York  County  Medical 


Association  to  compel  the  Medical  Society  of  the 
County  of  New  York  to  divide  with  it  the  work  of  en- 
forcing the  laws  on  medical  practice.  The  law  was 
very  explicit  in  its  statement  as  to  what  societies  to 
consider  its  representatives  in  this  matter,  and  it  did 
not  include  in  this  list  the  New  York  County  Medical 
Association.  The  section  of  the  law  providing  for  the 
collection  of  fines  for  violation  of  the  law  gave  the 
county  society  the  right  to  receive  the  fines  in  cases  in 
which  the  complaint  had  been  made  by  that  society. 
The  New  York  County  Medical  Association  claimed 
that  it  had  the  right  to  collect  fines  under  such  condi- 
tions, and  hence  this  suit.  The  comptroller  had  refused 
to  pay  over  the  fine,  claiming  that  the  law  referred  to 
the  Medical  Society  of  the  County  of  New  York.  The 
attorney-general  rendered  a  decision  to  the  effect  that 
the  word  "society"  in  the  law  could  be  made  to  in- 
clude the  New  York  County  Medical  Association. 
The  comptroller  refusing  to  be  governed  by  this  deci- 
sion, the  suit  mentioned  had  been  brought.  Judge 
McAdam,  in  the  supreme  court,  ruled  that  the  New 
York  County  Medical  Association  had  the  right  to 
collect  such  fines.  The  comptroller  and  the  corporation 
counsel  refused  to  abide  by  this  decision;  hence  the 
case  would  soon  be  again  argued,  this  time  in  the 
appellate  division  of  the  supreme  court.  Judge 
McAdam  had  evidently  been  greatly  influenced  in  giv- 
ing his  decision  by  the  fact  that  the  New  York  County 
Medical  Association  had  the  right  of  representation 
in  the  American  Medical  Association,  believing  that 
by  such  connection  the  medical  laws  could  be  better 
enforced.  This  raised  the  important  question  as  to 
whether  it  was  desirable  for  the  county  society  to  be 
so  related  to  the  American  Medical  Association. 
While  a  national  body,  it  was  purely  voluntary  in  its 
character,  and  was  not,  like  the  Medical  Society  of  the 
State  of  New  York,  incorporated,  or  an  integral  part  of 
the  government.  The  Medical  Society  of  the  State  of 
New  York  had  not  the  migratory  habit  of  the  Ameri- 
can Medical  Association,  but  met  annually  at  the 
State  capital  at  the  time  the  legislature  was  in  session. 
It  had  done  much  to  elevate  the  medical  profession, 
and  certainly  should  be  represented  in  every  national 
body,  and  would  be  represented  in  the  American 
Medical  Association,  were  it  not  for  the  code  of  ethics 
of  the  latter  body,  which  the  New-  York  State  Medical 
Society  refused  to  endorse,  and  which  even  the  mem- 
bers of  the  American  Medical  Association  confessed 
nobody  lived  up  to.  When  the  American  Medical  As- 
sociation agreed  to  allow  each  State  to  regulate  its 
own  affairs,  and  invited  tiie  Medical  Society  of  the 
State  of  New  Vork  to  send  delegates  to  it,  the  unhappy 
breach  which  now  existed  in  the  profession  of  this 
State  would  be  closed. 

It  was  perhaps  unfortunate  that  any  medical  society 
should  be  burdened  with  enforcing  the  medical  law'S, 
for  it  led  to  a  widespread  and  deeply  rooted  suspicion 
that  the  prosecution  of  alleged  illegal  practitioners 
savored  more  of  persecution.  However,  years  of  experi- 
ence had  enabled  the  county  medical  society  to  build 
up  a  system  which  made  the  detection  of  illegal  prac- 
titioners of  medicine  comjiaratively  easy,  and  the  di- 
vision of  this  responsibility  would  surely  lead  to  con- 
fusion and  to  a  lax  enforcement  of  the  law,  A 
division  of  this  work  would  also  greatly  increase  the 
expense.  The  county  society  now  employed  legal 
counsel,  paying  therefor  a  salary  of  $1,000,  and  ex- 
pending annually  about  eighteen  hundred  dollars  in 
securing  the  necessary  evidence.  It  might  seem  to 
some  persons  that  the  division  of  this  work  would  dis- 
tribute the  burden,  but  this  was  not  so,  for  most  of  the 
members  of  the  New  York  County  Medical  Associa- 
tion were  also  members  of  the  county  society.  \\'hat 
a  spectacle  was  presented  in  this  State  with  two  county 
organizations  having  almost  an  identical  membership, 


December  8,  1900] 


MEDICAL    RECORD. 


913 


yet  supposed  to  be  diametrically  opposed  in  their  guid- 
ing principles  and  beliefs!  The  New  York  State 
Medical  Association  had  had  seventeen  presidents, 
eleven  of  whom  were  now  living.  Of  these  eleven, 
eight  were  members  of  county  societies.  How  these 
gentlemen  could  reconcile  this  peculiar  dual  position 
was  difficult  to  understand.  The  sole  purpose  of  the 
State  association  was  the  overthrow  of  the  State 
society,  and  it  was  due  to  their  efforts  alone  that  the 
breach  still  remained  ojjen  between  the  Medical  So- 
ciety of  the  State  of  New  York  and  the  American 
Medical  Association. 

In  conclusion,  the  speaker  said  if  he  had  succeeded 
in  demonstrating  to  any  considerable  number  the 
necessity  of  caution  in  connecting  themselves  with 
organizations  whose  purpose  was  to  destroy  the  influ- 
ence and  work  of  the  Medical  Society  of  the  State  of 
New  York,  and  its  branches,  he  would  feel  amply  re- 
paid for  having  written  this  historical  sketch. 

Notes  on  Influenza. — Dr.  A.  Jacobi  read  a  paper 
witli  this  title. 

Gastro-Intestinal  Form — He  said  that  in  the  gas- 
tro-intestinal  form  the  tongue  was  usually  heavily 
coated,  and  there  were  also  loss  of  appetite  and  vomit- 
ing, or  perhaps  moderate  diarrhcea  and  moderate  jaun- 
dice. Frontal  headache  was  very  common.  In  some 
cases,  on  post-mortem,  the  patches  of  Peyer  had  been 
found  enlarged  and  ulcerated  in  cases  that  had  ex- 
hibited severe  diarrhoea.  In  the  circulatory  system 
the  heart  suffered  more  than  the  blood-vessels.  In 
many  cases  it  was  ditficult  to  say  whether  it  was  the 
heart  muscle  or  the  innervation  of  the  heart  which  was 
most  affected,  yet  often  it  was  plainly  the  latter. 
Bradycardia  was  more  frequent  in  the  young  when 
suffering  from  influenza  than  from  any  other  infectious 
disease,  even  typhoid  fever.  A  disproportion  between 
the  pulse  and  temperature  was  very  frequently  noted. 
Even  with  a  complicating  pneumonia  the  pulse  might 
be  found  comparatively  slow.  Syncope  was  not  in- 
frequent and  sudden  deaths  were  not  unheard  of. 
Acute  dilatation  of  the  heart  could  be  occasionally 
diagnosticated;  however,  myocardial  murmurs  were 
not  often  noted. 

Nervous  Form. — The  nervous  form  of  influenza 
was  quite  frequently  met  with  in  later  childhood  and 
in  adults.  It  ran  its  course  with  few  local  symptoms, 
and  hence  was  less  easily  recognized  in  the  beginning 
when  it  occurred  in  the  very  young.  While  there  were 
nervous  symptoms  in  every  sort  of  infectious  fever,  in- 
fluenza appeared  to  be  mainly  localized  in  the  nervous 
system  in  a  great  many  cases.  Severe  headache,  ex- 
citement, delirium,  semi-consciousness  and  coma, 
persistent  insomnia,  pains  in  the  muscles  about  the 
joints,  were  all  explained  by  this  infection.  F.ncephali- 
tis,  meningitis,  myelitis,  and  neuritis  were  all  observed 
in  this  class  of  cases.  He  had  observed  in  infants 
suffering  from  influenza  rigid  contraction  of  the  neck 
lasting  for  several  days.  He  had  seen  a  few  cases  of 
neuritis  and  neuritic  paralysis  associated  with  in- 
fluenza. It  was  more  probably  a  toxin  than  a  microbe 
which  caused  the  tedious  convalescence  from  influenza. 
Almost  every  form  of  paralysis  had  been  observed  since 
influenza  had  been  common  amon^  us. 

Respiratory  Form.— Bronchitis  in  the  larger  tubes 
was  easily  diagnosticated  by  the  usual  methods.  When 
it  affected  the  finer  bronchi  it  gave  rise  to  suffocation 
and  cyanosis  more  readily  than  in  the  ordinary  forms 
of  bronchitis.  The  interstitial  form  was  not  met  with 
by  itself.  Terminations  in  abscess,  gangrene,  and 
death  were  much  more  common  during  influenza  epi- 
demics than  at  other  times.  Complication  with  pleu- 
ritis,  frequently  suppurative,  was  especially  common 
during  an  epidemic  of  influenza.  Young  infants  were 
not  so  liable  to  an  attack  of  influenza  as  older  persons. 
In  this  respect  they  resembled   old  persons.     When 


infected  they  lost  weight  rapidly.  The  temperature 
was  not  always  high:  indeed,  it  might  often  be  sub- 
normal, as  in  other  forms  of  septic  infection.  As  to 
this  relative  immunity  of  the  young  infant  it  was  sug- 
gested that  perhaps  the  nasal  mucus  had  a  bactericidal 
effect,  or  that  the  influenza  bacilli  might  be  stopped  in 
the  throat  by  the  relatively  large  size  of  the  tonsils. 
The  onset  was  apt  to  be  sudden  and  the  prostration 
marked,  but  the  temperature  was  very  erratic.  A  few- 
cases  ran  their  course  in  a  few  days,  but  many  patients 
suffered  from  angina,  otitis  media,  and  conjunctivitis. 
Accommodation  paralysis  and  amblyopia  were  not  un- 
known. 

Prognosis.— The  prognosis  was  not  unfavorable  if 
the  patient  was  in  good  health  at  the  time  of  the  at- 
tack. Infants  might  die  from  enteritis.  Altogether 
the  immediate  mortality  was  not  very  large,  but  indi- 
rectly the  disease  might  prove  dangerous,  and  was 
very  often  fatal  on  account  of  the  respiratory  diseases 
of  adynamic  type  which  were  common  sequelae.  Not 
infrequently  influenza  was  the  starting-point  for  tuber- 
culosis. The  prognosis  should  never  be  considered 
positively  safe,  for  the  physiological  strength  of  the 
child's  heart  was  no  protection  against  the  debilitating 
eflect  of  the  toxin  of  the  influenza  bacillus.  Relapses 
were  frequent,  for  there  was  no  immunity,  but,  on  the 
contrary,  a  seeming  predisposition  to  subsequent  at- 
tacks. The  microbic  cause  might  at  one  time  attack 
the  nervous  system,  and  at  the  next  the  respiratory 
organs.  The  persistent  cough  should  warn  us  not  to 
make  the  prognosis  too  favorable.  In  his  experience, 
nephritis  had  not  been  an  infrequent  occurrence  after 
influenza.  The  diagnosis  should  not  be  made  from 
the  positive  albumin  test,  which  indicated  all  of  the 
albuminoids.  Microscopical  examination  of  the  cen- 
trifuged  urine  should  always  follow  the  chemical 
test,  and  would  reveal  nephritis  in  a  respectable  pro- 
portion of  cases.  Fortunately  the  nephritis  which  com- 
plicated influenza  was  not  ominous,  but  it  should 
lead  the  physician  to  be  cautious  in  making  the  prog- 
nosis. 

Prophylaxis — The  communicability  of  influenza 
was  extraordinary.  It  should  be  kept  out  of  sanatoria 
by  strict  isolation  during  an  epidemic  of  influenza. 
Closing  schools  would  be  futile  as  a  prophylactic 
measure  because  the  little  ones  would  contract  the 
disease  outside  of  the  schools.  If  nursing  mothers 
were  sick  with  influenza  the  suckling  infant  should 
be  brought  to  the  mother  only  for  nursing.  A  good 
preventive  was  to  wash  out  the  throat  with  water 
slightly  acidulated  with  hydrochloric  acid.  Medi- 
cinal preventives  had  been  recommended — cod-liver 
oil,  calcium  sulphide,  and  quinine.  His  experience 
with  them  had  been  very  small  and  unsatisfactory. 

Treatment. — There  was  no  specific  for  influenza. 
A  purgative  dose  of  calomel  should  be  given,  as  the 
bowel  was  the  principal  point  of  attack  in  very  young 
infants.  The  patient  should  be  kept  in  bed  in  a  room 
having  a  temperature  of  70°  F.  or  a  little  higher. 
The  diet  at  first  should  be  light.  Alcohol  and  other 
stimulants  were  required  only  in  selected  cases,  and 
in  this  respect  influenza  differed  from  certain  other 
infectious  diseases,  notably  typhoid  fever  and  diph- 
theria. If  the  temperatue  was  high,  cold  water  was 
not  indicated,  either  as  a  bath  or  as  a  pack.  The  irri- 
tative cough  was  apt  to  be  aggravated  by  cold  water. 
When  there  were  much  muscular  pain  and  restlessness 
a  warm  bath  was  often  beneficial.  A  hot  bath,  except 
a  very  short  one  in  the  event  of  threatened  collapse, 
should  be  avoided.  Influenza  pneumonias  did  better 
with  warm  than  with  cold  packs.  In  the  German  col- 
lective investigation  reports  some  observers  praised 
quinine  highly,  while  others  expressed  great  disap- 
pointment with  its  action.  When  the  vomiting  was 
severe,  rectal  alimentation  was  indicated.     Peptones 


914 


MEDICAL    RECORD. 


[December  8,  1900 


and  liquid  albumins  were  readily  absorbed  in  the 
colon,  which  even  in  the  smallest  infant  was  made 
accessible  by  raising  the  hips,  but  not  raising  the  irri- 
gator more  than  a  foot  above  the  anus.  Dextrin ized 
starch  would  add  to  the  nutrient  value  of  the  enema. 
The  best  relief  from  medicines  was  secured  by  the  use 
of  morphine,  A  tablet  containing  gr.  -j'^-  of  morphine 
should  be  placed  in  the  mouth  of  a  child  from  two 
to  four  years  old,  there  to  be  absorbed,  or  one-half 
drop  to  two  drops  of  Magendie's  solution  might  be 
given  in  the  same"  manner.  The  treatment  of  the 
symptom  fever  offered  no  hope  of  shortening  the  dis- 
ease, but  it  contributed  to  the  patient's  comfort  and  did 
not  interfere  with  recovery.  To  be  satisfied  with  de- 
pressing temperature  was  a  great  mistake,  but  to  allow 
influenza  or  any  other  disease  to  run  its  course  with  no 
attempt  to  combat  the  obviously  injurious  effects  of 
fever  on  the  system  was  equally  reprehensible.  Con- 
tinuous fever,  even  though  moderate,  should  not  be 
allowed  to  run  indefinitely  without  any  attempt  to 
check  it.  Nervines  and  analgesics  were  valuable  aids 
to  bathing,  or  as  substitutes  for  baths,  and  they  usually 
increased  the  comfort  and  favored  metabolism.  He 
had  formerly  asserted  that  acetanilid  should  be  pre- 
ferred among  the  poor,  because  of  its  low  price;  anti- 
pyrin  when  solubility  was  important,  and  phenacetin 
was  preferable  to  either  when  it  could  be  given  by  the 
mouth,  because  of  its  superior  action  on  the  brain  and 
on  the  skin.  Antipyrin,  when  employed  during  nor- 
mal conditions,  increased  the  pulse  and  blood  press- 
ure; hence  it  was  contraindicated  in  haemoptysis.  It 
was  not  a  nervine,  as  it  acted  chiefly  upon  the  blood- 
vessels. To  get  the  antipyretic  effect  the  dose  should 
be  repeated  in  two  hours.  In  general,  its  action  was 
favorable.  Phenacetin  resembled  acetanilid,  but  was 
milder.  The  dose  should  be  gr.  =4  to  ji:  for  infants  and 
young  children.  Salipyrin  should  be  given  in  twice  the 
dose  of  antipyrin.  It  was  usually  better  borne  than  an- 
tipyrin by  neurotic  persons.  In  using  these  drugs  it 
should  always  be  borne  in  mind  that  influenza  showed 
a  strong  tendency  to  prostration  and  heart  debility,  and 
hence  when  there  was  any  indication  of  such  an  oc- 
currence these  remedies  should  always  be  guarded  by 
the  coincident  adminstration  of  caffeine  benzoate  or 
salicylate.  This  w-as  preferable  to  the  use  of  alco- 
holic stimulants.  When  caffeine  unpleasantly  excited 
the  brain  it  should  be  replaced  by  camphor  in  doses 
of  gr.  iss.-vi.  Camphor  was  soluble  in  four  parts  of 
sweet  almond  oil.  A  most  useful  though  little  used 
cardiac  stimulant  was  Siberian  musk.  The  ten-per- 
cent, tincture  should  be  given  in  doses  of  five  to  ten 
minims  every  half-hour  for  eight  or  ten  doses.  This 
remedy  had  many  times  tided  his  cases  over  desperate 
crises. 

Dr.  Francis  J.  Quinlan  urged  that  general  practi- 
tioners, when  treating  influenza,  should  give  due  at- 
tention to  its  effect  on  the  respiratory  passages,  thus 
preventing  many  complications,  and  shortening  the 
period  of  convalescence. 

Dr.  Wickes  VVashhurn  said  he  felt  positive  that  an 
attack  of  influenza  could  be  cut  sliort  by  washing  out 
the  bowel  and  abstaining  as  far  as  possible  from  all 
food  for  the  first  two  days.  Wiien  this  was  not  prac- 
ticable, broths  should  be  given  in  preference  to  milk. 
Thirst  could  be  assuaged,  and  the  renal  function 
stimulated,  by  frequent  small  doses  of  citrate  of  mag- 
nesia. 

Carbonic-Acid-Gas  Douche  in  the  Nose — Dr.  A. 
Rose  advocated  the  use  of  tiie  carbonic-acid-gas 
nasal  douche  in  cases  of  influenza.  This  gas 
caused  anesthesia,  and  at  the  same  time  hyperremia, 
but  its  application  greatly  facilitated  the  discharge  of 
mucus.  The  application  was  pleasant  and  a  few  ai> 
plications  only  were  necessary  to  give  marked  relief. 
This   infiprovement  was  not  merely  temporary,  for,  ac- 


cording to  his  experience,  this  use  of  the  carbonic-acid 
gas  acted  as  a  tonic  to  the  nose,  and  its  good  effects 
often  continued  for  months  or  years.  The  treatment 
was  absolutely  harmless,  and  could  be  most  readily 
applied,  even  among  the  ignorant. 

Dr.  Mennen  remarked  that  although  he  had  de- 
voted many  years  to  the  study  of  infectious  diseases, 
he  felt  sure  that  little  was  known  as  yet  about  the  true 
nature  of  influenza. 

Vaccine  Lymph  a  Potent  Alterative. —  Dr.  H. 
HoLBROOK  Curtis  spoke  of  the  effect  of  vaccine  as  an 
alterative.  He  said  that  at  the  time  that  Koch's 
lymph  had  attracted  so  much  attention,  several  articles 
had  appeared  on  the  effect  of  the  subcutaneous  injec- 
tion of  vaccine  lymph  in  cases  of  phthisis.  The 
speaker  said  that  he  had  since  tried  this  treatment, 
using  a  dose  of  i  mgm.  of  the  board-of-health  vaccine, 
and  injecting  it  into  the  muscles  of  the  back.  The 
results  had  seemed  to  him  marvellous,  and  further 
study  had  led  him  to  look  upon  this  lymph  as  a  power- 
ful alterative.  He  had  treated  a  great  many  cases  of 
influenza  with  good  success,  yet  had  made  no  use  of 
the  coal-tar  derivatives.  He  was  a  firm  believer  in 
aconite,  being  of  the  opinion  that  it  acted  like  a  car- 
diac stimulant  by  diminishing  the  work  the  heart  was 
called  upon  to  do. 

Dr.  El.mer  Lee  said  that  he  regarded  these  epi- 
demics of  influenza  as  merely  a  periodic  welling-up  of 
impurities,  principally  in  the  blood  and  lymph  systems. 
The  eliminative  treatment  he  considered  the  ideaL 
This  consisted  in  feeding  the  patient  for  four  or  five 
days  almost  exclusively  on  water,  while  the  bowel  w-as 
washed  out,  and  the  patient  received  frequent  baths. 
Very  little  medicine  was  required.  This  simple 
treatment  would  get  most  patients  well  in  an  astonish- 
ingly short  time.  Morphine  might  be  used  to  relieve 
the  distress,  but  it  should  be  given  in  very  small 
doses,  preferably  by  dropping  half  a  grain  or  one 
grain  into  a  glass  of  water,  and  giving  a  teaspoonful 
of  this  mixture  at  short  intervals  until  the  desired  re- 
lief had  been  obtained. 

Committee  on  the  Certification  of  Milk — Dr.  H. 
D.  Chai'IN  said  that  this  committee  was  carrying  on 
its  work  with  energy,  and  had  been  greatly  encouraged 
by  the  large  and  interested  audience  that  had  assem- 
bled in  response  to  the  invitation  of  the  committee. 
Many  prominent  dairymen  had  been  present  and  had 
shown  a  desire  to  co-operate  with  the  medical  profes- 
sion in  securing  the  certification  of  milk  of  proper 
standard. 

Tax  on  Legacies. — Dr.  A.  jAconi  introduced  the 
following  preamble  and  resolution,  which  were  unani- 
mously adopted  by  the  society: 

IV/ioras,  The  War  Revenue  Act  of  1S98  laid  a  tax 
on  legacies  of  educational,  charitable,  and  religious 
organizations;  and 

W/iciras,  Such  organizations  and  institutions  are, 
and  should  be,  considered  as  the  most  solid  pillars  of 
our  intellectual  and  moral  culture;  and 

U'/icirds,  The  crippling  of  their  means,  always  in- 
sufficient for  reaching  their  highest  legitimate  aims,  is 
very  great  as  a  result  of  this  tax,  as  they  are  so  largely 
dependent  upon  individual  generosity  and  good  will; 

Be  it  Ri'so/veti,  That  the  Medical  Society  of  the 
County  of  New  York  respectfully  petitions  the  Con- 
gress of  the  United  States  to  repeal  such  parts  of  the 
revenue  law  of  1898  as  enact  a  tax  on  legacies  of  edu- 
cational, charitable,  and  religious  institutions  and  or- 
ganizations. 

Copenhagen  is  reported  to  be  suffering  from  an  epi- 
demic of  what  the  cable  calls  "typhus"  fever,  twenty 
new  cases  having  been  reported  in  one  day  last  week. 
Wiiether  the  disease  is  typhus  abdominalis,  which  we 
call  typhoid,  or  actual  typhus  is  not  stated. 


December  8,  1900] 


MEDICAL    RECORD. 


915 


NEW    YORK   ACADEMY    OF    MEDICINE. 

SECTION     ON     OBSTETRICS    AND    GYN/ECOLOGY. 

Stated  Meeting,  November  22.  igoo. 

J.  Riddle  Goffe,  M.D.,  Chairman. 

The  Abdominal  versus  Vaginal  Hysterectomy  for 
Cancer  of  the  Uterus.  -  Dk.  W.  R.  rkvoR  opened 
the  discussion  on  this  subject,  excluding  a  considera- 
tion of  cancer  of  the  uterine  body  in  connection  with 
his  comparison  of  statistics.  He  said  that  enougii  had 
been  learned  about  this  disease  to  allow  of  the  laying 
down  of  certain  fundamental  principles.  All  opera- 
tions for  uterine  cancer  should  proceed  with  a  due 
regard  to  the  manner  in  which  cancer  spread  and  re- 
curred. Recurrence  after  operation  was  seen  in  the 
perimetric  tissue  in  ninety-si.K  per  cent,  of  the  cases. 
A  successful  operation  must  remove  not  only  the  uterus 
and  adne.xa  but  a  considerable  portion  of  the  vagina 
and  adjacent  glands.  These  glands  were  in  three 
groups,  viz.,  (i)  the  obturator  glands,  (2)  the  glands 
situated  near  the  bifurcation  of  the  common  iliac,  and 
(3)  the  glands  at  the  utero-sacral  folds.  The  removal 
of  the  obturator  glands  was  the  most  important.  Vag- 
inal hysterectomy  was,  therefore,  only  a  partial  and 
incomplete  operation  for  cancer  in  all  but  a  few  cases 
of  cancer  of  the  uterus,  f  he  next  principle  was  that 
the  immediate  mortality  must  not  be  so  high  that  one 
dared  not  depart  from  mere  palliative  measures.  A 
collection  made  abroad  of  thirty-one  hundred  and 
fifty-five  vaginal  operations  gave  a  mortality  of  nine 
per  cent.,  and  he  had  himself  shown  that  the  mortality 
from  the  abdominal  operation  in  America  was  1 1.8  per 
cent.  Abdominal  hystert-ctomy  by  progressive  liga- 
tion was  not  a  proper  operation  for  cancer.  The  next 
fundamental  principle  was  that  in  the  act  of  removal 
all  possibility  of  infecting  the  wound  by  either  cancer 
cells  or  by  the  particularly  septic  contents  of  a  can- 
cerous uterus  must  be  avoided.  This  accident  could 
be  escaped  wh.ther  the  operation  was  done  through 
the  vagina  or  the  abdomen.  The  first  step  in  either 
operation  should  be  a  thorough  curettage  and  a  cau- 
terization, which  disinfected  the  cancerous  mass,  and 
closed,  to  a  certain  extent,  the  mouths  of  the  absorb- 
ents. The  fourth  principle  was  that  in  the  removal 
of  the  cancerous  uterus  as  little  violence  as  possible 
must  be  inflicted  upon  the  growth  and  upon  the  sur- 
rounding structures.  The  preliminary  charring  of  the 
uterus  aided  in  this,  but  it  was  advisable  to  exercise 
preliminary  hasmostasis  in  the  removal  of  the  lymph 
glands.  This  could  not  be  done  in  vaginal  hysterec- 
tomy. He  believed  that  in  cancer  of  the  cervix  the 
sum  total  of  human  life  saved  by  palliative  methods 
was  far  greater  by  vaginal  hysterectomy.  In  all  the 
great  clinics  about  seven  per  cent,  only  of  all  the 
women  coming  with  cancer  of  the  uterus  were  in  the 
operable  stage.  The  speaker  said  that  every  single 
essential  could  be  carried  out  fully  in  the  abdominal 
operation.  The  foregoing  statements  were  given  in 
order  to  show  why  vaginal  hysterectomy  had  failed, 
and  what  was  required  in  an  operation  which  should 
give  satisfaction. 

Dk.  H.J.  BoLDT  continued  the  discussion.  He  said 
it  was  impossible,  in  his  opinion,  to  advocate  either 
operation  in  all  cases.  Personally,  he  thought  that 
only  in  exceptional  instances  should  abdominal  hyster- 
ectomy for  cancer  be  performed  until  we  were  in  pos- 
session of  facts  proving  its  superiority  over  vaginal 
hysterectomy  in  ultimate  results.  Cancer  of  the  uterus 
should  be  divided  into  three  varieties,  viz.,  (i)  cancer 
of  the  infravaginal  portion  of  the  cervix,  (2)  cancer 
of  the  supravaginal  portion  of  the  cervix,  and  (3 )  can- 
cer of  the  uterine  body.  This  division  was  dependent 
upon  the  variations  in  the  extension  of  the  neoplasm 


to  the  neighboring  structures.  We  knew  that  cancer 
beginning  in  the  mucous  membrane  covering  the  vag- 
inal portion  of  the  cervix  had  a  decided  tendency  to 
encroach  upon  the  vaginal  mucosa.  Cancer  of  the 
supravaginal  portion  had  a  tendency  to  extend  upward 
into  the  uterine  body.  Cancer  beginning  in  the  body 
of  the  uterus  not  infrequently  extended  downward.  It 
must  be  conceded  that  the  blood-vessels  were  affected 
only  in  the  late  stages  of  cancer  and  that  metastasis 
seldom  occurred  through  their  medium.  The  lym- 
phatics were  the  usual  means  of  the  extension  of  the 
disease.  Abundant  experience  had  shown  that  the 
glands  were  not  usually  invaded  by  the  disease  until 
late;  even  in  advanced  stage  of  cancer  of  the  uterus 
the  lymphatic  glands  were  not  constantly  invaded  by 
cancerous  elements.  Experience  had  also  shown  that 
recurrence  after  radical  operation  seldom  took  place 
in  the  glands.  Vaginal  hysterectomy  permitted  a 
smaller  opening  of  the  peritoneal  cavity;  it  usually 
took  less  time  to  perform ;  convalescence  was  much 
more  rapid;  the  abdominal  wound,  with  its  occasional 
ill  consequences,  was  avoided,  and  the  direct  mortal- 
ity was  less.  He  had  always  practised  extirpation  of 
the  parametria  as  far  as  possible,  and  exsected  a  large 
portion  of  the  upper  part  of  the  vagina.  The  advan- 
tage of  abdominal  hysterectomy  was  that  it  permitted 
more  extensive  removal  of  the  lymphatics  and  retro- 
peritoneal glands.  He  doubted,  however,  whether  it 
would  give  a  larger  percentage  of  recoveries,  because 
of  the  frequency  with  which  the  lymphatics  were  not 
involved  evtn  in  the  late  stages.  Time  alone  could 
settle  this  question. 

Dr.  J.  E.  Janvkin  opened  the  general  discussion. 
He  said  that  his  own  ideas  concurred  very  strongly 
with  those  expressed  by  Dr.  Boldt.  He  believed  that 
at  first  all  cancerous  disease  was  local,  and  was  gener- 
ally the  result  of  some  injury.  This  was  particularly 
true  of  cancer  of  the  cervix,  and  hence,  in  cases  com- 
ing early,  before  there  was  any  extension  of  the  dis- 
ease into  the  lymphatic  glands  and  into  the  parametria, 
the  proper  course  to  pursue,  in  his  opinion,  was  to 
perform  vaginal  hysterectomy.  These  cases  were  seen 
now  quite  frequently,  probably  because  the  profession 
at  large  diagnosticated  uterine  cancer  at  an  earlier 
stage  than  formerly.  His  own  successes  thus  far, 
counting  cases  dating  back  eighteen  years,  comprised 
fully  one-third  permanent  recoveries.  They  were 
early  cases,  and  hence,  in  a  certain  sense,  might  be 
said  to  have  been  selected  cases.  If  the  disease  had 
extended  some  distance  down  the  vaginal  wall  this 
made  no  difference,  because  it  was  very  easy  to  extir- 
pate a  considerable  portion  of  the  vagina.  If  exam- 
ination showed  pretty  extensive  disease,  the  uterus 
being  large  and  fixed,  and  there  was  reason  for  believ- 
ing that  the  patient  was  suffering  from  the  cancerous 
cachexia,  he  always  felt  that  the  operation,  however 
performed,  was  purely  palliative,  and  that  each  sur- 
geon must  exercise  his  individual  judgment  as  to 
which  method  would  give  the  greater  relief.  He 
was  of  the  opinion  that  it  was  better  to  operate  in 
such  cases  because  the  pelvis  was  closed  in  from  be- 
low, and  the  vagina  from  above,  and  the  recurrence  of 
the  disease  did  not  bring  with  it  the  offensive  dis- 
charge and  the  hemorrhages  which  occurred  if  the 
uterus  was  simply  curetted  and  left. 

Dr.  William  AI.  Polk  said  that  his  own  experience 
in  this  field  had  been  so  ghastly  that  he  doubted  if  he 
could  add  much  of  material  value  to  this  discussion. 
Of  all  the  cases  of  cancer  of  the  uterus  upon  which  he 
had  operated  he  had  cured,  he  believed,  only  one,  and 
all  patients  had  died  from  the  recurrence  of  the  dis- 
ease. He  was  of  the  opinion  that  all  of  the  opera- 
tions hitherto  offered  for  cancer  of  the  uterus  were  of 
but  little  value,  being  nothing  more  than  an  effort  to 
make  the  patient's  condition  somewhat  more  tolerable. 


9i6 


MEDICAL    RECORD. 


[December  8,  1900 


He  had  searched  for  some  more  extensive  and  more 
radical  method  of  operating  in  cancer  of  the  uterus, 
but  even  the  more  recent  extensive  operations  had  not 
seemed  to  him  to  hold  out  much  encouragement.  He 
preferred  the  more  open  field  of  the  abdominal  route, 
because  he  had  not  been  able  to  do  a  sufficiently  ex- 
tensive operation  through  the  vagina,  though  well 
knowing  tiie  seriousness  of  the  abdominal  operation. 

Dr.  W.  Gill  Wvlie  said  that  his  experience  had 
been  that  in  young  women  the  disease  was  easily  rec- 
ognized, but  was  rapid  in  progress  and  difficult  of 
control.  In  older  women  the  onset  was  more  insidi- 
ous, but  the  disease  spread  less  rapidly  than  in  younger 
subjects,  and  was  more  amenable  to  operation.  If 
such  cases  came  to  the  surgeon  before  they  had  been 
disturbed  by  active  treatment,  it  was  possible  to  attain 
a  considerable  degree  of  success.  It  seemed  to  him 
very  reprehensible  to  take  away  a  piece  of  tissue  for 
examination,  and  then  allow  an  interval  of  two  or  three 
weeks  to  elapse  before  doing  a  radical  operation.  He 
could  count  amotig  his  successes  patients  who  had 
been  operated  upon  from  sixteen  to  twenty-five  years 
ago  and  were  still  alive.  In  his  first  sixty  or  seventy 
cases  he  had,  in  almost  every  instance,  operated 
through  the  vagina,  at  first  with  the  ligature,  and  later 
with  the  forceps.  The  condition  of  the  lymphatics 
and  surrounding  tissues  had  more  to  do  with  a  suc- 
cessful result  than  the  particular  method  of  operating. 
When  he  had  been  able  to  feel  lymphatic  glands  in 
the  broad  ligaments  he  had  rarely,  if  ever,  secured  a 
good  ultimate  result,  no  matter  how  extensive  the 
operation  or  the  method  selected.  He  firmly  believed 
that  the  only  method  of  treatment  was  by  some  opera- 
tion designed  thoroughly  to  remove  the  disease.  It 
had  seemed  to  him  at  times  that  the  occurrence  of 
suppuration  had  insured  against  a  recurrence  of  the 
cancer. 

Dr.  Ramsay,  professor  of  gynaecology  at  Yale,  was 
invited  to  take  part  in  the  discussion.  He  expressed 
his  belief  that  it  was  a  mistake  for  one  to  adhere  to 
any  one  operation  in  all  cases  of  cancer  of  the  uterus. 
In  the  greater  number  of  cases  he  was  of  the  opinion 
that  the  suprapubic  method  was  the  preferable  one, 
though  the  combined  operation  might  perhaps  be 
found  in  the  future  to  be  still  more  generally  useful. 
Up  to  the  present  time  enough  cases  had  not  been 
treated  by  the  combined  method  to  enable  one  to  de- 
cide this  point.  It  had  been  discovered  lately  that 
enlargement  of  tiie  lymphatic  glands  did  not  necessar- 
ily mean  that  cancer  had  invaded  them;  the  increase 
in  size  was  sometimes  the  result  of  mere  hyperplasia 
of  the  glandular  tissue. 

Dr.  a.  Palmer  Dudley  said  that  the  field  under 
discussion  was  the  only  one  in  gynecology  in  which 
he  would  recommend  a  single  operation  for  all  cases, 
and  that  operation  was  the  combined  one.  No  two 
cases  of  cancer  of  the  uterus  were  exactly  alike,  but 
the  object  in  eacli  instance  was  to  remove  the  disease 
as  thoroughly  as  possible.  By  either  the  abdominal 
or  the  vaginal  route  one  was  apt  to  leave  some  of  the 
disease.  There  was  no  more  shock  from  the  combined 
operation  than  from  the  suprapubic  operation  alone. 
In  addition  to  this  method  of  operating  he  had  derived 
aid  from  the  hypodermic  injection  of  an  alkaloid,  but 
he  was  not  in  a  position  at  the  present  time  to  go  fur- 
ther into  the  details  of  this  mode  of  treatment. 

Dr.  VV.  Evelyn  Porter  said  that  at  first  he  had 
been  a  very  strong  advocate  of  the  vaginal  route,  but 
had  subsequently  come  to  look  upon  the  combined 
method  as  the  best  of  all.  He  believed  when  there 
was  extensive  glandular  involvement  no  operation 
would  effect  a  cure.  However,  when  there  was  exten- 
sive involvement  of  the  vagina  and  any  operation 
must  be  merely  palliative,  he  would  select  the  vaginal 
route. 


Dr.  I'rvor  said  that  his  reason  for  selecting  the 
abdominal  loute  was  that  it  enabled  one  to  make  the 
dissection  of  cancer  in  healthy  tissue,  and  after  all  the 
blood  supply  had  been  cut  off.  He  personally  pre- 
ferred to  ligate  the  internal  iliac  arteries  and  also  the 
obturator  artery.  The  object  of  this  preliminary 
hamostasis  was  not  so  much  to  secure  a  dry  field  as 
to  enable  the  operator  to  reach  glands  which  were 
practically  inaccessible  if  this  procedure  were  omitted. 
Vaginal  hysterectomy  seemed  to  him  an  illogical 
method  of  dealing  with  cancer  of  the  uterus. 

Dr.  Boldt,  in  closing  the  discussion,  said  that  as 
he  understood  it  Dr.  Pryor  refused  to  wait  for  the  ulti- 
mate results  from  vaginal  hysterectomy.  All  were 
agreed  that  the  glands  were  involved  late  in  the  dis- 
ease, and  he  could  see  no  reason  for  operating  at  all 
if  these  glands  were  extensively  implicated,  because 
the  patient  would  surely  die.  All  must  recognize  that 
the  results  of  operation  in  cancer  of  the  uterus  were, 
on  the  whole,  quite  poor,  and  few  surgeons,  he  thought, 
would  be  willing  to  claim  the  exceptionally  good  re- 
sults that  had  been  mentioned  in  this  discussion.  In 
cases  of  supravaginal  cancer  occurring  in  young 
women  he  would  expect  a  larger  proportion  of  good 
ultimate  results  from  the  abdominal  operation  ;  but,  on 
the  other  hand,  if  the  patients  were  more  advanced  in 
years  he  would  look  for  better  results  from  the  vaginal 
operation. 

.SECTION   ON    MEDICINE. 

Stated  Meetmg,  November  20,  igoo. 

John  H.  Huddleston,  M.D.,  Chairman. 

The  Early  Recognition  of   Typhoid  Fever. — Dr.  J. 

K.  Crook  presented  this  paper.  He  said  that  there 
were  some  cases  labelled  typhoid  fever  which  showed 
none  of  the  symptoms  of  typhoid  except  a  moderate 
and  atypical  range  of  temperature,  with  loss  of  appe- 
tite and  strength.  Not  infrequently  the  patient  with 
typhoid  fever  in  the  early  stage  called  at  the  physi- 
cian's office  complaining  of  troublesome  headache, 
chilly  sensations,  and  aching  in  the  muscles.  The 
tongue  was  usually  dry,  the  pulse  somewhat  raised, 
and  its  frequency  easily  increased  on  slight  excite- 
ment or  exertion.  Even  at  this  early  period  there 
would  usually  be  found  in  the  afternoon  a  rise  of 
temperature  of  one  or  two  degrees.  Gurgling  in  the 
right  iliac  fossa  possessed  no  diagnostic  significance 
in  typhoid  fever,  because  it  was  often  present  in  cases 
of  ordinary  diarrhoea  or  even  in  perfect  health.  There 
was  nothing  about  these  symptoms  to  warrant  a  diag- 
nosis of  typhoid  fever,  but  enough  were  present  to  put 
the  physician  on  his  guard,  and  he  should  insist  upon 
seeing  the  patient  twice  daily  for  two  or  three  days,  or 
if  this  were  impracticable,  should  instruct  him  in  the 
use  of  the  clinical  thermometer.  After  a  day  or  two 
the  syn)ptoms  first  observed  would  be  more  marked, 
and  the  prostration  and  dull  expression  of  the  face 
would  be  more  noticeable.  Perhaps  at  this  time  it 
would  be  possible  to  detect  on  careful  percussion  an 
enlargement  of  the  spleen.  If  malaria  was  suspected, 
an  examination  of  the  blood  or  the  result  of  the  ad- 
ministration of  full  doses  of  quinine  would  clear  up 
this  aspect  of  the  case.  By  the  end  of  the  first  week 
there  would  be  so  much  prostration  that  the  patient 
would  be  perfectly  willing  to  remain  in  bed,  and  most 
likely  the  pulse  would  be  soft,  rapid,  and  perhaps 
dicrotic.  The  temperature  would  possibly  reach  a 
maximum  of  104°  or  ids'"  F.  If  carefully  sought  for, 
the  speaker  said,  he  believed  the  presence  of  a  typhoid 
eruption  would  be  found  in  a  larger  proportion  of  cases 
than  was  usually  stated.  Two  or  three  spots  were  as 
diagnostic  as  two  or  three  dozen,  though,  of  course, 
not  so  easily  detected.     As  early  as  the  seventh   or 


I 


December  8,  1900] 


MEDICAL    RECORD. 


917 


eighth  day  the  diazo  reaction  of  Ehrlich  was  obtaina- 
ble in  the  urine.  It  was  a  sign  of  much  negative 
value,  but  it  should  be  remembered  that  it  occurred  in 
many  other  conditions,  notably  in  measles  and  acute 
tuberculosis.  In  his  experience  this  sign  had  never 
failed.  If  an  e.xaminatioii  of  the  blood  showed  the 
VVidal  reaction,  the  dia^iosis  was  positively  estab- 
lished. 

The  Treatment  of  Typhoid  Fever  at  the  New 
York  Hospital. — Dk.  Frkderick  L.  Keavs  presented 
this  papiT  (See  page  851  |. 

Practical  Home  Methods  of  Bathing  in  Typhoid 
Fever.  —  Uk.  S.  JS.vklch  discussed  this  phase  of  the 
subject.  He  said  that  the  first  impression  of  cold 
upon  the  skin  was  the  so-called  shock;  it  was  really  a 
physiological  irritant.  The  impression  lasted  a  longer 
or  shorter  time,  depending  upon  the  method  of  pro- 
cedure and  its  duration.  The  friction  stimulated  the 
contracted  arterioles  to  dilate  again,  and  performed 
the  important  normal  function  of  propelling  the  blood, 
tlius  keeping  up  a  proper  peripheral  circulation.  The 
latter  was  usually  so  crippled  in  typhoid  fever  that  the 
heart  was  compelled  to  beat  faster  and  more  forcibly. 
By  the  proper  use  of  cold  water  the  pulse  diminished 
in  frequency  and  gained  in  force.  The  skin  assumed 
a  rosy  liue  because  its  arterioles  had  been  dilated  in  a 
tonic  fashion.  The  countenance  lost  its  apathy,  the 
respirations  were  deepened,  and  the  kidneys  were 
aroused  to  renewed  activity.  Friction  should  always 
accompany  the  cold-water  treatment  —  a  fact  which 
even  at  this  late  day  needed  reiteration  and  emphasis. 
As  an  illustration  of  how  the  cold-water  treatment 
should  not  be  applied  in  typhoid  fever  the  speaker 
mentioned  the  abdominal  ice  coil,  still  so  popular 
with  many  physicians.  Tiiis  was  a  direct  violation 
of  the  fundamental  principle  of  all  hydrotherapy,  that 
cold  applications  must  be  accompanied  by  frictions. 
In  home  practice  the  ablution  was  the  simplest  pro- 
cedure. The  patient  was  stripped,  a  blanket  placed 
underneath  him,  and  first  the  back,  and  then  the  anterior 
surface  of  the  body  treated  to  the  ablution.  It  should 
be  given  with  considerable  friction,  the  temperature  of 
the  water  being  reduced  from  time  to  time  until  the 
temperature  reached  Oo"  F.  The  abdominal  compress 
was  another  useful  method  of  applying  cold  water. 
This  consisted  of  three  folds  of  towelling  wrung  out  of 
water  at  a  temperature  of  70^  and  applied  snugly, 
being  covered  with  thin  flannel.  It  should  be  renewed 
hourly.  When  the  temperature  persisted  in  remaining 
at  103°  or  above,  the  towel  bath  was  appropriate.  A 
towel  was  dipped  into  water  at  85'^  F.  and  laid  drip- 
ping and  smooth  over  the  entire  back.  Water  at  70° 
was  dipped  up  with  a  cup  and  poured  on  the  upper 
left  part  of  the  back,  and  then  this  part  was  rubbed 
with  the  hand.  This  was  done  three  times,  and  then 
the  other  parts  of  the  back  were  successively  treated 
in  tlie  same  way.  The  water  on  the  sheet  was  mopped 
up  with  a  sponge,  and  then  the  anterior  parts  were 
similarly  treated,  care  being  taken  not  to  use  pressure 
over  the  iliac  region.  The  temperature  might  be  re- 
duced five  degrees  each  time  until  the  temperature  of 
the  water  for  the  towel  reached  60  and  that  in  the 
cup  reached  50  .  The  '"  sheet  bath  "  was  still  more 
potent,  and  was  very  useful  when  objection  was  made 
to  the  full  bath,  or  the  latter  was  impracticable.  An 
old  linen  sheet  or  tablecloth  should  be  dipped  in  water 
at  90°,  and  wrung  out  very  lightly.  The  patient  hav- 
ing been  wrapped  in  this,  water  at  temperature  of  about 
ten  degrees  lower  should  be  poured  successively  upon 
different  parts  of  the  body,  and  each  part  rubbed  with 
the  hands  until  it  no  longer  warmed  up.  The  typhoid- 
fever  patient  should  be  given  internally  from  four  to 
six  ounces  of  water  at  40'  every  two  hours,  and  this 
should  be  alternated  with  the  same  quantity  of  milk. 

Giaourdi ;    a  Sterilized   Fermented   Milk   Prepa- 


ration Used  in  Greece.  — Dr.  .Achilles  Rose  read  a 
paper  on  this  article  of  diet,  which,  he  said,  was  of 
decided  value  in  cases  of  typhoid  fever  and  gastric 
ulcer.  Milk  was  boiled  for  an  hour  under  constant 
stirring  until  it  became  of  a  certain  thickness,  and 
then  the  ferment  was  added.  This  ferment  was  made 
by  the  Greeks  as  follows:  A  dry  fig  was  soaked  over 
night  in  ;  xxv.  of  water,  and  the  next  morning  a  few 
drops  of  lemon  juice  were  added  and  a  slight  trace  of 
rennet.  The  result  was  a  smooth,  semi-solid,  easily 
digestible  milk  food.  In  the  months  of  .August  and 
September  giaourdi  was  not  made  in  Greece.  After 
the  ferment  had  been  added  to  the  milk  the  tempera- 
ture of  the  product  must  be  reduced  to  45°  Celsius. 
The  speaker  said  that  he  had  given  this  food  in  cases 
of  gastric  ulcer,  and  the  patients  had  enjoyed  it  very 
much.  In  one  case  in  which  there  was  commencing 
stenosis  of  the  pylorus,  kumyss  and  matzoon  had  been 
tried,  but  giaourdi  had  been  preferred  by  the  patient. 

Dr.  E.  QiiNTAKD  said  that  he  had  used  giaourdi  in 
fifteen  cases,  and  had  found  it  exceedingly  useful.  He 
had  used  it  in  cases  of  neurasthenia  in  which  even 
kumyss  and  milk  seemed  to  distend  the  stomacli.  It 
was  in  these  cases  that  giaourdi  seemed  to  act  espe- 
cially well.  He  had  also  tried  it  with  satisfaction  in 
a  case  of  pyloric  stenosis.  The  great  value  of  this 
article  of  diet  was  best  shown  by  the  fact  that  it  liad 
seemed  to  be  superior  to  even  those  most  excellent 
foods,  kumyss  and  matzoon. 

Dr.  Helen  E.  ("oRRELL-LoEWEXsrEiN  said  that  she 
had  e.\amined  this  food  for  alcoholic  fermentation,  but 
had  not  found  it  present.  She  had  tried  various  ex- 
periments with  it,  and  had  come  to  the  conclusion  thai 
there  must  be  some  special  ferment  in  the  fig.  She 
recalled  that  once  while  travelling  in  Switzerland  a 
farmer  had  told  her  that  he  had  a  secret  in  the  manu- 
facture of  cheese.  Inquiry  had  shown  that  this  secret 
consisted  in  using,  in  addition  to  rennet,  a  watery 
solution  of  fig.  The  speaker  said  that  she  had  cur- 
dled some  milk  with  fig,  and  had  found  that  it  pro- 
duced a  very  smooth,  soft  curd. 

Dr.  Max  Eixhorn  said  that  the  well-known  farm- 
er's food,  called  "bonny-clabber.''  prepared  from  cur- 
dled or  sour  milk,  was  very  much  like  giaourdi  except 
that  the  latter  tasted  a  little  sweeter.  It  was  an  admir- 
able food,  and  for  its  preparation  only  required  that 
the  milk  be  placed  in  a  jar  and  allowed  to  stand  for 
three  or  four  days.  This  curdled  milk  was  found  to 
keep  well  for  a  long  time.  It  was  used  by  the  i)eas- 
ants  of  Russia  for  the  manufacture  of  cheese. 

Dr.  Rose  said  that  giaourdi  was  very  different  from 
ordinary  bonny-clabber  or  sour  milk.  The  latter  con- 
tained a  great  deal  of  lactic  acid,  which  would  not  be 
tolerated  by  some  sensitive  persons,  though  they  could 
retain  giaourdi. 

Gastro-Intestinal  Diseases  at  the  Paris  Congress. 
—  Dr.  Jamks  J.   Walsh  read  this  paper. 

Gastric  Ulcer. —  He  said  that  gastric  ulcer  became 
a  formidable  complication  in  many  infectious  dis- 
orders. Ulcers  having  the  characteristics  of  gastric 
ulcers  occurred  only  in  those  parts  of  the  digestive 
tract  where  there  was  free  acid.  Ulcerative  lesions 
below  the  pancreatic  duct  occurred  very  rarely,  and 
were  of  a  superficial  character,  quite  different  from  the 
deep  erosion  which  characterized  the  gastric  and  duo- 
denal ulcer.  Gastric  ulcers,  therefore,  were  probably 
due  to  self-digestion,  though  the  cause  of  this  self- 
digestion  was  yet  in  dispute.  It  was  worthy  of  note, 
in  this  connection,  that  those  predisposed  to  gastric 
ulcer  were  just  the  ones  in  whom  there  was  apt  to  be 
a  gastric  hyperacidity.  Acute  gastric  ulcer  seemed  to 
be  a  pathological  entity.  The  affection  occurred  most 
commonly  in  young  women  leading  a  sedentary  life. 
Its  presence  was  often  announced  by  the  occurrence 
of  hemorrhage.     In  a  certain  number  of  cases  of  acute 


9i8 


MEDICAL    RECORD. 


December  8,  1900 


gastric  ulcer  pure  cultures  of  the  pneumococcus  had 
been  found,  although  pneumonia  had  not  been  present. 
Another  form  of  gastric  ulcer  occurred  in  connection 
with  appendicitis.  In  France  it  had  been  described 
under  the  title  of  "appendicitis  with  black  vomit." 
It  was  surprising  that  in  the  face  of  such  extensive 
literature  on  appendicitis  in  this  country  no  mention 
should  have  been  made  of  this  association  of  appen- 
dicitis and  acute  gastric  ulcer.  Patients  who  were 
anaemic  or  who  were  suffering  from  infectious  dis- 
orders should  be  given  remedies  tending  to  reduce  the 
gastric  hyperacidity,  and  these  persons  should  be 
warned  against  swallowing  coarse  food,  or  food  before 
it  had  been  thoroughly  masticated.  Gastric  crises, 
the  speaker  said,  were  now  known  to  occur  in  many 
other  affections  than  locomotor  ataxia.  A  striking 
feature  of  the  discussion  on  gastric  ulcer  at  the  Paris 
congress  was  the  general  trend  of  opinion  in  favor  of 
surgical  intervention.  Old  ulcers  and  their  scars  were 
especially  liable  to  be  the  seat  of  carcinoma,  and  this 
constituted  one  reason  for  advocating  operation. 

Olive  Oil  in  Painful  Affections  of  the  Stomach. 
— A  number  of  German  observers  had  called  attention 
to  the  value  of  olive  oil  in  certain  painful  afYections  of 
the  stomach.  From  three  to  ten  ounces  of  the  oil  were 
given  in  the  twenty-four  hours.  It  had  been  found 
especially  useful  in  cases  of  gastric  ulcer.  It  had 
been  stated  at  the  congress  by  one  speaker  that  mor- 
phine was  contraindicated  because  it  was  excreted 
largely  through  the  stomach,  and  this  led  to  an  in- 
crease of  the  gastric  acidity.  However,  atropine  could 
be  used  with  benefit. 

Muco-Membranous  Colitis. — This  disease  seemed 
to  have  become  much  more  frequent  in  recent  years, 
probably  because  of  the  keen  competition  in  all  walks 
of  life.  Another  alleged  cause  was  the  greater  preva- 
lence of  the  habit  of  taking  irritating  laxatives.  The 
disease  was  chiefly  seen  in  nervous,  high-strung  indi- 
viduals. The  nervous  element  seemed  to  be  the  most 
important  factor  in  its  etiology.  When  the  disease 
occurred  in  young  men  it  was  almost  always  in  con- 
nection with  sexual  neurasthenia.  From  the  fact  that 
appendicitis  was  scarcely  ever  associated  with  muco- 
membranous  colitis  it  had  been  argued  that  the  latter 
was  not  truly  an  inflammation — it  was  more  probably 
a  nervous  disorder.  The  symptomatology  consisted  in 
the  presence  of  glairy  mucus  in  the  stools,  usually 
preceded  by  constipation  and  followed  by  pain.  As 
soon  as  the  neurotic  symptoms  subsided  the  mucous 
colitis  rapidly  improved,  and  ultimately  disappeared. 
The  treatment  should  be  directed  toward  the  underly- 
ing neurotic  conditions. 

Prognosis  in  Gastric  Ulcer  Good  without  Opera- 
tion.—  Dr.  Eixhorn  said  that  he  certainly  believed 
that  the  gastric  juice  played  a  prominent  part  in  the 
formation  of  gastric  ulcers,  but  it  was  not  the  only 
factor.  Cases  had  been  reported  of  absence  of  the 
gastric  juice,  and  yet  at  operation  gastric  ulcers  had 
been  accidentally  discovered.  He  had  seen  one  such 
case  himself.  Dieulafoy  had  spoken  about  infectious 
diseases  in  which  there  w'ere  almost  imperceptible 
erosions  of  the  stomach,  and  yet  they  had  been  suffi- 
cient to  cause  serious  hemorrhage.  Dr.  Kinhorn  said 
that  he  could  not  agree  with  Dieulafoy  that  severe 
hemorrhage  originated  in  such  insignificant  erosions, 
and  said  that  the  hemorrhages  and  even  the  deaths 
which  Dieulafoy  attributed  to  these  erosions  were 
really,  in  his  opinion,  caused  by  the  concomitant  in- 
fectious disorder.  His  opinion  was  that  seventy-five 
per  cent,  of  cases  of  severe  gastric  hemorrhage  ended 
in  recovery  without  operation,  even  when  the  condi- 
tion appeared  to  be  exceedingly  grave.  The  risk  from 
the  operation  was  usually  just  as  great  as  the  danger 
from  the  disease,  and  hence  it  was  an  exceedingly 
difucult  matter  to  decide  as  to  whether  or  not  an  oper- 


ation should  be  undertaken.  As  a  rule,  he  did  not 
think  the  mere  occurrence  of  a  hemorrhage  from  the 
stomach,  even  though  a  severe  one,  justified  one  in 
operating.  Even  when  there  was  beginning  stenosis 
of  the  pylorus  he  was  in  favor  of  not  operating  until 
it  became  evident  that  enough  nutriment  could  not  be 
introduced  to  sustain  life.  He  had  taken  this  posi- 
tion because  twenty-five  per  cent,  of  his  patients  with 
benign  stenosis  of  the  pylorus  who  had  been  operated 
upon  had  succumbed.  Regarding  mucous  colitis,  he 
expressed  the  opinion  that  it  was  a  purely  neurotic 
disorder.  The  diagnosis  of  membranous  enteritis 
rested  upon  the  finding  of  small  pieces  of  mucus  in 
the  stools.     It  was  not  really  an  enteritis. 

Dr.  F.  F.  Ward  said  that  he  had  often  wondered 
if  gastric  ulcer  might  not  itself  be  the  cause  of  hyper- 
secretion, its  presence  giving  rise  to  irritation  and,  in 
this  way,  to  increased  secretion  of  gastric  juice.  He 
had  not  been  able  to  bring  himself  to  believe  that  the 
hyperacidity  was  the  cause  of  the  ulcer.  Reference 
was  made  to  a  case  which  had  given  all  the  typical 
symptoms  of  ulcer.  It  had  proved  very  obstinate  to 
treatment,  and  as  the  man's  health  was  steadily  failing 
an  operation  had  been  undertaken.  Gastro-enteros- 
tomy  had  been  performed,  and  recovery  had  been  un- 
eventful. At  the  operation  a  tumor  had  been  felt 
under  the  liver.  Six  weeks  later  the  abdomen  had 
been  opened  again  with  the  intention  of  removing  this 
tumor,  but  then  none  could  be  found.  It  was  sup- 
posed that  the  tumor  felt  at  the  first  operation  had 
been  produced  by  contraction  at  the  pylorus.  For 
eight  months  after  the  operation  the  man  had  done 
exceedingly  well;  then  an  examination  had  shown  an 
almost  complete  absence  of  gastric  juice.  About  one 
year  after  the  operation  the  man  had  been  seized  in 
the  night  with  severe  abdominal  pain.  A  diagnosis 
of  perforation  had  been  made,  but  death  had  occurred 
before  an  operation  could  be  done.  At  the  autopsy, 
the  stomach  had  been  found  adherent  to  the  abdomi- 
nal wall,  and  there  was  a  perforation  through  the 
stomach  at  that  point,  where  there  was  also  quite  a 
large  malignant  growth.  Hemorrhages  from  the  stom- 
ach sometimes  arose  from  anamic  conditions.  A  case 
illustrating  this  point  was  quoted,  in  which  at  autopsy 
no  ulcer  of  the  stomach  or  of  the  duodenum  could  be 
found.  He  agreed  with  Dr.  Finhorn  that  in  most 
cases  of  gastric  hemorrhage  medical  treatment  should 
be  preferred  to  surgical  measures. 

Dr.  Quintard  said  that  the  exulceration  of  Dieula- 
foy was  so  minute  that  it  required  examination  with  a 
magnifying-glass  to  detect  it.  The  severe  hemorrhage 
reported  as  having  come  from  such  a  minute  ulcera- 
tion had  been  explained  by  supposing  that  the  ulcera- 
tion had  involved  a  capillary  only  to  such  an  extent  as 
to  hold  the  rent  in  it  open,  and  so  allow  of  the  pro- 
fuse bleeding. 

Diseases  of  the  Mastoid  Process — Dr.  G.  H.  Cox, 
in  the  Alaritime  Medical  News,  October,  states  that 
there  are  two  signs  which  are  characteristic  of  mastoid 
involvement  and  which,  when  present,  are  diagnos- 
tic. They  are:  (1)  Tenderness  upon  pressure  and 
percussion  over  the  antrum  or  tip  of  the  mastoid. 
Taking  care  not  to  move  the  auricle  or  meatus,  we 
press  firmly  with  the  thumb  over  the  regions  men- 
tioned, comparing  the  effects  with  those  of  similar 
pressure  on  the  opposite  healthy  process.  (2)  The 
second  sign,  namely,  a  bulging  or  sagging  of  the  pos- 
tero-superior  wall  of  the  meatus  at  its  innermost  ex- 
tremity, is  the  most  characteristic  sign  of  the  disease. 
It  is  boggy  and  tender  to  the  touch,  and  may  be  con- 
sidered absolutely  indicative  of  pus  in  the  mastoid. 
A  third  sign  of  value  frequently  found  in  these  cases 
is  a  bulging  of  the  postero-superior  quadrant  of  the 
membrana  tympani. 


December  8,  1900] 


MEDICAL    RECORD. 


919 


^cdical  Items. 

Contagious   Diseases — Weekly   Statement Report 

of  cases  and  deaths  from  contagious  diseases  reported 
to  the  Sanitary  Bureau,  Health  Department,  for  the 
week  ending  December  i,  1900: 


Cases. 


Tuberculosis 221 

Typhoid  fever no 

Scarlet  fever 117 

Measles 95 

Diphtheria 244 

Laryngeal  diphtheria  (croup) 14 

Cerebro-spinal  meningitis o 

Varicella 26 

Smallpox    34 


Deaths. 


137 
21 


41 

II 

I 

o 

o 


The  Cost  of  Running  a  Big  Hospital  in  London. 

— "Always  crying  out  for  money?  "  said  a  gentleman 
connected  with  the  administrative  department  of  a 
great  hospital,  echoing  tiie  chiding  remark  made  to 
him  by  the  writer.  "Of  course  we  are  always  crying 
for  money,  more  money,  and  simply  because  there  is 
always  a  crying  need  of  money  in  an  establishment 
like  this.  ,  I  am  often  surprised  at  the  lamentable 
ignorance  people  evince  upon  the  subject  of  hospital 
finances;  not  one  person  in  a  hundred  seems  to  have 
the  remotest  idea  what  it  costs  to  run  a  big  institution 
like  this.  I  heard  a  city  man  tell  another  a  few  days 
ago  that  this  hospital  had  an  income  of  nearly  ^20,- 
000  [$ioo,ooo|.  He  seemed  astonished  at  the  large- 
ness of  the  sum.  As  a  matter  of  fact,  the  income  of 
this  hospital  is  more  than  twice  that  amount,  and  yet 
it  always  has  a  deficiency  on  the  balance  sheet,  and 
a  precious  heavy  deficiency  to  boot.  In  round  figures 
this  institution  costs  between  ;^7o,ooo  [$350,000]  and 
;^8o,ooo  [S400.000]  to  run.  There  are  a  hundred  and 
one  expenses  which  a  stranger  would  never  expect. 
You  will  hardly  credit  it.  but  we  pay  over  ;£"i,ooo 
[$5,000]  a  year  for  milk  alone,  while  eggs  cost  us  from 
;£"3oo  [§1,500]  to  ;{^40o  [S2,oooJ  a  year.  Our  meat 
bill  runs  between  ;^i,5oo  [$7,500]  and  ;^2,ooo  [$io,- 
000],  and  that  is  quite  exclusive  of  poultry  and  fish, 
which  cost  an  additional  ^"800  [$4,000].  A  mere 
item  like  butter  and  cheese  runs  away  with  over  ;£^7oo 
[$3,500]  a  year;  vegetables  and  flour  taking  about 
^600  [$3,000]  or  /"700  [$3,500].  It  may  seem 
strange  to  you  that  while  milk  costs  us  such  a  large 
sum  alcoholic  liquors  rarely  cost  more  than  ,^"250 
[$1,250]  in  the  course  of  twelve  months.  That  prac- 
tically exhausts  the  list  of  provisions,  though  you  must 
understand  the  items  I  have  mentioned  are  those 
things  consumed  by  the  patients;  the  boarding  of  the 
staff  of  medical  officers  and  nurses  is  treated  as  a  sep- 
arate account,  and  adds  an  extra  ;£^3,ooo  [$15,000] 
or  ^4,000  [$20,000]  to  the  total  bill  for  provisions, 
which  usually  exceeds  ^10,000  [$50,000]  per  annum. 
Drugs,  disinfectants,  and  chemicals  usually  cost  us 
about  ^2,500  [$12,500].  while  dressings  and  instru- 
ments swallow  up  approximately  ^^3,000  [§15,000]. 
Altogether  the  dispensing  and  surgery  departments, 
exclusive  of  salaries,  involve  an  expenditure  of  about 
;^6,ooo  [§30,000 1.  I  mentioned  salaries,  which  is 
always  a  heavy  item;  ;^i 0,000  [$50,000]  would  not 
cover  it.  The  nurses  get  some  ^4,500  [§22,500]  di- 
vided between  them  during  the  twelve  months;  the 
dispensers  between  ^?goo  [§4,500]  and  ;^i.ooo  [§5,- 
ooo|,  and  the  medical  staff  _j£'2,ooo  [$10,000].  An 
additional  ^3,000  [§15,000]  is  required  to  pay  other 
salaries  which  I  cannot  classify.  Of  course  you  \vill 
understand  that  I  am  giving  you  round  figures,  and  that 
when  I  say  simply  ordinary  repairs  made  on  the  prem- 
ises cost  about  ;^5,ooo  [$25,000]  you  must  take  it  that 


I  do  not  guarantee  to  be  within  a  couple  of  pounds  of 
the  exact  sum — but  I  may  be,  as  I  am  in  other  figures, 
under-  or  over-estimating  by  ;^5o  [$250]  or  ;^6o 
[§300].  Lighting  and  heating  are  costly,  and  the 
/■3000  [$15,000]  which  it  usually  entails  will  proba- 
bly be  greatly  exceeded  this  year  owing  to  the  increase 
in  the  price  of  coal.  Our  laundress  receives  ^"1,700 
(§8,500]  from  us,  and  the  tax  collector  ^{^2,500  [$12,- 
500];  ^800  [$4,000]  goes  in  printing,  stationery,  and 
stamps.  But  though  I  have  not  been  more  than  half 
through  the  list  of  expenses,  I  think  1  have  said  enough 
to  show  you  what  an  enormous  amount  of  money  is 
required  to  keep  a  hospital  going  for  twelve  months. 
Let  me  just  say  this:  The  eighteen  largest  items  on 
the  expenditure  side  of  our  balance  sheet  for  last  year 
amounted  to  the  very  respectable  total  of  /,'68,5oo 
[$342,500].  Think  of  that — write  it  down  on  a  piece 
of  paper,  and  you  will  not  complain  that  hospitals  are 
'always  crying  for  money,'  without  the  best  reasons." 
—  Tit-Bits. 

Medical    Men    and    the    Morphine    Habit.— The 

London   Lancet^  October  27th,  has  an   article  on  this 
much-vexed  question,  taking  as  its  text  an   article  on 
morphinism  among  physicians  which  appeared   in  the 
Medical  Tunperaiice  Ri;vie7i>  for  October.      It  may  per- 
haps be  remembered  by  our  readers  that  Dr.  Crothers, 
of  Hartford,  Conn.,  about  a  year  ago  gave  some  sta- 
tistics, as  well  as  delivered  himself  of  some  very  de- 
cided  opinions   bearing  on   this   matter,  which   gave 
rise  to  somewhat  heated  discussions,  and  which  were 
commented  upon  editorially  in  the  Mkdicai,  Record. 
riie  Medical  Temperance  Kerie'iv  would   seem   to  hold 
almost  similar  views  upon  the  morphine  habit  as  does 
Dr.  Crothers,  but  the  writer  in  The  Lancet  is  by  no 
means  in  agreement  with  them  and  says:    "  If  we  are 
to  credit  the  writer  >the  habit  of  taking  opium   and 
allied  drugs  is  more  or  less  prevalent  among  six  to 
ten   per  cent,  of  medical   men.     The   statement   is  a 
vague  one  and  no  precise  data  are  advanced    in  sup- 
port of  it,  though  the  reader  is  referred  to  a  former  re- 
port dealing  with  the  subject.     It  would  be  better  for 
all   purposes  if  a  paper  of  this  kind,  which   contains 
only  the  most  general   assertions,  were   elucidated  by 
verified  details;    lacking  these  its  value  cannot  be  es- 
timated or  even  recognized.      It  would  be  idle  to  deny 
that  medical  men,  like  all  other  men,  are  occasionally 
liable  to  propensities  which  do  not  make  for  their  ad- 
vantage and  from  which  not  even  a  knowledge  of   the 
action    of  drugs  can  always  deliver    them.      On    the 
other  hand,  indefinite  assertions,  like  those  contained 
in  this  brief  paper,  cannot  be  accepted  without  those 
proofs   which   are   absent   from    it.      That   accidental 
opium  poisoning  has  repeatedly  cut  off  a  useful   pro- 
fessional  career   is   unfortunately   true.      But   a  mor- 
phine habit  which  controls  one  in  every  ten  or  twenty 
men   is  certainly  not  known  to  exist   in  the  medical 
profession.     Such   a  habit,  if   it  does  exist,  must  be 
quite  exceptional.     It    is  probably   unknown    among 
practitioners  engaged  in  active  duty.      We  observe  that 
the  writer  above  mentioned  speaks  of  the   morphine 
habit  as  if  it  were  merely  a  disease  and  nothing  more. 
It  has  become  customary  with  many  persons  to  refer 
to  this  and  other  aggravated  forms  of  self-indulgence 
in  similar  terms.     They  are  regarded   as  vices  which 
have  ceased  to  give  pleasure—  as  master  passions  which 
are  hated  but  which  will  not  be  denied.      Against  this 
tyranny  the  will  is  supposed  to  have   lost  its  power  of 
resistance.     There  are  doubtless  cases  of  habitual  ex- 
cess, the   character   of   which   is  fairly   so   described. 
We  are,  however,  of  the  opinion   that   too   much  has 
been  made  of  such  cases.     It  cannot  be  and  it  is  not 
true  that  a  vice  even  after  long  indulgence   is  always 
master  and  cannot  be  withstood.     It  is  equally  certain 
that    apparently  confirmed  inebriates   and    morphine 


920 


MEDICAL    RECORD. 


[December  8,  1900 


takers  have  been  enabled  to  release  themselves  and 
have  remained  in  a  state  of  freedom.  The  force  of 
habit,  whether  innocent  or  hurtful,  is  usually  very 
great,  but  this  by  no  means  implies  that  it  must  nec- 
essarily, even  after  long  duration,  annihilate  the  other 
controlling  forces  of  will.  To  what  extent  it  may  have 
done  so  remains  in  many  cases  an  unsolved  problem, 
and  in  this  very  uncertainty  lies  the  germ  of  hope. 
Unless  we  recognize  this  potent  fact  all  prospect  of 
reform,  all  reason  for  the  efforts  of  temperance  even, 
may  be  abandoned.  No  amount  of  therapeutics  will 
make  a  bad  man  good,  or  a  drunkard  abstemious, 
unless  he  is  allowed  credit  for  such  will  power  as  he 
has  and  is  assisted  or  obliged  to  use  it  for  his  moral 
reclamation.  W'iiile,  therefore,  we  do  not  deny  the 
e-xistence  of  the  states  known  as  dipsomania  or  mor- 
phinomania,  we  deprecate  as  pessimistic  and  subver- 
sive of  rational  treatment  the  too  general  tendency  to 
apply  these  and  like  terms  to  all  aggravated  forms  of 
self-indulgence."' 

Medical  Attaches  to  German  Embassies. — Some 
Berlin  periodicals,  in  discussing  the  possibility  of  an 
outbreak  of  plague  in  Europe,  propose  that  medical 
attache's  should  be  appointed  to  the  German  embassies 
abroad,  and  should  be  assigned  the  duty  of  studying 
the  hygienic  conditions  of  the  countries  where  they 
happen  to  be  stationed,  and  of  promptly  informing  the 
German  government  of  the  occurrence  of  cases  of  in- 
fectious disease.  The  arrangements  should  be  settled 
by  international  agreement,  and  in  this  way  inter- 
national regulations  for  the  notification  and  prevention 
of  epidemic  diseases  might  be  put  on  a  more  satisfac- 
tory footing  than  at  present.  Precedents  already  exist 
for  embassies  having  attache's  charged  with  other  than 
diplomatic  functions  because  agricultural  experts, 
architects,  and  engineers  have  for  many  years  held  ap- 
pointments in  connection  with  the  German  embassies  in 
order  that  they  may  inform  the  government  of  anything 
remarkable  happening  in  their  respective  branches  in 
foreign  countries.  The  position  of  the  medical  attached 
would  be  analogous  to  that  of  the  other  technical  at- 
taches.—  Berlin  correspondent  of  The  Lancet. 

The  Pneumonia  of  the  Aged.— Professor  Lemoine 
{Le  Nord  AK'dical,  August  15,  1900,  p.  181)  discusses 
the  treatment  of  pneumonia  in  the  aged,  so  far  as  it 
differs  from  pneumonia  in  the  adult.  The  differential 
characteristics  of  the  affection  are  briefly  as  follows: 
As  in  the  adult  the  onset  maybe  marked  by  shivering; 
dyspncea  may  occur,  but  as  a  rule  it  is  not  intense; 
the  pulse  does  not  exceed  goto  100;  expectoration, 
generally  slight  in  amount,  is  ordinarily  composed  of 
greenish  masses;  the  cough  is  not  very  frequent ;  the 
temperature  follows  a  similar  curve  to  that  in  the 
adult,  but  is  a  degree  or  more  lower.  The  summit  of 
the  lung  is  more  often  affected  than  the  base.  Steth- 
oscopic  examination  may  give  the  same  signs  as  in  the 
adult,  but  in  other  cases  absolutely  nothing  is  heard 
and  the  diagnosis  must  depend  upon  the  general 
symptoms.  Between  these  two  extremes  we  may  get 
all  varieties,  but  as  a  rule  crepitation  is  absent  and 
subcrepitant  rales  are  most  commonly  heard.  'I'he  in- 
dications on  which  treatment  must  be  based  are  to 
diminish  the  afllux  of  blood,  to  calm  the  respiration, 
to  sustain  the  heart  and  the  general  strength.  In  ad- 
dition, the  elimination  of  toxins  must  be  aided  and 
the  expectoration  must  be  facilitated.  Hyperpyrexia 
is  unlikely  to  occur,  .\cetate  of  ammonium  and  ether 
are  among  the  most  valuable  stimulants.  Alcohol  is 
often  most  valuable  as  a  general  stimulant  except  in 
alcoholics.  In  these  musk  deserves  to  be  more  widely 
used.  Strychnine  and  nux  vomica  are  most  valuable 
aids  to  expectoration  because  of  their  effect  on  the 
muscular  tissue,  which  is  deficient  in  power  in  these 
pat  i  c  n  ts.  —  Trealment. 


Health  Reports. — The  following  cases  of  smallpox, 
yellow  fever,  cholera,  and  plague  have  been  reported 
to  the  surgeon-general  of  the  United  States  Marine- 
Hospital  service  during  the  week  ended  November 
30,  1900: 

Cases.    Deaths. 
Smallpox — IJnited  States. 

Alaska.  Skaguay November  24th i 

Whitehorse November  24th i 

Kentucky,  Lexington November  lylh  to  24th i 

Louisiana,  New  Orleans  ....November  17th  to  24th 1 

Michigan,  Detroit November  i7lh  to  24th 1 

Minnesota.  Minneapolis     ...November  17th  to  24th 3 

Missouri.  St    Joseph   October  1st  to  31st 1 

Nebraska,  Omaha November  17th  to  24th 3 

N.  Hampshire,  Manchester  .  November  17th  to  24th 3 

New  Vork.  New  York November  17th  to  24th   i  1 

Ohio,  Cleveland November  i7tht0  24lh 23 

Pennsylvania,  Pittsburg.  .. .    November  17th  to  24th 3 

Steelton November  17th  to  24lh 2 

Te.xas,  Houston November  17th  to  24th 17 

Utah,  Salt  Lake  City November  17th  to  24th. . .  31 

Smallpox — Foreign. 

Belgium,  Antwerp November  3d i 

Bohemia,  Prague October  27th  to  November  3d  ...  ig 

Kritish  Columbia.  Nanaima. November  23d  12 

Ecuador,  Guayaquil September  8th  to  30lh 33 

Eg>'pt,  Alexandria November  5th     i 

England,  Southampton November  3d  to  loth 3 

France,  Paris November  3d  to  icth 11 

Greece,  Athens October  27tn  to  November  3d 3 

Ciibraltar November  nth. , ,      i 

I  ndia,  Calcutta October  2cth  to  27th i 

Madras October  20th  to  27th 3 

Italy,  Naples November  14th 5  i 

Me-xico,  Mexico November  4th  to  nth j 

Russia,  Moscow October  27th  to  November  3d  ...     7  2 

Odessa ..November  3d  to  10th 16  7 

St.  Petersburg October  27th  to  November  3d   ...     7  i 

Warsaw October  27th  to  November  3d ' . .  30 

San  Domingo,  Puerto  Plata.  November  loth  to  17th 3 

Scotland,  (ilasgow November  9th  to  16th 22 

Spain,  Corunna November  3d  to  loth I 

Yellow  Fever. 

Cuba.  Matanzas November  19th 3 

Mexico,  Vera  Cruz November  loth  to  lylh 9  x 

Cholera. 

India,  Bombay October  23d  to  30th  . 


Calcutta October  20th  to  27th. 

Madras October  20th  to  27lh  , 

Straits    Settlements,    Singa- 
pore   September  22d 


Plague. 

China,  Hong  Kong October  15th  to  22d 3 

Kyypt,  .Mexandria October  22d  to  29th 1 

India,  Ftombay October  30th ..    .. 

Calcutta October  20th  to  27lh 

Madras October  20th  to  27th 

Japan.  K'lbe November  2d 2 

Osaka November  2d 11 

Madagascar,  Tamatave October  8lh    to  15th 4 

Straits  Settlements,  Penang.. October  i6th 


8 
•3 


8S 
7 


While  the  Medical  Record  is  pleased  to  receive  all  new  pub- 
lieations  which  may  be  sent  to  it,  and  an  acknowledi^tnent  will  be 
promptly  made  of  their  receipt  under  this  heading,  it  must  be  loith 
the  distinct  understanding  that  its  necessities  are  such  that  it  can- 
not  be  considered  under  obligation  to  notice  or  rezneiv  any  publica- 
tion received  by  it  ivhich  in  the  Judgment  of  its  editor  will  not  be 
of  interest  to  its  readers. 

Diseases  of  the  Eye.  By  Kent  O.  Foltz.  Svo,  566  pages. 
Illustrated.     The  Scudder  Brothers  Co.,  Cincinnati,  Ohio. 

State  Commission  i.n  Lunacy.  Eleventh  Annual  Report. 
Svo,  701  pages.     James  B.  Lyon,  Albany,  N.  Y. 

Transactions  of  the  Association  of  American  Physi- 
cians. Svo,  542  pages.  Illustrated.  Printed  for  the  Associa- 
tion, Philadelphia,  I'a. 

Sexual  Debility  in  Man.  By  F.  R.  Sturgis,  M.D.  Svo, 
432  pages.      E.  B.  Treat  &  Company,  New  York. 

Vasectomy  and  Urethrostenosis.  By  Reginald  Harrison. 
Svo,  68  pages.      Illustrated.      J.  &  A.  Churchill,  London. 

Text-Book  of  the  Emrrvoi.ogy  of  Invertehkates.  By 
Dr.  E.  Korschelt  and  Dr.  K.  Ileider.  Svo,  594  pages.  Illus- 
trated.    Swan,  .Sonnenschein  &  Co.,  London. 

ArrENDiciTis  and  its  Surgical  Treatment.  By  Herman 
Mynter,  M.D.     231  pages.     J.  B.  Lippincott  Co.,  Philadelphia. 

Enlarged  Tonsils  Cured  by  Medicines.  By  J.  Comp- 
ton  Burnett,  M.D.  i6mo,  100  pages.  Boericke  &  Tafel,  Phila- 
delphia, I'a. 

.\kzneiverordnungen  in  der  Kinderpraxis.  By  H. 
Guttmann,  M.D.  i6mo,  no  pages.  Verlag  von  S.  Karger, 
Berlin,  (iermany. 

Medical  News  Visiting-List.  i<)2  pages.  Lea  Brothers 
&  Co.,  Philadelphia,  Pa. 

The  Physician's  Visiting-List.  P.  Blakiston's  Son  & 
Co.,  Philadelphia,  Pa. 


Medical  Record 

A    Weekly  youmal  of  Medicine  and  Surgery 


Vol.  58,  No.  24. 
Whole  No.  1571. 


New  York,  December   15,  1900. 


$5.00  Per  Annum. 
Single  Copies,  loc. 


©riciwat  Articles. 

WOUNDS  OF  THE  HEART  WITH  A  REPORT 

OF    SEVKNTKEX    CASES    OF    HEART    SU- 
TURE.' 

«Y    L.     L.    HILL,    .\LU.. 

MONTGOMRK^.    ALA. 

VVHENSir  John  Erichsen  visited  Philadelphia  in  1874. 
he  said:  "Surgery  has  attained  its  highest  plane,  and 
reached  its  limit  of  usefulness,  and  nothing  in  the 
way  of  improvement  or  advance  need  be  looked  for 
except  in  detail  of  technique."  Were  this  remark  of 
Erichsen  applied  to  day  to  the  surgery  of  the  heart,  it 
would  be  as  eminently  correct  as  it  was  woefully 
wrong  then  as  to  surgery  in  general. 

Strange  that  the  credit  of  the  wondrous  achieve- 
ment of  completely  revolutionizing  surgical  treatment 
by  the  introduction  of  the  methods  of  asepsis  and  an- 
tisepsis—the ciiart  and  compass  of  all  surgical  ad- 
vancement— is  due  to  Ericiisen's  former  house  surgeon, 
Joseph  Lister,  whose  name  is  imperishably  embalmed 
in  the  memory  of  man  wherever  surgery  is  taught  as  a 
science,  and  practised  as  an  art. 

Wounds  of  the  heart  may  be  either  non-penetrating 
or  penetrating  -injuring  the  cardiac  wall  or  opening 
a  cavity.  The  chief  dangers  from  the  former  are 
shock  and  injury  to  a  coronary  artery.  Ninety  per 
cent,  are  penetrating.  Therigiit  ventricle  is  most  fre- 
quently injured,  and  the  left  auricle  is  least  so. 
Auricular  wounds  are  more  fatal  than  ventricular,  and 
injuries  to  tiie  apex  are  less  dangerous  than  either.  A 
needle  puncture  will  rarely  cause  iiemorrhage  from  a 
ventiicle,  but  excessive  bleeding  is  liable  to  follow  a 
like  injury  to  an  auricle.  A  wound  inflicted  during 
diastole  is  less  dangerous  than  a  similar  injury  during 
systole,  perpenc^cular  wounds  are  more  fatal  than  diag- 
onal, and  those  of  the  right  heart  bleed  more  profusely 
than  those  of  the  left.  The  presence  of  the  foreign 
body  in  the  heart,  the  size  of  the  wound,  the  number 
of  the  wounds,  the  connecting  of  cavities,  the  attending 
syncope,  the  involvement  of  Kronecker's  co-ordination 
centre,  are  important  factors  in  determining  the  out- 
come. Pericarditis,  myocarditis,  endocarditis,  and 
empyema  are  frequent  secondary  complications. 
J  When  the  wound  heals  there  is  a  possibility  of  cica- 

f  tricial  stretching  and  subsequent  rupture  as  in  a  case 
reported  by  Izzo  of  a  man  stabbed  in  the  left  ventri- 
cle, who  was  conveyed  to  the  hospital  from  which  he 
was  discharged  cured  on  the  twenty-eighth  day;  a  few 
hours  afterward,  while  lifting  a  heavy  body,  he  fell 
and  quickly  died.  At  the  autopsy  the  cicatrix  of  the 
left  ventricle  was  found  ruptured.  Blows  upon  the 
chest  are  more  liable  to  cause  rupture  of  the  heart 
after  a  full  meal,  as  the  distended  stomach  pushes  the 
heart  upward  and  forward,  and  causes  a  large  area  of 
the  organ  to  be  in  contact  with  the  thoracic  wall  and 
receive  the  impact,  .\ewton  and  Gamgee  have  col- 
lected forty-five  cases  in  which  traumatisms  caused 
rupture  of  the  heart  without  opening  the  pericardium. 
All  were   fatal.      Only  one    of   Gamgee's   cases    sur- 

'  Read  before  the  Jefferson  County  .Medical  and  .Surgical  Soci- 
ety at  Birmingham,  Ala.,  on  November  12,   1900. 


vived  the  injury  fourteen  hours.  The  fatality  is  eas- 
ily understood,  for  there  being  no  exit,  as  soon  as  the 
accumulation  of  blood  exceeds  the  limit  of  pericardial 
distensibility,  the  cardiac  movements  are  mechani- 
cally stopped.  The  surgeon  not  only  would  be  justi- 
fied, but  it  is  his  bounden  duty  to  operate  upon  every 
one  of  these  cases,  for  it  is  more  important,  if  possible, 
to  rescue  a  drowning  heart  than  to  relieve  a  strangu- 
lated gut.  It  is  possible  for  a  foreign  body,  as  a  gun 
missile,  to  remain  quiescent  for  years  in  the  myocar- 
dium, as  in  the  case  of  a  liritish  officer,  reported  by 
Stevenson,  who  carried  a  bullet  encapsuled  for  eleven 
years,  or  the  still  more  remarkable  case  of  Beers 
(Cincinnati  J.aiiat  Clinic,  1898),  of  an  American  sol- 
dier who  survived  the  lodgment  of  a  bullet  in  the  wall 
of  the  left  ventricle  for  thirty-seven  years.  I  can  bet- 
ter illustrate  the  symptoms  of  these  injuries  by  a  brief 
report  of  two  cases  that  have  come  und<r  my  observa- 
tion. 

Case  I. — M.  J ,  female,  eight  years  of  age.  was 

brought  to  my  home  by  her  fatiier  on  the  night  of  Jan- 
uary 5,  1897.  She  had  carried  in  her  shirt  waist  a 
needle  two  and  a  half  inches  in  length,  which  she  had 
driven  into  her  heart  by  accidentally  falling  against 
a  tree. 

Her  countenance  was  anxious,  pulse  rapid  and  weak, 
and  respiration  somewhat  labored.  She  had  slight 
pain  about  her  heart.  Upon  inspection  I  found  that 
the  foreign  body  had  entered  the  fifth  intercostal  space 
on  the  left  side,  and  with  the  pulsation  of  the  heart 
the  head  of  the  needle  could  be  seen  to  move  under 
the  skin — a  symptom  centuries  ago  enshrined  in  the 
magnificence  of  indestructible  verse: 

"  He  fell,  the  spear  point  quivering  in  his  heart 

Which,  with  convulsive  throbbing,  shook  the  shaft." 

The  case  being  one  of  unusual  interest  to  me,  I 
summoned  my  friend  Dr.  R.  F.  Michel,  and  my 
brother  Dr.  R.  S.  Hill,  and  proceeded  to  operate  by 
injecting  ten  drops  of  a  four-per-cent.  solution  of  co- 
caine into  the  skin.  I  made  an  incision  an  inch  in 
length  down  to  the  needle,  and  CNtracted  it  with  a  pair 
of  dressing  forceps.  The  wound  was  immediately 
closed,  and  the  child  sent  to  a  relative's  house,  with 
instructions  to  the  parent  that  they  detain  her  in  bed, 
and  that  she  be  kept  quiet  for  ten  days.  She  had  no 
subsequent  trouble. 

Case  II. — Through  the  courtesy  of  Dr.  J.  M.  Ander- 
son I  had  the  opportunity  of  examining  Robert  F. , 

colored,  twenty-eight  years  of  age,  who  had  received  a 
stab  wound  in  the  fourth  intercostal  space  a  little  to 
the  right  of  the  left  nijjple.  Seen  shortly  after  the 
injury  there  was  complete  relaxation  of  the  extremi- 
ties, and  the  pulse  was  hardly  perceptible.  The  coun- 
tenance depicted  a  suffering  and  distress  that  would 
seem  to  welcome  death  with  the  wintry  sterility  of  the 
grave  as  a  kind  and  sympathizing  friend.  Ausculta- 
tion revealed  the  heart  sounds  very  indistinct,  and 
percussion  elicited  increased  dulness.  It  was  evident 
that  the  pericardium  was  rapidly  filling  with  blood, 
and  that  the  heart's  action  would  soon  be  overcome  by 
compression.  The  external  hemorrhage  was  slight. 
The  blood  was  evacuated  by  enlarging  the  opening  in 
the  pericardium,  and  the  patient's  condition  at  once 


922 


MEDICAL    RECORD. 


[December  15,  1900 


improved,  and  he  ultimately  recovered,  though  subse- 
quently traumatic  pericarditis  supervened. 

Treatment:  I  presume  no  one  will  question  the  pro- 
priety of  operative  interference,  as  experience  demon- 
strates that  a  little  in  excess  of  forty-one  per  cent,  re- 
covered that  had  been  operated  upon,  as  against  ten 
per  cent,  of  recoveries  in  cases  in  which  no  operation 
had  been  performed. 

For  temporary  hajmostasis  some  operators  have  rec- 
ommended Pcan's  forceps  and  various  modifications 
of  it,  but  they  all  more  or  less  lacerate  the  myocar- 
dium and  can  never  replace  digital  pressure.  All 
are  agreed  that  interrupted  sutures  are  preferable  in 
closing  a  wound  of  the  myocardium;  they  should  be 
close  together  and  not  involve  the  endocardium. 
Giordano  from  his  experiments  upon  rabbits  con- 
cludes that  auricular  wounds  might  be  closed  advan- 
tageously with  Lembert's  sutures.  Silk  is  preferable 
to  any  other  material.  The  needle  should  be  the 
same  as  that  used  in  suturing  the  intestines.  The  su- 
tures should  be  passed  and  tied  during  diastole.  The 
first  suture  may  be  used  to  steady  the  heart  and  facili- 
tate the  passage  of  the  others.  In  sewing  the  pericar- 
dium either  interrupted  or  continuous  sutures  may  be 
used. 

It  hardly  seems  necessary  to  accentuate  the  fact  of 
the  necessity  of  perfect  cleanliness  in  these  operations 
whenever  the  urgency  of  the  case  does  not  require 
instant  intervention  as  in  the  patients  of  Longo  and 
Ninni. 

The  question  of  administering  an  anassthetic  is  a 
mooted  one.  Oilier  says  general  anaesthesia  should 
not  be  thought  of.  Parrozzani  operated  upon  his  two 
cases  without  an  anesthetic,  and  observed  only  slight 
movement  when  he  cut  the  skin  and  in  passing  the 
sutures  in  the  myocardium.  Giordano  made  the  same 
observation  in  his  case,  but  thinks  Ollier's  statement  is 
too  sweeping,  as  if  the  pulse  is  strong  and  the  general 
condition  good  chloroform  may  be  administered.  Strug- 
gling from  an  anesthetic  is  liable  to  produce  detach- 
ment of  a  clot  and  renew  the  hemorrhage,  as  occurred 
in  Parlavecchio's  case.  I  have  been  able  through  the 
valuable  assistance  received  from  the  writings  of  Pro- 
fessor Giordano  to  give  here  the  history  of  the  seven- 
teen recorded  cases  of  heart  suture. 

Case  I. —  Farina,  of  Rome,  in  1896,  sutured  a  wound 
of  the  right  ventricle  6  mm.  in  length.  The  dagger 
entered  just  above  the  upper  margin  of  the  sixtli  rib, 
near  the  sternum,  on  the  left  side.  Operation  was 
performed  by  making  an  incision  four  inches  in  length 
along  the  superior  border  of  the  sixth  rib,  which  was 
divided  at  the  sternum.  Divarication  was  made  of  the 
fifth  and  seventh  rib.  The  opening  in  the  pericardium 
was  enlarged,  the  wound  in  the  right  ventricle  closed 
with  three  silk  stitches,  and  the  pericardium  sutured. 
Stimulating  injections  were  given  and  autotransfusion 
was  practised.  The  pulse  at  times  became  very  rapid. 
The  patient  died  on  the  sixth  day  of  broncho-pneu- 
monia. At  the  autopsy  the  wound  in  the  ventricle 
was  found  cicatrized. 

Case  II. — Cappelen,  in  1896,  operated  upon  a  man 
twenty-four  years  of  age,  who  had  been  stabbed  one 
hour  before  entering  the  hospital.  The  knife  had  en- 
tered the  fourth  left  intercostal  space  in  the  mid-axil- 
lary line.  The  wound  was  i  cm.  in  length,  and  there 
was  no  external  bleeding.  The  left  half  of  the  thorax 
was  immovable  from  compression  of  the  lung  due  to  an 
accumulation  of  blood  in  the  pleural  cavity.  The 
pulse  was  imperceptible,  and  the  heart  sounds  were 
lieard  with  difficulty.  The  third  and  fourth  ribs  were 
resected,  and  the  blood  in  the  pleural  cavity  was  evacu- 
ated, which  permitted  the  lung  to  expand.  The  peri- 
cardium was  distended  with  blood,  and  when  emptied 
a  wound  of  the  left  ventricle,  four-fifths  of  an  inch  in 
length,  was  observed.     One  of  the  large  branches  of  a 


coronary  vessel  was  cut.  The  artery  was  tied,  and  the 
wound  in  the  ventricle  sutured.  The  patient  was  very 
weak  but  improved  after  an  injection  of  a  saline  solu- 
tion.    He  died  several  days  afterward  of  pericarditis. 

Case  HI. — Rehn,  of  Frankfort-on-the-Main,  oper- 
ated upon  a  young  man  who  had  been  stabbed  with  a 
dagger  in  tjie  fourth  left  intercostal  space  in  proximity 
to  the  sternum.  He  was  found  unconscious  upon  the 
street  and  carried  to  the  hospital.  The  following  day 
his  condition  was  more  favorable  in  the  morning,  but 
toward  evening  there  were  signs  of  oppression,  and  ex- 
treme dulness  extended  to  the  top  of  the  left  lung. 
An  incision  was  made  along  the  fifth  rib,  which  was 
resected.  The  pericardium  was  greatly  distended,  and 
upon  being  emptied  a  wound  of  the  right  ventricle  was 
observed,  from  wliich  blood  came  at  every  diastole.  It 
was  sutured  with  three  silk  stitches.  They  were  intro- 
duced and  tied  during  diastole.  The  pleura  and  peri- 
cardium were  drained.  The  patient  had  suppuration 
of  the  pleura  but  eventually  recovered.  This  is  the 
first  successful  case  of  heart  suture  in  man  recorded. 
The  patient  was  presented  to  the  Congress  of  German 
Surgeons  in  Berlin  in  1897. 

Case  IV. — Parrozzani,  in  1897,  operated  upon  a 
young  man  who  had  been  cut  three  times.  Two  of  the 
cuts  were  of  no  importance.  He  followed  his  assail- 
ant thirty  steps  and  fell.  Five  hours  after  the  injury 
he  was  carried  to  the  hospital,  where  it  was  found  that 
the  dagger  had  entered  the  seventh  left  intercostal 
space  in  the  mid-axillary  line.  His  general  condi- 
tion was  extremely  grave — '"heart  beats  and  pulse 
almost  imperceptible,  and  respiration  rapid  and  super- 
ficial." Immediate  intervention  without  an  anesthetic 
was  decided  upon.  An  incision  through  the  soft  parts 
one  and  one-fourth  inches  from  the  margin  of  the  ster- 
num in  the  fourth  intercostal  space  was  carried  for  a 
distance  of  five  and  one-half  inches,  then  it  descended 
vertically  in  the  mid-axillary  line  as  far  as  the  superior 
margin  of  the  ninth  rib.  The  fifth,  sixth,  seventh,  and 
eighth  ribs  were  cut  through  in  the  mid-axillary  line 
with  the  pleura.  The  musculo-osseous  flap  or  door  was 
raised,  with  the  cartilages  of  the  ribs  acting  as  the 
hinges.  The  pleural  cavity  was  filled  with  blood  and 
an  opening  one  inch  in  length  was  found  in  the  peri 
cardium  which  was  subsequently  enlarged  to  two  and  a 
half  inches.  There  was  very  little  blood  in  the  peri- 
cardium, because  the  injury  was  in  the  most  dependent 
part  and  the  blood  readily  escaped  into  the  pleural  cav- 
ity. A  wound  in  the  apex  was  observed  three-fouiths  of 
an  inch  in  length,  through  which  the  little  finger  was 
passed  into  the  left  ventricle.  This  served  the  double 
purpose  of  checking  the  hemorrhage  and  steadying  the 
organ  for  the  introduction  of  the  sutures.  Four  deep 
silk  stitches  were  used,  not  touching  the  endocar- 
dium. Passing  the  needle  caused  violent  throbbing  of 
the  heart.  The  pleura  and  pericardium  were  thoroughly 
cleansed,  and  the  flap  was  sutured  in  position.  Stim- 
ulating hypodermic  injections  were  used,  and  hypodcr- 
moclysis  and  autotransfusion  practised.  The  oper- 
ation lasted  one  hour  and  a  quarter.  Recovery  re- 
sulted. For  the  full  report  of  this  case  I  am  indebted 
to  Dr.  (}.  Sanderson  Brock,  to  whom  details  were  given 
by  Dr.  Parrozzani. 

Case  V. — Parrozzani  operated  upon  a  woman  who 
had  been  stabbed  in  the  third  left  intercostal  space. 
Half  an  hour  afterward  she  was  conveyed  to  the  hos- 
pital. Her  condition  was  exceedingly  unfavorable. 
She  was  operated  upon  immediately  without  an 
anaesthetic,  the  operation  being  very  similar  to  the 
other,  excepting  that  the  fourth,  fifth,  and  sixth  ribs 
were  cut  through.  The  pericardium  was  found  filled 
with  blood,  and  upon  its  evacuation  an  opening  in  the 
anterior  wall  of  the  left  ventricle  about  three-fifths  of 
an  inch  in  length  was  observed.  This  was  closed 
with  two  stitches.     Hypodermoclysis  and  stimulating 


December  15,  1900] 


MEDICAL    RECORD. 


923 


injections  were  employed.  The  patient  died  on  thie 
second  day.  The  autopsy  revealed  that  the  interven- 
tricular septum  had  been  cut.  There  was  profound 
anaemia. 

Case  VI. —  Fummi  reported  in  1898  that  a  patient 
had  been  stabbed  under  the  left  nipple.  Several  hours 
afterward  an  operation  was  performed,  and  the  pericar- 
dium was  found  dilated  with  blood.  The  wound  was 
in  the  apex  but  did  not  open  a  cavity.  It  was  closed 
with  one  stitch.  Hypodernioclysis  was  employed. 
The  patient  had  empyema  but  recovered. 

Case  VII.  —  Ninni  reported  in  1898  a  patient 
stabbed  in  the  fifth  left  intercostal  space.  The  man 
was  quickly  carried  to  the  hospital  and  subjected  to 
an  operation  without  an  anesthetic.  An  incision  was 
made  outward  from  the  sternum  along  the  superior 
border  of  the  sixth  rib.  A  parallel  incision  along  the 
inferior  margin  of  the  third  rib  was  made.  They  were 
united  by  a  vertical  incision.  The  fourth  and  fifth 
ribs  were  cut  through,  and  the  shutter  was  turned  back 
toward  the  sternum.  The  pericardium  was  found 
enormously  distended  with  blood.  There  was  an 
opening  into  the  left  ventricle  through  which  the  sur- 
geon introduced  his  right  index  linger,  which  acted  as 
a  stopper,  but  upon  substituting  his  left  so  as  to  sew- 
up  the  wound  a  violent  hemorrhage  followed.  Three 
interrupted  stitches  closed  the  cardiac  wound,  and  a 
continuous  suture  had  shut  the  pericardium,  when  the 
operation  was  discontinued  on  account  of  the  patient's 
death. 

Case  \TI1. —  Parlavecchio,  in  1898,  operated  upon 
a  patient  who  had  been  stabbed  in  the  fifth  left  inter- 
costal space.  The  wounded  man  went  to  the  hospital. 
After  five  hours  blood  was  observed  in  the  pleural 
cavity.  The  pulse  became  very  weak  and  intermit- 
tent, and  the  heart  sounds  were  heard  with  difficulty. 
Intervention  after  eight  hours  was  resorted  to  under 
chloroform.  The  fifth  rib  was  resected.  The  finger 
was  introduced,  and  the  wound  in  the  pericardium 
was  grasped  and  enlarged.  There  was  a  wound  of  the 
apex  about  an  inch  and  a  half  in  length,  penetrating 
obliquely  the  left  ventricle.  It  was  closed  with  four 
interrupted  sutures.  After  thorough  cleansing  the 
pericardium  and  external  wounds  were  closed.  The 
duration  of  the  operation  was  forty  minutes.  Recov- 
ery took  place. 

Case  IX. — Giordano,  in  1898,  reported  the  case  of 
a  man  who  had  been  stabbed  through  the  second  left 
intercostal  space.  When  he  reached  the  hospital  a 
half-hour  after  the  injury  he  was  thought  to  be  dead. 
Immediate  operation  was  done  without  an  anassthetic 
and  without  cleansing  of  the  field  of  the  operation.  The 
introduction  of  the  index  finger  showed  that  the  wound 
ranged  downward  and  inward.  An  incision  was  made 
extending  from  the  wound  to  the  margin  of  the  ster- 
num; a  second  incision  from  the  sternal  end  of  the 
first  descended  to  the  superior  margin  of  the  fifth  rib. 
The  third  and  fourth  ribs  were  cut  through,  and  an 
immense  quantity  of  blood  was  evacuated.  \\'hen  the 
pericardium  was  opened  a  wound  in  the  left  auricle, 
four-fifths  of  an  inch  in  length,  transverse  to  the  axis 
of  the  organ,  was  observed.  Bleeding  was  very  free. 
Four  silk  stitches  were  introduced,  which  was  done  in 
less  than  fifteen  minutes.  The  third  rib  was  placed  in 
position,  but  a  portion  of  the  fourth  was  resected  for 
free  drainage  of  the  pleural  cavity.  Stimulating  in- 
jections were  given  and  autotransfusion  was  employed. 
Empyema  commenced  a  few  days  later  and  the  ninth 
rib  was  resected.  Death  occurred  on  the  nineteenth 
day.  The  autopsy  revealed  many  abscesses  in  the 
right  lung.  This  is  the  first  recorded  case  of  suture 
of  an  auricle. 

Case  X. —  Xicolai,  in  1899,  operated  upon  a  man 
w'ho  had  been  stabbed  in  the  fourth  left  intercostal 
space  midway  between  the  margin  of  the  sternum  and 


the  nipple.  The  point  of  the  dagger  ranged  upward. 
He  was  operated  upon  under  an  anaesthetic  one  and 
one-half  hours  after  the  injury.  The  fourth  and  fifth 
ribs  were  divided,  and  a  wound  in  the  right  ventricle 
was  found  and  sutured.  The  patient's  condition 
seemed  favorable,  but  death  occurred  suddenly  twelve 
hours  after  the  operation.  At  the  autopsy  the  pericar- 
dium was  found  empty,  and  the  sutures  were  in  posi- 
tion. 

Case  XI. — Tuzzi  saw  a  man  who  had  been  stabbed 
in  the  fourth  left  intercostal  space.  Intervention  was 
done  without  an  anaesthetic.  The  fourth  and  fifth  ribs 
were  divided  as  in  the  previous  case.  'I'here  were  two 
wounds  of  the  myocardium — a  penetrating  and  a  non- 
penetrating. There  was  a  coaguUim  between  the  lips 
of  the  former.  The  cardiac  wound  was  sutured,  and 
the  pleura  drained.  Hypodermocljsis  was  performed. 
'I'he  patient  died  on  the  twenty-second  day  of  empy- 
ema. At  the  autopsy  it  was  discovered  that  the  pa- 
tient had  sero-fibrinous  pericarditis,  and  that  the 
wound  of  the  heart  had  healed. 

Case  XII. — Longo  reported  a  case  in  which  the 
knife  entered  at  the  fifth  left  intercostal  space  two- 
fifths  of  an  inch  internal  to  the  nipple.  The  patient's 
general  condition  was  so  unfavorable  that  the  oper- 
ation was  performed  at  once  without  an  anaesthetic. 
A  vertical  incision  was  made  from  the  lower  border 
of  the  third  rib  to  the  superior  border  of  the  sixth 
rib,  two-fifths  of  an  inch  from  the  sternal  margin.  A 
second  incision  parallel  to  the  preceding  was  made 
through  the  nipple,  and  a  third  united  their  lower 
ends.  The  fourth  and  fifth  ribs  were  divided.  There 
was  found  an  opening,  one  and  one-fifth  inches  in 
length,  in  the  pericardium,  which  was  enlarged,  and  a 
wound  of  tlie  left  ventricle  was  discovered  and  closed 
with  three  interrupted  silk  stitches.  The  pericaidium 
was  closed  with  continuous  sutures.  The  patient  was 
transfused  with  a  saline  solution,  but  died  in  fifteen 
minutes. 

Case  XIII. — Ramoni  reported  that  his  patient  was 
stabbed  at  the  third  cartilage  four-fifths  of  an  inch  to 
the  left  of  the  sternum.  Without  an  anaesthetic  an 
incision  was  made  about' four  inches  in  length  along 
the  third  rib  from  the  sternum.  Two  vertical  inci- 
sions descended  from  each  end  of  it,  and  the  third, 
fourth,  and  fifth  ribs  were  cut  through.  The  pericar- 
dium was  emptied  of  blood,  and  two  wounds  near  the 
base  of  the  right  ventricle  were  observed.  A  suture 
was  passed  during  diastole  which  provoked  a  strong 
systole,  causing  a  laceration  of  the  myocardium  and 
abundant  hemorrhage.  The  finger  was  introduced 
and  the  opening  closed  with  four  interrupted  sutures, 
which  did  not  pass  through  the  endocardium.  Stimu- 
lating injections,  autotransfusion,  and  iiypodermocly- 
sis  were  at  this  time  resorted  to.  The  second  wound 
was  closed  with  two  stitches.  'I'he  pleura  was 
drained.  The  operation  lasted  three-fourths  of  an 
hour.     Recovery  took  place. 

Case  XIV. — Marion  reported,  in  1899,  a  patient 
who  had  been  shot  through  the  breast.  The  fourth, 
fifth,  and  sixth  ribs  and  a  part  of  the  sterum  were  cut. 
The  wound  of  the  myocardium  was  sutured.  The 
autopsy  showed  that  the  missile  had  passed  entirely 
through  the  body. 

Case  XV. — Rosa  reported,  in  1899.  that  a  man  upon 
whom  he  operated  was  stabbed  in  the  fifth  intercostal 
space.  Operation  was  performed  without  an  anaes- 
thetic. An  incision  four  inches  in  length  was  made 
along  the  fifth  rib.  It  was  resected,  and  a  severe  hem- 
orrhage from  a  wound  of  the  lung  was  stopped  with  a 
stitch.  The  sixth,  seventh,  and  eighth  ribs  were  cut 
in  the  anterior  axillary  line.  The  pericardium  was 
emptied  of  blood,  and  a  wound  of  the  left  ventricle, 
near  the  base,  three-fifths  of  an  inch  in  length  was 
observed,   but   the  operator  could  not  say   whether  it 


924 


MEDICAL    RECORD. 


[December  15,  1900 


penetrated  the  cavity.  It  was  closed  with  one  stitch, 
and  the  pericardium  and  pleura  were  drained.  Recov- 
ery resulted. 

Case  XVI. — Pagenstecher  reported  his  case  in  1899. 
The  dagger  entered  the  fourth  left  intercostal  space 
beneath  the  nipple.  The  patient  came  under  observa- 
tion a  half-hour  after  the  injury,  and  it  was  discovered 
that  there  was  no  external  bleeding.  The  pulse  was 
imperceptible,  and  respiration  had  almost  stopped. 
The  corneal  reflex  was  abolished.  Dulness  extended 
over  almost  the  whole  left  side  of  the  chest.  The  pa- 
tient was  operated  upon  sixteen  hours  after  the  injury 
by  an  incision  along  the  fifth  rib,  which  was  resected 
about  two  and  one-half  inches.  The  opening  in  the 
pericardium  was  enlarged  two  inches,  and  a  wound 
was  observed  of  the  left  ventricle  about  one  and 
one-third  inches  from  the  apex  and  one  and  two- 
fifths  of  an  inch  long,  from  which  ran  a  stream  of 
blood.  Three  deep  celluloid  sutures  and  one  super- 
ficial one  were  used.  The  pleura  was  cleansed  and 
the  pericardium  sutured.  The  threads  of  the  knots  in 
the  myocardium  were  left  long,  so  as  to  come  through 
the  external  wound.  Pulling  the  threads  on  the  ninth 
day  caused  two  to  come  away,  and  the  other  two  came 
ten  days  later.     Recovery  took  place. 

Ca.se  XVII. — Maselli  reported,  in  1900,  the  case  of 
a  man  who  had  been  stabbed  below  and  internal  to 
the  left  nipple.  He  revived  a  little  after  injections 
of  ether  and  caffeine.  He  was  operated  upon  one  and 
one-half  hours  after  the  injury  without  an  anaesthetic. 
A  transverse  incision  was  made  from  the  margin  of 
the  sternum  to  a  point  beyond  the  nipple.  About  two 
and  a  half  inches  of  the  sixth  rib,  which  was  cut  by 
the  weapon,  was  resected.  The  lips  of  the  wound  of 
the  pericardium  were  caught  with  Pean's  forceps  and 
drawn  toward  the  external  opening.  The  finger  was 
introduced,  and  a  wound  of  the  left  ventricular  wall 
discovered  near  the  apex,  which  was  closed  with  two 
sutures.  The  pericardium  was  cleansed  and  contin- 
uous sutures  were  used.  The  pleura  was  drained  with 
gauze.  Stimulating  injections,  hypodermoclysis,  and 
autotransfusion  were  employed.  The  operation  lasted 
more  than  an  hour.  At  first  the  patient  improved,  but 
twelve  hours  later  symptoms  of  collapse  appeared, 
which  did  not  yield  to  a  repetition  of  stimulating  in- 
jections and  hypodermoclysis.  The  autopsy  showed 
that  one  of  the  stitches  in  the  myocardium  had  become 
untied,  but  the  edges  were  in  apposition,  and  the  peri- 
cardium was  empty. 

John  Bell,  who  was  far  in  advance  di  his  time,  taught 
and  practised  pericardiotomy,  removing  foreign  bodies 
and  washing  out  the  sac.  Dr.  John  E.  Roberts,  of 
Philadelphia,  in  1881,  suggested  heart  suture,  and  Dr. 
Del  Vecchio,  of  Naples,  in  1894,  demonstrated  its 
feasibility  before  the  Kleventh  International  Medical 
Congress  in  Rome,  by  his  experiments  on  dogs.  Two 
years  later  the  human  heart  was  sutured  by  Farrina 
and  Cappelen.  It  is  surprising  to  find  the  statistics 
collected  by  Fischer,  of  Breslau,  in  1868,  quoted  by 
leading  text-books  on  surgery  as  late  as  1900  as  au- 
thoritative in  computing  the  prognosis  in  this  class  of 
injuries.  The  successful  suturing  of  the  heart  by 
Rehns,  Parrozzani,  Parlavechio,  and  others  has  revo- 
lutionized the  treatment  and  changed  the  probable 
outcome.  F'ischer's  statistics,  though  a  monument  to 
his  untiring  zeal  and  energy,  are  now  like  an  anti- 
quated sign-board  on  a  discarded  highway;  but 

"  Faith,  fanatic  faith,  once  wedded  fast 
To  some  dear  falsehood,  hugs  it  to  the  last." 

Anti-Cigarette  Laws.— The  Vermont  legislature  be- 
fore its  recent  adjournment  passed  a  bill  prohibiting 
the  sale  of  cigarettes  in  the  State.  The  bill  passed 
both  houses  of  the  legislature  and  has  been  signed  by 
the  governor. 


INTERNAL  HEMORRHAGE,  THE  RESULT 
OF  TRAUMATIC  RUPTURE  OF  ADHE- 
SIONS DUE  TO  ACUTE  APPENDICITIS, 
WITH    THE   REPORT    OF    A    CASE. 

By    LOUIS   J.    LADINSKL    M.D, 

ADJUNCT     PROFESSOR     OF     CVN-CCOLOGV,     NEW     VORK      POLYCLINIC  ;     VISITING 
SURGEON,    GOUVERNEUR    AND  UETH    ISRAEL  JlOSl'I  lALS 

The  patient  is  a  boy  eleven  and  one-half  years  old, 
whom  I  saw  in  consultation  with  Dr.  M.  Girsdansky. 
Family  and  previous  history  is  negative;  there  is  no 
personal  or  family  history  of  hcTemophilia. 

On  Wednesday,  August  i,  1900,  he  complained  of 
slight  cramps  in  the  abdomen;  at  no  time,  however, 
was  the  pain  severe  enough  to  prevent  him  from  play- 
ing and  jumping  about.  On  the  same  day,  at  about  7 
P.M.,  while  sliding  down  the  balustrade,  he  lost  his 
hold  and  landed  with  considerable  force  upon  the 
floor.  He  was  picked  up  and  carried  to  his  room, 
complaining  of  severe  pains  in  the  abdomen  and  suf- 
fering from  nausea  and  vomiting.     On  the  evening  of 


Fig.  I.— Site  of  Rupture  Shown  at  Junction  of  Concave  and  Perpendicular 
Portions  of  Specimen. 

August  2d,  Dr.  Girsdansky  was  called  in  to  treat  the 
patient.  He  found  him  lying  in  bed  with  legs  drawn 
up  and  moaning  constantly;  his  face  pale,  anxious, 
and  drawn;  breathing  was  labored,  pulse  120.  small 
and  hard,  and  occasionally  irregular,  and  the  tempera- 
ture was  101°  F.  On  examination  he  found  the  abdo- 
men to  be  painful  and  tender;  tenderness  was  espe- 
cially marked  in  the  lower  abdomen.  The  boy  had 
urinated  regularly  and  normally,  and  had  had  a  move- 
ment of  the  bowels.  He  ordered  small  doses  of  calo- 
mel and  ice  applications,  and  decided  to  wait  for 
surgical  interference  till  the  next  morning,  when,  on 
finding  the  patient  much  worse,  he  invited  me  to  see 
the  case  with  him. 

I  saw  the  boy  at  twelve  o'clock  on  the  3d  of  August, 
about  forty  iiours  after  tlie  fall,  and  found  him  in  a 
condition  of  extreme  collapse;  his  i)ulse  ranged  be- 
tween 130  and  140,  small  and  irregular;  his  tempera- 
ture was  104°,  and  the  breathing  rapid  and  shallow. 
There  was  general  cyanosis,  the  face  was  anxious  and 
drawn,  and  the  eyes  were  deeply  sunken.  The  abdo- 
men was  very  much  distended,  extremely  tender  and 
sensitive,  and  was  tympanitic  above  and  boggy  below. 
There  was  distinct  evidence  of  fluid  in  the  peritoneal 
cavity.     The  pain  and  the  tenderness  were    slightly 


more  marked  in  the  region  of  the  appendix.  In  short, 
there  was  every  sign  and  symptom  of  a  general  peri- 
tonitis. 

The  differential  diagnosis  was  between  hemorrhage 
from  some  internal  organ,  rupture  of  the  bladder,  rup- 
ture of  the  intestine,  and  general  peritonitis  due  to  a 
rupture  of  an  unrecognized  appendicitis.  Rupture  of 
the  bladder  was  dismissed  from  consideration  for  the 
reason  that  the  urination  was  absolutely  normal. 
Rupture  of  the  intestine  was  excluded  because  the 
bowels  had  moved,  and  there  was  no  evidence  of  gas 
in  the  peritoneal  cavity.  The  collapse,  cyanosis,  and 
the  high  temperature  pointed  to  a  septic  condition 
which  could  not  be  accounted  for  by  a  simple  internal 
hemorrhage.  Considering  the  fact  that  the  boy  had 
had  an  attack  of  abdominal  pain  previous  to  the  fall, 
and  viewing  all  the  signs  and  symptoms  in  the  light 
of  past  experience,  a  diagnosis  of  general  peritonitis, 
due  to  ruptured  appendicitis,  was  made. 

Though  a  fatal  prognosis  was  given,  the  parents 
accepted  the  slight  chance  an  operation  offered.  The 
boy  was  transferred  by  ambulance  to  my  service  at 
Gouverneur  Hospital,  and  was  at  once  placed  upon  the 
table  and  prepared  for  operation.  A  median  incision 
was  made,  and  when  the  peritoneal  cavity  was  opened, 
it  was  found  to  be  tilled  with  blood.  As  much  as 
possible  of  the  blood  was  sponged  out  and  mopped  up. 
The  appendix  was  sought  for  and  was  isolated  from 
the  surrounding  parts  by  means  of  pads;  and  on  care- 
fully exposure  and  drying  of  this  region  it  was  found  to 
be  the  site  of  the  hemorrhage.  The  appendix,  which 
was  unusually  long,  was  doubled  up  like  the  letter  U, 
being  held  in  that  position  by  the  adherent  meso- 
appendix.  and  lay  in  front  of  and  to  the  inner  surface 
of  the  caecum,  to  which  it  was  attached  by  recent  ad- 
hesions. The  entire  appendical  region  was  injected 
and  congested.  At  the  bend  of  tiie  meso-appendix 
there  was  a  rent  to  the  extent  of  about  a  half-inch,  in 
which  several  small  spurting  vessels  were  distinctly 
made  out.  The  meso-appendix  was  ligated;  the  ap- 
pendix was  separated  from  the  adhesions  and  removed; 
the  blood  and  clots  were  wiped  away,  and  the  peri- 
toneal cavity  was  washed  with  saline  solution  and  the 
wound  closed.  The  following  day  the  temperature 
dropped  to  normal,  and  the  boy  made  an  uneventful 
recovery,  being  discharged  from  the  hospital  thirteen 
days  after  the  operation. 

The  fall  undoubtedly  caused  the  tear  in  the  meso- 
appendix,  which  was  the  source  of  the  hemorrhage  in 
the  peritoneal  cavity,  and  the  sepsis  was  due  to  the 
appendicitis.  The  case  is  undoubtedly  unique.  As 
far  as  I  can  learn  from  the  literature  up  to  date,  there 
has  never  been  reported  a  similar  complication  in 
acute  appendicitis.  Dr.  Edebohls,  in  his  excellent 
resume  of  the  literature  of  appendicitis,  cites  cases  of 
hemorrhage  complicating  appendicitis  as  a  result  of 
ulcerative  processes  of  the  small  intestines;'  of  the 
sigmoid;"  of  the  right  external  iliac  artery;'  of  the 
right  iliac  vein;'  and  in  a  conversation  with  him 
Dr.  Edebohls  informed  me  that  he  had  a  record  of  a 
case  of  fatal  hemorrhage  due  to  the  slipping  of  a  liga- 
ture of  the  artery  of  the  meso-appendix,  but  he  corrob- 
orates the  statement  that  there  is  no  previous  record 
of  a  traumatic  internal  hemorrhage  from  vessels  of  the 
meso-appendix.  The  case  is  of  further  interest  be- 
cause of  its  very  close  similarity  to  general  peritonitis, 
the  result  of  perforative  appendicitis. 

128Q  Madison  Avenub. 


'  Osier  :  Montreal  General  Hospital  Report,  1880,  i,  330. 

*  Stedman  :   Lancet.  London,  1S93,  i,  1061. 

^Powell;  New  Orleans  Medical  and  Surgical  Journal.  1S55. 
-xi.,  463;  and  Sourdille  :  Bulletin  de  la  Societe  d'Anatomie  de 
Paris.  1894.  Ixix..  447. 

■*  Fowler  ;  Annals  of  .Surgery,  Philadelphia,  1894.  xix. ;  and 
Lewis  ;  Medical  Record.  New  York,  1894,  xlvi.,  463. 


INSANITY,  ITS  CAUSES:  IS  THERE  IN 
WOMAN  A  CORRELATION  OF  THE  SEX- 
UAL FUNCTION  WITH  INSANITV  AND 
CRIME? 

15v    M.ARV   1J1.\0.\    JONES,    M.D.,    F.R.M.S.. 

NEW    VOHK. 

That  the  brain  is  the  organ  of  the  mind  must  be  rec- 
ognized as  a  fundamental  fact,  as  an  axiom  in  mental 
science  and  in  the  pathology  of  "mental  diseases." 

The  brain,  with  its  wonderfully  complex  structure, 
its  many  varied  and  complicated  parts,  is  the  organ  or 
instrument  by  which  the  intellectual  and  moral  powers 
make  their  manifestations:  and  any  indication  of 
mental  disease  or  inability  to  carry  on  any  of  the 
mental  processes  must  come  from  some  abnormal  con- 
dition, disease,  or  structural  lesion  of  the  brain.  If 
the  mental  faculties  make  abnormal  presentations,  or  if 
insanity  in  any  form  occurs,  it  is  only  because  some 
tissue  or  structure  of  the  brain  is  diseased  or  in  some 
temporary  or  chronic  jiathological  condition.  It  is 
not  that  the  mind — the  mentality,  the  thinking  pait  of 
our  being — is  diseased.  And  whenever  there  is  any 
morbid  or  diseased  condition  of  the  brain  it  will  be 
shown  in  the  mental  operations.  They  will  be  more 
or  less  disturbed  or  abnormal.  When  the  brain  is 
diseased,  as  from  a  musical  instrument  out  of  repair 
there  are  given  forth  uncertain  sounds.  One  part  may 
be  diseased  and  another  portion  sound,  so  that  there 
may  be  a  union  of  abnormal  and  normal  manifestations ; 
but  we  will  ever  find  the  causes  of  insanity  to  be  in 
the  varying  conditions  of  the  brain  substance.  This  is 
the  only  true  theory,  any  other  leads  into  mazes  of 
doubt  and  mystery,  and  to  an  infinite  number  of  vague 
speculations. 

The  brain  is  the  great  masterful  organ  of  the  whole 
body,  surpassingly  wonderful  in  every  part  of  its  ana- 
tomical structure,  and  far  beyond  our  comprehension 
in  its  mode  of  acting,  the  manner  of  its  manifesta- 
tions, and  in  its  methods  of  giving  expression  to 
thought,  feeling,  and  the  emotions. 

We  cannot  begin  to  comprehend  the  wonders  and 
powers  of  the  human  brain,  nor  can  we  understand  all 
the  high  mysteries  of  what  is  the  mind,  or  what  is  the 
spiritual  part  of  man.  "God  breathed  into  him  the 
breath  of  life,  and  man  became  a  living  soul."  So  the 
living  soul,  or  mind,  is  of  God.  It  is  immortal,  eter- 
nal, everlasting.  It  does  not  get  sick  or  die,  and  from 
it  does  not  come  mental  disease. 

That  the  brain  is  tiie  instrument  or  organ  of  the 
mind  we  have  the  testimony  of  many  eminent  writers. 
Sir  William  C.  Ellis,  superintendent  of  the  Middlesex 
Lunatic  Asylum  in  England,  declared :'  "Insanity  is 
a  disease  of  the  brain."  J.  M.  Cox  in  1805  said:"  "I 
am  inclined  to  believe  that  in  every  case  of  insanity, 
be  the  remote  causes  what  they  may,  the  proximate 
causes  reside  in  the  brain.''  Dr.  John  S.  Gray,  who 
has  done  excellent  work  in  this  department,  at  one 
time  editor  of  'J'/ie  Journal  oj  Jiisanily,  ^nit  professor 
of  psychological  medicine  in  bellevue  College,  1868, 
said:'  "Insanity  is  now  generally  recognized  as  a 
disease  of  the  brain.  A  necessary  antecedent  to  mad- 
ness is  a  disordered  physical  state  of  the  brain,  that 
it  never  occurs  in  a  person  of  sound  brain."  C.  B. 
Coventry,  professor  of  obstetrics  and  medical  juris- 
prudence, Geneva  College,  wrote:*  "Insanity  is  only 
a  symptom  of  derangement  of  some  portion  of  the 
brain.  That  the  brain  is  the  instrument  or  medium 
of  all  mental  and  moral  manifestations,  is  a  fact  so 
clearly  established  and  susceptible  of  demonstration." 

'  "A  Treatise  on  the  Nature.  Symptoms,  Causes,  and  Treat- 
ment of  Insanity. "  London.  1S38. 

'  "  I'ractical  Observations  on  Insanity,''  p    42. 

'Journal  of  Insanity.  1S72.  xxix  .  p    261 

■"  Trans,  of  the  Med   Soc,  State  of  New  York,  vol.  v.,  1841-43. 


Henry  Maudsley  says:'  "Insanity  is  disorder  of  the 
brain  producing  disorder  of  the  mind."  Dr.  Folsom, 
lecturer  on  hygiene  and  mental  disease  in  Harvard 
University,  wrote  :'"  "No  one  will  pretend  to  deny  that 
the  brain  is  the  organ  of  the  mind,  and  that  anomalous 
action  of  the  mind  depends  directly  upon  abnormal 
conditions  of  the  brain,  idiopathic,  functional,  or  re- 
flex." Tuke  says  :^  "  Insanity  consists  of  morbid  con- 
ditions of  the  brain,'' and  Morel  declares'  that  "all 
these  extraordinary  phenomena  have  their  seat  in  the 
brain,  and  we  will  find  when  we  prove  them,  that  it  is 
the  brain  that  is  not  sound  (c'est  que  le  cerveau 
n'est  pas  sain)." 

Going  far  back  to  the  close  students  and  clear 
thinkers  of  ancient  times,  Hippocrates  more  than  two 
thousand  years  ago  declared:'  "It  is  by  the  brain 
that  we  think,  comprehend,  see,  understand,  that  we 
know  the  evil  and  the  good,  the  agreeable  and  the  dis- 
agreeable. ...  It  is,  too,  by  that  we  are  fools,  by  that 
we  are  delirious,  and  by  that  the  fears  or  terrors  be- 
siege us  by  night  and  by  day."  Lord  Bacon,  with  his 
clear  intuition,  said:  "If  ever  the  true  nature  of  in- 
sanity was  discovered  it  would  be  found  to  exist  in 
corporeal  changes,  or  the  effects  of  external  agents  act- 
ing on  the  gross  machines,  not  on  the  immaterial  prin- 
ciple." 

F.  Winslow,'  in  his  book  on  "  Diseases  of  the 
Brain,"  tells  us  "  Defour  attempts  to  prove  that  the 
brain  has  directly  no  connection  with  insanity,  that 
alienation  of  the  mind  is  consequent  upon  some  affec- 
tion of  the  nervous  ganglia  of  the  abdomen,  and  that 
Fode're  imputes  insanity  to  an  alteration  of  the  vital 
principle,  and  that  Pinel  is  of  opinion  that  insanity 
frequently  arises  from  visceral  complications." 

Bancroft  says:  "I  fully  admit  that  a  large  propor- 
tion of  cases  of  insanity  even  in  both  sexes  are  of 
reflex  origin,  and  not  the  result  primarily  of  cerebral 
disease."  Storer'  tells  us  that  Workman,  of  Toronto, 
argued  for  the  extracerebral  causation  of  insanity 
that,  unless  in  confirmed  low  dementia  and  idiocy, 
insanity  has  no  necessary  connection  with  diseased 
brain  properly  so-called.  Storer  admits  that  "the 
brain  is  the  seat  of  insanity,  but  not  always  of  its 
cause;  that  we  are  compelled  at  times  to  seek  the  ulti- 
mate cause  of  insanity  outside  of  the  brain,"  adding: 
"Of  the  various  forms  of  insanity  occurring  in  females, 
the  majority  of  them  are  owing  to  functional  or  organic 
diseases  of  the  uterus  and  its  appendages." 

So  an  infinite  number  of  causes  of  insanity  are  given 
by  different  writers.  Scarcely  an  organ  or  function 
of  the  body,  or  any  human  act  or  passion  but  has  been 
presented  as  a  cause. 

Forbes  Winslow  makes  the  inquiry  :  "  Whether  there 
is  any  specific  and  clearly  definable  characteristic 
organic  alterations  in  the  encephalic  mass  invariably 
present  in  insanity  and  that  can  be  considered  to 
stand  in  relation  to  cause  and  effect."  He  adds:  "I 
have  often  been  much  surprised  when  examining  the 
heads  of  patients  who  have  died  from  the  effects  of 
acute  insanity,  by  the  remarkable  absence,  or  even  an 
approximation  to  an  adequate  physical  cause  of  the 
fatal  disease." 

There  is  reason  to  believe  that  in  all  cases  of  in- 
sanity there  will  be  found  in  the  brain  some  corre- 
sponding pathological  condition.  In  many  organs  of 
the  body  we  have  often  observed  that  even  profound 
pathological  changes  cannot  always  be  recognized  by 

'  "  Responsibility  in  Mental  Disease."  International  Scientific 
Series,   New  York,   lS8l. 

'  Boston  Medical  and  Surgical  Journal,  1880. 

'"  Dictionary  of  Psychological  Medicine." 

■*  "  Traite  des  maladies  mentales,"  1S60,  p.  3. 

*  "  Les  maladies  sacrees." 

'"On  Obscure  Diseases  of  the  ISrain  and  Disorders  of  the 
Mind,"  1868.  p.  774. 

'  "  Insanity  in  Women,"  Horatio  R.  Storer,  1871,  p.  37. 


the  naked  eye.'  I  believe  in  all  cases  of  acute  or 
chronic  insanity  there  are  structural  changes  in  the 
brain.  John  S.  Gray  says:'  "We  are  every  day  dis- 
covering structural  degeneration  of  brain  tissues  which 
throws  more  and  more  light  on  causation." 

Storer  asserts  that  insanity  may  exist  without  struc- 
tural changes  in  the  brain,  quoting  the  following  au- 
tJiorities  to  sustain  his  views:  Bell,  of  MacLean  Asy- 
lum, "  Autopsies  of  the  insane  generally  present  no 
material  lesion  of  the  brain  "  ;  Worthington,  "  Insanity 
is  unattended  with  any  organic  cerebral  change,  the 
disease  is  very  commonly  consecutive  to  disorders  of 
the  general  system;"  Bucknell,  "A  large  number  of 
brains  of  the  insane  we  have  diligently  investigated 
with  a  first-rate  microscope.  The  results  appear  to  us 
to  have  afforded  no  distinction  between  the  sane  and 
the  insane  brain." 

In  opposition  to  these  views,  Armstrong  declares 
that  in  regard  to  the  anatomical  pathology  of  insan- 
ity he  has  never  seen  the  body  of  a  patient  who  died 
mad  in  which  there  was  not  disease  of  the  brain  ;  that  he 
has  never  seen  an  autopsy  without  some  one  unequiv- 
ocal appearance  of  organic  change  presenting  itself  to 
the  careful  and  patient  examiner.  Portal  writes  as 
follows:  "Morbid  alterations  in  the  brain  and  spinal 
marrow  have  been  so  constantly  observed,  that  I  should 
greatly  prefer  to  doubt  the  sufficiency  of  my  own  senses 
than  to  believe  thatinental  disease  could  exist  without 
any  physical  disease  of  this  viscus."  Dr.  Brigham, 
one  time  editor  of  The  Journal  oj  Insanity,  says:  "On 
examining  the  heads  of  those  who  die  insane,  some 
disease  of  the  brain  or  appendages  is  generally  found." 

Probably,  if  these  diseased  portions  of  the  brain 
were  prepared  by  the  best  processes  for  microscopical 
investigation,  we  should  find  a  more  wonderful  record 
than  we  have  yet  conceived  of.  Dr.  Davison,  of  the 
Lancaster  County  Lunatic  Asylum,  says  he  scarcely 
ever  met  with  a  single  instance  where  traces  of  disease 
either  of  the  brain  or  membrane  were  not  evident. 
Dr.  Clutterbach,  of  Great  Britain,  says:  "I  think 
we  are  warranted  in  attributing  every  disorder  of  the 
mental  functions  to  a  diseased  condition  of  the  brain 
as  its  immediate  cause,  of  which  the  derangement  of 
the  intellect  is  but  a  sign  or  symptom."  Another 
writer  adds:  "The  reason  why  it  is  not  detected  is 
owing  to  our  defective  means  of  examination."  Ellis 
in  his  excellent  work  wrote:'  "We  know  quite  as 
little  of  the  anatomy  of  the  brain  as  of  any  other  part 
of  the  human  body."  E.  C.  Mann  declares  that  "the 
pathology  of  insanity  is  as  yet  in  its  infancy."  Still 
we  should  endeavor  to  look  into  it,  for,  as  Mauds- 
ley  says:'  "We  have  not  to  deal  with  disease  of  a 
metaphysical  character  which  the  methods  of  induc- 
tive inquiry  cannot  reach,  nor  the  resources  of  the 
medical  art  touch,  but  with  disease  of  the  nervous 
system,  disclosing  itself  by  physical  and  mental  symp- 
toms." 

The  question  is  asked.  Is  there  in  woman  a  "corre- 
lation of  sexual  function  with  insanity  and  crime?" 
\^'ould  not  this  prove  some  defect  in  the  formation 
of  one-lialf  of  the  human  race?  As  little  could  I  be- 
lieve that  menstruation,  when  normal,  originates  mor- 
bid impulses.  Can  any  normal  function  give  rise  to 
abnormal  impulses?  Is  it  likely  that  in  a  young  girl, 
in  this  her  first  function  of  womanhood,  are  originated 

'  I  said  in  the  American  Journal  of  Obstetrics,  February,  18SS, 
p.  15S:  "We  cannot  always  tell  by  naked-eye  appearances 
whether  there  is  disease  or  not  ;  apparently  the  healthiest  ovary  I 
ever  removed  from  the  human  body  contained  in  it  an  encysted 
sarcoma,  yet  before  its  removal  I  knew  well  from  the  history  and 
examination  that  it  was  diseased,  but  the  naked-eye  appearances 
did  not  show  it." 

■-' Journal  of  Insanity.  October,  1872,  p.  26S. 

■' "  A  Treatise  on  the  Nature,  Symptoms,  Causes,  and  Treat- 
ment of  Insanity,"  London,  1S38. 

■"New  York  Medical  Journal,  1874,  p.  561. 


morbid  impulses?  Many  a  young  won. an  I  have  seen 
suffering  almost  untold  agony  during  this  period,  yet 
there  were  no  abnormal  impulses,  nor  was  the  young 
girl  prompted  to  any  crime,  nor  did  she  manifest  any 
criminal  intent.  She  was  an  angel  in  goodness,  pu- 
rity, and  innocence,  and  a  martyr  in  her  sufferings. 

Menstruation  naturally  should  be  a  normal  func- 
tion, and  should  not  be  accompanied  by  any  suffering 
or  pain.'  Only  past  violations  of  the  laws  of  health 
make  these  conditions  of  suffering.  I  know  women  who 
during  all  the  long  years  of  their  lives  had  never  one 
painful  menstruation.  ISut  even  abnormalities  of  the 
menstrual  function  and  the  sufferings  thereof  have  no 
correlation  witii,  nor  do  they  point  to  or  lead  to  crime. 
The  criminal  intents  are  in  the  individual's  mind  and 
heart.  Nothing  could  be  farther  from  a  true  presen- 
tation of  the  subject  than  that  the  process  of  menstrua- 
tion, or  abnormal  conditions  thereof,  affect  a  woman 
by  originating  morbid  impulses  and  criminal  intents. 

Just  as  impossible  is  it  to  believe  that  that  most 
complex  function,  ovulation — as  yet  une.xplained — 
when  normal  is,  in  any  of  its  processes,  a  source  of 
irritation,  or  of  the  least  disturbance  to  the  mental 
organization;  nor  does  this  high  function  originate 
morbid  impulses.  Ovulation  is  a  normal  process,  con- 
trolled by  fixed  laws,  and  when  normal  makes  no 
mental  disturbance,  nor  has  it  any  connection  with  or 
tendency  to  produce  insanity.  I  believe  the  perform- 
ance of  any  and  every  function,  when  normal,  contrib- 
utes to  and  helps  perfect  tiie  general  health,  mental 
and  physical.  The  whole  .system,  every  part  and 
every  function,  in  a  state  of  health  is  in  such  liarmony 
that  it  is  almost  the  music  of  the  spheres,  and  even 
more  beautiful. 

It  is  true  and  is  recognized  by  many  eminent  phy- 
sicians that  a  disease  of  the  genital  organs  in  woman 
may  be  a  source  of  great  irritation  and  disturbance  to 
her  whole  system,  and  may  cause  such  exhaustion  and 
prostration  as  to  produce  extreme  nervousness,  and, 
in  some  cases,  more  or  less  abnormal  manifestations, 
and  even  mania  and  insanit)'.  But  these  mental  ab- 
normalities can  take  place  only  in  those  who  have 
some  neurosis,  brain  lesion,  or  disease  of  the  brain 
of  some  kind,  or  an  inherited  tendency  thereto.  In 
over  one  hundred  laparotomies  performed  in  the  Wo- 
man's Hospital  of  Brooklyn  for  some  of  the  worst  and 
most  varied  forms  of  pelvic  disease,  there  were  four 
cases  of  abnormal  mental  conditions. 

Cask  I. — Ovaries  and  tubes  showed  most  serious 
conditions  of  disease.  The  cervix  and  perineum  were 
lacerated,  the  torn  edges  of  each  covered  by  hard  cica- 
tricial tissue.  All  these  conditions  were  not  only 
sources  of  suffering  and  ill  health,  but  apparently  of 
abnormal  irritations  to  her  nervous  system.  Her  men- 
tal conditions  were  so  disturbed  that  her  friends  thought 
she  was  becoming  insane.  The  patient  told  me  tiiat 
she  felt  as  if  she  must  kill  some  one,  that  many  times 
she  felt  like  killing  her  own  children. 

This  woman,  no  doubt,  had  some  inherited  tendency 
to  insanity.  There  was  some  lesion  of  the  brain,  and 
the  diseased  condition  of  the  pelvic  organs  proved  to 
be  a  source  of  increased  irritation  to  this  already  sen- 
sitive and  diseased  brain.  These  pelvic  conditions 
were  also  destroying  her  physical  health,  and  rendering 
her  system  less  able  to  overcome  and  prevent  the  de- 
vastating results  of  the  brain  lesion.  Such  a  diseased 
condition  of  the  genital  organs  would  in  the  most 
sane  woman  have  been  a  source  of  great  distress  and 

'  I  said  in  an  article.  Amer.  Jour,  of  Obstet.,  Februar)-.  iS88, 
p.  173  :  "  The  functions  of  ovulation  and  menstruation  are  physi- 
ological and  their  healthy  performance  certainly  has  a  benign 
effect  upon  all  the  organs  and  functions  of  the  body."  In  the 
Medical  and  Surgical  Reporter,  Philadelphia.  May  27,  iS()3.  I 
said  :  "A  woman  with  a  healthy  genital  organization  goes 
through  the  function  of  menstruation  as  naturally,  normally,  and 
painlessly  as  the  digestion  of  food  by  a  vigorous  stomach." 


disturbance  to  her  general  health.  This  mentally 
affected  woman  was  less  able  to  bear  it;  it  was  such 
an  irritation  that  it  had  a  tendency  to  increase  or  ex- 
cite an  abnormal  mental  condition.  Indeed,  this  dis- 
eased condition  of  the  genital  apparatus  may  have 
been  at. first  the  exciting  cause  to  an  already  diseased 
brain  to  awaken  the  abnormal  manifestations;  but  it 
was  only  because  of  a  pre-existing  brain  lesion,  or 
the  brain  was  by  some  defect,  disease,  or  inherited 
tendency  predisposed  to  insanity.'  I  have  repeatedly 
found  etiually  and  profoundly  diseased  conditions  of 
the  genital  organization,  in  women  suffering  infinitely 
more,  and  not  the  least  indication  of,  or  tendency  to, 
mental  aberration. 

We  often  find  some  of  the  worst  forms  of  disease  of 
the  genital  organs,  continued  suffering  for  years,  ac- 
companied by  the  greatest  prostration  in  those  who  are 
mentally  sound,  or  who  have  no  structural  lesion  of 
the  brain  or  inherited  tendency  thereto,  and  there  will 
be  no  indications  of  insanity.  Manifestly  these  dis- 
eased organs  in  this  partially  insane  woman  were  not 
only  destroying  her  health,  taking  her  strength,  endan- 
gering her  life,  but  were  an  irritation  to  the  whole 
nervous  system,  and  increasing  her  tendency  to  insan- 
ity. The  removal  of  such  hopelessly  diseased  struc- 
tures and  repair  of  the  surgical  injuries  were  certainly 
demanded  in  her  case,  and  would  have  been  a  bless- 
ing to  any  woman  who  had  similar  conditions,  whether 
sane  or  insane.  The  diseased  tubes  and  ovaries,  so 
bound  in  adhesions,  were  removed;  as  was  the  cicatri- 
cial tissue  from  the  cervix  and  perineum,  and  the  gaping 
wounds  were  sewed  up.  All  indications  of  insanity  dis- 
appeared in  her  case;  she  was  under  observation  some 
two  or  three  years,  apparently  in  good  mental  and 
physical  health.  I  saw  the  patient  last  in  August, 
1889.  She  was  well  and  gave  every  indication  of 
good  health,  both  of  body  and  of  mind,  and  with  proper 
care  she  may  continue  to  grow  stronger  and  stronger, 
mentally  and  physically.  Yet,  from  adverse  causes, 
there  may  be  a  return  of  the  insanity. 

Case  II. — In  1887  I  was  rec|uested  by  a  physician 
in  Bridgeport,  Conn.,  to  see  a  patient  in  the  neighbor- 
ing town  of  Ansonia.  The  patient  was  twenty-five 
years  old,  a  teacher  by  profession,  married  six  years; 
no  children;  weighed  seventy-five  pounds;  tempera- 
ture 101°.  For  five  years  she  had  been  an  invalid,  un- 
able to  attend  to  her  household  duties.  She  was  now- 
confined  to  her  bed,  nervous,  hysterical,  and  at  times 
wildly  insane,  more  than  once  threatening  to  take  her 
own  life.  The  patient  was  so  weak,  and  so  great  were 
her  paroxysms  of  pain,  that  a  number  of  times  her 
husband  and  mother  thought  she  was  dying. 

She  was  carried  in  her  husband's  arms  to  the 
Woman's  Hospital  of  Brooklyn,  of  which  I  then  had 
charge,  and  while  there  she  had  hallucinations  that 
could  not  be  dispelled.  The  uterine  appendages  were 
found  to  be  enlarged,  sensitive,  and  low  down  behind 
a  retroverted  uterus.  Kvery  evacuation  of  the  bowels 
caused  extreme  pain  and  almost  a  deathlike  weakness. 
Menstruation  was  accompanied  by  suffering  and  a 
prostration  so  extreme  that  it  did  not  seem  possible 
for  her  feeble  frame  long  to  endure  it.  The  patient 
had  pyosalpinx  on  both  sides  and  pelvic  peritonitis. 
There  seemed  to  be  no  other  help  than  the  removal  of 
the  diseased  organs.  After  consultation  it  was  de- 
cided to  perform  the  operation,  which  was  done  in 
July,  1887.  Dr.  A.  M.  Jacobus  was  present.  The 
patient  made  a  good  recovery,  and  at  the  end  of  the 
second  week  went  up  and  down  stairs  without  assist- 
ance, and  rode  out.     At  the  end  of  the  fourth  week  she 

'  I  am  glad  to  find  a  corroboration  of  my  views  by  so  e.xcellent 
an  authority  as  T.  Claye  Shaw  ("St.  Bartholomew's  Hospital 
Report."  vol.  x.xii.,  1SS6,  p.  105).  "  It  seems  the  uterine  affec- 
tioes  do  not  cause  insanity  unless  there  is  already  a  predisposi- 
tion to  it." 


accompanied  her  husband  home,  and  that  day  walked 
as  much  as  a  mile.  Subsequent!}'  her  general  health 
and  mental  state  still  more  improved,  and  she  was 
soon  able  to  attend  to  her  household  duties.  The 
•ovaries  when  examined  microscopically  were  found 
to  be  not  only  in  a  state  of  intense  oophoritis,  but 
there  were  large  gyromatous  formations;  which  latter, 
no  doubt,  were  the  cause  of,  or  certainly  intensified, 
the  morbid  conditions  of  the  nervous  system. 

Such  is  about  the  report  I  felt  justified  in  making 
of  this  case  in  1890  and  1892.'  I  supposed  the  pa- 
tient was  well,  that  her  abnormal  mental  conditions 
were  relieved.  I  had  then,  and  have  still,  no  doubt 
that  the  large,  solid,  gyromatous  formations  impinged 
upon  and  compressed  the  nerves  so  as  to  cause  severe 
reflex  irritations.  Yet  all  this  suffering  I  do  not  be- 
lieve would  have  caused  insanity  in  this  vi'oman  unless 
she  already  had  some  disease  of  the  brain,  or  an  in- 
herited tendency  thereto. 

After  the  removal  of  the  incurably  diseased  struc- 
tures her  health  was  so  much  better  in  every  way  that 
I  thought  she  was  cured  both  mentally  and  physically. 
But  subsequently,  amid  the  multiplied  discourage- 
ments of  her  household — no  pleasant  lookout  for  a 
fine  nature  previously  educated — there  came  again  the 
depression  and  melancholy,  and  the  slighter  symptoms 
of  insanity.  I  could  imagine  that  if  it  had  been  pos- 
sible for  this  woman  to  have  the  happiness  of  chil- 
dren, with  that  brightness  and  ever  new  delight  she 
might  have  passed  through  life  without  another  symp- 
tom of  insanity.  The  removal  of  these  diseased  struc- 
tures had,  no  doubt,  greatly  improved  her  health,  and 
may  have  saved  her  from  a  more  helpless  madness; 
and,  under  more  favorable  circumstances,  she  might 
have  been  cured. 

When  these  organs  are  incurably  diseased  I  believe 
it  is  a  blessing  to  any  woman  to  have  them  removed. 
The  removal  not  only  saves  much  suffering,  but  in  many 
instances  saves  her  life,  and  tends  to  cure  the  mental 
malady. 

Case  III. — The  third  patient,  Mrs.  F ,  with  in- 
dications of  insanity.  Blood  cyst  in  one  ovary,  endo- 
thelioma in  the  other;  intense  oophoritis,  waxy  de- 
generation of  the  ovum.  There  was  a  great  mental 
disturbance.  The  patient  had  suffered  for  some  years, 
and  was  unable  to  attend  to  her  household  duties. 
After  the  operation  she  regained  her  health  and  im- 
proved in  mental  condition.  She  was  under  observa- 
tion for  several  years,  and  at  times  I  thought  her  mind 
was  a  little  unbalanced.  Yet  I  believed  that  after  re- 
moving this  source  of  irritation  and  suffering  and  in- 
creasingly bad  health,  there  were,  with  proper  care, 
many  chances  for  the  brain  gradually  to  recover  its 
wonted  good  health. 

Case  IV.— On  May  30,  1888,  a  patient,  Mary  G , 

was  brought  by  her  mother  to  me.  She  was  an  epilep- 
tic, had  had  repeated  attacks  of  peritonitis,  and  now 
complained  especially  of  great  distress  in  the  pelvis. 
One  ovary  was  enlarged  into  a  blood  cyst,  the  size  of  an 
orange;  there  was  pyosalpingitis  of  both  tubes,  and  the 
appendages  on  each  side  were  bound  in  inflammatory 
adhesions.  I  informed  the  mother  and  daughter  that 
these  organs  could  not  be  cured,  and  that  they  were  not 
only  a  cause  of  increased  suffering,  but  attended  by  some 
danger.  The  mother  and  daughter  were  both  anxious 
that  the  operation  siiould  be  performed.  They  called 
again,  and  in  a  few  days  the  mother  brought  the 
daughter  to  the  hospital,  725  Greene  Avenue.  It  was 
deemed  advisable  to  perform  the  operation  as  soon  as 
possible.  It  took  place  December  13,  1888.  The 
tumor  was  foun.d  to  be  a  blood  cyst  of  the  ovary,  de- 
veloped from  an  endothelioma.  This  blood  cyst  was 
bound  firmly  by  pseudo-membranous  adhesions  to  the 

'  New  Vorlt  Medical  Journal,  May  10,  17,  1S90.  p.  511  ;  and 
liuPfalo  Medical  Journal.  November,  1892. 


w-alls  of  the  pelvis,  so  also  was  the  other  ovary.  The 
tubes  also  gave  evidence  of  long  existing  disease. 
The  patient  made  an  excellent  recovery,  and  was  able 
to  be  up  in  three  weeks,  free  from  pain,  and  every  day 
seemed  to  grow  stronger  and  better,  and  did  not  at  the 
time  have  a  return  of  the  epilepsy. 

As  this  operation  seemed  to  be  of  such  essential 
benefit,  wishing  to  remove  all  trouble  I  passed  the 
patient  over  to  the  department  of  general  surgery  for 
the  depressed  bone  of  the  skull  to  be  raised,  several 
physicians  whom  she  had  consulted  having  considered 
this  the  cause  of  the  epilepsy.  The  operation  was 
successfully  performed,  January  25.  1899,  and  from  it 
the  patient  made  an  excellent  recovery,  but  after  it  the 
attacks  of  epilepsy  seemed  to  recur,  though  they  again 
gradually  diminished  in  number.  Certainly  the  pa- 
tient was  cured  of  her  pelvic  trouble,  and  to  that  ex- 
tent her  general  system  was  benefited.  But  epilepsy 
is  a  disease  or  defect  of  the  brain,  and  after  we  have 
removed  what  may  be  the  exciting  cause,  the  trouble  is 
still  there,  as  Hippocrates,'  whom  Fode're  "  calls  "  le 
divin  vieillard,"  says  of  epilepsy:  "The  truth  is  the 
brain  is  the  origin  of  this  affection  as  of  all  other 
great  maladies.'' 

When  the  ovaries  are  diseased  their  removal  does 
good,  but  when  the  organs  are  normal,  their  removal 
can  result  in  no  benefit,  but  rather  in  harm  to  the  indi- 
vidual. Professor  Schroeder  stated  that  he  had  oper- 
ated twelve  times  for  the  removal  of  healthy  ovaries 
for  neurosis.  I  said  in  an  article,  1893  :  "  I  denounce 
the  removal  of  the  uterine  appendages  for  any  cause, 
neurotic  condition,  or  constitutional  disturbance,  or 
for  any  reason  except  incurable  disease  of  the  organs 
themselves;  and  when  thus  diseased  they  are  a  con- 
tinual injury  to  the  system,  and  their  removal  is  a  last- 
ing benefit."''  In  the  same  article  I  said:*  "Even  if 
the  epilepsy  results  from  deep  lesion  of  the  nervous 
system,  yet  a  disease  of  the  uterine  appendages  will 
aggravate  the  conditions  and  be  a  source  of  increasing 
suffering,  and  there  is  no  reason  why  a  person  should 
not  be  relieved  as  much  as  possible." 

I  further  remarked.  "  pelvic  disease  may  in  some  so 
disturb  the  nervous  system  as  to  cause  some  form  of 
insanity;"  but  this  can  be  only  in  those  who  have  a 
tendency  to  or  a  pre-existing  brain  trouble.  I  con- 
tinued: "The  removal  of  the  diseased  structures  will 
assuredly  relieve  the  physical  suffering  of  the  patient 
in  this  direction,  and  there  is  no  reason  why  sick 
women  should  not  be  relieved  as  much  as  possible. 
The  same  in  cases  of  insanity,  when  the  uterine  ap- 
pendages are  profoundly  diseased  and  are  only  a  source 
of  suffering  and  danger,  is  there  any  reason  why  they 
should  not  be  removed.'"  I  closed  the  article  by 
saying,  "  I  plead,  in  the  interest  of  humanity,  for  these 
poor  overburdened  women."  ' 

From  The  Jouinal  of  the  American  Aledical  Associa- 
tion, September   i,    1900,  we   see   that   this   important 

»  '  "  I.es  maladies  sacrees. " 

'-  "  Medecine  legale,"  1S13,  p.  17. 

'  In  the  Amer.  Jour,  of  Obstet.  Februarj',  1888,  vol.  xxi..  p. 
158,  I  say;  "I  would  not  remove  healthy  ovaries  for  dys- 
menorrhcca,  or  any  suflering  in  the  regions  of  the  ovaries.  I 
would  not  remove  them  for  epilepsy,  Ijelieving  the  lesion  to  be 
elsewhere.  ...  I  would  not  remove  them  for  mental  or  neurotic 
disease.  I  have  never  operated  on  a  case  but  I  had  full  and  sub- 
stantial reason  to  diagnose  incurable  disease  of  the  appendages. " 
I  said  again  in  the  New  \'ork  Medical  Journal,  May  10,  iS.  1890, 
p.  511,  "I  make  the  'uncompromising'  sweep  of  excluding  all 
cases  from  this  operation  except  where  there  is  hopeless  disease 
of  the  organs  themselves." 

^  The  Medical  and  Surgical  Reporter,  Thiladelphia,  May  22, 
1893. 

■■■  Hut  \  realize  the  difliculty  as  stated  by  some  neurologists, 
and  for  their  opinion  I  have  the  most  profound  respect.  T. 
C'laye  Shaw  says  in  St.  Bartholomew's  Hospital  Report,  vol. 
xxii.,  1886,  p.  105;  "Many  women  are  too  violent  to  be  ex- 
amined, in  others  there  may  be  danger  of  setting  up  delusions  of 
a  sexual  nature," 


December  15,  1900] 


MEDICAL    RFXORD. 


929 


subject  was  presented  by  several  of  the  learned  mem- 
bers before  the  association  at  its  late  meeting.  Dr. 
G.  H.  Noble,  of  Atlanta,  Ga.,  in  an  excellent  paper 
put  forth  the  question,  "  Do  you  regard  malformations 
and  traumatisms  of  the  female  genital  apparatus  as  a 
cause  of  insanity?  "  He  gives  the  reply  of  Dr.  Maury, 
of  Memphis,  who  has  operated  a  number  of  times  and 
who  states  that  he  could  "'  not  recall  a  case  of  mental 
recovery,  and  that  his  cases  of  surgical  traumatism 
showed  evidence  of  previous  insanity."  Dr.  Noble 
quotes  Hobbs  as  saying:  "I  have  never  yet  seen  a 
patient  entirely  relieved  of  a  mental  disease  as  the 
result  of  operative  treatment."  Dr.  Noble  closes  his 
article  with  the  timely  words,  "  Have  we  the  right  to 
deny  insane  women  the  privilege  their  more  fortunate 
sisters  receive?  " 

Operative  treatment  in  time  might  possibly  save 
many  who  have  a  tendency  to  insanity.  i5ut  this  ten- 
dency in  them  and  (because  of  this  tendency)  insanity 
may  be  excited  by  various  adverse  causes,  physical  or 
mental.  Dr.  Vender  Veer,  of  Albany,  answered  Dr. 
Noble's  question  by  saying  that  he  did  not  believe 
traumatism  and  malformations  contribute  to  insanity. 
How  could  we  think  otherwise  when  there  are  millions 
of  women  who  suffer  from  these  traumatisms  who  do 
not  go  insane?  It  is  only  those  whose  innate  insanity 
is  developed  in  connection  with,  before,  or  after  the 
traumatism. 

Dr.  Carpenter,  professor  of  nervous  and  mental  dis- 
eases in  Ohio  Medical  University,  in  his  paper  quotes 
KralTt-Ebing  as  maintaining  that  the  influence  of  dis- 
eased generative  organs  in  women  should  not  be  un- 
derrated as  a  physical  cause  of  insanity.  Dr.  Car- 
penter adds  :  "  It  is  questionable  if  medical  knowledge 
and  experience  would  justify  operating  on  the  defective 
classes..  .  .  All  our  asylums  have  representatives  from 
these  classes  who  have  not  only  been  not  benefited,  but 
in  reality  have  been  made  worse  by  the  operation." 

Dr.  H.  .\.  Tomlinson,  superintendent  of  St.  Peter's 
Hospital,  Minnesota,  in  a  paper  presented  before  the 
American  Medical  Association.  September  3,  1899, 
tells  us  that  in  "only  ten  out  of  the  four  hundred  and 
fifty  women  was  there  any  exaggeration  of  the  mental 
disturbance  during  the  menstrual  period,  and  only 
two  complained  of  pliysical  discomfort:  two  women 
in  whom  there  was  apparently  a  distinct  relation  be- 
tween tile  menstrual  disorder  and  mental  disturbance. 
In  both  cases  the  uterus  and  ovaries  were  removed, 
and  there  was  not  only  no  improvement  in  the  mental 
condition,  but  a  distinct  increase  of  disturbance  after 
the  direct  effect  of  the  surgical  procedures  had  sub- 
sided, and  more  rapid  determination  of  dementia  fol- 
lowed the  artificial  establishment  of  the  menopause. 
Many  of  the  women  have  been  operated  on,  and  all 
needing  local  treatment  received  it,  but  in  the  major- 
ity of  cases  the  relief  of  the  pelvic  disorder  has  been 
practically  without  influence  on  the  mental  condition 
of  the  women." 

Dr.  Tomlinson  says  finally:  '"We  have  not  found 
that  there  is  any  particular  form  of  insanity  associated 
with  pelvic  disease.  In  fact,  most  of  the  cases,  after 
careful  examination  and  study  in  the  hospital  failed 
to  disclose  any  evidence  of  severe  pelvic  disease,  or 
any  connection  between  the  insanity  and  disease  of 
the  generative  organs." 

Dr.  R.  M.  Hucke'  reports  the  results  of  one  hundred 
and  ninety-five  operations:  "In  three  cases  the  pa- 
tients died  as  the  result  of  the  operation,  in  nearly  all 
the  rest  of  the  cases  the  physical  health  of  the  patient 
has  been  restored  or  greatly  improved."  As  regards 
the  mental  health :  "  In  thirty-nine  cases  the  patients 
recovered  from  insanity.  In  thirty-two  cases  there  has 
been  improvement  in  the  mental  insanity  of  the  pa- 
tients.    In  thirty-five  cases  there  has  been  noimprove- 

'  American  Journal  of  Insanity.  July.   iSgS,  Xo.  i.,  vol.  v. 


ment  in  the  patients'  mental  condition.  So  that 
seventy-two  out  of  ono  hundred  and  six  cases  who 
survived  the  operation  either  recovered  their  mental 
health,  or  this  was  improved."  The  author  remarks 
on  page  1 1,  "  It  is  my  opinion  that  very  few  of  these 
cases  would  have  recovered,  or  greatly  improved  if 
they  had  not  been  operated  upon.  Some  of  them  who 
did  well  must  have  very  soon  died  had  no  operation 
been  done." 

Dr.  Bucke  gives  some  most  remarkable  cases,  for 
instance  the  following,  the  patients  recovering  their 
mental  and  physical  healUi  soon  after  the  several 
operations:  i.  Chronic  mania  three  and  a  half  years' 
duration,  two  cystic  ovaries  removed.  2.  Chronic 
mania  two  years'  standing,  lacerated  cervix  repaired. 
3.  Chronic  mania  over  seven  years'  duration,  cystic 
ovaries  removed  and  lacerated  cervix  repaired.  4. 
Destructive  mania  for  five  years,  both  ovaries  re- 
moved— one  a  niultilocular  cyst,  size  of  an  orange,  the 
other  ovary  adherent  and  atrophied.  5.  Three  years 
insane,  ovariotomy  and  ventral  fixation.  6.  Chronic 
mania  sixteen  years'  standing;  ovaries  enlarged  and 
cystic,  tubts  adherent;  removal  of  tubes  and  ovaries. 
7.  Delusional  mania  five  years'  standing;  both  ova- 
ries removed,  one  a  cyst  of  fifteen  pounds.  8.  Delu- 
sional mania  two  years'  standing,  trachelorrhaphy. 
Many  other  cases  are  referred  to,  all  so  successful  that 
one  is  strongly  impressed  that  those  who  are  suffering 
and  need  an  operation  should  be  helped;  yet  the  emi- 
nent authority,  Dr.  Percy  Smith,  of  London,  says,  "he 
could  not  accept  the  views  held  by  some  American 
gynecologists  that  the  uterine  appendages  should  be 
removed  in  insanity."  Still  we  see  that  a  certain 
number  of  patients  are  relieved  of  at  least  a  portion 
of  their  distress.  F.  Claye  Shaw  in  1886,'  speaking  of 
one  of  his  patients  who  was  more  violent  during  the 
periods,  said  :  "  I  think  the  operation  of  oophorectomy 
would  have  much  relieved  her  symptoms,"  Dr,  Smith 
stated  that  "in  asylums  in  only  a  small  proportion  of 
cases  in  females  was  the  mental  disorder  due  to  dis- 
ease of  the  sexual  organs." 

I  believe  in  no  case  is  mental  disease  due  to  a  dis- 
ease of  the  sexual  organs.  Dr.  Holmes,  ex-president 
of  the  Canadian  Medical  Association,  years  ago  came 
to  the  conclusion  that  "  puerperal  insanity  is  nearly 
always  dependent  upon  some  lesion  of  the  generative 
organs."  Yet  there  are  millions  of  women  who  have 
lesions  of  the  generative  organs  and  no  tendency  to 
insanity. 

Dr.  Kellogg  is  of  opinion  that  "pelvic  disease  in 
women  may  be,  and  at  times  is,  the  cause  of  insanity, 
and  that  the  removal  of  the  pelvic  disease  by  opera- 
tion is  often  followed  by  a  relief  or  cure  of  the  mental 
alienation." 

This  subject  was  presented  before  the  British  Gyna;- 
cological  Society,  January,  1900.  The  president,  Dr. 
H.  McNaughton  Jones,  made  the  address  on  the  occa- 
sion: "The  Correlation  between  Sexual  Function, 
Insanity,  and  Crime."  Dr.  Jones  is  authority  on  all 
gyna;cological  questions.  His  work  on  "  Diseases  of 
Women  "  is  one  of  the  best  published — comprehensive, 
accurate,  and  reliable.  He  scans  every  fact  and 
brings  it  in  line  for  medical  instruction.  In  his  ad- 
dress before  the  Gynaecological  Society,  after  present- 
ing the  many  difterent  viev.s,  he  says:  "Personally! 
at  present  take  the  view  that,  in  the  great  majority  of 
cases  in  whicli  there  are  gross  lesions  of  the  sexual 
organs  present  in  insane  women,  and  even  w^hen  the 
lesion  has  preceded  the  insanity,  there  still  has  been 
pre-existing  to  the  lesion  what  Robert  Barnes  well 
calls  '  an  antecedent  nervous  condition  as  a  predispos- 
ing factor.'  " 

Let  us  glance  for  a  moment  at  some  of  the  causes 
of   insanity  as  presented   by  various  authors.     E.  Es- 

'  St.  Bartholomew's  }{o.spital  Report,  vol.  .xxii.,  1886,  p.  105. 


93° 


MEDICAL    RECORD. 


[December  15,  1900 


quirol  in  1858  published  a  learned  work  on  "Mala- 
dies Mentales,"  and  in  it  he  states  that  "the  causes  of 
mental  alienation  are  as  numerous  as  various."  This 
work,  he' says,  was  the  result  of  forty  years  of  study. 
But  this  great  scholar  not  being  fixed  by  the  funda- 
mental fact  that  the  brain  is  the  organ  of  the  mind 
wanders  in  much  mystery,  and  gives  a  countless  num- 
ber of  theories  and  untenable  suppositions  as  the 
causes  of  insanity.  They  may  be  interesting,  but  lead 
only  to  more  confusion  in  the  scientific  discussion  of 
this  most  important  subject. 

His  first  cause  of  insanity  is  "climats,"  saying: 
"Cold  climates  are  not  those  which  produce  le  plus 
de  fous,  mais  bien  les  climats  tempe're's."  Then  we 
might  expect  an  army  of  insane  people  in  all  temper- 
ate climates.  According  to  the  table  he  gives,  the 
greatest  number  of  insane  people  are  in  May,  June, 
July,  August,  and  September. 

Third  cause  of  insanity,  "ages."  lisquirol  says  of 
insanity  in  infants  that  some  vice  of  conformation 
or  infantile  convulsions  may  throw  them  into  imbecil- 
ity and  idiocy;  of  the  insanity  of  puberty,  that  in  the 
young  insanity  may  have  a  rapid  march;  that  mental 
alienation  may  be  divided  relatively  to  age — imbecil- 
ity for  the  infant,  mania  for  the  youth,  melancholy  for 
the  aged,  and  dementia  for  the  advanced  age. 

We  do  not  find  that  the  young  or  old  as  they  ap- 
proach any  particular  age  have  any  special  tendency 
to  insanity. 

Fourth  cause  of  insanity,  "  sexe,"  as  if  mental  dis- 
ease was  any  more  confined  to  sex  than  are  chills, 
fevers,  consumption,  etc.  The  author  says:  "Coelius 
Aurelianus  asserted  that  women  were  less  subject  to 
insanity  than  men."  This,  says  the  author,  was  true 
at  the  time  of  Coelius,  is  still  true  in  Italy  and  in 
Greece,  but  in  the  north  of  France  the  contrary  condi- 
tion exists  ("  le  nombre  des  femmes  alienees  y  est  plus 
considerable  que  celui  des  hommes").  He  tells  us 
from  1745  to  1775  Raymond  did  not  find  the  differ- 
ence between  the  two  sexes  among  the  insane  at  the 
Hospital  of  Marseilles,  and  that  in  1786  Tenon  found 
there  was  almost  an  equal  number  among  the  men  and 
the  women  in  the  public  and  special  houses  of  Paris; 
in  1802  Pinel  established  the  difference  of  one  man 
to  two  female  aliens  in  comparing  IJicetre  to  La  Sal- 
petriere;  that  in  1807  and  18 10,  among  the  hospitals 
of  the  principal  cities  of  France,  there  were  found 
about  six  thousand  aliens,  five  men  to  seven  women. 

The  director  of  the  Hospital  of  St.  Luke  reported 
that  he  received  annually  in  the  hospital  nearly  one- 
third  more  women  than  men.  In  the  hospital  of  Ber- 
lin the  proportion  of  men  to  women  is  one  to  two.  In 
the  hospital  of  Pennsylvania  the  proportion  is  the  re- 
verse, one  woman  to  two  men. 

So  we  might  goon  in  these  endless  endeavors.  We 
would  find  continually  varying  proportions.  Insanity 
is  not  controlled  by  sex,  or  necessarily  found  propor- 
tionally more  in  one  sex  than  in  the  other.  Just  as 
well  raise  the  question  in  regard  to  scarlet  fever,  how 
many  female  children  have  it  and  how  many  male. 
Richard  Grundy'  tells  us  that  "  Dr.  Thurman,  of  Vork, 
England,  and  Dr.  Jarvis,  of  Dorchester,  Mass.,  agree 
that  Esquirol's  conclusions  are  based  upon  imperfect 
premises.  Th2ir  investigations  lead  them  to  the  con- 
viction th?L  '  i-.jies  are  somewhat  more  liable  to  insan- 
ity than  females.' "  He  says:  "  The  statistics  of  sev- 
enteen asylums  in  the  United  States  show  the  admission 
to  be  in  the  following  proportions:  38,416  patients, 
there  were  20,233  males  and  18,213  females." 

F.  E.  Foderc  '  says :  "  Among  the  many  maniacs  con- 
fined to  my  care  a  great  number  are  of  the  female 
sex." 


69. 


Columbus  Review  of  Medicine  and  Surgery,  .Vugust,  i860,  p. 
''  "  Traite  de  medecine  legale,"  1S13,  vol.  i.,  p.   2og. 


Esquirol  gives  the  fifth  cause  of  insanity,  "temper- 
ament," and  says:  ''The  temperament  sanguine  is  one 
of  predisposition  to  mania.  The  nervous  and  lym- 
phatic temperament  is  favorable  to  the  production  of 
mania  and  monomania.  Of  two  hundred  and  sixty-five 
aliens  Haslam  found  two  hundred  and  fifty  whose 
hair  was  dark,  and  sixty  who  had  light  hair.  In 
Pennsylvania  Hospital  out  of  seventy  aliens  only  one 
had  light  hair,  fifty-six  had  the  eyes  blue  or  light." 

What  has  the  color  of  the  hair  to  do  with  insanity 
any  more  than  the  shape  of  the  nose  or  size  of  the 
ear?  Yet  the  author  on  page  40  says:  "In  general, 
those  who  have  the  hair  dark,  who  are  strong,  robust, 
of  a  sanguine  temperament  are  the  maniacal,  furious, 
the  march  of  their  insanity  is  more  acute.  Those 
whose  hair  is  blond,  who  have  blue  eyes,  a  lymphatic 
temperament,  become  maniacal  and  monomaniacal, 
then /a/i'e  passes  easily  to  a  chronic  condition,  and 
degenerates  into  dementia." 

Sixth  cause  of  insanity,  "professions,"  manner  of 
living.  Those  who  give  themselves  up  to  study  pre- 
sent a  condition  favorable  to  the  development  of 
mental  alienation.  He  quotes  Dryden  as  saying  that 
"men  of  genius  and  fools  are  very  near  together," 
and  says:  "The  frequency  oijolie  always  corresponds 
with  the  professions  which  make  men  more  depend 
upon  social  vicissitudes,  that  Aristotle  demanded  to 
know  why  great  legislators  are  all  melancholic;"  and 
M.  de  Humboldt  is  said  to  have  seen  very  few  aliens 
among  the  savages  of  America.  Carr  says  he  rarely 
saw  one  in  Russia.  Esquirol  says  in  France  there  are 
less  ^^foiis"  in  the  country  than  in  the  cities;  that  in 
England,  where  we  find  united  all  the  excesses  of  civil- 
ization, folic  is  more  frequent  than  elsewhere.  The 
badly  assorted  marriages,  or  those  contracted  between 
parents  above  all  in  families  in  which  there  is  an  he- 
reditary disposition  to  insanity,  the  habits  of  alcoholic 
drinking,  etc.,  are  the  causes  which  multiply  insanity 
in  England.  He  quotes  J.  J.  Rousseau  as  saying: 
"  Without  doubt  civilization  occasions  some  maladies 
and  augments  the  number  of  others." 

Is  it  reasonable  to  suppose  there  are  proportionally 
more  insane  people  among  the  educated,  and  among 
those  most  advanced  in  civilization,  than  among  the 
uneducated  and  uncivilized?  We  have  no  means  of 
knowing  the  number  of  insane  people  among  the  un- 
civilized nations,  but  we  do  know  that  the  brain,  like 
every  organ  in  the  body,  will  be  more  healthful  by 
judicious  and  regular  exercise.  Exercise  tends  to 
balance  the  circulation  and  prevent  localized  conges- 
tions. 

The  author  next  tells  us,  "that  excesses  in  eating 
should  be  placed  among  the  causes  of  mental  aliena- 
tion." On  page  50  he  speaks  on  the  infiuence  of  mar- 
riage upon  the  production  of  mental  alienation.  Mar- 
riage in  itself  is  calculated  to  produce  contentment, 
harmony,  and  happiness.  Even  if  the  marriage  should 
prove  unhappy,  and  there  may  be  thousands  that  do, 
yet  the  parties  do  not  necessarily  become  insane;  and 
if  insanity  should  occur  in  a  happy  or  unhappy  mar- 
riage, it  is  because  there  is  a  previous  disease  of  the 
brain,  or  hereditary  tendency  thereto. 

Seventh  cause,  "  passions."  Esquirol  says:  "Those 
which  produce  most  frequently  insanity  are  pride,  fear, 
fright,  ambition,  and  distresses  from  financial  re- 
verses." The  author  adds  that  heredity  is  the  most 
ordinary  predisposing  cause  of  insanity,  that  children 
who  are  born  before  the  parents  become  insane  are 
less  subject  to  mental  aberration  than  those  born  after- 
ward. The  author  continues:  "Menstruation  often 
produces  mental  alienation;  leucorrhoea  also  insan- 
ity. Pregnancy  is  a  cause  of  insanity,  but  sudden  or 
violentyt>//c  is  more  frequent  after  confinement,  and 
during  the  period  of  nursing  (I'allaitemcnt).  At  La 
Salpetri&re  of  six  hundred  insane  women  fifty-two  had 


December  15,  1900] 


MEDICAL    RECORD. 


931 


lost   their  reason   after    raccouchement   or    lactation. 
Some  females  become  aliens  after  each  confinement." 

Menstruation,  pregnancy,  and  lactation  are  all  nor- 
mal functions  and  are  not  a  cause  of  insanity;  but, 
from  disease  of  the  brain,  a  woman  may  become  in- 
sane while  performing  any  of  these  functions. 

Esquirol  gives  beautiful  lectures  on  all  the  foibles 
of  humanity,  placing  them  as  the  causes  of  insanity, 
forgetting  that  there  are  millions  who  have  all  these 
foibles  and  do  not  go  insane.  He  says:  "Blows upon 
the  head,  even  in  earliest  infancy,  predispose  to  in- 
sanity." What  child  does  not  get  repeated  blows  upon 
the  head — do  all  become  insane?  He  says:  "First 
dentition  if  causing  convulsion  in  infants  predisposes 
to  insanity." 

He  next  gives  the  republican  form  of  government 
as  most  favorable  to  the  production  of  insanity,  then 
names  a  number  of  affections  and  passions  that  lead 
to  insanity,  making  almost  every  passion  and  every 
incident  inhuman  life  a  cause  of  insanity.  Ksquirol's 
work,  "  Les  maladies  mentales,"  is  almost  universally 
quoted,  but  probably  it  might  have  been  better  if  the 
learned  author  had  written  not  quite  so  many  pages, 
or  if  he  had  prayed  the  beautiful  prayer  with  which 
Ik'njamiii  Rush  opens  his  book.'  Rush  says:  "I 
humijly  implore  that  Being  whose  government  extends 
to  the  thoughts  of  all  his  creatures,  so  to  direct  mine, 
in  this  arduous  undertaking,  that  nothing  hurtful  to 
my  fellow-citizens  may  fall  from  my  pen,  and  that  this 
work  may  be  the  means  of  lessening  a  portion  of  some 
of  the  greatest  evils  of  human  life." 

Dr.  Benjamin  Rush  gives  many  causes  mentioned 
by  Esquirol.  Rush's  book  was  written  in  1812,  Ks- 
quirol's in  1858.  Dr.  Rush  says:  "I  shall  now  men- 
tion climate,  state  of  society,  form  of  government, 
revolutions,  and  religion,"  He  makes  the  same  quota- 
tions from  Dryden,  Humboldt,  and  several  others  as 
appear  in  Esquirol's  book.  Dr.  Rush  says:  "A  pre- 
disposition to  madness  is  said  to  be  connected  with 
dark-colored  hair.  Mr.  Haslam  informs  us  that  this 
was  the  case  in  205  out  of  265  patients  in  Betiilem 
Hospital.  Of  nearly  70  patients  who  were  examined 
in  our  hospital,  in  the  year  18 10,  with  reference  to 
this  fact,  all  except  one  had  dark-colored  hair.  In 
the  month  of  April,  1812,  I  requested  Dr,  Vandjke  to 
direct  his  inquiries  more  particularly  to  the  color  of 
the  eyes  in  the  maniacal  patients  in  our  hospital,  and 
he  discovered  that  56  out  of  79  of  them  had  light- 
colored  eyes,  of  which  number  but  6  had  fair  hair. 
Women  in  consequence  of  the  greater  predisposition 
imparted  to  their  bodies  by  menstruation,  pregnancy, 
and  parturition  are  more  predisposed  to  madness  than 
men." 

Here  I  feel  I  must,  in  the  cause  of  truth,  dififer  from 
this  great  man.  iVeither  menstruation,  nor  pregnancy, 
nor  parturition  predisposes  to  madness.  Dr.  Rush 
continues:  "In  St.  Luke's  Hospital  in  London,  the 
proportion  of  women  to  men  who  had  been  admitted 
in  a  given  number  of  years,  is  in  the  ratio  of  three  to 
two.  But  this  disproportion  of  women  to  men  who 
are  affected  with  madness  is  by  no  means  universal. 
In  a  hospital  for  mad  people  in  Vienna,  1 17  men  were 
admitted  in  a  given  number  of  years,  and  but  94  wom- 
en. In  a  hospital  of  the  same  kind  in  Berlin,  twice  as 
many  males  were  admitted  in  a  given  time  as  females. 
More  of  the  former  than  the  latter  have  been  admitted 
into  the  Pennsylvania  Hospital.  Certain  climates 
predispose  to  madness,  also  certain  forms  of  govern- 
ment." 

Mr.  Forbes  Winslow'  on  many  points  agrees  with 
Esquirol.  He  gives  the  "seasons"  as  a  cause  of  in- 
sanity, and  follows  Esquirol    in    supposing   there    is 

'  "  Medical  Inquiries  and  Observations  upon  Diseases  of  the 
Mind,"  1812. 

■'   "  .Mad  Humanity,"  by  Forbes  Winslow,  London,  1898. 


more  insanity  among  women,  saying:  "In  England, 
and  I  believe  in  most  otiier  countries,  insanity  is  more 
prevalent  among  women  than  among  men.  .  .  .  'I'he 
greater  liability  of  the  female  sex  to  become  insane  is 
associated  witli  other  peculiarities  worthy  of  consider- 
ation." 

It  is  not  "sex,"  that  causes  insanity,  but  the  disease 
of  the  brain  in  either  sex.  On  page  227  he  says: 
"Domestic  cares  are  the  chief  cause  of  insanity  in 
women."  Millions  of  women  undergo  the  greatest  la- 
bors and  the  most  taxing  domestic  cares  and  show  no 
tendency  to  insanity;  indeed,  it  is  not  those  who  have 
the  most  domestic  care  who  go  insane.  Mr.  V\inslow 
says,  page  228:  "Of  course  woman  from  her  formation 
and  the  duties  she  has  to  perform  in  life  is  liable  to 
become  mentally  unhinged."  Then  woman  is  imper- 
fectly made,  if,  from  her  formation  and  duties,  she  is 
"  liable  to  become  mentally  unhinged."  Such  an  as- 
sertion is  almost  a  libel  on  the  Creator's  wisdom. 

Winslow  says:  "Drink  is  at  the  head  of  the  real 
causes  both  of  insanity  and  crime."  Then  he  gives  the 
moral  and  physical  causes  of  insanity — pecuniary 
difficulties,  domestic  troubles,  loss  of  relations,  mental 
anxiety,  overwork  and  worry,  intemperance,  accidents, 
sunstroke,  privation,  starvation,  sexual  excesses,  pe- 
cuniary anxieties,  and  a  host  of  other  things.' 

Winslow  continues:  "Among  the  tendencies  that 
serve  in  fostering  this  malady,  European  civiliza- 
tion shows  itself  as  one  of  the  most  potent.  Mental 
alienation  is  scarcely  ever  met  with  among  the  Asiat- 
ics, or  Africans,  or  among  the  savages  of  America. 
The  number  of  insane  people  is  largest  in  those  coun- 
tries where  the  most  liberty  is  allowed.  What  we  call 
European  manners,  social  conditions  and  progress 
offer  conditions  which  can  be  accepted  only  at  the 
risk  of  our  health  and  morals.  At  the  present  day 
there  is  more  insanity  than  in  the  middle  ages,  there 
is  less  in  Russia  than  in  England  and  France,  and 
there  is  very  little  among  the  Turks,  Arabs,  and  in 
the  uncivilized  parts  of  the  world.  In  those  parts  of 
the  world  where  the  mind  has  but  little  to  occupy 
itself,  there  is  less  likelihood  of  mental  derange- 
ment." 

The  tendency  of  all  advancement  in  civilization, 
with  improved  conditions  of  public  health,  should  tend 
to  lessen  the  number  of  insane  people.  Dr.  Henry 
Maudsley'  says:  "A  higher  mental  development  must 
tend  to  prevent  insanity.  The  intellect  suffers  more 
from  rusting  and  disuse  than  it  does  from  its  utmost 
use.  .  .  .  One  fact,"  says  he,  "  which  the  statistics  of 
insanity  in  England  has  clearly  shown  is  that  the 
purely  agricultural  counties  furnish  the  largest  per- 
centage of  insanity  in  proportion  to  tiie  population; 
that  is  to  say,  there  is  more  madness  where  there  are 
the  fewest  ideas,  the  simpler  feeling,  and  the  coarsest 
desires  and  ways," 

In  Pinel's  great  work,  second  edition,  1809,'  we 
find  given  (page  11)  the  following  causes  of  insanity: 
"  Age,  sex,  climate,  the  manner  of  life,  certain  epochs 

'  Considering  the  vast  number  of  causes  of  insanity,  and  the 
infinite  number  of  cases,  one  will  appreciate  the  kindly  considera- 
tion of  the  superintendent  of  the  Provincial  Lunatic  Asylum,  of 
Toronto,  Canad.i  West,  in  planning  for  or  thinking  of  the  ac- 
commodation of  the  increasing  crowd.  He  says  :  "  Now  if  any 
one  of  these  agencies  may  be  regarded  as  adequate  to  the  over- 
throw of  reason  how  many  lunatics  should  this  province  contain  ? 
Intemperance  alone  would  people  fifty  asylums  as  large  as  our 
present  one.  Jealous  husbands  and  wives  would  probably  fill 
thirty.  Political  excitement  would  tenant  a  madhouse  in  every 
county  and  one  of  superior  class  and  size  in  the  metropolis. 
Religious  controversy  would  send  in  half  the  clerg)'  of  this 
province,  and  large  detachments  of  the  congregations.  Slander, 
excessive  study,  remorse  of  conscience,  would  leave  few  in  Canada 
at  large." 

'  "  The  Pathology  of  the  Mind,"  1896,  p.  29. 

~  "  Traite  mcdico-philosophique  sur  I'alienation  mentale."  Par 
Pinel,  professeur  a  I'ecole  de  medecine  de  Paris,  et  medecin- 
en-chef  de  I'hospice  de  la  Salpetriere. 


932 


MEDICAL    RECORD. 


[December  15,  1900 


in  the  life  of  woman  such  as  puberty,  pregnancy, 
childbirth,  et  ce  qu'on  appelle  I'age  critique. 

On  page  418  he  says:  "The  most  ordinary  physical 
causes  are:  The  original  disposition,  the  suppression 
of  periodical  discharges,  accidents  during  childbirth, 
the  abuse  of  alcoholic  liquors,  blows  upon  the  head. 
The  moral  causes:  Terror,  disappointed  love,  reverses 
of  fortune,  domestic  trouble,  and  religious  excitement, 
or  exalted  devotion." 

Aretreus,  who  lived  in  the  time  of  Vespasian 
(Homer  and  Hippocrates  being  the  only  authors  he 
quotes)  gives  as  causes  of  insanity:  "Drunkenness, 
excesses  of  the  table,  venereal  pleasures,  or  anything 
that  causes  obstruction  to  an  habitual  excretion.  Oc- 
casionally women  will  become  affected  with  mania 
from  anienorrhoea." 

Dr.  T.  S.  Clouston,  superintendent  of  the  Edinburgh 
Royal  Asylum,  in  his  learned  work  '  makes  rather  a 
new  departure  in  regard  to  the  technical  names  of  in- 
sanity. He  speaks  of  syphilis  as  a  cause  of  insanity, 
calling  it  "syphilitic  insanity."  Syphilis  in  the  sys- 
tem must  affect  the  brain,  as  it  does  every  organ  in  the 
body,  but  why  call  it  "syphilitic  insanity"?  The 
author  places  alcohol  among  the  most  common  of  all 
causes,  denominating  one  form  "alcoholic  insanity," 
and  says :  "  There  are  few  of  the  unfavorable  conditions 
of  life  that  cause  more  human  degradation  than  the 
excessive  use  of  alcohol."  Of  "rheumatic  choreic  in- 
sanity," he  says  that  in  many  cases  rheumatism  was  the 
true  cause  of  both  the  chorea  and  the  insanity. 

He  next  gives,  page  521,  "uterine  and  amenor- 
rhoeal  insanity."  Can  we  admit  such  a  technical  name 
as  scientifically  accurate?  With  this  mode  of  nomen- 
clature we  may  have  an  infinite  number  of  forms  of 
insanity.  The  author  speaking  of  "disorders  of  men- 
struation and  their  relation  to  insanity,"  says:  "Two 
kinds  of  insanity  resulting,  acute  mania  and  melan- 
cholia." Unnumbered  women  have  disorders  of  men- 
struation without  the  least  tendency  to  either  of  tliese 
two  forms  of  insanity.  The  author  next  tells  us  that 
"disturbed  menstruation  is  a  constant  danger  to  the 
mental  stability  of  some  women  " — only  to  those  who 
have  some  brain  lesion  or  disease,  or  an  inherited 
tendency  thereto.  The  author  says:  "The  constant 
difficulty  the  physician  has,  is  to  know  whether  the 
disordered  or  suspended  menstruation  is  a  cause  of 
insanity  or  a  symptom." 

It  is  neither  a  cause  nor  a  symptom.  The  cause  of 
insanity  is  some  disordered  condition  of  the  brain. 
Suspended  menstruation  may  come  from  various 
causes  of  ill  health.  Many  women  have  disturbed  or 
suspended  menstruation  without  the  least  indication 
of  insanity,  yet  the  author  continues:  "Insanity  in 
some  few  cases  actually  results  de  novo  from  this  as 
an  exciting  or  predisposing  cause." 

Insanity  comes  only  from  some  abnormal  condition 
of  the  brain,  therefore  we  cannot  see  that  tliese  cases 
can  be  termed  "uterine  or  amenorrhceal  insanity." 

The  author  tells  us,  "the  risks  to  the  mental  func- 
tions of  the  brain  from  the  exhausting  causes  of  men- 
struation, maternity,  and  lactation,  from  the  nervous 
reflex  influences  of  ovulation,  conception,  and  parturi- 
tion are  often  enormous." 

Might  we  not  just  as  well  speak  of  the  "enormous 
and  exhausting  causes"  of  continued  breathing,  the 
incessant  action  of  the  heart,  and  the  unparalleled  de- 
mands of  tlie  continued  function  of  digestion,  the  con- 
stant demand  for  nutrition  of  the  whole  body,  and  of 
how  tiiey  are  "  risks  to  the  mental  functions  of  the 
brain  "? 

All  these  are  natural  physiological  processes,  and 
certainly  can  be  performed  without  any  risks  to  the 
mental  balance. 

'  "  Clinic.il  Lectures  on  Mental  Diseases,"  T.  S.  Clouston, 
fourth  edition,  London,  i8g6. 


Next  we  have  in  large  type  "ovarian  insanity 
(old  maid's  insanity)."  The  author  observes: 
"There  is  a  somewhat  ludicrous  form  of  insanity  that 
Dr.  Skae  called  '  ovarian,'  and  more  correctly  I  think, 
'old  maid's  insanity.'"  Both  of  these  terms  seem  ex- 
ceedingly inappropriate  and  unscientific.  Dr.  Clous- 
ton adds:  "The  disease  usually  occurs  in  unprepos- 
sessing old  maids.  The  ovaries  are  not  disturbed  in 
function  or  diseased  in  structure." 

Of  insanity  of  masturbation,  Clouston  says:  "The 
subjects  will  be  found  to  have  had  early  indication  of 
brain  disease,  or  a  neurotic  heredit)'."  This  explains 
why  they  are  insane,  and  probably  gives  a  reason  for 
the  vice  named. 

In  lecture  XV.  on  "puerperal  insanity,  lactational 
insanity,  the  insanity  of  pregnancy  "  the  first  sentence 
is:  "  Childbirth,  nursing,  and  pregnancy  in  women  are 
liable  to  act  as  exciting  causes  of  mental  disease." 
Can  we  accept  the  doctrine  that  normal  functions  act 
as  excitirig causes  of  mental  disease?  I  challenge  the 
whole  theory.  Then  all  women  should  be  shut  up  in 
some  immense  La  Salpetriere. 

The  author  says:  "The  regular  performance  of  the 
reproductive  functions  is  of  the  highest  importance  to 
the  mental  soundness  of  the  female.  Disturbed  men- 
struation is  a  constant  danger  to  the  mental  stability 
of  some  women."  Aretaus  said:  "  JNIania  from  amen- 
orrhcea."  Pinel  repeated  that  "  pregnancy,  childbirth, 
and  suppression  caused  insanity."  Kraff^t-Ebing,  in 
conservative  words,  tells  us  the  same.  Esquirol  more 
plainly  declares:  "Menstruation  often  produces  men- 
tal alienation.     Leucorrhoea  also  causes  insanity." 

Neither  menstruation  nor  leucorrhcEa  has  the  power 
to  change  the  structure  or  condition  of  the  brain, 
therefore  they  cannot  be  a  cause  of  insanity.  It  can 
also  be  shown  that  the  brain  affects  the  genital  and 
other  visceral  organs  more  than  these  organs  or  their 
functions  affect  the  brain.  We  see  how  the  brain  may 
quicken  the  heart's  action,  make  more  rapid  breathing, 
hasten  the  circulation- — sending  the  blood  bounding 
with  increased  quickness,  the  flush  on  the  face,  the 
heat  and  excitement  of  the  whole  system.  The  men- 
tal agitation  increasing,  the  heart  with  its  immense 
machinery  of  muscles  and  multitude  of  blood-vessels 
may  be  overpowered,  give  way,  and  by  the  dominat- 
ing power  silenced  into  the  stillness  of  death. 

Continually  we  are  realizing  how  the  brain  will  dis- 
turb the  process  of  digestion,  and  that  mental  excite- 
ment may  take  away  the  appetite,  interfere  with  the  se- 
cretion of  the  gastric  juice,  the  bile,  the  secretion  from 
the  spleen,  or  so  change  the  lacteal  secretion  as  to  pro- 
duce in  infants  convulsions  and  death. 

Great  mental  excitement  many  times  causes  exces- 
sive menstruation.  It  may  even  suspend  menstruation. 
It  may  cause  premature  labor.  A  mother  said  good- 
by  to  her  dying  babe,  and  walked  into  the  next  room. 
Her  great  grief  had  stimulated  to  action  all  the  im- 
mense muscular  structure  of  the  uterus  and  the  whole 
system  in  sympathetic  action,  and  she  thus  brought 
forth  tJre  child  laefore  its  time.  "  When  Phinehas'  wife 
heard  that  her  fatiier-in-law  and  her  husband  were 
dead,  she  bowed  herself  and  travailed;  for  her  pains 
came  upon  her."  It  was  grief  in  the  mind  that  was 
producing  the  revolution  in  the  system. 

"Puerperal  insanity."  There  is  no  insanity  wliich 
should  be  regarded  as  necessarily  belonging  to  the 
puerperal  state.  It  is  only  possible  that  insanity  may 
be  developed  at  that  time,  and  we  will  find  the  subjects 
of  it  have  some  inherited  insane  neurosis.  The  author 
says;  "The  pains  of  labor,  the  mental  excitement  and 
stress,  the  maternal  emotions,  the  sudden  diversion  of 
the  stream  of  vital  energy  from  the  womb  to  the 
mamni;!--."  All  this  is  normal.  The  author  well 
adds  "acting  on  an  unstable  brain  hereditarily." 
That  is  the  secret — acting  on  an  unstable  brain.     And 


the  author  further  emphasizes  the  fact  by  saying:  "I 

know  a  woman   (page  552)  K.    B ,  who   had  six 

attacks  of  puerperal  insanity,  having  one  after  the 
birth  of  each  child."  We  see  the  cause  was  in  the 
patient.  Anotlier  w^oman  may  have  had  twice  six 
children  and  no  attack  of  insanity.  The  author  then 
gives  another  proof  of  the  same — what  he  calls  "a 
typical  case  of  puerperal  insanity.  K.  G— — ,  at. 
twenty-three;  sister  and  aunt  had  been  insane.  The 
patient  had  pains  in  the  head  before  delivery.  On 
post-mortem,  brain  intensely  congested."  Here  was 
the  reason  of  the  insanity,  the  hereditary  tendency 
and  the  congestion  of  the  brain. 

Normal  labor  makes  no  insanity.  Scripture  says: 
"  Thou  art  He  who  took  me  out  of  my  mother's 
womb."  Infinite  wisdom  devised  the  plans  and  fixed 
the  laws,  so  there  can  be  no  imperfection  by  which 
insanity  should  ensue. 

Clouston  in  his  work  on  page  560  heads  the  chap- 
ter, "Lactational  Insanity,"  and  opens  by  saying: 
"Nursing  in  woman  is  a  cause  of  mental  disease 
sometimes."  Lactation  is  a  normal  function,  not  nec- 
essarily attended  with  any  ill  health,  nor  does  it 
cause  insanity  or  mental  disease.  Women  become  in- 
sane during  lactation  only  because  of  some  brain  le- 
sion. As  confirmatory  of  this,  the  author,  on  the  next 
page,  gives  "atypical  case  of  lactational  insanity." 
The  patient  '"  had  headaches,  noises  in  the  ear,  giddi- 
ness, flashes  of  light  before  the  eye."  All  these  are 
indications  of  some  local  disease  of  the  brain. 

The  next  chapter  is  headed  "The  Insanity  of  Preg- 
nancy." The  first  sentence  is:  "Few  women  carry  a 
child  without  being  influenced  mentally  thereby  in 
some  way  or  another."  They  are  influenced  mentally 
by  the  coming  joy,  the  added  responsibility,  and  how 
best  to  care  for  and  promote  the  happiness  of  the  little 
one.  The  author  continues:  "In  this  state  (preg- 
nancy) many  women  have  endless  caprices,  unfounded 
dislikes,  causeless  weeping  and  laughing,  stealing, 
lying,  etc."  1  can't  see  that  unfounded  dislikes, 
stealing,  and  lying  are  symptoms  of  "this  state." 
Yet  the  author  asserts  that  "  a  considerable  number  of 
women  are  mentally  unsound  during  pregnancy."  All 
this  may  be  true  of  women  in  the  Koyal  Asylum  of 
Edinburgh,  but  it  is  not  so  with  women  of  the  outside 
world.  If  insanity  results  from  pregnancy,  then  there 
has  been  a  sad  failure  in  the  formation  of  women. 
Insanity  may  be  developed  during  pregnancy,  but 
only  in  those  women  who  have  some  insane  neurosis. 
The  author,  as  if  to  prove  this  point,  says:  "  1  have  a 
patient  K — - — ,  who  has  been  five  times  pregnant,  and 
five  times  insane,  each  time  during  pregnancy." 
Many  other  women  may  be  twice  five  times  pregnant, 
and  yet  not  one  time  insane.  The  author  further  sub- 
stantiates the  fact  by  saying:  "I  had  one  patient  who 
had  six  different  attacks  of  insanity,  two  of  pregnancy, 
two  puerperal,  and  two  of  lactation — in  each  she  was 
most  determinedly  suicidal  and  homicidal,  strangling 
and  killing  her  first  child,  and  attempting  at  least  six 
different  times  to  take  her  own  life." 

The  insanity  in  each  individual  case  results  from  a 
state  of  the  brain,  not  from  the  physiological  functions 
the  patient  may  be  performing.  As  further  to  prove 
this  point,  the  author  gives  two  more  instances  of 
puerperal  insanity.     "  One,  K.  M — — ,  thirty-four  years 

old,  with  an   insane  heredity;"   the  other  "  K.  O , 

thirty  years  old,  and  hereditary  history  oj  insanity." 

In  lecture  XVI.  on  "The  Insanities  of  Puberty, 
Adolescence,  the  Developmental  Insanities  "  the  au- 
thor says:  "Puberty  is  the  first  really  dangerous  pe- 
riod in  the  life  of  both  sexes  as  regards  the  occurrence 
of  insanity;  but  is  not  nearly  so  dangerous  as  the  pe- 
riod of  adolescence  a  few  years  afterwards,  when  the 
body  as  well  as  the  functions  of  reproduction  have 
more  fully  developed." 


Neither  puberty  nor  adolescence  is  a  dangerous  pe- 
riod, and  at  neither  period  is  there  in  the  normal  proc- 
esses any  tendency  to  insanity.  Nor  are  there  any 
insanities  that  are  an  outgrowth  of,  or  that  necessarily 
accompany,  physiological  development,  which  should 
be  called,  "developmental  insanities."  VVould  not 
this  put  a  note  of  interrogation  as  to  the  wisdom  of 
our  formation?  It  is  only  that  insanity  may  occur 
during  these  periods  in  those  who  have  already  disease 
of  the  brain,  or  an  inherited  predisposition  thereto. 
The  process  of  normal  development  gives  no  "peril  to 
the  healthy  mental  balance." 

The  autlior  next  says:  "  The  following  is  one  of  the 
most  characteristic  cases  of  early  insanity  of  puberty 

I  have  met  with:   K.  P ,  aged  eleven  and  one-half 

years.  His  mother  had  an  attack  of  puerperal  insan- 
ity (mania),  and  attack  of  acute  delirious  mania,  and 
she  died  melancholic.  An  elder  brother  at  the  age  of 
nineteen  had  adolescent  insanity  (mania),  and  became 
demented.  A  sister  became  insane,  and  another  sister 
was  devoid  of  all  moral  feeling  or  self-control." 

Does  not  all  this  explain  wliy  the  boy  had  insanity 
at  puberty,  or  at  any  other  period?  It  was  an  inher- 
ited predisposition ;  and  from  such  cases  the  conclu- 
sion should  not  be  drawn  that  "puberty  is  a  dangerous 
period  as  regards  tiie  occurrence  of  insanity."  Puberty 
has  nothing  to  do  with  the  origination  of  insanity.  It 
was  an  inherited  mental  disease  in  the  boy,  and  in 
consequence,  as  is  stated,  he  had  five  attacks;  yet  the 
author  says :  "  I  look  upon  such  a  case  as  an  example 
of  the  evolution  of  a  new  function."  Does  nature 
then  evolute  a  new  function  by  producing,  or  accom- 
panying it  with,  'attacks  of  insanity"?  The  author 
incidentally  remarks  it  was  "a  brain  strongly  predis- 
posed by  heredity  to  insanity."     This  explains. 

Dr.  Clouston  next  gives  a  remarkable  case  of  adoles- 
cent insanity,  as  he  says,  "terminating  in  recovery." 
The  following  is  tiie  history,  and  in  the  same  line  are 
revealed  the  fundamental  facts:  "The  boy  had  neu- 
rotic heredity,  his  mother  having  had  puerperal  mania 
after  the  birth  of  almost  every  child,  his  father  having 
been  nervous,  two  sisters  and  one  brother  having  at- 
tacks of  mania." 

Does  not  such  an  heredity  sufficiently  explain  the 
"adolescent  insanity"?  On  the  next  page  the  author 
says  of  this  patient:  "His  whole  mental  state  sug- 
gested secondary  dementia.  ...  It  seemed  to  be  in 
truth  a  toss  up  between  recovery  and  dementia.  .  .  . 
Fortunately,"  continues  the  narrative,"  the  recuperative 
power  of  his  brain  and  constitution  prevailed.  .  .  . 
In  six  months  from  the  commencement  of  his  illness 
he  was  quite  well  in  mind  and  strong  and  stout  in 
body."  When  I  had  read  thus  far,  I  made  the  note: 
The  boy  will  probably  have  "adolescent  insanity"  by 
the  time  he  is  forty  or  fifty  years  of  age.  The  narrative 
continued:  "  He  became  insane  in  eighteen  months, 
recovered,  kept  well  for  a  time,  then  had  another  at- 
tack of  mania,  which  ended  in  secondary  dementia." 

It  was  clearly  a  case  of  hereditary  insanity.  The 
author  says:  "Another  case  of  adolescent  insanity, 
heredity  very  neurotic,  mother  very  nervous,  aunt  in- 
sane, and  father  drunken.  He  sank  into  dementia  in 
about  two  years." 

Of  a  similar  case  the  author  asserts:  "There 
seemed  absolutely  no  exciting  cause  whatever  for  the 
attack  but  the  completion  of  the  period  of  adoles- 
cence" ;  yet  Dr.  Clouston  states:  "He  came  of  one 
of  the  families  of  the-fishing  village  of  New  Haven, 
that  must  have  had  some  very  unstable  mental  stock 
introduced  into  them  many  generations  since,  and  in 
many  of  which  now  there  is  an  enormous  amount  of 
insanity  or  epilepsy." 

Why  attribute  this  case  of  insanity  to  "adoles- 
cence," when  here  is  the  efficient  cause?  Adolescence 
is  not  a  cause  of  insanity. 


Causes  of  insanity  as  presented  by  Dr.  Regis.'  Dr. 
Regis  says:  "There  exists  in  no  part  of  tlie  economy 
a  sympathy  more  intimate  than  that  which  connects  to 
the  nerve  centres  the  organs  of  generation,  and  it  is 
not  rare  to  see  the  processes  physiological  and  patho- 
logical of  these  organs  determine  some  intellectual  dis- 
orders which  go  even  to  madness  or  insanity,  and  in 
particular  h  la  pubertc,  a  la  menstruation,  h  la  meno- 
pause et  aux  affections  locales  de  I'uterus  et  de  ses  an- 
nexes." 

I  do  not  believe  the  physiological  processes  or  func- 
tions of  the  organs  of  generation  ever  cause  madness 
or  insanity;  and  not  one  developmental  process  has  a 
tendency  to,  or  does  lead  to,  insanity.  The  insanity 
is  from  some  other  cause. 

The  author  says  :  "  The  physiological  disorders  con- 
nected with  ]Hiberty  are  various.""  He  then  gives  a 
long  list,  adding:  "Above  all  the  young  boys  are 
awakened  to  a  very  marked  propensity  to  suicide, 
wicked  tendencies,  impulses  to  robbery,  to  incendiar- 
ism, and  to  murder.'"  Continues  the  author:  "Other 
phenomena  more  grave  may  join  these  and  lead  to  a 
veritable  state  of  mental  alienation." 

Puberty  is  normal  development;  there  can  naturally 
be  no  insanity  or  psychological  disease  connected  with 
nature's  normal  processes. 

Next  Dr.  Regis  speaks  of  menstruation  (folie  men- 
struelle)  insanity,  and  says:  "  With  most  females,  even 
in  physiological  condition,  the  return  of  menstruation 
is  accompanied  each  time  by  trouble,  intellectual  and 
moral."  Adding:  "  During  menstruation  females  are 
subjected  to  singular  caprices,  fantastic  tastes  .  .  . 
some  have  a  spontaneous  tendency  to  wrongdoing,  and 
give  themselves  up  to  irresistible  impulses." 

All  these  views  may  seem  to  be  very  scientific  as  one 
passes  through  the  wards  and  immense  halls  of  La  Sal- 
petriere.  But  outside  of  that  hospital  there  is  a  great 
big  world,  and  there  are  untold  millions  of  women 
who  pass  through  the  menstrual  period  without  any  of 
these  psychical  symptoms,  or  any  form  of  menstrual 
insanity.  Normal,  healthful  menstruation  is  accom- 
panied by  none  of  these  supposed  changes.  I  have 
seen  hundreds  of  women  pass  through  this  period  with- 
out the  least  pain  or  disturbance,  mental  or  physical. 
I  have  seen  thousands  of  young  girls,  at  different 
schools  and  colleges,  going  regularly  through  the 
function  of  menstruation  without  the  least  trouble,  in- 
tellectual or  moral.  Nearly  ten  years  I  spent  in  col- 
leges for  young  women,  over  three  years  I  was  a  student, 
and  six  years  a  professor  of  physiology  and  belles 
letters,  and  subsequently  for  many  years  had  charge 
of  a  young  ladies'  boarding-school.  Thus  many  thou- 
sands of  young  women  came  directly  under  my  observa- 
tion, and  never  had  they  thought  of  such  a  thing  as 
intellectual  or  moral  trouble  during  the  period  of 
menstruation.  With  hundreds  and  hundreds  of  young 
girls  each  year  menstruation  passed  off  so  quietly  that 
it  was  not  thought  of  or  recognized,  nor  was  the  time 
of  its  occurrence  known.  The  young  ladies  continued 
just  the  same  at  their  studies,  and  were  apparently  just 
as  ambitious  to  excel,  and  answered  just  as  brilliantly 
in  their  recitations. 

Dr.  Regis  says:  "Authors  have  reported  a  certain 
number  of  cases  of  insanity  connected  with  the  men- 
strual period,  which  can  leave  no  doubt  of  the  reality 
of  its  existence." 

If  there  were  many  more  cases  cited,  that  would  not 
prove  the  rule,  and  no  such  conclusion  should  be 
drawn.  They  were  all  insane  people.  If  normal 
menstruation  had  a  tendency  to  produce  insanity  we 
might  well  doubt  and  fear  the  results  of  any  normal 
function  of  the  whole  body. 

'Journal  de  mudecine  de  Bordeau.'t,  vol.  xiii.,  1884,  p.  413. 
Also.  "  Dictionnaire  encyclopcdiquc  des  sciences  medicales, " 
Paris. 


The  author  continues:  "As  to  the  troubles  of  this 
function,  and  notably  the  suppression  of  menstruation 
and  dysmenorrhita,  their  action  upon  the  intelligence 
is  more  evident  and  more  frequent  still,  and  it  leads 
also  frequently  to  folic,  to  theft,  to  incendiarism,  to 
homicide,  to  periodic  dipsomania,  but  above  all  there 
is  the  impulsion  to  suicide  which  predominates  in  this 
variety  of  alienation."" 

The  author  quotes  Ksquirol.  As  H.  R.  Storer'  says: 
"  Each  successive  text-book  has  repeated  the  errors,  or 
many  of  them,  of  its  predecessors." 

In  my  large  and  extensive  practice  of  over  thirty 
years,  though  I  saw  many  sick  women  suffering  from 
menstruation,  which  most  frequently  I  found  a  symptom 
of  more  serious  conditions,  yet  I  never  found,  w  ith  the 
exception  of  the  four  cases  referred  to,  one  woman 
who  gave  any  indication  of  the  least  mental  or  intel- 
lectual trouble. 

"Folie  de  la  menopause."  Dr.  Regis  says:  "The 
menopause,  so  justly  called  the  age  critique,  is  a  pe- 
riod dangerous  to  pass  through  for  many  women,  and 
it  is  very  frequently  the  occasion  of  perturbations  in- 
tellectual and  moral,  and  psychological  changes  which 
can  go  even  to  madness  or  insanity.  ...  It  is  not 
doubted  that  among  the  most  part  of  women,  normal 
or  not,  the  time  critique  leads  to  revolutions  more  or 
less  profound  of  the  organism,  and  that  among  some 
these  modifications  of  intelligence  attain  the  propor- 
tion of  true  insanity."" 

The  menopause  is  not  a  dangerous  period  to  pass 
through,  many  women  pass  through  it  without  the 
least  disturbance.  The  author  continues:  "Above  all 
there  is  a  tendency  to  dipsomania,  to  theft,  to  homi- 
cide, to  incendiarism,  but  still  more  to  suicide."' 

This  is  almost  a  libel  on  the  natural  formation  of 
one-half  of  the  human  race,  that  such  manifestations 
should  take  place  in  natural  physiological  processes. 
Can  any  one  recognize  it  as  reasonable  that  there  is  a 
tendency  to  madness  in  the  normal  suppression  of 
menstruation?  No  function  when  it  is  normal,  or  the 
normal  change  of  the  system,  goes  naturally  to  in- 
sanity. 

The  author  next  speaks  of  the  local  affections  of 
the  uterus  and  the  uterine  adnexa,  saying:  "If  the 
physiological  processes  which  have  for  their  point  of 
departure  the  organs  of  the  genetial  organization  are 
frequently  the  object  of  intellectual  troubles,  the  mala- 
dies of  these  organs  are  perhaps  more  frequently  so." 

I  have  seen  many  women  with  the  worst  forms  of  dis- 
ease of  the  uterus  and  the  uterine  adnexa  and  not  the 
least  indication  of  intellectual  disturbances.  Among 
all  the  women  I  have  attended  for  diseases  of  the 
genetial  organization,  I  have  found  only  four  with  a 
tendency  to  insanity,  and  they  had  not  the  worst  forms 
of  these  diseases.  Uesides  I  have  reason  to  believe 
they  had  manifestations  of  insanity  before  the  develop- 
ment of  these  troubles. 

Causes  that  by  changing  the  structure  of  the  brain 
may  produce  insanity.  Recognizing  that  the  brain  is 
the  organ  of  the  mind,  and  that  abnormal  conditions 
or  diseases  of  the  brain  are  the  causes  of  insanity, 
our  next  question  is,  What  are  some  of  the  causes  that 
will  more  directly  produce  these  abnormal  or  diseased 
conditions  in  the  brain  structure?  Such  morbid 
changes,  however  produced,  will  be  found  to  be  the 
true  causes  of  insanity. 

I  will  name  first  heredity.  Heredity  may  change 
the  normal  structure  of  the  brain,  producing  perma- 
nent defects  and  degenerations.  Heredity  determines, 
in  a  large  measure,  the  character,  form,  power,  and 
constitutional  tendencies  of  a  child's  brain.  Mental 
defects  in  the  parent,  insane  neuroses,  or  neurotic  ten- 
dencies will  leave  their  mark  and  impress  on  the 
young  brain,  probably  producing  various  tissue 
'  11.  K.  Storer  ■   "  Insanity  in  Women,"  1S71,  p.  27. 


changes.  While  a  good  heredity  may  give  a  breadth, 
a  light,  a  clearness,  and  a  joy  to  this  wonderful  forma- 
tion, a  bad  heredity  will  stunt  it,  darken  it,  make  its 
nature  less  fine,  and  leave  upon  it  its  sad  impressions 
and  imperfections.  Children  are  what  their  parents 
are.  From  whom  else  can  they  get  their  physical  for- 
mation, or  constitutional  tendencies,  or  their  make  up? 
They  partake  of  the  conditions  of  their  parents,  in- 
herit their  physical  and  mental  characteristics,  and 
their  defects. 

These  physical  and  mental  defects  may  decide  the 
character  of  the  descendants.  A  parent  may  have  un- 
toward conditions  from  unhealthful  living  or  previous 
inheritance,  and  the  children  will  take  on  these  condi- 
tions. A  violation  of  the  laws  of  health,  in  time, 
makes  physical  changes  in  the  constitution  of  the  par- 
ent. These  physical  changes  or  degenerations  of  one 
kind  or  another  the  children  inherit. 

Whatever  disease  or  ailment  our  parents  or  ances- 
tors may  have,  a  tendency  to  it  will  be  reproduced  in 
the  descendants.  The  condition  of  the  brain  of  the 
parent  or  any  changes  in  it  from  untoward  circum- 
stances may,  in  the  child,  become  a  constitutional  im- 
perfection. Scripture  says:  "  The  fathers  have  eaten 
sour  grapes,  and  the  children's  teeth  are  put  on  edge." 
Other  momentous  words  are :  "  The  sins  of  the  parent 
are  visited  upon  the  children  to  the  third  and  fourth 
generation."  Hippocrates  wisely  said  many  years 
ago:  "Where  is  the  malady  with  which  the  father  or 
mother  is  afflicted  that  alTects  not  the  children?" 
And  speaking  of  epilepsy,  he  says:  "  It  is  as  the  other 
maladies,  by  heredity." 

The  peculiar  make-up  necessary  to  produce  any  dis- 
ease may  be  given  by  heredity.  Thus  from  inheritance 
some  brains  are  naturally  better  than  others,  have  less 
liability  to  disease,  and  are  less  predisposed  to  abnor- 
mal conditions.  So  some,  by  inheritance,  have  better 
and  stronger  lungs,  healthier  hearts,  and  stomachs  less 
predisposed  to  disease.  When  the  lungs  are  small 
and  contracted,  slight  causes  may  bring  on  disturb- 
ances, and  induce  most  serious  conditions.  Hearts 
that  are  feeble  in  their  action,  one  part  or  another  being 
diseased  or  defective,  may  even  from  slight  excitement 
have  most  serious  results,  as  stomachs  naturally  pre- 
disposed to  disease  may  have  most  distressing  forms 
of  indigestion. 

A  tendency  in  the  parents  to  disease,  or  any  evil 
predisposition  may  be  inherited,  as  one  auther  says: 
"  I  know  now  the  history  of  one  family  in  which  there 
has  been  insanity  for  five  generations,  and  of  another 
family  in  which  it  has  been  for  four  generations." 

The  records  of  all  insane  asylums  show  that  one- 
third  or  one-half  of  the  insane  patients  have  hereditary 
taint  of  insanity.  If  the  true  history  could  lie  ascer- 
tained, probably  it  would  be  found  that  all  have  this 
taint;  and  probably  the  reason  why  there  are  so  many 
insane  persons  in  the  various  asylums  in  the  world  is 
the  propagation  of  this  insane  neurosis.  It  may  skip 
a  generation,  but  it  is  still  there.  It  is  a  cause  that 
always  operates.  Moreau  de  Torey  says  that  "nine- 
tenths  of  the  cases  of  insanity  come  from  inheritance." 
Dr.  Edward  Jarvis'  said:  "According  to  the  British 
reports,  twenty-two  per  cent,  of  all  whose  history  could 
be  ascertained,  owe  their  lunacy  solely  to  hereditary 
taint."  Pinel  said  in  1809:  "In  many  successive 
generations  some  one  of  the  members  of  certain  fami- 
lies have  attained  this  malady." 

Henry  Maudsley  says:  "  The  insane  neurosis,  which 
the  child  inherits  in  consequence  of  its  parents'  insan- 
ity, is  as  surely  defect  of  physical  nature  as  is  the  epi- 
leptic neurosis  to  which  it  is  so  closely  allied.  Past 
all  question,  it  is  the  most  important  element  in  the 
causation  of  insanity.'" 

A  second  cause  of  brain  injury  that  may  result  in 
'Norfolk  Medical  Society,  Massachusetts,  May  14,  1S61. 


insanity  is:  "The  use  and  abuse  of  alcoholic  liquors." 
This  is  universally  given  as  a  cause  of  insanity.  It 
causes  insanity  by  changing  and  injuring  the  brain 
structure.  Prof.  Charles  L.  Dana  in  his  excellent 
work  '  says  on  page  25  :  "  Excessive  indulgence  in  al- 
cohol is  a  most  prolific  cause  of  nervous  disease."  An 
editorial  in  the  Britis/i  Meiiual  Jotit-nal,  page  848, 
1900,  says:  "Alcoholism  is  responsible  as  an  etiolog- 
ical factor  for  twenty-five  per  cent,  of  all  male  cases  of 
insanity  admitted  to  our  asylum." 

There  is  a  large  record  that- cannot  be  put  down, 
how  alcohol  is  silently  doing  its  work  of  evil,  poisoning 
and  making  the  most  deleterious  changes  in  the  brain 
structure.  A  few  years  ago  I  was  making  micro- 
scopical investigations  in  the  minute  anatomy  of  the 
pathology  of  the  kidneys,  and  I  clearly  saw  how  dur- 
ing life  the  millions  of  fine  cilia  were  destroyed  and 
rendered  inactive  in  those  who  habitually  use  alco- 
holic drinks.  In  the  same  manner  the  fine  structures 
of  the  brain  may  be  injured  and  made  inactive.  Al- 
cohol hardens  and  deadens  the  wonderful  comple.\ity  of 
fine  fibres,  so  that  they  cannot  respond  with  their  more 
than  electric  quickness  and  brightness;  and  an  untold 
injury  does  it  do  to  these  marvellously  complex  struc- 
tures, the  convolutions  of  the  brain.  We  cannot 
weigh  or  measure  the  immensity  of  these  injuries. 

Alcohol  has  its  deleterious  effect  upon  all  the  vital 
organs,  and,  in  a  measure  that  we  cannot  conceive  of, 
disturbs  the  secretions  and  excretions,  and  thereby 
does  direct  and  indirect  damage  to  the  whole  system. 
It  benumbs  the  brain,  deadens  the  perceptions,  and 
no  child  of  a  drunkard  can  be  as  bright  as  he  or  she 
otherwise  would  be.  The  drunken  man  has  not  his 
normal  mental  faculties.  As  one  says:  "Drunken- 
ness, a  brief  chronicle  of  insanity,  winding  up  with  a 
temporary  dementia."  Benton  said:  "If  a  drunken 
man  gets  a  child,  it  will  never  likely  have  a  good 
brain."  One  of  the  leading  physicians  in  America 
showed  by  his  statistics  that  "out  of  three  hundred 
idiots,  whose  history  could  be  traced,  one  hundred  and 
forty-five  were  the  children  of  drunken  parents.  .  .  . 
I  may  state  that  quite  thirty  per  cent,  of  lunacy  in 
all  parts  of  the  universe  originates  in  habits  of  intoxi- 
cations.'' 

But  the  most  serious  of  all :  We  must  recognize  the 
great  facts  of  physiology — children  take  on  the  then 
conditions  of  the  parents.  The  temporary  condition 
of  either  one  may  affect  the  child.  The  father  is  in 
a  drunken  stupor,  this  "temporary  insanity"  is  trans- 
mitted, not  the  otherwise  brightness  of  his  ordinarily 
active  mind.  Yesterday,  as  I  hastily  passed  along  the 
street,  on  the  pavement  was  lying  a  man  in  a  dead 
drunken  stupor.  I  had  never  before  had  the  oppor- 
tunity of  looking  into  the  face  of  a  man  while  drunk, 
so  by  a  hasty  glance  I  learned  all  I  could.  The 
head  was  lower  than  the  body,  the  face  red  and  pur- 
plish. His  brain  was  wonderfully  shut  up  and  be- 
numbed in  this  insanity  of  intoxication.  The  child 
begotten  has  little  brains,  can't  have  much  vigor  of 
constitution,  is  a  true  impress  of  this  temporary  de- 
mentia, and  notwithstanding  the  public-school  train- 
ing the  child  may  still  be  stupid,  ignorant,  and  with 
an  unsteady  mental  balance.  Unnumbered  instances 
—  how  many  thousands  of  children — are  thus  injured! 
Deprived  of  their  natural  birthright,  their  rightful  in- 
heritance, losses  of  inestimable  value  which  time  nor 
eternity  can  make  up!  The  light  they  might  have  had, 
the  clearness,  the  broad  comprehension,  where  there 
is  now  darkness  and  an  inability  or  imbecility. 
What  a  devastation!  A  consideration  of  these  things 
is  the  greatest  and  most  powerful  lecture  that  can  be 
given  against  drunkenness.  It  is  a  crime  against  their 
own  children,  and  it  is  the  destruction  of  future  gener- 
ations. The  London  Lancet  in  an  editorial  (August 
'  "  Te.\t-Book  on  Nervous  Diseases,"  1897. 


II,  iQoOi  page  411)  said:  "The  intoxication  of  mar- 
ried couples  on  their  wedding  night  has  been  believed 
to  result  in  the  production  of  offsprings  sutl'ering  from 
imbacility  or  other  forms  of  cerebral  disease."  Still 
goes  on  the  injury  to  the  bright  spirits  that  should 
come  without  a  flaw,  stain,  or  drawback. 

Considering  all  this,  is  it  any  wonder  that  insanity 
is  on  the  increase,  and  that  the  children  of  drunken 
parents  go  insane,  or  are  in  a  measure  idiotic?  All  of 
which  tells  on  the  advancement  of  tiie  human  race,  on 
the  country's  resources,  and  on  the  history  of  the 
world. 

The  third  cause  of  deterioration  of  the  brain,  and  in- 
directly tending  to  produce  insanity,  is  the  condition  of 
the  stomach  and  the  state  of  digestion.  If  the  diges- 
tion is  not  good,  not  so  good  nutrition  is  carried  to 
the  brain,  the  brain  cannot  be  as  well  nourished  or 
make  as  good  tissues;  and  the  results  of  this  con- 
tinued-indigestion may,  and  gradually  does,  change  the 
structure  of  the  brain.  The  brain  cannot  be  as  sound 
or  healthy,  and  thereby  insanity  may  ensue. 

As  to  the  "correlation  of  the  genital  organs  and 
functions  in  women  with  the  brain  or  with  insanity," 
there  are  other  organs  in  the  body  that  more  decidedly 
and  more  directly  afTect  the  condition  and  health  of 
the  brain,  and  produce  more  marked  anatomical 
changes,  and  more  serious  results  than  can  possibly 
come  from  the  sexual  organs  and  their  functions. 

Fourth  cause :  An  abnormal  and  unhealthy  condition 
of  the  general  system.  Thus  aoy  organ  in  the  body 
may  be  more  or  less  diseased.  Ancient  physicians 
seem  to  have  caught  a  glimpse  of  this  subject  when 
they  speak  of  splenic  difficulties,  etc.  Continued  in- 
activity of  the  bowels  and  constipation  would  most 
deleteriously  affect  the  nutrition  and  texture  of  the 
brain.  It  is  impossible  that  the  brain  should  have  as 
good  nourishment,  or  be  made  of  as  healthful  material 
when  there  is  habitual  constipation. 

Fifth  cause  of  injury  to  the  structure  of  the  brain, 
and  thereby  a  cause  of  insanity.  Diseased  lungs,  and 
breathing  of  bad  air.  If  the  lungs  are  not  fully  ex- 
panded, the  blood  is  not  thoroughly  purified,  and  a  more 
or  less  diseased  condition  of  the  brain  must  necessarily 
ensue.  The  breathing  of  impure  air  tends  to  make 
tubercles  and  phthisis  and  an  unhealthful  condition 
of  every  tissue  of  the  body,  and  will  similarly  affect 
the  brain.  The  brain  will  necessarily  be  deteriorated 
in  structure.  I  can  but  think  this  breathing  of  foul  air 
is  one  of  the  most  fruitful  sources  of  injury  to  the  tex- 
ture of  the  brain  and  produces  an  unhealtiiful,  dis- 
eased condition  of  that  organ.  By  impure  air  the  brain 
suffers  as  do  other  organs  of  the  body.  It  is  every- 
where recognized  that  impure  air  produces  in  many  per- 
sons scrofula.  Lugol  found  insanity  to  be  by  no  means 
rare  among  the  parents  of  the  scrofulous  and  tuber- 
culous. Schroeder  van  der  Kolk  was  of  opinion  that 
hereditary  predisposition  to  phthisis  might  develop 
into  or  predipose  to  insanity;  and,  on  the  other  hand, 
insanity  predisposes  to  phthisis.  We  need  not  won- 
der then  that  authors  so  often  notice  the  fact  that  in- 
sane patients  are  consumptive.  Clouston  says:  "The 
frequent  association  of  scrofula  with  idiocy  and  con- 
genital imbecility  is  well  known."  Both  may  result 
from  the  same  cause,  as  I  have  stated;  breathing  im- 
pure air  will  cause  consumption,  and  tends  to  produce 
pathological  changes  in  the  brain. 

Clouston  also  calls  attention  to  the  common  occur- 
rence of  pulmonary  phthisis  as  a  cause  of  death  among 
the  insane,  and  says  that  it  has  been  noted  by  those 
having  charge  of  the  older  lunatic  asylums.'     Mauds- 

'  Clouston  terms  it  phthisical  insanity.  Maiidsiey  in  his  work 
rightly  objects  to  Dr.  Clouston's  term,  "  phthisical  insanity," 
asking  :  "  How  then  rightly  style  phthisical  a  clinical  variety  of 
insanity?  The  name  phthisical  cannot.  I  think,  be  accepted  as 
convenient    to   designate   a   clinical    group    and    succession    of 


ley  says:  "Tubercle  is  often  found  in  the  bodies  of  the 
insane  who  have  died  without  ever  having  been  thought 
to  have  tubercle,"  adding :  "  The  frequency  of  phthisis 
among  the  insane  in  asylums  is  great,  but  the  infer- 
ence that  insanity  directly  predisposes  the  phthisis  has 
been  invalidated  by  proof." 

Insanity  does  not  predispose  to  phthisis,  nor  does 
phthisis  predispose  to  insanity,  hut  the  same  cause 
may  produce  them  both.  Maudsley  asks:  "Does  in- 
sanity affect  the  progress  of  phthisis.'  "  The  serious- 
ness of  the  existing  conditions  decides  as  to  the  prog- 
ress of  either  disease. 

Sixth:  Another  prolific  cause  of  disease  of  the 
brain  is  unbalanced  circulation.  A  whole  world  of 
meaning  is  in  this.  If  we  could  only  weigh  or  meas- 
ure its  import!  The  question  of  the  fundamental 
principles  of  health  and  liygiene  does  not  seem  to  have 
been  especially  dwelt  upon  in  relation  to  diseases  of 
the  brain.  We  must  come  back  to  first  principles. 
The  brain  is  a  physical  organ  of  the  body,  and  is  con- 
trolled by  the  same  laws  of  health  as  are  other  portions 
of  our  physical  being.  If  the  external  skin,  the  feet, 
and  extremities  are  cold,  the  blood  will  be  driven  from 
these  parts  and  necessarily  congest  in  other  portions 
of  the  body.  The  blood  is  where  it  should  not  be, 
■  and  frequently  from  this  results  more  or  less  conges- 
tion of  the  brain.  Congestion  is  the  first  condition 
of  brain  disease,  and  then  may  follow  inflammation; 
and  from  the  inflammation  may  in  time  be  developed 
fibrous  tissues  and  atrophy,  or  more  serious  conditions 
of  disease,  suppuration,  abscess,  or  any  abnormal 
formation.  Dr.  Benjamin  Rush  tells  us  that  as  one  of 
the  first  symptoms  "  there  is  a  sense  of  fulness,  and 
sometimes  pain  in  the  head."  This  would  be  a  direct 
result,  and  one  of  the  first  indications,  of  too  much 
blood  in  the  brain.  Dr.  Rush's  theory  is  that  "  mad- 
ness is  seated  primarily  in  the  blood-vessels  of  the 
brain."  Certainly  in  congestion  and  inHammation  we 
always  find  the  blood-vessels  more  or  less  changed. 
I  have  studied  various  diseased  tissues  under  a  power 
of  300,  400,  700,  and  1,000.  The  blood-vessels  always 
were  changed  according  to  the  state  and  chronicity  of 
the  inflammation.  AH  this  may  be  the  direct  result 
of  unbalanced  circulation. 

M.  Parchappe  remarks  that  "  in  acute  insanity  the 
prominent  alterations  are  hypersmic  conditions." 
This  would  be  directly  produced  b)  unbalanced  circu- 
lation; and, "if  the  hyperemia  continues,  then  we  have, 
as  Parcheppe  terms  it,  "  chronic  insanity;  the  predomi- 
nant alterations  are  atrophy  of  the  convolutions  and 
induration  of  the  two  substances." 

If  the  congestion  continues  there  would  be  first  in- 
flammation, then  some  other  abnormal  conditions  may 
be  produced,  or  the  inflamed  tissue  may  chaige  to 
fibrous  connective  tissue,  then  we'  will  have  what  is 
called  chronic  atrophy. 

Any  or  all  of  these  conditions  may  follow  directly 
from  unbalanced  circulation  in  the  system. 

The  external  skin  is  an  immense  circulatory  appa- 
ratus. A  pin  point  cannot  enter  it  without  wounding 
or  rupturing  some  blood-vessel.  From  some  cause 
this  circulation  may  become  unbalanced;  the  blood  is 
driven  from  the  external  skin;  consequently  too  much 
in  some  other  portions  of  the  body,  centering  on  the 
brain,  may  produce  a  fatal  apoplexy  or  sudden  death.' 
Or  a  slow  congestion  may  gradually  change  the  struc- 
ture of  some  portion  of  the  tissues  of  the  brain,  and 
thereby  may  result  some  brain  disease  and  some  form 
of  insanity.     Thus,  I  think,  it  can  be  proved  that  the 

symptoms.  There  is  no  phthisical  insanity  anywhere."  Mauds- 
ley  does  not  seem  to  object  to  Clouston's  other  instances  of  this 
method  of  nomenclature  for  insanity  when  there  is  even  more 
reason. 

'  Ellis  says  :  "A  very  trifling  alteration  may  produce  the  most 
important  results,  as  in  apoplexy  the  sudden  extravasation  of  a 
small  quantity  of  blood  causes  death." 


December  15,  1900] 


MEDICAL    RECORD. 


937 


external  skin  has  more  correlation  with  the  brain, 
more  power  over  it,  more  effect  upon  its  condition,  and 
more  capability  of  producing  insanity  than  the  ovaries 
possible  can  have,  with  all  their  "menstruation," 
"  ovulation,"  etc. 

The  first  principles  of  the  laws  of  health — good  di- 
gestion, the  breathing  of  pure  air,  a  well-balanced  circu- 
lation, maintained  by  suitable  warmth  and  sufficient 
exercise — are  essential  to  the  health  of  the  brain,  and 
are  really  prophylactic  and  curative  of  insanity.  It 
would  be  a  beautiful  problem  to  study  the  direct  effect 
of  regular  exercise  in  the  open  air,  not  only  in  balanc- 
ing the  general  circulation,  but  making  a  healthful  cir- 
culation in  the  brain. 

An  eminent  scholar  who  had  written  many  books 
said,  on  his  deathbed,  that  all  his  knowledge  and 
learning  were  comprehended  in  the  one  simple  direc- 
tion :  "  Keep  the  feet  warm,  head  cool,  and  the  bowels 
open."  Certainly  to  promote  the  health  of  the  brain 
we  must  think  of  these  first  principles.  Many  dis- 
eased brains,  if  carefully  attended  to  in  time,  may 
thereby  be  restored  to  health.  Following  this  direc- 
tion and  the  ordinary  laws  of  health  have  much  to  do 
with  preventing  and  curing  insanity.  The  touching 
and  beautiful  words  of  the  eminent  and  distinguished 
Dr.  13enjamin  Rush  come  in  here.  He  says:'  "I 
should  lay  down  my  pen,  and  bedew  my  paper  with 
my  tears,  did  I  not  know  that  tlie  science  of  medicine 
has  furnished  a  remedy  for  it.  Blessed  science! 
Which  thus  extends  its  friendly  empire,  not  only  over 
the  evils  of  the  body,  but  over  those  of  the  mind  of 
the  children  of  men." 


ANALGESIA  IN  CHILDREN  BY  SPINAL  IN- 
JECTION, WITH  A  REPORT  OF  A  NEW 
METHOD  OF  STERILIZATION  OF  THE 
INJECTION    FLUID. 

Bv    \VILLI.\M     SEA.MAN    BAINBRIDGE,   A.M.,    M.D., 

ATTENDING   SURGEON,    RANDALL's    ISLAND    HOSPITAL;     INSTRUCTOR    IN    OPERA- 
TIVE SURGERV,    NEW  VORK    POST-GRADUATE  HOSPITAL  MEDICAL  COLLEGE. 

Notwithstanding  the  general  employment  of  both 
chloroform  and  ether,  over  a  long  period  of  years,  fre- 
quently there  arises  discussion  as  to  the  relative  draw- 
backs in  the  employment  of  both  of  these  anesthetics. 
The  advocates  of  each  endeavor  to  prove  the  dangers 
attending  the  use  of  the  other.  While  the  profession 
believes  strongly  in  the  general  usefulness  of  both  of 
these  remedies,  the  majority  is  convinced  that  there 
are  cases  in  which  either  is  liable  to  do  harm.  The 
presence  of  a  marked  kidney  affection,  acute  inflam- 
mation of  the  bronchi,  advanced  pulmonary  condi- 
tions, as  well  as  pronounced  arteriosclerosis,  causes  the 
surgeon  no  little  apprehension  concerning  the  use  of 
any  anaesthetic  in  such  patients.  While  this  does  not 
apply  so  fully  to  children,  still  there  are  occasional 
cases  when  some  substitute  for  ether  or  chloroform  is 
greatly  needed.  Such  an.  instance  has  occurred  re- 
cently in  my  own  practice,  when  a  child  had  not  been 
able  to  bear  well  the  use  of  ordinary  anaesthetics,  and  I 
resorted  to  spinal  injection  of  cocaine  with  gratifying  re- 
sults. This  has  led  me  to  a  further  study  of  the  "  Com- 
ing-Bier' method,"  especially  in  children  in  whom 
hitherto  nothing  has  been  done  for  those  under  eight 
years  of  age.  The  youngest  cases  recorded,  so  far  as 
I  know,  were:  by  Murphy,  a  patient  of  eight  years;  by 
Bier,  Lugueu,  and  Kinderdjy,  who  each  reported  one 
at  the  age  of  eleven  ;  by  Tuffier  one  at  twelve,  and  by 

'  "  Medical  Inquiries  and  Observations  upon  the  Diseases  of 
the  Mind,"  by  Benjamin  Rush.  1S12.  p.  95. 

''Corning  in  his  book  on  "Pain,"  published  in  1S94,  reports 
cases  of  cocaine  injection  into  the  Cauda  equina  for  the  relief  of 
spinal  irritation.  This  was  years  before  Bier  began  his  experi- 
ments. 


after-effects  from   the 
1st:    The    patient    is 


Seldowitsch  one  at  thirteen.  The  following  patients, 
which  I  report,  range  in  age  from  two  and  a  half  to 
eleven  years. 

Case  I. — A.  S ,  male,  aged  nine  years;  strong 

healthy  boy  of  moderate  size  but  rather  nervous  tem- 
perament.    Deformity  of  the  left  hip. 

Cocaine  analgesia,  October  27,  1900.  Place  of 
puYicture  to  the  right  between  the  fourth  and  fifth 
lumbar  vertebra;.  Amount  of  cocaine  VI  x.  of  a  one- 
per-cent.  solution.  Injection  complete  at  11:39  A.M. 
Nausea  and  vomiting  at  11:40  a.m.,  but  none  there- 
after. Analgesia  up  to  the  level  of  the  diaphragm  at 
I  :42  -x.M.  The  operation  lasted  twenty  minutes,  and 
consisted  of  a  four-inch  incision  over  the  trochanter 
major,  thoroughly  exploring  the  hip  joint.  The  pa- 
tient complained  of  no  pain  and  was  quiet  or  talking 
to  the  nurse  while  the  surgeons  were  at  work.  Before 
operation,  temperature,  99.4°  I''.;  pulse,  100;  respi- 
ration, 28.  One  hour  after  operation,  temperature, 
99°;  pulse,  92;  respiration,  28.  Analgesia  disap- 
peared completely  at  3  p.m.  During  the  afternoon 
the  patient  was  fretful  and  complained  of  headache. 
Some  milk  was  taken  and  retained  during  the  after- 
noon. A  small  dose  by  mouth  of  acetanilid,  sodium 
bicarbonate,  and  caffeine  citrate  gave  a  restful  night. 

October  28th:  Slight  afternoon  elevation  of  tem- 
perature. The  patient  seems  natural  and  has  no 
headache.  October  29th :  No 
analgesia  are  left.  December 
perfectly  well. 

Case  II. — J.  J ,  female,   aged   four  years   ten 

months;  a  healthy  child  of  large  size  and  very  ner- 
vous temperament.  Umbilical  entero-epiplocele,  size 
of  a  small  hen's  egg.  (The  parents  were  unwilling  to 
use  a  mechanical  support  and  insisted  upon  an  oper- 
ation.)    The  usual  radical  operation  was  done. 

Cocaine  analgesia,  October  28,  1900.  Place  of 
puncture  to  the  right  between  the  fourth  and  fifth  lum- 
bar vertebra.  Amount  of  cocaine  V[  viii.  of  a  one- 
per-cent.  solution.  Analgesia  to  the  level  of  the  dia- 
phragm in  two  minutes.  A  return  of  the  pain  sense 
over  the  operative  field  in  eighteen  minutes  necessi- 
tated a  temporary  discontinuance  of  the  operation  and 
a  second  injection.  This  was  made  to  the  left  but  be- 
tween the  same  vertebra;  as  before,  and  consisted  of 
ni  vi.  of  the  one-per-cent.  solution.  Analgesia  to  the 
level  of  the  diaphragm  in  two  minutes.  Slight  nausea 
and  vomiting  occurred  directly  after  each  injection. 
At  times  during  the  operation  the  patient  was  some- 
what hysterical  and  cried  as  if  in  pain,  but  careful 
tests  proved  that  the  analgesia  was  complete.  Before 
operation,  temperature,  98.8^;  pulse,  136;  respiration, 
30.  One  hour  after  operation,  temperature,  992°; 
pulse,  140;  respiration,  42.  Analgesia  disappeared 
completely  in  three  hours  from  the  second  injection. 
The  patient  complained  of  headache,  but  had  no 
nausea  or  vomiting.  She  retained  a  small  quantity 
of  milk  during  the  evening. 

October  30th :  She  has  passed  a  comfortable  night. 
No  after-effects  of  the  injection  are  present.  Decem- 
ber 1st:  Convalescence  has  been  uninterrupted. 

Case  III. — R.  K ,  male,  aged  nine  years;  gen- 
eral condition  only  fair.  Tuberculous  caries  of  the 
ilium  with  inguinal  sinus. 

Cocaine  analgesia,  November  2,  1900.  Place  of 
puncture  between  the  third  and  fourth  lumbar  vertebra.'. 
Amount  of  cocaine  iTj  xv.  of  a  one-per-cent.  solution. 
Analgesia  to  the  level  of  the  diaphragm  in  two  and 
one-half  minutes.  In  twelve  and  one-half  minutes  the 
loss  of  the  pain  sense  had  extended  to  the  third  costal 
cartilage  in  front,  to  the  base  of  the  spine  of  the 
scapula  behind,  and  laterally  over  the  axillse  and  up- 
per extremities  to  the  middle  of  the  forearm,  excepting 
the  deltoid  regions.  Slight  nausea  and  vomiting  oc- 
curred four  and  one-half  minutes  zfter  the  injection 


938 


MEDICAL    RECORD. 


[December  15,  1900 


was  completed.  Operation,  consisting  of  an  enlarge- 
ment of  the  sinus  and  thorough  curettage  of  the  cavity 
with  removal  of  some  dead  bone,  was  done  without 
any  pain  or  apparent  nervousness.  IJefore  operation, 
temperature,  99  ;  pulse,  80;  respiration,  24.  One 
hour  after  operation,  temperature,  98.4  ;  pulse.  So; 
respiration,  23.  Four  hours  after  operation,  temper- 
ature, 101°;  pulse,  124;  respiration,  24.  Analgesia 
disappeared  completely  two  and  one-half  hours  after 
injection.  Headache  was  present  for  twenty-four 
hours  but  was  controlled  by  acetanilid,  caffeine  citrate, 
and  sodium  bicarbonate.  He  vomited  twice  during  the 
first  night.     There  were  no  other  after-effects  to  record. 

December  ist:  The  patient  is  doing  very  well. 

Case  IV. — E.  R ,  female,  aged  two  and  one-half 

years;  a  strong,  healthy  child.  Severe  congenital 
talipes  equino-varus  with  considerable  genu  varum  of 
the  right  leg. 

(i)  Cocaine  analgesia,  November  2,  1900.  Place 
of  puncture  to  the  right  between  the  third  and  fourth 
lumbar  vertebra.  Amount  of  cocaine  TTl  vii.  of  a  one- 
per-cent.  solution.  Involuntary  stool  in  seven  minutes 
and  analgesia  to  the  level  of  the  diaphragm  in  twelve 
minutes  from  the  completion  of  the  injection.  The 
operation  lasted  thirty  minutes  and  consisted  of  an 
osteotomy  of  the  right  tibia,  and  an  open  tenotomy  of 
all  tendons  behind  the  right  internal  malleolus.  (Not 
wanting  to  overtax  the  child,  I  decided  to  let  the  left 
talipes  remain  until  another  time.)  No  vomiting  or 
pain  was  experienced,  and  the  condition  of  the  patient 
after  the  operation  was  as  good  as  before.  A  few  mo- 
ments after  the  injection  the  child's  attention  was 
absorbed  in  a  new  doll,  which  was  presented  to  her  on 
this  occasion.  Even  the  rough  handling  necessary  in 
the  forcing  of  the  foot  into  the  normal  position  did 
not  cause  any  apparent  discomfort.  Before  operation, 
temperature,  98.8  ;  pulse,  136;  respiration,  30.  One 
hour  after  operation,  temperature,  99.4°;  pulse,  132; 
respiration,  36.  Analgesia  disappeared  about  two 
hours  after  the  injection.     She  passed  a  restless  night. 

November  4th  :   No  after-effects  are  present. 

(2)  Eucaine  analgesia,  November  20,  1900.  Place 
of  puncture  to  the  left  between  the  third  and  fourth 
lumbar  vertebras.  Amount  of  eucaine  ill  vii.  of  a  one- 
per-cent.  solution.  Analgesia  to  the  level  of  the  um- 
bilicus in  ten  minutes  and  gone  in  eighteen  minutes. 
Second  injection  to  the  right  between  the  third  and 
fourth  lumbar  vertebra;.  Amount  of  eucaine  ni  xv.  of 
a  one-per-cent.  solution.  Analgesia  to  the  level  of  the 
diaphragm  in  five  minutes.  Not  feeling  sure  of  how 
long  the  eucaine  would  act,  and  being  unwilling  to  use 
more  of  the  drug  at  this  time,  I  dressed  the  right  leg  and 
foot,  thoroughly  stretching  the  soft  parts.  No  vomit- 
ing or  pain  appeared,  but  the  patient  seemed  far  more 
nervous  than  after  the  cocaine.  Analgesia  disappeared 
twenty  minutes  after  the  second  injection,  liefore 
operation,  temperature,  98.8° ;  pulse,  112;  respiration, 
26.  Three  hours  after  operation,  temperature,  101.2°; 
pulse,  108;  respiration,  24.  Some  headache  was  pres- 
ent for  a  few  hours.     She  vomited  once. 

November  2  1  st :   No  after-effects  are  noted. 

(3)  Cocaine  analgesia,  November  27,  1900.  Place 
of  puncture  between  the  third  and  fourth  lumbar  ver- 
tebra;. Amount  of  cocaine  ii[  x.  of  a  one-per-cent. 
solution.  Analgesia  to  the  level  of  the  diaphragm  in 
seven  minutes.  The  operation  for  the  left  talipes  was 
the  same  as  that  done  for  the  right,  but  no  osteotomy 
was  required.  The  patient  was  somewhat  nervous  and 
cried  at  times,  but  tests  showed  absence  of  pain  during 
operation.  Analgesia  disappeared  in  a  few  hours,  but 
the  exact  time  was  not  taken.  Before  operation,  tem- 
perature, 98.4°;  pulse,  1 16;  respiration,  26.  One 
hour  after  operation,  temperature,  99.6";  pulse,  50; 
respiration,  32.  Some  headache  and  restlessness  were 
present  the  first  night. 


December  1st:  She  is  doing  well.  No  after-effects 
are  noted. 

Case  V.— F.  B— — ,  male,  aged  nine  years;  epilep- 
tic. Congenital  malformation  of  the  glans  and  pre- 
puce with  slight  hypospadias. 

Cocaine  analgesia,  November  3,  1900.  Place  of 
puncture  between  the  third  and  fourth  lumbar  verte- 
bra:. Amount  of  cocaine  ill  xii.  of  a  one-per-cent. 
solution.  Analgesia  to  the  level  of  the  diaphragm  in 
six  minutes  from  the  completion  of  the  injection  and 
at  the  same  time  slight  nausea  and  vomiting  occurred. 
The  operation  consisted  of  circumcision  and  meatot- 
omy  and  lasted  ten  minutes.  No  pain  or  nervousness 
was  noted.  Before  operation,  temperature,  99'  ;  pulse, 
80;  respiration,  24.  One  hour  after  operation,  tem- 
perature, 99.6° ;  pulse,  130;  respiration,  34.  Analge- 
sia was  entirely  gone  two  hours  after  operation,  and 
seven  hours  afterward  the  patient  had  three  slight 
epileptic  convulsions,  which  were  repeated  a  number  of 
times  during  the  night. 

December  ist:  Since  the  first  sixteen  hours  after 
operation  no  epileptic  convulsions  have  occurred,  and 
the  convalescence  has  been  uninterrupted. 

Case  VI. — F.  V ,  male,  aged   seven  years;    in 

very  poor  general  condition.  Slight  lumbar  kyphosis 
and  large  psoas  sinus  with  small  inguinal  opening. 

Cocaine  analgesia,  November  3,  1900.  Place  of 
puncture  to  the  right  between  the  twelfth  dorsal  and 
first  lumbar  vertebra;,  thus  avoiding  the  site  of  the 
spinal  curve.  Amount  of  cocaine  Til  ix.  of  a  one-per- 
cent, solution.  In.  nine  minutes  after  the  injection 
analgesia  was  present  over  the  entire  body,  except  a 
space  bounded  behind  by  the  posterior  fontanel le,  in 
front  by  the  point  of  the  chin,  and  laterally  on  each 
side  by  the  angle  of  the  jaw,  the  malar  bone,  tlie  tem- 
poral ridge,  and  the  parietal  boss.  Some  nausea  and 
vomiting  occurred  for  a  few  minutes  after  the  injec- 
tion. During  operation,  which  consisted  of  enlarge- 
ment of  the  sinus,  curettage  of  the  bodies  of  the  third 
and  fourth  lumbar  vertebra;,  besides  a  circumcision, 
the  patient  was  free  from  pain  and  showed  no  sign  of 
nervousness.  He  answered  questions  and  showed  full 
command  of  all  his  faculties.  Analgesia  disappeared 
in  one  and  three-fourths  hours.  Before  operation,  tem- 
perature, 98.4°;  pulse,  126;  respiration,  34.  One 
hour  after  operation,  temperature,  100.6°;  pulse,  108; 
respiration,  36.  The  headache  was  controlled  by 
medication.  He  vomited  twice  during  the  night. 
The  pulse  was  good. 

November  4th:  The  child  is  restless  at  intervals 
and  cries  out.  An  ice  cap  is  applied.  Sodium  bro- 
mide is  given  in  small  doses.  The  bowels  are  thor- 
oughly opened. 

November  5th:  He  seems  stupid,  and  apparently  is 
unable  to  express  his  desires  in  words.  He  does  not 
move  the  right  arm  and  hand,  and  the  legs  are  drawn 
up.  There  is  a  slight  elevation  of  temperature,  with 
weak  and  rapid  pulse. 

November  6th:  He  continues  stupid,  does  not  talk, 
and  there  is  very  little  movement  of  the  right  arm. 
The  pulse  demands  stimulation.  Strychnine  and 
digitalin  in  small  doses  are  given  by  the  skin. 

November  7th:   He  is  improving. 

November  8th:  He  is  slowly  gaining.  There  is 
slight  movement  of  the  right  arm. 

November  loth:  He  raisetl  himself  up  in  bed,  and 
is  brighter.  The  legs  can  be  extended.  He  is  mov- 
ing the  right  arm. 

November  12:  Medication  is  discontinued.  I'he 
pulse  is  strong. 

November  15th:   He  is  beginning  to  talk  a  little. 

November  16th:  He  seems  well,  and  speaks  with  no 
difficulty. 

December  ist:  He  is  in  excellent  condition,  better 
than  before  operation. 


December  15,  1900] 


MEDICAL    RECORD. 


939 


Case  VII. — A.  F ,  male,  aged  eleven  years;   in 

a  fair  general  condition.  Tuberculous  ostitis  of  the 
head  of  the  tibia  with  discharging  sinus. 

Eucaine  analgesia,  Xovember  22,  1900.  IMace  of 
puncture  to  the  right  between  the  third  and  fourth 
lumbar  vertebra;.  Amount  of  eucaine  ill  xxx.  of  a 
one-per-cent.  solution.  In  four  minutes  after  the  in- 
jection a  short  period  of  nausea  and  vomiting  oc- 
curred, and  in  seven  minutes  there  was  complete 
analgesia  to  the  level  of  the  diaphragm.  The  oper- 
ation, consisting  of  the  removal  of  dead  bone  and 
curettage  of  the  sinus,  was  accomplished  without  pain. 
After  twenty-five  minutes  the  analgesia  extended  up- 
ward to  the  third  rib  in  front,  to  the  base  of  the  spine 
of  the  scapula  behind,  and  laterally  on  each  side  over 
the  axilla,  the  inner  aspect  of  the  arm  and  forearm  to 
within  an  inch  of  the  styloid  process  of  the  ulna. 
Uefore  operation,  temperature,  98.2  ;  pulse,  84;  res- 
piration, 24.  (Jnc  hour  after  operation,  temperature, 
99°  ;  pulse,  96  ;  respiration,  28.  Analgesia  disappeared 
in  about  two  and  one-half  hours,  but  the  exact  time  was 
not  taken.  The  pulse  was  weak  after  operation  and 
the  headache  severe. 

November  23d:  Medicine  is  still  necessary  for  the 
headache. 

November  24th;   He  is  feeling  perfectly  well. 

Decem'jer  ist:  He  isdoingnicely.  No  after-effects 
are  noted. 

General  Comments These  cases  have    not   been 

specially  selected.  The  preparation  of  each  was  the 
same  as  usual  before  a  general  anesthetic.  The  pa- 
tient was  placed  in  a  sitting  posture,  well  bent  for- 
ward, and  prevented  from  moving  during  the  injec- 
tion. After  the  skin  over  the  site  of  puncture  had 
been  treated  in  the  usual  antiseptic  way  an  ethyl- 
chloride  spray  was  employed,  rendering  the  introduc- 
tion of  the  needle  practically  painless.  I  experienced 
no  difficulty  in  introducing  the  needle.  A  point  one- 
half  inch  to  either  side  of  the  median  line  and  mid- 
way between  the  spinous  processes  was  taken,  and  the 
needle  pushed  forward,  inward,  and  upward.  Special 
effort  was  made  to  keep  away  from  the  central  part  of 
the  spinal  canal  by  a  close  relation  of  the  needle  point 
to  the  dura.  The  instrument  used  was  of  the  simplest 
kind.  A  small-sized  steel  aspirating-needle  with  a 
short-bevelled  pointed  end,  having  a  well-fitting  hypo- 
dermic barrel,  answered  every  purpose.  As  nearly  as 
possible  the  same  amount  of  cerebro-spinal  fluid  was 
allowed  to  escape  as  of  the  injection  medium  which 
was  to  be  introduced.  The  injection  was  given  slow- 
ly, usually  taking  one  and  one-half  to  two  and  one- 
half  minutes.  Often  the  first  evidence  that  the  co- 
caine was  taking  effect  was  some  dilatation  of  the 
pupil  or  a  slight  nausea.  During  the  operation  a 
nurse  known  to  the  child  stood  close  at  hand,  and  the 
operative  field  and  the  instruments  were  screened  from 
view.  Anything  which  resembled  a  blindfolding  ex- 
cited and  disturbed  the  patient.  As  far  as  possible 
general  tests  were  made.  There  seemed  to  be  no  loss 
of  motor  power,  and  the  ability  to  detect  heat  and  cold 
and  the  muscular  and  tactile  sense  were  retained. 
These  are  important  points  to  remember,  for  too  hot  a 
solution  or  unduly  rough  handling  may  be  thoughtless- 
ly applied,  causing  the  patient  to  become  difficult  to 
manage. 

There  have  been  many  cases  of  failure  reported 
which  were  attributed  to  the  use  of  heat  in  the  sterili- 
zation of  the  injection  fluid.  This  fact  led  me  early 
to  experiment  with  other  means.  In  all  the  above 
cases  the  following  method  has  been  employed  with 
uniform  success.  While  this  simple  way  of  sterilizing 
may  be  open  to  bacteriological  objections,  practical 
experiments,  so  far  as  I  know,  have  proven  it  to  be 
satisfactory.  About  a  drachm  of  ether  is  poured  over 
gr.    V.   of    powdered  cocaine    or  eucaine  in   a   meas- 


uring-glass, which  has  been  boiled,  as  well  as  the 
glass  rod  used  to  mix  the  ether  thoroughly  with  the 
powder.  The  mixing-process  is  continued  until  all 
the  ether  has  disappeared.  Then  one  ounce  of  boiled 
filtered  water  is  added.  The  solution  is  made  fresh 
before  each  operation. 

After-effects;  In  all  cases  any  after-effects  of  an  un- 
pleasant nature  were  temporary.  The  urine  on  the 
day  following  the  injection  was  examined  in  all  cases 
for  sugar  and  albumin.  The  result  was  uniformly 
negative.  In  only  one  case  (No.  VI.)  were  there  any 
serious  symptoms  following  the  operation.  Here  was 
a  high  injection,  with  I'ott's  disease  of  the  spine,  in  a 
patient  in  bad  general  condition.  I  was  greatly  aided 
in  this  work  by  Dr.  W.  K.  Young  and  his  assistants  at 
the  Randall's  Island  Hospital. 

Cocaine  versus  eucaine:  My  cases  so  far  have 
proved  more  satisfactory  when  cocaine  has  been  em- 
ployed. In  one  patient  I  had  the  opportunity  of  notic- 
ing the  effects  of  both  cocaine  muriate  and  beta-eucaine 
hydrochlorate  at  different  operations.  The  after-effects 
seemed  no  greater  in  one  than  in  the  other,  and  the 
analgesia  was  not  so  uniform  or  lasting  when  eucaine 
was  employed.  Most  of  the  experimenters  with  this 
method  of  operating  are  using  cocaine,  but  Lugueu 
and  Kinderdjy  are  strong  advocates  of  eucaine  a'nd 
are  discarding  the  former  in  preference  to  the  latter. 

No  final  verdict  for  or  against  spinal  injection,  or 
what  remedy  is  best  to  use,  can  be  reached  without 
further  experimental  evidence.  The  remote  after- 
effects are  yet  to  be  determined. 

(Since  writing' this  paper  I  learn  that  Dr.  A.  Palmer 
Dudley  reports  in  the  Transactions  of  the  New  York 
Obstetrical  Society,  December,  1900,  the  use  of  chloro- 
form in  the  sterilization  of  cocaine  for  spinal  in- 
jection.) 

BIBLIOGRAPHY. 

Anderson,  C.  H.:  Medical  REcORn,  November  3,  1900. 

Bier,  A.:   Deutsche  Zeitschr.  f.  Chirurg, .   1899,  51,  p.  361. 

liogart,  J.  B.:  N.  Y.   Med.  Jour.,  November  3,  1900.' 

lioldt,  H.  I.:  N.  Y.  Med.  Jour.,  November  3,  igoo.  p.  749; 
N.  Y.  Med.  Press,  1885-86,  105. 

Cartledge  :  Med.  News,  November  24,  1900. 

Cadol  ;  These  de  Paris,  igoo. 

Coe,  II.  C:   N.  V.  Med.  Jour.,  November  3,  1900.' 

Corning,  J.  L.:  N.  Y.  Med.  Jour.,  18S5,  42,  p.  483  ;  Med- 
ical Record,  March  17,  188S,  p.  291  ;  Medical  Record,  Oc- 
tober 20,  1900;   Pain,  J.  B.   I.ippincott  &  Co.,  I'hila. ,  1894. 

Dudley,  A.  P.:  N.  Y.  Med.  Jour..  November  3,  1900.' 

Kngelmann,  F.:  Mlmch.  med.  Woch. ,  October  3,  1900,  p. 
1531. 

Fowler,  G  R.:  Phila.  Med.  Jour.,  November  3,  1900,  p.  843; 
N.  Y.  Med.  Jour.,  October  20,   igoo. 

Goldan,  S.  O. :  Phila.  Med.  Jour.,  November  3,  1900,  p.  850; 
N.  Y.  Med.  Jour.,  November  3,  1900  ;  Med.  News,  November 
10.  Igoo. 

Goffe.  J.  R.:  Med.  News,  October  13,  igoo;  Jour.  Am.  Med. 
.\ssn.,  November  17.  Igoo. 

Grandin,  E.  H.:   N.  Y.  Med.  Jour.,  November  3,  1900.' 

(lumprecht  ;   Deutsche  med.  Woch..  June  14,  1900. 

Hopkins:   Phila.   Med.  Jour.,  Novembers,   1900,  p.  864. 

Ilamer:   Indiana  Med.  Jour.,   November,  1900. 

Jacob  :   Berliner  klin.  Woch..   i8g8,  21.  p.  488. 

Jonnesco:  Bull,  ct  mem.  de  la  Soc.  de  Chir.  de  Bucharest, 
December,  iSgg,  and  I'ebruar)',  igcx),  v.  ii.,  3,  4. 

Keen.  W.  W.:   Phila.  Med.  Jour.,  November  3,  igoo,  p.  863. 

Kinderdjy  :   Presse  mcdicale,  October  27,  igoo. 

Kreis,  O. :  Centralblatt  f.  Gynak.,   igoo.  28. 

Laplace,  E.:   Phila.   Med.  Jour.,  Novembers,  igoo,  p.  867. 

Lee,  E.  W. :   Phila.  Med.  Jour..  Novembers,   igoo,  p.  865. 

Leyden,  E.  von:   Berliner  klin.  Woch.,   1899,  p.  632. 

Lugueu  :  Presse  mcdicale,  October  27,  Igoo. 

Mar.x.  S. ;  N.  Y.  Med.  News,  August  15,  ig'Xj  ;  Medical  Rec- 
ord, November  3,  igoo;  Phila.  Med.  Jour.,  Novembers,  igoo. 

Masse  :  Gaz.  hebd.  de  la  Soc.  med.  de  Bordeaux,  1900, 
xxvii.,  316. 

Matas  :  Phila.  Med.  Jour.,  November  3,  1900,  p.  820. 

Morange  :   Union  med.  du  nord  et  Reims,  1900,   13,  p.  Ig8. 

Murphy,  J.  B. :  Jour.  .Vm.  Med.  Assn.,  September  i.  1900; 
Med.  News.  November  10,  Igoo. 

Nicoletti  :   Presse  mcdicale,  August  7,  Igoo. 

Phelps,  A.  M. :   Phila.  Med.  Jour.,  November  3,  Igoo,  p.  868. 

'  Reported  in  general  discussion  at  a  society  meeting. 


940 


MEDICAL    RECORD. 


[December  15,  1900 


Pitesci :   Presse  medicale,  August  7,  1900. 

Quincke  :  Cong.  f.  inner.  Med.,  1891.  10,  321  ;  Berliner  klin. 
Wocli.,  1891,  2S,  p.  929;  iliid.,  1S95,  32,  pp.  889-891;  ibid., 
1893,  21,  p.  4S8. 

Rodman:  Med.  News,  N.  Y.,  November  24,  1900,  p.  827; 
Phila.   Med.  Jour.,   November  3.  1900,  p.  866. 

Seldowitsch  :   Centralblatt  f.  Cliir.,  iSgg,  41. 

Severeano  and  Geroto:  Bull,  et  mem.  de  la  Soc.  de  Chir.  de 
Bucharest,  December,  1S99,  and  February,  1900,  v.  ii. ,  3,  4. 

Severeano:   Presse  mt'dicale.  August  7,  1900,  p.  91. 

Schmidt,  L.  E.:   Phila.  Med.  Jour.,  November  3,  1900,  p.  80S. 

Shoemaker:   Jour.  Am.  Med.  Assn..  1900,  xx.sv. ,  1339. 

TulBer  ;  Compt.  rend,  et  mem.  de  la  Soc.  de  Biol.,  November 
II,  i39')  ;  Semaine  med.,  1S99,  156;  ibid..  May  16,  igoo;  Bull, 
et  mem.  de  la  Soc.  de  Chir.,  November  29,  1899  ;  Presse  medi- 
cale,  August  7,  1900. 

34  Gramercv  Park,  New  York. 


The  Value  of   Rest  In  Bed  in  the  Treatment  of 

Certain  Digestive  Disorders Albu  draws  attention 

to  the  frequency  with  which  neurasthenia,  aneemia, 
and  malnutrition  are  associated  and  the  great  amount 
of  injury  to  the  system  at  large  that  may  be  produced 
by  such  a  triad.  The  deficiency  in  nerve  energy  and 
the  consequent  imperfect  innervation  of  the  tissues 
lead  to  a  general  lack  of  muscular  tone  which  finds 
expression  in  different  ways  according  to  the  region 
of  the  body  affected.  In  the  abdomen  the  general  re- 
laxation has  for  its  consequences  visceroptosis  and 
atony  of  the  stomach  and  intestines  with  their  attend- 
ant evils,  and  in  proportion  as  the  lack  of  proper  nu- 
trition increases  the  somatic  weakness  the  debilitating 
events  move  in  a  vicious  circle  of  greater  and  greater 
circumference  and  constantly  involve  more  remote 
regions  in  the  disease.  Under  such  conditions  the 
evident  indications  are  rest  and  feeding.  But  to  be 
properly  effective  the  patient  must  completely  change 
his  previous  faulty  mode  of  life  and  be  treated  in  a 
wholly  alien  environment.  As  a  routine  for  such  cases 
at  least  three  weeks  of  absolute  rest  in  bed,  in  some 
institution  away  from  home,  is  to  be  advised,  together 
with  a  full  diet,  for  even  though  the  state  of  the  stom- 
ach may  seem  to  contraindicate  this  over-feeding,  in 
most  cases  it  will  relieve  the  symptoms  more  quickly 
than  the  most  carefully  adjusted  but  quantitatively 
insufficient  re'gime.  By  these  means  bodily  waste  of 
all  sorts,  nerve  and  muscle,  is  reduced  to  a  minimum 
and  the  depleted  cells  are  enabled  to  regain  their  nor- 
mal tone  and  vigor. — Zeitschrijt  Jiir  Kraiikcnpflc^e, 
October,  1900. 

The  Elimination  of  the  Inflamed,  Gangrenous, 
or  Perforated  Vermiform  Appendix  from  the  Gen- 
eral Peritoneal  Cavity. — A.  J.  Ochsner  urges  a  form 
of  treatment  which  practically  eliminates  the  appen- 
dix from  the  general  peritoneal  cavity.  It  consists  of 
total  abstention  of  food  given  through  the  mouth,  the 
object  being  to  secure  absolute  rest  of  the  intestinal 
tract.  The  patient's  strength  is  maintained  by  non- 
irritating,  predigested,  nutrient  enemata  every  four  to 
six  hours,  which  should  not  exceed  four  ountes  at  a 
time.  Water,  preferably  hot,  can  usually  be  given  by 
the  moutii,  but  if  it  causes  peristalsis  or  nausea  should 
be  given  by  enema.  This  treatment  will  not  protect 
the  patient  against  a  recurrence,  nor  against  the  trou- 
blesome digestive  disturbances  due  to  adhesions  fol- 
lowing appendicitis,  but  it  will  carry  the  patient  safely 
over  an  acute  attack,  and  will  enable  the  surgeon  to 
select  a  favorable  time  for  operation.  The  author  re- 
ports a  number  of  cases. —  The  Chicago  Medical  Recorder, 
November,  1900. 

Heart  Disease  or  Epilepsy. — F.  Savary  Pearce  re- 
ports several  cases  which  tend  to  reinforce  the  fact  of 
the  possible  existence  of  a  great  similarity  between 
epileptoid  phenomena — a  petit  mal  —  when  the  cardiac 
action   is   affected  primarily,  or  when   the    so-called 


"heart  failure "  predominates  in  its  symptomatology 
— and  syncopal  attacks  independent  of  the  epilepsy 
neurosis.  As  to  early  recognition  of  the  significance 
of  syncope,  organic  heart  disease  would  be  a  sign  in  a 
diflicult  case,  with  a  comatose  mental  state  during  the 
spell,  that  the  syncope  was  of  cardiac  origin.  Organic 
disease  of  the  heart  rarely  causes  convulsions.  The 
less  frequent  and  variable  the  apparent  unconscious- 
ness during  an  attack  of  syncope,  the  more  likely  the 
hysteroid  nature.  The  presence  of  a  slow,  full,  and 
irregular  pulse,  with  or  even  without  unconsciousness, 
makes  more  likely  the  epileptoid  nature  of  the  case. 
Leaky  skin  and  cold  extremities  are  more  in  favor  of 
hystero-anaimic  cases.  The  absence  of  pain  in  any 
case  eliminates  angina.  Cyanosis  is  not  common,  ex- 
cept in  the  organic  heart  cases.  A  tendency  to  rigidity 
without  convulsion  is  in  favor  of  hysteria  being  the 
background  of  the  clinical  picture. — Annals  oj  Gyne- 
cology and  Pediatry,  November,  1900. 

Fibrinous  Rhinitis — J.  M.  Gill  reports  the  case  of 
a  girl  of  five  years  who  for  three  weeks  had  suffered 
from  nasal  obstruction  and  for  a  short  period  from 
fever.  The  right  nostril  was  full  of  a  substance  look- 
ing like  wet  blotting-paper,  but  which  proved  to  be  a 
fibrinous  cast  of  the  inferior  turbinate.  The  mem- 
brane re-formed  several  times,  but  finally  disappeared. 
Examination  showed  almost  a  pure  culture  of  a  bacil- 
lus resembling  in  all  respects  that  of  diphtheria,  and 
this  view  was  confirmed  by  the  result  of  inoculating 
guinea-pigs.  One  of  the  animals  received  along  with 
the  injection  a  dose  of  antitoxin,  while  another  simi- 
larly inoculated  did  not.  The  animal  receiving  cul- 
ture and  antitoxin  showed  no  signs  of  illness.  The 
animal  receivingonly  culture  died  in  forty-eight  hours. 
— Australasian  Medical  Gazette,  October  20,  1900. 

Saturnism  among  Stone-C utters. — Ch.  Fiessenger 
says  that  many  of  the  cutters  of  precious  stones  in  the 
Jura  Mountains  suffer  from  lead  poisoning,  due  to  the 
use  of  a  leaden  wheel  in  their  work.  The  number  of 
those  affected  has  greatly  diminished  in  the  past  fifteen 
years,  owing  to  the  progress  made  in  a  knowledge  of 
hygiene  and  to  decreasing  use  of  the  lead  wheel.  Sa- 
turnine gout  is  not  known  among  these  patients,  prob- 
ably because  of  their  habits  of  sobriety,  their  moder- 
ate meat  diet,  and  the  high  altitude  at  which  they  live. 
All  the  other  symptoms  of  lead  poisoning  are  present: 
hysteria,  dyspepsia,  neurasthenia,  epilepsy,  nephritis, 
ansmia,  and  paralysis.  Tuberculosis  is  a  frequent 
disease  among  lapidaries,  but  profound  lead  poisoning 
seems  to  confer  immunity  from  this  affection. — Bulle- 
tin de  r Academic  de  Ml-dccinc,  October  30,  1900. 

The  Treatment  of  Insomnia  due  to  Arteriosclero- 
sis.— Friedeberg  advises  moderate  outdoor  exercise, 
which  must  be  carefully  regulated,  however,  and  never 
include  hill  climbing  owing  to  the  palpitation  likely 
to  result.  Cool  baths  are  to  be  avoided,  and  even 
warm  ones,  taken  at  night,  are  prone  to  cause  excite- 
ment in  the  aged.  Sponging  at  bedtime  is  often  bene- 
ficial, as  are  also  warm  drinks,  but  tea  and  coffee  are 
to  be  interdicted.  Care  should  be  taken  that  the  noon- 
day nap  does  not  exceed  one-half  hour  in  lengtii. 
Narcotic  drugs  are  to  be  avoided  as  much  as  possible, 
and,  since  the  condition  is  due  mainly  to  cerebral  anae- 
mia, attention  should  be  given  rather  to  the  state  of 
the  circulation.  Digitalis  is  nearly  always  useless  for 
this  purpose,  but  the  nitrites  give  excellent  results. 
Owing  to  its  toxicity  amyl  nitrite  should  not  be  used, 
but  both  nitroglycerin  and  erythrol  tetranitrite  are 
often  of  signal  service.  The  former  may  be  given 
nightly  in  doses  of  gr.  jl^  by  mouth;  should  head- 
ache or  nausea  follow  on  awaking,  it  is  an  indication 
for  omitting  the  drug  for  a  week.  —  Klinisch-thera- 
petttische  IVochenscltriJt.  October  21,  1900. 


December  15,  1900] 


MEDICAL    RECORD. 


941 


Medical  Record: 

A    Weekly  Journal  of  Medicine  and  Surgery. 


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

Publishers 

WM.  WOOD  &  CO.,  51    Fifth  Avenue. 

New  York,  December  15,  1900. 

ABUSE  OF  PROFESSIONAL  POWER. 

A  RECENT  occurrence  in  one  of  our  large  hospitals 
deserves  more  tlian  a  passing  mention,  for  it  has 
rarely  been  our  duty  to  record  a  more  unnecessary 
abuse  of  power  on  the  part  of  a  board  of  trustees. 

The  house  physician  of  the  institution  referred  to 
was  a  man  of  great  promise.  He  had  graduated  from 
his  medical  college  among  the  first  ten  in  his  class, 
and  he  had  earned  the  esteem  and  affection  of  all  who 
knew  him.  In  the  hospital,  to  which  he  was  appointed 
after  competitive  examination,  he  was  regarded  as  the 
equal  in  every  way  of  any  one  who  had  ever  held  the 
position  there  of  house  physician.  His  term  of  ser- 
vice would  have  expired  at  the  end  of  this  month,  and 
during  his  residence  in  the  hospital  he  had  never  re- 
ceived a  reprimand  for  neglect  of  duty  or  breach  of 
discipline.  A  few  weeks  ago  a  member  of  the  board 
of  trustees  of  this  institution,  himself  a  physician,  sent 
to  the  hospital,  for  admission  to  a  medical  ward,  the 
servant  of  a  lady  of  his  acquaintance.  The  patient 
was  suffering  from  the  vomiting  caused  by  chronic 
gastritis  and  recent  pregnancy.  Arriving  at  the  hos- 
pital, accompanied  by  a  physician  from  the  country, 
she  was  taken  to  the  accident-room,  placed  under  the 
care  of  a  very  experienced  trained  nurse,  and  the 
usual  and  ordinary  notice  was  sent  to  the  house  physi- 
cian that  a  patient  awaited  his  examination.  The 
house  physician's  occupation  at  the  time  was  such 
that  he  failed  to  visit  this  serious  and  distressing  case 
until  perhaps  thirty  minutes  (but  not  more)  had 
elapsed.  The  patient  was  then  admitted  to  the  pub- 
lic ward,  her  needs  were  attended  to,  and  at  the  end  of 
one  week  the  symptoms  of  which  she  had  complained 
were  entirely  relieved. 

Complaint  was  made  to  the  medical  member  of  the 
board  of  trustees  who  had  recommended  the  patient 
for  admission  to  the  hospital  that  she  had  been  un- 
duly kept  waiting  before  being  seen  by  the  house 
physician.  This  trustee,  himself  a  medical  man  noted 
for  his  delicate  sympathy  with  charity  patients  and 
with  his  professional  brothers  when  they  are  in  trou- 
ble, would,  of  course,  under  other  circumstances,  have 
been  satisfied  with  warning  the  )'oung  man  that  he 
must  be  more  prompt  in  his  attendance  on  patients 
waiting  for  examination.  But  he  himself  had  recom- 
mended the  patient,  and  the  patient  was  a  servant  of 
one  of  his  well-to-do  lady  acquaintances.    A  few  days 


later  a  very  severe  reprimand  was  administered  to  the 
house  physician  by  the  executive  committee  of  the 
hospital  and  about  two  weeks  ago  the  young  man  was 
summoned  before  the  full  board  of  trustees. 

Very  severe  remarks  were  made  to  him,  and  he  wns 
informed,  among  other  things,  that  the  professional 
men  connected  with  the  hospital  were  to  understand 
that  they  were  itj  servants.  The  medical  member 
added  his  words  of  abuse. 

The  result  of  the  deliberations  of  the  elderly  men 
who  manage  this  important  charitable  institution  was 
that  the  house  physician  was  suspended  for  the  re- 
mainder of  his  term  of  service,  and  requested  to  leave 
the  hospital  at  the  earliest  possible  moment.  For  an 
entirely  harmless  and  innocent  breach  of  discipline  a 
professional  man  of  unblemished  character  and  of  fine 
education  has  been  dismissed  from  his  hospital  ser- 
vice as  though  he  had  committed  a  crime. 

In  addition  to  the  grave  injury  done  to  the  individ- 
ual, the  harm  done  by  such  action  as  this  spreads  very 
widely.  It  breeds  dislike  and  disloyalty  at  a  rapid  rate 
among  the  young  men  who  would  naturally  be  the 
staunchest  supporters  of  the  institution  with  which 
they  have  associated  themselves,  and  whose  friendship 
it  is  very  desirable  for  the  institution  to  cultivate. 
It  serves  as  a  loud  warning  to  those  seeking  hospi- 
tal positions  to  go  where  they  will  be  treated  with 
ordinary  kindness  and  courtesy;  and  it  leads  the  pub- 
lic entirely  to  distrust  the  capacity  of  a  management 
which  is  capable  of  so  grossly  mismanaging. 

Discipline  must  be  maintained  in  all  institutions, 
but  the  Chinese  method  of  beheading  for  trivial  of- 
fences will  never  find  favor  in  this  country. 


ANGINA    PECTORIS. 

Angina  pectoris  may  be  defined  as  a  symptom  com- 
plex dependent  upon  disturbance  in  the  functional 
activity  of  the  heart  muscle,  resulting  either  from  or- 
ganic causes,  such  as  disease  of  the  coronary  arteries 
or  of  the  myocardium  itself,  or  from  toxic  influences, 
such  as  may  arise  from  excessive  indulgence  in  alco- 
hol, tea,  or  coffee.  It  has  been  the  custom  to  desig- 
nate cases  of  the  first  kind  "  true "  and  those  of  the 
second  kind  "false,"  but  it  would  seem  better  to  era- 
ploy  instead  the  qualifications  "severe"  and  "mild" 
respectively.  Derangement  of  function  must  always 
be  referred  to  alteration  in  structure  or  in  nutrition, 
and  the  degree  of  the  former  will  necessarily  vary  with 
the  character  and  the  intensity  of  the  latter.  Normal 
function  must  be  looked  upon  as  the  resultant  of  meta- 
bolic activity,  whose  derangement  will  be  attended 
with  altered  nutrition,  which  if  profound  or  long  con- 
tinued or  frequently  repeated,  in  consequence  of  either 
intrinsic  or  extrinsic  influences,  may  lead  to  structu- 
ral alteration.  In  accordance  with  the  foregoing  con- 
siderations, angina  pectoris  would  not  necessarily  be 
a  disorder  of  the  degenerative  period  of  life,  and  not 
invariably  fatal,  but  the  prognosis  would  vary  with  the 
nature  of  the  underlying  condition.  In  reporting 
briefly  five  cases  of  angina  pectoris,  three  of  which 
terminated  fatally,  and  in  two  of  which  recovery  en- 


942 


MEDICAL    RECORD. 


[December  15,  1900 


sued,  Salomon  {^Berliner  klinische  Woc/tensdiri/t,  1900, 
No.  36,  p.  275)  points  out  that,  inasmuch  as  the  etio- 
logical factors  are  so  varied,  it  is  not  to  be  expected 
that  the  lesions  present  should  always  be  the  same. 
Thus,  among  the  conditions  assigned  as  causative  in- 
fluences are  syphilis,  alcoholism,  long-continued  men- 
tal and  physical  strain,  frequently  repeated  and  long- 
continued  depressing  emotional  states,  diabetes,  gout, 
acute  infectious  diseases,  excessive  indulgence  in  to- 
bacco, tea  and  coffee,  over-eating  with  insufficient  ex- 
ercise, and  lead  poisoning.  In  any  event  the  treat- 
ment is  much  the  same.  In  the  paroxysm  inhalations 
of  ether,  chloroform,  or  amyl  nitrite,  hypodermic  in- 
jections of  morphine,  or  the  administration  of  nitro- 
glycerin may  be  practised,  while  in  the  intervals  the 
diet  and  the  mode  of  life  generally  will  require  to  be 
regulated,  and  iodide  should  be  administered. 


THE    SOUTH    AFRICAN    MILITARY    HOSPI- 
TALS   COMMISSION. 

This  commission  has  just  completed  the  taking  of  evi- 
dence, and  until  it  makes  its  report  it  would  be  impos- 
sible to  say  what  its  finding  may  be.  However,  to 
judge  from  the  statements  tendered  by  witnesses,  the 
summing  up  cannot  be  altogether  favorable  to  the 
medical  arrangements  of  the  British  army.  In  fact,  it 
is  admitted  by  every  unprejudiced  person  who  has  seen 
the  conditions  of  the  South  African  hospitals  that  the 
provision  was  insufficient  in  many  respects.  Almost 
all  the  British  medical  journals  at  the  commencement 
of  the  war  drew  attention  to  the  inadequacy  of  the 
army  medical  corps,  and  some  indeed  went  so  far  as  to 
predict  a  complete  breakdown  of  that  branch  of  the 
service  if  the  campaign  should  be  a  long  one.  These 
presages  of  evil  were  not  fulfilled,  and,  until  enteric 
fever  broke  out  and  spread  on  a  large  scale,  the  army 
surgeons,  supplemented  by  a  number  drawn  from  civil 
life,  showed  themselves  well  able  to  cope  with  the  diffi- 
culties of  the  situation.  Even  then  it  is  claimed  that 
the  blame  for  the  partial  breakdown  rests  on  the  war  of- 
fice and  military  authorities  rather  than  on  the  medical 
department.  One  fact  stands  out  prominently,  and  of 
this  the  whole  British  nation  seems  to  be  thoroughly 
convinced — that  the  army  medical  corps  must  be  re- 
formed, root  and  branch.  There  are  some  points  of 
similarity  between  the  conduct  of  the  South  African 
war  as  regards  the  medical  service  and  our  war  with 
Spain.  In  both  campaigns  the  supply  of  army  sur- 
geons was  not  equal  to  the  demand,  and  in  both  the 
gaps  had  to  be  filled  by  non-military  nia<iical  practi- 
tioners. Again  there  would  appear,  from  all  accounts, 
to  have  been  a  certain  parallel  between  the  manner  in 
which  medical  supplies  failed  to  reach  the  places 
where  they  were  needed.  With  regard  to  nursing,  the 
opinion  of  the  most  distinguished  liritish  military 
authorities  has  undergone  a  considerable  change  dur- 
ing the  progress  of  the  South  African  war.  A  writer 
of  note  in  the  Edinbiiii^li  Rnneu'  has  this  to  say  on  tlie 
subject:  "Although  the  traditions  of  the  army  medi- 
cal corps  are  opposed  to  female  nursing,  assigning 
nearly  nine  times  as  many  male  as  female  nurses  to  a 


general  hospital,  suffice  it  to  say  that  at  the  present 
time  almost  all  men  from  Lord  Wolseley  and  Lord 
Roberts  downwards,  recognize  its  desirability,  more 
especially  in  fever  cases,  which  are  the  common 
scourge  of  young  soldiers."  And  in  another  part  of  the 
same  article  the  writer  says:  "The  army  has  hitherto 
neglected  the  question  of  female  nursing.  In  the 
early  stages  of  the  war  nurses  were  not  only  deficient, 
but  offers  of  trained  nurses  were  actually  declined. 
As,  however,  the  war  proceeded,  orderlies  became 
scarce,  and  as  Lord  Roberts  insisted  on  female  nurs- 
ing, and  as  the  usefulness  of  such  assistance  became 
apparent  to  all,  more  particularly  at  the  base  hospitals 
and  in  the  fever  hospitals,  the  number  of  nurses  was 
increased.  Clearly  the  experience  of  the  war  is  in 
favor  of  female  nursing  to  be  utilized  to  a  far  greater 
extent  than  hitherto,  having  this  further  advantage  of 
releasing  men  for  work  at  the  immediate  front.  This 
in  turn  will  necessitate  that  organization  of  a  female 
nursing  service  which  has  hitherto  been  neglected." 
In  the  Spanish-American  war  the  services  of  female 
nurses  were  dispensed  with  as  much  as  possible,  and 
our  medical  and  military  authorities,  like  the  British, 
declined  to  engage  female  nurses.  In  an  editorial  in 
the  Medical  Record  some  few  months  ago  the  ques- 
tion of  female  nursing  was  briefly  touched  upon,  and 
the  opinion  was  expressed  that  when  feasible  well- 
trained  female  nurses  should  be  employed  in  prefer- 
ence to  men  nurses,  especially  in  base  hospitals.  It 
is  therefore  some  gratification  that  our  views  should 
be  borne  out  by  the  experience  of  a  man  so  versed  in 
all  pertaining  to  modern  warfare  as  Lord  Roberts. 
The  report  of  the  South  African  military  hospitals 
commission  must  be  instructive,  and  will  be  awaited 
with  much  interest  by  army  and  civil  medical  men  in 
this  country. 


THE   SURGICAL  TREATMENT  OF    PRIMARY 
RENAL    TUBERCULOSIS. 

Although  it  is  known  that  tuberculosis  in  any  organ 
may  undergo  spontaneous  recovery,  and  while  the  re- 
sults of  intelligent  medicinal  and  hygienic  treatment 
are  at  times  entirely  satisfactory,  the  outcome  cannot 
be  safely  predicated  in  any  given  case.  For  this  rea- 
son, and  in  view  of  the  relative  malignancy  of  the  dis- 
ease, the  adoption  of  surgical  measures  for  its  removal 
would  seem  to  be  indicated  whenever  practicable.  The 
decision  will  often  be  a  most  delicate  one,  in  conse- 
quence of  the  difficulty  at  times  encountered  in  diag- 
nosis, the  uncertainty  of  result,  and  the  possibility  of 
extensive  involvement.  This  general  statement  is  ap- 
plicable with  especial  force  to  tuberculosis  of  the 
kidney,  in  which  often  tlie  disease  is  primary  and  cir- 
cumscribed. If  surgical  intervention  has  been  decided 
upon,  the  question  as  to  the  character  of  the  operation 
will  arise.  For  the  purpose  of  reaching  a  decision  in 
these  matters,  O.  G.  Ramsay  (AiinahoJ  Surgery,  Octo- 
ber, 1900,  p.  461  )  has  collected  from  various  sources 
three  liundred  and  four  cases  of  renal  tuberculosis  in 
which  some  form  of  operative  treatment  was  employed, 
and  from  an  analysis  of  which  he  believes  that  renal 


December  15,  1900] 


MEDICAL    RECORD. 


943 


tuberculosis  maybe  considered  a  semi-malignant  form 
of  inflammation,  and  that  for  this  reason  surgical  treat- 
ment of  some  sort  is  always  indicated.  This  treat- 
ment will  have  a  palliative  or  a  curative  end  in  view, 
in  accordance  with  the  condition  of  the  patient  and 
the  duration  and  extent  of  the  disease.  Nephrotomy 
in  cases  of  renal  tuberculosis  is  to  be  considered  a 
palliative  operation,  and,  practised  from  this  point  of 
view  for  the  immediate  relief  of  dangerous  symptoms 
and  as  not  precluding  subsequent  nephrectomy,  ne- 
phrotomy with  drainage  of  the  abscess  cavity  is  a  most 
valuable  procedure.  Resection  of  the  diseased  por- 
tion of  the  kidney  is  contraindicated,  because  of  the 
danger  of  leaving  a  tuberculous  focus  in  the  remain- 
ing portion.  Nephrectomy,  or  nephro-ureterectomy,  is 
indicated  in  all  suitable  cases,  in  55.5  per  cent,  of 
which  it  should  effect  a  permanent  cure.  The  contra- 
indications to  nephrectomy  are  tuberculous  or  other 
disease  of  the  second  kidney,  or  the  presence  of  tuber- 
culosis in  other  organs.  Tuberculosis  of  the  bladder 
is  not  to  be  considered  a  contraindication  to  nephrec- 
tomy, as  it  will  probably  undergo  subsequent  cure. 
A  small  tuberculous  focus  in  the  lung,  if  the  patient 
is  otherwise  in  good  condition,  may  sometimes  not 
be  considered  a  contraindication.  In  doubtful  cases, 
when  it  is  questionable  whether  the  patient  can  stand 
an  immediate  nephrectomy,  it  is  better  to  perform 
nephrotomy,  to  be  followed  later  by  nephrectomy. 
The  clamp  method  of  controlling  the  pedicle  is  con- 
traindicated on  account  of  the  danger  of  hemorrhage 
on  removal  of  the  clamp.  It  is  safest  to  remove  the 
ureter  with  the  kidney,  as  otherwise  a  permanent  fistula 
may  remain.  A  certain  proportion  of  such  fistulas 
will  finally  disappear,  either  after  the  removal  of  a 
deep  suture  or  in  consequence  of  the  slow  disappear- 
ance of  the  tuberculous  disease  of  the  ureter,  which 
under  such  circumstances  is  gradually  converted  into 
a  fibrous  cord.  A  steadily  increasing  number  of  cases 
of  permanent  recovery  may  be  expected  as  our  means 
of  diagnosis  improve,  and  as  our  surgical  technique 
is  carried  out  more  carefully  and  scientifically. 


^nus  of  tixe  'gmcck. 

Pathological  Society  of  Philadelphia. — At  a  stated 
meeting  held  November  2 2d  Drs.  George  E.  de 
Schweinitz  and  Edward  A.  Shumway  reported  "Two 
Cases  of  Glioma  of  the  Retina,"  and  discussed  current 
views  as  to  the  histology.  Dr.  Charles  Wardell 
Stiles,  of  the  bureau  of  animal  industry  of  the  depart- 
ment of  agriculture,  presented  by  invitation  a  commu- 
nication entitled  '"  Parasitic  Hamoptysis,'"  an  atYec- 
tion  that  has  been  observed  in  considerable  numbers 
of  human  beings  in  China  and  Japan  and  of  animals 
in  the  United  States.  The  disorder  is  dependent 
upon  the  presence  of  the  Paragonimus  Westermannii, 
a  fluke,  which  most  often  finds  lodgment  in  the  lungs 
and  sometimes  in  other  viscera  also.  The  parasite  is 
derived  from  snails,  which  act  as  the  intermediate 
hosts,  and  are  ingested  with  the  water.  Dr.  Stiles 
demonstrated  both  the  parasite  and  the  ova,  and  he 


pointed  out  the  possibility  of  the  importation  of  the 
disease  with  a  return  of  American  soldiers  who  had 
seen  service  in  China  and  the  Philippines.  Dr.  ¥. 
Savary  Pearce  presented  the  specimen  from,  and  re- 
lated the  history  of,  "  A  Case  of  Hemorrhage  into  the 
Crus  Cerebri  and  Pons  Varolii."  Dr.  Joseph  McFar- 
land  exhibited  a  heart  containing  a  mural  thrombus  in 
the  left  ventricle  and  a  globular  thrombus  in  the  left 
auricle,  and  also  a  heart  presenting  extreme  aortic 
obstruction  with  enormous  hypertrophy  of  the  myo- 
cardium. 

Memorial  to  Physician. — It  is  proposed  by  the 
people  of  Purlington,  N.  J.,  to  secure  by  popular  sub- 
scription funds  for  the  purchase  of  the  old  colonial 
mansion  in  which  the  late  Dr.  Frederick  Ganutt  lived, 
and  its  conversion  into  a  memorial  hospital. 

Faith    Curists   Held   for    Murder Two   men,   a 

"healer"  and  one  of  his  followers,  are  held  in  Vic- 
toria, B.  C,  for  murder  on  account  of  the  death  of  the 
son  of  one  of  the  accused  from  diphtheria.  The  only 
treatment  the  child  received  consisted  in  the  incanta- 
tions of  the  healer,  who  was  one  of  Dowie's  "  Zionites." 

The  Army  Hospitals  Scandal. — The  testimony  in 
regard  to  the  charges  brought  by  Mr.  Burdett-Coutts 
against  the  management  of  the  British  army  hospitals 
in  South  Africa  is  now  all  in.  The  last  witness  ex- 
amined by  the  hospital  commission  was  Mrs.  Richard 
Chamberlain,  who  had  been  before  the  commission 
once  before.  At  the  first  examination  she  said  that 
"  the  army  surgeons  were,  with  very  few  exceptions, 
a  low  class  of  men.  Those  in  South  .Africa  neglected 
their  patients.  Six  cases  of  drunkenness  among  army 
doctors  came  under  my  observation.  After  these  peo- 
ple had  come  into  contact  with  the  police  they  were 
sent  home  in  charge  of  invalids."  At  her  final  exam- 
ination she  repeated  her  former  testimony  and  branched 
out  into  vituperation  of  the  army  surgeons,  the  com- 
missioners, and  everybody  else  who  did  not  agree  with 
her.  She  said  that  she  considered  herself  more  ca- 
pable of  conducting  hospitals  than  medical  officers, 
and  she  insulted  the  president.  Justice  Romer,  telling 
him  that  he  acted  more  like  counsel  with  a  brief  from 
the  army  doctors  than  an  inquisitor. 

War  against  Malaria  in  Italy We  read  in  the 

Meitical  Press  and  CiiciiUir  that  an  attempt  on  an  enor- 
mous scale  to  stamp  out  malaria  is  about  to  be  initi- 
ated in  Italy.  The  plan,  which  has  been  elaborated 
by  Professor  Grassi,  is  to  begin  operations  on  the  coast 
south  of  Naples.  In  a  region  covering  some  thirty 
thousand  square  miles  every  house  is  to  be  provided 
with  wire  screens  to  the  doors  and  windows  (a  possi- 
bly feasible  though  somewhat  expensive  measure),  and 
all  the  inmates  of  these  screened  houses  are  to  be  kept 
indoors  between  sunset  and  sunrise  (but  how  they  are 
to  be  kept  inside,  unless  there  are  guards  outside  to 
watch  them,  is  not  made  clear).  Those  who,  in  spite 
of  these  precautions,  are  attacked  by  malaria  will  be 
isolated  in  mosquito-proof  quarters  and  will  be  sup)- 
plied  with  quinine  free  of  cost.  It  is  possible,  of 
course,  that  Professor  Grassi  will   succeed,  but   it   is 


944 


MEDICAL    RECORD. 


[December  15,  1900 


hardly  probable.  An  attempt  to  exterminate  all  the 
mosquitos  in  the  district  would  be  less  expensive  and 
more  likely  to  succeed. 

The  Smallpox  Outbreak  in  this  city  is  fairly  well 
under  control,  though  new  cases  are  found  from  time 
to  time. 

The  Plague  in  San  Francisco — It  is  reported 
that  another  death  from  the  plague  has  occurred  in 
San  Francisco.  The  quarantine  against  the  city  is 
still  maintained  by  the  Texas  authorities,  and  it  is 
believed  that  Louisiana  and  other  of  the  Southern 
States  will  also  declare  a  quarantine  against  it. 

Faith-Curists  Sentenced  to  Imprisonment — Two 

faith-curists,  who  pleaded  guilty  to  a  charge  of  man- 
slaughter in  connection  with  the  death  of  a  child  con- 
fided to  their  care,  were  sentenced  to  an  imprisonment 
of  three  months  in  the  county  prison  by  Judge  Au- 
denried  at  Philadelphia  on  December  6th. 

An  Epileptic  Colony  in  Illinois.^ — The  board  of 
commissioners  of  public  charities  has  reported  to 
Governor  Tanner  on  the  question  of  a  site  for  an  Illi- 
nois colony  of  epileptics,  favoring  a  location  in  Ogle 
County.  The  legislature  will  be  asked  to  appropriate 
$350,000  for  the  purchase  of  the  grounds  and  the  erec- 
tion of  the  buildings. 

The  Western  Surgical  and  Gynaecological  Asso- 
ciation.— The  next  annual  meeting  of  this  association 
will  be  held  at -Minneapolis,  Minn.,  December  27  and 
28,  1900.  The  following  are  the  officers  for  this  meet- 
ing :  Presidetit,  O.  B.  Campbell,  St.  Joseph,  Mo. ;  Fhst 
Vice-President,  A.  C.  Bernays,  St.  Louis,  Mo. ;  Second 
Vice-President,  J.  R.  HoUingsworth,  Rock  Island,  111.; 
Secretary  and  Treasurer,  George  H.  Simmons,  Chi- 
cago, 111. 

College    of    Physicians    of    Philadelphia At   a 

stated  meeting  held  December  5th,  Dr.  Joseph  Leidy 
presented  "Some  Replicas  of  Surgical  Instruments 
Found  in  the  Ruins  of  Pompeii."  Dr.  Charles  P. 
Noble  read  a  paper  entitled  "  The  Making  of  a  New 
Urethra  After  its  Complete  Destruction,"'  reporting 
an  illustrative  case.  Dr.  A.  E.  Woldert  read  by  invi- 
tation a  paper  entitled  "  Cultivation  of  the  ^-Estivo- 
Autumnal  Malarial  Parasite  in  the  Mosquito — Ano- 
pheles quadrimaculata  (claviger) — with  Presentation 
of  Original  Specimen." 

The  Pan-American  Medical  Congress  at  Havana 
has  been  postponed  until  February  4-9,  1901,  because 
of  the  unusual  prevalence  of  yellow  fever  in  that  city. 
This  will  be  a  more  convenient  season  for  American 
physicians  to  visit  Cuba,  and  there  will  probably  be 
a  larger  attendance  of  them  at  that  time  than  there 
would  have  been  in  Christmas  week.  Perhaps,  also, 
by  that  time  certain  irate  Cuban  physicians,  whose 
names  do  not  appear  on  any  of  the  committee  lists 
and  who  have  been  abusing  General  Wood  and  other 
Americans  in  Ei  Progreso  Medico,  will  have  cooled 
down  a  little.  They  are  now  enraged  because  Gen- 
eral Wood  did  not  sanction  a  public  appropriation  to 
pay  the  expenses  of  the  congress,  but  said  very  prop- 
erly that  they  should  be  met  by  private  subscriptions. 


The    Study  of   Tropical   Medicine   in   France 

The  Faculte'  de  Mcdecine  of  Paris  has  decided  to 
establish  a  school  for  the  study  of  tropical  diseases, 
with  special  chairs  of  bacteriology  and  parasitology. 
A  public  appeal  will  be  made  for  funds  to  carry  on 
the  school. 

The  Water  Supply  of  Cheyenne,  Wyoming,  has 
been  examined  and  found  to  be  badly  contaminated — 
so  states  the  Leader  of  that  city.  The  immediate  oc- 
casion of  the  examination  was  the  occurrence  of  an 
unusually  large  number  of  cases  of  typhoid  fever,  over 
fifty  deaths  having  taken  place  in  the  past  four  weeks. 

A  Congress  for  the  Study  of  Cancer  will  be  held 
in  Chicago  on  the  first  Tuesday  in  May,  1901.  The 
following  are  the  subjects  announced  for  the  set  dis- 
cussions: (i)  What  are  the  most  successful  methods 
of  treatment?  (2)  What  are  the  values  of  antitoxins? 
(3)  What  is  the  cause  or  the  causes  of  cancer?  (4) 
Why  is  cancer  on  the  increase?  (5)  Classification 
of  the  varieties  of  cancer  and  the  most  important  ad- 
vances made  in  the  study  of  their  pathology. 

Philadelphia  Hospital. — The  fourteenth  annual 
reunion  and  dinner  of  the  Association  of  Ex-Resi- 
dent and  Resident  Physicians  of  the  Philadelphia 
Hospital  was  held  on  December  4th,  with  an  attend- 
ance of  nearly  sixty.  Dr.  E.  L.  Duer  presided,  and 
Dr.  J.  B.  Walker  acted  as  chairman  of  the  executive 
committee  and  as  toastmaster.  Toasts  were  responded 
to  as  follows:  "Our  Rulers,"  Dr.  H.  C.  Wood;  "Our 
Chiefs,"  Dr.  W.  Frank  Hachules;  "Our  Nurses,"  Dr. 
D.  J.  McCarthy;  "Our  Residents,"  Dr.  Edward 
Robinson ;  "  Our  Patients,"  Dr.  Augustus  A.  Eshner. 
The  following  officers  were  elected  for  the  ensuing 
year:  President,  Dr.  E.  L.  Duer;  Vice-Presidents,  Dr. 
H.  C.  Wood  and  Dr.  J.  K.  Lineaweaver;  Secretary, 
Dr.  E.  R.  Stone;  Chairman pj  the  Exeaitive  Committee, 
Dr.  R.  G.  Curtin. 

Precautions  against  Tuberculosis  in  Germany • 

The  German  department  of  the  interior  has  issued  in- 
structions for  compulsory  precautions  against  the 
spread  of  tuberculosis  in  the  empire.  The  orders 
provide  that  physicians  having  patients  with  pulmo- 
nary or  laryngeal  tuberculosis  shall  give  written  notice 
to  the  police  as  soon  as  the  diagnosis  has  been  made; 
that  immediately  after  the  death  of  a  person  from 
tuberculosis  the  deceased's  room  and  effects  must  Be 
thoroughly  disinfected;  that  professional  women  who 
lay  out  the  dead  must  report  at  once  in  writing  to  the 
police  authorities  whether  the  disease  was  of  the  lungs 
or  larynx,  and  that  keepers  of  hotels,  lodging-houses, 
asylums,  or  other  public  institutions  shall  report  im- 
mediately the  appearance  of  the  disease  in  the  estab- 
lishments under  their  control.  Non-compliance  with 
the  regulations  is  subject  to  a  fine  of  150  marks  or  six 
weeks'  imprisonment. 

Arseniated  Beer  in  England. — Referring  to  the 
Manchester  beer-poisoning  cases,  the  Lancet oi  Decem- 
ber 8th  says  that  definite  steps  are  being  taken  to  stop 
the  sale  in  England  of  beer  containing  poisonous  im- 
purities. A  specimen  of  invert  sugar  (a  variety  of 
sugar  consisting  of  a  mixture  of  dextrose  and  levulose, 


found  naturally  in  fruits  and  produced  artificially  by 
the  inversion  of  cane  sugar)  used  in  brewing  was  ex- 
amined in  the  Lancet  laboratory,  and  was  found  to  con- 
tain three  grains  of  arsenious  acid  per  pound.  Hence 
a  glass  of  beer  might  contain  one-fifth  of  a  grain  of 
arsenic.  An  examination  into  the  form  in  which  arse- 
nic existed  in  this  sugar  showed  that  it  was  mostly  in 
that  of  arsenious  acid  in  small  quantities.  Arsenic 
acid  was  also  detected.  The  Lancet  appeals  to  the  gov- 
ernment to  define  beer  as  a  liquid  brewed  exclusively 
from  barley,  malt,  and  hops,  so  that  beer  made  from  sub- 
stitutes for  these  ingredients  will  have  to  be  called  by 
another  name.  It  says  that  arsenic  was  found  in  beers 
manufactured  from  glucose  in  other  countries  years  ago. 

Conviction  of  the  Proprietors  of  a  Chicago  Di- 
ploma   Mill A   verdict  of  guilty   was   rendered   on 

December  8th  against  the  two  proprietors  of  the 
"Metropolitan  Medical  College  "of  Chicago,  who  had 
been  arrested  for  using  the  mails  to  defraud. 

Typhoid  Fever  at  Sing  Sing.— On  last  Saturday 
there  were  seventeen  cases  of  typhoid  fever  in  the  Sing 
Sing  prison  hospital,  and  several  cases  have  developed 
since  that  time. 

Appointments. — Dr.  Joseph  Collins  has  been  ap- 
pointed consulting  neurologist  to  the  Hospital  for  the 
Ruptured  and  Crippled  of  this  city.  Dr.  Henry 
Heiman  has  been  appointed  adjunct  visiting  phy- 
sician to  the  children's  service  in  the  Mt.  Sinai  Hos- 
pital. 

Physician,  Convict,  and  Turnkey. — A  physician 
in  a  Colorado  town  is  serving  a  sentence  in  the  county 
jail  for  manslaughter.  He  is  a  "trusty"  and  is 
allowed  to  go  at  will  through  the  town,  where  he  en- 
joys a  considerable  practice.  At  the  same  time  ho  is 
acting  sheriff,  the  county  sheriff  having  gone  away  for 
a  time,  leaving  to  him  the  care  of  the  keys  of  the  jail. 

Graduation  of  Colored  Nurses.— Six  colored 
women,  graduates  of  the  Colored  Home  and  Hospital 
Training-School  for  Nurses,  received  their  diplomas 
one  evening  last  week  in  the  lecture  hall  of  the  Acad- 
emy of  Medicine.  This  is  the  first  time  that  tiiere  has 
been  graduated  a  class  of  colored  nurses  in  any  north- 
ern city.  There  are  in  the  South  two  schools  for  the 
education  of  negro  nurses,  but  they  are  of  compara- 
tively recent  foundation.  Dr.  Stephen  Smith  deliv- 
ered the  address  to  the  graduates. 

New  Buildings  of  the  New  York  Hospital. — The 
new  buildings  of  the  New  York  Hospital  were  opened 
last  week.  They  are  located  just  west  of  the  older 
buildings  on  West  Fifteenth  Street,  and  consist  of  a 
ten-story  building  for  private  patients,  a  four-story 
dormitory  for  the  hospital  employees,  and  the  gover- 
nor's building,  which  is  in  the  centre  of  the  group. 
The  first  door  of  the  private  patients'  building  is  for 
administrative  purposes.  The  physicians  have  their 
quarters  on  the  second  floor,  the  operating-rooms  are 
on  the  top  floor,  and  the  rest  of  the  building  is  for  the 
patients.  There  are  many  single  rooms  and  some 
suites  of  several  rooms.  Each  of  the  two  operating- 
rooms  on  the  top  floor  has  its  own  separate  suite  of 


etherizing,  sterlizing,  and  wash  rooms,  and  each  has  a 
separate  ventilating-plant.  In  the  rear  of  the  build- 
ing for  private  patients  there  is  an  isolating-depart- 
ment. 

Pink  Eye  is  reported  to  be  epidemic  in  Chicago, 
the  extremely  dusty  condition  of  tlie  windy  city  being 
set  down  as  the  cause. 

Vaccination  in  the  Yukon. — It  is  reported  that 
there  were  thirty  cases  of  smallpox  at  Dawson  City  the 
first  of  November.  The  Yukon  council  has  passed  an 
ordinance  requiring  all  persons  in  Yukon  territory  to 
be  vaccinated.  Fifteen  tliousand  persons  are  affected 
by  this  order. 

Typhoid  Fever  in  Washington. — In  presenting  a 
report  of  a  committee  of  piiysicians  upon  the  filtration 
of  the  water  supplied  to  the  city  of  Washington,  in  tiie 
senate  on  Friday  of  last  week.  Dr.  Gallinger  adverted 
to  the  alarming  prevalence  of  typhoid  fever  in  the  Dis- 
trict of  Columbia.  He  declared  that  the  death  rate  in 
this  city  from  that  disease  was  seven  or  eight  times  as 
great  as  in  European  cities  of  the  same  class.  The 
wells  of  the  District  had  been  closed,  but  the  ravages 
of  the  fever  had  rather  increased  than  diminished. 

Medical  Colleges  United  in  St.  Louis. — The  an- 
nouncement is  made  that  the  Marion-Sims  College  of 
Medicine  and  the  Beaumont  Hospital  Medical  Col- 
lege of  St.  Louis  have  agreed  to  a  consolidation, 
which  will  become  effective  May  i,  1910.  The  terms 
of  the  consolidation  contemplate  a  utilization  of 
the  entire  teaching-force  of  the  two  institutions  and  a 
union  of  their  clinical  facilities  and  laboratory  equip- 
ments. The  old  Beaumont  building  at  Jefferson 
Avenue  and  Pine  Street  will  be  sold,  and  the  Marion- 
Sims  building  at  Grand  Avenue  and  Caroline  Street, 
with  new  additions  already  projected,  will  be  used  by 
the  new  Marion-Sims-Beaumont  College  of  Medicine. 

Navy  Department,  Bureau  of  Medicine  and  Sur- 
gery, Washington,  D.  C. — Changes  in  the  medical 
corps  of  the  navy  for  the  week  ending  December  8, 
1900.  November  20th. — Passed  Assistant  Surgeon 
R.  B.  Blakeman  ordered  to  be  examined  December 
loth,  at  VYashington,  D.  C,  for  retirement,  and  thence 
home  to  wait  orders.  Passed  Assistant  Surgeon  A.  W. 
Dunbar  ordered  to  the  Vcrtiioiit  for  duty  with  the  crew 
of  tlie  Wisconsin  revoked;  ordered  to  duty  at  naval 
hospital,  Mare  Island,  December  14th.  Assistant 
Surgeon  W.  M.  Carton  ordered  to  the  Washington 
navy  yard,  December  sth.  December  5th. — Surgeon 
C.  Biddle  ordered  to  the  naval  hospital,  Norfolk,  Va., 
for  temporary  duty.  December  7th. — Assistant  Sur- 
geon E.  J.  Grow  detached  from  the  Monadnock  and 
ordered  to  the  Ciilgoa.  Pharmacist  J.  Cowan  detached 
from  the  Monadnock  and  ordered  to  the  Cu/goa,  and  to 
additional  duty  at  the  Cavite  naval  station. 

Obituary  Notes. — Dr.  K.  Frederick  Kebler,  for- 
merly of  Cincinnati,  died  at  Somerville,  Mass.,  on  No- 
vember 23d.  He  was  born  in  Cincinnati  in  1850  and 
was  graduated  from  the  Ohio  Medical  College  in  1875. 
He  early  gave  promise  of  a  brilliant  career  as  a  pa- 


thologist,  but  became  mentally  afflicted  and  spent  the 
last  years  of  his  life  in  a  sanatorium. 

Dr.  George  U.anks,  of  Huntington,  L.  I.,  died  on 
December  4th  at  the  age  of  seventy-five  years.  He 
was  a  graduate  of  the  College  of  Physicians  and  Sur- 
geons of  New  York  in  the  class  of  i860. 

The  Rev.  \Vili,i.\m  Everett,  rector  of  the  Roman 
Catholic  Church  of  the  Nativity  in  this  city,  died  on 
December  7th  at  the  age  of  eighty-six  years.  He  was 
born  in  Albany  and  was  graduated  in  medicine  in  this 
city  in  1S34.  He  practised  for  a  few  years  and  tlien 
studied  divinity,  being  ordained  a  priest  in  1853. 

Dr.  Edward  Smith  died  at  his  home  in  this  city  on 
December  loth  at  the  age  of  seventy-one  years.  He 
was  born  in  Stonington,  Conn.,  and  was  graduated  in 
medicine  from  the  University  of  Pennsylvania  in  1S52. 
For  a  time  he  served  as  assistant  physician  in  the 
State  Lunatic  Asylum  at  Worcester,  Mass.  In  1856 
he  was  appointed  an  assistant  physician  in  tiie  Penn- 
sylvania Hospital  for  the  Insane  at  Philadelphia.  In 
1862  he  resigned  to  become  one  of  the  surgeons  in  the 
United  States  Military  Hospital  at  Philadelphia.  After 
the  war  he  took  up  private  practice  in  Philadelpliia. 
In  1S78  he  moved  to  New  York,  where  he  had  since 
lived. 

Dr.  Joseph  T.  Shoemaker  died  at  Philadelphia  on 
December  6th  at  the  age  of  sixty-two  years.  He  was 
graduated  from  the  medical  department  of  the  Univer- 
sity of  Pennsylvania  in  1861,  and  during  the  War  of 
the  Rebellion  served  as  surgeon  in  the  Eighty-eighth 
Pennsylvania  Volunteers. 

Dr.  Frederick  W.  Pleibel  died  at  Philadelphia  on 
December  6th  at  the  age  of  sixty-six  years.  He  was 
graduated  from  the  medical  department  of  the  Univer- 
sity of  Pennsylvania  in  1857. 


progress  of  |3^ccTical  .Science. 

JVe'iC/  Yi>rk  Medical  Journal ,  Dcconher  S,  igoo. 

Notes  on  the  Hospital  Scarlet-Fever  Service  in  New  York 
City  from  1893  to  1899  Inclusive. — By  W.  L.  Somerset.  This 
is  a  study  of  2,627  cases  treated  during  the  period  men- 
tioned in  the  Riverside  and  Willard  Parker  hospitals.  The 
mortality  rate  was  nine  per  cent.  Concerning  treatment 
the  author  writes  as  follows :  For  the  general  welfare  of 
the  patients  and  for  the  avoidance  of  complications,  rest 
in  bed,  and  fluid  or  semi-fluid  diet  were  insisted  on  for 
three  weeks.  For  the  scarlet  fever  itself,  streptococcus 
antitoxin  was  tried  for  a  short  time,  the  immediate  object 
being  to  test  its  effect  on  scarlatinal  throats.  The  results 
obtained,  however,  did  not  seem  to  justify  the  continuance 
of  its  use.  Frequent  sponging  with  weak  solutions  of  car- 
bolic acid  or  bicarbonate  of  sodium  was  utilized  for  itching, 
painful  tension,  or  other  irritable  conditions  of  the  skin.  The 
temperature  was  usually  treated  according  to  its  effects  on 
the  patient.  In  cases  in  which  the  distress  was  out  of  propor- 
tion to  the  rise  of  temperature,  the  relief  afforded  to  the  ex- 
treme restlessness,  insomnia,  or  even  delirium,  by  means 
of  baths,  could  be  very  much  augmented  by  the  use  of  sed- 
ative drugs.  Among  the  various  remedies  used,  a  phe- 
nobromide  combination  was  most  effective.  It  acted  well 
as  both  a  sedative  and  an  antipyretic,  and  could  be  given 
to  children  in  much  larger  and  more  effective  doses  with- 
out causing  depression  than  any  of  the  other  sedatives. 
With  temperatures  unusually  higli  or  unusually  persistent, 
baths  and  packs  were  largely  used.  A  graduated  bath 
was  often  given,  beginning  at  the  tem])erature  of  the  pa- 
tient, and  reducing  the  temperature,  in  from  ten  to  Hfteen 
minutes,  20,  30,  or  even  40  F.  There  is  no  particular 
danger  of  the  patient's  taking  cold,  and  there  are  very 
few,  if  any,  contraindications  to  the  reduction  of  a  temper- 
ature of  106'  F.     If  the  temperature  of  the  bath  must  be 


very  low — say  O5'  F. — or  even  that  of  an  ice  pack,  heat  ap- 
plied during  the  bath  or  pack  to  the  arms  and  legs  by  wrap- 
ping them  with  hot  blankets,  is  an  excellent  aid  in  avoid- 
ing depression.  Too  mueh  stress  eannot  be  laid  on  the 
necessity  for  careful  and  skilful  attention  to  the  ears : 
early  diagnosis,  anticipation  of  rupture  of  the  membrana 
tympani  by  early  operative  intervention,  or  proper  en- 
largement of  the  opening  when  rupture  has  occurred,  both 
to  promote  freer  discharge  and  to  secure  better  drainage  ; 
scrupulous  and  persistent  cleanliness  in  all  cases  with  dis- 
charging ears,  are  all  of  the  highest  importance.  Equally 
important  is  attention  to  every  detail  affecting  the  best 
interests  of  the  kidneys. 

Mastoid  Abscess. — R.  A.  Wright  comments  on  the  case 
reported  by  Ilarrigan  in  the  issue  of  November  loth, 
and  states  that  the  selective  time  for  successful  operation 
in  mastoid  disease  is  early  after  diagnosis ;  just  so  soon  as 
ordinary  antiphlogistic  measures  (Leiter's  coil,  leeching, 
etc.)  fail  to  check  the  inflammation.  There  is  no  reason 
to  wait  until  pain  and  suffering  have  so  reduced  the  pa- 
tient's strength  that  operative  procedure  means  almost 
certain  death.  He  conclvides  by  saying  that  early  recog- 
nition of  the  site  of  the  perforation,  with  adequate  treat- 
ment, usually  prevents  mastoid  complications  in  disease 
affecting  primarily  Prussak's  space,  with  perforation  of 
Shrapnell's  membrane. 

A  Plea  for  General  Anesthesia  in  the  Treatment  of  Mam- 
mary Abscess. —  F.  H.  Field  condemns  the  superficial  in- 
cisions so  often  made  in  the  treatment  of  this  condition,  for 
we  do  not  know  in  what  directions  or  how  deeply  the  pus 
may  have  burrowed,  and  it  is  often  necessary  to  resort 
finally  to  a  late  and  extensive  operation  when  a  simple  one 
done  earlier  would,  if  thoroughl}'  performed,  have  been  suf- 
ficient. He  prefers  chloroform  anaesthesia.  Healing  may 
be  confidently  predicted  in  from  seven  to  ten  days.  The 
use  of  linseed  poultices  under  the  circumstances  he  strongly 
condemns. 

The  Operation  for  Hypospadias  with  the  Demonstration  of 
Three  Cases  Successfully  Treated  by  Forward  Dislocation  of 
the  Urethra.— By  Carl  Beck. 

The  Present  Status  of  the  Treatment  of  Prostatic  Hyper- 
trophy in  the  United  States. —  By  Ramon  Guiteras. 

What  is  Normal  Menstruation? — By  George  Engelmann. 

Aledical  AV«'J,  December  8,  igoo. 

A  Modification  of  the  Mosquito  Theory. — Charles  R. 
Graudy  declares  that  he  believes  in  the  potency  of  the 
Anopheles  to  propagate  the  malarial  organism,  but  he  also 
believes  that  they  can  and  do  obtain  organisms  from  other 
sources  than  direct  from  the  human  blood.  He  thinks  it 
probable  that  when  feeding  on  other  things  than  human 
blood  (which  seems  to  be  more  of  a  delicacy  than  a  staple 
article  of  diet  with  the  mosquito  tribe)  it  also  injects  the 
parasites  into  whatever  it  is  eating.  Other  uninfected 
Anopheles  may  take  in  the  parasites  directly  from  this 
food  or  water  ;  or  the  plasmodia,  in  the  form  in  which  they 
are  found  in  the  parotid  glands,  may  be  able  to  live  in 
water  or  damp  .soil  as  other  sporozoa  do,  and  later  on  they 
may  be  taken  up  by  other  Anopheles  and  be  inoculated  by 
them  into  man.  It  is  also  possible  that  the  plasmodia  may 
pass  into  the  water  from  the  bodies  of  the  Anopheles 
which  have  died  in  the  water  after  depositing  their  eggs, 
and  may  be  taken  up  in  feeding  by  other  mosquitos. 
Whenever  malarial  fever  regularl)'  appears  there  is  found 
the  Anopheles.  Anopheles  breeds  only  in  pools  and 
not  in  tubs ;  it  is  the  country  mosquito  in  contradis- 
tinction to  Culex,  which  is  found  in  both  towns  and 
country.  They  feed  at  night.  They  are  most  numerous 
at  the  time  of  the  heavy  dews  in  August  and  September. 
Their  larvae  feed  on  algse,  hence  the  theory  that  stagnant 
water  causes  malaria.  The  two  objections  to  this  modified 
theory  are:  (i)  The  malarial  organisms  have  never  been 
cultured  artificially  ;  but  no  other  parasitic  protozoon  has 
been  thus  cultured.  (2)  They  have  never  been  found  free 
in  nature  ;  but  the  tiny  thread-like  organisms  are  so  mi- 
nute that  they  could  easily  escape  observation  when  looked 
for  in  water.  The  writer  believes  that  although  there  is  as 
yet  no  positive  proof  of  this  theory,  still  it  comes  nearer 
fulfilling  all  conditions  and  answering  all  objections  than 
any  other  which  he  has  seen. 

A  Study  of  Drainage. — A.  M.  Pond  states  that  drainage 
was  first  used  to  remove  the  pus  which  was  the  inevitable 
concomitant  of  surgery  before  the  present  era  of  asepsis 
and  antisepsis.  Drainage  was  then  considered,  and  justly, 
a  necessity,  since  without  it  absorption  of  poisonous  mate- 
rial was  inevitable.  Latterly  we  have  drained  to  pre- 
vent pus  formation,  a  process,  the  writer  believes,  essen- 
tially unscientific.  In  certain  of  the  septic  and  infective 
cases  we  must  continue  to  drain,  because  we  know  pus 
has  formed,  although  many  septic  cases  can  be  made  sterile 
and  the  wound  closed  without  drainage.  In  abdominal 
surgery  there  is  another  method  of  combating  infection. 


viz.,  purgation.  By  diluting  infection  we  promote  absorp- 
tion, f.g..  by  the  use  of  salt  solution.  Many  unfortunate 
sequelae  follow  in  the  wake  of  abdominal  drainage.  Her- 
nia is  common.  No  other  cause  of  ileus  is  so  common,  and 
removal  of  the  gauze  drain  when  the  tender  granulations 
have  grown  through  the  drain's  meshes,  and  are  torn, 
causes  great  pain  and  sometimes  serious  relap.se.  Blood 
serum  plays  an  important  part  in  the  repair  of  wounds, 
chemotaxis  bears  an  important  relation  to  pus  formation, 
and  in  sterile  cases  drainage  is  not  only  unnecessary  but 
positively  detrimental.  Consequently  the  writer  con- 
cludes that  drainage  should  be  restricted  to  those  cases 
which  all  the  means  at  disposal  fail  to  render  aseptic  and 
non-infective. 

An  Improved  Technic  in  Amputation  of  Large  Rectal  Pro- 
lapse.— George  Rycrson  Fowler  describes  this  method  in 
whicli  the  patient  assumes  the  combined  lithotomy  and 
Trendelenburg  position  in  order  to  prevent  the  descent  of 
the  small  intestines  during  the  operation,  thus  providing 
against  injury  to  these  during  the  suturing.  In  the  case 
which  he  reports  cocaine  ana-sthesia  was  used,  thus  en- 
abling the  patient  to  e.xtrude  the  prolapse  fully,  so  that  no 
traction  was  necessary.  A  cuff  at  the  muco-cutaneous  mar- 
gin was  turned  back  for  the  purpose  of  preserving  the  nor- 
mal conditions  at  the  rectal  outlet,  and  at  the  same  time 
permitting  the  removal  of  all  the  relaxed  and  overstretched 
mucous  and  submucous  structures  at  this  point.  The  cuff 
also  offers  a  covering  for  the  sutured  edges  of  the  stump 
of  tlie  prolapse  and  diminishes  opportunities  for  subse- 
quent infection.  Another  advantage  of  this  particular 
method  described  consists  in  the  step-by-step  application 
of,  first,  a  suture,  and  then  an  extension  of  the  incision 
through  both  cylinders  to  correspond  with  the  sutured 
area,  in  this  manner  avoiding  exposure  of  the  peritoneal 
cavity  to  infection. 

State  Sanatoria  for  Consumptives  in  Michigan.  — By  Her- 
bert .Maxon  King. 

Heat-Stroke  as  a  Post-Operative  Complication. — By  C.   L. 
Gibson. 
A  New  Urethrotome.— By  George  Rubin. 
Chloralamid. — By  S.  V.  Cleveuger. 

Jmirual  of  the  Aincriian  Medical  Ass'  n,  Dec.  S,  i()oo. 

Immature     Cataract     and     its     Treatment.— G.     E.    De 

Schweinitz  concludes  that:  (i)  Certain  lenticular  opaci- 
ties, most  often  situated  in  tlie  uaso-inferior  quadrant  of 
tile  lens,  occasionally  are  practically  stationary  and  may 
be  designated  "non-progressive."  They  do  not  handicap 
tlie  patient's  ocular  abilities,  and  may  with  propriety  be 
separated  from  the  class  to  which  the  name  incipient  cata- 
ract is  ordinarily  given.  (2)  Certain  lenticular  opacities 
undoubtedly  depend,  as  Risley  and  others  have  shown,  on 
what  may  be  designated  "disturbances  of  the  choroid,"  as 
apart  from  active  and  actual  choroiditis  ;  and  their  progress 
is  sometimes  apparently  checked  by  measures — ojitical, 
local,  and  general  medicinal — which  restore  the  choroid  coat 
to  normality.  Such  measures  do  not,  however,  remove 
from  the  lens  the  opacities  which  have  already  formed 
when  the  patient  comes  under  treatment.  (3)  Certain 
lenticular  opacities  which  appear  in  association  with  dia- 
betes mellitus,  nephritis,  litha'iiiia,  and  arteriosclerosis, 
particularly  the  last  two  diseases,  are  sometimes  appar- 
ently retarded,  like  those  in  No.  2.  by  measures  which 
are  suited  to  the  patient's  general  condition  in  connection 
with  local  and  optical  therapeutics,  but  these  measures 
never  dissipate  the  lens  lesions  already  present.  (4) 
The  extraction  of  unripe  cataracts  is  preferable  to  any  of 
the  ordinary  operations  for  rijicning  cataract.  {5)  There 
is  no  evidence  that  electricity  has  the  slightest  influence  in 
checking  the  rate  of  progress  of  incipient  cataracts,  or  in 
dissipating  the  opacities  which  have  formed.  (6)  There 
is  very  insufficient  evidence,  if  any,  that  massage  of  the 
eyeball  favorably  modifies  the  rate  of  development  of  cata- 
ract. (7)  Tliere  are  no  "specific  remedies"  for  the  treat- 
ment of  cataract,  and  there  is  no  reliable  evidence  that 
drugs  exist  which  cause  the  ab.sorption  of  partially  or  fully 
formed  cataracts.  (S)  All  lenticular  opacities,  unless  the 
"  non-progressive  "  group,  should  indicate  a  thorough  in- 
vestigation of  the  patient  from  the  general  as  well  as  the 
ocular  standpoint  and  the  employment  of  remedies  ac- 
cording to  the  findings. 

Subtrochanteric  Amputation  for  Diffuse  Skin  Carcinoma. — 

This  casiJ  is  reported  by  Emanuel  J.  Senn.  The  patient, 
a  man  aged  twenty-three  years,  was  struck  on  the  inner 
side  of  the  thigh  when  he  was  nine  )-ears  of  age.  After 
the  injury  there  was  a  denuded  surface  on  the  inner  aspect 
of  the  knee  about  the  size  of  the  palm  of  the  hand.  It  was 
skin-grafted.  An  area  the  size  of  a  dime  never  healed. 
Later,  when  the  patient  was  twenty-two  years  of  age,  an 
ulcer  formed  above  this  spot  and  grew  rapidly.  Almost 
the  entire  circumference  of  the  thigh  was  affected  and 
theie  was  a  chain  of  enlarged  glands  in  the  groin.    At  this 


time  he  was  admitted  to  the  hospital  and  given  a  thorough 
course  of  supportive  treatment.  After  he  had  gained  in 
strength,  a  subtrochanteric  amputation  was  performed  in 
the  orthodox  manner.  The  wound  healed  by  primary  in- 
tention. He  refused  an  operation  for  removal  of  the  lym- 
phatic glands.  Microscopical  examination  showed  this  dis- 
eased tissue  to  be  carcinomatous.  The  patient  has  been 
seen  lately  and  is  in  excellent  health,  having  gained  over 
thirty  pounds.  The  lymphatic  glands  are  much  reduced 
in  size. 

Colostomy  for  the   Cure  of   Amoebic  Dysentery.— William 

Norbert  Sullivan  reports  a  case  which  resisted  all  attempts 
at  treatment.  Finally,  right  inguinal  colostomy  wa:  per- 
formed, the  bowel  being  brought  up  and  attached  to  the 
abdominal  wall  and  a  few  days  later  incised,  while  a 
stream  of  pyrozone  solution  was  passed  through  the  large 
intestine,  passing  out  by  both  outlets,  the  anus  and  the  arti- 
ficial anus,  thus  thoroughly  Hushing  the  whole  of  the  large 
intestine.  The  patient  was  kept  under  this  treatment  from 
April  to  August  30,  !(;(«,  when  the  opening  was  closed  and 
the  bowel  dropped  back  into  the  abdominal  cavity.  The 
pain  which  had  been  severe  ceased  after  the  first  few  days. 
The  method  jiossesses  two  valuable  features  :  (i)  It  affords 
rest  to  an  inflamed  surface.  (2)  It  permits  direct  applica- 
tions of  remedial  solutions  to  a  portion  of  the  bowel  which 
is  practically  beyond  the  reach  of  injections  into  the 
rectum. 

Lupus  Healed  with  Roentgen  Rays. — William  Allen  Pusey 
treated  this  case.  The  jiatient  was  a  woman  aged  thirty- 
eight  years.  The  di-sease  had  been  in  progress  four  years 
and  had  extensively  infiltrated  the  chin,  neck,  and  cheeks. 
The  treatment  consisted  in  exposures  to  .i-rays  after  the 
method  of  Schiff  and  Freund,  of  Vienna.  The  treatment 
was  continued  with  necessary  intermissions  from  Mav  8th  to 
date.  Since  October  8th  there  has  been  no  evidence  of  the 
disease,  and  the  .scars  have  been  wonderfully  benefited  by 
the  exposures.  The  results  of  the  treatment  are  indicated 
in  a  photograph  presented  in  this  ])aper. 

Acute  Articular  Rheumatism :   its  Etiology  and  Pathology. 

— By  David  Kiesnian. 

Colostomy    for    Permanent    Fecal    Fistula.— By    John   A. 

Wyeth. 

Repair  after  Intestinal  Resection. — By  William  A.  Evans. 
Prolonged  Fevers  of  Obscure  Origin.— By  R.  B.  Preble. 

Hemorrhagic  Glaucoma. — By  William  Campbell  Posey. 
Coma  Diabeticum  :  its  Treatment. — By  Heinrich  Stern. 
Complete  Transposition  of  Viscera. — By  .S.  P.  Delaup. 
Dietetic  Treatment  of  Diabetes. — By  N.  S.  Davis,  Jr. 
Tuberculosis  of  the  Testicle. — By  John  J.  Murphy. 
Hemorrhagic  Glaucoma. — By  Charles  A.  Oliver. 

Boston  Medical  and  Surgical  Journal,  Dec.  6.  igoo. 

A  Case  of  Alexia,  Mind   Blindness,  etc.,  with   Autopsy.— 

Edwin  E.  Jack  describes  the  case  of  a  man  who  consulted 
him  for  failing  vision.  Examination  revealed  a  deejier 
than  mere  visual  trouble.  The  patient  could  see  letters, 
numbers,  and  words,  but  could  not,  except  to  a  slight  ex- 
tent, recognize  them.  Even  objects  such  as  matches,  keys, 
photographs,  etc.,  brought  no  recognition,  and  other  ob- 
jects which  he  recognized  he  could  not  name.  Hearing 
usually  set  him  on  the  right  track ;  touch  sometimes  failed. 
He  could  speak  fairly  well,  but  would  often  stop  short,  the 
whole  mental  picture  of  what  he  wished  to  say  vanishing. 
He  could  write  voluntarily  a  little.  Other  symptoms  de- 
veloped and  the  patient  died.  At  the  autopsy  a  glioma 
and  localized  softening  of  the  brain  were  found. 

Note  on  the  X-Rays  as  a  Curative  Agent  in  Certain  Dis- 
eases of  the  Skin. — Francis  H.  Williams  says  that  his  own 
experience  with  the  .i-rays  as  a  curative  agent  in  lupus  has 
demonstrated  to  him:  (i)  That  excellent  results  can  be 
obtained  by  exposing  the  diseased  portion  of  the  skin  near 
a  Crookes  tube  which  is  giving  off  .r-rays,  and  that  the 
treatment  causes  no  pain,  and  that  it  is  not  necessary  to 
repeat  it  so  frequently  as  to  produce  an  inflammatory  reac- 
tion ;  (2)  it  is  essential  that  the  treatment  should  be  under- 
taken only  by  one  who  has  learned  how  to  manage  an  .1- 
ray  apparatus  and  has  provided  himself  with  special 
appliances  for  carrying  out  tliis  method. 

The  Treatment  of  Placenta  Previa  by  Cssarean  Section, 
with  Report  of  a  Successful  Case. — By  Francis  D.  Don- 
oghue. 

The  Duties  of  the  Medical  Examiner  in  Massachusetts. — 
By  Julian  A.  Mead. 

Philadelphia  Medical  Journal.  December  S,  igoo. 

Suprarenal  Gland  in  Hay-Fever. — Lewis  S.  Somers  gives 
his  experience  in  the  internal  use  of  this  drug  :  he  has  care- 
fully ob.ser\'ed  its  effects  on  twenty-one  patients,  nineteen 
males  and  two  females,  the  youngest  being  seventeen,  and 


the  oldest  fifty-six  years.  The  time  during  which  the  pa 
tients  received  the  adrenal  exclusively  varied  from  one  to 
six  weeks,  ten  being  obliged  to  discontinue  the  tablets  after 
a  week's  trial  on  account  of  disagreeable  symptoms,  while 
seven  used  them  continuously  for  six  weeks  and  in  four 
they  were  administered  at  irregular  intervals,  but  at  least 
one  tablet  was  given  daily  for  two  or  three  weeks.  The 
nasal  symptoms,  as  sneezing,  rliinorrhcea,  and  obstruction 
to  breathing,  were  but  .slightly  influenced  ;  the  sneezing-at- 
tacks were  apparently  more  infrequent  while  the  drug  was 
being  used,  but  the  attack  in  itself  was  as  severe  as  be- 
fore. The  nasal  stenosis  was  somewhat  favorably  influ- 
enced. In  about  one-half  of  the  cases  in  which  the  obstruc- 
tion was  marked  there  was  diminution  in  size  of  the 
engorged  turbinals.  The  pruritus  of  the  chin  and  buccal 
membrane  was  lessened  when  the  tablets  were  dissolved 
in  the  mouth,  but  when  they  were  swallowed  no  changes 
were  observed,  the  same  being  the  case  with  the  eye  symp- 
toms, which  were  not  favorably  influenced.  There  was  a 
decidedly  unfavorable  influence  on  the  asthmatic  symp- 
toms. The  two  methods  of  administration,  as  already  in- 
dicated, are,  (i)  dissolving  a  tablet  on  the  tongue  and  (2) 
immediately  swallowing  it.  The  former  method  is  prefer- 
able, as  almost  no  results  are  observed  in  the  latter.  The 
disagreeable  effects  noted  are :  Nausea,  a  .sen.se  of  chest 
constriction,  and  the  development  of  asthma  or  tlie  in- 
crease of  the  paroxysm  when  already  existing.  The  fa- 
vorable results  are  slight.  Control  experiments  were  made 
to  determine  the  local  effects,  showing  that  the  drug  was 
not  inert.  Its  local  application  is  of  great  value,  the  writer 
believing  it  to  be  the  most  satisfactory  single  remedy  that 
we  possess  at  present. 

Principles  of  Asepsis  Applied  to  Operative  and  Other 
Wounds  of  the  Eye. — By  Edward  Jackson. 

The  X-Rays  in  the  Treatment  of  Carcinoma. — By  Wallace 
Johnson  and  Walter  H.  Merrill. 

Naso-pharyngeal  Mycosis  with  Report  of  a  Case. — By  P. 
S.  Donnellan. 

Sanitary  Work  in  the  City  of  Havana.— By  W.  N.  Bis- 
pham. 

A  Tropical  Ration.— By  J.  R.  Kean. 

The  Lancet ,  December  1,  igoo. 

South  African  Horse  Sickness  :  its  Pathology  and  Methods 
of  Protective  Inoculation. — By  A.  Edington.  This  is  a  dis- 
ease peculiar  to  the  locality  mentioned.  The  symptoms 
are  thus  described :  The  disease  occurs  under  two  forms — ■ 
the  "dikkopziekte  "  and  the  "dunpaardeziekte. "  In  the 
former  the  head  and  neck  swell  up  enormously,  thus  af- 
fording trustworthy  indications  of  illness  during  life.  In 
the  latter  form,  as  a  rule,  no  symptoms  appear  until  clo.se 
to  the  period  of  death,  when  the  animal  becomes  subject 
to  very  rapid  breathing  with  heaving  at  the  flanks.  At 
the  moment  of  death,  in  both  forms,  it  is  common  to  find 
a  huge  cloud  of  white  foam  ejected  from  the  mouth  and 
nose.  This  foam  is  produced  from  a  free  exudation  of 
blood  plasma  into  the  air-passages.  Owing  to  the  fact 
that  the  animals  suffering  from  the  "dunpaardeziekte" 
showed  no  symptoms  until  toward  the  end  of  the  period  of 
illness,  it  had  come  to  be  believed  that  the  whole  period 
of  the  disease  was  limited  to  a  few  hours'  duration.  The 
remainder  of  the  article  is  of  interest  only  to  veterinarians. 

Fungus  Disease  of  the  Ear. — W.  K.  Hatch  and  R.  Row 
report  a  series  of  cases  of  fungus  of  the  ear  seen  in  Bom- 
bay. They  believe  that  in  most  cases  the  condition  is  a 
variety  of  aspergillosis.  The  symptoms  are  deafness 
and  pain.  The  latter  is  sometimes  replaced  by  a  feeling 
of  stuffiness,  varying  in  severity  according  to  the  amount 
of  the  growth  present.  In  some  instances  there  is  a  wa- 
tery discharge.  For  treatment  frequent  syringing  is  ad- 
vised, with  the  subsequent  use  of  iodoform  and  boric  acid 
in  equal  parts.  The  article  closes  with  a  de.scription  of  the 
methods  employed  in  cultivating  the  fungi  on  artificial 
media. 

The  Open-Air  Treatment  of  Phthisis  :  an  Interesting  Case. 
— By  J.  F.  Little  and  F.  W.  Forbes.  This  is  the  history 
of  a  case  which  shows  how  much  can  be  done  by  home 
open-air  treatment.  There  are  no  features  in  the  case 
calling  for  special  mention. 

Perforating  Shell  Wound  of  the  Left  Chest  Apparently 
Hjaled  ;  Acute  Strangulated  Diaphragmatic  Hernia ;  Laparot- 
omy ;  Dsath. — By  \V.  K.  Home. 

On  a  Method  of  Measuring  the  Bactericidal  Power  of  the 
Blood  for  Clinical  and  Experimental  Purposes. — By  A.  E. 
Wright. 

Two  Cases  of  Effusion  into  the  Sac  of  the  Pericardium 
with  Fatal  Termination  in  Twenty-four  Hours.— By  1".  Wil- 
son. 

Treatment  of  Certain  Chronic  Abscesses  by  Simple  Aspi- 
ration.— Clinical  lecture  by  W.  H.  Bennett. 


Arsenical    Poisoning    from    Beer    Drinking. — By    T.    N. 

Kelynac,  S.  Delepine,  and  C.  11.  Tattersall. 

Prognosis   and    Treatment    in    Pulmonary   Tuberculosis. — 

Harveian  lecture  by  Robert  Maguire. 

Some  Notes  on  Cases  of  Movable  Kidney  with  Remarks 
on  Them. — By  Ikiiry  Davy. 

A  Case  of  Spontaneous  Evolution  in  Arm  Presentation. — 
By  J.  Bell. 

The  New  Prophylaxis  against  Malaria. — By  Angelo  Celli. 

British  Medical  Journal,  December  j,  igoo. 

Clinical  Lectures  on  the  Causes  and  Cure   of   Insomnia. — 

Sir  James  Sawyer  states  tliat  sleep  is  an  appetite  ;  an  ap- 
petite being,  according  to  Bain,  a  craving  produced  by  the 
recurring  wants  and  necessities  of  our  bodily  or  organic 
life.  The  two  striking  characteristics  of  sleep  are  its  peri- 
odic recurrence  and  its  organic  necessity.  As  to  the  phys- 
iology of  sleep,  there  are  two  vital  changes  which  take 
place  in  this  condition  :  The  one  is  some  intrii  sic  change 
in  those  ultimate  tissue  elements  of  the  brain  which  are 
concerned  in  consciousness  ;  the  other  is  a  diminished  sup- 
ply of  blood  to  the  brain,  especially  to  the  blood-vessels  of 
the  cortex.  The  etiology  of  insomnia  may  be  considered 
under  two  heads,  "secondary"  and  "intrinsic"  insomnia. 
The  former  may  be  produced  by  various  evident  causes, 
viz.,  pain,  high  fever,  frequent  coughing,  dyspucea,  etc. 
Sleeplessness  of  this  nature  may  be  controlled  by  hypnotics 
or  soporifics,  or  by  measures  which  combat  the  cause  of 
the  insomnia.  "Intrinsic  "  insomnia  is  said  to  exist  when 
no  objective  or  obvious  physical  cause  can  be  discovered. 
It  may  be  divided  into  three  groups:  (i)  psychic,  (2) 
to.xic,  and  (3)  senile.  The  subjects  of  psychic  insomnia 
are  generally  men,  and  almost  invariably  those  possessed 
of  the  nervous  temperament.  This  state  of  sleeplessness 
may  follow  a  severe  mental  shock,  or  more  commonly  it 
may  be  subsequent  to  prolonged  mental  strain  caused  by 
over-study  or  financial  anxiety  or  arduous  literary  compo- 
sition. The  cause,  whatever  it  may  have  been,  seems 
sufficient  to  rouse  a  given  group  of  cerebral  cells  into  per- 
sistent activity.  The  arterioles  of  the  brain  have  no  longer 
that  contractility  without  which  sleep  is  impossible.  In 
these  cases  probably  the  initial  fault  is  unnatural  excita- 
tion of  the  cerebral  cells.  In  the  toxic  variety  the  cause 
acts  primarily  upon  the  blood-vessels  of  the  brain,  giving 
rise  to  some  degree  of  arterial  hyperasmia.  'I  he  poisons  to 
be  considered  here  are  tobacco,  alcohol,  tea  and  coffee,  and 
the  poisons  generated  by  the  gouty  diathesis.  As  to  senile 
insomnia,  a  person  may  truthfully  be  said  to  be  as  old  as 
his  arteries,  not  as  old  as  his  \-ears.  The  senile  vessels 
are  less  elastic  and  less  contractile  than  normal,  and 
their  weakened  walls  often  lead  to  their  permanent  dila- 
tation. The  smaller  cerebral  arteries  are  physically  unable 
to  adapt  themselves  completely  to  that  condition  of  relative 
arterial  ansemia  which  is  the  essence  of  healthy  sleep. 

Severe  Angina  Pectoris   Relieved   by  Oxygen   Inhalations. 

— Charles  Steele  reports  the  ca:<e  of  a  man  aged  fifty 
years,  who  suff^ered  severely  from  spasmodic  attacks  of 
dyspncea  which  were  increasing  in  frequency  and  sever- 
ity. Careful  dieting  relieved  his  digestive  difficulties,  and 
the  toUowing  was  jirescribed :  sp.  eth.  sulph,  co.  mxx.,  tr. 
digitalis  mx.,  bismuthi  subnit.  gr.  x.,  mucilag.  ti-ag.  Ji., 
aq.  menth.  pip.  to  make  one  ounce,  thrice  daily  after  food ; 
and  for  the  attacks,  sp.  amm.  arora.  3  i.  in  an  ounce  of  water, 
together  with  inhalations  of  oxygen.  Each  attack  since 
this  treatment  has  been  cut  short  at  once:  the  pain,  dysp- 
noea, and  horror  have  been  promptly  arrested.  For  six 
weeks  he  has  had  no  attack. 

The  Face  and  Pupil  in  Alcoholic  Neuritis. — Sir  T.  Lauder 

Brunton  speaks  of  the  peculiar  expression  of  the  face  which 
he  has  observed  in  subjects  of  alcoholic  neuritis.  The  face 
is  mask-like  and  expressionless,  the  lips  appear  to  move 
apart  from  the  cheeks,  while  the  lips  themselves  seem  very 
mobile.  A  fixed  and  unexpressionless  band  stretches 
across  the  nose  and  cheeks  between  the  eyes  and  lips,  the 
skin  upon  the  cheeks  remaining  motionless  and  unwrinkled, 
while  the  lips,  eyebrows,  and  forehead  may  be  moving 
freely.  The  condition  of  the  pupil  reflex  is  just  the  con- 
verse of  the  Argyll-Robertson  phenomenon. 

The  Hydrostatic  Test  of  Stillbirth.— T.  Dil worth  made  a 
post-mortem  examination  on  an  infant  that  was  thought 
to  be  born  rather  precipitately.  In  examining  tlie  lungs 
they  were  found  collap.sed  and  in  a  state  of  "atelectasis." 
When  the  hydrostatic  test  was  made,  the  lungs,  entire  or 
when  cut  into  small  pieces,  sank  when  immersed.  The 
only  explanation  seems  to  be  that  the  infant  kept  its  feeble 
hold  on  life  by  the  amount  of  aeration  whicli  the  blood 
received  through  the  trachea  and  the  larger  bronchi. 

On  the  Operations  for  Congenitally  Misplaced  and  Unde- 
scended Testicle ;  with  Notes  of  Cases  of  Congenital  Defi- 
ciency of  the  Testicle. — By  Thomas  Annandale. 


December  15,  1900] 


MEDICAL   RECORD. 


949 


Cases  of  Acromegaly  and  Infantile  Myxoedema  Occurring 
Respectively  in  Father  and  Daughter. — By  F.  M.  I'opu  and 
Astley  V.  Clark. 

On  the  Causation  of  the  Congenital  Stridor  of  Infants. — 
By  John  Thompson  and  A.  Lojjau  Turner. 

Hughlings  Jackson  and  the  Cortical  Motor  Centres  in  the 
Light  of  Physiological  Research.  —  By  Eduard  Hitzig. 

Case  of  Lateral  Dislocation  of  the  Knee  Caused  by  Direct 
Violence. — By  Thomas  B.  Carlyon. 

Presidential  Address  on  the  Relation  of  Veterinary  Sci- 
ence to  Human  Medicine. — By  Sir  C.  J.  >."i,\on. 

The  Harveian  Lectures  on  Prognosis  and  Treatment  in 
Pulmonary  Tuberculosis.  — By  Robert  Majjuire. 

Fundamental  Points  Connected  with  the  Pathology  of  Dia- 
betes Mellitus.— By  F.  W.  Pavy. 

Development  of  Rodent  Ulcer  from  Sebaceous  Cyst. — By 
J.  Bustield. 

A  Case  of  Rodent  Ulcer  Treated  with  Piue  Resorcin.— By 
H.  Bowen  Williams. 

French  Journals. 

Neurasthenia. — In  treating  this  subject.  Lemoine  states 
that  there  are  two  clinical  forms  of  this  affection — the  one, 
hereditary,  is  observed  iu  individuals  having  a  nervous  or 
arthritic  heredity  ;  the"  other,  acquired  or  spinal  (the  he- 
reditary form  being  rather  cerebral).  The  two  funda- 
mental symptoms  of  neurasthenia  are  headache  and  in- 
somnia, both  causing  much  suffering.  The  headache  is 
rather  diffuse  than  localized.  Vertigo  is  frequent.  Speech 
is  rarely  affected.  Defective  memory  is  quite  constantly 
observed  in  neurasthenics.  Tachycardia  is  often  noticed. 
The  stomach  is  nearly  always  dilated.  Several  theories  as 
to  the  etiology  of  this  disease  have  been  propounded. 
Bouchard  has  concluded  that  neurasthenia  occurs  in  i>a- 
tients  with  <lilated  stomachs.  But  there  are  cases  with 
normal  digestive  functions.  Glenard  thinks  that  neuras- 
thenia occurs  in  patients  suffering  from  ptosis  of  the  vari- 
ous organs.  Another  theory  is  that  troubles  of  the  genital 
organs  are  the  causal  agent  of  this  malady.  The  writer 
believes  neurasthenia  to  be  due  to  a  lack  in  the  nervous 
system  of  principles  which  are  absolutely  necessary  to  its 
correct  functions.  Neurasthenics  generally  suffer  from 
phosphaturia.  The  treatment  of  this  malady  is  very  com- 
plex. The  writer  uses  the  following  method :  he  gives  a 
subcutaneous  injection  every  two  days  of  from  2  to  5  grams 
of  the  following  solution  : 

'B,  Phosphate  of  sodium 3  gm. 

Chloride  of  sodium 2     " 

Boiled  water. . . ! 100    " 

This  dose  of  phosphates,  although  very  weak,  acts  with 
great  rapidity.  In  Leraoine's  experience,  patients  have, 
under  its  influence,  come  from  a  state  of  profound  depres- 
sion into  a  condition  of  excitement  so  marked  that  he  was 
obliged  lo  diminish  or  suspend  the  injections.  In  addition 
to  this  medication,  lukewarm  douches  followed  by  friction 
and  rest  in  bed  were  used.  As  a  tonic,  valerianate  of 
quinine  may  be  used.  The  moral  treatment  must  not  be 
overlooked.  Weir-Mitchel's  treatment  may  be  tried  for 
serious  cases.  Electric  treatment  is  also  used  and  is  suc- 
cessful w-ith  certain  cases. — Le  Nord  Medical,  November 
15,  iyo<j. 

Asepsis  and  the  Hands  of  a  Snrgeon. — A.  Ricard  states 
that  gloves  in  surgery  have  both  their  advantages  and 
disadvantages.  They  should  be  impermeable.  Sdk  gloves 
have  been  unanimously  rejected.  Rubber  gloves  may  be 
thin  or  thick  at  the  convenience  of  the  operator.  The  for- 
mer render  the  sense  of  touch  less  obtuse  than  the  latter, 
but  they  are  more  expensive  and  more  easily  torn,  which 
is  a  great  inconvenience.  Gloves  may  be  easily  sterilized. 
They  isolate  completely  the  integument  of  the  surgeon 
from  the  field  of  operation,  and  from  that  point  of  view 
offer  a  perfect  a.sepsis.  On  the  other  hand,  the  writer 
argues  that  gloves  tend  to  deprive  the  operator  of  his  deli- 
cate touch.  He  thinks  them  a  source  of  danger  from  their 
liability  to  become  perforated.  In  conclusion  Ricard  gives 
as  his  own  opinion  that  there  are  two  principal  indications 
for  gloves  :  (i)  When  a  septic  case  mtist  be  operated  upon, 
such  as  the  opening  of  phlegmons,  abscesses,  osteomyeli- 
tis, purulent  peritonitis,  etc.  (2)  When,  after  contact  with 
septic  material,  necessity  forces  the  surgeon  to  undertake 
at  once  an  aseptic  operation. — Gasette  des  Hopitaux,  No- 
vember 10.  igoo. 

Hysterical  Astasia-Abasia. — Terrien  reports  a  case  of  this 
nature  which  he  treated  by  hypnotic  suggestion.  Ordinar- 
ily these  patients  are  confined  to  bed,  but  this  patient,  a 
farmer,  chose  the  only  method  of  locomotion  which  was 
left  to  him — transporting  himself  along  by  means  of  his 
knees,  forearms,  and  hands.  The  forearms  and  hands 
were  paralyzed,  so  he  supported  himself  on  his  elbows. 


This  paralysis  was  not  attended  by  disorders  of  sensation, 
but  was  manifestly  of  an  hysterical  nature.  The  patellar 
reflexes  were  nuich  exaggerated.  This  condition  had  ex- 
isted for  four  years.  Terrien  plunged  the  patient  into  a 
hypnotic  sleep  and  commanded  him  first  to  get  up,  then  to 
walk,  then  to  shake  hands,  all  of  which  he  was  able  to  ac- 
complish. Eight  days  later  he  went  to  work,  to  the  great 
astonishment  of  those  who  had  known  him. — Progrls 
Medical,  November  17,  1900. 

Simple  Acholuric  Icterus. — A.  Gilbert  and  P.  Lereboullet 
conclude  that  by  this  term  is  meant  a  pathological  state 
characterized  by  a  yellow  tint  of  the  skin  either  more 
marked  at  certain  points,  or  generalized,  without  elimina- 
tion of  biliary  pigments  in  the  urine,  but  with  their  con- 
stant presence  in  the  blood  serum.  Acholuric  icterus  is 
distinguished  by  its  hereditary  character  and  by  its  rela- 
tions to  the  diverse  forms  of  chronic  biliary  infection  (bili- 
ary lithiasis,  biliary  cirrhosis,  etc.).  which  exist  either  in 
his  ancestors  or  in  the  patient  himself.  But  under  the 
term  simple  acholuric  icterus  are  grouped  only  the  cases  in 
which  the  acholuric  icterus  exi.sls  by  itself  without  preced- 
ing or  accompanying  the  other  modifications  of  chronic 
biliary  infection.  The  hereditary  predisposition  appears 
especially  marked  in  the  Israeliti.sh  race. — Gnzi'/te  Heb- 
domad air  c-.  November  11,  lyoo. 

The  Therapeutic  Use  of  Salicylate  d'Amyle  (Ether  Amyl- 
Salicylique  or  Amylenol).  —  .M.  B.  Lyonnet  states  that 
this  new  product  is  obtained  by  the  action  of  chlorine  on 
a  saturated  solution  of  salicj-lic  acid    in  amylic   alcohol. 

OH 

Its  formula  is  C«  H, ^ It  bas  hitherto  been  eni- 

CO2  Cj  Hii 
ployed  without  any  inconvenience  whether  administered 
externally  or  internally.  Its  penetration  through  the  skin 
is  very  easily  accomplished,  as  analysis  of  the  urine  shows. 
In  different  maladies  attended  by  acute  or  subacute  rheu- 
matism it  has  had  excellent  results.  Its  odor  is  less  marked 
than  that  of  methyl  salicylate,  and  it  seems  to  enjoy  an 
advantage  in  a  good  number  of  cases  over  this  latter  drug. 
It  has,  besides  its  antirheumatic  properties,  the  sedative 
properties  of  amylic  derivatives. — Lyon  Mi'dical,  Novem- 
ber iS,  igoo. 

MiiHchener  niedicinisclie  M'ochenschrijt,  Xov.  so,  /goo. 

The  Treatment  of  Pachydermia  Laryngis  with  Salicylic 
Acid. — W.  Lublinski  refers  to  an  article  by  Fein  in  a  re- 
cent number  of  the  same  journal  in  which  salicylic  acid 
was  highly  lauded  in  the  treatment  of  this  somewhat 
rare  disease,  and  reports  the  results  of  his  own  experience 
with  this  drug,  which  he  has  used  for  years.  His  conclu- 
sions, however,  based  on  the  observation  of  twenty-five 
cases  are  not  quite  so  gratifying  as  those  of  Fein,  for  while 
he  admits  that  the  salicylic-acid  therapy  is  the  only  non- 
surgical treatment  likely  to  be  of  any  use,  the  good  results 
following  its  application  are  never  more  than  temporary. 
In  its  etiology  and  general  nature  pachydermia  laryngis 
strongly  resembles  leukoplakia  oris,  and  it  is  therefore 
only  natural  that  salicylic  acid,  which  serves  so  well  in  the 
latter  affection,  should  also  be  of  use  in  the  former.  The 
inaccessibility  of  the  parts,  however,  which  makes  self- 
treatment  impossible,  and  the  fact  that  the  very  essential  ■ 
drying  off  of  the  mucous  membrane  before  the  application 
is  made,  rob  the  treatment  of  much  of  its  utility,  and  re- 
lapses are  always  to  be  e.xpected.  For  both  diseases  a 
ten-per-cent.  solution  of  the  acid  in  equal  parts  of  alcohol 
and  water,  with  or  without  the  addition  of  glycerin,  is  to 
be  recommended. 

The  Psychoses  of  Typhoid. — Deiters  says  that  these  may 
be  grouped  in  three  classes:  (i)  The  initial  deliria.  %vhich 
are  chiefly  due  to  the  toxic  action  of  the  specific  ferment; 
(2)  the  psychoses  of  the  febrile  period,  in  which  there  is 
also  present  the  damaging  effect  on  the  nervous  system  of 
high  temperatures,  and  (3)  the  asthenic  forms  due  to  the 
exhaustion  following  the  course  of  the  disease.  Of  these 
it  is  particularly  the  first  type  that  is  of  interest  to  the  gen- 
eral practitioner,  and  he  describes  two  cases  affecting  the 
children  of  neurotic  parents  in  which  various  irrational 
manifestations  (restlessness,  hebetude,  uncleanliness,  vio- 
lence, inability  to  answer  questions  rationally,  etc.)  were 
observed  a  week  or  ten  days  before  the  onset  of  specific 
symptoms.  The  conclusions  are  that  when  a  ri.se  of  temper- 
ature is  accompanied  by  acute  psychical  derangement  ty- 
phoid should  be  thought  of,  and  that  the  initial  delirium  of 
the  disease  may  persist  for  some  time  without  any  temper- 
ature elevation  or  the  appearance  of  the  usual  symptoms. 

A  Case  of  Foreign  Body  in  the  Nose. — Breitung  reports  a 
case  in  wiiich  the  foreign  body,  a  button,  was  removed 
from  the  nasal  cavity  of  a  three-year-old  child  by  inflation 
through  the  opposite  nostril,  the  mouth  being  closed,  fol- 
lowed by  extraction  with  aural  forceps  when  it  had  been 
brought  within  reach.  The  difficulties  in  this  instance  had 
been  much  increased  by  a  previous  unsuccessful  attempt 


950 


MEDICAL    RECORD. 


[December  15,  1900 


at  removal  by  the  family  physician,  and  the  author  makes 
a  plea  for  the  early  calling  in  of  the  specialist  in  such 
cases. 

Does  Congestion  or  Cocaine  Anaemia  of  the  Conjunctiva  In- 
fluence the  Calibre  of  the  Superficial  Temporal  Artery  ?— By 
O.  Roscnbauh. 

The  Treatment  of  Gastro-Enteritis  with  Biedert's  Cream 
Mixture. — By  Gernsheini. 

Variation  and  Pleomorphism  in  Bacteria.— By  Ernst 
Scluvalbe. 

Antisepsis  and  Asepsis  among  the  Ancients.— By  J.  Mar- 
cuse. 

The  Curability  of  Habitual  Scoliosis.— By  Kourad  Port. 

Notes  on  the  Subject  of  Meats.— By  J.  C.  Huber. 

Deutsche  iiicd.    Wochenschrijt,  yovember  i^  and  22,  igoo. 

Connective-Tissue  Induration  of  the  Heart  Muscle  (Myo- 
fibrosis Cordis). — K.  IJehu)  reiterates  his  statements  con- 
cerning tlie  heart  lesion  to  which  he  has  given  this  name, 
and  which  have  lately  been  called  in  question  by  other 
writers.  The  essential  point  of  dilference  between  this 
and  other  forms  o£  degeneration  described  appears  to  be 
the  fact  that  it  is  universally  diffused  throughout  the  en- 
tire substance  of  the  muscle  instead  of  being  limited  only 
to  small  areas.  The  process  is  an  e.\aggeration  of  the  in- 
crease in  the  connective-tissue  groundwork  of  the  muscular 
structure  of  the  organ,  which  is  a  normal  senile  change, 
but  which  may  be  found  as  a  pathological  manifestation  at 
any  age.  In  well-marked  cases  the  lesion  is  unmistak- 
able ;  the  usually  angular,  polygonal  cross  sections  of  the 
muscle  bundles  have  become  circular,  and  are  widely  sepa- 
rated by  the  new-formed  tissue.  In  advanced  stages  the 
fascicle's  themselves  are  invaded  and  each  individual  fibre 
lies  embedded  in  connective  tissue.  Changes  take  place  in 
the  hl)res  also,  which  may  be  hypertrophied  in  some  re- 
gions, while  in  others,  owing  to  the  pressure,  they  become 
atrophied  and  seem  to  be  in  process  of  replacement  by  the 
new  growth.  The  lesion  appears  to  be  a  direct  conse- 
quence of  hypertrophy  and  dilatation,  which  view  is  borne 
out  by  the  fact  that  it  is  never  found  except  where  such 
changes  have  taken  place,  and  also  because  it  is  always 
most  marked  in  the  auricles,  which  are  the  first  portion  of 
the  heart  to  feel  the  effect  of  overstrain. 

Traumatic  Diabetic  Coma.— W.  Spitzer  contributes  the 
hi<itory  of  a  case  in  which  a  fatal  attack  of  diabetic  coma 
was  apparently  induced  by  a  combination  of  trauma  and 
psychical  shock.  The  patient,  a  man  aged  forty-six  years, 
had  been  suffering  for  six  years  from  a  diabetes  of  moder- 
ate severity  with  a  daily  excretion  of  from  gr.  Ixxv.  to  cl. 
of  sugar  without  any  subjective  symptoms  or  disturbance 
of  nutrition.  Under  these  conditions  a  fall  resulted  in 
fracture  of  the  right  clavicle,  while  in  addition  to  the  ac- 
tual injury  the  very  emotional  patient  sustained  a  profound 
emotional  shock.  In  spite  of  energetic  stimulation  and  the 
administration  of  large  amounts  of  alkalies  the  symptoms 
of  developing  coma  appeared,  which  finally  became  com- 
plete and  ended  fatally  six  days  later.  Severe  psychical 
disturljance  in  predisposed  individuals  seems  greatly  to 
increase  an  existing  glycosuria,  while  there  is  no  immedi- 
ate provision  for  preventing  the  formation  of  abnormal 
organic  acids.  In  addition,  owing  to  the  sudden  onset  of 
this  condition  of  acidosis,  the  organism  is  unable  to  cope 
with  it  by  the  usual  processes  of  oxidation,  which  suffice 
in  cases  of  long  standing,  the  organism  being,  as  it  were, 
"startled  "  out  of  its  normal  means  of  self-defence. 

The  Pathogenesis  and  Therapy  of  Asthma. — Cohen-Kysper 
considers  the  usually  accepted  theory  that  this  disease  is 
in  most  cases  a  reflex  neurosis  depending  on  stimuli  affect- 
ing the  re_spiratory  mucous  membrane  in  some  portion  of 
its  extent  as  erroneous,  and  would  substitute  the  view 
that  it  is  the  consequence  of  some  nasal  conditions,  mo.st 
often  a  stenosis.  This,  even  though  the  patient  may  be 
quite  unconscious  of  its  presence,  in  tlie  course  of  time  in 
predisposed  individuals  produces  a  state  of  respiratory 
hypericsthcsia,  or  increased  consciousness  of  the  normal 
respiratory  sense,  which  eventually  leads  to  the  various 
forms  of  the  malady  known  as  p.seudo-asthma.  In  every 
case  of  true  asthma  in  which  there  are  distinct  pulmonary 
changes  present,  this  factor,  a  psychical  reflex  as  it  were, 
also  plays  a  large  part,  especially  in  those  attacks  coming 
on  in  close  rooms,  in  a  heated  atmosjjhere,  at  night,  etc. 
The  treatment  is  obvious  from  this  view  of  the  etiology 
and  consists  in  a  thorough  search  for  and  removal  of  any 
existing  nasal  abnormality 

The  Use  of  Hydrogen  Peroxide  in  Wound  Treatment. — 
Oskar  Miiller  warmly  recommends  the  routine  employment 
of  this  agent,  which  apparently  has  not  yet  reached  the 
same  popularity  abroad  that  it  enjoys  with  us.  Its  ad- 
vantages are  its  very  jiowerful  bactericidal  action  ;  its  prop- 
erty of  undergoing  catalysis  and  splitting  up  into  water 
and  free  oxygen  when  in  contact  with  bacteria,  pus,  etc.. 


whereby  the  remotest  recesses  of  a  suppurating  cavity  are 
reached  and  a  mechanical  cleansing  is  effected  by  means  of 
the  active  gas  liberation  ;  its  great  value  as  a  deodorizing 
agent ;  its  absolute  harmlessness  to  skin  or  mucous  mem- 
branes ;  the  absence  of  toxic  symptoms  after  absorption, 
and  tinally  its  cheapness. 

Sympathetic  Ear  Disease.— Rhese  describes  three  cases 
in  which  after  excision  of  the  malleus  of  one  ear  for  chronic 
middle-ear  disease  a  ver)- notable  and  permanent  improve- 
ment followed  in  the  hearing  of  the  other  car,  which  had 
been  subjected  to  no  therapeutic  measures.  In  explanation 
the  author  offers  the  hypothesis  of  an  anastomosis  between 
the  two  auditory  nerves  through  which  possibly  inhibitory 
stimuli  may  pass  from  the  diseased  to  the  well  organ,  which 
impulses  cease  as  soon  as  their  causes  (the  cicatricial  con- 
traction, circulatory  changes,  etc.)  are  removed. 

A  Contribution  to  the  Specific  Demonstration  of  Egg  Al- 
bumen by  a  Biological  Reaction. — By  Uhlenhutli. 

Second  Report  on  Malaria  and  Mosquitos  on  the  West 
Coast  of  Africa. — By  II.  Ziemann. 

A  Case  of  Fatal  Parenchymatous  Colonic  Hemorrhage. — By 
L.  Iluisans. 

Kidney  Exclusion  by  Ligature  of  the  Ureter. — By  L. 
Landau. 

The  Freezing-Point  of  the  Blood  in  Typhoid.— By  Wald- 
vogel. 

Medicine,  December,  igoo. 

A  Case  of  Malarial  Cystitis. — William  F.  Benart  reports 
the  case  of  a  man  who  suffered  at  about  noon  every  day 
from  pain,  uneasiness,  vesical  tenesmus,  and  painful  uri- 
nation, the  attack  reaching  its  maximum  between  3  and  6 
P.M.,  lasting  from  one  to  three  hours,  and  gradually  ceas- 
ing. The  urine  was  laden  with  pus.  There  were  no 
symptoms  pointing  to  malaria  excepting  the  periodicity  of 
the  attacks — no  chills,  no  rise  of  temperature  exceeding 
four-fifths  of  a  degree  ;  but  the  patient  was  troubled  with 
sleeplessness,  poor  appetite,  a  worn-out  feeling,  and  a 
gradual  loss  of  weight.  "When  it  was  noted  that  every 
other  day  the  symptoms  were  more  severe,  malaria  was 
suspected,  and  quinine  sulphate  given  as  follows:  7  .a.m., 
gr.  ix.  ;  12  M.,  gr.  ix.  ;  3  p.m.,  gr.  iii.  The  second  day  the 
symptoms  began  to  subside,  and  by  the  fifth  day  had 
nearly  disappeared.  A  specimen  of  the  blood  showed  the 
presence  of  the  malarial  parasite. 

A  Case  of  Cirrhosis  of  the  Liver  and  of  the  Pancreas, 
with  Diabetes  and  Hasmachromatosis. — A.  P.  Condon  de- 
scribes a  case,  and  says  that  regarding  the  etiology  of 
bronze  diabetes  three  theories  may  be  mentioned:  (i) 
That  it  is  a  distinct  pathological  entity — advanced  by 
Marie  and  supported  by  Hanot  and* other  French  writers; 
(2)  that  it  is  a  diabetes  mellitus,  the  diabetic  poisons  pro- 
ducing the  hasmachromatosis,  cirrhosis  of  the  liver,  pan- 
creas, etc. — advanced  by  Letulle  ;  (3)  that  hsemachromato- 
sis  is  the  primary  affection,  and  the  deposition  of  pigment 
causes  the  hypertrophic  cirrhosis  of  the  liver  and  pancreas, 
diabetes  resulting  when  the  pancreatitis  reaches  a  certain 
stage — advanced  by  Opie. 

Remarks  on  the  Treatment  of  Exstrophy  of  the  Bladder, 
with  Report  of  a  Case  of  Vesico-sigmoidal  Anastomosis  with 
the  Frank  Coupler  for  Exstrophy.— By  A.  K.  Ilalstead. 

Examination  of  the  Stomach  Contents  with  Respect  to 
Hydrochloric  Acid. — By  F"rederick  A.  McGrew. 

One  Case  of  Cerebro-spinal  Rhinorrhoea,  and  Two  Cases 
Nasal  Hydrorrhoea.— By  John  Harold  Philip. 

I'lii't'crsilv  Medical  Magazine,  Xo-'cnibey,  igoo. 

Nature  and  Distribution  of  the  New  Tissue  in  Cirrhosis  of 
the  Liver. — The  following  conclusions  are  reached  by  Simon 
Flexner:  i.  In  all  forms  of  cirrhosis  the  white  fibrous  tis- 
sue is  increased.  2.  Along  with  the  increase  of  white 
fibrous  tissue  there  is  a  new  formation  of  elastic  tissue. 
This  new  elastic  tissue  is  derived  from  pre-existing  tissue 
in  the  adventiti;iof  blood-vessels  and  the  hepatic  capsules. 

3.  Both  white  fibrous  tissue  and  elastic  tissue,  in  all  forms 
of  cirrhosis,  may  penetrate  into  the  lobules.  This  penetra- 
tion takes  place'along  the  line  of  capillary  walls  or  follows 
the  architecture  of  the  reticulum.  The  chief  distinctions 
between  the  histology  of  atrophic  and  hypertrophic  cirrho- 
sis depend  upon  the  degree  of  extralobular  growth  and 
the  freedom  with  which  the  lobules  are  invaded.  In  hy- 
pertrophic cirrhosis  there  would  appear  to  be  less  interlob- 
ular growth  and  an  earlier  and  finer  intralobular  growth. 

4.  The  alterations  in  the  reticulum,  per  se,  consist,  as  far 
as  can  be  made  out  at  present,  of  hypertrophy  rather  than 
hyperplasia  of  the  fibres.  It  is  still  uncertain  whether  any 
of  the  differential  methods  now  in  use  suffice  to  distinguish 
between  tlie  reticulum  and  certain  fibres  derived  from  the 
white  fibrous  tissue  of  (he  iierijihery  of  the  lobules. 

The  Dissemination  of  Tubercle  Bacilli  by  Cows  in  Cough- 
ing a  Possible  Source  of  Contagion.  —  Mazijck    P.    Ravencl 


December  15,  1900] 


MEDICAL    RECORD. 


951 


gives  the  results  of  numerous  experiments  on  this  subject. 
In  order  to  collect  the  sjjutum  from  tuberculous  cows  he 
made  use  of  an  ordinary  nose-bag.  near  the  bottom  of 
which  is  placed  a  shelf  of  soft  pine  wood,  sterilized  l)y  steam 
heat  each  time  before  using.  The  wood  catches  the  small- 
est particles  ejected  by  the  cow  during  the  act  of  coughing. 
The  more  solid  particles  may  be  removed  by  a  platinum 
needle  for  experiment.  Tubercle  bacilli  have  been  detect- 
ed in  the  bronchial  secretions  of  every  tuberculous  cow  on 
which  the  experiment  has  been  tried.  Of  forty-five  guinea- 
pigs  inoculated  in  the  peritoneal  cavity  with  the  tuberculous 
mucus,  twenty-three  died  within  a  few  days,  most  of  them 
from  peritonitis,  too  early  for  the  development  of  tubercu- 
lous lesions.  Of  the  remaining  twenty-two.  eleven,  or  fifty 
percent.,  became  markedly  tuberculous.  Fourteen  guinea- 
pigs  were  exposed  by  means  of  a  special  nose- bag  directly 
to  the  breath  of  the  tuberculous  cows,  and  after  several 
weeks  were  killed.  No  evidence  of  tuberculosis  could  be 
detected  in  any  of  them. 

The  Justus  Test  in  Sjrphilis  :  its  Application  in  Twenty- 
nine  Cases. — H.  M.  Christian  and  Otto  II.  Foerster  from 
their  investigations  draw  the  following  conclusions:  I. 
That  in  the  diagnosis  of  doubtful  ulcers  it  is  of  no  value. 

2.  That  it  seems  to  occur  in  a  certain  proportion  of  cases 
of  acute  secondarj'  syphilis,  where  it  appears  to  be  a  symp- 
tom of  the  disease  and  can  in  no  sense  be  considered  a  true 
test,  as  the  diagnosis  in  such  ca.ses  is  already  complete. 

3.  That  as  a  test  it  is  unreliable,  occurring  as  it  does  in 
conditions  other  than  syphilis. 

Review  of  the  History  of  Cardiac  Pathology,  with  Especial 
Reference  to  Modern  Conceptions  of  Myocardial  Disease. — By 
Alfred  Stengel. 

Renant's  Bodies  in  a  Case  of  Vesiculo-bullous  Dermatitis  and 
Gangrene. — By  William  G.  Spiller. 

Personal  Observations  of  the  Bubonic  Plague  in  Manila. — 
By  E.  F.  Robinson. 

Ptillctin  i'l  the  Johns  Hopkins  Hospital,  .W'T'.,  igoo. 

Aneurism  of  the  Aorta  Treated  by  the  Insertion  of  a  Per- 
manent Wire  and  Galvanism  (Moore-Corradi  Method). — Guy 
L.  Huniier  feels  convinced  fnmi  study  of  the  literature  that 
this  malady  is  usually  a  surgical  disease.  The  wire  which 
the  writer  lielieves  quite  ideal  for  this  operation  is  a  silver 
alloy,  highly  drawn  ;  seventy-five  ])arts  of  copper  to  the 
thousand  makes  a  wire  which  when  drawn  from  No.  8  to 
No.  27  (standard  gauge)  takes  a  closer  coil  than  steel ;  it  is 
also  more  pliant  than  steel,  thus  minimizing  the  danger  of 
puncture  should  the  end  come  in  contact  with  the  thin  an- 
eurismal  wall.  It  can  more  easily  be  passed  into  the  needle 
without  kinking  than  the  pure  silver  wire,  for  it  has  more 
body.  It  erodes  more  than  steel,  thus  having  a  rougher 
surface  for  whipping  out  fibrin.  The  writer  believes,  how- 
ever, that  the  formation  of  fibrin  is  far  more  a  chemical 
than  a  mechanical  process ;  and  silver,  being  one  of  the 
metals  least  resistant  to  the  electric  current,  transmits  more 
of  a  given  current  for  action  on  the  blood.  The  positive 
pole  of  the  galvanic  battery  is  connected  by  means  of  its 
insulated  conducting  cord  with  a  long  end  of  the  wire  from 
the  aneurismal  sac  ;  the  negative  pole  is  c<mnected  with  a 
metal  plate  at  the  back.  The  sac  should  never  receive 
both  poles,  and  the  current  should  not  be  so  passed  that  the 
negative  electrode  is  in  the  sac.  In  thoracic  aneurism, 
operated  on  by  the  method  described  by  the  writer,  the 
patient  does  not  require  an  anaesthetic.  Locally,  cocaine 
or  ethyl  chloride  may  be  used.  In  abdominal  cases  the 
usual  preparations  for  coeliotomy  are  made.  Abstracts  of 
the  cases  treated  by  the  wire  method,  and  of  those  treated 
by  passing  electricity  through  a  permanent  wire  are  then 
given.  The  writer  adds  a  report  of  the  five  cases  which 
have  been  operated  on  at  the  Johns  Hopkins  Hospital.  A 
review  of  the  cases  treated  by  the  two  methods  mentioned 
above,  with  their  results,  certainly  argues  for  the  efficacy  of 
the  Moore-Corradi  method.  Clinical  and  post-mortem  evi- 
dence is  also  in  its  favor.  Its  great  drawback  is  the  diffi- 
culty of  accurate  diagnosis.  The  cases  under  consideration 
were  not  picked  cases, but  were  generally  considered  hope- 
less. When,  too,  it  is  considered  that  the  method  is  still 
in  its  infancy,  it  seems  still  further  to  merit  great  consider- 
ation. 

Oxygen  and  Steam  with  the  Vapors  of  a  Special  Mixture 
in  Pulmonary  Diseases. — By  Clenieiit  \.  Penrose. 

Obstetrical  Paralysis,  Infantile  and  Maternal. — By  H.  M. 
Thomas. 

Archives  Generates  tie  Me'Jeeine.  Octo/'er.  iqoo. 

Endocranial  Complications  of  Sphenoidal  Sinusitis. — M. 
Joubert  calls  attention  to  the  fact  that  (i)  the  sphenoidal 
sinuses  may  become  inflamed  in  nasopharyngeal  infections, 
especially  during  the  course  of  certain  general  affections, 
such  as  grippe,  pneumonia,  erysipelas,  typhoid  fever,  etc., 
and  this  much  oftener  than  is  generally  supposed.  (2) 
The  sphenoidal  sinuses  may  become  complicated  by  fatal 


meningitis  or  phlebitis,  the  infection  being  carried  by  an 
osseous  or  venous  passage  or  by  means  of  the  lymphatics. 
Many  cases  of  so-called  spontaneous  meningitis  may  be 
due  to  an  unrecognized  sinusitis.  (3)  The  diagnosis  of 
sphenoiditis  is  extremely  difiicult,  the  symptoms  being  va- 
riable and  not  very  definite.  Catheterisni  or  puncture  of 
the  sinuses  is  the  best  method  of  diagnosis.  (4)  Treat- 
ment of  complicated  sphenoiditis  is  merely  prophylactic, 
and  consists  in  prevention  of  infection  of  the  sphenoidal 
sinus ;  or  in  the  treatment  of  the  inflammation  if  it  be  al- 
ready present. 

Two  Cases  of  tJraemic  Hemiplegia  with  Autopsy.— L.  Bro- 
dier,  from  a  study  of  these  and  other  cases,  concludes  that 
ura^mic  hemiplegia  may  in  excei)lional  cases  persist  for 
several  years.  It  is  then  accompanied  by  no  trophic  or 
vasomotor  disturbances  of  the  paralyzed  parts,  but  death 
occurs  in  the  midst  of  other  symptoms  of  ura;mia  of  the 
nervous  system,  siich  as  Jackson's  epilepsy,  delirium,  or 
coma.  In  all  cases  of  hemiplegia  accompanied  by  albumi- 
nuria the  physician  should  remember  the  possibility  of  a 
renal  origin  of  the  functional  disorder,  and  search  for  evi- 
dences of  chronic  nephritis,  or  for  other  symjjtoms  of 
chronic  uraemia.  The  mere  coexistence  of  renal  insuffi- 
ciency and  hemiplegia  do  not  suflice  for  the  assertion  that 
the  motor  trouble  is  due  to  uraimia.  When  hemiplegia  of 
some  duration  is  found  in  a  patient  suff'ering  from  chronic 
nephritis,  the  absence  of  exaggerated  reflexes,  of  Babin- 
ski's  symptom,  and  of  trophic  or  vasomotor  phenomena 
should  cause  a  suspicion  of  the  urxmic  nature  of  the  paral- 
ysis. 

Clinical  Forms  of  Paralysis  of  the  Brachial  Plexus. — Henri 
Grenet  says  that  there  are  as  many  forms  of  paralysis  as 
there  are  segments  of  the  plexus,  but  the  only  two  real 
clinical  types  are  paralyses  of  radicular  type  and  those  of 
a  terminal  type.  The  former  are  characterized  by  the  lo- 
calization of  the  trouble  in  a  special  group  of  muscles  and 
by  the  zone-like  arrangement  of  the  anaesthesia.  Paralyses 
of  a  terminal  type  are  recognized  by  the  localization  of  the 
trouble  to  the  area  of  one  or  more  peripheral  nerves.  Hys- 
teria may  be  recognized  by  the  mode  of  distribution  of  the 
sensory  troubles  (also  by  other  evidences  of  neurosis). 
Paralyses  of  the  peripheral  nerves  may  simulate  those  of 
a  radicular  type  when  several  nerves  are  attacked  simul- 
taneously, or  when  the  affection  extends  into  the  territory 
of  neighboring  nerve-. 

Hydatid  Cyst  Evacuated  through  the  Intestines ;  Icterus 
from  Retention ;  Spontaneous  Abortion ;  Fever  for  Forty 
Days ;  Recovery.^By  P.  Le  Noir  and  G.  Leven. 


Cllorvcspoutlcucje. 

OUR    LONDON    LETTER. 

( Krom  our  Special  Coircspondenl.) 

WAR  HOSPITALS  COMMISSION:  THE  COMING  REPORT — MEETING 
OK  ROYAL  COLLEGE  Ol'  SURGEONS — VAGINAL  HYSTERECTOMY 
FOR  CARCINOMA  UTERI — OSSEOUS  DISEASE — LATE  OR  CON- 
TINUED RICKETS — PULSATING  SWELLING  OK  THYROID — 
PRINCE  OK  walks'  HOSPITAL  KUND — THE  LATE  DR. 
COCKLE. 

London,  November  23,   iqoo. 

It  is  .said  that  the  rejOTrt  of  the  commission  on  the  war 
hospitals  will  be  ready  for  presentation  when  Parliament 
meets.  Accordingly  attempts  to  forecast  the  tenor  of  the 
report  are  being  made.  That  regrettable  incidents  hap- 
pened will  scarcely  be  overlooked,  but  it  will  probably  be 
made  clear  that  tliese  were  unavoidable  under  the  system 
which  exists  and  under  the  stress  of  active  war.  Will  re- 
organization of  the  medical  service  be  recommended?  That 
is  the  question  which  most  interests  outsiders.  It  is  al- 
most certain  that  changes  will  be  recommended  with  the 
intention  of  rendering  the  service  more  attractive,  and  that 
the  actual  grievances  which  remain  unredressed  will  be  dis- 
tinctly condemned.  I  claim  no  telepathic  communication 
for  my  anticipation :  the  grievances  are  so  obvious  to  all 
who  look  into  the  matter.  The  commissioners  are  inde- 
pendent and  will  not  be  afraid  to  tell  the  government  that 
the  army  surgeons  must  be  treated  better  as  to  pay, 
allowances,  and  study  furlough.  The  report  will  endorse 
the  claims  of  the  doctors  and  justify  them  before  the  pub- 
lic. Perhaps  the  government  with  this  support  and  with 
no  longer  the  opposition  of  Lord  Wolseley  and  his  gang 
will  decide  to  do  justice  to  the  .service. 

A  good  deal  of  nonsense  has  been  written  about  orderlies 
by  editors  and  correspondents  who  seem  unable  to  distin- 
guish a  trained  male  nurse  from  an  untrained  helper.  Of 
course  a  war-hospital  orderly  is  a  soldier,  but  his  training 
as  a  nurse  is  verj-  complete  and  careful.     A  certain  num- 


952 


MEDICAL    RECORD. 


[December  15,  1900 


ber  of  women  will  not  see  this  because  they  are  so  set  upon 
pushing  women  into  every  possible  office.  In  deference 
perhaps  to  this  outcry  a  number  of  additional  ■  female 
nurses  were  engaged  during  the  war,  but  the  experiment 
was  not  successful  enough  to  encourage  the  authorities  to 
continue  it,  and  a  number  of  the  women  who  had  been 
temporarily  employed,  on  applying  for  permanent  engage- 
ments have  been  told  that  there  are  no  vacancies  and  that 
none  is  likely  to  occur. 

The  hospital  orderly  may  no  doubt  be  improved  ;  so  may 
the  female  nurse,  if  her  hysterical  patronesses  will  .suffer 
such  an  assertion.  The  orderly's  education  may  be  some- 
what improved,  but  his  hospital  training  is  quite  as  good 
as  that  of  tlie  females  in  civil  hospitals,  and,  as  I  said,  he 
must  be  a  soldier  too.  Novices,  even  civilian  consulting 
surgeons,  are  not  necessarily  the  best  judges  of  the  require- 
ments of  an  active  campaign  ;  nor  are  war  correspondents, 
with  all  their  critical  powers.  A  good  illustration  of  this 
was  Mr.  Julian  Ralph,  a  brilliant  correspondent,  but  by  no 
means  infallible.  Any  medical  man  who  reads  some  of 
his  letters  in  which  medical  matters  are  mentioned  will  see 
how  incompetent  he  is  to  discuss  them. 

The  meeting  of  fellows  and  members  or  the  College  of 
Surgeons  was  duly  held  on  the  15th,  when  the  council  was 
once  more  urged  to  agree  to  some  degree  of  representation 
of  members.  A  resolution  was  in  fact  passed  tiein.  con. 
asking  the  council  "not  to  carry  into  the  new  century  the 
unfortunate  controversy  which  has  existed  so  many  years 
with  disastrous  results." 

Another  resolution  requested  the  council  "to  take  any 
steps  in  its  power  toward  obtaining  a  parliamentary  in- 
quiry into  tlie  working  of  the  medical  acts,  with  a  view  to 
their  amendment."  This  was  allowed  to  stand  on  the 
minutes,  but  the  president.  Sir  W.  MacCormac,  in  his 
address  mentioned  that  the  council  considered  it  somewhat 
out  of  order,  as  the  matter  concerned  the  General  Medical 
Council  rather  than  the  college.  Mr.  George  Brown,  who 
brought  forward  the  motion,  is  a  member  of  that  general 
council,  but  thought  it  no  use  to  look  in  that  direction. 
He  also  said  men  who  held  a  double  qualification  ought  to 
be  allowed  to  use  the  prefix  "Dr."  This  remark  elicited 
from  the  president  the  statement  that  application  was  made 
by  the  college  in  1SS8  for  this  privilege  but  was  refused. 

A  claim  was  put  forward  for  the  members  to  have  the 
annual  report  posted  to  them  as  it  is  to  fellows.  The  only 
objection  is  the  wasteful  expense  of  posting  a  document 
nobody  wants.  Anyone  can  have  a  copy  on  asking  for  one 
by  a  post  card  ;  but  it  was  said  only  six  members  had 
asked  for  one  during  the  year. 

There  was  a  further  resolution  on  the  question  of  com- 
bining with  the  Society  of  Apothecaries  and  on  the  recog- 
nition of  science  courses  in  ordinary  schools.  The  latter 
subject  is  still  under  consideration  and  the  former  is  per- 
haps not  opportune  while  the  newly  organized  university 
is  getting  into  working  order.  But  both  these  questions  I 
have  dealt  with  in  former  letters. 

The  closing  meeting  of  the  century  will  probably  be  as 
fruitless  as  its  predecessors,  and  reformers  must  look  to 
the  future  and  show  more  earnestness  and  determination. 

Dr.  A.  H.  N.  Lewers  read  a  paper  at  the  Medico-Chirur- 
gical  Society  on  the  13th  on  the  "After  Results  of  Vaginal 
Hysterectomy  Performed  for  Cancer  of  the  Uterus."  He 
gave  some  account  of  forty  cases,  iu  twelve  of  which  there 
.  had  been  no  recurrence.  Omitting  one  case  in  which  little 
more  than  a  year  had  passed  since  the  operation,  in  eleven 
cases  (27.5  per  cent.)  the  patients  remained  well  from  two 
to  seven  years  after  the  operation.  Dr.  Lewers  attributed 
this  large  percentage  to  careful  selection.  He  examines 
under  anasthesia  and  operates  only  if  the  disease  seems 
to  be  limited  to  the  uterus  itself.  He  performs  suprava- 
ginal amputation  of  the  cervix  only  for  very  early  cases, 
and  for  cancer  of  the  vaginal  portion  in  which  the  growth 
is  limited  and  superficial. 

Iu  each  of  the  twelve  non-recuiTent  cases  the  specimen 
had  been  reported  on  by  Mr.  Targett,  and  Dr.  Lewers  gave 
very  full  details  of  the  evidence  of  non-recurrence.  He 
concludes  that  in  a  certain  proportion  of  cases  the  relief 
by  operation  may  continue  so  long  (seven  years  or  more) 
that  it  may  probably  bo  permanent,  though  this  propor- 
tion must  be  small  .so  long  as  patients  seek  relief  only  at  a 
late  stage.  The  great  desideratum  is  early  diagnosis.  As 
to  this  it  is  most  important  to  recognize  the  grave  signifi- 
cance of  bleeding  after  the  menopause,  or  at  an  earlier  age 
between  the  menstrual  periods.  Another  point,  almost  as 
important,  is  that  patients  may  look  quite  well  and  fat  for 
a  long  while  after  cancer  of  the  uterus  has  set  in.  Dr. 
Lewers  exhibited  s])ecimens  and  illustrations  of  his  cases 
and  an  interesting  discussion  followed. 

Dr.  Briggs,  of  Liverpool,  said  he  had  operated  on  ei.ghty- 
three  cases  of  malignant  disease.  Up  to  April,  1899,  he 
had  fifty-seven  cases  with  three  deaths.  Of  these,  one  was 
sarcoma  of  the  cervix  without  recurrence  ;  fifty-six  were 
cancer — ten  of  the  body,  forty-si.K  of  the  cervix.  Of  these 
patients  ten  are  living  now,  but  in  five  of  them  recurrence 


has  appeared.  In  malignant  adenoma  the  results  are  better 
than  in  cancer.    He  thought  Dr.  Lewers'  paper  encouraging. 

Dr.  Amand  Routh  had  operated  on  forty  cases — fourteen 
of  the  body,  twenty-six  of  the  cervix.  Of  the  fourteen,  re- 
currence took  place  in  three  within  twelve  months,  and  in 
one  in  seventeen  months  ;  one  patient  was  well  after  two  and 
one-quarter  years,  one  after  three  and  one-half  years,  and 
one  after  four  years.  Of  the  twenty-six  cases  of  cervical 
cancer,  the  disease  recurred  in  several  within  a  year ;  one 
very  disajjpointing  case  recurred  after  seven  years.  One 
patient  operated  on  in  1S92  and  another  in  1895  are  now  alive. 

Jlr.  Bowermau  Jessett,  who  has  performed  the  operation 
one  hundred  and  fifty  times  (one  hundred  and  seven  cases 
having  been  jjublished  last  year),  said  his  results  quite  justi- 
fied Dr.  Lewers'  conclusions,  and  he  added  that  cases  of 
fibroid  which  became  malignant  were  favorable.  To  this 
remark  objection  w-as  taken  by  subsequent  speakers :  Dr. 
Chanipneys  said  he  had  seen  only  one  case  in  which  such  a 
change  seemed  in  any  degree  probable,  and  Dr.  Lewers 
couhl  not  admit  that  fibroids  might  become  malignant. 

Mr.  Chaides  Ryall,  commenting  on  the  comparative  fre- 
quency of  recurrence  in  cancer  of  the  cervix,  attributed  it 
to  reinfection  of  the  wound  during  operation,  and  related 
a  case  illustrating  this  explanation.  On  this  Dr.  Herbert 
Spencer  expressed  extreme  interest,  as  he  was  certain  there 
was  great  risk  of  implanting  the  growth  upon  the. vagina, 
vulva,  or  other  parts  wherever  there  might  be  a  scratch  or 
abrasion.  This  risk  had  often  induced  him  to  do  a  high 
amputation  and  to  use  the  cautery.  The  entire  operation 
could  be  done  by  cautery,  as  shown  by  Dr.  Byrne,  an 
American  surgeon  who  has  done  some  four  hundred  opera- 
tions by  it  with  only  one  death. 

Mr.  Walter  Tate  regretted  that  Dr.  Lewers  had  not  sep- 
arated his  cases  of  cancer  of  the  body  and  cervix,  and  he 
thought,  too,  the  operation  was  justifiable  even  when  it 
did  not  give  permanent  relief. 

At  a  "clinical  evening"  of  the  Medical  Society  on  Mon- 
day last,  several  interesting  cases  were  shown.  Mr.  Kellock 
showed  a  female  child,  aged  seven  years,  suffering  from 
what  he  -diagnosed  as  mollities  ossiuni,  although  he  said 
that  it  might  better  be  described  as  fragilitas  and  mollities, 
as  was  a  case  of  Mr.  Dents,  recorded  in  the  transactions. 
Multiple  fractures  occurred,  and  tenderness  and  pain  at  the 
site  of  fracture  preceded  the  pccurrence.  The  first  fracture 
occurred  when  the  child  was  five  months  old. 

Mr.  Muirhead  Little  showed  the  radius  and  femur  from 
a  case  of  late  or  continued  rickets.  The  patient,  a  girl  aged 
seventeen  years,  was  exhibited  to  the  society  last  April, 
and  although  on  that  occasion  one  speaker  had  insisted 
that  it  was  not  a  case  of  rickets,  but  of  mollities  or  some 
such  condition,  these  specimens  showed  the  characteristic 
changes  of  rickets  in  and  about  the  epiphyseal  lines,  thus 
proving  the  correctness  of  the  diagnosis.  This  patient 
died  after  two  days'  illness  with  symptoms  of  acute  cere- 
bral disturbance.  He  had  now  under  his  care  a  lad  aged 
seventeen  years,  with  marked  enlargement  of  the  epiphy- 
ses and  severe  knock-knee,  whose  bones  were  quite  soft, 
containing  little  lime  salts,  as  shown  by  the  .i-ray  and  by 
the  trifling  resistance  offered  to  the  osteotome  in  Mace  wen's 
osteotomy.     He  hoped  to  exhibit  the  case  later  on. 

Dr.  Caley  showed  a  pulsatile  swelling  of  the  thyroid 
(aneurism,  sarcoma,  or  cyst?).  J^r.  Weeks  showed  a  rare 
case  of  locomotor  ataxia  in  a  boy  aged  eight  and  one-half 
years.  He  had  nearly  all  the  symptoms  of  the  disease, 
which  was  said  to  be  congenital.  The  father  had  locomo- 
tor ataxy,  but  no  other  member  of  the  family  as  far  as 
known.  Various  cases  of  skin  disease  were  shown,  and 
one  of  Baker's  cyst  of  the  kg. 

The  great  demands  on  the  public  for  the  war  and  famine 
funds  have  had  an  adverse  influence  on  the  finances  of  our 
hospitals,  some  of  which  are  suffering  severely  from  dimin- 
ished sub.scriptions.  Even  the  Prince  of  Wales'  hospital 
fund  has  been  affected,  and  an  appeal  on  its  behalf  is  now 
being  circulated.  It  is  hoped  that  _^25, 000  may  be  given 
before  the  15th  prox.  It  is  unfortunate  that  this  fund  to 
some  extent  duplicates  the  Sunday  fund.  If  the  Prince 
had  kept  the  committee  clear  of  the  persons  whose  admin- 
istration of  the  Sunday  fund  has  given  offence  it  would 
have  greatly  helped  this  appeal. 

John  Cockle,  M.D.,  M.A.,  for  many  years  physician  to 
the  Royal  Free  Hospital,  died  on  the  14th  inst.,  aged 
eighty-seven.  He  w'as  also  at  one  time  a  teacher  in  the 
now  extinct  Grosvenor  School.  He  retired  from  practice 
some  years  ago.  Prior  to  that  I  used  frequently  to  meet 
him.  He  was  a  very  courteous  and  genial  man,  with  abun- 
dant information.  He  was  scholarly,  too,  a  fact  recognized 
by  his  university,  which  confirmed  on  him  its  honorary  de- 
gree in  arts.  He  was  a  fellow  of  both  the  royal  colle.ges. 
There  is  iu  the  Hunterian  Museum  a  specimen  from  a  case 
of  aneurism  of  the  arch  of  the  aorta  on  which  at  his  request 
Mr.  Heath  operated  by  tying  the  left  carotid.  The  patient 
lived  four  years.  Dr.  Cockle  had  for  a  long  time  given 
attention  to  tlioracic  aneurisms,  and  had  found  records  of 
what  appeared  to  be  cures  from  obliteration  of  the  carotid. 


NEW    YORK    COUNTY    MEDICAL    ASSOCIA- 
TION. 

Stated  Meeting,  JSovember  iq,  igoo. 

Parker  Sy.ms,  M.D.,  President. 

Myoma  Uteri. — Dr.  George  Tucker  Harrison  pre- 
sented a  large  myoma  which  he  used  as  a  text  for 
some  remarks  on  the  method  of  removal.  He  said 
that  every  myoma  at  first  was  interstitial,  and  he  was 
of  the  opinion  that  by  proper  treatment  such  a  tumor 
might  be  made  submucous  and  removed  after  the  man- 
ner employed  in  obtaining  this  specimen.  The  pa- 
tient, an  elderly  sin<jle  lady,  had  been  treated  by  him 
at  first  by  the  administration  of  thyroid  extract,  as  she 
had  refused  radical  operation.  Subsequently  she  had 
consulted  him  because  of  irritation  of  the  bladder,  and 
examination  had  shown  this  to  be  caused  by  an  effort 
of  nature  to  rid  the  uterus  of  the  tumor  which  had 
been  converted  into  a  submucous  myoma,  largely,  he 
believed,  as  a  result  of  the  treatment  employed.  The 
tumor  was  so  large  that  it  had  been  necessary  to  make 
two  deep  lateral  incisions  into  the  narrow  vagina  in 
order  to  get  sufficient  room  to  deliver  the  tumor. 
After  this  had  been  done  he  had  sutured  these  incis- 
ions. He  would  not  at  the  present  time  make  use  of 
the  thyroid  extract,  because  it  produced  great  emaci- 
ation, and  its  use  was  attended  by  certain  dangers. 
He  preferred  now  to  employ  the  suprarenal  extract, 
which  had  served  him  well  in  controlling  the  hemor- 
rhage. The  method  employed  in  this  case  was,  of 
course,  not  applicable  to  cases  in  which  the  tumor  was 
so  large  that  it  could  not  descend  low  into  the  pelvis, 
or  in  which  the  uterus  had  not  already  made  efforts  to 
expel  the  growth.  A  necessary  preliminary  to  the 
operation  was  dilatation  of  the  cervix  by  instruments 
or  by  the  insertion  of  laminaria  tents.  During  the 
removal  of  the  tumor  there  was  always  danger  of  en- 
tering the  peritoneal  cavity.  The  great  advantage  of 
the  method  was  its  freedom  from  shock. 

General  Septic  Peritonitis.— ^Dr.  Irving  S.  Haynes 
read  a  paper  on  this  subject.  He  defined  the  term 
"general  septic  peritonitis"  as  an  inflammation  of  the 
peritoneum,  septic  in  origin,  and  unlimited  in  extent 
by  adhesions."  It  might  originate  from  many  sources 
of  infection.  Thus  in  the  fifteen  cases  forming  the 
basis  of  the  paper  eight  had  been  caused  by  rupture 
of  the  appendix,  while  others  had  originated  from  ruf>- 
ture  of  cancer  of  the  bowel,  rupture  of  pus  tubes,  ex- 
tension of  sepsis  from  the  uterus  after  an  abortion, 
traumatism  of  the  abdomen,  etc.  The  affection  was 
conveniently  divided  into  three  stages:  (i)  the  stage 
of  shock;  (2)  the  stage  of  reaction,  and  (3)  the  stage 
of  recovery,  or  of  collapse  and  death.  The  vomiting 
at  the  beginning  was  due  to  shock,  and  was  not  signifi- 
cant unless  it  persisted  after  a  washing-out  of  the 
stomach  and  bowel,  and  the  vomited  matter  consisted 
of  the  contents  of  the  bowel.  In  the  adult  cases  seen 
early,  the  pulse  had  varied  from  90  to  120  and  the 
temperature  from  101.6°  to  102''  F.,  and  the  respira- 
tions had  been  rapid  and  shallow.  The  pulse  was 
thin,  thready,  and  weak — the  pulse  of  shock.  In  the 
cases  that  had  ended  in  recovery  the  pulse  had  at  first 
been  100,  and  in  the  cases  that  had  terminated  fatally 
had  been  about  130,  thus  pointing  to  the  early  infec- 
tion of  the  system  in  the  grave  cases.  A  short  time 
before  death  the  temperature  began  to  rise,  but  rarely 
went  above  104^  F.  One  of  the  earliest  signs  of  re- 
covery was  a  more  restful  facial  aspect.  These  pa- 
tients died  unless  operated  upon,  and  the  only  hope 
lay  in  removing  the  infectious  material  by  an   early 


abdominal  section.  His  operative  cases  had  been 
operated  upon  on  an  average  within  four  hours  after  the 
infection.  While  one  might  be  sure  that  death  would 
occur  without  operative  intervention,  it  was  not  so 
certain  that  operative  intervention  would  be  followed 
by  a  fatal  issue.  Every  now  and  then,  even  an  appar- 
ently hopeless  case  would  end  in  recovery;  hence  it 
should  not  be  assumed  that  death  was  inevitable,  and 
that,  therefore,  nothing  should  be  done.  In  all  doubt- 
ful cases  the  incision  should  be  made  through  the 
linea  alba.  The  character  of  the  fluid  which  gushed 
out  would  give  a  clew  to  the  locality  of  the  trouble. 
The  abdominal  cavity  should  be  at  once  thoroughly 
irrigated,  by  means  of  a  large  glass  tube  perforated 
laterally,  with  a  very  large  quantity  of  decinormal 
salt  solution.  This  irrigation  should  be  kept  up  until 
the  fluid  returned  clear,  and  should  be  done  without 
sponging  before  a  search  was  made  for  the  lesion. 
The  handling  and  chilling  of  the  intestine  should  be 
most  carefully  avoided.  When  there  was  great  dis- 
tention of  the  bowel,  interfering  with  the  necessary 
manipulations,  the  gas  should  be  allowed  to  escape 
through  a  small  linear  incision,  which  should  afterward 
be  closed  by  suture.  Full  strength  peroxide-of-hydro- 
gen  solution  could  be  used  locally,  if  followed  by  a 
washing  with  salt  solution,  but  he  would  not  advise  its 
use  throughout  the  peritoneal  cavity  as  it  certainly 
possessed  the  power  of  injuring  the  epithelium.  Prob- 
ably the  best  form  of  drain  was  the  "wick  drain," 
made  by  wrapping  strips  of  gauze  in  gutta-percha 
tissue.  The  dressings  should  be  frequently  renewed 
to  favor  capillary  drainage.  The  speaker  cautioned 
against  overstimulation  of  the  heart  by  hypodermic 
injections  of  caffeine,  strychnine,  sparteine,  and  simi- 
lar drugs,  but  did  not  think  there  was  much  likelihood 
of  overstimulation  from  all  the  whiskey  that  would  be 
given  with  a  hypodermic  syringe. 

Dr.  Charles  N.  Dowd  said  that  not  long  ago  a 
case  of  general  septic  peritonitis  w-as  considered 
necessarily  doomed,  yet  quite  recently  cases  had  been 
reported  from  almost  every  hospital  in  this  city  with 
an  encouraging  percentage  of  recoveries.  A  large 
number  of  surgeons  were  in  the. habit  of  flushing  out 
the  peritoneal  cavity  with  warm  saline  solution; 
others  depended  upon  their  ability  to  wipe  clean  the 
surfaces  of  the  intestine,  and  did  not  wash  out  the 
peritoneal  cavity;  others  depended  largely  upon  in- 
cisions made  into  the  intestine  with  the  object  of 
liberating  the  intestinal  contents  and  diminishing  the 
distention,  and  in  this  way  restoring  the  function  of 
the  peritoneum.  All  of  these  methods  had,  in  certain 
instances,  given  good  results.  It  was  noticeable  that 
the  successes  and  failures  in  this  class  of  cases  from 
different  hospitals  occurred  in  groups.  The  inference 
from  all  the  foregoing  considerations  was  that  the 
good  results  were  not  dependent  upon  the  particular 
methods  employed.  In  studying  the  course  of  peri- 
tonitis it  would  be  noticed  that  at  the  beginning  there 
would  be  a  small  spot  of  inflammation  and  the  effusion 
of  a  considerable  quantity  of  serum.  Most  surgeons 
paid  no  special  attention  to  this  effusion.  Later  on, 
however,  it  would  be  found  that  this  serum  became 
cloudy,  indicating  that  the  infection  had  gone  somewhat 
farther.  Still  later,  one  would  find  an  effusion  of  sero- 
pus.  The  successful  cases  had  been,  generally  speak- 
ing, those  in  which  the  general  peritonitis  had  been 
mild,  the  serum  being  but  slightly  cloudy — in  other 
words,  they  were  border-line  cases.  It  was  true  there 
might  be  thick  pus  at  the  site  of  the  infection.  When 
flakes  of  fibrin  were  scattered  all  through  the  intestinal 
coils,  and  thick  pus  was  matted  over  the  bowel,  or 
localized  abscesses  had  formed,  recovery  seldom,  if 
ever,  occurred.  Many  patients  would  recover  simply 
by  drainage  of  the  infecting  abscess.  There  could  be 
no  doubt  that  at  the  present  day  the  majority  of  sur- 


geons  favored  the  free  use  of  hot  saline  solution.  The 
power  of  the  peritoneum  to  deal  with  sepsis  was  cer- 
tainly great;  hence  the  confidunce  placed  by  experi- 
enced surgeons  in  mere  irrigation  and  drainage.  How- 
ever, ten  years  ago  drainage  had  been  used  far  more 
frequently  than  at  the  present  time.  The  surgeons  of 
to-day  preferred  to  use  moderate  drainage  and  supple- 
ment this  with  means  for  increasing  peristalsis.  The 
tapping  of  the  intestine  at  one  or  more  places  was 
looked  upon  as  an  additional  means  of  increasing 
peristalsis. 

Dr.  Benj.amin  T.  Tilton  thought  general  septic 
peritonitis  offered  a  peculiarly  favorable  field  in  hos- 
pital practice  for  improving  the  mortality  statistics. 
Modern  methods  had  already  greatly  improved  the 
statistics.  The  older  methods  of  treatment  by  opium 
and  rest  of  the  affected  parts  had  yielded  a  mortality 
of  ninety-five  per  cent,  or  more,  whereas  the  more  re- 
cent methods  had  reduced  it  to  eighty  per  cent.,  and 
in  some  instances  as  low  as  sixty  per  cent.  There 
must  necessarily  be  a  large  number  of  fatal  cases,  as 
for  instance  from  sudden  invasion  of  the  peritoneal 
cavity  and  a  general  poisoning  before  operation  could 
be  undertaken,  or  cases  which  might  have  been  favor- 
able had  they  been  brought  to  the  surgeon  sooner. 
Cases  in  which  there  were  numerous  pus  foci  walled 
in  by  adhesions  did  not  come  under  the  class  consid- 
ered in  this  discussion.  When  nature  had  made  any 
attempt  to  limit  the  exudation  of  pus  by  adhesions, 
one  had  reason  to  hope  for  recovery.  He  did  not  look 
for  any  great  improvement  in  the  present  surgical 
technique;  progress  in  this  department  of  surgery 
must  rest  chiefly  upon  the  co-operation  of  the  medical 
profession  in  bringing  these  desperate  cases  earlier  to 
the  attention  of  the  surgeon.  He  was  opposed  to  the 
method  of  wiping  off  the  intestine,  because  it  was  in- 
adequate for  the  removal  of  the  pus  and  bacteria,  and 
inflicted  a  certain  amount  of  trauma. 

Dr.  a.  Brothers  said  that  Dr.  George  R.  Fowler, 
of  Brooklyn,  had  suggested  that  in  cases  in  which  the 
peritoneal  cavity  was  full  of  pus,  the  elevation  of  the 
foot  of  the  bed  was  contraindicated;  instead  of  this 
the  head  of  the  bed  should  be  raised  in  order  to  favor 
the  escape  of  pus.  The  speaker  said  that  he  had  tried 
this  method,  and  had  been  convinced  that  the  sepsis 
had  been  diminished  by  the  adoption  of  this  practical 
suggestion.  As  his  experience  in  abdominal  surgery 
had  increased,  his  confidence  in  the  power  of  the  peri- 
toneal cavity  to  take  care  of  a  limited  amount  of  in- 
fection had  increased.  Formerly  he  had  been  in  the 
habit  of  flushing  the  peritoneal  cavity  frequently ;  now 
he  did  it  only  in  cases  in  which  a  very  large  quantity 
of  pus  was  already  distributed  throughout  the  peri- 
toneal cavity,  for  in  ordinary  cases  of  general  septic 
peritonitis  such  flushing  seemed  to  him  to  do  more 
harm  than  good  by  disseminating  the  septic  matter 
into  the  remotest  parts  of  the  peritoneal  cavity. 

Dr.  John  F.  Erdmann  said  that  he  was  disposed  to 
agree  with  the  last  speaker  rather  than  with  the  others 
as  to  the  technique.  In  many  cases  showing  pus  foci 
he  simply  cleansed  the  cavity  with  a  sponge  moistened 
with  peroxide  of  hydrogen,  following  this  with  the  ap- 
plication of  a  sponge  moistened  with  decinormal  salt 
solution.  After  twenty-four  or  forty-eight  hours  he  en- 
deavored to  discard  all  drainage.  He  certainly  agreed 
with  the  preceding  speaker  that  the  flushing  with  salt 
solution  served  to  disseminate  the  septic  matter  rather 
than  to  cleanse  the  peritoneal  cavity. 

Dr.  Haynes,  in  closing,  said  that  he  believed  tlie 
most  virulent  cases  were  those  in  wliich  the  infection 
was  due  to  the  bacillus  coli  communis.  His  experi- 
ence led  him  to  think  that  most  patients  operated 
upon  within  six  or  eight  hours  after  infection  would 
recover,  while  those  operated  upon  after  that  time 
would  usually  die.     He  could  not  agree  with  those 


who  had  spoken  against  flushing  with  salt  solution, 
and  did  not  believe  that  this  irrigation  would  tap  the 
lesser  cavity  of  the  peritoneum.  When  it  was  sus- 
pected that  the  infection  was  present  there,  this  cavity 
should  be  opened  and  cleansed. 

The  Use  of  Hot-Water  Vaginal  Injections Dr. 

James  Hawlev  Burtenshaw  read  this  paper.  He 
said  that  old  as  this  therapeutic  measure  was  he  be- 
lieved it  was  more  commonly  misunderstood  and  more 
generally  abused  than  almost  any  other  popular  mode 
of  treatment.  The  distinction  should  be  sharply 
drawn  between  the  cleansing  and  the  therapeutic  vag- 
inal douche.  The  application  of  the  douche  for  four 
or  five  minutes  served  only  to  increase  the  pelvic  con- 
gestion. At  least  three  gallons  of  water  at  a  temper- 
ature of  107°  to  120°  F.  should  be  used  for  each 
douche,  and  the  douche  should  be  taken  twice  daily, 
the  patient  having  been  instructed  to  remain  in  the 
recumbent  position  for  at  least  half  an  hour  afterward. 
On  account  of  the  large  quantity  of  water  employed, 
it  would  be  found  most  convenient  for  the  patient  to 
take  such  a  douche  while  lying  in  a  bath-tub,  pro- 
vided the  latter  was  of  sufficient  size.  The  hips 
should  be  raised  while  the  douche  was  taken.  It  was 
not  generally  advisable  to  add  antiseptics  or  other 
medicaments  to  these  douches. 

Dr.  George  Tucker  Harrison  said  that  he  heart- 
ily agreed  with  all  that  had  been  said  in  the  paper 
about  the  method  of  giving  vaginal  douches.  In  this 
connection  he  wished  to  give  full  credit  for  this  most 
important  therapeutic  measure  to  its  originator,  Dr. 
Thomas  A.  Emmet,  who  had  first  brought  it  to  the 
notice  of  the  profession  in  1862.  In  cases  of  para- 
metritis following  childbirth  he  had  seen  most  won- 
derful results  from  a  proper  use  of  the  hot  vaginal 
douche. 

Harmful  after  Certain  Operations. — Dr.  J.  Rid- 
dle GoFFE  said  that  he  was  in  accord  with  the  gen- 
eral views  expressed  in  the  paper,  yet  he  had  not  made 
use  of  such  large  quantities  of  hot  water.  He  had 
often  advised  the  use  of  a  hinged  board  fitting  over 
the  bath  tub.  When  this  could  not  be  conveniently 
arranged,  the  woman  should  be  directed  to  lie  down 
on  the  bottom  of  the  tub  and  take  the  hot  water  from 
a  combination  faucet.  It  was  the  custom  in  the 
Woman's  Hospital  to  use  hot  douches  after  curettage 
and  perineal  operations,  yet  he  felt  sure  that  this  prac- 
tice was  harmful  in  that  it  caused  anaemia  of  the  parts, 
and  interfered  with  the  healing-process.  He  much 
preferred  in  such  cases  to  make  use  of  a  light  vaginal 
tampon.  The  use  of  hot  douches  after  vaginal  hyster- 
ectomy was  often  responsible  for  a  sluggish  granu- 
lating process  because  of  the  maceration  of  the  tissues 
by  the  retained  douche  water.  It  had  been  suggested 
that  hot  vaginal  douches  of  short  duration  might  be 
useful  when  it  was  desired  to  aid  the  development  of 
imperfectly  formed  pelvic  organs,  but  to  this  he  could 
not  subscribe,  for  congestion  of  the  venous  circulation 
did  not  seem  to  him  a  rational  method  of  trying  to 
accomplish  this. 

Contraindications. — Dr.  F.  P.  Hammond  ex- 
pressed the  opinion  that  the  quantity  of  water  used  in 
the  douche  was  of  little  consequence.  The  important 
point  to  consider  was  the  duration  of  the  douche,  and 
as  good  results  could  be  secured  from  the  use  of  one 
gallon  of  fluid  as  from  three  gallons,  provided  the 
aperture  of  the  nozzle  was  suflSciently  small.  The 
douche  was  entirely  contraindicated  in  pronounced 
anx'niia,  especially  when  there  was  marked  headache, 
because  with  an  effective  vaginal  douche  from  one- 
third  to  one-half  of  the  blood  in  the  body  was  forced 
into  the  pelvis.  It  was  a  safe  rule  to  interdict  the  use 
of  the  hot  vaginal  douche  until  the  anamia  had  been 
at  least  partially  controlled.  The  douche  was  also  con- 
traindicated in  acute  perimetritis  or  salpingitis,  be- 


cause  it  was  not  always  easy  to  say  whether  or  not  pus 
was  already  present,  and  the  hot  douche  would  cer- 
tainly favor  suppuration.  In  cases  of  uterine  dysmen- 
orrhcea  without  marlced  involvement  of  tlie  ovaries,  a 
prolonged  hot  vaginal  douche  would  often  give  com- 
plete relief.  It  did  this  by  softening  the  cervical 
mucosa  and  relieving  the  tension. 

Dr.  W.  Evelyn  Porter  said  that  it  had  been  his 
practice  for  several  years  to  have  his  patients  make 
use  of  a  vulvar  pad  with  an  outlet  tube  of  smaller  size. 
The  nozzle  was  held  in  place  by  a  T-bandage,  and  the 
outllow  was  regulated  by  pinching  the  tubing  more  or 
less.  This  gave  a  prolonged  douche  with  a  moderate 
quantity  of  water,  and  at  the  same  time  distended  the 
vagina.  The  vulvar  pad  and  the  Kemp's  tube  would 
accomplisli  this  nicely,  and  would  require  the  use  of 
only  from  four  to  six  quarts  of  water. 

Dr.  a.  B.  Tucker  said  that  he  had  found  that  by  the 
use  of  large  hot  vaginal  douches  it  was  possible  to  do 
so  much  good  in  cases  of  retrodisplacements  that  pes- 
saries would  be  rarely  required. 

Dr.  F.  H.  Wiogin  said  he  firmly  believed  that  this 
method  was  far  more  useful  in  1S62  tiian  at  tiie  jires- 
ent  time  when  there  were  other  and  better  methods  of 
treating  acute  intlammatory  diseases  of  the  female 
pelvic  organs. 

Dr.  a.  Palmer  Dudley  said  that  hot  vaginal 
douches  were  not  used  much  at  the  present  time  by 
the  younger  practitioners  because  it  was  known  that 
their  action  did  not  reach  beyond  the  cellular  tissue. 
The  treatment  had  been  introduced  by  Dr.  Emmet  at 
a  time  when  the  theory  of  cellulitis  had  dominated 
gynaecology.  He  thought  Dr.  Emmet  had  lived  long 
enough  to  see  many  of  the  younger  men  go  out  of  the 
Woman's  Hospital  with  different  notions  as  to  the 
value  of  these  douches.  His  own  point  of  view  being 
surgical  he  could  see  but  little  need  at  tiie  present  day 
for  such  treatment. 


NEW    YORK    ACADEMY    OF    MEDICINE. 

Anniversary  Meeting,  December  6,  igoo. 

William  H.  Thomson,  M.D.,  Presidext. 

Appendicitis  from  the  Medical  and  Surgical  Points 
of  View. — This  was  the  topic  of  the  anniversary 
discourse,  which  was  delivered  by  Dr.  Rohert  Ahhe. 
He  called  attention  to  the  fact  that  appendicitis 
had  held  its  own  in  the  surgical  field  in  spite  of 
prejudice  and  of  the  new  and  interesting  problems 
constantly  arising.  The  experienced  surgeon  often 
treated  at  the  present  time  as  many  as  one  hundred 
cases  a  year.  The  question  was  often  asked,  Wiiy  was 
so  much  heard  of  appendicitis  at  the  present  day 
when  it  was  an  almost  unknown  affection  a  few  years 
ago?  The  answer  was  to  be  found  in  the  different 
nomenclature  formerly  employed.  Most  of  the  cases 
now  designated  as  appendicitis  were  formerly  spoken 
of  as  attacks  of  inflammation  of  the  bowels.  The  first 
attack  of  appendicitis  recognized  by  the  patient  was 
probably  the  terminal  stage  of  the  disease,  because 
examination  of  the  appendix  showed  stricture,  and  it 
w-as  well  known  that  strictures  usually  required  a  long 
time  for  their  formation.  It  was  true  that  strictures 
might  sometimes  form  rapidly,  but  even  in  these  cases 
one  would  usually  find  behind  them  concretions,  and 
certainly  these  masses  had  required  a  long  time  to 
grow.  With  some  recent  writers  the  erroneous  idea 
still  prevailed  that  these  concretions  formed  in  the 
colon  and  dropped  into  the  appendix,  but  the  fact  that 
the  concretion  was  always  on  the  distal  side  of  the 
stricture  negatived  this  view.  In  no  case  had  he  not 
found  concretions  detained  there  by  strictures,  and  the 


concretions  would  always  be  found  packed  in  close  to 
the  stricture.  These  concretions  acted  as  a  ball-valve. 
It  had  been  seriously  suggested  that  gout  might  be  a 
cause  of  appendicitis,  but  it  should  be  remembered 
that  appendicitis  occurred  largely  in  ciiildhood,  that  it 
was  a  bacterial  infection,  and  thai  the  type  of  joint 
disturbance  was  a  low  grade  of  pya;mic  infection.  The 
speaker  objected  to  the  term  "chronic"  appendicitis, 
preferring  to  speak  of  the  condition  as  latent  appendi- 
citis, because  the  latter  term  indicated  that  in  the  in- 
terval the  presence  of  appendicitis  might  not  be  capa- 
ble of  detection.  In  considering  the  statistics  of 
medical  and  surgical  treatment  of  appendicitis  one 
should  bear  in  mind  that  every  case  coming  to  the 
surgeon  represented  on  an  average  from  five  to  twenty 
medical  cures.  It  could  not  be  denied  that  in  a  very 
limited  number  of  cases  nature  was  competent  to  deal 
with  the  gravest  conditions,  but  the  statistics  of  such 
cases  showed  a  far  higher  mortality  than  the  cases 
that  had  been  promptly  treated  by  operation.  One 
stood  appalled  at  times  at  the  wonderful  surgical  feats 
accomplished  by  Nature,  and  yet  she  was  a  most 
bungling  surgeon.  As  in  all  studies  of  medical  prob- 
lems, truth  spelled  itself  out  letter  by  letter,  and  a  long 
time  must  elapse  before  a  full  knowledge  of  the  sub- 
ject was  within  our  grasp. 

The    Library    of   the    Surgeon-General Dr.  A. 

Jacobi  moved  the  adoption  of  the  following  resolution: 

"  Whereas,  The  library  of  the  Surgeon-General's 
office  in  Washington,  D.  C.,  has  for  a  long  time  needed 
additional  shelving ;  and 

"  Whereas,  Books  are  piled  upon  the  floor  and  win- 
dow sills,  making  it  inconvenient  and  sometimes  well- 
nigh  impossible  to  find  anything  which  is  wanted,  and 
greatly  to  the  injury  of  the  books;  and 

"  Whereas,  Estimates  have  been  made  from  year  to 
year  for  an  appropriation  to  meet  the  cost  of  six  iron 
book  stacks;  be  it 

"Resolved,  By  the  New  York  Academy  of  Medicine, 
in  its  meeting  of  December  6,  1900,  to  petition  the 
Congress  of  the  United  States  to  make  the  appropria- 
tion of  $9,000  asked  for  for  the  above  purpose,  on  the 
ground  that  without  it  the  usefulness  of  the  library  of 
the  Surgeon-General's  office — the  best-appointed  li- 
brary of  the  world,  and  the  pride  of  the  medical  profes- 
sion of  all  countries — will  be  seriously  interrupted  and 
crippled." 

The  resolution  was  carried  unanimously. 

War  Tax  on  Charitable  Institutions.— On  motion 
of  Dr.  Jacori  the  following  resolution  was  also  unan- 
imously adopted: 

"  Whereas,  In  the  .session  of  1898  the  Congress  of 
the  United  States  has  laid  a  war  tax  on  legacies  of 
charitable,  educational,  and  religious  institutions;  and 

"  Whereas,  The  revenue  from  this  and  other  war 
taxes  has  been  unnecessarily  large  and  in  need  of 
being  reduced;  and 

"  Whereas,'Y\\Q  charitable  and  religious  institutions 
of  the  country  are  seriously  interfered  with  by  the 
crippling  of  the  income  of  organizations,  almost  exclu- 
sively derived  from  private  sources;  therefore,  be  it 

"  Reso/vei/,  By  the  New  York  Academy  of  Medicine, 
at  its  meeting  of  December  6,  1900,  to  petition  the 
Congress  of  the  I'nited  States  to  relieve  charitable 
and  religious  institutions  of  the  war  tax  hitherto 
levied,  and  to  request  every  fellow  of  the  Academy  to 
inform  our  representatives  in  Congress  of  the  reasons 
for  such  petition." 


Inebriety  in  Russia. — The  Russian  minister  of 
justice  has  transmitted  to  the  commission  appointed 
to  reform  the  penal  code  a  proposition  emanating 
from  the  National  Hygienic  Society  forcibly  to  detain 
confirmed  inebriates  in  hospitals. 


^jewj  instruments. 

A  NEW  INSTRUMENT  FOR  OPERATING  ON 
CONGENITAL  DISLOCATION  OF  THE  HIP 
AND  OTHER  PATHOLOGICAL  DISEASES 
OF    BONE. 

Hy    a.    M.    PHELPS,    A.M.,    M.D., 

NEW    VOKK. 

The  orthopedic  profession  are  pretty  generally  con- 
vinced that  anything  short  of  an  operation  of  some 
kind  in  congenital  dislocation  of  the  hip  will  prove 
an  absolute  failure.  Braces  have  been  discarded,  or 
if  they  have  not  been  by  some,  they  should  be.  It  is 
little  short  of  arrant  charlatanism  to  humbug  patients 
by  applying  braces.  In  congenital  dislocation  of  the 
hip  there  are  two  reasons  why  braces  are  absolutely 
worthless. 

In  the  dissections  which  I  published  a  few  years 
ago,  and  in  something  like  seventy-five  cases  of  opera- 
tions, I  did  not  find  an  acetabulum  in  more  than  two 
or  three  of  the  cases  into  which  it  was  possible  to  put 
the  head  of  the  bone  and  have  it  remain.     It  has  been 


the  femur,  beginning  at  the  upper  border  of  the 
acetabulum,  and  is  carried  down  to  the  neck  of  the 
bone.  This  incision  is  a  modification  from  Langen- 
beck's  incision,  which  was  advocated  by  Lorenz. 
The  capsule  is  now  detached  from  the  interior  tro- 
chanteric line  two-thirds  the  distance  around,  and  the 
head  of  the  bone  is  then  rotated  out.  The  capsule  is 
then  split  so  as  to  admit  the  instrument,  which  was 
devised  by  Dijou,  and  it  is  one  of  tlie  most  useful  I 
have  ever  yet  seen.  This  instrument  is  a  steel  tube, 
ending  with  cutting  edges  on  the  curve  to  correspond 
to  a  perfect  circle.  It  is  on  the  principle  of  the  old- 
fashioned  pot  auger.  A  few  turns  of  this  bores  a  hole 
into  the  pelvis,  at  the  site  of  the  rudimentary  acetabu- 
lum, which  perfectly  fits  the  head  of  the  bone. 

As  will  be  seen  by  the  illustration  there  are  three 
sizes,  corresponding  to  the  three  sizes  of  heads  that 
are  usually  found  in  such  cases.  The  upper  instru- 
ment is  for  tlie  purpose  of  cleaning  out  the  tube. 
After  a  few  turns  the  bone  which  is  removed  from  the 
pelvis  will  be  found  inside  of  the  tube,  and  can  be 
emptied  out  usually  without  the  use  of  the  hook. 

Another  application  of  this  instrument  is  in  excision 
of  the  hip.  I  find  that  the  acetabulum  can  be  cleaned 
out  with  it  better  than  with  the  scoop,  and  frequently 


argued  that  pulling  the  limb  down  with  the  brace,  and 
holding  the  head  of  the  bone  opposite  the  acetabulum 
would  result  in  the  head  of  the  bone  eventually  grind- 
ing out  a  new  socket.  Clinical  observation  demon- 
strates this  to  be  an  error.  All  such  cases  relapse  or 
are  not  benefited,  and  this  has  induced  the  profession 
to  resort  to  some  operative  procedure  for  tlie  relief  of 
this  deformity,  which  in  the  female  results  in  distor- 
tion of  the  pelvis,  endangering  her  life  during  the 
period  of  childbearing,  so  say  nothing  of  the  wobbling, 
shuffling  gait  in  either  sex  which  attends  the  displace- 
ment. 

Hoffa's  method  of  making  a  new  acetabulum,  and 
placing  the  head  of  the  bone  into  it  is  one  that  has 
commended  itself  to  me.  Lorenz's  method  of  "  forci- 
ble replacement,"  as  he  calls  it,  is  the  twisting  of  the 
head  of  the  bone  around  to  a  normal  position,  the  soft 
parts  holding  tiie  head  of  the  bone  against  the  acetabu- 
lum. This  latter  method  I  do  not  endorse,  because  in 
all  of  the  cases  which  I  have  examined,  with  occasional 
exceptions,  I  have  seen  merely  the  posterior  converted 
into  an  anterior  dislocation,  and  the  apparent  benefit 
which  is  derived  from  it  is  that  the  anterior  disloca- 
tion is  attended  with  only  one-half  the  shortening  of 
the  posterior.  Then  again,  these  cases  I  have  observed 
as  a  rule  are  attended  with  continued  increase  in  short- 
ening. This  is  not  always  true,  but  it  is  altogether  too 
common. 

In    Hoffa's    operation   an   incision    is  made    along 


in  children  in  whom  the  head  of  the  bone  is  partially 
consolidated,  after  removing  the  great  trochanter  with 
this  instrument,  the  neck  and  head  of  the  bone  and 
acetabulum  can  be  bored  out  with  very  few  turns,  and 
the  operation  completed  within  two  or  three  minutes. 

I  first  saw  Hofta  use  the  instrument  in  Kirmesson's 
clinic  in  Paris,  and  was  so  favorably  impressed  with 
it  that  I  brought  a  set  home,  and  have  been  operating 
at  the  Post-Graduate  Hospital  since  my  return,  until  I 
can  commend  the  instrument  to  the  profession  without 
any  qualification.  In  bone  surgery  it  is  better  than 
the  scoop.  I  can  think  of  a  great  many  operations 
upon  bone  in  which  chisel  and  scoop  have  hitherto  been 
employed,  when  this  instrument  will  do  the  work  much 
more  quickly  and  easily,  and  with  less  shock  to  the 
patient.  The  wound  which  is  made  by  this  boring  in- 
strument is  perfectly  smooth,  with  no  ragged  pieces  of 
bone  hanging  to  the  soft  parts,  and  no  debris  left  in 
the  wound. 

62  East  Thirtv-kourth  Street. 


Quarantine   Barges   for  Cuba  and  Porto  Rico.— 

The  steamship  Orion  sailed  from  Philadelphia  on 
November  27th  for  Cuba,  having  in  tow  two  disinfect- 
ing barges,  the  Guardian  and  the  Sentinel,  the  former 
to  be  put  in  service  at  Matanzas  and  the  other  at 
Cienfuegos.  The  barges  were  converted  from  schoon- 
ers. .Another  barge,  the  Z>ty£-Wf;-,  is  being  equipped' 
at  Philadelphia  for  quarantine  work  in  Porto  Rico. 


December  15,  1900] 


MEDICAL    RECORD. 


957 


giXcdical  Items. 

Contagious   Diseases — Weekly   Statement — Report 

of  cases  and  deaths  from  contagious  diseases  reported 
to  the  Sanitary  Bureau,  Health  Department,  for  the 
week  ending  December  8,  1900; 


Cases, 

Tuberculosis 246 

Typhoid  fever 1  110 

Scarlet  fever I  144 

Measles 63 

Diphtheria |  2<j2 

Laryngeal  diphtheria  (croup) i  27 

Cerebro-spinal  meningitis |  o 

\'aricella 66 

Smallpox   12 


Deaths. 
134 

21 

3 
4 
40 
7 
4 
o 


No  Plague  Serum  in  Melbourne.  —  \\  hen  the 
plague  came  to  Melbourne  a  millionaire  wool  exporter 
sent  for  his  doctor  post-haste  to  inoculate  him  and  his 
family.  The  doctor  sent  word  he  had  no  serum. 
"Get  some,"  wired  the  millionaire.  The  doctor  did 
his  best,  but  failed.  The  millionaire,  who  was  horri- 
bly nervous  about  infection,  wired  again,  saying: 
"Get  it  at  any  price."  The  doctor  offered  $5,000  for 
a  single  syringe  full  of  the  culture;  but  all  in  vain. 
It  appeared  that  a  quantity  of  gelatin  culture  full  of 
bubonic  germs  had  been  sent  over  from  India  some 
time  before,  but  the  authorities  objected  to  it  being 
landed.  Taking  advantage  of  the  fact  that  gelatin 
was  liable  to  duty,  they  confiscated  and  burned  it. — 
Answers. 

Abnormalities  of  Vaccination. — Dr.  C.  D.  Smith, 
president  of  the  State  board  of  health  of  Maine,  has 
published  in  the  eleventh  report  of  that  body  a  valu- 
able and  exhaustive  paper  upon  vaccination  and  vac- 
cine lymph.  Referring  to  the  abnormalities  of  vac- 
cination, and  more  especially  to  the  eruption  commonly 
known  as  "  vaccinia,"  Dr.  Smith  says:  "In  the  French 
classifications  mention  is  made  of  a  generalized  vesic- 
ular eruption  known  as  vaccine  generalise'e,  due  to 
blood  infection.  In  this  country  it  has  been  common 
practice,  with  a  disregard  of  any  systematic  study  of 
the  points  of  difference,  to  speak  of  any  general  erup- 
tion associated  with  vaccination  as  '  vaccinia.'  That 
this  is  incorrect  must  be  apparent,  from  a  review  of 
the  painstaking  studies  of  our  English  and  French 
confreres.  I  do  not  wish  to  do  more  than  outline  as 
briefly  as  may  be  the  facts  with  reference  to  the  char- 
acteristics of  a  true  '  vaccinia,'  or,  more  properly 
speaking,  vaccinal  eruption,  due  to  the  introduction 
into  the  blood  of  the  specific  vaccine  virus.  It  ap- 
pears in  two  forms:  spontaneous  when  due  to  the 
absorption  into  the  general  circulation  of  the  active 
principle  of  vaccine  lymph.  This  is  noted  as  a  very 
rare  affection  ;  its  tendency  being  to  remain  localized. 
It  apparently  results  from  the  fact  that  the  lymph  loses 
its  fixed  character,  and  the  organisms  instead  of  fol- 
lowing the  rule  seen  in  normal  vaccination  and  pro- 
ducing their  peculiar  phenomena  in  a  localized  area, 
are  diffused.  It  is  confined  almost  wholly,  though  not 
invariably,  to  infants  or  young  children.  It  may  ap- 
pear with  the  vesicles  or  later.  When  the  infection 
results  from  taking  the  virus  into  the  alimentary  canal, 
as  by  sucking,  the  period  of  incubation  is  from  four  to 
eight  days  and  the  symptoms  and  eruption  appear 
identical  with  true  variola.  Sometimes  the  secondary 
vesicles  appear  at  the  same  time  as  those  on  the  vac- 
cinated arm  and  follow  the  same  time  of  development. 
When  the  symptoms  appear  suddenly,  there  is  marked 
fever,  and  the  appearance  in  the  areola  of  papules 
developing   in   two  or  three  days  into  vesicles,  being 


most  closely  grouped  in  the  centre,  often  confluent, 
and  becoming  fewer  and  smaller  and  less  markedly 
developed  toward  the  periphery.  At  once,  or  soon 
after,  there  appear  in  other  areas  of  the  body,  isolated, 
or  in  irregularly  disposed  patches,  similar  papules 
having  the  same  shotty  feel  as  in  smallpox.  These 
have  an  affinity  for  weak  places  in  the  skin  (near  orig- 
inal mark),  and  when  occurring  on  the  extremities 
select  the  flexor  surfaces.  The  vesicles  become  scabs 
in  a  fortnight  or  a  little  more,  sometimes  in  severer 
cases  extending  over  three  weeks  and  are  not  followtd 
by  pits,  nor  does  the  eruption  attack  the  mucous  sur- 
faces. The  other  form  due  to  auto-inoculation  is  less 
rare,  and  is  usually  accompanied  by  some  cutaneous 
affection,  such  as  eczema,  erythema,  or  one  of  the 
papulo-vesicular  eruptions.  It  occurs  from  the  third 
to  the  eighteenth  day  after  vaccination ;  it  is  conveyed 
from  one  to  another  part  of  the  body  by  scratching 
and,  as  might  be  supposed  from  its  mode  of  trans- 
ference, frequently  exhibits  much  infianimatory  action 
and  ulceration.  There  is  no  typical  mark  when  the 
vesicles  terminate  without  septic  complications,  and 
their  duration  is  the  same  as  in  the  spontaneous  form. 
The  chief  interest  in  these  two  forms  of  eruption  lies 
in  their  complication  of  a  diagnosis  during  the  prev- 
alence of  smallpox.  F'rom  varicella  they  are  to  be 
distinguished  by  the  larger  size  of  vesicle;  their  irreg- 
ularities of  shape,  and  the  fact  of  vaccination,  and  the 
length  of  time  elapsing  before  their  appearance,  and 
the  absence  of  any  regularity  or  order  of  appearance. 
In  variola  the  vesicles  are  as  a  rule  equal  in  size. 
The  clinical  features  are,  with  rare  exceptions,  uni-' 
form,  and  they  are  evenly  distributed.  Rarely  in 
variola  or  varioloid  are  lesions  absent  from  the  mouth 
or  pharynx."  Dr.  Smith  wisely  says  that  when  in 
doubt  between  this  eruption  and  varioloid,  isolate 
promptly. 

Wearing  Out  the  Brain.— A  French  investigator 
has  come  to  the  conclusion  that  the  brains  of  military 
and  naval  men  give  out  most  quickly.  He  states  that 
out  of  every  100,000  men  of  the  army  or  naval  pro- 
fessions 199  are  hopeless  lunatics.  Of  the  so-called 
liberal  professions,  artists  are  the  first  to  succumb  to 
the  brain  strain,  next  the  lawyers,  followed  at  some 
distance  by  doctors,  clergy,  literary  men,  and  civil 
servants.  Striking  an  average  of  this  group,  177  go 
mad  to  each  100,000.  Domestic  servants  and  laborers 
are  not  far  behind ,  the  professional  men  supply  155 
out  of  each  100,000  as  candidates  for  the  lunatic  asy- 
lum. Next,  but  with  a  long  interval,  come  the  me- 
chanics, of  whom  only  66  in  each  100,000  lose  their 
wits.  Wonderful  to  relate,  commercial  men  retain 
their  sanity  the  best  of  the  whole  group,  as  they  send 
only  42  out  of  100,000  to  the  madhouse.  The  French 
scientist  may  be  right,  and  doubtless  he  is  so  far  as 
France  is  concerned,  but  in  the  United  States  we  are 
convinced  the  order  would  be  different.  Doctors  as  a 
class  would  take  a  higher  rank  and  the  commercial 
men  of  this  country  go  mad  more  frequently  than  the 
"  hewers  of  wood  and  drawers  of  water."  It  is  not 
complimentary  to  the  business  men  to  put  them  in  a 
lower  category  than  the  ordinary  day  laborer.  To  be- 
come insane  in  itself  is  a  presumption  that  one  pos- 
sesses brains,  often  indeed  above  the  common.  "  Great 
wits  are  oft  to  madness  close  allied."  Will  some  en 
thusiastic  gatherer  of  statistics  endeavor  to  clear  this 
matter  up? 

Microbe  Lamps. — An  English  weekly  journal  con- 
tains the  following:  "That  some  microbes  can  pro- 
duce a  bright  light  is  the  discovery  of  a  French 
scientist.  The  newly  found  microbes  have  been  named 
photobacteria,  and  with  them  a  living  lamp  has  been 
manufactured.     The  minute  creatures  are  so  small  that 


958 


MEDICAL    RECORD. 


[December  15,  1900 


two  hundred  and  fifty  million  of  them  could  find  stand- 
ing room  on  a  postage  stamp,  and  the  number  required 
to  produce  a  light  bright  enough  to  read  by  reaches  a 
few  thousand  billions.  'Ihe  microbe  lamp  is  merely 
a  glass  bottle  containing  water  in  which  the  bacteria 
have  been  cultivated.  In  a  dark  room  the  bottle  glows 
like  a  'rosted  electric  lamp,  and  gives  a  light  strong 
enougli  to  enable  fine  print  to  be  read  at  a  distance  of 
five  or  six  feet.  The  light  is  perfectly  steady,  and 
when  the  microbes  can  be  cultivated  on  a  large  scale 
it  is  calculated  that  the  cost  will  be  about  one  half- 
penny [one  cent]  per  two  hundred  hours.  The  microbe 
lamps  would  not  be  renewed  when  the  light  dimin- 
ished, but  would  simply  be  replaced  by  new  ones,  half 
a  dozen  of  which  could  be  carried  in  the  pocket  ready 
for  use  at  any  time;  and  as  the  bottles  are  sealed,  the 
lamps  are  perfectly  harmless.  The  light  is  continu- 
ous day  and  night,  and  only  goes  out  when  the  mi- 
crobes die."  It  is  proposed,  we  believe,  to  light  Paris 
and  a  few  other  French  towns  by  means  of  these 
microbes,  that  is  to  say,  if  a  sufficient  number  of  the 
right  sort  can  be  found.  Wonderful  are  the  discov- 
eries in  the  bacteriological  laboratories! 

The   Use    of    Tobacco    on    Active    Service — The 

Lancet  oi  November  loth  says  that  "the  war  in  South 
Africa  has  taught  many  things  of  greater  and  of  less 
importance.  Perhaps  nothing  that  it  has  demonstrated 
has  been  more  marked  than  the  important  part  which 
tobacco  plays  in  the  soldier's  existence.  VVhetherthis 
is  to  be  reckoned  as  a  great  fact  or  a  small  one,  there 
can  be  no  doubt  about  the  truth  of  it.  Yet  the  Duke 
of  Wellington's  armies  had  no  tobacco  worth  speaking 
of.  If  they  did  not  forbid  its  use,  at  any  rate  the  Iron 
Duke's  officers  were  directed  to  advise  their  men 
strongly  against  it.  What  a  curious  contrast  with  the 
campaigning  in  South  Africa,  where  marches  and  pri- 
vations as  long  and  as  stern  as  any  sufi^ered  by  our 
great-grandfathers  were  borne  by  the  volunteers  and 
soldiers  of  to-day  with  a  grumble  only  when  their 
'smokes'  failed  them.  We  have  it  from  many  who 
took  part  in  the  forced  marches  leading  to  Paardeberg, 
to  Bloemfontein,  to  Pretoria,  and  beyond  that,  when 
rations  were  but  two  or  three  biscuits  a  day,  the  only 
real  physical  content  of  each  twenty-four  hours  came 
with  the  pipe  smoked  by  the  smouldering  embers  of  a 
camp  fire  ("his  pipe  eased  the  way  to  sleep  that 
might  otherwise  have  lingered,  delayed  by  the  sheer 
bodily  fatigue  and  mental  restlessness  caused  by  pro- 
longed and  monotonous  exertion.  It  is  difficult  then 
to  believe  that  tobacco  is  anything  but  a  real  help  to 
men  who  are  suffering  long  labors  and  receiving  little 
food,  and  probably  the  way  in  which  it  helps  is  by 
quieting  cerebration — for  no  one  doubts  its  sedative 
qualities — and  tiius  allowing  more  easily  sleep  which 
is  so  all-important  when  semi-starvation  has  to  be  en- 
dured. The  cases  of  acute  mental  derangement  in  the 
course  of  campaigns  such  as  the  present  are  many. 
There  have,  indeed,  been  many  in  South  Africa.  It 
would  be  most  profitable  and  interesting  could  medi- 
cal officers  have  taken  special  note  of  the  capacity  for 
sleep  previously  evidenced  by  those  who  broke  down 
and  also  of  their  indulgence  or  non-indulgence  in 
tobacco.  We  are  inclined  to  believe  that  used  with 
due  moderation  tobacco  is  of  value  second  only  to 
food  itself  when  long  privations  and  exertions  are  to 
be  endured.  Two  features  are  to  be  noted  with  regard 
to  the  smoking  practised  on  active  service.  It  is  al- 
most entirely  in  the  open  air  and  is  largely  on  an 
empty  stomach.  The  former  is  always  an  advantage, 
the  latter  we  generally  reckon  a  most  unfavorable  con- 
dition. Shall  we  see  in  the  near  future  patients  with 
tobacco  amblyopia  or  smoker's  heart  accpiired  while 
the  trusting  friend  of  tobacco  thought  that  he  was  en- 
joying the  well-earned  solace  of  a  hard  day's  march.' 


We  believe  not — and  that  the  open  air  will  have 
saved  what  might  have  been  the  untoward  results  of 
smoking  when  unfed."  The  most  suggestive  part  of 
this  instructive  article  is  that  which  refers  to  the 
cases  oi  mental  derangement  in  the  course  of  cam- 
paigns and  their  connection,  if  any,  with  smoking. 
Insanity  has  been  considerable  among  our  soldiers  in 
the  Philippines,  and  the  surgeons  there  might  with 
advantage  investigate  the  question  raised  by  The  Lan- 
cet writer  as  to  the  capacity  for  sleep  previously  evi- 
denced by  those  who  broke  down  and  also  of  their  in- 
dulgence or  non-indulgence  in  tobacco. 

Diseases  of  the  Philippine  Islands Medical  In- 
spector Remus  C.  Persons,  U.  S.  A.,  writing  in  the  re- 
port of  the  surgeon-general  of  the  United  States  navy 
on  the  above  subject,  says:  "The  prevailing  diseases 
are  of  the  various  types  of  fevers;  of  rheumatism, 
dysentery,  and  diarrhcea,  of  heat  exposure,  skin  dis- 
orders, smallpox,  beriberi,  plague,  and  other  diseases 
which  are  common  everywhere,  including  the  ever- 
present  venereal  troubles  and  alcoholic  addiction. 
Dengue  and  thermic,  malarial  and  typhoid  fevers  ex- 
ist throughout  the  group  of  islands;  nor  is  it  to  be 
wondered  at,  since  no  attempt  at  sanitation  has  been 
made  outside  of  the  Spanish-dwelling  cities.  Few 
places  have  water  supplies  or  sewerage  of  any  kind. 
The  water-closet  system  is  practically  unknown,  cess- 
pools or  privies  above  ground  being  the  rule,  and  in 
native  towns  anywhere  that  is  convenient.  Most  of 
the  coast  towns  lie  so  low  that  but  an  imperfect  sys- 
tem of  drainage  is  practicable  at  the  best.  .  .  .  The 
mortality  has  been  about  the  same  as  at  other  plague 
infected  centres.  It  has  been  diligently  fought,  both 
at  Manila  and  Cavite.  In  Cavite  the  houses  are  also 
built  with  the  lower  story  on  the  ground,  in  which 
many  people  are  liuddled,  and  it  was  among  them  the 
cases  occurred,  all  fatal.  There  have  not  been  any 
cases  among  the  whites.  The  plague  has  not  become 
epidemic,  but  the  recognized  cases  have  been  so  wide- 
spread as  to  lead  to  a  belief  that  it  is  endemic,  and 
that  conditions  have  not  become  ripe  for  its  becoming 
epidemic  in  the  islands.  All  through  the  towns  and 
in  the  country  fevers  of  all  kinds  exist.  A  severe  type 
of  dengue  is  common,  and  in  Cavite  very  few  escape 
it.  Fortunately  it  does  not  prove  fatal,  although  it  is 
often  very  distressing.  There  malarial  fever  is  un- 
common. There  are  no  pools  of  stagnant  water  in 
wliich  mosquitos  can  breed,  and  when  it  appears  the 
Plasmodium  is  evidently  imported.  In  many  sections 
of  the  lower  islands  it  exists  at  its  worst,  and  often 
proves  quickly  fatal.  Smallpox  is  so  widely  spread  as 
to  be  little  regarded,  and  in  some  parts  is  considered 
by  the  natives  as  an  almost  necessary  disease  of  child- 
hood, and  no  attempt  is  made  to  keep  it  from  spread- 
ing. A  vaccine  farm  lias  been  established  in  Manila, 
alfording  excellent  virus  from  the  native  carabao,  and 
compulsory  vaccination  has  been  established  in  Ma- 
nila and  many  of  the  captured  towns,  and  it  is  hoped 
to  check  its  further  spread,  but  it  will  require  time  to 
immunize  eight  or  ten  million  people.  Rheumatism 
stubbornly  resists  treatment,  and  relapses  are  com- 
mon, and  when  once  the  disease  obtains  a  good  foot- 
hold the  subject's  usefulness  is  gone,  and  he  should 
be  given  a  change  of  climate.  Oiarrlueas  from  many 
causes  are  common  but  quickly  yield  lo  suitable  treat- 
ment. Dysenteries,  on  the  other  hand,  may  be  either 
t|uickly  fatal  or  run  into  a  chronic  condition.  The 
latter  is  of  the  amctbic  variety,  and  though  sometimes 
fatal,  its  tendency  is  to  run  into  the  chronic  form 
when  not  promptly  cured.  The  acute  and  generally 
fatal  form  is  due  to  a  specific  bacillus.  It  is  not  as 
common  as  the  amcebic  form,  which  is  fortunate,  for 
it  is  very  sudden  and  overwhelming  in  its  action,  and 
may  prove  fatal  in  three  days.      Periberi    is  one  of  the 


December  15,  1900] 


MEDICAL    RECORD. 


959 


common  diseases  of  the  natives  and  most  often  proves 
fatal,  if  its  ravages  among  the  Filipino  prisoners  held 
in  Cavite  are  not  exceptional,  where  the  fatality  was 
so  great,  notwithstanding  treatment  by  Filipino  phys- 
icians, that  the  rest  were  liberated  to  prevent  the 
further  spread.  Venereal  troubles  abound  as  else- 
where, but  show  no  special  virulence.  Fever  after 
e.xposure  to  the  sun  often  occurs.  .  .  .  Tiiere  arc  many 
insect  pests  on  shore,  as  mosquitos  and  the  different 
forms  of  itch.  It  is  not  known  whether  or  not  the 
former  are  malaria  breeding,  but  it  is  certain  they  are 
voracious  and  poisonous.  The  'dhobie '  or  washer- 
man's itch  finds  its  way  on  shipboard  and  is  quite 
common  and  annoying,  but  the  insect  is  easily  killed. 
The  variety  known  as  sama  makes  deep  and  excessive- 
ly painful  .sores,  which  are  hard  to  heal." 

The  Mosquito  Family. —  I'he  word  mosquito  has 
no  scientific  import.  Derived  from  the  Spanish  or 
Portuguese,  it  simply  means  "little  Hy";  it  is  used 
popularly  to  denote  a  gnat  which  bites,  and  most  gnats 
bite  when  they  have  a  chance.  The  word  is  sometimes 
extended  to  include  certain  midges.  The  Dipterous 
family  Culicid;e,  to  which  the  gnat  belongs,  contains, 
according  to  .\fajor  (iiles,  some  two  hundred  and  forty- 
two  species  divided  among  eight  genera.  The  great 
majority  of  species  (some  one  hundred  and  sixty ),  how- 
ever, belong  to  the  genus  Culex;  .Anopheles  includes 
thirty,  while  the  remainder  are  divided  among  the 
other  six  genera,  none  of  which  are  large.  The  col- 
lections which  have  recently  been  made  at  the  liritish 
Museum  are  said  to  contain  ten  species  of  Anopheles 
new  to  science,  so  that  if  all  Major  (files'  species  are 
accepted  we  have  a  total  of  some  forty  species  of  the 
genus  which  has  been  hopelessly  convicted  of  being 
the  medium  by  which  the  malaria  parasite  is  trans- 
mitted from  person  to  person. —  Quarterly  Review. 

Anti-Plague  Inoculation.  — Professor  Calmette,  of 
the  Pasteur  Institute  at  Lille,  who  has  made  a  spe- 
cial study  of  the  bubonic  plague,  was  requested  by  the 
College  of  Physicians  and  Surgeons  of  England  to  de- 
liver the  second  of  the  Harbcn  lectures.  The  subject 
selected  was  anti-plague  serum  therapy.  Dr.  Calmette 
said:  "In  all  cases  the  infection,  whatever  the  mode 
of  entry  of  tiie  virus,  resulted  in  the  multiplication  of 
the  plague  bacillus,  first  in  the  lymphatic  channel  and 
then  in  the  blood.  Even  a  few  hours  after  infection 
the  bacilli  were  to  be  found  in  the  blood,  and  they 
existed  in  immense  quantities  in  all  the  organs  of  the 
person  attacked.  The  effect,  therefore,  of  an  injec- 
tion of  the  serum  should  be  to  provoke  their  rapid 
destruction  by  phagocytosis  and  bacteriolysis.  But 
this  result  was  scarcely  attained  by  the  slow  absorption 
of  serum  injected  subcutaneously.  The  organism  not 
being  at  once  impregnated  with  the  active  substance, 
some  of  the  bacilli  escaped  the  phagocytic  process, 
and  growing  accustomed  to  the  action  of  the  serum  this 
was  powerless  to  check  it.  This  explanation  of  the 
non-success  of  the  sero-therapic  treatment  was  con- 
firmed by  clinical  observation.  But  the  results  were 
different  if  the  serum,  instead  of  being  introduced 
merely  below  the  skin,  was  as  soon  as  possible  after  the 
beginning  of  the  disease  injected  straight  into  the 
veins.  Four  or  five  hours  after  such  injection  the 
temperature  dropped,  rising  again  for  eight  or  twelve 
hours  afterward,  and  then  dropping  finally.  This  tem- 
porary drop  corresponded  to  the  period  during  which 
the  bacilli  were  being  removed  from  the  circulation 
by  the  leucocytes.  If  the  treatment  had  been  speedy, 
cure  was  effected  in  two  or  three  days.  The  serums 
of  vaccinated  animals  contained  two  substances — one 
alexin,  which  had  the  power  of  digesting  the  bacterial 
cell  and  which  existed  in  normal  serums,  and  the  other 
the  reagent  or  intermediary  substance,  which  existed 


only  in  very  small  quantities  in  normal  serums.  In 
unvaccinated  animals,  as  the  reacting  substance  did 
not  exist  in  sufficient  amount,  the  normal  alexins  in 
the  blood  were  unable  to  dissolve  the  microbic  bodies 
when  serious  infection  took  place.  Hence  to  over- 
come the  infection  a  sufficient  quantity  of  the  reacting 
substance  must  be  supplied  to  the  organism.  .Anti- 
plague  serum  was  a  reacting  substance,  and  within  its 
sph^e  of  action  when  infected  tiie  leucocytes  and 
alexins  were  unable  to  dissolve  the  plague  bacilli; 
though  beyond  it  the  bacilli  escaping  phagocytosis 
gradually  became  immune.  Hence  it  was  necessary 
that  the  reaction  of  the  leucocytes  and  alexins  should 
be  carried  on  simultaneously  through  the  organism, 
and  as  rapidly  as  possible,  and  hence  the  reason  why 
the  serum  must  be  injected  into  the  general  circula- 
tion. A  very  small  quantity  of  the  serum  was  suffi- 
cient to  react  on  an  enormous  quantity  of  alexin." 

Entries  at  the  English  Medical  Schools.— Sev- 
eral of  the  English  medical  papers  have  alluded  with 
pleasure  to  the  fact  that  the  entries  at  the  various 
medical  schools  show  a  decided  falling  off  this  year. 
In  London  this  is  especially  niarked,  as  the  following 
figures  will  show:  For  the  full  course  there  are  less 
students  entered  to  the  extent  of  28  at  St.  Bartholo- 
mew, 12  at  St.  Thomas,  lo  at  St.  George,  9  at  the 
London,  8  at  Charing  Cross,  7  at  St.  Mary,  and  i  at 
University  College.  In  the  provincial  schools  the 
decrease  is  said  to  be  as  follows:  Owen's  College, 
Manchester,  29,  Liverpool  18,  Bristol  10,  Durham 
University  7.  The  schools  showing  an  increase  are 
London  School  of  Medicine  for  Women  5,  King's 
College  4,  Guy's  5.  .At  Leeds  the  increase  is  12, 
Sheffield  3,  London  School  of  'Propical  Medicine  4, 
and  London  School  of  Dental  Surgery  10.  .Altogether 
the  net  decrease  up  to  date  amounts  to  102.  The 
cause  for  this  condition  of  affairs,  which  must  be 
termed  satisfactory,  is  twofold:  First,  parents  now 
recognize  that  the  expense  of  putting  a  young  man 
through  his  medical  course  does  not  meet  with  an 
adequate  return:  and,  secondly,  now  that  the  curricu- 
lum is  lengthened  to  five  years,  and  that  the  e.xaniina- 
tions  are  more  severe,  many  youthful  aspirants  to  a 
medical  degree  are  daunted  by  a  fear  of  failure.  If 
some  such  system  could  be  introduced  into  this  coun- 
try it  might  be  for  the  good  of  all  concerned. 

The  Twentieth  Century  Baby — The  baby  of  to- 
day bids  fair  to  replace  the  crush  of  ancient  creeds 
and  the  wreck  of  superstitions  that  have  been  every- 
where undermined  by  tiie  ruthless  hand  of  modern 
science.  For  its  behoof  many  books  are  written,  many 
carriages  are  constructed,  many  foods  are  invented, 
many  garments,  many  toys,  and  many  medicines  are 
advertised.  As  a  matter  of  sober  fact,  it  is  threatened 
with  manifold  drawbacks  to  development,  short  of 
actual  extinction,  by  the  wholesale  substitution  of  the 
artificial  for  the  natural.  Instead  of  the  most  perfect 
food  in  nature,  mother's  milk,  we  find  a  host  of  arti- 
ficial substitutes,  each  one  of  them,  if  we  may  trust 
the  proprietary  representations,  calculated  to  rear  an 
infant  with  the  brains  of  a  Newton  combined  with  the 
frame  of  a  Samson.  How  often,  alas!  the  outcome  of 
all  these  costly  cares  is  a  being  of  stinted  body  and 
limited  intellect,  unfitted  to  play  a  soldier's  part  in  the 
battle  of  life.  This  question  of  food  strikes  deep  into 
the  physical  welfare  of  a  race,  and  there  can  hardly 
be  a  more  serious  national  problem  than  how  to  rear 
this  twentieth-century  baby  of  curs  in  strength  and 
happiness.  There  is  a  vast  deal  of  nonsense  written 
and  taught  about  the  proper  way  to  clothe,  nurture, 
and  tend  babies  generally.  The  best  basis  is  that  of 
plain  milk  diet,  either  from  the  breast  or  from  modified 
cow's  milk.     For  the  rest,  those  ills  that  are  preventa- 


960 


MEDICAL    RECORD. 


[December  15,  1900 


ble  should  be  prevented.  Most  of  the  mischief  done 
in  the  nursery  is  the  result  of  attempting  to  do  too 
much.  It  would  be  an  important  step  toward  the  sta- 
bility and  future  of  our  race  were  the  laws  of  health 
to  be  taught  in  our  schools,  with  a  special  class  on 
nursery  management  for  the  girls'  classes. — Aledkal 
Fress. 

Tuberculous  Milk.  —  Professor  Uelepine,  in  the 
section  of  preventive  medicine  at  the  late  annual  con- 
gress of  the  British  Sanitary  Institute,  read  a  paper  on 
the  above  subject,  the  gist  of  vhich  is  contained  in 
the  following:  "  It  was  known  that  tuberculous  cows 
did  not  yield  tuberculous  milk  when  their  udders  were 
healthy.  Exception  might  be  taken  to  this  statement 
on  the  ground  that  a  few  cases  of  tuberculous  cows 
with  reputed  healthy  udders  had  been  reported  in 
which  the  milk  was  found  to  contain  tubercle  bacilli. 
Such  cases  might  occur,  but  must  be  rare,  and  he  had 
examined  many  udders  from  cows  which  had  given 
tuberculous  milk  and  had  not  yet  found  a  single  cow 
in  which  the  udder  was  healthy.  .  .  .  Notwithstand- 
ing an  experience  of  some  seventeen  years,  he  felt  still 
unable  to  place  much  confidence  in  the  negative  re- 
sults of  microscopical  examination.  .  .  .  The  practi- 
cal conclusion  was  evident  that  sanitary  authorities 
would  not  be  able  to  stop  very  rapidly  and  completely 
the  sale  of  tuberculous  milk.  It  was  therefore  neces- 
sary that  the  public  should  be  reminded  again  and 
again  that  they  must  boil  all  milk  which  they  con- 
sumed, and  more  especially  that  which  was  supplied 
to  infants." — Alcilica!  Magazine. 

Is   the    Anglo-Saxon    '"ace    Degenerating  ?— Dr. 

J  unes  Russell,  of  Hamilton,  Ont.,  read  a  paper  on  the 
above  subject  before  the  American  Psychological  As- 
sociation, in  which  he  ascribed  the  decadence  of  the. 
Anglo-Saxon  race  to  the  dearth  of  good  literature. 
The  pith  of  Dr.  Russell's  remarks  was  as  follows: 
"  Nowadays  men  have  no  time  for  reading  except  for 
recreation  or  business  demands.  They  scan  the  morn- 
ing newspaper  for  the  war  news,  the  stock  exchange 
re-iorts,  or  the  latest  horse  race  or  prize  fight.  The 
gambling  spirit  is  dominant  everywhere,  and  is  not 
confined  to  one  sex.  There  is  no  time  for  deep  read- 
ing or  profound  thinking.  The  mad  struggle  is  after 
wealth.  Literary  barrenness  is  the  consequence,  and 
the  tendency  is  everywhere  to  superficial  thinking,  with 
a  little  knowledge  of  everything.  There  are  no  great 
living  poets,  philosophers,  or  divines  whom  the  masses 
are  looking  to  for  guidance.  They  are  not  forthcom- 
ing because  there  is  no  demand  for  them.  The  mind 
of  the  age  is  focussed  on  one  great,  paramount  idea — 
the  acquisition  of  wealth.  The  human  brain  is  a 
composite  organ  and  susceptible  of  enormous  expan- 
sion and  development,  but  like  everything  human  it 
has  its  limitations.  Whether  or  not  it  can  stand  the 
enormous  strain  of  the  present  rate  of  activity  and 
continue  to  project  itself  with  unabated  vigor  into  the 
fut\ire,  is  the  great  problem  now  before  us  for  discus- 
sion. If  we  are  to  be  guided  by  the  history  of  the 
past  we  must  answer  in  the  negative." 

Smollett  on  Surgeons.  — It  lias  been  customary  of 
late  to  quote  Smollett's  "  Roderick  Random  "  as  af- 
fording a  perhaps  complete  picture  of  the  state  of  the 
profession  of  surgery  in  England  in  th  •  age  preceding 
that  of  John  Hunter.  Roderick  Random,  it  will  be 
reT  ;mbered,  was  examined  at  Surgeon's  Hall  in  the 
Old  Bailey,  where  he  was  twitted,  mulcted,  and  brow- 
beaten by  a  group  of  examiners  who  were  certainly  a 
dishonor  to  their  profession.  A  plump  gentleman,  it 
is  true,  asked  him  to  describe  "the  operation  of  the 
trepan  "  in  such  a  sensiiile  manner  that  Roderick  was 
able  to  give  a  sensible  answer,  but  the  next  examiner 
was  a  wag.     "  If,"  said  he.  "  during  an  engagement  at 


sea  a  man  should  be  brought  to  you  with  his  head 
shot  off,  how  would  you  behave  ?  "  The  next  examiner 
with  a  pert  air  asked  Random,  who  of  course  was 
CmoUett  himself,  ''what  method  of  cure  he  would  fol- 
low in  wounds  of  the  intestines.'"  Then  follovied  a 
pretty  altercation  between  the  plump  gentleman,  who 
had  authority  for  supposing  that  such  wounds  are  cu- 
rable, and  the  examiner,  who  affirmed  all  wounds  of 
the  intestines,  whether  great  or  small,  to  be  incurable. 
"  Sir,  excuse  me,"  interrupted  the  irate  examiner,  "  I 
despise  all  authority  iiulUus  in  rerbo  ;  I  stand  on  my 
own  bottom."  "  But  sir,  sir,"  replied  his  antagonist, 
■'the  reason  of  the  thing  shows "  "A  fig  for  rea- 
son! "  cried  this  sufficient  member;  "I  bugh  at  rea- 
son; give  me  ocular  demonstration."  A  grand  quarrel 
now  ensued,  and  Smollett  was  ordered  out  of  the  room, 
only  to  be  recalled  to  receive  his  sealed  qualification 
and  to  pay  his  fee.  He  laid  down  a  long-hoarded 
half-guinea  on  the  table  and  waited  for  change,  the  fee 
being  five  shillings.  The  examiners  were  once  more 
unanimous;  one  of  them  bade  him  begone.  "I  will," 
said  Random,  "when  I  have  got  my  change."  There- 
upon another  examiner  threw  him  his  five  shillings 
and  sixpence,  remarking,  "1  should  not  be  a  true 
Scotsman  if  I  went  away  without  my  change." — Eng- 
lish Medical  Review  of  lieriews. 

Health  Reports. — The  following  cases  of  smallpox, 
yellow  fever,  and  plague  have  been  reported  to  the 
surgeon-general  of  the  United  States  Marine-Hospital 
service  during  the  week  ended  r)eceniber  8,  1900: 

Cases.    Deaths. 


Smallpox — United  States, 
District  of  Columbia,  Wash- 
ington     November 

Kansas,  Wichita November 

Kentucky.  Le.\ington Novembtr 

Illinois,  t_airo November 

Minnesota,  Duluth November 

Minneapolis Noveml>er 

St,  Paul November 

W'inona November 

Counlit-s,  Carlton.  , ,  ] 
Hennepin,  I 
Kandiyohi 
Le  Sueur,.  I 

Lyon ^November 

Meeker. , ,  I 
Pine   . 
Ramsey  . ,  | 
Wrisht  . .   J 

M  issouri,  St,  Louis November 

New  York,  New  York November 

Ohio.  .Ashtabula November 

C  leveland November 

Pennsylvania,  Alleghany  .,, November 
South  Carolina.  Greenville, , November 

Tennessee,  Nashville November 

Te,\as,  P.lue  Springs November 

Sublime November 

Vashti November 

Vir,trinia.  Alexandria  Co December 

W.  Virginia,  Harrison  Co  .,, November 
Wheeling November 


12th  to  24th 3 

17th  to  December  ist  ,    lo 
17th  to  December  i-st,.     3 

27th     I 

8th  to  22d 54 

24th  to  December  1st  .     i 

8th  to  22d 2 

24tli  to  L>ecember  1st.  60 


8th  to  22d 73 


23d  to  December  3d, , .  3 

24th  to  December  1st,,  34 

24th  to  December  ist. ,  7 

24th  to  LJecember  1st.,  34 

24th  to  l>eceniber  1st,,  1 

24th  to  L>ecember  1st. ,  3 

24th  to  December  ist..  i 

22d Present, 

22d 14 

2d Present, 

5th I 

28th 18 

24th  to  December  tst  .  2 


Smallpox— Fokeic;n. 

Austria,  Prague .      ....  November  loth  to  17th 29 

Ecuador,  Guayaquil (October  6th  to  November  17th 

Egypt,  Cairo November  3d  to  nth 

France,  Paris November  loth  to  17th 

Clibraltar November  3d  to  nth I 

Greece.  Athens November  ioth  to  17th  ,,  - 2 

Mexico,  Tampico November  nth  to  i8th 

Vera  Cruz November  t7th  to  24th 

Russia,  Moscow November  3d  to  loth 2 

Odessa November  icth  to  17th 14 

St.  Petersburg November  3d  to  loth 2 

Scotland,  Glasgow November  17th  to  2  d 24 

Spain,  Barcelona October  27th  to  November  3d 

Yellow  Fever- United  States, 

Louisiana,  forty  miles  south 

of  Natchez,  Miss November  27th   5 

Mississippi,  Natchez November  27th.    ■ 

Osyka. December  4th * 

*  Possibly  one  fatal  case. 

Yellow  Fever— Foreign  and  Insvlar, 

Cuba,  Havana November  17th  to  24th 

Dominican  Republic,  Puerto 

Plata November  3d  lo  17th     

Mexico,  Vera  Cruz November  17th  to  24th 

Pi,AGfE— Tnsclar, 
Philippine  Islands,  Manila  .,  September  20th  to  October  6ih. , ,     i 
Placiie— Foreign, 

Africa.    Cape    Williamtown, 

vicinity November  17th 8 

China,  Hong  Kong October  13th  to  27th 

Japan,  Kobe ■     October  15th  10  27th 3 


40 
1 

«5 


48 


Medical  Record 

A    Weekly  yotirnal  of  Medicine  and  Surgery 


Vol.  58,  No.  25. 
Whole  No.  1572. 


New  York,  December  22,  1900. 


$5.00  Per  Annum. 
Single  Copies,  loc. 


I 


ON  A  CASE  WHICH  ILLUSTRATED  CON- 
SERVATISM   IN    SURGERY. 

THE  LIABILITY  OF  AN  ANCIENT  CICA- 
TRIX   TO    CANCEROUS    DEGENERATION. 

A  NEW  METHOD  OF  AMPUTATION  AT  THE 
KNEE  WHEN  THE  ARTERIAL  CIRCULA- 
TION   OF   THAT   REGION    IS    IMPAIRED. 

BEING    THE    .VBSTRACT   OF    A    LECTURE    DELIV- 
ERED IN  BELLEVUE  HOSPITAL,  JANU.\RY.  1900. 

Bv  STEPHEN   SMITH,    M.D.,    LL.D., 

COSSfLTING  SURGEON. 

This  patient  gives  a  history  which  recalls  conservatism 
in  surgery  half  a  century  ago  and  also  illustrates  the 
liability  of  an  old  cicatrix  to  cancerous  degeneration. 
In  the  treatment  of  the  conditions  existing  in  the  limb 
at  present  I  shall  take  occasion  to  demonstrate  a  meth- 
od of  amputation  at  the  knee  which  has  proved  suc- 
cessful in  similar  cases  in  which  the  arterial  circulation 
in  this  region  has  been  impaired. 

For  the  early  history  of  the  case  I  must  rely  upon 
the  patient  himself  chiefly,  though  I  have  a  recollec- 
tion of  its  principal  features.  Michael  R — - —  is  now 
between  si.xty  and  seventy  years  of  age.  He  came  to 
this  country  as  a  young  man,  and  engaged  in  business 
as  a  stone-cutter.  Without  other  assignable  cause 
than  the  accidents  incident  to  his  trade  he  developed 
either  an  acute  periostitis  or  an  osteomyelitis  of  the 
right  tibia,  which  resulted  in  the  death  of  the  entire 
shaft  of  that  bone.  He  states  that  after  a  long  period 
of  suffering  he  entered  the  New  York  Hospital,  then 
located  at  Duane  Street  in  Broadway.  The  leg  was 
greatly  enlarged  and  from  numerous  openings  pus  was 
constantly  flowing  in  large  quantities.  He  was  in 
feeble  condition,  and  his  irregular  chills  and  night 
sweats  indicated  that  he  was  suffering  from  septicsemia 
if  not  pya;mia.  A  consultation  was  held,  and  the  unan- 
imous opinion  was  that  amputation  must  be  imme- 
diately performed  to  save  his  life.  Looking  backward 
to  the  personnel  of  the  staff  of  visiting  surgeons  of 
that  hospital  forty  years  ago  we  recognize  that  the  con- 
sultation was  notable  for  the  character  of  the  surgeons 
composing  it.  Dr.  Valentine  Mott  ranked  among  the 
most  eminent  of  living  surgeons;  Dr.  Alfred  C.  Post 
was  noted  for  his  precision,  Dr.  Gurdon  Buck  for  his 
conservatism,  Dr.  John  Watson  for  his  learning.  It 
is  quite  certain  that  Ryan's  case  was  thoroughly  exam- 
ined in  all  its  aspects,  for  a  consultation  in  those  days 
was  no  mere  formal  affair,  but  an  occasion  for  the 
most  critical  comparison  of  the  learning,  skill,  and  ex- 
perience of  the  consultants.     R promptly  rejected 

the  conclusion  of  the  consultation,  and  determined 
that  his  body  and  leg  must  not  be  separated.  He 
was  accordingly  discharged  from  the  hospital  for  re- 
fusing treatment,  and  soon  after  entered  Bellevue  Hos- 
pital. At  that  time  Bellevue  was  passing  through  the 
preliminar)'  stages  of  conversion  from  the  regime  of  an 
almshouse  to  that  of  a  well-organized  hospital,  and 
was  beginning  to  attract  the  attention  of  students  en- 
gaged in  clinical  studies.     The  New  York  and  Belle- 


vue hospitals  were  then  the  only  hospitals  in  the  city, 
and  though  the  former  had  long  been  the  favorite  re- 
sort of  medical  students  owing  to  its  age,  the  reputa- 
tion of  its  medical  staff,  and  the  number  of  operations 
which  were  performed,  the  latter  had  the  advantage  of 
a  greater  number  of  patients  and  of  location.  Its 
surgical  staff  was  composed  of  young  surgeons  who 
were  very  ambitious  to  render  it  as  attractive  as  pos- 
sible to  students.  To  this  end  they  sought  to  multiply 
those  conditions  most  likely  to  secure  a  large  attend- 
ance, the  most  important  of  which  always  proves  to  be 

a  large  supply  of  operable  cases.      R 's  advent  and 

the  report  that  he  had  refused  amputation  at  the  New 
York  Hospital  and  thus  secured  it  to  Bellevue  were 
regarded  as  happy  auguries  for  the  future  of  the  latter 
hospital. 

It  is  quite  impossible  for  the  surgical  student  of  to- 
day to  realize  how  limited  was  the  field  of  operative 
surgery  fifty  years  ago.  Then  an  amputation  was  a 
capital  operation  and  when  advertised  to  occur  in  the 
New  York  or  Bellevue  Hospital,  it  attracted  crowds 
of  eager  students  and  practitioners.  Now  amputations 
are  for  the  most  part  relegated  to  the  house  staff  and 
the  attending  surgeon  interests  himself  in  new  and 
curious  vivisections  which  tend  more  and  more  to 
bring  human  ills  within  the  domain  of  practical  sur- 
gery. You  may  witness  durin  a  winter  session  in  the 
thirty  or  more  hospitals  of  the  city  scores  and  scores 
of  operations  of  which  the  surgeons  who  consulted  in 
the  case  before  us  had  not  the  remotest  conception. 

R informs  us  that  on  entering  Bellevue  he  was 

assigned  to  the  wards  of  Dr.  James  R.  Wood.  Dr. 
Wood  was  one  of  the  leading  surgeons  of  the  city  and 
was  especially  skilled  as  an  operator.  He  concurred 
in  the  decision  of  the  consultants  of  the  New  York 
Hospital  that  amputation  offered  the  only  chance  of 
saving  the  life  of  the  patient.  R stubbornly  re- 
fused to  submit  and  was  in  turn  discharged  from  Belle- 
vue for  refusing  to  submit  to  treatment.  At  that  time 
I  was  the  junior  surgeon  of  the  visiting  staff  and,  as 
was  the  custom  of  the  recent  graduates  of  that  period, 
was  engaged  in  teaching  private  classes  and  in  giving 
them  clinical   instruction  at  the  bedside  in  the  wards 

— true  clinical  teaching.     R states  that  while  he 

was  in  Bellevue  I  visited  a  patient  near  him  who  was 
suffering  from  a  disease  of  the  arm  which  involved 
the  question  of  amputation.  He  overheard  me  remark 
to  the  students,  "  I  should  regard  it  more  creditable 
to  save  one  arm  than  to  amputate  a  dozen."  This 
statement  greatly  impressed  him  and  he  at  once  deter- 
mined to  return  to  the  hospital  after  his  discharge,  and 
obtain  admission  to  my  wards.  He  carried  out  his 
purpose  and  entered  my  service.  It  appears  that  on 
examination  I  proposed  to  make  an  exploratory  opera- 
tion. At  the  general  consultation  which  followed,  the 
leg  was  condemned  to  amputation  by  all  of  the  sur- 
geons, but,  as  was  the  custom,  when  the  surgeon-in- 
charge  proposed  tentative  measures  he  was  allowed  to 
employ  them  at  his  discretion.  At  the  last  moment  be- 
fore taking  the  anesthetic  R directed  me  to  ampu- 
tate the  limb  if  I  believed,  on  exploration,  that  it 
could  not  be  saved.  The  first  steps  in  the  operation 
revealed  necrosis  of  the  entire  shaft  of  the  tibia  and  a 
large,  well-organized  involucrum.     This  ensheathing 


962 


MEDICAL    RECORD. 


[December  22,  1900 


bone  was  laid  open  the  whole  length  of  the  tibia,  the 
dead  shaft  was  divided  in  the  centre,  and  the  separate 
portions  were  removed.  The  recovery  was  rapid  and 
complete.  For  thirty  years  R pursued  his  trade  ac- 
tively— making  and  losing  a  fortune  during  that  time. 
Within  the  last  few  years  the  cicatrix  at  its  upper  ex- 
tremity has  opened  and  allowed  the  escape  of  small 
fragments  of  necrosed  bone,  but  he  suffered  no  incon- 
venience from  the  discharge  until  a  year  or  more  ago 
when  the  opening  began  to  enlarge  and  show  no  ten- 
dency to  heal  as  formerly.  He  then  came  under  my 
observation  again  and  on  microscopical  examination 
of  sections  of  the  surrounding  parts  of  the  ulcerating 
wound  it  was  found  that  the  granulation  tissue  was 
cancerous.  It  was  now  apparent  that  we  had  to  deal 
with  a  new  condition.  Cancer  had  developed  in  the 
ancient  cicatrix.  Prolonged  efforts  were  made  to  de- 
stroy the  new  growth  but,  while  the  external  surfaces 
assumed  a  healthy  appearance  and  partially  healed, 
the  disease  penetrated  the  bone  and,  finally,  the  shaft 
separated.  Amputation  is,  of  course,  now  the  only 
remedy,  and  it  is  an  interesting  circumstance  that, 
after  actively  using  the  once  condemned  limb  nearly 
a  third  of  a  century,  R returns  to  me  with  the  re- 
quest and  determination  that  I  shall  perform  the  opera- 
tion originally  proposed  at  two  hospitals,  but  strenu- 
ously rejected  by  him. 

The  only  interest  which  attaches  to  his  previous 
history  is  as  to  the  position  of  conservatism  in  the 
practice  of  surgery  forty  years  ago.  The  amputation 
of  a  leg  in  the  condition  of  R 's  was  regarded  pref- 
erable to  the  removal  of  the  necrosed  shaft  of  the 
tibia  because  it  was  believed  to  be  the  safer  procedure. 
Only  the  student  personally  familiar  with  the  practice 
in  one  of  these  great  hospitals  prior  to  the  introduc- 
tion of  antiseptics  can  appreciate  the  line  of  reasoning 
which  led  that  able  body  of  consultants  to  what  now 
seems  a  strange  and  inconsistent  conclusion.  I  can 
vividly  recall  the  morning  and  evening  rounds,  while 
a  member  of  the  resident  staff  of  this  hospital,  with 
pus  basin  or  pail  in  hand;  the  offensive  dressings  that 
had  to  be  removed,  the  screams  of  suffering  patients; 
the  cadaveric  faces  of  those  recently  operated  upon, 
now  slowly  passing  into  the  septicamic  or  pyaimic 
state.     The  consultants   reasoned,  as  I    recollect,   in 

this  way:  "  R is  slowly  failing  on  account  of  the 

extensive  suppuration  in  his  leg;  this  suppuration  will 
be  greatly  increased  by  the  large  wound  necessary  to 
remove  the  dead  bone;  he  will  not  survive  any  addi- 
tional exhaustion.  If,  however,  an  amputation  is  per- 
formed and  this  suppurating  mass  removed,  thus  sub- 
stituting a  fresh  and  comparatively  small  wound  which 
may  quickly  heal,  his  chances  of  recovery  will  be 
greatly  improved."  They  reasoned  correctly  from 
their  premises  that  the  real  danger  to  this  patient,  as 
in  all  surgical  cases  at  that  time,  was  suppuration,  and 
amputation  was  the  only  method  of  relief  from  this 
fatal  complication.  In  our  time  the  question  of  the 
dangers  of  suppuration  would  not  have  been  mentioned 
in  the  consultation. 

The  second  interesting  feature  of  this  case  is  the 
appearance  of  cancer  in  an  ancient  cicatrix.  This  is 
by  no  means  an  unusual  occurrence  and  is  quite  in 
accord  with  the  known  histology  of  this  disea.se. 
Cancer  always  represents  degeneracy  of  tissues,  and 
hence  is  far  more  frequent  at  the  period  of  life  when 
all  the  structures  of  the  body  are  undergoing  degenera- 
tive changes,  indicated  by  diminished  vitality.  For 
the  same  reason  cancer  appears  by  preference  in  tissues 
of  low  vitality,  whether  from  old  age  or  from  their  in- 
herent structure.  A  cicatrix  always  has  a  low  vitality 
and  belongs   to  the   degenerate   tissues  from  the  very 

nature  of   its  organization.     In  the  case  of  R we 

have  both  conditions,  viz.,  old  age  and  a  lowly  organ- 
ized tissue.     The  development  of  cancer,  therefore,  in 


this  cicatrix  was  to  have  been  expected  rather  than  to 
have  caused  surprise. 

The  treatment  is  clear  and  unmistakable.  There 
can  be  no  question  now  as  to  the  propriety  of  an 
amputation.  This  is  the  only  alternative  left  us. 
The  real  question  is,  Where  shall  be  the  point  of  elec 
tion?  We  have  the  knee  and  the  thigh  to  select  from, 
and  as  between  the  two  we  should  select  the  place 
which  will  most  certainly  protect  the  patient  from  a 
recurrence  of  the  disease  and  give  a  stump  best  adapted 
for  an  artificial  limb.  Fortunately  amputation  at  the 
knee  answers  affirmatively  both  indications.  I  pur- 
pose, therefore,  to  amputate  at  that  point.  But  owing 
to  the  extensive  cicatrix  around  the  joint  the  flaps  are 
so  poorly  nourished  that  there  will  be  great  danger  of 
sloughing  if  the  amputation  is  performed  by  the  usual 
method  of  making  a  hood-like  covering  for  the  stump. 
I  shall,  therefore,  adopt  a  procedure  which  I  devised 
in  a  case  of  senile  gangrene  due  to  extensive  atheroma 
of  the  arteries.  As  this  operation  is,  I  believe,  new 
and  well  adapted  to  feeble  or  impaired  circulation  at 
the  knee  it  may  prove  useful  to  you  hereafter  if  I  give 
the  details  of  the  original  case  and  the  reasons  which 
led  to  the  new  procedure,  together  with  the  several 
steps  of  the  operation. 

The  patient  was  a  laborer,  seventy-eight  years  old 
and  much  addicted  to  the  use  of  whiskey.  He  had 
been  suffering  upward  of  a  month  with  gangrene  of 
the  great  toe  of  the  right  foot.  He  was  greatly  emaci- 
ated, had  no  appetite,  was  extremely  feeble,  and  com- 
plained of  the  excessive  pain  in  his  toe  which  pre- 
vented sleep.  On  examination  his  arteries  were 
everywhere  rigid  with  calcification  and  the  heart's 
action  was  very  feeble  and  intermittent.  The  urine 
was  of  low  specific  gravity  and  a  small  amount  of  al- 
bumin was  found,  but  there  were  no  evidences  of 
sugar.  The  toe  was  black  to  the  second  joint  and  dry, 
but  there  was  some  swelling  of  the  foot  and  dusky 
spots  were  noticed  on  its  dorsum  and  on  the  leg  above 
the  ankle.  The  capillary  circulation  was  very  feeble, 
as  appeared  on  pressure  at  different  points  of  the  leg. 

In  his  enfeebled  condition  the  only  treatment  pos- 
sible was  directed  to  relieving  his  sufferings  from  pain 
in  the  affected  toe  and  to  nourishing  him  with  the 
most  digestible  foods.  To  meet  the  first  indication 
he  was  ordered  the  opium  and  soap  pill,  one  grain  of 
each,  and  one  pill  to  be  given  three  times  daily.  His 
diet  was  to  be  as  much  peptonized  milk  as  he  could 
be  induced  to  take  and  two  ounces  of  whiskey  every 
six  hours.  As  tonics  he  took  gr.  -g\-  of  strychnine 
three  times  daily,  and  ;  ss.  of  compound  tincture  of 
cinchona  three  times  daily.  Hot  irrigations  of  weak 
solutions  of  carbolic  acid  were  employed  at  intervals, 
and  at  other  times  cloths  wet  with  a  solution  of  the 
same  material  were  applied.  He  soon  began  to  show 
marked  signs  of  improvement.  With  the  abatement  of 
pain  he  slept  much  of  the  time,  while  the  whiskey  and 
milk  agreed  perfectly  with  his  previous  habits.  The 
heart's  action  improved,  the  pulse  becoming  full  and 
regular.  The  gangrene  slowly  extended,  the  margins 
being  moist  while  the  extremity  was  black  and  mum- 
mified. He  now  began  to  be  anxious  to  have  more 
radical  measures  employed  and  was  willing  to  submit 
to  amputation  provided  he  was  liberally  supplied  with 
stimulants. 

The  question  of  amputation  was  again  seriously 
discussed,  and  the  point  of  interest  was  to  determine 
the  place  of  election.  Surgeons  have  in  these  latter 
days  been  inclined  to  select  the  knee  joint  or  some 
point  in  the  lower  part  of  the  thigh  as  the  safest  place 
of  amputation  in  cases  of  senile  or  dry  gangrene  of 
the  toes,  and  by  some  this  election  is  regarded  as  a  de- 
parture from  the  rule  governing  the  older  surgeons. 
It  is  true,  however,  that  the  surgeons  of  half  a  century 
ago  recognized  the  importance  of  amputating  at  a  dis- 


December  22,  1900] 


MEDICAL    RECORD. 


963 


tance  from  the  seat  of  gangrene  and  often  selected  a 
point  of  healthy  tissue  between  the  ankle  and  the  knee 
joint.  It  is  also  true  that  several  American  surgeons 
preferred  amputation  at  and  above  the  knee  joint  for 
the  same  disease.  Pitney,  of  Auburn,  N.  V.,  advo- 
cated amputation  above  the  knee  joint  in  senile  gan- 
grene of  the  toes  as  early  as  1837.  Mott  was  accus- 
tomed to  advise  and  frequently  practised  amputation 
above  the  knee  in  these  cases.  Parker,  of  .Xew  York, 
also  gave  careful  instruction  in  his  lectures  as  to  the 
selection  of  a  point  above  the  knee  for  amputation  in 
dry  gangrene  of  the  foot.  More  recently  Mr.  Jonathan 
Hutchinson,  of  London,  published  a  paper  read  be- 
fore the  Medico-Chirurgical  Society  in  which  he  ad- 
vocated amputation  above  the  knee  in  gangrene  of  the 
foot  and  reported  several  cases.  He  gives  the  credit 
of  definitely  proposing  the  operation  to  James,  of 
Exeter,  but  it  had  been  frequently  performed  both  in 
this  country  and  on  the  Continent  before  that  date. 
The  operation  above  the  knee  has  attracted  attention 
in  Europe  and  Heidenhain,  Kruger,  and  others  have 
reported  favorably  upon  it.  In  this  country  Powers, 
of  Denver,  has  advocated  the  so-called  high  operation 
for  gangrene  of  the  toes  in  an  interesting  paper 
recently  published. 

Those  writers  who  have  given  their  reasons  for  pre- 
ferring the  high  operation  allege  that  it  is  impossible 
to  determine  at  what  point  the  obstruction  of  the  artery 
exists  and  that,  as  the  operation  must  be  above  that 
obstruction,  it  is  better,  as  a  matter  of  safety,  to  be 
sure  of  healthy  and  well-nourished  flaps  by  operating 
far  above  the  limits  of  gangrene.  In  my  case  the 
condition  of  the  arteries  throughout  the  leg  was  most 
unfavorable  to  amputation  at  any  point,  for  the  capil- 
lary circulation  was  everywhere  greatly  impeded. 
The  question  was,  therefore,  Where  under  the  circum- 
stances can  flaps  be  secured  having  an  adequate  blood 
supply  to  prevent  mortification?  It  was  apparent  that 
amputation  at  or  above  the  knee  by  any  previous 
method  would  not  meet  the  indications,  for  in  each  of 
these  operations  the  arteries  supplying  the  flaps  are 
liable  to  be  divided  near  their  origins. 

The  question  as  to  the  best  method  of  procedure  in 
this  case  was  decided  by  the  following  considerations: 
The  structures  about  the  knee  are  more  largely  and 
directly  supplied  by  arterial  blood  than  any  other 
tissues  of  the  leg.  The  arteries  distributed  to  the 
knee  are  (see  illustration)  the  four  articular,  the  anas- 
tomotica  magna,  the  recurrent  tibial,  the  azygos,  and 
the  sural.  If  an  amputation  at  the  knee  joint  could 
be  so  performed  as  to  save  all  these  arteries  at  their 
origins  it  is  evident  that  the  flaps  would  have  an  im- 
mense supply  of  arterial  blood.  On  reflection  the 
following  method  of  procedure  was  adopted: 

Operation:  Make  a  straight  incision,  commencing 
two  inches  above  the  upper  border  of  the  patella, 
downward  over  the  centre  of  that  bone  to  the  tuberosity 
of  the  tibia;  from  the  lower  extremity  of  this  incision 
make  two  curved  incisions,  the  convexity  of  each  be- 
ing downward,  one  toward  the  external  border  and  the 
other  toward  the  internal  border  of  the  leg;  now  join 
these  two  incisions  posteriorly  by  a  straight  incision 
across  the  upper  border  of  the  calf.  Dissect  these  two 
flaps  from  the  tibia  and  fibula,  remove  the  patella,  and 
disarticulate  the  tibia. 

The  advantage  of  the  operation  will  be  recognized 
on  referring  to  the  distribution  of  the  arteries  at  the 
knee.  It  may  be  stated  as  follows:  The  straight  in- 
cision on  the  anterior  part  of  the  knee,  which  opens 
the  joint,  divides  only  the  terminal  extremities  of  the 
articular  arteries,  thus  preserving  to  the  flaps  the  full 
amount  of  blood  which  they  normally  receive.  In  the 
other  approved  methods  of  amputating  at  the  knee 
joint  the  dissection  involves  the  division  at  their  ori- 
gins  of   several   arteries  supplying   the   flaps,  by  the 


straight  incision  on  the  posterior  part  of  the  leg  or  in 
the  ham.  Though  the  recurrent  tibial  is  divided  at  its 
origin,  yet  its  anastomosis  with  the  articular  arteries 
is  preserved  and  thus  the  capillary  circulation  is 
well  maintained  at  the  extremity  of  the  flaps.  The 
precautions  to  be  taken  are  these:  the  lateral  incisions 
from  the  lower  extremity  of  the  perpendicular  incision 
should  curve  well  forward,  the  internal  to  secure  an 
ample  flap  for  the  long  internal  condyle  of  the  femur 
and  the  external  to  include  the  branches  of  the  recur- 
rent tibial  artery. 

As  all    the  arteries  of  the   leg  were  very  brittle, 
neither  the  tourniquet  nor  Esmarch's  bandage  could 


be  safely  applied,  and  the  circulation  was  controlled 
by  gentle  pressure  with  the  fingers  on  a  large  com- 
press placed  over  the  femoral  in  its  first  part. 

The  patient  was  prepared  for  the  operation  as  I  am 
accustomed  to  prepare  the  old  or  feeble  who  are  liable 
to  collapse  during  an  operation  from  failure  of  the 
heart,  by  giving  him  one  ounce  of  whiskey  in  four 
ounces  of  hot  milk  every  two  hours,  commencing  at 
8  o'clock  A.M.  of  the  day  of  the  operation.  At  3 
o'clock  of  that  day  his  pulse  was  96  per  minute,  full, 
regular,and  slow;  his  respirations  were  22  per  min- 
ute; his  mind  was  undisturbed,  and  he  expressed  him- 
self as  glad  that  the  operation  was  to  be  performed. 
He  required  but  little  ether  and  passed  through  the 
operation  without  a  struggle,  his  pulse  remaining  at  96, 
and  respirations  at  22  per  minute.  Primary  union  of 
the  flaps  followed,  without  an  appearance  of  pus.     It 


964 


MEDICAL    RECORD. 


[December  22,  1900 


was  noticeable,  on  removal  of  pressure  on  the  artery 
at  the  groin,  that  the  Haps  resumed  a  pink  color,  show- 
ing that  the  capillary  circulation  was  fully  and  imme- 
diately restored.  In  due  time  the  patient  was  supplied 
with  an  artificial  limb  which  took  direct  bearing  upon 
the  extremity  of  the  stump  and  he  walked  with 
scarcely  a  limp,  using  only  a  cane. 


THE    NEURON 


DOCTRINE:     ITS    PRESENT 
STATUS.' 


By   CHARLES   LEWIS   ALLEN,    M.D., 

TRENTON,    N.    J., 

PATHOLOGIST   AND    ASSISTANT    PHYSICIAN,    NEW    JERSEY     STATE     HOSPITAL    AT 
TRENTON. 

While  the  name  is  of  comparatively  recent  origin, 
having  been  proposed  by  Waldeyer  in  189 1,  the  con- 
ception of  the  neuron  is  closely  connected  with  the 
development  of  the  idea  of  cell  individuality.  This, 
first  brought  forward  by  Schleiden  in  1838,  received 
a  great  impetus  through  the  adoption  of  the  cellular 
pathology  of  Virchow.  Until  the  advent  of  Deiters 
in  1865,  however,  the  relation  of  the  nerve  cell  to  the 
nerve  fibre  was  involved  in  much  confusion.  Deiters 
first  distinguished  sharply  between  the  two  kinds  of 
processes  arising  from  the  nerve  cell,  and  confirmed 
the  earlier  observation  of  Wagner  that  but  one  of  them 
was  in  direct  relation  with  a  nerve  fibre,  while  all  the 
other  processes,  separating  themselves  from  their  cell 
origin,  divided  and  subdivided  until  they  became  lost 
in  the  ground  substance  of  the  nervous  system.  To 
the  former  of  these  processes  he  gave  the  name  of  axis 
cylinder;  to  the  latter,  that  of  protoplasmic  processes, 
which  names  are  still  retained.  As  now  generally 
understood,  by  the  term  neuron  is  meant  the  nerve 
cell  and  its  processes,  the  biological  unit  of  the  ner- 
vous system. 

While  it  is  perhaps  somewhat  questionable  just  how 
far  the  term  should  be  restricted,  by  the  nerve  cell  is 
generally  meant  the  mass  of  protoplasm,  sharply  out- 
lined and  provided  with  a  nucleus,  from  which  the  two 
sets  of  processes  arise. 

Nerve  cells  differ  enormously  in  size  and  shape,  and 
their  structure  appears  differently,  depending  upon  the 
method  of  preparation  of  the  specimen.  Since  the 
modern  conception  of  the  neuron  had  its  origin  very 
largely  in  the  pictures  furnished  by  the  method  of 
metallic  impregnation,  it  will  be  well  first  to  con- 
sider briefly  the  general  appearance  of  the  nerve  cell 
and  its  processes  as  brought  out  by  its  use.  This 
method,  first  proposed  by  Golgi  in  a  number  of  com- 
munications published  between  1871  and  1885,  con- 
sists in  a  hardening  and  metallic  impregnation  by 
chromic  salts  with  silver  or  mercury.  It  has  been 
variously  modified,  and,  in  the  hands  of  Golgi  himself 
and  of  others,  has  furnished  the  most  striking  pictures. 
Among  the  numerous  workers  by  this  method  is  es- 
pecially to  be  mentioned  Santiago  Ramon  y  Cajal,  to 
whose  untiring  energy  and  to  whose  wonderful  tech- 
nique we  owe  so  much  of  our  modern  knowledge  of 
the  nervous  system.  The  method,  however,  while  it 
gives  a  sharp  and  distinct  silhouette  picture,  furnishes 
no  information  as  to  the  internal  constitution  of  the 
neuron.  Again,  while  the  cell  body  and  the  proto- 
plasmic processes  are  brought  out  at  any  age,  it  is 
possible  to  trace  out  the  axis  cylinder  only  in  the  ner- 
vous system  of  very  young  or  embryonic  animals,  since 
after  its  medullary  sheath  is  acquired  the  axon  is  not 
reached  by  the  metallic  impregnation.  When  the 
coloring-process  has  been  successfully  carried  out  the 
nerve  cells  appear  as  solid  black  bodies  without  trace 

'  Read  before  the  Mercer  County  Medical  Society,  October  y. 
1 900. 


of  structure,  varying  enormously  in  size  and  shape. 
The  protoplasmic  processes  vary  in  appearance  and  in 
number  in  different  cells,  but,  in  a  general  way,  after 
leaving  the  cell  body  they  divide  and  subdivide  much 
like  the  branches  of  a  tree;  hence  they  are  also  called 
dendrites  or  dendritic  processes.  Their  final  divi- 
sions form  a  close  meshwork  and  do  not  anastomose, 
but  end  free. 

Upon  these  processes  there  are  small  pyriform  pro- 
jections, the  gemmula;.  The  axis-cylinder  process, 
or  axon,  may  arise  directly  from  the  cell  body  or 
through  the  intermediary  of  a  protoplasmic  process. 
It  may  break  up  in  the  immediate  neighborhood  of 
the  cell,  or  may  pass  along,  giving  off  at  intervals  col- 
laterals. 

Both  the  original  process  and  its  collaterals  termi- 
nate eventually  in  an  end  brush,  which  comes  into 
close  relationship  with  either  the  branched  protoplas- 
mic processes  or  with  the  cell  body  of  another  nerve 
unit.  Here,  then,  we  have  the  conceptions  of  a  neu- 
ron:  the  nerve  cell,  its  dendrites  in  close  relationship 
to  the  end  brushes  of  axis  cylinders  or  collaterals  of 
one  or  more  other  cells,  is,  by  its  own  axon  and  collat- 
erals, brought  into  relation  with  still  other  cells, 
either  directly  or  through  the  protoplasmic  processes 
of  these  last,  connection  thus  existing  from  neuron  to 
neuron  throughout  the  nervous  system. 

Along  the  different  neurons  the  nervous  impulse  is 
transmitted.  For  example,  let  us  trace  the  course  of 
the  impulse  from  the  brain  cortex  to  the  limb  muscles. 
The  large  pyramidal  cells  of  the  motor  region  of  the 
cortex  are  related  through  their  dendrites  with  fibres 
from  different  sources.  Excited  to  discharge,  their 
impulse  is  transmitted  along  their  axons  through  the 
centrum  ovale,  internal  capsule,  and  brain  axis; 
crosses  to  the  opposite  lateral  pyramidal  tract  in  the 
lower  part  of  the  medulla,  and  proceeds  down  the 
spinal  cord — the  central  motor  neuron.  In  the  cord 
the  axons  give  off  collaterals,  and  eventually  them- 
selves pass  forward  to  break  up  around  the  large  mo- 
tor cells  in  the  anterior  horns.  These  cells  discharg- 
ing send  out  an  influence  through  their  axons  into  the 
anterior  roots  of  the  spinal  nerves,  and  thence  to  the 
muscles — the  peripheral  motor  neuron.  Impulses  from 
the  periphery  travel  by  the  posterior  roots  and  spinal 
ganglia,  to  be  transmitted  either  in  the  posterior 
columns  to  higher  levels,  or  by  fibres  or  collaterals 
which  turn  inward  and  pass  to  other  neurons  of  the 
cord,  some  of  them  being  transmitted  via  the  periph- 
eral motor  neuron  to  the  muscles,  as  in  the  common 
phenomena  of  the  reflex.  In  a  similar  manner,  an  im- 
pulse may  pass  through  a  number  of  neurons.  While 
the  protoplasmic  processes  are  usually  sharply  distin- 
guished from  the  axis-cylinder  processes  in  appear- 
ance, such  is  not  always  the  case,  and  it  may  be  diffi- 
cult to  tell  one  from  the  other. 

The  mass  of  evidence  goes  to  show  that,  under 
normal  conditions,  the  protoplasmic  processes  conduct 
only  toward  the  axons  away  from  the  cell.  As  to 
whether  tiie  relation  between  adjacent  neurons  is  one 
of  continuity  or  of  contiguity  has  always  been  dis- 
puted. Heretofore  the  evidence  has  been  almost  en- 
tirely in  favor  of  the  latter  view.  The  end  brushes  of 
the  axons  and  collaterals,  and  the  finest  ramifications 
of  the  protoplasmic  processes,  are  intimately  interlaced 
and  closely  applied  one  to  another,  but  in  no  case  has 
either  the  Golgi  method  or  yet  the  vital  niethylene- 
blue  method  shown  direct  continuity  between  them 
from  neuron  to  neuron.  The  results  of  some  methods 
more  recently  applied  will  be  considered  later. 

The  gemmuL'E  of  the  protoplasmic  processes  have 
been  thought  to  play  an  important  role  in  bringing 
about  the  relations  of  contact.  An  interesting  attempt 
has  been  made  to  account  for  certain  psychical  and 
other  processes,  notably  for  sleep  and  for  hysterical 


December  22,  1900] 


MEDICAL    RECORD. 


965 


paralyses,  by  assuming  that  the  nerve  cells  are  able  to 
retract  their  processes,  increasing  and  diminishing  the 
size  of  their  gemmula  by  a  species  of  amoeboid  move- 
ment. This  idea,  whicli  seems  to  have  been  based 
almost  entire'y  upon  theoretical  grounds,  has  never 
been  widely  accepted,  and  is  strongly  opposed  by  the 
evidence  of  recent  investigations.  As  stated  above, 
the  chrome-silver  method  gives  no  information  as  to 
the  internal  structure  of  the  neuron. 

The  ner\'e  cell  was  long  ago  studied  by  means  of 
haematcxylin,  carmin,  and  other  stains,  and  its  general 
shape  and  nucleated  structure  were  made  out,  but  our 
knowledge  of  its  finer  internal  arrangement  we  owe  al- 
most entirely  to  the  method  of  .\issl  and  its  homologues. 
This  method,  preferably  applied  to  paraffin  sections, 
consists  in  staining  by  a  solution  of  methylene  blue 
and  soap,  decolorizing  in  aniline  alcohol,  deliydrating, 
clearing,  and  mounting.  When  properly  applied,  it 
shows  the  cell  to  consist  of  a  colored  and  an  uncolored 
jxirtion.  The  stained  portion,  chromatophile  sub- 
stance, Nissl  bodies,  or  tigroid  is  variously  arranged 
in  different  cells,  but  consists  in  a  general  way  of  par- 
ticles varying  in  size  and  shape,  contained  in  the 
meshes  of  an  unstained  lattice  work. 

Within  the  last  few  years  the  study  of  the  nerve  cells 
in  normal  and  pathological  conditions  by  this  method 
has  occupied  the  attention  of  a  large  number  of 
workers,  and  much  information  has  been  obtained 
about  the  changes  subsequent  to  injuries  of  the  axon 
in  various  diseases,  and  as  an  effect  of  poisons.  Upon 
this  subject  alone  extended  monographs  have  ap- 
peared, and  space  does  not  permit  entering  upon  it 
here.  Suffice  it  to  say  that  the  changes  observed  have 
been  mainly  those  of  disappearance  or  of  alteration  of 
the  Nissl  bodies — a  chromatolysis,  and  displacement 
of  the  nucleus. 

Tlie  chromatophile  substance  extends  to  some  extent 
into  the  processes  of  the  cell,  but  it  is  impossible  by 
this  method  to  trace  these  for  any  distance.  The  con- 
sensus of  opinion  at  the  present  time  seems  to  point 
to  the  unstained  portion  as  the  functionally  active 
part  of  the  cell.  Uy  the  finer  methods  the  axon  is 
shown  to  have  a  fibriilated  structure.  The  apparent 
method  of  conduction  of  nervous  impulses  has  already 
been  discussed.  Besides  this,  the  nerve  cell,  as  is 
well  known  to  all,  appears  to  exert  a  trophic  influ- 
ence, not  only  over  its  own  processes,  but  over  mus- 
cles and  other  structures  to  which  its  axon  extends. 
It  was  shown  long  ago  by  Waller,  that  when  a  nerve 
was  cut  the  part  separated  from  its  cell  of  origin  de- 
generated. Now,  besides  this  Wallerian  degeneration, 
it  is  now  known  that  the  central  portion  of  a  cut  nerve 
also  degenerates,  and  further  that  the  cells  from  which 
its  axons  originate  show  degenerative  changes,  ex- 
plained as  being  due  to  ''  reaction  at  distance."  Hence 
it  is  evident  that  there  is  a  close  interdependence  be- 
tween the  nerve  cell  and  its  processes. 

The  study  of  degeneration  gives  very  strong  testi- 
mony in  favor  of  the  neuron  idea,  since  it  is  found  to 
be  quite  sharply  limited  to  the  cell  and  its  processes. 
Diseases  due  to  poisons  also  show  a  special  tendency 
to  be  limited  to  certain  neurons.  To  review  the  evi- 
dence in  favor  of  the  neuron  theory,  embryological 
studies  distinctly  show  the  development  of  each  nerve 
cell  and  its  processes  from  an  individual,  primitive 
cell,  the  neuroblast;  the  microscopical  anatomical 
methods,  mentioned  above,  clearly  put  in  evidence  the 
independence  of  each  neuron.  Physiology  presents 
nothing  incompatible  with  the  neuron  concept,  w-hile 
pathology  is  entirely  in  favor  of  it. 

Let  us  now  consider  the  other  side  of  the  question. 
In  order  to  do  this,  it  is  necessary  to  review  briefly 
the  researches  which  have  led  up  to  conclusions  ap- 
parently in  startling  contrast  to  those  mentioned 
above,  and  which  if  confirmed  will  compel  a  consider- 


able modification  of  our  ideas.  As  early  as  1871, 
Max  Schultze  asserted  that  both  the  axis  cylinder 
and  the  ganglion  cell  possessed  a  fibrillary  structure, 
and  even  suggested  that  the  fibrils  entered  the  cell 
through  the  protoplasmic  processes,  to  pass  directly 
into  the  axon.  Since  his  studies  were  made  on  quite 
imperfect  preparations,  and  his  conclusions  were  large- 
ly sjieculative,  we  are  struck  with  his  intuitive  genius, 
now  that  his  ideas  seem  likely  to  be  confirmed  by 
actual  specimens.  That  cells  in  other  regions  are 
connected  by  intercellular  bridges  is  admitted.  Why 
not  in  the  nervous  system  ? 

Dogiel,  after  a  series  of  investigations  upon  the  ret- 
ina— a  nervous  structure — has  affirmed  that  in  it  groups 
of  cells  of  the  same  kind  are  connected  by  a  veritable 
anastomosis  of  their  protoi^lasmic  processes.  His 
conclusions  have  been  supported  by  some,  and  dis- 
puted by  other  competent  workers  using  the  same 
method.  Recently  (1897)  Apathy,  working  with 
sp»ecially  developed  methods  upon  the  nervous  system 
of  the  leech  and  of  the  earth-worm,  has  secured  beau- 
tiful preparations,  the  study  of  which  has  brought  over 
to  his  views  a  number  of  competent  observers  to  whom 
he  has  demonstrated  them.  Apathy  is  of  the  opinion 
that  the  conducting  element  in  the  nervous  system  is 
composed  of  fine  fibrils,  the  primitive  fibrils  ("  leitende 
I'rimitiv-Fibrillen '')  which  make  up  the  axon.  Kach 
of  these  fibrils  is  made  up  of  still  finer  fibrils — the 
elementary  fibrils — and  each  forms  an  anatomically 
independent  entity.  Whence  come  these  primitive 
fibrils?  They  anastomose  and  form  a  network,  both 
within  and  around  the  nerve  cells  and  also  in  the 
muscles  and  other  structures  at  the  periphery,  forming, 
as  it  were,  an  endless  chain. 

.Apathy  divides  tiie  cells  of  the  nervous  system  into 
nerve  cells  and  ganglion  cells,  the  former  producing 
the  conducting  element,  the  fibrils;  the  latter  what  is 
to  be  conducted,  the  nervous  impulse.  He  distin- 
guishes between  sensory  and  motor  fibrils,  the  former 
being  extremely  fine,  the  latter  much  thicker,  but  few 
or  only  one  being  contained  in  a  nerve  fibre.  The 
motor  fibrils  come  direct  from  the  ganglion  cells. 
The  sensitive  nerve  fibrils  pass  into  the  nerve  cells, 
and  dividing  into  their  elementary  fibrils  form  an 
anastomosing,  intracellular  network  more  or  less  ex- 
tensive. In  other  cells  the  sensitive  fibrils  form 
equally  a  network  which  occupies  the  periphery  of  the 
cell.  From  this  network  fine  prolongations  are  given 
off,  and  these  converge  to  a  network  at  the  centre  of 
the  cell.  This  central  network  is  composed  of  coarser 
fibrils.  These  latter  unite  again  to  form  a  much 
thicker  fibril,  which  passes  out  of  the  cell  and  may  be 
traced  into  a  motor  fibre. 

The  cells  of  the  animals  examined  being  unipolar, 
their  single  processes  are  traversed  at  the  same  time  by 
both  sensory  (afferent)  and  motor  (efferent)  fibrils. 
Other  sensory  fibrils  arriving  in  the  ganglion  do  not 
proceed  directly  to  the  cells,  but  breaking  up  form  an 
extracellular  network  from  which  fine  fibrils  are  given 
off.  These  last  fibrils  passing  into  the  cells  go  to 
make  up  the  intracellular  network.  The  motor  fibrils, 
then,  do  not  arise  from  the  ganglion  cells,  but  are  di- 
rectly continuous  with  the  sensory  fibrils  through 
the  nervous  network.  The  ganglion  cells  .seem  to  be 
simply  intercalated  like  the  cells  of  an  electric  bat- 
tery in  a  circuit.  Extending  his  investigations  to  the 
spinal  cords  of  the  fish,  the  newt,  and  the  ox,  Apathy 
has  felt  justified  in  claiming  that  the  same  arrange- 
ment exists  in  vertebrates.  The  sensory  fibrils  pass- 
ing in  through  the  protoplasmic  processes  form  a 
network  occupying  the  whole  area  of  the  somatoplasm. 
Leaving  this  network,  the  elementary  fibrils  gradually 
unite  again  into  the  coarser  primitive  fibrils,  which 
leave  the  cell  by  the  axon,  which  they  make  up. 
Apathy  began  his  investigations  some  fourteen  or  fif- 


966 


MEDICAL    RECORD. 


[December  22,  1900 


teen  years  ago.  but  his  work  did  not  attract  much  at- 
tention until  recently.  Bethe,  who  had  studied 
Apathy's  preparations  at  Naples  and  had  become 
converted  to  his  views,  working  along  similar  lines 
with  a  special  technique  developed  by  himself,  has 
partly  confirmed  and  extended,  and  partly  modified 
Apathy's  deductions,  at  the  same  time  bringing  them 
widely  into  notice.  Bethe  has  studied  especially  the 
nervous  system  of  a  species  of  crab  (Carcinus  m.x-nas) 
and  has  been  able  to  demonstrate  the  nerve  fibrils 
with  astonishing  clearness.  According  to  him  the  fin- 
est ramifications  of  both  axon  and  protoplasmic  proc- 
esses anastomose  one  with  another  to  form  a  network 
so  intricate  that  it  is  impossible  to  say  which  fibrils 
belong  to  one  neuron  and  which  to  another.  Sensory 
fibrils  arriving  in  a  ganglion  divide  into  their  elemen- 
tary fibrils,  which  become  lost  in  the  nervous  network. 
Through  this  network  these  fibrils  may  be  continuous 
with  the  motor  fibrils  without  passing  through  a  cell. 
The  fibrils  observed  in  the  protoplasmic  processes  and 
axons  are  not  all  in  direct  connection  with  the  cell 
body;  only  a  few  proceed  to  the  central  protoplasm, 
the  others  pass  in  by  one  prolongation  and  out  by  an- 
other from  neuron  to  neuron.  Hence  all  the  nerve 
elements  are  in  direct  continuity,  and  if  the  neuron 
concept  implies  entire  anatomical  independence  it 
must  fall  to  the  ground. 

The  Golgi  method  he  declares  is  incomplete,  since 
it  colors  only  the  external  sheath  of  the  conducting 
element,  and  not  the  conducting  element  itself,  hence 
fails  to  show  the  connection  from  neuron  to  neuron. 
Bethe  fails  to  find  the  intracellular  network  of  Apathy, 
but  regards  the  motor  fibrils  as  arising  from  the  extra- 
cellular network.  His  statement  that  the  conducting 
fibrils  sometimes  pass  into  a  cell  by  one  protoplasmic 
process  and  out  by  another,  if  correct,  proves  that  con- 
duction in  these  processes  is  not  always  cellulipetal. 
A  close  examination  of  his  statements,  however,  shows 
that  he  does  not  say  positively  that  either  in  the  crab 
or  in  other  animals  he  has  seen  sensory  fibrils  pass 
directly  into  motor  fibrils,  but  he  assumes  that  such  is 
the  case. 

In  studying  the  nervous  system  of  the  crab  Bethe 
found  that,  in  the  ganglia  from  which  the  antenna; 
are  innervated,  the  large  motor  cells  are  situated 
around  the  periphery  of  the  ganglion.  Each  cell 
gives  off  a  process  which  passes  to  the  centre  of  the 
ganglion  and  gives  off  a  number  of  branches  there, 
then  leaves  the  ganglion  with  the  nerve  to  the  per- 
ipheral muscles.  The  centre  of  the  ganglion  is  entire- 
ly occupied  by  a  network  of  fibrils,  the  neuropile 
formed  of  these  motor  fibrils  and  of  sensory  fibrils 
coming  from  the  periphery.  Choosing  the  ganglion 
connected  with  the  second  antenna,  he,  by  a  series  of 
cuts,  separated  the  motor  cells  at  the  periphery.  He 
found  that,  after  the  animal  had  recovered  from  the 
shock  of  the  operation,  it  could  move  the  antenna  in 
question.  Tonus  was  preserved,  and  reflexes  occurred 
as  usual,  except  for  slight  exaggeration.  This  per- 
sisted for  several  days,  and  then  the  antenna  slowly 
became  paralyzed.  If,  on  the  contrary,  the  motor 
nerve  to  the  antenna  was  cut,  paralysis  of  the  latter 
was  immediate  and  complete.  This  experiment  would 
seem  to  show  that  the  tonus  and  reflexes  are  indepen 
dent  of  the  nerve  cells  and  can  occur  directly  through 
the  intermediary  of  the  neuropile.  That  the  influence 
of  the  nerve  cell  is  not  indispensable,  however,  is  evi- 
denced by  the  occurrence  of  paralysis  after  a  certain 
period. 

The  views  of  Apathy  and  of  Bethe  have  found  both 
supporters  and  opponents  among  those  equally  quali- 
fied to  form  an  opinion.  It  is  claimed  by  Held  that 
the  extracellular  network  of  Apathy  is  non-nervous  in 
character.  Bethe's  physiological  experiment  has  been 
objected  to  on  the  ground  that  he  failed  to  remove  all 


of  the  acti\e  part  of  the  ganglion  cells,  enough  being 
left  to  furnish  the  nervous  impulse.  It  is  impossible 
to  dispute  the  presence  of  the  intracellular  network, 
say  those  who  have  examined  the  preparations  of 
Apathy,  and  his  drawings  are  but  a  faithful  represen- 
tation of  his  specimens.  The  preparations  of  liethe  are 
said  to  show  the  neuro-fibrils  with  a  clearness  which  is 
"stupefying.'"  Now,  according  to  Bethe,  these  fibrils 
traverse  the  body  of  the  cell,  but  neither  branch  nor 
anastomose  there.  Here,  then,  is  a  discrepancy  be- 
tween the  two  observers.  No  one  else  seems  so  far  to 
have  been  able  to  obtain  preparations  comparable  to 
those  of  either  Apathy  or  Bethe.  Their  methods  evi- 
dently require  skill  and  experience  in  a  high  degree. 
Nissl,  in  an  article  which  has  attracted  a  good  deal  of 
attention,  rather  contemptuously  thrusts  aside  the  neu- 
ron theory  as  utterly  discredited.  He  is  evidently  no 
friend  of  the  Golgi  method,  and  says  with  regard  to  it: 
"  By  it  it  is  impossible  to  say  what  is  blackened  and  what 
is  not."  He  recognizes  the  existence  of  the  neuro- 
fibrils, and  says  that  Bethe's  method  colors  the  part  of 
the  cell  left  uncolored  in  his  (Nissl's)  method.  This 
he  regards  as  the  functionally  active  portion  of  the 
cell,  consisting  in  part  of  the  fibrils.  The  active  ele- 
ments of  the  nervous  system,  he  thinks,  are  the  nerve 
cells,  and  an  intercellular  gray  matter  which  probably 
consists  in  part  of  the  neuro-fibrils,  but  of  whose  ori- 
gin and  of  whose  exact  constitution  he  confesses 
ignorance.  The  whole  article  seems  largely  hypothe- 
tical, and  cannot  be  said  to  give  any  new  facts.  Balanc- 
ing the  evidence  for  and  against,  as  it  exists  at  the 
present,  what  conclusions  are  we  justified  in  drawing.^ 
To  recapitulate:  It  has  long  been  known  that  an 
injury  to  nerve  cell  or  nerve  fibre  is  followed  by  de- 
generation which  is  siiarply  limited  in  extent.  The 
application  of  the  Golgi  method  shows  that  each  nerve 
cell  (and  its  processes)  is  developed  from  a  primi- 
tive cell,  the  neuroblast ;  hence  it  forms  an  embryologi- 
cal  unit.  Moreover  to  all  appearance  the  separation 
of  these  units,  one  from  another,  always  remains  com- 
plete. The  neuron  conception  appears  logically  to 
follow.  So  far,  it  seems  no  more  proven  that  the 
Golgi  and  vital  methylene-blue  methods  give  decep- 
tive results,  than  that  the  methods  of  Apathy  and  of 
Bethe  do.  The  latter  have  had  nothing  like  so  wide 
an  application  as  the  former,  and  more  extended  in- 
vestigations seem  to  be  needed  before  we  throw  ap- 
parently so  faithful  a  servant  overboard.  There 
seems  a  good  deal  of  difference  in  the  conceptions  of 
different  authors  as  to  just  what  the  neuron  means. 
It  will  be  remembered  that  the  idea  of  continuity  be- 
tween neuron  and  neuron  has  never  been  without 
supporters.  Even  if  the  views  of  Apathy  are  con- 
firmed, and  we  have  to  admit  a  continuity  of  the 
neuro-fibrils,  it  does  not  seem  to  follow,  necessarily, 
that  we  must  abandon  our  idea  of  the  neuron  as  a 
functional  unit.  Its  embryological  unity  is  not  af- 
fected. It  may  be  necessary  to  modify  our  views  with 
regard  to  it,  but  our  conception  of  the  existence  of  the 
neuron,  as  a  means  of  explaining  certain  facts,  we  are 
as  yet  hardly  called  upon  to  give  up.  Preserving  an 
entirely  impartial  attitude  we  can  only  await  the  re- 
sults of  further  investigations. 


Scanty  Amniotic  Fluid  as  a  Factor  in  Prociden- 
tia of  the  Cord  and  Foetal  Disorders.  — I  m  peri  ale 
I'astore  reports  a  case  in  which  a  deficient  amount  of 
amniotic  fluid  induced  prolapse  of  the  cord,  the  pre- 
disposing cause  being  a  deformed  pelvis.  Fcetal  dis- 
orders in  such  a  case  when  the  membranes  are  intact 
may  be  due  to  pressure  exerted  upon  the  funis  and 
compression  of  the  head  or,  during  labor,  to  the  un- 
equal pressure  of  the  tumor  upon  the  prolapsed  cord. 
— La  Kijorma  Medica,  November  10,  1900. 


December  22,  1900] 


MEDICAL    RECORD. 


967 


A  FFAV  REMARKS  ON  THE  USE  OF  MED- 
ULLARY NARCOSIS  IN  OBSTETRICAL 
CASES. 

By    HUGO    EHRENFEST,     M.D.. 

ST.    l.Ol'IS,    MO. 

Among  the  numerous  reports  concerning  the  use  of 
medullary  narcosis  we  find  comparatively  few  dealing 
with  the  employment  of  this  new  method  in  obstetrical 
practice.  But  it  is  almost  certain  that  the  encourag- 
ing reports  of  Marx'  will  induce  many  physicians  to 
try  this  method. 

A  careful  study  of  all  articles  that  I  have  been  en- 
abled to  collect  creates  the  doubt  in  my  mind,  whether 
we  are  yet  justified  in  recommending  the  subarach- 
noideal  injections  of  cocaine  to  the  obstetrician  for 
general  use.  The  reports,  as  published  in  nearly  every 
number  of  American  journals  with  reference  to  the  use 
of  this  method,  seem  to  place  special  weight  on  the 
more  or  less  dangerous  symptoms  following  the  use  of 
the  injections.  The  only  scientific  value  of  such  pub- 
lications will  be  to  gather  material  for  statistics  of 
morbidity  and  mortality.  Should  the  percentage  of 
unfavorable  cases'  be  found  high,  medullary  anres- 
thesia  will  disappear  as  have  other  forms  of  narcosis 
which,  after  their  discovery,  were  lauded  as  ideal.  But 
it  occurs  to  me  that  the  accounts  of  the  use  of  this 
method  in  obstetrics.should  not  be  limited  to  describ- 
ing the  dangerous  symptoms  in  mother  and  child.  To 
my  mind  these  cases  offer  a  special  opportunity  for 
estimating  the  value  of  this  new  method  from  other 
points  of  view. 

The  two  main  indications  for  the  employment  of 
subarachnoideal  injections  of  cocaine  in  obstetrical 
cases  are,  first,  to  produce  a  painless  labor  in  normal 
cases,  and,  secondly,  to  substitute  this  method  for 
other  forms  of  narcosis  when  such  is  deemed  neces- 
sary. To  produce  painless  labor  seems  to  have  been 
the  predominant  idea  in  the  experiments  so  far  made. 
Dole'ris  and  Malarctic^  concede  this  as  their  object. 
Marx'  says:  "  But  at  last,  so  far  as  we  are  concerned, 
it  is  a  method  ideally  suited  to  mitigate  or  absolutely 
allay  the  dreadful  pains  of  a  normal  labor." 

To  accomplish  such  a  purpose,  however,  according 
to  my  opinion,  we  must  make  use  only  of  a  method — 
(1)  which  does  not  carry  with  it  too  great  a  danger  for 
either  mother  or  child,  (2)  which  does  not  produce 
conditions  more  disagreeable  than  the  pain  that  we 
are  endeavoring  to  assuage,  and  (3)  which  does  not 
produce  complications  during  parturition,  i.e.,  does  not 
change  a  birth,  which  under  ordinary  circumstances 
would  be  normal,  into  instrumental  delivery.  In  ref- 
erence to  these  three  points  I  would  like  to  make  the 
following  comments: 

I.  No  one  should  at  present  state  that  medullary 
narcosis  is  a  harmless  procedure.  An  exact  opinion 
with  reference  to  this  point  can  be  arrived  at  only 
after  the  above-mentioned  statistics  of  morbidity  and 
mortality  are  established.  2.  All  reports  tell  of  dis- 
agreeable symptoms  following  these  injections,  viz., 
vomiting,  intense  headache,  etc.,  sometimes  lasting 
longer  than  after  the  usual  chloroform  or  ether  narcosis. 
Cases  of  immediate  high  elevation  of  temperature 
with  deep  collapse  are  on  record: '  such  a  great  risk, 
indeed,  does  a  woman  take  in  exchange  for  labor  pain. 
3.  This  point  is  by  far  the  most  important,  and  neces- 

'  Philadelphia  Medical  Journal,  November  3,  1900. 

"  One  fatal  ease  is  reported  by  Tuffier  (Intern.  Congress,  Paris, 
1900),  another  by  F.  Dumont  (Correspondenzbl.  f.  Schweizer 
Aerzte,  igoo,  No.  19). 

'Session  of  July  14,  1900,  of  the  Academic  de  .Medecine  in 
Paris. 

^  ^[EDICAL  Record,  October  6,  igoo. 

'  See  the  reports  of  Professor  Bier  and  Doctor  Engelmann 
of  experiments  made  on  themselves  (Munchener  medicinische 
Wochenschrift,  1900,  September  4th  and  October  30th). 


sitates  a  further  discussion.  Most  of  the  authors 
(Kreis,  Doleris,  Malarctic.  Marx)  state  that  the  uter- 
ine contractions  were  observed  during  the  anxsthesia. 
According  to  their  observations  there  seems  to  be  no 
change  in  their  frequency,  but  of  course  whether  their 
active  power  is  of  the  same  value  during  the  anses- 
thesia  remains  to  be  determined.  One  thing,  how- 
ever, is  positive — the  active  help  of  the  abdominal 
muscles  is  lacking.  Naturally,  the  patient  can  bear 
down  when  asked  to,  or  when  she  herself  is  so  in- 
clined, as  strongly  as  under  normal  conditions,  but  as 
a  consequence  of  the  painlessness  the  reflex  action  is 
not  brought  on,  which  causes  the  automatic  help  of  the 
abdominal  muscles,  nor  is  the  woman  able  to  bear 
down  synchronously  with  the  uterine  contractions, 
since  she  does  not  feel  them.  From  our  knowledge, 
based  on  modern  views  of  the  great  importance  of  ab- 
dominal pressure  in  the  last  stage  of  labor,  we  should 
consider  its  loss  to  be  a  very  decided  disadvantage. 

Schroeder  was  the  pioneer  in  demonstrating  by 
clinical  studies  the  necessity  of  the  help  of  the  abdom- 
inal muscles  in  the  expression  of  the  ftttus.  At  the 
present  time  his  opinion  is  generally  accepted  and  is 
to  be  found  in  the  principal  text-books. 

Olshausen  and  Veit '  say:  "When  the  delivery  ap- 
proaches its  close,  and  when  especially  this  termina- 
tion is  a  difficult  one,  then  tiie  abdominal  pressure  be- 
comes more  important,  while  the  effect  of  the  uterine 
contractions  becomes  less."  On  page  587  we  find  the 
following  statement:  "Complete  deficiency  of  abdom- 
inal pressure  during  the  expulsive  stage  is  fortunately 
v&ry  rare.  There  are  only  a  few  records  of  deliveries 
in  cases  of  paralysis  of  the  lower  part  of  the  body. 
But  in  these  cases  the  second  stage  of  parturition 
seemed  to  be  very  much  delayed."  Probably  in  those 
cases  the  paralyzed  perineal  muscles  offered  less  re- 
sistance to  the  child's  head.  This  advantage  is  lack- 
ing in  medullary  narcosis. 

Ahlfeld"  expresses  the  following  opinion:  "  During 
the  last  (second)  stage  of  parturition  we  can  only  con- 
sider the  effect  of  the  abdominal  pressure,  the  influ- 
ence of  the  uterine  contractions  being  very  inferior  to 
it."  "A  primary  inability  to  use  the  abdominal  mus- 
cles is  rare,  but  even  in  entirely  healthy  parturients 
the  inactivity  of  these  muscles  sometimes  disturbs  the 
normal  course  of  labor  to  a  very  marked  degree." 

Schatz  and  I'ouUet  endeavored  to  measure  the  ab- 
dominal pressure  by  means  of  a  manometer,  and  demon- 
strated the  fact  that  during  the  expulsive  stage  the 
pressure  produced  by  the  abdominal  muscles  is  nearly 
as  great  as  that  of  the  uterine  contractions. 

Galabin'  says:  "The  effect  of  the  auxiliary  muscles 
is  therefore  to  add  to  each  of  the  resultant  forces  al- 
ready mentioned.  It  has  also  another  influence  of 
great  practical  value,  namely,  that  it  tends  to  press 
the  uterus,  as  a  whole,  toward  the  pelvis.  This  lakes 
off  the  tension  placed  by  the  uterine  contractions  on 
that  lower  distensible  uterine  segment,  which  ...  is 
the  part  of  the  uterus  most  liable  to  rupture.  Thus 
the  tendency  to  rupture  of  the  uterus  is  resisted  by  an 
efficient  action  of  the  auxiliary  muscles,  and  is  more 
likely  to  occur  if  the  abdominal  walls  are  weak- 
ened." 

In  Hirst's  "System  of  Obstetrics"  (Philadelphia, 
1888)  Barvin  in  his  work'  says:  "These  [abdominal] 
contractions  are  chiefly  voluntary,  only  at  the  close  of 
the  second  stage  of  labor  do  they  seem  to  escape  en- 
tirely, or  almost  entirely,  the  dominion  of  the  will. 
Such  contractions  exerted  during  the  first  stage  of 
labor,  and  usually  in  the  second  stage,  if  not  syn- 
chronous with  uterine  action,  are  worse  than  useless." 

'  "  Lehrbuch  der  Geburtshilfe,"  1899,  p.  173. 
'  "  Lehrbuch  der  Geburtshilfe."  1898.  p.  122. 
'  "  Manual  of  Midwifer)',"  London,  1897,  p.  167. 
■•  "  Anomalies  of  the  Forces  in  Labor,"  p.  702. 


968 


MEDICAL    RECORD. 


[December  22,  1900 


I  could  recall  easily  a  larger  number  of  opinions  of 
well-known  autfiors,  all  expressing  the  same  idea  on 
this  subject.  By  studying  the  histories  of  the  obstet- 
rical cases  in  which  medullary  anaesthesia  was  em- 
ployed the  correctness  of  these  views,  to  my  mind  at 
least,  seems  to  be  proven.  I  have  taken  into  consid- 
eration only  those  cases  in  which  there  exist  tolerably 
exact  histories,  viz.,  tiie  six  cases  of  Kreis'  and 
twenty-three  cases  of  Marx.-  Out  of  the  six  cases  of 
Kreis  it  was  necessary  to  finish  three  by  means  of 
forceps.  The  causes  assigned  were :  in  one  case  ex- 
haustion of  the  mother  and  insufficiency  of  the  labor; 
in  the  second,  symptoms  of  asphyxia  of  the  foetus ;  while 
in  the  third  no  cause  is  mentioned.  Among  the 
twenty-three  cases  of  Marx  there  were  twenty-one  cases 
of  labor.  Of  these  it  was  necessary  to  apply  forceps 
in  seven  cases.  Unfortunately,  the  indications  for 
this  procedure  are  not  mentioned.  However,  it  is 
worthy  of  note  that  the  three  operative  cases  of  Kreis 
and  these  seven  of  Marx  were  in  primiparae.  The  non- 
elasticity  of  the  perineum — as  characteristic  of  primi- 
paraj— may  have  made  the  last  stage  of  confinement 
more  tedious,  the  abdominal  pressure  not  exerting  a 
helping  influence.  Of  the  subsequent  nineteen  deliv- 
eries in  which  medullary  narcosis  was  employed  by 
Marx,"  in  nine  were  forceps  used.  Naturally,  as  we 
have  no  data  giving  in  detail  the  indications  for  the 
use  of  instruments  in  each  case,  we  are  at  a  loss  to 
draw  correct  conclusions.  At  any  rate,  the  remarkably 
high  percentage  of  forceps  deliveries  is  very  striking, 
particularly  when  there  was  no  note  of  any  abnormal- 
ities of  either  the  pelvis  or  the  child.  At  least  it  Is 
supposed  that  none  existed,  as  otherwise  they  would 
have  been  reported  in  the  histories. 

According  to  my  view  it  is  very  necessary  in  future 
descriptions  of  confinements  under  medullary  narcosis, 
in  which  obstetrical  operations  have  to  be  performed, 
to  give  exact  details  of  the  indication  of  each  opera- 
tion, to  remark  all  a.bnormalities  in  the  course  of  con- 
finement, such  as  marked  delay  during  the  expulsive 
stage,  excessive  stretching  of  the  lower  segment  of  the 
uterus,  rupture  of  the  uterus,  etc.  It  is  also  indis- 
pensable to  measure  the  diameters  of  the  pelvis  and 
child's  head,  to  describe  the  forms  of  both,  and  to  make 
note  of  all  abnormalities  if  they  exist. 

Should  we,  however,  prove  that  the  parturition  is  in 
nowise  harmed  by  medullary  anesthesia,  such  a  dis- 
covery would  be  of  the  greatest  scientific  interest, 
forcing  us,  as  it  would,  to  change  our  opinion  with 
regard  to  the  value  and  importance  of  abdominal  press- 
ure. 

On  the  other  hand,  should  we  find  out  that  we  are 
compelled  to  make  use  of  the  forceps  more  often  than 
under  the  usual  conditions,  as  a  consequence  of  the 
deficiency  of  a  normal  automatic  help  of  the  abdomi- 
nal muscles,  this  condition  alone  would  contraindicate 
the  use  of  medullary  narcosis  as  a  means  of  making  a 
normal  labor  painless.  Notwithstanding  the  best  anti- 
and  asepsis,  subsequent  puerperal  or  gynaecological 
diseases  are  invariably  more  frequent  after  delivery 
by  operative  procedures.' 

The  second  indication  for  the  use  of  cocaine  anres- 
thesia  of  the  spinal  cord,  as  before  mentioned,  is  as  a 
substitute  for  other  narcosis  in  cases  in  which  such  a 
procedure  becomes  necessary  either  for  purposes  of 
examination  or  operative  work.  In  regard  to  this  in- 
dication the  remarks  I  made  in  discussing  points  i 
and  2  (danger  to  the  patients  and  disagreeable  symp- 
toms) are  to  be  taken  into  consideration.  I  would  add 
to  those  only  the  statement  of  Marx,  in  which  he  says: 

'  Centralbl.  flir  Gynakologie,  July  14,  rgoo. 
''  "  Medic/u.  Record,  October  6,  igoo. 

'See   the    table   in   Philadelphia   Medical  Journal,    Xovember 
10,  1900. 
■•SeeEhrenfest:  St.  Louis  Medical  Review,  September  22,  iqoo. 


"  Explorations,  versions,  extractions,  placental  removal, 
were  readily  done  not  with  quite  as  great  ease  as  under 
chloroform." 

In  the  event  that  future  work  along  this  line  estab- 
lishes the  fact  that  subarachnoideal  injections  of  co- 
caine are  free  from  danger,  they  may  add  some  advan- 
tages in  cases  in  which  heart  failure,  nephritis,  etc., 
contraindicate  the  use  of  chloroform  or  ether.  In 
country  practice  it  might  prove  profitable,  as  one  as- 
sistant— the  aneesthetist — could  be  spared  (Kreis). 
So,  in  conclusion,  it  seems  to  me  more  than  doubtful 
whether  we  are  justified  at  the  present  time  in  rec- 
ommending medullary  narcosis  as  a  means  of  ren- 
dering normal  labor  painless  or  as  a  substitute  for 
light  chloroform  narcosis,  which  is  always  sufficient 
for  the  usual  obstetrical  operations. 

3301    LUCUS   AVENI-E. 


PERFORATION  OF  A  TYPHOID  ULCER 
WITHOUT  F/ECAL  EXTRAVASATION  ; 
OPERATION  FOUR  HOURS  AFTER  THE 
FIRST    SYMPTOM;    RECOVERY. 

By   E.    G.    cutler,    M.D., 

PHYSICIAN     TO    THE    MASSACHUSETTS    GENERAL   HOSPITAL, 
AND 

JOHN    W.    ELLIOT,    M.D., 

SURGEON    TO    THE    MASSACHUSETTS    GENERAL    HOSPITAL, 

Without  discussing  the  comparative  merits  of  the 
terms  "  pre-perforative  stage"  (Cushing),  "  pre-per- 
forative  necrotic  area"  (Cobb;,  perforation  without 
extravasation,  etc.;  they  all  describe  the  all-import- 
ant moment  for  operating  on  a  typhoid  ulcer.  We 
early  learned  in  appendicitis  that  the  peritoneum  was 
often  infected  before  the  appendix  was  perforated  and 
we  now  know  that  the  same  thing  is  true  in  a  typhoid 
ulcer.  The  mortality  of  these  operations  will  depend 
largely  on  the  extent  of  the  septic  peritonitis  present 
at  the  time  of  the  operation.  If  we  could  more  often 
make  sure  that  an  ulcer  was  about  to  perforate  or  was 
slowly  infecting  the  peritoneum  our  results  would  be 
much  improved.  This  single  case  is  offered  then  as 
one  of  a  few  already  observed  in  which  the  early 
symptoms  were  sufficiently  well  marked  to  induce  the 
physician  in  charge  to  operate  before  an  opening  in 
the  intestine  had  actually  occurred. 

C.  S ,  worker  in  a  woollen  mill,  nineteen  years 

of  age,  single,  a  native  of  Italy,  lives  in  Lawrence, 
Mass.  He  entered  the  Massachusetts  General  Hos- 
pital, March  9.  1899,  for  treatment  of  acute  enteritis, 
and  was  discharged  March  14th,  much  relieved. 
The  family  history  was  good;  he  occasionally  used  al- 
cohol, but  his  habits  were  otherwise  good;  his  personal 
history  was  negative,  he  denied  having  had  venereal 
disease.     Heenteredthe  hospital  again.  May  31,  1899. 

Present  illness:  Since  leaving  the  hospital  he  had 
been  well  until  about  one  week  ago  when  he  became 
feverish  (no  chill),  had  headache  and  loss  of  appetite. 
He  vomited  three  times  the  day  before  admission,  but 
not  before  or  since.  He  had  no  cough  at  first,  but  has 
a  slight  cough  now;  there  is  no  pain  anywhere,  he  has 
had  no  nose  bleed,  and  the  bowels  are  constipated. 
The  patient  had  not  been  in  bed  until  the  day  before 
admission. 

The  patient  was  well  developed  and  nourished, 
swarthy;  liis  face  was  slightly  flushed,  the  skin  was 
hot  and  dry,  the  pupils  and  reflexes  were  normal; 
there  were  no  enlarged  glands;  the  teeth  were  fair 
but  dirty;  the  tongue  was  dry  and  coated;  the  pulse 
was  regular,  of  fair  volume,  dicrotic,  and  moderately 
compressible;  the  lungs  were  normal;  the  heart  area 
was  not  increased;  the  apex  beat  was  felt  in  the  fifth 
interspace  three-quarters  of  an  inch  inside  the  nijjple 


December  22,  1900] 


MEDICAL    RECORD. 


969 


line;  the  second  sound  was  sliarp;  the  pulmonary 
second  sound  was  not  increased;  the  first  sound  was 
reduplicated.  The  liver  was  not  enlarged;  the  spleen 
was  enlarged  to  the  costal  margin.  There  were  one  or 
two  rose  spots  on  the  chest;  the  abdomen  was  slightly 
distended  and  tympanitic  but  not  tender.  The  blood 
count  showed  white  corpuscles  7,600;  U'idal's  reaction 
was  absent;  the  urine  was  high  colored,  acid.  1,028 
specific  gravity;  there  was  a  slight  sediment;  of  al- 
bumin there  was  the  slightest  possible  trace;  sugar 
was  absent;  chlorides  were  normal;  cliazo  reaction 
was  absent;  an  occasional  small  round  cell  and  an 
abnormal  blood  globule  were  found;  there  were  fairly 
many  leucocytes;  an  occasional  squamous  cell,  and 
large  round  cells  like  those  of  the  neck  of  the  bladder; 
no  casts  were  seen.  The  patient  was  put  upon  liquid 
enteric  diet;  baths  were  given  according  to  schedule; 
special  precautions  were  taken. 

On  June  0th  the  man  was  reported  about  5  a.m.  for 
pain  in  abdomen.  He  had  a  pinched  e.\pression. 
The  abdomen  was  rigid,  more  in  the  right  lower 
quadrant,  slightly  tympanitic;  there  was  general  ten- 
derness, mora  marked  in  the  right  lower  quadrant. 
A  high  soap-suds  enema  was  given  with  turpentine 
one  teaspoonful,  and  a  turpentine  stupe  was  applied. 
The  patient  had  a  large  dejection  about  6  a.m.  He 
was  reported  again  at  6:45  for  severe  pain  and  vomit- 
ing; vomiius  was  of  food  only.  Liquid  Dover's 
powder,  ^^.  x.,  was  given.  At  7  :4s  the  patient  was 
still  in  considerable  pain.  He  lay  on  the  left  side 
with  knees  licxed.  The  countenance  was  anxious  and 
there  was  an  evident  expression  of  severe  suffering. 
The  face  was  somewhat  whiter  than  usual  but  not 
markedly  pale.  The  pulse  had  risen  from  90  to  120 
per  minute,  with  but  little  or  no  alteration  in  volume. 
There  was  no  fall  in  temperature.  The  abdomen  was 
generally  rigid  but  more  so  in  the  right  lower  quadrant ; 
the  tenderness  was  general  but  most  marked  o\er  this 
area;  the  abdomen  was  slightly  tympanitic  as  before. 
The  white  corpuscles  numbered  17,200.  The  U'idal 
reaction  was  present  in  twenty-five  minutes.  The  pa- 
tient was  seen  about  9  a.m.  by  Dr.  Elliot,  who  con- 
curred in  the  diagnosis  of  perforation  of  the  intestine, 
and  the  patient  was  transferred  at  once  to  the  surgical 
side.  E.  G.  C 

Dr.  Elliot  found  that  the  patient,  in  the  third  week 
f  typhoid  fever,  had  been  attacked  with  a  sudden 
severe  abdominal  pain  four  hours  earlier.  He  was 
still  suffering  greatly  in  spite  of  a  small  opiate.  The 
abdomen  w^as  moderately  distended,  rigid,  and  tympa- 
nitic. There  was  no  dulness  and  nothing  abnormal 
could  be  detected  by  palpation  except  a  general  tender- 
ness. The  white  blood  count  had  risen  from  S,ooo  the 
day  before  to  17,000.  Pulse,  110;  temperature,  103.8°. 
The  patient  had  the  expression  of  a  very  sick  man. 
It  seemed  quite  evident  hat  an  acute  peritonitis  was 
beginning  and  the  perfor  tion  of  a  typhoid  ulc:r  was 
considered  to  be  the  most  likely  cause,  although  an 
acute  inflammation  of  the  gall  bladder  w-as  considered 
a  possible  cause.  A  laparotomy  was  done  at  once. 
When  the  abdomen  was  opened  in  the  median  line  the 
peritoneal  cavity  was  found  filled  with  a  turbid  fluid 
containing  white  fibrinous  flakes.  The  intestines  were 
darkly  reddened  and  congested.  Several  adherent 
patches  of  greenish-white  fibrinous  exudation  were 
seen  on  the  intestines.  The  intestines  were  not  glued 
together.  The  picture  w-as  that  of  a  general  septic 
peritonitis  which  was  most  acute  in  the  neighborhood 
of  a  certain  part  of  the  small  intestine.  The  carcum 
presented  and  the  appendix  was  found  to  be  normal. 
The  ascending  colon  was  withdrawn  and  examined; 
the  ileum  was  next  traced  upward  from  the  cabcuni. 
The  ileum  was  more  reddened  than  the  colon  and  about 
four  feet  from  the  caecum  a  gray  fibrinous  mass  covered 
the  surface  of    the  gut.     This  coil  of   intestine  was 


withdrawn  from  the  wound  and  surrounded  with  gauze. 
On  the  side  opposite  the  mesentery  an  ulceration  was 
plainly  to  be  seen,  the  centre  of  which  was  just  ready 
to  slough  out.  It  was  difficult  to  know  how  much 
leakage  had  taken  place  and  gentle  pressure  failed 
to  force  the  fa;ces  through.  The  ulcer  appeared  as  an 
indurated  area  about  as  large  as  a  quarter  of  a  dollar, 
which  was  deep  red  in  color  and  in  the  centre  of  which 
was  a  gray  crater  the  size  of  a  pea,  which  had  lost  its 
peritoneal  covering  and  looked  very  friable  and  dis- 
organized. The  mucous  membrane  of  the  bowel  was 
not  seen  and  it  was  not  considered  wise  to  probe  the 
opening,  but  it  was  quite  evident  that  some  of  the  in- 
fectious contents  of  the  intestine  had  passed  through 
to  give  rise  to  the  general  peritonitis.  Other  small 
patches  of  fibrin  were  seen  on  the  bowel  in  the  region, 
but  no  other  ulceration  was  found, 

Lembert  silk  sutures  were  so  placed  as  to  fold  the 
gut  longitudinally  over  the  perforation,  a  second  layer 
of  sutures  being  placed  to  cover  in  the  first  series. 
The  abdomen  was  very  carefully  wiped  out  with  gauze 
sponges;  the  patient  being  first  raised  to  a  sitting 
posture  to  cause  the  turbid  Huid  to  flow  into  the  pelvis. 
The  patient  was  then  placed  in  the  Trendelenburg 
position  and  the  pelvis  wiped  out  with  great  care. 
There  was  no  irrigation  of  the  abdomen.  The  wound 
was  closed,  leaving  a  small  thread  of  gauze  drainage 
at  the  lower  angle  leading  down  to  the  line  of  sutures. 

The  patient  was  not  in  a  critical  condition  after 
the  operation,  but  bore  it  fairly  well,  considering  the 
general  typhoidal  condition.  Pulse,  120;  tempera- 
ture, 104.5"  that  night.  On  the  following  morning 
the  temperature  was  normal  and  pulse  90.  On  tiie 
third  day  the  bowels  were  moved  by  an  enema,  and 
on  the  fourth  day  the  gauze  drainage  was  removed. 
The  wound  healed  by  first  intention.  The  patient 
was  generally  comfortable  without  opiates  and  com- 
plained only  of  hunger.  He  was  given  liquid  diet 
with  large  nutritive  enemata,  but  on  the  sixth  day  he 
was  allowed  soft-boiled  e^s  and  a  larger  quantity  of 
liquids.  On  the  eighth  day  his  temperature  rose  to 
104.8  .  As  there  seemed  to  be  a  relapse  in  his  typhoid, 
he  was  then  transferretl  back  to  the  medical  wards 
where  he  again  came  under  Dr.  Cutler's  care. 

J.  VV.   E. 

June  15th:  Relapse  began  on  the  13th. 

P^xamination  shows  the  abdomen  considerably  dis- 
tended, rigid,  and  tympanitic,  not  tender.  The  spleen, 
increased  to  costal  margin,  was  not  palpable.  The 
wound  was  healed,  and  covered  with  collodion  dress- 
ing. The  pulse  was  regular,  of  fair  volume,  rather 
easily  compressible,  and  dicrotic.  The  tongue  was 
dry  and  coated.  White  corpuscles  7,000.  A  few  rose 
spots  on  abdomen.  P'or  the  next  twelve  days  the  pa- 
tient was  fairly  ill  with  his  relapse,  when  there  was 
lysis  and  an  uneventful  convalescence  followed. 

The  patient  now,  on  January  8,  1900,  reports  him- 
self as  perfectly  well  in  every  way.  E.  G.  C. 


Bacteriological  Examination  of  the  Blood  in 
Pneumonia — A.  Prochaska  attributes  the  conflicting 
results  reported  by  different  investigators  who  have 
studied  this  subject  to  the  fact  that  insufficient  quan- 
tities of  blood  have  been  taken  for  the  purpose.  In 
using  small  amounts  he  himself  obtained  very  irregu- 
lar figures,  but  on  taking  the  material  directly  from  a 
vein  and  adding  4-5  c.c.  to  bouillon  positive  results 
were  noted  in  every  one  of  ten  cases  examined.  These 
were  chosen  indiscriminately,  without  regard  to  the  se- 
verity of  infection,  and  four  presented  complications 
such  as  empyema,  acute  nephritis,  and  gangrene  of  the 
lung.  In  every  instance  pure  cultures  were  obtained 
at  the  first  sowing. —  Ceiilralblatt /iir  innere  Aledicin, 
November  17,  1900. 


97  o 


MEDICAL    RECORD. 


[December  22,  1900 


ON     THE     TREATMENT      OF     LARYNGEAL 

TUBERCULOSIS.' 

By    ROBERT    D.    COliN,    M.D., 

SAN    FRANCISCO, 

•OCULIST  TO  THE   MOUNT  ZiON    HOSPITAL;   SURGEON   TO  THE   CALIFORNIA   R^'E 
AND    EAR    HOSI'ITAL. 

If  I  take  the  liberty  of  encroaching  upon  your  patience 
with  a  few  remarks  on  the  treatment  of  laryngeal  tu- 
berculosis, it  is  because  the  theme  is  one  that  interests 
not  only  the  throat  specialist,  but  the  general  practi- 
tioner as  well.  Before  we  proceed  to  our  subject  prop- 
er, a  few  words  may  not  be  out  of  place  on  the  path- 
ological anatomy  of  the  affection  under  consideration, 
for  the  reason  that  an  understanding  of  the  morbid 
processes  involved  in  laryngeal  pthisis  is  essential  to 
any  rational  treatment. 

Tuberculous  laryngitis  begins  with  an  infiltration 
in  the  lower  layers  of  the  mucosa  and  in  the  submu- 
cosa.  The  question  as  to  how  the  tubercle  bacilli 
reach  the  lower  layers  of  the  mucosa  and  the  submu- 
cosa  is  here  immaterial.  Whether  those  investigators 
are  right  who  contend  that  the  infection  takes  place 
from  the  surface,  the  germs  entering  in  through  the 
epithelium,  this  having  suffered  previous  structural 
changes,  or  whether  the  others  are  correct  who  main- 
tain that  the  germs  find  their  way  into  the  lower  lay- 
ers from  the  lung  and  bronchial  lymphatics  by  way  of 
the  blood  and  lymph  channels — that  question  is  for 
our  present  purposes  irrelevant,  as  it  has  no  bearing 
upon  the  treatment  of  the  affection.  For  the  treat- 
ment only  one  circumstance  is  of  importance — the  cir- 
cumstance that  the  first  morbid  changes  begin,  con- 
trary to  a  still  very  general  belief,  not  on  the 
surface  but  in  the  deeper  strata  of  the  larynx.  In 
other  words,  tuberculous  laryngitis  does  not  begin  as 
a  superficial  ulceration  that  secondarily  creeps  inward, 
but  as  a  deep-seated  infiltration  that  spreads  outward 
until  it  reaches  the  surface,  when  it  ulcerates.  VVith 
the  sole  exception  of  aphthous  ulcers,  which  result 
from  the  action  of  irritant  sputa  coming  in  direct  con- 
tact with  the  surface  of  the  larynx  in  pulmonary 
phthisis  of  long  standing,  the  mucosa,  above  all  the 
epithelium,  is  in  the  initial  stage  of  laryngeal  tuber- 
culosis intact,  the  surface  smooth.  Deeper  down  in 
the  lower  layers  of  the  mucosa  and  in  the  subniucosa 
the  primary  infiltration  appears.  If  in  this  stage  lac- 
tic acid  or  any  other  cauterizing  agent  be  applied,  how 
is  it  to  influence  the  morbid  tissue?  It  produces 
merely  an  erosion  or  an  ulceration  which  heals  of  it- 
self, without  having  had  the  slightest  effect  upon  the 
tuberculous  process.  Let  us  take  for  instance  the 
changes  upon  the  posterior  laryngeal  wall.  Here,  as 
everywhere  else  in  the  larynx,  the  primary  process  is 
a  deep-seated  infiltration,  which  later  extends  on  the 
one  hand  still  farther  inward  till  it  reaches  the  peri- 
chondrium, causing  there  ankylosis  of  the  crico-aryte- 
noid  joint,  or  on  the  other  hand  spreads  outward  toward 
the  surface,  on  reaciiing  which  it  sends  forth  granula- 
tions which  extend  into  the  lumen  of  the  larynx. 
Secondarily  these  granulations  ulcerate,  exactly  as  in 
the  case  of  neoplasmata,  and  we  then  have  for  the  first 
time  an  ulcer,  so  that  the  sequence  is  infiltration, 
granulation,  ulceration.  Often  in  the  primary  stage 
the  patient  cannot  phonate,  because  the  swelling  of 
the  posterior  wall  prevents  in  a  purely  mechanical  way 
the  vocal  cords  from  approaching  each  other.  In  the 
third  stage,  a  year  or  two  later,  he  can  once  more  pho- 
nate, for  the  simple  reason  that  the  swelling  and  the 
granulations  on  the  posterior  wall  have  disappeared  and 
given  way  to  an  ulcerated  surface,  thus  permitting  an 
approximation  of  the  cords.  He  naturally  believes 
his  condition  changed  for  the  better,  whereas,  in  fact, 

'  Read  before  the  San  h'rancisco  County  Medical  Society, 
October  <j,  1900. 


it  has  changed  for  the  worse.  The  return  of  the  voice 
denotes  in  this  instance  progression  not  retrogression 
of  the  tuberculous  process.  I  dwell  on  this  point  be- 
cause only  a  few  years  ago  the  opinion  prevailed  very 
generally  that  in  tuberculous  laryngitis  hoarseness  and 
development  of  the  disease  keep  equal  pace — the 
greater  the  degree  of  hoarseness  the  farther  advanced 
the  disease — whereas,  in  point  of  fact,  the  reverse  is 
often  the  case.  These  briefly  sketched  changes  on  the 
posterior  wall  are  in  all  essential  respects  the  same 
that  occur  in  the  various  other  parts  of  the  larynx. 

We  now  come  to  our  subject  proper.  Before  the 
invention  of  the  laryngoscope  the  treatment  of  laryn- 
geal phthisis  was  necessarily  limited  to  general  thera- 
peutics, dietetics,  and  hygiene.  It  is  true  numerous 
attempts  were  made  to  treat  the  affected  parts  locally, 
but  without  success.  On  the  one  hand  all  manner  of 
inhalations,  sprays,  etc.,  were  used,  which  at  best  gave 
a  certain  temporary  relief,  on  the  other  hand  the  vari- 
ous astringents  and  cauterizing  agents  were  introduced 
blindly  into  the  larynx  by  means  of  bent  probes,  and 
probably  did  more  harm  than  good.  It  is  therefore 
easy  to  understand  the  extravagant  hopes  raised  by  the 
invention  by  Czermak  and  Tuerck,  of  Vienna,  in  1858, 
of  the  laryngoscope.  As  if  by  magic  the  entire  larynx 
was  now  exposed  to  view  and  nothing  seemed  more 
easy  or  more  certain  of  success  than  carefully  localized 
treatment.  The  ulcers  were  diligently  cauterized  with 
silver  nitrate  and  copper  sulphate,  and  a  bitter  disap- 
pointment followed.  The  outcome  of  every  effort  was 
the  disheartening  confession  that  cauterization  was  of 
no  avail,  the  tuberculous  process  went  its  way  in  spite 
of  it,  and  medical  skill  was  as  helpless  as  before. 
Hence  a  few  years  later  Stoerk,  professor  of  laryngol- 
ogy in  Vienna,  formulated  the  principle  that  tuberculous 
laryngitis  is  a  noli  me  tangere — it  is  forbidden  ground, 
no  local  treatment  is  permissible.  The  principle  found 
general  acceptance,  and  until  the  end  of  the  seventies 
tuberculosis  of  the  larynx  was  considered  an  incurable 
disease. 

In  1880  M.  Schmidt,  who  with  others  had  pro- 
nounced this  pessimistic  standpoint  inhuman,  an- 
nounced that  he  had  discovered  a  simple  method  of 
healing  a  tuberculous  throat  ulcer  by  means  of  inhala- 
tions of  three-per-cent.  carbolic  acid.  The  method  was 
eagerly  seized  upon  and  tried  with  results  which,  while 
they  by  no  means  justified  Schmidt's  enthusiasm, 
showed  that  he  had  hit  upon  a  procedure  of  great 
value.  The  reason  for  his  mistake  in  supposing  that 
he  had  found  a  cure  was  the  following:  tiie  tubercu- 
lous ulcer  is  only  in  the  beginning  specifically  tuber- 
culous, a  secondary  strepto-  and  staphylococci  inva- 
sion very  soon  takes  place,  and  we  then  have  a  mixed 
ulcer;  so  that  every  tuberculous  throat  ulcer,  except 
those  entirely  fresh,  is  mixed.  Schmidt's  carbolic  in- 
halations iiad  had  the  effect  of  removing  tiie  secondary 
products,  the  dirty  grayish  coating.  The  original 
tuberculous  ulcer  with  rosy,  healthy-looking  granula- 
tions remained.  This  Schmidt  mistook  for  the  heal- 
ing of  the  ulcer.  In  other  words,  with  carbolic  acid 
or  any  other  antiseptic  agent  we  cannot  influence  the 
tuberculous  process  as  such,  but  we  can  prevent  sec- 
ondary infection.  Is  it  now  of  any  benefit  to  the  pa- 
tient if  we  do  this?  It  most  certainly  is.  For  it  is 
secondary  infection  that  produces  swelling  of  the 
larynx,  with  dyspniL-a  and  dyspliagia,  and  the  dyspha- 
gia of  laryngeal  tuberculosis  is  one  of  the  most  terri- 
ble things  that  are.  It  is  secondary  infection,  more- 
over, that  is  responsible  for  acute  perichondritis  of  the 
crico-arytenoid  joint.  VVithoul  warning,  over  night, 
chill  and  fever  set  in,  the  entire  capsule  of  the  joint 
becomes  infiltrated,  and  the  arytenoid  cartilage  swims 
in  pus,  all  in  twenty-four  liours.  Tuberculous  granu- 
lations that  had  existed  for  months  on  the  posterior  end 
of  one  of  the  vocal  cords  had  finally  ulcerated,  where- 


December  22,  1900J 


MEDICAL    RECORD. 


971 


upon  strepto-  and  staphylococci  from  the  surface  had 
entered  and  produced  a  violent  intlammation  of  the 
joint.  A  tuberculous  process  existing  for  months  alone 
never  bursts  out  as  suddenly  as  that — that  is  always 
the  work  of  secondary  infection.  By  preventing  this  we 
prevent  all  such  occurrences,  and  if  we  thereby  spare 
the  patient  during  the  last  week  of  his  life  that  awful 
dyspnoea  and  dysphagia  we  have  done  at  least  our  duty. 
Whether  we  use  carbolic  acid,  creosote,  glycerin, 
menthol,  or  iodoform,  is  immaterial. 

Schmidt's  carbolic  inhalations  having  failed  to 
realize  expectations,  the  search  for  remedies  was  con- 
tinued. In  1885  the  Vienna  surgeon  Mosetig  recom- 
mended lactic  acid  in  tuberculous  affections  of  the 
knee.  Impelled  by  Mosetig's  success  attendant  upon 
the  use  of  the  acid,  Krause,  struck  by  a  fortunate  in- 
spiration, in  that  same  year  made  a  trial  of  the 
remedy  in  the  throat.  He  began  to  cauterize  the 
tuberculous  ulcers  with  lactic  acid,  and  with  success 
exceeding  anticipations.  His  reports  were  so  glow- 
ing that  a  large  number  of  laryngologists  immediately 
availed  themselves  of  the  method  with  results  equally 
good,  and  from  that  day  to  this  lactic  acid  has  re- 
mained by  far  the  most  eflficacious  remedy  in  laryn- 
geal phthisis.  As  Schcch  says:  "It  acts  almost 
specifically  in  that,  while  it  attacks  the  morbid  tissue, 
it  leaves  the  healthy  tissue  intact."  If  any  agent  can 
bring  about  the  cicatrization  of  a  tuberculous  throat 
ulcer,  it  is  this  acid.  Its  employment  is  limited, 
however,  to  open  processes,  that  is,  to  ulcerated  sur- 
faces, and  does  not  extend  to  non-ulcerated  infiltra- 
tions, for  if  the  surface  be  intact  it  cannot  penetrate 
to  the  morbid  tissue  underneath.  Moreover,  the 
method  of  application  must  be  rational.  The  treat- 
ment of  tuberculous  ulcers  with  twenty-  to  thirty-per- 
cent, lactic  acid,  as  often  practised,  is  unavailing,  as 
that  concentration  is  too  weak  to  accomplish  the  pur- 
pose intended.  One  must  use  a  fifty-  to  eighty-per- 
cent, solution,  which  must  be  rubbed  so  energetically 
into  the  ulcer  that  a  brownish  or  blackish  eschar  re- 
sults. For  this  reason  I  agree  with  Lennox  lirowne 
in  thinking  the  advocacy  of  application  by  means  of 
the  laryngeal  spray  ill  advised.  Some  apply  the  acid 
daily  or  every  second  day;  this  is  an  entirely  irration- 
al procedure.  The  application  should  not  be  repeated 
until  the  eschar  sloughs  through  reactive  irritation — 
a  process  requiring  from  seven  to  fourteen  days.  In 
the  mean  time  insutllations  of  iodol,  iodoform,  or 
another  disinfecting  powder  are  in  place.  Preceding 
every  cauterization  a  thorough  cocainization  is  neces- 
sary, a  fifteen-  to  twenty-per-cent.  solution  being  the 
strength  generally  required.  On  the  detachment  of 
the  eschar  the  surface  is  smooth,  the  superficial  granu- 
lations having  been  actually  destroyed  by  cauteriza- 
tion. The  chief  deposits,  however,  are  still  below, 
and  the  cauterizing  procedure  must  therefore  be  re- 
peated four  or  five  or  a  dozen  times,  often  through 
many  months,  before  we  can  hope  to  have  entirely 
eliminated  the  morbid  tissue. 

And  yet  it  is  not  permissible  in  every  case  in  which 
there  are  tuberculous  ulcers  in  the  larynx  without 
further  consideration  to  apply  lactic  acid.  In  this 
Bosworth  goes  too  far,  in  my  estimation,  in  stating 
that  "in  view  of  the  excellent  results  which  have  fol- 
lowed the  lactic-acid  treatment,  we  have  not  done  our 
full  duty  in  any  given  case  without  fully  testing  its 
efficacy,"  Several  strict  indications  must  first  be 
fulfilled.  In  the  first  place,  the  ulcers  must  be  cir- 
cumscript.  If,  for  instance,  the  posterior  wall,  both 
vocal  cords,  and  one  or  both  arytenoid  cartilages  be 
already  ulcerated,  lactic  acid  is  strictly  forbidden,  for 
such  ulcers  do  not  heal,  even  with  lactic  acid.  One 
ulcerated  vocal  cord  or  an  ulcerated  posterior  wall  has 
a  fair  chance  of  healing;  these  plus  additional  ulcers 
have  practically  none  whatever.     In  the  second  place, 


the  general  condition  must  be  good.  If  the  pulmonary 
process  be  already  far  advanced  or  advancing  rapidly, 
if  the  appetite  be  poor,  or  if  the  patient  do  not  tolerate 
cocaine,  cauterization  should  not  be  undertaken.  If 
the  patient's  appetite  be  ruined  with  cocaine,  the 
greatest  harm  is  done  him,  for  as  long  as  the  tubercu- 
lous subject's  appetite  remains  good,  there  is  always 
hope  of  eradicating  the  disease  or  at  least  of  checking 
its  progress.  So  much  for  tuberculous  ulcerations, 
I  repeat  that  lactic  acid  is  the  sovereign  remedy  in 
their  treatment;  that,  as  Solis  Cohen  says,  there  is 
nothing  else  which  bears  comparison  with  it,  that  it 
acts  almost  s]x;cifically,  and  that,  if  the  above-men- 
tioned indications  be  fulfilled,  its  use  is  imperative, 

W'e  now  come  to  the  tuberculous  infiltrations.  After 
the  introduction  of  lactic  acid  in  the  treatment  of  tu- 
berculous ulcers,  Heryng  hit  upon  the  idea  of  treating 
tuberculous  infiltrations  by  the  same  means,  cauteriza- 
tion being  preceded  by  multiple  scarifications.  The 
object  of  these  was  to  convert  the  non-ulcerated  infil- 
tration into  an  open  process,  into  which  the  acid 
could  then  be  rubbed.  Although  diminution  in  size 
of  the  infiltration  and  cicatrization  of  the  wound  fre- 
quently followed,  Heryng  soon  saw  the  inadequacy  of 
the  procedure  and  devised  in  1887  the  method  upon 
which  the  entire  present  surgical  treatment  of  laryn- 
geal phthisis  is  based,  and  that  is  curettage.  The 
single  curette  is  an  oval  sharp  spoon,  the  curve  of 
which  is  adapted  to  the  various  regions  of  the  larynx. 
With  it  the  tuberculous  infiltrations  are  thoroughly 
scraped  with  the  intention  of  eliminating  the  tuber- 
culous products  and  leaving  a  wound  which  later  cica- 
trizes. There  are,  however,  certain  parts  of  the  larynx 
to  which,  on  account  of  their  lack  of  tenseness,  we 
cannot  apply  the  single  curette;  these  are  the  epiglot- 
tis, the  ary-epiglottic  folds,  and  the  posterior  wall.  For 
these  parts  we  use  the  double  curette.  It  acts,  more- 
over, more  energetically  than  the  single  curette,  and 
is  therefore  adapted  to  those  infiltrations,  irrespective 
of  their  localization,  which  by  reason  of  their  hard- 
ness do  not  yield  to  the  single  curette.  It  is  needless 
to  add  that  before  the  employment  of  the  curette  the 
larynx  must  be  thoroughly  cocainized,  for  which  pur- 
pose, as  in  the  application  of  lactic  acid,  a  fifteen-  to 
twenty-jjer-cent.  solution  is  necessary.  On  account  of 
the  sensitiveness  and  excessive  reflex  irritability  of 
the  posterior  wall,  this  region  is  the  most  diflScult  to 
manage.  With  the  single  curette  hemorrhage  is 
slight,  with  the  double  curette  more  profuse.  This 
danger  is,  however,  not  very  great.  In  case  of  trouble 
a  mixture  of  lactic  acid  and  liquor  ferri  sesquichloridi 
in  equal  parts  will  be  found  serviceable.  After  the 
operation  insutllations  of  idoform,  iodol,  aristol,  or  a 
similar  disinfecting  powder  are  all  that  is  necessary. 
The  reaction  is  slight;  at  worst  the  patient  complains 
of  rawness  in  the  throat  and  painful  deglutition, 
sometimes  of  headache  and  slight  fever.  As  some  one 
has  said,  many  stapd  the  operation  better  than  the 
cocaine.  In  general  seven  to  fourteen  days  must 
elapse  before  the  operative  procedure  is  repeated. 
As  to  the  indications  for  curettage,  they  are  the 
same  as  for  cauterization  with  lactic  acid,  only  that 
in  the  case  of  curettage  they  are,  if  anything,  still 
stricter. 

If  now  in  conclusion  I  am  permitted  a  brief  reca- 
pitulation, I  should  like  to  divide  laryngeal  tubercu- 
losis as  regards  its  therapeutics  into  three  stages.  In 
the  first  stage,  with  the  exception  of  a  circumscript  in- 
filtration or  ulceration,  the  larynx  is  healthy.  In  this 
stage  (the  only  one  in  which  we  can  hope  for  a  per- 
manent cure)  the  treatment  consists  in  curettage  in 
case  an  infiltration  be  present,  in  cauterization  with 
lactic  acid  in  case  an  ulcer  be  present.  If  the  gen- 
eral condition,  especially  that  of  the  lungs,  be  good, 
these  procedures   are   imperative.     As    above  stated, 


972 


MEDICAL    RECORD. 


[December  22,  1900 


they  must  be  repeated  at  intervals  of  one  to  three 
weeks,  until  the  diseased  tissue  is  completely  removed. 

In  the  second  stage  the  larynx  presents  extensive 
infiltrations  or  ulcerations.  Here  we  can  no  longer 
hope  for  a  complete  elimination  of  the  morbid  tissue; 
in  other  words,  if  we  get  the  case  in  this  stage  we  can 
no  longer  count  on  a  cure.  Here  the  antiseptic  treat- 
ment conies  to  the  front,  for  here  our  main  aim  is  to 
prevent  secondary  infection.  The  mildest  method  is 
by  means  of  antiseptic  inhalations;  whether  we  use 
one-  to  three-jjer-cent.  carbolic  acid,  two-  to  four-per- 
cent, boracic  acid,  or  one-  to  two-per-cent.  lysol  is  of 
no  consequence.  If  the  epiglottis  permit  an  inspec- 
tion of  the  interior  of  the  larynx  the  antiseptic  swab 
is  still  more  efficacious,  for  which  purpose  a  ten-per- 
cent, solution  of  carbolic  acid  in  glycerin  can  be  re- 
commended. More  in  favor  than  this  is  a  ten-  to 
thirty-per-cent.  solution  of  menthol  in  olive  oil.  which 
acts  both  antiseptically  and  analgetically.  As  above 
outlined,  by  means  of  this  antiseptic  treatment  we 
forestall  secondary  infection  and  thereby  the  terrible 
dyspnoea  and  dysphagia  of  the  last  stage. 

And,  finally,  if  we  see  the  case  first  in  this  last  piti- 
ful stage,  all  that  it  is  in  our  power  to  do  is  to  treat  it 
symptomatically,  to  administer  a  morphine  powder 
before  each  meal,  or  better  still  to  apply  a  ten-  to 
twenty-percent,  solution  of  cocaine  to  the  pharynx. 
In  impending  suffocation  tracheotomy  must,  of  course, 
be  performed. 

I  have  confined  myself  entirely  to  the  local  therapy 
of  laryngeal  tuberculosis.  There  remains  the  general 
treatment  —  internal  medication,  dietetics,  and  hy- 
giene— on  which,  however,  I  refrain  from  dwelling, 
as  it  corresponds  closely  to  that  in  pulmonary  tuber- 
culosis. 

13s  Geary  Street. 


LOCAL     ANAESTHESIA     IN     THE     RADICAL 
OPERATION    FOR   INGUINAL    HERNIA. 

By   LEO  B.    MEYER,   A.M.,    M.D., 

NEW   YORK. 

It  was  my  good  fortune,  not  long  ago,  to  assist  at  an 
operation  for  the  radical  cure  of  inguinal  hernia  under 
local  anresthesia.  Personally,  I  have  always  operated 
on  hernias  with  the  aid  of  general  anaesthesia.  The 
operation  was  performed  on  the  house  surgeon  of  a 
large  New  York  hospital.  A  careful  perusal  of  the 
following  description,  which  for  simplicity's  sake  is 
given  in  the  words  of  the  patient,  will,  I  think,  be  as 
instructive  to  the  reader  as  it  was  to  me,  especially  so, 
because  the  patient  underwent  the  operation  by  this 
method  for  the  purpose  of  testing  its  merits.  The 
accuracy  of  the  account  I  can  vouch  for.  The  anass- 
thetic  used  was  eucaine  ;5  six  per  cent.  The  pa- 
tient conversed  with  the  operator  and  his  assistants 
during  the  entire  operation,  so  as  more  accurately  to 
describe  his  sensations  subsequently. 

"Local  anaesthetization  :  The  operation  down  to  the 
exposure  of  the  external  oblique  aponeurosis  was 
painless,  as  was  also,  practically,  the  splitting  of  the 
latter  to  expose  the  cord.  The  separation  of  the  sac 
from  the  cord  was  excruciatingly  painful.  The  sensa- 
tion was  as  if  the  testicle  were  being  constantly  and 
thoroughly  mauled.  It  vias  present  when  the  cord  was 
touched  ever  so  lightly;  its  severity  during  the  strip- 
ping of  an  adherent  sac  from  the  cord  can  therefore 
be  easily  imagined.  The  ligation  and  excision  of  a 
large  portion  of  the  omentum  was,  contrary  to  every 
one's  expectation,  absolutely  painless.  Traction  on 
the  omentum,  however,  while  not  actually  painful, 
was  responsible  for  a  very  disagreeable  nausea,  which, 
by  the  way,  persisted  for  two  days  following  the  oper- 
ation.    The    introdu.;tion   of   the  purse-string  suture 


into  the  neck  of  the  sac,  and  the  ligation  and  excision 
of  the  latter,  were  painless.  The  suturing  of  Poupart's 
ligament  to  the  conjoined  tendon  and  its  muscles,  to 
construct  a  new  posterior  wall  for  the  canal,  was  prac- 
tically without  pain.  On  the  other  hand,  the  suturing 
of  the  external  oblique  aponeurosis  was  surprisingly 
painful,  the  passage  of  the  needle  feeling  like  a  knife 
passing  through  infianied  tissues ;  the  drawing  together 
of  the  edges  of  tlie  aponeurosis,  howe\er,  did  not  cause 
much  pain.  The  edges  of  the  skin  were  drawn  to- 
gether with  India-rubber  zinc  plaster,  and  not  sutured. 

"VVhile  the  suturing  in  itself  was  on  the  whole  not 
very  painful,  it  must  not  be  forgotten  that  during  the 
first  part  of  the  procedure  the  cord  had  to  be  held  out 
of  the  way  with  a  blunt  hook,  causing  the  testicular 
pain  pre\iouslv  described. 

"The  operation  lasted  sixty  minutes.  During  the 
first  minute  there  was  no  pain;  during  ihe  other  fifty- 
nine  minutes  the  pain  was  such  that  should  any  one 
who  reads  this  contemplate  undergoing  an  operation 
for  the  radical  cure  of  inguinal  hernia  under  local 
anaesthesia,  I  should  advise  him  not  to.  If  he  wants  to 
know  how  it  would  feel,  let  him  give  his  testicles  a 
good  hard  squeeze,  and  imagine  the  pain  lasting  from 
thirty  to  fifty  minutes;  then,  if  he  cares  to  try  it,  well 
and  good;  at  any  rate  he  knows  what  to  expect.  I, 
for  one,  would  prefer  general  anjesthesia,  if  I  had  to 
undergo  a  similar  operation  on  the  other  side.'' 

How  much  less  pain  the  patient  would  have  expe- 
rienced had  the  ileo-inguinal  nerve  been  cocainized 
at  the  beginning  of  the  operation,  according  to  the 
method  described  by  Cushing  in  the  Annals  oj  Sur- 
gery, January,  1900,  I  do  not  know.  In  the  only  case 
I  have  seen  this  method  used  it  seemed  to  be  ineffec- 
tual. The  case  was  one  of  double  inguinal  hernia,  in 
a  patient  who  could  endure  pain  well,  and  who  said 
he  was  willing  to  stand  a  good  deal  for  the  sake  of  a 
cure.  Both  sides  were  operated  upon  under  local  an- 
aesthesia, the  first  side  according  to  Cushing's  method, 
the  other  in  the  usual  way.  The  amount  of  pain  expe- 
rienced seemed  to  be  the  same  on  both  sides.  Even 
in  the  hands  of  its  originator  this  method  is  by  no 
means  ideal,  as  may  be  inferred  from  statements  in 
the  original  article,  to  the  eff^ect  that  morphine  and 
chloroform  in  small  whiffs  are  excellent  adjuvants 
and  have  to  be  used  at  times,  that  some  pain  must 
necessarily  be  inflicted,  and  to  spare  the  patient  it  is 
a  temptation  lo  slight  certain  steps.  And  why,  indeed, 
should  any  one  expose  himself  to  such  needless  suffer- 
ing? Every  patient  whom  I  have  seen  operated  on  in 
this  way  has  solemnly  stated  afterward  that  no  power 
on  earth  could  make  him  undergo  the  experience  again. 

What  are  the  advantages  claimed  for  this  method  of 
operating  in  hernia?  In  the  order  of  importance  they 
are:  (i)  absence  of  the  dangers  of  general  anaesthesia, 
both  immediate  and  remote;  (2)  absence  (usually)  of 
the  unpleasant  sequelae  of  ana-sthesia;  (3)  tlie  aid  liie 
patient  can  give  the  operator,  e.g.,  by  coughing,  so  that 
the  sac  can  be  more  easily  isolated.  Before  consider- 
ing the  advantages  further,  let  me  mention  the  disad- 
vantages: (i)  the  severe  suffering  mental  and  phys- 
ical which  is  caused,  resulting  in  more  or  less 
shock;  (2)  the  tendency  on  the  part  of  the  operator 
to  hurry  and  slight  certain  steps;  (3)  the  condition  of 
neurasthenia  in  which  the  operation  may  leave  the 
patient.  The  case  of  double  hernia  mentioned  above 
is  a  good  example  of  the  last-named  disadvantage. 
For  the  three  months  following  the  operation,  during 
which  time  I  had  the  patient  under  observation,  he 
was  in  a  condition  of  marked  neurasthenia,  such  as 
is  often  seen  in  people  who  have  been  in  railroad 
accidents. 

Inasmuch  as  one  or  more  of  these  disadvantages  is 
always  present  to  a  greater  or  less  degree,  this  method 
of  operating  should  not  be  employed  unless  the  ad- 


December  22,  1900] 


MEDICAL    RECORD. 


973 


vantages  are  sufficiently  strong  to  offset  them.  Of 
those  mentioned  (2)  and  (3)  are  certainly  insignificant 
—  (2)  because  post-anjEsthesia  unpleasantness  is  but 
temporary,  and  not  always  present,  and  (3)  because 
we  can,  and  in  practically  all  cases  do,  get  along  very 
well  without  any  help  on  the  part  of  the  patient. 

I  do  not  wish  to  be  understood  as  an  unqualified 
opponent  of  operating  upon  hernias  under  local  anajs- 
thesia.  I  simply  wish  to  help  in  defining  its  limita- 
tions, and  since  the  only  real  advantage  of  the  method 
is  the  removal  of  the  element  of  danger  of  general  an- 
aesthesia (and  this  element  nowadays  is  practically 
nil,  except  in  old  people  and  those  subject  to  certain 
diseases,  such  as  advanced  emphysema,  and  advanced 
chronic  endocarditis)  it  seems  to  me  that  the  method 
should  be  employed  only  in  those  cases  in  which  the 
administration  of  a  general  anesthetic  is  dangerous. 

For  this  reason  I  believe  that  this  method  of  oper- 
ating in  hernia  should  not  even  be  suggested  to  pa- 
tients whose  condition  is  good,  and  in  whom  the 
administration  of  a  general  anesthetic  is  reasonably 
free  from  danger.  Indeed,  it  is  quite  possible  that 
the  method  will  not  be  practised  so  extensively,  even 
by  those  who  are  now  its  strongest  advocates,  if  cocaini- 
zation  of  the  spinal  cord  prove  finally  to  be  as  free 
from  danger  as  recent  experiments  seem  to  indicate. 

60  West  One  Hl-nuked  and  Twestv-mnth  Stkhet. 


CCHnicjil  gcpurtmcut. 

REPORT   OF    A    CASE   OF    FRACTURED 
LIVER. 

By   SEELYE    \V.    LITTLE.    .\LI).. 

KOCHESTEK,    N.    V. 

Recovery  from  this  accident  seems  to  be  rare,  which 
is  the  only  reason  for  making  this  report. 

R ,  aged  thirty-five  years,  a  canaller,  was  struck 

in  the  epigastrium  a  hard  blow  with  a  stick  of  wood. 
He  was  brought  to  the  City  Hospital  on  September 
8th  for  treatment  within  three  or  four  hours  of  the  ac- 
cident. On  entering  he  was  in  collapse;  his  pulse 
was  small  and  feeble,  his  face  was  pale  and  anxious, 
and  his  extremities  were  cool.  He  complained  of 
severe  pain  in  the  epigastrium.  On  examination  no 
mark  of  injury  could  be  seen.  There  was  no  unusual 
dulness  on  percussion  over  the  abdomen.  Clear  urine 
was  obtained  by  the  catheter.  There  was  some  vom- 
iting. The  diagnosis  lay  between  the  ordinary 
"knock-out"  blow  over  the  solar  plexus  and  rupture 
of  some  organ  with  hemorrhage.  When  the  abdomen 
was  opened  it  was  found  to  contain  a  large  amount  of 
free  fluid  and  clotted  blood,  and  the  bleeding  was  evi- 
dently still  going  on.  The  first  organ  examined,  the 
liver,  was  found  to  have  been  torn  to  the  extent  of 
three  or  four  inches  on  the  anterior  inferior  surface  of 
the  right  lobe  between  the  gall  bladder  and  the  longi- 
tudinal fissure.  The  rent  was  large  enough  to  contain 
the  ends  of  four  fingers,  and  was  about  three-fourths 
of  an  inch  deep,  with  ragged  sides  and  edges.  The 
wound  was  packed  with  gauze  in  a  gauze  bag,  which 
was  held  in  position  by  a  heavy  silk  ligature  passed 
through  the  abdomen  from  the  right  side  behind  close 
to  the  free  border  of  the  ribs  to  the  left  side  in  front 
just  below  the  rib  cartilage  at  that  point.  This  liga- 
ture thus  hugged  the  right  lobe  of  the  liver,  and,  by 
passing  over  the  gauze  packing,  held  it  firmly  in  place. 
The  ligature  was  tied  tightly  on  the  outside  of  the 
body,  care  being  taken  to  feel  that  no  coil  of  intestine 
was  caught  by  the  tightened  silk.  The  lower  part  of 
the  wound  was  closed,  the  upper  part  being  left  open 
for  the  removal  of  the  gauze.  For  the  first  day  or  two 
there  was  considerable  oozing  of   blood.     Then   for 


about  ten  days  or  two  weeks  there  was  a  profuse  dis- 
charge of  bile,  gradually  lessening  until  there  was 
none.  The  gauze  and  ligature  were  removed  on  the 
eighth  day.  The  large  cavity  left  by  the  gauze  filled 
up  rapidly,  and  on  October  30th  the  patient  was  dis- 
charged well. 


FRACTURE  OF  THE  CLAVICLE,  RESULT- 
ING IX  RUPTURE  OF  THE  SUPRASCAPU- 
LAR   ARTERV(.>). 

By    IL    T.    miller,    M.D., 

SURGEON,  MITCHKLL-THOMAS   HOSPITAL,    SfRINGPlBLD,    OHIO. 

Mrs.  B ,  aged  forty-five  years,  housewife,  was  ad- 
mitted to  the  hospital  last  June,  giving  the  history  of 
having  fallen  in  an  epileptic  attack  four  weeks  pre- 
vious to  the  date  of  admission ;  upon  regaining  con- 
sciousness she  had  discovered  a  swelling,  about  the 
size  of  an  orange,  over  the  middle  portion  of  the 
clavicle  on  the  right  side.  This  swelling  had  grown 
very  rapidly,  and  given  her  considerable  pain.  An 
examination  revealed  a  large  pulsating  tumor  extend- 
ing from  above  downward  from  the  omohyoid  muscle 
to  the  fifth  rib,  and  laterally  from  the  suprasternal 
fossa  to  the  axilla. 

At  this  time  a  fracture  of  the  clavicle  was  not  sus- 
pected, nor  had  it  been  by  the  physicians  who  had 
previously  attended  her:  however,  a  rupture  of  an  ar- 
tery of  magnitude  was  diagnosed,  and  it  was  thought 
that  in  all  probability  an  operation  would  terminate 
faUlly. 

Two  days  after  admission  to  the  hospital  two  inci- 
sions were  made,  one  extending  from  the  lower  margin 
of  the  thyroid  gland  to  the  suprasternal  fossa,  the  sec- 
ond incision  extending  from  the  latter  point  to  about 
three  inches  over  the  clavicle.  The  skin,  superficial 
fascia,  platysma  myoides,  superficial  layer  of  the  deep 
fascia,  the  clavicular  and  sternal  heads  of  the  sterno- 
mastoid,  and  the  sternohyoid  and  sternothyroid  mus- 
cles were  divided.  The  inferior  thyroid  veins  were 
divided  between  ligatures.  There  was  great  difficulty 
in  the  dissection  on  account  of  the  close  proximity  of 
the  tumor,  and  then  there  was  constant  fear  of  ruptur- 
ing it.  After  the  subclavian-  artery  had  been  exposed, 
it  was  found  that  the  finger  could  be  inserted  between 
the  artery  and  vein  into  the  substance  of  the  tumor, 
which  was  found  to  be  largely  composed  of  disorgan- 
ized blood  clots.  A  portion  of  the  clavicle  was  re- 
moved, and  was  found  to  have  been  fractured  and 
partly  necrosed,  probably  from  pressure.  The  patient 
being  in  severe  shock,  it  was  deemed  advisable  to  dis- 
continue the  operation  and  defer  further  procedure  to 
a  future  time.  However,  before  the  wound  was  closed, 
an  incision  into  the  tumor  was  made  over  the  fifth 
rib,  and  a  drainage  tube  was  inserted  from  the  first 
incision  to  the  latter  opening.  The  treatment  from 
now  on  was  rather  expectant — every  day  the  wound 
was  thoroughly  irrigated  with  an  antiseptic  solution, 
and  all  loose  blood  clots  were  removed. 

It  was  soon  seen  that  nothing  would  be  accom- 
plished by  this  treatment,  for  as  fast  as  the  clots  were 
removed  from  below  more  would  push  down  from 
above,  showing  that  the  hemorrhage  still  continued. 

The  patient  being  in  a  condition  to  hazard  another 
operation,  she  was  again  prepared,  and  two  weeks 
after  the  first  operation  the  second  was  performed. 

An  incision  was  made  nearly  in  line  with  the  origi- 
nal, but  the  hemorrhage  here  was  so  severe  that  this 
region  was  at  once  abandoned,  and  the  incision  over 
the  fifth  rib,  made  at  the  first  operation,  was  enlarged, 
and  the  tumor  emptied  of  all  clots — we  being  prepared, 
however,  to  cut  down  at  once  to  the  suprascapular 
artery,  which  was  now  thought  to  be  the  artery  rup- 
tured, should  hemorrhage  follow  the  emptying  of  the 


974 


MEDICAL    RECORD. 


[December  22,  1900 


tumor.  No  hemorrhage  following,  an  incision  about 
five  inches  long  was  made  over  the  clavicle,  connecting 
with  the  original  incision.  At  least  two  inches  of  the 
sternal  end  of  the  clavicle  had  been  absorbed,  leaving 
a  spiculum  of  bone  as  sharp  as  a  needle,  protruding  into 
the  wound.  It  was  concluded  that  it  was  this  pointed 
piece  of  the  clavicle  that  caused  the  rupture  of  the  ar- 
tery, or  at  least  was  a  contributing  cause  of  the  hemor- 
rhage. 

Three  inches  of  the  clavicle  was  resected,  and  a  por- 
tion of  the  subclavius  and  pectoralis  major  muscles  was 
cut  away,  owing  to  a  disorganized  condition  of  the  mus- 
cular tissue,  no  doubt  from  pressure.  The  ruptured 
blood-vessel  not  being  found,  and  no  hemorrhage  fol- 
lowing the  operation,  the  wound  was  closed;  not,  how- 
ever, before  it  had  been  well  packed  with  iodoform 
gauze,  which  two  days  later  was  removed,  no  bleeding 
following  its  removal.  From  now  on  up  to  the  time 
I  left  for  my  vacation — a  week  later — the  patient 
seemingly  did  well;  she  suffered  no  pain,  was  quite 
cheerful,  and  gave  every  promise  of  making  an  un- 
eventful recovery. 

On  my  return  from  my  vacation,  August  28th,  I 
found  the  patient  very  weak  and  greatly  emaciated. 
The  tumor  had  assumed  its  original  size,  but  had 
changed  completely  in  character;  it  was  nodular,  the 
apices  of  the  nodules  being  blue,  and  in  some  places 
were  not  connected  with  the  body  of  the  tumor,  and 
honeycombed  with  sinuses  which  connected  with 
large  cavities  containing  a  foul-smelling,  semi-puru- 
lent matter.  This  condition  grew  steadily  worse  up 
to  the  moment  of  death,  which  occurred  a  few  days 
later. 


AN    UNUSUAL    CASE    OF    NOSE-BLEED. 

By   G.    \V.    squires,    M.D., 

E.^ST    .WON,    LU'I.NGSTON    COUNTY,    NEW    \ORK. 

J.  B ,  aged  fifty  years,  up  to  the  time  of  attack  con- 
sidered his  health  perfect,  and  worked  at  his  trade  of 
iron  moulder.  He  awoke  at  night  and  found  blood 
trickling  down  the  outside  of  his  neck.  He  called 
his  wife  who  put  cold  water  on  the  back  of  his  neck, 
and  gave  him  a  hot  mustard  foot  bath.  Home  treat 
ment  failing  to  stop  the  bleeding  a  physician  was 
sent  for,  who  tamponed  the  anterior  nares  and  gave 
ergot.  The  blood  soon  appeared  at  the  posterior  nares 
and  they  also  were  plugged.  Especially  in  the  right 
naris,  which  seemed  to  bleed  the  more  profusely,  the 
packing  caused  such  a  feeling  of  fulness  in  the  nose, 
eyes,  and  frontal  sinus,  that  the  patient  begged  to 
have  it  removed.  This  was  done  under  protest,  and 
the  escape  of  a  large  quantity  of  blood  followed. 
The  patient  fainted  and  showed  such  efifects  of  hemor- 
rhage that  the  attending  physician.  Dr.  Goodrick, 
called  me  in  consultation.  I  was  surprised  at  the 
bloody  appearance  of  the  bed  and  the  patient's  clothes, 
and  remarked  that  he  had  evidently  lost  some  blood. 
The  doctor  told  me  what  he  had  done,  and  what  medi- 
cines he  had  given,  which  seemed  the  most  judicious 
treatment.  The  nose  was  again  packed  fore  and  aft 
with  less  discomfort  to  the  patient,  and  to  all  appear- 
ance stopped  the  escape  of  blood.  The  patient  was 
now  after  forty-eight  hours  so  exsanguinated  as  to  be 
unable  to  raise  his  head;  he  was  partially  blind,  and 
nauseated  with  intolerable  thirst.  Supporting  treat- 
ment was  used,  with  hypodermic  medication  of  ergot, 
digitalis,  strychnine,  etc.,  without  benefit  in  checking 
the  bleeding  unassisted  by  tampon.  VVhen  it  was 
necessary  to  remove  the  packing  for  cleansing  pur- 
poses, the  blood  would  start  to  run,  and  the  patient 
would  lose  all  he  had  gained  for  several  days.  Three 
physicians  were  now  in  attendance  in  relays,  as  it 
seemed  the  man  would  die  by  a  short  hemorrhage  in 


the  absence  of  frequent  stimulations  of  brandy,  strych- 
nine, etc.  This  state  of  things  went  on  for  ten  days, 
when  conditions  looked  more  encouraging:  there  was 
less  bleeding  on  removal  of  the  tampon,  and  the  pa- 
tient was  stronger.  For  two  months  there  occurred 
occasional  but  slight  epistaxis,  when  it  stopped  entire- 
ly, and  the  patient  gradually  got  around  again. 

About  four  months  afterward  the  patient,  on  scratch- 
ing his  nose,  felt  something  sharp  in  contact  with  his 
finger.  He  called  his  wife,  and  asked  her  to  see  what 
was  there.  She  saw  the  point  of  something  sticking 
through  the  skin  on  the  outside  of  the  right  nostril, 
and  taking  a  pair  of  tweezers  extracted  a  rusty  needle 
an  inch  long,  broken  off  near  the  eye.  This  was,  of 
course,  an  explanation  of  the  cause  of  his  severe  epis- 
taxis. I  saw  the  needle  and  the  place  through  which 
it  had  worked  out  of  the  nose.  After  two  years  the 
man  has  never  had  another  attack  of  nose-bleed. 

The  interesting  features  in  this  case  are  the  unas- 
certainable  cause  of  the  trouble  at  its  occurrence,  the 
sudden  alarming  and  hard-to-control  epistaxis  in  a 
man  of  previous  good  health,  the  whence  and  the  why 
of  this  needle's  presence  in  the  nasal  cavity  of  a  man 
of  his  age  and  intelligence. 


DISLOCATION  OF  THE  CRYSTALLINE  LENS 
IN    IMMATURE   CATARACT. 

liv    NORBURNE    B.    JENKINS.    M.D., 

CHICAGO. 

Dislocation  of  the  crystalline  lens  usually  takes 
place  in  advanced  life.  The  thin  membrane  envelop- 
ing the  lens  ruptures,  and  the  lens  passes  forward  into 
the  aqueous  humor  or  backward  into  the  vitreous 
humor.  Spontaneous  dislocation  is  supposed  to  be 
caused  by  disease  or  atrophy  of  the  lens  capsule.  It 
is  probable  that  immature  cataract  is  often  the  cause 
of  such  dislocation. 

In  beginning  cataract  the  crystalline  lens  swells  and 
often  increases  in  convexity  so  much  that  glasses  are 
not  needed  in  reading.  It  has  long  been  known  that 
the  lens  increases  in  size  in  cataract.  It  is  probable 
that  the  enlarged  lens  occasionally  bursts  its  capsule. 
Intralenticular  pressure  may  cause  capsular  atrophy, 
and  rupture  may  follow. 

Cataract  usually  comes  in  advanced  life  and  in  both 
eyes.  The  writer's  observation  goes  to  show  that,  in 
spontaneous  dislocation,  cataract  of  the  fellow-eye,  if 
not  already  present,  may  usually  be  expected,  so  con- 
stituting a  diagnostic  criterion. 


AN    EPIDEMIC    OF   TYPHOID    FEVER. 
By   benjamin    K.    HAVS,    M.D., 

OXFORD,    N.    C. 

In  an  unpublished  paper  on  typhoid  fever,  written  by 
the  late  Dr.  John  \V.  Booth,  of  Stem,  N.  C,  is  the 
following  interesting  report  of  an  epidemic  which  oc- 
curred in  his  practice  in  1886:  '"North  of  Moore's 
church  is  a  log  house,  and  near  the  back  of  the  liouse 
is  a  depression  terminating  in  a  gully.  In  the  gully, 
one-half  mile  below  this  house,  is  a  spring  which  in 
part  supplies  water  to  the  congregation  at  Moore's. 
A  well,  some  distance  beyond  the  spring,  is  also  used 
by  the  congregation.  A  rock  dam  turns  the  water 
from  the  spring  when  Hushed  by  rain,  but  this  dam  is 
not  impervious  to  water.  During  and  just  preceding 
a  protracted  meeting  at  Moore's,  a  negro  living  in  the 
log  house  had  typhoid  fever.  Her  dejections  were 
thrown  into  tlie  gully  at  the  back  of  the  house,  and 
were  in  part  at  least  in  a  very  dilute  solution.  Of 
course   they  were   taken  by   the   first  rain   down   the 


December  22,  1900] 


MEDICAL    RECORD 


975 


gully,  and,  trickling  through  the  rocks,  contaminated 
the  water  in  the  spring.  The  woman  first  called  in 
medical  aid  August  3d,  and  on  August  16th  a  member 
of  the  congregation  was  taken  ill  of  the  fever,  and  was 
followed  by  others  in  quick  succession,  numbering  over 
seventy  in  all.  Several  members  of  the  congregation, 
including  the  preacher,  had  the  fever  at  their  homes 
out  of  the  neighboriiood,  and  were  the  only  cases  in 
their  respective  communities." 


THE    REMOVAL    OF    THIRTY-FIVE    SCREW- 
WORMS    FROM    THE    NOSE. 

i;v    ll.\l.    I'OSTEK,    A.li.,    M.I)., 

KANSAS   CITY,    MO. 

The  jiatient,  Tiiomas  K. ,  aged  seventy-two  years, 

lived  in  Wyandotte  County,  Kans.  He  was  admitted 
to  St.  Margaret's  Hospital  September  12,  1900.  The 
nose,  eyes,  and  face  were  badly  swollen.  He  had  ex- 
cruciating frontal  headache,  and  the  discharge  from 
the  nose  was  bloody  and  very  offensive.  On  making 
a  nasal  examination  the  worms  could  be  readily  seen 
in  the  nose.  Tiie  tissue  on  the  middle  turbinated 
bone  had  been  ijadiy  injured  by  them.  Tiie  great 
majority  of  the  worms  were  found  in  the  posterior 
nares.  They  had  made  quite  a  large  opening  in  the 
hard  palate.  A  solution  of  alcohol  and  water  was 
used  in  the  nose  first.  This  was  followed  by  the  ap- 
plication of  chloroform  directly  to  the  worms  by  cotton 
applicators.  This  remedial  agent  soon  dislodged  and 
brought  the  worms  away.  Hot  water  was  u.sed  by 
means  of  a  fountain  syringe,  and  gave  great  relief  to 
the  patient.  The  patient  informed  me  that  the  worms 
had  been  in  his  nose  about  two  weeks.  He  was  very 
weak  and  greatly  surprised  when  he  saw  the  worms 
taken  from  his  nose.  He  was  given  a  nutritious  diet, 
and  iron  was  administered.  The  sinuses  were  not  in- 
volved.    The  patient  made  a  rapid  recovery. 

Nearly  every  September  I  have  a  case  of  screw 
worms  in  the  nose.  In  all  cases  of  obscure  nasal  dis- 
charge, bloody  in  character,  a  careful  nasal  examina- 
tion should  be  made.  As  a  rule  the  worms  can  be 
easily  seen  and  dislodged,  much  to  the  comfort  of  the 
patient.  Occasionally  the  worms  enter  the  sinuses, 
causing  meningitis  and  death.  I  desire  to  thank  Dr. 
O'Donnell,  the  house  physician,  and  the  sister  in 
charge  for  kindly  assisting  in  this  case. 


Potatoes  in  Diabetes  Mellitus A.  Mossd  answers 

the  mooted  question  as  to  whether  potatoes  may  have 
a  place  in  the  dietary  of  the  diabetic,  in  the  affirmative, 
and  cites  two  cases  in  which  the  wisdom  of  such  addi- 
tion to  the  fare  was  evidenced  by  a  prompt  decrease 
in  the  amount  of  sugar  excreted  in  the  urine.  The 
potatoes  should  be  given  to  the  amount  of  from  two  to 
three  pounds  daily  as  a  substitute  for  the  whole  or  a 
part  of  the  bread  allowed.  The  cases  which  seem  to 
respond  best  to  such  management  are  those  of  medium 
intensity  and  of  the  arthritic  type. — Kliiiisch  -  thcm- 
peutische  Wochenschrift,  October  7.  1900. 

Nasal  Tuberculosis.— Three  cases  are  reported  by 
L.  Bar  and  V^  Texier.  The  first  was  a  primary  mani- 
festation assuming  the  polypoid  form,  the  second 
secondary,  of  granular  form,  and  the  third  secondary, 
presenting  an  ulcerated  polypoid  condition.  For  treat- 
ment the  authors  advise  the  use  of  curetting  with  sub- 
sequent application  of  lactic  acid  preceded  by  cocaini- 
zation.  Scarifications  may  be  necessary,  followed  by 
the  use  of  iodoform  in  glycerin,  mentholated  oil,  etc., 
with  orthoform  for  pain.  Systemic  treatment  must  not 
be  forgotten  in  these  cases. — Rnice  Hebilomadairc  de 
Laryngologie,  September  29,  1900. 


Heredity  in  Disease.— James  Jamieson  considers 
the  modern  tendency  to  minimize  the  infiuence  of  he- 
redity in  disease  causation  a  happy  one.  The  outlook 
becomes  hopeless  when  we  admit  that  disea.se  is  inher- 
ited, i'he  change  in  opinion  along  this  line  is  doubt- 
less largely  referable  to  the  steady  multiplication  of 
evidence  that  infection  plays  a  much  larger  part  than 
was  believed  not  long  ago.  It  is  freely  admitted  that 
a  liability  to  disease  may  be  inherited,  though  in  just 
wliat  this  liability  consists  pathologists  are  not  agreed. 
Tiicre  may  well  be,  there  probably  enough  is,  some 
delicacy  of  constitution,  some  fragility  of  tissue,  which 
may  be  hereditarily  transmitted,  but  that,  or  some- 
thing tantamount  to  it,  may  be  as  readily  acquired. 
Gout  is  always  invoked  as  an  hereditary  malady;  but 
that  the  son  of  a  gouty  father  should  witii  greater 
frequency  than  the  average  exhibit  tills  gouty  tendency, 
admits  of  at  least  ])artial  explanation  in  the  surround- 
ings of  ins  life,  and  the  probability  of  habits  of  lux- 
ury or  of  over-indulgence  among  those  with  whom  he 
is  brought  np.  So  if  we  run  through  the  whole  cate- 
gory of  so-called  hereditary  diseases,  and  consider  the 
matter  in  a  broad  light,  we  shall  find  that  the  factor 
of  heredity  is  not  so  potent  as  has  been  believed. 
Jamieson  admits  the  iiereditary  intluence  in  haemophilia, 
which  is  something  more  than  a  tendency  capable  of 
prevention  or  cure.  In  a  way  it  is  a  tendency,  but  it 
is  also  a  ]iersistent  condition  i)orn  with  the  person, 
and  to  all  appearance  lasting  through  life,  tiiough  its 
exact  nature  seems  hard  to  settle.  ^ — Jiitercoloiiial  Medi- 
cal Journal  of  Aitshalia.  September  20.   1900. 

The  Cure  of  Inveterate  Cases  of  Trigeminal 
Neuralgia.  ('.  J.  Aldrich  thus  details  his  plan  of 
treatment.  Tlie  patient  is  put  to  bed  under  the  care 
of  a  competent  nurse,  and  receives  a  thorough  exami- 
nation of  all  his  bodily  organs  and  functions.  The 
next  morning  he  receives  an  initial  dose  of  castor  oil, 
which  is  \  i.  if  the  patient  is  not  taking  opiates,  and 
5  ii.  if  he  has  become  an  habitue'  or  is  temporarily 
using  them.  A  solution  of  nitrate  of  strychnine  is 
prepared,  ii[  i.  of  which  should  represent  gr.  ^J^.  Of 
this  solution  he  receives  til  xx.  four  times  a  day  as 
the  initial  dose,  with  orders  that  the  dose  should  be 
increased  one  drop  every  twenty-four  hours,  being  an 
actual  increase  of  gr.  j,',,,  each  twenty-four  hours.  If 
the  patient  has  been  taking  morphine,  the  least  possi- 
ble dose  that  will  relieve  the  pain  is  continued  for 
the  first  two  or  three  days,  after  which  time  the  dose 
is  gradually  diminished.  In  addition  it  may  be  nec- 
essary in  cases  of  arteriosclerosis  to  give  some  nitro- 
glycerin. When  evidence  of  atheroma  is  present,  the 
last-named  remedy  can  advantageously  be  combined 
with  thyroid  extract.  Aldrich  suggests  that  the  good 
effects  of  the  castor  oil  may  be  due  to  the  elimination 
of  some  toxic  principle  which  acts  as  a  nerve  irritant, 
thus  causing  the  neuralgia. —  Clevclatid  Medical  Ga- 
zette, November,  igoo. 

A  Case  of  Sudden  Blindness  Subsequent  to  Cau- 
terization of  the  Nose.— A.  R.  Baker  reports  the  case 
of  a  man  of  tliirty-one,  in  whom  one  week  after  cau- 
terization of  the  turbinate  pain  developed  within  three 
days  on  the  same  side  of  the  face;  later  a  chill  came 
on  and  was  repeated  on  the  third  day.  At  the  latter 
time  there  was  a  partial  blurring  of  vision  on  the  same 
side  as  the  cauterization.  The  lower  part  of  the  vis- 
ual field  was  gradually  obliterated  and  in  three  days 
more  the  eye  was  totally  blind.  Examination  showed 
the  eye  to  be  absolutely  blind,  without  perception  of 
light,  the  pupil  moderately  dilated,  not  responding  to 
light  or  accommodation  when  the  fellow-eye  was  cov- 
ered. Ophthalmoscopic  examination  was  negative. 
Hyperopic  astigmatism  of  50  D.  against  the  rule  was 
present.     Left  eye  =  vision  Snellen  fj,  increased  to 


976 


MEDICAL    RECORD. 


[December  22,  1900 


IJJ  with  50  D.,  axis  180°.  Thie  test  was  made  under 
homatropine.  The  lower  part  o£  the  field  was  slightly 
contracted.  The  fundus  was  normal.  There  was  a 
large,  olTensive-smelling,  grayish-green  slough  filling 
the  right  nostril,  which  was  removed  with  difficulty, 
leaving  a  bleeding  ulcerated  surface.  The  patient  was 
put  on  mixed  treatment,  though  no  specific  history 
was  obtainable.  Under  this  routine  the  eye  condition 
gradually  improved  and  finally  became  normal.  A 
mild  condition  of  the  same  nature  had  shown  itself 
in  the  left  eye.  Baker  does  not  think  that  there  was 
a  gumma  present  anywhere. —  Cleveland  Medical  Ga- 
zette, November,  1900. 

Tumors  of  the  Heart — .\lessandro  Tedeschi  says 
that  the  symptoms  of  this  condition  are  oedema  of  the 
upper  extremities,  of  the  head,  and  of  the  chest,  with 
dilatation  of  the  anastomotic  blood-vessels  between 
the  internal  mammary  and  epigastric  veins.  These 
phenomena  clearly  indicate  an  obstruction  to  the  pas- 
sage of  the  venous  blood  from  the  superior  vena  cava 
into  the  right  auricle — a  supposition  which  has  been 
confirmed  at  autopsy  by  the  finding  of  cardiac  tumors 
situated  in  the  upper  portion  of  the  two  auricles. 
These  tumors  frequently  cause  symptoms  in  remote 
parts  of  the  body  by  means  of  emboli.  In  some  cases 
a  cardiac  tumor  has  been  so  well  tolerated  by  the 
heart  that  the  only  symptoms  have  been  a  slight  sys- 
tolic murmur  and  a  slow,  small  pulse. — La  liijorma 
Medica,  October  20,  22,  and  23,  1900. 

Erythromelalgia    Following    Influenza. — Erminio 

Crespolani  reports  a  case  of  "Weir  Mitchell's  dis- 
ease" in  a  man  of  twenty-two  years.  The  affection  is 
characterized  by  spasmodic,  burning  pain,  oedematous 
swelling  of  the  part  affected,  redness,  local  hyperther- 
mia, and,  according  to  some  authorities,  local  hyper- 
idrosis.  The  author  gives  the  various  theories  which 
are  held  in  regard  to  the  etiology  of  the  disease,  and 
leans  to  the  view  that  it  is  due  to  vasomotor  reflex 
action  —  probably  a  dilatation  of  the  blood-vessels 
caused  by  over-excitability  of  the  nerve  centres.  In 
the  case  reported,  the  parts  affected  were  first  the  right 
foot  and  then  the  left.  The  pain  was  intense;  the 
local  rise  of  temperature  increased  to  3.  i  °  C.  Neither 
the  internal  use  of  bromides  nor  the  topical  applica- 
tion of  the  usual  sedatives  succeeded  in  relieving  the 
pain.  Tonics  and  cold  friction  of  the  spinal  column 
effected  a  cure.  The  patient  was  obliged  to  keep  his 
bed  from  February  nth  until  April  14th. —  Giornale 
Internazionale  delle  Scieiize  Mediche,  October  15,  1900. 

The  Use  and  Abuse  of  Cardiac  Stimulants.— H. 
A.  Hare  calls  attention  to  the  abuse  of  digitalis  in 
heart  troubles,  saying  that  in  many  cases  of  palpitation 
such  as  comes  from  overwork,  this  remedy  simply 
aggravates  the  symptoms,  for  what  the  patients  need  is 
not  cardiac  stimulation  but  rest.  The  taking  of  strong 
coffee  under  these  circumstances  still  further  increases 
the  cardiac  irregularity.  Very  frequently  the  use  of 
small  doses  of  aconite  or  veratrum  will  effect  the  de- 
sired result  far  more  quickly  and  efficiently  than  digi- 
talis. A  patient  with'  a  feeble  heart  receives  digitalis, 
it  may  be,  to  overcome  feebleness,  when  in  reality  the 
cause  of  the  feebleness  lies  in  a  degenerated  heart 
muscle  which  is  incapable  of  gaining  any  advantage 
from  this  drug,  and  the  drug  by  contracting  the  blood- 
vessels actually  increases  the  labor  of  the  heart.  Un- 
der these  circumstances,  if  any  drug  is  used  it  should 
be  one,  like  strophanthus  or  cactus,  the  action  of 
which  is  cardiac,  and  but  slightly  if  at  all  vascular. 
Not  only  is  rest  needed  for  the  tired  but  otherwise 
healthy  heart,  but  it  is  even  more  needful  in  cases  in 
which  there  is  cardiac  breakdown,  actual  or  threat- 
ened, in  cases  already  suffering  from  grave  valvular 
lesions.     The  cardiac    stimulants   are   sometimes  ex- 


pected to  perform  miracles,  although  the  patient  pur- 
sues the  same  mode  of  life  as  before.  This  is  in 
reality  an  abuse  of  a  drug,  since  it  is  being  used  to  do 
something  which  is  practically  impossible.- — Ihcrapeu- 
tic  Gazette,  October  15,  igoo. 

Renal  Calculi,  with  Report  of  Cases.— Stuart  Mc- 
Guire  says  that  his  endeavor  is  to  show  that  when  a 
stone  is  known  to  exist  in  the  kidney  an  operation 
should  be  done  for  its  removal,  not  as  a  last  resort  to 
save  life  but  as  an  early  efifort  to  save  the  organ.  An 
early  nephrolithotomy  entails  little  risk  and  is  not 
attended  by  mutilation ;  while  a  late  nephrectomy  is 
followed  by  high  mortality,  frequently  persistent  and 
annoying  fistulae,  and  the  sacrifice  of  an  important  or- 
gan. The  diagnosis  of  renal  calculi  is  sometimes  very 
difficult  to  make.  Often  a  calculus  has  been  found 
post  mortem  without  its  presence  having  been  diag- 
nosed, and  often  a  kidney  has  been  opened  for  sus- 
pected stone  with  negative  results.  The  symptoms  are 
due  to  obstruction  and  depend  more  upon  the  position 
than  the  size  of  the  stone.  They  are  pain;  the  pas- 
sage of  fragments  of  calculi;  the  presence  of  blood 
crystals,  blood,  and  pus  in  the  urine;  frequent  and 
urgent  urination,  and  irregularity  in  the  amount  of 
urine  passed,  varying  from  anuria  to  marked  polyuria. 
—  The  Virginia  Aledical  Setni-JMouthly,  October  26, 
1900. 

Rest  in  Bed  in  the  Treatment   of   Acute  Forms 

of  Mental  Disease S.  S.  Korsakov  says  that  in  the 

systematic  use  of  this  form  of  treatment  rest  in  bed  is 
obtained  by  moral  influence  and  suggestion  rather 
than  by  violence.  The  use  of  a  large  room  in  com- 
mon is  of  the  greatest  advantage.  This  form  of  treat- 
ment brings  about  a  more  orderly  condition  of  affairs 
in  crowded  asylums,  gives  greater  security  to  the  pa- 
tients, and  allows  of  more  accurate  care  and  clinical 
observation.  By  its  use  solitary  confinement  in  cells 
is  rendered  unnecessary  except  in  extreme  cases. 
Violent  cases  are  favorably  affected  by  rest  in  bed; 
and  in  asylums  where  it  is  used,  the  mortality  percen- 
tage from  acute  psychoses  is  notably  diminished.  The 
chief  indication  for  the  treatment  is  excitability.  In 
the  case  of  patients  of  indolent  habit,  predisposed  to 
apathy  and  anaemia,  it  is  contraindicated.  It  is  es- 
pecially effectual  in  maniacal  cases,  in  those  suffering 
from  alcoholic  delirium,  and  in  many  forms  of  mental 
confusion  and  melancholy. — AnluTes  de  Neuiologie, 
October,  igoo. 

The  Management  and  Treatment  of  Whooping- 
Cough. — J.  \V.  VViltse  says  that  RcTskam's  modification 
of  Moncorvo's  method  would  seem  to  be  a  rational  pro- 
cedure, and  according  to  his  statistics  has  succeeded 
well.  It  consists  of  the  application  to  the  glottis  of 
a  one-third-per-cent.  solution  of  resorcin  every  four 
hours  during  the  day,  and  when  possible  once  or  twice 
during  the  night.  In  a  series  of  two  hundred  and 
ninety  ca.ses  treated  in  this  way  all  patients  recovered. 
The  treatment  was  usually  begun  during  the  catarrhal 
stage,  though  in  some  cases  the  convulsive  stage  had 
begun.  Of  the  series  two  patients  recovered  in  four- 
teen days.  Seventy  patients  were  cured  before  the  end 
of  twenty-five  days  and  eighteen  recovered  within  a 
month  from  the  beginning  of  treatment.  As  a  rule, 
children  under  one  year  of  age  recovered  most  rapidly, 
usually  within  eight  days.  This  is  important,  as  it  is 
admitted  by  all  writers  that  whooping-cough  is  most 
fatal  in  the  very  young.  This  method  differs  from 
Moncorvo's  only  in  the  fact  that  Moncorvo  applied  a 
ten-per-cent.  solution  of  cocaine  to  the  throat  before 
using  the  resorcin.  Roskam  rejected  the  cocaine  be- 
cause he  found  it  frequently  caused  spasm  of  the  glottis. 
— Albany  Medical  Annals,  October,  1900. 


December  22,  1900] 


MEDICAL    RECORD. 


977 


Medical  Record: 

A    IVeckly  Journal  of  Medicine  and  Surgery. 


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

I'lBLlSHERS 

WM.  WOOD  &.  CO.,  51    Fifth  Avenue 
New  York,  December  22,  1900. 

THE    SOLDIER'S    TROPICAL    RATION. 

In  the  present  conjunction  of  affairs,  everything  relat- 
ing to  the  tropics  concerns  the  inhabitants  of  the 
United  States  intimately.  Thus  the  etiology  and 
treatment,  both  preventive  and  remedial,  of  the  dis- 
eases prevalent  in  those  regions  are  questions  of  seri- 
ous moment.  All  that  can  be  learned  with  regard  to 
the  mode  of  life  best  suited  to  the  preservation  of  the 
health  of  white  men  who  make  their  home  in  tropical 
countries  is  devoured  with  avidity.  Under  existing 
circumstances  the  army  in  the  Philippines  is  the 
focus  of  absorbing  interest.  Therefore  the  report  of 
the  board  appointed  to  study  the  matter  of  tropical 
ration  for  American  troops,  and  to  suggest  beneficial 
changes  therein,  will  be  attentively  read  by  the  gen- 
eral public.  It  goes  without  saying  that  diet  is  one 
of  the  most  important  of  considerations  when  the  ren- 
dering of  a  white  man  able  to  cope  with  his  un- 
accustomed environment  is  the  object  in  view.  On 
this  point,  opinions  clash.  There  are  those  who  in- 
sist that  under  no  conditions  can  the  inhabitant  of 
the  temperate  zone  dwell  in  perfect  health  in  tropical 
lands.  On  the  other  hand,  many  men  of  experience 
state  that,  if  these  individuals  live  in  a  manner  befit- 
ting the  climate,  paying  strict  heed  to  the  laws  of 
hygiene,  and  if,  above  all,  they  are  discreet  in  eat- 
ing and  drinking,  there  is  no  valid  reason  why  they 
should  not  enjoy  good  health.  So  far  as  the  kind  of 
food  is  concerned,  a  wide  divergence  of  views  exists. 
Some  argue  that  an  entirely  different  dietary  is  indi- 
cated in  tropical  countries,  and  that  the  person  who 
imagines  that  he  can  thrive  on  the  same  description  of 
food  that  he  eats  when  at  home,  will  be  certain  quickly 
to  break  down.  Others  assert  that  but  a  slight  change 
of  diet  is  needed  from  the  ordinary  fare  of  an  Ameri- 
can in  his  own  country,  and  that  if  the  stranger  in  the 
tropics  endeavors  to  live  as  does  the  native,  he  will 
soon  lose  both  energy  and  physical  power.  Major 
Louis  Seaman,  late  surgeon  in  the  United  States  En- 
gineers, IS  an  upholder  of  the  former  contention,  and 
writing  to  the  Medical  Record  says,  "A  personal 
experience  in  two  of  the  latest  tropical  wars,  and 
a  study  of  the  statistics  of  others,  have  led  me  to  the 
conviction  that  the  most  prominent  cause  in  bringing 
about  the  development  of  preventable  diseases  in  both 
these  wars  was  the  misuse  of  food."  Speaking  gen- 
erally, he  considers  that  the  majority  of  the  diseases 


met  with  among  troops  serving  in  the  tropics  have 
their  origin  in  improper  food,  in  overfeeding,  or  in 
the  abuse  of  stimulants;  and  he  suggests  a  dietary 
scale  containing  much  less  meat  and  fat  than  was 
issued  to  the  United  States  troops.  Dr.  Seaman  is  of 
the  opinion  that  the  ration  was  an  excellent  winter 
food,  rich  in  the  elements  requisite  for  respiration  un- 
der a  low  temperature;  but  for  a  tropical  land,  the 
enormous  excess  of  carbon  furnished  by  it  to  the  lungs 
over  and  above  that  which  they  could  dispose  of,  im- 
posed upon  the  liver  and  kidneys  additional  duties  of 
elimination,  producing  congestions,  fermentation  and 
catarrhs,  dyspepsia  and  lithasmia,  glycosuria  and 
phosphaturia,  interfering  with  metabolism,  and  creat- 
ing conditions  favorable  to  bacterial  development,  to- 
gether with  almost  the  entire  train  of  diseases  which 
have  crowded  our  army  hospitals.  As  remarked 
above,  many  medical  men  who  have  gained  experience 
from  a  lengthened  sojourn  in  the  Philippines  hold 
that  meat  is  a  necessity  for  the  American  soldier,  and 
that,  lacking  it,  his  bodily  powers  will  fail.  The  board 
have  cautiously  steered  a  middle  course,  and  while 
recommending  that  the  fresh-meat  ration  should  not 
be  reduced  in  quantity,  declare  that  the  problem  is  to 
find  such  a  ration  as  will,  by  substitutes  among  its 
various  ingredients,  be  suitable  for  all  climates. 
Cornmeal  has  been  excluded  from  the  ration,  as  have 
dried  peas,  for  the  latter  of  which  oatmeal  has  been 
substituted.  The  sugar  ration,  as  in  all  European 
armies,  has  been  increased,  and  coffee  has  been  re- 
tained. The  action  of  the  board  appears  to  be  amply 
justified  and  will  probably  meet  with  the  approval  of 
the  majority  of  those  who  have  spent  some  time  in  the 
tropics.  P'resh  meat,  fresh  vegetables,  fresh  fruit,  sup- 
plied in  suflicient  quantities,  should  tend  to  preserve 
the  health  of  the  dweller  in  tropical  countries,  and 
whenever  obtainable  will  undoubtedly  meet  the  ex- 
igencies of  the  situation  better  than  embalmed  meat 
and  canned  vegetables.  Universal  agreement  pre- 
vails on  the  point  that  alcoholic  drinks  are  almost  in- 
variably injurious  to  the  white  man  in  the  tropics.  It 
may  be  said  that  when  the  problem  of  the  most  healthy 
diet  for  the  foreigner  in  the  tropics  is  solved,  the 
greatest  obstacle  in  the  way  of  rendering  these  coun- 
tries salubrious  will  have  been  overcome. 


THE   AMERICAN    GIRL   OF    TO-DAY. 

The  influence  of  modern  education  on  the  functional 
development  of  girls  is  a  matter  the  importance  of 
which  it  is  almost  impossible  to  overestimate,  and 
it  is  one  which  will  bear  discussion  with  advantage. 
From  all  sides  and  from  all  parts  of  the  civilized 
world  comes  the  cry  that  the  vitality  of  the  race  is 
being  sapped  by  injudicious  methods  of  education. 
In  the  case  of  growing  girls  this  is  a  question  that 
closely  concerns  the  physical  and  mental  welfare  of 
every  nation,  for  it  stands  to  reason  that  in  order  to 
produce  and  rear  a  healthy  progeny,  the  mothers  of 
our  children  should  be  thoroughly  sound  in  mind  and 
body.  In  the  United  States,  perhaps  to  a  greater  ex- 
tent than  in  any  other  country,  has  the  present  system 


978 


MEDICAL    RECORD. 


[December  22,  1900 


of  educating  girls  shown  its  worst  effects.  Dr.  George 
J.  Engelmann,  of  Boston,  dealt  with  this  subject  in 
liis  eloquent  presidential  address  delivered  before 
the  American  Gynaecological  Society.  Dr.  Kngelmann 
points  out  that  the  gravity  of  the  question  and  tlie 
practical  bearing  of  the  results  obtained  are  perhaps 
more  fully  apparent  when  we  realize  not  only  how  im- 
portant but  how  large  an  element  of  our  population  is 
concerned — 374,487  young  women  in  colleges  and 
high  schools,  and  over  one  million  of  the  same  ages 
ill  the  industries.  Dr.  Engelmann  goes  on  to  say 
that  "statistics  have  clearly  shown  the  tremendous 
susceptibility  and  the  almost  feverish  activity  of  the 
system  in  the  prepubertal  period,  the  period  of  devel- 
oping womanhood:  susceptibility  indicated  by  height- 
ened morbidity;  nerve  excitement  by  an  increase  of 
stuttering  and  hysteria;  heightened  physiological 
activity  by  increased  growth,  and  resistance  to  dis- 
ease by  lowered  mortality;  all  gradually  wane  as  the 
vital  energies  are  claimed  more  and  more  by  the  re- 
productive function,  and  reach  their  lowest  ebb  with 
the  advent  of  puberty,  again  rising  after  menstruation 
is  established,  and  it  is  at  this  period  of  still  unstable 
equilibrium  that  we  find  the  schoolgirl."  The  con- 
tentior.  is  made  that  the  system  of  education  in  vogue 
in  the  schools  and  colleges  of  this  country  tends  to  ag- 
grivate  these  conditions  in  the  rising  generation  of 
American  womankind,  with  the  result  of  a  general  and 
functional  deterioration  in  health.  Dr.  VV.  Gill  Wylie 
puts  the  case  forcibly  and  well  when  he  says  that 
"  the  American  horse  receives,  on  the  average,  better 
treatment  than  the  young  woman  of  America  from  the 
time  of  early  girlhood  until  the  age  of  development 
has  passed.  The  stock-breeder  never  forces  the  young 
animal  during  the  period  of  development,  realizing 
that  it  is  the  time  the  greatest  care  should  be  taken; 
while  American  parents,  especially  of  the  middle 
classes,  with  great  ambition  for  their  children  and  the 
desire  that  they  develop  intellectually  beyond  their 
own  standard,  allow  their  heads  to  be  crammed  with 
knowledge  so  rapidly  that  the  brain  cannot  assimilate 
it,  and  the  result  is  that  all  strength  of  development  is 
devoted  to  the  brain,  and  physique  finds  expansion  as 
best  it  can:  New  England  furnishing  the  extreme 
type  of  the  woman,  supposedly  more  perfect  than  in 
any  other  section  ;  intellectually  above  the  average,  but 
with  a  physique  below  par,  with  greatly  reduced  re- 
productive powers — all  due  to  the  forcing  of  study  at 
the  age  of  development."  Dr.  Engelmann  believes 
that  many  of  the  evil  effects  produced  by  this  irra- 
tional mode  of  education  may  be  overcome  by  judi- 
cious physical  training  and  by  strict  adherence  to  the 
laws  of  hygiene.  But  above  all  he  urges  preventive 
measures,  and  holds  that  the  real  solution  is  in  rea- 
sonable hours  of  study,  in  mental  training  adapted 
to  physiological  possibilities,  and  in  a  regard  for  the 
claims  of  woman's  sensitive  organization.  The  paper 
concludes  with  the  following  advice:  "ITpon  the 
mother  I  would  impress  that  perfect  development  of 
the  female  function,  and  maintenance  of  tliis  func- 
tion, once  developed,  in  a  healthy  condition,  is  essential 
to  perfect  development  of  the  girl  and  perfect  health 
of  the  woman;   that  self-care,  a  well-regulated  female 


hygiene,  is  the  foundation  of  her  well-being,  and  that 
it  is  the  mother's  first  duty  so  to  guard  herself  and  so  to 
guard  her  daughter.  To  the  educator  1  would  say  that 
heed  must  be  given  the  instability  and  susceptibility 
of  the  girl  during  the  functional  waves  which  per- 
meate her  entire  being;  that  emotional  stimulation 
must  be  avoided,  and  decided  concessions  must  be 
made  to  the  depression,  physical  and  psychical,  the 
lessened  inhibition  and  physiological  control  during 
the  fluctuations  of  puberty  and  menstruation.  Upon 
the  physician  I  would  urge  care  and  guidance  of  the 
girl  during  the  great  waves  of  female  life,  those  pe- 
riods of  increased  susceptibility,  and  of  physiological 
intensification  and  depression;  and  such  care  is  the 
first  and  essential  step  in  preventive  gynaecology." 
The  present-day  native  American  girl  of  the  middle 
class  is  the  artificial  product  of  advanced  civilization. 
She  is  a  bundle  of  nerves  encased  in  a  fragile  frame, 
and  there  is  undoubtedly  reason  to  fear  that,  unless  a 
radical  change  is  made  in  her  upbringing,  the  conse- 
quences will  be  serious  to  the  entire  community.  Less 
brain  work  and  more  fresh  air  and  exercise  are  the 
remedies  recommended. 


THE    INFLUENCE     ON     HEALTH     OF     THE 
FILTRATION    PLANT   AT  ALBANY. 

An  editorial  in  the  Medical  Record  of  December  8th 
drew  attention  to  the  decreased  rate  of  mortality  in 
those  cities  in  which  a  filtration  plant  had  been  intro- 
duced, and  it  was  shown  that  a  comparatively  pure 
water  supply  greatly  affected  the  occurrence  of  typhoid 
fever.  Efforts  are  being  made  at  the  present  time  in 
several  American  cities  of  the  first  magnitude,  as 
well  as  in  some  smaller  ones,  to  curtail  the  spread 
of  diseases,  and  especially  that  of  typhoid  fever, 
by  insuring  an  unpolluted  service  of  water  for  do- 
mestic purposes.  The  majority  of  experts  have 
come  to  the  conclusion — which  is  also  borne  out  by 
practical  proofs — that  an  efficient  system  of  filtration 
is  the  best  means  of  purifying  water.  The  Albany 
filtration  plant,  established  quite  recently,  is  possibly 
the  most  satisfactory  instance  on  a  fairly  large  scale  of 
the  good  results  accruing  from  such  a  system  in  the 
country.  In  the  Albany  Medical  Annals  for  December, 
Dr.  Martin  MacHarg,  vice-president  of  the  Medical 
Society  of  the  County  of  Albany,  contributes  a  well- 
written  account  of  the  construction  and  working  of  the 
newly  erected  filtration  plant  in  that  city.  Up  to 
September  6,  1898,  when  the  filters  were  completed, 
Albany  had  been  dependent,  for  its  drinking-water, 
upon  reservoirs  supplied  by  small  streams  and  upon  the 
Hudson  River.  In  recent  years  the  greater  portion  of 
the  water  was  drawn  from  the  Hudson.  Owing  to  the 
fact  that  the  Hudson  was  seriously  contaminated  by 
local  sewerage,  as  well  as  by  the  sewerage  of  Troy, 
Cohoes,  and  other  cities,  it  is  not  surprising  that  the 
typhoid-fever  death  rate  was  excessive.  Steps  were 
therefore  taken  to  instal  an  up-to-date  filtration  plant. 
Dr.  MacHarg  gives  a  description  of  the  plant,  which 
lack  of  space  does  not  permit  us  to  quote.  Suffice  it, 
then,  to  say  that   the   nieliiods   in   use   are  of  the  most 


December  22,  1900] 


MEDICAL    RhXORD. 


979 


approved  type.  With  regard  to  the  benefits  conferred 
upon  the  inhabitants  by  the  system,  Ur.  MacHarg 
says:  "The  filters  were  designed  to  remove  from  the 
•water  the  bacteria  which  caused  disease.  The  super- 
intendent of  the  plant,  Mr.  Bailey,  in  August  last 
issued  a  report  on  the  results  of  the  plant  for  three 
hundred  and  nineteen  days'  actual  operation,  and  I 
give  his  report  verbatim.  The  number  of  gallons 
filtered  was  3,817,200,000,  or  on  an  average  of  near- 
ly 12,000,0000  gallons  a  day.  This  is  the  largest 
amount  of  water  ever  filtered  by  a  single  American  fil- 
tration plant  in  so  short  a  period.  The  cost  of  operat- 
ing the  filtering  beds  and  care  of  the  grounds  has 
been  $1.94  per  1,000,000  gallons,  and  that  of  chemi- 
cal and  bacteriological  examination  is  34  cents  per 
1,000,000  gallons.  The  cost  of  pumping  is  $2.4?.  per 
1,000,000  gallons.  The  efficiency  in  bacterial  re- 
moval has  been  good.  As  regards  its  removal  for  the 
first  three  months  of  1900,  the  average  number  of 
bacteria  in  the  unfiltered  water  for  the  whole  plant 
never  fell  below  200  in  a  cubic  centimetre,  reaching 
that  figure  on  March  30,  1900.  On  April  2d  and  6th, 
respectively,  when  the  bacteria  in  the  raw  water  num- 
bered 45,000  and  37,000  respectively,  99.07  per  cent, 
of  the  total  was  removed.  The  influence  upon  the 
death  rate  from  typhoid  fever  has  been  quick  and  de- 
cided. The  average  number  of  deaths  from  typhoid 
fever  in  Albany  for  nine  years  up  to  1899  was  85 
in  a  year.  From  January,  1899,  to  August  i,  1899, 
when  the  city  was  using  unfiltered  water,  there  were 
71  deaths  from  typhoid  fever;  and  from  August  i, 
1899,  to  January  i,  1900,  or  when  filtered  water  was 
in  use,  there  were  only  7  deaths  from  this  disease. 
From  January  ist  of  the  present  year  up  to  July  ist, 
there  were  only  19  deaths  for  the  six  months,  or  a 
total  of  24  for  the  year,  against  85,  the  average  for 
the  preceding  years.  These  figures  show  plainly  that 
the  Albany  Filtration  Plant  has  been  the  most  promi- 
nent factor  in  decreasing  the  death  rate  from  typhoid 
fever;  and  the  evidence  from  other  cities  and  towns 
in  which  a  similar  system  has  been  instituted  has 
given  equally  conclusive  results.'"  Therefore  it  would 
appear  that  the  moral  to  be  extracted  from  these  rec- 
ords by  those  cities  which  do  not  at  present  possess  a 
filtration  plant  is,  "Go  thou  and  do  likewise." 


ADULTERATION    OF    FOOD. 

Embalming  food  seems  to  be  a  universal  custom,  an  out- 
come probably  of  advanced  civilization.  In  Kuropethe 
practice  of  adding  foreign  substances  to  articles  of  diet 
— sometimes  for  the  purpose  of  preserving  these  arti- 
cles, sometimes  with  the  aim  of  imitating  genuine  food 
with  intent  to  deceive — is  carried  on  to  an  alarming  ex- 
tent. In  Great  Britain,  although  adulteration  has  not 
reached  these  proportions,  yet  the  discoveries  made 
recently  with  respect  to  the  addition  of  arsenic  to  beer 
prove  that  manufacturers  there  are  not  altogether  quite 
innocent.  The  New  Vork  Tribune,  Sunday,  December 
9th,  contains  a  strong  leader  on  the  subject,  taking  as 
its  text  the  case  of  an  infant  who.  after  investigation, 
was  found  to  have  been  killed  by  the   use  of  formal- 


dehyde in  the  milk  upon  which  it  had  been  fed.  The 
writer  of  the  editorial  referred  to  says :  "  We  have  no 
doubt  that  the  same  or  a  similar  verdict  might  be  ren- 
dered in  the  cases  of  tens  of  thousands  of  people, 
children  and  adults,  who  are  literally  done  to  death 
with  embalmed  food.  The  use  of  drugs,  such  as 
formaldehyde,  boric  acid,  and  salicylic  acid,  as  '  pre- 
servatives is  widespread  to  a  most  alarming  ex- 
tent.' These  drugs  are  put  into  milk  and  cream 
to  keep  them  sweet,  into  butter  and  cheese  to  keep 
them  from  becoming  rancid,  into  canned  fruits,  and 
vegetable,  and  meats,  and  indeed  into  nearly  all  food 
products  that  are  of  a  perishable  nature,  and  that  are 
to  be  kept  for  a  length  of  time  in  which  their  freshness 
might  be  imperilled.  They  are  tasteless,  odorless, 
colorless,  and  their  presence  cannot  be  detected  save 
by  an  expert."  The  article  in  the  Tribune  then  goes 
on  to  demonstrate  that  the  addition  of  drugs  to  food 
is  a  harmful  and  pernicious  practice,  and  that  the 
same  object  can  be  attained  by  natural  and  legitimate 
means.  The  Medical  Record  has  ever  strongly  dep- 
recated the  use  of  drugs  as  preservatives  of  food,  and 
has  been  foremost  in  denouncing  the  custom.  It  is 
scandalous  that  the  health  of  the  people  at  large,  and 
especially  of  young  children,  should  be  at  the  mercy 
of  manufacturers  who,  eager  for  a  little  more  profit, 
have  no  scruples  as  to  the  manner  in  which  it  is 
gained.  Stringent  laws  rigidly  enforced  are  called  for 
to  correct  this  evil. 


OXALURIA. 


There  have  always  been  differences  of  opinion  as  to  the 
significance  of  the  presence  of  oxalic  acid  or  oxalates  in 
the  urine,  and  as  to  whether  their  presence  was  due 
solely  to  ingestion  with  the  food  or  whether  it  could  be 
attributed  to  generation  within  the  body.  This  acid  oc- 
curs in  many,  though  not  all,  vegetables,  grains,  and 
fruits,  and  is  not  contained  in  proteids  and  sugar.  It 
has  been  found  in  the  urine  under  many  varied  condi- 
tions, and  certain  vague  symptoms  have  been  associated 
with  its  presence.  For  the  purpose  of  determining 
whether  all  of  the  oxalic  acid  excreted  in  the  urine  is 
ingested  with  the  food,  or  whether  any  is  ever  formed  in 
the  animal  organism  by  metabolism,  as  well  as  for 
the  purpose  of  studying  the  influence  of  the  ingestion 
of  oxalic  acid  in  foods  upon  the  amount  excreted  in  the 
urine,  and  also  the  physiological  action  of  soluble  oxa- 
lates.with  the  view  of  deciding  in  what  measure  the  pres- 
ence of  oxalic  acid  in  the  system  is  responsible  for  the 
symptoms  attributed  to  the  so-called  oxalic-acid  diathe- 
sis. Dr.  Helen  Baldwin  {Journal  of  Experimental  Medi- 
cine, vol.  v.,  No.  r,  p.  27)  engaged  in  a  series  of  ob- 
servations and  experiments,  as  a  result  of  which  the 
opinion  has  been  formed  that  as  varying  amounts  of 
calcium  oxalate  may  be  held  in  solution  in  the  urine, 
conclusions  based  upon  the  presence  or  number  of 
calcium-oxalate  crystals  found  therein  are  of  no  real 
value  as  an  indication  of  the  quantity  of  oxalic  acid 
present.  Unless  the  utmost  care  is  exercised,  the  re- 
sults obtained  by  quantitative  estimations  of  oxalic 
acid  are  subject  to  large   percentages  of  error.     An 


980 


MEDICAL    RECORD. 


[December  22,  1900 


ordinary  mixed  diet  regularlj' contains  traces  of  oxalic 
acid  or  its  salts.  A  portion  of  the  oxalic  acid  in- 
gested with  the  food  may  be  absorbed  and  reappear 
unchanged  in  the  urine.  The  normal  daily  excretion 
of  oxalic  acid  in  the  urine  fluctuates  with  the  amount 
taken  in  the  food,  and  varies  from  a  few  milligrams  to 
two  or  three  centigrams,  being  usually  below  ten  mil- 
ligrams. In  health  no  oxalic  acid,  or  only  a  trace,  is 
formed  in  the  body,  but  that  present  in  the  urine  has 
been  ingested  with  the  food.  In  certain  clinical  dis- 
turbances sometimes  associated  with  absence  of  free 
hydrochloric  acid  in  the  gastric  juice,  oxalic  acid  is 
formed  in  the  organism  as  a  result  of  fermentative 
activity  in  the  alimentary  canal.  The  prolonged  feed- 
ing of  dogs  with  excessive  quantities  of  glucose,  to- 
gether with  meat,  leads  eventually  to  a  state  of  ox- 
aluria.  This  experimental  oxaluria  is  associated  with 
a  mucous  gastritis  and  with  absence  of  free  hydro- 
chloric acid  from  the  gastric  contents. 


'g.cvos  of  tlxe  'tmccli. 

Philadelphia  Pediatric  Society. — At  a  stated  meet- 
ing held  December  nth  Drs.  C.  H.  Frazier  and  A. 
L.  Newhall  exhibited  a  small  colored  boy  in  whom  a 
peJicled  flap  from  the  buttock  had  been  transplanted 
to  the  palm  of  the  hand  to  replace  a  cicatrix  left  by 
a  burn.  Dr.  C.  F.  Judson  exhibited  a  child  five  years 
old  presenting  symptoms  of  "  Spastic  Paraplegia  "  fol- 
lowing traumatism  and  apparently  resulting  from  trans- 
verse myelitis.  Dr.  Alfred  Stengel  exhibited  four 
cases  of  "Acute  Anterior  Poliomyelitis"  in  young 
children,  and  referred  to  the  relatively  epidemic  prev- 
alence of  the  disease.  Dr.  J.  P.  Crozer  Griffith  exhib- 
ited a  case  of  "  Nodding  Spasm"  in  a  colored  child  with 
slight  symptoms  of  rickets.  Dr.  L.  C.  Peter  exhibited 
a  boy,  about  twelve  years  old,  with  a  history  of  repeated 
attacks  of  chorea,  who  presented  spasmodic  movements 
of  the  laryngeal  structures  giving  rise  to  a  peculiar 
sound,  together  with  other  muscular  movements  of  the 
type  of  "Spasmodic  Tic."  Dr.  Luther  exhibited  also 
a  child  with  weakness  in  the  right  arm  and  leg,  in- 
creased knee  jerk,  staggering  gait,  headache,  and  loss 
of  vision,  with  degeneration  of  the  optic  discs,  prob- 
ably dependent  upon  "  Cerebellar  Tumor."  Drs.  J. 
F.  Schamberg  and  H.  P.  Keech  reported  "  A  Case  of 
Acute  Fatal  Pemphigus,"  developing  in  a  child  in  the 
sequence  of  vaccination.  Dr.  R.  A.  Cleeman  read  a 
paper  entitled  "Thirty-five  Cases  of  Diphtheria  in 
Private  Practice  Treated  with  Antitoxin."  There 
were  four  deaths,  but  only  one  of  these  was  directly 
due  to  the  primary  disease.  Intubation  was  required 
in  three.  Comparatively  large  doses  of  the  antitoxin 
were  employed.  Dr.  S.  Seilikovitch  read  a  paper  en- 
titled "  A  Group  of  Symptoms;  No  Diagnosis."  He 
reported  the  case  of  a  child  that  had  passed  through 
attacks  of  influenza,  pneumonia,  and  typhoid  fever, 
and  died  as  the  result  of  copious  hemorrhage  from  the 
mouth.  There  had  been  no  symptoms  of  disease  of 
the  lungs,  and  the  patient  had  not  responded  to  treat- 
ment for  scurvy. 


The  New  York  State  Hospital  for  the  Care  of 
Crippled  and  Deformed  Children,  incorporated  by 
the  last  legislature,  is  now  open  for  the  reception  and 
treatment  of  patients.  The  hospital  is  located  at 
Tarrytown,  N.  Y.,  at  Paulding  Avenue  and  the  Hud- 
son River,  about  a  mile  south  of  the  railroad  station. 
It  has  accommodations  for  about  thirty  jiatients.  The 
board  of  managers  appointed  by  Governor  Roosevelt 
are  the  Right  Rev.  Henry  C.  Potter,  Bishop  of  New 
York,  President;  George  Blagden,  Jr.,  Secretary  and 
Treasurer;  J.  Hampden  Robb,  J.  Adriance  Bush,  and 
Dr.  Newton  M.  Shafter.  The  hospital  was  established 
"for  the  care  and  treatment  of  any  indigent  children 
who  may  have  resided  in  the  State  of  New  York  for 
a  period  not  less  than  one  year  who  are  crippled  or 
deformed,  or  are  suffering  from  a  disease  from  which 
they  are  likely  to  become  deformed."  The  following 
conditions  are  imposed  upon  all  applicants:  "No 
patient  shall  be  received  except  upon  satisfactory 
proof  made  to  the  surgeon-in-chief,  by  the  next  of  kin, 
guardian,  or  a  State,  town  or  county  officer,  under  the 
rules  to  be  established  by  the  board  of  managers, 
showing  that  the  patient  is  unable  to  pay  for  private 
treatment.  Such  proof  shall  be  by  affidavit.  If  there 
was  an  attending  physician  before  the  patient  entered 
the  hospital,  it  shall  be  accompanied  by  the  certificate 
of  such  physician  giving  the  previous  history  and  con- 
dition of  the  patient."  Patients  from  three  to  fifteen 
years  will  be  received  for  treatment,  and  all  applica- 
tions will  be  acted  upon  in  the  order  of  their  recep- 
tion. No  patient  will  be  admitted  without  an  examina- 
tion by  and  a  certificate  from  the  surgeon-in-chief  or 
his  assistants.  No  patient  whose  condition  is  such 
that  death  is  likely  to  occur  in  the  immediate  future, 
or  whose  condition  precludes  a  reasonable  amount  of 
relief  as  the  result  of  treatment,  will  be  admitted. 
Application  for  admission  should  be  made  to  Dr. 
Newton  M.  Shaffer,  surgeon-in-chief,  No.  28  East 
38th  Street,  New  York,  who  will  appoint  a  time  and 
place  for  the  examination  of  the  patient.  Patients 
living  at  remote  points  in  the  State  are  referred  to  the 
following  gentlemen  (out-of-town  members  of  the  con- 
sulting staff)  :  Dr.  A.  Vander  Veer  and  Dr.  S.  B.  Ward, 
of  Albany,  N.  Y. ;  Dr.  Louis  A.  Weigel,  Rochester,  N. 
Y. ;  Dr.  Roswell  Park  and  Dr.  Charles  G.  Stockton, 
Buffalo,  N.  Y.;  and  Dr.  Richard  B.  Coutant,  Tarry- 
town,  N.  Y. 

The  Samuel  D.  Gross  Prize. — ^The  next  award  of 
this  prize,  of  the  value  of  $1,000,  will  be  made  in 
October,  190 1,  no  essay  which  the  trustees  deemed 
worthy  of  the  prize  having  been  received  in  January, 
1900.  The  conditions  are  that  the  prize  "shall  be 
awarded  every  five  years  to  the  writer  of  the  best 
original  essay,  not  exceeding  one  hundred  and  fifty 
printed  pages,  octavo,  in  length,  illustrative  of  some 
subject  in  surgical  pathology  or  surgical  practice, 
founded  upon  original  investigations,  the  candidates 
for  the  prize  to  be  American  citizens."  It  is  expressly 
stipulated  that  the  competitor  who  receives  the  prize 
shall  publish  his  essay  in  book  form,  and  that  he  siiall 
deposit  one  copy  of  the  work  in  the  Samuel  D.  Gross 
library  of  the  Philadelphia  Academy  of  Surgery,  and 


December  22,  1900] 


MEDICAL    RECORD. 


981 


that  on  the  title  page  it  shall  be  stated  that  to  the 
essay  was  awarded  the  Samuel  D.  Gross  prize  of  the 
Philadelphia  Academy  of  Surgery.  The  essays,  which 
must  be  written  by  a  single  author  in  the  English 
language,  should  be  sent  to  the  "Trustees  of  the 
Samuel  D.  Gross  prize  of  the  Philadelphia  Academy  of 
Surgery,  care  of  the  College  of  Physicians,  2  19  S.  13'lh 
Street,  Philadelphia,"  on  or  before  October  i,  1901. 
Each  essay  must  be  distinguished  by  a  motto,  and 
accompanied  by  a  sealed  envelope  bearing  the  same 
motto,  and  containing  the  name  and  address  of  the 
writer.  Xo  envelope  will  be  opened  except  that  which 
accompanies  the  successful  essay.  The  committee 
will  return  the  unsuccessful  essays  if  reclaimed  by 
their  respective  writers,  or  their  agents,  within  one 
year.  The  Committee  reserves  the  right  to  make  no 
award  if  the  essays  submitted  are  not  considered 
worthy  of  the  prize. 

Pennsylvania  State  Medical  Examinations. — Of 
three  hundred  and  si.xty-eight  applicants  for  the  li- 
cense to  practise  medicine  in  the  State  of  Pennsyl- 
vania forty-one  failed  to  pass  the  necessary  examina- 
tion. 

Typhoid  Fever  in  South  Africa — It  was  stated 
recently,  in  reply  to  a  question  in  Parliament,  that 
there  had  been  15,625  cases  of  typhoid  fever  among 
the  British  troops  in  South  Africa,  and  that  of  this 
number  3,642  proved  fatal. 

The  Water  Supply  of  Chicago. — We  are  informed 
that  the  water  supply  of  Chicago  in  1899  was  equiva- 
lent to  a  daily  per  capita  of  one  hundred  and  eighty- 
seven  gallons  instead  of  one  hundred  and  nineteen, 
as  stated  in  a  recent  issue. 

A  Woman's  Hospital  in  Toronto. — A  committee 
was  appointed  at  a  meeting  of  women  held  recently 
in  Toronto  to  formulate  plans  for  the  maintenance  of 
a  women's  hospital  in  connection  with  the  Women's 
Medical  College  of  Ontario.  All  the  members  of  the 
medical  staff,  both  attending  and  interne,  are  to  be 
women.  It  is  proposed  to  ask  for  twenty-five-cent 
subscriptions  for  the  work  from  women  of  Ontario. 

Legislation  against  Alcoholism  in  France — A 
resolution  has  been  adopted  unanimously  by  the 
French  chamber  of  deputies  calling  upon  the  gov- 
ernment to  prohibit  the  manufacture  and  sale  of  all 
alcoholic  liquors  pronounced  "dangerous"  by  the 
Academy  of  Medicine.  The  resolution  is  said  to  be 
aimed  especially  at  absinthe,  the  consumption  of 
which  has  nearly  doubled  in  France  since  1894,  and 
now  stands  at  10,000,000  litres  annually. 

A  Veterinary  Corps  for  the  Army.— An  amend- 
ment to  the  army  bill  now  before  congress  provides 
for  a  veterinary  corps,  consisting  of  one  colonel,  one 
major,  four  captains,  ten  first  lieutenants,  and  twenty 
second  lieutenants.  The  pay  of  these  officers  will 
amount  to  $64,000  a  year,  besides  longevity  pay,  allow- 
ances, and  travelling-expenses.  At  present  there  are 
thirty-four  veterinarians  in  the  army.  Fourteen  of  these 
are  sergeants,  one  being  attached  to  each  field  bat- 
tery.    Twenty    are  commissioned  officers   known    as 


senior  and  junior  "veterinarians,"  one  of  each  grade 
being  attached  to  each  of  the  ten  cavalry  regiments. 

Pathological  Society  of  Philadelphia.— At  a  stated 
meeting  held  December  13th  a  general  exhibition  of 
card  specimens  was  made  and  proved  most  interesting 
and  successful. 

The  British  Congress  of  Tuberculosis  will  be  held 
in  London  during  the  week  beginning  July  22,  1901, 
under  the  auspices  of  the  National  Association  for  the 
Prevention  of  Consumption.  The  president  of  the 
executive  committee  of  the  congress  is  Dr.  T.  Clifford 
Allbutt  and  the  general  secretary  is  Mr.  Malcolm 
Morris.  The  congress  will  be  opened  by  the  Prince  of 
Wales.  There  will  be  four  sections  on  state  medicine, 
pathology,  human  medicine,  and  veterinary  medicine 
respectively.  The  section  meetings  will  be  held  in  the 
forenoons  and  the  general  sessions  in  the  afternoons. 
Foreign  governments  and  universities  will  be  invited 
to  send  delegatus. 

Cornell  Medical  College  Building  in  Ithaca.— 
The  executive  committee  of  the  board  of  trustees  of 
Cornell  University  has  awarded  the  contract  for  a 
building  for  the  use  of  the  medical  department  on 
Cornell  campus.  The  building  will  cost  $125,000, 
and  when  finished  will,  it  is  said,  be  tiie  handsomest 
on  the  campus.  The  building  will  be  situated  next  to 
the  College  of  Law,  and  will  nearly  complete  the  large 
quadrangle  of  university  buildings.  The  contract 
calls  for  the  completion  of  the  work  so  that  the  build- 
ing will  be  ready  for  occupancy  in  the  autumn  of  1902. 

Philadelphia  County  Medical  Society At  a  stated 

meeting  held  December  12th  Dr.  Ernest  Laplace  ex- 
hibited a  young  man  from  whom  he  had  removed  a 
neuroma  of  the  ulnar  nerve  resulting  from  traumatism, 
with  almost  immediate  restoration  of  motility  and  sen- 
sibility. Dr.  John  C.  Munro,  of  Boston,  read  by  in- 
vitation a  paper  entitled  "Lymphatic  and  Portal  In- 
fection Following  Appendicitis."  The  discussion  was 
participated  in  by  Drs.  H.  A.  Hare,  Edward  Martin, 
John  B.  Roberts,  John  G.  Clark,  Simon  Flexner,  M. 
H.  Fussell,  Mordecai  Price,  T.  S.  K.  Morton,  and  G. 
E.  Shoemaker. 

Sanitation  in  Havana — Some  of  the  residents  of 
Havana  are  getting  uneasy  over  the  work  of  the  sani- 
tary authorities  and  are  complaining  bitterly  of  the 
new  order  of  things.  We  learn  from  The  Sun  that  a 
meeting  of  three  hundred  householders  and  tenants  was 
held  in  Havana  last  Sunday,  under  the  auspices  of  the 
Havana  Union  of  Property  Holders,  to  protest  against 
the  sanitary  department.  Various  house  owners  who 
addressed  the  meeting  declared  that  the  sanitary  de- 
partment had  no  definite  plan,  and  that  it  often  issued 
unnecessary  and  even  impossible  orders  (such  as  to 
connect  the  houses  with  the  street  drains  when  the 
streets  had  no  drains),  the  householders  then  being 
heavily  fined  for  not  obeying.  The  meeting  resolved 
to  name  a  committee  to  explain  to  Governor-General 
Wood  the  cause  of  the  discontent,  and  to  ask  him  to 
define  all  the  requisites  which  householders  must  ful- 
fil in  order  that  they  might  know  how  they  stood  within 
the  law.     They  will  also  ask  that  the  sanitary  depart- 


98: 


MEDICAL    RECORD. 


[December  22,  1900 


ment  be  abolished.  Some  of  the  speakers  asserted 
that  many  of  the  changes  made  in  houses  resulted  only 
in  profit  to  the  contractors  who  furnish  the  labor  and 
material.  The  sanitary  department  may,  as  these 
complainants  assert,  have  occasionally  been  somewhat 
arbitrary  in  its  provisions,  but  that  it  has  on  the  whole 
been  productive  of  an  enormous  improvement  in  the 
health  conditions  of  the  city  no  one,  except  those  who 
have  to  pay  for  making  their  houses  clean,  will  deny. 
Major  Gorgas  in  his  report  for  November  states  that 
the  number  of  deaths  during  that  month  was  only  444, 
which  is  the  smallest  number  of  deaths  for  any  one 
month  in  the  past  ten  years.  _  "  The  mortality  records,'" 
he  says,  "  show  a  steady  and  rapid  improvement  in  the 
sanitary  condition  of  the  city,  and  the  death  rate  of 
this  month,  21.31,  will  compare  very  favorably  with 
that  of  many  of  the  large  cities  of  the  world.  Munich 
with  23.09,  St.  Petersburg  with  25.02,  Dublin  with 
30. oS,  and  several  other  large  centres  in  Europe,  had 
a  very  much  larger  death  rate  for  the  year  1899  than 
we  had  during  the  month  of  November.''  While  the 
general  sanitary  conditions  show  such  marked  evidence 
of  improvement,  the  number  of  yellow-fever  cases  has 
been  large  for  the  time  of  the  year.  The  total  for  the 
month  was  214  cases,  or  one-third  less  than  it  was  for 
October,  and,  from  the  rapid  way  in  which  it  is  de- 
creasing. Dr.  Gorgas  thinks  that  it  will  disappear  by 
the  middle  of  December.  If  that  proves  to  be  the 
case,  the  congress  will  have  been  unnecessarily  post- 
poned. The  idea  of  a  body  of  medical  men  postpon- 
ing a  meeting  through  fear  of  disease  has  already 
been  the  occasion  of  some  gentle  banter  on  the  part 
of  the  unthinking  laity,  and  if  there  should  be  no  dis- 
ease after  all,  then  the  banter  might  become  ridicule. 

College  of  Physicians  of  Philadelphia,  Section 
on  General  Medicine. — .\t  a  stated  meeting  held 
December  loth  Dr.  F.  A.  Packard  exhibited  "A  Case 
of  Probable  Localized  Interlobar  Pleurisy."  Dr.  D. 
J.  Milton  Miller  reported  '"A  Case  of  Malignant  En- 
docarditis with  Extensive  Vegetations  on  the  Pulmo- 
nary Valves  Alone,  and  he  exhibited  the  heart.  Dr. 
J.  Dutton  Steele  read  a  paper  entitled  "  The  Associa- 
tion of  Chronic  Jaundice  with  Gastroptosis,  with  the 
Report  of  a  Case  and  the  Exhibition  of  the  Patient." 
Dr.  F.  A.  Packard  exhibited  an  enlarged  liver  and  a 
greatly  distended  gall  bladder  containing  calculi  from 
a  case  presenting  during  life  symptoms  of  ball-valve 
calculus  of  the  gall  bladder. 

Navy  Department,  Bureau  of  Medicine  and  Sur- 
gery, Washington,  D.  C. — Changes  in  the  medical 
corps  of  the  navy  for  the  week  ending  December  15, 
1900.  December  7th. — Pharmacist  J.  F.  Pearson  or- 
dered to  the  naval  academy.  December  loth. — As- 
sistant Surgeon  J.  C.  Pryor  detached  from  the  A/lxi- 
tross  on  reporting  of  relief  and  ordered  home  to  wait 
orders.  Assistant  Surgeon  C.  S.  Butler  detached  from 
the  Independence  and  ordered  to  the  Albatross.  Assist- 
ant Surgeon  J.  B.  Dennis  detached  from  the  Wlu-diiii; 
on  reporting  of  relief  and  ordered  home  and  to  wait 
orders.  Assistant  Surgeon  C.  N.  Fiske  detached  from 
the  naval  hospital,  Mare  Island,  Cal.,  and  ordered  to 


the  Wheeling.  December  13th. — Passed  Assisttan 
Surgeon  W.  M.  Wheeler  detached  from  the  Kcarsarge 
and  ordered  to  the  Alabama.  Passed  Assistant  Sur- 
geon T.  W.  Richards  detached  from  the  Alabama  and 
ordered  to  the  Bureau  of  Medicine  and  Surgery,  navy 
department.  Passed  Assistant  Surgeon  F.  L.  Plead- 
well  detached  from  the  Bureau  of  Medicine  and  Sur- 
gery and  ordered  to  the  Kearsarge. 

Philadelphia  Association  of  Medical  Inspectors 
of  Schools. — The  medical  inspectors  of  the  Scliools 
of  Philadelphia  have  formed  a  permanent  organization 
for  the  purpose  of  raising  to  the  highest  standard  the 
service  rendered.  Meetings  are  to  be  held  monthly, 
when  papers  will  be  read  and  topics  having  relation 
to  school  hygiene  will  be  discussed.  The  work  of  the 
inspectors  has  thus  far  been  voluntary  and  gratuitous, 
but  it  is  hoped  that  an  appropriation  will  be  made 
sufficient  to  yield  each  a  nominal  honorarium. 

Influenza  is  reported  to  be  prevailing  to  an  unusual 
degree  in  Berlin. 

Smallpox  Cases  are  still  found  nearly  every  day  in 
the  city,  but  most  of  them  can  be  traced  to  the  original 
focus  of  infection,  and  the  threatened  epidemic  is 
wholly  under  control  by  the  board  of  health.  A  case 
was  reported  in  Jersey  City  last  week  and  according 
to  the  daily  papers  was  the  third  case  that  has  come 
to  the  notice  of  the  health  authorities  in  that  city  in 
four  years. 

Obituary  Notes. — Dr.  William  K.  Jones  died  of 
diabetes  at  Bethlehem,  Pa.,  on  December  13th,  at  the 
age  of  sixty  years.  He  was  graduated  from  the  medi- 
cal department  of  the  University  of  Pennsylvania  in 
1863  and  was  appointed  acting  assistant  surgeon  in 
the  United  States  navy,  becoming  passed  assistant 
surgeon  three  years  later.  In  1873  he  was  commis- 
sioned surgeon  and  in  1891  medical  inspector,  being 
retired  in  1S93. 

Dr.  Leroy  J.  Brooks,  of  Norwich,  N.  Y.,  died  on 
December  12th.  He  was  a  graduate  of  the  Bellevue 
Hospital  Medical  College  in  the  class  of  1872.  He 
was  a  prominent. member  of  the  Chenango  County  (N. 
Y.)  Medical  Society,  which  body  met  in  special  session 
on  the  day  of  his  funeral  and  adopted  resolutions  of 
regret  and  of  sympathy  with  the  family  of  the  deceased. 

Dr.  James  Fleurv  Stewart  died  on  December 
iith  at  the  S.  R.  Smith  Infirmary,  at  New  Brighton, 
S.  I.,  where  he  was  resident  physician.  He  was 
twenty-three  years  of  age. 

Dr.  Henry  Barton  Fellows,  a  homoeopathic 
physician  of  Chicago  and  at  one  time  dean  of  the 
Hahnemann  Medical  College  in  tiiat  city,  died  on 
December  i6th  at  the  age  of  sixty-three  years.  He 
was  a  graduate  of  the  Homoeopathic  Hospital  College 
of  Cleveland,  Ohio,  in  the  class  of  1861. 

Dr.  John  C.  Acheson  died  at  his  home  in  this  city 
on  December  12th,  of  vahular  heart  disease.  He  was 
born  here  in  1832  and  was  graduated  from  the  College 
of  Physicians  and  Surgeons  in  1859.  He  was  one  of 
the  founders  of  the  Medical  Association  of  Greater 
New  York. 


December  22,  1900] 


MEDICAL    RECORD. 


985 


gro  Dress  of 


.\L-,lual  .\t 


lUctUciil 


Ihceiiiber 


J'Cicuce. 


ll^OO. 


Influenza  and  the  Nervous  System. — J.  M.  Mosher  con- 
cludes thai:  (I)  The  infection  of  influenza  produces  a 
toxin,  which  has  a  severe  and  selective  action  upon  the  ner- 
vous system.  (2)  The  immediate  effects  of  this  to.\in  are 
shown  in  affections  of  the  peripheral  nerves  and  the  cere- 
bro-spinal  centres.  (3)  The  remote  effects  are  manifested 
in  lowered  tone  of  the  nervous  system,  predisposing  to 
other  diseases.  14)  These  ensuinjj  diseases  arise  in  weak- 
ened or  predispo.sed  organs,  giving  rise  to  the  different 
classes  of  "respiratory,"  "alimentary,"  "gtnito-urinary." 
and  "circulatory"  forms  of  intiueuza.  (5)  Post-infiu- 
enzal  insanities  are  also  a  complication  of  the  post-in- 
fluenzal  states  of  nervous  deljility,  in  ])atients  mentally 
predisposed.  (6)  The  post-inHuenzal  insanities  are  not  es- 
sentially different  from  other  insanities  due  to  vital  depres- 
sion. (7)  The  prognosis  of  influenzal  affections  is  gener- 
ally good,  under  proper  management.  (8)  Exception  to 
this  is  in  influenzal  affections  arising  during  the  course  of 
other  severe  di.seases,  as  pneumonia  and  general  paralysis, 
and  during  senility  complicated  by  mental  or  physical  de- 
terioration. 

The  Clinical  Picture  of  Epidemic  Influenza.  — Glentworth 
R.  Butler  declares  that  the  symi>lomatology  of  this  disease 
is  extraordinarily  diverse.  The  attack  is  generally  ush- 
ered in  by  chilliness  or  rigor.  Fever  is  nearly  always 
present.  As  a  rule  there  are  severe  headache  and  general 
aching,  with  weakness  and  prostration.  Delirium  is  not  un- 
common. Dependent  upon  the  special  localization  of  the  in- 
fection, certain  varieties  of  the  disease  with  their  attendant 
symptoms  are  recognized,  viz.,  the' respiratory  form,  the 
nervous  form,  etc.  Circulatory  symptoms  are  common. 
The  nervous  system  is  affected  to  some  extent  in  all  case-s. 
The  spleen  may  enlarge  acutely.  Acute  nephritis  is  not 
rare.  Vertigo  is  not  infrequently  observed.  Herpes  labia- 
lis  is  common.  In  doubtful  cases  a  bacteriological  exami- 
nation is  valuable.  The  disease  may  require  differen- 
tiation from  typhoid  fever,  cerebro-spinal  meningitis,  and 
broncho-pneumonia.  Recovery  occurs  in  the  large  major- 
ity of  cases. 

A  Note  Concerning  the  Treatment  of  Influenza  by  the 
Employment  of  Hydrotherapy.—  E.  L.  Sliurley  states  that 
the  first  therajieutic  indication  should  be  to  assist  nature 
in  the  elimination  of  the  infection  and  in  the  modification 
of  the  action  on  the  ganglionic  nervous  system.  The  hot- 
water  bath,  steam  bath,  or  hot  pack  with  quinine  and  mild 
anodynes  should  be  used  at  first.  When  the  temperature 
is  very  high,  the  cold  pack  should  be  used  instead  of  the 
hot  baths.  Especially  for  pain  tinctura  opii  camphorata 
or  opium  may  be  given.  To  relieve  debility  and  nervous- 
ness, following  the  first  stage,  phosphorus  (gr.  ^,',^5)  in 
capsule,  in  oil,  is  good.  Stryclinine  is  useful.  Complica- 
tions and  sequelae  must  be  treated  according  to  the  circum- 
stances of  the  case.  The  employment  of  the  coal-tar  prod- 
ucts is  as  a  rule  inadvisable. 

The  Bacteriology  of  the  Influenza  Bacillus. — By  August 
Jerome  Lartigau. 

The    Treatment   of    Influenza    in    Adults. — Hy   Reynold 

Webb  Wilcox. 

The  Treatment  of  Influenza  in  Children.— By  A.  Jacobi. 

The  Journal  I'J  liie  Aiiu-r.    Mtdical  Ass' n,  Dei.  /j,  /goo. 

Ear  Diseases  in  Infancy  and  Childhood. — J.  Homer  Coul- 
ter states  that  the  ear  conditions  most  often  met  with  in 
infancy  and  childhood  are  acute  middle-ear  suppuration 
with  or  without  its  complications — impacted  cerumen,  for- 
eign bodies,  furunculosis,  granulations,  eczema,  necrosis, 
polyi)i.  meningitis,  extradural  ab.scess,  cerebral  abscess, 
and  traumatism.s.  The  main  causes  of  ear  troubles  in 
children  are;  (i)  General,  as  exposure,  climatic  influ- 
ences, etc.  (2)  Exanthemata,  typhoid,  diphtheria,  post- 
nasal pathologies,  etc.  (3)  Traumatisms  and  foreign 
bodies  in  the  tympanic  cavity.  The  prognosis  will  depend 
on  the  following  conditions  :  (i)  The  age  and  physical  con- 
dition of  the  child.  (2)  The  severity  of  the  attack  and,  if 
purulent,  on  the  seriousness  of  the  concomitant  disease 
which  gives  rise  to  the  purulency.  (3)  Whether  or  not 
there  be  brain  or  sinus  involvement  pending  or  threatened. 

(4)  The  extent  of  bone  necrosis  present  when  first  seen. 

(5)  Nursing.  As  to  treatment,  the  earlier  it  is  instituted 
the  better.  The  use  of  opium  in  earache  is  rarely  or  never 
to  be  advised.  The  application  of  heat  or  cold  will  usually 
give  quite  as  much  relief  from  the  pain.  If  this  method 
does  not  greatly  relieve  the  suffering  in  twenty-four  hours, 
then  heroic  measures  must  be  adopted.  Usually  there  will 
by  such  time  be  indications  sufficient  to  warrant  a  para- 
centesis.    That  such  operation  should  be  done  as  soon  as 


there  is  any  bulging  noted  in  the  tympanum,  is  now  the 
unanimous  verdict  of  otologists.  Many  authorities  advise 
the  use  of  leeches  to  deplete  the  congestion.  Politzeriza- 
tion in  any  of  the  ear  di.seases  of  childhood  is  impracticable 
In  almost  every  conceivable  case.  So  also,  as  a  rule,  is  the 
application  of  poultices.  The  pathological  conditions  of 
the  nasopharynx  and  pharynx  should  always  be  thor- 
oughly treated.  The  diet  should  be  limited  and  mild. 
Early  and  thorough  cleansing  and  antisepsis  are  always  a 
necessity. 

Treatment  of  Skin  Cancers  without  Operation. — Henry  W. 
Stelwagon  is  convinced  that  tor  the  more  superficial  skin 
cancers  the  treatment  by  the  caustic  method  is  equal  and 
in  many  cases  superior  to  operation.  Irrespective  of  the 
natural  objections  of  many  patients  to  operative  measures, 
he  believes  that  the  caustic  method,  properly  followed  out, 
lessens  the  chances  of  recurrence.  There  is  no  damage 
done  with  caustics  if  they  are  judiciously  and  boldly  used  ; 
it  is  the  temporizing  treatment  with  mild  caustics,  or  the 
hesitating  treatment  with  active  caustics,  which  may  often 
do  harm.  The  caustics  which  the  writer  has  found  most 
useful  are:  Arsenious  acid,  caustic  potash,  zinc  chloride, 
and  pyrogallol.  The  first  three  are  most  commonly  used, 
the  most  valuable  being  arsenious  acid.  Pyrogallol  and 
arsenious  acid  have  practically  an  elective  action,  destroy- 
ing the  |)athological  tissues,  and  having,  when  properly 
employed  and  not  too  long  applied,  but  little  influence  on 
healthy  structures.  The  writer  has  never  seen  toxic  ab- 
sorption from  the  cautious  use  of  arsenic.  The  arsenious 
acid  is  made  into  a  i)aste  with  mucilage  acacia  by  mixing 
with  a  little  water  or  a  solution  of  cocaine  hydrochlorate 
which  somewhat  lessens  the  pain  of  application.  The 
writer  also  describes  the  methods  of  application  of  each  of 
the  four  caustics  mentioned  in  the  beginning. 

Tjenia  Flavopunctata. — Frederick  A.  Packard  describes  a 
parasite  taken  from  a  Syrian  woman  aged  forty  years. 
One  specimen  was  passed  during  life  and  another  was 
taken  from  the  intestine  after  death  ;  the  latter  was  27 
cm.  long  and  different  from  the  former  specimen  in  no 
way  except  by  the  presence  of  the  head  and  of  a  short 
neck,  and  by  its  color.  The  specimen  jjassed  during  life 
was  brownish-yellow,  while  that  found  at  autopsy  was 
almost  pure  white  with  a  faint  yellow  tinge.  This  speci- 
men consists  of  a  head  and  a  short  neck  separated  by  a 
slight  constriction,  and  of  a  segmented  body.  The  head  is 
black  at  the  tip,  the  pigment  being  arranged  somewhat 
like  the  leaves  of  a  four-leaf  clover,  as  though  each  divis- 
ion represented  the  sucking-discs  seen  in  other  ta;nia.  No 
distinct  cupping  is  visible.  At  a  distance  of  1.5  cm.  from 
the  head,  distinct  transverse  striations  are  seen  which  evi- 
dently indicate  division  into  proglottides.  There  is  no 
branched  arrangement  of  the  egg-sacs  nor  any  central 
clumping  as  in  the  bolhriocephalus  latus.  This  cannot  be 
a  taenia  common  to  this  part  of  the  world,  nor  is  it  an  ex- 
ample of  bolhriocephalus.  It  must,  the  writer  believes,  be 
a  specimen  of  taenia  flavopunctata  which  has  been  de- 
scribed but  six  times  as  occurring  in  the  human  subject. 

Treatment  of  Immature  Cataract. — John  E.  Weeks,  after 
speaking  of  general  and  local  therapeutic  measures  in 
respect  to  cataract,  re%'iews  the  operative  jjrocedures  for  the 
removal  of  immature  cataract  as  follows:  In  young  individ- 
uals, needlingof  the  lens.withor  without  subsequent  extrac- 
tion of  the  broken-up  lens  substance,  by  means  of  small 
linear  incision  in  the  cornea  ;  preliminary  iridectomy,  with 
or  without  direct  or  indirect  trituration  of  the  lens,  for  the 
purpose  of  hastening  the  maturity  of  the  cataract,  appli- 
cable to  old  or  young  individuals  ;  extraction  either  simple 
or  combined.  The  ripening  operations  have  been  aban- 
doned by  the  writer.  Whenever,  in  the  development  of 
cataract,  the  vision  is  reduced  to  such  a  degree  that  the 
individual  cannot  follow  the  ordinary  pursuits  of  life,  pro- 
vided there  is  any  rea.son  for  not  waiting  until  the  cataract 
is  mature,  he  does  not  hesitate  to  advise  operation. 

New  Points  in  the  Anatomy  and  Histology  of  the  Rectum 
and  Colon  ;  the  Treatment  of  Obstinate  Constipation  Based 
on  Points  Set  Forth  in  the  Foregoing. — By  J.  Rawson  Pen- 
nington. 

The  Use  of  Alcohol  in  Treatment  of  Carbolic-Acid  Bums 
and  Poisoning. — By  Herman  A.  Klein. 

Sarcoma  of  Vermiform  Appendix ;  Sarcoma  of  the  External 
Urethral  Orifice. — By  Theo.  G.  Davis. 

Colitis,  Constipation,  and  Appendicitis:  their  Etiological 
Relations.— By  .Miles  K.  Porter. 

Rheumatism  and  the  Prevention  of  Heart  Complications.^ 
By  James  J.  Walsh. 

Compact  Operating-Case  for  Military  Service. — By  Nich- 
olas Senn. 

The  Heart  in  Acute  Rheumatism. — By  Delancy  Roch- 
ester. 

Nephrorrhaphy. — By  Charles  P.  Noble. 


984 


MEDICAL    RECORD. 


[December  22,  1900 


AVif  ]'ori  Medical  Journal,  December  is,  igoo. 

Derangements  of  the  Organs  of  Vision  which  may  be  At- 
tributed to  Auto-infection,  or  to  Auto-intoxication.— J.  H. 
Woodward's  headings  of  tliis  subject  are  functional  de- 
rangements (neurastlienia  and  migraine)  and  organic  de- 
rangements (rLieumatism,  Briglit's  disease,  and  intra-ocu- 
lar  heraorrbage).  In  neurasthenic  cases  we  find  imperfect 
gastric  and  intestinal  digestion  with  constipation  and  a 
sluggish  liver.  These  patients  complain  of  blurring  of  vi- 
sion, lacryraation,  photophobia,  inability  to  read  without 
pain  in  the  eyes,  etc.  As  soon  as  the  prima?  viae  are  regu- 
lated, the  ocular  disturbances  disappear.  A  similar  line  of 
reasoning  applies  to  migraine  and  the  other  bodily  states 
mentioned.  The  importance  of  the  matter  lies  in  the 
proper  recognition  of  the  underlying  cause  in  each  individ- 
ual case. 

The  Prevention  of  Nausea  and  Vomiting  during  Anaesthe- 
sia.— L.  J.  Hirschman  advocates  the  use  of  a  new  prepara- 
tion called  chloretone,  which  is  in  general  a  hypnotic,  anti- 
septic, and  analgesic.  It  is  given  in  doses  of  from  gr.  x. 
to  XV.  half  an  hour  before  the  ausesthetic  is  administered. 
From  an  experience  with  sixty  cases,  half  of  which  re- 
ceived the  drug,  while  half  did  not,  the  claim  is  made  that 
nausea  and  vomiting  were  seventy  per  cent.  less  in  the 
former  group  than  in  the  latter. 

The  Treatment  of  Trachoma  by  Expression,  with  Special 
Reference  to  the  Recurrence  of  the  Disease. — By  T.  R. 
Pooley. 

Strangulated  Inguina  Hernia  Containing  the  Csecum  and 
Appendix. — By  L.  J.  Hirschman. 

Remarks  on  Indication  for  the  Radical  Therapy  of  Uterine 
Fibroids. — By  O.  Thienhaus. 

Cysts  in  the  Ligamentum  Latum ;  their  Kinds  and  Loca- 
tion.— By  Byron  Robin.son. 

Philadelphia  Medical  Journal,  December  rj,  rgoo. 

Venesection  in  Pneumonia  followed  by  Injection  of  Normal 
Salt  Solution. — -William  Porter,  in  treating  this  subject, 
refers  to  the  lobar  or  so-called  croupous  inflammation.  In 
the  experiments  which  he  reviews,  venesection  is  ordered 
as  soon  as  the  diagnosis  is  well  established,  i.e.,  within 
four  days,  at  farthest,  from  the  initial  chill,  and  generally 
earlier.  The  amount  of  blood  removed  is  not  necessarily 
large.  From  eight  to  ten  ounces  will  generally  give  relief 
in  average  cases.  At  once  the  subcutaneous  injection  of 
the  salt  solution  is  ordered.  Transfusion  could  be  per- 
formed in  an  urgent  case.  The  following  solution  is 
useful : 

5  Sodium  chloride gr.  30 

Potassium  chlorate , "    60 

Sodium  sulphate '•    60 

Sodium  phosphate "    40 

Sodium  ca  bonate *'    60 

Distilled  water to  make  fl  3    ^ 

One  pint  of  this  solution  in  sixty  of  distilled  water. 

The  writer  hopes  that  further  investigation  may  justify 
this  method  as  an  addition  to  our  treatment  in  pneumonia. 

The  Electrical  Treatment  of  Uterine  Fibroids. — Gideon  C. 
Segur  concludes  that ;  (i)  Electricity  properly  applied  may 
be  considered  a  specific  for  the  treatment  of  uterine  fibroids. 
(2)  A  moderate  dosage,  40  to  50  milliamperes,  applied  for 
twenty  to  thirty  minutes  relieves  pain  and  influences  a'di- 
minution  in  size.  (3)  There  are  no  dangers  to  be  feared 
from  its  use  if  carefully  conducted.  (4I  Puncture  is  not 
necessary  in  order  to  obtain  practical  results.  (5)  No  seri- 
ous operation  should  be  undertaken  until  after  electricity 
has  been  tried. 

National  Volunteer  Emergency  Service  Medical  Corps ;  its 
Objects,  Scope,  and  Importance. — By  J.  Adelphi  Gottlieb. 

Principles  of  Asepsis  Applied  to  Operative  and  Other 
Wounds  of  the  Eye. — By  Edward  Jackson. 

The  X-Ray  In  the  Treatment  of  Carcinoma. — By  Wallace 
Johnson  and  Walter  H.  Merrill. 

Congenital  Unilateral  Ptosis  with  Associated  Movements. 
— By  Frederick  Krauss. 

Report  of  a  Case  of  Foreign  Bodies  in  the  Brain.— By 
Clarence  A.  Greenleaf. 

Some  Remarks  on  Catalepsy,  with  Notes  of  a  Case. — By 
George  William  Norris, 

Hyaline  Casts  Present  in  Puerperal  Eclampsia.— By  L.  Na- 
poleon Boston. 

Foreign  Bodies  In  the  Air  Passages.— By  Francis  T. 
Stewart. 

Some  Remarks  on  Hygiene  of  the  Ear.— By  Emil  Am- 
berg. 

The  Struggle  for  Like  Lobule.— By  Wallace  Wood. 

A  Tropical  Ration.— By  J.  R.  Kean. 


British  Medical  Journal,  December  S,  igoo. 

Clinical  Lectures   on  the   Causes  and  Cure  of  Insomnia.— 

Sir  James  Sawyer  declares  that  liyimotics  should  be  given 
only  in  e.xceptional  cases  and  only  when  unavoidable.  As 
a  rule  the  successful  treatment  of  a  case  of  sleeplessness 
follows  from  the  discovery  of  its  cau.se.  In  the  severer 
forms  of  psychic  insomnia  sleep  must  often  be  secured  by 
the  action  of  some  efficient  hypnotic,  of  which  opium  and 
chloral  are  to  be  preferred.  A  few  nights  of  good  sleep 
will  do  more  than  anything  else  to  restore  to  the  brain  the 
power  of  sleeping  without  further  aid  from  drugs.  A  pa- 
tient should  never  be  allowed  to  dose  him.self  with  hyp- 
notics. An  overworked  man  or  woman  must  never  be  per- 
mitted to  go  on  with  overwork  and  haljitually  secure  sleep 
by  chloral  or  any  other  hypnotic.  It  is  mostly  worry,  not 
overwork,  or  it  is  work  under  wrong  conditions,  which 
brings  unrest.  When  a  drug  is  necessary,  potassium  bro- 
mide is  by  far  the  best  hypnotic  in  well-nourished  patients 
and  in  the  slighter  cases  generally.  It  is  marvellously 
powerful  in  producing  nervous  calm  ;  it  is  a  direct  and 
quite  safe  brain  sedative.  After  getting  into  bed,  gr.  xxx. 
to  Ix.  dissolved  in  water  should  be  the  dose.  In  many 
cases  of  chronic  wakefulness  arising  from  prolonged  men- 
tal strain,  the  patient  is  distinctly  anaemic.  This  patient 
needs  hsematinics,  of  which  the  best  are  iron  and  arsenic, 
singly  or  combined.  The  diet  must  be  generous,  contain- 
ing plenty  of  fish,  meat,  and  eggs.  For  such  a  patient 
alcohol  is  often  the  best  hypnotic.  Alcohol  is  the  best 
hypnotic  in  many  cases  of  chronic  psychic  insomnia  when 
the  patient  is  worried  and  weakly,  sorrowful  and  anemic. 
A  bicycle,  a  horse's  back,  gardening  in  the  open  air,  mus- 
cular exercise  of  various  kinds — all  have  a  place  in  the  cure 
of  insomnia.  Sunshine  is  a  valuable  adjuvant  in  the  cure 
of  insomnia.  Monotonous  counting  has  been  suggested. 
Deep  inspirations  often  help  to  induce  sleep.  Bedclothes 
should  be  sufficient,  but  not  excessive.  In  all  cases  the 
bedroom  window  should  be  open  all  night  and  all  the  year 
round,  but  so  arranged  that  there  be  no  draught.  A  hair 
mattress  is  the  best  bed.  In  some  cases  a  little  food  taken 
just  at  the  time  for  sleeping  is  an  efficient  soporific.  In 
the  toxic  kinds  of  insomnia  the  consumption  of  the  disturb- 
ing tobacco,  tea,  etc.,  must  be  lessened  or  stopped.  Senile 
insomnia  is  very  obstinate.  Perhaps  the  bromides,  with 
full  doses  of  hop  or  henbane,  are  the  most  efficient  reme- 
dies in  these  cases. 

Remarks  on  the  Diagnosis  and  Treatment  of  Arsenical 
Neuritis. — Judson  S.  Bury,  in  speaking  of  the  recent  epi- 
demic, points  out  several  symptoms  which  serve  to  diag- 
nosticate arsenical  neuritis;  Hypera;sthesia  of  the  skin 
and  muscles,  although  common  in  alcoholic  neuritis,  is 
more  constant  and  generally  more  severe  in  the  cases  now 
under  observation.  Erythromelalgia.  • — The  vasomotor 
phenomena  which  characterize  the  condition  known  by  this 
name,  while  only  occasionally  present  in  alcoholic  cases, 
have  been  conspicuous  features  in  the  present  epidemic. 
Ataxia  has  been  comparatively  frequent  in  the  present  se- 
ries of  cases.  There  seems  to  be  no  evidence  that  arsenic 
directly  attacks  the  muscular  tissue  of  the  heart.  Psychi- 
cal disturbances  in  arsenical  neuritis  are  mentioned  by 
several  authorities.  The  first  step  in  the  treatment  is  re- 
moval of  the  cause.  Next,  rest  in  bed  is  advisable.  A 
water-bed  affords  great  comfort.  The  patient  should  be 
handled  as  gently  as  possible.  The  limbs  should  never 
be  massaged.  Warm  fomentations  are  indicated  for  the 
relief  of  tender  nerves  and  muscles.  Salicylate  of  sodium 
and  potassium  iodide  are  of  great  service  in  the  early 
stages.  Antipyrin,  phenacetin,  or  exalgin  are  efficacious 
in  the  presence  of  neuralgic  pains.  Strychnine  must  not 
be  given  in  the  acute  stage.  Diet  is  of  more  importance 
than  are  drugs  and  should  consist  of  boiled  milk,  beef  tea, 
beef  extracts,  soups,  and  broths.  Nutrient  enemas  should 
be  administered  when  vomiting  is  troublesome.  Complete 
rest  in  bed  in  a  well-ventilated  room,  careful  feeding,  and 
exposure  to  sunlight  are  the  essential  points  in  the  treat- 
ment of  the  early  stages  of  multijile  neuritis.  When  the 
acute  symptoms  have  subsided,  but  not  before,  recourse 
may  be  had  to  massage,  electricity,  and  tonic  treatment. 
Of  all  drugs  tending  to  the  restitution  of  the  paralyzed 
parts,  strychnine  is  unquestionably  the  most  valuable. 

Foreign  Body  Long  Retained  in  the  External  Auditory 
Meatus. — William  L.  Culleii  reports  the  case  of  a  lady  aged 
seventy-eight  years,  who  had  com])lained  for  thirty  years 
of  deafness  in  her  left  ear.  The  ear  was  syringed,  and 
after  one  or  two  large  pieces  of  hardened  wax  had  come 
away,  a  small  round  ball  about  the  size  of  a  pea  was  di.s- 
charged.  This  ])roved  to  be  a  i>iece  of  tortoise  shell  which 
had  broken  off  from  a  comb  she  liad  worn  thirty  years  pre- 
viously. After  using  Politzer's  bag  twice,  the  hearing  was 
almost  normal  in  the  ear  in  question. 

Dislocation  of  the  Styloid  Process. — Wyatt  Wingrave 
calls  attention  to  the  existence  of  the  stibpharyngeal  carti- 
lage of  Luschka,  which  is  probably  often  mistaken  for  a 


December  22,  1900] 


MEDICAL    RECORD. 


985 


disjjlaccd  styloid  process.  It  consists  of  hyaline  cartilage 
embedded  in  a  capsule  of  white  fibrous  tissue,  and  is  sup- 
posed to  be  a  vestige  of  the  third  post-oral  arch.  It  sorae- 
titnes  offers  an  exceptional  resistance  to  the  guillotine. 

Case  of  Hour-Glass  Stomach  and  Pyloric  Stenosis ;  Gas- 
tro-enterostomy ;  Death. ^Uv  Sidntv  Martin  and  KUton  Pol- 
lard. 

The  Harveian  Lectures  on  Prognosis  and  Treatment  in 
Pulmonary  Tuberculosis. — l?y  Roliert  Maguire. 

On  Recent  Researches  with  Regard  to  the  Parasitology  of 
Malaria. — By  llie  Kight  linn,  the  Lord  Lister. 

The  Surgery  of  Chronic  Ulcer  of  the  Stomach  and  its 
Sequelae. — By  B.  (J.  A.  Moynilum. 

A  Case  of  Conglutinatio  et  Atresia  Orificii  Uteri  during 
Parturition. — By  P.  G.  Edgar. 

Aneurism  Bursting  into  Pericardial  Sac  — By  John  Wil- 
liam Taylor. 

A  Case  of  Scarlatina  Pemphigoides.— By  E.  A.  C.  Baylor. 

French  Journals. 

Hygiene  of  the  Cyclist. — Just  Lucas-Championnicre  states 
that  cycling,  like  all  exercise,  should  be  taken  up  moderate- 
ly. Tlie  heart  sliouKl  be  carefully  watched,  not  because  this 
exercise  is  more  harmful  in  lliis  respect  than  others,  but 
because  it  can  be  iinlulged  in  much  longer  without  giving 
a  sense  of  fatigue.  Vicious  attitudes,  such  as  a  crooked 
posture,  although  not  being  so  important  as  is  generally 
supposed,  nevertheless,  ought  to  be  avoided.  In  a  long 
journey  the  position  in  which  the  body  is  moderately  in- 
clined is  best  for  the  organs  of  respiration  and  circulation. 
The  position  in  the  .saddle  is  hard  to  decide  u])on  for  every 
case.  Practice  shows  that  the  ])erineum  accommodates  it- 
self to  the  saddle  better  than  would  have  been  supposed. 
Moderation  in  eating  is  a  necessity  in  muscular  work,  as 
is  also  abstention  from  alcohol.  The  bicycle  should  vary 
in  details  for  the  man,  the  woman,  the  child,  the  racer, 
and  the  invalid.  In  the  case  of  a  man,  the  perineum,  with 
its  component  parts,  should  be  carefully  watched.  As  to 
the  woman,  this  exercise  is  easier  for  her  than  for  the  man, 
since  .s*he  is  more  supple.  •  It  causes  far  less  fatigue  than 
walking.  Its  etfects  on  the  pelvic  organs  are  good.  The 
exercise  should  be  suspended  during  menstruation,  and  it 
is  not  to  be  recommended  during  pregnancy.  The  cliild 
does  not  feel  so  much  fatigue  as  the  adult,  but  it  should 
use  the  bicycle  with  the  greatest  moderation.  As  a  rule 
the  courier  understands  his  limitations  well.  He  should, 
like  all  athletes,  possess  perfect  organs.  As  to  the  invalid, 
many  ailments  are  improved  or  even  cured  by  the  u.se  of 
the  bicycle,  e.i^..  gastro-intestinal  troubles,  deformities  of 
the  vertebral  column,  etc.  Indeed,  the  author  believes 
that  this  branch  of  the  subject  is  so  extensive  as  to  deserve 
a  special  chapter. — Gazette  Medienle  de  Strasbourg;,  No- 
vember I,  1900, 

Foreign  Bodies  in  the  Orbit. — Paul  Boudin,  in  reviewing 
this  subject,  says  that  no  cla.ssification  of  foreign  bodies 
that  liave  been  found  in  the  orbit  could  be  really  complete 
since  the  variety  is  so  very  great.  Bits  of  lead,  fragments 
of  wood,  needles,  bits  of  stone,  bits  of  glass,  pencils,  metal 
tips,  umbrellas,  etc.,  are  found  in  the  list.  As  to  the  symp- 
toms, there  is  no  real  pathognomonic  sign  of  the  affection. 
It  is  really  remarkable  how  many  cases  there  are  in  which 
no  clear  symptoms  of  inflammation  are  seen.  Recently 
radiography  has  proved  an  efficient  aid  in  diagnosis.  By 
this  method  it  is  possible  to  determine  the  presence  of  the 
foreign  body,  its  form,  and  its  position.  As  a  general  rule 
extraction  should  be  advised  if  the  wound  is  recent,  the 
foreign  body  visible,  tangible,  easily  accessible,  and  if  it 
is  retained  in  the  orbital  cavity  without  affecting  the  walls. 
As  to  the  use  of  the  magnet,  although  it  has  been  success- 
ful when  the  body  was  superficial,  it  has  failed  when  the 
object  to  be  extracted  was  either  deeply  or  firmly  fixed. 
Treatment  of  foreign  bodies  in  the  orbit  should  depend  en- 
tirely on  the  symptoms  which  tell  whether  the  physician 
may  temporize  or  no\.. —Oacette  ttes  llopitaux,  November 

17.    KJOO. 

Seborrhoeic  Eczema  of  Unna. — Leon  Perrin  declares  that 
Uniia  with  his  conception  of  eczema  has  revolutionized  all 
ancient  dermatology.  For  him  the  majority  of  eczemas  are 
seborrhoeic.  Seborrhoeic  eczema  is  the  type  of  eczema. 
Wherever  the  eczema  may  be  found  the  extension  of  sebor- 
rhieic  eczema  in  the  adult  and  in  the  nursling  has  a  cer- 
tain number  of  common  characteristics :  (I)  A  centrifugal 
extension  in  discs  and  circles.  (2)  A  yellowi.sh  coloration 
that  is  frequently  seen  after  it  is  healed.  (3)  Three  varie- 
ties of  lesions ;  (a)  Squamous,  in  which  inflammation  is 
very  slight ;  (b)  erythematous  with  crusts  :  (c\  humid  and 
oozing,  frequent  in  children  and  women.  (4)  The  odor  of 
the  discharge  ;  the  thickness,  the  j-ellow  color,  the  friabil- 
ity and  the  oily  condition  of  the  scales.  As  to  the  thera- 
peutic agents  for  this  affection,  preparations  with  a  base 
of  sulphur,  salicylic  acid,  resorcin,  oil  of  cade,  etc.,  form 


the  basis  of  treat.nent.  The  individual  who  has  once  suf- 
fered with  seborrheic  eczema  should  observe  extreme  pre- 
cautions in  external  antisepsis  and  cleanliness. — Gazette 
ties  Jiopitaux,  November  15,  1900. 

The  Relation  of  Leucoplakia  Buccalis  to  Syphilis  and  Can- 
cer.— Alfred  Founiier  concludes  that:  (i)  Leuc(j])lakia  is 
an  affection  confined  almost  exclusively  to  the  masculine 
sex  (three  hundred  and  nineteen  cases  out  of  three  hun- 
ilred  and  twenty-four).  (2)  The  two  principal  etiological 
factors  are  syphilis  and  tobacco.  (3)  It  ends  in  buccal 
cancer  with  a  frequency  greater  than  thirty  per  cent.  (4) 
When  it  is  found  in  syphilitic  subjects,  it  proves  absolutely 
refractory  to  treatment  said  to  be  speciHc  for  syphilis.  (5) 
Its  pathological  classification  would  place  it  among  the 
l)arasyphilitic  affections.  (6)  Finally,  it  makes  a  great 
difference  in  the  prognosis  of  syphilis  since  so  many  syph- 
ilitics  die  of  buccal  cancer  through  the  intervention  of  leu- 
coplakia.— Gazette  Jteiu/oiiiai/aire,  November  15,  igoo. 

Two  Cases  of  Intestinal  Occlusion  by  Cancer  of  the  Colon. 
— Victor  Pauchet  concludes  after  reviewing  the.se  two  cases 
that  when  there  exists  an  acute  intestinal  occlusion  from 
cancer  of  llie  colon,  if  the  intestinal  coils  are  very  much 
distended  and  conditions  for  relief  are  not  favorable,  and 
if  the  general  condition  of  the  patient  permits,  an  artificial 
anus  should  be  established.  This  will  be  only  a  temporary 
condition,  for  some  weeks  later  the  cancerous  segment  can 
be  treated  and  the  artificial  opening  can  be  clo.sed. — Ga- 
selte  t/es  Hopitaii.x,  November  13,  1900. 

Miinchener  viedicinische  Wochenschrift,  Nov.  zj,  igoo. 

Observations  on  Suicide  Based  on  Three  Hundred  Au- 
topsies.— Arnold  Heller  draws  some  interesting  conclusions 
from  a  careful  analysis  of  the  results  of  three  hundred  au- 
topsies on  suicides.  The  fallacy  of  the  belief  curre':t  in 
professional  as  well  as  lay  circles,  that  such  individuals  are 
usually  subjects  of  some  definite  mental  disease,  is  shown 
by  the  fact  that"  this  was  found  in  only  five  per  cent,  of  the 
cases.  A  more  important  observation,  however,  is  that 
nearly  one-half  of  the  subjects,  at  the  time  the  act  was 
committed,  were  in  such  a  state  of  disturbed  mental  equilib- 
rium as  to  be  unable  to  resist  impulses  which  would  ordi- 
narily have  left  them  unaffected.  More  exactly  stated,  it 
was  found  that  forty-three  per  cent,  were  in  such  a  condi- 
tion, owing  to  the  early  stages  of  unrecognized  acute  infec- 
tious diseases,  the  menstrual  epoch,  pregnancy,  etc.,  as  to 
be  temporarily  incapable  of  .sound  judgment,  without  being 
the  victims  of  any  actual  mental  disease.  The  .significance 
of  such  a  result  may  be  realized  when  it  is  considered  that 
this  really  means  that  nearly  fifty  per  cent,  of  these  three 
hundred  cases  were  not  true  suicides  at  all  in  the  sense  so 
severely  condemned  by  sociologists  and  moralists,  since  the 
act  was  performed  at  a  time  when  the  individual  was  not 
responsible  for  his  actions,  and  the  inference  is  that  a  care- 
ful post-mortem  examination  should  be  made  by  competent 
pathologists  in  every  case  of  supposed  suicide  before  it  is 
pronounced  as  such,  with  the  consequent  stigma  on  the  de- 
scendants, loss  of  insurance,  etc. 

Hereditary  Progressive  Spinal  Muscular  Atrophy  in  Child- 
hood.— J.  Hoffmann  describes  a  disease  of  which  he  has 
seen  six  ca.ses  and  of  which  the  essentials  may  be  summed 
up  as  follows  :  The  patients  are  children  of  good  jiaientage 
and  usually  between  the  ages  of  five  and  nine  months. 
The  first  symptom  is  a  symmetrical,  atrophic,  slowly  pro- 
gressive paralysis  of  the  muscles  of  the  thigh  and  pelvis, 
shown  by  cessation  of  the  natural  kicking  and  attempts  at 
crawling  and  standing.  The  process  gradually  invades 
the  musculature  of  the  back,  abdomen,  neck,  and  shoulder 
girdle,  involving  both  upper  and  lower  extremities  in  a 
descending  palsy  to  their  very  tips.  At  the  same  time  the 
reaction  of  degeneration  and  absence  of  the  tendon  reflexes 
are  noted,  together  with  obesity  and.  ultimately,  contrac- 
tures. The  sensory  system  is  unaffected,  the  organs  of 
special  sense  functionate  normally,  and  muscular  hyper- 
trophy or  pseudo-hypertrophy  is  absent.  The  disease  al- 
ways terminates  fatally  in  from  one  to  four  years  after 
its  onset,  death  being  due  to  secondary  pulmonary  infec- 
tions. 

The  Atropine  Treatment  of  Intestinal  Obstruction. — By 
LUttgen.  The  results  of  other  advocates  of  this  method 
of  dealing  with  intestinal  obstruction  have  already  been 
reported  in  abstract  in  this  journal  and  the  observations  of 
the  above  writers  confirm  the  favorable  conclusions  of  their 
predecessors.  Of  the  four  cases  thej-  detail,  recovery  fol- 
lowed in  three,  and  was  undoubtedly  due  to  the  atropine  in- 
jection, and  though  the  fourth  terminated  fatally  the  med- 
ical treatment  was  not  re.sorted  to  until  after  operation  had 
failed  to  relieve.  The  dose  employed  is  the  huge  one  of 
0.005  grn.  (gr.  ^j),  but  toxic  symptoms  were  noted  in  only 
one  instance  and  then  soon  subsided,  while  happy  results 
have  now  been  reported  in  so  many  cases  as  to  justify  a 
trial  of  the  method  whenever  operation  is  contraindicated 
or  refused. 


986 


MEDICAL    RECORD. 


[December  22,   igoo 


A  Practical  Method  of  Increasing  the  Digestibility  of 
Cow's  Milk. — The  process  suggested  by  v.  iJuugein  con- 
sists iu  raising  the  previously  sterilized  milk  to  the  body 
temperature  and  precipitating  the  casein  witli  lab  ferment. 
The  resulting  curds  may  now  be  easily  subdivided  by  agi- 
tation or  churning  until  they  remain  suspended  as  tine 
flakes  which  resemble  the  coagula  produced  in  human 
milk.  By  this  means  the  chief  factor  in  making  cow's  milk 
less  digestible  than  breast  milk,  viz.,  the  large  and  tough 
casein  clots  formed  on  contact  with  the  gastric  juice,  is 
eliminated,  wdiile  experiment  has  shown  that  milk  so  pre- 
pared is  just  as  readily  taken  and  retained  as  wheu  given 
in  the  usual  way. 

Further  Contributions  to  the  Atropine  Treatment  of  Intes- 
tinal Obstruction. — By  Demnie. 

Personal  Prophylaxis  and  the  Abortive  Treatment  of  Gon- 
orrhoea.—  By  C.  Kopp. 

The  Action  of  Naphthalan  in  Eczema  of  the  External  Ear. 
—  By  II.  Sag-ebiel. 

The  Atropine  Treatment  of  Intestinal  Obstruction. — By 
Holz. 

Disinfection  with  Carbo-formal  Glow  Blocks. — By  Erne. 

Auto-infection  in  Obstetrics. — By  H.  Feliling. 

Artificial  Infant  Feeding. — By  Soxhlet. 

Deutsche  vit'dicinische  Wockcnsclirift,  Xo't<.  2g,  igoo. 

The  Value  of  the  Serum  Reaction  in  the  Early  Diagnosis 
of  Tuberculosis. — Arloing  and  Courmont  publish  a  refuta- 
tion of  the  conclusions  drawn  by  Beck  and  Rabinowitsch 
in  a  recent  number  of  the  same  journal,  which  reflected  on 
the  utility  of  the  serum  reaction,  to  which  the  names  of  the 
first  two  authors  are  now  attached.  The  discrepancies  of 
the  results  obtained  by  the  later  observers  are  attributed 
to  differences  in  technique,  and  the  authors  adhere  to  their 
former  dicta  that  (i)  in  tuberculous  subjects  agglutination 
takes  place  at  a  dilution  of  from  i  :  5  to  i  :  20  or  even  higher. 
(2)  The  reaction  is  most  marked  in  light  cases  and  may 
even  fail  completely  in  advanced  stages.  (3)  Tiie  diag- 
nosis of  tulierculosis  by  means  of  the  serum  reaction  seems 
adapted,  on  account  of  its  quickness  and  harralessness,  to 
win  clinical  consideration  in  spite  of  the  technical  difficul- 
ties its  performance  pre.sents. 

The  Treatment  of  Heart  Disease. — H.  Hellendall's  device 
consists  of  a  truss  having  a  pad  controlled  by  a  spring  and 
designed  to  support  the  ape.x  beat.  Not  all  cases  derive 
benefit  from  this  apparatus  ;  out  of  ten  it  was  found  inap- 
plicable in  two,  viz.,  one  of  aortic  insufficiency  and  one  of 
aortic  aneurism.  In  the  others,  which  comprised  exophthal- 
mic goitre,  neurasthenia,  mitral  and  aortic  incompetence, 
and  secondary  hypertrophy,  the  beneficial  effect  was  very 
great  in  reducing  tlie  tendency  to  palpitation  and  relieving 
the  sense  of  oppre.ssion  and  dyspnu?a  on  exertion. 

Second  Report  on  Malaria  and  Mosquitos  on  the  West 
African  Coast. — By  H.  Ziemann. 

The  Radiograph  of  a  Tablespoon   in  the  (Esophagus. — By 

L.  .Stem  bo. 

The  Technique  of  X-Ray  Examinations. — By  Albers-Shon- 
berg. 

Berliner  klinisclie  Jl'oc/iensc/irif/,  \o.  ^7,  Aov.  ig,  igoo. 

Symptomatology  of  Facial  Paralysis. — By  M.  Bernhardt. 
Details  are  given  of  a  series  of  cases  differing  .somewhat 
from  the  classical  type.  They  show  that  cases  due  to  pe- 
ripheral lesion  exist,  in  which  there  is  no  reaction  of  degen- 
eration, but  in  which  the  mu.scles  react  instantly  to  the 
electric  stimulus  ;  in  addition  there  are  cases,  probably  con- 
genital, in  which  are  contractions  on  the  aft'ected  side  of 
the  muscles  in  the  vicinity  of  the  middle  line  of  the  chin 
and  lower  lip  from  the  crossing  over  of  exempt  fibres  from 
the  normal  side.  Finally,  there  are  cases  congenital  or 
occurring  in  early  years,  wdiich  sliow  this  peculiarity  that 
irritation  with  currents  .so  weak  that  no  contraction  results 
on  the  sound  side,  causes  a  lessened  irritability  of  the  af- 
fected side. 

Woman's  Milk. — M.  Cohn  has  examined  many  specimens 
of  human  milk  under  various  conditions  of  lactation  and 
finds  tlierein  certain  elements  which  he  suggests  may  pos- 
sibly be  the  cause  of  infantile  dysjiepsia. 

Effect  of  Bloodletting  or  Metabolism.— Bv  G.  Ascoli  and 
A.  Ur.iglii. 

Morphology  of  the  Staphylococcus  Albus. — By  E.  Saul. 

Treatment  of  Cross  Presentations. — By  A.  Cramer. 

Arcliiiu-s  11/  J'ei/iii/rus,  December,  igoo. 

Foetal  and  Infantile  Typhoid.— John  Lovett  Morse  says 
that,  except  for  the  lessened  exposure  in  the  first  year 
through  food,  there  seems  no  obvious  reason  why  typhoid 
should  be  less  frequent  in  infancy  tlian  in  later  life.     Nev- 


ertheless, judging  from  the  small  number  of  ca.ses  reported, 
it  is  less  frequent.  As  to  foetal  typhoid,  the  bacillus  can 
traverse  the  abnormal,  and  possibly  the  normal,  placenta 
from  mother  to  foetus,  and  infection  of  the  foetus  results. 
The  foetus  as  a  result  usually  dies  in  utero  or  at  birth,  or 
it  may  possibly  live  a  few  days.  Intrauterine  typhoid  is. 
from  the  first,  a  general  septica;mia.  Classical  lesions  of 
typhoid  are  wanting.  Infection  does  not  always  occur, 
the  pregnant  woman  not  necessarily  transmitting  the  dis- 
ease to  her  child.  The  serum  reaction  occurs  in  infantile 
as  in  adult  typhoid.  There  are  no  data  as  to  whether  or 
not  It  occurs  in  f<x-tal  typhoid. 

Pulmonary  Tuberculosis  in  Infants  and  Children. — Frank 
P.  Norbury  holds  that  this  disease  is  not  a  rarity  among 
children.  It  may  occur  by  direct  hereditary  transmission, 
but  is  more  likely  to  be  due  to  infection  from  a  tuberculous- 
mother.  Milk  is  also  a  source  of  infection.  The  child  of 
a  tuberculous  motlier  should  be  artificiall)'  fed  with  ster- 
ilized milk,  should  sleep  in  a  room  apart  from  its  mother, 
and  kissing  by  her  should  be  prohibited.  To  the  child 
afflicted  with  the  disease,  the  open-air  treatment  is  the 
best,  the  most  suitable,  and  the  most  satisfactory.  Knopf 
says.  "Children  and  young  people  often  develop  tubercu- 
losis for  no  other  reason  tlian  that  they  are  naturally  bad 
eaters."  Hence  wholesome  food,  plenty  of  it,  at  proper 
intervals  should  be  given.  Raw  eggs  are  good.  Children 
often  acquire  a  real  liking  for  pure  Norwegian  cod-livei 
oil.  The  weight  of  the  patient  is  the  best  guide  for  us  in 
determining  the  benefits  of  treatment. 

A  Report  of  One  Hundred  and  Eighty-seven  Cases  of 
Measles  with  Reference  to  Koplik's  Spots,  and  their  Value 
in  Diagnosis. — John  I.  Cotter  gives  the  following  figures 
as  the  results  of  the  observations  made  :  Koplik's  spots — 
positive, one  hundred  and  sixty-nine  cases  ;  negative,  eight ; 
doubtful,  ten.  Of  the  entire  one  hundred  and  eighty-seven 
cases  not  a  single  one  presented  Koplik's  spots  as  the  only 
evidence  of  the  disease  which  was  to  follow.  Other  evi- 
dence regularly  presented  was  a  rise  (f  temperature  to- 
more  than  gg'  F.  The  authors  were  unable  to  diagnose  a 
single  case  on  the  strength  of  the  spots  alone,  because  the 
two  symptoms,  fever  and  spots,  travelled  together  invari- 
ably. However,  it  is  not  known  that  any  disease  other 
than  measles  presents  the.se  spots,  and  their  value  in  diag- 
nosis should  meet  with  the  universal  appreciation  which 
their  importance  demands. 

Fatal  Intestinal  Hemorrhage  without  Known  Cause  in  an 
Infant  of  Five  Months. — By  Maurice  Ostheimer. 

Poisoning  by  Vapo-Cresolene. — By  S.  S.  Adams. 

Annals  0/  Surgery,  December,  igoo. 

Structure,  Fracture,  and  Refracture  of  the  Patella. — E.  M. 

Corner  states  tliat  the  patella  is  peculiar  in  that  when  sub- 
mitted to  direct  violence  the  femur  acts  as  an  anvil  and  it 
is  violently  compressed  between  the  "hammer"  and  the- 
"anvil."  Under  such  circumstances  a  stellate  fracture  re- 
sults. In  two  directions  the  above  must  be  modified,  viz.,. 
the  extent  of  the  areas  over  which  the  direct  violence  is 
diffused  or  applied,  and  tlie  relations  of  the  size  of  the 
"force-areas"  to  tliat  of  the  "contact-areas"  between  the 
patella  and  the  femur.  To  deal  with  the  first  of  these,  it 
may  be  stated  that  the  greater  the  "force-area  "  the  greater 
the  likelihood  of  stellate  tracture  and  comminution,  and 
vice  versa.  With  regard  to  the  second,  if  the  force-area 
equals  or  is  greater  than  the  contact-area,  a  stellate  frac- 
ture will  probably  result.  If,  on  the  other  hand,  the  force- 
area  is  less  than  the  contact-area,  a  transverse  or  oblique 
fracture  may  result,  and  the  smaller  the  force-area  the  more 
likely  is  this  result  to  be  attained.  Such  an  accident  as  the 
last  is  of  rare  occurrence.  From  a  study  of  one  hundred 
and  ninety-one  cases  occurring  during  nine  years  and 
treated  at  St.  Thomas'  Hospital,  Corner  finds  that  in 
transverse  fractures  the  upper  fragment  was  the  larger  in 
37.7  per  cent.,  the  line  of  fracture  about  at  the  centre  in 
45.5  per  cent.,  and  the  lower  fragment  the  larger  in  16.S- 
per  cent.  Hence  the  lower  half  of  the  bone  is  more  often, 
broken  than  the  upper,  and  this  is  accounted  for  by  the 
fact  that  anatomically  this  lower  half  is  weaker  in  struc- 
ture. He  believes  that  one  of  the  reasons  for  the  failure 
of  ossification  to  extend  into  even  short  fibrous  unions  is- 
the  fact  that  the  jiatella  is  a  sesamoid  bone  ;  it  differs  from 
other  bones  in  that  it  is  not  surrounded  by  a  jieriosteum. 
In  consequence  of  this,  the  osteogenetic  jjowers  must  be 
comparatively  small,  and  so  bony  union  will  not  occur  un- 
less there  is  close  appro.ximation  of  the  fragments. 

The  Radical  Cure  of  Inguinal  Hernia  in  the  Female. — W. 
B.  Coley  has  eni]iloyed  in  one  Inindrcd  and  twenty-three 
cases  a  method  of  operation  which  is  practically  Bassim's 
method  as  performed  in  the  male,  the  single  step  of  trans- 
planting tlie  cord  being  omitted.  The  incision  is  made 
one-half  to  tliree-fourths  of  an  inch  above  and  parallel  to 
Poupart's  ligament,  and  should  extend  nearly  to  the  level 
of  the  anterior  superior  spine.     The  aponeurosis  of  the  ex- 


December  22,  1900] 


MEDICAL    RP:C0RD. 


987 


ternal  oblique  is  slit  up  well  over  the  internal  ring  and  dis- 
sected baL'k  to  the  edge  of  the  rectus  on  the  inner  side  and 
on  the  outer  sufficiently  far  to  expose  the  thick  fold  of  Pou- 
part's  ligament.  If  the  sac  is  sought  for  high  up  just  be- 
low the  edge  of  the  internal  oblitjue  muscle,  there  will  be 
no  difficulty  in  tinding  it.  After  the  sac  has  been  dissected 
from  the  round  ligament  and  thoroughly  freed  well  within 
the  external  ring,  it  is  transfixed  and  tied  off  witli  catgut. 
Tlie  wound  is  then  closed  in  three  layers,  as  in  1-Sassiui's 
method,  a  medium-sized  kangaroo  tendon  being  used  for 
all  buried  sutures  and  catgut  for  the  skin.  In  the  deep 
layer,  interrupted  sutures,  usually  four  or  hve  in  number, 
are  introduced  from  above  downward,  bringing  ihe  inter- 
nal ol)lique  and  transversal  is  muscle  over  to  Foupart's 
ligament.  The  round  ligament  is  allowed  to  drop  back 
into  the  lower  angle  of  the  wound,  and  as  it  approaches 
the  pubic  bone  it  is  so  small  that  it  recpiires  much  less 
space  than  the  cord  in  the  male.  The  aponeurosis  is  now 
sutured  with  a  continuous  suture  ot  kangaroo  tendon, 
about  the  size  of  a  number  one  catgut.  The  skin  is  closed 
without  drainage,  and  the  wound  dressed  with  iodoform 
gauze  and  moist  bichloride  gauze  i  :  5,000. 

Fracture  of  the  Spine. — \V.  Lathrop  thus  summarizes  in- 
dications for  operative  intervention:  (i)  In  partial  lesions 
we  should  operate.  (2)  Where  the  lumbar  region  is  in- 
volved with  lesions  of  the  cauda  equina,  operation  offers 
the  best  chance  for  recovery.  (3)  In  fracture  of  the  spi- 
nous process,  lamina,  or  entire  neural  arch,  operation  is 
demanded.  (4)  Should  immediate  operation  not  be  done, 
and  we  wait  six  to  eight  weeks,  with  the  result  that  paral- 
ysis of  the  bladder  and  bowel  continues,  with  cystitis  and 
severe  bedsores  present,  we  may  be  sure  that  nature  can- 
not relieve  the  case,  and  an  operation  is  not  only  indicated 
but  demanded. 

Suppurative  Pericarditis  and  its  Surgical  Treatment,  with 
an  Analysis  of  Fifty-one  Cases  Reported  in  Literature. -By 
C.  B.  Porter. 

Transperitoneal  Ureterolithotomy,  Report  of  a  Case  in 
which  the  Stone  was  located  by  the  X-Ray. — By  G.  N.  J. 
Somnier. 

A  Complete  Series  of  Clinical  Charts  for  Keeping  the 
Records  of  Surgical  Cases. — By  C.  II.  Frazier. 

Echinococcus  Cyst  of  the  Liver. — By  R.  S.  Fowler. 

Operation  for  Cancer  of  Penis. — By  N.  Raw. 

American  Journal  0/  thi:  Medical  Sciences,  Dec,  ii)oo. 

The  Cortical  Localization  of  Sight  and  Hearing. — Clarence 
A.  (rood  reports  the  case  of  a  woman  lifty-hve  years  old. 
About  seventeen  years  previous  to  her  admission  to  the 
asylum  she  had  hts  at  night.  These  lasted  for  about  two 
years.  When  admitted  to  the  hospital  she  was  practically 
blind.  The  pupils  were  equal,  reacting  to  light.  She  was 
deaf.  Thesenseof  smell  was  keen.  The  speech  was  drawl- 
ing and  the  gait  lame.  She  was  slightly  paretic  in  all 
limbs.  Cutaneous  sensibility  was  normal  so  far  as  could 
be  determined.  Mental  action  was  slow  and  incoherent, 
memory  ////.  From  April,  1S92,  to  )ier  death  in  November, 
1893.  she  suffered  from  convulsions.  The  brain  was  care- 
fully examined,  and  the  writer  draws  the  following  conclu- 
sions: I.  Destruction  of  the  cortical  visual  areas  will  lead 
to  a  degeneration  of  the  cells  in  the  geniculate  ganglia  and 
the  corpora  quadrigemina,  and  to  a  degeneration  of  the 
nerve  fibres  of  the  optic  tracts  and  nerves.  2.  The  macula 
lutea  of  one  eye  is  in  connection  with  the  opposite  angular 
gyrus. 

The  Operative  Treatment  of  Cirrhosis  of  the  Liver. — Charles 
H.  Frazier  believes  that  operative  interference  has  a  future 
in  properly  selected  cases,  viz.,  (i)  cases  in  which  the  liver 
is  cirrhotic  ;  (2)  cases  in  which  there  is  reason  to  believe 
the  liver  cells  are  not  devoid  of  function  ;  (3)  cases  in  which 
internal  medication  (particularly  iodide  of  potassium)  and 
paracentesis  fail  to  afford  relief,  or,  in  other  words,  in  ut- 
terly hopeless  cases  ;  and  (4)  cases  in  which  there  is  no  rea- 
sonable contraindication.  The  cases  are  so  hopeless,  the 
technique  is  so  simple,  the  dangers  are  so  trivial,  and  the 
outlook  is  so  promising  that  the  prospects  of  this  mode  of 
treatment  becoming  an  established  one  seem  bright.  That 
surgeons  now  have  at  their  command  a  method  both  ra- 
tional and  reliable  of  affording  relief  (sometimes  temporary 
but  often  permanent)  to  intractable  cases  of  ascites,  seems 
a  very  fair  conclusion  to  draw  from  the  accumulated  evi- 
dence. 

The  Leucocyte  Count  In  Serous  Pleurisy.  —  John  Lovett 
Morse  presents  the  following  conclusions  :  Serous  pleurisy 
is  only  exceptionally  accompanied  by  an  increase  in  the 
number  of  white  corpuscles,  and  then  intermittently.  The 
white  count  is  of  value  in  two  ways  in  the  diagnosis  of  serous 
pleurisy :  If  the  physical  signs  are  doubtful  and  there  is  no 
leucocytosis  the  condition  is  almost  certainly  not  pneumo- 
nia or  empyema,  but  serous  pleurisy.  If  there  is  a  serous 
pleurisy  with  a  continuous  leucocytosis,  some  complication 


is  present.  The  white  count  in  serous  pleurisy  affords  no 
information  as  to  the  duration  of  the  process,  the  amount 
of  the  fluid,  and  its  increase  or  dmiinution.  The  number 
of  white  cells  is  not  influenced  by  the  presence  of  blood  or 
microscopical  pus  in  the  liuid  or  by  the  degree  of  fever. 

On  the  So-Called  "Irritable  Bladder"  in  the  Female.— 
Frederic  Bierhoff  concludes  that :  i.  The  term  "  vesical  hy- 
periesthesia  "  or  "  irritable  bladder  "  is  in  almost  every  case 
in  the  female  erroneously  applied.  2.  As  a  true  neurosis 
vesical  hyijcra-stliesia  rarely  occurs.  3.  When  vesical 
hypertesthesia  exists  it  does  so  only  as  a  symptom  ;  in  the 
majority  of  cases  as  a  direct  result  of  some  change  in  the 
vesical  mucous  membrane,  in  the  minority  as  an  indirect 
result  of  changes  in  other  organs  adjoining  or  near  the 
bladder.  4.  The  diagnosis  of  the  causative  factor  must 
rest  upon  a  thorough  examination  not  only  of  the  bladder, 
but  of  the  urethra  and  genital  and  pelvic  organs  as  well. 
5.  The  treatment  must  be  directed  against  both  the  local 
changes  and  the  causative  factors. 

A  Case  of  Malaria  Presenting  the  Symptoms  of  Dissemi- 
nated Sclerosis,  with  Necropsy. — By  William  (!.  Sjjiller. 

Report  of  a  Case  of  Extensive  Dissecting  Aneurism  of  the 
Aorta. — By  Herbert  Swift  Carter. 

The  Laryngoscope,  Oclober  and  November ,  igoo. 

Report  of  a  Case  of  Spontaneous  Cure  of  a  Severe  Mastoid- 
itis. II.  S.  -Mcdavren  saw  a  girl  of  ten  years  witli  a  su]j- 
puratioii  from  the  right  middle  ear.  On  examiuingtlie  left 
ear  he  found  a  depression  of  the  mastoid  eminence  similar 
to  that  following  an  ordinary  operation  for  mastoiditisex- 
cept  that  it  was  cup-sliaped.  nearly  round,  and  api)eaied 
to  be  very  deep.  There  was  no  tenderness.  'I'he  mother 
stated  that  two  years  before  there  had  been  trouble  in  the 
left  ear,  and  that  finally  there  had  been  an  exfoliation  of  a 
bony  mass,  about  the  size  of  the  thumb-nail,  and  that  there- 
after all  trouble  ceased  in  that  ear.  No  physician  was  con- 
sulted at  the  time  ami  only  household  remedies  were  used. 

Adenoids  from  the  Standpoint  of  Hemorrhage.— I.  E.  Kim- 
ball advises  keeping  the  patient  in  bed  for  from  twenty- 
four  to  forty-eight  hours,  during  which  time  nothing  but 
cold  food  should  be  given.  He  insists  upon  the  following 
points:  I.  Thoroughness  of  removal  and  carefulness  iu 
technique  at  the  expense  of  time.  2.  The  selection  of  in- 
struments the  best  suited  to  perform  the  operation  safely 
and  efficiently.  3.  The  positi.ve  exclusion  of  the  hemor- 
rhagic diathesis.  4.  Competent  supervision  of  the  patient 
until  the  danger  from  hemorrhage  is  over. 

Nasal  Synechia. — M.  1).  Lederman  advises  the  use  of  sur- 
gical sponge  or  spunk  for  the  relief  of  this  condition.  One 
should  select  the  soft  elastic  variety,  which  can  be  cut  into 
any  shape,  may  be  covered  with  any  anti.septic  powder  and 
allowed  lo  remain  in  the  naris  for  forty-eight  hours.  It 
comes  away  from  the  wound  very  easily  and  does  not  cause 
any  bleeding.  In  introducing  the  plug  we  must  be  care- 
ful to  avoid  bruising  the  tissues  with  the  end  of  the  forceps, 
as  synechi;e  .sometimes  form  behind  the  site  of  the  tampon. 

Primary  Epithelioma  of  the  Antrum  of  Highmore.  —  H. 
Holbrook  Curtis  reports  a  case  of  this  nature  occurring  iu 
a  woman  of  fifty  years.  The  points  of  interest  were  that 
the  antrum  was  primarily  invaded,  that  the  growth  was  of 
an  epitheliomatous  nature,  and  that  after  operative  proce- 
dure it  extended  with  startling  rapidity,  finally  proving 
fatal  six  weeks  after  the  evulsion  of  the  antrum  contents. 
A  review  of  the  literature  of  similar  cases  closes  the  report. 

Journal  oj  Laryngology,  A'o''eml>er,  igoo. 

Anosmia. — A.  Onodi  divides  anosmias  into  three  clas.ses  : 
I.  Essential  or  true  anosmia,  either  central  or  peripheral, 
caused  by  inllammation  of  the  olfactory  region,  syphilitic 
changes.  oz;ena.  various  central  changes,  intoxications  from 
various  drugs,  irritating  gases,  toxins  of  various  diseases, 
congenital  structural  defects,  and  pigmentary  atrophy  ;  2. 
Respiratory  or  mechanical  anosmia,  caused  by  any  local 
change  preventing  free  respiration  through  the  nares ; 
and  3.  Functional  anosmia  due  generally  to  hysteria,  but 
which  may  come  from  various  reflexes,  e.g.,  after  ovarioto- 
my, during  menstruation,  after  cauterization  of  the  inferior 
turbinals,  and  after  extirpation  of  the  Gasserian  ganglion. 
Hallucinations  of  smell,  various  parosmias,  and  kakos- 
mias  are  frequent  precursors  of  anosmia. 

Experiments  on  Anaesthesia  of  the  Semicircular  Canals  of 
the  Ear. — -G.  Gaglio  insists  on  the  conclusion  that  the  iiys- 
tagmatic  movements  of  the  eyeballs  which  are  observed 
to  follow  destruction  of  the  labyrinth  are  phenomena  not 
of  excitation  but  of  paralysis  ;  that  is,  of  a  loss  of  function 
of  an  organ  which  normally  by  a  reflex  path  influences  the 
function  of  the  muscles  of  the  eyes.  In  other  words,  he 
admits  that  the  semicircular  canals  and  other  parts  of  the 
membranous  labyrinth  originate  normally  a  wave  of  exci- 
tation, slow  and  continuous,  which  carried  to  the  nerve 


988 


MEDICAL    RECORD. 


[December  22,  1900 


centres  and  following  them,  extends  to  the  nerves  and  mus- 
cles of  the  eyes. 

Treatment  of  Laryngeal  Tuberculosis  by  Intra-Tracheal  In- 
jections.— L.  Vaclier  advises  tlic  use  of  the  foUowinjf :  Sat- 
urated solution  of  iodoform  in  ether  loo  parts,  guaiacol 
9  parts,  eucalyptol  2  parts,  and  menthol  i  part.  The 
amount  to  be  injected  should  not  pass  beyond  2  c.c.  It  is 
better  to  begin  with  a  smaller  quantity.  He  found  that  by 
its  use  pain  was  lessened,  eating  made  easier,  and  respi- 
ration more  ample. 


©orvcspoudcwce. 

OUR   LONDON    LETTER. 

(From  our  Special  Correspondent.) 

rOISON  IN  BKER  ;  A  TRAGIC  RESULT — PROFESSOR  (ALMETTe's 
IIARBEN  LECTURES  ON  PLAGUE — GENERAL  MEDICAL  t:oUNCIL 
—  CHILDHOOD  SOCIETY — THE  "MEDICAL  DIGEST";  DEATH 
OF    ITS    AUTHOR — OTHER    DEATHS. 

LuNOON,  November  30,  1900. 

"  A  THOUSAND  cases  of  poisoning  !  "  "  .-Xrsenic  in  the  beer  !  " 
Startling  enough  headings  these  for  the  most  sensational 
papers.  But  they  were  nearer  the  truth  than  many  sup- 
posed. Manchester  is  the  centre  of  an  epidemic  which  has 
for  weeks  puzzled  tlie  medical  men.  It  is  said,  indeed, 
tliat  cases  may  be  traced  back  fcrr  six  months.  .Some  were 
at  first  supposed  to  be  alcoholic  peripheral  neuritis,  but 
the  numbers  increased  so  much  tliat  some  other  explana- 
tion was  sought.  At  the  various  hospitals  and  infirmaries 
great  numbers  of  applicants  presented  anomalous  symp- 
toms of  peripheral  neuritis,  and  at  length  it  was  recog- 
nized that  they  were  all  drinkers  of  beer — mostly  cheap 
beer.  Then  Dr.  Reynolds,  of  the  Union  Hospital,  an- 
nounced at  the  Medical  Society  that  he  had  found  arsenic 
in  the  beer,  and  the  fact  was  published  in  the  newspapers. 
How  the  arsenic  got  into  the  beer  was  the  next  question 
and  one  more  easily  solved.  Chemists  knew  the  large 
quantities  of  glucose  employed  by  brewers  and  that  sul- 
phuric acid  is  used  in  its  manufacture.  They,  therefore, 
at  once  went  for  the  glucose,  and  while  some  samples  in 
use  were  pure,  others  were  contaminated  with  arsenic. 
The  amount  of  glucose  used  by  different  brewers  varies 
largely,  and  this  fact  goes  to  explain  the  remarkaljle  vari- 
ations noticed  in  the  intensity  of  the  symptoms  produced. 
The  typical  symptoms  of  arsenic  poisoning  can  be  traced 
in  groups  of  cases,  though  individuals  present  great  diver- 
gences. Tlius  the  sensory  symptoms  are  said  to  have  been 
almost  always  obvious  but  of  every  degree  of  severity, 
from  a  sensation  of  sliglit  numbness  to  pain  .so  intense  that 
the  patients  dreaded  to  be  touched.  Cramps,  too,  of  the 
extremities  frequently  occurred,  and  there  was  often  im- 
paired motility — in  some  cases  complete  paralysis.  The 
catarrh  of  the  respiratory  membrane  extending  over  the 
eyes,  nose,  and  larynx  was  marked,  but  did  not  seem  to 
implicate  the  bronchi.  The  digestive  membrane  seemed 
less  affected  ;  the  silvery  tongue  was  present  and  anorexia 
common,  but  vomiting  and  diarrhcca  were  often  absent. 
The  skin  seemed  always  to  suffer.  Pigmentation  of  every 
degree  ;  erythematous,  papular,  and  vesicular  eruptions, 
followed  by  desquamation,  were  generally  complained  of. 
Many  ]iatients  paid  little  attention  to  their  rashes,  but 
others  found  them  marked  enough  to  alarm  them.  Others 
sought  advice  for  intense  itching ;  others  again,  for  con- 
stant colds,  hoarseness,  or  smarting  and  running  of  the 
eyes  and  nose ;  otliers,  for  the  nervous  symptoms.  Many 
cases  so  closely  reseml)led  beriberi  that  physicians  famil- 
iar with  the  tropics  were  inclined  so  to  call  the  trouble. 

Not  only  Manchester  but  Liver])ool  and  other  northern 
and  midland  towns  have  suffered,  and  about  eiglit  hundred 
patients  have  sought  relief  at  the  various  hospitals.  It  is 
estimated  that  more  than  sixty  deatlis  during  the  last  si.x 
months  have  really  been  due  to  arsenical  poisoning  through 
beer  drinking,  altliough  they  have,  of  course,  been  regis- 
tered under  different  names. 

Profes.sor  Calmttte  has  been  over  here  and  delivered  the 
Harben  lectures.  In  them  he  discussed  the  bacteriology, 
diagnosis,  clinical  a))i)earances,  transmission,  [H-eveution, 
and  treatment  of  plague.  All  that  he  said  went  to  show 
the  importance  of  serum  treatment.  lie  said  it  had  been 
clearly  proved  that  after  repeated  subcutaneous  or  venous 
injections  of  the  bacilli,  killed  by  heat,  it  is  possible  to  in- 
ject, after  an  interval,  into  small  animals  cultures  which 
would  be  fatal  without  the  previous  injections.  He  de- 
scribed Haffkine's  mode  of  ]ireparing  dead  cultures,  and 
said  if  they  were  injected  twice  or  three  times  at  a  week's 
interval,  a  more  durable  immunity  could  he  obt.'iincd,  e.\- 
tending  over  three  or  four  months  in  guinea-pigs  or  mon- 
keys and  six  months  in  rats.     Haflfkine  believed  a  single 


inoculation  might  often  suffice  to  render  a  man  immune 
during  an  epidemic.  But  it  has  been  shown  that,  during 
the  period  of  immunization,  animals  are  extremely  suscept- 
ilile  to  minute  doses  of  plague  virus.  Therefore,  if  any  one 
were  to  ha  inoculated  during  the  incubating  period  of  a 
slight  attack  of  ])lague  that  attack  would  be  aggravated 
and  most  likely  prove  fatal.  Other  methods  of  prepara- 
tion devised  to  meet  this  objection  were  also  described. 
Professor  Calmette's  own  cultures  are  from  a  virus  taken 
at  Oporto,  whicli  has  never  passed  through  any  animal 
and  which  he  keei)s  on  gelose  and  re-fertilizes  every  eight 
or  ten  days,  raising  the  temperature  to  36  C.  for  twenty- 
four  hours  each  time.  These  cultures  he  then  places,  still 
on  gelose.  in  large  flat  bottles  and  in  forty-eiglit  hours  an 
enormous  development  has  taken  place.  An  emulsion  with 
sterilized  water  is  filtered  and  the  microbes  are  washed, 
heated  up  to  70°  C.  for  an  hour,  and  dried  in  vacuo.  Thus 
the  dead  bodies  of  the  dried  bacilli  are  obtained  free  from 
any  trace  of  toxin  and  are  kept  in  sealed  tubes  until 
wanted.  When  required  for  use  they  are  suspended  in 
sterilized  salt  .solution  and  may  be  injected  under  the  skin 
or  into  a  vein. 

Prophylaxis  must  be  based  on  the  knowledge  that  rats 
and  fleas  are  the  principal  agents  in  propagating  plague. 
The  best  methods  of  destroying  vermin  nmst  therefore  be 
employed.  Any  town  threatened  with  plague  should  spare 
no  effort  to  exterminate  vermin.  If  a  suspicious  case  oc- 
curs a  confidential  note  detailing  the  symptoms  and  the 
requisite  precautions  against  contagion  should  be  sent  to 
the  .several  medical  men.  A  supply  of  serum  should  be  at 
hand. 

The  General  Medical  Council  met  on  Tuesday.  The 
l^resident.  Sir  William  Turner,  had  more  excuse  than 
usual  for  indulging  in  an  address,  but  his  performance 
ought  to  have  been  much  curtailed.  The  finances  of  the 
council  are  in  a  parlous  state,  and  its  inteiTninable  discus- 
sions at  a  guinea  a  minute  ought  to  be  shortened.  The 
presidential  address  is  useless.  A  brief  report  of  any- 
thing done  since  the  previous  session  should  be  prefixed  to 
a  proper  programme.  Surely  the  representatives  of  uni- 
versities and  colleges  could  understand  the  programme 
and  proceed  without  instruction  from  the  chair  as  to  its 
meaning.  But  there  is  a  tendency  to  keep  matters  in  the 
hands  of  the  chairman,  and,  to  this  end,  it  is  convenient  to 
delay  the  programme  and  spring  important  work  on  the 
council  wthout  notice.  A  glaring  illustration  of  this  truth 
was  furnished  when  the  report  of  the  public-health  com- 
mittee was  brought  forward.  It  contained  important  state- 
ments and  suggestions,  as  well  as  a  set  of  new  draft  rules 
concerning  the  diploma  in  public  health,  but  it  was  pro- 
duced to  members  only  on  the  morning  of  the  discussion. 
Why,  it  ought  to  have  been  circulated  weeks  before.  The 
subject  has  been  debated  again  and  again  for  years.  There 
was  no  reason  for  this  absurd  method  of  burking  ])roposals 
up  to  the  last  minute,  and  objection  to  such  a  course  was 
taken  by  several  councillors.  A  long  di.scussion  ended 
with  no  more  decisive  result  than  in  other  ca.ses.  So  the 
time  of  the  council  was  squandered,  and  time  in  this  case 
is  money. 

A  communication  was  read  from  our  consul  at  Chicago 
about  the  bogus  dii)loma  mill.  The  names  of  parties  who 
had  corresponded  with  those  engaged  in  that  fraud  were 
sent,  but  none  of  them  are  "registered  practitioners." 

There  are  changes  in  tlie  council — three  new  members  : 
one.  Professor  Windle,  reijresenting  the  new  Birmingham 
University — quite  an  apt  illustration  of  the  strange  consti- 
tution of  the  council.  Here  is  a  Ijrand  new  university  with 
no  graduates — it  can  have  none  in  the  medical  faculty  for 
five  years — sending  its  representative  to  the  medical  coun- 
cil. Prof.  C.  B.  Ball  succeeds  Sir  Philip  Sniyly  who  has 
resigned.  Professor  Young  takes  the  place  of  the  late  Ur. 
Leech.  A  portrait  of  the  last-named  gentleman  has  been 
presented  to  the  council  by  a  fellow-worker  on  the  pharma- 
coptx'ia  committee. 

It  was  duly  reported  that  all  connection  of  the  Dublin 
College  and  Hall  for  the  purpose  of  a  conjoint  examination 
ceased  last  July. 

The  new  "Society  for  the  Study  of  Disease  in  Children," 
or,  as  it  is  already  being  called,  the  "Children's  Society" 
and  the  "Childhood  Society,"  has  already  more  than  one 
hundred  members.  For  the  present  it  is  arranged  to  hold 
the  meetings  at  various  hospitals  —  a  chairman  being 
cho.sen  at  each  meeting  from  those  present. 

Doubtless  you  know  the  "Medical  Digest,"  a  monument 
of  the  patience  and  perseverance  of  its  author,  Richard 
Neale,  M.D.  Lond..  etc.  He  died  cm  the  22d,  aged  sev- 
enty-three years.  He  spent  about  four  hours  a  day  for 
fifty  vears  on  this  labor  of  love.  It  was  a  costly  work  to 
print,  and  though  several  editions  appeared  .it  rather  a 
high  price,  it  could  not  pay.  Nevertheless,  he  continued 
his  self-imiiosed  task  for  the  benefit  of  his  profession — the 
last  appendix  appearing  last  year.  People  ask.  Who  will 
continue  the  work?  Can  any  one  be  expected  to  do  so? 
I   fear  it  must  be  as  with  your  Billings  and  his  "Index." 


December  22,  1900] 


MEDICAL   RECORD. 


989 


And  Dr.  Xeale's  "Digest"  was  after  all  only  his  hobby. 
He  had  an  active  medical  life,  too.  He  retired  about  three 
years  ago  and  went  to  live  at  the  seaside.  It  was  intended 
to  present  him  with  his  portrait  as  a  testimonial  of  the 
esteem  felt  for  him  personally  and  the  admiration  with 
which  his  devotion  to  his  great  work  is  regarded.  Failing 
health  prevented  the  accomplishment  of  this  purpose  and 
now  the  end  has  come. 

IJr.  Mortimer  (Iranville  died  on  the  23d,  aged  sixty- 
seven  years.  He  was  at  one  time  on  the  staff  of  The  I.an- 
tt't.  but  eventually  devoted  himself  to  practice.  He  wrote 
on  gout  and  nervous  di.seases  several  little  books — his  best 
perhaps  lieing  on  "The  Care  and  Cure  of  the  Insane." 
which  consisted  for  the  most  part  of  articles  he  had  contrib- 
uted to  The  Taiicft.  He  devised  the  "percuteur"  for 
treating  nen-ous  disease  by  rapid  vibrations  and  some 
other  instruments — also,  I  think,  a  modification  of  the 
sph  y  gmograp  h. 

Among  other  deaths  are  three  octogenarians  :  Dr.  Cord- 
went,  aged  eighty-live  years;  Dr.  Riggall.  aged  eighty- 
two  years  ;  and  Deputy-Surgeon-General  George  Mackay, 
M.D.,  aged  eighty-one  years. 


TREATMENT    OF   GASTROPTOSIS. 

To    THK     Kl>nOK    OK    IME    .MkHIlAL    Rli(_<.'Kl>. 

Sir  ;  In  your,  issue  of  tivday  I  read  with  great  interest  the 
article  "Gaslroptosis,"  by  Dr.  George  Roe  Lockwood. 
which  gives  many  important  original  observations.  The 
author,  as  it  appears,  has  not  seen  my  publication  on  the 
same  subject  in  T he  Fost-Gradiiate,  March,  icjoj ;  other- 
wise, I  am  certain  he  would  have  mentioned  a  methotl  of 
treatment  which  I  have  suggested,  namely,  the  support  of 
the  abdomen  b\-  a  i)iece  of  rubber  plaster  cut  to  cover  the 
whole  abdominal  wall,  tapering  off  behind,  with  two  e.vtra 
pieces  for  support  of  the  hypogastric,  inguinal,  and  iliac 
regions. 

This  bandage  was  described  by  Dr.  H.  W.  Lincoln  '  who 
had  assisted  me  in  the  out-door  clinic  of  the  Post-Graduate 
Medical  School  when  I  first  applied  this  method  there. 
My  experience  now  extends  over  about  one  hundred  cases 
of  gastroptosis  with  and  without  nephroptosis,  hepatopto- 
sis,  a  number  of  cases  in  which  no  diagnosis  of  gastroptosis 
could  be  made  but  where  splashing  sound  could  be  easily 
produced  and  extended  far  down.  The  effect  was  most 
gratifying  in  all  instances,  and  it  was  most  remarkable  in 
the  cases  of  reflex  vomiting  and  reflex  cough  caused  by 
gastroptosis.  The  distressing  symptoms  of  the  so-called 
nervous  dyspepsia  would  at  once  disappear  after  the  ap- 
plication of  the  bandage.  I  have  expressed  myself  on 
former  occasions  to  the  effect  that  we  have  here  the  ideal 
treatment  for  floating  kidney,  since  it  is  not  the  displaced 
kidney  which  causes  gastric  symptoms  but  the  coexisting 
displacement  of  the  stomach.  In  one  case  of  floating  kid- 
ney, after  the  plaster  had  been  borne  for  only  six  weeks,  I 
could  observe,  for  months  afterward,  that  the  relief  had 
been  permanent,  the  relaxation  of  the  organs  or  ligaments 
suspending  the  organs,  together  with  tiie  relaxation  of  the 
abdominal  w;dl.  was  not  found  any  more  ;  such  was,  at 
least,  the  case  when  I  .saw  the  patient  last,  si.x  months  after 
the  plaster  had  been  removed.  In  cases  in  which  the  skin 
is  tender  the  rubber  plaster  may  cause  unpleasant  irritation  ; 
in  such  instances  we  may  apply  first  to  the  skin,  for  pro- 
tection, Unna's  pink  rubber  plaster  and  over  this  the  ordi- 
nary rubber  plaster. 

Perhaps  some  Parisian  or  Berlin  colleague  will  now  dis- 
cover this  method  and  have  it  a.scribed  to  his  name,  in 
order  that  the  profession  in  America  may  find  it  worth 
while  to  take  notice  of  it.  A.' Rose,  M.D. 

New  York. 


HOW    IS    MOTILITY    IN    THE    RED    BLOOD 
CELLS    EFFECTED? 

To  THE  Editor  of  the  Medical  Record. 

Sir  ;  A  recent  number  of  the  Popular  Science  Monthly 
contained  an  interesting  article,  entitled  "The  Psychology 
of  Red,"  by  Havelock  Ellis.  The  author  quotes  Finseu  as 
having  shown  that  inflammation  of  the  skin  caused  by 
chemical  or  violet  light  leads  to  contraction  of  the  red  cor- 
puscles. In  the  same  way  heat  and  moisture  at  about  the 
body  temperature  lead  to  contraction  of  the  cells. 

But  these  investigations,  like  observations  of  these  cells 
under  varying  pathological  conditions,  may  .give  varying 
results,  and  hence  investigators  on  this  subject  may  be 
a  little  at  variance.  Without  wishing  to  discredit  the  in- 
fluence of  physical  factors  in  leading  to  contraction  of  these 
cells,  I  think  the)"  would  not  in  themselves  solve  the  prob- 

1  "  Gastroptosis  with  Special  Reference  to  a  new  Mechanical  Support.'' 
Medical  News.  September  i.  1900. 


lem  as  to  how  the  motility  is  effected,  unless  numerous 
observations  under  varying  conditions  were  made. 

The  red  blood  cell,  like  other  cells  in  the  body,  has  a 
function  to  perform  in  the  ecommiy,  and  it  is  this  physio- 
logical function,  I  belie\-e,  which  influenc-es  the  motion 
more  than  the  light  or  heat  employed.  These  latter  agents 
may  set  the  cells  in  motion,  but  when  once  this  is  effected 
it  will  be  seen  that  they  possess  a  self-movement  which  is 
not  to  be  confounded  with  a  "  Brownian  movei^ient."  This 
latter  motion  is  an  oscillatory  or  rotary  motion  on  their 
own  axes,  and  is  purely  i)hysical.  It  is  seen  in  the  red 
cells  when  the  specimen  of  blood  to  be  examined  is  not  in 
as  thin  a  layer  on  the  cover  glass  as  it  ought  to  be. 

Microscopical  examinations  alone  have  convinced  me 
that  the  motility  of  this  cell  can  be  effected  in  only  three 
ways,  and  these  are  the  following  ; 

1.  By  continuous  inherent  contractility. 

2.  By  alternate  contraction  and  expansion. 

3.  By  the  side-to-side  movement  of  the  protoplasmic 
process,  which  acts  as  the  propelling  force  and  carries  the 
rest  of  the  cell  or  cell  body  with  it.  The  process  is  not 
retractile. 

In  my  opinion,  it  is  not  the  light  (or  the  beat)  which 
controls  the  motion,  but  the  cells  must  move  in  conformity 
with  certain  physiological  laws. 

They  may  be  quickened  in  movement  by  the  chemical 
prf>ducts  circulating  in  the  blood  in  pernicious  ana.-niia, 
but  the  erroneous  deduction  must  not  h«  made  that  it  is  the 
chemical  substance  circulating  in  the  blood  which  propels 
the  cells,  any  moi-e  than  light  or  heat  does.  The  construc- 
tion of  the  rvA  cell  differs  from  that  of  the  white  cell  which 
has  a  different  function  to  perform.  The  white  blood  cell 
is  a  phagocyte,  the  red  cell  carries  oxygen  to  the  tissues. 

"Physiology  is  the  study  of  the  phenomena  ot  life,  and 
knowledge  thereof  can  only  be  obtained  by  direct  observa- 
tion and  not  by  analogy  or  inference  "  (Dalton's  "  Physiol- 
ogy,"  p.  I).  If  we  take  one  cell,  common-sense  reasoning 
would  refute  the  idea  that  the  cell  could  move  in  all  three 
ways  at  one  and  the  same  time.  But  if  we  study  different 
cells,  as  in  pernicious  ansemia,  we  can  observe  the  motility 
to  be  effected  in  the  three  different  ways  before  described 
and  in  no  other  way,  and  investigators  who  have  studied 
this  subject  have  at  times  confounded  physical  or  non- 
vital  movements  with  self-movement  or  vital  movements. 

I  believe  the  movements  in  the  red  cells  in  pernicious 
anaemia  are  all  self-movements.  The  cells  are  simply 
quickened  in  their  movements.  Hence  I  differ  from  some 
writers  on  this  subject.  'l"he  "Brownian  movement" 
causes  the  cell  by  the  rotary  or  oscillatory  motion  to 
change  its  position.  But  this  is  always  slight ;  and  the 
cell  even  slightly  changes  its  shape,  but  this  appearance 
is  nearly  always  stellate.  A  close  observation  of  both 
forms  of  movements  in  the  red  blood  cells  readily  distin- 
guishes the  two. 

The  object  of  this  letter  is  not  to  discredit  careful  work, 
but  to  show  how  investigators  can,  according  to  the  meth- 
ods employed,  arrive  at  different  results. 

\V.   MosER,   M.D. 

Brooklyn,  N.   Y. 


THE  POVERTY  OF 
AS  A  CAUSE  OF 
THE    NATIVES. 


TROPICAL    COUNTRIES 
THE    FEEBLENESS    OF 


Cordoba,  State  of  Vera  Cbi-z,  Mexico. 
All  men  dream  of  the  marvellous  riches  of  the  tropics,  of 
the  birds  with  rainbow  plumage,  of  the  extravagant  flow- 
ers, of  the  elegant  tree  ferns,  of  the  banana  and  palms 
with  waving  leaves,  and  of  the  cocoa  palm  which  furnishes 
man  with  everything  necessary  for  life.  Indeed,  we  pity 
him  who  has  never  seen  a  tropical  landscape,  as  we  pity 
him  who  has  never  seen  the  sea.  Then  we  think  of  the 
enormous  treasures  the  English,  Spaniards,  and  Dutch 
have  harvested  from  their  tropical  colonies,  and  naturally 
we  think  that  the  tropics  are  the  richest  regions  of  the 
world.  All  this  may  be  true,  yet  nevertheless,  in  another 
sense,  instead  of  being  rich,  the  tropics  are  fatally  poor. 
Unable  to  secure  the  necessaries  of  life,  the  people  of 
tropical  countries  are  like  the  man  in  whose  hand  every- 
thing turns  to  gold,  yet  who  perishes  of  hunger  and  thirst. 
Of  all  the  breadstuffs  nece.ssary  for  man,  the  tropics  fur- 
nish only  corn  and  rice,  and  these  only  to  a  limited  extent. 
They  have  no  wheat,  rye,  or  potatoes.  The  banana 
may  be,  as  Humboldt  says,  one  hundred  and  thirty-three 
times  more  productive  than  wheat  and  forty-four  times 
more  so  than  potatoes,  yet  it  cannot  replace  either  as  food. 
Nor  can  white  men  live  for  any  length  of  time  on  rice  and 
com  alone,  nor  on  bananas  and  palm  nuts.  Native  tropi- 
cal foods  can  only  hold  body  and  soul  together,  as  they 
furnish  but  little  vigor,  energy,  and  power.  No  machine 
can  do  good  work  with  poor  fuel.  A  man  who  has  neither 
bread  nor  meat,  cannot  get  life  and  strength  and  push 


990 


MEDICAL    RECORD. 


[December  22,  1900 


from  tea,  coffee,  sugar,  vanilla,  and  all  the  precious  spices. 
Tropical  products  are  merely  commercial  luxuries,  and  if 
the  inhabitants  of  cold  climes  did  not  buy  them  the  people 
of  the  tropics  would  lack  the  necessaries  and  comforts  of 
life  and  would  yet  choke  with  their  own  riches. 

If  we  wish  to  know  the  effects  of  the  poor  diet  of  the 
tropics  combined  with  the  effects  of  the  heat,  we  have  only 
to  look  at  the  inhabitants  of  these  countries.  As  a  general 
rule,  they  are  thin,  poorly  built,  and  unfit  for  intellectual 
or  physical  labor.  Occasional  exceptions  will  only  confirm 
the  rule. 

Even  the  foods  which  are  produced  are  insufficient  in 
amount,  so  that  the  least  interference  with  the  annual 
crops  results  in  famines,  as  is  the  case  in  India  to-day. 
Indeed,  India  has  always  been  the  land  of  fabulous  riches 
of  a  tow  and  of  famines  of  the  millions.  Until  recentl)'  in 
the  cold  countries  there  were  none  of  fabulous  wealth  and 
but  tew  famiues. 

Everything  in  hot  countries  is  harmful  to  man ;  the 
ground,  the  water,  and  the  air,  swarming  with  miasms  and 
vermin,  and  with  torment  and  danger.  Life  is  as  much  a 
torment  as  a  pleasure,  for  whatever  makes  life  worth  living 
is  lacking.  They  depend  for  indispensable  necessaries 
upon  the  temperate  zones,  to  which  they  furnish  only  the 
luxuries. 

Some  one  may  mention  the  art,  science,  and  culture  of 
Hindoostan,  Ceylon,  Java,  and  the  tropical  Americas. 
The.se  were  possible  when  the  Aryans  and  other  conquerors 
who  had  come  from  the  colder  countries  had  still  preserved 
their  original  vigor  and  energy  before  they  mingled  with 
the  former  inhabitants  and  degenerated.  Then,  we  ought 
not  to  forget  that  all  these  great  works  were  done  when 
the  great  institution  of  slavery  ])laced  tools  in  the  hands  of 
the  conquerors  to  do  work  they  themselves  could  not  do  in 
the  iieat.  In  our  day,  it  is  machinery,  the  great  liberator 
of  man,  which  does  the  work  performed  in  those  remote 
ages -by  the  hundreds  of  thousands  of  miserable  slaves. 

The  temperate  zone  is  the  one  which  breeds  everything 
grand,  and  of  these  countries,  and  not  of  the  tropics, 
Goethe  sang, 

"  Nach  der  Warme  Ziehen  sich  Musen, 
Nach  der  Warme  Charitinnen." 

Lord  Macaulay,  in  his  essay  on  AVarren  Hastings,  Edin- 
burgh Rc-i'iew,  October,  1S41,  p.  174,  in  discussing  the 
prevalent  ideas  of  the  wonderful  riches  of  the  Indies,  said, 
"Nobody  seemed  to  be  aware  of  what  nevertheless  was 
most  undoubtedly  the  truth,  that  India  was  a  poorer  coun- 
try than  countries  which  in  Europe  are  reckoned  poor,  than 
Ireland,  for  example,  or  than  Portugal.  It  was  confidently 
believed  by  lords  of  the  treasury  and  members  for  the  city 
that  Bengal  would  not  only  defray  its  own  charges,  but 
would  afford  an  increased  dividend  to  the  proprietors  of 
India  stock  and  large  relief  to  the  English  finances.  These 
expectations  were  disappointed."  Are  not  the  people  of 
the  L'nited  States  to  be  disappointed  in  the  Philippines? 

F.   Semeleder,  M. D. 


ILjeMinuB  and  ^jlotices. 

A  Text-Book  upon  the  Pathogenic  Bacteria,  for  Students 
of  Medicine  and  Physicians.     By  Joseph   McFakland, 
M.D.,  Professor  of  Pathology  in  the  Medico-Chirurgical 
College,     Philadelphia,     etc.      With     142     illustrations. 
Third  edition,  revised  and  enlarged.     Philadelphia  ;  W. 
B.  Saunders  &  Co.     igoo. 
This  is  the  third  edition  of  a  work  which  had  already  a 
field  of  usefulness  as  a  convenient  handbook  of  tlie  natu- 
ral history  of  the  various  forms  of  bacteria.     This  edition 
is  considerably  enlarged  and  to  some  extent  remodelled. 
The  accounts  of  the  characteristics  of  the  diiferent  bacteria 
are  lucid  and  concise,  and  in  its  new  form  the  volume  will 
undoubtedly  increase  its  popularity  and  usefulness,  espe- 
cially as  a  reference  text-book. 

Practical  Manual  ok  Diseases  ok  Women  and  Uterine 
Therapeutics,  for  Students  and  Practitioners.      By  H. 
MacNaughton-Jones,    M.D.,  M.Ch..   Master  of   Obstet- 
rics (Honoris  Causa),  Royal  University  of  Ireland;  Fel- 
low of  the  Royal   Colleges  of  Surgeons  of  Ireland  and 
Edinburgh  ;  President  of  the  British  Gyiifccological  So- 
ciety ;  Formerly  University  Professor  of  Midwifery  and 
Diseases   of   Womert   and   Children,   and    Examiner   in 
Midwifery  and  Diseases  of  Women  and  Children,  in  the 
Royal   University  of   Ireland.     Eighth   edition,  revised 
and  enlarged,  with  (140  illustrations  and  2S  plates.     New 
York;   William  Wood  &  Co.      igoo. 
The  eighth  edition  of  the'English  gynaecologist,  H.  Mac- 
Naughton-Jones,  shows  an  improvement  that  speaks  well 
for  the  enormous  strides  gynaecology  has  made  in  the  last 


half-dozen  years.  In  every  direction  has  this  work  been 
enlarged  and  improved,  making  it  rather  too  bulky  and 
cumbersome  a  volume  to  handle  with  ease.  Concise  is 
the  general  analysis  of  the  author,  as  respects  this  new 
edition,  when  he  states  in  the  preface:  "Obsolete  views, 
practices,  and  appliances  have  been  omitted,  and  I  have 
endeavored  to  make  it,  for  both  student  and  practitioner, 
a  condensed  Cfmijicndium  of  gynfecology,  including  every- 
thing of  practical  importance  which  has  appeared  up  to  the 
date  of  its  publication."  To  give  a  thorough  review  con- 
sciously and  critically  is  much  beyond  the  space  allotted  to 
the  reviewer.  Of  the  scientific  work  shown  by  the  writer 
we  can  say  nothing  but  the  warmest  praise.  We  accept 
the  instructions  given  us  with  good  grace,  for  we  feel 
satisfied  that  such  teaching  is  safe  and  worthy  of  the 
deepest  consideration.  A  few  chapters,  then,  of  greater 
importance  and  worth  will  be  more  fully  gone  into ;  not, 
remember,  for  purposes  other  than  the  frankest  criticism, 
but  solely  for  calling  attention  to  these  particular  chapters. 
In  the  subject  "Ectopic  Gestation"  we  call  especial  at- 
tention to  his  classification  of  varieties,  his  careful  study 
of  pathology  and  etiology.  When  the  treatment  is  advo- 
cated we  note  great  progress,  and  advice  which,  while  radi- 
cal, paradoxic  as  it  may  appear  is  ultra-conservative.  One 
sentence  makes  clear  the  author's  positive  position.  There 
is  no  procrastination,  no  wavering.  "Whenever  tubal  ges- 
tation is  discovered,  operation  for  the  removal  of  the  foetus 
and  sac  should  be  undertaken  at  the  earliest  possible  mo- 
ment." This  is  the  spirit  in  the  right  direction,  and  ex- 
perts nearly  all  the  world  over  look  upon  ectopic  gestation 
as  a  malignant  condition,  to  be  treated  as  such,  imme- 
diately and  thoroughly,  and  by  the  knife  only.  We  cannot 
accept  the  statement  made  that  in  cases  of  abdominal  or 
other  forms  of  vicious  pregnancy,  operation  is  best  at  mid- 
term, and  not  at  term  or  as  near  such  as  possible.  Surely 
the  experience  of  Cragin,  of  New  York,  in  his  recent  case,  as 
well  as  of  others,  proves  that  a  living  child  can  be  de- 
livered and  remain  alive  for  some  years  when  elective 
operation  is  undertaken  at  term.  The  chapter  on  the 
Bladder  has  been  very  thoroughly  gone  over,  lai-gely 
quoting  from  Kelly  ;  and  while  we  do  not  believe  that 
bladder  affections  should  occupy  a  place  in  gynecic  sur- 
gery, the  chapter  is  so  complete  that  it  adds  very  much  to 
the  value  of  the  book.  The  last  chapter,  which  includes 
the  subject  of  "Massage,"  would  better  have  been  omitted, 
since  mechanical  treatment  is  to-day  hardly  looked  upon 
by  us  as  a  justifiable,  let  alone  a  legitimate  aid  to  the  cure 
of  diseases  peculiar  to  women. 

A  Text-Book  ok  the  Diseases  of  W'omen.  By  Henry  J. 
Garrigues,  A.M.,  M.D.,  Gynaecologist  to  St.  Mark's  Hos- 
pital in  New  York  City  ;  Gynaecologist  to  the  German 
Dispensary  in  the  City  of  New  York  ;  Consulting  Obstet- 
ric .Surgeon  to  the  New  York  Maternity  Hospital ;  Con- 
sulting Physician  to  the  New  York  Mothers'  Home  and 
Maternity  Hospital ;  Ex-President  of  the  German  Medi- 
cal Society  of  the  City  of  New  York  ;  Fellow  of  the 
American  Gynsecological  Society  ;  Fellow  of  the  New 
York  Academy  of  Medicine  ;  Member  of  the  Society  for 
Medical  Progress,  of  the  Eastern  Medical  Society,  of  the 
New  York  County  Medical  Society,  etc.  With  367  illus- 
trations. Third  edition,  thoroughly  revised.  Philadel- 
phia ;  W.  B.  Saunders  &  Co.     igoo. 

The  gynjecological  surgeon  will  find  much  to  interest  him 
in  this  very  complete  work  on  diseases  of  women.  A 
third  edition  is  now  before  us,  thoroughly  revised  in  every 
respect  and  up  to  date  in  many  particulars.  The  distin- 
guished author  finds  many  wa5-s  of  making  his  particular 
specialty  a  decidedly  interesting  one,  and  after  a  careful 
perusal  and  study  such  as  we  have  given  the  work,  we 
can  earnestly  recommend  it  not  only  to  experts  in  this 
field  but  also  to  jiractitioners  in  general.  It  is  just  enough 
theoretical  and  just  enough  ]iractical  to  stand  as  an  excel- 
lent text-book  for  students  of  medicine.  The  arrangement 
of  the  topics  is  particularly  to  be  admired,  since  one  topic 
follows  the  other  in  a  fashion  that  makes  both  reading  and 
study  a  sort  of  continuous  performance,  connected  and 
jointed  as  it  were.  The  classification  is  so  perfect  that  one 
is  led  gradually  and  uncon.sciously  into  deeper  and  deeper 
subject  matter,  until  the  book  is  read  through  before  one 
is  aware  of  it.  His  generalization  of  the  various  subdi- 
visions is  as  complete  as — we  were  going  to  say.  an  ency- 
clopedia— we  have  ever  read.  For  cxanqile,  under  "  Ex- 
amination in  (jeneral,"a  topic  of  great  importance,  tlie 
author  covers  over  forty  pages,  replete  with  many  jiracti- 
cal  suggestions  ;  but  what  appealed  to  us  most  was  the 
chapter  on  "Treatment  in  General,"  comprising  eighty 
full  ]iages,  which  certainly  increases  our  previously  i>ro- 
found  res|)cct  fnr  the  author,  and  stamps  him  as  one  who 
knows  his  suliject  not  alone  from  the  standpoint  of  the  ex- 
pert in  diseases  of  women,  but  from  the  thorough  exjicri- 
ence  obtained  in  the  school  of  general  medicine.  Under 
operative  technique  we  have  clear  wording,  concise  and  to 


December  22,  1900] 


MEDICAL    RECORD. 


991 


the  point,  making  plain  even  to  the  most  obtuse  mind  the 
delineation  of  the  various  steps  in  the  many  complicated 
gynaecological  operations.  All  descriptions  of  operations 
are,  as  far  as  possible,  accompanied  by  good,  well-marked 
plates,  which  further  assist  us  in  our  perusal.  Speaking 
of  plates,  while  we  feel  that  they  are  well  worth  printing 
when  they  have  an  object  in  view,  we  certainly  object  to 
one  that  is  unnecessary  and  flavors  of  padding.  Such  is 
the  plate  after  Spencer  Wells,  showing  the  "facies  ovari- 
ana, "  which,  so  far  as  we  could  make  out  without  reading 
what  it  was  all  about,  might  have  represented  an  old  lady 
with  a  lace  hat  on.  This  we  would  advise  the  doctor  to 
omit  in  his  next  work.  We  pardon  tliis  minor  defect,  be- 
lieving full  well  that  the  distinguished  author  will  know 
that  the  good  more  than  compensates  for  the  little  with 
which  we  do  not  agree. 

Die  UROr.F.NrTALMUSKULATUR  DES  DaMMES,    MIT   BKSONDERER 

BERUCKSiciiTu;fN<:  iiKS  Harnhi.asenvf.rsciii.isses.  Von 
Dr.  Otto  Kai.ischer,  in  Berlin.  Mit  3*)  farbigen  Abbil- 
dungen    ini   Text   und   33   Tafeln.     Berlin:    .S.   Karger. 

IQOO. 

TiiK  author  considers  carefully  both  the  striped  and  the  un- 
striped  muscle  of  the  urogenital  regions.  He  takes  up  the 
subject  from  the  standpoint  of  both  sexes,  treating  it  both 
tnacroscopically  and  microscopically.  Since  the  muscles 
in  the  very  young  are  so  much  more  sharply  defined  than 
in  the  adult,  and  consequently  the  origin  and  insertion  far 
more  easily  traced,  the  author  begins  his  studies  on  the 
fcctus  and  the  child.  The  work  is  richly  supplied  with  il- 
lustrations of  serial  sections  taken  from  subjects  represent- 
ing both  sexes  and  various  ages. 

Handereinigicung.  Handedesinfektion  und  Handeschutz. 

Eine  experimentelle  und  kritische  Studie.     Von  Dr.  Carl 

S.  HAEdi.KK,  Docent  fiir  Chirurgie  und  I.  Assistenzarzt 

der    chirurgischen   KHuik  zu   Basel.      Jlit  vier  Tafeln. 

Basel :  Benno  Schwabe.     1900. 

The  author  has  been  particularly  interested  in  the  subjects 

of   wound    infection   and   wound    treatment    for   the   last 

twelve  years,  and  now,  in  looking  over  the  ground  covered, 

he  treats  of  the  localization  of   micro-organisms   on   the 

hand,  of  the  mechanical  cleansing  and  the  cleansing  by 

disinfectants  of  the  hands.     He  takes  up  the  subject  of 

oiierating-gloves,  and  concludes  his  work  with  a  chapter 

on  prophylaxis. 

Medical   Diagnosis,  with  Special    Reference  to  Practical 
Medicine.     A  Guide  to  the  Knowledge  of  Discrimination 
of  Diseases.     By  J.   M.   Da  Costa,  M.D.,  LL.D.,  Physi- 
cian to  the  Pennsylvania  Hospital,  etc.     Ninth  edition. 
Philadelphia  and   London :  J.    B.   Lippincott  Company. 
1900. 
In  calling  attention  to  the  ninth  edition  of  this  classic,  a 
book  which  has  been  the  guide  of  several  generations  of 
medical  men,  thirty-six  years  having  passed  since  the  first 
edition  saw  the  light,  we  are  saddened  with  the  thought 
that  this  is  the  last  revision  of  the  accomplished  author, 
death  having  put  a  seal  upon  his  works.     In  this  edition 
Dr.  Da  Costa  added  much  new  matter,  especially  in  the 
sections  on  fevers  and  diseases  of  the  blood  and  of  the 
stomach,  and  in  other  parts  made  changes  necessitated  by 
the  constant   advances   being    made   in   the   direction  of 
greater  diagnostic  precision.     The  plan  of  clinical  classifi- 
cation adopted  when  the  work  was  composed  has  been  re- 
tained, since  long  experience  has  demonstrated  its  utility 
The   list  of   illustrations   has   received   several   additions 
inade  necessary  by  the  new  process  of  skiagraphy.     Da 
Costa's   work   was   a  pioneer  in  this  essential  branch  of 
medicine,  and  it  remains  to-day  in  the  first  rank  of  guides 
to  the  diagnosis  of  disease. 

AlANfAL  OF  Pathologv  :  Including  Bacteriology,  the  Tech- 
nique of  Post-Mortems,  and  Methods  of  Pathological 
Research.  By  W.  M.  Late  Cori.iN,  M.D.,  Professor  of 
Pathology  and  Bacteriology,  Jefferson  Medical  College, 
Philadelphia  ;  Pathologist  to  Jefferson  Medical  College 
Hospital  and  to  the  Philadelphia  (Blockley)  Hospital  : 
Bacteriologist  to  the  Pennsylvania  State  Board  of 
Health.  Third  edition,  revised  and  enlarged.  Three 
hundred  and  thirty  illustrations  and  seven  colored 
plates.     Philadelphia;  P.  Blakiston's  Son  &  Co.     1900. 

We  are  glad  to  welcome  a  new  edition  of  this  exceedingly 
practical  guide  for  the  worker  in  the  post-mortem  room  and 
the  pathological  laboratory.  In  this  edition  the  number  of 
pages  has  been  increased  by  two  hundred,  and  that  of  il- 
lustrations by  over  thirty,  and  colored  plates  have  been 
introduced.  The  work  is  divided  into  three  parts,  viz., 
technique,  general  pathology,  and  special  pathology.  The 
aim  of  the  author  was  the  practical  one  of  providing  a 
manual  for  the  actual  worker,  and  not  merely  furnishing 
a  work  of  reference  for  the  student  and  practitioner  ;  but 
while  he  has  succeeded  in  attaining  the  first-named  obiect 


he  has  also  written  a  treatise  on  pathology  which  may  be 
studied  with  profit  away  from  the  laboratory  and  may  be 
kept  on  the  shelf  as  a  valuable  work  of  reference  by  the 
practitioner.  Its  usefulness  in  this  respect  is  enhanced  by 
a  very  complete  inde.x. 

Clinical  Studies  in  Vice  and  in  Insanity.  By  George 
R.  Wilson,  M.D. ,  Medical  Superintendent,  Mavisbank 
Asylum.     New  York  :  The  Macmillan  Company.     1899. 

Drawn  from  the  records  of  cases  kept  by  the  graphic  and 
chart  methods  in  the  Mavisbank  Asylum  the  author  has 
presented  the  subject  in  a  practical  manner,  quoting  cases 
freely  to  illustrate  his  ideas  and  points  of  view  from  which 
they  are  discussed.  L'nder  "alcoholic  predisposition" 
types  of  alcoholists  are  given  and  considered  from  the 
point  of  view  of  the  question,  "what  kind  of  men  and 
women  are  predispo.sed."  There  is  included  the  report  of 
an  exceptional  instance  of  voluntary  or  conscious  mania. 
The  cases  make  interesting  reading. 

Canine  and  Feline  SfROKRV.  Bv  Frk.dkriik  T.  S.  Hob- 
day, F.R.C.V.S.  Edinburgh  aiid  London:  W.  &  A.  K. 
Johnston.     1900. 

This  little  text-book  gives  simple  directions  with  illustra- 
tions for  the  management  of  cases.  Much  of  the  material 
appeared  in  serial  form  in  the  /oitriia/  of  Coiiiparalh'e 
Patlioloi^y  and  T lu-rapcutics.  The  book  is  built  upon  the 
clinical  experience  of  .several  years  in  the  out-door  depart- 
ment of  the  Royal  Veterinary  College. 

La  Peste  et  son  Microbe.  Par  le  Dr.  Netter,  Profes- 
seur  agrege  a  la  faculte  de  m6decine  de  Paris.  Paris : 
Georges  Carre  et  C.  Naud,  Editeurs.     1900. 

A  VERY  timely  little  work  including  orrhollierapy  and  vacci- 
nation questions.  The  microbe  of  the  plague  is  illustrated 
in  five  figures  on  inserted  leaves.  There  are  also  maps 
showing  localities  affected  in  recent  times  and  charts  to 
illustrate  the  difference  in  course  in  those  vaccinated  and 
those  not  protected. 

Normal  Histoi.oi-.v.  By  Edward  K.  Diniiam,  Pii.B., 
M.D.  Second  edition.  New  York  :  Lea  Brothers  &  Co. 
I  goo. 
There  is  hardly  a  book  i)ublished  in  the  English  language 
that  can  compete  with  the  one  under  discussion.  It  is  well 
adapted  to  convey  to  both  student  and  advanced  physician 
all  modern  views  concerning  normal  histology.  It  is  amply 
illustrated  and  written  in  a  comprehensive  style. 

Contagious  Ophthalmia,  Acute  and  Chronic.  By  Sydney 
Stephenson,  M.D.  London:  Bailliere,  Tindall  &  Cox. 
I  goo. 
This  is  one  of  the  most  practical  monographs  on  this  sub- 
ject, dealing  with  the  bacteriology,  diagnosis,  and  treat- 
ment of  this  disease.  A  great  deal  is  concentrated  herein, 
and  it  fully  serves  its  purpose. 

The  Medical  Diseases  of  Childhood.  By  Nathan  Oppen- 
HEiM,  M.D.  New  York  :  The  Macmillan  Company.   1900. 

In  this  new  book  we  are  brought  face  to  face  with  a  new 
method  of  instructing  in  the  diagnosis  and  therapeutics  of 
pediatrics.  The  author  maintains  that  photomicrographs 
of  pathological  sections  are  of  greater  didactic  value  than 
pictures  of  instruments  and  photographs  of  patients.  He 
does  not  believe  in  the  efficacy  of  statistics.  Some  of  the 
illustrations  are  very  good.  The  book  consists  of  over  six 
hundred  and  fifty  pages,  and  is  printed  with  clear  type  on 
good  paper. 

University  ok  Pennsylvania  :  Contributions.  William 
Pepper  Laboratory  of  Clinical  Medicine.  Philadelphia. 
I  goo. 
Whoever  is  in  search  of  valuable  contributions  to  mod- 
ern medicine  may  well  read  the  various  articles  in  this 
excellent  book.  Commencing  with  an  article  on  "Muscu- 
lar Dystrophy,"  we  next  see  an  article  on  "Amyotrophic 
Lateral  Sclerosis  "  ;  following  this,  "  Cellular  Changes  "  ; 
following,  "Venom  Injections."  Next  follows  an  article  on 
'Melanotic  Sarcoma  of  the  Spinal  Cord  "  ;  then,  "Studies 
in  Leukaemia."  "The  Pathology  of  the  Erythrocyte,"  "The 
Blood  Plasma  after  Saline  Injections";  then,  "The 
Influences  of  Immoderate  Water-drinking  upon  Metabo- 
lism and  Absorption";  then,  "Experimental  Ajipendici- 
tis "  ;  then,  "  Primary  Endothelioma  of  the  Left  Supe- 
rior Pulmonary  Vein,"  the  "Estimation  of  Proteids  in 
Milk"  ;  and  lastly.  "The  Etiology  and  Treatment  of  Per- 
tussis." The  value  of  the  work  is  greatly  enhanced  by  the 
excellent  illustrations.  There  is  hardly  a  more  complete 
contribution  published,  and  we  feel  that  the  authors  should 
be  congratulated,  as  their  type  of  good  work  will  serve  to 
illustrate  what  American  physicians  can  do. 


992 


MEDICAL    RECORD. 


[December  22,  1900 


J>ocietxj  ^vqjovts. 

THE      MEDICAL      ASSOCIATION      OF      THE 
GREATER    CITY    OF  NEW    YORK. 

Robert  F.  Weir,  M.D.,  in  the  Chair. 

Stated  Meeting,  Held  December  10,  igoo. 

Spinal  Anaesthesia The  entire  evening  was  devoted 

to  a  discussion  on  this  subject. 

The  Neuro-Physiological  Aspect — Dr.  J.  Leonard 
Corning  opened  he  discussion.  In  response  to  a  re- 
quest to  tell  how  he  first  came  to  make  an  experiment 
on  spinal  anaesthesia,  he  said  that  he  knew  that  co- 
caine possessed  a  chemical  affinity  for  the  sensory 
nerves,  or,  at  least,  for  those  parts  of  their  structure 
essential  to  conduction.  Why,  then,  should  not  this 
same  atHnity  hold  good  of  the  sensory  conducting  paths 
in  tlie  cord?  To  prove  this  theory  he  injected  twenty 
minims  of  a  two-per-cent.  solution  of  the  hydro- 
chlorate  of  cocaine  into  the  space  situated  between  the 
spinous  processes  of  two  of  the  inferior  dorsal  verte- 
bra; of  a  young  dog.  Five  minutes  after  the  injection 
there  were  evidences  of  marked  inco-ordination  in  the 
posterior  extremity.  A  few  minutes  later  there  was 
marked  evidence  of  weakness  in  the  hind  legs,  but 
there  were  no  signs  whatever  of  feebleness  in  the  an- 
terior extremities.  He  tested  the  condition  of  sensi- 
bility by  means  of  a  powerful  faradic  battery.  When 
the  wire  brush  was  applied  to  the  hind  legs,  there  was 
no  reflex  action  whatever,  but  when  it  was  applied  to 
either  of  the  anterior  extremities  the  limb  was  drawn 
away  violently,  and  the  animal  set  up  the  most  dismal 
howls.  Traces  of  inco-ordination  were  observed  two 
hours  after  the  injection  had  been  made.  After  the 
lapse  of  about  four  hours  the  dog  seemed  to  have  re- 
covered his  usual  health.  The  action  of  the  anjESthet- 
ic  was  practically  local;  however,  if  the  quantity  of 
anaesthetic  fluid  injected  had  been  greater,  the  anterior 
limbs  might  also  have  been  affected.  Absolute  local- 
ization of  the  ancesthetia  was  scarcely  possible,  but  the 
local  action  of  the  drug  was  greatly  favored,  so  far  as 
the  anterior  segment  of  the  cord  was  concerned,  by 
reason  of  the  lethargy  of  the  circulation  at  this  point. 
Dr.  Corning  then  applied  the  principle  in  the  human 
subject,  developing  the  refinements  of  technique  as 
time  and  opportunity  allowed.  tJf  late  there  had  been 
much  discussion  touching  a  possible  poisonous  action, 
more  or  less  permanent,  of  the  ansesthetic  upon  the 
central  nervous  system.  The  same  question  was 
raised  when  periplieral  anaesthesia  was  enjoying  its 
first  vogue.  These  fears  seemed  to  be  ill  founded, 
for  when  the  peripheral  nerves  were  copiously  steeped 
in  the  anaesthetic,  a  considerable  quantity  of  the  latter 
must  reach  the  central  nervous  system  through  the 
general  circulation,  sufficient  to  set  up  permanent 
trouble  if  such  a  thing  were  probable.  The  previous 
hypodermic  exhibition  of  morphine,  nitroglycerin,  and 
strychnine  served  to  minimize  the  symptoms.  A  minor 
objection  was  the  rather  frequent  defecation  observed. 
This  might  be  remedied  by  inserting  a  short  pear- 
shaped  electrode  into  the  lower  rectum  and  passing  a 
faradic  current  of  sufficient  intensity  to  cause  contin- 
uous contraction  of  the  spiiincter.  it  was  possible  to 
achieve  the  same  results  by  emptying  both  the  rectum 
and  the  bladder  shortly  before  making  the  injection. 
Vomiting  was  more  difficult  to  remedy,  but  tliis  incon- 
venience was  not  peculiar  to  spinal  anaesthesia.  Ab- 
stinence from  food  for  .several  hours  before  the 
injection  was  made  would  tend  to  minimize  the  diffi- 
culty. In  fleshy  persons  a  sliort  incision  through  the 
integument,  immediately  over  and  down  to  the  apices 
of  the    spinous    processes    at   the  point   of    election. 


would  enable  one  to  introduce  the  point  of  the  finger, 
and  so  establish  the  most  positive  orientation.  The 
question  of  rigid  asepsis  was,  of  course,  of  the  first 
importance.  Spinal  ana;sthesia  must  necessarily  re- 
main sub  jndiie  for  a  long  time.  Technically  com- 
plete as  it  might  appear  at  first  view,  modifications  in 
method  were  sure  to  come  about,  and  no  one  could 
foretell  what  the  future  might  bring  forth. 

Spinal  Analgesia  in  General  Surgery. — Dr. 
George  R.  Fowler,  of  Brooklyn,  continued  the  dis- 
cussion. His  experience  with  spinal  anesthesia  em- 
braced eighty-one  cases,  which  he  divided  into  the 
following  classes. 

I.  Operations  involving  the  peritoneum.  These 
numbered  twenty-six.  In  five  the  analgesia  was  in- 
complete, and  in  three  of  these  the  operation  was  for 
inguinal  hernia,  tlie  patients  complaining  of  pain  when 
the  distribution  of  the  ilio-inguinal  and  the  ilio-hypo- 
gastric  nerves  was  invaded.  In  all  the  cases  of  abdomi- 
nal section  vigorous  peritalsis  of  short  sections  of  the 
intestinal  canal  was  noted,  the  contracted  areas  resem- 
bling hard  fibrous  cords  and  presenting  sharp  borders 
between  the  contracted  and  uncontracted  portions, 
which  suggested  an  imminent  intussusception.  Com- 
plaint was  made  when  the  hand,  previously  dipped  in 
an  alcoholic  solution  of  corrosive  sublimate,  came  in 
contact  with  the  peritoneum.  The  moderate  Trende- 
lenburg position  was  not  complained  of,  but  the  pa- 
tients did  express  discomfort  when  an  extreme  elevated 
pelvis  was  maintained  for  some  time. 

II.  Operations  in  the  pelvic  region  not  involving 
the  peritoneum.  These  cases  numbered  thirty-four. 
In  cases  of  varicocele  the  patients  complained  of  pain 
when  the  cord  was  handled. 

III.  Amputations.  These  cases  numbered  five.  In 
all  of  these  cases  the  analgesia  was  absolute  and  com- 
plete, and  the  length  of  time  which  it  lasted  was  am- 
ple for  the  purposes  of  the  operation. 

IV.  Operations  upon  the  lower  extremities  not  in- 
cluded in  the  above.  These  cases  numbered  thirteen. 
In  a  case  of  ligaturing  of  the  internal  saphenous 
veins,  the  patient,  in  spite  of  the  fact  that  her  eyes 
were  bandaged  and  her  ears  stuffed  with  cotton,  heard 
the  doctor  call  for  a  second  knife  after  an  absolutely 
painless  incision  of  the  skin  had  been  made;  there- 
after she  complained  of  pain  upon  the  slightest 
touch.  The  operation  of  arthrotomy  was  upon  a  dis- 
tended Charcot's  joint  in  a  case  of  advanced  loco- 
motor ataxia;  here  the  analgesia  lasted  one  hour  and 
twenty  minutes  above  the  knee,  and  three  hours  and 
forty  minutes  in  the  parts  below  the  knee. 

V.  Unclassified  operations.  These  numbered  three. 
In  a  case  of  costal  resection  the  patient  complained 
greatly  when  the  periosteum  and  intercostal  nerves 
were  peeled  off  the  bone.  In  the  case  of  nephrectomy 
the  patient  declared  her  absolute  disbelief  in  the  doc- 
tor's statement  that  he  had  removed  the  kidney. 

Teciinique  of  the  operation.  The  space  between 
the  third  and  fourth  spinous  processes  was  usually  the 
most  available,  but  either  the  space  above  or  below 
that  point  might  be  utilized  if  more  easily  identified. 
A  sensation  of  suddenly  passing  through  a  tense 
membrane  and  entering  a  free  cavity  was  sometimes 
distinctly  appreciated  by  the  operator  as  the  needle 
perforated  the  intraspinous  ligament.  The  use  of  a 
double  needle  permitted  the  operator  to  eliminate  the 
accident  of  occlusion  of  the  lumen  of  the  instrument. 
A  full  minute  was  used  for  the  injection,  thus  allow- 
ing time  for  the  solution  to  mingle  evenly  with  the 
cerebro-spinal  fluid. 

The  solution  should  be  freshly  made  with  sterilized 
water  and  boiled  one  minute  before  being  used.  A 
concentrated  solution  of  a  definite  quantity  was  no 
more  likely  to  produce  disagreeable  symptoms  than 
the  same  dose  in  a  diluted  solution,  and  its  effects 


December  22,  1900] 


MEDICAL    RECORD. 


993 


lasted  longer.  He  believed  the  Sims  position  ren- 
dered the  patient  more  comfortable  and  tended  to  re- 
lax the  muscles  of  the  back.  For  short  operations  he 
used  a  quarter  of  a  grain,  for  longer  operations  half  a 
grain  of  cocaine. 

Extent  of  the  analgesia.  Analgesia  was  present  in 
the  soles  of  the  feet  in  from  one  to  five  minutes  and 
extended  to  the  umbilicus  in  from  five  to  fifteen  min- 
utes. In  two  of  his  cases  it  had  reached  the  vertex. 
In  no  case  did  the  analgesia  subside  in  the  region 
below  the  umbilicus  under  twenty-seven  minutes  (one 
case);  in  all  the  rest  it  lasted  more  than  forty  min- 
utes. If  from  one-fourth  to  three-eighths  of  a  grain 
dissolved  in  ten  minims  of  sterilized  water  be  injected, 
analgesia  to  and  including  the  perineum  may  be  de- 
pended upon  for  a  forty-five  minute  operation.  Prob- 
ably the  extent  of  the  analgesia,  as  well  as  its  duration, 
depended  somewhat  upon  the  amount  of  the  cere- 
bro-spinal  lluid  present.  Progressive  dilution  of  the 
cocaine  solution  from  this  point  of  introduction  less- 
ened the  effect  of  the  drug  upon  the  nerve  structures 
with  which  it  came  in  contact  until,  finally,  if  the 
amount  of  cerebro-spinal  fluid  be  larger,  this  was  prac- 
tically ////at  points  high  up  in  the  canal.  The  circu- 
lation of  the  cerebro-spinal  (hiid,  comparatively  free 
from  cocaine,  through  the  lymph  spaces  in  the  nerve 
structure  washed  out  the  cocaine  solution  carried  to 
these  by  the  cerebro-spinal  fluid  when  the  injection 
was  first  made,  until  finally  the  cocaine  was  so  diluted 
in  the  general  bulk  of  cerebro-spinal  fluid  as  to  be  use- 
less for  the  purpose  of  analgesia. 

Disagreeable  features.  In  the  majority  of  his  cases 
one  or  more  of  the  disagreeable  features — vertigo, 
nausea,  vomiting,  headache,  chills,  rise  of  tempera- 
ture and  increased  pulse  rate,  pallor,  cold  sweat,  and  in- 
voluntary defecation  and  urination  upon  the  operating- 
table — were  present.  He  would  not  admit  that  all 
these  were  due  to  the  drug  per  se,  in  the  face  of  the 
fact  that  they  had  occurred  to  an  equal  extent  whether 
large  or  small  doses  were  used,  as  well  as  in  cases  in 
which  antipyrin  or  chlorotone  were  used.  Not  only 
this,  but  in  one  case  of  vertigo,  pallor,  cold  sweat, 
sighing  respiration,  increased  pulse  rate  with  lessened 
force,  cough,  nausea,  and  vomiting,  all  these  symp- 
toms took  place  when  the  puncture  was  made  and  a 
drop  or  two  of  cerebro-spinal  fluid  witiidrawn  and  be- 
fore any  injection  whatever  iiad  been  made.  Among 
the  cases  reported,  vertigo  was  complained  of  in  but 
three  cases.  Nausea  occurred  in  about  one-iialf  the 
cases  and  actual  vomiting  in  about  two-thirds  of 
these.  In  the  majority  of  instances  in  which  vomit- 
ing took  place  it  subsided  in  less  than  two  minutes. 
Headache  occurred  in  about  two-thirds  of  the  cases, 
the  severity  and  duration  varying  greatly.  Ri.se  of 
temperature  was  noted  in  all  the  cases.  Increased 
pulse  rate  always  seemed  to  the  doctor  to  be  an  inci- 
dent of  the  nervousness  of  the  patient  rather  than  an 
effect  of  the  injection,  for  the  reason  that,  in  the  ma- 
jority of  cases,  it  had  been  less  when  the  patients  left 
the  operating-table  than  when  they  were  placed  upon 
it.  There  had  seemed  to  him  to  be  some  relation  be- 
tween the  nausea  and  vomiting  and  the  force  of  the 
circulation.  When  the  former  had  been  most  pro- 
nounced, the  heart's  action  had  been  the  feeblest.  In 
recent  cases  he  had  attempted  to  guard  the  heart  dur- 
ing this,  the  most  trying  portion  of  the  seance,  by  a 
preliminary  injection  of  gr.  J,  of  strychnine,  and  with 
some  success.  Involunary  defecation  took  place  in 
less  than  one-eighth  of  the  cases.  The  patients  were 
conscious  of  its  occurrence  in  four  out  of  the  five 
cases.  The  entire  aggregation  of  symptoms,  save  the 
nausea  and  vomiting,  had  been  decidedly  lessened 
since  he  began  the  preliminarj-  injection  of  a  gr.  ^V 
dose  of  strychnine,  administered  hypodermically.  In- 
asmuch as  the  dangers  from  this  method  probably  re- 


lated entirely  to  circulatory  failure,  he  deemed  it  im- 
portant that  provision  should  be  made  against  this 
contingency  by  the  preliminary  use  of  a  full  dose  of 
strychnine. 

His  cases  were  not  selected  ones.  Cardiac,  renal, 
and  pulmonary  lesions  had  been  disregarded  for  the 
sake  of  giving  the  method  an  aijsolutely  fair  trial. 
Many  of  the  cases  had  heart  murmurs  and  not  a  few 
were  the  subjects  of  degenerative  kidney  diseases,  and 
one  suffered  from  the  gravest  of  all  pulmonary  lesions, 
gangrene  of  the  lungs,  from  which  death  occurred  one 
week  later.  One  case  had  actual  suppression  of  urine, 
unknown  to  the  speaker  at  the  time  of  operation.  One 
case  of  amputation  at  the  hip  joint  was  in  an  exceed- 
ingly weak  and  feeble  old  woman  of  sixty-eight.  One 
case  of  tuberculous  peritonitis  was  in  a  patient  far  ad- 
vanced in  the  di.sease  and  greatly  emaciated,  and  in 
whom  an  incision  from  the  ensiform  cartilage  to  the 
symphysis  pubis  was  made.  The  upper  part  of  the 
incision  was  necessary  to  enable  him  to  reach  a  gas- 
tric ulcer.  The  case  of  tuberculous  ulceration  of  the 
thigh  was  in  an  old  man  of  sixty-three.  Another  case 
of  amputation  of  the  leg  was  in  an  old  and  feeble 
woman  of  sixty-nine  with  arterial  sclerosis,  gangrene 
of  the  foot  and  ankle,  in  a  condition  of  septicaemia. 
He  referred  to  many  other  of  the  cases  operated  upon, 
and  he  believed  that  these  cases,  unsuitable  for  general 
an.-Esthesia  in  the  judgment  of  any  surgeon,  showed,  as 
a  rule,  less  pronounced  alarming  effects  frtim  the  spinal 
cocainization  than  many  of  the  younger  and  more  vig- 
orous subjects  in  his  lists.  He  had  also  tried  to  ob- 
tain analgesic  effects  from  antipyrin  alone  and  in 
combination;  also,  from  a  solution  of  chlorotone; 
none  proved  successful. 

Conclusions.  In  closing  he  stated  that,  in  spite  of 
the  favorable  experiences  with  spinal  cocainization,  he 
held  to  the  proposition  that  the  ideal  anesthetic  agent 
was  one  which,  with  absolute  safety,  %vould  render  the 
patient  entirely  oblivious,  not  only  of  the  pain  of  the 
operation,  but  of  each  of  the  disagreeable  features,  in- 
cluding knowledge  of  the  surroundings,  the  fear  of  fatal 
results,  etc.  These,  together  with  the  disagreeable 
incident  of  vomiting,  to  say  nothing  of  the  di.sgusting 
occurrence  of  involuntary  urination  and  defecation 
wliile  upon  the  operating-table,  should  be  eliminated 
from  the  conscious  environment  of  the  patient  when- 
ever possible  with  safety. 

Obstetric  and  Gynaecological  Aspect.- Dr.  S. 
Marx  continued  the  discussion  on  this  topic.  His 
first  cases  were  absolute  failures  for  the  reason  that 
he  did  not  feel  that  it  was  necessary  to  get  cerebro- 
spinal fluid.  One  case  he  had  had  gave  the  classical 
picture  of  locomotor  ataxia,  and  he  thought  then  that 
he  never  would  give  it  again :  but  afterward  he 
thought  it  was  an  ideal  anresthetic.  In  the  hospital  he 
had  used  it  for  experimental  purposes  only.  He 
thought  we  were  invading  a  dangerous  territory,  if 
infection  occurred  it  was  beyond  one,  and  the  patient 
was  beyond  one's  help.  Up  to  the  present  day  he  had 
had  one  hundred  and  twenty-five  spinal  punctures,  and 
he  had  had  two  absolute  failures.  In  one  the  anaes- 
thesia was  incomplete.  The  question  of  failure  after 
spinal  anresthesia  might  be  relative  or  absolute;  some 
of  the  cases  seen  in  the  hands  of  other  surgeons  were 
only  apparent  failures.  The  psychical  pain  we  could 
not  get  rid  of;  there  was  something  so  very  uncanny 
about  it  all,  that  the  psychical  fear  was  very  great. 
The  other  day  he  operated  upon  an  old  lady  who  had 
chronic  emphysema,  chronic  bronchitis,  etc.,  for  the 
radical  cure  of  a  hernia;  when  the  needle  was  thrust 
in  forcibly  she  cried  out;  but  when  the  parts  were 
sewn  up  carefully  and  deliberately  there  was  no  pain. 
In  all  these  cases  he  had  never  failed  to  get  cerebro- 
spinal fluid;  in  one  case  he  had  punctured  six  times 
before  he  had  succeeded.     One  young  man,  whom  he 


994 


MEDICAL    RECORD. 


[December  22,  1900 


was  showing  how  to  do  the  puncture  on  the  cadaver, 
introduced  the  needle,  endeavoring  to  get  within  the 
cavity,  and  it  was  later  shown  when  the  abdomen  was 
opened  that  the  needle  had  been  thrust  into  the  peri- 
toneal cavity.  It  was  a  simple  matter  to  perforate 
large  blood-vessels,  and  the  conditions  could  not  be 
controlled,  because  the  trouble  was  beyond  the  point 
of  the  needle. 

The  symptoms  produced  could  not  be  always  at- 
tributed to  the  cocaine.  These  symptoms  were  quite 
regular  in  their  occurrence,  and  they  occurred  whether 
cocaine  was  injected  or  not.  In  one  case,  instead  of 
cocaine  solution,  a  salt  solution  was  injected,  and  the 
same  symptoms  were  produced  but  no  anaesthesia.  In 
one  case  a  woman  had  a  terrific  headache  for  three 
days,  with  a  temperature  of  nearly  104°,  and  yet  not 
one  drop  of  cocaine  had  been  used.  In  another  case 
in  which  no  cocaine  was  used  the  same  symptoms  ap- 
peared due  to  the  shock  or  disturbance  in  the  equili- 
brium inside  the  canal.  He  never  gave  this  injection 
without  e.vpecting  to  have  chill,  vertigo,  and  nausea 
following;  but  these  symptoms  disappeared  as  soon  as 
the  flow  of  fluid  ceased.  He  did  not  think  these 
symptoms  could  be  anticipated  by  the  use  of  any 
drugs;  he  believed  that  some  of  them  were  due  to  ner- 
vous conditions  and  others  to  shock,  for  the  reason  that 
if  powerful  sedatives  and  bromides  were  given,  they 
did  not  counteract  all  the  symptoms;  this  probably 
proved  that  'all  the  symptoms  were  purely  nervous. 
Certain  classical  symptoms  would  always  arise,  but 
the  doctor  did  not  fear  them;  if  the  pulse  ran  up  to 
140  or  160  or  even  further,  he  knew  relief  would  fol- 
low when  the  patient  vomited.  He  was  satisfied  that 
gr.  ^  or  yV  would  do  all  of  the  work. 

Area  of  analgesia.  He  did  not  think  that  the  anal- 
gesia was  increased  by  a  larger  amount  of  the  drug. 
He  had  seen  analgesia  from  the  ears  down.  The  in- 
creased area  was  not  due  either  to  the  amount  of  the 
drug  or  to  the  position  of  the  patient.  He  had  stood 
patients  nearly  on  their  heads  to  permit  gravity  to  act, 
and  yet  no  effect  on  the  area  of  analgesia  was  pro- 
duced. 

Eucaine  had  proven  an  absolute  failure.  He  was 
now  experimenting  with  the  idea  of  making  the  solu- 
tion isotonic  with  the  cerebro-spinal  fluid.  We  knew 
that  the  specific  gravity  of  the  latter  was  from  1,009 
to  1,010,  and  he  thought,  by  injecting  a  solution  of 
the  drug  of  a  similar  specific  gravity  as  that  of  the 
cerebro-spinal  fluid,  he  might  be  able  to  get  rid  of 
some  of  the  disagreeable  symptoms. 

tlffect  upon  labor.  The  effect  upon  labor  was  ab- 
solutely nil,  except  that  the  pains  continued  without 
the  patient  being  cognizant  of  them.  These  patients 
did  not  feel  the  necessity  for  bearing  down;  if  the 
anaesthesia  was  incomplete  bearing  down  followed, 
which  fact  showed  a  relationship  between  the  two. 
He  believed  the  method  was  indicated  in  a  prolonged 
first  stage.  In  gyneecology  he  did  not  think  this 
method  would  ever  supplant  general  anesthesia.  If 
one  injection  failed  .he  waited  half  an  hour  and 
then  gave  a  second  injection.  As  to  the  ultimate  re- 
sults he  knew  of  no  deaths  from  cocaine  poisoning,  but 
he  had  heard  of  innumerable  reports  of  failures  and 
death,  but  none  was  authenticated.  A  Parisian  oper- 
ator had  reported  that  out  of  one  hundred  punctures 
there  were  seventeen  failures  and  five  deaths,  but  the 
name  of  this  operator  was  refused.  These  were  the 
reports  that  tended  to  damn  the  operation.  Another 
case  of  failure  was  mentioned  by  a  doctor  who  asked 
"if  he  had  heard  of  that  death  in  Carbondale  where 
the  patient  died  three  days  after  the  injection."  Co- 
caine did  not  kill  in  three  days;  it  killed  in  three 
hours.  This  was  an  operation  that  belonged  to  the 
domain  of  skilled,  aseptic  surgery. 

Contraindications.     He  considered  that  there  were 


two  absolute  contraindications:  first,  in  that  class  of 
individuals  upon  whom  cocaine  had  absolutely  no 
effect:  second,  in  the  highly  neurotic  individuals  in 
whom  cocaine  had  absolutely  no  value. 

Intra-Spinal  Cocainization  from  the  Anaesthet- 
ist's Standpoint. —  Dk.  S.  Ormond  Goldan,  since  the 
report  of  his  last  series  of  twenty  cases,  had  eleven 
more  to  present,  making  a  total  of  thirty-one  cases. 
The  last  eleven  did  not  differ  materially  from  the 
others.  Of  the  thirty-one,  nineteen  were  in  women 
and  twelve  in  men.  The  punctures  were  uniformly 
successful,  and,  in  all  his  patients,  he  never  failed  to 
get  the  cerebro-spinal  fluid.  The  twenty-first  case  pre- 
sented no  special  features  except  that,  after  the  oper- 
ation, she  did  not  have  the  intense  headache  that  she 
did  formerly.  The  twenty-second  case  was  that  of  an 
Italian  woman  in  whom  it  was  necessary  to  substitute 
chloroform  on  account  of  her  being  such  a  highly  neu- 
rotic individual.  The  twenty-third  case  was  one  of 
vaginal  hysterectomy  and  no  after-symptoms  were 
present.  The  twenty-fourth  case  was  one  of  vaginal 
section.  The  operation  was  begun  ten  minutes  after 
the  injection,  and  there  was  a  decided  sensation; 
toward  the  end  of  the  operation  there  was  no  pain. 
The  twenty-fifth  case  was  one  of  inguinal  herniotomy. 
The  anaesthesia  extended  as  far  as  the  chest,  the 
operation  was  satisfactorily  performed,  and  no  after- 
effects occurred.  The  twenty-sixth  case  was  also  a 
herniotomy  and  operation  for  hemorrhoids.  No  after- 
effects occurred.  The  twenty-seventh  case  was  for  the 
removal  of  a  tuberculous  testicle.  The  anaesthesia 
was  perfect,  but  during  the  tying  of  the  cord  the  pa- 
tient complained  of  pain;  after  the  tying  of  the  cord 
there  was  no  sensation.  The  analgesia  extended  to 
the  lower  ribs.  There  were  no  after-effects.  The 
twenty-eighth  case  required  two  injections.  The  pa- 
tient was  a  large,  strong  fellow,  and  the  doctor  had 
difficulty  in  getting  the  man  to  bend  his  back,  making 
it  almost  impossible  to  get  into  the  canal.  The  sec- 
ond injection  was  tried  upon  the  opposite  side,  be- 
tween the  fourth  and  fifth  lumbar  vertebrae,  and  there 
no  difficulty  was  experienced  in  getting  in.  The 
twenty-ninth  case  had  TTl,  xx.  injected  without  anses- 
thesia  resulting;  this  patient  was  not  hysterical,  and 
she  had  much  pain  during  the  operation.  The 
thirtieth  case  was  of  a  highly  neurotic  person.  After 
waiting  five  or  ten  minutes  he  got  fluid;  m  xx.  were 
injected  with  perfect  aneesthesia.  Just  before  the 
needle  was  withdrawn  the  patient  started  up,  bend- 
ing the  gold  needle  at  a  right  angle.  The  thirty-first 
case  was  in  a  highly  neurotic  patient,  but  she  Vias  car- 
ried through  without  evidences  of  pain. 

Dr.  Virgil  P.  Gibnev  said  that  in  orthopedic  surgery 
this  method  had  but  a  small  range.  He  had  experience 
with  but  five  cases,  in  four  of  which  there  was  no  dif- 
ficulty in  obtaining  the  cerebro-spinal  fluid.  In  one 
case  a  second  puncture  was  required.  In  some  cases  of 
osteotomy  the  girls  rather  laughed  at  the  idea  of  pain. 
Nausea  and  vomiting  usually  occurred  in  tapping  the 
spinal  canal,  and  he  did  not  think  these  symptoms 
should  always  be  attributed  to  the  cocaine  used. 

Dr.  Egbert  H.  Grandin  said  his  experience  with 
this  method  was  limited  to  three  cases.  One  was  an 
exploratory  abdominal  section.  He  secured  the  ser- 
vices of  an  expert,  and  he  furnished  a  solution  of  co- 
caine from  the  hospital.  He  had  quite  an  attendance, 
and  all  said  that  the  anaesthetic  was  a  failure.  He 
waited  twenty-nine  minutes  and  then  had  to  resort  to 
the  use  of  chloroform.  Gr.  1  was  injected  between 
the  fourth  and  fifth  vertebrre  and  so  far  as  the  anas- 
thetic  effect  was  concerned  it  did  not  prove  successful. 
The  cocaine  was  tested  afterward  and  was  found  to  be 
good.  His  second  case  was  in  a  patient  upon  whom 
he  operated  for  a  pyosalpinx.  Here  the  same  expert 
was  obtained,  gr.  \  was  injected  between  the  fourth 


December  22,  1900] 


MEDICAL    RECORD. 


995 


and  fifth  vertebrs,  fluid  was  obtained  as  in  the  first 
case,  he  waited  nineteen  minutes,  and  when  he  started 
to  do  a  posterior  section  to  evacuate  the  pus  the  pa- 
tient shrieked.  Both  women  were  neurotic  Italians. 
The  third  case  was  one  of  strangulated  hernia  occur- 
ring in  the  practice  of  Dr.  Walsh  at  St.  Vincent's 
Hospital.  The  same  expert  was  there,  and  the  same 
anaesthetic  was  used.  The  patient  was  an  apoplectic 
woman  seventy-three  years  of  age,  with  emphysema 
and  a  chronic  bronchitis — a  typical  case  for  this 
method,  i.e.,  a  case  in  which  there  were  contraindica- 
tions for  the  use  of  ether  or  chloroform,  although  the 
use  of  the  infiltration  method  or  nitrous-oxide  gas 
might  not  be  considered  contraindicated.  In  this 
case  the  fluid  was  obtained,  gr.  I  was  injected,  there 
was  a  wait  of  fifteen  minutes,  and  then  the  operation 
was  proceeded  with.  During  the  course  of  the  oper- 
ation, which  lasted  thirty  minutes,  the  woman  com- 
plained. The  hot  water  poured  on  caused  her  dis- 
tress. The  above  cases  represented  his  experience 
with  this  method  of  anaesthesia,  and  he  was  rather 
sceptical  as  to  its  value.  He  questioned  if  there  was 
any  surgeon  who  cared  to  deal  with  anything  that  was 
uncertain.  In  dealing  with  ether  and  chloroform  and 
nitrous  oxide  during  the  past  twenty  or  twenty-five 
years  he  had  never  known  them  to  fail.  What  was 
desired  in  an  anaesthetic  was  certainty.  In  regard  to 
ether  it  was  stated  that  it  affected  the  kidneys;  might 
not  cocaine,  he  asked,  affect  the  cord?  Might  we  not 
get  a  septic  meningitis?  Again,  chloroform  was  said 
to  affect  the  iieart;  even  so  might  cocaine.  He  failed 
to  see  why  cocaine,  if  injected  into  the  spinal  canal, 
could  not  affect  the  heart  as  cocaine  would  if  injected 
under  the  skin.  He  wished  to  go  on  record  in  the 
statement  that  he  did  not  think  this  method  was  justi- 
fiable in  obstetric  practice.  He  considered  labor  a 
physiological  act,  and  he  did  not  deem  it  right  to  sub- 
ject these  women  to  the  possibility  of  pathological 
conditions  from  the  practice  of  such  a  procedure.  He 
had  always  been  able  to  control  a  tedious  first  stage 
by  the  use  of  chloral  or  morphine.  In  the  thiid  stage 
he  never  hesitated  to  give  the  women  chloroform.  He 
knew  of  only  one  death  that  was  due  to  this  an*thetics, 
and  that  was  because  the  anaesthetist  watched  him  oper- 
ate instead  of  watching  the  patient.  In  gyna;cology  he 
did  not  think  there  was  a  need  for  such  a  method.  If 
work  of  a  minor  nature  was  to  be  performed  he  pre- 
ferred nitrous  oxide.  He  did  not  wish  to  be  regarded 
as  one  who  was  pouring  cold  water  upon  these  enthu- 
siasts in  any  way  or  as  blocking  the  wheels  of  pro- 
gress, but  he  could  not  help  remembering  Dr.  Com- 
ing's statement  that  "he  trembled  for  the  cord." 

Dr.  W.  S.  Bainbridge  said  that,  several  months 
ago,  he  started  to  experiment  with  spinal  injection. 
At  that  time  there  had  been  no  cases  reported  of  chil- 
dren under  eleven  years  of  age,  so  he  determined  to 
try  the  method  in  such  patients.  While  he  did  not 
believe  for  a  moment  that  here  we  had  a  substitute  for 
the  general  anesthetics  now  employed,  he  felt  that 
there  might  be  a  limited  field  of  usefulness  in  certain 
selected  cases,  both  of  children  and  of  adults  in  which 
ether  and  chloroform  were  considered  far  from  safe. 
In  the  next  issue  of  the  Medical  Record  would  ap 
pear  a  paper  on  analgesia  in  children,  giving  the  re- 
sults of  his  first  seven  cases.  To  date  he  had  had 
some  twelve  cases  with  about  twenty  punctures. 
Several  times  he  had  had  the  advantage  of  testing  the 
potency  of  eucaine  in  comparison  with  cocaine  in 
different  operations  on  the  same  patient.  The  results 
so  far  showed  that  the  former  was  less  certain,  more 
evanescent,  the  analgesia  less  complete,  and  accom- 
panied with  the  same  sequelae  as  the  latter.  Know- 
ing of  the  failure  attributed  by  a  number  of  observers 
to  the  use  of  heat  in  the  sterilization  of  the  cocaine, 
he  endeavored  to  secure  the  same  end  in  some  other 


way.  He  used  ether  without  heat  and  secured  a  satis- 
factory injection  fluid.  He  had  had  some  cases  with- 
out nausea  or  vomiting.  In  only  two  involuntary 
defecation  occurred.  It  was  very  interesting  to  see 
many  of  the  children  go  through  a  severe  surgical 
operation,  while  their  attention  was  wholly  taken  up 
by  some  plaything.  One  failure  he  had  to  report — a 
boy  of  ten  years  received  two  injections  of  one-per- 
cent, solution  of  cocaine,  in  all  ill  xii.  He  showed 
all  the  physiological  symptoms  presented  in  the  other 
cases,  except  the  analgesia.  Tests  were  made  of  the 
solution  which  was  used  with  this  patient,  and  it  was 
found  to  be  inert. 

Dr.  Frederick  Kammerer  said  he  had  had  forty 
cases  in  general  surgical  practice  in  which  he  had  em- 
ployed this  method,  and  he  had  made  it  a  point  to  use 
as  small  a  dose  of  the  cocaine  as  it  was  possible  to 
give.  He  found  that  the  method  answered  best  in 
operations  upon  the  lower  extremities,  and  that  abdo- 
minal hernias,  operations  upon  the  genito-urinary 
tract,  upon  the  kidneys  and  bladder  seemed  to  be 
specially  well  adapted  to  this  method.  He  did  not 
think  it  was  so  well  suited  for  intra-abdominal  work. 
The  most  interesting  question  pertained  to  the  causes 
of  the  symptoms.  In  some  of  his  cases  they  had  been 
quite  alarming,  the  pulse  going  to  about  180,  and  then 
down  to  70.  He  could  not  look  upon  these  symptoms 
as  not  alarming.  The  after-effects  in  his  cases  had 
been  mild — headaches  and  slight  rise  of  temperature. 
He  asked  why  these  symptoms  did  not  appear  after  re- 
moval of  the  fluid  in  lumbar  puncture  if  they  were  not 
due  to  the  cocaine.  The  difference  in  pressure  had 
nothing  to  do  with  the  symptoms,  nor  did  operative 
shock.  He  thought  we  were  now  face  to  face  with  an 
important  method  which  should  be  approached  in  a 
very  serious  manner. 

Dr.  Robert  F.  Weir  said  that  TuflSer,  of  Paris, 
showed  this  brilliant  procedure  at  the  recent  meeting 
of  the  congress,  when  a  large  number  of  physicians, 
especially  Fnglish.  surrounded  him,  watching  him 
taking  out  a  kidney,  or  removing  a  uterus,  and  which 
was  one  of  the  most  impressive  things  witnessed  in 
surgery;  it  excited  admiration.  Fsmarch's  bandage 
treatment  of  aneurism,  too,  was  a  most  brilliant  thing, 
but  it  died  down.  There  were  all  sorts  of  fads  and 
fashions  in  medicine  and  surgery,  and  spinal  anesthe- 
sia might  be  one  of  them.  TufTier  had  been  asked 
about  his  deaths,  and  stated  he  had  had  five,  but  only 
one  was  due  to  the  cocaine.  TufTier  was  an  enthusiast 
in  this  department.  As  Dr.  Fowler  stated,  this  was 
something  yet  in  abeyance:  it  could  not  yet  be  classed 
as  a  perfectly  safe  thing  to  use,  certainly  not  so  safe 
as  ether.  VVas  it  suitable  for  those  cases  in  which  it 
was  found  that  ether  and  chloroform  were  not  advis- 
able? Tuffier  said  he  did  not  think  so.  It  was  inter- 
esting to  note  that  most  of  the  Americans  present  at 
Tuffier's  operation  under  spinal  cocainization  had 
flushed  faces  from  the  excitement,  all  svere  interested 
to  the  same  degree.  Several  said  to  each  other:  "  We 
will  try  this  when  we  get  home."  This  procedure 
spread  in  America  more  widely  than  in  England  or 
France,  while  Germany  practically  ignored  it.  What 
was  being  done  was  largely  experimental.  At  the 
Roosevelt  Hospital  it  had  been  tried  in  ten  cases,  in 
three  of  which  eucaine  was  used  and  failure  resulted. 
In  seven,  there  were  two  or  three  anxious  moments, 
more  so  than  he  had  ever  had  with  ether  in  many, 
many  years.  P'.xperience  at  the  New  York  Hospital 
since  1847  showed  that  but  one  death  occurred  in 
three  thousand  cases,  and  he  could  not  make  the  state- 
ment too  strong  that  this  new  procedure  did  not  pre- 
sent itself  to  him  in  an  encouraging  way,  yet  Dr.  Weir 
had  collected  the  following  cases:  Matas.  9,  severe 
symptoms  occurring  in  3;  Fowler,  81;  Goldan,  31, 
severe  symptoms  occurring  in    i ;   Keen,  i  which  was 


996 


MEDICAL    RECORD. 


[December  22,  1900 


fatal  (eucaine  was  used);  Lee,  7;  La  Place,  2,  severe 
symptoips  occurring  in  i;  Murphy,  25;  Severaneau, 
70;  Tuffier,  125,  death  occurring  in  5;  Brewer,  6 
(eucaine  used  in  2  of  these) ;  Rodman,  2  ;  Weir,  3, 
severe  symptoms  occuring  in  i  (eucaine  used  in  1). 
This  made  a  total  of  362  cases,  of  which  6  were  fatal 
(4  of  these  Tuffier  claimed  were  not  due  to  the  injec- 
tion) and  6  had  severe  symptoms.  In  other  words,  i 
in  every  30  was  in  danger.  Of  the  failures.  Fowler  had 
5  out  of  81  ;  Goldan,  3  out  of  31  ;  Murphy,  i  out  of 
25  (this  makes  9  failures  in  126  cases  in  which  cocaine 
was  used).  Brewer  had  2  out  of  6  (in  2  eucaine  was 
used);  Weir,  i  out  of  3  (in  i  eucaine  was  used).  In 
the  3  cases  in  which  eucaine  was  used  failure  fol- 
lowed. He  did  not  see  why  one  should  speak  of  co- 
caine, when  used  in  this  particular  line,  as  ever  safe; 
it  seemed  that  there  was  a  certain  amount  of  risk  in 
thrusting  it  into  the  canal.  He  did  not  wish  to  pose 
as  one  opposed  to  this  method  of  ana'sthesia.  He 
looked  upon  it  with  circumspection.  We  must  wait; 
a  time  limit  must  be  allowed  before  this  method  was 
considered  of  much  value. 


NEW  YORK  ACADEMY  OF  MEDICINE. 

SECTION    ON    SURGERY. 

Stated  Meeting,  December  10.  igoo. 

Ch.arles  N.  Dowd,  M.D.,  Chairman. 

Total  Ureterectomy Dr.  Willy  Meyer  presented  a 

man,  thirty-seven  years  of  age,  who  had  suffered  from 
pyelonephrosis  on  the  left  side  several  years  ago.  A 
surgeon  had  performed  nephrectomy  at  that  time,  and 
had  cut  off  the  ureter  as  low  as  possible.  Four 
months  later  some  surgeon  had  found  it  necessary  to 
drain  the  bladder,  and  had  done  so  by  means  of  a 
perineal  section.  Later  on  another  surgeon  had 
opened  and  drained  the  bladder  through  a  suprapubic 
incision.  On  coming  under  the  speaker's  observation, 
he  had  complained  of  pain  on  the  left  side  and  run- 
ning into  the  e.xtremity.  and  had  also  suffered  from 
frequent  micturition.  Owing  to  the  existence  of  a 
valve  in  the  posterior  urethra,  such  as  repeatedly  oc- 
curred after  prolonged  perineal  drainage,  he  had  found 
it  impossible  to  examine  the  interior  of  the  bladder 
with  the  cystoscope.  Not  being  able  to  verify  the 
possible  presence  of  a  chronic  suppurative  p\elone- 
phritis  he  had  collected  two  specimens  of  urine,  one 
before  and  the  other  after  massage  of  the  ureter  on 
the  suspected  side.  There  had  been  such  a  marked 
difference  in  the  two  specimens,  and  this  had  been  ob- 
served so  many  times,  that  lie  had  felt  satisfied  regard- 
ing the  diagnosis.  The  attempt  to  remove  the  ureter 
iiad  proved  very  difficult,  because  of  the  fact  that  at 
the  previous  operation  the  ureter  had  been  cut  off  so 
low  down.  He  had  had  to  dissect  through  a  mass  of 
dense  adhesions,  and  had  perforated  into  the  peritoneal 
cavity,  so  that  lie  had  felt  compelled  to  tampon  and 
leave  the  wound  open.  The  man  had  made  a  good  re- 
covery. The  speaker  said  it  was  most  important  al- 
ways to  test  the  patency  of  the  ureter  by  means  of  a 
bougie  in  every  case  of  nephrotomy. 

Pecularities  in  Appendicitis. — Dr.  John  Rogers 
presented  three  cases.  The  first  was  that  of  a  boy  who 
had  been  admitted  to  St.  Francis'  Hospital  in  October. 
About  one  pint  of  fetid  pus  had  been  evacuated  at  the 
operation,  and  for  a  few  days  he  had  done  well. 
Then,  after  some  error  in  diet,  he  had  suddenly  de- 
veloped pain  on  the  left  side,  and  exploration  had 
revealed  a  large  abscess  on  that  side.  About  Novem- 
ber 5th  he  had  begun  to  have  an  afternoon  rise  of 
temperature,  and  with  this  a  secondary  agglutinative 


peritonitis  simulating  abscess.  The  second  case  was 
that  of  a  boy  who  had  been  supposed  to  be  ill  with 
typhoid  fever  for  three  or  four  weeks  before  admis- 
sion. On  examination  there  was  a  tumor  in  the  iliac 
region,  and  every  appearance  of  sepsis.  There  was  a 
history  of  a  violent  gastro-enteritis  following  an  error 
in  diet,  and  associated  with  tenderness  on  the  left  side 
of  the  abdomen.  A  diagnosis  of  appendicitis  had 
been  made  on  liiis  history,  and  this  had  been  con- 
firmed by  the  finding  of  a  gangrenous  appendix  and  a 
collection  of  pus.  The  third  case  was  that  of  a  little 
child  who  also  had  had  an  appendicitis  marked  by 
pain  in  an  atypical  position.  Within  an  iiour  after 
an  indiscretion  in  diet  the  boy  had  developed  symp- 
toms of  a  violent  gastro-enteritis.  There  was  much 
abdominal  distention  with  dulness  in  the  region  of  the 
gall  bladder.  The  next  day  an  operation  had  been 
done,  and  had  revealed  a  long,  crooked,  and  gangren- 
ous appendix  adherent  to  the  duodenum. 

Dr.  a.  a.  Berg  presented  a  man  who  had  been  ad- 
mitted to  tiie  Mount  Sinai  Hospital  about  the  middle 
of  September  with  a  typical  history  of  suppurative  ap- 
pendicitis. The  next  day,  immediately  after  bimanual 
rectal  examination,  the  man  had  begun  to  complain  of 
much  more  pain,  and  this  had  been  followed  b)'  a 
rapid  pulse  and  a  temperature  of  104"  F.  By  even- 
ing the  pain  had  become  excruciating.  The  abdomen 
had  been  at  once  opened.  There  was  a  diffuse,  exten- 
sive, fetid  peritonitis,  which  could  hardly  have  been  of 
a  few  hours'  formation.  The  peritonitis  appeared  to 
be  as  general  as  was  usually  seen  on  the  operating- 
table.  The  exudate  had  been  sponged  out  from  the 
pelvis  and  beneath  the  liver  and  spleen,  and  a  collec- 
tion of  about  four  or  five  ounces  of  pus  had  been  evac- 
uated around  the  appendix.  This  cavity  alone  was 
cleansed  with  peroxide  of  hydrogen,  and  a  very  small 
wick  drain  inserted  down  to  the  stump  of  the  appen- 
dix. As  was  usual  in  such  cases,  the  patient  had  re- 
acted most  admirably  after  the  operation.  Two  or 
three  weeks  later  a  secondary  accumulation  under  the 
liver  had  been  found  and  drained.  This  abscess  was 
probably  owing  to  the  fact  that  the  speaker  had  neg- 
lected to  sponge  out  thoroughly  the  suprahepatic 
region. 

Dr.  Robert  T.  Morris  said  that  left-sided  infec- 
tion in  cases  of  appendicitis  was  not  very  rare.  He 
would  explain  it  on  the  theory  that  the  infective  proc- 
ess on  the  right  side  had  so  stimulated  leucocytosis 
as  to  protect  the  person  on  that  side,  but  the  infection 
extending  across  to  the  other  side  of  the  pelvis  was 
not  so  quickly  met  by  leucocytosis. 

Dr.  a.  a.  Berg  said  that  he  had  very  recently  seen 
a  little  child  with  a  large  appendicular  abscess  oc- 
cupying the  left  iliac  fossa.  This  situation  was  ex- 
plained by  the  pathologist  on  the  theory  that  the 
streptococci  present  had  w-andered  out  through  the 
peritoneal  coat  of  the  appendix  across  the  cavity  into 
the  left  iliac  fossa. 

Dr.  J.  F.  Erdmann  also  reported  a  case  of  large 
left-sided  accumulation  with  a  history  of  appendicitis, 
and  two  others  situated  in  the  epigastric  region.  He 
remarked  that  the  very  fetid  character  of  the  pus  in 
Dr.  Berg's  case  seemed  to  him  a  favorable  omen,  par- 
ticularly as  he  understood  the  infection  had  been  one 
of  the  colon  bacillus.  His  own  experience  had  been 
that  this  form  of  infection  gave  a  very  favorable  prog- 
nosis. 

Dr.  Berg  replied  that  this  had  not  been  his  experi- 
ence. It  was  not  so  much  a  question  of  the  nature  of 
the  bacteria  present  as  it  was  as  to  the  quantity  of 
toxins  that  had  been  absorbed  prior  to  the  operation. 

A  Method  of  Fixation  of  Loose  Kidneys. — Dr. 
Robert  T.  Morris  presented  a  paper  on  this  subject. 
He  .said  that  since  188 1  surgeons  had  been  busily 
engaged  in  perfecting  the  technique  of  this  operation. 


December  22,  1900] 


MEDICAL   RECORD. 


997 


Guyon  had  suggested  the  removal  of  a  part  of  the  cap- 
sule together  with  the  fatty  capsule.  Some  operators 
since  then  had  even  gone  so  far  as  to  strip  the  kid- 
ney of  its  capsule,  and  stitch  the  bared  organ  into 
the  muscle  defect.  Kidneys  anchored  by  Guyon's 
method  usually  remained  where  they  were  placed,  but 
they  had  not  been  free  from  pain.  Senn  adopted  a 
radically  different  procedure  when  he  removed  the  fat, 
scarified  the  capsule,  and  passed  iodoform  gauze 
around  the  kidney  to  support  it  at  the  site  of  the 
wound  until  granulations  had  formed  on  the  fibrous 
capsule.  In  this  way  secondary  firm  adhesions  were 
secured.  Dr.  Morris  said  that  in  the  two  cases  in 
which  he  had  tried  this  method  the  result  had  been 
excellent,  but  the  healing-process  had  been  entirely 
too  slow.  For  the  past  two  years  he  had  made  use  of 
a  method  which  he  had  seen  described  in  literature, 
but  he  had  been  unable  to  learn  the  name  of  the  per- 
son who  had  devised  it.  A  quadrangular  portion  of 
the  fibrous  capsule  of  the  kidney  was  turned  up  and 
drawn  through  a  slit  in  the  psoas  or  quadratus  muscle, 
and  sutured  there.  No  injury  was  done  to  the  paren- 
chyma of  the  kidney,  as  occurred  when  sutures  were 
passed  through  this  part.  The  insertion  of  sutures  in 
the  parenchyma  of  the  kidney  was  followed  by  the 
formation  of  more  or  less  fibrous  tissue,  and  this 
fibrous  substitution  led  at  times  to  neuralgia.  His 
experience  with  the  method  just  described  had  been 
entirely  satisfactory. 

Frequency  of  Movable  Kidney. — Regarding  the 
frequency  of  loose  kidney  the  speaker  said  this  ques- 
tion could  not  be  settled  until  some  standard  of  meas- 
urement was  adopted;  in  any  event  it  was  kijown  that 
movable  kidney  was  very  common.  One  of  our  very 
prominent  pathologists  had  told  him  that  he  almost 
never  saw  loose  kidney  at  the  post-mortem  table. 
When  death  occurred  the  kidney  usually  slid  back 
into  its  normal  situation,  and  was  fixed  there  by  rigor 
mortis. 

Symptomatology. — He  was  inclined  to  believe 
that  direct  pressure  of  a  loose  kidney  on  the  common 
bile  duct  caused  jaundice  and  other  symptoms  oftener 
than  most  authors  would  lead  us  to  believe.  Some- 
times great  pressure  was  exerted  upon  the  duodenum, 
or  upon  the  superior  mesenteric  vein.  A  large  pro- 
portion of  these  patients  presented  chronic  congestion 
of  the  caecum  and  appendix  with  symptoms  referable 
to  the  appendix.  .-Vmong  the  retlex  disturbances  were 
those  arising  from  involvement  of  Meissner's  plexus, 
as  for  example  membranous  colitis.  In  support  of 
this  view  a  case  was  reported  which  had  occurred  in 
the  person  of  a  physician.  The  membranous  colitis 
had  been  severe  and  obstinate,  but  had  been  complete- 
ly relieved  by  fixation  of  the  kidney,  and  the  man's 
general  health  had  been  greatly  improved.  The 
speaker  said  that  he  was  accustomed  to  operate  only 
in  those  cases  of  movable  kidney  which  were  not  read- 
ily controlled  by  a  support,  or  in  which  the  suffering 
continued.  There  were  very  few  dangerous  features 
about  the  operation. 

Dr.  G.  M.  Edebohls  said  the  advantage  claimed 
for  the  operation  advocated  by  Dr.  Morris  was  that  no 
sutures  were  passed  through  the  parenchyma  of  the 
kidney.  This  would  certainly  appeal  to  every  sur- 
geon, but  it  must  be  remembered  that  a  careful  series 
of  experiments  had  shown  that  regeneration  of  kidney 
tissue  promptly  followed  such  an  injury  as  was  done 
by  the  introduction  of  sutures.  If  the  sutures  were 
absorbable,  no  permanent  trace  of  their  introduction 
would  be  left.  He  had  done  over  two  hundred  nephro- 
pexies, and  had  made  it  a  rule  to  pass  the  sutures 
through  the  parenchyma  of  the  kidney.  The  chief 
cause  of  pain  in  the  region  of  operation  after  nephro- 
pexy was  from  division  of  the  ilio-inguinal  and  ilio- 
gluteal  nerves  during  the  operation.     If  it  were  im- 


possible to  avoid  dividing  them  at  the  operation,  they 
should  be  sutured  afterward.  He  would  not  like  to 
trust  entirely  to  the  capsule  of  the  kidney  to  hold  this 
organ  in  place.  The  capsule  was  often  a  thin,  frail 
membrane,  and  the  making  of  the  Hap  of  capsule  ne- 
cessitated leaving  a  large  area  of  denuded  kidney.  It 
was  strange  that  Dr.  Morris  favored  this  operation,  as 
he  seemed  to  dread  so  much  the  results  of  leaving 
such  a  bare  surface.  He  would  say  that  his  own  ex- 
perience had  taught  him  that  there  was  no  better  or 
surer  way  of  fixing  the  kidney  than  by  extensively  de- 
nuding this  organ.  Whatever  fixation  was  secured  by 
the  method  advocated  in  the  pa[)er,  he  believed,  was  in 
proportion  to  the  amount  of  denudation  of  the  kidney. 
His  rule  was  to  anchor  the  middle  of  the  kidney  to  the 
entire  length  of  the  space  between  the  last  rib  and  the 
crest  of  the  ilium.  Forty-day  catgut  should  be  the 
suture  material  used.  The  capsule  should  be  split  on 
the  convex  border,  and  reflected  on  either  side  a  dis- 
tance of  two  or  three  inches,  and  then  the  sutures 
should  be  inserted  into  the  rellected  jiortions  as  well 
as  into  the  kidney  corresponding  to  the  denuded 
areas.  He  had  examined  most  of  his  cases  again  and 
again,  some  of  them  six  or  eight  years  after  operation. 
With  the  exception  of  a  few  of  his  earlier  cases  he 
knew  of  none  that  had  become  loose  again. 

Dr.  Willy  Meyer  said  that  after  one  had  partially 
stripped  off  the  fibrous  capsule,  one  could  not  be  sure 
that  the  capsule  would  not  be  stripped  off  further,  thus 
neutralizing  the  effect  of  the  operation.  He  had  been 
making  use  of  Dr.  Kdebohls'  method,  and  had  been 
entirely  satisfied  with  the  results.  He  had  been  care- 
ful to  avoid  injuring  the  nerves  in  the  field  of  opera- 
tion, and  had  found  no  difficulty  in  doing  this. 

Dr.  a.  a.  Bek<;  said  that  he  was  under  the  impres- 
sion that  the  experiments  cited  by  Dr.  Edebohls  in 
support  of  the  theory  of  regeneration  of  kidney  tissue 
had  been  overthrown  by  the  recent  investigation  of 
Max  Wolff,  who  had  shown  that  the  regeneration  was 
only  apparent  and  due  to  a  hypertrophy. 

Dr.  Morrls,  in  closing,  said  that  he  had  also  been 
careful  not  to  injure  the  large  nerves,  but  he  knew  of 
a  number  of  physicians  who  had  had  their  patients 
complain  of  most  persistent  pain  after  nephropexy. 
Possibly  this  was  to  be  explained  by  their  lack  of  care 
in  preserving  these  large  nerves. 

A  New  and  Simple  Method  of  Sterilizing 
Sponges  by  Boiling. —  Dr.  f.  A.  Elskerg  gave  a 
demonstration  of  this  method.  He  said  that  steriliza- 
tion of  sponges  by  boiling  had  hithereto  been  imprac- 
ticable because  it  had  rendered  the  sponges  inelastic 
and  unfit  for  use.  Other  methods  of  sterilization  had 
been  so  tedious  and  troublesome  that  gauze  pads  had 
largely  taken  the  place  of  sponges  in  surgery. 
Sponge  consisted  essentially  of  an  albuminoid  mate- 
rial called  "  spongein."  It  was  perfectly  precipitated 
from  its  solutions  by  a  solution  containing  two  per 
cent,  of  tannic  acid  and  one  per  cent,  of  caustic  pot- 
ash; hence  it  should  be  perfectly  possible  to  sterilize 
sponges  in  such  a  solution  without  destroying  their 
desirable  qualities.  On  testing  this  in  practice  the 
theory  had  been  found  correct.  The  solution  could 
be  used  again  and  again,  and  after  infected  sponges 
had  been  treated  in  this  way  bacteriological  investi- 
gation showed  them  to  have  been  rendered  absolutely 
sterile.  The  method  of  procedure  was  briefiy  as  fol- 
lows: The  sponges  were  freed  from  calcareous  matter 
by  immersion  for  twenty-four  hours  in  eight  per  cent, 
muriatic-acid  solution,  and  then  thoroughly  washed  in 
water.  They  were  next  boiled  for  fifteen  minutes  in  a 
solution  containing  one  part  of  potassium  hydrate  and 
two  parts  of  tannic  acid  to  one  hundred  parts  of  water. 
The  sponges  were  then  washed  and  squeezed  in  sterile 
water  or  in  carbolic-acid  or  corrosive-sublimate  solu- 
tion until  the  potassium  hydrate  and  tannic  acid  solu- 


998 


MEDICAL    RECORD. 


[December  22,  1900 


tion  had  been  removed.  They  were  then  preserved  in 
a  three-  to  five-per-cent.  solution  of  carbolic  acid. 

A  Cystoscopic  Prostatic  Incisor. — This  instrument 
was  presented  by  Dr.  Willy  Mkyer.  It  was  easy  to 
understand,  said  the  speaker,  that  at  the  time  when 
Freudenberg  of  Berlin,  with  the  aid  of  his  improved 
modernized  instruments,  revived  Bottini's  operation, 
the  desire  to  perform  the  operation  under  the  guidance 
of  the  eyes  found  expression.  A  few  operators  pro- 
posed suprapubic  incision,  with  the  help  of  which  one 
was  enabled  not  only  to  see  exactly  how  the  beak  of 
the  incisor  was  placed,  but  also  to  guide  it  so,  with  the 
finger  in  the  bladder,  tiiat  it  firmly  and  properly 
hugged  the  body  of  the  gland.  This  procedure,  how- 
ever, was  inadvisable,  because  of  the  fact  that  it  would 
interfere,  to  a  greater  or  less  extent,  with  the  passage 
of  the  urine  through  the  newly  established  gateways 
in  the  prostatic  gland — so  necessary  in  order  to  insure 
a  good  result.  Besides,  such  an  incision  would  un- 
necessarily complicate  the  operation. 

Thus  the  only  available  instrument  for  the  shed- 
ding of  light  on  the  otherwise  obscure  field  of  oper- 
ation was  the  cystosocpe.  It  was,  therefore,  entirely 
correct  on  the  part  of  Freudenberg  to  insist  upon 
cystoscopy  as  a  preliminary  step  to  Bottini's  oper- 
ation. The  visual  examination  of  the  bladder  might 
be  done  either  a  few  days  prior  to,  or  simultaneously 
with,  the  operation.  If  the  trouble  was  not  far  ad- 
vanced, and  the  kidneys  were  not  yet  affected,  it  was 
immaterial  when  the  inspection  of  the  bladder  was 
done.  However,  in  the  case  of  a  markedly  enlarged 
prostate  accompanied  by  pronounced  renal  symptoms, 
the  additional  procedure  of  performing  cystoscopy 
might  sometimes  mean  a  serious  complication.  If 
done  immediately  preceding  Bottini's  operation  it 
would  unnecessarily  lengthen  the  operation,  and 
meant  repeated  introduction  of  steel  instruments, 
which  a  large  prostate  in  an  advanced  stage  of  the 
disease  often  seriously  resented.  And  if  done  a  few 
days  prior  to  the  operation  in  this  class  of  cases, 
symptoms  of  urethral  fever  might  follow  its  perform- 
ance, so  severe  in  character  as  to  render  impossible 
the  principal  part  of  the  work,  viz.,  Bottini's  oper- 
ation. The  speaker  stated  that  in  cases  complicated 
with  pyelo-nephritis  he  now  generally  omitted  cystos- 
copy. In  view  of  these  drawbacks  incidental  to 
cystoscopy  as  a  preliminary  step  to  Bottini's  oper- 
ation, the  news  that  Freudenberg,  with  the  help  of 
Dr.  Bierhoff,  had  constructed  an  instrument  which  per- 
mitted of  simultaneously  performing  cystoscopy  and 
Bottini's  operation  was  hailed  with  a  great  deal  of 
satisfaction.  The  device  was  called  the  cystoscopic 
prostatic  incisor.  As  a  whole,  the  instrument  was  a 
most  ingenious  one,  and  beautifully  manufactured,  as 
were  all  the  instruments  that  came  from  the  Berlin 
firm  which  had  placed  also  this  one  upon  the  market. 
The  cystoscope,  with  its  lamp  firmly  attached,  passed 
through  the  centre  of  the  incisor,  the  same  as  we  found 
it  arranged  in  the  various  instruments  belonging  to 
the  set  of  Casper's  operating  cystoscope.  The  chan- 
nel through  which  it  passed  could  also  be  used  for 
irrigation  of  the  bladder  whenever  the  injected  water 
should  become  turbid  by  hemorrhage,  etc.  As  a  mat- 
ter of  course,  the  handle  as  well  as  the  screw  which 
moved  the  knife  had  to  be  arranged  on  a  somewhat 
different  plan.  The  cystoscopic  prostatic  incisor, 
however,  had  a  number  of  drawbacks  if  compared  with 
Freudenberg's  improved  Bottini's  incisor  which  really 
was  a  most  beautiful  and  reliable  instrument.  These 
drawbacks,  some  of  which,  by  the  way,  had  already 
been  mentioned  by  the  two  gentlemen  who  designed 
the  instrument,  were  evidently  unavoidable,  and  they 
were  certain  to  make  *he  new  cystoscopic  prostatic  in- 
cisor not  the  principal  instrument  for  Bottini's  oper- 
ation, but  only  an  adjunct,  indicated  in  but  a  certain 


number  of  cases.  The  drawbacks  were  :  The  size  (26, 
the  incisor  being  only  23  French);  the  shorter  shank 
and  smaller  knife;  the  latter  point  especially  was  one 
which  would  limit  the  usefulness  of  the  instrument. 
Referring  to  Freudenberg's  improved  incisor,  the 
speaker  explained  that  if  we  saw  to  it,  when  making 
the  posterior  (backward)  incision  through  the  prostate 
gland — which  must  lower  the  internal  urethral  open- 
ing to  the  base  of  the  bladder  (interior  galvano-caus- 
tic  prostatotomy) — that  the  beak  of  the  incisor  slid 
gently  over  the  base  of  the  bladder  when  pulled  for- 
ward in  order  to  hug  the  body  of  the  gland,  and  if  we 
then,  by  means  of  the  assistant's  finger,  or  our  own,  in 
the  rectum,  measured  the  distance  of  the  tip  of  the 
beak  from  the  external  sphincter  ani  muscle,  we  were 
generally  enabled  to  know  that  the  beak  was  in  its 
proper  place.  If,  furthermore,  on  repeating  this  man- 
oeuvre a  number  of  times,  the  distance  of  the  tip  of 
the  beak  from  the  sphincter  ani  muscle  was  found  to 
be  always  exactly  the  same,  we  could  rest  assured  that 
we  hooked,  not  a  transverse  fold  of  the  bladder,  but 
the  prostate  itself,  and  that,  therefore,  we  need  have  no 
fear  of  perforating  the  bladder  when  proceeding  with 
the  operation.  The  direction  of  the  lateral  incisions, 
whether  they  be  done  at  an  angle  of  forty-five,  sixty, 
or  ninety  degrees,  was  generally  not  of  great  value  as 
far  as  the  final  result  of  the  operation  was  concerned. 
The  speaker,  therefore,  stated  that,  so  far,  he  had  not 
felt  the  necessity  of  doing  the  operation  under  the 
guidance  of  the  eyes.  Nevertheless,  cases  would  oc- 
cur in  which  it  would  be  of  value  and  importance  to 
see  exactly  where  the  beak  was  located.  This  applied 
especially  to  such  cases  as  had  been  operated  upon 
before,  but  in  vv'hich  the  obstruction  had  not  yet  been 
entirely  overcome,  and  to  early  cases  of  prostatic  en- 
largement. Unfortunately  suflierers  from  the  latter 
condition,  so  far,  were  rarely  willing  to  submit  to 
operation.  On  account  of  the  nearness  of  the  prism 
to  the  beak  of  the  incisor,  the  latter  was  seen  very 
much  magnified,  so  that  only  a  very  narrow  circle  of 
the  inner  surface  of  the  bladder  became  visible.  It 
was  also  to  be  expected  that,  in  the  more  advanced 
cases,  the  generally  occurring  slight  hemorrhage 
would  eventually  prevent  a  proper  view  when  the 
lateral  incisions  were  made,  although  the  water  within 
the  bladder  had  been  changed.  In  view  of  the  fore- 
going, it  was  evident  that,  before  passing  definitely 
upon  the  value  of  the  instrument,  we  should  have  to 
gain  further  experience  with  it.  There  could  be  no 
doubt,  though,  that  it  should  be  in  possession  of  all 
who  took  an  interest  in  and  were  used  to  perform  Bot- 
tini's operation. 

A  Useful  Saw  for  Bier's  Osteoplastic  Amputa- 
tion.— Dr.  Willy  Meyer  also  exhibited  an  instrument 
which  he  had  devised  for  this  purpose.  The  two  es- 
sentials were  to  have  the  saw  blade  under  strong  ten- 
sion, and  so  made  that  it  would  cut  in  all  directions. 
The  blade  in  this  instrument  was  3  mm.  wide,  and  the 
frame  holding  this  blade  was  a  metallic  semicircle. 
With  such  an  instrument  it  was  possible  readily  to 
cut  out  a  very  small  circle  of  bone,  and  hence  it  was 
particularly  useful  in  operating  upon  the  humerus 
and  femur. 

Neuro-Serum :  Destructive  and  Protective  Serum 

for  the  Nervous  System Eugenio  Centanni  reports 

the  results  of  his  experimentation  with  an  emulsion  of 
nerve  substance  taken  from  a  sheep.  A  dose  of  one- 
third  c.c,  introduced  by  trephining  into  a  rabbit's 
skull,  proves  fatal  in  forty-eight  hours.  When  intro- 
duced intravenously,  however,  it  is  perfectly  well  tol- 
erated, although  the  dose  be  twenty  or  thirty  times 
greater  than  that  which  kills  when  introduced  into 
the  brain.  Ten  or  more  c.c.  will  prove  fatal.— Z<7 
Kijorma  Medica,  November  7,  1900. 


December  22,  1900] 


MEDICAL    RECORD. 


999 


^cdicat  Jtctns. 

Contagious   Diseases — Weekly   Statement Report 

of  cases  and  deaths  from  contagious  diseases  reported 
to  the  Sanitary  Bureau,  Health  Department,  for  the 
week  ending  December  15,  1900: 


Tuberculosis 

Typhoid  fever 

Scarlet  fever 

Measles 

Diphtheria 

Laryngeal  diphtheria  (croup) 
Cerebro-spinal  meningitis. . . . 

Varicella 

Smallpox   


Cases. 


Deaths. 


210 

161 

104 

28 

171 

6 

III 

I 

264 

37 

12 

8 

0 

5 

80 

0 

15 

0 

A  Doll  House  for  a  Hospital.— One  of  the  most 
famous  of  very  modern  doll  houses  is  the  one  given  to 
the  children  of  Edinburgh  hospital  by  the  King  of 
Siam.  In  all  his  travels,  so  said  the  soft-spoken,  gen- 
tle-faced Oriental,  nothing  else  moved  liini  and  ap- 
pealed to  him  as  did  that  pathetic  crowd  of  white- 
faced,  suffering  children:  so  he  went  back  to  London 
and  took  counsel  with  English  friends.  As  a  result 
of  this  consultation  a  $500  doll  house  went  to  the 
Children's  Hospital  at  Edinburgh,  with  the  compli- 
ments of  the  King  of  Siam — and  Queen  V^ictoria  is 
second  in  the  hearts  of  one  group  of  her  subjects. — 
Sun. 

Comparative  Physique  of  Recruits  for  the  Navy, 
East  and  West.  — Passed  Assistant  Surgeon  Dr.  Ed- 
ward R.  Stitt,  United  States  steamer  Ilartjori/,  in  his 
report  to  the  surgeon-general.  United  States  navy, 
says:  "  In  connection  with  the  physical  examination 
of  the  landsmen  received  from  the  Richmoihl  -d-nA  Ver- 
mont on  the  arrival  of  the  Hartjoni  from  the  Pacific 
station,  a  great  superiority  has  been  observed  as  re- 
gards the  outward  manifestations  of  a  sound  physique 
among  those  born  in  the  middle  West  over  tiie  natives 
of  the  Atlantic  coast.  There  were  noted  among  the 
recruits  from  the  Eastern  cities  a  large  number  of  cases 
of  persons  who  would  probably  develop  unfitness  for 
the  service  by  reason  of  catarrhal  conditions  of  throat 
and  nose,  as  well  as  from  relaxation  of  inguinal  rings; 
these  conditions  being  far  less  frequent  among  the  re- 
cruits from  the  VVestern  States.  While  the  most 
striking  feature  differentiating  the  two  classes  was  as 
regards  general  appearance,  yet  the  following  averages, 
obtained  from  measurements,  are  in  a  degree  indica- 
tive of  this  superiority:  Of  163  men,  natives  of  the 
Eastern  coast  cities,  the  averages  were:  age,  20.3 
years;  weight,  129  pounds;  height,  66  inches;  chest 
expansion,  3.2  inches;  circumference  of  arm,  ii 
inches,  and  circumference  of  thigh,  19  inches.  Among 
those  born  in  the  middle  VVest,  numbering  92,  the 
average  was  20.5  years;  average  weight,  135  pounds; 
average  height,  67  inches;  average  chest  expansion, 
3.4  inches;  average  circumference  of  arm,  11.5  inches, 
and  average  circumference  of  thigh,  19.5.  Of  the  251 
recruits  who  were  enlisted  for  this  ship  about  one  year 
ago,  all  coming  from  the  VVest,  the  following  averages 
pertained  at  time  of  first  examination:  Age,  21; 
weight,  139  pounds;  height,  66.6  inches;  chest  ex- 
pansion, 3.2  inches;  circumference  of  arm,  11.7  inches; 
of  thigh,  19  inches." 

First  Woman  Medical   Graduate   in  Germany — 

It  was  in  the  year  1754,  says  the  Berlin  correspondent 
of  the  London  Lancet,  that  the  degree  of  M.I),  was  first 
conferred  on  a  woman  in  Germany.  The  Vossisdte 
Zeitung  oi  July  i3,  1754,  mentions  that  the  medical 


faculty  of  the  University  of  Halle  had  granted  the 
degree  of  M.D.  to  Mrs.  Dorothea  Christiana  Erxlebin, 
after  she  had  passed  the  examination  with  distinction. 
The  title  of  her  dissertation  which,  according  to  the 
custom  of  that  time,  was  written  in  Latin,  was  "Quod 
niniis  cito  et  jucunde  curare  sa;pe  fiat  causa  nimis  tutae 
cu'rationis."  This  lady  had  been  an  apprentice  of  her 
father,  a  well-known  medical  practitioner  at  Quedlin- 
burg,  and  as  she  could  not  matriculate  at  a  university 
she  learned  medicine  by  reading  only.  By  a  royal 
decree  of  Frederick  the  Great,  she  was  then  recom- 
mended to  the  faculty  of  Halle  as  a  candidate  fo"- 
graduation,  but  she  presented  herself  only  after  the 
death  of  her  husband.  She  also  published  an  essay 
on  the  utility  of  learning  for  the  female  sex. 

The  First  Public  Free  Bath  in  the  United  States. 
— Chicago  claims  that  the  Carter  Harrison  Bath  in 
Maher  Street  was  the  first  free  public  bath  in  the 
United  States,  and,  so  far  as  is  known,  the  first  in  the 
world  to  be  absolutely  free;  all  other  public  baths 
prior  to  the  opening  of  this  charging  a  small  fee,  rang- 
ing from  five  kreut/.ers  (about  two  cents)  at  the  Volks- 
bad  in  Vienna  to  five  cents  in  the  public  rain  baths  in 
New  York  City.  The  Harrison  bath  was  opened  to 
the  public  in  January,  1894,  having  cost  to  construct 
$7,825  for  the  building  and  $2,511  for  plumbing  and 
heating  apparatus.  It  is  needless  to  say  that  the  Har- 
rison bath  has  been  a  conspicuous  success. 

Knock-Out  Drops. — In  at  least  fifty  stores  in  this 
town,  says  a  writer  in  the  Sunday  Sun,  of  December  2d, 
a  stranger  can  buy  chloral  hydrate  without  a  physician's 
prescription.  Some  of  the  druggists  know  what  use 
it  is  to  be  put  to  at  the  time  they  sell  it,  but  they 
charge  $2  to  $3  for  an  ounce  bottle  of  the  mixture, 
and  so  long  as  they  get  a  good  price  for  it  they  ask 
no  questions.  There  are  two  drug  stores  in  Man- 
hattan tliat  are  thriving  on  the  sale  of  chloral  hydrate. 
Their  customers  are  thieves  who  make  a  practice  of 
drugging  and  robbing  men  who  come  to  New  York  to 
see  the  town. 

Boiling-Point  of  Water. — Most  persons  are  apt  to 
regard  the  point  at  which  the  water  in  the  domestic 
saucepan  boils  as  a  fixed  quantity,  unalterable  as  the 
law^s  of  the  Medes  and  Persians;  but  the  cooks  of  a 
certain  town  in  New  Mexico  have  discovered  that  in 
consequence  of  its  great  altitude  above  the  sea,  water 
boils  there  at  202°  F.  instead  of  at  the  normal  212"^. 
This  means  that  all  the  cooking  calculations  depend- 
ing upon  the  heat  of  the  water  have  to  be  revised. 
Everything  from  a  breakfast  egg  to  a  silver  side  of 
beef  takes  longer  to  cook  than  it  does  lower  down  in 
the  atmosphere.  Another  thing  which  militates 
against  the  calculations  of  the  ordinary  cook  of  the 
same  town  is  that  the  air  is  so  dry  that  vegetables  are 
deprived  of  half  their  natural  moisture,  and  must  be 
left  a  long  time  in  water  to  recover  themselves  before 
being  cooked.  In  connection  with  this  matter  of  the 
boiling-point  we  might  observe  that  if  our  cooks  at 
home  could  only  realize  the  fact  that  it  is  impossible 
to  heat  the  water  in  an  open  vessel  above  boiling- 
point  they  would  save  much  of  the  gas  used  in  so 
many  houses  for  fuel. —  Chambers'  Journal. 

A  Remarkable  Weapon.— At  a  meeting  of  the 
Zurich  Medical  Society  on  October  27th,  Professor 
Kronlein  demonstrated  a  pistol  which  is  creating  quite 
a  stir  in  army  circles.  A  man  shot  himself  with  this 
weapon,  a  "  Selbstlade-Pistole  "  (self-loading  pistol) 
Patrick  Mauser  modification.  Bergmann  was  admitted 
to  the  surgical  clinic  with  a  perforated  skull  and  died 
soon  after.  The  necropsy  revealed  a  most  extraordi- 
nary power  of  destruction  in  the  bullet,  there  being 
quite  a  network  of  fissures  in  the  skull,  besides  the 


lOOO 


MEDICAL    RECORD. 


[December  22,  1900 


small  wounds  of  entrance  and  exit.  Professor  von 
Bruns,  of  Tubingen,  made  experiments  on  the  dead 
subject  with  the  original  Mauser  pistol  three  years 
ago,  and  the  German  army  authorities  intend  to  intro- 
duce this  destructive  weapon  into  the  army.  The 
Swiss  army  authorities  have  not  yet  come  to  a  final 
decision.  The  weapon  is  very  light  and  has  a  light 
but  strong  leather  case  into  which  the  weapon  can  be 
so  fixed  that  it  serves  as  a  short  gun,  which  greatly 
facilitates  taking  aim.  The  weapon  is  remarkable 
from  its  simplicity  of  construction  and  want  of  screws. 
The  projectile  has  a  diameter  of  7.6  mm.,  and  the 
velocity  on  firing  is  450  metres  or  482  yards;  the 
velocity  after  the  bullet  has  reached  a  distance  of  1,000 
metres  or  1,093.6  yards  is  still  120  metres  or  130 
yards.  The  simplicity  of  loading  is  such  that  120 
shots  can  be  fired  in  one  minute.  It  seems  a  weapon 
admirably  adapted  for  cavalry  forces  and  mounted 
infantry. — Zurich  correspondent  of  The  Lancet. 

Health  Reports. — The  following  cases  of  smallpox, 
yellow  fever,  cholera,  and  plague  have  been  reported 
to  the  surgeon-general  of  the  United  States  Marine- 
Hospital  service  during  the  week  ended  December  14, 
igoo : 

Cases.    Deaths. 
Smallpox— United  States. 

California.  Oakland November  24th  to  December  ist. .     4 

Georgia,  Houston  December  1st  to  7th 24  i 

Illinois,  Chicago     December  ist  to  8th i 

Kansas December  ist  to  8th q 

Kentucky,  Lexington December  ist  to  8th 2 

Russell November  20th * 

Michigan,  l3etroit    December  ist  to  8th 2 

Grand  Rapids. . .  .November  24th  to  December  ist..     i 
Reported     present 

at  28  places November  25th  to  December  ist. . 

Minnesota,  Minneapolis December  ist  to  8th i 

Nebraska,  Omaha November  24th  to  December  ist  .     3 

N.  Hampshire,  Manchester. .  December  ist  to  8th 20 

New  York,  New  York December  ist  to  8th 12  3 

Ohio,  Ashtabula December  ist  to  8th 4 

Cleveland December  ist  to  8th 32  2 

Pennsylvania,  Steelton December  ist  to  8th 1 

Tennessee,  Memphis November  24th  to  December  8th.     5 

Nashville December  1st  to  8th 5 

Utah,  Salt  Lake  City November  24th  to  December  8th.  69 

*  Epidemic. 

Smallpox — Foreign. 
British    Columbia,    Gabriola 

Island November  21st 1 

Nanaimo November  21st 13 

Egypt,  Cairo November  nth  to  i8th i 

France,  Paris November  i8th  to  25th 8 

Mexico,  Tuxpam.. November  ipth  to  26th 4 

Russia,  St.  Petersburg November  loth  to  17th 4  1 

Vladivostock Jnly  ist  to  30th i 

Warsaw November  loth  to  17th 32 

Scotland,  Glasgow November  23d  to  30th 30  1 

Spain,  Barcelona   October  6th  to  November  nth 49 

Valencia November  4th  to  i8th i 

Yucatan,  Merida November  15th  to  30th Several. 

Yellow  Fever — Foreign. 

Cuba,  Havana November  24th  to  December  ist.  7 

Puerto  Padre December  3d i 

Mexico,  Mexico November  i8th  to  25th i 

Tampico November  i8th  to  25th  6 

Vera  Cruz November  24th  to  December  ist, .   ..  2 

Cholera. 

India,  Bombay October  30th  to  November  6th. . .    .  3 

Madras October  27th  to  November  2d 10 

Plague— Foreign. 

Egypt,  Alexandria   November  5th  to  12th i 

Germany,  Bremen November  6lh  , 

India,  Bombay  , , , October  30th  to  November  6th 

Madras t  )ctober  27th  to  November  2d      , .    , . 

Madagascar,  Tamatave October  15th  to  29th 2 

Plague — Insular, 
Philippine  Islands,  Manila. -October  13th  to  20th 3  2 

Diabetes  Mellitus  and  its  Treatment.— J.  H.  Reed 

says  that  if  not  more  than  25  to  30  gm.  of  sugar  are 
being  passed  daily  it  is  not  necessary  to  resort  to  the 
severe  regime  so  often  forced  upon  patients.  The 
chief  point  is  to  see  to  it  that  the  patient  does  not  lose 
flesh.  It  is  a  mistake  to  restrict  the  diet  to  the  extent 
to  which  it  is  so  often  done.  Antipyrin  gr.  xv.  given 
morning  and  night  with  gr.  vi.-viii.  of  bicarbonate  of 
sodium  will  show  a  disappearance  from  the  urine  of 
from  30-50  gm.  of  sugar  within  thirty-six  hours.  Reed 
prefers,  instead   of  Fowler's  solution,  the  arsenate  of 


sodium  in  a  solution  of  3  :  80  gm.  of  water,  of  which 
a  teaspoonful  is  to  be  taken  at  each  meal.  He  also 
believes  that  it  is  not  necessary  to  suppress  milk  in 
the  dietary  because  of  the  lactose  it  contains,  but  thinks 
it  should  be  given,  as  lactose  is  not  transformed  into 
glucose.  In  cases  of  severe  diabetes  the  patient  should 
be  allowed  to  drink  freely,  to  wash  out  the  sugar  if 
possible,  instead  of  allowing  it  to  accumulate.  For 
diabetic  coma  he  advises  small  doses  of  antipyrin  and 
rectal  injections  of  bicarbonate  of  sodium,  3  ii.  in  a 
pint  of  hot  water.  He  positively  interdicts  stimulants. 
He  also  advises  the  free  use  of  citrate  and  carbonate 
of  lithium,  regulating  the  amount  according  to  the 
quantity  of  sugar  present. — Physician  and  Surgeon, 
October,  1900. 

Pelvic  Massage. — E.  E.  Montgomery  describes  the 
process,  which  he  considers  advantageous  in  uterine 
displacements;  in  chronic  inflammation  of  the  uterus, 
tubes,  and  ovaries;  in  subacute  and  chronic  peritoni- 
tis.and  cellulitis;  for  the  removal  of  pelvic  exudates 
and  unfortunate  adhesions  after  pelvic  operations.  It 
is  contraindicated  in  all  cases  in  which  it  is  evident 
that  recent  pus  collections  are  present,  in  suspected 
ectopic  gestation  or  in  recent  internal  hemorrhage, 
in  ovarian  cysts,  unless  they  are  very  small,  when  it 
has  been  advised  that  they  should  be  forcibly  ruptured 
with  the  hope  that  the  cysts  will  be  obliterated  and 
their  subsequent  growth  be  prevented.  The  procedure 
is  absolutely  criminal  in  every  case  of  suspected  malig- 
nant disease. —  The  Therapeutic  Gazette,  November  15, 
1900. 


While  the  Medical  Record  is  pleased  to  receive  all  new  pub- 
lications which  may  be  sent  to  it,  and  an  acknowledgment  will  be 
promptly  made  0/  their  receipt  under  this  heading,  it  must  be  with 
the  distinct  understanding  that  its  necessities  are  such  that  it  can- 
not be  considered  under  obligation  to  notice  or  review  any  publica- 
tion received  by  it  which  in  tlie  judgment  of  its  editor  will  not  be 
of  interest  to  its  readers. 

The  Medical  Examination  for  Life  Insurance,  By 
Charles  Lyman  Greene.  M,  D,  Svo,  426  pages.  Illustrated,  P, 
Blakiston's  Son  &  Co, ,  Philadelphia,  Pa. 

Materia  Medica  and  Therapeutics.  By  John  V.  Shoe- 
inaker.  Svo,  766  pages.  F,  A,  Davis  Company.  Philadelphia, 
Pa. 

Studies  in  the  Psychology  of  Sex.  By  Havelock  Ellis. 
Svo,  275  pages.      F.  A.  Davis  Company.  Philadelphia,  Pa. 

Diseases  of  the  Nervous  System.  By  H,  Oppenheim. 
M,D.  Sgg  pages.  Illustrated.  J.  B,  Lippincott  Co,,  Philadel- 
phia, Pa. 

Grundriss  der  Inneren  Medicin.  By  Max  Kahane.  Svo, 
810  pages.     Illustrated.      Franz  Deutickle,  Leipzig,  Germany. 

Proceedings  of  the  Association  of  Military  Surgeons 
OF  THE  United  States.  Svo,  3S2  pages.  Berlin  Printing 
Co.,  Columbus,  Ohio. 

Practical  Homifopathic  Therapeutics,  By  W,  A, 
Dewey,  M,I).  Svo,  379  pages.  Boericke  &  Tafel,  Philadel- 
phia, Pa. 

Orthopedic  Surgery.  By  Charles  Bell  Keetley,  Svo,  527 
pages.      Illustrated.      Smith,  Elder  &  Co  .  London,  England, 

Physiology  of  the  Brain.  By  Jacques  Loeb,  M  D.  Svo, 
309  pages.      Illustrated.     G.  P.  Putnam's  Sons,   New  York. 

Thomas  Sydenham.  By  Joseph  Frank  Payne,  MIL  i2mo, 
264  pages.      Longmans,  Green  &  Co.,  New  York. 

The  Treatment  ok  Fractures.  By  \V.  L.  F.stus,  M.D. 
i2mo,  216  pages.  Illustrated.  International  Journal  of  Sur- 
gery Company,  New  York. 

Disinfection  and  Disinfectants.  By  H.  ^L  Bracken. 
^LD,  l2mo,  85  pages.  Illustrated,  The  Trade  Periodical 
Company,  Chicago,  III, 

In.struments  and  Arri.iANCEs  Required  in  Operations. 
By  A,  W,  Mayo  Robson,  i6mo,  62 pages.  Cassell  &  Co.,  Ltd., 
London,  Paris,  New  York. 


Medical  Record 

A    IVeekly  yournal  of  Medicine  and  Surgery 


Vol.  58,  No.  26. 
Whole  No.  1573. 


New  York,  December   29,  1900. 


$5.00  Per  Annum. 
Single  Copies,  loc. 


©rioinat  Articles. 

SOME    REMARKS   ON    MEDICINE  IN    1800.' 
Uy   GEORGE    K.    WELCH.    M.I)., 

HARTFORD.  CONN. 

The  subject  of  the  somewhat  disconnected  paper  to 
whicli  you  are  about  to  listen,  was  suggested  by  the 
date  assigned  for  its  reading.  As  this  is  the  last 
regular  meeting  but  one  of  our  society  in  tlie  nine- 
teentli  century,  the  topic  seemed  timely.  Not  long 
since  the  State  and  county  societies  celebrated  their 
centennials,  and  the  Hartford  Medical  Society  its 
semi-centennial,  on  these  occasions  many  able  papers 
were  prepared  and  read,  describing  the  organization 
and  progress  of  these  societies,  containing  much  in- 
teresting information  in  regard  to  medicine  during 
their  life,  and  many  reminiscences  of  old  physicians, 
this  paper  cannot,  does  not  attempt  to,  and  does  not 
desire  to  compete  with  these,  but  it  has  seemed  that 
by  treating  of  a  different  portion  of  the  subject  some 
things  of  interest  and  perhaps  novelty  might  be  set 
down. 

It  is  a  twice-told  tale,  and  would  not  be  interesting 
or  informing  to  you  to  discuss  at  lengtii,  with  names 
and  dates,  the  discovery  and  employment  of  the 
stethoscope,  the  microscope,  tlie  clinical  tiiermometer. 
and  vaccination,  all  of  which  date,  however,  in  a  gen- 
eral way,  from  the  beginning  of  the  century. 

Medicine,  however,  in  1800,  with  a  very  accurate 
knowledge  of  gross  anatomy  bequeathed  to  it  from 
past  centuries,  waited  only  for  these  helps  to  begin  the 
study  of  physiology  and  the  symptoms  of  disease  in  a 
scientific  way. 

A  further  impulse  toward  the  more  scientific  study 
of  medicine  was  tlie  fact  that  the  beginning  of  the 
nineteenth  century  coincides  quite  closely  with  the 
emergence  of  tlie  art  from  the  domination  of  the  so- 
called  ''systems"  which,  one  by  one,  arose,  Nourished, 
and  died  out.  Cullen,  who  died  in  1790,  and  his 
pupil  Hrown,  later  the  author  of  a  rival  "system,'" 
were  almost  the  last  to  consider  it  incumbent  upon 
prominence  in  their  profession  to  promulgate  a  com- 
plete personal  theory  of  medicine,  a  "bed  of  Pro- 
crustes," to  which  all  facts,  if  necessary,  must  be 
clipped  or  stretched  to  fit. 

They,  however,  had  no  premonition  of  tiiis,  and 
their  te.xt-books  on  "Practice"  show  that  each  was 
convinced  that  his  was  the  only  true  theory  of  medi- 
cine. In  his  very  long  introduction  Cullen  reviews 
at  length  the  history  of  medicine  for  two  centuries, 
treating  first  of  the  Galenists  and  their  partial  over- 
throw by  the  chemical  theory  of  Paracelsus.  He 
slates  that  later,  Galileo's  introduction  of  mathematical 
reasoning  and  Lord  Bacon's  method  of  induction,  with 
the  discovery  of  the  circulation  of  the  blood,  favored  a 
disposition  to  observe  facts  and  make  experiments,  but 
(to  quote)  ''  it  is  easy  to  show  that  it  never  could  be 
applied  to  any  great  extent  in  explaining  the  animal 
economy." 

Stahl's  system   (which  seems  to  have  been  an  ap- 

•  Read  before  the  Hartford  Medical  Society,  December  3 
1900. 


preach  to  "Christian  Science  ")  held  that  the  rational 
soul  governed  the  whole  economy  of  the  body,  and  was 
the  art  of  curing  by  expectation,  accompanied  by  the 
administration  of  inert  or  frivolous  remedies,  with  op- 
position to  the  most  elTicacious. 

Hoffman's  system  followed,  laying  the  cause  of  all 
diseases  on  the  nervous  system,  with  spasm  and  atony 
as  the  two  extremes.  He  then  refers  to  the  system  of 
Boerhaave,  the  one  under  which  he  was  instructed,  in 
which  disease  was  considertd  due  to  the  laxny  or 
rigidity  of  the  solids  and  the  acidity  or  alkalinity  of 
the  fluids  of  the  body,  as  the  most  important  of  all. 
Having  said  this,  he  goes  on  to  criticise  it,  root  and 
branch,  and  points  out  errors  in  all  its  theories,  claim- 
ing that,  although  still  taugiit,  it  should  be  superseded. 

He  then  discusses  Lieutaud's  system,  which  lays 
stress  upon  the  collection  of  facts,  and  while  admilling 
that  they  are  useful,  insists  that  some  "system''  is 
necessary  for  their  proper  interpretation.  He  holds 
up  to  ridicule,  not  unjustly  perhaps,  Lieutaud  s  re- 
marks on  the  cure  of  dropsy  ■  "  The  cure  may  be  be- 
gun by  bloodletting  in  certain  conditions,  but  in  others 
it  cannot  be  employed  without  danger,  it  gives  relief 
in  difficult  breathing,  but  after  it  is  practised  the 
symptoms  are  aggravated  ;  .  .  .  some  persons  have  been 
cured  by  repeated  bloodletting.  .  .  but  the  remedy.  .  . 
has  in  many  instances  hastened  the  fatal  result." 

Having  thus  attacked  all  previous  systems,  he  lays 
down  his  own,  which,  based  upon  Hoffman's,  which 
he  considers  the  least  objectionable,  makes  diseases 
dependent  upon  the  motions  and  moving  powers  of  the 
animal  economy. 

Brown,  in  a  shorter  but  equally  combative  preface, 
says  that  he  had  wasted  twenty  precious  years  of  his 
life  (when  he  was  Cullen's  disciple)  before  he  dis- 
cerned the  true  light.  He  then  details  his  own  divi- 
sion of  all  diseases  into  the  sthenic  and  asthenic  types, 
with  a  copper-plate  schedule  of  diseases  and  a  diagram 
resembling  a  thermometer  scale  divided  into  eighty 
degrees  with  "Mors"  at  each  end,  indicating  the 
sthenic  and  asthenic  modes  of  death.  He  airily  con- 
cludes in  these  words.  "Medical  art,  hitherto  con- 
jectural, incoherent  and  in  the  great  body  of  it  false, 
is  at  last  reduced  to  a  demonstrated  science,  which 
might  be  called  the  science  of  life." 

Before  this  the  names  of  Locke,  Sydenham, Boerhaave, 
and  others  stand  out — men  whose  natural  abilities 
were  so  great  as  to  render  them  successful  and  famous 
in  spite  of  imperfect  knowledge,  prevalent  incorrect 
theories,  and  lack  of  instruments  of  precision.  These 
men,  however,  were  so  hamjiered  by  their  environment 
that,  although  they  and  their  predecessors  stand  credited 
with  single  brilliant  discoveries,  they  were  not  able  to 
advance  practical  medicine  so  much  as  many  of  less 
ability  since.  Many  others,  whose  names  have  not 
come  down  to  us,  doubtless  had  much  honor  in  their 
day,  for  as  Dr.  John  Brown  says,  "  It  is  the  lot  of  the 
successful  medical  practitioner  to  be  invaluable  while 
alive,  and  to  be  forgotten  soon  after  he  is  dead,  and 
this,  not  altogether  or  chiefly  from  any  special  ingrati 
tude  or  injustice  on  the  part  of  mankind,  but  from  the 
very  nature  of  the  case.'' 

Rosari,  about  this  time,  was  the  author  of  a  system 
by  which  patients  were  treated  with  enormous  doses 


I0O2 


MEDICAL    RECORD. 


[December  29,  igoo 


of  powerful  and  poisonous  drugs,  and  cases  were  re- 
lated at  length  of  i)ersons  with  slight  illness  slowly 
dying,  poisoned  by  aconite,  tartar  emetic,  and  digitalis. 
To  this  and  the  unmentionable  "  system  ''  of  "  isopathy  " 
homivopathy  was  to  some  extent  a  reaction. 

Although  the  significance  of  temperature  as  a  symp- 
tom of  disease  had  always  been  recognized,  the  ac- 
curate determination  of  the  body  heat  as  a  help  to 
prognosis,  and  the  importance  of  its  fluctuations  as  a 
means  of  diagnosis,  was  not  recognized  until  the  be- 
ginning of  the  nineteenth  century.  The  uniformity 
of  animal  heat  under  extremes  of  heat  and  cold  was 
demonstrated  in  1775  by  Blagden  and  John  Hunter, 
but  the  latter  held  that  the  temperature  of  the  body 
was  not  maintained  by  the  circulation  of  the  blood, 
but  by  a  different  principle,  intimately  connected  with 
life  itself,  and  considered  the  seat  of  the  power  to  be 
the  stomach.  In  1787  Cullen  published  a  work  on 
temperature  containing  much  practical  matter  and  it 
attained  considerable  notice  at  the  time,  but  it  fell 
into  oblivion,  and  although  the  subject  of  fever  and  the 
theories  of  its  production  were  discussed,  there  was  no 
endeavor  to  evolve  practical  laws  until  forty  years  later. 

The  physician  of  1800  had  at  his  service  a  very 
complete  and  accurate  knowledge  of  gross  anatomy. 
Dissection  had  been  practised  for  five  hundred  years, 
and  the  sixteenth  and  seventeenth  centuries  gave  birth 
to  many  of  the  great  anatomists  whose  names  are  forever 
impressed  upon  our  organs.  This  being  a  department 
of  medical  science  consisting  entirely  of  facts  of  struc- 
ture patent  to  the  eye,  could  not  be  distorted  by  the  ad- 
herent of  this  or  that  "system."  Small  practical  use, 
however,  could  be  made  of  this  anatomical  knowledge, 
in  the  absence  of  correct  physiology  and  microscopical 
anatomy. 

Against  the  statement  that  the  beginning  of  the  nine- 
teenth century  marked  the  fall  of  all-embracing  systems 
of  medicine  it  might  be  argued  that  homoeopathy  exists 
at  present,  and  that  other  absurdities — "Christian  Sci- 
ence," osteopathy,  and  the  like — in  turn  are  born, 
flourish,  and  die.  The  difference,  however,  is,  that 
before  1800  the  leaders  in  the  profession  felt  it  neces- 
sary, or  at  least  desirable,  and  a  proof  of  their  leader- 
ship, that  they  should  originate  a  special  personal 
theory  of  disease  and  its  treatment;  and  that  the  rank 
and  file  of  physicians  should  profess  an  almost  religi- 
ous adherence  to  one  of  these  systems;  whereas  since, 
the  regular  profession,  finding  still,  it  is  true,  suffi- 
cient opportunities  for  differences  of  opinion,  is  not 
divided  into  several  hostile  camps  with  opposite 
opinions  on  the  essential  facts  of  their  art,  and  have 
placed  the  mushroom  theories  of  recent  times  where 
they  belong — in  the  region  of  quackery  and  pretense 
for  the  purpose  of  money-making. 

This  release  of  the  professional  mind  from  the 
necessity  of  constructing  or  accepting  an  imaginary 
theory  of  medicine,  joined  to  the  discovery  of  means 
which  rendered  it  no  longer  necessary  to  diagnose  ill- 
ness merely  by  the  appearance  of  the  patient  and  his 
statements,  was  a  great  incentive  to  the  noting  and  re- 
cording of  facts  which  served  as  a  basis  for  further 
advance.  The  achromatic  microscope,  ana;sthesia,  and 
the  cell  theory  toward  the  middle  of  the  century,  and 
later,  antisepsis,  powerfully  aided  this  advance,  and 
with  steadily  increasing  rapidity  medicin'  has  become 
what  it  is  to-day. 

The  illness  and  death  of  Washington,  occurring  so 
near  the  close  of  the  last  century,  caused  by  an  acute 
disease  demanding  energetic  and  intelligent  treatment, 
as  well  as  the  great  prominence  of  the  patient,  natur- 
ally attract  attention,  as  the  management  of  his  case 
affords  an  example  of  the  most  approved  treatment  of 
that  day.  From  the  popular  record  of  his  illness  in 
Irving's  "Life"   it  would  appear  that  he  died  from 


laryngeal  diphtheria  after  an  illness  of  about  one  day, 
and  that  the  principal  treatment  was  large  and  repeated 
blood-letting,  and  external  applications,  and  that  the 
symptoms  steadily  increased  until  death.  Dr.  Craik, 
the  attending  physician,  perhaps  naturally  affected  and 
unnerved  by  the  prominence  of  his  patient,  seems  to 
have  done  little.  At  his  second  call  (to  quote)  "  he 
pressed  his  hand  in  silence,  retired  from  the  bedside, 
and  sat  by  the  fire  absorbed  in  grief."  Dr.  Dick,  the 
consulting  physician,  was  made  of  sterner  stuff,  and 
although  he  apparently  held  his  peace  for  eight  years, 
he  then  wrote  a  letter  to  a  medical  journal  in  which 
he  speaks  very  frankly  of  the  treatment  pursued  by 
the  attending  physician,  states  that  the  disease  was 
manifestly  hastening  to  a  fatal  termination,  and  that 
he  (Dr.  Dick)  strenuously  recommended  tracheotomy. 
He  says  further  (to  quote) :  "At  first  I  had  reason  to 
Hatter  myself  that  I  had  obtained  the  concurrence  of 
the  other  physicians,  and  was  about  to  make  prepara- 
tions to  carry  the  measure  into  immediate  execution, 
when  I  was  rendered  unhappy  by  discovering  that  Dr. 
Brown  had  availed  himself  of  the  few  minutes  of  my 
absence  to  operate  unfavorably  on  the  mind  of  Dr. 
Craik,  whose  assent  I  was  unable  to  reclaim,  by  either 
argument  or  entreaty.  Both  of  these  gentlemen  were 
advanced  in  years  and  had  each  acquired  a  consider- 
able share  of  reputation  in  his  profession;  but  that 
increased  timidity,  which  is,  perhaps,  a  common  at- 
tendant on  old  age,  seemed  not  only  to  have  extin- 
guished all  ardor  in  pursuit  of  additional  celebrity,  but 
also  to  have  created  a  determination  to  hazard  no  part 
of  that  stock  which  liad  already  been  acquired.  ...  I 
know  not  what  might  have  been  the  result  .  .  .  but  I  shall 
never  cease  to  regret  that  the  operation  was  not  per- 
formed. In  this  awful  and  afflicting  state  of  things 
the  lancet  was  once  more  resorted  to." 

This  was  published  about  eight  years  after  Wash- 
ington's death;  but  Dr.  Dick,  in  1800,  signs  with  the 
other  physicians  an  account  of  Washington's  illness 
published  in  the  Alcdical  Repository,  in  which  no  men- 
tion is  made  of  tracheotomy.  It  is  somewhat  long  to 
quote  in  full,  but  quite  interesting. 

"  Sometime  on  Friday,  the  night  of  December  13th, 
General  Washington  was  attacked  with  an  inflamma- 
tory affection  of  the  upper  part  of  the  windpipe  called 
in  technical  language  cynanche  trachealis.  The  dis- 
ease commenced  with  a  violent  ague  accompanied  with 
some  pain  in  the  upper  and  fore  part  of  the  throat,  a 
sense  of  stricture,  a  cough,  and  a  difficult,  rather  than 
a  painful,  deglutition.  The  necessity  of  blood-letting 
suggested  itself  to  the  General,  and  he  procured  a 
bleeder  in  the  neighborhood,  who  took  from  his  arm 
in  the  night  twelve  or  fourteen  ounces  of  blood.  He 
would  not  by  any  means  be  prevailed  upon  by  the 
family  to  send  for  the  attending  physician  until  the 
following  morning,  who  arrived  at  Mount  Vernon 
about  eleven  o'clock  on  Saturday.  Discovering  the 
case  to  be  highly  alarming,  and  foreseeing  the  fatal 
tendency  of  the  disease,  two  consulting  physicians 
were  immediately  sent  for.  In  the  interim  were  em- 
ployed tw'o  copious  bleedings,  a  blister  was  applied  to 
the  part  affected,  two  moderate  doses  of  calomel  were 
given,  and  an  injection  was  administered,  which  oper- 
ated on  the  lower  intestines,  but  all  without  any  per- 
ceptible advantage,  the  respiration  becoming  still 
more  difficult  and  distressing.  Upon  the  arrival  of 
he  first  of  the  consulting  physicians  it  w'as  agreed 
that,  as  yet  there  were  no  signs  of  accumulation  in 
the  bronchial  vessels  of  the  lungs  to  try  the  result  of 
another  bleeding.  When  about  thirty-two  ounces  of 
blood  were  drawn  without  the  smallest  apparent  al- 
leviation of  the  disease,  vapours  of  vinegar  and  water 
were  frequently  inhaled,  ten  grains  of  calomel  were 
given,  succeeded  by  repeated  doses  of  emetic  tartar, 
amounting  in  all  to  five  or  six  grains  with  no  other 


December  29,  1900] 


MEDICAL    RECORD. 


1003. 


effect  than  a  copious  discharge  from  the  bowels.  The 
powers  of  life  were  now  manifestly  yielding  to  the 
force  of  the  disorder,  respiration  grew  more  and  more 
contracted  and  imperfect,  till  half  past  eleven  o'clock 
on  Saturday  night  when  retaining  the  full  possession 
of  his  intellect  he  expired  without  a  struggle. 

"Several  hours  before  his  decease,  after  repeated 
efforts  to  be  understood,  he  succeeded  in  expressing  a 
desire  that  he  might  be  permitted  to  die  without  inter- 
ruption. (Signed)  James  Craik,  Att.  I'/iys.  Elisha 
C.  Dick,  Cons.  P/iys." 

The  treatment,  therefore,  of  an  old  man,  sick  with 
a  disease  very  exhausting  to  vitality,  and  so  severe  that 
the  illness  lasted  but  twenty-four  hours,  consisted  in  the 
abstraction  of  between  two  and  three  quarts  of  blood, 
the  administration  of  about  gr.  xx.  of  calomel  and  gr. 
vi.  of  tartar  emetic,  an  injection,  with  external  applica- 
tions of  a  blister — and  a  pressure  of  the  hand.  This 
treatment  administered  to  a  well  man  in  so  short  a  time 
would  go  far  toward  preparing  him  for  his  last  journey. 

The  repeated  regretful  statements  of  the  physicians 
that  they  noted  no  benefit  from  their  treatment,  with 
continual  repetition  of  the  unsatisfactory  means  of 
cure  already  employed,  and  their  apparent  inability  to 
suggest  others,  and  the  last  request  of  General  Wash- 
ington that  he  might  be  allowed  to  "die  without  in- 
terruption "  have  their  pathetic  side.  lirandy  was 
surely  in  common  use  at  the  time,  and  no  doubt  "in 
the  house."  Peruvian  bark,  iron,  and  digitalis  were 
well-known  drugs  in  the  materia  medica  of  1800,  but 
there  is  no  record  of  their  use.  The  almshouse  pa- 
tient to-day  has  more  rational  treatment  than  the  ex- 
president  of  the  United  States  had  in  iSoo. 

An  examination  of  the  medical  periodical  of  one 
hundred  years  ago  is  of  greater  assistance  in  showing 
what  the  physician  of  that  time  w'as  interested  in,  than 
a  similar  examination  of  the  more  formal  medical 
treatise.  The  latter  was  more  under  the  influence  of 
the  moribund  theories  of  medicine.  Absurdities  are 
not  lacking,  but  some  such  will  be  found  by  the  in- 
vestigator of  2000  in  the  periodicals  of  to-day. 

The  Medical  Repository  began  publication  in  New 
York  in  1798,  and  the  first  four  annual  volumes  will 
cover  the  period  of  our  investigation.  The  magazine 
was  a  quarterly  containing  about  120  pages.  The  first 
number  begins  with  a  "  Circular  Address,"  the  gist  of 
which  was  that  the  absurd  "systems"  of  medicine,  in 
which  facts  were  made  to  fit  preconceived  theories, 
had  lost  their  value  and  authority,  and  that  the  time 
had  arrived  when  "Collections  of  Histories  and  Ob- 
servations" and  the  accurate  record  of  facts  should 
take  their  place,  and  was  therefore  ripe  for  the  estab- 
lishment of  the  magazine. 

The  articles  and  comnuinications  are  many  of  them 
quite  informal,  and  the  publishers  print  in  the  second 
volume  a  list  of  their  subscribers  as  a  society  might 
print  a  list  of  its  members.  In  this  list  appear  the 
names  of  two  Hartford  jjhysicians,  Mason  F.  Coggswell 
and  Nathaniel  Dwiglit.  One  of  the  original  editors 
was  Elihu  H.  Smith,  who  was  the  first  clerk  of  the 
Hartford  County  Medical  Society.  His  death  in 
1798,  at  the  age  of  twenty-seven,  of  yellow  fever,  then 
epidemic  in  New  York,  is  recorded  in  the  second  vol- 
ume, with  a  very  laudatory  sketch  of  his  life.  In  this 
it  is  stated  that  he  had  practised  in  W'ethersfield, 
Conn.,  where  (to  quote)  "finding  little  employment  in 
the  place  for  any  but  his  social  and  moral  virtues  " 
he  went  to  New  York.  While  there,  in  addition  to 
his  professional  and  editorial  duties  he  found  time  to 
write  an  opera  in  three  acts  entitled  "  Edwin  and 
Angelina,"  a  copy  of  which  is  among  the  Brinley 
books  in  the  XVatkinson  Library  in  this  city,  very 
beautifully  printed,  in  a  stjle  which  would  do  credit 
to  typographical  art  to-day. 


There  seemed  to  be  a  tendency  to  the  publication 
of  papers  describing  epidemics  in  comparatively  re- 
mote countries  such  as  the  West  Indies,  numerous 
articles  on  chemistry,  of  varying  degrees  of  absurdity, 
as  for  example  a  paper  by  Dr.  Gertamer,  who  had  dis- 
covered that  phosphorus,  sulphur,  and  arsenic  were  not 
simple  bodies  (which,  indeed  may  be  true)  but  com- 
posed of  carbone,  azote,  and  hydrogene ;  a  paper  "  prov- 
ing "  that  water  could  be  entirely  converted  into  air 
by  repeated  freezing,  and  another  on  the  noxiousness 
of  rain-water  and  dew.  Another  long  paper  treats  of 
"  Observations  on  the  Influence  of  the  Moon  on  Cli- 
mate and  the  Animal  Economy";  with  a  proper 
method  of  treating  diseases  when  under  the  power  of 
that  luminary.  'I'here  are  also  papers  of  no  medical 
significance  whatever,  as  one  describing  a  cabinet  of 
coins  and  medals. 

It  is  interesting  to  note  that  at  this  time  smallpox 
inoculation  was  quite  common  in  the  United  States, 
and  in  one  report  of  such  inoculations  a  physician 
was  proud  of  the  fact  that  in  only  one  case  had  he  had 
as  many  as  thirty  pustules.  In  the  New  York  City 
Dispensary  from  January  to  July  of  this  year  forty  cases 
of  smallpox  were  treated,  all  of  which  ended  in  recov- 
ery. Through  the  four  volumes  examined  short  items 
and  paragraphs  occur  from  time  to  time  in  reference  to 
Jenner's  experiments  in  cowpox  inoculation,  with  a 
gradual  increase  of  confidence  in  the  efficiency  of  the 
"vaccine  disease"  in  preventing  smallpox,  but  the 
subject  does  not  seem  to  have  been  regarded  with  such 
lively  interest  as  its  nature  and  importance  would 
deserve,  and  volcanic  eruptions  in  Guadaloupe  and  a 
"theory  of  hail"  take  up  much  more  space.  In  a 
paper  on  the  subject  of  vaccination  it  appears  that 
from  I  in  2,000  to  i  in  6,000  died  of  the  vaccine  dis- 
ease. 

In  the  first  volume  are  some  matters  of  local  inter- 
est. A  report  of  a  meeting  of  the  Connecticut  Medi- 
cal Society  records  the  expulsion  of  Elisha  Perkins 
for  patenting  his  tractors.  An  open  letter  from  Dr. 
Coggswell  to  Dr.  E.  H.  Smith  records  the  diseases 
prevalent  in  Hartford  and  vicinity  during  the  winter, 
with  an  account  of  the  weather  which  appears  to  have 
been  as  changeable  as  at  present.  In  this  account  he 
implies  that  Indian  summer  is  due  about  the  middle 
of  January.  He  notes  a  freshet  covering  all  the  town 
east  of  Market  Street,  but  states  that,  in  spite  of  this, 
catarrhal  and  pneumonic  complaints  have  been  less 
frequent  than  usual. 

An  abstract  of  a  paper  on  "  Sick-Head-ach  "  read 
before  the  Hartford  County  Society  in  September, 
1797,  by  Dr.  Natlianiel  Dwight  is  printed.  His 
treatment  was  "half  a  pint  of  hard  cyder  drank  on  an 
empty  stomach  in  the  morning."  We  must  conclude 
that  if  the  "head-ach  "  sees  fit  to  appear  after  dinner 
it  must  wait  till  the  next  day  for  treatment. 

Hospital  reports  are  given  in  each  number.  In  the 
list  of  diseases  treated  the  classification  is  somewhat 
vague.  In  one  quarter  we  note  seventeen  cases  of 
"sore  legs"  and  two  of  "disordered  spine."  This 
quarter  was  also  somewhat  exciting,  for  two  patients 
were  "discharged  disorderly"  and  nine  "eloped." 

A  large  proportion  of  the  second  volume  was  taken 
up  with  papers  and  discussions  upon  yellow  fever,  as 
was  natural  in  view  of  the  great  epidemic  then  pre- 
vailing throughout  the  United  States. 

This  paragraph  also  occurs  in  the  same  volume: 
"  It  is  pleasing  to  find  Philadelphia  engaged  with  so 
much  assiduity  in  the  plan  of  supplying  their  city  with 
water.  Measures  are  begun  and  already  in  forward- 
ness by  which  the  waters  of  the  Schuylkill,  which  were 
found  upon  experiment  to  be  eminently  pure  and  whole- 
some, will  be  conveyed  to  the  town  in  any  desirable 
quantity."  One  hundred  years  later  the  people  of  the 
same  Philadelphia  are  engaged  with  the  same  assiduity 


IC04 


MEDICAL    RECORD. 


[December  29,  1900 


in  avoiding  the  water  of  the  SchuylkiU,  which  have 
ceased  to  be  "emineiuly  pure  and  wholesome.'" 

In  Volume  III.  is  a  long  review  of  "A  History  of 
Epidemic  and  Pestilential  Diseases"  written  by  Noah 
VVebster  and  published  in  Hartford  in  1800.  The 
book  is  an  endeavor  to  prove  that  epidemics  of  all 
kinds  are  closely  connected  with,  and  dependent  upon, 
comets,  volcanic  eruptions,  earthquakes,  meteors,  ex- 
tremes of  temperature,  excessive  rain  and  drought, 
tempests,  high  winds,  plagues  of  insects  and  famine: 
and  that  all  these  outbreaks  of  nature's  forces  and  tlie 
resulting  epidemics  of  disease  are  due  to  the  electric 
lluid;  that  when  the  atmosphere  becomes  surcharged 
with  electricity  the  normal  action  of  the  animal 
economy  could  not  be  maintained. 

The  report  of  a  case  of  chylous  dropsy  is  attractive. 
I  quote:  "The  patient,  a  boy  of  twelve  years,  was 
brought  to  town  and  tapped.  On  withdrawing  the 
stilette  you  may  judge  our  surprise  to  find  a  most 
pure,  white  and  fragrant  chyle,  or  milk,  which  con- 
tinued to  How  until  we  had  obtained  between  seven 
and  eight  quarts.  It  was  perfectly  sweet  and  pleasant 
both  to  the  smell  and  the  taste;  and  after  standing 
through  the  night  afforded  a  good  cream,  though  not 
quite  so  much  as  is  usually  obtained  from  the  same 
quantity  of  cow's  milk."  This  novel  source  of  dairy 
products  was  not,  however,  destined  to  long  service, 
for  after  a  second  tapping  there  was  no  return  of  the 
lluid,  and  recovery  took  place.  The  diagnosis  was 
rupture  of  some  of  the  chyliferous  vessels. 

In  the  fourth  volume  is  printed  a  paper  of  especial 
interest  to  us,  entitled  "  The  Improvements,  Progress 
and  State  of  Medicine  in  the  Eighteenth  Century; 
read  on  the  first  day  of  the  nineteenth  century  before 
the  Medical  Society  of  South  Carolina."  The  author, 
of  course,  would  make  the  most  of  his  subject  and 
record  as  much  progress  as  possible.  His  list  of  the 
discoveries  and  developments  of  the  hundred  years 
then  just  past  is  as  follows:  improvements  in  anatomy 
in  the  preparation  of  specimens,  new  operations  in 
surgery,  instruction  of  the  deaf,  experiments  with 
poison  on  living  animals,  establishment  of  humane 
societies,  cool  regimen  in  fevers  and  smallpox,  estab- 
lishment of  medical  societies,  hospitals  and  infirm- 
aries, improvement  and  simplification  of  the  materia 
niedica,  discoveries  in  chemistry,  triumph  of  physic 
over  smallpox  by  inoculation  and  over  scurvy  by 
vegetable  diet  and  oxygen,  and  the  abatement  of 
plague  and  pestilential  fevers.  This  is  the  record  for 
one  hundred  years  previous  to  1800. 

The  writer  of  this  paper  made  no  prophecy  for  the 
coming  century,  but  if  he  had,  we  must  believe  that 
the  facts  would  have  exceeded  his  reasonable  imagina- 
tion. Can  we  safely  predict  an  equal  advance  in  the 
coming  twentieth  century?  At  first  thought  one  might 
say,  VVhy  not?  The  nineteenth  century  has  made 
discoveries  not  only  wonderful  but  previously  incon- 
ceivable in  their  nature — why  should  not  the  twentieth  ? 

Alfred  Russel  \\allace  says  that  for  a  proper  esti- 
mation of  the  nineteenth  century  it  should  be  com- 
pared, not  with  the  preceding  century,  but  with  all 
historic  time;  and,  doing  this,  he  finds  twenty-five  dis- 
coveries of  the  first  rank  in  the  nineteenth  century  and 
fifteen  of  equal  importance  in  all  preceding  time.  He 
enumerates  these  twenty-five,  of  which  five  are  medical, 
as  follows:  railways,  steamships,  electric  telegraph, 
telephone,  matches,  gas  illumination,  electric  lighting, 
photography,  the  phonograph,  Roentgen  rays,  spectrum 
analysis,  anaesthetics,  antiseptic  surgery,  theory  of  the 
conservation  of  energy,  molecular  theory  of  gases, 
measurement  of  the  velocity  of  light,  rotation  of  the 
earth  experimentally  shown,  the  uses  of  dust,  definite 
proportions  in  chemistry,  the  meteoric  theory,  the  gla- 
cial epoch,  the  antiquity  of  man,  organic  evolution,  the 
cell  theory,  and  the  germ  theory  of  disease.     The  fifteen 


discoveries  of  all  previous  time,  of  which  only  one  is 
medical,  are  the  mariner's  compass,  the  steam  engine, 
the  telescope,  the  barometer  and  thermometer,  print- 
ing, arable  numerals,  alphabetical  writing,  modern 
chemistry,  gravitation,  Kepler's  laws,  the  differential 
calculus,  the  circulation  of  the  blood,  the  finite  veloc- 
ity of  light,  and  the  development  of  geometry. 

This  enumeration  must  infiuence  us  toward  the 
opinion,  that,  since  the  nineteenth  century  so  over- 
shadows not  one  but  all  previous  centuries,  it  is  not 
likely  that  any  succeeding  one  will  equal  it.  The 
reasonable  prophecy  seems  then  to  be  that  the  coming 
century  will  witness  very  great  advance  growing  out 
of  discoveries  already  made,  and  less  discovery  of  new 
principles. 

Professor  Dolbear,  in  a  Boston  address,  sums  it  up 
as  follows:  "This  century  inherited  the  horse,  it  be- 
queaths the  bicycle,  the  locomotive,  and  the  auto- 
mobile; it  inherited  the  goose-quill,  it  bequeaths  the 
typewriter;  it  inherited  the  scythe,  it  bequeaths  the 
mowing-machine;  it  inherited  the  hand  printing-press, 
it  bequeaths  the  Hoe  cylinder;  it  inherited  the  painted 
canvas,  it  bequeaths  the  photograph;  it  inherited  the 
hand  loom,  it  bequeaths  the  cotton  and  woolen  factory; 
it  inherited  gunpowder,  it  bequeaths  nitroglycerin;  it 
inherited  the  tallow  dip,  it  bequeaths  the  arc  and  in- 
candescent light;  it  inherited  the  galvanic  battery,  it 
bequeaths  the  dynamo,  it  inherited  the  flint-lock,  it 
bequeaths  the  Maxim  gun;  it  inherited  the  sailing- 
ship,  it  bequeaths  the  steamship;  it  inherited  the 
beacon  signal  fire,  it  bequeaths  the  telephone  and 
wireless  telegraphy;  it  inherited  ordinary  light,  and 
it  bequeaths  the  Roentgen  ray." 

In  the  field  of  medicine  the  antithesis  is  equally 
striking.  If  we  note  the  contrast  between  the  fanci- 
ful and  changeable  theories  of  medicine  in  1800.  and 
the  well-grounded  and  stable  theories  of  to-day;  the 
practically  non-existent  physiology  of  1800,  and 
physiology  to-day;  the  surgery  of  1800,  without  anaes- 
thesia or  antisepsis,  and  surgery  to-day;  the  therapeu- 
tics of  1800,  with  the  domination  of  the  lancet,  pros- 
trating emetics  and  cathartics,  and  modern  treatment; 
the  guesswork  diagnosis  of  1800,  and  the  scientific 
investigation  of  the  functions  of  the  body  with  instru- 
ments of  precision,  and  of  its  organs  by  many  well- 
adaped  means,  to-day;  the  wild  theories  of  etiology 
prevalent  in  1800,  with  the  present  steadily  lengthen- 
ing list  of  the  diseases  the  exciting  cause  of  which  is 
certain — we  shall  be  assured  that  medicine  stands 
abreast  of  other  arts  and  sciences  in  the  century's 
advance. 

"  For  still  the  new  transcends  the  old, 
In  signs  and  tokens  manifold  ; 
And  step  by  step  since  time  began 
I  see  the  steady  gain  of  man." 

The  twentieth  century  enters  the  hundred-year  race 
with  a  good  pedigree  (by  "  Science  "  out  of  "  Nature  "), 
vigorous,  well-shod,  well-trained,  and  ambitious; 
sound  in  wind  and  limb;  "will  tiot  stand  without 
hitching;"  but  the  race  is  "against  time,"  and  the 
odds  are  that  the  record  will  not  be  beaten. 


The  Treatment  of  Puerperal  Fever.  —  Victor 
Steiner  reports  three  such  cases.  In  one  of  these 
Marmorek's  serum  was  used  with  apparently  specific 
results,  in  another  the  serum  therapy  failed,  but  re- 
covery followed  the  employment  of  the  more  usual 
measures,  and  in  the  third  the  temperature  came  down 
to  normal  under  ordinary  treatment  before  the  serum 
could  be  obtained.  This  does  not  seem  to  promise 
very  well  for  the  serum  therapy,  but  in  desperate  cases 
the  author  advises  its  use. —  Centralhlatt  Jiir  Gyiiako- 
logic,  November  3,  1900. 


December  29,  1900] 


MEDICAL    RECORD. 


100^ 


A  CASE  OF  GONORRHtEAL  EXDOCARDI'I'IS 
WITH  CONGENITAL  MALFORMATION  OF 
MITRAL    VALVES.' 

By   G.    W.    McCASKEV,    A.M..    M.D., 

FOKT    WAVN8      I.VD..  ' 

PROFESSOR  OF  CLINICAL  AIEDICINR  AND  NERVOIIS  DISEASES  IN  THE  FORT 
WAVNB  COLLEGE  OF  MEUICINE  ;  PRESIDENT  OF  THE  INDIANA  STATE 
-MEDICAL   SOCIETN'. 

The  following  case  is  reported  principally  because 
the  physical  signs  of  a  cardiac  lesion  were  carefully 
studied  during  life  and  compared  with  the  anatomical 
changes  found  at  the  autopsy,  although  it  presents 
several  other  points  of  considerable  interest. 

Mr.  H ,  aged  thirty-three  years,  was  first  seen  in 

consultation  with  his  attending  physician,  November 
21,  1899.  His  health  was  always  good  until  January, 
1898,  when  he  had  a  severe  attack  of  typhoid  fever 
with  intestinal  hemorrhages,  which  was  very  pro- 
tracted, lasting  over  three  months.  Recovery  was 
very  slow  but  was  apparently  complete  and  he  re- 
mained in  good  health  until  January,  1899,  when  his 
attending  physician  was  called  to  see  him  on  account 
of  a  severe  chill  following  self-catheterization  on  ac- 
count of  a  stricture  from  an  old  gonorrhtta.  Some 
five  or  si.v  weeks  later  (February,  1899)  the  present 
illness  began  with  general  malaise,  afternoon  elevation 
of  temperature  ranging  from  100'  to  102°,  with  morn- 
ing temperature  99  or  less.  From  this  time  there 
was  progressive  loss  of  strength  with  emaciation.  One 
or  two  slight  pulmonary  hemorrhages  occurred  about 
the  time  of  my  study  of  the  case. 

For  several  weeks  preceding  my  first  examination 
he  had  been  suffering  from  joint  pains  in  the  fingers, 
toes,  and  knees.  There  was  also  some  soreness  on 
deep  pressure  over  the  right  kidney  and  a  tendency  to 
looseness  of  the  bowels  which  had  been  present  since 
the  attack  of  typhoid  fever,  prior  to  which  there  was  a 
tendency  to  constipation.  Urination  was  normal; 
there  was  no  headache,  nausea,  or  vomiting.  Some 
dyspnoea  was  experienced  on  slight  exertion.  The 
tongue  was  red  and  irritable,  and  slightly  coated. 
Physical  examination  showed  the  liver  greatly  enlarged 
but  not  indurated.  The  stomach  could  be  distinctly 
outlined  by  succussion  and  the  phonendoscope,  and 
was  in  the  umbilical  region,  but  not  much  enlarged 
— principally  ptosis.  In  the  left  second  interspace 
there  were  both  a  diastolic  and  a  systolic  bruit,  and 
also  a  distinct  visible  impulse  synclironous  with  each 
systole  of  the  heart.  There  was  marked  hypertrophy 
of  the  left  ventricle,  the  dulness  extending  beyond  the 
nipple  line,  and  the  impulse  was  also  felt  far  to  the 
left.  The  physical  examination  was  otherwise  nega- 
tive. 

Uranalysis:  Total  quantity  in  twenty-four  hours, 
1,200  c.c;  sp.  gr.  1,019;  '°'^'  solids,  53  gm.;  urea, 
2.4  per  cent.,  total  29  gm.  Trace  of  albumin  by 
Tanret's  and  Heller's  test  but  not  enough  to  be  esti- 
mated by  centrifuge.  No  sugar.  Acidity,  40";  uric 
acid,  1.6  gm.;  ratio  to  urea,  i  to  18;  total  sulphates, 
2.3  gm.,  ratio  i  '_■  to  10;  indican,  .03  per  cent,  or  360 
mgm.  Microscopical:  granular  casts,  pus,  and  a 
branched  organism  closely  resembling  this  fotm  of 
tubercle  bacilli.  At  another  time  the  albumin  was 
two  per  cent,  by  centrifuge  estimation. 

Blood  examination:  Red  cells  40  per  cent,  of  total 
bulk  by  centrifuge  method,  equivalent  to  about  4,000,- 
000  per  c. mm.  Haemoglobin  65  per  cent.  White  cell 
count  1,300  to  c.mm.  A  fresh  slide  showed  very  poor 
rouleaux  formation,  with  numerous  irregular  extra- 
cellular granular  masses  — probably  the  nuclei  and 
other  de'bris  of  disintegrated  leucocytes. 

The  diagnosis  was  endocarditis  due  either  to  typhoid 

'  Read  before  the  Northern  Tri-State  Medical  .Association  at 
Montpelier,  Ohio,  July.  1900. 


or  gonorrhoeal  infection,  the  lesion  being  limited  to 
the  aortic  and  mitral  valves,  and  subacute  nephritis  of 
recent  date  and  toxic  origin.  It  will  be  noted  that  the 
greatest  intensity  of  the  aortic  murmur  was  in  the  left 
interspace;  but  the  diagnosis  of  aortic  lesion  was 
nevertheless  made  on  account  of  the  hypertrophy  of 
the  left  ventricle  and  associated  symptoms.  This 
point  will  be  referred  to  again  later.  The  bruit  was 
distinctly  transmitted  posteriorly  over  the  third  and 
fourth  ribs  near  the  inner  margin  of  the  left  scapula. 
One  month  after  my  first  visit  he  had  a  distinct  hemi- 
plegic  attack  the  result  of  a  cardiac  embolism,  the  right 
side  being  completely  paralyzed.  The  patient  gradu- 
ally lost  strength  and  flesh  and  finally  died  January 
4,  1900.  Shortly  before  his  death  purpuric  spots  ap- 
peared over  the  upper  part  of  the  body  and  there  was 
marked  haniaturia. 

The  autopsy  was  made  by  attending  physicians 
twenty-four  hours  after  death.  The  liver  was  enlarged, 
weighing  five  and  one-half  pounds,  and  on  its  outer 
surface  was  found  a  number  of  calcareous  deposits. 
The  gall  bladder  was  greatly  distended,  the  stomach 
was  somewhat  dilated  and  prolapsed.  The  right  lung 
showed  slight  general  adiiesion.  Nothing  else  ab- 
normal was  noted.  Heart  left  ventricle  greatly  hy- 
pertrophied,  right  flabby  and  tiiin.  The  valves  on  the 
right  side  of  the  heart  were  perfectly  normal  in  ap- 
pearance and  seemingly  competent.  The  aortic  valves 
were  thickened,  distorted,  roughened  and  covered  with 
vegetations,  and  obviously  incompetent.  The  mitral 
valve  was  also  the  seat  of  inflammatory  changes  and 
did  not  completely  close  the  orifice,  although  its  in- 
competency was  partly  due  to  the  predominance  of 
dilatation  which  greatly  enlarged  the  orifice  of  the 
auriculoventricular  septum.  There  were  two  perfora- 
tions in  the  posterior  cusp  of  the  mitral  valve  which 
led  into  two  sac-like  formations  perhaps  half  a  centi- 
metre in  diameter,  on  its  auricular  aspect.  The  spleen 
was  about  twice  its  normal  size,  and  just  beneath  its 
capsule  were  also  found  calcareous  concretions  similar 
to  those  found  on  the  liver.  Both  kidneys  were  en- 
larged, the  right  presenting  a  pelvic  hemorrhage. 

Scrapings  from  the  aortic  valve  showed  micro-organ- 
isms morphologically  identical  with  the  gonococcus, 
which  proves  the  endocarditis  to  be  of  gonorrheal 
origin.  The  liver,  in  sections,  showed  the  typical 
structure  of  chronic  congestion  from  heart  disease. 

Tliere  are  several  points  of  interest  in  this  case. 
One  of  especial  interest  from  a  diagnostic  viewpoint 
is  the  left-sided  location  of  the  greatest  intensity  of  a 
basal  murmur,- proven  by  autopsy  to  have  been  the  re- 
sult of  an  aortic  lesion.  Tiie general  statement  of  the 
authorities  with  reference  to  this  question  ought  to  be 
qualified  materially,  as  there  are  doubtless  many  cases 
in  which  this  anomalous  location  of  the  greatest  in- 
tensity of  aortic  murmur  exists;  and  unless  the  excep- 
tional cases  are  kept  well  in  mind  may  lead  to  errors 
in  diagnosis. 

With  reference  to  the  bruits  caused  by  aortic  disease 
Vierordt '  says  that  they  are  heard  over  the  right  second 
intercostal  space;  H.  A.  Hare,'  that  they  are  heard 
over»the  aortic  cartilage,  Whittaker,'  that  they  are 
heard  over  the  aortic  valve  or  second  right  interspace; 
Osier'  says  that  the  murmur  of  incompetency  is  heard 
over  the  second  right  interspace  and  the  stenotic 
murmur  over  the  aortic  cartilage.  In  his  article  in 
Pepper's  "System  of  Medicine,"  however,  vol.  iii.,  p. 
663,  he  says  that  the  systolic  murmur  may  be  heard 
at  any  point  over  the  base  of  the  heart  and  usually 
has  its  maximum  intensity  at  the  sternal  end  of  the 
right  second  cartilage  or  at  the  sternal  junction  of  the 

'  "  Medical  Diagnosis.  '  p    102 

'"  Medical  Diagnosis."  p    324 

'"Twentieth  Century  Practice.'   vol.  iv..  p.  251. 

■*  "  Practice  of  .Medicine."  p.  640 


ioo6 


MEDICAL    RECORD. 


[December  29,  1900 


third  rib  on  the  left  side;  CJibson  says'  that  '"  it  may 
be  laid  down  as  a  general  principle  that  the  maximum 
intensity  of  the  aortic  regurgitant  murmur  is  rarely 
found  in  the  conventional  aortic  area."  Gibson  cites 
a  case  with  autopsy  in  which  the  aortic  murmur  had 
the  same  location  as  in  the  case  which  I  have  here 
recorded. 

It  will  thus  be  seen  that  it  is  necessary  to  take  into 
account  all  other  physical  conditions,  as  well  as  the 
location  and  transmission  of  bruits,  in  reaching  a  con- 
clusion in  regard  to  the  precise  seat  of  a  cardiac  lesion. 
Another  point  of  interest  in  connection  with  the  heart 
is  the  very  marked  visible  impulse  seen  in  the  second 
left  interspace  near  the  sternum.  This  pulsation  is 
generally  regarded  as  due  to  a  morbid  expansion  of 
the  conus  arteriosus  and  is  therefore  present  in  disease 
of  the  right  side  of  the  heart.  It  was  a  perplexing 
phenomenon  in  this  case,  especially  when  taken  in 
conjunction  with  the  anomalous  location  of  the  great- 
est intensity  of  the  aortic  bruit.  I  did  not  have  an 
opportunity  of  examining  the  entire  heart,  but  it  is 
positively  stated  by  the  physician  in  the  case,  who  is 
an  intelligent  and  capable  man,  that  both  the  right 
auricle  and  ventricle  were  practically  normal.  The 
pulsation  was  probably  caused  in  the  manner  just  in- 
dicated; only  the  over-distention  was  due  to  disease, 
not  on  the  right  but  upon  the  left  side  of  the  heart, 
the  chain  of  causes  acting  through  the  pulmonary  cir- 
culation, the  evidence  of  which  was  furnished  by  one 
or  two  slight  hemorrhages,  or  there  may  have  been  a 
right-sided  incompetency  due  to  dilatation,  without 
valvular  disease. 

Reviewing  the  case  in  a  general  way  we  find  in  the 
first  place  the  evidence  of  a  general  infection  or  auto- 
intoxication, for  the  explanation  of  which  we  naturally 
turn  to  the  typhoid  or  gonorrhLeal  disease.  The  germs 
of  both  these  diseases  may  remain  in  the  organism  in 
a  latent  form  for  a  considerable  length  of  time.  The 
germs  of  typhoid  fever,  for  instance,  have  been  de- 
monstrated in  disease  processes  within  the  organism 
many  years  after  the  existence  of  the  acute  disease. 
The  protective  forces  of  the  organism  may  be  just 
sufficient  to  prevent  the  increase  of  an  organism  to  a 
degree  of  virulence,  but  not  strong  enough  to  bring 
about  its  destruction,  thus  constituting  the  condi- 
tions recently  described  by  Adami  under  the  title  of 
latent  infection  and  subinfection.  Such  conditions 
may  exist  for  a  long  time  without  manifest  symptoms 
and  may  finally  gain  the  mastery  of  the  organism,  the 
occurrence  of  which  is  heralded  by  general  malaise  and 
joint  pains,  as  in  this  case,  or  by  various  functional 
and  nutritional  disturbances.  The  cause  of  fever  must 
be  sought  in  the  reaction  of  the  organism  to  the  con- 
ditions just  described,  while  the  nephritis  shown  by 
the  existence  of  albumin  and  casts  in  the  urine  may 
be  regarded  as  the  result  of  the  irritant  action  of  the 
toxins  upon  these  organs  in  the  performance  of  the 
function  of  their  elimination.  The  further  disturb- 
ances of  the  chemical  processes  of  the  body,  which 
go  to  make  up  what  is  known  as  nutrition,  are  further 
evidenced  by  the  deposition  througli  the  blood  serum  of 
lime  salts  beneath  the  capsules  of  the  liver  and  spleen. 


Temperature  as  a  Sign  of  Unsuccessful  Nursing 
in  the  Infant.  —  During  the  first  four  or  five  days  the 
most  important  sign  of  insufiicient  food  is  a  rise  of 
temperature,  "inanition  fever,"  so-called.  The  range 
maybe  from  101°  to  102°  F.,or  in  extreme  cases  from 
104''  to  106"  F.  If  no  obvious  symptoms  of  illness 
are  present,  such  a  temperature  before  the  fiftii  day 
may  be  regarded  as  due  to  inadequate  nursing. — 
Sajous'  "Annual  and  Analytical  Cyclopa-dia  of  Prac- 
tical Medicine,"  vol.  v.,  p.  219. 

'    '  Diseases  of  the  Heart  and  Aorta,"  iSyS,  p.  496. 


THE  OPERATIVE  TREATMENT  OF  VARI- 
COSE VEINS  OF  THE  LOWER  EXTREMITIES.' 

Bv    W.    C.    BORDEN,    M.D.,    F.K..M.S., 

CAPTAIN,  MEDICAL  DKPARTMENT,  V.  S.  ARMV ;  PROFESSOR  OF  SURGICAL 
PATHOLOGY  AND  MILITARY  sl'RGERV,  GEORGETOWN  t'NIVERSlTV  SCHOOL 
OF  AlBUICINE,   \vashi.\»;ton,   D.   C. 

In  order  to  discuss  intelligently  the  surgical  treatment 
of  varicose  veins  of  the  lower  extremities,  certain  ana- 
tomical peculiarities  of  the  vessels  involved  and  the 
etiology  and  pathology  of  varix  have  to  be  considered, 
as  they  have  a  direct  bearing  upon  the  treatment  of 
this  disease. 

Anatomy  and  Histology  of  the  Saphenous  Veins. 
— In  considering  the  gross  and  microscopical  anatomy 
of  the  saphenous  veins,  it  will  be  necessary  to  con- 
sider only  such  details  as  relate  particularly  to  the 
cause  and  treatment  of  the  disease  under  discussion. 

The  internal  saphenous  vein  in  its  course  upward  in 
the  thigh  is  subcutaneous  from  its  commencement  to 
the  saphenous  opening,  and  is  supported  by  the  super- 
ficial fascia  only.  The  external  saphenous  is  sup)- 
ported  by  a  fold  of  aponeurosis  in  the  upper  part  of 
its  course,  while  the  deep  veins  are  surrounded  by 
compressing  muscles.  This  accounts  in  part  for  the 
great  susceptibility  of  the  internal  saphenous  and  its 
branches,  and  of  the  distal  portion  and  branches  of 
the  external  saphenous,  to  abnormal  dilatation;  for, 
the  superficial  fascia  being  extremely  yielding,  and 
the  veins  being  covered  only  by  it  and  the  elastic  skin 
and  subcutaneous  tissues,  but  little  support  is  afforded 
the  blood-vessels.  Under  the  influence  of  gravitation 
and  blood  pressure,  the  veins  contained  within  the 
superficial  fascia  dilate  more  readily,  and  can  less 
readily  overcome  the  blood  pressure  than  those  veins 
which  run  in  deep  aponeurotic  structures  and  between 
muscles. 

The  valves  of  the  veins  play  an  important  part  in 
the  etiology  of  varix;  and,  in  this  relation,  their  great 
variability  in  number,  position,  and  development  is  to 
be  noted.  In  the  external  saphenous  vein,  the  valves 
vary  in  number  from  seven  to  twentv.  One  of  these 
valves  is  generally  situated  just  at  the  termination  of 
the  vein,  and  another  just  at  the  outer  side  of  the 
cribriform  fascia,  but  both  of  these  valves  are  some- 
times imperfect  or  absent.  The  valves  of  the  external 
saphenous  vary  in  number  from  nine  to  thirteen.  In 
relation  to  the  back  blood  pressure  in  the  saphenous 
veins,  it  is  to  be  noted  that  the  femoral  vein  above  the 
entrance  of  the  saphenous  and  the  external  iliac  vein 
are  frequently,  and  the  superior  vena  cava  is  con- 
stantly, devoid  of  valves. 

Relative  to  operative  procedures,  it  is  important  to 
remember  that  the  saplienous  veins  are  sometimes 
double  and  that  the  double  veins  are  united  by  anas- 
tomotic branches. 

It  is  also  important  to  remember  that  an  anterior 
branch  which  ascends  the  thigh  over  the  position  of 
the  femoral  artery,  and  a  posterior  branch,  in  the  upper 
and  back  part  of  the  thigh,  which  opens  in  the  saphe- 
nous a  little  below  the  saphenous  opening,  are  liable  to 
enlaigement,  and  tiiat  they  give  off  frequent  anas- 
tomotic brandies  to  the  main  vein,  through  which 
communication  may  be  established  with  the  lower 
veins  of  the  limb  when  the  main  trunk  has  been 
ligated.  Another  very  important  branch  of  the  sa- 
plienous is  the  nearly  constant,  communicating  vein 
which  extends  from  the  external  saphenous  near  its 
termination,  upward  to  the  internal  saphenous.  In 
some  cases  the  external  saphenous  itself  takes  the 
course  of  this  branch  and  enters  into  the  internal  sa- 
phenous instead  of  the  popliteal  vein;  while  in  other 
cases  it  sometimes  ascends  the  back  of  the  thigh  to 
empty  into  the  sciatic  vein. 

'  Kead  l^efore  ihe  Medical  Society  of  the  District  of  Columbia, 
Washington,  U.  C. ,  October  3,  tgoo. 


December  29,  1900] 


MEDICAL    RECORD. 


1007 


These  anatomical  variations  are  important  to  bear 
in  mind  when  operating;  for,  if  these  blood  channels 
exist,  it  is  necessary  to  ligate  or  obliterate  them,  or 
the  collateral  circulation  set  up  through  them  will 
lead  to  a  recurrence  of  the  disease. 

The  most  important  histological  peculiarities  of  the 
saphenous  veins  are  that  tlie  intinia  is  well  developed 
and  the  media  is  particularly  thick  and  strong.  The 
media  is  more  developed  in  the  veins  of  the  lower  ex- 
tremities than  in  any  other  veins  of  the  body;  thus 
approximating  their  structure  closely  to  that  of  the 
arteries — a  structural  condition  due.  probably,  to  the 
necessity  for  overcoming  the  force  of  gravity  in  the 
blood  current  in  these  dependent  parts.  ']"he  media 
in  these  veins  consists  of  bundles  of  muscle  cells  con- 
centrically arranged  and  associated  with  lamellx-  of 
fibro-elaslic  connective  tissue.  The  muscle  cells  are 
quite  well  developed  and,  in  consequence,  these  veins 
have  considerable  contractile  power.  This  develop- 
ment of  the  media  enables  these  veins  to  empty  them- 
selves, as  they  frequently  must,  working  against  the 
force  of  gravity  and  without  that  support  and  inter- 
mittent pressure  from  surrounding  muscles  which  is 
given  to  the  deeper  veins. 

Longitudinal  section  of  a  vein  shows  that  the  wall 
of  a  vein  on  the  cardiac  side  of  the  valves  is  dilated 
into  a  pouch  or  sinus,  while  on  the  distal  side  of  the 
valve  the  wall  is  thinner  than  elsewhere.  Under  nor- 
mal conditions  the  blood  pressure  and  strain  are  less 
upon  this  weaker  part  of  the  vein  wall,  but  in  abnor- 
mal conditions  the  strain  may  be  so  great  throughout 
the  entire  vein  as  to  bring  undue  pressure  upon  the 
weak  wall  below  the  valve — a  point  of  importance  in 
the  development  of  varix. 

Etiology  of  Varix. — The  causes  of  varix  may  be 
divided  into  predisposing  and  exciting.  Of  the  pre- 
disposing causes,  weakness  of  the  vein,  either  congen- 
ital or  acciuired,  and  the  existence  of  a  small  number 
of  valves  within  it.  are  of  major  importance. 

SoborolT  has  demonstrated  that  the  veins  vary  in 
thickness  and  strength  in  different  individuals  from 
birth.  Under  normal  conditions  of  the  circulatory 
system,  a  perfect  balance  is  maintained  between  the 
blood  pressure  and  resistance  to  pressure  by  the  walls 
of  the  blood-vessels.  As  a  result  of  imperfect  devel- 
opment of  the  vessels,  either  from  hereditary  inllu- 
ences  (and  there  is  evidence  to  show  that  a  tendency 
to  weakness  of  the  veins  may  be  transmitted)  or  their 
malnutrition,  or  other  factors  deleterious  to  normal 
tissue  development,  the  vein  walls  may  be  weakened, 
the  normal  balance  between  the  contained  blood  and 
the  resisting  walls  may  be  disturbed,  and,  as  a  result, 
the  veins  may  yield  to  the  strain  from  the  blood  press- 
ure. 

When  a  vein  with  weak  walls  has  few  valves,  the 
tendency  to  varix  is  increased;  and  even  when  the 
vein  wall  is  of  average  strength,  if  the  valves  in  the 
vein  are  few  in  number,  this  latter  condition  alone 
may  act  as  a  predisposing  cause.  For,  with  few 
valves,  each  segment  of  the  vein  between  the  valves 
will  have  to  support  a  longer  column  of  blood  than 
would  be  the  case  if  the  valves  were  more  numerous 
and  nearer  together.  In  consequence,  the  strain  will 
be  greater  upon  both  the  valves  and  the  vein  wall,  and 
should  an  exciting  cause  occur,  the  vein  or  valve  will 
be  apt  to  yield  to  the  increased  blood  pressure.  These 
factors  of  inequality  in  vein  strength  and  inequality 
in  number  of  valves  undoubtedly  account  in  part  for 
the  asymmetry  of  varix.  Varices,  when  they  occur  in 
both  limbs,  are  rarely  symmetrical ;  and  cases  are  fre- 
quently seen  in  which  they  exist  in  one  limb  only.  As 
statistics  show  that  varix  has  no  predilection  for  either 
the  right  or  left  lower  extremity,  the  difference  in  vein 
strength  or  in  the  number  of  valves  must  account  for 
the  asymmetry  of  varix.  except  in  those  cases  in  which 


there  is  some  local  exciting  cause  which  is  present  in 
one  limb  only. 

Thinness  of  the  vein  wall  just  distal  to  (he  valves 
is,  probably,  also  an  important  predisposing  cause. 
Under  ordinary  conditions  the  strain  upon  the  vein 
from  the  internal  blood  pressure  is  least  just  below 
the  \alves;  but,  when  the  venous  flow  is  obstructed 
and  the  vein  becomes  fully  distended  with  blood, 
abnormal  pressure  will  be  brought  to  bear  upon  the 
vein  in  this  weak  place.  If  such  pressure  is  long 
continued  or  frequently  repeated,  the  vein  will  dilate 
at  this  point,  and  in  doing  so  will  pull  upon  the  valves 
and  flatten  them  out,  or  separate  them.  As  a  result, 
the  valves  will  become  incompetent  and  the  blood 
column  will  be  extended  to  the  next  proximally  situ- 
ated valve,  so  increasing  the  height  of  the  blood  col- 
umn, the  internal  pressure  in  the  vein,  and  the  likeli- 
hood to  furtiier  extension.  In  this  way  the  entire 
length  of  a  vein  may  become  varicose,  unless  the 
process  is  stopped  by  sufficient  strength  of  the  vein 
wall,  or  removal  of  the  internal  pressure  by  passage  of 
the  blood  through  anastomosing  channels.  Or,  the 
process  may  occur  in  different  parts  of  the  same  vein 
or  in  different  veins,  thus  producing  localized  varices. 

When  the  process  continues  until  the  whole  length 
of  a  vein  is  involved,  the  most  pronounced  type  of 
varix  is  produced.  It  is  this  process  of  vein  dilata- 
tion and  valve  separation  that  explains  why  most 
varices  proceed  in  a  centripetal  dirtclion. 

Verneuil  first  described  the  existence  of  varices  of 
the  deep  veins  of  the  lower  extremities,  and  their  ex- 
istence has  been  noted  by  other  observers,  notably  by 
Schwartz  and  Agnew.  \'erneuil  was  so  impressed  by 
the  occurrence  of  these  deep  varices  that  he  formu- 
lated: '■  that  far  from  being  rare,  deep  varices  are 
more  common  than  subcutaneous  varices,"  and  "the 
primitive  state  of  phlebismus  is  in  the  deep  veins." 

While  the  testimony  of  numerous  oi)servers  puts  the 
occasional  existence  of  varices  of  the  deep  veins  be- 
yond doubt,  there  is  evidence  that  they  do  not  exist  in 
all  cases,  and,  when  they  do  occur,  that  they  are  most 
commonly  associated  with  the  most  pronounced  types 
of  superficial  varix.  When  the  factors  causative  of 
varix  are  excessive,  it  is  reasonable  to  suppose  that 
varix  will  be  produced  in  both  the  superficial  and  the 
deep  veins.  The  deep  veins,  being  supported  by  the 
deep  fascia  and  subject  to  intermittent  compression 
by  the  surrounding  muscles,  are  in  a  much  more  favor- 
able position  to  withstand  the  effects  of  the  exciting 
causes  of  varix  than  are  the  superficial  veins  which 
have  the  support  of  the  skin  and  superficial  fascia 
only.  Also,  it  is  known  clinically  that  superficial 
varices  occur  with  no  evidence  of  implication  of  the 
deep  veins;  and  surgical  interference  often  gives  com- 
plete cure  in  these  cases,  which  would  not  be  the  case 
if  the  deep  veins  were  also  involved.  For  these  rea- 
sons Verneuil's  conclusion  that  superficial  varices  are 
always  accompanied  by  deep  ones,  and  that  superficial 
varices  always  originate  in  the  deep  veins,  cannot  be 
considered  correct  for  the  large  majority  of  cases. 

The  remaining  predisposing  causes  of  varix  are  sex 
and  age.  The  factor  of  age  is  closely  connected  with 
those  changes  in  the  walls  of  the  blood-vessels  which 
tend  toward  increased  weakness  as  age  advances. 
The  factor  of  sex  enters  in  that  women  are  more  liable 
to  varix  through  pressure  of  the  gravid  uterus  upon 
the  iliac  veins. 

The  exciting  causes  of  varix  are  physiological  or 
pathological  conditions  which  produce  back  pressure 
in  the  veins  by  obstructing  the  venous  flow. 

Organic  diseases  of  the  heart,  by  causing  back  press- 
ure in  the  vena  cava  and  its  branches,  may  be  ex- 
citive;  or  back  pressure  may  be  produced  by  pressure 
upon  the  great  veins  in  the  body  by  the  pregnant 
uterus;    by  ovarian  or  other  tumors;    by  aneurisms  of 


ioo8 


MEDICAL    RECORD. 


[December  29,  1900 


the  aorta ;  by  fecal  accumulations  in  tiie  colon,  and  so 
forth;  or  back  pressure  may  be  due  to  pressure  from  a 
tumor  in  the  groin  or  other  part  of  the  limb;  or  con- 
strictions by  artificial  appliances.  An  excellent  ex- 
ample of  this  latter  cause  is  sometimes  seen  in  women 
who  have  worn  tight  garters.  In  these  cases  varicosi 
ties  are  fretjuently  very  pronounced  below  the  line  of 
constriction  by  the  garter,  while  above  it  the  veins 
may  be  perfectly  normal.  These  cases  conclusively 
prove  that  varix  may  be  produced  by  back  pressure  in 
the  external  veins,  even  when  there  is  no  predisposing 
cause;  so  disproving  the  conclusions  of  Van  Lesser, 
who  attempted  to  produce  varicosities  in  animals  by 
increasing  the  blood  pressure  and,  failing  to  do  so, 
assumed  that  increased  blood  pressure  alone  would 
not  cause  varix;  and,  in  consequence,  concluded  that 
the  formation  of  varix  was  analogous  to  the  growth  of 
tumors. 

Trades  and  occupations  act  as  exciting  causes  in 
persons  predisposed  to  the  diseases,  particularly  those 
occupations  which  necessitate  the  workers  remaining 
long  in  the  erect  position,  especially  in  overheated 
rooms,  where  tissue  relaxation  is  favored. 

Pathological  Anatomy.  —  The  first  pathological 
condition  in  varix  is  a  localized  dilatation  of  the 
vein.  This  dilatation  may  be  symmetrical  or  may 
be  confined  to  one  side  of  the  vein  only.  Weakness 
of  the  vein  is  generally  at  first  most  pronounced  in 
the  tunica  media,  the  muscular  fibres  of  which  lose 
their  normal  tone  and  contractile  power.  At  the 
same  time,  from  the  continued  distention  of  the  vein, 
the  elastic  fibres  of  the  connective  tissues  become 
stretched,  and  all  three  of  the  coats  of  the  vein  lose 
their  contractility.  In  consequence,  the  vein  remains 
permanently  dilated,  and  blood  stasis  occurs.  As  a 
result  of  the  blood  stasis  and  the  increased  blood 
pressure,  leucocytes  pass  out  into  the  surrounding  tis- 
sue in  abnormal  numbers,  and  transudation  of  blood  se- 
rum into  the  surrounding  tissues  is  increased.  Through 
these  pathological  processes,  the  nutrition  of  the  vein 
is  progressively  interfered  with  as  these  factors  become 
more  pronounced. 

The  passive  congestion  and  the  tissue  malnutrition 
produce  a  condition  of  chronic  inflammation  with  its 
accompanying  connective-tissue  formation.  This 
chronic  inflammatory  condition  affects  the  intinia  par- 
ticularly, so  that  it  frequently  becomes  greatly  thick- 
ened, while  the  media,  from  destruction  of  the  muscle 
cells,  may  become  much  thinner  than  normal.  The 
adventitia  may  be  affected  in  a  similar  way,  and  the 
process  may  continue  so  far  that  the  intima  may  even 
bulge  through  the  two  outer  coats,  forming  purse-like 
projections  on  the  side  of  the  vein.  Even  when  these 
changes  do  not  progress  so  far  as  this,  the  conditions 
of  increased  blood  pressure,  destruction  of  muscle 
cells  in  the  media,  and  stretching  of  all  the  coats  of 
the  vein  lead  to  local  dilatations  of  the  vessel  wall. 
From  the  resulting  inequalities  of  strength,  lateral  de- 
viations in  the  course  of  the  vessel  are  produced, 
which,  with  continuation  of  the  trouble,  may  lead  to 
marked  convolutions  in  the  course  of  the  vein.  With 
the  dilatation  of  a  vein  the  valves  become  incompe- 
tent, fall  against  the  walls  of  the  vessels,  undergo 
atrophy,  and  may  even  become  wholly  obliterated. 

As  a  result  of  the  increased  exudation  of  serum  in 
the  perivascular  connective  tissue  and  lymph  spaces, 
the  lymph  channels  are  unable  to  carry  away  the  ex- 
cessive exudate  and  itdema  occurs  in  the  neighbor- 
hood of  the  varix.  This  osdematous  condition,  by 
pressure  upon  the  arterial  capillaries  and  venules, 
may  produce  such  disturbance  of  nutrition  in  the  sur- 
rounding tissues  as  to  cause  eczema,  ulceration, 
pseudo-elephantiasis,  pigmentation,  etc. 

From  these  observations  it  will  be  seen  that  varix 
may  arise  either  from   local  insufficiency  of  a  vein,  or 


from  excessive  blood  pressure  within  a  vein,  or  from 
a  combination  of  these  factors.  It  will  also  be  seen 
that  varix  is  at  the  beginning  generally  localized  and 
confined  to  one  or  several  parts  of  a  vein,  that  it  is 
usually  a  progressive  disease,  and  that  the  diseased 
condition  is  apt  to  continue  and  extend  until  the  whole 
vein  and  its  branches  may  be  involved.  These  facts 
are  of  importance  from  a  standpoint  of  treatment,  in 
that,  considering  the  tendency  of  varix  to  increase,  the 
necessity  for  interference  in  early  stages  of  the  trouble 
becomes  evident. 

Operative  Treatment. —  In  considering  the  opera- 
tive treatment  of  varix,  it  is  presupposed  that  it  will 
be  attempted  only  in  tiiose  cases  in  which  the  diseased 
condition  is  primarily  in  the  vein  and  is  not  due  to 
central  causes,  such  as  heart  disease,  pressure  by 
tumors,  or  like  etiological  factors. 

Surgical  interference  in  varix  was  so  disastrous  in 
pre-antiseptic  days  that  traditionary  timidity  still  ob- 
tains to  a  large  extent,  and  has  been  a  potent  factor  in 
preventing  the  more  general  use  of  radical  methods. 
With  the  safeguards  of  modern  aseptic  methods,  this 
attitude  should  no  longer  be  maintained.  In  fact,  the 
milder  forms  of  the  disease,  in  which  palliative  treat- 
ment is  ordinarily  the  only  measure  thought  of,  are 
frequently  the  very  ones  in  which  operative  treatment 
should  be  adopted.  The  course  of  the  disease  is  so 
generally  progressive  that  this  characteristic  of  the 
trouble  is  one  of  the  greatest  reasons  for  early  surgical 
interference.  By  doing  away  with  the  trouble  before 
it  has  become  excessive,  extension  of  the  disease  may 
be  prevented,  as  well  as  the  necessity  for  large  opera- 
tions in  the  future. 

Considering  the  pathological  condition  of  a  vari- 
cose vein  and  the  malnutrition  of  the  tissues  surround- 
ing it,  the  conclusion  is  reached  that  such  a  vein  is 
not  only  physiologically  useless  but  has  a  continued 
and  increasing  ill-effect  upon  the  parts  with  which  it 
is  in  relation.  Retention  of  such  a  blood-vessel  under 
the  supposition  that  it  is  still  functionally  useful  is 
an  error  productive  of  continued  and  probably  in- 
creased trouble  to  the  patient.  Experience  has  de- 
monstrated that  the  obliteration  of  one  or  both  of  the 
saphenous  veins  does  not  interfere  with  proper  nutri- 
tion of  the  lower  limbs —the  other  superficial  and  deep 
veins  of  the  part  being  sufficient  to  carry  on  the  cir- 
culation. U'hen,  therefore,  a  vessel  bucomes  the  seat 
of  varix,  that  vessel  should  be  removed  or  obliterated 
as  a  blood  channel.  When  this  is  done,  collateral 
circulation  is  established  by  means  of  the  adjoining 
veins;  and,  by  ridding  the  part  of  the  diseased  blood 
channel  with  its  greatly  increased  blood  pressure,  blood 
stasis,  with  its  resulting  cedema,  is  done  away  with. 
With  removal  of  the  cedema,  and  consequent  pressure 
upon  the  capillaries,  the  metabolic  cell  functions  of 
the  part  may  be  normally  resumed. 

Relative  to  the  surgical  means  employed  to  accom- 
plish these  results,  all  modern,  approved  methods  of 
surgical  intervention  resolve  themselves  into  two 
main  classes:  (<?)  Those  procedures  which  aim  to 
prevent  further  dilatation,  and  produce  contraction  of 
the  vein  by  occluding  it  proximally,  as  in  the  opera- 
tion of  Remi  or  Schode;  (/')  those  which  aim  to  oblit- 
erate the  vein  by  multiple  ligation  or  total  removal. 

Method  by  proximal  occlusion  (single  ligation). 
The  first  recorded  operations  by  this  method  were  those 
of  Evard  Holm,  who,  in  1799,  reported  the  ligation  of 
the  saphenous  just  below  tlie  knee  joint  in  twelve 
cases.  This  method  was  afterward  occasionally  prac- 
tised; but,  like  other  operative  procedures  previous  to 
the  discovery  of  aseptic  methods,  proved  so  disastrous 
from  resulting  phlebitis  and  py;vmia  that  it  was  sel- 
dom done. 

After  the  discovery  of  aseptic  methods,  single  liga- 
tion  of   the   saphenous   veins   was   first   brought    into 


December  29,  1900] 


MEDICAL    RECORD 


1009 


prominence  by  Trendelenburg,  who,  in  1890-91,  advo- 
cated high  ligation  of  the  internal  saphenous  for  ad- 
vanced varix  of  that  vein  and  its  branches.  It  is 
interesting  to  note  that  a  similar  operation  was  advo- 
cated by  Remi,  of  Venice,  in  1825,  and  that  he,  in 
1848,  published  a  report  of  thirty-seven  cases  treated 
by  high  ligation  of  the  internal  saphenous  with  four- 
teen cures,  thirteen  cases  improved,  and  but  two  deaths 
—a  most  excellent  showing  for  those  days  of  septic 
infection. 

Remi.  in  advocating  this  operation,  brought  forward 
the  theory  that  varix  of  the  lower  extremity  is  due  to 
incompetence  of  the  valves  of  the  main  saphenous 
vein;  that,  in  consecpience,  the  vein  becomes  tilled 
with  blood  from  above  downward,  distending  it  and 
producing  the  pathological  changes  and  appearances 
present  in  this  disease.  In  support  of  this  theory,  he 
showed  that  elevation  of  the  limb  caused  the  enlarged 
vein  to  empty  itself,  and  that  with  the  limb  elevated, 
if  the  vein  was  compressed  and  the  limb  lowered,  the 
vein  would  fill  from  above  downward.  He  also  showed 
that,  if  the  \ein  was  wounded  in  advanced  cases  of 
this  touble,  tlie  blood  (lowed  in  larger  quantity  from 
the  proximal  than  from  tlie  distal  cut  end,  and  ad- 
duced this  as  further  evidence  of  the  fact  that  the 
vein  is  filled  with  blood  from  above  downward.  He 
stated  :  ■'  We  considered  ourselves  even  then  (  1825  )  in 
a  condition  to  prove  both  by  reasoning  and  facts  that 
the  cause  of  varix  in  the  lower  extremity  consists  in 
an  inverse  movement  of  the  blood  in  the  great  saphena 
which  gravitates  in  a  column  from  above  to  below, 
from  centre  to  extremity,  that  hence  the  valves  are 
powerless  and  the  venous  tunica;  are  in  various  ways 
obliterated.''  With  this  theory  as  a  guide,  Remi 
ligated  the  internal  saphenous  in  the  middle  of  the 
thigh  in  order  to  obliterate  the  vein  at  that  point  and 
so  relieve  the  distal  part  of  the  vein  from  the  pressure 
of  the  blood  column;  holding  that,  with  the  removal 
of  this  pressure,  the  dilated  vein  below  the  ligature 
would  regain  its  normal  volume  and  elasticity. 

Trendelenburg,  in  advocating  the  same  operation 
forty-two  )ears  later,  brought  forward  arguments  iden- 
tical with  those  of  Remi  without  mentioning  the  pub- 
lication or  work  of  the  latter,  apparently  not  having 
seen  the  earlier  work  of  the  Venetian  surgeon.  Tren- 
delenburg's paper  is  so  like  Remi'sas  to  appear  almost 
like  an  amplified  translation.  There  is  some  slight 
difference,  though  both  writers  are  alike  in  statement 
of  clinical  facts  and  argue  alike  as  to  the  indications 
for  the  operation  which  they  advocate.  The  differ- 
ence in  the  two  papers  is,  that  while  Remi  makes  no 
mention  of  minor  varicosities,  referring  only  ;o  the 
pronounced  variety  in  which  the  main  trunk  of  the 
saphenous  is  involved,  Trendelenburg  recognizes  but 
does  not  discuss  the  treatment  of  the  smaller  varices. 

Trendelenburg  opens  his  paper  by  stating  that  vari- 
cose veins  of  the  leg  may  be  divided  into  two  groups, 
and  says:  "There  are  cases  in  which  the  varicose  de- 
generation is  restricted  to  the  branches  of  the  vena 
sapiiena  magna,  while  the  trunk  does  not  show  any 
perceptible  change,  and  again  others  in  which  the 
trunk  of  the  saphena  is  likewise  strongly  dilated 
and  varicosely  degenerated.  Only  the  last-mentioned 
group,  the  cases  of  simultaneous  varicose  dilation  of 
the  branches  and  trunk  of  the  saphena,  will  receive 
attention."  Following  this.  Trendelenburg  confines 
himself  to  the  cases  in  which  the  main  saphenous 
trunk  is  involved,  and  advocates  high  ligation  of  that 
vessel  for  the  same  reasons  that  were  brought  forward 
by  Remi. 

With  the  cardinal  indication  for  high  ligation  in 
mind,  namely,  complete  involvement  of  the  main  trunk 
of  the  saphenous,  the  operation  of  high  ligation  may 
be  resorted  to  in  certain  selected  cases. 

When  a  varix  has  extended  so  far  as  to  involve  the 


entire  trunk  of  the  saphenous,  the  dilatation  of  the 
vein  and  the  absence  or  incompetency  of  the  valves 
cause  the  vessel  to  support  a  column  of  blood  extend- 
ing from  the  lowest  dilatation  to  the  heart.  In  such 
cases  high  ligation,  by  removing  the  back  pressure^  will 
in  some  instances  do  good,  and  numerous  cures,  both 
of  the  varix  and  accompanying  ulcers,  have  been  re- 
ported as  a  result  of  this  procedure.  In  doing  this 
operation,  a  short  length  of  the  vein  should  be  excised 
between  two  ligatures;  as  simple  ligation  may  be 
eventually  followed  by  re-establishment  of  the  patency 
of  the  vessel,  while  Minkewitsch  has  shown  that  no 
restoration  of  a  vessel  can  occur  after  excision  of  a 
portion  of  it. 

Unfortunately,  relapse  occurs  in  some  cases  from 
the  free  collateral  circulation,  and,  to  obviate  this, 
Schede  devised  a  more  radical  operation,  the  object  of 
which  was  to  occlude  all  the  subcutaneous  veins  at  the 
same  level.  His  operation  consists  in  making  a  cir- 
cular incision  about  the  leg  just  below  the  knee  down 
to  the  fascia  covering  the  muscles,  and  ligating  tlie  cut 
ends  of  all  vessels  above  and  below.  The  superficial 
nerves  are  severed,  but  the  internal  sapiienous  nerve 
may  be  saved  by  careful  dissection.  Cures  have  been 
reported;  followed,  however,  in  many  cases  by  later 
breaking  down  of  healed  ulcers  and  persistent  local 
ana.-sthesia  from  the  severed  nerves.  In  view  of  the 
etiology  and  pathology  of  varix,  it  does  not  seem  to 
the  writer  that  Schede's  operation  can  be  considered  a 
proper  procedure  in  any  case,  as  the  damage  it  does 
to  the  nerves,  and  the  uncertaintj'  of  cure,  makes  it  of 
doubtful  propriety. 

The  operation  of  high  ligation  of  the  saphenous  can 
well  be  employed  in  a  certain  number  of  cases,  namely, 
those  in  which  the  trunk  of  the  saphenous  is  dilated 
throughout,  or  in  those  in  which  the  varix  is  too  exten- 
sive to  remove  entire,  or  in  which  the  condition  of  the 
patient  is  such  as  to  contraindicate  an  extensive  oper- 
ation. The  operation  is  a  simple  one,  and  does  not 
prevent  recourse  to  more  extensive  operations  should 
they  become  necessary. 

Methods  by  obliteration  of  the  vein  (multiple  liga- 
tion and  excision).  Excision.  Bearing  in  mind  the 
fact  that  a  varicose  vein  is  in  a  pathological  condition 
which  makes  it  a  source  of  continued  trouble,  it  is  the 
opinion  of  the  writer  that  its  entire  obliteration  or  re- 
moval is  indicated  in  preference  to  all  other  surgical 
procedures.  P'ortunately,  the  great  majority  of  cases 
are  suitable  for  this  treatment.  This  is  particularly 
the  case  in  those  instances  in  which  the  varices  are  local- 
ized; namely,  in  which  only  a  portion  of  a  vein  is  in- 
volved, or  in  which  a  vein  or  its  branches  are  involved, 
in  different  parts,  the  intervening  portions  being  nor- 
mal. 

A  small  varix  will  frequently  produce  great  discom- 
fort and  almost  incapacitate  for  manual  labor  through 
swelling  of  the  limb,  pain,  soreness,  and  a  feeling  of 
intense  fatigue  in  the  part  affected.  When  such  cases 
are  treated  by  excision  of  the  diseased  vein,  the  cure  is 
often  complete,  particularly  if  the  case  is  operated 
upon  early — the  completeness  of  the  cure  conclusively 
negativing  the  assertion  that  superficial  varix  is  always 
preceded  or  accompanied  by  varix  of  the  deep  veins. 
The  writer  has  had  a  number  of  such  cases,  and  from 
them  is  fully  satisfied  that  removal  of  the  vein  should 
be  practised  rather  than  palliative  treatment  in  all 
localized  varices  in  which  the  consent  of  the  patient 
can  be  secured. 

'i'he  removal  of  the  more  extensive  varices  by  exci- 
sion is  to  be  recommended  in  all  cases  in  which  the  con- 
dition of  the  patient  will  warrant  it.  The  entire  in- 
ternal saphenous  has  been  repeatedly  removed  with 
brilliant  result.  The  writer,  in  the  case  of  a  soldier 
who  was  totally  incapacitated  from  military  duty  on 
account  of  a  varix  involving  the  entire  internal  sa- 


lOIO 


MEDICAL    RECORD. 


[December  29,  igcxj 


phenous  and  several  of  its  branches,  excised  the  vessel 
from  tlie  saphenous  opening  to  a  point  midway  of  the 
leg,  and  either  removed  the  varicose  branches  or 
placed  multiple  ligations  upon  them.  Recovery  was 
complete,  and  eight  months  later  the  soldier  reported 
that  he  was  doing  full  duty  with  no  inconvenience. 

In  this,  as  in  all  operations  on  the  veins,  measures 
of  strictest  asepsis  should  be  employed,  and  ulcers,  if 
present,  be  thoroughly  cauterized  with  the  Paquelin 
cautery.  E.xposure  of  the  vein  is  facilitated  if  the 
limb  is  depressed  and  constricted  by  an  elastic  bandage 
placed  pro.ximally  to  the  enlarged  vein.  By  begin- 
ning at  tiie  proximal  end  of  the  varicose  portion  and 
dissection  toward  the  distal  part,  ligating  the  branches 
as  they  are  reached,  the  vein  is  kept  distended  with 
blood,  and  its  course  and  condition  can  be  easily  de- 
termined.    If   emptied,   it   contracts,  and   it  then  be- 


only  requiring  care  as  to  asepsis  and  in  so  placing 
the  ligatures  as  not  to  include  the  nerve  wliich  ac- 
companies the  vessel.  The  operation  is  not  so  grave 
as  complete  excision,  and  is,  therefore,  indicated  in 
weak  individuals;  but,  if  properly  done,  it  is  more 
tedious  than  excision. 

Conclusions. — From  the  foregoing  it  will  be  seen 
that  the  writer,  arguing  from  the  pathological  condi- 
tion of  a  varicose  vein,  favors  complete  excision  in  all 
cases  in  which  no  contraindications  are  present;  that, 
following  this,  multiple  ligation,  or  excision  combined 
with  multiple  ligation,  is  advocated;  and,  in  cases 
in  which  these  measures  are  contraindicated  and  the 
entire  saphenous  is  dilated,  trial  of  the  high  ligation 
of  Remi  and  Trendelenburg. 

Also,  arguing  from  the  etiology,  pathology,  and 
proneness    of   varix   to    extend,  the   writer   advocates 


Combined  excision  and  multiple  ligaliun.     The  photograph  shows  the  condition  of  the  part  on  the  ninth  day  when  the  first  dressing  was  removed.     U'he  sl<in 

was  united  with  interrupted  sutures  of  horsehair.     Cure  was  complete  and  permanent. 


comes  difficult  to  determine  where  the  varicose  part  of 
the  vein  ends  and  the  normal  begins. 

Multiple  ligation.  Multiple  ligation  is  to  be  re- 
sorted to  in  those  cases  in  wliicli  the  varix  is  so  exten- 
sive as  to  render  excision  of  the  entire  varix  impossible. 
or  in  which  the  condition  of  the  patient  is  such  as  not 
to  allow  the  more  extensive  incision  required  for  exci- 
sion. In  such  cases  multiple  ligation,  or  multiple 
ligation  combined  with  excision,  is  to  be  advocated. 

In  the  operation  of  multiple  ligation  it  is  of  cardi- 
nal importance  to  apply  the  ligatures  near  together,  at 
most  not  more  than  two  inches  apart.  As  early  as 
1772  Hewson  demonstrated  that  blood  does  not  coag- 
ulate in  a  normal  blood-vessel,  and  liriicke  and  others 
have  shown  that  the  blood  will  remain  fluid  in  a  blood- 
vessel so  long  as  the  intima  is  not  injured  by  mechan- 
ical or  pathological  processes.  When,  therefore,  a 
vein  is  ligated  antiseptically,  the  clot  produced  by 
mechanical  injury  to  the  intima  in  no  case  extends 
beyond  the  first  anastomotic  branch.  In  consequence, 
if  ligatures  are  not  placed  so  closely  together  as  to 
occlude  every  anastomotic  branch,  the  vein  will  re- 
main filled  with  blood  and  the  varix  will  not  be  cured. 

In  pre-antiseptic  days  the  surgeon  in  operating  upon 
varix  was  aided  by  septic  infection,  for  the  resulting 
endophlebitis  extended  along  the  vein  and  caused  in- 
llammatory  changes  in  the  intima  which  led  to  throm- 
bosis and  obliterative  piilebitis.  In  aseptic  ligation 
these  changes  do  not  occur,  and  obliteration  of  the 
\ein  can  be  accomplished  only  by  placing  the  liga- 
tures so  close  together  as  entirely  to  obliterate  the 
vein  as  a  blood  channel. 

The  operation  of  multiple  ligation  is  a  simple  one. 


early  operation.  The  tendency  is  too  much  toward 
palliative  treatment  in  this  disease,  especially  in  its 
early  stages.  Under  palliative  treatment,  the  disease 
too  often  extends  until  serious  complications  occur,  or 
operations  of  magnitude  are  demanded.  By  removing 
the  diseased  vein  when  the  diseased  area  is  small  and 
localized,  the  varix  may  be  permanently  cured.  If 
more  early  operations  were  done  we  would  see  fewer 
extreme  cases  in  which  the  whole  or  a  large  part  of 
the  saphenous  and  its  branches  are  involved. 


The  Curability  of  Inebriety  by  Medical  Treat- 
ment.— T.  1).  Crothers  believes  that  when  inebrity 
shall  be  more  generally  studied  and  treated  as  a  dis- 
ease by  the  profession,  a  degree  of  curability  will  be 
obtained  far  beyond  any  present  expectation.  The 
continued  or  occasional  excessive  use  of  spirits  to  in- 
toxication is  not  the  disease,  but  is  a  symptom  of 
some  central  irritation  and  exhaustion;  also  of  poison- 
ing and  starvation.  Many  of  these  cases  are  self-lim- 
ited, and  follow  a  certain  course,  dying  away  after  a 
time.  'I'he  subsidence  of  the  drink  symptom  by  the 
removal  of  the  exciting  causes  antl  building  up  tiie 
system  to  greater  vigor  and  health  is  the  only  rational 
treatment.  The  highest  medical  judgment  will  be 
needed  to  determine  the  exact  condition  in  each  case, 
and  the  possible  range  of  remedies  required — not  any 
one  drug  or  combination  of  drugs,  not  so-called  moral 
remedies,  not  appeals  to  the  will  power,  but  a  clear, 
broad,  scientific  application  of  every  rational  means 
and  measure  demanded. — S/.  Louis  Medical  Rerieui, 
October  13,  1900. 


December  29,  1900] 


MEDICAL    RECORD. 


lOI  I 


TWO  UXUSUAL  CASKS  OF  APHASIA,  WITH 
SPECIAL  REFKRENCE  TO  THE  SO-CALLED 
NAMING    CENTRE.' 

By   GR.K.ME    M.    HAMMOND,    I.I..Ii.,    M.D.. 

NKW    VOKk. 

At  the  meeting  of  the  American  Neurological  .Asso- 
ciation in  1899  I  reported  a  case  of  aphasia  which 
seemed  to  me,  at  that  time,  to  be  a  most  valuable  con- 
tribution to  the  subject  of  cerebral  localization.  It  was 
one  in  which  a  small  circumscribed  lesion  in  the  pos- 
terior part  of  the  superior  temporal  convolution  was 
accompanied  by  an  absolute  inability  for  naming  per- 
sons and  tilings.  In  other  words,  it  seemed  to  indi- 
cate the  topographical  position  of  the  "  naming  centre." 

A  naming  centre  existed  only  as  a  proposition  ad- 
vanced by  Broadbent"  until  Mills"  reported  a  case 
which  seemed  to  remove  the  naming  centre  from  its 
theoretical  jjosition  to  one  established  upon  a  firm 
foundation  of  fact.  In  Mills'  case,  in  whicii  absolute 
anomia  was  the  most  prominent  feature,  a  tumor  was 
discovered  post  mortem  in  the  inferior  temporal  con- 
volution. Mills  therefore  concluded,  and  his  conclu- 
sion seemed  inevitable,  that  there  is  a  distinct  naming 
centre,  and  that  it  is  situated  in  the  inferior  temporal 
convolution. 

In  my  ca.se  the  anomia  was  as  prominent  a  symptom 
as  in  Mills'  case,  but  the  lesion,  plainly  brought  to 
view  by  a  surgical  operation,  was  found  to  be  in  the 
posterior  third  of  the  superior  temporal  convolution, 
in  no  wise  corresponding  topographically  to  the  lesion 
observed  by  .Mills. 

I  attempted  to  harmonize  these  two  cases,  which 
seemed  so  hopelessly  antagonistic  from  a  localization 
point  of  view,  by  the  following  theory:'  "The  first 
cells  in  the  higher  auditory  centre  which  begin  to  reg- 
ister the  memory  of  words  heard,  register  the  memory 
of  names.  The  first  words  the  infant  learns  are  names 
such  as  '  papa,'  '  mamma,'  '  bow-wow,'  etc.  These, 
with  other  simple  names,  for  a  considerable  period  of 
time  constitute  the  child's  entire  vocabulary. 

"  Can  it  be  claimed  that  all  of  the  cells  in  the  higher 
auditory  centre  in  all  infants  develop  simultaneously 
and  with  the  same  degree  of  perfection,  and  that  there- 
fore the  cells  in  a  particular  and  preordained  part  of 
the  auditory  word  centre  are  ready  and  prepared  for 
the  reception  of  name  sounds  and  the  memorizing  of 
those  words?  Is  it  not  more  probable,  yes  even  cer- 
tain, that  some  cells  are  in  a  higher  state  of  develop- 
ment than  others,  and  that  the  cells  which  are  most 
highly  organized  are  the  ones  which  will  naturally 
register  and  retain  the  memories  of  names?  These 
cells  of  superior  development  may  be  situated  in  any 
part  of  the  higher  auditory  centre.  If  this  is  the  case 
the  location  of  the  group  of  cells  in  which  name 
memories  are  stored,  while  being  an  integral  part  of 
the  higher  auditory  centre,  might  differ  widely  in 
location  in  different  individuals."  Put  in  the  light 
of  the  subsequent  study  of  both  Mills'  case  and  my 
own,  and  of  another  one  of  my  own  which  1  will  pre- 
sent to  you  in  a  moment,  it  would  seem  that  this 
theory,  while  possibly  true  in  the  main,  is  not  neces- 
sary to  explain  the  condition  of  anomia  in  limited 
lesions  of  the  speech  area.  In  order  to  make  my 
remarks  more  comprehensive  it  will  be  necessary 
brieHy  to  refer  to  the  report  of  this  case  already'  pub- 
lished, otherwise  the  subsequent  developments  ob- 
served would  lose  their  relevancy. 

The  patient,  who  is  now  brought  before  you  for  your 

'  Read  before  the  New  York  Neurological  Society,  Febrnarj', 
1900. 

'Med.-Chir.  Trans.,  1S72,  vol.  Iv.,  and  1877-S. 

'Journal  Xerv.  and  Mental  Iiis. ,  vol.  .\.\.,  1S95. 

^ilammond:  "  .\  Case  of  Subdural  Hemorrhage,  etc."  Trans. 
.\mer.   Neurol.  Assn..  1S99. 


inspection,  is  twenty-five  years  old,  of  fair  education, 
and  a  clerk  by  occupation.  He  denies  syphilis,  and 
there  is  no  evidence  of  his  having  had  that  disease. 
He  admits  that  he  drinks  alcoholic  liquors,  but  says 
he  seldom  does  so  to  excess.  His  physician  said  he 
had  observed  albumin  and  granular  casts  in  the  urine 
for  several  months  previous  to  his  injury.  He  was 
apparently  in  good  health  at  the  time  he  was  hurt. 
During  a  fight  he  was  knocked  down  by  being  struck 
over  the  left  temporal  bone  with  a  loaded  whip-handle. 
He  was  not  rendered  unconscious.  He  did  not  have 
any  difficulty  in  conversing  for  several  hours  after- 
ward. At  the  end  of  that  period  he  was  suddenly 
seized  with  a  general  convulsion,  which  was  severe 
and  prolonged.  When  he  regained  consciousness  it 
was  observed  he  had  completely  lost  the  ability  to 
name  objects  and  persons. 

He  was  brought  to  the  Post-Graduate  Hospital  a 
few  days  later,  when  1  first  saw  him.  I  had  him  un- 
der observation  for  several  days,  during  which  time  his 
symptoms  were  carefully  observed  both  by  myself  and 
by 'my  colleague,  Dr.  Joseph  Collins,  who  rendered 
me  valuable  assistance. 

There  were  no  disorders  of  taste,  smell,  vision,  or 
hearing.  There  were  no  motor  paralyses,  and  no  dis- 
turbance of  sensibility.  There  was  no  motor  aphasia. 
All  the  words  he  could  say  were  pronounced  distinctly 
and  fluently.  There  was  no  word  blindness.  All 
simple  directions  and  orders  written  out  for  him  were 
promptly  understood  and  executed.  He  could  talk 
and  voluntarily  say  almost  all  words  except  the  names 
of  objects  and  persons.  He  readily  recognized  all 
objects  he  saw,  and  indicated  by  appropriate  gestures 
that  he  understood  what  they  were,  and  what  they  were 
used  for,  but  he  could  not  say  the  name  of  a  single 
one,  even  when  he  was  told  what  the  name  was. 
When  shown  a  cup  and  asked  if  he  knew  what  it  was, 
he  said:  "  \'es,  sir;  yes,  sir,"  and  raised  it  to  his  lips. 
When  told  to  describe  how  he  was  hurt  he  said: 
"Yes,  sir:  I  was  struck  on  the — yes,  sir;  here,  sir 
(pointing  to  his  head),  by  (after  an  attempt  to  remem- 
ber the  person's  name)  an  acquaintance.  He  hit  me 
with  a"  (here  a 
pantomime  illus- 
trating the  size 
and  shape  of  the 
implement  he  was 
struck  with). 

He  could  copy 
both  writing  and 
printing.  In  vol- 
untary writing  and 
in  writing  from 
dictation  he  made 
frequent  errors. 
When  told  to  write 
the  alphabet  he 
made  many  mis- 
takes, and  when  directed  to  write  "cat"  and  "horse" 
he  wrote  "ceat"  and  "heort."  He  recognized  that 
what  he  had  written  was  wrong,  but  could  not  correct  it. 

He  was  slightly  word  deaf.  Generally  he  compre- 
hended all  that  was  said,  and  almost  always  recog- 
nized enough  words  in  every  sentence  to  enable  him 
to  grasp  the  meaning.  Put  occasionally  a  sentence 
had  to  be  repeated,  or  some  of  the  words  changed  be- 
fore he  could  understand.  There  was  slight  choked 
disc  in  the  right  eye.  The  diagnosis  was  made  of 
subdural  hemorrhage  over  the  posterior  portion  of  the 
superior  temporal  gyrus.  .\n  operation  was  performed 
by  Dr.  Seneca  Powell  two  weeks  after  the  injury.  A 
linear  fracture  was  found  in  the  left  temporal  bone, 
and  there  was  a  subdural  clot  which  covered  the  en- 
tire superior  temporal  gyrus,  but  did  not  extend  in  any 
direction    beyond    that   convolution.     At    a   point   at 


Fl 


-Case  I.  Siibdtiral  Hemorrhage  Over 
the  Superior  'l'enip<'ral  Convolution  with 
l.aceration  of  tile  Cortex.  Deep  shading  in- 
dicates the  extent  of  the  hcmorrhaKc  ;  the 
black  sp<)t.  the  location  of  the  laceration. 


IOI2 


MEDICAL    RECORD. 


[December  29,  1900 


about  the  junction  of  the  posterior  and  midcile  thirds 
of  this  gyrus,  there  was  a  rupture  of  the  cortex.  This 
was  about  a  quarter  of  an  inch  in  diameter,  and  ex- 
tended straight  into  the  cerebrum  to  a  depth  of  about 
an  inch.  The  lesion  was  evidently  caused  by  the 
pressure  of  blood,  as  it  was  certainly  two  and  a  half 
inches  posterior  to  the  fracture,  and  could  hardly  have 
been  caused  by  the  direct  violence  of  the  blow. 

His  present  condition,  now  nearly  a  year  after  his 
injury,  is  as  follows:  In  reading  aloud  he  reads  sim- 
ple words  and  understands  them.  He  says  he  reads 
the  papers,  but  often  conies  across  words  he  cannot 
comprehend.  Such  words  as  "originally,"  "incom- 
petence," and  "desirability,'"  and,  in  general,  words 
of  more  than  three  syllables  he  can  understand  neither 
when  he  hears  them  nor  when  he  reads  them.  But  he 
understands  so  many  words  that  he  is  able  to  carry  on 
a  conversation  so  well  that  his  friends  think  he  has  en- 
tirely recovered. 

The  tests  for  the  various  forms  of  aphasia  were  very 
thorough,  but  are  too  voluminous  for  production  here 
in  detail.  It  will  suffice,  1  think,  to  present  a  single 
specimen  of  each,  taken  at  random  from  a  great 
many. 

When  given  letters  and  told  to  arrange  them  so  as 
to  spell  words,  he  does  so  correctly  when  he  is  not 
word  deaf  for  the  word  given. 

Writing  spontaneously.  When  told  to  write  the  al- 
phabet he  wrote  it  correctly,  except  the  letters  v  and 
X,  which  he  printed.  In  writing  the  alphabet  he  often 
had  to  stop  and  think,  saying  the  letters  over  from  the 
beginning,  until  he  could  get  the  one  he  wished  to 
write,  and  then  he  was  able  to  write  it.  He  printed 
X  and  V  because  he  had  forgotten  how  to  write  them. 
When  directed  to  write  me  a  note  about  his  health  he 
wrote.  "  I  am  much  better.  I  think  I  will  soon  be 
well." 

Writing  from  dictation.  When  told  to  write, 
"This  is  the  21st  of  January,''  he  wrote  "This  is  the 
2  I  St  of  Janure,"  and  said  he  couldn't  think  of  the  let- 
ters, though  he  knew  it  was  incorrect.  In  writing 
other  sentences  he  made  similar  errors  in  spelling. 
>Vhen  told  to  write  "  When  in  the  course  of  human 
events,"  he  was  word-deaf  for  "in,"  "human."  and 
"events."  He  wrote  "w-hen"  readily,  and  although 
I  repeated  "in  "  for  him  four  or  five  times,  he  could 
not  understand  it,  but  asked  if  I  said  "a,"  "and," 
and  "on,"  and  tiien  was  obliged  to  give  it  up. 

Repeating  words  from  dictation.  He  can  readily 
repeat  words  of  one  or  two  syllables.     He  cannot  say 

"arithmetic."  He 
can  say  each  syl- 
lable after  me.  but 
cannot  say  them 
all  together.  It  is 
impossible  for  him 
to  pronounce  other 
words  of  three  or 
four  syllables. 

Test  for  word 
blindness.  H  e 
readily  recognized 
all  simple  words 
when  he  saw  them 
written  or  printed. 
Words  of  three  syllables  or  more  he  could  read  but 
could  not  understand  after  he  had  read  them,  even 
when  he  read  them  aloud.  Tliis  is,  however,  a  condi- 
tion depending  upon  a  lesion  of  the  higher  auditory 
centre  rather  than  of  the  higher  visual  centre. 

The  ability  to  name  objects.  He  named  all  ob- 
jects readily.  The  former  difficulty  which  was  so  ap- 
parent when  lie  first  came  under  observation  had  en- 
tirely disappeared.  Such  articles  as  the  telephone,  the 
mirror,  and  various  objacts  of   furni-ture  around   the 


1  i.  i. — Case  [I.  Thrombotic  SofleninR  of  tlic 
Middle  Third  of  Ihc  Second  Temporal 
( ryrus.  Deep  shading  indicates  the  position 
of  the  lesion. 


room,  and  the  articles  on  my  table  and  in  my  pockets 
he  could  name  without  hesitation. 

This  patient  at  first  suffered  from  complete  ano- 
mia,  and  was,  and  is,  word  deaf  to  a  slight  degree. 
His  inability  to  comprehend  some  written  and  printed 
words  and  to  write  certain  words  from  dictation  is,  of 
course,  due  to  word  deafness  and  not  to  word  blind- 
ness. After  a  period  of  nearly  a  year  from  the  date 
of  his  injury  the  anomia  has  almost,  if  not  entirely, 
disappeared,  while  the  word  deafness,  apparent  at  the 
very  beginning,  has  not  changed  at  all.  The  degree 
of  word  deafness  from  which  he  suffers  is  quite  com- 
mensurate with  the  extent  of  cortical  destruction  in 
the  higher  word-hearing  centre. 

The  second  case  is,  as  you  will  observe  from  your 
inspection  of  the  brain  which  1  now  present  for  your 
observation,  a  case  of  softening  of  the  middle  third  of 
the  second  temporal  gyrus.  It  resulted  from  throm- 
bosis. The  patient  entered  the  Charity  Hospital  on 
January  9,  1900.  Of  his  family  history  nothing  is 
known,  but  a  few  details  of  his  personal  history  were 
secured  for  me  by  my  house  physician,  who  obtained 
them  from  the  patient's  friends.  He  was  about  forty 
years  old  and  was  a  gambler.  He  was  a  man  of  good 
address,  could  read  and  write,  talked  well,  and  seemed 
to  have  a  fair  education.  His  memory,  particularly 
for  faces,  was  a  matter  of  note.  He  seemed  to  be  well 
up  to  tiiree  or  four  months  before  he  came  under  our 
observation.  During  this  time  his  memory  became 
noticeably  defective;  he  forgot  people's  names  and 
faces,  made  errors  in  changing  money  and  in  playing 
roulette,  which  game  he  had  charge  of  in  the  gam- 
bling-house. There  were  no  ascertainable  defects  of 
speech. 

When  he  entered  the  hospital  he  was  in  a  semi- 
comatose condition.  He  could  be  aroused  but  did  not 
seem  to  be  conscious  of  his  surroundings.  The  next 
day  he  began  to  regain  consciousness,  and  in  a  day  or 
two  more  his  general  intelligence  seemed  to  be  nor- 
mal. From  this  time  up  to  the  day  of  his  death,  on 
January  23d,  from  cerebral  hemorrhage,  he  seemed 
fairly  bright.  He  always  recognized  me  when  I  saw 
him.  would  shake  hands  with  me,  and  always  made 
tremendous  efforts  to  express  his  feelings  in  sponta- 
neous speech  and  to  comprehend  what  I  said  to  him. 
His  face  would  flush  with  the  eftort,  and  finally  put- 
ting his  hand  to  his  head,  as  if  the  strain  had  caused 
him  pain,  he  would  give  up  in  despair.  During  the 
time  he  was  under  observation  there  was  no  motor 
paralysis  in  any  muscle  of  the  body,  nor  were  there 
any  disorders  of  sensibility.  Many  examinations 
were  made  until  the  exact  conditions  of  aphasia  were 
ascertained,  and  these  were  carefully  verified  by  sub- 
sequent tests  which  also  demonstrated  tiie  unchange- 
able character  of  the  symptoms. 

He  did  not  show  any  evidence  of  the  so-called 
motor  aphasia.  During  the  examinations  he  spoke 
many  words,  which,  though  they  were  seldom  relative 
to  the  subject,  were  articulated  plainly  and  distinctly 
and  without  effort.  The  special  senses  were  unaf- 
fected so  far  as  wx  could  ascertain.  He  certainly 
heard  with  both  ears,  and  seemed  to  see  equally  well 
with  both  eyes,  and  did  not  suffer  from  hemianopsia. 
Slight  noises  made  on  either  side  of  him  caused  liini 
to  turn  his  head  in  the  direction  from  which  the 
sound  came,  and  when  lie  was  spoken  to  even  in  low 
tones  he  invariably  concentrated  his  attention  upon 
the  speaker.  Anything  handed  to  him  from  either 
side  was  quickly  seen,  and  his  hand  would  go  out  to 
receive  it.  'J'he  pupils  responded  well  to  both  light 
and  accommodation.  He  was  almost  completely 
word  deaf.  Even  such  simple  commands  as  "give 
me  your  hand."  "  put  the  palms  of  your  hands  to- 
gether.'' "pull  up  your  bedclothes,"  were  absolutely 
uncom^reheiided,  though  he  readily  understood  what 


December  29,  1900J 


MEDICAL    RECORD. 


lor 


I  wanted  him  to  do  when  the  same  things  were  com- 
municated by  signs,  and  immediately  complied. 
When  told  to  close  his  eyes,  and  the  command  was  re- 
peated two  or  three  times,  he  did  so ;  he  also  pfotruded 
his  tongue,  but  only  after  being  told  to  do  so  several 
times.  Once  when  I  told  him  to  touch  his  eyes  with 
his  hand  he  passed  the  hand  to  his  chin.  Other 
speeches  more  complex  in  their  scope  seemed  to  be 
absolutely  meaningless  to  him.  When  I  spoke  to  him 
he  would  say  "yes,"  and  "no,"  or  such  words  as  "do 
tell,"  "any,"  "  sometimes,"  "  some."  but  all  of  them 
without  any  relevancy  to  the  question  asked.  When 
shown  a  number  of  things  together  and  told  to  select 
a  certain  one,  he  always  took  the  one  nearest  to  him. 
He  was  completely  word  blind.  When  given  a  book 
or  paper  he  was  as  apt  to  hold  it  upside  down  as 
not,  and  when  either  was  placed  correctly  in  his 
hands,  he  could  not  read  it.  Written  requests,  as  to 
pick  up  things,  to  put  them  down,  to  move  parts  of 
his  body,  to  perform  certain  acts,  were  absolutely  un- 
heeded;  but,  as  in  former  tests,  he  readily  did  as  de- 
sired when  shown  by  signs.  When  given  a  paper  on 
which  something  was  written  he  would  take  it  in  his 
hands,  look  at  it  intently,  turn  it  around,  then  shake 
his  head  in  negation,  and  hand  the  paper  back  without 
making  any  effort  to  obey  the  order. 

Squares  of  pasteboard  upon  which  were  large  printed 
letters  were  placed  before  him  and  arranged  into  words 
and  sentences,  but  did  not  arouse  any  look  or  act  of 
intelligence.  He  had  absolute  agraphia.  When  given 
a  pencil  and  a  piece  of  paper  he  took  the  pencil  and 
placed  it  properly  in  his  fingers,  but  did  not  write. 
When  shown  an  object,  such  as  a  watch  or  a  key  or  a 
knife,  and  it  was  indicated  by  signs  and  also  by  words 
that  he  was  to  write  the  name  of  the  object  exhibited, 
he  could  not  do  so.  He  could  not  write  from  dicta- 
tion; he  could  not  copy  words,  letters,  numerals,  or 
simple  geometrical  figures,  such  as  squares  and  cir- 
cles. He  could  not  write  spontaneously.  He  could 
not  express  his  thoughts  in  spontaneous  speech. 
He  could,  and  often  did,  say  a  number  of  words,  but 
they  were  uttered  singly  and  disjointedly,  and  never 
in  logical  sequence.  He  could  not  name  anything  he 
saw,  heard,  or  touched,  though  he  was  tested  many 
times.  He  understood  fairly  well  the  uses  of  various 
objects,  could  feed  himself,  used  his  glass  or  cup 
properly,  arranged  his  bedclotiies  to  his  satisfaction, 
and  indicated  by  his  handling  such  familiar  objects 
as  keys,  match-boxes,  nails,  and  other  things  that  he 
knew  their  use.  He  was  not  by  any  means  stupid. 
He  took  considerable  interest  in  what  was  going  on 
about  him,  would  smile  at  many  things  he  saw,  and 
tried  his  utmost  to  understand  and  make  himself  un- 
derstood, and  ceased  only  after  the  effort  gave  him 
headache,  or  it  appeared  hopeless. 

In  this  case  of  complete  word  blindness,  agraphia, 
and  almost  total  word  deafness,  with  tlie  consequent 
loss  of  voluntary  speech,  was  not  the  diagnosis,  during 
the  life  of  the  patient,  of  a  lesion  involving  the  supe- 
rior temporal  gyrus  and  the  angular  gyrus  justifiable? 
And  yet  the  inspection  of  the  brain  demonstrates  that 
neither  of  these  regions  was  diseased.  The  area  of 
softening  is  confined  to  the  middle  of  the  second  tem- 
poral gyrus,  a  -.egion  almost  outside  of  the  accepted 
word-hearing  centre. 

Another  fact  of  great  interest  is  that  though  the 
lesion  was  confined  to  the  temporal  gyrus  word  blind- 
ness was  absolute,  while  word  deafness  possibly  was 
not. 

In  jNIills'  case  there  was  word  blindness  associated 
with  anomia,  and  yet  the  lesion  was  farther  from  the 
higher  visual  centre  than  in  my  second  case.  Is  it 
likely  that  in  a  case  like  this — word  blindness  w-ith 
anomia — the  real  situation  of  the  lesion  in  the  third 
temporal  gyrus  would  ever  have  been  suspected  with- 


out the  actual  demor.stration  atTorded  by  the  autopsy? 
In  my  first  case  the  lesion  was  much  nearer  the  angular 
gyrus  than  in  either  of  the  others,  but  there  was  no 
word  blind-ness  at  all. 

A  careful  consideration  of  these  cases  must  enforce 
the  conclusion  that  the  presence  of  word  blindness 
and  word  deafness,  either  alone  or  in  combination, 
does  not  always  imply  that  the  lesion  is  to  be  found 
in  the  hi'gher  visual  or  higher  auditory  centres  or  in 
both,  but  that  a  lesion  in  any  part  of  the  speech  area 
may  so  disorder  the  complex  mechanism  of  the  asso- 
ciated speech  centres  that  any  or  all  forms  of  sensory 
aphasia  may  be  induced.  This  view  of  the  case  re- 
ceives further  confirmation  by  the  conditions  which  al- 
most invariably  accompany  the  so-called  motor  apha- 
sia. I  refer  to  agraphia,  the  inability  of  the  patient 
to  tell  the  number  of  letters  in  a  word  and  the  number 
of  syllables  in  words,  the  impossibility  of  combining 
numbers  to  any  great  extent,  and  the  frequently  coexist- 
ing amnesia.  These  factors  are  all  evidences  of  the 
great  disturbance  which  the  partial  or  complete  destruc- 
tion of  one  centre  induces  in  neighboring  centres. 

The  ability  of  remembering  names  of  objects  and 
persons  must  be  a  part  of  the  function  of  the  higher 
auditory  centre.  It  would,  therefore,  seem  probable 
that  any  lesion  destroying  this  area  or  a  part  of  it,  or, 
in  fact,  any  part  of  the  general  speech  area,  may  cause 
anomia.  If  this  is  so,  and  it  seems  to  be,  it  can  read- 
ily lie  understood  how  two  such  widely  separated 
lesions  as  the  ones  observed  in  Mills'  case  and  my 
own  could  both  cause  anomia. 

The  naming  centre  has  yet  to  be  found.  It  may  be 
discovered  some  day.  but  at  present  it  lies  in  the 
dreamland  of  theory  only. 


Antidotes  for  lodism — In  a  general  article  on 
iodism  Douglass  V\'.  Montgomery  says  that  iodisni  de- 
pends on  a  personal  peculiarity  of  the  patient,  an  idio- 
syncrasy, and  nothing  will  absolutely  prevent  it  where 
the  tendency  exists.  There  are  some  agents,  however, 
which  sometimes  are  capable  of  modifying  some 
of  the  symptoms  of  iodism.  They  are  belladonna, 
Fowler's  solution,  bromide  of  potassium,  morphine, 
salol,  sulphanilic  acid,  bicarbonate  of  sodium,  chlorate 
of  sodium,  iielladonna  is  by  far  the  best  drug  to  re- 
lieve the  coryza-like  effects  of  iodide  of  potassium, 
and  Montgomery  generally  gives  five  drops  of  the 
tincture  with  each  dose  of  the  iodide.  Any  other 
preparation  of  the  drug,  such  as  atropine,  may  be  used. 
It  may  also  control  some  other  forms  of  iodism,  as  in 
the  case  mentioned,  in  which  it  prevented  oedematous 
swelling  in  the  neighborhood  of  the  eyes.  Fowler's 
solution  is  undoubtely  the  best  associate  drug  to  use 
when  iodide  of  potassium  causes  indigestion.  It  is 
best  given  in  one-  or  two-drop  doses,  just  as  one  would 
prescribe  it  for  indigestion. — Medical  Age,  October  25, 
1900. 

The  Natural   Process  of  Cure  in  Constipation. — 

Charles  J.  Hill  Aitken  reports  in  detail  the  progress 
of  a  patient  who  for  more  than  three  years  suffered 
from  dyspepsia  with  constipation.  No  drugs  were  ad- 
ministered, but  he  was  put  upon  a  simple,  ordinary, 
well-cooked  diet,  which  included  fruit,  vegetables,  and 
fiuids.  He  was  ordered  to  go  daily  to  stool  after 
breakfast.  His  bowels  became  regular  in  their  action, 
but  any  departure  from  his  usual  routine  at  once 
caused  constipation.  The  intestinal  muscles  finally 
became  so  much  more  active  that  they  reacted  to  the 
stimulus  of  food  twice  a  day.  To  prevent  the  second 
motion  which  occurred  at  the  inconvenient  hour  of  5 
P.M.,  he  was  told  to  restrain  his  desire  for  evacuation 
if  possible,  but  if  not,  to  take  chlorodyne.  In  time 
this  treatment  succeeded  perfectly. —  The  Medical  J'ress, 
November  14,  igoo. 


IOI4 


MEDICAL    RECORD. 


[December  29,  1900 


Medical   Record: 

A    \l'ic/:/j   Journal  of  Medicine  and  Surgery. 


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

I'lBLISHEKS 

WM    WOOD  &   CO.,  51    Fifth   Avenue. 
New  York,  December  29,  1900. 


REFORMS    IN    BF.LLEVUE. 

The  necessity  for  reforms  in  tiie  management  of 
Bellevue  Hospital  lias  been  painfully  apparent  for  a 
long  time,  and  discussion  on  the  subject  has  worn  itself 
threadbare  in  vain  appeals  for  the  institution  of  radical 
measures  tending  toward  the  accomplishment  of  de- 
sired results.  The  medical  profession,  deeply  inter- 
ested in  its  welfare  as  a  grer.t  institution  for  the  care 
of  the  sick  poor,  has  been  pardonably  jealous  of  its 
good  name  and  reasonably  anxious  concerning  tho 
grand  opportunities  it  should  afford  for  the  study  and 
treatment  of  disease  on  strictly  up-to-date  scientific 
principles. 

Its  greatest  handicap  has  been  its  association  with 
politics.  This  has  been  proven  in  every  part  of  its 
government  from  the  appointment  of  an  attending 
physician  or  surgeon  to  the  employment  of  the  lowest 
menial.  A  medical  man  may  be  ever  so  well  quali- 
fied for  a  position,  but  if  he  has  no  friend  in  the  coun- 
cils of  the  dominating  party,  or  is  not  connected  with 
some  medical  school,  his  chances  for  preferment  are 
almost  invariably  discounted. 

Fortunately,  the  present  medical  staff  is  in  every 
way  a  good  one,  but  under  the  circumstances  it  is 
more  a  matter  of  luck  than  grace,  and  the  argument 
goes  no  farther  than  to  show  that  with  the  same  prin- 
ciple at  work  e.xactly  opposite  results  may  be  obtained 
at  any  future  time.  Even  in  the  face  of  facts  bearing 
at  present  on  the  right  side  of  this  question,  the  whole 
system  is  wrong  and  calls  for  radical  change.  The 
latter  remark  applies  with  particular  force  at  this  time 
to  the  male-nurse  scandal,  which,  during  the  past 
week,  has  been  so  freely  ventilated  by  the  daily  press. 
The  revelations  of  the  brutal  treatment  of  patients  in 
the  insane  pavilions  and  the  alcoholic  wards  seem 
almost  past  belief.  That  the  charges  made  by  the 
helpless  victims  of  these  outrages  are  substantially 
based  on  facts  '■>  evident  enough  by  the  admission  of 
Commissioner  Keller  and  his  prompt  suspension  of 
the  guilty  parties. 

The  possibility  for  the  disgraceful  occurrences  in 
question  appears  to  have  been  due  to  the  lack  of  a 
proper  supervision  of  nurse  work  and  of  the  appoint- 
ment of  unfit  persons  for  its  performance.  The  mere 
graduation  from  a  male-nurse  training-school  does 
not,  in  itself,  guarantee  the  proper  discharge  of  some 
of  the  most   responsible  duties  of   the  calling.     In  no 


other  sphere  is  it  more  necessary  to  control  one's  tem- 
per and  suppress  vengeful  and  cruel  instincts  than  in 
the  care  of  the  wild  maniac,  or  in  the  control  of  the 
wilful  and  perverse  alcoholic.  It  would  appear,  how- 
ever, that  these  nurses  were  positively  cruel  without 
provocation,  and  that  the  slightest  excuses  for  the  exer- 
cise of  their  assumed  privileges  of  beating,  cuffing, 
and  partially  strangulating  and  stupefying  patients 
were  in  most  instances  eagerly  seized. 

All  thi.s  proves  the  absolute  necessity  for  constant 
supervision  of  ward  work,  and  the  great  danger  of 
delegating  discretionary  power  to  incompetent  agents. 
The  managers  of  lunatic  asylums  have  long  since 
learned  this  lesson,  and  having  taken  its  precepts  to 
heart  have  virtually  abolished  every  form  of  cruelty  in 
their  institutions,  liellevue  was  so  much  behind  in 
this  respect  that  she  required  a  gross  and  horrifying 
scandal  to  bring  her  to  her  senses. 

The  strange  part  of  the  recent  development  is  that 
all  these  things  should  have  been  going  on  so  long 
without  the  knowledge  of  the  house  staff,  the  at- 
tending physicians,  or  the  commissioner  of  chari- 
ties. It  is  not  necessary  to  discuss  here  whose  duty 
it  was  to  know  that  this  shocking  state  of  aft"airs  ex- 
isted. It  is  perhaps  a  matter  for  congratulation  that 
the  real  truth  has  come  out  at  last.  Commissioner 
Keller  has  done  his  part  after  the  matter  has  been 
so  directly  and  forcibly  brought  to  his  attention.  The 
appointment  of  a  special  physician  whose  duty  it  shall 
be  to  supervise  the  nurses  and  be  responsible  for  every 
other  detail  of  ward  management  is  a  very  important 
step,  and  will  at  least  tend  to  prevent  the  barefaced 
brutality  which  has  existed  in  time  past.  While  the 
alcoholic  wards  are  necessities  for  Bellevue,  there 
does  not  seem  to  be  any  good  reason  why  the  insane 
pavilion  should  be  used  for  other  purposes  than  those 
of  diagnosis,  immediately  after  which  a  transfer 
should  be  made  to  a  State  asylum. 

Commissioner  Keller,  now  that  he  is  impressed  with 
the  fact  that  Bellevue  Hospital,  as  a  whole,  is  not  what 
it  should  be,  has  promised  to  examine  the  working  of 
every  one  of  its  departments,  with  a  view  of  suggesting 
necessary  reforms.  We  doubt  not  that  the  result  of 
his  inquiries  may  throw  much  light  in  the  darker 
corners,  and  may  be  very  forceful  arguments  in  favor 
of  an  entirely  different  system  of  government  for  the 
great  charity  hospital.  To  this  end  the  proposed 
amendments  in  the  charter  will  especially  appeal. 
The  more  we  discuss  the  question  from  this  stand- 
point, the  nearer  will  we  come  to  the  truth  and  the 
right.  So  long  as  politics  rules  our  hospital,  so  long 
will  preventable  abuses  show  themselves  At  times 
there  will  be  attempts  to  remedy  existing  evils,  but 
the  lapsing  into  old  conditions  is  inevitable  when 
party  interests  are  at  stake  and  favorites  must  be 
served.  There  is  really  no  excuse  for  politics  as 
such  in  the  managetnent  of  our  hospitals.  As  charity 
has  no  creed,  science  should  have  no  political  com- 
plexion. What  is  needed  is  a  radical  reform  of  the 
entire  system,  a  government  by  an  independent  board 
and  a  nianagement  on  a  par  with  the  model  public  hos- 
pitals elsewhere.  All  this  is  contemplated  in  the  pro- 
posed amendment  to  the  charier,  and   as  a  reasonable 


December  29,  [  900J 


mp:uical  rhcokd. 


1015 


reform  measure  it  should  commend  itself  to  the  ap- 
proval of  every  unprejudiced  and  broad-minded  citi- 
zen. 


METALLIC    SUTURES. 

Silver  wire  as  a  material  for  sutures  has  long  been 
popular,  and  tlie  reasons  for  this  fact  are  more  or  less 
self-evident.  The  material  is  easily  obtained,  is 
easily  and  certainly  sterilized,  and  it  is  strong.  Re- 
cently some  actual  antiseptic  properties  have  been  at- 
tributed to  it  from  the  alleged  action  of  the  liuids  of 
the  tissues  forming  in  the  track  of  each  stitch  a  minute 
quantity  of  silver  salts  which,  as  is  well  known,  are 
antiseptic.  In  a  recent  publication  (P'iore,  /<7  A'ijoniht 
Medico,  August  28,  igoo)  the  use  of  gold  wire  has 
been  suggested  for  much  the  same  reasons  as  are  cited 
in  favor  of  silver  wire,  except  that  no  intrinsic  anti- 
septic properties  are  claimed  in  the  case  of  the  more 
e.xpensive  metal.  Several  cases  of  hernia  are  reported 
by  this  writer  in  which  wire  of  this  metal  has  been 
used  with  satisfaction,  but  nothing  is  offered  to  show 
any  superiority  of  gold  over  silver  in  this  connection, 
so  that,  surgically  speaking,  the  two  metals  may  be 
considered  together,  and  are,  as  far  as  we  can  judge, 
of  about  equal  value.  The  good  points  of  metallic 
sutures  may  be  freely  admitted,  but  the  possession  of 
these  desirable  attributes  does  not  by  any  means  prove 
that  such  varieties  of  suture  give  better  results  in  con- 
ditions in  which  permanence  of  suture  material  is  sup- 
posed to  be  necessary  than  are  obtained  with  any  other 
form  of  suture.  In  hernia,  for  instance,  when  metallic 
sutures  are  used,  the  priinary  results  are  often  excel- 
lent, but  other  varieties  of  suture  are  also  employed 
with  excellent  result,  and  it  is  good  secondary  and 
late  results  which  are  claimed  for  the  metallic  sutures 
by  those  w^ho  urge  their  use  most  strongly. 

In  one  recently  described  operation  for  hernia,  in 
this  country,  the  use  of  silver  wire  is  advocated  for 
suturing  in  all  stages  of  the  operation,  the  claim  being 
made  that  the  silver  wire  being  used  in  the  deeper  parts 
of  the  wound  forms  a  network  in  the  tissues  against 
which  the  intra-abdominal  pressure  spends  itself 
harmlessly.  The  fallacy  of  this  argument  in  favor  of 
the  permanent  utility  of  this  form  of  suture  is  evident 
when  we  remember  that  these  sutures,  on  which  so 
much  reliance  is  placed,  are  passed  through  relatively 
soft  tendinous  anil  muscular  tissues,  and  that,  no  mat- 
ter how  strong  the  bridge  or  mattress  of  sutures  may 
be.  the  whole  structure  can  be  only  as  strong  as  the 
anchorage  of  the  sutures,  which  is  in  soft  tissue  easily 
and  certainly  cut  through  by  any  undue  tension. 
This  is  only  another  illustration  of  the  trite  saying 
that  a  chain  is  as  strong  as  its  weakest  link.  Yield- 
ing tissues,  dragged  into  an  abnormal  position  by  a 
wire  suture,  will  return  to  approximately  their  origi- 
nal position,  by  allowing  the  suture  to  cut  through  far 
enough  to  restore  the  circulatory  equilibrium  in  the 
minute  vessels  of  the  tissue  in  the  line  of  tension  of 
the  suture,  and  if  tension  is  increased  the  sutures  will 
cut  farther,  so  that  in  the  operation  for  hernia  which 
we  have  mentioned  we  cannot  logically  expect  a  really 


permanent  result.  The  true  function  of  a  suture  is  to 
hold  surfaces  in  apposition  with  as  little  tension  as 
possible,  until  union  can  occur  by  the  formation  of 
new  tissue  between  the  surfaces.  Kven  in  bone  it  is 
very  rarely  necessary  to  use  a  metallic  suture,  though 
such  use  is  often  made,  for  we  can  never  be  sure  that 
there  will  not  be  some  sort  of  irritation,  which  will 
make  a  secondary  operation  of  greater  or  less  extent 
necessary  in  order  to  remove  the  offending  unabsorbed 
suture.  The  present  supply  of  absorbable  suture 
material  is  by  no  means  satisfactory  in  all  particulars, 
but  it  is  improving  continually.  The  ideal  suture  is 
certainly  that  made  of  a  strong,  sterile,  absorbable 
material  which  does  not  slip  when  tied,  and  these 
requirements  are  so  nearly  met  in  the  best  specimens 
of  prepared  catgut,  that  it  is  in  this  direction  that  we 
should  seek  improvement  which  may  lead  to  perfec- 
tion. U'e  need  not  introduce  complications  by  em- 
ploying new  materials  which  possess  no  advantages 
over  what  we  already  have.  Gold  wire  is,  no  doubt, 
a  good  enough  material  to  use  for  suturing  in  a  cir- 
cumscribed field,  but  we  do  not  need  it,  and  it  is  much 
more  expensive  than  silver,  the  good  qualities  and 
disadvantages  of  which  it  has  in  equal  degree. 


EPILKl'TU;    INSANITY. 

TnK  association  with  epilepsy  of  mental  changes  of  a 
degenerative  character  is  a  well-known  clinical  fact, 
the  explanation  for  which  is  probably  to  be  found  in 
alterations  in  the  nerve  cells  of  the  cerebral  cortex, 
which  are  being  detected  with  increasing  frequency 
and  facility  by  means  of  modern  methods  of  fixation 
and  staining.  In  a  discussion  of  the  subject  of  epi- 
leptic insanity  at  the  recent  meeting  of  the  British 
Medical  Association,  Pasmore  (British  Medical  Jour- 
nal, September  22,  1900,  p.  792)  describes  as  the 
characteristics  of  epilepsy  and  epileptic  insanity  their 
markedly  hereditary  and  periodic  character,  the  exist- 
ence of  a  normal  mental  state  in  the  intervals  between 
attacks,  with  the  development  of  dementia  only  after 
varying  periods,  the  occurrence  of  maniacal  attacks 
before  and  after  the  epileptic  convulsions,  the  alterna- 
tion at  times  of  such  attacks  with  the  convulsive  seiz- 
ures, or  the  replacement  of  the  latter  by  the  former. 
The  maniacal  attacks  are  of  a  sudden,  impulsive,  and 
dangerous  character,  being  attended  with  violence, 
suicidal  and  homicidal  tendencies,  and  destructive- 
ness.  It  was  pointed  out  that  epilepsy  with  insanity 
on  the  one  hand,  and  recurrent  mania  on  the 
other,  have  in  common  hereditary  transmission,  peri- 
odicity of  occurrence,  the  presence  of  a  normal  state 
in  the  intervals  betw-een  outbreaks.  Further,  epilepsy 
may  alternate  with  maniacal  symptoms,  while  mania 
may  precede  or  follow  epilepsy.  Maniacal  attacks 
may  entirely  replace  the  epileptic  state,  especially  if 
of  the  minor  type.  There  is  marked  similarity  be- 
tween the  mania  associated  with  ordinary  epileptic 
insanity  and  recurrent  mania.  For  the  foregoing  rea- 
sons it  is  suggested  that  recurrent  mania  is  an  epi- 
lepsy of   psychic   type,  and  the   designation    psychic 


ioi6 


MEDICAL    RECORD. 


[December  29,  1900 


epilepsy  or  epileptic  mania  is  proposed  for  it.  The 
condition  appears  to  occur  especially  in  those  who 
exhibit  a  dual  family  history  of  epilepsy  and  insanity. 
The  following  clinical  classification  of  the  insanities 
associated  with  epilepsy  is  proposed:  (i)  congenital, 
including  (a)  idiocy  (epileptic),  {l>)  imbecility  (epi- 
leptic); (2)  idiopathic  epileptic  insanity,  the  ordi- 
nary insanity  of  epilepsy  as  met  with  in  the  adult;  (3) 
hystero-epileptic  insanity,  found  chiefly  in  young  girls 
about  the  age  of  puberty ;  (4)  psycho-epileptic  insanity  : 
(d)  recurrent  or  epileptic  mania,  (/')  transitory  amne- 
sia, and  masked  epilepsy. 


UNBRIDLED    QUACKERY. 

Dr.  Kenwood  writes  in  English  Public  Health  of 
"  the  ways  that  are  dark  and  the  tricks  that  are  vain  " 
of  the  numerous  members  of  the  quack  fraternity. 
Referring  to  indecent  advertisements  in  the  papers  he 
says :  "  The  advertisements  of  the  sexual  quack  tend 
to  corrupt  the  sense  of  public  decency  and  propriety. 
His  other  literature  is  invariably  of  the  same  type. 
Those  who  care  to  read  this  sort  of  stuff  will  find  in  it 
long  columns  of  puffery,  inuendo,  and  '  dirt '  in  the 
files  of  many  papers,  but  mainly  in  certain  Sunday 
and  weekly  papers,  which  are  the  most  frequently  read 
by  those  female  members  of  the  community  who  are 
most  likely  to  be  in  need  of  that  relief  promised  and 
least  likely  to  hesitate  in  accepting  the  specious  offers 
made  to  them.  The  printed  matter  sent  out  with  these 
pills  and  potions  leaves  no  doubt  as  to  what  the  ven- 
dors wish  to  be  understood  as  selling.  They  deliber- 
ately advertise  their  wares  as  capable  of  producing 
abortion,  although  they  avoid  using  the  actual  word. 
They  are  mostly  thinly-veiled  invitations  to  purchase 
and  employ  the  advertised  agents  for  the  purpose  of 
procuring  miscarriage.  As  to  their  actual  power  in 
this  direction  it  appears  that  some  preparations  con- 
tain well-recognized  abortifacients  (pennyroyal,  aloes, 
etc.),  and  the  vendors  evidently  aim  at  acting  up  to 
their  professions,  but  others  are  designedly  inert. 
The  literature  of  the  trade  often  contains  a  warning 
to  the  effect  that  the  remedy  must  not  be  taken  by 
those  expecting  to  become  mothers.  This  is,  of  course, 
a  transparent  device  undertaken  to  attract  attention  in 
order  to  sell  the  goods."  Whatever  may  be  the  situa- 
tion in  Great  Britain  with  regard  to  quackery,  and 
from  all  accounts  it  is  bad  enough,  we  venture  to  say 
without  fear  of  contradiction  that  the  custom  is  not 
nearly  so  widespread  or  unrestrained  as  in  this  coun- 
try. The  laws  in  the  United  Kingdom  are,  on  the 
whole,  much  more  stringent  with  respect  to  an  indi- 
vidual practisrng  without  a  proper  qualification  than 
here.  Doubtless  means  can  be  and  are  found  to  evade 
the  law,  but  at  least  quacks  do  not  get  direct  encour- 
agement to  pursue  their  calling  as  in  many  States  of 
the  Union.  It  is  undoubtedly  largely  owing  to  this 
cause  that  the  medical  profession  in  the  United  States 
is  to  a  certain  extent  in  a  perilous  condition,  and  that 
a  large  number  of  the  rank  and  file  find  it  difficult  to 
earn  their  daily  bread.  Competition  among  legally 
qualified  physicians  is  sufficiently  acute,  but  when  in 


addition  to  this  the  unfortunate  practitioner  has  to 
contend  with  a  numerous  and  ever-increasing  horde  of 
illegitimate  followers  of  the  healing-art  it  cannot  be 
said  that  "his  lines  are  cast  in  pleasant  places."  In 
the  Medical  Record  some  few  months  ago  attention 
was  drawn  to  the  question  of  nauseous  advertisements 
inserted  in  religious  journals,  and  we  are  willing  to 
imagine  that  our  animadversions  have  done  some  good. 
Many  suggestions  have  been  from  time  to  time  thrown 
out  with  the  object  of  protecting  the  ignorant  public 
against  its  own  folly,  but  no  really  effective  steps  have 
been  taken  to  stamp  out  or  even  to  scotch  the  evil. 
In  the  mean  time  it  would  seem  that  the  most  the  med- 
ical journals  can  do  is  thoroughly  to  ventilate  the 
matter  and  to  urge  on  every  possible  occasion  the  need 
of  prohibitive  legislation  against  unbridled  quackery. 
Dr.  Kenwood  has  the  courage  of  his  opinions,  and 
"  hits  from  the  shoulder."  He  is  to  be  congratulated 
upon  his  public  spirit,  the  only  pity  is  that  there  are 
not  more  like  him  in  the  medical  profession. 


^cius  of  tTte  ^Slceli. 

The  Committee  on  Scientific  Research  of  the 
American  Medical  Association  announces  that  it  has 
the  available  sum  of  $500  for  the  assistance  of  re- 
searches to  be  undertaken  in  the  next  six  months,  and 
that  the  money  will  be  appropriated  if  applications  be 
received  within  the  month  of  January,  1901.  Appli- 
cants should  state  clearly  the  character  of  the  research 
to  be  undertaken,  and  the  facilities  at  their  command, 
addressing  Dr.  H.  C.  Wood,  chairman,  1925  Chestnut 
Street,  Philadelphia,  Pa. 

The  German  Hospital  of  Brooklyn — On  Decem- 
ber I  St  the  board  of  trustees  celebrated  the  first  anni- 
versary of  the  opening  of  this  institution  for  the  recep- 
tion of  patients.  Appropriate  speeches  were  made  by 
several  of  the  gentlemen  present.  The  ambulance  ser- 
vice of  the  hospital  was  considered  and  a  large  district 
was  asked  for  by  the  hospital  authorities.  There  are 
at  present  accommodation  for  one  hundred  and  ten  pa- 
tients in  the  main  pavilions  and  for  ten  in  the  isola- 
tion building. 

The  Philadelphia  Neurological  Society.— At  a 
stated  meeting  held  December  lylh.  Dr.  D.  J.  Mc- 
Carty  exhibited  a  man  presenting  atrophy  of  the  mus- 
cles of  the  shoulder  girdle,  with  fascicular  twitching, 
and  possibly  dependent  upon  amyotrophic  lateral 
sclerosis.  Drs.  Charles  K.  Mills  and  T.  H.  Weisen- 
berg  exhibited  three  cases  of  cerebral  heniianasthesia 
and  reported  one  case  of  hysterical  hemiana'sthesia, 
and  made  some  remarks  on  differential  diagnosis. 
Dr.  William  C.  Pickett  (by  invitation)  read  a  paper 
entitled  "  .^  Study  of  the  Insanities  of  Adolescence." 
Dr.  Charles  W.  Burr  read  a  paper  entitled  "  Astere- 
ognosis,"  in  which  he  reported  several  cases  present- 
ing this  jihenomenon,  which  he  looked  upon  merely  as 
a  symptom  and  dependent  upon  impairment  of  various 
forms  of  sensibility.  Dr.  F.  Savary  Pearce  read  a 
paper  entitled  "  Xeuraslhenia:    Especial   Involvement 


December  29,  1900] 


MEDICAL    RECORD. 


101 


of  the  Sensory  Neuron."  He  exhibited  a  man  pre- 
senting analgesia  of  both  sides  of  the  face  and  of  the 
perineum,  together  with  abolition  of  the  knee  jerks 
and  periodic  laryngeal  spasm,  but  with  good  station 
and  preservation  of  the  pupillary  reactions.  Opinions 
were  expressed  that  the  disorder  was  hysterical,  and 
that  it  might  be  due  to  tabes  dorsalis. 

The  Chicago  Eye,  Ear,  Nose  and  Throat  College 

will  soon  occupy  a  new  building  at  the  corner  of 
Franklin  and  Washington  Streets. 

Typhoid  Fever  prevails  widely  in  Galveston,  the 
estimated  number  of  cases  in  the  city  being  about  five 
hundred.  It  is  believed  that  the  infection  is  spread 
by  the  use  of  cistern  water,  the  cisterns  having  become 
contaminated  at  the  time  of  the  great  storm. 

Influenza  is  reported  to  be  exceedingly  prevalent  in 
Chicago.  It  is  of  a  comparatively  mild  type.  This 
is  far  from  being  the  case,  however,  in  St.  Petersburg, 
where,  a  press  despatch  states,  the  influenza  epidemic 
is  so  severe  that  the  mortality  returns  for  the  week  have 
been  the  highest  for  a  decade.  A  meeting  of  physi- 
cians was  summoned  to  discuss  remedies,  but  scarcely 
half  a  dozen  responded  to  the  call,  the  rest  being  over- 
worked, or  themselves  being  victims  of  the  malady. 

The  Hospital  Ship  "Maine"  is  now  making  her 
last  trip,  the  British  government  having  decided  that 
it  will  not  need  the  vessel  any  longer.  The  ship 
sailed  from  China  on  December  ist,  with  one  hundred 
and  eight  sick  and  wounded  soldiers.  The  Maine  was 
fitted  out  by  a  committee  of  American  women  resident 
in  Great  Britain,  and  was  employed  first  in  South 
African  waters  and  later  was  sent  to  China.  She  has 
been  in  commission  somewhat  over  a  year. 

The  State  Tuberculosis  Hospital. — It  is  reported 
that  a  majority  of  the  trustees  of  the  new  State  tuber- 
culosis hospital  have  practically  decided  upon  Ray- 
brook,  in  Essex  County,  as  an  alternative  site  for  the 
new  institution,  and  will  so  report  at  the  next  joint 
conference-  of  the  Forest  Preserve  Board,  the  State 
board  of  health,  and  themselves.  Raybrook  is  be- 
tween Saranac  Lake  and  Lake  Placid,  and  on  the  rail- 
road connecting  those  places.  The  advocates  of  the 
Dannemora  site  still  contend  that  that  is  the  best 
place  for  the  hospital,  the  main  argument  urged  being 
that  the  buildings  could  be  erected  by  convict  labor 
at  little  or  no  cost  to  the  State. 

Pan-American  Medical  Congress .\mong  the  so- 
cial features  of  the  Fan-American  Congress  to  be  held 
in  Havana  in  February  will  be  a  grand  ball  at  the 
Tacon  Theatre  under  the  management  of  the  entertain- 
ment committee  and  an  auxiliary  ladies'  committee. 
There  will  also  be  an  excursion  to  the  sugar  estate  of 
Senor  La  Coste  near  Havana.  The  guests  will  be 
carried  on  three  government  transports,  and  on  arriv- 
ing- at  the  plantation  will  be  shown  the  manner  of 
growing,  cutting,  and  grinding  the  cane,  and  of  boil- 
ing and  refining  the  juice,  as  well  as  all  other  points 
of  interest  in  connection  with  life  on  a  sugar  planta- 
tion. Refreshments  will  be  served  on  the  estate  on 
the  transports  during  their  return  trip  to  the  city.     On 


another  day  there  will  be  a  parade  of  the  police  and  an 
exhibition  drill  of  the  fire  department  in  honor  of  the 
visiting  members  of  the  congress.  Public  receptions 
will  be  held  by  various  officials,  and  many  private  din- 
ners will  be  given  by  the  Cuban  physicians  to  their 
acquaintances  among  the  visitors. 

Rabies  is  reported  epidemic  in  Rochester,  many  dogs 
having  died  recently  of  the  disease,  and  a  number  of 
persons  having  been  bitten  by  rabid  animals. 

Animal  Diseases  in  Germany. — The  Imperial 
German  Health  Ofiice  has  published  statistics  of  ani- 
mal diseases  in  1898,  showing  that  twenty-four  of  the 
twenty-six  German  States  were  affected  by  anthrax. 
All  the  States  were  affected  with  foot-and-mouth  dis- 
ease and  with  wildfire  among  swine.  Various  other 
diseases  prevailed  lo  a  considerable  extent. 

A   New   Englewood   (N.    J.)   Hospital A    new 

building  of  the  F.nglewood  Hospital,  New  Jersey,  will 
be  ready  for  occupancy  in  a  week  or  two.  The  new 
building  provides  for  a  men's  ward  and  a  women's 
ward  of  twelve  beds  each,  a  children's  ward  of  eight 
beds,  six  rooms  for  private  patients,  nine  nurses'  rooms, 
a  sitting-room,  a  large  operating-room,  an  upstairs 
dining-room,  an  isolating-room,  a  morgue,  and  a  dis- 
pensary. The  old  hospital  had  long  been  inadequate 
for  the  needs  of  the  community,  for  it  accommodated 
only  sixteen  ward  patients,  and  had  but  three  small 
private  rooms. 

Navy  Department,  Bureau  of  Medicine  and  Sur- 
gery, Washington,  D.  C. — Changes  in  the  medical 
corps  of  the  navy  for  the  week  ending  December  22. 
1900.  December  iSth. — Assistant  Surgeon  R.  E.  Led- 
better  detached  from  the  Constellation  and  ordered  to 
the  Monoitgalu-lii.  December  21st. — Assistant  Surgeon 
J.  A.  Murphy  detached  from  the  Solace  and  ordered  to 
the  Don  Juan  de  Austria.  December  2  i  st. — Assistant 
Surgeon  Jacob  Stepp  detached  from  the  Solace  and 
ordered  to  the  Cavite  naval  station.  December  2  ist. — 
Assistant  Surgeon  M.  V.  Stone  detached  from  the 
Vosemite  Isla  and  ordered  to  the  de  Luzon.  December 
2  ist. — Assistant  Surgeon  J.  C.  Thompson  detached 
from  the  naval  hospital,  Cavite,  P.  I.,  and  ordered  to 
the  Solace. 

Obituary  Notes.— Dr.  Charles  J.ames  O'Hagan, 
of  Greenville,  N.  C,  one  of  the  oldest  and  best-known 
physicians  in  that  State,  died  suddenly  on  December 
19th,  of  apoplexy.  He  was  a  graduate  of  the  New 
York  Medical  College  in  the  class  of  1856. 

Dr.  Ch.-.rles  S.  Taft  died  in  Mount  Vernon,  N.  Y., 
on  December  i8th,  at  the  age  of  sixty-five  years.  He 
was  born  in  this  city,  and  soon  after  graduation  entered 
the  medical  corps  of  the  army,  where  he  served  until 
about  fifteen  years  ago.  Dr.  Taft  was  in  Ford's  The- 
atre, Washington,  on  the  night  President  Lincoln  was 
shot,  and  remained  in  attendance  upon  him  with  the 
other  surgeons  until  he  died. 

Dr.  Richard  A.  Wise,  member  of  Congress  from 
the  Second  Virginia  District,  died  at  his  home  in 
Williamsburg,  Va.,  on  December  21.  The  cause  of 
his   death  was  chronic    nephritis.     He   was   born   in 


ioi8 


MEDICAL    RECORD. 


[December  29,  1900 


Philadelphia  in  1S43.  He  served  in  ihe  Confederate 
Army  during  the  Civil  War,  and  then  studied  medi- 
cine, being  graduated  from  the  Medical  College  of 
Virginia,  Richmond,  in  1868.  After  practising  in 
Richmond  for  two  years,  he  became  Professor  of  Chem- 
istry and  Physiology  at  William  and  Mary  College 
until  1880,  when  he  resigned,  and  was  from  1882  to 
1884  superindentent  of  the  Eastern  Lunat.ic  Asylum 
in  the  same  city.  Dr.  Wise  became  active  in  politics 
in  1877,  and  was  a  strong  Republican.  He  entered 
Congress  in  1898. 

Dr.  George  H.  Elliott,  of  this  city,  died  in  Man- 
chester, N.  H.,  on  December  17th,  at  the  age  of  fifty- 
tive  years.  He  was  a  graduate  of  the  Medical  Depart- 
ment of  the  University  of  Denver  in  1882.  At  the 
time  of  his  death  he  was  a  Commissioner  of  Lunacy 
in  New  York. 

Dr.  Frederick  Osborn  Lloyd  died  at  Hamilton, 
N.  Y.,  on  December  19th  of  cardiac  disease.  He  was 
a  graduate  of  the  New  York  University  Medical  Col- 
lege in  the  class  of  1885.  He  was  a  member  for  a 
term  of  the  house  staff  of  the  Presbyterian  Hospital. 

Dr.  John  E.  Losee,  one  of  the  oldest  and  most 
prominent  physicians  in  Northern  Dutchess  County, 
died  on  Saturday  at  his  home  in  Upper  Red  Hook, 
N.  Y.,  aged  seventy-four  years.  He  had  practised  his 
jjrofession  for  forty-seven  years  in  that  locality.  He 
was  born  in  Saratoga  County,  N.  V.,  and  was  graduated 
from  the  Albany  Medical  College  in  1852.  He  served 
for  several  months  on  the  house  staff  of  the  New  York 
Hospital. 

Dr.  Ephraim  Ingals  died  at  his  home  in  Chicago 
on  December  20th,  at  the  age  of  seventy-eight  years. 
He  was  a  graduate  Rush  Medical  College  in  the  class 
of  1847.  He  was  an  energetic  advocate  of  higher 
medical  education  and  did  much  practically  to  promote 
it,  both  as  a  lecturer  in  and  contributor  to  the  medical 
institutions  of  the  city.  At  the  time  of  the  affiliation  of 
Rush  Medical  College  with  the  Llniversity  of  Chicago 
he  gave  $25,000  to  aid  in  paying  off  the  college  debt 
and  to  found  a  chair  of  therapeutics  and  preventive 
medicine.  He  also  gave  $10,000  to  the  Northwestern 
University  Medical  School  for  the  equipment  of  its 
laboratories.  For  a  number  of  years  he  was  associate 
editor  of  The  Nortlnvestcrn  Meilical  Journal.  He  was 
one  of  the  founders  of  the  Republican  party. 

Dr.  John  Henry  Fruitnight,  of  this  city,  died  on 
December  i8th,  at  the  age  of  forty-nine  years.  He 
was  born  in  New  York  on  November  9,  1851,  and 
after  graduating  in  arts  from  the  College  of  the  City 
of  New  York  in  1872,  received  his  medical  degree 
from  the  Bellevue  Hospital  Medical  College  in  1875. 
His  attention  was  early  turned  to  the  diseases  of  child- 
hood, and  he  soon  won  an  enviable  reputation  as  a 
pediatrist.  .Among  the  many  organizations  to  which 
he  belonged  were  the  American  Pediatric  Society, 
New  York  .Academy  of  Medicine,  Medical  Society  of 
the  County  of  New  York,  Society  of  Medical  Jurispru- 
dence, Physicians'  Mutual  Aid  Association,  Medico- 
Surgical  Society,  Northwestern  Medical  and  Surgical 
Society,  Good  Government  Association,  and  St.  John's 
uuild.  Of  the  last  named  he  was  a  trustee  and  the 
consulting  physician. 


^^roovcss  of  |3^Xctlical  J'Cicncc. 

Sew  Yorl;  Mviliial  /ouiiiiil.  J)i\i-iii/H-r  jj,  /goo. 

The  Diagnosis  of  Empyema    in  Children  ^By  F.   L.  Wacli- 

ciilicini.  Tliu  general  aij]n.arance  ol'  the  patient  is  often 
suggestive.  A  wa.xy  eonijilexion  suggestive  of  .sepsis  is 
often  present.  Local  inspection  frequently  shows  relative 
retardation  anil  diminution  of  the  lespiratoiy  e.\cursion  on 
the  afi'ectcd  side,  occasionally  obliterating  or  even  bulging 
the  intercostal  space.s.  Right-sitled  exudation  may  dis- 
place the  apex  beat.  Fever  with  remi,>-sions  and  with 
sweating  is  present,  while  the  pulse  is  rapid  and  of  poor 
quality.  In  examining,  we  should  percuss  lightly,  use  the 
tactile  sense  to  determine  if  possible  a  feeling  of  resistance 
characteristic  of  elVusion.  Percussion  gives  more  or  less 
dulness  over  the  affected  area,  usually  increasing  down- 
ward ;  sometimes  we  obtain  a  tympanitic  quality,  but  more 
rarely  than  in  solid  infiltrations.  In  the  upper  part  of  the 
thorax  we  obtaui  more  or  less  dulness  or  tympanitic  reso- 
nance, according  to  the  condition  of  the  compres.sed  lung. 
The  upper  line  of  fluid  can  hardly  ever  be  so  sharply 
mapped  out  in  empyema  as  in  serous  effusion,  owing  to 
its  irregular  limitation  by  adhesions  and  the  usual  conco- 
mitant pneumonic  infiltrations.  The  determination,  by 
percussion,  of  small  effusions  may  be  quite  impossible. 
In  empyema  of  the  left  side,  dulness  over  Traube's  sjiace 
is  very  characteristic.  Auscultation  fails  to  give  as  accu- 
rate and  reliable  results  as  in  adults.  We  usually  have 
bronchial  breathing,  sometimes  hardly  at  all  diminished  in 
intensity  over  the  affected  area  ;  entire  absence  of  respi- 
ratory sounds  is  verj-  exceptional.  It  will  be  useful  to  re- 
member that  rales  over  the  dull  area  speak  decidedly 
against  fluid,  while  faint  and  distant  respiration  denotes 
its  probable  presence.  Friction  sounds  are  exceedingly 
rare.  If  the  child  is  crying,  as  it  usually  is,  we  may  ob- 
tain more  information.  The  voice  over  a  pleuritic  exudate 
is  almost  always  faint  and  distant,  and  increased  vocal 
fremitus  is  the  best  auscultatory  sign  we  have  for  exclud- 
ing fluid.  Differential  diagnosis  is  especially  to  be  made 
from  pneumonia  and  indmonary  abscess  and  gangrene. 
Exploratory  puncture  must  be  employed  to  settle  the  diag- 
n(.>sis  in  doubtful  eases. 

The  Treatment  of  Supra-Condyloid  Fracture  of  the  Hu- 
merus.— By  A.  K.  Shands.  When  the  least  doubt  exists 
as  to  the  position  of  the  broken  fragments  of  the  broken 
bone,  the  .i-ray  should  be  employed.  The  broken  ends 
should  be  brought  into  the  best  possible  approximation 
and  held  there  until  union  is  firm  :  when  it  is  impossible 
to  obtain  a  perfect  approximation,  an  incision  should  be 
made  exposing  the  fragments  to  view,  which,  when  put  in 
the  desired  relation,  the  one  to  the  other,  should  be  secured 
there  by  some  extraneous  means.  There  are  many  condi- 
tions that  may  oppose  this  end.  such  as  intervening  tissue 
and  muscular  action,  especially  when  the  line  of  fracture 
is  oblique.  His  ])reference  is  to  drill  a  hole  through  the 
fragments  and  then  to  suture  them  in  position  with  kanga- 
roo tendon.  When  the  fracture  is  oblique,  he  has  found  the 
tendency  for  the  fragments  to  override  each  other  so  great 
that  suturing  did  not  do  so  well.  In  tliese  ca.ses  he  has  left 
the  drill  in,  which  is  a  perfect  method  of  holding  the  frag- 
ments !i!  si/u.  He  uses  a  drill  that  is  long  enough  to 
liroject  through  the  dressings,  including  the  plaster  of 
Paris.  Tlie  operation  being  done  under  the  strictest  an- 
tiseptic conditions,  the  wtmnd  is  closed  and  the  drill  is  re- 
moved at  the  end  of  the  second  week  ;  the  little  wound 
closes  almost  at  once. 

A  Case  of  Superimposed  Uvula. — By  T.  A.  iJe  Blois. 
The  writer  found  on  exannnijig  the  throat  of  a  young  man 
tliat  while  the  anterior  pillars  appeared  normal  and  there 
seemed  to  be  a  perfectly  formed  uvula,  there  hung  from 
the  posterifir  pillar  a  second  uvula  almost  masked  by  the 
first.  This  additional  oiijan  was  removed  with  the  gal- 
vano-cautery  snare,  wliereupiui  the  from  uvula  I'ell  right 
back  into  the  median  line.  Tile  part  removed  api)eared 
normal  in  structure. 

The  Combination  of  a  Plaster-of-Paris  Jacket  with  a  Brace 
to  Correct  and  Retain  Correction  of  the  Kyphosis  of  Pott's 
Disease  of  the  Spine.     P>\  .\.  M.  Forbes. 

A  Report  upon  One  Hundred  and  Seventy  Cases  of  Appen- 
dicitis.—Hy  K.  T.  Morns. 

Intraspinal  Cocainization  from  the  Anaesthetist's  Stand- 
point.—By  .S,  O.  Col, Ian. 

Recrudescing  Angina  due  to  Friedlander's  Bacillus.— By 
Kniil  .Mayer. 

.Miiiiiiil  Xi'-.os.  lh\i'in/)fr  2j,  n^oo. 

The  Treatment  of  Bronchitis  in  Infants  and  Young  Chil- 
dren.—Samuel  S.  .Adams  liclieves  that  the  treatment  of 
Ijronchitisin  infants  and  young  children  is  largely  dependent 
upon  tae  etiology  of  the  disease.     The  disease  may  be  pri- 


December  29,  19CK)] 


MEDICAL    RECORD. 


1019 


mary  or  secondary.  It  may  be  excited  by  cold  or  atmo- 
splieric  conditions  or  by  microbial  irritants.  It  is  usually 
sporadic,  but  may  become  epidemic.  Prophylaxis  consists 
in  attenliou  to  the  laws  of  hygiene.  Attempts  to  abort 
bronchitis  by  a  hot  foot  bath,  free  i>urjjiiig.  and  profuse 
sweating  are  seldom  successful.  Local  measures  are 
often  beneficial.  The  turpentine  stupe  or  mustard  jjastc 
may  be  used.  Inhalations  of  medicated  vapors  arc  valua- 
ble, t'.,t'.,  tincture  of  benzoin,  eucalyptol,  carbolic  acid,  etc. 
Expectorants  are  not  well  bf)rne  by  infants.  In  the  dry 
stage  of  the  disease  small  doses  of  ammonium  i(>di<le  in  an 
agreeable  menstruum,  to  which  a  few  drops  of  syrup  of 
ipecac  are  added,  will  hasten  the  secretion.  Opiates  should 
be  withheld  as  long  as  possible,  but  when  necessary  a 
little  codeine  or  paregoric  may  be  given.  Emetics  are  sel- 
dom indicated.  Cardiac  stimulants  are  lecpiired  in  most 
severe  cases.  Respiratory  stimulants  are  required  in  a  few 
cases.  Jacobi's  plan  of  flagellation,  which  causes  the  in- 
fant to  cry,  will  relieve  feeble  respiration  and  ])assivc  ]m\- 
monary  congestion.  The  general  hot  bath  is  good.  ().\y- 
j;en  may  relieve  the  feeling  of  suffocation  temporarily. 

Some  Notes  on  the  Treatment  of  Rheumatism. ^Alfred 
Stengel  states  that  in  considering  the  (piistioii  of  rheuma- 
tism several  fundamental  facts  must  be  recognized  :  i. 
The  tendency  in  many  cases  of  this  disea.se  toward  spon- 
taneous recovery.  2.  Complications  are  frequent  ;uid  arc 
more  likely  to  occur  in  protracted  cases  than  in  those  oi 
short  duration.  3.  The  complications  are  juobably,  as  a 
rule,  secondary  to  the  joint  disease  and  not  to  the  infective 
lesion  that  was  the  primary  focus.  Of  the  drugs  u.sed  in 
treating  rheumatism  the  derivatives  of  salicylic  acid  occupy 
the  first  place.  The  rapidity  and  thuroughuess  of  action 
indicate  a  relationship  of  the  drug  to  the  disease  or  some 
cases  of  the  disease  that  warrants  a  place  near  to  the  rem- 
edies we  term  specifics.  The  simultaneous  or  separate  use 
of  salicylate  of  methyl,  apjilied  to  the  skin  in  the  form  of 
a  ten-per-cenl.  or  twenty-per-cent.  ointment  and  covered 
with  lint  and  oiled  silk,  is  extremely  satisfactory.  In  cer- 
tain cases  of  polyarticular  rheumatism  which  <Ii>  not  yield 
to  treatment  with  salicylic  acid  omibined  with  rest,  gun 
eral  tonics  are  often  effective.  The  writer  has  employed 
bichloride  of  mercury  in  small  doses  with  good  effect. 
Thus  far  no  useful  results  from  serum  treatment  have 
been  obtained.  The  writer  speaks  also  of  casts  and  the 
fixation  method  for  affected  joints. 

Report  of  Two  Cases  of  Sporadic  or  Family  Trichinosis ; 
with  Remarks  on  the  Importance  of  Eosinophilia  in  the 
Peripheral  Circulation  as  an  Aid  to  Diagnosis.  —  Hy  Hermon 
C  (jordiniur. 

A  Rapid  and  Simple  Operation  for  Gall  Stones,  Found  by 
Exploring  the  Abdomen  in  the  Course  of  a  Lower  Abdominal 
Operation. — By  Howard  A.  Kelly. 

Fatal  Angina  Pectoris  without  Lesions  of  the  Coronary 
Arteries  in  a  Young  Man. — By  T,  K.  Bullard. 

The  Surgery  of  the  Gasserian  Ganglion. — Bv  Wallace 
Neft". 

Bos/oit  MeU.  aiul  Siirt^iiiil  /i<iirnal,  Th-c.  ij  and 20,  nfoo. 

The  Results  of  Operations  on  Varicose  Veins. — J.  B.  Blake 
considers  tliat  the  conditions  whicli  will  jirobably  militate 
against  satisfactory  results  are  :  old  age  or  extreme  debil- 
ity :  excessive  or  very  extensive  varicosity ;  occupations 
whicli,  to  an  extraordinary  degree,  favor  the  development 
of  varicose  veins.  Cases  which  may  be  cured  by  a  thor- 
ough and  careful  operation  are:  Local  varix,  particularly 
if  thrombosis  has  occurred,  either  in  thigh  or  lower  leg; 
extensive  varix  limited  10  a  single  venous  stem  ;  varicosi- 
ties which  are  a  bar  to  passing  civil  service,  military  or 
naval  examinations  ;  cases  in  youth  and  middle  life  ;  cases 
in  which  the  development  of  the  permanent  varicosity  was 
at  least  partially  due  to  more  or  less  reniovaijle  conditions 
(rtatfoot,  garters,  etc.).  Operation,  even  if  not  entirely 
successful,  will  usually  relieve  such  complications  as 
thrombosis,  hemorrliage,'  and  ulceration,  'i'iie  usual  con- 
ditions which  follow  unsuccessful  o])erations  are:  Pain  in 
and  around  the  scar;  general  swelling  and  tenderness  of 
the  leg;  develoi>inent  of  varicosities  above  or  below  the 
operation  scar,  but  not  at  the  site  of  the  operation  itself. 
In  all  operated  cases,  general  systemic  as  well  as  local 
treatment  should  be  i>rescribed,  together  with  exercise  and 
the  avoidance  of  a  continued  upright  position  wherever 
possible. 

The  Value  of  the  Hot-Water  Immersion  Bath  in  the  Treat- 
ment of  Threatening  Puerperal  Eclampsia.  —  Charles  M. 
<lreen  believes  that  the  hot-air  bath  is  most  api)ropriately 
used  in  the  treatment  of  actual  eclampsia.  'I'he  hot  wet 
pack  is  often  successful  in  its  results,  but  when  circum- 
stances permit  its  use  the  hot-water  immersion  bath  more 
satisfactorily  meets  the  indications.  Not  only  does  it  pro- 
<luce  profuse  diaphoresis  and  reduce  blood  tension,  but  it 
acts  as  a  marked  sedative  to  the  ner\-ous  system.  The 
bath  is  easily  administered  to  a  conscious  patient,  the  aid 


of  a  single  assistant  being  sufficient.  The  water  should 
be  as  hot  as  can  be  borne,  and  the  patient  should  remain 
therein  until  pnjfuse  jjeispiration  of  the  face  shows  that 
the  sweat  glands  are  in  full  activity.  If  the  heart's  action 
is  at  all  weak,  it  is  wise  to  administer  brandy  before  im- 
mersion. When  free  perspiration  has  been  induced  the 
patient  should  be  rolled  in  a  blanket,  ])laced  in  a  warm 
bed,  and  covered  with  several  blankets  and  ])erhaps  a  rub- 
ber sheet.  The  author  gives  a  number  of  cases  illustrating 
the  good  effects  of  these  baths. 

A  Plea  for  Larger  Doses  of  Antitoxin  in  the  Treatment 
of  Diphtheria. — John  11.  McCollom  says  that  the  clinical 
observation  of  nearly  eight  thousand  cases  of  diphtheria 
justify  the  following  conclusions  :  That  the  ratio  of  mortal- 
ity of  diphtheria  Jier  ten  thousand  of  the  living  was  very 
high  in  Boston  previous  to  1895.  That  this  mortality  has 
been  greatly  leiluced  since  the  introduction  of  antitoxin. 
That  the  percentage  c)f  mortality  in  the  south  department 
is  lower  than  that  of  any  of  the  hosi)itals  taken  for  com- 
parison. That  since  larger  doses  of  antitoxin  have  been 
given,  the  death  rate  has  been  materially  reduced,  this  re- 
duction having  occurred  in  the  apparently  moribund  cases. 
That  no  injurious  effect  has  followed  the  use  of  the  serum. 
That  to  arrive  at  the  most  satisfactory  results  in  the  treat- 
ment of  diphtheria  antitoxin  should  be  given  at  the  earliest 
|)ossible  moment  ill  the  course  of  the  disease. 

Remarks  upon  Questions  Arising  during  the  Removal  of 
Fibroids,  with  Especial  Reference  to  the  Technique  of  the 
Operation.- -P. \'  Maurice  II.  Kichanlsoii. 

Notes  from  the  Neurological  Department  of  the  Massachu- 
setts General  Hospital.  IV.  Case  of  Myasthenia  Gravis 
Pseudo-Paralytica.— By  W.  V..  Paul. 

A  Contribution  to  the  Therapeutic  Action  of  Heroin. — By 
Beriiar<l  Lazarus. 

Cases  of  Acute  Oral  Inflammation. — By  John  C.  Munro. 

Pericarditis  with  Effusion.  -By  ("icorge  G.  Sears. 

/our  It  a  I  0/  I  III-  .l)iiiriiiiii  Miu/icii/  Ass'  11,  Dci.  22,  igoo. 

Symmetrical  Development,  or  does  Our  Present  School  Sys- 
tem Develop  the  Highest  Powers  of  the  Pupil?  L.  Stuver 
concludes  that:  i.  The  pliysical.  intellectual,  and  moral 
jiowers  of  the  jiupils  should  be  developed  at  the  same  time. 
2.  Parents  and  teachers  should  realize  that  in  its  develop- 
ment the  child  is  an  epitome  of  the  development  of  the 
race  and  possesses  many  characteristics  of  the  savage, 
barbarous,  and  semi-civilized  races,  and  that  instruction 
must  ever  be  adapted  to  its  changing  needs.  3.  The  suc- 
cessful teacher  must  understand  his  own  powers  and  limi- 
tations ;  he  must  understand  the  growing  inipil  and  be  able 
to  put  himself  in  the  hitter's  (ilace  ;  he  should  have  a  more 
comprehensive  knowledge  of  the  laws  of  mental  develop- 
ment, a  better  understanding  of  educational  methods,  and 
the  best  means  of  imparting  instruction.  He  should  be 
better  paid  and  thus  encouraged  to  make  teaching  a  life- 
work.  4.  More  enthusiasm  is  needed  and  less  routine ; 
more  original  investigation  and  search  after  truth  for  the 
truth's  sake,  and  less  cramming  for  examinations;  less 
talking  and  lecturing  on  the  part  of  the  teacher,  and  more 
time  devoted  to  training  pujiils  in  systematic  and  logical 
analysis,  and  in  clearness  and  accuracy  of  expression.  5. 
So  many  studies  should  not  be  pursued  at  the  same  time. 
The  number-drill  and  arithmetic,  together  with  other 
formal  and  abstruse  work,  should  be  greatly  curtailed  for 
the  younger  children  and  more  time  be  given  to  the  study 
of  natural  objects  in  their  n;itural  surroundings.  6.  ilore 
time  should  be  given  to  manual  training.  7.  (Jreatercare 
should  be  exercised  in  promoting  the  health  and  proper 
physical  development  of  the  pupils.  8.  All  harsh  and  dan- 
gerous punishments  should  be  banished  from  the  schools. 

The  Antecedents  of  Organic  Heart  Disease  in  Children. — 
I'rederick  .V.  Packard  from  a  study  of  seventy-five  histories 
gleans  the  following  facts  :  Rheumatism  occurred  in  only 
34  of  the  cases,  chorea  in  id,  scarlet  fever  in  1 1,  diphtheria 
in  S,  while  in  14  of  the  cases  none  of  these  diseases  had 
been  experienced  by  the  child.  If  the  small  control  series 
of  cases  can  be  taken  as  any  guide,  it  would  seem  that 
measles,  varicella,  whooping-cough,  and  typhoid  fever 
have  littleor  no  influence  in  the  production  of  endocarditis. 
Therefore  many  instances  of  inflammatory  lesions  of  the 
endocardium  must  be  attributed  to  the  slighter  infections, 
such  as  coryza,  various  skin  lesions,  affections  of  the 
mucous  membranes  of  the  throat  and  nose,  and  the  infec- 
tions of  the  gastro-intestinal  tract.  The  study  of  these 
cases  emphasizes  the  necessity  of  a  careful  examination 
of  the  heart,  both  during  and  after  slight  infections. 

Separation  of  the  Recti  Abdominis  Muscles  and  Stretching 
of  the  Linea  Alba;  Unnoticed  Factors  in  the  Production  of 
Abdominal  and  Pelvic  Disturbances  in  Women. — By  J.  Clar- 
ence Webster. 

Arthritis  Deformans ;  its  Clinical  Features ;  Differential 
Diagnosis  and  Pathogenesis. — By  Aloysius  <■).  J    Kelly. 


I020 


MEDICAL    RECORD. 


[December  29,  1900 


The  Control  and  Prevention  of  Ear  Diseases  among  School 
Children. — By  Louis  J.  Lautcnbacli. 
The  Essential  Factors  for  the  Cure  of  Hernia  in  the  Male. 

—By  Henry  O.  Marcy. 

Improved  Technique   for  the  Cure  of  Ventral  Hernia. — By 
M.  M.  Johnson. 

Treatment  of  Hernia  in  Children.— By  A.  J.  Ochsner. 

Hydrencephalocele. — By  Carl  Beck. 

J'/ii/i>,/c-/p/iia  Mi'dical  Journal,  December  22,  igoo. 

The  Use  and  Abuse  of  Zoological  Names  by  Physicians.—* 

Ch.  Warden  Stiles  stales  that :  It  is  incumbent  ui^on 
physicians  to  follow  zoological  customs  in  dealing  with 
zoological  subjects,  as  it  is  incumbent  upon  zoologists  to 
govern  themselves  by  the  code  of  medical  ethics  in  deal- 
ing with  medical  cases.  He  adds  that  the  terminology  in 
medicine  is  more  or  less  subjective  and  based  upon  author- 
ity, without  being  bound  by  any  regularly  adopted  national 
or  international  rules.  In  zoology  the  nomenclature  is  ob- 
jective, based  upon  priority  instead  of  authority,  and  sub- 
ject to  certain  iron-clad  rules  and  regulations,  the  result  of 
a  century  and  a  half  of  study,  and  adopted  by  tlie  national 
and  international  congresses  ;  they  are  known  as  the  code 
of  nomenclature.  To  take  a  few  examples  of  the  liberties 
physicians  take  with  zoological  terms :  Amibi  coli  is  the 
technical  name  of  a  zoological  object,  and  it  should  be 
written  as  above  or  Amoeba  coli ;  many  write  it  Ameba 
coli,  but  this  latter  spelling  is  confusing  and  has  no  zoolog- 
ical authority.  Taenia  is  the  name  of  a  genus  of  tape- 
worms and  was  proposed  by  Linnaeus  in  175S.  Some  write 
it  Tenia,  and  others  use  Tinea,  but  Tinea  is  the  name  of  a 
genus  of  lepidoptera,  while  Tenea  is  a  genus  of  mollusk.s. 
Since  in  zoology  there  are  several  million  systematic 
names,  every  genus  must  have  a  distinct  generic  name, 
and  every  species  in  a  genus  must  have  a  specific  name 
distinct  from  the  name  of  every  other  species  in  that 
genus.  These  facts  make  it  imperative  that  the  rigid  rules 
which  have  been  adopted  governing  the  use  of  these  names 
be  enforced. 

Angina  Ludovici. — G.  G.  Ross  declares  that  Ludwig"s 
angina,  or  phlegmonous  cellulitis  of  the  floor  of  the  mouth, 
is  a  comparatively  rare  affection.  The  tissue  affected  is 
rich  in  lymphatics  and  blood-vessels  and  contains  the  ducts 
of  the  sublingual  and  submaxillary  glands.  The  disease 
may  be  either  primary  or  secondary.  In  true  angina  Ludo- 
vici the  infection  is  essentially  primary.  The  point  of  en- 
trance is  in  the  mouth  proper,  and  the  disease  manifests 
itself  primarily  in  the  floor  of  the  mouth,  and  secondarily 
in  the  pharynx  and  larynx.  The  pathology  is  very  simi- 
lar if  not  identical  with  that  of  erysipelas.  The  organ- 
isms which  have  been  discovered  are  the  streptococcus  and 
the  staphylococcus.  G.  Leterier  has  collected  thirty-one 
cases  with  thirteen  recoveries.  This  series  includes  cases 
collected  from  old  literature.  The  symptoms  are  marked 
from  the  onset,  developing  rapidly.  They  are  very  severe. 
Locally,  there  is  a  hard  swelling,  which  spreads,  however, 
till  it  involves  the  neck  and  face.  Respiration  is  impeded. 
Deglutition  becomes  diflicult  or  impossible.  A  marked 
general  sepsis  follows  the  local  condition.  The  writer  re- 
ports two  cases.  The  clinical  manifestations  and  patho- 
logic finds  so  nearly  resemble  erysipelas  that  in  an  active 
surgical  hospital  these  cases  should  be  isolated. 

The  Diagnosis  of  Calculous  Disease  of  the  Kidneys,  Ure- 
ters, and  Bladder  by  the  Roentgen  Method.— By  Charles 
Lester  Leonanl. 

Primary  Carcinoma  of  the  Pancreas,  with  Reports  of  Four 
New  Cases. — By  Frederick  A.  Baldwin. 

Acute  Infective  Endocarditis  following  Vaccination ;  Re- 
covery.— By  Warren  Coleman. 

Composite   Teratoma   of   the  Ovary ;   Pathologic  Report. — 

By  Edgar  Allen  Jones. 

A  Case  of  Deciduoma  Malignum.— By  Joseph  JIcFarland. 
A  New  Photographometer.  — By  John  Jlilton  Garratt. 
Dermatomycosis  Tonsurans. —  By  W.  B.  Reid. 

T he  I.aneel,  December  S  and  /j,  igoo. 

Concerning  Certain  Apparently  Injurious  Constituents  of 
Potable  Spirits.— By  Lauder  Brunton  and  F.  W.  Tunni- 
cliffe.  The  main  points  in  which  potable  spirits  differ 
inter  se  are  with  regard  to  their  aldehyde,  compound  ether, 
fusel  oil,  and  certain  volatile  base  contents.  This  article 
has  to  do  with  a  special  aldehyde — furfural.  This  comes 
from  a  class  of  substances  known  as  pentosanes  derived 
from  the  cellulose  of  grain  husks.  Furfural  can  be  detected 
in  whiskey  by  adding  to  a  drachm  of  the  latter  in  a  test 
tube  an  equal  volume  of  water  and  then  a  few  drops  of  a 
sodium-carbonate  solution  and  then  a  few  drops  of  aniline- 
acetate  solution.  If  the  tube  be  shaken  up  and  allowed  to 
stand  a  rose-pink  color  will  develoj).  Injections  of  furfu- 
ral in  cats,  dogs,  and  rabbits  caused  paralysis  of  the  vol- 


untary muscles,  later  clonic  and  tonic  convulsions,  with 
rapid  and  irregular  breathing.  Rapid  recovery,  however, 
was  the  rule.  In  addition,  spirits  containing  the  furfural 
and  spirits  free  therefrom  were  given  to  animals  with  a 
view  to  comparison  of  effects.  Speaking  generally  it  was 
found  that  the  return  from  what  may  be  termed  profound 
drunkenness  in  the  cases  of  animals  was  more  sudden  and 
was  accompanied  by  less  secondary  symptoms  when  alde- 
hyde-free spirit  had  been  given.  The  interest  of  these 
ob.servations  lies  in  the  fact  that  these  disagreeable  symp- 
toms, which  seem  analogous  to  those  occurring  in  the  hu- 
man subject  after  too  free  potations,  seem  to  be  more  refer- 
able to  the  aldehydes  in  the  spirit,  including  furfural,  than 
to  the  s])irit  itself  or  any  higher  alcohols.  Fusel  oil  was 
jjresent  in  the  spirit  both  before  and  after  distillation. 

_  Dietetic  Problems.— Abstract  of  the  Purvis  lecture  by  G. 
V.  Poore.  After  alluding  to  some  of  the  advances  made 
in  the  dietary  of  the  sick,  the  lecturer  cautioned  his  hearers 
against  looking  too  exclusively  at  the  chemistry  of  food. 
Who  when  they  ate  considered  whether  they  were  taking 
too  much  carbohydrate  or  too  much  proteid?  It  was  what 
they  digested  that  did  good,  and  this  depended  on  whether 
it  was  savory  and  stimulating  to  the  glands  of  the  palate, 
and  so  forth.  If  a  person  sat  down  to  a  rejiast  selected  so 
as  to  contain  a  certain  percentage  of  proteids  it  was  very 
likely  that  the  stomach  would  rebel.  He  thought  that 
there  was  too  much  of  this  sort  of  thing  and  that  phvsio- 
logical  chemistry  was  doing  itself  no  good  by  it.  He  could 
not  help  thinking  sometimes  that  there  were  manufactur- 
ing firms  who  kept  chemists  very  much  as  advertising  tail- 
ors used  to  keep  poets  and  for  the  same  reason.  In  conclu- 
sion, Dr.  Poore  referred  to  "  shop  eggs  "  and  to  the  difference 
between  fresh  and  frozen  meat.  He  aLsogave  a  humorous 
account  of  a  visit  to  a  village  on  a  Saturday  night  where 
the  grocers'  shop-windows  were  filled  with  potted  vegeta- 
bles and  where  the  smell  from  shops  in  which  slabs  of 
semi-transparent  flabbiness  were  frying  in  oil  could  be 
appreciated  a  quarter  of  a  mile  away.  Replying  to  a  note 
that  was  handed  to  him  asking  for  his  opinion  on  the  doc- 
trine of  not  taking  any  meat,  he  said,  "All  flesh  is  as 
grass." 

The    Bowel-Lesion   of    Typhoid   Fever.— T.   J.    Maclagan 

enumerates  as  the  special  points  to  be  considered  the  fol- 
lowing:  (I)  That  the  structures  on  which  the  typhoid  ba- 
cillus exercises  its  specific  effects  are  the  solitary  and  agmi- 
nated  glands  situated  in  the  submucous  coat  of  the  small 
intestine.  (2)  That  the  change  which  it  causes  in  these 
glands  is  inflammatory  in  nature  and  essentially  consists 
in  proliferation  of  their  cellular  and  granular  contents, 
with  consequent  swelling  and  hardening  of  the  glands. 

(3)  That  this  inflammation  is  generally  sufficiently  severe 
to  cause  gangrene  and  sloughing  of  the  affected  glands. 

(4)  That  the  direct  action  of  the  typhoid  bacillus  is  limited 
to  the  glands  of  the  submucous  coat ;  and  that  it  has  no 
direct  action  on  the  mucous,  muscular,  or  peritoneal  coats. 

(5)  That  the  sloughing  process  which  destroys  the  glands 
necessarily  also  destroys  the  mucous  membrane  situated 
over  them.  (0)  That  with  the  process  of  sloughing  and 
suppuration  there  come  into  play  other  and  new  morbid 
agencies,  the  various  forms  of  cocci  associated  with  these 
processes.  (7)  That  to  these  new  agencies  rather  than  to 
the  typhoid  bacillus  are  to  be  attributed  all  the  more  seri- 
ous complications  and  all  the  formidable  symptoms,  gen- 
eral as  well  as  local,  which  are  apt  to  show  themselves 
during  the  third  and  fourth  weeks  of  the  disease. 

A  Peculiar  Case  of  Purpura. — II.  W'.  Spraight  reports  the 
case  of  a  girl  of  nine  whose  whole  body,  including  the  face 
and  the  scalp,  was  covei'ed  with  purpuric  spots,  varying 
from  petechiae  to  large  ecchymoses.  When  slie  was  going 
to  bed  on  the  night  before,  the  patient  had  noticed  some 
dark-red  .spots  about  her  abdomen  and  thorax,  and  in  the 
morning  she  found  her  body  covered  with  purple  spots. 
She  felt,  and  appeared  to  be,  in  perfect  health.  She  was 
not  an;emic  and  had  not  been  ill  since  she  was  four  years 
old,  when  she  had  measles.  There  was  no  history  of 
scurvy,  rheumatism,  or  hiemophilia.  Her  family  history 
was  good.  Next  day  hemorrhages  occurred  from  patches 
on  the  limbs  and  continued  during  the  following  day,  when 
haematemesis,  ha.'moptysis,  mcla."na.  epistaxis.  and  bleed- 
ing from  the  ears  came  on  and  continued  until  the  second 
day  after.  During  these  three  days  the  patient  had  no 
symi)toins  besides  those  of  hemorrhage.  On  the  following 
day  the  patches  on  the  limbs  began  to  fade,  and  five  days 
later  the  skin  looked  perfectly  clear  and  healthy.  She  was 
treated  medicinally  with  v\  ii.  of  Fowler's  solution  and 
"  i.  of  compound  syrup  of  phosphate  of  iron,  three  times 
daily. 

Suggestions  for  the  Practical  Treatment  of  Typhoid  Fever. 
— W.  Kwart  says  that  until  we  shall  find  a  germicidal  cure 
for  this  disease  our  efforts  must  be  confined  to  limiting  the 
extent  of  ulceration,  treating  the  ulcers,  and  obviating 
their  giving  rise  to  hemorrhage  and  perforation.     He  finds 


December  29,  1900] 


MEDICAL    RECORD. 


1021 


danger  iu  the  stagnation  of  putrid  feces,  relative  inactiv- 
ity of  the  liver,  and  distention  of  the  thinned  and  ulcerated 
membrane.  He  finds  it  a  good  plan  to  keep  the  patients 
lying  in  bed  so  as  to  be  slightly  inclined  to  the  left  side. 
This  position  seems  to  facilitate  the  emptying  of  the  ca;- 
cum.  Internally  lie  advises  the  administration  of  \i\,  x.x. 
of  the  liquor  hydrargyri  perchloridi  (B.  P.j  with  m  xv.  of 
the  tinctura  ferri  perchloridi  flavored  with  orange  or  lemon 
given  in  an  ounce  of  water  every  si.\  hours  throughout  the 
attack  and  for  ten  days  after  to  prevent  relapse. 

Notes  of  Two  Cases  of  Foreign  Body  in  the  Air  Passages. 
— By  E.  F.  Syrett.  In  neither  of  the  cases  was  the  pres- 
ence of  a  foreign  body  suspected,  and  in  neither  were  there 
any  urgent  symptoms  i)resent.  Case  I.  was  that  of  a  boy 
of  thirteen  years  with  evidences  of  involvement  of  entire 
right  lung,  whose  condition  went  on  to  convalescence  and 
who  some  two  months  later  coughed  up  a  cherry-stone 
which  it  was  afterward  learned  must  have  been  in  the 
bronchus  for  thirteen  weeks.  Case  II.  was  that  of  a  woman 
of  thirty-three  years  who  had  swallowed  a  wisdom  tooth 
during  its  extraction  by  a  dentist.  It  was  expelled  twelve 
days  later. 

A  Case  of  Puerperal  Septicsemia  Treated  by  Anti-Strepto- 
coccus Serum  ;  Complicated  by  Pulmonary  Embolism,  Peri- 
metritis, and  Axillary  Abscess ;  Recovery.  By  B.  T.  Read. 
The  episodes  of  the  case  arc  sufficiently  indicated  in  the 
title.  Serum  was  injected  in  doses  of  lo  c.c.  daily  for  over 
a  week.  The  author  believes  that  recovery  in  this  case 
can  be  directly  attributed  to  its  use. 

A  Case  of  Morphine  Poisoning  Treated  by  Atropine. — By 
E.  Ciround.  The  patient  was  a  man  of  sixty-one  years  who 
was  supposed  to  liave  taken  a  little  over  four  grains  of 
morphine.  In  all  about  one-eighth  of  a  grain  of  atropine 
was  given,  together  with  the  use  of  potassium  permanga- 
nate.    Recovery  ensued. 

The  Condition  Three  Years  after  Operation  of  Fifty  Suc- 
cessful Consecutive  Ovariotomies ;  Five  Patients  Lost  Sight 
of,  Thirty-two  in  E.xcellent  Health,  Seven  Cases  Not  Quite 
Satisfactory,  Three  Unsatisfactory,  and  Three  Patients  Dead. 
—  By  John  1).  .Malcolm. 

A  Case  of  Complete  Transverse  Septum  of  the  Vagina 
Impeding  Delivery;  Urethral  Coitus. — By  E.  Rumley  Daw- 
son. 

Prognosis  and  Treatment  in  Pulmonary  Tuberculosis.— 
Second  Harveian  lecture,  by  Robert  Maguire. 

Prognosis  and  Treatment  in  Pulmonary  Tuberculosis. — 
Third  Harveian  lecture  by  Robert  Maguire. 

Symptoms  of  Arsenical  Poisoning  Produced  in  a  Young 
Child  from  Drinking  Beer. — By  J.  Brown. 

Operative  Teatment  of  Fibroid  Tumors  of  the  Uterus. — 
Clinical  lecture  by  Edward  Malins. 

An  Obscure  and  Complicated  Case  of  Carcinoma  of  the 
Stomach.— By  C.  I'.  .Steele. 

The  Treatment  of  a  Case  of  Acute  Dilatation  of  the  Stom- 
ach. — By  George  Coates. 

Psoriasis  with  Insanity  ;  Thyroid  Treatment ;  Recovery. — 
By  H.  de  -M.  Alenaiider. 

A  Note  on  Excision  of  Wrist-Joint  by  a  Transverse  In- 
cision.— By  J.  C.  Retiton. 

Mercurol  as  an  Antiseptic  in  Diseases  of  the  Nose  and 
Ear. — By  Richard  Lake. 

An  Instance  of  Extensive  Enteric  Rash  in  Childhood. — By 
Arthur  Maude. 

A  Case   of  Arsenical   Beer   Poisoning.— By  J.  H.   Bailey. 

British  Medical  Jotirnaly  December  /j,  igoo. 

A  Clinical  Lecture  on  Polyorrhomenitis,  or  Combined  Serous 
Inflammations. — Frederick  Taylor  reports  the  case  of  a 
woman  aged  thirty-nine  years  who  was  admitted  to  the 
hospital  for  pain  and  swelling  in  the  abdomen.  It  was  a 
case  of  ascites,  and  the  point  to  be  determined  was  the 
nature  of  the  origin  of  the  peritoneal  effusion.  The  choice 
in  this  case  seemed  to  lie  between  tuberculous  peritonitis 
and  cirrhosis  of  the  liver.  Dulness  at  the  base  of  the  left 
chest  was  discovered  which  in  a  few  days  increased  in  an 
upward  direction.  It  then  seemed  probable  that  the  case 
consisted  of  a  liquid  effusion  into  the  pleura  as  well  as  into 
the  peritoneum.  Thereupon  the  diagnosis  of  tubercle  be- 
came more  probable,  and  that  of  cirrhosis  was  out  of 
count  as  explanatory  of  the  whole  case,  though  it  was  con- 
ceivable that  an  ascites  from  cirrhosis  might  coexist  with 
an  independent  pleural  effusion  arising  in  some  other  way 
Still  another  disease  would  account  for  the  simultaneous 
existence  of  pleural  with  peritoneal  effusion — heart  disease 
causing  passive  effusions  into  both  these  cavities.  But 
there  was  no  evidence  that  the  valvular  apparatus  of  the 
heart  was  actually  upset.  Polyorrhomenitis  may  be  acute 
or  subacute  or  chronic,  and  the  causes  of  these  varieties 
are  likely  to  be  different.     One  cause  of  the  acute  form  is 


the  pneumococcus.  There  may  be  also  a  streptococcal  or 
staphylococcal  invasion.  Rheumatic  fever  is  sometimes 
the  cause  of  the  acute  form.  Now  and  then  the  tubercle 
bacillus  is  found,  but  it  plays  its  most  important  part  in 
relation  to  chronic  and  subacute  inflammations,  and  is  by 
far  the  most  frequent  cause  of  them.  Polyorrhomenitis  is 
more  frequent  in  males  than  females,  and  the  majority  of 
the  cases  occur  between  tlie  ages  of  sixteen  and  thirty.  It 
is  generally  the  peritoneum  which  is  first  attacked,  then  fol- 
low the  pleura-,  as  a  rule  the  riglit  one  first.  Pericarditis 
generally  follows  a  pleurisy,  especially  a  left-sided  ])leurisy. 
The  inflammation  may  first  involve  one  pleura,  then  the 
peritoneum,  then  the  other  pleura.  The  duration  is  vari- 
able. The  prognosis  in  general  must  depend  very  much 
on  the  cause.  Tuberculous  peritonitis,  c.j,''.,  is  ]irobably 
fatal  in  more  than  half  the  cases  ;  pleurisy  is  directly  fatal 
in  much  less;  but  the  associated  lesion  is  not  likely  to  be 
less  fatal  than  the  more  fatal  of  the  two  operating  alone. 
The  treatment  must  be  conducted  on  the  lines  of  the  treat- 
ment of  the  separate  tuberculous  lesions  concerned. 

Myokymia,  or  Persistent  Muscular  Quivering.^R.  T.  Wil- 
liamson reports  a  case  of  this  kind,  the  patient  being  a 
young  man  of  twenty-one  years.  The  quivering,  which  had 
begun  in  the  mu.scles  of  the  right  leg,  spread  to  the  muscles 
of  the  limbs,  trunk,  and  face.  It  was  persistent.  During 
the  four  weeks  he  was  at  the  hosjiital  there  was  no  definite 
change.  The  writer  has  found  eight  cases  in  medical  rec- 
ords, the  ages  varying  from  twenty-one  to  seventy-one, 
years.  All  were  males.  In  all  the  legs  were  most  affected. 
The  treatment  in  the  cases  in  which  recovery  occuned  was 
by  warm  baths  and  galvanism,  by  bipolar  faradic  baths,  and 
by  rest  in  bed.  Sodium  salicylate  has  been  recommended. 
The  cau.se  and  pathology  of  this  peculiar  affection  are  at 
present  unknown. 

Quinine  Hsemoglobinuria. — A.  G.  Welsford  reviews  two 
interesting  cases  of  this  nature.  It  is  of  very  rare  occur- 
rence. H;emoglobinuria  maybe  produced  by  several  poi- 
sons, among  whicli  are  potassium  chlorate,  carbolic  acid. 
an<l  arseniuretted  hydrogen.  It  is  in  this  category  that 
cpiinine  luemoglobiiiuria  must  be  placed. 

A  Case  of  Varicose  Aneurism  of  the  Aorta  Communicating 
with  the  Pulmonary  Artery.— By  J.  Michell  Clarke. 

The  Harveian  Lectures  on  Prognosis  and  Treatment  in 
Pulmonary  Tuberculosis. — By  Robert  Maguire. 

A  Brief  Account  of  the  Recent  Epidemic  of  Cholera  in 
Kashmir. — By  l^rnest  I".  Neve. 

The  After-History  of  Applicants  Rejected  for  Life  Assur- 
ance.—  By  Andrew  Macphail. 

The  Relation  between  Cause  and  Effect  in  Disease. — By 
Charles  .Powell  White. 

A  Fatal  Case  of  Poisoning  with  Zinc  Sulphate  ;  Necropsy. 
—By  G.  D.  Mackintosh. 

What  is  a  Disease? — By  S.  W'.  Macllwaine. 

Metabolic  Fever.— By  Arthur  Todd-White. 

I'iiis/cij  LiXkaresatlskapcts  Handlingar,  November,  igoo. 

Gastric  Myasthenia. — Max  Buch  regards  myasthenia  of 
the  stomach  as  a  lessened  tone  of  the  muscular  tissue  with- 
out stenosis.  Insufficiency  is  not  identical  with,  but  may 
be  caused  by  myasthenia.  By  auscultation  and  percus 
sir)n  the  author  has  found  that  a  myasthenic  stomach 
changes  position  even  when  empty,  its  mobility  being  due 
to  a  slight  gasiroptosis.  It  is  larger  than  normal,  but  there 
is  not  always  insufficiency.  The  cause  of  the  affection  is 
to  be  found  in  local  muscular  weakness,  usually  following 
chronic  catarrh,  or  in  nervous  troubles  such  as  those  which 
follow  infectious  diseases,  typhoid  fever,  dysentery,  chol- 
era, peritonitis,  etc.,  in  which  we  find  the  local  sympa- 
thetic plexuses  inflamed  and  many  nerve  cells  degener- 
ated, or  irritated  conditions  of  the  cceliac  plexus  or  the 
sympathetic  nerve. 

Hernia  of  the  Linea  Alba. — A.  F.  Hornborg  reports  thirty 
cases  due  to  subserous  lipomata,  traumatism,  emaciation 
from  tuberculosis  or  gastric  cancer  (loss  of  fat  and  general 
relaxation  of  the  tissues),  and,  finally,  to  a  general  predis- 
position to  hernia.  The  usual  symptoms  were  digestive 
disorders  occurring  immediately  after  a  shock  or  a  fall,  or 
there  might  be  pain  after  muscular  efforts,  or  in  certain 
positions  of  the  body,  or  after  meals,  etc..  which  always 
disappeared  when  the  patient  assumed  a  horizontal  posi- 
tion. The  indications  for  radical  operation  are  many. 
The  author  was  able  to  follow  the  after-history  of  twenty- 
two  of  the  thirty  operated  upon.  Seven  died,  twelve  were 
completely  cured,  two  had  relapses — one  in  the  cicatrix, 
the  other  in  the  neighborhood  of  the  former  hernia. 

Dysentery  in  Finland. — F.  E.  Hellstrom  observes  that 
during  the  last  century  this  disease  has  assumed  a  more 
and  more  benign  character,  as  it  has  in  all  northern 
Europe.  It  is  therefore  often  difficult  to  distinguish  it 
from  intestinal  catarrh.     He  gives  the  mortality  per  too,- 


I022 


MEDICAL    RECORD. 


[December  29.  1900 


cx«  of  tlie  ixjpulalion.  and  note--  that  it  is  gioalest  when 
the  temperature  is  liighest  in  any  given  seasDii.  He  gives 
tables  of  the  mortality  of  dysentery  in  the  various  months, 
and  at  different  ages.  In  early  childhood  there  is  the 
greatest  mortality. 

Temporal  Hemianopsia  due  to  Lesion  of  the  Chiasm. — Hy 
Kniile  Juselius, 


(£ovvc5poiulcncc. 

()'   R    LONDON    LETTER. 

( From  our  Special  Corrcspondenl.) 

rnlSONKI)  JiKF.R — i;KSF.RAL  MF.niC.M,  COf.NCII.— THE  COLLEGES, 
TIIK  mRMIM;H.\M  CONSULTATION  SCHEME — .SURGERY  OK 
THE  BLADDER — THROMBOSIS  AM)  SVI'IIILITIC  1-EVER  — 
SPLENECTOMY — NEl'HRITIS  WITHOUT  AI.IIUMINURIA — KOYAI. 
SOCIETY. 

London,  December  6,  1900. 

Hekk  -arsenic  in  beer — peripheral  neuritis  and  poisoned 
beer.  If  vou  could  have  heard  our  conversation  all  the 
week,  you  might  have  thought  that  beer  monopolized  all 
our  thoughts.  Unquestionably  it  has  bulked  largely  in  all 
t,he  talk  of  the  day.  Even  those  who  never  drink  beer  can- 
not but  feel  shocked  at  the  epidemic  of  poisoning  about 
which  I  wrote  to  you  last  week,  and  the  epidemic  is  spread- 
ing. One  naturally  expected  a  further  crop  of  cases  in  the 
district  affected,  as  the  arrest  of  the  consumption  of  beer, 
even  if  complete,  would  not  sta)-  the  effects  of  that  which 
had  been  previously  drunk,  and  in  many  cases  the  time  for 
the  appearance  of  symptoms  must  have  only  just  been 
reached.  For  the  same  reason,  further  cases  may  still  be 
anticipated.  But,  what  is  worse  than  this,  there  is  evi- 
dence that  poisoned  beer  has  had  a  wider  distribution  than 
was  at  first  believed.  Even  London  has  not  been  without 
cause  for  alarm — one  case  of  death  having  been  found,  by  a 
coroner's  jury,  due  to  peripheral  neuritis.  The  inquests 
held  in  the  northern  district  have  been  adjourned  for  the 
jiurpose  of  analyses  and  some  outcry  has  been  raised 
against  this  as  an  attempt  to  shield  those  on  whom  the  re- 
sponsibility rests.  The  public  does  not  understand  why  an 
analyst  should  not  detect  the  arsenic  in  the  tissues  of  a 
body  as  quickly  as  in  the  beer.  Certainly  the  adjournments 
need  not  have  been  for  so  long  a  period.  Meantime,  the 
brewers  have  emptied  thousand  of  gallons  of  their  beer 
down  the  sewers  and  taken  all  precautions  for  the  defence 
of  their  interests.  Some  of  them  have  announced  that  in 
future  they  will  u.se  only  malt  and  hops,  and  the  public 
ask  whether  all  should  not  be  compelled  to  do  so. 

The  matter  is  to  be  raised  in  parliament,  and  it  is  jirob- 
able  that  a  government  inquiry  will  be  insisted  on.  Per- 
haps it  may  result  in  some  stringent  measure  against  sub- 
stitutes as  well  as  adulteration. 

Meantime  I  may  note  that  in  some  cases  the  diagnosis 
has  been  confirmed  by  the  detection  of  arsenic  in  the  urine 
of  the  patients.  This  fact  may  go  far  to  defeat  the  defence 
threatened  that  the  poison  has  not  been  found  in  the  bodies 
of  those  who  have  died  of  it. 

The  Medical  Council  has  taken  its  full  time  and  nullified 
the  reports  that  the  session  would  be  a  short  one.  It  con- 
tinued its  work  until  Wedne.sday  evening.  To  the  surprise 
of  some  of  its  friends  and  critics,  the  council  has  shown 
some  signs  of  backbone,  but  you  need  not  run  away  with 
tlie  idea  that  it  is  a  fully  develojied  vertebrate  ;  a  little  stiff- 
neckedness  is  not  a  very  portentous  symptom.  The  coun- 
cil has  actually  resolved  to  adhere  to  its  former  resolutions 
on  two  subjects.  One  is  the  diploma  in  [jublic  health, 
which  affects  only  a  few  persons,  but  it  is  intended  to  be 
a  high  distinction,  and  tlie  council  hasdetermined  to  main- 
tain the  standard.  The  other  suliject  is  much  more  im- 
l)ortant — the  conflict  with  the  two  royal  colleges  which 
stood  over  from  last  session.  Vou  will  remember  I  gave 
you  an  outline  of  the  dispute.  The  two  colleges  want  to 
neutralize  the  effect  of  the  five-years'  curriculum  by  recog- 
nizing the  teacliingof  science  in  grammar  schools  and  even 
in  board  schools.  The  other  corporations  have  fallen  in 
with  the  views  of  the  council,  and  the  move  of  the  two  col- 
leges looks  like  an  attempt  to  outflank  their  rivals.  Coun- 
sel's opinion  has  been  taken  on  both  sides,  and  the  two 
agree  no  betler  than  a  couple  of  doctors.  Litigation  is 
most  undesirable,  and  I  hope  the  two  colleges  will  fall  into 
line  with  the  other  medical  authorities  now  they  have  ex- 
))loited  their  chartered  rights;  for,  if  insisted  on,  they 
might  become  "chartered  wrongs."  But  will  the  council 
carry  out  the  resolution  to  which  it  now  "adheres  "?  Of 
any  other  body  we  might  e.\i)ect  it.  But,  alas  1  we  remeni- 
lier  how.  having  threatened  the  Obstetrical  Society,  it 
climbed  down. 

Another  su'ojecl  on  which  the  council  has  displayed  un- 
expected firmness  is  the  consulting  institution  at  Birming- 


ham, which  I  form  ..ly  described.  The  "consultant  "  was 
summoned  on  the  ground  of  the  canvassing  and  advertis- 
ing of  this  new  aid  society,  and  the  case  was  conducted  by 
Or.  Bateman  of  the  Defence  I'nion.  The  witnesses  for  the 
institution  contradicted  themselves  as  to  whether  it  was  a 
charity  or  not.  .Mr.  Arthur  Chamberlain,  who  seems  to  be 
the  father  of  the  scheme,  came  up  and  tried  to  bounce  the 
council,  and  talked  of  the  Birmingham  practitioners  as 
"street  doctors,  "  and  of  the  "higher  skill  and  knowledge" 
his  plan  would  supply.  But  he  exemplified  only  his  own 
want  of  knowledge  of  the  subject  and  his  own  self-import- 
ance. 

The  council  listened  and  eventually  informed  the  con- 
sultant that  the  charge  had  been  proved,  and  that  he 
would  have  to  appear  before  them  at  the  next  session. 
The  president  informed  him  that  the  council  regarded  his 
conduct  as  serious,  and  in  adjourning  the  case  gave  him 
the  opportunity  of  reconsidering  his  position. 

If  the  council  adheres  to  this  and  the  two  other  resolu- 
tions the  profession  will  certainly  rejoice  in  its  new-found 
decision  of  character. 

The  surgery  of  the  bladder  occupied  the  attention  of  the 
last  meeting  at  the  Medico-Chirurgical.  Sir  Thomas 
Smith  read  a  paper  offering  some  suggestions  for  a  possi- 
ble improvement  in  the  method  of  removing  stones  and 
morbid  growths  from  the  interior  of  the  bladder.  He 
brought  the  subject  forward  in  order  to  hear  the  opinions 
of  other  surgeons  before  carrying  out  the  suggestions  in 
])ractice.  The  proposals  were  not  very  favorably  enter- 
tained by  most  of  the  speakers,  but  received  some  support 
from  Mr.  Bennett  and  Mr.  W.  G.  Spencer.  The  latter,  in- 
deed, said  the  suggestions  commended  themselves  to  him 
very  strongly.  Sir  Thomas  did  not  seem  discouraged,  for 
lie  remarked  that  when  years  ago  he  made  analogous  sug- 
gestions as  to  the  removal  of  stone  from  the  kidney  by  oper- 
ation, the  proposal  was  less  favorably  received  than  the 
jiresent  one.  The  new  suggestion  is  briefly  this  :  In  view 
of  the  diminished  risk  of  interfering  with  the  peritoneal 
cavity,  might  it  be  worth  considering  whether  the  oper- 
ation should  be  intra-peritoneal  in  cases  in  which  it  is  de. 
sirable  to  obtain  immediate  union  of  the  bladder  wound? 
The  precautions  which  would  have  to  be  adopted  were 
pointed  out,  as  well  as  the  modifications  in  the  mode  of 
performing  supra-pubic  cystotomy.  These  included  the 
adoption  of  the  Trendelenburg  position,  distention  of  the 
bladder  with  air  rather  than  fluid,  opening  of  the  abdo- 
men at  a  higher  point  than  usual,  immediate  closure  of  the 
bladder  wound  by  suture,  and  after-treatment  as  required 
after  traumatic  rupture.  In  the  discussion  Mr.  C.  Lucas 
said  supra-cystotoniy  is  now  very  different  to  what  it  was 
when  Sir  H.  Thompson  revived  it.  Then  the  bladder  was 
torn  and  drainage  above  the  pubes  used  ;  now  the  bladder 
is  cut.  It  was  a  great  thing  to  clear  the  bladder  thorough- 
ly, but  he  saw  no  advantage  in  going  through  the  perito- 
neum, and  septic  matter  could  not  be  excluded.  Mr. 
Bruce  Clark  also  insisted  on  the  sepsis  that  was  sure  to 
occur.  Mr.  Freyer  said  the  proposal  opened  up  the  ques- 
tion of  supra-pubic  operation,  the  ease  and  simplicity  of 
which  were  its  dangers,  and  the  mortality  was  very  heavy. 
Mr.  H.  G.  Barling  liad  collected  statistics  from  six  Lon- 
don and  six  provincial  hospitals.  Out  of  one  hundred  and 
eighty  cases  the  mortalitiy  was  twenty  per  cent.,  while 
lateral  lithotomy  averaged  onlj-  five  per  cent.  The  supra- 
pubic operation  was  adapted  only  for  very  large  stones  or 
tumors.  He  did  not  think  distention  with  air  would  be 
advantageous,  and  held  that  the  intra-peritoneal  plan 
must  be  very  dangerous.  Mr.  Christojiher  Heath  agreed 
with  this,  and  thought  it  flying  in  the  face  of  Providence 
to  open  the  peritoneum  when  it  could  be  avoided. 

After  this  discussion  Mr.  \V.  G.  Spencer  described  a  mode 
of  performing  median  perineal  urethrotomy  and  cystotomy 
through  a  transverse  superficial  incision — a  plan  similar  to 
that  (if  Celsus,  and  which  he  recommended  in  certain  cases. 
Mr.  Barling's  statistics  were  referred  to  by  Mr.  Freyer. 
who  said  lateral  lithotomy  was  still  employed  in  India  and 
elsewhere,  but  Mr.  Heath  supported  Mr.  Spencer  in  the 
statement  that  it  was  obsolete.  He  said  this  subject  came 
up  periodically,  and  reierred  to  Mr.  Ward's  jiaper  in  1S60, 
which  contained  much  of  what  Mr.  Spencer  now  said. 

After  this  Dr.  Bradshaw,  of  Liverpool,  exhibited  a  crys- 
talline deposit,  previously  undescribed,  from  an  alkaline 
urine  of  a  jiatient  with  dilated  stomach,  who  was  taking 
large  quantities  of  magnesia.  The  crystals  were  of  ex- 
treme tenuitv  and  consisted  of  monoliydric  magnesium 
jihosphate  (MgHl'O.). 

.\t  the  Clinical  Society  Dr.  S.  Phillips  narrated  a  ca.se  of 
thrombosis  of  the  inferior  vena  cava,  iliac  and  femoral 
veins,  setting  in  suddenly  in  an  ana-mic  maiiiservant  aged 
nineteen,  who  had  had  symptoms  of  indigestion.  She 
was  seized  with  syni]Homs  resembling  perforation  of  gas- 
tric ulcer,  and  a  few  days  later  with  swelling  of  the  lower 
extremity,  abdominal  pains,  etc.  At  the  post-mortem  the 
thrombosis  was  found,  and  Dr.  Phillips  regarded  it  as  pri- 
mary and  infective.  . 


December  29,  1900] 


MEDICAL    RECORD. 


1023 


Mr.  Campbell  Williams  reiwrted  to  the  same  society  a 
case  of  late  syphilitic  intermittent  jiyrexia  treated  by  mer- 
cury. Such  cases  do  not  seem  to  be  .so  rare  as  might  be 
supposed  from  the  te.\t-books  not  describing  them ;  for 
several  speakers  mentioned  having  met  with  them.  One 
of  them  said  there  was  always  a  jjeriostitis  or  some  gum- 
matous dei)osit  as  a  cause  for  the  constitutional  disturb- 
;tuce,  though  it  might  not  always  be  discovered.  In  Mr. 
Williams'  case  he  liad  mentioned  periostitis  of  the  right 
clavicle  as  once  detected.  There  were  differences  of  opin- 
ion as  to  the  treatment — some  thinking  mercury  acted  more 
quickly  than  iodide,  others  thinking  the  reverse. 

Mr.  Bland  Sutton  tlien  reported  a  case  of  splenectomy 
for  an  enlarged  and  wandering  spleen  in  a  w<mian  of 
thirty-four  years,  mother  of  seven  children  and  pregnant 
at  the  time  of  operation.  Since  1892  he  has  jjcrformed 
splenectomy  nine  times  with  two  deaths.  The  seven  sur- 
vivors are  in  good  health.  He  always  avoids  operating  in 
cases  of  leucocytha;mia.  His  rule  is  that  the  operation 
may  be  undertaken  if  the  white  corpuscles  do  not  exceed 
twenty  to  the  one  thousand.  He  looks  out  for  an  acces- 
sory spleen  sr)  as  to  leave  it  if  present. 

Dr.  Herringham  then  related  a  case  of  nei)liritis  without 
albuminuria  in  a  boy  of  four  years,  which  he  thought 
unique.  The  cliild  was  under  observation  in  hospital  and 
convale.scent  homes  three  months  before  the  onset,  .so  that 
scarlet  fever  could  be  excluded.  At  the  post-mortem  the 
viscera,  including  the  kidneys,  seemed  normal,  but  micro- 
scopic preparations  showed  cloudy  swelling  in  .some  con- 
voluted tubes  and  albuminous  plugs  in  many.  An  exuda- 
tion was  found  in  almost  all  the  glomeruli. 

iJr.  .S.  West  said  lie  had  seen  several  cases  of  this  sort. 
It  was  not  uncommon  in  infants,  and  up  totwo  years:  they 
had  all  the  symptoms  of  renal  disease  without  any  albu- 
min, and  all  got  well.  Dr.  ICwart  mentioned  acupuncture, 
but  Dr.  Herringham  said  he  had  never  seen  a  recovery 
after  treatment  by  acupuncture. 

The  death-rate  of  London  has  been  rising  lately.  The 
return  for  last  week  was  17.9.  In  the  thirty-three  largest 
towns  it  was  eighteen  per  one  thousand.  The  deaths  from 
resjjiratory  diseases  were  rather  over  the  average. 

Lord  Lister's  farewell  address  at  the  Royal  Society  was 
largely  devoted  to  the  recent  dicoveries  as  to  malaria.  He 
is  succeeded  in  the  presidency  by  Sir  William  Huggins. 


SOME  ASPECTS  OF  MEDICAL  GYNECOL- 
OGY FROM  THK  STANDPOINT  OF  THE 
GENERAL   CONSULTANT. 

To  THE  Editor  of  the  Medical  Record. 

Sir:  "Next  to  the  originator  of  a  good  sentence  is  the 
first  quoter  of  it,"  dogmatizes  Emerson.  If  "sentence," 
so  much  the  more  in  the  case  of  a  scientific  observation. 

Therefore — having  thought  much  and  written  .some  alimg 
the  same  line,  and  frankly  envying  the  jiriority  of  succinct 
statement — I  beg  to  throw  into  the  black  type  of  quotation 
the  following  from  Dr.  Beverley  Robinson's  masterful  pa- 
per on  ".Some  Clinical  Aspects  of  Gout,"  published  in  the 
Mkdic.vi.  Rkcoki),  November  10,  1900: 

"The  most  evident  tendency  (in  medicine)  is  the  all- 
pervading  dijwsition  to  localize  human  ills.  .  .  .  From  the 
laboratory  point  of  view  .  .  .  micro-organisms  are  brought 
to  the  front  almost  invariably,  and  serve  to  explain  what- 
ever morbid  sequences  may  arise.  .  .  .  The  general  path- 
ology of  other  days  saw  undoubted  facts  also  in  atmos- 
pheric changes,  constitutional  peculiarities,  habits  of  mind 
or  body  .  .  .  now  relegated  frequently  to  the  past.  .  .  . 
And  yet  how  true  it  is  for  the  man  of  large  observation 
and  philosophic  mind  to  trace  many  of  our  ills  to  purely 
functional  disturbances." 

The  following  is  fruitful  for  those  of  us  who  work  in 
gynaecological  lines,  and  as  a  consequence  fall  more  or  less 
under  the  inevitable  sway  of  the  rule  of  environment,  from 
which  none  are  exempt : 

"In  some  persons  the  gouty  disturbance  is  apparently 
ushered  in  with  functional  upset  of  the  liver.  Under  these 
circumstances  I  have  known  the  urinary  excretion  to  pre- 
sent nothing  abnormal,  or,  at  all  events,  not  enough  to  be 
in  any  way  characteristic  of  an  imj)ending  gouty  .seizure. 
Rapid  dyspnoea  has  occasionally  followed,  of  a  distressing 
type,  which  nothing  organic  would  explain,  and  relief  was 
obtained  only  when  colchieuni  was  duly  administered. 

"I  have  little  doubt,  it  is  true,  that  many  gouty  mani- 
festations which  appear  to  be  functional  .  .  .  are  of  the 
nature  of  congestive  or  inflammatory  disorders.  /  have 
seen  this  notably  in  the  ftrostate.  I  lie  uterus  anii  ovary,  and 
rarely  the  intestines.  My  views  in  regard  to  the  probable 
rheumatic  or  gouty  origin  of  not  a  few  cases  of  appendici- 
tis are  already  known  to  many.  .  .  .  For  example,  I  do 
not    believe    because    a    tonsil   occasionallv   becomes   in- 


flamed and  enlarged  under  rheumatic  or  gouty  influ- 
ences, it  should  therefore  be  removed.  .  .  .  What  is  true 
0/  the  tonsil  is  true  oj  the  o'.'ary,  with  added  force  in  the 
latter  ease  because  .  .  .  more  dangerous  .  .  .  and  affect- 
ing child-bearing  .  .  .  and  future  changes  of  qualities  and 
disposition  of  the  woman." 

The  italics  above  are  mine.  Having  pointed  on  every 
possible  occasion  to  the  frequency  with  which  pelvic  dis- 
eases of  woman  are  associated  with  renal  insufficiency, 
litha'mia,  rheumatism,  gout — and  all  the  group  of  troubles 
included  in  passive  congestion,  faulty  muscular  develop- 
ment, and  elimination — the  above  observations  from  an- 
other standpoint,  to  the  same  end,  are  welcome  and  sig- 
nificant. 

A  study  of  these  medical  aspects  of  modern  gyna;ct>logy 
is  sometimes  dangerous  because  to  cite  surgical  results 
seems  to  be  making  a  criticism  of  the  surgeons  who  oper- 
ated. It  would  be  impolitic  for  any  one  but  a  general  con- 
sultant to  utter  the  following: 

"We  are  apt,  I  believe,  also  to  regard  an  operation  from 
the  point  of  view  of  mere  danger  and  not  enough  from  the 
standpoint  of  what  shall  be  the  ultimate  result.  How 
many  times  have  I  seen  patients  operated  on.  even  by 
surgeons  of  widest  experience  and  most  careful,  conscien- 
tious judgment,  who  have  few  or  no  thoughts  subsequent- 
ly except  to  wish  that  they  had  never  had  recourse  to  the 
knife.  Sometimes  the  patient's  bodily  disability  or  suffer- 
ing has  been  greater  than  if  they  had  really  borne  the 
trouble  they  already  had  and  had  become  accustomed  to." 

Oi)position  to  ojierations  (other  than  plastic)  in  a  large 
class  of  female  troubles  has  become  a  fixed  rule  of  practice 
with  me,  and  I  am  happy  to  note  a  growing  support  from 
the  profession.  The  class  of  cases  is  with  me  almost  a 
hobby  class — my  environment  pressure — and  comjirises  the 
soreness  in  the  venous  system  of  women,  the  headaches  and 
reflex  neuroses,  the  abdominal  jitoses,  due  to  congestion, 
mal-elimination.  and  muscular  debility,  which  properly^ip- 
l)lied  regime  almost  invariably  clears  up.  It  is  upon  pa- 
tients in  this  class  that  operations  (other  than  plastic)  so 
frequently  fail  to  restore  health.  It  is  with  patients  in  this 
class  that  local  treatment  is  .sometimes  no  more  indisi)ens- 
able  than  it  is  for  a  periodical  mammary  tenderness  ;  it  is, 
of  course,  always  an  aid,  but  a  minor  detail  of  the  general 
plan. 

This  statement,  these  quotations,  all  seeming  agitations 
against  surgery,  may  do  great  harm  with  those  who  do  not 
understand  and  cannot  discriminate  between  case  and  case. 
But  while  we  may  be  justified  sometimes  in  taking  the 
esoteric  position  with  the  laity,  no  specialist  is  right  in  as- 
suming this  attitude  toward  the  rest  of  the  medical  profes- 
sion. 

Vet  the  modification  of  standpoint  by  environment — as 
important  as  the  personal  equation  in  astronomical  calcu- 
lations— suggests  that  a  routine  warning  .should  accom- 
pany every  di.scussion  of  the  medical  side  of  gyna;coIogy. 
It  is  an  unpardonable  error  to  delay  surgery  in  a  large  and 
well-defined  group  of  female  troubles. 

EudKNt    Col.KMAN   S.WIDGE,   M.D. 
66  West  Piktieth  Stkekt,  New  York. 


MALARIA    AND    MOSQUITOS. 

'i'r>   THE    KuiTOK  OK   'IHE    MhUICAL    KecUKU. 

Sir  ;  Dnce  more  malaria  and  mosquitos.  There  is 
railroad  being  built  from  here  running  south  and  east  to 
join  the  railroad  of  the  Isthmus  of  Tehuantepec  at  a  cer- 
tain place.  At  a  distance  of  93  km.  from  Cordoba  is  a 
marshy  i)lain  with  a  few  houses  and  no  drinkable  water. 
The  place  is  called  "Tierra  blanca."  When  I  went  there  I 
was  greatly  surpri.sed  not  to  Hnd  any  mosquitos,  and  yet 
the  place  is  a  first-class  malaria  breeder. 

F".  Semei.edkr,   M.D. 

CoRDOHA,  Mexico. 


Treatment  of  Acute  Alcoholism. — The  expectant 
plan  is  the  most  rationaL  Opiates  are  dangerous,  be- 
cause they  additionally  derange  digestion,  and,  acting 
as  powerful  cardiac  sedatives,  tend  to  paralyze  the 
heart,  and.  finally,  because  they  check  elimination, 
interfere  with  the  normal  secretions  and  digestion. 
Sleep  is  never  to  be  attained  at  risk  or  hazard  to  the 
patient,  but  is  to  be  expected  as  one  of  the  harbingers 
of  a  convalescence  not  to  be  enforced.  In  acute  alco- 
holism, as  in  many  other  acute  diseases,  the  vis  medi- 
catrix  is  fully  adequate  in  most  cases  to  produce  the 
happiest  results. — Dr.  J.  K.  B.AfDUv,  St.  Louis  Medi- 
cal Raieii'.  December  i st. 


I024 


MEDICAL    RECORD. 


[December  29,  1900 


Society  ivcpovts. 

THE  NEW    YORK  ACADEMY    OF    MEDICINE. 

SKCTION    ON    MELUCINE. 

Stated  Meeting,  Held  December  18,  igoo. 

John  H.  Huddleston,  M.D.,  i.n  the  Chair. 

Treatment  of  Acute  Alcoholism  at  Bellevue  Hospi- 
tal  Ur.  a.   R.    Braunlich   read   this  paper.     The 

cases  treated  were  divided  into  three  clases:  isi. 
Acute  alcoholic  intoxication.  2d.  Delirium  tremens. 
3d.  Alcoholic  mania.  On  admission  all  cases  re- 
ceived a  cathartic  consisting  of  calomel  gr.  x.,  bicar- 
bonate of  sodium  gr.  xx. 

ist.  Acute  alcoliolic  intoxication.  These  cases  were 
divided  into  two  classes:  (a)  Those  in  the  emotional 
and  boisterous  stage.  These  were  given  bromide  of 
potassium  gr.  xxx.,  and  chloral  hydrate  gr.  xv.,  to  be 
repeated  in  an  hour  if  necessary.  They  were  put  to 
bed  and  next  morning  were  discharged.  Lack  of  room 
prevented  the  treatment  of  after-symptoms.  (/')  The 
stage  of  "dead"  drunkenness.  Here  the  patient  was 
in  a  semi-conscious  state  or  in  a  wholly  unconscious 
condition.  The  stomach  was  evacuated  and  washed 
out  with  the  siphon.  External  heat  was  applied  and 
the  patient  rolled  in  a  blanket,  and,  if  necessary,  stim- 
ulants were  given,  such  as  hypodermics  of  strychnine 
gr.  ^',7,  or  digitalis  (H.  ext.)  iili.  or  ii.  Patients  were 
usually  belter  in  from  six  to  twenty-four  hours,  or  else 
they  gave  symptoms  of  another  form  of  acute  alcohol- 
ism, usually  those  of  delirium  tremens.  These  cases 
frequently  developed  an  acute  gastritis,  for  which  small 
doses  of  morphine  gr.  -.',-  were  given,  to  be  repeated 
every  fifteen  minutes  to  half  an  hour  until  they  were 
able  to  retain  small  quantities  of  fluid,  beginning  with 
one  drachm  of  milk  or  water. 

2d.  Delirium  tremens  cases.  This  occurred  in 
chronic  alcoholics,  or  in  other  persons  after  one  or 
more  excessive  drinking  bouts.  These  were  the  diffi- 
cult cases  to  treat.  The  withdrawal  of  all  stimulants 
from  these  patients  was,  at  times,  a  very  serious  pro- 
cedure, and  he  had  seen  cardiac  failure  supervene 
upon  such  a  course,  and  cedema  of  the  brain  and  lungs 
set  in.  The  treatment  of  these  cases  was  directed 
toward  the  circulatory  apparatus.  Alcohol  was  sel- 
dom given.  The  drugs  which  held  first  place  for 
stimulation  were  strychnine  in  doses  of  gr.  -,.'„  to  .^\^ 
and  atropine  in  doses  of  gr.  -^l^.  To  produce  sleep 
and  rest,  sodium  bromide  gr.  xxx.,  and  chloral  hydrate 
gr.  XV.,  were  given,  to  be  repeated  in  an  hour  if  nec- 
essary. Morphine  gr.  ]/{  and  hyoscine  gr.  ^^^  were 
also  used.  On  account  of  these  drugs  producing  de- 
pression, hypodermics  of  strychnine  and  atropine,  and 
at  times  digitalis,  had  to  be  used.  Patients  who  re- 
ceived large  and  frequent  doses  of  the  above  and  in 
whom  it  produced  a  fitful  and  unnatural  sleep  did  not 
seem  to  derive  much  benefit,  but  appeared  to  be  worse. 
He  thought  that  a  doctor  who  attempted  to  keep  a 
quiet  delirium-tremens  ward  fattened  the  grave-yard. 
For  its  soothing  effect  upon  the  nervous  system  and  to 
reduce  the  temperature,  the  wet  pack  was  successful 
in  many  cases.  Patients  were  restrained  as  little  as 
possible,  the  strait-jacket  never  being  used.  To  pre- 
vent patients  from  leaving  their  beds  their  wrists  were 
tied  to  the  side  of  the  bed,  which  allowed  considerable 
freedom  of  movement.  The  question  of  food  was  an 
all-important  one,  and  they  were  given  milk  and  raw 
eggs  by  the  mouth  or  rectum.  Six  to  eigiit  eggs  a  day 
was  not  unusual  for  a  patient.  So  many  eggs  were 
used  that  a  serious  clash  with  the  authorities  had  al- 
most resulted.     The  unquenchable  thirst  present  was 


treated  by  large  quantities  of  water.  Freshly  pre- 
pared liquor  ammonia;  acetatis  was  given  in  half- 
ounce  doses  every  hour  or  two,  and  seemed  to  produce 
great  benefit. 

3d.  Acute  alcoholic  manias.  These  patients  were 
given  the  combination  of  morphine  and  hyoscine  men- 
tioned above,  and  this  seemed  to  be  the  only  combina- 
tion that  would  procure  them  a  moderate  amount  of 
rest.  The  neuritic  cases,  the  epileptic  cases,  and  epi- 
leptic-mania cases  were  transferred  elsewhere.  He 
wished  to  emphasize  that  alcoholics  should  be  as 
closely  watched  as  cases  of  pneumonia.  Complica- 
tions, as  they  arose,  received  appropriate  treatment. 
In  the  anorexia,  so  common  to  alcoholics,  a  mixture 
containing  tincture  of  capsicum  ilL  x.,  tincture  of  nux 
vomica  Til  x.,  and  tincture  of  ginger  Til  x.,  was  given 
three  times  a  day. 

In  closing  his  ])aper  Dr.  Braunlich  mentioned  some  of 
the  treatments  followed  by  others.  .Ml  the  hypnotics  had 
been  tried.  Some,  on  the  advice  of  their  visiting  phy- 
sicians, had  tried  exercise  in  the  acute  delirious  stage, 
by  walking  the  patient  between  two  attendants  until 
he  was  somewhat  exhausted  and  able  to  sleep.  Under 
this  treatment  the  mortality  was  increased.  The  digi- 
talis-and-capsicum  treatment  for  delirium  tremens 
consisted  in  the  administration  of  one-ounces  doses  of 
the  infusion  of  digitalis  every  four  hours,  for  the 
purpose  of  eliminating  the  poison  and  stimulating  the 
heart;  with  it  were  given  large  doses  of  powdered 
capsicum.  A  severe  gastritis,  of  course,  was  a  contra- 
indication. By  giving  an  egg-nog  before  the  capsicum 
the  latter  could  usually  be  retained.  The  capsicum 
was  supposed  to  increase  the  appetite.  Lumbar  punc- 
ture for  wet-brain  had  been  performed,  but  no  conclu- 
sions as  to  its  efficacy  had  been  drawn.  One  of  his 
successors  followed  this  treatment,  dividing  his  cases 
into  three  classes:  (i)  The  emotional  and  boisterous 
alcoholics.  These  were  quieted  and  subdued  by  brom- 
ide of  potassium  gr.  xxx.,  and  chloral  hydrate  gr.  xv., 
repeated  at  short  intervals  if  necessary,  (j)  Those 
on  the  verge  of  delirium  tremens.  These  patients  re- 
ceived solution  of  Magendie  tH  v.,  hyoscine  gr.  y^-j, 
and  strychnine  gr.  J^y  (3)  Delirium-tremens  patients. 
These  received  HI  x.  of  solution  of  Magendie,  gr.  ^l  of 
hyoscine,  and  gr.  v,'y  of  strychnine.  His  idea  was  to 
knock  them  out  with  one  blow.  He  reasoned  that  one 
big  dose  of  the  hypnotic  was  not  so  depressing  as  fre- 
quent small  doses  and,  therefore,  not  so  apt  to  cause 
heart  failure.  He  was  a  firm  believer  in  the  hot  bath 
for  delirium,  altliough,  not  knowing  its  efficacy  while 
on  service,  he  did  not  u.se  it  at  Bellevue.  His  own 
personal  belief  was  that  the  important  elements  in  the 
treatment  were  forced  feeding  and  sufficient  stimula- 
tion. 

Classification  and  Asylum  Treatment  of  Chronic 
Alcoholism. — Dr.  T.  D.  Crothers,  of  Hartford, 
Conn.,  read  a  paper  with  tiiis  title.  He  made  the  fol- 
lowing divisions:  I  St.  The  paroxysmal  inebriates;  2d. 
The  delusional  inebriates;  3d.  The  senile  and  de- 
mented inebriates. 

I  St.  The  paroxysmal  inebriates.  This  included  the 
largest  class  of  alcoholics.  Tliere  were  two  divisions 
of  this  class  of  so-called  periodical  drinkers — one  in 
whicii  the  spirit  was  taken  at  stated  times,  followed  by 
a  distinct  interval  of  abstinence.  The  onset  and  ter- 
mination of  these  periods  comprised  a  distinct  neurotic 
cycle;  in  one  instance  a  man  drank  every  ninety-one 
days,  this  period  rarely  varying  more  than  four  or  five 
hours.  The  other  division  included  those  in  whom 
the  abstinent  period  and  the  time  of  using  spirits  were 
irregular  and  uncertain,  depending  upon  causes  both 
known  and  unknown. 

2d.  Delusional  inebriates.  These  exhiiiited  an  in- 
creasing confidence  in  their  power  to  control  the  desire 
for  drink.     This  grew  and  became  a  veritable  delu- 


December  29,  1900] 


MKDICAL    RECORD. 


102: 


sion  of  strength  of  will  and  ability  to  regulate  conduct 
under  all  circumstances  and  conditions.  These  cases 
were  usually  ascribed  to  outside  causes  which  could 
not  be  foreseen.  .\  certain  number  developed  paresis, 
and  it  was  diflficult  to  say  whether  the  early  drink 
symptom  was  not  due  to  the  oncoming  paresis  or 
whether  the  paresis  followed  thepoisoning  from  drink. 
Persons  of  this  class  were  voluble,  assertive,  and  dog- 
matic, and  were  imperious  for  help  when  suffering 
from  the  desire  for  spirits,  and  the  moment  this  had 
passed  the  delusion  of  confidence  and  ability  to  care 
for  them.selves  appeared  again. 

3d.  The  senile  and  demented  inebriates.  These, 
it  was  stated,  drank  without  any  motive  or  purpose, 
depending  largely  upon  their  ability  to  procure  spirits. 
They  were  wanting  in  vigor  and  persistent  energy  to 
procure  spirits,  and  while  they  seemed  always  alert  to 
seize  the  opportunity  to  drink,  were  averse  to  any  par- 
ticular effort  for  this  purpose.  Most  of  these  people 
were  degenerate  from  birth;  some  weie  traumatic 
cases;  some  had  suffered  from  profound  wasting  dis- 
ease. Many  persons  of  this  class  had  been  paroxys- 
mal and  delusional  inebriates,  and  finally  h?d  come- 
down to  this  senile  stage. 

Treatment — In  the  treatment  of  these  cases  there 
must  be  control  of  the  patient,  and  a  change  of  sur- 
roundings and  conditions  of  life.  He  must  go  away 
from  home  and  all  home  associations  and  be  placed 
among  strangers.  The  author  thought  a  hospital  or 
asylum  a  long  distance  away,  where  the  patient  was 
unknown,  the  first  requisite.  If  he  belonged  to  the 
paro.xysmal  class,  and  the  drink  storm  was  beginning, 
spirits  must  be  continued  for  a  day  or  two.  If  the 
drink  storm  was  ending,  spirits  could  be  removed  at 
once.  In  the  other  two  classes  it  was  found  most  de- 
sirable to  cut  off  all  spirits  at  the  beginning.  The 
withdrawal  of  spirits  should  always  be  followed  by 
calomel  or  a  saline  purge,  with  a  prolonged  hot-air  or 
hot-water  bath,  followed  by  vigorous  massage.  Irri- 
tation following  the  withdrawal  of  the  spirits  could  be 
readily  overcome  by  strong  infusion  of  quassia  in 
3  ii.  doses  every  hour  until  a  profound  disgust  and 
sudden  voluntary  abstinence  came  on.  The  removal 
of  alcohol  and  the  breaking  up  of  the  demand  for 
spirits  were  only  a  small  part  of  the  treatment.  Giv- 
ing remedies  to  produce  a  disgust  and  destroy  a  crav- 
ing was  simple,  and  could  easily  be  accomplished. 
The  use  of  strychnine  after  the  quassia  had  been 
discontinued  was  very  effectual.  Nu.x  vomica  was 
often  more  valuable  and  could  be  used  for  a  longer 
period  of  time.  On  the  subsidence  of  the  craving  for 
spirits  two  conditions  seemed  to  be  very  prominent  — 
one  of  poisoning,  and  the  other  of  starvation.  The 
condition  of  poisoning  required  continuous  treatment 
for  a  long  time.  The  hot-air  or  electric  bath  seemed 
to  be  almost  specific  in  these  cases.  The  object  to  be 
attained  was  the  rapid  elimination  of  the  to.xins 
through  the  skin ;  also,  of  the  waste  from  faulty  as- 
similation and  of  the  products  of  decomposition. 
The  electric-light  bath  seemed  to  have  the  power  of 
combining  the  effects  of  both  light  and  heat  in  stimu- 
lating the  surface  circulation.  The  removal  of  the 
spirits  often  revealed  conditions  unsuspected  before, 
which  would  require  special  treatment.  Narcotics 
should  be  given  with  great  caution.  In  his  experience 
lupulin,  lactucarium,  valerian,  and  others  of  this  class 
were  more  valuable  than  the  stronger  drugs.  The 
general  treatment,  after  the  first  acute  stage  was  over, 
should  consist  largely  of  rest,  foods,  liaths,  and  min- 
eral tonics.  The  mental  treatment  was  very  important 
and  effort  should  be  made  to  foster  and  impress  domi- 
nant ideas  and  direct  the  activities  of  the  unstable 
mind  along  exact  lines  of  living.  One  great  object  in 
the  treatment  was  the  removal  of  the  causes  and  con- 
ditions for  which  spirits  were  taken.     The  full  recog- 


nition of  inebriety  as  a  neurosis  due  to  degeneration 
from  inheritance  and  to  physical  and  psychical  in- 
juries, also  to  the  corroding  and  destructive  intiuences 
of  alcohol,  must  be  noted.  The  principal  points  of 
treatment  might  then  be  grouped  as  follows:  The 
patient  should  be  placed  in  exact  surroundings,  the 
alcohol  removed,  and,  if  necessary,  quassia  or  cin- 
chona bitters  should  be  substituted  until  all  desire  for 
spirits  subsided.  This  was  usually  accomplished  in  a 
day  or  two.  Then  Turkish  baths  with  salines  and  free 
elimination  through  the  bowels  and  kidneys  should 
follow.  The  baths  should  be  given  daily,  with  rest  in 
bed  and  hot  liquid  foods.  Keyond  this  the  judgment 
of  the  physician  should  determine  when  narcotics  were 
to  be  given,  and  when  they  should  be  abandoned  ;  also, 
the  value  of  strychnine  or  nux  vomica  or  any  of  the 
tonics  required  by  the  conditions.  The  cessation  of 
the  drink  craze  was  always  temporary  and  the  latter 
was  likely  to  recur  unless  conditions  of  vigor  and 
strength  to  overcome  it  were  created.  The  medical 
judgment  would  determine  the  exact  conditions  and 
requirements  in  each  case;  not  any  particular  drug  or 
combination  of  drugs  or  so-called  moral  remedies,  but 
a  broad,  accurate,  scientific  application  of  every  ra- 
tional means  and  measures  which  might  be  demanded. 
The  Treatment  of  the  Drink  Habit  by  Hypnotic 
Suggestion.— Dr.  J.  D.  Quackf.nbos  read  this  paper. 
He  had  been  requested,  he  stated,  to  discuss  the  treat- 
ment of  the  drink  habit  by  hypnotic  suggestion,  with 
reference  especially  to  the  technique,  the  class  of  cases 
that  were  amenable,  the  time  limits  of  treatment,  with 
the  general  results  and  the  permanency  of  cure.  In 
default  of  a  more  perspicuous  pliilosophy,  he  had  ac- 
cepted the  theory  of  a  duplex  personality,  and  ex- 
plained the  phenomena  of  hypnotism  on  the  supposi- 
tion of  a  double  self,  each  self  having  a  distinct  state 
of  consciousness.  One  of  these  states  was  called  the 
primary  consciousness,  and  for  want  of  a  better  defini- 
tion it  might  be  explained  as  the  self-luminousness  of 
the  objective  mind,  the  inner  light  in  which  all  the 
actions  of  the  waking  mind  were  made  visible  to  that 
mind.  The  other,  called  the  secondary  consciousness, 
held  those  mental  procedures  of  which,  objectively,  we 
knew  nothing — all  automatic  actions.  Kach  human 
being  was  thus  an  individual  with  two  distinct  phases 
of  existence,  a  combination  of  two  personalities  which 
did  not  shade  into  each  other — the  personality  by 
which  he  was  known  to  his  associates,  which  took  cog- 
nizance of  the  outside  world  and  consciously  carried 
on  the  ordinary  business  of  life;  and  a  higher,  more 
subtle  personality,  which  science  had  demonstrated  to 
be  capable  of  acting  independently  of  a  physical  en- 
vironment, which  intuitively  apprehended,  and  which 
automatically  controlled  the  physical  and  intellectual 
man  in  the  line  of  its  apprehensions.  Through  hyp- 
notization  this  subliminal  or  submerged  self,  which 
spontaneously  asserted  itself  in  the  natural  somnam- 
bulistic state,  was  brought  into  active  control.  The 
technique  adopted  by  him  involved  the  conventional 
concentration  of  the  visual  attention  upon  some  bril- 
liant object,  the  securing  of  the  patient's  confidence  in 
the  physician's  desire  and  ability  to  help  him,  and  the 
usual  sleeping  suggestions,  as  an  accompaniment  of 
impression  by  the  personality  of  the  doctor.  Dipso- 
maniacs, as  a  rule,  were  easy  subjects,  in  that  they 
yielded  readily  to  the  hypnotic  influence  and  accepted 
unconditionally  the  suggestions  communicated  by  the 
operator.  Regular  drinkers  might  be  dealt  with 
whenever  they  could  be  induced  to  sober.  He  had 
found  it  unprofitable  to  attempt  the  hypnotization  of 
an  intoxicated  person.  Periodic  drinkers  should  be 
treated  just  before  the  close  of  the  cycle  of  sobriety. 
Regularly  recurring  debauches  have  periods  of  vary- 
ing length,  the  longest  in  his  experience  being  three 
years;  and  he  had  satisfied  himself  that  in  some  in- 


I026 


MEDICAL    RECORD. 


[December  29,  igoo 


stances  a  relationship  existed  between  the  abuse  of 
tobacco  and  the  oncoming  of  the  irresistible  thirst,  the 
depressing  effects  of  the  nicotine  instinctively  suggest- 
ing resort  to  the  antidote.  I'eriodic  drink-storms  were 
usually  forecast  by  significant  indications — well  known 
to  the  family  and  friends  of  the  victim — irritability  of 
temper,  unreasonable  suspicion,  so-described  "crank 
spells,"  abnormal  restlessness,  unaccountable  depres- 
sion. Immediately  upon  the  appearance  of  these 
symptoms  the  patient  should  be  treated  by  suggestion. 
Many  such  subjects  recognized  their  danger,  and  sin- 
cerely w  ished  to  be  cured.  They  were  hypnotized  and 
assured  that  they  had  lost  their  craving  for  beer,  wine, 
or  whiskey;  that  alcohol  in  any  form  would  disgust 
them,  and  that  they  could  not  take  it,  could  not  carry 
the  containing  glass  to  their  lips.  The  society  of  low 
companions  was  tabooed ;  the  pleasures  associated  with 
drink  and  the  glamour  of  the  bar-room  were  pictured 
as  meretricious  and  jjlaced  in  vivid  antithesis  to  the 
chaste  delights  of  home  life.  The  physical,  mental, 
moral,  and  financial  bankruptcy  that  accompanied 
dipsomania  was  held  up  before  the  view  of  the  sleeper, 
and  he  was  forced  to  the  con\iction  that,  begotten  of 
this  apprehension,  had  come  into  his  soul  an  abhor 
rence  for  drink  and  all  that  it  stood  for.  The  subper- 
sonal  mind  was  then  directed  to  the  vocation  or  the 
avocations,  or  both,  as  circumstances  suggested,  and 
a  career  of  wholesome  activities  and  satisfactory  suc- 
cesses was  imaged  as  the  legitimate  result  of  the  aban- 
donment of  the  compromising  habit.  It  would  thus  be 
seen  that  hypnotic  suggestion  was  of  the  nature  of 
inspiration.  It  was  a  summoning  into  control  of  the 
true  man;  an  accentuation  of  insight  into  life  and  its 
procedures,  a  revealing — in  all  its  beauty  and 
strength  and  significance — of  infinite,  absolute,  uni- 
versal, and  necessary  ethical  truth;  and  a  portraiture 
of  happiness  as  the  assured  outcome  of  living  in  con- 
sonance with  this  truth.  It  was  not  a  mere  pulling  up 
of  weeds  by  the  roots,  as  Horace  Fletcher  described  it 
in  "  Menticulture;"  but  it  was  a  sudden  overshadow- 
ing: and  starving  out  of  character  defect  and  mental 
weaknesses  by  a  tropical  growth  of  ethical  energy 
which  sought  immediate  outlet  in  the  activities  of  a 
moral  life.  The  patient  freely  expressed  his  best  self 
post-hypnotically,  without  effort,  from  a  plane  above 
the  will — the  plane  of  apprehension  and  spontaneous 
control  along  lines  of  thought  and  action  that  were 
high  and  true.  Such  inspiration  could  not  be  mere 
lip-work  or  rote  lesson.  It  implied  a  belief  in  the  sug- 
gestions offered,  an  eloquent  and  incisive  manner  born 
of  the  courage  of  conviction;  in  short,  a  reciprocal 
transfer  of  personality.  Perfunctory  speeches  were  of 
no  avail,  for  the  mind  of  the  mesmerized  was  endowed 
with  supra-normal  insight,  instantaneously  detected 
the  disingenuous,  and  rejected  the  counsel  of  an  un- 
candid  or  lukewarm  guide.  In  practical  hypnotics, 
the  best  thing  one  had  to  give  was  himself.  A  sine 
qua  non  of  success  was  the  consent  of  the  patient,  an 
honest  desire  on  his  part  to  reform.  Habitual  drink- 
ers, those  who  "soaked,"  as  Goldsmitli  described  it, 
did  not,  as  a  rule,  wish  to  be  cured.  They  enjoyed 
indulgence  in  alcoholic  fluids  and  the  false  pleasures 
that  attended  it;  and  about  ninety  per  cent,  of  them, 
women  as  well  as  men,  resented  the  approaches  of 
those  who  desired  to  save  them.  Sometimes,  wlien  no 
other  form  of  appeal  was  effective,  they  might  be 
frightened  into  a  realization  of  the  fact  that  constant 
use  of  alcoholic  stimulants  would  result  in  organic 
changes  in  the  liver,  kidneys,  and  brain;  or  by  lower 
ing  the  general  powers  of  resistance  and  at  the  same 
time  irritating  the  bronchial  tubes  and  the  lungs, 
through  which  the  alcohol  was  in  pari  eliminated, 
markedly  predisposed  to  pneumonia  and  pulmonary 
consumption.  In  fact,  immoderate  drinkers  might,  in 
sober  intervals,  be  made  to  realize,  not  only  that  they 


were  physically  depraved,  but  intellectually  deterior 
ated  as  to  the  faculties  of  memory,  attention,  concen 
tration,  judgment,  and  that  they  were  deficient  in  busi- 
ness tact  and  in  the  general  address  essential  to 
success.  Once  apprised  of  their  enervated  mental 
condition,  they  honestly  desired  to  correct  the  habit, 
but  could  not  of  themselves,  the  craving  simulated  a 
mania.  Under  these  circumstances  it  was  conipara- 
tively  easy  to  persuade  a  patient  to  accept  treatment, 
and  a  rescue  might  be  effected  in  a  week's  time.  ]5ut 
the  treatment  must  be  persisted  in  for  a  much  longer 
period,  the  tendency  being  to  abandon  it  too  soon  be- 
cause of  a  belief  in  cure.  A  patient,  whose  language 
he  quoted  to  show  his  confidence  after  a  single  treat- 
ment, subsequently  fell  :  "  I  am  getting  on  splendidly, 
and  my  better  self  still  has  complete  control,  causing 
me  to  feel  that  I  shall  never  return  to  those  miserable 
times  again,  for  I  have  not  the  slightest  desire  in  the 
world  for  anything  in  the  alcohol  line."  It  was  quite 
common  for  patients  to  express  themselves  similarly 
after  the  first  series  of  suggestions,  and  for  relatives  to 
write  that  they  were  "astounded  at  the  result."  But 
if  some  unlooked-for  pressure  of  passion  and  allure- 
ment was  brought  to  bear  on  the  self-confident  subject, 
he  was  almost  sure  to  yield.  An  inebriate  patient 
who  went  two  months  in  New  York  without  experienc- 
ing the  slightest  desire  for  alcohol,  and  was  proof 
against  all  solicitations  to  enter  a  saloon,  encountered 
in  Philadelphia  a  combination  of  business  disappoint- 
ments and  temptation  that  proved  irresistible.  Could 
the  operator  foresee  such  a  contingency,  he  might 
avert  it.  It  was  not  claimed  that  the  tendency  to  re- 
lapse was  obliterated  by  hypnotism.  The  cure  might 
or  might  not  be  permanent,  as  was  the  case  willi  rheu- 
matism, quinsy,  bronchitis,  intermittent  fever  with  its 
distinct  germ  and  distinct  specific.  No  physici.m  was 
asked  to  guarantee  a  patient  against  a  recurrence  of 
tonsillitis,  especially  when  the  patient  deliberately  ex- 
posed himself  to  the  appropriate  conditions  for  a  re- 
lapse. No  more  could  be  expected  of  the  physician 
suggestionist,  who  was  not  a  miracle-monger  The 
utmost  he  could  do  in  a  prophylactic  line  was  to  reject 
all  compromises  in  his  treatment,  suggest  total  absti- 
nence, forbid  exposure  to  temptation,  and  render  in- 
sensible to  the  psychology  of  the  saloon.  Experience 
proved  that  it  was  always  better  to  deal,  in  drink- 
habit  cases,  with  the  nearest  of  kin  rather  than  direct- 
ly with  the  patient,  who  naturall)  overestimated  his 
powers  of  resistance.  Courting  a  conflict  with  the 
demon  of  drink,  as  many  did,  was  playing  with  fire. 
A  dipsomaniac  who  was  sent  to  him  from  Pans  a  year 
ago,  for  treatment  at  his  summer  home,  was  practically 
cured  in  a  week.  He  returned  to  New  York,  and 
there  insisted  on  living  in  a  cabaret.  The  inevitable 
soon  occurred.  There  were  cases  in  which  the  drink 
habit  had  become  so  ingrained  that  the  early  promise 
of  post-hypnotic  suggestion  was  gradually  brought  to 
naught  by  continual  returns,  seemingly  inexi)licable, 
of  the  uncontrollable  craving.  The  automatic  mind 
struggled  in  vain  for  mastery  of  a  habit,  which  had  not 
only  evolved  into  a  second  nature,  but  was  forever 
converting  an  unnatural  appetite  into  a  fiery  passion. 
Suggestion  in  such  an  event  should  be  supplemented 
by  appropriate  drugs,  and  in  some  instances  by  dis- 
cipline. 'l"he  physical  side  must  not  be  lost  sight  of. 
While  hypnotic  suggestion  might  regulate  a  disturbed 
metabolism  in  the  nerve  organs  or  check  atrophic 
changes  in  cell  protoplasm,  it  could  not  be  expected 
to  repair  lesions  in  the  bloodvessel  sheaths  or  sud- 
denly atone  for  the  results  of  an  exaggerated  destructive 
metamorphosis  in  the  nerve-cell  bodies.  Fortunately, 
the  damage  to  the  cells  was  measurably  reparable 
by  discontinuance  of  the  poison  and  judicious  admin- 
istration of  nourishment.  Therefore,  m  his  treatment, 
alcohol  was  immediately  withdrawn,  stimulating  liquid 


December  29,  1900] 


MEDICAL    RECORD. 


1027 


food  was  given  every  two  hours  for  a  day  or  two,  a 
phospho-glycerite  was  administered  with  a  view  10  re- 
fininjr  the  quality  and  increasing  the  quantity  of  the 
lecithin,  also  a  tablet  containing  strychnine,  nitro- 
glycerin, and  capsicum,  fluid  extract  of  coca  if  re- 
quired, a  valerianate  to  control  undue  nervous  expres- 
sion, and  bromide  and  chloral  to  induce  sleep.  In 
the  insanity  of  extravagant  drinking,  coupled  with 
chronic  nicotine  poisoning,  suggestive  treatment  might 
sometimes  be  delayed  with  advantage  until  after  the 
compulsory  reduction  or  withdrawal  of  the  artificial 
stimulant.  Patients  who,  to  rid  themselves  tempo- 
rarily of  the  importunity  of  relatives,  accepted  an  in- 
stitutional life,  with  mental  reservation  as  to  their 
habits  at  tiie  termination  of  the  period  of  treatment, 
were  proper  subjects  for  suggestion  while  in  sanatoria. 
"The  tongue  has  taken  tlie  oath,  but  the  mind  is  un- 
sworn." Under  such  circumstances,  with  the  craving 
in  lull,  the  subliminal  self  might  be  successfully  im- 
pressed. The  views  advanced  were  based  upon  an 
experience  with  some  forty  cases,  extending  over  a 
period  of  nearly  two  years.  Of  these  cases,  some  of 
which  were  quite  recent,  fifty  per  cent,  had  not  re- 
turned to  drink,  appro.xiniately  thirty-three  per  cent, 
had  been  lost  sigiit  of  and  could  not  be  heard  from, 
approximately  seventeen  per  cent,  were  known  to  have 
relapsed,  without  rebound.  More  than  half  the  latter 
were  practically  hopeless  from  the  beginning.  'I'he 
success  of  the  treatment  bore  a  distinct  relation  to  the 
amount  of  injury  already  inflicted  upon  the  brain  cells 
and  the  accompanying  mental  deterioration.  Its  ad- 
vantage consisted  in  the  rapidity  of  restoration  to 
self-control  without  the  necessity  for  effort,  witiiout 
the  physical  discomfort  or  suffering  that  usually  ac- 
companied abandonment  of  the  habit,  and  most  con- 
spicuously without  tlie  breaking  of  family  ties  and  tiie 
enforced  absence  from  professional  or  business  duties 
that  were  implied  in  sanatorium  treatment. 


l^tXcdical   Items. 


Diseases  of  Samoa.  —  Dr.  Edward  .\I.  Blackwell, 
assistant  surgeon  U.S.N.,  discusses  in  the  report  of 
the  surgeon-general,  U.S.N.,  the  disease  of  the 
Samoan  Islands.  He  says  concerning  the  maladies 
which  attack  the  natives  of  the  harbor  of  Pago-1'ago, 
Tutuila  Island,  that  "  the  most  common  of  these  are 
bronchial,  rheumatic,  neuralgic,  and  digestive  troubles. 
The  first  three  are  probably  due  in  great  part  to  the 
fact  that  the  natives  get  their  clothes  wet  very  often, 
and  allow  them  to  dry  upon  their  bodies.  Those  who 
wear  least  clothes  are  generally  least  affected.  The 
digestive  troubles  are  probably  due  to  the  character 
and  mode  of  preparing  and  eating  their  food,  and  to 
sedentary  liabits.  Blindness  in  one  eye  is  very  com- 
mon, and  it  is  generally  due  to  ophthalmia  in  child- 
hood, which  has  been  neglected.  The  cornea  is 
opaque,  and  the  lens  generally  bulges  forward  and  ad- 
heres to  it.  .\s  a  rule,  all  the  children  have  a  peculiar 
eruption,  which  I  have  been  unable  to  diagnose.  It 
generally  spreads  over  the  whole  body  and  limbs.  It 
is  macular,  papular,  vesicular,  and  pustular  in  the 
different  stages,  and  often  in  the  later  stages  there  are 
large  foul  ulcers.  The  natives  think  it  is  a  necessary 
disease  of  childhood,  and  if  it  is  late  in  making  its 
appearance  they  sometimes  inoculate  the  child  with 
virus  from  the  pustules  of  another  child.  There  ap- 
pears to  be  verv  little  constitutional  disturbance  at- 
tendant upon  it.  .  .  .  A  lady  who  lives  at  Faga-Toga 
has  practised  considerably  among  the  natives  and  with 
very  good  results.  She  has  had  no  medical  education, 
except  what  she  has  picked  up  from  a  United  States 
dispensatory,  and  from  surgeons  who  have  visited  the 


harbor.  She  keeps  tiie  commoner  drugs,  and  appears 
to  understand  their  uses  fairly  well,  and  to  prescribe 
them  intelligently.  I  have  seen  several  fractures  she 
has  reduced  antl  treated  with  very  good  results.  Two 
amputations  that  she  has  performed,  one  of  the  arm 
and  one  of  the  forearm,  have  come  under  my  observa- 
tion, and  the  results  were  very  good.  She  had  native 
assistants,  and  the  only  instruments  she  had  were  a 
hand  saw  and  a  razor." 

A  Toe  for  a  Finger. —Nicoladoni  has  recently 
published  a  case  in  which  a  toe  was  surgically  substi- 
tuted fur  a  lost  finger.  Four  months  before  operation, 
the  patient  lost  his  right  forefinger  by  accident.  The 
second  toe  was  so  divided  that  an  attachment  siill  re- 
mained to  his  foot  by  means  of  the  soft  parts,  and  the 
toe  was  applied  in  the  place  of  the  absent  finger,  the 
parts  being  kept  in  position  by  a  plaster  cast.  For 
twelve  days  a  gradual  severance  of  the  connecting 
bridge  of  tissue  was  carried  out,  until  a  complete  sepa- 
ration was  effected.  The  whole  toe  retained  its  vital- 
ity, and  it  is  further  reported  that  it  has  developed  sen- 
sibility, although  the  power  of  movement  has  not  yet 
been  established.  Nicoladoni  liojies  that  it  will  oc- 
cur. This  is  his  second  case  of  the  V\nA.—  Miriiicti/ 
Tillies  and  Hospital  Gazette. 

A   New   Detention    Hospital    for    Minneapolis - 

Philanthropic  citizens  of  Minneapolis  have  generously 
subscribed  S24.000  for  a  new  detention  hospital  on 
the  city  hospital  grounds. —  7'/ie  Mcdiial  Dial.  Decem- 
ber. 

Health  Reports The  following  cases  of  smallpox, 

yellow-  fever,  cholera,  and  plague  have  been  reported 
to  the  surgeon -general  of  the  United  States  Marine- 
Hospital  service  during  the  week  ended  December  2  1, 
1900 : 

Smallpox— tjNiTRD  Statrs. 


Cases.    Deaths. 


District  of  Columbia,  Wash- 
ington  

Illinois,  Chicago 

Kansas,  Wichita 

Kentucky.  Lexington 

Michi>;an,  Detroit 

Minncsuta.  MinncapoHs 

Nebraska,  Omaha    

N.  Hampshire,  Manchester 
New  lerscy,  Jersey  City. . .. 

New  S'ork,  >few  York 

Ohio,  Ashtabula - 

Cleveland 

Portsmouth . .    . 

Pennsylvania,  Krie 

South  Carolina,  Greenville.. 

Tennessee,  Memphis 

Texas.  Houston     ..- 

Utah,  Salt  l.ake  City 

West  \'irginia.  Wheeling 

Wisconsin,  Milwaukee 


December  1 5th 5 

December  8th  to  15th 3 

December  8th  to  isth         it 

December  8th  to  15th ...     1 

December  8th  to  15th    3 

Decern  bcr  8th  to  1  eith 7 

December  ist  to  8th t, 

Decenilicr  8th  to  15th 22 

December  8th  to  iMh i 

Jiecember  15th 15 

December  Sth  to  15th a 

December  8th  to  15th 37 

December  8th  to  15th 2 

December  I  sth 5 

December  8th  to  icth 2 

December  Sth  t<i  15th 1 

December  15th t8 

December  Sth  to  15th 40 

December  I  ^th 8 

December  Sth  to  I3lh 1 


\<y 


S.MALLeOX^FoKKH;s. 

Hohemia.  Pril^ue November  24lh  to  December  tst 

Brazil.  I'ernambuco November  15th 

Rio  dc  Janeiro Oct<ibcr  1 'th  to  31SI 

F.gypt,  .\lexandria November  27th. . . 3 

England,  London Novcmljer  24th  to  j)eceinber  isl..    14 

Sunderlantl F>ecember  ist i 

France,  I'aris I^ccember  ist 

C.ibraltar Novemoer2^th 1 

Creecc,  .\lhens Decemlwrr  ist 2 

India,  Calcutta November  3d  to  15th     

Mexico,  Me.\  ico December  2d i 

Tuxpan Dectrmber  3d  to  loth 

Russia.  Mti'.cow November  17th  to  :4th     -x 

Odessa November  24th 62 

St.  IVtcrsburg November  24th 5 

Warsaw November  2jth   .      

Scotland,  ( llasgow December  7th 45 

Spain,  f 'orrmna November  3d 

Valencia Decembcrad        i 

VEr.Low  Fkxer. 

Brazil,  Rio  dc  Janeiro October  iCth  to  31SI .    . 

Mexico,  Vera  K'.  ruz .  December  Sth 

\'ucatan November  30th 


3 

I 


Cholkka. 

India,  P'Ombay.  November  13th  to  20th 

Calcutta November  ;d  to  15th 

Madras  November  loth  to  i6th 2 

Straits    Settlements.    Singa- 
pore    November  3d 

Pi.Aci'E— Foreign. 

Brazil,  Rio  de  Janeiro October  i6th  to  31st 

India,  P.ombay November  i3lh  to  2cth 

Madras    November  loth  to  l6th 

Philippine  Islands,  Manila.  .November  3d 3 


INDEX. 


Abdomen,  apparent  tumor  of  the.  Soi  ; 
local  trophic  effect  of  massage  of  the, 
585  ;  sudden  appearance  of  non-trau- 
matic tumors  in  the,  ;Si. 

.\bdominal  lesions,  delusive  stage  of  grave, 
707  ;  section,  nutritive  enemata  after, 
797;  surgery,  drainage  in,  S71  ;  sur- 
gery, evil  results  following,  536 ; 
symptoms,  early  treatment  of,  744 ; 
wounds,  the  I'helps  method  of  closing, 
441. 

Abortion,  treatment  of,  267. 

Abrams.  .Mbert.  a  new  physical  sign  in  dis- 
location of  the  heart  ;  gastrectatic  dysp- 
ntea  and  pseudo- angina.  372. 

Abscess,  peritonsillar,  in  children,  575. 

Acetaniliii  habit.  21S. 

Acetonuria,  production  of,  306. 

Acheson.  John  C,  death  of,  982. 

Achondroplasia,  145. 

Acland.  Sir  Henry  Wentworth  Dyke,  death 
of,  662.  744. 

Acne,  treatment  of  necrotic,  with  sea-water, 

417- 

Acranial  monster,  198. 

Acromegaly,  pathology  of,  226,  906. 

Acromion,  luxation  of  the.  244. 

Acropar.iisthesia,  23. 

Actinomycosis,  465,  743,  7S7 ;  diagnosis 
and  treatment  of  cutaneous,  145. 

Acton,  Robert,  death  of,  S61. 

Addison's  disease,  116;  and  leucoderma, 
225. 

Adenitis,  sternal,  540. 

Adenoids,  headache  in  relation  to  post- 
nasal. 5S4  ;  imperfect  aeration  symp- 
toms of  post-nasal,  353  ;  in  a  woman 
of  forty-seven  years,  54  :  prevention  of 
hemorrhage  following  the  removal  of, 
9S7  ;  treatment  of,  861. 

Adrenals,  blood  of  animals  deprived  of  the, 
117. 

Air  passages,  chronic  disease  of  the,  386 ; 
foreign  bodies  in  the,   1021. 

.Air-ship,  a  new,  27S. 

Alaska,  sickness  and  destitution  in,  421,779. 

Albumin,  precipitation  of,  by  pathogenic 
bacteria,   117. 

Albuminuria,  acute,  with  uraemia,  625  ;  in 
young  men,  417  ;  of  adolescence,  705. 

Albumosuria,  experimental  Bence-Jones, 
70O  ;  myelopathic,  785. 

Alcohol  as  an  antidote  to  carbolic  acid, 
236  ;  consumption  of,  678  ;  dressings 
of,  226  ;  effects  of,  339  ;  relation  of, 
to  nutrition,  103,  42;  ;  sterilization  of 
the  hands  by,  226  ;  therapeutic  uses 
of,  677. 

Alcoholism,  a  new  sign  of,  227 ;  asylum 
treatment  of,  1024;  classification  of 
chronic,  1025;  treatment  of  acute,  263, 
1023,  1024. 

Alexia,  a  case  of,  947. 

Allen,  Charles  Lewis,  the  neuron  doctrine, 
its  present  status,  964. 

Alopecia,  relation  of,  to  dental  lesions,  905. 

Althaus,  Julius,  death  of,  27. 

Amberg.  l-'.mil.  the  cooperation  of  the 
medical  profession  of  the  United  States 
with  the  National  Confederation  of 
State  Medical  E.xamining  and  Licens- 
ing lioards  in  establishing  interstate 
reciprocity  for  the  license  to  practise 
medicine,  493. 

Ambidexterity,  786  ;  advantages  of,  425. 

Ambulance  corps,  return  of  a  disgraced, 
from  the  Transvaal,  821. 

Ambulances,  electric.  422. 

Amenorrhiea,  133  ;  an  Interesting  case  of, 
826. 


American  Academy  of  Medicine,  33. 
American   Academy  of  Railway  Surgeons. 

463. 
American  Association  for  the  Advancement 

of  Science,  18. 
American  Association  of  Obstetricians  and 

Gynecologists,  549. 
American  Electro-Therapeutic  -Association, 

593 

American  Institute  of  Ilomrt-opathy,  ig. 

American  Medical  Editors'  Association,  19. 

American  medicine,  201. 

American  Proctologic  Society,  112. 

American  Public  Health  Association,  753. 

American  Therapeutic  Society.  259. 

Amniotic  tluid.  scanty,  as  a  factor  in  proci- 
dentia of  the  cord  and  foetal  disorders, 
<,(ib. 

Amputation,  construction  of  stumps  in, 
S33  ;  osteoplastic,  427. 

Amyl  salicylate,  therapeutic  use  of,  949. 

Amemia,  breathlessness  in,  S55  ;  diagnosis 
and  treatment.  657  ;  etiology  of  pro- 
gressive pernicious,  7S4  ;  limits  of 
heart  dulness  in.  624  ;  lymphatic.  In 
children,  ?S3 ;  pernicious.  227,  633, 
S24  ;  pernicious,  and  its  relation  to  in- 
heritance. S41,  909".  pernicious,  dis- 
eases of  the  organ  of  hearing  in,  707  : 
pernicious,  following  on  traumatic 
stricture  of  the  small  intestine,  183 ; 
pernicious.  Hunter's  treatment,  193; 
pernicious,  with  spinal  symptoms,  826 ; 
phenylhydrazin  in,  264  ;  rapidly  pro- 
gressive, 656  ;  recognition  and  treat- 
ment of  the,  264. 

Anivsthesia  by  chloroform  and  ether,  ar- 
terial pressure  In,  42S  ;  by  nitrous 
oxide  and  ether,  740 ;  general,  24 ; 
prevention  of  nausea  and  vomiting 
during,  984;  spinal,  344,  508,  521, 
561,  577,  &01.  615.  624,  674.  714,  740, 
744,  750,  791.  799,  82S,  S62.  868,  937, 
967,  992. 

.Anaesthetics,  effects  of  certain,  upon  the 
liidneys,  545. 

Anasarca,  surgical  treatment  of,  733, 

Anderson,  John,  death  of,  388, 

Anderson,  William,  death  of,  830. 

Aneurism,  excision  of,  626  ;  gelatin  in  the 
treatment  of,  185;  multiple,  902; 
mycotic  embolic.  427  ;  of  the  abdom- 
inal aorta  simulating  chronic  colitis, 
22O  ;  of  the  aorta,  galvanic  treatment 
of.  951  ;  of  the  aorta,  treated  by  gela- 
tin. 904  ;  of  the  arch  of  the  aorta,  196; 
of  the  renal  artery,  624. 

Angina  LudovicI,  1020. 

Angina  pectoris,  941  ;  nervous  disturbances 
in  the  domain  of  the  brachial  plexus 
in.  34f>;  oxygen  in.  94S. 

Angiotribe  in  vaginal  cicliotomy.  143  ;  use 
of  the,  62. 

.\nglo  .Saxon  race,  degeneration  of  the, 
960. 

Animal  diseases.  757. 

.■\nkle  clonus,  656. 

.\nkle  joint,  rupture  of  the  anterior  annular 
ligament,  5S3  ;  sprains  of  the,  267. 

Ankylosis,  universal,  795,  907. 

Ankylostomiasis,  358  ;  in  the  Leeward 
Islands,  266. 

Anosmia.  9S7. 

Antagonism  of  diseases,  439. 

Anthracene,  death  from,  539. 

Anthrax,  a  case  of,  625  :  connection  of  the 
Cyprus  sphalangi  with,  359;  immuni- 
ty of  the  dog  against,  786 ;  local 
injections  of  pure  carbolic  acid  in, 
45S 

.\ntisepsis.  Lord  Lister  on  the  develop- 
ment of,  6ub. 


.Vntistrcptococcic  serum,  employment  of, 
22f;  some  results  of ,  146. 

.\ntitoxin,  a  plea  for,  159. 

Antivenene,  677. 

Antivivisection  in  Sheffield,  360. 

Antrum,  treatment  of  empyema  of  the, 
467. 

Anus,  temporary  artificial,  113. 

Aorta,  dissecting  aneurism  of  the,  105, 
115  ;   ligature  of  the  abdominal,  3S7 

Aphasia,  two  unusual  cases  of,  with  spe- 
cial  reference   to   the  naming  centre, 

lOIO. 

Apomorphine  as  a  hypnotic,  827. 

.Apoplexy,  diagnosis  of,  unaccompanied  by 
motor  paralysis,  103  ;  high  tempera- 
ture following,  465. 

Appendicitis.  799,  955  ;  and  typhoid  fever, 
diagnosis  between,  by  means  of  iodine 
reaction,  S61  ;  an  unusual  symptom  of 
perforative,  576  ;  conservatism  in  the 
treatment  of,  339;  diagnosis  of  sup- 
purative, 652  ;  facts  concerning,  466  ; 
fistula  after  operations  for.  220;  ful- 
minating, 713;  hemorrhage  due  to 
rupture  of  adhesions  following.  924; 
in  infancy  and  childhood.  42;  .  intes- 
tinal obstruction  complicating.  653 ; 
in  women,  870  ;  latent,  905  ;  latent, 
and  inflammation  of  the  right  broad 
ligament,  tube,  and  ovary.  531  ; 
medicinal  treatment  of,  173;  neuroses 
in  relation  to,  828;  peculiarities  in, 
996;  pseudo-.  16;  rheumatism  in  rela- 
tion to,  S30;  significance  of  pain  in, 
80;  some  cases  of  acute,  6SS,  716; 
subphrenic  abscess  following,  104  ;  the 
blood  in,  633;  treatment  of,  155:  ty- 
phoid, 142  ;  when  and  why  to  operate 
in,  55,  224. 

-Appendix,  anatomical  researches  in  regard 
to,  427  ;  cancer  of  the,  347  ;  elimina- 
tion of  the  inflamed,  gangrenous,  or 
perforated,  from  the  peritoneal  cavity, 
940  ;  safest  method  of  removal  of  the, 
264. 

Arcularius,  Louis,  death  of,  21. 

-Argyll- Robertson  pupil,  significance  of  the, 
■5S3. 

Army,  veterinary  corps  for  the,  9S1. 

Arrhythmia  cordis,  complicating  fibroma 
uleri.  224. 

Arsenic,  .-iccidents  of  medication  with, 
S27  ;  in  a  popular  purgative,  560  ;  in 
beer,  S9S,  944.   1022. 

.Arterial  duct,  persistence  of  the.  146. 

Arteries,  suture  of.  386. 

Arteriosclerosis.  510;  senile,  log;  treat- 
ment of  insomnia  due  to,  940. 

.Artery  clamp,  a  modified.  7S. 

Arthritis,  gout,  and  rheumatism,  differenti- 
ation of,  17;  infective,  iodide  of  iron 
in,  142  ;  tuberculous,  673. 

.Artificial  respiration  for  14)^  hours  in  a 
child  one  week  old,  905. 

.Ascites,  chylous,  23,  380,  795. 

Ashhurst.  John,  obituary  of.  61. 

.Aspergillosis,  38O. 

Aspirin,  therapeutics  of,  145. 

-Astasia-abasia,  hysterical,  949. 

Asthma,  cause,  nature,  and  treatment  of, 
6O3  ;  pathogenesis  and  treatment  of, 
950  ;  reh-ition  of.  to  nasal  disease,  535  ; 
renal,  (15;  ;  treatment  of.  066. 

.Ataxia,  acute,  S77  ;  hereditary  cerebellar, 
476. 

Athletics  barred  from  Chicago  University, 
160. 

.Atriplicism.  574. 

.Atrophy  and  development,  743  ;  progres- 
sive muscular,  475. 

Atropine,  notes  on,  518, 


December  29,  1900] 


INDEX. 


1029 


Attache's,  medical,  to  German  embassies, 
920. 

Audition,  blood  circulation  in  the  head  in 
relation  to,  7S3. 

Autotoxa'mia,  234 ;  diagnosis  and  treat- 
ment of,  265  ;  gingivitis  from,  303  ; 
in  nervous  disease,  534 ;  tetany  de- 
pendent upon,  910. 

Azoospermia,  508. 


Ti 


Babinski's  sign,  diagnosti-    alue  of ,  775. 

Baby,  the  twentieth  century,  959. 

Bacillus  aerogenes  capsulatus,  morbid  con- 
ditions caused  by,  183. 

Bacillus  coli  communis  in  drinking-water, 
significance  of  the,  324. 

Bacillus  xerosis  in  progressive  phlegmon, 
wound  infection,  and  otitis  media,  706. 

Bacteria,  demonstration  of  the  capsule, 
when  grown  in  non-liquid  media,  545  ; 
influeiKc  of  the  temperature  of  liquid 
hydrogen  upon,  225  ;  prehistoric, 
120. 

Bacteriology,  present  status  of,  460. 

Bainbridge.  William  Seaman,  analgesia  in 
children  by  spinal  injection,  with  a  re- 
port of  a  new  method  of  sterilization 
of  the  injection  Huid,  937. 

Balliet,  Howard  P.,  death  of,  21. 

Balneotherapy  among  the  Indians,  79. 

Bandler.  S.  \V.,  the  value  of  thermal  car- 
bonated saline  baths  in  g)'naecology, 
8n. 

Banks,  George,  death  of.  946. 

Baran,  J.,  protracted  gestation  in  an  old 
primipara,  194. 

Baruch,  .Simon,  hydrotherapy  in  pneumo- 
nia, 16S. 

Baths,  first  public  free,  in  the  United 
States,  999. 

Beck,  Carl,  errors  caused  by  the  false  in- 
terpretation of  the  Roentgen  rays,  and 
their  medico-legal  aspects,  281  ;  liga- 
mentopaxis,  590. 

Becker,  \V.  ¥..  h.xmatomyelia.  with  report 
of  three  cases,  252. 

Beer,  poisoning  by  arsenical,  8g8,  944,988. 

Bellamv,  Kussell,  a  modified  artery  clamp, 
78: 

Bellevue  Hospital,  reform  in,  1014. 

Beriberi,  544  ;  clinical  notes  on  cases  of, 
146. 

Bcyrout,  letters  from,  28,  349. 

Bile  secretion,  physiology  and  pathology 
of,  706. 

Bioscopy,  545. 

Birth  rate,  decreasing,  in  F^urope,  560. 

Bissell,  Joseph  B. ,  extravasation  of  urine 
following  stricture  of  large  calibre, 
149  ;  the  relief  of  prostatic  enlarge- 
ment, 725. 

Bissell,  William  CI.,  incineration  vs.  earth 
sinks  and  chemical  disinfection,  684. 

Blackwater  fever,  see  IIu:moglohinuria. 

Bladder,  instruments  for  use  in  the,  5gl  ; 
irritable,  in  women,  fi4,  9S7  ;  neuroses 
of  the,  146  ;  operation  for  exstrophy 
of  the.  345;  suprapubic  drainage  of 
the,  S3 1;  tuberculosis  of  the,  742. 

Blaise,  T.  T.,  the  spectacle  and  eyeglass 
habit,  270,  548. 

Blake,  J.  Gibbs.  death  of.  27. 

Blake,  Joseph  A.,  the  relative  bearing  of 
the  conjoined  tendon  and  the  internal 
oblique  muscle  upon  the  radical  cure 
of  hernia,  321. 

Bleything,  George  Dacre,  embolus  and 
hemianopsia,  395. 

Blindness,  sudden,  following  cauterization 
of  the  nose.  975. 

Blisters,  treatment  of.  466. 

Blood,  degeneration  of  the  red  corpuscles, 
257  ;  discussion  on  the,  632  ;  exami- 
nation of  the,  182;  examination  of  the, 
for  diagnostic  purposes,  S61  ;  identifi- 
cation of  individual,  61  ;  motility  of 
the  red  corpusles,  989  ;  parasites  in 
the,  633  ;  pathological  studies  of  the, 
514. 

Body,  specific  gravity  of  the,  as  a  factor  in 
physical  diagnosis,  674. 


Boer  war,  medical  aspects  of  the,   29,  79  ; 
mortality  of  British   officers   and   pri- 
vates in,  302  ;  nursing  in  the,  320. 
Boiling-point  of  water,  999. 
Bone  food,  420. 
Bones,  abscess  of,  509  ;  endotheliomata  of 

the,  65  ;  tuberculosis  of,  673, 
Book  Notices  : 

Accidents,  atlas  and  epitome  of  diseases 
caused  by,  by  K.  Golebiewski.  391. 

American  year-book  of  medicine  and  sur- 
gery, edited  by  George  M.  Gould, 
25- 

Anatomy,  surgical,  by  John  B.  Deaver, 
473 

Appendicitis,  treatise  on,  by  John  B. 
Deaver,  261. 

Atlas  and  epitome  of  special  pathological 
histology,  by  Hermann  Durck,  261. 

Bacteria,  text-book  of  pathogenic,  by  J. 
McKarland,  990. 

Beneath  Hawaiian  palms  and  stars,  by 
K.  S.  (joodhue.  512. 

Bigelow.  Henry  Jacob,  memoir  and 
works  of,  471. 

Canine  and  feline  surgery,  by  F.  T.  S. 
Hobday,  991. 

Cell  in  development  and  inheritance,  by 
Edmund  li.  Wilson.  147. 

Chemistry  and  physics,  by  Walton  Mar- 
tin and  William   H.  Rockwell,  147. 

Chemistr)'.  essentials  of  medical  and 
clinical,  by  Samuel  K.  Woody,  391. 

Chest,  throat,  and  nasal  cavities,  dis- 
eases of  the,  by  K.  Fletcher  Ingals, 
391- 

Childhood,  medical  diseases  of,  by  N. 
(Ippenheim,  991. 

Chirurgia  del  pericardio  e  del  cuore,  par 
Krrico  Giordano,  20. 

Criminal,  the.  by  .\ugust  Drahms.  472. 

Uermatohistologische  Technik,  von  Max 
Joseph  und  (jeorg  l.ocwenbach.  512. 

Diagnosis,  essentials  of  medical,  by  Sol- 
omon Solis-Cohen  and  Augustus  A. 
Kshner,  186. 

Diagnosis,  manual  of  clinical,  by  Charles 
E.  .Simon.  261. 

Diagnosis,  medical,  by  J.  M.  Da  Costa, 
991. 

Dictionary  of  medicine  and  allied  sci- 
ences, by  Alexander  Duane,  511. 

Diet  and  food,  by  Alexander  Haig,  26. 

Eclectic  medicine  and  surgery,  annual  of, 
147-  , 

Electrotherapie  gynecologique,  par  E. 
Albert-Weil,  390. 

Eye,  diseases  of  the,  by  Edward  Nettle- 
ship,  147. 

Eye.  glandular  structures  appertaining 
to  the,  by  Adolph  Alt,  391. 

Eye,  injuries  to  the,  in  their  medico-le- 
gal aspect,  by  S.  Baudrj-,  261. 

Eye,  manual  of  diseases  of  the,  by 
Charles  11.  May.  512. 

Eye,  refraction  of  the,  by  Gusta\'us  Har- 
tridge,  261. 

Forty  years  in  the  medical  profession,  by 
John  Janvier  Black,  147. 

Fractures,  by  Carl  Beck,  261. 

Gall  bladder  and  bile  ducts,  diseases  of 
the,  by  A.  W.  Mayo  Robson,  1S6. 

Genito-urinary  system,  diseases  of  the, 
by  P'ugene  Fuller,  14S. 

Genito-urinary  tract,  surgical  diseases  of 
the,  by  G.  Frank  Lydston,  25. 

Ginnastica  razionale  senza  attrezzi,  par 
T.  E.  Gatti,  26. 

Gynaecology,  by  Montgomer)-  A.  Crock- 
ett, 2;. 

lliinderreinigung,  von  Carl  S.  Haegler, 
991. 

Histology,  normal,  by  E.  K.  Dunham, 
991. 

Home  Nursing,  by  Eveleen  Harrison, 
186. 

Hiiftgelenkes,  angeborene  Luxation  des, 
von  Max  .Schede.  262. 

Hygiene,  manual  of  personal,  edited  by 
Walter  L.  I'yle,  511. 

International  clinics,  edited  by  Henry 
W.  Cattell.  472. 

International  clinics,  edited  by  Judson 
Daland,  2;. 


Book  Notices  : 

International  medical  annual  and  practi- 
tioner's index.  186. 

Intestines,  diseases  of  the,  by  Max  Ein- 
horn,  25. 

Tacobi.  Abraham,  Festschrift  in  honor 
of,  2()I. 

Law  in  relation  to  physicians,  by  Arthur 
N.  Taylor,  472. 

Lesione  traumatiche  dei  centri  ner\'0si, 
par  Salvatore  Salinari,  148. 

Medical  directory  of  New  York,  New- 
Jersey,  and  Connecticut.  512. 

Medical  Director)'  of  the  City  of  New 
York,   loi. 

Medical  treatment  of  diseases  and  symp- 
toms, by  Nestor  Tirard,  473. 

Membership  director)-  of  national  medi- 
cal societies  of  the  United  States, 
_M7- 

Medicine  and  the  mind,  by  Maurice  de 
Fleury.  translated  bv  Stacy  B.  Col- 
lins, 186. 

Medicine,  contributions  to  the  science  of, 
dedicated  bv  his  pupils  to  William 
Henr)-  Welsh,  186. 

Medicine,  text-book  of  practical,  391. 

Moeller-Barlow'sche  Krankheit,  Unter- 
suchungen  Uber,  von  .Schoedel  und 
C.  Nauwerck.   147. 

Mortality  records  of  the  Mutual  Life 
Insurance  Company,  by  Elias  J. 
Marsh  and  Granville  M.  White,  512. 

Nervous  and  mental  diseases,  by  Charles 
S.  I'otts,  25. 

Neuroma  and  neurofibromatosis,  261. 

Nose,  throat,  and  ear,  year-book  of,  ed- 
ited by  G.  P.  Head  and  A.  H.  An- 
drews. 472. 

Obstetrical  technique,  manual  of,  by  Jo- 
seph Brown  Cooke,  390. 

Obstetrics,  manual  of,  by  A.  F.  A. 
I-^ing,  ,390- 

Operative  surgery,  manual  of,  by  Lewis 
A.  Stimson.  147. 

Ophthalmia,  contagious,  by  S.  Stephen- 
son, 99 1. 

Ophthalmic  patient,  by  Percy  Frieden- 
berg,  261. 

Ophthalmic  practice,  golden  rules  of,  by 
G.  Hartridge,  391. 

Orthopadischen  Chirurgie,  Gundriss  der, 
von  Max  David,  472. 

Pathology,  manual  of,  by  \V.  M.  Late 
Coplin.  991. 

Pays  chauds  et  tropicaux,  traite  pratique 
des  maladies  des,  par  J.  Brault,  25. 

Peste  et  son  microbe,  par  le  Dr.  Netter, 
991. 

Presbyterian  Hospital,  medical  and  sur- 
gical report  of  the,  147. 

Progressive  medicine,  edited  bv  H.  A. 
Hare,  148. 

Rein,  chirurgie  du,  par  Y.  Rochet.  390. 

Sanatoria  :  traitement  et  prophylaxie  de 
la  phtisie  pulmonaire,  par  S.  A. 
Knopf,  262. 

Sexual  disorders  of  the  male  and  female, 
by  Robert  W.  Taylor,  261. 

Surgical  pathology  and  therapeutics,  by 
John  Collins  Warren.  25. 

Surgical  treatment,  manual  of.  by  W. 
Watson  Cheyne.  391. 

Thcrapie,  Fncyclopidie^der,  von  Oscar 
l.iebreich,  39I. 

Therapeutics,  text-book  of  practical,  by 
II.  A.  Hare,  512. 

Traite  de  mcdecine,  par  Bouchard  et 
Brissaud,  147. 

Traite  de  medecine  et  de  thcrapeutique, 
par  P.  Brouardel  et  A.  Gilbert.  148. 

Transactions  of  the  American  Associa- 
tion of  Obstetricians  and  Gynaecolo- 
gists, 512. 

Transactions  of  the  American  Dermato- 
logical  Association,  148. 

Transactions  of  the  Luzerne  County 
Medical  Society,  147. 

Transactions  of  the  New  York  State 
Medical  Association  for  the  year 
1899.  390. 

Transactions  of  the  sixth  international 
otological  congress,  edited  by  E. 
Cresswell  Baber,  472. 


INDEX. 


[December  29,  igoo 


Book  Notices  : 

Transactions  of  the  Southern  Surgical 
and  dynoecological  Association.  512. 

Tubercules  des  peduncles  cerebraux,  par 
G.  E.  Raviart,  512. 

Tumors,  pathology  and  surgical  treat- 
ment of.  by  N.  Senn.  148. 

Twentieth  Century  Practice,  vol.  .\i.\., 
edited  by  Thomas  L.  Stedman,  14S. 

University  of  I*enns\'lvania,  contribu- 
tions in  the  William  Pepper  Labor- 
atory of  Clinical  Medicine.  991. 

Urogenitalmuskulatur  des  Dammes,  von 
Otto  Kalischer.  ycji. 

Vice  and  insanity,  clinical  studies  in,  by 
George  K.  Wilson,  991. 

AVater  Supply  of  the  City  of  New  York, 

473- 
AVomen,  practical  manual  of  diseases  of, 
and    uterine    therapeutics,     by     fl. 
MacNaughton  Jones,  ggo. 
Women,    text-book   of   diseases   of,    by 

Henry  J.  Garrigues,  990. 
Zucchero  nelle  orine  delle  donne  gravide 
e  puerpere,  par  Guiseppe  Crisstalli, 
14S. 

Booth,  Franklin,  death  of,  302. 

Borden,  W.  C,  the  operative  treatment  of 
varicose  veins  of  the  lower  extremities, 
1006. 

Boric  acid,  erythematous  rash  due  to,  904. 

Botry'omycosis,  24. 

Boyer,  David  Pellman,  death  of,  602. 

Brachial  plexus,  paralysis  of  the,  951. 

Brain,  abscess  of  the,  435,  517  ;  actinomy- 
cosis of  the,  5S4;  abscess  of  the,  of 
otitic  origin,  spontaneous  disappear- 
ance of,  33S  ;  concussion  of  the,  536  ; 
congenital  hernia  of  the,  305  ;  hem- 
orrhage in  the,  due  to  violent  cough- 
ing, 616;  hemorrhage  on  the  surface 
of  the,  904;  intradural  abscess  at  the 
site  of  the  saccus  endolymphaticus,  53  ; 
nonsuppurative  inflammations  of  the, 
I;  pressure  on  the,  22  ;  syphilis  of  the, 
142  ;  tuberculosis  of  the.  in  children, 
16;  wearing  out  the,  957. 

Brand  method  in  typhoid  fever,  substitutes 
for,  635. 

Brannan,  John  Winters,  endocardial  mur- 
murs of  organic  origin  localized  in  the 
pulmonary  area  of  the  heart,  4S,  72. 

Brass,  poisoning  by,  177. 

Brazil,  letters  from,  29,  loS. 

Breast,  abscess  of  the.  general  annesthesia 
in  the  treatment  of,  946 ;  irritable, 
903  ;  oophorectomy  in  cancer  of  the, 
276. 

Breast  feeding,  622. 

Breckinridge,  John  S. ,  death  of,  343. 

Brewer,  ( leorge  Emerson,  differential  diag- 
nosis in  diseases  of  the  gall  bladder 
and  ducts,  761. 

British  armv.  medical  report  of  the,  for 
1S98,  239. 

British  Medical  Association,  272,  306,  307, 
308,  34S,  3SS ;  extraordinary  general 
meeting  of  the,  228;  Section  of  (ien- 
eral  Medicine,  276,  351;  Section  of 
Obstetrics  and  Gynecology,  31 1  ;  Sec- 
tion of  Surgery.  275,  315  ;  Section  of 
Tropical  Diseases,  355. 

Bronchial  diseases,  suprarenal  capsule  in, 
774  ;  treatment  of,  by  position,  742. 

Bronchitis,  fibMnous,  etiology  of,  184; 
in  children.  477  ;  pseudo-membranous. 
377 ;  treatment  of,  in  infants  and 
young  children,   1018. 

Bronchopneumonia,  necrotic,  with  strepto- 
thrix,  784. 

Bronchus,  tubular  cast  of  the,  115. 

Brooke,  Henjamin,  death  of,  662. 

Brooks,   I.eroy  J.,  death  of,  982. 

Brooks,  M.  J.,  the  modern  treatment  of 
pulmonary  tuberculosis,  563. 

Brown,  John  McMahon,  death  of,  465  ; 
resolutions  on  the  death  of,  662. 

Brown,  Robert  li. ,  death  of,  823. 

Brown,  Sanger,  myasthenia  gravis,  with 
clinical  report  of  a  case.  806. 

Brown,  William  M..  a  few  remarks  rela- 
tive to  typhoid  feeding,  854. 

Browning,  William  Webb,  death  of,  580. 

Bubo,  abortive  treatment  of,  418. 


Buck,  Louis,  ha-mophilia  in  the  negro,  149. 

BulTet,  Edward  P..  a  mistake  in  therapeu- 
tics, 894. 

bull,  Charles  Stedman,  three  cases  of  vas- 
cular tumor  of  the  orbit  ;  two  cured 
by  operation,  one  apparently  cured 
spontaneously,  11  ;  tuberculosis  of  the 
eye,  its  differential  diagnosis,  pathol- 
ogy, and  treatment.  8S1. 

Hullets,  wounds  from  small-bore.  519,  7S1. 

Bullock,  Earle  .Sprague,  the  modern  treat- 
ment of  pi'lmonary  tuberculosis,  790. 

Hunting.  Ross  Richardson,  death  of,  622. 

Hurchard,  Laston,  death  of,  383. 

Burger,  G.  Leo  Hagen,  ptomain  poisoning 
from  eating  cheese,  795. 

Burial  weddings,  639. 

Burke,  William  P. .  fecundity,  6g. 

liurns.  John  Francis,  death  of,  260. 

Burns,  treatment  of,  297. 

Bussey,  Hennett,  death  of,  21. 


C 


Caesarean  section,  632  ;  a  case  of.  235  ; 
modern,  in  cases  of  placenta  prajvia, 
740. 

Calculi,  hepatic,  set  Ga// S/onc-s  ;  prostatic, 
424;  renal,  go8  ;  renal,  976;  renal, 
composition  of,  145 ;  vesical,  best 
method  of  removing  a  large,  625  ; 
vesical,  causing  rectal  stricture,  103  ; 
vesical,  large,  637;  vesical,  prevention 
of,  666  ;  vesical,  removal  of  large,  316. 

Calentura,  623. 

Camp  fevers  at  Massowah,  266. 

Campbell,  C.  G.,  the  constant  quantity  in 
the  various  climatic  treatments  of  tu- 
berculosis, 729. 

Canadian  Medical  Association,  513. 

Cancer,  arising  from  congenital  moles, 
46S  ;  cataphoric  method  of  treating, 
597;  etiology  of,  297,  S27;  nature 
and  origin  of,  103  ;  occurrence  of,  667  ; 
of  the  breast,  expectancy  of  life  in 
cases  of,  467  ;  of  the  breast,  oopho- 
rectomy in,  704,  705  ;  of  the  breast, 
results  of  operation  for,  384  ;  of  the 
heart,  741  ;  of  the  parovarium,  452  ; 
of  the  rectum,  825  ;  of  the  skin,  non- 
operative  treatment  of,  983 ;  of  the 
stomach  and  intestines,  161  ;  of  the 
stomach,  early  diagnosis  of,  379  ;  of 
the  stomach,  surgery  of,  S72  ;  of  the 
stomach  with  unusual  symptoms,  386; 
of  the  thyroid,  546  ;  of  the  uterus,  711  ; 
of  the  uterus,  results  of  vaginal  hys- 
terectomy for,  952  ;  of  the  uterus,  treat- 
ment of,  799  ;  parasites  of,  6,  742  ; 
tuberculosis  in  relation  to,  808. 

Cancriamn-ba  macroglossa,  6. 

Carbohydrates  and  disease,'  225. 

Carbolic  acid,  alcohol  as  an  antidote  to, 
70,  236  ;  gangrene  from,  64  ;  in  sur- 
gery, S73  ;  poisoning  by.  794  ;  strong, 
used  as  a  throat  spray.  266. 

Cardio-psychical  associations,  544. 

Cardeza,  J.  L.  M.,  death  of,  61. 

Carotid  artery,  excision  of  the  external,  in 
cases  of  inoperable  malignant  diseases 
of  the  face,  S74. 

Castration,  self-,  396. 

Casts,  renal,  863. 

Cataphoresis,  auricular,  266. 

Cataract,  treatment  of  immature,  947,  974, 

983- 

Caterson,  William  >L,  death  of,  622. 

Catgut,  dry  sterilized,  555,  S39. 

Cathartic  lemonade,  71 8. 

Cavey,  J.  E.,  a  diprosopus,  68. 

Cecil  County  (Md.)  Medical  .Society,  223. 

Cellular  pathology  of  to-day,  385. 

Cellulitis  succeeding  contusion  of  the  leg, 
624. 

Cells,  obser\'ations  on  injury  to  living,  545. 

Celtic  Medical  Society  of  j\ew  ^'ork,  20. 

Census,  results  of  the,  67S. 

Cephalotripsy  of  the  after-coming  head, 
312. 

Cerebellum,  abscess  of  the,  218;  functions 
of  the,  536 ;  tumor  of  the,  with  hy- 
drops ventriculi,  136  ;  tumors  of  the, 
265. 

Cerebral  localization.  345. 


Cerebrospinal  fluid,  study  of  the,  546; 
meningitis,  diphtheria  antitoxin  in, 
855  :  in  an  emigrant  ship,  387  ;  in 
Dublin,  23  ;  internal  hydrocephalus 
following,  706  ;  treatment  of,  797. 

Cervical  lymph  nodes,  medical  and  surgical 
treatment  of,  713. 

Champetier  de  Ribes  balloon,  a  modified, 
361. 

Chancre,  pathology  of,  346. 

Chaplain,  objection  to  a,  541. 

Charcot- Leyden  crystals,  3S6. 

Chatard,  Ferdinand  E.,  death  of,  343. 

"Chelsea  Pensioner,"  iSS. 

Chenery,  Elisha.  death  of,  223. 

Chestnut,  John  H.  W..  death  of,  302. 

Chicago  College  of  Physicians  and  Sur- 
geons, gifts  to  the,  (too ;  drainage  ca- 
nal, 538;  improved  sanitary  conditions 
in,  S59. 

Chickenpox,  smallpox,  and  measles,  con- 
comitant. 377. 

Childbed,  spontaneous  gangrene  of  the 
legs  in,  895. 

Childbirth,  after-treatment  of  the  mother 
and  child,  630 ;  external  abdominal 
examination  during,  390  ;  maternal 
mortality  in,  309 ;  treatment  of  the 
woman  during  the  weeks  preceding, 
605. 

Children,  effect  of  modern  education  upon, 
759 ;  medical  supervision  of,  in  their 
homes,  34  ;  simple  method  of  writing 
prescriptions  for,  814  ;  Slate  care  of 
dependent,  279. 

China,  American  ambulance  corps  in,  382  ; 
climate  and  diseases  of  northern,  300; 
German  military  expedition  to,  479 ; 
medical  missionaries  in,  59. 

Chinese,  character  of  the,  239  ;  physique 
of  the,  439. 

Chloasma,  uterine,  treatment  of.  271. 

Chloroform,  death  under,  779. 

Chlorosis,  limits  of  heart  dulness  in,  624  ; 
position  of  the  stomach  in,  666. 

Cholecystocolostoniy,  276. 

Choledochotomy,  717. 

Cholera  in  India,  519  ;  in  India,  inocula- 
tion against,  501. 

Chondroma  of  the  leg  in  a  patient  with  cu- 
taneous angioma.  509, 

Chorea  and  disorders  simulating  it,  143  ; 
as  an  indication  for  the  induction  of 
labor,  616;  minor,  etiology  of,  470; 
psychoses  accompanying,  417;  ther- 
apy of,  536. 

Chorioepithelioma  malignum,  121. 

Chylous  ascites,  3S0. 

Cicatrix,  cancerous  degeneration  of  a,  961. 

Cirrhosis  of  the  liver,  S34  ;  and  pancreas 
with  diabetes  and  ha'machroniatosis, 
950:  llanot's,  78S  ;  nature  and  dis- 
tribution of  new  tissue  in,  950;  the 
pancreas  in,  26S. 

Claiborne,  J.  Herbert,  three  cases  of  spe- 
cilic  basal  meningitis,  with  special  ref- 
erence to  eye  symptoms,  Igo. 

Clavicle,  fracture  of  the,  resulting  in  rup- 
ture of   the   suprascapular   artery  (?), 

g73- 

Clavicular  crutch.  717. 

Cleft  palate,  closure  of,  by  lingual  implan- 
tation, 22. 

Clinical  opportunities  in  American  medical 
centres,  36,  86. 

Clowes.  Joseph  Washington,  death  of,  423. 

Club-foot,  open  incision  for,  317. 

Cocaine  and  hypnotics,  antagonism  be- 
tween, 576. 

Cocainism,  62S. 

Cod-liver  oil,  addition  of  iodine  and  phos- 
phorus to,  665. 

Cicliotomy,  blood  changes  following,  24  ; 
dressings  left  behind  after,  1S4  ;  fol- 
lowing ventral  hernia,  711  ;  objections 
to  bilateral  inguinal,  549;  one  hundred 
consecutive  cases  of,  without  a  death, 
104;  some  considerations  on,  716. 

Coffee,  adulteration  of,  in  Europe,  479. 

Cohn.  Robert  D. ,  treatment  of  laryngeal 
tuberculosis,  970. 

Cold  feet,  treatment  of,  34S. 

Cold,  influence  of  intense,  upon  bacteria, 
225. 


December  29,  1900] 


INDEX. 


103 1 


Colds,  potassium  bicarbonate  in,  784  ;  pre- 
vention and  treatment  of.  623  ;  pro- 
duction of,  17!). 

Colic,  causes  of,  21 S  ;  renal,  faradic  elec- 
tricity in,  23;. 

Colitis,  muco-membranous.  ijiS;  mucous, 
sodium  sulphate  in  the  treatemnt  of, 
S(>A. 

College  of  I'hvsicians  of  I'hiladelphia,  780, 
982. 

Collins,  William  T.,  death  of,  823. 

Colon,  dilatation  of  the.  622. 

ColpoccL-liotomy,  posterior,  for  lesions  of 
the  adnexa  and  uterus;  its  indications 
and  technique.  247. 

Coma,  diabetic,  840 ;  traumatic  diabetic, 
950. 

Compensation,  processes  of ,  S2S. 

Confederate  States.  Association  of  .Sur- 
geons of  the.   102. 

Conjunctiva,  diphtheria  of  the,  143  ;  infec- 
tion through  the,  425;  injections  be- 
neath the,  546. 

Conjunctivitis,  demode.x  folliculorum  in  re- 
lation to,  804. 

Connell    suture   in  intestinal  anastomosis, 

7'7.  739- 

Consanguineous  marriages,  undesirable, 
183. 

Conservatism  in  surgery,  a  case  illustrat- 
ing, yOi. 

Constantinople,  letter  from,  70S. 

Constipation,  bearing  of  the  ileo-ca'cal  ori- 
fice on,  469 :  natural  process  of  cure 
of,  1013;  proctitis  as  a  factor  in,  114; 
treatment  of,  557,  7S6. 

Consumption,  Canadian  league  against, 
51S  ;  deaths  from,  839  ;  fat  food  as  a 
preventive  of,  559  ;  isolation  of  con- 
victs with,  857 ;    racial   tendency  to, 

5>3- 

Consumptives  (see  also  Phthisis,  Piilmon- 
iirv  Tuherctitosis,  and  Titheri-ulosis'), 
care  of,  by  the  city,  746 ;  isolation  of 
insane,  578  ;  Liverpool  sanatorium  for, 
77S;  marriage  of,  760;  New  York  State 
Hospital  for,  579,  659;  open-air  treat- 
ment of,  in  southern  lirittany,  120; 
plea  for,  639  ;  spray  for  room  occupied 
by,  797  ;  State  sanatoria  for,  3(10,  063  ; 
treatment  of,  at  home,  58 1. 

Converse,  Ceorge  M.,  a  case  of  tetanus 
treated  with  antito.\in,  I94. 

Convulsions,  50. 

Convulsive  states,  53;. 

Cool,  art  of  keeping,  543. 

Copper,  food  poisoning  by,  a  fallacy,  679  ; 
poisoning  by,  731,  828. 

Corning.  J.  Leonard.  Coming's  subarach- 
noid cocaine  anesthesia,  791  ;  some 
conservative  jottings  apropos  of  spinal 
anaesthesia.  601. 

Corynebacterium  lymphre  vaccinalis,  105. 

Costello,   Henry  J.,  death  of,  260. 

Coup-de-foudre,  428. 

Courtney,  j.  E.,  two  cases  of  self-castra- 
tion, 396. 

Cousins,  marriage  of,  15.S. 

Craig  Colony  for  Epileptics,  737. 

Craniectomy,  I.annelongue's,  63. 

Crazes,  psychology  of,  320. 

Creed.  Cortland  Van  Rensselaer,  death  of, 
260. 

Cremation  in  Spain,  539. 

Creosote  pills.  393. 

Crete,  leprosy  in,   102. 

Crime,  prevention  of.  35  ;  sexual  function, 
and  insanity,  correlation  between,  698. 

Cross-eye,  effect  of,  upon  the  general 
health,  90. 

Croup,  symptoms  of,  175. 

Cuba,  quarantine  service  in,  19;  saving  of 
life  in,  30. 

Cumston,  Charles  Greene,  posterior  colpo- 
creliotomy  for  lesions  of  the  adnexa 
and  uterus  ;  its  indication  and  tech- 
nique, 247. 

Curette,  a  new,  397. 

Curry,  James  Hart,  death  of,  505. 

Curtis,  I?.  Farquhar,  cancer  of  the  stomach 
and  intestines,  161. 

Curtis,  Romaiiie  J.,  death  of,  861. 

Cutler,  E.  G. ,  perforation  of  a  typhoid  ul- 
cer without  f.-ecal  extravasation,  oper- 


ation four  hours  after  the  first  symp- 
tom, recovery,  96S. 

Culler,  Joseph  1...  death  of,  622. 

Cycling,  hygiene  of,  985  ;  Kuskin's  dislike 
of.  39S. 

Cystitis,  agglutination  by  the  patient's  se- 
rum of  the  bacteria  found  in,  784 ; 
etiology  of,  792  ;  malarial,  950  ;  sup- 
pression of  urine  following,  347  ;  treat- 
ment of,  in  women,  50b,  551  ;  typhoid, 

743- 
Cytolytic  sera,  144. 


D 


Da  Costa.  J.  M.,  medical  bequests  of,  539; 
obituary  of.  423. 

Dacrocystitis  aggravans,  665. 

Uana.  t'harles  1...  pernicious  an.tmia  and 
its  relation  to  inheritance,  S41,  909; 
the  non-suppurative  inllammations  of 
the  brain,  with  report  of  a  case  of 
hemorrhagic  (malarial  ?)  encephalitis,  i. 

iJannemora.  prison  hospital  at.  737. 

Davies,  M.  J.,  crying  of  a  child  in  utero, 
19;. 

Davis,  Edward  I'.,  treatment  of  the  patient 
during  the  weeks  previous  to  expected 
contmement.  605. 

Davis,  fleorgc  E.,  a  clinical  study  of  the 
liver  as  a  factor  in  elimination,  and  in 
the  production  of  nephritis,  41;. 

D-iyton,  Hughes,  aneurism  of  the  arch  of 
the  aorta,  igb. 

Deaf  children,  care  of,  269. 

Deane,  Louis  C..  a  method  for  the  deter- 
mination of  eye  defects  in  school-chil- 
dren, with  a  report  of  1747  examina- 
tions,  815. 

Death,  apparent,  after  suffocation,  chloro- 
form poisoning,  or  electric  shock,  res- 
toration of  life  in,  760;  sudden,  prob- 
ably due  to  pulmonary  embolism.  740  ; 
sudden,  shortly  after  operation,  264. 

Decinormal  salt  solution,  738. 

Degenerates  in  the  army,  577. 

I  )egeneracy.  34. 

1  )elirium  in  the  course  of  infective  diseases, 
855. 

Delirium  tremens,  824. 

Delusion,  a  peculiar,  154. 

Delusions,  400. 

Dementia,  senile,  70S. 

DeMund,  Erederick  Cornell,  death  of, 
861. 

Dermatitis  vesiculo-bullosa  et  gangrenosa 
mutilans  manuum,  586  :  venenata,  424. 

Dermatology,  static  electricity  in,  609. 

Dermographia  and  anidrosis.  197. 

Development,  symmetrical,  1019  ;  theorises 
of.  576. 

Diabetes,  63  ;  abdominal  colic,  andccdema, 
interrelationship  of,  106  ;  a  blood  re- 
action in,  264;  a  cured  case  of,  305  ; 
cutaneous  manifestations  in,  466;  dis- 
cussion on,  no  ;  in  children.  466,  825; 
in  relation  to  life  insurance.  306 ;  mor- 
tality from,  in  New  S'ork  City,  766 ; 
pancreatic,  due  to  calculi,  144  ;  pathol- 
ogy of,  306  ;  potatoes  in,  975  ;  prog- 
nosis of,  10;.  299  ;  quantitative  pro- 
portions of  the  carbohydrates  in  the 
urine  in,  305  ;  relation  of  surgery  to, 
3S4  ;  tabes  dorsalis  in  relation  to,  788 ; 
treatment  of,   1000. 

Diabetograph,  587. 

Diaphragm,  echinococcus  cysts  of  the 
domed  surface  of  the,  536. 

Diarrha.a,  hot-weather,  in  India,  35S;  in 
the  tuberculous,  abdominal  faradiza- 
tion for,  175  :  summer,  in  infants, 
treatment  of.  225,  256. 

Dietetic  problems,  1020. 

Digestive  disorders,  rest  in  bed  in  the  treat- 
ment of.  940  ;  organs,  praT;tical  physi- 
ology of  the,  182. 

Digitalis,  fat-free  tincture  of,  506. 

Diphtheria,  antitoxic  globulins  instead  of 
the  entire  serum  in  the  treatment  of, 
535  ;  bacilli  of,  in  healthy  throats,  862  ; 
effects  of  petroleum  on  the  bacillus  of, 
667 :  epidemic  of.  traced  to  the  milk 
supply,  670;   in  the  horse,  3S5  ;  local 


treatment  of,  879;  management  of,  in 
small  cities,  670  :  paralysis  following, 
905  ;  quantity  of  antitoxin  required  in 
treatment  of,  S29,  1019  ;  relapse  in,  55; 
relation  of,  to  contagious  catarrh  in 
fowls,  104  ;  saline  infusions  in  severe 
cases  of,  703  ;  shortening  of  the  period 
of  infectiveness,  470. 

Diploma,  the  saving  of  a,  542. 

Diprosopus.  68. 

Dirt  eating,  an.-vmia  of  dyspepsia  conse- 
quent upon.  741. 

Diseases  transmissible  from  the  lower  ani- 
mals to  man,  626. 

Disinfection,  methods  of.  756. 

Dislocations,  early  excision  for  irreducible, 
874. 

Doty,  Alvah  H.,  modern  quarantine  in  its 
relations  to  passengers,  crew,  and 
cargo,  08 1,   754. 

Douche,  prophylactic,  536. 

Drainage,  surgical.  946. 

Dropsy,  cupping-glasses  in  the  treatment 
of,  667. 

Drugstore  physicians,  677. 

Dulles,  Charles  \V.,  mumps  in  pneumonia, 
68. 

Dumbness,  hysterical,  the  result  of  intoxi- 
cation, 184. 

Dunning,  L.  H..  anienorrhrca,   133. 

Dupuytren's  contraction.  347. 

Dust,  transport  of  disease  by,  224. 

Dysentery,  African  remedy  for.  431  ;  colos- 
tomy for  the  cure  of.  947  ;  etiology  of 
tropical.  3S4,  583;  in  lirittany.  905; 
in  Finland.  1021  ;  methylene  blue  in 
the  treatment  of.  705  ;  speci^c  cause 
of,  667  ;  treatment  of,  797,  S26. 

Oysmenorrhcea.  belladonna  in,  156. 

Dyspepsia,  remedy  for,  18S. 

Dyspncea,  gastrectatic,  372 


E 


Eagleton,  S.   I'otts,  death  of,  543. 

Earache,  treatment  of,  718. 

Ears,  acute  catarrh  of  the  middle,  facial 
paralysis  in  the  course  of.  25O  ;  ana-s- 
thesia  of  the  semicircular  canals  of 
the.  987  ;  diseases  of  the.  in  infancy 
and  childhood.  9S3  ;  diseases  of  the, 
in  pernicious  anaemia,  707  ;  foreign 
body  for  many  years  in  the  external 
auditory  meatus.  7S5,  984  ;  fungus  dis- 
ease of  the,  948  ;  injury  to  the  mem- 
brana  tympani.  544  ;  pilocarpine  in  the 
treatment  of  catarrhal  adhesive  proc- 
esses in  the  tympanum,  906;  pneu- 
matocele of  the  auditory  canal,  656 ; 
sympathetic  disease  of  the,  950  ;  treat- 
ment of  furunculosis  of  the,  71S;  tu- 
berculosis of  the.  672  ;  ugly,  operative 
treatment  of,  S62. 

E.arth,  age  of  the,  638. 

Eccles.  Symons.  death  of,  830. 

Eclampsia,  treatment  of  puerperal,  740. 

Eczema,  hot-air  treatment  of,  345  ;  para- 
sitic origin  of,  305,  426,  695,  862  ; 
seborrho^ic,  of  Unna,  985  ;  strong  so- 
lution of  tar  in,  479 ;  treatment  of 
gouty,  66;. 

Edebohls.  George  M.  migrated  ovarian  and 
parovarian  tumor,  245. 

Edelmann,  George,  death  of,  iSi. 

Education,  effect  of  modern,  upon  children, 
759 ;  medical,  need  of  uniformity  in 
the  standards  of,  138, 

Edwards,  Thomas  I'.,  death  of,  61. 

Ehrenfest,  Hugo,  a  few  remarks  on  the 
use  of  medullary  narcosis  in  obstetri- 
cal cases,  967. 

Einhorn.  Max,  on  apparent  tumors  of  the 
abdomen,  801. 

Eisen,  Gustav,  preliminary  report  on  the 
presence  of  and  nature  of  parasitic 
amcebae  (cancriamnba  macroglossa)  in 
the  epithelial  carcinomata,  6. 

Electric  currents,  generating  and  transform- 
ing, for  therapeutic  uses,  597  ;  light  as 
a  therapeutic  agent,  594 ;  storage  in 
human  system,  378. 

Electricity,  displacement  or  wave  current, 
596.    597  ;    in  gynajcology,  486,  589, 


I032 


INDEX. 


[December  29,  19CXD 


596;  static,  indermatologj',  6ug;  thera- 
peutic use  of  alternating  currents  of 
high  frequency  and  tension,  42O. 

Klectrization,  combined,  595. 

Klectrodes,  593.  , 

KIcctrolysis,  treatment  of  tumors  by,  884. 

Klectrotherapeutic  sins,  593. 

Klephantiasis,  a  case  of  enormous,  153  ; 
congenital,  175. 

Kliiot,  John  \V.,  perforation  of  a  typhoid 
ulcer  without  fecal  extravasation,  op- 
eration four  hours  after  the  first  symp- 
tom, recovery,  968. 

Elliott,  George  11.,  death  of,  lOiS. 

Klliott,  H.  A.,  universal  ankylosis,  795. 

Kmbolism  of  the  pulmonary  artery,  136. 

lunerjjency  ration,  trial  of  a.  780. 

Lmotion,  physiological  theory  of,  535 

Kmphysenia.  general  subcutaneous,  469. 

Empyema,  diagnosis  of,  in  children,  lOlS  ; 
surgical  treatment  of  chronic,  5;. 

Encephalitis,  hemorrhagic  (malarial?),  i. 

Endocarditis,  gonorrhreal,  with  congenital 
malformation  of  the  mitral  valve,  1005  ; 
orrhotherapy  of  malignant,  354  ;  re- 
covery from  ulcerated,  under  the  use 
of  antistreptococcus  serum,  1S4. 

Endometritis,  acute  senile,  55O. 

Endotheliomata.  118. 

Enteritis,  chronic  and  tuberculous,  treated 
with  arsenic.  263  ;  muco-membranous, 
231. 

Enterocolitis.  426 ;  muco-membranous, 
treatment  of,  155. 

Enteroptosis  with  factitious  urticaria,  55. 

Epidemic,  definition  of  an.  756. 

Epiglottis,  cyst  of  the,  345. 

Epilepsy  cured  by  operation  upon  the  nose, 
68  ;  disorders  of  memory  associated 
with,  509  ;  due  to  cerebral  abscess  fol- 
lowing typhoid  fever,  470 ;  heart  dis- 
ease in  relation  to.  940;  influence  of 
measles  and  erysipelas  upon. 90 . ;  treat- 
ment of.  by  Fleisig's  method.  41S. 

Epileptic  colony  in  England.  463  ;  colony 
in  Illinois,  944  ;  idiocy,  cure  of  a  case 
of,  742;  insanity,  1015  ;  seizures,  rela- 
lation  of  uric-acid  excretion  to,  227  ; 
status,  837. 

Epileptics,  salt  in  the  alimentation  of, 
227. 

Epistaxis.  unusual  case  of.  974. 

Epithelioma,  624. 

Epityphlitis,  sequela;  of,   I43. 

Equilibrium,  disturbance  of,  864, 

Erdmann,  John  F.,  report  of  three  cases  of 
intestinal  obstruction  due  to  Meckel's 
diverticula,  645. 

Erythema  circinatum.  pemphigus  with,  347  ; 
induratum  scrofulosorum,  470  ;  scarla- 
tiniforme,  24, 

Erythematous  rash  due  to  boric  acid,  904. 

lOrythromelalgia  following  influenza,  976. 

Ether  anasthesia  in  abdominal  surgery, 
bronchial  disease  not  always  a  contra- 
indication to,  7S2 ;  upright  position 
for.  in  operations  on  the  nose,  throat, 
and  ear,  622. 

Eustachian  tube,  catheterization  of  the, 
218. 

Euthanasia,  advocacy  of,  471. 

Evans,  Edwin,  death  of,  302. 

Eventration,  case  of.  703. 

Everett,  William,  death  of,  946. 

Eyeball,  massage  of  the,  825  ;  spontaneous 
hemorrhage  in  the,  followed  by  rup- 
ture, 305  ;  treatment  of  infected  per- 
forating wounds  of  the,  304. 

I'^yeglasses,  wearing  of,  548. 

Eyes,  care  of  the,  639  ;  cleansing  of  the 
«  nasal  cavities  before  operation  on  the, 
624  ;  congenital  defect  of  the,  782  ;  dis- 
orders of  the,  due  to  auto-intoxication, 
984  ;  effect  of  electric  light  on  the,  424  ; 
errors  regarding  the  treatment  of  strain 
of  the.  from  various  causes.  5S1  ;  etiol- 
ogy of  phlyctenular  affections  of  the, 
62;  ;  lime  or  mortar  injuries  to  the,  545  ; 
mental  disturbances  after  operation  on 
the,  466  ;  method  of  determining  de- 
fects in,  in  school  children.  815  ;  power 
of  the.  280  ;  relation  of  diseases  of  the, 
to  those  of  the  teeth,  576;  tubercu- 
losis of  the,  672,  bSi. 


Eyestrain  as  a  cause  of  gastro-enteric  neuro- 
ses. 739  ;  common  but  unrecognized 
symptoms  of.  (>2  ;  headache  from,  182. 

Ewald.  C.  A.,  cxtrabuccal  feeding,  241. 

Exanthemata,  shall  children  be  kept  from  ? 
783. 

Exophthalmic  goitre,  425;  fatal  case  of, 
4I9  ;  removal  of  the  cervical  sympa- 
thetic ganglia  for  the  relief  of,  574  ; 
treated  by  internal  antiseptics,  473. 

Experiments,  inhuman,  279. 

Exposition,  International,  awards  of  the, 
to  American  institutions,  381. 


E 


Facial  neuritis  associated  with  unilateral 
retro-orbitaV  neuritis,  782. 

Freces,  incineration  in  tlie  disposal  of, 
684. 

Fallopian  tube,  primary  cancer  of  the,  102. 

F'amine  in  India,   159. 

Eat  embolism,   105. 

Fatigue,  effect  of.  in  modifying  the  minute 
structure  of  the  liver  and  kidneys,  298, 
825. 

Fear,  morbid,  62. 

Fecal  intoxication,  268. 

Fecundity,  69. 

P'eeble-minded.  care  of  the.  559  ;  physio- 
logical training  of  the,  3S4. 

Feeding,  extrabuccal,  241,  668;  infant,  see 
Infant  feeding. 

F'eet,  treatment  of  sweating  of  the,  719. 

Fellows.  Henry  Barton,  death  of,  982. 

Femur,  delayed  union  of  fracture  of  the, 
456  ;  intra-uterine  fracture  of  the,  50S  ; 
separation  of  the  epiphyseal  head  of 
the,  740. 

Fenger.  Christian,  testimonial  banquet  to, 
S22. 

Fever,  hysterical.  706  ;  on  the  day  of  ad- 
mission to  hospital,   175. 

Fibrolipoma.  extirpation  of.  from  the  retro- 
peritoneal and  pelvic  connective  tissue, 
185. 

Field  hospitals  in  war.  800. 

Filaria  sanguinis,  photomicrographs  of. 
835  ;  transmission  of,  by  the  mosquito, 
17,  342,  357.  785. 

Filter,  a  pocket  and  canteen.  156. 

Filtration  of  the  water  supply,  advantages 
of,  978. 

Finlay,  Charles,  mosquitos  and  yellow  fever, 
867. 

Finger,  infection  of,  623  ;  plastic  substitu- 
tion for,  of  a  toe,   1027. 

Finney.  Oswald  B.,  death  of,  141. 

Fischer,  Louis,  infant  feeding.  893. 

Fisher.  Charles  S.,  observations  on  the  gas- 
tric functions  before  and  after  gastro- 
enterostomy. 366. 

Fisher,  \V.  C,  a  large  ovarian  cyst,  235. 

Fistula  in  ano,  115  ;  its  relation  to  phthisis, 
14. 

Fitzpatrick,  Thomas,  death  of,  27. 

Flat-foot,  pathogenesis  of,  in  cases  of  vari- 
cose veins,  535. 

Fleas  as  carriers  of  plague,  280. 

Floersheim,  Samuel,  the  use  of  the  supra- 
renal capsule  in  diseases  of  the  lower 
air  passages,  774. 

FlUgge's  theory  and  its  application  to  sur- 
gery, 696. 

Fatus,  perforation  of  the  skull  of  a,  intra 
partum,  with  favorable  outcome,  575  ; 
prolapse  of  the  intestines  during  labor, 
584. 

Food,  adulteration  of,  979  ;  borax  and  for- 
maldehyde as  preservatives  of,  143 ; 
refusal  of,   827. 

Foramen  ovale,  patent,  in  advanced  life, 
581. 

Fordyce,  J.  A.,  some  clinical  observations 
on  lupus  erythematosus,  41. 

Formacetone,  disinfection  by,  (j68. 

Formalin,  poisoning  by,  70(1.  906. 

Foster,  Clarence  E.,  death  of.  901. 

Foster.  Frederick  May.  death  of,  21. 

Foster,  Hal,  the  removal  of  thirty-five 
screw-worms  from  the  nose,  975. 

"  Fourth  disease,"  345. 

Fourth  of  July,  accidents  on  the,  59, 


Fractures,  discussion  on,  315;  massage  in 
the  treatment  of  periarticular,  469  ; 
modern  treatment  of,  499 ;  subperios- 
teal, 903. 

Fragilitas  ossium  in  subjects  with  dark  scle- 
rotics,  226. 

Freeman,  (ierald,  death  of,  Oi. 

Freudenthal,  W.,  electric  light — its  physio- 
logical action  and  therapeutic  value  in 
tuberculosis  of  the  throat  and  lungs. 
647. 

Frlih,  Carl  D.  S. ,  faradic  electricity  in  renal 
colic,  235. 

Fruit,  fatal  bloom  on  the,  55?. 

F"ruitnight,  John  Henry,  death  of,  1018. 


Gall  bladder  and  ducts,  differential  diag- 
nosis in  diseases  of  the,  761 ;  sponta- 
neous dilatations  and  ruptures  of  the, 
in  .adhesive  supra-umbilical  peritonitis, 
428;   surgery  of  the,  552,  799. 

Gall-stones,  etiology  of,  5S3;  medical  treat- 
ment of  56 ;  olive  oil  in  the  treatment 
of,  7S6;  simulating  cancer,  908;  sur- 
gery of,  62;  treatment  of,  417,  585; 
treatment  of  the  attack,  3S6. 

Gall  tracts,  surgery  of  the,  610. 

Gangrene,  spontaneous,  of  the  legs  in 
childbed.   895. 

Gant,  Samuel  G. ,  flstula  in  ano.  its  relation 
to  phthisis.  14. 

Gaseous  emphysema.  7S4. 

Gasoline  as  a  surgical  detergent,  517. 

Gasserian  ganglion,  excision  of  the.  for 
epileptiform  neuralgia,  904. 

Gastrectomy,  total,  507. 

Gastric  secretion,  artificial  modification  of, 
106  ;  therapeutic  application  of,  14O. 

Gastritis,  chronic,  8S0. 

Gastro-enteric  infections  in  infancy,  232. 
266  ;  neuroses,  eye-strain  as  a  cause 
of,  739- 

Gastro-enterostomy.  observations  on  the 
gastric  functions  before  and  after,  366; 
two  cases  of.  516. 

Gastro-jejunostomy.  unusual  complications 
following,  104. 

Gastroptosis,  S43  ;  treatment  of,  989. 

Gastrotomy,  two  cases  of,  516. 

Gauntt,  F'ranklin,  death  of.  61. 

Gauze  carrier,  543. 

Gelatin  in  the  arrest  of  renal  hemorrhage, 

743- 
Genius,  Mr.  Treves'  definition  of,  260. 
Gestation,  protracted,  in  an  old  primipara, 

194. 
Gilbert,  .Samuel  F.,  death  of,  423. 
Gillespie,  James  S.,  death  of.  141. 
Gillette,   William   J.,    report  of  a   case  of 

I'orro-Ciesarean  operation,  96. 
Gingivitis,  chemical   factor  in,   345  ;   from 

auto-intoxication,    303  ;   treatment   of, 

345- 

Gingivostomatitis  with  albuminuria.   79S. 

Girl,  the  .\merican,  976. 

Gish,  .Samuel  H.,  death  of,  260. 

Glandular  fever,  cases  simulating,  760:  in 
an  adult.  237;  in  epidemic  form,  S2(). 

Glaucoma,  acute,  with  suhln'aloiti  hemor- 
rhage supervening  upon  unilocular  ret- 
initis albuminuria,  3S5;  resection  of 
the  superior  cervical  sjinpathetic  gan- 
glia for,  (165;  secondary.  263. 

Gloves,  sterilization  of  rubber,  54S. 

Glycosuria  in  gastro-entcrilis  of  the  new- 
born. 705;  in  relation  to  life  insurance. 
306  ;  metatraumatic  alimentary,  305  ; 
prognosis  of,  299;  relation  of  kidney 
disease  to,  789. 

Goitre  in  France,  24:  retrosternal,  with 
grave  dyspncva,  510;  treatment  of  sim- 
ple, in  young  adults.  347. 

Goldan,  S.  Orniond,  description  of  new  in- 
struments: (I)  lip  retractor;  (2)  inter- 
dental mouth  props,  43S. 

Goldspohn,  .\..  two  cases  of  intestinal  ob- 
struction following  vaginal  hysterec- 
tomy, and  one  alter  pelvic  abscess, 
with  a  secondary  operation  in  each  case. 
374. 


December  29,  1900] 


INDEX. 


1033 


Gold  wire,  use  of,  in  operations  for  hernia, 
574. 

Gonococci,  diplococci  resembling,  in  the 
normal  vaj^ina  of  children,  175. 

Gonorrhix-a  in  relation  to  insurance,  C)- ; 
treatment  of,  99. 

Gonorrhccal  endocarditis,  with  congenital 
malformation  of  the  mitral  valve,  :005  ; 
joints  secondary  to  ophthalmia  neona- 
torum, 468. 

Goorkhas,  diseases  of,  35S. 

Gout,  233;  a  function  failure.  2q8;  clinical 
study  of,  427;  diagnosis  of,  585;  patho- 
genesis of,  345,  351,  573,  584;  some 
clinical  aspects  of,  721,  745. 

Granville,  Mortimer,  death  of,  989. 

Gravel,  prevention  of,  666. 

Graves,  Schuyler  Colfa.t,  obser\ations  on 
subclavian  deligation,  52S. 

Gray.  Ethan  K..  a  case  of  myxcedema,  with 
treatment,  69. 

Gray,  Landon  Carter,  resolutions  on  the 
death  of,  21. 

Grier,  Matthew  J.,  death  of.  739. 

Growth,  primary  disorders  of,  63. 

Gunshot  injuries,  modern  small-calibre, 
739.  824. 

Guam,  sanitary  condition  of.  621. 

Gymnastics,  non-hygienic,  160. 

Gynascology,  electricity  in.  486,  589,  596 ; 
medical,  1023  ;  resources  of  modern 
minor,  673  ;  the  value  of  thermal  car- 
bonated saline  baths  in,  811. 

11 

Habitations,  essential  conditions  of  healthy, 
384  ;  sanitation  of,  34. 

Haematemesis,  gastrotomy  for.  743  ;  in  the 
course  at  intestinal  occlusion.  742 ; 
post-operative.  544. 

Hscmatomyelia.  252. 

Haematuria,  treatment  of  malarial,  175. 

H;tmoglobin,  determination  of,  632. 

Hjemoglobinuria,  24.  35S,  667  ;  in  Trini- 
dad, S65  ;  malarial,  696  ;  peculiarly  al- 
tered blood  pigment  in  the  urine  in, 
296";  quinine,  io2[. 

Haemophilia,  gelatin  in,  743  ;  in  the  negro, 
149. 

Haffkine's  plague  serum,  method  of  using, 
741- 

Hammond,  Grceme  M..  two  unusual  cases 
of  aphasia,  with  special  reference  to 
the  so-called  naming  centre.  loio. 

Hands,  disinfection  of  the.  226.  265.  304, 
398,  733.  949  ;  value  of  pedicled  flaps 
in  injuries  of  the,  707. 

Hands,  W.  C,  a  case  of  sudderf  and  un- 
expected deliver)'  of  twins,  69. 

Hanford,  Maria  L"pton.  death  of.  5S0. 

Hanks.  Horace  Tracy,  obituar)'  of,  823. 

Hanoi's  cirrhosis,  788. 

Hanson,  J.  G.,  malaria  coexisting  with 
typhoid  fever,  434. 

Harris,  Elias  1!.,  death  of,  260. 

Harvard  Medical  School,  new  site  for,  699  ; 
Veterinary  School,  860. 

Havana,  sanitation  in.  981. 

Hawaii  Medical  Association.  503. 

Hayden.  James  R.,  extravasation  of  urine, 
150. 

Hay  fever,  preventive  treatment  of,  55.  62  ; 
treatment  of,  104,  41S,  467,  666,  947. 

Haynes,  Irving  S.,  a  consideration  of  the 
anatomical  construction  predisposing 
to  inguinal  and  femoral  hernia-,  and 
the  measures  to  be  taken  in  securing 
their  radical  cure,  566. 

Haynes,  S.,  position  in  labor,  511. 

Hays,  Benjamin  K.,  an  epidemic  of  ty- 
phoid fever,  974. 

Headache  from  eye-strain,  182,  41S. 

Health  reports  of  the  Marine-Hospital  ser- 
vice, 80,  120,  160,  200,  240,  280,  320, 
400,  440,  4S0,  520,  560,  621,  680,  719, 
760,  800,  840,  8S0,  920.  960.  1000. 

Health  resorts,  necessary  and  reliable  data 
upon,  292. 

Hearing,  cortical  localization  of,  9S7. 

Heart,  a  case  of  pulmonarj-  stenosis,  668  ; 
accentuation  of  the  second  sound  in 
the  pulmonary  area.  616;  action  of 
the.    in    mitral   stenosis,     347  ;    acute 


dilatation  of  the,  in  influenza  in  chil- 
dren, 263 ;  antecedents  of  disease  of  the, 
in  children,  1019;  beginning  of  idio- 
pathic enlargement  of  the,  743;  cancers 
of  the,  741 ;  clinical  study  of  disease  of 
the.  704;  complications  on  the  part  of 
the,  in  rheumatism,  629  ;  connective- 
tissue  induration  of  the,  950 :  diag- 
nostic dilficulties  associated  with  dila- 
tation of  the  right  ventricle,  53  ; 
diastolic  expansion  movement  of  the 
ventricles  as  a  factor  in  compensation 
for  disease  of  the  mitral  valve,  353; 
disease  of  the,  bearing  of,  upon  life 
insurance.  655;  double  beat  of  the, 
418;  endocardial  murmurs  of  organic 
origin  localized  in  the  pulmonary  area, 
48.  72  ;  functional  diseases  of  the.  828  ; 
inhibition  of  the,  as  an  aid  in  diagno- 
sis, 543  ;  lesions  of  the,  following  the 
acute  specific  fevers,  733  ;  metastatic 
epithelioma  of  the.  S34  ;  minor  forms 
of  dilatation  of  the,  227  ;  new  physical 
sign  in  dislocation  of  the.  372  ;  non- 
traumatic rupture  of  the.  116  ;  physio- 
logical dilatation  and  the  mitral  sphinc- 
ter as  factors  in  functional  and  organic 
disturbances  of  the,  702  ;  prevention 
of  valvular  disease  of  the,  in  cases  of 
acute  rheumatism,  704;  pulmonary 
stenosis  due  to  ulcerative  endocarditis 
of  the  aortic  valve,  834  ;  relation  of  in- 
fluenza to  chronic  disease  of  the.  137  ; 
suprarenal  capsule  in  diseases  of  the, 
5S2  ;  treatment  of  disease  of  the,  467. 
9S6 :  treatment  of  failure  of  the,  in  the 
aged,  665;  tumorsof  the,  976;  useand 
abuseof  stimulants  of  the,  976  ;  venous 
obstruction  complicating  disease  of  the, 
72:  woundsof  the,  921. 

Heat-stroke  as  a  post-operative  complica- 
tion, S32  ;  in  India,  507;  venesection 
in,  144. 

Hemianopsia  from  embolism,  395. 

Hemiplegia,  ura-mic.  951. 

Hemorrhage,  anaesthetic  solution  for.  199; 
concealed  accidental,  143  ;  in  typhoid 
fever,  decinormal  salt  solution  in  the 
treatment  of,  426;  post-operative.  711, 
862  ;  post-partum,  313  ;  treatment  of 
cholajmic,  199. 

Hemorrhoids,  new  operation  for,  901;  sim- 
ple operation  for.  713  ;  submucous  lig- 
ature for,  113. 

Hepatitis,  acute  dysenteric,  348. 

Heredity  and  imitation,  519;  in  disease. 
975- 

Hernia,  anatomical  construction  predispos- 
ing to,  566  ;  gold  wire  in  the  radical 
operation  for,  574  :  hypodermic  cure 
of,  199  ;  indications  for  operation  in, 
796  ;  local  anesthesia  in  the  radical 
operation  for,  972;  obscure  abdominal 
pains  in,  S32  ;  of  the  ovary  and  tube 
and  the  vermiform  appendix,  I92;  rad- 
ical cure  of,  465  ;  nidical  cure  of  in- 
guinal, in  women,  9S6  ;  radical  cure  of 
inguinal,  relative  bearing  of  the  con- 
joined tendon  and  the  internal  oblique 
muscle  upon,  321  ;  radical  operation 
for  oblique  inguinal,  264  :  repairing 
the  abdominal  wall  in  ventral,  702  ; 
surgical  management  of  umbilical, 
670;  the  Phelps  operation  for.  441  ; 
treatment  of.  515  ;  treatment  of  stran- 
gulated, 115,895;  ventral,  following 
laparotomy,  711. 

Herold,  Henr)-  T.,  death  of,  181. 

Hervey,  Edward  Addison,  death  of,  701. 

Hiccough,  treatment  of,  797. 

High  altitudes,  alleged  increase  of  blood 
cells  in,  145;  hygiene  of,  640  ;  prac- 
tice of  medicine  and  surger)-  in,  97. 

Highmore's  antrum,  empyema  of,  of  fif- 
teen years'  duration.  902  ;  primary  epi- 
thelioma of.  987. 

Hill  heart.  467. 

Hill,  L.  L. .  wounds  of  the  heart,  with  a 
report  of  seventeen  cases  of  heart  su- 
ture. 921. 

Hip  joint,  amputation  at  the,  674  ;  con- 
genital dislocation  of  the.  702  ;  etiology 
of  congenital  dislocation  of  the.  256; 
instrument  for  operating  on  congenital 


dislocation  of  the,  956:  t.eatment  of 
tuberculous  and  purulent  disease  of  the, 
714. 

Iloag,  Ciitus  S.,  death  of.   141. 

Hobby.  Harold  E.,  death  of,  662. 

Hodgkin's  disease.  192. 

Holder.  O.  H. .  the  pathology  of  lupus  ery- 
thematosus, 43. 

Hoornbeck,  Stephen  E.  D.,  death  of,  580. 

Horse  sickness,  200,  948. 

Horsley,  J.  Shelton,  the  treatment  of  ne- 
crosis of  the  entire  shaft  of  a  long  bone, 
with  report  of  a  case,  604. 

Hospital,  a  race-track,  867:  abuse,  380; 
discrimination  in  the  reception  of  pa- 
tients by  a,  55s  ;  economics,  course  of, 
at  the  Teachers'  College,  540  ;  suit  for 
injuries  received  in,  259. 

Hospital  ship,  a  French,  in  China,  383; 
Japanese,  429  ;  the  Maine,  79,  477. 

Hospitals,  expenses  of  the  London.  919; 
New  York  City  public,  proposed 
change  in  the  management  of.  896; 
private,  and  their  management,  554 ; 
private,  for  transmissible  disease,  258, 
430. 

Hot  air  in  affections  of  the  upper  air  pas- 
sages, 305 ;  in  the  treatment  of  eczema, 
345- 

lluber.  John  li.,  summer  vacations  for  the 
poor,  62S. 

Hughes,  A.  \\..  death  of.  S67. 

lliihner.  Max,  a  simple  method  for  writing 
prescriptions  for  children.  814. 

Ilulseberg.  Frederick  W. .  death  of.  223. 

Humerus,  fracture  of  the  greater  tuberos- 
ity of  the,  829:  treatment  of  supra- 
condyloid  fracture  of  the.   1018. 

Hussey,  M.  F..  a  case  of  placenta  pra;via 
with  twins.  23S. 

Hygiene,  domestic.  36  ;  in  New  York  City, 
75S  ;   teaching  of,  756 

Hydrocephalus,  acute  internal,  784  ;  con- 
genital, of  non-inflammatory  type,  474; 
internal,  following  cerebrospinal  men- 
ingitis, 706. 

Hydrogen  gas.  weight  of.  520;  peroxide, 
therapeutic  value  of,  864. 

Hydrotherapy  in  gynecology  and  obstet- 
rics, 427  ;  in  some  common  dispensary 
diseases,  7S8. 

Hyoid  bone,  median  osteotomy  of  the,  16. 

Hyperacidity,  fat  diet  in,   106. 

Hyperchlorhydria.  simple  primary,  667, 

Hypertrichosis  universalis.  788. 

Hypnotism,  use  of,  in  general  practice, 
170. 

Hypospadias,  operation  for,  124,  635. 

Hysterectomy,  abdominal,  42S  ;  abdominal 
i-s.  vaginal.  710,  91 5  ;  for  myoma,  344  ; 
vaginal,  313. 

Hysteria,  224  ;  etiology  and  cure  of,  142  ; 
in  the  child.  56  ;  in  the  male,  226  ;  na- 
ture of,  709  ;  painful  anesthesia  in, 
378  ;  treatment  of,  O96. 


Ichthyosis  hystrix,  electric-light  treatment 
of,  673. 

Idiocy,  epileptic,  cure  of  a  case  of,  742  ; 
infantile  amaurotic  family,  56. 

Immigrants,  ages  of,  2cx>. 

Immunity,  46S  ;  study  of,  427. 

Incineration  -j.  earth  sinks  and  chemical 
disinfection.  684. 

Inebriety,  curability  of,  by  medical  treat- 
ment, 715.  1013. 

Infant  feeding,  104,  182,  I  S3,  232,  234, 
591,  893  ;  relation  of  scurvy  to,  675. 

Infant  mortality  in  New  York,  reduction  of, 
541- 

Infants,  fever  as  a  sign  of  unsuccessful 
nursing,  1006  :  weight  cune  in.  136. 

Infection,  theory  of,  584. 

Infections,  local,  boiling  water  in,  705. 

Inflammation,  nomenclature  of,  537, 

Influenza.  913  ;  acute  nephritis  following. 
668  ;  cough  in.  simulating  whooping- 
cough,  S29  :  effect  of,  on  the  nervous 
system,  9S3  ;  epidemic,  983 ;  er^thro- 
meialgia  following,  976;  fibrinous 
bronchitis  due  to,   S55  ;  hydrotherapy 


I034 


INDEX. 


[December  29,  1900 


in,  gSj  ;  in  children,  sodium  benzoate 
for,  22  ;  of  the  ner\ous  system,  276  ; 
pathology  of,  1S5;  potassium  bicarbo- 
nate in,  784 ;  relation  of  chronic  heart 
disease  to,  137. 

Ingals,  Ephraim,  death  of,  1018. 

Ingrowing  toe-nail,  treatment  of,  7q6. 

Inheritance,  physiology  and  pathology  of, 
826  ;  relation  of  pernicious  ansemia  to, 
S41,  gog. 

Insane,  hospital  for  the,  in  Palestine.  S5S  ; 
isolation  of  the  tuberculous,  578  ;  sur- 
gery among  the,  g7. 

Insanity,  alleged  increase  of,  184  ;  among 
lead  workers,  544;  contagious,  S55; 
crime,  and  sexual  function,  correlation 
between.  figS,  g25  ;  electro-therapy  of, 
5gg  ;  epileptic,  1 015  ;  in  Great  Britain, 
398  ;  In  the  United  States  army,  701 ; 
in  Virginia,  58  ;  incipient,  377  ;  legal 
and  medical,  534;  post-febrile,  1S2; 
prevention  of,  SiS;  traumatic,  425. 

Insomnia,  causes  and  cure  of,  94S,  984  ; 
treatment  of,  when  due  to  arterioscle- 
rosis, 940. 

Insufflation  of  the  oesophagus,  stomach, 
and  colon,  diagnostic  and  therapeutic 
value  of,  262. 

International  Congress  of  Deontology  and 
Professional  Medicine,  222. 

International  Congress  of  Gynecology  and 
Obstetrics,  the  place  of  meeting  of 
the,  6ig. 

International  Congessof  the  Medical  Press, 
2;S.  420. 

International  Medical  Congress,  221,  229, 
428. 

Intestine,  anastomosis  of  the,  345,  71 7, 
739;  atropine  for  obstruction  of  the, 
144,  9S5  ;  cancer  of  the,  161  ;  obstruc- 
tion of  the.  complicating  appendicitis, 
653  ;  obstruction  of  the,  due  to  Meck- 
el's diverticula,  645  ;  obstruction  of 
the,  following  vaginal  hysterectomy 
and  pelvic  abscess,  574  ;  occlusion  of 
the,  by  cancer  of  the  colon,  9S5  ;  per- 
foration of  a  typhoid  ulcer  of  the, 
without  fecal  extravasation,  96S;  trau- 
matic rupture  of  the  small,  7S7  ;  treat- 
ment of  obstruction  of  the,  786;  syph- 
ilis of  the,  145. 

Intubation,  case  of  prolonged,  298  ;  effects 
of  repeated,  835. 

Intussusception,  839  ;  in  an  infant,  306. 

Iodide  of  potassium  in  ophthalmic  practice, 
825. 

lodism,  antidotes  for,  1013. 

lodo-parotiditis,  306. 

Ipecacuanha,  production  of,  480. 

Iritis    581. 

Irwin,  Crawford,  death  of,  622. 

Isaacs,  .'\.  E. ,  alveolar  sarcoma  of  the 
uterus,  152. 

Isaacson,  Charles  B. ,  after-pains  from  ex- 
traction of  teeth.  216. 

Italy,  students  of  medicine  in.  6gg. 


J 


Jacobi.  A..  American  medicine.  201,  710; 
on  medical  journalism,  300  ;  presenta- 
tion of  a  loving-cup  to,  31. 

Japan,  letter  from,  429. 

Japanese  navy,  report  of  the  surgeon-gen- 
eral of  the,  430. 

Jaundice  due  to  gummatous  infiltration, 
(J25  ;  pathogenesis  of.  574 ;  simple 
acholuric,  949  ;  surgical  importance  of, 
S24. 

Jaw,  dislocation  of  the,  in  epilepsy,  104  ; 
jerk  and  jaw  clonus,  627. 

Jenkins,  Xorburne  B. ,  dislocation  of  the 
crystalline  lens  in  immature  cataract, 
974  ;  the  spectacle  and  eye-glass  habit, 
431- 

Johimbin,  effect  of,  787. 

Johnson.  Alexander  I!.,  some  cases  of  acute 
appendicitis,  688.  716. 

Johnson,  Alexander  II.,  death  of,  702. 

Joint,  affections  of  the,  the  rheumatic  and 
gouty  di.tthesis  in  relation  to,  443 ; 
gonorrhii'al  inflammation  of.  585  ; 
neuropathic,  (i<-4  ;  restoiation  of  func- 


tion to  ankylosed,  695  ;  septic  and 
gonorrhreal.  664  ;  treatment  of  tuber- 
culous and  purulent,  465  ;  traumatic, 
544  ;  tuberculosis  of,  673. 

Jones,  Hugh  E.,  a  new  nasal-duct  irriga- 
tor, 397. 

Jones,  Mary  Dixon,  insanity,  its  causes ; 
is  there  in  woman  a  correlation  of  the 
sexual  function  with  insanity  and 
crime  ?  925. 

Jones,  Noble  W.,  the  presence  of  virulent 
tubercle  bacilli  in  the  healthy  nasal 
cavities  of  healthy  persons,  285. 

Jones,  William,  observations  on  the  sur- 
gerj'  of  the  gall  tracts,  610. 

Jones,  William  K.,  death  of,  982. 

Judkins,  Charles  P.,  death  of,  6l. 


Kales,  J.  W.,  chylous  ascites,  795. 

Kashmir,  letter  from,  389. 

Keays.  Frederick  L.,  the  treatment  of  ty- 
phoid fever  at  the  New  York  Hospital, 
851. 

Kebler,  Frederick,  death  of,  945. 

Keefe,  D.  E. ,  notes  on  typhoid  fever,  with 
a  report  of  fifteen  cases,  808. 

Kelley.  Carl  M..  death  of.  260. 

Kelliher,  .Michael,  death  of,  739. 

Kellogg.  Edward  L.,  hospital  for  scarlet 
fever  and  diphtheria  patients,  430 ; 
sterilization  of  rubber  gloves,  548. 

Kemp,  Robert  Coleman,  a  glass  hydro- 
static-pressure irrigator  for  the  urethra 
or  bladder,  157. 

Kendall,  H.  E.,  a  case  of  carbolic-acid 
poisoning,  with  a  question  concerning 
asphyxia,  794. 

Keratitis  bullosa.  344 ;  interstitial,  799 ; 
scrofulous.  263. 

Kernig's  sign  in  meningitis.  S53. 

Keyes,  Edward  L..  Jr.,  the  evidences  of 
prostatic  atrophy  after  castration,  81. 

Kidneys,  calculi  of  the,  908,  976  ;  cystic 
degeneration  of  both,  54  ;  determination 
of  the  functional  integrity  of  the,  by 
means  of  the  freezing-points  of  the 
blood  and  urine,  82S  ;  diagnosis  of  tu- 
berculosis of  the,  679  ;  eye  affections 
associated  with  lesions  of  the,  256 ; 
functional  diagnosis  of  diseases  of  the, 
226;  lipoma  of  the,  5S4  ;  lymphosar- 
coma of  the,  S33  ;  movable,  reefing 
operation  for,  5S2 ;  movable,  treat- 
ment of,  298,996  ;  surgical  treatment  of 
tuberculosis  of  the,  54,  943  ;  treatment 
of  primary  tuberculosis  of  the,  5S6. 

Kime,  J.  W.,  light  as  a  remedial  agent, 
572". 

King,  Clarence,  convulsions,  50. 

King,  George  W.,  foreign  bodies  in  the 
oesophagus,  643. 

Kirkbridge.  Thomas  Story,  death  of,  141. 

Knapp,  Mark  I.,  an  improved  stethoscope, 
119. 

Knee  joint,  amputation  at  the,  658  ;  ampu- 
tation at  the,  when  the  arterial  circu- 
lation of  the  region  is  impaired,  961  ; 
intermittent  hydrops  of  the,  711  ; 
suppurative  inflammation  of  the,  fol- 
lowing a  penetrating  wound,  509  :  sur- 
gery of  non-tuberculous  affections  of 
the,  J06  :  tuberculosis  of  the,  294. 

Knt>ck-out  drops,  999. 

Knopf,  S.  .\.,  neglected  clinical  opportuni- 
ties in  American  medical  centres.  36. 
86;  prize  of  the  Berlin  Tuberculosis 
Congress  awarded  to,  221. 

Koplik's  spots  in  measles,  54,  344,  840, 
9S6. 

Kurth,  Henry  A.,  chronic  copper  poison- 
ing among  artisans,  731. 


L 


Labor,  chorea  and  leukaemia  as  indications 
for  the  induction  of,  616  ;  difficult,  in- 
terference in,  22  ;  management  of  nor- 
mal, 629;  position  in,  511. 

Laboratory  research,  relation  of,  to  practi- 
cal medicine   902. 


Labyrinth,  physiology  of  the,  733. 

Lacrymal  ducts,  chronic  inflammation  of 
the,  703  ;  electrolysis  in  stricture  of 
the,  663  ;  punctum,  dilatation  of  the, 
118. 

I.adinski,  Louis  J.,  internal  hemorrhage 
the  result  of  traumatic  rupture  of  ad- 
hesions due  to  acute  appendicitis,  with 
the  report  of  a  case.  924. 

Lameness,  intermittent.  782. 

Lange,  Karl,  death  of.  60. 

Langmann,  Gustav,  poisonous  snakes  and 
snake  poison,  401. 

Language,  international,  341. 

Laparotomy,  see  Caliolomy. 

Larimore,  F.  C,  hernia  of  the  ovar)- and 
tube  and  the  vermiform  appendix,  190. 

Larkin,  William  R.,  death  of,  662. 

Larson,  C.  I'rithiof,  women  medical  grad- 
uates in  Sweden,  67. 

Laryngeal  hypokinesis,  hysterical,  268 ; 
nerve,  recurrent,  paralysis  of  the,  740. 

Larynx,  atresia  of  the,  due  to  faulty  intu- 
bation, 668;  naked-eye  diagnosis  of 
cancer  of  the,  707  ;  neuralgia  of  the, 
906 ;  papilloma  of  the,  in  children, 
703.  799 ;  pathology  and  treatment  of 
toxic  paralyses  of  the,  707 ;  perichon- 
dritis of  the,  in  typhoid  fever,  34S; 
polyp  of  the,  with  signs  of  pulmonary 
phlhists,  54  ;  salicylic  acid  for  pachy- 
dermia of  the,  3S6 ;  stenosis  of  the, 
due  to  injury  of  the  thyroid  cartilages, 
703  ;  tuberculosis  of  the,  671,  970,  9S8. 

Lavage,  indications  for  the  use  of,  797. 

Lazear,  Jesse  W.,  death  of.  543. 

Lead  poisoning  among  stonecutters,  940  ; 
encephalopathy  in,  63 ;  through  the 
use  of  lead  ointment,  220,  22S  ;  two 
cases  of  fatal,  469.  • 

Leech,  D.  J.,  death  of,  149. 

Leg,  technique  of  amputation  of  the,  743. 

Leontiasis  ossea,  696. 

Leper  colony  at  Robben  Island,  6g6  ;  in 
the  Philippines,  222. 

Lepers,  disinfection  of  the  mail  of,  77S. 

Lepine.  R.,  nature  of  hysteria.  709. 

Leprosy  in  China,  677  ;  in  France.  239  ; 
in  Germany.  878  ;  in  the  Philippines, 
341  ;  in  the  United  States,  756  ;  treat- 
ment of,  545. 

Letters  from  Beyrout,  28,  349  ;  from  Bra- 
zil, 29,  108 ;  from  Constantinople, 
708  ;  from  Japan,  429  ;  from  Kash- 
mir, 389  ;  from  London,  26,  65,  106, 
148,  187,  228,  26S,  306,  34S,  38S, 
470,  510,  547,  588,  627,  668,  708,  743, 
7Sg,  82g,Sb6,go6,  g5i,  988,1022  ;  from 
New  Zealand,  269,  907  ;  from  Paris, 
27,  107,  428,  5S9;  from  Peru,  590. 

Leukaemia,  633  ;  acute,  584  ;  a  disease  re- 
sembling acute,  378;  as  an  indication 
for  the  induction  of  labor,  616. 

Leukocytosis,  differential,  715. 

Leukoderma  in  India,  266. 

Leukoplakia  buccalis,  relation  of,  to  syph- 
ilis and  cancer,  9S5. 

Levin,  Isaac,  pathological  physiology  or 
experimental  pathology,  its  scope  and 
significance  in  medicine,  327. 

I.eviseur,  Fred.  J.,  a  new  urethroscope, 
38- 

I.igamentopaxis,  590. 

light  as  a  remedial  agent.  572. 

Lightning  stroke,  recovery  from.  393. 

Lincoln,  kufus  P.,  death  of.  S61  ;  obitu- 
ary of,  901. 

l.inea  alba,  hernia  of  the.  102 1. 

Lingual  tonsil,  scissors  for  the.  iiS. 

l.insley,  J.  II.,  the  significance  of  the 
bacillus  coli  communis  in  drinking- 
water,  324. 

Lip  retractor,  438. 

Lipoma  of  the  plantar  arch,  familial,  42S. 

Lipomatous  abdominal  wail,  retrenchment 
of  the,  787. 

Lippitt,  T.  M..  wounded  in  Peking,  302. 

Lister  in  Paris.  399. 

Little.  Seelye  W.,  report  of  a  case  of  frac- 
tured liver,  973. 

Liver,  accessory  lobe  of  the,  834;  clinical 
study  of,  as  a  factor  of  elimination, 
415  ;  contusions  of  the,  305  ;  cure  of 
a  case   of  hypertrophic    alcoholic  cir- 


December  29,  1900] 


INDEX. 


1035 


rhosis  of  the,  4SS  ;  fracture  of  the,  973  ; 
hepatic  odor  in  abscess  of  the,  827  ; 
pathology  of  acute  yellow  atrophy  of 
the,  177  ;  rupture  of  the,  98  ;  sarcoma 
and  cirrhosis  of  the,  707  ;  sequel  of 
hydatids  of  the,  906  ;  surgical  treat- 
ment of  hydatid  cysts  of  the,  600 ; 
tropical  abscess  of  the,  359- 

I.loyd,  Frederick  Osborne,  death  of,  1018. 

Lock-wood,  (leorge  Roe,  gastroptosis,  843. 

Locomotor  ataxia,  see  Tabes  dorsalis. 

London,  letters  from,  26,  65,  106,  148, 
187,  228,  268,  306,  34S,  388,  470,  510, 
547,  588,  627,  668,  708,  743,  789,  829, 
866,  906,  951,  9S8,  1022. 

Loomis.  Henry  I'.,  some  personal  observa- 
tions on  the  effects  of  intrapleural  in- 
jections of  nitrogen  gas  in  tuberculosis, 
481. 

Los  Angeles,  consumptives  in,  22;. 

J.osdorfer's  bodies  in  syphilitic  blood, 
176. 

Losee,  John  E. ,  death  of,  1018. 

Louisiana,  care  of  lepers  in,  140  ;  local 
health  boards  in,  73S. 

Luckett,  \V.  II.,  a  new  needle-holder  that 
will  not  break  needles.  177. 

Lumbricoids,  pseudo-meningitis  due  to, 
176. 

Lungs,  abscess  of  the,  106;  and  spleen, 
percussion  of  the  boundary  between, 
106;  ccdenia  of  the,  231;  suprarenal 
capsule  in  diseases  of  the,  774. 

Lupus  erythematous.  41  ;  vulgaris,  incision 
of,  534  ;  vulgaris,  .r-rays  in  the  treat- 
ment of,  7S3,  947. 

Lu.\alions,  voluntary,  16. 

Luzzatto.  M..  a  cure  of  a  case  of  hyper- 
trophic alcoholic  cirrhosis  of  the  liver, 
4S8. 

Lymph  node  as  a  factor  in  diagnosis,  574. 


M 


Macalester.  Richard  K.,  balneotherapy  as 
practised  by  the  Indians.  79. 

McCartee,  IMvie  liethune,  death  of,  141. 

McCaskey,  G.  \V.,  a  case  of  gonorriucal 
endocarditis  with  congenital  malfor- 
mation of  mitral  valves,  1005. 

Mctniire,  Hunter,  obituary  of,  464. 

McNulty,  James  XL,  death  of,  181. 

Mahoney,  James  F. ,  death  of,  662. 

Malaria,  action  and  value  of  quinine  in, 
356,  546  ;  acute  abdominal  pain  in, 
224 ;  coe.xisting  "ith  typhoid  fever, 
434 ;  conjugation  in  the  asexual  cycle 
of  the  parasite  of,  831  ;  dififerential 
staining  of  the  parasites  of,  1S5  ;  epi- 
demiological contribution  to  the  ques- 
tion of.  23  ;  estivo-autumnal,  in  Euro- 
peans in  West  Africa,  785 ;  house- 
plants  in  relation  to,  268  ;  in  Canada. 
1 5S  ;  inoculation  theory  of,  624 ; 
Koch  on,  659;  malignant,  with  urti- 
<rarial  and  petechial  eruptions,  546 ; 
mosquitos  as  spreaders  of,  63,  538.669, 
703,  704.  S65,  879,  946,  1023;  para- 
site of  quartan,  740;  parasites  of  ter- 
tian and  quotidian,  799  ;  polyneuritis 
following,  626;  the  problem  of.  610; 
treatment  of.  in  the  Roman  Campagna, 
3I9;  war  against  in  Italy,  943. 

Malarial  coma  in  children,  829. 

Malpractice,  defence  of  suits  for  alleged. 
511. 

Malta  fever,  24  :  at  Manila,  863. 

Mammary  gland,  therapeutics  of  the.  75. 

Man.  descent  of,  699. 

Mandel,  Louis.  J.,  large  subdural  abscess 
and  abscess  of  the  brain  following  a 
penetrating  wound,  with  but  slight 
pressure  symptoms,  435. 

Mania,  acute  delirious,  545. 

Manila,  health  of,  59;  improved  temper- 
ance conditions  in.  637  ;  sanitary  re- 
forms in,  221, 

Marcus,  L.,  medullary  narcosis  (Coming's 
method)  ;  its  histor\'  and  develop- 
ment, 561. 

Maritime  Medical  Association,  423. 

Martin,  E.  II.,  the  use  of  hypnotism  in 
general  practice,  170. 


Marx,  S.,  medullary  narcosis  during  labor, 
521. 

Massage,  pelvic,  1000. 

Mastitis,  chronic  lobular,  903;  typhoid, 
377- 

Mastoid,  abscess  of  the,  946;  operation  on 
the,  management  of  the  soft  parts  in, 
904  ;  wounds  of  the,  carbolic  acid  in, 
296. 

Mastoiditis,  918:  abortive  treatment  of 
acute,  344  ;  bacteriology  of  purulent, 
go2 ;  following  infectious  diseases, 
297  ;  spontaneous  cure  of,  987. 

Masturbation,  albuminuria  from,  880. 

Maternal  impressions,  638,  785. 

Maxilla,  fracture  of  the  superior,  in  an  aged 
man,  385. 

Mayer,  Abraham,  a  case  of  glandular  fever 
in  an  adult,  237. 

Measles,  chickenpox,  and  smallpox,  con- 
comitant, 377  ;  Koplik  sign  in,  54, 
344,  840,   986  ;  preliminary   rules   in, 

345- 
Meat,  dietetic  value  of  white  and  dark,  40  ; 
putrid,    utilization   of,  in   France,  80; 
white   and    dark,    in    kidney   disease, 

63- 

Meckel's  diverticulum,  intestinal  strangula- 
tion by,  716. 

Mediastinum,  dermoid  cyst  of  the,  64. 

Medical  Association  of  the  Greater  City  of 
New  York.  634,  992. 

Medical  Defence  I'nion,  plea  for  a,  420. 

Medical  reciprocity  in  Canada,  301. 

Medical  Society  of  the  County  of  New- 
York,  591,  758.  911;  history,  aim, 
and  purpose  of  the,  91 1. 

Medical   .Society  of  the   Missouri  Valley, 

579- 

Medical  Society  of  the  State  of  Pennsylva- 
nia, 502. 

Medical  Society  of  Virginia,  660. 

Medical  students,  preliminary  education  of, 
1S4. 

.Medical  writing,  some  tendencies  of,  17S. 

Medicine  as  a  science  and  as  an  art,  274, 
715;  in  1 800,  looi. 

Meilicine  habit  in  Great  Britain,  600. 

Medullary  narcosis,  344,  508,  521,  561, 
577,  601,  615,  624,  674,  714,  740, 
744,  750,  791,  799,  82S,  862,  868,  937, 
967,  992. 

Melancholia,  trinitrin  in,  377. 

Memory,  mechanics  of.  546. 

Meniere's  disease.  507.  654. 

Meningitis,  basal,  with  special  reference  to 
the  eye-symptoms,  190;  complicating 
pneumonia,  798 ;  cured  tuberculous, 
54- 

Meningocele,  spurious,  575. 

Meningo-myelitis  with  bacteriological  ex- 
amination of  a  cord.  264. 

Menopause,  hemorrhage  after  the,  616; 
psychosis  of  the,  344. 

Menstrual   condition   of  the  average  girl, 

873- 

Mental  aberration,  temporary,  346  :  devel- 
opment, arrested,  following  depressed 
fracture  of  the  skull,  7S5  ;  disease, 
rest  in  bed  in  the  treatment  of  acute 
forms  of,  976;  sanitation  51S;  trou- 
bles, intoxications  and  infections  in. 
905. 

Meralgia  par.i'Sthelica,  with  intermittent 
lameness,  7S2. 

Merriam,  Frank  C.,  death  of,  465.  548. 

Merritt,  .Salome,  death  of,  7S1. 

.Mersereau,  Charles  IL,  death  of,   141, 

Mesenteric  cysts,  586;  glands,  tuberculo- 
sis of  the.  671. 

Metabolism,  influence  of  sodium  salicylate 
upon,  57J;  studies  in.  in  chronic  nu- 
tritional diseases,  543. 

Metacarpal  fracture,  treatment  of,  224. 

Metatarsus,  are  spontaneous  fractures  of. 
accidents?  265;  indirect  fracture  of, 
508. 

Metritis,  cervical,  S27. 

Metrorrhagia,  faradization  in  the  treatment 
of,  742. 

Mexico,  negroes  in,  66. 

Meyer,  Leo  B.,  local  anresthesia  in  the 
radical  operation  for  inguinal  hernia, 
972. 


Microbe  lamps,  957. 

Midwives'  bill  in  England,  58. 

Migraine  with  aphasia  and  numbness  in  one 
arm,  348. 

Milbury,  Frank  Stephen,  death  of,  343. 

Miles,  A.,  death  of,  823. 

Military  surgery,  303. 

Milk,  control  of  dealers  in.  in  Japan,  39; 
feeding  of  infants  with  unsterilized, 
424  ;  formalin  as  a  preservative  of, 
835  ;  home  modilication  of,  623  ;  hu- 
man, pathology  of,  185  ;  method  of 
increasing  the  digestibility  of  cow's, 
986  ;  sterilizing  and  pasteurizing,  675  ; 
tuberculous,  960. 

Miller,  George  I.,  a  case  of  tuberculous 
intra-peritoncal  effusion  cured  by  in- 
cision and  permanent  drainage.  70. 

Miller,  IL  T.,  fracture  of  the  clavicle,  re- 
sulting in  rupture  of  the  suprascapular 
artery  (?),  973. 

Minnesota,  medical  defence  association  for, 
736. 

Mississippi  Valley  Medical  Association, 
710. 

Mock,  E.  \'.,  dermographia  and  anidrosis, 
197. 

Mole,  vesicular,  malignancy  of,  895. 

Moor,  William  Ovid,  the  discovery  of 
"ureine,"  the  principal  organic  con- 
stituent of  urine  and  the  true  cause  of 
ur.vmia,  336,  471. 

Morbific  agent  and  reparative  effort,  145. 

Moreton,  Ilenry.  death  of,  662. 

Morphine,  use  of,  in  surgical  practice, 
575- 

Morphinism  among  physicians,  919;  treat- 
ment of,  303,  304,  1021. 

Morrison,  J.  II. ,  lingual  tonsil  scissors, 
iiS. 

Mortality,  summer,  f>o. 

Morton  wave  current,  596,  597. 

Moschcowitz,  Alexis  V.,  the  radical  treat- 
ment of  tuberculosis  of  the  testis, 
412. 

Moser,  W. ,  a  peculiar  delusion,  154;  how 
is  motility  in  the  red  blood  cells  effect- 
ed ?  989. 

Mosquitos,  558;  distinction  between  an- 
opheles and  culex,  7S0;  transmission 
of  filaria  by,  17.  342.  357,  785;  trans- 
mission of  malaria  by,  63,  53S.  669, 
703,  704,  S65.  879,  946,  1023  ;  trans- 
mission of  yellow  fever  bv,  697,  703, 
754,  S5S.  S63,  867. 

Mould  infection  in  man.  23,  439. 

Mouth  props,  interdental.  438. 

.Mouth,  septic  condition  in  the.  as  a  cause 
of  disease.  225. 

Muehleck.  (George  A.,  death  of,  702. 

Mulcahey,   Dennis  Dowling,  death  of.  423. 

Mules'  operation,  582. 

Mumps  in  pneumonia,  68;  pancreatitis 
complicating,  23. 

Munde,  Paul  F.,  external  abdiminal  exam- 
inations during  pregnancy  and  labor, 
390  ;  why  gyna.'cologists  are  reluctant 
to  use  electricity,   589. 

Munn,  William  11..  death  of,  506. 

Murder,  attempt  at,  by  a  youth,  509. 

Muscular  atrophy  following  slight  trauma- 
tism, 268;  hereditary  spinal,  in  child- 
hood. 9S5. 

Mushrooms.  557. 

Mutilations,  inheritance  of.  66. 

.Myasthenia,  gastric,  1021  ;  gravis,  S06. 

.Myers,  T.  Ilalsted,  sarcomatosis  of  the 
vertebra;  simulating  tuberculous  ostei- 
tis in  a  case  of  pulmonary  tuberculosis, 

394- 
Myokymia,  1021. 
Myomectomy  per  vaginam,  224. 
Myositis  ossificans.  387. 
-Myotherapy.  S'^S. 
Myxitdema,  a  case  of,   6(1 ;  in  childhood, 

510. 


N 


Nievus,  varicose  osteo-hypertrophic,  218. 
Nammack,  Charles  E..  a  case  of  pernicious 

anaemia.  Hunter's  treatment,  autopsy, 

i93. 


1036 


INDEX. 


[December  29,  1900 


Naphthol.  camphorated,  poisoning  by,  470, 

Nasal  cavities,  empyema  of  the.  182;  fossa, 
sarcoma  of  the  right,  with  acute  sinu- 
sitis and  orbital  cellulitis,  513;  poly- 
pus, 733  ;  sinuses,  anatomy  of  the  ac- 
cessory. 742. 

Nasal-duct  irrigator,  397. 

Naso-pharyngeai  disease  in  children,  305, 

Naso-pharynx,  sarcoma  of  the,  cured  by 
injections  of  formalin,  05;. 

Navy,  comparative  physique  of  recruits  for 
the,  ggg. 

Neale.  Richard,  death  of,  988. 

Necrosis  of  the  entire  shaft  of  a  long  bone, 
treatment  of,  604. 

Nectrianine,  227. 

Needle  holder,  a  new.  157. 

Neftel.  William  IS.,  the  treatment  of  tu- 
mors by  electrolysis,  SS4. 

Negroes  in  Me.'cico.  66. 

Nelson.  William  J.,  death  of,  701. 

Nephrectomy,   76. 

Nephritis,  acute,  following  influenza.  66S  ; 
interstitial,  prophyla.\is  and  manage- 
ment of,  1S2  ;  role  of  the  allo.xuric 
bases  in,  865  ;  the  liver  as  a  factor  in 
the  production  of,  415. 

Nephrorrhaphy.  7b. 

Nervous  conductibility  and  electric  con- 
ductibility,  analogy  between,  62S,  849. 

Nervous  diseases,  gonorrhceal,  82S;  trau- 
matic,   506  ;    traumatic,  diagnosis  of, 

499- 

Neuralgia,  epileptiform,  excision  of  the 
Gasserian  ganglion  for.  904  ;  surgical 
treatment  of  trigeminal,  509  ;  trigemi- 
nal, cure  of  inveterate  cases  of,  975 ; 
typical  form  of  laryngeal,  906. 

Neurasthenia,  949  ;  causes  and  treatment 
of  some  cases,  59S  ;  diagnosis  of,  535  ; 
subjective  symptoms  of.  906 ;  the 
blood  in,  S65  ;  treatment  of,  346,  696 ; 
uric  acid  in.  534. 

Neuritis,  alcoholic  face  and  pupil  in,  94S  ; 
arsenical,  984  ;  facial,  associated  with 
unilateral  retro-orbital  neuritis,  7S2  ; 
motor  ganglion  cells  in  peripheral,  3S5  ; 
multiple.  104:  multiple,  following 
pneumonia,  474 ;  puerperal  multiple, 
346. 

Neuron,  doctrine  of  the,  964. 

Neuroserum,  998. 

Neuroses,  gastro-enteric  affections  due  to, 
42S  ;  into.\ications  and  infections  in, 
905  ;  traumatic,   506. 

Newark,  diphtheria  antitoxin  plant  in, 
755- 

Newborn,  apparent  death  in  the,  575  ;  pre- 
vention of  colds  in  the,  142. 

New  lirunswick  Medical  Society,  422. 

Newman.  Robert,  electricity  in  gynaecology 
and  the  present  reluctance  of  gynaecol- 
ogists to  use  electricit}'.  4S6,  596 ; 
modifications  of  Holtini's  instrument 
for  the  treatment  of  hypertrophy  of  the 
prostate  by  galvano-cautery,  77. 

Newspapers,  medical  editor  on  the  staffs  of, 

36- 
New  \  ork  .-Xcademy  of  Medicine,  591,  675, 

792,   831.   955;    section  on   medicine. 

746,   916,  1024  ;  section  on   obstetrics 

and  gynecology,  76,  750,  915  ;  section 

on  surgery.  716,  831,  996;  ventilation 

at  the,  65S. 
New  Vork  County  Medical  Association,  74, 

75S,  953- 
New  Vork,  the  health  of.  819. 
New  York  Hospital,  new  buildings  of  the, 

945- 
.Vcw    y'ork  Medical  Journal,   change   of 

ownership  of  the,  138. 
New  York  Neurological  .Society,  473,  836, 

876. 
New  York  Obstetrical  Society,  661. 
New  York  Pathological  .Society,   115,  833. 
New   York   State  Conference  of  Charities 

and  Correction.  S22. 
New  York  State   Hospital  for  the  Care  of 

Crippled  and  Deformed  Children,  9S0. 
New  Vork  .State  Medical  Association.  628, 

670;  tifth  district  branch,  110. 
New  Zealand,  letters  from,  269.  907. 
Nitrous  oxide,   alleged  death   from,  really 

due  to  apoplexy,  400. 


Nome,  disease  at.  140. 

Nose,  affections  of  the,  in  relation  to  gen- 
eral diseases.  467 ;  carbonic  acid  gas 
in  affections  of  the,  54  ;  foreign  body 
in  the,  949  :  importance  of  preliminary 
treatment  for  operations  on  the,  6? u ; 
screw-worms  in  the,  975  ;  sudden 
blindness  following  cauterization  of 
the.  975  :  synechia  of  the,  9S7  ;  steno- 
sis of  the,  from  defective  septum,  op- 
eration for.  350;  tuberculosis  of  the, 
975- 

Nosebleed,  unusual  case  of,  974 

Noyes,  Henry  Drury,  obituary  of,  781  ; 
resolutions  on  the  death  of.  S99. 

Nucleic  acid  extracted  from  the  tubercle 
bacillus.  1 1 7. 

Nutrition  and  stimulation,  712  ;  in  infants, 
physiology  of,  265. 


O 


Obesity,  hygiene  of,  37S  ;  medical  super- 
vision of  "cures"  for,  6(17  ;  treatment 
of,  S79. 

Obstetric  conjugate,  an  instrument  for  de- 
termining the,  150. 

Obstetric  fraud,  343  ;  practice,  asepsis  in. 
417  ;  work,  some  life-saving  measures 
in,  S75. 

Obstipation.  713  ;  symptomatic  diagnosis 
of  valvular,  56;  valvular,  114. 

Gidema,  circumscribed  cutaneous.  266, 
S65  ;  malignant,  585;  of  the  skin, 
chronic  diffuse,  626. 

(Esophageal  growths,  gastrotomy  for,  546. 

(Esophagus,  atony  of  the,  386  ;  diverticula 
and  dilatations  of  the.  788;  foreign 
bodies  in  the.  643  ;  idiopathic  dilata- 
tion of  the,  387*;  rupture  of  the  appar- 
ently healthy,  1S3  ;  stenosis  of  the, 
50S.' 

Oettinger.  Bernard,  an  early  experience 
with  the  rain  bath,  270. 

O'Hogan.  Charles  James,  death  of,  1017. 

Oliver's  sign  in  aortic  aneurism.  S64. 

Omental  torsion,  7S7,  S31. 

Operation  without  digital  contact  with  the 
wound,  575. 

Ophthalmia  neonatorum,  631. 

Opium  inebriety,  medico-legal  relations  of, 
303  :  new  sources  of  danger  in  the  use 
of,  263 ;  poisoning,  permanganate  of 
potassium  in.  616. 

Optic  chiasm,  lesions  of  the.  623. 

Orbit,  foreign  bodies  in  the,  9S5;  three 
cases  of  vascular  tumor  of  the.  11. 

Organization  in  the  profession,  need  of 
better,  75S. 

Organotherapy,  discussion  on,  74  ;  signifi- 
cance of  certain  cell  problems  in,  7S7. 

Orrhotherapy,  discussion  on,  666. 

()steitis,  syphilitic  fibro-spongioid,  63. 

Osteomalacia.  742. 

Osteomyelitis,  acute,  56  ;  chronic  prolifer- 
ating, 65. 

Osteopaths,  annual  convention  of,  59. 

Osteopathy,  regulation  of,  500. 

(r^steopsathyrosis,  idiopathic,  97. 

Otalgia,  treatment  of.  155. 

Otis,  I'xlward  O.,  what  are  necessary  and 
reliable  data  upon  health  resorts  ? 
292. 

Otitis  media,  danger  of  purulent,  in  ad- 
vanced life,  467  ;  media  in  infants.  534; 
media  in  its  relation  to  the  cranial  cav- 
ity, 712;  media  purulenta.  bacteriol- 
ogy of,  902  ;  media,  treatment  of  fun- 
goid, 338  ;  septic  pyohai-mic,  297  ; 
suppurative,  carbolic  acid  in,  297. 

Otitic  lateral  sinus  disease,  two  cases  of. 
707  ;  treatment  of,  707. 

Ovarian  cyst,  a  large.  235  ;  dermoids,  his- 
togenesis of,  876;  tumor,  large  multi- 
locular,  143  ;  tumor,  solid.  875  ;  tu- 
mors, migrated,  245. 

Ovariotomy  for  ovarian  pain.  77  ;  in  cancer 
of  the  breast.  704,  70;. 

Ovary,  composite  teratoma  of  the,  550  ; 
conservative  surgery  of  the,  314;  fibro- 
ma of  the,  554  ;  internal  secretion  of 
the,  58 1  ;  papilloma  of  the,  with  sec- 
ondary deposits  in  the  peritoneum,  116; 


plea  for  avoidance  of  exsec'ion  of  the, 
in  connection  with  operations  upon  dis- 
eased tubes,  702. 

Overcrowding  in  the  etiology  of  tuberculo- 
sis. 064. 

Oxaluria,  979 ;  experimental  study  of,  585. 

Oxygen,  subcutaneous  administration  of, 
666. 

Oysters,  disease  spread  by,  639  ;  phos- 
phorus in,  462;  some  of  the  properties 
of,  557- 

Oza;na,  probably  of  sphenoidal  origin,  544; 
purulent  frontal  sinusitis  in,  733. 


Pachydermia  larj-ngis.  salicylic  acid  in  the 
treatment  of,  949. 

Page,  C.  I.,  recurrent  trance,  236. 

Pain,  surgical.  303. 

Pains,  labor,  carbonic-acid  gas  for  the  re- 
lief of,  76. 

Palate,  myxomatous  endothelioma  of  the 
soft,  46S  :   tumor  of  the  soft.  324. 

Palatine  muscles,  clonic  spasm  of  the,  pro- 
ducing a  sound  heard  at  a  distance, 
176. 

Pancreas,  histology  of  the  islands  of  I.an- 
gerhans  in.  469. 

Pancreatitis,  acute,  complicating  mumps, 
23  ;  hemorrhagic.  23,  S26  ;  sympto- 
matology and  treatment  of.  776. 

Panton.  A.  C..  a  case  of  perversion  of  sex- 
ual instinct.  436. 

Paralysis,  diphtheritic.  905 ;  double  facial, 
237;  Duchenne  Erb  type  of,  876; 
facial,  gS6,  post-diphtheritic.  544. 

Paris,  letters  from.  27,  107.  428.  589  ;  ty- 
phoid fever  in,   1 8. 

Park.  Herbert,  death  of,  302. 

Parotid  gland,  abscess  of  the,  225  ;  lipoma 
of  the,  705  ;  therapeutics  of  the.  75. 

Parotitis,  recurring,  in  a  healthy  child,  654. 

Parovarium,  primary  carcinoma  of  the,  452. 

Parturition  complicated  by  suppurating 
fibroids.   142. 

Pasteur  hospital  in  Paris,  the  new,  107. 

Patella,  structure,  fracture,  and  refracture 
of  the,  gS6  ;  treatment  of  fracture  of 
the,  497. 

Pathological  problems  of  the  present  day, 
230. 

Pathological  Society  of  Philadelphia,  620, 
700,  780,  943. 

Pathology,  biological  studies  with  reference 
to,  S65  ;  experimental.  327. 

Paul,  Thomas  M.,  intestinal  obstruction 
complicating  appendicitis,  with  the  re- 
port of  a  case.  653. 

Payne.  Albert  S. ,  an  acranial  monster,  I9S. 

Peabody.  Elias  S. .  death  of.  141. 

Pearsall.  Samuel  J.,  death  of.  S60. 

Peckham.   Frank  E. .  tumor  albus.  294. 

Peery.  E.  W..  a  new  curette.  397. 

Peking,  climate  of,  360. 

Pellagra,  pathogeny  of.  426. 

Pelvic  disturbances  in  women  an  unnoticed 
factor  in  the  production  of.  516  ;  mas- 
sage, 1,000;  organs,  malignant  dis- 
ease of  the,  556  ;  suppuration,  poste- 
rior coloptomy  in  the  treatment  of, 
142  ;  surgery,  difficult  and  obscure  pus 
cases  in.  557  ;  surgery,  evil  results 
following,  536  ;  surgerj-,  simple  meth- 
ods in,  555. 

Pelvis,  glass  drainage  tube  broken  off  in 
the.  716;  removal  of  inflannnatory 
masses  from  the.  86g  ;  thrombosis  in 
the  veins  of  the.  after  operation.  507. 

Pemphigus  with  er)'thema  circinatum.  347. 

Penis,  gangrene  of  the,  712,  793;  webbed, 
350. 

Pericarditis  of  liright's  disease,  176;  sup- 
purative, surgical  treatment  of.  664. 

Perineal  tears,  immediate  repair  of.  344. 

Perineum,  repair  of  old  lacerations  of  the, 

'55- 
Periostitis,  multiple  typhoid,  626. 
Peristalsis,   stomach  pump  as  a  stimulant 

to,  38(1. 
Peritoneum,     anatomy,     physiology,     and 

pathology  of  the.    126;    sarconiatosis 

of  the,   833  ;    tuberculous  effusion  in 


December  2g,  1900] 


INDEX. 


10 


0/ 


ihe,  cured  by  incision  and  permanent 
drainage.  70. 

Peritonitis,  diagnosis  of  tuberculous,  626  ; 
dilTuse.  suppurative,  from  gangrene  of 
the  appendix,  467  ;  from  perforation 
'  of  the  stomach  wall  by  a  toothpick, 
909  ;  general  septic.  953  ;  in  the  fixtus, 
143  ;  the  blood  in,  633  ;  tuberculous, 
116. 

Permanganate  of  potassium  in  opium  poi- 
soning, 616. 

Peru,  letter  from,  590. 

Pest  house,  right  of  a  city  to  establish,  73S. 

Phagocytosis,  5S6. 

Pharynx,  subacute  tuberculosis  of  the,  in 
childhood,  378  ;  the  atrophic,  624 ; 
toxic  paralysis  of  the.  418. 

Phelps.  A.  M.,  a  new  instrument  for  oper- 
ating on  congenital  dislocation  of  the 
hip  and  other  diseases  of  bone,  956; 
the  Phelps  operation  for  hernia  and 
method  of  closing  abdominal  wounds, 
441  ;  tuberculous  hip  disease,  714. 

Phenacetin,  physiological  action  of,  267. 

Philadelphia  County  .Medical  Society,  660, 
700,  S21,  901.  981. 

Philadelphia  Hospital,  association  of  ex.- 
residents  of  the,  944. 

Philadelphia  Neurological  Society,  736, 
900,  1016. 

Philadelphia  Pediatric  Society,  659,  9S0. 

Philippines,  diseases  prevalent  in  the,  95S  ; 
leprosy  in  the,  222,  341  ;  quarantine 
in  the.  341. 

Phillips.  James  W'illoughby,  death  of,  506. 

Phillips,  Wendell  C,  a  further  report  upon 
the  use  of  pure  carbolic  acid  in  the 
treatment  of  mastoid  wounds  and 
chronic  suppuration  of  the  middle  ear, 
296. 

Phlegmasia  alba  dolens.  treatment  of,  902. 

Phototherapy,   185,  572. 

Phthisis  (see  also  Consumptives,  Pulmo- 
nary lubcnutosis,  and  Tuberculosis). 
feeding  of  patients  with,  347  ;  influ- 
ence of  wind  on,  S30 ;  marriage  of 
patients  with,  5S7  ;  psychology  of. 
5S7  ;  relation  of  fistula  in  ano  to,  14  ; 
results  of  open-air  treatment  of,  in  the 
Berlin  homes,  1 59 ;  some  causes  of 
failure   in    the  climatic   treatment  of, 

739- 

Physical  training,  517  ;  therapeutic  uses  of, 
79S. 

Physician,  definition  of  the  word,  39  ;  evo- 
lution of  the  modern,  272  ;  in  politics, 
857. 

Physiological  research,  experimental  ther- 
apy as  an  aid  to,  229 

Physiology,  pathological.  327. 

Pierson,  William,  resolutions  on  the  death 
of,  21. 

Piffard,  Henry  J.,  some  applications  of 
static  electricity  in  dermatology,  609. 

Pillsbury,  B.,  poisoning  by  oil  of  winter- 
green,  150. 

Pistol,  a  self-loading,  999. 

Placenta,  origin  of  cysts  of  the,  64  ;  praevia. 
Cesarean  section  in  cases  of,  740 ; 
prajvia  with  twins,  238  ;  transmission 
through  the,  257. 

Plague,  bacillus  of,  .action  of  soil  on  the, 
80  ;  bacteriology  of,  478,  741  ;  clinical 
aspects  of,  in  Oporto,  304  ;  diagnosis 
of,  905  ;  diagnosis  of,  from  typhoid 
fever,  74 1 ;  endemic  centres  of,  39  ; 
in  various  places,  19,  29,  30,  loi,  179, 
223,  269,  27S,  302,  341,  342.  349, 
382,  422,  429,  464,  470,  510,  541,  547, 
557,  53s.  622,  627,  669,  70S;  inocula- 
tions against  the,  959 ;  introduction 
and  spread  of,  23  ;  laboratory  for  the 
study  of,  in  New  York,  737  ;  lectures 
on,  988  ;  Lustig's  serum  for,  340;  pre- 
cautions against,  in  New  Orleans, 
858 ;  preparation  of  antitoxin  from 
the  peritoneal  exudate  of  infected  ani- 
mals, 226  ;  resistance  of  the  bacillus 
of,  to  cold,  296  ;  symptoms  of  bubonic, 
pneumonic,  and  septicemic,  741. 

Pleibel,  Frederick  W  ,  death  of,  946. 

Pleural  exudate,  with  the  physical  sig^s  of 
pneumonia,  543. 

Pleurisy,  leucocyte  count  in,  987. 


Pneumonia,  abortive,  53  ;  bacter.ological 
examination  of  the  blood  in,  969;  iliet 
in  the  acute  stage  of,  Sio;  ending  la- 
tally  with  a  convulsion  of  ura?mic  ori- 
gin, 73;  etiology  of  acute  lobar,  656; 
following  laparotomy  in  the  neigh- 
borhood of  the  diaphragm,  425  ;  hy- 
drotherapy in,  168,  664  ;  in  the  aged, 
g20 ;  in  the  obese,  227  ;  meningitis 
complicating,  798 ;  meningococcus 
producing,  O67  ;  mumps  in,  68  ;  orrho- 
therapy  of,  902  ;  saline  injections  in, 
351,  5S4  ;  serum  therapy  of,  5S1  ; 
treatment  of,  104,  189,  232  ;  varieties 
of  acute,  1 84:  venesection  and  injec- 
tion of  a  salt  solution  in,  984. 

Pneumothorax  with  a  valve  due  to  pleural 
adhesions,  58S. 

Pneumotomy  with  resection  of  ribs,  428. 

I^oisoners  in  olden  times,  438. 

Poisoning,  acute,  864. 

Poisons,  chemical  resistance  of  the  body  to, 
50S. 

Polyorrhomenitis,  1021. 

Polypus,  nasal,  733. 

Porcelain  ware,  alleged  danger  in,  599. 

Porcher,  W.  Peyre.  an  impersonator  of, 
823. 

Porro-Ca.'sarean  operation,  96. 

Porter,  William  Henry,  to  what  e.\tent  does 
"  rheumatic  and  gouty  diathesis  "  enter 
into  traumatic  joints,  etc.?  443. 

Post-Graduate  Medical  School  in  London. 
269. 

Post-partum  hemorrhage,  prevention  .and 
treatment  of,  707. 

Post-rectal  or  pre-sacral  growths,  555. 

Potassium  chlorate,  poisoning  by,  176; 
iodide,  effects  of,  on  the  upper  respira- 
tory tract,  543. 

Poultice,  substitute  for  the,  392. 

Power,  abuse  of  professional,  941. 

Pozzi-Devillers  duel,  27. 

Practitioners'   Society  of  New   York,    72, 

745.  908- 

Pregnancy,  diagnosis  of  extra-uterine,  552  ; 
external  abdominal  examinations  in, 
390 ;  extra-uterine,  differential  diag- 
nosis of.  673  ;  repeated  ectopic,  344  ; 
simulation  of,  77. 

Premature  burial,  a  society  for  the  preven- 
tion of,  139. 

Prepuce,  operations  on  the,  346. 

Prescriptions  for  children,  simple  method 
of  writing,  814. 

Preston,  George  J.,  a  case  of  double  facial 
paralysis.  237. 

Prize,  .\lvarenga.  of  the  College  of  Physi- 
cians of  Philadelphia.  579;  award  of 
the  Middlemore.  275 ;  award  of  the 
Moscow,  230;  Craig  Colony,  for  orig- 
inal research  in  epilepsy,  859 ;  of  the 
College  of  Physicians  and  Surgeons. 
20 ;  Samuel  D.  Gross,  980. 

Proliferation  and  phagocytosis,  586. 

I'ri^staie,  a  cystoscopic  incisor  of  the.  998  ; 
calculus  of  the.  424  ;  castration  for, 
hypertrophy  of.  81,  469;  hypertro- 
phy of  the,  modifications  of  Bottini's 
instrument  for  the  treatment  of,  77  ; 
relief  of  enlargement  of  the,  725  ; 
vasectomy  for  enlarged,  796. 

Prostatectomy,  perineal,  832. 

Prostatitis,  traumatic,  61. 

Prostitutes,  medical  inspection  of,  737. 

Protective  coverings,  organic,  1S5. 

Proteids.  immunity  against,  144. 

Pruritus,  relief  of,  l8g;  ani,  treatment  of, 
114.  350. 

Pryor,  William  R. ,  puerperal  sepsis,  its 
patholog)'  and  treatment.  641. 

Psychic  factor  in  disease,  303. 

Psychology  preliminar)-  to  medical  educa- 
tion, 36. 

Psychosis  accompanying  chorea,  417;  op- 
erative, 545;  periodical,  836;  treat- 
ment of,  by  repose  in  bed,  706. 

Ptomain  poisoning,  559,  795. 

Puberty,  hygiene  antl  therapeutics  of,  in 
women,  S27 

Public  speaking  in  the  medical  profession, 
734- 

Puerperal  eclampsia,  263 ;  hot  baths  in 
threatening,  1019  ;  treatment  of,  740. 


Puerperal  sepsis,  641  :  as  a  notifiable  dis- 
ease, 311  :  nature  and  treatment  of, 
143;  prevention  of,  546;  treatment 
of,  too;,  1021. 

Pulmonary  arter)-,  acquired  stenosis  of  the, 

5(>- 

Pulmonary  tuberculosis  (see  also  Consump- 
tion, Phthisis,  and  Tuberculosis),  di- 
agnosis of,  663  ;  early  diagnosis  of, 
459;  in  infancy  and  childhood,  714, 
986  ;  iodine  in,  824  ;  new  diagnostic 
sign  of,  388  ;  nitrogen  gas  by  intra- 
pleural injection  in  the  treatment  of, 
271  ,  operation  in  cases  of ,  23;organo- 
toxin  in,  587 ;  pneumonic  complica- 
tions in,  64  ;  sanatorium  treatment  of, 
in  Kngland,  354  ;  SchouU's  treatment 
of,  718;  significance  of  heredity  in, 
5S7  ;  sodium  cinnamate  in  the  treat- 
ment of,  179;  subcutaneous  injections 
of  oil  of  camphor  for,  7g  ;  the  modern 
treatment  of,  563,  790 ;  treatment  of, 
24. 

Pulse  intermittent,  584. 

Pupil,  a  little  known  reaction  of  the,  864. 

Purgation  with  opium,  303. 

Purple,  Samuel  Smith,  obituar)'  of,  542 ; 
resolutions  on  the  death  of,  73S. 

Purpura  hamiorrhagica.  666  ;  peculiar  case 
of,  to20;  rhcumatica,  576;  rheumatica 
and  angina,  905. 

Pyelitis,  calculous,  nephrectomy  for,  905. 

Pyloroplasty,  276. 

Pylorus,  congenital  hypertrophic  stenosis 
of  the,  425. 

Pyorrhcca  alveolaris  as  a  cause  of  disease, 
225  ;  cruel  method  in  the  treatment  of, 
•75  I  syphilitic,  303. 

Pyosalpinx,  review  of  thirty  cases  of,  544. 

Pyrexias  of  hot  countries,  145. 


O 


Quackery,  unbridled,  1016. 

Quarantine,  modern,  681,  754. 

Quinine,  action  and  value  of,    in^  malaria, 

.356. 
Quintard,  Edward,  a  few  cases  of  erosions 
of  the  stomach,  409. 

R 

Rabies,  diagnosis  of,  509  ;  in  man,  curable 
forms  of,  218;  in  New  York.  779; 
statistics  of  preventive  inoculations  in 
Paris,  461  ;  theory  of  the  Pasteur  inoc- 
ulation for,  227. 
Rachitis,  color  of  living  bone,  707, 
Railway   accidents,    439;  sanitation,    158, 

5'9.  753- 

Rain  bath,  an  early  experience  with  the, 
270. 

Ranney,  Ambrose  L. ,  does  "cross-eye" 
affect  the  general  health  ?  go. 

Ration  in  the  British  army,  240 ;  of  the 
soldier  in  the  tropics,  78,  612,  977. 

Rats,  method  of  extirpating.  108,  520. 

Raw-food  eaters,    503. 

Raynaud's  disease  a  gangrenous  type,  476. 

Read.  Louis  W.,  death  of,  739. 

I^eciprocity  in  medical  licensure,  493  ;  ac- 
tion of  the  New  Jersey  board  looking 
■  toward,  140. 

Recto- vaginal  opening,  combined,  in  the 
human  subject,  143. 

Rectum,  cancer  of  the,  825 :  causes  and 
treatment  of  non-malignant  stricture 
of  the,  C25  ;  diarrhcca  in  disease  of 
the,  103  ;  fistula  of  the,  744  ;  inter- 
mittent fibrous  polyps  of  the,  64  ;  op- 
eration for  prolopse  of  the,  in  women, 
S24,  S73  ;  stricture  of  the.  276  ;  surg- 
ery of  the,  1 13  ;  treatment  of  abscesses 
around  the,  713 ;  treatment  of  pro- 
lapse of  the.  947. 

Red  Cross  Society  in  China.  1  So  ;  reorgani- 
zation of  the,  100,  the  ;   Russian,  778. 

Red  nose,  treatment  of,  348. 

Reilly.  William  ¥..  death  of,  662. 

Renal  arter)',  aneurism  of  the.  624  ;  insuffi- 
ciency, auto-intoxication  from.  875. 

Rest  in  bed  in  the  treatment  of  digestive 
disorders,  940. 


lo: 


INDEX. 


[December  29,  1900 


Rheumatic  fever,  424  ;    etiolog)'  of,  5S3. 

Rheumatic  state,  family  predisposition  to 
various  manifestations  of  the,  704. 

Rheumatism,  chronic,  assimilative  proc- 
esses in,  146  ;  differential  diagnosis 
of  chronic,  3S4  ;  etiology  of  acute  ar- 
ticular, S56  ;  heart  complications  of, 
629  ;  in  children,  danger  of  heart  le- 
sions in,  705  ;  pathology  and  etiology 
of  acute,  29S  ;  pyogenic  origin  of, 
875  ;  sore  throat  of ,  905;  treatment  of, 
1019. 

Rhinitis,  atrophic,  3S5  ;  fibrinous,  940 ; 
in  childhood,  22  ;    purulent,  297. 

Rhodan  in  the  nasal  and  conjunctival  secre- 
tion, 425, 

Rice,  Nathaniel  P.,  death  of,  782. 

Richardson,  Everard  Hamilton,  perfect  re- 
covery following  gangrene  of  the  scro- 
tum and  penis,  793. 

Richardson,  J.  J.,  a  case  of  epilepsy  cured 
by  operation  on  the  nose,  68. 

Ringworm  of  the  scalp,  treatment  of,  234. 

Robin.  A.,  a  contribution  to  the  diagnosis 
of  suppurative  peritonitis,  652. 

Robinson,  Beverley,  some  clinical  aspects 
of  gout,  721,  745. 

Robinson.  Kyron,  the  peritoneum  in  anat- 
omy, physiology,  and  pathology,  1 26. 

Robinson,  William  J . ,  subarachnoid  cocaine 
anesthesia,  744. 

Rockwell,  A.  D. ,  on  the  analogy  between 
the  nervous  conductibility  and  the 
electric  conductibility,  and  their  rela- 
tion to  the  functional  neuroses,  S49. 

Rocky  >[ountain  Interstate  Medical  Asso- 
ciation, 100,  3S1. 

Rodman,  11.,  report  of  a  case  of  carbolic- 
acid  poisoning  successfully  treated 
with  alcohol,  70. 

Roentgen  rays,  differentiation  of  aortic 
aneurism  and  intrathoracic  tumor  by 
the,  468  ;  errors  caused  by  false  inter- 
pretation of,  281  ;  experience  essential 
to  the  satisfactory  use  of  the,  266  ;  in 
diseases  of  the  nose,  throat,  and 
neighboring  organs,  218  ;  in  lupus, 
7S3  :  in  skin  diseases,  947  ;  in  the  study 
of  fractures  and  dislocations,  232;  new 
appliances  for  work  with,  595;  pho- 
tography, 59.S  ;  practical  hints  for  work- 
ers in,  37  ;  role  of  the  tube  in  the  thera- 
peutic application  of,  426  ;  use  of,  in 
surgery,  317. 

Rogers.  Philip  F..  a  case  of  enormous  ele- 
phantiasis. 153. 

Rome,  Robert  S.,  an  instrument  for  de- 
termining the  obstetric  conjugate,  156. 

Rooms,  air  of.  440. 

Rose,  A.,   treatment  of  gastroptosis,  9S9. 

Rosewater,  Charles,  some  points  bearing  on 
the  medicinal  treatment  of  appendicitis 
173- 

Roth,  Philip,  death  of,  662. 

Rothein,  differentiation  of,  from  measles  or 
scarlet  fever,  7S3. 

Roumania,  hospitals  in.  239. 

Royal  College  pf  Surgeons  of  England, 
centenary  of  the,  268. 

Rubella  and  scarlet  fever,  differentiation 
from,  of  a  disease  resembling  both, 
735  ;  confusion  of  two  diseases  under 
one  name.  144. 

Russel,  Jacob  P.,  death  of,  622. 

Russian  army,  tuberculosis  in  the,  679. 


Sacro  co.xalgia,  668. 

St.  John,  David,  report  of  a  case  of  Csesa- 
rean  section,  235. 

St.  John's  Guild,  jubilee  of.  139. 

St.  Louis  Academy  of  Medical  and  Surgi- 
cal Sciences,  858. 

Samoa,  diseases  of,  1027. 

Sanatoria,  psychical  influences  acting  on 
patients  in,   817. 

Sanatorium  treatment  of  tuberculosis,  354, 
387- 

Santiago  de  Cuba,  sanitar)'  condition  of 
540. 

Saratoga  County  Medical  Association,  620. 

Sarcomatosis  of  the  peritoneum,  833. 


Sargent,  George  \V. ,  alcohol  as  antidote  to 
carbolic  acid.  236. 

Satterlee,  G.  Reese,  complete  recovery 
following  a  severe  compound  fracture 
of  the  skull.  154. 

Sausage  poi.soning.  666. 

Savage,   Henry,  death  of,  669. 

Savell.  Richard,  death  of,  709. 

Savidge,  Eugene  Coleman,  some  aspects 
of  medical  gyn,T.>cology  from  the  stand- 
point of  the  general  consultant,   1023. 

Sayre,  Louis  Albert,  obituary  of,  505  ;  res- 
olutions on  the  death  of,  661,  823. 

Scabies,  treatment  of.  626. 

Scandinavian  physicians,  biennial  congress 
of,  5  So. 

Scapula,  total  excision  of  the,  62. 

.Scar,  contracting,  of  the  palm  replaced  by 
a  flap  from  the  abdomen.  702. 

Scarlatina,  a  constant  bacteriological  result 
in,  1S5 ;  and  rubella,  differentiation 
from, of  a  disease  resembling  both,  735  ; 
etiology  of,  543  ;  hospital  treatment 
of,  in  New  York  City,  946  ;  rash  of, 
783;  unusual  case  of ,   345. 

.Schlapp,  M.  G.,  the  non-suppurative  in- 
flammations of  the  brain,  with  report 
of  a  case  of  hemorrhagic  (malarial  ?) 
encephalitis,  i. 

Schleich  mi.xture,  death  from,  236. 

Schmidt,  Ernst,  death  of,  343. 

School  chairs,  improperly  consl.-ucted, 
3S4.  , 

School  children,  method  of  determining  eye 
defects  in,  815. 

Schools,  hygienic  and  medical  inspection 
of,  34. 

Schoull's  treatment  of  pulmonary  tubercu- 
losis, 71 8. 

Sciatica  cured  by  snake-bite.  305;  syphi- 
litic, 817  ;  treatment  of,  575. 

Sclerosis,  multiple,  etiology  of,  136. 

.Sclerotics,  dark,  fragilitas  ossium  associated 
with,  226. 

Scott.  Preston  B.,  death  of,  506. 

Scrotum,  gangrene  of  the.  712,  793. 

Scurvy,  cause  and  prevention  of  infantile, 
425  ;  etiolog)'  of,  264  ;  is  it  an  infec- 
tious and  contagious  disease  ?  42S  ; 
relation  of,  to  artificial  feeding,   675. 

Seaman.  Louis  I,.,  the  soldiers'  ration  in 
the  tropics,  its  use  and  its  abuse,  612. 

Secrecy, ethics  of,  in  the  learned  professions, 
1S4. 

Semeleder,  F.,  malaria  and  niosquitos, 
1023;  negroes  in  the  Mexican  Repub- 
lic.6b  ;  the  poverty  of  tropical  countries 
as  a  cause  of  the  feebleness  of  the  na- 
tives, 989;  the  soldier  in  the  tropics, 
389. 

.Seminal  vesicles,  thimbles  for  massage  and 
stripping  of  the.  702';  vesiculitis,  re- 
lation cf.  to  impotence.  262. 

Senecio  jacobre,  physiological  action  of, 
576. 

Senn,  N.,  gift  to  Rush  Medical  College  by, 

737- 

Septicaemia  following  angina  follicularis. 
426. 

.Sewage  farm  of  Paris.  600. 

Sexual  development,  abnormal,  424  ;  func- 
tion, insanity,  and  crime,  correlation 
between,    69S;    perversion,    a  case  of 

436- 

Shannon,  J.  R..  dilatation  of  the  lacrymal 
punctum.   118. 

Sharp,  C.  Edwards,  lightning  stroke  with 
recovery,  393. 

Shiels,  George  Franklin,  a  race-tr.ick  hos- 
pital. S67. 

Shipps,  William  IL,  simple  fracture  of  the 
shaft  of  the  femur,  with  report  on  two 
cases  of  delayed  union,  456. 

Ships,  infectious  diseases  in,  560. 

Shock,  prevention  of,  207.  656. 

Shoemaker,  Joseph  T.,  death  of.  946. 

Shoe-varnish,  poisoning  by,  574. 

Shoulder,  congenital  dislocation  of  the,  303; 
prognosis  of  dislocation  of  the,  796. 

Sight,  cortical  localization  of,  987. 

Sinus  py3>mia.  665 

.Skene.  Alexander  J.  C,  obituar\- of ,  61. 

Skin,  diseases  of  the,  lantern-slide  demon- 
strations of,  jlS;  non-operative  treat- 


ment of  cancer  of  the,  9S3  ;  sarcona 
of  the.  74  ;  subtrochanteric  amputation 
for  diffuse  carcinoma  of  the,  947  ;  tu- 
berculosis of  the,  673. 

Skoda's  sign,  616. 

Skull,  arrested  mental  development  follow- 
ing depressed  fracture  of  the,  785 ; 
compound  fracture  of  the,  followed  by- 
recovery,   1 54  ;  fracture  of  the,  786. 

Sleep,  physiology  of,  424, 

Smallpox  and  vaccination.  8g6;  contagi- 
ousness of,  360 ;  measles,  and  chicken- 
pox,  concomitant,  377. 

Smith,  Edward,  death  of,  946, 

Smith,   Franklin,  death  of.  622. 

Smith,  Stephen,  on  a  case  which  illustrated 
conservatism  in  surgery  ;  the  liability 
of  an  ancient  cicatrix  to  cancerous  de- 
generation ;  a  new  method  of  amputa- 
tion at  the  knee  when  the  arterial  cir- 
culation of  that  region  is  impaired, 
961. 

Smoke  nuisance.  720. 

Smollett  on  surgeons.  960. 

Smyser.  Henry  L. ,  death  of,  506. 

Snakes,  poisonous,  401  ;  treatment  of  the 
bites  of,  615. 

Society  for  the  Study  of  Diseases  of  Chil- 
dren, 259. 

Soldier  in  the  tropics,  389. 

South  Africa,  criticism  of  the  British  army 
medical  ser\'ice  in,  19,  107,  148,  159, 
223,  228,  240,  268,  278,  306,  343, 
399,  463,  471,  5TO,  547,  627,  678,  829, 
866.  942,  943,  951. 

Southern  and  northern  hemispheres,  medi- 
cal differences  between  the,  535. 

Southern  Surgical  and  Gynecological  As- 
sociation. 868. 

Spanish-American  War  Nurses'  Associa- 
tion, establishment  of  the.  421. 

Sparks.  George  W.,  death  of ,  823. 

Specialties,  future  of,  622. 

.Spectacle  habit.  182,  262,  270,  431. 

Spermin  crystals.  3S6. 

Sphenoidal  sinusitis,  endocranial  complica- 
tion of,  951. 

Spina  bifida,  treatment  of.  667. 

Spinal  cord,  diseases  of  the,  in  syphilitic 
infants.  34S  ;  gumma  of  the,  treated 
with  enormous  doses  of  potassium 
iodide,  515  ;  non-tabetic  lesions  of  the 
posterior  columns  of  the,  29S. 

Spinal  an;"ethesia,  344,  50S,  521,  561,  577, 
601,  615,  624,  674,  714,  740,  744, 
750,  79'.  799.  828,  862,  868,  937,  967, 
992. 

Spinal  sclerosis,  posterior,  ocular  symptoms 
in,  64. 

Spine,  caries  of  the,  with  abscess.  7S3  ; 
fracture  of  the.  263,  79S,  9S7;  rigid- 
ity of  the,  775  ;  sarcomatosis  of  the, 
simulating  tuberculosis,  394 ;  trau- 
matic disease  of  the.  667  ;  tuberculosis 
of  the,  713. 

Spirits,  certain  apparently  injurious  con- 
stituents of  potable,  1020. 

Spitting  habit,  municipal  regulation  of  the, 
664,  860. 

Spleen  and  lung,  percussion  of  the  boun- 
dary between.  106;  enlarged,  with  he- 
patic cirrhosis,  55  ;  enlargement  of,  in 
children,  425,  535. 

Splenectomy,  a  successful,  904  ;  Splenome- 
galy, primary,  706. 

Spoke-shave  in  the  removal  of  septal  spurs, 
265. 

Spondylosis,  rhizomelic.  267. 

Sponges,  sterilization  of,  997. 

Sporothrix  Schenckii.  abscess  due  to,  586. 

Sprains,  treatment  of.  863. 

Sputum,  examination  of,  for  tubercle  ba- 
cilli, 267  ;  significance  of  tubercle  ba- 
cilli and  other  bacteria  in  the,  57. 

Squibb,  Edward  Robinson,  death  of,   701. 

Squires,  G.  W.,  an  unusual  case  of  nose- 
bleed, 974. 

Stanton,  Maigaret.  tuberculosis  and  its 
treatment.   529. 

St.irvation,  death  from,  346. 

Stature  and  intelligence,  709. 

Stebbins,  Roswell  O.,  a  pocket  andean, 
teen  filter,  156. 

Stephen,  Walker  B. ,  death  of,  901. 


December  29,  1900] 


INDEX. 


1039 


Sterility  in  man,  130,  637. 
Sterilization  of  sponges,  gg? 

Stern,  Heinrich,  the  mortality  from  diabe- 
tes mellitus  in  the  City  of  New  York, 
(Manhattan  and  the  Hronx)  in  181J9, 
766. 

Stethoscope,  an  improved.   119. 

Stewart,  James  Kleury,  death  of,  982. 

Stillbirth,  hydrostatic  test  of,  948. 

Stille,  Alfred,  medical  bequests  of  the  late, 
659  ;  obituary  of,  542. 

Stitch  abscesses,  797. 

Stokes,  Sir  William,  death  of,  38S. 

Stomach,  cancer  of  the,  161,  267  ;  connec- 
tion between  the  disorders  of  the.  and 
of  the  uterus,  534  ;  diagnosis  of  cancer 
of  the,  379  ;  dilatation  and  prolapse  of 
the.  517;  disturbances  of  motility  of  the 
703  ;  disturbances  of  the,  in  relation 
to  diseases  of  the  chest,  6g6  ;  effect  of 
nutrient  eneniata  on  the  secretion  of 
the.  864  ;  erosions  of  the.  409,  829  ; 
examination  of  the  contents  of  the,  7S2 ; 
functions  of  the,  before  and  after  gas- 
tro-enterostomy,300;  hemorrhage  from 
the.  516;  intluenceof  morphine  on  the 
secretions  of  the,  546;  menstrual  trou- 
bles in  certain  diseases  of  the.  706  ; 
moulds  in  the,  142  ;  position  of  the, 
in  chlorosis.  006  ;  yucirolo's  method 
of  determining  the  boundaries  of  the, 
467  ;  receptive  quiescence  of  the,  dur- 
ring  mastication,  739 ;  treatment  of 
cancer  of  the,  S72  ;  tuberculous  ulcer 
of  the,  587  ;  ulcer  of  the,  231,  305, 
351,  419.  A(>7,  551.  627,  917. 

Stone,  U.  H.,  the  significance  of  the  ba- 
cillus coli  communis  in  drinking-water, 
324- 

Stone,  R.  M.,  a  death  from  the  Schleich 
mixture,  236. 

Storer,  V.  B.,  universal  ankylosis,  907. 

Stoughton,  James,  death  of,   3S3. 

Strabismus,  effect  of.  on  the  general  health, 
go  ;  management  of,  674  ;  necessity  of 
early  treatment  of,  350  ;  time  to  begin 
treatment  of,  399  ;  transient  spastic 
convergent,  347. 

Stretcher  for  army  use,  78. 

Stricture,  urethral,  remote  results  of  struc- 
tural lesions  in,  304. 

Strychnine,  neutralization  of,  by  the  animal 
tissues,  655,  740. 

Study,  J.  N.,  a  case  of  liodgkin's  disease, 
192. 

Stupor,  a  case  of  protracted.  904. 

Sturgeon,  William  II.,  death  of,  662. 

Styloid  process,  dislocation  of  the,  984. 

Subarachnoid  space.  O2. 

Subclavian  artery,  deligation  of  the,  528. 

Subphrenic  abcess,  275  ;  following  appen- 
dicitis, 45S  ;  resulting  from  a  trauma- 
tic suppuration  of  the  pancreas.  145. 

Sugar  as  an  oxytocic,  425. 

.Suggestion  as  a  therapeutic  agent,  425. 

Suicide,  causes  of.  777;  increase  in.  617; 
in  the  French  army,  503  ;  observations 
on,  9S5. 

Sultan's  fete,  medical  aspects  of,  709. 

Summer  v.ications  for  the  poor,  62S. 

Sunstroki ,  deaths  from,  at  Aldershot,  158. 

Suprarenal  bodies,  hemorrhages  of  the, 
2OS  ;  in  diseases  of  the  lower  air 
passages,  774  ;  in  hay  fever,  947;  sar- 
coma of  the,  in  an  infant,  509  ;  thera- 
peutics of  the.   74,  715. 

Surgeon  in  the  igth  century.  308. 

Surgery,  limitations  of  operative.  874. 

Surgical  operations,  care  of  patients  dur- 
ing, 207. 

Sutures,  metallic,  1015. 

Sweat-shops,  spread  of  disease  by,  560. 

Sweden,  women  medical  graduates  in, 
67. 

Swindler,  arrest  of  a,  gro. 

Symblepharon.  treatment  of.  O75. 

Symphyseotomy,  O32  ;  subcutaneous,  744. 

Syncope,  significance  of,  940. 

Syphilis,  calomel  ointment  in,  loO  ;  cere- 
bral, 142  ;  inter\'ention  of  the  dentist 
in  the  treatment  of,  786 ;  intestinal, 
145  ;  Losdorfer's  bodies  in  the  blood 
in,  176  ;  malignant  precocious,  348  ;  of 
the  upper  air  tract,  S61  ;   of  the  uveal 


tract,  182  ;    origin  of,  719  ,  pathology 
of  the  initial  sclerosis  in,  34O  ,    pseu 
do-keloid  following,  lO;  relation  of.  to 
tuberculosis,  387  ;  slow  pulse  in,  100  , 
spinal,  60S;   the  Justus  test  in,  951. 
Syphiloma,  treatment  of  initial,  377. 

T 

Tabes  dorsalis.  co-ordination  exercises  in 
the  treatment  of,  424  ;  cutaneous  hy- 
per^esthesia  in,  427  ;  diabetes  in  rela- 
tion to,  7S8  ;  early  diagnosis  of,  226  ; 
etiology  and  therapy  of,  264  ;  nasal 
crisis  in,  428  ;  recognition  and  manage- 
ment of,  514, 

Tachycardia  following  typhoid  fever,  225, 
304  ;  paroxysmal,  62. 

Trenia  llavopunctata,  g83. 

Taft,  Charles  S.,  death  of,  1017. 

Tailless  mice,  alleged  breeding  of,  66. 

Talipes  calcaneus,  treatment  of,  in  young 
children,  465. 

Talmey,  13.  S. ,  chorio-epithelioma  malig- 
num,  121  ;  primary  carcinoma  of  the 
parovarium,  452. 

Tea,  adulteration  of,  in  Europe,  479. 

Tear  passages,  surgery  of  the,  142. 

Teeth,  after-pains  from  extraction  of,  216. 

Temperance  Congress,  International,  65. 

Tendon  suture,  4O5. 

Test-meal,  a  new.  783. 

Tetanus,  587  ;  following  poisoning,  906  ; 
orrhotherapy  of,  194,  4O8.  go4  ;  pecul- 
iar form  of,  265  ;  recovery  from,  6O3  ; 
traumatic,  complicated  by  intestinal 
obstructions,  468  ;  treatment  of,  62. 

Tetany  due  to  auto-infection,  gio  ;  gastric, 
5og. 

Therapeutics,  a  mistake  in,  8g4 ;  rational, 
500. 

Thienhaus.  Otto,  appendicitis  larvata  and 
intlammation  of  the  right  broad  liga- 
ment, tube,  and  ovary,  531. 

Thirst,  control  of,  O38. 

Thompson,  Guion,  practical  hints  for  jr-ray 
workers,  37.  ■ 

Thrombosis  in  the  veins  of  the  pelvis  and 
iower  extremities  after  operation.  507. 

Thymus  gland,  therapeutics  of  the.  75. 

Thyroid  gland,  acute  enlargement  of  the, 
24  ;   therapeutics  of  the.  54,  74. 

Thyrotomy,  indications  of,  304. 

Tissues,  experimental  repair  of,  705. 

Tobacco,  use  of,  by  soldiers  in  active  ser- 
vice, 958. 

Toboldt,  A.  L.  A.,  death  of,  901. 

Tongue,  black,  646;  furring  of  the,  in 
health  and  disease,  385. 

Tonsillar  diseases,  acute,  and  their  sc- 
quelrc,  143. 

Tonsillitis,  glandular  complications  of 
acute,  when  accompanied  by  influenza, 
224  ;  septicemia  following,  426  ;  treat- 
ment of,  717. 

Tonsils,  concealed  tuberculosis  of  the,  55  ; 
effects  of  enlarged,  417;  hypertrophy 
of  the,  S24;  hypertrophy  of  the  phar- 
yngeal, 739  ;  infection  through  the. 
297,  670  ;  lingual,  46O  ;  primary  epi- 
thelioma of  the,  55  ;  ulcerations  of  the, 
297. 

Toxicity  -j.  septicity  in  the  infectious  path- 
ogenic bacteria.  507. 

Toxins,  effect  of  repeated  injections  of,  on 
metabolism,  427. 

Trachea,  multiple  ossified  enchondroses  of, 
865. 

Tracheloplasty,  712. 

Tracheotomy,  rare  complication  in,  105. 

Trance,  recurrent,  23O. 

Transfusion,  470. 

Traumatism  and  infection.  22g  ;  etiological 
significance  of,  742  ;  psychical,  death 
following,  545, 

Travel,  therapeutics  of,  303. 

Tremor,  forms   and    clinical   character  of, 

Trichinosis,  blood  examinations  in  the  di- 
agnosis of,  634. 

Trigger  finger.  82^. 

Trimble.  William  B. ,  treatment  of  frac- 
tured patellre,  497. 

Triplets,  two  sets  of.  69S. 


Tropical  diseases,  instruction  in,  503. 

Tropics,  improvement  of  sanitary  medical 
practice  in  the.  359  .  poverty  of  coun- 
tries in  the,  causing  enfeeblement  of 
the  natives.  989 ;  some  problems  of 
medicine  in  the,  625  ;  the  soldier  in  the, 
389;    the  soldier's  ration  in  the,  O12. 

Tubal  disease,  massage  in  the  treatment  of, 
64. 

Tubercle  bacilli,  dissemination  of.  by  cows 
coughing,  950  ;  methods  of  identifica- 
tion  of    the,    226 ;     virulent,    in    the 
healthy  nasal  cavities  of  healthy  per 
sons,  285. 

Tubercle  tax  on  alcohol,  a  proposed,  439. 

Tuberculin,  diagnostic  value  of,  587. 

Tuberculosis,  liritish  Congress  on.  301  , 
buccopharyngeal,  78O  ;  cancer  in  rela- 
tion to,  808;  cerebral,  in  children,  16, 
climate  for,  6O4  ;  climatic  treatment  of, 
729  ,  congenital.  225  ;  consanguinity 
as  a  factor  in  the  etiology  of,  354, 
Courmont's  scrum  reaction  in  the  early 
diagnosis  of,  63 ;  cured  peritoneal,  in 
children,  545  ;  diagnosis  of  peritoneal. 
626  ;  earliest  signs  of,  477  ;  early  di- 
agnosis of,  387  ;  educational  and  leg- 
islative control  of,  5S7  ,  electricity  in 
the  treatment  of,  594  ,  epididymo- 
testicular,  treated  by  ligature  of  the 
spermatic  cord,  585 ;  erythemas  of. 
386  ;  etiology  of.  593  ;  fight  against  in 
France,  398  ;  infection  of,  through 
milk  and  dairy  products,  105  ;  infec- 
tiousness of,  539  ;  in  the  Russian 
army,  679  ;  intrapleural  injections  of  ni- 
trogen in,  4S1  ;  latent,  of  a  pharyngeal 
tonsil,  175  ;  nasal.  975  ;  nasal  cough  in, 
828;  nature  treatment  of.  8O2  ;  occupa- 
tion in  relation  to,  465  ;  of  bone,  injec- 
tion for,  796  ;  of  the  ear,  297  ,  of  the 
eye,  881  ;  of  the  knee.  294  ;  of  the 
testes,  radical  treatment  of.  412  ;  palla- 
dium chloride  in  the  treatment  of,  388  ; 
pharyngeal,  in  childhood.  378  ;  precau 
tions  against  in  (Jermany.  944  .  prog- 
nostic value  of  the  diazo  reaction  in. 
468;  prophylaxis  of,  864;  pulmonary 
see  Pulmonary  titbtrcuhsis  ;  raw-meat 
cure  of,  6gg  ;  renal,  diagnosis  of.  O79  , 
renal,  surgical  treatment  of,  942  ;  san- 
atorium treatment  of,  746  ;  serum  re- 
action in  the  diagnosis  of,  986  ,  sodium 
cinnamate for,  903,  spinal.  713,  spread 
of.  in  milk,  757  .  symposium  on,  O71  ; 
therapeutic  value  of  electric  light  in 
laryngeal  and  pulmonary,  647  ;  treat- 
ment of,  529;  treatment  of  articular, 
465  ;  treatment  of  laryngeal,  970, 
988  ;  treatment  of  primary  renal,  58O  ; 
trophic  changes  in,  424  ;  vesical.  742  ; 
where  the  danger  lies  in,  903. 

Tuberculous  lesions  from  a  clinical  point  of 
view,  50S,   514. 

Tubo-ovarian  abscess,  management  of,  556; 
disease,  how  best  to  deal  with  it,  765, 

Tumor  albus,  2g4 

Tumors,  distribution  of  connective  tissue 
in,  468  ;  electrolysis  in  the  treatment 
of,  8S4;  post-rectal  or  pre-sacral,  555 

Turbinate,  bullous  enlargement  of  the  mid- 
dle, 663. 

Turbinated  bodies,  hypertrophy  of  the. 
544- 

Turck,  Kenton  B.,  the  care  of  patients  dur- 
ing  surgical  operations ;  with  some 
methods  of  preventing  shock  and  in- 
fection, 207. 

Turnbull,  Lawrence,  death  of,  701. 

Turpentine,  action  of  the  oil  of,   184. 

Tuttle,  George  H  . ,  a  new  vaginal  douche. 
838. 

Twins,  sudden  and  unexpected  delivery  of, 
69. 

Tympanum,  fibroma  involving  the,  2O6. 

Typhoid  and  colon  bacilli,  a  pathogenic 
group  intermediate  between,  347. 

Typhoid  bacillus,  detection  of.  in  water, 
78  ;  differentiation  of,  from  the  colon 
bacillus,  104. 

Typhoid  fever,  916  ;  agglutinating  proper- 
ties of  the  blood  of  a  healthy  infant 
born  of  a  mother  with  the  disease.  105  ; 
among  soldiers,  158  ;  among  the  Brit- 


I040 


INDEX. 


[December  29,    1900 


ish  troops  in  South  Africa,  gS,  279  ; 
and  appendicitis,  diagnosis  between,  by 
means  of  iodine  reaction,  SOi  ;  antisep- 
tic and  eliminative  treatment  of,  142, 
37S.575.  (>S5't  bowellesions  of,  1020; 
coexisting  with  malaria,  434;  cystitis  in, 
743;  development  of,  during  the  course 
of  active  syphilis,  5SS  ;  diagnosis  of, 
from  plague,  741  ;  eliminative  and  an- 
tiseptic treatment  of,  513;  epidemics 
of,  821,  974;  feeding  in,  S24,  S54  ; 
foetal  and  infantile,  (jS6  ;  gangrene  of 
the  leg  following,  51S;  hydrotherapy 
for,  in  private  practice,  634;  in  chil- 
dren, 4bg  ;  in  New  York,  900  ;  in  South 
Africa,  3gS  ;  intestinal  paralysis  in, 
396  ;  laryngeal  manifestations  of,  22  ; 
mortality  from,  in  South  Africa,  43S  ; 
notes  on,  SoS ;  pathology  and  treat- 
ment of,  789 ;  perichondritis  of  the 
larynx  in.  348  ;  periostitis  complicat- 
ing. 626 ;  peritoneal  infection  in,  22  ; 
preventive  inoculations,  144,  2ig,  228, 
355.  385>  501.  fe20. ;  prognosis  in, 
818  ;  psychosis  of,  g4g  ;  puttee  (?)  pa- 
ralysis after ;  7S5  ;  several  attacks  of, 
342  ;  self-limitation  of,  S95  ;  soup  diet 
and  rectal  irrigations  in,  775;  sterili- 
zation of  excreta  in,  S26  ;  tachycardia 
following,  225  ;  treatment  of,  22,  664. 
1020;  treatment  of,  at  the  Johns  Hop- 
kins Hospital.  623  ;  treatment  of,  at  the 
New  York  Hospital,  851  ;  Widal  tests 
for,  at  the  New  York  quarantine  sta- 
tion, 898  ;  with  unusual  features,  62. 

Typhoid  gangrene,  bilateral,  3S7. 

Tj-phoid-like  disease,  caused  by  a  typhoid- 
iike  bacillus,  346. 


U 


Ulcer,  rodent,  resorcin  in,  393. 

Umbilicus,  infection  through  the,  417. 

University  of  Dallas,  Texas,  661. 

Ura:mia,  the  cause  of,  336,  471  ;  venesec- 
tion for,  144. 

Ureine,  the  discovery  of,  336,  471 . 

Ureters,  anastomosis  of,  with  the  intestine, 
262  ;  catheterization  of  the,  107  ;  pel- 
vic pain  from  calculi  in  the,  54';  total 
extirpation  of  the,  507,  996. 

Urethra,  forward  dislocation  of  the.  634  ; 
hydrostatic-pressure  irrigator  for  the, 
157;  rupture  01  the,  782;  treatment 
of  resilient  stricture  of  the,  865. 

Urethroscope,  a  new    38. 

Urinary  infection,  ascending,  due  to  the 
bacillus  pyocyaneus  and  proteus  vul- 
garis, 506;  organs,  systemic  infection 
in  diseases  of  the,  264. 

Urine,  bile  pigment  in  the,  in  cardiac  dis- 
ease, 144;  dextrose  in.  no;  excre- 
tion of,  with  diminished  kidney  weight, 
62  ;  extravasation  of,  150  ;  extravasa- 
tion of,  following  stricture  of  large  cali- 
bre, I4g;  floaters  in  the,  103;  new 
disease  with  a  specific  action  of  the, 
304  ;  pigments  of  the,  in  their  patho- 
logical aspects,  866. 

Urogenital  tuberculosis,  surgical  treatment 
of,  672. 

Urticaria,  factitious,  with  enteroptosis,  55. 

Uterus,  alveolar  sarcoma  of  the,  1 52  ;  can- 
cer of  the,  711;  connection  between 
the  disorders  of  the,  and  of  the  stom- 
ach, 534  ;  dilatation  of  the  cervix  by 
means  of  a  modified  Champetier  de 
Kibes  Jjalloon,  361  ;  electrical  treat- 
ment of    fibroids  of  the,  gS4  ;   enor- 


mous fibroma  of  the.  642  ;  fibroids  of 
the.  224,  312;  fibroids  of  the,  compli- 
cating pregnancy.  385  ;  fibroids  of  the, 
mortality  of  hysterectomy  for,  344  ; 
hysterectomy  for  cancer  of  the,  22,915  ; 
inversion  of  the,  of  three  years'  dura- 
tion, 315,  863;  myomata  of  the,  750, 
953  ;  operative  treatment  of  prolapse  of, 
in  elderly  women,  817  ;  osteofibroma  of 
the,  S70;  prolapse  of  the,  hysterectomy 
for,  77;  resultsof  vaginal  hysterectomy 
for  cancer  of  the,  952  ;  round  ligament 
ventro-suspension  of  the,  549,  590 ; 
surgical  treatment  of  displacements  of 
the,  553;  treatment  of  cancer  of  the, 
79g ;  treatment  of  complete  prolapse  of 
the.  in  elderly  women,  798;  treatment 
of  fibroids  in  the  non-pregnant,  555; 
treatment  of  inflammation  of  the  ad- 
nexa  by  water  at  60°  C  827  ;  treat- 
ment of  prolapse  of  the.  5S5;  treat- 
ment of  retroversion  and  prolapse  of 
the,  517  ;  treatment  of  rupture  of  the, 
509  ;  treatment  of  spasmodic  contrac- 
tion of  the,  46S. 
Uvula,  superimposed,  1018, 


V 


Yaccinal  immunity,  extreme  brevity  of. 
742. 

Yaccination,  abnormalities  of,  957  ;  com- 
pulsory. 590;  eruptions,  263;  in  Paris, 
.    1026  ;  utility  of,  896. 

Yaccinator  charged  with  assault,  540. 

Yaccine  lymph  as  an  alterative,  914;  club- 
shaped  bacterium  in,  105  :  infection 
of  the  lips  by,  8S0;  influence  of  tem- 
perature on,  755  ;  micro-organisms  of, 
863. 

Y'agina,  hot-water  injections  in  the,  954. 

Vaginal  douche,  a  new,  838. 

Vaginitis,  treatment  of.  189. 

Valentine,  Ferd.  C,  hypospadias  operated 
on  by  Beck's  method,   124. 

Varicose  veins,  operative  treatment  of, 
1006  ;  results  of  operation  on,  1019. 

Varix,  g04. 

Vas  deferens,  latero-lateral  anastomosis  of 
the,  29S. 

Y'eins,  wounds  of,  796. 

Y'ena  cava,  compression  of  the  superior, 
5SS. 

Venesection  and  saline  infusion,  638. 

Vertigo  of  doubtful  origin,  745. 

Vesiculitis,  acute  seminal,  507. 

Veterinary  surgeons   in    the   U.    S.   army, 

759- 

Viscera,  transposition  of,  105. 

Viscin,  therapeutic  application  of,  742. 

Vitiligo  in  Peru,  5go. 

Vitreous,  implantation  of  an  artificial,  582. 

Voice,  physiology  of  the  production  of  the, 
266,  574. 

Voorhees,  James  D. ,  dilatation  of  the  cer- 
vix by  means  of  a  modified  Champetier 
de  Ribes  balloon,  361. 

Vulva,  diffuse  non-malignant  papilloma  of 
the,  554. 


W 


Walters.  J.  S.,  death  of,  7S2. 
\Var,  mortality  in,  47g. 
Ward,  Cleorge  S.,  death  of,  21. 
Ward,  William  Spencer,  obituary  of,  383. 
Warts  cured  by  vaccination,  544. 
\Vater,     extemporaneous     purification    of, 
680;    proper    use    of,     543;     supply. 


filtration  of  the  Albany,  improved 
health  conditions  following,  97S  ;  sup- 
ply in  military  camps,  7I9;  supply  of 
New  York,  filtration  of  the,  856,  897; 
supply,  pollution  of,  755. 

Waterman,  William  B.,  death  of,  343. 

Weather,  influence  of,  on  infectious  dis- 
ease, 426. 

Welch,  George  K.,  some  remarks  on  medi- 
cine in  1800,  looi. 

Welles.  Samuel  Russell,  death  of.  141. 

Wens,  interstitial  injection  of  ether  for,  105. 

West,  Benjamin  Hussey,  death  of,  622. 

Wheelock  .George  G.,  presentation  to,  822. 

White,  Moses  C,  death  of,  701. 

White,  Richard  H.,  death  of,  505. 

Whooping-cough,  bacteriology  of,  346 ; 
treatment  of,  976  ;  treatment  of  the 
paroxysmal  stage  of,  7S5. 

Wiggin,  Frederick  Holme,  defense  of  suits 
for  alleged  malpractice,  511. 

Williamson,  George  Edward,  death  of,  27. 

Wind,  influence  of.  on  phthisis,  830. 

Wintergreen,  poisoning  by  oil  of,  150, 

Wise,  Richard  A.,  death  of,  1017. 

Woman  medical  graduate,  the  first,  in 
Germany,  ggg. 

Woman's  Hospital,  nurses'  home  for  the, 
S;g. 

Women,  medical  graduation  of,  75g. 

Wood,  F.  C. ,  sarcomatosis  of  the  vertebrae 
simulating  tuberculous  osteitis  in  a 
case  of  pulmonar)-  tuberculosis,  394. 

Woodruff.  Charles  E.,  stature  and  intelli- 
gence, 709;  the  alleged  breeding  of 
tailless  mice  through  the  inheritance  of 
mutilations,  66. 

Wounds,  hydrogen  peroxide  in  the  treat- 
ment of,  930  ;  inflammation-producing 
agents  in  the  treatment  of,  45S  ;  in 
war,  278  ;  modern  bullet,  338. 

Wright,  John  D.,  a  word  through  the  fam- 
ily physician  to  the  mothers  of  deaf 
children,  269. 

Wrist-joint,  relation  of  the  os  magnum  to 
tuberculosis  of  the,  267. 

W'ry-neck,  treatment  of  spasmodic.  S62, 
S77. 

Wylly,  King,  death  of,  21. 


X 


Xiphopagous  twins,  separation  of,  108. 


Yale  Medical  School,  new  buildings  for 
the,  860. 

Yaws,  359  ;  not  related  to  syphilis,  3S7. 

Yellow  fever,  etiology  of,  697,  703,  754, 
820,  825;  expedition  of  the  Liverpool 
School  of  Tropical  Medicine  to  study, 
466  ;  germ  of,  663  ;  in  various  places, 
57,  loi,  139,  221,  302,  422,  464,  621, 
779.  S59  ;  mosquito  theory  of  the 
spread  of,  697,  754,  858,  863,  S67; 
nature  and  cause  of,  582  ;  prognosis 
of.  in  Havana,  539  ;  treatment  of,  in 
children,  176. 

Verba  mate  tea.  480. 

Yukon,  disease  in  the,  736. 


Zabriskie.  William  Arthur,  death  of,  701. 
Zeta  Phi  Society,  421. 

Zoological   names,    use   and   abuse  of,   by 
j)liysicians,  1020. 


•0 


BINDING  SECT.  MAY  1 B 


Biologicdl 
&   Medical 
Serials 


PLEASE  DO  NOT  REMOVE 
CARDS  OR  SLIPS  FROM  THIS  POCKET 


UNIVERSITY  OF  TORONTO  LIBRARY 


I 


■l  ■'■■'"'.  -'l^-- 

;.;:;■, 

^cKr 

..    ,.  .  .    ,.,.^ 

... 

''""!"■'■ 

mi